2014_FinalProgram

IPEG’s 23rd Annual Congress
for Endosurgery in Children

Held in Conjunction with
BAPS 61st Annual Meeting

July 22-26, 2014
EDINBURGH INTERNATIONAL CONFERENCE CENTRE (EICC)
EDINBURGH, SCOTLAND
FINAL PROGRAM 2014

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IPEG’s 23rd Annual Congress
Held in Conjunction with
BAPS 61st Annual Meeting
July 22-26, 2014
EDINBURGH INTERNATIONAL CONFERENCE CENTRE (EICC)
The Exchange, Edinburgh
EH3 8EE, Scotland
T: +44 (0) 131 300 3000
www.eicc.co.uk
International Pediatric Endosurgery Group (IPEG)

11300 W. Olympic Blvd, Suite 600
Los Angeles, CA 90064
T: +1 310.437.0553
F: +1 310.437.0585
E: [email protected]
Edinburgh skyline over East Princes Street Garden
WWW.IPEG.ORG | 1
DEAR COLLEAGUES,
Welcome to IPEG’s 23rd Annual Congress for Endosurgery in Children!
IPEG is very pleased that this congress will be held in conjunction with the British
Association of Paediatric Surgeons (BAPS) for the first time. Therefore, I would like to
particularly welcome the President of BAPS, Rick Turnock and his team and to thank
them for their efforts to ensure that this congress will be successful. The congress
chairman of IPEG, Philipp Szavay and his co-chairs, Katherine Barsness, Go Miyano and
Pablo Laje have set up an excellent program. Panels deal with hot topics and again,
experts will teach their tips and tricks in the IPEG workshops.
IPEG is a relatively young association with a strong innovative drive. BAPS has its
tradition and unique standing within our paediatric surgical community. These differing
perspectives give this inaugural joint congress the opportunity to offer unique joint
sessions and discussions on pros and cons of endosurgical techniques in children.
Numerous aspects of endoscopic surgery in children remain to be evaluated and a new
generation of surgeons is ready to get involved. IPEG is a unique association with many
opportunities for young surgeons. I am happy to invite you all to participate, to get
involved with IPEG and to find new friends during this congress.
Finally, don’t miss our main event which will be extraordinary fun.
Enjoy the traditional Celeigh, an outrageous party and don’t forget to
bring your dancing shoes.
Welcome to Edinburgh!
Benno Ure, MD, PhD
2014 IPEG President
TABLE OF CONTENTS
Edinburgh Information3 Commercial Bias Reporting Form 60
General Information4 CME Worksheet61
Meeting Hours6 Faculty Disclosures63
Accreditation6 Presenter Disclosures65
Program Chairs 7 Long Term Research Fund Donors69
CME Chairs10 New Membership72
Meeting Leaders12 Hotel Information74
Meeting Faculty14 Social Programs74
Schedule-at-a-Glance 16 Oral Abstracts75
Innovations Corner18 Video Abstracts157
Complete Schedule24 Top Posters171
Exhibitors & Exhibit Hall Floorplan56 Poster Abstracts201
Exhibitor Profiles57
IPEG’s 23rd Annual Congress for Endosurgery in Children ■ July 22-26, 2014 | 2
Table of Contents
Edinburgh Information
Scotland’s Inspiring capital city – is one of the
most beautiful cities in Europe, where stunning
cultural heritage fuses with the best of modern,
dynamic World Heritage city.
The city can be warm and pleasant during the
summer although being close to the Firth of Forth
means there can also be a cool coastal breeze and
occasional mists (known locally as ‘haar’).
From April to September, temperatures are mild
and compare favourably with other European
cities. Annual rainfall is the same as Frankfurt,
New York and less than in Rome. Edinburgh Castle
AIRPORT/TRAVEL INFORMATION
Edinburgh Airport lies 8 miles (12 km) west of the city centre and is easy to reach
thanks to reliable and frequent bus services. A range of taxi services and car hire
options using major companies are also available.
By Bus: The Airlink 100 express bus service operates a 24-hour shuttle service
between Edinburgh Airport and Waverley Bridge (near Princes Street and the main
rail and bus stations), with designated stops en route. The service is frequent -
every 10 minutes at peak times – with a journey time of about 25 minutes.
By Taxi: Official airport taxis, pre-booked private hire taxis and city black cabs are
all available, each with separate ranks. Many taxis are wheelchair-accessible and the
journey time is around 25 minutes (although this may be longer during rush hours).
Car hire and driving: Vehicles can be hired from all major companies at Edinburgh
Airport’s new car rental facility close to the main terminal building.
Train and Tram: At present, there is no direct rail access between central Edinburgh
and the airport. A high-quality, modern and efficient tram network is currently
being built for Edinburgh and is scheduled to be running from the airport to the city
centre from 2014.
VISA Information for International Attendees

As part of the United Kingdom, Scotland has the same visa requirements. Visitors
from the EU, rest of Europe and US, Canada, Australia and New Zealand can
visit without a visa. Visitors from all other countries must have a valid visa to visit
Scotland and details can be found at www.ukba.homeoffice.gov.uk.
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General Information
Why IPEG?
Now is an excellent time to become an IPEG member. Join IPEG now and receive
a substantial discount on the meeting registration by being an IPEG member!
Your dues also include a subscription to the Journal of Laparoendoscopic &
Advance Surgical Techniques (a $900 value is yours for FREE with your paid IPEG
membership.)
Who Should Attend?

The 23rd Annual Congress of the International Pediatric Endosurgery Group (IPEG)
as elements that have been specifically designed to meet the needs of practicing
pediatric surgeons, urologists, and other related specialties, physicians-in-
training, GI assistants, and nurses who are interested in minimally invasive surgery
in children and adolescents. The IPEG Program Committee recommends that
participants design their own attendance schedule based on their own personal
educational objectives.
2014 Meeting Objectives

The objectives of the activity are to educate pediatric surgeons and urologists
about developing techniques, to discuss the evidence supporting adopting these
techniques, to provide a forum for discussions at a scientific level about the
management principles regarding minimally invasive surgical techniques and to
reveal scientific developments that will affect their patient population.
Specific Objectives include:

1. Presentation of new and developing minimally invasive surgical techniques in a
scientific environment.
2. Interaction with experts in the fields of minimally invasive pediatric surgery and
urology via panel discussions and informal networking.
3. Debates about controversial issues regarding indications, techniques and
outcomes of minimally invasive surgery in infants and children.
4. Encourage and establish international networking in the management and
minimally invasive surgical interventions for infants and children.
At the conclusion of the activity, pediatric surgeons and urologists will be
able to safely incorporate minimally invasive surgical techniques into their
practice by applying the evidence-based medical knowledge and skills learned,
recognizing pitfalls and monitoring patient outcomes.
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General Information CONTINUED

Best Science Award
The Best Science Award will be a cash prize of US $1,000 to be presented on
Saturday during the Awards Presentation Session. The Program Committee
will select the Award recipient. The IPEG Executive Committee is committed to
education and feels that this is a very concrete way to express that commitment.
IRCAD Award
As a result of a generous grant provided by Karl Storz Endoscopy, the best
resident abstract presenters will be selected by the IPEG Publications Committee
to receive the 2014 IRCAD Award. The Award recipients will travel to Strasbourg
France to participate in a course in pediatric minimally invasive surgery at the
world famous European Institute of Telesurgery. This center at the University
of Strasbourg is a state-of-the-art institute for instruction in all aspects of
endoscopic surgery that is now providing a series of courses in pediatric surgery.
IPEG Member Benefits

IPEG exists to support excellence in Pediatric Minimal Access Surgery and
Endoscopy through education and research; to provide a forum for the exchange
of ideas in Pediatric Minimal Access Surgery and Endoscopy; and to encourage and
support development of standards of training and practice in Pediatric Minimal
Access Surgery and Endoscopy. Benefits of membership include:
■■ Subscription to the Journal of Laparoendoscopic & Advance Surgical Techniques
(a $900 value is yours for FREE with your paid IPEG membership.)
■■ Significant discounts on registration fees for the Annual Congress for
Endosurgery in Children. (Note: registering for the IPEG Scientific Session, as a
member, will save you the equivalent of one year’s dues)
■■ Affordable dues for surgeons and surgeons-in-training in any country.
■■ Opportunities to meet and discuss pediatric minimally invasive surgery with
leaders and innovators in the field.
For more information and applications, please go to:
www.ipeg.org/member/memberapplication.
Event Dress Code

Please note that the dress code for the entire conference is business casual.
The average temperature is expected to be 19°C.
WWW.IPEG.ORG | 5
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Meeting Hours
Registration Hours Strathblane Hall
Tuesday, July 22, 2014 12:00 pm – 5:00 pm
Wednesday, July 23, 2014 6:30 am – 6:00 pm
Thursday, July 24, 2014 6:30 am – 5:30 pm
Friday, July 25, 2014 6:30 am – 5:30 pm
Saturday, July 26, 2014 7:00 am – 12:00 pm
Exhibit Dates & Times Cromdale Hall
Wednesday, July 23, 2014 5:00 pm – 7:00 pm
IPEG/BAPS Welcome Reception
Top Posters 1-20: Digital Presentation 12:00 pm – 1:00 pm
Friday, July 25, 2014 9:30 am – 4:30 pm
Top Posters 21-40: Digital Presentation 12:00 pm – 1:00 pm
Speaker Prep Hours Soutra
Wednesday, July 23, 2014 6:00 am – 6:00 pm
Friday, July 25, 2014 6:00 am – 5:30 pm
Saturday, July 26, 2014 6:00 am – 12:00 pm
Accreditation
The Activity has been planned and implemented in accordance with the Essentials
and Standards of the Accreditation Council for Continuing Medical Education
through the joint sponsorship of the Society of American Gastrointestinal and
Endoscopic Surgeons (SAGES) and IPEG. SAGES is accredited by the ACCME to
provide medical education for Physicians.
The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)
designates this live activity for a maximum of 24.25 AMA PRA Category 1 Credits™.
Physicians should claim only the credit commensurate with the extent of their
participation in the activity.
Date Total Credits

Tuesday, July 22, 2014 3.75
Thursday, July 24, 2014 8.25
Friday, July 25, 2014 9
Saturday, July 26, 2014 3.25
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2014 Program Chairs

PROGRAM CHAIR: Philipp O. Szavay, MD
CO-CHAIR: Katherine A. Barsness, MD
CO-CHAIR: Pablo Laje, MD
CO-CHAIR: Go Miyano, MD
Philipp O. Szavay, MD
Program Chair
Children’s Hospital, Lucerne, Switzerland
Philipp Szavay is currently Professor of Pediatric Surgery
and Head of the Department of Pediatric Surgery at the
Children’s Hospital in Lucerne, Switzerland.
He attended Medical School at the University of
Tuebingen, Germany from 1988-1995 and residency
and fellowship at the Department of Pediatric Surgery
at the Hannover Medical School in Hannover, Germany
from 1995-2002. He then became Attending Surgeon
at the Department of Pediatric Surgery at the University
Children’s Hospital again in Tuebingen, Germany from 2002-2006. From 2006-2013
he was assigned to the Deputy Head of the Department.
Dr. Szavay is particularly interested in minimally invasive pediatric surgery as well
as in pediatric urology. He has a strong focus on surgical education especially in
the field of minimally invasive techniques and directed numerous national and
international courses respectively. He is a member of the Executive Board of the
German Society of Pediatric Surgery as well as of several professional societies.
Dr. Szavay has published more then 37 manuscripts, 3 book chapters and 2 DVD’s
on minimally invasive pediatric urology and on thoracoscopy and presented over
120 abstracts.
IPEG 2014 CORPORATE SUPPORTERS

Diamond Level Gold Level
Stryker Endoscopy Karl Storz Endoscopy
WWW.IPEG.ORG | 7
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2014 Program Chairs CONTINUED

Katherine A. Barsness, MD
Program Co-Chair
Ann & Robert H Lurie Children’s Hospital, Chicago, Illinois
Dr. Katherine A. Barsness received her cum laude B.S.
degree in Biochemistry and her honors M.D. degree from
the University of Tennessee. Dr. Barsness then went on to
complete her internship and residency in general surgery,
and a two-year basic science and trauma research program,
at the University of Colorado. In 2007, Dr. Barsness completed her pediatric
surgery fellowship at the University of Pittsburgh, and then joined the faculty at
Northwestern University Feinberg School of Medicine, where she currently holds
a joint appointment as an Assistant Professor in the Departments of Surgery
and Medical Education. Dr. Barsness has received numerous teaching awards
throughout her career, and is well recognized for her work in pediatric surgical
education, both in the US and abroad. Dr. Barsness is the Director of Surgical
Simulation for Ann and Robert H. Lurie Children’s Hospital of Chicago. Dr. Barsness
was also recently appointed as the Director of Surgical Clinical Outcomes Research
and an Associate Director of Surgical Translational Research for the Children’s
Research Center at Lurie Children’s Hospital. She sits on the curriculum committee
for simulation-based education, and serves as the Director of External Relations,
for the Center for Education in Medicine in Northwestern University Feinberg
School of Medicine. Dr. Barsness’ research focuses on the development and
validation of educational tools and simulation models for use in pediatric surgical
training. Dr. Barsness is a strong advocate for the advancement of surgical skills
across the continuum of medical education, and remains committed to the growth
and development of IPEG into a world-class organization, advancing the science of
advanced minimally invasive surgical techniques for infants and children.
Pablo Laje, MD
Program Co-Chair
Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
Dr. Pablo Laje is currently Assistant Professor of Surgery at
the University of Pennsylvania and Attending Surgeon at the
Children’s Hospital of Philadelphia (CHOP), USA. He attended
Medical School at the University of Buenos Aires and graduated
in 1999. He trained in pediatric surgery at the JP Garrahan
Pediatric Hospital in Buenos Aires, Argentina and obtained his Board Certification
in 2005. Pursuing further training he went to CHOP in 2005 for a clinical/research
fellowship in pediatric and fetal surgery. In 2011 he was appointed CHOP faculty.
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2014 Program Chairs CONTINUED

Dr. Laje has a particular interest in pediatric minimally invasive surgery and has
conducted numerous basic science research projects to study the physiological
implications of minimally invasive surgery on healthy and diseased organs. In
2008 he won the Best Basic Science Abstract Award at IPEG and obtained IPEG’s
Research Grant for his work on biliary atresia.
He has more than 30 publications on PubMed and has written multiple book
chapters in the pediatric surgery literature.
Go Miyano, MD
Program Co-Chair
Juntendo University School of Medicine, Tokyo, Japan
Go Miyano is currently an Associate Professor in the
Department of Pediatric General and Urogenital Surgery at
Juntendo University School of Medicine, and Chief Medical
Officer in the Department of Pediatric Surgery at Shizuoka
Children’s Hospital. He attended Juntendo University School
of Medicine, Tokyo, Japan from 1995-2001 and completed his residency and
fellowship in the Department of Pediatric General and Urogenital Surgery at
Juntendo University Hospital under the supervision of Atsuyuki Yamataka from
2001-2006. He was a visiting research fellow in the Department of Pediatric Surgery
at Blank Children’s Hospital under the supervision of Professor Thom E. Lobe from
2006-2007 and in the Department of Pediatric General and Thoracic Surgery at
Cincinnati Children’s Hospital under the supervision by Professor Thomas H. Inge
from 2007-2008. He has held his current position since 2009. He has a keen
interest in the education of medical students and residents, and was voted the
best tutor by his peers during his first year on faculty at Juntendo University School
of Medicine and awarded. He has since been actively involved as a member of the
Board of Directors for Medical Student Education at Juntendo University. He has
a strong focus on minimally invasive pediatric surgery, and has published over 60
manuscripts in authoritative peer-reviewed journals, over 30 as first author. He has
also given over 30 presentations at various international conferences.
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2014 CME Chairs

Celeste Hollands, MD
St. John’s Children’s Hospital in Springﬁeld, IL, USA
University of South Alabama in Mobile, AL, USA
Dr. Hollands is currently a Pediatric Surgeon at St. John’s
Children’s Hospital in Springﬁeld, Illinois and is Adjunct Associate
Professor of Surgery at the University of South Alabama in
Mobile, Alabama. Dr. Hollands completed medical school at the
University of South Alabama and completed her surgical
residency at The Graduate Hospital of the University of Pennsylvania. She completed
a Pediatric Trauma fellowship at The Children’s Hospital of Philadelphia and a Pediatric
Surgery Fellowship at Miami Children’s Hospital. She served on the surgical faculty
as Assistant Professor of Surgery and Pediatrics at Louisiana State University Health
Sciences Center in Shreveport, Louisiana where her research focused on developing
pediatric robotic surgical procedures. She served on the faculty of the University at
Buffalo, Women’s and Children’s Hospital of Buffalo as Associate Professor of Surgery
and Pediatrics where she was Director of the Miniature Access Surgery Center and
Director of Trauma. Dr. Hollands was Associate Professor of Surgery and Pediatrics at
the University of South Alabama where she served as Chief of Pediatric Surgery and
Director of Surgical Simulation. Dr. Hollands has published on topics that include:
minimally invasive and robotic surgery, pediatric trauma, simulation, and faculty
development. She serves on the Executive Committee of the American College of
Surgeons Committee on Medical Student Education, on the American College of
Surgeons and Association for Surgical Education Medical Student Core Curriculum
Steering Committee, is Secretary of the Association of Women Surgeons, and is active
in committee service in the International Pediatric Endosurgery Group, Society of
American Gastrointestinal and Endoscopic Surgeons, and Association for Surgical
Education. She serves on the editorial board of The American Journal of Surgery and
The Journal of Laparoendoscopic and Advanced Surgical Techniques and is an ad hoc
reviewer for several other journals. Her interests include advanced minimally invasive
surgery and robotics, technical skills acquisition, surgical simulation and education
Holger Till, MD, PhD

Medical University of Graz, Graz, Austria
Professor Holger Till is currently Chair Professor and Director of the
Department of Paediatric and Adolescent surgery at the Medical
University of Graz. He attended Medical School at the University of
Goettingen and the University of California in San Diego (UCSD). He
also participated in a student exchange program with the Harvard
Medical School and got fascinated by pediatric surgery while
working with Professor Patricia Donahoe at the Massachusetts General Hospital in Boston.
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2014 CME Chairs CONTINUED

After graduation in 1989 he completed his residency in General Surgery and his
fellowship in Pediatric Surgery at the Ludwig-Maximilians University of Munich. His
career as a Pediatric Surgeon started at the Dr. von Hauner Children’s Hospital of the
University of Munich. In 2004 he became an Assistant Professor of Pediatric Surgery
at the Chinese University of Hong Kong with Professor Yeung. In 2006 he returned to
Germany and accepted the Professorship for Pediatric Surgery in Leipzig until becoming
the successor of Professor Michael Höllwarth in Graz in 2012.
Professor Till has a special interest in pediatric minimal invasive surgery and was the
director of the Single-Portal Laparoscopic Surgery (SPLS) training course at the IRDC
(International Reference and Development Center for Surgical Technology) in Leipzig.
He also chaired the training academy of the German Society of Pediatric Surgery. His
present research introduces modern techniques like metabolomics and proteomics to
malformations of the newborn as well as morbid obesity. He has published more than
130 scientific articles in national and international indexed journals and presented over
100 abstracts. Professor Till is a member of several professional societies and serves on
the Editorial Board of many prestigious journals.
Suzanne M. Yoder, MD
Pediatric Surgeon in Arizona and Kansas, USA
Dr. Yoder graduated from Jefferson Medical College in
Philadelphia and completed her surgical residency at the
University of California San Diego. After spending one year
at the Fetal Treatment Center at the University of California
San Francisco Dr. Yoder completed a surgical critical care
fellowship at Children’s Mercy Hospital in Kansas City and then
her pediatric surgery fellowship at Yale. Dr. Yoder then joined the pediatric surgery
practice at the Rocky Mountain Hospital for Children in Denver Colorado. After
four years in Denver, Dr. Yoder moved back to California to pursue her interest in
international surgical initiatives. Currently, Dr. Yoder works as a locum tenens pediatric
surgeon in Arizona and Kansas while continue her involvement in various international
surgery projects. She is an active member in the SAGES Global Affairs Committee
having traveled to Mongolia four times to teach laparoscopic surgery in that country.
Besides Mongolia, Dr. Yoder has participated in surgical outreach in Bolivia, Vietnam,
Belize, Tanzania, and Haiti. Dr. Yoder remains active in the education committee and
the CME committee of IPEG. Outside of surgery, Dr. Yoder enjoys surfing, skiing,
hanging out with her dog and training for triathlons.
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2014 Meeting Leaders

PROGRAM COMMITTEE
Aayed R. Al-Qahtani, MD Philipp O. Szavay, MD
Maria Marcela Bailez, MD ★ Hiroo Uchida, MD
Katherine A. Barsness, MD Benno Ure, MD, PhD
Ciro Esposito, MD Jean-Stephane Valla, MD
Alan W. Flake, MD Kenneth Wong, MD
James D. Geiger, MD Mark L. Wulkan, MD ★
Keith E. Georgeson, MD C.K. Yeung, MD
Miguel Guelfand, MD
Anna Gunnarsdottir, MD
★ Executive Committee
Munther J. Haddad, FRCS
Carroll M. Harmon, MD, PhD
Ronald Hirschl, MD 2014 Pediatric Colorectal,
George W. Holcomb III, MD Motility and Pelvic
Celeste Hollands, MD ★ Reconstruction Conference
Satoshi Ieiri, MD November 12-14, 2014
Saleem Islam, MD Nationwide Children’s Hospital
Columbus, Ohio
Tadashi Iwanaka, MD ★
Pablo Laje, MD Led by Program Directors, Marc Levitt, MD
and Karen Diefenbach, MD, and experts in
Marc A. Levitt, MD ★ GI and Urology, the conference will feature
Long Li, MD ★ hands-on labs and case submissions from
attendees. Visiting faculty will include
Sean S. Marven, FRCS
Drs. Georgeson, Langer, De la Torre,
John J. Meehan, MD Teitelbaum and many others.
Go Miyano, MD
Oliver J. Muensterer, MD
Todd A. Ponsky, MD ★
Steven Rothenberg, MD
Atul J. Sabharwal, MD
Shawn D. St Peter, MD
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2014 Meeting Leaders CONTINUED

EXECUTIVE COMMITTEE
PRESIDENT: Benno Ure, MD, PhD
PRESIDENT-ELECT: Mark L. Wulkan, MD ◆
1st VICE PRESIDENT: Maria Marcela Bailez, MD ◆
2nd VICE PRESIDENT: David C. van der Zee, MD, PhD
SECRETARY: Todd A. Ponsky, MD ◆
TREASURER: Marc A. Levitt, MD ◆
EDITOR: Daniel J. Ostlie, MD
AMERICAS REPRESENTATIVE: Timothy D. Kane, MD
EUROPE REPRESENTATIVE: Holger Till, MD, PhD
WORLD-AT-LARGE REPRESENTATIVE: Edward Esteves, MD
WORLD-AT-LARGE REPRESENTATIVE: Long Li, MD ◆
CME CHAIR: Celeste Hollands, MD ◆
PAST PRESIDENT: Tadashi Iwanaka, MD, PhD ◆
◆ Program Committee
PAST PRESIDENTS
Tadashi Iwanaka, MD, PhD (2013)* Craig Albanese, MD (2003)*
Carroll M. Harmon, MD, PhD (2012)* Vincenzo Jasonni, MD (2002) – Retired
Gordon A. MacKinlay, OBE (2011)* – Peter Borzi, MD (2001)*
Retired Steven Rothenberg, MD (2000)*
Marcelo Martinez Ferro, MD (2010)* Juergen Waldschmidt, MD (1999) –
George W. Holcomb III, MD (2009)* Deceased
Jean-Stephane Valla, MD (2008)* Hock L. Tan, MD (1998) – Retired
Atsuyuki Yamataka, MD (2007)* Takeshi Miyano, MD (1997) – Retired
Keith Georgeson, MD (2006)* – Retired Steven Rubin, MD (1996) – Retired
Klaas (N) M.A. Bax, MD (2005) – Retired Gunter-Heinrich Willital, MD (1995)*
C.K. Yeung, MD (2004)*
*Active Past Presidents
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2014 IPEG Faculty *CONFIRMED

Hossein Allal, MD – Montpellier, France
Aayed R. Al-Qahtani, MD – Riyadh, Saudi Arabia ◆
Georges Azzie, MD – Toronto, Canada
Maria Marcela Bailez, MD – Buenos Aires, Argentina ◆
Katherine A. Barsness, MD – Chicago, IL, USA ◆
Simon Clarke, MD – London, United Kingdom
Matthew S. Clifton, MD – Atlanta, GA, USA
David C. G. Crabbe, MD – Leeds, United Kingdom ▲
Mark Davenport, MD – London, United Kingdom ▲
Dafydd A. Davies, MD – Halifax, Canada
Karen A. Diefenbach, MD – Columbus, OH, USA
Alex Dzakovic, MD – Chicago, IL, USA
Simon Eaton, PhD – London, United Kingdom
Peter Thomas Esslinger, MD – Lucerne, Switzerland
Paula Flores, MD – Buenos Aires, Argentina
Stefan Gfroerer, MD – Frankfurt, Germany
Miguel Guelfand, MD – Santiago, Chile ◆
Carroll M. Harmon, MD, PhD – Buffalo, NY, USA ◆
George W. Holcomb III, MD – Kansas City, MO, USA ◆
Celeste Hollands, MD – Mobile, AL, USA ◆
Timothy D. Kane, MD – Washington, DC, USA
Joachim F. Kuebler, MD – Hannover, Germany
Martin Lacher, MD – Hannover, Germany
Pablo Laje, MD – Philadelphia, PA, USA ◆
Andreas Leutner, MD – Dortmund, Germany
Marc A. Levitt – Columbus, Ohio, USA ◆
Charles M. Leys, MD – Madison, WI, USA ◆ Program Committee
Long Li, MD – Beijing, China ◆ ▲ BAPS Faculty
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2014 IPEG Faculty CONTINUED

Manuel Lopez, MD – Saint Etienne, France
Tobias Luithle, MD – Tuebingen, Germany
Gordon A. MacKinlay, OBE – Edinburgh, United Kingdom
Maximillano Marcic, MD – Buenos Aires, Argentina
Marcelo Martinez Ferro, MD – Buenos Aires, Argentina
Sean S. Marven, FRCS – Sheffield, United Kingdom ◆
Milissa A. McKee, MD – Branford, CT, USA
John J. Meehan, MD – Seattle, WA, USA ◆
Martin L. Metzelder, MD – Vienna, Austria
Marc P. Michalsky, MD – Columbus, OH, USA
Carolina A. Millan, MD – Buenos Aires, Argentina
Go Miyano, MD – Tokyo, Japan ◆
Oliver J. Muensterer, MD – New York, NY, USA ◆
Daniel J. Ostlie, MD – Madison, WI, USA
Agostino Pierro, MD – Toronto, Canada ▲
Todd A. Ponsky, MD – Akron, OH, USA ◆
Steven Rothenberg, MD – Denver, CO, USA ◆
Juergen Schleef, MD – Torino, Italy
Shawn D. St. Peter, MD – Kansas City, MO, USA ◆
Philipp O. Szavay, MD – Lucerne, Switzerland ◆
Holger Till, MD, PhD – Graz, Austria
Rick Turnock, MD – Liverpool, United Kingdom ▲
Benno Ure, MD, PhD – Hannover, Germany ◆
Reza M. Vahdad, MD – Bochum, Germany
David C. van der Zee, MD, PhD – Utrecht, The Netherlands
Mark L. Wulkan, MD – Atlanta, GA, USA ◆
CK Yeung, MD – Hong Kong, China ◆ ◆ Program Committee
Suzanne M. Yoder, MD – Venice, CA, USA ▲ BAPS Faculty
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Schedule-at-a-Glance
PRE-MEETING COURSE
Tuesday, July 22 Lowther
4:00 pm – 8:00 pm Postgraduate Lecture: MIS in Infants and Neonates
IPEG’S 23rd ANNUAL CONGRESS

Wednesday, July 23 Lennox 1 & 2
8:00 am - 11:00 am Hands On Lab: Critical Technical Skills for Neonatal
and Infant Minimally Invasive Surgery
8:00 am – 11:00 am Simulator Hands On Lab: Advanced Neonatal High
Fidelity Course for Advanced Learners
1:00 pm – 5:00 pm Simulator Hands On Lab: Innovations in Simulation-
Based Education for Pediatric Surgeons
5:00 pm – 7:00 pm Joint IPEG/BAPS Opening Ceremony/Welcome Reception
in the Exhibit Hall
Thursday, July 24 Lennox 3
7:00 am – 8:00 am Morning Scientific Video Session I:
Coolest Tricks, Extraordinary Procedures
8:00 am – 8:05 am Welcome Address
8:05 am – 9:00 am Scientific Session: Gastrointestinal
9:00 am – 9.30 am Presidential Address & Lecture:
“Music, Endoscopic Surgery and IPEG”
9:30 am – 4:00 pm Exhibits/Posters Open
9:30 am – 10:00 am Break
10:00 am– 11:30 am Basic Science and Misc
11:30 am – 12:30 pm Lunch Break
12:00 pm – 1:00 pm Top Posters 1-20: Digital Presentation
1:00 pm – 5:50 pm IPEG & BAPS JOINT PROGRAMS Pentland, Sidlaw &
Fintry Auditorium
1:00 pm – 3:00 pm IPEG/BAPS Presidential Debate:
“Esophageal and Diaphragmatic Surgery –
Thoracoscopic vs. Open”
3:00 pm – 3:30 pm Break
3:30 pm – 5:20 pm IPEG/BAPS Best Clinical Paper Session
5:20 pm – 5:50 pm Karl Storz Lecture: “Developing Neonatal MIS Surgery,
Innovation, Techniques, and Helping an Industry to Change”
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Schedule-at-a-Glance CONTINUED
Friday, July 25 Lennox 3
7:00 am – 8:00 am Morning Scientific Video Session II
8:00 am – 9:30 am Scientific Session: Urogenital
9:30 am – 10:00 am Break
10:00am – 11:00 am Scientific Session: Gastrointestinal & Hepatobiliary II
11:00 am – 12:00 pm Scientific Session: Panel – “Laparoscopy in the Neonate
and Infant: What’s New?”
12:00 pm – 1:00 pm Lunch Break
12:00 pm – 1:00 pm Top Posters 21-40: Digital Presentation
1:00 pm – 1:30 pm Keynote Lecture: “Lean Processes in the Hospital”
1:30 am – 2:30 pm Panel: Single Site Surgery
2:30 pm – 3:30 pm Scientific Session: Thorax
3:30 pm – 4:00 pm Break
4:00 pm – 5:00 pm Scientific Session: Bariatric, Robotics & Alternative
Technologies
5:00 pm – 6:00 pm Panel: Live Surgery
7:00 pm – 11:30 pm Main Event Lennox 1 & 2
Celeigh and IPEG Dance Off – After Hours!
Saturday, July 26 Lennox 3
8:00 am – 9:00 am Miscellaneous: Short Oral Papers
9:00 am – 9:30 am General Assembly: Presentation of the IPEG 2015
President
9:30 am – 9:45 am Awards: Coolest Tricks/Basic Science/IRCAD
9:45 am – 10:45 am Scientific Session: Single Site Surgery
10:45 am – 12:00 pm Saturday Movie Matinee: Complications –
“My Worst Nightmare” – Complicated Cases, Pitfalls
and Unusual Solutions
12:00 pm Closing Remarks
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Innovations Corner
ESOPHAGEAL ATRESIA MODEL
A Training Model in Thoracoscopic Surgery for Esophageal Atresia
INTRODUCTION: Through time, the training
and development of technical skills
have been performed in the operating
room. Clinical training using simulated
environments may improve the efficiency
and safety of laparoscopic surgery. We
present a training model in laparoscopic
surgery for esophageal atresia (EA).
MATERIAL & METHODS: To confine the

training model, we divide it in three parts:
A) Video surgery equipment. A video
endoscopic unit with an image integrated
module, three 3.5mm trocar, one 5.5 mm
trocar, 3mm instruments. B) A doll is used,
which simulated a term newborn having a
longitudinal anterior and posterior opening
of 10 cms long and 2cms wide, through
which a separator is introduced. C). Rabbit
tissue or synthetic material are used. We
proceed to place the videosurgery unit
just like a real procedure. Placing the optic, visualizes the first image of esophagus
and trachea. Afterwards, performing a meticulous dissection the separation of the
tracheoesophagean partition is done, a suture thread 5/0 is placed around the
esophagus, making an intracorporeal knot. The same surgical technique, end to end
anastomosis is performed.
CONCLUSION: Since the beginning of laparoscopy, the use of simulators have proven a
great potential for training and acquiring skills , shortening the learning curve and the
early use in real procedures. This model which perfectly simulates the environment of
an EA has been used by pediatric surgeons in the unit, allowing them to acquire skills
that could then be applied during surgery.
KEYWORDS: Training model, esophageal atresia.
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Innovations Corner CONTINUED

ESPHAGEAL ATRESIA - COLEDOCO YEYUNO ANASTOMOSIS
An Inanimate Model for Training Toracoscopic Repair
of TEF/Esophageal Atresia
AIM: Present the evolution of
a model developed for specific
trainning in toracoscopic repair of
TEF/ Esophageal atresia.
MATERIAL & METHODS: The
video starts showing the view of
a complete repair using the final
version of the model done with
a 4mm lens, 3 mm instruments,
6/0 sutures and an HD camera.
The procedure is being done by a
postresidency fellow trained in open
surgery who has never participated
in a MIS TEF assisted by a senior MIS surgeon after being trained in basic inanimate
models (PedFLS) and practising endoscopic suturing for 144 hours. Exercises consisted
in dividing and suturing the fistula and doing an esophageal anastomosis with a
transanastomotic tube. Extracorporeal and intracorporeal sliding knot tying were used.
Aspects of the same model using 5mm instruments, 5/0 sutures and a 10mm lens
inside the pediatric FLS trainer follows. This was the previous environment that we
have used. Finally the domestic materials utilized are shown. We started with tubular
balloons of 2 different colours to simulate the esophageal mucosal layer and a bended
piece of for the traqueal simulation, always reproducing the view in an almost prone
position. A small piece of wood was used as a support and half of a larger plastic
corrugated tube (PVC) as a toracic posterior wall resembling ribs and intercostal spaces.
A white plastic ribbon as the vagus nerve and, a half inflated round balloon as the
lung were added and everything covered with an auto adhesive film as pleura. At the
beginning we used it inside the Pediatric FLS trainer which was replaced by a plastic toy
pink suitcase which can be perforated in the upper surface, making it easily portable.
RESULTS: A pediatric surgeon with little experience in MIS and none in neonatal
MIS was able to complete aTEF/ Esophageal atresia repair in the final version of the
model in 70 minutes assisted by an experienced MIS surgeon. Cost of the matherials
was less than 50 US$.
DISCUSSION: A reproducible unexpensive inanimate model has been developed as an
additional tool to facilitate the learning curve for MIS TEF surgery. Future validation is
needed.
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MAGNETIC ASSIST LAP TRAINER
Simulation Model for the Training of Magnet-Assisted
Laparoscopic Surgery
Magnet-Assisted laparoscopy is
a novel surgical technique that
requires additional training. In
order to train surgeons with this
technique, we have designed a
model that simulates the outer and
inner environment during magnet-
assisted laparoscopy. With the aid
of a local pediatric orthopedist, we
built the core of the trainer with
propylene (45 cm long x 28 cm wide
x 18 cm thick). At the outer surface,
we covered the center portion
of the trainer with a 4-mm thick neoprene fabric (40 cm vertical axis x 50 cm wide)
attached with Velcro. This system creates a hinge mechanism that allows for practical
removal of surgical tools and simulated organs. So far, we have custommade several
organs with foam rubber including liver-gallbladder (cystic duct and artery), uterus and
most recently colon and appendix.
During manufacture, we have taken into account several key factors:
1. To develop a trainer with optimal ergonomics.
2. To use simulated organs with similar appearance and consistency as the human tissue.
3. To use low cost of materials.
4. The model should require straightforward transportation.
5. The trainer should have smooth surfaces that enable optimal sliding of the
magnetic instruments in the outer surface as well in the inside.
NEEDLESCOPIC SURGERY WITH STRYKER’S MINILAP

Stryker’s needlescopic instruments have the ability to eliminate ports without
compromising proven safe surgical techniques. Because there are no trocars used, these
13 gauge percutaneous instruments may reduce trauma and may offer increased cosmetic
benefits for all laparoscopic procedures, including hysterectomies and sacrocolpopexies
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NEONATAL
Neonatal Minimally Invasive Surgery Trainers
Scaled-neonatal trainers were designed to
develop specific minimally invasive surgery
skills. Initial measurements were taken of
infants in the neonatal ICU between 2.5
and 3.5 kg with an average of 2.8 kg. Scaled
training models were fabricated to simulate
both laparoscopic and thoracoscopic
procedures. Six models were developed in
2006 including the laparoscopic dexterity
skills, laparoscopic running the bowel,
laparoscopic suturing under tension,
laparoscopic suturing of an anastomosis,
thoracoscopic diaphragmatic hernia repair,
and thoracoscopic esophageal atresia repair.
The initial construct validity results were
presented at IPEG in Buenos Aires at the
2007 meeting followed by expert testing
at IPEG 2009 with benchmark results
presented at the 2010 IPEG conference.
DA VINCI SURGICAL SKILLS SIMULATOR

The da Vinci Skills Simulator contains
a variety of exercises and scenarios
specifically designed to give users
the opportunity to improve their
proficiency with the da Vinci surgeon
console controls.
The case seamlessly integrates with
an existing da Vinci® Si™ or Si-e™
surgeon console* and no additional
system components are required.
Built-in metrics enable users to
assess skills, receive real-time feedback and track progress.
Administrative tools let users structure their own curriculum to fit with other learning
activities in their institution.
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PEDIATRIC LAPAROSCOPIC SKILLS
Pediatric Laparoscopic Surgery (PLS) simulator
The Pediatric Laparoscopic Surgery
(PLS) simulator has been developed
over several years, the emphasis being
on tasks proven to benefit in the
performance of Minimal Access Surgery
(MAS) and for which construct validity
(the ability to differentiate between
novices, intermediates and experts) has
been established.
The model is a box trainer tailored to
represent the size constraints (limited
domain) faced by a pediatric surgeon.
Performance with regard to time
for completion and precision on individual tasks, as well as total score, allow one to
discriminate between novice, intermediate and expert. The simulator’s simple design
makes it very practical, whether using the validated tasks or a model of your choice.
Further development using motion tracking of instruments within the PLS simulator may
allow real time analysis of movement, and further improve the educational benefit.
TEF-CDH MODELS
Accurate measurements of ribs,
thoracic space and scapulae for
term neonates (50th% for age) were
obtained from literature review.
Solidworks 3D modeling software
was used to design a rib cage with
scapulae, replicating the exact
dimensions of the thoracic cavity of
a neonate. The rib cage was printed
in ABS plastic on rapid prototyping
machinery. The right side of the rib
cage was printed for the esophageal
atresia/tracheoesophageal fistula (EA/
TEF) model, while only the left side of the rib cage was printed for the diaphragmatic
hernia (DH) model. Artificial tissue was modeled to recreate the anatomic abnormalities
of EA/TEF and DH and secured to a base of platinum-cured silicon rubber. The entire
apparatuses were then covered with synthetic silicon skin.
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PYLORUS MODEL
History of the UK pylorus model
When I arrived at the University
of Kentucky in 2003, one of my
senior partners expressed a desire
to learn how to do a laparoscopic
pyloromyotomy. However, he
had very limited laparoscopic
experience. We had a “dry lab”
in the department that had MIS
set-ups. We wanted to design an
inexpensive model that would
allow him to get used to the 2
dimensional world of laparoscopy
as well as practice the key sequence of steps for a pyloromyotomy. We quickly realized
that we could make a glove into a “stomach” very easily. Our first model used foam
rubber for the muscularis and ioban drape for serosa. The glove itself is the mucosa.
This is the model which we used to teach the cadence and the “feel” for lap pylorics. He
successfully transitioned to laparoscopic pyloromyotomy but pointed out that the foam
rubber did not feel the same when the spread was completed. The following year, I was
approached by Stryker to use the model at an APSA meeting to get pediatric surgeons
to try a pyloric spreader they were hoping to market. At that meeting we took the
opportunity to get feedback from surgeons on both the instrument AND the model.
The same issues with the foam came up. One day, I was thinking about fixing the model
and the thought of using an olive came to mind. I made some trials and found that an
green olive had the right “feel” for splitting the pylorus when stretched. A pitted green
“queen” size olive is consistently 5mm thick and 15-20 mm long and when wrapped in
ioban, has a feel that is very close to the inflamed muscle of pyloric stenosis The final
change in the model occurred when the procedure switched in the OR form a cold knife
to a bovie to cut the serosa. The ioban serosa is now pre cut and the bovie maneuver
is not made with heat in the model. To date, over 300 learners have used the model
and the feedback is good. A pilot study showing the results of training novices with the
model showed good reliability and reproducibility was published in 2010. J Laparoendosc
Adv Surg Tech A. 2010 Jul-Aug;20(6):569-73.
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Complete Schedule TUESDAY, JULY 22

PRE-MEETING COURSE
Tuesday, July 22 Lowther
4:00 pm – 8:00 pm POSTGRADUATE LECTURE: MIS in Infants and Neonates
CHAIR: Katherine A. Barsness, MD
DESCRIPTION: This course includes a series of didactic lectures that focus on the
successful strategies for implementing neonatal minimally invasive surgery. Each
speaker will discuss preoperative concerns, intraoperative set up and patient
positioning, as well as tips and tricks for successfully overcoming any barriers to
completing a neonatal MIS procedure. This course is designed for beginning and
advanced MIS pediatric surgeons who are looking to expand their knowledge on
the skills, techniques, and strategies for neonatal minimally invasive surgery.
OBJECTIVES
By the conclusion of the course, participants will be able to:
• Articulate proper intra-operative set-up for a variety of neonatal MIS procedures
• Describe appropriate patient positioning and port placement for a variety of
neonatal MIS procedures
• Describe common barriers to success for a variety of neonatal MIS procedures,
and describe strategies to overcome these barriers
• Understand how to add simulation-based educational strategies to the their
current practice.
TIME TOPIC FACULTY

4:00 pm Duodenal Artresia Karen A. Diefenbach, MD
4:30 pm Tracheoesophageal Fistual Philipp O. Szavay, MD
5:00 pm Urology MIS Joachim F. Kuebler, MD
5:30 pm Break
5:45 pm Neonatal Robotics John J. Meehan, MD
6:15 pm Diaphragmatic Hernia Matthew S. Clifton, MD
6:45 pm Simulation-based Education Katherine A. Barsness, MD
7:15 pm Q&A All
IPEG acknowledges our Diamond Level Donor for their support of the course:
Stryker Endoscopy
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Complete Schedule WEDNESDAY, JULY 23

Wednesday, July 23 Lennox 1 & 2
8:00 am - 11:00 am HANDS ON LAB: Critical Technical Skills for Neonatal
and Infant Minimally Invasive Surgery
CHAIR: Karen A. Diefenbach, MD
CO-CHAIRS: Manuel Lopez, MD, Go Miyano, MD
& David C. van der Zee, MD, PhD
DESCRIPTION: Learn the critical skills necessary to safely perform operations
in newborn infants, including instrument and suture selection, port placement,
intracorporeal suturing, and instrument handling skills. Neonatal simulation
models and 3 mm instruments will be used at all stations. Performance metrics
will be assessed at the completion of the course.
OBJECTIVES
At the conclusion of this session, participants will be able to:
• Choose appropriate instruments for neonatal and infant laparoscopy and
thoracoscopy
• Demonstrate improved instrument handling within the confines of a newborn
chest or abdomen
• Perform a successful intracorporeal knot.
FACULTY: Alex Djakovic, MD; Peter Thomas Esslinger, MD; Stefan Gfroerer, MD;
Joachim F. Kuebler, MD; Andreas Leutner, MD; Martin L. Metzelder, MD; Manuel
Lopez, MD; Reza M. Vahdad, MD; and David C. van der Zee, MD, PhD
IPEG acknowledges support for this course from: Karl Storz Endoscopy and
Stryker Endoscopy
8:00 am – 11:00 am SIMULATOR HANDS ON LAB: Advanced Neonatal High

Fidelity Course for Advanced Learners
CO-CHAIRS: Georges Azzie, MD & Pablo Laje, MD
DESCRIPTION: This course is designed for advanced MIS pediatric surgeons who
are about to begin, or have already begun, to introduce laparoscopic duodenal
atresia repair, thoracoscopic diaphragmatic hernia repair (with and without a
patch), thoracoscopic TEF repair, and/or thoracoscopic lobectomy. All participants
must provide a Departmental Chief’s letter documenting expertise in basic MIS
procedures, to be eligible to attend this course. Performance metrics will be
assessed at the completion of the course.
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OBJECTIVIES
• Choose appropriate instruments for neonatal laparoscopy and thoracoscopy
• Demonstrate improved instrument handling and knot tying skills within the
confines of a newborn chest or abdomen
• Demonstrate and describe port placement for common neonatal procedures.
FACULTY: Georges Azzie, MD; Maria Marcela Bailez, MD; Simon Clarke, MD;
Matthew S. Clifton, MD; Pablo Laje, MD; Tobias Luithle, MD; and Philipp O.
Szavay, MD
Stryker Endoscopy
1:00 pm – 5:00 pm SIMULATOR HANDS ON LAB: Innovations in Simulation-

Based Education for Pediatric Surgeons
CO-CHAIRS: Karen A. Diefenbach, MD & Carolina A. Millan, MD
DESCRIPTION: Practice your MIS skills and learn some new ones at the Innovations
in Simulation-based educational course. Simulation-based instruction will include
advanced surgical techniques for TEF, duodenal atresia, diaphragmatic hernia,
choledochojejunostomy, pyloromyotomy, single incision surgical techniques,
gastrostomy, technical skills models, and many more innovative models.
Participants of all levels of MIS skill are encourage to attend the course.
OBJECTIVIES
• Choose appropriate instruments for neonatal and infant laparoscopy and
thoracoscopy
• Demonstrate improved instrument handling and knot tying skills within the
confines of a newborn chest or abdomen
• Describe port placement for TEF and duodenal atresia operations.
FACULTY: Hossein Allal, MD; Georges Azzie, MD; Maria Marcela Bailez, MD;
Katherine A. Barsness, MD; Matthew S. Clifton, MD; Karen A. Diefenbach, MD;
Paula Flores, MD; Pablo Laje, MD; Charles M. Leys, MD; Manuel Lopez, MD;
Tobias Luithle, MD; Maximillano Marcic, MD; Marcelo Martinez Ferro, MD; Marc P.
Michalsky, MD; Milissa A. McKee, MD; Carolina A. Millan, MD; Oliver J. Muensterer,
MD; Shaw D. St Peter, MD; Philipp O. Szavay, MD; Holger Till, MD, PhD; and
Suzanne M. Yoder, MD
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STATIONS/FACULTY STATION
Hossein Allal, MD TEF doll Model
Georges Azzie, MD PLS
& Dafydd A Davies, MD
Maria Marcela Bailez, MD, TEF trainer
Maximillan Marcic, MD Duodenal atresia trainer
& Paula Flores, MD Hepaticojejunostomy model
Katherine A. Barsness, MD DH
DA
TEF
Gastrostomy Tube
Karen A. Diefenbach, MD Skills
Intestine
CDH
Marc P. Michalsky, MD Ethicon band Model
Olympus single port
Applied medical single site
Marcelo Martinez Ferro, MD, Magnet Model
& Carolina Millan, MD Hybrid for single site cholecystectomy
Stryker Endoscopy
5:00 pm – 7:00 pm Joint IPEG/BAPS Opening Ceremony/Welcome Reception
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Complete Schedule THURSDAY, JULY 24

Thursday, July 24 Lennox 3
7:00 am – 8:00 am MORNING SCIENTIFIC VIDEO SESSION I:
Coolest Tricks, Extraordinary Procedures
CHAIRS: Miguel Guelfand, MD & Todd A. Ponsky, MD
7:00 am V001: LEFT UPPER LOBECTOMY FOR CPAM USING A 3MM TISSUE
SEALING DEVICE; A STEP BY STEP APPROACH S tephen Oh, MD, Steven
S. Rothenberg, MD, The Morgan Stanley Children’s Hospital, Columbia
University
7:06 am V002: THORACOSCOPIC DIVISION OF H-TYPE TRACHEOESOPHAGEAL
FISTULA M atthew S. Clifton, MD, Paul M. Parker, MD, Emory University/
Children’s Healthcare of Atlanta
7:12 am V003: THORACOSCOPIC RESECTION OF A BRONCHOGENIC CYST
LOCATED AT THE THORACIC INLET M eghna V. Misra, MD, Tulio Valdez,
MD, Anthony Tsai, MD, Brendan T. Campbell, MD, MPH, Connecticut
Children’s Medical Center
7:18 am V004: THORACOSCOPIC APPROACH IN RECURRENT
TRACHEOESOPHAGEAL FISTULA R uben Lamas-Pinheiro, MD, Carlos
Mariz, MD, Joaquim Monteiro, MD, Tiago Henriques-Coelho, MD, PhD,
Pediatric Surgery Department, Faculty of Medicine, Hospital de São
João, Porto, Portugal
7:24 am V005: A THORACOSCOPIC APPROACH TO AN UNUSUAL MEDIASTINAL
MASS V ictoria K. Pepper, MD, Peter C. Minneci, MD, Karen A.
Diefenbach, MD, Nationwide Children’s Hospital
7:30 am V006: THORACOSCOPIC PERICARDIAL WINDOW FOR TREATMENT
OF REFRACTORY PERICARDIAL EFFUSION AND TAMPONADE O liver J.
Muensterer, MD, PhD, Samir Pandya, MD, Matthew E. Bronstein, MD,
Gustavo Stringel, MD, Suvro S. Sett, MD, Divisions of Pediatric Surgery
and Pediatric Cardiac Surgery, New York Medical College
7:36 am V007: COMBINATION OF VALUABLE TECHNICAL RESOURCES FOR THE
CORRECTION OF DIAPHRAGMATIC HERNIA (VIDEO) C arolina Millan,
MD, Fernando Rabinovich, MD, Luzia Toselli, MD, Horacio Bignon, MD,
Gaston Bellia, MD, Mariano Albertal, MD, Guillermo Dominguez, MD,
Marcelo Martinez Ferro, MD, Private Children´s Hospital of Buenos Aires,
Fundación Hospitalaria, Buenos Aires, Argentina
7:42 am V008: THORACOSCOPIC MANAGEMENT OF AN ESOPHAGEAL LUNG,
REPORT OF A CASE Ivan Dario Molina, MD, S antiago Correa, MD, Ana
Garces, MD, Mizrahim Mendez, MD, Edgar Alzate, MD, Fundación
Hospital de la Misericordia, Universidad Nacional de Colombia
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7:48 am V009: TRANSCONTINENTAL TELEMENTORING WITH PEDIATRIC

SURGEONS- PROOF OF CONCEPT AND TECHNICAL CONSIDERATIONS
Todd A. Ponsky, MD, Marc H. Schwachter, MD, Ted Stathos, MD, Michael
Rosen, MD, Robert Parry, MD, Margaret Nalugo, Steven Rothenberg,
MD, Akron Children’s Hospital, Rocky Mountain Hospital for Children,
University Hospitals Case Medical Center
8:00 am – 8:05 am Welcome Address

Benno Ure, MD, PhD, 2014 President
8:05 am – 9:00 am SCIENTIFIC SESSION: Gastrointestinal

CHAIRS: Marc A. Levitt, MD & Juergen Schleef, MD
8:05 am S001: MINIMALLY INVASIVE SURGERY FOR PEDIATRIC TRAUMA – A
MULTI-CENTER REVIEW Hanna Alemayehu, MD, Diana Diesen, MD, Matt
Santore, MD, Matthew Clifton, MD, Todd Ponsky, MD, Margaret Nalugo,
MPH, Timothy Kane, MD, Mikael Petrosyan, MD, Ashanti Franklin, MD,
George W Holcomb III, MD, MBA, Shawn D St. Peter, MD, The Children’s
Mercy Hospital, Kansas City, MO; Children’s Medical Center, Dallas, TX;
Children’s Healthcare of Atlanta at Egleston, Atlanta, GA; Akron Children’s
Hospital, Akron, Ohio; Children’s National Medical Center, Washington, DC
8:10 am S002: OPEN VS. LAPAROSCOPIC MANAGEMENT OF APPENDICITIS
PERITONITIS IN CHILDREN: CLINICAL TRIAL F ernando Rey, MD, Andres
Perez, MD, William Murcia, MD, Fenando Fierro, MD, Ivan Molina, MD,
Juan Valero, MD, Jorge R. Beltran, MD, Fundación HOMI Hospital de la
Misericordia, Pediatric Surgery Unit, Universidad Nacional de Colombia,
Bogotá (COL)
8:15 am S003: FEASIBILITY OF SINGLE INCISION 3 STAGE TOTAL
PROCTOCOLECTOMY AND ILEAL POUCH ANAL ANASTOMOSIS
Avraham Schlager, MD, Matthew T. Santore, MD, Ozlem Balci, MD,
Drew A. Rideout, MD, Kurt F. Heiss, MD, Matthew S. Clifton, MD, Emory
University/Children’s Healthcare of Atlanta
8:20 am S004: EVALUATION OF LIFE QUALITY OF CHILDREN AFTER
LAPAROSCOPIC-ASSISTED TRANSANAL ENDORECTAL (SOAVE) PULL-
THROUGH FOR HIRSCHSPRUNG’S DISEASE Bo Xiang, MD, Yang Wu, PhD,
West Chian Hospital
8:25 am S005: SELECTIVE TRANSPERITONEAL ASPIRATION OF A DISTENDED
BOWEL WITH A SMALL-CALIBER NEEDLE DURING LAPAROSCOPIC
NISSEN FUNDUPLICATION: A PROSPECTIVE RANDOMIZED
CONTROLLED TRIAL C arlos Garcia-Hernandez, MD, Lourdes Carvajal-
Figueroa, MD, Sergio Landa-Juarez, MD, Adriana Calderon-Urrieta, MD,
Hospital Star Medica Lomas Verdes, México
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8:30 am S006: LAPAROSCOPIC REPAIR OF MALROTATION. WHAT ARE THE

INDICATIONS IN NEONATES AND CHILDREN? G o Miyano, MD,
Keiichi Morita, MD, Masakatsu Kaneshiro, MD, Hiromu Miyake, MD,
Hiroshi Nouso, MD, Masaya Yamoto, MD, Koji Fukumoto, MD, Naoto
Urushihara, MD, Department of Pediatric Surgery, Shizuoka Children’s
Hospital
8:35 am S007: LAPARSCOPIC REPAIR OF CONGENITAL DUODENAL
OBSTRUCTION IN NEONATE J inshi Huang, MD, Department of surgery,
Jiangxi provincal Children’s Hospital
8:40 am S008: COMPLICATIONS AFTER LAPAROSCOPY FOR RECTOVESICAL
FISTULA H amidReza Foroutan, Dr., Abbas Banani, Dr., Sultan Ghanem,
Dr., Reza Vahdad, Dr., Laparoscopic research center, Shiraz university
of Medical Sciences
8:45 am S009: LAPAROSCOPIC MESH RECTOPEXY FOR COMPLETE RECTAL
PROLAPSE Cindy Gomes Ferreira, MD, Paul Philippe, MD, Isabelle
Lacreuse, MD, Anne Schneider, MD, François Becmeur, PhD, MD,
1) Department of Paediatric Surgery, Clinique Pédiatrique, Centre
Hospitalier Luxembourg, Luxembourg 2) Department of Paediatric
Surgery, Hôpital de Hautepierre, Centre Hospitalier Universitaire de
Strasbourg, France
8:50 am S010: SINGLE INCISION LAPAROSCOPIC SPLENECTOMY USING THE
SUTURE SUSPENSION TECHNIQUE FOR SPLENOMEGALY IN CHILDREN
WITH HEREDITARY SPHEROCYTOSIS S uolin Li, MD, Meng Li, MD,
Weili Xu, MD, PhD, The Second Hospital of Hebei Medical University,
Shijiazhuang, China
8:55 am S011: LAPAROSCOPIC GASTROSTOMY AND LAPAROSCOPIC NISSEN/
GT IN CHILDREN WITH COMPLEX CONGENITAL HEART DEFECTS V .
Mortellaro, MD, J. Alten, MD, R. Russell, MD, R. Griffin, PhD, C. Martin,
MD, S. Anderson, MD, D. Rogers, MD, E. Beierle, MD, M. Chen, MD,
Children’s Hospital of Alabama
9:00 am – 9.30 am PRESIDENTIAL ADDRESS & LECTURE:

Benno Ure, MD, PhD, 2014 President
9:30 am – 10:00 am Break
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10:00 am – 11:30 am Basic Science and Misc
CHAIRS: Aayed R. Al-Qahtani, MD & Daniel J. Ostlie, MD
10:00 am S012: ENDOSCOPIC SURGICAL SKILL VALIDATION SYSTEM FOR

PEDIATRIC SURGEONS USING A REPAIR MODEL OF CONGENITAL
DIAPHRAGMATIC HERNIA S atoshi Obata, MD, Satoshi Ieiri, MD, PhD,
Munenori Uemura, PhD, Ryota Souzaki, MD, PhD, Noriyuki Matsuoka,
Tamotsu Katayama, Makoto Hashizume, MD, PhD, FACS, Tomoaki
Taguchi, MD, PhD, FACS, Department of Pediatric Surgery, Faculty
of Medical Science, Kyushu University, Department of Advanced
Medicine and Innovative Technology, Kyushu University Hospital,
Kyoto Kagaku Co., Ltd
10:09 am S013: THE DEVELOPMENT AND PRELIMINARY EVALUATION
OF A SYNTHETIC NEONATAL ESOPHAGEAL ATRESIA/
TRACHEOESOPHAGEAL FISTULA REPAIR MODEL K atherine A.
Barsness, MD, MS, Deborah M. Rooney, PhD, Lauren M. Davis, BA,
Ellen K. Hawkinson, BS, Northwestern University Feinberg School of
Medicine; University of Michigan School of Medicine
10:18 am S014: VIDEO-BASED SKILL ASSESSMENT OF ENDOSCOPIC SUTURING
IN A PEDIATRIC CHEST MODEL AND A BOX TRAINER S hinya Takazawa,
MD, Tetsuya Ishimaru, MD, PhD, Kanako Harada, PhD, Yusuke Tsukuda,
Naohiko Sugita, PhD, Mamoru Mitsuishi, PhD, Tadashi Iwanaka, MD,
PhD, The University of Tokyo Hospital
10:25 am S015: ANATOMICAL VALIDATION OF AN INANIMATE MODEL FOR
TRAINING THORACOSCOPIC REPAIR OF TRACHEO ESOPHAGEAL
FISTULA/ESOPHAGEAL ATRESIA – TEF/EA M aximiliano A. Maricic, MD,
Maria M. Bailez, MD, National Children’s Hospital S.A.M.I.C. “Prof. Dr.
Juan P. Garrahan”
10:32 am S016: THE LAPAROSCOPIC DUODENO-DUODENOSTOMY SIMULATOR:
A MODEL FOR CUSTOMIZABLE MINIMALLY INVASIVE SURGERY
TRAINERS Joanne Baerg, MD, Nicole Carvajal, Danielle Ornelas,
Candice Sanscartier, Diana Lopez, Cristine Cervantes, William Grover,
PhD, Gerald Gollin, MD, Loma Linda University Children’s Hospital and
University of California Riverside Biomedical Engineering Department
10:39 am S017: OPTIMIZING WORKING SPACE IN LAPAROSCOPY - CT
MEASUREMENT OF THE INFLUENCE OF SMALL BODY SIZE IN A
PORCINE MODEL J . Vlot, MD, Lme Staals, MD, PhD, Prof. RMH Wijnen,
MD, PhD, Prof. RJ Stolker, MD, PhD, Prof. NMA Bax, MD, PhD, Erasmus
MC: University Medical Center Rotterdam
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10:46 am S018: THE EFFECTS OF CO2-INSUFFLATION WITH 5 AND 10 MMHG

DURING THORACOSCOPY ON CEREBRAL OXYGENATION AND
HEMODYNAMICS IN PIGLETS L isanne J. Stolwijk, MD, Stefaan H.
Tytgat, MD, Kristin Keunen, MD, N. Suksamanapan, MD, Maud Y. van
Herwaarden, MD, PhD, Petra M. Lemmers, MD, PhD, David C. van der
Zee, Prof., Dr., Wilhelmina’s Children Hospital University Medical Center
Utrecht
10:53 am S019: MAGIC (MAGNETIC ANTI-GLYCEMIC ILEAL CONDUIT) I: JEJUNAL-
ILEAL MAGNETIC COMPRESSION ANASTOMOSIS CORRECTS INSULIN
RESISTANCE IN DIABETIC PIGS Hilary B. Gallogly, MD, Elisabeth J.
Leeflang, MD, Dillon A. Kwiat, Corey W. Iqbal, MD, Karyn J. Catalano,
PhD, Kullada O. Pichakron, MD, M ichael R. Harrison, MD, Department
of Surgery, University of California, Davis, Departments of Pediatric
Surgery and Obstetrics, Gynecology & RS, University of California, San
Francisco, Department of Surgery, David Grant Medical Center, Travis Air
Force Base
11:00 am S020: AMNIOSEAL I: A BIOMIMETIC POLYMER ADHESIVE TO PRESEAL
THE AMNIOTIC MEMBRANE TO PREVENT PPROM AFTER FETOSCOPY
Corey W. Iqbal, MD, Dillon A. Kwiat, BS, Stephanie Kwan, BS, Hoyong
Chung, PhD, Robert H. Grubbs, PhD, Michael R. Harrison, MD, University
of California San Francisco Fetal Treatment Center, Children’s Mercy
Hospital Fetal Health Center
11:07 am S021: THE PEDIATRIC DEVICE CONSORTIUM: A MODEL FOR SURGICAL
INNOVATION Elisabeth J. Leeflang, MD, Elizabeth A. Gress, Dillon A.
Kwiat, Hanmin Lee, MD, Shuvo Roy, PhD, M ichael R. Harrison, MD,
Departments of Pediatric Surgery and Bioengineering and Therapeutic
Sciences, University of California, San Francisco.
11:14 am S022: LONG TERM HEMODYNAMIC EFFECTS OF NUSS REPAIR IN PECTUS
EXCAVATUM FOR VENTRICULAR FUNCTION BY “CARDIOVASCULAR
MAGNETIC RESONANCE CINE-SSFP-IMAGING”, RESULTS OF BERLIN-
BUCH NUSS-CARDIO-MRI STUDY K . Schaarschmidt, Prof., MD, Susanne
Polleichtner, MD, A. Töpper, MD, A. Zagrosek, MD, M. Lempe, MD, F.
Schlesinger, MD, J. Schulz-Menger, Prof., MD, Helios Center of Pediatric
and Adolescent Surgery Berlin-Buch
11:21 am S023: 3-DIMENSIONAL VISION IMPROVES LAPAROSCOPIC SURGERY IN
SMALL SPACES Xiaoyan Feng, MD, Anna Morandi, MD, Martin Boehne,
MD, Tawan Imvised, MD, Benno Ure, MD, PhD, Joachim F. Kuebler, MD,
Martin Lacher, MD, PhD, Center of Pediatric Surgery, Department of
Pediatric Cardiology and Intensive Care Medicine, Hannover Medical
School, Germany
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11:30 am – 12:30 pm Lunch Break
12:00 pm – 1:00 pm TOP POSTERS 1-20: Digital Presentation

CHAIR: Oliver J. Muensterer, MD
12:00 pm T001: REDUCED PORT DISTAL PANCREATECTOMY FOR GIANT

PANCREATIC NEOPLASM: BEYOND THE EVENT HORIZON AND BACK
Samir Pandya, MD, Allison Sweny, MD, Oliver Muensterer, MD, New York
Medical College / Maria Fareri Children’s Hospital
12:03 pm T002: LAPAROSCOPIC ADRENALECTOMY USING A SINGLE WORKING
PORT: A CASE OF PRIMARY PIGMENTED NODULAR ADRENOCORTICAL
DISEASE Neetu Kumar, Kathryn Evans, Imran Mushtaq, Great Ormond
Street Hospital, London
12:06 pm T003: ROBOTIC-ASSISTED RESECTION OF A PYLORIC PANCREATIC
REST WITH PERORAL ENDOSCOPIC REMOVAL AND RECONSTRUCTION
BY PARTIAL GASTRODUODENOSTOMY O liver J. Muensterer, MD, PhD,
Samir Pandya, MD, Matthew E Bronstein, MD, Fouzia Shakil, MD, Aliza
Solomon, DO, Michel Kahaleh, MD, Division of Pediatric Surgery and
Pathology, New York Medical College, Division of Gastroenterology and
Pediatric Gastroenterology, Weill Cornell Medical College
12:09 pm T004: LAPAROSCOPY FOR SMALL BOWEL OBSTRUCTION IN CHILDREN
– AN UPDATE H anna Alemayehu, MD, Bryan David, Amita A. Desai, MD,
Corey W. Iqbal, MD, Shawn D. St. Peter, MD, The Children’s Mercy Hospital
12:12 pm T005: LAPAROSCOPIC TRANSDUODENAL DEROOFING OF THE
PERIAMPULLARY DUODENAL DUPLICATION CYST IN AN INFANT Y u
Sokolov, MD, PhD, Dm Donskoy, MD, A. Vilesov, MD, M. Shuvalov, MD,
M. Akopyan, MD, Dm Ionov, MD, E. Fokin, MD, St. Vladimir Children
Hospital, Moscow, Russia
12:15 pm T006: LAPAROSCOPIC ENUCLEATION OF TRUE PANCREATIC
CONGENITAL CYST M ariana Borges-Dias, Manuel Oliveira, José Estevão-
Costa, Miguel Campos, Pediatric Surgery Department, Faculty of
Medicine, Hospital São João, Porto, Portugal
12:18 pm T007: BIMANUAL SUTURING - A NOVEL TECHNIQUE IN
LAPAROSCOPIC REPAIR OF MORGAGNI HERNIA Kanika A. Bowen,
MD, Dean M. Anselmo, MD, N am X. Nguyen, Children’s Hospital Los
Angeles, Los Angeles, CA
12:21 pm T008: ROBOTIC CHOLEDOCHAL CYST EXCISION Adam C. Alder, MD,
Stephen M. Megison, MD, Children’s Medical Center Dallas
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12:24 pm T009: THE VACUUM BELL FOR CONSERVATIVE TREATMENT OF PECTUS

EXCAVATUM: ASSESSMENT OF ITS EFFICACY WITH DISTANCE AND
PRESSURE SENSORS S ergio B. Sesia, MD, Stefan Weiss, MSc, David
Hradetzky, D. Eng., Frank-Martin Haecker, MD, University Children’s
Hospital of Basel, Department of Paediatric Surgery, Basel, University
of Applied Sciences and Arts Northwestern Switzerland, School of Life
Sciences, Institute for Medical and Analytical Technologies, Muttenz,
Switzerland
12:27 pm T010: OUTCOME OF LAPAROSCOPIC SUTURE RECTOPEXY IN
PERSISTENT RECTAL PROLAPSE IN CHILDREN K arim Awad, MSc, MRCS,
Amr Zaki, MSc, MD, Mohamed Eldebeiky, MSc, MD, MRCS, Ayman
Alboghdady, MSc, MD, Tarak Hassan, MSc, MD, MRCS, Sameh Abdelhay,
MSc, MD, ain Shams University Hospitals
12:30 pm T011: SURGICAL TECHNIQUES FOR LAPAROSCOPY-ASSISTED REPAIR
OF MALE IMPERFORATE ANUS WITH RECTO-BULBAR FISTULA.
COMPARISON WITH RECTO-PROSTATIC FISTULA Hiroyuki Koga,
MD, M anabu Okawada, MD, Takashi Doi, MD, Go Miyano, MD, Hiroki
Nakamura, MD, Takanori Ochi, MD, Shogo Seo, MD, Geoffrey J Lane,
MD, Atsuyuki Yamataka, MD, Department of Pediatric General and
Urogenital Surgery,Juntendo University School of Medicine
12:33 pm T012: DIAPHRAGMATIC EVENTRATION REPAIR: SHOULD WE USE A
THORACOSCOPIC OR LAPAROSCOPIC APPROACH? Saidul Islam, K irsty
Brennan, Rajiv Lahiri, Anies Mahomed, Department of Paediatric
Surgery,Royal Alexandra Children’s Hospital,Brighton,U.K.
12:36 pm T013: EVOLUTION OF MINIMALLY-INVASIVE TECHNIQUES WITHIN AN
ACADEMIC SURGICAL PRACTICE AT A SINGLE INSTITUTION S hannon
N. Acker, MD, Susan Staulcup, David A. Partrick, MD, Stig Somme, MD,
Children’s Hospital Colorado
12:39 pm T014: ENDOSCOPIC CLOSURE OF PERSISTENT GASTROCUTANEOUS
FISTULA IN CHILDREN S andra M. Farach, MD, Paul D. Danielson, MD,
Daniel McClenathan, MD, Nicole M. Chandler, MD, All Children’s Hospital
Johns Hopkins Medicine
12:42 pm T015: INPATIENT ADMISSION IS NOT NECESSARY FOLLOWING
SUCCESSFUL ENEMA REDUCTION OF INTUSSUSCEPTION IN CHILDREN
Mohamed I. Mohamed, MBBS, S tephanie F. Polites, MD, Abdalla E.
Zarroug, MD, Michael B. Ishitani, MD, Christopher R. Moir, MD, Division of
Pediatric Surgery, Mayo Clinic, Rochester, MN, USA
12:45 pm T016: EVALUATION OF ENDOSCOPIC AND TRADITIONAL OPEN
APPROACHES TO LOCAL ADRENAL NEUROBLASTOMA W ei Yao,
Kuiran Dong, Kai Li, Yunli Bi, Gong Chen, Xianmin Xiao, Shan Zheng,
Department of Pediatric Surgery, Children’s Hospital of Fudan
University, Shanghai , China
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12:48 pm T017: COMPARISON OF MULTI-PORT AND SINGLE-PORT

LAPAROSCOPIC INGUINAL HERNIORAPHY IN SMALL BABIES Y ury
Kozlov, MD, Vladimir Novozhilov, MD, Department of Neonatal Surgery,
Municipal Pediatric Hospital, Irkutsk, Russia, Department of Pediatric
Surgery, Irkutsk State Medical Academy of Continuing Education
(IGMAPO), Irkutsk, Russia
12:51 pm T018: METAL-POLYMER COMPOSITE NUSS BAR FOR “MINIMALLY”
INVASIVE BAR REMOVAL AFTER PECTUS EXCAVATUM TREATMENT
Leonardo Ricotti, PhD, Gastone Ciuti, PhD, Marco Ghionzoli, MD, PhD,
Arianna Menciassi, PhD, Antonio Messineo, MD, 1) The BioRobotics
Institute, Scuola Superiore Sant’Anna, Pontedera (Pisa), Italy, 2)
Department of Pediatric Surgery, Children’s Hospital A. Meyer, Florence,
Italy
12:54 pm T019: SINGLE-INCISION THORACOSPCOPIC RESECTION FOR PEDIATRIC
MEDIASTINAL NEUROGENIC TUMOR USING CONVENTIONAL
INSTRUMENTS IN CHILDREN J iangbin Liu, PhD, Professor, Department
of Pediatric Surgery, Shanghai Children’s Hospital, Shanghai Jiao Tong
University
12:57 pm T020: THORACOSCOPIC AORTOPEXY FOR TRACHEOMALACIA:
DEMONSTRATING FEASIBILITY AND EFFICACY Avraham Schlager, MD,
Ozlem Balci, MD, Matthew T. Santore, MD, Mark L. Wulkan, MD, Emory
University School of Medicine/Children’s Healthcare of Atlanta
1:00 pm – 5:50 pm IPEG & BAPS JOINT PROGRAMS Pentland, Sidlaw &
Fintry Auditorium
1:00 pm – 3:00 pm IPEG/BAPS PRESIDENTIAL DEBATE: “Esophageal

and Diaphragmatic Surgery – Thoracoscopic vs. Open”
CHAIRS: Benno Ure, MD, PhD (IPEG) & Rick Turnock, MD (BAPS)
DESCRIPTION: This panel will discuss the pros and cons of thoracoscopic surgery
for esophageal atresia and diaphragmatic hernia in the newborn. The discussion
will include technical aspects, the pathophysiological responses of newborns and
data on the outcome.
OBJECTIVES
• Appropriately apply thoracosopic techniques for esophageal atresia and
diaphragmatic hernia in newborns
• Apply these techniques to relevant cases
• Decide on when to convert to open surgery and how to monitor
pathophysiological responses and to how to react appropriately.
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TIME TOPIC FACULTY

1:00 pm Pathophysiology and Intra-Operative Agostino Pierro, MD
Physiology in OA-TOF/CDH
1:20 pm OA-TOF: Open Mark Davenport, MD
1:35 pm OA-TOF: Thoracoscopic Steven Rothenberg, MD
1:50 pm Q&A
2:10 pm CDH: Open David C G Crabbe, MD
2:25 pm CDH: Thoracoscopic Mark L Wulkan, MD
2:40 pm Q&A
S024: MINIMALLY INVASIVE CDH REPAIR: EFFECTIVE FOR SELECT PATIENTS
Tate Nice MD, Scott Anderson MD, Sebastian Pasara, Rafik M. Bous, Robert
Russell MD, MPH, Carroll M. Harmon MD, PHD, Children's of Alabama,
University of Alabama at Birmingham
3:00 pm – 3:30 pm Break

3:30 pm – 5:20 pm IPEG/BAPS Best Clinical Paper Session
CHAIRS: Philipp O. Szavay, MD (IPEG) & Simon Eaton, MD (BAPS)
INTRODUCTION: Gordon A. MacKinlay, OBE
3:30 pm S025: FURTHER EXPERIENCE WITH STAGED THORACOSCOPIC REPAIR
OF A LONG GAP ESOPHAGEAL ATRESIA USING INTERNAL STATIC
TRACTION SUTURE Dariusz Patkowski, Prof., MD, PhD, Wojciech Górecki,
MD, PhD, Sylwester Gerus, MD, Anna Piaseczna-Piotrowska, Prof,
MD, PhD, Piotr Wojciechowski, MD, PhD, A.I. Prokurat, Prof., MD, PhD,
Przemyslaw Galazka, MD, PhD, Michal Blaszczynski, MD, PhD, Maciej
Baglaj Prof, MD, PhD, Departments of Pediatric Surgery and Urology:
Wroclaw, Krakow, Lodz, Poznan, Bydgoszcz
3:39 pm S026: B-TYPE NATRIURETIC PEPTIDE LEVELS CORRELATE
WITH PULMONARY HYPERTENSION AND REQUIREMENT FOR
EXTRACORPOREAL MEMBRANE OXYGENATION IN CONGENITAL
DIAPHRAGMATIC HERNIA E mily A. Partridge, Lisa Herkert, Brian Hanna,
Natalie E. Rintoul, Alan W. Flake, N. Scott Adzick, Holly L. Hedrick, William
H. Peranteau, Children’s Hospital of Philadelphia Philadelphia, PA USA
3:48 pm S027: SINGLE INCISION LAPAROSCOPIC ILEAL POUCH-ANAL
ANASTOMOSIS IN CHILDREN—HOW DOES IT COMPARE TO A
TRADITIONAL LAPAROSCOPIC-ASSISTED APPROACH? S tephanie F.
Polites, MD, Abdalla E. Zarroug, MD, Christopher R. Moir, MD, Donald D.
Potter, MD, Mayo Clinic, Rochester, MN, University of Iowa, Iowa City, IA
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3:57 pm S028: CURRENT OPERATIVE STRATEGIES AND EARLY COMPLICATIONS

OF DEFINITIVE SURGERY FOR HIRSCHSPRUNG’S DISEASE IN THE UK
AND IRELAND: FINDINGS FROM A PROSPECTIVE NATIONAL COHORT
STUDY Tim Bradnock1, Simon Kenny2, Paul Johnson3, Marian Knight4, Jenny
Kurinczuk4, Gregor Walker1, 1Department of Paediatric surgery, Yorkhill
hospital, Glasgow, UK, 2Department of Paediatric surgery, Alder Hey
Children’s Hospital, Liverpool, UK, 3Department of Paediatric surgery,
University of Oxford, Oxford, UK, 4National Perinatal Epidemiology Unit
4:06 pm S029: PRELIMINARY EVALUATION OF A NOVEL INFANT
THORACOSCOPIC LOBECTOMY SIMULATOR K atherine A. Barsness, MD,
MS, Deborah M. Rooney, PhD, Lauren M. Davis, BA, Ellen K. Hawkinson,
BS, Northwestern University Feinberg School of Medicine, University of
Michigan Medical School
4:15 pm S030: GASTROSCHISIS – THE ROLE OF BREAST MILK IN REDUCING TIME
TO FULL FEEDS Deirdre Kriel1, Anne Aspin1, Jonathan Goring1, Robert
West 2, Jonathan Sutcliffe1, 1Leeds Teaching Hospitals NHS Trust, Leeds,
UK, 2Leeds Institute of Health Sciences - University of Leeds, Leeds, UK
4:24 pm S031: ONCOLOGIC MIS SURGERY : ROLE OF IDRFS CRITERIA IN PATIENT
SELECTION AND PLANNING * Claudio Vella, MD, *Camilla Viglio, MD,
*Sara Costanzo, MD, **Salvatore Zirpoli, MD, **Marcello Napolitano, MD,
***Roberto Luksch, MD, *Giovanna Riccipetitoni, MD, *Pediatric Surgery
Department, “V.Buzzi” Children’s Hospital ICP, **Pediatric Radiology and
Neuroradiology Department “V.Buzzi” Children’s Hospital ICP, Milan
– Italy,*** Pediatric Department , Fondazione IRCCS National Cancer
Institute, Milan, Italy
4:33 pm S032: GLUTAMINE SUPPLEMENTATION IMPROVES MONOCYTE
FUNCTION IN SURGICAL INFANTS REQUIRING PARENTERAL NUTRITION
- RESULTS OF A RANDOMISED CONTROLLED TRIAL M ark Bishay1,
Venetia Simchowitz2, Danielle Petersen2, Marlene Ellmer2, Sarah
Macdonald2, Jane Hawdon4, Elizabeth Erasmus4, Kate MK Cross2, Joseph
I Curry2, 1UCL Institute of Child Health, London, UK, 2Great Ormond
Street Hospital, London, UK, 3Hospital for Sick Children, Toronto,
Canada, 4University College Hospital, London, UK
4:42 pm S033: COMPARISON OF 30-DAY OUTCOMES BETWEEN THORACOSCOPIC
AND OPEN LOBECTOMY FOR CONGENITAL PULMONARY LESIONS Justin
Mahida, MD, MBA, Lindsey Asti, MPH, Victoria K. Pepper, MD, Katherine J.
Deans, MD, MHSc, Peter C Minneci, MD, MHSc, Karen A. Diefenbach, MD,
Nationwide Children’s Hospital, Columbus Ohio
4:51 pm S034: HIGH VOLUMES IMPROVE OUTCOMES - A NATIONAL REVIEW OF
HYPOSPADIAS SURGERY IN ENGLAND 1999-2009 P atrick Green3,1, David
Wilkinson2,1, Shanthi Beglinger1, Rachel Hudson1, David Edgar1, Simon
Kenny1,2, 1University of Liverpool, Liverpool, UK, 2 Alder Hey Children’s
Hospital NHS Foundation Trust, Liverpool, UK, 3Royal Liverpool and
Broadgreen University Hospitals Trust, Liverpool, UK
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5:00 pm S035: TRANSUMBILICAL LAPAROENDOSCOPIC SINGLE SITE SURGERY

WITH CONVENTIONAL INSTRUMENTS FOR CHOLEDOCHAL CYST IN
CHILDREN: EARLY RESULTS OF 86 CASES T ran N. Son, MD, PhD, Nguyen
T. Liem, MD, PhD, Vu X. Hoan, MD, National Hospital of Paediatrics,
Hanoi, Vietnam
5:09 pm S036: SALINE VERSUS TISSUE PLASMINOGEN ACTIVATOR IRRIGATIONS
AFTER DRAIN PLACEMENT FOR APPENDICITIS-ASSOCIATED ABSCESS: A
PROSPECTIVE RANDOMIZED TRIAL Shawn St. Peter, Obinna Adibe, Sohail
Shah, Susan Sharp, David Juang, Brent Reading, Brent Cully, Whit Holcomb
III, Doug Rivard, Children’s Mercy Hospital, Kansas CIty, MO, USA
5:20 pm – 5:50 pm KARL STORZ LECTURE: “Developing Neonatal MIS

Surgery, Innovation, Techniques, and Helping an Industry
to Change”
SPEAKER: Steven Rothenberg, MD
Dr. Rothenberg is the Chief of Pediatric Surgery at the Rocky

Mountain Hospital for Children at PSL in Denver, Co. He is also
a Clinical Professor of Surgery at Columbia University College
of Physicians and Surgeons. He is a world leader in the field of
endoscopic surgery in infants and children and has pioneered
many of the procedures using minimally invasive techniques.
Dr. Rothenberg completed medical school and general surgery residency at the
University of Colorado in Denver. He then spent a year in England doing a fellowship
in General Thoracic Surgery prior to returning to the states where he completed a two
year Pediatric Surgery fellowship at Texas Children’s Hospital in Houston. He returned
to Colorado in 1992 where he has been in practice for over the last 20 years.
Dr. Rothenberg was one of the founding members of the International Pediatric
Surgical Group (IPEG) and is a past-president. He was also the Chair of the
Pediatric Committee and on the Board of Directors for SAGES (The Society of
American Gastr-intestinal Endoscopic Surgeons). He has authored over 180
publications on minimally invasive surgery in children and has given over 300
lectures on the subject nationally and internationally. He is also on the editorial
board for the Journal of Laparoendoscopic Surgery and Advanced Surgical
Technique, The Journal of Pediatric Surgery, and Pediatric Surgery International.
Dr. Rothenberg has been married to his wife Susan for over 30 years and has three
children Jessica, Catherine, and Zachary. He is an avid outdoorsman and spends
most of his free time in the mountains of Colorado skiing, hiking, biking, and fishing.
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Complete Schedule FRIDAY, JULY 25

Friday, July 25 Lennox 3
7:00 am – 8:00 am Morning Scientific Video Session II

CHAIRS: Katherine A. Barsness, MD & Holger Till, MD, PhD
7:00 am V010: VAGINAL AGENESIS AND ATRESIA OF THE UTERINE CERVIX

ASSOCIATED TO VESTIBULAR FISTULA M aria M. Bailez, MD, Lucila
Alvarez, MD, Garrahan Children’s Hospital, Buenos Aires, Argentina
7:06 am V011: ENDOSCOPIC GASTROCUTANEOUS FISTULA CLOSURE USING AN
OVER THE SCOPE CLIP James Wall, MD, MS, Lucile Packard Children’s
Hospital Stanford
7:12 am V012: LAPAROSCOPIC RESECTION OF A NEUROENDOCRINE TUMOR OF
THE COMMON BILE DUCT WITH HEPATICODUODENOSTOMY Steven S.
Rothenberg, MD, The Rocky Mountain Hospital For Children
7:18 am V013: LAPAROSCOPIC RESECTION OF A LARGE RETROPERITONEAL
GANGLIONEUROMA Bethany J. Slater, MD, Steven S. Rothenberg, MD,
Rocky Mountain Hospital for Children
7:24 am V014: LAPAROSCOPIC LEFT PARTIAL ADRENALECTOMY IN A CHILD
WITH VON HIPPEL-LINDAU AND RECURRENT PHEOCHROMOCYTOMA
A . B. Podany, MD, A. Dash, MD, D. V. Rocourt, MD, Pennsylvania State
Hershey Medical Center
7:30 am V015: LAPAROSCOPIC LATERAL PANCREATICOJEJUNOSTOMY-
PEUSTOW PROCEDURE- IN A 4 YEAR OLD WITH PANCREATIC DUCTAL
OBSTRUCTION Miller Hamrick, MD, Mikael Petrosyan, MD, Eric Jelin, MD,
Timothy D. Kane, MD, Children’s National Medical Center
7:36 am V016: LAPAROSCOPIC CORRECTION OF COLORECTAL DUPLICATION
AND VAGINOPLASTY K anika A. Bowen, MD, Kevin Platt, BS, Alli Wu, BS,
Kasper Wang, MD, Children’s Hospital of Los Angeles
7:42 am V017: LAPAROSCOPIC PROPHYLACTIC TOTAL GASTRECTOMY IN
CHILDHOOD FOR THE PREVENTION OF HEREDITARY DIFFUSE GASTRIC
CANCER Benjamin Zendejas, MD, MSc, Abdalla E. Zarroug, MD, Michael L.
Kendrick, MD, Department of Surgery, Mayo Clinic, Rochester, MN, USA
7:48 am V018: LAPAROSCOPIC GASTRIC PLICATION IN ADOLESCENTS AND
YOUNG ADULTS WITH SEVERE OBESITY: DESCRIPTION OF FIRST
PATIENT ENROLLED IN PILOT STUDY S hannon F. Rosati, MD, Dan
Parrish, MD, Poornima Vanguri, MD, Matthew Brengman, MD, FACS,
Patricia Lange, MD, Claudio Oiticica, MD, David Lanning, MD, PhD,
Children’s Hospital of Richmond at Virginia Commonwealth University
Medical Center
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8:00 am – 9:30 am SCIENTIFIC SESSION: Urogenital
CHAIRS: Martin L. Metzelder, MD & CK Yeung, MD
8:00 am V019: LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR THE TREATMENT
OF LARGE CYSTIC NEPHROMA IN CHILDREN Y ujiro Tanaka, MD, PhD,
Hiroo Uchida, MD, PhD, Hiroshi Kawashima, MD, Shinya Takazawa,
MD, Takayuki Masuko, MD, PhD, Kyoichi Deie, MD, Hizuru Amano, MD,
Michimasa Fujiogi, MD, Tadashi Iwanaka, MD, PhD, Prof, Department of
Pediatric Surgery, Saitama Children’s Medical Center & The University
of Tokyo
8:05 am S037: LAPAROSCOPIC FOWLER-STEVENS ORCHIOPEXY, A

RANDOMIZED PILOT STUDY COMPARING THE PRIMARY AND 2-STAGE
APPROACHES D aniel J. Ostlie, MD, Charles M. Leys, MD, Jason D.
Fraser, MD, Charles L. Snyder, MD, Shawn D. St. Peter, MD, University
of Wisconsin/American Family Children’s Hospital, Children’s Mercy
Hospital and Clinics
8:11 am S038: LONG TERM FOLLOW UP OF MODIFIED LAPAROSCOPIC
TRANSCUTANEOUS INGUINAL HERNIA REPAIR WITH HIGH SUTURE
LIGATURE OF THE HERNIA SAC M atias Bruzoni, MD, FACS, Zachary J.
Kastenberg, MD, Joshua D. Jaramillo, BA, James K. Wall, MD, Robert
Wright, MA, Sanjeev Dutta, MD, MBA, Stanford University
8:17 am S039: LAPAROSCOPIC PYELOPLASTY IN INFANTS: SINGLE-SURGEON
EXPERIENCE WITH 114 OPERATIONS Chandrasekharam Vvs, Dr.,
Rainbow Children’s Hospitals
8:25 am S041: LAPAROSCOPIC URETERO-PYELOLITHOTOMY IN CHILDREN
Ana María Castillo-Fernández, MD, Sergio Landa-Juárez, MD, Ramón
Esteban Moreno Riesgo, MD, Hermilo De La Cruz-Yañez, MD, Carlos
Garcia-Hernández, MD, Hospital de Pediatria, Centro Médico Nacional
SXXI. IMSS
8:29 am S042: EXPERIENCE OF LAPAROSCOPIC PYELOPLAST IN THE
TREATMENT OF URETEROPELVIC JUNCTION OBSTUCTION IN INFANTS
(<3 MONTHS) A iwu Li, Jian Wang, Qiangye Zhang, Wentong Zhang,
Hongchao Yang, Weijing Mu, Department of Pediatric Surgery, Qilu
Hospital, Shandong University
8:35 am S043: LAPAROSCOPIC EXTRAVESICAL URETERAL REIMPLANTATION
FOLLOWING LICH GREGOIRE TECHNIQUE. MEDIUM-TERM PROSPECTIVE
STUDY M anuel Lopez, Eduardo Perez-Etchepare, MD, François Varlet,
MD, PhD, Department of Pediatric Surgery, University Hospital of Saint
Etienne
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8:41 am S044: ROBOTIC ASSISTED LAPAROSCOPIC MANAGEMENT OF DUPLEX

RENAL ANOMALY IS FEASIBLE AND SAFE WITH EQUAL SHORT TERM
SURGICAL OUTCOMES TO TRADITIONAL PURE LAPAROSCOPIC AND
OPEN SURGERY D aniel B. Herz, MD, Paul A. Merguerian, MD, Venkata
R. Jayanthi, MD, Seth A. Alpert, MD, Jennifer A. Smith, RN, Nationwide
Children’s Hospital; Children’s Hospital at Dartmouth
8:47 am S045: TRANSRENAL STENTING IN LAPAROSCOPIC PYELOPLASTY
IN INFANTS AND CHILDREN: A SAVE TECHNIQUE T obias Luithle, MD,
Florian Obermayr, MD, Joerg Fuchs, MD, Department of Pediatric
Surgery and Pediatric Urology, University Children’s Hospital, Tuebingen,
Germany
8:53 am S046: RETROPERITONEOSCOPIC PYELOPLASTY IN 134 CHILDREN
Ravindra Ramadwar, Dr., Bombay Hospital, Hinduja Hospital & Joy
Hospital, Mumbai, India
8:59 am S047: PREOPERATIVE COLOUR DOPPLER ULTRASOUND IN CHILDREN
WITH PELVIURETERIC JUNCTION OBSTRUCTION AND SUSPECTED LOWER
POLE CROSSING VESSELS – VALUE FOR THE LAPAROSCOPIC SURGEON?
Nagoud Schukfeh, Martin Metzelder, Paul Andreas, Udo Vester, Division
of Pediatric Surgery, Department of General-, Visceral- and Transplant
Surgery, University Clinic Essen, Essen, Germany and Department of
Pediatric Nephrology, University Clinic Essen, Essen, Germany
9:05 am S048: ONE TROCAR ASSISTED PYELOPLASTY IN CHILDREN G iovanni
Cobellis, PhD, Fabiano Nino, MD, Carmine Noviello, PhD, Mercedes
Romano, PhD, Francesco Mariscoli, MD, Lorenzo Rossi, MD, Ascanio
Martino, MD, Pediatric Surgery Unit, Academic Children’s Hospital,
Ancona
9:11 am S049: LAPAROSCOPIC WILMS’ TUMOUR NEPHRECTOMY E wan M.
Brownlee, Fraser D. Munro, Gordon A. MacKinlay, OBE, Hamish Wallace,
Royal Hospital for Sick Children, Edinburgh
9:30 am – 10:00 am Break
10:00 am – 11:00 am SCIENTIFIC SESSION: Gastrointestinal & Hepatobiliary II

CHAIRS: Karen A. Diefenbach, MD & Long Li, MD
10:00 am S050: EVOLUTION OF MINIMALLY INVASIVE TREATMENT OF
CHOLEDOCHOLITHIASIS (CL) IN PEDIATRICS. EXPERIENCE AT A SINGLE
CENTER Mauro Capparelli, MD, Horacio Questa, MD, M
aria M Bailez, MD,
Garrahan Children’s Htal Buenos Aires; Argentina
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10:07 am S051: THE LEARNING CURVE ON THE LAPAROSCOPIC EXCISION OF

CHOLEDOCHAL CYST WITH ROUX-EN-Y HEPATOENTEROSTOMY IN
CHILDREN Jiangbin Liu, PhD, Zhibao Lv, Professor, Department of
Pediatric Surgery, Shanghai Children’s Hospital, Shanghai Jiao Tong
University and Department of Pediatric Surgery, Children’s Hospital of
Fudan University, Shanghai, PR China
10:14 am S052: PERIOPERATIVE COMPLICATIONS OF LAPAROSCOPIC
CHOLEDOCHAL CYST EXCISION Z higang Gao, MD, Qixing Xiong, MD,
Jinfa Tou, MD, Qiang Shu, Pro, Pediatric Surgery Department
10:21 am S054: LAPAROSCOPIC SIMPLE OBLIQUE DUODENO-DUODENOSTOMY
IN MANAGEMENT OF CONGENITAL DUODENAL OBSTRUCTION IN
CHILDREN Tran N. Son, MD, PhD, Nguyen T. Liem, MD, PhD, Hoang H.
Kien, MD, National Hospital of Paediatrics, Hanoi, Vietnam
10:28 am S055: THREE-PORT TOTAL COLECTOMY AND SUBSEQUENT ROBOTIC
PROCTECTOMY WITH ILEAL POUCH-ANAL ANASTOMOSIS IN
FULMINANT ULCERATIVE COLITIS. INITIAL EXPERIENCE G . Elmo, MD, T.
Ferraris, MD, D. Liberto, MD, M. Urquizo, MD, P. Lobos, MD, F. De Badiola,
MD, Pediatric Surgery Hospital Italiano de Buenos Aires
10:35 am S056: WHAT HAPPENS BEYOND AN OPEN ANULUS INGUINALIS
PROFUNDUS FOUND AT LAPAROSCOPIC PYLOROMYOTOMY IN
INFANTS? - A JOURNEY INTO TERRA INCOGNITA Reza M. Vahdad, MD,
Lars B. Burghardt, Matthias Nissen, MD, Svenja Hardwig, MD, Ralf B.
Troebs, Prof, Dr., med, Tobias Klein, MD, Alexander Semaan, Thomas
Boemers, Prof., Dr., med, Grigore Cernaianu, MD, 1) Department of
Pediatric Surgery, Cologne, Germany, 2) Department of Pediatric
Surgery, Ruhr-University Bochum, Germany, 3) Department of Pediatric
Surgery, University Hospital Luebeck, Germany
10:42 am S057: LAPAROSCOPIC TRANSHIATAL GASTRIC PULL-UP IN 6 CHILDREN
Nidhi Khandelwal, Dr., Ravindra Ramadwar, Dr., Bombay Hospital,
Mumbai, India
10:49 am S058: THE SMALL BOWEL IN ITS HAMMOCK: HOW TO AVOID
IRRADIATION THANKS TO THE SIGMOID Sabine Irtan, MD, PhD, Eric
Mascard, MD, Stephanie Bolle, MD, Laurence Brugieres, MD, PhD, Sabine
Sarnacki, MD, PhD, Department of pediatric surgery, APHP, Hopital
Necker, Paris, France; Sorbonne Paris City University, Paris, France
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11:00 am – 12:00 pm SCIENTIFIC SESSION: Panel – “Laparoscopy in the Neonate
and Infant: What’s New?”
MODERATOR: David C. van der Zee, MD, PhD
DESCRIPTIONS: This panel will provide an update of the most recent
developments in neonatal minimally invasive surgery.
OBJECTIVES
• Describe the technique for a safe anastomosis with low risk of postoperative
leakage
• Define the different steps of the procedure
• Avoid using too high pressures in neonates.
TIME TOPIC PANELIST
11:00 am MIS in the Neonate and Infant: David C. van der Zee, MD, PhD
What’s New - Introduction
11:05 am Approaches to Long Gap David C. van der Zee, MD, PhD
Esophageal Atresia
11:20 am Thoracoscopy Indications and Timothy D. Kane, MD
Techniques for Rare Conditions
11:35 am Laparoscopy in the Neonate - Milissa A. McKee, MD
Indications, Techniques
11:50 am Round Table Discussion All
12:00 pm – 1:00 pm Lunch Break
12:00 pm – 1:00 pm TOP POSTERS 21-40: Digital Presentation

CHAIR: Joachim F. Kuebler, MD
12:00 pm T021: THORACOSCOPIC IBIS HEAD REPAIR OF CONGENITAL

PARTIAL DIAPHRAGMATIC EVENTRATION. A NEW ANATOMICAL
RECONSTRUCTIVE CONCEPT Mohamed M. Elbarbary, MD, Ahmed
E. Fares, MD, Haytham E. Tantawy, MD, Ayman H. Abdelsattar, MD,
Mahmoud M. Marei, MD, Hamed M. Seleim, MD, Wissam M. Mahmoud,
MD, Departments of Pediatric Surgery, Cairo University, Fayoum
University, Tanta Univerity
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12:03 pm T022: IS LAPAROSCOPIC PERCUTANEOUS EXTRAPERITONEAL

CLOSURE FOR INGUINAL HERNIA EFFECTIVE COMPARED WITH THE
OPEN METHOD? –A SINGLE INSTITUTION EXPERIENCE OF OVER 1000
CASES H iromu Miyake, Koji Fukumoto, Go Miyano, Masaya Yamoto,
Hiroshi Nouso, Keiichi Morita, Masakatsu Kaneshiro, Naoto Urushihara,
Shizuoka Children’s Hospital
12:06 pm T023: DEVELOPMENT OF MINIMALLY INVASIVE SURGERY (MIS) IN
A MEDIUM-VOLUME PEDIATRIC SURGICAL CENTER: A TEN YEAR
EXPERIENCE OF 1387 OPERATIONS Patrick Ho Yu Chung, MBBS, FRCS,
Kenneth Kak Yuen Wong, PhD, Paul Kwong Hang Tam, MBBS, MS,
Department of Surgery, Li Ka Shing Faculty of Medicine, The University
of Hong Kong
12:09 pm T024: HYBRID SIMULATION: A NOVEL CURRICULAR CHANGE FOR
AN ESTABLISHED TRAINING COURSE K atherine A. Barsness, MD, MS,
Deborah M. Rooney, PhD, Carroll M. Harmon, MD, PhD, Northwestern
University Feinberg School of Medicine, University of Michigan Medical
School, University of Buffalo School of Medicine
12:12 pm T025: LAPAROSCOPIC INTERRUPTED MUSCULAR ARCH REAPIR IN
RECURRENT UNILATERAL INGUINAL HERNIA AMONG CHILDREN
Sherif M. Shehata, PhD, A kram M. ElBatarny, MD, Mohamed A. Attia,
MD, Ashraf A. AlAttar, MD, Abdel Ghani Shalaby, MD, Department of
Pediatric Surgery, Tanta University Hospital, Tanta, Egypt
12:15 pm T026: LAPAROSCOPIC TREATMENT OF LIVER HYDATID DISEASE IN
CASES OF CYST RUPTURE IN CHILDREN Sagidulla Dosmagambetov,
Bulat Dzenalaev, Aitzan Baimenov, V ladimir Kotlobovskiy, Aslan
Ergaliev, Aslbek Tusupkaliev, Ibatulla Nurgaliev, Roza Kenzalina,
Kidirbek Altaev, Kuben Satibaldiev, Egor Roskidailo, Department of
Laparoscopic Surgery, Regional Pediatric Hospital, Aktobe, Kazakhstan
12:18 pm T027: OUTCOMES OF SINGLE PORT SURGERY FOR PERFORATED
APPENDICITIS IN CHILDREN: SINGLE SURGEON EXPERIENCE. Adesola
C. Akinkuotu, MD, Paulette I. Abbas, MD, Shiree Bery, MD, A shwin
Pimpalwar, MD, Texas Children’s Hospital and the Division of Pediatric
surgery, Michael E. DeBakey Department of Surgery, Baylor College of
Medicine, Houston, TX
12:21 pm T028: THORACOSCOPIC APPROACH OF BILATERAL CHYLOTHORAX:
VIDEO M arcelo Martinez Ferro, MD, Fernando Rabinovich, MD, Carolina
Millan, MD, Horacio Bignon, MD, Gaston Bellia, MD, Luzia Toselli, MD,
Mariano Albertal, MD, Private Children´s Hospital of Buenos Aires,
Fundación Hospitalaria, Buenos Aires, Argentina
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12:24 pm T029: THE USE OF ROBOTIC SURGERY ALLOWS FOR IMPROVED

DEXTERITY AND VISUALIZATION DURING THORACOSCOPIC
THYMECTOMY Shannon F. Rosati, MD, Dan Parrish, MD, Patricia Lange,
MD, Claudio Oiticica, MD, David Lanning, MD, PhD, Children’s Hospital of
Richmond at Virginia Commonwealth University Medical Center
12:27 pm T030: TREATMENT OF THE CHYLOPERICARDIUM THROUGH MINIMAL
INVASIVE TECHNIQUES REPORT OF A PEDIATRIC CASE C arlos Garcia-
Hernandez, MD, Lourdes Carvajal-Figueroa, MD, Adriana Calderon-
Urreta, MD, Sergio Landa-Juarez, MD, Hospital Star Medica Lomas
Verdes. México
12:30 pm T031: LAPAROSCOPIC URETEROVESICAL PLASTY FOR MEGAURETER`S
TREATMENT S ergio Landa-Juárez, MD, Ana María Castillo-Fernández,
MD, Angélica Alejandra Guerra-Rivas, MD, Arturo Medécigo Vite, MD,
Hermilo De La Cruz-Yañez, MD, Carlos Garcia-Hernández, MD, Hospital
de Pediatria, Centro Médico Nacional Siglo XXI. IMSS
12:33 pm T032: VIDEO ASSISTED EXTRACORPOREAL PYELOPLASTY E dgar Rubio
Talero, MD, Fernando A. Escobar Rivera, MD, Clinica Saludcoop Tunja
12:36 pm T033: THE USE OF A 5-MM ENDOSCOPIC STAPLER FOR RECTAL
TRANSECTION DURING LAPAROSCOPIC SUBTOTAL COLECTOMY S imone
Frediani, MD, Silvia Ceccanti, MD, Romina Iaconelli, MD, Falconi Ilaria,
MD, Debora Morgante, MD, Denis A Cozzi, MD, Policlinico Umberto I
Hospital and Sapienza University of Rome, Rome, Italy
12:39 pm T034: THE CHARACTERIZATION OF PECTUS EXCAVATUM INCLUDING
ITS ASYMMETRY S ergio B. Sesia, MD, Margarete M. Heitzelmann, Sabine
Schaedelin, MSc, Olaf Magerkurth, MD, Frank-Martin Haecker, MD,
University Children’s Hospital of Basel, Department of Pediatric Surgery
and Department of Pediatric Radiology, Spitalstrasse 33, 4056 Basel,
Switzerland; University of Basel, Clinical Trial Unit,Schanzenstrasse 55,
4031 Basel, Switzerland
12:42 pm T035: CURRENT PRACTICE AND OUTCOMES OF THORACOSCOPIC
ESOPHAGEAL ATRESIA AND TRACHEOESOPHAGEAL FISTULA REPAIR: A
MULTI-INSTITUTIONAL ANALYSIS IN JAPAN H iroomi Okuyama, MD, PhD,
Hiroyuki Koga, MD, PhD, Tetsuya Ishimaru, MD, PhD, Hiroshi Kawashima,
MD, Atsuyuki Yamataka, MD, PhD, Naoto Urushihara, MD, Osamu
Segawa, MD, PhD, Hiroo Uchida, MD, PhD, Tadashi Iwanaka, MD, PhD,
Dept of Pediatric Surgery, Hyogo College of Med.; Juntendo University
School of Med.; The University of Tokyo Hosp.; Saitama Children’s Hosp.;
Shizuoka Children’s Hosp.; Tokyo Women’s Medical University; Nagoya
University Graduate School of Med.
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12:45 pm T036: SINGLE-INCISION LAPAROSCOPIC ENDORECTAL PULL-THROUGH

FOR HIRSCHSPRUNG’S DISEASE WITH TROCARLESS INSTRUMENT VIA
AN ANOTHER STAB INCISION S hao-tao Tang, MD, Shi-wang Li, MD, Li
Yang, Department of Pediatric Surgery, Union Hospital of Tongji Medical
College, Huazhong University of Science and Technology, Wuhan
430022, China
12:48 pm T037: AUDIT OF INITIAL EXPERIENCE OF LAPAROSCOPIC
PYLOROMYOTOMY H elai Habib, MBBS, BSc, Mohamed Shalaby, FRCS,
Paed, Surg, Philip Hammond, FRCS, Paed, Surg, Atul Sabharwal, FRCS,
Paed, Surg, Royal Hospital for Sick Children, Yorkhill, Glasgow, UK
12:51 pm T038: OUTCOMES AFTER EARLY SPLENECTOMY FOR HEMATOLOGICAL
DISORDERS Elizabeth Renaud, MD, Nirmal Gokarn, MD, Deepa Manwani,
MD, Steven Borenstein, MD, Dominique Jan, MD, PhD, Montefiore.
Medical Center
12:54 pm T039: BRINGING SURGEONS TOGETHER ACROSS THE WORLD:
DIAGNOSIS AND MANAGEMENT OF ACUTE APPENDICITIS. Margaret
Nalugo, MPH, T odd A. Ponsky, MD, George W. Holcomb III, MD, Akron
Children’s Hospital, Children’s Mercy Hospital
12:57 pm T040: A NOVEL REPAIR OF A VAGINAL FORNIX LACERATION
FOLLOWING INTERCOURSE Ulises Garza Serna, MD, David Bliss, MD,
Nam Nguyen, MD, Kasper Wang, MD, University of Southern California,
Children’s Hospital Los Angeles
1:00 pm – 1:30 pm KEYNOTE LECTURE: “Lean Processes in the Hospital”

SPEAKER: Dirk Pfitzer, Porsche Consulting GmbH.
Dirk Pfitzer is a partner at PORSCHE CONSULTING and
responsible for the center of competence in the field of
health care/pharmaceuticals/medical technique. He joined
PORSCHE CONSULTING 9 years ago after 5 years working at a
major consulting and strategy company. He studied business
management at the University of Bayreuth, Germany and Madrid,
Spain. PORSCHE CONSULTING is a 100% subsidiary of PORSCHE
Corp. and belongs to the leading consulting companies for operative excellence.
Dirk Pfitzer was in charge for a variety of projects regarding the improvement
of efficiency and competitiveness in the field of health care providers. He and
his team could successfully accomplish projects in more than 70 hospitals,
either private or university hospitals. The spectrum of their activities comprises
projects in order o reduce costs and increase proceeds as well as to implement
improvements at a process level.
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1:30 pm – 2:30 pm PANEL: Single Site Surgery
MODERATOR: Todd A. Ponsky, MD
DESCRIPTIONS: Designed for practicing pediatric surgeons who have an interest in
advanced laparoscopy. Specifically this session will address the pros and cons of
single port laparoscopy in children.
OBJECTIVES
• Identify situations where there is an increased risk of injury to the bowel or bile
ducts from single site surgery in pediatric patients. (patient safety)
• Articulate the application of single site surgery in children
• Compare single site surgery to standard laparoscopy in children in regards to
technical feasibility and patient outcome.
TIME TOPIC PANELIST

1:30 pm Current Practice with Impact on Routine Martin Lacher, MD
1:45 pm How Far Can We Go? Carroll M. Harmon, MD, PhD
2:00 pm A Critical Appraisal Shawn D. St. Peter, MD
2:15 pm Q&A All
2:30 pm – 3:30 pm SCIENTIFIC SESSION: Thorax

CHAIRS: Timothy D. Kane, MD & Pablo Laje, MD
2:30 pm S059: EXTENDED NUSS FOR 146 RECURRENCES OF PECTUS

EXCAVATUM K . Schaarschmidt, Prof, MD, S. Polleichtner, MD, M. Lempe,
MD, F. Schlesinger, MD, U. Jaeschke, MD, Helios Center of Pediatric &
Adolescent Surgery Berlin-Buch
2:38 pm S060: 100 INFANT THORACOSCOPIC LOBECTOMIES: LEARNING CURVE
AND A COMPARISON WITH OPEN LOBECTOMY P ablo Laje, MD, Erik G.
Pearson, MD, Tiffany Sinclair, MD, Mohamed A. Rehman, MD, Allan F.
Simpao, MD, David E. Cohen, MD, Holly L. Hedrick, MD, N. Scott Adzick,
MD, Alan W. Flake, MD, The Children’s Hospital of Philadelphia
2:46 pm S061: TWO DECADES EXPERIENCE WITH THORACOSCOPIC LOBECTOMY
IN INFANTS AND CHILDREN, STANDARDIZING TECHNIQUES FOR
ADVANCED THORAOCSOCPIC SURGERY S teven Rothenberg, MD,
William Middlesworth, MD, Angela Kadenhe-chiweshe, MD, The Morgan
Stanley Children’s Hospital, Columbia University; The Rocky Mountain
Hospital For Children
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2:54 pm S062: THORACOSCOPIC THORACIC DUCT LIGATION FOR CONGENITAL

