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Comparison of subcutaneous analgesic system and epidural analgesia for postoperative pain control in open pediatric oncology operations: A randomized controlled trial. J Pediatr Surg 2023; 58:153-160. [PMID: 36283845 DOI: 10.1016/j.jpedsurg.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 09/16/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE Children undergoing open oncologic surgery can have significant post-operative pain. The purpose of this trial was to compare a surgeon-placed subcutaneous analgesic system (SAS) to epidural analgesia. METHODS Single center randomized controlled trial including children ≤18 years undergoing open tumor resection between October 2018 and April 2021. Randomization to SAS or epidural was done preoperatively and perioperative pain management was standardized. Families were blinded to the modality. Comparisons of oral morphine equivalents (OME) and pain scores for three postoperative days, clinical outcome parameters, and parental satisfaction following unblinding were completed using non-parametric analyses. RESULTS Of 36 patients (SAS 18, Epidural 18), median age was 5 years (range <1-17). The Epidural cohort had less OME demand on postoperative day one (SAS 0.76 mg/kg, Epidural 0.11 mg/kg; p<0.01) and two (SAS 0.48 mg/kg, Epidural 0.07 mg/kg, p = 0.03). Pain scores were similar on postoperative days 1-3 (0-2 in both groups). The Epidural cohort had more device complications (SAS 11%, Epidural 50%; p = 0.03) and higher urinary catheter use (SAS 50%, Epidural 89%; p = 0.03). More than 80% of parents would use the same device in the future (SAS 100%, Epidural 84%, p = 0.23). CONCLUSION For children undergoing open oncologic abdominal or thoracic surgery, early post-operative pain control appears to be better with epidural analgesia; however, SAS has decreased incidence of device complications and urinary catheter use. Parental satisfaction is excellent with both modalities. SAS could be considered as an alternative to epidural, especially in settings when epidural placement is not available or contraindicated. TYPE OF STUDY Treatment study, Randomized controlled trial. LEVEL OF EVIDENCE Level 1.
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Landman MP, Billmire D. Umbilical access in laparoscopic surgery in infants less than 3 months of age: A survey of the American Pediatric Surgical Association. J Pediatr Surg 2020; 55:2094-2098. [PMID: 32147235 DOI: 10.1016/j.jpedsurg.2020.01.055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 12/03/2019] [Accepted: 01/29/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Laparoscopy is commonplace in pediatric surgery. Abdominal access via the umbilicus may present a unique challenge in neonates and young infants predisposing them to complications. We hypothesized that these complications may occur more than described in the literature. METHODS Members of the American Pediatric Surgical Association (APSA) were anonymously surveyed in February of 2018 via REDCap™ regarding technique of umbilical access in infants less than 3 months of age and complications experienced during umbilical access. Approval was obtained from the IRB and the APSA Outcomes and Evidence-based Practice Committee. RESULTS The response rate was 31.3% (329/1050). 62.3% of respondents performed 21 or greater neonatal laparoscopic procedures annually. 34 of 322 respondents reported a direct complication from umbilical access for laparoscopy in this age group (10.6%). Surgeons described 37 specific cases with complications related to umbilical access, with laparoscopic pyloromyotomy making up 47.2% (17/36). CO2 embolism was the most common complication; 15.4% of surgeons reported not knowing about the possibility of CO2 embolism. 41% of surgeons confirm intraabdominal placement of the umbilical trocar prior to insufflation. There was no association between any complication and where the umbilical trocar was placed (above/below/through umbilicus) or placement technique in patients with no umbilical cord stump. There may be an association between complication and where the umbilicus is entered in patients with an umbilical cord stump still in place (p = 0.013). CONCLUSIONS Umbilical access for laparoscopy in neonates and infants less than 3 months of age can present a unique challenge and result in significant complications. All techniques and methods had complications. Surgeons should be aware of these risks and be prepared to manage them emergently if they arise. LEVEL OF EVIDENCE V, expert opinion.
