Are Cardiac Anomalies and Persistent Fetal Circulation a Risk Factor for Cardiovascular Events During Minimally Invasive Surgery in Neonates?

Introduction: Minimally invasive surgery (MIS) in neonates is progressively performed. The aim of this study was to evaluate the risk for cardiovascular events during endoscopic surgery in neonates and to analyze the influence of persistent fetal circulation and/or cardiac anomalies. Materials and Methods: This is a retrospective single institution study including all neonates undergoing MIS. The charts were reviewed for intraoperative cardiovascular events and operative procedure was performed. Special attention was paid to cardiac anomalies and persistent fetal circulation. In addition, a review of the literature was performed. Results: Between January 2004 and December 2012, 108 neonates underwent MIS at our institution. Laparoscopic surgery was performed in 91 (84.3%) and thoracoscopy in 17 (15.7%) babies. None of these 108 patients developed a cardiovascular event during endoscopic surgery (0.0%). Persistent fetal circulation and/or cardiac anomalies were evaluated in 50 of 108 (46.3%) neonates. In the additionally performed review of the literature, four single case reports were identified. All 4 authors published a major cardiovascular event during laparoscopic surgery in neonates. In all 4 patients, gas embolism through a patent umbilical vein was assumed to be responsible for the cardiovascular event. Conclusions: In our opinion, the main risk factor for the development of a major cardiovascular event during MIS in neonates is vascular injury of a persistent umbilical vein. Persistent fetal circulation and/or cardiac anomalies seem to be less important. In case of injury of a persistent umbilical vein, the risk of gas embolism has to be respected and conversion to the open approach has to be considered.

The Role of Laparoscopy in the Acute Neonatal Abdomen.

IntroductionThe surgical treatment of the acute neonatal abdomen still poses a challenge in pediatric surgery. Various underlying etiologies require different surgical procedures. Until today the role of laparoscopy in the surgical treatment of the acute neonatal abdomen is controversial. The aim of this study was to analyze our experiences with laparoscopy and to perform a review of the literature. Methods Retrospective, single-institution study including all term and preterm neonates initially undergoing laparoscopy due to an acute abdomen. Results Altogether, 17 neonates presenting with an acute neonatal abdomen initially underwent laparoscopy. Unnecessary laparotomy could be avoided in 9 of 17 (53%) neonates. After diagnostic laparoscopy, 2 patients did not require any further surgical intervention. Eight neonates presented midgut atresia intraoperatively, 5 of them underwent laparoscopic-assisted correction. Successful laparoscopic derotation of an acute volvulus (n = 1) and laparoscopic appendectomy (n = 1) could be performed. Conversion to open surgery was necessary in 8 neonates (47%) due to creation of a stoma (n = 5), multiple intestinal bands causing poor visualization (n = 2), and bowel necrosis (n = 1). Conclusions Laparoscopy is a useful diagnostic tool to evaluate the need for further surgical intervention in the acute neonatal abdomen and enables immediate surgical treatment of acute volvulus, appendicitis, or intestinal atresia. In case of conversion to laparotomy, precise localization of the incision is guaranteed. Minimization of the surgical trauma and avoidance of unnecessary laparotomy are the most important benefits of the minimal-invasive approach for the critically ill neonate.

The effect of intermittent intraabdominal pressure elevations and low cardiac output on the femoral to carotid arterial blood pressure difference in piglets.

