微创开放切口离断性肾盂成形术

目的 总结微创开放切口离断性肾盂成形术治疗儿童肾盂输尿管连接部梗阻的经验.方法 2008年2月至2008年12月连续开展了57例微创开放切口离断性肾盂成形术.取腰肋部开放切口,长度1.5～2.0 cm(平均1.7 cm).最近14例小于3岁的患儿切口均为1.5 cm.手术年龄18 d～7.6岁(平均1.6岁).所有手术均经腹膜后间隙完成.手术时间55～75 min(平均63 rain).结果 所有患儿均在术后5 d内出院.术后随访,所有患儿均有肾形态和/或功能的改善.结论 微创开放切口离断性肾盂成形术治疗儿童肾盂输尿管连接部梗阻安全、有效,且容易开展.     

后腹腔镜在小儿肾及半肾切除术中的应用

目的：探讨腹腔镜在小儿肾及半肾切除术中的应用。方法：应用后腹腔镜手术治疗4例女性肾畸形患儿，年龄4－7岁，其中2例行重复肾及输尿管切除术，2例行发育不良小肾切除术。结果：4例手术均成功。平均手术时间3．2h。失血量约50－60ml，1例术后7d拆线出院，1例因右下腹切口感染，术后13d出院，2例术后4d出院。随访1－15个月，结果满意，切口小，外观好。结论：腹腔镜肾切除术具有微创、术后恢复快的优点，可以代替开放肾切除术，对该微创技术的进一步要求是提高功效及减少手术时间。     

电视辅助胸腔镜手术在小儿支气管源性囊肿外科治疗上的应用

目的 探讨电视辅助胸腔镜手术(VATS)在小儿支气管源性肺囊肿治疗中的作用.方法 回顾性分析笔者两院1993年6月至2007年6月经VATS切除并病理证实的41例小儿支气管源性肺囊肿患儿的临床资料.麻醉方式全部采取单腔管插管吸入全麻,手术采取胸腔镜进行,必要辅助小切口协助将病灶以及肺组织取出;气管残端采取间断缝合或者Endo-cutter钉合,统计分析手术时间、切口大小、术后引流时间及总量、术后住院时间.结果 患儿均经VATS手术治疗.年龄从8d～12岁,平均为4.81岁.2例纵隔型支气管囊肿行VATS纵隔囊肿切开+翻转术,14例肺内型行肺楔形切除术,25例肺内单发性囊肿或局限于肺段的多发性肺囊肿行肺叶切除术.全组手术时间为45～265min,平均71.5 min;切口为1.5～7.0 cm.平均4.4 cm;术中失血5～400ml,平均41.5 ml;术后均放置胸管1～2条,引流1～7 d,平均2.0 d;总引流量1 5～770 ml,平均207.2 mt;平均术后住院时间为1～25 d,平均7.0 d.结论 VATS的d,JL支气管源性肺囊肿治疗是可行、安全、彻底、微创的,可成为标准术式.     

微创开放切口肾切除术治疗小儿多房性肾囊性变的初步经验

多房性肾囊性变(multicystic dysplastic kidney,MCDK)是小儿常见的先天性肾发育畸形,我们自2008年5月至2009年10月采用微创开放切口肾切除术(mininlally invasive open nephrectomy)治疗小儿多房性肾囊性变5例,现报告如下.     

经腋乳入路腔镜下小儿甲状腺腺瘤切除术的应用研究

目的：探讨小儿甲状腺腺瘤内镜手术治疗的可行性与疗效。方法回顾性分析2003-2013年我中心开展的35例经腋乳入路腔镜手术治疗的小儿甲状腺腺瘤临床资料,对内镜治疗小儿甲状腺腺瘤的手术适应证、禁忌证、手术方法、疗效进行讨论。结果35例患儿中,男9例,女26例,年龄6～14岁,平均10.2岁;其中单侧28例,双侧7例;腺瘤直径为0.8～5 cm,平均3.2 cm。均表现为颈部无痛性包块。所有病例均在内镜下成功完成甲状腺腺瘤切除术,无一例中转开放手术,无一例发生术后出血。1例术后出现可逆性声音嘶哑（术后4d内恢复）,无永久性口周、四肢麻木和（或）手足痉挛、抽搐等。手术时间40～70 min,平均55 min;术中出血5～20 mL,平均10 mL;术后疼痛轻,均未使用术后镇痛;术后住院时间3～6 d,平均4．2 d。所有病例术后随访时间1～10年,无复发。切口瘢痕隐蔽,美容效果好。结论小儿甲状腺腺瘤的内镜手术治疗安全可靠,并发症少,相比传统手术,术后疼痛轻,恢复快,美容效果好。     

