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In Australia and most other invaded locations, rates of range expansion by the European shore crab, Carcinus maenas, are typically only a few kilometres per year, despite a planktonic duration upwards of 50 days and off-shore larval development. This relatively static distribution is punctuated by rare episodes of long-distance and large-scale spread, some of which appear to be related to unusual oceanographic conditions and some of which are likely to be human assisted. These observations suggest, first, that long planktonic duration and off-shore development in a marine invertebrate does not preclude very localised recruitment, and, second, that this recruitment norm may be punctuated by brief episodes of wide scale mixing of propagules. Punctuated dispersal has previously been suggested to account for large-scale biogeographic patterns of distribution and speciation, but may also have implications for the processes that stabilise structured spatial metapopulations.

Byline: F. N. Hofman (1), N. M. A. Bax (1), D. C. van der Zee (1), W. L. M. Kramer (1) Keywords: Necrotising enterocolitis; Surgery; Primary anastomosis; Enterostomy Abstract: The ideal surgical management of neonates with necrotising enterocolitis (NEC) is still a matter of debate. The purpose of this study was to compare the results of bowel resection with primary anastomosis with the results of bowel resection with enterostomy. Sixty-three neonates with NEC had a bowel resection in the acute phase of the disease in the period between February 1990 and March 2001. Thirty-four of them (54%) underwent resection of the bowel with primary anastomosis (Group A), and 29 (46%) had resection with enterostomy (Group B). Group A had a lower gestational age and lower birth weight. Mortality, complication rate, and postoperative weight gain were not significantly different between the groups. However, Group B had a significantly longer primary hospital stay (80+-49 days versus 58+-31 days, P&lt 0.04) and needed a 2nd hospital stay for restoring gastrointestinal continuity. For both reasons, it can be argued that primary anastomosis is superior to enterostomy after resection. Author Affiliation: (1) Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center, P.O. Box 85090, 3508 AB , Utrecht, The Netherlands Article History: Registration Date: 29/04/2004 Accepted Date: 09/01/2004 Online Date: 09/06/2004

Background: In 1998, the one-year experience in minimally invasive abdominal surgery in children at a pediatric training center was assessed. Seven years later, we determined the current status of pediatric minimally invasive surgery in daily practice and surgical training., Methods: A retrospective review was undertaken of all children with intra-abdominal operations performed between 1 January 2005 and 31 December 2005., Results: The type of operations performed ranged from common interventions to demanding laparoscopic procedures. 81% of all abdominal procedures were performed laparoscopically, with a complication rate stable at 6.9%, and conversion rate decreasing from 10% to 7.4%, compared to 1998. There were six new advanced laparoscopic procedures performed in 2005 as compared to 1998. The children in the open operated group were significantly smaller and younger than in the laparoscopic group (p < 0.001 and p = 0.001, respectively). The majority (64.2%) of the laparoscopic procedures were performed by a trainee. There was no difference in the operating times of open versus laparoscopic surgery, or of procedures performed by trainees versus staff surgeons. Laparoscopy by trainees did not have a negative impact on complication or conversion rates., Conclusions: Laparoscopy is an established approach in abdominal procedures in children, and does not hamper surgical training.

Background: Few studies are available comparing open with laparoscopic treatment of Hirschsprung's disease. This study compares a laparoscopic series of 30 patients with a historical open series of 25 patients., Methods: The charts of all patients having had a Duhamel procedure in the period from June 1987 through July 2003 were retrospectively reviewed. Open procedures were performed until March 1994. Patients with extended aganglionosis, pre-Duhamel ostomy, or syndrome were excluded from the study. End points were intraoperative complications, postoperative complications, time to first feeding, hospital stay, and outcome at follow-up such as stenosis, enterocolitis, constipation, fecal incontinence, and enuresis., Results: Twenty-five patients had an open Duhamel (OD) and 30 had a laparoscopic one (LD). There were no differences in patient characteristics and there were no intraoperative complications in either group. Time to first oral feeds was significantly longer in the OD group as was the duration of hospital stay. No significant differences at follow-up were observed but there was a tendency for a higher enterocolitis rate in the LD group. In contrast, the adhesive obstruction and enuresis rates were higher in the OD group. Cosmetic results were superior in the LD group., Conclusions: Except for a significantly shorter hospital stay and shorter time to first oral feeds in favor of LD, no significant differences could be observed. The cosmetic result was not an end point but there was no doubt that it was better in the LD group. Although not statistically significant different, there were no adhesive bowel obstructions in the LD group compared with 3 of 25 in the OD group. Fecal incontinence was not encountered in either group.

