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Pediatric surgery

Find all the surgical interventions, lectures, experts opinions, debates, webinars and operative techniques per specialty.
Laparoscopic ligation of middle sacral artery and dissection of sacrococcygeal teratoma to decrease intraoperative hemorrhagic risk
Sacrococcygeal teratomas are the most common teratomas presenting at birth. Life-threatening bleeding is a major complication during tumor excision in children. In this video, we demonstrate our technique for the laparoscopic division of the middle sacral artery during dissection of sacrococcygeal teratomas in two pediatric patients.
Two female infants diagnosed with type IV and type III sacrococcygeal teratomas underwent preoperative evaluation in the postnatal period. The first patient was an 18-month-old female patient who presented with a metastatic type IV teratoma resected after neoadjuvant therapy. The second patient was a 6-day-old female infant with a prenatal diagnosis of cystic type III teratoma. Using laparoscopy in both patients, the presacral space was reached by opening the peritoneal reflection with blunt dissection and the middle sacral artery was identified. It was then carefully isolated and divided with a 5mm LigaSure™ vessel-sealing device. The pelvic components of the tumors were partially dissected using laparoscopy. The first patient’s tumor resection was completed using a posterior sagittal approach and the second patient required a standard Chevron incision.
Both patients underwent a successful laparoscopic division of the middle sacral artery and resection of the sacrococcygeal teratomas without complications. As a result, laparoscopic middle sacral artery division before sacrococcygeal teratoma excision offers a safe approach which can reduce the risk of hemorrhage during surgery.
T Huy, H Osei, AS Munoz Abraham, R Damle, GA Villalona
Surgical intervention
2 months ago
336 views
4 likes
0 comments
05:33
Laparoscopic ligation of middle sacral artery and dissection of sacrococcygeal teratoma to decrease intraoperative hemorrhagic risk
Sacrococcygeal teratomas are the most common teratomas presenting at birth. Life-threatening bleeding is a major complication during tumor excision in children. In this video, we demonstrate our technique for the laparoscopic division of the middle sacral artery during dissection of sacrococcygeal teratomas in two pediatric patients.
Two female infants diagnosed with type IV and type III sacrococcygeal teratomas underwent preoperative evaluation in the postnatal period. The first patient was an 18-month-old female patient who presented with a metastatic type IV teratoma resected after neoadjuvant therapy. The second patient was a 6-day-old female infant with a prenatal diagnosis of cystic type III teratoma. Using laparoscopy in both patients, the presacral space was reached by opening the peritoneal reflection with blunt dissection and the middle sacral artery was identified. It was then carefully isolated and divided with a 5mm LigaSure™ vessel-sealing device. The pelvic components of the tumors were partially dissected using laparoscopy. The first patient’s tumor resection was completed using a posterior sagittal approach and the second patient required a standard Chevron incision.
Both patients underwent a successful laparoscopic division of the middle sacral artery and resection of the sacrococcygeal teratomas without complications. As a result, laparoscopic middle sacral artery division before sacrococcygeal teratoma excision offers a safe approach which can reduce the risk of hemorrhage during surgery.
Laparoscopic partial nephrectomy on non-functional, symptomatic right lower pole of the kidney
In this video, we present the case of a 13-year-old girl presenting with a complicated urological anomaly discovered very late. The lower part of her right kidney is dysplastic (or destroyed) with pseudocystic pyelocalyceal cavities filled with stones and cloudy urine. The first hypothesis is that we are dealing with a true renal duplicity with a destroyed non-functional inferior pole. In this case, there is one ureter per kidney pole. As a result, polar ureteronephrectomy does not cause any potential vascular problems.
In this case, thanks to 3D reconstruction (Visible Patient™, a spinoff of IRCAD), it is clear that there is no kidney duplicity, but a pyelic bifurcation. It means that we should manage the only ureter, which drains the superior and inferior pelvis. For that reason, the placement of a double J catheter is essential prior to partial nephrectomy. This catheter should be pulled up until the superior pelvis.
Tridimensional reconstruction of the CT-scan images of a patient with a malformation is extremely helpful to better understand the original and unique anatomy of the patient and to determine a tailored operative strategy.
This video demonstrates a laparoscopic partial nephrectomy on non-functional, symptomatic right lower pole of the kidney in a 13-year-old girl as an outpatient surgery.
F Becmeur, A Lachkar, L Soler
Surgical intervention
8 months ago
1681 views
2 likes
0 comments
07:24
Laparoscopic partial nephrectomy on non-functional, symptomatic right lower pole of the kidney
In this video, we present the case of a 13-year-old girl presenting with a complicated urological anomaly discovered very late. The lower part of her right kidney is dysplastic (or destroyed) with pseudocystic pyelocalyceal cavities filled with stones and cloudy urine. The first hypothesis is that we are dealing with a true renal duplicity with a destroyed non-functional inferior pole. In this case, there is one ureter per kidney pole. As a result, polar ureteronephrectomy does not cause any potential vascular problems.
In this case, thanks to 3D reconstruction (Visible Patient™, a spinoff of IRCAD), it is clear that there is no kidney duplicity, but a pyelic bifurcation. It means that we should manage the only ureter, which drains the superior and inferior pelvis. For that reason, the placement of a double J catheter is essential prior to partial nephrectomy. This catheter should be pulled up until the superior pelvis.
Tridimensional reconstruction of the CT-scan images of a patient with a malformation is extremely helpful to better understand the original and unique anatomy of the patient and to determine a tailored operative strategy.
This video demonstrates a laparoscopic partial nephrectomy on non-functional, symptomatic right lower pole of the kidney in a 13-year-old girl as an outpatient surgery.
Pheochromocytoma: laparoscopic right adrenalectomy in a child
In the context of major headaches in a 9-year-old patient whose brother had been operated on for pheochromocytoma, a right adrenal pheochromocytoma with severe arterial hypertension was found.
The given video aims to demonstrate the usefulness of performing a 3D reconstruction of the tumor (using Visible Patient™ 3D reconstruction tool). It is essential to have precise preoperative information and work out a surgical strategy taking into account observed anatomical anomalies, since tumor and/or vascular anatomy may have numerous variations in case of pheochromocytomas.
A reconstruction model can be easily manipulated on a touch screen. It can be oriented in such a way that the angle of view changes allowing for a better understanding of the anatomy, so that an approach to vessels or neighboring organs is easily decided upon. Additionally, the option of adding or deleting this or that anatomical element allows for a simplified visual approach, which usually represents a potential difficulty during dissection.
Finally, the 3D reconstruction of this patient perfectly corresponds to her real anatomy. Thanks to a mere scanning based on the reconstruction, the vascularization mode of the tumor as well as the existence of a hidden part of healthy tissue can be verified.
F Becmeur, A Lachkar, L Soler
Surgical intervention
8 months ago
2088 views
5 likes
0 comments
08:30
Pheochromocytoma: laparoscopic right adrenalectomy in a child
In the context of major headaches in a 9-year-old patient whose brother had been operated on for pheochromocytoma, a right adrenal pheochromocytoma with severe arterial hypertension was found.
The given video aims to demonstrate the usefulness of performing a 3D reconstruction of the tumor (using Visible Patient™ 3D reconstruction tool). It is essential to have precise preoperative information and work out a surgical strategy taking into account observed anatomical anomalies, since tumor and/or vascular anatomy may have numerous variations in case of pheochromocytomas.
A reconstruction model can be easily manipulated on a touch screen. It can be oriented in such a way that the angle of view changes allowing for a better understanding of the anatomy, so that an approach to vessels or neighboring organs is easily decided upon. Additionally, the option of adding or deleting this or that anatomical element allows for a simplified visual approach, which usually represents a potential difficulty during dissection.
Finally, the 3D reconstruction of this patient perfectly corresponds to her real anatomy. Thanks to a mere scanning based on the reconstruction, the vascularization mode of the tumor as well as the existence of a hidden part of healthy tissue can be verified.
IRCAD Webinar: Third ESPES/IPEG Masterclass with the participation of the ESPU
ACUTE APPENDICITIS and PERITONITIS
1. Laparoscopic vs. open appendectomy in children - Mark Wulkan (IPEG)
2. Single port vs. Multiport and the role of new technologies in the management of pediatric complicated appendicitis - Ciro Esposito (ESPES)

