Veronika Engel

Microlaparoscopic-assisted gastrostomy in children: early experiences with our technique.

INTRODUCTION The aim of this prospective study was to evaluate the feasibility and safety of a new technique for microlaparoscopic-assisted gastrostomy (MAG) in children and infants by using a 1.9-mm scope only. In this paper, we report our early experiences with this method. MATERIALS AND METHODS In a prospective study, MAG was performed on 12 children (7 boys and 5 girls) after a primary percutaneous endoscopic gastrostomy procedure was considered not feasible or unsafe. The median patient age at the time of surgery was 1.2 years (range, 4 months to 4 years). A 1.7- or 1.9-mm 0-degree scope was introduced at the umbilicus. A 5-mm port was placed over the stomach at the designated site for the tube placement. The stomach was grasped and exteriorized. The gastrostomy was opened, and a balloon gastrostomy tube was placed. RESULTS In 12 children, the procedure was successfully completed without conversions. Mean operative time was 19 minutes (range, 13-35). No intraoperative complications occurred. Feeds were instituted 5 hours postoperatively and quickly advanced the following day in 11 of 12 children. The procedure may be performed as day surgery. CONCLUSIONS In our opinion, MAG is a feasible, safe procedure in children. Technically, it is a simple method, particularly in cases where percutaneous tube placement is not feasible. It combines the advantages of microlaparoscopy and open surgery. It is easy to perform in children and allows a primary gastrostomy tube placement. Parents and nursing staff also seem satisfied.

Microlaparoscopic Cholecystectomy with an Unorthodox Scope Position

PURPOSE We report our initial experiences with microlaparoscopic cholecystectomy (MLCE) in children using a 2.4-mm mini-scope placed to the right of the umbilicus. The umbilicus was used as the working trocar for large-diameter instruments. METHODS The mini-scope was inserted 2-3 cm to the right to the umbilicus and slightly above the umbilical line. A miniport for the 2-mm grasper was inserted laterally through the right abdominal wall, and a 5-mm working trocar was inserted infra-umbilically. The three-angle principle of laparoscopic instrumentation remained, as the trocar positions were merely shifted to the right side of the abdominal wall. With the patient in the supine position, the surgeon stood on the left side of the patient, facing the monitor. RESULTS MLCE was successfully performed in 12 children (average age: 15 years, average body weight: 46.4 kg). In two cases, the optic trocar was repositioned one cm laterally, because the initial trocar position was too close to the umbilicus and was colliding with the 5-mm instruments. The view at the cystohepatic triangle was sufficient. There were no specific complications due to the rearranged trocar positions or the use of a mini-scope. It was possible to displace the scope out of the umbilical area without compromising the superior cosmesis allowed by using only miniports. CONCLUSION Based on our early experiences, MLCE is safe and feasible. This technique helps reduce the access trauma and operative time while allowing for superior cosmesis.

A Microlaparoscopically Assisted Pull-Through Procedure for Hirschsprung's Disease: Initial Experiences

PURPOSE The purpose of this prospective study was to evaluate the efficiency, feasibility, and surgical outcomes of microlaparoscopy-assisted pull-through (MAPT) for Hirschsprungs disease. METHODS Starting in 2005, pull-through procedures for Hirschsprungs disease were performed exclusively using 2-mm instruments and miniscopes (microlaparoscopy). Three miniports were inserted laterally in the right abdominal wall in one line, with the miniscope at the level of the umbilicus and the working trocars cranially/caudally of the scope. The left colon was dissected, and transanal pull-through was performed. RESULTS MAPT was performed in 16 children (10 boys and 6 girls; average age: 5.7 months). Six patients had previous abdominal surgeries. A 1.9-mm cystoscope or a 2.4-mm arthroscope was used in the first 5 cases. In the remainder, a recently developed 2.4-mm miniscope was used for visualization. The length of the resected colon segment was up to the left colonic flexur in 5 children, up to the middle of the descending colon in 4 cases and up to the sigmoid-descending segment in 7 children. The average operation time was 185 minutes (range: 120-330 minutes). The only intraoperative complication that occurred was an injury of the right iliac vein by inadvertent slippage of an electrocautery hook requiring laparotomy. At follow-up, 80% of the parents were unable to identify the scars after microlaparoscopy. CONCLUSION MAPT is a safe and practical procedure regardless of age or previous surgery.

Small omphalocele with umbilical evagination of the bladder: a distinct entity?

A neonatal case of umbilical evagination of the bladder combined with a small omphalocele is presented. This rare congenital malformation has previously been described in only three cases. Umbilical evagination can be understood as a disturbance of development of both the vitelline and allantoic ducts, resulting in a non-descended but otherwise normal bladder opening to the inferior margin of a small omphalocele. Diagnosis is made by clinical inspection and ultrasound. Since other malformations are not present, this entity may be regarded as a minor form of a lower midline defect with excellent prognosis.