AND ACQUIRED DISEASE B ethany J. Slater, MD, Steven S. Rothenberg,
MD, FACS, FAAP, Rocky Mountain Hospital For Children
3:02 pm S063: COMPARISON OF THORACOSCOPIC AND OPEN DIAPHRAGMATIC
PLICATION IN NEONATES AND INFANTS Y ury Kozlov, MD, Vladimir
Novozhilov, MD, Department of Neonatal Surgery, Municipal Pediatric
Hospital, Irkutsk, Russia; Department of Pediatric Surgery, Irkutsk
State Medical Academy of Continuing Education (IGMAPO), Irkutsk,
Russia
3:10 pm S064: THORACOSCOPIC LEFT CARDIAC SYMPATHETIC DENERVATION
IN CHILDREN WITH MALIGNANT ARRHYTHMIA SYNDROMES R yan
Antiel, MD, Aodhnait Fahy, BMBCh, PhD, J. Martijn Bos, MD, PhD,
Abdalla Zarroug, MD, Michael Ackerman, MD, PhD, Christopher Moir,
MD, Mayo Clinic
3:18 pm S065: DIAPHRAGMATIC EVENTRATION IN CHILDREN; LAPAROSCOPY
VERSUS THORACOSCOPIC PLICATION G o Miyano, MD, Masaya Yamoto,
MD, Masakatsu Kaneshiro, MD, Hiromu Miyake, MD, Keiichi Morita,
MD, Hiroshi Nouso, MD, Manabu Okawada, MD, Hiroyuki Koga, MD,
Geoffrey J Lane, MD, Koji Fukumoto, MD, Atsuyuki Yamataka, MD,
Naoto Urushihara, MD, Department of Pediatric Surgery, Shizuoka
Children’s Hospital, Department of Pediatric General & Urogenital
Surgery, Juntendo University of Medicine.
3:26 pm S097: THORACOSCOPIC CDH REPAIR – A SURVEY ON OPINION AND
EXPERIENCE AMONG IPEG MEMBERS Martin Lacher, MD, PhD, Shawn
D St. Peter MD, Paolo Laje MD, Benno M Ure MD, PhD, Caroll M
Harmon MD, PhD, Joachim F Kuebler MD, Hannover Medical School
(on behalf of the IPEG Research Committee)
3:30 pm – 4:00 pm Break

4:00 pm – 5:00 pm SCIENTIFIC SESSION: Bariatric, Robotics & Alternative
Technologies
CHAIRS: John J. Meehan, MD & Holger Till, MD, PhD
4:00 pm S066: LEARNING CURVE ANALYSIS IN PEDIATRIC SURGERY USING

THE CUMULATIVE SUM (CUSUM) METHOD – A STATISTICAL PRIMER
AND CLINICAL EXAMPLE T homas P. Cundy, Nicholas E. Gattas, Alan
White, Guang-Zhong Yang, Ara Darzi, Azad Najmaldin, Imperial College
London, UK. Leeds General Infirmary, UK
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4:06 pm S067: MAN VS. MACHINE: A COMPARISON OF ROBOTIC-ASSISTED

VS. LAPAROSCOPIC SLEEVE GASTRECTOMY IN SEVERELY OBESE
ADOLESCENTS Victoria K. Pepper, MD, Terrence M. Rager, MD, MS,
Karen A. Diefenbach, MD, Wei Wang, MS, MAS, Mehul V. Raval, MD, MS,
Steven Teich, MD, Ihuoma Eneli, MD, Marc P. Michalsky, MD, Nationwide
Children’s Hospital
4:12 pm S068: INTERNATIONAL ATTITUDES OF EARLY ADOPTERS TO CURRENT
AND FUTURE ROBOTIC TECHNOLOGIES IN PEDIATRIC SURGERY T homas
P. Cundy, Hani J. Marcus, Archie Hughes-Hallett, Azad Najmaldin,
Guang-Zhong Yang, Ara Darzi, Imperial College London
4:18 pm S069: LAPAROSCOPIC SLEEVE GASTRECTOMY IN CHILDREN AND
ADOLESCENTS: THE TECHNIQUE AND THE STANDARDIZED PERI-
OPERATIVE CLINICAL PATHWAY A ayed R. Alqahtani, MD, FRCSC, FACS,
Mohamed O. Elahmedi, MD, Department of Surgery and Obesity Chair,
King Saud University
4:24 pm S070: COMORBIDITY RESOLUTION IN MORBIDLY OBESE CHILDREN
AND ADOLESCENTS UNDERGOING SLEEVE GASTRECTOMY Aayed R.
Alqahtani, MD, FRCSC, FACS, Mohamed O. Elahmedi, MD, Awadh R. Al
Qahtani, MD, FRCSC, Department of Surgery and Obesity Chair, King
Saud University
4:30 pm S072: EVALUATION OF THE SAFETY OF LAPAROSCOPIC GASTROSTOMY
IN PEDIATRIC PATIENTS WITH HYPOPLASTIC LEFT HEART SYNDROME
USING INTRAOPERATIVE TRANSESOPHAGEAL ECHOCARDIOGRAPHY
Hanna Alemayehu, MD, E. Marty Knott, DO, Jason D. Fraser, MD, William
B. Drake, MD, Shawn D. St. Peter, MD, Kathy M. Perryman, MD, D avid
Juang, MD, Children’s Mercy Hospital
4:36 pm S073: A COMPARATIVE STUDY OF OUTCOME OF SIMPLE PURSE STRING
SUTURE LAPAROSCOPIC HERNIA REPAIR IN CHILDREN M airi Steven,
Miss, Stephen Bell, Dr., Peter Carson, Dr., Rebecca Ward, Dr., Merrill
McHoney, Mr., Royal Hospital for Sick Children, Edinburgh, UK
4:42 pm S074: VERTICAL SLEEVE GASTRECTOMY: PRIMARY VERSUS REVISIONAL
WEIGHT LOSS SURGERY IN ADOLESCENTS AND YOUNG ADULTS Jeffrey
Zitsman, MD, Melissa Bagloo, MD, Beth Schrope, MD, PhD, Aaron Roth,
MD, Miguel Silva, MD, Mary DiGiorgi, PhD, Marc Bessler, MD, Columbia
University Medical Center
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5:00 pm – 6:00 pm PANEL: Live Surgery
CHAIR: Marcelo Martinez Ferro, MD
DESCRIPTION: This panel will discuss the current status and the real value of Live
Surgery as an education tool for Pediatric Minimally Invasive Surgeons.
OBJECTIVES
• Identify special settings needed to perform live case demonstrations
• Develop a “Live case Surgical Time Out” a specific “Check list” for live case
demonstrations to enhance patient safety
• Recognize the real educational value of live case demonstrations in their
practice
• Recommend specific “IPEG Live case demonstrations guidelines”.
TIME TOPIC PANELIST

5:00 pm Introduction Marcelo Martinez Ferro, MD
5:02 pm State of the Art Steven Rothenberg, MD
5:14 pm Ethical Implications Go Miyano, MD
5:26 pm Pitfalls and Complications Maria Marcela Bailez, MD
5:38 pm IPEG Survey George W. Holcomb III, MD
5:50 pm Q&A All
7:00 pm – 11:30 pm MAIN EVENT: Celeigh and IPEG Dance Off – After Hours!
(Black Tie and Kilts Optional)
Table of Contents
Complete Schedule SATURDAY, JULY 26

Saturday, July 26 Lennox 3
8:00 am – 9:00 am MISCELLANEOUS: Short Oral Papers
CHAIRS: Celeste Hollands, MD and Sean S. Marven, MD
8:00 am S075: A ROBOTIC APPROACH TO MEDIAN ARCUATE LIGAMENT

SYNDROME V ictoria K. Pepper, MD, Karen A. Diefenbach, MD, Andy
C. Chiou, MD, David L. Crawford, MD, University of Illinois School of
Medicine at Peoria, Order of Saint Francis Medical Center, Nationwide
8:04 am S076: LAPAROSCOPIC EXCISION OF PERIPANCREATIC TUMOR AND
MESENTERIC CYST Thai Lan N. Tran, MD, Nam X. Nguyen, MD, University
of California, Irvine Medical Center
8:08 am S077: HIDING THE SCARS. EVOLUTION OF THE PEDIATRIC
LAPAROSCOPIC CHOLECYSTECTOMY - THE 2X2 HYBRID TECHNIQUE Jeh
Yung, MD, Georgios Karagkounis, MD, Gavin Falk, MD, T odd Ponsky, MD,
FACS, Akron Children’s Hospital; Cleveland Clinic
8:12 am S078: FETOSCOPY AND LASER: A GOOD THERAPEUTIC ALLIANCE IN
MINIMALLY-INVASIVE FETAL SURGERY A lan Coleman, MD, Jose Peiro,
MD, Foong-Yen Lim, MD, Cincinnati Children’s Hospital Medical Center
8:16 am S079: IMPACT OF CUSTOMIZED PRE-BENDED BAR IN SURGICAL
TREATMENT OF PECTUS EXCAVATUM Ruben Lamas-Pinheiro, MD,
Pedro Correia-Rodrigues, Jaime C Fonseca, PhD, João L Vilaça, PhD, Jorge
Correia-Pinto, MD, PhD, Tiago Henriques-Coelho, MD, PhD, Pediatric
Surgery Department, Faculty of Medicine, Hospital de São João, Porto,
Portugal
8:20 am S080: SINGLE INCISION LAPAROSCOPIC SURGERY FOR PERFORATED
APPENDICITIS: DOES OBESITY AFFECT OUTCOMES ? Adesola C. Akinkuotu,
MD, Paulette I. Abbas, MD, A shwin Pimpalwar, MD, Texas Children’s Hospital
and the Division of Pediatric Surgery, Michael E. DeBakey Department of
Surgery, Baylor College of Medicine, Houston, TX
8:24 am S081: DIAGNOSTIC LAPAROSCOPY FOR INTRA-ABDOMINAL
EVALUATION AND VENTRICULOPERITONEAL SHUNT PLACEMENT IN
CHILDREN Sandra M. Farach, MD, Paul D. Danielson, MD, Nicole M.
Chandler, MD, All Children’s Hospital Johns Hopkins Medicine
8:28 am S082: RISK OF REDO LAPAROSCOPIC FUNDOPLICATION IN CHILDREN:
BEWARE THE RESPIRATORY PHYSICIAN? Edward Gibson, MBBS,
Warwick J. Teague, DPhil, FRACS, Sanjeev Khurana, MS, FRCSI, FRACS,
Department of Paediatric Surgery, Women’s and Children’s Hospital,
Adelaide, Australia
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8:32 am S083: THORACOSCOPIC REPAIR ON THE CONGENITAL DIAPHRAGMATIC

EVENTRATION IN CHILDREN?CONTINUOUS OR INTERRUPTED SUTURE
FOR PLICATION Jiangbin Liu, PhD, Professor, Zhibao Lv, Professor,
Department of Pediatric Surgery, Shanghai Children’s Hospital, Shanghai
Jiao Tong University and Department of Pediatric Surgery, Children’s
Hospital of Fudan University, Shanghai, PR China
8:36 am S084: VALIDATION OF A NOVEL PARAMETER FOR THE EVALUATION OF
PECTUS EXCAVATUM: THE KANSAS CITY CORRECTION INDEX Gaston
Bellia, MD, Mariano Albertal, MD, Luzia Toselli, MD, Carolina Millan,
MD, Horacio Bignon, MD, Giselle Corti, Javier Vallejos, MD, M
arcelo
Martinez Ferro, Private Children´s Hospital of Buenos Aires, Fundación
Hospitalaria, Buenos Aires, Argentina
8:40 am S085: SPONTANEOUS PNEUMOTHORAXES: A SINGLE-INSTITUTION
RETROSPECTIVE REVIEW Victoria K. Pepper, MD, Terrence M. Rager, MD,
MS, Wei Wang, MS, MAS, Dennis R. King, MD, Karen A. Diefenbach, MD,
Nationwide Children’s Hospital
8:44 am S086: LAPAROSCOPIC RESECTION OF ABDOMINAL NEUROBLASTOMA
WITH RENAL PEDICLE INVOLVEMENT P aula Flores, MD, Martin Cadario,
MD, Yvonne Lenz, MD, Garrahan Hospital. Buenos Aires. Argentina.
8:48 am S087: LOWER ESOPHAGEAL BANDING IN EXTREMELY LOW BIRTH
WEIGHT PREMATURE INFANTS WITH OESOPHAGEAL ATRESIA
AND TRACHEO-ESOPHAGEAL FISTULA IS A LIFE SAVING PRACTICE
FOLLOWED BY A SUCCESSFUL DELAYED PRIMARY THORACOSCOPY
RECONSTRUCTION M anuel Lopez, MD, Eduardo Perez-Etchepare,
François Varlet, MD, PhD, Department of Pediatric Surgery, University
Hospital of Saint Etienne
9:00 am – 9:30 am General Assembly

Presentation of the IPEG 2015 President
9:30 am – 9:45 am Awards

Coolest Tricks, Basic Science and IRCAD
Table of Contents

9:45 am – 10:45 am SCIENTIFIC SESSION: Single Site Surgery
CHAIR: Martin L. Metzelder, MD
9:45 am S088: DEVELOPMENT OF BLIND AREA VISUALIZATION SYSTEM

IN MAGNIFIED FIELD OF VIEW USING AN AUGMENTED REALITY
IN PEDIATRIC ENDOSURGERY ~AMAZING SEE-THROUGH NEEDLE
DRIVER~ S atoshi Ieiri1,2, MD, PhD, Yuya Nishio3, Satoshi Obata1, MD,
Ryota Souzaki 1,2, MD, PhD, Yo Kobayashi3, PhD, Masakatsu Fujie3,
PhD, Makoto Hashizume2, MD, PhD, FACS, Tomoak, 1Department of
Pediatric Surgery, Faculty of Medicine, Kyushu University, 2Department
of Advanced Medicine and Innovative Technology, Kyushu University
Hospital, 3The faculty of science and engineering, Waseda University
9:51 am S089: IS SINGLE INCISION APPENDECTOMY SUPERIOR TO
TRADITIONAL LAPAROSCOPY IN CHILDREN? S tephanie F. Polites, MD,
Shannon D. Acker, MD, James T. Ross, David A. Partrick, MD, Abdalla E.
Zarroug, MD, Kristine M. Thomsen, Donald D. Potter, MD, Mayo Clinic,
Rochester, MN; Children’s Hospital Colorado, Aurora, CO; University of
Iowa, Iowa City, IA
9:57 am S090: IMPACT OF EXPERIENCE ON QUALITY OUTCOMES IN SINGLE-
INCISION LAPAROSCOPY FOR SIMPLE AND COMPLEX APPENDICITIS
IN CHILDREN S andra M. Farach, MD, Paul D. Danielson, MD, Nicole M.
Chandler, MD, All Children’s Hospital Johns Hopkins Medicine
10:03 am S091: CAN HYPERTROPHIC PYLORIC STENOSIS BE TREATED WITH
NATURAL ORIFICE TRANSESOPHAGEAL SURGERY APPROACH USING
A NOVEL ENDOLUMINAL CATHETER DEVICE? EX-VIVO VALIDATION OF
A NEW RABBIT MODEL FOR PYLORIC STENOSIS Carolyn T. Cochenour,
BS, T
imothy Kane, MD, Axel Krieger, PhD, Peter Kim, MD, PhD, Sheikh
Zayed Institute for Pediatric Surgical Innovation, Children’s National
Health System, Washington, DC, USA
10:09 am S092: ROUTINE UTILIZATION OF SINGLE-INCISION PEDIATRIC
ENDOSURGERY (SIPES): A FIVE YEAR INSTITUTIONAL EXPERIENCE
Aaron D. Seims, MD, Tate R. Nice, MD, Vincent E. Mortellaro, MD,
Martin Lacher, MD, PhD, Muhammad E. Ba'ath, MD, Scott A. Anderson,
MD, Elizabeth A. Beierle, MD, Colin A. Martin, MD, David A. Rogers, MD,
Carroll M. Harmon, MD, PhD, Mike K. Chen, MD, Robert T. Russell MD,
MPH, Children's of Alabama
10:15 am S093: SILS APPROACH TO INFLAMMATORY BOWEL DISEASE C laudio
Vella, MD, Sara Costanzo, MD, Giorgio Fava, MD, Luciano Maestri, MD,
Giovanna Riccipetitoni, MD, Pediatric Surgery Department, “V.Buzzi”
Children’s Hospital ICP, Milan – Italy
WWW.IPEG.ORG | 53
Table of Contents
10:21 am S094: CLIPPED VERSUS STAPLED SIPES (SINGLE INCISION PEDIATRIC

ENDOSURGERY) APPENDECTOMY: PATIENT OUTCOME, ECONOMIC
CONSIDERATIONS, AND ENVIRONMENTAL IMPACT Hayden W.
Stagg, MD, Oliver Muensterer, MD, PhD, Samir Pandya, MD, Matthew
Bronstein, MD, Lena Perger, MD, McLane Children’s at Scott and
White, Texas A&M,Temple TX, USA; Maria Fareri Children’s Hospital at
Westchester Medical Center New York Medical College, Valhalla NY,
USA
10:27 am S095: INITIAL EXPERIENCE OF MINIMALLY INVASIVE LAPAROSCOPIC
SURGERY ASSISTED BY PERCUTANEOUS INSTRUMENTS ASSEMBLED
IN OPERATIVE FIELD Ryosuke Satake, MD, Keisuke Suzuki, MD, Tetsuro
Kodaka, PhD, Kan Terawaki, PhD, Makoto Komura, PhD, Saitama
Medical University, Department of pediatric surgery
10:33 am S096: INTERNATIONAL OPINION ON THE FUTURE OF MINIMALLY
INVASIVE SURGERY - FROM A(BESECON) TO Z(AGREB) R oland W.
Partridge, Paul M. Brennan, Mark M. Hughes, Iain A. Hennessey, Royal
Hospital for Sick Children, Edinburgh, UK, Alder Hey Children’s Hospital,
Liverpool, UK
10:45 am – 12:00 pm SATURDAY MOVIE MATINEE: Complications:

“My Worst Nightmare” – Complicated Cases,
Pitfalls and Unusual Solutions
Popcorn and soft drinks will be provided
CHAIRS: Philipp O. Szavay, MD & Mark L. Wulkan, MD
DESCRIPTION: This session is designed to show videos of operations where a
complication occurred. The causes and strategies to prevent those complications
will be discussed.
OBJECTIVES
• Identify strategies to decrease conversion rates due to complications occurring
during MIS.
• Describe techniques to manage complications safely and appropriately (patient
safety).
• Identify technical strategies to manage complications.
• Apply techniques learned in the situation of a complication.
• Predict cases, where a complication might be anticipated (patient safety).
12:00 pm Closing Remarks
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Table of Contents
Exhibitors & Exhibit Hall Floorplan
EXHIBITORS
B. Braun Aesculap Booth #10 Richard Wolf UK Ltd. Booth #3
JustRight Surgical Booth #13 Shire Booth #6
Cardica Inc. Booth #9 Stryker Endoscopy Booth #8
Karl Storz Endoscopy Booth #1 Surgical Innovations Booth #4
LaproSurge Ltd Booth #7 Vygon (UK) Ltd. Booth #5
RADistribution Booth #11 Wisepress Medical Bookshop Booth #14
Table of Contents
Exhibitor Profiles
AUS SYSTEMS/LAPROSURGE Cardica Inc.
Booth #7 Booth #9
73a High Road 900 Saginaw Drive
Bushey Heath WD23 1EL Herts Redwood City, CA 94063
Germany T: 1.650.364.9975
T: 0208 950 8662 F: 1.650.364.3134
www.laprosurge.com www.cardica.com
The rbi2 suction rectal biopsy system Cardica's MicroCutter is the world’s
is easy to use, providing consistent first and only 5mm stapler that
and controlled suction and delivering articulates to 80°. The MicroCutter
uniform sub mucosa specimens for XCHANGE 30 is a cartridge-based
pathological examination for the surgical stapling system available in
diagnosis of Hirschsprung’s Disease. selected European countries for use
Offering superior efficacy, proven in a wide variety of open, laparoscopic
performance and a reduction in costs, and thoracoscopic surgical procedures
the system includes a fully assembled including appendectomies, intestinal,
single-use capsule packaged for lung and liver resections, and pediatric
convenience in a sterile procedure pack. procedures for congenital disease.
B. BRAUN AESCULAP JUSTRIGHT SURGICAL

Booth #10 Booth #13
Am Aesculap-Platz 6325 Gunpark Dr., Suite G
78532 Tuttlingen Boulder, CO 80301
Germany T: 720.287 7130
T: +49746195256 F: 720.287.7135
F: +497461952072 www.justrightsurgical.com
www.bbraun.com
JustRight Surgical is moving the
B. Braun Sharing Expertise benefits of minimally invasive surgery
into the pediatric surgical arena. We
Through exchanging knowledge with its
design, develop and market precision
customers, B. Braun helps to improve
instrumentation for the pediatric
treatments and working procedures in
surgical community. With our devices
hospitals and medical practices and to
we expect to foster advancements in
increase the safety of patients, doctors
surgical approaches that reach beyond
and nursing staff. With useful products
what traditional instruments have
and process-oriented advice Aesculap,
allowed.
a B. Braun company is pursuing a
goal: to improve therapies and make
processes more efficient.
WWW.IPEG.ORG | 57
Table of Contents
Exhibitor Profiles
KARL STORZ GMBH & CO. KG RICHARD WOLF UK LTD.
Booth #1 Booth #3
Mittelstr. 8 Waterside Way
78532 Tuttlingen Wimbledon, London, SW17 0HB
Germany United Kingdom
T: +49 (0) 7461 7080 T: 020 8944 7447
F: +49 (0) 7461 708105 F: 020 8944 1311
www.karlstorz.com www.richardwolf.uk.com
KARL STORZ is a renowned Richard Wolf UK Ltd is proud to provide
manufacturer that is well established the highest quality surgical products
in all fields of endoscopy. The still and with a focus on innovation and
family held company has grown to excellence, we are thrilled to announce
one with a worldwide presence and the launch of the Texas Paediatric
6700 employees. KARL STORZ offers Bronchoscope in August 2014. Please
a range of both rigid and flexible speak to a staff member about this
endoscopes for a broad variety of exciting development.
applications.
SHIRE PHARMACEUTICALS (UK)
OCEANA THERAPEUTICS LTD. Booth #6
Booth #11
Hampshire International Business Park
Sandyford Industerial Estate Lime Tree Way
Q House, 76 Furze Road, Suite 602 Chineham, Basingstoke
Sandyford Dublin 18 Hampshire RG24 8EP
T: +353 12930153 United Kingdom
www.deflux.com T: +44 (0)1256 894000
www.radistribution.com F: +44 (0)1256 894708
www.shire.com
Deflux™ by Oceana Therapeutics
is the only FDA approved bulking Shire enables people with life-altering
agent for the treatment of conditions to lead better lives. Our
Vesicoureteral Reflux and is also strategy is to focus on developing
indicated for the treatment of Stress and marketing innovative specialty
Urinary Incontinence. Deflux™ medicines to meet significant unmet
gel is composed of dextranomer patient needs. We provide treatments
microspheres and stabilized in Neuroscience, Rare Diseases,
hyaluronic acid of non-animal origin Gastrointestinal and Internal Medicine
(NASHA™). Deflux™ is represented by and we are developing treatments for
its distributor RADistribution symptomatic conditions treated by
specialist physicians in other targeted
therapeutic areas.
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Exhibitor Profiles
STRYKER VYGON (UK) LTD.
Booth #8 Booth #5
5900 Optical Ct, San Jose CA 95138 The Pierre Simonet Building
T: 408.754.2000 V-Park, Gateway North
www.stryker.com Latham Road
Swindon SN25 4DL
Stryker is a leading medical technology
United Kingdom
company and together with our
T: (01793) 748800
customers, we are driven to make
F: (01793) 748899
healthcare better. Stryker offers
www.vygon.co.uk
innovative reconstructive, medical,
surgical, neurotechnology, spine and We are a leading supplier of medical
robotic arm assisted technologies and surgical devices with a reputation
to help people lead more active, for delivering high quality products
satisfying lives. We are committed to and excellent customer service,
enhancing quality of care, operational helping healthcare professionals
effectiveness and patient satisfaction. offer best practice solutions to their
patients. Our products cover many
SURGICAL INNOVATIONS therapeutic specialties, including
Booth #4 vascular access, IV management,
Clayton Wood House neonatology and enteral feeding.
Unit 6, Clayton Wood Bank
WISEPRESS MEDICAL BOOKSHOP
Leeds LS16 6QZ UK
Booth #14
T: +44 (0)113 230 7597
www.surginno.com 25 High Path, Merton Abbey
London, SW19 2JL, UK
Surgical Innovations (SI) specialises
T: +44 20 8715 1812
in the design and manufacture of
F: +44 20 8715 1722
creative solutions for minimally
www.wisepress.com
invasive surgery (MIS). Designed and
manufactured in the UK, our medical Wisepress are Europe’s principal
devices are pioneering, ergonomic, conference bookseller. We exhibit
easy to assemble and easy-to-use. the leading books, sample journals
Our Resposable® products – made up and digital content relevant to this
of reusable and disposable elements meeting. Books may be purchased
– have been specifically designed at the booth, and we offer a postal
to offer hospitals high quality, cost- service. Visit our online bookshop for
effective solutions. We have recently special offers and follow us on Twitter
launched a pioneering range of 3mm for the latest news @WisepressBooks.
‘Ultra MIS’ technologies.
WWW.IPEG.ORG | 59
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IPEG 2014 ANNUAL MEETING

Commercial Bias Reporting Form
You are encouraged to…
1. Document (on this form) any concerns about commercially-biased presentations/
materials during educational sessions, and
2. Immediately take your completed form to the IPEG staff at Meeting Registration Desk
Your feedback will be shared with a members of the Executive Committee, who will
make the faculty and course chair(s) aware of these concerns.
COMMERCIAL BIAS
The International Pediatric Endosurgery Group (IPEG) has an obligation to the medical
profession and society as a whole to elucidate bias in order to protect the objectivity,
scientific integrity and quality of its continuing medical education (CME) programs and
to provide CME in an ethical and impartial manner. Bias is defined when a preference
or predisposition exist toward a particular perspective or result that interferes with an
individual’s ability to be impartial, unprejudiced or objective in order to further personal
gain and disregard for data. Particular preferences may be favorable or unfavorable.
When bias exists, impartial judgment and neutrality may be compromised. Bias may
be minimized through a declaration of conflict of interest or commercial interests, an
evaluation of peer-reviewed evidence-based medicine with an integration of clinical
expertise and/or experience, and an assertion of published sources for evidence-
based reporting. IPEG requires presenters at all educational events to specifically avoid
introducing bias, commercial or otherwise, into their presentations.
Presentation: (eg session name, etc)

Commercial Bias by: (ie faculty name, company rep)

Promotion via: (eg handouts, slides, what they said, actions)

Commercial Bias about: (check all that apply)
££ Patient treatment/management recommendations weren’t based on strongest
levels of evidence available.
££ Emphasis was placed on one drug or device versus competing therapies, and no
evidence was provided to support its increased safety and/or efficacy.
££ Trade/brand names were used.
££ Trade names versus generics were used for all therapies discussed.
££ The activity was funded by industry and I perceived a slant toward the grantors.
££ The faculty member had a disclosure and I perceived a slant toward the companies
with which he/she has relationships.
££ Other (please describe):
Please return this form to Vanessa Cheung at [email protected] or fax to 310-437-0585.
Table of Contents
CME Worksheet 2014 Meeting

CREDITS HOURS
TIME ACTIVITY AVAILABLE ATTENDED
TUESDAY, JULY 22, 2014
4:00 pm – 8:00 pm Postgraduate Lecture: MIS in Infants
3.75
and Neonates
TOTAL CREDITS AVAILABLE FOR TUESDAY 3.75
WEDNESDAY, JULY 23, 2014
8:00 am – 11:00 am Hands On Lab: Critical Technical
Skills for Neonatal and Infant 0
Minimally Invasive Surgery
8:00 am – 11:00 am Simulator Hands on Lab: Advanced
Neonatal High Fidelity Course for 0
Advanced Learners
1:00 pm – 5:00 pm Simulator Hands On Lab: Innovations
in Simulation-Based Education for 0
Pediatric Surgeons
5:00 pm – 7:00 pm Joint IPEG/BAPS Opening Ceremony/
0
Welcome Reception
TOTAL CREDITS AVAILABLE FOR WEDNESDAY 0
THURSDAY, JULY 24, 2014
7:00 am – 8:00 am Morning Scientific Video Session
I: Coolest Tricks, Extraordinary 1.0
Procedures
8:05 am – 9:00 am Scientific Session: Gastrointestinal 1.0
9:00 am – 9:30 am Presidential Address & Lecture:
0.5
10:00AM – 11:30AM Basic Science and Misc 1.5
12:00 pm – 1:00 pm Top Posters 1-20: Digital
0
Presentation
1:00 pm – 3:00 pm IPEG/BAPS Presidential Debate:
“Esophageal and Diaphragmatic 2.0
Surgery-Thoracoscopic vs Open”
3:30 pm – 5:20 pm IPEG/BAPS Best Clinical Paper Session 1.75
5:20 pm – 5:50 pm Karl Storz Lecture: “Developing
Neonatal MIS Surgery, Innovation,
0.5
Techniques, and helping an Industry
to Change”
TOTAL CREDITS AVAILABLE FOR THURSDAY 8.25
CONTINUED }
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Table of Contents
CME Worksheet 2014 Meeting CONTINUED

CREDITS HOURS
TIME ACTIVITY AVAILABLE ATTENDED
FRIDAY, JULY 25, 2014
7:00 am - 8:00 am Morning Scientific Video Session II 1.0
8:00 am - 9:30 am Scientific Session: Urogenital 1.5
10:00 am - 11:00 am Scientific Session: Gastrointestinal &
1.0
Hepatobiliary II
11:00 am - 12:00 pm Scientific Session: Panel –
“Laparoscopy in the Neonate and 1.0
Infant: What’s New?”
12:00 pm – 1:00 pm Top Posters 21-40: Digital
0
Presentation
1:00 pm - 1:30 pm Keynote Lecture: “Learn Processes in
0.5
the Hospital”
1:30 pm - 2:30 pm Panel: Single Site Surgery 1.0
2:30PM-3:30 pm Scientific Session: Thorax 1.0
4:00 pm - 5:00 pm Scientific Session: Bariatric, Robotics
1.0
and Alternative Technologies
5:00 pm - 6:00 pm Panel: Live Surgery 1.0
TOTAL CREDITS AVAILABLE FOR FRIDAY 9.0
SATURDAY, JULY 26, 2014
8:00 am – 9:00 am Miscellaneous: Short Oral Papers 1.0
9:00 am – 9:30 am General Assembly 0
9:30 am – 9:45 am Awards 0
9:45 am – 10:45 am Scientific Session: Single Site Surgery 1.0
10:45 am – 12:00 pm Saturday Movie Matinee:
Complications-“ My Worst
1.25
Nightmare” – Complicated Cases,
Pitfalls and Unusual Solutions”
12:00 pm – 1:00 pm Closing Remarks 0
TOTAL CREDITS AVAILABLE FOR SATURDAY 3.25
TOTAL POSSIBLE CREDITS 24.25
To receive a CME Certificate for this meeting, please complete

the on-line survey at www.research.net/s/2014ipeg.
If you have questions about this CME section, please email
Vanessa Cheung/IPEG CME Department at [email protected].
AN ADDITIONAL CHARGE OF US$25.00 WILL BE ASSESSED
FOR REQUESTS RECEIVED AFTER SEPTEMBER 30, 2014
Table of Contents
Faculty Disclosures
The following faculty, IPEG Program and Executive Committee Members provided
information indicating they have a financial relationship with a proprietary entity
producing health care goods or services, with the exemption of non-profit or
government organizations and non-health care related companies. (Financial
relationships can include such things as grants or research support, employee,
consultant, major stockholder, member of speaker's bureau, etc.)
Commercial What Was What Was
Faculty Disclosure
Interest Received the Role
Hossen Allal Nothing to Disclose
Aayed Al-Qahtani ◆ Nothing to Disclose
George Azzie Nothing to Disclose
Marcela Bailez ★ ◆ Nothing to Disclose
Katherine Barsness ◆ Nothing to Disclose
Matthew Clifton Nothing to Disclose
David Crabbe Nothing to Disclose
Mark Davenport Nothing to Disclose
Dafydd A. Davies Nothing to Disclose
Alex Dzakovic Nothing to Disclose
Karen A. Diefenbach Nothing to Disclose
Simon Eaton Nothing to Disclose
Peter Thomas Esslinger Nothing to Disclose
Paula Flores Nothing to Disclose
Justin Gerstle Nothing to Disclose
Stefan Gfroerer Nothing to Disclose
Miguel Guelfand ◆ Nothing to Disclose
Carroll M. Harmon ◆ Nothing to Disclose
George W. Holcomb JustRight Ownership Advisory
III ◆ Surgical Interest Committee
JustRight Ownership Consultant
Surgical Interest
Celeste Hollands ★ Nothing to Disclose
Timothy Kane ★ Nothing to Disclose
Joachin Kuebler Aesculap AG Expense Speaking/
allowance for Teaching
being tutor of a
MIC Course
Aesculap Reimbursement Speaking/
Academy for teaching Teaching
in workshop:
Minimal Invasive
Pediatrc Surgery
Martin Lacher Nothing to Disclose
Pablo Laje ◆ Nothing to Disclose
★ Executive Committee ◆ Program Committee
WWW.IPEG.ORG | 63
Table of Contents
Faculty Disclosures CONTINUED

Commercial What Was What Was
Faculty Disclosure
Interest Received the Role
Andreas Leutner Nothing to Disclose
Marc A. Levitt ★ Nothing to Disclose
Charles Leys Nothing to Disclose
Long Li ★ ◆ Nothing to Disclose
Manuel Lopez Nothing to Disclose
Tobias Luithle Nothing to Disclose
Gordon MacKinlay Nothing to Disclose
Maximillano Marcic Nothing to Disclose
Marcelo Martinez Nothing to Disclose
Ferro
Sean Marven ◆ Nothing to Disclose
Milissa McKee Nothing to Disclose
John J. Meehan Nothing to Disclose
Martin Metzelder Nothing to Disclose
Mac P. Michalsky Nothing to Disclose
Carolina A. Millan Nothing to Disclose
Go Miyano Nothing to Disclose
Oliver Muensterer ◆ Nothing to Disclose
Daniel Ostlie ★ Nothing to Disclose
Dirk Pfitzer Nothing to Disclose
Agostino Pierro Nothing to Disclose
Todd A. Ponsky ★ ◆ GlobalCastMD Ownership Owner
Steven Rothenberg JustRight Ownership Consultant
Surgical Interest
Juergen Schleef Nothing to Disclose
Shawn D. St Peter ◆ Nothing to Disclose
Philipp O. Szavay ◆ Nothing to Disclose
Holger Till ★ Nothing to Disclose
Rick Turnock Nothing to Disclose
Benno Ure ★ ◆ Braun Honoraia Independent
Aesculap Contractor
Rezza Vahdad Nothing to Disclose
David C. van der Zee ★ Nothing to Disclose
Mark L. Wulkan ★ ◆ Nothing to Disclose
CK Yeung ◆ Nothing to Disclose
Suzanne Yoder Nothing to Disclose
★ Executive Committee ◆ Program Committee
Table of Contents
Presenter Disclosures
What Was What Was
Presenter Disclosure Company
Received the Role
Shannon N. Acker, MD Nothing to Disclose
Adam C. Alder, MD Nothing to Disclose
Hanna Alemayehu, MD Nothing to Disclose
Aayed R. Alqahtani, MD, Nothing to Disclose
FRCSC, FACS ◆
Ryan Antiel, MD Nothing to Disclose
Karim Awad, MSc, MRCS Nothing to Disclose
Joanne Baerg, MD Nothing to Disclose
Maria M. Bailez, MD ◆ Nothing to Disclose
Katherine A. Barsness, Nothing to Disclose
MD, MS ◆
Mark Bishay Nothing to Disclose
Mariana Borges-Dias Nothing to Disclose
Kanika A. Bowen, MD Nothing to Disclose
Tim Bradnock Nothing to Disclose
Kirsty Brennan Nothing to Disclose
Ewan M. Brownlee Nothing to Disclose
Matias Bruzoni, MD, Nothing to Disclose
FACS
Ana Maria Castillo- Nothing to Disclose
Fernandez, MD
Patrick Ho Yu Chung, Dr. Nothing to Disclose
Matthew S. Clifton, MD Nothing to Disclose
Giovanni Cobellis, PhD Nothing to Disclose
Alan Coleman, MD Nothing to Disclose
Santiago Correa, MD Nothing to Disclose
Thomas P. Cundy Nothing to Disclose
Kuiran Dong, MD Nothing to Disclose
Mohamed M. Elbarbary, Nothing to Disclose
MD
Akram M. Elbatarny, Nothing to Disclose
MD, MRCSEd
Gaston Ricardo Elmo, Nothing to Disclose
MD
Sandra M Farach, MD Nothing to Disclose
Xiaoyan Feng, MD Nothing to Disclose
Paula Flores, MD Nothing to Disclose
HamidReza Foroutan, Nothing to Disclose
Dr.
Simone Frediani, MD Nothing to Disclose
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Presenter Disclosures CONTINUED

What Was What Was
Received the Role
Zhigang Gao, MD Nothing to Disclose
Carlos Garcia- Nothing to Disclose
Hernandez, MD
Cindy Gomes Ferreira, Nothing to Disclose
MD
Jonathan Goring Nothing to Disclose
Patrick Green Nothing to Disclose
Helai Habib, MBBS, BSc Nothing to Disclose
Michael Harrison, MD Nothing to Disclose
Daniel B. Herz, MD Nothing to Disclose
Jinshi Huang, MD Nothing to Disclose
Satoshi Ieiri , MD, PhD Nothing to Disclose
Corey W. Iqbal, MD Nothing to Disclose
Sabine Irtan, MD, PhD Nothing to Disclose
David Juang, MD Nothing to Disclose
Timothy D. Kane, MD Nothing to Disclose
Nidhi Khandelwal, Dr Nothing to Disclose
Vladimir Kotlobovskiy, Nothing to Disclose
Prof.
Yury Kozlov, MD Nothing to Disclose
Neetu Kumar Nothing to Disclose
Pablo Laje, MD ◆ Nothing to Disclose
Ruben Lamas-Pinheiro, Nothing to Disclose
MD
Sergio Landa-Juarez, Nothing to Disclose
MD
Suolin Li, MD Nothing to Disclose
Aiwu Li Nothing to Disclose
Jiangbin Liu, PhD, Nothing to Disclose
Professor
Manuel Lopez, MD Nothing to Disclose
Tobias Luithle, MD Nothing to Disclose
Justin B. Mahida, MD, Nothing to Disclose
MBA
Maximiliano Alejo Nothing to Disclose
Maricic, MD
Marcelo Martinez Ferro, Nothing to Disclose
MD
Antonio Messineo, MD Nothing to Disclose
Martin Metzelder Nothing to Disclose
Table of Contents

What Was What Was
Received the Role
Carolina Millan, MD Nothing to Disclose
Meghna V Misra, MD Nothing to Disclose
Hiromu Miyake Nothing to Disclose
Go Miyano, MD ◆ Nothing to Disclose
Vincent Mortellaro, MD Nothing to Disclose
Oliver J. Muensterer, MD, Nothing to Disclose
PhD ◆
Nam X Nguyen, MD Nothing to Disclose
Tate Nice, MD Nothing to Disclose
Satoshi Obata, MD Nothing to Disclose
Stephen Oh, MD Nothing to Disclose
Manabu Okawada, MD Nothing to Disclose
Hiroomi Okuyama, MD, Nothing to Disclose
PhD
Daniel J. Ostlie, MD Nothing to Disclose
Samir Pandya, MD Nothing to Disclose
Roland W. Partridge 1 Disclosure esSurgical Ltd Ownership Management
“Simulator” Interest Position
Emily A. Partridge Nothing to Disclose
Dariusz Patkowski, Prof, 1 Disclosure Bbraun Honoraria Speaking/
MD, PhD Teaching
Victoria K Pepper, MD Nothing to Disclose
Lena Perger, MD Nothing to Disclose
Ashwin Pimpalwar, MD Nothing to Disclose
Abigail B. Podany, MD Nothing to Disclose
Stephanie F Polites, MD Nothing to Disclose
Todd Ponsky, MD, FACS 4 Disclosures Stryker Honoraria Speaking/
◆ Teaching
GlobalCastMD Ownership Management
Interest Position
Storz Honoraria Consultant
Covidian Honoraria Consultant
Ravindra Ramadwar, Dr. Nothing to Disclose
Elizabeth Renaud, MD Nothing to Disclose
Fernando Rey, MD Nothing to Disclose
Shannon F. Rosati, MD Nothing to Disclose
Steven Rothenberg, 2 Disclosures Karl Storz Consulting Fee Consultant
MD ◆
Just Right Ownership Consultant
Surgical Interest
WWW.IPEG.ORG | 67
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What Was What Was
Received the Role
Edgar Rubio Talero, MD Nothing to Disclose
Ryosuke Satake, MD Nothing to Disclose
K. Schaarschmidt, Prof., Nothing to Disclose
MD
Avraham Schlager, MD Nothing to Disclose
Aaron D. Seims, MD Nothing to Disclose
Sergio B. Sesia, MD Nothing to Disclose
Bethany J. Slater, MD Nothing to Disclose
Yu. Sokolov, MD, PhD Nothing to Disclose
Tran N. Son, MD, PhD Nothing to Disclose
Shawn St. Peter ◆ Nothing to Disclose
Mairi Steven, Miss Nothing to Disclose
Lisanne J. Stolwijk, MD Nothing to Disclose
Shinya Takazawa, MD Nothing to Disclose
Yujiro Tanaka, MD, PhD Nothing to Disclose
Shao-tao Tang, MD Nothing to Disclose
Warwick J. Teague, DPhil, Nothing to Disclose
FRACS
Reza M. Vahdad, MD Nothing to Disclose
Claudio Vella, MD Nothing to Disclose
J. Vlot, MD, PhD Nothing to Disclose
Chandrasekharam Vvs, Nothing to Disclose
Dr.
James Wall, MD, MS 2 Disclosures Cardica Consulting Fee Consultant
Magnamosis Ownership Advisory
Interest Committee
Bo Xiang, MD Nothing to Disclose
Benjamin Zendejas, MD, Nothing to Disclose
MSc
Jeffrey Zitsman, MD Nothing to Disclose
SAVE THE DATE!

For IPEG’s 24th Annual Congress for Endosurgery in Children,
April 14-18, 2015, held at Gaylord Resort & Convention Center, Nashville,
Tennessee, in conjunction with the Society of American Gastrointestinal and
Endoscopic Surgeons (SAGES).
Abstract submission open in Summer 2014.
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Long Term Research Fund Donors

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members in basic science. The IPEG Research Grant is made possible by the donations
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Thank you to all those who have donated!
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New Membership
Hanna Alemayehu, MD Alexander Dzakovic, MD
The Children’s Mercy Hospital Loyola Univ Med Ctr
USA USA
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Asir Central Hospital, Abha, Cleveland Clinic Foundation
Children and Mat USA
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Fuad Alkhoury, MD All Children’s Hospital
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University of Utah USA
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University Medical Center Ulm University Children’s Hospital
GERMANY SWITZERLAND
Gemana Casaccia, MD Nicholas Hamilton, Fellow
Pediatric Hispotal, Cesare Arriogo Oregon Health and Sciences University
ITALY USA
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Texas Tech University Health Sciences Mie University Graduate School of
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Klinikum Brememn Mitte Kinderchirgische Klinikum Dortmund, gGmbH
Klinik GERMANY
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Christian Lorenz, MD Hans K. Pilegaard, MD
Klinikum Bremen-Mitte Aarhus University Hospital, Skejby
GERMANY DENMARK
Jeffrey Lukish, MD Drew Rideout, MD
John Hopkins University USA
USA Avraham Schlager, MD
Brian MacCormack, MD Children’s Healthcare of Atlanta
Royal Hospital For Sick Children Edinburgh USA
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Justin Mahida, MD Klinikum Kassel
Nationwide Children’s Hospital GERMANY
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Maximiliano Maricic, MD Children’s of Alabama
Garrahan Children Hospital USA
ARGENTINA Valerie Soroutchan, MD
Jarod McAteer, MD, MPH National Med Uni of O.O. Bogomolets
Univesity of Washington UKRAINE
USA Dylan Stewart, MD
Vincent Mortellaro, MD Johns Hopkins School of Medicine
Children`s hospital of Alabama USA
USA Xu Ke Tao, MD
Anja Neugebauer, MD Affiliated Hospital School of Medicine
University Hospital Charite Berlin CHINA
GERMANY Xavier Tarrado, MD
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Children’s of Alabama SPAIN
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Oral Abstracts
S001: MINIMALLY INVASIVE SURGERY FOR Indications for the MIS approach included
PEDIATRIC TRAUMA – A MULTI-CENTER penetrating injury (n=53), peritonitis
REVIEW H anna Alemayehu, MD, Diana (n=30), free fluid with abdominal pain
Diesen, MD, Matt Santore, MD, Matthew in the setting of blunt trauma (n=24),
Clifton, MD, Todd Ponsky, MD, Margaret pneumoperitoneum (n=15), and other
Nalugo, MPH, Timothy Kane, MD, Mikael indications (n=77). Of the 110 procedures
Petrosyan, MD, Ashanti Franklin, MD, completed without conversion, 60
George W Holcomb III, MD, MBA, Shawn D. (55%) were diagnostic, while the
St. Peter, MD, The Children’s Mercy Hospital, remaining were therapeutic. The most
Kansas City, MO; Children’s Medical Center, common therapeutic procedure was
Dallas, TX; Children’s Healthcare of Atlanta laparoscopic or laparoscopic assisted
at Egleston, Atlanta, GA; Akron Children’s repair of bowel injuries (n=19), followed
Hospital, Akron, Ohio; Children’s National by various laparoscopic repairs (n=12),
Medical Center, Washington, DC laparoscopic distal pancreatectomy (n=5),
thoracoscopic evacuation of hemothorax
INTRODUCTION: Although minimally (n=4), other thoracoscopic interventions
invasive surgery (MIS) has been used in the (n=4), laparoscopic splenectomy (n=2),
management of pediatric trauma for over and laparoscopic repair of traumatic
three decades, the literature remains sparse. abdominal wall hernias (n=2). Procedures
The purpose of this study is to characterize that required conversion were also most
the role of MIS in pediatric trauma. commonly for bowel injury (n=54). Patients
METHODS: After obtaining Institutional with peritonitis and pneumoperitoneum
Review Board approval at each were most likely to require conversion
institution, a retrospective review was to an open procedure (76.6% and 60%
conducted on children who underwent respectively). Reasons for conversion
thoracoscopy or laparoscopy for the included technical difficulty (n=66),
management of trauma over the past hemorrhage (n=16), or hemodynamic
13 years. Five pediatric regional trauma instability (n=3), and some patients had
centers in the United States participated. more than one reason for conversion.
Data included patient demographics, Mean time to a regular diet was 4.6 ±9
mechanism of injury, indication for days, and mean hospital stay was 6.7 ± 6.6
operative intervention, conversion to days. Complications occurred in 19 patients
open procedure, complications, and post- and included intra-abdominal abscess
operative course. (n=5), pancreatic pseudocyst (n=2), wound
RESULTS: There were 175 patients with a infection (n=2), small bowel obstruction
mean age of 9.1 (1.0-17.3) years and 71% were (n=2), and others (n=9). Long-term
male. Blunt trauma occurred in 65% with sequelae following their traumatic injuries
the most common mechanism of injury occurred in 10 patients, and permanent
being all-terrain vehicle or motor vehicle disability was found in 2 patients.
crash (40%). Laparoscopy performed in CONCLUSION: Laparoscopy and
164 (94%), thoracoscopy in 7 (4%), and 4 thoracoscopy hold utility for a wide
(2%) patients had both. Conversion to open variety of traumatic injuries in stable
occurred in 39%, although no additional children and can be used to accomplish
procedure was necessary after conversion the goals of the operation without
in 4 cases. Median operative time was conversion in the majority of cases.
84(16-369) minutes.
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Oral Abstracts CONTINUED

S002: OPEN VS. LAPAROSCOPIC (21-168) vs (20-120) p: 0.64)) respectively
MANAGEMENT OF APPENDICITIS for open and laparoscopic surgery. Mean
PERITONITIS IN CHILDREN: CLINICAL surgical time was 43.78 minutes for open
TRIAL F ernando Rey, MD, Andres Perez, surgery and 75.11 for the other one (range
MD, William Murcia, MD, Fenando Fierro, (20-86) vs (32-175) p: 0.0001). Pain was
MD, Ivan Molina, MD, Juan Valero, MD, rated by patients at 24 after surgery with
Jorge R. Beltran, MD, Fundación HOMI postoperative analog pain scale, a mean
Hospital de la Misericordia, Pediatric of 2.67 points for open approach and 1.94
Surgery Unit, Universidad Nacional de points to laparoscopic (range (1-4) vs. (1-3)
Colombia, Bogotá (COL) p: 0.0094).
SUMMARY: The minimally invasive Patients with complications had longer
surgical treatment for perforated time of abdominal pain before surgery
appendicitis and peritonitis in children than those did not complicated, 76.53 and
has taken an important place in the 54.48 hours respectively (range (48 - 168)
management of this condition. Questions vs (20 - 126) p: 0.0033)
regarding the comparative results of open
There was no statistical difference in
and laparoscopic approach in this disease
the mean postoperative hospital days
are under investigation. The literature
(8.21 days to 9.94 days open and the
currently lacks evidence to come to new
laparoscopic). All patients were free of
conclusions on this issue.
symptoms at five months follow-up.
STUDY DESIGN: Randomized clinical
CONCLUSIONS: For patients with
trial of the surgical approach of patients
appendicitis with peritonitis without
with appendicitis and peritonitis, from
signs of shock, the laparoscopic
October 2010 to March 2011. A 18-month
approach requires more operative time,
postoperative follow up is also included.
but provides better results in terms
Demographic data, symptoms, surgical
of postoperative pain. Laparoscopic
results and postoperative data were
approach seems to have a trend of lower
recorded.
rate of reoperation; however this is not
RESULTS: 46 patients were included, 28 significant statistically. For other variables
patients managed with open surgery and there are not statistical significant
18 with laparoscopy. There were no deaths differences.
in either group. We had 6 reinterventions
S003: FEASIBILITY OF SINGLE INCISION
in the open group and none in the
3 STAGE TOTAL PROCTOCOLECTOMY
laparoscopic one (p=0.06), with an
AND ILEAL POUCH ANAL ANASTOMOSIS
average of 1.32 porc and 1 respectively,
Avraham Schlager, MD, Matthew T.
6 surgical site infections in the open
Santore, MD, Ozlem Balci, MD, Drew A.
approach and 5 in the laparoscopic. A
Rideout, MD, Kurt F Heiss, MD, Matthew S.
total of 6 bowel obstruction in the open
Clifton, MD, Emory University/Children’s
approach and 2 in laparoscopic, the
Healthcare of Atlanta
average age for both groups was 8.72
and 9.46 years (confidence interval [CI] BACKGROUND: Total proctocolectomy
8.04-10.88 vs 95% 7.07 - 10.37) (p: 0.4); (TPC) and ileal pouch anal anastomosis
the average time in hours of abdominal (IPAA) is the standard of care for patients
pain at the time of the assessment by the with ulcerative colitis refractory to
surgeon was 60.71 and 60.72 hours (range medical care. Safety and efficacy have
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been demonstrated for both the two and of 4.6 ± 2.4 days. Median length of stay
three stage laparoscopic approach. We was 6 days (range 3-18). There were two
present a 3 stage single-site laparoscopic surgical complications after TPC, both
TPC and IPAA series and discuss potential of which required ileostomy revision;
advantages of this technique. one following a conventional 5-port
laparoscopic resection and the other after
METHODS: We retrospectively reviewed
a single-site resection.
all patients who underwent single-site
three-stage TPC and IPAA for ulcerative Mean operating time for IPAA using
colitis at our institution. Primary the single-site approach was 283 ± 50
outcomes included operative time, time minutes. Mean time to tolerance of clear
to oral intake, time to stoma function, liquids was 1.0 ± 0.5 days and regular
time to cessation of intravenous opiates, diet was 3.3 ± 1.1 days. Stoma function
length of stay, and post-operative returned on average at 1.6 ± 0.5 days.
surgical complications. The Gelpoint Postoperative intravenous opioid use
advanced access platform (Applied lasted an average of 3.3 ± 1.4 days. Median
Medical, Santa Margarita, CA) was used length of stay was 4 days (range 3-9 days).
in at least one stage of all cases. This Surgical complications following IPAA
device facilitated open division of major included one anastomotic leak at the
arterial vessels, extraction of the colon, J-pouch (which closed spontaneously) and
and extracorporeal construction of the another patient who developed a mucosal
J-pouch. bridge in the J-pouch staple line requiring
surgical division.
RESULTS: A total of 8 patients were
identified that had undergone single- CONCLUSION: Single-site TPC-IPAA using
site surgery with the Gelpoint advanced the Gelpoint advanced access platform is
access platform for at least one both feasible and safe. In addition to the
component of their TPC-IPAA. Six of improved cosmetic result, the single-site
8 underwent single-site TPC and all 8 access point offers added advantages
underwent single-site IPAA followed by of wound protection, ease of ligation
standard ileostomy closure. No single- for major arterial vessels, extraction of
site patient required additional port the specimen, as well as extracorporeal
placement or conversion to open surgery. J-pouch construction.
Median age at TPC was 14 years (range
S004: EVALUATION OF LIFE QUALITY
10-17 years). Five patients were female.
OF CHILDREN AFTER LAPAROSCOPIC-
Overall median follow up time was 20
months (range 5-45 months) from the ASSISTED TRANSANAL ENDORECTAL
first operation and 6 months (range 1-12 (SOAVE) PULL-THROUGH FOR
months) from the time of ileostomy HIRSCHSPRUNG’S DISEASE Bo Xiang, MD,
closure. Yang Wu, PhD, West Chian Hospital
Mean operating time for TPC was 227 PURPOSE: To assess the life quality of
± 41 minutes. Mean time until patients patients two years after laparoscopic-
tolerated clear liquid diet was 1.3 ± 0.5 assisted transanal endorectal (Soave)
days and 4.1 ± 2.6 days until tolerating a pull-through for Hirschsprung’s disease
regular diet. Stoma function returned on (HD) and compare with that of traditional
average at 1.75 ± 0.71 days. Post-operative Duhamel procedures in the same center.
intravenous opioid use lasted an average
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METHODS: A total of 297 cases of HD CONCLUSIONS: Our present 2-year data
from January, 2007 to December, 2010 limited to the normal – segment type
had been diagnosed in our hospital. revealed that life quality of children
And 245 of them belonged to the receiving laparoscopic-assisted transanal
normal-segment type which were endorectal (Soave) pull-throughs did
included in our study. 173 of them had not significantly differ from those who
received laparoscopic-assisted transanal receiving traditional Duhamel procedures.
endorectal (Soave) pull-throughs and Meanwhile traditional Duhamel
72 had traditional Duhamel procedures. procedures might be more beneficial
Post-surgical anal dilations lasted for 6 regarding to RAIR recovery.
months. Anorectal manometry had been
TABLE 1: Life Quality Scoring 2 year after
performed regularly at 3, 6, 12 and 24
surgery
months after operations. We adopted the
Wenxer scores, Fecal Incontinence Quality Life Quality Scoring
of Life (FIQL) questionnaire, and Self-
80~ 60~80 ~60 Total
rated Health Measurement Scale Version
(good) (moderate) (poor)
1.0 (SRHMS) scores to evaluate life
quality after surgery for Hirschsprung’s Lap- Soave 23 28 7 58
disease. Chilren with 2-year follow-ups Tra – Duhamel 13 12 2 27
and more had been included in this study.
Those younger than five at the time of Total 36 40 9 85
investigations were excluded. t test, p=0.22
RESULTS: Effective 2-year follow-ups Lap - Soave: laparoscopic-assisted transanal
were carried out and clinical data had endorectal (Soave) pull-through
been retrieved among 85(58 laparoscopic
Soave , 27 traditional Duhamel ) of those Tra – Duhamel: traditional Duhamel procedures
103 children (82.5%) older than three at
TABLE 2: Recto-anal inhibitory reflex (RAIR) 2
the time of surgery.
year after surgery
1. Life quality scoring: Classified as
RAIR Lap- Soave Tra – Duhamel Total
~60(poor), 60~80(moderate) and
occurrence
80~(good), the average scores for
laparoscopic Soave group and traditional Positive 9 9 8
Duhamel group were 75.43±13.01 and
Negative 49 18 67
79.00±10.77 respectively(t test, p=0.22)
with no statistical significance.(Table 1) Total 58 27 85
2. Anorectal manometry: recovery chi-square p=0.06
of recto-anal inhibitory reflex (RAIR)
occurred in nine of 58(15.5%) of Lap - Soave: laparoscopic-assisted transanal
laparoscopic Soave patients and nine of endorectal (Soave) pull-through
27(33.3%) of traditional Duhamel patients Tra – Duhamel: traditional Duhamel procedures
(chi-square p=0.06). The occurrence rates
were higher in the traditional Duhamel
group though there was no statistical
difference. (Table 2)
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S005: SELECTIVE TRANSPERITONEAL advanced the needle into the transverse
ASPIRATION OF A DISTENDED BOWEL colon at its anti-mesenteric border
WITH A SMALL-CALIBER NEEDLE and continued with gentle aspiration.
DURING LAPAROSCOPIC NISSEN In case of suboptimal result after first
FUNDUPLICATION: A PROSPECTIVE attempt, aspiration could be performed
RANDOMIZED CONTROLLED TRIAL at other sites if required. Afterwards, the
Carlos Garcia-Hernandez, MD, Lourdes procedure proceeded as planned. In the
Carvajal-Figueroa, MD, Sergio Landa- control group, the operators performed
Juarez, MD, Adriana Calderon-Urrieta, conventional maneuvers such as deviating
MD, Hospital Star Medica Lomas Verdes, downwards the dilated loop using surgical
México tools and/or placing the patient on a high
Fowler´s position.
BACKGROUND/PURPOSE: Anecdotal
reports have demonstrated the We performed 403 Nissen procedures
feasibility of needle aspiration to deflate laparoscopically, 102 were in infants ≤6
a distended bowel loop during open months old, while only 44 presented
surgery, but we are not aware of any severe transverse colonic distension.
prospective study that has evaluated
SAMPLE SIZE: STAB facilitated the surgical
the safety and efficacy of this technique
procedure and drastically reduced
during laparoscopic surgery. Therefore,
surgical time. Thus, we calculated our
we designed a randomized controlled
sample size with use of the following
study to evaluate the use of the selective
inputs: 90% power, a critical p value of
transperitoneal needle aspiration of a
0.05, and 50% reduction in surgical time.
bowel loop (STAB) in infants undergoing
This resulted in a necessary sample size of
laparoscopic Nissen Fundoplication.
21 subjects per group, for a total required
METHODS: The study was conducted sample size of 42 subjects.
between January 2010 and December
RESULTS: We performed STAB in 23
2013. Candidates were patients of less
patients and conventional measures in 21.
than 6 months of age, scheduled for
STAB attempts were 45: 8 (36.4%) patients
laparoscopic Nissen fundoplication,
required one puncture, 8 (36.4) required
in which severe colonic distention was
two punctures and 7 (27.3%) required
observed during the surgery.
three. Mean age was 66.9±38.1 days in
We randomized the patients to the the STAB group and 64.7±36.2 days in
study drug or placebo in a 1:1 mode. The the control group, p=NS. Mean operative
treatment group received STAB, while the time was shorter in the STAB group than
control group was subject to conventional in controls (34.6±6.1vs. 70.8±7.1minutes,
maneuvers discretionally by the surgeon. p<0.001), which constituted a 50.7±9.1%
absolute reduction. Open conversion
PROCEDURE: In both groups, we (N=3, 14.3%) only occurred in the
performed the Nissen Technique open group. There were no additional
according to standard laparoscopic intraoperative or postoperative
approach. The presence of severe colonic complications.
distention was identified after placing
all ports. We introduced a 30-gauge DISCUSSION: We proposed the use
hypodermic needle into the abdominal of STAB as alternative therapy to
wall in a perpendicular fashion. We decompress a dilated large-bowel
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loop during laparoscopic surgery. This lap-Ladd; 11 open-Ladd) and 12 cases in
maneuver is simple and efficient and has group C (6 lap-Ladd; 6 open-Ladd). None
no clinical complications. Future studies of the cases in our series had suspected
are required to evaluate its role in the diagnoses of ischemic or necrotic bowel
subset of other patients or procedures, preoperatively. Mean age and mean body
as well as the safety of STAB in dilated weight at surgery were higher in lap-Ladd
small-bowel loops. Nonetheless, the than open-Ladd but differences were
present study may be considered not significant. Intestinal volvulus was
hypothesis generating for other surgical confirmed at surgery in 3/3 lap-Ladd and
settings. 9/11 open-Ladd in group N and in 5/6
lap-Ladd and 6/6 open-Ladd in group C
S006: LAPAROSCOPIC REPAIR OF
(p=ns). No cases required bowel resection
MALROTATION. WHAT ARE THE
in our series. Mean operating time was
INDICATIONS IN NEONATES AND significantly longer in lap-Ladd (130.7
CHILDREN? G o Miyano, MD, Keiichi minutes) versus open-Ladd (81.1 minutes)
Morita, MD, Masakatsu Kaneshiro, MD, in group N, as well as in lap-Ladd (119.2
Hiromu Miyake, MD, Hiroshi Nouso, MD, minutes) versus open-Ladd (74.2 minutes)
Masaya Yamoto, MD, Koji Fukumoto, MD, in group C. The rate of conversion of
Naoto Urushihara, MD, Department of lap-Ladd to open-Ladd was 1/3 (33.3 %) in
Pediatric Surgery, Shizuoka Children’s group N and 1/6 (16.7 %) in group C. There
Hospital was 1 case each of bowel obstruction
AIM: To present our experience of treating (1/11, 9.1%) in open-Ladd in group N and
malrotation with laparoscopy to more chylorrhea from mesentery (1/6, 16.7%) in
clearly define its role in neonates and open-Ladd in group C both necessitating
children and to compare outcome of open laparotomy. Recurrence of signs and
repair with outcome of laparoscopic repair symptoms of malrotation occurred in
with respect to age at the time of surgery. 1/3 (33.3%) lap-Ladd in group N. Mean
time taken to recommence feeding in
MATERIALS & METHODS: We conducted group N was shorter for lap-Ladd (3.7
a retrospective analysis of all Ladd’s days) versus open-Ladd (4.1 days) as it
procedures performed at our institution was also in group C; lap-Ladd (2.6 days)
between 2007 and 2012. In order to versus open-Ladd (3.0 days), but these
compare postoperative outcome, we differences were not significant (p=0.73
divided our subjects into 2 groups for group N; p=0.64 for group C). Length
according to age at the time of surgery. of hospitalization was similar for all group
The neonate group (N) comprised N cases (lap-Ladd: 13.7 days; open-Ladd:
subjects who had surgery up to and 13.9 days), but shorter for lap-Ladd (6.6
including day 30 of life, and the child days) compared with open-Ladd (8.2 days)
group (C) comprised subjects who had in group C, which was not statistically
surgery from day 31 of life onwards. significant (p=0.94 for group N; p=0.28 for
RESULTS: There were 26 Ladd’s group C).
procedures performed during the study CONCLUSION: Our data confirm that lap-
period. Of these, 9 were laparoscopic Ladd is a safe procedure, but we do not
(lap-Ladd) and 17 were open (open-Ladd). recommend lap-Ladd for the treatment
When categorized according to age at of malrotation in patients 30 days of age
surgery, there were 14 cases in group N (3 or less.
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S007: LAPARSCOPIC REPAIR OF anorectal malformation. The traditional
CONGENITAL DUODENAL OBSTRUCTION procedure of PSARP, Laparatomy and
IN NEONATE J inshi Huang, MD, then pull-through is the treatment of
Department of Surgery, Jiangxi Provincal choice. With the advances in Laparoscopic
Children’s Hospital surgery in small children, it seemed that
laparoscopic assisted anorectoplasty
OBJECTIVE: To evaluate the curative would be an accepted alterative.
effect of laparoscopic surgery
treatment of congenital duodenal Here we present the intermediate term
obstruction(CDO),such as web or annular results of 3-7 years for these patients
panctreasl, in neonate.
METHODS AND MATERIALS: Eleven
METHODS: Thirty-eight neonates with patients with rectovesical fistula were
CDO who underwent laparoscopic operated on laparoscopically during
surgery were analyzed retrospectively the last 7 years. All of these patients
from September 2009 to August 2013(22 had diverting colostomy at newborn
with web,and 16 with annular panctreas), age and had laparoscopic assisted
Outcomes of interest were operative time, anorectoplasty at the age of 3-6 months.
postoperative leaks, and postoperative The operations were performed in supine
full time of feeding. position and the external sphincter was
localized with muscle stimulator. The
RESULTS: The laparoscopic procedures patients were followed for 3-7 years
w ere completed without intraoperative postoperatively. Anorectal manometry,
complication in 38 neonates, Conversion MRI, endosonography were performed.
to open surgery was required in 2 patients
(5.3 %).Average operating time was RESULTS: Eleven patients were followed.
102±19 minutes. There were no duodenal Three were continent with very occasional
anastomotic leaks. time to initial feeding soilage. Five patients had frequent bowel
5.7±2.8 days, and time to full oral intake movement with soilage. Three patients
8.7±2.0 days. Average hospitalization had severe perineal dermatitis, one of
time was 10.7±3.2 days.Follow-up upper whom had sigmoid pull through due to
gastrointestinal tests show no evidence of very short rectum. Three patients had
stricture or bstruction. constipation. Two patients had dribbling.
All had good weight gain. Most patients
CONCLUSION: The laparoscopic surgery had decreased sphincter tone. MRI
treatment of CDO is safe and efficacious. showed well positioning of the sphincter.
INDEX WORDS: Laparscopic ,congenital, CONCLUSION: Laparoscopic assisted
duodenal obstruction anorectoplasty is feasible and
S008: COMPLICATIONS AFTER intermediate term follow up showed
LAPAROSCOPY FOR RECTOVESICAL relatively high complications. Some
FISTULA H amidReza Foroutan, Dr., modifications of the procedure can
Abbas Banani, Dr., Sultan Ghanem, Dr., improve the results
Reza Vahdad, Dr., Laparoscopic Research
Center, Shiraz University of Medical
Sciences
INTRODUCTION: Rectovesical fistula
is one of the challenging cases of
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S009: LAPAROSCOPIC MESH RECTOPEXY and efficient treatment of persistent
FOR COMPLETE RECTAL PROLAPSE complete RP in children. To avoid post-
Cindy Gomes Ferreira, MD, Paul Philippe, operative constipation, it is important to
MD, Isabelle Lacreuse, MD, Anne perform a tension-free mesh rectopexy.
Schneider, MD, François Becmeur, PhD,
S010: SINGLE INCISION LAPAROSCOPIC
MD, Department of Paediatric Surgery,
SPLENECTOMY USING THE SUTURE
Clinique Pédiatrique, Centre Hospitalier
SUSPENSION TECHNIQUE FOR
Luxembourg, Luxembourg, Department of
SPLENOMEGALY IN CHILDREN WITH
Paediatric Surgery, Hôpital de Hautepierre,
HEREDITARY SPHEROCYTOSIS S uolin
Centre Hospitalier Universitaire de
Li, MD, Meng Li, MD, Weili Xu, MD, PhD,
Strasbourg, France
The Second Hospital of Hebei Medical
AIM: To describe the operative technique of University, Shijiazhuang, China
the treatment of complete rectal prolapse
BACKGROUND: Laparoscopic splenectomy
(RP) through minimal invasive approach in
has become a gold standard in the
children presenting recurrent RP.
treatment of spleen disorders related to
MATERIAL AND METHODS: We present hematologic diseases. With increasing
an operating technique inspired from laparoscopic surgery experience and
the Orr-Loygue-Cerbonnet operating improved new vessel sealing equipment,
technique modified for laparoscopy. The single incision laparoscopic splenectomy
operative steps are: diagnosis (presence (SILS) has emerged as an alternative to
of a peritoneal hernia in the Douglas), multiport laparoscopy, but the application
peritoneal opening of the Douglas, of SILS to massive splenectomy is still
posterior rectal dissection, tension-free challenging due to technical difficulties.
mesh rectopexy, peritoneal closure. The aim of this study was to describe the
Operative treatment was proposed after suture suspension technique contributing
complete work-up excluding cystic to SILS for the treatment of hereditary
fibrosis and medullar anomalies, for spherocytosis with splenomegaly.
persistent RP despite well conducted
METHODS: A retrospective review
medical treatment during 6 months at
was conducted to evaluate all SILS
least. Low-fibre diet was prescribed for
for splenomegaly performed by a
the first 2post-operative weeks.
single surgeon between June 2010
RESULTS: Since 2001, eight patients and December 2013. On preoperative
(3M/5F) with a median age of 6, 5years ultrasonography, the spleen size index
(2-17years) benefitted from laparoscopic ranged from 0.67 to 0.82 (the normal
treatment of RP. Mean operative time was spleen index should be <0.2). A 2-3
98minutes (range 80-125). There were no cm umbilical incision was used for the
conversion, nor operative complications. placement of a multichannel single-
Mean hospital stay was 3.5days (range port. A needle with a 1-0 suture was
2-5). No post-operative constipation, percutaneously introduced from the left
nor recurrence were reported during the hypochondriac region at the midaxillary
mean follow-up period of 4.1years. line into the abdomen, then penetrated
out from the anterior chest wall at the
CONCLUSION: The modified Orr-Loygue-
midclavicular line for suspending the
Cerbonnet laparoscopic operating
massively enlarged spleen. Pulling
technique is a simple, reproducible
the suture both ends could provide
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excellent exposure of the splenic hilum. described. The goal of this paper was
Dissection was facilitated by the use of to describe intraoperative physiology,
a 5-mm curved reusable grasper and a estimate intraoperative physiologic
5-mm conventional Harmonic scalpel, stability, and report operative outcomes
and splenic vessels were ligated at the during laparoscopic gastrostomy tube
hilum with a 5-mm Hem-o-lok clips. (GT), and laparoscopic fundoplication
The resected spleen was placed in an with gastrostomy tube in patients with
endosurgical bag, morcellated, and complex congenital heart defects.
removed from the abdomen via the
METHOD: An IRB approved retrospective
umbilical incision.
chart review of all children with complex
RESULTS: Nine children with hereditary congenital heart defects who underwent
spherocytosis underwent SILS during the GT or Nissen with GT from January
study period without conversion to an 2010 to January 2014 was conducted.
open procedure or requiring additional Data collection included patient
ports. The suture suspension technique demographics, intraoperative physiologic
was successfully used in all patients and parameters, and postoperative outcomes.
markedly improved the exposure of the All procedures were performed
splenic hilum. The median operative in the cardiovascular operating
time was 122.6±31.2 min, and the median rooms, with cardiovascularly trained
extracted spleen weight was 562±74.5 anesthesiologists. Statistical analysis
g (range, 420-1260 g). No intraoperative consisted of descriptive statistics, and
or postoperative complications were non-parametric analysis.
recorded. The umbilical incision healed
RESULT: 28 patients were identified, 16
well with a satisfactory cosmetic effect.
male and 12 female, with a mean age
CONCLUSIONS: Our preliminary of 115 days (range 20 – 1173 days). The
experience shows the the suture mean weight at operation was 4.2kg
suspension technique that enables safe (range 2.2 – 12.5kg). Cardiac defects
and feasible SILS for the management of included hypoplastic left heart syndrome
splenomegaly in children with hereditary (n=6), complex single ventricle (n=7),
spherocytosis. More experience is needed tetralogy of Fallot (n=6), AV Canal (n=1),
to assess advantages and disadvantages aortic arch hypoplasia/interruption
compared with the standard laparoscopic (n=3), ventriculoseptal defects (n=3),
approach. pulmonary vein hypoplasia (n=1) and large
patent ductus arteriosum (n=1). There
S011: LAPAROSCOPIC GASTROSTOMY
were 21 laparoscopic GTs placed and 7
AND LAPAROSCOPIC NISSEN/GT IN
laparoscopic Nissen/GTs performed. The
CHILDREN WITH COMPLEX CONGENITAL mean operative time was 35min (range
HEART DEFECTS V . Mortellaro, MD, 12 – 63min) for GT, and 71min (range
J. Alten, MD, R. Russell, MD, R. Griffin, 62 – 200min) for Nissen/GT. The mean
PhD, C. Martin, MD, S. Anderson, MD, D. blood loss was 1mL (0 – 2mL) for GT,
Rogers, MD, E. Beierle, MD, M. Chen, MD, and 2mL (range 2 – 10mL) for Nissen/
Children’s Hospital of Alabama GT. There were no conversions to an
BACKGROUND: In children with complex open procedure for either procedure.
congenital heart defects, the effect of Intraoperatively the mean minute
laparoscopy on cardiac physiology and ventilation was 1.3L (range 0.1 – 2.3L) with
the resultant morbidity are not well a mean intervention rate of 4 changes per
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case in patients who underwent GT. The PURPOSE: Pediatric surgeons require
mean minute ventilation was 1.4L (range both basic and, highly advanced
0.2 – 2.2L) with a mean intervention rate endoscopic surgical skills because of
of 9 changes per case in patients who the various operations and different
underwent Nissen/GT. The mean end tidal physical sizes of patients. The Japanese
CO2 was 35 (range 28 – 45) for GT and 45 Society for Endoscopic Surgery
range (range 41 – 45) for Nissen/GT. The developed an endoscopic surgical
mean FiO2 was 50% (range 20 – 100%) skill qualification(ESSQ) system for
for GT with a mean of 4 interventions all surgical fields, including pediatric
per case. The mean FiO2 was 47% (range surgery. However, it is difficult to evaluate
27 – 100) for Nissen/GT with a mean of 7 quantitative endoscopic skills using this
interventions per case. The mean sPO2 ESSQ system. We therefore developed
was 87% (range 77 – 100%) for GT and a validation system for objective
92% (range 71 – 100%) for Nissen/GT. endoscopic surgical skills for pediatric
The mean temperature was 36.0C (range surgeons based on a disease model.
32.8 – 37.9C) for GT, and 35.4C (range The aim of this study is to verify the skill
33.0 – 37.7C) for Nissen/GT. There was quality for pediatric endoscopic surgery.
one intraoperative complication due to
METHODS: We developed a thoracic
hypothermia resulting in cardiac shunting
repair model of congenital diaphragmatic
and the need for ECMO. There were no
hernia mimicking a new born case(body
postoperative complications.
weight:3 kg, diaphragm defect:1.5 x 1.0
CONCLUSION: The increased CO2 cm, Fig. 1, 2). The examinees divided into
introduced via laparoscopic insufflation two groups, 10 experts and 19 trainees(all
does not appear to adversely affect right handed). They performed 2 tasks;
patient stability and can be adequately Task 1 was a reduction of the herniated
managed with intraoperative ventilation. small intestine(5 mm diameter, length
The performance of laparoscopic GT 30 cm) from the thoracic space to the
and Nissen/GT can be achieved safely in abdomen (Fig 3a); Task 2 was to perform 3
patients with complex congenital heart suture ligatures of the diaphragm defect
defects. using an intracorporeal knot tying(Fig.
3b). The evaluation points were the time
S012: ENDOSCOPIC SURGICAL SKILL
required to complete Task 1, the time
VALIDATION SYSTEM FOR PEDIATRIC
score calculated using the residual time
SURGEONS USING A REPAIR MODEL OF from 900 seconds(time limit:15 min)
CONGENITAL DIAPHRAGMATIC HERNIA for Task 2, the number of complete
Satoshi Obata, MD, Satoshi Ieiri, MD, PhD, full-thickness sutures, maximum air
Munenori Uemura, PhD, Ryota Souzaki, pressure tolerance, degree of diaphragm
MD, PhD, Noriyuki Matsuoka, Tamotsu deformation, and residual defect areas
Katayama, Makoto Hashizume, MD, PhD, after suturing. This model improved
FACS, Tomoaki Taguchi, MD, PhD, FACS, using the Suture Simulator Instruction
Department of Pediatric Surgery, Faculty Evaluation Unit(Kyoto Kagaku Co., Ltd).
of Medical Science, Kyushu University, Additionally, we evaluated the total
Department of Advanced Medicine and path length and velocity of each tip
Innovative Technology, Kyushu University of the forceps using a 3-dimensional
Hospital, Kyoto Kagaku Co., Ltd position measurement instrument
with an electromagnetic tracking
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system(AURORA; Northern Digital Inc.
Canada) to assess bi-hand coordination.
All data were expressed as the mean ±
standard deviation. A statistical analysis
was performed using the two tail paired
and unpaired t test and p<0.05 was
considered statistically significant.
RESULTS: Table 1 shows the results
of the time of Task 1(p=0.0074),
time score(p=0.0118), numbers
of complete full-thickness
suture(p=0.0056), maximum air
pressure tolerance(p=0.0119), degree of
diaphragm deformation(p=0.0109), and
defect residual areas(p=0.1573). In the
time of Task 1, time score, the number
of complete full-thickness sutures,
maximum air pressure tolerance, and
degree of diaphragm deformation,
experts were significantly superior to
the trainees. Tables 2 and 3 compare the
total path length and velocity of tip of the
forceps between the left and right hand in
tasks 1 and 2. In trainees(Table2), the total
length and velocity of the left forceps
were inferior to those of the right forceps
in both Tasks(p<0.05, respectively).
Conversely, no significant differences
were seen among experts between both
forceps(Table3)(p>0.05, respectively) for
both tasks.
CONCLUSIONS: This study revealed that
experts possessed quick and accurate
skills. Experts have excellent bi-hand
coordination and they can use both hands
equally compared to trainees. Our model
validated the quality of endoscopic
surgical skills between experts and
trainees of pediatric surgeons. We next
plan to develop effective training models
for novice pediatric surgeons.
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S013: THE DEVELOPMENT AND repair and were ranked as undesignated.
PRELIMINARY EVALUATION OF A All comparative data between expert
SYNTHETIC NEONATAL ESOPHAGEAL and novice participants excluded the
ATRESIA/TRACHEOESOPHAGEAL undesignated group. Participants
FISTULA REPAIR MODEL Katherine A. completed a self-report, six-domain,
Barsness, MD, MS, Deborah M. Rooney, 24-item instrument consisting of
PhD, Lauren M. Davis, BA, Ellen K. twenty-three 5-point rating [D2]scales
Hawkinson, BS, Northwestern University (1=not realistic to 5=highly realistic) and
Feinberg School of Medicine; University of one 4-point Global rating scale. Content
Michigan School of Medicine validity was evaluated using the many-
Facet Rasch model and estimating inter-
BACKGROUND: Thoracoscopic esophageal rater consistency was estimated using
atresia/tracheoesophageal fistula (EA/ iIntra-class correlation (ICC) for items
TEF) repair is technically challenging. We relevant to simulator characteristics.
have previously reported our experiences
with a high-fidelity hybrid model for RESULTS: A review of the participants’
simulation-based educational instruction ratings indicates there were no overall
in thoracoscopic EA/TEF, including the differences across sites (IPEG vs. WOFAPS,
high cost of the tissue for these models. p=0.84), or experience (Expert vs.
The purposes of this study were to 1) to Novice, p=0.17). The highest observed
create a low-cost synthetic tissue EA/ averages were 4.4 (Value of Simulator as
TEF repair simulation model and 2) to a Training Tool), 4.3 (Physical Attributes-
evaluate the content validity of the chest circumference, chest depth and
synthetic tissue simulator. intercostal space) and 4.3 (Realism of
Experience-fistula location). The lowest
METHODS: Review of the literature and observed averageOA’s were 3.5 (Ability to
computed tomography images were Perform-closure of fistula) and 3.7 (Ability
used to create Computer-aided drawings to Perform-Acquisition target trocar
(CAD) for a synthetic, size appropriate EA/ sites), 3.8 (Physical Attributes-landmark
TEF tissue insert. The inverse of the CAD visualization), 3.8 (Ability to Perform-
image was then printed in six five different anastomosis and dissection of upper
sections to create a mold that could be pouch) and 3.9 (Realism of Materials-
filled with platinum-cured silicone. The skin). The Global Rating was 2.9, coinciding
silicone EA/TEF insert was then placed with a response of “this simulator can be
in a previously described neonatal considered for use in neonatal TEF repair
thorax and covered with synthetic skin. training, but could be improved slightly”.
Following IRB-exempt determination, 47
participants performed some or all of a CONCLUSIONS: We have successfully
simulated thoracoscopic EA/TEF during created a low-cost synthetic EA/
two separate international meetings (IPEG TEF tissue insert for use in a neonatal
and WOFAPS). X[D1]Fourteen participants thoracoscopic EA/TEF repair simulator.
were identified as “experts”, having Analysis of the participants’ ratings of
6-50 self-reported thoracoscopic EA/ the synthetic EA/TEF simulation model
TEF repairs, and thirty “novice”, having indicate that it has value and can be used
0-5 self-reported thoracoscopic EA/TEF to train pediatric surgeons to performn
repairs. Three participants did report prior thoracoscopic EA/TEF repair, with minor
experience with thoracoscopic EA/TEF revisions. Areas for improvement were
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identified, and these areas will be the or slightly worse than the expert group
focus for future modifications to this in the box trainer. In contrast, the
novel synthetic EA/TEF repair simulator. performance of the expert group was
significantly better than the intermediate
S014: VIDEO-BASED SKILL ASSESSMENT
group in the pediatric chest model.
OF ENDOSCOPIC SUTURING IN A
Significant specific differences between
PEDIATRIC CHEST MODEL AND A BOX the expert and trainee groups in the
TRAINER S hinya Takazawa, MD, Tetsuya pediatric chest model were observed in
Ishimaru, MD, PhD, Kanako Harada, PhD, some checklist items related to the ability
Yusuke Tsukuda, Naohiko Sugita, PhD, to keep the needle in view at all times, the
Mamoru Mitsuishi, PhD, Tadashi Iwanaka, knot-tying technique, and techniques for
MD, PhD, The University of Tokyo Hospital avoiding possible tissue damage.
PURPOSE: Pediatric minimally-invasive CONCLUSIONS: The expert group showed
surgery requires special surgical skills significantly better suturing performance
because of the small working space and than either the intermediate or trainee
tissue fragility. We previously reported groups in the pediatric chest model,
a pediatric chest model developed for suggesting that this method can better
the training and assessment of specific assess the pediatric-specific expert skills
pediatric surgical skills. This paper presents obtained by performing many clinical
a video-based method for assessing skills procedures. Therefore, we conclude that
for endoscopic suturing in the pediatric the pediatric chest model together with a
chest model compared with a box trainer. training program for the identified pediatric-
METHODS: A commercial suture pad was specific skills is a good endoscopic surgical
placed in a rapid-prototyped pediatric training and assessment platform for
chest model of a one year-old patient pediatric surgeons.
to simulate a suture required in the
thoracoscopic repair of esophageal
atresia type C. Twenty-eight pediatric
surgeons (9 experts, 9 intermediates,
and 10 trainees) each completed an
endoscopic intracorporeal suturing and
knot-tying task both in the pediatric chest Median values (interquartile
model and in a box trainer. The tasks were range);*p<0.05 vs Trainee, #p<0.05 vs
video-recorded and rated by two blinded Intermediate(Mann-Whitney U)
observers using two evaluation methods: S015: ANATOMICAL VALIDATION OF
the 29-point checklist method and the AN INANIMATE MODEL FOR TRAINING
error assessment sheet method. The THORACOSCOPIC REPAIR OF TRACHEO
experimental protocol was approved by ESOPHAGEAL FISTULA/ESOPHAGEAL
the Ethics Committee. ATRESIA – TEF/EA Maximiliano A. Maricic,
RESULTS: The suturing performance of MD, Maria M., Bailez, MD, National
the three groups is shown in Table 1. In all Children’s Hospital S.A.M.I.C. “Prof. Dr.
metrics for both setups, the expert group Juan P. Garrahan”
performed significantly better than the INTRODUCTION: We present the results
trainee group. The overall performance of anatomical validation of an inanimate
of the intermediate group was similar model created for training thoracoscopic
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repair of esophageal atresia with lower in relation to external and endoscopic
trachea esophageal fistula (EA/TEF) appearance (visual environment),
dimensions, esophageal anatomy and
MATERIALS & METHODS: This model has
double layer anastomosis; 91% (15/16)
been previously presented in IPEG 2013.
in relation to instruments positioning,
It is made of a piece of wood used as a
internal dimensions and appearance
support, 3 corrugated plastic tubes of
of work area esophageal dimensions,
different diameters (50mmø, 25mmø,
ligation and section of TEF and upper
and 15mmø) simulating ribs, intercostal
pouch dissection; 82% (14/16) regarding
spaces, trachea and spine and tubular latex
anatomical appearance (pleura, ribs,
balloons as the acigos vein and esophagus,
trachea, Azygos vein, nerve, lung),
with a thin self-adhesive transparent film
trans anastomotic tube, placement and
that fixed all structures as the parietal and
positioning of trocars and 73% (13/16)
mediastinal pleura, all introduced into a
refering to dissection of the esophagus
plastic container with a lid that simulates
and azygos vein.
the thoracic cavity of a newborn. The cost
of materials is less than 50U$. All respondents believe that the simulator
can generate skills in use of 3mm
A compact system monitor, light source
Instrumental; 91% of them in handling
and endocamera, a 4mm lens and 3mm
camera and 82% in dissection, suturing
instruments are used to reproduce all
and tissue handling.
steps of the procedure.
DISCUSION: The process of functional
Initial validation consisted of a
anatomical validation is a necessary step
Liker type survey completed by 16
before its validation as a training method.
international experts and pediatric
After survey results we are in the process of
surgeonsfrom different countries (Brazil,
improving the items that had a lower rate
France, Luxemburg, Switzerland and
to develop a more accurate and reliable
Argentina),already trained in MIS TEF
model for example including it into a doll to
repair. We define 4 categories depending
improve similarity with port positioning and
on their experience in MISTEF/AE repair: a)
including a tubular acigos vein.
beginners (less than 5) b) intermediate (5-
20) c) seniors (20-30) d) experts (+30). S016: THE LAPAROSCOPIC DUODENO-
DUODENOSTOMY SIMULATOR: A MODEL
The survey included 18 questions
FOR CUSTOMIZABLE MINIMALLY
regarding different aspects related to
INVASIVE SURGERY TRAINERS J oanne
similarity with real surgery with 5 possible
Baerg, MD, Nicole Carvajal, Danielle
answers graded from non to high degree
Ornelas, Candice Sanscartier, Diana Lopez,
of similarity, and “not serve to generate
Cristine Cervantes, William Grover, PhD,
skills” to “can generate the vast majority
Gerald Gollin, MD, Loma Linda University
of skills”
Children’s Hospital and University
RESULTS: Seven respondents were of California Riverside Biomedical
experts, 4 intermediate, 3 beginners and Engineering Department
2 seniors.
INTRODUCTION: Simulator training is
One hundred percent of them felt that an important step toward proficiency
the model has a high degree or good in minimally invasive surgery (MIS) for
likeness of similarity (grade 5 and 4) pediatric surgeons. MIS repair of duodenal
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atresia requires suturing skills that are modeled small intestine, duodenum
difficult to acquire. We sought to develop and stomach were placed in the bottom
a prototype of an inexpensive, synthetic, frame and the liver was placed inside the
and customized MIS simulator for top frame of the body cavity. A silicone
laparoscopic duodeno-duodenostomy. rubber sheet covered the top frame. The
simulated duodeno-duodenostomy was
METHODS: Two pediatric surgeons,
judged to be realistic by the surgeons who
in cooperation with a University
trialed the simulator. The material was
Bioengineering Department, designed and
durable and did not tear or deform after
developed a synthetic model to simulate
multiple anastomoses.
laparoscopic duodenal atresia repair in an
infant. CONCLUSION: An inexpensive, life-
sized and durable synthetic simulator
RESULTS: The simulator was constructed
for MIS duodeno-duodenostomy was
in three parts: organ construction, training
constructed. This serves as an initial
box construction and assembly.
proof of concept that customizable
Organ construction: Solid molds of small simulators of pediatric MIS procedures
intestine, duodenum, stomach and liver can be constructed using 3-D printing
were designed in SolidWorks software technology and latex to construct organs.
in acrylonitrile butadiene styrene using The development of operation-specific
a 3D printer. The size of each mold was simulators has the potential to speed
designed to be dimensionally accurate to the safe and efficient integration of rare
life-sized infant organs. Premium liquid pediatric MIS procedures into practice.
latex rubber was then dispersed over the
plastic molds to construct the organs.
The duodenal segments included a layer
of thin gauze sandwiched between layers
of latex. Training box construction: The
box was modeled after the body cavity
of an infant, from the lower neck to the
top of the thighs. The interior volume
mimics the pneumoperitoneum of an
infant abdomen during laparoscopic S017: OPTIMIZING WORKING SPACE IN
surgery. After constructing a Styrofoam LAPAROSCOPY - CT MEASUREMENT OF
top and bottom frame template that THE INFLUENCE OF SMALL BODY SIZE
simulated the top and bottom of the IN A PORCINE MODEL J . Vlot, MD, Lme
infant body, fiberglass resin was painted Staals, MD, PhD, Prof. RMH Wijnen, MD,
over the template to construct the PhD, Prof. RJ Stolker, MD, PhD, Prof. NMA
body cavity. Three holes designating the Bax, MD, PhD, Erasmus MC: University
placement of a grasper, a needle driver Medical Center Rotterdam
and an endoscope were cut from the
INTRODUCTION: In our continuing
top frame. Top and bottom frames were
research into the determinants of
secured to each other. A reusable rubber
laparoscopic working space, the influence
grip was secured over the top frame so
of small body size was investigated.
the laparoscopic instruments could be
placed through it. Assembly: Organs METHODS: In eight 6-kg pigs,
were secured in the box with Velcro. The the effects of intra-abdominal
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CO2pneumoperitoneum pressure (IAP), S018: THE EFFECTS OF CO2-
pre-stretching of the abdominal wall, INSUFFLATION WITH 5 AND 10 MMHG
and neuromuscular blockade (NMB) DURING THORACOSCOPY ON CEREBRAL
on laparoscopic working space volume OXYGENATION AND HEMODYNAMICS
and distances were studied. Computed IN PIGLETS L isanne J. Stolwijk, MD,
tomography was used to measure working Stefaan H. Tytgat, MD, Kristin Keunen,
space during two stepwise abdominal MD, N Suksamanapan, MD, Maud Y. van
insufflation-runs up to an IAP of 15 Herwaarden, MD, PhD, Petra M. Lemmers,
mmHg. Results were compared with data MD, PhD, David C. van der Zee, Prof., Dr.,
from earlier experiments in 20-kg pigs. Wilhelmina’s Children Hospital University
Medical Center Utrecht
RESULTS: In 6-kg pigsworking-space
dimensions werefive times smaller than in AIMS: An increasing percentage of surgical
20-kg pigs. Cardiorespiratory parameters interventions in neonates is performed by
were stable up to an IAP of 8-10 mmHg. minimal invasive techniques. Near infrared
Working-space volume, anteroposterior spectroscopy is a non-invasive method
(AP) diameter and symphysis-diaphragm that can be used to assess changes in
distance increased linearly up to an IAP cerebral oxygenation, an estimator of
of 8 mmHg. Above 8 mmHg, compliance cerebral perfusion, by monitoring regional
decreased. Eighty percent of the total cerebral oxygen saturation (rScO2).
volume (618 ml) and of AP diameter (3 Values below 40% are related with brain
cm) at 15 mmHg had been achieved at damage. rScO2can be influenced by
an IAP of 10 mmHg. Pre-stretching by a mean arterial blood pressure (MABP),
first insufflation resulted in a statistically mean airway pressure, arterial saturation
significant increase in working space (SaO2) and pCO2. Recently, concerns
volume and in AP-diameter during the have been raised regarding a decrease
second insufflation. This effect was of cerebral oxygenation in neonates
significantly larger than in 20-kg pigs. during thoracoscopy as a result of CO2-
Neuromuscular blockade did not have a insufflation (Bishay 2013).
significant effect on working space.
METHODS: Piglets were anaesthetized,
CONCLUSIONS: Working space in growing intubated, ventilated and surgically
individuals is very limited. Eighty percent prepared for CO2-insufflation and
of the working space created by an insertion of a trocar in the right
IAP of 15 mmHg was already achieved hemithorax took place. Insufflation
at 10 mmHg, while cardiorespiratory was done with 5 or 10 mmHg CO2during
side effects at an IAP of 8-10 mmHg one hour. Physiologic parameters SaO2,
seem acceptable. Pre-stretching of the heart rate (HR), MABP and rScO2were
abdominal wall significantly increased monitored. cFTOE, an estimator of
working space, even more so than in cerebral oxygen extraction ((SaO2 -
20-kg pigs. As in 20-kg pigs, NMB had no rScO2) / SaO2)) was calculated. Arterial
significant effect on laparoscopic working blood gases were drawn every 15’:
space. Pre-stretching of the abdominal pre(T0), during(T1-T4) and after CO2-
wall is a promising cheap, safe and easy insufflation(T5).
strategy to increase laparoscopic working
space, lessening the need for prolonged RESULTS: Ten piglets (4kg) were
high-pressure pneumoperitoneum. randomized for 5(P5) and 10(P10) mmHg
CO2-insufflation.
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Two P10 piglets needed resuscitation PURPOSE: Bariatric
after insufflation, none P5. surgery corrects insulin
resistance independent
P5 showed stable SaO2, HR and MABP
of weight loss, possibly
during the entire procedure. pCO2(mmHg)
through enterokine
increased from 36±4 at T0 to 70±19 at T4
signaling pathways.
(p<0.05) and rScO2(%) from T0 42±3 to
We hypothesize that a
57±1 at T5 (p<0.001).
Magnetic Anti-Glycemic
P10 showed a decrease of MABP (mmHg) Ileal Conduit (MAGIC),
from 84±8 at T0 to 54±21 at T3 (p<0.05). created with a magnetic compression
HR increased from T0152±18 to 218±9 at anastomosis between the proximal
T3 (p<0.05), pCO2(mmHg) from 35±6 at T0 jejunum and distal ileum, corrects insulin
to 74±8 at T3 (p=0.01), rScO2(%) from 37±4 resistance.
at T0 to T5 50±5 (p=0.05).
METHODS: Yucatan mini pigs (n = 12)
cFTOE in P10 compared to P5 was higher received a high fat diet for 3 months to
at all time points and significant at induce insulin resistance. Animals were
T5(p<0.05)(fig 1). randomly assigned to 4 groups (n=3).
Baseline intravenous glucose tolerance
CONCLUSION: Insufflation of CO2during tests (IVGTT) were performed in fat-fed
thoracoscopy with 10 mmHg caused more pigs and one farm pig as a control. Eight
severe hemodynamic instability compared animals underwent the MAGIC procedure
to 5 mmHg. Although higher CO2-levels using either 23 mm (n=3) or 17 mm
are related with higher brain perfusion diameter (n=5) magnets. Four animals
by cerebral vasodilation insufflation of underwent sham operation. Groups were
10 mmHg seemed to be related with survived for 2, 4, 8 or 12 weeks, at which
a decrease of cerebral perfusion as points IVGTTs were repeated to assess
represented by a higher oxygen extraction. changes in insulin sensitivity. Plasma
CO2-Insufflation of 5 mmHg for glucose and serum insulin by ELISA was
thoracoscopy seems to be safe for measured (n=8). Animals were euthanized
cerebral oxygenation. and the anastomosis procured for
histology.
S019: MAGIC (MAGNETIC ANTI-
GLYCEMIC ILEAL CONDUIT) I: JEJUNAL- RESULTS: Baseline insulin resistance was
ILEAL MAGNETIC COMPRESSION confirmed in fat-fed pigs versus control
ANASTOMOSIS CORRECTS INSULIN (Insulin area under the curve normalized
RESISTANCE IN DIABETIC PIGS Hilary B. to weight [AUC]: 0.330 ± 0.206 vs 0.053, p
Gallogly, MD, Elisabeth J. Leeflang, MD, < .005). Insulin sensitivity improved by 2
Dillon A. Kwiat, Corey W. Iqbal, MD, Karyn weeks in animals after MAGIC treatment
J. Catalano, PhD, Kullada O. Pichakron, compared with sham (AUC: 0.169 ± 0.098
MD, Michael R Harrison, MD, Department vs 0.382 ± 0.30, p < 0.005). While animals
of Surgery, University of California, Davis. with 23 mm magnets experienced
Departments of Pediatric Surgery and excessive weight loss (>25%) observed by
Obstetrics, Gynecology & RS, University 4 weeks, this was ameliorated in pigs with
of California, San Francisco. Department 17 mm magnets (48% ± 3 vs 18% ± 14).
of Surgery, David Grant Medical Center, No anastomotic leaks or strictures were
Travis Air Force Base. observed in any animals. All animals took
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liquids on the day of surgery and were RESULTS: Eighty-seven rabbit fetuses
tolerating solids on POD 1. Two animals were studied. Direct evidence of
had diarrhea that abated, but none membrane leakage was present in 36%
required supplements or TPN. of Amnioseal treated animals and 67%
of saline treated animals (p=0.03). The
CONCLUSION: MAGIC jejunal-ileal bypass
membrane was completely disrupted in
may be an effective treatment for insulin
43% of the saline group compared to 15%
resistance and the metabolic syndrome,
with Amnioseal (p=0.03). Mean lung-to-
with the potential for an outpatient
body weight ratio was lowest (suggesting
minimally invasive procedure.
oligohydramnios) in the saline control
S020: AMNIOSEAL I: A BIOMIMETIC group (0.026±0.001) while the Amnioseal
POLYMER ADHESIVE TO PRESEAL THE group (0.030±0.002) was closer to the
AMNIOTIC MEMBRANE TO PREVENT untreated group (0.0.32±0.002).
PPROM AFTER FETOSCOPY C orey W. CONCLUSIONS: Amnioseal was effective
Iqbal, MD, Dillon A. Kwiat, BS, Stephanie in reducing membrane rupture as
Kwan, BS, Hoyong Chung, PhD, Robert measured by direct membrane
H. Grubbs, PhD, Michael R. Harrison, MD, assessment and fetal lung-to-body
University of California San Francisco weight ratio. This may be a useful
Fetal Treatment Center; Children’s Mercy strategy to prevent PPROM after
Hospital Fetal Health Center fetoscopy.
PURPOSE: Preterm premature rupture S021: THE PEDIATRIC DEVICE
of membranes (PPROM) is a common CONSORTIUM: A MODEL FOR SURGICAL
problem after fetoscopy and remains the INNOVATION E lisabeth J. Leeflang,
“Achilles Heel” of fetal therapy. MD, Elizabeth A. Gress, Dillon A. Kwiat,
HYPOTHESIS: We hypothesize that Hanmin Lee, MD, Shuvo Roy, PhD,
presealing the amniotic membrane with Michael R. Harrison, MD, Departments
a biomimetic polymer adhesive that of Pediatric Surgery and Bioengineering
works in an aqueous environment, similar and Therapeutic Sciences, University of
to that produced by the mollusk, prior to California, San Francisco
amniotomy will prevent PPROM.
The Pediatric Device
METHODS: With IACUC approval, Consortium (PDC) has
pregnant rabbits underwent celiotomy served for 4 years as
with exposure of the uterus. Fetuses a platform for open
were randomly assigned (by position brainstorming, creating
in the uterine horns) to either (1) no solutions through
intervention, (2) Amnioseal injection a multidisciplinary
between the myometrium and amnion approach and completing the cycle
followed by needle puncture or (3) saline of device innovation from concept to
injection between the myometrium and commercialization.
amnion followed by needle puncture.
The consortium’s twice weekly
One week postoperatively, the integrity
meetings afford a venue for iteration
of the amniotic sac was assessed for
of its 13 active projects and support for
leak by injection of methylene blue and
people with new ideas at any stage of
oligohydramnios was assessed indirectly
development. These meetings are a
by fetal lung-to-body weight ratio.
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sounding board for potential devices, S022: LONG TERM HEMODYNAMIC
project updates and future directions. EFFECTS OF NUSS REPAIR IN PECTUS
The interactive web portal provides EXCAVATUM FOR VENTRICULAR
resources for education, collaboration FUNCTION BY “CARDIOVASCULAR
and communication. The organization MAGNETIC RESONANCE CINE-SSFP-
consists of a program administrator, IMAGING”, RESULTS OF BERLIN-
principal investigators, partner programs, BUCH NUSS-CARDIO-MRI STUDY K .
and specialists in product development, Schaarschmidt, Prof., MD, Susanne
regulatory affairs, and intellectual Polleichtner, MD, A. Töpper, MD,
property. Residents, engineers and A. Zagrosek, MD, M. Lempe, MD, F.
students from a variety of disciplines Schlesinger, MD, J. Schulz-Menger,
work on physical devices and are Prof., MD, Helios Center of Pediatric and
surrounded by a diverse technological Adolescent Surgery Berlin-Buch
pool.
OBJECTIVE: Exercise intolerancein
The model of the PDC has contributed pectus excavatum is known,but true
to over 30 pediatric devices, with 3 physiological impairment is difficult to
projects in the clinical stages and one prove. Controversial is, whether Nuss
commercially available device. Fifteen improvescardio-pulmonary performance
articles have been published in peer- althoughcardiac relief was reported
reviewed medical and engineering 2006 by Colnecho-cardiographically
journals and research presented at and in 2013 by Maagaard clinically.
over 20 conferences. Meetings attract Cardiac nuclear magnetic resonance
12-20 people on average from different imaging(CMRI)has low inter-observer
backgrounds. To accelerate the adoption variance but shows severeinterferences
of pediatric devices into the market, by ferro-magnetic Nuss bars and
the PDC has facilitated 5 partnerships investigation capacities are limited.
between innovators and existing
companies and has helped launch 6 METHODS: 7/2009- 11/2011 53 PE
start-ups around technologies born in patients of 12.8-42.9y (21.1±8.6) with
the PDC. The PDC has raised more than a Haller of 9.9± 5.7 (4.3-18.1) and
$11 million as an impressive return on BMI of 20.8±3.6 entered the study
the Food and Drug Administration’s $2 and37series(30 male /7 female) free of
million investment. artifacts allowed complete evaluation.
This ongoing prospective studyquantifies
Momentum continues to gather in the right +left ventricular function by CMR
newly formed Surgical Innovations Group before, 2 weeks, 3months, 1 year after
- encompassing all surgical specialties, Nuss and finally 3 years postop after
bioengineering and a multicenter bar removal. The use of titanium bars
incubator, a device accelerator for (13´-17´) in all patients avoided bar
funding devices and the Innovation interferences in CMR. Cardiac function
Pathway for researchers. What began was assessed by Cine-SSFP-imaging
as a free forum has grown into an covering the left ventricle (LV) as short
innovation powerhouse with name axis and the right ventricle (RV) axial
recognition and clinical solutions. orientation in axial orientationWe
quantified the enddiastolic and
endsystolic volumes of LV and RV: and
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calculated the ejection fractions (EF) and S023: 3-DIMENSIONAL VISION
stroke volumes (SV) using CMR42 (circle IMPROVES LAPAROSCOPIC SURGERY
cvi, Canada). IN SMALL SPACES X iaoyan Feng, MD,
Anna Morandi, MD, Martin Boehne, MD,
Tawan Imvised, MD, Benno Ure, MD, PhD,
Joachim F. Kuebler, MD, Martin Lacher,
MD, PhD, Center of Pediatric Surgery,
Department of Pediatric Cardiology
TABLE 1: Change of cardiac function in and Intensive Care Medicine, Hannover
pectus excavatum after Nuss repair Medical School, Germany
RESULTS: Haller index was significantly AIM OF THE STUDY: Three-dimensional

improved after Nuss surgery (pre: 9.9± 5.7 (3D) cameras, a recent technical
vs. post: 2.8± 0.5, p <0.001) indicating a innovation in laparoscopic surgery, have
successful repair in all patients. The right been postulated to enhance depth
ventricle lies anteriorly and to the right perception and to facilitate operations.
and is predominantly compromised by However, they have not been tested in
pectus excavatum. Thus right ventricular conditions where the focus is close to the
ejection fraction (RVEF) and stroke optical system. Thus, it is unclear whether
volumes of both ventricles (RVSV and 3D cameras could improve laparoscopic
LVSV) are highly significantly increased 2 surgery in neonates and infants. We
wk, 3 mo and 1 year after Nuss (see table tested the advantages of 3D vs 2D vision
1), while LVEF just reaches significance during laparoscopic surgery in rabbits,
with p of 0.05. mimicking the size of a neonatal patient.
CONCLUSIONS: Cardiovascular MATERIALS & METHODS: Cadaver New

improvement by Nuss repair has been Zealand white rabbits (mean weight 2800
suspected for a long time due to g) were operated by two experienced
decreased palpitations and exercise heart laparoscopic surgeons. All animals
rates but could never be measured in a underwent 6 surgical procedures: Nissen
strictly reproducible way.Although this fundoplication, small bowel anastomosis
is an early report and still a small series and closure of a diaphragmatic hernia
it shows hemodynamic improvement using 2D and 3D systems (3D: 0°, 10mm
after Nuss repair significantly and laparoscope; 2D: 30°, 10mm laparoscope,
consistently in all control scans. Karl Storz, Tuttlingen, Germany). The
Cine-volumetric CMR measurement sequence of the three cases and visual
shows preoperative impairment technique (2D vs 3D) was changed every
in PEand significant postoperative time. Primary endpoint was operation
improvement of the most important (OR) time. Secondary endpoints were
right and left functional parametersafter measured to exclude confounders and
severalpostoperativeperiods following included the hemodynamic response of
Nuss repair and may become a new the surgeon (heart rate, blood pressure,
standard for PE evaluation in the future. cardiac output assessed by noninvasive
electrical velocimetry Aesculon®)
as well as the assessment of the
psychomental stress level (measurement
of concentration by a “bp-test”, reaction
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time (seconds) and performance in a PURPOSE: Minimally invasive approaches
video game (Score; Pac-man). Finally, to congenital diaphragmatic hernia
subjective data were assessed with (CDH) repair were once hailed for their
questionnaires on a 0–4 scale after each perceived benefits. However, increased
operation. recurrence rates have been frequently
reported, demonstrating that a minimally
RESULTS: 42 procedures were completed
invasive approach may be less effective
in 7 rabbits with a total of 21 2D- and 21
than conventional open repair. The
3D-operations. The mean cumulative OR
purpose of this study was to examine the
time for all three operations in the 3D
outcomes of infants selectively chosen
group was significantly shorter compared
for minimally invasive repair compared to
to the 2D group (3D: 23.0 min vs 2D: 29.5
infants who underwent open repair with
min, p<0.01). This effect could be shown
special attention to recurrence.
for all three operations independently
(Nissen fundoplication: mean time METHODS: A retrospective review of
3D 8.9min vs 2D 11.6min, p=0.02; patients with CDH repair at our institution
Diaphragmatic reconstruction: mean was performed from June 1999 to June
time 3D 7.5 min vs 2D 9.7 min, p=0.0009; 2012. (IRB #X130829007). Only Bochdalek
Intestinal anastomosis: mean time 3D CDH repairs were included. Participants
6.6 min vs 2D 8.2 min, p=0.014). There were excluded for repair after 6 months
were no differences in the cardiovascular of age or death. Infants were then
response of the surgeon comparing 3D grouped based on repair type: open repair
and 2D (heart rate, blood pressure, cardiac (laparotomy or thoracotomy), endoscopic
output) as well as psychomental stress repair (thoracoscopic or laparoscopic),
levels (concentration, reaction time and or conversion (starting endoscopic and
performance in the Pac-man video game). converting to an open procedure). Repair
Subjective evaluation of the surgical type was chosen based on surgeon’s
performance revealed that 3D offers a assessment of patient’s condition and
better perception of the depth. organ involvement. Demographic data
(gestational age, birth weight, Apgar scores
CONCLUSION: The use of 3D laparoscopy
at 1, 5, and 10 minutes) and treatment
in small spaces using a rabbit model is
data (repair day of life, patch use) were
associated with faster operation times.
collected. Hernia data included side and
This finding was independent of the
organ involvement. Outcome measures
overall shape of the surgeon assessed
included length of stay, ventilator days,
by hemodynamic and psychomental
follow-up length, and hernia recurrence.
measurements. 3D may therefore
Hernia recurrence was based on chest
facilitate reconstructive minimal invasive
x-ray, CT scan, or need for recurrent hernia
surgery in small children.
surgery. The three patient groups were
S024: MINIMALLY INVASIVE CDH compared using analysis of variance and
REPAIR: EFFECTIVE FOR SELECT the Freeman-Halton extension of Fisher’s
PATIENTS T ate Nice, MD, Scott Anderson, exact test for continuous and categorical
MD, Sebastian Pasara, Rafik M. Bous, variables, respectively; non-parametric
Robert Russell, MD, MPH, Carroll M. statistics were used when deemed
Harmon, MD, PHD, Children’s of Alabama, appropriate. An intention-to-treat analysis
University of Alabama at Birmingham was also performed comparing open to
the aggregate group of endoscopic and
conversion repairs.
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RESULTS: Sixty-four infants underwent S025: FURTHER EXPERIENCE WITH
open repair and 26 underwent STAGED THORACOSCOPIC REPAIR OF A
endosurgical repair, 7 of which were LONG GAP ESOPHAGEAL ATRESIA USING
converted to open during the study INTERNAL STATIC TRACTION SUTURE
period. Demographically the groups differ Dariusz Patkowski, Prof, MD, PhD,
only by APGAR scores at 1 minute of Wojciech Górecki, MD, PhD, Sylwester
life (Open:5, Endoscopic:7, Conversion:7, Gerus, MD, Anna Piaseczna-Piotrowska,
p= 0.025) and ECMO requirement Prof, MD, PhD, Piotr Wojciechowski,
(Open:37.5%, Endoscopic:5.3%, MD, PhD, A.I. Prokurat, Prof, MD, PhD,
Conversion:14.3%, p= 0.011). While hernia Przemyslaw Galazka, MD, PhD, Michal
side and patch use were not statistically Blaszczynski, MD, PhD, Maciej Baglaj
different between repair groups, organ Prof, MD, PhD, Departments of Pediatric
involvement differed significantly [Table Surgery and Urology: Wroclaw, Krakow,
1]. Ventilator days were decreased in the Lodz, Poznan, Bydgoszcz
endoscopic group, however length of stay
was not significantly different. Median BACKGROUND: Repair of long gap
follow-up in days was similar between esophageal atresia (EA) is a challenge.
groups. There were 11 (17.2%) recurrences Several different techniques have been
in the open group, none (0%) in the invented. Most of them require staged
endoscopic group, and 1 (14.3%) in the procedures with negative consequences
conversion group (p= 0.114). The intention- of rethoracotomy. Three years ago, we
to-treat analysis confirmed no statistical presented our initial experience with
difference in recurrence between the endoscopic technique using internal static
open (17.2%) and endoscopic/conversion traction suture for management of long
repair (3.8%) (p= 0.169). gap esophageal atresia (EA).
CONCLUSION: By selectively utilizing OBJECTIVE: To evaluate the safety and

