Pediatric Laparoscopic Surgery Research Articles

Safety of the spray-type adhesion barrier “AdSpray®”in pediatric laparoscopic surgery

Safety of the spray-type adhesion barrier “AdSpray®”in pediatric laparoscopic surgery

Comparison of postoperative analgesia and side effects in pediatric laparoscopic surgery with morphine and nalbuphine

There is currently no consensus on the optimal perioperative pain management strategy involving specific opioids. This study aims to compare the postoperative analgesia, the associated side effects between nalbuphine and morphine in children undergoing laparoscopic surgery. One hundred ninety children were randomly assigned to nalbuphine (0.2mg/kg) or morphine (0.2mg/kg). Nalbuphine's analgesic effect was non-inferior to morphine, with similar total rescue analgesic consumption during PACU stay (0.03± 0.05mg vs. 0.04± 0.06mg, p>0.05). Nalbuphine group had a lower incidence of respiratory depression (RR ≤ 10/min) (4.8% vs. 38.6%, p<0.001), PONV (2.4% vs. 18.1%, p= 0.002), and pruritus (0% vs. 16.9%, p<0.001) than morphine. Additionally, nalbuphine showed a shorter laryngeal mask airway removal time (13.9 [12.7, 15.1]) compared with morphine (17.0 [15.1, 18.9], p= 0.011). Nalbuphine provides equipotent analgesia with significantly lower incidences of respiratory depression, PONV, and pruritus compared with morphine in pediatric laparoscopic surgery.

Physiological and Anesthetic Considerations of Safe and Optimal Pneumoperitoneal Pressures for Laparoscopic Surgeries in Children.

In the era of minimally invasive surgeries, pediatric laparoscopic surgeries are now becoming the standard of care. In this study, we aim to determine the safe and optimal pneumoperitoneal pressures (PPs) for laparoscopic surgery in children aged 1-5 years, along with the technical ease for the surgeon. Prospective, randomized, single-blinded study was conducted at SGPGI Lucknow. Children aged 1-5 years were randomized into Group I (n = 24): PP = 6-8 mmHg and Group II: (PP) = 9-10 mmHg. Hemodynamic, ventilatory, and blood gas changes were measured before CO2 insufflation (T0), 20 min after insufflation (T1), before desufflation (T2), and 10 min after desufflation (T3). Surgeon's technical ease of surgery, postoperative pain, the requirement of rescue analgesia, time to resume feeding, and complications were recorded and analyzed. Paired t-test, Mann-Whitney test, and Wilcoxon signed-rank test were used for nonparametric/parametric data. Chi-square/Fisher's test was used for nominal data. Partial pressure of CO2 (PaCO2) was significantly higher in Group II at T1, T2, and T3, requiring frequent changes in ventilatory settings. Postoperative pain scores were higher in Group II at 1, 6, and 12 h, requiring rescue analgesia. Surgeon's scores and hemodynamics were similar in both groups. Higher PP in Group II caused significant changes in PaCO2, end-tidal CO2, and postoperative pain requiring rescue analgesia, but blood gas changes were clinically insignificant and there were no significant changes in hemodynamic parameters. Since the surgeon's ease of performing surgery was similar in both groups, we recommend that laparoscopy in children aged 1-5 years can be started with lower PPs of 6-8 mmHg, which can be increased if needed based on the surgeon's comfort and the patient's body habitus.

Transversus Abdominis Plane Block VS. Local Wound Infiltration for Elective Minimally Invasive Cholecystectomy in Children: A Prospective Randomized Trial

