Laparoscopic upper pole heminephroureterectomy in children: Seven-year experience

Background:

Minimally invasive surgery is the current approach to perform heminephroureterectomy (HN) in children. This can be obtained through a transperitoneal (TP) or a retroperitoneal approach. Here, we report our experience using a TP approach.

Materials and Methods:

From 2005 to 2014, 22 TP laparoscopic upper poles HN were performed at our institution. There were nine girls and 13 boys aged between 20 months and 6 years (mean age 3.9). Eight patients were diagnosed prenatally, 17 patients presented with urinary tract infection (UTI) and three with vomiting and failure to thrive. The indication for HN was reflux nephropathy and UTI in non-functioning upper pole in 19 patients and cystic dysplasia in 1 patient. The surgical technique involved the following steps: Cystoscopic recognition; positioning of 3-4 trocar (right HN); identification of the kidney (detachment of the colon); isolation and low ligation of the dilated ureter; decrossing from renal vessels; section of the parenchyma by LigaSure; haemostasis with clips and LigaSure; drain.

Results:

The mean operative time was 154 min (range: 81-220 min). All patients were discharged from the 2^nd to 4^th day. Neither major complication nor conversion was recorded. 1 patient presented leakage of urine for 7 days from the drainage which resolved spontaneously. At ultrasound follow-up, 5 patients showed a secondary perirenal cyst, 2-5 cm diameter that resolved spontaneously.

Conclusion:

The results indicate that laparoscopic upper pole heminephrectomy is the treatment of choice in cases of non-functioning dilated lower segments of duplicated kidneys. The use of laparoscopic approach offers a good working space, a good visual control of the vessels and allows a very low isolation of the ureteral stump which counterbalance the peritoneal violation.Key words: Duplex kidney, heminephrectomy, infants, laparoscopy     

Laparoscopic surgery for choledochal cyst in children: a case review of 31 patients.

INTRODUCTION: The results of the first substantial series of children suffering from choledochal cysts treated using laparoscopic surgery at the Shanghai Children's Medical Center, Shanghai, China are presented. METHODS: Data from 31 sequentially treated children (average age 45.2 months, SD 36.5, range 2 to 168 months) with choledochal cyst treated by laparoscopic surgery were collected prospectively. The chief complaints included intermittent abdominal pain, vomiting, jaundice or pancreatitis. Two cases had no clinical symptoms; their diagnoses were based on prenatal ultrasound findings and confirmed postnatally. The laparoscopic technique included excision of the gall bladder and cyst, followed by a Roux-en-Y anastomosis constructed after exteriorization of the small bowel via an infraumbilical trocar incision. After repositioning of the bowel, an end-to-side hepaticojejunostomy was carried out laparoscopically. RESULTS: The procedures were carried out successfully in 27 children and the average operating time was 5.2 hrs (4-7.5 hrs). In 4 patients, the operations were converted to open surgery because of a giant cyst (diameter 10 cm; 1 case), serious inflammation and adhesions (2 cases), and hepatic duct malformation (1 case). Complications occurring postoperatively and cured by conservative treatment included hepaticojejunostomosis leakage (1 case), bowel ileus (1 case), pancreatitis (1 case), and pneumonia (1 case). Oral food intake was started within 3-5 days and patients were discharged within 7-14 days (average 8.6 days). All patients are well with bile-stained stools after an average follow-up of 16.3 months (range 2-43 months). The average cost was RMB 19,167 ($2522, range RMB 12,600-34,538). CONCLUSIONS: Laparoscopic resection of congenital choledochal cyst and choledochojejunostomy in children is feasible and safe. The long-term results are good. There was a considerable learning curve during the development of the technique as experienced by the team.     