BACKGROUND: Our previous work in a laparoscopic setting in piglets revealed that the systolic femoral artery pressure was approximately 5 % higher than its carotid counterpart, whereas the mean and diastolic values showed no significant difference. This remained idem when the intraabdominal pressure (IAP) was gradually increased. In this study, we aimed to investigate the effect of (1) intermittent IAP elevations and (2) a low cardiac output (CO) on the blood pressure (BP) difference cranially (carotid artery) and caudally (femoral artery) of a capnoperitoneum (ΔP = P a fem-P a carot). METHODS: A total of twenty-two piglets (mean body weight 11.0 kg; range 8.9-13.3 kg) were studied. Of these, 14 underwent intermittent IAP elevations at 8 and 16 mmHg, and ΔP was measured. In another 8 piglets, a model of reduced CO was created by introducing an air embolism (2 ml/kg over 30 s) in the inferior caval vein (VCI) at 12 mmHg IAP to further assess the influence of this variable on ΔP. RESULTS: Systolic ΔP remained at a mean of 5.6 mmHg and was not significantly affected by insufflation or exsufflation up to an IAP of 16 mmHg. Diastolic and mean values showed no differences between P a carot and P a fem. P a fem, systol remained higher than its carotid counterpart as long as the cardiac index (CI) was above 1.5 l/min/m2, but fell significantly below P a carot, systol at a low CI. There was no CO-dependent effect on diastolic and mean ΔP. Repeated IAP elevations do not significantly influence ΔP. CONCLUSIONS: Intermittent IAP elevations do not significantly influence ΔP. Despite of a CO-dependent inversion of systolic ΔP, mean BP measurements at the leg during laparoscopy remain representative even at low CO values.

Risk of Malignancy and Need for Surgery in Pediatric Patients with Morris or Y-chromosome Turner Syndrome: A Multicenter Survey.

STUDY OBJECTIVE: The management of intersex patients with Y-chromosome Turner or Morris syndrome remains a challenge. We report our experience with a multicenter European survey. DESIGN: We collected the data on 18 patients (mean age 10.2 years, range 2-17 years) with Morris (10 patients) or Turner (8 patients) syndrome harboring the Y chromosome who were treated in 1 of 6 European centers of pediatric surgery between 1997 and 2013. All patients were evaluated by use of a multidisciplinary diagnostic protocol. All patients received a bilateral gonadectomy via laparoscopy; only 1 center performed ovarian cryopreservation. Seven patients received a concomitant genitoplasty. Operative notes and histology were reviewed for details. RESULTS: No conversions to laparotomy and no complications were recorded. For the patients receiving only the gonadectomy, the length of hospital stay was 24-48 hours, whereas for the patients receiving an associated genitoplasty, it was 6-10 days. Specimens were negative for tumors in 83.3% of cases, whereas in 3 patients (16.6%), benign abnormalities (Sertoli cell hyperplasia in 1 patient and ovotestis in 2 patients) were recorded. A malignant tumor was not recorded in our series. CONCLUSION: If the risk of malignancy is considered as the main indication for surgery in case of Turner or Morris syndrome, on the basis of our study, this indication should be reevaluated. However, based on the non-negligible rate of benign abnormalities reported in our series (16.6%), the performance of cryopreservation to preserve fertility and the possibility of performing genitoplasty during the same anesthetic procedure represent additional valid indications for surgery.

Gender-related differences of inguinal hernia and asymptomatic patent processus vaginalis in term and preterm infants.

INTRODUCTION: The aim of this study was to analyze the gender-related differences of inguinal hernia (IH) and patent processus vaginalis (PPV) in term and preterm infants. METHODS: Over a nine-year-period 411 infants underwent laparoscopic herniorrhaphy within the first six months of life. 246 term (191 male; 55 female) and 165 preterm (118 male; 47 female) infants were included in this retrospective study. Initial presentation of IH and intraoperative anatomical findings of PPV were reviewed. RESULTS: We found that term boys (58.6%) and girls (58.2%) predominantly presented with right-sided IH whereas preterm boys (36.4%) and girls (44.7%) mostly presented with bilateral IH. Female babies had a higher incidence of initial left-sided IH. Term and preterm girls with initial left-sided hernia were found to have highest incidence of PPV. Male term babies with initial left-sided IH were found to have the lowest incidence of PPV (25.0%). The highest incidence of PPV in male was found in preterm boys with either left- or right-sided IH. CONCLUSION: Incidence and laterality of IH and PPV differ between term and preterm girls and boys. In open hernia repair decision concerning contralateral groin exploration should consider term/preterm birth as well as gender.

