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The objective of this study was to report on the use of vesicoscopy in the treatment of symptomatic congenital bladder diverticula (CBD) in children. Material and Methods In this study, 16 males, aged 4 to 12 years (median age, 6.25 years), were treated for symptomatic CBD; 3 patients presented double diverticulum and 13 presented single diverticulum. The presenting symptoms were recurrent urinary tract infection, hematuria, lower abdominal pain, and voiding dysfunctions as urgency, frequency alone, or in association. A first midline 5-mm trocar was introduced for a 0-degree telescope at the dome of the bladder, and two left and right 3- or 5-mm trocars were inserted through the anterolateral wall. The bladder was then insufflated with carbon dioxide to 10 to 12 mm Hg pressure. The diverticula were inverted into the bladder and the mucosa around the neck was circumcised by using scissors and hook. The defect was sutured and the bladder was drained. Vesicoureteral reflux (VUR) of third grade or higher was treated endoscopically. Results Mean operative time was 90 minutes for procedures. At 6-month follow-up, ultrasound and voiding cystourethrogram (VCUG) showed the disappearance of the diverticulum in 15 out of the 16 patients. The patient, with huge double diverticulum and fourth grade right VUR, presented recurrence of a small left diverticulum. Patients with voiding disorders presented a gradual improvement of their urgency. VUR disappeared at VCUG in all patients. Conclusion Vesicoscopic diverticulectomy resulted a safe and effective procedure and can be considered a valid alternative to the open or laparoscopic procedures. In our opinion, routine use of vesicoscopy could become the gold standard for the treatment of CBD in children.

The authors reported their experience in the laparoscopic orchidopexy for intra-abdominal testis (IAT). Since 2003, 173 laparoscopy for NPT were performed for a total of 181 testicular units. In 75 patients cord structures entering the inguinal ring were observed, and 43 had an inguinal exploration. In 34 patients a blind ending vas and vessels were observed and 8 showed testicular agenesis: these patients were managed by laparoscopy only. In 62 cases an intra-abdominal testes (IAT) were found: 42 had a primary orchidopexy and 22, with high IAT, were managed by a laparoscopic Fowler-Stephens (FS) procedure. In 12 testes we performed a two stage procedure while 10 had one stage. There were no differences in hospitalisation and early surgical complications were not recorded. Follow up ranged from 1 to 5 years. Of 22 patients who underwent FS orchidopexy, testicular atrophy developed in 4; the remaining are in scrotal position, with normal consistency and well perfused at color doppler ultrasound. Laparoscopy is essential in the surgical and therapeutic management of non-palpable testis. FS orchidopexy is reserved to high intra-abdominal testes that have a distance more than 3 cm from the internal inguinal ring. There were no differences between the group managed by one or two step FS. The minimal morbidity with an high success rate prove to be a significant contribution to the intra-abdominal testis management.

According to scientific literature, laparoscopy as aid in diagnosis and therapy for chronic pain in the right iliac quadrant shows a undeniable advantage thanks to its mini-invasiveness, the possibility of a methodical and thorough exploration of the entire abdominal cavity in those cases of recurrent pain, emotionally and socially debilitating, that do not find an answer in the usual etiological diagnostic clinical-instrumental. In those cases in which any significant organic pathology that justifies the recurring pain in the right iliac fossa is found during laparoscopic exploration, it has been seen that it is useful to perform appendectomy anyway, that leads to the disappearance of symptoms, which are probably due to inflammatory recurrent catarrhal phenomena of appendix in such patients, as it is demonstrated by the adhesions found at cecum-appendicular level. From January 2011 to December 2013, 24 children with chronic recurrent right lower quadrant pain were subjected to diagnostic laparoscopy. Ages varied from 11 to 18 years (mean, 14 years). There were 6 males and 18 females. Laparoscopic findings included macroscopical signs of acute appendicitis in 15 patients; cecal adhesions in 20 patients, kink of the appendix in 3. The abdominal pain completely resolved in all the patients following laparoscopy.

Aims: The laparoscopic “Spaghetti Maneuver” consists in holding an organ by its extremity with a grasper and rolling it up around the tool to keep the organ stable and facilitate its traction within a small space. We describe our experience with the “Spaghetti Maneuver” in some minimally invasive procedures. Materials and Methods: We successfully adopted this technique in 13 patients (5F : 8M) aged between 6 and 14 years (average age, 10) on whom we performed 7 appendectomies, 2 ureteral reimplantation and 4 cholecystectomies. In all cases, after the first steps, the appendix, the gallbladder and the ureter were rolled around the grasper and easily isolated; hemostasis was thus induced and the organ was mobilized until removal during cholecystectomy and appendectomy, and before the reimplantation in case of ureteral reimplantation. Results: We found that this technique facilitated signifi cantly the acts of holding, isolating and removing, when necessary, the structures involved, which remained constantly within the visual field of the operator. This allowed a very ergonomic work setting, overcoming the problem of the “blind” zone, which represents a dangerous and invisible area out of the operator’s control during laparoscopy. Moreover the isolation maneuvers resulted easier and reduced operating time. Conclusion: We think that this technique is easy to perform and very useful, because it facilitates the dissection of these organs, by harmonizing and stabilizing the force of traction exercised.Key words: Appendectomy, children, cholecystectomy, laparoscopy, pneumovesicoscopy