BackgroundThe efficacy of transversus abdominis plane (TAP) block versus local anesthetic wound infiltration (LWI) in pediatric laparoscopic surgery is largely unknown. The objective of this study was to prospectively analyze this in minimally invasive cholecystectomy. We hypothesized that TAP block would be superior to LWI in terms of pain control and post-operative complications. MethodsWe conducted a prospective, randomized, single-blinded, controlled trial between 2017 and 2022 after obtaining Institutional Review Board (IRB) approval. After randomization, patients received a standard amount of ropivacaine via either 1) ultrasound-guided TAP block after general anesthesia induction or 2) local injection at port insertion by the operating surgeon. We collected data including operative time, pain scores, and medication usage post-operatively. We used descriptive statistics to report all endpoints and compared data with t-tests and Fisher's exact tests. A p-value less than 0.05 was considered statistically significant. ResultsWe enrolled 85 patients (43 LWI, 42 TAP). Mean [standard deviation] age and body mass index (BMI) in the LWI and TAP groups were 14.8 [1.9] and 14.7 [2] years and 29.9 [7.2] and 27.4 [8.2] kilogram/meter2 (kg/m2) respectively. We did not find any significant differences in postoperative opioid use, pain scores, and gastrointestinal symptoms. TAP patients had significantly longer time between anesthesia-start and procedure-start (p < 0.001), although total time under anesthesia was not significantly different (p = 0.540). ConclusionThere are no significant differences between equal administration of local anesthetic by TAP block and surgeon administered LWI during minimally invasive cholecystectomy. Type of StudyRandomized clinical trial. Level of EvidenceLevel II.

Supraglottic airway device versus tracheal tube for pediatriclaparoscopic surgery-A systematic review and meta-analysis.

Conventionally, tracheal tubes have been used for general anesthesia in pediatric laparoscopic surgeries. Recently, supraglottic devices are being used for the same. The performance of supraglottic devices versus tracheal tubes in children undergoing laparoscopic surgery is uncertain. A systematic review and meta-analysis of randomized controlled trials that compared supraglottic devices versus tracheal tubes in patients ≤18 years undergoing laparoscopic surgery under general anesthesia was conducted. The outcomes were peak airway pressures (cm H2 O), end-tidal carbon dioxide during pneumoperitoneum (mm Hg), recovery time (min), postoperative sore throat and adverse events. Mean difference and odds ratio, with 95% confidence intervals were reported using a random effect model. Eight trials (n = 591) were included in the final meta-analysis. There was no statistically significant difference in the peak airway pressures (MD 0.58, 95% CI: -0.65 to 1.8; p = .36) and end-tidal carbon dioxide (MD -0.60, 95% CI: -2.00 to 0.80; p = .40) during pneumoperitoneum in the supraglottic device and the tracheal tube group. The tracheal tube group had higher odds of sore throat (OR 3.30, 95% CI: 1.69-6.45; p = .0005) and the supraglottic airway group had faster recovery time (MD 4.21, 95% CI: 3.12-5.31; p < .0001), which were statistically significant. The certainty of evidence is graded low. There is low quality evidence to suggest that for pediatric laparoscopic surgeries of short duration, supraglottic devices could provide comparable intraoperative ventilation in terms of peak airway pressures and end tidal carbon dioxide, with lower odds of postoperative sore throat and faster recovery time when compared to tracheal tubes.

Comprehension of fundamental knowledge about pediatric endoscopic surgery: a cross-sectional study in Japan.

Pediatric endoscopic surgery has become an alternative to conventional techniques with the development of medical equipment. However, there is no formal, standardized curriculum for pediatric endoscopic surgery, and its requirement remains elusive. The purpose of this study is to determine the baseline knowledge of pediatric surgeons that is considered essential for pediatric laparoscopic and thoracoscopic surgery. Sixteen web-based multiple-choice questions based on the fundamental cognitive knowledge of pediatric endoscopic surgery were administered. The questions were created based on the fields covered by the Fundamentals of Laparoscopic Surgery ™ (FLS) certification examination blueprints and eight specific diseases of pediatric surgery. Pediatric surgeons and pediatric surgical trainees participated in this study voluntarily. A total of 122 surgeons participated through the Japanese Society of Pediatric Surgeons. The response rate was 95% (122/128). The total mean examination score of all participants was 79.4% (77.3-81.4%). There were no significant differences in total scores between the board-certified pediatric surgeons without an endoscopic surgical skill qualification and the non-board-certified pediatric surgeons (80.4% vs. 77.1%, p = 0.12). The endoscopic surgical skill-qualified surgeons had significantly higher percentages of correct responses in specific subjects than board-certified pediatric surgeons and surgeons without pediatric board certification (94.3% vs. 82.9%, p = 0.02; 94.3% vs. 77.5%, p = 0.0002). The FLS original subjects' scores were not significantly different among them. The mean score of surgeons who had experienced more than 200 cases of endoscopic surgery, including adult cases, was 83.2% (80.4-85.9%). A knowledge gap exists between surgeons, board-certified pediatric surgeons, and endoscopic surgical skill-qualified surgeons in Japan. In the field of pediatric surgery, an effective formal curriculum, such as FLS, is required to help address this vast knowledge gap for the safe conduct of endoscopic surgeries.

