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Nowadays laparoscopic Nissen fundoplication represents the gold standard in surgical treatment of complicated Gastro-Esophageal-Reflux Disease (GERD), above all in cerebral palsy patients. In non-neurological patients without gastrostomy Nissen fundoplication can create some problems (gas bloat syndrome, dysphagia). Laparoscopic Hill-Snow repair is an established surgical alternative, but it is reported only in adult population. We describe our modification of Hill-Snow technique and our experience in a large series of non-neurological children in order to report its effectiveness and applicability in pediatric patients affected by complicated GERD. Between 2000 and 2022, 319 children underwent surgical correction of gastro-esophageal reflux at our Department. All were affected by complicated gastro-esophageal reflux unresponsive to PPI (Proton Pump Inhibitors). 251 underwent laparoscopic Nissen fundoplication; 68 non-neurological patients underwent laparoscopic Hill-Snow repair. Of these 68 children 48 were males (71%) and 20 females (29%); median age was 5years (3 months-11 years). Weight range was 4-37kg. 52 patients (76.5%) presented the following symptoms: retrosternal pain, dysphagia, regurgitation, coughing, failure to thrive, persisting reflux esophagitis. 16 (23.5%) had chronic respiratory problems (aspiration, apneic-spells, dysphagia, coughing, choking, gagging). For 8 (11.8%) symptoms were expression of chronic recurrent gastric volvulus. All underwent modifiedlaparoscopic-Hill-Snow repair. Contrast study showed sliding hiatal hernia in 55 patients (81%), while endoscopy demonstrated 16 cases of histologically severe esophagitis (23.5%) and 52 of mild esophagitis (76.5%). No intraoperative/postoperative complications were recorded. 60patients had a complete follow-up (range 1-20 years). 60/68 patients were evaluated with bariumswallow-study at 6-12 months; 40/68 patients with upper-gastrointestinal-endoscopy at 12months. No relapse was reported. 50 patients (73.7%) were symptom-free. 18 (26.3%) referred occasional epigastric pain, associated with vomit in 2 cases. 64 (94.1%) referred ability to vomit; 4 temporary difficulty to swallow (average 30 days). All patients reported being able to burp. 3(4.5%) presented episodes of gas-air-bloat during the first 2 months with spontaneous resolution. No case of dumping syndrome was recorded. This technique's modification yields excellent results in term of relapse and side effects at long-term followup. We reported the first and largest pediatric series in non-neurological children with encouraging results. [ABSTRACT FROM AUTHOR]

Introduction: Gastric volvulus (GV) is a rare and life-threatening condition if not promptly diagnosed and treated. Extreme rotation can cause obstruction cutting off blood supply to stomach and distal organs, leading to ischemia and necrosis. It is a clinically significant cause of acute/recurrent abdominal pain and chronic vomiting in children. GV can be classified into the following: primary, secondary, organoaxial, mesenteroaxial, or combined, acute, or chronic. Materials and Methods: Six neonates (5 males-1 female) were admitted to our department for recurrent postprandial vomiting associated with paleness, hyporeactivity, transitory abdominal distension, failure to thrive, and respiratory infections (only-1). Median age: 6 months (range 2-9 months). Patients metabolic and neurological evaluations were normal. A barium-swallow-study (upper gastrointestinal [UGI]) allowed definitive diagnosis. Results: UGI and esophagogastroduodenoscopy (EGDS) showed a gastric abnormal dilatation (gastric fundus), hiatal hernia (HH) in 5 patients, a large/small curvature discrepancy in 3 patients. Four were chronic-organoaxial-GV, 2 chronic-mesenteroaxial-GV. All underwent Laparoscopic-Hill-Snow-gastropexy (LHSG) with HH correction. No intraoperative/postoperative complications were recorded. Refeeding started in first postoperative day. Average hospital stay: 6-days. At long-term follow-up, all patients were symptoms free (able to vomit/burp); 2 referred occasionally epigastric pain sometimes with vomit. At 10-12 years follow-up UGI and EGDS confirmed correct gastric position revealing gastroduedenitis. Discussion: GV is a rare clinical entity in children considering etiology and management with an important morbidity and mortality rate. Its diagnosis could be missed simply. Vomiting or HH on imaging studies should suggest GV regardless patient's stable appearance. Conclusions: Chronic GV can manifest with atypical chest, abdominal, and gastrointestinal symptoms. Early diagnosis and treatment reduce the risk of developing acute form. LHSG is a long-term effective and safe solution with a very low complication rate, and no symptoms correlated to Nissen procedure. [ABSTRACT FROM AUTHOR]

