Single cannula technique and robotic telescopic assistance in infants and children who require laparoscopic Nissen fundoplication

Background/Purpose: Laparoscopic Nissen fundoplication (LNF) is being utilized more extensively in the management of symptomatic gastroesophageal reflux disease in infants and children. The traditional approach utilizes 5 3- to 5-mm cannulas for telescope and instrument access to the peritoneal cavity. The purpose of this study is to report the technique and document the results using a single 5-mm umbilical cannula for LNF, stab incisions for placement of the instruments, and robotic telescope assistance. Methods: From November 1999 through March 2002, 154 patients underwent LNF by the senior author for pathologic gastroesophageal reflux disease. All operations were performed with a single 5-mm umbilical cannula through which a 4- or 5-mm telescope was placed for operative visualization. Four stab incisions were made through the upper/lateral abdominal wall under direct visualization avoiding the epigastric vessels. Through these stab incisions, instruments were inserted into the peritoneal cavity. The maximum insufflation pressure was 15 mm Hg in all cases. The ability to perform the procedure in the absence of additional operative cannula placement, complications during instrument insertion, the ability to maintain adequate pneumoperitoneum, the patient's age, weight, operating time, and the addition of a gastrostomy were recorded. Results: All but one of the 154 LNFs were completed successfully using this technique. The mean age at operation and mean operating time was 23.9 months (range, 3 weeks to 180 months) and 91 minutes (31 to 160 minutes), respectively. Patients weight ranged from 2.4 to 57 kg (mean, 10.4 kg). Gastrostomies were placed in 52 cases. There were no complications associated with the stab incisions or insertion of the operative instruments through the abdominal wall. Pneumoperitoneum was maintained adequately in all cases. Conclusions: LNF can be performed safely and effectively with a single umbilical cannula. We recommend its use for pediatric patients who require LNF. J Pediatr Surg 38:111-115.     

Uptime as a measure of recovery in children postappendectomy

Purpose: The aim of this study was to objectively measure recovery time after open and laparoscopic appendectomy using an activity monitor (PAL 1).Methods: The PAL 1 records the amount of time that the subject is upright (uptime). Children wore the PAL 1 for 10 days continuously, beginning within the first 48 hours postoperatively.Results: Uptime data were collected for 5 or more days for 42 children (open, n = 16; laparoscopic, n = 26). All children had low levels of uptime in the initial postoperative period. There was weak evidence of a quicker recovery rate for children in the laparoscopic group (P = .09). The difference in mean uptime between groups was of statistical significance by day 7 postoperatively with children in the laparoscopic group having a higher mean uptime than those in the open group (difference of 0.7 hours; 95% confidence intervals 0.0 to 1.4 hours in a 24-hour period).Conclusions: The results of this study show that recovery postappendectomy can be quantified by the measurement of uptime and that children undergoing a laparoscopic procedure may recover marginally more quickly than those undergoing an open procedure.     

A simple technique of laparoscopic full-thickness anterior abdominal wall repair of retrosternal (Morgagni) hernias

Background/Purpose: Previous reports of laparoscopic repair of Morgagni hernias in children have involved relatively complex laparoscopic techniques. This report describes a simpler method of repair that we have applied to 4 children. Methods: Four children with retrosternal (Morgagni) hernias underwent primary laparoscopic repair by placement of interrupted synthetic nonabsorbable sutures through the full-thickness of the anterior abdominal wall, incorporating the posterior rim of the defect and returning back out through the anterior abdominal wall, with the sutures tied in the subcutaneous tissue. Results: The children, ranging in age from 11 to 36 months, underwent laparoscopic repair of their Morgagni hernias and had an uneventful postoperative recovery, apart from a port site hernia in one. Conclusions: This technique for primary laparoscopic repair of Morgagni hernia is easy to perform, well tolerated by the patient, and gives excellent cosmetic results. Laparoscopic closure of the defect by suturing the posterior rim of the hernia to the full thickness of the anterior abdominal wall would appear to provide a safe and effective means of repairing this type of hernia. J Pediatr Surg 38:768-770. [copy ] 2003 Elsevier Inc. All rights reserved.     