Noninvasive carbon dioxide monitoring in pediatric patients undergoing laparoscopic surgery: transcutaneous vs. end-tidal techniques

PurposeThe present study aimed to investigate the correlation between transcutaneous carbon dioxide partial pressure (PtcCO2) and arterial carbon dioxide pressure (PaCO2) and the accuracy of PtcCO2 in predicting PaCO2 during laparoscopic surgery in pediatric patients.MethodsChildren aged 2–8 years with American Society of Anesthesiologists (ASA) class I or II who underwent laparoscopic surgery under general anesthesia were selected. After anesthesia induction and tracheal intubation, PtcCO2 was monitored, and radial arterial catheterization was performed for continuous pressure measurement. PaCO2, PtcCO2, and end-tidal carbon dioxide partial pressure (PetCO2) were measured before pneumoperitoneum, and 30, 60, and 90 min after pneumoperitoneum, respectively. The correlation and agreement between PtcCO2 and PaCO2, PetCO2, and PaCO2 were evaluated.ResultsA total of 32 patients were eventually enrolled in this study, resulting in 128 datasets. The linear regression equations were: PtcCO2 = 7.89 + 0.82 × PaCO2 (r2 = 0.70, P < 0.01); PetCO2 = 9.87 + 0.64 × PaCO2 (r2 = 0.69, P < 0.01). The 95% limits of agreement (LOA) of PtcCO2 – PaCO2 average was 0.66 ± 4.92 mmHg, and the 95% LOA of PetCO2 – PaCO2 average was –4.4 ± 4.86 mmHg. A difference of ≤ 5 mmHg was noted between PtcCO2 and PaCO2 in 122/128 samples and between PetCO2 and PaCO2 in 81/128 samples (P < 0.01).ConclusionIn pediatric laparoscopic surgery, a close correlation was established between PtcCO2 and PaCO2. Compared to PetCO2, PtcCO2 can estimate PaCO2 accurately and could be used as an auxiliary monitoring indicator to optimize anesthesia management for laparoscopic surgery in children; however, it is not a substitute for PetCO2.Registration number of Chinese Clinical Trial RegistryChiCTR2100043636.

Comparison between Ultrasound-Guided Transversus Abdominis Plane Block and Ultrasound-Guided Erector Spinae Plane Block During Pediatric Laparoscopic Surgeries: A Randomized, Controlled, Prospective Study

Comparison between Ultrasound-Guided Transversus Abdominis Plane Block and Ultrasound-Guided Erector Spinae Plane Block During Pediatric Laparoscopic Surgeries: A Randomized, Controlled, Prospective Study

Laparoscopic cholecystectomy under spinal anesthesia in a 5-year-old child: A case report

Symptomatic cholelithiasis in pediatric patients should be dealt with cholecystectomy. Due to its minimally invasive nature, laparoscopic approach is better than conventional open approach. Although safety of spinal anesthesia (SA) in adult laparoscopic surgeries including cholecystectomy is well established, its use in pediatric laparoscopic surgeries is extremely limited with only a few studies being published till date. Here, we report a case of laparoscopic cholecystectomy (LC) in a 5-year-old child which was successfully managed with SA. This may be the very first case report of pediatric LC under SA.

Implementation of enhanced recovery protocols reduces opioid use in pediatric laparoscopic cholecystectomy surgery.

