[The significance of minimally invasive surgery in the treatment of inguinal hernia and hypertrophic pyloric stenosis]. / Der Stellenwert der minimalinvasiven Chirurgie bei der Behandlung der Leistenhernie und Pylorusstenose.

BACKGROUND: Inguinal hernia repair and pyloromyotomy are among the most common operations performed on children. In the last two decades minimally invasive surgery has been employed for an increasing number of these procedures. This review describes the development of the techniques involved, and their current role in therapy. MATERIAL AND METHODS: A systematic review of the paediatric surgical literature since 1990 was performed on laparoscopic inguinal hernia repair and pyloromyotomy. Relevant publications were summarised. RESULTS: The first laparoscopic pyloromyotomy was described in 1991, the first laparoscopic inguinal hernia repair in children was published in 1998. The learning curve for both procedures is initially steep and reaches a plateau only after about 20 to 30 cases. Both randomised controlled trials and meta-analyses are available comparing the laparoscopic and open techniques for both procedures. The advantages of laparoscopic versus open pyloromyotomy include faster recovery and shorter hospital stay, at similar complication rates. The operation times of laparoscopic inguinal hernia repair are shorter in bilateral cases, while the complication rate again is similar. However, the incidence of metachronous contralateral inguinal hernia is lower after laparoscopic repair. CONCLUSION: Laparoscopic pyloromyotomy and paediatric inguinal hernia repair require special skills. As a minimum, a surgeon's first 20 cases should therefore be performed under competent supervision. Besides resulting in smaller scars, both procedures have concrete advantages and the same complication rates compared to the open techniques. Therefore, both operations can be regarded as the current gold standard.

Single-incision pediatric endosurgical epigastric hernia repair.

PURPOSE: Epigastric hernias represent about 4 % of all abdominal hernias in children and require surgical repair. Traditionally, these hernias are repaired by an open surgical technique. More recently, laparoscopic epigastric hernia repairs have been described using two trocars in the upper abdomen. In this paper, we describe a novel single-incision pediatric endosurgical (SIPES) technique. METHODS: Patients with symptomatic epigastric hernias that were deemed to be too far superior to be repaired with an open technique through an umbilical incision were selected for SIPES repair. Two trocars (5 and 3 mm) were introduced through a single umbilical incision and the hernia repair was performed using looped 4-0 polypropylene sutures introduced through a 17-gage spinal needle in a lasso technique. RESULTS: Five girls (age 4.4-12.6, median 6.4 years) underwent single-incision endosurgical epigastric hernia repair. The mean operative time was 25 ± 6 min, and there were no intraoperative complications. All patients were discharged home from the recovery room on the day of surgery. All patients were followed up 2-3 weeks after the operation, with no recurrence and excellent cosmetic results. CONCLUSIONS: The described SIPES technique offers a virtually scarless, quick, and simple option for the repair of symptomatic epigastric hernias that can be performed with standard laparoscopic equipment.

Impact quantification of the daVinci telemanipulator system on surgical workflow using resource impact profiles.

BACKGROUND: It has yet to be determined whether surgical assist systems benefit surgical workflow. This question should be answered qualitatively and quantitatively and must be supported by evidence gathered from structured and rigorous analyses. METHODS: A method is presented to quantify the benefits of the daVinci telemanipulator system to surgical workflow. Based on the modeling of surgical processes, resource impact profiles (RIPs) were generated. RIPs are statistical mean intervention courses for a sample of surgical process models that were performed using a specific surgical assist system as a resource. A total of 12 laparoscopic and 12 telemanipulator-supported Nissen fundoplications were modeled and analyzed to quantify the impact of the surgical assist system. RESULTS: Few statistically significant benefits of the system to surgical workflow were found. It was found that the daVinci system is not superior to the conventional laparoscopic strategy if the surgeon follows the same workflow. CONCLUSIONS: RIPs are a valuable method to estimate the impact of a surgical assist system on the surgical workflow. For the use case investigated, changes in workflow may be necessary to fully benefit from the advantages of using a telemanipulator in Nissen fundoplications. Conversely, the telemanipulator may only reach its full potential in more complex operations.

Survival time of ECMO circuits on and off bleeding protocol: is there a higher risk of circuit clotting?