腹腔镜下膈肌折叠术治疗小儿先天性右侧膈膨升的疗效分析

目的探讨腹腔镜下膈肌折叠术治疗小儿先天性右侧膈膨升的可行性。方法选取2002年1月至2013年12月于本院诊断为右侧膈膨升,并行膈肌折叠术的患儿17例,其中7例采取开放性手术(均经腹完成手术),为开放手术组;10例采取腔镜手术,为腹腔镜手术组。结果17例手术均获成功,术后胸片(DR)复查膈肌反常运动消失,Kienbock征均为阴性。治愈16例中,经开放手术治愈6例,腹腔镜手术治愈10例。开放手术组平均手术时间145 min,术后住院时间(11.19±2.29)d,术后1例并发切口感染,经换药至切口愈合出院;腹腔镜手术组平均手术时间130 min,术后住院时间(8.86±2.31)d,无一例发生并发症。随访半年至2年,无一例复发。结论腹腔镜治疗膈膨升相对安全,创口小,恢复快,效果满意,且可实现对腹腔其他脏器的探查,是值得推广的微创手术方式。     

腹腔镜与小斜切口手术治疗肥厚性幽门狭窄

目的比较腹腔镜下与小斜切口手术治疗肥厚性幽门狭窄(hypertrophic pyloric stenosis,HPS)的疗效。方法 2006年1月至2015年1月于本院确诊并住院手术治疗的肥厚性幽门狭窄患儿133例,其中54例腹部小斜切口入路(小斜切口组/开放组),79例腹腔镜入路(腹腔镜组),比较两组手术时间、住院时间、术后并发症的发生率。结果 133例手术成功,并获得3~6个月随访,术后体重增长与同龄儿无差异,开放组手术时间平均41.76 min(41.76±9.82)min,术后住院天数平均4.44 d(4.44±1.25)d,术后1例并发切口裂开,再次手术缝合,术后恢复良好。腹腔镜组手术时间平均23.54min(23.54±5.22)min,术后住院天数2.38 d(2.38±1.17)d,并发症2例,均为皮下气肿,经住院观察3d内均吸收,两组手术时间(t=25.542,P0.01)及术后住院天数(￡=9.711,P0.01)经t检验提示差异有统计学意义,术后并发症发生率无显著差异(χ~2=0.811,P=0.569)。结论在具有熟练操作腹腔镜经验的前提下,腹腔镜法治疗HPS创口小、住院时间短、效果满意且安全,同时可实现对腹腔其他脏器的探查,是值得推崇的微创技术。     

后腹腔镜手术治疗肾上腺肿瘤的疗效及安全性

目的评价后腹腔镜手术治疗小儿肾上腺肿瘤的疗效及安全性。方法2003年6月～2006年12月应用腹腔镜经腹膜后途径行小儿肾上腺肿瘤摘除术5例,肾上腺切除术3例,对其临床资料进行总结分析。结果8例均获成功,手术时间为78～255min,平均148min,患儿术中、术后均未输血。术后恢复顺利,术后住院时间3～8d,平均4.8d。术后病理诊断：原发性醛固酮症腺瘤3例,肾上腺无功能腺瘤、嗜铬细胞瘤各2例,皮质醇腺瘤1例。结论后腹腔镜手术治疗小儿肾上腺肿瘤安全、有效,具有创伤小、痛苦轻、肠功能恢复快、住院时间短等优点,有望成为小儿肾上腺疾病的首选或重要手术方法。     