CONGENITAL DIAPHRAGMATIC HERNIA (CDH)
1. Open approach for the treatment of CDH - François Becmeur (ESPES)
2. Minimally invasive management of pediatric CDH - Holger Till (IPEG)

VESICOURETERAL REFLUX (VUR)
1. Open, endourological, and robotic management of pediatric VUR - Ramnath Subramaniam (ESPU)
2. Laparoscopic management of VUR according to Lich-Gregoir procedure - François Varlet (ESPES)

Masters of ceremonies:
François Becmeur (IRCAD-Strasbourg)
Philippe Montupet (APHP-Paris)

Chairmen:
Mario Mendoza Sagaon (ESPES)
Alaa El Ghoneimi (ESPU)
Philippe Szavay (IPEG)
F Becmeur, P Montupet, A El-Ghoneimi, P Szavay, M Mendoza Sagaon, M Wulkan, C Esposito, H Till, R Subramaniam, F Varlet
Surgical intervention
1 year ago
1223 views
87 likes
0 comments
11:17
IRCAD Webinar: Third ESPES/IPEG Masterclass with the participation of the ESPU
ACUTE APPENDICITIS and PERITONITIS
1. Laparoscopic vs. open appendectomy in children - Mark Wulkan (IPEG)
2. Single port vs. Multiport and the role of new technologies in the management of pediatric complicated appendicitis - Ciro Esposito (ESPES)

