Laparoscopic versus Open Pediatric Surgery: Three Decades of Comparative Studies

The Impact of Pediatric Laparoscopic Inguinal Hernia Repair in a Community Based Children's Ambulatory Surgery Center - It's Safe and Effective

PURPOSE

Pediatric surgery in a free-standing children's ambulatory surgery center (C-ASC) is a common practice. The implementation of minimally invasive surgery in this setting may be associated with unique challenges. The purpose of this study was to compare a cohort of children who underwent laparoscopic (LHR) and open inguinal hernia repairs (OHR) at the C-ASC as part of a quality assurance initiative to assess safety and efficacy.

METHODS

From January 2021 to December 2021, the records of all children who underwent LHR or OHR at our C-ASC were analyzed. The following data was retrieved and compared with the Student's t-test: age, weight, gender, procedure type, total room time (RT), total operative time (OT), and outcomes.

RESULTS

Eighty-eight (n = 88) children underwent LHR or OHR during this period. There was no difference between the two groups regarding their age or weight. Both groups had equal outcomes, specifically, no wound infections or recurrent hernias. (2.5 year follow-up). There was a significant reduction in RT and OT in those children who underwent unilateral LHR compared to unilateral OHR (15% and 17% respectively, p < 0.05). In those children who underwent bilateral LHR and bilateral OHR, there was a reduction in RT and OT in the LHR group compared to OHR, but it was not significant (10% and 12% respectively, p > 0.05).

CONCLUSIONS

Pediatric LHR is safe and effective in the C-ASC. The unilateral LHR technique is associated with a significant reduction in total room time and operative time compared to the unilateral OHR technique. Additional analyses would be important to examine the relationship of time and outcomes in this setting.

TYPE OF STUDY

Original Research Retrospective Case-control study.

Robotic-assisted Pediatric Thoracic and Abdominal Tumor Resection: An Initial Multi-center Review

INTRODUCTION

Robotic-assisted minimally invasive surgery (RA-MIS) for tumor resection is an emerging technology in the pediatric population with significant promise but unproven safety and feasibility.

METHODS

A multi-center retrospective review of patients ≤18 years undergoing RA-MIS tumor resection from December 2015-March 2023 was performed. Patient demographics, perioperative variables, and complication rates were analyzed.

RESULTS

Thirty-nine procedures were performed on 38 patients (17 thoracic, 22 abdominal); 37% female and 68% non-Hispanic White. Median age at surgery was 8.3 years (IQR 5.7, 15.7); the youngest was 1.7 years-old. Thoracic operations included resections of neuroblastic tumors (n = 16) and a single paraganglioma. The most common abdominal operations included resections of neuroblastic tumors (n = 5), pheochromocytomas (n = 3), and angiomyolipomas (n = 3). Six patients underwent retroperitoneal lymph node dissection (RPLND) for paratesticular tumors. Median operating time for the cohort was 2:52 h (IQR 2:04, 4:31). Two thoracic cases required open conversion due to poor visualization and lack of working domain. All patients underwent complete tumor resection; one had tumor spillage from a positive margin (Wilms tumor). Median LOS was 1.5 days (IQR 1.1, 3.0). Postoperatively, one patient developed a chyle leak requiring interventional radiology drainage, but none required a return to the operating room.

CONCLUSIONS

Robotic-assisted surgery is safe and feasible for tumor resection in carefully selected pediatric patients, achieving complete resection with minimal morbidity and short LOS. Resection should be performed by those with robotic expertise for optimal outcomes.

LEVEL OF EVIDENCE

IV.

TYPE OF STUDY

Original Clinical Research.

Robotic-Assisted Surgery in Children Using the Senhance® Surgical System: An Observational Study

BACKGROUND

Robotic-assisted surgery (RAS) holds many theoretical advantages, especially in pediatric surgical procedures. However, most robotic systems are dedicated to adult surgery and are less suitable for smaller children. The Senhance® Surgical System (SSS®), providing 3 mm and 5 mm instruments, focuses on making RAS technically feasible for smaller children. This prospective observational study aims to assess whether RAS in pediatric patients using the SSS® is safe and feasible.

