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Byline: M. Hollwarth (1), M. Rivosecchi (4), J. Schleef (1), S. Deluggi (2), G. Fasching (3), E. Ceriati (4), G. Ciprandi (4), F. De Peppo (4) Keywords: Hirschsprung's disease Transanal pull-through Surgical technique Abstract: The transanal approach (TAA) is a new technique for surgery of Hirschsprung's disease (HD) that was introduced by de la Torre in 1998. The purpose of this multicenter study, including experience from three Austrian and one Italian departments of peadiatric surgery, was to evaluate the role of this approach in HD in 18 children aged 1--72 months. In 14 children the TAA only was performed in 3 an additional laparoscopy was performed and in 1 conversion to a laparotomy was necessary. One complication (abscess) occurred after laparoscopic-assisted pull-through. The postoperative recovery was rapid, no severe long-term problems were observed. The transanal pull-through technique is generally possible in most classic cases of HD with extension of the disease to the sigmoid colon. If necessary, it can be combined with laparoscopy. Our preliminary results show that the technique is safe, less invasive, and gives excellent cosmetic results, and allows rapid recovery. Long-term results are still pending. Author Affiliation: (1) Department of Pediatric Surgery, University of Graz, Medical School, Garz, Austria (2) Department of Pediatric Surgery, Kinderspital Linz, Linz, Austria (3) Department of Pediatric Surgery, von Preyer'sches Kinderspital Vienna, Austria (4) Department of Pediatric Surgery, Pediatric Hospital 'Bambino Gesu', Palidoro -- Roma, Italy Article History: Accepted Date: 26/06/2001 Article note: Electronic Publication

Byline: G. Steinau (1), B. Dreuw (1), J. Schleef (2), G. Lawong (1), V. Schumpelick (1) Keywords: Key words Diaphragmatic replacement; Absorbable material; Experimental study Abstract: To evaluate absorbable materials for use for replacement of the diaphragm, we implanted materials in experimentally-created diaphragmatic defects in pigs. As a short-term absorbable material, bovine serosa (BS) was used. Its absorption was complete after 4--6 weeks. In a control group, the defect was repaired with a continuous running polypropylene suture. In two other groups the defect was closed with lyophilized dura (LD) and a modified transverse abdominal muscle flap according to Hecker, respectively. Physical studies (load capacity and elasticity) and histologic investigations were performed in one-half of the animals of each group after 3 and 6 months, respectively. Considering their physical properties, it could be shown that all materials tested are suitable for replacement of the diaphragm, but that BS best resembled native diaphragm. We conclude that short-term absorbable BS is suitable for replacement of the diaphragm in pigs. Author Affiliation: (1) Surgical Clinic of the Rheinish Westphalian Technical University of Aachen, Pauwelsstrasse 30, 52057 Aachen, Germany, DE (2) Pediatric Surgical University Clinic of Graz, Graz, Austria, AT Article note: Accepted: 12 July 1999

Byline: J. Schleef (2), A. Wagner (1), R. Kleta (1), K. Schaarschmidt (2), B. Dockhorn-Dworniczak (3), G.-H. Willital (2), H. Jurgens (1) Keywords: Key words Ovarian tumor; Children; Hypercalcemia; Small-Cell carcinoma Abstract: Tumors of the ovary in girls represent about 80% of pediatric genital tumors approximately 30% of these tumors are malignant. The risk of malignancy increases with decreasing age. The most frequent finding is a teratoma other tumors are rare. Small-cell carcinoma (SCCO) of the ovary is extremely rare, occurring mostly in young women. We present an 8-year-old girl with a SCCO of the hypercalcemic type. The findings and treatment are discussed with emphasis on the poor prognosis in these patients, even in stage 1 disease. The current literature is reviewed. Author Affiliation: (1) Department of Pediatric Hematology and Oncology, WW University of Munster, Germany, DE (2) Department of Pediatric Surgery, WW University of Munster, Germany, DE (3) Department of Pathology, WW University of Munster, Germany, DE Article note: Accepted: 17 June 1998

Byline: J. Schleef (1), K. Oleszuk-Raschke (2), J.-J. Morcate (1), G. Steinau (3), G.-H. Willital (1) Keywords: Key words Cystic abdominal mass; Diagnostic; Ultrasound; Laparoscopy; Gastric duplication Abstract: Abdominal cysts in girls are frequently observed by abdominal ultrasound (US) and are usually ovarian. In this case a cystic structure located in the right abdomen was seen in a female newborn without symptoms and was initially described as a possible ovarian cyst. Frequent US examinations showed an increase in volume and diameter, and temporary, recurring episodes of hyperbilirubinemia were observed. The US scans showed no relationship to the biliary tree. During a diagnostic laparoscopy, a cystic structure attached to the pyloric region was seen. A laparotomy revealed a cystic duplication of the stomach, which could be resected completely. The finding is discussed emphasizing the importance of clinical findings and diagnostic methods in the diagnosis and management of abdominal cystic masses in females. Author Affiliation: (1) Pediatric Surgical Clinic of the W.W. University of Munster Albert-Schweitzer-Strasse 33, D-48155 Munster, Germany, DE (2) Department of Pediatric Radiology, University of Munster, D-48155 Munster, Germany, DE (3) Department of Surgery, RWTH Aachen, Germany, DE Article note: Accepted: 25 June 1997