CONGENITAL DIAPHRAGMATIC HERNIA (CDH)
1. Open approach for the treatment of CDH - François Becmeur (ESPES)
2. Minimally invasive management of pediatric CDH - Holger Till (IPEG)

VESICOURETERAL REFLUX (VUR)
1. Open, endourological, and robotic management of pediatric VUR - Ramnath Subramaniam (ESPU)
2. Laparoscopic management of VUR according to Lich-Gregoir procedure - François Varlet (ESPES)

Masters of ceremonies:
François Becmeur (IRCAD-Strasbourg)
Philippe Montupet (APHP-Paris)

Chairmen:
Mario Mendoza Sagaon (ESPES)
Alaa El Ghoneimi (ESPU)
Philippe Szavay (IPEG)
IRCAD Webinar: Third ESPES/IPEG Masterclass with the participation of the ESPU
ACUTE APPENDICITIS and PERITONITIS
1. Laparoscopic vs. open appendectomy in children - Mark Wulkan (IPEG)
2. Single port vs. Multiport and the role of new technologies in the management of pediatric complicated appendicitis - Ciro Esposito (ESPES)

CONGENITAL DIAPHRAGMATIC HERNIA (CDH)
1. Open approach for the treatment of CDH - François Becmeur (ESPES)
2. Minimally invasive management of pediatric CDH - Holger Till (IPEG)

VESICOURETERAL REFLUX (VUR)
1. Open, endourological, and robotic management of pediatric VUR - Ramnath Subramaniam (ESPU)
2. Laparoscopic management of VUR according to Lich-Gregoir procedure - François Varlet (ESPES)

Masters of ceremonies:
François Becmeur (IRCAD-Strasbourg)
Philippe Montupet (APHP-Paris)

Chairmen:
Mario Mendoza Sagaon (ESPES)
Alaa El Ghoneimi (ESPU)
Philippe Szavay (IPEG)
F Becmeur, P Montupet, A El-Ghoneimi, P Szavay, M Mendoza Sagaon, M Wulkan, C Esposito, H Till, R Subramaniam, F Varlet
Webinar
1 year ago
860 views
5 likes
1 comment
11:17
IRCAD Webinar: Third ESPES/IPEG Masterclass with the participation of the ESPU
ACUTE APPENDICITIS and PERITONITIS
1. Laparoscopic vs. open appendectomy in children - Mark Wulkan (IPEG)
2. Single port vs. Multiport and the role of new technologies in the management of pediatric complicated appendicitis - Ciro Esposito (ESPES)

CONGENITAL DIAPHRAGMATIC HERNIA (CDH)
1. Open approach for the treatment of CDH - François Becmeur (ESPES)
2. Minimally invasive management of pediatric CDH - Holger Till (IPEG)

VESICOURETERAL REFLUX (VUR)
1. Open, endourological, and robotic management of pediatric VUR - Ramnath Subramaniam (ESPU)
2. Laparoscopic management of VUR according to Lich-Gregoir procedure - François Varlet (ESPES)

Masters of ceremonies:
François Becmeur (IRCAD-Strasbourg)
Philippe Montupet (APHP-Paris)