小儿后腹腔镜Anderson-Hynes肾盂成形术

目的 探讨小儿后腹腔镜Anderson-Hynes术治疗小儿肾盂输尿管连接部梗阻(UPJO)的应用价值.方法 对36例确诊为UPJO的患儿行后腹腔Anderson-Hynes手术.结果 35例手术成功,1例中转开放.手术时间65～130 min,平均95 min;术中出血5～20 ml,平均10 ml,术后住院时间7～15 d,平均8 d.2例出现尿漏,分别于术后第9天、第12天消失.平均随访时间6个月(1～24个月),B超复查手术侧肾积水减轻,IVU检查UPJ吻合口无狭窄,肾盂输尿管排尿功能好,症状基本消失.结论 后腹腔镜Anderson-Hynes术是治疗小儿UPJO安全、有效及微创的方法,值得临床推广应用.     

改良切口经胸微创封堵术治疗膜周室间隔缺损

目的 探讨改良切口经胸微创室间隔缺损封堵术的可行性和安全性.方法 2011年5月至2015年5月,289例单纯膜周室间隔缺损患儿在我中心接受改良切口经胸室间隔缺损封堵术.该操作采用长约1～2 cm的微创切口,无需损伤胸骨,完全食道超声引导下完成室间隔缺损封堵.术后1、3、6个月定期随访.结果 289例患儿中,277例(95.8％)成功完成微创封堵;12例封堵失败,改行常规外科修补术.277例患儿均经改良微创切口入路,切口长度1～2cm,平均(1.53±0.46)cm.均未损伤胸骨,亦未放置引流管.术后早期均未出现心包积液.膜周室缺直径平均(5.30±2.88)mm.封堵器大小4～12mm,平均(6.70±3.10)mm,包括对称封堵器191例,偏心封堵器86例.12例(4.3％)患儿术中存在少量残余分流.9例(3.2％)术后发生不完全性右束支传导阻滞;1例患儿于术后4d出现完全性房室传导阻滞,经激素治疗5d后好转.所有患儿平均住院时间(3.2±0.8)d,随访期间,没有主动脉瓣反流、恶性心律失常、封堵器脱落等严重并发症发生.至随访结束仍有4例(1.4％)存在少量残余分流.结论 改良切口经胸壁微创封堵术,不损伤胸骨,可以有效治疗膜周室间隔缺损.但其长期疗效尚需进一步随访研究.     

Trends and outcomes of total and partial nephrectomy in children: A statewide analysis

ObjectiveTo report trends in surgical approach and associations with outcomes in children undergoing extirpative renal surgery in the state of Maryland over a 12-year period.MethodsThe Maryland Health Services Cost Review Commission (HSCRC) database was queried to identify children undergoing total or partial nephrectomy between 2000 and 2011. Demographic, clinical, hospital, and charge data were compared between children undergoing open and minimally invasive renal surgery. Multivariable logistic regression analysis was performed to identify independent predictors of prolonged length of hospital stay and 30-day readmission. Multivariable linear regression was performed to identify independent predictors of increased hospital charges.ResultsOf the 346 children undergoing extirpative renal surgery, 289 (83.5%) underwent total nephrectomy and 48 (13.9%) underwent minimally invasive surgery. Utilization of minimally invasive surgery for congenital urinary anomalies has steadily increased from 15% to 35% over the past decade. Children undergoing minimally invasive total nephrectomy were healthier, had shorter hospital stay, and were more likely to have surgery at a high-volume institution. No such differences were noted in patients undergoing open and minimally invasive partial nephrectomy. On multivariable regression analyses, high patient complexity was the main predictor of increased length of stay (OR 16.02, 95% CI 7.06–36.31), 30-day readmission (OR 3.04, 95% CI 1.38–6.70), and total hospital charge (p < 0.001).ConclusionIn Maryland hospitals, most extirpative renal surgeries in children are total nephrectomies performed using an open technique by high-volume surgeons. Although the overall proportion of minimally invasive surgeries has not increased over time, the utilization of MIS in congenital anomaly cases has. Patient complexity and not operative approach dictates postoperative morbidity and hospital charges.     