minimally invasive techniques rather than efficacy of repetitive thoracoscopic
applying to all patients, effective repairs technique using static internal traction
of Bochdalek CDH can be obtained with suture for repair of long gap EA.
a low recurrence rate. Overall patient METHOD: Between June 2010 and January
condition, need for ECMO, and organ 2014, fourteen infants (7 girls, 7 boys)
involvement should factor into the repair with long gap EA (no distal tracheo-
technique decision. Hernia recurrence is esophageal fistula - TEF), were managed
similar between open and endoscopic by a thoracoscopic approach in 5 different
repairs as long as minimally invasive hospitals. The first author was involved
repairs are utilized selectively. in all chest procedures except two. All
the children had a feeding gastrostomy.
The thoracoscopic procedure was
preceded by bronchoscopy to exclude
a proximal fistula. Thoracoscopy was
performed in right semi-supine position
using 3 ports around the right scapula.
The azygos vein was not divided. Both
esophageal ends were mobilized and the
proximal TEF present in four newborns
was closed. Non-absorbable 2-0 suture
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was advanced to the proximal and distal because of heart defect. Six children
esophagus and with the aid of sliding required calibration/dilatation of the
knot; both ends were approximated and anastomosis for a mild and treatable
left under the tension. At the subsequent stricture. One case had antireflux
endoscopic approach, under favorable surgery.
conditions, a definite anastomosis over
CONCLUSION: We believe our technique
an 8F nasogastric tube by single stitches
is an alternative option for the repair of
of 5-0 absorbable braided suture was
long gap esophageal atresia, and offers
constructed. Otherwise, new traction
functional native esophagus in early
suture was applied.
infancy. Thoracoscopic approach allows
RESULTS: The first stage thoracoscopic for avoiding negative consequences of
surgery was performed between 2 and 51 open thoracotomy for a growing child.
days of life. The esophageal anastomosis Repetitive thoracoscopy does not hinder
was completed in 12 infants between the exposure for dissection in posterior
31 and 175 days of life: 10 infants mediastinum.
were managed only by thoracoscopic
S026: B-TYPE NATRIURETIC PEPTIDE
approach, one baby was converted in
LEVELS CORRELATE WITH PULMONARY
the last procedure and the other one
had the last procedure performed in an HYPERTENSION AND REQUIREMENT
open fashion by intention. Two infants FOR EXTRACORPOREAL MEMBRANE
are still awaiting a definitive procedure. OXYGENATION IN CONGENITAL
All infants had 37 procedures performed DIAPHRAGMATIC HERNIA E mily A.
(35 thoracoscopies, 1 thoracoscopy Partridge, Lisa Herkert, Brian Hanna,
with conversion, 1 thoracotomy). The Natalie E. Rintoul, Alan W. Flake, N.
number of procedures to complete Scott Adzick, Holly L. Hedrick, William
the anastomosis was between 2 and 5 H. Peranteau, Children’s Hospital of
(mean: 2.86). The traction suture caused Philadelphia ,Philadelphia, PA USA
esophageal perforation in one case AIM OF THE STUDY: B-type natriuretic
that required thoracoscopic closure. peptide (BNP), an established biomarker
The other baby had probably hidden of ventricular pressure overload, is used
perforation that resulted in pleural cavity in the assessment of disease severity
obliteration and required conversion and treatment guidance in children
during esophageal anastomosis. In other with pulmonary hypertension (PH). PH
cases, we experienced no difficulties is commonly observed in congenital
with repetitive approach to the pleural diaphragmatic hernia (CDH) and
cavity, as well as exposition, dissection represents the most frequent indication
and suture of esophagus after the for the initiation of extracorporeal
previous procedures. membrane oxygenation (ECMO) therapy.
In 12 children with anastomosed However, the use of BNP levels to guide
esophagus, a contrast study was treatment in this patient population has
performed 5-7 days postoperatively. not been well defined. We investigate
Anastomotic healing was satisfactory in BNP levels in a large cohort of CDH
each case. Oral feeding was progressively patients treated at a single institution
started replacing the gastrostomy route. and correlate them with clinical
There was late mortality in one case outcomes
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METHODS: We retrospectively reviewed PURPOSE: Laparoscopic ileal pouch-anal
charts of all CDH patients enrolled in anastomosis (IPAA) has been associated
our pulmonary hypoplasia program with decreased complications when
from 2004-2013. PH was assessed by compared to open IPAA in children.
echocardiography using defined criteria, Though single incision laparoscopic (SIL)
and patients were further stratified into IPAA has been shown to be feasible and
the following cohorts: no PH, short-term safe, outcomes have not been compared
PH (requiring nitric oxide but no additional to those of traditional laparoscopic-
vasodilatory therapy), long-term PH assisted (LA) procedures. The purpose
(requiring continued vasodilatory therapy of this study was to compare the two
post-discharge), and ECMO (requiring techniques to determine if benefits to the
ECMO therapy). BNP levels prior to CDH single incision approach exist in children
repair and/or ECMO cannulation from with ulcerative colitis (UC) and familial
each patient cohort were analyzed by adenomatous polyposis (FAP).
Mann-Whitney t-test (p<0.05).
METHODS: All children ≤18 who
RESULTS: One hundred and eleven underwent SIL and LA IPAA between 2000
patients were studied. BNP levels were and 2013 at our institution were identified
significantly lower in patients with from a prospectively maintained database
normal pulmonary pressures compared of surgical procedures. Single incision
to patients with PH (p<0.0001) [Table 1]. laparoscopic IPAA was first performed in
Those patients who went on to require 2010 and utilized a modified glove port
ECMO therapy had significantly higher with a wound protector/retractor. Many
BNP levels compared to patients with SIL procedures required one accessory
no PH (p=0.0341). BNP levels were also port and traditional LA procedures
significantly increased in both ST-PH and often used a 5-cm Pfannenstiel incision
LT-PH patients compared to those with no for proctectomy and IPAA following
PH. Although not statistically significant, laparoscopic colon mobilization.
there was a trend towards higher BNP Demographic, preoperative, operative,
levels in patients with LT-PH compared to and postoperative information was
ST-PH (p=0.0696). obtained retrospectively from patients’
medical records and compared between
CONCLUSION: Plasma BNP levels
SIL and LA approaches usingt-tests for
correlate with pulmonary hypertension
continuous variables and chi square
and requirement for ECMO in CDH
or fisher exact tests for discrete
patients. Monitoring of serial BNP levels
variables. Results for operative time and
may provide a useful prognostic tool in
postoperative length of stay (LOS) were
the management of CDH.
stratified by number of stages (one, two,
S027: SINGLE INCISION LAPAROSCOPIC or three) and postoperative complications
ILEAL POUCH-ANAL ANASTOMOSIS IN were stratified by diagnosis (UC or FAP).
CHILDREN—HOW DOES IT COMPARE TO A RESULTS: Children who underwent SIL
TRADITIONAL LAPAROSCOPIC-ASSISTED IPAA (n=19) and LA IPAA (n=62) were not
APPROACH? S tephanie F. Polites, MD, significantly different in age, gender,
Abdalla E. Zarroug, MD, Christopher R. diagnosis, biologic use (UC patients
Moir, MD, Donald D. Potter, MD, Mayo only), staged approach, and stapled
Clinic, Rochester, MN; University of Iowa, vs. mucosectomy with hand sewn
Iowa City, IA
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anastomosis (Table 1). An accessory S028: CURRENT OPERATIVE STRATEGIES
port was used in 53% of SIL procedures AND EARLY COMPLICATIONS
and a Pfannenstiel incision in 87% of LA OF DEFINITIVE SURGERY FOR
procedures.Single incision laparoscopic HIRSCHSPRUNG’S DISEASE IN THE
IPAA had equivalent mean operative UK AND IRELAND: FINDINGS FROM
times to LA for two (353 vs. 385 minutes, A PROSPECTIVE NATIONAL COHORT
p=.32) and three stage (316 vs. 339 STUDY T im Bradnock1,Simon Kenny2,
minutes, p=.60) procedures but operative Paul Johnson3, Marian Knight4, Jenny
time for one stage procedures was Kurinczuk4, Gregor Walker1, 1Department
shorter with SIL (308 vs. 355 minutes, of Paediatric surgery, Yorkhill hospital
p<.001). Median LOS was shorter following Glasgow UK;2Department of Paediatric
SIL for all patients (4 vs. 7 days, p<.001) Surgery, Alder Hey Children’s Hospital
and, specifically, for two stage patients Liverpool UK;3Department of Paediatric
(4 vs. 6 days, p=.009). Patients with CUC surgery, University of Oxford Oxford UK;4
had more unplanned returns to the
operating room following LA IPAA (40% AIM OF STUDY: 1) To describe operative
vs. 13% for SIL, p=.07) and more bowel strategies and early complications
obstructions (18% vs. 7% for SIL, p=.43); for a national cohort of infants with
however, these differences were not Hirschsprung’s Disease (HD) and 2)
significant. Occurrence of pelvic abscess, investigate factors associated with
anastomotic leak, and revision of IPAA surgical complications.
was also equivalent between SIL and LA METHODS: Between October 2010 -
for both UC (7 vs. 11%, p=.99) and FAP September 2012, each paediatric surgical
(25% vs. 24%, p=.99) but these results are centre in the UK and Ireland prospectively
limited by small sample size. identified infants presenting before
6 months of age with histologically-
proven HD. Data including demographics,
operative approach and complications
(anastomotic leak/stricture, infection,
TABLE 1: Characteristics of children who perianal excoriation, enterocolitis, and
underwent IPAA unplanned operations) in the first 28 days
were recorded.
CONCLUSIONS: Single incision
laparoscopic IPAA is a safe alternative to Univariate analysis using Mann-Whitney
traditional laparoscopic-assisted IPAA for tests for numerical variables and chi-
children with UC or FAP and may reduce squared tests for categorical variables
postoperative LOS without affecting short were used to investigate factors
term postoperative morbidity. Additional predictive of any complication. Variables
studies are needed to determine if there significant at 5% level were used for
are long term benefits. multivariate logistic regression analysis
to determine independent predictors of
complications. All analyses were done
using Minitab (v16) at P<0.05.
RESULTS: In 2 years, there were 317
reported cases of HD and data were
available for 287/317(91%). 260 infants
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had definitive surgery (180 primary the potential to improve these skills
and 80 staged pull-throughs). Colonic without patient risk. Although validity
mobilization was laparoscopic, open evidence exists for an “adult” simulator,
and exclusively transanal in 113(43.5%), none exists for a pediatric simulator. The
108(41.5%) and 39(15%) cases respectively. study purpose was to 1) create a size-
Rectal dissection technique was appropriate infant scale lobectomy model
submucosal, posterior and perirectal and 2) evaluate validity evidence for
in 137(52.7%), 96(36.9%) and 26(10%) performance measures on the simulator.
respectively.
METHODS: IRB exempt pilot study. A size
The overall early complication rate was appropriate rib cage for a 3-month old
96/260(36.9%). Independent predictive infant was created from literature and CT
factors of complications were any image review. Fetal bovine tissue injected
additional anomaly (OR=2.32, 95% C I with a blood substitute completed
1.19-4.51, p=0.013) and rectal dissection the model. Thirty-three participants
technique (table 1). Compared to performed the simulated thoracoscopic
submucosal dissection, complications lobectomy during a national course.
were more likely with posterior (OR=1.93, Participants completed a self-report,
95% C I 1.11-3.36, p=0.02) and perirectal six-domain, 26-item instrument
dissection (OR 2.87, 95% C I 1.21-6.81=, consisting of 4-point rating scales (1=Not
p=0.017). Factors not significantly realistic to 4=Highly realistic). Using
predictive of complications were self-reported thoracoscopic lobectomy
age, weight, primary/staged surgery, experience, we categorized participants
aganglionosis length, abnormal as “experienced” (n=11) or “novice” (n=
proximal resection margin, and colonic 20). Content validity was evaluated
mobilization technique. Case fatality by examining the rating differences
was 8/287(2.8%). No infant died after using the many-Facet Rasch model and
definitive surgery. estimating inter-rater consistency using
Intraclass correlation (ICC).
CONCLUSIONS: This national cohort study
delineates current operative strategies RESULTS: Table 1. Experienced surgeons
for HD in the UK and Ireland. Early (Observed Average (OA)=3.6) had slightly
complications are common and appear higher overall ratings than novice
related to coexisting anomalies and rectal (OA=3.4), p = .001. The highest combined
dissection technique. observed averages were for Chest
circumference and depth (both OA = 3.8),
S029: PRELIMINARY EVALUATION OF
while the lowest ratings were Realism
A NOVEL INFANT THORACOSCOPIC
of mediastinum, (OA = 3.3), and Realism
LOBECTOMY SIMULATOR K atherine A. resistance-trocar placement (OA = 3.2).
Barsness, MD, MS, Deborah M. Rooney, Averaged global opinion rating was 2.9,
PhD, Lauren M Davis, BA, Ellen K. indicating the simulator can be considered
Hawkinson, BS, Northwestern University for teaching thoracoscopic lobectomy,
Feinberg School of Medicine, University of but could be improved slightly. Inter-rater
Michigan Medical School reliability was high [ICC(1,k)α=.91].
PURPOSE: Thoracoscopic lobectomy CONCLUSIONS: With comments/ratings
requires advanced minimally invasive consistent with high physical attributes and
skills. Simulation-based education has realism, we successfully created an infant
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lobectomy simulator. Simulator ratings (26 days) and FM (31 days) (p=0.024) (figure
from novice and experienced participants 1). The mean cost of treating patients in the
were high, indicating it was realistic, BM group was £17,615 and the mean cost
relevant to clinical practice and valuable as for patients fed C M and FM was £28,556.
a learning tool. In spite of high ratings, the (p < 0.001). If all patients had been fed
simulator requires minor improvements exclusively with BM, then there would have
and evaluation of additional validation been a reduction in cost of £49,230 per
evidence prior to implementation as an year.
educational and testing tool.
CONCLUSION: Our data demonstrate
S030: GASTROSCHISIS – THE ROLE that breast milk significantly reduced the
OF BREAST MILK IN REDUC ING TIME time to full feed in our population and
TO FULL FEEDS D eirdre Kriel1, Anne was associated with a reduction in bed
Aspin ,Jonathan Goring1,Robert West 2,
1 occupancy and cost. We recommend that
Jonathan Sutcliffe1, 1Leeds Teaching breast milk is the feed of choice for all
Hospitals NHS Trust, Leeds UK;2Leeds children with simple gastroschisis where it
Institute of Health Sciences - University is practically available.
of Leeds, Leeds UK
S031: ONCOLOGIC MIS SURGERY :
AIM OF STUDY: Gastroschisis is increasingly ROLE OF IDRFS CRITERIA IN PATIENT
common and is associated with prolonged SELECTION AND PLANNING *Claudio
hospital stay and cost. This study aimed Vella, MD,*Camilla Viglio, MD,*Sara
to examine the effect of feed type on the Costanzo, MD,**Salvatore Zirpoli, MD,
time to full enteral nutrition in infants with **Marcello Napolitano, MD,***Roberto
simple gastroschisis. Luksch, MD,*Giovanna Riccipetitoni, MD,
*Pediatric Surgery Department, “V.Buzzi”
METHODS: In this prospective study, data
Children’s Hospital ICP,**Pediatric
were collected for all neonates born
Radiology and Neuroradiology
with simple gastroschisis between April
Department “V.Buzzi” CHILDREN’S
2007 and May 2011. Information obtained
Hospital ICP, Milan – Italy,***Pediatric
included patient demographics, feed type
Department, Fondazione IRCCS National
and rate of feed advancement. Patients
Cancer Institute, Milan, Italy
were divided into 3 groups: Group A –
exclusively breast milk fed (BM), Group INTRODUCTION: Minimally invasive
B - combination of breast and formula surgery (MIS) in solid tumors is reserved
feeds (C M) and Group C - formula milk for selected patients according to
(FM). Time to full feed was calculated for morphological criteria and cancer
each patient. Cost of hospitalisation was protocols. The availability of high-
estimated for each group using current resolution imaging techniques and the
Healthcare Resource Group (HRG) codes. application of Image-Defined Risk Factors
(IDRFs) for neuroblastoma allows to
MAIN RESULTS: 50 patients were born with
select cases of solid tumors that could be
gastroschisis during the 210 week study
submitted to MIS procedures.
period of which 38/50 were “simple”. The
number of patients in each group were: BM MATERIAL AND METHODS: Records
n=20, C M n=8 and FM n=10. A significant of patients affected by solid tumors,
difference in the median time to full feed diagnosed and treated in our centre in the
was observed between BM (19 days), C M last 6 years were reviewed.
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For the diagnostic findings: CT oncologic surgery. This classification is
angiography, MR angiography with of utmost importance not only for the
multiplanar reconstruction technique morphological assessment of the mass
with maximum intensity projection (MIP) but also as a guidance for patients’
and volume rendering (VR) to define the selection and planning in MIS surgery.
anatomical features, vascular supply,
S032: GLUTAMINE SUPPLEMENTATION
relationships of the tumor with vital
IMPROVES MONOC YTE FUNC TION
structures were used to determine an
IDRFs classification for the surgical risk IN SURGIC AL INFANTS REQUIRING
in solid masses. The multidisciplinary PARENTERAL NUTRITION - RESULTS
approach involving surgeon, radiologist, OF A RANDOMISED CONTROLLED
oncologist and pathologist allowed us to TRIAL M ark Bishay1,Venetia Simchowitz 2,
identify cases eligible for a MIS procedure: Danielle Petersen2, Marlene Ellmer2,
biopsy or surgical excision, according to Sarah Macdonald2, Jane Hawdon4,
IDRFs, staging and biology of the tumor. Elizabeth Erasmus4, Kate MK Cross2,
Joseph I Curry2, Edward M Kiely2, Paolo
RESULTS: In the period of study a total De Coppi1,2, Nigel Klein1,2, Agostino Pierro3,
of 221 patients with solid tumor (aged 3 Simon Eaton1, 1UCL Institute of Child
months-14 years) were surgically treated. Health, London UK;2Great Ormond Street
50 of them met the criteria for MIS Hospital, London UK;3Hospital for Sick
approach. 25 patients underwent a MIS Children, Toronto Canada;4University
diagnostic biopsy : 3 hepatoblastoma, College Hospital, London UK
2 hepatocellular carcinoma, 1 focal
nodular hyperplasia, 4 lymphoma, 2 BACKGROUND: Our aim was to determine
Castleman disease, 5 neuroblastoma, whether, in surgical infants requiring
2 rhabdomyosarcoma, 2 germ cell parenteral nutrition (PN), parenteral
tumors, 1 pulmonary blastoma, 1 and enteral glutamine supplementation
retroperitoneal osteosarcoma and influences monocyte HLA-DR expression,
2 renal neoplasms. Primary surgical a marker of monocyte activation and
exicision was planned in 25 patients: 6 immune function.
neuroblastoma, 2 ganglioneuroblastoma, METHODS: This was an ethically-approved
3 ganglioneuroma, 1 pheochromocytoma, prospective double-blind randomised
1 adrenal lymphangioma, 4 ovarian controlled trial in surgical infants (corrected
cystadenoma, 5 ovarian teratoma, 1 gestational age <3 months) receiving PN
granulosa tumor, 1 presacral teratoma for at least five days for congenital or
, 1 chest teratoma,. All the procedures acquired intestinal anomalies (July 2009
were successfully completed with MIS - March 2012). Infants were randomised
technique. A good hemostasis was always using weighted minimisation to receive
achieved. No secondary localizations either parenteral plus enteral glutamine
at trocarsites or local recurrences were supplementation ((total 400mg/kg/day) or
observed. The median hospital stay isonitrogenous control. Monocyte HLA-DR
was 48 hours for patients undergone a expression was assessed (as a secondary
diagnostic biopsy and 5 days for patients outcome measure) at enrolment, after five
submitted to primary surgery. days, and on reaching full enteral feeds (or
CONCLUSIONS: The extension of prior to transfer to another centre). Data
IDRFs criteria to the vast majority are given as mean±SEM and compared by
of solid tumors can be effective in unpaired t-test with Welch’s correction.
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MAIN RESULTS: Sixty infants (35 boys, congenital pulmonary lesions using a
25 girls) were enrolled in the study. The validated national database.
median age at enrolment was 6 days
METHOD: We identified all lobectomies
(range 0-95), corrected gestational age
performed on patients with congenital
37 weeks (24-49), and weight 2.3 kg
pulmonary lesions in the 2012 National
(0.6-4.6). The underlying diagnoses were:
Surgical Quality Improvement Program
25 patients had congenital/neonatal
Pediatric (NSQIP Pediatric) database and
intestinal obstruction, 19 had anterior
compared demographic, clinical, and
abdominal wall defects, 13 had necrotising
30-day outcome characteristics between
enterocolitis, and 3 had other causes of
patients who underwent an open or
intestinal dysfunction. Glutamine and
thoracoscopic lobectomy. Patients who
control groups had similarly low HLA-DR
underwent an emergent operation or had
expression at enrolment/surgery, which
a resection associated with a diagnosis
slowly increased in each group during the
of cancer were excluded. Minor and
study (Figure). However, the postoperative
major complications were defined as any
restoration in HLA-DR expression was
occurrence of the complications listed
faster in infants receiving glutamine so
in the table within 30 days of surgery. A
that HLA-DR expression was significantly
multivariable regression model was fit to
higher after five days and at the end
determine the risk-adjusted effect of a
of the study. HLA-DR expression was
thoracoscopic approach on postoperative
significantly lower during episodes of
length of stay (LOS) after adjusting for
clinical sepsis (51±4 vs. 64±2; p=0.008).
factors associated with open resection on
CONCLUSION: Parenteral plus enteral univariable analysis.
glutamine supplementation in infants
RESULTS: Of the 102 patients who
receiving PN after gastrointestinal surgery
underwent a non-emergent lobectomy
significantly increases monocyte activation,
for a congenital pulmonary lesion,
reflecting improved immune function.
40 (39%) underwent thoracoscopic
S033: COMPARISON OF 30-DAY lobectomy. In comparison to patients
OUTCOMES BETWEEN THORACOSCOPIC undergoing thoracoscopic lobectomy,
AND OPEN LOBECTOMY FOR patients undergoing open lobectomy
CONGENITAL PULMONARY LESIONS were less likely be admitted from
Justin Mahida, MD, MBA, Lindsey Asti, MPH, home on the day of surgery (82% vs.
Victoria K Pepper, MD, Katherine J. Deans, 97%, p=0.02), and were more likely to
MD, MHSc, Peter C. Minneci, MD, MHSc, be classified as American Society of
Karen A. Diefenbach, MD, Nationwide Anesthesia (ASA) class 3 or greater (47%
Children’s Hospital, Columbus Ohio vs. 15%, p=0.001), to receive oxygen
support prior to surgery (13% vs. 0%,
INTRODUCTION: Multiple single- p=0.021), to have other congenital
institution studies have demonstrated anomalies (50% vs. 30%, p=0.046), and
feasibility and safety of thoracoscopic to have cardiac risk factors (26% vs. 5%,
resection for congenital pulmonary p=0.007). Both groups had similar total
lesions. The purpose of this study was operative time (open vs. thoracoscopic,
to compare postoperative length of p-value) (144 vs. 173 minutes, p=0.196),
stay and 30-day outcomes between duration of time in the operating room
thoracoscopic and open lobectomy (252 vs. 271 minutes, p=0.397), and
performed non-emergently for
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duration of anesthesia from induction to S034: HIGH VOLUMES IMPROVE
recovery (316 vs. 283 minutes, p=0.598). OUTCOMES - A NATIONAL REVIEW OF
In comparison to patients undergoing HYPOSPADIAS SURGERY IN ENGLAND
thoracoscopic lobectomy, patients 1999-2009 Patrick Green3,1, David
undergoing open lobectomy had Wilkinson2,1, Shanthi Beglinger1, Rachel
significantly longer postoperative LOS (4 Hudson1, David Edgar1, Simon Kenny1,2,
vs. 3, p=0.002) and more often received 1
University of Liverpool, Liverpool
an intraoperative or postoperative UK;2 Alder Hey Children’s Hospital NHS
transfusion within 72 hours of surgery Foundation Trust, Liverpool UK;3Royal
(12% vs. 0%, p=0.003) (Table). The Liverpool and Broadgreen University
difference in LOS was not significant in the Hospitals Trust, Liverpool UK
multivariable analysis.
AIMS: A review of outcomes following
CONCLUSION: This NSQIP Pediatric study hypospadias surgery reveals a wide
represents the largest multi-institutional disparity in reported outcomes. This
compilation of patients undergoing may in part be explained by variations
non-emergent lobectomy for congenital in surgical technique, caseload and the
pulmonary lesions using validated data with availability of specialist perioperative
standardized definitions of postoperative care. Having previously reported
outcomes. This study suggests that patients preliminary data from specialist paediatric
undergoing thoracoscopic lobectomy centres in England, we sought to
have fewer comorbidities at baseline and determine outcomes from all centres
receive fewer perioperative transfusions performing hypospadias surgery in
and have a shorter postoperative length England to identify whether there is a
of stay. Accrual of additional patients direct relationship between caseload and
within the NSQIP Pediatric database will surgical outcome.
allow for further risk-adjusted analyses
of outcomes to control for differences in METHODS: All children undergoing
baseline characteristics between patients hypospadias surgery in English NHS
undergoing open and thoracoscopic trusts were identified using the Hospital
resections. Episode Statistics database (1999-
2009). Patient demographics, institution
type and associated diagnostic (IC D10)
and treatment codes (OPC S4.6) were
collected for both primary repairs
and postoperative complications. The
unique patient identifier allows all
operative complications to be tracked
irrespective of the centre to which they
present. Analysis was performed on the
whole cohort with separate subgroup
analysis for those cases with severity of
hypospadias recorded. Statistical analysis
included linear regression and Mann-U
Whitney for non-parametric data with
p<0.05 taken as significant.
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RESULTS: 18357 primary operations for incision. Excision of ChC and hepatico-
hypospadias were performed in England intestinal anastomosis were performed
between 1999 and 2009 at a median age using conventional straight laparoscopic
of 24.5months. Hypospadias operations instruments.
were carried out at a total of 60 different
RESULTS: 86 patients (64 girls, 22 boys)
centres each carrying out between 1 and
were identified with median age 24.5
144 cases/year. The overall, non-adjusted
months (range: 1 month - 11 years). The
complication rate for low (<20cases/year)
most common clinical manifestations
volume centres was 18.1% falling to 12.2%
were abdominal pain – 67.4%, vomiting
in high (>20cases/year) volume centres
– 51.2%, jaundice – 26.7 %. The median
(odds ratio 1.6, 95%C I 1.4-1.8, p<0.0001).
diameter of ChC was 3 cm (range: 1.5 – 12
CONCLUSIONS: There appears to cm). The ChC was successfully excised
be a significantly increased risk of by TULESS in all cases. Ladd procesdure
complications following primary for associated intestinal malrotation
hypospadias surgery performed in centres was carried out at the same time in one
operating on less than 20 cases per year. patient. Hepaticoplasty was performed
Population-level HES data provides a in 12 cases (13.9%) with hepatic duct
valuable resource to determine outcomes diameter less than 5mm. Hepatico-
for conditions such as hypospadias which jejunostomy was performed in 84 cases
are treated in a range of centres and by (97.7%) and hepatico-duodenostomy
different surgical specialties. in 2 cases (2.3%). Anastomosis with an
aberrant bile duct was performed in 5
S035: TRANSUMBILICAL
patients. Additional trocars were needed
LAPAROENDOSCOPIC SINGLE SITE
in just one case (1.2%). There was no
SURGERY WITH CONVENTIONAL conversion to open surgery. The median
INSTRUMENTS FOR CHOLEDOCHAL operative time was 195 minutes (range:
CYST IN CHILDREN: EARLY RESULTS OF 150 minutes to 400 minutes). Abdominal
86 CASES T ran N. Son, MD, PhD, Nguyen T. drain was used in 8 patients (9.3%) in the
Liem, MD, PhD, Vu X. Hoan, MD, National early period and no drain was used in the
Hospital of Paediatrics, Hanoi, Vietnam remaining 78 patients (90.7%). There was
INTRODUCTION: Reported experience with no anastomotic leakage. Mild umbilical
trans-umbilical laparo-endoscopic single infection was noted in 2 patients (2.3%).
site surgery (TULESS) for choledochal cyst The median postoperative hospital stay
(ChC) in children is still limited. The aim of was 5 days (range 3-9 days). At a median
this study is to present our early results of follow up of 6 months (range: 1 – 14
TULESS for childhood ChC. months), one patient (1.2%) from the early
period suffered from hepaticojejunal
METHODS: Medical records of all children anastomotic stenosis with cholangitis and
undergoing TULESS for ChC at our center needed a redo surgery; all other patients
from September, 2012 to December, 2013 were in good health. The postoperative
were reviewed. Our TULESS operations cosmesis was excellent as all TULESS
started with a z-shaped umbilical skin patients were virtually scarless.
incision and placement of three 3-5mm
ports at separate points in the same CONCLUSIONS: TULESS with conventional
incision site. Roux-en-Y loop was created laparoscopic instruments for ChC in
extracorporally through the umbilical children is feasible, cost effective, with
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excellent postoperative cosmesis. The abscess number, admission temperature,
early outcome is promising and TULESS admission white blood cell count or
can be a viable option for scarless duration of symptoms. There was no
surgical management of childhood ChC at difference in duration of hospitalization
experienced centers. after drainage (Table). One patient could
not tolerate tPA secondary to pain with
S036: SALINE VERSUS TISSUE
flushes.
PLASMINOGEN ACTIVATOR IRRIGATIONS
AFTER DRAIN PLACEMENT FOR CONCLUSION: There are no advantages
APPENDICITIS-ASSOCIATED ABSCESS: to routine tPA flushes in the treatment
A PROSPECTIVE RANDOMIZED TRIAL of abdominal abscess secondary to
Shawn St. Peter, Obinna Adibe, Sohail perforated appendicitis in children.
Shah, Susan Sharp, David Juang, Brent
S037: LAPAROSCOPIC FOWLER-STEVENS
Reading, Brent Cully, Whit Holcomb III,
ORCHIOPEXY, A RANDOMIZED PILOT
Doug Rivard, Children’s Mercy Hospital,
STUDY COMPARING THE PRIMARY AND
Kansas City, MO USA
2-STAGE APPROACHES D aniel J. Ostlie,
BACKGROUND: Emerging data suggest MD, Charles M. Leys, MD, Jason D. Fraser,
instillation of tissue plasminogen MD, Charles L. Snyder, MD, Shawn D.
activator (tPA) is safe and potentially St. Peter, MD, University of Wisconsin/
efficacious in the treatment of intra- American Family Children’s Hospital,
abdominal abscesss. To date, prospective Children’s Mercy Hospital and Clinics
comparative data are lacking in children.
BACKGROUND: Intra-abdominal testes
Therefore, we conducted a prospective,
that lack sufficient vessel length to
randomized trial comparing abscess
perform an orchiopexy require division
irrigation with tPA to irrigation with saline
of the testicular vessels. Historically, the
alone.
vessels are divided at the initial operation
METHODS: After IRB approval, children and the orchiopexy is then performed as
with an abscess secondary to perforated a 2-stage procedure with the assumption
appendicitis who had a percutaneous that development of neovascularization
drain placed for treatment were occurs along the vas deferens during
randomized to twice daily instillation the interim. Recent reports suggest the
of 13ml of 10% tPA or 13 ml of normal orchipexy may be performed primarily at
saline. All patients were treated with the time of vessel division. However, these
once daily dosing of ceftriaxone and strategies have not been prospectively
metronidazole throughout their course. compared. Therefore, we conducted a
The primary outcome variable was randomized pilot trial to examine the role
duration of hospitalization after drain for a larger comparative study.
placement. Utilizing a power of 0.8 and an
METHODS: After IRB approval, all patients
alpha of 0.05, a sample size of 62 patients
undergoing laparoscopic orchiopexy for a
was calculated. Data was analyzed on
non-palpable testis were considered for
intention to treat basis.
enrollment. This study was designed as a
RESULTS: 62 patients were enrolled pilot study to evaluate testicular survival
between 1/2009 and 2/2013. There were at 6 months follow-up. After obtaining
no differences in age, weight, body mass consent, computer randomization
index, gender distribution, abscess size, was used to determine a primary or
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2-stage orchiopexy. All procedures were the contralateral groin. Recurrence
performed by 5 surgeons and allotment rates remain a concern. In 2011, our
had no affect on surgeon selection. institution described a modification of the
laparoscopic transcutaneous technique
RESULTS: Between October 2007 and
that replicates high transfixation ligation
September 2013, 112 patients were
of the hernia sac with the aim of inducing
enrolled in the study. Twenty-nine
more secure healing, preventing suture
patients met criteria for randomization
slippage, and distributing tension across
based on inability to bring the testis to
two suture passes. We now describe
the contralateral internal ring. There was
our long-term follow-up of patients
no difference in the approach between
undergoing this novel repair.
surgeons. Data was complete in 27 cases.
Outcome data is shown in table 1. METHODS: After obtaining IRB approval,
a retrospective chart review and phone
CONCLUSION: Approximately 70% of
follow-up was performed of all patients
patients with a non-palpable testis will
that underwent this procedure between
not require vascular division. This study
October 2009 and November 2013.
suggests that when vascular division is
Data collection included demographics,
required, the primary orchiopexy may
laterality of hernia, evidence of recurrence,
be equivalent to the traditional 2-stage
complications, and time to follow-up.
with testicular survival with potential
advantages in total operative time and RESULTS: Three surgeons (0 – 10 years
charges. These data provide evidence experience) performed 207 laparoscopic
for sufficient equipoise to proceed transfixation suture ligature repairs on
with the development of a large multi- 146 patients.Demographics were as
institutional trial comparing these two follows: mean age 29.8 months (range
approaches. 1-192 mo); male 66.4% and female
33.6%; 59% of the neonates (n=61) were
premature infants (<37 weeks GA). Repairs
were bilateral in 41.8% of patients,
right sided in 34.2%, and left sided in
TABLE 1 24%. 31% of preoperatively diagnosed
unilateral hernias were found to have a
S038: LONG TERM FOLLOW UP contralateral defect. Mean follow-up
OF MODIFIED LAPAROSCOPIC was 24.1 months (range 2-50 mo). One 2
TRANSCUTANEOUS INGUINAL HERNIA month old syndromic patient with severe
REPAIR WITH HIGH SUTURE LIGATURE congenital heart disease recurred twice
OF THE HERNIA SAC Matias Bruzoni, MD, while another patient recurred after repair
FACS, Zachary J. Kastenberg, MD, Joshua post incarceration. Overall recurrence rate
D. Jaramillo, BA, James K. Wall, MD, Robert was 1.4%. The complication rate was 1.9%
Wright, MA, Sanjeev Dutta, MD, MBA, (3 hydroceles and 1 inguinal hematoma;
Stanford University all resolved spontaneously).
BACKGROUND: Laparoscopic inguinal CONCLUSION: The laparoscopic
hernia repair in children may reduce transcutaneous high transfixation
post-operative pain, improve cosmesis, ligature technique can be performed
allow for less manipulation of the cord by surgeons of varying experience and
structures, and offer easy access to produce recurrence rates comparable to
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the standard open repair, with the added to report the results our large single-
benefits of laparoscopy. surgeon experience with transperitoneal
laparoscopic pyeloplasty in infants with a
minimum of 6-month follow-up.
METHODS: The records of all infant
laparoscopic pyeloplasties over a 4.5-year
period (109 babies, 114 kidneys, mean
age 3.8 months, mean weight 5.3 kg)
were analyzed. Preoperative evaluation
included renal ultrasound and diuretic
renogram (using Tc 99m DTPA) in all
children. The indications for pyeloplasty
was severe hydronephrosis (SFU grade
4 and/or AP diameter > 20mm) with
obstructed drainage on DTPA renogram
and a differential function of <40% in
the affected kidney. Transperitoneal
laparoscopic pyeloplasty was performed
in all babies with 3 ports. Double J stent
was used in 102 kidneys. Follow-up
renal ultrasound (114 kidneys) was done
at 3-6 months and diuretic renogram
(76 patients) at 6-12 months after the
surgery; data were compared using
statistical software (medcalc).
RESULTS: There were 104 unilateral
and 5 bilateral pyeloplasties. The
mean operating time was 106 min
(70-145) and median hospital stay
was 2 days (2-8). There were no major
intraoperative complications. There was
one intraoperative cautery injury to the
appendix; appendicectomy was done in
S039: LAPAROSCOPIC PYELOPLASTY
the same sitting. One child (1%) developed
IN INFANTS: SINGLE-SURGEON
urinary leak that spontaneously resolved.
EXPERIENCE WITH 114 OPERATIONS
Four (5%) children had port-site infections
Chandrasekharam Vvs, Dr., Rainbow
which were managed conservatively.
children’s hospitals At a mean follow-up of 18 months, all
AIM: Laparoscopic pyeloplasty is a children are asymptomatic; ultrasound
technically demanding operation, demonstrated significant reduction
especially in infants. To our knowledge, in the anteroposterior diameter of
till date, there are only 5 published series renal pelvis in all children (mean pre-
of laparoscopic pyeloplasty specifically operative diameter 34.4 +/- 13.4 mm
in infancy, with a combined total of versus mean postoperative diameter
94 patients. The aim of this paper is 10.6 +/- 5.7mm, p< 0.0001). On Follow-up
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renogram, all renal units demonstrated RESULTS: Eleven procedures were
improved drainage.There was a significant performed in 10 patients, 9 peritoneal and
improvement in the differential function one retroperitoneal approach, because
of the operated kidney in unilateral one of the patients had bilateral lithiasis
cases (preoperative 22.1 +/- 8.6 % versus disease.
postoperative 35.6 +/- 11.4 %, p< 0.0001)
Ipsilateral additional ureterolithotomy
CONCLUSIONS: To our knowledge, this is was necessary in 3 patients for embedded
the largest series of infant laparoscopic stones in proximal uréter (27.2%). The
pyeloplasty reported till date. Laparoscopic mean operative time in abdominal
pyeloplasty could be safely and successfully procedures was 196 min (range 75-355
performed even in small infants, with min) and 170 min in the retroperitoneal
minimal complications and good results. approach. The blood loss volume was
Significant reduction in hydronephrosis & 59.3 ml (range 3-250 ml) and 10 ml
improvement in differential function can be respectively. One patient had urinary
expected in the majority of children. tract infection and urinary fistula which
closed spontaneously. Opioid analgesic
S041: LAPAROSCOPIC URETERO-
was required in 5 patients (45.4%) for 2.4
PYELOLITHOTOMY IN CHILDREN A na
days (range: 1-3 days ). The mean hospital
María Castillo-Fernández, MD, Sergio stay was 5.2 days (range 2-13 days). Stone
Landa-Juárez MD, Ramón Esteban disease free condition was ensured by
Moreno Riesgo MD, Hermilo De La Cruz- pyeloscopy in all patients before finishing
Yañez MD, Carlos Garcia-Hernández MD, the procedure (Fig. 2).
Hospital de Pediatria, Centro Médico
Nacional SXXI. IMSS
PURPOSE: To evaluate laparoscopic
uretero-pyelolithotomy as a feasible and
safe procedure in children.
PATIENTS & METHODS: We conducted
a descriptive study (case series) from
January 2011 to December 2013, including
patients 2 to 13 years old with pyelic and FIG 2: Pieloscopy
superior ureteral lithiasis, who underwent
laparoscopic pyelolithotomy (Fig.1) by
peritoneal or retroperitoneal approach
with additional ureterolithotomy when
necessary.
FIG 3: Removal of calculus