Chairmen:
Mario Mendoza Sagaon (ESPES)
Alaa El Ghoneimi (ESPU)
Philippe Szavay (IPEG)
Laparoscopic Mitrofanoff continent diversion in children
Neobladder surgery is often complex. It is readily proposed lately in a child’s life when he agrees to undergo a fairly heavy surgical operation, which will allow him to acquire a social body cleanliness. The poor vesical volume capacity may necessitate either a chemical enlargement with iterative Botox injections into the detrusor muscle, or a vesical enlargement surgery using a bowel segment.
Self-catheterization using natural orifices is often particularly uneasy in boys or in obese or handicapped patients. This mandates to leave an open vesicourethral neck, which however does not prevent potential urinary leaks. This mode of vesical voiding has an alternative, namely Mitrofanoff continent diversion using the appendix.
This procedure was described in 1980. The vesico-appendiceal junction is fashioned by means of an anatomical anti-reflux mechanism. The skin approximation onto the anterior abdominal wall can be performed either in the umbilicus, or in the inguinal region depending on different decisional criteria.
This procedure can now be envisaged laparoscopically. It is a demanding intervention, which requires advanced skills.
A El-Ghoneimi
Lecture
2 years ago
475 views
11 likes
0 comments
28:15
Laparoscopic Mitrofanoff continent diversion in children
Neobladder surgery is often complex. It is readily proposed lately in a child’s life when he agrees to undergo a fairly heavy surgical operation, which will allow him to acquire a social body cleanliness. The poor vesical volume capacity may necessitate either a chemical enlargement with iterative Botox injections into the detrusor muscle, or a vesical enlargement surgery using a bowel segment.
Self-catheterization using natural orifices is often particularly uneasy in boys or in obese or handicapped patients. This mandates to leave an open vesicourethral neck, which however does not prevent potential urinary leaks. This mode of vesical voiding has an alternative, namely Mitrofanoff continent diversion using the appendix.
This procedure was described in 1980. The vesico-appendiceal junction is fashioned by means of an anatomical anti-reflux mechanism. The skin approximation onto the anterior abdominal wall can be performed either in the umbilicus, or in the inguinal region depending on different decisional criteria.
This procedure can now be envisaged laparoscopically. It is a demanding intervention, which requires advanced skills.
The vascular hitch: a simpler procedure for vascular pyeloureteral junction obstruction (PUJO)
Ureteropelvic junction obstruction may occur in about 10% of cases, the origin of which is not an intrinsic organic obstruction in this transitional area between the renal pelvis and the ureter, but it is rather secondary to an extrinsic obstruction, related to the presence of aberrant lower pole vessels.
It is an intermittent ureteropelvic junction obstruction syndrome, which is usually diagnosed late and in which renal function is most often preserved. The operating technique was already described more than 60 years ago. It is a simple technique.
The greatest difficulty is not technical but lies in the indication which must be relevant. The main difficulty is to preoperatively and intraoperatively evaluate either the totally extrinsic nature or conversely the mixed nature of the obstruction, which in that case requires a pyeloplasty according to Anderson-Hynes with division of the ureterovesical junction posteriorly to the vessels and reconstruction of the ureteropelvic junction once enlarged, anteriorly to the lower pole vessels.
I Mushtaq
Lecture
2 years ago
479 views
31 likes
0 comments
13:17
The vascular hitch: a simpler procedure for vascular pyeloureteral junction obstruction (PUJO)
Ureteropelvic junction obstruction may occur in about 10% of cases, the origin of which is not an intrinsic organic obstruction in this transitional area between the renal pelvis and the ureter, but it is rather secondary to an extrinsic obstruction, related to the presence of aberrant lower pole vessels.
It is an intermittent ureteropelvic junction obstruction syndrome, which is usually diagnosed late and in which renal function is most often preserved. The operating technique was already described more than 60 years ago. It is a simple technique.
The greatest difficulty is not technical but lies in the indication which must be relevant. The main difficulty is to preoperatively and intraoperatively evaluate either the totally extrinsic nature or conversely the mixed nature of the obstruction, which in that case requires a pyeloplasty according to Anderson-Hynes with division of the ureterovesical junction posteriorly to the vessels and reconstruction of the ureteropelvic junction once enlarged, anteriorly to the lower pole vessels.
Laparoscopic retroperitoneal pyeloplasty
Ureteropelvic junction obstruction repair can be performed in the first months of the infant’s life by means of videoscopic surgery. Two approaches can be used. First, the transperitoneal access offers a fairly large surgical space. On the other hand, it implies that the surgeon accesses a retroperitoneal organ by opening the posterior parietal peritoneum. To the right, kidney exposure may necessitate the detachment of the right colon and of the duodenum and the surgeon often has to lift up the right liver.
To the left, the exposure of the ureteropelvic junction may require either a colonic detachment, or a transmesocolic opening by respecting the vascular supply of the left colon. The retroperitoneal approach is direct. It helps to better manage any potential urinary leaks, which will never occur intraperitoneally. It prevents any intraperitoneal dissection. However, it is a demanding technique technically speaking.
A El-Ghoneimi
Lecture
2 years ago
899 views
48 likes
0 comments
28:15
Laparoscopic retroperitoneal pyeloplasty
Ureteropelvic junction obstruction repair can be performed in the first months of the infant’s life by means of videoscopic surgery. Two approaches can be used. First, the transperitoneal access offers a fairly large surgical space. On the other hand, it implies that the surgeon accesses a retroperitoneal organ by opening the posterior parietal peritoneum. To the right, kidney exposure may necessitate the detachment of the right colon and of the duodenum and the surgeon often has to lift up the right liver.
To the left, the exposure of the ureteropelvic junction may require either a colonic detachment, or a transmesocolic opening by respecting the vascular supply of the left colon. The retroperitoneal approach is direct. It helps to better manage any potential urinary leaks, which will never occur intraperitoneally. It prevents any intraperitoneal dissection. However, it is a demanding technique technically speaking.
Minimally invasive management of vesicoureteric reflux (VUR) and related anomalies
Operative indications in case of vesicorenal reflux in children have become increasingly rare. The true minimally invasive spirit first necessitates an endoscopic treatment, also called the STING procedure. A ureterovesical reimplantation is required in the presence of clinical or anatomical circumstances. Dr. Paul Philippe describes the operative pneumovesicoscopy developed by CK Yeung and Jeff Valla more than 15 years ago. Despite brilliant presentations, this technique has remained very confidential, probably because of the difficulties come across by the operators when performing the procedure. It is undoubtedly a very demanding technique as far as manual expertise is concerned.
The scarcity of operative indications and the difficulties met in the realization of this surgery render the acquisition of an expertise in the field difficult. However, the technique and the tricks described by Paul Philippe are absolutely remarkable and postoperative outcomes are particularly interesting. We are truly in the context which was initially described 25 years ago when laparoscopic surgery barely started to develop. It is key to reproduce exactly what was previously performed in open surgery in a laparoscopic fashion (or in the present case using pneumovesicoscopy).
P Philippe
Lecture
2 years ago
418 views
21 likes
0 comments
15:24
Minimally invasive management of vesicoureteric reflux (VUR) and related anomalies
Operative indications in case of vesicorenal reflux in children have become increasingly rare. The true minimally invasive spirit first necessitates an endoscopic treatment, also called the STING procedure. A ureterovesical reimplantation is required in the presence of clinical or anatomical circumstances. Dr. Paul Philippe describes the operative pneumovesicoscopy developed by CK Yeung and Jeff Valla more than 15 years ago. Despite brilliant presentations, this technique has remained very confidential, probably because of the difficulties come across by the operators when performing the procedure. It is undoubtedly a very demanding technique as far as manual expertise is concerned.
The scarcity of operative indications and the difficulties met in the realization of this surgery render the acquisition of an expertise in the field difficult. However, the technique and the tricks described by Paul Philippe are absolutely remarkable and postoperative outcomes are particularly interesting. We are truly in the context which was initially described 25 years ago when laparoscopic surgery barely started to develop. It is key to reproduce exactly what was previously performed in open surgery in a laparoscopic fashion (or in the present case using pneumovesicoscopy).
Transperitoneal ureteric reimplantation Lich-Gregoir technique for vesicoureteral reflux (VUR) in children
The Lich-Gregoir technique, still currently used in prominent Northern American centers in the nineties, had more or less fallen into disuse. Currently, the scarcity of operative indications for ureterovesical reimplantation, with the advent of the STING procedure, the real technical difficulties found during pneumovesicoscopy for Cohen procedure, the debates on long-term difficulties (e.g., in adult life) to undergo a ureteral endoluminal surgery after a previous Cohen procedure, all these reasons have led to vested and renewed interest in performing the Lich-Gregoir technique laparoscopically. The rigorous evaluation of potential functional vesical disorders is indispensable in case of bilateral surgery.