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Affiliation(s)
- Matthew P Landman
- Indiana University, Department of Surgery, Division of Pediatric Surgery, Indianapolis, IN.
| | - Deborah Billmire
- Indiana University, Department of Surgery, Division of Pediatric Surgery, Indianapolis, IN
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Babb J, Davis J, Tashiro J, Perez EA, Sola JE, Pandya S. Laparoscopic Versus Open Cholecystectomy in Pediatric Patients: A Propensity Score-Matched Analysis. J Laparoendosc Adv Surg Tech A 2020; 30:322-327. [PMID: 32045322 DOI: 10.1089/lap.2019.0655] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Background: As minimally invasive pediatric surgery becomes standard approach to many surgical solutions, access has become an important point for improvement. Laparoscopic cholecystectomy (LC) is the gold standard for many conditions affecting the gallbladder; however, open cholecystectomy (OC) is offered as the initial approach in a surprisingly high percentage of cases. Materials and Methods: The Kids' Inpatient Database (1997-2012) was searched for International Classification of Disease, 9th revision, Clinical Modification procedure code (51.2x). LC and OC performed in patients <20 years old were identified. Propensity score-matched analyses using 39 variables were performed to isolate the effects of race, income group, location, gender, payer status, and hospital size on the percentage of LCs and OCs offered. Cases were weighted to provide national estimates. Results: A total of 78,578 cases were identified, comprising LC (88.1%) and OC (11.9%). Girls were 1.6 (CI: 1.4, 1.7) times more likely to undergo LC versus boys. Large facilities were 1.4 (1.3, 1.7) times more likely to perform LCs than small facilities. Children in lower income quartiles were 1.2 (1.1, 1.3) times more likely to undergo LC compared with those in higher income quartiles. Rates of LC were not affected by race, hospital location, or payer status. Conclusions: Risk-adjusted analysis of a large population-based data set demonstrated evidence that confirms, but also refutes, traditional disparities to minimally invasive surgery access. Despite laparoscopic gold standard, OC remains the initial approach in a surprisingly high percentage of pediatric cases independent of demographics or socioeconomic status. Additional research is required to identify factors affecting the distribution of LC and OC within the pediatric population.
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Affiliation(s)
- Jaqueline Babb
- Department of Surgery, UT Southwestern Medical Center, Dallas, Texas
| | - James Davis
- Department of Surgery, University of North Texas Health Science Center, Dallas, Texas
| | - Jun Tashiro
- Department of Surgery, Children's National Medical Center, Washington, District of Columbia
| | | | - Juan E Sola
- Department of Surgery, University of Miami, Miami, Florida
| | - Samir Pandya
- Department of Surgery, UT Southwestern Medical Center, Dallas, Texas
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Kwon H, Lee JY, Cho YJ, Kim DY, Kim SC, Namgoong JM. How to safely perform laparoscopic liver resection for children: A case series of 19 patients. J Pediatr Surg 2019; 54:2579-2584. [PMID: 31575411 DOI: 10.1016/j.jpedsurg.2019.08.030] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Accepted: 08/24/2019] [Indexed: 11/19/2022]
Abstract
PURPOSE The purpose of this study was to determine the feasibility and outcome of laparoscopic hepatectomy in pediatric patients with liver tumors and introduce surgical techniques to minimize complications. METHODS This was a retrospective study of 19 patients less than the age of 18 years old who underwent LLR for liver tumors between November 2005 and May 2017. RESULTS Ten females and nine males with a median age of 26 months and a median body weight of 14.7 kg were enrolled. Diseases of these patients were hepatoblastoma, neuroblastoma, biliary atresia, and liver abscess. The numbers of resected hepatic segments were more than two in thirteen patients and one in six patients. One patient required conversion to laparotomy to control bleeding caused by injury to the left hepatic vein. Nine patients received transfusions perioperatively. Median duration of operation was 230 min, and median postoperative hospital stay was 7.0 days. There was no postoperative complication. Only one patient showed nonhepatic recurrence of neuroblastoma which caused mortality. CONCLUSIONS LLR for benign and malignant liver tumors showed acceptable amount of bleeding and low complication rate. Therefore, LLR would be a safe and feasible option for liver tumors in children with proper technical efforts and selection of patients. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Hyunhee Kwon
- Division of Pediatric Surgery, Asan Medical Center Children's Hospital, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ju Yeon Lee
