Minimally invasive surgery in the neonate: review of current evidence

Birth weight and thoracoscopic approach for patients with esophageal atresia and tracheoesophageal fistula-a retrospective cohort study

BACKGROUND

This study aimed to analyze the results, feasibility and safety of the thoracoscopic approach for patients with esophageal atresia with tracheoesophageal fistula (EA/TEF) depending on the patient's birth weight.

METHODS

The study involved only type C and D EA/TEF. Among the analyzed parameters were the patients' characteristics, surgical treatment and post-operative complications: early mortality, anastomosis leakage, anastomosis strictures, chylothorax, TEF recurrence, and the need for fundoplication or gastrostomy.

RESULTS

145 consecutive newborns underwent thoracoscopic EA with TEF repair. They were divided into three groups-A (N = 12 with a birth weight < 1500 g), B (N = 23 with a birth weight ≥ 1500 g but < 2000 g), and C-control group (N = 110 with a birth weight ≥ 2000 g). Primary one-stage anastomosis was performed in 11/12 (91.7%) patients-group A, 19/23 (82.6%)-group B and 110 (100%)-group C. Early mortality was 3/12 (25%)-group A, 2/23 (8.7%)-group B, and 2/110 (1.8%)-group C and was not directly related to the surgical repair. There were no significant differences in operative time and the following complications: anastomotic leakage, recurrent TEF, esophageal strictures, and chylothorax. There were no conversions to an open surgery. Fundoplication was required in 0%-group A, 4/21 (19.0%)-group B, and 2/108 (1.9%)-group C survivors. Gastrostomy was performed in 1/9 (11.1%)-group A, 3/21 (14.3%)-group B and 0%-group C.

CONCLUSION

In an experienced surgeon's hands, even in the smallest newborns, the thoracoscopic approach may be safe, feasible, and worthy of consideration. Birth weight seems to be not a direct contraindication to the thoracoscopic approach.

Gaps and priorities in innovation for children's surgery

Lack of access to pediatric medical devices and innovative technology contributes to global disparities in children's surgical care. There are currently many barriers that prevent access to these technologies in low- and middle-income countries (LMICs). Technologies that were designed for the needs of high-income countries (HICs) may not fit the resources available in LMICs. Likewise, obtaining these devices are costly and require supply chain infrastructure. Once these technologies have reached the LMIC, there are many issues with sustainability and maintenance of the devices. Ideally, devices would be created for the needs and resources of LMICs, but there are many obstacles to innovation that are imposed by institutions in both HICs and LMICs. Fortunately, there is a growing interest for development of this space, and there are many examples of current technologies that are paving the way for future innovations. Innovations in simulation-based training with incorporated learner self-assessment are needed to fast-track skills acquisition for both specialist trainees and non-specialist children's surgery providers, to scale up access for the larger population of children. Pediatric laparoscopy and imaging are some of the innovations that could make a major impact in children's surgery worldwide.

Perioperative outcomes in minimally-invasive versus open surgery in infants undergoing repair of congenital anomalies

BACKGROUND

This study compared perioperative outcomes among infants undergoing repair of congenital anomalies using minimally invasive (MIS) versus open surgical approaches.

METHODS

The ACS NSQIP Pediatric (2013-2018) was queried for patients undergoing repair of any of the following 9 congenital anomalies: congenital lung lesion (LL), mediastinal mass (MM), congenital malrotation (CM), anorectal malformation (ARM), Hirschsprung disease (HD), congenital diaphragmatic hernia (CDH), tracheoesophageal fistula (TEF), hepatobiliary anomalies (HB), and intestinal atresia (IA). Inverse probability of treatment weights (IPTW) derived from propensity scores were utilized to estimate risk-adjusted association between surgical approach and 30-day outcomes.

RESULTS

12,871 patients undergoing congenital anomaly repair were included (10,343 open; 2528 MIS). After IPTW, MIS was associated with longer operative time (difference; 95% CI) (16 min; 9-23) and anesthesia time (13 min; 6-21), but less postoperative ventilation days (-1.0 days; -1.4- -0.6) and shorter postoperative length of stay (-1.4 days; -2.4- -0.3). MIS repairs had decreased risk of any surgical complication (risk difference: -6.6%; -9.2- -4.0), including hematologic complications (-7.3%; -8.9- -5.8). There was no significant difference in risk of complication when hematologic complications were excluded (RD -2.3% [-4.7%, 0.1%]). There were no significant differences in the risk of unplanned reoperation (0.4%; -1.5-2.2) or unplanned readmission (0.2%; -1.2-1.5).

