Single-incision Pediatric Endosurgery Research Articles

The learning curve of single-incision pediatric endosurgery

BackgroundSingle incision pediatric endosurgery (SIPES) has been established in some pediatric surgery centers for certain operations. A concern in implementing these technically challenging procedures is the associated learning curve. This study describes the learning curve associated with the 3 most common procedures appendectomy, cholecystectomy, and pyloromyotomy. MethodsAll SIPES appendectomies, cholecystectomies, and pyloromyotomies performed by an academic pediatric surgeon in the first 14 months of performing SIPES were chronologically divided into thirds of equal number, groups A (first), B (middle), and C (last). The learning curve for each operation was assessed by comparing operating times, conversion rates (defined as adding additional trocars) and complication rates among these groups. ResultsDuring the study period, 183 appendectomies, 51 cholecystectomies, and 49 pyloromyotomies using SIPES technique were performed. With increasing experience, operating times (mean±standard deviation) decreased significantly for all 3 operations (42±14 to 36±13 min for appendectomies, p = 0.015; 78±20 to 59±18 for cholecystectomies, p = 0.004; 26±7.7 to 20±5.5 min for pyloromyotomies, p = 0.015). The number of additional trocars placed during appendectomies declined steadily from 21 % in group A to 0 % in group C (p < 0.001). There were more complications during appendectomy in groups A versus B (8 % versus 0 %, p = 0.03), but no other differences in complication rates were found. ConclusionOperating times for all SIPES operations declined throughout the study period. With experience, the need for additional trocars and the complication rate during appendectomy approaches zero. We have shown that it is feasible to safely and effectively transition to the new surgical technique. Level of evidenceII - prospective cohort study

Single-Incision Pediatric Endosurgery Cholecystectomy Performed by Residents in Children with Sickle Cell Disease.

Introduction: Few centers worldwide have advanced single-incision pediatric endosurgery (SIPES) for pediatric age group. Up to our knowledge this is the first study assessing the safety of SIPES cholecystectomy in children with sickle cell disease (SCD) done by surgical residents. Aims: To determine the feasibility, safety, and expediency of SIPES cholecystectomy in children with SCD performed by surgical residents. Materials and Methods: Retrospective study of all SIPES cholecystectomies performed in our unit from April 1, 2011 to March 31, 2018. We compared the outcome of SIPES cholecystectomy done by fellows and residents. SIPES Covidien 5-12 mm port was inserted through umbilicus. Long 50 cm laparoscope, straight regular instruments, and transabdominal gallbladder traction suture were used in all patients. The cystic duct and artery were identified and divided. The gallbladder is then dissected off the liver and extracted from the abdomen through the port. Results: Forty-three SCD patients underwent SIPES cholecystectomy for 7 years. Mean HbS was 37.56%. Mean age was 10 years. Twenty-four cases (56%) and 19 (44%) were performed by 8 fellows and 10 residents, respectively. Nine other procedures were done simultaneously with cholecystectomy and were excluded from the mean operative time (MOT). The MOT for all cases was 85 minutes, 78 minutes for fellows and 94 minutes for residents (P value is <.001). One extra port was inserted in 2 patients at the beginning of the series. Conclusion: SIPES cholecystectomy in children with SCD is safe and feasible if done by residents under supervision. Stepwise training is essential in this challenging surgery. Involving residents with other SIPES procedures and hands-on minimally invasive surgery single port workshops help them in improving their skills.

Is It Safe for Trainees to Perform Single-Incision Pediatric Endosurgery Splenectomy?