METHODS AND RESULTS

A total of 42 children (aged 0-17 years, weight ≥ 10 kg) underwent a RAS procedure on the abdominal area using the SSS® between 2020 and 2023. The study group consisted of 20 male and 22 female individuals. The mean age was 10.7 years (range 0.8 to 17.8 years), with a mean body weight of 40.7 kg (range 10.1 to 117.3 kg). The 3-mm-sized instruments of the SSS® were used in 12 of the 42 children who underwent RAS. The RAS procedures were successfully completed in 90% of cases. The conversion rate to conventional laparoscopy was low (10%), and there were no conversions to open surgery. One of the 42 cases (2%) experienced intraoperative complications, whereas six children (14%) suffered from a postoperative complication. Overall, 86% of the patients had an uncomplicated postoperative course.

CONCLUSIONS

The results of the current observational study demonstrate the safety and feasibility of utilizing the SSS® for abdominal pediatric RAS procedures. The study provides new fundamental information supporting the implementation of the SSS® in clinical practice in pediatric surgery.

Enucleation for intestinal duplications: a comparative study with intestinal resection and anastomosis

PURPOSE

Duplication enucleation (DE) has been described as an alternative to intestinal resection with primary anastomosis (IRA) for intestinal duplications, but no comparative study exists. The aim of this study was to compare both surgical procedures for intestinal duplication.

METHODS

A retrospective study was performed, including all children treated for intestinal duplication (2005-2023). Patients that underwent DE were compared to those that underwent IRA. Statistical significance was determined using p < 0.05. Ethical approval was obtained.

RESULTS

A total of 51 patients (median age: 5 months) were treated for intestinal duplication, including 27 patients (53%) that underwent DE and 24 IRA (47%). A cystic image was detected prenatally in 19 patients (70%) with DE and 11 patients (46%) with IRA (p = 0.09). Enucleation was performed using laparoscopy in 7 patients (14%). Patients that underwent DE had shorter time to first feed (1 vs 3 days, p = 0.0001) and length of stay (4 vs 6 days, p < 0.0004) compared to IRA. A muscular layer was identified in 68% of intestinal resection specimens.

CONCLUSION

Compared to intestinal resection with anastomosis, duplication enucleation is associated with decreased postoperative length of stay and delay to first feeds without increasing post-operative complications. Regarding histological analysis, enucleation seems feasible in most cases.

Surgical effect and gastrointestinal functional recovery of laparoscopic-guided total mesorectal excision in patients with rectal cancer

INTRODUCTION

To explore the surgical effect and gastrointestinal functional recovery of laparoscopic-guided total mesorectal excision (LGTME) in patients with rectal cancer.

PATIENTS AND METHODS

A total of 150 rectal cancer patients who underwent surgical treatment in our hospital from July 2022 to July 2023 were selected and randomly divided into two groups using a random number table. There were 75 cases in the control group (CG) who underwent traditional open rectal total mesorectal excision surgery and 75 cases in the experimental group (EG) who underwent LGTME. The surgical effects of the two groups were compared, and the gastrointestinal and anal functional recovery of the two groups were compared before and after treatment.

RESULTS

Intraoperative bleeding, incision length, time to initial feeding and time to anal exhaust in the EG were significantly lower than those in the CG ( P < 0.05). Before treatment, there was no significant difference in gastrointestinal function and anal function between the two groups ( P > 0.05). After treatment, the levels of motilin, gastrin, neuropeptide Y and basic fibroblast growth factor in the EG were significantly higher than those in the CG, with statistical significance ( P < 0.05); the maximum anal systolic pressure and resting anal sphincter pressure in the EG were significantly lower than those in the CG ( P < 0.05); the rectal sensitivity threshold volume (RSTV) and rectal maximum volume threshold in the EG were significantly higher than those in the CG ( P < 0.05). There was no significant difference in most postoperative complications between the two groups ( P > 0.05).

CONCLUSION

LGTME improves the surgical effects of rectal cancer patients, promotes the recovery of gastrointestinal function and has a small effect on anal function indicators, thereby reducing hospital stay.

Transumbilical single-site laparoscopic treatment of small intestinal cavernous hemangioma in child: a case report

Background

While hemangiomas are the most commonly occurring benign vascular tumors, their occurrence in the gastrointestinal system is rare. This case report presents a unique instance of small intestinal hemangioma in a pediatric patient.