CONCLUSIONS

MIS repair of congenital anomalies is associated with improved perioperative outcomes when compared to open. Additional studies are needed to compare long-term functional and disease-specific outcomes.

MINI-ABSTRACT

In this propensity-weighted multi-institutional analysis of nine congenital anomalies, minimally invasive surgical repair was associated with improved 30-day outcomes when compared to open surgical repair.

LEVEL OF EVIDENCE

III.

Thoracoscopic Repair of Neonatal Congenital Diaphragmatic Hernia: Minimizing Open Repair in a Low-Income Country

Aim: To assess the severity of persistent pulmonary hypertension (PPH) in congenital diaphragmatic hernia (CDH) neonates solely using oxygenation index (OI). Study Design: A prospective study was carried out from April 2016 to March 2019, where all confirmed CDH neonates were evaluated for the possibility repair through thoracoscopic approach. The severity of PPH was assessed using OI. It is calculated using the equation: mean airway pressure (MAP) × FiO₂ × 100 ÷ PaO₂. Neonates having OI <5 were considered to have a mild degree of pulmonary hypertension; hence, thoracoscopic repair was offered for them. Results: Thirty-nine CDH cases met the selection criteria; therefore, they underwent thoracoscopic repair. Primary diaphragmatic repair was successfully accomplished thoracoscopically in all neonates without any perioperative complications. Conversion from thoracoscopy to open method occurred in five cases. The causes were due to difficulties encountered during repair and none was due to a pure anesthetic problem or general deterioration during thoracoscopy. Recurrence had occurred in two cases only. Conclusion: OI is a reliable subjective parameter that could be used as an adjuvant to the usually used cardiovascular and pulmonary parameters for thoracoscopic repair decision. With increasing surgical experience, a wider range of neonates may be considered for thoracoscopic CDH repair.

Patent ductus arteriosus in preterm infants: is early transcatheter closure a paradigm shift?

The optimal management approach of the patent ductus arteriosus (PDA) in premature infants remains uncertain owing the lack of evidence for long-term benefits and the limited analyses of the complications of medical and surgical interventions to date. In recent years, devices suitable to plug the PDA of premature infants (including extremely low birthweight, <1000 g) have become available and several trials have demonstrated successful and safe transcatheter PDA closure (TCPC) in this population. Whether TCPC represents a paradigm shift in PDA management that will result in improved short- and long-term outcomes, less bronchopulmonary dysplasia, improved neurodevelopment, or better long term renal function remains to be seen. Careful rigorous study of the potential benefits of TCPC in this highly vulnerable population in the context of well-designed adequately powered trials is needed prior to widespread adoption of this approach.

Thoracoscopy vs. thoracotomy for the repair of esophageal atresia and tracheoesophageal fistula: a systematic review and meta-analysis

Esophageal atresia (EA) and tracheoesophageal fistula (TEF) require emergency surgery in the neonatal period to prevent aspiration and respiratory compromise. Surgery was once exclusively performed via thoracotomy; however, there has been a push to correct this anomaly thoracoscopically. In this study, we compare intra- and post-operative outcomes of both techniques. A systematic review and meta-analyses was performed. A search strategy was developed in consultation with a librarian which was executed in CENTRAL, MEDLINE, and EMBASE from inception until January 2017. Two independent researchers screened eligible articles at title and abstract level. Full texts of potentially relevant articles were then screened again. Relevant data were extracted and analyzed. 48 articles were included. A meta-analysis found no statistically significant difference between thoracoscopy and thoracotomy in our primary outcome of total complication rate (OR 0.98, [0.29, 3.24], p = 0.97). Likewise, there were no statistically significant differences in anastomotic leak rates (OR 1.55, [0.72, 3.34], p = 0.26), formation of esophageal strictures following anastomoses that required one or more dilations (OR 1.92, [0.93, 3.98], p = 0.08), need for fundoplication following EA repair (OR 1.22, [0.39, 3.75], p = 0.73)-with the exception of operative time (MD 30.68, [4.35, 57.01], p = 0.02). Considering results from thoracoscopy alone, overall mortality in patients was low at 3.2% and in most cases was due to an associated anomaly rather than EA repair. Repair of EA/TEF is safe, with no statistically significant differences in morbidity when compared with an open approach.Level of evidence 3a systematic review of case-control studies.

Laparoscopic skills assessment: an additional modality for pediatric surgery fellowship selection

AIM

The Pediatric Surgery fellow selection is a multi-layered process which has not included assessment of surgical dexterity.

