The role of laparoscopy in recurrent right lower quadrant pain in children.

According to scientific literature, laparoscopy as aid in diagnosis and therapy for chronic pain in the right iliac quadrant shows a undeniable advantage thanks to its mini-invasiveness, the possibility of a methodical and thorough exploration of the entire abdominal cavity in those cases of recurrent pain, emotionally and socially debilitating, that do not find an answer in the usual etiological diagnostic clinical-instrumental. In those cases in which any significant organic pathology that justifies the recurring pain in the right iliac fossa is found during laparoscopic exploration, it has been seen that it is useful to perform appendectomy anyway, that leads to the disappearance of symptoms, which are probably due to inflammatory recurrent catarrhal phenomena of appendix in such patients, as it is demonstrated by the adhesions found at cecum-appendicular level. From January 2011 to December 2013, 24 children with chronic recurrent right lower quadrant pain were subjected to diagnostic laparoscopy. Ages varied from 11 to 18 years (mean, 14 years). There were 6 males and 18 females. Laparoscopic findings included macroscopical signs of acute appendicitis in 15 patients; cecal adhesions in 20 patients, kink of the appendix in 3. The abdominal pain completely resolved in all the patients following laparoscopy.

Single-incision laparoscopic surgery and conventional laparoscopic treatment of varicocele in adolescents: Comparison between two techniques.

BACKGROUND: Single-incision laparoscopic surgery (SILS) has gained great popularity in paediatric surgery due to its minimally invasive approach and improved cosmetic results. Notwithstanding, reports describing its adoption in children are still fragmentary and some perplexities have been raised by some surgeons. We reviewed our experience with the SILS Palomo varicocelectomy procedure (SIL-V) in children and adolescents, comparing this group with a similar series operated using conventional laparoscopic varicocelectomy (CL-V). PATIENTS AND METHODS: A total of 69 Palomo laparoscopic varicocelectomies were performed in patients aged 11-17 years from January 2011 to January 2013. Indications for surgery included grades II-III varicocele or ipsilateral testicular hypotrophy. The SIL-V procedure was performed in 44 patients with roticulating and conventional 5 mm instruments. Testicular vessels were isolated "en bloc," clipped and cut. Operating time, visual analogue scale and post-operative results were compared to a similar group of 25 patients operated with CL-V. RESULTS: No patient of the SIL-V group required conversion to conventional laparoscopy, none to open surgery. Mean operative time was 22 min (range: 19-28) in the SIL-V group, not significantly different compared with CL-V (mean 21 min, range: 18-25). All patients experienced a smooth recovery from surgery without any complications, and were discharged on day 1. No difficulties were found in the SIL-V group. The post-operative pain score was significantly better in SIL-V. CONCLUSION: The SIL-V procedure is safe and effective and allows a fast and efficient isolation of the vascular bundle. The use of conventional instruments is technically feasible in SIL-V.

Laparoscopic approach to Meckel's diverticulum.

AIM: To retrospective review the laparoscopic management of Meckel Diverticulum (MD) in two Italian Pediatric Surgery Centers. METHODS: Between January 2002 and December 2012, 19 trans-umbilical laparoscopic-assisted (TULA) procedures were performed for suspected MD. The children were hospitalized for gastrointestinal bleeding and/or recurrent abdominal pain. Median age at diagnosis was 5.4 years (range 6 mo-15 years). The study included 15 boys and 4 girls. All patients underwent clinical examination, routine laboratory tests, abdominal ultrasound and technetium-99m pertechnetate scan, and patients with bleeding underwent gastrointestinal endoscopy. The abdominal exploration was performed with a 10 mm operative laparoscope. Pneumoperitoneum was established based on the body weight. Systematic overview of the peritoneal cavity allowed the ileum to be grasped with an atraumatic instrument. The complete exploration and surgical treatment of MD were performed extracorporeally, after intestinal exteriorization through the umbilicus. All patients' demographics, main clinical features, diagnostic investigations, operative time, histopathology reports, conversion rate, hospital stay and complications were registered and analyzed. RESULTS: MD was identified in 17 patients, while 1 had an ileal duplication and 1 a jejunal hemangioma. Fifteen patients had painless intestinal bleeding, while 4 had recurrent abdominal pain and exhibited cyst like structures in an ultrasound study. Eleven patients had a positive technetium-99m pertechnetate scan. In the patients with bleeding, gastrointestinal endoscopy did not name the source of hemorrhage. All patients were subjected to a TULA surgical procedure. An intestinal resection/anastomosis was performed in 14 patients, while 4 had a wedge resection of the diverticulum and 1 underwent stapling diverticulectomy. All surgical procedures were performed without conversion to open laparotomy. Mean operative time was 75 min (range 40-115 min). No major surgical complications were recorded. The median hospital stay was 5-7 d (range 4-13 d). All patients are asymptomatic at a median follow up of 4, 5 years (range 10 mo-10 years). CONCLUSION: Trans-umbilical laparoscopic-assisted Meckel's diverticulectomy is safe and effective in the treatment of MD, with excellent results.

