Steven S. Rothenberg

Experience with 220 consecutive laparoscopic nissen fundoplications in infants and children

BACKGROUND/PURPOSE Fundoplication for gastroesophageal reflux disease is a common procedure performed in infants and children. This report describes a 4-year experience with 220 consecutive laparoscopic Nissen fundoplications. METHODS Ages ranged from 5 days to 18 years and weight from 1.4 to 100 kg. The procedures were performed using a five-trocar technique and with 5- or 3.4-mm instruments depending on the size of the patient. RESULTS Two hundred eighteen fundoplications were completed successfully. Average operative time dropped dramatically from 109 to 55 minutes for the first 30 cases compared with the last 30. Intraoperative and postoperative complication rates were 2.6% and 7.3%, respectively. Average time to discharge postfundoplication was 1.6 days. The wrap failure rate is 3.4%. CONCLUSIONS This study shows that although the learning curve for laparoscopic fundoplication may be steep, the procedure is safe and effective in the pediatric population. The clinical results are comparable to the traditional open fundoplication but with a significant decrease in morbidity and hospitalization.

First decade's experience with thoracoscopic lobectomy in infants and children

PURPOSE This study evaluates the safety and efficacy of thoracoscopic lobectomy in infants and children. METHODS From January 1995 to March 2007, 97 patients underwent video-assisted thoracoscopic lobe resection. Ages ranged from 2 days to 18 years and weights from 2.8 to 78 kg. Preoperative diagnosis included sequestration/congenital adenomatoid malformation (65), severe bronchiectasis (21), congenital lobar emphysema (9), and malignancy (2). RESULTS Of 97 procedures, 93 were completed thoracoscopically. Operative times ranged from 35 minutes to 210 minutes (average, 115 minutes). There were 19 upper, 11 middle, and 67 lower lobe resections. There were 3 intraoperative complications (3.1%) requiring conversion to an open thoracotomy. Chest tubes were left in 88 of 97 procedures for 1 to 3 days (average, 2.1 days). Hospital stay ranged from 1 to 12 days (average, 2.4 days). CONCLUSIONS Thoracoscopic lung resection is a safe and efficacious technique. It avoids the inherent morbidity of a major thoracotomy incision and is associated with the same decrease in postoperative pain, recovery, and hospital stay as seen in minimally invasive procedures.

Experience with modified single-port laparoscopic procedures in children.

PURPOSE The aim of this study was to determine the safety and efficacy of limited-access laparoscopic procedures in children by using a modified single-port access (SPA) technique. METHODS A number of different basic laparoscopic procedures were attempted by using a modified 8-mm operating laparoscope with a 4-mm, 6-degree lens and an incorporated 5-mm operating channel. The operating scope was placed though an umbilical incision. The majority of cases also involved the use of a 3-mm instrument placed through a separate stab-wound incision or 3-mm port. Patient age ranged from 9 months to 16 years and weight from 7 to 60 kg. Procedures included laparoscopic cholecystectomy in 10, appendectomy in 8, enterolysis in 2, ovarian cystectomy in 1, and inguinal hernia repair in 15 patients. RESULTS All procedures, except one, were successfully completed by using the SPA technique. A hernia repair in a 15-year-old male was converted to a three-port laparoscopic repair, because the operating scope could not adequately access the area. Operative times were longer than comparable procedures if using a standard laparoscopic approach, but a statistical analysis was not performed. There were no operative or postoperative complications. CONCLUSIONS A modified SPA technique appears to be a safe, viable alternative to a standard laparoscopic approach for some procedures in children. The primary advantage is cosmetic. Visualization and tissue manipulation are more difficult and time consuming. The addition of a single 3-mm instrument at a separate site allows for easier dissection and triangulation, with almost no visible scarring. This may be more beneficial than creating a single 20-mm incision in the umbilicus with multiple ports, with nearly the same cosmetic result.