Case description

A 21-month-old girl was admitted to the hospital with a history of "recurrent blood in the stool for one year and anemia for five months." Upon evaluation at our facility, abdominal color ultrasound and enhanced CT scans revealed a protruding mass in the wall of the small intestine, leading to a preliminary diagnosis of small intestinal hemangioma. Subsequent single-site umbilical laparoscopic exploration identified a tumor measuring approximately 6cm×2.5cm×1.2cm on the jejunum wall. Consequently, segmental resection of the intestine was performed, and the postoperative pathological diagnosis confirmed cavernous hemangioma.

Conclusion

Small intestinal hemangiomas, particularly in pediatric patients, are exceptionally rare and challenging to diagnose as the cause of gastrointestinal bleeding prior to surgery. Hence, small intestinal hemangiomas should be considered in such cases. Laparoscopic surgical resection emerges as the optimal approach for addressing small intestinal hemangiomas.

Is transumbilical laparoscopic-assisted appendectomy feasible for complicated appendicitis? A single-center experience

PURPOSE

Transumbilical laparoscopic-assisted surgery (TULS) mixed benefits of laparoscopic and open surgeries. Transumbilical laparoscopic-assisted appendectomy (TULAA) is a well-known procedure, accepted and currently used by pediatric surgeons for treatment of uncomplicated appendicitis (UA). There is no current agreement in its use for the complicated appendiceal infections (CA). We reported our results using TULAA for both UA and CA.

METHODS

We retrospectively collected TULAA performed between April 2017 and April 2022. Appendicitis were classified in UA and CA. We analyzed conversion rate, operative time, length of stay, surgical site infections (SSIs) rate, postoperative intra-abdominal abscess and costs.

RESULTS

Over 5 years, 316 children underwent TULAA. Conversion rate was 3%. Mean age at surgery was 9.36 years (IQR 2-16). Forty-nine appendicitis were CA. Operative time and hospital stay was higher in CA than in UA group (38.33 vs. 60.73 min, p < 0.00001; 4 vs. 7 days, p < 0.00001). SSIs rate showed no statistically significant difference between two groups. Incidence of postoperative intra-abdominal collections was 11% in CA and 1% in UA. TULAA's cost was 192.07 €.

CONCLUSION

In our series, TULAA seems to be safe, feasible and cost-effective for both uncomplicated and complicated appendicitis, with no disadvantage in terms of outcomes compared to what is reported in literature for CLS.

Outcomes of Incidental Appendectomy During Ovarian Operations in a National Pediatric Cohort

INTRODUCTION

The utility of incidental appendectomy (IA) during many ovarian operations has not been evaluated in the pediatric population. This study sought to compare outcomes after ovarian surgery with IA in the pediatric population.

METHODS

Females (≤20 y old) undergoing ovarian surgeries (oophorectomy, detorsion and/or drainage) were identified from the Nationwide Readmissions Database (2016-2018). Those with appendicitis were excluded. A propensity score-matched analysis (PSMA) with 46 covariates (demographics, comorbidities, hospitalization factors, etc.) was performed between those receiving ovarian surgery with or without IA.

RESULTS

There were 13,202 females (median age 17 [IQR 14-20] y old) who underwent oophorectomy (90%), detorsion (26%), and/or ovarian drainage (13%). There were more episodes of torsion in the PSMA cohort receiving ovarian surgery alone (17% versus 10% IA; P = 0.016), while other indications (ovarian mass, cyst) were similar. Open (66% versus 34% laparoscopic) IAs were more frequent. Length of stay (LOS) was longer for those undergoing IA (3 [2-4] versus 2 [2-4] days ovarian surgery alone; P < 0.001). There was a higher rate of postoperative GI complications in the IA cohort. Subgroup analysis of those undergoing laparoscopic operations demonstrated no difference in LOS or postoperative complications between patients undergoing IA or not.

CONCLUSIONS

These data indicate that IA in pediatric ovarian operations is associated with longer LOS and higher GI postoperative complications. However, laparoscopic IA was not associated with higher cost, complications, LOS, or readmissions. This suggests that IA performed during ovarian surgeries in select patients may be cost-effective and worthy of future study.