Comparison of inguinal hernia and asymptomatic patent processus vaginalis in term and preterm infants.

INTRODUCTION: The aim of this study was to evaluate the characteristics of inguinal hernia (IH) and patent processus vaginalis (PPV) in term and preterm infants less than the age of 6months. METHOD: Between January 2004 and December 2012, 246 term and 165 preterm infants underwent laparoscopic herniorrhaphy within the first 6months of life. Preoperative clinical presentation and intraoperative anatomical findings during the laparoscopic procedure were evaluated. Additionally, initial side of hernia, laterality of IH and PPV were analyzed in term and preterm infants. RESULTS: In the group of term infants, most infants presented with a primary right-sided IH (58.5%) versus 17.9% left-sided and 23.6% bilateral IH. Babies with primary unilateral IH were found to have a contralateral PPV in 41.0% of cases. A difference between left-sided PPV and right-sided PPV could not be identified. In the group of preterm infants, initial bilateral presentation was predominant (38.8%) versus right-sided (30.3%) and left-sided IH (30.9%). Infants with primary unilateral IH were found to have a contralateral PPV in 56.4%. We identified a slight difference between left-sided PPV (54.0%) and right-sided PPV (58.8%). CONCLUSION: IH is predominantly right sided in term infants, whereas preterm infants mostly present with bilateral IH. The incidence of PPV was found to be significantly higher in the preterm group. Regarding the incidence of a contralateral PPV in term and preterm infants, no difference between initial left-sided and right-sided IH could be identified between both groups.

Hemodynamic effects of thoracoscopic surgery in neonates with cardiac anomalies.

INTRODUCTION: Thoracoscopic repair of esophageal atresia (EA) and congenital diaphragmatic hernia (CDH) repair is increasing in popularity. However, minimally invasive surgery is avoided in infants with heart defects. The aim of this study was to clarify whether cardiac anomalies are a reasonable contraindication to thoracoscopic surgery in term and preterm neonates. PATIENTS AND METHODS: In this retrospective, single-institution study 15 neonates (8 boys and 7 girls) with cardiac anomalies underwent thoracoscopic repair of either EA or CDH. Between January 2004 until November 2012 4 preterm and 11 term neonates were identified. Type of cardiac anomaly, operative procedure performed, operative time, intrapleural pressure, and early postoperative complications were evaluated. RESULTS: Over this 9-year period, 10 neonates underwent thoracoscopic EA repair, and 5 neonates underwent thoracoscopic CDH repair. Median operative time was 177 minutes with a median intrapleural pressure of 9 mm Hg. Cardiac anomalies ranged from persistent foramen ovale to atrium septal defect to ventricular septal defect and tetralogy of Fallot. In the postoperative course hemodynamic impairment was noted in only 1 patient. This patient presented cardiorespiratory instability already preoperatively and required dobutamine until postoperative Day 6. CONCLUSIONS: From this experience it appears that thoracoscopic surgery can be performed safely in term and preterm neonates with cardiac anomalies. Even in babies with multiple cardiac anomalies and complex heart defects, thoracoscopic repair of EA or CDH could be performed without hemodynamic instability. Nevertheless, further studies are necessary to gain sufficient information about the effects of thoracoscopy in neonates with heart defects.

Work-related upper limb musculoskeletal disorders in pediatric minimally invasive surgery: a multicentric survey comparing laparoscopic and sils ergonomy.