Laparoscopic Ladd's Procedure in Infants With Malrotation

PURPOSE This clinical study was undertaken to examine the feasibility of a laparoscopic approach for the treatment of documented malrotation. METHODS From May 1994 through January of 1997, 12 patients, aged 5 days to 4 months, weighing 3 to 7 kg, underwent laparoscopic Ladds procedure for malrotation. All patients had symptoms of intermittent upper intestinal obstruction, and malrotation was documented by an upper gastrointestinal contrast study. None of the patients had acute volvulus or compromised bowel. The procedure was performed using 3 trocars of 3.5 mm diameter. Ports were placed in the infraumbilical ring, and the right and left mid to lower quadrants. A standard Ladds procedure with appendectomy was performed in all cases. RESULTS All procedures were completed successfully through the laparoscope. Operative times averaged 58 minutes (35 to 120 minutes). One patient with Pierre-Robin underwent a laparoscopic Nissen fundoplication and gastrostomy tube placement at the same time requiring 120 minutes. Feedings were started on postoperative day (POD) 1 in 10 cases and POD 2 in two cases. Hospital stay ranged from 2 to 4 days (average, 2.2) in the patients with isolated malrotation. The patient with Pierre-Robin had a prolonged hospitalization because of chronic respiratory problems not associated with surgery. There were no complications. All patients had resolution of their symptoms. CONCLUSIONS Laparoscopic Ladds procedure is a safe and effective technique. It can be performed in neonates in times equivalent to standard open techniques, and it appears to allow for earlier feeds and decreased hospital stays.

Thoracoscopic lung resection in children

PURPOSE The aim of this study was to evaluate the technique of video-assisted thoracic surgery (VATS) in lung resections in infants and children. METHODS From December 1992 to December 1998 113 consecutive patients, ages 3 weeks to 19 years, underwent VATS for biopsy or resection of various lung pathology. This included 88 wedge biopsies, 12 resections of bullous or cystic disease, 9 lobectomies or segmental resections, and 4 bronchogenic cysts. RESULTS All procedures were completed successfully. Two patients with metastatic disease had surgery converted to a standard thoracotomy for extensive resections. The average operating time for a wedge biopsy of 2 sites was 26 minutes and 210 minutes for a lobectomy. The average hospital stay after wedge resection was 1.1 days. There were no complications related to the VATS approach. CONCLUSION VATS is a safe and effective technique in the diagnosis and treatment of pediatric pulmonary disease.

Primary laparoscopic placement of gastrostomy buttons for feeding tubes. A safer and simpler technique.

AbstractBackground: During a 4-year period, 240 gastrostomy buttons were placed in children, as the initial surgical feeding tube, using laparoscopic techniques. Materials and methods: The technique requires the use of a minilaparoscope (1.6-mm) and a single 5-mm trocar placed at the exit site for the gastrostomy button. It can also be performed in addition to a laparoscopic fundoplication using the same trocar sites. The technique requires no special instrumentation or kits. When performed alone, operative times average 15 min. When performed with fundoplication, it adds ∼5–10 min to the time for the procedure. Results: There were no intraoperative complications and five (2.1%) postoperative complications. Conclusions: This technique has proven to be simple and effective. It allows primary placement of a gastrostomy button that is cosmetically and functionally superior to a gastrostomy tube.

Experience with minimally invasive surgery in infants

BACKGROUND This study evaluates the feasibility, safety, and efficacy of performing advanced endoscopic procedures in infants under 5 kg. METHODS Over a 51-month period 183 infants weighing 1.3 to 5.0 kg underwent 195 procedures using minimally invasive techniques. The majority of the procedures were performed using 3.5-mm instruments and 2.7-mm scopes. Procedures include Nissen fundoplication, pyloromyotomy, colon pull-through, patent ductus arteriosus closure, Ladds procedure, colon resection, congenital diaphragmatic hernia repair, ovarian cyst excision, and exploration. RESULTS All but two procedures were completed successfully endoscopically. There were two intraoperative complications and no mortality. Days to discharge for patients admitted for their specific procedure were Nissen 2.1, patent ductus arteriosus 2, pyloromyotomy 1, and pull-through 3.4. CONCLUSIONS This study demonstrates that advanced endosurgical techniques in infants is safe, effective, and associated with the same benefit as that seen in older patients.

