Minimally invasive surgery in the diagnosis and treatment of abdominal pain in children

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.

Total laparoscopic management of spontaneous biliary perforation

Spontaneous biliary perforation (SBP) in pediatrics is rare and historically has been treated with laparotomy for attempted repair and cholecystectomy. In recent years, management has evolved into a conservative approach, opting for cholecystostomy and peritoneal drainage over cholecystectomy. In this case, we report the first successful conservative management of SBP using an exclusively laparoscopic approach without cholecystectomy in a pediatric patient.

Evolving pediatric epidural practice: An institution's clinical experience over 20 years-A retrospective observational cohort study

BACKGROUND AND OBJECTIVES

Epidural analgesia is an effective, established perioperative intervention in all age-groups. In children, however, epidural-related data are limited compared to the adult population. The aim of this study was to examine the use of pediatric epidural analgesia in our institution and, thereby, add to the existing data pool.

METHODOLOGY

Patients who received epidural analgesia as part of their perioperative management between 1996 and 2016 at Great Ormond Street Hospital, London, UK, were studied to determine how epidural practice has changed over time, associated incidence of serious adverse events, complications, and patient/parent satisfaction. Epidural use and monitoring were in accordance with standard hospital protocols. Data were prospectively collected and entered into a secure database by trained personnel. These data were subsequently extracted for retrospective analysis.

RESULTS

A total of 3876 patients were included. The median age was 4.4 years (range 1 day to 20 years), and the median weight was 20.3 kg. Across all age-groups, the lumbar region was the most common site of epidural insertion while urology (42.2%) and general surgery (37.3%) were the specialities for which it was most utilized. Over the study period, the number of epidurals performed declined while the number of surgical procedures performed simultaneously increased. The infusate most commonly used was local anesthetic with preservative-free morphine (71.9%). In 923 (23.2%) patients, systemic opioids were additionally used for analgesic management by means of patient-controlled analgesia or nurse-controlled analgesia. There was one serious adverse event in the form of permanent nerve injury, giving an overall incidence of approximately 1:3800. Other complications included postoperative nausea and vomiting (35.9%), urinary retention (4.4%), and pruritus (31%). Overall global satisfaction with the service was generally high, with 95% providing a rating of "very good" or "good."

CONCLUSION

This study evaluated two decades of epidural practice in our institution. Epidural analgesia remains a safe, effective option for postoperative analgesia, but its use has declined over time, and this trend is likely to continue. Rates of serious adverse events and complications were low and comparable to those published in other similar studies. Global satisfaction among patients/parents remains high.

Rare occurrence of small bowel volvulus following laparoscopic appendicectomy for perforated appendicitis

Intestinal volvulus is a rare complication following laparoscopic surgery. We present the case of a young boy who had developed a small bowel obstruction following laparoscopic appendicectomy for perforated appendicitis. He had no evidence of any congenital malrotation on initial laparoscopy, yet was subsequently found to have a midgut volvulus requiring emergency laparotomy. No resection was required and subsequent convalescence was uncomplicated. This case highlights the importance of recognition of this uncommon but potential early complication of laparoscopy that warrants urgent surgical intervention.

Pediatric anesthesia for minimally invasive surgery in pediatric urology

Laparoscopic or robotic minimally invasive approaches have become the standard of care for many urological pediatric surgical procedures. Anesthetic concerns for conventional and robotic laparoscopy are similar since they both require insufflations of CO₂ to allow visualization of surgical field and perform surgery. Even if required insufflation pressures and volumes are lower in pediatric patients (given the small size of the abdomen and laxity of the abdominal walls), the associated increase of intra-abdominal pressure, along with absorption of CO₂ and surgical positioning requirement, may result in neurendocrine and mechanical impact capable to mine cardiopulmonary function. Moreover, laparoscopic approach may require specific positioning. A correct positioning is essential to allow the surgical team to optimally and safely access to the patient. The knowledge of patient's health status, along with the multiple physiologic changes that can occur and specific potential complications, allow the anesthesiologist to provide a safer an aesthesia.