PURPOSE: Surgeons are at risk for developing work-related musculoskeletal symptoms (WMS). The present study aims to compare laparoscopy and SILS ergonomy among pediatric surgeons. METHODS: A questionnaire formed by 17 questions was mailed to 14 pediatric surgeons, seven with a large experience in laparoscopy and seven in SILS. All surgeons completed the survey. The questionnaires were focused on the type of laparoscopic or SILS activity, location and type of pain, need for drugs and its physical consequences. Results were analyzed using χ(2) test. RESULTS: Results indicated a similar incidence of WMS with shoulder symptoms (>75%) in both groups. In laparoscopic group this pain is evident only after a long lasting procedure, while in SILS group the pain is present after each procedure performed. SILS surgeons used painkillers and other therapies statistically more frequently than laparoscopic group (χ(2) = 0.001). CONCLUSIONS: This study confirms there is a strong association between WMS and MIS surgery. The incidence of pain is similar in both groups. Pain was present only after long lasting procedures in laparoscopic group, while SILS surgeons have pain after each procedure performed. In addition SILS surgeons use more frequently painkillers and other therapies compared to laparoscopic surgeons. In conclusion, it seems that SILS has a worse ergonomy compared to laparoscopy.

Cardiorespiratory complications after laparoscopic hernia repair in term and preterm babies.

PURPOSE: The aim of this study was to clarify the incidence of postoperative complications in infants undergoing laparoscopic hernia repair within the first six months of life. METHODS: Retrospective, single-institution study comparing term and preterm babies undergoing surgery between March 2005 and September 2012. The charts were reviewed for postoperative complications and pre-existing diseases. RESULTS: In the term group 188 of 199 babies (94.5%) had an uneventful postoperative course. Eleven patients (5.5%) presented postoperative complications, three of them (1.5%) developed severe respiratory complications. A relation between pre-existing diseases and postoperative complications could be identified in two patients. Laparoscopy possibly induced cardiorespiratory instability in one infant. In the preterm group 109 of 137 babies (79.6%) had an uneventful postoperative course. 28 preterm infants (20.4%) developed postoperative complications, seven of them (5.1%) presented severe respiratory complications. Pre-existing diseases were identified as an influencing factor in 22 preterm infants. In one patient laparoscopy possibly caused minor instability of a pre-existing cardiac anomaly. CONCLUSIONS: Postoperative complications are low in both groups, although the incidence is increased in preterm infants. Pre-existing diseases are a major influencing factor for preterm infants. In very few infants laparoscopy may have induced instability of cardiac anomalies.

Work-related upper limb musculoskeletal disorders in paediatric laparoscopic surgery. A multicenter survey.

BACKGROUND: Surgeons are at risk for developing work-related musculoskeletal symptoms (WMS). The present study aims to examine the physical factors and their association with WMS among pediatric laparoscopic surgeons. METHODS: A questionnaire consisting of 21 questions was created and mailed to 25 pediatric laparoscopic surgeons (LG). 23/25 surgeons (92%) completed the survey. The questionnaire was analyzed and then split into 2 groups. Group 1 (LG1) included surgeons with greater laparoscopic experience, and group 2 (LG2) included surgeons with less important laparoscopic experience. In addition, we constructed and sent to the same surgeons a similar questionnaire focused on WMS after an open procedure (OG) with the aim to compare results of LG with OG. RESULTS: The prevalence rate of WMS with shoulder symptoms was 78.2% in surgeons that performed laparoscopy for more than 10 years, with 60.8% also reporting other pain. In 66.6% this pain is evident only after a long-lasting procedure. Forty-four percent of these surgeons require painkillers at least twice a week. Fifty percent of these surgeons also suffer at home. Fifty-five and one half percent of surgeons indicate that this pain is related to their laparoscopic activity. Forty-three and a half percent think that laparoscopy is beneficial only for the patient but has a bad ergonomic effect for surgeons. Sixty-five and two-tenths percent think that robotic surgery can be helpful to improve ergonomics. Comparing the groups, WMS occur more frequently in LG (78.2%) than in OG (56.5%), but this difference was not statistically significant (χ(2)=0.05). In addition, WMS occur more frequently in LG1 (84.6%) than in LG2 (70%), but this difference was not statistically significant (χ(2)=0.05). CONCLUSIONS: These results confirmed a strong association between WMS and the number of laparoscopic procedures performed. Skilled laparoscopic surgeons have more pain than less skilled laparoscopic surgeons. WMS in the same group of surgeons are more frequent after laparoscopy than after open procedures. The majority of surgeons refer to shoulder symptoms.