F Varlet
Lecture
2 years ago
740 views
48 likes
0 comments
14:58
Transperitoneal ureteric reimplantation Lich-Gregoir technique for vesicoureteral reflux (VUR) in children
The Lich-Gregoir technique, still currently used in prominent Northern American centers in the nineties, had more or less fallen into disuse. Currently, the scarcity of operative indications for ureterovesical reimplantation, with the advent of the STING procedure, the real technical difficulties found during pneumovesicoscopy for Cohen procedure, the debates on long-term difficulties (e.g., in adult life) to undergo a ureteral endoluminal surgery after a previous Cohen procedure, all these reasons have led to vested and renewed interest in performing the Lich-Gregoir technique laparoscopically. The rigorous evaluation of potential functional vesical disorders is indispensable in case of bilateral surgery.
Renal cancer in children and laparoscopy
Dr. François Varlet reflected on the laparoscopic management of Wilms’ tumors.
The framework of existing possibilities to perform such interventions is extremely limited and would concern 5 to 10% of patients that we currently manage. Dr. François Varlet has undertaken a prospective study on a national scale, in France, and he supervises every proposal for laparoscopic surgery to manage Wilms’ tumors. The rigorous and thorough nature of his work, the caution he takes in his work are truly outstanding.
In France, any proposal for a laparoscopic surgery to manage nephroblastoma will be discussed at national level, and the intraoperative conditions and long-term follow-up are meticulously reported, in the framework of the prospective study undertaken by François Varlet.
F Varlet
Lecture
2 years ago
256 views
14 likes
0 comments
15:45
Renal cancer in children and laparoscopy
Dr. François Varlet reflected on the laparoscopic management of Wilms’ tumors.
The framework of existing possibilities to perform such interventions is extremely limited and would concern 5 to 10% of patients that we currently manage. Dr. François Varlet has undertaken a prospective study on a national scale, in France, and he supervises every proposal for laparoscopic surgery to manage Wilms’ tumors. The rigorous and thorough nature of his work, the caution he takes in his work are truly outstanding.
In France, any proposal for a laparoscopic surgery to manage nephroblastoma will be discussed at national level, and the intraoperative conditions and long-term follow-up are meticulously reported, in the framework of the prospective study undertaken by François Varlet.
Single port laparoscopic assisted anorectal pull-through in anorectal malformation
This is the case of a 21-month-old male infant, referred from another center, with anorectal malformation and rectourethral fistula. The patient underwent a colostomy two months earlier and weighed 10Kg. On physical examination, the intergluteal cleft is evident, the infant has a good anal fovea, and his coccyx is palpable. In the distal colostogram, the distance between the rectum and the anus is approximately 2.7cm. The patient underwent single port laparoscopic anorectal pull-through, using the GelPOINT® Mini advanced access platform at umbilical level and a 3mm accessory port was placed at left upper quadrant level. Dissection of the distal part and division of the fistula by a white cartridge 45mm and 10mm ECHELON™ Hem-o-Lok® to remove the fistula at the level of the membranous urethra. A 5mm trocar was placed at the level of the fovea anal and rectum is lowered. The length of the procedure was approximately 3 hours and the patient was discharged on postoperative day 3, and progressed satisfactorily. One advantage of the use of the GelPOINT® Mini advanced access platform is that it allows the introduction of a larger number of instruments of different diameters (3 to 15mm) through the GelSeal® cap without placing other working ports. The single port laparoscopic anorectal pull-through procedure seems to be an efficient method that allows for adequate visualization and tissue manipulation in these patients.
A Parilli, J Mejías, W Salcedo, G Contreras
Surgical intervention
4 years ago
1335 views
22 likes
0 comments
09:55
Single port laparoscopic assisted anorectal pull-through in anorectal malformation
This is the case of a 21-month-old male infant, referred from another center, with anorectal malformation and rectourethral fistula. The patient underwent a colostomy two months earlier and weighed 10Kg. On physical examination, the intergluteal cleft is evident, the infant has a good anal fovea, and his coccyx is palpable. In the distal colostogram, the distance between the rectum and the anus is approximately 2.7cm. The patient underwent single port laparoscopic anorectal pull-through, using the GelPOINT® Mini advanced access platform at umbilical level and a 3mm accessory port was placed at left upper quadrant level. Dissection of the distal part and division of the fistula by a white cartridge 45mm and 10mm ECHELON™ Hem-o-Lok® to remove the fistula at the level of the membranous urethra. A 5mm trocar was placed at the level of the fovea anal and rectum is lowered. The length of the procedure was approximately 3 hours and the patient was discharged on postoperative day 3, and progressed satisfactorily. One advantage of the use of the GelPOINT® Mini advanced access platform is that it allows the introduction of a larger number of instruments of different diameters (3 to 15mm) through the GelSeal® cap without placing other working ports. The single port laparoscopic anorectal pull-through procedure seems to be an efficient method that allows for adequate visualization and tissue manipulation in these patients.
Laparoscopic right ureterovesical reimplantation according to Lich-Gregoir
In 2010, François Varlet from Saint Etienne, France, proposed the laparoscopic extravesical transperitoneal approach according to the Lich-Gregoir technique for the treatment of vesicoureteral reflux in children. If the position of the ureterovesical junction is not ectopic, and by avoiding megaureters, this technique is safe with success rates similar to the open technique. Discussions remain as to a bilateral simultaneous approach, which could lead to bladder dysfunction.
Reference:
Laparoscopic extravesical transperitoneal approach following the Lich-Gregoir technique in the treatment of vesicoureteral reflux in children. Lopez M, Varlet F. J Pediatr Surg 2010;45:806-10.
F Becmeur
Surgical intervention
5 years ago
1118 views
12 likes
0 comments
04:14
Laparoscopic right ureterovesical reimplantation according to Lich-Gregoir
In 2010, François Varlet from Saint Etienne, France, proposed the laparoscopic extravesical transperitoneal approach according to the Lich-Gregoir technique for the treatment of vesicoureteral reflux in children. If the position of the ureterovesical junction is not ectopic, and by avoiding megaureters, this technique is safe with success rates similar to the open technique. Discussions remain as to a bilateral simultaneous approach, which could lead to bladder dysfunction.
Reference:
Laparoscopic extravesical transperitoneal approach following the Lich-Gregoir technique in the treatment of vesicoureteral reflux in children. Lopez M, Varlet F. J Pediatr Surg 2010;45:806-10.
Laparoscopic diagnosis in disorders of sex development: ovotesticular DSD
Background: A normal sex development and appropriate sex assignment take place when sex chromosomes, gonadal histology and genital phenotype are concordant.
A disorder of sex development (DSD) is defined whenever a discordance between two of the aforementioned features is found.
DSDs can be caused by an alteration in the chromosomal complement, or by an abnormal development of the gonads, by a defect in one of the enzymatic pathways for the synthesis of sex hormones or by the absence (or altered structure) of hormone receptors.
In the majority of cases, DSD is heralded by ambiguity of the external genitalia that generally speaking is the result either of a hypervirilization of a 46, XX individual or of a hypovirilization of a 46, XY individual. However, there are cases of DSD in which the genital phenotype is not ambiguous. Those cases are the most difficult to diagnose and are sometimes identified at puberty when unexpected development of secondary sexual characters or primary amenorrhea are observed.
When an obvious ambiguity of the external genitalia is not found, the presence of a DSD should be suspected whenever a newborn with apparent male phenotype shows one of the following features (bilateral impalpable gonads, unilateral undescended testis associated with hypospadias, isolated perineal hypospadias, bifid scrotum) or when an apparent female newborn shows a gonad palpable in a hernia sac, hypertrophied clitoris or fused small labia: such findings should prompt investigation in order to rule out a possible DSD.
Karyotype is key in the diagnosis of suspected DSD. Next step is defining the presence/absence of Müllerian remnants with ultrasound or MRI. At this point, most of the DSD due to an enzymatic defect can be identified by means of hormonal tests (either basal levels or stimulation tests). In the remaining cases in which hormonal tests are not diagnostic, a gonadal biopsy is mandatory to identify a gonadal dysgenesis, an ovotesticular DSD (former hermaphroditism), or a sex reversal.
In cases in which gonads are not palpable, laparoscopy is the gold standard to define their presence, site and macroscopic appearance. It is also very easy to perform a laparoscopic gonadal biopsy and gonadal removal in cases of streak gonads. Finally, laparoscopy is an invaluable tool for the examination of the internal genitalia: it adds useful information to the data obtained by imaging studies and consequently allowing for planning of the definitive treatment.
The video shows a DSD patient in whom laparoscopic gonadal biopsies and left gonadectomy were performed.