Background: Life-threatening events resulting from tracheomalacia are a well-known complication of infants with esophageal atresia. Aortopexy is accepted as the most effective method for managing severe life-threatening and localized tracheomalacia with a success rate of 85% to 90%. Since the advent of minimally invasive surgery (MIS), the procedure also can be performed using thoracoscopic MIS., Methods: Between January 2002 and November 2005, six children with esophageal atresia were treated using MIS for life-threatening events attributable to tracheomalacia., Results: The patients tolerated the thoracoscopic procedure well, and all tracheoaortopexies could be performed thoracoscopically. There were two recurrences, which could be treated using thoracoscopy. After a follow-up period of 27 months (range, 10-45 months), all the patients are doing well and have had no more life-threatening events., Conclusions: Although this is the largest thoracoscopic series to date, the series is too small for any conclusions yet to be drawn. Thoracoscopic tracheoaortopexia is feasible and offers the advantages of MIS.

Background: Percutaneous and open liver biopsies are routine procedures for diagnosing liver pathology. However, the procedure can carry significant morbidity and even mortality, especially in the event of an uncorrectable coagulopathy or a highly vascular tumor., Methods: A technique described for use in such circumstances involves laparoscopy for identification of the lesion to be biopsied, enables placement of a gelatin hemostatic plug in the core biopsy tract, and confirms hemostasis after percutaneous plugging of the biopsy site., Results: The technique was successfully used for seven patients: six patients with hepatic coagulopathy and one with a highly vascular liver tumor. There were no complications during either the intra- or postoperative period. The patients experienced minimal postoperative discomfort and returned to baseline activity on the first postoperative day., Conclusion: The authors believe that the described technique of biopsy site plugging offers a safe alternative for liver biopsy among patients with an uncorrectable coagulopathy and those requiring a biopsy before correction of the bleeding disorder.

Background: Nissen fundoplication is the most popular laparoscopic operation for the management of gastroesophageal reflux disease (GERD). Partial fundoplications seem to be associated with a lower incidence of postoperative dysphagia, and thus a better quality of life for patients. The aim of this study was to compare the long-term outcome in neurologically normal children who underwent laparoscopic Nissen, Toupet, or Thal procedures in three European centers with a large experience in laparoscopic antireflux procedures., Methods: This study retrospectively analyzed the data of 300 consecutive patients with GERD who underwent laparoscopic surgery. The first 100 cases were recorded for each team, with the first team using the Toupet, the second team using the Thal, and the third team using the Nissen procedure. The only exclusion criteria for this study was neurologic impairment. For this reason, 66 neurologically impaired children (52 Thal, 10 Nissen, 4 Toupet) were excluded from the study. This evaluation focuses on the data for the remaining 238 neurologically normal children. The patients varied in age from 5 months to 16 years (median, 58 months). The median weight was 20 kg. All the children underwent a complete preoperative workup, and all had well-documented GERD. The position of the trocars and the dissection phase were similar in all the procedures, as was the posterior approximation of the crura. The short gastric vessels were divided in only six patients (2.5%). The only difference in the surgical procedures was the type of antireflux valve created., Results: The median duration of surgery was 70 min. There was no mortality and no conversion in this series. A total of 12 (5%) intraoperative complications (5 Nissen, 5 Toupet, 2 Thal) and 13 (5.4%) postoperative complications (3 Toupet, 4 Nissen, 6 Thal) were recorded. Only six (2.5%) redo procedures (2 Thal, 2 Toupet, 2 Nissen) were performed. After a minimum follow-up period of 5 years, all the children were free of symptoms except nine (3.7%), who sometimes still require medication. The incidence of complications and redo surgery for the three procedures analyzed with the Mann-Whitney U test are not statistically significant., Conclusions: For pediatric patients with GERD, laparoscopic Nissen, Toupet, and Thal antireflux procedures yielded satisfactory results, and none of the approaches led to increased dysphagia. The 5% rate for intraoperative complications seems linked to the learning curve period. The authors consider the three procedures as extremely effective for the treatment of children with GERD, and they believe that the choice of one procedure over the other depends only on the surgeon's experience. Parental satisfaction with laparoscopic treatment was very high in all the three series.