Few centers worldwide have advanced single-incision pediatric endosurgery (SIPES) splenectomy. The safety and feasibility of SIPES performed by trainees were not assessed before. SIPES splenectomy is a demanding technique that needs high level of skills. This is the largest series of 39 SIPES splenectomies performed by 14 trainees in one single center. To assess the safety, feasibility, and technical challenges of SIPES splenectomy performed by trainees and to compare it with other published series. Retrospective study of all patients operated with SIPES splenectomy for 7 years. SIPES port was inserted through 1.5 cm umbilical incision. One type of port and straight regular instruments were used in all cases. Forty-nine patients underwent SIPES splenectomy. Eighty percent was done by our trainees. Six cholecystectomies were done simultaneously. Forty-five patients with sickle cell disease, two with thalassemia, one spherocytosis, and one Fanconi's anemia. Mean operative time (MOT) for splenectomy was 182 minutes (130-190) and 251 minutes for splenectomy with cholecystectomy (230-270) depending on severity of adhesions and size of the spleen; P value <.001. Two conversions have to be opened due to bleeding. There is neither wound infection nor incisional hernia up to date. SIPES splenectomy is safe and feasible when performed by surgical trainees without adding any morbidity to the patient. Learning curve can quickly improve with more exposure of trainee to different SIPES procedures and hands-on workshops. More than one procedure could be done at the same time. It has excellent cosmesis and almost invisible scar.

Homemade Glove Port for Single-Incision Pediatric Endosurgery (SIPES) Appendectomy-How We Do It.

Introduction Single-incision pediatric endosurgery (SIPES) for the treatment of acute appendicitis in children has recently gained popularity due to its advantages including minimization of postoperative scars or less incisional pain. The principal disadvantages of SIPES include the limited degrees of freedom of movement and high health care costs. To overcome these issues, some surgeons have reported to use noncommercial ports for SIPES appendectomy. Case Report In this report, we present a case of a 10-year-old female patient with acute appendicitis undergoing SIPES appendectomy using own homemade glove port and straight rigid instruments. Conclusion SIPES appendectomy using the glove port is a low-cost alternative to commercially available port systems. It is easy to set up and use.

Single-Incision Pediatric Endosurgery (SIPES) oophoropexy in an adolescent with Hodgkin lymphoma prior to pelvic irradiation

Abstract Oophoropexy for fertility preservation during pelvic irradiation dates back to the mid-1960s. For Hodgkin lymphoma (HL), this was performed during a staging laparotomy. Laparoscopic ovarian fixation has supplanted open pexy with advancements in technology and abandonment of staging laparotomies. Single-Incision Pediatric Endosurgery (SIPES) is applicable to numerous multi-port operations. Use of this technique for oophoropexy prior to pelvic irradiation, however, has not been reported. A 19 year-old with stage IVb HL involving the left iliac node basin was to receive radiotherapy and was evaluated for bilateral oophoropexy. An Olympus TriPort™ was introduced at the umbilicus, through which a 5 mm zero-degree laparoscope and a needle driver were introduced. Transabdominal passage of a ski needle through a 2 mm nick in the skin of the anterolateral wall allowed for right sided fixation of the ovaries. Operative recovery was uncomplicated, and post-operative imaging demonstrated satisfactory positioning of the gonads outside the planned radiation field. In conclusion, SIPES oophoropexy is a technically simple method for fertility preservation that offers improved cosmesis.

Single-incision pediatric endosurgery in newborns and infants.

This study focuses on the successful application of single-incision pediatric endosurgery in the treatment of congenital anomalies and acquired diseases in neonates and infants. The purpose of this scientific review consists in highlighting the spectrum, indications, applicability, and effectiveness of single-port endosurgery in children during the first 3 postnatal months.

Single-incision pediatric endosurgery (SIPES) splenectomy: what dictates the need for additional ports?

As proficiency with single-incision pediatric endosurgery (SIPES) increases, more challenging operations are being performed. While the ultimate goal is safe surgery, it may be beneficial to know what anatomical and technical factors contribute to the need for additional ports. This aspect of SIPES splenectomy has yet to be evaluated. The study objective was to identify these factors, potentially allowing surgeons to gauge appropriateness for single incision and to tailor techniques for optimal results. This was an institutional review board-approved retrospective analysis of prospectively collected data (FWA00005960). SIPES splenectomies performed at a tertiary children's hospital since March of 2009 were included. Demographic and technical factors pertaining to each operation were available in our SIPES database. Fischer's exact and Wilcoxon rank sum tests were used to analyze categorical and continuous variables, respectively. Thirty-seven patients 18 years of age and younger underwent attempted SIPES splenectomy. Two operations were converted directly to open and were excluded from analysis. Of the remaining 35 operations, 15 (42.9 %) were completed with additional ports. Gender, age, body mass index, splenic weight, indication for operation and the presence of accessory spleens did not contribute to the need for added ports. The only factor to reach statistical significance was the number of channels present in the SIPES access device (p = 0.002). Completion of SIPES splenectomy was associated with the decision to utilize an access device with four channels. Anatomic variables did not appear to affect the ability to complete SIPES splenectomy.