What are the prospects for non-scheduled robotic procedures in pediatric surgery?

Robotic technology allows for the management of complex surgical cases with a minimally invasive approach. The aim of this study was to communicate our experience using robotic technology for non-scheduled pediatric procedures (NSP). We performed a prospective study over the last 5 years including all consecutive cases where surgery was performed with a robot. NSP procedures were defined as a time to surgery of <24 h. Preoperative time, operative time, overall completion rate, and postoperative course were analyzed. Of the 85 cases recorded, five corresponded to robot-assisted NSP with a mean weight of 10 kg (3-36 kg). The mean time before surgery was 19 h (11-24 h). Conversion rate to open procedure was 40 %. Fifteen NSP had to be performed without robotic plateform. Robotic surgery is a potentially relevant option for most pediatric thoracic or abdominal procedures performed in a non-scheduled setting and offers technical advantages.

Laparoscopic excision of a ciliated hepatic foregut cyst in a child: A case report and review of the literature

Introduction

Ciliated hepatic foregut cysts (CHFC) are rare congenital hepatic lesions derived from the embryonic foregut. Because of potential transformation to squamous cell carcinoma in adulthood, the mainstay of therapy is surgical resection. To our knowledge, we report the first case of CHFC in a child that was successfully excised laparoscopically.

Presentation of case

We report a case of a 4-year-old boy that was diagnosed with an asymptomatic 5-cm liver cyst. After surveillance for 3 years, the cyst grew to 7 cm at which time it was successfully resected laparoscopically. The pathology was consistent with CHFC.

Discussion

There have been few previous reports of CHFCs in children, all of which described excision via a laparotomy. This is the first case report of laparoscopic resection of CHFC in a child.

Conclusion

This case report suggests that laparoscopy may be safe and effective for resection of CHFCs with favorable anatomy such as peripheral location and noninvolvement of key vascular and biliary structures.

•

Ciliated hepatic foregut cyst (CHFC) is a rare congenital hepatic lesion.

•

Indications for excision include large size, symptoms and LFT abnormalities.

•

Laparoscopic excision is safe for CHFC and should be considered.

Robotic Surgery may Not "Make the Cut" in Pediatrics

Since the introduction of robotic surgery in children in 2001, it has been employed by select pediatric laparoscopic surgeons, but not to the degree of adult surgical specialists. It has been suggested that the technical capabilities of the robot may be ideal for complex pediatric surgical cases that require intricate dissection. However, due to the size constraints of the robot for small pediatric patients, the tight financial margins that pediatric hospitals face, and the lack of high level data displaying patient benefit when compared to conventional laparoscopic surgery, it may be some time before the robotic surgical platform is widely embraced in pediatric surgical practice.

The impact of visual scanning in the laparoscopic environment after engaging in strain coping

OBJECTIVE

We aimed to determine whether visual scanning has a detrimental impact on the monitoring of critical signals and the performance of a concurrent laparoscopic training task after participants engaged in Hockey's strain coping. Strain coping refers to straining cognitive (attentional) resources joined with latent decrements (i.e., stress).

BACKGROUND

DeLucia and Betts (2008) reported that monitoring critical signals degraded performance of a laparoscopic peg-reversal task compared with no monitoring. However, performance did not differ between displays in which critical signals were shown on split screens (less visual scanning) and separated displays (more visual scanning). We hypothesized that effects of scanning may occur after prolonged strain coping.

METHOD

Using a between-subjects design, we had undergraduates perform a laparoscopic training task that induced strain coping. Then they performed a laparoscopic peg-reversal task while monitoring critical signals with a split-screen or separated display. We administered the NASA-Task Load Index (TLX) and Dundee Stress State Questionnaire (DSSQ) to assess strain coping.