Hydatid disease of the liver in children

Between 1986 and 1997, 21 children (ten boys and 11 girls) had surgery for hydatid disease of the liver. Their mean age was 6.5 years (range 3-12). Abdominal distention with a mass was the commonest presenting symptom (71.4%), followed by abdominal pain (38%). Hepatomegaly with a palpable mass was present in 12 (57%). Three children had concomitant pulmonary and brain hydatid disease. The diagnosis was established clinically and by skin testing, serology and imaging techniques. All patients received a pre-operative course of mebendazole (50 mg/kg/day) for between 1 and 8 weeks. At surgery, 11 children had a single cyst, eight of which were in the right lobe of the liver. Ten children had multiple cysts occupying both liver lobes. Three forms of surgical treatment were used: capitonnage + partial excision of fibrous capsule; total excision of the cyst; and external drainage of the cyst cavity. Three children required re-operation. Mean follow-up time was 24 months. There were no deaths, but five children developed post-operative complications. Surgical treatment in the form of primary closure of the cyst cavity without drainage seems to offer the best therapeutic option for patients with large hydatid cysts.     

Childhood abdominal cystic lymphangioma

BACKGROUND: Abdominal lymphangioma is a rare benign congenital malformation of the mesenteric and/or retroperitoneal lymphatics. Clinical presentation is variable and may be misleading; therefore, complex imaging studies are necessary in the evaluation of this condition. US and CT have a major role in the correct preoperative diagnosis and provide important information regarding location, size, adjacent organ involvement, and expected complications. OBJECTIVE: To evaluate the clinical and imaging findings of seven children with proven abdominal cystic lymphangioma. MATERIALS AND METHODS: Clinical and imaging files of seven children with pathologically proven abdominal lymphangioma, from three university hospitals, were retrospectively evaluated. Patient's ages ranged from 1 day to 6 years (mean, 2.2 years). Symptoms and signs included evidence of inflammation, abnormal prenatal US findings, chronic abdominal pain, haemorrhage following trauma, clinical signs of intestinal obstruction, and abdominal distension with lower extremities lymphoedema. Plain films of five patients, US of six patients and CT of five patients were reviewed. Sequential imaging examinations were available in two cases. RESULTS: Abdominal plain films showed displacement of bowel loops by a soft tissue mass in five of six patients, two of them with dilatation of small bowel loops. US revealed an abdominal multiloculated septated cystic mass in five of six cases and a single pelvic cyst in one which changed in appearance over 2 months. Ascites was present in three cases. CT demonstrated a septated cystic mass of variable sizes in all available five cases. Sequential US and CT examinations in two patients showed progressive enlargement of the masses, increase of fluid echogenicity, and thickening of walls or septa in both cases, with multiplication of septa in one case. At surgery, mesenteric lymphangioma was found in five patients and retroperitoneal lymphangioma in the other two. CONCLUSIONS: US and CT are highly sensitive in the diagnosis of abdominal lymphangioma. Our limited experience with follow-up examinations in two patients suggests that progressive enlargement, multiplication and thickening of septa and increased echogenicity of the cystic fluid are signs indicating complications demanding urgent treatment.     

Laparoscopic heminephrectomy in infants and children: first 54 cases

ObjectiveHeminephrectomy in the pediatric population remains a popular open surgical procedure. We describe our experience with laparoscopic heminephrectomy using a retroperitoneoscopic approach.Materials and methodsData were collected retrospectively and prospectively on all patients undergoing laparoscopic heminephrectomy by a single surgeon using a prone retroperitoneoscopic approach. Information relating to the age, sex, laterality, duration of surgery, analgesic requirements, duration of hospital stay, postoperative complications and outcome was recorded.ResultsBetween March 2001 and August 2005 54 laparoscopic heminephrectomies were performed in 48 children (34 girls and 14 boys). The median age at surgery was 14 months (range 2–112 months). Forty-four upper and 10 lower moieties were removed. The median operative time was 105 min (range 50–150 min). There were no intraoperative complications and no conversions. There were four minor complications, comprising haematuria (n = 1) and postoperative pyrexia (n = 3). The median length of follow up was 22 months (range 3–57 months). All patients remained asymptomatic at last follow up. Ultrasound findings included presence of a visible ureteric stump (n = 7) and cysts at the resection margin of the remaining remnant (n = 17); none of these patients manifested clinical symptoms (e.g. infection, pain).ConclusionsWith advanced laparoscopic skills, laparoscopic heminephrectomy is a feasible operation for the treatment of non-functioning duplex renal units in children and infants.     