Single-Incision Pediatric Endosurgical Epigastric Hernia Repair

Abstract Introduction: Epigastric hernias represent about 4% of all abdominal hernias in children and require surgical repair. Traditionally, these hernias are repaired by an open surgical technique. More recently, laparoscopic epigastric hernia repairs have been described using two trocars in the upper abdomen.1 Single-incision pediatric endosurgery (SIPES) has been described for virtually scarless inguinal hernia repair.2 In this video presented at IPEG's 22nd Annual Congress for Endosurgery in Children,3 we describe a corresponding novel SIPES technique for epigastric hernia repair. Materials and Methods: Patients with symptomatic epigastric hernias, which were deemed to be too far superior (4 to 7 cm) to be repaired with an open technique through an umbilical incision, were selected for SIPES repair. Two trocars (5 and 3 mm) were introduced through a single umbilical incision and a 30° 5 mm endoscope was introduced, directing the optical angle anterior toward the abdominal wall. After location of the ...

Single instrument intracorporeal knot tying during single port laparoscopic hernia repair in children: A new simplified technique

BackgroundWith the increasing number of open surgical procedures shifting to laparoscopy, laparoscopic suturing and knot tying are becoming integral parts of the skills that any laparoscopist must acquire. It is the most difficult step in laparoscopic surgery, especially in single incision pediatric endosurgery (SIPES). It needs special laparoscopic skills and very long learning curve. The aim of this study is to introduce a new simplified technique for single instrument intracorporeal suture tying during single incision laparoscopic hernia repair (SILHR). Patients and methodsThis study was conducted at Al-Azhar University Hospitals between June 2008 and June 2010. Three-hundred and eighty three patients with 402 congenital inguinal hernias were subjected to SILHR using percutaneous insertion of purse string suture by Reverdin Needle (RN) with single instrument intracorporeal suture knot tie. Description of the techniqueUnder general endotracheal tube anesthesia, a 0.8–1.2-cm. longitudinal transumilical skin incision was done for insertion of the umbilical port and a 3-mm Maryland forceps. RN was used for insertion of a purse string suture with single instrument intracorporeal suture tie around internal inguinal ring (IIR). The purse-string knot airtightness was stress-tested by raising the intraperitoneal CO2 pressure to 16–24mm Hg for about 30seconds. ResultsA total of 383 patients with 402 congenital inguinal hernias were subjected to SILHR. They were 304 males and 79 females with a mean age of 2.2±2.25years. A single instrument technique was used for intracorporeal suture knot tie and all cases were completed laparoscopically without conversion. The mean operative time was 12.5±3.3minutes for unilateral hernia repair and 17±4.37 for bilateral cases. All patients achieved full recovery without intraoperative or postoperative complications. ConclusionSingle instrument intracorporeal suture tie is feasible, simple, and rapid as it resulted in marked decrease of operative time. It is of low cost, secure and gives great help during SIPES surgery without struggling. It is a good alternative option to extra corporeal knot tying.

