Outcomes of bedside sutureless umbilical closure without endotracheal intubation for gastroschisis repair in surgical infants.

INTRODUCTION: Newborns with gastroschisis have historically undergone surgical repair under general anesthesia. Our institution recently transitioned to the sutureless umbilical closure for gastroschisis. We sought to evaluate the feasibility of bedside gastroschisis repair without endotracheal intubation. METHODS: A retrospective review was performed of neonates with gastroschisis who underwent sutureless umbilical closure from 2011 to 2015. Clinical characteristics and outcomes between groups were compared. RESULTS: In total, 53 infants underwent sutureless umbilical closure. Closure without endotracheal intubation was attempted in 23 (43%) babies and was successful in 15 (65%) infants. Two of the 8 patients who required intubation needed a temporary silo. Neonates successfully repaired without intubation were more premature (p < 0.01), smaller at birth (p = 0.01), and repaired nearly an hour sooner (p < 0.01). There were no differences in time to full enteral nutrition, length of stay, bowel ischemia, or sepsis. CONCLUSION: Bedside sutureless umbilical closure without intubation is feasible and effective in newborns with gastroschisis. The procedure decreases time to gastroschisis closure. Smaller and more premature neonates were more likely to be successfully closed without intubation.

Contemporary trends in the use of primary repair for gastroschisis in surgical infants.

BACKGROUND: Gastroschisis is a newborn anomaly requiring emergent surgical intervention. We review our experience with gastroschisis to examine trends in contemporary surgical management. METHODS: Infants who underwent initial surgical management of gastroschisis from 1996 to 2014 at a pediatric hospital were reviewed. Closure techniques included primary fascial repair using suture or sutureless umbilical closure, and staged repair using sutured or spring-loaded silo (SLS). Data were separated into 3 clinical eras: pre-SLS (1996 to 2004), SLS (2005 to 2008), and umbilical closure (2009 to 2014). RESULTS: In the pre-SLS era, 60% (34/57) of infants with gastroschisis underwent primary repair. With the advent of SLS, there was a decrease in primary repair (15%, 10/68, P < .0001). Following introduction of sutureless umbilical closure, 61% (47/77) of infants have undergone primary repair. On multivariate regression, primary repair was associated with shorter intensive care unit stays (P < .001) and time to initiate enteral nutrition (P < .01). CONCLUSIONS: Following introduction of a less invasive technique for gastroschisis repair, most infants with gastroschisis were able to be repaired primarily. Primary repair should be considered in all babies with gastroschisis and favorable anatomy.

Robotic surgery for pediatric tumors.

Robotic surgery is an ever-moving target of advancing technology. The need for prospective data may be a hallmark for good science, but collecting that data is difficult if not impossible in such a rapidly progressing technology. At present, published pediatric robotic outcomes data are very scarce, especially when it is filtered to select oncology. In order to understand what robotic surgery is and how we can apply it to children with cancer, the benefits as well as the limitations of robotic surgery need to be understood. Next, we will discuss all of the known published and even unpublished data with a focus on seeing what procedures may work and which need more scrutiny. Finally, we will discuss the latest additions to this technology and where the future may lead us in the surgical treatment of cancer in children.

Spontaneous Clostridium perfringens myonecrosis: Case report, radiologic findings, and literature review.

The utility of computed tomography (CT) has not been studied in the initial evaluation of a patient with suspected spontaneous Clostridial myonecrosis. Here, we present a patient with acute lymphoblastic leukemia (ALL) and neutropenia who developed spontaneous Clostridium perfringens myonecrosis after induction chemotherapy. Although suspected, the patient's symptoms and physical exam findings were not specific for Clostridial myonecrosis. CT confirmed the diagnosis and helped direct surgical intervention.

Robotic lateral pancreaticojejunostomy (Puestow).