Hemodynamic effects of laparoscopic surgery in term and preterm infants with cardiac anomalies.

PURPOSE: The aim of this study was to clarify whether cardiac anomalies are a reasonable contraindication to laparoscopic surgery in infants. METHODS: Between January 2004 and January 2013, 131 term and preterm infants with cardiac anomalies underwent laparoscopic surgery within the first 6 months of life. In this retrospective study type of cardiac anomaly, performed operative procedure, operative time, intraabdominal pressure and postoperative complications were evaluated. RESULTS: Over this 9-year period, 80 preterm and 51 term infants underwent different complex and even long-lasting laparoscopic procedures. Median operative time was 67 min with a median intraabdominal pressure of 13 mmHg. Cardiac anomalies ranged from persistent foramen ovale, atrium septal defect to ventricular septal defect and tetralogy of Fallot. In the postoperative course hemodynamic impairment was noted in three infants (2.3 %). Only one of them presented cardiorespiratory instability. CONCLUSION: In this study different laparoscopic procedures could be performed in numerous infants with cardiac anomalies. Due to the inhomogeneity of this group of patients and individual combinations of heart defects with or without hemodynamic relevance, preoperative evaluation by a firm pediatric cardiologist is crucial. Prospective studies are necessary to further clarify the use of laparoscopic surgery in this distinct group of patients.

Air in the insufflation tube may cause fatal embolizations in laparoscopic surgery: an animal study.

BACKGROUND: The aim of this study was to evaluate the risk of an air embolization with the volume of the insufflation tube during induction of laparoscopy. A further objective was to determine the LD50 of air in young piglets. METHODS: End-tidal carbon dioxide pressure ([Formula: see text]), pulmonary arterial pressure (P pa), heart rate (f c), and mean arterial pressure (P a carot) were measured in 17 piglets divided into three groups: group 1 (n = 6), bolus application (CO2 embolization, followed by air embolization, 2 mL/kg each), group 2 (n = 7), continuous air embolization (30 min, 0.2 mL/kg/min), and group 3 (n = 4), continuous CO2 embolization (30 min, 0.4 mL/kg/min). RESULTS: All animals survived CO2 embolism. Air embolization as a bolus (2 mL/kg) or with an accumulated volume of 3.1 mL/kg led to death. Decreases in [Formula: see text] indicated air or massive CO2 embolization only. There was a good correlation between [Formula: see text] and P pa in case of air embolization (r = -0.80, p < 0.0001). In contrast, no dependency was recognized during CO2 embolism (r = -0.17, p = 0.2). CONCLUSIONS: In order to minimize the lethal risk of gas embolization, the insufflation system has to be completely filled with CO2 before connecting to the patient.

Embolism risk analysis--helium versus carbon dioxide.

BACKGROUND: Helium is used as an insufflation gas to avoid the negative properties of carbon dioxide (CO(2)), such as CO(2) accumulation, acidosis, and tachycardia, particularly in the case of insufficient respiratory function, seen also in infancy. Any laparoscopic procedure carries the risk of a gas embolism. MATERIALS AND METHODS: Seven anesthetized piglets (weighing 9.9-12.8 kg), randomized into three groups, served as models for pre-teenage children. Three piglets received a CO(2) embolism, followed by a helium embolism of 2 mL/kg, respectively. Helium was administered to three piglets, whereas both gases were repeatedly administered alternately to one piglet. The embolisms were administered for 30 seconds via a central venous line. Cardiac output was measured using the thermodilution method. The observation period for each embolism was 60 minutes in Groups 1 and 2 and 15 minutes in Group 3. RESULTS: All animals survived CO(2) embolisms. Four of the six piglets died after helium embolisms. Following helium embolisms there was a prompt initial decrease in the end-tidal CO(2) pressure and an initial increase in the pulmonary arterial pressure. A further decrease in arterial blood pressure was prevented by a compensatory increase in the heart rate and appeared just before death. After only 5 minutes cardiac output showed a 25% decline from the initial value. Helium embolisms led to a severe increase in the pulmonary dead space. CONCLUSIONS: Embolisms with the smallest amounts of helium administered via direct venous puncture have an immediate lethal impact. Extended perioperative monitoring and trocar placement under vision should be performed.

