monthly focus

surgical intervention video

This video presents the case of a laparoscopic liver right sectionectomy in a 14-year-old girl. Laparoscopic liver resections are not well-reported in pediatric oncology due to the low frequency of liver tumors in children. Published data are limited by several case series, and left lateral sectionectomy represents the most common indication. The resection of central liver segments is believed to be the most difficult type of resection, especially using a minimally invasive approach. Glissonian pedicle isolation according to Takasaki’s technique allows to reduce intraoperative blood loss and to provide a more precise anatomical hepatectomy. This video may be useful to pediatric surgeons and oncologists.

Bibliography:

1\. Moritz Schmelzle, Felix Krenzien, Wenzel Schöning, Johann Pratschke. Laparoscopic liver resection: indications, limitations, and economic aspects. Langenbecks Arch Surg 2020 Sep;405(6):725-735. doi: 10.1007/s00423-020-01918-8. Epub 2020 Jul 1. PMID: 32607841 PMCID: PMC7471173 DOI: 10.1007/s00423-020-01918-8

2\. Maciej Murawski, Marcin Łosin, Andrzej Gołębiewski, Katarzyna Sinacka, Irena Zabolska, Ewa Iżycka-Świeszewska, Piotr Czauderna. Laparoscopic resection of liver tumors in children. J Pediatr Surg 2021 Feb;56(2):420-423. doi: 10.1016/j.jpedsurg.2020.08.037. Epub 2020 Sep 17. PMID: 33046224 DOI: 10.1016/j.jpedsurg.2020.08.037

3\. Gabriele Calaminus, Dominik T Schneider, Dietrich von Schweinitz, Heribert Jürgens, Nacera Infed, Stefan Schönberger, Thomas A Olson, Peter Albers, Christian Vokuhl, Raimund Stein, Leendert Looijenga, Jalid Sehouli, Martin Metzelder, Alexander Claviez, Michael Dworzak, Angelika Eggert, Birgit Fröhlich, Nicolas U Gerber, Christian P Kratz, Jörg Faber, Thomas Klingebiel, Dieter Harms, Ulrich Göbel. Age-Dependent Presentation and Clinical Course of 1465 Patients Aged 0 to Less than 18 Years with Ovarian or Testicular Germ Cell Tumors; Data of the MAKEI 96 Protocol Revisited in the Light of Prenatal Germ Cell Biology. Cancers (Basel) 2020 Mar 6;12(3):611. doi: 10.3390/cancers12030611. PMID: 32155835 PMCID: PMC7139559 DOI: 10.3390/cancers12030611

4\. Claudius Conrad, Satoshi Ogiso, Yosuke Inoue, Nairuthya Shivathirthan, Brice Gayet. Laparoscopic parenchymal-sparing liver resection of lesions in the central segments: feasible, safe, and effective. Surg Endosc 2015 Aug;29(8):2410-7. doi: 10.1007/s00464-014-3924-9. Epub 2014 Nov 13. PMID: 25391984 DOI: 10.1007/s00464-014-3924-9

Laparoscopic hepatic right anterior sectionectomy for a liver tumor in a 14-year-old child

Section antérieure droite hépatique par laparoscopie pour une tumeur du foie chez un enfant de 14 ans

Congenital solitary liver cysts are rare conditions, typically asymptomatic in infancy, and often discovered incidentally during imaging studies. The etiology remains unclear. However, hypotheses suggest that obstruction of aberrant bile ducts, possibly due to infection or vascular disruption during the fetal period, may contribute to cyst formation. Such cysts may present as simple cysts or intrahepatic biliary cysts.

The authors report the case of a full-term female infant with an antenatal suspicion of choledochal cyst. Postnatal abdominal ultrasound and MRI revealed an intrahepatic cystic mass crossing liver segments IVa, VII, and Vb, raising questions about a possible connection between the cyst and the right intrahepatic bile duct. The cyst could not be classified under the Todani classification. The infant remained asymptomatic since birth, with no abnormalities on physical examination.

