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ABSTRACT: Abstract Background and Objectives: Despite being pioneered by gynecologists, single-incision endosurgery has not been widely reported for the treatment of ovarian and adnexal pathology in neonates, children, and adolescents. We describe our initial experience using single-incision pediatric endosurgery (SIPES) for these indications and discuss advantages and drawbacks. Subjects and Methods: All children who underwent SIPES with a preoperative diagnosis of ovarian or adnexal pathology were included in the study. Data on age, operative time, complications, length of hospital stay, and outcomes were collected. Results: From January 2010 until January 2012, 19 girls (mean age, 11.4 years; range, 6 days-17 years; weight range, 4.0-90 kg) underwent SIPES procedures for ovarian or adnexal diagnoses, including hemorrhagic/follicular/paratubal cysts (n=8), torsion (n=7), tumor (n=3), and parauterine cyst (n=1). The operations included cyst unroofing (n=4), detorsion and oophoropexy (n=7), (salpingo)oophorectomy (n=5), marsupialization of cyst (n=2), and cyst aspiration (n=1). Median operative time was 42±29 minutes; there were no conversions to conventional laparoscopy or open surgery. Fifteen patients (79%) were discharged within 24 hours after the procedure. There were no peri- or postoperative complications. Histopathology showed hemorrhagic/follicular/paratubal cyst (n=7), necrotic/calcified ovarian tissue after torsion (n=6), cystadenofibroma (n=1), granulosa cell tumor (n=1), and mature teratoma (Grade 0) (n=1). Conclusions: SIPES is an excellent alternative to conventional laparoscopy for the treatment of adnexal pathology. Using a single umbilical incision that can be enlarged instead of three smaller trocar sites facilitates the resection and extraction of ovarian masses without compromising cosmesis.
Journal of Laparoendoscopic & Advanced Surgical Techniques 03/2013; 23(3):291-6. · 1.40 Impact Factor
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ABSTRACT: Abstract Background/Purpose: Single-incision pediatric endosurgery (SIPES) is gaining popularity. The aim of this study was to review the authors' experience with SIPES splenectomy and compare it with conventional laparoscopic splenectomy. Subjects and Methods: After institutional review board approval, data on SIPES splenectomy in children were collected prospectively. The study group was compared with a control group of patients who were retrospectively identified as having undergone conventional laparoscopic splenectomy during the same time period. Results: Sixteen children underwent SIPES splenectomy. Ages ranged from 1 to 15 years, with a median of 7 years, and weights were between 10 and 70 kg, with a median of 24 kg. The control group was similar in age and weight characteristics. The most common diagnoses were hereditary spherocytosis, sickle cell disease, and immune thrombocytopenic purpura. There were two conversions to open splenectomy in the SIPES group and one in the laparoscopic group. Operative times were 40-190 minutes (median, 84 minutes) in the SIPES group and 51-154 minutes (median, 99 minutes) in the conventional laparoscopic group. Conclusions: The SIPES technique is well suited for splenectomy. Despite instruments and camera being in-line, working angles are not compromised, and visualization is adequate. Operating time and hospital stay are comparable to those with standard laparoscopic splenectomy, but the cosmetic result may be superior.
Journal of Laparoendoscopic & Advanced Surgical Techniques 01/2013; · 1.40 Impact Factor
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Martin Lacher, Oliver J Muensterer,
Govardhana R Yannam,
Charles J Aprahamian,
Lena Perger,
Michael Megison,
David C Yu,
Elizabeth A Beierle,
Scott A Anderson,
Mike K Chen,
Carroll M Harmon
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ABSTRACT: Single-incision pediatric endosurgery (SIPES) has gained popularity for ablative procedures such as appendectomy in many pediatric surgical centers. This study evaluates the outcome of SIPES for treatment of appendicitis in our institution.
After Institutional Review Board approval was obtained, data were prospectively collected on all patients undergoing SIPES appendectomy in our hospital from March 2009 through October 2011. The surgical techniques, operative times, complications, conversion rates, and outcomes were recorded.