Background: Single-incision laparoscopic surgery (SILS) has gained great popularity in paediatric surgery due to its minimally invasive approach and improved cosmetic results. Notwithstanding, reports describing its adoption in children are still fragmentary and some perplexities have been raised by some surgeons. We reviewed our experience with the SILS Palomo varicocelectomy procedure (SIL-V) in children and adolescents, comparing this group with a similar series operated using conventional laparoscopic varicocelectomy (CL-V). Patients and Methods: A total of 69 Palomo laparoscopic varicocelectomies were performed in patients aged 11-17 years from January 2011 to January 2013. Indications for surgery included grades II-III varicocele or ipsilateral testicular hypotrophy. The SIL-V procedure was performed in 44 patients with roticulating and conventional 5 mm instruments. Testicular vessels were isolated “en bloc,” clipped and cut. Operating time, visual analogue scale and post-operative results were compared to a similar group of 25 patients operated with CL-V.Results: No patient of the SIL-V group required conversion to conventional laparoscopy, none to open surgery. Mean operative time was 22 min (range: 19-28) in the SIL-V group, not signifi cantly different compared with CL-V (mean 21 min, range: 18-25). All patients experienced a smooth recovery from surgery without any complications, and were discharged on day 1. No diffi culties were found in the SIL-V group. The post-operative pain score was signifi cantly better in SIL-V. Conclusion: The SIL-V procedure is safe and effective and allows a fast and effi cient isolation of the vascular bundle. The use of conventional instruments is technically feasible in SIL-V.Key words: Palomo, single-incision laparoscopic surgery, varicocele

Aims: To assess the feasibility and safety of a laparoscopic approach to UPJ obstruction (UPJO) in ectopic pelvic kidneys. Material and Methods: In a retrospective analysis we selected 14 children, aged 6months to 17 years, 12 males, 2 females, who had been treated in our Department between January 2004 and June 2011. 9 patients presented ureteropelvic junction obstruction (in 3 cases pelvic stones coexisted) with normal/moderately reduced (≥25%) relative function at radionuclide scan (MAG3), 3 nonfunctioning kidneys associated or not to hypertension, 2 congenital hypo-dysplastic kidneys. The evaluation of each patient involved the medical history, ultrasound examination, VCUG, MAG3 diuresis renogram and MRI in some cases. Of the patients presenting UPJO, 5 underwent dismembered pyeloplasty with pyelolithotomy, if required, and 4 pelvic derotation with straightening of the uretero-pelvic junction. A previous cystoscopic placement of a Double J stent was utilized. This facilitated the identification and dissection around the pelvis. With the patient in Trendelenburg position we utilized an umbilical trocar and two trocar in the right and left iliac fossae; an additional trocar, when required, was inserted more cephalad on the midclavear line contralaterally to the lesion. The derotation of ureteropelvic junction was obtained by freeing the kidney’s lower pole and by placing intraperitoneally the junction protected with a Double J stent. This was obtained by suturing the peritoneum behind the ureteropelvic junction resulting in a forward rotation of the major axis of the kidney and a straightening of the junction. The 5 patients presenting nonfunctioning ectopic kidneys underwent laparoscopic nephrectomy. While the removal of congenital hypoplasic kidneys resulted easy, the removal of nonfunctioning kidneys was more difficult due to their complex vascular situation and for the embryonic disposition. Results: The operating time varied between 40 to 200 minutes. No patient required conversion to open surgery. The hypertension resolved after nephrectomy in all cases. 2 cases of dismembered pyeloplasty required a placement of Double J stent due the recurrence of symptoms and ! patient is waiting for redo operation. The pelvic derotation showed an improvement of diuretic MAG3 renogram and the function remained stable and patiens are symptoms-free. Conclusion: The UPJO in ectopic pelvic kidneys present a large spectrum of presentation. The laparoscopic approach provides good surgical exposure, and operative times are acceptable compared to those of laparoscopic procedure in anatomically normal kidneys. It has also proved a very useful tool in the non-functioning kidney nephrectomy thank to the help of magnification in the identification of numerous aberrant vessels that are quite often found in the pelvic kidneys. The derotation of the pelvis seems a useful procedure in moderate obstruction even if a longer follow-up is needed. Key words: ectopic, kidney, UPJ Obstruction

Sir, We have been called into question on the proper use of term laparoscopic Palomo varicocelectomy by Letter to the Editor: Nitinkumar Borkar, Nitin K. Kashyap, Debajyoti Mohanty: Is it a Palomo’s operation? Afr J Paed Surg. October-December 2014/Vol 11/Issue 4 371-372 who refer to: Marte A, Pintozzi L, Cavaiuolo S, Parmeggiani P. Single-incision laparoscopic surgery and conventional laparoscopic treatment of varicocele in adolescents: Comparison between two techniques. Afr J Paediatr Surg 2014;11:201-5. It’s unquestionable that the original report of Dr. Alejandro Palomo of J Urol 1949[1] (in prelaparoscopic era) refers to an open retroperitoneal approach with an en bloc section of testicular vascular bundle, and according to the Author, this can be implemented without compromising the testicular vitality. From the original drawings: “Veins and artery have been freed and are removed after clamps have been applied. Proximal and distal stumps of the vessels are ligated by transfixations sutures”.[1]

We report on a case of a mesenteric cyst occurred in an 11-year-old girl referred to our institution after a period of 2 months of recurrent abdominal pain. The girl underwent laparoscopic surgery after abdominal Ultrasound Scan (US) and Magnetic Resonance Imaging (MRI) demonstrated a voluminous cyst of about 18 cm × 10.7 cm × 5.8 cm, occupying principally left abdomen. The cyst's root extended into retroperitoneum (Losanoff type 3) so the majority was excised and the remaining was marsupialized with good results. Laparoscopic excision of the mesenteric cyst has been facilitated by rolling the isolated cyst progressively around a grasper obtaining a constant control of the structure: the “spaghetti maneuver”. As confirmed by our experience, a mesenteric cyst can be easily and safely managed by laparoscopy, and the “spaghetti maneuver” is a feasible and effective surgical tool to facilitate the excision.