The International Experience of Single-Incision Pediatric Endosurgery: Current State of the Art

As application and awareness of single-incision pediatric endosurgery (SIPES) are increasing, various techniques and indications have been independently described by select centers around the world. In order to facilitate a cooperative approach toward advancing and investigating the practice of SIPES, we conducted a survey among members of the International Pediatric Endosurgery Group (IPEG), asking them about their experience and attitudes toward single-incision endosurgery. After institutional review board approval, an invitation to participate in an online survey was sent to all IPEG members. Questions focused on demographic information, practice patterns, indications, and equipment used regarding SIPES. Of the 560 contacted active IPEG members, 115 completed the survey (recall 21%). The respondents represented pediatric surgeons from 32 countries on six continents. Of respondents, 97% had heard of, while 71% had performed, SIPES. Reasons for not having performed SIPES included disbelief in benefit (59%), lack of proficiency (34%), and inadequate resources (28%). The most commonly performed SIPES procedures were appendectomy (85%), cholecystectomy (66%), splenectomy (42%), pyloromyotomy (35%), and intestinal surgery (13%), as well as Nissen fundoplication and gynecologic adnexal pathology (7%). The equipment and techniques utilized showed large variation and included some self-devised, innovative, low-resource approaches. Complications with SIPES reported by the survey participants included technical difficulties, wound infection, and prolonged operating time. SIPES is being performed worldwide for a large spectrum of common indications in pediatric surgery. The equipment and techniques used vary with geographic location and resources. Some encountered complications are common to those seen with conventional minimally invasive surgery, whereas others may be SIPES-specific. Different respondents reported diverging views on pain, operating time, and cost.

Single incision pediatric endosurgery (SIPES) appendectomy—is obesity a contraindication?

IntroductionSingle-incision pediatric endosurgery (SIPES) is gaining popularity and has been reported to be safe in acute (non-perforated) and perforated appendicitis. The feasibility of SIPES appendectomy in obese children is uncertain. Materials and methodsAfter IRB approval, data were collected from a prospectively maintained SIPES appendectomy database for cases performed between April 2009 and March 2012. Patients were divided into obese and non-obese groups based on Center for Disease Control criteria. The surgical techniques, operative times, complications, conversion rates, and outcomes were recorded. Chi-square test and t-test were used for statistical analysis. ResultsSIPES appendectomy was attempted in 500 children. There were 21% obese, and 37% were female with median age of 10.9±3.8years. Mean operative time, blood loss, requirement of additional trocars, and intraoperative complications in non-obese and obese children were not significantly different. Mean hospital stay (2.3days in each group), post operative wound infections (3.3% vs. 4.8%, p=0.55, non-obese vs. obese), and intraabdominal abscesses (4.3% vs. 2.9%, p=0.77, non-obese vs. obese) were not significantly different. ConclusionSIPES appendectomy may be accomplished successfully and safely in obese children. Obesity did not appear to be associated with increased risk of complications and was not a contraindication for SIPES appendectomy.

Single-Incision Pediatric Endosurgery: A Systematic Review

Single-incision pediatric endosurgery (SIPES) is defined as minimally invasive surgery performed through a unique incision in the abdomen, chest, or retroperitoneum. Several publications exist, but no previous systematic review has been made to evaluate the real benefits of this approach in terms of feasibility and clinical outcomes. We performed an electronic search in PubMed up to March 2012 with the terms "single AND incision OR site OR port OR trocar AND children" including related articles and obtained 197 articles. After applying our inclusion criteria, 78 articles were reviewed. We identified prospective controlled trials (n=1), case-control studies (n=12), case series (n=49), and case reports (n=16). In total, 4212 patients had been operated on by SIPES and were separated by systems: gastrointestinal (n=2888), urologic (n=390), gynecologic (n=27), other abdominal (n=874), and thoracic (n=33) procedures. The most common procedure was SIPES appendectomy, and a unique prospective controlled trial supports its safety and effectiveness. Technically demanding surgeries such as hepatojejunostomy and colonic surgeries were described. Multichannel ports and multiple ports, standard and articulated instruments, transparietal instruments, retraction sutures, and magnets were used. Operative times, length of stay, and complications similar to standard laparoscopic surgery were described. A low conversion rate (to a reduced port, standard laparoscopy and open procedures) was also mentioned. No comparable measure for pain and cosmesis assessment was used. A wide experience in SIPES and feasibility has already been described with good clinical outcomes and low rate of conversion. Appendectomy is the unique procedure in which SIPES has been demonstrated to be safe and effective. It is pending the execution of prospective controlled trials for other operations to demonstrate, with objective evidence, the real benefits of this less invasive approach.

