Laparoscopic-assisted Procedure Research Articles

Technical evaluation and fecal continence of laparoscopic-assisted procedures for total colonic aganglionosis

Total colonic aganglionosis (TCA), defined as aganglionosis extending from the anus up to the distal ileum, is a rare variant of Hirschsprung's disease. Surgery for TCA aims to remove the aganglionic colon and reconstruct the intestinal tract by bringing the normally innervated ileum down to the anus while preserving normal sphincter function. Laparoscopy with surgeries including laparoscopic-assisted Duhamel-like and Soave-like pull-through procedures have been progressively applied to the treatment of TCA over the past two decades and may become the dominant treatment for TCA in the future. Postoperative fecal continence, involving issues such as normal defecation, Hirschsprung-associated enterocolitis (HAEC), frequent stool and perianal erosion (perineal rash), soiling/fecal incontinence and constipation/obstructive symptoms, is very important to patients. These complications require nutritional support and comprehensive postoperative gastroenterological care and even require permanent ileostomy and redo pull-through. Some patients have previously seen a psychologist for frequent complaints of diarrhea and other physical symptoms. Patients with TCA postoperatively must be evaluated regularly by pediatric surgeons, enterostoma therapists, gastroenterologists, dieticians and psychologists to achieve a good nutritional status and psychological health.

O147: Use of the National Consultant Information Programme to evaluate surgical practice in England for rectal prolapse repair, identifying points of variation for improvement and the impact of the Covid-19 pandemic

Abstract Introduction Using the National Consultant Information Programme (NCIP) tool to extract and analyse data surrounding rectal prolapse repair procedures, to identify key trends and variation. Analysing data across a 4-year period to evaluate how the Covid-19 pandemic impacted current surgical practice. Methods NCIP compiles hospital episode statistics data gathered by NHS analysts. Data is categorised by key metrics including length of stay (LOS), procedure approach, deprivation score and pseudonymised provider. Data is for elective procedures in patients 17+ and has been contextualised by recent available literature. Results Of the 6702 procedures, 65.8% (4413) were carried out in the first time period, 1st April 2018 to 31st March 2020. Abdominal prolapse repair increased from 37.0% of procedures in the first 2 years, to 42.4% in the second period (1st April 2020 to 31st March 2022). Perineal approach decreased from 45.6% of procedures to 41.1% in the second period. 87.7% of patients were female. Most procedures were open (77.7%). Average LOS was 2.5 days and was highest in laparoscopic assisted procedures (5.38), 2.33 in open procedures. From 141 providers, the top 15 did 100-218 procedures each across the 4 years. 24 providers performed 15 or less, while 5 performed only 1 repair. Mortality within 90 days was 0.81% in the first data period and increased to 1.1% in the second. Conclusion Data suggests an impact on procedure numbers due to Covid-19, but not on approach type. Significant observed variation between provider approach and procedure count invites further research into reasons behind this.

Combined laparoscopic and endoscopic method for foreign body removal from descending colon: A case report

BACKGROUND The majority of published reports on foreign bodies (FBs) involve the rectum and applied a transanal retrieval. Usually, patients with FB above the rectum are subjected to laparotomy for removal. Here, we illustrate the case of a man with an FB that had migrated into the descending colon, and its successful removal via a laparoscopic approach. CASE SUMMARY A 43-year-old man, who had the habit of FB insertion into his anus to aid defecation, presented upon experience of such an FB slipping through and migrating upward to the distal colon. Plain abdominal radiograph revealed a bottle-shaped FB, positioned in the left iliac fossa region. The FB was successfully removed via a laparoscopic-assisted procedure in which we combined diagnostic laparoscopic and endoscopic techniques during surgery. The patient was monitored for 2 d postoperatively and subsequently discharged home. CONCLUSION A minimally invasive approach should be adopted to aid extraction of colorectal FB as it is effective and safe.

Long-term outcomes following ileocolic resection for Crohn's disease: does earlier elective resection affect disease recurrence rates?

