The safe introduction of robotic surgery in a free-standing children's hospital.

The aim of this study is to report the experience of implementing a pediatric robotic surgery program at a free-standing pediatric teaching hospital. A database was created to prospectively collect perioperative data for all robotic surgeries performed by the pediatric surgery department. The database was queried for all operations completed from October 2015 to December 2021. Descriptive statistics were used to characterize the dataset, using median and interquartile ranges for continuous variables. From October 2015 to December 2021, a total of 249 robotic surgeries were performed in the department of pediatric surgery. Of the 249 cases, 170 (68.3%) were female and 79 (31.7%) were male. Across all patients, there was a median weight (IQR) of 62.65 kg (48.2-76.68 kg) and a median (IQR) age of 16 years (13-18 years). The median (IQR) operative time was 104 min (79.0-138 min). The median console time was 54.0 min (33.0-76.0 min) and the median docking time was 7 min (5-11 min). The majority of procedures were performed on the biliary tree (52.6%). In the 249 procedures, there were no technical failures of the robot and only two operations (0.8%) were converted to open procedures and one (0.4%) to laparoscopic. This study highlights the ability to successfully integrate a pediatric robotic surgery program into a free-standing children's hospital with a low conversion rate. Additionally, the program extended across multiple surgical procedures and offered real-time exposure to advanced surgical techniques for current and aspiring pediatric surgery trainees.

Pediatric Single-Incision Robotic Cholecystectomy: A 6-Year Update from a Single Institution.

Introduction: In children, gallbladder disease has become more common due to the rise in childhood obesity and subsequent shift in etiology. While the gold standard of surgical management remains a laparoscopic technique, there has been increasing interest in robotic-assisted techniques. The aim of this study is to report a 6-year update on the experience of treating gallbladder disease with robotic-assisted surgery at a single institution. Materials and Methods: A database was created to prospectively collect patient demographic and operative variables at the time of operation from October 2015 to May 2021. Descriptive analysis of select available variables was performed using median and interquartile ranges (IQRs) for all continuous variables. Results: In total, 102 single-incision robotic cholecystectomies and one single-port subtotal cholecystectomy were performed. From available data, 82 (79.6%) patients were female, median weight was 66.25 kg (IQR: 58.09-74.24 kg), and median age was 15 years (IQR: 15-18 years). Median procedure time was 84 minutes (IQR: 70.25-103.5 minutes) and median console time was 41 minutes (IQR: 30-59.5 minutes). The most frequent preoperative diagnosis was symptomatic cholelithiasis (79.6%). One (0.97%) operation was converted from a single-incision robotic approach to open. Conclusion: Single-incision robotic cholecystectomy is a safe and reliable technique for the treatment of gallbladder disease in the adolescent population.

Percutaneous endoscopic gastrostomy tube placement via the introducer technique is safe and effective in children when compared to the laparoscopic technique.

PURPOSE: We compare our experience of percutaneous endoscopic gastrostomy, introducer technique (PEG) and laparoscopic technique (LapGT) at a tertiary care pediatric hospital. METHODS: Isolated PEGs and LapGTs placements were reviewed at our institution from August 2016 through January 2018. Demographics, procedure time, operative charges, and 30-day complications were reviewed. Means of quantitative values were compared using the student's t test. Categorical values were compared using the X2 test. RESULTS: Ninety-three isolated gastrostomy tubes were placed in children aged 2 weeks to 19 years. There were 56 PEGs (60%) and 37 LapGTs (40%), based on surgeon preference. There was no significant difference in demographics between the two groups. Mean operative time for PEG was 59% shorter (14 vs. 33 min, p < 0.001). Operating room charges averaged $4500 less in the PEG group ($11,400 vs. $15,900, p < 0.001). Neither group had complications that required a return to the operating room within 30 days postoperatively. There was no difference in the rate of fundoplication after gastrostomy tube placement. In two cases PEGs were converted to LapGTs after safety criteria for PEG were not met. CONCLUSION: The PEG introducer technique, when used with clearly defined safety criteria, decreased operative time and cost without compromising safety. LEVEL OF EVIDENCE: III.