Single-Incision Pediatric Endosurgical Approach to Right Ovarian Torsion in a 9-Year-Old Girl

Background and Objectives: Despite being pioneered by gynecologists, single-incision endosurgery has not been widely reported for the treatment of ovarian and adnexal pathology in neonates, children, and adolescents. We describe our initial experience using single-incision pediatric endosurgery (SIPES) for these indications and discuss advantages and drawbacks. Video: This video shows a single-incision pediatric endosurgical approach to right ovarian torsion in a 9-year-old girl. The instrument is introduced through the umbilicus, grasps the ovary, and performs a counter clockwise derotation of the ovary into anatomic position. Once this is achieved, the ovary is pexied to the round ligament that is overlying the iliac vessels. This fixation of the ovary in an additional point should prevent torsion in the future. Intracorporeal knot tying is performed by using the needle as an angulation device to wrap the suture around the instrument and then lay down the knot. There were no peri- or postoperative complications. The girl was discharged on the first postoperative day. On follow-up 3 months postsurgery, the girl was without complaints. Conclusion: SIPES is an excellent alternative to conventional laparoscopy for the treatment of adnexal pathology. Using a single umbilical incision that can be enlarged instead of three smaller trocar sites facilitates the resection and extraction of ovarian masses without compromising cosmesis. No competing financial interests exist. Runtime of video: 2 mins 56 secs

Single-Incision Pediatric Endosurgery for Ovarian Pathology

Despite being pioneered by gynecologists, single-incision endosurgery has not been widely reported for the treatment of ovarian and adnexal pathology in neonates, children, and adolescents. We describe our initial experience using single-incision pediatric endosurgery (SIPES) for these indications and discuss advantages and drawbacks. All children who underwent SIPES with a preoperative diagnosis of ovarian or adnexal pathology were included in the study. Data on age, operative time, complications, length of hospital stay, and outcomes were collected. From January 2010 until January 2012, 19 girls (mean age, 11.4 years; range, 6 days-17 years; weight range, 4.0-90 kg) underwent SIPES procedures for ovarian or adnexal diagnoses, including hemorrhagic/follicular/paratubal cysts (n=8), torsion (n=7), tumor (n=3), and parauterine cyst (n=1). The operations included cyst unroofing (n=4), detorsion and oophoropexy (n=7), (salpingo)oophorectomy (n=5), marsupialization of cyst (n=2), and cyst aspiration (n=1). Median operative time was 42 ± 29 minutes; there were no conversions to conventional laparoscopy or open surgery. Fifteen patients (79%) were discharged within 24 hours after the procedure. There were no peri- or postoperative complications. Histopathology showed hemorrhagic/follicular/paratubal cyst (n=7), necrotic/calcified ovarian tissue after torsion (n=6), cystadenofibroma (n=1), granulosa cell tumor (n=1), and mature teratoma (Grade 0) (n=1). SIPES is an excellent alternative to conventional laparoscopy for the treatment of adnexal pathology. Using a single umbilical incision that can be enlarged instead of three smaller trocar sites facilitates the resection and extraction of ovarian masses without compromising cosmesis.

Single-Incision Pediatric Endosurgery (SIPES) Splenectomy: A Case-Control Series

Single-incision pediatric endosurgery (SIPES) is gaining popularity. The aim of this study was to review the authors' experience with SIPES splenectomy and compare it with conventional laparoscopic splenectomy. After institutional review board approval, data on SIPES splenectomy in children were collected prospectively. The study group was compared with a control group of patients who were retrospectively identified as having undergone conventional laparoscopic splenectomy during the same time period. Sixteen children underwent SIPES splenectomy. Ages ranged from 1 to 15 years, with a median of 7 years, and weights were between 10 and 70 kg, with a median of 24 kg. The control group was similar in age and weight characteristics. The most common diagnoses were hereditary spherocytosis, sickle cell disease, and immune thrombocytopenic purpura. There were two conversions to open splenectomy in the SIPES group and one in the laparoscopic group. Operative times were 40-190 minutes (median, 84 minutes) in the SIPES group and 51-154 minutes (median, 99 minutes) in the conventional laparoscopic group. The SIPES technique is well suited for splenectomy. Despite instruments and camera being in-line, working angles are not compromised, and visualization is adequate. Operating time and hospital stay are comparable to those with standard laparoscopic splenectomy, but the cosmetic result may be superior.

