Update on ENT anaesthesia in children

This article is an update of anaesthesia for common paediatric ear, nose and throat (ENT) procedures. ENT pathology is the most common indication for surgery in children. An increasing number are performed as day cases, even in the presence of comorbidities such as obstructive sleep apnoea, but judicious selection of suitable children remains important. Considerations include severity of disease, known difficult airway, complex comorbidities and the surgical centre. The anaesthetic management of frequently performed paediatric ENT procedures will be discussed, including the potential role for dexmedetomidine and recent advances using transnasal humidified rapid insufflation ventilatory exchange.     

Ear,Nose and Throat Day-Case Surgery at a District General Hospital

INTRODUCTION

In 2000, The NHS Plan in the UK set a target of 75% for all surgical activity to be performed as day-cases. We aim to assess day-case turnover for ENT procedures and, in particular, day-case rates for adult and paediatric otological procedures together with re-admissions within 72 h as a proxy measure of safety.

PATIENTS AND METHODS

Retrospective collection of data (procedure and length of stay) from the computerised theatre system (Galaxy) and Patient Information Management System (PIMS) of all elective patients operated over one calendar year. The setting was a district general hospital ENT department in South East England. All ENT operations are performed with the exception of oncological head and neck procedures and complex skull-base surgery.

RESULTS

Overall, 2538 elective operations were performed during the study period. A total of 1535 elective adult procedures were performed with 74% (1137 of 1535) performed as day-cases. Of 1003 paediatric operations, 73% (730 of 1003) were day-cases. Concerning otological procedures, 93.4% (311 of 333) of paediatric procedures were day-cases. For adults, we divided the procedures into major and minor, achieving day-case rates of 88% (93 of 101) and 91% (85 of 93), respectively. The overall day-case rate for otological procedures was 91% (528 of 580). Re-admission rates overall were 0.7% (11 of 1535) for adults and 0.9% (9 of 1003) for paediatric procedures. The most common procedure for re-admission was tonsillectomy accounting for 56% of all adult re-admissions and 78% of paediatric re-admissions. The were no deaths following day-case procedures.

DISCUSSION

ENT surgery is well-suited to a day-case approach. UK Government targets are attainable when considering routine ENT surgery. Day-case rates for otology in excess of targets are possible even when considering major ear surgery.     

A survey of current usage of anticholinergic drugs in paediatric anaesthesia in Finland

BACKGROUND: The aim of this survey was to obtain information about the current use of anticholinergic preanaesthetic medication in children. It was carried out as a follow-up study of the previous survey amongst Finnish anaesthesiologists in 1990. METHODS: A questionnaire was send to all members of the Finnish Society of Anaesthesiologists. Data from anaesthesiologists taking care of at least three paediatric anaesthesias/week (n= 183) were analyzed. RESULTS: In 1998 only one-third of the Finnish anaesthesiologists routinely used anticholinergics before paediatric anaesthesia. The main indications for routine anticholinergic premedication were ENT surgery (66%), eye surgery (71%) and endoscopic procedures (67%). Anticholinergic drugs were administered principally via the intravenous route (90%) briefly before induction of anaesthesia, and glycopyrrolate was the most frequently used (66%). CONCLUSION: During the last eight years in Finland the routine use of anticholinergic premedication has decreased. As in 1990 the anticholinergic prophylaxis is directed to ENT and eye surgery, endoscopic procedures and to children younger than 1 year. Use of glycopyrrolate has gained popularity at the expense of atropine and scopolamine.     

Anaesthesia for eye surgery in paediatrics

In contrast to adult practice, the majority of paediatric eye surgery is performed under general anaesthesia. Most patients presenting on a paediatric ophthalmology operating list will be otherwise healthy children who are suitable for day surgery. However, some children may present with eye pathology as part of a congenital disorder. The perioperative plan should be formulated after assessment of the child's behaviour and medical comorbidities, taking into account the surgical conditions required for the intended procedure. Factors influencing intraocular pressure (IOP) may require careful manipulation, and anaesthetists should be vigilant of the oculocardiac reflex (OCR). Postoperative nausea and vomiting (PONV) is more common in ocular surgery, particularly following strabismus correction. In most cases, simple analgesics and intraoperative application of topical local anaesthesia are sufficient to provide effective postoperative pain relief.     