CONCLUSIONS: Laparoscopic uretero-
pyelolithotomy by either peritoneal or
retroperitoneal approach is a feasilble
and safe alternative treatment in the
FIG 1: Pielotomy pediatric population. In our experience
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all patients with stone free condition (Fig. wall. Clinical data was collected and
3). The promising results of this series, compared between laparoscopy group
encourages further clinical trials. and open group, such as operation time,
intraoperative blood loos, postoperative
S042: EXPERIENCE OF LAPAROSCOPIC
blood transfusion, postoperative hospital
PYELOPLAST IN THE TREATMENT
stay and postoperative complication.
OF URETEROPELVIC JUNCTION
OBSTUCTION IN INFANTS (<3 MONTHS) RESULTS: In laparoscopy group the
Aiwu Li, Jian Wang, Qiangye Zhang, operation time was 123.1±34.8 minutes
Wentong Zhang, Hongchao Yang, Weijing which were similar to that of open
Mu, Department of Pediatric Surgery, Qilu procedure (P > 0.05); intraoperative
Hospital, Shandong University blood loss was 4.2±1.7 ml, which was
much lower than that of open procedure
BACKGROUND: Although early detection (16.8±2.5ml) (P < 0.05); the postoperative
and early therapy are important to the hospital stay was 8.1±2.3 days, which
treatment of Ureteropelvic Junction was obviously lower than that of open
Obstuction (UPJO) and laparoscopic procedure.(14.4±2.8 days) (P < 0.05);
pyeloplast has been widely applied in no conversions to open surgery and
older children patients with UPJO, related no postoperative blood transfusion
reports are still less in the treatment were required; no incision infection,
of infants (< 3 months) patients with retroperitoneal hematoma, double J tube
UPJO up to now. The aim of this study shifting or anastomotic leakage was in
was to summarize the therapeutic this group besides 1 urinary infection
efficacy and our operative experience of case. In the open group there were 3
transperitoneal laparoscopy pyeloplasty retroperitoneal hematoma cases, 2
in infants (< 3 months) with UPJO. incision infection cases, 2 double J tube
PATIENTS & METHODS: From Jan 2010 to shifting cases, 1 anastomotic leakage case
Dec 2013, 40 infants patients (54.45±5.72 and 2 0.5U erythrocyte concentrated
days, from 20 to 88 days) with UPJO cases. Compared with the long incision of
were treated with transperitoneal abdominal wall (8.5±1.3cm) in open group,
laparoscopy pyeloplasty, and 22 infants 3 5-mm trocars were much more artistic
patients (57.61±6.32 days, from 22 to for infants in the laparoscopy group. After
90 days) with UPJO were treated with a follow-up period from 6 months to 2
open pyeloplasty. Three-hole method years, all the infants patients recovered
was used in laparoscopy pyeloplasty well and no cases in the two groups had
and 3 5-mm trocars were punctured at obstruction of ureter or vesicoureteral
umbilical, middle point between umbilical reflux by the imaging examination such as
and anterior superior iliac spine and the magnetic resonance hydrography (MRU)
intersection point of costal margin at or computed tomography hydrography
midclavicular line respectively. Ultrasonic (CTU).
scalpel was used to discover the renal CONCLUSION: As a well minimally
pelvis. Suspension with silk thread of renal invasive surgical method, transperitoneal
pelvis was applied for a better suture and laparoscopic-assisted pyeloplasty
a easier insertion of double J tube into the brings less injury to both order children
ureteral. Double J tube was inserted easily patients and infants(< 3 months) patients
with the help of a pneumoperitoneum with UPJO. According to our operative
puncturing through the abdominal
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experience and the analysis of clinical The mean hospital stay was 27 hours.
data, this operative method is safe, The overall Vesicoureteal reflux
reliable and effective in the treatment resolution was 96.5%. Three renal units
of UPJO of infants(< 3 months) patients, were downgraded to unilateral grade 2
which should be generalized on the basis Vesicoureteral reflux were considered
of qualified endoscopic techniques. to have failure treatment. Two of them
underwent subsequent sub-ureteral
S043: LAPAROSCOPIC EXTRAVESICAL
injection therapy and one underwent redo
URETERAL REIMPLANTATION
open procedure. The follow-up period
FOLLOWING LICH GREGOIRE was 27 months.
TECHNIQUE. MEDIUM-TERM
PROSPECTIVE STUDY M anuel Lopez, CONCLUSION: Laparoscopic Extravesical
Eduardo Perez-Etchepare, MD, François Ureteral Reimplantation following Lich-
Varlet, MD, PhD, Department of Pediatric Gregoir technique is an effective procedure
Surgery, University Hospital of Saint in unilateral, bilateral and Duplex Collector
Etienne System with Vesicoureteral reflux and
obstructive megaureter. When refluxing
OBJECTIVES: to evaluate medium terms Duplex Collector System is associated
results of Laparoscopic Extravesical with obstruction, and total deterioration
Ureteral Reimplantation, following Lich- of upper polar function; hemi-nephro-
Gregoir Technique in the treatment of ureterectomy with excision of ureterocele
Vesico Ureteral Reflux and obstructive can be safely and effectively performed in
megaureter. a single-stage. Laparoscopic Extravesical
METHODS: Between August 2007 and Ureteral Reimplantation permits shorter
November 2013, 115 renal units in 89 hospital stay, decreased postoperative
patients, 113 with VUR and Two with discomfort, reduced recovery period
obstructive Megaureter with deterioration with success rates similar to the open
of renal function were treated by technique.
Laparoscopic Extravesical Ureteral S044: ROBOTIC ASSISTED
Reimplantation. 24 patients had Duplex LAPAROSCOPIC MANAGEMENT OF
Collector System;in five cases were DUPLEX RENAL ANOMALY IS FEASIBLE
associated to obstruction: three with AND SAFE WITH EQUAL SHORT TERM
complete deterioration of upper polar SURGICAL OUTCOMES TO TRADITIONAL
function.6 Patients presented recurrence PURE LAPAROSCOPIC AND OPEN
of VUR after endoscopic ureteral
SURGERY D aniel B. Herz, MD, Paul A.
injection.
Merguerian, MD, Venkata R. Jayanthi, MD,
RESULTS: Laparoscopic Extravesical Seth A. Alpert, MD, Jennifer A. Smith, RN,
Ureteral Reimplantation was feasible Nationwide Children’s Hospital; Children’s
in all cases. Mean age was 52 month; Hospital at Dartmouth
mean surgical time was 70 minutes in
OBJECTIVE: The surgical management
unilaterals, 144 minutes in bilateral
of duplex renal anomalies is as varied
Vesicoureteral reflux and 135min in
as their presentation. Traditionally, open
Obstructive megaureter. In one-stage:
or Laparoscopic Heminephrectomy with
three laparoscopic hemi-nephro-
partial ureterectomy (HN), upper to
ureterectomy with excision of ureterocele
lower ureter ureteroureterostomy (UU),
and one nephrectomy were performed.
common sheath ureteroneocystostomy
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(UN), or a combination is employed in 8 and persisted in 2 children after
based on renal moiety function, and/or common sheath UN. VUR developed in 10
presence or absence of vesicoureteral lower ureters after RAL upHN (Grade II-III
reflux (VUR). In children, Robot Assisted in 8 and Grade IV in 2). Of these, 5 were
Laparoscopy (RAL) adds value because successfully treated endoscopically, 1 with
it allows renal moiety removal and/ RAL UN, and 4 resolved spontaneously.
or ureteral reconstruction in situ with Of those who had RAL UU, VUR was
excellent visualization and the ability to present pre-operatively in the recipient
suture in a confined space. ureter in 4 (29%, Grade I-III) and all
resolved spontaneously within 2 years of
METHODS: IRB approved retrospective
post-operative observation. A total of 4
analysis of all children with duplex
(7.7%) complications occurred: ureteral
renal anomalies that had robot assisted
leak (1), ureteral obstruction (1), vascular
laparoscopic surgery between 2008
injury to lower renal moiety (1), and port-
and 2013 was performed. All children
site herniation (1). There were no open
had either RAL HN, RAL UU, or RAL UN
conversions. Hypertension either improved
based on renal moiety function, degree
or was cured in 3 of 4 children with this
of ureteral obstruction, and/or the
pre-operative co-morbidity.
presence or absence of vesicoureteral
reflux. Data collection included CONCLUSIONS: RAL surgical management
demographics and diagnosis at the time of duplex renal anomaly is safe and
of RAL surgery, type of RAL surgical effective, and has similar outcomes and
intervention, immediate RAL surgical complication rates to open and pure
outcomes and complications, as well as laparoscopic surgery. However, our report
renal outcomes at 2 years post-surgery. shows that RAL can be used for pelvic
reconstruction in this population which, if
RESULTS: A total of 55 children (57 renal
more widely accepted and applied, could
units) were treated. Twenty-eight (29)
obviate the need for open surgery.
children had RAL HN, 14 had RAL UU, and
10 had RAL UN. Forty (73%) children were S045: TRANSRENAL STENTING IN
female and 15 (27%) male. Ages were 4 LAPAROSCOPIC PYELOPLASTY IN
months to 14.8 years (Average = 4.2 years) INFANTS AND CHILDREN: A SAVE
at the time of surgery. Diagnoses were TECHNIQUE Tobias Luithle, MD, Florian
Duplex Ureterocele (n=28), Duplex Ectopic Obermayr, MD, Joerg Fuchs, MD,
Ureter (n=23), and High Grade Secondary Department of Pediatric Surgery and
VUR (n=4). RAL ureteral tailoring was Pediatric Urology, University Children’s
required in 7 children, 4 during UU for Hospital, Tuebingen, Germany
mismatched donor and recipient ureteral
caliber, and 3 during common sheath UN. INTRODUCTION: Laparoscopic
Of the children who had HN, the moiety dismembered pyeloplasty is increasingly
removed was upper pole (upHN) in 26 becoming the standard treatment for
and lower pole (lpHN) in 3, and the mean ureteropelvic junction obstruction in
differential function of the excised moiety infants and children. As in the open
was 9% (range = 2-13%). Of the children approach various techniques for
who had UU or common sheath UN, the temporary ureteral stenting have been
upper moiety differential renal function proposed. We present our experience
was 31% (range = 17-44%). VUR was cured with transrenal transanastomotic stenting
via a transperitoneal approach.
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METHODS: A retrospective analysis was CONCLUSION: Laparoscopic transrenal
performed on a consecutive series of transanastomotic stenting is safe and
161 patients (166 renal units, RU) who easy to perform. Placement under direct
underwent a laparoscopic pyeloplasty vision reduces the risk of bleeding.
using a transperitoneal laparoscopic Stent associated complications are low
approach at our institution between and rarely requiring major secondary
March 2004 and December 2013. In intervention. Stent removal without the
150 patients (155 RU) a silicon ureteral necessity of cystoscopy and therefore
catheter (Dirocath®, Braun, Germany) additional anesthesia is a major advantage
was used for stenting the anastomosis. compared to double-J stent placement.
The catheter was fixed on a curved
S046: RETROPERITONEOSCOPIC
metal spear which was introduced
PYELOPLASTY IN 134 CHILDREN R avindra
transabdominally via a renal calix under
laparoscopic vision and led out through Ramadwar, Dr., Bombay Hospital, Hinduja
the flank. Two additional holes were cut in Hospital & Joy Hospital, Mumbai, India
the catheter draining the renal pelvis. No AIM: Retroperitoneoscopic pyeloplasty was
perirenal drainage was inserted routinely. performed in 134 patients since January
Eleven patients were excluded (no stent 2005 to January 2014. The aim of the study
(n=4), double-J-ureteral stent (n=3), was to identify all the parameters that
percutaneous nephrostomy (n=4)). helped in reducing the operative time.
RESULTS: 104 boys and 46 girls with a median METHOD: All patients who underwent
age of 22 months (range: 1-214 months) retroperitoneoscopic pyelopasty since
underwent laparoscopic transabdominal January 2005 were enrolled in the study.
pyeloplasty. An aberrant lower-pole Data were collected prospectively and
vessel was evident in 24 cases. Associated results were analyzed.
anomalies were horseshoe kidney (n=2) and
a duplex system with lower pole obstruction RESULTS: 134 patients (Age 4 weeks
(n=2). Stent size was 4 French in 7, 6 French -18 years) (right side 63, left side 71)
in 130 and 8 French in 17 RU. Stents were underwent retroperitoneoscopic
removed without anesthesia after 7 days Anderson Hynes pyeloplasty since January
(median, range: 3-21 days) 2005 to January 2014. Mean operative
time was 122 minutes. A balloon was
Stent associated complications occurred used to open retroperitoneal space in
in 11 patients (7,3 %). The stent dislocated 87 procedures and open insertion of
in 6 RU. 2 Stents were repositioned, trocar with CO2 insufflation was used
a percutaneous nephrostomy was to open the retroperitoneal space in 47
introduced in1 and a double-J stent in procedures. Movement of kidney and
2 RU, respectively. Stent obstruction pelvis during ventilation added to the
occurred in 3 RU, and was treated difficulty in suturing in 81 procedures.
conservatively in 2 RU and with early Addition of trans-abdominal suture
removal and double-J stent placement on pelvis in 53 procedures reduced the
in one. Leakage along the catheter in movements and mean operative time
one RU and percutaneous leakage after decreased significantly (93 min vs. 158
stent removal in two RU was treated min). 12 patients had UTI preoperatively
conservatively. Transrenal stenting was and 4 patients had preoperative insertion
not associated with relevant blood loss. of DJ stent. In 14 patients cystoscopy,
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retrograde pyelography and insertion to intraoperative misinterpretation of
of stent or guide wire was performed anatomic findings.
just before pyeloplasty. Mean operative
AIM: To evaluate sensitivity and specifity
time for these patients with preoperative
of CD with regard to intraoperative
stenting was 168 minutes. Antegrade
findings in children with suspected LCV
stenting was performed in 84 patients
causing PUJO.
and pelvi-ureteric stent was kept in
32 infants below 6 months of age. METHODS: Between November, 2012, to
Pyeloplasty sutures were interrupted in February, 2014, 13 consecutive children (5
initial 16 procedures and continuous in 116 male, 8 female; mean age 9.8 years, range
procedures. Mean operative time reduced 2 - 17 years) with unilateral PUJO ( 9 left,
significantly (189 min vs. 100 min). 4 right-sided) underwent laparoscopic
transabdominal dismembered pyeloplasty
CONCLUSION: Open insertion of
and were prospectively studied. All had
trocar and CO 2 insufflation opens
usual criteria with need for surgery.
the retroperitoneal space adequately
Preoperative CD was applied to investigate
in children. There is no need to use a
the presence of LCV and films were linked
balloon for this purpose. Placement of
to the surgeon for a detailed briefing.
trans-abdominal stay suture, ante-grade
stenting and continuous suturing reduced RESULTS: CD was correct in 12 out of
the operative timings significantly. 13 (92%). LCV was found at CD in 9 and
in 10 cases at surgery, whereas 3 cases
S047: PREOPERATIVE COLOUR
without LCV were proven to be absent
DOPPLER ULTRASOUND IN CHILDREN
intraoperatively. A very thin LCV was
WITH PELVIURETERIC JUNCTION
found at surgery in 1 case but not at CD.
OBSTRUCTION AND SUSPECTED LOWER
CD had a sensitivity, specifity, positive
POLE CROSSING VESSELS – VALUE
predictive, and negative predictive
FOR THE LAPAROSCOPIC SURGEON?
value of 90%, 100%, 100% and 75%,
Nagoud Schukfeh, Martin Metzelder, Paul
respectively. Attending preoperative
Andreas, Udo Vester, Division of Pediatric
CD by the surgeon was extremely
Surgery, Department of General-,
helpful, due to precise one-to-one
Visceral- and Transplant Surgery,
transformation of ultrasonographic into
University Clinic Essen, Essen, Germany
intraoperative findings.
and Department of Pediatric Nephrology,
University Clinic Essen, Essen, Germany CONCLUSION: CD is of high value for
the laparoscopic surgeon, due to high
BACKGROUND: Lower pole crossing sensitivity and specifity as well as
vessels (LCV) are known to be present highly accurate to detect the position
in about 15 to 45% of pediatric patients of LCV and main renal vessels to avoid
with pelviureteric junction obstruction misinterpretation, due to the variety of
(PUJO). Colour Doppler ultrasound LCV anatomy. Thus, laparoscopic surgeons
(CD) is a reliable non-invasive tool to should attend CD prior to laparoscopic
identify LCV especially in older children, pyeloplasty especially in older children
when hydronephrosis is symptomatic with renovascular hydronephorisis to
and/or intermittent. However, the increase the patient`s safety.
caliber of LCV varies as well as their
position and distance differs to main
renal hilar vessels, which might lead
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S048: ONE TROCAR ASSISTED 1, 23% in group 2 (p>0.05 vs G1) and 60%
PYELOPLASTY IN CHILDREN G iovanni in group 3 (p<0.05 vs G1; p <0.05 vs G2).
Cobellis, PhD, Fabiano Nino, MD, Carmine Mean hospital stay was 3.5 days in all
Noviello, PhD, Mercedes Romano, PhD, groups. One recurrent UPJO was observed
Francesco Mariscoli, MD, Lorenzo Rossi, in group 1. Cosmetic results were
MD, Ascanio Martino, MD, Pediatric excellent in all patients.
Surgery Unit, Academic Children’s
DISCUSSION: In our experience OTAP is
Hospital, Ancona
a safe and effective minimally invasive
INTRODUCTION: Anderson-Hynes technique, easily reproducible, with fast
dismembered pyeloplasty is considered learning curve, low operative time, low
the gold standard in the surgical costs and good cosmetic results. In case
treatment of ureteropelvic junction of inadequate exposure of the pelvis the
obstruction (UPJO) in children. Minimally procedure can be easily completed with
invasive approaches have been an extension of the incision. The OTAP
proposed but all presents technical could be considered the procedure of
difficulties. Retroperitoneoscopic choice in early childhood.
approach is limited by the small working
S049: LAPAROSCOPIC WILMS’ TUMOUR
space, while the laparoscopic one
NEPHRECTOMY E wan M. Brownlee,
convert an extraperitoneal surgery in
Fraser D. Munro, Gordon A. MacKinlay,
transperitoneal. The techniques based
OBE, Hamish Wallace, Royal Hospital for
on the use of robots still have high costs
Sick Children, Edinburgh
and are not adequately widespread. Aim
of the study was to evaluate the efficacy AIM OF THE STUDY: Since 2002, Wilms’
of the One Trocar Assisted Pyeloplasty tumour nephrectomies have been
(OTAP) in pediatric age. performed laparoscopically in our centre
where possible. We planned to review
MATERIALS & METHODS: Between May
the outcomes of our initial 10 years’
2006 and June 2013 a total of52 children
experience with this approach.
underwent OTAP for UPJO. Patients
were divided in three groups according METHODS: A retrospective review of case
to age at intervention. Group 1: 30 notes and local electronic databases
patients (range 1 month - 2 years; mean was performed examining all patients
9 months); Group 2: 13 patients (range undergoing laparoscopic Wilms’ tumour
2 - 6 years; mean 4,1 years); Group 3: 9 nephrectomies at a single centre from
patients (range 6 - 14 years; mean age 2002 to 2011 inclusive.
11 years). Intraoperative complications,
operative time, conversion rate, length MAIN RESULTS: 12 patients were identified
of hospitalization, recurrence and the with median age at surgery of 43 months
cosmetic results were considered. (IQR 25-47). SIOP protocol was followed
with tumours initially biopsied (either
RESULTS: There were no intraoperative laparoscopic-assisted or image-guided)
complications. Mean operative time was then neo-adjuvant chemotherapy
127 minutes (range 85 - 213) in group 1, administered. 2 of the first 3 procedures
107 minutes (range 90 - 195) in group 2 required conversion to open procedures
(p>0,05 vs G1) and 156 minutes (range due to large size of tumour preventing
95 - 215) in group 3 (p<0.05 vs G1; p <0.05 access to renal vessels. Since then, no
vs G2). Conversion rate was 21% in group further conversions have been required,
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although one procedure required insertion of this study is to show the evolution
of an extra port. Of the 10 patients in the diagnosis and treatment of this
successfully undergoing laparoscopic disease in a single center and propose a
resection, median operative time was 180 diagnostic and therapeutic algorithm.
mins (IQR 176-210). Pathological staging
MATHERIAL & METHODS: A retrospective
was: Stage I – 4 patients; Stage II – 4
analysis of the medical records of
patients; Stage III – 1 patient; Stage IV – 1
patients with suspected CL, assisted
patient. Histology confirmed complete
between December 1992 and June 2013,
resection of all tumours except the
was performed. Patients were divided
Stage III tumour which had widespread
into 2 groups, based on the inclusion of
peritoneal deposits. The resected Stage
nuclear magnetic cholangioresonance
III tumour showed 99% necrosis and the
(NMCR) and endoscopic retrograde
patient responded well to further post-
cholangiopancreatography (ERCP) in 2009.
operative chemotherapy, not requiring any
The suspicion of CL was compared with
radiotherapy. The patient with Stage IV
the subsequent confirmation by ERCP or
Wilms had a Stage I tumour pathologically,
intraoperative cholangiography (IOC) .
but had pulmonary metastases
which were treated successfully with RESULTS: Group 1: CL was suspected
radiotherapy. One patient with a Stage in 61 patients among 443 undergoing
I tumour had recurrence of disease, laparoscopic cholecystectomy (LC)
presenting 9 months post-operatively (13,8%), Only 24.5% (15/61) had CL during
with ascites. This renal bed and peritoneal the IOC, requiring instrumentation of the
recurrence was biopsied and treated with bile duct (BD) through initial trans-cystic
chemotherapy and radiotherapy, and the approach (TCA) with 9 failures. Of these,
patient has now been disease free for 7 were converted to open surgery and
59 months since. All other patients are 2 were resolved by postoperative ERCP.
disease-free at follow up to a median of 61 Group 2: From a total of 270 patients
months (range 39-122). undergoind cholecystectomy, CL was
suspected in 101. Of these, 31(30,6%)
CONCLUSION: Laparoscopic approach for
required instrumentation of the BD:
Wilms’ tumour nephrectomy can achieve
23 preoperative ERCP (only 1 required
similar results to open nephrectomy.
subsequent TCA) and 9 TCA, with 4
There seems to be a learning curve for this
failures, which underwent postoperative
procedure although this was not reflected
ERCP.There were no conversions to
in a trend in operative times. All patients
open surgery.Overall 69.3 to 75.5% of
have disease-free survival to date.
patients,in whom CL was suspected,
S050: EVOLUTION OF MINIMALLY did not require any instrumentation of
INVASIVE TREATMENT OF the BD.The presence of jaundice and
CHOLEDOCHOLITHIASIS (CL) IN CL at ultrasonography (US), had a high
PEDIATRICS. EXPERIENCE AT A SINGLE percentage of CL detected by IOC or ERCP
CENTER M auro Capparelli, MD, Horacio (60%), whereas pancreatitis and dilated
Questa, MD, Maria M. Bailez, MD, bile duct (DBD) on US, only 10.8 and
Garrahan Children´s Htal Buenos Aires; 22%, respectively. CRNM showed a 100%
Argentina specificity and 95.8%.sensitivity .
INTRODUCTION: Sequence of treatment CONCLUSIONS: 1) There is a high
of CL in children is controversial. The aim percentage of spontaneous resolution
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of CL in pediatric patients. 69.3 to 75.5% April 2009 to September 2010, 17 cases;
of patients,in whom CL was suspected, group B, from November 2010 to May
did not require any instrumentation of 2012, 31 cases; group C, from June 2012 to
the BD. 2) NMCR and ERCP are useful September 2013, 25 cases. All the surgical
tools and, used selectively, have lowered procedure were finished by one surgeon
conversion rate to open surgery in our The following factors such as average
serie (0% in Group 2). 3) We propose this operative time, conversion rate, volume
diagnostic and therapeutic algorithm: a) of bleeding, postoperative hospital stay,
In patients with a pancreatitis background and postoperative complications were
without CL or DBD in US we propose: LC analyzed among the 3 groups.
without neither previous NMCR nor ERCP
RESULTS: The average operative time in
. b) In those presenting with jaundice
group A (6.7±1.9 hours ) was longer than
and CL in US we propose a NMCR. In the
those of group B( 3.5±0.7 hours) and
presence of CL in this study, we indicate
C(3.7±0.5 hours, and all P values < 0.01)
an ERCP. If it is successful, we performed
respectively. And also the conversion
LC without IOC. In the presence of normal
rate of group A (5/17, 29.4%) was higher
BD at CRNM we propose LC without CIO,
than those of group B(3/31, 9.6%) and
while the finding of DBD without CL in this
C(2/25, 8%, all P values < 0.01). Volume
study, we indicate IOC during LC.
of bleeding (32.5±12.2ml) was larger
S051: THE LEARNING CURVE ON than those of group B (18.5±9.4ml)
THE LAPAROSCOPIC EXCISION OF and C(19.5±5.7ml, all P vales <0.05).
CHOLEDOCHAL CYST WITH ROUX-EN-Y But the postoperative hospital stay or
HEPATOENTEROSTOMY IN CHILDREN postoperative complications in all the 3
Jiangbin Liu, PhD, Zhibao Lv, Professor, groups were nearly same. And there were
Department of Pediatric Surgery, no difference between group B and group
Shanghai Children’s Hospital, Shanghai C on the upper 5 factors.
Jiao Tong University and Department of
CONCLUSION: The learning curve on the
Pediatric Surgery, Children’s Hospital of
laparoscopic cyst excision of choledochal
cyst with Roux-en-Y hepatoentemstomy
AIMS & OBJECTIVES: To review the in children is extremely steep before 15
experience from the two major children’s cases for surgeon. After that, the average
hospital of Shanghai city in China on the operative time, conversion rate and
laparoscopic cyst excision with Roux-en-Y volume of bleeding declined dramatically.
hepatoenterostomy for choledochal cyst
S052: PERIOPERATIVE COMPLICATIONS
in children and to establish the learning
OF LAPAROSCOPIC CHOLEDOCHAL
curve for surgeons.
CYST EXCISION Z higang Gao, MD, Qixing
MATERIAL & METHODS: from April Xiong, MD, Jinfa Tou, MD, Qiang Shu, Pro,
2009 to September 2013, 73 cases of Pediatric Surgery Department
choledochal cyst were performed by
OBJECTIVE: To investigate perioperative
laparoscopic cyst excision with Roux-en-Y
complications of laparoscopic chiledochal
hepatoenterostomy in Shanghai Children’s
cyst excision and the hepatic-jejunum
Hospital, Shanghai Jiao Tong University and
Roux-en-Y anastomosis.
Children’s Hospital of Fudan University2.
All the patients were divided into 3 METHODS: March 2012- December
groups chronologically. group A, from 2013 , 72 cases of chiledochal cyst were
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performed laparoscopic chiledochal cyst from postoperative bile leakage. One
excision and the hepatic-jejunum Roux- case found bile from drainage. 21 days
en-Y anastomosis including 9 males and after surgery the bile disappeared. The
63 female cases, 55 cases of cystic type other case got abdomen pain and fever
and spindle type of 17 cases. after 5 days of surgery. Ultrasound show
encapsulated fluid around the liver
RESULTS: 72 cases of choledochal
with diameter about 10cm. Peritoneal
cyst were successfully completed
drainage was performed, after 3
under laparoscopic procedure, average
weeks of drainage bile leakage cured
operation time 3.5h (2.5-5.5 h).
and the drainage tube was removed.
INTRAOPERATIVE COMPLICATIONS: 1) 3) Anastomotic stenosis: Obstructive
Right hepatic duct injury: one case jaundice was found in one case after
suffered right hepatic duct injury from 2 weeks of cholangioenterostomy.
the sharp separation process because Laparoscopic procedure found
right hepatic duct adhesion to the neck cholangioenterostomy anastomotic
of gallbladder. We find bile leak from the stenosis. Recholangioenterostomy
right bile duct. Interrupted suture with was performed by laparoscopic
5-0 PDS-2 line repair was performed procedure.4) Pancreatitis: Pancreatitiswas
directly. No postoperative bile leakage found in one case after 6 days surgery
was found. 2) Hepatic duct separation: 1 , sudden abdominal pain started in
case suffered hepatic duct separation. this case. Blood amylase increased
The diameter of the cyst is 8cm. MRCP significantly suggesting pancreatitis. After
can not show the right and lefthepatic 4 weeks nasal tubes feeding the baby
duct clearly. When separate the common was cured. All 72 cases of patients were
bile duct. The diameter of the left followed up for 1-19 months. No long-
hepatic duct is about 1.5cm. So we take term complications were found.
left hepatic duct as common bile duct
CONCLUSIONS: Laparoscopic choledochal
and take right hepatic duct as the neck
cyst excision and hepatic-jejunal Roux-
of the gallbladder. During separate the
en-Y anastomosis is a complex, high-risk
right side of the duct we found we make
procedure, it need skilled laparoscopic
a mistake. At last intraoperative two
techniques. Precise intraoperative
cholangioenterostomy was performed.
skills help to reduce intraoperative and
No postoperative bile leakage was found.
postoperative complications.
POSTOPERATIVE COMPLICATIONS: 1)
S054: LAPAROSCOPIC SIMPLE OBLIQUE
Bleeding: 2 cases suffered postoperative
DUODENO-DUODENOSTOMY IN
bleeding when one case had laparotomy
MANAGEMENT OF CONGENITAL
8 hours after laparoscopic procedure.
DUODENAL OBSTRUCTION IN CHILDREN
600ml continuous blood transfusion
Tran N. Son, MD, PhD, Nguyen T. Liem, MD,
can not stable the blood pressure.
PhD, Hoang H. Kien, MD, National Hospital
Bleeding lies the bed of cyst, continue
of Paediatrics, Hanoi, Vietnam
suture of cyst bed was performed and
bleeding stopped. The other bleeding INTRODUCTION: The technique of
case had conservative treatment after diamond-shape duodeno-duodenostomy
continuous blood transfusion. This is usually recommended for surgical repair
case had postoperative bleeding about of congenital duodenal obstruction (CDO).
400ml. 2) Bile leakage: 2 cases suffered The aim of this report is to present our
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technique of laparoscopic simple oblique (range 1 - 48 months), all the patients were
duodeno-duodenostomy (LSOD) and its asymptomatic.
results in management of CDO in children.
CONCLUSIONS: The technique of LSOD
METHODS: Medical records of patients is safe, efficacious and can be a viable
with diagnosis CDO undergoing LSOD option in management of selected cases
at our center from March, 2009 to of CDO in children at experienced centers.
December, 2013 were reviewed. For
S055: THREE-PORT TOTAL COLECTOMY
the LSOD, one infra- or trans-umbilical
AND SUBSEQUENT ROBOTIC
5mm port for camera and two 3mm
PROCTECTOMY WITH ILEAL POUCH-
ports for instruments were used. After
ANAL ANASTOMOSIS IN FULMINANT
mobilization of the distant part of the
ULCERATIVE COLITIS. INITIAL
duodenum, two 5.0 PDS seromuscular
EXPERIENCE G . Elmo, MD, T. Ferraris, MD,
sutures were placed on the duodenal wall
D. Liberto, MD, M. Urquizo, MD, P. Lobos,
proximal and distal to the obstruction
MD, F. De Badiola, MD, Pediatric Surgery
and tacked to the anterior abdominal wall
Hospital Italiano de Buenos Aires
for traction. The lower duodenum was
incised longitudinally distal to the traction SUMMARY: INTRODUCTION: Three-stage
suture. The upper duodenum incision was total colectomy with ileal pouch-anal
placed away from the traction suture anastomosis is indicated in patients
and extended downward obliquely. The with fulminant ulcerative colitis (UC) in
duodeno-duodenostomy was performed which medical treatment fails or suffer
as a “simple” anastomosis. complications such as toxic megacolon
or intestinal perforations due to
RESULTS: 48 patients were identified (23 chemotherapy.
boys, 47.9%) with median age at operation
11 days (ranged 1 day – 4 years, 42 patients The purpose of this paper is to present
(87.5%) were neonates). The median our initial surgical experience in pediatric
weight at operation was 2600 g (ranged patients with fulminant UC which
1600g to 10kg). . Type I atresia, annular underwent total laparoscopic colectomy
pancreas and type III atresia were found in using three ports only and subsequent
31 (64.5%), 9 (18.8%) and 8 (16.7%) patients, robotic proctectomy.
respectively. The median operative time MATERIALS & METHODS: We analyze
was 90 minutes (ranged 60 - 150 minutes). pediatric patients with UC treated
There was no conversion to open surgery, at Hospital Italiano de Buenos Aires
no anastomotic leakage or stenosis. The Gastroenterology service since January
median time from the operation to initial 2010 until December 2013. We only
oral feeding was 3 days. Postoperative included patients tested and treated
complications were documented in because of fulminant UC.
2 patients (4.2%): severe ventilator-
associated pneumonia causing death at Three stage surgery correspond to:
postoperative day17 in one patient with Three-port total colectomy as the first
bodyweight 1700g and gastrointestinal stage, robotic proctectomy as the second,
bleeding due to decreased prothrombin and finally ileostomy closure.
treated successfully in another. All other RESULTS: All five patients underwent
patients were discharge in good health with total colectomy with only three ports
a median postoperative hospital stay of 7 without intraoperatory complications
days. At a median follow-up of 18 months or conversion to laparotomy. One
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patient was explored because of partial This prospective study was done to
bowel obstruction, with enterolysis and analyze the incidence of metachronous
subsequent full recovering. inguinal hernia (MIH) after identification of
Every patient improved and normalized an asymptomatic open anulus inguinalis
laboratory variables leaving corticosteroid profundus (OAIP) during laparoscopic
therapy. pyloromyotomy (LP) in infants. We
deliberately used this term instead of
Three of this patients underwent robotic patent processus vaginalis (PPV) as the
proctectomy with ileal pouch-anal latter implies intraoperative information
anastomosis without complications and about length, width and diameter of the
good postoperative evolution. The other processus vaginalis. This term suggests
two patients are waiting for surgery. that MIH is almost obligate. Instead,
Following time is an average of 17 months. this information is not provided by most
They didn’t present pouchitis and present studies and exact data about MIH after
approximately 5 to 8 stools per day with LP is rare.
good anal continence. METHODS: We prospectively analyzed
CONCLUSION: Although this is our initial the incidence of OAIP at LP and MIH in
experience, we can infer that: 80 infants (68 boys, 12 girls, m:f = 5.6:1)
who underwent LP at one institution
Patients with fulminant UC must be between February 2007 and October
hospitalized and stabilized clinically. Total 2012. The incidence of MIH after LP was
laparoscopy colectomy with three ports additionally compared retrospectively
and Hartmann’s closure of the rectum can between all infants who underwent LP
be easily performed, reaching nutritional (92) and 141 infants who underwent open
recovering of these patients. pyloromyotomy (OP) between February
Once the patient is stabilized and 2004 and August 2012 at the same
corticosteroid therapy is finished, robotic institution.
proctectomy and J ileal pouch seems to be RESULTS: OAIP was prospectively
a feasible alternative to open proctectomy evaluated and encountered in 32/80
or laparoscopic proctectomy in patients (40%) of infants (1 girl and 31 boys, Table
with fulminant UC. 1). MIH after LP developed only in 8/32
S056: WHAT HAPPENS BEYOND (25%) of infants (1 girl and 7 boys) in this
AN OPEN ANULUS INGUINALIS group. Retrospectively, MIH developed
PROFUNDUS FOUND AT LAPAROSCOPIC in 8/92 of all LP and in 2/141 of OP, being
PYLOROMYOTOMY IN INFANTS? - A more frequent (P=.016, Fisher exact test)
JOURNEY INTO TERRA INCOGNITA Reza after LP. The median follow-up period was
M. Vahdad, MD, Lars B. Burghardt, Matthias 22.5 months (range: 4 – 52 months) for
Nissen, MD, Svenja Hardwig, MD, Ralf B. LP and 73 months (range: 6 – 108 months)
Troebs, Prof., Dr., med, Tobias Klein, MD, for OP.
Alexander Semaan, Thomas Boemers, CONCLUSION: OAIP during LP was a
Prof., Dr., med, Grigore Cernaianu, MD, frequent finding, but only one quarter of
1
Department of Pediatric Surgery, Cologne, infants with OAIP developed MIH. MIH
Germany,2Department of Pediatric developed significantly more often after
Surgery, Ruhr-University Bochum, LP comparing to OP.
Germany,3Department of Pediatric Surgery,
University Hospital Luebeck, Germany
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Prognostic factors for the identification disorder
of MIH after OAIP are lacking. Since it is
METHOD: Six children (age 1- 5 years)
a frequent finding, further standardized
were selected for laparoscopic transhiatal
laparoscopic parameters for the
gastric pull-up. Four patients had
measurement of the PPV are needed. A
had oesophageal atresia with feeding
system that laparoscopically quantifies
gastrostomy and oesophagostomy. One
a PPV and correlates with MIH remains
patient patient had a caustic oesophageal
to be developed. Further studies with
stricture requiring dilatation every
this aim are needed. Until such a system
two weeks for more than one year.
has been established and validated, we
Sixth patient had severe dilatation of
recommend that the surgeon should
oesophagus with respiratory distress with
record the presence of an OAIP, but
aperistaltic oesophagus on manometry.
not proceed with prophylactic repair of
All patients underwent laparoscopic
asymptomatic OAIP.
transhiatal gastric pull-up. In five patients
The increased incidence of MIH after LP feeding jejunostomy was also performed.
compared to OP needs to be validated by In two patients oesophagectomy was
further studies. performed under vision upto arch of
aorta. The cervical and upper thoracic
oesophagus was dissected easily from
neck incision on right side. The posterior
mediastinal dissection was done under
vision to create adequate space for
stomach.
RESULTS: All children withstood the
procedure very well. The mean operative
time was 140 min (range 120- 190 min).
Posterior mediastinal dissection was
bloodless and none of the patients
require blood transfusion. Postoperatively
S057: LAPAROSCOPIC TRANSHIATAL five patients were electively ventilated
GASTRIC PULL-UP IN 6 CHILDREN N idhi for 24 hours and in them jejunostomy
Khandelwal, Dr., Ravindra Ramadwar, Dr., feeding was commenced after 48 hours.
Bombay Hospital, Mumbai, India One patient with large dilated oesophagu
was extubated on table and nasogastric
INTRODUCTION: Oesophageal feeding was commenced after 72 hours.
replacement for oesophageal atresia and In the same child oral feeding was
caustic oesophageal strictures involves commenced on 5th postoperative day and
major dissection in abdomen, chest was on soft diet on 7th postoperative day.
and neck. To minimise surgical trauma, Contrast study was performed on postop
laparoscopic transhiatal gastric pull up day 7 in all patients. Four patients had
appeared to be a good alternative. minor leak which resolved spontaneously
AIM: To evaluate the feasibility and safety within 14 days of surgery. In these patients
of laparoscopic transhiatal gastric pull- oral fluids were introduced on 7th day
up in children with oesophageal atresia, after contrast study. Five patients were
caustic oesophageal stricture and motility on full oral feeds by 15th postop day.
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Jejunostomy was removed after one MATERIALS & METHODS: Three patients,
month. In one patient anastomotic one male and two females, aged 13.1,
ulcer blleding occurred on 21st postop 5.7 and 12.9 years were respectively
day. He had carotid blow out which was diagnosed with metastatic Ewing
embolized. He needed thoractomy and sarcoma of the right iliac branch,
revision of his gastric pull up in staged localized MPNST of the left sciatic
operation. He ws on jejunstomy feeds notch and localized BECOR tumor of the
for 8 months and then was successfully left hemisacrum. All three underwent
weaned of to oral feeding. At follow-up neoadjuvant chemotherapy according
(1-7 years) there was significant weight to leading protocols. A hemisacrectomy
gain and no major feeding issues. under S2 was performed for the two
female patients while no orthopedic
CONCLUSION: Laparoscopic transhiatal
surgery was required for the male
gastric pull-up with dissection of posterior
patient due to excellent local response
mediastinum under vision appears to be
to chemotherapy. A 54 Gy intensity-
feasible and safe.
modulated radiotherapy of the posterior
S058: THE SMALL BOWEL IN part of the pelvis was intended for
ITS HAMMOCK: HOW TO AVOID all patients either after surgery or
IRRADIATION THANKS TO THE SIGMOID neoadjuvant chemotherapy.
Sabine Irtan, MD, PhD, Eric Mascard, MD,
RESULTS: The laparoscopy procedure was
Stephanie Bolle, MD, Laurence Brugieres,
performed the same day as the orthopedic
MD, PhD, Sabine Sarnacki, MD, PhD,
surgery. It consisted in the fixation of
Department of pediatric surgery, APHP,
the sigmoid to the anterior parietal
Hopital Necker, Paris, France; Sorbonne
wall, the anterior transposition of the 2
Paris City University, Paris, France.
ovaries and of the rectum associated to
BACKGROUND: Irradiation is the a colostomy for the two female patients,
cornerstone treatment of bone cancers the anterior fixation of the uterus in one
of the pelvic rim, either Ewing sarcoma female patient and the dissection of left
or Malignant peripheral nerve sheath iliac vessels to move them anteriorly in
tumors (MPNSTs). High doses exceeding the other female patient. For the male
50 Gy may be required causing early or patient, only the fixation of the sigmoid to
late damages to the surrounded organs. the anterior parietal wall was performed.
The small bowel is particularly sensitive Three ports were used for each procedure,
to high dose radiotherapy with functional one 10-mm optic umbilical port and two
and anatomical side effects such as 5-mm working ports in the right and left
malabsorption, diarrhea, stricture or flanks. Fixation was done with resorbable
fistula formation. Several surgical or sutures. The loop of sigmoid was moved
non-surgical methods have already been to the right, fixed to the anterior parietal
described to displace the bowel out of the wall on a transversal line two centimeters
radiotherapy field with various results. below the umbilicus. Stomas were placed
in the right iliac fossa and complete the
AIM: We hereby described the use of hammock to prevent slippage of the small
laparoscopy to perform a hammock intestine in the pelvis. If needed, sutures
with the sigmoid to avoid small bowel were added between the mesocolon of
irradiation and following consequences. the right colon and those of the sigmoid.
The post-operative course was uneventful
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in all patients. Stomas were closed 5 Lennard, 2 Sulama, 1 bilateral free gluteal
and 7 months after completeness of the flaps. 7 were our own recurrences (4 Nuss,
radiotherapy course, associated with the 3 Willital). 17 had a preschool repair and
replacement of the uterus, ovaries and an asphyxiating chondrodystrophy and 21
colon. With a mean follow-up of 7, 29 and presented with severe instability. 61 were
30 months, all patients are alive without referred from German Hospitals, 85 from
any recurrences or symptoms. European countries and abroad. As a rule
existing Ravitch incisions were extended
CONCLUSION: The laparoscopic
laterally but not opened in the midline,
“hammock technique” is an efficient and
previous Nuss scars were used sometimes
safe approach not only to protect the
extended. Very extensive pleurolysis of
small bowel from irradiation by using
both lungs was required in 80% of the
the sigmoid but also to ease and secure
patients, particularly in the 28 patients
the orthopedic procedure done only
who had more than one previous chest
by posterior approachby displacing the
repair. The majority of patients required
abdominal organs forward.
2 Nuss bars (12-17 inch), 11 required 3
S059: EXTENDED NUSS FOR 146 Nuss bars, 4 patients >3 bars up to 8
RECURRENCES OF PECTUS EXCAVATUM bars (3 Nuss + 5 longitudinal Willital). 37
K . Schaarschmidt, Prof., MD, S. patients required multiple sternal and
Polleichtner, MD, M. Lempe, MD, F. rib osteotomies, 9 patches (surgisis). 9
Schlesinger, MD, U. Jaeschke, MD, Helios patients were referred with persisting
Center of Pediatric & Adolescent Surgery pericardial effusions mostly caused by
Berlin-Buch displaced Nuss bars, in 2 thoracoscopic
pericardial windows had to be performed
OBJECTIVE: Nuss procedure for primary in 2 pericardial cyst were resected during
pectus excavatum repair in adolescents Redo Nuss.
has stood the test of time. The difficult
cases are recurrences after Ravitch + Nuss RESULTS: In 146 patients recurrent or
or multiple previous repairs particularly resudual deformities could be corrected
at an advanced age, asphyxiating to very near normal from the Nuss
chondrodystrophy and floating sternum. accesses. In 7 Patients existing midline
In many patients additional procedures incision were partly opened in addition
like longitudinal bars, patches for closure to fix sternal deformities, fractures or
of chest wall defects and lung hernias pseudoarthroses. Meanwhile in 113/146
or repair of excessive rib flare have to be patients the bars are removed: 98 rated
added to standard Nuss procedure all of their result as excellent, 12 as good, 3
which we call “Extended Nuss”. as fair; 2 of the latter had a second redo
Nuss (second high bar) meanwhile.
METHODS & PROCEDURES: Under
epidural PCA 146/1429 adolescents and CONCLUSION: In our hands Extended
adults had a redo Nuss repair in Berlin- Nuss is a very reliable Method to repair
Buch (age 13-54 years, mean 19.3 +/- 8.7 y; all sorts of recurrences regardless of the
129 male / 17 female. Previous Operations method previously used. It seems to be an
were 53 Ravitch (14 with floating sternum), advantage to approach the sternum from
29 Nuss (11 with massive bar dislocation, a new access (laterally) after failed Ravitch
6 with secondary pectus carinatum), 17 type surgery. Very often the bilateral
Ravitch+ Nuss, 11 multiple operations thoracoscopic view gives valuable clues
(3-6), 13 Willital, 7 Rehbein, 4 Brunner, 3 why the previous surgery failed
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S060: 100 INFANT THORACOSCOPIC time in the thoracoscopic group was
LOBECTOMIES: LEARNING CURVE AND A significantly longer: 185 minutes (103 to
COMPARISON WITH OPEN LOBECTOMY 515; median: 174 - SD = 64) compared to
Pablo Laje, MD, Erik G. Pearson, MD, 111 minutes (56 to 272; p < 0.001; median
Tiffany Sinclair, MD, Mohamed A. 101 - SD = 42 minutes) in the open group.
Rehman, MD, Allan F. Simpao, MD, David However, the operative time decreased
E. Cohen, MD, Holly L. Hedrick, MD, N. markedly with increasing thoracoscopic
Scott Adzick, MD, Alan W. Flake, MD, The experience from 208 to 175 minutes
Children’s Hospital of Philadelphia (mean) for the first and last thirds of the
thoracoscopic series, respectively. This was
OBJECTIVE: To assess the learning curve
despite the primary surgeon increasingly
and outcomes for 100 consecutive
assuming a teaching role for the second
attempted infant thoracoscopic
half of the series. Similarly, the conversion
lobectomies by a single surgeon for
rate to open lobectomy decreased with
asymptomatic, prenatally diagnosed lung
increasing experience from 10 to 2 during
lesions and to compare the outcomes to a
the first and second thirds of the series
contemporaneous series of age-matched
respectively, with no cases converted in
patients undergoing open lobectomy.
the final third (total conversion rate: 12%).
METHODS: The medical records of all Three cases were converted for bleeding
patients undergoing lung lobectomy and the remainder for fused fissures or
between March 2005 and January abnormal lobulation. There was 1 major
2014 at a prenatal referral center were hemorrhage in the thoracoscopic group
retrospectively reviewed. Included in the early in the series and no other major
study were asymptomatic infants less complications in either group. There were
than 4 months of age with congenital 9 minor postoperative complications in
lung lesions who underwent: 1) attempted the thoracoscopic group (9%) and 9 in the
thoracoscopic lobectomy, or 2) open open group (4.8%); p = 0.248. There were
lobectomy. Patients older than 4 4 prolonged air leaks in the thoracoscopic
months, patients undergoing emergent group (4%) and 6 in the open group (3.2%);
lobectomy for symptomatic disease, p = 0.984. From an anesthetic perspective,
and patients with isolated extralobar at equivalent minute ventilation volumes
bronchopulmonary sequestrations were the mean end-tidal CO2 was higher in the
excluded. thoracoscopic group: 51.7 mmHg versus
38.6 mmHg (p < 0.001). However, with
RESULTS: The first 100 attempted appropriate ventilator management, this
thoracoscopic lobectomies by a single value plateaued and did not progressively
surgeon were compared with 188 open increase during the operation.
lobectomies performed in asymptomatic
infants younger than 4 months of age CONCLUSION: Infant thoracoscopic
with prenatally diagnosed lung lesions. lobectomy is a technically challenging
There were no significant differences in procedure with a noteworthy learning
mean age (7.2 vs. 7.9 weeks), mean weight curve. In centers with high prenatal
at surgery (4.8 vs. 5.0 kg), mean interval referral volumes, the learning curve can
to chest tube removal (1.5 vs. 1.5 days), be rapidly overcome and the procedure
and mean hospital stay (2.9 vs. 3.1 days) can be safely performed with comparable
between the thoracoscopic and open outcomes and superior cosmetic results
groups, respectively. The mean operative to open lobectomy.
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S061: TWO DECADES EXPERIENCE and efficacious technique. With proper
WITH THORACOSCOPIC LOBECTOMY mentoring it is an exportable technique,
IN INFANTS AND CHILDREN, which can be performed by pediatric
STANDARDIZING TECHNIQUES FOR surgical trainees. The procedures are safe
ADVANCED THORAOCSOCPIC SURGERY and effective even when performed in
Steven Rothenberg, MD, William the first 3 months of life. Early resection
Middlesworth, MD, Angela Kadenhe- avoids the risk of later infection and the
chiweshe, MD, The Morgan Stanley small but real risk of malignancy.
Children’s Hospital, Columbia University;
S062: THORACOSCOPIC THORACIC
The Rocky Mountain Hospital For Children
DUCT LIGATION FOR CONGENITAL AND
OBJECTIVES: This study evaluates the ACQUIRED DISEASE Bethany J. Slater, MD,
safety and efficacy of thoracoscopic Steven S. Rothenberg, MD, FACS, FAAP,
lobectomy in infants and children. Rocky Mountain Hospital For Children
METHODS: From January 1994 to PURPOSE: Congenital and acquired
November 2013, 346 patients underwent chylothorax presents a unique
video assisted thoracoscopic lobe management challenge in neonates and
resection at 2 institutions (RMHC/ infants. A failure of conservative therapy
CHONY). All procedures were performed requires surgical ligation to prevent
by or under the direct guidance of a continued fluid and protein losses. This
single surgeon. Ages ranged from 1 day paper exams a 15-year experience with
to 18 years and weights from 2.8 to 78 thoracoscopic ligation of the thoracic
kg. Pre-operative diagnosis included duct.
sequestration/congenital adenomatoid
METHODS: From June 1999 to December
malformation (CPAM) -306, severe
2013, 20 patients presented with chronic
bronchiectasis -24, congenital lobar
chylothoracies refractory to conservative
emphysema -13, and malignancy -3
management. 16 patients were s/p cardiac
RESULTS: 341 of 346 procedures were procedures, 1 patient was s/p TEF repair,
completed thoracoscopically. Operative 1 patient was s/p ECMO for meconieum
times ranged from 35 minutes to 240 aspiration, and 2 cases had congenital
minutes (avg. 115 minutes). Average chylothoracies. Ages ranged from 3
operative time when a trainee was the weeks to 3 years old and weights ranged
primary surgeon was 160 minutes. There from 2.6 to 12.7 Kg. All procedures were
were 80 upper, 25 middle, and 241 lower performed in the right chest with 3 ports.
lobe resections. There were 4 intra- Initially a 5 mm port was needed to insert
operative complications (1.1%) requiring a 5mm tissue sealing device but the last
conversion to an open thoracotomy. 2 procedures were performed with 3mm
The post-operative complication rate ports as a 3mm sealer became available.
was 3.3%, and 3 patients required re- All cases consisted of sealing of the duct
exploration for a prolonged air leak. at the level of the diaphragm with the
Hospital stay (LOS) ranged from 1 to 16 tissue sealer and or sutures, a mechanical
days (avg 2.4) at RMHC and 4.2 at CHONY. pleurodesis, and insertion of tissue glue at
In patients < 5kg and < 3 months of the level of the diaphragm. A chest tube
age the average operative time was 90 was left in all cases. The chyle leak was
minutes and LOS 2.1 days. CONCLUSIONS: noted to significantly diminish during the
Thoracoscopic lung resection is a safe procedure in all cases.
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RESULTS: All cases were completed METHODS: We reported the data of 35
successfully thoracoscopically. Operative small babies who underwent standard
time ranged from 20 to 55 minutes. There posterolateral thoracotomy (18 patients –
were no intra-operative complications. Group I) and video-assisted thoracoscopic
One patient with congenital bilateral surgery for diaphragmatic plication (17
chylothoracies required a second patients – Group II). The two groups were
procedure with a left partial pleurectomy. compared for patients demographics,
The chest tube duration post-procedure operative report and postoperative
ranged from 4 to 14 days. Two patients parameters.
failed the ligation and required a second
RESULTS: The groups were similar
procedure, a thoracoscopic pleurectomy
in terms of demographics and
in one, and a chemical pleurodesis in the
preoperative parameters. There
other.
was significant difference in mean
CONCLUSION: Thoracoscopic thoracic operative time between open and
duct ligation is a safe and effective thoracoscopic procedure (71,67 min vs
procedureeven in sick post-cardiac 51,76 min; p<<0,05). Duration of care
surgery patients. The site of the leak in neonatal intensive unit and length
can be identified in the majority of cases of hospital stay were significantly
and tissue sealing technology appears shorter in the Group II (5,89 d vs 3,23 d;
to be effective in sealing the duct. p<0,05 and 13,06 d vs 9,88 d; p<0,05).
The minimally invasive nature of the Early postoperative complications
procedure has hastened the request from (hemothorax, pneumothorax) were
the PICU and cardiac services to perform frequent in thoracotomy group (16,67%
the operative to avoid the often chronic vs 0%; p=0,229). Rate of the reccurences
and debilitating fluid and protein losses was dominated in the thoracotomy group
associated with a major chyle leak. (11,11% vs 0%; p=0,486).
S063: COMPARISON OF THORACOSCOPIC CONCLUSION: Thoracoscopic plication of
AND OPEN DIAPHRAGMATIC PLICATION the diaphragm in infants of the first three
IN NEONATES AND INFANTS Y ury months of the life demonstrated results
Kozlov, MD, Vladimir Novozhilov, MD, better than open surgery.
Department of Neonatal Surgery,
S064: THORACOSCOPIC LEFT CARDIAC
Municipal Pediatric Hospital, Irkutsk,
SYMPATHETIC DENERVATION
Russia; Department of Pediatric Surgery,
IN CHILDREN WITH MALIGNANT
Irkutsk State Medical Academy of
ARRHYTHMIA SYNDROMES R yan Antiel,
Continuing Education (IGMAPO), Irkutsk,
MD, Aodhnait Fahy, BMBCh, PhD, J. Martijn
Russia
Bos, MD, PhD, Abdalla Zarroug, MD,
BACKGROUND: Thoracoscopic plication Michael Ackerman, MD, PhD, Christopher
of the diaphragm is an alternative Moir, MD, Mayo Clinic
to conventional surgical treatment
BACKGROUND: Long QT syndrome (LQTS)
of diaphragmatic evisceration via
and catecholaminergic polymorphic
thoracotomy in neonates and infants.
ventricular tachycardia (CPVT) can lead
The aim of this study is to compare of
to ventricular arrhythmias and sudden
these two groups of patients for the last
death. Video-assisted thoracoscopic
11 years.
left cardiac sympathetic denervation
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(LCSD) surgery provides another viewed as curative, prophylactic LCSD
treatment option for patients with either offers a safe, minimally invasive
pharmacologic therapy resistance/ treatment option for patients with
intolerance or those with a particularly sudden-death-predisposing conditions.
severe arrhythmic phenotype. Failure to recognize and remove anatomic
variations of the sympathetic chain could
METHODS: Retrospective evaluation of all
result in a suboptimal denervation.
pediatric patients who underwent LCSD
surgery at our institution between January S065: DIAPHRAGMATIC EVENTRATION
2005 and May 2013. IN CHILDREN; LAPAROSCOPY VERSUS
THORACOSCOPIC PLICATION Go Miyano,
RESULTS: 79 patients (37 female,
MD, Masaya Yamoto, MD, Masakatsu
mean age 9.8 years) underwent LCSD;
Kaneshiro, MD, Hiromu Miyake, MD,
77 patients (97.5%) underwent a
Keiichi Morita, MD, Hiroshi Nouso, MD,
thoracoscopic approach, while 2 patients
Manabu Okawada, MD, Hiroyuki Koga,
(2.5%) underwent an open approach.
MD, Geoffrey J Lane, MD, Koji Fukumoto,
LCSD was performed on 14 patients (18%)
MD, Atsuyuki Yamataka, MD, Naoto
for high-risk LQTS, 33 (42%) required
Urushihara, MD, Department of Pediatric
additional protection, 19 (24%) for beta-
Surgery, Shizuoka Children’s Hospital.
blocker intolerance, and 13 (16%) for a
Department of Pediatric General &
break through cardiac event. Sixty-two
Urogenital Surgery, Juntendo University of
percent of these patients (49/79) were
Medicine.
classified clinically as high risk of fatal
arrhythmias. Pathology confirmed AIM: To determine what is the most
successful removal of sympathetic appropriate minimally invasive surgical
chain in all cases. Anatomical chain approach for performing diaphragmatic
abnormalities were noted in 31 patients plication; thoracoscopy or laparoscopy.
(39%), with split trunk or bifid chain being
MATERIALS & METHODS: We
the most commonly identified variant.
retrospectively reviewed the medical
The average operation time was 48.6
records of children diagnosed with
± 21 minutes. One thoracoscopic case
congenital diaphragmatic eventration
was converted to an open approach
at Shizuoka Children’s Hospital and
due to hemorrhage. Thirty-five
Juntendo University Hospital between
patients (44%) had a radiographically
2007 and 2012. Thoracoscopic plication
detected, hemodynamically insignificant
(TP) is performed under general
pneumothorax post-LCSD. Only 5 (6%)
anesthesia using single lung ventilation
patients had a pneumothorax that
with three 5mm ports; pneumothorax
required chest tube placement. There was
is established at a pressure of 4mmHg,
no significant difference noted between
and plication is performed using
the average preoperative QTc value (490
interrupted 4-0 nonabsorbable sutures.
± 68 ms) and postoperative QTc values
Laparoscopic plication (LP) is performed
(478 ± 56 ms). The average time from
with three or four 5mm trocars with
operation to dismissal was 2.6 days (range
pneumoperitoneum at a pressure of
1-17 days).
8mmHg; plication is performed with 4-0
CONCLUSION: We present the largest nonabsorbable sutures, and the initial
single center series of pediatric patients line of plication is sutured to the anterior
who underwent LCSD. Although not abdominal wall for stability. Choice
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of procedure, whether laparoscopic CONCLUSION: Both TP and LP appear to
or thoracoscopic was based on each be safe and beneficial for treating small
operating surgeons’ preference. children with diaphragmatic eventration.
Although we found a statistically higher
RESULTS: We treated 20 cases of
incidence of recurrence of eventration
diaphragmatic eventration by LP (n=13)
after LP, there is no consensus about
and TP (n=7). Etiology in LP was phrenic
the role of TP for treating eventration in
nerve injury secondary to cardiac surgery
patients who need further cardiac surgery.
(n=9) and mediastinal tumor resection
(n=2), and congenital muscular deficiency S066: LEARNING CURVE ANALYSIS
of the diaphragm (n=2). Etiology in TP IN PEDIATRIC SURGERY USING THE
was phrenic nerve injury secondary to CUMULATIVE SUM (CUSUM) METHOD –
cardiac surgery (n=1) and congenital A STATISTICAL PRIMER AND CLINICAL
muscular deficiency of the diaphragm EXAMPLE T homas P. Cundy, Nicholas E.
(n=6). In LP, eventration was left-sided Gattas, Alan White, Guang-Zhong Yang,
in 9 cases, right-sided in 2 cases, and Ara Darzi, Azad Najmaldin, Imperial
bilateral in 2 cases. In TP, eventration was College London, UK, Leeds General
left-sided in 4 cases, and right-sided in Infirmary, UK.
3 cases. Respiratory distress developed
BACKGROUND: Cumulative sum (CUSUM)
in all cases and preoperative ventilator
analysis is recognized as a preferred
support was required in 6 LP cases and 3
statistical method for evaluating
TP cases. Mean age at the time of surgery
outcomes following introduction
was 18.3 months (range: 0 – 45) in LP and
of any newly implemented surgical
25.1 months (range: 0 – 75) in TP. Mean
technique or technology, and particularly
weight at the time of surgery was 8.0kg
for monitoring individual surgeons’
(range: 2.7 – 15.9) in LP and 9.7kg (range:
performance. Despite its ostensive
2.2 – 27) in TP. Mean operating time was
virtues, the CUSUM method remains
155.6 minutes (range: 90 - 290) in LP and
under-utilized in the surgical literature in
167.0 minutes (range: 122 – 303) in TP
general, and is described in only a small
(p=NS). Mean intraoperative end-tidal
number of publications within the field
CO2 was 41.9mmHg (range: 35 – 52) in
of pediatric surgery. This study aims to
LP and 36.9mmHg (range: 33 - 41) in TP
introduce the CUSUM analysis technique
(p=.01). One TP case required conversion
and apply this statistical method to
to thoracotomy (p=NS). Mean duration
evaluate the learning curve for pediatric
of postoperative ventilator support
robot-assisted laparoscopic pyeloplasty
was 1.2 days (range: 0 - 5) in LP and 1.3
(RP).
days (range: 0 - 5) in TP (p=NS). Mean
time taken to recommence feeding METHODS: Intra-operative and post-
postoperatively was 1.6 days (range: 1 - operative clinical data were prospectively
4) in LP and 1.6 days (range: 1 - 4) in TP recorded for consecutive pediatric RP
(p=NS). Atelectasis occurred in 1 case in cases performed by a single-surgeon
each of LP and TP (p=NS) and while there (ASN) between March 2006 and October
were 6 cases of recurrence in LP, there 2013. CUSUM charts and tests were
were none in TP (p=.04). Mean duration of generated to quantitatively investigate
follow-up, 2.7 years for LP and 2.4 years the learning curve for set-up time,
for TP, were not statistically different. docking time, console time, operating
time, total operating room time, and post-
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operative complications. Conversions were attributed to surgical assistant
and avoidable operating room delay were inexperience or error (39%), equipment
separately evaluated with respect to case unavailability or malfunction (29%),
experience. Comparisons between case nursing scrub staff inexperience or error
experience and time-based outcomes (22%), anesthesia issues (7%), and robot
were assessed using the Student’s t-test malfunction (3%). There was no significant
and one-way ANOVA for bi-phasic and difference between case experience and
multi-phasic learning curves respectively. avoidable delay (P = 0.48).
Comparison between case experience
CONCLUSIONS: The CUSUM method
and complication frequency was assessed
has a valuable role for learning curve
using the Kruskal-Wallis test.
evaluation and outcome quality
RESULTS: A total of 90 RP cases were monitoring in pediatric surgery. In
evaluated. The youngest patient in applying this statistical technique to the
the series was 1 month of age, and the largest reported single-surgeon series of
smallest patient weighed 4.1 kilograms. pediatric RP, we demonstrate numerous
The median duration of follow up was distinctly shaped learning curves and
3.9 years (range 0.6 – 7.9 years). Multi- well-defined learning phase transition
phasic learning curves were observed for points.
set-up and docking time, and bi-phasic
S067: MAN VS. MACHINE: A
learning curves for all other operating
COMPARISON OF ROBOTIC-ASSISTED VS.
room time variables. The learning curve
LAPAROSCOPIC SLEEVE GASTRECTOMY
transitioned beyond the learning phase at
IN SEVERELY OBESE ADOLESCENTS
cases 10, 15, 42, 57, and 58 for set-up time,
Victoria K. Pepper, MD, Terrence M. Rager,
docking time, console time, operating
MD, MS, Karen A. Diefenbach, MD, Wei
time, and total operating room time
Wang, MS, MAS, Mehul V. Raval, MD, MS,
respectively. All comparisons of mean
Steven Teich, MD, Ihuoma Eneli, MD, Marc
operating times between the learning
P. Michalsky, MD, Nationwide Children’s
phase and subsequent phases were
Hospital
statistically significant (P = <0.001 – 0.01).
No significant difference was observed PURPOSE: Coupled with the rising
between case experience and frequency prevalence of childhood obesity, the
of post-operative complications (P concomitant increase in obesity-
= 0.125), although the CUSUM chart related comorbid diseases, including
demonstrated a directional change cardiovascular disease, type 2 diabetes,
in slope for the last 12 cases in which dyslipidemia, obstructive sleep apnea
there were high proportions of more and hypertension, poses new challenges
complicated re-do cases and patients for both the current and future health
< 6 months of age. Two cases were care systems. While accumulating
converted to open procedures (2.2%, evidence demonstrates the safety and
Cases 8 and 86). Three cases required efficacy of weight loss surgery in the
repeat procedures for PUJO recurrence treatment of severely obese adolescents,
(3.4%, Cases 28, 52 and 79). We regard the application of operative robotic
the overall success rate of this series as technology has not been explored in
96.7%. Avoidable delay was recorded in this emerging surgical population. The
53% of cases with mean delay time of aim of this study was to determine the
26.6 ± 12.3 minutes. The causes of delay safety and efficacy of robotic-assisted
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laparoscopic sleeve gastrectomy in the greater ($41,006 (ROB) vs. $31,824 (LAP),
treatment of severe adolescent obesity. In p=0.0016). On initial analysis of the total
addition, we compared 30-day outcomes hospital charges, the robotic cohort
and associated total operative and was less compared to the laparoscopic
hospital charges among robotic-assisted group ($57,836 (ROB) vs. $64,541 (LAP),
versus laparoscopic vertical sleeve p=0.0366). Following the exclusion of
gastrectomy at the same institution. outliers however, (n=3 LAP, n=0 ROB),
total hospital charges in the robotic group
METHODS: A retrospective analysis
were higher compared to the laparoscopic
of 14 consecutive robotic (ROB) and
group ($57,836 (ROB) vs. $47,587 (LAP),
14 consecutive laparoscopic (LAP)
p=0.0004).
adolescent patients undergoing sleeve
gastrectomy by one surgeon at a
single institution was conducted. Data
collection included age, gender, body
mass index (BMI), ethnicity, obesity-
related comorbidities, hospital length
of stay (LOS), operative time, post-
operative complications and 30-day
clinical outcomes and readmission rates.
The total operative and hospital charges
were also examined. Subjects with a LOS
greater than seven days were considered
outliers for the purpose of analysis. A CONCLUSIONS: Robotic-assisted sleeve
comparative analysis was performed gastrectomy is both safe and efficacious
using nonparametric Wilcoxon two- within the adolescent population and
sample test or t-test as appropriate. demonstrates results similar to the
RESULTS: Analysis between groups laparoscopic approach. The charges for
demonstrated no difference in age, sleeve gastrectomy are currently higher
gender, BMI, ethnicity, and associated when performed using robotic assistance.
comorbidities. In addition, there This difference appears to be driven
was no difference in post-operative almost entirely by operative charges,
complications, 30-day readmission but may be partially offset by shorter
rates (n=1 LAP, n=1 ROB), or weight loss post-operative length of stay. Additional
between groups. While the operative prospective studies are warranted.
time was significantly longer within the S068: INTERNATIONAL ATTITUDES OF
robotic group (ROB 136 minutes vs. LAP EARLY ADOPTERS TO CURRENT AND
99 minutes, p = 0.0006), the LOS was FUTURE ROBOTIC TECHNOLOGIES IN
significantly less on initial analysis (ROB PEDIATRIC SURGERY T homas P. Cundy,
67.5 hours vs. LAP 115.1 hours, p = 0.0094). Hani J. Marcus, Archie Hughes-Hallett,
Following exclusion of outliers (n=3 LAP, Azad Najmaldin, Guang-Zhong Yang, Ara
n=0 ROB), the reduction in hospital LOS Darzi, Imperial College London
still approached statistical significance
(ROB 67.5 vs. LAP 76.1 hours, p = 0.052). BACKGROUND: Perceptions toward
Analysis of the operative charges for surgical innovations are critical to the
the robotic group were significantly social processes that influence an
individual’s innovation-decision process
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and drive the technology’s overall rate In comparing responses between expert
of adoption. Cross-sectional surveys and non-expert sub groups, significant
are therefore important tools for differences were found only for the
understanding and tracing the diffusion feature of motion scaling with experts
of an innovation such as robotic surgery. being less agreeable that this was of
This focused survey study aims to benefit (P = 0.008). The most highly rated
capture international attitudes of early limitations were capital outlay expense,
adopter pediatric surgeons to current instrument size, and consumables/
and future robotic technologies in order maintenance expenses. Statistically
to 1) examine what specific features are significant differences in responses
driving its appeal and enthusiasm, 2) to between expert and non-expert groups
explore attitudes toward limiting factors were observed only for haptic feedback
to adoption that are acting as barriers to loss (P = 0.023), with experts being less
diffusion, and 3) to investigate opinions agreeable that this was a limitation.
toward future robotic technologies for The most preferred instrument and
pediatric surgery and the detailed needs scope diameter sizes were 3mm and
of this technology end-user community. 5mm respectively. The majority of
respondents (51%) felt a price of
METHODS: An electronic survey was
€500,000 - €1.0 million was reasonable
distributed to pediatric surgeons with
for a new robotic system. When asked, “is
personal experience or exposure
there is a future role for robot-assisted
in robotic surgery. The survey was
minimally invasive surgery in children?”,
distributed over one calendar month
72% (34/47) responded “definitely”, 26%
between June and July 2013. Surveys
(12/47) responded “probably”. Future
were circulated in the following three
technologies that respondents were
settings; 1) personal approach of
most interested in were microbots,
recognized experts attending the 22nd
image guidance, and flexible snake
IPEG Annual Congress, 2) delegates and
robots (mean aggregated 5-point level
faculty attending the Inaugural European
of interest Likert scale scores 4.43 ± 0.62,
Paediatric Robotic Surgery Workshop at
4.30 ± 0.75, and 4.30 ± 0.72 respectively).
the 6th Hamlyn Symposium on Medical
Robotics, and 3) personal email invitation CONCLUSIONS: Existing features of
to corresponding authors of relevant putative benefit and limitation in robotic
publications in the field identified surgery are perceived with widely varied
during a recent systematic review. weightings. Insight provided by these
Participants were classified as experts responses will help to inform relevant
or non-experts for further sub-group clinical, engineering, and industry groups
analysis. Coded Likert scale responses such that unambiguous goals and
are analyzed using the Friedman test or priorities may be assigned for the future.
Mann-Whitney test. In general, the early adopter cohort
of pediatric surgeons sampled seem
RESULTS: A total of 48 responses were
most receptive towards future robotic
received (22 experts, 26 non-experts),
technology that is smaller, less expensive,
with 14 countries represented. The
more intelligent and flexible.
most highly rated benefits of robot-
assistance were wristed instruments,
stereoscopic vision, and magnified view.
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S069: LAPAROSCOPIC SLEEVE CONCLUSIONS: Applying a standardized
GASTRECTOMY IN CHILDREN AND clinical pathway in LSG for pediatric
ADOLESCENTS: THE TECHNIQUE AND patients results in safe and effective
THE STANDARDIZED PERI-OPERATIVE outcomes with low complication rates,
CLINICAL PATHWAY A ayed R. Alqahtani, maximum co-morbidity resolution, and
MD, FRCSC, FACS, Mohamed O. Elahmedi, minimum morbidity as well as improved
MD, Department of Surgery and Obesity follow-up compliance.
Chair, King Saud University
S070: COMORBIDITY RESOLUTION
BACKGROUND: In the presence of IN MORBIDLY OBESE CHILDREN AND
growing concerns about bariatric surgery ADOLESCENTS UNDERGOING SLEEVE
in children and adolescents, knowledge GASTRECTOMY A ayed R. Alqahtani, MD,
regarding peri-operative management FRCSC, FACS, Mohamed O. Elahmedi,
and standardized care are lacking. This MD, Awadh R. Al Qahtani, MD, FRCSC,
study establishes a pediatric bariatric Department of Surgery and Obesity Chair,
surgery clinical pathway, utilizing our King Saud University
current largest-to-date experience in
BACKGROUND: Bariatric surgery is
Laparoscopic Sleeve Gastrectomy (LSG) in
becoming important for the reversal
this age group.
of co-morbidities in children and
METHODS: This study reviews the adolescents. We previously reported
details of the clinical pathway including the safety and efficacy of laparoscopic
preoperative workup and planning, sleeve gastrectomy (LSG) in the pediatric
intraoperative and in-hospital population. However, evidence pertaining
management, and postoperative care and to the effect of LSG on co-morbidities in
follow-up. Results attained by patients this age group is scarce.
on whom this protocol was applied were
OBJECTIVE: To assess the remission
reported
and improvement of co-morbidities
RESULTS: Up to December 2013, (dyslipidemia, hypertension, diabetes, and
273 patients underwent LSG (50.4% obstructive sleep apnea (OSA)) after LSG
females) with standardized care. Mean in children and adolescents.
age was 14.4 ± 4.0 years (Range: 5 to
SETTING: Data extracted from King
21 years). Median preoperative BMI
Saud University Obesity Chair Research
(interquartile range) was 46.5 (41.56 –
Database for all pediatric patients under
52.63). Median excess weight loss at 1,
the age of 21 years who underwent LSG
2, and 3 postoperative years was 61.7%,
between March 2008 and December 2013.
62.8%, and 68.9% respectively. There
were minor complications in 9 patients METHODS: Anthropometric changes,
whom were all managed conservatively, complications, remission and improvement
and there were no mortalities, leaks or in comorbidities were assessed over
reoperations. At 3 postoperative years, 3 years. OSA was diagnosed using the
compliance to follow-up dropped to Pediatric Sleep Questionnaire (PSQ) and
22%. Applying the protocol increased polysomnography. Diabetes, prediabetes,
the compliance rate to 73.6%, bringing hypertension, prehypertension and
the overall compliance during the study dyslipidemia were assessed using standard
period to 90.3%. pediatric-specific definitions.
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RESULTS: The review yielded 273 S072: EVALUATION OF THE SAFETY
patients. 94 patients were prepubertal OF LAPAROSCOPIC GASTROSTOMY IN
(5-12 years of age, mean: 9.8 ± 2.3), 139 PEDIATRIC PATIENTS WITH HYPOPLASTIC
adolescents (13-17 years of age, mean: LEFT HEART SYNDROME USING
15.4 ± 1.7), and 40 were young adults INTRAOPERATIVE TRANSESOPHAGEAL
(18-21 years of age, mean: 19.1 ± 0.8). ECHOCARDIOGRAPHY Hanna Alemayehu,
Overall mean age was 14.4 ± 4.0 years MD, E. Marty Knott, DO, Jason D. Fraser,
(range: 4.94 – 20.99), and 50.4 % were MD, William B. Drake, MD, Shawn D. St.
females. Mean Body Mass Index (BMI) Peter, MD, Kathy M. Perryman, MD, David
and BMI z-score were 48.2 ± 10.1 kg/m2 Juang, MD, Children’s Mercy Hospital
and 2.99 ± 0.35 respectively. Mean BMI
z-score at 1, 2 and 3 years postoperative INTRODUCTION: Patients with single
was 2.01 ± 0.87, 2.00 ± 1.1, and 1.65 ± ventricle physiology (SVP), specifically,
0.65, respectively with no significant hypoplastic left heart syndrome (HLHS)
difference observed across age groups. frequently need long-term enteral
Mean preoperative height was 158.0 ± access, however they are at an extremely
15.1 cm, and at one, two, and three years high operative risk. Nothing has been
postoperative it was 160.3 ± 13.5, 161.4 published on the physiologic impact on SV
± 14.1, and 163.2 ± 11.0, respectively. function during laparoscopy in this patient
The highest height gain was observed population. Therefore, we performed
in prepubertal children (11.6 ± 5.5 cm). intraoperative echocardiography (TEE)
All patients at different age groups to study the physiologic effects of
experienced normal growth velocity laparoscopic surgery in these patients.
between the 3rd and 97th centile for METHODS: After IRB approval patients
height. Within two years of follow-up, with SVP undergoing laparoscopic
90.3% of comorbidities were in remission gastrostomy were studied with
or improved, 64.9% of which were within intraoperative TEE. Patients were
the first three months postoperatively. separated into those with HLHS and
No further improvement or remission others with SVP. Data is reported as mean
was observed beyond two years, and +/- standard deviation. Student’s T-test
there was no recurrence up to 3-years in was used for continuous variables.
those patients who were seen in follow-
up. The lost to follow-up in each of the RESULTS: From 8/2011 – 2/2013 a total
three years was 4.2%, 7.6%, and 15.3% of 11 patients with SVP underwent
respectively. laparoscopic gastrostomy, including
6 with HLHS. One of the 6 HLHS and
CONCLUSIONS: LSG performed on 1 of the SVP underwent concurrent
children and adolescents results in fundoplication. All patients were post-
remission or improvement of more than first stage palliation. Average follow-up
90% of comorbidities within 2 years after was 335 +/- 163 days. There was no 30 day
bariatric surgery, with few complications, mortality. TEE data is in found in Table 1.
no mortality and normal growth. Depression in fractional shortening was
found to be statistically significant in
HLHS during insufflation( P= 0.03).
CONCLUSIONS: There was a statistically
significant depression in cardiac function
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in children with HLHS with initiation of suture. Patient demographics were
pneumoperitoneum, which resolves collected and outcomes compared
with desufflation. Overall, the children including operation time, length of stay
tolerated pneumoperitoneum. TEE allows and complication rate. Groups were
for real-time assessment of ventricular compared using independent t test or
function and volume and may improve Mann Whitney test as appropriate with
safety during longer procedures. a p value <0.05 deemed significant. 95%
confidence intervals (CIs) are given.
MAIN RESULTS: 103 patients (23F: 80M)
underwent LH over four years compared
to 151 (25F:126M) OH in the first two years.
Median age in the LH group was 0.56 years
(range 0.04 to 14.7) compared to 0.52
years (range 0.04 to 13.47) in the OH group
(p=0.81). The median weight in the LH group
was 7.8 kilograms (2-58.2) compared to
7.6 kilograms (2.06-48.4) in the OH group
(p=0.84). In the OH group there were 8
bilateral herniae and 143 unilateral of which
3 had contralateral explorations. In the LH
group the intended operation was bilateral
in 18 (17.4%) and 85 were clinically unilateral
but at operation a contralateral patent
processus vaginalis was repaired in26 i.e.
S073: A COMPARATIVE STUDY OF 30.5%. The median operative time was 50.5
OUTCOME OF SIMPLE PURSE STRING minutes (range 20-95 minutes) in the LH
SUTURE LAPAROSCOPIC HERNIA REPAIR group and 20 minutes (range 10-90) in the
IN CHILDREN M airi Steven, Miss, Stephen OH cohort (p<0.0001). Same day discharge
Bell, Dr., Peter Carson, Dr., Rebecca Ward, was possible in 56 % who had LH and in 33%
Dr., Merrill McHoney, Mr., Royal Hospital who had OH (p=0.0002). No intraoperative
for Sick Children, Edinburgh, UK complications were encountered during LH
AIM OF THE STUDY: To compare surgical and the procedure was well-tolerated. The
outcomes for a simple purse string comparative post-operative complications
method of laparoscopicinguinalhernia are shown in the table.
repair (LH), with a traditional open inguinal
hernia repair (OH) in children in a single
centre.
METHODS: Following institutional ethical
approval, a retrospective review of all
children undergoing LH from January
2010 to December 2013 was compared
to a historic cohort of all OH between
January 2010 and December 2011. LH
was performed by a simple purse string
technique using non-absorbable braided
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CONCLUSION: LH yields similar results were recorded as were co-morbid
to OH, however, the operation time is conditions and complications.
significantly longer. All complication
RESULTS: Mean pre-operative weight
rates were statistically similar on balance.
and BMI were 139.0 kg and 49.2 kg/
The differencein metachronous hernia
m2 , respectively, in Group 1, and
rates is tending to significance owing to
154.0kg and 55.2 kg/m2 in Group 2 (p
the concurrent detection and repair of a
= .104). All procedures were completed
contralateral patent processus vaginalis
laparoscopically without intraoperative
at laparoscopy.
complication. Mean operating time was
S074: VERTICAL SLEEVE GASTRECTOMY: 128 minutes in Group 1 and 197 minutes
PRIMARY VERSUS REVISIONAL WEIGHT in Group 2 (p < .0001). One patient in
LOSS SURGERY IN ADOLESCENTS AND each group underwent laparoscopic
YOUNG ADULTS J effrey Zitsman, MD, cholecystectomy concurrently. One
Melissa Bagloo, MD, Beth Schrope, MD, patient in each group stayed in the
PhD, Aaron Roth, MD, Miguel Silva, MD, hospital an additional day for pain control.
Mary DiGiorgi, PhD, Marc Bessler, MD, No patient experienced significant
Columbia University Medical Center vomiting or abdominal pain in follow-
up of 2-36 months. One patient (Group
INTRODUCTION: Laparoscopic vertical
1) experienced mesenteric venous
sleeve gastrectomy (VSG) is becoming
thrombosis in the second week post-op.
the preferred weight loss operation for
BMI decreased an average of 10.0+4.1
morbidly obese adolescents and young
kg/m2 at 6 months post-op in Group 1
adults. The procedure has been used
and 7.0+2.6 kg/m2 (p=0.033). All patients
both as a primary procedure as well as
were able to tolerate a regular diet.
a secondary procedure following failed
Comorbidities improved with weight loss
laparoscopic adjustable gastric banding
following VSG.
(LAGB). We retrospectively reviewed
our case series to date to compare early CONCLUSION: Early results demonstrate
post-operative outcomes in patients who successful weight loss in adolescents
underwent VSG as a primary weight loss and young adults following VSG used as
procedure with those who underwent either a primary or secondary weight loss
VSG as a secondary procedure following procedure.
previous LAGB.
S075: A ROBOTIC APPROACH TO MEDIAN
METHODS: Between June, 2010 and ARCUATE LIGAMENT SYNDROME V ictoria
January, 2014, 50 consecutive patients K. Pepper, MD, Karen A. Diefenbach, MD,
(range 12.7 to 22.7 yr, mean 17.3 yr) Andy C. Chiou, MD, David L. Crawford, MD,
underwent VSG to treat morbid obesity University of Illinois School of Medicine
under an IRB-approved protocol. 40 at Peoria, Order of Saint Francis Medical
patients underwent VSG as a primary Center, Nationwide Children’s Hospital
weight loss procedure (Group 1) while
INTRODUCTION: Median arcuate ligament
10 underwent conversion for failure
syndrome (MALS) is an uncommon and
to lose weight following LAGB (Group
controversial disease. The syndrome is
2). All patients were evaluated by a
characterized by a triad of postprandial
multidisciplinary team. Data collected
abdominal pain, an epigastric bruit which
included age, gender, and ethnicity.
increases with expiration, and a > 50%
Weight and body mass index changes
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extrinsic compression of the celiac artery feasibility of the procedure within the
on vascular imaging. Patients can have pediatric population as well as the
significant history of weight loss and potential improvement in visablity and
this weight loss is a positive prognostic range of motions offered by the robotic
indicator for surgical intervention. While instruments.
most frequently seen in females ages
S076: LAPAROSCOPIC EXCISION
40-50, we present a case of MALS in an
OF PERIPANCREATIC TUMOR AND
18-year-old female.
MESENTERIC CYST Thai Lan N. Tran,
METHODS: An 18-year-old female MD, Nam X. Nguyen, MD, University of
was referred to vascular surgery after California, Irvine Medical Center
extensive work-up for post-prandial pain
The patient is a 13 year-old previously
and weight loss. The patient underwent
healthy male who presented with
CTA with inspiratory and expiratory
an acute onset of epigastric pain. He
phases which revealed compression of
underwent extensive workup, which
the celiac axis. The patient was scheduled
revealed a cystic mass at the root of
for robotic median arcuate ligament
the mesentery abutting the SMA. In
release. After induction of anesthesia,
addition, there weretwo solid lesions
insufflation of the abdomen was
locating within the body of the pancreas,
performed via a Verus needle. Five trocars
straddling between the splenic vein and
were placed including a 12-mm trocar
the portal vein. The patient was brought
just left and superior of the umbilicus, a
to the operating room and placed supine
second 12 mm trocar in the left lateral
on the split leg table. Four 5 mm trocars
abdomen, and three 8 mm trocars (left
were inserted in the following locations:
upper quadrant, right lateral abdomen,
infraumbilical, left subcostal, andtwo
and right upper quadrant). After division
on either side of the umbilicus at the
of the gastrohepatic ligament, the right
midclavicular line.
crus of the diaphragm was identified and
freed from the esophagus. This dissection We began the operation by taking down
was continued inferiorly until the left the gastrocolic ligaments and entering the
gastric artery was identified and isolated. lesser sac. Two stay sutures were placed
Dissection was continued proximally through and through the abdominal wall
until the celiac trunk and common and tacking the posterior aspect of the
hepatic artery were identified. The bands stomach up to the abdominal wall in order
composing the median arcuate ligament to expose the retroperitoneal space.
were divided, releasing and straightening We noticed a solid tumor locating within
celiac axis. the body of the pancreas. The mass was
abutting against the portal vein to the right
RESULTS: The patient tolerated the
and the splenic vein inferiorly. We began
procedure well and was discharged post-
taking down the retroperitoneal tissues
operative day 3. The patient had complete
and meticulously dissect the tumor using a
resolution of symptoms with weight gain
combination of Harmonic scalpel and hook
and is currently 1 year post-op.
electrocautery. After peeling the tumor
CONCLUSIONS: Robotic-assisted median away from the surrounding tissues, we
arcuate ligament release has been noticed that this is actually a bilobar tumor,
shown to be safe and feasible in previous with the inferior lobe extended underneath
studies. This video demonstrates the the pancreas towards the inferior border
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of the pancreas. With tedious dissection, laparoscopic surgery (SILS) has arguably
we were able to circumferentially remove reached that goal; technical limitations
both lobes without any injuries to the are, however, preventing it from replacing
major blood vessels. traditional multiport laparoscopic surgery
(MLS). Lack of instrument triangulation
Next, we turned our attention to the
and inconvenient proximity between the
cystic lesion by first reflecting the colon
surgeon’s and the assistant’s ports result
superiorly. We noticed that the tumor
in prolonged operative time and a steeper
is located at the root of the mesentery.
learning curve. Our hybrid method
We began by scoring the overlying
intends to combine the benefits of both
peritoneum and dissected out the surface
MLS and SILS through a 2x2 approach, in
of the cyst. As we nearly complete the
which two umbilical ports are combined
circumferential dissection, we opened the
with two 3 mm subcostal access points.
cyst and looked inside to confirm this is
Thanks to this configuration, instrument
the cyst with a previously placed pigtail
triangulation is possible, the surgeon
drain. With careful dissection, we were
and the assistant can work comfortably
able to dissect the cyst off of the SMA
in tandem and the cosmetic result is
and shell the cyst out of the root of the
excellent, with a scarless abdominal wall
mesentery.
after healing. Furthermore, the steps of
Postoperative course was uncomplicated the operation parallel those of traditional
and the patient was sent home on POD MLS, which facilitates its adoption by
3. Final pathology revealed benign experienced laparoscopic surgeons.
hamartoma.
S078: FETOSCOPY AND LASER: A
In conclusion, we showed in this GOOD THERAPEUTIC ALLIANCE IN
patientthat laparoscopic approach is MINIMALLY-INVASIVE FETAL SURGERY
feasible for complex abdominal masses. Alan Coleman, MD, Jose Peiro, MD, Foong-
Yen Lim, MD, Cincinnati Children’s Hospital
S077: HIDING THE SCARS. EVOLUTION Medical Center
OF THE PEDIATRIC LAPAROSCOPIC
CHOLECYSTECTOMY - THE 2X2 HYBRID INTRODUCTION: Fetoscopy is becoming
TECHNIQUE Jeh Yung, MD, Georgios more widely utilized in the diagnosis
Karagkounis, MD, Gavin Falk, MD, Todd and treatment of a variety of prenatal
Ponsky, MD, FACS, Akron Children’s conditions. The indications and uses are
Hospital; Cleveland Clinic also expanding with further innovation of
techniques and equipment. In some cases
Cholecystectomy has evolved such as twin-twin transfusion syndrome
impressively in the past 30 years. (TTTS), fetoscopic laser photocoagulation
From traditional open to mini-open to has become the therapy of choice in
laparoscopic and now single-incision, treating prenatal disorders. We will
incisions have become gradually smaller, review our outcomes with fetoscopic
significantly improving injury to the laser interventions for various indications
patient, length of stay, postoperative pain and discuss the current literature on the
and cosmesis. This evolution has been subject.
of particular importance for pediatric
surgery due to the higher expectations for METHODS: We retrospectively reviewed
cosmetic outcome, with the ideal being a all patients who underwent fetoscopic
truly scarless operation. Single-incision interventions with laser therapy from
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2004 – 2014. Diagnoses included TTTS, become more prevalent with improved
amniotic band syndrome (ABS), and giant outcomes compared initial descriptions.
chorioangioma. Indications for laser Further innovation and experience will
intervention and complications were only lead to an increase in the indications
recorded. Outcomes included mortality treated with fetoscopy and laser
and rate of complications. We reviewed interventions.
the literature for current outcomes and
S079: IMPACT OF CUSTOMIZED PRE-
further indications.
BENDED BAR IN SURGICAL TREATMENT
RESULTS: We performed over 730 OF PECTUS EXCAVATUM Ruben Lamas-
interventions with fetoscopic laser from Pinheiro, MD, Pedro Correia-Rodrigues,
2004 – 2014. Among the diagnoses Jaime C. Fonseca PhD, João L. Vilaça
treated were TTTS (n=714), ABS (n=14), PhD, Jorge Correia-Pinto MD, PhD, Tiago
and chorioangioma (n=3). In those Henriques-Coelho MD, PhD, Pediatric
treated for TTTS, 5 patients had two Surgery Department, Faculty of Medicine,
consecutive laser treatments and 35 Hospital de São João, Porto, Portugal
patients had incomplete delivery data.
INTRODUCTION & AIMS: Pre-surgical
Of the remaining 674 interventions,
automatic and personalized bar bending
33 pregnancies were triplets and 641
for pectus excavatum (PE) allows a
pregnancies were twins. In our twin
correct size and shape of the bar using CT
cases, both twins survived to delivery in
scan information. In the present study,
70% (n=446/641) of cases and at least
we reviewed the experience in PE surgical
one twin in 90% (n=560/624) of cases.
treatment at a tertiary center comparing
Among our ABS patients, we performed
the Nuss procedure performed using
release of amniotic bands involving the
pre-bended (i3D) with manual bended
umbilical cord in 64% (n=9/14) of cases
(MB) bars.
and isolated compromised extremities
in the remaining 36% (n=5/14). Laser MATERIAL & METHODS: Patients
therapy was utilized in conjunction submitted to NP from January of 2000
with other modalities in 3 cases of to December 2013 were included. Clinical
chorioangioma that led to high output files were retrospectively reviewed for
cardiac states. In reviewing the literature, demography, previous PE correction,
we also found other indications anesthetic and operative details. Patients
for laser therapy not currently in submitted to surgery with the new
widespread use including posterior i3DExcavatum system pre-bended bars
urethral valve ablation in bladder outlet were compared to those where classic
obstruction, cord coagulation in twin manual bar bending was performed.
reversed arterial perfusion sequence,
fetoscopic balloon decompression/ RESULTS: During 14 years, 139 patients
deflation for tracheal occlusion release were operated, 98 males (78%), with
in congenital diaphragmatic hernia, a mean age of 14.9±3.2 years. Eight
and decompressive laryngotomy for patients had been previously submitted
congenital high airway obstruction to Ravitch procedure. Since 2007, the
syndrome. i3D pre-bended bar was used in 96
patients (69%). The i3D and MB groups
CONCLUSIONS: Minimally invasive were identical for gender, but the
fetoscopic laser interventions have patients in MB were younger (median
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13.9 vs. 14.7 years, p=0.024) and had compared to non-obese children
a superior Haller index (mean 4.2 vs. undergoing SILS appendectomy for
3.4, p=0.002). In i3D group, surgery last acute, perforated appendicitis.
less time (median 72 vs. 120 minutes,
METHODS: We reviewed the records of
p<0.001), the hospital stay was shorter
all pediatric patients who underwent
(median 5 vs. 7 days, p<0.001) and
SILS appendectomy for acute,
there were less complication (7% vs.
perforated appendicitis, performed by
43%, p<0.001). Complications were
a single surgeon, between 2008 -2013.
mainly skin erosion (i3D - 0 vs. MB - 6),
The diagnosis of acute, perforated
pneumothorax (i3D - 1 vs. MB - 5), lung
appendicitis was based on pathology
atelectasis (i3D - 1 vs. MB - 1) and wound
results. Patient characteristics including
infections (i3D - 2 vs. MB - 1). There was
age, body weight, gender and outcomes
no mortality in both groups. The bar was
were compared between both obese
removed later in the i3D group: median
and non-obese children.Body weight
period with the bar was 32 months
percentiles were calculated based on
versus 28 months (p<0.001).
age-appropriate growth charts.Obesity
DISCUSSION: The introduction of was defined as body weight greater than
i3DExcavatum system improved the 95th percentile.
outcomes. Since the bar is bended before
RESULTS: 70 patients underwent SILS
surgery, a clear reduction in operative time
appendectomy for acute, perforated
was achieved. However, we cannot exclude
appendicitis. 26 of these were obese. Of
the learning curve in the first years of
these patients, 35(48.6%) were male.
implementation of the NP in our center.
None of the patients in either group were
S080: SINGLE INCISION LAPAROSCOPIC converted to conventional laparoscopic
SURGERY FOR PERFORATED or open appendectomy. There was
APPENDICITIS: DOES OBESITY AFFECT no difference in length of operation
OUTCOMES? Adesola C. Akinkuotu, MD, (69.2±25.1vs.65.6±25.8 minutes; p=0.57),
Paulette I Abbas, MD, Ashwin Pimpalwar, length of hospital stay (6.0±3.9vs.5.1±3.1
MD, Texas Children’s Hospital and the days; p=0.32) or time to full diet
Division of Pediatric surgery, Michael E. (2.9±2.0vs2.6±2.1 days; p=0.55) between
DeBakey Department of Surgery, Baylor obese and non-obese children.Obese
College of Medicine, Houston, TX patients had a higher incidence of post-
operative wound infection than non-
INTRODUCTION: In children with acute
obese children (26.9%vs.4.7%; p=0.02).
appendicitis, obesity has been linked
There were no differences in other post-
with worse post-operative outcomes
operative complications such as intra-
in open and conventional laparoscopic
abdominal abscess, wound seroma and
appendectomy. Improvements in
post-operative ileus (Table 1).
laparoscopic surgery have led to the
use of single incision laparoscopic CONCLUSION: Obese children treated
surgery (SILS) for surgical procedures with SILS appendectomy for acute,
including appendectomies. At our perforated appendicitis appear to have
institution, SILS appendectomies are similar outcomes when compared to non-
performed routinely by a single surgeon. obese children except for a higher wound
We hypothesize that obese children infection rate.
have worse post-operative outcomes
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TABLE 1: Outcomes of obese and March 2013 was performed. Patient
non-obese children undergoing demographics and outcomes were
SILS appendectomy for perforated analyzed, including age at diagnostic
appendicitis laparoscopy, gender, diagnosis or
indication for shunt placement, previous
shunt placement, prior abdominal
operations or procedures, cause of shunt
failure, shunt revisions, and length of
shunt patency.
RESULTS: During the four year
study period, a total of 27 patients
underwent diagnostic laparoscopy for
ventriculoperitoneal shunt placement
at a mean age of 7.7 ± 6.8 years. Medical
indications for shunt placement included:
hemorrhagic hydrocephalus (40.7%),
congenital hydrocephalus (22.2%), spina
S081: DIAGNOSTIC LAPAROSCOPY FOR bifida (18.5%), myelomeningocele (11.1%),
INTRA-ABDOMINAL EVALUATION AND and arachnoid cyst (7.4%). Twenty five
VENTRICULOPERITONEAL SHUNT patients who underwent laparoscopy had
PLACEMENT IN CHILDREN S andra M. previous shunts placed in the peritoneum
Farach, MD, Paul D. Danielson, MD, Nicole (mean number of prior shunts placed
M. Chandler, MD, All Children’s Hospital was 1.6 ± 0.8), while two underwent
Johns Hopkins Medicine initial shunt placement. Sixteen patients
(59%) had undergone previous non-
BACKGROUND: Studies have shown that
shunt related abdominal operations.
laparoscopic assistance for the placement
Indications for shunt externalization
of ventriculoperitoneal (VP) shunts is a
prior to diagnostic laparoscopy included:
safe, effective, and minimally invasive
infection (n=10), malfunction (n=10), and
approach for distal peritoneal shunt
pseudocyst (n=5). Twenty three (85%)
placement. A relative contraindication
patients had successful peritoneal shunt
to abdominal shunt placement is a
placement. There were four patients
history of peritonitis or prior abdominal
(15%) in whom peritoneal shunt could
surgery. In an effort to reduce the need
not be placed at the time of laparoscopy
for ventriculoatrial shunt placement,
secondary to extensive adhesions. Of
laparoscopy can be used for diagnosis
the 23 patients who had successful
and intervention. The purpose of our
peritoneal shunt placement, 13 (57%) did
study was to review our experience with
not require further shunt intervention,
diagnostic laparoscopy for VP shunt
5 (22%) underwent conversion to a
placement in patients with a potential
ventriculoatrial shunt, 4 (17%) underwent
hostile abdomen.
re-externalization, and 1 (4%) required
METHODS: After Institutional Review distal shunt revision (Figure 1). Of the four
Board approval, a retrospective analysis patients who required externalization,
of all patients who underwent diagnostic 3 underwent a second diagnostic
laparoscopy for ventriculoperitoneal laparoscopy procedure with successful
shunt placement from March 2009 to peritoneal shunt placement. Mean length
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of follow up after diagnostic laparoscopy mobilisation as a cause of surgical
was 1.6 ±1.1 years. Two patients (7.4%) were failure due to wrap transmigration. We
lost to follow up. however, have neither adopted minimal
oesophageal mobilisation nor perceived
CONCLUSIONS: Utilization of diagnostic
a preponderance of wrap transmigration
laparoscopy eliminated the need for
at redo fundoplication. This study aimed
initial ventriculoatrial shunt placement in
to determine the incidence of wrap
85% of patients. Sixty percent of patients
transmigration in children requiring redo-
required no further shunt revision and
fundoplication, and to quantify the risk of
this resulted in an overall long term shunt
hypothesised alternative antecedents for
patency of 70%. Laparoscopic assisted
redo surgery.
peritoneal shunt insertion in pediatric
patients is a safe and minimally invasive METHODS: A single-centre retrospective
technique with the additional benefit of study was performed of all children
exploration and adhesiolysis to determine undergoing primary laparoscopic
suitability of shunt placement. fundoplication between 2008 and 2012
inclusive. Primary outcome was need
for redo-fundoplication. Data were
also collected regarding demographics,
medical history, referral details,
investigations and operative approach.
Relative risk of redo-fundoplication
was calculated for each hypothesised
antecedent with Cox regression; p<0.05
significant.
MAIN RESULTS: 95 children underwent
primary laparoscopic fundoplication;
1/95 was followed up interstate and
so excluded from analysis. 15/94 (16%)
S082: RISK OF REDO LAPAROSCOPIC children required redo-fundoplication and
FUNDOPLICATION IN CHILDREN: a further 2/94 died. 3/15 required >1 redo.
BEWARE THE RESPIRATORY PHYSICIAN? Indications for redo-fundoplication were:
Edward Gibson, MBBS, Warwick J. Teague, 5/15 too tight wrap, 10/15 GOR recurrence.
DPhil, FRACS, Sanjeev Khurana, MS, 4/15 (27%) had wrap transmigration.
FRCSI, FRACS, Department of Paediatric The risk of redo-fundoplication was
Surgery, Women’s and Children’s Hospital, significantly increased if referral for
Adelaide, Australia fundoplication was by a respiratory
physician (vs. gastroenterologist; HR 19.9,
AIM OF THE STUDY: The success
CI 95% 2.7-145.2, p=0.003). However,
and shortcomings of laparoscopic
neurological status, indication for
fundoplication in children with
primary fundoplication, and presence
complicated gastro-oesophageal reflux
of a gastrostomy were not significantly
(GOR) remains a matter of scrutiny
associated with redo surgery; see table.
and debate. Redo-fundoplication
presents challenges for the patient
and surgeon alike. Recent literature
has emphasied extensive oeosphageal
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Shanghai Children’s Hospital, Shanghai
Jiao Tong University and Children’s
Hospital of Fudan University. There were
9 boys and 12 girls, average age 1.5±0.9
years(range 0.4-4.5 years). The patients
were divided into 2 groups according to
different suture in the thoracoscopic
repair and duplication. Group 1, the
diaphragm were repaired by interrupted
suture. 8 cases. Group 2, the repair on the
diaphragm were treated by continuous
suture, 13 cases. The following factors
such as average operation time, volume
CONCLUSIONS: This, like other series, of bleeding, drainage, postoperative
reports a concerning incidence of redo hospital stay and postoperative
fundoplication. However, even if wrap complications were analyzed.
transmigration were eliminated, our RESULTS: The age, body weight of
redo surgery rate remains >10%. The patients, symptoms or signs and the
association of redo-fundoplication numbers of eventrated intercostal space
with referral by a respiratory physician of diaphragm were no difference between
is thought-provoking. This may reflect 2 groups. The average operation time in
the severity of GOR sequelae and/or group 1 and group 2 was different (75±21
superadded strain on the fundoplication vs 33±17min, P < 0.01). The volume of
wrap in the most respiratory-impaired bleeding, postoperative stay in hospital,
children. and drainage in the two groups were
S083: THORACOSCOPIC REPAIR ON nearly same, There was no mortality in
THE CONGENITAL DIAPHRAGMATIC operation and the patients were followed
EVENTRATION IN CHILDREN? up from 0.45 to 3.3 years, and only 1 case
CONTINUOUS OR INTERRUPTED of recurrence was found in group 1.
SUTURE FOR PLICATION Jiangbin Liu, CONCLUSIONS: Thoracoscopic repair
PhD, Professor, Zhibao Lv, Professor, on the diaphragmatic eventration by
Department of Pediatric Surgery, continuous suture is a safe, reliable,
Shanghai Children’s Hospital, Shanghai convenient and effective procedure for
Jiao Tong University and Department of plication, which can take the place of
Pediatric Surgery, Children’s Hospital of interrupted suture.
KEY WORDS: Eventration of diaphragm;
OBJECTIVES: To review the experience and Congenital;Diaphragm/Malformation;
compare the results of the continuous Diaphragm/Surgery;Thoracoscopy
or interrupted suture on the congenital
diaphragmatic eventration in children by
thoracoscopic repair.
METHODS: From January 2010 to
September 2013, 21 children with
congenital diaphragmatic eventration
were repaired by thoracoscopic repair in
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S084: VALIDATION OF A NOVEL two lines (D1 and D2) is the amount of
PARAMETER FOR THE EVALUATION OF defect the patient has in their chest. KCI
PECTUS EXCAVATUM: THE KANSAS CITY formula was as follows: D2-D1/D2*100.
CORRECTION INDEX Gaston Bellia, MD,
RESULTS: The mean age was similar
Mariano Albertal, MD, Luzia Toselli, MD,
between groups (19.5±9.3 years old for PE
Carolina Millan, MD, Horacio Bignon, MD,
and 22±2.9 years old for controls, p=0.92).
Giselle Corti, Javier Vallejos, MD,Marcelo
Thetableillustrates the HI and KCI values
Martinez Ferro, Private Children´s Hospital
from our study and St. Peters et al. In our
of Buenos Aires, Fundación Hospitalaria,
study, 10/87 (11.4%) patients with PE had
Buenos Aires, Argentina
overlapped with controls (area under the
INTRODUCTION: The Haller index (HI) ROC curve 0.48, p=0.67) compared to 47%
is the ratio of the distance between the in St. Peters et al. Using the KCI, only 2/87
anterior spine and posterior sternum (2.3%) patients overlapped (area under
to the widest transverse diameter of ROC curve 0.99, p<0.001), while no overlap
the chest. Although the HI remains was reported in St. Peters et al.
the most commonly used parameter
to determine surgical candidacy in
patients with pectus excavatum (PE),
it cannotdiscriminate between PE
and controls. Recently, a group of
investigatorsfrom Kansas introduced
a new PE index, the correction index
(St Peter SD et al.A novel measure for CONCLUSION: 1) Similat to St. Peters et
PE: thecorrectionindex, J Pediatr Surg. al.KCI resulted in less overlap thanHI. 2)
2011 Dec;46 (12):2270-3.) The Kansas Overlapwith HI was low in our study, likely
correctionindex (KCI) expresses the due to greater PE severity compared to St.
percentage of thoracic depression Peters et al.
represented by the sternal defect,
demonstrating optimum discrimination S085: SPONTANEOUS
between PE and controls. In order to PNEUMOTHORAXES: A SINGLE-
confirm those results, we aim to report INSTITUTION RETROSPECTIVE REVIEW
our experience with the KCI for the Victoria K. Pepper, MD, Terrence M. Rager,
assessment of PE severity. MD, MS, Wei Wang, MS, MAS, Dennis
R. King, MD, Karen A. Diefenbach, MD,
METHODS: Retrospective analysis of Nationwide Children’s Hospital
prospectively collected chest computed
tomographic data in PE (N=87) and PURPOSE: Previous studies have
controls (N=24). We calculated HI in a evaluated the management of
standard fashion. For the KCI, we drew spontaneous pneumothorax in the
a horizontal line across the anterior pediatric population, but no standard
spine and measured two distances: the of care has emerged with regard to the
minimum distance between the posterior timing of surgical management. While
sternum and the anterior spine (D1) and some surgeons opt for a “conservative”
the maximum distance between the line approach with either observation or
placed on the anterior spine and, the inner chest tube placement initially, others
margin of the most anterior portion of the proceed with surgical intervention on
chest (D2). The difference between these the first occurrence. The purpose of this
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study was to review the management There was no difference in LOS between
of spontaneous pneumothorax by patients treated with immediate surgery
multiple surgeons in a single institution (8.6 days) versus those converted
in order to compare the outcomes of to surgery from either chest tube
initial conservative and early operative management (9.9 days, p=0.3013) or
treatment. observation (11 days, p=0.4152).
METHODS: A retrospective review of all Of the 59 occurrences which did not
patients at a single institution between undergo surgical management on the
October 2008 and October 2013 was first admission, 19 developed a recurrent
performed. The diagnosis code for pneumothorax (32.2%). Fifteen of these
“pneumothorax” was used to identify patients (78.9%) received immediate
all possible study candidates. Exclusion surgical management. Of the remaining
criteria included underlying pulmonary 4 patients, one (25%) was converted
pathology, iatrogenic pneumothorax, to surgery. Of the three patients
traumatic pneumothorax, and age who did not have surgery after their
less than 10 years. Data was collected second occurrence, two (66.7%) had a
regarding age, race, gender, weight, and third episode. Both of these patients
comorbidities. The initial management, underwent surgery during their third
any alterations in management, and admission.
length of stay (LOS) were examined for
Of the total number of patients
each occurrence of pneumothorax.
undergoing surgical management (n=41),
RESULTS: A total of 72 patients with 82 7 (17.1%) had a recurrent ipsilateral
occurrences of initial pneumothorax pneumothorax post-operatively, and one
were identified (10 patients had bilateral child developed a contralateral lesion
disease). Of the 82 occurrences, seven after bilateral pleurodesis.
(8.54%) were treated at the outset
SUMMARY: While the timing of
with surgery (SM). Thirteen (17.3%) of
surgery in patients with spontaneous
the patients initially managed with
pneumothoraxes is a controversial
conservative treatment (CM) were
subject, most surgeons agree that surgical
converted to surgical treatment during
management should be performed after
their first admission and an additional
the first or second occurrence. With a
3 patients underwent elective surgical
total postoperative recurrence rate of
management after initial discharge.
19.5% post-operatively, 32.2% after the
There was no significant difference
first occurrence, and 66.7% after the
in age, gender, race, or comorbidities
second episode, our data would suggest
between those treated successfully
that patients may best benefit from
conservatively versus those managed
surgical intervention after the second
with surgery. There was a predominance
occurrence of pneumothorax.
of left-sided pneumothoraces in both
subgroups (CM = 60.4% vs. SM = 65%). S086: LAPAROSCOPIC RESECTION OF
There was a significant difference ABDOMINAL NEUROBLASTOMA WITH
between the average length of stay (LOS) RENAL PEDICLE INVOLVEMENT P aula
in patients treated conservatively versus Flores, MD, Martin Cadario, MD, Yvonne
those with surgical management (CM Lenz, MD, Garrahan Hospital. Buenos
= 3.9 days vs. SM = 9.7 days, p<0.0001). Aires. Argentina.
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Neuroblastoma is the most common reduction of kidney estimated dimension
extracranial solid malignancy in was found and the patients present
childhood, accounting for 8% to 10% of normal blood pressure at the time of the
all cancers in the pediatric population. analysis.
Almost half of the patients have
The INRG classification system was
disseminated disease. Patients with
developed to facilitate the comparison
local compromise will have a better
of risk-based clinical trials conducted in
prognosis, although some will develop
different regions of the world by defining
either local or disseminated relapse. One
homogenous pretreatment patient
of the factors that determine treatment
cohorts. However, there are patients
strategy is the tumor resectability. The
that will benefit with primary surgery,
International Neuroblastoma Risk Group
although the presence of IDRF. In our
(INRG) classification is a pretreatment
experience, there are some tumors
staging system based on tumor imaging.
with vessel encasement that can be
The goal is to reduce the surgery-
bluntly resected founding the correct
related complications in those patients
surgical dissection plane. Some tumors
undergoing primary surgical treatment.
considered “unresectable” according
According to the INRG classification,
to current protocols, are amenable
abdominal tumors invading one or
to complete laparoscopic resection
both renal pedicles are considered as
despite vessel involvement. Minimal
“image defined risk factors” (IDRF),
invasive surgery allows an effective local
and neoadyuvant chemotherapy is
control. In order to benefit from this de-
highly recommended. On the other
escalation therapy strategy, the patients
hand, complete resection of localized
have to be strictly selected.
neuroblastoma would be the best option
to spare chemotherapy in selected S087: LOWER ESOPHAGEAL
patients who will not benefit with it. BANDING IN EXTREMELY LOW BIRTH
WEIGHT PREMATURE INFANTS
We present 2 patients aged 11
WITH OESOPHAGEAL ATRESIA AND
months and 3 years old with localized
TRACHEO-ESOPHAGEAL FISTULA IS
neuroblastoma with renal pedicle
A LIFE SAVING PRACTICE FOLLOWED
invasion. Tumor location and size were
BY A SUCCESSFUL DELAYED PRIMARY
determined by preoperative CTscan.
THORACOSCOPY RECONSTRUCTION
The mean tumor volume was 18 cc.
Manuel Lopez, MD, Eduardo Perez-
A complete macroscopic resection
Etchepare, François Varlet, MD, PhD,
was achieved in both cases with no
Department of Pediatric Surgery,
perioperative morbidity. The mean
University Hospital of Saint Etienne
operative time was 190 minutes and
the patients’ hospital stay was 2 INTRODUCTION: In extremely low birth
days. Pathological exams confirmed weight infants (ELBW<1000 g), several
neuroblastoma with favorable biological abnormalities are associated making
factors in both cases. During the follow- surgical treatment a real challenge. High
up period (19 months and 27 months), the morbidity is associated with primary
patients did not receive any additional repair in these patients. Here, we report
therapy. Both patients are alive and our experience with three cases of ELBW
with no evidence of disease. Kidneys babies with EA.
size was calculated by ultrasound. No
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MATERIAL & METHODS: From september Kyushu University, 2Department of
2012 to January 2013, Three low birth Advanced Medicine and Innovative
weight infants with EA and TEF born Technology, Kyushu University
prematurely with severe respiratory Hospital,3The faculty of science and
distress,the mean gestational age was engineering, Waseda University
26(25-27) weeks,the median birth weight
BACKGROUND & AIM: In pediatric
was 690 gr (500-790)were treated with
endosurgery, surgeons receive much
initial banding of the gastroesophageal
benefit of magnified visual filed even for
juncture followed by a gastrostomy. ARM
small bady patients. On the other hand,
was associated in one of them.
the more visual filed was magnified,
RESULTS: One baby died in the the more blind area of the forceps
postoperative period because became bigger. In the previous study,
intracerebral hemorrhage at 7 days we developed augmented reality (AR)
after initial surgery. In one of them a navigation system and applied pediatric
ligation without section of the TEF with laparocopic splenectomy (Ieiri S, et al.,
removal of lower esophageal band Pediatr Surg Int, 2012) and oncologic
was performed by thoracoscopy at surgery (Souzaki R et al., J Ped Surg,2013).
30 days and 1100 gr. The esophageal Therefore we developed the blind area
reconstruction and section of fistula was visualization system to resolve these
done by thoracoscopy at 70 and 80 days demerits using AR technique for pediatric
and 2100gr and 2200 gr. with uneventful endosurgery. In this study, we verify an
course. None early complication. The effectiveness of this system for pediatric
follow-up was 12 months, one baby surgeons.
presented a small stricture requiring only
METHODS: Developed system was
one dilation of lower esophageal with
composed of two cameras. One is for
unevenful course
usual view point of surgeon, and the
CONCLUSION: LEB is a life saving other is for compensation of blind area
practice in premature ELBW babies. The of forceps. Image of blind area of forceps
esophagus can tolerate the ligation even was fused with a real-time endoscopic
with a thread without having a long time image of the operative field, providing
stricture complication. Thoracoscopic a transparent forceps for the surgeon
reconstruction of the esophagus is (Fig.1a).Surgeons can get “See-Through
possible in these babies. Needle Driver” using this augmented
reality technique (Fig.1b). We examined
S088: DEVELOPMENT OF BLIND AREA
the effectiveness of this system
VISUALIZATION SYSTEM IN MAGNIFIED
by backhand needle driving (Fig.2).
FIELD OF VIEW USING AN AUGMENTED
Examinees were 17 pediatric surgeons
REALITY IN PEDIATRIC ENDOSURGERY
and they were divided into 2 groups, 3
~AMAZING SEE-THROUGH NEEDLE
experts and 14 trainees. They had to
DRIVER~ S atoshi Ieiri 1,2, MD, PhD, Yuya
perform 3 backhand needle driving in the
Nishio3, Satoshi Obata1, MD, Ryota
box with(Fig.2a) or without this system
Souzaki 1,2, MD, PhD, Yo Kobayashi3,
(Fig.2b). The tip of the needle was hidden
PhD, Masakatsu Fujie3, PhD, Makoto
by shaft of forceps. Such being the case,
Hashizume2, MD, PhD, FACS, Tomoaki
this task was setup. Evaluation points
Taguchi 1, MD, PhD, FACS, 1Department of
were time and accuracy. Accuracy was
Pediatric Surgery, Faculty of Medicine,
calculated by measuring of deviation
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of exertion error. Statistical analysis
was performed Mann-Whitney U test
and p<0.05 was considered statistically
significant.
RESULTS: All 17 participants completed
the evaluation task. There was no
significant difference between with and
without system for time, in experts and
trainees, respectively. Figure 3 showed
the results of needle driving accuracy.
Exertion error of experts with and
without system was 0.63 ± 0.43 and 1.40
± 2.33 (p=0.001158) (Fig.3a), respectively.
Exertion error of trainees with and
without system was 0.63 ± 0.43 and 1.40
± 2.33 (p=0.843972) (Fig.3b), respectively.
Experts improved the backhand needle
driving accuracy using this system.
CONCLUSIONS: The results revealed
that the experts made skillful use
“See-Through Needle Driver” using an
AR technique. They would receive the
maximum merit of this system for the
S089: IS SINGLE INCISION
magnified view of small working space.
APPENDECTOMY SUPERIOR TO
Next step, we must refine this system for
TRADITIONAL LAPAROSCOPY IN
in-vivo experiments. In the near future,
CHILDREN? S tephanie F. Polites, MD,
this system would be applied for clinical
Shannon D. Acker, MD, James T. Ross,
use of advanced pediatric endosurgery,
David A. Partrick, MD, Abdalla E. Zarroug,
espscially for small neonate and infant
MD, Kristine M. Thomsen, Donald D.
patients.
Potter, MD, Mayo Clinic, Rochester, MN;
Children’s Hospital Colorado, Aurora, CO;
University of Iowa, Iowa City, IA
INTRODUCTION: Laparoscopic
appendectomy (LA) has largely become
the standard of care for children with
acute appendicitis, and some institutions
are now moving to single incision
laparoscopic appendectomy (SILA).
Data comparing SILA and LA is limited,
and existing data originate from single
institutions that select patients based on
if they are best suited for SILA or LA. We
aimed to compare SILA and traditional
LA for acute appendicitis in children
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by comparing outcomes between two confirmed by multivariable analysis
institutions which each use SILA or LA (p<.001). Postoperative LOS was shorter
preferentially. We hypothesized that SILA following SILA for both perforated (4.2
and LA would have at least equivalent vs. 5.0 days, p=.11) and nonperforated
outcomes. (1.0 vs. 1.5 days, p<.001) appendicitis.
Extended postoperative LOS (>2 days)
METHODS: We performed a
was more likely following LA (30.0% vs.
retrospective review of all children
12.7%, OR=3.3, 95% CI: 1.9-5.8, p<.001)
≤18 who underwent SILA at a single
on multivariable analysis. Rate of
institution between July 2010 and July
unplanned readmission (4.3% SILA group
2013 for acute appendicitis. Each SILA
vs. 1.9% LA group, p=0.10), superficial
patient was matched to 2-3 patients
wound infections (1.6% vs. 0.2%, p=.07)
who underwent LA at a second
and intra-abdominal abscess (4.3% vs.
institution during the same time period.
2.1%, p=.11) were similar in both groups;
Patients were matched based on age,
however, on multivariable analysis,
sex, weight, and perforation status.
SILA was predictive of infectious
Demographic information, preoperative
complications (OR=3.6, 95% CI: 1.4-10.0,
clinical information, operative time,
p=.012). Other complications were rare.
and outcomes were collected. Linear
regression was used to compare
operative time and postoperative
LOS and logistic regression was used
to compare extended length of stay
(>75th percentile) for nonperforated
appendicitis and infectious complications
(superficial wound infections and
intra-abdominal abscess). Multivariable
analyses controlled for preoperative LOS
and preoperative antibiotic use to adjust
for differences between institutions. TABLE: Comparison of outcomes of single
incision and traditional laparoscopic
RESULTS: A total of 184 children appendectomy
underwent SILA and were matched to
478 children who underwent LA. There CONCLUSION: Operative outcomes
were no clinically significant differences for single incision laparoscopic
in age (mean 11.8 vs. 11.2 years), sex appendectomy are similar to traditional
(52.2% vs. 54.8% male), weight (mean laparoscopic appendectomy for
50.5 vs. 46.3 kg), or perforation status perforated and nonperforated acute
(22.8% vs. 24.7% perforated) between appendicitis in children. Traditional LA
the cohorts. Conversion to traditional was associated with shorter operative
LA was required in 2 SILA patients. times and reduced risk of infectious
Conversion to open appendectomy was complications as compared to SILA. Single
required in 2 SILA patients and no LA incision laparoscopic appendectomy was
patients. On univariate analysis (Table), associated with a shorter hospital stay.
mean operative time was significantly Both techniques have an acceptably low
greater for SILA (64.1 vs. 45.9 minutes, complication rate; thus, the choice of
p<.001) as compared to LA and this was procedure can be surgeon dependent.
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S090: IMPACT OF EXPERIENCE ON a single center. Mean age for all patients
QUALITY OUTCOMES IN SINGLE- was 11.8 ± 4 (0-21.5) years and mean weight
INCISION LAPAROSCOPY FOR SIMPLE was 47.5 ± 20.4 (9.8-134) kilograms. The
AND COMPLEX APPENDICITIS IN population consisted of 61% males. Four
CHILDREN S andra M. Farach, MD, Paul hundred eleven (58.5%) patients were
D. Danielson, MD, Nicole M. Chandler, diagnosed with acute appendicitis and
MD, All Children’s Hospital Johns Hopkins 292 (41.5%) with complex appendicitis.
Medicine Prior to the start of our training program,
357 patients and 248 patients underwent
BACKGROUND: Single incision
appendectomy for acute and complex
laparoscopy (SIL) has been performed
appendicitis, respectively. Surgical
by more than 70% of pediatric surgeons.
trainees were involved in 54 and 44
However, evolving surgical technology
appendectomies for acute and complex
is often adapted without rigorous
appendicitis, respectively. Quality
scientific investigation. Single incision
measures are summarized in Table 1. There
appendectomy has been shown to be
was a significant decrease in operative
an effective treatment in appendicitis
time between early and late groups for
in children, but factors that impact
both simple appendicitis (p<0.05) and
outcomes are not well understood. We
complex appendicitis (p<0.05). There was
report our large experience with SIL,
a significant increase in operative time
focusing on the impact experience may
following introduction of surgical trainees
play on quality outcomes.
compared to the late group (p<0.05), but
METHODS: At the inception of our SIL not compared to the early group for simple
program, all patients were entered appendicitis. There was no difference in
into a prospective database for quality operative times following the introduction
monitoring. After Institutional Review of trainees for complex appendicitis.
Board approval, a retrospective review of There were no significant differences
patients who underwent SIL from August in complications or readmission
2009 to November 2013 was performed. rates between any of the groups. No
A total of 919 patients were reviewed. conversions occurred in patients with
Patients who underwent appendectomy simple appendicitis, while two conversions
were grouped by early experience without (0.7%) occurred in patients with complex
trainees (first consecutive 100 cases), late appendicitis.
experience without trainees, and late
CONCLUSION: The adoption of new
experience with surgical trainees. Our
technology requires a significant
training program began in October 2012.
learning curve even for the experienced
Each cohort was further stratified into
laparoscopist. There is the potential for
simple (acute) appendicitis and complex
significantly decreased operative times
appendicitis. Quality measures including
once experience is obtained. Surgical
operative time, conversion to multi-port
trainees with laparoscopic experience
or open, and 30-day complications were
likely perform similar to attendings when
analyzed.
introducing new technology. While there
RESULTS: A total of 703 patients may be an appreciated increase in overall
underwent SIL appendectomy during operative time with the introduction of
the study period. All procedures were trainees, this does not impact quality
performed by two attending surgeons at outcomes.
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pylori. Furthermore we hypothesize that
we can effectively dilate the obstruction
restoring flow through the pyloric channel
using our novel balloon device.
METHODS: Five adult rabbit (4-5kg) cadaver
pylori were excised and reserved for testing.
Each pylorus was held vertically while 2cc
of infant formula was poured into the
antrum and the time for formula to exit
the duodenum was recorded. Cross-linked
hyaluronic acid (HA) dermal filler was
S091: CAN HYPERTROPHIC PYLORIC injected subcutaneously with a 25G needle
STENOSIS BE TREATED WITH NATURAL to bulk the pyloric muscle circumferentially.
ORIFICE TRANSESOPHAGEAL On average 1.28cc was injected per pylorus
SURGERY APPROACH USING A NOVEL over 23 injection sites. Flow through the
ENDOLUMINAL CATHETER DEVICE? bulked pylorus was measured using the
EX-VIVO VALIDATION OF A NEW RABBIT same method as for the normal pylorus.
MODEL FOR PYLORIC STENOSIS Carolyn The balloon catheter was advanced through
T. Cochenour, BS,Timothy Kane, MD, Axel the lumen of the bulked pylori. The balloon
Krieger, PhD, Peter Kim, MD, PhD, Sheikh was inflated to 10atm for approximately
Zayed Institute for Pediatric Surgical 30 seconds, deflated and inflated for a
Innovation, Children’s National Health second cycle. The balloon was deflated
System, Washington, DC, US and removed from the pylori. Flow through
the dilated pylorus was measured using the
AIM OF THE STUDY: Hypertrophic pyloric same method as for the normal pylorus.
stenosis (HPS) is a common foregut The samples were fixed in formaldehyde
obstruction in the neonatal period for 24 hours and embedded in paraffin for
requiring surgery. Laparoscopic or open gross histological analysis. Measured pyloric
pyloromyotomy currently provides emptying times were converted to flow (cc/
effective relief of gastric outlet obstruction. second) and compared in the unbulked state
Both approaches require trans-abdominal (normal), bulked state (simulated-HPS) and
access as well as myotomy which may dilated state (treated HPS) (see Figure 1).
lead to complications associated with the
invasive nature used to treat this condition RESULTS: Flow through the unbulked
such as wound infection, perforation, and samples were 0.24±0.08cc/s (n=5).
hernias. We have specifically designed a Flow through the bulked samples was
novel catheter-based device to isolate and completely obstructed in 3/5 samples
dilate the hypertrophied area in a controlled and slowed the flow to 0.11±0.06cc/s
safe manner using a natural orifice in the other 2 samples (p=0.008). The
transesophageal surgery (NOTES) approach. balloon catheter was able to anchor in
the duodenum while isolating and dilating
In the absence of any clinically relevant the bulked pyloric region. In the dilated
animal model to test the approach, herein samples, flow was restored to 1.48±0.63cc/s
we report a novel ex vivo validation of HPS (p=0.001) (n=5). Figure 1 shows that gross
using a rabbit model. We hypothesize that histology revealed no breach in mucosal
we could create a functional and repeatable or muscular integrity (n=5). No transmural
obstruction as measured by flow in rabbit perforation was noted.
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CONCLUSION: We report a novel NOTES- METHODS & PROCEDURES: This is an IRB
based catheter device for potential approved (FWA00005960) retrospective
treatment of HPS. In addition, we describe analysis of prospectively collected data.
a new clinically relevant rabbit model of All SIPES cases performed at a tertiary
HPS using HA based dermal filler injection children’s hospital from March 2009
creating an effective obstruction of the to December 2013 were included. Our
pylorus mimicking HPS. Ex vivo validation prospective database includes standard
of our approach using the endoluminal demographics, procedure types, operative
catheter resulting in an effective relief of duration, estimated blood loss, instances
pyloric obstruction confirms the potential of added ports or conversion to an open
for our non-invasive approach. procedure, intraoperative and postoperative
complications and duration of follow-up.
Statistical analysis was performed using
JMP® Software.
RESULTS: During the study period, 1322
SIPES operations were performed. Cases
performed were: appendectomy (66.2%),
cholecystectomy (15.9%), pyloromyotomy
(4.3%), splenectomy (3.2%), intestinal
procedure (3.0%), gynecologic operation
(2.7%), inguinal hernia repair (2.6%)
and miscellaneous procedure (2.1%).
Miscellaneous operations included
Nissen fundoplication (N=12), diagnostic
S092: ROUTINE UTILIZATION OF SINGLE- laparoscopy (N=6), laparoscopic assisted
INCISION PEDIATRIC ENDOSURGERY biopsy (N=4), Ladd’s procedure (N=2), hiatal/
(SIPES): A FIVE YEAR INSTITUTIONAL epigastric hernia repair (N=2), duodenal
EXPERIENCE Aaron D Seims, MD, Tate R web resection (N=1) and peritoneal dialysis
Nice, MD, Vincent E Mortellaro, MD, Martin catheter repositioning (N=1). Table 1
Lacher, MD, PhD, Muhammad E Ba'ath, MD, presents data regarding median operative
Scott A Anderson, MD, Elizabeth A Beierle, time, comparative multi-port operative
MD, Colin A Martin, MD, David A Rogers, MD, times, need for additional ports and
Carroll M Harmon, MD, PhD, Mike K Chen, conversion to open for each procedural
MD, Robert T Russell MD, MPH, Children's of category. 871 (66%) patients were seen in
Alabama follow-up, with a median duration of 26
INTRODUCTION: Single-Incision Pediatric days. 53 (6.1%) children experienced post-
Endosurgery (SIPES) is a technical operative complication. 42 (4.8%) of these
innovation that allows procedures to were surgical site infections, of which only
be performed through a single access four required incision and drainage. This
site, which replaces the multiple ports compares favorably to published traditional
traditionally utilized. Large series evaluating laparoscopic wound infection rates of 3-6%.
the versatility of SIPES in the pediatric Less frequent post-operative complications
population are not abundant in the that required operative intervention include
literature. The purpose of this study is recurrent inguinal hernia (N=4), umbilical
to review our long term experience with hernia (N=3), intra-abdominal abscess (N=1),
routine SIPES use. bleeding (N=1), abdominal compartment
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syndrome (N=1), bowel obstruction (N=1), challenge and a further step compared
stitch granuloma (N=1) and pain (N=1). to conventional video assisted therapies.
We report our recent experience with
CONCLUSIONS: SIPES can be safely
the application of SILS technique in IBD
integrated into the routine of a busy
patients.
operative practice for most traditional
multi-port procedures. Operative times MATERIALS & METHODS: Over the last
and complication rates for SIPES are 22 months, 13 procedures were carried
comparable to prior reported multi- out in 5 IBD patients using SILS technique.
port laparoscopic series in the pediatric Demographics, clinical presentation and
population. Future investigations may diagnostic details are briefly described.
need to compare patient satisfaction with In all cases, a preformed SILS port was
cosmesis and differences in post-operative used, inserted into the abdomen through a
pain between SIPES and traditional skin incision of approximately 2.5 cm. The
laparoscopic methods. ileocecal segment in Crohn’s disease (CD)
and the colon in ulcerative colitis (UC) were
mobilized using articulating instruments
and Ligasure ™ device. In all CD patients,
the affected bowel was exteriorized
through the umbilical SILS port to perform
resection, anastomosis and stricturoplasty
when needed. Total colectomy in UC
patients was performed using a SILS access
in the right lower quadrant, employing the
portsite to pack the terminal ileostomy.
During further reconstructive procedures,
the SILS was introduced at the level of the
previous ileostomy to perform dissection
of the rectal stump, J-pouch creation ,
assistance of the ileoanal anastomosis.
Then the SILS access became the site of
protective ileostomy
S093: SILS APPROACH TO INFLAMMATORY
BOWEL DISEASE C laudio Vella, MD, Sara RESULTS: Three males and 2 females, aged
Costanzo, MD, Giorgio Fava, MD, Luciano 7-14 years, were treated, 3 for Crohn’s diseas
Maestri, MD, Giovanna Riccipetitoni, MD, (CD) and 2 for ulcerative colitis (UC). The 3
Pediatric Surgery Department, “V.Buzzi” CD cases presented with ileocecal stenosis,
Children’s Hospital ICP , Milan – Italy in 1 case associated with six further ileal
stenoses. The 2 UC patients presented with
INTRODUCTION: Patients affected by
hemorrhagic colitis resistant to medical
chronic inflammatory bowel diseases (IBD)
treatment. A total of 13 procedures were
may require numerous surgical procedures
performed using the SILS: 4 procedures
during lifetime. For this group of patients,
in UC (2 colectomy + ileostomy and 2 J
laparoscopic surgery represents the gold
pouch ileoanalanastomosis + protective
standard, allowing to perform major
ileostomy), 9 procedures in CD ( 3
procedures with minimal invasiveness
ileocecal resections + 6 stricturoplasties).
and rapid remission. The single incision
The operative time ranged from 180 to
laparoscopic technique (SILS) is the ultimate
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360 minutes. All the SILS procedures METHODS: We performed a retrospective
were completed without conversion. analysis of SIPES appendectomies
No intraoperative nor postoperative performed using the sterilizable
complications occurred. The oral nutrition polyethylene clip applier and compared
started 4 days after surgery in all cases. No them to a same size control group of our
adhesions were detected during procedures most recent stapled appendectomies,
even after colectomy in complicated UC. done before transitioning to the clip
technique. Patient demographics,
CONCLUSIONS: Our preliminary experience
operative time, training level of operating
suggests that the SILS technique can be
surgeon, blood loss, complications, and
safely performed on patients with IBD.
patient outcomes were recorded. We
This approach permits a surprisingly rapid
calculated the cost of the disposable
recovery of the patient with limited pain and
items necessary for an appendectomy
excellent cosmetic results. The laparoscopic
using either the traditional stapler or
approach, avoiding multiple laparotomies,
the novel polyethylene clip method. We
reduces the risk of adhesions, facilitating
also measured the amount of paper,
further surgical procedures if needed.
plastic, and metal trash generated using a
S094: CLIPPED VERSUS STAPLED disposable stapler or polyethylene clips.
SIPES (SINGLE INCISION PEDIATRIC
RESULTS: A total of 20 patients per group
ENDOSURGERY) APPENDECTOMY:
were included. In the clipped group, there
PATIENT OUTCOME, ECONOMIC
were 13 simple, 4 complex, and 3 interval
CONSIDERATIONS, AND ENVIRONMENTAL
appendectomies, and in the stapled group
IMPACT H ayden W. Stagg, MD, Oliver
there were 17 simple, 2 complex, and1
Muensterer, MD, PhD, Samir Pandya, MD,
interval. The average operating time was
Matthew Bronstein, MD, Lena Perger, MD,
51.6 (31-87) minutes in clipped versus 47.4
McLane Children’s at Scott and White,
(26-96) minutes in stapled. All procedures
Texas A&M,Temple TX, USA; Maria Fareri
were performed by general surgery
Children’s Hospital at Westchester Medical
residents (PGY 1-4) and in some cases
Center New York Medical College, Valhalla
included other concomitant interventions
NY, USA
(resection of a vitelline artery, removal
BACKGROUND: In our practice, single- of endometrial implants, mesenteric
incision pediatric endosurgical (SIPES) lymph node biopsy) Mean estimated
appendectomy has been performed with a blood loss (EBL) was 4.3 (0-10) ml, and
linear cutting endosurgical stapler. Recently, mean length of stay (LOS) was 1 (0-6) day
we transitioned to applying a series of in clipped group. In the stapled group
polyethylene clips around the base with mean EBL was 5.2 (2-10) ml, and mean
a reusable, sterilizable clip applier, and LOS was 0.8 (0-3) days. There were no
subsequently cutting the appendix with complications in either group. Between the
endoscopic shears, leaving one to three two institutions involved in the study, costs
clips in situ. for the disposable items were US$ 32 for a
cartidge of 6 polyethylene clips, versus a
OBJECTIVE: This study compares the total of US$ 291-338 for the endosurgical
polyethylene clip technique to stapled stapler (cost saving of US$ 259-306 per
technique in terms of peri-operative case). Using clips generated 0.4g of paper
variables, patient outcome, costs, and and 9.8g of plastic trash, while using the
amount of trash generated. disposable stapler generated 12.9g of
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paper, 381g of plastic, and 582g of metal puncture method. The abdominal inner-
trash (54x more trash than with clips). side tip of shaft is pulled out through the
laparoscopic trocar. And the forceps shaft
CONCLUSIONS: The performance of
of 5 mm in diameter is connected to the
laparoscopic appendectomies with
tip of the shaft and the other outside tip of
polyethylene clips appears just as safe and
the shaft is attached to the handle in the
efficient as using endosurgical staplers, but
operative field. We used Endo ReliefTM
is more economical, and environmentally
in 1 case each of oophorocystectomy,
friendlier.
ovarian hemostasis, splenectomy, and right
S095: INITIAL EXPERIENCE OF hemicolectomy and 4 cases of pediatric
MINIMALLY INVASIVE LAPAROSCOPIC appendectomy in minimally invasive
SURGERY ASSISTED BY PERCUTANEOUS surgery since 2013. A retrospective review of
INSTRUMENTS ASSEMBLED IN chart and Operative reports was performed
OPERATIVE FIELD R yosuke Satake, MD, on all laparoscopic surgeries using Endo
Keisuke Suzuki, MD, Tetsuro Kodaka, PhD, ReliefTM at Saitama Medical University,
Kan Terawaki, PhD, Makoto Komura, PhD, Saitama, in Japan.
Saitama Medical University, Department of
RESULTS: In all cases but the first case, the
pediatric surgery
required time for assembly of instruments
BACKGROUND: Needlescopic surgery is was less than 2 minutes without problem.
defined as minimally invasive surgery with Oophorocystectomy was performed
instruments that are 3 mm in diameter by single-incision laparoscopic surgery
or less and is sometimes referred to as (TANKO) and the percutaneous instrument.
minilaparoscopy. The major limitation of Ovarian hemostasis was performed with
needlescopic surgery is the instruments 2 ports and the percutaneous instrument.
themselves. The strength and durability The instrument was inserted from the
of the instruments may limit tissue lower-side abdomen to reach the ovary.
manipulation. Trocar-less instruments Splenectomy was performed by TANKO
may also be useful to reduce abdominal and the percutaneous instrument. The
trauma. Recently, the US Food and Drug instrument was inserted from the left-
Administration approved the Percutaneous side abdomen to reach the splenic hilum.
Surgical Set (Ethicon), which is designed Right hemicolectomy was performed
to be assembled and disassembled by TANKO and two percutaneous
inside the body with limitations. We used instruments. They were inserted at the
percutaneous instruments assembled in lower abdomen and at the supraumbilical
the operative field for minimally invasive region as grasping forceps for the bowel.
laparoscopic surgery. The Needle Forceps Appendectomy with strong adhesion in
- Endo ReliefTM was made by Hirata the 4 cases was performed by TANKO
Precisions Co., Ltd. and was approved by and percutaneous instruments. Two
the Ministry of Health and Welfare of Japan. percutaneous instruments were inserted in
The purpose of this study was to evaluate 2 cases, and one instrument was inserted
operative outcomes and ergonomics using in the other 2 cases. The instruments
new percutaneous instruments assembled did not malfunction in any operation.
in the operative field. No operation was converted to open
surgery. The strength and durability of the
METHODS: The Endo ReliefTM shaft of percutaneous instruments were sufficient
2.4mm in diameter was inserted by the for tissue manipulation, blunt dissection
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and coagulation. Wound infection at was strong. 91% favour mandatory
the insertion point was not observed in simulator training during surgical
any patient. In addition, the wound by residency and 79% advocate compulsory
percutaneous instruments leaves minimally demonstration of basic competency prior
visible scars. to trainees being allowed to operate on
patients. 76% believe there is a role for
CONCLUSION: Percutaneous instruments
‘take-home’ MIS simulators to be used
could be simply assembled in the
outside normal working hours. Amongst
operative field with safety and certainty.
Pediatric Surgeons these figures were
This instrument had enough force for
95%, 79% and 73% respectively. Access to
grasping tissues and organs. It may make an
simulators was poor however, with only 32%
important contribution to shorten operative
having access to a simulator during working
duration. Also, it ultimately limited tissue
hours, falling to 18% outside working hours
trauma and minimized the visibility of scars.
(Pediatric Surgeons: 42% and 15%).
S096: INTERNATIONAL OPINION ON
The Pediatric Surgery group did not
THE FUTURE OF MINIMALLY INVASIVE
differ significantly from other specialties
SURGERY - FROM A(BESECON) TO
regarding warm-up, SiMIS and Robotic
Z(AGREB) R oland W. Partridge, Paul
surgery, thus these are presented as overall
M. Brennan, Mark M. Hughes, Iain A.
results. ‘Informal mental’ warm-up, such as
Hennessey, Royal Hospital for Sick Children,
thinking though the steps of an operation,
Edinburgh, UK, Alder Hey Children’s
is practiced by 79%. 22% regularly perform
Hospital, Liverpool, UK
a ‘formal mental’ warm-up, eg. revising a
AIMS: Minimally Invasive Surgery (MIS) procedure on a smartphone application.
is now performed worldwide. This study 13% practice ‘informal physical’ warm-up,
quantifies the use of simulators, pre- eg. placing a smaller case on a list before
operative ‘warm-up’, single incision MIS a major MIS procedure, and 5% regularly
(SiMIS) and robotic MIS in Pediatric Surgery perform ‘formal physical’ warm-up eg.
and other surgical specialties globally. using a MIS simulator prior to an operating
list. Significantly, 83% stated they would use
METHOD: An online survey was a MIS simulator to warm-up before some or
generated using a web-based survey all cases if they had regular access to one.
tool (SurveyGizmo.com, Survey Gizmo,
Boulder, USA). The authors invited contacts 44% have SiMIS equipment in their
they have establish on the ‘professional department but it is used infrequently, with
media’ network LinkedIn.com (LinkedIn only 13% having performed more than 25
Corporation, California, USA).A total of 1314 SiMIS cases in their careers to date. Only
operating clinicians throughout the world 25% have access to Robotic MIS equipment
were contacted. and just 7% have performed more than
25 Robotic MIS cases in their career so far.
RESULTS: 257 responses were received from There was greater enthusiasm for Robotic
145 different cities ranging alphabetically MIS than SiMIS, with 49% (vs SiMIS: 42%)
from Abesecon to Zagreb and spanning 63 hoping to undertake more of this type
countries. 25% were Pediatric Surgeons. of MIS in the future. Perceived risks and
The responders are an experienced group benefits of robotic and SiMIS are reported.
(86% fully qualified specialists) with 63%
performing more than 50 MIS cases per CONCLUSION: This study provides a unique
year. Support for the use of MIS simulators international perspective, presenting a
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snapshot of the current global ‘state- (42%), right sided hernia (15%), liver in chest
of-the-art’ of minimally invasive surgery (32%), weight < 2.5kg (35%), and persistent
and surgeons’ aspirations for the future. R-to-L shunting (50%). 72% of participants
It demonstrates that the global use of indicated that recent reports on significant
simulators, pre-operative ‘warm-up’, hypercapnia and severe acidosis during
single incision MIS (SiMIS) and robotic thoracoscopic CDH repair have changed
MIS in Pediatric Surgery is similar to that their management. 52% of participants
in other surgical specialties worldwide. It said that during thoracoscopy they would
highlights strong support for the use of MIS tolerate any pH. In contrast, 48% indicated
simulators, but that access to these devices that they would only tolerate pH/pCO2
remains poor. levels down/up to 7.2/80mmHg (range
pH:6.9-7.3; pCO2:55-100mmHg). In cases
S097: THORACOSCOPIC CDH REPAIR – A
where a patch is needed 39% of participants
SURVEY ON OPINION AND EXPERIENCE
said they would continue thoracoscopically,
AMONG IPEG MEMBERS Martin Lacher MD,
31% would convert and 31% stated that
PhD, Shawn D St. Peter MD, Paolo Laje MD,
the decision would be based on the size
Benno M Ure MD, PhD, Caroll M Harmon
of the defect. In case of conversion, 26%
MD, PhD, Joachim F Kuebler MD, Hannover
would convert to thoracotomy and 74% to
Medical School (on behalf of the IPEG
laparotomy. 56% of participants reported
Research Committee)
recurrences after thoracoscopic repair. Of
BACKGROUND: Thoracoscopic repair of the last 5 thoracoscopic CDH repairs of each
congenital diaphragmatic hernia (CDH) has participant, the following recurrence rates
become popular among pediatric surgical were reported: 0/5 (44%), 1/5 (35%), 2-4/5
centers. Given the fact that there is an (6%), 5/5 (none). Recurrences occurred
ongoing discussion on whether the benefits early (less than 6 months after surgery) in
of the thoracoscopic repair outweigh 43% of the cases, late (more than 6 months
the potential side effects, we aimed to after surgery) in 37%, and early AND late in
investigate the opinion and experience of 20% of the cases. Overall, 50% of surgeons
the members of IPEG on this topic. stated that CDH can be repaired equally by
thoracoscopy and open thoracotomy and
METHODS: An online based survey was 50% disagreed with this statement.
conducted between 10/2013 a 12/2013 on
behalf of the IPEG Research Committee. CONCLUSION: Thoracoscopic CDH repair
All IPEG members were contacted is currently being performed by 89% of
by email and asked to complete an all participating IPEG members. ECMO (at
anonymous questionnaire that included the time of surgery or prior to the surgery)
personal background and 28 items on the and persistent R-to-L shunting are the
management of CDH. Trainees/fellows were main contraindications to thoracoscopic
excluded from the study. repair. CDH recurrence after
thoracoscopic repair has occurred to 56%
RESULTS: 159 attending pediatric surgeons of participants at least once. The fact that
(consultants), who perform thoracoscopic only 50% of surgeons stated that CDH
CDH repair routinely (40%), occasionally can be repaired equally by thoracoscopy
(49%), or never (11%), completed the and open surgery suggests that future
questionnaire. Contraindications to studies should focus on identifying the
thoracoscopic repair included: patient on appropriate patient population.
ECMO (78%), preoperative need for ECMO
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Video Abstracts
V001: LEFT UPPER LOBECTOMY FOR V002: THORACOSCOPIC DIVISION
CPAM USING A 3MM TISSUE SEALING OF H-TYPE TRACHEOESOPHAGEAL
DEVICE; A STEP BY STEP APPROACH FISTULA M atthew S. Clifton, MD, Paul M.
Stephen Oh, MD, Steven S Rothenberg, Parker, MD, Emory University/Children’s
MD, The Morgan Stanley Children’s Healthcare of Atlanta
Hospital, Columbia University
INTRODUCTION: H-type
PURPOSE: This video demonstrates a tracheoesophageal fistula repairs have
step by step method for performing a historically been approached from
thoracoscopic lobectomy in an infant. The either a low cervical or high thoracic
anterior approach and the use of a 3mm incision, both of which are associated
tissue dissector/ vessel sealer facilitates with attendant problems. Chief amongst
the case in the small chest cavity of an these is adequate identification and
infant. isolation of the fistula; it is commonly
located at the level of the thoracic inlet.
METHODS: A 3 month old female with
The thoracoscopic approach provides a
a pre-nataly diagnosed LUL CPAM
magnified, improved view of the relevant
underwent elective left upper lobectomy.
anatomy, and pulls the operative field to
The procedure was performed through 3
a site remote from the recurrent laryngeal
trocars, a 4mm for the 30 degree 4mm
nerve.
telescope and 2 -3 mm ports. One of the
3mm ports was changed top a 5 mm port RUN TIME: 4 minutes 54 seconds
at the end of the procedure to apply a
METHODS: A 3 day-old 2.2 kg baby girl was
5mm clip to the bronchus and remove the
referred for repeated coughing with feeds
specimen. The 3 mm sealer was used to
and an esophagram which demonstrated
dissect out and seal all pulmonary vessels
an H-type tracheoesophageal fistula.
as well as complete the major fissure.
Echocardiogram identified an atrial
RESULTS: The procedure took 65 minutes. septal defect. In the operating room, rigid
There were no failed seals, no intra- bronchoscopy showed a normal airway
operative bleeding, and no airleak post- with the exception of a fistula in the
operatively. The chest tube was removed posterior wall of the trachea; a #3 Fogarty
on day 2 and the patient was discharged balloon catheter was inserted through
on day 3. the fistula and the balloon inflated.
Traction on the catheter wedged it into
CONCLUSIONS: The use of the anterior
the esophageal lumen at the position of
approach and a 3mm sealer allows for
the fistula. Flexible bronchoscopy was
safe and effective lobectomy, even in
used to perform a left mainstem bronchus
the small chest cavity of an infant. The
intubation. The child was positioned in
anterior approach provides the greatest
an exaggerated left lateral decubitus
space between the instrument insertion
position. A right thoracoscopic approach
and the mediastinum. The 3 mm sealer
was used with 3mm equipment. Dissection
works more efficiently and ergonomically
commenced cephalad to the azygous vein,
in this small cavity then previously used
below the level of the fistula. The position
5mm devices, improving the ease of the
of the Fogarty balloon in the esophagus
operation.
was identified and followed to isolate
the fistula. The fistula was isolated with a
silicone vessel loop and then the Fogarty
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Video Abstracts CONTINUED

withdrawn. The tracheal side of the fistula METHODS: The patient is a 9 month-old
was closed with two 5mm Hem-o-lok female who presented to the Emergency
clips, the esophageal side tied off with size Department with progressive stridor for
0 braided absorbable suture twice, and 3 weeks. Her symptoms did not improve
the fistula divided. At the completion of despite trying a regimen of antibiotics
the operation, an 8 French feeding tube and steroids. A chest Xray and neck Xray
was guided through the esophagus and a showed significant tracheal deviation.
12 French chest tube placed into the right Bronchoscopy revealed tracheal
hemithorax. compression by an external source. CT
scan confirmed a mass at the thoracic
RESULTS: Operative time for
inlet.
thoracoscopic division of the H-type
tracheoesophageal fistula was 90 RESULTS: The decision was made to
minutes. Nasogastric feeds were approach the mass thoracoscopically. One
initiated with return of bowel function. 5mm port was used for the camera, one
An esophagram on postoperative day 5 mm port, one 3 mm port, and one 3
7 showed no leak and no stricture. Oral mm stab incision were used for exposure
feeds were started and the thoracostomy and dissection. Upon placing the camera
tube removed. Repeat esophagram at 14 in the chest, a bulge from the cyst was
months showed no evidence of stricture. seen lying posterior to the subclavian
vessels and anterior to the aorta. Once
CONCLUSION: We demonstrate the
the cyst was exposed, a combination of
thoracoscopic approach to repair of
blunt and sharp dissection was performed
an H-type tracheoesophageal fistula.
to mobilize the cyst. The cyst was
This approach utilizes placement of an
decompressed to ease the dissection. As
intraluminal balloon catheter to identify
medial dissection of the cyst proceeded,
the location of the fistula. Caudal
attachment to the cricopharyngeus
traction on the fistula down into the
muscle was visualized. Dissection
chest minimizes the risk of injury to the
proceeded through a translucent plane
recurrent laryngeal nerve.
between the cyst and the esophagus until
V003: THORACOSCOPIC RESECTION the cyst came off of it completely. Once
OF A BRONCHOGENIC CYST LOCATED the cyst was removed, the trachea and
AT THE THORACIC INLET M eghna V. the esophagus were clearly seen at the
Misra, MD, Tulio Valdez, MD, Anthony medial dissection plane. These structures
Tsai, MD, Brendan T. Campbell, MD, MPH, appeared grossly intact.
Connecticut Children’s Medical Center CONCLUSION: The patient did well
BACKGROUND: Bronchogenic cysts are overall postoperatively. Her course was
a type of foregut duplication cyst. They complicated by development of an
can appear in several different locations asymptomatic esophageal diverticulum
in the mediastinum. Controversy exists and a left recurrent laryngeal nerve traction
over the best method by which to excise injury. She recovered from both of these
cysts that are located at the thoracic inlet. injuries completely. Complete thoracoscopic
This is the first case report on complete excision of bronchogenic cysts at the
thoracoscopic excision of a bronchogenic thoracic inlet can be performed safely.
cyst located at the thoracic inlet. However, complications can happen with
any type of resection that is performed at
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this location. Expectations should be set TIPS: Its possible to apply the
accordingly with family members regarding thoracoscopic approach in the treatment
possible complications. of recurrent fistulisation after TEF repair.
The use of a mesh or a tissue to separate
V004: THORACOSCOPIC APPROACH IN
the esophagus from the trachea is highly
RECURRENT TRACHEOESOPHAGEAL
recommended.
FISTULA R uben Lamas-Pinheiro, MD,
Carlos Mariz, MD, Joaquim Monteiro, V005: A THORACOSCOPIC APPROACH
MD, Tiago Henriques-Coelho, MD, PhD, TO AN UNUSUAL MEDIASTINAL MASS
Pediatric Surgery Department, Faculty Victoria K. Pepper, MD, Peter C. Minneci,
of Medicine, Hospital de São João, Porto, MD, Karen A. Diefenbach, MD, Nationwide
Portugal Children’s Hospital
INTRODUCTION: Recurrent fistulisation PURPOSE: We present a thoracoscopic
after tracheoesophageal fistula (TEF) resection of an unusual mediastinal cystic
repair can be a complication of difficult mass in a 2-year-old boy.
management. There is very few data on
METHODS/FINDINGS: A previously-
thoracoscopic reintervention. The authors
healthy 2-year-old male presented to
present a video of a thoracoscopic
the emergency room with cough. On
approach in a recurrent fistula after TEF
chest x-ray, he was found to have a
repair by thoracotomy.
mediastinal widening and subsequent
CASE: A child with 20 months of life was chest CT revealed a cystic mediastinal
diagnosed with a recurrent fistula by mass. The patient was taken to the OR
bronchoscopy. The boy had a history of for thoracoscopic excision. A 5-mm port
recurrent respiratory symptoms after a was inserted in the mid-axillary line.
surgical correction of esophageal atresia Two 5-mm ports were placed in the 4th
with TFE by thoracotomy. A right side and 8th intercostal spaces. Although
thoracocopy was performed: three trocars pre-operative imaging suggested a
were used (two 5mm and one 3mm). thymic cyst, the thymus was visualized
Right upper lobe adhesions from previous and no mass was associated with it.
surgery were divided with electrocautery. Inspection revealed that the mass
The azygus vein was identified and was intrapericardial. After opening the
preserved. The TEF was identified just pericardium, the mass was noted to be
above the azygus vein, dissected and adherent to the aortic root. It was freed
isolated, two titanium clips were applied from the aorta with careful dissection. The
and the fistula was then divided. The patient did well post-operatively and was
clips were reinforced with endoloops®. A discharged home on post-operative day 3.
prolene® mesh was interposed between Final pathology revealed a mature cystic
the trachea and the esophagus. There teratoma.
were no postoperative complications.
CONCLUSION: While intrapericardial
The nasogastric tube was removed in
teratomas are rare, they should be a
the first postoperative day and the child
part of the differential in an abnormally
was discharged in the second day after
presenting anterior or middle mediastinal
starting oral feeding. Currently, the child
mass. While care must be taken both
is followed in outpatient clinic and he is
with patient selection and intraoperative
otherwise healthy.
management, thoracoscopic resection
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of these lesions is feasible, and has the RESULTS: The procedure was
potential benefits of smaller incisions, well tolerated by the patient, and
less post-operative pain, a shorter length hemodynamics improved immediately.
of stay, and a quicker return to normal The operative time was 36 minutes and
activity. blood loss was minimal. The chest tube
was removed on postoperative day 8,
V006: THORACOSCOPIC PERICARDIAL
at which time the cardiac silhouette
WINDOW FOR TREATMENT OF
had normalized (Figure C). A chest CT
REFRACTORY PERICARDIAL EFFUSION performed one month later for worsening
AND TAMPONADE O liver J. Muensterer, pulmonary status showed no recurrent
MD, PhD, Samir Pandya, MD, Matthew pericardial or pleural effusion (Figure D).
E. Bronstein, MD, Gustavo Stringel, MD,
Suvro S. Sett, MD, Divisions of Pediatric CONCLUSIONS: Pericardial windows can
Surgery and Pediatric Cardiac Surgery, be performed safely via a thoracoscopic
New York Medical College approach in children with symptomatic
chronic pericardial effusions. The
BACKGROUND: Chronic pericardial procedure is simple, quick, and normalizes
effusions may present with a spectrum cardiac function immediately. The surface
of symptoms. When the volume of fluid area of the pleura seems to be adequate
in the pericardium increases briskly, it for resorption of the pericardial fluid in
may compromise cardiac function. In this case.
such cases, urgent pericardiocentesis for
short term management is indicated. A V007: COMBINATION OF VALUABLE
more permanent solution is the creation TECHNICAL RESOURCES FOR THE
of a pericardial window. In children, this is CORRECTION OF DIAPHRAGMATIC
mostly performed through a subxiphoid HERNIA (VIDEO) C arolina Millan, MD,
open approach. Fernando Rabinovich, MD, Luzia Toselli,
MD, Horacio Bignon, MD, Gaston Bellia,
OBJECTIVE: We describe a thoracoscopic
MD, Mariano Albertal, MD, Guillermo
technique for creation of a pericardial
Dominguez, MD, Marcelo Martinez Ferro,
window in a toddler.
MD, Private Children’s Hospital of Buenos
CASE: A 2 year old girl with Down syndrome Aires, Fundación Hospitalaria, Buenos
with acute myeloid leukemia treated Aires, Argentina
with bone marrow transplant developed
The surgical management of anterolateral
a large, chronic pericardial effusion as a
diaphragmatic hernia can pose a
result of graft-versus host disease (Figure
challenge to surgeons. In this video we
A). Several attempts of ultrasound-guided
shown several technical resources used to
pericardiocentesis were performed, with
overcome limitations during laparoscopic
re-accumulation of the fluid and signs
correction of a left anterolateral
of cardiac tamponade within a few days.
diaphragmatic hernia.
After stabilization, she was taken to the
operating room where a pericardial window
anterior to the right phrenic nerve was
created thoracoscopically using ultrasound
shears (Figure B). An 8F Jackson-Pratt drain
was placed as a chest tube.
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V008: THORACOSCOPIC MANAGEMENT V009: TRANSCONTINENTAL
OF AN ESOPHAGEAL LUNG, REPORT TELEMENTORING WITH PEDIATRIC
OF A CASE I van Dario Molina, MD, SURGEONS- PROOF OF CONCEPT AND
Santiago Correa, MD, Ana Garces, MD, TECHNICAL CONSIDERATIONS T odd A.
Mizrahim Mendez, MD, Edgar Alzate, MD, Ponsky, MD, Marc H. Schwachter, MD, Ted
Fundación Hospital de la Misericordia, Stathos, MD, Michael Rosen, MD, Robert
Universidad Nacional de Colombia Parry, MD, Margaret Nalugo, Steven
Rothenberg, MD, Akron Children’s Hospital,
Esophageal lung is a rare
Rocky Mountain Hospital for Children,
broncopulmonary foregut malformation,
University Hospitals Case Medical Center
in which the main stem bronchus arises
from the esophagus. Since the description New skill acquisition poses a challenge
by Keely et al. in 1960, less than 20 for post-graduate practicing surgeons.
cases have been reported. We present Current methods for skill acquisition
a case of a 4-month-old female, who include practicing on simulation models
was referred to our institution after 2 and attending courses. However, these
months of management for respiratory are probably not adequate for true skill
recurrent infections. Contrast studies acquisition. The true skill acquisition
were performed during the evaluation model for postgraduate surgeons most
and a right broncography was identified likely involves developing a relationship
in the esophagogram. Bronchoscopy was with an expert in which the mentee visits
performed confirming the atresic right the mentor and vice versa. However,
bronchus. Complementary imaging and for this to be realistic there must be
cardiology evaluation confirmed the ongoing mentorship which can only
absence of major vascular anomalies, be accomplished realistically with
especially a pulmonary artery sling that Telementoring. The concept of Tele
has been described in relation with this mentoring has been discussed and even
entity. Due to the hypoplastic lung in the piloted in other areas of medicine. Here
absence of major vascular anomalies, we show proof of concept and technical
thoracoscopic pneumonectomy was considerations for Telementoring in
deemed possible. Procedure was pediatric surgery. We describe the logistics
performed with four ports and 3 mm and technical details of six transcontinental
equipment was used. Special attention pediatric surgery telemonitoring cases
was made identifying and dissecting between an expert in the less experienced
the vascular structures first, and then pediatric surgeon.
the arising esophageal bronchus was
dissected. The hypoplastic lung was V010: VAGINAL AGENESIS AND ATRESIA
extracted through a small incision inferior OF THE UTERINE CERVIX ASSOCIATED TO
to the axilla. As for our knowledge this is VESTIBULAR FISTULA Maria M. Bailez, MD,
the first case reported of thoracoscopic Lucila Alvarez, MD, Garrahan Children’s
management of this pathology, and we Hospital, Buenos Aires, Argentina
consider that due to the hypoplastic lung Uterovaginal anomalies are a spectrum of
and vessels, the thoracoscopic approach anomalies, which are often associated with
is safe and feasible for the management renal and sometimes anorectal anomalies.
of the esophageal lung and even for de
esophageal bronchus in the absence of AIM: Show a succesful staged laparoscopic
major vascular anomalies. treatment of a patient previously
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operated for an ARM with a non diagnosed entity. It is often associated with
associated vaginal agenesis and atresia of absence of the vagina. Although there
the uterine cervix. is general agreement that if the cervix
is absent, without any cervical stroma,
CASE: A 13 years old female presented
hysterectomy is advisable to prevent
with severe acute pelvic pain .She had
ovarian endometriosis and pelvic
undergone an anorectoplasty through a
infections, preservation of the uterus
posterior sagital approach for a vestibular
may be intented in selected patients.We
fistula at the age of 2. She had never had
have previously treated 4 patients with
menses yet. No vaginal opening was found
vaginal associated to cervix agenesis using
at perineal exam. Ultrasonography showed
a combined laparoscopic and perineal
an hematomethra and a left complex
approach Laparoscopy was useful to
adnexal mass. An initial laparoscopic
define the anomaly and to complete
approach showed a single uterus with
hysterectomy after the evidence of total
an hematomethra and a left ovarian
cervix aplasia and to perform a sigmoid
endometrioma that was removed. With
vaginal replacement. This is our first
no evidence of associated hematocolpos,
patient undergoing a long term successful
a cervical atresia associated to vaginal
laparoscopic assisted sigmoid vaginal
agenesis was suspected and a drain
replacement, cervical canalization and
was placed in the fundus . Menses were
uterovaginal anastomosis even after
inhibited using , allowing psycological
previous abdominal and perineal surgery
support .An MRI confirmed atresia of
(sigmoid colostomy and PSARP).
the cervix. A combined laparoscopic and
perineal approach to enable sigmoid 2) The diagnosis of a uterovaginal anomaly
vaginal replacement,cervical canalization is a common misleading finding in patients
and a uterovaginal anastomosis followed. with vestibular fistula . A meticulous
perineal exam is mandatory in newborns
Three working ports were used . Bowel
with this anomaly to plan combined vaginal
adhesions secondary to colostomy take
and anorectal reconstruction avoidiing
down were freed . A 15 cm long distal
redo surgery and sequela related to
sigmoid was isolated. Dissection between
obstructive functional mullerian ducts
theurethra and rectum followed.Linear
q.We have previously reported a combined
staplers were inserted from this approach
endoscopic and laparoscopic initial
to transect the colon.The uterine cervix area
assesment as a less invasive and time
was dissected preserving its vascular supply.
consuming approach for atypical ARM like
Recanalization of its lumen was achieved.
the one presented.
Enlarging the suprapubic port entry was
used to facilitate suturing of the proximal V011: ENDOSCOPIC GASTROCUTANEOUS
end of the neovagina around the cervix. FISTULA CLOSURE USING AN OVER THE
SCOPE CLIP James Wall, MD, MS, Lucile
RESULTS: Operative time was 210 minutes.
Packard Children’s Hospital Stanford
The patient presents irregular menses
without clinical and ultrasonographic BACKGROUND: Gastrocutaneous fistula
evidence of infection or obstruction after a closure is commonly required for long-
38 months follow up period term gastrostomy sites. Standard surgical
repair can be complicated in cases of
DISCUSSION: 1) Agenesis or atresia
local skin excoriation or extensive prior
of the cervix uteri is an uncommon
abdominal operations. Endoscopic
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methods have been described for INTRO: This video demonstrates the
closing a variety of enteric fistulas. laparoscopic resection of a neuroendocrine
Shape memory metal (Nitinol) clips that tumor of the common bile duct (CBD) with
fit over an endoscope have recently a hepaticoduodenostomy
been approved for several endoscopic
METHODS: A 15 year old female presented
purposes including closure of the
with evidence of acute cholangitis and
intestinal wall. Such over the scope clips
evidence of biliary obstruction. Total
enable circumferential closure of larger
bilirubin was 2.4 and an ultrasound showed
defects than standard endoscopic clips
a markedly dilated common hepatic
passed through the working channel.
duct and a question of a large intra-
METHODS: We report a series of 4 hepatic stone. An ERCP was performed
patients who underwent endoscopic and the obstructing mass was found to
gastrocutaneous fistula closure using be extra-luminal. A transductal biopsy
gold probe cauterization of the fistula failed to obtain tissue for diagnosis. An
tract followed by placement of an over intraductal stent was placed to relieve the
the scope clip. Ages ranged from 6 to obstruction. A CT scan was obtained and
21 years old. The patients were selected showed a 2.5 x 2.5 x 2.4 mass adjacent to
for this intervention based on persistent and compressing the CBD. A laparoscopic
skin excoriation around the fistula site biopsy was performed for diagnosis
or history of extensive prior abdominal primarily to rule out lymphoma.
operations.
A laparoscopic resection was then
RESULTS: The procedure was technically performed using 3 - 5mm ports. The
feasible in all cases with an average specimen was removed thru an enlarged
operative time of 18 minutes. There were umbilical incision intact inside a specimen
no failures at 1-month follow-up. One bag. Proximal and distal margins were
patient reported mild throat pain for 2 checked for tumor by frozen section.
weeks following the procedure.
A hepaticoduodenostomy was then
CONCLUSION: Endoscopic performed to reconstruct the bile drainage
gastrocutaneous fistula closure using over system.
the scope clips is technically feasible in the
RESULTS: The surgery was completed
pediatric population with promising initial
successfully laparoscopically in 140
results. The size of the current endoscopic
minutes. The patient was started on po
caps required to deliver these clips may
feeds on the 4th post-operative day and
not be suitable for very small children. The
discharged on day 5. The final pathology
existing caps may additionally contribute
showed a Grade 1 neuroendocrine
to oropharyngeal trauma resulting in post-
neoplasm with papillary features. There
operative dysphagia.
was no evidence of local or distant
V012: LAPAROSCOPIC RESECTION invasion.
OF A NEUROENDOCRINE TUMOR
At 2 week follow-up all lab values had
OF THE COMMON BILE DUCT WITH
returned to normal. A complete metastatic
HEPATICODUODENOSTOMY S teven S.
work-up was negative.
Rothenberg, MD, The Rocky Mountain
Hospital For Children CONCLUSION: This case presents a rare
finding of a primary bile duct tumor.
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Laparoscopy was a safe and effective entrance from the vertebral column. The
technique for resecting the tumor infraumbilical port site was changed to
and avoided the morbidity of a large a 10mm trocar and an EndoCatch bag
laparotomy without compromising the was inserted. The specimen was placed
cancer operation. into the bag, morcelated sharply, and
brought out in a piecemeal fashion. The
V013: LAPAROSCOPIC RESECTION
patient did well post-operatively and
OF A LARGE RETROPERITONEAL
was discharged home on POD # 3 with
GANGLIONEUROMA B ethany J. Slater, no complications. The final pathology
MD, Steven S. Rothenberg, MD, Rocky revealed ganglioneuroma, and no further
Mountain Hospital for Children treatment was required.
A 4 year old female presented with V014: LAPAROSCOPIC LEFT PARTIAL
recurrent UTIs. An ultrasound was ADRENALECTOMY IN A CHILD WITH
obtained for workup and demonstrated
VON HIPPEL-LINDAU AND RECURRENT
a 5 cm mass solid mass near the porta
PHEOCHROMOCYTOMA A. B. Podany,
hepatis. A subsequent MRI showed
MD, A. Dash, MD, D. V. Rocourt, MD,
a 5.8x4.9x4.8 cm heterogenous
Pennsylvania State Hershey Medical
retroperitoneal mass compressing
Center
the inferior vena cava and displacing
the second and third portions of the PURPOSE: Patients with Von Hippel-
duodenum. Laboratory values were Lindau are at high risk of developing
unremarkable. A laparoscopic biopsy of recurrent pheochromocytoma. In this
the mass was performed with pathology 13 year-old patient status post right
consistent with a ganglioneuroma. adrenalectomy with recurrence on the
MIBG scan confirmed the localized left, we hypothesized that a laparoscopic
mass with no evidence of metastatic left partial adrenalectomy would be safe
disease. The patient was then taken to and effective at removing the tumor,
the operating room for laparoscopic while preserving native adrenal function.
resection of the retroperitoneal tumor.
METHODS: Though asymptomatic,
A 4 mm infraumbilical trocar was used
due to the patient’s prior history of
for the camera, and a 3mm trocar in the
pheochromocytoma, preoperative alpha
right mid quadrant and 5 mm trocar in
blockade was undertaken. He presented
the left mid quadrant were inserted.
electively on the day of surgery and
The gallbladder was retracted superiorly
underwent a laparoscopic left partial
with a suture through the abdominal
adrenalectomy. Key portions of the
wall. The transverse colon was mobilized
procedure include mobilization of the
inferiorly. The duodenum, which was
splenic flexure, circumferential dissection
densely adherent to the tumor, was
of the tumor with preservation of the
dissected medially. The tumor was
renal vein, renal artery, and the adrenal
then carefully mobilized from the
vein, and separation of the tumor from
surrounding tissues including the inferior
normal residual adrenal gland.
vena cava. There was a feeding vessel
from the inferior vena cava which was RESULTS: Final pathology demonstrated
sealed and divided using the Ligasure complete resection and was consistent
device. There were also two nerve roots with a 2.6x2.3x1.9 cm pheochromocytoma
identified which were divided near their with intact capsule. Postoperatively,
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the patient recovered well, with no ERCP. On MRCP, she was found to have
complications and no requirement for a diffusely dilated main pancreatic duct
cortisol replacement. He was discharged (6-9 mm) distal to a large stone which
home on postoperative day number two. was located at a strictured area of the
He will continue to be followed by his main pancreatic duct. The accessory duct
endocrinologist for annual screening. was draining the uncinate process and
non-dilated. ERCP was performed and
CONCLUSIONS: The technique for
small pancreatic stone fragments were
laparoscopic partial left adrenalectomy
removed but the large stone could not be
described here has utility in the pediatric
accessed. She was referred for operative
population to preserve adrenal function
intervention.
during years of growth. Patients with
Von Hippel-Lindau are at high risk RESULTS: At 4 years 9 months of age,
of recurrence and need continued the child underwent a laparoscopic
surveillance. This patient will continue to cholecystectomy, pancreatic duct
benefit from preserved native adrenal stone clearance, and Roux-en-Y
function for months to years before pancreaticojejunostomy (Peustow)
potential recurrence. anastomosis. The child weighed 17.9
kg at the time of operation which took
V015: LAPAROSCOPIC LATERAL
235 minutes and there were no intra-
PANCREATICOJEJUNOSTOMY- PEUSTOW
operative complications. This video shows
PROCEDURE- IN A 4 YEAR OLD WITH the Peustow portion of the procedure.
PANCREATIC DUCTAL OBSTRUCTION Five trocars were used. One 12 mm trocar
Miller Hamrick, MD, Mikael Petrosyan, in the umbilicus; and 4 x 5mm trocars
MD, Eric Jelin, MD, Timothy D. Kane, MD, in the left upper abdomen, left lower
Children’s National Medical Center abdomen (periumbilical), right upper
BACKGROUND: Pancreatic ductal quadrant, and right lateral abdomen
obstruction leading to ductal dilation (periumbilical). The lesser sac was
and recurrent pancreatitis is uncommon entered after taking down the gastrocolic
in children. This is a video of a 4 year old omentum and utilizing trans-abdominal
girl who presented at 10 months of age stay sutures to elevate the stomach
with high grade duodenal obstruction, anteriorly to expose the pancreas. A 10
gastric pneumatosis, pneumobilia, and mm laparoscopic ultrasound probe was
gas within a dilated pancreatic duct used to identify the main pancreatic
on abdominal computed tomography duct and cautery used to perform the
scan with presumed annular pancreas pancreatotomy. A 3 cm longitudinal
or pancreatic head enlargement or incision in the pancreatic duct was created
mass. At that time, she had undergone and duct was irrigated clear of debris
a laparoscopic duodenoduodenostomy and protein plugs. A 3 French Fogarty
and had symptomatic relief for 2 years. catheter was used to remove the large
She returned at 3 years of age with stone from the proximal duct. A Roux-
pancreatitis on 3 separate occasions, en-Y jejunojejunostomy was created 20
once requiring hospital admission. At 4 cm from the ligament of Treitz extra
years of age, she had 3 more episodes corporeally using an endostapler and the
of pancreatitis and was admitted to Roux loop limb was passed retrocolic
undergo magnetic resonance imaging into the lesser sac. Stay sutures and a
cholangiopancreatography (MRCP) and running 4-0 PDS non-absorbable suture
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were used to complete the side to side performed. At 13 months of age, after
pancreaticojejunostomy anastomosis. A having accomplished adequate anal
drain was left in the lesser sac. dilations, a colostomy takedown was
performed. However, four weeks later,
CONCLUSION: Indication for lateral
the patient was noted to be passing
pancreaticojejunostomy or Puestow
stool per vagina as well as per rectum.
procedure is rare in children and even
She was taken back to the operating
less often performed using laparoscopy.
room where a rectovaginal fistula was
The use of laparoscopic ultrasound was
again identified within the introitus, and a
critical in identifying the dilated pancreatic
diverting colostomy was re-established.
duct and enabled the performance of
A subsequent postoperative contrast
the procedure. Only 4 other laparoscopic
enema also visualized the fistula. At 18
Peustow procedures have been reported
months, the patient returned to the OR
in children (ages 6-12), in addition to 1
for a planned ligation of the rectovaginal
robotic-assisted Puestow operation in a
fistula via a posterior sagittal approach.
14 year old. The rarity of this anomaly as
In the prone position, the fistulous
well as the complexity of performing the
connection could not be identified. Thus,
operation laparoscopically likely impacts
a laparoscopic exploration was performed
this observation.
whereupon a colorectal duplication with
V016: LAPAROSCOPIC CORRECTION two distinct blood supplies, starting
OF COLORECTAL DUPLICATION AND approximately 4 cm distal to the mucus
VAGINOPLASTY K anika A. Bowen, MD, fistula, was identified. One lumen
Kevin Platt, BS, Alli Wu, BS, Kasper Wang, communicated with the vagina and the
MD, Children’s Hospital of Los Angeles other lumen connected to the anus.
Proximally the two lumens coalesced
INTRODUCTION: Tubular colorectal to form a single lumen just distal to the
duplications are rare congenital anomalies mucus fistula. The rectovaginal fistula was
with widely varied presentations. These divided laparoscopically. The duplicated
anomalies are often misdiagnosed lumens were made into a single channel
until discovered intra-operatively. by using a laparoscopic stapler passed
Here, we present a case of an unusual distally through the mucus fistula under
colorectal duplication which we repaired laparoscopic guidance, and the PSARP
laparoscopically. was revised. A subsequent postoperative
CASE DESCRIPTION: An 8-month-old contrast enema demonstrated no leak.
girl with a suspected cloaca, status CONCLUSION: An imperforate anus with a
post creation of a diverting colostomy colorectal duplication terminating in dual
and mucus fistula was referred from rectovaginal fistulae has not previously
an outside hospital. The child also had been reported. This case illustrates
an associated cleft lip/palate, a small the difficulty in diagnosing colorectal
ventricular septal defect, and hydroureter. duplications and the utility of laparoscopy
On physical examination, the patient in the treatment of these duplications.
was thought to have an imperforate
anus with a rectovestibular fistula. In the
operating room, a rectovaginal fistula
was instead identified, and a posterior
sagittal anorectoplasty (PSARP) was
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V017: LAPAROSCOPIC PROPHYLACTIC The duodenocolic ligament was incised,
TOTAL GASTRECTOMY IN CHILDHOOD and the first portion of the duodenum was
FOR THE PREVENTION OF HEREDITARY cleared circumferentially and transected
DIFFUSE GASTRIC CANCER B enjamin 2 cm distal to the pylorus. The right and
Zendejas, MD, MSc, Abdalla E. Zarroug, left gastric vessels were divided. The
MD, Michael L. Kendrick, MD, Department gastroesophageal junction was cleared
of Surgery, Mayo Clinic, Rochester, MN, circumferentially. An esophagogastroscopy
USA was performed to localize and mark
the Z-line and the distal esophagus was
INTRODUCTION: Mutations in the divided with a stapler. A Roux limb was
E-cadherin (CDH1) gene confer an created dividing the proximal jejunum 50
80% lifetime risk of hereditary diffuse cm distal to the ligament of Treitz. A 150-
gastric cancer (HDGC).1Due to unreliable cm limb was measured, and a side-to-side
screening modalities, prophylactic total enteroenterostomy was created with a
gastrectomy (PTG) is recommended for linear stapler. A window was made in the
individuals at risk for HDGC.2-3Due to left mesocolon, and 20-cm of Roux limb
genetic anticipation (cancer occurring was passed through this window into the
at an earlier age with each successive lesser sac. A hand-sewn, two-layered end-
generation), the age at which PTG is to-side esophagojejunostomy was created.
recommended is not clearly defined, An air leak test was performed, no air leaks
but generally recommended before 20 were identified. The gastrectomy specimen
years of age.4We present the case of an was removed and no intra-operative
asymptomatic 15 year old male, positive complications occurred.
for CDH1 mutation, with a strong family
history of HDGC (father and paternal RESULTS & CONCLUSIONS: Operative time
uncle, both died from biopsy-proven was 117 minutes, estimated blood loss was
diffuse gastric cancer at ages 42 and 40 milliliters, and the patient tolerated
15, respectively), who underwent a the procedure well. A water soluble
laparoscopic PTG for the prevention of contrast esophagogram was performed
HDGC. the following morning which showed
no contrast extravasation. His diet was
MATERIALS AND METHODS: Pre- advanced and he left the hospital without
operative evaluation included genetic, sequelae. Pathologic evaluation of the
psychological, endocrine, nutritional and specimen revealed no invasive cancer.
surgical evaluations; the patient essentially With a mean follow-up of 6 months, no
went through our adolescent bariatric perioperative complications have been
surgery program. Upper gastrointestinal identified. In conclusion, laparoscopic PTG
endoscopy was unremarkable. His can be safely and successfully performed
comorbidities included obesity (body mass in childhood kindreds at risk for hereditary
index 34kg/m2), asthma, and depression. diffuse gastric cancer. Until more is known
A laparoscopic PTG with Roux-en-Y about when these patients develop
esophagojejunostomy reconstruction was gastric cancer, strong consideration
planned. Intraoperatively, with patient in should be given to perform prophylactic
the supine position, 5 working ports were gastrectomy during mid-teenage years
placed. The gastrocolic ligament was in patients with a family history of early
divided and mobilized to the angle of His gastric cancer.
with division of the short gastric vessels.
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REFERENCES: Harmonic scalpel, which was also used to
1. Guilford P, et. al. Nature. ligate the short gastric blood vessels up to
1998;392(6674):402. the angle of His as well as the vessels into
the antrum, just inside the gastroepiploic
2. Huntsman DG, et. al. N Engl J Med.
artery to approximately 4-cm above the
2001;344(25):1904
pylorus. Cautery injury to the stomach
3. Hebbard PC, et. al. Ann Surg Oncol. was carefully avoided. Four 2-0 polyester
2009;16(7):1890. sutures were placed in an interrupted
4. Cisco RM, et. al. Cancer. 2008;113(7 fashion along the greater curvature, as
Suppl):1850. well as at the incisura, and one on the
antrum. Each of these sutures included a
V018: LAPAROSCOPIC GASTRIC small portion of the posterior stomach as
PLICATION IN ADOLESCENTS AND well as the anterior stomach to imbricate
YOUNG ADULTS WITH SEVERE OBESITY: in the greater curvature. A 35-cm 2-0
DESCRIPTION OF FIRST PATIENT polypropylene running suture was then
ENROLLED IN PILOT STUDY S hannon F. started just inferior to the angle of His and
Rosati, MD, Dan Parrish, MD, Poornima further plicated the greater curvature and
Vanguri, MD, Matthew Brengman, antrum. Flexible esophagogastroscopy
MD, FACS, Patricia Lange, MD, Claudio confirmed that the plication was initiated
Oiticica, MD, David Lanning, MD, PhD, in a satisfactory manner. A shorter second
Children’s Hospital of Richmond at Virginia polypropylene suture was used to further
Commonwealth University Medical Center imbricate the antrum of the stomach. A
INTRODUCTION: Laparoscopic Gastric final running 2-0 polypropylene suture
Plication (LGP) is a novel restrictive bariatric further imbricated the greater curvature
operation that has had some success in from the angle of His to below the incisura.
the adult patients with weight loss and Care was taken to ensure that the diameter
improvement in associated comorbidities. of the incisura was not compromised.
We are currently conducting a prospective Final esophagogastroscopy confirmed
research study, IRB # HM14809, entitled good apposition of the plicated stomach
“A Pilot Study of Laparoscopic Gastric mucosa along the entire course of the
Plication in Adolescents and Young Adults” lesser curvature without evidence of
and have included the details from our first obstruction. The port sites were closed in
case in this abstract. standard fashion. The patient tolerated
the procedure well with minimal blood
PATIENT: This 17 year old girl is followed loss and no perioperative complications.
in our multidisciplinary weight loss She was discharged home on the third
program. While she had been adherent postoperative day on a liquid diet. At her
to the program, she was only able to lose two week follow up, she was noted to have
approximately 7 pounds over 6 months no nausea or pain, was advanced onto her
(preop BMI was 42.5) and had several pureed diet, and had lost ten pounds.
comorbidities.
CONCLUSION: This report details the
TREATMENT: Three 5-mm and one 12- perioperative results of the first patient
mm trocars were placed across the upper enrolled in a new pilot study examining
portion of her abdomen and a Nathanson LGP in morbidly obese adolescents and
liver retractor in the epigastrium. The fat young adults. As the LGP is purported
pad over the cardia was excised with a to be reversible and some parents are
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hesitant to consent to gastric bypass CASE 2: Another 9-month-old boy
or sleeve resection for their child, this was referred to our department for
operation may be a reasonable alternative intussusception, and a left upper polar
for young patients that have not been renal multilocular cystic mass was
successful with nonoperative treatment incidentally detected by abdominal
of their morbid obesity. ultrasound. CT showed a well-
circumscribed 5.2 × 4.3 × 3.5 cm mass,
V019: LAPAROSCOPIC PARTIAL
occupying three-fourths of the kidney.
NEPHRECTOMY FOR THE TREATMENT
OF LARGE CYSTIC NEPHROMA IN In both cases, CN or CPDN was suspected,
CHILDREN Yujiro Tanaka, MD, PhD, Hiroo but differential diagnosis was not possible
Uchida, MD, PhD, Hiroshi Kawashima, MD, without surgical resection.
Shinya Takazawa, MD, Takayuki Masuko,
PROCEDURE: After inserting a ureteral
MD, PhD, Kyoichi Deie, MD, Hizuru Amano,
catheter to the pelvis, the affected kidney
MD, Michimasa Fujiogi, MD, Tadashi
was approached transperitoneally. The
Iwanaka, MD, PhD, Prof, Department
precise area of the lesion was detected
of Pediatric Surgery, Saitama Children’s
using a laparoscopic ultrasound probe,
Medical Center & The University of Tokyo
and the vessels of the affected part were
BACKGROUND: Cystic nephroma (CN), also identified, dissected and excised. After
called multilocular cyst of the kidney, is a clamping the renal artery with a hemostat,
rare benign renal neoplasm. The differential the parenchyma of the affected part
diagnosis of cystic partially differentiated was dissected out and divided using a
nephroblastoma (CPDN) is only possible Harmonic Scalpel™. The partly cut pelvis
based on pathological findings. Therefore, was closed by monofilament sutures.
surgical resection is necessary to diagnose The resected stump was coated with
lesions suspected to be CN. Because CNs Beriplast™ P, covered with Surgicel™,
are usually well-demarcated and have and finally covered with the pediculate
a good prognosis, partial nephrectomy peritoneum, which was used for hemostat
without preoperative chemotherapy sealing and fixation of the remaining
is recommended for their treatment. kidney.
However, to our knowledge, laparoscopic
RESULTS: Laparoscopic partial nephrectomy
treatment of CN has not been reported. In
was performed at 11 months (Case 1) and
the present report, we describe two cases of
10 months (Case 2) of age. Operative time
large CN, which were successfully treated by
for Cases 1 and 2 was 460 min and 415 min,
laparoscopic partial nephrectomy.
and total warm ischemia time was 63 min
CASE HISTORY: and 28 min, respectively. The lesion was not
CASE 1: A 9-month-old boy was referred exposed during the operation in both cases,
to our department because of a lower and the microscopic features were cysts
polar multilocular cystic mass of the right lined by cuboidal cells separated by fibrous
kidney, which was incidentally detected septae without any sign of malignancy,
by abdominal ultrasound during the consistent with CN. Although some fluid
follow-up of slight ureteropelvic junction accumulation was detected at the resection
stenosis of the left kidney. Computed stump, it diminished in a month. The
tomography (CT) showed a well- residual renal function was good and no
circumscribed 4.3 × 3.7 × 3.8 cm mass, residual tumor was found in both cases over
occupying two-thirds of the kidney. a year.
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DISCUSSION: Laparoscopic partial covering the stump with hemostatic
nephrectomy is a feasible approach to agents and pediculate peritoneum
treat large CNs occupying more than half is feasible. However, this procedure
the kidney, and preserve residual renal must be considered because, in CPDN,
function. When it is difficult to close the intraoperative tumor spill will result in a
resection stump by parenchymal suturing, higher tumor stage.
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Top Poster Abstracts

