Risk factors for early peritoneal dialysis catheter failure in children

Background

There is uncertainty regarding the optimal approach for surgical placement of peritoneal dialysis (PD) catheters in children. Operative technique, catheter selection, and patient variables (eg, age or prior surgical history) may influence catheter lifespan.

Methods

A retrospective review of all PD catheters placed at a tertiary children's medical center during a 6-year period was performed. Our primary outcome was catheter function 2 months after placement. Data were analyzed using Student 2-tailed t test or χ² analysis.

Results

There were 121 PD catheters placed in 81 patients. The median primary functional catheter lifetime was 109 days. Primary PD catheter failure (within 2 months) occurred in 36 catheters (30%). Patients with primary catheter failure (8 ± 7 years) were younger than patients with a functioning catheter at 2 months (12 ± 5 years; P = .002). Catheters placed without simultaneous omentectomy were more likely to fail (P = .042). Catheter failure rate was not significantly different based upon operative technique or catheter type.

Conclusion

Omentectomy at the time of catheter placement decreased the risk of early catheter failure. In contrast, type of catheter or laparoscopic placement did not influence the likelihood of early catheter failure.     

Laparoscopic Tenckhoff catheter placement in children using a securing suture in the pelvis: comparison to the open approach

Background/Purpose

Secure placement of peritoneal dialysis (PD) catheters in the pelvis has been described by various techniques. We describe minimally invasive placement using an Endo Close device, securing the catheter in the pelvis, and compare this method with standard open technique in children.

Methods

A retrospective institutional review was conducted for children requiring PD access from 2001 to 2007. Patients were grouped into laparoscopic with secure placement (SP) and open placement (OP) groups. Groups were cohort-matched based on age, paying particular attention to the number of catheter migrations.

Results

Twenty-seven patients underwent 36 procedures in SP, whereas 23 patients in OP had 32 catheter-related procedures. Exit site infections were decreased in SP (0.57 vs 1.33 episodes per patient-year). There was no difference in the number of catheter migrations (3 vs 5); however, time to migration was statistically longer in the SP group (9 vs. 2.4 months, P < .05).

Conclusions

Laparoscopic placement of PD catheters using a securing suture in the pelvis is a more durable technique when compared to open placement. Extending the catheter migration time is important in children when PD is used as a bridge to renal transplantation.     

Laparoscopic inguinal hernia repair by the hook method in emergency setting in children presenting with incarcerated inguinal hernia

Background

The development of laparoscopic hernia repair has provided an alternative approach to the management of incarcerated inguinal hernia in children. Different laparoscopic techniques for hernia repair have been described. However, we hereby review the role of laparoscopic hernia repair using the hook method in the emergency setting for incarcerated inguinal hernias in children.

Methods

A retrospective review was conducted of all children who presented with incarcerated inguinal hernia and underwent laparoscopic hernia repair using the hook method in emergency setting between 2004 and 2010.

Results

There were a total of 15 boys and 1 girl with a mean age of 30 ± 36 months (range, 4 months to 12 years). The hernia was successfully reduced after sedation in 7 children and after general anesthesia in 4 children. In 5 children, the hernia was reduced by a combined manual and laparoscopic-assisted approach. Emergency laparoscopic inguinal hernia repair using the hook method was performed after reduction of the hernia. The presence of preperitoneal fluid secondary to recent incarceration facilitated the dissection of the preperitoneal space by the hernia hook. All children underwent successful reduction and hernia repair. The median operative time was 37 minutes. There was no postoperative complication. The median hospital stay was 3 days. At a median follow-up of 40 months, there was no recurrence of the hernia or testicular atrophy.

Conclusions

Emergency laparoscopic inguinal hernia repair by the hook method is safe and feasible. Easier preperitoneal dissection was experienced, and repair of the contralateral patent processus vaginalis can be performed in the same setting.     

Laparoscopic hernia repair in children by the hook method: a single-center series of 433 consecutive patients

Background

The relatively high recurrence rate reported in laparoscopic hernia repair in children using intracorporeal suturing technique remains a concern. We aimed to investigate the effectiveness of the hook method during hernia repair that allows extraperitoneal passage of suture to close the hernia sac without creating any tension or skip areas and does not require laparoscopic suturing skills.

Methods

A retrospective review was conducted on 433 consecutive children who underwent laparoscopic hernia repair using the hook method by 1 of 4 surgeons from July 2004 to June 2007.