Byline: A. K. Saxena (1), J. Schleef (1), J. J. Morcate (1), K. Schaarschmidt (1), G. H. Willital (1) Keywords: Key words Infrared thermography; Clostridium perfringens; Childhood; Gas gangrene Abstract: Gas gangrene is not a frequently encountered toxic wound infection in childhood. We present a case of postoperative Clostridium perfringens infection with proximal forearm myonecrosis. In order to reveal the full extent of tissue viability in the right upper extremity, infrared thermography was performed. Although dyschromia was evident in the proximal forearm, thermographs revealed viable tissue only up to the supracondylar region. Angiography, which provided valuable clues to the patency of the vascular supply, and subsequent intraoperative findings confirmed the extent of tissue perfusion as revealed by infrared thermography. Author Affiliation: (1) Department of Pediatric Surgery, University of Munster, Germany, DE Article note: Accepted: 8 April 1998

Hepatic pulmonary fusion is a rare malformation associated with right congenital diaphragmatic hernia (CDH), often only discovered during surgical repair of the defect. Fourteen previous cases have been reported in the literature. We describe a case of a full term male newborn with prenatal ultrasound diagnosis of right CDH who underwent a thoracoscopy converted to a thoracotomy, due to this rare aforementioned intraoperative incidental finding. We reviewed the previous reported literature, especially focusing on the chosen surgical approach, concluding that an early and appropriate preoperative imaging investigation may be crucial for the best management of these kinds of patients.

Background: Minimally invasive surgery (MIS) for late-presenting congenital diaphragmatic hernia (CDH) has been described previously, but few neonatal cases of CDH have been reported. This study aimed to report the multicenter experience of these rare cases and to compare the laparoscopic and thoracoscopic approaches., Methods: Using MIS procedures, 30 patients (16 boys and 14 girls) from nine centers underwent surgery for CDH within the first month of life, 26 before day 5. Only one patient had associated malformations. There were 10 preterm patients (32-36 weeks of gestational age). Their weight at birth ranged from 1,800 to 3,800 g, with three patients weighing less than 2,600 g. Of the 30 patients, 18 were intubated at birth., Results: The MIS procedures were performed in 18 cases by a thoracoscopic approach and in 12 cases by a laparoscopic approach. No severe complication was observed. For 20 patients, reduction of the intrathoracic contents was achieved easily with 15 thoracoscopies and 5 laparoscopies. In six cases, the reduction was difficult, proving to be impossible for the four remaining patients: one treated with thoracoscopy and three with laparoscopy. The reasons for the inability to reduce the thoracic contents were difficulty of liver mobilization (1 left CDH and 2 right CDH) and the presence of a dilated stomach in the thorax. Reductions were easier for cases of wide diaphragmatic defects using thoracoscopy. There were 10 conversions (5 laparoscopies and 5 thoracoscopies). The reported reasons for conversion were inability to reduce (n = 4), need for a patch (n = 5), lack of adequate vision (n = 4), narrow working space (n = 1), associated bowel malrotation (n = 1), and an anesthetic problem (n = 1). Five defects were too large for direct closure and had to be closed with a patch. Four required conversion, with one performed through video-assisted thoracic surgery. The recurrences were detected after two primer thoracoscopic closures, one of which was managed by successful reoperation using thoracoscopy., Conclusions: In the neonatal period, CDH can be safely closed using MIS procedures. The overall success rate in this study was 67%. The indication for MIS is not related to weeks of gestational age, to weight at birth (if >2,600 g), or to the extent of the immediate neonatal care. Patients with no associated anomaly who are hemodynamically stabilized can benefit from MIS procedures. Reduction of the herniated organs is easier using thoracoscopy. Right CDH, liver lobe herniation, and the need for a patch closure are the most frequent reasons for conversion.

