Utilization of Single-Incision Laparoscopy in the Management of Ingested Magnets.

Background: A ban on neodymium magnets was lifted by the U.S. Consumer Product Safety Commission in 2016. Pediatric gastroenterologists and surgeons were increasingly tasked with removing these problematic objects. The purpose of this study was to assess the utility of single-incision laparoscopic surgery (SILS) in the management of ingested magnets. Patients and Methods: This is a single-center, retrospective assessment of surgical interventions for ingested magnets. International Classification of Disease, 10th revision codes were used to identify 349 patients ≤21 years of age evaluated for foreign body ingestion over a 4.5-year period. A medical record review helped isolate 29 (8.3%) magnet ingestions, 9 requiring surgical intervention. RedCap was used for analysis. Results: Of 9 surgical patients, 7 underwent SILS intervention by 1 surgeon. Another surgeon performed an open operation, whereas a third performed a multiport operation. Of the 7 SILS cases, 3 were completed without conversion to open. In one of these cases, bowel resection with primary anastomosis was performed. For SILS cases, average operating room time was 109 minutes (38-170 minutes), time to enteral feeds was 23 hours (0.28-79.2 hours), and hospital length of stay (LOS) was 3.8 days (1.96-6.68 days). Thirty-day readmission for SILS was 14.3%. No other complications were observed. Conclusions: SILS has been safely utilized for magnet retrieval. It offers an ability to identify the affected intestinal segment and an opportunity to intervene extracorporeally through an uncapped port. In addition, knowing where matted bowel is located can direct a limited incision during conversion to laparotomy. This may confer benefits of decreased pain, shortened time to enteral feeds, and decreased hospital LOS.

Modified Uniportal Video-Assisted Thoracic Surgery Versus Three-Port Approach for Lung Nodule Biopsy in Pediatric Cancer Patients.

BACKGROUND: Uniportal video-assisted thoracic surgery (VATS) is gaining popularity among thoracic surgeons, but the limited space in the thorax of children makes uniportal VATS difficult to perform. The purpose of this study was to evaluate procedural and outcome differences between a modified uniportal VATS (MU-VATS) and three-port VATS (TP-VATS) for peripheral lung nodule biopsy in pediatric cancer patients. MATERIALS AND METHODS: This is an Institutional Review Board-approved retrospective analysis of all consecutive MU-VATS and TP-VATS peripheral lung nodule biopsies performed at a single institution between June 2014 and December 2016. Patients with diffuse lung disease who underwent a lung biopsy were excluded. RESULTS: Over a 30-month period, 22 patients with a median age of 12 years (range, 7-21) underwent MU-VATS or TP-VATS for excisional biopsy of a peripheral lung nodule. MU-VATS lung biopsy was attempted in 11 patients and TP-VATS lung biopsy in the remaining 11. Both groups were comparable with regard to demographics, primary diagnosis, purpose of biopsy, and lung nodule location. MU-VATS demonstrated no difference when compared with TP-VATS lung biopsy in operative time (54 versus 62 min, P = .899), estimated blood loss (14 versus 15 mL, P = .587), pain score (2.8 versus 2.9, P = .717), and discharge day (1.3 versus 1.2 days, P = .572). No difference existed between groups with regard to conversion, need for intraoperative blood transfusion, and duration of chest tube. Complications including pneumothorax (n = 2) and subcutaneous emphysema (n = 1) were only seen in the TP-VATS group. CONCLUSIONS: MU-VATS can be safely utilized for biopsy of peripheral lung nodules in pediatric cancer patients without increasing procedural duration, hospitalization, pain scores, or need for intraoperative blood transfusion. Further studies need to evaluate the theoretical cosmetic advantage from a single surgical scar.

Use of ultrasound in diagnosing postoperative small-bowel intussusception in pediatric surgical oncology patients: a single-center retrospective review.