Surgical resection in Crohn's disease is sometimes the only alternative treating disease complications or refractory disease. The implications of early resection on disease course are still debatable. We aimed to assess the influence of preoperative disease duration on long-term postoperative disease course. A retrospective analysis of all Crohn's disease patients who underwent an elective primary ileocolic resection between 2010 and 2021 in a single tertiary medical center. The cohort was divided based on disease duration, Group A (47 patients) had a disease duration shorter than 3 years (median of 1 year) and Group B (139 patients) had a disease duration longer than 3 years (median of 11 years). Surgeries were less complex among Group A as noted by higher rates of laparoscopic assisted procedures (68.1% vs. 45.3%, P = 0.006), shorter surgery duration (134 vs. 167 min, P < 0.0001) less estimated blood loss (72.5 vs. 333 mL, P = 0.016) and faster return of bowel function (3 vs. 4 days, P = 0.011). However, propensity score matching nullified all the differences. Younger age (OR = 0.86, P = 0.004), pre-op steroids (OR = 3.69, P = 0.037) and longer disease duration (OR = 1.18, P = 0.012) were found to be independently significantly associated with severe complications. After a median follow-up time of 71.38 months no significant differences were found between the groups in terms of endoscopic (P = 0.59), or surgical recurrences rates (P = 0.82). The main effect of preoperative short disease duration was noted within the surgical complexity; however, matching suggests confounders as cause of the difference. No significant long-term implication was noted on disease recurrence.

Changing trends in the minimally invasive surgery for corrosive esophagogastric stricture.

Esophagogastric stricture is the troublesome long-term complication of corrosive ingestion with a significant adverse impact on the quality of life. Surgery remains the mainstay of therapy in patients where endoscopic treatment is not feasible or fails to dilate the stricture. Conventional surgical management of esophageal stricture is open esophageal bypass using gastric or colon conduit. Colon is the commonly used esophageal substitute, particularly in those with high pharyngoesophageal strictures and in patients with accompanying gastric strictures. Traditionally colon bypass is performed using an open technique that requires a long midline incision from the xiphisternum to the suprapubic area, with adverse cosmetic outcomes and long-term complications like an incisional hernia. As most of the affected patients are in the second or third decade of life minimally invasive approach is an attractive proposition. However, minimally invasive surgery for corrosive esophagogastric stricture is slow to evolve due to the complex nature of the surgical procedure. With advancements in laparoscopic skills and instrumentation, the feasibility and safety of minimally invasive surgery in corrosive esophagogastric stricture have been documented. Initial series have mainly used a laparoscopic-assisted approach, whereas more recent studies have shown the safety of a total laparoscopic approach. The changing trend from laparoscopic assisted procedure to a totally minimally invasive technique for corrosive esophagogastric stricture should be carefully disseminated to preclude adverse long-term outcomes. Also, well-designed trials with long-term follow-ups are required to document the superiority of minimally invasive surgery for corrosive esophagogastric stricture. The present review focuses on the challenges and changing trends in the minimally invasive treatment of corrosive esophagogastric stricture.

Laparoscopic versus laparoscopy-assisted suturing of perforated peptic ulcers (meta-analysis)

To compare laparoscopic and laparoscopy-assisted repair of perforated peptic ulcer using evidence-based methods. A systematic review and meta-analysis were carried out in accordance with the recommendations of the Ministry of Health of Russian Federation and Cochrane Handbook for Systematic Reviews. We found no randomized trials devoted to comparison of laparoscopic and laparoscopy-assisted surgeries in patients with perforated peptic ulcer. Meta-analysis was based on non-randomized trials with satisfactory methodological quality according to the I-ROBINS formalized assessment. Overall clinical material included 478 observations: 229 (47.9%) laparoscopic surgeries and 249 (52.1%) laparoscopy-assisted procedures via minimally invasive access. There were no conversions. Incidence of postoperative complications was 4.36 and 8.83% (OR=0.39, 95% CI 0.08, 1.87), postoperative mortality 0.87 and 0.81%, respectively (OR=1.26, 95% CI 0.08, 8.24). Laparoscopic surgeries were shorter (MD= -8 min, 95% CI -9.7, -6.4). Length of hospital-stay was also shorter after laparoscopic surgery (MD= -4.6, 95% CI -9.7, -6.4). Laparoscopic operations are shorter and accompanied by lower incidence of postoperative complications and less hospital-stay. Large statistical power is required to confirm these differences.

Comparison of short term results following robotic and laparoscopic total gastrectomy and D2 lymph node dissection.

In the last decade, there has been a progressive shift from open to mini-invasive operative techniques for surgical resection of gastric cancer. Advanced equipment of surgical robots, with its 3D visualization, steady camera view, flexible instrument tips, attracts more and more practitioners in performing robotic gastrectomy with D2 dissection in gastric cancer patients. Thus, the comparison of some basic oncological as well as some surgical variables related to laparoscopic and robotic gastrectomy and D2 lymphadenectomy is necessary.