Lumbotomy approach for upper urological tract surgery in children--an analysis of 68 consecutive lumbotomies.

OBJECTIVES: To comprehensively analyse the results of upper urological tract surgery performed using a lumbotomy approach in the paediatric age group. METHODS: 68 consecutive patients underwent upper urological tract surgery during the last 5 years in our surgical unit. In all of these patients, a lumbotomy approach was used with a transverse skin incision. The hospital charts were reviewed for age, sex, diagnosis, type of surgery, intra-operative problems, duration of surgery, time to oral feeds, postoperative pain, length of hospitalisation and complications. RESULTS: Age range was 1 month to 12 years with a mean of 66 months. There were 47 boys and 16 girls. Surgeries performed were: pyeloplasty, pyelolithotomy, nephroureterectomy, ureterostomy and heminephrectomy. No intraoperative problems were encountered and the mean duration of surgery was 64.68 minutes. All patients resumed full oral feeds within 24 hours of surgery and postoperative pain was minimal. The mean duration of hospital stay was 6.16 days. No incision-related complications were seen. CONCLUSIONS: Lumbotomy incision is a safe, easy and effective approach for upper urological tract surgery in children.     

Fibrous lesion of the bowel complicating the management of bilateral Wilms' tumor

A 31 month old black male with known bilateral Wilms' tumor, who had right nephrectomy and left lower pole heminephrectomy developed a papable mass in the left lower quadrant. Several studies could not clearly determine the nature of the mass lesion, a laparotomy was performed, a keloidlike lesion was found in the bowel wall.Presented at the Members Miscellany, 23rd Annual Meeting, The Society for Pediatric Radiology, April 18–20, 1980, Salt Lake City, Utah, USA     

小儿肝囊性包虫病的诊断与外科治疗(附67例报告)

目的 总结小儿肝囊性包虫病的诊断与外科治疗经验.方法 回顾性分析中心2002年1月至2010年1月期间收治的67例14岁以下(包含14岁)肝囊性包虫病患儿,对其临床表现、治疗方法及术后并发症进行分析.结果 67例患儿均行手术治疗,行传统内囊摘除术47例,行完整外囊剥离术式11例,行外囊次全切除术6例,行肝叶切除术3例,术后肺部感染1例,1例患儿术后11d因反复应激性溃疡出血伴发多器官功能衰竭死亡,随访1～8年,包虫残腔积液7例,残腔积液合并感染2例,1例患儿术后3年包虫原位复发再次行手术治疗治愈.结论小儿肝囊性包虫具有生长快,囊壁薄,较易合并其他脏器等特点,超声、CT及实验室检查等可明确术前诊断,内囊摘除术为有效治疗肝囊性包虫术式,内囊次全切除术及术中胆道造影可有效降低术后残腔并发症.     

Cysts of the ejaculatory system--a treatable cause of recurrent epididymo-orchitis in children.

PURPOSE: The commonest causes of acutely painful scrotum are torsion (of appendix of the testis or the testis itself) and epididymo-orchitis. Exploration is the only way to prove the diagnosis and multiple such procedures are performed in patients with recurrent epididymo-orchitis. The purpose of our study was to investigate the cause of recurrent epididymo-orchitis in pre-pubertal children. Four children, aged three years or less, were investigated for recurrent left epididymo-orchitis. All four had cystic dilatation of the ejaculatory duct in the region of the prostatic utriculus, associated in two children with ectopic opening of the vas in the bladder. Initial ultrasound appeared to be normal in all four patients, a retrospective review of the sonographic films, however, revealed a retrovesical cyst in three of them. The diagnosis was established by a combination of urethroscopy with retrograde contrast study via the utriculus and open vasography. All four cases were treated operatively by a transtrigonal approach. The cyst was excised in each case. In one, a vasovasostomy was performed between the left and the normal right vas; in the other three the left vas was anastomosed to the blind end of the contralateral seminal vesicle. All four are symptom-free at one year follow-up. Cysts of the ejaculatory duct are a treatable cause of recurrent epididymo-orchitis. Pre-pubertal children with recurrent epididymo-orchitis and no obvious underlying cause should have a thorough sonographic examination of the retrovesical region for cystic lesions.     