Feasibility of Single-Incision Pediatric Endosurgery for Treatment of Appendicitis in 415 Children

Single-incision pediatric endosurgery (SIPES) has gained popularity for ablative procedures such as appendectomy in many pediatric surgical centers. This study evaluates the outcome of SIPES for treatment of appendicitis in our institution. After Institutional Review Board approval was obtained, data were prospectively collected on all patients undergoing SIPES appendectomy in our hospital from March 2009 through October 2011. The surgical techniques, operative times, complications, conversion rates, and outcomes were recorded. SIPES appendectomy was attempted in 415 children (mean age, 10.9 years; age range, 1.4-17.9 years; 266 males, 149 females; median weight, 43 kg; weight range, 9.8-146 kg). Intraoperatively, acute appendicitis was found in 298 cases and perforated appendicitis in 79 cases. Thirty-eight patients underwent interval appendectomy. Appendectomy was carried out solely as SIPES in 397 cases (96%). Median operative time was 40±16 minutes (37±16 minutes for fellows [n=284] and 46±15 minutes for residents [n=131]). There were three intraoperative complications, which could be handled during the procedure. Pathologic reports revealed inflammatory changes of the appendix (n=386), other pathology (n=11), and no pathologic change (n=18). Overall, 24 patients (5.8%) were readmitted for intra-abdominal abscess (n=14), umbilical wound infection (n=3), and other reasons (n=7). Twelve patients (2.9%) underwent reoperation: drainage of intra-abdominal abscess (n=8) (3 by the surgeon, 5 by the interventional radiologist), wound drainage (n=3), and right hemicolectomy for carcinoid (n=1). In perforated appendicitis the postoperative intra-abdominal abscess rate was 10 of 79 cases (12.7%), which is similar to the previous report with conventional laparoscopic appendectomy from our institution (13.6%). The wound infection rate (5 of 79 cases [6.3%]) was also similar to the previously report (6.8%) with conventional laparoscopic appendectomy for perforated appendicitis. Appendectomy can be accomplished successfully and safely using single-incision endosurgery in children with acceptable operative times without leaving any appreciable scar. Additional trocars are infrequently necessary. So far, the intraoperative and postoperative complication rates are comparable to those of triangulated laparoscopic appendectomy.

Single-Incision Thoracoscopic Surgery in Children: Equivalent Results with Fewer Scars When Compared with Traditional Multiple-Incision Thoracoscopy

Single-incision pediatric endosurgery is gaining popularity, especially for abdominal operations. Several reports in the literature support the feasibility of the single-incision approach in pediatric laparoscopy. Here we compare our experience with single-incision thoracoscopic surgery (SITS) to traditional multiple-incision video-assisted thoracoscopic surgery (VATS) in children. A chart review of all patients who underwent SITS at our institution was performed. The same number of demographically matched VATS case controls were selected from a pool of patients operated on during the same time period. Operative time, time until chest tube removal, length of stay, complications, and any need for further intervention were recorded. Statistical analysis was done by Student's t-test using Instat 3. Fourteen SITS procedures were performed during the study period. These patients were compared with 14 VATS case controls. Both groups were similar with regard to age, weight, sex, and procedures performed. The mean operative time in the SITS group was 84 ± 43 minutes versus 64 ± 30 in the VATS group (P=.18). Days until chest tube removal was 4 ± 2.2 in the SITS group and 2.8 ± 1.4 in the VATS group (P=.09). Length of hospital stay was 5.5 ± 4.4 days in the SITS group versus 7.2 ± 8.6 in the VATS group (P=.51). There were no intraoperative complications and no procedure conversions in either group. One SITS patient who underwent a wedge resection and mechanical pleurodesis for a spontaneous pneumothorax was readmitted for a recurrent pneumothorax and required a reoperation. Our experience demonstrates that there are no statistically significant differences in operative time, time until chest tube removal, and length of hospital stay when comparing SITS to VATS in children. We believe that SITS is an equivalent procedure that allows for fewer scars when compared with traditional multiple-incision VATS in children.