SIPES appendectomy was attempted in 415 children (mean age, 10.9 years; age range, 1.4-17.9 years; 266 males, 149 females; median weight, 43 kg; weight range, 9.8-146 kg). Intraoperatively, acute appendicitis was found in 298 cases and perforated appendicitis in 79 cases. Thirty-eight patients underwent interval appendectomy. Appendectomy was carried out solely as SIPES in 397 cases (96%). Median operative time was 40±16 minutes (37±16 minutes for fellows [n=284] and 46±15 minutes for residents [n=131]). There were three intraoperative complications, which could be handled during the procedure. Pathologic reports revealed inflammatory changes of the appendix (n=386), other pathology (n=11), and no pathologic change (n=18). Overall, 24 patients (5.8%) were readmitted for intra-abdominal abscess (n=14), umbilical wound infection (n=3), and other reasons (n=7). Twelve patients (2.9%) underwent reoperation: drainage of intra-abdominal abscess (n=8) (3 by the surgeon, 5 by the interventional radiologist), wound drainage (n=3), and right hemicolectomy for carcinoid (n=1). In perforated appendicitis the postoperative intra-abdominal abscess rate was 10 of 79 cases (12.7%), which is similar to the previous report with conventional laparoscopic appendectomy from our institution (13.6%). The wound infection rate (5 of 79 cases [6.3%]) was also similar to the previously report (6.8%) with conventional laparoscopic appendectomy for perforated appendicitis.
Appendectomy can be accomplished successfully and safely using single-incision endosurgery in children with acceptable operative times without leaving any appreciable scar. Additional trocars are infrequently necessary. So far, the intraoperative and postoperative complication rates are comparable to those of triangulated laparoscopic appendectomy.
Journal of Laparoendoscopic & Advanced Surgical Techniques 06/2012; 22(6):604-8. · 1.40 Impact Factor
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ABSTRACT: Temporary tracheal occlusion induces lung growth in congenital diaphragmatic hernia (CDH) but has significant drawbacks because the device must be removed in utero. We devised a gel plug (GP) that can be placed in the fetal trachea in a rabbit model of CDH to provide temporary tracheal occlusion and evaluated its effect on lung growth and postnatal ventilation mechanics.
In each of 16 pregnant rabbits, experimental CDH was created in 4 fetuses. These were randomized to intratracheal instillation of a fibrin GP, tracheal suture ligation, intratracheal instillation of normal saline, or sham amniotomy. Unmanipulated fetuses of the litter without CDH served as controls. Fetuses were harvested at gestational day 29 and mechanically ventilated to determine lung compliance and airway resistance. Fetal lung-to-body weight was compared among the groups.
Mean fetal lung-to-body weight was higher in GP-treated fetuses than in the normal saline group, although not as high as that in fetuses subjected to tracheal ligation. Gel plug-treated fetuses had the highest airway resistance, whereas non-CDH control fetuses had the most compliant lungs.
Prenatal instillation of an intratracheal GP leads to increased postnatal lung mass in rabbit fetuses with CDH but also increases airway resistance.
Journal of Pediatric Surgery 06/2012; 47(6):1063-6. · 1.45 Impact Factor
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ABSTRACT: Tibial tuberosity fractures are rare and occur mainly in adolescent males during vigorous quadriceps contraction. So far,
only ten simultaneous bilateral fractures have been reported. We report the case of a 16-year-old male who avulsed both tibial
tuberosities when he landed on his feet after a gymnastics routine. Diagnostic imaging demonstrated Ogden Type IIIA fractures.
He underwent bilateral open reduction and screw fixation with a good functional result after 3 months. While closed reduction
and percutaneous fixation has been proposed by some, the intraoperative findings in our patient would have prevented correct
adaptation of the fragments because of a flap of periosteum impinged in both fracture gaps. This case emphasizes that minimally
invasive techniques may sometimes be inappropriate in the management of these types of fractures.
European Journal of Trauma and Emergency Surgery 04/2012; 34(1):83-87. · 0.33 Impact Factor
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ABSTRACT: Surgical robots are designed to facilitate dissection and suturing, although objective data on their superiority are lacking. This study compares conventional laparoscopic Nissen fundoplication (CLNF) to robot-assisted Nissen fundoplication (RANF) using computer-based workflow analysis in an infant pig model.