BACKGROUND: Postoperative intussusception can be a complication of abdominal surgery and often poses a diagnostic dilemma. OBJECTIVE: The purpose of this study was to evaluate the utility of ultrasonography in the diagnosis of intussusception in children who had recently undergone resection of a primary solid tumor. MATERIALS AND METHODS: We performed a retrospective review of all pediatric surgical oncology patients undergoing laparotomy for excision of an abdominal tumor at our institution from 1995 to 2015. We reviewed those with documented postoperative intussusception. In addition we searched the radiology database for all ultrasound examinations requested to rule out postoperative intussusception during our study interval. We analyzed demographics, primary diagnosis, surgical procedure, presentation, diagnostic investigations and definitive treatment. RESULTS: At our institution 852 laparotomies for abdominal tumor resection were performed during the study period, resulting in 10 postoperative intussusceptions (1.2% of cases), of which half were following neuroblastoma resection and the other half following nephrectomy for Wilms tumor. Postoperative intussusception was suspected if the patient had increasing nasogastric output, abdominal distension or feeding intolerance. Ultrasound was used to diagnose intussusception in 9/10 cases, on postoperative day 6 (standard deviation [SD] 5.6 days) on average, with a sensitivity of 89% (8/9; one false negative; 95% confidence interval [CI] 0.52, 1.00) and a specificity of 100% (no false positives; 95% CI 0.96, 1.00). CONCLUSION: Ultrasound was highly accurate in diagnosing postoperative intussusception in children who underwent resection of retroperitoneal tumors.

Operative and Immediate Postoperative Differences Between Traditional Multiport and Reduced Port Laparoscopic Total Splenectomy in Pediatric Patients.

BACKGROUND: Laparoscopy offers many benefits to splenectomy, such as reduced incisional pain and shortened hospital duration. The purpose of this study is to evaluate procedural and outcome differences between multiport (MP) and reduced port (RP) splenectomy when utilized to treat children. PATIENTS AND METHODS: An institutional review board approved retrospective analysis of all consecutive laparoscopic total splenectomies performed at a single institution between January 2010 and October 2015 was conducted. We evaluated demographics, surgical technique, instance of conversion, operative duration, estimated blood loss, need for intraoperative blood transfusion, postoperative length of stay, time to full feeds, complications, and follow-up duration. RESULTS: Over a 5-year period, 66 patients less than 20 years of age underwent laparoscopic total splenectomy. RP splenectomy was attempted in 14 patients. The remaining 52 were MP operations. Populations were comparable with regard to demographics. Preoperative splenic volumes (mL) were greater in the RP population (median [IQR]: 1377 [747-1508] versus 452 [242-710], P = .039). RP splenectomy demonstrated no difference compared to MP splenectomy in operative time (153 versus 138 minutes, P = .360), estimated blood loss (120 versus 154 mL, P = .634), or percent of cases requiring intraoperative blood transfusion (14 versus 23, P = .716). By the first postoperative day, 57% of RP and 17% of MP patients could be discharged (P = .005). Thirty-day readmission rates were similar, at 7% for RP and 8% for MP operations. Fever was the indication for all readmissions. Mean duration of follow-up is 28 months for MP and 13 months for RP cases. CONCLUSION: A reduced number of ports can be safely utilized for total splenectomy in pediatric patients without increasing procedural duration or need for intraoperative blood transfusion. In addition, rate of discharge on the first postoperative day was significantly higher in the RP splenectomy group.

Modified uniportal video-assisted thoracic surgery in children.

Video-assisted thoracic surgery (VATS) has been traditionally performed by a multi-port approach, but uniportal VATS is gaining popularity among thoracic surgeons. The use of only one intercostal space may result in less pain, but competition among camera and operating instruments may be a disadvantage. In children, the limited space in the thorax makes the uniportal VATS difficult to accomplish. We present a modification of the uniportal VATS, using a single skin incision but placing the thoracoscope in the superior or inferior intercostal space relative to the working instruments to increase instrument range of motion within a single intercostal space.

Routine utilization of single-incision pediatric endosurgery (SIPES): a 5-year institutional experience.

BACKGROUND: Single-incision pediatric endosurgery (SIPES) allows operation through one access site, eliminating the multiple sites traditionally used. There are few large series evaluating the versatility of SIPES. The purpose of this study is to review a 5-year single-institution experience with routine SIPES use. PATIENTS AND METHODS: This is an Institutional Review Board-approved retrospective analysis of prospectively collected data. All SIPES cases from March 2009 to December 2013 were included. Our database contains demographics, procedure type, operative duration, estimated blood loss, instance of added ports or conversion to open, complications, and follow-up duration. RESULTS: Of 1322 SIPES operations performed, most (82.1%) were appendectomies and cholecystectomies. Of 871 (66%) patients seen in follow-up, with a median duration of 26 days, 53 (6.1%) experienced postoperative complications. Forty-two cases (4.8%) were surgical-site infections, of which 4 required drainage. Less frequent complications that required operative intervention include recurrent inguinal hernia (n=4), umbilical hernia (n=3), intraabdominal abscess (n=1), bleeding (n=1), abdominal compartment syndrome (n=1), bowel obstruction (n=1), stitch granuloma (n=1), and persistent postoperative pain (n=1). CONCLUSIONS: Operative times and complication rates are comparable to those in prior reported multiport laparoscopic series, allowing safe integration of SIPES into the routine of a surgical practice for most common procedures.