Pure endoscopic resection versus laparoscopic assisted procedure for upper gastrointestinal stromal tumors: Perspective from a surgical endoscopist.

Management of upper gastrointestinal (UGI) tract gastrointestinal stromal tumor (GIST) has evolved significantly over the past two decades. For GIST size smaller than 5 cm, laparoscopic resection has become the current standard. To avoid postoperative gastric deformity and preserve gastric function, laparoscopic endoscopic cooperative surgery (LECS) was developed and various modifications have been reported and utilized successfully. Pure endoscopic resection techniques have also been reported at a similar period of time, which further push the boundary of incisionless surgery in managing these lesions. Both tunneling and nontunneling exposed type endoscopic full thickness resection are well described procedures for resection of small UGI GIST. In this review, a summary of these procedures is provided, and the pros and cons of each technique from the perspective of a surgical endoscopist are discussed in detail. LECS and endoscopic resection are complementary to each other. The choice of technique should be tailored to the location, morphology, and size of the target lesions, taking into account the experience of the laparoscopic surgeons and endoscopists.

Occurrence and Definitions of Intra and Postoperative Complications Related to Laparoscopy in Equids: A Scoping Review.

Simple SummaryLaparoscopy and laparoscopic-assisted procedures in equines are nowadays common procedures with several advantages compared to laparotomy. However, despite the numerous benefits of minimally invasive surgery, there can be surgical complications which could have important welfare and economic consequences. Nevertheless, standard definitions of intra and postoperative complications are rarely reported and there is a lack of standard criteria to define and classify complications, limiting comparison of complication rates between studies. Thus, there is a need for implementation of rigorous criteria for defining complications and for greater numbers of research study with high quality of evidence. Adoption of classification systems and standard definitions would help surgeons to have a complete picture of the efficacy of a procedure or treatment and it is also essential to allow comparisons between studies, centers or time periods.Laparoscopy is a common approach in equine surgery and has the advantage of improved visibility and diagnostic accuracy, decreased morbidity and hospitalization time. However, despite the numerous benefits, there can be intraoperative and postoperative complications which could have important welfare and economic consequences. The aim of this study was to perform a scoping review to identify current evidence on the occurrence, definition and classification of intra and postoperative complications in equine laparoscopy. A scoping review was conducted in scientific databases. Peer-reviewed scientific articles in the English language on laparoscopy in equids between 1992 and 2022 were included. Data on the study method, sample size, surgical procedure, intra and postoperative complications were extracted and charted. One hundred sixty-four articles met the final inclusion criteria. A definition of “intraoperative complication” was given in one study. Difference between “minor” or “major” intraoperative complications were reported in 12 articles and between “minor” or “major” postoperative complications in 22 articles. A total of 22 intraoperative and 34 postoperative complications were described. The most reported intraoperative complication was hemorrhage from ovary or mesovary (12.7%), while the most reported postoperative complications were incisional complications (64.2%) and postoperative pain (32.7%). There is a need for implementation of criteria for defining complications. The adoption of classification systems and standard definitions would help surgeons to make decisions about the most appropriate treatment, and it is also essential to allow comparisons between research results.

Whipple's pancreaticoduodenectomy at a resource-poor, low-volume center in Trinidad and Tobago.

BACKGROUNDMany authorities advocate for Whipple’s procedures to be performed in high-volume centers, but many patients in poor developing nations cannot access these centers. We sought to determine whether clinical outcomes were acceptable when Whipple’s procedures were performed in a low-volume, resource-poor setting in the West Indies.AIMTo study outcomes of Whipple’s procedures in a pancreatic unit in the West Indies over an eight-year period from June 1, 2013 to June 30, 2021. METHODSThis was a retrospective study of all patients undergoing Whipple’s procedures in a pancreatic unit in the West Indies over an eight-year period from June 1, 2013 to June 30, 2021. RESULTSThis center performed an average of 11.25 procedures per annum. There were 72 patients in the final study population at a mean age of 60.2 years, with 52.7% having American Society of Anesthesiologists scores ≥ III and 54.1% with Eastern Cooperative Oncology Group scores ≥ 2. Open Whipple’s procedures were performed in 70 patients and laparoscopic assisted procedures in 2. Portal vein resection/reconstruction was performed in 19 (26.4%) patients. In patients undergoing open procedures there was 367 ± 54.1 min mean operating time, 1394 ± 656.8 mL mean blood loss, 5.24 ± 7.22 d mean intensive care unit stay and 15.1 ± 9.53 d hospitalization. Six (8.3%) patients experienced minor morbidity, 10 (14%) major morbidity and there were 4 (5.5%) deaths.CONCLUSIONThis paper adds to the growing body of evidence that volume alone should not be used as a marker of quality for patients requiring Whipple’s procedures. Low volume centers in resource poor nations can achieve good short-term outcomes. This is largely due to the process of continuous, adaptive learning by the entire hospital.