CLNF and RANF were performed in 12 pigs. Surgical workflow was segmented into phases. Time required to perform specific actions was compared by t test. The quality of knot-tying was evaluated by a skill scoring system. Cardia yield pressure (CYP) was determined to test the efficacy of the fundoplications, and the incidence of complications was compared.
There was no difference in average times to complete the various phases, despite faster robotic knot-tying (p = 0.001). Suturing quality was superior in CLNF (p = 0.02). CYP increased similarly in both groups. Workflow-interrupting hemorrhage and pneumothorax occurred more frequently during CLNF (p = 0.040 and 0.044, respectively), while more sutures broke during RANF (p = 0.001).
The robot provides no clear temporal advantage compared to conventional laparoscopy for fundoplication, although suturing was faster in RANF. Fewer complications were noted using the robot. RANF and CLNF were equally efficient anti-reflux procedures. For robotic surgery to manifest its full potential, more complex operations may have to be evaluated.
Pediatric Surgery International 12/2011; 28(4):357-62. · 1.25 Impact Factor
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ABSTRACT: Many different techniques for laparoscopic inguinal hernia repair have been introduced recently, using either an intraperitoneal [1-3] or an extraperitoneal [4-6] approach. One of the main challenges is to obtain a complete circumferential closure of the sack at the level of the internal ring without injury to the adjacent vas deferens or spermatic vessels. In an effort to separate these structures from the peritoneum before passing a suture around the base of the sack, we developed the hydrodissection-lasso technique, which is performed using a single-incision endosurgical approach.With the patient in Trendelenburg position, an 8-mm skin incision is made in the umbilicus, and a 5-mm trocar is placed in the inferior aspect for the endoscope. A 3-mm Maryland grasper is placed directly through the fascia in the upper part of the incision. Using a 22-gauge needle inserted percutaneously over the internal inguinal ring, saline is injected into the subperitoneal plane circumferentially, hydrodissecting the peritoneum off the vas deferens and vessels and creating a safe space through which the suture can pass without compromising these structures. A 2-mm stab incision is made directly over the internal inguinal ring, and a lasso technique is used to pass two strands of braided polyester suture around the hernia sack, as demonstrated in the video. Both sutures are tied tightly, leaving the knots under the skin. No direct or indirect manipulation of the vas deferens or vessels takes place during any part of the procedure.In contrast to other described techniques [7], the hydrodissection-lasso technique can be used for all indirect inguinal hernias in both girls and boys, and hydrodissection itself may be a useful adjunct to any of the other aforementioned techniques. Although an age limit for exclusive high ligation of the hernia sack for indirect inguinal hernias has not been established, the recurrence rate may be higher for adults if the procedure is not combined with inguinal floor reconstruction [8]. At this time, we therefore limit the proposed technique to prepubertal patients.We have performed the described procedure for 22 patients without any recurrences during a maximum follow-up period of 12 months (Table 1). The patients had minimal postoperative pain. There were no complications except for a transient genitofemoral nerve paresis experienced by one girl in whom the hydrodissection was performed using 1% lidocaine instead of the usual normal saline solution. Although the sack was not resected, there were no cases of postoperative hydroceles.To evaluate whether this novel technique is an adequate long-term solution, a prospective clinical trial comparing standard open and single-incision endosurgical inguinal hernia repair using hydrodissection should be performed.
Surgical Endoscopy 06/2011; 25(10):3438-9. · 4.01 Impact Factor
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ABSTRACT: To identify technical difficulties during single-incision pediatric endoscopic surgery (SIPES) cases and to highlight solutions.
After IRB approval, all SIPES cases were prospectively collected, and the surgeons involved were polled for technical difficulties encountered and their operative solutions.