Background: The improved outcome after endoscopic surgery has been attributed to less surgical trauma. However, the underlying mechanisms are not fully understood, and direct effects of CO2 used for pneumoperitoneum, cellular acidification, and/or the lack of air contamination have been postulated to additionally modulate immune functions during endoscopic surgery. We investigated the effects of CO2 incubation, extracellular acidification, and air contamination on the inflammatory response of two distinct macrophage populations., Methods: R2 and NR 8383 rat macrophage cell lines were used. Interleukin-6 (IL-6) and nitric oxide after lipopolysaccharide (LPS) stimulation were determined in these sets of experiments: incubation in 100% CO2, 5% CO2, and room air for 2h; incubation at pH 7.4, 6.5, and 5.5 for 2 h in 5% CO2; and incubation in 100% CO2, 5% CO2 and room air in fixed pH 6.3. The extracellular pH was monitored during incubation. We determined the alteration of intracellular pH in cells subjected to extracellular acidification by fluorescence microscopy., Results: Extracellular pH decreased to 6.3 during 100% CO2 incubation. IL-6 release was reduced after CO2 incubation in NR 8383 cells and increased in R2 cells (p < 0.05). It was not altered by air incubation. Decreasing the extracellular pH to 6.5 mimicked the effects of CO2 and a decrease to 5.5 suppressed IL-6 release in both cell lines. In fixed pH at 6.3, CO2 and air incubation had no effect. CO2 and pH had no impact on nitric oxide release and vitality. Intracellular pH decreased with extracellular acidification without significant difference between the two cell lines., Conclusions: A decrease in extracellular pH during incubation in CO2 differentially affects IL-6 release in macrophage subpopulations. This may explain contradictory results in the literature. Moreover, we demonstrated that air contamination does not affect macrophage cytokine release. The decrease in extracellular pH is the primary underlying mechanism of the alteration of macrophage cytokine release after CO2 incubation, and it appears that the ability to maintain intracellular pH is not determined by the effects of CO2 or extracellular acidification.

Background: The adoption of laparoscopic pyloromyotomy (LPM) by pediatric surgeons has been limited due to concerns about long execution times and higher-than-expected morbidity. The aim of the present study was to examine the performance of LPM by pediatric surgeons during the initial stages of their experience., Methods: Complete videotapes of 50 early LPM performed in one hospital were subjected to Observational Clinical Human Reliability Analysis (OCHRA) by an independent team., Results: This series had a total morbidity of 6% (one intraoperative bleed, one gastric perforation, one incomplete pyloromyotomy). Using OCHRA, we identified 77 consequential and 233 inconsequential errors (mean of 6 +/- 5.4 per operation, 16.7% total error probability) during an average operative time of 29.8 min. Eighty percent of the errors were of the execution type. A high probability of error was observed with the use of the following key instruments: holding graspers (68%), retractable blade (79%), and splitting forceps (77%). The OCHRA system confirmed that task III was the hazard zone for LPM. Excessive force (task III) resulted in gastric perforation and bleeding from the pyloric mass. Movement in the wrong direction and misorientation in tissue planes were the external error modes underlying misaligned cuts of the pyloric mass and poor tissue splitting (task zones II and III)., Conclusions: This early series of LPM was associated with an appreciable execution error rate, largely due to the poor functionality of the specific instruments used for the procedure. Human factors identified by the external error modes played a subsidiary but important role, underscoring the importance of skills training and experience (proficiency-gain curve).

Background: There has been discussion about the value of laparoscopic pyloromyotomy (LP) for the treatment of hypertrophic pyloric stenosis (HPS). In their initial small series, the authors reported a relatively high complication rate. The current study was undertaken to investigate the influence of experience with LP on operative time, complication rate, and postoperative hospital stay for a large number of patients., Methods: Between October 1993 and March 2002, 182 children underwent LP for HPS. These procedures involved 11 surgeons, 4 consultants, and 7 trainees. The end points of the study were operative time, complications, and postoperative hospital stay. The outcome of 146 LPs performed after July 1996 was compared with the outcome of 36 LPs performed before that period., Results: There was no significant difference in the mean operative time between the two series, but the operative time per surgeon dropped with experience. Mucosal perforation was experienced by 8.3% of the patients in the initial series, as compared with 0.7% in the later series. Insufficient pyloromyotomy occurred in 8.3% of the initial series, as compared with 2.7% of the later series. Other minor complications such as wound infection were infrequent and not influenced by further experience. Major wound-related problems did not occur. The LP procedure was easily learned by novices. After about 15 pyloromyotomies, the operative time was approximately 25 min. The length of postoperative hospital stay also dropped with increasing experience., Conclusions: The value of LP for the treatment of HPS has been proved. The LP procedure is as quick as the open procedure, has a low morbidity, and is devoid of major wound-related problems. Moreover, the procedure seems to be well teachable.