T001: REDUCED PORT DISTAL vein. The specimen was removed via
PANCREATECTOMY FOR GIANT the umbilicus and resulting cosmesis
PANCREATIC NEOPLASM: BEYOND excellent.
THE EVENT HORIZON AND BACK S amir
CONCLUSION: Single incision distal
Pandya, MD, Allison Sweny, MD, Oliver
pancreatectomy with splenic preservation
Muensterer, MD, New York Medical
for large tumors is technically very
College, Maria Fareri Children’s Hospital
demanding with straight instruments. Early
BACKGOUND: Giant pancreatic masses addition of a port at a proposed drain site
in the pediatric population are managed can facilitate the dissection significantly.
with resection when feasible. When Reduced port surgery however may still
located in the distal pancreas, a distal have a role in select cases.
pancreatectomy with splenic preservation
T002: LAPAROSCOPIC ADRENALECTOMY
is typically the ideal approach. Multiport
USING A SINGLE WORKING PORT: A CASE
laparoscopic surgery has been successful
OF PRIMARY PIGMENTED NODULAR
in small to moderate sized lesions.
ADRENOCORTICAL DISEASE N eetu
OBJECTIVE: We report a reduced port Kumar, Kathryn Evans, Imran Mushtaq,
approach to a giant neoplasm at the Great Ormond Street Hospital, London
tail of the pancreas treated with distal
Primary Pigmented Nodular Adrenocortical
pancreatectomy and splenic preservation.
Disease (PPNAD) is a rare condition of
METHOD & MATERIALS: A 15-year-old the adrenal glands. It is associated with
otherwise healthy male with left upper adrenocorticotrophin hormone (ACTH)
quadrant fullness, nausea and vomiting. independent cushing syndrome. It is
A CT scan and MRI showed a 10cm mass characterised by multiple small nodules
at the tip of the pancreas. Tumor markers (<1cm in diameter) in a small or normal
were negative. The patient had already sized adrenal gland. We present a case
undergone an open appendectomy with PPNAD that was treated with bilateral
previously and was very concerned about adrenalectomy: the video showing the
cosmesis. A single incision approach was right-sided adrenalectomy completed
therefore employed for the resection. laparoscopically using a single working
Straight stick laparoscopic instruments port.
and a vessel sealing device were used.
A two and a half year old girl presented
RESULT: Intraoperatively, the mass was with weight gain over 6 months,
densely adherent to the surrounding cushingoid appearance, behavioural
structures. The dissection of the distal changes and androgen hair. Biochemically
splenic vein and artery proved to she had ACTH independent disease.
be extremely challenging using this Radiological investigations did not show
approach. An additional 5mm port was a tumour/mass in the adrenals and was
placed in the left lower quadrant, which inconclusive. Adrenal venous sampling
improved triangulation and facilitated showed excessive cortisol secretion from
completion of the procedure. The site was the left adrenal but studies on the right
subsequently used for a flat suction drain. side were inconclusive. Laparoscopic left
A distal pancreatectomy was successfully adrenalectomy was performed using a
performed along with complete single working port.
preservation of the splenic artery and
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Top Poster Abstracts CONTINUED

Post operatively she recovered well T003: ROBOTIC-ASSISTED RESECTION
but was noted to have persistent OF A PYLORIC PANCREATIC REST WITH
cortisol secretion indicative of right PERORAL ENDOSCOPIC REMOVAL
adrenal disease. 3 weeks later, the AND RECONSTRUCTION BY PARTIAL
patient underwent laparoscopic right GASTRODUODENOSTOMY O liver J
adrenalectomy. This again was performed Muensterer, MD, PhD, Samir Pandya, MD,
with a single working port. Histology Matthew E Bronstein, MD, Fouzia Shakil,
showed appearances in keeping with MD, Aliza Solomon, DO, Michel Kahaleh,
bilateral PPNAD. MD, Division of Pediatric Surgery and
Pathology, New York Medical College,
The accompanying video demonstrates
Division of Gastroenterology and Pediatric
laparoscopic right adrenalectomy
Gastroenterology, Weill Cornell Medical
performed in the prone position.
Retroperitoneal space was created using College
the ‘finger glove’ balloon dissection BACKGROUND: Gastric pancreatic rests
method. A 5mm camera port was inserted consist of ectopic pancreatic tissue within
just lateral to the erector spinae muscle the stomach wall and exhibit a typical
in between the 12th rib and iliac crest. The endoscopic appearance. They frequently
second port was placed anterior to the are asymptomatic, but can cause pain,
camera. Gerotas fascia was opened, the erosions, and depending on their location,
kidney mobilised and the right adrenal gastric outlet obstruction. Symptomatic
gland identified. Using the spread and pancreatic rests should be resected
dissect method the vessels were divided surgically.
with ligasure and the adrenal gland was
removed. No assistant was required OBJECTIVE: We report the first robotic-
for this technique and the procedure assisted resection of a pyloric pancreatic
completed within an hour. rest with endoscopic removal of the tumor
through the pharynx and subsequent
The treatment of choice for PPNAD is reconstruction of the gastric outflow tract
bilateral adrenalectomy. The laparoscopic by partial gastroduodenostomy.
approach is much preferred to the open
one. Various techniques have been CASE: A 10 year old girl presented with
described in the literature including the several months of worsening abdominal
traditional 3 port, single port and robotic pain and nonbilious emesis. An upper
procedures. However, the single working gastrointestinal endoscopy showed a large
port technique is a very efficient and pancreatic rest adjacent to and obstructing
safe way of dealing with such cases. With the pylorus (Figure, A), confirmed by
just 2 small incisions bilaterally, the child endoscopic ultrasound. The patient was
recovered very well and was discharged scheduled for robotic-assisted resection
without any complications. We propose of the tumor. Intraoperatively, resection
this technique as an additional novel of the mass with part of the pylorus was
approach for benign adrenal conditions performed (B). To avoid augmenting one
like PPNAD. of the robotic trocar sites for removal of
the tumor, the mass was pushed into the
stomach and retrieved endoscopically
via the esophagus and pharynx (C). The
Pylorus was reconstructed robotically by
transverse gastroduodenostomy using
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interrupted sutures in 2 layers (D). The T004: LAPAROSCOPY FOR SMALL BOWEL
operative time was 320 minutes. OBSTRUCTION IN CHILDREN – AN
UPDATE H anna Alemayehu, MD, Bryan
RESULTS: The patient tolerated the
David, Amita A Desai, MD, Corey W Iqbal,
procedure well, advanced on her diet
MD, Shawn D St. Peter, MD, The Children’s
without difficulties, and was discharged
Mercy Hospital
home on postoperative day 3.
Histopathology confirmed the diagnosis. INTRODUCTION: We previously reviewed
She remained asymptomatic, and an upper our institutional experience with
gastrointestinal contrast study 3 months laparoscopic management of small bowel
later showed normal passage of contrast obstruction (SBO) in children. The purpose
from the stomach into the duodenum. of this study was to evaluate the evolution
She remains asymptomatic at 8 months of minimally invasive surgery (MIS) for
follow-up. these patients, and compare our current
outcomes with a historical control.
CONCLUSIONS: Symptomatic pyloric
pancreatic rests require careful excision METHODS: After obtaining Institutional
with precise reconstruction of the Review Board approval, a retrospective
gastric outflow tract, and therefore lend review of patients undergoing MIS for
themselves to a robotic-assisted approach. the management of acute SBOs was
Endoscopic removal through the mouth as performed over a five-year period from
a natural orifice allows for removal without 2008 to 2013. MIS was defined as a
augmenting one of the trocar sites and completely laparoscopic procedure, a
thereby minimizes visible scars. If careful laparoscopic-assisted procedure, or a
resection and reconstruction is achieved, laparoscopic procedure converted to open.
the outcome is excellent. Patients with chronic obstructions, colonic
obstructions, or acute intussusceptions
FIGURE: On the initial endoscopy (A),
were excluded. Patients with inflammatory
the pancreatic rest (asterisk) partially
bowel strictures were included only if
obstructing the pylorus (arrow) is seen.
they presented with acute SBO. Data
The mass (arrows) was resected robotically
was collected; both descriptive and
(B) and removed through the mouth by
comparative analysis was performed.
endoscopy (C). After resection, the pyloric
Additionally, this study population was
channel (D) was reconstructed by partial
compared to a historical control including
gastroduodenostomy.
patients from 2001 to 2008. All means
reported ± standard deviation.
RESULTS: There were 71 patients that were
managed with MIS for SBO during the
study period, of which 35 were male and
36 were female. 62 children underwent
laparoscopy for their first episode of
SBO, and 12 underwent laparoscopy for
recurrent SBO, accounting for 74 episodes
of SBO managed with MIS. The mean
age at time of MIS for SBO was 10.2 ± 5.8
years, with a mean weight of 36.0 ± 20.4
kg. 55.3% (n=42) of these had previous
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abdominal surgery, with a mean number
of 1.4 ± 0.7 surgeries prior to MIS for SBO.
The mean time from a previous operation
to undergoing MIS for SBO was 28.6 ± 48.1
months. The most common etiology of
SBO was adhesions (n=40), followed by
Crohn’s disease (n=10), other causes (n=8),
Meckel’s diverticulum, (n=5), perforated
T005: LAPAROSCOPIC TRANSDUODENAL
appendicitis (n=5), volvulus (n=4), internal
DEROOFING OF THE PERIAMPULLARY
hernia (n=2) and anastamotic strictures
DUODENAL DUPLICATION CYST IN
(n=2). 50% (n=37) of SBOs were managed
completely laparoscopically, 27% (n=20) AN INFANT Yu. Sokolov, MD, PhD, Dm
with laparoscopic assisted procedures Donskoy, MD, A Vilesov, MD, M Shuvalov,
and 23% (n=17) converted to open MD, M Akopyan, MD, Dm Ionov, MD, E
procedures. The most common procedure Fokin, MD, St Vladimir Children Hospital,
performed was adhesiolysis only (n=28), Moscow, Russia
followed by bowel resection with primary INTRODUCTION: Duodenal cysts
anastomosis (n=19). Post-operatively the constitute about 5% of all gastrointestinal
mean number of days of nasogastric tube duplications with an incidence of less
(NGT) decompression was 2.2 ± 3.4 days, than 1 per 100,000 birth. In extremely rare
mean time to a regular diet was 5.0 ± 4.2 instances, duodenal duplication cysts can
days, and mean length of stay was 9.6 ± communicate with pancreaticobiliary ducts.
19.1 days. Laparoscopy is associated with a Here, we report a case of the periampullary
shorter time of NGT decompression and duodenal duplication cyst communicating
time to regular diet (Table 1). There were with the biliary system in an infant, which
8 post-operative complications; intra- was treated with laparoscopic approach.
abdominal abscess (n=3), anastomotic
stricture (n=2), anastomotic leak (n=1), MATERIAL & METHODS: A 2-year-old
bowel obstruction (n=1), and respiratory girl presented with 2-week history of
failure (n=1). intermittent epigastric abdominal pain and
bilious vomiting associated with failure
Compared to the historical control there to gain weight. Physical examination
were similar outcomes: mean number of showed diffuse abdominal tenderness
days of NGT use was 1.6 ± 1.6 vs. 2.2 ± 3.4 in the right upper quadrant. Laboratory
in the current study (p=0.42), mean length studies were normal. The initial imaging
of stay was 12.5 ± 20.2 days vs. 9.6 ± 19.1 with ultrasonography and CT showed 3 cm
days (p=0.53), mean complication rate cystic mass, which was located within the
was 14.7% vs. 10.8% (p=0.45), and mean duodenal wall in continuity with the head
conversion rate to open was 30.8% vs. of the pancreas thereby causing some
23.0% (p=0.59). degree of duodenal obstruction. MRCP
CONCLUSION: Laparoscopy continues to be also revealed the cyst in the second part of
a safe and vital diagnostic and therapeutic duodenum, which occupied more then half
tool in the management of pediatric small of the duodenal circumference and was
bowel obstructions secondary to a wide adjacent to the confluence of the common
variety of etiologies. bile duct and pancreatic duct. Upper GI
endoscopy showed the large submucosally
located duodenal mass close to the
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ampulla of Vater, considerably protruding laparoscopic thansduodenal deroofing of
in the duodenal lumen. Laparoscopy was this lesion is safe and feasible technique
performed utilizing 5mm umbilical optical even in small children.
port and two 5mm working ports. After
T006: LAPAROSCOPIC ENUCLEATION OF
mobilization of the hepatic flexure of the
TRUE PANCREATIC CONGENITAL CYST
colon and duodenum the temporary stay
sutures brought through the abdominal Mariana Borges-Dias, Manuel Oliveira, José
wall were then placed on the duodenal wall. Estevão-Costa, Miguel Campos, Pediatric
A 2.5-cm longitudinal duodenotomy was Surgery Department, Faculty of Medicine,
then made on the antimesenteric lateral Hospital São João, Porto, Portugal
portion of the descended duodenum. INTRODUCTION: True solitary pancreatic
The intraduodenal submucosal cyst, cysts are rare entities, since 80% to 90% of
3.0x2.0x2.0cm in size, was thus exposed. Its benign pancreatic cysts are pseudocysts.
inferior border was observed to be involving In recent years, its incidence has increased
and displacing the Vater ampulla. The cyst due to the generalized use of CT and
was opened with the help of diathermy MRI and a better accuracy thereof. Most
hook and it was found that the cyst was congenital pancreatic cysts are multiple
filled with viscous and bile stained material. and associated with diseases such as Cystic
The anterior wall of the cyst was excised, Fibrosis, the Von Hippel-Lindau Syndrome
leaving the posterior one intact. Hemostasis or Polycystic Kidneys.
was assured with monopolar diathermy.
Extreme care was taken not to cause CASE REPORT: We present a clinical case of
any damage to the papilla of Vater. The a 7-years-old girl, asymptomatic, followed
duodenum was then closed in a transverse as an outpatient at a pediatric nephrologist
fashion using extracorporeal interrupted due to repeated pyelonephritis, without
sutures PDS 5-0. other relevant history. In a routine
ultrasound, a cystic lesion with about 4 cm
RESULTS: The procedure was successfully larger diameter, in close relation with the
completed. Operative time was pancreatic tail was detected. In order to
100 minutes. The patient recovered better characterize the lesion an MRI was
uneventfully and was discharged on the performed. The images showed a “Cystic,
7th postoperative day and remained simple lesion of 41x40mm, centered on
asymptomatic at follow up at intervals the tail of the pancreas, unilocular, well-
up to 1 year. No evidence of the cyst circumscribed, thin-walled and regular,
recurrence was demonstrated on US. with no areas of contrast uptake, in intimate
Pathological evaluation of the cyst sac relation with the left renal vein (...)”. The
showed inner mucosal lining with well authors present in the following video a
formed villi and also well developed laparoscopic enucleation of the pancreatic
muscular coat, confirmed features of the cyst with pancreas and spleen preservation.
intestinal duplication cyst. No relevant post-op complications
CONCLUSION: The imaging, intra-operative occurred. Histology revealed a cavitary
and pathology findings in this patient lesion lined by cuboid and simple columnar
appeared to be consistent with a very rare epitheliums of ductal type, without atypia.
periampullary duodenal duplication cyst These aspects were compatible with
communicating with the biliary system. congenital pancreatic cyst.Nowadays she is
We believe that, the therapeutic mode of monitored in Pediatric Surgery and Pediatric
Gastroenterology consults.
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COMMENTS: This case study aims to CONCLUSION: Bimanual suturing technique
document a rare, usually asymptomatic facilitates closure of anterior defects and
and incidentally diagnosed entity, that provides better cosmetic outcomes.
was treated successfully by laparoscopic
T008: ROBOTIC CHOLEDOCHAL CYST
technique, as shown in the video
EXCISION A
dam C Alder, MD, Stephen M
presentation.
Megison, MD, Children’s Medical Center
T007: BIMANUAL SUTURING - A NOVEL Dallas
TECHNIQUE IN LAPAROSCOPIC REPAIR
This video highlights the technical aspects
OF MORGAGNI HERNIA Kanika A. Bowen,
of choledochal cyst excision using a
MD, Dean M. Anselmo, MD, Nam X.
surgical robot platform. The technique
Nguyen, Children’s Hospital Los Angeles,
illustrated includes: confirmation of
Los Angeles, CA
the suspected pathology, creation of a
INTRODUCTION: Laparoscopic approach has roux-en-y enteroenterostomy, isolation
become a preferred technique in Morgagni of the anterior wall of the choledochal
diaphragmatic hernia repair. However, cyst, opening of the duct to allow for the
laparoscopic suturing of the anterior defect safe dissection of the posterior wall of
is technically challenging. Many surgeons the common duct, proximal and distal
place sutures through-and-through the dissection of the abnormal common bile
anterior abdominal wall in order to secure duct, ligation of the distal duct remnant,
the hernia closure. This method leads to creation of a hepaticojejunostomy to the
undesirable cosmetic results. We present a roux limb, cholecystectomy. The video
novel technique using “bimanual suturing” highlights the advantages of the robotic
to overcome this dilemma. platform: 10x magnification, 3D viewing,
wristed instrumentation, natural motion
METHOD: The patient is placed in a supine
with tremor dampening.
position at the far end of the table. The
operation is performed using three 5 mm T009: THE VACUUM BELL FOR
ports (one at the umbilicus and one on CONSERVATIVE TREATMENT OF
each side of the umbilicus along the mid- PECTUS EXCAVATUM: ASSESSMENT
clavicular line) with the operating surgeon OF ITS EFFICACY WITH DISTANCE AND
standing at the patient’s feet. The hernia sac PRESSURE SENSORS S ergio B Sesia, MD,
is completely excised. The defect is then Stefan Weiss, MSc, David Hradetzky, D,
closed with interrupted 3.0 Ethibond® RB-1 Eng, Frank-Martin Haecker, MD, University
(Ethicon, Cincinnati, OH) sutures. During Children’s Hospital of Basel, Department
the suturing, the surgeon’s left hand is of Paediatric Surgery, Basel; University of
pushing down on the anterior abdominal Applied Sciences and Arts Northwestern
wall allowing big bites on the fascia. The Switzerland, School of Life Sciences,
needle is then passed through the edge of Institute for Medical and Analytical
the diaphragm, and the knots are secured Technologies, Muttenz, Switzerland
extra-corporally using a knot pusher.
BACKGROUND: The conservative
RESULT: Postoperative chest X-ray shows a treatment of a pectus excavatum (PE) by
complete resolution of the hernia. At three using the vacuum bell (VB) represents a
month follow-up, a chest X-ray shows an valid alternative to the surgical minimally
intact hernia repair, and the patient has invasive repair (MIRPE) technique by Nuss
no scars other than those from the trocar for selected patients.
incisions.
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The objective assessment of its efficacy T010: OUTCOME OF LAPAROSCOPIC
(elevation of the sternum) is still a SUTURE RECTOPEXY IN PERSISTENT
challenge. RECTAL PROLAPSE IN CHILDREN K arim
Awad, MSc, MRCS, Amr Zaki, MSc, MD,
So far, there is no method for a
Mohamed Eldebeiky, MSc, MD, MRCS,
quantitative measurement of the
Ayman Alboghdady, MSc, MD, Tarak
improvement of PE, nor a method to
Hassan, MSc, MD, MRCS, Sameh Abdelhay,
evaluate the applied pressure during the
MSc, MD, ain Shams University Hospitals
VB therapy. The aim of our study was to
evaluate the reliability of a three-sensor BACKGROUND: Rectal prolapse is a
tool to assess the improvement of the PE relatively common problem, specially
during the VB application. in developing countries with high rates
of Gastroenteritis, parasitic infestations
PATIENTS & METHODS: Based on a three-
and malnourishment. Despite absence
point distance measurement, a device with
of accurate statistical studies regarding
three sensors was developed to assess the
its prevalence, yet it is frequently seen in
distance between the window of the VB
outpatient clinic.
and the sternum as well as the differential
pressure in the VB. The differential pressure The majority of the cases are managed
depending on the sternum elevation can conservatively, yet intervention is
be calculated in relation to a reference mandatory in some cases.
pressure. The clinical application was
started after the institutional review board Hundreds of approaches have been used
approval and written consent was obtained. in management of full thickness prolapse
The patient in supine position fixed the with variable degrees of success, we
device on the top of its own VB and started aim to evaluate the laparoscopic suture
to create a vacuum in order to elevate rectopexy (LSRP) as regards safety and
the sternum. The data were recorded recurrence rate in children with persistent
continuously and send via USB-cable to full thickness rectal prolapse.
a computer. The raising of the sternum as PATIENTS AND METHODS: during period
well as the pressure in the VB over the time from August 2011 till January 2014, patients
and the pressure in relation to the raising of who presented with rectal prolapse
the sternum were assessed have been screened as regards history
RESULTS: 17 patients were included. of prolapse and predisposing factors, all
The elevation of the sternum increases have been examined and investigated
with diminishing pressure. This relation is with stool analysis, barium enema in
non-linear. The elevation of the sternum addition to colonoscopy and EMG as
continued during the application of the VB needed. Cases who failed to respond to
while the pressure was kept constant. The conservative measures were corrected
younger a patient is, less pressure is needed using (LSRP).The procedure was done
to reach the same elevation of the sternum. under general anesthesia and completed
with laparoscopic approach with fixation of
CONCLUSION: Sensor-based measurement the mobilized rectum to sacral promontory
represents a reliable tool to assess the by multiple non absorbable sutures.
efficacy of the use of the VB. Statements
to the flexibility of the chest and the After discharge, all patients were asked
duration of therapy become possible. to visit outpatient clinic for clinical
assessment and their data were recorded.
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RESULTS: Seventy four patients presented PURPOSE: Laparoscopically assisted
to our outpatient clinics during this period, anorectoplasty (LAARP) is now considered
47 patients where successfully managed to be the radical surgical treatment of
conservatively. Twenty seven failed to choice for male imperforate anus (MIA)
respond to conservative measures and 20 with recto-vesical, recto-prostatic, or
of them were managed by LSRP. absent fistula in many centers. However,
only a few centers treat recto-bulbar
Their age ranged from 2 to 11 years with
fistula (RBF) which is the most challenging
mean 5.3 years, duration of conservation
type to treat laparoscopically. We introduce
ranged from 6 weeks to 72 months with
our current treatment techniques including
mean 15.3 months, operative time ranged
technical refinements and some novel
from 25 to 150 minutes with mean of 80
procedures of LAARP for MIA with RBF.
minutes, no intraoperative complications
were encountered other than the need for SURGICAL TECHNIQUES: Scope and
conversion to open in one case. Feeding Trocar positions:Dissecting the rectum
toleration was achieved between Day 0 laparoscopically in MIA with RBF can be
to Day 4. Patients were discharged home so difficult that surgeons are tempted
Day 0 to Day 5, all were followed up for to abandon dissection early, leaving the
a period ranging from 6 to 26 months most distal part of the RBF behind with
with mean of 14.5 months.one patient great likelihood of it becoming a posterior
(5%) developed recurrence requiring redo urethral diverticulum. To overcome such
surgery and one patient suffered partial frustration with dissection, surgeons would
thickness prolapse (5%) which improved benefit from: (1) refining trocar placement
spontaneously on follow up. in RBF cases by placing the right and left
trocars much closer to the laparoscope,
CONCLUSION: LSRP is a minimally invasive
compared with the trocar positions in
procedure for children with full thickness
recto-prostatic fistula (RPF) cases, so that
rectal prolapse, it has the advantage of
their ends can reach the distal end of the
being safe, having low recurrence rate,
RBF. (2) Using an adjustable scope with
short hospital stay and minimal post-
fixed-rod rotating lens. This device allows
operative discomfort. When expertise
the laparoscope to be adjusted from 0
available, it can be done as a day case
to 120 intraoperatively, eliminating the
procedure. However longer follow up is
need to choose a type of laparoscope
needed to detect any further recurrence.
in advance or be limited to a fixed view.
T011: SURGICAL TECHNIQUES FOR Deep exposure of the pelvis:Insertion of a
LAPAROSCOPY-ASSISTED REPAIR OF suprapubic catheter into the bladder with
MALE IMPERFORATE ANUS WITH RECTO- continuous suction of urine to decompress
BULBAR FISTULA. COMPARISON WITH the bladder improves exposure of the
RECTO-PROSTATIC FISTULA Hiroyuki distal part of the RBF located deep in the
Koga, MD, Manabu Okawada, MD, Takashi pelvis. This catheter is not needed for the
Doi, MD, Go Miyano, MD, Hiroki Nakamura, RPF.Measurement of the fistula:The RBF
MD, Takanori Ochi, MD, Shogo Seo, MD, is dissected carefully close to the urethra
Geoffrey J Lane, MD, Atsuyuki Yamataka, and opened. A fine catheter with 10mm
MD, Department of Pediatric General and calibrations is inserted by the laparoscopic
Urogenital Surgery,Juntendo University surgeon until it is seen to emerge into the
School of Medicine urethra by another surgeon performing
cystoscopy. The laparoscopic surgeon
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then measures the distance from the operation ranged from 0.2-84 months
point where dissection was ceased at ( mean 15.7 months). A thoracoscopic
the rectal end to the urethral orifice. The approach was used in 70 patents (85 %)
RBF can then be dissected distally with with four patients requiring conversion
confidence without any risk for injury to to open (co2 insufflation not tolerated,
genitourinary structures for exactly the high diaphragm reducing operative field,
length measured, tied, and excised. mobile intra-thoracic kidney following
previous diaphragmatic hernia repair,
CONCLUSIONS: Our refinements during
inadequate operative field). A laparoscopic
LAARP would appear to provide excellent
approach was performed in 12 patents
exposure for dissecting RBF and facilitate
(15%) with no cases converted to open
complete excision of RBF, improving the
surgery. Right sided eventration was
accuracy of treatment and minimizing
more common (48/82, 59%) and 45/48
complications.
(94%) were performed thoracoscopically.
T012: DIAPHRAGMATIC EVENTRATION Interestingly, a laparoscopic approach was
REPAIR: SHOULD WE USE A more common in left sided eventration
THORACOSCOPIC OR LAPAROSCOPIC (10/19, 53%). In 15 cases, laterality was
APPROACH? S aidul Islam, Kirsty Brennan, not specified.
Rajiv Lahiri, Anies Mahomed, Department CONCLUSION: Case series predominate
of Paediatric Surgery,Royal Alexandra in the literature with regard to minimally
Children’s Hospital,Brighton,U.K. invasive approaches to diaphragmatic
AIMS: Minimally invasive surgery has eventration. There is a predilection
permeated through paediatric surgery. We towards a thoracoscopic approach in
performed a systematic review to identify published series, especially in right sided
the preferred minimally invasive approach diaphragmatic eventration. However,
for diaphragmatic eventration repair. laparoscopic diaphragmatic eventration
repair is feasible, and should be considered
METHODS: A systematic review of the when operative field in chest is reduced. A
online literature using Embase and randomised control trial comparing both
Medline was performed. The initial search approaches is required to delineate the
criteria of ‘Diaphragmatic Eventration possible advantages of either approach.
repair in children‘ was further narrowed
down to select only thoracoscopic or T013: EVOLUTION OF MINIMALLY-
laparoscopic cases. We included two INVASIVE TECHNIQUES WITHIN AN
cases of laparoscopic eventration repair ACADEMIC SURGICAL PRACTICE AT A
from the author’s institution. The number SINGLE INSTITUTION S hannon N Acker,
of patents, age at operation, type of MD, Susan Staulcup, David A Partrick,
procedure, conversion rate and laterality MD, Stig Somme, MD, Children’s Hospital
(right or left) were noted. Colorado
MAIN RESULTS: The initial search for AIM: We aimed to better understand how
diaphragmatic eventration repair in changes in surgical techniques are being
children identified 20 publications which transferred into surgical practice. We
included 236 patients. After excluding hypothesize that as the use of minimally
open cases and including two cases invasive surgical techniques (MIS) have
from our institution, 15 publications increased, the integration of these
with 82 patients were included. Age at techniques into a pediatric surgical practice
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is dependent on the hiring of junior
partners with extensive training in MIS who
can then transfer their knowledge to senior
surgeons.
METHODS: We reviewed the operative
techniques used to perform six different
general pediatric surgical procedures
from 1999-2013. Procedures evaluated
include appendectomy (average
238/year), fundoplication (129/year),
gastrostomy tube placement (102/year),
pyloromyotomy (56/year), colectomy CONCLUSIONS: The hiring of junior
(8/year), and lobectomy - lung (7/ surgeons with MIS training was associated
year). Records were obtained from both with an increase in adoption of MIS
the hospital’s surgical database and techniques by the entire surgical group.
the department’s billing records. The Trends in procedures that were early
percentage of cases performed with in the MIS era demonstrate a gradual
MIS was calculated for each procedure rise towards uniform adoption of MIS
annually. Our group is comprised of 4-7 techniques. More advanced and recently
pediatric general surgeons at any time. adopted MIS techniques demonstrate a
Three surgeons completed training in the rapid rise to uniform adoption.
era of MIS and were hired in 2001, 2007, T014: ENDOSCOPIC CLOSURE OF
and 2009. PERSISTENT GASTROCUTANEOUS
RESULTS: In 1999 a median of 16.7% of FISTULA IN CHILDREN S andra M Farach,
these six procedures were performed MD, Paul D Danielson, MD, Daniel
with MIS. This increased to 85.3% in 2013 McClenathan, MD, Nicole M Chandler,
(P<0.05). Figure 1 depicts the changes MD, All Children’s Hospital Johns Hopkins
in MIS use for each procedure over Medicine
time. Three procedures: appendectomy, BACKGROUND: The literature has reported
pyloromyotomy, and fundoplication, the incidence of persistent gastrocutaneous
demonstrate early adoption and uniform fistula (GCF) after removal of gastrostomy
use of laparoscopy (>85% laparoscopy tubes in pediatric patients to be up to
by 2007). Gastrostomy tube placement 44%. The use of endoscopy may spare the
reached 90% laparoscopy utilization in patient the potential morbidity associated
2009. Lung lobectomy and colectomy with surgical approaches to this problem.
also reached >80% use of MIS in 2009 and The purpose of our study was to review the
2010 respectively. From 2000 to 2013, the outcomes of GCF closure by an endoscopic
rate of MIS use for pyloromyotomy among technique that utilizes a combination of
senior surgeons with no formal MIS training cautery and endoclips.
increased from 0% to 96% (p<0.0001) and
from 24% to 96% (p<0.0001) for G-tube METHODS: After Institutional Review
placement. Board approval, a retrospective analysis
of pediatric patients who underwent
endoscopic treatment for persistent GCF
following gastrostomy tube removal
from January 2010 to September 2013
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was performed. This technique utilized with endoscopy. The mean length of follow
esophagogastroduodenoscopy with up from the first endoscopic procedure
cauterization of the fistula track and was 1.1 ± 1.1 (0.1-3.5) years.
endoclip closure of the gastric mucosa.
CONCLUSIONS: Benefits of endoscopic
Demographics and outcomes recorded
closure of gastrocutaneous fistulas include
included age, diagnosis, duration of
the potential for a more minimally invasive
gastrostomy tube presence, number of
intervention that can be performed as an
interventions, and length of follow up.
outpatient procedure. While endoscopy
RESULTS: A total of 21 patients underwent with cautery and endoclipping proves to
endoscopic treatment for persistent GCF be a safe method for fistula closure, many
following gastrostomy tube removal. Five patients require multiple procedures and
patients had inadequate follow up and may require eventual surgical closure.
were excluded from analysis. Techniques Patient selection and refinement of this
for gastrostomy tube placement included technique may improve outcomes.
percutaneous endoscopic gastrostomy
in 75%, surgical gastrostomy in 12.5%,
and unknown in 12.5%. Indications for
gastrostomy tube placement included:
neurological dysfunction (37.5%),
mechanical feeding difficulty (25%),
congenital/genetic disease (12.5%),
gastrointestinal disease (12.5%), and
congenital heart disease (12.5%). The mean
age at the time of endoscopic treatment
was 7.5 ± 5.5 (1.1-17) years. Females
comprised 56% of the group. Gastrostomy
tubes were in place for a mean of 5.5 ±
5.2 (0.5-14.2) years prior to removal. The
average time from gastrostomy tube
removal to first endoscopic clipping was
6.7 ± 9 (0.7-28.9) months. Seven patients
(44%) had successful closure after their
first endoclipping procedure. Six patients
underwent a second endoclipping T015: INPATIENT ADMISSION IS
procedure, with three successful closures. NOT NECESSARY FOLLOWING
A total of 4 patients (25%) required SUCCESSFUL ENEMA REDUCTION
surgical closure for persistent fistulas and OF INTUSSUSCEPTION IN CHILDREN
2 patients (13%) have continued drainage Mohamed I Mohamed, MBBS, Stephanie F
(Figure 1). Seven (44%) patients underwent Polites, MD, Abdalla E Zarroug, MD, Michael
more than one intervention for treatment B Ishitani, MD, Christopher R Moir, MD,
of a persistent GCF. Fifteen (94%) patients Division of Pediatric Surgery, Mayo Clinic,
had the endoscopic clipping procedure Rochester, MN, USA.
performed on an outpatient basis. A total
of ten patients (63%) had definitive GCF BACKGROUND: Following successful enema
closure after endoscopic clipping alone. reduction of intussusception in children,
There were no complications associated the need for admission is controversial.
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Many institutions are moving towards early (range) duration of 3 (1-21) hours. No
discharge after brief observation in the recurrence was observed in this group.
emergency department. The concern is that The overall recurrence rate was 10% with a
intussusception may recur following early median (range) time to recurrence from 2
discharge. The purpose of this study was days (0 days- 10 months). All recurrences
to evaluate patterns of management and were successfully managed non-surgically.
recurrence at a tertiary care center over two
CONCLUSION: Recurrence of
decades.
intussusception following successful enema
METHODS: We performed a retrospective reduction or spontaneous reduction is
review of all patients ≤18 years who were infrequent and does not result in surgical
treated for intussusception at our institution management. Ambulatory monitoring
from January, 1992 to October, 2013. of children following successful enema
Patient clinical data and outcomes were reduction of intussusception appears to be
analyzed with a focus on recurrence of a safe and feasible option.
intussusception and time to recurrence.
T016: EVALUATION OF ENDOSCOPIC AND
RESULTS: We identified 109 children with TRADITIONAL OPEN APPROACHES TO
intussusception over 21 years. Patients’ LOCAL ADRENAL NEUROBLASTOMA W ei
ages ranged from 3 months to 16 years; Yao, Kuiran Dong, Kai Li, Yunli Bi, Gong Chen,
however, 62 % were <2 years. The most Xianmin Xiao, Shan Zheng, Department
frequent presentation was abdominal pain of Pediatric Surgery, Children’s Hospital of
(87%) and the classic triad of abdominal Fudan University, Shanghai, China
pain, abdominal mass and rectal bleeding
was only present in 6%. Abdominal OBJECTIVE: To investigate and compare
radiographs (65%) and ultrasound (57%) long term oncologic outcomes in
were the primary initial diagnostic tools. children undergoing laparoscopic or
Nine (8%) patients required emergent open adrenalectomy for local adrenal
surgery and did not receive enemas. Enema neuroblastoma.
reduction was attempted in 100(92%) METHODS: A retrospective review was
patients, including pneumatic enemas conducted of 43 children with local adrenal
(93%) and barium enemas(25%) . In 5 (5%) neuroblastoma treated between July 2005
patients, the enema failed to identify the and July 2013 in Children’s Hospital of Fudan
intussusception and no further intervention University. These patients met inclusion
was required. Reduction was successful in criteria for having adrenal neuroblastoma
48(44%) patients. Surgery was required in and undergoing operative resection.
a total of 56 (51%) patients including 9 who
required emergent surgery and did not RESULTS: The local adrenal neuroblastoma
have an enema, 43 (39%) who failed enema cases included 19 males and 14 females,
reduction, 2 who recurred immediately aged 5 days -158 months, mean 32.44
after enema reduction, and 2 for which months. Left adrenal lesions was in 14
the diagnosis could not be confirmed cases, the right in 29 cases. According to
via enema. Surgery was laparoscopic in 7 INSS staging system, there were 27 cases
patients. Meckel’s diverticulum was the lead of stage I, 10 of stage II, 6 of stage IVs.
point in 7 patients. Post successful enema Open adrenalectomy was peformed in 28
reduction, 22 patients were observed in patients. Laparoscopic adrenalectomy was
the emergency department for a median peformed in the other 15 patients, two of
whom were converted to open surgery
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because of adhesions to renal vessels RESULTS: We did’t investigate the
and diaphragmatic rupture. There was no difference in operative time, number
difference in tumor size (3.92 & 5.22cm) and doses of the analgesia and duration of
operative time (141.33 & 137.68min) between the hospital stay in patients of compared
laparoscopic and open surgery except groups. The mean operative time
blood loss (P = 0.033). All patients were (summarized duration of mono- and
followed up for 2-93 months, mean 34.47 bilateral repair) in Group I was 16 min.
months. There were two recurrence cases in In contrast, the mean duration of the
open surgery, but there was no recurrence operation in the Group II was 15,73 min.
in laparoscopic surgery. The overall 5-year The number of the doses of postoperative
survival rate of open and laparoscopic analgesia was 1,19 and 1,22. The length
surgery were 88.5 % and 100 % (P = 0.348). of hospital stay in Group I was 8,12 hours
and 8,27 hours in Group II. No differences
CONCLUSIONS: Laparoscopic resection of
between groups were registrated in follow-
adrenal neuroblastoma is feasible and can
up periode – recidive (0:0) and hydrocele
be performed with equivalent recurrence
formation (0:1).
and mortality rates in open resection. For
tumor size <6cm, absence of vascular CONCLUSION: We must conclude similar
encasement, the adrenal neuroblastoma functional results in treatment of inguinal
may be preferred laparoscopic surgery. hernia in babies of the first 3 months of
the life with using single- and multi-port
T017: COMPARISON OF MULTI-PORT AND
laparoscopy and demonstrated scarless
SINGLE-PORT LAPAROSCOPIC INGUINAL
cosmetic results in group of single-incision
HERNIORAPHY IN SMALL BABIES laparoscopic surgery.
Yury Kozlov, MD, Vladimir Novozhilov,
MD, Department of Neonatal Surgery, T018: METAL-POLYMER COMPOSITE NUSS
Municipal Pediatric Hospital, Irkutsk, Russia; BAR FOR “MINIMALLY” INVASIVE BAR
Department of Pediatric Surgery, Irkutsk REMOVAL AFTER PECTUS EXCAVATUM
State Medical Academy of Continuing TREATMENT L eonardo Ricotti, PhD,
Education (IGMAPO), Irkutsk, Russia Gastone Ciuti, PhD, Marco Ghionzoli, MD,
PhD, Arianna Menciassi, PhD, Antonio
BACKGROUND: The aim of this study was
Messineo, MD, 1 – The BioRobotics Institute,
the comparison of single-port and multi-
Scuola Superiore Sant’Anna, Pontedera
port laparoscopic methods of the treatment
(Pisa), Italy. 2 – Department of Pediatric
of inguinal hernia in children of the first 3
Surgery, Children’s Hospital A. Meyer,
months of life.
Florence, Italy.
MATERIALS AND METHOD: Between January
BACKGROUND: The insertion in the chest of
2002 and December 2012 children were
a metallic implant and the need to remove
performed 260 laparoscopic operation
it after years represent the main drawback
in neonates and infants with diagnosis of
for the Nuss “mini-invasive” procedure In
inguinal hernia. Surgical procedures were the
Pectus Excavatum (PE) patients. The idea
single-port endoscopic hernioraphy (Group
of using an entirely reabsorbable bar was
I – 180 patients) and multi-port laparoscopic
hypothesized but soon abandoned because
hernioraphy (Group II – 80 patients). The
of concerns about its mechanical stability
two groups were compared for patient’s
due to the strong forces at work in the chest.
demographics, operative report, early and
Accounting these limits, we developed and
late postoperative outcomes.
patented an innovative approach for the
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treatment of PE which is based on a metal RESULTS: FEM simulations performed on
and polymer composite bar. the composite structures (Figure 1) revealed
that metal/polymer composite bars can
MATERIAL & METHODS: We designed a new
be developed by using a few combinations
configuration of bar with dimensions similar
of metal and polymers. When stainless
to a Nuss bar, composed by internal metals
steel (AISI316L) has been considered, we
element and an external biodegradable
discovered that only metal sheet-based
polymeric shell in order to facilitate
bars embedded in PLLA, PHB and PBPA
the removal intervention. Two different
are mechanically stable. For titanium
geometries for the metal elements to be
alloy (Ti-6Al-4V) matrices, instead, both
embedded in the polymeric matrix were
configurations are mechanically stable (leaf
tested: in the former thin metal sheet, in
or rod). Moreover, metal component can
the latter cylindrical metal reinforcing rods
be further scaled down in comparison to
were considered. Finite element method
stainless steel, still assuring bar integrity and
simulations (FEM) were performed applying
mechanical stability. Similar results were
a force on the bar of 250 N and by varying
obtained when Tungsten has been used as
metal sheet thickness or rod diameter
metal element.
for different material combinations. The
maximum stresses and strains of the CONCLUSIONS: FEM simulations were
bar were figured out and the optimal able to establish the adequate compound
configuration for the PE treatment was proportions to ensure bar integrity and
identified for a composite bar. mechanical stability. The insights herein
reported should serve as guidelines for
the design of advanced composite bars for
the correction of chest wall deformities, as
well as for the development of other load-
bearing implanted and partly reabsorbable
composite devices.
T019: SINGLE-INCISION
THORACOSPCOPIC RESECTION FOR
PEDIATRIC MEDIASTINAL NEUROGENIC
TUMOR USING CONVENTIONAL
INSTRUMENTS IN CHILDREN J iangbin Liu,
PhD, Professor, Department of Pediatric
Surgery, Shanghai Children’s Hospital,
Shanghai Jiao Tong University
AIMS AND OBJECTIVES: to review the
experience on the thoracoscopic resection
of mediastinal neurogenic tumors using
conventional instruments in children.
METHODS: 5 children with mediastinal
FIGURE 1: Example of FEM simulation
tumors treated by single-incision with
performed on a metal-polymer composite
thoracoscopic resection using conventional
bar. Stress distribution, elastic strain and
instruments between July 2010 and
total deformation of the composite bar are
October 2013.. Medical charts were
shown.
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reviewed for collection of data on age, sternum as a method of treatment for
sex, histological type of tumor, clinical severe tracheomalacia. Although many
manifestations, tumor size, duration of approaches have been described, left
thoracic drainage, surgical complications, anterior thoracotomy remains the most
tumor recurrence, and mortality. common surgical approach. Recent
case reports of have demonstrated the
RESULTS: 3 males and 2 females were
feasibility of a thoracoscopic approach in
studied. Median age was 22 months
selected cases. We present our experience
(range, 18.5-85 months), 3 children
with thoracoscopic aortopexy describing
had ganglioneuroma, 1 child had
our technique as well as our outcomes.
ganglioneuroblastoma and the another
1 had neuroblastoma,. The median METHODS: We performed a retrospective
time of the operation was 75 minutes review of all patient who underwent
(range, 45-120minutes) with complete thoracoscopic aortopexy for tracheomalacia
thoracoscopic resection in all cases and at our institution. Primary outcomes
no conversion to 3 ports or opening. No included operative time, number, type and
children developed Horner syndrome but 1 location of stitches, comparative caliber
got chylothorax postoperatively, the child change at post-operative bronchoscopy,
recovered by TPN administration after 3 time until extubation, length of stay
weeks. The duration of thoracic drainage following surgery, recurrence requiring
was 7.5 days (range, 3.5-21.5 days), No revision and long term dependence
deaths were reported, and no recurrence on respiratory support. Intra-operative
was noted during a median follow-up bronchoscopy performed at the conclusion
period of 21 months (range, 3-40 months) of each case was used to document the
effectiveness of the procedure.
CONCLUSIONS: Based on our experience,
single-incision thoracospcopic resection RESULTS: A total of 6 patients were
for pediatric mediastinal neurogenic tumor identified that underwent thoracoscopic
using conventional instruments could be aortopexy. The median follow up time
completed successfully in children. More was 7.5 months (2 months to 72 months).
data are needed to fully assess the benefit Pre-operative bronchoscopy reported
of this technique. The major advantages of severe or near complete obstruction in
this approach are cosmetic improvement all 6 patients. The median age and weight
and minimal scars. at the time of surgery was 5 months
(3kg to 33 kg) and 5.1 kg ( 3.9 kg to 14.5
KEY WORDS: Single-incision,
kg). The procedure was performed using
thoracospcopic mediastinal, neurogenic,
left thoracoscopy in five cases and right
conventional instruments, children
thoracoscopy in one case. The median
T020: THORACOSCOPIC AORTOPEXY FOR operative time was 102 minutes (82
TRACHEOMALACIA: DEMONSTRATING minutes to 105 minutes). Four of the
FEASIBILITY AND EFFICACY A vraham aortopexies were performed using 3
Schlager, MD, Ozlem Balci, MD, Matthew stitches into the aorta, one using 4 stitches
T Santore, MD, Mark L Wulkan, MD, Emory and the final case using five stitches
University School of Medicine/Children’s distributed between the pericardium
Healthcare of Atlanta and the aorta. The pexy was performed
using 3-0 PDS in two of the patients,
BACKROUND: Aortopexy refers to the 3-0 prolene in another two and 3-0 silk
surgical suspension of the aorta to the
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in the remaining two. Post-operative BACKGROUND: Congenital partial
bronchoscopy demonstrated near- diaphragmatic eventration describes an
complete resolution or markedly improved antrolateral defect in the diaphragm. The
caliber in five patients and approximately defect boundaries can be clearly defined
50 percent improvement in the final thoracoscopically. The anterolateral edge is
patient. The two of the six patients that formed by the costal margin, whereas, the
were not ventilator-dependent at the postromedial edge is formed by a relatively
time of surgery were extubated in the longer elevated “C-shaped” muscle. We
operating room following the case. hereby describe a simple tension free
Of the remaining four that had been thoracoscopic technique for its repair.
ventilator-dependent prior to surgery,
METHODS: The Ibis is a sacred Egyptian
one patient was extubated in the PACU,
bird with a peculiar sickle shaped peak
one on post-operative day number 4, one
and head. Using three 5-mm ports,
patient on post-operative day number 8
several rib-anchoring stitches (plicating
and the final patient remainedventilator-
the fibroelastic membrane) are inserted
dependent until he died of unrelated
to reorient the postromedial C-shaped
causes 6 months following surgery. Of the
diaphragmatic muscle edge into an
five surviving patients, the median hospital
Ibis head sickle shaped repair. This
stay following surgery was 6.5 days (2
reorientation creates two limbs: one lateral
days to 72 days). One patient experienced
between the costal margin and the muscle
recurrent bronchoscopic compression 2
and the other vertical where the muscle
months following surgery necessitating
is sutured to itself. In a five year period, 31
open aortopexy via right thoracotomy.
patients were treated using this technique.
All five of the surviving patients have
been discharged home off all respiratory RESULTS: The age range was from 8
support. months to 3 years. The side of diaphragm
eventration was on left in 26 and on the
CONCLUSION: Future studies directly
right in five cases. There was no procedure-
comparing thoracoscopic to the open
related major complications or mortality.
aortopexy are needed to ascertain their
The repair was completed in all case
comparative effectiveness. In this small
thoracoscopically using 2/0 Ethibond Excel
series, thoracoscopic aortopexy proved
® Polyester stitches. Prolonged ileus was
to be both a feasible and an effective
noticed in 3 patients, reflux symptoms in 7
treatment for tracheomalacia refractory to
patients, buried stitches caused discomfort
non-operative management.
in two patients and chest deformity was
T021: THORACOSCOPIC IBIS HEAD reported in one patient. No recurrences
REPAIR OF CONGENITAL PARTIAL were reported in any of the patients.
DIAPHRAGMATIC EVENTRATION. A
CONCLUSION: Thoracoscopic Ibis-head
NEW ANATOMICAL RECONSTRUCTIVE
repair offers a tension free repair of
CONCEPT M ohamed M Elbarbary, MD,
late presenting antrolateral congential
Ahmed E Fares, MD, Haytham E Tantawy,
diaphragamticdefects An added benefit
MD, Ayman H Abdelsattar, MD, Mahmoud
is the elimination of use of synthetic
M Marei, MD, Hamed M Seleim, MD,
material.
Wissam M Mahmoud, MD, Departments of
Pediatric Surgery, Cairo University, Fayoum
University, Tanta Univerity
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these 29 patients were excluded from
this study. Mean follow-up period was
95 months with OR and 35 months with
LPEC (p<0.001). In consideration of this
difference in follow-up, log-rank testing
was used to analyze long-term results.
RESULTS: Mean age at operation was 3.72
years with OR and 3.75 years with LPEC
(p=0.81). Mean body weights were 14.73
kg and 14.72 kg, respectively (p=0.98).
Male:female ratios were 617:433 and
561:456, respectively (p=0.10). Preoperative
Fig shows the c-shaped diaphragmatic
laterality of hernia (right/left/bilateral) was
muscle edge after reorientation
546/319/113 and 534/319/92, respectively
resembling the Ibis -head
(p=0.42). All operations were performed
T022: IS LAPAROSCOPIC PERCUTANEOUS under general anesthesia. With LPEC, an
EXTRAPERITONEAL CLOSURE FOR asymptomatic contralateral internal ring
INGUINAL HERNIA EFFECTIVE was routinely observed, and when a patent
COMPARED WITH THE OPEN METHOD? processus vaginalis (PPV) was confirmed,
– A SINGLE INSTITUTION EXPERIENCE prophylactic surgery was performed
OF OVER 1000 CASES H iromu Miyake, Koji regardless of the size of patency. In the
Fukumoto, Go Miyano, Masaya Yamoto, LPEC group, of 908 patients preoperatively
Hiroshi Nouso, Keiichi Morita, Masakatsu diagnosed as unilateral (excluding cases
Kaneshiro, Naoto Urushihara, Shizuoka in which contralateral surgery had already
Children’s Hospital been performed), 379 patients (41.7%)
were confirmed with contralateral PPV
BACKGROUND: Laparoscopic percutaneous and underwent prophylactic LPEC. Mean
extraperitoneal closure (LPEC) for pediatric operative times for unilateral surgery in
inguinal hernia has recently been gaining OR and LPEC were 28.5 min and 21.2 min,
popularity. However, few reports have respectively (p<0.001). Mean operative times
compared LPEC with traditional open for bilateral surgery were 52.3 min and 25.4
repair (OR) using a certain level of cases min, respectively (p<0.001). Mean operative
and follow-up. The aim of this study was time was significantly shorter for bilateral
to compare LPEC with OR performed in a LPEC than for unilateral OR (p<0.001). The
single institution. frequency of postoperative recurrence
METHODS: This was a retrospective was 0.52% in OR (6/1158 sides) and 0.27%
study in one institution. Our institution in LPEC (3/1109 sides; p=0.53, log-rank
started LPEC for essentially all patients test). The frequency of postoperative
with inguinal hernia in July 2008. This contralateral metachronous inguinal hernia
study compared LPEC with OR using (CMIH) was 6.48% in OR (57/879) and 0.33%
1050 patients who underwent OR from in LPEC (3/908; p<0.001, log-rank test). No
July 2003 to June 2008 and 1017 patients postoperative testicular atrophy, iatrogenic
who underwent LPEC from July 2008 to cryptorchism or serious complications were
June 2013. From July 2008, 29 patients encountered in either group. Among the
underwent OR for reasons such as history 6 patients who underwent repeated LPEC
of peritonitis and associated cryptorchism; due to recurrence or CMIH, none showed
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intraabdominal adhesions during second RESULTS: Results of 1387 operations
surgery. were reviewed. Overall, 339 cases (24.4%)
were operated by trainees. The youngest
CONCLUSION: In our institution, both OR
patient was operated on day 2 of life with
and LPEC obtained satisfactory results
body weight 2.2kg (thoracoscopic repair
from the perspective of recurrence rate
of esophageal atresia). MIS advanced
and complications. In our series, operative
remarkably in volume (n=952; 68.6%)
time was shorter for bilateral LPEC than for
and complexity (neonatal, thoracic) in
unilateral OR. This shows that prophylactic
the second 5-year period. Statistical
contralateral LPEC is useful for preventing
improvement was seen in operative
CMIH without prolonging operative time
durations in four procedures (pyeloplasty,
compared with OR. Of course, some
splenectomy, fundoplication and resection
controversy remains regarding long-term
of CCAM, 25-40% reduction in operative
effects of LPEC, including fertility. Midterm
time, p=ns) and in complication/recurrence
safety and efficacy of LPEC are yet to be
in two procedures (hernioplasty and
proven, and lifelong assessment remains
appendicectomy, 50-75% reduction in
an outstanding issue with LPEC.
complications or recurrences, p = ns).
T023: DEVELOPMENT OF MINIMALLY Proportion of trainees and young fellows
INVASIVE SURGERY (MIS) IN A MEDIUM- performing I and II operations increased
VOLUME PEDIATRIC SURGICAL CENTER: significantly in recent years.
A TEN YEAR EXPERIENCE OF 1387 CONCLUSIONS: MIS can be developed
OPERATIONS P atrick Ho Yu Chung, MBBS, safely and comprehensively in a medium-
FRCS, Kenneth Kak Yuen Wong, PhD, Paul volume centre. Mastering the technique
Kwong Hang Tam, MBBS, MS, Department of common procedures fast-tracks the
of Surgery, Li Ka Shing Faculty of Medicine, development of rare, complex operations.
The University of Hong Kong MIS skills are transferrable across different
OBJECTIVE: A major challenge to the procedures and among surgeons, and can
development of minimally invasive be effectively incorporated in a surgical
surgery (MIS) in paediatric surgery is the training program.
wide spectrum of rare diseases. Here, we T024: HYBRID SIMULATION: A
present our institutional experience in its NOVEL CURRICULAR CHANGE FOR
development as a model for medium- AN ESTABLISHED TRAINING COURSE
volume comprehensive service and Katherine A Barsness, MD, MS, Deborah M
training centers. Rooney, PhD, Carroll M Harmon, MD, PhD,
METHODS: We reviewed our single- Northwestern University Feinberg School
centered MIS program in 2003-2012. of Medicine, University of Michigan Medical
Eleven index operations were selected School, University of Buffalo School of
and categorized into I, II and III according Medicine
to increasing technical demands
BACKGROUND: For more than 20 years,
(simple dissection/suturing to major
the annual minimally invasive surgery
reconstruction). Experience of surgeons
(MIS) fellows’ course maintained a basic
ranged from trainees, young fellows to
structure of morning lectures and an
senior surgeons. Comparison between
afternoon animate porcine laboratory skills
early (2003 - 2007) and late (2008-2012)
session. In 2012, a hybrid simulation model
developmental periods was made.
(inanimate tissue with synthetic surround)
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for esophageal atresia was introduced. evidence supports continued use of hybrid
Based on data from 2012 evaluations simulation during pediatric surgery training.
(“more access to simulation models” and
T025: LAPAROSCOPIC INTERRUPTED
“less time with [live animals]), the 2013
MUSCULAR ARCH REAPIR IN RECURRENT
course was converted from an animate
porcine lab to a fully hybrid simulation UNILATERAL INGUINAL HERNIA AMONG
laboratory session, eliminating the animate CHILDREN S herif M Shehata, PhD, Akram
porcine laboratory. We present our M ElBatarny, MD, Mohamed A Attia, MD,
subsequent evaluation results. Ashraf A AlAttar, MD, AbdelGhani Shalaby,
MD, Department of Pediatric Surgery,
METHODS: IRB-exempt study. Fifty-two Tanta University Hospital, Tanta, Egypt
previously described hybrid simulation
models (13 each: esophageal atresia/ INTRODUCTION: Laparoscopy became
tracheoesophageal fistula [TEF], duodenal widely used in the management of
atresia [DA], diaphragmatic hernia [DH] and pediatric inguinal hernia (PIH) especially
[Lobectomy]) were surgically modified/ in recurrent cases as we approach virgin
assembled. Thirty-seven pediatric surgery field with many advantages. In unilateral
residents performed MIS procedures on cases, many cases can be repaired by
the four hybrid models. The student to herniorraphy.
faculty member ratio was 3:1. At course AIM: We present a procedure with suturing
conclusion, participants were asked to the transverse abdominal fascial arch to the
evaluate the course across six domains ileopubic tract laparoscopiccally in order to
(29 items) using 5-point rating scales (1=no repair recurrent unilateral inguinal hernia.
value, 5=extremely valuable). Ratings were
evaluated using the many-Facet Rasch PATIENTS & METHODS: Twenty
model, reported as observed averages (OA). consecutive children with recurrent
unilateral PIH were treated along 5 years
RESULTS: Table 1. The highest observed period in a tertiary academic center. All
average (OA) was for Relevance to cases were subjected to laparoscopic
participants’ personal educational needs exploration followed by laparoscopic
(OA=4.9). Didactic sessions had an overall hernia repair as a day case surgery. Sutures
OA of 4.7 [4.4-4.86]. Hybrid models OAs were placed on from the fascial arch to
were 4.7 (DH), 4.6 (DA), 4.3 (TEF) and the ileopubic tract avoiding the spermatic
4.3 (Lobectomy). The global course OA vessels and duct in interrupted manner
was 3.3, with 3=continue the course for using 2/0 Prolene or Vicryl sutures. In
pediatric surgery training as is, with slight some cases, a purse string suture is added
improvements and 4=continue to use the to narrow the internal ring. The knot is tied
course, no changes. either intra corporeally or extra corporeally
CONCLUSIONS: With the availability of according to surgeon’s preference. The
high fidelity hybrid simulation models needle removed transabdominally.
relevant to pediatric surgical training, we Operative findings and post operative
have successfully converted a previously results and complications were assessed.
exclusive animate porcine educational The patients were followed for a period
course to a fully simulated course. ranged between 6 and 52 months.
Additional validity evidence for the use of RESULTS: We have 18 boys and two girls.
hybrid simulation models as educational Operative age ranged between 18 months
tools are still required, but preliminary and 15 years. Three or four sutures
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were placed in either case. In 4 cases, brain, in 3 (0,8%) – in retroperitoneal space,
additional purse string suture was added. in 2 (0,5%) - in mussels, in 2 (0,5%) - in
Operative time ranged between 35 & 70 pancreas. There were 12 (5,1%) urgent cases
min in unilateral cases without conversion. of liver cysts rupture. In 9 (75%) cases the
Scrotal edema reported in 4 cases, 2 cyst rupture was associated with trauma.
cases of port infection were reported In 3 (25%) - it happened spontaneously.
and treated conservatively. One case of Abdominal ultrasonography, CT, MRI
recurrence among boys was reported performed as a diagnostic procedures
and no case of testicular atrophy was before surgery. In 11 (91,6%) patients we
reported in the follow up period. Cosmetic performed laparoscopic approach for
outcomes were excellent. treatment of th?se complicated cases, in
1 (8,4%) – open surgery. Four trocar (10, 6,
CONCLUSION: This procedure is helpful
6, 22 mm) approach was performed. Free
in the functional reconstruction of the
hydatid fluid was identified and aspirated
inguinal canal in recurrent cases of
from abdomen cavity. In 8 (72,7%) cases
unilateral inguinal hernia. Laparoscopic
ruptured cysts were located in a right lobe,
inguinal herniorraphy by this technique
in 3 (27,3%) – in a left. We used 22 mm
is feasible and safe. Consequently, there
trocar for vacuum extraction of endocyst.
is lower risk of injury to the spermatic
Abdomen cavity was irrigated by saline
duct or vessels than the conventional
solution. We performed betadine solution
herniorrhaphy. Larger studies and long-
for the processing of fibrous capsule.
term follow up are needed to support our
One tube used for draining of residual
encouraging results.
cavity. One, or two - for draining of the
T026: LAPAROSCOPIC TREATMENT OF abdominal cavity. All patients accepted
LIVER HYDATID DISEASE IN CASES OF 10 mg/kg of albendazolum during 6
CYST RUPTURE IN CHILDREN S agidulla weeks postoperatively. Operation time,
Dosmagambetov, Bulat Dzenalaev, Aitzan conversion rate, complications rate, length
Baimenov, Vladimir Kotlobovskiy, Aslan of hospital stay were analyzed.
Ergaliev, Aslbek Tusupkaliev, Ibatulla RESULTS: It was no mortality. Duration
Nurgaliev, Roza Kenzalina, Kidirbek of operation time was 61.3+-13.6 min. It
Altaev, Kuben Satibaldiev, Egor Roskidailo, was 1 (8,4%) case of billiary peritonitis,
Department of Laparoscopic Surgery, associated with billiary fistula. Laparoscopic
Regional Pediatric Hospital, Aktobe, suturing of billiary fistula was performed
Kazakhstan on a third day after primary procedure.
AIM: Evaluation of efficiency of Duration of the hospital stay was 9.8+-1.5
laparoscopic treatment of liver hydatid days. It was 1 (8,4%) case of recurrence
disease in cases of cyst rupture in children. with dissemination of the process in an
abdomen cavity.
MATERIALS: Since 1993 till February 2014
375 children ranging from 4 to 14 years CONCLUSION: Laparoscopic approach could
of age with hydatid disease underwent be successfully performed for treatment of
surgery. In 236 (62,9%) cases hydatid liver hydatid disease in cases of cyst rupture.
located in liver, in 83 (22,1%) cases – in It demonstrates good post-operative
lung, in 36 (10,9%) – in kidney, in 6 (1,6%) – results, low rate of complications and
in omentum, in 2 (0,5%) – in uterine tubes, recurrence, short duration of operation time
in 3 (0,8%) – in spleen, in 2 (0,5%) – in and hospital stay.
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T027: OUTCOMES OF SINGLE PORT effective and has comparable outcomes
SURGERY FOR PERFORATED APPENDICITIS to traditional approaches for perforated
IN CHILDREN: SINGLE SURGEON appendicitis in historical literature.
EXPERIENCE A desola C Akinkuotu, MD,
T028: THORACOSCOPIC APPROACH
Paulette I Abbas, MD, Shiree Bery, MD,
OF BILATERAL CHYLOTHORAX: VIDEO
Ashwin Pimpalwar, MD, Texas Children’s
Marcelo Martinez Ferro, MD, Fernando
Hospital and the Division of Pediatric surgery,
Rabinovich, MD, Carolina Millan, MD,
Michael E. DeBakey Department of Surgery,
Horacio Bignon, MD, Gaston Bellia, MD,
Baylor College of Medicine, Houston, TX.
Luzia Toselli, MD, Mariano Albertal, MD,
INTRODUCTION: Advances in laparoscopic Private Children´s Hospital of Buenos Aires,
surgery have led to the use of single- Fundación Hospitalaria, Buenos Aires,
incision/port laparoscopy surgery (SILS) Argentina
for general surgical operations including
The development of chylothorax is a
appendectomies. At our institution, a
relatively common complication after
single surgeon routinely performs SILS
pediatric cardiac surgery. The resolution
appendectomies for acute appendicitis.
of this complication poses a significant
There is limited data in literature for
challenge to surgeons and there is no
outcome of SILS in perforated appendicitis.
consensus for the most appropriate
PURPOSE: To report outcomes for SILS in therapeutic strategy.In this video, we shown
children with acute perforated appendicitis. thethoracoscopic correction of a bilateral
chylothorax on a 2-month old baby.
METHODS: We reviewed the records of
all pediatric patients who underwent T029: THE USE OF ROBOTIC SURGERY
SILS appendectomy for acute, ALLOWS FOR IMPROVED DEXTERITY
perforated, appendicitis, performed by AND VISUALIZATION DURING
a single surgeon, between 2009 -2013. THORACOSCOPIC THYMECTOMY S hannon
Appendectomy was performed using the F Rosati, MD, Dan Parrish, MD, Patricia
single port (Olympus Triport) by single Lange, MD, Claudio Oiticica, MD, David
incision through center of the umbilicus Lanning, MD, PhD, Children’s Hospital
(keeping within the limits of the umbilicus) of Richmond at Virginia Commonwealth
completely intra-corporeally by using University Medical Center
conventional laparoscopy equipment.
INTRODUCTION: Myasthenia gravis (MG) is
RESULTS: 72 patients underwent SILS for an autoimmune neuromuscular disease,
acute, perforated, appendicitis. Age of the effects of which can be improved
patients undergoing SILS was (Median of or alleviated by thymectomy in young
8.7±3), length of operation was (median, patients. However, median sternotomies
58(36-140) minutes and length of hospital or thoracotomies have a high degree
stay was (Median 5.5±3.4days). Only of morbidity, especially when already
one patient was converted to traditional weakened from their MG. A thoracoscopic
laparoscopy. Post-operative complications approach allows for a minimally-invasive
included wound infection 9/71 (12.7%), intra- approach but it can be technically
abdominal abscess formation 12/71 (16.9%), challenging to completely remove all of
and post-operative ileus 15/72 (20.8%). the thymic tissue in the contralateral chest
and lower neck, especially in the smaller
CONCLUSION: SILS for perforated
children that typically have larger glands.
appendicitis in children is safe and
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The robotic-assisted approach allows for that had been placed through the slightly
the use of articulating instruments and 3D widened 8-mm trocar defect. The lungs
visualization were fully inflated prior to the fascia being
closed at all port sites without placing a
PATIENT: This patient is a three year old boy
chest tube. No pneumothorax was seen on
who had been suffering from generalized
the postoperative chest xray. The patient
MG. Due to disease progression that was
tolerated the procedure well without any
only partially controlled by medications, his
postoperative complications, had minimal
neurologist referred him for thymectomy.
blood loss, and was discharged home the
After a lengthy conversation with his
following day.
parents, the decision was made to proceed
with a robotic-assisted left thoracoscopic CONCLUSION: The use of robotic-
thymectomy. assistance in thoracoscopic thymectomies
with its articulating instruments and 3D
TREATMENT: The patient was placed in
visualization has allowed for this approach
the supine position on the operating room
to be offered to younger and smaller
table. Through a transverse incision in the
patients despite having a larger thymus.
left axilla, a 5-mm XCEL trocar was placed
This approach allows these patients to
in the ? interspace, and pneumothorax
benefit from an earlier thymectomy while
was created with a pressure of 4 mmHg.
avoiding the morbidity from a sternotomy
One additional 5-mm robotic trocar was
or large thoracotomy.
placed in the left mid-clavicular line in
the 6th interspace, and an additional 8mm T030: TREATMENT OF THE
trocar was placed in the 6th interspace in CHYLOPERICARDIUM THROUGH MINIMAL
the anterior axillary line. The XCEL trocar INVASIVE TECHNIQUES REPORT OF A
was replaced with a 5mm robotic trocar. At PEDIATRIC CASE C arlos Garcia-Hernandez,
this point, the robot was docked, and the MD, Lourdes Carvajal-Figueroa, MD,
8-mm camera and 30 degree scope was Adriana Calderon-Urreta, MD, Sergio
placed in the central trocar. Hook cautery Landa-Juarez, MD, Hospital Star Medica
and a Maryland grasper were used to Lomas Verdes. Mexico
dissect the gland off of the heart. The left
lateral aspect of the thymus was lateral to INTRODUCTION: The chylopericardium is
the left phrenic nerve, which was identified a rare entity in pediatrics. There are few
and preserved. Dissection was continued publications about the occurrence of
in a caudad direction to free up the entire this disorder in children, and most of the
left lobe of the gland and carried over available reports are related to cases in
toward the right chest. A small hole was cardiovascular surgeries. The objective of
made in the right pleura to prevent tension this paper is to present the case of a child
pneumothorax from developing. At this that developed chylopericardium without
point, the dissection was carried around an apparent cause, its diagnostic, as well as
the right lobe of the thymus with care its successful resolution through a ligature
taken to preserve the right phrenic nerve. of the thoracic conduct and the creation of
Dissection was continued to free the gland a pericardial window using approach.
from the heart as well as both superior CASE PRESENTATION: Male patient of
horns that extended well into the lower 6 years of age, started with symptoms
neck. Once the organ was dissected free, (cervical and thoracic pain) 3 weeks
it was placed into a 10-mm Endocatch bag before admission to hospital after
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falling from his own height. The it is rather believed that such occurrence is
x-ray showed cardiomegaly and the a consequence of a leakage in the insertion
echocardiogram demonstrated the of the thoracic conduct in the superior cava
existence of a pericardial effusion. After vein. When the medical treatment happens
300 ml. of a white liquid were drained to fail it must be solved through surgery,
through pericardiocentesis, a pericardial as demonstrated in the above mentioned
catheter was placed. The aspired liquid case. The best option is to perform a
presented 1910 mg/dl of triglycerides ligature of the conduct with the creation
and chylomicrons of 21.3. Treatment of a pericardial window. Performing this
was initiated using NPT, octreotide and surgery through thoracoscopic approach
diet with mid-chain triglycerides. With results in the well-known advantages of
magnetic resonance lymphatic anomalies minimum invasive procedures in terms of
were discarded. Upon failure of the recovery, in addition to the magnification
medical treatment, due to an increase of images that allows us to locate and link
in expenditures, surgery was performed the thoracic conduct safely, immediately
using a thoracoscopic approach through controlling the chilothorax and avoiding
the right. The thoracic conduct was future complications.
dissected upon entry to the thorax and
T031: LAPAROSCOPIC URETEROVESICAL
linked with a 2-0 silk, the pericardia was
PLASTY FOR MEGAURETER`S
incised to create a window ranging from
the diaphragm until the union of the TREATMENT S ergio Landa-Juárez, MD,
superior cava and the auricular, resulting in Ana María Castillo-Fernández MD,
an engrossed pericardia. Oral feeding after Angélica Alejandra Guerra-Rivas MD,
24 hours without increasing the pleural Arturo Medécigo Vite MD, Hermilo De La
expenditure and catheter was removed Cruz-Yañez MD, Carlos Garcia-Hernández
after 72 hours; patient was discharged on MD, Hospital de Pediatria, Centro Médico
the fourth day. Follow up after 6 months Nacional Siglo XXI. IMSS
without complications, with normal PURPOSE: The ureterovesical junction
echocardiographic and radiological control. stenosis is a distal ureteral obstructive
DISCUSION: The chylopericardium anomaly which causes megaureter. When
in children occurs most of the time surgical reconstruction is necessary the
after cardiovascular surgery. The megaureter is traditionally detached, the
aforementioned case could be stenotic segment resected and in some
considered idiopathic as the traumatism cases tailoring is recommended. This paper
was reduced and the event provoked proposes an alternative laparoscopic
an x-ray that marked the beginning treatment for obstructive and obstructive-
of the study. Disregarding the volume refluxing megaureter sparing the
of the accumulated liquid, as well as uterovesical junction (UVJ).
for an unknown reason, the patients PATIENTS AND METHODS: 7 patients with
with this disorder can have severe febrile urinary tract infection were studied
tamponed symptoms or otherwise be with ultrasound, cystogram, excretory
asymptomatic as in the reported case. In urography and MAG3 renal scan. Six were
the idiopathic cases the physiopathology diagnosed with obstructive and one with
of the accumulation of the chylo in the obstructive-refluxing megaureter. The
pericardium rather than in the pleural diameters varied between 8 to 10mm.
space has yet been thoroughly studied, and Laparoscopic ureterovesical plasty
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consisted in a longitudinally incision on the The patient with febrile urinary tract
anterior ureteral wall above and through infection after surgery was tested with
the stenotic segment including vesical renal scan reporting improvement from
mucosa maintaining the ureter´s posterior preoperative to postoperative conditions.
wall attached to the bladder (Fig. 1).
Cystourethrogram study was done for
study purposes only. Six of seven patients
with no reflux reported. The remaining
patient without cistourethrogram moved
from country residence and the study has
not been considered necessary by new
physician.
CONCLUSIONS: Laparoscopic approach
FIG. 1
allows a good ureteral stenotic segment
Then a transverse ureter to bladder identification and combined with
mucosa anastomosis was peformed to Lich Gregoir and Heineke-Mickulicz
relieve obstruction (Fig. 2). ureterorraphy of stenotics segments at
ureterovesical junction is a novel, simple
and speedy technique for megaureter
treatment.
Further more, allows to calculate the need
for detrusotomy extension when needed
to ensure antireflux mechanisms.
T032: VIDEO ASSISTED
FIG. 2 EXTRACORPOREAL PYELOPLASTY E dgar
RESULTS: From a total of 7 cases, 2 were Rubio Talero, MD, Fernando A Escobar
women and 5 men aged between 5 Rivera, MD, CLINICA SALUDCOOP TUNJA
months and 3 years old. The operative time Dismembered Pyeloplasty is still the “Gold
ranged from 90-120 minutes with a 48- Standard” in the treatment of obstructive
hour hospital stay. Urethral catheter and hydronephrosis.
double “pig” tail stent were used for 48
hours and six weeks respectively. Antibiotic What has changed in recent years is the
was used in therapeutic doses for 7 days approach to perform this operation.
and prophylactic doses for 8 weeks. The Robotics and Laparoscopy have
average follow-up was 17.7 months. demonstrated to be good surgical
resources to solve Uretero-Pelvic-
One female patient developed febrile Junction (UPJ) obstruction. Nevertheless,
urinary tract infection a week from surgery. the complexity of robotic surgery,
Thereafter she remained asymptomatic, the unaffordable that it is to most of
with normal urinalysis, as did the remaining the patients around the world and
patients. the advanced skills that has to have a
Ultrasound and excretory urography at laparoscopic surgeon, working in limited
six months from surgery demonstrated space, make these techniques too
improvement in ureteral and pyelocaliceal demanding and not always reproducible.
diameters. This makes sound the idea of combine the
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benefits of laparoscopic approach and T034: THE CHARACTERIZATION OF
the agility of the open surgery suturing. PECTUS EXCAVATUM INCLUDING
This is the case of VIDEO ASSISTED ITS ASYMMETRY S ergio B Sesia, MD,
EXTRACORPOREAL PYELOPLASTY. Margarete M Heitzelmann, Sabine
Schaedelin, MSc, Olaf Magerkurth, MD,
The aim of this Video presentation is
Frank-Martin Haecker, MD, University
to review step by step this technique,
Children’s Hospital of Basel, Department
highlighting the tricks and maneuvers
of Pediatric Surgery and Department of
to get success and improve the results
Pediatric Radiology, Spitalstrasse 33, 4056
in the management of obstructive
Basel, Switzerland; University of Basel,
hydronephrosis
Clinical Trial Unit,Schanzenstrasse 55, 4031
T033: THE USE OF A 5-MM ENDOSCOPIC Basel, Switzerland
STAPLER FOR RECTAL TRANSECTION
BACKGROUND: The Haller-Index (HI) >
DURING LAPAROSCOPIC SUBTOTAL
3.25 by computed tomography (CT) is the
COLECTOMY S imone Frediani, MD, Silvia
main criterion to indicate surgical repair
Ceccanti, MD, Romina Iaconelli, MD,
in patients with pectus excavatum (PE).
Falconi Ilaria, MD, Debora Morgante, MD,
However, the level along the sternum
Denis A Cozzi, MD, Policlinico Umberto I
in which the HI is measured, is not
Hospital and Sapienza University of Rome,
standardized. Commonly, the deepest
Rome, Italy
point of the sternum is considered.
This video depicts a 9.5-year-old boy with Additionally, the HI alone is unable to
longstanding ulcerative colitis resistant describe asymmetric deformities of the
to maximal medical therapy. Following anterior chest wall.
unsuccessful split ileostomy performed
The aim of this study was to propose an
elsewhere, he was then elected for
Asymmetry-Index (AI) in addition to the
laparoscopic subtotal colectomy.
HI for a more objective characterization
The procedure entailed a 12-mm
of both the depth of the PE and its
transumbilical port for the camera and
asymmetry and to evaluate its impact in
three 5-mm working ports. Dissection
the surgical indication.
and hemostasis were achieved utilizing a
single vessel sealing device throughout METHODS: After institutional review board
the procedure. The present video focuses approval, the HI of 43 PE-patients and
on the transection of the rectosigmoid of 33 children of the control group from
junction, which was carried out utilizing the University Children’s Hospital of Basel
a newly devised 5-mm endoscopic (UKBB) was measured retrospectively
articulating linear stapler. The specimen at three different levels (HI1, HI4, HI5).
was easily extracted via the distal stoma Sensitivity and specificity of the HI in these
site. Given the patient’s poor general levels were compared. Furthermore, an
health status, clinical improvement was asymmetry index was calculated at the
slow but progressive. Ultimate cosmetic same three levels (AI1, AI4, AI5). All the
results were excellent. We believe that measurements were based on CT scan.
the above described 5-mm endoscopic Validity was assessed using McNemar and
stapler has the potential for wide scope exact McNemar tests.
and application in pediatric minimally
RESULTS: There is a moderate higher
invasive surgery.
sensitivity of the HI when measured at
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level 4 instead of level 1 or 5. The AI at MATERIALS & METHODS: A survey was
level 1 has a higher sensitivity than at sent to the seven institutes regarding the
level 4 and 5. Combining HI4 and AI1, the operative indications, surgical technique,
sensitivity significantly increases compared postoperative management and outcomes
to HI4 alone. of thoracoscopic repair of EA/TEF.
CONCLUSIONS: Our study showed that RESULTS: All institutes responded to the
HI evaluated at level 4 combined with AI survey. A low birth weight (five institutes),
at level 1 increases the accuracy of the associated anomalies (three institutes) and
description of the chest wall deformity compromised physiologic status (three
compared to HI4 alone. Additionally, HI institutes) were identified as common
at level 4 combined with A1 at level 1 exclusion criteria for thoracoscopic
increases the accuracy of the indication to repair. The operation was uniformly
surgical repair of the PE. performed via an intrapleural approach
in the 0~45?prone position. Preoperative
T035: CURRENT PRACTICE AND
bronchoscopy was routinely performed
OUTCOMES OF THORACOSCOPIC
in six (85.7%) institutes, and single lung
ESOPHAGEAL ATRESIA AND ventilation was performed in two (28.6%)
TRACHEOESOPHAGEAL FISTULA REPAIR: institutes. The TEF was occluded with suture
A MULTI-INSTITUTIONAL ANALYSIS ligature in four (57.1%) institutes and clips
IN JAPAN H iroomi Okuyama, MD, PhD, in the remaining three (42.9%) institutes.
Hiroyuki Koga, MD, PhD, Tetsuya Ishimaru, Anastomosis was performed using the
MD, PhD, Hiroshi Kawashima, MD, Atsuyuki extracorporeal knot-tying technique
Yamataka, MD, PhD, Naoto Urushihara, using 5-0 to 6-0 absorbable sutures in
MD, Osamu Segawa, MD, PhD, Hiroo four institutes and the intracorporeal
Uchida, MD, PhD, Tadashi Iwanaka, MD, technique in three institutes. In order to
PhD, Dept of Pediatric Surgery, Hyogo facilitate anastomosis, stay sutures were
College of Med.; Juntendo University used in three (42.9%) institutes. During
School of Med.; The University of Tokyo surgery, chest and transanastomotic tubes
Hosp.; Saitama Children’s Hosp.; Shizuoka were placed in all institutes. Patients were
Children’s Hosp.; Tokyo Women’s Medical routinely left intubated and paralyzed for
University; Nagoya University Graduate three to seven days postoperatively in four
School of Med. institutes.A total of 58 patients underwent
BACKGROUND: The optimal surgical thoracoscopic repair of EA/TEF at the seven
treatment of infants with esophageal institutes. Fifty-two (89.7%) of the patients
atresia and tracheoesophageal fistula underwent successful thoracoscopic repair.
(EA/TEF) remains controversial. In order Six (10.3%) operations were converted
to better understand the current practice to open thoracotomy due to a long gap
and outcomes of thoracoscopic repair (4), right aortic arch (1) and intraoperative
of EA/TEF, a multi-institutional analysis instability (1). One operation was staged
was conducted among seven Japanese due to the patient’s low birth weight. The
institutes that perform advanced body weight at operation ranged from 1.2
laparoscopic and thoracoscopic procedures to 4.6 kg, while the age ranged from 0 to
in infants and children. All of the co- 194 days and the operative time ranged
authors belong to these institutes. from 115 to 428 minutes. There were no
major intraoperative complications. The
gap distance between the proximal and
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distal esophagus for anastomosis ranged risk of impaired defecation function in
from zero to four vertebral bodies. Eleven long term follow-up. Single-incision
patients (19.0%) suffered from anastomotic laparoscopic endorectal pull-through
leakage, which healed following (SILEP) was technically feasible and safe
conservative management. Twenty-eight in selected HD patients offering better
patients (48.3%) developed anastomotic cosmesis and less postoperative pain in
stricture, all cases of which responded comparison with conventional laparoscopic
successfully to endoscopic dilatation. One procedures. However, it is stressful for the
patient died during the postoperative period surgeons in view of its low manipulability
due to an unrelated disease. Recurrent and poor visualization because clashing of
TEF developed in three infants (5.2%). instruments. We applied the technique of
Thirteen patients (22.4%) later required SILEP using a trocarless instrument via an
fundoplication. another abdominal stab incision to obtain
further improvement of SILEP.
CONCLUSIONS: Considerable variability was
observed among the seven institutes with METHODS: Between August 2010 and July
respect to the operative indications, surgical 2013, 32 patients with HD were performed
technique and postoperative management SILEP with a trocarless instrument. There
of thoracoscopic repair of EA/TEF, which were 24 males and 8 females, with a
can be safely performed with less surgical mean age of 3.6 months. Under general
trauma by experienced endoscopic anesthesia, a single transumbilical vertical
surgeons. However, postoperative stricture incision was made. Two 5.0 mm trocars
was common in this series, although there were inserted into the peritoneal cavity
were no major intraoperative complications. at horizontal ends of umbilical incision. A
The identification of variance in this survey 3.0 mm instrument was inserted through
is the first step to conducting future studies the left abdominal stab incision. After
to identify best practices. Standardizing obtaining the critical view, two or three
the surgical technique and postoperative seromuscular leveling biopsies of the
management may reduce the incidence of rectum and colon were obtained to identify
complications after thoracoscopic repair for the transitional zone. Rectum and colon
EA/TEF. were mobilized 5 cm proximal to the
normal colon by elevating the mesentery
T036: SINGLE-INCISION LAPAROSCOPIC
using a 3 mm grasping forceps and
ENDORECTAL PULL-THROUGH FOR
dissecting it using the ultrasonic scalpel,
HIRSCHSPRUNG’S DISEASE WITH until the colon pedicle was long enough
TROCARLESS INSTRUMENT VIA AN to reach deep into the pelvis without
ANOTHER STAB INCISION S hao-tao tension. The dissection was continued to
Tang, MD, Shi-wang Li, MD, Li Yang, the peritoneal reflection of the rectum.
Department of Pediatric Surgery, Union Rectal mucosa dissection was performed
Hospital of Tongji Medical College, transanally by the electrocautery
Huazhong University of Science and technique. The aganglionic and dilated
Technology,Wuhan 430022, China segments were resected and coloanal
BACKGROUND: Transanal endorectal anastomosis was performed.
pull-through for HD was a relatively safe RESULTS: 10 patients with the transitional
and feasible procedure. However, over zone in the rectum, 17 patients in the
stretching on anal sphincter and mesentery sigmoid colon and 5 patients in the
of sigmoid colon might cause potential
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descending colon. All procedures were the laparoscopic group, median age at
performed without adding another ports presentation was 5 weeks (range: 2-9weeks),
or conversion to open approach. The mean gender (31 male, 78%), mean weight 3.9kg
operative time was 116 min. There was no (range: 2.5-5.3kg) and 3 had positive family
major intraoperative complications. In history. Complications were noted in 5
regard to early postoperative complications, patients (13%); 3 had duodenal perforation
mainly perianal excoriation occurred in 9 (site of perforation; 2 at site of grasper and
patients. No anastomotic leak occurred. 1 at site of pyloromyotomy) repaired with
Postoperative enterocolitis occurred in one open conversion, 1 further patient had open
patient, who was relieved by transfusion and conversion due to technical difficulty, 1
colon irrigations requiring rehospitalization. had open re-do pyloromyotomy 4 weeks
There was no recurrent constipation. later for inadequate pyloromyotomy, 1 had
Clashing between the laparoscope and the port-site infection requiring oral antibiotics,
instruments was reduced by changing the and 1 had epigastric port-site omental hernia
insertion site of forceps. Follow-up for 6 requiring surgical repair.
months to 3 years in all patients showed
CONCLUSION: Laparoscopic
excellent cosmetic appearance.
pyloromyotomy is a feasible treatment
CONCLUSION: Our procedure is feasible for pyloric stenosis although technical
and safe for performing SILEP in selected challenges should be appreciated. Our
HD patients, and the improved results are experience highlights the importance
attributable to the introduction of a 3 mm of gentle grasping of the duodenum
forceps through the left abdominal stab for stabilisation during pyloromyotomy
incision. and ensuring clear visualization whilst
spreading the pyloric muscle.
T037: AUDIT OF INITIAL EXPERIENCE OF
LAPAROSCOPIC PYLOROMYOTOMY H elai T038: OUTCOMES AFTER EARLY
Habib, MBBS, BSc, Mohamed Shalaby, SPLENECTOMY FOR HEMATOLOGICAL
FRCS, Paed, Surg, Philip Hammond, FRCS, DISORDERS E lizabeth Renaud, MD, Nirmal
Paed, Surg, Atul Sabharwal, FRCS, Paed, Gokarn, MD, Deepa Manwani, MD, Steven
Surg, Royal Hospital for Sick Children, Borenstein, MD, Dominique Jan, MD, PhD,
Yorkhill, Glasgow, UK Montefiore.Medical Center
AIM: Laparoscopic pyloromyotomy has PURPOSE: Acute splenic sequestration
recently been introduced at our institution. crisis is a potentially life threatening
Our aim was to audit this initial experience, complication of sickle cell disease which
focusing on complications. can require prophylactic splenectomy.
Historically, splenectomy before age 5
METHODS: Patients who had laparoscopic
was avoided due to fear of overwhelming
pyloromyotomy between 2005 and 2014
post-splenectomy sepsis. Recently,
inclusive were identified retrospectively
splenectomy has been performed as early
from the theatre database. These
as age 2, but the safety of this approach is
case notes were reviewed regarding
unknown. This study compared outcomes
demographics, presentation, operative
of splenectomy performed in patients
details and post-operative course.
under 5 to those 5 years and older.
RESULTS: During the study period 605
METHODS: A retrospective chart review
pyloromyotomies were performed, 40
of patients registered in a children’s
attempted laparoscopically (7%). For
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hospital hematology database was INTRODUCTION: Appendicitis is one of
performed to examine intra-operative, the most common surgical emergencies
post-operative, and long-term outcomes in the pediatric population. Despite this,
after splenectomy. Statistical data analysis there is still a great deal of debate among
included Chi-Square test and Fisher’s pediatric surgeons regarding the workup
exact tests for categorical variables and and treatment of this condition. The
the Non-Parametric Median test for introduction of virtual broadcasts has
continuous variables. The Institutional created a forum where surgeons all over
Review Board approved this study. the world can discuss various controversial
topics without being in one physical
RESULTS: From 1997 to 2013, 30 sickle cell
location. A case in point is appendicitis.
patients underwent splenectomy. At time
While there is an immense body of
of surgery, 18/30 patients were under age 5
literature relating to the management of
(group1) and 12/30 patients were 5 years or
appendicitis, the literature is often varied
older (group2). Mean age at splenectomy
and so are common practices, especially
was 34.2 months for group1 and 83.6
internationally. During a live, virtual,
months for group2. Almost all procedures
consensus conference in September
were laparoscopic, and there was no
of 2013, we polled pediatric surgeons
difference between groups in frequency of
from around the world regarding their
laparoscopic or open splenectomy (group1,
preferences in the management of
18 laparoscopic; group2, 9 laparoscopic
appendicitis. Results are reported here.
and 1 open). There was no difference in
the operative time, rate of conversion METHODS: During the interactive
from laparoscopic to open procedure, or broadcast session, questions about
frequency of intra-operative complications. diagnosis and management of appendicitis
The median length of stay was 4 and 6 days were displayed on the screen. World-
for group1 and group2 respectively. Both renowned faculty and pediatric surgeon
groups had similar lengths of follow up audience members were then asked to
(median of 62.5 months group1, 63 months respond to the poll questions.
group2). No portal vein thromboses or
RESULTS: Questions asked were in the
post-splenectomy sepsis events occurred in
form of clinical scenarios. These included:
either group.
A 12 –year old boy with classic history
CONCLUSIONS: While the statistical and exam for appendicitis. Is imaging
power of this study was limited, there needed? Majority (69.2%) reported no
was no evidence that the incidence imaging, 26.9% - Ultrasound, none chose
of complications was higher after CT scan. When a question was asked
splenectomy at a younger age. A large, about acute, non-ruptured appendicitis
multi-center study is needed to further to be treated non-operatively, 7.1% said
evaluate the safety of this practice. they would treat non-operatively with
antibiotics whereas the majority (92.9%)
T039: BRINGING SURGEONS TOGETHER
said they would operate.For suspected,
ACROSS THE WORLD: DIAGNOSIS AND
acute, non-ruptured appendicitis at 11pm,
MANAGEMENT OF ACUTE APPENDICITIS when would you operate? The majority
Margaret Nalugo, MPH, Todd A Ponsky, (65%) reported that they would operate
MD, George W Holcomb III, MD, Akron the next day, the rest reported that they
Children’s Hospital, Children’s Mercy would operate that night. Regarding
Hospital
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Poster Abstracts
technique the majority (56.8%) preferred INTRODUCTION: Vaginal and cervical
standard 3- port laparoscopy for non- avulsions after sexual intercourse are
perforated appendicitis, 37.8% preferred very rare in healthy female patients. The
single-incision appendectomy and the rest standard approach for such lacerations
preferred open appendectomy. Regarding utilizes a tenaculum to pull the cervix out
antibiotic doses after appendectomy more superficially in order to facilitate
for acute, non–ruptured appendicitis repair. There is one reported case in the
and length of stay, the majority (56.67%) literature of laparoscopic intraabdominal
preferred one more dose of antibiotic repair of a vaginal rupture with evisceration
and discharge 24hours postoperatively, after intercourse. Here we describe a
16.67% preferred no further antibiotic transvaginal endoscopic repair of a deep
and discharge 24hours postoperatively, vaginal laceration.
20% preferred no further antibiotic and
DESCRIPTION: An otherwise healthy 17
discharge from recovery room or soon
year-old girl presented with a one week
thereafter , while 6.67% preferred one
history of heavy vaginal bleeding after her
more dose of antibiotics and discharge
first sexual intercourse encounter. The
after the dose. Regarding return to
patient described using 4 to 5 pads per
full activity following laparoscopic
day with evacuation of large blood clots.
appendectomy; Majority of the surgeons
No external trauma was observed so the
(33.3%) reported after two weeks, 16.67%
patient was emergently scheduled for
and 16.67% reported after three and
examination under anesthesia.
4 weeks respectively, 20% reported
after one week and 13.33% reported no The patient was placed in a lithotomy
restrictions. position. Using a speculum, we visualized
an actively bleeding partial cervical
If on postoperative day 10 the child is not
avulsion due to a deep partial thickness
clinically well and still has a low grade
laceration in the posterior vaginal fornix.
fever; 56.25% of the surgeons would get a
Repair using standard surgical instruments
CT scan, the rest would get an ultrasound
was unsuccessful. Given the risk of
and none would continue intravenous (IV)
completely avulsing the cervix if pulled
antibiotics without any studies.
outward using a tenaculum for repair,
CONCLUSION: The use of virtual broadcasts we opted to use a 5 mm, 30 degree
affords a unique opportunity for surgeons laparoscope and laparoscopic instruments
around the world to share their practice including a knot pusher to repair the
strategies with each other and gauge if laceration cervix. Hemostasis was
they practice significantly different than accomplished and the patient recovered
the majority of others. This is especially uneventfully thereafter.
suited for topics such as appendicitis were
CONCLUSION: We describe the successful
diagnosis and treatment can be widely
use of laparoscopic instruments to
varied.
repair a deep vaginal laceration in lieu
T040: A NOVEL REPAIR OF A VAGINAL of maneuvers to pull the cervix out
FORNIX LACERATION FOLLOWING superficially. This technique is simple and
INTERCOURSE U lises Garza Serna, MD, should be considered to avoid worsening
David Bliss, MD, Nam Nguyen, MD, existing tears that may occur with
Kasper Wang, MD, University of Southern manipulating the anatomy.
California, Children’s Hospital Los Angeles
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P001: THE INFLUENCE OF OPEN P002: LAPAROSCOPIC MANAGEMENT OF
APPENDECTOMY AND LAPAROSCOPIC POSOPERATIVE BOWEL OBSTRUCTION
APPENDECTOMY ON CD14, MD-2 AND IN CHILDREN F ernando Rey, MD, William
TLR4 SIGNAL PATHWAYS IN CHILDREN Murcia, MD, Andrés Pérez, MD, Nidia
WITH PERFORATED APPENDICITIS J ian Vera, MD, David Díaz, MD, Clinica Infantil
Wang, MD, Jie Zhu, MD, Children’s Hospital Colsubsidio Bogotá, Colombia
of Soochow University
INTRODUCTION: Peritoneal adhesions are
BACKGROUND: The inflammatory process a major cause of postoperative intestinal
in the post-appendectomy period is not obstruction in children, the surgical
well characterized. This study aimed to treatment is considered in cases where
compare the inflammatory response the non-surgical management does not
during open appendectomy (OA) and work or when there are signs of intestinal
laparoscopic appendectomy (LA) and ischemia . Historically, the open release of
the underlying Toll-like receptor (TLR)- peritoneal adhesions was the conventional
mediated signal transduction pathways. treatment for this pathology; in recent
years, laparoscopic management has
MATERIAL & METHODS: We examined
showed lower recurrence of adhesions,
17 children with perforated appendicitis
less postoperative pain and shorter
undergoing OA and 19 children undergoing
postoperative hospitalization. The objective
LA. Monocytes at different time points
of this study is to describe our experience
before and after surgery were evaluated.
in the management of adhesive intestinal
TLR4, CD14, and MD-2 expression, LPS-
obstruction in a children’s hospital.
mediated inflammatory response, and TLR
signaling pathways were examined. OBJECTIVE: To describe the results of
laparoscopic management of adhesions
RESULTS: The expression of TLR4 and
in children with postoperative intestinal
MD-2 is increased in LA group, while there
obstruction.
is no difference in CD14, TLR4, and MD-2
expression in OA group. LPS stimulated RESULTS: 6 patients with postoperative
ex vivo production of inflammatory intestinal obstruction were managed with
cytokines was not affected in LA group, adhesiolysis by laparoscopy, the mean
but the diminished TNF-a was found after age was 11.6 years (range 3-17 years),
surgery in OA group. The phosphorylation 67% female and 33 % male, all patients
of STAT3 and ERK1/2 in monocytes after were studied with abdominal X-ray,
LPS stimulation was also suppressed in OA evidencing signs of mechanical intestinal
group, while no difference was found in LA obstruction. They were initially managed
group. with nasogastric tube between 1 and
5 days without improvement, so they
CONCLUSIONS: LA, rather than OA, could
were taken to surgery. All patients had
protect monocyte-mediated inflammatory
had peritonitis secondary to perforated
response upon LPS stimulation, which
appendicitis, 2 patients had been operated
may help reduce the risk of postoperative
by Rockey Davis incision, and 4 patients
infection in children with perforated
by median laparotomy, one of which had
appendicitis.
two previous surgeries for the same via
for previous intestinal obstruction. The
average operative time was 71 minutes
(range 45-100 min), the procedure was
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Poster Abstracts CONTINUED