- Department of Pediatric Surgery, Chonnam National University Children's Hospital, Republic of Korea
| | - Yu Jeong Cho
- Division of Pediatric Surgery, Asan Medical Center Children's Hospital, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dae Yeon Kim
- Division of Pediatric Surgery, Asan Medical Center Children's Hospital, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Seong Chul Kim
- Division of Pediatric Surgery, Asan Medical Center Children's Hospital, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jung-Man Namgoong
- Division of Pediatric Surgery, Asan Medical Center Children's Hospital, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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5
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Nolan H, Glenn J. Minimally Invasive Pediatric Cholecystectomy: A Comparison of Robotic and Laparoscopic Single and Multiport Techniques. J Laparoendosc Adv Surg Tech A 2018; 28:770-773. [PMID: 29432055 DOI: 10.1089/lap.2017.0532] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Pediatric laparoscopic cholecystectomy is the current standard of care for gallbladder pathology. Single-incision and multiport procedures, as well as robotic and minimally invasive platforms, have been described; however, there is no head-to-head assessment of these interventions in the existing literature. The purpose of our study was to directly compare the minimally invasive cholecystectomy techniques of laparoscopic multiport (LMP), laparoscopic single incision (LSI), robotic multiport (RMP), and robotic single incision (RSI). MATERIALS AND METHODS All cholecystectomies performed by a single surgeon at a tertiary-care center from 2010 to 2014 were retrospectively reviewed. Seventy-one subjects were included as follows: 30 LMP, 20 LSI, 11 RMP, and 10 RSI. Data were collected on patient characteristics, operative technique, operative times, medications, and postoperative course and analyzed using a Kruskal-Wallis test with a significance of P < .05. RESULTS Operative times for LMP and RSI were similar and shortest of all groups, while LSI was the most time consuming (P = .04). Pain medication use, both narcotic and non-narcotic, was not statistically different with any operation type (P = .37 and .98, respectively). Postoperative length of stay was similar across all groups except for the RSI group which was significantly shorter (P = .04). CONCLUSIONS RSI cholecystectomy has significantly shorter postoperative length of stay compared to other minimally invasive techniques. In addition, operative times for RSI are equivalent to the current standard LMP technique.
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Affiliation(s)
- Heather Nolan
- Mercer University School of Medicine/The Medical Center Navicent Health , Macon, Georgia
| | - Joshua Glenn
- Mercer University School of Medicine/The Medical Center Navicent Health , Macon, Georgia
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Chu DI, Tan JM, Mattei P, Costarino AT, Rossano JW, Tasian GE. Mortality and Morbidity after Laparoscopic Surgery in Children with and without Congenital Heart Disease. J Pediatr 2017; 185:88-93.e3. [PMID: 28410089 PMCID: PMC5529241 DOI: 10.1016/j.jpeds.2017.02.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 12/15/2016] [Accepted: 02/06/2017] [Indexed: 02/04/2023]
Abstract
OBJECTIVES To determine the risk of morbidity and mortality after laparoscopic surgery among children with congenital heart disease (CHD). STUDY DESIGN Cohort study using the 2013-2014 National Surgical Quality Improvement Program-Pediatrics, which prospectively collected data at 56 and 64 hospitals in 2013 and 2014, respectively. Primary exposure was CHD. Primary outcome was overall in-hospital postoperative mortality. Secondary outcomes included 30-day mortality and 30-day morbidity (any nondeath adverse event). Among 34?543 children who underwent laparoscopic surgery, 1349, 1106, and 266 had minor, major, and severe CHD, respectively. After propensity score matching within each stratum of CHD severity, morbidity and mortality were compared between children with and without CHD. RESULTS Children with severe CHD had higher overall mortality and 30-day morbidity (OR 12.31, 95% CI 1.59-95.01; OR 2.51, 95% CI 1.57-4.01, respectively), compared with matched controls. Overall mortality and 30-day morbidity were also higher among children with major CHD compared with children without CHD (OR 3.46, 95% CI 1.49-8.06; OR 2.07, 95% CI 1.65-2.61, respectively). Children with minor CHD had similar mortality outcomes, but had higher 30-day morbidity compared with children without CHD (OR 1.71, 95% CI 1.37-2.13). CONCLUSIONS Children with major or severe CHD have higher morbidity and mortality after laparoscopic surgery. Clinicians should consider the increased risks of laparoscopic surgery for these children during medical decision making.