Children in day surgery: clinical practice and routines. The results from a nation-wide survey

Background: Day surgery is common in paediatric surgical practice. Safe routines including parental and child information in order to optimise care and reduce anxiety are important. Most day surgery units are not specialised in paediatric care, which is why specific paediatric expertise is often lacking.
Methods: We studied the practice of paediatric day surgery in Sweden by a questionnaire survey sent to all hospitals, obtaining an 88% response rate. Three specific paediatric cases were enquired for in more detail.
Results: The proportion of paediatric day surgery vs. in-hospital procedures was 46%. Seventy-one out of 88 responding units performed paediatric day surgery. All units had anxiolytic pre-medication as a routine in 1–6-year-olds, and in 7–16-year-olds at 60% of the units. Most units performed circumcision and adenoidectomy, while 33% performed tonsillectomy. Anaesthesia induction was intravenous in older children, and also in 1–6-year-olds at 50% of the units. Parental presence at induction was mandatory. Post-operatively, 93% of units routinely assessed pain. Paracetamol and NSAIDs were the most common analgesics, as monotherapy or combined with rescue medication in the recovery as IV morphine. At 42% of units, take-home bags of analgesics were provided, covering 1–3 days of treatment. Pain was the most frequent complaint on follow-up. Micturition difficulties were common after circumcision, nausea after adenoidectomy and nutrition difficulties after tonsillectomy.
Conclusions: In Sweden, most day surgery units perform paediatric surgery, most children receive pre-medication, anaesthesia is induced IV and take-home analgesics paracetamol and or NSAIDs are often provided. Still, pain is a common complaint after discharge.     

Diseases of the adenoids and tonsils in children

Diseases of the tonsils and adenoids are extremely common in children and make up a significant part of the paediatric ENT surgeon's practice, as well as presenting frequently to paediatric and primary care teams. The majority of adenotonsillar pathology in children is either infective or obstructive in nature. This article discusses the anatomy and pathophysiology of acute and chronic adenotonsillar disease and discusses how to evaluate a child with suspected adenotonsillar pathology clinically, in both the outpatient and emergency scenario. Surgical management and the adenoidectomy and tonsillectomy techniques are described. The current multidisciplinary working group guidelines regarding surgery for obstructive sleep apnoea in children are also highlighted.     

Perioperative anaesthetic morbidity in children: a database of 24,165 anaesthetics over a 30-month period

BACKGROUND: This study reports the practices and morbidity of 24,165 anaesthetics performed over a 30-month period in a paediatric teaching hospital. METHODS: Data describing practices and adverse events during anaesthesia and in the postanaesthesia care unit (PACU) were collected prospectively from 1 January 2000 to 30 June 2002 on an audit form as a part of the Quality Assurance Program. All surgical specialties are covered except for open heart surgery and neurosurgery. RESULTS: A total of 724 adverse events were reported during anaesthesia and 1105 in PACU. Respiratory events represented 53% of all intraoperative events. They were more frequent in infants compared with older children, in ENT surgery compared with other surgery, in children in whom the trachea was intubated and in children with ASA status 3-5 compared with those with ASA score 1 or 2. Cardiac events accounted for 12.5% of intraoperative events and were mainly observed in children with ASA score 3-5. In PACU, vomiting was the most frequent adverse event with an overall incidence of 6%. Vomiting was more frequent in older children compared with infants and young children and more frequent after ENT surgery compared with other surgery. Only one death was reported in a premature newborn infant and was not anaesthesia-related. CONCLUSIONS: This observational study confirms previous reports, and indicates that there is still a relative higher rate of adverse events in infants compared with older children even in a teaching paediatric hospital with a high annual caseload.     