Results

A total of 572 successful laparoscopic hernia repairs were performed among the 433 children with an age range of 1 week to 15 years (mean = 56 months). Conversion rate was 1.04%. Contralateral patent processus vaginalis was found in 26.8%. Mean operating time was 23.8 and 40.2 minutes for unilateral and bilateral repair, respectively. At a median follow-up of 20 months, there were 2 recurrences (0.35%), 2 hydroceles, 1 ascending testis, and 1 instance of testicular atrophy. No serious complications were associated with the procedure.

Conclusions

Medium-term results suggest that laparoscopic hernia repair with the hook method is a sound alternative to open herniotomy in children.     

Laparoscopic injection of dermabond tissue adhesive for the repair of inguinal hernia: short- and long-term follow-up

Purpose

Is laparoscopic injection of 2-octyl-cyanoacrylate tissue adhesive (Dermabond: Db) into the inguinal hernia sac (IHS) effective for inguinal hernia repair?

Methods

Thirty male 4-week-old Lewis rats were used as subjects for this study. In the right Db (R-Db) group (n = 10), a fine catheter was passed through an 18-guage indwelling intravenous cannula inserted in the right lower quadrant, and 0.2 mL Db was injected into the right IHS under laparoscopic control. The left side was not treated. Both IHSs were treated in the bilateral Db (B-Db) group (n = 10). In the no Db (N-Db or control) group (n = 10), only laparoscope insertion was performed. Herniography was performed before death. B-Db and N-Db rats were mated 50 days after treatment. Half of all rats were killed 2 months after treatment and the remaining half 12 months after treatment.

Results

All rats survived until killing. Macroscopic findings postdeath confirmed herniography results; treated IHS were closed, and untreated IHS were patent. There were minor adhesions in 3 of 20 treated rats. Sperm were identified in the vaginas of all mated rats.

Conclusions

These results suggest that our new technique is simple, safe, and reliable as an alternative to standard operative repair for inguinal hernia.     

A novel laparoscopic technique for the repair of pediatric umbilical and epigastric hernias

Background/Purpose

The aim of this study was to determine whether a novel laparoscopic technique for pediatric umibilical and epigastric hernia repair is safe, quick, effective, durable, and cosmetically acceptable.

Methods

Forty-one consecutive umbilical and 13 epigastric hernias were repaired laparoscopically. Six patients had concomitant epigastric and umbilical hernias repaired during one procedure. Two 3-mm ports were used via a lateral approach. Mean age was 4.2 years for those with an umbilical hernia and 2.0 years for those with an epigastric hernia.

Results

All procedures were completed laparoscopically. The mean operative time was 27 minutes for umbilical hernia repair and 16 minutes for epigastric hernia repair. There were no intraoperative or postoperative complications. Follow-up was 100% and ranged from 6 to 35 months. There have been no recurrent hernias, and patient/parent satisfaction was subjectively excellent.

Conclusion

This case series demonstrated that this novel technique of laparoscopic anterior abdominal wall hernia repair is safe, quick, effective, durable, and cosmetically acceptable. It requires few instruments and minimal advanced laparoscopic techniques.     

Laparoscopic peritoneal dialysis catheter implantation using a Tenckhoff trocar under local anesthesia with nitrous oxide gas insufflation

Background

Laparoscopic implantation of peritoneal dialysis catheters has many advantages over conventional methods. The ability to perform laparoscopy with the patient under local anesthesia allows renal failure patients, who ordinarily might not be considered candidates for general anesthesia, an opportunity to undergo this procedure.

Methods

Using local anesthesia and nitrous oxide pneumoperitoneum, 175 catheters were implanted in long musculofascial tunnels under laparoscopic guidance to minimize the risk of catheter migration and flow dysfunction.

Results

Nitrous oxide pneumoperitoneum was well tolerated, allowing all procedures to be safely completed with the patients under local anesthesia. The overall 1- and 2-year catheter survival rates were 92.7% and 91.3%, respectively. The incidence of catheter tip migration and omental entrapment was 1.7% and 2.9%, respectively. Temporary pericatheter leak occurred in 7.4% of cases.

Conclusions

Nitrous oxide insufflation enables safe performance of laparoscopic surgery with the patient under local anesthesia. Patients benefit from a minimally invasive technique with the assurance of obtaining successful long-term catheter function.     

Laparoscopic-assisted repair of Morgagni hernia in children

Purpose

Morgagni hernia is a rare entity that accounts for less than 6% of all surgically treated diaphragmatic hernias in pediatric age group. They are mostly asymptomatic and discovered incidentally. Open surgical repair has been the gold standard in all cases once diagnosed. However, since the introduction of minimal access surgery, different laparoscopic techniques of Morgagni hernia repair have been reported in the literatures. Most of them are reporting on few cases and the immediate outcomes. Herein, we report the largest experience to date assessing the safety and efficacy of laparoscopic-assisted full-thickness anterior abdominal wall repair of Morgagni hernia in children with more emphasis on the short-term outcomes, such as the recurrence and the fate of the hernia sac.