MATERIALS AND METHODS

Data was collected prospectively as part of the 2016 Pediatric Surgery Match interview process. Applicants completed a questionnaire to document laparoscopic experience and fine motor skills activities. Actual laparoscopic skills were assessed using a simulator. Time to complete an intracorporeal knot was tabulated. An initial rank list was formulated based only on the ERAS application and interview scores. The rank list was re-formulated following the laparoscopic assessment. Un-paired T-test and regression were utilized to analyze the data.

RESULTS

Forty applicants were interviewed with 18 matched (45%). The mean knot tying time was 201.31s for matched and 202.35s for unmatched applicants. Playing a musical instrument correlated with faster knot tying (p=0.03). No correlation was identified between knot tying time and either video game experience (p=0.4) or passing the FLS exam (p=0.78). Laparoscopic skills assessment lead to significant reordering of rank list (p=0.01).

CONCLUSIONS

Laparoscopic skills performance significantly impacted ranking. Playing a musical instrument correlated with faster knot tying. No correlation was identified between laparoscopic performance and passing the FLS exam or other activities traditionally believed to improve technical ability.

TYPE OF STUDY

Prospective study.

LEVEL OF EVIDENCE

Level II.

Variation in pediatric surgical care

Variation in care and outcomes are common in the management of children with surgical diseases. Differences in the availability of resources, patient and family preferences, ever-increasing fiscal pressure, and lack of high-quality data to guide clinical decision making are just a few factors that contribute to both the over and under-utilization of healthcare resources. Identification of data-driven, value-based "best practices" that are sensitive to differences in resource availability and patient preferences may be an important first step in establishing a practical framework for reducing unwarranted practice variation. The goal of this article is to explore the causes and influence of practice variation using appendicitis as a common condition to illustrate key concepts, and to propose solutions to mitigate unwarranted practice variation while preserving the spirit of innovation necessary to advance the field.

Congenital cystic lesions of the lungs: The perils of misdiagnosis - A single-center experience

Background:

A majority of cystic lesions in the western world are detected antenatally, whereas, the diagnosis in our setup occurs once the child becomes symptomatic. Surgical management is primarily dictated by the presence of symptoms, recurrent infection, and rarely by the potential risk of malignant transformation.

Materials and Methods:

A retrospective analysis was carried out on all consecutive patients with cystic lung lesions managed at our center from January 2000 through June 2011 for antenatal diagnosis, presentation, diagnostic modalities, treatment, and complications.

Results:

Forty cystic lung lesions were identified. Only 8% were antenatally detected. Out of 40, the final diagnosis was congenital cystic adenomatoid malformation in 19, congenital lobar emphysema in 11, and bronchogenic cysts and pulmonary sequestration in five each. Of these, 20% had received a course of prior antitubercular therapy and 30% had an intercostal drain inserted prior to referral to our center. Postoperative morbidity in the form of bronchopleural fistula, pneumothorax, and non-expansion of the residual lung was noted in 10% of the patients.

Conclusion:

Antenatal diagnosis of these lesions is still uncommon in third world countries. Prior to referral to a pediatric surgical center a large number of patients received antitubercular drugs and an intercostal drain insertion, due to incorrect diagnosis.

Design and Analysis of a Novel Articulated Drive Mechanism for Multifunctional NOTES Robot

This paper presents a novel articulated drive mechanism (ADM) for a multifunctional natural orifice transluminal endoscopic surgery (NOTES) robotic manipulator. It consists mainly of three major components including a snakelike linkage, motor housing, and an arm connector. The ADM can articulate into complex shapes for improved access to surgical targets. A connector provides an efficient and convenient modularity for insertion and removal of the robot. Four DC motors guide eight cables to steer the robot. The workspace, cable displacement and force transmission relationships are derived. Experimental results give preliminary validation of the feasibility and capability of the ADM system.

Advances in minimally invasive surgery in pediatric patients

Surgery has changed dramatically over the last several decades. The emergence of MIS has allowed pediatric surgeons to manage critically ill neonates, children, and adolescents with improved outcomes in pain, postoperative course, cosmesis, and return to normal activity. Procedures that were once thought to be too difficult to attempt or even contraindicated in pediatric patients in many instances are now the standard of care. New and emerging techniques, such as single-incision laparoscopy, endoscopy-assisted surgery, robotic surgery, and techniques yet to be developed, all hold and reveal the potential for even further advancement in the management of these patients. The future of MIS in pediatrics is exciting; as long as our primary focus remains centered on developing techniques that limit morbidity and maximize positive outcomes for young patients and their families, the possibilities are both promising and infinite.

