Laparoscopic Repair of Pediatric Femoral Hernias.

Background: Current rates of reported pediatric femoral hernias remain exceedingly low, with their incidence reported to be <1%. The mainstay of repair has traditionally been through an open approach, and pediatric surgeons remain reluctant to repair otherwise. Owing to its rarity, consensus regarding management remains absent. Because of this, we present a scoping review on the use of laparoscopy and minimally invasive techniques to repair pediatric femoral hernias. Methods: A scoping literature review was performed using PubMed, Embase, Scopus, and Web of Science for related articles (keywords). Full-text articles and abstracts were then reviewed for relevance using inclusion and exclusion criteria with data extracted from each piece. Results: The search identified 268 articles published from 1992 to 2023. Eleven articles met our inclusion criteria. After reviewing their content, a total of 87 patients were identified. Of these, 42 laparoscopic repairs were reported. Three primary laparoscopic surgical techniques were described, with no recurrence reported. Conclusion: Laparoscopy remains a viable tool in diagnosing and managing femoral hernias. Various technically feasible options for laparoscopy and minimally invasive techniques have been described with excellent results and limited recurrence. However, given the quality of the data, further studies are needed to investigate the long-term durability of such repairs.

Spontaneous Pneumomediastinum is Not Associated With Esophageal Perforation: Results From a Retrospective, Case-Control Study in a Pediatric Population.

What is the optimal management of spontaneous pneumomediastinum (SPM) and is there a risk of esophageal perforation in patients with SPM? We performed a retrospective case-control study of children through age 21, diagnosed with SPM in one hospital system over 10 years with the primary aim of describing the diagnostic workup, treatment patterns, and clinical outcomes. We hypothesized that SPM is a self-limited disease and is not associated with esophageal injury. Cases were identified using International Classification of Disease codes and excluded for trauma or severe infections. Median age was 16 years, 66% were male (n = 179). Chest radiography was performed in 97%, chest computed tomography (CT) in 33%, and esophagrams in 26%. Follow-up imaging showed resolution in 83% (mean = 17.2 days). SPM was not associated with esophageal perforation. We recommend avoiding CT scans and esophagrams unless there is discrete esophageal concern. Management of SPM should be guided by symptomatology.

The Evolving Effectiveness of Biologics in Avoiding Surgery in Children With Ulcerative Colitis: At what Nutritional Cost?

BACKGROUND: Pediatric ulcerative colitis (UC) treatment has changed dramatically with the introduction of multiple biologics. The goal of this study was to determine the effectiveness of these new biologics on achieving remission, nutritional impact, and eventual need for surgery in children. METHODS: We retrospectively analyzed hospital records of UC patients (ages 1-19) seen at a pediatric gastroenterology clinic between January 2012 andAugust 2020. Patients were divided into groups: 1) medically without biologics or surgery; 2) patients treated with one biologic; and 3) patients treated with multiple biologics 4)patients that underwent colectomy. RESULTS: There were 115 UC patients with a mean follow-up of 5.9 ± 3.7 years (1 month-15.3 years). PUCAI score at diagnosis was mild in 52 patients (45%), moderate in 25 (21%), and severe in 5 (4.3%). PUCAI score for 33 patients (29%) could not be calculated. There were 48 (41.3%) in group 1 with 58% remission, 34 (29.6%) in group 2 with 71% remission, 24 (20.8%) in group 3 with 29% remission, and only 9 (7.8%) in group 4 with 100% remission. The majority (55%) of surgical patients had colectomy within the first year of diagnosis. BMI improved after surgery (P = 0.001). The change from one biologic to others did not improve nutrition over time. DISCUSSION: New biologics are changing the landscape in maintaining remission from UC. The current need for surgery is much lower than previously published studies. In medically refractive UC, nutritional status only improved after surgery. Addition of another biologic for medically refractory ulcerative colitis in order to avoid surgery must take into account the positive impact surgery has on nutrition and disease remission.

Preoperative Splenic Artery Embolization for Massive Splenomegaly in Children: A Single Center Experience.