Ventriculopleural shunting is usually reserved for patients with limited options for shunt revisions. We report the case of a 16-year-old boy with posthemorrhagic hydrocephalus who required numerous shunt procedures. At the age of 6 years, a ventriculopleural shunt was inserted by an intercostal thoracotomy, and 4 years later replacement of the distal catheter was necessary. Recently, he presented again with a shunt malfunction due to migration of the pleural catheter. We describe a technique for performing the placement of the distal catheter under direct thoracoscopic vision by a peel-off needle into the unscarred thoracic cavity despite two previous pleural procedures. The postoperative course was uneventful. Thoracoscopic assistance in ventriculopleural shunt placement appears to be a safe and effective technique, offering several advantages over the open procedure: it is less invasive, allows a precise positioning of the thoracic catheter under visual control, and confirms appropriate function.

Laparoscopic antireflux surgery is becoming a standard procedure in pediatric surgery. Anterior gastropexy is often performed in antireflux procedures, as well as in children with recurrent and intermittent volvulus of the stomach. We present a simple and secure technique for anterior laparoscopic-assisted gastropexy.

In children, the diagnostic approach for cystic abdominal tumors (e.g., intestinal duplication) usually includes CT scan, ultrasound (US), and MRI. In small children and babies, the diagnosis is often made by laparotomy. We present our preliminary experience with laparoscopic-assisted surgery (LAS) in two girls. Both children underwent US as the diagnostic approach using imaging techniques. If an intraabdominal mass was identified as cystic or solid, the second step was diagnostic laparoscopy with LAS. One of the girls, a 9-year-old, had a history of appendectomy and abdominal cramps. US revealed a cystic structure in the right lower quadrant. Laparoscopy showed an intestinal duplication, which was mobilized; a segmental small bowel resection was then performed. The second girl, a (6-month-old,) had an antenatal diagnosed cystic mass. A small bowel duplication was found laparoscopically, completely mobilized and excised, and harvested through a small umbilical incision. The postop course was uneventful. In former times, transverse laparotomy and Pfannenstil incision were the most common surgical approaches. LAS combines an excellent means of exploration with the simultaneous performance of definitive surgery. Perfect cosmetic results can be achieved even in children with rare pathology.

Background: Only a few indications exist for diaphragm replacement: aplasias, tumours and accidents. The defect may be so extensive that it is impossible to close the gap. Allogenic and autologous materials are proposed for replacement of the diaphragm. The disadvantages of allogenic materials are recurrence rates of up to 20% and a high rate of malalignment of thoracic muscles and bones; the implication of autologous materials requires a longer operation time and no long-term results exist. To avoid these disadvantages, we have tested a material from bovine serosa, which is absorbable for a short time, for diaphragm replacement., Methods: The merits of four methods of diaphragmatic hernia repair were evaluated in animals. One hundred Sprague-Dawley rats underwent laparotomy. The control group had an incision in the diaphragm with primary repair. The other four groups underwent partial resection of the left hemidiaphragm. The defects were repaired in 20 rats with lyophilized dura, in 20 with polytetrafluoroethylene (PTFE), in 20 with autologous transversus muscle and in another 20 with absorbable serosa from a cow. The animals were followed up by electromyography (EMG) and post-mortem physical and histological examinations after 3 and 6 months., Results: Eighty-nine animals survived the operations. The EMG showed normal function for the absorbable material and the transversus muscle. Only scanty physiological waves were recorded in the PTFE group. The examination for stretching and stress showed good results for all materials tested. The histological examinations showed strong foreign body reactions in the dura and PTFE groups. The absorbable bovine serosa had vanished after 3 months postoperatively., Conclusion: We conclude that bovine serosa can be recommended for the treatment of diaphragmatic defects.

Inguinal hernia is a frequent surgical disease during infancy, occurring in 1 to 2% of all mature newborns and rise up to 30% of all premature babies. In 9.5% a contralateral hernia is found after unilateral operation. In our own patients this rate was 5.6%. The development of a contralateral hernia was significantly more often found in boys than in girls. If the hernia occurred during the first two months of life, a contralateral hernia developed later highly significant (p > 0.0001). Within the first two postoperative years the second hernia arose in 84.9%. We recommended to routinely operation for a contralateral hernia in all children younger than two months.

The relative merits of three methods of diaphragmatic hernia repair were evaluated in animals. Eighty Sprague-Dawley rats underwent laparotomy. The control group had an incision in the diaphragm with primary repair. The other three groups underwent partial resection of the left hemidiaphragm. The defects were repaired in 20 rats with lyophilized Dura, in 20 with polytetrafluoroethylene (PTFE) and in another 20 with absorbable serosa from a cow. Seventy-two animals survived the operation; they were followed up by electromyography (EMG) and post-mortem physical and histological examinations after 3 and 6 months. The EMG showed normal function for the absorbable material. Only scanty physiological waves were registered in the PTFE group. The examination for stretching and stress showed good results for all materials tested. The histological examinations amount to strong foreign body reactions with Dura and PTFE groups. The absorbable bovine serosa had vanished after 3 months postoperatively. It is concluded that bovine serosa can be recommended for diaphragmatic hernia.