Over a period of 13 months, 224 pediatric SIPES cases were performed in 223 pediatric patients (92 female, 131 male) aged 3 weeks to 19 years. Among these were 130 appendectomies, 32 pyloromyotomies, 32 cholecystectomies, 11 inguinal hernia repairs, 6 Nissen fundoplications and 4 laparoscopic-assisted endorectal pullthrough procedures. Eighteen procedures (8%) employed a primary extra-umbilical instrument in addition to the transumbilical trocar(s). Thirty procedures (13%) begun via a single-site technique required additional trocars for completion. None required laparotomy. Intraoperative complications are discussed. The main challenges of SIPES are: (1) variable umbilical anatomy, (2) large size of current proprietary multitrocar devices, (3) trocar crowding, (4) intra-abdominal exposure, (5) fewer degrees of freedom, (6) clashing instruments, (7) in-line endoscope viewing, and (8) limited number of working ports. We discuss coping strategies to address these issues.
Many of the drawbacks of SIPES can be overcome by specific techniques, which can make SIPES procedures more broadly feasible and applicable within pediatric endosurgery.
Pediatric Surgery International 06/2011; 27(6):643-8. · 1.25 Impact Factor
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ABSTRACT: This study attempted to evaluate the association of early hypoalbuminemia with the risk of intestinal failure in gastroschisis patients.
Neonates with gastroschisis treated at a tertiary children's hospital over a 10-year period were initially categorized into groups based on the lowest serum albumin measurement during the first 7 days of life. Based on preliminary analysis, patients with serum albumin <1.5 g/dL were considered to have early severe hypoalbuminemia. Intestinal failure was defined as inability of the patient to wean from parenteral nutrition (PN) during the initial hospital admission, thus requiring home PN. Logistic regression modeling was performed to adjust for sex, gestational age, birth weight, and concomitant intestinal complications.
One hundred and thirty-five gastroschisis patients were included, of whom 21% had early severe hypoalbuminemia. Patients with early severe hypoalbuminemia had a significantly higher risk of intestinal failure compared to those with higher albumin levels (26 vs. 8%, p = 0.015). On multivariable logistic regression modeling, early severe hypoalbuminemia was strongly associated with intestinal failure (OR 6.4, 95% CI 1.8-23.3, p = 0.005).
Early severe hypoalbuminemia appears to be an independent risk factor for long-term intestinal compromise rather than merely an indicator of overall illness. Further interventional studies are needed to determine whether clinical protocols utilizing judicious fluid administration, exogenous albumin, and early enteral feeding can improve clinical outcomes in gastroschisis.
Pediatric Surgery International 05/2011; 27(11):1155-8. · 1.25 Impact Factor
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ABSTRACT: Single-incision pediatric endosurgery (SIPES) is used in many centers for routine cases such as appendectomies and cholecystectomies, but more complex procedures are still infrequently performed. We report the case of a 9-month-old girl with Down syndrome diagnosed with a duodenal web who underwent duodenal web resection and tapering using a SIPES technique. The procedure was performed through a single 2-cm incision in the umbilicus and took 209 minutes. Postoperatively, the patient was feeding well, gaining weight, and had no appreciable scar at a follow up of 6 months. SIPES duodenal web resection in an infant is a reasonable alternative to conventional triangulated laparoscopy that can be performed safely with good functional and cosmetic postoperative results.
Journal of Pediatric Surgery 05/2011; 46(5):989-93. · 1.45 Impact Factor
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ABSTRACT: The objective was to investigate the relationship of high gun ownership and gun death rate on children and determine predictors influencing the incidence and outcome of pediatric firearm injuries in a major pediatric level 1 trauma center.
We performed a retrospective review of our trauma registry to identify hospital admissions between April 1999 and March 2010. We extracted demographic and geographic data, seasonal variation, injury type, firearm type, and outcome.
We identified 194 firearm injuries. The incidence did not change during the past decade. Most occurred during the second half of the year (61.4%). Mean age was 12.2 ± 4.6 years (range, 0.4-19.2 years). Unintentional shootings accounted for 100 injuries followed by assaults (n = 55) and innocent bystanders (n = 39). African American children were most often injured because of a violent cause (60.3%), whereas white children were shot unintentionally (80.1%). Powder-propelled firearms caused 82.5% of injuries. Overall, 17.5% of children required an operation, and 9.3% died.
The overwhelming majority of children were injured after a gun went off unintentionally, whereas most African American children were shot violently. We identified certain seasonal and geographic clusters. These data can be used to target gun injury prevention programs.