Introduction: Massive splenomegaly in children can complicate minimally invasive splenectomy. Splenic artery embolization (SAE) before splenectomy has been shown to decrease splenic volume, reduce intraoperative blood loss, and decrease conversion rates in laparoscopic surgery. Our objective was to review our recent experience with immediate preoperative SAE in massive splenomegaly for pediatric patients using both laparoscopic and robotic techniques. Materials and Methods: We retrospectively reviewed preoperative SAE outcomes in pediatric patients with massive splenomegaly undergoing minimally invasive splenectomy between January 2018 and July 2021. Results: Four patients, 3 female, ages 5-18 years, had SAE immediately before minimally invasive splenectomy. Two cases were completed robotically, one laparoscopically, and one laparoscopic case required conversion to open. SAE time ranged from 69 to 92 minutes. Time between embolization and surgical start ranged from 26 to 56 minutes, with operative times from 153 to 317 minutes. Estimated blood loss ranged from <10 to 150 mL. Mean length of stay was 3.5 days (range 2-6). Postoperative complications included one patient with ileus and another with concurrent gastritis and urinary tract infection. Splenic size comparisons were difficult to perform due to morselization of the spleen; however, excised spleen weights, measurements, and surgeon's impression suggested decreased size of the spleen after SAE. There were no transfusions, postembolization complications, or deaths. Conclusion: SAE subjectively appears to decrease splenic distension, which should allow for easier manipulation and possibly better visualization of splenic hilar vessels during minimally invasive surgery. Immediate preoperative SAE is safe and feasible and should be considered in pediatric patients with massive splenomegaly.

Imaging for Pediatric Blunt Abdominal Trauma With Different Prediction Rules: Is the Outcome the Same?

BACKGROUND: Computerized tomography (CT) of the abdomen and pelvis is the standard imaging modality to diagnose intra-abdominal injury (IAI). Clinicians must weigh the risk-benefit of CT compared with the degree of clinical suspicion for an IAI. Pediatric Emergency Care Applied Research Network (PECARN), Streck, and blunt abdominal trauma in children (BATiC) prediction rules have been published to help guide evaluation of these patients. Pediatric Emergency Care Applied Research Network uses history and physical examination findings, whereas Streck and BATiC use examination plus laboratory and imaging findings. At the time of the study, there was not a protocol that was more routinely sited. Our goal was to compare these different prediction rules. METHODS: This was a retrospective electronic chart review of all children younger than 18 years presenting for either level 1 or 2 trauma activations at our pediatric emergency department (ED) between June 1, 2015, to June 30, 2017. Charts were manually reviewed for a mechanism concerning for abdominal trauma, and demographic data, history and physical examination findings, laboratory and imaging results per prediction rules, and revisits in 7 days were collected.The prediction rules were applied to all charts that had all data necessary. For study purposes, a score of zero for PECARN and Streck, and score of ≤5 for modified BATiC (mBATiC) were defined as "low risk." Patients with no CT, negative CT, and no new injury found on revisit were classified as "no IAI identified," and patients with positive CT or revisit with injury found as "IAI identified." The results were compared via Fisher exact test. RESULTS: A total of 249 patients met the inclusion criteria with a median age of 12 years. Of the low-risk patients, 119 (98.7%) of 121 in PECARN group, 21 (100%) of 21 in Streck, and 48 (85.7%) of 56 in mBATiC group had no IAI identified. None of the low-risk patients required any intra-abdominal intervention. No missed IAI was identified during revisit review. Negative predictive values of all 3 rules were significant for PECARN, Streck, and mBATiC (98.35%, 100%, and 85.71%, respectively). Overall, 27 patients had positive CT results for IAI. CONCLUSIONS: The PECARN and Streck rules have high negative predictive values to predict low-risk patients who do not require CT. When laboratory studies are not obtained, PECARN is an effective means of excluding IAI for low-risk patients. When laboratory tests were obtained, the Streck rule performed well. Overall, the results are similar to the past individual studies done on each individual rule. History and physical examination findings are of high importance in pediatric trauma. This study supports limited imaging when no abnormal findings are present in children with blunt torso trauma. This is the only study found in the literature that has compared 3 different prediction rules.

Prospective evaluation of an evidence-based decision tool to assess pediatric blunt abdominal trauma (BAT).