performed by 3 ports in all patients, only 1 effect of pre-stretching of the abdominal
case required reoperation by laparoscopy wall by a previous abdominal insufflation
for drainage of postoperative residual was found to be significant.
collection, non intestinal resection was
CONCLUSIONS: NMB does not influence
performed. The averaged time of oral
laparoscopic working space. Studies
feeding was 48 hours (range 24-96). There
dealing with working space during
were not intraoperative or postoperative
laparoscopy should take note of pre-
complications, nether conversion to open
stretching bias.
surgery.
P004: LAPAROSCOPIC MANAGEMENT
CONCLUSIONS: Laparoscopic adhesiolysis
FOR VENTRICULAR PERITONEAL SHUNT
was safe in these patients; it is an
COMPLICATION IN TWO PATIENTS WITH
alternative management that could be
CEREBROSPINAL FLUID PSEUDOCYST
consider the best treatment in children
Fernando Rey, MD, William Murcia, MD,
with these pathology, even in the first
Andres Perez, MD, David Diaz, MD, Nidia
episode of postoperative intestinal
Vera, MD, Faber Pelaez, MD, Clinica Infantil
obstruction.
Colsubsidio Bogotá, Colombia
P003: OPTIMIZING WORKING SPACE
INTRODUCTION: Peritoneal pseudocysts
IN LAPAROSCOPY - CT MEASUREMENT
of cerebrospinal fluid and intestinal
OF THE EFFECT OF NEUROMUSCULAR
obstruction due to adhesions are common
BLOCKADE AND ITS REVERSAL IN A
complications in ventriculo peritoneal
PORCINE MODEL J . Vlot, MD, Pac Specht,
shunt in hydrocephalus. Recently,
BSc, Prof. RMH Wijnen, MD, PhD, Eg
laparoscopic drainage of collections
Mik, MD, PhD, Prof. NMA Bax, MD, PhD,
and release of peritoneal adhesions
Erasmus MC: University Medical Center
shows favorable results with less
Rotterdam
intestinal manipulation, shorter ileus and
BACKGROUND: Conflicting results on postoperative hospitalization time.
the effect of neuromuscular blockade
Two patients with hydrocephalus and
(NMB) on laparoscopic working space are
ventricular peritoneal derivation consulted
found in literature. Studies are limited by
for abdominal pain, associated with signs
the absence of objective assessment of
of partial intestinal obstruction.
working space or use surrogate outcomes.
We investigated this issue in a porcine CASE 1: 11 Year old male with multiple
model using an objective method for ventricular peritoneal shunts for non-
evaluating working space. communicating hydrocephalus, and
previous liberation ofadhesions by
METHODS: In a standardized porcine
laparotomy, consulted with abdominal
laparoscopy model, laparoscopic working-
distension and tense mass at palpation,
space dimensions with and without NMB
abdominal pain and vomiting. The
were investigated in 16 animals using
abdominal x ray showed absence of
computed tomography at intra-abdominal
intestinal gas and round center radiopaque
pressures of 0, 5, 10 and 15 mmHg during
image. In the ultrasound and abdominal
multiple runs of abdominal insufflation.
scanography a round pseudocyst was
RESULTS: No statistically significant effect displayed in the center of the abdomen
of NMB on laparoscopic working-space surrounded by bowels. The patient
dimensions was found. In contrast, the was managed by laparoscopy draining
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a pseudocyst of 1000 cc clear fluid. Due to development endovideosurgery
Peritoneal adhesions of the bowel loops it became possible to perform difficult
to the abdominal wall were released. 12 reconstructive surgeries on the biliary tract
hours after surgery the gastric tube was by the aid of laparoscopy.
removed, and in the third day, the patient
The main goal of our work was to compare
was released with adequate oral intake.
the results of surgical treatment in two
CASE 2: 4 Year old girl with hydrocephalus patient groups: “open surgery” and
and ventricle peritoneal shunt, consulted “endovideosurgery” patients.
for abdominal pain and distention,
Since 2008, 26 patients with choledochal
vomiting, and liquid stools. Abdominal
cyst have been treated at National
ultrasound showed ascites without
Research Center for Mother and Child
evidence of abdominal pseudocyst. At
Health. Eight of them had complaints
72 hours of consultation, the abdominal
on pain at epigastrium, three children –
pain increased in association with
transitory jaundice, and six patients had no
tense abdomen and fever, a diagnostic
clinical symptoms. All the children passed
laparoscopy was performed, finding
CT and ultrasound investigation.
multiple collections of clear liquid.
Collections were drained and the catheter We applied endovideosurgery in 11
exteriorized. Postoperative abdominal children. Roux-en-Y hepaticojejunostomy
scanography showed underlying were performed after laparoscopic
pseudocyst in the posterior aspect of choledochocystectomy had been
the abdomen, another laparoscopy was completed. First two cases were a kind of
performed after 4 days of the first surgery, open surgery with laparoscopic assistance.
with appropriated drainage of pseudocyst. Roux-en-Y hepaticojejunostomy in these
The externalized catheter was removed. patients were performed through arciform
The patient did not require nasogastric incision at umbilicus.
tube and the release was at 24 hours.
In remained nine cases all the stages of
CONCLUSIONS: Laparoscopic asses of intervention have been completed by
abdominal pseudocyst was safe in both the aid of laparoscopic surgery. Affected
patients, achieving appropriated drainage choledoch was incised very close (0.5cm)
of the collections and early postoperative to the left and right hepatic ducts
oral intake. This approach is a useful in the conjunction. While performing Roux-en-Y
treatment of ventricular peritoneal shunts hepaticojejunostomy extracorporeal ties
complications in pediatric age. were used.
P005: ENDOVIDEOSURGERY FOR The similar open surgery was perfomed in
TREATMENT OF CHOLEDOCHAL CYST 15 patients of control group.
IN CHILDREN D amir Jenalayev, National
Research Center for Mother and Child At postoperative period we used
Health standard antibacterial treatment (wide
spectrum antibiotics), parenteral nutrition
The surgical treatment of congenital biliary within three days, and painkillers. No
disorders is one of the tough issues in complications during the intra- and
pediatric surgery. Choledochal cysts are postsurgery period were noticed.
also of a current interest.
For comparative assessment of body’s
postagressive response to laparoscopic
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and traditional types of operations we performed undergeneral endotracheal
studied: the state of stressful hormones anesthesia with muscle relaxation.
(cortisol, prolactin) and several biochemical
The patient was in the supine position.
blood parameters, reflecting the functional
Pneumoperitoneum was established with
state of the suprarenal glands and liver,
an open technique by introducing a 2.5- or
the balance of carbohydrate and protein
5-mm reusable trocar through a transverse
metabolism.
incision at the lower part of umbilicus.
The analysis of the comparative evaluation Insufflation pressure was between
of body’s postagressive response to 8–10 mm Hg, based on the patient’s
laparoscopic and traditional surgeries age. The size of the trocar depends on
has showed that laparoscopic surgery is the size of the telescope. Two sizes of
less invasive, less traumatic, less durable telescope diameter may be used: either
surgical intervention which is characterized 2.5-mm 5-degree, or 5-mm 5-degree
to have more favorable postoperative or 25-degree. The whole peritoneal
period. cavity is inspected. Any hernia is reduced
manually or with the aid of the telescope
Taking into consideration our experience of
tip. All needle movements are performed
laparoscopic surgery for choledochal cysts
from outside the body cavity under
endovideosurgery could become a method
camera control. To choose the location
of choice for correction of external biliary
for the needle puncture, the position
ducts disorders.
of the internal inguinal ring is assessed
P006: PERCUTANEOUS INTERNAL by pressing the inguinal region from the
RING SUTURING: MINIMALLY INVASIVE outside with the tip of a Pean the needle
TECHNIQUE FOR INGUINAL HERNIA into the thread loop and the needle is
REPAIR IN CHILDREN D amir Jenalayev, withdrawn. Next, the thread loop is pulled
Omar Mamlin, Bulat Jenalayev, Dulat out of the abdomen with the thread end
Mustafinov, National Research Center for caught by the loop. In this way the thread
Mother and Child Health is placed around the inguinal ring under
the peritoneum and both ends exit the
Since January 2013, 47 patients , from 1 skin through the same puncture point.
month to 16 years old with inguinal hernia The knot is tied to close the internal ring
have been treated by PIRS (Percutaneuos and is placed under the skin. If an open
Inguinal Ring Suturing) at National inguinal ring is found contralaterally, it is
Research Center for Mother and Child closed during the procedure, regardless of
Health. There were 26 boys with 33 hernias its diameter. The umbilical wound is closed
(27% bilateral) and 21 girls with 30 hernias with absorbable stitches and covered with
(43% bilateral). In 3 of 7 (42, 8%) boys and pressure dressing to prevent hematoma
6 of 9 (66, 6%) girls with bilateral hernias, formation. The skin puncture point in the
the diagnosis was made preoperatively. inguinal region is left without any ressing.
The other children with bilateral hernias
had an open contralateral inguinal canal There were no conversions in our series.
diagnosed perioperatively that was The mean time under anesthesia for
regarded as a hidden hernia. PIRS was 42± 12.35 minutes. The mean
operative time was 17.34±6.30 minutes for
All apparatus introduced into the body unilateral hernia and 25.20±6.56 minutes
cavity were manufactured by Karl Storz for bilateral hernias, from the beginning of
(Germany). The PIRS procedure was
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cleaning the operative field to dressing the bead transfer task, 6 beads were lifted
umbilicus. The cosmetic results after PIRS from pegs by one operator and passed
were excellent, with no scars in the inguinal to the other operator, who placed them
region and an almost invisible scar in the on opposite pegs. In the experimental
umbilicus. There were not intraoperative group, both operators controlled their own
complications in our experience. instrument-centered image. There were
two controls: 1) static, wide-angle view of
CONCLUSION: The PIRS method seems
all the pegs, and 2) single moving camera
to be a simple and effective minimally
allowing close-up and tracking of the bead
invasive procedure with excellent
as it was transferred. Each team of two
cosmetic results and a complication rate
operators performed every test at least
comparable to other laparoscopic
once; the order in which the tests were
techniques of inguinal hernias repair in performed was randomly assigned. Time
children. According to our experience, PIRS to completion and number of bead drops
should be taken into consideration as an were recorded.
alternative technique.
RESULTS: Thirty-six individual sessions
P007: INTERACTIVE INSTRUMENT- were performed by pairs of surgical
DRIVEN IMAGE DISPLAY IN residents in their second-through-fifth
LAPAROSCOPIC SURGERY Austin Y. Ha, post-graduate year. Average total time
Eleanor A. Fallon, MD, Derek L. Merck, PhD, for bead transfer was 127.3 ± 21.3 s in
Sean S. Ciullo, MD, Francois I. Luks, MD, the Experimental group, 139.1 ± 27.8 s
Alpert Medical School of Brown University in Control 1 and 186.2 ± 18.5 s in Control
2 (P=0.034, ANOVA). Paired analysis
BACKGROUND: A significant limitation (Wilcoxon Signed Rank Test) showed that
of minimally invasive surgery (MIS) is the the Experimental group was significantly
dependence of the entire surgical team faster than the Control 1 group (P=0.035)
on a single endoscopic viewpoint. We have and the Control 2 group (P=0.004).
developed an individualized, instrument-
driven image display system that allows CONCLUSIONS: An image navigation
all members of the surgical team to system that allows two (or more)
simultaneously control their view of the simultaneous, independent image displays
operative field. We tested its efficacy in centered on each laparoscopic instrument
vitro using a modified Fundamentals in allows intuitive and significantly faster
Laparoscopic Surgery (FLS®) bead transfer laparoscopic task performance than
task. either the standard, static FLS® camera
view or a single tracking close-up image
METHODS: An image navigation program of the field. Specifically, it offers higher
was custom-written in Python, numpy and resolution images and the possibility of
OpenGL to allow zooming and centering multi-tasking. In addition, the instrument-
of the image window on two specific color driven tracking system guarantees that the
signals, each one attached near the tip close-up image is always centered on the
of a different laparoscopic grasper. The laparoscopic target. Further development
navigation router receives the image signal of robust prototypes will allow the
from a stationary camera via USB interface transition of this in vitro system into clinical
and splits it into the respective daughter application.
windows (one monitor per user). In the
modified, two-operator FLS® endotrainer
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P009: THE GONZALEZ HERNIA REVISTED: DISCUSSION: The ischiorectal fat pad is
USE OF THE ISCHIORECTAL FAT PAD TO easily visualized and mobilized, either via
AID IN THE REPAIR OF RECTOVAGINAL a posterior sagittal or transanal approach,
AND RECTOURETHRAL FISTULAE Marc providing excellent coverage with native,
Levitt, Sebastian King, Andrea Biscoff, well-vascularized tissue, in an area that is
Shumyle Alam, G Gonzalez, Alberto difficult to heal. It is an excellent option
Pena, Nationwide Children’s Hospital, The for recurrent rectovaginal and rectovaginal
Royal Children’s Hospital, Morgan Stanley fistulaeand may have other additional
Children’s Hospital creative applications. This approach when
the rectum requires mobilization already,
INTRODUCTION: During the development
may be less invasive than a laparoscopic
of the posterior sagittal approach to
omental mobilization.
anorectal malformations a vital technical
challenge was a precise midline dissection, P010: THE INITIAL RESULTS OF
which if off, allowed for the ischiorectal LAPAROSCOPIC-ASSISTED DUHAMEL
fat pad to bulge into the wound. This OPERATION IN TOTAL COLONIC
occurrence became affectionately known AGANGLIONOSIS Tri T. Tran, MD, Pediatric
as a “Gonzalez hernia”, after a trainee Hospital No 2
of Dr Pena’s. For both traditional PSARP
BACKGROUND: Total colonic aganglionosis
and the laparoscopic approach (ideal for
(TCA) is the rarest type of Hirschsprung’s
rectobladderneck and high rectoprostatic
disease. and has been traditionally
fistulae), this technical aspect of
managed by enterostomy and various
staying precisely in the midline remains
different techniques of pull-through
paramount. With a twist of this idea, we
operation. Since Jan 2012, laparoscopic-
have put this fat pad to use, and have
assisted Duhamel operation has been
found that it can be an effective structure
performed in our hospital.
to aid in the repair of acquired rectovaginal
and rectourethral fistulae. The aim of this study was to evaluate the
initial results of laparoscopic-assisted
METHODS: Patients with recurrent
Duhamel operation in TCA at Children’s
vaginal or urethral fistulae were selected
Hospital 2.
for review. The ischiorectal fat pad was
deliberately mobilized, (via a posterior METHODS: Case series reports from Jan
sagittal or transanal approach) and used to 2012 – June 2013.
buttress the repair of the posterior vagina
or urethra. RESULTS: There were 6 TCA children
underwent the laparoscopic-assisted
RESULTS: The ischiorectal fat pad Duhamel operation. Mean age was 20.3 (13
technique was used in 9 patients. All had -36) months, mean operating time was 5.4 (3,
an acquired fistula (6 rectovaginal fistula, 6-7) hours. No intraoperative complications.
3 rectourethral fistulas). We used the No conversion to open surgery. In 5
posterior sagittal approach in 7 and in 2 the successful cases, mean time of oral feeding
transanal approach. 6 patients had had at was 5.6 (4-8) days and the average length
least two prior attempts at fistula repair. 6 of hospital stay was 11.2 (10-13) days. There
patients had a stoma, and 3 did not. There was one case of failure due to postoperative
were no recurrences in greater than six adhesive intestinal obstruction and
month follow-up. anastomotic stenosis. This case was operated
8 months after first operation.
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Mean follow-up time is 9.2 months with left abdominal quadrant. To confirm the
good functional outcome. 5 of 6 cases had suspicion of hereditary pancreatitis a biopsy
3 to 6 bowel movements per day and the was performed. But the result was not clear.
remaining case had 10 times per day. One year later the ultrasound follow-up
showed the spleen lying in the small pelvis
CONCLUSIONS: This is a safe operation
above the bladder. Also a mild pancreatitis
with good results, and highly aesthetic. The
was still existent. A few months later, the
laparoscopic-assisted Duhamel procedure
patient came back to the hospital with an
is our procedure of choice in total colonic
exacerbation of the abdominal pain. The
aganglionosis.
physical examination resulted in an acute
KEYWORDS: laparoscopic-assisted abdomen. The ultrasound examination
Duhamel operation, total colonic presented a torsion of the greatly enlarged
aganglionosis, Hirschsprung’s disease. spleen (20cm) lying above the bladder
surrounded by ascites. Via contrast gain,
P011: WANDERING SPLEEN - a very slow tide and two areas cutted out
LAPAROSCOPIC SPLENOPEXY S onja Kern, were detected. Immediately, an emergency
Julia Syed, P. Lux, Dr., R. T. Carbon, Prof., Dr., laparoscopy was performed. The pedicle
Pediatric Surgery Department of University was twisted about 240 degrees. Now
Hospital Friedrich-Alexander University of the spleen was turned back and brought
Erlangen-Nuremberg into the normal position in the upper left
BACKGROUND: A wandering spleen is a abdominal quadrant. After a few minutes,
very rare clinical condition associated with the spleen was reperfused. Splenopexy was
a high risk of splenic torsion along the mandatory and was realized by gluing with
vascular pedicle leading to splenomegaly fibringlue. The inferior pole was positioned
and infarction. The incidence is about into a peritoneal pouch sutured out of the
0.2%. The suspected etiology is the lack peritoneum of the abdominal wall. After one
of suspensory ligaments and laxity of the week of bed rest, a planned second-look
peritoneal fixation resulting from a fusion laparoscopy was performed. The spleen was
anomaly of the dorsal mesogastrium of found still in place with a little overturning
the spleen. The predominant symptoms at the top. Further fixation was applied with
vary from an asymptomatic incidental two stripes of vicryl-net anchored to the
finding to an abdominal mass, recurrent diaphragm and the abdominal wall.
abdominal pain, intestinal obstruction, RESULT: The postoperative course was
hemoperitoneum or in the case of uneventful. Mobilization and defecation
infarction even the acute abdomen. were without problems. The clinical and
CASE REPORT: We report a case of a ultrasonic follow-up showed the spleen
17-year-old girl presenting with recurrent fixed in anatomical position. Since then,
abdominal pain for a year and a half. no pancreatic problems appeared. A
Interestingly, the 13-year-old sister of our light elevation of the diaphragm was
patient had a wandering spleen with total evident without breathing impairment.
torsion and necrosis of the organ one year Laparoscopic splenopexy by forming a
before with consecutive splenectomy. peritoneal pouch and inserting a vicryl-net
The blood test resulted in an increase fashioned around is feasible, less invasive
of the pancreatic enzymes. In the first and does not diminish splenic function.
examinations the spleen was minimally It is a safe and effective treatment for
enlarged and positioned in the upper symptomatic wandering spleen.
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P012: LAPAROSCOPIC REPAIR OF the duodenum. The suspension stitch
CONGENITAL DUODENAL OBSTRUCTION facilitated completion of the anastomosis
Brian J. MacCormack, Mr., Jimmy P. Lam, with excellent visualisation and minimal
Mr., Royal Hospital For Sick Children manipulation of the tissues.
Edinburgh
RESULTS: Of the three cases, one was a
BACKGROUND: Congenital duodenal duodenal web, while the other two were
obstruction (CDO) occurs in 1 in 6000 live duodenal atresias. All three cases were
births and is often associated with other successfully managed by laparoscopic
anomalies including trisomy 21 and cardiac duodenoduodenostomy. The operative
malformations. Laparoscopic repair of CDO duration was between 170 and 195
has become popularised over the past mins. There were no conversions to an
decade, however the variable anatomy and open procedure, no intra-operative
small operating space poses a challenge complications and no anastomotic leaks
for surgical repair utilising minimally observed. Enteral feeds were initiated on
invasive techniques. It has therefore been post-operative day 3, once nasogastric
suggested that laparoscopic treatment tube output had decreased. Full feeds
of CDO should be restricted to a limited were established between 10 and 14 days.
number of designated centres of expertise. Post-operatively one patient developed
After gaining extensive experience with chylous acities, which was successfully
intracorporeal suturing in other procedures managed conservatively with medium
we evaluated the feasibility of this chain triglyceride (MCT) feed for 4 weeks.
approach in a single centre.
CONCLUSIONS: Laparoscopic
METHODS: Three consecutive cases of duodenoduodenostomy is a technically
CDO were approached laparoscopically. challenging procedure which involves
The gestational age at operation was delicate intracorporeal suturing. The
between 35 and 37 weeks, and the weight published results have been reported by
between 1.7 and 2.6 kg. In each case a 5 very experienced paediatric endoscopic
mm 30° telescope was inserted through surgical groups. This has led to the
the inferior umbilical fold, using a open conclusion that laparoscopic treatment of
Hassan technique. Pneumoperitoneum CDO should be restricted to a few centres
to 8 mmHg with CO2 was established. of expertise. This series demonstrates
Two 3.5 mm working ports were inserted; that laparoscopic duodenoduodenostomy
one in the right iliac fossa, and one in can be safely and successfully performed
the left flank. In the first case a side to with excellent short-term outcome. We
side anastomosis was performed. In the found that suspension stitches facilitate
subsequent two cases, after transverse the complex anastomosis by allowing
enterotomy of the dilated proximal excellent visualisation. We conclude that
duodenum, and longitudinal enterotomy if experience of intracorporeal suturing
of the collapsed distal duodenum, a has been attained in other areas that
diamond-shaped Kimura anastomosis laparoscopic duodenoduodenostomy can
with interrupted 6 - 0 Vicryl sutures be safely and successfully performed in
was performed. A 4-0 PDS suture was small preterm neonates, even in lower
placed through the abdominal wall, volume centres.
through the proximal duodenum, and
back out the abdominal wall to display
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P013: LAPAROSCOPIC SPLENECTOMY P014: ENDOSCOPIC REMOVAL OF
IN CHILDREN WITH BENIGN SHARP OBJECTS IN THE UPPER
HEMATOLOGICAL DISEASES: LEAVING GASTROINTESTINAL TRACT B urak
NOTHING BEHIND POLICY M ohammad Tander, MD, Unal Bicakci, MD, Mithat
Gharieb, PhD, Departement of Pediatric Gunaydin, MD, Riza Rizalar, MD, Ender
Surgery. Facullty of Medicine. Tanta Ariturk, MD, Ferit Bernay, MD, Ondokuz
University Mayis University, Department of Pediatric
Surgery, Samsun, Turkey
INTRODUCTION: Laparoscopic splenectomy
(LS) is considered the standard approach AIMS: Removal of ingested sharp objects
for the treatment of children with non is challenging in children, when they
malignant hematological diseases due are stuck in the upper gastrointestinal
to the advances in minimal invasive tract. We evaluated the role of flexible
surgery over conventional splenectomy endoscopy and the snare as a removing
(CS). Different techniques are involved instrument on patients with ingested sharp
in the operation to secure the hilum. We objects.
assessed the value of bipolar sealing device
METHODS: Within the last four years,
(LigasureTM ) as a safe, effective and less
eight patients with a history of sharp
time consuming with less complication rate.
object swallowing were admitted. The
PATIENTS & METHODS: Sixty chidren (33 primary diagnostic tool was a direct
with thalassemia, 20 with ITP, and 7 with X-ray of the upper body. The foreign
spherocytosis) were operated upon in bodies were removed by flexible
Tanta University Hospital. These children esophagogastroduodenoscopy and its
had undergone LS using bipolar sealing associated instruments.
devices (LigasureTM). We excluded
RESULTS: Four of the foreign bodies were
cases with mean splenic span <16cm. We
lodged in the esophagus, three in the
evaluated the overall operative time, total
stomach and one in the duodenum. There
amount of blood loss and the occurance of
were six open safety pins and two jewels
any other complications.
with sharp tips. Three were lodged in the
RESULTS: Sixty children (37 girls and esophagus one of them with the pin’s
23 boys) with mean age 10.2 years had open end pointed caudally; it was held
undregone LS using LigasureTM with with the endoscopic forceps by its tail
mean operative time 85 minutes. There end and removed, two of them had the
were no mortality, two cases converted open end with cranially pointed; they were
to convensional open splenectomy due pushed into stomach rotated, grasped by
to difficulty to complete the procedure. their blunt end and taken out. One sharp
Two cases had postoperative subphrenic tipped jewel was in the upper esophagus
collection resolved with conservative and it was removed similarly. Another
measures. No complications related to sharp tipped jewel was in the stomach and
injury of adjacent strctures. it was grasped by the snare used in the
“percutaneous endoscopic gastrostomy”.
CONCLUSION: Laparoscopic splenectomy
An open safety pin lodged in the distal
using bipolar vessel sealing device is
part of duodenum was also removed by
techniqually safe, less time consuming
the same snare. The last foreign body
with less complications compared with
was an open safety pin in the stomach. It
other techniques.
was noticed that the object had already
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passed into the jejunum after induction of between both groups. In LAP group, mean
anesthesia. It left the gastrointestinal tract OP time was significantly longer (70.4 ±
spontaneously within 3 days. 37.7 vs. 47.3 ± 15.1 mins, p< 0.01); mean PO
time (1.57 ± 0.83 vs. 2.23 ± 0.97 days, p<
CONCLUSIONS: Open surgery or other
0.01) and LOS (3.34 ± 1.19 vs. 4.37 ± 1.59
invasive removal methods are mostly
days, p= 0.01) were significantly shorter.
not necessary in children with sharp
One surgical recurrence occurred in
object ingestions. The best way to extract
each group occurring (4.3% vs. 2.8%, p=
the sharp objects from the esophagus,
0.76). In comparison of IP (n= 15) and NIP
stomach or duodenum is using a flexible
(n= 8), there is no significant difference
endoscopic device and a powerful snare.
on recurrence rate and OP time. The
P016: IDIOPATHIC INTUSSUSCEPTION IN overall conversion rate was 13.0% (6.8%
CHILDREN: EFFICACY OF LAPAROSCOPY vs. 25%, p= 0.21). The conversion rate
AND ILEOPEXY C hin-Hung Wei, MD, was significantly higher in cases with
Yu-Wei Fu, MD, Nien-Lu Wang, MD, the intussusceptum to transverse and
PhD, Yi-Chen Du, MD, Mackay Memorial descending colon than to ascending colon
Hospital (p< 0.05). With the exclusion of conversion,
OP time was significantly shorter in NIP (p=
PURPOSE: This study aims to compare the 0.01).
results of laparoscopy and open surgery
for idiopathic intussusception in children as CONCLUSION: Laparoscopy should be
well as evaluate the efficacy of ileopexy. considered the primary modality for
radiologically irreducible idiopathic
METHODS AND MATERIALS: Between intussusception in children. Ileopexy
January 2007 and July 2013, children provides no benefit on recurrence
aged < 18 years who were operated for prevention but longer OP time.
intussusception in our institution were
reviewed. Patients were classified into P017: BILIARY-ENTERIC
two groups, laparoscopy (LAP) and open RECONSTRUCTION WITH
(OPEN). LAP group was further divided into HEPATICOJEJUNOSTOMY (HJ) VERSUS
two subgroups, ileopexy (IP) and non- HEPATICODUODENOSTOMY (HD)
ileopexy (NIP). Parameters investigated FOLLOWING LAPAROSCOPIC EXCISION OF
included age, gender, operative indication, CHOLEDOCHAL CYST IN CHILDREN F anny
surgical procedure, type of intussusception, Yeung, MBBS, Patrick Chung, FRCSEd, Ivy
level of intussusceptum, presence of Chan, FRCSEd, Paul K. Tam, ChM, FRCSEd,
spontaneously reduced intussusception Kenneth K Wong, MD, PhD, The University
and pathologic lead points, operative time of Hong Kong
(OP time), time to oral intake (PO time),
BACKGROUND: With the advent of
length of postoperative hospital stay (LOS),
laparoscopic surgery, more choledochal
surgical recurrence.
cysts are excised laparoscopically. In this
RESULTS: There were 23 and 35 cases study, we compared the outcomes from
in LAP and OPEN group respectively. laparoscopic hepaticojejunostomy (HJ) and
No significant difference was found hepaticoduodenostomy (HD) for biliary-
on age, operative indication, surgical enteric reconstruction performed in our
procedure, type of intussusception, level early era.
of intussusceptum, and presence of
spontaneously reduced intussusception
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METHODS: A retrospective analysis of P018: INTRAOPERATIVE
patients who had undergone laparoscopic ESOPHAGOGASTRODUODENOSCOPY FOR
choledochal cyst excision between LAPAROSCOPIC-ASSISTED DUODENAL
February 2005 and May 2013 was WEB RESECTION IN THE PEDIATRIC
performed. Demographic data and surgical POPULATION P aul M. Jeziorczak, MD, MPH,
outcomes were analysed using SPSS Jill S. Whitehouse, MD, Kevin P. Boyd, DO,
Statistics 21.0. Alfonso Martinez, MD, John C. Densmore,
MD, Medical College of Wisconsin/
RESULTS: A total of 38 patients were
Children’s Hospital of Wisconsin
identified, with initial 28 patients
underwent HJ. The most recent 10 PURPOSE: To demonstrate the benefit of
patients underwent HD. The first 8 METHODS: This is a 13 m.o. female with a
patients of the HJ series were excluded as prolonged history of intermittent vomiting
it was deemed to be the learning curve of undigested food. An UGI study was
period. Overall, there were no significant concerning for a proximal small bowel
differences in terms of demographics. stenosis or web. She was taken electively
Mean operative time was significantly to the operating room for intraoperative
shorter in HD group (269 vs 403 minutes, EGD with laparoscopic assisted resection of
p= 0.004) with lower conversion rate (0% her enteric obstruction.
vs 35%, p=0.033). Although postoperative
A 1cm vertical incision was made through
enteral feeding was initiated later in
the umbilicus and a 5mm trocar was
HD group (5.2 vs 4.7 days, p=0.026),
placed and the abdomen was insufflated.
postoperative stay in intensive care
Upon inspection of the abdominal
unit (ICU) (0.8 vs 2.35 days, p=0.011)
contents using a laparoscope, a very
and overall hospital stay (9 vs 10 days,
dilated duodenum was immediately
p=0.248) favoured HD group. There was
observed. The normal-caliber transverse
no perioperative mortality. One patient
colon was draped over the duodenum. In
in HJ group had postoperative cholangitis
the distal duodenum, a very clear transition
related to anastomotic stricture whereas
point was visualized. At this point, a 2nd
no cholangitis noted in HD group.
trocar was placed in the left mid-abdomen
Although four patients in HD group
under direct visualization. An intraoperative
had asymptomatic biliary reflux, none
EGD was performed to identify the etiology
required reoperation while five patients
of the obstruction. A stenotic web was
in HJ group required second operation for
located directly at the point of transition,
complications and residual diseases.
which was visualized endoscopically as well
CONCLUSIONS: Laparoscopic as laparoscopically. The transition point
excision of choledochal cyst with was grasped and brought out through the
hepaticoduodenostomy reconstruction umbilical incision.
is safe and feasible with shorter
The bowel was opened longitudinally
operative time, lower conversion rate
through the transition point where a web
and shorter ICU stay. It is not inferior to
was found with a 3mm central opening.
hepaticojejunostomy in terms of various
The web was excised and the mucosal
postoperative outcomes.
defect was closed with a running chromic
suture. The duodenum was closed
transversely in a Heineke-Mikulicz fashion.
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RESULTS: She did well after surgery, no down into the abdominal cavity, pulled
fevers, appetite is better than before back into the posterior mediastinum
surgery, no emesis, stooling 1-3 times per simply when the stomach was detached.
day-soft, back to usual activity. The vessel at the lesser omentum was
damaged when the assistant held and
CONCLUSIONS: Intraoperative endoscopic
pulled the stomach strained in one
examination during laparoscopic
case. The hernia sac consisted of a
exploratory laparotomy is useful to identify
thickened phrenoesophageal ligament.
the etiology and location of proximal small
Resection of the sac at posterior site of
bowel enteric obstructions and to rule out
the stomach is relatively difficult, and
a windsock deformity more proximal to the
it’s troublesome to dissect it from lesser
transition point.
omentum (hepatogastric ligament). The
P019: LAPAROSCOPIC MANAGEMENT important procedure is to expose crura
OF PARAESOPHAGEAL HERNIA WITH firmly, not to excise the sac. Insufficient
INTRATHORACIC STOMACH IN INFANT : dissection of the crura brought type2
PITFALLS IN THE TREATMENT FROM OUR hiatal hernia recurrence in one case.
3 CASE EXPERIENCES Kan Suzuki, PhD, The abdominalesophagus was wrapped
Akira Nishi, PhD, Hideki Yamamoto, PhD, with the mobilized fundus in a 2- to
Tetsuya Ishimaru, PhD, Tadashi Iwanaka, 3-cm floppy Nissen fundoplication in
PhD, Gunma Children’s Medical Center all cases. An anchoring, wrapping cuff
was approximated to the anterior edge
PURPOSE: The aim of this report was of the diaphragmatic crura in all cases.
to analyze pitfalls in the laparoscopic Stamm gastrostomy was added to double
management of type3 paraesophageal as gastropexy in one case. Transient
hernia in infant. dysphagia was found in 2 cases after
METHODS: Between 2009 and 2013, operation. The solid was got blocked in the
the records of 3 infants with type3 case of 1 y/o and needed to remove. The
paraesophageal hiatal hernia were esophageal passage was improved in all
retrospectively reviewed for age, cases two months after the operation.
presenting symptoms, operative findings CONCLUSIONS: The opportunity of
and approaches, and outcomes. operation is recommended before starting
RESULTS: All cases (1 male, 2 female) the baby food. Laparoscopic intervention
had right-sided type3 paraesophageal of hiatal hernia with intrathoracic stomach
hiatal hernia. Diagnosed until neonatal is a safe and feasible method in infantile
period in two cases, their symptom was patients. Management consists of retrieval
only intermittent vomiting and they of the intrathoracic stomach, closure of
had good weight gain. We conducted the hiatus and subsequent antireflux
the operation before the baby food procedure. In our experiences, perfect
start. The other patient had clinical excision of the sac is relatively difficult,
features of chest infection and anemia and firm exposure of the crura and precise
at 9 months, she underwent electively closure of the hiatus is the most important.
operation at 1 y/o. Surgical procedures The method of antireflux procedure leaves
were conducted with laparoscopy, and room for discussion.
open conversion was not required in
any case. At the operation, though the
intrathoracic stomach was easily pulled
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P020: LAPAROSCOPIC CORRECTION OF contrast fluoroscopy may help in cases of
DUODENAL WIND-SOCK ATRESIA WITH intraluminal obstruction; other procedures
ASSOCIATED MALROTATION R uben than diamond shaped anastomosis can be
Lamas-Pinheiro, MD, Tiago Henriques- performed in the correction of this type of
Coelho, MD, PhD, Hospital de São João, duodenal atresia.
Porto, Portugal
P021: THE FEASIBILITY OF EMERGENCY
INTRODUCTION: The most complex LAPAROSCOPIC COLECTOMY FOR
neonatal procedures have already CHILDREN WITH ACUTE COLONIC
been performed by minimal invasive PERFORATIONS AND FIBROPURULENT
approaches. The authors present a video PERITONITIS Y u-Tang Chang, Jui-Ying Lee,
of a challenging laparoscopic correction Chi-Shu Chiu, Jaw-Yuan Wang, Kaohsiung
of type I duodenal atresia (Wind-sock) Medical University Hospital
associated with intestinal malrotation and
BACKGROUND: Several studies have
volvulus.
demonstrated that laparoscopic surgery
CASE: Preterm female newborn, 34 is safe and effective for urgent and
weeks gestation with prenatal diagnosis emergent colectomy in adulthood. The aim
of duodenal atresia. A postnatal of this study was to evaluate the feasibility
roentgenogram confirmed the diagnosis. of laparoscopic colectomy for children in
The neonate was submitted to laparoscopy emergent settings.
at D1: one 5 mm trocar was placed in
METHODS: Between March 2008 and
the umbilicus and two 3 mm trocars
August 2011, 10 consecutive children
were placed in both flanks. The liver was
with acute colonic perforations and
suspended using a percutaneous stich.
fibropurulent peritonitis secondary to
An intestinal volvulus was identified and
infectious colitis received emergency
reduced. Ladd bands were divided and the
laparoscopic colectomy. Simultaneously,
mesentery was widened. As there was no
we reviewed and recorded the same data
visible duodenal atresia, an intra-operative
of another consecutive 10 patients who
contrast study was performed and a Wind-
underwent standard laparotomy between
sock atresia was revealed. The duodenum
November 2004 and February 2008. The
was incised, the membrane was partially
two groups were compared regarding
excised and a duodenoplasty (Heineke-
operation time, length of hospital stay
Mikulicztype) was performed. There were
(LOS), and complications.
no intra- or post-operative complications.
The child started enteral feeding on 6th RESULTS: The gender, age, body weight,
post-operative day, suspended parenteral serum C-reactive protein, number of
feeding on the 13th and was discharged involved bowel segment, operation time
on the 15th. Currently she is followed in and LOS were not significantly different
outpatient without symptoms and with an (P = 0.36, 0.50, 0.33, 0.62, 0.81, 0.14 and
excellent cosmetic result. 0.23, respectively). Of the laparoscopy
group, one patient was converted to
TIPS: This video presents possible
open surgery because of extensive bowel
difficulties during duodenal correction
involvement and another with solitary
and ways to overcome them with safety
colonic perforation required reoperation
and assertiveness: laparoscopic volvulus
for anastomostic leakage. However,
reduction is safe and less difficult in the
patients receiving laparotomy had a higher
absence of bowel dilatation; intraoperative
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incidence of later complications, including respectively. All patients had concurrent
wound infection, incisional hernia and laparoscopic gastrostomy. The average
adhesion ileus (P = 0.03, 0.06 and 0.03, operative time was shorter in group I (157 ±
respectively), and thus required more 55 minutes vs 169 ± 52 minutes, p = 0.66).
additional unplanned operations (P = 0.05). Both groups had minimal blood loss only.
The surgical outcomes in both groups were
CONCLUSIONS: Emergency laparoscopic
comparable in terms of recurrence (0%
surgery is technically feasible in most
vs 3%, p = 0.105) and complications (9.5%
children with acute colonic perforations
vs 6%, p = 0.275). The median follow up
and fibropurulent peritonitis. However,
duration for group I and group II were 23
extensive intestinal involvement with
months and 40 months respectively.
multiple perforations should be an
indication for converting to open surgery. CONCLUSION: Laparoscopic Nissen
fundoplication can be safely performed
P022: LAPAROSCOPIC NISSEN
in infants with outcomes comparable to
FUNDOPLICATION FOR
older patients and a shorter operative
GASTROESOPHAGEAL REFLUX DISEASE
duration. Should infants develop GERD,
IN INFANTS J essie Leung, MRCSEd, Patrick
this operation should be performed early
Chung, FRCSEd, Ivy Chan, FRCSEd, Eugene
in order to avoid chronic lung disease due
Lau, MRCSEd, Kenneth Wong, MD, PhD,
to recurrent aspiration pneumonia.
Paul Tam, ChM, FRCSEd, Department of
Hong Kong, The University of Hong Kong P023: THE USE OF LAPAROSCOPY
FOR PEDIATRIC LIVER BIOPSIES: A
INTRODUCTION: Data on laparoscopic
REVIEW OF A SINGLE INSTITUTIONAL
Nissen fundoplication for
EXPERIENCE D an Parrish, MD, Shannon
gastroesophageal reflux disease (GERD) in
F. Rosati, MD, Michael Poppe, BS, Karen
infants remains limited. We describe our
Brown, BA, Patricia Lange, MD, Claudio
experience with this operation in children
Oiticica, MD, David Lanning, MD, PhD,
and in particularly, infants younger than 12
Children’s Hospital of Richmond at Virginia
months old.
Commonwealth University Medical Center
METHODS: Medical records of all
BACKGROUND: Percutaneous liver biopsy
paediatric patients who had laparoscopic
(PLB) is an important tool for diagnosing
fundoplication done for GERD from 1998 to
liver diseases, especially in the pediatric
2013 were reviewed. Patients were divided
population. Most PLB protocols require
into two groups based on age: group I: 0 -
a period of observation following the
12 months, and group II >12 months. Data
procedure that may be extended should
on indications, patient’s demographics,
complications arise in addition to post-
operative time, blood loss, conversions,
procedure blood work. While it is often
complications, recurrences and duration of
performed effectively and safely, it is
hospitalization were studied.
not without its complications. Most
RESULTS: A total of 86 patients were studies report minor complications
reviewed (group I = 21, group II = 65). While (mild perihepatic hemorrhage, mild
the mean age and body weight for group hemoperitoneum, pain, etc.) at rates
I were 8 months (range 2.6 to 12 months) of 6-10% and major complication
and 6 kg (range: 3.6 to 11 kg), the values for (perforation, large hemoperitoneum, etc.)
group II were 84 months (range 17 to 228 rates of 1-3%.
months) and 18 kg (range: 6.2 to 64.5 kg)
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METHODS: We retrospectively reviewed 24 with only 5% of symptomatic patients
of our pediatric patients who underwent being in this age group. The aim of this
laparoscopic-assisted liver biopsy between study was to evaluate the efficacy and
April 2006 and May 2013. This group was safety of laparoscopic esophagomyotomy
analyzed for length of stay, duration of with adjunctive intra-operative
operation, labs obtained, repeat biopsy esophagoscopy to treat children with
rate, and complication rate. Statistical achalasia.
analysis was not performed due to the
METHODS: Following ethical approval,
small sample size and the retrospective
we reviewed the medical charts of 10
nature of the design.
children (7 male; 3 female) submitted to
RESULTS: Of the 24 patients reviewed, laparoscopic esophagomyotomy to treat
the average length of stay was 5.8 ± 2.95 achalasia. Median age at surgery was 12
hours, average duration of operation was years (9-13.8). Surgeries were performed
43.7 ± 10.73 minutes, no complications at a single tertiary hospital between
were observed, no repeat biopsies January 2001 and December 2013. Anterior
were needed, and no preoperative or myotomy was performed with five trocars
postoperative labs were obtained. under intraoperative esophagoscopy. The
distal part of the myotomy was extended
CONCLUSIONS: Laparoscopic-assisted liver
over the esophagogastric junction, and a
biopsy allows for patients to be discharged
Dor fundoplication was done after the end
as soon as they have recovered from their
of myotomy.
anesthetic without the need for lab work
or a prolonged period of observation. This RESULTS: Median operating time was 2.4
study suggests that laparoscopic-assisted hours (2-5). Median myotomy length
liver biopsy is a viable option for diagnosing was 6 cm (5-8). One child had a mucosal
liver disease that may be a safer and more perforation that was sutured before
reliable alternative to PLB and should the Dor fundoplication. Two others had
be further studied with a prospective, dysphagia after surgery, one of which had a
randomized trial. redo surgery 6 months later. No conversion
to open surgery was necessary, and there
P024: LAPAROSCOPIC HELLER
were no deaths. At a median follow-up of
MYOTOMY WITH INTRAOPERATIVE
2.4 years (7 months-11.2 years), weight had
ESOPHAGOSCOPY AND DOR
improved in all children. Seven (70%) were
FUNDOPLICATION FOR CHILDREN WITH
symptom-free, whereas 2 (20%) presented
ESOPHAGEAL ACHALASIA J ose Carlos
intermittent retrosternal pain, and 1 (10%)
Fraga, MD, PhD, FAAP, Samanta S. Silva,
had mild dysphasia.
MD, Cristiane Hallal, MD, Cristina T. Ferreira,
MD, PhD, Daltro L. Nunes, MD, Helena A. CONCLUSIONS: Laparoscopic
Goldani, MD, PhD, Paola B. Santis-Isolan, esophagomyotomy associated with Dor
MD, PhD, Pediatric Surgery Service¹ and fundoplication is a safe and effective
Pediatric Gastroenterology Unit², Hospital treatment for pediatric esophageal
de Clinicas of Porto Alegre, Federal achalasia. Myotomy should be long and
University of Rio Grande do Sul, Brazil. extend through the esophagogastric
junction. Intraoperative esophagoscopy
PURPOSE: Achalasia is a functional disorder
is very important to ensure adequate
with abnormal motility of the esophageal
myotomy and to reduce the incidence of
body and incomplete relaxation of the
mucosal perforation.
lower sphincter. It rarely occurs in children,
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P025: ILEOCECAL RESECTION IN discharge was 7 days. The follow-up
CROHN’S DISEASE – COMBINED showed a normal course. The patient
LAPAROSCOPIC APPROACH J . Syed, does not need to take medication since
S. Kern, M. Besendoerfer, Rt Carbon, operation.
Pediatric Surgery Department of University
CONCLUSION: Minimally invasive
Hospital Friedrich-Alexander University of
procedures gain standard for bowel
Erlangen-Nuremberg
resection, and by using appropriate
BACKGROUND: As the number of patients technology (ultrasonic devices) it is
suffering from chronic inflammatory easily practicable. The combination of
bowel disease constantly increases, laparoscopy with an umbilical BIANCHI
operative treatment will gain more and approach for retrieving specimen offers an
more significance. Ileocecal resection elegant possibility. Advantages compared
with primary anastomosis represents the with open surgery are: earlier reset of
definitive management for drug – resistant digestion, shorter length of stay, earlier
Crohn’s disease. recovery, smaller wounds, less pain, better
cosmetic results, less adhesions with less
CASE REPORT: We report a case of a 14
long term digestive problems, better
year old boy with ileal Crohn’s disease.
overview during operation.
His dad suffered from ulcerative colitis,
his mum from Crohn’s disease as well. P026: COMPARISON OF INFLAMMATION
Because of a clinical relevant ileal VALUE AND INTRAABDOMINAL ABSCESS
obstruction with recurrent fistula, abscess FORMATION AFTER LAPAROSCOPIC AND
and probably perforation as well as severe OPEN APPENDECTOMIES IN TREATMENT
growth disturbance, the indication for OF PERFORATED APPENDICITIS FOR
operation was justified. We purposed CHILDREN Z ai Song, PHD, Shan Zheng,
a combination of minimally invasive PHD, Children’s Hospital of Fudan
procedures – laparoscopical and umbilical University
access. The ileocecal region was mobilized
AIM: Now, laparoscopic appendicetomy(LA)
by using ultrasonic device (Ultracision) and
is an accepted alternative to the open
the inflamed segment has been resected
appendicetomy(OA) in children. However,
by stapling device. Resected specimen was
in treatment of perforated appendicitis, it
retrieved via the umbilical approach which
has been suggested that there is a higher
was prepared (BIANCHI). After enlarged
incidence of intraabdominal abscesses
mobilization of the bowel the anastomosis
(IAAs) and increased inflammation due
(ileoascendostomy, single sutures) was
to carbon dioxide pneumoperitoneum.
performed extracorporeally. After the
Our aim is to determine the incidence of
mesenteric sutures the reposition of
IAAs and the level of inflammation in both
the anastomosis succeeded without
techniques with perforated appendicitis.
any difficulty. Peritoneal lavage and
placement of a peritoneal drainage were METHODS: 62 patients and 71patients with
administered. Umbilical reconstruction perforated appendicitis received LA and OA
worked tension-free. respectively in out hospital from January
to June, 2013. PH value and the value of
RESULT: Operation time was 90 minutes.
blood lactate(Lac) during the operation,
The postoperative process was uneventful,
as well as the value of proca lcit ionin(PCT)
defecation set in after 2 days and
and C-reactive protein(CRP) before
alimentation could be started. Time to
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operation , during operation and 2 days surgery for gastrointestinal bleeding with
after operation, were recorded. Incidence negative Tc-99m Meckel’s s diverticulum
of wound infection and IAA also studied in canning.
this study.
METHODS: During the period from
RESULTS: During the operation, the value Dec 2006 to October 2013, 13 cases
of PH value and value of Lac show no with gastrointestinal bleeding and
significant difference between LA and hypoalbuminemia were underwent
OA group. (PH value:7.36±0.7 VS 7.39±0.5, DBE and laparoscopic surgery in the
p=0.271, >0.05;value of Lac:1.3±0.4 VS department of pediatric surgery, Shanghai
1.4±0.7 , p=0.376>0.05). The value of Children’s Hospital, Shanghai Jiao Tong
PCT and CRP also indicate no significant University and Children’s Hospital of Fudan
different difference between LA and University. All the patients got Tc-99m
OA group. In LA group, incidence of Meckel’s diverticulum scanning but failed
wound infection is much lower than that to find positive spot. With the aid of a
of OA group (4/62 6.4% VS 16/71 22.5, specially designed DBE, with the alternate
p=0.017<0.05). However, comparing with inflation and deflation of the balloons at
OA group, LA group did not reduced the the tip of the endoscope, the enteroscope
incidence of IAAs (10/62, 16.1% VS 16.9%, was advanced into small intestine under
12/71, p=0.072>0.05) . total anesthesia. If Meckel’s diverticulum
or other surgical disease was found, a
CONCLUSION: In this study, we found that
single umbilical incision were performed
in treatment of perforated appendicitis in
and then the laparoscopic surgery such as
children, the technique of appendectomy
ileoileostomy was followed at the same
does not appear to affect the incidence of
time.
IAAs and value of inflammation. Children
with LA seem to have a lower incidence of RESULTS: 8 patients of the final
wound infection. clinicopathological diagnosis was
Meckel’s diverticulum, duplication of
P027: THE COMBINATION OF DOUBLE
intestine was 4 cases and hemagiomas
BALLOON ENTEROSCOPY WITH
in 1. No complications such as aspiration
LAPAROSCOPIC SURGERY FOR THE
pneumonia, perforation or hemorrhage
GASTROINTESTINAL BLEEDING
occurred, and all the patients well
WITH NEGATIVE TC-99M MECKEL’S
tolerated during the procedure. No
DIVERTICULUM SCANNING IN CHILDREN
recurrence of bleeding was noted during
Jiangbin Liu, PhD, Professor, Department
a median follow-up period of 21 months
of Pediatric Surgery, Shanghai Children’s
(range, 3-60 months).
Department of Pediatric Surgery, Children’s CONCLUSION: DBE is a useful and feasible
Hospital of Fudan University, Shanghai, PR procedure in the pediatric patients,
China especially for the gastrointestinal
bleeding with negative Tc-99m Meckel’s
AIMS AND OBJECTIVES: Double balloon
diverticulum scanning, and combination
enteroscopy (DBE) is widely practiced in
with laparoscopic surgery at the same time
adults but rare in children. The study aimed
could make good results
to review the experience on the application
of double balloon enteroscopy (DBE) in
children, and to combine laparoscopic
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P028: LAPROSCOPIC OPERATION FOR months ago. He had been ill with severe
TREATMENT OF COMPLICATIONS IN cholangitis accompanied by intrahepatic
CHOLEDOCHOCYST Z haozhu Li, MD, bile ducts dilatation, we found stenosis of
Qingbo Cui, MD, Dapeng Jiang, MD, Bo Xu, biliary-intestinal anastomosis by PTC.
PhD, Department of Pediatric Surgery, the
RESULTS: Two girls ill with perforation
2nd Affiliated Hospital of Harbin Medical
of choledochocyst were treated by
University
laparoscopic drainage and irrigation of
OBJECTIVE: Choledochal cysts are peritoneal cavity for emergency therapy.
congenital cystic dilatations of the The patients were better in 7-10 days
extrahepatic or intrahepatic portion of and went home. One month later they
the biliary tree. Complete excision of came to hospital again for laparoscopic
choledochal cysts is currently regarded as choledochal cyst excision with Roux-en-Y
the gold standard treatment. Laparoscopic hepatico-jejunostomy and recovery. Two
operation for choledochocyst is becoming boys ill with stenosis of biliary-intestinal
popular. The complications may be anastomosis were operated by redo
occurred in preoperative and postoperative laparoscopic hepatico-jejunostomy. The
periods. Perforation of choledochocyst, procedure included splitting adhesions,
cholangitis, pancreatitis, and malignant enlarging anastomotic stoma, and calculus
may occur because of delay treatment. removed ect. The two boys recovered
Stenosis of biliary-intestinal anastomosis, well and were hospital stay for 10 and
cholelithiasis and infection of biliary tree 14 days, respectively. All patients were
may also occur in post-operation. Here we followed 6 months to 2 years and no more
treated 4 patients with the complications complications occurred.
associated with choledochocyst by
CONCLUSIONS: Laparoscopic operation for
laparoscopic technique.
complication treatment of choledochocyst
METHODS: Total 4 children were treated is suitable and not difficult. Because
in our hospital from June 2010 to June laparoscopic drainage and irrigation
2013. Two girls were ill with perforation of of peritoneal cavity for perforation of
choledochocyst. Of them one girl was 3 choledochocyst are easy, it can rinse
years old and had been diagnosed with peritoneal cavity thoroughly and the wall
choledochocyst before. Another girl was of perforative bile duct can heal by itself
8 months old and was first attacked with quickly. It will be convenient and safe for
abdominal pain, fever and abdominal the subsequent laparoscopic cyst excision.
distension. We found her dilated common For hepaticojejunostomy stricture and
bile duct by ultrasound exam and CT. intrahepatic stone formation, it will be
Two boys were ill with stenosis of biliary- very important preoperative and operative
intestinal anastomosis. Of them one boy cholangiography. It is not difficult to
was 12 years-old and had been treated by separate adhesion of omentum and
open choledochal cyst excision with Roux- intestine carefully. When the stoma site is
en-Y hepatico-jejunostomy 6 years ago. recognized, hepaticojejunostomy need to
He had been ill with reoccured cholangitis redo.
and cholelithiasis for one year. Another boy
KEY WORDS: Choledochocyst;
was 6 years-old, he had been operated
Laparoscopic operation; Complications
by laparoscopic choledochal cyst excision
with Roux-en-Y hepatico-jejunostomy 3
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P029: SIGMOID VOLVULUS. We consider that endoscopic devolvulation
VIDEOASSISTED SIGMOIDECTOMY AS followed by an early videoasisted
AN OPTION FOR MANAGEMENT IN sigmoidectomy is the ideal technique for
PEDIATRIC POPULATION S . Castañeda, the management of this patients.
MD, I. Molina, MD,P. Jaimes, MD, J.
P030: REDUCED PORT LAPAROSCOPIC
Beltran, MD, J. Valero, MD, F. Fierro, MD,
RESTRATIVE PROCTOCOLECTOMY WITH
Universidad Naccional de Colombia,
ILEAL POUCH-ANAL ANASTOMOSIS IN
Fundación Hospital de la Misericoridia
PEDIATRIC PATIENTS M ikihiro Inoue,
Sigmoid volvulus is one of the most MD, Junichiro Hiro, MD, Keiichi Uchida,
frecuent causes of acute large bowel MD, Hiroyuki Fujikawa, MD, Yuhki Koike,
obstruction. In children, it is a rare cause of MD, Yoshiki Okita, MD, Kohei Otake, MD,
bowel obstruction with an incidence that Toshimitsu Araki, MD, Masato Kusunoki,
varies from 3 to 5%. MD, Department of Gastrointestinal and
Pediatric Surgery, Mie University Graduate
A redundant sigmoid with a shortened
School of Medicine
mesentery (Dolichosigmoid) is necessary
for the formation a volvulus. In the Restorative proctocolectomy with ileal
pediatric population the cause of a pouch-anal anastomosis is the treatment
dolicohsigmoid may be an abnormal of choice for most patients with ulcerative
fixation that causes a widened mesentery colitis (UC) and familial adenomatous
with a small base . Other causes are history polyposis (FAP). Technical feasibility and
of anorectal malformation , Prune Belly safety for conventional laparoscopic
syndrome, intestinal malrotation and approaches to this procedure have been
Hirschsprung Disease. established since 1992 mostly in adult
settings. Recently, not only short term but
We report a series of 4 patients managed
also long term benefits including reduced
in our service with Sigmoid volvulus. Each
postoperative adhesion and increased
patient was taken to endoscopic reduction
pregnancy rate have become evident in
of the volvulus and latterly taken to
the laparoscopic procedure compared with
videoassisted sigmoidectomy. This case
open surgery. Meanwhile, reduced port
series is composed by 4 patients between
laparoscopic surgery including single-
9 and 14 years. One of the patients had to
incision laparoscopic surgery has been
be taken to a second reduction of volvulus
developed as an option for minimally
before sigmoidectomy during hospital
invasive laparoscopic procedures for
stay. Another patient that initially rejected
better cosmesis in the past few years. We
sigmoidectomy, had a recurrence of the
report four pediatric cases that underwent
volvulus requiring a second endoscopic
reduced port laparoscopic restorative
reduction. There were no intraoperative
proctocolectomy (RPL-RPC) with ileal
complications, and patients have been
pouch-anal anastomosis using single-port
followed up for at least 6 months . During
device in the different ways.
this time, one of the patients required
reintervention ; this patient had a diagnosis Three of four cases with ulcerative
of an intestinal miopathy: Inflamatory colitis were planned to perform 2-stage
Leiomiocytis which is a predisposition for procedure and underwent RPL-RPC as the
intestinal obstruction. first operation. At operation, single-port
device (Lap protectorTM and oval shaped
EZ-access, Hakko CO.,LTD., Nagano, Japan)
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was positioned through the intra-umbilical P031: A CASE SERIES OF LAPAROSCOPIC
longitudinal 30 mm incision and two 5 DUODENOJEJUNOSTOMY FOR THE
mm ports were placed in the umbilical TREATMENT OF PEDIATRIC SUPERIOR
device. A 12 mm port was used at the MESENTERIC ARTERY SYNDROME
site of ileostomy in the right iliac fossa. A Fredrick J. Bohanon, MD, Lance W. Griffin,
5 mm port was also placed at the drain MD, Laila Rashidi, MD, Sam Hsieh, MD,
insertion site in the left iliac fossa. Colonic Geetha L. Radhakrishnan, MD, Ravi S.
mobilization and mesenteric division Radhakrishnan, MD, MBA, FACS, FAAP,
was firstly achieved antegradely from University of Texas Medical Branch
terminal ileum to splenic flexture and then
Superior mesenteric artery (SMA)
retrogradely from sigmoid colon to splenic
syndrome is a rare debilitating clinical
flexture. Division of the mesenteric vessels
condition caused by compression of
was performed using ENSEAL G2 Tissue
the third portion of the duodenum by
Sealers (Ethicon Endo-Surgery, Ohio, US)
the SMA. It is often associated with
without ligation. Terminal ileum was divided
scoliosis corrective surgery, anorexia
by endoscopic linear stapler through the 12
nervosa, rapid growth, and dramatic
mm port. Colonic specimen was removed
weight loss. Prevalence rates are
through the umbilical incision and ileal J
reported to vary between 0.01 – 0.08%.
pouch was created extracorporeally at the
Common symptoms include intermittent
same site. Hand-sewn ileal pouch-anal
postprandial abdominal pain, nausea,
anastomosis was performed transanally.
weight loss, bilious vomiting and
Remaining one case with familial obstruction. SMA syndrome is also
adenomatous polyposis underwent 1-stage associated with pancreatitis of unknown
RPL-RPC without ileostomy. Same single- etiology. Here we present a case series
port device was used transumbilically and a of three patients with SMA syndrome
5 mm port was placed at the drain insertion that were treated with laparoscopic
site in the right iliac fossa. Additional 3 mm duodenojejunostomy.
forceps for retraction was directly inserted
Patients were female between 12-17
in the left upper abdomen. Division of the
years old. One patient presented post-
terminal ileum was performed through a
scoliosis corrective surgery, one patient
glove that was temporally exchanged from
with anorexia nervosa, and one patient
EZ-access.
with rapid weight loss after pneumonia.
All procedures were successfully All patients underwent a successful
completed without any perioperative laparoscopic duodenojejunostomy after
complications. Operative time ranged 385 imaging suggested SMA syndrome. Mean
to 490 min. There were two long term time to feedings after surgery was 4.00 ±
adverse events, including one afferent 1.15 days (mean ± SEM). Mean length of
limb syndrome and one acute pouchitis. stay after surgery was 8.6 ± 2.7 days. One
patient presented with pancreatitis (Lipase
Our RPL-RPC to optimize the umbilicus
4432 U/L) that resolved after surgery.
and the essential incisions is technically
One patient developed acute pancreatitis
comparable and cosmetically superior
(Lipase 2220 U/L) on post-operative day 9
to conventional laparoscopy. This
requiring readmission and treatment. One
procedure can be an alternative for the
patient didn’t develop pancreatitis.
pediatric patients in needs of restorative
proctocolectomy.
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SMA syndrome remains a complex disease IRB exempt determination, 23 participants
to diagnose and treat. Once suspected performed the simulated laparoscopic DA
current therapy consists of either non- repair during a national pediatric surgery
surgical or surgical intervention. Post- conference. All participants completed
obstructive placement of nasojejunal a self-report, six-domain, 24-item
feeding tubes and total parental nutrition instrument consisting of 4-point rating
allow for adequate nutritional intake scales (1=Not realistic, 4=Highly realistic).
and decompression, but often require Content validity was evaluated using the
prolonged hospitalization and increased many-Facet Rasch model and estimating
costs. Reported hospital length of stay inter-rater consistency using Intra-class
is between 21 days and 4 months in a correlation (ICC) for items relevant to
small series. Surgical management mainly simulator characteristics.
consists of open lysis of the ligament
RESULTS: The highest observed averages
of Trietz or duodenojejunostomy with
(OA) were for Value as a training and
possible risk of complications. Here we
testing tool (both OAs = 3.9), while the
demonstrate that laparoscopic treatment
lowest ratings associated with simulator
of SMA syndrome is a safe treatment
characteristics were Palpation of liver,
option and is associated with early initiation
(OA = 3.3), and Realism of skin (OA = 3.2),
of enteral feeds and a short hospital stay
which aligned with “adequate realism,
after surgery.
but could be improved.” The Global
P032: THE DEVELOPMENT AND opinion rating was 3.2, indicating the
PRELIMINARY EVALUATION OF A NOVEL simulator can be considered for use as is,
LAPAROSCOPIC DUODENAL ATRESIA but could be improved slightly. Validity
REPAIR SIMULATOR K atherine A. Barsness, evidence relevant to internal structure was
MD, MS, Deborah M. Rooney, PhD, Lauren supported by high inter-rater agreement
M. Davis, BA, Ellen K. Hawkinson, BS, [ICC(1,k)α=.88].
Northwestern University Feinberg School
CONCLUSIONS: We have successfully
of Medicine, University of Michigan Medical
created a size appropriate, high fidelity
School
laparoscopic DA simulator. Participants
BACKGROUND: Laparoscopic duodenal agreed that the simulator was relevant
atresia (DA) repair is a relatively uncommon to clinical practice and valuable as a
pediatric operation requiring advanced learning/testing tool, but it may require
minimally invasive skills. Currently, there minor improvements. Comments were
are no commercial simulators available consistent with the Value ratings. Prior to
that address surgeons’ needs while refining implementing this simulator as a training
skills associated with this procedure. The tool, minor improvements should be
purposes of this study were 1) to create an made, with subsequent evaluation of
anatomically correct, size relevant model additional validation evidence.
and 2) to evaluate the content validity of
P033: ENDOVIDEOSURGERY FOR
the simulator.
TREATMENT OF HIRSCHPRUNG DISEASE
METHODS: Review of literature and IN CHILDREN B ulat Jenalayev,Damir
X-ray/CT images were used to create an Jenalayev, Omar Mamlin, National
abdominal domain, size consistent with a Research Center for Mother and Child
full-term infant. Fetal bovine tissue was Health
used to complete the simulator. Following
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Hirschprung disease possesses the No perioperative complications were
second place (after pylorostenosis) by noticed. Blood loss during surgery didn’t
frequency among the disorders leading exceed 20.0-30.0 ml and didn’t require
to gastrointestinal obstruction in children transfusion. In all cases the gastrointestinal
that require surgical treatment. There were contents appeared within 12-18 days
17 cases of Hirschprung disease treatment after surgery, since that moment enteral
by the aid of laparoscopic assistance. The feeding has been extended. These patients
age of patients were between 3 and 14. were under observation of outpatient
The rectosigmoidal form of Hirschprung department at late postoperative period
disease were revealed in all the cases while and received anal bougienage by dilators
X-ray examination. of sizes according to the age. There were
no symptoms of stenosis. One of the
Surgeries were performed under
patients had high body temperature
endotracheal narcosis and consisted of the
and difficulty of defecation at 7th day
following stages:
after surgery. A cavern of 3.0x4.0 cm
Stage I – laparoscopic. After insertion of with liquid content was revealed while
three troacars the left side of abdomen rectal examination and ultrasound
were visually investigated. Further, examination. In the result of puncture
transition fold of peritoneum was through the posterior wall of the rectum
dissected and rectum was mobilized about 30.0 ml of rheumic content with
circularly deep in small pelvis. In order to fibrin was aspirated. The cavern was
assess the adequacy of mobilization and rinsed by insertion irrigating catheter
the degree of tension of the mesentery a under ultrasound scan control. After
trial traction of a mobilized colon toward these manipulations the cavern have
the anus was conducted. been closed up and infiltration nearby
diminished. The patient was discharged
Stage II - perineal. Anal orifice was in 15 days after the surgery. The other
extended, tack-up sutures were patients were discharged in 8-9 days after
performed around the anus. Dissection surgery. Control observation in 6 month
and mobilization of rectal mucous coat showed good condition of all the patients.
was performed for 5.0 – 6.0 cm starting 0.5 There were no complaints, abdominal
cm from linea serrata. distention, encopresis or obstipation.
Then, the colon was resected and brought Conclusion. Laparoscopic surgery by K.
down to perineum through demucousized Georgson for surgical treatment of colon
channel. This step was conducted under aganglionosis in children is considered to
laparoscopic visual control while the be both radical and minimally traumatic;
correct performance could be seen. The following the principles of preoperative
coloanal anastomosis was completed by examination and treatment, following
separate absorbable sutures. the steps and specific aspects of surgery
III stage - laparoscopic revision and allows to minimize the risk of intra- and
sanitation of the pelvis, restoring the perioperative complications, to achieve
transitional fold of peritoneum, elimination significant improvement the results of
of the “window” in the colon mesentery the treatment reducing trauma, severity
were performed through the abdominal or postoperative period, length of stay,
cavity. providing quick recovery along with good
cosmetic effect.
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P034: SINGLE-INCISION p<0.01). All patients resumed feeding on
LAPAROSCOPIC-ASSISTED postoperative day 1. The median follow-
ANORECTOPLASTY FOR HIGH up period was 20 months. No injuries of
AND INTERMEDIATE ANORECTAL vessels, urethral or vas deferens occurred
MALFORMATIONS: COMPARISON WITH in operations. No mortality or morbidities
CONVENTIONAL LAPAROSCOPIC- of wound infection, rectal retraction,
ASSISTED ANORECTOPLASTY recurrent fistula, urethral diverticulum,
AND POSTERIOR SAGITTAL anal stenosis, or rectal prolapse was
ANORECTOPLASTY M ei Diao, MD, PhD, encountered. Overall complication rate
Long Li, MD, PhD, Mao Ye, B., Med, MPhil, in high ARM group was comparable to
Department of Pediatric Surgery, Capital that of our historical CLAARP group
Institute of Pediatrics, Beijing, P. R. China (12.5%, p=0.15), and lower than that of our
historical PSARP group (35.3%, p<0.01).
BACKGROUND: The current study aims
to evaluate the safety and efficacy of CONCLUSIONS: SILAARP is safe,
single-incision laparoscopic-assisted feasible and effective for both high and
anorectoplasty (SILAARP) for children intermediate ARMs. One-stage SILAARP
with high and intermediate anorectal or combined transumbilical colostomy
malformations (ARM). and 3-stage SILAARP offers a viable
alternative treatment for children with
METHODS: Children with high and
high and intermediate ARMs.
intermediate ARMs who underwent
SILAARP between May 2011 and P035: LAPAROSCOPIC CARDIOMYOTOMY
December 2012 were reviewed. The ARM AND FUNDOPLICATION IN A 2-MONTH-
patients who had poor-developed pelvic OLD INFANT WITH ACHALASIA: A CASE
muscles on magnetic resonance images REPORT S hin-Young Kim, MD, Hye Kyung
were excluded. The operative time, early Chang, MD, PhD, Myung Duk Lee, MD,
postoperative and follow-up results were PhD, Departmenf of Surgery, Seoul St.
compared with our historical controls who Mary’s Hospital, The Catholic University of
underwent conventional laparoscopic- Korea College of Medicine
assisted anorectoplasties (CLAARP)
INTRODUCTION: Achalasia is an
and posterior sagittal anorectoplasties
uncommon condition in children. The
(PSARP).
purpose of the study is to report a case
RESULTS: Thirty-one patients (high vs. of an infant with achalasia treated with
intermediate ARM: 15/16) successfully laparoscopic Heller’s cardiomyotomy and
underwent SILAARPs without conversions. Nissen’s fundoplication.
Mean ages at operation were similar in 2
CASE REPORT: Two-month-old boy
groups (high vs. intermediate ARM: 4.94
presented with projectile vomiting
months vs. 5.67 months, p=0.46). Average
for one month. Ultrasonographic
operative time in intermediate ARM
finding was not remarkable. Upper GI
children was 1.94 hours, which did not
study showed passage disturbance at
differ from 1.78 hours in high ARM children
esophagogastric junction with suspicious
(p=0.39). The mean operative time in high
esophageal motility disorder and
ARM group was comparable to that in
combined gastroesophageal reflux with
our historical CLAARP group (1.62 hours,
relaxation of lower esophageal sphincter.
p=0.12), and significantly shorter than that
Endoscopic findings were decreased
in our historical PSARP group (2.13 hours,
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esophageal peristalsis and narrowing of oesophageal dilatation for eosinophilic
esophagogastric junction with proximal oesophagitis between 2008 and 2013
esophageal dilation. Symptoms were was performed. Demographics, symptom
not relieved by medical treatment duration, medical therapies, endoscopy
of gastroesophageal reflux. He was findings, dilatation technique, post
underwent Heller’s cardiomyotomy and dilation endoscopic findings and response
Nissen’s fundoplication laparoscopically. to treatment were analysed.
Using two 5mm working ports, liver
RESULTS: Three patients of a cohort
retractor and 5mm endoscope, distal
of circa 30 patients with eosinophilic
esophagus around the hiatus was
oesophagitis underwent bougienage
dissected, and longitudinal esophageal
dilatation of an oesophageal stricture.
myotomy was performed on the anterior
Median age at dilatation was 16 (range 14-
side of distal esophagus about 5 cm in
16). All patients presented with symptoms
length. Nissen’s fundoplication was done.
of dysphagia and odynophagia. Time of
The postoperative progress was not
referral from paediatric gastroenterology
remarkable without complication. Feeding
to oesophageal dilatation was between 4
with adequate amount of milk became
and 8 months. All patients had endoscopy
tolerable in a week without vomiting.
and passage of a guidewire into the
CONCLUSION: Laparoscopic Heller’s stomach followed by serial dilatation
cardiomyotomy and Nissen’s with savary-guilliard© dilators and check
fundoplication was successfully endoscopy. In all cases dilatation was
performed in 2-month-old infant with noted to be traumatic with deep linear
achalasia resulting complete relief of fractures of the oesophageal mucosa
vomiting. (figure 1). All patients remained well after
dilatation with no evidence of perforation
P036: EOSINOPHILIC OESOPHAGITIS:
on chest radiograph. All patients reported
THE TRUTH ABOUT DILATATION
immediate symptom relief and on
Kirsty Brennan, Saidul Islam, Michael
maintenance medical treatment none has
Hii, Assad Butt, Anies Mahomed,
required further endoscopic evaluation or
Department of Paediatrics & Paediatric
repeat dilatation.
Surgery,Royal Alexandra Children’s
Hospital,Brighton,U.K. CONCLUSIONS: Our experience
suggests that the diffuse nature of the
AIM: Eosinophilic oesphagitis is a
inflammation in eosinophilic oesophagitis
debilitating condition with significant
is associated with long strictures which
associated morbidity. Dilatation is
respond to tangential dilatation. We
reserved for patients with strictures
suspect it is the degree of mucosal
resistant to medical therapy. Strictures
inflammation with relatively normal
are commonly long and difficult to
underlying serosa that leads to impressive
assess with radiological imaging. We aim
mucosal trauma without perforation.
to investigate whether endoscopy and
The presented series supports tangential
tangential bougienage dilatation is a safe
bougienage dilatation for paediatric
and effective treatment.
eosinophilic oesophageal stricture that
METHODS: Retrospective analysis fails to respond to medical therapy.
of prospectively collected database savary-guilliard© Cook Medical
of patients undergoing tangential
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FIGURE 1 and descending colon is grasped and
exteriorized identifying the attachments to
left retroperitoneum and his progression
distally to Douglas. Division of the colon is
performed outside and the distal colon is
displaced to the port in the midline. Both
stomas are then fixed without wound in
between, being the distal intentionally
small (mucous fistula).
RESULTS: Two patients with ARM were
Long Linear fracture in Anterior wall operated this way. No complications were
seen during and after the procedure.
P037: 2 PORT LAPAROSCOPIC Oral intake was achieved before the first
COLOSTOMY FOR ANORECTAL 24 hours. Colostomy bag was placed
MALFORMATIONS IN NEWBORNS C arlos immediately after surgery. In one case, an
Gine, MD, Saioa Santiago, MD, Nerea anomaly of internal genitalia was identified
Vicente, MD, Jesus Broto, MD, Javier Bueno, and recorded. Time of procedure was less
PhD, Hospital Vall d’Hebron. Barcelona than 1 hour.
INTRODUCTION: Standard colostomy DISCUSSION: This technique allows
in anorectal malformations (ARM) is rigorous inspection of internal genitalia,
a descending colostomy in separate eliminates the wound infection possibility
stomas, leaving the distal stoma as a because the are no scars, colostomy bag is
mucous fistula. Oblique laparotomy in left easily and painlessly managed immediately
lower quadrant (LLQ) is needed leaving after surgery, twisted colostomy is less
the stomas at each edge of the wound. probable because it is checked during
This procedure may quite often lead to surgery, the procedure is not technically
minor complications as skin infection demanding and better cosmetic result are
of the surgical wound and discomfort achieved by transversal scars in colostomy
during management of the colostomy closure.
bag immediately after the surgery. Rarely,
wound infection and evisceration can P038: THE DOGMA OF ARTERIO-VENOUS
occur. We describe a 2 port laparoscopic FISTULA AFTER SPLENECTOMY: STILL
colostomy for ARM in descending colon RELEVANT WITH LAPAROSCOPIC JOINT
and separate stomas without other SEALING OF SEGMENTAL SPLENIC
incisions than those created to place the ARTERY AND VEIN? S ara Silvaroli, MD,
stomas. We emphasize the advantages of Marianne De Montalembert, MD, Valentine
this technique. Brousse, MD, Sabine Irtan, MD, PhD,
Department of pediatric surgery, Necker
METHODS: First port is located in LLQ Hospital, Paris, France.
equally distant from the umbilicus and
iliac crest, where proximal stoma should BACKGROUND: Splenectomy in
be. This incision is circular and ballooned children is nowadays widely performed
trocar is needed. Inspection of internal by laparoscopy. Either by anterior or
genitalia is then achieved. Supra-pubic 5 lateral approach, the splenic vessels are
mm trocar is placed next in the midline separately dissected and divided at the
where we would like the mucous fistula left upper part of the pancreas before their
to be. Camera is introduced in this port division in the splenic hilum according to
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the princeps technique aiming to prevent cholecystectomy was performed in 12
arterio-venous fistula. children. A fourth port was added in 7
patients. The mean operative time was 115
AIM: We hereby describe a new technique
mn (49-240). No operative bleeding or
of vascular control in splenectomy thanks
conversion was noticed. The postoperative
to the development of new laparoscopic
course was uneventful, except for one
coagulation devices.
female patient presented an isolated
MATERIALS AND METHODS: The fever 2 days after the procedure treated
laparoscopic splenectomy was performed by IV antibiotics in fear of occult infection.
by a lateral approach with the left side The mean postoperative hospital stay was
of the patient elevated 30 to 45 degrees 2,25 days (2-8). No venous thrombosis
thanks to a small roll under the back. or arterio-venous fistulas were found at
The 10-mm optic port was placed in the postoperative ultrasound scan with a mean
umbilicus via an open approach for a 0° follow-up of 15,5 months (8-42,5).
laparoscope. Two 5-mm working ports
CONCLUSION: With the introduction of new
were placed in the left lower quadrant and
technology, the joint sealing of segmental
in the right upper part of the abdomen
splenic artery and vein appeared safe and
near the midline. An additional port
efficient in laparoscopic splenectomy,
was placed in the epigastrium to ease
without any increased risk of operative
the dissection if needed or in case of
bleeding or postoperative arterio-venous
cholecystectomy. All the procedure was
fistula.
performed with the LigaSure (Valleylab,
Tyco Healthcare Group, Boulder, CO). The P039: LAPAROSCOPIC MANAGEMENT OF
dissection began at the lower pole of the CHOLEDOCHAL CYST – OUR EXPERIENCE
spleen with the division of the splenocolic OF 62 CASES Ravindra Ramadwar, Dr.,
ligament. Short gastric vessels were Nidhi Khandelwal, Dr., Bombay Hospital,
divided allowing access to the splenic Mumbai, India
hilum. Each segmental splenic vessel was
INTRODUCTION: Laparoscopic
dissected at the lower, middle and upper
excision of choledochal cyst with
part of the spleen. They were then divided
hepaticodochoenterostomy is an
without individualizing the artery from the
alternative to open operation in children.
vein. Progressing from bottom to top, the
The aim of the study was to evaluate our
splenophrenic ligament was sectioned
experience of laparoscopic management
allowing complete mobilisation of the
of choledochal cyst and assess the
spleen. The specimen was exteriorized
medium term results.
through an enlarged umbilical incision
after finger fragmentation in a retrieval METHOD: We reviewed 62 patients who
pouch. had undergone laparoscopic surgery for
choledochal cyst since January 2003 to
RESULTS: Thirty patients aged 6.36
January 2014. The data were analysed
years (2-15.6) have been operated on
for operative approach, intraoperative
in our institution from 2009 to 2013.
problems, postoperative complications
The indications of splenectomy were
and postoperative follow up.
sickle cell anemia (n=18), hereditary
spherocytosis (n=9), hemolytic anemia RESULTS: Since January 2003, 62 patients
(n=1), idiopathic thrombocytopenic purpura have undergone laparoscopic surgery
(n=1) and hystiocytosis (n=1). An additional for choledochal cyst. Mean age was 6
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years (6 weeks – 18 years), mean weight INTRODUCTION: Persistent
was 12 kg (3.5 kg - 52 kg). 57 patients hyperinsulenemic hypoglycemia of infancy
had type I and 5 patients had type IV (PHHI) is one of the most common cause
A choledochal cyst. In 39 patients the of persistent neonatal hypoglycemia.
cyst diameter was more than 5 cms. Management of PHHI involves use
In 3 patients the posterior segmental of medical agents and its failure is an
duct was opening directly into the cyst. indication for surgical intervention. PHHI
Preoperative ERCP and stenting was done in infants requiring surgery is rare and
in 2 patients. Mean operative time was traditionally an open pancreatectomy
175 minutes (115 – 290 minutes). Mean was the gold standard surgical approach.
intraoperative blood loss was 25 ml (10 – But recently trend has shifted towards
45 ml). Lilly’s technique of mucosectomy use of laparoscopy. We describe a case
was performed in 41 patients. 44 patients of PHHI managed by laparoscopic spleen
underwent Roux-en-y hepaticodocho- preserving near total pancreatectomy in a
jejunostomy and 18 patients had 2month old infant.
hepaticodocho-duodenostomy. The
METHODS: A 2 month old male child
mean time taken for intra-corporeal
diagnosed with PHHI with failure of
hepaticodocho-enterostomy was 60
medical therapy. A laparoscopic near total
minutes (45-100 minutes). Conversion
spleen preserving pancreatectomy was
to open surgery was required in 1 patient
done. Laparoscopic pancreatectomy was
with recurrent pancreatitis. Bile leak was
performed using a 5-mm cannula at the
seen in 4 patients, three were treated
umbilicus, one 5mm and two additional
conservatively and one patient required
3mm cannula sites. The stomach was
percutaneous placement of stent. Mean
retracted and lesser sac opened. The entire
hospitalisation was 6 days (4 – 14 days). At
pancreas was exposed. The pancreas was
mean follow-up of 4 years (6 months – 11
resected from the splenic hilum to the
years) one patient had recurrent sub-acute
mesenteric vessels. The splenic vein was
obstruction and 2 patients had cholangitis.
dissected from the under surface of the
60 patients have normal liver function
pancreas using harmonic scalpel, and
tests and ultrasonography. 2 patients with
the spleen was easily preserved. Leaving
recurrent cholangitis had abnormal liver
behind a small rim of pancreatic head
function tests during cholangitis which
along the C- loop of duodenum, a near
reverted to normal after antibiotic therapy.
total pancreatectomy was done by using
HIDA scan in these patients show good
Ligasure. Surgery time was 90 min, and
drainage with no stasis.
minimal blood loss occurred. The specimen
CONCLUSION: Laparoscopic excision of was extracted in a bag. Drains were kept
choledochal cyst with hepaticodocho- in pancreatic bed and pelvis. The patient
enterostomy is a safe alternative to open tolerated the procedure well and the
surgery and has satisfactory results. post operative recovery was uneventfull.
Histopathology showed evidence of islet
P040: LAPAROSCOPIC NEAR TOTAL
cell adenoma with the background of
PANCREATECTOMY FOR PERSISTENT
nessidioblastosis in the entire pancreas.
HYPERINSULENEMIC HYPOGYCEMIA OF
INFANCY Ravindra Ramadwar, Dr., Vrajesh RESULT: The patient has remained
Udani, Dr., Soonu Udani, Dr., Hinduja euglycemic for ten months now after the
Hospital, Mumbai procedure and currently is not on any
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medication. The extent of pancreatectomy RESULTS: Medical treatment was effective
was 95%. No postoperative complications in 2 patients with liver hydatid cysts less
were noted. than 4cms. The deep seated liver cyst
responded well to ultrasound guided
CONCLUSION: The magnification afforded
aspiration of cyst fluid and instillation of
by laparoscopic vision allows for safe
scolicidal agent(hypertonic saline 3%).
dissection of pancreas. Laparoscopcic near
Rest of the 21 cases(87.5%) with cyst size
total pancreatectomy is safe and feasible
more than 5cms underwent minimal
approach for infants with PHHI with failure
access surgery. None of these patients had
of medical management with minimal
postoperative complications (including
blood loss and lesser wound morbidity.
recurrence) requiring reoperation. The
P042: EVALUATION OF ROLE OF MINIMAL overall long-term results were good.
ACCESS SURGERY IN TREATMENT OF
CONCLUSIONS: Hydatid cysts with sizes
HYDATID DISEASE IN CHILDREN G . M.
exceeding 5cm in diameter should be
Irfan, MS, MRCSEd, MCh, P. S. Reddy, MS,
treated surgically and minimal access
MCh, Vinod Kumar, MS, MCh, Niloufer
surgery seems to be more effective and
Hospital, Institute for Woman and Child
has almost nil complications with less
Health.Hyderabad AP India
morbidity to the patient. Also use of
PURPOSE: Hydatid disease is not so antihelmenthic agents for 2weeks prior to
commom in children even in endemic surgery may decrease recurrence.
areas but has serious complications if
P043: LAPAROSCOPIC-ASSISTED
not treated properly. There are various
PANCREATICODUODENECTOMY IN A
methods for treatment of this disease
CHILD WITH A GASTRINOMA H iroo Uchida,
both medically and surgically. The aim of
MD, Yasuyuki Ono, MD, Naruhiko Murase,
this prospective study is to present our
MD, Satoshi Makita, MD, Kazuki Yokota,
experience in the management of hydatid
MD, #Hiroshi Kawashima, MD, #Yujiro
disease in children by minimal access
Tanaka, MD, #Kyoichi Deie, MD, #Hizuru
surgery and its efficacy.
Amano, MD, Department of Pediatric
MATERIAL & METHODS: Over a 3-year Surgery, Nagoya University Graduate
period (2010 - 2013), 24 children with School of Medicine, Nagoya 466-8550,
abdominal and pulmonary hydatid disease Japan. # Department of Pediatric Surgery,
(ECHINOCOCCUS) were treated at our Saitama Children’s Medical Center, Saitama
department of paediatric surgery. The 339-8551, Japan
anatomical location of the parasite was
BACKGROUND: Zollinger–Ellison
as follows: liver 17, lungs 4 spleen 2, and
syndrome is very rare in children. Ninety
mesentery 1 case. Medical treatment with
percent of gastrinomas are located in the
oral antihelminthic agents was given to all
pancreaticoduodenal region referred to
patients for two weeks before taking up for
as the gastrinoma triangle. Prompt and
surgery so as to make them less infective.
complete removal of the gastrinoma
Only medical management was used for
is necessary in patients with Zollinger–
2 cases of liver hydatid cysts less than
Ellison syndrome, even in patients with
5cms and in one case of deep seated liver
negative imaging findings, because a
hydatid cyst while rest of the 21 cases(87.5
long delay in surgery may cause liver
%) underwent minimal access surgery
metastases and disease-related deaths.
(laparoscopic or thoracoscopic procedure).
We performed laparoscopic-assisted
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pancreaticoduodenectomy (LAPD) in treated a grade A pancreatic fistula. He
a child with a biochemical diagnosis of was discharged in a healthy condition 20
gastrinoma but negative imaging findings. days after surgery and biochemical tests
Although LAPD has not been reported in confirmed the absence of gastrinoma 1
a child until now, we believe it is safe and year after surgery.
feasible in children.
DISCUSSION: The optimal surgical
CASE: A 9-year-old boy with Down procedure for resecting a gastrinoma is
syndrome presented at an outpatient unclear, but aggressive resection following
clinic complaining of weight loss and its accurate localization with a selective
vomiting. Upper gastrointestinal images arterial secretagogue injection test with
and endoscopy showed severe stenosis calcium was biochemically curative.
of the duodenal bulb because of a The complications associated with a
semicircular ulcer. His symptoms did pancreatic fistula mean that laparoscopic
not improve following treatment with a PD is technically challenging for pediatric
proton pump inhibitor. His gastrin level surgeons. Our LAPD approach should
was very high (834 pg/ml; normal range: enable pediatric surgeons to perform
37–137 pg/ml). A peripheral vein calcium pancreaticojejunostomy as confidently
injection test was positive for gastrinoma. as open PD because it can be performed
However, imaging studies did not reveal a under direct vision through a small
gastrinoma. Injection of a selective arterial laparotomy. LAPD is a minimally invasive
secretagogue revealed a tumor within and reproducible procedure.
the gastroduodenal arterial zone. The
P044: LAPAROSCOPIC SURGERY FOR
clinical course of the patient was poor as
HIATAL HERNIA ASSOCIATED WITH
he intermittently felt well and nauseous
MICROGASTRIA IN ASPLENIA SYNDROME
intermittently. The patient and his parents
Takeo Yonekura, MD, PhD, Yuji Morishita,
opted for surgery at 11 years of age.
MD, PhD, Masafumi Kamiyama, MD, PhD,
OPERATIVE PROCEDURE & Katuji Yamauti, MD, PhD, Tomohiro Ishii,
POSTOPERATIVE COURSE: The patient Md, PhD, Dep. of Pediatric Surgery, Nara
was placed in a supine position with his Hosp., Kinki Univ. Sch. Med.
legs apart. The surgeon stood between
INTRODUCTION: Hiatal hernia associated
the patient’s legs. A 12 mm camera port
with microgastria in asplenia syndrome
was introduced via the umbilicus while 12
is a rare but well-described congenital
and 5 mm ports were inserted into the
anomaly. Surgical treatment is technically
left and right abdomen. A 4 cm incision
difficult due to associated anatomical and
was made directly above the pancreatic
cardiovascular anomalies.
stump to remove the resected tissue. After
minilaparotomy, which was covered by a METHODS: Four out of 22 infants with
wound retractor and a sealed cap, LAPD asplenia syndrome had had hiatal hernia
was performed with child Roux-en-Y and microgastria for the last 10 years. One
reconstruction. Pancreaticojejunostomy infant underwent open hiatal repair due to
and gastrojejunostomy were done under associated severe cardiorespiratory failure.
direct vision, while hepaticojejunostomy Another infant had VATS, which resulted in
was done laparoscopically. The operative residual gastric herniation. The 2 remaining
time was 694 minutes. Oral intake infants underwent laparoscopic repair
was started on postoperative day 3. of the hiatal hernia and anti-reflux with
The surgical procedure conservatively microgastria in asplenia syndrome. Herein,
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we review these 2 latter infants and discuss BACKGROUND: Percutaneousendoscop-
the role of laparoscopic procedures. icgastrostomy(PEG) is widely accepted
as the preferred procedure to establish
RESULTS: Case 1: A 3-month-old male
long-term enteral feeding in children. Sur-
infant who had underwent PA banding for
prisingly, various published series suggest
SASV showed melena due to herniation
conflicting morbidity rates differing from
of the microgastria and colon through
5-33% associated with PEG procedure
the esophageal hiatus near the left-sided
in children. Therefore, we reviewed our
IVC. Laparoscopic surgery confirmed
experience with children who underwent
a preduodenal portal vein and large
PEG placement to find out the complica-
esophageal hiatus located in the deep
tion rates and long-term outcomes of this
cranial portion of the subhepatic recessus.
procedure.
He underwent crural repair after reduction
of the herniated stomach, pancreas, and METHODS: The records of the patients
colon. However, he still showed GERD with who underwent PEG placement between
failed anti-reflux surgery due to severe January 2008 and December 2012 were
microgastria. reviewed. The patients were called
to evaluate their latest situation. The
CASE 2: A-four-month-old female infant
procedure was performed with the
received an antenatal diagnosis of hiatal
standard pull technique under general
hernia with asplenia syndrome. After
anesthesia. Prophylactic antimicrobial
placing an arterial-pulmonary shunt
drugs were not used. Tube feeding was
for PA stenosis and SASV, she received
begun 12 hours after the PEG placement.
laparoscopic surgery at 2 months of age.
The patients were visited regularly by
Laparoscopy revealed a preduodenal
an experienced nurse in their homes
portal vein and large esophageal hiatus
and evaluated in terms of potential
located in the deep cranial portion of the
complications.
subhepatic recessus. She underwent hiatal
repair and partial fundoplication. RESULTS: A total of 40 pediatric patients
(22 males and 18 females), with a mean
CONCLUSION: Accurate preoperative
age of 5.6±4.1 years (17 day old to 14
evaluation of cardiovascular and
years), underwent 41 PEG placement. The
anatomical anomalies is extremely
mean weight of the patients during the
important in asplenia syndrome. MIS
procedure was 13.7±10.2 kg. The underlying
is warranted for hiatal repair; however,
diseases of the patients were neurological
complications resulting from microgastria
dysfunction (n=34), metabolic disorders
and cardiovascular abnormalities still
(n=4), total intestinal aganglionosis (n=1)
remain.
and cleft palate (n=1). There was no early
P045: DETERMINATION OF complication. Mean follow-up time of
PERCUTANEOUS ENDOSCOPIC the patients was 2 ±1.2 years. The late
GASTROSTOMY COMPLICATION RATES IN complications were stoma infection
CHILDREN G onul Kucuk, MD, Gulnur Gollu, which was managed conservatively in
MD, Meltem Bingol-Kologlu, Prof., Aydin three children (7.5%), buried bumper in
Yagmurlu, Prof., Murat Cakmak, Prof., Tanju one (2.5%) and gastroesophageal reflux
Aktug, Prof., Huseyin Dindar, Prof, Ankara disease which required laparoscopic
University School of Medicine Department Nissen fundoplication in one (2.5%). Three
of Pediatric Surgery patients died because of their underlying
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disease The PEG tube was removed performed and lower esophageal sphincter
permanently in four patients because they was seen firm even with air insufflations
resumed an adequate oral intake. and did not opened. Endoscopic balloon
dilatation was performed all 5 patients
CONCLUSION: PEG is a minimal invasive,
and botox injection was performed to
easy, safe and reusable route for long
one. They did not get benefit, and Heller
term enteral feeding. Rates of PEG
myotomy and fundoplication to prevent
complications observed in this study are
reflux were performed. Postoperative third
low and are generally minor. Observed
week videofluoroscopy was performed and
rates of PEG-specific complications are
no reflux or stricture were seen. In 7-24
lower than previous reports. Therefore
months follow ups, (median 10 months)
it should be first preferred choice of
especially fluid need of swallowing firm
procedure in children who require long
food was detected and videofluoroscopy
term enteral feeding.
was performed. Increased esophagus
P046: PATIENT COMFORT DOES NOT calibration, no strictures of lower
ALWAYS GET BETTER WITH SURGICAL esophageal sphincter and tertiary
INTERVENTION IN ACHALASIA G ulnur contractions were seen all of the patients.
Gollu1, MD,Ergun Ergun1, MD, Gonul
CONCLUSION: Achalasia, a rare motor
Kucuk1, MD, Numan Demir2, Tanju
disease of esophagus. Esophagus that
Aktug1, Prof., Huseyin Dindar1, Prof., Aydin
diagnosed late and dilated or tortiosed,
Yagmurlu1, Prof., 1Ankara University School
surgical interventions may not be able to
of Medicine Department of Pediatric
prevent dysphagia even there was no lower
Surgery,2Hacettepe University, Swallowing
esophageal sphincter stricture.
Disorders Application and Research Center
P047: LAPAROSCOPIC MANAGEMENT
PURPOSE: Achalasia, an esophageal
IN ACUTE DUODENAL PERFORATION IN
motility disease which is characterized with
AN ADOLESCENT GIRL G ulnur Gollu, MD,
absence of relaxation of lower esophageal
Gonul Kucuk, MD, Bilge Turedi, MD, Nil Y.
sphincter. Dilatation, botox injection, and
Tastekin, MD, Aydin Yagmurlu, Prof, Ankara
for the last chance, surgical intervention
University School of Medicine Department
are among treatment choices. The
of Pediatric Surgery
dysmotilities of patients who had surgical
operations because of achalasia is aimed Duodenalulcerperforationis an
to evaluate. uncommon entity in pediatric age group
and it is not usually considered in the
METHODS: Patients who had been
differential diagnosis of acute abdomen
operated between 2006- 2012 and
in these patients. A thirteen-year old
who had swallowing disorder reviewed
who had abdominal pain and vomiting
retrospectively. Three girls and two boys
had prominent abdominal tenderness.
were brought to the hospital with swallow
Abdominal X-ray revealed free gas under
trouble.
diaphragm. She had a history of non-
RESULTS: Videofluoroscopy was performed steroidal anti-inflammatory drug ingestion
five children for having troubles of four days ago because of tooth pain. After
swallowing firm food.” Bird beak” deformity fluid resuscitation, laparoscopy revealed
at the lower esophagus and dilatation free bilious fluid in the abdomen. A discrete
of upper segments had seen. Upper perforation was found on the anterior
gastrointestinal tract endoscopy was wall of the first part of duodenum. Simple
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closure was performed laparoscopically. RESULTS: Among all patients, 16 were
The aim of this video presentation is to male, 9 were female. Age at admission
show the technical details of this minimal ranged from 2 h to 1 d.Ten patients were
invasive surgery. preterm (gestational age 34w~37w) and
12 were low birth weight (1580g~2450g).
P048: LAPAROSCOPIC
The duodenal obstruction was due to
GASTRODUODENOSTOMY IN A
malrotation (n=11), atresia (n=4), web (n=5),
NEWBORN WITH PYLORIC ATRESIA Gulnur
and annular pancreas (n=5). Laparoscopic
Gollu, MD, Gonul Kucuk, MD, Bilge Turedi,
procedure was performed in all the cases
MD, Hakan Tuzlali, MD, Aydin Yagmurlu,
by 3 to 4 trocars. During operation, 2
Prof, Ankara University School of Medicine
to 3 sutures for lifting were performed
Department of Pediatric Surgery
in the cases who needed anstamosis
Pyloric atresia is a very rare condition (atresia, web and annular pancreas), and
with an incidence of 1:100000 newborns. abdominal drainage was performed in
A 2500g boy who had non-projectile these cases. The operation time was
and non-bilious vomiting had single 60-180 min(mean, 85min). Twenty-three
gastric bubble with no air in distal cases were accomplished by LP surgery,
segments in abdominal X-ray. He had two cases with malrotation shifted to open
no associated anomalies. Laparoscopic procedure due to volvulus more than 720°.
gastroduodenostomy was performed. One case suffered anastomotic leakage
The aim is to present technical details by and recurred 2w later with conservative
showing video of the surgery. treatment of fasting and drainage. For
the other 24 patients, full feeding started
P049: LAPAROSCOPIC PROCEDURE FOR on postoperative day 4-11 (mean, 6.2),
NEONATAL DUODENAL OBSTRUCTION IN and discharged from hospital on the
25 CASES : A RETROSPECTIVE ANALYSIS postoperative day 7-21(mean, 12). The
IN A SINGLE CENTER Jinfa Tou, PhD, Qixing follow-up ranged from 1 to 24 months, all
Xiong, MD, Zhigang Gao, MD, Jinhu Wang, cases grew up healthily.
PHD, Shoujiang Huang, PHD, Qiang Shu,
PHD, The Children’s hospital Zhejiang CONCLUSION: In treatment of neonatal
University School of Medicine, Hangzhou, duodenal obstruction, laparoscopic
China. procedure performed by skilled surgeon
is a safely and effective technique with
BACKGROUND: Laparoscopic (LP) surgery satisfactory outcomes.
for neonatal congenital duodenal
obstruction have been reported recently. To P050: USE OF FULLY COVERED SELF-
summarize the experiences and advantages EXPANDABLE METAL STENTS FOR
of laparoscopic surgery for neonatal BENIGN OESOPHAGEAL DISORDERS IN
duodenal obstruction, here we report a CHILDREN B ettina Lange, MD, Rainer
series or 25 cases in our single center. Kubiak, MD, Lucas M Wessel, MD, Georg
Kähler, MD, Department of Paediatric
METHODS: Twenty-five neonates with Surgery, Central Interdisciplinary
congenital duodenal obstruction were Endoscopy
treated with LP procedure in Children’s
hospital Zhejiang University School of BACKGROUND: There is a lack of
Medicine between Jan 2012 and Dec 2013. experience withfully covered self-
The clinical data were retrospectively expandable metal stents (SEMSs) for
analyzed. benign oesophageal disorders in children.
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PATIENTS AND METHODS: Eleven P051: LAPAROSCOPIC HEPATIC
children (6M, 5F) with a median age of PORTOJEJUNOSTOMY FOR FETALLY
30.5 months (range, 1 month - 11 years), DIAGNOSED CYSTIC BILIARY ATRESIA
who underwent treatment with a SEMS Hiroyuki Koga, MD, Takashi Doi, MD,
for a benign oesophageal condition Manabu Okawada, MD, Tadanori Ochi, MD,
between February 2006 - January 2014 Shiho Yoshida, MD, Hiroki Nakamura, MD,
were recruited to this retrospective study. Geoffrey J. Lane, MD, Atsuyuki Yamataka,
Aetiologies included: oesophageal atresia MD, Department of Pediatric General and
with postoperative stricture (n=5) and/ Urogenital Surgery, Juntendo University
orrecurrent fistula (n=1), anastomotic School of Medicine
leakage (n=1); iatrogenic perforation of
PURPOSE: To present a case of
the oesophagus following endoscopy
hepatic portojejunostomy performed
(n=3)or laparoscopic fundoplication (n=1).
laparoscopically (LapPE) for fetally
As part of an interdisciplinary approach
diagnosed cystic biliary atresia (cystic BA).
patients were jointly managed from the
Department of Paediatric Surgery and CASE: Cystic BA was initially suspected
Central Interdisciplinary Endoscopy at our on routine fetal ultrasonography and was
institution. confirmed after birth by clinical signs,
diagnostic imaging, and blood biochemistry.
RESULTS: Median duration of individual
LapPE was performed on day 37 of life;
stenting was 29 days (range, 17-91 days).
weight was 3.6kg. On examination of the
In4 casesup to four differentSEMSs
abdominal cavity after insertion of the initial
were placed over time. There were no
trocar, the gall bladder was found to be
complications noted on stent placement
small but not atrophied, the liver was mildly
or removal. Follow-up showed successful
cirrhotic, and the bile duct was cystic-in
treatment in 6 patients (55%). Minor
shape and 1.5 x 1.5cm in size. Intraoperative
stent-related complications occured in5
cholangiography confirmed cystic BA type
cases, mainly attributed to mild gastro-
III. The gall bladder, cystic duct, and the
oesophageal reflux and silent stent
thickened fibrous cystic-shaped common
displacement. In two children each (18%)
bile duct were dissected and the common
one single dilatation wasperformed after
bile duct transected distal to the point of
stent removal. Three patients (27%) did not
confluence with the cystic duct. Next, full-
improve following stenting and required
thickness dissection of the duodenal side of
further surgery.
the cyst was commenced but about a third
CONCLUSION: SEMS placement for of the way through, an elliptical area of
benign oesophageal disorders in children lumenal mucosa within the cyst separated
can be used safe and effective either spontaneously together with the mucosa
as an emergency procedure or as an from the lower two thirds of the cyst. This
additive treatment further to endoscopy elliptical area appeared like waxed paper
or previous surgery. Establishment of a macroscopically and on histopathology
standardized approach in the paediatric was found to be composed entirely of
population is mandatory. fibrous tissue with no mucosal epithelial
structure. Because of this spontaneous
separation, there was no mucosa left on
the duodenal side of the cyst to dissect;
i.e., there was no need to proceed further
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with dissection on the duodenal side. Thus, PURPOSE: Percutaneous endoscopic
full-thickness dissection of the portal gastrostomy (PEG) is a commonly used
side was commenced. Once the fibrotic technique for establishing enteral feeding.
biliary remnant was exposed adequately Many complications of the procedure are
on the portal side it was transected. After known, especially in children. The aim of
transecting the fibrotic biliary remnant at this study was to review the indications
the porta hepatis a 3mm diameter hepatic and the results of the PEG procedure in
duct was identified almost in the center Icelandic children.
of the transected biliary remnant which
METHODS: A retrospective review of all
meant that LapPE could be executed
children (0-18 years) who received PEG at
by placing 2 sutures to the center of the
Landspitali University Hospital of Iceland in
posterior wall of the common hepatic duct,
the years 1999-2010. Their medical records
one suture to the center of the anterior
were reviewed with regards to indication
wall, and other sutures superficially to the
for the procedure, age, pre-operative use
liver parenchyma and connective tissue
of nasogastric tube, the result of operation,
around the transected biliary remnant at
complications (major and minor) one year
the porta hepatis. A drain was placed in
from insertion of PEG, length of hospital
the Pouch of Winslow and the trocar site
stay and weight gain after the procedure.
was closed. Operating time was 8 hours 38
minutes. From the 3rd postoperative day RESULTS: 98 children (51 girls and 47 boys)
bile colored feces began to be passed, and received PEG during the study period.
jaundice clearance was achieved on the 72% received enteral feeding through
33rd postoperative day after 3 courses of nasogastric tube prior to the operation.
corticosteroids. At follow-up of 6 months, The median age was 2 years (range 1 mo
she remains jaundice-free, current total -17 y). The most common indication for
bilirubin is 0.5mg/dL, and there have PEG insertion was failure to thrive due to
been no episodes of cholangitis. The neurological disease (56%). Median length
classification of BA was reviewed to be II-d of stay after PEG insertion was 4 days
(cystic )-α. (range 1 - 189 days). None of the extented
length of stay was in relation with the PEG
CONCLUSION: Fetally diagnosed cystic
procedure.
BA should be included as an indication for
LapPE. Median body mass index (BMI) before
surgery was 14,5 (range 9,8 – 20,8) and
P052: PERCUTANEOUS ENDOSCOPIC
median BMI-for-age z-score was -1,4
GASTROSTOMY IN CHILDREN. A
(range -5,9 – 3,0). Median BMI one year
POPULATION BASED STUDY FROM
after surgery was 15,3 (range 11,2 – 22,1)
ICELAND 1999-2010 M argret Brands
and median BMI-for-age z-score was
Viktorsdottir, MD, Kristjan Oskarsson,
-0,5 (range -5,1 – 3,8). The median weight
MD, Luther Sigurdsson, MD, Anna
increased significantly in one year by 1,0
Gunnarsdottir, MD, PhD, Dpt of Surgery
SD (P<0,0001, 95% CI -1.4820 to -0.7387).
and Dpt of Pediatric Surgery, Landspitali
Height and weight 12 months after PEG
University Hospital, Iceland. Dpt of
procedure was documented for 54
Pediatrics, University of Wisconsin, USA.
children.
Dpt of Pediatric Surgery, Astrid Lindgren
Children Hospital, Karolinska University 166 complications were registrated in
Hospital, Sweden. 65 children of which 96% were minor.
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The most common complications were group 5 had an underlying diagnosis
granuloma formation (19%) and superficial of oesophageal atresia. 0.5mg/ml of
skin infection (25%). The incidence of Mitomycin-C was endoscopically applied
infection was not statistically different under direct vision to the stricture
between those who received pre-operative following balloon dilatation. The rate and
antibiotics vs. no antibiotics. Major need for subsequent stricture dialatation
complications were 4% and included three were assessed. Out comes for this group
children with peritonitis due to gastric leak were compared with oesophageal atresia
from the gastrostomy site, one child with patients who did not receive adjuncts/
esophageal tear, one child with buried Mitomycin-C for management of post
bumper and in one case malposition of the operative strictures at our institution.
gastrostomy tube. Median follow up time
RESULTS & CONCLUSION: There were
was 47 months (range 1-152). 14 children
no complications following application
died (1 mo - 3 y) after PEG insertion
of Mitomycin C in any of our patients.
and none of the deaths were related to
Demonstrated reduction in frequency
PEG insertion. 27 children were without
of stricture dilatation were statistically
gastrostomy at follow up.
compared. The rate of post-operative
CONCLUSION: According to our results oesophageal stricture are affected by
the PEG procedure is a safe technique for meticulous technique, aggressive acid
establishing enteral feeding in children. suppression and tensison at time of
Gastrostomy is sometimes temporary. anastomosis. The use of Mitomycin C
Complication rate is high but the majority may be helpful in selective patients for
of complications are minor og easily management of refractory oesophageal
treatable. Enteral feeding through PEG in strictures.
children causes significant weight gain in
P054: LAPAROSCOPIC SURGERY FOR
one year.
PEDIATRIC ESOPHAGEAL HIATUS HERNIA
P053: THE ROLE OF MITOMYCIN-C IN Lishuang Ma, MD, Ning Dong, BA, Capital
THE MANAGEMENT OF OESOPHAGEAL institue of Pediatrics
STRICTURES SECONDARY TO
BACKGROUND AND PURPOSE: Esophageal
OESOPHAGEAL ATRESIA E . Achimugu,
hiatus hernia mostly need surgical
Miss, M. Thompson, MBChB, DCH, FRCP,
procedure. As the development of
FRCPCH, MD, R. M. Lindley, Mr., The
laparoscope surgery, esophageal hiatus
Children’s Hospital Sheffield
hernia repair and fundoplication under
Local application of the anti-fibroblastic laparoscope have become the leading
agent Mitomycin-C, has been reported treatment of esophageal hiatus hernia. We
as an alternative treatment of refractory herewith explore the safety and effectivity
oesophageal strictures in children. We to of laparoscopic surgery for esophageal
our knowledge, present the largest case hiatus hernia.
series assessing efficacy of Mitomycin
MATERIALS & METHODS: We treated 29
c in refractory oesophageal strictures
cases with esophageal hiatus hernia by
secondary to oesophageal atresia.
laparoscopic esophageal hiatus hernia
METHOD: All patients prescribed repair between Sept. 2007 and Oct. 2012.
Mitomycin-C for Oesophageal Strictures Of the patients, 21 were male and 8 were
at our centre were identified. Of this female. They were aged 7 days to 5.5
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years(average,1.2 years) . Of the patients, P055: THE PRETZELFLEX™, A KINDER
9 were neonates. 25 cases presented with LIVER RETRACTOR FOR CHILDREN D .
intermittent vomiting, among which one Dass, Mr., K. Elmalik, Mr., J. Rae, Dr., R.
case was accompanied by haematemesis Sahay, Miss, S. Marven, Mr., Sheffield
and melena, and 6 accompanied by Children’s Hospital
noticeable malnutrition and delayed
Laparoscopic liver retractors in children
growth. 4 cases presented with cough
are hazardous. Nathanson liver retractor
and dyspnea. According to Barrett typing
has steadily supplanted others for use in
standard, 6 cases belonged to type I
fundoplication in all ages. Association with
(sliding hernia), which still suffered from
liver ischaemia and parenchymal injury is
recurrent vomiting after conservative
well recognised; the retractors are typically
treatment for 3 months~1 year; 18
inserted via stab incision which may result
were type II and 5 type III. All pantiets
in contemporaneous bleeding and gas
underwent LP esophageal hiatus hernia
leakage. The smallest Nathanson retractor
repair and Nissen fundoplication. The
(5mm) has a hook height of almost 70mm
Surgical procedures carried out as follow: ?
making the device arduous to deploy in
Exposure of esophageal hiatus , ? Incision
small children.
of hernia sac. ? Dissociation of esophagus.
? Contraction of esophageal hiatus. ? AIM: To evaluate the use of 3mm re-
Fundoplication. useable organ and tissue retractor,
PretzelFlexTM (Surgical Innovations),
RESULTS: One of 29 patients, 2 patients
during laparoscopic fundoplication.
was transferred to open surgery due
to severe abdominal adhesion. 27 METHODS: Fundoplication was performed
patients completed laparoscopic in four children using 3mm laparoscopic
repair of esophageal hiatus and Niseen instruments.
fundoplication successfully. The average
time of surgery was 147min (90~390min); The 3mm PretzelFlex retractor device was
intraoperative bleeding was 5mL on inserted via stab incision using a 69 blade
average (1~10mL); All cases began to drink (Swann-Morton Ltd) in one patient.
water 24~48h later after surgery, and A 3mm YelloPort+plus™ (Surgical
backed to preoperative diet on the 4th- Innovations) was used in the latter three
5thday; hospital stay lasted for 4~12 days patients; the first placed in the right upper
after surgery, 6.5 days on average. 25 cases quadrant (RUQ) and the latter two in the
were followed up for 1 month to 5 years. infra-Xiphisternal position.
The 1-year follow-up after surgery showed
no evidence of recurrence. The retractor was stabilised using Fast
ClampTM (Surgical Innovations).
CONCLUSIONS: Laparoscopic surgery
for pediatric esophageal hiatus hernia RESULTS: At procedure, patients weighed
had more advantages than traditional 5 kg, 12 kg, 14.7 kg and 18kg. Deployment
opening surgery, such as minor injury, of PretzelFlex within the abdomen was
rapid recovery. The procedure is safety prompt and uncomplicated. Whilst key
and efficiency, and the clinical effect was in providing optimal view of the hiatus,
satisfactory. no evidence of liver injury was noted.
The breadth of retraction likely reduced
transfer of pressure across the large
retractor-tissue interface.
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Use without a port caused bending of endoscope -“one stop” for obscure
the retractor. Some external clashing of massive gastrointestinal bleeding from Jan
instruments was noted when placed in the 2011 to December 2013 was performed.
RUQ position.
RESULTS: In our series, a total of 11 patients
CONCLUSIONS: Used with YelloPort+plus, with obscure massive gastrointestinal
the 3mm PretzelFlex offers the following bleeding were included. There were 7
potentials: males and 4 females with a median age of
• reduced liver trauma 3.5 years, the most common etiologies of
• improved view obscure massive gastrointestinal bleeding
• less bleeding were Meckel’s Diverticulum (MD; 72.7%),
• minimal gas leak perforation of duodenal ulcer (DU; 18.2%)
• improved cosmesis and unknown cause (UC; 9.1%). All of
Meckel’s Diverticulum were successfully
Though our early paediatric experience has
treated, including 8 cases (72.7%) of
shown PretzelFlex is safe and may present
laparoscopic Meckels diverticulectomy
a new standard in laparoscopic liver
and enteroenterostomy. The other two
retraction for infants and toddlers, further
of perforation of duodenal ulcer were
experience is warranted to qualify this.
successfully treated by Subtotal Gastrectomy
P056: GASTROINTESTINAL ENDOSCOPE (Billroth ?Method). One child died for failing
COMBINES LAPAROSCOPY FOR OBSCURE to treat in time in early stage (ten months old
MASSIVE GASTROINTESTINAL BLEEDING boy, failed to timely diagnosis).
IN CHILDREN B ian M. Hongqiang,
CONCLUSION: Though rare, massive
Gastrointestinal Endoscope Combines
hemorrhage of gastrointestinal tract
lapa, Wuhan Medical & Health Center for
can present with several lifethreatening
Women and Children, General Surgery,
complications that mandates immediate
Wuhan, 430016 China
surgery. While the surgical procedure
BACKGROUND: Gastrointestinal (GI) bleeding may be technically simple, achieving
is a common medical problem associated the accurate preoperative diagnosis
with significant morbidity and mortality is often fraught with challenges. The
in children. Although most patients stop implementation of “one stop” to
bleeding spontaneously without intervention manage patients with obscure massive
and most do not re-bleed, a small number gastrointestinal bleeding will evidently
have obscure massive gastrointestinal shorten the patients rescuing time.
bleeding (OMGI) that may require acute
KEYWORDS: Children Gastrointestinal
surgical intervention to prevent shock and
bleeding Gastrointestinal endoscope
coagulopathy. Many choices are available in
Laparoscopy
managing such patients. The clinician faces
decisions regarding the timing and nature of P057: LAPAROSCOPIC PROCEDURE FOR
investigations and treatment options. The CHILDREN WITH CYSTIC LESION IN
aim of this study is to analyse the impact of ABDOMEN S huli Liu MD, Long Li MD, Jun
a protocol to improve clinical practice in this Zhang MD, Xu Li MD, Capital Institute of
area. Pediatrics
METHODS: A retrospective review of BACKGROUND AND PURPOSE: Cystic
11 patients who underwent surgery in lesion in abdomen mostly require
laparoscopy combines gastrointestinal surgical excision for histological
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diagnosis, symptom relief, and to prevent PURPOSE: To find a cost effective, safe,
complications,preferably before the onset and easy alternative for primary retrograde
of complication. It has become feasible to gastrostomy button placement.
accomplish the excision Laparoscopically
METHODS: Gastroscopy is performed with
in children. We herewith reviewed our
the Olympus flexible endoscope. After
experience of laparoscopic procedure for
transillumination and digital indentation
children with cystic lesion in abdomen.
an 18-French spinal tap needle with a #0
To summarize the effectiveness and polydioxanone loop is transcutaneously
principles of laparoscopic procedure for advanced into the stomach. A second
cystic lesion in abdomen. Materials and needle is introduced 1.5cm more distally.
Methods:160 patients, 91girls and 56 boys, Through the second needle, a #0
suffered cystic lesion were involved in this polydioxanone is advanced through the
group, from 2002 to 2013. Their ages ranged previously introduced polydioxanone loop.
from 3 months to 16 years (average, 8±3.5y). The loop snares the single polydioxanone
The average diameter of lesions were 5.5 strand and is pulled out. This creates
cm (ranged, from 3 to 17 cm). Three trocars a U-stitch. Another U-stitch is placed
were utilized with 3 to 5mm instruments. using identical technique, medially to the
Under laparoscopic guidance a transfixion first one. Mild traction is applied to the
pin was prick into cyst. Then the fluid in the U-stitches apposing the gastric wall to the
cyst was aspiration through the pin. The bulk peritoneum. In between the U-stitches, an
of the cyst contracted. Then decompression incision is made and a 16-French needle
procedure, internal drainage procedure, is directed into the stomach; a guide-wire
resection or dissection procedure were is advanced through the needle. Dilations
applied according cystic character. to 22-French are performed over the
guide-wire. The abdominal wall thickness
RESULTS: Average duration of operation
is measured and a gastrostomy button
was 1.5 hours (range, from 0.6 to 3.2 hours)
placed. Correct placement is confirmed
without intraoperative complications,
by endoscopy. The previously placed
intraoperative bleeding was 5 to 10 ml
U-stitches are tied around the G-tube and
without necessity for blood transfusion.
left in place for one week.
Return of oral food intake postoperative
was 12 hours (range, from 6 to 48 hours). RESULTS: N=10. Age 3 months to 21 years
The postoperative course was uneventful old. 40% Females (n=4) , 60% males (n=6).
in all patients with hospital stay 6.8days Mean weight 22.01kg ±6.31, BMI 17.08±1.31.
(range, from 1 to 9 days) after the Mean operative time 22±3.49 min. Two
operation. There was no postoperative cases were performed in a combined
complication during followed-up visits. procedure. No intra- or postoperative
complications. 4 patients experienced
CONCLUSIONS: Laparoscopic procedure for
irritation around sutures. Tubes sizes 12-14
children with cystic lesion in abdomen is
Fr, ranging from 1.2 to 3 cm length.
safe and effective.
CONCLUSION: This endoscopic technique
P058: ENDOSCOPIC GASTROSTOMY
is a save and cost effective alternative for
BUTTON PLACEMENT WITH
primary retrograde gastrostomy button
TRANSCUTANEOUS LASSO U-STITCH
placement with high patient satisfaction -
Alfredo D. Guerron, MD, Jose S. Lozada,
without the need for placement of more
MD, Federico Seifarth, MD, Cleveland Clinic
expensive T fasteners or blind needle
Foundation
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sweeps. The PDS sutures are absorbable RESULTS: Wearing Glass throughout the day
and there is no risk for potential gastric for the study interval was well tolerated.
erosion/abscess formation from retained Colleagues, staff, families and patients
foreign bodies from T-fasteners. overwhelmingly had a positive response
Endoscopy allows proper intraluminal to Glass. Useful applications for Glass was
placement confirmation. hands-free photo-/videodocumentation,
making hands-free telephone calls, looking
P059: GOOGLE GLASS IN PEDIATRIC
up billing codes, and internet searches for
SURGERY: TESTING ITS APPLICABILITY
unfamiliar medical terms or syndromes.
Oliver J. Muensterer, MD, PhD, Martin
Drawbacks encountered with the current
Lacher, MD, PhD, Christoph Zoeller, MD,
equipment were low battery endurance,
Matthew E. Bronstein, MD, Joachim Kübler,
data protection issues, poor overall audio
MD, Division of Pediatric Surgery, New York
quality, as well as long transmission latency
Medical College, NY, USA; Department of
combined with interruptions and cut-offs
Pediatric Surgery, Medizinische Hochschule
during internet videoconferencing. In the
Hannover, Hannover, Germany
transatlantic vision test, all characters 8mm
INTRODUCTION: Personal portable or larger were correctly identified. None of
information technology is advancing at a the characters 3 mm or smaller were legible
breathtaking speed. Google has recently via the transatlantic link (see figure below).
introduced Glass, a device that is worn like Glass is an excellent tool for teaching
conventional glasses, but that combines complex tasks such as endotracheal
a computerized central processing unit, intubation, and has some applicability
touch pad, display screen, high-definition to show the user realtime radiographic
camera, microphone, bone-conduction information during procedures.
transducer, and wireless connectivity.
CONCLUSION: Glass has the some clear
We have obtained a Glass device
utility in the clinical setting. However,
through Google’s Explorer program and
before it can be recommended universally
have tested its applicability in our daily
for physicians and surgeons, substantial
pediatric surgical practice and in relevant
improvements to the hardware are
experimental settings.
required, issues of data protection must
METHODS: Glass was worn daily for be solved, and specialized medical
4 consecutive weeks in a University applications (apps) need to be developed.
Children’s Hospital. A daily log was kept,
and activities with a potential applicability
were identified. Performance of Glass
was evaluated for such activities. In-vitro
experiments were conducted where
further testing was indicated, including,
for example, a standard Snellen vision
test using Glass over a transatlantic
internet connection, with the Glass camera
positioned 50 cm away from the letter
chart. Glass was also tested as a training
tool for teaching intubation, and for
evaluating radiographic images in real-
time.
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P060: FIRST REPORT OF THORACOSCOPIC patient. An initial 5mm optical trocar was
LEFT UPPER PULMONARY LOBECTOMY placed 1cm below the angle of the scapula
USING FISSURELESS TECHNIQUE IN in the posterior axillary line (AL) using a
A SMALL CHILD H iroki Nakamura, MD, closed technique. Four other trocars were
Kenji Suzuki, MD, PhD, Hiroyuki Koga, MD, placed. 1. Fourth intercostal space (IS)
Manabu Okawada, MD, Takashi Doi, MD, slightly posterior to the anterior axillary
Kinya Nishimura, MD, PhD, Eiichi Inada, line (AAL) for the telescope; 2. Third IS in
MD, PhD, Geoffrey J. Lane, MD, Atsuyuki the AAL for the surgeon’s left hand; 3. Sixth
Yamataka, MD, PhD, Department of IS in the AAL for the surgeon’s right hand;
Pediatric Surgery and Urogenital Surgery, 4. Eighth IS in the mid AL for a retractor
Juntendo University School of Medicine; or stapler. On examination, the major
Department of General Thoracic surgery, fissure was tightly fused. Firstly, the LUL
Juntendo University School of Medicine; was retracted posteriorly and superiorly
Department of Anesthesiology, Juntendo to expose the hilum, allowing the apical/
University School of Medicine anterior/posterior branches (A1+2, A3) and
mediastinal lingular branches (A4, A5) of
BACKGROUND: Pulmonary lobectomy
the left pulmonary artery to be divided
involves ligating branches of the
using hemo-clips and Ligasure. Then, the
pulmonary artery, the pulmonary vein,
pulmonary veins to the LUL (V1-3, V4,
and bronchus. The pulmonary artery is
V5) were encircled, clipped, and divided,
exposed at a fissure by dividing the lung
exposing the LUL bronchus which was then
parenchyma overlying the artery using
divided using an endo-stapler and the cut-
electrocautery or sharp/blunt dissection
end retracted superiorly and posteriorly
that causes air/fluid leakage that prolongs
to expose the left pulmonary artery trunk
chest tube drainage and hospitalization.
clearly. Branches of the pulmonary artery
Recently, vessel/tissue sealing devices
(A6, A8) to the left lower lobe (LLL) were
(Ligasure, Harmonic scalpel, Enseal) are
identified and left intact, and branches to
being used to seal lung parenchyma
the lingular lobe (interlobar A4, A5) of the
and fissure surfaces, especially during
LUL where identified and divided. A stapler
thoracoscopic lobectomy. However, in
was then inserted and used to grasp the
cases where a fissure is fused so tightly
lung parenchyma gently while retracting
that it cannot be identified, air leakage can
the LUL superiorly, inferiorly, posteriorly,
occur even with sealing devices. We used
and anteriorly to confirm that the stapler
fissureless lobectomy, a novel technique
did not include arterial branches to the
for preventing parenchymal injury to the
LLL and that alignment with the proposed
lung during thoracoscopic lobectomy in
major fissure was “correct”. The stapler
children for the first time.
was then fired and the LUL divided and
CASE: Thoracoscopic left upper lobe (LUL) separated. Blood loss was 1mg. There
lobectomy was performed on a 2-year-old was no air leak from the chest tube
girl with prenatally diagnosed congenital postoperatively and minimal fluid leakage.
pulmonary airway malformation (CPAM) The chest tube was removed the next day
of the LUL. She was positioned in the right after surgery. She is currently symptomless
lateral decubitus position under general and well after follow-up of 10 months.
anesthesia with single lung ventilation.
CONCLUSION: Thoracoscopic fissureless
The surgeon and scopist stand in front of
lobectomy is safe and feasible even in
the patient and view a monitor behind the
small children.
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P061: COMBINED LAPAROSCOPICALLY distance from the urethra. A minimal
ASSISTED AND ANTERIOR SAGITTAL anterior sagittal incision was made, and
ANORECTOPLASTY FOR IMPERFORATE a ligature passer was inserted from the
ANUS WITH RECTOBULBAR URETHRAL center of the external anal sphincter
FISTULA Tetsuya Ishimaru, MD, PhD, to the center of the puborectalis under
Masahiko Sugiyama, MD, Mari Arai, MD, laparoscopic vision. The ligature was pulled
PhD, Jun Fujishiro, MD, PhD, Chizue Uotani, out from the abdominal cavity, and a
MD, PhD, Kyohei Miyakawa, MD, Tomo pull-through route was formed by cutting
Kakihara, MD, Tadashi Iwanaka, MD, PhD, the midline of the external sphincter
Department of Pediatric Surgery, The muscle and vertical fibers along the thread
University of Tokyo Hospital using a muscle stimulator. The fistula was
identified from the perineum by pulling
BACKGROUND: Laparoscopically
the thread, and resected close to the
assisted anorectoplasty (LAARP) was
urethra. The rectum was pulled through
introduced in 2000, and the number of
and anchored to the muscle fibers. The
hospitals adopting it for the treatment
muscles were closed to surround the
of high-type anorectal malformation
rectum and anocutaneous anastomosis
(rectovesical or rectoprostatic fistula) is
was performed. The post-operative course
increasing. However, the application of
was uneventful. The stoma was closed
LAARP for rectobulbar urethral fistula is
one month after the anorectoplasty.
controversial, because precise division
MRI performed at one year after the
of the fistula in the deep pelvic cavity
anorectoplasty showed the rectum at
is difficult and there is a potential risk
the center of the sphincter muscle and
of posterior urethral diverticulum. We
no residual fistula. Although he is still
herein introduce a novel procedure for an
administered a daily enema, a couple of
imperforate anus with a rectobulbar fistula
voluntary bowel movements are seen
involving precise ligation of the fistula and
every day.
appropriate placement of the rectum in
the center of the sphincter using combined CONCLUSIONS: Combined laparoscopically
laparoscopically assisted and anterior assisted and anterior sagittal
sagittal approaches. anorectoplasty for an imperforate anus
with a rectobulbar urethral fistula was
CASE REPORT: A boy weighing 2,220 g
feasible and advantageous for the precise
was born at a gestational age of 37 weeks,
division of the fistula.
and diagnosed with a imperforate anus
immediately after birth. No associated P062: PERCUTANEOUS SUTURING
malformations, including neurological TECHNIQUE AND SINGLE SITE UMBILICAL
abnormalities and sacral deformities, LAPAROSCOPIC REPAIR OF A MORGAGNI
were noted. Initially, a loop colostomy HERNIA: REVIEW OF 3 CASES M ohamed
was placed at the right transverse colon. Jallouli, Mahdi Ben Dhaou, Souhir Mefteh,
Distal colostography and urethrography Hayet Zitouni, Salwa Ammar, Riadh Mhiri,
showed a rectobulbar urethral fistula. Department of Pediatric Surgery. Hedi
Anorectoplasty was performed at the age Chaker Hospital. Sfax Tunisia University of
of 4 months (5.8 kg) Sfax. Tunisia
PROCEDURE: Rectal dissection was INTRODUCTION: Morgagni hernias are
performed laparoscopically, and the uncommon and account to only 1-5 %
fistula was ligated and resected at a short of all congenital diaphragmatic hernia.
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Although most are asymptomatic, surgical years of age. In the absence of peritonitis,
treatment is recommended to prevent initial treatment is either hydrostatic or
possible future complication. Minimal pneumatic reduction. If these measures
invasive surgery is today the gold standards fail, operative intervention is required. In
treatment. We present our technique using non-reducible cases, we propose the use
percutaneous suturing technique and of intraoperative hydrostatic enema to
single site umbilical laparoscopic repair of achieve or confirm reduction.
Morgagni hernias in 3 children.
METHODS: We performed intraoperative
PATIENTS & METHODS: In 2013 three boys’ hydrostatic enema reduction in seven
ages nine, sixteen and eighteen month children ages 4 months to 2 years. All
respectively were referred to our institution patients had ileocolic intussusception
for repair of their Morgagni hernia. that failed initial reduction by radiographic
enema. Under general anesthesia,
A 2- cm longitudinal incision was made in
saline enema was facilitated by direct
the umbilicus. A homemade single-port
laparoscopic visualization.
device with a wound retractor and surgical
gloves was introduced. A 5–mm 0 angle RESULTS: In two of the seven cases,
scope was used. The herniated bowel was intussusception reduction was visually
easily reduced into the abdomen using confirmed in real time. In these two
a grasper. The posterior diaphragmatic cases only a laparoscopic camera port
rim was clearly visualized. The defect was required. In one case, the bowel
was repaired using entirely 2-0 prolene was extensively dilated requiring mini-
percutaneous sutures. laparotomy for visualization; however,
the enema reduced the intussusception
RESULTS: The total operative time was
without any need for bowel manipulation.
respectively 100, 60 and 50 minutes.
In the remaining four cases, minimal
Recovery was uneventful in all 3 patients.
laparoscopic manipulation was required,
There were no recurrence and the chest
and enema confirmed reduction. No child
radiograph stayed normal during the
required bowel resection.
postoperative follow-up.
CONCLUSIONS: Intraoperative hydrostatic
CONCLUSION: Percutaneous suturing
enema is a safe and valuable addition to
technique and single site umbilical
laparoscopic reduction of intussusception.
laparoscopic repair of a Morgagni hernia
This technique gives the advantage of
is an easy and effective alternative to the
little or no bowel manipulation and can be
standard laparoscopic repair.
accomplished via a single port.
P063: THE UTILITY OF INTRAOPERATIVE
P064: LAPAROSCOPICALLY ASSISTED
HYDROSTATIC ENEMA DURING
REPAIR FOR FEMALE LOW TYPE
PEDIATRIC LAPAROSCOPIC
IMPERFORATE ANUS M anabu Okawada,
INTUSSUSCEPTION REDUCTION C ristina
MD, Takashi Doi, MD, Hiroyuki Koga, MD,
N. Budde, MD, Thomas Sims, MD, Andrew
Geoffrey J Lane, MD, Atsuyuki Yamataka,
Zigman, MD, Oregon Health and Science
MD, Juntendo University School of
University & Kaiser Permanente Northwest
Medicine
BACKGROUND/PURPOSE: Intussusception
OBJECTIVE: In recent years, laparoscopic
is the most common cause of bowel
intersphincteric resection for low rectal
obstruction in children 3 months to 3
cancer has been offered and performed
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successfully in adult patients, indicating distal fistula, 3-5 mm in length, was ligated
that laparoscopic manipulation can now with an endoloop suture. At this stage,
reach deep into the pelvic cavity, in other the surgeon moved to the perineum site
words, as far as the perineum. Because to perform mucosectomy of the residual
this revolutionary procedure would also fistula and close it with interrupted sutures.
improve chances of external sphincter Electrostimulation was used to define the
preservation, the authors were persuaded center of the anal dimple, and a 10mm skin
to perform laparoscopically-assisted repair incision was made. Minimal blunt dissection
of female low-type imperforate anus using of the perineum using a pair of mosquito
this technique. forceps with transillumination from the
laparoscope as a guide was commenced
SURGICAL TECHNIQUE: A 12-month-
to create a pull-through canal. Once an
old 8.1kg girl was diagnosed with ano-
adequate route for the pull-through canal
vestibular fistula at birth. She was prepared
was established, dilatation was commenced
for laparoscopically assisted repair
by passing a series of dilators. The rectum
(LAR) according to our standard bowel
with proximal ano-vestibular fistula was
preparation protocol involving colonic
then pulled-through, its distal end biopsied
irrigation, probiotics and insertion of a
to confirm normoganglionosis and the
central venous catheter the day before
coloanal anastomosis completed. If the
surgery. The principles of LAR are dissection
distal end was not normoganglionotic, it
of the fistula laparoscopically as distally
was cut back and rebiopsied until it was
as possible up to the perineum using four
normoganglionotic to prevent intractable
ports, division of the fistula laparoscopically,
postoperative constipation. Operating time
followed by mucosectomy of the
was 175 minutes. The postoperative course
approximately only 4-5mm long residual
was uneventful.
fistula from the perineum. For laparoscopic
dissection of the fistula, a newly developed CONCLUSION: Minimally invasive surgery
10-mm fixed-rod rotating scope was used, can now be considered actively for treating
which allows the direction of view to be female low-type imperforate anus
adjusted from 0° to 120° as required. This following our successful application of
scope was introduced through an umbilical LAR. Long-term follow-up is required to
trocar, and three additional 3 or 5mm evaluate fecal continence.
trocars were inserted as working ports. All 3
P065: A COMPARISON OF TWO
additional trocars were placed medial to the
TECHNIQUES FOR THE DELIVERY AND
rectus abdominis, similar to single incision
FIXATION OF EXTRACORPOREAL KNOTS
laparoscopy, in contrast to conventional
DURING LAPAROSCOPY: KNOT-PUSHER
trocar placement for imperforate anus
WITH INTEGRATED CUTTER VERSUS
repair in males with recto-prostatic or
CONVENTIONAL SUTURING C arolina
recto-vesical fistula where the tips of the
Millan, MD, Guillermo Dominguez, MD,
endoscopic instruments do not need to
Luzia Toselli, MD, Yolanda Martinez, MD,
reach deep into the pelvis that is narrow.
Fernando Rabinovich, MD, Horacio Bignon,
Using these trocar positions, the rectum
MD, Gaston Bellia, MD, Albertal Mariano,
and ano-vestibular fistula were dissected
MD, PhD, Marcelo Martinez Ferro, MD,
from the vaginal wall easily, and dissection
Private Children´s Hospital of Buenos Aires,
of the ano-vestibular fistula progressed
Fundación Hospitalaria, Buenos Aires,
to the level of the perineum. The fistula
Argentina
was then divided and the tiny residual
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INTRODUCTION: the use of knot-pusher CONCLUSION: the use of KP reduced
(KP) with integrated cutter simplifies the tasktime required for tying and cutting the
delivery and fixation of extracorporeal knot compared to CS and it was associated
knots to an intracorporeal surface with a short learning curve, mainly in less
and constitutes a technical alternative experienced operators.
to conventional knot sliding suturing
technique (CS). This study test the
hypothesis that KP shortens the time
require for tying and cutting a knot
compare to CS.
METHODS: Three surgeons (one expert,
one semi-expert and one fourth-year
pediatric surgeon resident) performed 10 P066: INTRAABDOMINAL PARTITIONING
knots each (five with KP and five with CS) OF THE LAPAROSCOPIC SLEEVE
using a laparoscopic abdominal trainer with GASTRECTOMY REMNANT OPTIMIZES
its own visual output. Surgical tools used THE SPECIMEN EXTRACTION
were as follows: 1) 10-mm 30ºlaparoscope ERGONOMICS AND POSTOPERATIVE
and 5-mm conventional surgical tools PAIN AND IS AN ATTRACTIVE TECHNIQUE
(Meryland, scissors). 2) KP with 5-mm IN TEENAGE PATIENTS P iotr Gorecki,
integrated cutter.3) 2 trocars (11-mm MD, Josue Chery, MD, Jennifer Lee,
and 5-mm). 4) 0, 40 mm Nylon (length Anthony Tortolani, Wojciech Gorecki,
75 cm). 5) 0.5-mm Nelaton catheters MD, Department of Surgery, New York
(length 7cm). All bows (10 per operator) Methodist Hospital, Brooklyn, NY, USA
were tight into the Nelaton catheters at
INTRODUCTION: Laparoscopic Sleeve
the bottom of the simulator and both free
Gastrectomy (LSG) becomes increasingly
ends exteriorizedthrough the 5-mm trocar.
popular bariatric procedure worldwide. The
In this manner, all sutures had the same
high failure rate of adjustable gastric band
length prior to tying and cutting the knot.
and the magnitude of the gastric bypass
In order control for differences in skills
make this option even more appealing
regarding knot design, only one operator
when adapted to pediatric patient
designed all 30 knots. We evaluated the
population. The fear of complications
time required to deliver and fix the knot
and the postoperative pain and recovery
into the Nelaton catheter (from outside
remain the significant factors when
the simulator up its fixation and cut inside
considering wider application of surgery
the trainer).
in the treatment of morbid obesity in
RESULTS: Overall task time was lower with pediatric patients.
KP than with CS (20.9±5.5 versus 39.39±5.9
CASE REPORT: A 16 year old girl with the
seconds, p<0, 01), which translated into
weight of 359 Lbs and BMI of 55 kg/m2
an absolute difference of 18.4±6 seconds
suffering from severe metabolic syndrome,
(88.2% reduction). This reduction in task
type II diabetes, hypertension and fatty
time was observed across all operators
liver disease underwent uneventful
(table). Improvement in task time from
laparoscopic sleeve gastrectomy and
first to the fifth knot was larger with KP
liver biopsy . The procedure time was
than with CS,but only in less experienced
65 min (specimen extraction time was 7
operators (table).
min). Her recovery was uneventful and
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she was discharged home on a second with conservative therapies for morbidly
postoperative day. Her mean in hospital obese patients and further improvement
visual analog pain scores with the in the safety and perioperative morbidity
utilization of standard PCA pump were 3.2 remain the main factors determining the
on a day of surgery, 1.7 on postoperative future growth of bariatric surgery. In this
day 1 and 0 on a postoperative day 2. After abstract we describe the novel technique
the discharge from the hospital, she did that may contribute to further reduction
not require any postoperative analgesics of perioperative morbidity and therefore
and returned to normal activities in 7 contribute to wider acceptance of LSG.
days. On a 1, 3 and 6-month follow up Detailed technique and the photographs
she has shown all the benefits of weight will be presented in the poster. Prospective
loss and associated improvement in comparison study will be designed to
metabolic parameters and quality of life further evaluate the benefits of this
as determined by the laboratory tests (Hb extraction technique.
A1C 6.5% preoperatively vs 4.7% at three
P067: LEFT THORACOSCOPIC
months after surgery, off hypoglycemic
ESOPHAGEAL ATRESIA REPAIR: TIPS FOR
agents) and SF-36 questionnaire (bodily
SUCCESS D rew A. Rideout, MD, Avraham
pain score 45 preoperatively vs 67 at 1
Schlager, MD, Amina M. Bhatia, MD, MS,
month after surgery). At 1, 3 and 6 month
Children’s Healthcare of Atlanta/Emory
after surgery her weight loss was 30, 49
University, Atlanta, Georgia; All Children’s
and 99 Lbs respectively. The patient and
Hospital/Johns Hopkins Medicine, St.
her family were also very satisfied with
Petersburg, Florida
the decision to undergo the bariatric
procedure. INTRODUCTION: Right aortic arch (RAA) is
present in 5% of patients with esophageal
EXTRACTION TECHNIQUE: A sleeve
atresia with or without tracheoesophageal
gastrostomy specimen containing
fistula (EA/TEF). Repair of EA/TEF in
gastric body and fundus and containing
the newborn with RAA adds technical
approximately 80 % of the stomach
challenges and hence the surgical
volume has been partitioned longitudinally
approach has been controversial. We
intracorporealy with endoshears, which
present a newborn with the prenatal
allowed its extraction in one partitioned
diagnosis of congenital heart disease, who
fragment via a 15-mm port site without
underwent a repair of EA/TEF through a
the need for increasing the length of the
left thoracoscopic approach.
incision, stretching of the fascia opening,
need for closure of the fascia or utilization CASE PRESENTATION: The patient was
of the Endocatch device. This technique born by elective C-section at 38 weeks
resulted in minimizing postoperative gestation, weighing 3.5 kg and with the
pain, reducing the operative costs and prenatal diagnosis of congenital heart
minimizing the likelihood of would disease. An orogastric tube was placed
infection. and found to be curled in the proximal
esophagus, consistent with the diagnosis
CONCLUSION: General application and the
of EA/TEF. Postnatal ECHO showed double
selection of the type of bariatric procedure
outlet right ventricle with VSD, ASD, and
in pediatric patient populations remains
RAA with mirror image branching. Vertebral
a controversial and widely discussed
anomalies were also present, consistent
topic. The hope for improved outcomes
with the diagnosis of VACTERL association.
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FISH analysis for the 22q deletion was but no such study has been published
normal. Because of the presence of RAA, in children. We report our experience
a left thoracoscopic approach was chosen. with laparoscopic self-adherent mesh
On the first day of life he underwent left hernioplasty in adolescent children.
thoracoscopy with repair of a type C EA/
RESULTS: Six patients who underwent
TEF utilizing high frequency oscillator
laparoscopic hernioplasty with self-
ventilation. A suspension suture between
adherent mesh by a single surgeon at our
the bulbous proximal pouch and small
institution during one year were included.
distal esophagus was used to elevate the
All patients were males with a median age
esophagus out of the posterior thorax and
of 15.4 years (14 - 16 years) and median BMI
facilitate construction of the anastomosis.
of 24.9 (19.8-32.6). Five patients presented
Because of the left-sided approach and
with complaints of unilateral painless
size discrepancy between the proximal
“groin bulge” while one had intermittent
pouch and distal esophagus, left-
severe pain, but no patient had obstructive
handed suturing proved advantageous.
symptoms or signs of incarceration. One
An esophagram on postoperative day
patient presented with a recurrent hernia
6 showed a persistent size discrepancy
while the remaining five patients had no
between the proximal and distal
previous hernia repairs. Patients were
esophagus but no leak or anastomotic
taken electively to the operating room.
stricture.
Five patients had unilateral inguinal
CONCLUSION: Left thoracoscopy is a hernias and one patient was found to have
feasible approach in the newborn with bilateral inguinal hernias intra-operatively.
EA/TEF, congenital heart disease, and All patients had the self adherent mesh
RAA. Technical pearls include use of placed without difficulty and without injury
oscillator ventilation for optimal exposure, to bowel or conversion to open. Median
a suspension suture to facilitate the operative time was 97 minutes (63 - 146
anastomosis, and left-handed suturing. min). All patients tolerated the procedure
well and were discharged on the same day.
P068: INNOVATIVE SELF-
Five patients had postoperative follow up.
ADHERENT (VELCRO) PROLINE
Three patients were seen in clinic 149 days,
MESH FOR LAPAROSCOPIC INGUINAL
24 days, and 29 days after the operation;
HERNIOPLASTY IN ADOLESCENT
one patient had a telephone follow up 314
CHILDREN P aulette I. Abbas, MD, Adesola
days after the operation. At time of follow
C. Akinkuotu, MD, Ashwin Pimpalwar, MD,
up, no patient had signs of recurrence,
Texas Children’s Hospital and the Michael
surgical site infection, or chronic post-
E. DeBakey Department of Surgery, Baylor
operative pain. The last patient was seen in
College of Medicine, Houston, Texas
the ED for concern of scrotal swelling and
INTRODUCTION: Laparoscopic hernia repair pain and was ultimately diagnosed with a
with mesh has been reported in adolescent scrotal hematoma; he was instructed to
children. The mesh generally requires return to clinic and has since been lost to
suturing or tacking on the abdominal wall follow up.
to secure it in place. Tacking or suturing in
CONCLUSION: Laparoscopic hernioplasty
the groin area has been reported to cause
with the innovative self-adherent mesh
chronic pain. An innovative self-adherent
is feasible and safe with good short to
mesh has been used as an alternative
mid term results. None of our patients
with good results in the adult population,
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had chronic postoperative pain previously CONCLUSIONS: TSSLPEC and TEC are
reported with mesh tacking technique. Our both reliable in treatment of hernia in
series is small and larger numbers would children, TEC procedure are trending
be needed to confirm our results. more acceptable by patients because
less postoperation pain at the puncture
P069: SINGLE-SITE LAPAROSCOPIC
location and more satisfied with the
PERCUTANEOUS TOTALLY
operation.
EXTRAPERITONEAL CLOSURE FOR
HERNIA IN CHILDREN L i GuiBin, Qiu Yun, P070: OUTCOME AFTER NUSS
The 5th Central Hospital of TianJin China PROCEDURE WITH DIAGONAL BAR
PLACEMENT: AN UPDATE ON TECHNIQUE
BACKGROUND: Single site laparoscopic
Bethany J. Slater, MD, Sara C. Fallon, MD,
percutaneous extraperitoneal closure for
Jed G. Nuchtern, MD, Darrell L. Cass, MD,
hernia is accepted by pediatric surgeons
Mark V. Mazziotti, MD, Texas Children’s
for its reliable effect, simple procedure,
Hospital, Division of Pediatric Surgery,
cosmetic result. However there is an issue
Baylor College of Medicine, Houston, TX
about this method is that the knot was
left in the subcutaneous tissue, and cause BACKGROUND: The correction of pectus
the postoperation pain at the puncture excavatum in pediatric patients allows
location, occasionally suture reaction for improvement of both lung physiology
occurred. We modified the procedure of and significant aesthetic concerns that
the operation as totally extraperitoneal can affect patient quality of life. At our
closure (TEC) : Firstly, puncture epidural institution, since 2003 we have routinely
needleand free half of processus vaginali. used the minimally invasive Nuss
Secondly, put the guide line and silk into procedure for surgical correction with
peritoneal through the needle. Thirdly, excellent results. However, some patients’
remove the needle. Following putting the deformities do not lend themselves to
needle to peritoneal at the same place we adequate correction with this procedure,
had reached before, and accomplished during which the pectus bar is placed at a
totally extraperitoneal closure. horizontal angle and secured to the same
rib space bilaterally. Recently, we have
METHODS: 115 patients who accepted the
begun to employ a technical modification
single-site laparoscopic percutaneous
of the traditional Nuss procedure for these
extraperitoneal closure procedure in our
difficult anatomical deformities by placing
hospital between July 2011 and January
the pectus bar at an angle, securing the
2014 were analyzed retrospectively.
bar bilaterally at different rib spaces. The
Postoperation pain of puncture location and
goal of this study was to evaluate the
suture reaction were targeted to compare.
surgical outcomes of these patients with
RESULTS: 65 patients who underwent challenging anatomic deformities who
traditional single-site laparoscopic underwent the modified Nuss procedure
percutaneous extraperitoneal with a diagonal bar, as opposed to the
closure(TSSLPEC),50 patients were given traditional horizontal bar, and determine if
TEC operation. Postoperation pain of this modification is an effective operative
puncture location after operation was 10 technique.
(15.4%,TSSLPEC) to 3( 6.0%,TEC). Suture
METHODS: After institutional review board
reaction was 1(TSSLPEC) to 0(TEC). There is
approval, a retrospective review of patients
no recurrence in either group.
who underwent a modified Nuss procedure
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at Texas Children’s Hospital was performed P071: ENDOSCOPIC MANAGEMENT OF
from Dec 2010 to May 2012. Patients were RECURRENT TRACHEOESOPHAGEAL
identified through the surgical record, and FISTULA WITH TRICHLOROACETIC ACID
the post-procedure chest radiographs CHEMOCAUTERIZATION: A PRELIMINARY
of all patients who underwent a Nuss REPORT M anuel Lopez, MD, Eduardo
procedure by the three surgeons (JGN, DLC, Perez-Etchepare, MD, François Varlet, MD,
MVM) who use this technical modification PhD, Department of Pediatric Surgery,
were reviewed for diagonal bar placement. University Hospital of Saint Etienne
Patients with the traditional placement
OBJECTIVE: Open repair with a second
were excluded from further review.
thoracotomy is technically challenging
Patient data including Haller index, patient
and has a high risk of complications
demographics, bar-related complications,
for the treatment of arecurrent
and cosmetic outcome were systematically
tracheoesophageal fistula(RTEF).
extracted from the medical record.
Therefore, less invasive endoscopic
RESULTS: We identified 12 patients who techniques have been developed.
underwent the Nuss procedure with a We report our initial experience with
diagonal bar. The median length of follow- trichloroacetic acid chemocauterization for
up was 10 months (range from 1 mo to recurrent trachea-esophageal fistula by
28 months). Two patients did not have endoscopy.
stabilizers placed at the time of operation;
METHODS: Two patients who had
despite an increased risk for bar migration,
an open repair with thoracotomy
neither of these patients has experienced
for congenitaltracheoesophageal
a complication. All patients reported
fistulaand were diagnosed with large
satisfaction with their post-operative
RTEF were included in this study. Rigid
cosmetic outcome to date. One patient
ventilating bronchoscopy with telescopic
with pyoderma gangrenosum developed
magnification was used to evaluate and
a wound dehiscence that required re-
manage the RTEF. After identification of
operation for debridement and closure.
thefistulaopening, a 50% TCA-soaked
CONCLUSIONS: Our data demonstrate small cotton ball was applied in the
that positioning the pectus bar diagonally opening 3 times during each session , in
during the minimally invasive Nuss day surgery.
procedure is feasible and leads to good
RESULTS: The mean number of procedures
cosmetic outcomes with a minimal early
was 3, and the fistulae were closed in both
complication profile; however, long-term
cases. Closure of thefistulawas confirmed
outcomes until after bar removal occurs
by esophagogram and/or bronchoscopy.
remain unknown in this series. Diagonal
There were no postoperative
bar placement should be considered in
complications.
patients with asymmetric defects, where
placing the bar in different interspaces CONCLUSION: The results of this study
allows for proper sternal alignment. showed that chemocauterization with
TCA can be safe and effective for the
management of RTEF.
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P072: RETROGRADE DILATATION VIA complete anastomotic stricture and the
GASTROSTOMY OF AN ANASTOMOTIC stricture was unable to be traversed using
STRICTURE IN A NEONATE WITH a guide wire.
REPAIRED OESOPHAGEAL ATRESIA B rian
Further attempts were abandoned and
MacCormack, Jimmy Lam, Fraser Munro,
a Stamm gastrostomy was created
Royal Hospital For Sick Children Edinburgh
and retrograde dilatation through the
Anastomotic stricture is the most gastrostomy was performed. A guide wire
common complication following repair was passed through the gastrostomy and
of oesophageal atresia, occurring in 18% by repeated probing through the stricture
- 50% of patients. Balloon dilatations and into the proximal oesophagus in a
remain the treatment of choice for retrograde direction. The wire was then
symptomatic oesophageal strictures. If retrieved from the mouth and a 5.5Fr
this fails re-operation is needed.Combined Accustick dilator passed down the wire,
oesophagoscopy and transgastrostomy allowing the stricture to be dilated using a
gastroscopy is a well established method 4mm balloon. A nasogastric tube was then
of dilating post-radiotherapy oesophageal passed over the wire and left in-situ.
strictures in adults. The retrograde
The gastrostomy was removed at 3
approach to dilate oesophageal strictures
months. The patient required one
in neonates is not well described. This
subsequent balloon dilatation following
report highlights the efficacy of this
this procedure, and has had no recurrence
technique in dilating an anastomotic
of the stricture since.
stricture at the time of gastrostomy
placement and therefore avoiding This report highlights that retrograde
potentially difficult re-do surgery. dilatation should be considered when
performing a gastrostomy following
A male infant, born at term with a birth
failure of traditional antegrade methods.
weight of 3kg, presented with oesophageal
Traversing a stricture in a retrograde
atresia and a distal tracheo-oesophageal
direction appears to be easier, due to the
fistula. On day 2 of life, the fistula was
progressive narrowing of the stricture. This
ligated throacoscopically. The procedure
has been previously noted in both adults
was converted to open due to poor view
with post-radiotherapy strictures and in
and the repair of oesophageal atresia
children following fundoplication. Our
completed without difficulty. The patient
case report demonstrates that retrograde
was discharged home at 1 week post-
dilatation is possible in neonates and
operatively, following a normal contrast
should be considered when performing
study. He was tolerating full oral feeds, and
a gastrostomy so as to avoid potentially
on maximal anti-reflux therapy.
difficult re-do surgery.
At 2 weeks post-operatively the patient
P073: ESOPHAGO-BRONCHIAL FISTULA
was re-admitted with intolerance to
(EBF) AFTER PREVIOUS TEF (TRACHEO-
feeds. A contrast study confirmed a near-
ESOPHAGEAL FISTULA) REPAIR: REPAIR
complete anastomotic stricture. This was
USING A THORACOSCOPIC APPROACH
unable to be traversed using a guide-wire
Ashwin Pimpalwar, Dr., Texas Children’s
despite multiple attempts. The decision
Hospital1 and the Division of Pediatric
was therefore made to allow the oedema
surgery, Michael E. DeBakey Department
to settle and re-attempt dilatation. 5
of Surgery, Baylor College of Medicine,
days later oesophagoscopy confirmed a
Houston, TX
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AIM: To report the thoracoscopic technique two suture lines. A chest tube was placed,
for repair of esophago-bronchial fistula. ports were withdrawn under vision and port
sites were closed with sutures and glue.
MATERIAL & METHODS: The chart of a 4
year old girl who presented with EBF was RESULTS: The child recovered well from
retrospectively reviewed. the procedure and underwent a contrast
esophagogram on the 5th postoperative
CASE: A 4 year old female presented
day which did not show a leak. The chest
with chronic coughing during feeding and
tube was removed and the child was
failure to thrive. She had a past history
allowed to feed orally. She was discharged
of TEF repair at an outside hospital.
on the 6th postoperative day on full
Esophagogram revealed an esophago-
regular diet. At 3 weeks follow-up the child
bronchial fistula (between a right sided
was asymptomatic and was tolerating diet
peripheral bronchus and esophagus).
well with no coughing.
Esophagoscopy cauterization of the fistula
and fibrin glue injection was successful CONCLUSION: The thoracoscopic
in occluding the fistula but was followed technique is a minimally invasive approach
by recurrence at 3 months which was that could be successfully used in the
managed by thoracoscopic repair. management of esophago-bronchial
fistula following previous repair of TEF in
TECHNIQUE: The child was laid in supine
children.
position and a guide wire was passed
through the fistula using the flexible P074: PIGGY-BACK (PARALLEL TO
Pentax pediatric esophagoscope and PORT) NEEDLE INSERTION FOR ENDO-
taped to the mouth. The child was turned SUTURING K etan P. Parikh, Dr., Tara
into a semi-prone position with the right Neo-Surg Hospital, Jaslok Hospital, L H
side elevated. The first 5mm STEP port Hiranandani Hospital, Seven Hills Hospital.
was introduced 1 cm below the angle of
Endosuturing has become an integral
scapula. The second port was introduced
part of advanced laparoscopic surgeries.
3-4 rib spaces below in the mid-axillary
Laparoscopic surgeries in small children
line. Placement of the third port required
or mini-laparoscopic procedures in older
extensive adhesiolysis. It was placed in
children are performed using thin cannulae
the axilla, 2 rib spaces above the first
(2-3mmin diameter) to minimise the
port, in the mid-axillary line. Using a hook
trauma related to ports. Every puncture
diathermy, adhesions between the chest
on the abdominal wall is independently
wall, esophagus and the lung were taken
capable of producing pain in the post-
down.
operative period (including a puncture of a
The esophagus was dissected above and surgical needle).
below the site of the fistula and a sling
Needle insertion for the purpose of
was placed around the lower esophagus to
endosuturing is traditionally achieved
help dissection. The fistula was identified
either by straightening a curved surgical
by the previously placed guide wire,
needle (converting to ski needle) and
divided and the bronchial and esophageal
insertion through these thin ports or
ends were closed with interrupted Vicryl
direct insertion through the abdominal
sutures. A pleural patch was designed
wall. The former is likely to lead to a mild
from the lateral chest wall and laid on the
distortion of the needle making it more
esophageal anastomosis to separate the
unsuitable for suturing tissues where an
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appropriate curve of the needle would unstable or have peritoneal signs.
be preferred and at tiimes even make the Ultrasound and CT scans were performed
needle more prone for rotation within the in both patients with identification of
needle-holder. In the latter method, 2 abdominal wall hernias containing bowel in
needle pricks (entry and exit) are made the absence of other injuries. Laparoscopic
for every insertion, thus adding to the repair were performed uneventfully in both
potential post-operative pain and at times patients with interrupted nonabsorbable
a significant extra time for this manoeuvre. multifilament suture with 2 and 3 ports
respectively. Oral intake was initiated one
Over the past 15 years, we have been
day after surgery and both patients were
following a simple manoeuvre for needle-
discharged home the second day after
insertion (and even retrieval) by which
surgery. In the follow-up visit patients were
surgical needles of any size, diameter,
asymptomatic and no signs of abdominal
length, shape and cross-section(cutting/
wall hernias were found.
round-bodied) can be inserted into the
abdominal or chest cavity parallel to Laparoscopic repair of blunt traumatic
an existing trocar (without making any abdominal wall hernias is safe and
additional punctures). We feel that this technically possible in children, and should
technique is easily reproducible and be considered as the standard initial
laparoscopic surgeons should add this to approach in the stable patient.
their technical skills for appropriate use
P076: LAPAROSCOPIC SUBTOTAL
with an added advantage of preserving the
PANCREATIC RESECTION IN INFANTS
shape of the needle and not increasing the
WITH CONGENITAL HYPERINSULINEMIA?
potential of post-operative pain.
COMPLICATIONS AND TREATMENT K uiran
P075: TRAUMATIC ABDOMINAL WALL Dong, MD, Gong Chen, MD, Wei Yao, MD,
HERNIA FROM HANDLEBAR INJURY, Xianming Xiao, Prof, Gongbao Liu, MD,
LAPAROSCOPIC REPAIR – REPORT OF Children’s Hospital of Fudan University
TWO CASES Santiago Correa, MD, Juan
PURPOSE: To report the experience
Valero, MD, Jorge Beltran, MD, Fundación
of laparoscopic subtotal pancreatic
Hospital de la Misericordia, Univerdidad
resection in infants with congenital
Nacional de Colombia.
hyperinsulinemia(ICHI) in our hospital, the
Although rare, traumatic abdominal wall laparoscopic technic, resection range , the
hernia associated with handlebar injury complication and treatment is discussed.
is a well-described entity in the pediatric
METHOD: Retrospective chlinical data
population with about 40 cases and
of 9 cases of laproscopic subtotal
only one laparoscopic repair reported in
pancreatic resection in infant congenital
children. We present two cases of male
hyperinsulinemia which operated in Mar
patients who were 9 and 13 years old,
2001~Jun 2013.
evaluated in our emergency room after
blunt abdominal trauma associated with RESULTS: Preoperative: The age of 9 cases
handlebar injury. Both patients presented was from 17days to 6 months,. There were
with the handlebar sign in the abdominal 6 males and 3 females. The diagnosis of
wall, one had a painful mass, and the persistent hyperinsulinemic hypoglycemia
other one had intermittent pain in the area were made by our endocrinology team.
of trauma without palpable mass. None Their fasting plasma glucose were
of the patients were hemodinamically 0.5~5.1mmol/L, insulin levels of the
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fasting test were 4.1~50.1u lU/ml. All hyperplasia. There are 2 cases were normal
these patients were failed in the Diazoxide morphology.
medical therapy. Glucagon treatment and
FOLLOW UP: Patients were followed up for
continuous hypertonic intravenous glucose
6~10 months. The fasting plasma glucose
treatment were needed all the time. CT
were 2.2~12mmol/L. Two patients still
and MRI showed normal pancreatics.
had symptoms of hypoglycemia required
Since 2013, three cases of CHI underwent
steroid therapy. Three cases have low
genetic testing, two of them prompted
fasting blood glucose, but can turn to
KATP channel gene mutations (ABBC8 and
normal after eating. The other 4 cases
KCNJ11).
have well controlled blood glucose.
SURGICAL APPROACH: Three holes
DISCUSSION: The main type of the CHI
laparoscopic technique were used in the
in infant is diffuse type. The genomics
procedure. The pancreatic tail was the
detect may take place of PET-CT. The
first mobilized from the spleen hila, and
uncinate part resection is an important
sent for the frozen pathology. When the
step to reach the 95% range during the
focal lesion was excluded, the pancreas
laparoscopic operation. Complication rate
was mobilized from the tail to the head,
of laparoscopic pancreatic resection is
when the right edge of the superior
22%. The pancreatic short vessels is the
mesenteric vein was reached, then pull
main reason of spleen vein damage and
out the uncinat part and separated it from
bleeding. Althought bile duct injury is one
the back of SMV. Along the left edge of
of the complications of this operation; the
the biliary duct, the subtoltal resection
chlodochol cyst is a rare event.
was performed by the harmonica, the total
amount of the resection was 95%. P077: LAPAROSCOPIC TREATMENT OF
FALLOPIAN TUBE TORSION SECONDARY
COMPLICATIONS AND TREATMENT:
TO HYDATIDS OF MORGAGNI C laudia M.
All 9 patients were completed surgery,
Mueller, PhD, MD, Sandra Tomita, MD,
no operative mortality. Intra and
Stanford University School of Medicine,
postoperation complication happened in
New York University School of Medicine
2 cases(22.2%). One case has spleen vein
injury during operation, the hemolocker PURPOSE: Hydatids of Morgagni, which
has to be used for hemostasis. After six are pedunculated cystic structures arising
months follow-up, the child developed from the fimbriated end of the fallopian
splenomegaly but no esophageal tubes, are embryologic remnants of the
and gastric varices or gastrointestinal mullerian duct. Torsion of the fallopian
bleeding. Another case appeared jaundice tube involving hydatids of Morgagni, is a
and liver function damage at 3 month rare cause of acute pelvic pain in young
postoperatively; MRI showed the biliary girls and can pose significant risks to future
was unobstructed but a choledochal fertility. In addition, it may present as a
cyst. The hepatic duct jejunal Roux-Y diagnostic dilemma since the ovary itself
operation was then performed, and the usually appears normal on ultrasound,
liver function returned to normal 1 month and the cystic hydatid may be incorrectly
postoperatively. recognized as a simple ovarian cyst. Thus,
surgical intervention can be delayed which
PATHOLOGY: The pancreases of all 9
may lead to worsening necrosis and result
cases have no atrophy; 2 cases have islet
in the need for resection of the affected
hyperplasia, 5 cases have partial islet cell
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tube. Laparoscopy is an effective way meatus. Both testes were non-palpabl.
to both diagnose and treat this unusual There was scrotal hyperpigmentation. USG
condition in a rapid fashion. did not detect any testicular tissue. MRI
revealed no testicules. A retrovesically
METHODS: We review two cases of
located uterus of 48×22×15 mm, bilateral
fallopian tube torsion associated with
ovaries and a 10 mm wide and 5 cm long
large hydatids of Morgagni in adolescent
vagina extending to the posterior urethra
females.
were present. The karyotype was 46XX.
RESULTS: Both patients were Psychosexual evaluation revealed male
perimenarchal (ages 10 and 13) and dominancy and endocrinologic studies a
presented with acute pelvic pain. virilizing congenital adrenal hyperplasia
Ultrasound showed a normal ovary with a due to 21-OHase deficiency. Committee
paratubal cyst in both cases. Both patients on “Sexually Development Disorders”
underwent diagnostic laparoscopy and evaluated the patients as a male. After
were found to have adnexal torsion approval of the parents, the patient
with large hydatids of Morgagni. In both underwent a total histero-salphyngo-
cases, the fallopian tube was detorsed oofero-vaginectomy. No surgical
laparoscopically and preserved. The cyst complication has been detected. There
was excised in one case and marsupialized were no postoperative hematuria no
in the other. voiding problems. The patient discharged
at postoperative 5th day.
CONCLUSIONS: Prompt recognition and
operative management of this relatively CONCLUSION: Laparoscopy is a safe and
uncommon disease entity may prevent effective procedure for the removal of
unnecessary tubal resection and improve internal genitalia in phenotypic male
long-term fertility in young women. patients with intersex.
Minimally-invasive surgical procedures can
P079: LAPAROSCOPIC TOUPET
be used to safely and efficiently diagnose
FUNDOPLICATION IN A 1.8KG INFANT
and treat this gynecologic emergency.
USING AIR SEAL INTELLIGENT FLOW
P078: LAPAROSCOPIC TOTAL HISTERO- SYSTEM AND ANCHOR PORT. A
SALPHYNGO-OOFERO-VAGINECTOMY TECHNICAL REPORT. G o Miyano, MD,
Unal Bicakci, MD, Ferit Bernay, MD, Dilek Keiichi Morita, MD, Masakatsu Kaneshiro,
Demirel, MD, Beytullah Yagiz, MD, Burak MD, Hiromu Miyake, MD, Hiroshi Nouso,
Tander, MD, Selim Nural, MD, Cengiz MD, Masaya Yamoto, MD, Koji Fukumoto,
Kara, MD, Riza Rizalar, MD, Ondokuz MD, Naoto Urushihara, MD, Department
Mayis University, Department of Pediatric of Pediatric Surgery, Shizuoka Children’s
Surgery, Radiology, Endocrinology Samsun, Hospital
Turkey
AIM: Laparoscopic fundoplication has been
We present here a laparoscopic total refined because of the development of
histero-salphyngo-oofero-vaginectomy in improved instruments and equipment. We
a patient with intersex. report the case of a 1.8kg infant who had
laparoscopic Toupet fundoplication (LTF)
Fourteen years old phenotypic male for severe gastroesophageal reflux (GER)
patient was admitted with hematuria. using the Air Seal Intelligent Flow System
Physical examination revealed 8 cm (ASIFS) and Anchor Port (AP).
long phallus, normal positioned urethral
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CASE REPORT: Our case had GER in LTF procedure, with optimum operative
association with genetic and cardiac field. Total operating time for LTF was 90
anomalies, and despite continuous minutes. During pneumoperitoneum, body
feeding, persistent vomiting caused failure temperature dropped from 37.4 to 35.7,
to thrive. At 4 months of age our case but recovered immediately after cessation
weighed 1.8kg and LTF was performed of pneumoperitoneum. Postoperative
using 4 trocars and 3mm instruments. progress was uneventful, and an upper
The ASIFS is a novel laparoscopic CO2 gastrointestinal study on postoperative day
insufflation system composed of the 2 showed no residual GER.
Air Seal IFS control, the Air Seal valve-
CONCLUSIONS: The AFIFS and AP
less trocar and the Air Seal Mode
contributed to the successful outcome
Evacuation Tri-lumen Filter Tube Set that
of LTF in a 1.8kg infant. However,
decreases camera smudging, improves
there would appear to be a risk for
the visual field by constant evacuation
hypothermia in neonates and small infants
of smoke, and provides a more stable
during insufflation for laparoscopic or
pneumoperitoneum. In addition, the AP is a
thoracoscopic procedures that requires
recently developed elastomeric low profile
constant vigilant monitoring.
cannula that is stretchable thus allowing
its laparoscopic footprint to be minimized P080: A SAFE AND EASY TECHNIQUE
both inside and outside the body. A 5mm TO POSITION A GASTROSTOMY TUBE
AP was inserted subumbilically using the AFTER LAPAROSCOPIC FUNDOPLICATION
blunt obturator supplied with the scope. Michimasa Fujiogi, Yujiro Tanaka, Hiroshi
After sufficient insufflation to establish Kawashima, Miki Toma, Takayuki Masuko,
pneumoperitoneum, a second and third Hiroyuki Kawashima, Kyouichi Deie, Hizuru
5mm AP were inserted in the right and Amano, Hiroo Uchida, Tadashi Iwanaka,
left upper abdomen as the surgeon’s Saitama Children’s Medical Center,The
working ports, a 5mm Air Seal trocar was University of Tokyo Hospital
inserted in the left lower abdomen for
the assistant, and a Nathanson retractor INTRODUCTION: Severely handicapped
was also placed in the mid epigastrium. children with gastroesophageal reflux
The gastrosplenic ligament was dissected disease commonly undergo gastrostomy
free and the intraabdominal esophagus with fundoplication. Although there are
was prepared by thorough dissection of many procedures, an optimal method is
the hiatus mediastinal paraesophageal awaited. Conventionally, we sutured the
ligament. A posterior hiatoplasty using stomach to peritoneum under direct vision
two 4-0 non-absorbable sutures was by port hole expansion. The expanded
performed to repair the large hiatus hernia wound was closed after gastrostomy tube
that was present before the tension- insertion.
free 270 degree fundoplication was However, with a 3-cm wound, infection and
performed by fixing the anterior wall of the external leakage risks were high. In 2011,
esophagus to the crus of the diaphragm we devised a new technique not requiring a
with two sutures followed by two sutures 3-cm wound. We report this technique.
each to fix the right and left wraps to the
esophagus. All eight sutures were tied METHOD: In fundoplication, we use 3 ports:
extracorporeally. Pneumoperitoneum was one is placed in the umbilicus as a camera
maintained stably throughout the whole port, and the two other are in the left and
right flanks as working ports. We use 2
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port-less forceps (PLF) (3-mm) for liver NP group: Age ranged from 3 months to 23
elevation and stomach traction. One PLF years (median: 42.5 months); bodyweight
insertion site is used for the gastrostomy ranged from 3.7 to 42 kg (median: 11.75).
tube. Age and bodyweight of the groups did not
differ (P=0.88 & 0.98, respectively).
After fundoplication, the anterior stomach
wall is grasped by PLF. Three 3-0 vicryl NP group complications were rare: 2
sutures are placed around it at the cases of external leakage around the
seromuscular layer laparoscopically. gastrostomy, 1 of internal leakage, and no
Ends of sutures are pulled through the infection. Infection was significantly lower
abdominal wall using a laparoscopic in the NP compared to CP group (n=0
percutaneous extraperitoneal closure vs. n=4, respectively; p=0.04). External
(LPEC) needle. The LPEC needle is leakage was lower in the NP compared
percutaneously inserted from the to CP group (n=2 vs. n=5, respectively;
same point and takes different routes p=0.24), with no other significant
subcutaneously to catch the ends of differences.
sutures.
DISCUSSION: Effective fixation is possible
The LPEC needle pierces the peritoneum at by triangular suturing of the stomach
intervals equivalent to the distance of the and abdominal wall. Since the PLF hole is
stitch. This is repeated for each stitch. used, no additional incision is necessary.
This procedure is applicable even for
A triangle is made with three sutures. Its
small infants. Since this technique is
center is the gastrostomy, and the three
simple with less infection, we recommend
sides are formed by the sutures.
it for gastrostomy after laparoscopic
We remove PLF at the site of gastrostomy, fundoplication
and insert the electrocautery needle from
P081: MINIMALLY INVASIVE REPAIR OF
the same site to penetrate the stomach
MORGAGNI HERNIA – A MULTICENTRIC
wall under laparoscopic vision.
NATIONAL STUDY R . Lamas-Pinheiro, MD,
We flatten the cutting area by holding J. Pereira, MD, F. Carvalho, MD, P. Horta,
the two nearest points of the triangle MD, A. Ochoa, MD, M. Knoblich, MD, J.
and pulling the opposite suture. Then, a Henriques, MD, T Henriques-Coelho, MD,
balloon-type gastrostomy tube is inserted. PhD, J. Correia-Pinto, MD, PhD, P. Casella,
MD, J. Estevao-Costa, MD, PhD, Pediatric
After insufflation, the 3 stitches are pulled Surgery Departments of: Hospital Sao Joao,
toward the abdominal wall and tied Porto; Centro Hospitalar do Porto; Hospital
extracorporeally. The LPEC needle pierces Pediátrico de Coimbra; Hospital Dona
the same skin surface for each stitch, so Estefania, Lisboa, Portugal
the knot goes under the skin.
INTRODUCTION: Morgagni hernia (MH) is
RESULTS: We compared complications extremely rare, representing less than 6%
between the new procedure (NP) group of all congenital diaphragmatic defects
from January 2011 to January 2014 (n=36; repaired at pediatric age. Children may
20 males, 16 females) and conventional benefit from the application of minimally
procedure (CP) group from January 2008 invasive surgery (MIS) in the correction
to December 2010 (n=37; 26 males, 11 of these defects, but larger studies are
females). needed to evaluate such potentiality.
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The present study aims to evaluate the P082: TWO-PORT LAPAROSCOPIC
outcomes of the MIS through a national HERNIOTOMY: A NOVEL WAY TO PROVIDE
multicentric study. BETTER COSMETIC RESULTS WITHOUT
INCREASING THE TECHNICAL DIFFICULTY
MATERIAL & METHODS: All national
IN PEDIATRIC INGUINAL HERNIA Yoon-
institutions that used MIS in the treatment
Jung Boo, MD, Ji-Sung Lee, PhD, Eun-Hee
of MH were included in a retrospective
Lee, MD, Division of Pediatric Surgery,
transversal study. Demographic data, co-
Department of Surgery, Korea University
morbidities, clinical presentation, operative
College of Medicine
details and follow-up were analyzed.
BACKGROUND: We previously have
RESULTS: Between December 2006 and
reported that laparoscopic hernia sac
June 2013, thirteen patients (6 males)
transection and intracorporeal ligation
were submitted to correction of MH
can be a safe alternative for conventional
by MIS (using similar percutaneous
pediatric herniotomy. We modified our
stitches technique), in 4 tertiary centers.
previous technique and used reduced
The children were operated at a mean
number of ports (two-port) to produce
age of 21.6 months (4.8-56.5 months).
better cosmetic results with less technical
Six patients had chromosomopathies
difficulty. The aim of this study was to
(46.2%), including five children with
evaluate the outcome of this two-port
Down syndrome (38.5%). The most
technique compared to the previous
common presentation was respiratory
three-port technique.
symptoms (53.8%) and 5 patients (38.5%)
had previous admissions for different METHODS: Between 2008 and 2013, 410
causes. The procedure last, in mean, records of children with inguinal hernia
95±23 minutes (range 40-120). There treated by laparoscopy were reviewed. Of
were no intra-operative complications; in them, 63 patients were treated by two-port
none of the patients the hernia sac was laparoscopic herniotomy and 347 patients
removed; prosthesis was never used. In were treated by three-port laparoscopic
the immediate post-operative period, 4 herniotomy. For two-port laparoscopic
patients (36%) were admitted to intensive herniotomy, we introduced one globe
care unit due to co-morbidities (all port through the umbilicus and inserted
presented Down syndrome); the remaining a 3mm assistant port at the suprapubic
patients started enteral feeding within area. We calculated the learning rate of
the first 24 hours. With a mean follow- the two-port technique and compared this
up of 17.5 months, there have been two to the result of the three-port method to
recurrences (18%) on the same institution; evaluate technical difficulty.
one of the recurrences was the only case in
RESULTS: There was no significant
which an absorbable suture was used.
difference in operation time between the
CONCLUSION: The application of MIS in the two-port group and three-port group
MH repair is effective even in the presence (25.2±7.0 minutes vs. 24.8±9.6 minutes:
of comorbidities such as Down syndrome; p=0.75). Learning rate analysis showed
the latter influenced only the immediate that there was no difference between
postoperative recovery. Removal of hernia the two-port and three-port technique
sac is not necessary. The use of absorbable (6.02 % vs. 10.60 %: p=0.23). No intra- or
suture is not recommended. postoperative complications were found in
two-port group. In the three-port group,
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we had two cases of recurrence (0.58 %) P083: LAPAROSCOPIC INFANT INGUINAL
and one metachronous hernia (0.28 %) HERNIA REPAIR: 5 YEAR EXPERIENCE IN
during the follow-up period (mean 28.5 A SINGLE CENTRE J oshua Rae, Caroline
months). Smith, S. S. Marven, G. V. Murthi, R. M.
Lindley, J. P. Roberts, Sheffield Children’s
CONCLUSION: The two-port laparoscopic
Hospital
herniotomy can be used as a safe
treatment option providing better AIM: Laparoscopic inguinal hernia repair
cosmetic results without increasing the in infancy is still a contentious issue. The
technical difficulty of the operation. purpose of this study was to look at the
outcomes of laparoscopic inguinal hernia
repair in children under one year of age
in terms of demographics, detection of
contralateral patent processus vaginalis
(PPV), length of post operative stay,
post operative complications and rate of
recurrence.
METHODS: A retrospective case note
review of 150 patients under the age of 12
months who underwent a laparoscopic
hernia repair at our institution between
November 2008 and November 2013 was
conducted. Mean time to first follow up
was 3 months. Median follow up was 6
months (0 – 24 months).
RESULTS: All operations were completed
laparoscopically. There were 118 (79%)
hernia repairs in males and 32 (21%) in
females. Mean Post conceptual age was
51.6 weeks. Mean weight at operation
was 5.2 Kg. The rate of detection of
contralateral PPV was 40%.
Median length of stay was 1 day (range
0-10 days). There were 3 patients who
required prolonged post operative
oxygenation and oral antibiotics for lower
respiratory tract infections.
There were 6 recurrences (4%) in the time
period, of these 4 had presented originally
as an emergency. Mean time to recurrence
was 8.5 months, median time to recurrence
was 2 ½ months (2 days – 24 months).
There were no instances of testicular
atrophy. 3 patients developed testicular
ascent requiring orchidopexy.
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No patients developed metachnronous full-thickness neck of the hernia and the
hernias during the study period. inguinal ligament and at the same time
minimized the suture line tension. The
CONCLUSION: Laparoscopic infant hernia
technique was used for IHR in 72 selected
repair is safe and our recurrence rate
patients aged from12 months to 14 years.
is within the reported range. Repair of
All procedures were carried out in the
inguinal hernia laparoscopically allows
minilaporoscopy mode. The total number
inspection of both internal rings and avoids
of IHR’s, including the contralateral
readmission for repair of a metachronous
metachronous hernias was 96. The patient
hernia.
outcomes were followed up at intervals of
P084: A POTENTIALLY MORE DURABLE one, three, six months, 1 and 1.5 years. The
MIS REPAIR FOR PEDIATRIC INGUINAL patient data were summarized.
HERNIA A natole Kotlovsky, MD, PhD,
RESULTS: All procedures were
Sergei Bondarenko, MD, PhD, Alexander
successfully completed without any
Lepeev, MD, PhD, Vitaly Ovchinnikoff,
complication encountered. The operative
MD, Oleg Chernogoroff, MD, Alexey
time ranged between 10 – 35 minutes for
Ryazantzev, MD, Solntzevo Clinical
the unilateral hernias and 25 – 45 minutes
Research Center of Medical Care for
for the bilateral. All patients made prompt
Children, Moscow, Central Children’s
uneventful recovery with only minimal
Hospital in Oryol Region, Oryol, Russian
requirement for analgesia. No evidence
Federation
of hernia recurrence was found at the
BACKGROUND: Certain advantages of MIS follow-up intervals. Patient/parent
techniques for the inguinal hernia repair satisfaction with the treatment was stated
(IHR) in children have been demonstrated. in all cases.
However, the fact of higher recurrence
CONCLUSION: IHR with the use of TMTF/
rates following the MIS repair vs the
RT appears to be effective in preventing/
conventional open procedure points to
minimizing risk of hernia recurrence. For
the desirability for further development.
the further evaluation a randomized
To enhance the potential durability of the
comparative study of the TMTF/RT vs the
laparoscopic repair we have modified the
open technique will be warranted.
technique of transperitoneal closure of
the hernia defect, following the principles P085: LAPAROSCOPIC PARTIAL
of mass and tension free/reduced SPLENECTOMY AND EXTROPERITONEAL
suturing. SPLENOPEXY FOR TORSION OF
WANDERING SPLEEN C hi Sun, MD, Suolin
OBJECTIVE: This study represents a
Li, MD, Department of Pediatric Surgery,
preliminary report of the proposed
The Second Hospital of Hebei Medical
transperitoneal mass, tension free/
University, Shijiazhuang, China
reduced technique (TMTF/RT) for
pediatric IHR. BACKGROUND: Wandering spleen is a
rare condition in which the spleen lacks
PROCEDURE & PATIENTS: The key
its usual peritoneal attachments and
elements of the TMTF/RT entailed
supporting ligments, thus its vascular
closure of the hernia defect while using
pedicle can twist resulting in ischemia
differentially, depending on the defect
and infarction. Although splenectomy
size, combinations of various types of
has traditionally been used for this
suturing that incorporated parts of the
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condition, splenopexy is increasingly This is a video presentation of laparoscopic
used in the pediatric population to resection of posterior gastric wall tumor
anchor the spleen and preserve splenic in a 12 year old boy. He was found to have
function. We describe a laparoscopic a transmural tumor of the gastric wall,
partial splenectomy and extroperitoneal extending into the lesser sac. The tumor
splenopexy of the remaining spleen for was excised laparoscopically. The resulting
torsion of a wandering spleen in a child. gastrotomy was repaired using continuous
full-thickness single layer suture using 2-0
CASE REPORT: The patient was a
absorbable, glycolic acid, barbed suture
3-year-old girl with a month history of
device.
intermittent abdominal pain. Abdominal
ultrasonography and axial computed Unidirectional barbed sutures like V-Loc
tomography demonstrated a wandering (Covidien, Mansfield, MA) allow easier
spleen with partial infarction in the left placement of continuous sutures during
mid-abdomin and the whirl appearance open and minimally invasive procedures.
of the splenic vessels. On laparoscopic This does not require knots at the
exploration the spleen was found to lack beginning or at the completion of the
its normal attachments and had made 3 suture. Neither does it need maintenance
complete clockwise rotations around its of tension on the material while suturing.
mesentery and there were signs of vascular
Use of this device allowed for expeditious
occlusions and infarction of the spleen. The
and secure closure of the gastric
spleen was detorsed around its mesentery
defect. The child recovered well without
and then the partial splenectomy and
complications and remained asymptomatic
extroperitoneal pocket splenopexy of the
six months after the procedure.
remaining spleen were performed. The
postoperative course was uneventful and P087: FIRST CASE REPORT OF
the well-perfused remaining spleen had PERCUTANEOUS TRANS-ESOPHAGEAL
maintained its position during a 2-year GASTRO-TUBING PERFORMED IN A
follow-up period. CHILD Hideto Oishi, MD, Katsunori Kouchi,
MD, Fumi Maeda, MD, Takeshi Ishita, MD,
CONCLUSION: Wandering spleen should
Masayuki Ishii, MD, Takuya Satou, MD,
be considered in cases of acute abdominal
Takayuki Iino, MD, Hidekazu Kuramuchi,
pain, and laparoscopic partial splenectomy
MD, Shunsuke Onizawa, MD, Eiichi Hirai,
with splenopexy is technically feasible and
MD, Mie Hamano, MD, Tutomu Nakamura,
safe, based on the well-known advantages
MD, Tatsuo Araida, MD, Shingo Kameoka,
that the minimally invasive approach
MD, Division of Gastroenterological
offers, and should be considered the
Surgery, Division of Pediatric Surgery,
treatment of choice for this rare condition,
Dept of Surgery, Yachiyo Med Ctr, Tokyo
with the goal of preservation of the organ
Women's Med Univ
whenever possible.
OBJECTIVE: We report the first
P086: KNOTLESS REPAIR OF
percutaneous trans-esophageal gastro-
GASTROTOMY USING UNIDIRECTIONAL
tubing (PTEG) procedure performed
BARBED SUTURE FOLLOWING EXCISION
in a child. We developed PTEG in 1994
OF GASTRIC LEIOMYOMA Ravindra K.
for patients in whom percutaneous
Vegunta, MBBS, Cardon Children’s Medical
endoscopic gastrostomy (PEG) would be
Center, Mesa, AZ and University of Arizona
difficult. In 1997, we invented a rupture-
College of Medicine, Phoenix, AZ
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free balloon (RFB) to aid the PTEG P088: MULTI-MODAL ASSESSMENT
procedure. In Japan, PTEG is usually used STRATEGY FOR ADVANCED MINIMAL
for gastrointestinal decompression and, ACCESS PAEDIATRIC SURGEON
like PEG, for enteral nutrition. It has proven SELECTION S imon Clarke, Mr., Munther
to be as useful as PEG. Of the 16,000 PTEG Haddad, Mr., Giuseppe Retrosi, Tom Cundy,
procedures performed in Japan to date, Chelsea and Westminster Hospital NHS
285 were performed by us. However, all Foundation Trust ; Imperial College London
patients were adults; the procedure was
The selection process for appointment
not performed in children. We recently
of consultant paediatric surgeons is a
performed the PTEG procedure in a child
highly competitive process. In an effort to
and report our experience herein.
improve transparency and objectiveness
MATERIALS & METHODS: The patient was of this process for an advanced minimal
a 9-year-old girl with cerebral palsy who access post, a multi-modal assessment
required enteral nutrition. Transperitoneal approach was designed utilizing the
dialysis was anticipated in this case; thus, resources of an established paediatric
PEG was not possible. PTEG was selected surgery simulation laboratory.
and carried out under general anesthesia.
AIMS: to assess the process and outcome
The PTEG procedure was performed in two
for two sets of consultant interviews using
steps. The first step was esophagostomy,
validated and non-validated surgical skill
which was accomplished by direct puncture
tests.
under ultrasonographic guidance. We
began by inserting an RFB into the cervical METHODS: Consultant selection took
esophagus via the nose, and we inflated place on two separate occasions. 10
the RFB to keep the esophageal lumen prospective candidates took part and
open for puncture. The second step was were rotated through three assessment
tube placement via the esophagostomy stations consisting of 1) validated Pediatric
under fluoroscopic guidance. An indwelling Laparoscopic Surgery (PLS) simulator
PTEG button catheter, 15 Fr x 90 cm, was peg transfer task, 2) neonatal box
placed in the patient’s jejunum via the trainer intracorporal suture task, and 3)
cervical fistula. structured interview with senior faculty.
An independent observer moderated the
RESULT: We encountered no technical
technical skills task stations. This observer
complication. Surgical antibiotic
was assigned to mitigate candidates being
prophylaxis prevented infection. Enteral
distracted in their task performance and
nutrition was begun on postoperative
to avoid uncontrolled bias. Candidates
day 1, and the patient was discharged on
consented to live video and audio
postoperative day 2.
being transmitted to an adjoining room
EXPECTATION: With the effectiveness of where faculty were able to observe
PTEG already confirmed in adults, we were the assessment stations via tele-feed.
able to show that it is likely to be feasible Results for each assessment station were
and safe in children. PTEG might be broadly scored and then pooled for an aggregate
applicable in pediatric cases for which PEG candidate score. Results were fed back to
would be difficult or is contraindicated. the appointments committee after their
preferred candidates had been named.
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RESULTS: All candidates completed all (SonoSite, Inc.,Bothell, Washington).
tasks. The median unnormalized PLS peg The packaged 0.025 inch diameter (ID) J
transfer score was 125 (range 76 – 62). wire within the set was used in all infants
The validated task coincided with all three weighing greater than 2.5 kg. A 0.018 ID
preferred candidates. The non-validated angled glidewire (Radiofocus® glidewire,
task scores coincided with 2 of 3 preferred Boston Scientific Inc., Natick, MA) was used
candidates. Feedback from candidates in infants less than 2.5 kg. The average
was variable and most felt the task did not size of the internal jugular vein was 4.0
demonstrate their ability on the day. mm (range of 3.5 to 5.0 mm). Twenty
infants underwent 21 UG CVC placements
CONCLUSION: Pre selection is increasingly
(mean weight 2.45 kg., range 1.4 to 3.4
being used at interview in medical
kg.). Vascular CVC placement occurred
specialities. We found those who
at the following access sites: 16 infants
performed well at interview correlated well
underwent 17 placements via the right
with task performance. Further validation
internal jugular (RIJ) vein, 3 infants via the
studies are planned to enable this to be
left internal jugular vein (LIJ). One infant
used with more confidence at future
had inadvertent removal of the UG CVC
appointments panels.
in the RIJ on post operative day 7. This
P089: ULTRASOUND GUIDED infant returned to the OR and underwent
PERCUTANEOUS CENTRAL VENOUS a successful UG CVC in the same RIJ.
ACCESS IN INFANTS S eth Goldstein, MD, (infant weight 2.8 kg). There were no other
Howard Pryor, MD, Dylan Stewart, MD, complications in the group.
Fizan Abdullah, MD, PhD, Paul Colombani,
CONCLUSIONS: The UG CVC approach is
MD, Jeffrey Lukish, MD, Johns Hopkins
a safe and efficient approach to central
University
venous access in infants as small as 1.4
PURPOSE: The insertion of tunneled kg. Our experience support the use of
central venous access catheters (CVC) in an ultrasound guided percutaneous
infants can be challenging. The use of the technique as the initial approach in infants
ultrasound guided approach (UG) to CVC who require central venous access.
placement has been reported in adults and
P090: HOW TO IMPACT DELIVERY
children but there is minimal information
OF PEDIATRIC SURGICAL CARE IN A
regarding these techniques in infants.
DEVELOPING COUNTRY—START A
METHODS: From August 2012 to FELLOWSHIP TRAINING PROGRAM
Novemeber 2013, retrospective analyses Stephanie F. Polites, MD, Abdelbasit Ali,
were carried out on the charts of MBBS, Diyaeldinn Y Mohammed, MBBS,
infants that were 3 kilograms or less Osman Taha, MBBS, Abdalla E. Zarroug,
who underwent attempted UG CVC MD, Mayo Clinic, Rochester, MN; Soba
placement. Data retrieval included infant Hospital, University of Khartoum, Sudan;
weight, vascular access site, diameter of University of Gezira, Wad Madani, Sudan
cannulated vein in mm, and complications.
INTRODUCTION: Providing pediatric
RESULTS: All infants underwent UG CVC surgical care in Sudan is difficult due to
placement utilizing a standard 4.2 Fr or 3.0 a shortage of surgeons and facilities. As
Fr CVC system. (Bard Access Systems, INC., of 2010, it is believed that only 7 pediatric
Salt Lake City, Utah). UG was performed surgeons practiced in Sudan and South
on all infants with the Sonosite M-Turbo® Sudan (Sudan) and no studies have been
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published regarding manpower in Sudan. the median reported wait time for patients
To address the manpower issue, a 2 year decreased from >9 months to 6-9 months.
pediatric surgery fellowship program was Three participants (33%) were worried
started. The first participants graduated about graduating surgeons taking business
in January, 2012. The purpose of this study from their practice and 6 (67%) were not
was to establish current workforce issues worried. All participants felt the fellowship
and evaluate the impact of the training was important for children in Sudan and
program on delivery of pediatric surgical that additional pediatric surgeons were
care in Sudan. needed, with 6 (67%) who felt that 4-10
more were needed.
METHODS: In February, 2013, all practicing
pediatric surgeons (7 surgeons before CONCLUSIONS: A 2 year pediatric surgery
the fellowship and 7 surgeons after the training program has been positively
fellowship) in Sudan received a previously received in Sudan and has doubled the
published modified questionnaire about number of surgeons, resulting in increased
training and delivery of pediatric surgical access to care as evidenced by a decreased
care. Results were analyzed in aggregate. wait time for children. We believe this
can serve as a model for others to have a
RESULTS: Surveys were returned by 9 of
long-term impact on the care of children
14 (64%) surgeons. Most participating
in developing countries by training local
surgeons received training in Africa (78%),
physicians in their environment. Pediatric
while one trained in Europe and one in
surgeons in developed nations should
Asia. Previous general surgery training
support such fruitful efforts.
was variable, as 3 particpants reported
3 years of training, 3 reported 4 years, P091: A ROBOTIC-ASSISTED APPROACH
and 3 reported >4 years. The majority TO SLEEVE GASTRECTOMY IN A
(78%) reported practicing in a city with a MORBIDLY OBESE ADOLESCENT
population of 1,000,000-10,000,000. The POPULATION V ictoria K. Pepper, MD,
median (range) of pediatric surgeons at Karen A. Diefenbach, MD, Terry M.
participants’ hospitals was 2 (1-3). The most Rager, MD, MS, Marc P. Michalsky, MD,
common pediatric surgical service offered Nationwide Children’s Hospital
was urology (100%), followed by general
PURPOSE: While minimally invasive
pediatric surgery, oncology, neurosurgery
surgery is an expanding field within
(all 89%), trauma (78%), orthopedics and
pediatric surgery, robotic techniques
minimally invasive surgery (both 22%). A
have not been widely applied within this
patient age limit of < 13 years was reported
population. Robotic techniques for adult
by 3 (33%) surgeons and 6 (67%) reported
bariatric surgery have been explored by
an age limit of <16 years. All (100%)
many investigators. Our purpose was to
participants reported inadequate pediatric
demonstrate a robotic-assisted approach
surgery facilities, manpower, support
to a sleeve gastrectomy within the
facilities, and anesthesia as problems
adolescent population.
impacting care. Only 4 (44%) reported
having access to pediatric anesthesiology METHODS/RESULTS: The procedure is
services. Five (56%) of the 9 participants initiated by insertion of a 5-mm Visiport
reported involvement in training future in the left lateral abdomen, which is later
pediatric surgeons. When asked about the exchanged for an 8-mm robotic port.
impact of the fellowship training program, A 12-mm camera port is inserted at the
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umbilicus, while a 15-mm assistant port Blood tests and tumor markers were
is inserted in the right upper quadrant. unremarkable.
An 8-mm port is inserted in the lateral
MRI demonstrated a 20 cm large cyst at
right upper quadrant, while a second
the abdominal left upper quadrant.
8-mm port is inserted in the left upper
quadrant. After docking the robot, the The patient was then scheduled for
procedure is initiated by measuring a 6 resection.
cm distance proximal to the pylorus. The
greater curvature of the stomach is freed SURGICAL TECHNIQUE:
by division of the gastrocolic ligament. This Four throcars were used, 3 of 5 mm and
dissection is continued up to the hiatus. one of 12mm at the umbilical site using a 5
Once the greater curvature is freed, the mm 30 degree laparoscope.
stomach is divided with a reinforced endo-
stapler along a 34 French Bougie, creating Evidence of the 20 cm cyst arising from the
the gastric sleeve. The gastric sleeve is spleen was done on the first inspection.
insufflated endoscopically to inspect for Aspiration of the cyst was done using and
any leak, which also allows inspection endoscopic needle aspirator obtaining
of the suture line intraluminally. The around 11 liters of cyst fluid.
gastric remnant is then removed and the
procedure is completed with closure of the Splenophrenic ligament was taken down
port sites. and then the short gastric vessels were
taken down using a combination of
CONCLUSION: Robotic-assisted monopolar cautery and a vessel sealing
laparoscopic sleeve gastrectomy is instrument.
safe in the adolescent population,
and demonstrates many advantages Once freed, thespleenpoleswere
over traditional laparoscopic surgery, demarcated for resection and divided using
including enhanced visualization, multiple endoscopic staplers.
increased articulation and mobility of Splenopexy was done from the splenocolic
the instruments, and increased operator ligament to the lower pole of the spleen
control. using interrupted vycril sutures.
P092: TOTAL LAPAROSCOPIC PARTIAL The cyst was extracted using a 15 mm
SPLENECTOMY AND SPLENOPEXY AS endocatchbag and morcerated.
A MANAGEMENT OF AN EXTREMELY
LARGE SPLENIC CYST U lises Garza Serna, Patient was sent home two days after
MD, Shin Miyata, MD, Aaron Jensen, MD, surgery.
Michael Zobel, BS, Nam Nguyen, MD,
Final path showed a benign epithelial cyst.
Children’s Hospital Los Angeles, University
of Southern California P093: COMPARING THE KINECT™ AND
MOUSE AS INTERACTION DEVICES FOR
INTRODUCTION: This is a 15 year old
MANIPULATING TISSUE DENSITY IN
girl, who had a left flank mass found on
VOLUME-RENDERED MEDICAL IMAGES
routine physical exam by pediatrician. The
Bethany Juhnke, Kenneth Hisley, PhD,
patient was unable to lose weight and the
David Eliot, Joseph Holub, Eliot Winer, PhD,
abdominal girth increased over several
Iowa State University and Touro University
months.
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Volume-rendered medical images have entire study. Ten tasks were selected by an
changed the way medical professionals anatomy professor to ensure participant
diagnose and treat patients. These three- knowledge. Each participant performed
dimensional (3D) representations enable five of the tasks then repeated those
non-invasive viewing inside a patient from tasks with a short break in-between. The
any angle. Volume-rendering technologies participant was then given the other five
are being integrated into every step of the tasks, a break, and then repeated those
healthcare process from classrooms to same five tasks. Tasks and interaction
patient’s rooms, including operating rooms devices were randomized to prevent
(OR) where sterility is critical. To maintain bias. Participants were given a pre and
OR sterility, commercial off-the-shelf post study survey to obtain relevant
(COTS) devices like Microsoft’s Kinect™ are demographic and personal experience
being used to provide computer interaction information as well as qualitative data
without the need for physical contact. It about their experience during the study.
is important to research what benefits
The qualitative results showed participants
or drawbacks are associated with using
enjoyed using the Kinect™ more than
the Kinect™ for manipulating volume-
the mouse, which was opposite from
rendered medical images especially in
the first study. This may be attributed
terms of the usability of the device and
to the novelty of the device; something
the accuracy associated with using it for
commented on by multiple participants.
medical diagnoses.
While the results confirmed the Kinect™
This research builds upon a previous study still had issues with window width precision,
attempting to quantify the differences this did not appear to impact performance.
in using a Kinect™ versus a tradition Both the mouse and the Kinect™ results
computer mouse for changing tissue showed no statistical difference in accuracy
densities (windowing) of a medical image. with approximately 75% accuracy for both
The results of the first study were not devices. The big difference was the task
positive for the Kinect™ with participants completion time where the Kinect™ held
indicating that they did not enjoy the a 2 minute advantage over the mouse
device and felt self-conscious while using which was statistically significant to a 99%
it. The participant’s performance with confidence. The results of the participant’s
the Kinect™ showed inefficiencies with general experience and performance
precision manipulations. indicate that the Kinect™ has the potential
for effectively manipulating medical data.
A new study was conducted to further
explore the previous study’s results. P094: ENDOSCOPIC TREATMENT OF
Specifically, the study was designed to AIRWAY MASSES AND OTHER LESIONS
evaluate the user’s experience when using IN A DEVELOPING COUNTRY Satish K.
the Kinect™ as well as their performance Aggarwal, Professor, Shandip K. Sinha, Dr.,
compared with a traditional mouse. 32 Simmi K Ratan, Dr., G. R. Sethi, Professor,
participants with a median age of 28 Anju Bhalotra, Professor, anaesthesiology,
volunteered for this study. Most were in Maulana Azad Medical College New Delhi,
their first or second year of medical school India.
at Touro University. Participants used
AIM: To Assess the role of Bronchoscopy
either the Kinect™ or a traditional mouse
for treatment of tracheobronchial masses
to manipulate the tissue density for the
and acquired stenotic lesions in children.
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MATERIAL & METHODS: Records of cases Polyp and granulomas were removed using
that underwent bronchoscopic treatment a combination of cautery, Pulse Diode
of tracheobronchial masses and acquired Laser, and physical retrieval by forceps.
stenotic lesions over 3 years (2011-2013) Hemangioma was partially ablated by
at a tertiary care Paediatric Surgery Holmium Laser. Dilatation was performed
department were retrospectively reviewed by using Balloon dilator on a guide wire
with reference to demographics, clinical under direct vision. The endobronchial
presentation, pre op work up and surgical retention cyst was de-roofed with cautery.
management. Innovations in techniques Patients with endobronchial TB were
and instrumentation were recorded. already on ATT when they presented
with obstructive symptoms. Endoscopic
RESULTS: Twelve patients (M: F-9:3) with
removal of granuloma was successful in
median age of 6 years (range: 3 months- 18
relieving obstructive symptoms.
years) underwent therapeutic bronchoscopy
for excision of mass lesions (7), dilatation of All mass lesions were completely excised
foreign body (FB) induced bronchial stenosis in the first attempt except the subglottic
(4), and for excision of post tracheoplasty hemangioma.
suture granuloma and dilatation of a
COMPLICATIONS: Recurrent Histiocytosis
recurrent stenosis (1). Mass lesions included
which was also excised. It recurred again
Histiocytosis X (1), foreign body granuloma
twice and excised twice. In the Hemangioma
following TEF repair (1), Endobronchial
case a gauge piece which was used to protect
tubercular granuloma (3), subglottic
the tracheostomy tube was dislodged distal
hemangioma (1), and Endobronchial cyst (1).
to tracheostomy and required retrieval.
Diagnostic evaluation was done with flexible
Transient collapse of lung was seen in 4
bronchoscopy. Rigid bronchoscopy (using
cases. One case with bronchial stenosis
Storz operating bronchoscope) was used
required re dilatation after 6 weeks. One case
for therapeutic intervention. All procedures
in which dilatation was successful but the
were performed under general anaesthesia
lung had chronic collapse and did not inflate.
using either conventional or jet ventilation.
She required pneumonectomy later.
Energy sources used were Electro cautery
and Lasers. Salient features in technique CONCLUSION: Endoscopic management
were: of mass lesion is feasible in children with
acceptable morbidity. Innovative use
• Using ureteric catheter with metallic
of urological equipment comes handy.
obturator, and Bugabee electrode for
Team approach with input from Paediatric
cautery.
pulmonologist and anaesthesiologist is
• Using 3mm laparoscopy dithery hook for necessary.
cauterising granuloma in an older child.
P095: COMPLICATIONS OF LONG
• Using MLS (Micro Laryngeal surgery) set STANDING FOREIGN BODY IN THE
up for direct access to the lesion. AIRWAY AND THEIR OUTCOMES AFTER
ENDOSCOPIC MANAGEMENT: AN
• Using Ureteric Balloon Dilators (Bard) for
EXPERIENCE OF 20 CASES S atish K.
bronchial dilatation
Aggarwal, Shandip K Sinha, Dr., G. R. Sethi,
• Improvising an optical forceps by Director, Professor, of, Paediatrics, Anjan
introducing telescope and an ordinary Dhua, Dr., Simmi Ratan, Dr., Nitin Pant, Dr.,
forceps together through the sheath. Maulana Azad Medical College New Delhi,
India.
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AIM: To study the complications of long for chronic erosion of bronchial wall
standing foreign body in the airway and by a battery, and the other died during
the outcomes after their endoscopic bronchoscopy because of dislodgement of
management. FB into the opposite normal bronchus.
MATERIAL & METHODS: Records of cases Of the 16 who had successful retrieval,
that underwent treatment of chronic foreign 11 recovered completely with full lung
body bronchus over 6 years 2008-2013 at a expansion after mean duration of three
tertiary care Paediatric Surgery department months. Four had persistent collapse
were retrospectively reviewed with reference due to residual granulation and / or
to demographics, clinical presentation, bronchial stenosis as diagnosed on flexible
pre op work up and management. The bronchoscopy. They underwent rigid
techniques for management and tips and bronchoscopy again and the granulations
tricks to prevent complications are presented were cauterised and stenoses dilated using
through this paper. Outcomes were assessed balloon dilators. All of them recovered
in terms of removal of FB, expansion of lung, on follow up with full lung expansion.
need for further treatment and resolution of One patient required a pneumonectomy
symptoms. because of persistent collapse despite
removal of FB and dilatation.
RESULTS: Twenty patients (M: F-16:4) with
mean age of 7 years (range: 10 months- In summary of the 20 cases, 11recovered
12 years) who underwent therapeutic completely after first removal of FB. Four
bronchoscopy and or thoracotomy needed follow up procedure for dilatation
for management of problem related or removal of granulation – and recovered.
to chronic foreign body in the airway. Two required pneumonectomy and one
Most cases initially presented to the patient died.
Paediatric pulmonologist (GRS) as referrals
CONCLUSION: Long standing FB in airway
for evaluation of chronic respiratory
should be suspected if there are chronic
symptoms. Diagnostic work up included
respiratory symptoms even if there is no
flexible bronchoscopy. If a FB was
definite history and flexible bronchoscopy
suspected on flexible bronchoscopy the
should be offered for diagnosis.
case was sent to Paediatric Surgery for rigid
Bronchoscopic removal leads to reversal of
bronchoscopy and removal.
lung changes in most cases. Tracheotomy
The diagnosis was made on flexible should be considered while removing large
bronchoscopy in 14 whereas in 6 it was impacted FBs with chronic lung damage.
evident from a radio opaque FB on chest
P096: PARAESOPHAGEAL HERNIA IN
X-ray. Chest CT scan was done in 6 cases
2.7 KG INFANT A aron Garrison, MD, Todd
foe evaluation of lung parenchyma. Rigid
Ponsky, MD, Robert L. Parry, MD, Akron
bronchoscopy (Storz) was performed in all
cases under GA with conventional or jet
ventilation. In 16 the FB could be retrieved A 2.7kg infant was evaluated for significant
successfully (tracheotomy required in 2). In gastroesophageal reflux. Pre-operative
2 cases there was a tracheo oesophageal floroscopy showed reflux to the thoracic
fistula resulting from eroding FB in the inlet along with a small hiatal hernia. At
oesophagus – both these cases required operation for a Nissen fundoplication, a
open surgery for removal of FB and repair of large paraesophageal hernia was noted
oesophagus and trachea. Of the remaining and repaired.
two cases one required pneumonectomy
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P097: LAPAROSCOPIC INGUINAL We have been performing laparosopic
HERNIOTOMY – MIMICKING THE herniotomy since the past 15 years. The
PRINCIPLES OF OPEN INGUINAL essential therapeutic stepsof the open
HERNIOTOMY FOR COMPARABLE (inguinal) herniotomy involve dissecting
RESULTS K etan Parikh, MD, Jaslok hospital, away the processus vaginalis protrusion
L H Hiranandani Memorial Hospital, Tara from the vas and vessels especially at
Neo-Surg hospital. the neck of the hernia sac and effective
disconnection of the herniated procesus
Laparoscopy has been well accepted as
vaginalis from the parietal peritoneum
a superior modality for most surgical
(principles of high ligation of sac).
procedures in children. In contrast,
Over these years, we have evolved a
laparoscopic herniotomy in children
technique which closely mimics the
continues to be a controversial issue. One
inguinal herniotomy in all its principles
of the main objections to the herniotomy
and employs the principles of MAS. In
by the laparoscopic approach has been the
contrast to our earlier surgical techniques,
relatively higher incidence of recurrences
we have achieved effective adherence
by the laparoscopic method. Whereas the
to these principles in our laparoscopic
surgical technique for inguinal herniotomy
procedure over the past 10 years and
has been fairly well standardised,
attribute ournear-zero recurrence rate for
laparoscopic herniotomy has the dubious
laparoscopic herniotomy in children.
distinction of being performed by perhaps
the largest variety of methods described in P100: TRANSUMBILICAL ONE-PORT
literature. LAPAROSCOPIC- ASSISTED TECHNIQUE
FOR INGUINAL HERNIA REPAIR IN
We feel that since the ‘open’ (inguinal)
CHILDREN S hiwang Li, MD, PhD, Shuai Li,
herniotomy has been so fairly standardised
Guoqing Cao, Yong Wang, Yongzhong Mao,
with minimal complication rate and
Shaotao Tang, Department of pediatric
recurrences, its evolved (laparosopic)
surgery, Tongji Medical College, Huazhong
counterpart should mimic the steps
University of Science and Technology,
of the ‘open’ procedure as closely as
Wuhan, China, 430022
possible to aim at comparable results.
Basic principles of the dynamics of BACKGROUND AND PURPOSE: Since
inguinal canal function also need to be laparoscopic hernia repair was reported a
remembered and respected.The intactness few decades ago, many techniques have
and the integrity of the posterior wall of been developed. Single-port endoscopic-
the inguinal canal, the maintenance of the assisted percutaneous extraperitoneal
shutter mechanism of the inguinal canal closure of inguinal hernia with variable
and the maintenance of the mobility of the devices is a novel technique in minimal-
spermatic cord within the inguinal canal are access surgery for pediatric inguinal
integral to the physiology of the inguinal hernias. In this study, we introduced a
canal which are well preserved during the new method, Transumbilical one-port
procedure of inguinal herniotomy. The laparoscopic- assisted technique (TOPLAT),
laparoscopic benefits of visualisation of and evaluated the safety and feasibility of
the contralateral deep inguinal ring and this method.
the superior visualisation of the vas and
PATIENTS & METHODS: One hundred
vessels during their dissection can only be
and sixty-eight patients who accepted
fully justified if the recurrence rates do not
the TOPLAT procedure in our hospital
betray the final outcome.
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from November 2009 to Octoberr 2013 BACKGROUND: Gastrostomy tube insertion
were analyzed retrospectively. During the in children can be accomplished via
TOPLAT procedure, a laparoscope was open surgery, laparoscopy, endoscopy,
placed through a Transumbilical incision. or fluoroscopy. Clinicians should use an
Epidural puncture needle and Non- approach that is safe, minimally invasive,
absorbable 2-0 Prolene sutures (Ethicon provides adequate visualization, and
products ) were used to close the hernia does not require tube exchanges post-
extraperitoneally. operatively. This study describes our
experience with a recently developed
RESULTS: A total of 210 inguinal repairs
technique for the placement of skin-level
were performed in 168 children (age
device (Mic-Key) in a single procedure.
range, 3 months to 12 years; median, 6.8
years; 145 boys, 23 girls). All operations METHODS: We identified 92 children
were completed successfully by TOPLAT. and young adults who underwent
The mean operating time was 18 minutes laparoscopic-assisted percutaneous
(range, 10-25 minutes). In this group endoscopic gastrostomy (LAPEG) tube
of patients no postoperative bleeding, insertion by one of three surgeons
hydrocele, or scrotal edema was found, no between October 2009 and June 2013.
known cases of postoperative testicular The steps of this procedure include upper
atrophy or hypotrophy nor hernia endoscopy, followed by single-port
recurrence on the symptomatic side. laparoscopy, gastropexy via percutaneous
Five months after the operation, most T-fasteners, and percutaneous endoscopic
patients had no obvious signs of a previous Mic-Key placement using an introducer
operation. and tear-away sheath.
CONCLUSIONS: The preliminary results
showed satisfactory outcomes with
TOPLAT in the treatment of inguinal hernia
in children, which enclose the hernia defect
without upper subcutaneous tissues. This
technique appeared to be safe, effective,
reliable, and had excellent cosmetic
results and aid in the achievement of a
near-zero recurrence rate.
P101: LAPAROSCOPIC-ASSISTED
PERCUTANEOUS ENDOSCOPIC
GASTROSTOMY (LAPEG) IN CHILDREN:
INSERTION OF A SKIN-LEVEL DEVICE IN A
SINGLE PROCEDURE M ichael H. Livingston,
MD, Daniel Pepe, BMSc, Andreana Bütter,
MD, FRCSC, Neil H. Merritt, MD, FRCSC,
Children’s Hospital of Western Ontario,
London Health Sciences Centre, London,
Ontario, Canada
RESULTS: Mean age was 3.7 years (range 3
weeks to 25 years) and mean weight was
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11.2 kilograms (range 2.8 to 54 kilograms). site surgeries (LESS).All procedures were
Median procedural time was 20 minutes performed by a homemade single-port
(range 12 to 76 minutes). Total operative device with a wound retractor and surgical
time for the most recent 25 procedures gloves. A prospective study was performed
(median 62 minutes) was lower compared to to evaluate the outcomes.
the first 25 procedures (median 79 minutes)
RESULTS: Our study includes 15 girls and 75
(p=0.004). Significant complications were
boys; their ages range from 4 to 14 years.
observed in 4 patients (4.3%). These
We used LESS on 78 appendectomies, one
included one intra-abdominal abscess and
unilateral impalpable testis, one inguinal
one leak that required surgical repair, one
hernia, three varicocelectomy and four
retained T-fastener that was assessed via
Morgagni-Larrey hernia. A conversion
upper endoscopy, and one dislodged tube
to open surgery was necessary in three
that required replacement by interventional
patients. The time required to assemble
radiology. No major complications have
the transumbilical glove port was 4
been observed in the most recent 50
minutes. The mean operative time was 55
procedures.
minutes. The average hospital stay was 3
CONCLUSIONS: LAPEG tube insertion is a days. The cosmetic results were excellent
viable option for infants and children of all with no postoperative complications.
ages. This approach allows for immediate
CONCLUSIONS: This homemade
use of a Mic-Key without the need for
transumbilical port offers a safe, reliable,
additional upsizing. The complication rate
flexible, and cost-effective access for
and operative time with LAPEG are low
LESSprocedure. This technique may be
and appear to improve with increased
an alternative for current specialized port
experience. This technique provides
systems.
excellent visualization and no visceral
injuries have been observed. P103: EARLY EXPERIENCE WITH A NEW 3
MM TISSUE AND VESSEL SEALING DEVICE
P102: PEDIATRIC HOMEMADE
Steven S. Rothenberg, MD, FACS, FAAP,
TRANSUMBILICAL PORT: INITIAL
Saundra M. Kay, MD, Kristin Shipman,
EXPERIENCE WITH 90 CASES M .
MD, William Middlesworth, MD, Angela
Ben Dhaou, S. Mesbehi, M. Jallouli, H.
Kadenhe-chiweshe, MD, Bethany Slater,
Zitouni, S. Mefteh, A. Kotti, R. Mhiri,
MD, Stephen Oh, MD, Rocky Mountain
Department of pediatric surgery, Hedi
Hospital For Children, Columbia University
Chaker Hospital,Sfax,Tunisia. University of
College of Physicians and Surgeons
Sfax,Tunisia
PURPOSE: To evaluate the functionality
BACKGROUND: Single-port laparoscopic
of a new 3mm vessel and tissue sealing
surgery is a new surgical technique. Some
device in neonates and children.
initial studies on adults have already been
published all over the world. METHODS: Over a 4 week divided test
period 23 patients underwent laparoscopic
This paper describes our initial
and thoracoscopic procedures using a new
pediatric experience with an innovated
3 mm tissue sealing device. The device is a
transumbilical port for 90cases.
3mm instrument with a 1 cm Maryland style
MATERIALS & METHODS: Between January grasper/dissector capable of sealing vessels
2013 and December 2013, we performed up to 5mm in diameter. The generator uses
consecutive laparoendoscopic single low bipolar RF output, which limits collateral
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tissue damage. Ages ranged from 7 days One hundred and sixty-eight patients
to nine years and weight from 1.1 kg to who accepted the Transumbilical one-
30kg. Procedures included Thoracoscopic port laparoscopic- assisted technique
lobectomy (7), Fundoplication (4), Thoracic (TOPLAT) procedure in our hospital from
Duct ligation (2), Lap assisted pull-thru (2), November 2009 to Octoberr 2013. During
Choledochocyst excisiopn (1), Malrotation the TOPLAT procedure, a laparoscope
(1), PDA ligation (2), Colectomy for NEC was placed through a Transumbilical
stricture (1), Splenectomy (1), TEF repair (1), incision. Epidural puncture needle and
Appendectomy (1). Non-absorbable 2-0 Prolene sutures
(Ethicon products ) were used to close the
RESULTS: All procedures were completed
hernia extraperitoneally. A total of 210
successfully endoscopically. The device
inguinal repairs were performed in 168
was used in all cases for tissue grasping,
children (age range, 3 months to 12 years;
dissection, and to seal all blood vessels
median, 6.8 years; 145 boys, 23 girls). All
taken during the procedure. The number
operations were completed successfully
of seals performed ranged from 10 to 140
by TOPLAT. The mean operating time was
seals. There were no failed vessel seals
18 minutes (range, 10-25 minutes). In
when the device cycled properly. In one
this group of patients no postoperative
case the device was exchanged after 80
bleeding, hydrocele, or scrotal edema was
seals because of a fault in the device. The
found, no known cases of postoperative
second device performed properly. The
testicular atrophy or hypotrophy nor hernia
device was easily inserted through a 3mm
recurrence on the symptomatic side.
re-usable trocar.
Five months after the operation, most
CONCLUSION: A new 3mm vessel and patients had no obvious signs of a previous
tissue sealer using a lower more efficient operation.
energy profile and RF bipolar technology,
P105: SINGLE SITE VERSUS MULTIPORT
works safely and effectively in a wide
LAPAROSCOPIC SURGERY FOR PEDIATRIC
range of cases. The 3mm shaft and 1
COMPLICATED AND NON-COMPLICATED
cm jaw design allow for excellent tissue
APPENDICITIS: IS ONE BETTER? C harles J.
manipulation and dissection in even
Aprahamian, MD, Nerina M. DiSomma, BA,
small premature infants, and allows entry
Edmund Y. Yang, MD, Carl V. Asche, PhD,
through a 3mm trocar limiting the number
Jinma Ren, PhD, Angela M. Kao, BS, Jeremy
of larger ports needed. The design limits
S. McGarvey, MS, Sharon A. Kauzlarich, MA,
the number of instrument changes as
Richard H. Pearl, MD, Division of Pediatric
all dissection and tissue sealing can be
Surgery, Children’s Hospital of Illinois,
done with a single instrument. Further
University of Illinois College of Medicine at
evaluation is necessary to determine the
Peoria
full range and application of the device
BACKGROUND: Current literature supports
P104: TRANSUMBILICAL ONE-PORT
that single incision laparoscopy (S-LA) and
LAPAROSCOPIC- ASSISTED TECHNIQUE
conventional multiport laparoscopic (M-
FOR INGUINAL HERNIA REPAIR IN
LA) techniques have comparable outcomes
CHILDREN S hiwang Li, MD, PhD,
for treatment of appendicitis, although
Department of pediatric surgery, Tongji
some reports express concern that S-LA
Medical College, Huazhong University of
causes more pain postoperatively. This
Science and Technology, Wuhan, China,
study evaluates the outcomes and cost of
430022
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S-LA as compared to M-LA for treatment 5%, p=0.42), or abscess rates (8% vs. 7%,
of both complicated and non-complicated p=0.63) between S-LA and M-LA groups.
appendicitis in a single institution over a Procedure time was significantly shorter
concurrent time frame. in S-LA as compared to M-LA (30 vs. 40
minutes, p<0.001). Direct cost of hospital
METHODS: An Institutional Review
stay for S-LA was significantly less than
Board–approved retrospective chart
M-LA ($3736 vs. $5486, p <0.001).
review was performed for all laparoscopic
appendectomies with a preoperative CONCLUSION: Our data demonstrates
diagnosis of appendicitis at the Children’s comparable clinical outcomes between
Hospital of Illinois from September S-LA and M-LA, regardless of type of
2010 through December 2013. Interval appendicitis. However, S-LA has shorter
appendectomies were excluded. Patient procedure time and a lower cost when
demographics, type of laparoscopic compared to M-LA in both acute and
appendectomy, intraoperative complicated appendicitis. Therefore the
complications, duration of surgery, hospital use of S-LA is supported for surgeons
stay, pain score, antibiotic use, narcotic use, comfortable with this technique.
postoperative complications, and direct cost
P106: COMPARATIVE STUDY BETWEEN
were collected and compared by statistical
SINGLE-INCISION LAPAROSCOPIC
analysis for the S-LA and M-LA populations.
INGUINAL HERNIA REPAIR AND
The M-LA group was defined by patients
CONVENTIONAL INGUINAL HERNIA
who had appendectomy using 3 disposable
REPAIR IN CHILDREN L i GuiBin, Wang Li,
trocars placed in different locations in the
The 5th Centrial Hospital of TianJin China
abdomen. For the S-LA group, patients who
had an appendectomy through a single OBJECTIVE: To discuss the clinical
umbilical incision were grouped together. application value of single-incision
These were either performed with individual laparoscopic inguinal hernia repair and
trocars or proprietary multiport device. conventional inguinal hernia repair in the
Direct hospital costs were computed from treatment of children’s inguinal hernia.
hospital charges using a cost to charge ratio
(total annual direct costs divided by total METHODS: From Mon.2012 to Oct.2013,the
annual charges) and converted to 2013 clinical data of 110 children with inguinal
dollar costs using data from the Consumer hernia who underwent processus vaginalis
Price Index. high ligation were analyzed retrospectively.
Among them, there were 50 cases of
RESULTS: A total of 341 patients underwent single-incision laparoscopic inguinal hernia
laparoscopic appendectomies at our repair, 60 cases of conventional inguinal
institution: S-LA (n=175) and M-LA (n=166). hernia repair.
Type of procedure was determined by
surgeon preference. According to the RESULTS: All the operations were
surgeon’s diagnosis, 22% of patients successful. There is no significant
had complicated appendicitis and difference in mean operative time,
76% non-complicated. There were no intraoperative blood loss, the duration of
statistical differences in appendicitis type, hospital stay, hospital total cost between
intraoperative complications, hospital stay, both groups, and no intraoperative or
narcotic use, antibiotic use, pain score (3.4 postoperative complications are observed
vs. 2.9, p=0.08), wound infection (7% vs. in both groups. Postoperative cosmetic
outcome of laparoscopic group is better.
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Conclusions:The present study shows RESULTS: None of the patients were
that single-incision laparoscopic inguinal underwent conversion from single-
hernia repair is feasible, safe, and more site laparoscpy to open approach or
aesthetically pleasing than conventional conventional laparoscopic surgery.The
operation. operational time was 35.15±6.68 minutes.
23%of the unilateral inguinal hernia was
P107: TRANSUMBILICAL SINGLE-SITE
found contralateral inguinal hernia.The
LAPAROSCOPIC INGUINAL HERNIA
patients were discharged the day after
INVERSION AND LIGATION IN GIRLS
operation.Follow-up with all cases in 7
Hongwei xI, Shanxi Children’s Hospital,
months showed no recurrence and no
Taiyuan, Shanxi, China
incision complication.
Objectives:Transumbilical single-site
CONCLUSION: Transumbilical single-site
laparoscopic inguinal hernia inversion and
laparoscopic inguinal hernia inversion and
ligation is a new approach for girls.We have
ligation is a reliable, safe, and cosmetic
done 13cases in our hospital since May
herniorrhaphy for girls with inguinal hernia.
2013.
P108: TO REMOVE ABDOMINAL
Methods:13 girls with inguinal hernia,
BENIGN TUMOR BY LAPAROSCOPIC
aged from 6 months to 10years old(mean
OPERATION Z haozhu Li, MD, Dapeng
3.92±2.60 years) ,were performed with
Jiang, MD, Shengyang Guan, MD, Mowen
transumbilical single-incision laparoscopy.
Yang, Master, Bo Xu, PhD, Department
Operation steps: Endotracheal of Pediatric Surgery, the 2nd Affiliated
anesthesia was conducted in all cases Hospital of Harbin Medical University
in trendelenburg position. A 5-mm
OBJECTIVES: Common abdominal benign
incision was made on the right side of
mass include: ovarian cysts or teratoma,
the umbilicus and laparoscope (0°or 30°
cyst of mesentery and omentum majus,
Storz Germany)was introduced through
enlarged mesenteric lymph node,
the incision after pneumoperitoneum
adrenal gland neoplasms, retroperitoneal
(pressure 9-12mm Hg) established. A 3mm
lymphangioma. To summarize the
or 5mm incision was made on the left side
advantage, experience, technique of
of the umbilicus for regular needle holder.
laparoscopic operations (LO).
Under the direction of the laparoscope, it
could be checked whether both internal METHODS: We analyzed the clinical
rings have been closed. Then the bottom findings, histologic diagnosis, and surgical
of the hernia sac was twisted and inversed outcomes in children. Before operation
into the peritoneal cavity and hung by the patient who was suspect of abdominal
the suture from the skin projection of mass had been examined by ultrasound,
the internal ring. The final portion of the CT or MRI. We also exam tumor immunity
operation is the ligation and resection of marker and selected the mass wasn’t
the hernia sac.The hernia sac was removed shown malignant for LO. The patients had
from the Trocar on the right side of the been general anaesthesia, and first trocar
umbilicus.The suture was cut off after the was inserted through umbilicus. After
needle penetrated out of the abdominal. found the mass, we select one or three
The pneumoperitoneum and trocar were trocar technique to remove the tumor.
removed. The umbilical incision was
RESULTS: From January 2010 to June 2013,
subcuticularly sutured with 5-0 absorbable
24 cases (10 girls, 14 boys) were treated.
thread and adhered with medical adhesive.
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Age was 3 months to 12 years old. Of them, CASE: The patient was born with
Eight mass were found in ovarian(6 cystic esophageal atresia and distal
tumor , 2 teratoma); Intra-abdominal cystic tracheoesophageal fistula (EA/TEF),
masses were found 3 in greater omentum, cloacal malformation, cross-fused
4 in mesentery, and in retroperitoneum, right renal ectopia, as well as vertebral
2 in cystic duplication of intestine, 2 in anomalies. She underwent thoracoscopic
mega-cyst of hydrocele; Other mass were EA/TEF repair on day of life 1, along with
2 enlarged mesenteric lymph node and a proximal sigmoid colostomy. At 10
1 bilatera adrenal gland neoplasms. All months of age, we addressed the cloacal
patients had been removed tumor or mass malformation by performing a total
by LO and recovery. Operation time was urogenital mobilization in combination
0.5-3h. less blood lost. Follow up for 3-6 with a SIPES-assisted pull-through of the
months, no complications occurred. rectum with anorectoplasty. One of the
challenges of the case was the dissection
CONCLUSIONS: LO for removing abdominal
of the presacral tissue creating sufficient
benign tumor has more advantage,
space for the pull-through without injuring
especially for cystic tumor. Complete
the newly reconstructed vagina (figure A,
excision was possible in almost all cases
below). The rectum was pulled down to the
despite the size, bringing a favorable
anus using a large Foley catheter to gently
outcome.
guide the structures into place (figure
P111: REPAIR OF CLOACAL B), facilitating a coloanal anastomosis
MALFORMATION USING SINGLE- separate from the urogenital incision
INCISION PEDIATRIC ENDOSURGERY AND (figure C).
TOTAL UROGENITAL MOBILIZATION IN A
RESULTS: The patient was discharged
PATIENT WITH VATER SYNDROME A llison
home on postoperative day 3 and started
Sweny, MD, Ariella Friedman, MD, Joseph
a dilation program of the neorectum and
J. Lopez, MD, Matthew E. Bronstein, MD,
vagina 2 weeks later. The colostomy was
Richard N. Schlussel, Oliver J. Muensterer,
taken down at 6 weeks, at which time her
MD, PhD, Divisions of Pediatric Surgery
perineum had healed nicely (Figure D). She
and Pediatric Urology, New York Medical
continued to do well with spontaneous
College, Maria Fareri Children’s Hospital
bowel movements 3-5x a day. At 2
BACKGROUND: Single-incision months follow up, the dilation program
pediatric endosurgery (SIPES) is usually had been weaned to once a week, and the
performed for routine operations such patient had excellent functional as well as
as appendectomy or nephrectomy. The cosmetic results.
approach is less often used for complex
CONCLUSION: Children with complex
procedures requiring interdisciplinary
syndromes including VATER and cloacal
reconstructive surgery. To our knowledge,
malformation can be managed with
a SIPES-assisted cloacal repair has not
advanced minimalinvasive techniques,
been reported previously.
including single-incision endosurgery.
OBJECTIVE: To present the first cloacal When combining SIPES imperforate anus
repair in a patient with VATER syndrome repair with urogenital reconstruction
using a SIPES-assisted pullthrough and in the setting of cloacal malformation,
urogenital mobilization technique. care must be taken not to injure the
neovagina during the presacral dissection
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and the pull-through maneuver. Using to the right 13th rib. The cryptorchidectomy
an interdisciplinary approach, excellent was performed using graspers, a bipolar
outcome can be achieved despite the vessel sealing device and a 300 telescope.
complexity of the malformation.
RESULTS: 22 dogs and 3 cats that had a
SPLC with a SILS port (15), TriPort (8) or
Endocone (2) were included in the study.
Median patient age was 365 days (range,
166-3285 days). Median weight was 18.9kg
(range, 1.3-70kg). Median surgical time was
38 minutes (range, 15-70 minutes). Thirty-
two testicles were removed (12 left, 6 right,
and 7 bilateral). Four patients had one other
abdominal surgical procedure performed
concurrently during the SPLC. No intra-
operative or post-operative complications
were encountered in any of the patients.
P112: SINGLE PORT LAPAROSCOPIC
CRYPTORCHIDECTOMY IN DOGS AND CONCLUSIONS AND CLINICAL RELEVANCE:
CATS: A MULTICENTER ANALYSIS OF 25 SPLC is a safe, feasible procedure that can
CASES (2009-2014) J effrey J Runge, DVM, be performed on a wide range of patient
DACVS, Philipp D Mayhew, BVMS, , DACVS, J. sizes and can be combined concurrently
Brad Case, DVM, MS, DACVS, Ameet Singh, with other elective surgical procedures.
DVM, DACVS, Kelli N Mayhew, VMD, DACVS, This technique provides an efficient, low
William T Culp, VMD, DACVS, University morbidity and potentially less invasive
of Pennsylvania, School of Veterinary alternative to the traditional open and
Medicine, University of California at Davis, multi-port laparoscopic techniques
School of Veterinary Medicine, College of described for the treatment canine and
Veterinary Medicine, University of Florida, feline cryptorchidism.
Gainesville, FL. Ontario Veterinary College,
University of Guelph, Guelph P113: SINGLE-INCISION LAPAROSCOPIC
INGUINAL HERNIOPLASTY IN GIRLS M ario
OBJECTIVE: To describe the operative Mendoza-Sagaon, MD, Flurim Hamitaga,
technique and evaluate the clinical MD, Natalia M Voumard, MD, Ospedale
outcome for dogs and cats that underwent Regionale di Bellinzona e Valli
single port laparoscopic cryptorchidectomy
(SPLC) INTRODUCTION: Several laparoscopic
procedures continue to evolve to
DESIGN: Retrospective case series achieve minimal tissular damage, less
post-operative pain and discomfort,
ANIMALS: 25 client-owned dogs & cats
and better esthetics. Laparoscopic
METHODS: Dogs and cats that underwent inguinal hernioplasty in children is gaining
a SPLC using 3 different commercially popularity, however, controversy still
available single port devices were exist regarding its benefits and the rate
retrospectively identified. A single port of recurrence. In this study we report our
device was placed through a 1.5-3.0 cm technique of single-incision laparoscopic
abdominal incision at either the region of hernioplasty in girls and analyze the
the umbilicus or a 2-3 cm incision caudal results.
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METHODS: The files of all girls operated CONCLUSION: Single-incision laparoscopic
by single-incision laparoscopic inguinal herniotomy in girls is a feasible
hernioplasty in our institution were and safe technique with an excellent
reviewed. Surgical technique: Briefly, post-operative outcome and esthetics.
a vertical transumbilical incision Moreover, it allows to diagnose and to
was performed. An 8 mmHg CO2 treat an asymptomatic contralateral
pneumoperitoneum was achieved using patent processus vaginalis (incidence
a small catheter with a stopcock valve. of 58% in this study) through a small
A 5-mm 30o telescope and 3-mm umbilicalsingle-incision.
instruments were used for the procedure.
P114: SINGLE-PORT LAPAROSCOPIC
The patent processus vaginalis (PPV)
ANORECTAL PULL-THROUGH A lejandra
was grasped and twisted with a 3mm
Parilli, MD, Gregory Contreras, MD, José
Babcock clamp and ligated with a 00-PDS
Gregorio Mejías, MD, Lisbeth Medina, MD,
Endo-loop. Finally the tip of the sac was
Hospital de Clínicas Caracas
cauterized with a monopolar hook.
This is 21 month old male infant, referred
RESULTS: Since 2010, we have operated
from another center, with anorectal
48 PPV in 29 girls, range of age was
malformation and rectourethral fistula,
from 11 months to 12 years (median
carrying two mouths colostomy and
4-5 years). Pre-operatively, 19 patients
10kg weight. At physical examination
presented clinicallyaright inguinal hernia,
intergluteal cleft are evident, had a
8 a left inguinal hernia and in 2 patients
good anal fovea and coccyx is palpable.
was bilateral. Per-operatively, 17 girls
In the distal colostrogram, the distance
with a pre-operative unilateral inguinal
between the rectum and anus is 2,7 cm
hernia, presented a contralateral PPV
approx. Was undergoing to single-port
associated. Duration of surgery was
laparoscopic anorectal pull-through,
initially 40 minutes for a single PPV and
using the Mini Gelpoint to umbilical
after the first 10 cases decreased to 10
level and an accessory port level 3mm
to15 minutes. All patients weretreated in
left upper quadrant. Dissection of the
the out-patient unit. No per-operative
distal part and section of the fistula
complications were recorded. There was
with a white cartridge Echelon 45mm
1 recurrence in the 5th patient operated
and 10mm Hemolock was performed
for an unilateral right inguinal hernia
because this was at the level of the
and 6 months after surgery she was re-
membranous urethra, 5mm trocar was
operated using the same technique with
placed at the level of the fovea anal and
an excellent outcome. In the majority
rectum decreased. The surgery last about
of the cases return to normal physical
3 hours and the patient was discharged
activity was achieved around the 2nd to
on the third hospital day, progressing
4th post-operative day and analgesic
satisfactorily. The single-port laparoscopic
therapy was necessary only in the first two
anorectal pull-through seems to be an
postoperative days. Patients and parents
efficient method that allows adequate
were very satisfied with post-operative
visualization and tissue manipulation in
esthetics. Follow up is from 3 months to
these patients.
3.5 years. To date, all patients are doing
very good and no late recurrences have
been reported.
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P115: SINGLE-PORT ACCESS major complications were encountered in
LAPAROSCOPIC APPENDECTOMY IN the two groups.
PEDIATRIC PATIENTS: A COMPARISON
CONCLUSION: Postoperative outcome of
STUDY WITH CONVENTIONAL
SLA doesn’t seem to be superior to that
LAPAROSCOPIC APPENDECTOMY T ae A.
of CLA in pediatric populations. Safety and
Kim, Jung Rae Cho, Won Me Kang, Soo
feasibility of SLA in pediatric population,
Min Ahn, Pediatric Surgery Clinic, Hallym
however, are comparable with CLA.
University Sacred Heart Hospital, Hallym
University College of Medicine P116: LAPAROSCOPIC AND ROBOTIC-
ASSISTED GASTROESOPHAGEAL
INTRODUCTION: Currently single-port
DISSOCIATION FOR RECURRENT
laparoscopic appendectomy became
GASTROESOPHAGEAL REFLUX DISEASE
popular in adult population. We sought to
Dan Parrish, MD, Shannon F. Rosati, MD,
investigate the essential prerequisites for
Claudio Oiticica, MD, Patricia Lange,
applying single-port access laparoscopic
MD, David Lanning, MD, PhD, Children’s
appendectomy (SLA) to children.
Hospital of Richmond at Virginia
MATERIALS & METHODS: Prospective Commonwealth University Medical Center
non-randomized consecutive data
INTRODUCTION: Laparoscopic Nissen
collection was performed in children
fundoplication has become a very
who had undergone SLA or conventional
important tool for controlling severe
laparoscopic appendectomy (CLA)
gastroesophageal reflux disease (GERD)
from September 2009 to June 2013.
in the pediatric population. However,
Preoperative diagnosis was confirmed
some patients, especially those that are
by ultrasonography for all patients. The
neurologically-impaired, may develop
preoperative patient characteristics
recurrent GERD that is refractory to
and surgical outcomes were compared
continued medical management.
between the groups in terms of age, sex,
BMI, leukocytosis, CRP, operation time, BACKGROUND: This is a 3 year old
hospital stay, frequency of postoperative child with Cornelia de Lange syndrome
intravenous painkiller usage, and and severe developmental delay who
perioperative complications. underwent a laparoscopic Nissen
fundoplication at 1 year of age. After
RESULTS: SLA and CLA were completed in
initially doing well, he began to have
total of 120 patients; 60 patients in both
repeated episodes of aspiration
groups irrespectively. Both group showed
pneumonia and severe reflux symptoms.
no difference of demographics and
While his fundoplication was intact, it had
disease severity. Overall anesthesia time
migrated into his mediastinum.
was longer in SLA (m ± sd, 88.7 ± 21.5 min
vs. 101.4 ± 27.4 min; p = 0.005) compared METHODS: The case began
to CLA, whereas there was no differences laparoscopically with placement of a
in operation time between groups 12-mm trocar in the umbilicus, and
(60.8 ± 22.0 min vs. 68.4 ± 28.3 min; p 8-mm robotic trocars were placed in the
= 0.098). There were no differences in right and left mid-abdomen using his
postoperative hospital stay (3.1 ± 1.4 vs. 2.7 old surgical scars. An additional 8-mm
± 1.4 day; p = 0.114), pain killer usage (2.7 robotic trocar was placed just medial to
± 2.2 vs. 2.4 ± 1.7; p = 0.404) and medical the gastrostomy tube site for the robotic
cost (p > 0.05) between the groups. No camera. Lysis of adhesions and repair
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of the hiatal hernia were performed CONCLUSIONS: For neurologically-
with preservation of the gastrostomy impaired patients with recurrent reflux
tube site, anterior and posterior vagus symptoms following fundoplication,
nerves, as well as a large replaced left especially those that take most of their
hepatic artery. Once the hiatus was feeds via a feeding tube, gastroesophageal
closed, the jejunum was measured dissociation may be a reasonable
about 30-cm distal to the ligament of alternative to performing multiple
Treitz and was brought out through the fundoplications. By utilizing the da
umbilical defect. It was marked in a way Vinci surgical robot with its articulating
to delineate orientation then divided instruments and 3D visualization to
with the Endo-GIA stapler. A side-to- perform the esophagojejunostomy, we
side jejunojejunostomy was created were able to ensure precise placement of
30-cm distal to the tip of the Roux limb sutures while preserving the vagus nerves,
with an Endo-GIA stapler. The bowel avoiding the need for a pyloroplasty,
was then returned to the abdomen with maintaining the replaced hepatic artery, as
the Roux limb passed in a retrocolic well as the gastrostomy site.
position toward the hiatus. The Petersen
P117: ROBOTIC-ASSISTED RESECTION
defect was reapproximated with multiple
OF A LARGE POSTERIOR MEDIASTINAL
interrupted 4-0 polyglactin sutures. An
MASS D an Parrish, MD, Shannon F.
Endo-GIA stapler was fired across the GE
Rosati, MD, Patricia Lange, MD, Claudio
junction just above the fundoplication,
Oiticica, MD, David Lanning, MD, PhD,
again preserving the vagus nerves. At
Children’s Hospital of Richmond at Virginia
this point, the da Vinci robot was docked
Commonwealth University Medical Center
and the esophagojejunostomy was
performed with multiple 4-0 polyglactin INTRODUCTION: Ganglioneuromas are rare,
sutures in a single-layered anastomosis typically benign, tumors that arise from
in an end to side manner after the tissues that have a neural crest cell origin.
esophageal staple line was excised. The They typically occur in patients ranging in age
esophagojejunostomy was confirmed from 10 to 40 years and are classically found
to be airtight via a nasoenteric tube that in the adrenal glands. Ganglioneuromas are
was left in place postoperatively as well frequently asymptomatic and discovered
as a 10-mm Jackson-Pratt drain near this incidentally while another condition is being
anastomosis. investigated.
RESULTS: The patient returned to the BACKGROUND: An 18 year old woman
pediatric intensive care unit and on who was being followed for scoliosis was
postoperative day two, he underwent found to have a large left chest mass on
contrast studies through the gastrostomy a chest x-ray. A chest CT scan revealed a
and nasoenteric tubes, which 10 x 7.5 x 6.5-cm mass in the left upper
demonstrated both anastomoses to chest, consistent with a bronchogenic cyst.
be intact. His tube feeds were gradually She had no reports of fever, shortness
advanced and he was discharged on of breath or chest pain, although she did
postoperative day 6 tolerating gastrostomy endorse frequent feelings of left chest/
feeds at goal. On follow up, his reflux shoulder tightness. In an attempt to
symptoms have resolved and his avoid a large thoracotomy or sternotomy,
respiratory has improved. we proceeded with a robotic-assisted
resection of the large mass.
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METHODS: The patient was laid supine CONCLUSIONS: Robotic-assisted thoracic
with the left chest slightly elevated and surgery provides great 3D visualization
her left arm extended above her head. and articulating instruments that can be
She was intubated with a Carlens tube used to dissect large intrathoracic tumors
for single lung ventilation. With the left and possibly avoid a large thoracotomy or
lung deflated, an 8-mm robotic trocar sternotomy.
was placed in the left midaxillary line, just
P118: ESSENTIAL ELEMENTS IN
below the axilla, and two 8-mm robotic
PLANNING AND IMPLEMENTING A
trocars were placed in left anterior axillary
MULTI-SPECIALTY PEDIATRIC ROBOT
line and left midclavicular line, all in the
ASSISTED SURGERY PROGRAM AT A
left inframammary fold. An additional
LARGE CHILDREN’S HOSPITAL Daniel
5-mm step trocar was placed as an
B. Herz, MD, Karen A. Diefenbach, MD,
assistant port, lower left midchest in the
Jennifer A. Smith, RN, Joeseph D. Tobias,
midaxillary line. Using hook cautery and
MD, Christopher T. McKee, DO, Nationwide
graspers with bipolar cautery, the tumor
Children’s Hospital; Children’s Hospital at
was dissected free from the surrounding
Dartmouth
tissues and the blood vessels cauterized.
The mass seemed to arise from the left PURPOSE: Robotic assisted surgery (RAS)
sympathetic ganglia chain, which had is growing tremendously in pediatric
to be sacrificed for tumor removal. The surgery and urology. Program success,
tumor extended into the apex of the left sustainability, and safety are dependent on
chest and into the lower part of the left infrastructure. Currently there is a paucity
neck just behind the head of the clavicle. of specific information about how to
Once the tumor was dissected free from establish and maintain a safe and efficient
the surrounding structures, an additional multi-specialty pediatric robotic surgery
2 x 2-cm mass was noted between the program. We discuss what we consider
first and second rib and removed. The are key factors for building a safe and
anterior axillary line trocar was removed successful multi-specialty pediatric RAS
and widened to approximately 5 cm to program.
allow specimen removal in an endocatch
bag and a 28-French chest tube was METHODS: In the fall of 2012, the purchase
placed. Final pathology revealed a of a robotic surgical system was approved
ganglioneuroma. by a steering committee consisting of
nursing, surgery, and finance hospital
RESULTS: She was admitted to the step leadership. By December 2012, a robotic
down unit postoperatively with PCA surgery director and nursing coordinator
pain control. She was transitioned to were named, and a dedicated team was
PO pain medicine with a general diet on identified and trained. Where appropriate,
postoperative day one. Her chest tube children considered candidates for
was removed and she was discharged minimally invasive surgery were referred
on postoperative day two. She was seen to a RAS program surgeon. Multi-specialty
in clinic the following month with some proctoring and credentialing guidelines
left arm numbness and slight symptoms were established. All nursing team
of Horner’s syndrome (left eye ptosis members were trained in circulating,
when tired and left eye miosis). Eight scrub, and bedside assistant roles. Specific
months later her Horner’s syndrome had emergency and communication protocols
significantly improved. were established. A multifactorial strategy
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with surgical training and simulation, by premeditated implementation of the
resident/fellow integration, pre-surgery above key essential elements. There is a
case-specific practical training, pre- modest initial cost increase associated with
operative huddles, robot-specific time use of the robot.
out, intra-operative video and time
P119: THE USE OF ROBOTIC SURGERY
stamp recording, post-operative case
IN THORACIC SURGERY: PATIENT
review and mentoring, weekly team
SATISFACTION IN CHILDREN AND ADULT
meetings to discuss quality improvement
POPULATIONS IN A SINGLE INSTITUTION
was employed. A longitudinal robotic
EXPERIENCE S hannon F. Rosati, MD, Dan
database is recorded. Case-by-Case
Parrish, MD, Michael Poppe, BS, Karen
review of reposable and disposable robotic
Brown, BA, Patricia Lange, MD, Claudio
equipment with quarterly cost data is
Oiticica, MD, Anthony Cassano, MD, David
reviewed for comparative effectiveness
Lanning, M., PhD, Children’s Hospital of
to identical open or purely laparoscopic
Richmond at Virginia Commonwealth
procedures.
University Medical Center
RESULTS: From January to December 2013,
BACKGROUND: Many thoracic surgeries are
136 robot assisted laparoscopic surgeries
maximally invasive procedures, requiring
were performed. 135 were technically
thoracotomies or median sternotomies to
successful with 1 open conversion.
remove large thymomas, or mediastinal
Ninety-Two operations were performed
masses. Due to the associated morbidity
by 2 pediatric urologists, and Forty-Two
of these procedures, the use of robotic
by 3 pediatric surgeons. At the outset,
surgery in both the pediatric and adult
one pediatric urologist proctored and
thoracic surgery populations is being
credentialed the 4 other robotic surgeons.
increasingly utilized. Due to the rarity
Surgery types were: Dismembered
of pediatric thoracic tumors, the use of
Pyeloplasty, Ureteroneocystostomy with
robotic thoracic surgery, performed in
and without ureteral tapering, ipsilateral
conjunction with adult thoracic surgeons,
Ureteroureterostomy, Nephrectomy/
allows for additional experience and
Heminephrectomy, Partial Nephrectomy,
collaboration. We review our experience
Continent Urinary Diversion, Bladder
in robotic thoracic surgery, which we have
Neck Reconstruction with and without
performed in both adults and children
Bladder Neck Sling, Gastric Sleeve,
over the past five years, and reviewed the
Cholecystectomy, Nissen Fundoplication,
satisfaction of both the patients and the
and Ileocecectomy/Colectomy. No
parents of children who have undergone
major robot-specific complications
robotic thoracic surgery.
were recorded. Four (3.7%) surgical
complications were managed successfully. METHODS: We conducted a retrospective
Two near miss events identified during the review of our adult and pediatric thoracic
robot-specific time out were recorded. robotic surgery cases over the past
An average increase of 12% in the charges five years. Additionally, we conducted
associated with the use of the robot was telephone interviews with the patients
recorded over a 12 month period. and the parents of the pediatric patients
to ascertain their experience with robotic
CONCLUSION: A multispecialty pediatric
surgery. After obtaining verbal consent
RAS program at large children’s hospital
over the phone, we inquired about their
can be successful, safe, and sustainable
overall satisfaction with robotic surgery,
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their post operative pain, if they were surgeons work together on these cases
satisfied with the cosmetic appearance can increase their robotic experience and
of their scars, and if they would undergo complement both programs.
robotic surgery again.
P120: ROBOTIC-ASSISTED
RESULTS: Forty-two patients have SINGLE-INCISION LAPAROSCOPIC
undergone robotic thoracic surgery, CHOLECYSTECTOMY IN A PEDIATRIC
27 adults and 15 children. Only one of PATIENT; FROM MULTI-PORT TO SINGLE-
these procedures was unsuccessful and PORT WITH INCREASED CONFIDENCE
required an additional operation. None Terrence M. Rager, MD, MS, Victoria K.
of the remaining 41 operations had to be Pepper, MD, Marc P. Michalsky, MD, Karen
converted to open procedures. Twenty- A. Diefenbach, MD, Nationwide Children’s
three patients had thymectomies (8 Hospital, Columbus, Ohio
children, 15 adults), 14 had mediastinal
PURPOSE: Single-port laparoscopic
masses or cysts (4 children, 10 adults),
cholecystectomy has been reported
1 pediatric patient had a left upper
in both the pediatric and adult surgical
lobectomy, 1 pediatric patient had a
populations. However, its widespread
resection of a diaphragm tumor, 1 patient
adoption has been limited in part by
had the insertion of a LV lead, and 1 patient
a steep learning curve due to well-
had a LIMA takedown. 23 patients and
described technical limitations. These
parents could be contacted. All 23 patients
limitations include instrument collision,
stated they were pleased with the cosmetic
poor visualization, a loss of ability to
appearance of their incisions or their
triangulate, and paradoxical instrument
child’s incisions. Also, 22/23 responded
control due to crossing of instruments
that they would undergo robotic surgery
as they traverse the single incision. We
again, or have their child undergo robotic
demonstrate a robotic-assisted single
surgery again. Satisfaction with their
incision laparoscopic cholecystectomy
overall experience or their child’s overall
in a pediatric patient performed in the
experience on a numbered scale from 1-10,
absence of these technical limitations.
with 10 being the most satisfied ranged
The increasing availability of robotic-
from 4-10, with an average of 8.3. Patients
assistance may lead to increased adoption
rated their post operative pain or the post
of robotic-assisted single-incision pediatric
operative pain of their child on a scale from
endosurgery (R-SIPES).
1-10 with 10 being the worst pain ranged
from 0-9, with an average of 6.2. METHODS: A four-port robotic-assisted
laparoscopic (R-L/S) cholecystectomy
CONCLUSIONS: Robotic surgery performed
was performed using two 5mm, one 8
in both adults and children allows for
mm, and one 12 mm ports. An R-SIPES
increased control and mobility when
cholecystectomy was performed using a
performing operations in small, confined
single multi-lumen port placed through
spaces, as is the case for thymectomy
a 2.5 cm umbilical incision. Video of the
and mediastinal mass resection. Patients
intra-abdominal portions of each surgery
appear to be satisfied with their overall
was recorded and are presented for visual
outcomes. Robotic surgery represents an
comparison. The placement and removal
alternative to VATS or open procedures
of the multi-lumen port used in the
in the adult and pediatric populations.
R-SIPES case was also recorded and is
Lastly, having pediatric and adult thoracic
presented.
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RESULTS: Side-by-side comparison RESULTS: 201 children underwent a rigid
demonstrates that both robotic-assisted bronchoscopy for a suspected FBA (133
surgical techniques allow the surgeon to M, 68 F). The mean age was 2.83 years
have nearly equivalent triangulation ability (1-17). 64 patients had a FB in right main
and anatomic visualization. Advances in bronchus, 62 in left main bronchus and
robotic instrumentation and software have 18 in the trachea. Remaining 57 patients
also eliminated the technical limitations with bronchoscopy had no FB. The main
of instrument collision as well as the symptom was cough. The aspirated
paradoxical and counter-intuitive hand- FBs are organic materials (nuts, seeds,
instrument movements that are often other food material) in 123 and inorganic
associated with single incision laparoscopic subjects (jewels, toy parts etc) in 21 cases.
surgery. The main symptoms were cyanosis in
26, stridor in 47, dyspnea in 59, fever
CONCLUSION: Using cholecystectomy,
in 6 and cough in 67 patients. Cyanosis
we demonstrate that the application of
and dyspnea were significantly more
robotic-assistance to SIPES eliminates
in patients with tracheal FBA. Organic
many of the limitations associated with
FBs causes significantly more dyspnea
laparoscopic single incision surgery, which
and cough than the inorganics. The
may result in increased utilization of single
mean age of the patients with organic
incision laparoscopic surgeries in the
FBA is significantly less than those with
future.
inorganic FBA (2.3 vs 6.7). 63 patients with
P121: BRONCHOSCOPIC REMOVAL OF bronchoscopy resided (49 with FBA) in
FOREIGN BODIES: FACTORS AFFECTING urban, 67 in suburban (43 with FBA) and
THE MANAGEMENT B urak Tander, MD, 63 in rural (49 with FBA) areas. Only one
Dilek Demirel, MD, Bahar Önaksoy, MD, patient needed a re-bronchoscopy for
Mithat Gunaydin, MD, Unal Bicakci, MD, Riza failed FB removal (0.4%).
Rizalar, MD, Ender Ariturk, MD, Ferit Bernay,
CONCLUSION: Rigid bronchoscopy is the
MD, Ondokuz Mayis University, Department
method of choice for both diagnosis and
of Pediatric Surgery, Samsun, Turkey
treatment of patients with suspected FBA.
AIM: In children, foreign body aspiration The failure rate of removal is extremely
(FBA) is common. It is not clear yet, which low. The radiologic images are frequently
demographic and clinic factors are more non-informative. Therefore, in case of
prominent in the FBA and indication for doubt, bronchoscopic examination is
bronchoscopy. necessary. Residence of the patients
seems to have no effect on likelihood of
METHODS: In children with FBA; gender, FBA. Younger children are more likely to
age, symptoms, type of residence aspirate organic FBs.
(urban vs rural), localization and type of
foreign body, the radiologic appearance, P122: THORACOSCOPIC ESOPHAGEAL
outcome were evaluated. In all cases, a RESECTION AND ANASTOMOSIS IN AN
rigid bronchoscopy was performed and INFANT WITH CONGENITAL ESOPHAGEAL
all foreign bodies were removed with an STENOSIS Burak Tander, MD, Ogunc
optic or regular bronchoscopic forceps. Apaydin, MD, Ferit Bernay, MD, Ondokuz
Descriptive tests and ANOVA were made to Mayis University, Department of Pediatric
analyze the determining factors on foreign Surgery, Samsun-Turkey
body ingestion.
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AIM: We report a 1 year old infant with children. The safety and effectiveness of
congenital esophageal stenosis treated by thoracoscopic diaphragmatic plication
a thoracoscopic esophageal resection and for diaphragmatic eventration in such
end-to-end anastomosis. patients remain unclear because
of possible concerns about serious
CASE REPORT: One year male infant
complication such as intraoperative
was admitted with emesis and failure
circulatory or respiratory failure and air
to thrive to the Department of
embolism caused by right to left shunt.
Pediatric Gastroenterology. His upper
The aim of the study was to clarify the
gastrointestinal contrast study revealed a
role of thoracoscopic diaphragmatic
2.5 cm stenosis at the distal portion of the
plication for diaphragmatic eventration
esophagus. At thoracoscopy, the stenosis
after surgery for CHD in children.
was identified at the distal part. The
stenotic segment was resected. The two PATIENTS & METHODS: Retrospective
ends of the esophagus was dissected and chart review was conducted in pediatric
freed. An end-to-end anastomosis was patients who underwent thoracoscpic
performed with interrupted sutures by diaphragmatic plication for diaphragmatic
means of intracorporeal suture tying and eventration after surgery for CHD from
extracorporeal knot-pushing techniques. 2008 to 2013 at our department.
No complication was encountered. The
RESULTS: Five patients, 4 boys and 1 girl,
postoperative course was uneventful
were identified during the study period.
and the patient was discharged at 12th
Median age and body weight of the
postoperative day. The patient is doing
patients at thoracoscopic diaphragmatic
well three years after surgery with normal
plication were 7.6 (1.8-17.9) months and
grow up and no swallowing difficulty.
6.6 (3.0-7.1) kg. All patients had left side
CONCLUSION: Thoracoscopic esophageal diaphragmatic eventration. Associated
resection and anastomosis is safe and CHDs are pulmonary artery atresia in
effective in infants with in congenital 3 patient, and truncus arteriosus and
esophageal stenosis. double outlet right ventricle in 1 patient,
respectively. Two patients received
P123: THORACOSCOPIC DIAPHRAGMATIC
previous ipsilateral thoracotomy for
PLICATION FOR DIAPHRAGMATIC
Blalock-Taussig shunt. Three patients
EVENTRATION AFTER SURGERY
had right to left shunt after Glenn
FOR CONGENITAL HEART DISEASE
operation at thoracoscopic diaphragmatic
IN CHILDREN J un Fujishiro, MD, PhD,
plication. Four of 5 patients needed
Tetsuya Ishimaru, MD, PhD, Masahiko
mechanical respiratory supports before
Sugiyama, MD, PhD, Mari Arai, MD,
thoracoscopic diaphragmatic plication.
PhD, Chizue Uotani, MD, PhD, Mariko
Median duration between previous
Yoshida, MD, Kyohei Miyakawa, MD, Tomo
CHD operation and thoracoscopic
Kakihara, MD, Tadashi Iwanaka, MD, PhD,
diaphragmatic plication were 56 (15-169)
Department of Pediatric Surgery, Faculty
days. At thoracoscopic diaphragmatic
of Medicine, The University of Tokyo
plication, 3 of 5 patients attempted
OBJECTIVE: Diaphragmatic eventration one-lung ventilation using bronchial
caused by phrenic nerve palsy is a rare blocker and all received CO2insufflation
but serious complication after surgery (4 mmHg) for ipsilateral lung collapse.
for congenital heart disease (CHD) in Thoracoscopic diaphragmatic plication
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was performed using 3 or 4 ports. P124: THORACOSCOPIC RESECTION OF A
Sufficient operative field was kept by VERY RARE EXTRA-LOBAR PULMONARY
CO2insufflation in all patients regardless SEQUESTRATION IN A 2-YEAR-OLD BOY
of one-lung ventilation, and no patients Kazuto Suda1, Hiroyuki Koga1, Manabu
were converted to open operation. Okawada1, Takashi Doi1, Kenji Suzuki2,
Intraoperative arterial blood pH and Ryohei Kuwatsuru3, Atsushi Arakawa4,
PCO2were 7.29 (7.22-7.39) and 51 (44.5- Atsuyuki Yamataka1, 1Department
67) mmHg. In one patient, dislodgement of Pediatric Surgery,2Department of
of bronchial blocker resulted in severe General Thoracic Surgery,3Department
respiratory and circulatory failure just of Radiology,4Department of Human
before starting the operation. While Pathology of Juntendo University School of
this patient needed intraoperative NO Medicine, Tokyo, Japan
inhalation, the patient also underwent
AIM: We report the thoracoscopic resection
thoracoscopic diaphragmatic plication
of a very rare case of right extra-lobar
after stabilization. Postoperatively, one
pulmonary sequestration.
patient was extubated at the operating
room, 2 were on the day of operation, CASE REPORT: A solid mass was identified
and 2 were on 1 and 2 postoperative days, in the right mediastinum of a male
respectively. One patient experienced fetus at 30 weeks’ gestation on fetal
minor pneumothorax and pleural magnetic resonance imaging (MRI).
effusion, which resolved spontaneously At 2 months old, a right pulmonary
without drainage. Air embolism was not sequestration comprising a hypervascular
observed in any patient. No recurrence racemous angiomatous arterial-venous
of diaphragmatic eventration was malformation (RAVM) with a feeding
experienced in these 5 patients after the artery coming from the thoracic aorta
thoracoscopic plication. was diagnosed on enhanced computed
tomography (CT). The sequestration
CONCLUSIONS: Our results show that
was initially considered to be intra-
thoracoscopic diaphragmatic plication
lobar since it drained into the inferior
is safe and effective procedure for
right basal pulmonary vein rather than
diaphragmatic eventration after surgery
the inferior vena cava or azygos vein as
for CHD in children. Considering the
extra-lobar sequestrations usually do.
serious complication of bronchial
When referred for further management,
blocker dislodgement and the sufficient
he was well and asymptomatic, however,
operative field kept by CO2insufflation
his cardiothoracic ratio (CTR) on chest
without one-lung ventilation, bronchial
radiography was elevated as a result of
blocker is unnecessary for this procedure.
systemic drainage from the RAVM in
With safety and good outcome of
the sequestration overloading the left
the procedure, early thoracoscopic
atrium. Thoracoscopic resection was
diaphragmatic plication is a good option
performed when 2 years old. Briefly,
for pediatric patients with symptomatic
conventional thoracoscopy under general
diaphragmatic eventration after surgery
anesthesia with single lung ventilation
for CHD.
was performed with the patient placed
laterally. The sequestration was
confirmed to be extra-lobar, was located
in the right inferior mediastinum between
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the right diaphragm and the inferior lobe history of vomiting , regurgitation ,
and was found to drain into the inferior dysphagia , and weight loss . Studies
right basal pulmonary vein, as shown on included , esophagoscopy, barium
preoperative CT. The sequestration was esophagogram, contrast tomography
retracted gently posteriorly and elevated with subclavian reconstruction . An
with endoscopic peanut swabs without Aberrant retroesophageal subclavian
the use of endoscopic Kelly retractors as artery was diagnosed. Patient was taken to
they may potentially cause injury to the thoracoscopic ligation of the artery without
lung parenchyma and cause hemorrhage, complications. After the procedure, the
which would be impossible to control. The patient was completely relieved from
feeding artery from the thoracic aorta symptoms , tolerated oral alimentation
and the drainage vein were very close without obstructive symptoms , and right
but with great caution, were successfully arm perfussion was preserved.
separated, hemo-clipped and divided.
Surgical management of ARSA includes
The sequestration was extracted through
ligation of the artery with or without
one of the trocar sites. No chest tube
reimplantation through thoracotomy or
was inserted. Postoperatively, CTR
sternotomy. Thoracoscopic ligation of the
improved from a preoperative 53% to
ARSA can show similar results compared
47%. Histopathology showed that the
with the open approach.
sequestration comprised increased
abnormal thick and thin walled arteries P126: THORACOSCOPIC RESECTION OF
and veins. A DISTAL OESOPHAGEAL DUPLICATION
CYST IN A 10-MONTH-OLD INFANT Leel
CONCLUSION: This is the first report
Nellihela, Mr., M. Agrawal, Ms., D. Drake,
of an extra-lobar sequestration with
Mr., N. Bouhadiba, Mr., Evelina London
hypervascularity due to an increase of
Children’s Hospital, Guy’s and St Thomas’
abnormal vessels being excised safely
NHS Foundation Trust, UK
using thoracoscopy. Postoperative
recovery was uneventful and cardiac load AIM: Literature related to thoracoscopic
was decreased. excision of oesophageal duplication
cyst (ODC) are rare and so far not being
P125: THORACOSCOPIC MANAGEMENT
reported in the UK. We are reporting the
OF ABERRANT RIGHT SUBCLAVIAN
successful a full thoracoscopic resection
ARTERY: CASE REPORT I. Molina, MD, F.
ODC in a ten month old infant.
Fierro, MD, S. Castañeda, MD, P. Jaimes,
MD, Universidad Naccional de Colombia, METHOD: A baby boy weighing 2.8Kg
Fundación Hospital de la Misericoridia was born at 38 week gestation. Prenatal
ultrasonography had shown an intra-
Aberrant retroesophageal subclavian
thoracic cystic lesion. The ultrasonography
artery (ARSA) is a type of vascular ring that
on day 2 of life suggest a possible
rarely produces symptoms , the majority
bronchogenicor duplication cyst.
of cases reported in the literature present
Upper GI contrast at 3 month of age
with dysphagia and vomiting due to
showed an extrinsic indentation of the
esophagic compression. Other symptoms
distal oesophagus by the cyst but no
may include apnea, cyanosis, and syncope .
communication with the oesophageal
We present the case of an 8-year-old lumen. MRI scan at the age of 6 month
girl that presented with a 2 month confirm anODC.
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At 10 month, under general anaesthesia We would like to introduce our first
thoracoscopy was performed with experience of pectus excavatum
5mm three-port system. A camera was treatment applying minimal invasive Nuss
inserted via a 5-mm trocar at the sixth procedure.
intercostal space, between mid-axillary
Patients with pectum excavatum that
to posterior axillary line. The other two
underwent thoracoscope-assisted Nuss
5-mm trocars were positioned at the fifth
procedures in our department from
and seventh intercostal spaces, in the
January 2013 were analyzed retrospectively.
mid axillary line. Cystic mass was found
Surgical technique, operation duration and
at the distal oesophagus to right side of
blood loss were analyzed. Postoperative
the oesophagus. Complete resection of
complication, hospital stay length and
the cyst was carried out without damaging
recovery were evaluated.
the oesophagus using hook and scissors.
The vagus nerve were clearly identified There were 32 cases, 17 boys and 15 girls,
and preserved, the cyst was excised from 4 to 16 years old. With the guidance
completely and intact, muscular defect of thoracoscope, all procedures were
was closed with 4 0 vicryl continuous completed smoothly without occurrence
stich. Cystic fluid was aspirated to allow of pericardium, heart, great vessels or
retrieval. 10Fr chest drain inserted and lung injury. All patients were kept stable
connected to an underwater seal. vital sings during operation. The operative
times ranged from 45 to 75 minutes and 5
RESULTS: The patient was discharged
ml to 15 ml blood loss were recorder. The
on the third postoperative day without
postoperative pain was most severe on the
complications. The pathology confirmed
first postoperative day and alleviated as
the diagnosis of foregut duplication cyst
the time passed. On the third postoperative
with no evidence of neoplasia. The video
day, the pain alleviated significantly. No
film is presented.
postoperative pneumonia, pleural effusion
CONCLUSION: We recommend or other complication occurred. Patients
thoracoscopic approach to resect ODC. It discharged from hospital 4 to 6 days after
provides a good access, better visualisation operation. All patients did well in the short
of the cyst by magnification. Patient have term follow-up with obvious improvement
a shorter hospital with good cosmetic in chest shape.
outcome.
CONCLUSIONS: Thoracoscopy-assisted
P128: FIRST EXPERIENCE WITH Nuss operation has many advantages
MINIMALLY INVASIVE NUSS REPAIR including small and masked incision, short
OF PECTUM EXCAVATUM IN CHILDREN operative time, minimal blood loss, fast
Damir Jenalayev, Bulat Nagimanov, Agabek recovery, less trauma, and satisfactory
Chikinayev, Vladislav Orlovsky, National outcomes of repair. Nuss is a safe and
Research Center for Mother and Child reliable technique for repair of pectus
Health excavatum.
Pectus excavatum - is the most common
defect in development of the chest and
is more than 90% of all deformities of the
chest.
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P129: THORACOSCOPIC CHEST WALL MASS CONCLUSION: Minimally invasive resection
EXCISION IN A FORMER PREMATURE of a benign chest wall mass is a safe
INFANT J effrey Zitsman, MD, Jeffrey technique that allows limited rib resection
Gander, MD, Julie Monteagudo, MD, Steven to minimize chest wall instability and may
Rothenberg, MD, Morgan Stanley Children’s reduce risk for respiratory compromise and
Hospital of New York Presbyterian, spinal deformity post-op.
Columbia University Medical Center, New
P130: THORACOSCOPIC
York, NY, USA; Rocky Mountain Hospital for
SEGMENTECTOMY OF INTRALOBAR
Children at Presbyterian/St. Luke’s Medical
SEQUESTRATIONS THROUGH DYE
Center, Denver, CO, USA
DELIMITATION X . Tarrado, MD, L. Saura,
INTRODUCTION: Mesenchymal hamartoma MD, Bejarano M., MD, J.M. Ribó MD, M.
(MH) of the chest wall in the newborn is a Castañón MD, Hospital Sant Joan de Déu.
rare tumor of infancy notable for distinct Universitat de Barcelona. Barcelona
radiographic findings. MH is usually benign
PURPOSE: The surgical resection of
but may cause respiratory compromise due
congenital lung lesions has evolved with
to extension into the pleural cavity. Surgical
the minimal invasive and the parenchyma-
excision is standard therapy for MH.
preserving techniques. Although these
METHODS: On routine ultrasound a child in lesions are usually small and its limits can
utero was noted to have a left intrathoracic be suspected by direct vision or palpation,
mass. MRI suggested mass was arising there is not a clear anatomic landmark
from rib tissue. The child was delivered to resect them. We present a new
at 27 weeks gestation after her mother technique that helps to define the limits
suffered premature rupture of membranes. of intralobar sequestrations (ILS) leading
CPAP was administered for mild respiratory to a safe and anatomic segmentectomy
distress. CXR confirmed the mass, arising thoracoscopically.
from the left 6th rib posteriorly. Surgery
PATIENTS & METHODS: We have
was deferred to allow the baby to grow. A
retrospectively reviewed this
thoracoscopic approach was planned.
segmentectomy technique on four cases
PROCEDURE: At age 4 months the patient (two boys and two girls) the last two
underwent thoracoscopic resection of the years. Three cases had a mean age of 10
left posterior chest wall mass. 3 ports were months and the last one was 15 years-
used (4mm x 2, 5mm x 1). Frozen section old. Preoperative diagnosis were ILS in
biopsy confirmed the diagnosis. The mass three and an hybrid lesion in one. After
was resected with a limited section of rib. dissecting the aberrant arterial vessel, a
The mass was morcellated from within a dye was injected through it to stain the
10mm retrieval bag and removed. The free sequestration. Then it was marked with
rib laterally was fixed to the chest wall. A monopolar cautery and resected with an
12Fr chest tube was left in the pleural space. endostapler.
RESULTS: All gross hamartoma was RESULTS: In three cases we obtained
resected, along with a limited segment of a good delimitation of the ILS so the
rib. The hospital course was uneventful procedure was carried out as described.
and the patient was discharged to home In one case the artery was so thin that we
on POD #4. She developed RSV 3 weeks could not inject through it properly. All
post-op and was hospitalized for 48hrs but cases were completed throracoscopically,
is well 3 months post op. with a mean operative time of 120’. Mean
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thoracic drainage time was 2,5 days starting the conservative treatment using
and mean discharge day was the 3rd the vacuum bell. The device was used for
POD. There where no intraoperative or 30 minutes twice a day.
postoperative complications and with
RESULTS: 6 patients were included. The
a mean follow-up time of 16 months
3D-phtography enabled an objective
they are all asympthomatic and control
assessment of the elevation of the
CT scans 1 year postoperatively show no
sternum, which was improved in the
residual disease.
median up to 16,8 mm.
CONCLUSIONS: In our experience dyeing
CONCLUSION: 3D photography represents
of ILS is a safe and effective technique
a valuable alternative to thoracal CT-scan
to define the limits of intralobar
to assess the degree of PE. It is a radiation-
sequestrations leading to a anatomic
free, reliable and a high qualitative tool to
resection thoracoscopically.
track the clinical course of the conservative
P131: THE VACUUM BELL FOR treatment of PE by the vacuum bell.
CONSERVATIVE TREATMENT OF PECTUS
P132: MANAGEMENT OF PEDIATRIC
EXCAVATUM: ASSESSMENT OF ITS
PRIMARY SPONTANEOUS
EFFICACY BY THREE-DIMENSIONAL
PNEUMOTHORAX IN A TERTIARY
PHOTOGRAPHY Sergio B. Sesia, MD,
CENTER J osé Branco-Salvador, Ruben
Matthias Kreutz, MD, Frank-Martin
Lamas-Pinheiro, MD, Catarina Ferraz,
Haecker, MD, University Children’s Hospital
MD, Luisa G Vaz, MD, Inês Azevedo MD,
of Basel, Department of Paediatric Surgery,
PhD, Tiago Henriques-Coelho MD, PhD,
Basel, Switzerland; University of Basel,
Pediatric Surgery Department & Pediatric
Department of Craniomaxillofacial Surgery,
Department, Faculty of Medicine, Hospital
Basel, Switzerland
de São João, Porto, Portugal
BACKGROUND: The conservative
INTRODUCTION: Treatment of Pediatric
treatment of pectus excavatum (PE)
Primary Spontaneous Pneumothorax (PSP)
using the vacuum bell represents a
can be achieved conservatively, through
valid alternative to surgical minimally
oxygen therapy, chest tube drainage or
invasive repair (MIRPE) technique by
thoracocentesis, or surgically, by using
Nuss for selected patients. The objective
video-assisted thoracic surgery (VATS).
assessment of its efficacy (elevation of the
The best therapeutic algorithm for PSP
sternum) is still a challenge. Until today,
continues to be sought, as well as the role
accurate measurement of the degree of PE
of thoracic Computed Tomography (CT)
is only ensured by a computer tomography
in its management. The aim of this study
of the chest. This study was performed
was to review the approach to pediatric
to evaluate the reliability and quality of
patients with PSP in a tertiary center.
the three-dimensional (3D) photography
to assess the improvement of the funnel MATERIAL & METHODS: Observational
chest under the vacuum bell therapy. Study, with retrospective analysis of 25
pediatric patients with a diagnosis of PSP,
PATIENTS & METHODS: After institutional
admitted in the first episode and treated in
review board approval and written
a third level care Hospital, between January
consent, the chest of six children with
1st 2006 and December 31st 2012. Data
pectus excavatum was analysed by 3D
was obtained from clinical processes of
photography before and 6 month after
the selected patients and were analyzed
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by demographic, diagnosis, treatment and were carried out before surgery, and then
follow-up perspective. followed with thoracoscopic resection
of esophageal stricture, esophageal
RESULTS: PSP occurred mainly in the
anastomosis without conversion to
male gender at the left hemithorax.
laparotomy .
Initial episodes were treated with
oxygenotherapy alone (n=8), chest tube RESULTS: All 8 patients performed
drainage (n=12) and VATS (n=5). Chest typical symptoms with repeated sickness
drainage had a failure rate of 25% in the without gastric juice and bile, especially
first episode and 100% in the recurrence with complementary feeding. Patients
group. The method that presented higher began to appear typical clinical symptoms
therapeutic success was VATS (100%). on average 6 months after birth and
Patients with blebs in CT were those that generally affect healthy development.
significantly recurred more frequently. With Barium meal examination, 3 among 8
Apical resection with mechanical patients showed a typical “pendulum sign
pleurodesis was the preferred surgical “ performance, 2 showed thin line change
technique. between the esophagus and cardia , and
others suspected achalasia 3 cases were
CONCLUSION: The best treatment for first
performed esophagoscopic examinations
PSP in pediatric patients seems to be non-
in surgerys, all showed a sudden expansion
surgical, namely thoracocenthesis or chest
of esophageal stenosis and without passing
drainage. VAST is the best option for the
the stenosis segment. Patients take the
recurrent episodes. The role of CT in the
left side of the prone position during the
management of these patients appears
operations, a rigid and inflexible mass
to be crucial in identifying patients with
in the narrow section were detected on
blebs. The using of VATS in asymptomatic
the esophageal wall, which located lower
patients with blebs in CT is still a matter of
esophagus away from the cardia about2.0
debate.
~ 4.0cm. The narrow section is about 0.5
P133: THORACOSCOPIC ESOPHAGECTOMY ~ 1.0cm in length, and about 0.2 ~ 0.4cm
FOR CHILDREN`S CONGENITAL in diameter. Diameter of the esophagus
TRACHEOBRONCHIAL CARTILAGE near terminal expansion is about 2.0 ~
REMNANTS OF ESOPHAGUS Shuli Liu, 3.0cm, distal esophageal diameter is 1.0
KaoPing Guan, Long Li, Capital Institute of ~ 1.2cm. We resected stenosis segment,
Pediatrics, interrupted full-thickness esophageal
anastomosis with 5-0 PDS and reserve an
OBJECTIVE: To investigate the clinical indwelling gastric tube 10. Among them, 4
manifestation, diagnostic characteristics patients appeared dysphagia after 1 month
and to evaluate the thoracoscopic surgery, esophageal graphy showed the
esophagectomy for congenital lower esophageal stricture, and symptoms
tracheobronchial cartilage remnants of were mitigated after esophageal balloon
esophagus . dilatation.
METHODS: A retrospective study of 8 cases CONCLUSIONS: Vomiting history while
between 1.1 to 4 years old with congenital complementary feeding and pendulum
tracheobronchial cartilage remnants symptoms and thread-like changes
of esophagus were collected in our between the esophagus and cardia by
department since Mar, 2008 to september, barium meal examination could be
2013. Preoperative imaging or endoscopy
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regarded as preoperative diagnosis of upper lobe, the middle lobe as well as
congenital tracheobronchial cartilage segments S7 and S10 in the lower lobewere
remnants of esophagus. Esophagoscopic free of disease.
examination would help the diagnosis.
The child was operated at the age of
Surgery is the only reliable way for
4 months, with a weight of 5.3 kg. A
treatment, and the patient nutrition
thoracoscopy, under lung exclusion and
condition should be adjusted before
CO2 pneumothorax, was performed
surgery. Thoracoscopic resection of
with a 5mm telescope and three 5 mm
esophageal stricture could get a clear
instruments ports. The greater fissure
surgical field, less bleeding, light chest
was incomplete and the malformation
wall injury, little effect on the lungs and
clearly seen bridging S6 and S3, whose
reducing the chance of postoperative
segmental artery arouse from A6. Using
pneumonia. The children would got a
the 3D reconstruction as a map, the various
quickly recovery after the thoracoscopic
segmental arteries and corresponding
surgery for less trauma in both
bronchi were dissected and divided
consciousness and chest.
respectively with a tissue sealing device
P134: 3D RECONSTRUCTION and clips, thus allowing the resection of
AIDED THORACOSCOPIC S3 from the upper lobe, S6,8and 9 from
MULTISEGMENTECTOMY AS A LUNG- the lower, using the tissue sealing device
SPARING PROCEDURE IN A CASE OF to divide the parenchyma. S3, S6 and the
MULTILOBAR PULMONARY CCAM Paul basal segments were divided individually to
Philippe, MD, Cindy Gomes Ferreira, facilitate exposure of the next segments,
MD, Luc Soler, PhD, Miriam Raffel, MD, and extracted at the end of the procedure
Jerry Kieffer, MD, Brigitte Crochet, MD, through an enlarged port-site. A good
Clinique Pédiatrique, Centre Hospitalier reexpansion of the remaining segments S1,
de Luxembourg, Luxembourg and IHU, 2 and 7 and middle lobe was documented,
IRCAD,Strasbourg,France S10 (postero-lateral segment) being non
functional. This extensive procedure lasted
Congenital Pulmonary Malformations are
5 hours. Blood loss was moderate during
the most common reason for pulmonary
the dissection, and the child received a
resection in children. If most of them have
10cc/kg transfusion. The post-operative
been treated by lobectomies, there is a
course was uneventful, with no air leak
trend toward limited resections such as
allowing for chest tube could removal
anatomical segmentectomies. We present
on POD 2and the child discharged on
a case of antenatally diagnosed cystic
POD 4. She has been asymptomatic
adenomatoid malformation involving both
since. A CTScan at 6 month confirms
the upper and lower lobes of the right
the completeness of the resection and
lung, for which a bilobectomy would have
the viability of the preserved segments.
sacrificed a huge amount of normal lung
Pathology confirmed a Stocker type 1
tissue, thus enforcing the indication of a
CCAM.
multisegmentectomy. In order to asses the
anatomy of the malformation and define 3D rendering provideda clear anatomical
the various segments involved, a three delineation of the anomaly and the
dimensional reconstruction using a specific lung segments, allowing the planning
software was used. The reconstruction of a lung-sparing procedure. Multiple
showed that segments S1 and S2 in the segmentectomies arepossible with
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meticulous thoracoscopic dissection of of sweeping the lung free from the chest
the hilar elements. The delineation of wall in empyema.
the anomaly was not easy to identify
CONCLUSION: attention to how best to
macroscopically, and the knowledge of the
modify the type of ventilation, selection
3 dimensional expected limits proved very
of the best location for the working ports,
important to ensure complete resection
and decompression of hyperinflated lung
as well as maximum lung preservation.
lesions, facilitates the ease and safety
Progresses in our ability to finely dissect
of thoracoscopic surgery in infants and
the anatomy minimally invasively and
children
improved imaging might improve our
ability to preserve functional lung tissue P137: ENDOSCOPIC DIAPHRAGMATIC
while assuring the completeness of the HERNIA REPAIR BY USING MESH FIXED
resection. WITH TITANIUM SPIRAL TACKS G ulnur
Gollu, MD,Gonul Kucuk, MD, Meltem
P136: ROOM TO MOVE: HOW TO CREATE
Bingol-Kologlu, Prof, Aydin Yagmurlu, Prof,
ADEQUATE WORKING SPACE IN
Huseyin Dindar, Prof, Ankara University
THORACOSCOPIC SURGERY FOR LUNG
School of Medicine Department of
RESECTION AND EMPYEMA Spencer
Pediatric Surgery
W. Beasley, MD, Mark D. Stringer, MD,
Nadeem Haider, MD, Kiki Maoate, MD, Primary closure is not always possible
Department of Paediatric Surgery, in thoracoscopic or laparoscopic
Christchurch Hospital, and University of diaphragmatic hernia repair. It is difficult
Otago to use sutures in approximating the mesh
especially near chest wall – rib / sternum.
INTRODUCTION: One of the limitations of
thoracoscopy in small children requiring The aim is to present three cases of
lung resection or debridement of Bochdalek and one case of Morgagni
empyema is the surgical exposure and the hernia whose defects were large and not
working space that can be achieved. suitable for primary closure. Dura mesh
was used in all of the three patients.
METHODOLOGY: A review, including video
Diaphragmatic rims were approximated
analysis, of 113 thoracoscopic procedures
to mesh by using extracorporeal sutures.
(including 37 for empyema) in children
Since the diaphragmatic rims were too
aged 2 months to 17 years, to evaluate
narrow at sternum and anterior chest wall,
the potential advantages and limitations
titanium spiral tacks were used to stabilize
of various techniques to improve the
mesh. There wasn’t any complication
exposure and operative working space.
during the operations however one of
RESULTS: Measures that can improve the children died because of pulmonary
vision and enhance the working space hypertension. Remaining patients
include: selective bronchial intubation, the recovered well and are doing well in two-
use of bronchial blockers, determination year follow-up.
of the best location for working ports
Titanium spiral tacks which are more
to facilitate exposure and optimize
routinely used in adults in incisional and
ergonomics, adjustment of insufflation
inguinal hernia repairs can also be used in
pressure, “popping” major cysts in CCAMs
Pediatric Surgery by confirming with larger
and deflating CLEs, selective use of an
further reports.
additional working port, and the technique
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P138: THORACOSCOPIC REPAIR OF operating time, simplicity and feasibility.
DIAPHRAGMATIC HERNIA IN NEONATES It may be preferable to intracorporeal
AND CHILDREN: A NEW SIMPLIFIED suturing and knot tying for the repair of
TECHNIQUE WITH SYRINGE NEEDLE B ing the posterolateral defects and worth
Li, Bing W. Chen, Qing S. Wang, Huai’an introduced.
Women and Children’s Hospital, Jiangsu,
P139: EARLY EXPERIENCE WITH
223002, P. R. China
PEDIATRIC THORACOSCOPIC LOBECTOMY
PURPOSE: New techniques with minor / SEGMENTECTOMY IN ISRAEL D ragan
modifications are evolving every day. The Kravarusic, MD, Steven Rothenberg, MD,
objective of this study was to describe and Enrique Freud, MD, Schneider Children’s
assess our initial experience by using a new Medical Center of Israel , Tel Aviv, Israel
simplified technique with syringe needle
OBJECTIVE: In our community
in thoracoscopic repair of diaphragmatic
for symptomatic congenital lung
hernia in neonates and children.
malformations open surgery is a common
METHODS: A retrospective review of a new practice. For asymptomatic cystic
simplified technique with syringe needle adenomatoid malformations / pulmonary
in thoracoscopic repair of diaphragmatic sequestrations , discovered on routine
hernia in 6 cases from March 2013 to pre / postnatal imaging, management is
December 2013 was performed. The three controversial. This report evaluates the
neonates that underwent thoracoscopic safety and efficacy of thoracoscopic lung
repair were physiologically stable with resections in pediatric patients.
minimal to moderate ventilatory support.
METHODS: During the 2013, eleven
In the procedure of elective thoracoscopic patients underwent thoracoscopic
repair, a syringe needle with nonabsorbable lobectomy / segmentectomy. Patients
2-0 sutures was used to insert between ages ranged from 8 months to 7 years.
the edges of the posterolateral defects. Preoperative diagnosis included congenital
The technique will be described in detail. cystic adenomatoid malformation (n
= 4) , pulmonary sequestration (n = 5),
RESULTS: A total of 6 neonates and
bronchogenic cyst (n = 1) and complex
children with CDH were repaired
bronchiectasis (n = 1). Four patients were
successfully using this new technique.
symptomatic with previous lung infections
There were 4 males and 2 females with a
and seven others were asymptomatic.
mean age of 4.94 months (range, 2 days–17
Single lung ventilation was desired but not
months). All the cases were left-sided. The
accomplished in 3 patients. Three ports 3–5
mean operative time was 85 min (range,
mm were used with controlled pressure
65–125 min) for each CDH repair. No cases
pneumothorax. A ligasure sealing device
required closure with a synthetic patch and
was the mode for tissue dissection / vessel
conversion to open surgery, blood loss was
ligation and bronchi were closed either by
minimal. The 6 cases were followed up for
stapling device or by interrupted sutures.
2–11 months (mean, 6.2 months), with no
deaths, and no single case of recurrence. RESULTS: All the procedures were
completed thoracoscopically. Operating
CONCLUSION: The new technique with
times ranged from 70 to 200 min
syringe needle had all the advantages
(remarkable longer in patients with
of thoracoscopy in children combined
previous infections ). We performed
with the advantages of reduced
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seven lobectomies and four segmental site intracorporeal purse string suture
lung resections. We had no intraoperative using a needle-holder (IP group), and 100
complications, chest tubes were left for patients by single-port extracorporeal
one day in all but two cases of extralobar knotting using an epidural needle with
sequestration. Hospital stay ranged from preperitoneal hydrodissection (EK group).
1 to 3 days and only one patient required Technical difficulties, operation time,
ICU admission post operatively. intra- and postoperative complications,
and recurrence rate were studied.
CONCLUSIONS: Supervised mentorship in
thoracoscopic approached surgeries for RESULTS: All patients could be completed
congenital lung malformations changed successfully without any serious
our paradgm of practice. Thoracoscopic complications. The operation time was
lobectomy / segmentectomy in selected significantly longer in the IP group than
patients is feasible and safe technique. in the EK group (unilateral: 23.7 vs. 15.4
There is a clear difference in dissection minutes; bilateral: 38.1 vs. 21.2 min; P<0.01).
complexity in patients with previous There were two recurrences (2.63%) in the
infectious complications. Decreased IP group while none in the EK group. The
postoperative pain, shorter hospital stay postoperative pain, functional recovery,
and better cosmetic results are definite hospital stay and satisfaction were similar.
advantages. There was no obvious scaring visible in any
patients after treatment.
P141: SINGLE-SITE INTRACORPOREAL
PURSE-SUTURING VERSUS SINGLE- CONCLUSIONS: Both IP and EK are safe
PORT EXTRACORPOREAL KNOTTING and feasible LESS. Accompanied by the
LAPAROSCOPIC HERNIORRHAPHY: A method of preperitoneal hydrodissection,
COMPARATIVE EVALUATION S uolin Li, single-port laparoscopic EK herniorrhaphy
MD, Lin Liu, MD, Meng Li, MD, The Second would be superior to single-site IP repair
Hospital of Hebei Medical University, with regard to prevention of recurrence.
Shijiazhuang, China It is easy to perfect and to perform and
therefore is a worthy choice for PIH.
BACKGROUND: Laparo-endoscopic
single-site or single-port surgery (LESS) P142: INTRODUCING NEW
is a rapidly evolving field, which offers LAPAROSCOPIC TECHNIQUES - THE
cosmetic advantage over standard FIRST TWENTY CASES MATTER C hristian
multiple-access laparoscopic surgery. The Lorenz, Prof., Dr., Carsten Driller, Dr.,
objective of this study was to compare Department of Pediatric Surgery and
the surgical and functional outcomes Urology, Klinikum Bremen-Mitte, Bremen
of single-site (transumbilical two-port)
BACKGROUND AND OBJECTIVES:
intracorporeal purse-suturing (IP) and
Minimally invasive laparoscopic techniques
single-port extracorporeal knotting (EK)
(MILT) replace well established open
for pediatric inguinal hernia (PIH) repair.
procedures. Practical aspects of this
METHODS: Between May 2008 and trend are best resembled by the learning
December 2011, the medical records of curve, a term undergoing a change of
176 children undergoing laparoscopic meaning - away from sole feasibility of a
inguinal herniorrhaphy by a single pediatric procedure to the point, that a major team
surgeon were retrospectively reviewed. Of of surgeons will be enabled to practice
them, 76 patients were treated by single- MILT comparably.
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PATIENTS & METHODS: We retrospectively procedure the most challenging one to
compared three groups (G) of patients in teach since it needs skilled and cautious
whom the first 20 MILT were performed preparation in a short operative time
for inguinal hernia in girls (G1/2006-2007: frame.
herniorrhaphy), dysplastic upper pole and
CONCLUSIONS: Introducing MILT for
megaureter in duplex kidneys (G2/2008-
standard pediatric surgical conditions
2013: heminephroureterectomy),
needs a limited group of skilled surgeons
and pyloric stenosis (G3/2012-2013:
and close follow-up at least for the
pyloromyotomy). The various operations
first 20 cases. On the basis of these
were performed by just 3 experienced
data performing the procedure may be
pediatric surgeons. We questioned if basic
spread among either skilled specialists or
surgical parameters, complications, and
doctors in advanced training. Again, close
outcome in short term are in such a way
supervision is needed to keep or improve
consistent, that a wider circle of surgeons
the results of the first series.
may get involved in processing these
operations under close supervision. P143: THE LIMITS OF LAPAROSCOPY:
INFLAMMATORY MYOFIBROBLASTIC
RESULTS: G1: mean age at surgery 43
TUMOR OF THE SMALL BOWEL
months (range 5-79), mean operation time
MESENTERY MASQUERADING AS
33 minutes (range 15-65, bilaterally in 3
PERFORATED APPENDICITIS C hristopher
patients), postoperative stay in hospital
D. Hughes, MD, MPH, Ioanna Mazotas, MD,
6-24 hours, observations/complications:
Anthony Tsai, MD, Abby Theriaque, APRN,
3/3 events. G2: 5/15 patients (boys/girls),
Richard G. Weiss, MD, Department of
mean age at surgery 33 months (9-216),
Surgery, University of Connecticut School
mean operation time 144 minutes (80-240,
of Medicine; Department of Surgery,
bilaterally in one), mean postoperative stay
Connecticut Children’s Medical Center
in hospital 4,6 days (3-7), observations/
complications: 7/0. G3: 17/3 (boys/girls), INTRODUCTION: Inflammatory
mean age at surgery 5,6 months (range pseudotumor, or inflammatory
3-9), mean postoperative stay in hospital myofibroblastic tumor (IMT), is a rare lesion
3,8 days (2-8), observations/complications: among pediatric patients. It is a unique
1/2. pathologic entity that is histologically
benign, but it can behave like a malignant
Operative time in all groups converges
tumor, with local invasion and even
to that in open surgery (G1/G3) or
metastasis. Symptoms vary depending
values reported in recent literature
on the tumor’s location, and diagnosis
(G2), Events (6/7/3 – 30/35/15%) and
can often prove challenging. Traditional
true complications among them (3/0/3
laparoscopic approaches may prove
-17,6/0/10%) occurred in the first 3
to be inadequate for effective surgical
quarters of these periods with an overall
treatment.
rate of 10% (6/60). Some of them could be
solved easily by changing suture material METHOD(S): We present a unique case
to prevent recurrent hernia(G1) or by study of a three-year-old girl who
administering antibiotics postoperatively presented with abdominal pain and
in light of the risk of fever (G2). Awareness symptoms consistent with perforated
of the risk of mucosal perforation or appendicitis.
incomplete myotomy in G3 makes this
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RESULTS: The patient was brought to ventilation support with BPAP (Bilevel
the operating room for a laparoscopic Positive Airway Pressure) during early
appendectomy. Upon inspection with the postoperative period.
operating laparoscope, we discovered
Eight years- old male patient with
hemoperitoneum and a necrotic segment
cerebral palsy and oxygen dependency
of small intestine that suggested a more
was admitted for frequent lower
complex pathology (Figure 1). We then
respiratory tract infections and severe
converted to laparotomy where we
growth deficiency (<3% percentile) Upper
discovered a large, dense mass at the
gastrointestinal tract fluoroscopy and 24
base the patient’s small bowel mesentery
hours pH monitorization had revealed
that had separated from the edge of the
gastroesophageal reflux. Laparoscopic
bowel wall resulting in a necrotic segment
Nissen Fundoplication and feeding
of proximal jejeunum (Figure 2). After
gastrostomy was decided and performed
resection, the patient was reanastomosed,
without complications. The patient
and she subsequently recovered following
required non invasive mask ventilation-
an uneventful postoperative hospital
BPAP during early postoperative period
course. Pathology revealed the lesion to be
because respiration problems. Enteral
an inflammatory pseudotumor (Figure 3).
feedings were started from gastrostomy
CONCLUSION(S): The diagnosis of IMT tube on postoperative day 3. Gastrostomy
can be challenging secondary to its site cellulitis and subcutaneous
rarity and its variable presentation. Our crepitations of the abdominal wall
report of an IMT presenting as perforated became evident on postoperative day
appendicitis is unique in the small body of 6. X-Ray imaging of abdomen revealed
literature on these tumors. Laparoscopy disseminated subcutaneous emphysema,
was helpful in the diagnostic process as dilated stomach and the spread of the
well as determining where to place the opaque given from gastrostomy tube to
laparotomy incision. Knowing when to the abdominal wall. Laparotomy was done
change course during an operation remains and a leak between the stomach and
critical. abdominal wall was found. Gastrostomy
site of the stomach was enlarged.
P144: EARLY DISLODGEMENT OF
Gastrostomy revision was done and the
LAPAROSCOPIC GASTROSTOMY IN
patient discharged after an uneventful
A PATIENT WHO REQUIRED NON-
postoperative course. In 18 months of
INVASIVE MASK VENTILATION DURING
follow up, there were no problems.
EARLY POSTOPERATIVE PERIOD E rgun
Ergun1, MD, Gulnur Gollu1, MD, Farid Fundoplication and gastrostomy are
Khanmammadov1, MD, Gonul Kucuk1, life saving options for children with
MD, Tanil Kendirli2, Prof., Meltem Bingol- neurological disorders. But unexpected
Kologlu1, Prof., 1Ankara University School complications can be seen if positive
of Medicine, Department of Pediatric pressure applied to the gastrointestinal
Surgery,2Pediatric Intensive Care Unit tract. In patients who underwent
gastrostomy procedure and require non-
The aim of this case report is to present
invasive mask ventilation, feeding from
an unusual complication of laparoscopic
gastrostomy tube should be delayed and
gastrostomy in a patient who was treated
gastric decompression should be done
by Laparoscopic Nissen Fundoplication and
during early postoperative period.
gastrostomy and required non-invasive
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P145: THORACOSCOPIC TRACTION P146: A CASE REPORT :LAPAROSCOPIC
SUTURES FOR LONG-GAP OESOPHAGEAL NEPHRON-SPARING SURGERY ON
ATRESIA MAY CAUSE SEVERE SOLITARY KIDNEY OF A 2 YEARS-OLD
COMPLICATIONS M artin L. van Niekerk, GIRL H
ua Xie, Yichen Huang, Yiqing Lv,
Prof., University of Pretoria Fang Chen, Shanghai Children’s Hospital ,
Shanghai Jiao Tong University
INTRODUCTION: Long-gap oesophagus
atresia is a challenging problem for A 2 years-old girl, who was admitted to our
surgeons. Thoracoscopically placed hospital because a mass was discovered
traction sutures is one of the recent on the mid polar of her right kidney by
approaches to manage this problem. ultrasonography. The girl was diagnosed
One of the reasons preventing the wide with Willm’s Tumor on her left kidney one
spread acceptance of this approach is the year ago. She underwent nephrectomy
problem of sutures cutting through tissue. and half year of chemotherapy. She was
We present two patients with isolated followed up by ultrasonography and a
oesophagus atresia who developed year later, a mass was discovered on the
severe complications following this mid polar of her right kidney. Further CT
procedure. indicated a enhanced tumor on the ventral
part of left kidney(Fig1). Laparoscopic
PATIENTS & METHOD: Thoracoscopic
nephron-sparing surgery was performed.
traction sutures were placed in two
Three 5mm trocar were used, one beneath
babies with long gap oesophageal atresia,
the umbilicus, the other two on the lateral
weighing 3.2 and 2.8 kg respectively. The
margin of the rectus of right abdomen.
first patient was operated primarily at our
The tumor is 2*2*2cm with a clear margin.
institution. The other patient was referred
The opertion took 90 min. Pathology
from another institution after traction
indicated clear cell carcinoma. The girl
sutures resulted in a leak. Both patients
was discharged from hospital 3 days after
developed a leak of the distal poach, 9
surgery. She was followed up every 2
and 5 days respectively after placement
months for half a year by ultrasonography
of traction sutures. Both patients
and no reccurence of the tumor has been
underwent two further operations to
discovered yet.
manage this problem. Currently these
babies are doing well, and are awaiting P147: LAPAROSCOPIC PERITONEAL
oesophageal replacement procedures. DIALYSIS CATHETER IMPLANTATION
IN CHILDREN: A PRIMARY EXPERIENCE
CONCLUSION: Thoracoscopically placed
Yichen Huang, Yiqing Lv, Fang Chen, Hua
traction sutures may lead to severe
Xie, Shanghai Children’s Hospital , Shanghai
complications.
Jiao Tong University
Thoracoscopic placement of sutures in
OBJECTIVES: To assess the feasibility and
the thin wall of the smaller distal poach is
complications of laparoscopic placement
a surgical challenge.
of peritoneal dialysis catheters in pediatric
This procedure is not recommended for patients.
small babies.
METHODS: A total of 3 patients underwent
laparoscopic peritoneal dialysis catheter
insertion in our institution in 2013.They
were all males, with the age of 7, 8 and 8
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years old respectively. 2-cuff Tenckhoff The upper moiety is frequently dilated or
catheters with arc bend in the intercuff dysplastic, while ureteropelvic junction
segment were used. The operation started obstruction (UPJO) in lower unit of
with three 5-mm trocars placed beneath duplex kidney is rare and preservation is
the umbilicus and on the lateral margin recommended when it is not significantly
of the rectus sheath on each side. Partial impaired. Laparoscopic reconstruction with
Omentectomy was performed till the lower pole preservation is presented as an
omentum couldn’t reach the pelvic cavity. alternative treatment.
The catheter was inserted through the left
PATIENTS & METHODS: Three patients
incision with the deep cuff placed within
with UPJO in lower unit of duplex kidney,
a peritoneal tunnel underneath the left
two presenting with abdominal pain and
rectus muscle and the superficial cuff
the other with no symptoms, were treated
upon the muscle. The catheter tip was
by laparoscopic ureteropyeloanastomosis.
positioned in the left iliac fossa with the
Patients’ records were analyzed
exit site oriented downward.
retrospectively for operative details and
RESULTS: The median operating time postoperative complications.
was 43 min. Peritoneal dialysis could be
RESULTS: Severe hydronephrosis, thin
performed just after the surgery. The
parenchyma and the presence of UPJO
patients were followed up for 3, 5 and 6
in lower moiety could be shown on CT
months respectively. Complications such
urography. The upper moiety had normal
as infection, leakage, dislodgement or
function without hydronephrosis.The
obstruction were not observed.
ureters were fused in a “Y” shape to
CONCLUSIONS: Laparoscopic peritoneal form a single ureteral orifice without any
dialysis catheter implantation is feasible dilation. According to the length between
and safe in children. Laparoscopic the fused ureter and UPJO, patients were
procedure allows for careful assessment classified to group 1(1 case,≤3cm) and
of the abdominal cavity, recognition and group 2 (2 cases, >3cm). In group 1, surgical
treatment of intra-abdominal diseases procedure envolved laparoscopic end-
such as inguinal hernias, accurate partial to-side ureteropyeloanastomosis of the
omentectomy which is important to lower pelvis to the fused ureter. The two
prevent catheter obstruction, and precise patients in group 2 underwent laparoscopic
placement of catheter in the pelvic cavity. pyeloplasty of lower moiety. Surgical
time varied from 100 to 150 minutes, with
P148: LAPAROSCOPIC
minimal blood loss in all cases. Follow-
URETEROPYELOANASTOMOSIS IN
up varied from 6 months to 2 years, with
THE TREATMENT OF URETEROPELVIC
resolution of the clinical symptoms and
JUNCTION OBSTRUCTION IN LOWER
preservation of the lower moiety function.
MOIETY OF DUPLEX KIDNEY R ongde Wu,
Prof, Wei Liu, PhD, Department of Pediatric CONCLUSION: Laparoscopic
Surgery, Provincial Hospital Affiliated to ureteropyeloanatomosis is a feasible
Shandong University, Jinan, China and safe minimally invasive option in the
treatment of duplex kidneys associated to
BACKGROUND: Duplex kidney is one of
a functioning lower moiety with UPJO.
the most common congenital anomalies
of the urinary tract. Anatomical and clinical
presentation determines its treatment.
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P149: LAPAROSCOPIC RADICAL inchildrenforWilms’tumoror renal cancer
NEPHRECTOMY OF WILMS’ TUMOR can be safely performed laparoscopically.
AND RENAL CANCER IN CHILDREN: For trained laparoscopic surgeons, by small
PRELIMINARY EXPERIENCE FROM tumors under about 10cm in diameter,
TWO-CENTERS STUDY IN EAST CHINA especially without crossing the lateral edge
Jiangbin Liu, PhD, Professor, Department of the vertebra on the CT scan at the time
of Pediatric Surgery, Shanghai Children’s of surgery.
Hospital, Shanghai Jiao Tong University1 and
KEY WORDS: Laparoscopic, nephrectomy,
Department of Pediatric Surgery, Children’s
wilms’ tumor, renal cancer, children
Hospital of Fudan University2
P150: TRANSVESICAL ENDOSCOPIC
OBJECTIVE: To review the preliminary
EXCISION OF REDUNDANT URETERAL
experience from two-centers study and
STUMP B aran Tokar, MD, Surhan Arda, MD,
to evaluate the laparoscopic radical
Umut Alici, MD, Eskisehir OGU Medical
nephrectomy inchildrenwith wilms’ tumor
School, Department of Pediatric Surgery,
and renal cancer.
Section of Pediatric Urology, Eskisehir,
\MATERIAL & METHODS: From January Turkey
2010 to October 2013, medical recordings
In children, transvesical endoscopic
on 7 caseswho underwent a laparoscopic
approach was described mainly for
radical nephrectomy for wilm’s tumor
vesicoureteral reflux and diverticulum.
and renal cancer in the department of
This video shows the surgical technique of
pediatric surgery, Shanghai Children’s
pneumovesicoscopic resection of a long
and refluxing distal redundant ureteral
Children’s Hospital of Fudan University
stump in a nephrectomized patient.
were included in this study.
Video presentation:10 years old boy was
RESULTS: Three underwent chemotherapy
admitted to our clinic with a history right
before operation according the COG
nephrectomy performed in another
(Children’s Oncological Group) protocol
hospital. The patient had frequent urinary
and all could be treated bylaparoscopy;
tract infections (UTI) in his postoperative
the biggest tumoral size was 10cm
follow up. We showed a refluxing stump
without crossing the lateral edge of the
with a 4 mm stone in it preoperatively and
vertebra. The median hospital stay was 8.5
performed cystoscopy. During cystoscopy,
days (6-11). The pathologic investigation
a 5 cm long distal redundant ureteral
showed 5Wilms’ tumors, 1 rhabdoid
stump with 1 cm diameter was determined
tumor and 1 renal cell carcinoma. With a
on the right side. Debris of suture and
median follow-up of 26months (range
stone in the stump was removed. He
3 and 48 months) after laparoscopic
did not have UTI following the removal
radical nephrectomy, all the childrenhad
of the debris and excision of the stump
no oncological complications (port site
was planned for the future. Transvesical
recurrence, pulmonary metastasis) and
excision of the stump was done by
without intraoperative tumoral rupture,
pneumovesicoscopy 6 months later. A 5
except the patients with rhabdoid tumor
mm port was introduced from the bladder
had a local recurrence
dome, and 2 three mm ports were inserted
CONCLUSIONS: From our own preliminary into the lateral sides of the bladder.
experience, the radical nephrectomy With a 12 mmHg insufflation pressure,
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refluxing distal redundant ureteral stump P152: POSTERIOR URETHRAL VALVE:
was removed by transvesical endoscopic OUR EXPERIENCE IN VIET NAM V an Thao
technique. Muscular and mucosa defect Tran, MD, Ngoc Thach Pham, MD, Duc Tri
was repaired by 5/0 monofilament Nguyen, MD, Children hospital number 2 in
suture. The patient was discharged on Ho Chi Minh city
postoperative 2nd day.
PURPOSE: to evaluate the results of
CONCLUSION: Pneumovesicoscopy could endoscopic valve ablation at Children
be considered as one of the options for hospital No 2 in Viet Nam.
intravesical ureteral surgery in children.
METHODS: We retrospectively reviewed
P151: LAPAROSCOPY- ASSISTED EXCISION the records of 25 consecutive patients
OF RENAL MATURE CYSTIC TERATOMA with posterior urethral valves from January
Baran Tokar, MD, Huseyin Ilhan, MD, 2008 to December 2012. On the basis of
Surhan Arda, MD, Umut Alici, MD, Cigdem the initial renal function and radiologic
Arslan, MD, Eskisehir OGU Medical School, findings, patients were divided into three
Department of Pediatric Surgery, Section groups: group 1, normal renal function and
of Pediatric Urology, Eskisehir, Turkey radiologically normal upper tracts; group 2,
normal renal function with hydronephrosis
Extragonadal teratoma predominantly
and/or reflux; and group 3, azotemia with
appears along the midline of the body.
hydronephrosis or reflux.
Renal teratoma is very rare pathology. In
this video, laparoscopic assisted excision of RESULTS: All 11 patients in group 1 were
a renal teratoma is presented. treated with valve ablation. After a
mean follow-up of 32 months, these
VIDEO PRESENTATION: An 11 year-old
children had normal renal function and
female patient was admitted with a right
no evidence of upper tract deterioration.
abdominal mass. Radiological investigation
All 6 patients in group 2 were also treated
showed a 13 cm cystic mass on the right
with valve ablation. The radiologic
upper quadrant just under the liver and
abnormalities (hydronephrosis, reflux)
above the right kidney. A mass related
resolved in 50% of cases, with an average
to the upper pole of the right kidney was
follow-up of 28 months. Of the 8 patients
found by laparoscopic exploration. The
in group 3, 5 underwent valve ablation
mass was totally excised with laparoscopy
after catheterisme and 3 underwent
-assisted technique. The histopathology
urinary diversion. Urinary diversion
showed that the mass was a mature cystic
was performed in patients with renal
teratoma.
deterioration and severe hydronephrosis
CONCLUSION: Differential diagnosis, and/or high-grade reflux. Renal function
dissection and excision of an returned to normal in all patients who
intraabdominal large cystic mass could underwent valve ablation except one;
be performed by laparoscopy-assisted renal function returned to normal in only
techniques. Teratoid Wilms’ tumor and 1of 3 patients who underwent urinary
other renal cystic lesions should be diversion. Radiologically, the severity
considered in the differential diagnosis in of the hydronephrosis and reflux was
that location. downgraded in patients who underwent
valve ablation but not in the diverted
group.
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CONCLUSIONS: endoscopic valve ablation CONCLUSIONS: Nephrostomy external
is the mainstay of treatment for patients drainage was associated with lowest rates
with posterior urethral valves. of postoperative complications after
laparoscopic pyeloplasty. However, three
P155: COMPARISON DIFFERENT
urine drainages have their own indication.
DRAINAGES IN LAPAROSCOPIC
The most suitable urine drainages could be
PYELOPLASTY Xing Liu, MD, Dawei He,
selected by actual situation.
Zedong Bian, De-ying Zhang, Tao Lin,
Children’s Hospital of Chongqing Medical P156: OUR EXPERIENCE OF
University, Chongqing, China THE SURGICAL TREATMENT OF
CRIPTORCHISM IN CHILDREN D amir
OBJECTIVE: To evaluate the benefits,
Jenalayev, Esmurat Nartbayev, Ardak
drawbacks and indication of different
Ainakulov, National Research Center for
pelvis urine drainages after laparoscopic
Mother and Child Health
pyeloplasty.
The purpose of this study was a comparative
METHODS: A total of 105 patients (112
evaluation the results of treatment of
sides) who had undergone laparoscopic
children with cryptorchism, operated by
pyeloplasty between January 2010 and
“open” and endovideosurgical ways.
October 2013 were divided into nephrostomy
external drainage group(66 sides), long-term Since August 2007, 61 patients with various
double J catheter internal drainage group forms of cryptorchism have been treated
(29 sides) and short-term double J catheter in the urology department of National
internal drainage group (17 sides). Research Center of Mother and Child
Health.
RESULTS: The incidence of postoperative
gross hematuria in nephrostomy external Age of patients ranged from one year to 14
drainage group was lower than long- years. Endovideosurgery has been applied
term double J catheter internal drainage in the treatment of 43 patients (study
group (P<0.01) and short-term double J group). The operation consisted of the
catheter internal drainage group (P<0.05). following steps: diagnostic laparoscopy in
The total incidence of postoperative order to clarify the level of retention, visual
complications in nephrostomy external evaluation of the testis, its blood vessels
drainage group was lower than long-term and the fixing apparatus, the intersection
double J catheter internal drainage group Gunter`s cord, the mobilization of the
and short-term double J catheter internal vascular bundle and ductus defferens,
drainage group (P<0.01). The incidence of forming a channel from the abdomen into
urinary infection in nephrostomy external the scrotum, bringing down the testis and
drainage group was lower than long-term fixation it in the scrotum.
double J catheter internal drainage group
The “open” brining down and fixation of
(P<0.05). The incidence of drainage tube
the testis by Petrivalskij-Schumaker has
blockage and omentum prolapsus in
been performed in 18 patients (control
nephrostomy external drainage group was
group).
lower than short-term double J catheter
internal drainage group (P<0.05). And For comparative assessment of body’s
there was no significant difference of postagressive response to laparoscopic
anastomosis obstruction incidence and and traditional types of operations for
postoperative successful rate in three cryptorchism we studied: the state of
groups (P>0.05).
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simpaticoadrenalic system (in circadian spermatic vessels offers a low recurrence
excretion of adrenaline and noradrenaline) rate but with the risk of postoperative
and several biochemical blood parameters, hydrocele in 10% short term and up to 30%
reflecting the functional state of the with extended follow-up. We present our
suprarenal glands and liver, the balance of experience with dye-assisted lymphatic-
carbohydrate and protein metabolism. To sparing laparoscopic varicocelectomy
assess the state of the testis we conducted (LSLV) to prevent postoperative hydrocele
ultrasound and Doppler exams of gonads in children. We contribute novel insights
in the preoperative period, on the 3rd and 6 regarding the number of lymphatic vessels
month of postoperative period. There were which need to be preserved.
no complications in the immediate and
MATERIALS & METHODS: Five consecutive
late postoperative period.
LSLVs were performed over a period of
The analysis of the comparative evaluation three years on children with a mean age
of body’s postagressive response to of twelve years. The varicocele grade was
laparoscopic and traditional operations has three in one case and grade 2 in four cases,
showed that laparoscopic surgery is less respectively. Indications of operation
invasive, less traumatic, less durable surgical were testicular volume asymmetry of
intervention, which is characterized to have greater than 20% in one patient (a grade
more favorable postoperative period. 3 varicocele) , scrotal pain or discomfort in
three patients and family preference in one
More expressive positive dynamics,
patient. A left subdartos injection of 2ml
concluded in the growth of gonads
of Indigo carmine dye was done using a
and the normalization of blood flow
25-gauge needle at ten minutes before an
parameters while ultrasound and Doppler
operation. Stained lymphatics were easily
study, has been in patients undergone
seen running alongside the spermatic
endovideosurgical interventions.
artery and vein. We intentionally spared
Thus, this study shows clear advantages one or two lymphatics and the rest of the
of endovideosurgical treatment of spermatic vessels were clipped and divided
cryptorchism in children and calls for
RESULTS: Lymphatic-sparing was
their widespread introduction into clinical
accomplished in all cases. No peri-
practice.
operative complication was noted. We
P157: HOW MANY LYMPHATIC spared one lymphatic channel in one
VESSELS NEED TO BE PRESERVED patient (20%) and two channels in four
IN DYE-ASSISTED LYMPHATIC- patients (80%). There were no cases
SPARING LAPAROSCOPIC PALOMO of hydrocele or residual varicocele.
VARICOCELECTOMY IN CHILDREN? H iroki No testicular atrophy was observed at
Ishibashi, MD, PhD, Hiroki Mori, MD, PhD, follow-up. Three patients who presented
Keigo Yada, MD, Mitsuo Shimada, MD, PhD, with scrotal pain or discomfort achieved
FACS, Department of Pediatric Surgery and complete resolusion of their symptoms.
Pediatric Endoscopic Surgery, Tokushima
CONCLUSION: Dye-assisted LSLV is easily
University Hospital
accomplished with an excellent surgical
BACKGROUD: The ideal method for outcome and preserving one or two
varicocelectomy in children remains lymphatics appears to be sufficient to
controversial. The Palomo method of avoid secondary hydrocele.
retroperitoneal mass ligation of the
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P158: RETROPERITONEOSCOPIC REDO were placed along the line of the erector
PYELOPLASTY AFTER AN UNSUCCESSFUL spinae muscle to free adhesions and create
OPEN PROCEDURE M anabu Okawada, MD, an adequate working space. A fourth port
Hiroyuki Koga, MD, Takashi Doi, MD, Go was placed in the mid-axillary line for
Miyano, MD, Kazuto Suda, MD, Geoffrey peritoneal retraction and assistance during
J Lane, MD, Atsuyuki Yamataka, MD, the pyeloplasty procedure.After releasing
Juntendo University School of Medicine dense adhesions of the left ureter and
area where the UPJO was suspected to
PURPOSE: Laparoscopic pyeloplasty (LP)
be, we found the ureter was being kinked
and retroperitoneoscopic pyeloplasty (RP)
by an aberrant artery to the inferior pole
have become widely accepted for treating
of the kidney that was located in front
ureteropelvic junction obstruction (UPJO)
of the ureter, causing UPJO. Adhesions
using minimally invasive surgery (MIS).
between the ureter and the aberrant
However, for re-do procedures, extensive
artery were dissected carefully and the
adhesions can make LP or RP technically
ureter transected at the site of kinking.
challenging. Here we report the use of RP
The ureter was thickened and extremely
for re-do pyeloplasty.
fragile because of chronic inflammation
CASE: A 16-year-old girl with left UPJO associated with prolonged insertion of
was referred following unsuccessful open the double J stent and recurrent urinary
surgery elsewhere. Other than the ureter tract infections and was re-anastomosed
being noted to be narrow and the narrow in front of the aberrant artery using 5/0
portion being excised and the ureter absorbable interrupted sutures over the
re-anastomosed, no further details were double J stent. Thus, the aberrant artery
available. However, a double J stent had came to lie behind the anastomosis, in
been inserted in the left ureter 2 years a position that would not compress the
earlier to treat recurrent urinary tract ureteropelvic junction. The anastomosis
infections and episodes of left flank pain. was complicated by suturing under tension
Both the patient and her mother requested and tissue fragility. Postoperative recovery
the old scar be used for open re-do and if was uneventful. She was discharged 3 days
not possible, MIS re-do. However, the old after surgery. The stent was removed 6
scar was so low that we doubted whether weeks postoperatively, and she is currently
the UPJO could be visualized adequately so well after follow-up of 2 years with no
RP was recommended for re-do as our MIS urinary symptoms or recurrence of UPJO.
procedure of choice.
CONCLUSIONS:This case demonstrates
RP: A 5mm optical trocar was used to reach that our RP technique is safe and effective
the left retroperitoneal space. As we were even in cases complicated by severe
anxious about adhesions around the scar retroperitoneal adhesions due to previous
from previous open surgery being dense, surgery.
we placed the first port 2cm inferior to its
P159: LAPAROSCOPIC PERCUTANEOUS
conventional position at the costovertebral
INTERNAL RING SUTURING FOR
angle. Although there were adhesions
INGUINAL HERNIA REPAIR IN CHILDREN
between the scar and the retroperitoneal
OF DIFFERENT AGES O leg Godik, MD,
space, blunt dissection was possible initially
Vasil Prytula, MD, Valerie Soroutchan, MD,
using the tip of the scope, whereupon two
Igor Mirochnik, MD, Roman Zhezhera, MD,
additional ports (one at the costovertebral
National Specialized Childrens’ Hospital
angle and the other above the iliac crest)
“OHMATDET”
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BACKGROUND: laparoscopic treatment of (10.6%) patients. In 6 (2.4%) cases the
inguinal hernias is a popular procedures inguinal hernias were diagnosed during
in pediatric surgery. Many techniques are simultaneous operations (3 laparoscopic
used in laparoscopic inguinal hernia repair appendectomies, 1 laparoscopic
in children. We present PIRS (Percutaneous cholecystectomy, 1 varicocelectomy,
Internal Ring Suturing) technique that was 1 pieloplastics in a PUJ obstruction ).
introduced by a polish surgeon Dariusz The average time of the operation was
Patkowski. The aim of this study was to 15±5 minutes for unilateral hernias, and
evaluate the efficacy of PIRS for inguinal 25±5 minutes for bilateral hernias. The
hernia repair in children of different ages. average hospital stay was from 6 hours to
1 day. There were 4 (1.6%) cases with an
MATERIALS AND METHODS: A review
intraoperative complication, in which the
of all PIRS procedures in children from
iliac vessels were accidentally punctured
28 days- 18 years, with a time period
during the ring suturing process, and
from March 2010 to December 2013. The
required no treatment. There were such
procedures were performed under general
post operative complications: 9 (3.5%)
endotracheal anesthesia. For the PIRS
patients experienced mild pain in the
method we used a 5 mm camera through
place of the puncture for up to 2-3
a transumbilical port, a curved 18 gauge
months that stopped with no treatment,
injection needle with a nonabsorbable
3 (1.2%) hydrocele that also required no
filament inside the barrel of the needle.
treatment, and 6 (2.4%)hernia recurrences
With the injection needle we made a
that were all reoperated with the PIRS
puncture through the abdominal wall in
method.
the place of the internal inguinal ring. By
moving the needle the thread passed CONCLUSION: The PIRS method showed
under the peritoneum around the entrance to be a safe, effective, and reliable for
into the hernia sac. Two semicircular inguinal hernia repair in children. The PIRS
sutures were made around the ring and the method showed that it can be used in
knot was tightened form the outside and different child ages from 28 days to 18
placed into the subcutaneous region. year. There was a low recurrence rate and
great cosmetic result.
RESULTS: Over the above years 254
children with 329 hernias underwent P161: IMPORTANCE OF ‘ADEQUATE AND
the PIRS procedure, 86 (33.9%) of them PROPER MATERIAL SUBSTANCE FOR THE
were girls and 168 (66.1%) were boys. The ENDOSCOPIC TREATMENT OF REFLUX.
average age of the children was 3 years 7 OUR EXPERIENCE IN THE LAST FIVE
months. There were 179 (70.5%) unilateral YEARS L uciano Sangiorgio, MD, Claudio
hernias and 75 (29.5%) cases presented Carlini, MD, Franco Rotundi, MD, Rossella
with bilateral inguinal hernias. Unilateral Arnoldi, MD, Pediatric Urology, * Pediatric
hernias consisted of 132 (73.7) right sided Surgery. A.O. “SS: Antonio e Biagio e C.
hernias and 47 (26.3%) left sided hernias. Arrigo” Alessandria Italy.
Out of the bilateral hernias in 65 (25.6%)
INTRODUCTION & OBJECTIVES: the aim of
cases a contralateral processus vaginalis
this paper is to emphasize the ‘importance
was diagnosed during the operation, and
of a’ proper substance and a proper
only in 10 (3.9%) cases were the bilateral
material for the endoscopic treatment of
hernias diagnosed prior to the operation.
reflux, in order to obtain a good success.
Incarcerated hernias appeared in 27
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MATERIALS & METHODS: in the last five impurities that could be included in the
years, we observed 232 patients with VUR thickness of bladder wall, the latter have
(354 units refluxing ureters). Twenty- found healing from VUR through a third
one cases were suffering from urinary injection of the polymer, using Deflux
double district (unilateral or bilateral). again. The remaining two patients with
One hundred twenty-six (54.31%) were recurrent VUR and suffering from urinary
male and one hundred and six (45.68%) double district were subjected to surgery.
females. We evaluated the radiological
CONCLUSIONS: it is stressed that the
grade of reflux, the presence in the past
endoscopic treatment with a stable co
of episodes of acute pyelonephritis, the
- polymer dextranomer and hyaluronic
scars on the static renal scintigraphy.
acid (Deflux) offers the same chance
Forty-two patients were undergoing
of recovery from VUR compared to
surgery according to the technique of
surgical treatment, definitely the choice
Cohen, one hundred and ninety performed
of a substance stable and valid material
the endoscopic treatment of reflux. The
ensures a great eventually find.
treatment consisted of the endoscopic
injection, below the ureteral meatus, using P162: TRANSPERITONEAL LAPAROSCOPIC
and comparing two different co - polymer HEMINEPHRECTOMY FOR DUPLEX
of the same substance: dextranomer KIDNEYS IN INFANTS AND CHILDREN
and hyaluronic acid (Deflux and Dexell), Stephane Thiry, MD, Delphine DEMEDE,
using the same technique by needle drive, MD, Jacques Birraux, MD, Pierre
lifting the bladder mucosa with the needle Mouriquand, PhD, Pierre-Yves Mure, PhD,
itself, so as to favor the detachment Department of Pediatric Urology, Hôpital
and thus the elongation of the junction Femme, Mère, Enfant, 59 Boulevard Pinel,
uretero – bladder and the creation of an Université Claude Bernard Lyon1. 69677
appropriate niche for the wheal of organic Bron, France.
material - compatible. (Nicola Capozza
Technique), however, always using two sub OBJECTIVE: To study the feasibility, safety,
ureteral meatal injections amounts being and results of transperitoneal laparoscopic
of a material of between 0.7 ml and 1 ml. heminephrectomy (TLHN) for non-
for injection. Were detected six cases of functional moiety in duplex kidneys.
persistent reflux to the second injection MATERIAL AND METHOD: Between 2008
(two treated with Deflux and all patients and January 2013, 34 TLHN were performed
treated with Dexell). Those treated with in 33 patients (18 girls, 15 boys), median
Deflux had urinary district, but there was age was 20 months (range 7-107). Twenty-
persistence of the wheal which was not six upper poles were removed and eight
sufficient to ensure a good valvular effect, lower pole. The mean follow up was 11
instead those treated with Dexell were months (range 2-32). In a subgroup of 19
suffering from reflux of single district and patients, pre and post operative nuclear
there was no trace of the wheal at the level investigations were compared to correlate
of the ureteral meatus, in addition, during the predicted and the real loss of function.
the injection of the second substance,
occurred in a case, breakage of the plunger RESULTS: TPLHN was feasible in all
of the syringe and in another case the patients without any conversion. The
needle was not properly milled for which median operating time was 130 min (range
were present in the tip of the metallic 75 – 210 min) and the median hospital stay
was four days (range 3-29). No major blood
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loss was observed. Two complications were were selected, either after initial open or
observed: a persistant secreting moiety laparoscopic repair. A phone interview was
and a ureteral injury requiring open surgical conducted with the parents of identified
repair. The subgroup with post operative patients. All patients with recurrences
nuclear studies showed a loss of function had clinical follow-up. In boys, testicular
corresponding to the predictive value of volume and echogenic texture were
the preoperative isotopic renographies with evaluated by ultrasound.
a median difference of 2% (mean 3.17%,
RESULTS: Between December 2003 and
range 0-8%).
December 2011, 1187 children underwent
CONCLUSION & DISCUSSION: LHN inguinal hernia repair, 1087 in a minimally
using a transperitoneal approach for invasive fashion and 100 children by
a duplex kidney is feasible, safe, and traditional groin exploration. From a
effective. Laparoscopic retroperitoneal total of 1547 laparoscopic inguinal hernia
heminephrectomies has long been repairs, 71 laparoscopic evaluations were
favoured as it reproduced the classical performed for suspected inguinal hernia
retroperitoneal approach used in open recurrences. In 11 children, a suspected
surgery. Our clinical experience suggests recurrence was not confirmed and the
that laparoscopic heminephrectomy using procedure was completed. 60 children
a transperitoneal approach for duplex (43 boys and 17 girls) underwent 67
kidneys is a safe and efficient procedure laparoscopic inguinal hernia repairs for
leading to a low rate of complication. recurrences (53 unilateral and 7 bilateral
Fears regarding potential intra-abdominal recurrences). Of all recurrences, 35 children
organ injury appear to be hypothetical. (58.3%) had laparoscopic repairs and 25
Furthermore, transperitoneal approach (41.7%) had traditional open herniotomies.
seems to be easier to perform due to a Of those 25 patients, five underwent
larger working space and a direct vision on multiple groin explorations (two
vascular pedicles. explorations (3) and three explorations (2),
respectively) prior to the final laparoscopic
P163: LOW (RE-) RECURRENCE RATE
repair. Of those, three patients had direct
AFTER LAPAROSCOPIC REPAIR OF
(2) and femoral (1) hernias. The overall
RECURRENT INGUINAL HERNIA S almai
recurrence rate in children after initial
Turial, MD, Ralph Hornung, Department of
laparoscopic hernia repair in this cohort
pediatric surgery, university medical center
was 1.3%. A second recurrence was noted
Mainz, Germany
in one patient (0.06%).
PURPOSE: The aim of this study is to
The median follow-up was 3.4 years. No
identify the incidence of (re-) recurrence
testicular atrophy was noted in patients
after laparoscopic repair of recurrent
after repair of a recurrent inguinal hernia.
inguinal hernias after initial laparoscopic or
open repair. CONCLUSION: The risk of (re-) recurrence
remains low after laparoscopic
METHODS AND PATIENTS: We performed
herniorrhaphy for recurrent inguinal
a retrospective analysis of the surgical
hernias. Laparoscopic evaluation of the
charts of children who underwent inguinal
groin can reveal previously unrecognized
hernia repair at our department. All
inguinal hernias as well as unusual cases
children, who underwent laparoscopic
of presumed hernias. Open redo groin
repair of a recurrent inguinal hernia,
explorations can be prevented in cases
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where a closed processus vaginalis is grade was I in 4, II in 24, III in 26, IV in 18
laparoscopically found. From a technical and V in 2 ureters. Within a follow-up of
perspective, the laparoscopic approach 48 months (1-66 months), 49 patients had
for recurrent inguinal hernias seems to be no postoperative VCUG, and none of them
less demanding, especially in cases after showed febrile UTI or recurrent non-febrile
multiple previous groin explorations. UTIs. 1 boy with bilateral VUR grade IV and
1 girl with VUR III in a duplex ureter had a
P164: IS A POSTOPERATIVE VOIDING
febrile UTI 6 months and 36 months, resp.,
CYSTURETHROGRAM STILL INDICATED
after ET. Further VCUG revealed recurrent
AFTER ENDOSCOPIC TREATMENT OF
VUR, and both patients underwent a
VUR? F
rank-Martin Haecker, MD, Martina
second ET.
Frech, MD, Sergio Sesia, MD, Christoph
Rudin, MD, Department of Pediatric CONCLUSION: In this series, we could
Surgery, University Children’s Hospital confirm our follow-up protocol that
postoperative VCUG is considered only
BACKGROUND: The management of
for selected patients. A larger prospective
follow-up for patients who underwent
study is necessary to evaluate this
endoscopic treatment (ET) using Dx/HA
approach.
for primary vesicoureteral reflux (VUR), is
controversially discussed. Recent studies P165: PAPILLARY UROTHELIAL
reveal different opinions concerning NEOPLASM OF LOW MALIGNANT
the necessity of a postoperative voiding POTENTIAL (PUNLMP) IN A 13 YEAR-OLD
cysturethrogram (VCUG). Additionally, PATIENT: CASE REPORT AND REVIEW OF
Stenberg and Läckgren reported in THE LITERATURE F rank-Martin Haecker,
2007 on the experience of patients and MD, Elisabeth Bruder, MD, Sergio Sesia,
the perception of parents with regard MD, Johannes Mayr, MD, Department of
to different diagnostic and treatment Pediatric Surgery, University Children’s
modalities, with VCUG mentioned as Hospital, Basel, Switzerland
the worst intervention. We sought to
PURPOSE: Urothelial carcinoma of the
determine whether a postoperative VCUG
bladder occurs rarely in the first two
is still necessary.
decades of life. We report a case of a 13
METHODS: A retrospective study year-old boy who presented with urothelial
evaluating 164 patients who underwent neoplasm of low malignant potential
ET from 2002 to present was performed. (PUNLMP).
In a subgroup of 51 patients, one week
METHODS: We describe clinical
after ET, prophylactic antibiotics were
presentation and diagnostic procedures
discontinued and patients were followed
as well as treatment and follow-up of
up clinically including periodical urinalysis
our patient. A review of the literature was
and renal ultrasound. Patients did not
performed to analyze recommendations
undergo further VCUGs unless febrile UTI
concerning diagnostic staging, treatment
or recurrent non-febrile UTIs developed.
and follow-up examinations as well as
RESULTS: 51 children with a total of surveillance of urothelial carcinoma in the
95 ureters underwent ET. Additional pediatric population.
malformations were: duplex ureters (15
RESULTS: Urothelial tumors in the first two
patients), posterior urethral valves (1
decades of life are distinctly unusual, with
patient) and dicerticulum (1 patient). VUR
most described in case reports and small
WWW.IPEG.ORG | 305
Table of Contents