PURPOSE: Bleeding is a dreaded complication of extracorporeal membrane oxygenation (ECMO). At our institution, we use a bleeding protocol (BP) with or without ε-amino caproic acid (ACA) for certain prophylactic or therapeutic indications. Subjectively, we have felt that placing a child on bleeding protocol shortens the circuit life because of clot formation. In this study, we evaluated the impact of BP with and without ACA on the survival time of the ECMO circuit. METHODS: A retrospective analysis of all ECMO patients treated in our institution from 2000 to 2008 was performed. An event was defined as a change of the ECMO circuit for thrombosis. The times until occurrence of an event were noted for children off (standard) or on bleeding protocol (BP) and ACA (BP+ACA). Survival curves were generated for each of these study groups and compared using the log rank test. RESULTS: A total of 164 patients were treated with ECMO during the study period. 32 events were noted in the standard, 20 in the BP, and 25 in the BP+ACA group. Mean survival time of the circuit was 10.5 ± 3.8 days for the standard, 8.6 ± 3.4 days for the BP, and 9.9 ± 4.6 days for BP+ACA protocols. The corresponding Kaplan-Meier survival curves are shown. The log rank test showed no significant differences between groups (standard vs. BP p=0.12; standard vs. BP+ACA p=0.92). CONCLUSIONS: We found no evidence that instituting a bleeding protocol with or without aminocaproic acid shortens circuit times. Clotting of the ECMO unit should not be a major concern when placing a patient on a bleeding protocol.

[The economics of contralateral laparoscopic inguinal hernia exploration. Cost calculation of herniotomy in infants]. / Okonomie der kontralateralen laparoskopischen Leistenexploration. Kostenkalkulation der Herniotomie im Säuglingsalter.

BACKGROUND: Diagnostic laparoscopy (DL) of the contralateral side during inguinal herniotomy via the hernia sack may avoid a subsequent second operation. Can this procedure however also reduce costs in the German health care system? METHODS: Prospective analysis was performed of children operated on for inguinal hernia (IH) from March 2006 until October 2007. Using a linear mathematic model, the costs for different scenarios were calculated regarding the risk of contralateral IH. We thereby determined the incidence of contralateral IH at which DL became economically reasonable. RESULTS: A total of 123 unilateral IH operations (IH-OP) were performed in infants during the study period. Of these, 31 patients underwent DL of the contralateral side. Thirteen open hernia sacks were identified and ligated during the same operation. The following costs were calculated: (1) IH-OP without DL, 286 Euro, (2) IH-OP with contralateral DL, 338 Euro, (3) IH-OP with DL and synchronous ligation of the contralateral side, 393 Euro, and (4) metachronous operations of bilateral IH, 572 Euro. The incidence of contralateral hernia described in the literature ranges from 20% to 50%. Linear regression of the relative costs shows an economic advantage for DL with an incidence above 23%. CONCLUSION: Laparoscopic evaluation of the contralateral side in IH-OP is a rational approach for the patient and makes economic sense in the German health care system.

Operative treatment of greater tuberosity fractures of the humerus--a biomechanical analysis.

BACKGROUND: Fractures of the greater tuberosity of the humerus present with increasing frequency. However, no biomechanical data about the optimal fixation technique of greater tuberosity fractures is available. This biomechanical cadaver study compares the stability of three standard fixation techniques used for the treatment of greater tuberosity fractures of the proximal humerus. METHODS: In 21 fresh frozen proximal humeri, standardized fractures of the greater tuberosity were created. The specimens were randomly assigned to one of three operation techniques: wire tension banding, two cancellous screws and transosseous sutures. These constructs were mechanically tested by applying an increasing force to the supraspinatus tendon. Load to 5mm displacement (load to 5mm yield point) and load to failure (maximum stretch strength) were measured in Newton (N). FINDINGS: Load to 5mm yield point values showed no significant differences between tension banding (498 N, SD 153) and two cancellous screws (400 N, SD 174) (P>0.01). Both techniques showed significantly higher values than transosseous sutures (185 N, SD 132) (P<0.01). Load to failure values were significantly higher for tension banding (1054 N, SD 125) than screws (842 N, SD 140) and sutures (480 N SD 101) (P<0.01). The difference between screws and sutures was also significant (P<0.01). INTERPRETATION: Tension banding and two cancellous screws provided the strongest fixation for isolated fractures of the greater tuberosity.

Conscious sedation: Off-label use of rectal S(+)-ketamine and midazolam for wound dressing changes in paediatric heat injuries.