PURPOSE: Computed tomography (CT) is currently the standard for evaluation of intra-abdominal injury (IAI) after BAT. Pediatric patients receiving CT scans based on adult clinical protocols are potentially exposed to unnecessary radiation. The purpose of this study is to determine the rate of CT scans before and after implementation of a pediatric BAT decision tool. METHODS: We adapted and implemented an evidence-based decision tool for pediatric BAT based on five clinical variables. We reviewed patient charts 18 months pre- and post-implementation. Demographics and outcomes were compared using Chi-square and Fisher's exact test, accordingly. RESULTS: The pre and post-implementation groups were uniform when comparing age, sex, mechanism, and Injury Severity Score. The decision tool was utilized in 85% of patients post-implementation. Fewer CT scans were obtained in the post-implementation group (28 vs. 21%, p = 0.215) with no missed injuries or late diagnoses. CONCLUSION: Implementation of a pediatric BAT decision tool decreased CT usage and radiation exposure without an obvious compromise to patient care. This experience supports the utilization of these tools for the assessment of IAI after BAT and have resulted in more selective use of CT during pediatric BAT in our program.

Impact of Clostridium difficile infection on pediatric appendicitis.

INTRODUCTION: Clostridium difficile is an important cause of nosocomial infection in the pediatric population. The purpose of this study is to estimate the impact of Clostridium difficile infection complicating pediatric acute appendicitis. METHODS: This study utilizes the combined 2009 and 2012 Kids' Inpatient Database. Statistical analysis is weighted and was done using Survey Sampling and Analysis procedures in SAS 9.4. RESULTS: We identified 176,934 cases with appendicitis and 0.2% (n = 358) had a concurrent diagnosis of C. difficile. The proportion of cases with C. difficile in perforated appendicitis was greater than in the non-perforated cases (0.39% vs. 0.06%; p < .01). Multivariate analysis showed that perforated appendicitis (OR 5.22), and anemia (OR 4.95) were independent predictors of C. difficile infection (p < .001). Adjusted for perforated appendicitis, cases with C. difficile had 4.78 days longer length of stay (LOS) and higher total charges of $29,887 (all p < 0.0001) compared to non-C. difficile cases. CONCLUSION: C. difficile infection is a rare, but impactful complication of pediatric appendicitis and is associated with greater disease severity. Proper antibiotic stewardship could minimize the risk of C. difficile in pediatric appendicitis.

Respiratory Modalities in Preventing Reintubation in a Pediatric Intensive Care Unit.

Post-extubation respiratory failure requiring reintubation in a Pediatric Intensive Care Unit (PICU) results in significant morbidity. Data in the pediatric population comparing various therapeutic respiratory modalities for avoiding reintubation is lacking. Our objective was to compare therapeutic respiratory modalities following extubation from mechanical ventilation. About 491 children admitted to a single-center PICU requiring mechanical ventilation from January 2010 through December 2017 were retrospectively reviewed. Therapeutic respiratory support assisted in avoiding reintubation in the majority of patients initially extubated to room air or nasal cannula with high-flow nasal cannula (80%) or noninvasive positive pressure ventilation (100%). Patients requiring therapeutic respiratory support had longer PICU LOS (10.92 vs 6.91 days, P-value = .0357) and hospital LOS (16.43 vs 10.20 days, P-value = .0250). Therapeutic respiratory support following extubation can assist in avoiding reintubation. Those who required therapeutic respiratory support experienced a significantly longer PICU and hospital LOS. Further prospective clinical trials are warranted.

Cost-Effective Approach to the Laparoscopic Appendectomy : Balancing Disposable Instrument Cost With Operative Time.

BACKGROUND: Surgeons can help reduce health care spending by selecting affordable and efficient instruments. The laparoscopic appendectomy (LA) is commonly performed and can serve as a model for improving health care cost. METHODS: We retrospectively reviewed all adult patients who underwent LA for non-perforated appendicitis from March 2015 to November 2017. Our objective was to determine which combination of disposable instruments afforded the lowest total operative cost without compromising postoperative outcomes. RESULTS: In total, 1857 consecutive patients were reviewed from 2 hospitals. After determining the 8 most commonly utilized combinations of disposable instruments, 846 patients were ultimately analyzed. The combination of a LigaSure, Endoloop, and an EndoBag (LEB) had the shortest median operative time (25 minutes, P < .001) and lowest median total operative cost ($1893, P < .001). CONCLUSIONS: The LEB instrument combination rendered the shortest operative time, lowest total operative cost, and can be used to maximize surgical value during LA.

Implementation of a pediatric trauma cervical spine clearance pathway.

