Paul D. Danielson

Single-incision laparoscopic appendectomy vs multiport laparoscopic appendectomy in children: a retrospective comparison.

BACKGROUND Minimally invasive surgery is commonly used to treat appendicitis. Single-incision laparoscopic surgery is an attractive modality to treat a commonly occurring problem with the advantage of minimal or possibly no scarring. We sought to compare our results of single-incision laparoscopic appendectomy (SILA) with those of patients undergoing traditional multiport laparoscopic appendectomy (MPLA). PATIENTS AND METHODS A retrospective review of all patients who underwent a minimally invasive appendectomy from September 2009 to February 2010 was performed. The patients were divided into 2 groups based on if they had a SILA or a traditional MPLA. Outcomes including demographics, diagnosis, operative time, length of stay, narcotic usage, and complications were evaluated. RESULTS A total of 110 patients underwent appendectomy. There were 50 patients who underwent SILA and 46 patients who underwent MPLA. Fourteen patients with perforated appendicitis were excluded. Mean age (11.1 vs 11.7 years, P = .43), weight (43.3 vs 50.9 kg, P = .27), and length of stay (1.1 vs 1.2 days, P = .56) were comparable between both groups. Operative time for SILA was slightly longer (33.8 vs 26.8 minutes, P = .01). Overall intravenous narcotic use was lower in the SILA group (0.9 vs 1.4 doses, P = .01), but there was no difference in the patients who also received ketorolac (0.8 vs 1.0 doses, P = .6). Four patients in the SILA group developed superficial wound infections and 1 patient in the SILA group was admitted for postoperative abscess. CONCLUSIONS Single-incision laparoscopic appendectomy is safe and effective in the pediatric population. Further studies should be performed to determine the impact on operative time and postoperative narcotic requirements.

Single-port laparoscopic repair of a Morgagni diaphragmatic hernia in a pediatric patient: advancement in single-port technology allows effective intracorporeal suturing.

We report a case of a foramen of Morgagni hernia repaired by a single-port laparoscopic technique. A 20-month-old (10 kg) boy underwent a 97-minute procedure through a 15-mm umbilical incision and had no complications. Although other pediatric single-port case series have been reported in the literature, this case represents the first time a diaphragmatic defect has been addressed. Moreover, unlike previous experiences that involved procedures of resection (appendectomy, cholecystectomy, etc), this case required operative repair and reconstruction with intracorporeal suturing via a single-access site. Advancement in instrument and port technology makes such procedures feasible in pediatric patients.

Single-incision laparoscopic cholecystectomy in children: a retrospective comparison with traditional laparoscopic cholecystectomy

PURPOSE The natural progression of minimal access surgery is to perform the same technical operation with minimal or no evidence of scarring. In children, small case series of single-incision laparoscopic cholecystectomy suggests that the operation is feasible; however, no comparison has been made to traditional, multiport laparoscopic cholecystectomy in patient safety, outcomes, and cost. METHODS A retrospective review of consecutive single-incision laparoscopic cholecystectomies in children was performed from January 2009 to November 2010. Demographics and outcome measures were recorded, including operative time, operative costs, length of stay, need for intravenous analgesia, and operative complications. A concurrent group of pediatric patients undergoing traditional, multiport laparoscopic cholecystectomy was used for comparison. RESULTS A total of 69 pediatric laparoscopic cholecystectomies were performed from January 2009 to October 2010. Forty-two patients with a mean age of 14.7 years (range, 5.9-18.9 years) underwent attempted single-incision laparoscopic cholecystectomy, and 27 patients with a mean age of 15 years (range, 2.8-19.4 years) underwent multiport laparoscopic cholecystectomy. Mean operative time (68 vs 64.5 minutes; P, not significant [NS]), length of stay (1.45 vs 1.19 days; P, NS), and doses of intravenous analgesia (1.7 vs 2; P, NS) were not significantly different for patients undergoing single-incision or multiport laparoscopic cholecystectomy, respectively. Two patients (5%) undergoing the single-incision approach required 1 additional port be placed to complete the operation. In addition, there was no significant difference in operative costs between the single-incision and multiport approach (

The 912th Forward Surgical Team in Operation New Dawn: Employment of the Forward Surgical Team During Troop Withdrawal Under Combat Conditions

7766 vs

Operative Findings Are a Better Predictor of Resource Utilization in Pediatric Appendicitis.

8383; P, NS). CONCLUSION Single-incision laparoscopic cholecystectomy is safe and effective in the pediatric population. It can be performed with the same technical exposure and outcomes as multiport laparoscopy, with the added benefit of little to no scarring and no increase in cost.

Single incision laparoscopic surgery for pediatric adnexal pathology

The Wars in Afghanistan and Iraq witnessed the first widespread use of U.S. Army Forward Surgical Teams (FSTs). Although doctrinally designed to support maneuver brigades in a linear front conflict, FSTs were quickly adapted to fulfill area support and special operation support missions as part of Operation Enduring Freedom and Operation Iraqi Freedom. FSTs were also split to cover a greater area in both theaters. We now report further adaptation of the split FST role to meet the unique requirements encountered during the final phase of Operation New Dawn. Maintaining resuscitative surgical capabilities for U.S. Forces withdrawing under combat conditions required changes in techniques, tactics, and procedures. We describe our experience within three different scenarios in which elements of an FST were successfully employed and discuss operational planning considerations.