31. THE PEDICLED VPAP FLAP ALLOWS FOR PRESERVATION OF THE ABDOMINAL WALL IN THE RECONSTRUCTION OF APR DEFECTS

PURPOSE: Abdominoperineal resections (APR) often leave large cavitary defects that have historically been reconstructed with vertical rectus abdominus muscle (VRAM) flaps. We present a case series and surgical technique for a novel approach to reconstructing complex defects with a fasciocutaneous flap, the pedicled vertical profunda artery perforator (VPAP) flap, which was first performed for reconstruction of robotic and minimally invasive APR defects in order to preserve the functional abdominal wall. METHODS: A total of 13 patients underwent immediate or delayed reconstruction of APR defects using a pedicled VPAP. Seven patients underwent a minimally invasive APR, with six robotic-assisted and one laparoscopic-assisted procedure, leaving the abdomen completely intact. One patient had a previously failed VRAM, thus the abdomen was unavailable for reconstruction. One patient had bilateral ostomies. Five reconstructions were performed secondarily due to post-operative infection and dehiscence. RESULTS: Of the 13 cases, 2 patients required take back to the operating room for venous congestion. The major complication rate (15.4%) in this series was similar to historically reported rates described for VRAM reconstruction of APR defects. There were no total flap losses or donor site complications. All patients ultimately had successful wound closure. CONCLUSION: The pedicled VPAP presents a viable solution for reconstruction of APR defects while simultaneously preserving the functional abdominal wall in patients who have undergone minimally invasive ablative procedures. Additionally, this technique offers a reconstructive solution in patients that experience post-operative infection and dehiscence, or in whom the abdominal donor site is not available due to bilateral ostomies.

Laparoscopic-assisted Soave procedure for Hirschsprung disease: 10-year experience with 106 cases

BackgroundThe purpose of this study was to summarize the clinical experience and 10 year follow-up results of laparoscopic assisted Soave procedure for the treatment of long-segment Hirschsprung disease (HD).MethodsFrom January 2010 to February 2020, 106 children with long-segment HD participated in this study. The laparoscopic-assisted Soave procedure was performed for the treatment of long-segment HD. The follow-up time was two weeks, one month, and three months after the operation, and then every six months to one year.ResultsThe operation was successful for all 106 children. All patients were discharged 5–7 days after the operation. The median time in surgery was 150 (100–190) minutes, and the median volume of bleeding was 6 (3–10) ml. The short-term postoperative daily defecation frequency was 4–11 times, 3–7 times within 6 months, and 2–3 times after 6–12 months. Postoperative complications included anastomotic leakage in two cases, perianal dermatitis in 13 cases, anastomotic stenosis in four cases, adhesive bowel obstruction in two cases, enterocolitis in 16 cases, soiling in 11 cases, and constipation recurrence in three cases.ConclusionsThe laparoscopic-assisted Soave procedure is a safe and effective surgical method for treating long-segment HD, and it causes little trauma or bleeding and has a fast postoperative recovery. Yet some complications may occur. Preoperative diagnosis, intraoperative and postoperative standardized processing can reduce the postoperative complications.

Outcomes of vaginal and laparoscopic hysterectomy with concomitant pelvic reconstructive surgery.