PURPOSE: Pediatric cervical spine injuries are rare events. Missed injuries must be weighed against radiation exposure and excess resource utilization in a young population. A universal pediatric cervical spine clearance algorithm does not exist. The study objective is to determine if care improved after the implementation of a standardized cervical spine clearance pathway by evaluating imaging rates, length of stay, speciality consultation, and injury detection. METHODS: A multidisciplinary group reviewed relevant literature to develop an algorithm for cervical spine clearance in pediatric trauma patients. We reviewed patient charts 15 months before and after implementation. Categorical comparisons were tested with Chi-square. A p value less than 0.05 was considered statistically significant. RESULTS: The pre- and post-implementation groups were homogenous when comparing demographics, mechanism and severity of injury. Using the cervical spine clearance pathway, patients received fewer plain cervical spine radiographs (34% vs 16%), fewer spine speciality consults (28% vs 13%), and more patients were cleared clinically (44% vs 62%) (p < 0.05). There were 2 (1.7%) documented injuries in the pre-implementation group and 3 (3%) documented injuries in the post-implementation group. There were no missed injuries. CONCLUSIONS: Use of a standardized pathway allows more patients' cervical spines to be cleared clinically and better utilizes resources without compromising patient care. LEVEL OF EVIDENCE: Level III. TYPE OF STUDY: Care Management Study.

Benefits of a family-centered approach to pediatric induction of anesthesia.

BACKGROUND/PURPOSE: We initiated a pediatric surgical program including a caregiver for the induction of anesthesia. We measured preoperative midazolam administration, preoperative time, induction time, and program satisfaction. METHODS: Families with children undergoing surgery during the study period were included. Preoperative midazolam administration, preoperative time, and induction time were compared between participants and controls. Satisfaction surveys were given to participating caregivers and staff. RESULTS: The rate of preoperative midazolam use decreased from 41% (392/964) to 13% (16/118) among participants vs controls (p < 0.0001). After linear regression analysis, this difference persisted as an adjusted odds ratio of 0.29 (95% CI = 0.16-0.52). Preoperative and induction times (minutes) were similar between groups (76.2 vs 82.2, 13.8 vs 16.2, p = nonsignificant). Based on 5-point Likert surveys, the program was rated as "beneficial" or "very beneficial" to the patient by caregivers (99.2%) and staff (77.5%). Caregivers stated it "reduced" or "greatly reduced" anxiety for them (87.1%) and their child (93.2%). CONCLUSIONS: Opponents of similar programs suggest familial presence slows care and is disruptive. Our program decreased utilization of preoperative anxiolytics with no effect on operating room efficiency. Both hospital staff and participants felt the program was beneficial to the patient. Perceived caregiver and child anxiety was reduced. TYPE OF STUDY: Treatment study. LEVEL OF EVIDENCE: Level III.

Advanced Techniques in the Use of Negative Pressure Wound Therapy for Closure of Complex Neonatal Abdominal Wounds.

BACKGROUND: Negative pressure wound therapy (NPWT) has been described for closure of complex neonatal abdominal wounds, but advanced techniques for stoma or fistula control, skin protection, and the use of high pressure therapy not as well established. CASES: We identified neonatal patients at our institution who received NPWT for a complex abdominal wound, defined as a wound associated with a stoma or fistula with partial or complete dehiscence of the abdominal fascia or skin. We then reviewed techniques for decreasing wound contamination and protecting the newborn's skin. One patient had an especially complex wound; she was born at ∼23 weeks' gestational age (birth weight 580 g). She developed necrotizing enterocolitis and strictures, requiring multiple surgeries to relieve obstruction, ultimately resulting in an end ileostomy with mucous fistula. She suffered from wound dehiscence and retraction of her surgically created stoma, resulting in a complex abdominal wound with significant damage to the surrounding skin. We used advanced NPWT techniques to heal her wound, including topical skin protectants, placement of an adhesive dressing over the skin prior to placement of negative pressure dressing, placement of a negative pressure sponge directly on the wound bed and stoma, diversion of enteric contents away from the wound using a Malecot catheter, and an increase in the negative pressure applied. CONCLUSION: Complex neonatal abdominal wounds can be treated effectively using NPWT. The techniques we describe divert enteric contents away from the wound bed while maintaining negative pressure and protecting the surrounding skin. In addition, we used negative pressure up to -125 mm Hg and found it was well tolerated by our patients.