Incidence and risk factors of perioperative respiratory adverse events in children undergoing elective surgery

BACKGROUND: Adverse respiratory events remain one of the major causes of morbidity during anaesthesia, especially in children. The purpose of this prospective study was to determine the incidence of perioperative respiratory adverse events (PRAE) during elective paediatric surgery and to identify the risk factors for these events. METHODS: Potential risk factors (atopy, eczema, rhinitis, food allergy, previous allergic tests, pollens or animal allergy, passive smoking, obstructive sleep disorders) were assessed using the International Society on Allergy and Asthma (ISAAC) questionnaire, which was submitted to the parents during preoperative anaesthetic assessment. Anaesthetic and surgical conditions were systematically recorded. A multivariate logistic regression explaining PRAE was developed in 800 children. RESULTS: The intraoperative incidence of respiratory adverse events was 21% and the incidence in the postanesthetic care unit was 13%. According to the multivariate analysis, children not anaesthetized by a specialist paediatric anaesthesiologist have 1.7 increased risk to present PRAE (95% CI = 1.13-2.57). Children anaesthetized for ear, nose, throat (ENT) surgery had a 1.57-fold higher risk of PRAE compared with other procedures (95% CI = 1.01-2.44). Furthermore, there was a synergistic interaction when two risk factors: residents and ENT surgery, were concomitant: the odds ratio (OR) of PRAE during non-ENT surgical procedures was 1.43 (95% CI = 0.91-2.24), but increased to 2.74-fold (95% CI = 1.15-4.32) for ENT surgery. The risk of PRAE was significantly lower when the anaesthetic technique included tracheal intubation with relaxants (OR = 0.6, 95% CI = 0.45-0.95) and decreased by 8% with each increasing year of age. CONCLUSIONS: This study demonstrates a high incidence of PRAE in paediatric surgical patients without respiratory tract infections, which appears to be primarily determined by the age of the child and the anaesthetic care rather than by the child's medical history.     

Total intravenöse Anästhesie

Since venous cannulation in children has become easier and extensive experience has been gained with total intravenous anaesthesia (TIVA) in adults, the interest in TIVA for children has recently increased. An intensified sensitivity of the operating room atmosphere to contamination with volatile anaesthetic agents is another important reason to choose intravenous techniques for paediatric anaesthesia. One of the most interesting agents for TIVA in paediatric anaesthesia is propofol. The pharmacokinetic and pharmacodynamic data for modern intravenous drugs is poor. Because the interpatient variability is relatively large, pharmacokinetic data can only provide guidelines for the dosage of propofol. Propofol has a rapid and smooth onset of action and is as easy to titrate in children as in adults. Propofol can be excellently controlled. Severe haemodynamic side-effects are missing in healthy children and plasma is cleared rapidly of propofol by redistribution and metabolism. There is no evidence of significant accumulation, not even after prolonged infusion times. Because propofol has no analgetic properties it must be combined with analgetics or a regional block for all painful procedures. The combination with the ultra-short acting remifentanil is a major advantage, but requires effective analgetic concepts for painful procedures. In comparison the combination of propofol with long acting opioids abolishes some of the favourable properties of propofol. Further studies of the kinetics and dynamics of propofol and other intravenous agents are needed in paediatrics which should focus on age, maturity and severity of illness. The whole importance of the propofol-infusion syndrome has to be cleared up urgently. TIVA has an important significance in paediatric anaesthesia for diagnostic and therapeutic procedures, especially where these have to be repeated. In day-case anaesthesia TIVA has advantages for all short procedures and for ENT and ophthalmic surgery: even after prolonged infusion children have an short recovery time. There is no evidence of agitation or other behavioural disorders after TIVA with propofol in paediatric anaesthesia. Propofol has anti-emetic properties. TIVA with propofol can be combined with regional anaesthesia advantageously to provide long-lasting analgesia after surgery. TIVA with propofol has been used successfully for sedation of spontaneously breathing children for MRI and CT and other procedures with open airways like bronchoscopy or endoscopy. Propofol facilitates endotracheal intubation without the use of muscle relaxants. Of course, in malignant hyperthermia TIVA will continue to be the technique of choice. Nothing is known about awareness under TIVA in paediatric patients. TIVA must be considered by comparison with the volatile agents. The use of ultra-short acting agents may cause problems such as awareness, vagal response, involuntary movements and in some cases slow recovery after prolonged infusion of propofol. But it is not known exactly how often this happens during paediatric anaesthesia. With TIVA an effective postoperative analgesia must be provided. Newer administration techniques such as the target-controlled infusions or closed-loop control systems are under development and will help to minimise the potential risk of overdosage with TIVA in paediatrics. At the present TIVA is an interesting and practicable alternative to volatile anaesthesia for pre-school and school children. TIVA with propofol in infants younger than 1 year old requires extensive experience with TIVA in older children and with the handling of this special age group and should be undertaken with maximum precautionary measures.     