Spermatogenesis and cryptorchidism.

Cryptorchidism represents the most common endocrine disease in boys, with infertility more frequently observed in bilateral forms. It is also known that undescended testes, if untreated, lead to an increased risk of testicular tumors, usually seminomas, arising from mutant germ cells. In normal testes, germ cell development is an active process starting in the first months of life when the neonatal gonocytes transform into adult dark (AD) spermatogonia. These cells are now thought to be the stem cells useful to support spermatogenesis. Several researches suggest that AD spermatogonia form between 3 and 9 months of age. Not all the neonatal gonocytes transform into AD spermatogonia; indeed, the residual gonocytes undergo involution by apoptosis. In the undescended testes, these transformations are inhibited leading to a deficient pool of stem cells for post pubertal spermatogenesis. Early surgical intervention in infancy may allow the normal development of stem cells for spermatogenesis. Moreover, it is very interesting to note that intra-tubular carcinoma in situ in the second and third decades have enzymatic markers similar to neonatal gonocytes suggesting that these cells fail transformation into AD spermatogonia and likely generate testicular cancer (TC) in cryptorchid men. Orchidopexy between 6 and 12 months of age is recommended to maximize the future fertility potential and decrease the TC risk in adulthood.

An unusual case of intra-abdominal testicular torsion: role of laparoscopy.

The authors report a case of intra-abdominal testicular torsion, where laparoscopy has been useful for diagnosis and surgical management. A boy was presented with a left impalpable testis. Laparoscopy revealed a twisted spermatic cord at the inlet pelvis, which ended in a testicular remnant located in the sub-umbilical area. After orchiectomy, the pathologist confirmed testicular atrophy. Diagnosis of intra-abdominal testicular torsion should be considered in patients with impalpable testis and abdominal pain, but could not be excluded in those with no symptoms.

"Spaghetti maneuver": a useful tool in pediatric laparoscopy - our experience.

AIMS: The laparoscopic "Spaghetti Maneuver" consists in holding an organ by its extremity with a grasper and rolling it up around the tool to keep the organ stable and facilitate its traction within a small space. We describe our experience with the "Spaghetti Maneuver" in some minimally invasive procedures. MATERIALS AND METHODS: We successfully adopted this technique in 13 patients (5F : 8M) aged between 6 and 14 years (average age, 10) on whom we performed 7 appendectomies, 2 ureteral reimplantation and 4 cholecystectomies. In all cases, after the first steps, the appendix, the gallbladder and the ureter were rolled around the grasper and easily isolated; hemostasis was thus induced and the organ was mobilized until removal during cholecystectomy and appendectomy, and before the reimplantation in case of ureteral reimplantation. RESULTS: We found that this technique facilitated significantly the acts of holding, isolating and removing, when necessary, the structures involved, which remained constantly within the visual field of the operator. This allowed a very ergonomic work setting, overcoming the problem of the "blind" zone, which represents a dangerous and invisible area out of the operator's control during laparoscopy. Moreover the isolation maneuvers resulted easier and reduced operating time. CONCLUSION: We think that this technique is easy to perform and very useful, because it facilitates the dissection of these organs, by harmonizing and stabilizing the force of traction exercised.

