Giant Anal Fibroepithelial Polyp in a Healthy Teenage Boy: A Case Report and Literature Review.

Background: Fibroepithelial polyps of the anus have been described as mucosal hypertrophy in response to chronic irritation or tissue damage. Lesions usually remain small and mostly present in elderly adults with local disease. Case Report: An otherwise healthy 15-year-old male presented with a giant pedunculated mass projecting out of the anal verge that enlarged over 2 years, causing discomfort. Results: Upon surgical excision and histologic examination, the mass resembled a fibroepithelial polyp with numerous dilated lymphatics. Conclusions: While literature describes the spectrum of pathology possible in such lesions, often consisting of a mixture of stromal and epithelial components, dilated lymphatics are less common. This giant anal fibroepithelial polyp characterized by edematous stroma and numerous dilated lymphatics is consistent with lymphangioma. To our knowledge, this presentation is novel in this age group with no underlying risk factors.

Nonpowder firearms cause significant pediatric injuries.

BACKGROUND: We hypothesize that nonpowder firearms cause significant injuries in children, often requiring intervention. We have noted a difference in demographics of children presenting with injuries from nonpowder firearms compared with patients injured by powder firearms. We reviewed our institution's experience with patients with nonpowder firearm injuries to evaluate these aspects. METHODS: A retrospective chart review was completed for all patients with a firearm injury from 2003 through February 2013 to a pediatric urban Level I trauma center. Patients were excluded if they were 18 years of age or older or readmitted. Demographics, injury circumstances, interventions, and outcomes were reviewed for 303 patients. The χ test and analysis of variance were completed with a statistical significance of p < 0.05. RESULTS: There were 57 nonpowder firearm injuries and 246 injuries from other firearms. Injuries occurred from BB, pellet, and paintball guns. Treatment included computed tomography scan in 39 patients, three bedside procedures, one angiography, and operative intervention in 25 patients. The most common injury locations were the eye (n = 37), head (n = 7), and neck (n = 6). Children injured by nonpowder firearms were less likely to be female (p = 0.04), more likely to be white (p < 0.01), and less likely to be injured in a violence-related event (p < 0.01). CONCLUSION: Nonpowder firearms can cause severe pediatric injuries requiring operative intervention and significant radiographic exposure from computed tomography scans. Prevention and education are important in decreasing this risk in the pediatric population and should be targeted to a different population than powder firearm prevention. LEVEL OF EVIDENCE: Epidemiologic study, level V.

Trends in pediatric firearm-related injuries over the past 10 years at an urban pediatric hospital.

PURPOSE: Firearm injuries are the second most common cause of trauma deaths in American children. We reviewed gunshot wounds treated at an urban children's hospital to determine the most likely time for injuries to occur over 10 years. METHODS: A retrospective chart review was completed for patients with a firearm injury from January 2003 to December 2012. Patients were excluded if over 17 years or readmitted. Demographics, injury circumstances, interventions, and outcomes were reviewed for 289 patients. Chi square and ANOVA analyses were completed. Alpha was chosen as p<0.05. RESULTS: Mean age was 12 years, 74% were male and 80% African American. Unintentional injuries occurred in 26% and violence related in 72%. The most common months of injury were August and June, the least common November and October. Unintentional injuries were more likely to occur during the day and violence related injuries were more likely at night (p=0.01). The incidence was lowest 2008-2010 and highest in 2006 and 2011. Mortality was 3.5%. CONCLUSIONS: We noted an increasing incidence of pediatric firearm related injuries in the last two years of the study with over half requiring operative intervention. Most injuries were violence related and occurred in a large city during summer months.

Consider benign Müllerian papilloma: a rare cause of vaginal bleeding in children.