At 20 months of age, the patient underwent a laparoscopic intervention. Intraoperative cholangiography confirmed the diagnosis of a solitary intrahepatic biliary cyst. A Roux-en-Y cystojejunostomy was performed. The procedure was uneventful, and the patient was discharged on postoperative day 3, remaining asymptomatic thereafter.

This case highlights the diagnostic challenges of congenital solitary liver cysts. Intraoperative cholangiography is crucial to define the anatomical relationship between the cyst and the biliary tree. Total excision is recommended for accessible solitary cysts, while internal drainage procedures, such as cysto-enterostomy or Roux-en-Y hepaticojejunostomy, are effective alternatives when excision is not feasible. These approaches ensure a safe and effective biliary system reconstruction.

Bibliography:

1\. Tutku Soyer 1, Ibrahim Karnak, Mehmet Emin Senocak. Congenital solitary intrahepatic biliary cyst in a newborn: report of a case. Surg Today 2007;37(6):521-4. doi: 10.1007/s00595-006-3442-z. Epub 2007 May 28. [https://pubmed.ncbi.nlm.nih.gov/17522776/](https://pubmed.ncbi.nlm.nih.gov/17522776/) PMID: 17522776 DOI: 10.1007/s00595-006-3442-z

2\. Anil Kumar Yadav, Jianghua Zhan, Shujian Zhang, Nita Yadav. Congenital solitary intrahepatic biliary cyst in infant: A rare case report. Journal of Pediatric Surgery Case Reports Volume 30, March 2018, Pages 64-67. [https://www.sciencedirect.com/science/article/pii/S2213576617302348?via%3Dihub](https://www.sciencedirect.com/science/article/pii/S2213576617302348?via%3Dihub)

3\. M B Macken, J R Wright Jr, H Lau, M C Cooper, E B Grantmyre, D L Thompson, M K O'Brien. Prenatal sonographic detection of congenital hepatic cyst in third trimester after normal second-trimester sonographic examination. J Clin Ultrasound 2000 Jul-Aug;28(6):307-10. doi: 10.1002/1097-0096(200007/08)28:6\<307::aid-jcu8>3.0.co;2-7. [https://pubmed.ncbi.nlm.nih.gov/10867671/](https://pubmed.ncbi.nlm.nih.gov/10867671/) PMID: 10867671 DOI: 10.1002/1097-0096(200007/08)28:6\<307::aid-jcu8>3.0.co;2-7

Laparoscopic Roux-en-Y cystojejunostomy for a congenital solitary intrahepatic biliary cyst in a 1-year-old infant

Cystojéjunostomie par voie d'abord laparoscopique pour kyste biliaire intrahépatique solitaire congénital chez un nourrisson d'un an

Primary hyperhidrosis is an idiopathic condition characterized by excessive sweat secretion, which has a significant impact on psychosocial well-being and overall quality of life. The palms, axillae, and soles are areas that are most commonly affected.

The authors report the clinical case and video of a 15-year-old girl followed in outpatient consultation for primary palmar and plantar hyperhidrosis. She underwent a thoracoscopic bilateral sympathectomy at the age of 14, targeting the T3-T4 levels, which resulted in significant improvement of palmar hyperhidrosis. However, due to persistent plantar hyperhidrosis, which continued to significantly affect her quality of life, a bilateral retroperitoneal lumbar sympathetic blockade was proposed and performed.

The retroperitoneal space was created and insufflated on both the right and left sides of the patient, and the sympathetic chain was identified at the L3 and L4 levels, along the medial aspect of the psoas muscle. The blockade was then performed using the Hem-o-Lok™ polymer ligation system. There were no intraoperative or postoperative complications, with minimal blood loss estimated. The patient presented with dry feet immediately after surgery.

Retroperitoneal lumbar sympathetic blockade is a safe and effective procedure for pediatric patients with plantar primary hyperhidrosis.