Infantile Hemangiomas (IH) are the most common benign tumor of infancy, occurring in over 10% of newborns. The head and neck is the most frequently affected area (60%), and the scalp is a typical site for such large lesions. Scalp-IHs are usually focal lesions that can be both disfiguring and may lead to complications such as ulceration and bleeding. We describe a case of a 30-months old female who presented a large scalp-IH at birth that rapidly grew in the first year of life. Topical and systemic treatments (with timolol ointment and oral propranolol, respectively) were not effective in reducing dimensions of the hemangioma. After vascular imaging study, the patient underwent surgical resection of the IH and primary closure with excellent cosmetic outcome. When medical therapy is ineffective or cosmetic and functional integrity is threatened, early surgery allows to completely removing large scalp-IHs, with good cosmetic results. [ABSTRACT FROM AUTHOR]

Introduction: The management of primary spontaneous pneumothorax (PSP) in children still remains controversial. The current literature shows a lack of scientific evidence supporting a standardized management. Materials and Methods: A multicenter retrospective study was performed, patients admitted for PSP in five Pediatric Surgical Units over a 9-year period (from 2008 to 2017) were included. Patient data were reviewed for each case. Management and outcomes were statistically analyzed. Results: Overall 159 patients (135 males and 24 females) were included in this study. During the first hospital admission, 62/159 patients (39%) were conservatively managed with oxygen therapy; 95/159 patients (60%) required a chest drain insertion; 2/159 patients (1%) underwent surgery because of a bilateral pneumothorax. Thoracoscopy was performed in 75/159 (47%) patients after the second hospital admission or for persistent air leak during the first access. Postoperatively, 8/75 (11%) patients developed recurrent pneumothorax requiring chest drain insertion in 3/8 (37%) cases or aspiration in 1/8 (13%), whereas 4/8 (50%) patients were conservatively managed. All of the patients but one, were confirmed to be affected by emphysematous-like changes at histology. Conclusions: Despite the limitations of being a retrospective study, we suggest that the early surgical management in children with PSP is feasible and safe and it seems to significantly reduce the recurrence rate. To the best of our knowledge there are no pediatric guidelines for the management of PSP, therefore, we support the need for prospective studies to create the evidence-based pillars for correct and standardized management of this condition. [ABSTRACT FROM AUTHOR]

The SIVI (Italian Society of Videosurgery in Infancy) guidelines are clinical practice guidelines edited and approved by the Society's steering committee. They are the products of a detailed systematic review of the literature, integrated with expert opinion in the field of pediatric minimally invasive surgery. These guidelines are intended to assist the pediatric surgeons experienced or not experienced in minimally invasive surgery, with the goal to inform choices related to the indications, approach, and techniques to use when treating the major pediatric surgical pathologies. Given the complexities of congenital malformations and other pediatric surgical conditions, as well as large variations in available regional health services, we must note that these guidelines are not intended as a cookbook recipe to follow for all possible patients. Rather, the guidelines should serve as a flexible framework, to be used by the physician in concert with the parents, to choose the best approach for each individual patient. Decisions tailored to available scientific knowledge and the needs and desires of the patient's family serve both patient autonomy and medical science. All guidelines are published in this scientific Journal, in order to ensure their availability to all physicians. The Guidelines project has been approved by the SIVI General Assembly of the 2016 Madrid congress. Review of guidelines has been performed by the Steering Committee of SIVI and experts. [ABSTRACT FROM AUTHOR]

The SIVI (Italian Society of Videosurgery in Infancy) guidelines are clinical practice guidelines edited and approved by the Society's steering committee. They are the products of a detailed systematic review of the literature, integrated with expert opinion in the field of pediatric minimally invasive surgery. These guidelines are intended to assist the pediatric surgeons experienced or not experienced in minimally invasive surgery, with the goal to inform choices related to the indications, approach, and techniques to use when treating the major pediatric surgical pathologies. Given the complexities of congenital malformations and other pediatric surgical conditions, as well as large variations in available regional health services, we must note that these guidelines are not intended as a cookbook recipe to follow for all possible patients. Rather, the guidelines should serve as a flexible framework, to be used by the physician in concert with the parents, to choose the best approach for each individual patient. Decisions tailored to available scientific knowledge and the needs and desires of the patient's family serve both patient autonomy and medical science. All guidelines are published in this scientific Journal, in order to ensure their availability to all physicians. The Guidelines project has been approved by the SIVI General Assembly of the 2016 Madrid congress. Review of guidelines has been performed by the Steering Committee of SIVI and experts. [ABSTRACT FROM AUTHOR]