Methods

Fifteen children with Morgagni hernias underwent primary laparoscopic repair by placement of interrupted nonabsorbable sutures through the full thickness of the anterior abdominal wall, incorporating the hernia sac, the posterior rim of the defect, and returning back out through the anterior abdominal wall with the sutures tied in the subcutaneous tissue.

Result

Between January 2004 and January 2008, 15 children with Morgagni hernia were treated laparoscopically in our institution-affiliated hospitals. Male-female ratio was 2:1. Mean age was 21.7 months. The average operative time was 42.6 minutes. Average time to full feed was 22.9 hours. Postoperative analgesia requirement was minimal. The average hospital stay was 24 hours. All operations were completed laparoscopically. None of the patients developed intraoperative or postoperative complications. The maximum follow-up was 48 months (mean, 20 months). All patients are in good health without recurrence or significant sac residual.

Conclusion

Laparoscopic-assisted Morgagni hernia repair is a safe and effective modality of treatment. It is well tolerated and gives all the advantages of minimal access surgery, without adverse effects from leaving the sac plicated in place.     

Management of duodenal injuries in children

Background/purpose

The natural history and management of pediatric duodenal injuries are incompletely described. This study sought to review injury mechanism, surgical management, and outcomes from a collected series of pediatric duodenal injuries.

Methods

A retrospective chart review was conducted for a 10-year period of all children less than 18 years old treated for duodenal injuries at 2 pediatric trauma centers.

Results

Forty-two children were treated for duodenal injuries. There were 33 blunt and 9 penetrating injuries. Injuries were classified using the Organ Injury Scale for the Duodenum. Twenty-four patients underwent operative management by primary repair (18), duodenal resection and gastrojejunostomy (4), or pyloric exclusion (2). Duodenal hematomas were treated nonoperatively in 94% of cases. The average ISS for operative versus nonoperative cases was 23 and 10, respectively. Delay in diagnosis or operative intervention (>24 hours) was associated with increased complication rate (43% v 29%) and hospitalization (32 v 20 days). Nine children requiring surgery experienced delays and were most highly associated with foreign body, child abuse, and bicycle injuries. There were no deaths caused by duodenal injuries.

Conclusions

Duodenal injuries in children were predominantly blunt and had a low mortality rate. When surgery was required, primary repair was usually feasible.     

Thoracoscopic-assisted central line placement for a thrombosed superior vena cava

Background

In children who require prolonged and multiple venous catheterizations, the superior vena cava and iliofemoral veins may become occluded, making central venous access a difficult challenge. We report an innovative technique of catheter insertion percutaneously from the neck into the right atrium traversing a thrombosed superior vena cava using video-assisted thoracoscopic surgery.

Methods

Two children with irreversible intestinal failure had 4 central venous accesses insertions using the above-mentioned technique. Both had occluded major central veins after multiple catheterizations. An interventional radiologist and cardiologist failed to establish a central venous access in both patients.

Results

A 9-year-old boy has a long-term catheter functioning for 8 months, and in an 18-month-old girl, the line was removed accidentally 6 weeks from its insertion and 2 months later for a line leak. It was then reinserted each time using the same technique.

Conclusion

This technique of catheter placement into the right atrium using video-assisted thoracoscopic surgery when other conduits are unavailable can be lifesaving in children depending on total parenteral nutrition.     

Laparoscopic contralateral groin exploration: is it cost effective?

Background

Transinguinal laparoscopy offers a safe and effective method for evaluating the contralateral groin during unilateral inguinal hernia repair (UIHR). The purpose of this study is to determine whether laparoscopic contralateral groin exploration (LCGE) is cost effective.

Methods

A retrospective review of all children who underwent UIHR and LCGE from 2006 to 2007 by a single surgeon was performed. Cost analysis comparing the time to perform the LCGE and time to repair the contralateral patent processus vaginalis (CPPV) to the cost saved by preventing future operation for a contralateral inguinal hernia repair was calculated based on Medicare reimbursement.

Results

Eighty-one patients underwent UIHR with planned LCGE; 78 (96.3%) had successful LCGE; 8 (10.3%) had a CPPV and underwent contralateral open repair. The total cost for the additional time to perform LCGE and repair of the 8 CPPV was $13 080. The total cost for returning for a second operation to repair the contralateral inguinal hernia was $20 440.