Journal of Pediatric Surgery 05/2011; 46(5):927-32. · 1.45 Impact Factor
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ABSTRACT: Single-incision pediatric endosurgical (SIPES) pyloromyotomy is frequently used for the treatment of hypertrophic pyloric stenosis at our center. Our initial SIPES approach mirrored the conventional, triangulated laparoscopic pyloromyotomy. Because an increased number of perforations were noted on our initial analysis, a more straightforward Cross-technique SIPES pyloromyotomy was developed. This study compares the current Cross-technique SIPES pyloromyotomy to the previous standard SIPES operation.
The Cross-technique entails grasping the antrum with the surgeon's left hand instrument, retracting toward the left lower quadrant, and thereby orienting the pylorus obliquely toward the right upper quadrant. The serosal incision and muscular spreading is accomplished using a right-hand instrument that crosses over the left hand grasper. Demographic variables, operative times, estimated blood loss (EBL), complications, conversion rate, and postoperative length of stay were compared.
Twenty-nine Cross-technique patients were compared with 23 in the standard group. The Cross-technique was faster than the standard procedure (21 ± 5 vs. 27 ± 12 min, p = 0.03) and EBL was lower (1.3 ± 0.5 vs. 1.7 ± 0.6 ml, p = 0.02). There were two mucosal perforations requiring conversions to triangulated 3-access-site laparoscopy in the standard, and one conversion to open surgery in the Cross-technique group. Patients who underwent cross-technique pyloromyotomy weighed less (3.6 ± 0.6 vs. 4.0 ± 0.5 kg, p = 0.012), but there were no differences in age, gender ratio, conversion rate, or length of stay. There was one postoperative wound infection in the cross-technique, but none in the standard group. No patients required reoperation. All participating surgeons felt that the cross-technique was more ergonomic and easier to perform than the standard SIPES technique.
The Cross-technique appears superior to standard SIPES pyloromyotomy and should be preferentially used for single-incision endosurgical pyloromyotomy for hypertrophic pyloric stenosis.
Surgical Endoscopy 04/2011; 25(10):3414-8. · 4.01 Impact Factor
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ABSTRACT: A single-incision pediatric endosurgery (SIPES) has not been typically used for operations in premature infants yet. We report a case of a 3-month-old 25-week premature infant who underwent SIPES-assisted ileocecal resection for a stricture after medically treated necrotizing enterocolitis. The patient recovered uneventfully, and was discharged on full feeds 15 postoperatively with virtually no appreciable scar. SIPES is a reasonable alternative for NEC stricture resection in premature infants. Prematurity should not be considered a contraindication to single-incision endosurgery.
Pediatric Surgery International 04/2011; 27(12):1351-3. · 1.25 Impact Factor
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ABSTRACT: Single-incision pediatric endosurgery (SIPES) is gaining popularity for routine ablative operations such as appendectomy and cholecystectomy in a number of centers. We have employed this technique for Nissen fundoplication for the first time as a major reconstructive procedure. This study describes the technical evolution of SIPES fundoplication at our center, discusses the challenges, and evaluates the outcome.
After IRB approval was obtained, data were prospectively collected on all SIPES fundoplications performed in our hospital from September 2009 through August 2010. The surgical techniques, operative times, blood loss, complications, conversion rates, and outcomes were recorded.
SIPES fundoplication was attempted in 10 children (ages 3 months to 11 years, median 21 months; weight 3.45-51 kg, median 9 kg). Fundoplication was performed as the sole procedure in 4, and combined with a gastrostomy in 6 patients in which case the gastrostomy was used as an additional trocar site. On average, total operative time was 104 ± 31 minutes, and reached a baseline around 90 minutes after five procedures. The mean estimated blood loss was 6 ± 5 mL, and postoperative length of stay 2.6 ± 1.4 days. Different trocars, liver retraction methods, and suturing techniques were employed. Extracorporeal knot tying was used in six operations. There were no intraoperative complications, but unplanned additional trocars or access sites were added in 2 cases, leaving 3 patients in which the procedure was carried solely through the umbilicus. Reflux symptoms subsided in all patients, but 1 patient had recurrence at 12 months postoperative and underwent conventional laparoscopic redo-fundoplication.