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Affiliation(s)
- David I. Chu
- Department of Surgery, Division of Urology, The Children’s Hospital of Philadelphia Philadelphia, PA
| | - Jonathan M. Tan
- Department of Anesthesia and Critical Care Medicine, Division of General Anesthesiology, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Peter Mattei
- Department of Surgery, Division of General, Thoracic, and Fetal Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Andrew T. Costarino
- Department of Anesthesia and Critical Care Medicine, Division of Cardiac Critical Care Medicine, The Children’s Hospital of Philadelphia Philadelphia, PA
| | - Joseph W. Rossano
- Department of Cardiology, Cardiac Center, The Children’s Hospital of Philadelphia, Philadelphia, PA,Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Gregory E. Tasian
- Department of Surgery, Division of Urology, The Children’s Hospital of Philadelphia Philadelphia, PA,Center for Pediatric Clinical Effectiveness, The Children’s Hospital of Philadelphia, Philadelphia, PA,Department of Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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7
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Tejwani R, Young BJ, Wang HHS, Wolf S, Purves JT, Wiener JS, Routh JC. Open versus minimally invasive surgical approaches in pediatric urology: Trends in utilization and complications. J Pediatr Urol 2017; 13:283.e1-283.e9. [PMID: 28344019 PMCID: PMC5483194 DOI: 10.1016/j.jpurol.2017.01.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 01/07/2017] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Minimally invasive surgery (MIS) techniques are anecdotally reported to be increasingly used, but little objective data supports this. Our objective was to assess trends in MIS utilization across various procedures in pediatric urology and to compare postoperative complication rates between MIS and open procedures. METHODS We analyzed the 1998-2012 Nationwide Inpatient Sample. We identified children (<18 years old) undergoing open and MIS inpatient procedures and any in-hospital post-operative complications that occurred during that postoperative hospitalization. We utilized propensity score matching and multivariable logistic regression to adjust for confounding factors. RESULTS We identified 163,838 weighted encounters in the "overall cohort," 70,273 of which were at centers performing more than five MIS procedures over the years studied. Use of MIS techniques increased significantly over time for several procedures, most prominently for nephrectomy (Fig.). The overall rate of complications was lower in patients undergoing MIS compared with open surgery (6% vs. 11%, p < 0.001). Specialized centers had a significantly lower overall rate of complications than unspecialized centers (9% vs. 12%, p < 0.001). Within specialized centers, MIS had lower complication rates than open procedures (7% vs. 9%, p < 0.001); this finding was consistent even after adjusting for other factors (OR 0.71, p = 0.02). DISCUSSION Limitations include that these data may not be generalizable to encounters not in the sample pool. As a large, retrospective, administrative database, NIS may be affected by miscoding bias - rendering our analysis sensitive to the accuracy of procedure coding in NIS. Although the accuracy level of NIS is high for an administrative database, it is possible at least some portion of our cohort may be incorrectly coded. Further, the NSQIP complications we identified may represent associated comorbidities and not true postoperative complications, as NIS does not provide temporal relationships between different diagnosis codes. Despite these limitations, we note that the NIS database is rigorously monitored and audited for coding accuracy and, therefore, represents a reasonably reliable panorama of the characteristics of an inpatient surgical cohort. However, it is important to note that the choice of operative modality is, undoubtedly, multifactorial and patient/setting-specific. CONCLUSIONS There is increasing use of MIS for pediatric urology procedures, although utilization rates vary among procedures. MIS was associated with a lower postoperative complication rate than for open procedures. Higher-volume MIS centers have a lower complication rate than lower-volume centers.
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Affiliation(s)
- Rohit Tejwani
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Brian J Young
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Hsin-Hsiao S Wang
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Steven Wolf
- Dept of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - J Todd Purves
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - John S Wiener
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jonathan C Routh
- Division of Urologic Surgery, Duke University Medical Center, Durham, NC, USA.
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Loveland J, Numanoglu A, Hay SA. Pediatric minimally invasive surgery in Africa: limitations and current situation. Semin Pediatr Surg 2012; 21:160-3. [PMID: 22475122 DOI: 10.1053/j.sempedsurg.2012.01.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The second largest and most populous continent, with an exploding pediatric population, Africa has an overwhelming burden on its very limited pediatric surgical services. In an international environment of progressively advancing endoscopic and robotic surgical techniques, the authors focus on the current role of endoscopic surgery on the continent and explore the potential reasons for its delayed acceptance and implementation. They proceed to document the spectrum of what is available and, using their "African experience," expand on financially viable models of further rolling out these techniques, including discussion around suitable training models for surgeons and their teams.