Guide wire-assisted urethral dilatation for urethral strictures in pediatric urology

Purpose: The aim of this study was to report the results of 32 cases of dilatation of urethral stricture using a guide wire and sheath dilator technique supplemented by clean intermittent catheterization if further stabilization of the urethral stricture was felt warranted.Methods: The procedure involves insertion of a straight flexi-tip lubricated guide wire through the urethral stricture under cystoscopic guidance followed by insertion of a series of sheath dilators. Dilatation was followed by insertion of a Foley catheter, which was left in situ for 1 to 3 days. Patients underwent repeat cystoscopy to evaluate the urethra for recurrent stricture and those with a recalcitrant stricture were commenced on clean intermittent catheterization (CIC) to stabilize the narrowing.Results: Thirty-two patients were included. They have been followed up for up to 2 years after their last cystoscopy (mean, 16 months). Thirteen of 32 patients had more than 4 dilatations under anesthesia. Twelve patients had undergone CIC postoperatively. Complications included a urinary tract infection in 3 boys and bladder spasms in one. No false passage or sepsis occurred with this approach.Conclusions: Guide wire-assisted urethral dilatation helps avoid risks associated with blind dilatation techniques and appears to be a safe and simple alternative for management of urethral strictures in pediatric urology.     

Surgical management of open versus laparoscopic adrenalectomy: outcome analysis

Purpose: The authors sought to compare the outcome of children undergoing open versus laparoscopic adrenalectomy for an adrenal tumor. Methods: Medical records of children that underwent an adrenalectomy from 1990 through 1999 were reviewed. Sixty-four adrenalectomies were performed: 27 pheochromocytomas, 36 neuroblastomas, and 1 virilizing tumor. Sixty adrenalectomies were performed open and 4 laparoscopically. The patient's age, surgical length of stay, operative charge, hospital cost, operating time, blood loss, and outcome were examined. Results: Mean age for an open procedure was 8.9 [plusmn] 0.9 years and 14 [plusmn] 1.1 for laparoscopic (P = .019). Surgical length of stay for open was 5.4 [plusmn] .38 days and 2.7 [plusmn] .62 days for laparoscopic (P = .006). Patient operative charges were $12,941 [plusmn] 676 for laparoscopic and $4,714 [plusmn] 411 for open (P [lt ] .001). When total estimated patient cost, including hospital stay, were compared between groups there was no significant difference. Similar mean operating times and blood loss were noted. There were no deaths or complications in children with a pheochromocytoma. The mortality rate in children with neuroblastoma was 28%. Conclusions: Adrenalectomy for benign tumors can be performed safely. In selected children a laparoscopic procedure can be expected to decrease the surgical length of stay without increasing operating time or complications. J Pediatr Surg 37:1027-1029.     

Economic implications of current surgical management of gastroesophageal reflux disease

Background/Purpose: Surgical management of gastroesophageal reflux disease in children has evolved with the development of laparoscopy. Because concerns persist regarding increased costs associated with this technique, the authors studied the economic parameters of antireflux surgery at their institution. Methods: Seventy-eight patients undergoing either laparoscopic or open fundoplication were studied retrospectively between June 1998 and June 2000 comparing average operating room costs, total inpatient costs, and length of stay. Univariate comparisons were performed using Student's t test, and multivariate analysis was performed using multiple linear regression. Results: Univariate analysis showed that patients receiving the laparoscopic procedure had significantly shorter inpatient stays (2.4 v. 3.96 days; P = .004) than those receiving open procedures. Average operating room costs were similar (laparoscopic, $2,611; open, $2,162; P = .237), but total costs for the laparoscopic procedure were lower ($4,484 v $5,129; P = .006). Multivariate analysis results suggested that in addition to procedure type, patients who required an intensive care unit admission incurred $6,595 in additional total costs (P [lt ] .0001) and 4.8 additional hospital days (P [lt ] .0001). After controlling for other variables, the laparoscopic procedure did not significantly reduce total hospital costs ($447; P = .192) but was associated with a significant decrease in length of stay of 1.3 days (P [lt ] .0001). Conclusion: These results suggest that laparoscopic procedures are comparable with open operations in terms of operative costs and that other factors are important determinants of the costs associated with antireflux surgery in children.     