series. Most of the small series describe METHODS: We made a retrospective
these tumors as being characteristically analysis of 28 patients with malformation
superficial and low grade. As in our patient, of ureterovesical junction from January
silent macrohematuria is the predominant 2009 to November 2013. 9 cases were
clinical symptom. Abdominal ultrasound male and other 19 cases were female.
revealed a papillary mass measuring 1.5cm, Their average age was 3.3y(4Mo-10.4y).
and abdominal CT scan showed no evidence All cases accepted examination such
of additional tumor manifestations. as Ultrosound, MRU, MCU, etc, and
Therapy included cystoscopy and hydronephrosis with ureteral dilatation
transurethral resection of the tumor. were found in all of them. Of which 17
Histologic examination confirmed the patients were obstruction of ureterovesical
diagnosis of a PUNLMP. Three months later, junction, 11 patients were believed to have
control cystoscopy including fluoroscopy VUR with grade IV-V. These patients were
demonstrated no residual tumor in the divided into two groups. In group A, from
bladder. Within the next 36 months, the January 2009 to October 2011, 18 cases
clinical course was uneventful. were operated by open procedure. Of
which 6 cases were male, 12 cases were
CONCLUSIONS: Urothelial tumors in the
female. Their average age was 3.7y(4Mo-
first two decades of life are unusual,
10.4y). In group B, from November 2011 to
with most described in case reports.
November 2013, 10 cases were operated
Regarding the tumor characteristics,
by pneumocystoscopic Cohen ureteric
transurethral local resection is the therapy
reimplantation. Of which 3 cases were
of choice, followed by control cystoscopy
male, 7 cases were female. Their average
including fluoroscopy. General treatment
age was 3.1y(5Mo-9.2y). Operative time,
protocols including recommendations for
blood loss, postoperative hospital stay,
staging, tumor markers, and follow-up
complications and therapeutic efficacy
examinations are not available for this
were analyned.
tumor entity.
RESULTS: 10 cases were performed
P166: COMPARATIVE STUDY OF
pneumocystoscopic Cohen ureteric
PNEUMOCYSTOSCOPIC COHEN
reimplantation, of which 1 case gave up
URETERIC REIMPLANTATION AND
laparocopic procedure because the trocar
OPEN SURGERY FOR MALFORMATION
was out of work and the gas leaked into
OF URETEROVESICAL JUNCTION IN
the abdominal cavity .The remaining
CHILDREN: EXPERIENCE AT A SINGLE
9 cases were accepted successful
CENTER C hang Tao, BA, Daxing Tang, MD,
surgery. The mean operative time was
Shan Xu, BA, Dehua Wu, BA, Yong Huang,
(177.3±47.5 minutes) longer than open
BA, Department of Urology Children’s
procedure(114.3±24.2minutes),(P<0.05).
Hospital Zhejiang University School of
The mean blood loss was (4.4±1.1 ml)
Medicine
lower than open procedure (12.8±4.3
OBJECTIVE: To compare the results ml), (P<0.05). The average postoperative
of open and pneumocystoscopic hospital stay was (9.2±2.4 d) lower than
Cohen ureteric reimplantation for open procedure(14.6±3.7 d), (P<0.05).
malformation of ureterovesical junction Postoperative follow-up was 2 ~ 38
in children and review the experience months. In group A , 5 cases with UTI
of pneumocystoscopic Cohen ureteric were cured after antibiotic therapy. 1
reimplantation . patient got cut-infection and 1 patient
Table of Contents