Laparoscopic Nissen fundoplication can be accomplished successfully and safely using single-incision endosurgery in children with good antireflux efficacy and without leaving any appreciable scar. Extracorporeal knot tying appears to be superior to other methods. So far, the failure rate is not higher than in conventional laparoscopic Nissen fundoplication.
Journal of Laparoendoscopic & Advanced Surgical Techniques 03/2011; 21(7):641-5. · 1.40 Impact Factor
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Oliver J Muensterer
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ABSTRACT: This report describes laparoscopic Fowler-Stephens orchidopexy for cryptorchidism resulting from orchidogastric fusion in an infant born with gastroschisis. At 11 months of age, the left testicle remained impalpable, and diagnostic laparoscopy was performed. Intraoperatively, a normal-appearing testicle was found attached to the stomach. The testicle was dissected, mobilized down to the left inguinal ring, exteriorized through a transscrotal trocar, and subsequently fixated in the lower left scrotum. On follow-up 5 months later, both testicles were normal in size and location. Single-stage laparoscopic Fowler-Stephens orchidopexy is easily accomplished in cases of orchidogastric fusion resulting from a long vas deferens.
Urology 02/2011; 78(3):687-8. · 2.43 Impact Factor
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ABSTRACT: This study examined the effects of multidisciplinary prenatal care and delivery mode on gastroschisis outcomes, with adjustment for key confounding variables.
This retrospective cohort study included all gastroschisis patients treated at a single tertiary children's hospital between 1999 and 2009. Prenatal care, delivery mode (vaginal vs cesarean section before labor vs after labor), patient characteristics, and clinical outcomes were determined by chart review. Time to discontinuation of parenteral nutrition (PN) was the primary outcome of interest. Effects of multidisciplinary prenatal care and delivery mode were evaluated using Cox proportional hazards regression models that included gestational age, birth weight, sex, concomitant intestinal complications, and year of admission.
Of 167 patients included, 46% were delivered vaginally, 69% received multidisciplinary prenatal care, and median time to PN discontinuation was 38 days. On multivariable modeling, gestational age, uncomplicated gastroschisis, and year of admission were significant predictors of early PN independence. Delivery mode and prenatal care had no independent effect on outcomes, although patients receiving multidisciplinary prenatal care were more likely to be born at term (49% vs 27%, P = .01).
Gestational age and intestinal complications are the major determinants of outcome in gastroschisis. Multidisciplinary prenatal care may facilitate term delivery.
Journal of Pediatric Surgery 01/2011; 46(1):86-9. · 1.45 Impact Factor
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ABSTRACT: The increased use of computed tomography (CT) to diagnose appendicitis in children has led to a concern for the possibility of increased CT-related cancer morbidity. We designed a clinical protocol for the diagnosis and treatment of appendicitis in children in an attempt to decrease the use of CT scans at our institution.
Patients who had surgical consultation for suspected appendicitis were placed on the clinical protocol. Data concerning diagnosis and treatment were collected prospectively. Retrospective data from patients admitted to our institution with acute appendicitis before the clinical protocol were collected as historical controls.
One hundred twelve patients were diagnosed and treated by our protocol between June and November 2009. Of these, 100 patients underwent an appendectomy for acute appendicitis. They were compared with 146 patients from 2007. In-house CT use decreased from 71.2% to 51.7% (P = .01). Preoperative ultrasound use increased from 2.7% to 21% (P < .001). The negative appendectomy rate increased (6.8% vs 11%, P = .25).
Our findings suggest that the implementation of an evidence-based clinical protocol for the diagnosis and treatment of acute appendicitis in children may safely decrease the use of CT scans and increase the use of ultrasound.
Journal of Pediatric Surgery 01/2011; 46(1):192-6. · 1.45 Impact Factor
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ABSTRACT: Over the last 15 years, the laparoscopic-assisted endorectal pull-through procedure first described by Georgeson has become the standard treatment for Hirschsprung disease in many centers around the world. We report the first six patients who were operated using a single-incision endosurgical approach.