Supraumbilical incision with U-u umbilicoplasty for congenital duodenal atresia: the Stockholm experience

BACKGROUND

Minimizing scars has become a major concern in pediatric surgery. Since Tan and Bianchi introduced the minimally invasive umbilical incision for Ramstedt's pyloromyotomy, their technique has been adopted for a variety of neonatal abdominal conditions. The aim of this study was to evaluate a modification of the skin incision.

MATERIAL AND METHODS

We have modified Bianchi's original technique to access the abdomen through the linea alba by introducing a novel U-to-u umbilicoplasty and compare the results with the traditional transverse incision. This new approach improves the abdominal access and is easy to perform.

RESULTS

The operating time with the U-to-u umbilicoplasty is not longer than in standard transverse laparotomy, the access to the abdomen is more than adequate, the incidence of postoperative complications is similar and the cosmetic results are excellent.

CONCLUSIONS

We conclude that the umbilical approach with this novel U-to-u umbilicoplasty to treat congenital duodenal obstruction in the newborn is a safe and effective method and a good alternative to the standard transverse laparotomy approach.

Minimal access surgery in newborns and small infants; five years experience

AIMS AND OBJECTIVES:

The aim of this study was to assess and present the outcome (initial experience and lessons learnt) of minimally invasive surgery for various indications in neonates and small infants (< 5 kg) at a single medical centre.

MATERIALS AND METHODS:

A retrospective analysis was performed on 65 patients (age day 2 to 10 months) managed with minimal access surgery (MAS) for various indications, between 2005 and 2010. We analyzed demographic information, procedures, complications, outcomes, and follow-up and overall feasibility of the procedure.

RESULTS:

No serious complications except one death in congenital diaphragmatic hernia (CDH) (due to other comorbidities) occurred. Intra operative hypercarbia and hypoxia were observed more frequently in thoracoscopic procedures. Intra operative hypothermia was not common and was well tolerated. Conversion to open procedure (n = 5), post operative ileus (n = 3), port site infection (n = 5) were other complications.

CONCLUSION:

MAS in neonates and small infants is a technically demanding but a feasible choice available. Some prior experience in older children is required for safe and effective outcome. Good quality optics, video equipments and instruments are required for safe and effective procedure. Intra operative measurement of oxygen saturation and temperature, and diligent post operative ICU care are mandatory for safe and successful outcome.

Pediatric minimally invasive surgery: laparoscopy and thoracoscopy in infants and children

This article discusses the potential benefits and challenges of minimally invasive surgery for infants and small children, and discusses why pediatric minimally invasive surgery is not yet the surgical default or standard of care. Minimally invasive methods offer advantages such as smaller incisions, decreased risk of infection, greater surgical precision, decreased cost of care, reduced length of stay, and better clinical information. But none of these benefits comes without cost, and these costs, both monetary and risk-based, rise disproportionately with the declining size of the patient. In this review, we describe recent progress in minimally invasive surgery for infants and children. The evidence for the large benefits to the patient will be presented, as well as the considerable, sometimes surprising, mechanical and physiological challenges surgeons must manage.

Thoracoscopic plication for diaphragmatic eventration in a neonate

BACKGROUND

Currently, thoracoscopic surgery is replacing thoracotomy for an ever increasing number of indications, even in pediatric surgery. However, there are few reports describing thoracoscopic plication (TP) for diaphragmatic eventration in children, particularly in neonates. We report a case of TP under single-lung ventilation in a neonate with diaphragmatic eventration.

CASE REPORT

A 10-day-old boy was referred for surgical management of right diaphragmatic eventration. Birth was at term, following an uncomplicated pregnancy and delivery. Shortness of breath, labored respiration and chest retraction presented soon after birth, necessitating mechanical ventilation. Chest radiography and computed tomography revealed an elevated right hemidiaphragm. Attempted weaning off mechanical ventilation failed with persistence of respiratory symptoms, requiring nasal directional positive airway pressure. However, because there was no resolution of symptoms, TP was performed using a 3 port technique under single-lung ventilation on day 17 of life. The postoperative course was excellent with complete resolution of respiratory symptoms with no recurrence for 9 months.

CONCLUSION

To the best of our knowledge, this is the youngest case of TP for diaphragmatic eventration performed under single-lung ventilation. TP is safe, effective and minimally invasive and should be considered actively for the treatment of symptomatic diaphragmatic eventration even in neonates.