Bibliography:

1\. Retroperitoneoscopic lumbar sympathectomy for plantar hyperhidrosis. Sonia O Lima, Vanessa R de Santana, Daisy P Valido, Renata L B de Andrade, Leticia M Fontes, Victor Hugo O Leite, José M Neto, Jéssica M Santos, Lucas L Varjão, Francisco P Reis. J Vasc Surg 2017 Dec;66(6):1806-1813. doi: 10.1016/j.jvs.2017.05.126. PMID: 29169540 DOI: 10.1016/j.jvs.2017.05.126

2\. Retroperitoneoscopic lumbar sympathectomy for the treatment of primary plantar hyperhidrosis. Kyung Jae Hur, Hyong Woo Moon, Yong Hyun Park, Woong Jin Bae, Hyuk Jin Cho, U-Syn Ha, Ji Youl Lee, Sae Woong Kim, Sung-Hoo Hong. BMC Surg 2021 Nov 12;21(1):397. doi: 10.1186/s12893-021-01393-y. PMID: 34772374 PMCID: PMC8590320 DOI: 10.1186/s12893-021-01393-y

Retroperitoneal lumbar sympathetic blockage in a pediatric primary plantar hyperhidrosis

 Blocage rétropéritonéal du sympathique lombaire dans une hyperhidrose plantaire primaire chez l'enfant

A teenage boy presented with abdominal pain and a 3cm non-transfixing wound in the right umbilical region. He had fallen on his bike’s handlebars while cycling down a slope at high speed, without a helmet.

A CT-scan of the chest and abdomen found single air bubbles, intraperitoneal effusion, right common iliac artery dissection with focal subocclusive tight stenosis. The radiologists assured that the air bubbles were not specific; as a result, the patient was admitted to the pediatric surgery department. However, after a 2-day monitoring, and as strong pain persisted, a new CT-scan of the chest and abdomen showed a large amount of pneumoperitoneum, increased diffuse peritoneal effusion, perforation of the lower gastric wall, and a large left pneumothorax. An exploratory laparoscopy using the AirSeal® insufflation system, a valveless low-pressure device, highlighted a 3cm long open wound in the lower gastric wall. The stomach was sutured, and the abdominal and left pleural cavities were drained. The child was discharged home on postoperative day 14. After a 6-week and a 4-month follow-up, postoperative outcomes were uneventful.

Bibliography:

1\. Koirala DP, Shrestha BM, Kansal A, Poudel D, Neupane S, Dahal GR. Perforation of gastroesophageal junction, stomach, and diaphragm following blunt abdominal trauma: A near miss: A case report. Int J Surg Case Rep. 2021 Mar 17;81:105786. PMID: 33887842 PMCID: PMC8041729 DOI: 10.1016/j.ijscr.2021.105786

2\. Stringel G, Xu ML, Lopez J. Minimally Invasive Surgery in Pediatric Trauma: One Institution’s 20-Year Experience. JSLS 2016 Jan-Mar;20(1):e2015.00111. doi: 10.4293/JSLS.2015.00111. PMID: 26877626 PMCID: PMC4744998 DOI: 10.4293/JSLS.2015.00111

3\. George AK, Wimhofer R, Viola KV, Pernegger M, Costamoling W, Kavoussi LR, Loidl W. Utilization of a novel valveless trocar system during robotic-assisted laparoscopic prostatectomy. World J Urol. 2015 Nov;33(11):1695-9. PMID: 25725807 DOI: 10.1007/s00345-015-1521-8

4\. Tytgat SHAJ, Zwaveling S, Kramer WLM, van der Zee DC. Laparoscopic treatment of gastric and duodenal perforation in children after blunt abdominal trauma. Injury. 2012 Sep;43(9):1442-4. PMID: 21129741 DOI: 10.1016/j.injury.2010.11.002

Laparoscopic repair of gastric perforation after blunt trauma in an adolescent using the AirSeal® insufflation system: a case report and literature review

Traitement laparoscopique d'une perforation gastrique après traumatisme contondant chez un adolescent à l'aide du système d'insufflation AirSeal® : rapport de cas et revue de la littérature

Traitement thoracoscopique d'un chylothorax postopératoire

Introduction: 

Chylothorax is a rare postoperative complication of congenital heart surgery. A staged treatment is the general principle to manage this serious complication. However, a failure of conservative therapy requires surgical ligation to prevent continued fluid and protein losses. 