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Affiliation(s)
- Jerome Loveland
- Department of Paediatric Surgery, Baragwanath Hospital, University of the Witwatersrand, Johannesburg, Gauteng, South Africa.
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Stormer EJ, Sabharwal AJ. Review of laparoscopic training in pediatric surgery in the United Kingdom. J Laparoendosc Adv Surg Tech A 2009; 19 Suppl 1:S3-6. [PMID: 19281421 DOI: 10.1089/lap.2008.0002.supp] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIM To review the exposure pediatric surgery trainees have to laparoscopic surgery in the United Kingdom (UK). METHODS A confidential postal questionnaire was sent to all trainees working at registrar level in centers responsible for pediatric surgical training in the UK. Questions assessed the number of consultants with an interest in laparoscopic surgery, types of cases performed laparoscopically, and trainees' role in laparoscopic appendicectomy (LA). RESULTS Questionnaires were sent to 112 trainees with a 55% response rate (62 replies). At least one response was received from each unit. Based on responses, 49 to 67 consultants in 21 training centers have an interest in laparoscopic surgery (0%-100% of consultants per unit). LA was offered in 20 out of 21 training centers. There was no significant difference in the proportion of appendicectomies performed laparoscopically by junior (years 1-3) and senior (years 4-6) trainees. A significantly higher proportion of junior trainees had not performed any LAs (P = 0.02). Seventy-three percent of trainees were the principal operator. For trainees who were principal operators, the cameraperson was a consultant in 52% and a junior trainee in 17%. The time of day affected the likelihood of a procedure being carried out laparoscopically in 43 (81%) responses. CONCLUSIONS The majority of trainees' exposure to laparoscopic surgery could be viewed as suboptimal; however, the exposure gained varies significantly between different units throughout the UK. In an age moving in favor of minimal access surgery, all units must be in a position to offer pediatric laparoscopic surgical training.
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Affiliation(s)
- Emma J Stormer
- Department of Pediatric Surgery, Royal Hospital for Sick Children Yorkhill Glasgow, Glasgow, UK.
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10
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Osthaus WA, Huber D, Bäumker C, Witt L, Metzelder M, Kuebler J, Sümpelmann R. Plasma volume replacement with HES 130/0.42 obviates negative side effects of pneumoperitoneum in piglets. Paediatr Anaesth 2008; 18:922-8. [PMID: 18647273 DOI: 10.1111/j.1460-9592.2008.02694.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Evidence-based guidelines on optimal perioperative fluid management in infants have not been established. Recent randomized trials in major abdominal surgery in adults suggest that large volumes of fluid may increase morbidity and hospital stay. Our own clinical experience in infants undergoing laparoscopic surgery is different. So the aim of this study was to compare a crystalloid vs a plasma volume stabilizing fluid management regime during prolonged pneumoperitoneum (PP) in an experimental setting. METHODS Fifteen German landrace piglets were randomized to one of the following treatment groups: control (no PP, 5 ml x kg(-1) x h(-1) electrolyte solution); crystalloid (180 min of PP, 5 ml x kg(-1) x h(-1) electrolyte solution); colloid (180 min of PP, single bolus of 5 ml x kg(-1) followed by 5 ml x kg(-1) x h(-1) hydroxyethyl starch 130/0.42/6:2). After decompression, monitoring was continued for a further 120 min. During the investigation, the hemodynamic situation including transpulmonary thermodilution and blood gases was monitored periodically. RESULTS During the study, mean arterial pressure remained within the normal range in colloid-treated animals and controls, but was significantly lower in crystalloid-treated animals after decompression of PP. Cardiac output remained within the normal range in the colloid and control groups, but decreased in the crystalloid-treated animals. In the crystalloid group, the lactate concentrations were higher and base excess was lower than in the colloid and control groups at 240 and 300 min (study end). CONCLUSION This study shows that the negative effects of prolonged PP on hemodynamics and acid-base balance can be obviated by a liberal plasma volume stabilization regimen with colloids.
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Affiliation(s)
- Wilhelm Alexander Osthaus
- Klinik für Anästhesiologie und Intensivmedizin, Medizinische Hochschule Hannover, Hannover, Germany.