Pericardial cyst in a child treated with video-assisted thoracoscopic surgery

A pericardial cyst is a rare condition in childhood. We report on a 10-year-old girl who presented with an intrathoracic mass detected on a chest X-ray performed during a routine medical examination. She had no symptoms and a physical examination revealed no abnormalities. Ultrasonography, computed tomography and magnetic resonance imaging showed a multiloculated cystic mass in the right upper thorax. The cyst was resected using a thoracoscopic procedure. Histologically, the findings were consistent with a pericardial cyst. Thoracoscopic surgery was an effective surgical technique even for such a young patient and the results successfully reduced the morbidity. Conclusion A pericardial cyst, a rare condition in childhood, was treated successfully by video-assisted thoracoscopic surgery. Received: 10 April 2000 / Accepted: 5 July 2000     

Hydatid disease in childhood

To review the results of different modalities of treatment of hydatid disease of the liver (HDL) in pediatric patients, 31 children treated surgically between 1990 and 2000 at the departments of general surgery and pediatric surgery, Atatürk University School of Medicine, were reviewed retrospectively; 19 were male and 12 were female. The mean age was 8.4 years (range 4-12 years). The most common complaints were an abdominal mass and right-upper-quadrant pain, which were present in 35.5% and 77.4% of cases, respectively. Twenty-five cysts were in the right lobe, 2 in the left lobe, and 4 in both lobes; 8 patients had multiple hepatic cysts and 5 had coexisting cysts in other organs. Surgical procedures were: unroofing plus tube drainage (UTD); capitonnage; omentoplasty; and pericystectomy. Of the patients treated by UTD, 2 developed cholangitis and 1 developed a biliary fistula. Of the patients with capitonnage, 1 developed cholangitis. Surgery is still one of treatment modalities for management of HDL. Omentoplasty and capitonnage are the most effective modalities for the management of the cyst cavity.     

Nonparasitic splenic cysts in children: a multicentric study.

PURPOSE: Nonparasitic splenic cysts (NPSCs) are uncommon in children. The aim of this multinational and multicentric study was to present the authors' experience as well as the changing trends in the management of NPSCs over the last 25 years. MATERIAL AND METHODS: From 1981 to 2005, 50 children or adolescents were surgically treated for NPSCs in 6 paediatric surgical centres in four European countries. The medical records of these 50 patients with NPSCs were reviewed retrospectively. RESULTS: Twenty-six male and 24 female patients were operated on. Age at surgery ranged from 1 to 17 years (mean 11.9). Seventeen patients were symptomatic. Six total (4 open and 2 laparoscopic) and 26 partial (22 open and 4 laparoscopic) splenectomies were performed. Laparoscopic fenestration or deroofing and open cystectomy was carried out in 9 patients, respectively. Histological findings revealed the lesion to be an epidermoid cyst (n = 28), a pseudocyst (n = 15) or a mesothelial cyst (n = 2). In 5 patients haemangioma or lymphangioma was the pathological diagnosis. At a mean follow-up of 2.9 years, residual cysts were found in 8 laparoscopically treated patients, 4 of whom required re-do laparoscopy or open surgery. CONCLUSIONS: Over the last two decades, the surgical treatment of NPSCs has changed from a formerly customary total splenectomy to spleen-conserving procedures, such as total cystectomy with or without partial splenectomy or partial cystectomy. These therapeutic modalities can be performed laparoscopically, if technically possible. Fenestration or deroofing of the cyst resulted in a high recurrence rate (7/9).     

Laparoscopic treatment of biliary atresia and choledochal cyst

Minimally invasive surgery (MIS) has overcome many technical limitations and has evolved into a safe alternative for the treatment of many complex pediatric surgical procedures. The introduction of this approach for the correction of congenital biliary tract anomalies had to wait until instrumentation and surgeons' skills improved enough. This happened not so long ago: less than 10 years have elapsed since the first reported case of a minimally invasive operation for choledochal cyst and less than 3 years since the first reported case of a laparoscopic Kasai. This article summarizes the experience gained by the authors in laparoscopic treatment of 41 patients with biliary atresia and 15 patients with choledochal cyst with similar surgical techniques, which are described in detail. Based on the encouraging results, the authors believe that MIS will soon become the gold standard for the correction of congenital biliary tract anomalies.     