The SIVI (Italian Society of Videosurgery in Infancy) guidelines are clinical practice guidelines edited and approved by the Society's steering committee. They are the products of a detailed systematic review of the literature, integrated with expert opinion in the field of pediatric minimally invasive surgery. These guidelines are intended to assist the pediatric surgeons experienced or not experienced in minimally invasive surgery, with the goal to inform choices related to the indications, approach, and techniques to use when treating the major pediatric surgical pathologies. Given the complexities of congenital malformations and other pediatric surgical conditions, as well as large variations in available regional health services, we must note that these guidelines are not intended as a cookbook recipe to follow for all possible patients. Rather, the guidelines should serve as a flexible framework, to be used by the physician in concert with the parents, to choose the best approach for each individual patient. Decisions tailored to available scientific knowledge and the needs and desires of the patient's family serve both patient autonomy and medical science. All guidelines are published in this scientific Journal, in order to ensure their availability to all physicians. The Guidelines project has been approved by the SIVI General Assembly of the 2016 Madrid congress. Review of guidelines has been performed by the Steering Committee of SIVI and experts. [ABSTRACT FROM AUTHOR]

Background: Thoracoscopic correction of esophageal atresia (EA) with tracheoesophageal fistula (TEF) has been increasingly widespread, but is still one of the most advanced pediatric surgical skills. This procedure has a challenging learning curve, and usually initially requires a longer operative time than the open approach; furthermore to perform this intervention, the surgeon must be very experienced in endocorporeal knotting. In our opinion, standardization of the technique and the application of "tricks" (including the use of titanium endoclips for TEF closure) to make surgical steps easier, faster, and safe would be useful to the surgeon and to the patient above all. Materials and Methods: We present our experience in thoracoscopic treatment of EA/TEF over the past 12 years; during this period, we have treated 32 neonates. We reviewed all patient clinical records evaluating demographics, surgical technique, postoperative period, and long-term follow-up. Results: Thirty-one patients were affected by type C EA (five presented with a long-gap defect); one by type E EA. Mean gestational age was 36 + 5 weeks (29-41). Mean weight at surgery was 2340 g (990-3715 g). Through a transpleural thoracoscopic approach, after Azygos vein division, TEF was closed by sutures (silk/polydioxanone [PDS]) in 4 patients while in the remaining 28 two 5 mm titanium endoclips were applied. Esophageal anastomosis was then performed with 8-12 interrupted 5/0 absorbable sutures. We had two intraoperative complications in endoclips application (migration and misplacement), which were immediately resolved. After a contrast study on sixth to seventh postoperative day (average eighth), in the absence of leakage, oral feeding was started and chest tube removed. Four to six weeks after surgery, patients underwent endoscopic evaluation. At a follow-up of 9 years, we had no postoperative complications due to endoclips: neither TEF recurrence, nor problems due to clips dislocation. Conclusions: Although the benefits of thoracoscopic correction of EA/TEF are still discussed, we agree with this part of recent literature that considers thoracoscopic approach as a feasible, safe, and advantageous alternative to the traditional open approach. We also want to emphasize that in our experience, TEF closure by titanium endoclips is fast, reducing operative time, and effective, with no reported long-term complications in our case series. Overall success rate after clips application is, in our series, 100%. The only limit we have found, above all for low-weight patients, is the diameter of the clip applier which needs a 5 mm access even if the surgeon uses 3 mm operative instruments. [ABSTRACT FROM AUTHOR]