Kidney safety during surgical pneumoperitoneum: an experimental study in rats

BACKGROUND

Elevations of intraabdominal pressure during laparoscopic procedures may lead to oliguria or anuria in mammals. Despite this, previous research has not been able to confirm an associated kidney injury. This study aimed to investigate the occurrence of an early kidney lesion secondary to surgical pneumoperitoneum in a rat model using the expression of neutrophil gelatinase-associated lipocalin (N-GAL) as a biomarker for early kidney injury.

METHODS

In this study, 20 male Sprague-Dawley rats under general anesthesia and mechanically ventilated were allocated to one of five experimental time-dependent groups: group 1 (1-h control), group 2 (1-h pneumoperitoneum), group 3 (2-h control), group 4 (2-h pneumoperitoneum), and group 5 (positive kidney injury group induced by intravenous administration of cisplatin 7.5 mg/kg). To evaluate the renal expression of N-GAL 24 h after the procedure, all the rats underwent a 2-h urine output evaluation as well as laparotomy and bilateral nephrectomy performed sequentially to investigate the presence of renal injury using immunofluorescence qualification and western blotting.

RESULTS

Urine output was reduced and N-GAL expression was increased in the animals from the cisplatin group. The animals undergoing 1- or 2-h pneumoperitoneum displayed urine output and N-GAL expression similar to that of the animals from the matching control groups.

CONCLUSIONS

Under the experimental conditions of this study, the animals with normal preoperative renal function did not show any type of acute kidney injury associated with the presence of a stabilized surgical pneumoperitoneum.

Physiological impact of pneumoperitoneum on gastric mucosal CO2 pressure during laparoscopic versus open appendectomy in children

INTRODUCTION

Funded knowledge about the physiological impact of laparoscopic surgery in children is sparse. Although there are data on hemodynamic compromise after creation of a pneumoperitoneum in children, little is known about microcirculatory changes at the mucosa level. Therefore, the aim of this study was to assess gastric microcirculation by continuous gastric air tonometry in the setting of laparoscopic versus open appendectomy.

PATIENTS AND METHODS

Twenty children 5-17 years old undergoing laparoscopic and 7 children undergoing open appendectomy were included in the study. Gastric intramucosal CO(2) pressure (pCO(2)i) was measured under standardized flow and intraperitoneal pressure using continuous air tonometry (TONOCAP(®), Datex Ohmeda), and ΔpCO(2) (pCO(2)i - end-expiratory CO(2) pressure [pCO(2)e]) was obtained for the time course of surgery.

RESULTS

ΔpCO(2) increased significantly from the baseline value not only in the laparoscopic group but also in the open surgery group. Even though ΔpCO(2) was higher in the laparoscopic group at all time points, the overall increase in ΔpCO(2) for both groups was uniform. The largest differences were observed during the initial 20 minutes of the operation. The changes observed were exclusively due to an increase of pCO(2)i in relation to a constant pCO(2)e.

DISCUSSION

In the setting of a standardized, simple operation in an otherwise healthy child above the age of 5 years, our data suggest that the effect of a pneumoperitoneum on splanchnic perfusion is comparable to the compromise caused by open surgery. Further research must be obtained when evaluating the full impact of laparoscopy in children.

Laparoscopic surgery for acute neonatal appendicitis

We present the first two cases of acute neonatal appendicitis operated on through the laparoscopic approach. Acute neonatal appendicitis is uncommon and rarely considered by clinicians when assessing the neonatal acute abdomen. Our two cases demonstrate the potential value of diagnostic laparoscopy in the acute neonatal abdomen that poses a diagnostic dilemma. Furthermore, technical modifications of well-established laparoscopic techniques in the older child enable its use in neonates as a therapeutic tool.

Evaluation of a simple valve mechanism used to stabilize intraabdominal pressure during surgically induced pneumoperitoneum in small animals

BACKGROUND

Preventing sudden changes in intraabdominal pressure (IAP) during surgical pneumoperitoneum may reduce adverse events. This study aimed to describe a valve system that stabilizes intraabdominal pressure, minimizing complications of erratic fluctuations in IAP.

METHODS

Five male Sprague-Dowley rats were submitted to pneumoperitoneum, with the insufflator set sequentially at 5, 10, and 15 mmHg for each rat. Measures of IAP were taken initially without the valve and then using the same insufflator levels with the valve system regulated to three different pressures (5, 10, and 15 mmHg). The mean of the three highest registered pressures during a 15-min observation was used as the maximal pressure, and the mean of the three lowest registered pressures was used as the minimal pressure for each experimental setting.