Background: Early feeding after pyloromyotomy for hypertrophic pyloric stenosis (HPS) has been advocated because this would lead to earlier discharge. However, some authors remain reluctant to introduce early feeding because of concern about postoperative vomiting. This study aimed to clarify the effects of early versus later feeding after laparoscopic pyloromyotomy on postoperative vomiting, time required to reach full oral feeding, hospital stay, and follow-up evaluation., Methods: During the period from October 1993 through March 2002, 185 infants underwent laparoscopic pyloromyotomy for HPS. Of these patients, 164 patients were included in the study. The initial feeding was within 4 h after surgery in group A and after 4 hours in group B. The outcome variables were postoperative vomiting subdivided into vomiting requiring adjustment of the feeding schedule or not, time required to reach full feeding, hospital stay, and vomiting as well as weight gain at follow-up assessment., Results: In 23% of the 62 patients of group A and in 6% of the 102 patients of group B (p = 0.003), vomiting was so severe that it necessitated modification of the feeding schedule. Th time required to reach full feeding and the postoperative hospital stay were similar in the two groups. Analysis of the subgroups that required modification of the feeding schedule because of vomiting showed a significant delay in time required to reach full feedings as well as a significant delay in hospital discharge. There was an 11% incidence of ongoing vomiting after discharge irrespective of early or later feeding. Weight gain at follow-up assessment did not differ significantly between the two groups, and did not bear any relations to in-hospital vomiting., Conclusions: Feeding within 4 h postoperatively leads to more severe vomiting than later feeding. Vomiting leads to discomfort for the child, anxiety for the parents, a prolonged time required to achieve full oral feeding, and a prolonged postoperative hospital stay. However, clinical outcome after discharge is not adversely affected by early feeding. According to this study, it appears that it would be better to withhold feeding for the first 4 h after surgery.

Background: Sacrococcygeal teratomas (SCT) are classically approached posteriorly through an inverted chevron incision. In large, external, mainly solid SCT, prior interruption of the arterial supply is warranted because of impending heart failure and life-threatening hemorrhagic diathesis. Hitherto, this has required prior laparotomy. A laparotomy is also added when the tumor extends presacrally into the pelvis. The presacral region is, however, difficult to access. A laparoscopic-assisted approach seems to offer a solution for both problems., Methods: A laparoscopic-assisted approach was used in five patients with SCT. In one neonate, it was used to interrupt the arterial blood supply only; in the other four patients, it was used to dissect the internal extension of the tumor., Results: Laparoscopic interruption of the median sacral artery proved to be simple in the neonate with a large, external, mainly solid SCT. In three of the remaining four patients with presacral extension of the tumor, good visualization and dissection of the intrapelvic portion of the tumor was obtained. In one patient, the procedure had to be converted because of a lack of working space due to extensive intraabdominal growth of the tumor., Conclusion: A laparoscopic-assisted approach seems to be ideal for SCT. It provides the opportunity to interrupt the median sacral artery before the dissection. Moreover, it enables far better access to the presacral area than the conventional surgical approach when the SCT extends presacrally into the pelvis. Such a meticulous laparoscopic dissection may improve the functional results.

Background: Esophageal atresia (EA) has always been considered the hallmark of pediatric surgery. In the past decade, mortality was primarily the result of associated diseases, and operative morbidity had greatly improved. Yet the consequences of opening the thoracic cavity remained unchanged. In the era of endoscopic surgery, a thoracic approach to EA has become feasible, but is it of benefit for the patient?, Methods: Between May 2000 and June 2002, 13 neonates underwent thoracoscopic repair of EA. There were 12 boys and 1 girl. Mean gestational age was 36.9 weeks. Mean weight was 3093 g. Eleven children had associated anomalies., Results: All of the procedures were performed thoracoscopically. There were no intraoperative complications, although anastomosis was difficult in one patient due to an extensive distance between the two stumps. Mean operating time was 2.6 h (range, 1.45-3.5). Five short-term postoperative complications occurred. Four of the early patients had stenosis due to a too-small incision in the proximal pouch, which needed one or more dilatations. One of these children, as well together as one other child, had anastomotic leakage, which was treated conservatively. Late complications consisted of gastroesophageal reflux ( n = 5) and tracheomalacia ( n = 1); these conditions required endoscopic correction in, respectively, two and one cases. Feeding by nasogastric tube was started after 3.5 days (mean), and total oral feeding was possible after 8.6 days (mean). Mean hospitalization was 12.2 days. Mean follow-up was 15.2 months. Scar formation was minimal, and the thoracic cage was preserved., Conclusion: The feasibility of thoracoscopic repair of EA has already been demonstrated. Today, its results in terms of operating time, feeding, hospital stay, and postoperative complications are equal to open procedures. Its advantages include better cosmesis and preservation of the thorax.