Hemodynamic design requirements for in-series thoracic artificial lung attachment in a model of pulmonary hypertension.

Recent thoracic artificial lung (TAL) prototypes have impedances lower than the natural lung. With these devices, proximal pulmonary artery (PA) to distal PA TAL attachment may be possible in patients without right ventricular dysfunction. This study examined the relationship between pulmonary system impedance and cardiac output (CO) to create TAL design constraints. A circuit with adjustable resistance and compliance (C) was attached in a PA-PA fashion with the pulmonary circulation of seven sheep with chronic pulmonary hypertension. The pulmonary system zeroth harmonic impedance modulus (Z(0)) was increased by 1, 2.5, and 4 mmHg/(L/min) above baseline. At each Z(0), C was set to 0, 0.34, and 2.1 ml/mmHg. The change in pulmonary system zeroth and first harmonic impedance moduli (ΔZ(0) and ΔZ(1)), the percent change in CO (%ΔCO), and the inlet and outlet anastomoses resistances were calculated for each situation. Results indicate that ΔZ(0) (p < 0.001) but not ΔZ(1) (p = 0.5) had a significant effect on %ΔCO and that %ΔCO = -7.45*ΔZ(0) (R(2) = 0.57). Inlet and outlet anastomoses resistances averaged 0.77 ± 0.16 and 0.10 ± 0.19 mmHg/(L/min), respectively, and the relationship between %ΔCO and TAL resistance, R(T), in mmHg/(L/min) was determined to be %ΔCO = -(7.45f)×(R(T) + 0.87), in which f = the fraction of CO through the TAL. Thus, newer TAL designs can limit %ΔCO to less than 10% if f < 0.75.

A low mortality model of chronic pulmonary hypertension in sheep.

BACKGROUND: Pulmonary hypertension and right ventricular failure are major contributors to morbidity and mortality in chronic lung disease. Therefore, large animal models of pulmonary hypertension and right ventricular hypertrophy are needed to study underlying disease mechanisms and test new treatment modalities. The objective of this study was to create a low-mortality model of chronic pulmonary hypertension and right ventricular hypertrophy in sheep. METHODS: The vena cavae of nine sheep weighing 62 ± 2 (SEM) kg were injected with 0.375 g of dextran beads (sephadex) every day for 60 d. Pulmonary hemodynamics were assessed via pulmonary artery catheterization prior to the first injection and again on d 14, 28, 35, 42, 49, and 56. At the end of the experiment, the heart was removed, dissected, and weighed to determine the ratio of right ventricular mass to left ventricle plus septal mass (RV:LV+S). RESULTS: All sheep survived to 60 d. The average pulmonary artery pressure rose from 17 ± 1 mmHg at baseline to 35 ± 3 mmHg on d 56 with no significant change in cardiac output (8.7 ± 0.7 to 9.8 ± 0.7 L/min, P = 0.89). The RV:LV+S was significantly higher (0.42 ± 0.01, P < 0.001) than a historic group of untreated normal animals (0.35 ± 0.01, n = 13). CONCLUSION: This study provides a low-mortality large animal model of moderate chronic pulmonary hypertension and right ventricular hypertrophy.

Veno-venous extracorporeal membrane oxygenation with interatrial shunting: a novel approach to lung transplantation for patients in right ventricular failure.

