Twenty-Five-Year Experience with Minimally Invasive Splenectomy in Children: From Minilaparotomy to Use of Sealing Devices and Indocyanine Green Fluorescence Technology: Tips and Tricks and Technical Considerations.

Background: This study aimed to review our 25-year experience with pediatric laparoscopic splenectomy (LS) and describe tips, tricks, and technical considerations. Methods: The records of 121 children, undergoing minimally invasive splenectomy in the last 25 years (1996-2021), were retrospectively reviewed. Median patient age was 10.2 years (range 7-17). The patients were grouped according to the period: G1 (1996-2005) included 31 patients undergoing open splenectomy using left subcostal minilaparotomy (G1a) and 28 receiving LS using supine position (G1b); G2 (2006-2021) included 62 patients undergoing LS using lateral decubitus. A five-trocar technique was adopted in G1b, with the spleen removed through a Pfannenstiel incision. In G2, we preferred to use lateral decubitus, 10-mm 30° optic, only four trocars, and sealing devices. In such cases, the spleen was placed in an endobag, finger-fragmented, and extracted through the umbilicus. Furthermore, indocyanine green (ICG) fluorescence was used in the last 4 G2 patients to clearly identify the vascular anatomy. Results: The median operative time was 65 minutes in G1a, 125 in G1b, and 95 in G2. Complications occurred intraoperatively in 14 cases (11.5%): 5 bleedings during dissection (G1b), 4 endobag breakages during spleen removal (G2); 3 spleen capsule breakages during removal (G1a); and 2 instrumentation failures (G2). No conversions to open occurred. Median hospital stay was 6 days in G1a and 4 days in G1b and G2. Conclusions: LS is a standardized and effective procedure in children and is preferable to mini- or conventional open splenectomy. Our 25-year experience showed that major complications may occur even in expert hands, mainly during hilar dissection or spleen extraction. Technically, sealing devices and ICG fluorescence were helpful to perform a safer and faster procedure. We believe that lateral decubitus and 30° optic should be considered technical key points to provide excellent organ exposure and easier dissection of hilar structures.

Peritoneal morphological changes due to pneumoperitoneum: the effect of intra-abdominal pressure.

INTRODUCTION: Carbon dioxide (CO2) used in laparoscopy evokes local and systemic effects. This study was designed to evaluate the histopathologic morphologic changes due to CO2 and air insufflation, at different pressure levels, on visceral and parietal peritoneum in rats. MATERIALS AND METHODS: A total of 56 rats were object of the study, randomly divided into five groups. Pneumoperitoneum (PN) was maintained for 30 minutes, at a flow rate of 0.5 L/min and at a pressure of 10 and 6 mm Hg with CO2 (group S1-S2, n = 32) and filtered air (group A1-A2, n = 16). Only anesthesia was performed in the fifth group (group C, n = 8). Peritoneal samples were obtained 24 hours later for blinded histological evaluation. A grading system was adopted to evaluate histological peritoneal changes (0, no change; 1, mild; 2, moderate; and 3, severe) such as mesothelial aspect, inflammatory response, edema, and hemorrhage. The score reflected the severity of damage and was calculated by the sum of the degree evaluated separately. Values were compared with the analysis of variance analysis. RESULTS: CO2 and air insufflation caused reactive mesothelial cells and peritoneal inflammation of different degrees depending on the level of intra-abdominal pressure (IAP) and type of gas. These modifications were absent in group C and were less evident in low pressure S2 group with respect to S1 and A1-A2 groups. The average values of histopathologic peritoneal score showed significant differences between S2 (11.5) versus S1 groups (16.83) with respect to A groups (A1 = 27.83; A2 = 20.5) and compared with the controls (C = 2.5). CONCLUSIONS: Our data confirm that PN affects the peritoneal integrity. The grades of morphological peritoneal changes are related to the level of IAP. Low CO2 pressure causes minor peritoneal changes with respect to high pressure and air insufflation.

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.