Pediatric open partial nephrectomy: analysis of contemporary outcomes with a supracostal-12 approach

ObjectiveReports in the literature increasingly have demonstrated a shorter length of stay (LOS) with the laparoscopic approach to partial nephrectomy compared to historic open partial nephrectomy. We present data from the largest open series to date, to provide a more contemporary perspective.MethodsA retrospective review was performed on all pediatric patients who underwent upper pole partial nephrectomy from 1999 to 2011. Using univariate and multivariate linear regression, the associations between multiple explanatory covariates and outcomes such as pain and length of stay were analyzed.ResultsTwenty-five surgeries were performed via a supracostal-12 approach. The mean incision length and operative time was 3.7 cm and 137 min, respectively. The average pain score was 1.7/10 and 72% of patients did not require morphine. The mean LOS was 36 h and all patients with postoperative imaging had normal blood flow. Multivariate analysis demonstrated that a later date of surgery was the only covariate significantly associated with decreased operative time and LOS.ConclusionOpen partial nephrectomy can be performed in a minimally invasive manner via a small supracostal-12 incision with minimal pain and LOS. Surgeon experience is associated with decreased operative time and LOS. These contemporary open results should be considered when comparisons are made with laparoscopic surgery.     

Single trocar retroperitoneoscopic nephrectomy for unilateral multicystic dysplastic kidney in children

The author presents the first report in performing single trocar nephrectomy for five patients with multicystic dysplastic kidney (MCDK). The mean operative time was 66 min and mean postoperative hospital stay was 36 h. There were no perioperative complications. The one-trocar nephrectomy is a feasible and safe procedure for patients with MCDK.     

Short-stay open appendectomy.

PURPOSE: This report describes a minimally invasive short-stay open appendectomy technique which improves the length of stay in comparison to traditional open appendectomy and improves the cost of hospitalization in comparison to laparoscopic appendectomy. STUDY DESIGN: This retrospective analysis reviewed 100 consecutive children treated with traditional open appendectomy and 100 consecutive children treated with a minimally invasive short-stay open technique with local infiltration of bupivacaine hydrochloride. Data collected for each child included age, sex, diagnosis, operative time, return to activity time, complications, length of stay, and hospital charge. RESULTS: The mean length of stay (LOS) was reduced from 2.7 days for traditional open appendectomy patients to 1.0 day for minimally invasive short-stay open appendectomy. The mean hospital charge (HC) for this short-stay open appendectomy, US dollars 6795, was significantly less than the mean HC for traditional open appendectomy (US dollars 8162), and for laparoscopic appendectomy (US dollars 7668). CONCLUSION: This short-stay open appendectomy technique offers an efficacious alternative to both traditional open appendectomy and laparoscopic appendectomy.     

Does the multicystic dysplastic kidney really involute? The role of the retroperitoneoscopic approach

ObjectiveTo assess the role of video-assisted retroperitoneoscopy in the follow up of multicystic dysplastic kidney (MCDK) that has involuted – disappeared? – on serial renal ultrasonography (US).Patients and methodsProspectively, we performed a retroperitoneoscopy in 14 patients, nine girls and five boys, with unilateral MCDK that had involuted on serial US. MCDK was diagnosed in utero (80%) and confirmed postnatally by US and Tc99m dimercaptosuccinic acid radionuclide scan. Follow up US examinations were performed at 1 month, 5 months and 12 months in the first year of life and every 6 months from then on. US showed complete involution at a mean age of 13 months (range 5–18 months). Retroperitoneoscopy was then indicated, at a mean age of 23 months (range 8–24 months), to confirm the disappearance of the kidney dysplastic remnant.ResultsRetroperitoneoscopy detected persistence of anomalous kidney tissue in 100% of cases. The mean length of the renal remnant was 2 cm (range 1–3.5 cm). Two cases showed a pelvic ectopic location that was not detected by US before involution. The remnant was removed during the same procedure. Anatomo-pathological findings were found to be compatible with dysplastic renal tissue. There were no intra- or postoperative complications. All patients had a mean length of stay of less than 24 h.ConclusionsComplete resolution on US does not mean disappearance of MCDK, as US does not detect renal dysplastic remnants after cyst involution has occurred. The retroperitoneoscopic approach to the renal and pelvic area is a minimally invasive, safe and effective procedure to diagnose and treat the renal dysplastic remnant in US-involuted MCDK.     