The role of laparoscopy in the treatment of duodenal obstruction in term and preterm infants.

PURPOSE: The aim of this study was to evaluate the role of laparoscopy in the surgical treatment of intrinsic and extrinsic duodenal lesions referring to the underlying cause of obstruction. METHODS: Retrospective chart review of all cases of duodenal obstructions undergoing surgery at our institution between April 2004 and March 2012. RESULTS: Twenty patients underwent surgery for duodenal obstruction (11 female, 9 male). Seven infants were born prematurely. Eleven infants had extrinsic, seven had intrinsic and two had a combination of intrinsic and extrinsic duodenal lesions. A laparoscopic procedure was initially started in 18 of 20 patients (90 %). Thirteen of the 18 infants (72 %) underwent various laparoscopic procedures: laparoscopic duodenoduodenostomy, resection of a duodenal membrane and the transsection of Ladd's bands. In five patents, a conversion became necessary due to poor visualisation of the duodenum. In three patients (15 %) with extrinsic duodenal lesion a reoperation was necessary. Two of the 20 patients (10 %) were operated with an "open" approach to begin with. CONCLUSION: Laparoscopy is feasible and safe in most cases. The few conversions were early in the series due to a lack of experience and necessitated by poor visualisation, most often caused by malrotation.

Gastric outlet obstruction in a neonate because of Peutz-Jeghers syndrome.

Neonatal detection of Peutz-Jeghers syndrome is unusual with only 2 cases previously reported in the literature. We describe a neonate presenting with gastric outlet obstruction owing to 2 large Peutz-Jeghers polyps. The child's father and grandmother were known to have Peutz-Jeghers syndrome. On the ninth day of life, the infant underwent colonoscopy, abdominal exploration, and complete surgical resection of 3 polyps. The postoperative course was uneventful, and the patient was discharged home at the age of 3 weeks on full oral feeds. This is the first case report of inherited Peutz-Jeghers syndrome causing gastric outlet obstruction in a neonate.

Decline in infantile hypertrophic pyloric stenosis in Germany in 2000-2008.

BACKGROUND AND OBJECTIVE: The incidence of infantile hypertrophic pyloric stenosis (IHPS) is highly variable over time and geographic regions. A decline in IHPS incidence was recently reported in Sweden, the United States, Denmark, and Scotland. In Sweden, the IHPS decline seemed to be concurrent with a declining incidence in sudden infant death syndrome (SIDS), which suggested a common cause; the latter was attributed to campaigns against the prone sleeping position. We investigated the time course of the IHPS incidence in all German federal states (N = 16) between 2000 and 2008. We examined correlations between the IHPS incidence and the SIDS incidence. METHODS: Data were extracted from the public report of health (Gesundheitsberichterstattung des Bundes). We collected the numbers of IHPS (International Classification of Diseases, 10th Revision [ICD-10], code 40.0), SIDS (ICD-10, R95), and live births (LB; male/female) in each federal state for 2000-2008. RESULTS: The IHPS incidence declined in Germany from 2000 (3.2086/1000 LB [range: 1.67-5.33]) to 2008 (2.0175/1000 LB [1.74-3.72]; P = .005). The recorded incidence was highly variable in different federal states and over time. The SIDS incidence also declined during the same time period (2000, median: 0.759/1000 LB [interquartile range: 0.54-1.029]; 2008, median: 0.416/1000 LB [interquartile range: 0.285-0.6485]; P = .0255). However, the SIDS regional distribution was different from that of IHPS. CONCLUSIONS: The IHPS incidence declined by ∼38% nationwide. A parallel decline in SIDS displayed a different pattern in regional distribution; thus, a common cause was unlikely. The regional differences indicated that etiologic factors remained unresolved.