Although vaginal hysterectomy(VH) is traditionally considered the safest route of hysterectomy, newer data suggest that laparoscopic hysterectomy (LH) might have lower risks of perioperative complications in contemporary practice. Using a large surgical database, we aimed to assess the hypothesis that there are no significant differences in rates of major and minor complications between LH and VH when performed with pelvic reconstructive surgery, controlling for the number and type of pelvic reconstructive procedures. A total of 27,941 eligible LH and VH from the 2010-2018 National Surgical Quality Improvement Program database were identified. Concomitant pelvic reconstructive surgery was defined as either an apical suspension, enterocele repair, or colporrhaphy. Laparoscopy-assisted VH, gynecological malignancy, and concomitant nongynecological procedures were excluded. Complications within 30days of surgery were grouped into major (Clavien-Dindo grade ≥3) or minor (grade 1-2) classifications. Bivariate analysis and inverse propensity-weighted logistic regression compared the outcomes of the VH and LH groups. Cochran-Armitage tests and multivariate regression assessed changes over time. The majority of hysterectomies (72%) were vaginal, although its utilization declined from 89% in 2010 to 64% in 2018 (p < 0.001). In multivariate analysis controlling for patient factors and the type and number of concomitant pelvic reconstructive procedures, LH was associated with a lower odds of major (adjusted odds ratio [aOR] 0.711, 95% confidence interval [CI]:0.639-0.791) and minor (aOR 0.659, 95% CI: 0.612-0.710) complications. Relative safety profiles should be considered among other patient factors when counseling women undergoing surgical prolapse repair. Our findings suggest that laparoscopic approaches can be safely utilized among older and sicker patients traditionally counseled toward a vaginal approach.

P-EGS24 Surgical case series of incarcerated diaphragmatic hernias following oesophagectomy for oesophageal cancer. Single centre experience

Abstract Background Incarcerated post-oesophagectomy diaphragmatic hernia (IPODH) is a recognised surgical emergency and potentially hazardous event. Information regarding the natural course for this emergency and guidelines regarding the management were not described clearly in literature. This case series aim to review patients who presented as emergency with IPODH Methods This observation study is conducted at Salford Royal Hospital that has one of the largest oesophago-gastric unit in United Kingdom. A 7-year period (April 2013 - April 2020) retrospective data collection is performed using prospectively maintained database. We reviewed the presentation and management course for all patients who presented as emergency with IPODH. Results We identified 341 patients who underwent oesophagectomies over the seven-year period. Seven patients (2%) developed IPODH which required emergency surgery. All these patients underwent 2 stage oesophagectomies. Out of these, 5 patients had laparoscopic assisted procedure (hybrid), 1 patient had minimally invasive procedure and another patient had open operation. Mean time interval from esophagectomy to the acute incarcerated hernia presentation was 23 months. Only 1 patient developed acute diaphragmatic hernia on day 4 post-oesophagectomy. The incarcerated hernia contents were reported as small bowels (4 patients), gastric conduit (2 patients) and colon (1 patient). Dealing with these acute emergency cases can be difficult as the hernia contents are threatened. Therefore, most of these patients underwent emergency laparotomy, only 1 patient had laparoscopic procedure to repair the incarcerated hernia. Collagen mesh used to repair the defect only in 2 patients, whereas the rest of the patients had the defect repaired with primary sutures only. Conclusions Minimally invasive techniques were associated with a higher incidence of post-oesophagectomy diaphragmatic hernia compared with open techniques. These hernias can lead to a significant and serious risk when they present with incarceration. The risk of the acute manifestation and significant post-repair morbidity support long-term surveillance for post-oesophagectomy diaphragmatic hernia and elective surgical treatment. Laparoscopic repair of non-complicated diaphragmatic hernia is feasible and effective in high-volume centres.

EP.FRI.874 Laparoscopic Assisted Submucosal Excision of an Intussuscepted Colonic Lipoma through a Colotomy; A New Technique

Abstract Lipomas are the most common non-epithelial tumours of the colon. Nevertheless, symptomatic colonic lipomas are a rare entity in adults. Intussusception is the commonest complication of submucosal lipomas and often presents with absent, non-specific or intermittent symptoms, hence the diagnosis is challenging. In non-emergency situations, most patients undergo computed tomography scan as well as endoscopic evaluation of the colon prior to any surgical intervention. While successful endoscopic excision of lipomas has been reported, segmental resection of the colon is most commonly practiced. To the best of our knowledge, this is the first report of laparoscopic assisted submucosal excision of an intussuscepting colonic lipoma through a colotomy. We present the case of a young female patient with few weeks history of intermittent abdominal pain associated with nausea. She had previously undergone various investigations including colonoscopy and was awaiting an elective left hemicolectomy. She presented to our Emergency department with subacute large bowel obstruction. A CT scan confirmed the diagnosis of colo-colic intussusception due to a large descending colon lipoma. The patient underwent a laparoscopic assisted procedure - following laparoscopic colonic mobilisation, submucosal excision of the large lipoma was performed through a colotomy placed through the taenia on the opposite wall. The mucosal defect and colotomy were closed following the excision. The patient recovery was uneventful and histopathology of the specimen confirmed the diagnosis.