Video: A 9-month-old baby with ambiguous genitalia was referred to our centre for evaluation. A female sex assignment was given at birth. At clinical examination, clitoral hypertrophy was evidenced, with a single perineal orifice; the left gonad was palpable in the groin and the right one was non-palpable. No inguinal hernias were detected. Testosterone levels at birth were high (95.8ng/mL) and this finding persisted throughout infancy. The chromosomal complement was 46 XY. Analysis of the AR gene was negative. MRI examination showed the presence of uterus (35 x 10mm); both gonads were visualized in the inguinal region. Laparoscopic gonadal biopsy was decided upon. A 5mm port was placed at the umbilicus through an open access. Pneumoperitoneum was established: carbon dioxide was insufflated at 1L/min and intra-abdominal pressure was set at 8mmHg. Two 3mm operating ports were placed in the right and left iliac fossa.
The presence of a normally developed uterus was confirmed; the right gonad resembled a normal ovary; on the left side, a patent processus vaginalis and an atypical round gonad with a regular surface were observed. Both gonads were biopsied and frozen sections examinations revealed a normal ovary on the right and an ovotestis on the left. Left gonadectomy ensued after monopolar division of the gonadal vessels. The specimen was extracted through the umbilicus.

Results: No conversion to open surgery nor additional trocars were necessary. Total operative time was 120 minutes (including histological examination); biopsy time was 5 minutes for each side; gonadectomy took 15 minutes. No drainage was required. The postoperative course was uneventful and the patient was discharged on day 2.