Pneumovesicoscopic treatment of congenital bladder diverticula in children: our experience.

AIM: In this article, we report our experience with diverticulectomies of symptomatic congenital bladder diverticula in children, which was performed by utilizing pneumovesicoscopy. MATERIALS AND METHODS: Six boys, 4-8 years of age (mean, 5.6) underwent pneumovesicoscopic diverticulectomy at our institution from June 2007 to June 2008. There were 4 right-single diverticula and 2 double-left diverticula. Under cystoscopic control, after the cystopexy to the abdominal wall, a midline 5-mm trocar for a 0-degree telescope and two lateral 3-mm reusable trocars through the anterolateral wall of the bladder in the midclavicular line were introduced, insufflating the bladder with carbondioxide to 10-12 mm Hg pressure. The diverticulum/a were inverted into the bladder and the mucosa around the neck was circumcized by using scissors and a monopolar hook. The defect was sutured with interrupted sutures and the bladder was drained with a Foley catheter, which was introduced at the site of the 5-mm port, and a urethral catheter. RESULTS: Mean operative time was 110 minutes. No major peri- or postoperative complications were recorded, except that the displacement of one of the lateral trocars that resulted in gas leakage in 1 case. The trocar was replaced and the procedure was completed. An ultrasound and a voiding cystourethrogram, performed from 3 to 6 months after the operation, showed the disappearance of the diverticulum/a. CONCLUSIONS: In our experience, pneumovesicoscopic diverticulectomy is an easy, safe procedure and can be considered a valid alternative to the open or laparoscopic procedures. It also provides no postoperative discomfort and a good cosmetic result.

Decreased recurrence rate in the laparoscopic herniorraphy in children: comparison between two techniques.

AIM: The laparoscopic herniorraphy in children is still associated to a high recurrence rate. The aim of this study was to assess whether the addition of the lateral incision of the sac to the sole suture of the inner inguinal ring could reduce the recurrence rate. MATERIALS AND METHODS: A retrospective review was performed of the collected data of 248 laparoscopic inguinal hernia repairs in 224 children (175 males, 49 females) between 8 months and 11 years of age (mean age, 5 years; median, 4) in our institution from January 2004 to December 2007. The hernia was unilateral in 204 patients (133 on the right side, 71 on the left) and bilateral in 20 patients. A 5-mm umbilical camera port for a 0-degree laparoscopic optics and two operative 2- or 3-mm reusable trocars inserted in the lower right and left quadrants of the abdominal wall were utilized. In a group of 123 patients, the inner inguinal ring was closed, adopting a W-shaped suture (inguinal ring suture; IRS). In the other group of 101 patients, a lateral incision of the sac of 1-2 cm was carried out before the W-shaped suture of the inner inguinal ring (inguinal ring incision suture; IRIS). RESULTS: At a mean follow-up of 24 months (range, 6-36), 5 of 133 (3.76%) hernias recurred between 6 and 12 months after surgery in the IRS group. In the IRIS group, none of the patients presented with recurrence. The rate of recurrences in the two groups was compared and analyzed with the x2 test. The resulting difference was statistically significant (P < 0.05). CONCLUSION: In our experience, the incision of the peritoneum lateral to the internal inguinal ring and the W-shaped suture, compared to the sole W-shaped suture, is safe and effective in preventing hernia recurrence.

LigaSure vessel sealing system in laparoscopic Palomo varicocele ligation in children and adolescents.

