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To determine the extent of progress in the treatment of sacrococcygeal teratomas (SCTs), we evaluated the experience with 73 patients over 40 years. The medical records of the children were reviewed for demographics, histology, clinical course, and outcome. Therapy differed depending on the type of SCT, histology, and decade of diagnosis. The female:male ratio was 4.2:1 and did not vary significantly with the histology of the tumor. Fifty-seven patients presented with benign disease. There were five recurrences in this group, only one of which did not have an initial coccygectomy. One tumor, originally thought to be benign with immature elements, had a local recurrence at 7 months, 10 months, and 16 months after the original operation and was discovered to have embryonal carcinoma with nodal involvement. This child was treated with chemotherapy and is disease-free at 7 years. Morbidity in the benign group included 3 postoperative wound infections. Three infants died, one before operation with β-hemolytic Streptococcus sepsis. Two neonates died in the earlypostoperative period, one on day 1 with a ruptured subcapsular hematoma of the liver, and the second on day 2 with disseminated intravascular coagulation/sepsis. Benign SCT occurs at a younger age than malignant tumors. The average age of presentation of benign tumors is 20 days versus 468 days in children with malignant disease. The technique of wide resection of benign lesions with coccygectomy is helpful in preventing recurrence and has changed little over the last four decades. Malignant SCT occurred in 16 children (22%). Seven of these children are long-term survivors with a mean follow-up of 4.5 years. The average survival was 9.3 months in the nine children who died of disease (range, 1 to 28 months). Long-term survival in the last two decades was achieved more often and may be attributed to modern chemotherapy.

Standard approaches to intrinsic obstructing duodenal lesions in the newborn include laparotomy with enteroenterostomy, bypassing the obstruction, or duoduodenotomy with excision. The advent of improved pediatric flexible fiberoptic endoscopes and fiberoptic laser technology makes endoscopic ablation of duodenal webs and windsocks in the newborn possible.

Although laparoscopic procedures are currently in vogue in general surgery, the role of this approach in children has not been prospectively evaluated in the United States using the new instrumentation now available to us. To assess the value of laparoscopic appendectomy (LA) in childhood, we prospectively compared 14 LAs with 50 open appendectomies (OA) over 6 months in a single children's hospital. Antibiotic usage was at the discretion of the surgeon regardless of the procedure performed and was not different between groups. LA was performed under the direction of a single laparoscopy-trained surgeon and patient selection was based on parental consent. A three-puncture LA technique was used; children from this group were allowed to return to full activities as soon as they were comfortable. There were no significant differences between groups for severity of disease, age, weight, hospital cost, or complications. The types of complications that developed were comparable in both groups. The percent of complicated appendicitis (gangrene or perforation) was 32% in the OA group and 36% in the LA group. Patients in the LA group spent significantly fewer days in the hospital and returned to unrestricted activities (school, athletics, etc) faster than patients in the OA group. LA is approximately $1,000 more expensive than OA, the differences being easily explainable by the cost of the disposable supplies necessary for the procedure (laser fibers, trocars, etc), but because of the shorter hospital stay in the LA group the mean total cost for each group was comparable. These data suggest that although there appears to be no cost advantage, LA shortens the hospital stay and allows children to return to unrestricted activity sooner than OA. LA should be considered as a reasonable alternative to OA and may be the procedure of choice in the hands of pediatric surgeons experienced in laparoscopic techniques.

Recent technological innovations have improved our ability to perform thoracoscopy in children. Video imaging improves thoracoscopic visualization and enhances the role of the surgical assistant. The placement of multiple access ports improves the thoracoscopic manipulation of tissue. The laser permits the application of thermal energy to intrathoracic tissue for hemostasis without the risk of cardiac fibrillation. The endoscopic stapler allows hemostatic, airtight lung resection which obviates the need for routine tube thoracostomy. Our initial experience with these innovations applied to thoracoscopy was successful in 9 of 12 patients, ages 5 months to 17 years. For diagnostic cases, adequate tissue for histologic evaluation was always obtained. Complications of successful thoracoscopy included suspected air embolus on establishing the initial pneumothorax and persistent air leak requiring tube thoracostomy after resection of a bronchogenic cyst. There were no perioperative deaths. We performed biopsy of mediastinal masses or nodes, and lung, drainage of loculated pleural effusions, and excision of bronchogenic cysts. Thoracoscopy provides a safe, effective alternative to thoracotomy in children and will continue to be enhanced by improving technology.