Materials and methods:

This is the case of an 8-month-old girl with Down syndrome, weighing 7.7 Kg. She presented with chylothorax following a cardiac procedure, refractory to conservative management. 

Surgery was facilitated using a selective endotracheal intubation. 

A methylene blue colored cream was administered preoperatively to visualize the thoracic duct during the surgical procedure. 

A video-assisted thoracoscopic surgery was performed to treat the chylothorax in our patient. The procedure was performed in the right chest using four ports. 

The duct was controlled via a direct thoracoscopic application of clips and fibrin glue, at the level of the diaphragm, and using a mechanical and chemical pleurodesis. 

Postoperative outcomes:

No intraoperative complication was observed. Operating time was 2 hours. Oral intake was allowed on postoperative day 5. Chest tubes were removed on postoperative day 7. There was no recurrence at 2 months of follow-up. 

Conclusion:

Thoracoscopic duct ligation is a safe and effective procedure, facilitated by means of selective intubation in our case. 



Bibliography:

1. Thoracoscopic Thoracic Duct Ligation: How I Teach It. Evgeny V Arshava , Kalpaj R Parekh. Ann Thorac Surg, 2020 May;109(5):1330-1334. PMID: 32035916 DOI: 10.1016/j.athoracsur.2020.01.004 

2. Talc Pleurodesis: A Medical, Medicolegal, and Socioeconomic Review. Ioana Baiu, MD, MPH, Elorm Yevudza, BS, and Joseph B. Shrager, MD. Ann Thorac Surg, 2020 Apr;109(4):1294-1301. PMID: 31593652 DOI: 10.1016/j.athoracsur.2019.08.104 

3. Thoracoscopic pleural clipping for the management of congenital chylothorax. Margaret E Clark, Russell K Woo, Sidney M Johnson. Pediatr Surg Int, 2015 Dec;31(12):1133-7. PMID: 26276425 DOI: 10.1007/s00383-015-3760-6 

Thoracoscopic management of postoperative chylothorax

Introduction:

Morgagni hernia is a rare congenital defect of the anteromedial portion of the diaphragm. This video demonstrates the robot-assisted repair of a Morgagni-Larrey diaphragmatic hernia using a laparoscopic approach.

Materials and methods:

The patient was a 17-month-old girl, weighing 11 kg. She was found to have a Morgagni-Larrey diaphragmatic hernia discovered as an incidental finding.

A thoracic radiography demonstrated the presence of an anterior diaphragmatic hernia, which was confirmed with a barium enema and a CT-scan.

The child underwent a laparoscopic repair of the hernia with the assistance of a robotic system.

The hernia sac contents were reduced. The diaphragmatic defect was then primarily closed using a 2/0 Ethibond suture in an interrupted fashion.

Results:

There was no intraoperative complication. Operating time was 3 hours. Oral intake was authorized on postoperative day (POD) 1. She was discharged on POD2. There was no recurrence at 6 months of follow-up.

Conclusion:

Robotic assistance offers improved vision and most particularly easiness for suturing and knot-tying. Despite the low weight of the child, the limited intra-abdominal space and decreased distance between ports did not pose any problem.