Is laparoscopic subtotal colectomy better than open subtotal colectomy in children?

Purpose: The role of laparoscopic colectomy is not defined clearly. The aim of this study was to compare clinical outcomes of laparoscopic versus open subtotal colectomy in children with inflammatory bowel disease. Methods: Eight consecutive patients undergoing laparoscopic subtotal colectomy were compared with 10 consecutive patients undergoing open subtotal colectomy. All patients were refractory to medical management on immunosuppressive regimens. Operating time, length of postoperative stay and intravenous narcotic use, time to return of intestinal function, and perioperative complications were compared between the groups. Results: Operating times were significantly longer in the laparoscopic group (mean laparoscopic, 4 hours 40 minutes v mean open 2 hours 25 minutes; P [lt ] .01). There was no difference between the 2 groups in length of postoperative intravenous narcotics or hospital stay. Ileostomy output occurred earlier (mean laparoscopic, 2.5 days v mean open 3.8 days; P = .01), and there was a trend toward earlier oral intake in the laparoscopic group. A total of 6 complications occurred in 4 patients in the laparoscopic group compared with 5 complications in 5 patients in the open group. Conclusions: Perioperative clinical outcomes, including complication rates, are similar with laparoscopic and open subtotal colectomy. Laparoscopic subtotal colectomy can be performed safely in children with improved cosmesis.     

Ultrasonic shear coagulation of main hilar vessels: A 4-year experience of 23 pediatric laparoscopic splenectomies without staples

Background: Ultrasonic shears (LCS) are used increasingly for laparoscopic splenectomy. So far however, all investigators use vascular staplers or clips for section of the main splenic artery and vein. Methods: After several trials the authors started to use the ultrasonic triple welding technique in open surgery to occlude major vessels of 5 to 8 mm by 10-mm LCS. In June 1997 the authors introduced triple welding into laparoscopic splenectomy to mobilize the complete spleen by LCS. Results: There was no hemorrhage in 23 laparoscopic splenectomies performed exclusively by LCS and no complications except 1 port site hernia. Conclusions: Laparoscopic splenectomy entirely by reusable LCS without clips and stapler is a safe, simple, and inexpensive technique. Moreover, the policy of [ldquo ]leaving nothing back[rdquo ] is an attractive strategy in endoscopic pediatric surgery.     

When can I be proficient in laparoscopic surgery? A systematic review of the evidence

Purpose: The aim of this study was to quantify the learning curve in laparoscopic surgery. Methods: A systematic review of the evidence using a defined search strategy (PubMed, Medline, OVID, Embase, ERIC, Cochrane databases) was performed. Studies without statistical evaluation of the learning curve and opinion articles were excluded. The authors analysed 7 common laparoscopic procedures: cholecystectomy, fundoplication, colectomy, herniorrhaphy, splenectomy, appendicectomy, and pyloromyotomy. The [ldquo ]initial[rdquo ] and [ldquo ]late[rdquo ] stages of experience were compared with regards to the following outcome measures: operating time, conversion rate, complication rate, and length of stay in hospital. Results: A total of 3,641 articles were reviewed, of which, 37 (25,777 patients) fulfilled the entry criteria (5 in children). In all articles, the definition of proficiency was subjective, and the number of operations required to reach it was highly variable. There were improvements in all 4 outcome measures for cholecystectomy, fundoplication, colectomy, herniorrhaphy, and splenectomy between the [ldquo ]initial[rdquo ] and [ldquo ]late[rdquo ] experience. No data were available for the learning curves in appendicectomy or pyloromyotomy. Conclusions: The number of procedures required to reach proficiency in laparoscopic surgery has not been defined clearly. These findings are important for training, ethical and medico-legal issues. J Pediatr Surg 38:720-724. [copy ] 2003 Elsevier Inc. All rights reserved.     