Vaginal bleeding in young girls is a distressing symptom. Due to the potential for malignancy, thorough investigation is needed. Though rare, Müllerian papillomas are a benign cause of such symptoms. We report the case of a 2-year-old female who presented with acute onset of vaginal bleeding. She had another episode of bleeding during admission and was taken to the operating room for vaginoscopy under general anesthesia. A single friable lesion with active bleeding was visualized near the anterior vagina or cervix, which was biopsied. Histopathologic examination demonstrated characteristic features of benign Müllerian papilloma of infancy. Müllerian papillomas require examination under anesthesia and vaginoscopy with biopsies for efficient and accurate diagnosis. Treatment consists of complete local excision. Local recurrences are not uncommon, though prognosis for primary or recurrent disease is excellent.

Neonatal ovarian torsion complicated by intestinal obstruction and perforation, and review of the literature.

We present a case of neonatal ovarian torsion complicated by bowel obstruction and perforation and review the literature regarding the incidence of bowel obstruction in neonatal ovarian cysts, the presentation, and treatment. A term neonate was prenatally diagnosed with a cystic abdominal mass palpable on physical examination. A postnatal abdominal x-ray showed paucity of gas in the left hemiabdomen with rightward displacement of bowel loops. Exploratory laparotomy on day 2 of life revealed a large cystic mass in the left lower quadrant consistent with a torsed left ovary, an omental band causing strangulation of the bowel mesentery, and a perforation of the distal ileum. Our literature search revealed 19 reported cases of neonatal ovarian cysts resulting in bowel obstruction. Infants may present with a palpable abdominal mass, respiratory distress, as well as signs and symptoms of intestinal obstruction. Two mechanisms exist for bowel obstruction: adhesions caused by a torsed necrotic ovary and mass effect of a large ovarian cyst, often measuring 9 to 10 cm in diameter. Options to treat ovarian cysts include antenatal or postnatal aspiration, laparoscopy, and laparotomy. Cysts less than 4 to 5 cm can be observed, whereas operative intervention is indicated in symptomatic cases and in persistent or enlarging ovarian cysts.

Minimally invasive surgery of the lung: lung biopsy, treatment of spontaneous pneumothorax, and pulmonary resection.

Thoracoscopy of pediatric patients has evolved from diagnostic lung biopsy to a myriad of both diagnostic and therapeutic procedures. In this chapter, we discuss those procedures related to the child's lung which are most commonly performed: lung biopsy; resection of bronchogenic cysts, pulmonary sequestrations, and pulmonary lobes; and the treatment of spontaneous pneumothorax.

Pediatric robotic surgery: lessons from a clinical experience.

PURPOSE: Robotic surgery may improve minimally invasive surgery at high magnification by tremor filtration, motion-scaling, and improved dexterity with the provision of a wrist at the end of the robotic instrument. MATERIALS AND METHODS: We chose the Zeus Microwrist robotic surgical system as more applicable to small children than the competing da Vinci surgical system. We attempted 57 surgical procedures and completed 54. RESULTS: Completed procedures included Nissen fundoplication (n = 25), cholecystectomy (n = 18), Heller myotomy (n = 2), splenectomy (n = 2), Morgagni hernia repair (n = 2), and single cases of complex pyloroplasty in the chest, bowel resection, left Bochdalek congenital diaphragmatic hernia repair, esophageal atresia and tracheoesophageal fistula repair, and choledochal cyst excision. There were no complications related to the use of the robot. The mean time for the surgeon at the console using the robot was 117 +/- 39 minutes for Nissen fundoplication, and the total operating room time was 250 +/- 60 minutes. Surgeons found dissection, suturing, and knot tying easier than with conventional laparoscopy. None of the surgeons thought the lack of touch feedback (haptics) was crucial. CONCLUSION: Robotic surgery offers increased dexterity to the pediatric minimally invasive surgeon, but procedures require more time, and there is no defined patient benefit. The fact that robotic surgery digitalizes minimally invasive surgery creates exciting possibilities for training surgeons, planning operations, and performing surgery at great distances from the operator.

Pediatric blunt renal trauma: its conservative management and patterns of associated injuries.