Background: The aim of this study was to investigate the feasibility and results of laparoscopic antireflux procedure in neurologically impaired children., Methods: Over a 5-yr period, 259 children affected by gastroesophageal reflux disease underwent laparoscopic antireflux procedure. Eighty of them (30.8%) were neurologically impaired. In 58 children we performed an anterior fundoplication according to Thal and in 22 patients a 360 degrees fundoplication according to Nissen. Forty-eight children underwent an associated gastrostomy placement at the same time as the laparoscopic antireflux procedure., Results: We recorded 4/80 intraoperative complications; in all cases the complication was managed laparoscopically and no conversion was needed. Follow-up ranged from 6 months to 6 yrs (median 3 yrs). We recorded 24/80 postoperative complications, 5 of which required a redo procedure. We have a mortality rate of 17.5% but in only one case was the event related to the antireflux procedure., Conclusions: Laparoscopic fundoplication can be performed safely and with acceptable results in neurologically impaired children. The indication to add a gastrostomy should be tailored to the needs of the individual patient. Mortality rate in neurologically impaired children patients with gastroesophageal reflux disease is high but in most cases unrelated to the antireflux procedure.

Background: Persistent hyperinsulinemic hypoglycemia of infancy (PHHI) is a heterogeneous condition. A number of children have focal lesions, and removal of these lesions is curative. However, these lesions are difficult to detect, even during surgery. A laparoscopic approach is beneficial., Methods: Two children with PHHI underwent laparoscopic pancreatic inspection at 32 and 29 days of age, respectively., Results: In both children, a lesion was easily found in the head of the pancreas. The lesions looked more lobular, had a more pronounced blood supply, and appeared to have a firmer texture than the remaining pancreas. Enucleation was curative., Conclusion: A laparoscopic approach seems to be ideal for patients with PHHI not only because of the magnification but also because of the delicate surgery it allows and the avoidance of major abdominal wall problems.

Background: Advantages of laparoscopic surgery have, among other factors, been attributed to a shorter length of abdominal incision and the use of CO2 versus air. An analysis of these factors taking pressure-induced alterations into account is lacking. The objective of the study was to determine the impact of laparoscopy and laparotomy with exposure to CO2 and room air under a similar pressure on local, systemic, and distant organ immune responses., Methods: Twenty piglets were randomized into four groups: CO2 laparoscopy, air laparoscopy, CO2 laparotomy, and air laparotomy. Laparotomy was performed in a sterile balloon pressurized similar to laparoscopy. Peritoneal interleukin-1, interleukin-6, tumor necrosis factor-a, and counts of polymorphnuclear cells (PMNs), and macrophages (MFs) were determined in abdominal lavage fluids at 0, 2, and 48 h. Macrophages were assessed for reactive oxygen species (ROS) production. Systemic responses were gauged by white blood cell count (WBC) and cytokines. Alveolar lavage was performed at 48 h to determine cytokine levels, cell counts, and MF ROS production. Blood, lavage fluids, and mesenteric lymph nodes were tested for bacterial translocation., Results: Regarding the peritoneal response, laparotomy versus laparoscopy when performed with CO2 significantly increased PMN and decreased the percentage of macrophages (%MF) up to 48 h. There was a significant increase in interleukin-6, and there was a fourfold increase in MF ROS production. Similar differences between the procedures were found with exposure to air. The use of air versus CO2 in laparoscopy, but not in laparotomy, resulted in an increase of peritoneal PMN and a decrease of the %MF up to 48 h. Air increased the local interleukin-6 release in both procedures and increased MF ROS production fourfold. Regarding the systemic response, laparotomy produced a significant increase in WBC, which was significantly more pronounced with exposure to air. No alteration of other systemic cytokines was seen. Regarding the pulmonary response, the number of MFs and MF ROS production were significantly increased after air versus CO2 laparoscopy. There were no such differences between the laparotomy groups. Regarding bacterial translocation, no bacteria were cultured from peritoneal fluids, lymph nodes, or blood., Conclusions: Inflammatory responses were reduced by a laparoscopic approach and by exposure to CO2 versus air. Peritoneal responses were affected to a larger degree than systemic parameters. Laparotomy overruled the effects of CO2 on chemotaxis and distant organ injury but not on peritoneal cytokine release.