A lateral pancreaticojejunostomy (LPJ), also known as the Puestow procedure, is a complex procedure performed for chronic pancreatitis when the pancreatic duct is dilated and unable to drain properly. Traditionally, these procedures are performed with open surgery. A minimally invasive approach to the LPJ using rigid handheld nonarticulating instruments is tedious and rarely performed. In fact, there are no prior laparoscopic case reports for LPJ in children and only a small handful of cases in the adult literature. This lack of laparoscopic information may be an indication of the difficulty in performing this complex operation with nonarticulating laparoscopic instruments. The advantages of robotic surgery may help overcome these difficulties. We present the first robotic LPJ ever reported in a 14-year-old child with idiopathic chronic pancreatitis. This case demonstrates the utility of this advanced surgical technology and may lead to a new minimally invasive option for both adults and children with chronic pancreatitis requiring surgical intervention.

Robotic surgery in small children: is there room for this?

Some pediatric surgeons may be reluctant to use robotic surgery for small patients because the only available surgical robot might seem too large for smaller patients. However, we have found this concern invalid. We have been successful in a wide variety of minimally invasive surgery procedures using robotics for general surgery applications in small children. However, several technical issues must be considered in order to optimize this technology for these children. In this article, we present a retrospective review of 45 patients of less than 10 kg who underwent robotic surgery and discuss the adjustments we made in order to adapt this technology to our small patients in a wide variety of general surgical procedures.

Robotic repair of congenital diaphragmatic anomalies.

PURPOSE: Congenital diaphragm anomalies, including eventration, Morgagni diaphragmatic hernias (M-CDH), and Bochdalek diaphragmatic hernias (B-CDH), have been successfully repaired by using minimally invasive surgery (MIS). However, some reports have shown a high recurrence rate for some defects, potentially due to difficulty associated with the rigid instruments. Robotic surgery may help close diaphragmatic anomalies more effectively. In this paper, we present a series of 8 consecutive patients with diaphragmatic anomalies who underwent robotic repair. METHODS: We retrospectively reviewed patients with diaphragmatic anomalies. There were 2 patients with eventration, 5 with B-CDH, and 1 with M-CDH. All procedures were performed by using the Standard Da Vinci surgical robot (Intuitive Surgical, Sunnyvale, CA) with one camera arm (5-mm two-dimensional scope) and two instrument arms (5 mm). RESULTS: Average age was 3.9 months (4 days to 12 months). Average weight was 3.6 kg (range, 2.2-10.5). Four B-CDH patients were approached through the chest and 1 from the abdomen. The patient with M-CDH had an abdominal repair, and both eventrations were performed from the chest. One B-CDH and 1 eventration were converted to thoracoscopic procedures. Average operative time was 1 hour and 20 minutes. One recurrence developed in a relatively large B-CDH repair that was closed primarily. Average follow-up was 20 months. CONCLUSIONS: Robotic surgery is safe and effective for repairing diaphragm anomalies in small children. Although we prefer the thoracic approach for repairing the B-CDH, occasionally smaller newborns-perhaps those less than 2.5 kg-may do better with the abdominal approach, since the articulating instruments requiring a significant length in order to maneuver.

Robotic pulmonary resections in children: series report and introduction of a new robotic instrument.

Thermal sealing devices, such as the LigaSure (ValleyLab-Tyco Healthcare; Boulder, CO) or Gyrus PK (Gyrus ACMI, Maple Grove, MN) are minimally invasive instruments that can be used to seal the pulmonary parenchyma in pediatric lung resections. But these devices were only available in laparoscopic form, and no robotically similar instruments were manufactured. This handicaps the surgeon at the console, because these nonrobotic instruments must be manipulated and used by the bedside assistant instead of the console surgeon. In July 2006, the robotic Gyrus PK was introduced for the da Vinci Surgical Robot (Intuitive Surgical, Sunnyvale, CA). In this paper, we present our initial experience in performing robotic pulmonary resections in infants and children, including all cases before and after the robotic Gyrus PK was introduced.

Robotic resection of mediastinal masses in children.