Single-incision pediatric endosurgery (SIPES) splenectomy: what dictates the need for additional ports?

BACKGROUND: As proficiency with single-incision pediatric endosurgery (SIPES) increases, more challenging operations are being performed. While the ultimate goal is safe surgery, it may be beneficial to know what anatomical and technical factors contribute to the need for additional ports. This aspect of SIPES splenectomy has yet to be evaluated. The study objective was to identify these factors, potentially allowing surgeons to gauge appropriateness for single incision and to tailor techniques for optimal results. METHODS: This was an institutional review board-approved retrospective analysis of prospectively collected data (FWA00005960). SIPES splenectomies performed at a tertiary children's hospital since March of 2009 were included. Demographic and technical factors pertaining to each operation were available in our SIPES database. Fischer's exact and Wilcoxon rank sum tests were used to analyze categorical and continuous variables, respectively. RESULTS: Thirty-seven patients 18 years of age and younger underwent attempted SIPES splenectomy. Two operations were converted directly to open and were excluded from analysis. Of the remaining 35 operations, 15 (42.9 %) were completed with additional ports. Gender, age, body mass index, splenic weight, indication for operation and the presence of accessory spleens did not contribute to the need for added ports. The only factor to reach statistical significance was the number of channels present in the SIPES access device (p = 0.002). CONCLUSIONS: Completion of SIPES splenectomy was associated with the decision to utilize an access device with four channels. Anatomic variables did not appear to affect the ability to complete SIPES splenectomy.

Risk of incomplete pyloromyotomy and mucosal perforation in open and laparoscopic pyloromyotomy.

BACKGROUND: Despite randomized controlled trials and meta-analyses, it remains unclear whether laparoscopic pyloromyotomy (LP) carries a higher risk of incomplete pyloromyotomy and mucosal perforation compared with open pyloromyotomy (OP). METHODS: Multicenter study of all pyloromyotomies (May 2007-December 2010) at nine high-volume institutions. The effect of laparoscopy on the procedure-related complications of incomplete pyloromyotomy and mucosal perforation was determined using binomial logistic regression adjusting for differences among centers. RESULTS: Data relating to 2830 pyloromyotomies (1802 [64%] LP) were analyzed. There were 24 cases of incomplete pyloromyotomy; 3 in the open group (0.29%) and 21 in the laparoscopic group (1.16%). There were 18 cases of mucosal perforation; 3 in the open group (0.29%) and 15 in the laparoscopic group (0.83%). The regression model demonstrated that LP was a marginally significant predictor of incomplete pyloromyotomy (adjusted difference 0.87% [95% CI 0.006-4.083]; P=0.046) but not of mucosal perforation (adjusted difference 0.56% [95% CI -0.096 to 3.365]; P=0.153). Trainees performed a similar proportion of each procedure (laparoscopic 82.6% vs. open 80.3%; P=0.2) and grade of primary operator did not affect the rate of either complication. CONCLUSIONS: This is one of the largest series of pyloromyotomy ever reported. Although laparoscopy is associated with a statistically significant increase in the risk of incomplete pyloromyotomy, the effect size is small and of questionable clinical relevance. Both OP and LP are associated with low rates of mucosal perforation and incomplete pyloromyotomy in specialist centers, whether trainee or consultant surgeons perform the procedure.

Partial versus total splenectomy in children with hereditary spherocytosis.