Three years of institutionalized paediatric day case surgery: organization — indications — frequency — complications

In the last seven years, the number of surgical procedures which are performed as day case surgery for infants and children has increased dramatically. Day case surgery should be able to be conducted effectively, with few complications, while saving time and money but also providing a pleasant atmosphere for the children and their parents. Since 1990, we have been practising day case surgery in the Department of Paediatric Surgery at the University of Tübingen twice a week. We have a special unit for this purpose with a team of day care personnel, paediatric nurses, anaesthesiologists and paediatric surgeons. The total number of operations performed in our department from 1990 to 1992 was 5330. Of these, 2111 (39.6%) were conducted as day case surgery for children of the ages six weeks to 20 years. The series includes 44 umbilical hernias, 385 phimoses, nine cervical cysts, 399 inguinal testes, 857 inguinal hernias, 90 hydroceles/funiculoceles, 19 haemangiomas, 43 meatotomies, 95 endoscopies and 170 other operations. Postoperative complications were defined as secondary haemorrhage, fever, obvious vomiting and urine retention. In a total of 35 (1.66%) children, the complications necessitated a stay in the hospital of up to eight (average 2.17) days, despite day case planning of the surgical procedure. Our experience shows that a large number of paediatric surgical procedures can be performed as day case surgery. Nevertheless, even with an expanded spectrum of possible operations there must always be ward capacities available in order to monitor and treat complications adequately.     

Robotic paediatric urology

What's known on the subject? and What does the study add? Robot assisted laparoscopic surgery (RALS) is slowly gaining acceptance in the field of paediatric urology. Accumulating data on safety and efficacy when performing paediatric robotic urologic procedures has led paediatric urologists to gradually embrace increasingly more complex reconstructive surgeries. Indeed, the unique and delicate movements generated by the robotic system make this technology ideal for children who often require reconstructive procedures. We critically review the current role of RALS in paediatric urology and to analyse the published data, with a special emphasis on the most common applications. We also propose a structured plan to expedite training and the surgical ‘learning curve’.

OBJECTIVES

• ? To critically review the current role of robot‐assisted laparoscopic surgery (RALS) in paediatric urology and to analyse the published data, with a special emphasis on the most common applications.
• ? One of the greatest benefits of RALS has been the ability to truly spread the application of minimally invasive surgery to paediatric surgical patients. The unique attributes of the robotic interface make this technology ideal for children with congenital anomalies, who often require reconstructive procedures.
• ? We also propose a structured plan to expedite training and the surgical ‘learning curve’.

PATIENTS AND METHODS

• ? Currently, almost all urological surgical procedures in children have been performed with the assistance of the robotic interface.
• ? The most commonly performed procedures include pyeloplasty, nephrectomy/hemi‐nephrectomy and surgery for vesico‐ureteric reflux.
• ? Initial series of bladder augmentation and appendicovesicostomy are available.

RESULTS

• ? Initial results with RALS are encouraging and have shown safety similar to open procedures, and outcomes at least equivalent to standard laparoscopy.
• ? Accumulating data have consistently shown that postoperative analgesia requirements and overall hospital stay are decreased.
• ? However, operative durations are significantly longer than their open counterparts, but this is decreasing as experience accumulates.

CONCLUSIONS

• ? RALS is already part of paediatric urological surgery.
• ? Larger single‐institution case series and comparative studies with the open approach and multi‐institutional meta‐analyses will help to identify the benefits of RALS in paediatric urology.