Epidemiology of pediatric trauma during the COVID-19 pandemic shelter in place.

INTRODUCTION: The first COVID-19 cases occurred in the US in January of 2020, leading to the implementation of shelter in place. This study seeks to define the impact of shelter in place on the epidemiology of pediatric trauma. METHODS: We examined pediatric trauma admissions at 5 Level 1 and 1 Level 2 US pediatric trauma centers between January 1 and June 30, 2017-2020. Demographic and injury data were compared between pre- and post-shelter in place patient cohorts. RESULTS: A total of 8772 pediatric trauma activations were reviewed. There was a 13% decrease in trauma volume in 2020, with a nadir at 16 days following implementation of shelter in place. Injury severity scores were higher in the post-shelter in place cohort. The incidence of nonmotorized vehicle accidents and gunshot wounds increased in the post-shelter in place cohort. CONCLUSION: We found an overall decrease in pediatric trauma volume following shelter in place. However, injuries tended to be more severe. Our findings help inform targeted injury prevention campaigns during future pandemics.

Early transition to oral antibiotics for treatment of perforated appendicitis in pediatric patients: Confirmation of the safety and efficacy of a growing national trend.

PURPOSE: We performed a quality improvement initiative to monitor the change in protocol from purely intravenous therapy for perforated appendicitis to oral antibiotics at discharge once patients could tolerate eating. METHODS: Standardized prospective data were gathered on all children with perforated appendicitis treated under the new oral protocol from January 1 to December 31, 2014. Retrospective data through chart review were gathered on all children treated for perforated appendicitis during 2013. We compared demographics, clinical parameters, and hospital charges. RESULTS: Comparing 115 patients in 2013 and 144 in 2014, demographics and clinical characteristics were similar. In 2014, 95% of patients were discharged on oral therapy. Compared to the intravenous group, the enteric group had statistically lower rates of repeat ultrasound imaging (49.6% vs 35.1%) and PICC placement (98.3% vs 9.1%) and similar rates of intraabdominal abscess (20.9% vs 16.0%) and antibiotic change (26.1% vs 22.2%). In 2014, 55% of patients were discharged by postoperative day 5, compared to 33% in 2013. Total antibiotic days and readmission rate were similar, while hospital charges decreased by half. CONCLUSION: Our results reaffirm that transition to oral antibiotics is safe, effective, and cost-efficient in treatment of perforated appendicitis in the child.

Single-Incision Single-Instrument Adnexal Surgery in Pediatric Patients.

Introduction. Pediatric surgeons often practice pediatric gynecology. The single-incision single-instrument (SISI) technique used for appendectomy is applicable in gynecologic surgery. Methods. We retrospectively analyzed the records of patients undergoing pelvic surgery from 2008 to 2013. SISI utilized a 12 mm transumbilical trocar and an operating endoscope. The adnexa can be detorsed intracorporeally or extracorporealized via the umbilicus for lesion removal. Results. We performed 271 ovarian or paraovarian surgeries in 258 patients. In 147 (54%), the initial approach was SISI; 75 cases (51%) were completed in patients aged from 1 day to 19.9 years and weighing 4.7 to 117 kg. Conversion to standard laparoscopy was due to contralateral oophoropexy, solid mass, inability to mobilize the adnexa, large mass, bleeding, adhesions, or better visualization. When SISI surgery was converted to Pfannenstiel, the principal reason was a solid mass. SISI surgery was significantly shorter than standard laparoscopy. There were no major complications and the overall cohort had an 11% minor complication rate. Conclusion. SISI adnexal surgery is safe, quick, inexpensive, and effective in pediatric patients. SISI was successful in over half the patients in whom it was attempted and offers a scarless result. If unsuccessful, the majority of cases can be completed with standard multiport laparoscopy.

Management of spontaneous pneumomediastinum in children.