Background: Some authors have argued that intussusception is best treated via a laparoscopic approach. As we did not have this impression, we reviewed our experience with this condition., Methods: : We reviewed all patients with intussusception who were treated at our hospital over the past 10 years. The choice of whether to use a laparoscopic or open approach depended on the patient's clinical condition and the availability of surgeons with laparoscopic expertise., Results: A total of 72 patients were identified. Based on age, two subgroups were distinguished-one comprised of patients under the age of 3 years and one of patients over the age of 3 years. Sixty-five patients were under 3 years of age. Thirty-five had surgery, and 19 required resection. Of the 10 patients who were treated with a laparoscopic approach, only three could be reduced laparoscopically. After conversion in the other seven patients, the intussusception was reduced in five whereas a resection was required in two cases. Seven patients were 3 years of age or older. All of them underwent surgery, and all but one required resection. All four children who were laparoscoped subsequently had a bowel resection at open surgery., Conclusions: Patients 3 years of age or older usually need resection and will not benefit from the laparoscopic approach. Under 3 years of age, little is to be gained from a laparoscopic approach, provided good nonsurgical reduction facilities are available. There is a place for the laparoscopic approach in cases of recurrent intussusception or doubtful reduction.

A 3,220-g newborn baby with trisomy 21 presented with duodenal atresia. No other congenital malformations were diagnosed. Informed consent for a laparoscopic approach was obtained. The child was placed in a supine, head-up position slightly rotated to the left at the end of a shortened operating table. The surgeon stood at the bottom end with the cameraperson to his left and the scrub nurse to his right. The screen was at the right upper end. Open insertion of a cannula for a 5-mm 30 degrees telescope through the inferior umbilical fold was performed. A carbon dioxide (CO2) pneumoperitoneum with a pressure of 8 mmHg and a flow of 2l/min was established. Two 3.3-mm working cannulas were inserted; one in the left hypogastrium and one pararectally on the right at the umbilical level. Two more such cannulas were inserted; one under the xyphoid for a liver elevator and one in the right hypogastrium for a sucker. Mobilization of the dilated upper and collapsed lower duodenum was easy. After transverse enterotomy of the upper duodenum and longitudinal enterotomy of the distal duodenum, a diamond-shaped anastomosis with interrupted 5 zero Vicryl sutures were performed. The absence of air in the bowel beyond the atresia increased the working space and greatly facilitated the procedure. The technique proved to be easy, and the child did very well. Laparoscopic bowel anastomosis in newborn babies had not been described previously. Recently, a diamond-shaped duodenoduodenostomy for duodenal atresia was performed. The technique proved to be simple and is described in detail. The child did very well.

Background: Gastroesophageal fundoplication currently is one of the three most common major operations performed on infants and children by pediatric surgeons in the United States. With the advent of laparoscopic surgery, the number of gastroesophageal fundoplications has virtually exploded. Morbidity always was substantial with this operation, and laparoscopy has not changed this. We describe our results with laparoscopic refundoplication in infants and children., Methods: From December 1993 to December 1998 100 children underwent a laparoscopic 180 degrees anterior wrap using the Thal procedure. Four children had to undergo a laparoscopic refundoplication. Two of these children were mentally handicapped. All of the children had recurrent symptoms, but only two of the four had an abnormal pH study. In three of the children, the Thal procedure was changed to a Nissen (n = 2) and Toupet (n = 1) fundoplication. One child with an intrathoracic wrap and a giant hiatal hernia underwent hernia repair with a Goretex patch and a redo-Thal., Results: In two of the children, the operation was relatively simple. For one child, the procedure had to be converted for anesthesiologic reasons. The procedure in the fourth child was more difficult because of a large hiatal hernia. Within a follow-up time of 2 to 4 years, all the children were free of pathologic gastroesophageal reflux symptoms and afterward displayed no recurrence., Conclusion: In children, laparoscopic refundoplication after a previous laparoscopic antireflux Thal procedure is feasible and does not increase morbidity.