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Jones VS, Cohen RC. Two decades of minimally invasive pediatric surgery-taking stock. J Pediatr Surg 2008; 43:1653-9. [PMID: 18779002 DOI: 10.1016/j.jpedsurg.2008.01.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2007] [Revised: 01/01/2008] [Accepted: 01/02/2008] [Indexed: 12/20/2022]
Abstract
BACKGROUND The past 2 decades have seen a rapid integration of minimally invasive surgery (MIS) to pediatric surgical practice. This study endeavored to delineate the current status of MIS in pediatric surgery. METHODS Three hundred six pediatric surgeons were invited to participate in an anonymous Web-based survey. Apart from demographic details and opinion regarding robotic surgery, surgeons were asked to choose between "perform MIS," "do not perform MIS but recommend it," and "MIS not indicated" for common pediatric surgical conditions. RESULTS Responses were received from 117 pediatric surgeons (38.2%). Sixty-one percent of respondents did more than 10% of their work using MIS, and 85% had more than 5 years experience in MIS. Cholecystectomy, nonpalpable testis, and exploration for abdominal pain scored highest among the positive recommendations for MIS, whereas liver tumors, biliary atresia, Wilms' tumor, and inguinal hernia scored highest among the negative recommendations for MIS. Fifty-one percent of the respondents had more than 20 years experience as a pediatric surgeon and were categorized as "senior" surgeons. Compared with the young surgeons, the senior surgeons were more likely to recommend MIS as a contraindication for simple and complicated appendicitis, reduction of intussusception, gastrostomy, fundoplication, pyloromyotomy, adhesiolysis, splenectomy, adrenalectomy, nephrectomy for dysplastic kidneys, heminephrectomy, pyeloplasty, anorectal malformations, pyeloplasty, achalasia cardia, hiatal hernia repair, lung resection, and diaphragmatic hernia repair. More than half the respondents believed that robotic surgery has a role for children in the future. CONCLUSIONS A widespread integration of MIS into the pediatric surgical practice is evident from this study. Current practice and recommendations of the surveyed surgeons have been outlined. Significant differences between the young and senior surgeons reflect the evolving nature of the recommendations.
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Affiliation(s)
- Vinci S Jones
- Department of Pediatric Surgery, The Children's Hospital at Westmead, Sydney 2145, NSW, Australia
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Patterns and predictors of laparoscopic complications in pediatric urology: the role of ongoing surgical volume and access techniques. J Urol 2008; 180:681-5. [PMID: 18554647 DOI: 10.1016/j.juro.2008.04.042] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2007] [Indexed: 11/23/2022]
Abstract
PURPOSE Laparoscopic surgery in children has evolved to include complex reconstructive procedures. While complication rates are low, they can have significant consequences. In this study we define the incidence and risk factors for complications in children undergoing laparoscopic urological surgery. MATERIALS AND METHODS We conducted a retrospective analysis of all conventional and robot assisted laparoscopic urological procedures performed at our institution from 1995 to 2005. Complications were graded based on Clavien's classification. Statistical analysis was performed using the t test and Fisher's exact test. RESULTS A total of 806 laparoscopic procedures were evaluated. Overall, there was a 2% complication rate, including 1.6% for access related and 0.7% for procedural complications (in 440 nondiagnostic cases). Complications related to access occurred in 9 of 396 cases (2.3%) using Veress access, compared to 3 of 389 cases (0.8%) using open access (p = 0.14). The incidence of grades III and IV complications was identical between techniques (0.8%). Complications included preperitoneal insufflation sufficient to necessitate conversion to an open procedure (0.7%), vessel injury (0.4%), small bowel injury (0.4%), bleeding requiring conversion (0.1%), bladder perforation (0.1%) and vas deferens injury (0.2%). Surgeons performing more than 12 laparoscopic cases annually had a significantly lower complication rate (p = 0.024). CONCLUSIONS The low risk of complications demonstrated in this series confirms that laparoscopic procedures are safe, although there remains a risk of significant injury. Determinants of surgical outcome include laparoscopic activity, and to a lesser extent access technique. Most if not all complications are preventable with proper adherence to technique and ongoing education.