RESULTS

Without the valve system, the pressure level set by the insufflator correlated poorly with the actual IAP. When the valve system was used, the IAP pressure was limited by the valve settings regardless of the insufflator settings. Also, the variability of IAP was significantly higher when no valve was used than in all situations that had implementation of the system.

CONCLUSIONS

The valve system was very effective in stabilizing IAP, allowing a reproducible and reliable estimate of IAP and greatly reducing the variability resulting from the cycling mechanism of the insufflator. Due to the small dimensions of intracorporeal cavities in the newborn, this mechanism may help to improve safety when neonatal video-assisted surgery is performed.

Ectopic extralobar pulmonary sequestrations in children: interest of the laparoscopic approach

BACKGROUND

Extralobar pulmonary sequestrations (EPS) are a rare benign congenital bronchopulmonary foregut malformation. Complete resection is necessary to confirm the diagnosis with histopathologic examination. The aim of this study was to describe the laparoscopic minimally invasive surgery (MIS) for a small series of ectopic EPS in small children and to show its feasibility and safety.

METHODS

From January 2001 to December 2008, 12 cases of EPS were prenatally diagnosed and retrospectively reviewed. From this group, we isolated 6 children with ectopic EPS. Ages ranged from 15 days to 14 months. Three infants were symptomatic, and the others showed persistence of the lesion with parental anxiety. All prenatal diagnoses were confirmed by postnatal Doppler ultrasound and intravascular contrast computed tomography scan with 3-dimensional reconstructions. Postnatally, all were ectopic lesions: 3 were hiatal and intradiaphragmatic, 3 infradiaphragmatic and left paramedian. Laparoscopic MIS consisted of 4 small trocars and low-pressure pneumoperitoneum. We carried out a retroesophageal dissection in 4 cases, an elective control of systemic vessels, and a removal of the EPS with histologic study.

RESULTS

We performed 5 procedures laparoscopically and 1 thoracoscopically. There were 2 abdominal conversions. Nevertheless, no intraoperative or immediate postoperative complications occurred. Hospital stay ranged from 1 to 5 days (mean, 2.7 days). The diagnosis of pure pulmonary sequestration with feeding vessels in 5 cases was confirmed by histopathology. Follow-up ranged from 13 to 84 months (mean, 43 months). Late complications were benign.

CONCLUSIONS

Laparoscopic MIS for ectopic EPS in small children is a feasible and safe technique. The great magnification provided by the endoscopic procedure allows for the search of associated congenital anomalies, meticulous retroesophageal dissection, and control of the systemic vessels. Resection provides definitive diagnosis and treatment, and confers the benefits of a minimal access technique.

[Minimally invasive pediatric surgery]

In recent years minimally invasive surgical techniques in children have made substantial progress. The feasibility and safety of a wide spectrum of laparoscopic and thoracoscopic procedures have been confirmed in numerous studies. Moreover, it was reported that minimally invasive pediatric surgery is associated with lower morbidity, a shorter hospital stay, lower costs, better cosmetics and clinical results similar to those achieved by open surgery. The present article reviews information on established as well as feasible but not yet established surgical procedures. The discussion of potential hemodynamic, respiratory and organ perfusion effects of the CO(2) pneumoperitoneum and the notation of special logistic aspects should support the reader in the process of decision-making to schedule infants and children for minimally invasive surgery.

Thoracoscopic versus open resection for congenital cystic adenomatoid malformations of the lung

PURPOSE

This study evaluated the potential advantages of thoracoscopy compared to thoracotomy for resection of congenital cystic adenomatoid malformations (CCAM).

METHODS

We conducted a retrospective chart review of consecutive cases of CCAM resection at University of California San Francisco Children's Hospital from January 1996 to December 2006.

RESULTS

Thirty-six cases of postnatal CCAM resections were done over the past 10 years; 12 patients had thoracoscopic resections, whereas 24 patients had open resections. Patients in the thoracoscopic group had significantly longer operative time (mean difference of 61.3 minutes; 95% confidence interval [CI], 30.5-92.1) but shorter postoperative hospital stay (mean difference of 5.7 days; 95% CI, 0.9-10.4) and duration of tube thoracostomy (mean difference of 2.6 days; 95% CI, 0.7-4.5) and lower odds of postoperative complications (odds ratio of 9.0 x 10(-4); 95% CI, 8.0 x 10(-6)-0.1). In the subgroup analysis of only asymptomatic patients, the thoracoscopy group still had a significantly shorter hospital stay (mean difference of 2.8 days; 95% CI, 0.7-4.8). There was also a pattern for reduced complications in the thoracoscopy group (OR, 0.13; 95% CI, 0.02-1.0; P = .05). The average hospital costs were similar in both groups. With a conversion rate of 33% (6/18), patients with a history of preoperative respiratory symptoms had a higher incidence of conversion than those who were asymptomatic (66.7% vs 0%, P = .005). These four patients had a history of pneumonia.