Laparoscopically assisted transhiatal esophagectomy with esophagogastroplasty for post-corrosive esophageal stricture treatment in children

A tight post-corrosive esophageal stricture in a child poses significant surgical challenges. Many studies have described minimally invasive esophagectomy in adults, but very few reports have described this technique in children. Minimally invasive esophagectomy represents a new alternative to conventional open esophagectomy. This retrospective study evaluated the safety and efficacy of laparoscopically assisted transhiatal esophagectomy and gastric transposition for post-corrosive esophageal stricture treatment. Twenty-seven children with post-corrosive esophageal stricture were subjected to this technique. Their ages ranged from 3 to 13.5 years (mean 5.6 years). Fourteen were females and thirteen were males. None of the procedures needed to be converted to an open approach, and there were neither intra-operative complications nor increased blood loss. Left-sided pneumothorax occurred in one case only (3.7%). The mean operating time was 160 min (range 120–180). Three patients were admitted postoperatively to intensive care unit for a period of 48 h for assisted ventilation. Mean hospital stay was 4 days (range 3–7 days). Anastomotic leakage occurred in three patients (11.1%), while anastomotic stricture occurred in four patients (14.8%). About 93.5% of our cases have achieved excellent results. Post-operative nutritional status was satisfactory and accepted. Laparoscopically assisted transhiatal esophagectomy and gastric transposition for post-corrosive esophageal stricture treatment in children is safe, visible, effective, and an accepted operative technique. The cosmetic result is excellent.     

Laparoscopic assisted dismembered pyeloplasty in children: intermediate results

To study the results of an innovative minimally invasive technique of performing dismembered pyeloplasty in children. Using 5 mm camera and 3 mm working ports, the ureteropelvic junction (UPJ) is mobilized by a transperitoneal laparoscopic technique. The UPJ is brought out through a tiny flank incision and a standard dismembered pyeloplasty is performed over a double J stent. Between October 2003 and January 2005, 13 children underwent laparoscopic assisted dismembered pyeloplasty. Indications, operative duration, hospital stay, preoperative and postoperative isotope renogram parameters were analyzed. The children were in the age range of 3 months to 6 years—three were right sided and ten were left sided. Only three were symptomatic while the remaining ten were detected to have UPJ obstruction during evaluation for antenatally detected hydronephrosis. Mean operative duration was 104.2 min (range 80–150 min) with no significant difference in the two patients with crossing vessels. Incision was smaller than 2 cms in all and the average postoperative hospital stay was 3.2 days (range 2–5 days). Follow-up ranging from 28 to 44 months showed reduction in hydronephrosis and improvement in renal function of all the operated units. Isotope renogram in only one patient showed equivocal slopes and prolonged half clearance times though no further surgical intervention was required. This technique has results comparable to that of open pyeloplasty and hence, maybe considered a good option for surgeons making the transition to laparoscopic pyeloplasty.     

Multicystic dysplastic kidney detected by prenatal ultrasonography: natural history and conservative management

Conservative management of multicystic dysplastic kidney (MCDK) without nephrectomy has recently been advocated. The purpose of this study was to determine the clinical course of conservatively managed unilateral MCDK detected prenatally. Between 1991 and 2001, ten children (three boys and seven girls) with unilateral MCDK detected by prenatal ultrasonography (US) were prospectively followed at our institution. At birth, US confirmed the prenatal findings in all cases. All patients underwent voiding cystourethrography, intravenous pyelography, and radionuclide scans. Postnatal follow-up US examinations were performed every 3 months until patients were 5 years old and annually from then forward. The mean age at diagnosis during the prenatal period was 29 weeks of gestation (range 21-38 weeks). Median follow-up time was 42 months (range 17-125 months). Follow-up US was performed in eight children; three (38%) showed partial resolution, three (38%) complete resolution, and two (24%) no change in cyst size. The mean age at complete resolution of the lesion was 23 months (range 9-33 months). No children developed hypertension or tumors, and all maintained normal growth. In the present study, the natural history of MCDK was benign, and serial US monitoring showed that the affected kidneys frequently showed resolution with time. The results of this study support the conclusion that a nonsurgical approach for patients with MCDK is advisable.