PURPOSE: We review our experience with laparoscopic Palomo varicocele ligation using the LigaSure device in children and adolescents. MATERIALS AND METHODS: Between June 2003 and December 2004, 25 varicoceles were treated by laparoscopic Palomo varicocele ligation using LigaSure vascular sealing. Patient ages ranged from 10 to 19 years (mean, 14.5 years). Indications for surgery included grade II-III varicocele or ipsilateral testicular hypotrophy. One patient was affected by recurrent contralateral inguinal hernia and 2 presented with an ipsilateral patent processus vaginalis. We placed a 5-mm umbilical port for access, and kept pneumoperitoneum below 15 mm Hg. Under laparoscopic guidance, two additional ports of 3 and 5 mm were inserted in the lower right and left quadrants, respectively. Once the vessels were isolated, the vascular sealant was applied 3-4 times to ensure coagulation of the spermatic vessels; the vessels were then divided with laparoscopic 5-mm scissors. Inguinal hernia and patent processus vaginalis were treated according to Schier's technique. All procedures were performed in our day surgery facility. RESULTS: Mean operative time was 18 minutes, which is significantly less than the time required in a similar group of 12 patients who underwent laparoscopic clip ligation. There were no perioperative complications. Eleven of 16 patients recovered testicular size. Two patients had postoperative hydrocele: the first was treated successfully with scrotal aspiration, while the other patient required scrotal hydrocelectomy. CONCLUSION: Laparoscopic Palomo varicocele sealing can be performed safely and rapidly and is highly successful in correcting varicoceles in young males. We also found it to be the ideal technique to correct the associated inguinal hernia or patent processus vaginalis.

Local and systemic impact of pneumoperitoneum on prepuberal rats.

Pneumoperitoneum (PN) and the gas used to insufflate the abdominal cavity during laparoscopy seem to be responsible for local and systemic modifications. The aim of this study was to verify the effects of intra-abdominal carbon dioxide (CO(2)) and air insufflation on the peritoneum, as well as the cortico-surrenal response in prepuberal rats. Sixty prepuberal rats were divided into three groups: in the first (S, n = 36), PN was induced with CO(2), whereas in the second (A, n = 14), it was induced with filtered room air; in both conditions, insufflation lasted 30 min at a pressure of 10-12 mmHg. The third group (C, n = 10), underwent general anesthesia only. Two hours after inducing anaesthesia, 12 rats in group S, 6 in group A and 6 in group C were killed and the remaining, after 24 h; specimens of the visceral and the parietal peritoneum were obtained for histological examination, blood sample was taken for cortisol and DHEA-S assays at the different study periods. At the histological examination performed 2 h later, the groups S and A presented inflammatory cell infiltrate in the parietal and visceral peritoneum; this finding was even more marked in group A, which presented also congestion, hemorrhage and disruption of the cell line. Twenty-four hours after the experiment, the peritoneum of the two insufflated groups presented chronic infiltrate and reactive mesothelial cells with congestion, which was more evident in group A, but totally absent in group C. Cortisol levels were significantly higher in groups S and A (2.15:1 ratio) killed 2 h later compared to those killed 24 h later and to the control group. DHEA-S levels were not significantly different between the groups. Our results demonstrate that the chemical, physical and molecular impact of CO(2) on the peritoneum causes inflammation and tissue damage, this was even more evident 24 h after our experiment and in the air insufflated group. PN induced a significant variation in blood cortisol levels at 2 h. The CO(2) insufflation should be limited in patients with pre-existing peritoneal damage.

Laparoscopic management of nonpalpable testes: a multicenter study of the Italian Society of Video Surgery in Infancy.

PURPOSE: Diagnostic laparoscopy has changed the surgical approach to nonpalpable testes (NPT). The aim of this study was to determine the value of laparoscopy in managing patients with NPT and to suggest guidelines for the interpretation of laparoscopic findings. The authors report the results of a multicenter study of the Italian Society of Video Surgery in Infancy on laparoscopic management of NPT. METHODS: Between 1993 and 2001, the authors collected records of 364 patients with NPT who underwent laparoscopy, for a total of 388 testicular units. RESULTS: Intraabdominal testes were found in 124 (34%) cases, for a total of 137 testes; 83 testicular units were classified as low and 54 as high. A total of 155 (43%) patients had cord structures entering the internal inguinal ring, 79 (22%) had intraabdominal blind-ending cord structures, and 6 (1%) had testicular agenesia. CONCLUSIONS: Laparoscopy is a valuable tool in diagnosing and treating more than 50% of cases of NPT. The laparoscopic evaluation of abdominal testes can provide indications for the most suitable surgical technique; moreover, in 23% of patients, it makes abdominal exploration unnecessary. The value of laparoscopy is even greater if the anatomical aspect of the internal ring and spermatic cord structures is carefully evaluated.