Conclusion: Laparoscopy in DSD cases is a valuable diagnostic tool in selected patients. It allows gonadal visualization and biopsy together with complete examination of Müllerian derivatives.
L Nanni, G Marrocco, VD Catania
Surgical intervention
6 years ago
1567 views
25 likes
0 comments
05:03
Laparoscopic diagnosis in disorders of sex development: ovotesticular DSD
Background: A normal sex development and appropriate sex assignment take place when sex chromosomes, gonadal histology and genital phenotype are concordant.
A disorder of sex development (DSD) is defined whenever a discordance between two of the aforementioned features is found.
DSDs can be caused by an alteration in the chromosomal complement, or by an abnormal development of the gonads, by a defect in one of the enzymatic pathways for the synthesis of sex hormones or by the absence (or altered structure) of hormone receptors.
In the majority of cases, DSD is heralded by ambiguity of the external genitalia that generally speaking is the result either of a hypervirilization of a 46, XX individual or of a hypovirilization of a 46, XY individual. However, there are cases of DSD in which the genital phenotype is not ambiguous. Those cases are the most difficult to diagnose and are sometimes identified at puberty when unexpected development of secondary sexual characters or primary amenorrhea are observed.
When an obvious ambiguity of the external genitalia is not found, the presence of a DSD should be suspected whenever a newborn with apparent male phenotype shows one of the following features (bilateral impalpable gonads, unilateral undescended testis associated with hypospadias, isolated perineal hypospadias, bifid scrotum) or when an apparent female newborn shows a gonad palpable in a hernia sac, hypertrophied clitoris or fused small labia: such findings should prompt investigation in order to rule out a possible DSD.
Karyotype is key in the diagnosis of suspected DSD. Next step is defining the presence/absence of Müllerian remnants with ultrasound or MRI. At this point, most of the DSD due to an enzymatic defect can be identified by means of hormonal tests (either basal levels or stimulation tests). In the remaining cases in which hormonal tests are not diagnostic, a gonadal biopsy is mandatory to identify a gonadal dysgenesis, an ovotesticular DSD (former hermaphroditism), or a sex reversal.
In cases in which gonads are not palpable, laparoscopy is the gold standard to define their presence, site and macroscopic appearance. It is also very easy to perform a laparoscopic gonadal biopsy and gonadal removal in cases of streak gonads. Finally, laparoscopy is an invaluable tool for the examination of the internal genitalia: it adds useful information to the data obtained by imaging studies and consequently allowing for planning of the definitive treatment.
The video shows a DSD patient in whom laparoscopic gonadal biopsies and left gonadectomy were performed.