RESULTS

The TLX and DSSQ profiles indicated that participants engaged in strain coping. Monitoring critical signals resulted in slowed peg-reversal performance compared with no monitoring. Separated displays degraded critical-signal monitoring compared with split-screen displays.

CONCLUSION

After novice observers experience strain coping, visual scanning can impair the detection of critical signals.

APPLICATION

Results suggest that the design and arrangement of displays in the operating room must incorporate the attentional limitations of the surgeon. Designs that induce visual scanning may impair monitoring of critical information at least in novices. Presenting displays closely in space may be beneficial.

Role of laparoscopy in non-trauma emergency pediatric surgery: a 5-year, single center experience a retrospective descriptive study with literature review

Background

Although laparoscopy is rapidly becoming the abdominal surgical modality of choice in adults, there are obstacles to its use in children. We analyzed our experience with pediatric laparoscopic surgery over the past 5 years, with particular emphasis on emergency procedures.

Findings

We retrospectively evaluated the records of patients aged <14 years who had undergone laparoscopic procedures for non-trauma emergency conditions at our institution from January 2006 to December 2010. The clinical parameters evaluated included operation time, total length of hospital stay, and postoperative complications.

During the 5-year study period, 482 laparoscopic procedures were performed on patients aged <14 years, comprising 300 emergency and 182 elective operations. The majority of procedures were laparoscopic appendectomies, with most of the others being resections of ovarian cysts or Meckel’s diverticulae, or adhesiolyses. We observed an improvement in outcomes over the 5-year period, as shown by shorter operation times and shorter postoperative hospital stays. The numbers of laparoscopic procedures performed increased over time.

Conclusions

Pediatric laparoscopic surgery for emergency conditions provides excellent results, including better exposure and cosmetic outcomes than laparotomy. At our institution, the numbers and types of laparoscopic procedures performed have increased over time, and the outcomes of laparoscopic procedures have improved.

Recent advances and controversies in pediatric laparoscopic surgery

Children represent a unique group of patients who are likely to greatly benefit from minimally invasive surgery (MIS). The promise of less postoperative pain, smaller scars, shorter hospital stays, and a faster return to school continues to drive growth in this area. The development of pediatric-specific techniques and documentation of improved outcomes form a critical gateway to widespread application of pediatric MIS. A brief perspective on current approaches to MIS for pediatric congenital and acquired disease is provided in this report. Technical departures from standardized adult MIS and the rationale for their modification are highlighted.

Perceptual distortions produce multidimensional stress profiles in novice users of an endoscopic surgery simulator

OBJECTIVES

We determine the impact of perceptual-motor distortions on multidimensional stress dynamics in novice users of an endoscopic/laparoscopic surgery simulator during performance of a peg-transfer task.

BACKGROUND

Surgeons find the endoscopic/laparoscopic surgery procedure to be more mentally stressful than open surgery. This investigation was designed to identify specific stress dimensions associated with these procedures and to determine the contributions to that stress made by loss of depth information resulting from image-guided views of the surgical field and by disruption of eye-hand mapping. Because stress reactions might depend upon familiarity with these procedures, the study focused upon novice participants.

METHOD

An endoscopic box-simulator featured in surgical training was used in conjunction with the Dundee Stress State Questionnaire, a well-validated multidimensional stress state instrument. A control group (no perceptual distortions) viewed the simulated "surgical field" directly. Two other groups viewed the surgical field through TV images in which spatial rotation of the images was absent or in which the images were rotated 90 degrees from the actual line of sight.

RESULTS

Performance efficiency in the simulator varied inversely with the degree of perceptual-motor distortion. Reactions reflecting increased task coping were observed in all groups. These were accompanied in the image groups by negative reactions involving decreases in hedonic tone and control and confidence and an increase in tense arousal.

CONCLUSIONS

Perceptual-motor distortions are sources of complex task-induced stress profiles in novices using an endoscopic surgery simulator.

APPLICATION

Procedures to reduce stress in endoscopic/laparoscopic surgery trainees may benefit from knowledge regarding specific stress dimensions involved.