PURPOSE: Robotic surgery may be particularly well suited for solid chest masses. In this paper, we present our initial experience by using robotic surgery to resect mediastinal masses in children. METHODS: Five pediatric patients with an average age of 9.8 years (range, 2-17) and an average weight of 41.5 kg (range, 13.9-70.5) underwent a robotic resection of a mediastinal chest mass using the da Vinci Surgical Robot (Intuitive Surgical, Sunnyvale, CA). RESULTS: Operative time ranged from 44 to 156 minutes, with an average of 113 minutes. The pathology varied considerably and included a ganglioneuroma, ganglioneuroblastoma, teratoma, germ cell tumor, and a large inflammatory mass of unclear etiology. No complications or conversions occurred. Average length of hospitalization was 1.4 days. Follow-up averaged 2 years, with no evidence of recurrence in any patient. CONCLUSIONS: Robotic surgery is safe and effective for resecting solid mediastinal chest masses. The articulating instruments are particularly helpful for dissecting around a solid mass within the rigid thoracic cavity.

The robotic Gyrus PK: a new articulating thermal sealing device and a preliminary series report.

Before 2006, thermal sealing devices, such as the LigaSure (ValleyLab-Tyco Healthcare, Boulder, CO) and the Gyrus (Gyrus ACMI, Maple Grove, MN), were not available for use with the Da Vinci Surgical Robot (Intuitive Surgical, Sunny Vale, CA). Surgeons had to incorporate standard nonarticulating handheld laparoscopic devices into their operations by having the bedside assistant use these devices. This took a significant portion of the procedure out of the hands of the operating surgeon. However, a new pulse-modulating device, the robotic Gyrus PK (RG-PK), has been manufactured specifically for the Da Vinci. We present our initial experience with this new device in 12 patients, all but 1 of which were children.

Erosion of the Nuss bar into the internal mammary artery 4 months after minimally invasive repair of pectus excavatum.

The minimally invasive repair of pectus excavatum has become increasingly popular. Life-threatening complications have included bleeding and cardiac perforation. There have been a number of delayed cases of bleeding, many of which never demonstrated a clear source. We present a case of a delayed acute bleed from the Nuss bar eroding into the internal mammary artery 4 months after bar placement.

Robotic repair of Morgagni congenital diaphragmatic hernia in an infant.

We describe a robotic repair of a large Morgagni congenital diaphragmatic hernia in a 12-month-old infant using the da Vinci surgical robot.

Common bile duct perforation resulting from a gastric duplication cyst.

Gastric duplication cysts are a rare cause of abdominal masses in infants. Most children present with a gastric outlet obstruction or some vague abdominal complaints. We present an unusual case of a gastric duplication cyst that created a distal common bile duct obstruction which led to a proximal common bile duct perforation.

Pediatric robotic surgery: A single-institutional review of the first 100 consecutive cases.

BACKGROUND: Robotic surgery is a new technology which may expand the variety of operations a surgeon can perform with minimally invasive techniques. We present a retrospective review of our first 100 consecutive robotic cases in children. METHODS: A three-arm robot was used with one camera arm and two instrument arms. Additional accessory ports were utilized as necessary. Two different attending surgeons performed the procedures. RESULTS: Twenty-four different types of procedures were completed using the robot. The majority of the procedures (89%) were abdominal procedures with 11% thoracic. No urology or cardiac procedures were performed. Age ranged from 1 day to 23 years with an average age of 8.4 years. Weight ranged from 2.2 to 103 kg with a median weight of 27.9 kg. Twenty-two patients were less than 10.0 kg. Examples of cases included gastrointestinal (GI) surgery, hepatobiliary, surgical oncology, and congenital anomalies. The overall majority of cases had never been performed minimally invasively by the authors. The overall intraoperative conversion rate to open surgery was 13%. One case (1%) was converted to thoracoscopic because of lack of domain for the articulating instruments. No conversions or complications occurred as a result of injuries from the robotic instruments. Interestingly, four abdominal cases were converted to open surgery due to equipment failures or injuries from standard laparoscopic instruments used through non-robotic accessory ports. CONCLUSIONS: Robotic surgery is safe and effective in children. An enormous variety of cases can be safely performed including complex cases in neonates and small children. Simple operations such as cholecystectomies have minimal advantages by using robotic technology but can serve as excellent teaching tools for residents and newcomers to this form of minimally invasive surgery (MIS). The technology is ideal for complex hepatobiliary cases and thoracic surgery, particularly solid chest masses.