Enhanced recovery protocols [ERPs] standardize care and have been demonstrated to improve surgical quality in adults. We retrospectively compared outcomes before and after implementation of ERPs in children undergoing elective laparoscopic cholecystectomy [ELC] surgery. A pediatric-specific ERP was implemented for children undergoing ELC at one [C1] of the two Pediatric Surgical Centers in July 2016. We retrospectively reviewed 606 patients undergoing ELC between July 2014 and December 2019. Of these, 206 patients underwent ELC prior to ERP implementation [Pre-ERP] were compared to 400 patients undergoing ELC managed in the post-ERP implementation period (between January 2017 and December 2019), 21 of which were managed by enhanced recovery protocol. Primary Outcomes included immediate peri-operative and post-operative narcotic use in mean morphine equivalents [MME], narcotics at discharge, complications, nurse calls and returns to system [RTS]. There was a significant decrease in opioid use both post-operatively and at time of discharge in the ERP managed cohort. The MME use during the post-operative period was 0.85 in the in ERP-compliant patients compared to 6.40 in the non-compliant group (p < 0.027). Eighty-six percent of ERP-compliant patients in the study required no narcotics at discharge, which was statistically significant when compared to ERP non-compliant cohort (p < 0.0001). There was also no change in RTS, nurse calls or complications. In addition, in the post-ERP period (2017-2019), a dominant proportion of patients at C1 partially complied with the ERP, resulting in a statistically significantly decrease of opioid use between sites in the post-op period (6.54 vs 10.57 MME) post-ERP (p < 0.001). Similar effects were noted in discharge narcotics. The use of pediatric-specific ERP in children undergoing ELC is safe, effective, and provides compassionate pain control while leading to a reduction in opioid use peri-operatively and at discharge. This improvement occurred without changes in RTS, nursing calls or complications. Level III; Retrospective study.

Incidence of inadvertent perioperative hypothermia in pediatric laparoscopic surgery: a prospective observational single-center study.

Abstract&#x0D; Objective&#x0D; The pediatric age group is in the risk group for Inadvertent perioperative hypothermia (IPH) due to insufficient subcutaneous adipose tissue and underdeveloped thermoregulatory responses.&#x0D; We aimed to determine the frequency of IPH in the pediatric age group undergoing laparoscopic surgery.&#x0D; Methods&#x0D; The study is prospective observational.&#x0D; Pediatric patients (1-18 years old) who underwent laparoscopic surgery under general anaesthesia were evelueted. The tympanic membrane temperature measurements of the patients (°C) were recorded before anaesthesia induction (T0) and then every 15 minutes during the surgery.&#x0D; Results&#x0D; A total of 100 patients were evaluated. The frequency of inadvertent perioperative hypothermia was detected 13 (13%). Frequency of IPH on elective surgery patients was higher than emergency surgery (

Efficacy of dexmedetomidine versus magnesium sulfate as an adjuvant to intraperitoneal bupivacaine in pediatric laparoscopic surgery: a randomized clinical trial

BackgroundWe evaluated the efficacy of dexmedetomidine versus magnesium sulfate as an adjuvant to intraperitoneal (IP) bupivacaine in pediatric laparoscopic inguinal herniorrhaphy. MethodsNinety-seven male children, ASA I–II, 1–6 years old, undergoing laparoscopic inguinal herniorrhaphy, were randomized to receive before peritoneal insufflation, IP 2 mg.kg−1 bupivacaine 0.5% combined with either 1 μg.kg−1 of dexmedetomidine (Group D), 30 mg.kg−1 of magnesium sulfate (Group M), or normal saline (Group C). All tested drugs were diluted to the volume of 10 mL with normal saline. FLACC pain scores, need for rescue analgesics, time to flatus and first stool, emetic events, adverse effects, functional recovery, and parents’ satisfaction were recorded for the first 48 h postoperatively. ResultsFLACC scores were significantly higher in Group C than in the other two groups at 6, 8, 12, 18, 24, and 48 hours after surgery with no differences between Groups D and M. Rescue analgesia was significantly higher in Group C with none of the children in Groups D and M requiring rescue analgesia (p = 0.001). Times to first flatus and stool, emetic events, and adverse effects did not differ among groups. Times to return to normal functional activity were comparable in all groups. Parents’ satisfaction was greater in Groups D and M than in Group C (p = 0.026). ConclusionDexmedetomidine and magnesium sulfate added to IP bupivacaine improved the analgesia afforded by bupivacaine in the first two postoperative days in children scheduled for laparoscopic herniorrhaphy.

Robotic Anxiety-Parents' Perception of Robot-Assisted Pediatric Surgery.