OBJECTIVES: To review the conservative management of pediatric renal trauma and investigate the significance of associated nonrenal injuries. METHODS: We performed a retrospective review of 63 pediatric patients with blunt renal injury who were treated expectantly. A comparison was made between operative and nonoperative management, mechanism of injury, treatment complications, requirement for blood transfusion, length of hospital stay, associated injuries, and incidence of pre-existing urologic conditions. RESULTS: The renal injury grade was grade I in 31 patients, grade II in 12, grade III in 8, grade IV in 10, and grade V in 2. Two patients underwent acute surgical exploration; one for nonrenal causes and one (2%) for life-threatening renal bleeding (grade V injury). Renorrhaphy was not performed, and 98% of patients were initially treated nonoperatively. Three patients (5%) underwent delayed renal surgery: one nephrectomy for Wilms' tumor, one partial nephrectomy for nonhealing grade IV injury, and one attempted repair of a renal pelvis injury with subsequent nephrectomy. Excluding 1 patient who died and one nephrectomy for tumor control, our renal salvage rate was 97% (59 of 61). The overall mean hospital stay was 7.7 days and was similar across all grades (grade I, 7.7 days; grade II, 7.8; grade III, 6.1; grade IV, 9.2; and grade V, 10.5 days). CONCLUSIONS: The results of our study have shown that pediatric patients with blunt nonexsanguinating renal injuries treated conservatively do well. The length of hospital stay did not increase with worsening severity of renal injury and, instead, was determined by the severity of the nonrenal associated injuries. This report adds to a growing body of published data that suggest that conservative management of pediatric blunt renal trauma is safe.

Laparoscopic Morgagni hernia repair in children using robotic instruments.

BACKGROUND: Robotic surgery enhances minimally invasive surgery through tremor filtration, motion scaling, indexed movement, articulation, and improved ergonomics. We report 2 cases of computer- assisted, robot-enhanced, laparoscopic repair of Morgagni hernia in a 23-month-old weighing 10.2 kg and a 5-year-old weighing 21.6 kg. METHODS: Four 5 mm trocars were used to gain access to the abdomen. In the first case, standard laparoscopic instruments were used to dissect the liver from the rim of the defect and then reduce the hernia. In the second, robotic instruments were used for this dissection. In both cases, the robot- enhanced instruments were used to close the hernia defects with interrupted, nonabsorbable suture, using intracorporeal knot tying. RESULTS: Both cases were completed laparoscopically without a patch. The robotic system took 9 minutes to set up and drape. The average operative time was 227 minutes. The older child tolerated oral intake the day of surgery and went home the following day. The younger child tolerated oral intake and went home on postoperative day 2. CONCLUSION: Robot-assisted laparoscopic Morgagni hernia repair is feasible.

MRI detection of atrophic kidney in a hypertensive child with a single kidney.

The role of magnetic resonance imaging (MRI) in the work-up of secondary causes of pediatric hypertension is typically restricted to that of renovascular causes where main renal artery stenosis is suspected. We report a case of a 10-year-old female child with hypertension, who was thought to have unilateral renal agenesis, because only a solitary left kidney could be visualized on both ultrasound and renal scintigraphy. Our patient underwent magnetic resonance imaging because of suspected renal artery stenosis in her solitary left kidney. At MRI she was found to have a normal left kidney. However, a very tiny, atrophic right kidney was also visualized. A laparoscopic right nephrectomy was performed, which resulted in complete resolution of her hypertension. This case illustrates a possible additional role for MRI in a very small subset of pediatric hypertensive patients: those with a single kidney on ultrasound.

Computer-assisted, robot-enhanced open microsurgery in an animal model.