Robotic fundoplication in children: resident teaching and a single institutional review of our first 50 patients.

BACKGROUND: Robotic surgery is a new technology that may eventually replace laparoscopy in treating many surgical issues in children. Resident education using robotic surgery has been a concern for many institutions. We present our first 50 consecutive robotic fundoplications in children and our teaching experience with this procedure. METHOD: A 3-arm surgical robot was used to create a Nissen fundoplication with 1 additional port for liver retraction. Although there were exceptions, a 12-mm 3-dimensional camera was used in most patients greater than 10 kg, and a 5-mm 2-dimensional camera if less than 10 kg. Robotic instruments were either 8 or 5 mm. An accessory port was used for liver retraction. The console surgeon was either an attending surgeon or a fourth-year general surgery resident. The general surgery residents had limited prior minimally invasive experience consisting of cholecystectomies, appendectomies, and a few other procedures. RESULTS: Average age was 5.1 years (range, 1 month to 16 years). Average weight was 19.5 kg (range, 2.7-96.4 kg). No open conversions or intraoperative complications occurred. Postoperative complications included ileus (4%), dysphagia (4%), a G-tube site wound infection (2%), gas bloat syndrome (2%), and 1 wrap breakdown 3 years after the initial procedure (2%). Operative times for staff surgeons were down to 90 minutes after 5 fundoplications. CONCLUSION: Robotic fundoplication is an acceptable method to perform minimally invasive antireflux surgery in children. Resident education and teaching can be readily accomplished using the robot and the learning curve is relatively short and steep.

The robotic approach to complex hepatobiliary anomalies in children: preliminary report.

PURPOSE: Robotic technology allows surgeons to perform complex procedures which may be difficult with standard laparoscopic instruments. We believe that complex hepatobiliary procedures are ideally suited for robotic surgery in children and present our experience with Kasai portoenterostomy and excision of choledochal cysts. METHODS: We performed 4 complex hepatobiliary procedures in children using the Da Vinci surgical robot (Intuitive Surgical, Sunnyvale, CA): 2 Kasai portoenterostomies and 2 choledochal cyst resections. Both Kasais had the Roux-en-Y jejunojejunostomy performed extracorporeally through the 12 mm umbilical trocar site. Both choledochal cysts had the Roux-En-Y jejunojejunostomy performed intracorporeally. All patients had their hepatobiliary to enteric anastomosis performed intracorporeally. RESULTS: Total average time was 6 hours and 12 minutes for the Kasai and 7 hours and 38 minutes for the choledochal cysts. The average robotic console time for all cases was 6 hours. No intraoperative or perioperative complications occurred. Average length of hospital stay was 4 days. Both choledochal cyst patients were doing well after 9 and 12 months with no complications. One Kasai patient is doing well 14 months after Kasai with a normal bilirubin. The other Kasai patient did well for a year with a normal bilirubin. However, the patient slowly developed intrahepatic bile lakes despite a normal bilirubin and a well draining Kasai as demonstrated by hepatobiliary iminodiacetic acid (HDA) scan. He began having recurrent episodes of cholangitis and we referred him for liver transplantation. CONCLUSION: Minimally invasive robotic complex hepatobiliary surgery is safe and effective in children. The 3-dimensional imaging and improved articulations make these procedures particularly suited for robotics over standard laparoscopy.

Robotic repair of a Bochdalek congenital diaphragmatic hernia in a small neonate: robotic advantages and limitations.

Minimally invasive repair for a Bochdalek congenital diaphragmatic hernia has been performed over the last few years with mixed results. Although the anomaly has been approached from both the abdomen and the chest, the defect can be difficult to close as the posterolateral region may be difficult to reach with precise suturing using standard rigid laparoscopic instruments. The articulating instruments of robotic surgery offer a substantial improvement in degrees of freedom and may help over come these obstacles. However, other limitations including instrument length in relation to patient size need to be accounted for when planning a robotic procedure in small children. We present a robotic repair of a foramen of Bochdalek congenital diaphragmatic in a 2.2 kg neonate using and abdominal approach with the Da Vinci Surgical Robot (Intuitive Surgical, Sunnyvale, CA).