 

Bibliography:

1\. C Nistri, L Marinelli, A Di Giacomo, L Bonariol, M Massani. Robotic repair of a giant Larrey-type congenital left-sided diaphragmatic hernia in a young woman. A case report and literature review. Int J Surg Case Rep. 2022 Sep:98:107507. doi: 10.1016/j.ijscr.2022.107507. Epub 2022 Aug 13. PMID: 36027832 PMCID: PMC9424357 DOI: 10.1016/j.ijscr.2022.107507

2\. Colin G Knight, Kelly M Gidell, David Lanning, Attila Lorincz, Scott E Langenburg, Michael D Klein. Laparoscopic Morgagni hernia repair in children using robotic instruments. J Laparoendosc Adv Surg Tech A 2005 Oct;15(5):482-6. doi: 10.1089/lap.2005.15.482. PMID: 16185121 DOI: 10.1089/lap.2005.15.482

3\. M Anderberg, C Clementson Kockum, E Arnbjornsson. Morgagni hernia repair in a small child using da Vinci robotic instruments--a case report. Eur J Pediatr Surg 2009 Apr;19(2):110-2. doi: 10.1055/s-2008-1038500. Epub 2008 Jul 15. PMID: 18629776 DOI: 10.1055/s-2008-1038500

Robotic assisted repair of Morgagni-Larrey hernia in a 17-month-old girl

Cure d'une hernie de Morgagni-Larrey assistée par robot  chez une fillette de 17 mois

This video presents the case of a neuroblastoma of the posterior mediastinum. Neuroblastoma of the posterior mediastinum most often involves the thoracic aorta, intercostal arteries, and it often spreads into the spinal canal. This localization is classically the most frequent location site of neurogenic tumors. The patient underwent a one-step operation to remove a tumor from two hemithorax. This video may be useful to pediatric oncologists and surgeons.

Bibliography:

1\. Badiu Tișa I, Samașca G, Aldea C, Lupan I, Farcau D, Makovicky P. Ganglioneuroblastoma in children. Neurol Sci. 2019 Sep;40(9):1985-1989. doi: 10.1007/s10072-019-03932-1. Epub 2019 May 30. PMID: 31147856.

2\. Dingemann C, Ure B, Dingemann J. Thoracoscopic procedures in pediatric surgery: what is the evidence? Eur J Pediatr Surg. 2014 Feb;24(1):14-9. doi: 10.1055/s-0033-1350060. Epub 2013 Jul 12. PMID: 23852720.

Bilateral thoracoscopic approach in a child with posterior mediastinal neuroblastoma

Traitement d'un neuroblastome du médiastin postérieur chez l'enfant par voie thoracique bilatérale

Hepatobiliary ascariasis (HA) is a rare condition associated with significant morbidity. The laparoscopic extraction of Ascaris lumbricoides from the biliary tract is a safe approach in patients who do not improve with anthelminthic treatment and when endoscopic retrograde cholangiopancreatography (ERCP) is not feasible or when not all nematodes can be removed using this method. In this video, the author presents the technique used in pediatric patients with HA. 

Bibliography: 

1. Khuroo MS, Rather AA, Khuroo NS, Khuroo MS. Hepatobiliary and pancreatic ascariasis, World J Gastroenterol. 2016 Sep 7;22(33):7507-17. doi: 10.3748/wjg.v22.i33.7507. PMID: 27672273 PMCID: PMC5011666.

2. Canes M, Seaton C, Mawson J, Goldfarb DM, Kang KT. Biliary ascariasis and trisomy 21 in a child newly arrived to Canada. CMAJ. 2022 Oct 3;194(38):E1318-E1321. doi: 10.1503/cmaj.220089. PMID: 36191940 PMCID: PMC9529569.

3. Roy K, Das J, Mukherjee D, Kundu R. Pancreatic-Biliary Ascariasis in an Infant. Journal of Nepal Paediatric Society, October 2017, 37(1), 98-100. https://doi.org/10.3126/jnps.v37i1.16501

4. Hajaji K, Aljohary H, Althani H. Laparoscopic Management of Billiary Ascariasis: A Case Report and Review of Literature. World Journal of Laparoscopic Surgery. September-December 2010;3(3):113-115. doi: 10.5005/jp-journals-10007-1094

Focus on pediatric surgery