got extravasation of urine. In group ectopia with bilateral inguinal hernias,
B, 3 cases got UTI , 1 case of a female and identifying the remnant Mullerian
children complained abdominal pain two structures and a common vas deferens.
months later after operation. Ultrasonic Under laparoscopic guidance both testicles
examination clew: ureteral calculi. The were brought into the left internal ring and
stone disappeared after spasmolysis, a trans-septal orchidopexy was performed
alkalize urine and abdominal pain relief. followed by bilateral laparoscopic inguinal
Postoperative ultrasonic examination of hernia repairs. To our knowledge this
all cases showed hydronephrosis with is the first reported case of complete
ureteral dilatation were better than before. laparoscopic management of transverse
The therapeutic efficacy of two group was testicular ectopia in conjunction with
coincident. a common vas deferens, persistent
Mullerian duct syndrome, and bilateral
CONCLUSIONS: Pneumocystoscopic Cohen
inguinal hernias. Challenges encountered
ureteric reimplantation as a well minimally
included clear identification of the
invasive surgery with a small incision, less
vas deferens as it merged at the base
bleeding, small trauma, rapid recovery,
of the uterine remnant, the decision
unconspicuous scar was safe and reliable.
to leave the remnant Mullerian duct
It could achieve good clinical effects like
structures, and the approach to correction
open surgery. It could take the place of
of the inguinal hernias. Based on this
open surgery if surgeon had proficient
experience, we advocate a laparoscopic
laparoscopic technique.
approach in the treatment of transverse
P167: LAPAROSCOPIC MANAGEMENT testicular ectopia as it enables clear
OF TRANSVERSE TESTICULAR ECTOPIA identification of testicular anatomy and
IN CONJUNCTION WITH BILATERAL associated anomalies, thereby minimizing
INGUINAL HERNIAS, PERSISTENT unnecessary dissection and diagnostic
MULLERIAN DUCT SYNDROME AND A uncertainty, while facilitating management.
COMMON VAS DEFERENS K athryn Martin,
MD, Kyle Cowan, MD, PhD, Children’s
Hospital of Eastern Ontario, University of
Ottawa
Transverse testicular ectopia is a rare
congenital anomaly in which both testicles
descend into the same inguinal canal.
This condition has been associated with
contra-lateral inguinal hernias, persistent
Mullerian duct syndrome, common vas
deferens, seminal vesicle cysts, seminomas
and renal anomalies. We present the
case of an 11-month-old male infant with
a left inguinal hernia and a right non-
palpable testicle. Clinical examination and
ultrasound located the right and left testes
within the left inguinal canal. Laparoscopy
was instrumental in confirming the
presence of transverse testicular
WWW.IPEG.ORG | 307
2015
Save the Date!

IPEG’s 24th Annual Congress
Held in Conjunction with the Society of American
Gastrointestinal and Endoscopic Surgeons
April 14-18, 2015

GAYLORD OPRYLAND RESORT & CONVENTION CENTER
NASHVILLE, TENNESSEE
Surgical Spring Week
SAGES 2015
Society of American Gastrointestinal and Endoscopic Surgeons
April 15-18, 2015 Nashville, TN

Program Chair: Aurora Pryor, MD
Program Co-Chair: Michael Holzman, MD
www.sages.org • www.sages2015.org
@SAGES_Updates www.facebook.com/SAGESSurgery
WWW.IPEG.ORG

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IPEG’s 23rd Annual Congress

for Endosurgery in Children

BAPS 61st Annual Meeting

FINAL PROGRAM 2014

6325 Gunpark Drive, Suite G

International Pediatric Endosurgery Group (IPEG)

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IPEG’S 23rd ANNUAL CONGRESS

MATERIAL & METHODS: To confine the

KEYWORDS: Training model, esophageal atresia.

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