     

Desflurane or isoflurane for paediatric ENT anaesthesia A comparison of intubating conditions and recovery profile

Background: The inhaled anaesthetic desflurane is characterized by a rapid wash-in and wash-out and may be useful for short paediatric ENT procedures. Therefore, this study was designed to compare the effects of desflurane or isoflurane on intubating conditions and recovery characteristics in paediatric ENT patients. Methods: In this prospective, randomised investigation, we studied 44 children scheduled for ENT surgery, aged 4–12 yr and classified ASA I–II. After thiopentone induction (5–8 mg/kg) the lungs were ventilated by face mask and the vaporizer was dialed to 1 MAC (age-adapted) of desflurane of isoflurane. A reduced dose of vecuronium (0.05 mg/kg) was administered, and intubating conditions were rated 3 min later. Following tracheal intubation, 50% nitrous oxide were added, and the concentration of desflurane or isoflurane was adjusted according to clinical needs. At the end of surgery all anaesthetics were discontinued simultaneously and recovery times were recorded. Results: Intubating conditions were rated significantly better for desflurane (excellent or good 20 of 22) than for isoflurane (12 of 22). Recovery times were significantly shorter for desflurane than for isoflurane (mean±SE): spontaneous ventilation 4.0±0.5 min vs. 6.0±0.7 min, extubation 8.4±0.7 vs. 11.4±1.1 min and arrival at PACU 11.5±0.8 vs. 16.6±1.5 min. No airway complications (coughing, laryngospasm, or desaturation <97%) were noted for either anaesthetic. Conclusions: Following an intravenous induction improved intubating conditions, shorter recovery times and the lack of airway complications make desflurane a suitable alternative to isoflurane for paediatric ENT anaesthesia.     

Postoperative pain, nausea and vomiting following paediatric day-case tonsillectomy

More than 30% of all surgical activity for children in England and Wales is accounted for by routine ENT operations. There is known to be a high incidence of postoperative pain, nausea and vomiting following paediatric tonsillectomy with or without adenoidectomy. This prospective study examined the incidence of these complications in 100 children admitted for routine, elective day-case tonsillectomy, with or without adenoidectomy. The children were anaesthetised in accordance with our standard paediatric day-case protocol. The incidence of vomiting on the day of surgery was significantly less in the group anaesthetised in accordance with the protocol, compared to those in previously published studies. Postoperative pain was well controlled, with 88% of the children having minimal pain on the day of surgery, and reporting a pain score of 0-2. Modifying the anaesthetic care to a protocol designed to reduce postoperative pain, nausea and vomiting achieved measurable improvements in the recovery of this group following surgery. It has enabled us to evolve from a 100% inpatient stay for these operations to 98% day-case discharge rate, with minimal post anaesthetic or surgical morbidity. We describe the protocol and discuss the implications of implementing such a protocol for children undergoing these common operations.     

Endoskopische Verfahren in der Mund-, Kiefer- und Gesichtschirurgie

The visualization and approach to the highly complex craniomaxillofacial region, such as the nose and paranasal sinuses, the temporomandibular joint, the salivary glands and other only indirectly accessible structures require surgical skills as well as specialized technical equipment. Endoscopy offers an excellent diagnostic and therapeutic tool. Endoscopic surgery in oral and maxillofacial surgery (OMFS) in most cases is preferably performed with endoscopic support in contrast to interventional endoscopic procedures, i.e. minimally invasive surgery in a proper sense. So far in OMFS endoscopic techniques have been implemented in a rather curbed manner, whereas in the neighboring field of ear nose and throat (ENT) surgery endoscopy has continued its triumph and has now replaced the majority of traditional open head and neck access surgical procedures. Thus for example functional endoscopic sinus surgery (FESS), sialendoscopy and quite recently robotic-assisted surgery have expanded ENT indications for minimally invasive procedures which are not easily placed on an equal footing in OMFS.     