Single-port laparoscopic surgery in children: A new alternative in developing countries

Background:

Single-incision laparoscopic surgery (SILS) is a technique in laparoscopic surgery, which is based on the idea that all the laparoscopic trocars are inserted through a single umbilical incision. This paper documents a single-centre experience, which performed the single-port surgery in children using an improvised trans-umbilical glove-port with conventional rigid instruments.

Materials and Methods:

We prospectively studied the outcomes of SILS procedures between January 2013 and June 2014. Materials required making our homemade trans-umbilical port consisted on: A flexible ring, a rigid larger ring, one powder-free surgical glove, a wire-to-skin and standard standards laparoscopic trocars.

Results:

A total of 90 consecutive procedures had been done in our institution: 15 girls and 75 boys (mean age: 7.5 years). We used SILS on 59 appendectomies with an average operative time of 48 minutes. We needed conversion to conventional surgery in three cases (two with perforated appendicitis and one for difficulty to mobilize the appendix). SIL cholecystectomy was performed for four patients with symptomatic cholelithiasis; mean operative time was 60 min. All patients were discharged on postoperative day 2. Eighteen boys with non-palpable testis were explored and treated. Other procedures included: Varicocelectomy (n = 2), intra-abdominal lymph node biopsies (n = 2), ovarian cystectomy (n = 1), ovarian transposition (n = 1), aspiration of renal hydatid cyst (n = 1), explorative laparoscopy in research to Meckel''s diverticulum (n = 1) and intestinal intussusceptions (n = 1). No post-operative complications were seen in all cases.

Conclusions:

SILS in the paediatric population using conventional rigid instruments is feasible, safe and effective. It may be an alternative to the costly commercially available single-port systems especially in a developing country like Tunisia.Key words: Single-incision laparoscopy, children, rigid instruments     

Infant robot-assisted laparoscopic upper urinary tract reconstructive surgery

ObjectiveOur aim was to assess the outcomes of infant robot-assisted laparoscopic (RAL) upper urinary tract reconstruction.Materials and methodsThe medical records of all infants who underwent RAL upper urinary tract reconstruction were reviewed. Patients less than 1 year of age at surgery were included. Patient demographics, intraoperative details, narcotic usage, and complications were reviewed.ResultsTen infants met the study criteria. There were five right and five left-sided procedures. Eight pyeloplasties (4 right, 4 left) and two ureteroureterostomies (1 right single system, 1 left duplex system) were performed. The median age was 8 months (range 3–12 months). Median weight was 7.7 kg (range 5.8–10.9 kg). Median operative time was 128 min (range 95–205 min). There was no significant blood loss or intraoperative complications. One (10%) patient received a regional block. Eight (80%) patients did not receive postoperative narcotics. Median hospital stay was 1 day (range 1–2). Median follow-up was 10 months (range 3–18 months). Complications included one urinary leak, one ileus, and one urinary tract infection. Hydronephrosis improved in all patients.ConclusionsInfant RAL upper urinary tract reconstruction is technically feasible, safe, and effective. It can be applied for duplication anomalies and single system obstructions in infants.     

经腹腔镜行先天性胆总管囊肿切除肝管空肠Roux-Y吻合术的探讨

目的 探讨经腹腔镜行先天性胆总管囊肿切除，肝管空肠Roux-Y吻合术的可行性。方法 先天性胆总管囊肿5例，在腹腔镜监视下行胆囊穿刺胆道造影术，显示肝胆管和胰管病变，用电切或电凝切除胆总管囊肿。经脐部切口提出空肠，于腹壁外行空肠Roux-Y吻合，用5-0可吸收缝线，在腹腔镜监视下，将肝管与空肠端侧吻合。结果 本组5例患儿手术全部成功，手术时问平均为5．1h，(4．5h～6h)出血量20m1～50ml，吻合口直径1．0cm～1．5cm，平均住院时间6．5d，术后随访1个月～4个月，无肠粘连梗阻和吻合口狭窄发生。患儿肝功能各项指标正常。结论 经腹腔镜行先天性胆总管囊肿切除，肝管空肠吻合术是一种安全可靠的方法，具有创伤小，视野清楚，分离缝合准确、术后恢复快等优点。     