Skip segment Hirschsprung's disease: diagnostic clues and surgical management.

It is challenging to establish a definitive diagnosis and initiate timely management for skip segment Hirschsprung's disease (SSHD). Herein, we report three cases of SSHD at our institution between December 2008 and March 2018. Patient #1 was misdiagnosed and underwent three successive operations within 2years. Patient #2 and #3 were diagnosed timely based on previous experience. A segmental narrowing detected by barium enema may raise the possibility of SSHD. Laparoscopic-guided multipoint biopsy is regarded as a mini-invasive and purposeful way to take representative samples after locating the segmental narrowing intraoperatively and accurate the final diagnosis. The laparoscopic-assisted pull-through procedure with radical resection from the distal rectum to the most proximal margin of the diseased skip segment is safe and effective in treating patients with SSHD.Level of evidence: Level III.

Intra-Operative Vascular Injury and Control During Laparoscopic and Robotic Mesh Explantation for Chronic Post Herniorrhaphy Inguinal Pain (CPIP)

Chronic postherniorrhaphy inguinal pain (CPIP) is common following inguinal hernia repair. As even primary minimally-invasive inguinal hernia repairs carry a risk of significant intra-operative bleeding, it is unsurprising that reoperative groin exploration and mesh explantation for chronic post-inguinal herniorrhaphy pain confers an even higher risk of arteriotomy or venotomy due to a distorted anatomy and the presence of adhesions. In this report, we present a single institution's experience with the management of intra-operative vascular injury encountered during minimally invasive groin exploration and mesh explantation for CPIP. We performed a retrospective consecutive case series study at a single academic center of patients with CPIP who underwent minimally invasive groin exploration and mesh removal during which an iatrogenic arteriotomy or venotomy occurred from September 2015 to September 2020. Descriptive statistics were collected for age, laterality of hernia repair, mean follow-up time, surgical approach (robotic vs. laparoscopic), type of intra-operative vascular injury, vascular control technique, and post-operative complications. Of 196 minimally invasive groin exploration and mesh removal cases, 46 were performed with robotic assistance and 150 were performed using traditional laparoscopy. The overall incidence of intra-operative vascular injury was 43 (22%). Fifteen of 46 (32%) robotic groin exploration and mesh removal cases and 28 of 150 (19%) laparoscopic cases involved vascular control. Three of 15 (20%) robotic cases and 23 of 28 (82%) laparoscopic cases involved a hybrid open inguinal approach to address anterior pathology (neurectomy, anterior mesh removal, hernia repair) or facilitate exposure for vascular repair. The most common site of injury was the inferior epigastric vessels. Other sites included the iliac vein, iliac artery, corona mortis, and accessory obturator vessels. Vascular control techniques included ligation with an energy device or suture, primary suture repair of injured vessel, or bovine pericardium patch angioplasty. All were managed without intra-operative vascular surgery intervention except for one case with extensive calcification that required endarterectomy and angioplasty to improve patency. No cases required conversion to midline laparotomy. Ninety three percent of the cases with large vessel bleeding during laparoscopic-assisted procedures were repaired via an open groin incision, whereas all cases of large vessel bleeding during robotic-assisted procedures were repaired robotically. None of the patients required transfusion. Postoperative complications occurred in 3 patients (7%), 2 (5%) developed hematoma formation requiring surgical evacuation, and 1 (2%) developed ipsilateral iliofemoral deep vein thrombosis (DVT) and underwent peripheral angiography and thrombolysis. Although minimally invasive groin exploration and mesh explantation for CPIP is technically challenging, it is a safe and effective operation when performed at experienced centers. Iatrogenic vascular injury should be anticipated but can be effectively controlled laparoscopically, robotically, or via a hybrid open inguinal incision without conversion to a midline laparotomy and with low post-operative complication rates.

Perioperative Care of Patients Diagnosed With Twin-to-Twin Transfusion Syndrome Undergoing Laparoscopic-Assisted Fetoscopic Placental Laser Photocoagulation.