Anaesthesia for elective ear,nose and throat surgery in children

This review is an update of anaesthesia for elective ear, nose and throat procedures commonly performed in the paediatric population. Increasingly these often-complex procedures are being undertaken as day cases and so preoperative assessment needs to be tailored accordingly to identify those children requiring closer postoperative monitoring. Assessment of co-morbidities, consequences of the child’s presenting pathology (e.g. obstructive sleep apnoea (OSA)), bleeding risk and the presence of any concurrent upper respiratory tract infections needs to be the focus of the preoperative visit. Day case procedures involve careful patient selection and good communication with families regarding the post-operative phase and potential complications. Adenotonsillectomy is most commonly performed to relieve the symptoms of OSA. The main anaesthetic concerns include co-morbidities (e.g. obesity), analgesia including the potential use of non-opioids like dexmedetomidine, post-operative nausea and vomiting (PONV), risk of postoperative haemorrhage, postoperative respiratory complications and postoperative disposition. Children undergoing middle ear surgery need careful consideration to prevent problems associated with bleeding, hypothermia and PONV, and staff need to be aware of any hearing deficit that the child may have. Use of lasers is common in airway surgery with children often having repeated laser procedures; associated risks include airway fire and injury to the eyes of the patient and theatre staff.     

Arterial desaturation in healthy children during and after minor surgery

Pulse oximetry (PO) was applied to 79 otherwise healthy children during and after minor ENT surgery under general anaesthesia in private practice. The PO data were not available to the anaesthetist unless desaturation to less than or equal to 85% was present for greater than or equal to 30 s. This occurred in 12 and 9 cases during anaesthesia and recovery, respectively, only 8 and 5 cases, respectively, being diagnosed clinically. Desaturation during and after anaesthesia was more common in children undergoing adenoidectomy than during procedures for which endotracheal intubation was not performed. During recovery, desaturation was more likely to occur in the same patients again. Lower values of SaO2 were found in younger children and in children resisting or crying at induction. There was a (weak) negative correlation between SaO2 and HR. As clinically undiagnosed desaturation occurs even in healthy children undergoing minor surgical procedures, a more widespread use of PO during and after anaesthesia may be advisable.     

Paediatric ENT day surgery: Is it safe practice?

Day-case surgery is convenient and safe allowing patients to have the appropriate medical service without long waits. The issue of safety has been extensively studied and presented in the literature. In this paper, the Security Forces Hospital experience with otolaryngology day-surgery cases is presented.

Objective

To evaluate the rate of complications and their timing and to assess the safety of day-surgery procedures.

Methods

A total of 300 children undergoing tonsillectomy, adenotonsillectomy, adenoidectomy, myringotomy, and other minor surgeries (e.g. reduction of fracture nasal bone, foreign body removal, etc.) were observed. Post-operatively after recovery from anaesthesia, a number of parameters were recorded at intervals of 15 min for the first 4 h, 30 min for the following 3 h, and hourly until discharge. Bleeding was considered to have occurred only if medical attention was required.

Results

In the evaluation of haemorrhage as an important complication, nine cases (3%) bled in the first 6 h (six following adenoidectomy and three following tonsillectomies) after day-surgery procedures, while six cases bled after 3 days (2%). Results were compared with post-operative haemorrhage after operations done in the main OR and there it was reported in 11 out of 101 cases in whom adenotonsillectomy was performed: only one patient (1%) needed control in the OR.

Conclusion

Post-operative complications after day-surgery procedures are comparable to that after main OR procedures. The common paediatric ENT procedures, e.g. adenoidectomy, tonsillectomy, adenotonsillectomy, and myringotomy, can be done safely as day-case procedures in a busy hospital.     

Pediatric anesthesia practice in France: a survey of 1,526 anesthesiologists

OBJECTIVES: To assess the individual activity of anaesthetists in paediatric anaesthesia (PA), and collect their wishes about continuing education and recommendations in PA. STUDY DESIGN: Transversal, prospective study. METHODS: A questionnaire of 33 items, sent to 4,360 anaesthetists, spread over 15 health districts, working in a public or private institution. RESULTS: We gathered 1,526 replies (35%) of which 34% university hospitals, 32% public institutions and 31% private institutions. 943 physicians (63%) had no specific structure, and 1,119 (87%) considered a specialized nurse to be essential for PA. 1,127 physicians (74%) had undertaken a specific session during their formation. The practice of PA depends upon age and context. Above 1 year old, the surgery that is performed weekly was ENT (38%), abdominal and urologic surgery (28%). Mask induction was performed by 60% of the physicians in children under 5 years. 63% of the anaesthetists dreaded a laryngospasm during induction. 625 physicians undertook regional anaesthesia in children under 5 years (87% caudal anaesthesia, 48% peripheral nerve blocks). 1,029 physicians (67%) wished for recommendations in PA in children under 12 months. CONCLUSIONS: This survey showed that most of the anaesthetists wished for recommendations in their paediatric anaesthesia practice.     