Video: A 9-month-old baby with ambiguous genitalia was referred to our centre for evaluation. A female sex assignment was given at birth. At clinical examination, clitoral hypertrophy was evidenced, with a single perineal orifice; the left gonad was palpable in the groin and the right one was non-palpable. No inguinal hernias were detected. Testosterone levels at birth were high (95.8ng/mL) and this finding persisted throughout infancy. The chromosomal complement was 46 XY. Analysis of the AR gene was negative. MRI examination showed the presence of uterus (35 x 10mm); both gonads were visualized in the inguinal region. Laparoscopic gonadal biopsy was decided upon. A 5mm port was placed at the umbilicus through an open access. Pneumoperitoneum was established: carbon dioxide was insufflated at 1L/min and intra-abdominal pressure was set at 8mmHg. Two 3mm operating ports were placed in the right and left iliac fossa.
The presence of a normally developed uterus was confirmed; the right gonad resembled a normal ovary; on the left side, a patent processus vaginalis and an atypical round gonad with a regular surface were observed. Both gonads were biopsied and frozen sections examinations revealed a normal ovary on the right and an ovotestis on the left. Left gonadectomy ensued after monopolar division of the gonadal vessels. The specimen was extracted through the umbilicus.

Results: No conversion to open surgery nor additional trocars were necessary. Total operative time was 120 minutes (including histological examination); biopsy time was 5 minutes for each side; gonadectomy took 15 minutes. No drainage was required. The postoperative course was uneventful and the patient was discharged on day 2.

Conclusion: Laparoscopy in DSD cases is a valuable diagnostic tool in selected patients. It allows gonadal visualization and biopsy together with complete examination of Müllerian derivatives.
Laparoscopic transperitoneal nephrectomy for nephroblastoma
Laparoscopy may be suggested to manage total nephrectomy in specific cases of Wilms’ tumor in children.
Minimal access surgery in pediatric oncology should remain extremely prudent. Some tumors can readily be treated laparoscopically since there is no risk of seeding. On the contrary, in case of seeding, the prognosis would be endangered during surgery for Wilms’ tumor.
Consequently, the decision as to whether or not choose laparoscopy should absolutely be discussed.
Indications for laparoscopic nephrectomy involve tumors treated according to the SIOP treatment guidelines, including primary chemotherapy.
Laparoscopy is mostly decided upon in the presence of a stage I tumor, more rarely in the presence of a stage II tumor without distant metastasis and without tumor thrombus of the renal vein and/or of the vena cava.
Patients with a bilateral tumor are excluded from such therapeutic strategy. Therefore, they will be offered an open nephron-sparing surgery.
Contraindications to laparoscopy include massive post-chemotherapy residual tumor sizes and tumors located proximal to the hilum, since the risk of injuring the tumor during the primary vascular dissection is high.
F Becmeur, F Varlet
Surgical intervention
7 years ago
2599 views
34 likes
1 comment
09:22
Laparoscopic transperitoneal nephrectomy for nephroblastoma
Laparoscopy may be suggested to manage total nephrectomy in specific cases of Wilms’ tumor in children.
Minimal access surgery in pediatric oncology should remain extremely prudent. Some tumors can readily be treated laparoscopically since there is no risk of seeding. On the contrary, in case of seeding, the prognosis would be endangered during surgery for Wilms’ tumor.
Consequently, the decision as to whether or not choose laparoscopy should absolutely be discussed.
Indications for laparoscopic nephrectomy involve tumors treated according to the SIOP treatment guidelines, including primary chemotherapy.
Laparoscopy is mostly decided upon in the presence of a stage I tumor, more rarely in the presence of a stage II tumor without distant metastasis and without tumor thrombus of the renal vein and/or of the vena cava.
Patients with a bilateral tumor are excluded from such therapeutic strategy. Therefore, they will be offered an open nephron-sparing surgery.
Contraindications to laparoscopy include massive post-chemotherapy residual tumor sizes and tumors located proximal to the hilum, since the risk of injuring the tumor during the primary vascular dissection is high.