PURPOSE: We characterize the outcomes of pediatric spontaneous pneumomediastinum in the largest series to date and propose a management pathway. METHODS: All patients at our institution with ICD-9 code 518.1 confirmed to have isolated radiographic findings of spontaneous pneumomediastinum between January 2003 and February 2014 were retrospectively reviewed for admission, intensive care unit (ICU) stay, complications, and outcome. RESULTS: We identified 96 children with 99 episodes, median age 14.1 years (IQR: 8.7-16.4). Primary symptoms were chest pain, cough, and dyspnea. Most were hospitalized (n=91, 91.9%), with 20 (20.2%) admitted to ICU. Median lengths of stay (LOS) were 1 day (IQR: 1-2) for non-ICU admissions and 3 days (IQR: 2-3) for ICU admissions. The surgical service discharged non-ICU patients 0.94 days earlier than medical services (95% CI 0.38-1.50, p=0.0014). Asthma affected neither LOS nor ICU admission rates. Follow-up imaging, when obtained (n=81, 81.8%), did not alter management. Recurrences occurred in three asthmatics, all after one year. Each was rehospitalized and discharged uneventfully. No patient developed pneumomediastinum-related complications (e.g., pneumothorax, pneumopericardium, or mediastinitis). CONCLUSION: Spontaneous pneumomediastinum without associated comorbidities can be managed with expectant outpatient observation without further imaging. Children with asthma should be treated independent of spontaneous pneumomediastinum.

Nitrous oxide procedural sedation in non-fasting pediatric patients undergoing minor surgery: a 12-year experience with 1,058 patients.

BACKGROUND: Nitrous oxide's safety and efficacy for minor procedures is an alternative to general anesthesia, complex sedation protocols, or local anesthetic alone. METHODS: A retrospective review of prospectively-collected data (2000-2012) identified 1,058 children who received single-agent nitrous oxide for minor surgery. RESULTS: Children (n = 1,058, male 42 %, female 58 %) aged 1-23 years (mean = 9.8 + 5.1 years) were identified. Only nine children (0.9 %) fasted. ASA status was I-II in 1,053 (99.5 %) of patients; five (0.5 %) had an ASA III. There were no major complications (desaturation, emergency admission, apnea, airway obstruction, bradycardia) or aborted procedures. Minor complications occurred in 1.8 %; there was no association between these complications and ASA, fasting status or maximum nitrous oxide percentage administered (all p > 0.05). Post-operatively, 98 % of patients denied getting an injection. Eighty-two percent reported mild or no procedural pain. CONCLUSION: This is the longest reported study using non-anesthesiologist-administered nitrous oxide as a single-agent for minor surgical procedures. The technique provides safe sedation and excellent amnesia, allowing pain and anxiety-reduced surgery with no fasting or postoperative monitoring.

Chronic vomiting and recurrent pneumonia in an adolescent female.

A 17-year-old girl presented with episodic vomiting associated with chest pain, a 20-pound weight loss over the past year, and multiple hospitalizations for pneumonia. She was bradycardic, cachectic (<3rd percentile), pale, and had anterior cervical lymphadenopathy. CT angiography suggested an obstructive vascular ring (formed by a right aortic arch with an aberrant left subclavian artery), diverticulum of Kommerell, and a tracheoesophageal fistula (TEF). She underwent left thoracotomy with ligation and division of the ligamentum arteriosum to relieve the vascular ring. Flexible bronchoscopy at the time demonstrated a large H-type TEF. Eight weeks later, she had the TEF closed via a right cervical incision and recovered uneventfully. Our case is unique, with symptomatic presentation of a congenital TEF and vascular ring in a teenager. Such major congenital anomalies are rarely discovered outside of childhood, and TEFs virtually always (>90%) present as neonatal emergencies secondary to esophageal obstruction. They have a high incidence of associated abnormalities, cardiovascular being the most common. Unexplained recurrent respiratory symptoms in an otherwise normal child with dysphagia should prompt the clinician to evaluate patients for foreign bodies, reflux and other more common problems. Unusual etiologies, however, do occur - as in this case - and warrant more complex workup.

Prospective Comparison of Nonnarcotic versus Narcotic Outpatient Oral Analgesic Use after Laparoscopic Appendectomy and Early Discharge.