BACKGROUND: Computer-assisted, robot-enhanced surgery improves laparoscopic and thoracoscopic surgery through tremor filtration, motion scaling, articulation, and improved ergonomics. Surgeons perform many open cases under magnification that magnifies the tremor present in all surgeons' hands, so the tremor filtration and motion scaling of robotic surgery may improve microsurgery. Our goal was to compare microvascular anastomoses performed with a robot-enhanced technique with a standard technique. METHODS: We performed end-to-end anastomoses in 1-mm rat femoral arteries with interrupted 10-0 suture. We compared the anastomotic time, patency, and leak rates between traditional microsurgery techniques (by hand) and a robot-enhanced technique using the Zeus robotic surgery system (Computer Motion, Goleta, California). The surgeon used an operative microscope for visualization in both techniques. RESULTS: We performed 30 anastomoses by hand and 31 with Zeus. We observed a remarkable degree of tremor filtration in the robot-enhanced cases. Anastomotic times for both techniques demonstrated a learning curve. Anastomoses done by hand (mean time, 17.2 minutes) were significantly faster than those done with Zeus (mean time, 27.6 minutes) (P = 0.0006). All anastomoses from both groups were patent, and none leaked after 3 minutes. CONCLUSION: The Zeus system is effective at performing complex, open, microsurgery tasks in vivo. There was no measurable benefit from the remarkable tremor filtration and motion scaling offered by robot-enhanced surgery.

Devastating injuries in healthcare workers: description of the crisis and legislative solution to the epidemic of back injury from patient lifting.

The purpose of this report is to describe a crisis in healthcare, disabling back injuries in US healthcare workers. In addition, outlined is the proven solution of safe, mechanized, patient lifting, which has been shown to prevent these injuries. A "Safe Patient Handling--No Manual Lift" policy must be immediately instituted throughout this country. Such a policy is essential to halt hazardous manual patient lifting, which promotes needless disability and loss of healthcare workers, pain and risk of severe injury to patients, and tremendous waste of financial resources to employers and workers' compensation insurance carriers. Healthcare workers consistently rank among top occupations with disabling back injuries, primarily from manually lifting patients. Back injury may be the single largest contributor to the nursing shortage. Reported injuries to certified nursing assistants are three to four times that of registered nurses. A national healthcare policy for "Safe Patient Handling--No Manual Lift" is urgently needed to address this crisis. Body mechanics training is ineffective in prevention of back injury with patient lifting. Mandated use of mechanical patient lift equipment has proven to prevent most back injury to nursing personnel and reduce pain and injury to patients associated with manual lifting. With the national epidemic of morbid obesity in our country, innovative devices are available for use in emergency medical systems and hospitals for patient lifting and transfer without injury to hospital personnel. The US healthcare industry has not voluntarily taken measures necessary to reduce patient handling injury by use of mechanical lift devices. US healthcare workers who suffer disabling work-related back injuries are limited to the fixed, and often inadequate, relief which they may obtain from workers' compensation. Under workers' compensation law, healthcare workers injured lifting patients may not sue their employer for not providing mechanical lift equipment. Discarding healthcare workers disabled by preventable back injuries is an abuse which legislators must remedy. In addition, Medicare reimbursement policies must also be updated to allow the disabled community to purchase electrically operated overhead ceiling lifts. The US lags far behind countries with legislated manual handling regulations and "No Lifting" nursing policies. England and Australia have had "No Lifting" nursing policies in place since 1996 and 1998, respectively. The National Occupational Research Agenda (NORA) recognized a model in 2003 for reduction of back injuries to nursing staff in US healthcare facilities. Also in 2003, the American Nurses Association called for elimination of manual patient handling because it is unsafe and causes musculoskeletal injuries to nurses. The first state legislation for safe patient handling passed both houses in California but was vetoed by the Governor in September 2004. California and other states are preparing to (re)introduce legislation in January 2005. A national, industry-specific policy is essential to quell the outflow of nursing personnel to disability from manual patient lifting.

Totally minimally invasive robot-assisted unstented pyeloplasty using the Zeus Microwrist Surgical System: an animal study.