Difference in Postoperative Outcomes and Perioperative Resource Utilization Between General Surgeons and Pediatric Surgeons: A Systematic Review

Background: Both general surgeons (GS) and pediatric surgeons (PS) perform a high volume of appendectomies in pediatric patients, but there is a paucity of data on these outcomes based on surgeon training. We performed a systematic review and meta-analysis to compare postoperative outcomes and perioperative resource utilization for pediatric appendectomies.Methods: We searched PubMed to identify articles examining the association between surgeon specialization and outcomes for pediatric patients undergoing appendectomies. Study selection, data extraction, risk of bias assessment, and quality assessment were performed by one reviewer, with another reviewer to resolve discrepancies.Results: We identified 4799 articles, with 98.4% (4724/2799) concordance after initial review. Following resolution of discrepancies, 16 studies met inclusion criteria. Of the studies that reported each outcome, GS and PS demonstrated similar rates of readmission within 30 days (pooled RR 1.61 95% CI 0.66, 2.55) wound infections (pooled RR 1.07, 95% CI .55, 1.60), use of laparoscopic surgery (pooled RR 1.87, 95% CI .21, 3.53), postoperative complications (pooled RR 1.40, 95% CI .83, 1.97), use of preoperative imaging (pooled RR .98,95% CI .90, 1.05), and intra-abdominal abscesses (pooled RR .80, 95% CI .03, 1.58). Patients treated by GS did have a significantly higher risk of negative appendectomies (pooled RR 1.47, 95% CI 1.10, 1.84) when compared to PS.Discussion: This is the first meta-analysis to compare outcomes for pediatric appendectomies performed by GS compared to PS. Patient outcomes and resource utilization were similar among PS and GS, except for negative appendectomies were significantly more likely with GS.

Safety Issues in the Development of an Innovative Medical Parallel Robot Used in Renal Single-Incision Laparoscopic Surgery

Robotic-assisted single-incision laparoscopic surgery (SILS) is becoming an increasingly widespread field worldwide due to the benefits it brings to both the patient and the surgeon. The goal of this study is to develop a secure robotic solution for SILS, focusing specifically on urology, by identifying and addressing various safety concerns from an early design stage. Starting with the medical tasks and protocols, the technical specifications of the robotic system as well as potential; hazards have been identified. By employing competitive engineering design methods such as Analytic Hierarchy Process (AHP), Risk assessment, and Failure Mode and Effects Analysis (FMEA), a safe design solution is proposed. A set of experiments is conducted to validate the proposed concept, and the results strongly support the development of the experimental model. The Finite Element Analysis (FEA) method is applied to validate the mechanical architecture within a set of simulations, demonstrating the compliance of the robotic system with the proposed technical specifications and its capability to safely perform SILS procedures.

Application of a highly simulated and adaptable training system in the laparoscopic training course for surgical residents: Experience from a high-volume teaching hospital in China

Objective

To explore the effectiveness, feasibility, and training effect of a highly simulated and adaptable laparoscopic training system in the advanced integrated two-stage laparoscopic simulation training course for surgical residents.

Methods

This study prospectively took the surgical residents who received the advanced integrated two-stage laparoscopic simulation training course in our hospital from December 2019 to December 2021 as the research objects. In the stage one course, the trainees are randomly distributed into the dry simulation system group and Darwin laparoscopic training system group. The subjective assessment results of the trainees from the two groups are collected by questionnaires, and the simulation assessment results of the two groups are evaluated in a unified, objective, and standardized assessment form. The pre-course and post-course questionnaires were used to evaluate the feasibility and effectiveness of the Darwin system in the stage two course.

Results

A total of 62 trainees completed the stage one and stage two courses. In the stage one course, the trainees were randomly distributed into the dry simulation trainer group (N = 19) and the Darwin group (N = 43). The results of the subjective assessment questionnaire showed that compared with the dry simulator group, the students in the Darwin group had higher subjective scores (P < 0.05). The objective assessment results for the 3 modules of "One Track Transfer", "One Tunnel Pass" and "High and Low Pillars" in the Darwin group were significantly better than those in the dry simulator group (P < 0.05). The trainees who received the stage two course completed the questionnaires before and after the course. The results showed that compared with pre-course evaluation, "basic theoretical knowledge of laparoscopy", "basic skills of laparoscopy", "laparoscopic suture technique" and "camera-holding technique" were significantly improved after training (P < 0.05).

Conclusion

The highly simulated and adaptable laparoscopic training system is effective and feasible in the advanced integrated two-stage laparoscopic simulation training course for surgical residents.

Advances in the Treatment of Neonatal Biliary Disease

This article discusses current standard of care in neonatal biliary disease, particularly management of biliary atresia and choledochal cysts. It highlights surgical considerations, guidelines for adjuvant therapies, and promising therapeutic options that are under investigation.