Evolution of a percutaneous fetoscopic access system for single-port tracheal occlusion

Background/Purpose: Prenatal tracheal occlusion currently is being assessed as a treatment modality for congenital diaphragmatic hernia (CDH). The development of a totally percutaneous fetoscopic access system would help avoid the need for maternal laparotomy and reduce the morbidity rate of fetal surgical procedures for the mother. Laparoscopic radial expansion sheaths and Seldinger technique[ndash ]based vascular catheters both have been advocated as means of achieving amniotic cavity access. The authors have investigated these 2 systems in an attempt to develop a reliable method for achieving safe percutaneous fetoscopic access and present the first successful attempt to deploy an intratracheal balloon using an entirely percutaneous approach through a single port in an ovine model. Methods: A number of prototype systems were evaluated sequentially over a 3-year period in an ovine model: (1) the radially expanding InnerDyne step port system, (2) a new rigid cannula with a bulbous/sharp end preloaded onto the radially expanding InnerDyne port, (3) a conical removable addition to the rigid cannula in 2, (4) a modified bulbous/sharp ended cannula incorporating a circumferential protective insert, (5) a rigid split sheath with the radially expanding port placed through the lumen of the split sheath, (6) a flexible introducer and dilator with the split sheath (used in the Seldinger placement of central lines), and (7) a 2-needle approach using a superelastic shape-memory alloy Nickel-Titanium wire with the flexible dilator and sheath, incorporating a side perfusion port. For balloon tracheal occlusion, live anaesthetized time-mated pregnant ewes were used at 110 days' gestation. Tracheobronchoscopy was achieved using a 3-mm 0[deg ] telescope, and the cutaneotracheal tract was secured by a 3.3-mm sheath incorporating a side-perfusion port. The rigid telescope was replaced by a flexible choledochoscope preloaded with a silicone balloon. The balloon was deployed 2 cm above the carina proximal to the right upper lobe bronchus. Results: The many problems encountered in the evolution of the preferred system related mainly to separation and tenting of the chorioamniotic membranes in the ovine uterus and inconsistent access to the fetal parts of interest. Each resulted in significant modifications to our approach. Furthermore, the use of rigid access devices commonly caused fetal injury. Successful access to the intrauterine cavity and cannulation of the trachea was achieved consistently with minimal trauma, irrespective of fetal position by method 7. Multiple port placement allowed visualization of the entry of all components of the system confirming minimal chorioamniotic membrane separation and tenting. Single port tracheal occlusion was undertaken first on 6 cadavers before being performed successfully on 3 live anaesthetized ewes. Fetoscopic access and cannulation of the trachea was achieved consistently in all live animals irrespective of fetal position. Conclusions: This modified Seldinger technique using the unique properties of the memory-shaped alloy wire for initial uterine access offers a safe method for the percutaneous placement of fetoscopic ports in the ovine model for prenatal intervention. Successful placement of a tracheal balloon entirely through a single percutaneously placed port represents a further advance in prenatal therapy for CDH. J Pediatr Surg 38:45-50.     

Laparoscopic Nissen fundoplication for reactive airway disease

Background: Surgical management for gastroesophageal reflux disease (GERD)-induced reactive airway disease in children has been shown to be superior to medical therapy. Laparoscopic Nissen fundoplication is a safe and effective procedure in children. Methods: The authors performed a retrospective review of 24 patients who underwent a laparoscopic Nissen fundoplication for documented GERD and reactive airway disease. Results: Persistent cough was the primary symptom in 22 of 24 patients, and all but one had lipid laden macrophages on bronchoscopy. The mean length of hospital stay was 2.7 days. There were no major postoperative complications. Eighteen of 24 patients are symptom free and off all medications an average of 17 months postoperatively. The average medication burden of the 6 remaining patients was reduced from 6.8 to 2.3 medications. Conclusions: Children with reactive airway disease who do not respond to medical therapy should undergo a workup for GERD. These preliminary results suggest that laparoscopic Nissen fundoplication is a potentially effective treatment for pulmonary manifestations of GERD. J Pediatr Surg 37:1021-1023.     