In contrast to many other countries, robot-assisted (RA) pediatric surgery is not yet very common in Germany. Although the first pediatric RA intervention was published in 2001, RA pediatric surgery is still perceived as a “new technology”. As a consequence, little is known about parents’ perception of this operation method. In this study, we analyzed parents‘ intention to let their child undergo RA and laparoscopic (LA) surgery. Two subsamples (online and at the University Medical Center Goettingen) received a questionnaire addressing attitude towards RA and LA pediatric surgery with the help of a case example. Results showed that parents had a higher intention to consent to LA surgery. Perceiving more benefits, assuming a positive attitude of the social environment, and feeling less anxiety increased intention. A mediation analysis indicated that the type of surgery affected intentions through assumed attitude of the social environment. Exploratory analyses showed that the perception of risks and anxiety reduced intention for only RA surgery. These findings should be considered in preoperational discussions with parents. Anxiety and perceived risks should especially be addressed in order to encounter hesitancy.

Abstract No.: ABS3339: Effects of volume controlled and pressure controlled volume guaranteed modes of ventilation on respiratory dynamics during laparoscopic surgery in children: A prospective observational study

Background & Aims:The aim of the study was to compare the effects of Volume controlled ventilation (VCV) and Pressure controlled volume guaranteed ventilation (PCV-VG), which delivers the target tidal volume at the lowest possible pressure, on respiratory dynamics during paediatric laparoscopic surgery.Methods:In this prospective observational study, 52 patients of 0-15 years were included; (n= 26) each for VCV and PCV-VG.fraction of inspired oxygen(FiO2)50%, tidal volume 6-10 ml/kg, age appropriate respiratory rate (RR) to maintain end-tidal carbon dioxide (EtCO2) between 35-40 mm Hg, PEEP 4 cm and P-limit 10 cm above the initial peak pressure were set. Peak inspiratory pressure (PIP), Plateau pressure (PlatP), expiredtidal volume (VTe)/kg, compliance (Compl), airway resistance (R), ETCO2 and saturation of O2 (SaO2)were noted after intubation, creation of pneumoperitoneum, changing position, desufflation and change of position to supine.Results:Demographic criteria, haemodynamic parameters, set and measured respiratory parameters at all time points were similar inboth groups. Trendelenburg position was required in 11 children in VCV and 13 in PCV-VG group. Following this, there was similar increase in PIP, PlatP, R and decrease in CompL in both groups. However, significant increase in RR was required inVCV group (percentage change in RR- —VCV: 3.5±5.01, PCV-VG : 0±00, p=0.039) to maintain normal ETCO2.Conclusion:Either VCV or PCV-VG mode of ventilation, can be used during paediatric laparoscopic surgery in supine position.However, with Trendelenburg position, PCV-VG provides a marginal advantage over VCV mode of ventilation.

Effects of positive end-expiratory pressure on pulmonary atelectasis after paediatric laparoscopic surgery as assessed by ultrasound: A randomised controlled study

IntroductionPositive end-expiratory pressure (PEEP) following alveolar recruitment manoeuvre (RM) can effectively prevent anaesthesia-induced atelectasis in children. We aimed to evaluate the individual effect of PEEP following RM on atelectasis at the end of laparoscopic surgery in infants and small children. MethodsChildren undergoing laparoscopic inguinal hernia repair aged 5 weeks to 2 years were randomly allocated to either the PEEP or control group. A progressive RM was performed after intubation in all cases. The PEEP group received PEEP of 5 cmH2O until the end of mechanical ventilation, while the control group did not receive any PEEP. Lung ultrasonography was performed to compare the number of atelectatic regions between the two groups after anaesthesia induction, after RM, and at the end of surgery in 12 thoracic regions. ResultsOverall, 432 ultrasonographic images were acquired from 36 children. At the end of surgery, the number of atelectatic regions (median [interquartile range]) was significantly lower in the PEEP group compared to the control group (2.0 [1.0–3.0] versus 4.0 [3.0–4.0] out of 12 regions, respectively; p = 0.02). While no difference was observed between the number of atelectatic regions after induction and at the end of surgery in the control group (p = 0.30), a decrease was observed in the PEEP group (3.0 [2.0–4.0] to 2.0 [1.0–3.0], respectively; p = 0.02). ConclusionRM followed by a PEEP of 5 cmH2O can effectively reduce the regions of pulmonary atelectasis at the end of laparoscopic surgery in infants and small children.