Potential pitfalls in nuclear medicine: a paediatric teaching case

An infant with complex cardiac defects and isomerism had a persistent pyrexia of undetermined aetiology following cardiac surgery. Radionuclide leucocyte scan showed a focus of increased uptake in the right upper quadrant (RUQ) felt to be compatible with an abscess. However, correlation with clinical data and multimodality imaging allowed the correct diagnosis of ectopic splenic tissue in the RUQ to be made. This report emphasises the need for an integrated approach to imaging. Patients with abnormalities of viscero-atrial situs require careful assessment of their splenic status. Visceral heterotaxy may result in confusing imaging appearances unless the anatomy has been accurately documented. Received: 9 September 1999/Accepted: 24 September 1999     

Classic and unusual appearances of hydatid disease in children

BACKGROUND: In endemic regions, hydatid disease is commoner in children than in adults. The hydatid cysts may have classic appearances, but unusual sites and appearances may cause diagnostic difficulties. OBJECTIVE: To assess the classic and unusual appearances of hydatid disease in children. MATERIALS AND METHODS: A 3-year retrospective review of available imaging of proven hydatid disease at a tertiary paediatric institution. RESULTS. Review of imaging of 21 children (9 boys, 12 girls), with a mean age of 8 years and 1 month, demonstrated cysts in the liver ( n=9), lung ( n=8), brain ( n=7), spleen ( n=2), heart ( n=1), orbit ( n=1) and soft tissues ( n=1). Multi-organ involvement occurred in eight cases with two cases that did not involve the liver. Complicated cysts were found in 13 cases and usually involved the liver ( n=8) and lung ( n=5). An unusual case of spontaneous cerebrospinal fluid (CSF) spread was also documented. CONCLUSIONS: Hydatid disease in children classically involves the liver, lung and brain but can involve almost any organ and numerous organs simultaneously. Whether hydatid disease is discovered incidentally or by intentional imaging, extended imaging is recommended to identify multifocal disease which may also display complicated cysts that may assist in the diagnostic process. All patients with one known site should undergo a minimum of an abdominal US and CT scan of the chest and brain. CT may be used instead of US of the abdomen, and MRI may be used to replace CT of the brain. Over 50% of cases in our study showed complicated cysts. Unique findings of this study include multi-organ involvement without liver cysts. Multiplicity and complications of cysts can assist diagnosis. Intraventricular and intrathecal CSF spread of a spontaneously ruptured intracerebral cyst has not, to our knowledge, been previously reported.     

小儿腹腔镜胆总管囊肿切除术45例

目的总结腹腔镜下小儿胆总管囊肿切除、肝总管空肠Roux-en-Y吻合术的经验。方法回顾性分析2010年1月至2012年12月我们收治的45例小儿先天性胆总管囊肿患儿临床资料,其中囊肿型32例,梭形扩张型13例,囊肿直径约1．2-5．5em,均在腹腔镜下行胆总管囊肿根治术,空肠Roux-en-Y吻合在腹壁外经脐部小切口进行,肝肠吻合在腹腔镜下完成。结果本组45例中,1例因炎症较重,游离囊肿前壁时渗血较多,解剖困难而中转开腹手术;1例术后6d进食后出现乳糜腹（经肠内、肠外营养14d后治愈）。其余43例均未出现并发症,痊愈出院。术后平均住院时间11d。结论初期开展腹腔镜下胆总管囊肿切除手术时要严格挑选病人,先从囊肿小、炎症轻、发病时间短的病例开始,逐渐积累经验后再扩大腔镜手术指征。腹腔镜手术具有创伤小、视野清晰、恢复快,并发症少等优点。腹腔镜下胆总管囊肿切除术是先天性胆总管囊肿的理想手术方法。