Early perfluorodecalin lung distension in infants with congenital diaphragmatic hernia

Background/Purpose: Pulmonary hypoplasia contributes to mortality in infants with severe congenital diaphragmatic hernia (CDH). Accelerated postnatal lung growth with perfluorocarbon lung distension has been demonstrated in animals. The authors present a study measuring perfluorodecalin distension in neonates with severe CDH on extracorporeal membrane oxygenation (ECMO) support. Methods: Six consecutive neonates with CDH requiring ECMO support were recruited. The lungs were filled with perfluorodecalin, and continuous positive airway pressure was applied for 6 to 10 days (mean, 7.7 days [plusmn] 0.7). The perfluorodecalin was exchanged 4 times a day. Radiographic lung projections were measured, and from 2-dimensional measurements an estimated lung volume was calculated using the ECMO cannula as reference. Results: Perfluorodecalin instillation started soon after starting ECMO support (mean, 13.5 [plusmn] 5.3 hours). The volume required to fill the lungs increased significantly (P [lt ] .02). The radiographic dimension of the affected lung increased significantly (mean percentage increase, 272%; P [lt ] .02). The contralateral lung dimension also increased (mean percentage increase 51%; P [lt ] .02). CDH repair was undertaken on ECMO in all cases. All patients survived (follow-up, 3 to 42 months). Conclusions: This protocol of early perfluorodecalin lung distension in infants with severe CDH on ECMO support resulted in significant radiographic lung enlargement. Clinical outcomes are encouraging. Possible mechanisms include alveolar recruitment, alveolar dilatation, and accelerated postnatal lung growth. J Pediatr Surg 38:17-20.     

Submucosal pressure-air insufflation facilitates endorectal mucosectomy in transanal endorectal pull-through procedure in patients with Hirschsprung's disease

Background: Most children with Hirschsprung's disease (HD) can be treated with a transanal endorectal pull-through (TEP) procedure. The authors have developed a simple technique of submucosal pressure-air insufflation (SI) to facilitate the submucosal dissection, which is one of the crucial parts of the operation. Methods: Six patients with HD were treated by using TEP in one year. After adequate positioning and exposure, anal mucosa was incised 1 cm above the dentate line, and 4-quadrant SI with a simple system of scalp-vein needle connected to a 20-mL syringe was used in all of the patients. Submucosal proctectomy, aganglionic and dilated segment colectomy, and coloanal anastomosis were completed transanally, but, in 2 of the patients, laparoscopic assistance to release the colon was required. Results: There were no intraoperative and postoperative complications related to SI. Submucosal dissections were completed smoothly in all of the patients with negligible amount of bleeding. The only complication during the submucosal dissection was mucosal perforation at the site of previous rectal biopsy in 2 patients. Average operating time was 2.7 hours (range, 90-180 min), and mean length of resected bowel was 22.5 cm (range, 12 to 42 cm). Follow-up is 8 to 14 months. Frequent bowel movements ([gt ]8 times per day) and perianal dermatitis were observed in 2 patients but returned to acceptable limits in 3 months. One patient had to undergo reoperation for adhesive intestinal obstruction. Conclusions: SI is simple, and offers a safe and faster dissection with minimum amount of bleeding during the endorectal mucosectomy in TEP procedure. J Pediatr Surg 38:188-190.     

Omental infarction: risk factors in children

Purpose: A series of 4 cases of omental infarction are analyzed. It is shown that obesity, as well as idiosyncratic anatomy, are factors in the development of this rare clinicopathologic entity. Methods: The authors reviewed the preoperative and operative records of all patients. Results: All of the cases of omental infarction were seen in obese children. Other than persistent right-sided abdominal pain, there were no other signs or symptoms. None of the patients had an elevated white blood cell count, and none had fever. Conclusions: Computed tomography scanning is noted to be helpful in making the diagnosis. Laparoscopy is noted to be the procedure of choice, because standard incisions may preclude one from a proper exploration. J Pediatr Surg 38:233-235.     