Thoracoscopic closure of patent ductus arteriosus: A less traumatic and more cost-effective technique

The authors have developed a technique of thoracoscopic closure of patent ductus arteriosus (PDA) that significantly reduces the surgical morbidity, recovery time, and hospital costs traditionally associated with the standard open procedure. Ten patients have undergone the procedure, with nine completed successfully. One patient required conversion to an open thoracotomy. There were no operative complications, and closure of the ductus was confirmed in all cases with a postoperative echocardiogram. Eight of ten patients were discharged in under 24 hours, and hospital charges were on the average 30% to 40% less.

Thoracoscopic Lobectomy in Infants Less Than 10 kg with Prenatally Diagnosed Cystic Lung Disease

PURPOSE Thoracoscopic lobectomy for congenital cystic lung lesions is an accepted technique in pediatric surgery. Since an increasing number of these lesions are detected prenatally, the safety and efficacy of infant resections have been questioned. We reviewed our experience over a 10-year period to evaluate early resection of these lesions. METHODS From January 2001 to August 2009, 75 patients under 1 year of age and weighing <10 kg underwent thoracoscopic lobectomy at two institutions. Patients carried the following diagnoses: 52 had congenital cystic adenomatoid malformation, 20 had bronchopulmonary sequestration, and 3 had congenital lobar emphysema. All lesions were confirmed after birth by computed tomography scan. Patient age at operation ranged from 4 days to 11 months and patient weight from 3.1 to 10 kg. RESULTS Seventy-four of 75 lobectomies were thoracoscopically completed. There were 16 upper lobectomies, 1 middle lobectomy, and 55 lower lobectomies. Operative time ranged from 45 to 225 minutes. Hospital length of stay ranged from 1 to 5 days. A subset of 26 patients had surgery younger than 3 months of age and <5 kg, despite being asymptomatic. Their operative time averaged 90 minutes, and mean length of hospital stay was 1.5 days. CONCLUSION Thoracoscopic lobectomy is safe for infants <10 kg and avoids the morbidity associated with thoracotomy. Operating early on younger patients may avoid the inflammatory changes associated with both clinically apparent and subclinical infections, even in patients weighing <5 kg. This may make the procedures less technically challenging and may result in lower complication and conversion rates.

Laparoscopic fundoplication to enhance pulmonary function in children with severe reactive airway disease and gastroesopheagal reflux disease

AbstractBackground: The relationship between severe reactive airway disease (RAD) and gastroesophageal reflux disease (GERD) has been noted but the relationship is poorly understood. This study reports our experience with laparoscopic fundoplication and its effect on the pulmonary status of children with severe steroid-dependent reactive airway disease. Methods: Fifty-six patients with severe steroid-dependent RAD and medically refractory GERD underwent laparoscopic Nissen fundoplications. Mean age was 7 years and mean weight was 20 kg. All patients had the procedure completed successfully laparoscopically with an average operative time of 62 min. Average hospital stay was 1.6 days. Results: Forty-eight of 56 patients noted significant improvement in their respiratory symptoms in the first week. Fifty of 56 patients have been weaned off their oral steroids and four others have had a greater than 50% decrease in their dose. Sixteen patients had a documented increase in their FEV1 in the initial postoperative period (avg. 26%). Conclusion: Patients with steroid-dependent RAD and GERD refractory to medical management show improvement in their respiratory status following fundoplication and the majority can be weaned off of their oral steroids. Laparoscopic techniques allow this procedure to be performed safely even in this high-risk group of patients.