Laparoscopic removal of detached peritoneal end of ventriculo-peritoneal shunt

Review of laparoscopic median sacral artery ligation in sacrococcygeal teratoma Abstract Introduction Sacrococcygeal teratoma is one of the commonest neonatal tumour usually presenting as a large exophytic sacral mass in utero and at birth. It is a highly vascular tumour and the main blood vessel supplying it is median sacral artery (MSA) which can cause torrential haemorrhage during excision. Many surgeons advocate ligation of MSA prior to tumour excision. Traditionally it was done by laparotomy or by posterior midline approach prior to tumour excision. Methods Laparoscopic ligation of MSA in neonates prior to tumour excision was performed using a ultrasonic dissector to expose the area. Using endoclips the artery was ligated, following which the tumors were resected. Results The procedures were completed with minimal blood loss and successul excision of the tumor was achieved in our patients. Conclusion Haemorrhage is the principal concern during sacrococcygeal teratoma excision. This risk can be safely minimized by laparoscopically ligating the median sacral artery which is the principal feeding vessel for the tumor.

Is there a role for prophylactic drainage of the abdominal cavity after laparoscopic appendectomy for non-complicated appendicitis in children? Abstract Introduction Peritoneal drainage has been used to prevent infectious complications after either laparoscopic or open appendectomy. Unlike in complicated appendicitis, where intraoperative drainage at the end of the procedure has clear benefits, in un-complicated appendicitis, the usefulness of peritoneal drainage is still under debate. This study aims to clarify if intraoperative drainage of the peritoneal cavity during laparoscopic appendectomy for uncomplicated appendicitis in children has beneficial consequences for the postoperative course of the patient. Methods In a 12-month period, we performed 120 consecutive laparoscopic appendectomies, for uncomplicated appendicitis. Postoperative drainage was used in 44 patients. We have collected and analyzed data concerning operating time, postoperative course and complications, need for analgesia, time to resumption of bowel movement and hospital stay. Results No significant incidents during surgery have been recorded. Postoperative intraabdominal abscesses occurred in two cases, one for each group. Mean hospital stay, operating time, the need for postoperative analgesia and regain of the gastro-intestinal transit were all longer for the drained group. Conclusions Complication rate, postoperative pain, hospital stay are all higher after prophylactic drainage of the peritoneal cavity after laparoscopic appendectomy for non-complicated appendicitis. The prophylactic use of abdominal drainage after laparoscopic appendectomy for non-complicated appendicitis in children does not prevent postoperative complications and has no or even negative consequences for the postoperative course of the patients.

Urology robotic journey: demonstrating the learning curve in robot-assisted pyeloplasties (RALP) Abstract Introduction The advantages of robot-assisted pyeloplasties (RALP) have been widely documented and increasingly familiar. A ‘learning curve’ (LC) is difficult to define and its objective review remains problematic. We aimed to evaluate the LC, and outcomes, of RALP performed at our newly established robotic centre. Method and materials After the appropriate training, robot-assisted surgery (RAS) commenced at our centre. A prospective database was maintained regarding demographics and intra-operative timings of all cases, post-operative stay and complications. The data were statistically interrogated and linear regression analysis was performed. Results Between April 2014 and September 2018, 29 urological RAS were performed including 23 RALP. The total operating and total console times were significantly decreased over time, with no significant differences seen in length of stay or complication rates. Regression analysis predicted achievement of open pyeloplasty time (148 min) at 26 cases and ‘expert’ console time (58 min) by case 34. Median length of stay was 2 days and operative success rate 96%. Discussion RAS is proliferating across the globe. LC is difficult to define objectively. We suggest that the points described here in this ‘learning journey’ can be applied to other nascent departments and that RALP is safe and feasible within a developing urology unit.

Editorial: 14th pediatric endoscopic surgeons of India 2019 annual conference

Paediatric robotic surgery and urology: where are we?

Laparoscopic options in superior mesenteric artery syndrome in children: systematic review Abstract Purpose Superior mesenteric artery syndrome (SMAS) refers to the compression of the third portion of the duodenum between the aorta and the superior mesenteric artery, and usually results from weight loss or alteration in spine anatomy. This study reviewed laparoscopic options regarding SMA S in children. Methods MEDLINE/PubMed was reviewed. Studies in patients under 16 years of age and published in English/Spanish were included, and selected by two independent reviewers. Data were collected for age, gender, weight/body mass index, comorbidities, symptoms, surgical technique, complications, conversions, recurrence and mortality. Descriptive statistics were used to analyze the quantitative portion of the study, with results presented as percentages, means and medians. Results Twelve papers with n = 16 patients were included. Mean/median age were 10.7 and 13 years, respectively, with female predominance (n = 11, 68.75%). Emesis (n = 15, 93.75%) and abdominal pain (n = 11, 68.75%) were the most common symptoms. Anorexia nervosa was present in n = 1, and n = 1 patient had recent history of spinal fusion for idiopathic scoliosis. Regarding surgical technique, eleven cases consisted of duodenojejunostomy with side-to-side anastomosis (one associated with feeding jejunostomy); two Strong’s procedures; and three Ladd’s procedures. There were no conversions, and n = 2 (12.5%) minor complications (self-limited upper gastrointestinal bleed and persistence of vomiting for 48 h post-operatory). There was no mortality. Mean and median follow-up were 44.5 and 48 weeks, respectively, with no recurrences. Conclusions SMAS is uncommon in children. The preferred laparoscopic approach is duodenojejunostomy, which can provide definitive relief of the obstruction with minor complications and low recurrence.