BACKGROUND: Minimally invasive pyeloplasty is a difficult procedure even for an expert laparoscopic surgeon. The major difficulty is associated with the limitations of intracorporeal suturing and knot tying. Surgical robots, which hold minimally invasive surgical instruments, have wrists and provide tremor filtration and motion scaling that might be expected to facilitate complex procedures in newborns. METHODS: Seven survival piglets (4.0-7.5 kg) underwent a totally minimally invasive robot-assisted unstented pyeloplasty employing the Zeus Robotic Microwrist System. The ureter was transected at the level of the ureteropelvic junction and 8 mm was resected. The unstented anastomosis was fashioned with running suture and intracorporeal knot tying. The animals were recovered and intravenous urography was performed at 1 month. After sacrifice, the anastomosis and the kidney were evaluated grossly and histologically for leak, caliber, and healing. RESULTS: All animals survived the procedure without postoperative complications. The mean robotic setup time was 19 minutes (range, 10-30 min), mean anastomosis time 51 minutes (range, 39-63 min), and mean total operation time 76 minutes (range, 57-87 min). The urography showed hydronephrosis in the first animal. The other 6 animals had no abnormalities. Histopathology demonstrated severe hydronephrosis in the first pig and moderate hydronephrosis in the sixth and seventh. All other animals had no sign of hydronephrosis. All anastomoses were well healed and intact. CONCLUSIONS: Robot-assisted laparoscopic pyeloplasty is a technically feasible procedure with acceptable morbidity in an animal model. The robotic technology enhances surgical dexterity and precision. Robotic assistance can increase the applicability of minimally invasive surgery to complex procedures in children.

Robot-enhanced fetoscopic surgery.

BACKGROUND: Fetoscopic surgery carries with it less maternal morbidity than open fetal surgery. Robotic surgery facilitates endoscopic surgery through tremor filtration, motion scaling, indexed movement, articulation, and improved ergonomics. The goal of the authors was to explore using a robotic surgery platform in a fetal animal model. METHODS: Using the Zeus Robotic Surgery System (Computer Motion, Santa Barbara, CA), fetoscopic surgery in pregnant sheep was performed using a variety of techniques: uterus exteriorized or totally percutaneous and with liquid or gas insufflation. Using the percutaneous technique and gas insufflation, the authors created and sutured fetal skin and fascial defects. The ewes were recovered and killed 2 weeks postoperatively, and autopsies were performed on them and their fetuses. RESULTS: In the exteriorized uterus model, instrument movement was unpredictable and fluid leaked. In the fluid environment, clouding of the visual field and difficulty in immobilizing the fetus were major difficulties. In the survival model, 4 of the 6 fetuses survived to autopsy at 2 weeks and showed good healing grossly and histologically. CONCLUSIONS: The Zeus Robotic Surgery System can be used for fetoscopic surgery in a sheep model. The percutaneous approach with a nitrous oxide environment is the most effective. Advantages of robotic surgery may be applicable in fetoscopic surgery, but further work in a primate model is required.

Robotically assisted esophago-esophagostomy in newborn pigs.

PURPOSE: Repair of esophageal atresia and tracheoesophageal fistula (TEF) in the newborn is challenging when done as an open procedure but only a few surgeons have attempted this with minimally invasive surgery (MIS). Surgical robots that hold MIS instruments have wrists and provide tremor filtration and motion scaling, which might be expected to facilitate complex procedures in small spaces such as an esophageal anastomosis in a newborn. METHODS: Seven newborn pigs weighing 2 to 3 kg were used as a model. The authors performed an esophageal resection and end-to-end anastomosis using the Zeus Microwrist Robotic Surgical System. The authors monitored the following data-Zeus robotic set-up time, operating time, esophageal dissection time, and anastomosis time. After 1 month, the animals were anesthetized to perform esophagram and than were killed. RESULTS: In these very small animals the space available for performing an anastomosis is very limited, approximately 2 cm3. Two pigs each died 18 days postoperatively. One animal could not eat and died during esophageal dilation. The second pig died of unrelated enteritis. Neither had evidence of anastomotic leak at autopsy. The esophagram of the 5 pigs that survived for 30 days showed no narrowing or proximal dilation in 2. In 3 there was some stenosis requiring dilation. Histopathology was done on each operated animal. Two of the anastomoses were well healed, and 5 showed only focal small ulceration. CONCLUSIONS: Robotic assistance facilitates an MIS approach to the upper esophagus even in the limited space of the infant chest.