Purpose. To compare narcotic versus nonnarcotic outpatient oral pain management after pediatric laparoscopic appendectomy. Methods. In a prospective study from July 1, 2010, to March 30, 2011, children undergoing laparoscopic appendectomy on a rapid discharge protocol were treated with either nonnarcotic or narcotic postoperative oral analgesia. Two surgeons in a four-person faculty group employed the nonnarcotic regimen, while the other two used narcotics. Days of medication use, time needed for return to normal activity, and satisfaction rate with the pain control method were collected. Student's t-test was used for statistical analysis. Results. A total of 207 consecutive children underwent appendectomy for acute, nonperforated appendicitis or planned interval appendectomy. The age and time to discharge were equivalent between the nonnarcotic (n = 104) and narcotic (n = 103) groups. Both had an equivalent number of medication days and similar times of return to normal activity. Ninety-seven percent of the parents of children in the nonnarcotic group stated that the pain was controlled by the prescribed medication, compared to 90 percent in the narcotic group (P = 0.049). Conclusion. This study indicates that after non-complicated pediatric laparoscopic appendectomy, nonnarcotic is equivalent to narcoticbased therapy for outpatient oral analgesia, with higher parental satisfaction.

Treatment of suspected acute perforated appendicitis with antibiotics and interval appendectomy.

BACKGROUND: Initial antibiotics with planned interval appendectomy (interval AP) have been used to treat patients with complicated perforated appendicitis; however, little experience exists with this approach in children with suspected acute perforated appendicitis (SAPA). We sought to determine the outcome of initial antibiotics and interval AP in children with SAPA. METHODS: Over an 18-month period, 751 consecutive patients underwent appendectomy including 105 patients with SAPA who were treated with initial intravenous antibiotics and planned interval AP ≥ 8 weeks after presentation. All SAPA patients had symptoms for ≤ 96 hours. Primary outcome variables were rates of readmission, abscess formation, and need for interval AP prior to the planned ≥ 8 weeks. RESULTS: Intraabdominal abscess rate was 27%. Appendectomy prior to planned interval AP was 11% and readmission occurred in 34%. All patients underwent eventual appendectomy with pathologic confirmation confirming the previous appendiceal inflammation. White blood cell (WBC) count >15,000, WBC >15,000 plus fecalith on imaging, and WBC >15,000 plus duration of symptoms >48 hours were all significantly associated with higher rates of readmission (p=0.01, p=0.04, p=0.02) and need for interval AP prior to the planned ≥ 8 weeks (p=0.003, p=0.05, p=0.03). CONCLUSIONS: Treatment of SAPA with antibiotics and planned interval AP is successful in the majority of patients; however, complications such as abscess formation and/or readmission prior to planned interval AP occur in up to one-third of patients. Certain clinical variables are associated with increased treatment complications.

Conn syndrome and Crohn disease in a pediatric case: an interesting parallel.

Conn syndrome is characterized by surreptitious secretion of aldosterone in which patients are found to have hypertension, hypokalemia, and metabolic alkalosis. Although rare, the most common presentation in the pediatric population is bilateral hyperplasia of the adrenal glands as opposed to an adenoma. Crohn disease is part of the spectrum of inflammatory bowel disease, which manifests in children as flare-ups of bloody diarrhea and abdominal pain. The association of concurrent Conn syndrome and Crohn disease has been previously presented in two cases in adults. This is the first pediatric case to be reported in the literature.

Routine same-day discharge after acute or interval appendectomy in children: a prospective study.