BACKGROUND: Wound dressing changes after heat injuries expose the patient to repeated painful and frightening procedures in short intervals. Safe, adequate, and easily administered analgesia and sedation are required. The goal of this study was to evaluate the off-label use of rectally administered S(+)-ketamine and Midazolam by paediatric surgeons during repeated outpatient dressing changes for paediatric burns and scalding. PATIENTS AND METHODS: A total of 47 dressing changes of 30 children with I - IIa degrees burns were evaluated. Vital signs, side-effects, complications, anxiolysis, and analgesia were recorded during the procedure and for the following two hours. Patients were assessed by a discharge scoring system and an age-appropriate pain scoring system at regular intervals. Before discharge, parents were interviewed on their level of satisfaction with the protocol. RESULTS: Adequate sedation and analgesia was achieved in 44 procedures (94 %). No complications and, in particular, no compromise of breathing, ventilatory, and cardiovascular functions were recorded. The discharge scoring system indicated a return to baseline function 30 minutes after the procedure in all patients. The parents were generally very satisfied with the protocol. All children old enough to be questioned were found to have an anterograde amnesia for the duration of the procedure. CONCLUSION: Conscious sedation with rectally applied S(+)-ketamine and Midazolam allows safe and painless dressing changes after heat injuries in children.

Postpericardiotomy syndrome after minimally invasive pectus excavatum repair unresponsive to nonsteroidal anti-inflammatory treatment.

A 14-year-old boy developed postpericardiotomy syndrome after an otherwise uneventful minimally invasive pectus excavatum repair. Dyspnoea, chest pain, and pericardial effusion progressed despite nonsteroidal anti-inflammatory treatment. The symptoms rapidly resolved with intravenous methylprednisolone, and pericardiocentesis was thus avoided. This is the first report of postpericardiotomy syndrome after the Nuss procedure treated with systemic steroids.

Testosterone-producing adrenocortical neoplasm in a 6-year-old boy.

Adrenal tumours that predominantly secrete testosterone are virtually unknown in prepubertal male patients. We present the case of a 6-year-old boy with premature sexual development and markedly elevated serum testosterone, but normal urinary steroid levels. Diagnostic imaging demonstrated a spherical tumour of the left adrenal gland. Surgical excision led to normalisation of testosterone levels, and postoperative serial low hormone measurements ruled out tumour recurrence.Although extremely rare, this case illustrates that testosterone-producing adrenal adenomas may be encountered in boys without urinary steroid elevation. Surgical excision promises a definite cure. Testosterone is a useful tumour marker in these patients until the beginning of puberty.

Malignant peritoneal mesothelioma. Case-report demonstrating pitfalls of diagnostic laparoscopy.

Patients with peritoneal mesothelioma present with abdominal distension and clinical syndrome of debilitating ascites. Cytology of the peritoneal fluid obtained by laparocentesis often does not result in a diagnosis. Laparoscopy with biopsy of peritoneal nodules is a valuable method by which a histological diagnosis is established. However laparoscopy can greatly complicate the management of peritoneal mesothelioma by facilitating tumor dissemination to port sites. The patient presented was treated with cytoreductive surgery and perioperative intraperitoneal chemotherapy. Although palliation of intra-abdominal tumor and ascites was achieved, port sites-disease required extensive resection of the abdominal wall. Our experience with this patient suggests that if a malignant source of ascites is suspected and a diagnosis is not obtained by paracentesis, laparoscopy should be used to establish a diagnosis. However, trocars should only be placed along the midline of the abdominal wall so that port sites can be excised at the time of cytoreductive surgery. This diagnostic strategy is applicable to the majority of patients undergoing laparoscopy when there is known or suspected intraabdominal malignancy.

Computer-aided three dimensional assessment of knee-joint cartilage with magnetic resonance imaging.

OBJECTIVE: An MRI-based technique for non-invasive assessment of the quantitative distribution of articular cartilage in the knee-joint was to be developed, and its accuracy and reproducibility tested. DESIGN: Three cadaveric specimens and one patient were studied and MRI measurements compared with anatomical sections or arthroscopy. BACKGROUND: Data on articular cartilage thickness is needed for the design of computer models, determination of cartilage material properties from arthroscopy and staging of osteoarthrosis. METHODS: The knees were imaged using strongly T2-weighted spin-echo and FISP-3D sequences. After digital subtraction and automatic segmentation, three-dimensional reconstruction of the cartilages was performed. Surface areas, volumes and the mean cartilage thickness were calculated, and the regional distribution displayed after trigonometric correction. RESULTS: The difference between MRI volumes and those obtained from the sections ranged from 4 to 21% with a reproducibility of +/-4 to +/-12% after repositioning. The thickness maps obtained with MRI were very similar to those from the sections. In the patient, a full-thickness defect demonstrated with MRI was verified by arthroscopy. CONCLUSIONS: Using the technique presented, the quantitative distribution of knee-joint cartilage may be analysed non-invasively, accurately, and in a very time-effective manner, in cadavers and in living subjects. RELEVANCE: To date there exists no accepted method for the accurate, fast and non-invasive assessment of articular cartilage thickness. Such a technique is, however, very helpful for generating computer models of diarthrodial joints, determination of cartilage material properties during arthroscopy, staging of joint disease, and objective control of chondroprotective treatment.