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Abstract
Laparoscopy for the resection of liver masses in children has remained undeveloped despite the wide acceptance of laparoscopy in the field of pediatric surgery. The authors report a case of nonanatomical laparoscopic hepatic resection of a large mesenchymal hamartoma in a 2-year-old boy. The procedure was performed using an innovative approach with a combination of different technologies that allowed for a safe and precise resection. This case demonstrates the feasibility of a nonanatomical laparoscopic hepatic resection, even for very large tumors. Both technical expertise and use of novel technologies are necessary to ensure a precise and controlled resection.
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Affiliation(s)
- Sanjeev Dutta
- Division of Pediatric Surgery, Department of Surgery, Lucile Packard Children's Hospital, Stanford University Medical Center, Stanford, CA 94305, USA.
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14
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Partrick DA. Prospective evaluation of a primary laparoscopic approach for children presenting with simple or complicated appendicitis. Am J Surg 2006; 192:750-5. [PMID: 17161088 DOI: 10.1016/j.amjsurg.2006.08.039] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2006] [Revised: 08/10/2006] [Accepted: 08/10/2006] [Indexed: 11/16/2022]
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15
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Yoon YS, Han HS, Choi YS, Lee SI, Jang JY, Suh KS, Kim SW, Lee KU, Park YH. Total laparoscopic left lateral sectionectomy performed in a child with benign liver mass. J Pediatr Surg 2006; 41:e25-8. [PMID: 16410084 DOI: 10.1016/j.jpedsurg.2005.10.068] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Despite the increasing number of recent reports on laparoscopic liver resection in adults, there are only rare reports on such a procedure being performed in children. The authors report here on a total laparoscopic left lateral sectionectomy that was performed in a 5-year-old girl who had a cystic tumor of the liver. The operative time was 150 minutes, the estimated blood loss was about 100 mL, and no intraoperative transfusion was required. The patient was discharged on postoperative day 11 without any significant complications. The postoperative pathology of the specimen confirmed it to be a mesenchymal hamartoma of the liver with a disease-free resection margin. This case demonstrates that laparoscopic liver resection can be a safe and feasible operative procedure for the pediatric patient with liver disease.
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Affiliation(s)
- Yoo-Seok Yoon
- Department of Surgery, Seoul National University College of Medicine, Seongnam-si, Gyeonggi-Do, 463-707, Seoul, Korea
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Kalfa N, Allal H, Raux O, Lopez M, Forgues D, Guibal MP, Picaud JC, Galifer RB. Tolerance of laparoscopy and thoracoscopy in neonates. Pediatrics 2005; 116:e785-91. [PMID: 16322135 DOI: 10.1542/peds.2005-0650] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Video-surgery in neonates is recent. Data on the respiratory, hemodynamic, and thermic effects during the first month of life are still sparse. This study aimed to evaluate the tolerance of video-surgery in neonates and to determine the risk factors of per-operative complications. METHODS From 1994 to 2004, 49 neonates (mean age: 11 days; weight: 3285 g) underwent 50 video-surgical procedures. Indications for laparoscopy were duodenal atresias, volvulus with malrotation, pyloric stenosis, gastroesophageal reflux, cystic lymphangiomas, ovarian cysts, biliary atresia, and congenital diaphragmatic hernias; indications for thoracoscopy were esophageal atresias and tracheoesophageal fistula. RESULTS Median operative time was 79 minutes. Mean insufflation pressure was 6.7 mm Hg (range: 3-13). Oxygen saturation decreased, especially with thoracic insufflation or high-pressure pneumoperitoneum. Systolic arterial pressure, which decreased in 20% of the patients, was controlled easily with vascular expansion. Thermic loss (mean postoperative temperature: 35.6 degrees C) was proportional to the duration of insufflation. No surgical incident was noted. Ten anesthetic incidents occurred (20%), 3 of which required temporary or definitive interruption of insufflation (O2 saturation <70%). Risk factors for an incident were low preoperative temperature, high variation of end-tidal pressure of CO2, surgical time >100 minutes, thoracic insufflation, and a high oxygen or vascular expansion requirement at the beginning of insufflation. CONCLUSION The neonate's high sensitivity to insufflation is an important limiting factor of video-surgery. The described profile of the neonate at risk may help to reduce the frequency of adverse effects of this technique and improve its tolerance.