Inguinal hernia repair by single-incision pediatric endosurgery (SIPES) using the hydrodissection-lasso technique

Many different techniques for laparoscopic inguinal hernia repair have been introduced recently, using either an intraperitoneal [1-3] or an extraperitoneal [4-6] approach. One of the main challenges is to obtain a complete circumferential closure of the sack at the level of the internal ring without injury to the adjacent vas deferens or spermatic vessels. In an effort to separate these structures from the peritoneum before passing a suture around the base of the sack, we developed the hydrodissection-lasso technique, which is performed using a single-incision endosurgical approach.With the patient in Trendelenburg position, an 8-mm skin incision is made in the umbilicus, and a 5-mm trocar is placed in the inferior aspect for the endoscope. A 3-mm Maryland grasper is placed directly through the fascia in the upper part of the incision. Using a 22-gauge needle inserted percutaneously over the internal inguinal ring, saline is injected into the subperitoneal plane circumferentially, hydrodissecting the peritoneum off the vas deferens and vessels and creating a safe space through which the suture can pass without compromising these structures. A 2-mm stab incision is made directly over the internal inguinal ring, and a lasso technique is used to pass two strands of braided polyester suture around the hernia sack, as demonstrated in the video. Both sutures are tied tightly, leaving the knots under the skin. No direct or indirect manipulation of the vas deferens or vessels takes place during any part of the procedure.In contrast to other described techniques [7], the hydrodissection-lasso technique can be used for all indirect inguinal hernias in both girls and boys, and hydrodissection itself may be a useful adjunct to any of the other aforementioned techniques. Although an age limit for exclusive high ligation of the hernia sack for indirect inguinal hernias has not been established, the recurrence rate may be higher for adults if the procedure is not combined with inguinal floor reconstruction [8]. At this time, we therefore limit the proposed technique to prepubertal patients.We have performed the described procedure for 22 patients without any recurrences during a maximum follow-up period of 12months (Table1). The patients had minimal postoperative pain. There were no complications except for a transient genitofemoral nerve paresis experienced by one girl in whom the hydrodissection was performed using 1% lidocaine instead of the usual normal saline solution. Although the sack was not resected, there were no cases of postoperative hydroceles.To evaluate whether this novel technique is an adequate long-term solution, a prospective clinical trial comparing standard open and single-incision endosurgical inguinal hernia repair using hydrodissection should be performed.

Resection of a duodenal web using single-incision pediatric endosurgery

Single-incision pediatric endosurgery (SIPES) is used in many centers for routine cases such as appendectomies and cholecystectomies, but more complex procedures are still infrequently performed. We report the case of a 9-month-old girl with Down syndrome diagnosed with a duodenal web who underwent duodenal web resection and tapering using a SIPES technique. The procedure was performed through a single 2-cm incision in the umbilicus and took 209 minutes. Postoperatively, the patient was feeding well, gaining weight, and had no appreciable scar at a follow up of 6 months. SIPES duodenal web resection in an infant is a reasonable alternative to conventional triangulated laparoscopy that can be performed safely with good functional and cosmetic postoperative results.

Single-incision pediatric endosurgery-assisted ileocecectomy for resection of a NEC stricture

A single-incision pediatric endosurgery (SIPES) has not been typically used for operations in premature infants yet. We report a case of a 3-month-old 25-week premature infant who underwent SIPES-assisted ileocecal resection for a stricture after medically treated necrotizing enterocolitis. The patient recovered uneventfully, and was discharged on full feeds 15 postoperatively with virtually no appreciable scar. SIPES is a reasonable alternative for NEC stricture resection in premature infants. Prematurity should not be considered a contraindication to single-incision endosurgery.