Improved outcome in laparoscopic splenectomy in children with benign hematological disease after standardization of techniques Abstract Background Laparoscopic splenectomy has gained popularity in the management of children with benign hematological disease who required splenectomy. We aim to report the outcome after standardization of techniques in laparoscopic splenectomy. Materials and methods A retrospective study was conducted in which all children with benign hematological disease underwent laparoscopic splenectomy in our institute from 2003 to 2017. The demographics and outcomes before (Group 1) and after (Group 2) standardization of techniques were compared. The laparoscopic techniques were standardized in Group 2. They all underwent multiport laparoscopic splenectomy and the splenic pedicles were divided by bipolar sealing device (LigaSure). In Group 1, splenectomy could be performed by single port or multiple ports approach. The splenic pedicles could be divided by endovascular stapler or LigaSure. Results Group 1 included 14 children who underwent splenectomy from 2003 to 2010 and Group 2 included 9 children who were operated from 2011 to 2017. The demographics were comparable between the two groups. Group 2 was associated with lower complication (0 vs. 5, p = 0.043), shorter operative time in splenectomy (146 min vs. 173 min, p = 0.056) and shorter mean hospital stay (3.8 days vs. 7.1 days, p < 0.0001). Conclusions Superior outcomes including lower complication rates and shorter hospital stay were observed after standardization of surgical techniques in laparoscopic splenectomy in children using multiple ports and LigaSure.

Modified retroperitoneal laparoscopic dismembered pyeloplasty for children Abstract Aim We describe our modified retroperitoneal laparoscopic pyeloplasty (MRLP) and assess the incidence of anastomotic stricture and torsion of the ureter in the mid-term. Methods We reviewed 12 patients with ureteropelvic junction obstruction (UPJO) we treated with MRLP between 2013 and 2018. MRLP involves: identifying the lowest point of the renal pelvis and the lateral aspect of the ureter to ensure correct orientation of the anastomosis; placing the first suture between the lower edge of the incised pelvis and the distal end of the spatulated ureter to avoid crushing tissue that will be anastomosed; and complete excision of the narrow segment. Results All MRLP were completed successfully without conversion. UPJO was resolved completely, both clinically and radiologically, in all cases. Mean age at surgery was 6.8 years (range: 1.7–8.8 years); mean operative time was 212.1 min (range: 170–333 min); mean estimated blood loss was 4.2 mL (range: 2–8 mL); mean follow-up was 36.7 months (range: 6–65 months); mean post-operative differential renal function on the affected side was 53.1 ± 13.7% (range: 37.0–87.2%), increased from 44.9 ± 16.0% (range: 27.0–84.3%), pre-operatively (p = 0.02). All remain completely cured after mean follow-up of 36.7 ± 19.7 months (range: 6–65). Conclusions Our MRLP is safe and effective despite limited retroperitoneal space.

Long-term outcome of minimal access surgery for hydatidosis in children: a single institutional experience Abstract Background Human cystic echinococcosis continues to be a public health problem worldwide. The standard treatment of hydatidosis in children is open surgical intervention for removal of the cyst completely without spillage. The limited use of minimal invasive surgery (MIS) in hydatidosis has been due to the concern of inadequate removal and spillage, leading to recurrence or dissemination of the disease. Recently, a few authors have reported the successful use of minimal invasive surgery (MIS) for management of hydatid disease in children. We present our experience with successful use of MIS in the management of hydatid disease involving lung and liver in children. Methods Between 2006 and 2017, data of 22 children treated for hydatid disease in our institute were reviewed. The diagnosis was made radiologically with Computerised Tomography scan of chest and abdomen. All children received albendazole therapy prior to and after the surgery. Thoracoscopic/laparoscopic procedures were undertaken sequentially in all children. Children with synchronous disease involving lung and liver had an interval of 2 weeks between procedures. The techniques of puncture, aspiration, injection and re-aspiration (PAIR) and also our modifications of cyst removal are described. Results There were a total of 22 children with liver and or lung involvement. Four children had synchronous lung and liver involvement and four children had bilateral lung involvement. The duration of the procedure ranged from 60 to 90 min. There were 3 (18) conversions in the thoracic group and 1 (12) in the laparoscopic group. PAIR technique with our modification of cyst extraction was used in all except in one child. Capitonnage of the cyst wall in lung hydatidosis was not done. There were no postoperative events. Recurrence of the lesion at original site was seen in two children, one each in laparoscopic and thoracoscopic group. Occurrence of new lesion or dissemination of the disease was not identified on a mean follow-up of 7 years. Conclusion Our series demonstrates the safe and effective utility of MIS in management of pulmonary and liver hydatid in children. Use of MIS does not lead to dissemination of the disease. Albendazole therapy is an useful adjunct prior to surgery. Single lung ventilation with isolation of uninvolved lung is useful during surgery for lung hydatid.