Laparoscopy-assisted suction colonic biopsy and intraoperative rapid acetylcholinesterase staining during transanal pull-through for Hirschsprung's disease

Background: It is crucial to identify the exact level of transition to normal ganglion cells in instances of Hirschprung's disease. This report describes a technique for laparoscopy-assisted suction colonic biopsy during transanal pull-through. Methods: Laparoscopy-assisted suction colonic biopsy (SCBx) was used in 12 patients with Hirschsprung's disease affecting the rectosigmoid. Average age was 4.4 [plusmn] 2.1 months with a mean operative weight 6.2 [plusmn] 1.0 kg. The pull-through was performed as the primary operative procedure in 11 patients. Using a 2-team approach (laparoscopic team and transanal team), the site was chosen for transanal suction biopsy and marked externally by the laparoscopic team with a silver clip. Biopsies were processed for ganglion cells and rapid AChE technique. Results: There were no biopsy-induced perforations. Abnormal biopsies were repeated more proximally until ganglion cells were observed. Transanal pull-through was performed and an open full-thickness biopsy performed to confirm the presence of ganglion cells. All procedures were performed successfully. Conclusions: Laparoscopy-assisted SCBx can be used successfully in patients with Hirschsprung's disease affecting the rectosigmoid (80% of cases). The technique, when used with rapid AChE staining, provides accurate identification of the level of normoganglionosis.     

Enteral feeding tubes are a reservoir for nosocomial antibiotic-resistant pathogens

Background: Patients and their surroundings are known reservoirs for nosocomial pathogens. Enteral feeding tubes and formula are not thought of as reservoirs for nosocomial organisms. Methods: A prospective observation study was conducted comparing methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) cultured from nosocomial infections and MRSA/VRE cultured from enteral feeding tubes used in the same neonatal intensive care unit during the same time period but in different babies. DNA fingerprinting then was used to compare MRSA and VRE cultured from feeding tubes with MRSA/VRE isolates cultured from clinical infections. Results: There were 23 S aureus isolates; 12 of 23 were methicillin resistant (MRSA). There were 4 MRSA infections in patients without feeding tubes. DNA fingerprinting showed that the MRSA species causing each of the clinical infections also was found in the feeding tubes of other babies. There were no vancomycin-resistant Enterococcus infections during the study period. Conclusion: Feeding tubes are a reservoir for antibioticresistant pathogens that can be transmitted to other infants. J Pediatr Surg 37:1011-1012.     

Forme fruste choledochal cyst: long-term follow-up with special reference to surgical technique

Purpose: Forme fruste choledochal cyst (FFCC) is a choledochal cyst that has minimal or no dilatation of the extrahepatic bile duct (EHBD) and is associated with pancreaticobiliary malunion (PBMU). The authors reviewed the long-term outcome of their patients with FFCC.Methods: Inpatient and outpatient records of 281 patients with choledochal cyst were reviewed. In this study, minimal dilatation of the EHBD was defined as its maximum diameter being less than 10 mm.Results: There were 17 cases of FFCC identified. In all 17 patients, PBMU was present. The mean age at EHBD excision was 2.9 years. Fourteen patients had hepatico-jejunostomy, and three had hepatico-duodenostomy. The histology of the excised EHBD showed mucosal ulceration/sloughing (in 35.3% patients), fibrosis (52.9%), and inflammatory cell infiltration (41.2%). Over a mean postoperative follow-up period of 9.8 years, there have been no episodes of cholangitis or anastomotic stricture formation.Conclusions: The treatment of choice for FFCC in children is EHBD excision and hepatico-jejunostomy. There is little surgical morbidity if performed carefully.     