CONCLUSION

Minimally invasive resection of CCAM results in longer operative time but shorter hospital stay, potentially reduced complications, and no additional hospital costs. Thoracoscopic lobectomy in patients with a history of pneumonia is challenging and a risk factor for conversion to thoracotomy.

Fetoscopy under gas amniodistension: pressure-dependent influence of helium vs nitrous oxide on fetal goats

PURPOSE

Recently, gas amniodistension has been advocated for fetoscopic surgery to employ ergonomics similar to laparoscopy. However, neither the optimal type of gas nor its physiological influence on the fetus have been clearly outlined yet. This study investigates the impact of helium (HE) vs nitrous oxide (N2O) on fetal goats during fetoscopy.

METHODS

We insufflated either HE or N2O in 12 pregnant goats (15 fetuses; HE = 7, N2O = 8), then increased the pressures from 0, 4, 7, to 10 mm Hg in 30-minute intervals and recorded the fetal and maternal vital parameters. Finally, whole-body computed tomography to asses for intracorporeal gas was performed.

RESULTS

All fetuses survived. Mean fetal vital signs showed no significant differences between HE or N2O at specific pressure levels. In detail, HE/N2O at 0 vs 10 mm Hg caused a fetal temperature decrease (32.9 degrees C/33.2 degrees C vs 32 degrees C/32.5 degrees C), heart rate increase in the N2O group (100/102 vs 102/121 beats per minute), and no significant change in arterial pressure (45.8/48.3 vs 53.7/46.7 mm Hg). The PO2 was adequate (3.7/3.3 vs 3.7/2.9 kPa), whereas the pH remained unchanged (7.4/7.3 vs 7.3/7.3). However, fetal pCO2 was elevated in the N2O group before insufflation (5.5/7.2 vs 6.8/8.0 kPa) owing to maternal hypoventilation (maternal PCO2: 4.9/5.8 vs 5.0/5.4 kPa), correction of which was slower in the fetus than in the maternal animal. Computed tomography ruled out intracorporeal gas accumulation.

CONCLUSION

Neither HE nor N2O impose significant physiological harm for the fetus. Heating of the gas and maternal anesthesia seem essential. Considering the potential teratogenicity of N2O, however, HE could be the favorable environment for fetoscopic procedures under gas amniodistension.

Multicentric assessment of the safety of neonatal videosurgery

BACKGROUND

Complex procedures for managing congenital abnormalities are reported to be feasible. However, neonatal videosurgery involves very specific physiologic constraints. This study evaluated the safety and complication rate of videosurgery during the first month of life and sought to determine both the risk factors of perioperative complications and the most recent trends in practice.

METHODS

From 1993 to 2005, 218 neonates (mean age, 16 days; weight, 3,386 g) from seven European university hospitals were enrolled in a retrospective study. The surgical indications for laparoscopy (n = 204) and thoracoscopy (n = 14) were congenital abnormalities or exploratory procedures.

RESULTS

Of the 16 surgical incidents that occurred (7.5%), mainly before 2001, 11 were minor (parietal hematoma, eventration). Three neonates had repeat surgery for incomplete treatment of pyloric stenosis. In two cases, the incidents were more threatening (duodenal wound, diaphragmatic artery injury), but without further consequences. No mortality is reported. The 26 anesthetic incidents (12%) that occurred during insufflation included desaturation (<80% despite 100% oxygen ventilation) (n = 8), transient hypotension requiring vascular expansion (n = 7), hypercapnia (>45 mmHg) (n = 5), hypothermia (<34.9 degrees C) (n = 4), and metabolic acidosis (n = 2). The insufflation had to be stopped in 7% of the cases (transiently in 9 cases, definitively in 6 cases). The significant risk factors for an incident (p < 0.05) were young age of the patient, low body temperature, thoracic insufflation, high pressure and flow of insufflation, and length of surgery.

CONCLUSION

Despite advances in miniaturizing of instruments and growth in surgeons' experience, the morbidity of neonatal videosurgery is not negligible. A profile of the patient at risk for an insufflation-related incident emerged from this study and may help in the selection of neonates who will benefit most from these techniques in conditions of maximal safety.

