Reverse Tissue Expansion in Gastroschisis: What to do if the Defect is too large to close after Silo Removal?

A female baby with an antenatal diagnosis of gastroschisis was transferred to our institution. The defect was large but the bowel was in good condition and a silo was placed. After successful reduction of the bowel the abdominal wall defect was too large to allow fascial or even skin closure. We utilised a Gore-tex patch with two prolene purse string sutures placed concentrically to enable the diameter of the patch to be sequentially reduced. This enabled gradual stretching of the tissues with a progressive reduction in the size of the defect. The patch was removed after 8 days and a delayed fascial closure was achieved.

Omental cyst presenting with profound anaemia.

A male infant presented acutely with profound anaemia and abdominal distension. At laparotomy, a huge omental cyst was found. We reviewed our experience of this rare cause of abdominal pathology identifying five further cases since 2005, with a variety of presentations. The optimal treatment, complete resection, is associated with a low morbidity. The presentation with profound anaemia and shock due to haemorrhage into the cyst is unusual.

Magnetic bead toy ingestion: uses and disuses in children.

A 2-year-old female presented acutely with peritonitis and small bowel obstruction. An abdominal radiograph demonstrated a radiopaque foreign body. At laparotomy she was found to have bowel perforations with entero-enteric fistulae caused by four magnets. The magnets were removed, and debridement and closure of the perforations performed. We review our case and highlight this problem to other medical practitioners as a potential cause of significant morbidity and mortality in the paediatric population.

The risks of minimal access surgery in children: an aid to consent.

AIM: The aim of this study was to determine the risk of complications and conversions for minimally invasive procedures in children, thus allowing properly informed consent. METHODS: Data were retrieved for all minimally invasive surgical procedures performed between 1995 and 2009. RESULTS: There were 2352 cases performed in 2288 (1428 were male) patients. Of these, 2210 cases (94%) were laparoscopic, and 143 (6%), thoracoscopic. The median age at operation was 6 years and 4 months. The overall complication rate was 3.6%, with the risk of early reoperation at 1.7%. The risk was highest for fundoplication and pyloromyotomy at 3.2% and 4%, respectively. The risk of an infective complication was 0.5% and was highest for appendicectomy and nephrectomy. The risk of visceral injury overall in this series was 0.4%. Visceral injury, explicable only by port insertion, occurred in just under 1 in 1000 cases. The conversion rate was 2.3%. The lowest rates were observed with appendicectomy, fundoplication, and pyloromyotomy. Thoracoscopic cases, nephrectomies, and procedures for an underlying oncological diagnosis had a higher conversion rate. CONCLUSION: Informed consent requires knowledge of the risks of surgery. This series may serve as an aid for other units in obtaining consent for minimally invasive surgery in the pediatric population.

Intraoperative upper GI endoscopy ensures an adequate laparoscopic Heller's myotomy.

INTRODUCTION: In this article, we present our case series of laparoscopic Heller's myotomies. These were all performed with the aid of intraoperative upper gastrointestinal (GI) endoscopy. MATERIALS AND METHODS: During a 7-year period, 5 patients underwent a laparoscopic Heller's myotomy. There were 4 male patients and 1 female, with an average age of 12.1 years at operation (range, 9.3-14.9). One 14-year-old boy had had a laparoscopic Heller's procedure performed elsewhere and presented with severe dysphagia while undergoing orthopedic surgery in our hospital. His myotomy had been inadequate, and an intraoperative endoscopy had not been performed. All patients had preoperative upper GI contrast studies performed to confirm the diagnosis of achalasia. Two patients had manometry in addition to the contrast study. One patient had been treated with balloon dilatation preoperatively and another with botox injections. Endoscopy was performed pre- and postmyotomy to ensure adequacy. RESULTS: There were no cases of intraoperative mucosal perforation or conversions to an open procedure. Sixty percent of patients required extension of the myotomy after intraoperative endoscopy. All patients had an uneventful, complication-free postoperative recovery. CONCLUSION: We feel that the addition of endoscopy during laparoscopic Heller's myotomy confers a significant advantage in ensuring that the myotomy is adequate. In our experience, the outcome has been excellent even after previous balloon dilatation or submucosal botox injections.

Is conversion a complication of laparoscopic surgery.

INTRODUCTION: In this paper, we review our laparoscopic and thoracoscopic experience and look specifically at the cases that resulted in conversion. METHODS: Data were retrieved on all minimally invasive surgical procedures performed in our institution. RESULTS: There were 1,759 cases performed between 1997 and 2007. Of these, 1,648 cases were laparoscopic and 111 thoracoscopic. There were 508 appendicectomies (34 interval), 216 fundoplications (21 redo), 183 diagnostic laparoscopies, 137 pyloromyotomies, 35 cholecystectomies, 27 splenectomies, 98 Fowler-Stephens procedures,79 nephrectomies (including heminephrectomies), 48 Palomo procedures, 75 assisted percutaneous endoscopicgastronomies, 31 pull-through procedures for Hirschsprung's disease, and 210 others. There were 45 conversions (2.6%) over the time period; 40% of all cases converted were in children who had previously had surgery, and 13% of the conversions were enforced due to bleeding or visceral injury at the time of surgery.Looking at the conversion for specific operations, this was 1.4% for appendicectomies, 2% for pyloromyotomies,and 1% for fundoplications. The rate was highest for thoracoscopic cases and nephrectomies at 10%; 82% of all conversions occurred during the first 1,000 cases (56% of our experience). CONCLUSION: Our conversion rate is 2.6%. There has been a significant fall in our conversion rate over the 11 years, despite the increased number, breadth, and complexity of our caseload. We attribute this to the learning curve associated with minimally invasive surgery. Conversion is more common in patients who have had previous surgery, thoracoscopic procedures, and nephrectomies.

Neonatal laparoscopic Ladd's procedure can safely be performed even if the bowel shows signs of ischemia.

UNLABELLED: In this we describe two cases of neonatal malrotation with volvulus treated laparoscopically in our institution.CASE 1: A term baby girl was presented on day 3 of life with malrotation and volvulus. On inspection laparoscopically,the cecum was lying in a subhepatic position to the left of the midline. The small bowel was lying on the right, and there was a 180-degree rotation of the bowel. The rotated bowel was viable and of good color.The bowel was derotated, Ladd's bands divided, and the mesentery broadened. She was up to full feeds by postoperative day 2 and was discharged home on the 3rd day postsurgery.CASE 2: A baby boy presented with malrotation and volvulus on day 11 of life. At laparoscopy, there was freechyle in the peritoneal cavity and a midgut volvulus with an ischemic appearing bowel (with the exception of stomach duodenum and descending colon). The bowel was derotated, the ischemic bowel was returned to a healthy color, and Ladd's bands were divided and the root of the mesentery broadened. On post-operative day 2, he was commenced on feeds (expressed breast milk), and by post-operative 4, the baby was tolerating fullfeeds. CONCLUSION: In our unit, we have performed two laparoscopic Ladd's procedures. Neither of these children have had any complications and, on follow-up, are clinically well with excellent cosmetic results. We feel that laparoscopic treatment of malrotation with volvulus is a feasible procedure and should be performed where the expertise and equipment are available.