Objective. Duodenal atresia (DA) routinely has been corrected by laparotomy and duodenoduodenostomy with excellent long-term results. We revisited the patients with DA treated in the last 12 years (2004–2016) comparing the open and the minimally invasive surgical (MIS) approach. Methods. We divided our cohort of patients into two groups. Group 1 included 10 patients with CDO (2004–09) treated with open procedure: 5, DA; 3, duodenal web; 2, extrinsic obstruction. Three presented with Down’s syndrome while 3 presented with concomitant malformations. Group 2 included 8 patients (2009–16): 1, web; 5, DA; 2, extrinsic obstruction. Seven were treated by MIS; 1 was treated by Endoscopy. Three presented with Down’s syndrome; 3 presented with concomitant malformations. Results. Average operating time was 120 minutes in Group 1 and 190 minutes in Group 2. In MIS Group the visualization was excellent. We recorded no intraoperative complications, conversions, or anastomotic leakage. Feedings started on 3–7 postoperative days. Follow-up showed no evidence of stricture or obstruction. In Group 1 feedings started within 10–22 days and we have 1 postoperative obstruction. Conclusions. Laparoscopic repair of DA is one of the most challenging procedures among pediatric laparoscopic procedures. These patients had a shorter length of hospitalization and more rapid advancement to full feeding compared to patients undergoing the open approach. Laparoscopic repair of DA could be the preferred technique, safe, and efficacious, in the hands of experienced surgeons. [ABSTRACT FROM AUTHOR]

Nowadays laparoscopic Nissen fundoplication represents the gold standard in surgical treatment of complicated Gastro-Esophageal-Reflux Disease (GERD), above all in cerebral palsy patients. In non-neurological patients without gastrostomy Nissen fundoplication can create some problems (gas bloat syndrome, dysphagia). Laparoscopic Hill-Snow repair is an established surgical alternative, but it is reported only in adult population. We describe our modification of Hill-Snow technique and our experience in a large series of non-neurological children in order to report its effectiveness and applicability in pediatric patients affected by complicated GERD. Between 2000 and 2022, 319 children underwent surgical correction of gastro-esophageal reflux at our Department. All were affected by complicated gastro-esophageal reflux unresponsive to PPI (Proton Pump Inhibitors). 251 underwent laparoscopic Nissen fundoplication; 68 non-neurological patients underwent laparoscopic Hill-Snow repair. Of these 68 children 48 were males (71%) and 20 females (29%); median age was 5years (3 months-11 years). Weight range was 4-37kg. 52 patients (76.5%) presented the following symptoms: retrosternal pain, dysphagia, regurgitation, coughing, failure to thrive, persisting reflux esophagitis. 16 (23.5%) had chronic respiratory problems (aspiration, apneic-spells, dysphagia, coughing, choking, gagging). For 8 (11.8%) symptoms were expression of chronic recurrent gastric volvulus. All underwent modified-laparoscopic-Hill-Snow repair. Contrast study showed sliding hiatal hernia in 55 patients (81%), while endoscopy demonstrated 16 cases of histologically severe esophagitis (23.5%) and 52 of mild esophagitis (76.5%). No intraoperative/postoperative complications were recorded. 60patients had a complete follow-up (range 1-20 years). 60/68 patients were evaluated with barium-swallow-study at 6-12 months; 40/68 patients with upper-gastrointestinal-endoscopy at 12months. No relapse was reported. 50 patients (73.7%) were symptom-free. 18 (26.3%) referred occasional epigastric pain, associated with vomit in 2 cases. 64 (94.1%) referred ability to vomit; 4 temporary difficulty to swallow (average 30 days). All patients reported being able to burp. 3(4.5%) presented episodes of gas-air-bloat during the first 2 months with spontaneous resolution. No case of dumping syndrome was recorded. This technique's modification yields excellent results in term of relapse and side effects at long-term follow-up. We reported the first and largest pediatric series in non-neurological children with encouraging results.

Infantile Hemangiomas (IH) are the most common benign tumor of infancy, occurring in over 10% of newborns. The head and neck is the most frequently affected area (60%), and the scalp is a typical site for such large lesions. Scalp-IHs are usually focal lesions that can be both disfiguring and may lead to complications such as ulceration and bleeding. We describe a case of a 30-months old female who presented a large scalp-IH at birth that rapidly grew in the first year of life. Topical and systemic treatments (with timolol ointment and oral propranolol, respectively) were not effective in reducing dimensions of the hemangioma. After vascular imaging study, the patient underwent surgical resection of the IH and primary closure with excellent cosmetic outcome. When medical therapy is ineffective or cosmetic and functional integrity is threatened, early surgery allows to completely removing large scalp-IHs, with good cosmetic results.