Video-assisted thoracoscopic clipping of patent ductus arteriosus: close to the gold standard and minimally invasive competitor of percutaneous techniques

OBJECTIVE

To review our 12-year experience in video-assisted thoracoscopic surgery (VATS) for patent ductus arteriosus.

METHODS

VATS was performed in 743 patients. Three groups were compared: 24 low-birth-weight infants (LBWIs), 676 children between 2.5-25 kg and 43 boys > 25 kg. A diameter of > 8 mm was the main contraindication. For 85 consecutive patients, hospital stay underwent cost analysis.

RESULTS

Median age was 1.6 years (range 5 days-33 years) and median weight 9.0 kg (range 1.2-65 kg). Mortality was nil. Median operative time was 20 min and hospital stay 2 days. Residual patency at discharge was 0% in LBWIs, 0.7% in children, and 4.7% in boys (P = NS) and 0, 0.3, and 4.7% at follow-up (P = 0.001). Persistent recurrent laryngeal nerve dysfunction was recorded in 4.2% of LBWIs, 0.3% of children and 0% of boys (P = 0.012). Total mean cost was Euro 5954 +/- 2110.

CONCLUSIONS

The success rate of VATS clipping compares favorably with the thoracotomic approach but without chest wall trauma and it may have a very favorable cost-effective therapeutic balance compared to transcatheter techniques.

Minimal access surgery in neonates and infants

BACKGROUND

Minimal access surgery (MAS) in small infants carries an important consideration. The tolerance of these small babies and the assumed physiological effect of MAS, in addition to the required anesthetic and surgical skills, have made it difficult to perform these types of procedures in many international centers. The present article reviews our experience with MAS in neonates and infants in the first year of life.

METHODS

The medical records of all neonates and infants (<1 year) who underwent MAS over a period of 3 years were retrospectively reviewed for demographic information, procedures, operative time, complications, outcomes, and follow-up. Most of the operations were performed with 3-mm instruments and scopes and mean insufflation pressure of 10 mm Hg (range, 4-15 mm Hg).

RESULT

Seventy neonates and infants were included in this study: 19 females and 51 males. The weight ranged from 1.3 to 8.2 kg (mean, 4.3 kg). The mean age was 93 days (range, 1 day to 12 months). Twenty-four (34%) were neonates (first 30 days of life). Procedures performed included repair of tracheoesophageal fistula, lobectomy, repair of diaphragmatic or hiatus hernias, pull-through for imperforated anus and Hirschsprung's disease, plication of the diaphragm, Kasai procedure, excision of choledochal cyst, pyloromyotomy, Ladd's procedure, and reduction of intussusceptions. There were 2 conversions, both in neonates with tracheoesophageal fistula. All patients tolerated the procedure very well, with lesser degrees in neonates undergoing thoracoscopic procedures. Two neonates had postoperative hypothermia (<35 degrees C) and 1 neonate had high PCO2 postoperatively. There was 1 mortality and no morbidities. The follow-up ranged from 1 month to 3 years (mean, 19 months).

CONCLUSION

Minimal access surgery in neonates and infants is safe and well tolerated. Intraoperative monitoring of end-tidal CO2 and core temperature is essential in avoiding unwanted effects of performing these procedures, especially in neonates.

Outcomes from the correction of anorectal malformations

PURPOSE OF REVIEW

Anorectal malformations have been recognized and managed since antiquity, with surgical treatment evolving to maximize anatomic reconstruction, avoid complications, and understand mechanisms of incontinence, ultimately leading to improved quality of life for patients. This review describes recent advances in the management of anorectal malformations, including prenatal diagnosis, newborn treatment, surgical correction, and postoperative care.

RECENT FINDINGS

Surgical treatment has improved with better understanding and exposure of anatomy and appreciation of the intimate relation between rectum and urinary tract. Repair of cloacal malformations has evolved to include the total urogenital mobilization and an appreciation of the complex associated Mullerian anomalies. The importance of associated urologic, gynecologic, neurologic, and orthopedic malformations has been recognized. Addition of a bowel management program to patients' postoperative care has increased dramatically the number of children who are clean and dry.

SUMMARY

Management of anorectal malformations requires an accurate clinical diagnosis, proper newborn treatment, meticulous anatomic reconstruction, and comprehensive postoperative care with the goal of having a child who is clean and dry, with an excellent quality of life, because they either have the capacity for continence or can be kept artificially clean with a comprehensive bowel management program.