HYPOTHESIS: The outcomes of and parental satisfaction with same-day discharge in children undergoing laparoscopic appendectomy warrant making it the usual and customary pathway. DESIGN: Prospective cohort study. SETTING: Tertiary care children's hospital. PATIENTS: Between July 1, 2010, and March 30, 2011, a total of 207 children were considered for same-day discharge after acute or interval laparoscopic appendectomy. The all-in-one single-incision single-instrument technique was used in 95.7% of children. INTERVENTIONS: Same-day discharge vs overnight admission. MAIN OUTCOME MEASURES: Operative details, postoperative length of stay, adverse events, and parental satisfaction. RESULTS: Of 207 consecutive children undergoing acute (n = 186) or interval (n = 21) appendectomy, 162 (78.3%) were discharged on the day of surgery. The remaining 45 children were admitted overnight because the hour was too late for discharge in 35 (77.8%), medical indications dictated admission in 5 (11.1%), and social reasons required admission in 5 (11.1%). In all the children, oral medication alone was used for postoperative pain. The complication rates were similar in the same-day discharge group (8.0%) and in the admitted group (6.6%), as were the rates of urgent postoperative visits (7.4% vs 4.4%%) and the readmission rates (2.5% vs 2.2%) (P > .05 for all). The same-day discharge group had a reduced postoperative length of stay compared with the admitted group (mean, 5 vs 16 hours, P < .05). At the time of discharge, most parents (87.0%) stated they were happy with the expeditious discharge, whereas 8.0% indicated they felt nervous but were ultimately satisfied. In retrospect, 8 of 162 parents (4.9%) were not sure early discharge was best, but only 1 parent would insist on admission if faced with the situation again. CONCLUSION: Routine same-day discharge after pediatric appendectomy seems safe, with good parental satisfaction.

A prospective study of safety and satisfaction with same-day discharge after laparoscopic appendectomy for acute appendicitis.

BACKGROUND/PURPOSE: This study examines the safety and patient satisfaction in discharging children undergoing laparoscopic appendectomy (LapAppy) for acute appendicitis on the day of surgery. METHODS: After institutional review board approval, data were collected prospectively for 158 consecutive patients undergoing LapAppy for simple appendicitis. Time from operation to discharge and complications were analyzed. At follow-up, parents completed a satisfaction survey. The Student t test was used for statistical analysis. RESULTS: Laparoscopic appendectomy was performed in 158 children ranging from age 2 to 19 years (mean, 12 years) over a 6-month period. Single-port, single-instrument LapAppy was possible in 152 patients (96%). Eighty percent of patients (n = 126) were discharged on the day of surgery, a mean of 4.8 hours postoperatively (range, 1-12 hours). Of the remaining 32, 24 (75%) were admitted because the operation ended too late for postoperative discharge; 3 (9%), for medical reasons; and 5 (16%), when the families declined to leave. One hundred nine parents (87%) whose children went home postoperatively stated that they were happy with the expeditious discharge, whereas 17 (13%) felt nervous. In addition, 116 parents (92%) stated that, in retrospect, same-day discharge was preferable, whereas 10 parents (8%) were not sure that it was the best decision. None, however, would insist on admission if faced with the situation again. There were no major complications and no significant difference in the rate of umbilical wound infections for same-day discharge patients (2%) and admitted patients (3%). CONCLUSION: Routine same-day discharge after pediatric LapAppy for acute appendicitis is safe, with good parent satisfaction.

The "all-in-one" appendectomy: quick, scarless, and less costly.

BACKGROUND: A technique for laparoscopic appendectomy (LAP APPY) that involves brief surgeon and operating room times, results in no appreciable scar, and requires few disposable supplies would be desirable. METHODS: During 2009, 508 children underwent LAP APPY at our institution including 398 (78%) for acute, non-perforated appendicitis. Our "all-in-one" operative procedure involves use of a single instrument through a side-arm viewing operative laparoscope which is inserted through a single, trans-umbilical port. Successful procedure completion rates and operative times ("cut-to-close") were determined. Our data for surgeon-directed, disposable supply costs per procedure were collated by Child Health Corporation of America and compared with 2009 LAP APPY data (n = 5692) from 17 other children's hospitals in the United States. RESULTS: We successfully completed 359 (90.2%) LAP APPY procedures using the all-in-one technique resulting in no appreciable scar. Additional ports were used in 9.8% and there were no conversions to open procedures. Median operative time for the all-in-one technique was 24 minutes (5-66 min). Our median surgeon-directed, disposable supply cost was the lowest in the study group and significantly less than the other 17 children's hospitals ($166 vs $748, P < .001). Median variation of supply costs among surgeons within each institution was $448 ($3-$870). Aggregate savings of nearly $1.3 million are predicted if all study surgeons were to reduce their disposable costs per procedure to the 25th percentile ($551). CONCLUSIONS: We conclude that the all-in-one laparoscopic appendectomy technique is quick, scarless, and less costly than conventional multi-port techniques. Wider application of the all-in-one technique seems indicated.