Conclusion

Laparoscopic contralateral groin exploration at the time of unilateral inguinal hernia repair was cost effective.     

Laparoscopic inguinal hernia repair-a prospective personal series of 542 children

Purpose

This series prospectively evaluates a consecutive personal series of children undergoing laparoscopic hernia repair.

Methods

A total of 712 inguinal hernias were corrected laparoscopically in 542 children (396 boys and 146 girls, aged 4 days to 14 years, median 1.6 years). The internal inguinal ring was closed with a 4-0 nonabsorbable suture using 2-mm instruments. Patients were prospectively video-documented.

Results

There were no serious intraoperative complications. Operating time was comparable to open surgery. The contralateral inner ring was open on the left side in 16% of boys and 12% of girls, and on the right side in 18% of boys and 32% of girls. Direct hernias were found in 2.3%, femoral hernias in 1%, hernias en pantalon in 0.7%, and a combination of indirect and femoral hernia in 0.2%. Follow-up to date is 1-84 months (median 39 months). There were 4.1% hernia recurrences, 0.7% hydroceles and 0.2% testicular atrophies. Cosmesis is excellent.

Conclusions

Laparoscopic inguinal hernia repair can be a routine procedure with results comparable to those of open procedures. It is well suited for recurrences. The vas remains untouched. The visualization of structures is clear and leads to a defect-specific closure. The advantages of the laparoscopic approach include the following: its technical ease, it is an outpatient procedure, the cord structures remain untouched, the type of hernia is obvious, trocar placement is identical for any side or hernia type, clear visualization of the anatomy. Routine video documentation renders the diagnostic accuracy objective and absolute. Finally, recurrences are easier dealt with, be it from a previous open or from a laparoscopic approach. Although recurrences were slightly more frequent in the early stages, now they are closer to the rate with the open procedure.     

Abdominal wall repair using human acellular dermis

Background

The surgical repair of abdominal wall defects that cannot be closed primarily in contaminated fields is a difficult problem. The use of nonabsorbable synthetic materials usually is contraindicated in this setting because of the risk for colonization and chronic infection of the mesh. In this study we sought to determine the safety and efficacy of implanted human acellular dermal graft for abdominal wall reconstruction.

Methods

The records of all patients (n = 20) who underwent a repair of an abdominal wall defect with human acellular dermal graft at a Veteran Affairs hospital were reviewed retrospectively. Patient demographics, complications, and hernia recurrence were recorded.

Results

There were 15 perioperative complications in 11 patients: 6 graft dehiscences, 1 evisceration, 2 postoperative intra-abdominal bleeds, 5 bacterial graft infections, and 1 death. Patients with heart disease, American Society of Anesthesiologists classification of 4, and/or dirty wounds were more likely to have perioperative complications. The median follow-up period was 9.4 months (range, 2-16 mo), during which 6 hernia recurrences were noted.

Conclusions

Human acellular dermis use is safe in abdominal wall reconstructions in contaminated surgical wounds.     

Laparoscopic approach to incarcerated inguinal hernia in children

Purpose

The purpose of this study was to describe the laparoscopic approach to incarcerated inguinal hernia in children.

Methods

After unsuccessful manual reduction, 29 patients (aged 3 weeks to 7 years; median, 10 weeks; 44 boys, 15 girls) with incarcerated inguinal hernia underwent immediate laparoscopy. The hernial content was reduced in a combined technique of external manual pressure and internal pulling by forceps. The bowel was inspected, and the hernia was repaired.

Results

In all patients, the procedure was successful. No conversion to the open approach was required. Immediate laparoscopic herniorrhaphy in the same session was added. No complications occurred.

Conclusions

Laparoscopy allowed for simultaneous reduction under direct visual control, inspection of the incarcerated organ, and definitive repair of the hernia. Technically, it appears easier than the conventional approach because of the internal inguinal ring being widened by intraabdominal carbon dioxide insufflation. The hospital stay is shorter.     

Protocolized management of infants with congenital diaphragmatic hernia: effect on survival

Background/Purpose

In 2006, we introduced a new protocol for congenital diaphragmatic hernia (CDH) management featuring nitric oxide in the delivery room, gentle ventilation, lower criteria for extracorporeal membrane oxygenation (ECMO), and appropriately timed operative repair on ECMO. Our goals were to assess outcomes after institution of this protocol and to compare results with historical controls.

Methods

Charts were reviewed of all newborns admitted to a large metropolitan children's hospital from 2002 to 2009 with a diagnosis of CDH. Data were recorded regarding delivery, ECMO, operative repair, length of stay, comorbidities/anomalies, complications, and survival. Postprotocol outcomes were compared to those from the preprotocol era and to data from the international CDH Registry.