Increased incidence of acute patellar dislocations and patellar instability surgical procedures across the United States in paediatric and adolescent patients

PurposePatellofemoral instability is a common cause of knee pain and dysfunction in paediatric and adolescent patients. The purpose of the study was to evaluate the frequency of patellar dislocations seen in emergency departments (EDs) and the rates of surgical procedures for patellar instability at paediatric hospitals in the United States between 2004 and 2014.MethodsThe Pediatric Health Information System database was queried for all paediatric patients who underwent surgery for patellar instability or were seen in the ED for acute patellar dislocation between 2004 and 2014. This was compared with the annual numbers of overall orthopaedic surgical procedures.ResultsBetween 2004 and 2014, there were 3481 patellar instability procedures and 447 285 overall orthopaedic surgical procedures performed at the included institutions, suggesting a rate of 7.8 per 1000 orthopaedic surgeries. An additional 5244 patellar dislocations treated in EDs were identified. Between 2004 and 2014, the number of patellar instability procedures increased 2.1-fold (95% confidence interval (CI) 1.4 to 3.0), while orthopaedic surgical procedures increased 1.7-fold (95% CI 1.3 to 2.0), suggesting a 1.2-fold relative increase in patellar instability procedures, compared with total paediatric orthopaedic surgeries.ConclusionThis study shows a significant rise in the rate of acute patellar instability treatment events in paediatric and adolescent patients across the country. Surgery for patellar instability also increased over the study period, though only slightly more than the rate of all paediatric orthopaedic surgical procedures. This may suggest that increasing youth sports participation may be leading to a spectrum of increasing injuries and associated surgeries in children.Level of EvidenceIV     

Robot-assisted vaginal construction using ileum in a case of Mayer–Rokitansky–Küster–Hauser syndrome

The horizon of robotic paediatric surgery has grown in leaps and bounds with advances in technology. The aim of this study was to analyse the extent of robotic involvement in paediatric surgical practice. A systematic database search was performed. Data about children who had undergone robot-assisted procedures were reviewed retrospectively from all published reports up to October 2007. Success rates were defined in term of completion of the procedures, their complications, and the time taken. These results were further studied in comparison with the procedures performed by open and laparoscopic methods. A total of 31 studies were identified describing 566 patients. Of these, four studies were case control, comparing with either laparoscopic or open procedures, one study was a prospective trial, and the rest of the studies were either case reports or series. The most common robotic system used was the da Vinci (23 studies) followed by the Zeus (four studies). The mean age of the children was 8.3 years. The commonest operation was pyeloplasty (141 cases), followed by fundoplication (122 cases) and patent ductus arteriosus ligation (50 cases). The mean operation time for robot-assisted pyeloplasty was 221 min (open pyeloplasty 214 min). The mean operation times for fundoplication were robotic, 170 min, laparoscopic, 158 min, and open, 121 min. The mean operation times for patent ductus arteriosus ligation were 166 min (robotic) and 83 min (open). Overall conversion rate for all paediatric robotic procedures was 4.7% and complications ranged from 0 to 15%. For robotic fundoplications the conversion and complication rates were 0.8 and 3.3%, respectively. For robotic pyeloplasties the conversion and complication rates were 2.1 and 3.5%, respectively. Many other major operations were performed successfully. All studies recommended robotic procedure as safe and feasible. Currently, the most common robotic operations in practice are pyeloplasties and fundoplications. Most of the authors concluded that, despite taking more time, robotic surgery enables more refined hand–eye coordination, superior suturing skills, better dexterity, and precise dissection with minimal conversion and complication rates. The widespread acceptance of this technology largely depends on solving the issues: learning curve; suitable machine size for neonates and infants; ensuring efficacy and safety in all operations; and, most importantly, making this procedure cost effective, so as to cater for the needs of most, if not all, children. This paper was presented at the Annual Conference of IPEG (International Pediatric Endosurgery Group) in Buenos Aires, Argentina, 2007.