Six infants (one female) diagnosed with Hirschsprung disease underwent laparoscopic endorectal pull-through via a single 1 cm horizontal skin incision in the umbilicus. Firstly, laparoscopic seromuscular leveling biopsies of the rectum and sigmoid were obtained. The affected rectosigmoid colon and rectum was then mobilized distally beyond the peritoneal reflection, facilitating the subsequent perineal dissection, pull-through, and coloanal anastomosis. Operative variables were compared between single-incision and conventional laparoscopic endorectal pull-through.
The patients' average age and weight was 28 days and 3.8 kg, respectively. Operative time ranged from 90 to 220 min, with a mean estimated blood loss of 3.7 ml. There were no intraoperative complications. Postoperatively, all six patients recovered uneventfully and were discharged home on full feeds after a median of 7 days. On follow-up, the patients had virtually no appreciable scar, were feeding well, stooling, and gaining weight appropriately. The results were similar to those of conventional laparoscopic endorectal pull-through.
Although technically challenging, laparoscopic-assisted endorectal pull-through in infants with Hirschsprung disease can be performed safely through a single umbilical incision with good postoperative results and excellent cosmesis.
Journal of Gastrointestinal Surgery 12/2010; 14(12):1950-4. · 2.83 Impact Factor
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ABSTRACT: Single-incision pediatric endosurgical (SIPES) appendectomy has been reported in few pediatric surgical centers. We have adopted the technique recently and have offered it to all patients in whom appendectomy was indicated. The purpose of this study was to report our experience with SIPES appendectomy for acute appendicitis, perforated appendicitis, and interval appendectomy, and to compare the results with those from patients who underwent conventional laparoscopic appendectomy 1 year previously.
After IRB approval, data on all SIPES appendectomies performed in our hospital were prospectively collected, including operative time, intra- and postoperative complications, conversion rate, blood loss, and hospital length of stay. Cases were stratified into three categories: acute appendicitis, perforated appendicitis, and interval appendectomy. They were compared to patients operated on in 2007 using conventional laparoscopic (three-trocar) appendectomy.
During the study period, 75 SIPES appendectomies were undertaken. Mean age was 11 years (range = 2-19 years) and mean weight was 45 kg (range = 12-132 kg). All SIPES appendectomies were completed laparoscopically, and additional trocars were placed in 20% of cases. SIPES interval appendectomies took the longest and had the highest conversion rate (33%). Follow-up data was available in 63 patients (82%) at a median of 3 weeks. There were three wound infections in the SIPES group (4%) and one in the 151 control patients. Compared to historic controls, operative time was shorter with SIPES compared to conventional laparoscopy for acute appendicitis (37 ± 12.3 vs. 44.1 ± 20.3 min, p = 0.01, 95% CI = 32-42 min).
SIPES appendectomy is a very good alternative to the conventional laparoscopic approach, especially for acute appendicitis. It is technically more challenging for perforated appendicitis and interval appendectomy. Yet, with appropriate consideration and skill, scarless appendectomy is achievable.
Surgical Endoscopy 12/2010; 24(12):3201-4. · 4.01 Impact Factor
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ABSTRACT: The pediatric appendicitis score (PAS) has been used as a diagnostic tool for the assessment of acute abdominal pain. Our institution has utilized this scoring system as part of a clinical pathway for acute appendicitis. We sought to discover if the PAS could also serve as a prognostic indicator.
Patients treated within the clinical pathway were divided into three groups (A, B, and C) based on the PAS assigned on admission. Data pertaining to intraoperative findings and length of hospital stay were collected prospectively.
In 4 months, 112 patients were enrolled in the study (median age 10.5, range 1-18). 69 of these patients underwent early laparoscopic appendectomy. For group A, 75% had simple appendicitis and 5% were complex. For group B, 68.4% patients had simple appendicitis and 26.3% were complex. For group C, 27.3% were simple and 63.6% were complex. Mean length of hospital stay increased from 1.63 ± 0.34 for patients in group A to 5.9 ± 1.37 for patients in group C.
Our observational data suggests that the PAS may be a prognostic tool for acute appendicitis. It thereby may impact on preoperative management and postoperative clinical pathways. A larger cohort is necessary to validate our findings.
Pediatric Surgery International 10/2010; 27(6):655-8. · 1.25 Impact Factor