Twin-to-twin transfusion syndrome (TTTS) is a condition that results in unbalanced blood flow between two fetuses. Patients diagnosed with TTTS can experience maternal or fetal morbidity and mortality. Depending on the severity of TTTS, laser ablation of placental anastomoses may be the most effective treatment. The preferred treatment method requires percutaneous entry to the uterus; however, some patient circumstances (eg, placenta location) require a laparoscopic-assisted procedure. During the preoperative appointments, clinicians assess the condition of the fetuses and patients may participate in genetic counseling. Intraoperative care involves an interdisciplinary team that may include a pediatric general surgeon, maternal-fetal medicine specialists, an RN circulator, a scrub person, and an anesthesia professional. Perioperative nurses should have knowledge of the pathophysiology of TTTS, including its natural progression. They also should understand preoperative and intraoperative patient care requirements to provide safe and effective care for patients undergoing laparoscopic-assisted fetoscopic placental laser photocoagulation procedures.

Role of Minimally Invasive Surgery in Management of Penetrating Abdominal Trauma in Children.

Traditionally, exploratory laparotomy was used to treat penetrating abdominal trauma (PAT). At present, minimally invasive surgery (for diagnostic and therapeutic purposes) has developed and represents a rapidly evolving modality for dealing with PAT in stable children. In this article, we aim to present our experience, evaluate the effectiveness, and report the results of minimally invasive surgery (MIS) for PAT in stable pediatric patients. This prospective study involved 117 hemodynamically stable pediatric cases of PAT (caused by gunshots, stab, and accidental stab), admitted, and managed according to the severity of injury. The information recorded for analysis included demographic data, the anatomical location of injury, the initial vital data and scoring systems, the organs affected, the procedures done, operative time, need for conversion to laparoscopic-assisted approach, length of hospital stay, complications, missed injury, and mortality rate. Among 117 pediatric patients with PAT, 15 cases were treated conservatively and 102 cases were managed by MIS. They were 70 males and 47 females with a mean age of 7.3 ± 0.6 years (range = 1-14 years). They included 48 cases of gunshot injury, 33 cases of abdominal stab, and 36 cases of accidental stab. Laparoscopy was diagnostic (DL) in 33.3% (n = 34) and therapeutic (TL) in 66.7% (n = 68) of cases. Of the 68 TL cases, we completely managed 59 cases (86.8%) by laparoscopy, while 9 cases (13.2%) were converted to limited laparotomy. The mean operative time was 17 ± 1 minutes (range = 12-25 minutes) for DL, 85 ± 9 minutes (range = 41-143 minutes) for complete TL cases, and 89 ± 3 minutes (range = 47-149 minutes) for laparoscopic-assisted procedures. For DL cases, the mean length of hospital stay was 2 ± 0.4 days, while for complete TL cases, it was 5.4 ± 0.83 days, and for laparoscopic-assisted cases, it was 5.8 ± 0.37 days. Postoperative complications occurred in eight cases (7.84%), with five cases (4.9%) required reintervention. No missed injury or mortality was recorded in the study. The patients were followed up for a median period of 52 months. For management of PAT in children, MIS has 100% accuracy in defining the injured organs with zero percent missed injuries.

Laparoscopic insertion and revision of ventriculo-peritoneal shunts in children

Ventriculoperitoneal (VP) shunt is a common procedure used to drain cerebrospinal fluid to treat hydrocephalus. Advances in laparoscopy tools and techniques made it possible to perform this procedure laparoscopically assisted. Complications of this procedure are also amenable to laparoscopic correction. This study outlines the safety and feasibility of laparoscopy in performing the procedure and management of its complications. A retrospective file review for all cases underwent laparoscopic-assisted VP shunt or laparoscopic management of one of its complications in the period 2015–2019. Laparoscopic-assisted procedure was done either by 3-port technique or a peritoneocentesis needle technique. Management of complications was done according to its nature. Over 4 years, we performed 36 laparoscopic-assisted VP shunt placement and 17 laparoscopic interventions for abdominal complications related to VP shunts. There were no intraoperative or postoperative complications related to the laparoscopic technique. Conversion to conventional laparotomy was done in 3 patients presented with hugely infected CSF pseudocysts with amalgamated intestine with the wall of the cyst. Laparoscopic-assisted VP shunt placement and revisions in children are feasible and safe. No special tools are required for the procedure.