Background: This study investigates the feasibility of performing a subsequent laparoscopic antireflux procedure after former placement of a percutaneous endoscopic gastrostomy (PEG)., Methods: Between 1997 and 1998, five patients with a gastrostomy in place presented with an indication for laparoscopic antireflux procedure due to persisting vomiting., Results: All patients were managed laparoscopically with a four-trocar technique., Conclusions: Primary PEG placement has no adverse effects on a later secondary antireflux procedure. In some cases, four rather than five trocars can be used.

Splenic cysts are rare in pediatric surgery. Nowadays management consists of partial splenectomy or decapsulation of the cystic wall. The case reported in this article describes the successful laparoscopic decapsulation of the cystic wall in an 11-year-old child.

Background: The performance of laparoscopic antireflux surgery is steadily increasing among pediatric surgeons. Different techniques are being used. However, due to a lack of standardized follow-up methods, postoperative results are difficult to compare. In this study, we describe the results of postoperative 24-h pH study as an objective criterion for evaluating the results of laparoscopic Thal antireflux surgery., Methods: In a prospective study, 53 patients underwent a laparoscopic Thal procedure. Preoperatively, all patients were subjected to 24-h pH monitoring, an upper GI series, and esophagogastroscopy. pH monitoring was performed 3 months postoperatively to evaluate the effect of the fundoplication. Esophagogastroscopy was repeated in case of preoperative esophagitis., Results: In one patient, the laparoscopy was converted to an open procedure. Feeding was commenced on day 1 in 49 of the 53 children. Mean hospitalization time was 4.4 days. One patient was reoperated for a too-tight fundoplication, and two patients died of unrelated causes. Ultimately, 44 of 50 children (88%) were free of symptoms; however, 11 of 41 children (25%) still displayed pathological reflux on pH monitoring., Conclusions: The Thal fundoplication can be performed laparoscopically in children. Children have a quick recovery, and hospitalization is short (4.4 days). At follow-up, nearly 90% of the children are free of symptoms. However, 25% still have pathological reflux as measured with pH monitoring. Therefore, questionnaires alone are not a sufficient means of measuring outcome postoperative. pH monitoring is a valuable additional tool for the objective postoperative evaluation of the results of (laparoscopic) antireflux procedures.

Background: With new advances in diagnostic and therapeutic tools, the early management of adhesive bowel obstruction has become feasible., Methods: In a retrospective study, 20 children with adhesive bowel obstruction were investigated to assess the possible advantages of the laparoscopic approach., Results: Laparoscopy was performed in nine children. Six of them were managed laparoscopically. Recovery was uneventful. In two children, extensive adhesions warranted elective conversion. The single complication occurred in a child with obstruction of the colon due to perforation caused by a small instrument. Eleven children underwent primary laparotomy for adhesive obstruction. Five of them had a single band and might have benefited from a laparoscopic approach., Conclusions: Laparoscopic management of adhesive bowel obstruction in children is feasible and safe in experienced hands. Early management saves the child a great deal of discomfort and allows a quick recovery with early discharge.

Background: Laparoscopic treatment of intestinal malrotation in children is difficult, and most of our pediatric surgeon colleagues active in the field of laparoscopic surgery tell us that more often than not they must convert to an open procedure. Initially, we experienced much difficulty too, but after modification we were able to master the technique, and now we feel confident. We here describe the actual technique we use., Methods: Our experience encompasses nine children treated during the past 18 months. Five of the children presented in the newborn period and four later. During laparoscopic surgery, it is of paramount importance to concentrate not on the loops of bowel, but on the duodenum. By starting to identify the duodenum, mobilizing it, and carrying on the mobilization of the small bowel down until the whole small bowel has been seen, the pathologic anatomy is easily unraveled. Moreover, an existing volvulus is automatically reduced and the bowel automatically put in a nonrotation position in the abdomen., Results: All patients have done well, and no complications have been noted. Operative time has been reduced to about 1 hour., Conclusions: Laparoscopic treatment of intestinal malrotation in children is not so difficult provided certain rules, as described, are followed.