Majority of sequestrations fall into two categories: Intra-Lobar (ILS) and Extra-Lobar (ELS). Rarely the abnormal lung could be attached to the gastrointestinal tract, Bronchopulmonary Foregut Malformation (BPFM). We described a case of a girl of 3-years-old with antenatal diagnosis of left intrathoracic mass of the inferior lobe. Postnatal Computed-Tomography (CT) revealed a bilateral ELS with an isthmic bridge crossing the vertebral spine. She follows a MRI follow-up at 18months/30months confirming the lesion. Before surgery, a three-dimensional-CT-angiography was performed to study the mass, its blood supply and to plan surgery. She underwent to thoracoscopic resection. Two aberrant blood vessels were dissected from the thoracic aorta and ligated. The postoperative course was uneventful. She was discharged after 3 days. The rarity of our case is due to the bilateral extension. An appropriate preoperatory imaging study is necessary for the success of surgery while thoracoscopy is particularly appropriate in surgical treatment.

In the last three decades, fetal ovarian cysts were diagnosed more frequently, due to technological improvement and the increasing use of prenatal screening ultrasound. Nonetheless, treatment uncertainties are still present, either prenatally or postnatally. Recently, significant innovations on diagnosis and treatment have been proposed and a more conservative, minimally invasive approach may be offered to the Pediatrician or the Surgeon who face with this condition during prenatal or neonatal age. (...).

Throughout history, the pediatric laparoscopic nephrectomy was first described at the beginning of the Nineties by Erlich and colleagues in a child and by Koyle and colleagues in an unweaned patient. (...).

Esophageal Atresia (EA) is defined as an interruption in esophageal continuity that results in a proximal tract that ends in a blind pouch in 98% of cases, and a distal tract that in 87% of cases arises via a Fistula from the Trachea (TEF). (...).

The hydronephrosis, characterized by the dilation of the renal pelvicalyceal system with possible functional damage to the renal parenchyma, is the most common congenital abnormality of the urinary system detected in utero through the prenatal ultrasound screening. (...).

Epididymal cysts (ECs) are relatively common in adults, rare in children. Normally their treatment is conservative. They may be situated anywhere in the organ, frequently in the region of the head. Torsion of these cysts is extremely rare in both children and adults, causing acute scrotal swelling. The diagnosis is intraoperative. A 16-year-old boy was referred to our Divisional Clinic by the treating physician for scrotal swelling appeared 4 months earlier. Absence of a history of minor scrotal trauma. Ultrasonography showed a 40×50 mm fluid-filled right para-testicular mass. We performed surgery finding a large black cyst connected to the head of the epididymis with 720°-degrees rotation. Histology revealed an acquired EC. The particularity of our case is due to the absence of symptoms in association with a big EC twisted of 720° degrees. This is the only case reported in literature. All patients with EC torsion reported presented symptoms related to acute scrotum.

Horseshoe kidney (HSK) is a congenital defect of the urinary tract that occurs in 0.25% of the general population. Laparoscopic Vascular Hitch (LVH) according to Hellstrom-Chapman represent an alternative approach in treatment of extrinsic hydronephrosis by crossing vessels (CV) in pediatric age. In our Department from 2006 to 2016, 36 children with extrinsic-Uretero-Pelvic-Junction (UPJ)-Obstruction (UPJO) underwent laparoscopic vessels transposition. Over the last 4years, we have treated three patients with extrinsic hydronephrosis in HSK; two males and one female respectively of 6, 7 and 8years. The side affected was the left in all patients; symptoms of onset: recurrent abdominal pain, vomiting with associated intermittent hydronephrosis at ultrasonography. The preoperative examinations performed were: ultrasound/Doppler scan, MAG3-renogram, functional-magnetic-resonance-urography (fMRU). Mean operative time was 120'; median hospital stay 3- days. Intraoperative diuretic-test (DT) confirmed an extrinsic-UPJO in all patients. No JJ-stents and drain were used and there were no perioperative complications. Clinical and ultrasound follow-up (18 months-4 years) show resolution of symptoms and decrease in hydronephrosis grade in all patients. Our series is the largest in pediatric population by a revision of the literature. We believe that LVH is feasible in patients with symptomatic hydronephrosis by CV in HSK. Intraoperative-DT and the correct selection of patients are crucial to the success of the technique. According to us, this procedure is appropriate in those cases where the UPJ-anatomy is disadvantageous to a resection/re-anastomosis between ureter and renal pelvis. Our initial results are encouraging, although long-term follow- up and a more significant patient sample are required.

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