Pectus excavatum: history, hypotheses and treatment options.

Pectus excavatum and pectus carinatum represent the most frequent chest wall deformations. However, the pathogenesis is still poorly understood and research results remain inconsistent. To focus on the recent state of knowledge, we summarize and critically discuss the pathological concepts based on the history of these entities, beginning with the first description in the sixteenth century. Based on the early clinical descriptions, we review and discuss the different pathogenetic hypotheses. To open new perspectives for the potential pathomechanisms, the embryonic and foetal development of the ribs and the sternum is highlighted following the understanding that the origin of these deformities is given by the disruption in the maturation of the parasternal region. In the second, different therapeutical techniques are highlighted and based on the pathogenetic hypotheses and the embryological knowledge potential new biomaterial-based perspectives with interesting insights for tissue engineering-based treatment options are presented.

Microlaparoscopic hernia repair in children: initial experiences.

INTRODUCTION: This study reports the authors' experience with the exclusive use of 2-mm instrument sets and small diameter scopes in 100 children undergoing microlaparoscopic herniorrhaphy. METHOD: This prospective study was designed as a pilot feasibility study; all data related to patients and procedures were prospectively collected. A pneumoperitoneum was established, and 1.7 to 2 mm 0° or 30° scopes were introduced for visualization. Exclusively 2-mm instruments were used. RESULTS: This study included 100 children (aged 15 days to 11 years, median age 2.3 years) undergoing microlaparoscopic hernia repair. A total of 140 hernias were treated. The average operative time for the microlaparoscopically experienced surgeon was 16 minutes for bilateral inguinal hernia and 12 minutes for unilateral hernias. All procedures were completed microlaparoscopically. Hernia recurrence was observed in 2 patients. CONCLUSION: Based on the authors' early experience, it is found that microlaparoscopic hernia repair in children seems to be a safe and feasible procedure.

Comparison of a novel technique of the microlaparoscopic pyloromyotomy to circumbilical and Weber-Ramstedt approaches.

INTRODUCTION: The aim of this retrospective comparative study was to compare the surgical results and outcomes of the newly inaugurated approach of microlaparoscopic pyloromyotomy with open techniques. METHODS: The surgical charts of 110 infants (85 boys and 25 girls, ages ranging from 10 to 98 (average 28) days) undergoing pyloromyotomy microlaparoscopically (28), through the circumbilical approach (56), or via the right upper quadrant access (26) were reviewed. The variables were compared between the three surgical approach groups, and the statistical analysis was performed. RESULTS: There was a significant difference between Bianchi and microlaparoscopy in terms of operation time (average 38.5 vs. 20.5 min, p < 0.0001) and time to full enteral feed (average 48 vs. 32 h, p = 0.001). There was no significant difference in postoperative length of stay (75 vs. 82 h, p = 0.12). The operative time for the surgeons experienced in microlaparoscopy was in average of 14 min (range, from 9 to 18 min). When comparing the Weber-Ramstedt procedure and microlaparoscopy, microlaparoscopy required significantly less operative time (50 vs. 20 min, p < 0.0001), a shorter time to full enteral feed (70 vs. 32 h, p < 0.001), and a shorter postoperative length of stay (90 vs. 82 h, p = 0.04). There were no cases of mucosal perforation or incomplete pyloromyotomy. CONCLUSION: Despite the small sample size included in the present study, it seems that microlaparoscopic pyloromyotomy is safe and feasible with the lowest rate of complications and the shortest operative time. The Bianchi approach is a good alternative to achieve a small scar without laparoscopy.