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Affiliation(s)
- Nicolas Kalfa
- Département de Chirurgie Viscérale Pédiatrique, Hôpital Lapeyronie, CHU Montpellier, France
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Ku JH, Byun SS, Choi H, Kim HH. Laparoscopic nephrectomy for congenital benign renal diseases in children: comparison with adults. Acta Paediatr 2005; 94:1752-5. [PMID: 16421035 DOI: 10.1111/j.1651-2227.2005.tb01849.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To compare the results of laparoscopic nephrectomy for congenital benign renal diseases in children and adults. METHODS From August 1996 to February 2003, laparoscopic nephrectomies were performed on 26 children and 60 adults. Of these patients, 33 patients (17 children, 16 adults) with comparable diseases were included in the analysis. RESULTS Disease was on the right side in 16 patients and on the left in 17. Operative and convalescence parameters, including operative time, blood loss, transfusion rate, conversion rate to open surgery, resumption of oral intake, hospital stay, and complication rate, were evaluated in both groups. Median operative time in the paediatric group was 140 min compared to 147.5 in adults (p=0.626). The estimated blood loss was significantly different (median 25 and 75 cm(3) in children and adults, respectively; p<0.001). Other operative and convalescence parameters were not statistically different. However, whereas no child required a blood transfusion, three adults (18.8%) did. No major perioperative complications occurred in the paediatric group, but open surgical exploration was needed due to retroperitoneal bleeding in a single adult. CONCLUSION Our findings indicate that laparoscopic nephrectomy for congenital benign disease in children is achieved safely and that the modality offers additional advantages in children as compared to adults.
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Affiliation(s)
- Ja Hyeon Ku
- Department of Urology, Seoul National University College of Medicine, Seoul, Korea
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Fuh E, de la Fuente S, Shah MK, Okodiko DK, Cummings TJ, Eubanks WS, Reynolds JD. Long-term behavioral assessment of guinea pigs following neonatal pneumoperitoneum. Surg Endosc 2005; 19:715-9. [PMID: 15759194 DOI: 10.1007/s00464-004-8181-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2004] [Accepted: 11/16/2004] [Indexed: 11/29/2022]
Abstract
BACKGROUND Using guinea pigs, we previously demonstrated that pneumoperitoneum during pregnancy produces behavioral deficits in the offspring. In the current study, the purpose was to determine if CO(2) pneumoperitoneum during the early postnatal period also produced behavioral anomalies. METHODS Following delivery, guinea pig pups were randomly assigned to one of three treatment groups: CO(2) pneumoperitoneum (P), laparotomy (L), or isolation control (I). Surgeries were performed on postnatal day (PND) 5 under isoflurane anesthesia; control pups were isolated from the dams for an equivalent period of time. On PNDs 10, 20, 40, and 60, behavior was assessed by monitoring locomotor and exploratory activity. RESULTS A total of 29 animals were studied. We observed no immediate morbidity or mortality and the manipulations did not appear to affect postnatal growth. On PND 10, pups in group P exhibited lower levels of locomotor activity compared to L and I neonates, but this difference resolved as the animals got older. Histologic assessment of the adult offspring brains revealed no evidence of neurologic injury. CONCLUSION These data suggest that unlike insufflation during pregnancy, neonatal pneumoperitoneum does not produce behavioral deficits.
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Affiliation(s)
- E Fuh
- Department of Surgery, Room 119, Research Park Building 4, Box 3094, Endosurgical Research Group, Duke University Medical Center, Durham, NC 27710, USA
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Truchon R. Anaesthetic considerations for laparoscopic surgery in neonates and infants: a practical review. Best Pract Res Clin Anaesthesiol 2004; 18:343-55. [PMID: 15171508 DOI: 10.1016/j.bpa.2003.10.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Minimally invasive surgery is being applied to an increasing number of neonates and infants undergoing abdominal surgeries. Knowledge of specific implications, patient's health status and pathophysiological changes induced by the surgery allow the anaesthesiologist to provide safe anaesthesia to these high-risk patients. This chapter describes the specific pathophysiological effects, peri-operative management, major complications and contraindications related to endoscopic procedures.
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Affiliation(s)
- René Truchon
- Department of Laval University, 2705, boul. Laurier, Sainte-Foy, Que., Canada G1V 4G2.
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Affiliation(s)
- P K Tam
- Division of Paediatric Surgery, Department of Surgery, The University of Hong Kong Medical Center, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, China.
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