A case report of laparoscopic duodenal atresia repair in a neonate using a novel miniature stapling device

Highlights • Laparoscopic duodenal atresia repair is a technically demanding procedure.• First report a case of laparoscopic duodenal atresia repair in a neonate using a novel miniature stapling device.• Safe, quick and easier way to perform laparoscopic duodenal atresia repair.

Intralesional Endoscopy and Septectomy as a Diagnostic Tool and Treatment Method for Lymphatic Malformations

Sclerotherapy and surgery are both effective treatment methods for lymphatic malformations.1,2 However, recurrence due to incomplete resection is a common problem, often necessitating multiple treatment sessions.2 Intralesional endoscopy has been described as a diagnostic approach and potential therapeutic tool.1,3 We report a case of a 12-year-old male patient who presented with a mainly subcutaneous mixed lymphatic malformation located on the right flank (►Fig. 1). After suffering a direct trauma, the lesion had increased markedly in size and surgical interventionwas indicated due to the associated pain. Intralesional endoscopy was performed that showed a mixed macro-/microcystic lymphatic malformation with hemorrhage (►Fig. 2). Intercystic septa were dissected under endoNew Insights and the Importance for the Pediatric Surgeon

Laser Doppler spectroscopy of testes after unilateral orchiopexy

OBJECTIVE Undescended testes are the most common urogenital malformation in boys. Impaired microcirculation is among other factors addressed as a potential complication of surgery and scar formation, leading to long-term suboptimal results. OBJECTIVE Our aim was to compare the postoperative microcirculation in operated versus non-operated contralateral testis groups after unilateral orchiopexies versus a healthy control cohort. METHODS Ninety-nine consecutive patients were included after unilateral orchiopexy procedures at the age of 3.5 years (±2.9 years) at a single center for pediatric surgery. Eight-five patients were examined with a combination of laser Doppler (blood flow determination) and white-light spectroscopy (oxygen saturation and hemoglobin amount determinations) to determine the microcirculation at two different depth levels non-invasively. All relevant surgery data were obtained retrospectively. RESULTS The right side was operated in 53.5% of cases. Previous hormone treatment had been prescribed in 46.5%. There were no significant differences in perfusion measurements between patients with previous hormone therapy and patients without. There was no significant difference in age and clinical pubertal stage between groups; however, 65% of patients underwent surgery after their second birthday. When comparing oxygen saturation (So2), relative hemoglobin (rHb), flow, and velocity in the operated testis with the contralateral testis of the same patients, we found significantly higher flows and velocities for the contralateral testes (p = 0.041, p = 0.022). Similar higher flows and velocities were found in the healthy controls (p < 0.001). The differences between healthy controls and contralateral testis that were not operated on did not reach statistical significance. There was no difference in measurements at 2 mm depth (skin and subcutaneous tissue) between groups to rule out systemic or capillary differences. DISCUSSION Important limitations include the limited and relatively heterogeneous samples that were obtained for follow-up and retrospective surgery data collection. An additional limitation is missing presurgical data, which we hope to obtain in future studies. Hormonal data or bone age could not be obtained for study reasons. The age in our study was on average above the recommended age for orchiopexy in Germany (6-12 months), which could also restrict generalizability. In terms of complications, we observed reascending testes within the range but a rather high incidence of wound infections. The combination of Doppler and white-light spectroscopy was easily applicable and produced reliable data at 2 and 8 mm depth simultaneously in a standardized setting. CONCLUSIONS After orchiopexy, differences were found in the microcirculation between the operated and contralateral testes or healthy controls. It remains unclear if this is an effect of primary disease or surgery. The microcirculation of contralateral testes was also seemingly different from controls. This is most likely not a consequence of surgery alone, but a common problem for both testes in the affected patients.

1043 Evaluation of Pediatric Testes After Surgery by Laser Doppler and White Light Spectroscopy

Aim To evaluate testes after unilateral orchiopexy Laser Doppler and white light spectroscopy and compare microcirculation with contralaterat testis and healthy controls. Methods A combination of the laser Doppler (determination of blood flow) and white light spectroscopy (determination of oxygen saturation and hemoglobin amount) is used to determine microcirculation at two different depth levels non-invasively. Patients were recruited after unilateral orchiopexy. Controls were age-matched boys without relevant disease. Ethical approval was obtained. Results 99 patients were included after unilateral orchiopexy at the age of 3.5 years (+-2.9 years). 65% underwent surgery after their second birthday. Follow-up was at median 2.5 years after surgery (3months – 10.5 years). Controls were 29 boys at the age of median 6.3 years (3 month–13 years). There was no significant difference in age between both groups. 85 patients were examined on the operated side with laser doppler and white light spectroscopy. Significant higher flow and velocity were found contralateral (p=0.041, p=0.022). Surprisingly, when comparing the contralateral testes in patients after orchiopexy with healthy controls, flow and velocity were significantly higher in the healthy controls (p<0.001), even though this testis was previously not operated on. Conclusion After orchiopexy, expected differences were found in microcirculation between the operated and contralateral testes or healthy controls. Surprisingly, the contralateral testes’ microcirculation was also significantly different from controls. This is probably not a consequence of surgery alone, but more likely a common problem of both testes in the affected patients.