OBJECTIVE: This study evaluated the effectiveness of an atrial septostomy with veno-venous extracorporeal membrane oxygenation in alleviating high afterload right ventricular dysfunction while providing respiratory support. This technique could be applied as a bridge to lung transplantation. METHODS: Sheep (56±3 kg) underwent a clamshell thoracotomy and hemodynamic instrumentation, including right ventricular pressure and cardiac output. Sheep with and without tricuspid insufficiency (n=5 each) were examined. While sheep were on extracorporeal membrane oxygenation, right ventricular failure was established by banding the pulmonary artery until cardiac output was 40% to 60% of baseline. An extracardiac atrial shunt was created with modified vascular grafts to examine the effect of shunt flow on hemodynamics. Hemodynamic data were thus collected at baseline, during right ventricular failure, and for 1 hour at 100% (fully open), 70%, 50%, and 30% of baseline shunt flow. RESULTS: Cardiac output was returned to baseline values (tricuspid insufficiency: 5.2±0.2 L/min, without tricuspid insufficiency: 5.3±1.2 L/min) with 100% shunt flow (tricuspid insufficiency: 4.8±1.1 L/min, without tricuspid insufficiency: 4.8±1.0 L/min; P=.15) but remained significantly lower than baseline at 70% to 30% shunt flow. At 100% shunt flow, tricuspid insufficiency shunt flow was 1.4±0.8 L/min and without tricuspid insufficiency shunt flow was 1.7±0.2 L/min. Right ventricular pressure was significantly elevated over baseline values at all shunt flows (P<.001). In the group without tricuspid insufficiency, all sheep died beginning at the 70% shunt condition, whereas all animals with tricuspid insufficiency survived the entire experiment. Normal arterial blood gases were maintained under all conditions. CONCLUSIONS: An atrial septostomy accompanied by veno-venous extracorporeal membrane oxygenation is capable of eliminating right ventricular failure while maintaining normal arterial blood gases if sufficient shunt flows are achieved. The presence of tricuspid insufficiency improves the efficacy of the shunt.

Use of venovenous extracorporeal membrane oxygenation and an atrial septostomy for pulmonary and right ventricular failure.

BACKGROUND: Right ventricular failure is a major contributor to morbidity and mortality on the lung transplant waiting list. This study was designed to evaluate the effectiveness of an atrial septostomy with venovenous extracorporeal membrane oxygenation (VV-ECMO) as a novel potential bridge to transplantation. METHODS: Adult sheep (58±3 kg; n=12) underwent a clamshell thoracotomy and instrumentation to measure all relevant pressures and cardiac output (CO). Sheep with tricuspid insufficiency (TI [n=5]) and without tricuspid insufficiency (ØTI [n=7]) were examined. After creation of a 1-cm atrial septal defect and initiating VV-ECMO, the pulmonary artery (PA) was banded to allow progressive reduction of pulmonary blood flow, and data were collected. RESULTS: The CO in both groups remained unchanged from baseline at all pulmonary blood flow conditions. With TI, the CO was 5.1±1.2 L/min at baseline versus 5.1±1.2 L/min with a fully occluded PA (p=0.99). For ØTI, the CO was 4.5±1.4 L/min at baseline versus 4.5±1.2 L/min with no pulmonary blood flow (p=0.99). Furthermore, CO was not affected by the presence of TI (p=0.76). Mean right ventricular pressures were significantly lower in the TI group (TI=20.2±11 mm Hg versus ØTI=29.9±8.9 mm Hg; p<0.00001). Right and left atrial mean arterial pressures were not different between both groups (p>0.5). Lastly, VV-ECMO maintained normal blood gases, with mean O2 saturations of 99% ± 4.1% in both groups. CONCLUSIONS: Right to left atrial shunting of oxygenated blood with VV-ECMO is capable of maintaining normal systemic hemodynamics and normal arterial blood gases during high right ventricular afterload dysfunction.

Gastrostomy tube placement in infants and children: is there a preferred technique?

PURPOSE: Advances in percutaneous endoscopic gastrostomy (PEG) and laparoscopic (LAP) techniques, including LAP-assisted PEG, offer alternatives to the standard open gastrostomy technique. This study compares the outcomes of the PEG and LAP techniques. METHODS: All gastrostomy tube placements were reviewed at our institution from January 2004 to October 2008. Demographic, procedural, and outcome data were collected. Univariate and logistic regression statistical analysis was performed with SPSS (SPSS, Chicago, IL), and P < or = .05 considered significant. RESULTS: Of 238 gastrostomy tubes placed, 134 were PEG (56.3%) and 104 were LAP (43.7%). Most tubes were inserted for failure to thrive (74.4%) and feeding difficulties (52.1%). Patient weight and age were increased and operative time decreased for PEG compared with other methods. Percutaneous endoscopic gastrostomy patients also had a statistically higher number of postoperative complications, requiring a return trip to the operating room (P = .02). CONCLUSION: Minimally invasive PEG and LAP techniques have supplanted the open technique for most patients. Operative time for PEG placement is shorter than other methods, and patients chosen for the PEG method of placement are older and of greater weight. However, there were significant and more serious postoperative complications requiring a second operation in the PEG group when compared with the LAP group.