Background: We set out to determine whether laparoscopic pyloromyotomy (LPM) is superior to open pyloromyotomy (OPM) in babies with hypertrophic pyloric stenosis (HPS)., Methods: We performed a retrospective study of 36 LPM and 36 OPM. Both groups were comparable in terms of sex, age and weight on admission, and blood pH on admission and prior to surgery. In the LPM group, three trocars were used; in the OPM group, a small right upper quadrant transverse muscle-cutting laparotomy was carried out., Results: LPM produces a better cosmetic result, seems to produce less postoperative discomfort, and results in the absence of conversion in a shorter hospital stay. However, the duration of the operation was significantly longer (32 versus 18 min). Moreover, LPM clearly entailed more complications (three mucosal perforations against two, and two reoperations against none in the open group)., Conclusions: The actual series does not favor the laparoscopic approach over the open one, in view of the relatively high complication rate. Babies who are operated laparoscopically, however, seem to have less postoperative discomfort, a shorter hospital stay, and a better cosmetic result. As we are confident that the complication rate and duration of the operation will drop with further experience, we will continue to do LPM. LPM is not easy and should only be carried out when substantial experience has been gained in the field of pediatric laparoscopic surgery.

Huge sacrococcygeal teratomas in the newborn can cause significant morbidity and even death due to cardiac failure, hemorrhage, or both. Surgical removal is the treatment of choice, but can indicate these events. Ligation of the median sacral artery, which always supplies the tumor, prior to its removal has been advocated, but in the past this procedure required a formal laparotomy. Nowadays, it can be easily accomplished laparoscopically, as this case report demonstrates.

The slipping of trocars is a major problem, especially in pediatric laparoscopic surgery. Although the suturing of a trocar, along with its valve housing, to the fascia or skin is common, this technique only serves to prevent the trocar from being pulled out. We have found that the simple procedure of winding a +/- 1-cm broad tape several times around the base of the trocar, which has been sutured to the fascia or skin, will prevent the trocar, from being pushed in, even during lengthy operations. The tape that we use is derived from sterile disposable drapes and is therefore not only readily available but also an inexpensive solution to a chronic problem.

Background: An increasing number of reports indicate that Thal fundoplication is the procedure of choice in mentally retarded children. With the advent of laparoscopy, Nissen's fundoplication seems to have been repopularized. However, the choice of the operative technique should be based on the merits of the procedure itself rather than the laparoscopic feasibility. The aim of this study is to determine if laparoscopic Thal fundoplication is beneficial for mentally retarded children., Methods: Between November 1993 and 1994 laparoscopic Thal fundoplication was performed in 15 mentally handicapped children; 13 also had a feeding gastrostomy. Age varied from 1.5 to almost 17 years (mean 7 years). Mean weight was 18 kg (5-50 kg). All patients underwent an upper GI study and endoscopy as well as pre- and 3 months postoperative pH study. Indications for the procedure were reflux esophagitis in 11 and feeding problems with silent reflux in 4., Results: The laparoscopic procedure was converted in the second patient because of bleeding in the hiatus. No further procedure-related intra- or postoperative complications occurred. The mean hospitalization was 3.7 days. No symptomatic postoperative gastroesophageal reflux has been observed. All children have undergone postoperative pH studies, which displayed silent reflux in two. Gastrostomy feeding is well tolerated., Conclusion: We conclude that Thal fundoplication can be performed laparoscopically in mentally retarded children. The laparoscopic results are comparable to the open Thal procedure.

Surgical treatment of gastroesophageal reflux in severely scoliotic children can be quite bothersome because sometimes the working space between the subcostal margins, iliac crest, and spinal column is very limited; the hiatus lies extremely deep away and is frequently rotated, making exposure more difficult. The laparoscopic approach could lend the necessary extension to the surgeons' hands to reach the deep hiatus. Moreover the entrance of the ports can be adjusted to the special requirements dictated by the scoliosis. Between February and December 1994 laparoscopic Thal fundoplication was performed in five severely scoliotic children; four also had a feeding gastrostomy. There were no intraoperative complications. The laparoscopic approach allowed improved operative visibility. Mean hospital stay was 3 days. The children displayed no symptomatic postoperative gastroesophageal reflux, which was confirmed by 3 months postoperative pH study. The laparoscopic approach of fundoplication allows improved visibility and easier access to the hiatus in severely scoliotic patients in comparison to the open approach. Results so far are good.

This report describes the laparoscopic approach of closure of a congenital left posterolateral diaphragmatic hernia in a 6-month-old boy. The pros and cons of such an approach are discussed.