Results

Comparison of the protocolized group (n = 43) to the historical group (n = 51) revealed no significant differences in gestational age, birth weight, Apgar scores, or comorbidities. New treatment strategies substantially improved survival to discharge (67% preprotocol, 88% postprotocol; P = .015). Among ECMO patients, survival increased to 82% (20% preprotocol; P = .002).

Conclusions

Our new protocol significantly improved survival to discharge for newborns with CDH. Institution of such a protocol is valuable in improving outcomes for patients with CDH and merits consideration for widespread adoption.     

Four-triangular-skin-flap approach to umbilical diseases and laparoscopic umbilical port

Background/purpose

Surgery of umbilical pathology requires restoration of a normal umbilical appearance. Also, the umbilicus is used increasingly as the entry site during laparoscopic surgery. However, conventional approaches leave obvious scars. A simple alternative approach that creates a natural-looking umbilicus is described.

Methods

The umbilicus is opened by creating 4 isosceles triangular skin flaps. Closure is by suture of the flap apex only, creating scaring that resembles a natural umbilicus.

Results

Between November 1996 and March 2003, this technique was used in 204 children with umbilical hernia, 2 children with a small omphalocele, 1 child with a patent omphalomesenteric duct, 2 children with a urachal abscess, and 7 children with an umbilical granuloma. Five children underwent initial trocar insertion during laparoscopic surgery via this approach. All procedures were performed uneventfully. Transient erythema of one flap occurred in 64 patients (29.2%). Infection developed in 10 patients (5.0%) but was treated with oral antibiotics. The postoperative umbilical appearance was satisfactory in all but 5 patients.

Conclusions

The 4-triangular-skin-flap approach is useful for umbilical diseases and laparoscopic umbilical port access.     

Effective use of laparoscopy for long-term peritoneal dialysis access

Background

Laparoscopy is an underused modality for peritoneal dialysis access procedures. The strengths of laparoscopy are that it can both prevent and resolve the common mechanical problems that adversely effect dialysis catheter outcomes.

Method

Laparoscopically enabled catheter implantation and rescue procedures included rectus sheath catheter tunneling, omentopexy, adhesiolysis, resection of epiploic appendices, colopexy, salpingectomy, and appendectomy. Using these techniques, the outcomes of 428 laparoscopically implanted catheters were studied.

Results

During a mean follow-up of 21.6 months, mechanical obstruction complicated 3.7% of implantation procedures. The incidence of pericatheter leak was 2.6%. There were no occurrences of pericatheter hernia or subcutaneous cuff extrusion. Laparoscopic salvage procedures limited losses from mechanical catheter problems to .9%. Cumulative revision-free and assisted catheter survival probabilities for loss from mechanical complications at 5 years were .96 and .99, respectively.

Comments

Because it is enabled by techniques not available to other catheter-placement methods, laparoscopy produces superior outcomes.     

Is the use of laparoscopy to determine presence of contralateral patent processus vaginalis justified in children greater than 2 years of age?

Purpose

Contralateral inguinal hernia exploration in cases of unilateral inguinal hernia remains a controversial topic. The authors have been using the in-line laparoscopic technique of contralateral evaluation for unilateral inguinal hernia in children less than 2 years of age. Because of the case of the procedure and lack of morbidity, we decided to expand the use of this procedure up to age 8 years in January 2000. The purpose of this study is to evaluate if the incidence of contralateral hernia in children greater than 2 years justifies the procedure.

Methods

This is a retrospective study of all children who underwent contralateral exploration for unilateral inguinal exploration over a 20-month period. The procedure was offered routinely to all patients up to age 8 years. During the repair, the contralateral inguinal ring was examined laparoscopically using the in-line technique for the presence of a contralateral hernia. The incidence of contralateral hernia was determined, and the results were stratified by age. Patients who underwent unilateral inguinal hernia repair without laparoscopic contralateral exploration or bilateral inguinal hernia repair without laparoscopic contralateral explorations were excluded from the study.

Results

A total of 284 laparoscopic explorations were performed. Positive explorations were seen in 65 of 171 (38%) of children less than 2 years of age, 19 of 101 (20%) of children 2 to 8 years of age, and 1 of 12 children greater than 8 years of age (8%). There were no operative complications.

Conclusions

Laparoscopic contralateral exploration is safe and effective. Because of the low morbidity, the risk to benefit ratio warrants its use in children up to 8 years of age. This sample size is too small to make any meaningful statement in children older than 8 years.