Implementation of enhanced recovery protocols reduces opioid use in pediatric laparoscopic Heller myotomy surgery

BackgroundEnhanced recovery protocols (ERPs) are effective means of standardizing and improving the quality of surgical care in adults. Our purpose was to retrospectively compare outcomes before and after implementation of ERPs in children undergoing laparoscopic Heller myotomy for achalasia. MethodsA pediatric-specific ERP was used for children undergoing laparoscopic Heller myotomy starting July 2017 at two pediatric surgery centers within a single metropolitan healthcare system. A retrospective review of 8 patients undergoing Heller myotomies between July 2014 and July 2017 was performed as a control. This cohort was compared to 14 patients managed post-ERP implementation (2017–2020). Outcomes of interest investigated included opioid use during admission, narcotics at discharge, time to regular diet, length of stay (LOS), and readmissions. ResultsThere was a significant decrease in opioid use both while in the hospital and at time of discharge. Mean morphine equivalent use was 4.50 mg in the pre-ERP cohort and 1.97 mg in the post-ERP cohort. Furthermore, 8 out of 14 (57%) patients in the post-ERP cohort received no opioids during the admission compared with only 2 out of 8 (25%) patients in the pre-ERP cohort. Only 1 out of 14 (7.14%) patients in the post-ERP cohort was discharged with a prescription for opioid medication while 6 out of 8 (75%) in the pre-ERP cohort were discharged with an opiate prescription. ConclusionsThe use of ERP in children undergoing laparoscopic Heller myotomy surgery is safe and effective and leads to a reduction in opioid use during admission and at discharge. Levels of evidenceLevel III.

End-tidal carbon dioxide measurements as a surrogate to arterial carbon dioxide during pediatric laparoscopic surgeries: a prospective observational cohort study

BackgroundMaintaining normocapnia during mechanical ventilation in anesthetized children during laparoscopic surgeries is highly recommended. There is a debate regarding the use of capnography (ETCO2) as a trend monitor for evaluation of arterial carbon dioxide levels (PaCO2). We analyzed the relationship between ETCO2 and PaCO2 with time in elective pediatric laparoscopic surgeries. MethodsThis study was a prospective observational cohort analysis of 116 paired comparisons between PaCO2 and ETCO2 computed from 29 children (ASA I, 12–72 months). Arterial blood samples were withdrawn before, at 15 minutes and 30 minutes during pneumoperitoneum and 1 minute after deflation. ETCO2 value was recorded simultaneously, while arterial blood was withdrawn. PaCO2–ETCO2 relationship was evaluated by Pearson's correlation coefficients and Bland Altman Method of agreement. ResultsOut of the 116 comparisons analyzed, a PaCO2–ETCO2 difference beyond 0 to ≤ 5 mmHg was recorded in 71 comparisons (61.2%) with negative difference in 34 comparisons (29.3%). A positive significant correlation between PaCO2 and ETCO2 was recorded before (r = 0.617, p = 0.000) and at 15 minutes (r = 0.582, p = 0.001), with no significant correlation at 30 minutes (r = 0.142, p = 0.461), either after deflation (r = 0.108, p = 0.577). Bland-Altman plots showed agreement between ETCO2 and PaCO2 before inflation with mean PaCO2-ETCO2 difference 0.14 ± 5.6 mmHg (limits of 95% agreement -10.84–11.2, simple linear regression testing p-value 0.971), with no agreement at 15 minutes (0.51 ± 7.15, -13.5–14.5, p = 0.000), 30 minutes. (2.62 ± 7.83, -12.73–17.97, p = 0.000), or after deflation (1.81 ± 6.56, -10.93–14.55, p = 0.015). ConclusionUsage of capnography as a trend monitor in pediatric laparoscopic surgeries may not be a reliable surrogate for PaCO2 levels. Trial registrationClinical Trials. gov (Identifier: NCT03361657)