Laparoscopy in children with complicated appendicitis

Background/Purpose: Laparoscopic appendectomy is an accepted way of dealing with suspected uncomplicated appendicitis in children. The role of laparoscopy in complicated acute appendicitis is more controversial. The purpose of this trial was to compare laparoscopic appendectomy with open appendectomy in children with complicated appendicitis. Methods: A total of 102 children with suspected acute appendicitis were selected randomly to undergo either a laparoscopic or an open appendectomy. The outcomes of 25 children with complicated appendicitis, 13 in the laparoscopic group and 12 in the open appendectomy group, were analyzed. Children, their parents, and research nurses were blinded to which procedure had been performed and remained blinded until the control visit 7 days after the operation. All 25 children completed a 30-day follow-up. Results: There were no differences in terms of patients' age, sex, weight, height, and appendiceal histology between the 2 groups. All laparoscopic procedures were completed without conversion. The mean ([plusmn]SD) operating time was 63 ([plusmn]31) minutes in the laparoscopic group and 37 ([plusmn]18) minutes in the open appendectomy group (mean difference 26 minutes, 95% CI 5 to 47 minutes, P = .02). There were 2 major complications in the laparoscopic group in children with appendiceal masses. One child had an entero-cutaneous fistula of the residual appendiceal tip that needed open reoperation. Another child had a pelvic abscess that resolved with antibiotic treatment. Superficial wound infections were encountered in 2 patients in the open appendectomy group. Conclusions: Laparoscopic appendectomy is an alternative to open procedure in children with complicated appendicitis. Good surgical judgement is necessary in patients with an established appendiceal abscess. J Pediatr Surg 37:1317-1320.     

Long-term efficacy of partial splenic embolization in children

Purpose: To elucidate the role of partial splenic embolization (PSE) procedures, long-term outcome was assessed in terms of the recurrence of thrombocytopenia.Methods: A retrospective study was performed after 41 PSE procedures in 36 patients for hypersplenism owing to portal hypertension. The underlying disease was biliary atresia in 32 patients, extrahepatic portal obstruction in 3, and idiopathic cirrhosis in 1.Results: The average volume embolized was 70.1%. The patients were followed up from 20 days to 182 months (average, 70.8 months). Five patients subsequently died, and 6 underwent liver transplantation. The causes of death or the reasons for liver transplantation were not related to hypersplenism. Eleven patients (30.6%) had recurrence of thrombocytopenia (<100,000/mm³). There was no significant difference in the volume embolized or platelet count before PSE between the patients with and without recurrence of thrombocytopenia. The peak value of platelet count after PSE was significantly lower in the patients with recurrence of thrombocytopenia (P = .0091). In 17 of 24 survivors without liver transplantation, platelet counts remained normal throughout the follow-up period.Conclusions: PSE is a safe and effective procedure. Hematologic indices improved in all 36 patients after PSE, and its long-term efficacy was shown in 70% of the survivors.     

Author Index for oral presentations

Introduction and hypothesis

The objective is to describe our surgical approach for management of uterine prolapse using 5-mm skin incisions and transcervical morcellation.

Methods

This video presents a novel approach for laparoscopic supracervical hysterectomy, bilateral salpingectomy, and sacrocervicopexy using only 5-mm skin incisions and transcervical morcellation. The procedure begins with a laparoscopic supracervical hysterectomy with bilateral salpingectomy. A classic intrafascial supracervical hysterectomy (CISH) instrument is then used transvaginally to core the endocervical canal. A disposable morcellator is placed through the remaining cervix to morcellate the uterus and fallopian tubes. Following morcellation, the handle of the morcellator is removed, and it is used during the remainder of the surgery as an access cannula for the sacrocervicopexy. The polypropylene mesh is introduced through this cannula. It is secured to the anterior and posterior vaginal fascia with a suture that is also introduced through the transcervical port. At the conclusion of the surgery, a previously placed 0 Vicryl purse-string suture at the ectocervix is tied down as a cerclage around the cervix once the cannula is removed.

Conclusions

The transcervical morcellation technique demonstrated in this video allows the surgeon to maintain 5-mm skin incisions and core the endocervical canal during a laparoscopic supracervical hysterectomy with sacrocervicopexy.