Raman spectroscopy for neoplastic tissue differentiation: a pilot study.

BACKGROUND: Several changes occur during the transformation of normal tissue to neoplastic tissue. Such changes in molecular composition can be detected by Raman spectroscopy. Raman spectroscopy is a nondestructive method of measuring these changes, which suggests the possibility of real-time diagnosis during medical procedures. METHODS: This study seeks to evaluate the ability of Raman spectra to distinguish tissues. The Raman signatures of normal kidney, lung, and liver tissue samples from pigs and rats were characterized in vitro. Further, a human neuroblastoma and a hepatoblastoma, obtained at resection were also studied. RESULTS: The Raman spectra of the animal samples of kidney, liver, and lung are distinctly different in the intensity distribution of the Raman peaks. Further, the spectra of a given organ from pigs and rats, although similar, were different enough to distinguish between the 2 animals. In the patient tissues, the Raman spectra of normal liver, viable tumor, and fibrotic hepatoblastoma were very different. Fibrotic tissue showed a greater concentration of carotenoids, whereas viable tissue was rich in proteins and nucleic acids. The normal tissue showed both components. Similar differences were also seen in the neuroblastoma tissue. CONCLUSIONS: The results of this study show the potential use of Raman spectroscopy in clinical diagnosis.

Computer-assisted robot-enhanced laparoscopic fundoplication in children.

BACKGROUND/PURPOSE: Robotic surgery improves laparoscopic surgery through a more natural interface, tremor filtration, motion scaling, and additional degrees of freedom of the instruments. Here, the authors report that experience with robot-assisted fundoplication in children. METHODS: The authors have performed 15 laparoscopic fundoplications with the Zeus Robotic Surgery System and retrospectively reviewed prospectively collected data on set-up time, operating time, and outcome. RESULTS: All cases were completed successfully: one Heller myotomy with Dor fundoplication and 14 Nissen fundoplications. Patients ranged from 2 months to 18 years old (mean, 4.3 years) and from 3.4 kg to 37.7 kg (mean, 13.0 kg). There were no technical errors, equipment errors, or conversions. There were no complications in the first 30 days after surgery. The operating time declined from 323 minutes for the first case to 180 minutes for the last (mean, 195 minutes). The 14th case was the shortest at 123 minutes. Setting up the robotic surgery system took an average of 11 minutes. The surgeons perceived benefits of greater ease and confidence in suture placement and knot tying. CONCLUSIONS: The authors have successfully used surgical robots for gastric fundoplication at a pediatric teaching hospital. Our experience with this operation has shown the additional dexterity that the robot provides and will pave the way to more complex procedures.

Robotics in pediatric surgery: perspectives for imaging.

Robotic surgery will give surgeons the ability to perform essentially tremorless microsurgery in tiny spaces with delicate precision and may enable procedures never before possible on children, neonates, and fetuses. Collaboration with radiologists, engineers, and other scientists will permit refinement of image-guided technologies and allow the realization of truly remarkable concepts in minimally invasive surgery. While robotic surgery is now in clinical use in several surgical specialties (heart bypass, prostate removal, and various gastrointestinal procedures), the greatest promise of robotics lies in pediatric surgery. We will briefly review the history and background of robotic technology in surgery, discuss its present benefits and uses and those being explored, and speculate on the future, with attention to the current and potential involvement of imaging modalities and the role of image guidance.