Effect of neuromuscular block on surgical conditions during short-duration paediatric laparoscopic surgery involving a supraglottic airway

BackgroundUse of an LMA ProSeal™ laryngeal mask airway (P-LMA; Teleflex) with no neuromuscular block is considered a safe alternative to tracheal intubation in short-duration paediatric laparoscopic surgery. However, few studies have evaluated surgical conditions of short-duration paediatric laparoscopic surgery using this anaesthetic technique. We assessed surgical conditions for paediatric laparoscopic inguinal hernia repair using P-LMA with and without neuromuscular block. MethodsSixty-six patients undergoing laparoscopic inguinal hernia repair were randomised to receive a neuromuscular block (train-of-four 1–2 twitches) using rocuronium or no neuromuscular block with the P-LMA. All operations were performed by the same surgeon who determined the surgical conditions using the Leiden-surgical rating scale (L-SRS). Secondary outcomes included perioperative data, haemodynamics, and adverse events. ResultsNeuromuscular block improved surgical conditions compared with no neuromuscular block: mean (standard deviation) L-SRS 4.1 (0.5) vs 3.5 (0.6), respectively (P<0.0001). Mean rocuronium dose in the neuromuscular block group was 12.7 (4.4–29.7) mg or 0.7 (0.6–0.8) mg kg−1. The insufflation Ppeak was higher in the no neuromuscular block group than in the neuromuscular block group: mean (standard deviation) Ppeak 17.9 (1.8) cm H2O vs 16.2 (1.9) cm H2O, respectively (P=0.0004). Fifteen children (45.5%) in the no neuromuscular block group had adverse events during the surgery and anaesthesia vs four children (12.1%) in the neuromuscular block group (P=0.006). ConclusionsNeuromuscular block significantly improved surgical conditions and reduced the incidence of adverse events during surgery and anaesthesia when an LMA Proseal™ was used in short-duration paediatric laparoscopic surgery. Clinical trial registrationChiCTR2000038529.

Application of Evidence-based Nursing in Prevention of Hypothermia in Pediatric Laparoscopic Surgery

Application of Evidence-based Nursing in Prevention of Hypothermia in Pediatric Laparoscopic Surgery

Learning Curve for Laparoscopic Repair of Pediatric Inguinal Hernia Using Percutaneous Internal Ring Suturing.

Background: Percutaneous internal ring suturing (PIRS) is a simple and popular technique for the treatment of inguinal hernia in children. The aim of this study was to analyze the learning curves during implementation of PIRS in our department. Methods: A total of 318 pediatric patients underwent hernia repair using the PIRS technique by three pediatric surgeons with different levels of experience in laparoscopic surgery. These patients were enrolled in a prospective cohort study during the period October 2015–January 2021. Surgical times, intraoperative and postoperative complications, in addition to outcomes of treatment were compared among the pediatric surgeons. Results: Regarding operative time a significant difference among the surgeons was found. Operative time significantly decreased after 25–30 procedures per surgeon. The surgeon with advanced experience in laparoscopic surgery had significantly less operative times for both unilateral (12 (interquartile range, IQR 10.5, 16.5) min vs. 21 (IQR 16.5, 28) min and 25 (IQR 21.5, 30) min; p = 0.002) and bilateral (19 (IQR 14, 21) min vs. 28 (IQR 25, 33) min and 31 (IQR 24, 36) min; p = 0.0001) hernia repair, compared to the other two surgeons. Perioperative complications, conversion, and ipsilateral recurrence rates were higher at the beginning, reaching the benchmarks when each surgeon performed at least 30 PIRS procedures. The most experienced surgeon had the lowest number of complications (1.4%) and needed a fewer number of cases to reach the plateau. The other two surgeons with less experience in laparoscopic surgery had higher rates of complications (4.4% and 5.4%) and needed a higher number of cases to reach the plateau (p = 0.190). Conclusions: A PIRS learning curve for perioperative and postoperative complications, recurrences, and conversion rates reached the plateau after each surgeon had performed at least 30 cases. After that number of cases PIRS is a safe and effective approach for pediatric hernia repair. A surgeon with an advanced level of experience in pediatric laparoscopic surgery adopted the technique more easily and had a significantly faster learning curve.