BACKGROUND: Partial splenectomy is utilized selectively in children with hereditary spherocytosis (HS) to decrease hemolysis while maintaining immunity. Our aim was to compare outcomes between laparoscopic total splenectomy (LTS) and laparoscopic partial splenectomy (LPS). METHODS: After obtaining institutional review board approval, we reviewed the records for all children ≤18 years with HS undergoing LTS and LPS between 2002 and 2012. Wilcoxon rank-sum tests were used. RESULTS: Eighty-seven HS children underwent LTS (n = 71) and LPS (n = 16). Mean age was 7.1 ± 3.6 years (LTS) and 5.5 ± 2.8 years (LPS; P = .14). Concomitant cholecystectomy was performed in 32% of LTS and 38% of LPS cases. Operative time was 87 ± 33 minutes (LTS) and 140 ± 36 minutes (LPS; P = .0005). Duration of stay was 1.2 ± 0.5 days (LTS) and 2.4 ± 1.4 days (LPS; P = .003). Reticulocyte and hemoglobin levels improved after both operations. LPS children had lower preoperative (8.8 ± 1.9 vs 10.2 ± 1.7 g/dL; P = .0148) and postoperative (10.5 ± 1.7 vs 13.8 ± 1.1 g/dL; P < .0001) hemoglobin levels than did LTS patients. Three LPS children required transfusion (at 2, 4 and 5 postoperative years) for parvovirus-associated aplastic crises. No LTS child developed splenic function or anemia. CONCLUSION: These data demonstrate that LPS decreases hemolysis, although LTS is more effective. LPS children had lower preoperative hemoglobin levels, indicating more severe hemolysis. LPS also has greater operative time and duration of stay, disadvantages balanced by retained immunity.

Cervical tracheal transection after scarf entanglement in a go-kart engine.

BACKGROUND: Tracheal disruption secondary to blunt force occurs infrequently. Most individuals suffering such an injury die before arriving at a hospital. Diagnosis for those who do present alive is often delayed, as signs and symptoms typically do not match the severity of injury. OBJECTIVE: The objectives of this case report are to present a unique mechanism for tracheal disruption and to discuss our management strategy. CASE REPORT: We describe an 18-year-old man who suffered tracheal disruption after entanglement of his scarf in a go-kart engine. His initial workup was conducted by emergency physicians and included computed tomographic evaluation of the neck. After diagnosis, the patient was transported to an operating suite. Awake tracheostomy was performed in this controlled environment to secure the airway, after which the trachea was repaired via primary anastomosis. CONCLUSIONS: Prompt recognition and appropriate intervention are critical in the care of patients with suspected tracheal transection to prevent mortality.

The role of laparoscopic evaluation to detect a contralateral defect at initial presentation for inguinal hernia repair.

Our objective was to determine the accuracy of laparoscopic evaluation to detect a contralateral patent processus vaginalis (CPPV) at initial presentation for inguinal hernia (IH) repair and the rate of CPPV relative to age, sex, and initial hernia side. We performed a 5-year retrospective review of 1580 pediatric patients with unilateral IH in which surgeons selectively used laparoscopy to evaluate for a CPPV. There were 1205 boys and 303 girls; 980 (65%) presented with right IH (RIH) and 528 (35%) with left IH (LIH). Laparoscopic evaluation was performed in 459 (47%) patients presenting with RIH and 225 (43%) patients presenting with LIH. Laparoscopic evaluation was positive for CPPV in 32 per cent of patients with RIH and 42 per cent of patients with LIH (P = 0.0168). CPPV was associated with prematurity (P = 0.0003) and age younger than 6 months (P = 0.0001) but not with sex (P = 0.55). The future contralateral occurrence rate was 1.6 per cent and recurrence rate 0.2 per cent. This study supports the accuracy of CPPV evaluation by laparoscopy. Although the rate of CPPV decreases after 6 months of age, girls older than 2 years of age have a significantly higher rate of CPPV than boys, supporting laparoscopic evaluation in older girls.

Trauma laparotomy: evaluating the necessity of histological examination.

Trauma laparotomy is the most commonly performed procedure in the acute care setting. As current practice, removed specimens are sent for histological examination. A retrospective review of all trauma laparotomies with specimens removed and sent to pathology during a 12-month period was performed in a Level I trauma center. One hundred five procedures of 244 trauma laparotomies yielded specimens sent for examination. Eighty-six patients were male and 19 patients were female with an average age of 34 +/- 14 years. Fifty-six per cent of the injuries resulted from penetrating trauma and 44 per cent were from blunt trauma. Gunshot wound and motor vehicle crash were the most common penetrating and blunt injuries, respectively. One hundred thirteen specimens were sent to pathology. Forty-three per cent of the specimens were spleen, 24 per cent small bowel, 16 per cent large bowel, 4 per cent kidney, 2 per cent omentum, 3 per cent appendix, 3 per cent pancreas, and 1 per cent for gallbladder and lung. One hundred twelve of 113 grossly normal specimens had normal pathology. One grossly normal specimen exposed abnormal pathology revealing benign appendiceal mucocele. Therefore, 99.1 per cent of grossly normal specimens sent for histological examination after trauma laparotomy were normal. Based on our review, in select patients routine histological examination of tissues removed for traumatic injury is unnecessary.