A closer look at non-accidental trauma: Caregiver assault compared to non-caregiver assault

PURPOSE Post-operative management following appendectomy is dependent upon intraoperative assessment. We determined concordance between surgical and histopathologic diagnosis to better predict resource utilization in pediatric patients undergoing appendectomy. METHODS A retrospective analysis of 326 patients with operative appendicitis from July 2012 to July 2013 was performed. Based on operative findings, patients were classified as simple appendicitis (SA) or complex appendicitis (CA). RESULTS The SA group included 194 (59.5%) patients while the CA group included 132 (40.5%) patients. There were significant differences in WBC, CRP, operative time, length of stay, and 30-day complications. Seventy percent of patients with intra-operative findings of SA were found to have complex pathology while 10.6% with intra-operative findings of CA were found to have simple pathology. There is poor agreement between intra-operative findings and histopathologic findings (κ=0.173). Although 70% of patients with intra-operative findings of SA were labeled as complex pathology, 86% followed a fast track protocol (same day discharge) with a low complication rate (1.7%). CONCLUSIONS Pathology findings that overestimate the severity of disease correlate poorly with the post-operative outcomes for appendicitis. We conclude that operative findings are more predictive of clinical course than histopathologic results. This can have an impact on resource utilization planning.

Feasibility of Supraglottic Airway Use by Combat Lifesavers on the Modern Battlefield

PURPOSE Minimally invasive surgery is commonly used to treat gynecologic disease. Literature in the adult population supports that single incision laparoscopic surgery (SIL) is feasible and safe for the treatment of adnexal disease; however, there is little evidence for SIL in the pediatric population. METHODS A retrospective review of patients with gynecologic disease who underwent SIL from August 2009 to April 2012 was performed. All demographic data, clinical history, radiologic studies, indications for and type of operation, operative time and complications, and pathology were recorded. RESULTS Thirty-four patients with a mean age of 12.5 years (range 3.6-17.4 years) underwent SIL for adnexal pathology. Operative interventions included cystectomy (56%), salpingo oopherectomy (26.5%), detorsion (8.8%), adnexal biopsy (5.9%), and oophoropexy (2.9%). Forty-four percent of the patients also underwent appendectomy. The mean operative time was 42.8 minutes. There was 1 wound infection (2.9%) and 2 patients (5.9%) required additional ports. CONCLUSIONS Single incision laparoscopy provides a safe and effective approach to diagnostic laparoscopy with the ability to carry out operative interventions in multiple quadrants without adding additional ports. Single incision laparoscopy may be particularly effective in young women with abdominal pain requiring operative intervention.

Percutaneous ultrasound-guided vs. intraoperative rectus sheath block for pediatric umbilical hernia repair: A randomized clinical trial

PURPOSE The purpose of this study was to examine the outcomes of non-accidental trauma (NAT) patients compared to other trauma (OT) patients across the state of Florida. In addition, NAT and OT patients with a mechanism of injury of assault were further analyzed. METHODS A statewide database was reviewed from January 2010 to December 2014 for patients aged 0-18years who presented following trauma. Patients were sorted by admitting diagnosis into two groups: rule out NAT and all other diagnoses. Patients with a mechanism of assault were subanalyzed and outcomes were compared. RESULTS There were 46,557 patients included. NAT patients were younger, had more severe injuries and had a higher mortality rate compared to OT patients. Assault was the mechanism of injury in 95% of NAT patients. NAT assault patients were younger, required more intensive care unit (ICU) resources, and had a higher mortality rate compared to other assault patients. CONCLUSION Non-accidental trauma patients require more resources and have a higher mortality rate compared to accidental trauma patients, and these differences remain even when controlling for the mechanism of injury. LEVEL OF EVIDENCE III.

Impact of experience on quality outcomes in single-incision laparoscopy for simple and complex appendicitis in children.

BACKGROUND Airway compromise is a contributor to preventable mortality on the battlefield. Supraglottic airway devices are an accepted intervention for these casualties. Combat Medics, civilian prehospital care providers, and lay civilians have demonstrated proficiency with supraglottic airways. However, the Combat Lifesaver (CLS) course includes no instruction on their use. OBJECTIVE The purpose of this study was to assess feasibility of instructing CLS students to use a supraglottic airway (the King LT-D); compare their timed performance with that of Special Operations Combat Medics (SOCM); and assess their confidence utilizing the device. METHODS After standardized instruction, students were timed and evaluated in the placement of a King LT-D in a manikin. Student confidence was assessed by Likert-scaled surveys, and free response remarks collected before and after training. RESULTS 27 of 28 CLS students successfully used a King LT-D airway device in under 60 seconds following brief instruction. Placement times were not significantly different from those of SOCM. Self-rated confidence scores improved from an initial 1.4/5 to 4.9/5 following manikin trials. Both CLS and SOCM recommended the airway for future battlefield CLS use. CONCLUSIONS CLS students are capable and confident in the use of a supraglottic airway device after only brief instruction.