Go Miyano

Introduction: We compared laparoscopic Toupet fundoplication (LTF) and laparoscopic Nissen fundoplication (LNF) in neurologically normal children. Methods: Forty neurologically normal children who were followed up for more than 3 years after LTF (n = 22) or LNF (n = 18) were reviewed retrospectively. LTF and LNF were performed between 2006 and 2012. Results: There were no significant differences in gender (LTF, 15 male and 7 female patients; LNF:, 12 male and 6 female patients), mean age at surgery (LTF vs LNF: 2.5 vs 2.3 years), mean weight at surgery (LTF vs LNF: 9.6 vs 8.9 kg), preoperative symptoms, preoperative pH monitoring (pH < 4) (LTF vs LNF: 26.7% vs 21.8%), mean operative time (LTF vs LNF: 117 vs 126 min), postoperative recommencement of enteral feeding (LTF vs LNF: 3.7 vs 3.8 days), or duration of hospitalization (LTF vs LNF: 5.5 vs 6.3 days). Intraoperative complications were esophageal trauma (LTF; n = 1; 4.5%) and liver trauma (LNF; n = 1; 5.6%) (P = 0.70). Post-LTF complications were wrap stenosis (n = 1; 4.5%), and post-LNF complications were wrap stenosis (n = 1; 5.5%) and gastric outlet obstruction (n = 1; 5.5%) (P = 0.43); all were managed conservatively. No case required conversion to open repair. There was no recurrence after LTF, but there were three cases (16.7%) after LNF (P = 0.08). Reoperation was performed at 4, 11, and 13 months, respectively. Conclusion: Despite LTF and LNF appearing to be equally effective, three nLNF cases required reoperation.

Introduction: The aim of this study was to compare laparoscopic hepaticojejunostomy (LHJ) and open hepaticojejunostomy (OHJ) for choledochal cyst associated with hilar hepatic duct stenosis (HHDS).Methods: Data collection was prospective for LHJ cases from 2009 and retrospective for OHJ cases from 2003 to 2008. Data were compared with respect to HHDS. HHDS was incised longitudinally as required during hilar hepatic ductoplasty.Results: Fifty‐eight subjects were studied (LHJ: n = 27, 4 boys, 23 girls; OHJ: n = 31; 6 boys, 25 girls). HHDS was present in 10 LHJ cases and 10 OHJ cases. Todani classification of choledochal cyst in LHJ patients was type 1A (n = 16) and type 4A (n = 11), and in OHJ patients, it was type 1A (n = 19) and type 4A (n = 12). There were significant differences between LHJ and OHJ with regard to mean operative time (386 vs 341 min), mean blood loss (5.9 vs 18.4 mL), recommencement of enteral feeding (3.9 vs 6.4 days), and hospital stay (11.7 vs 15.5 days) (all P < 0.05). Hepatic ductoplasty was performed in 23 LHJ patients and in 21 OHJ patients. There were no intraoperative complications and no conversions to OHJ. There were no significant differences between LHJ and OHJ, regardless of the presence of HHDS, for postoperative complications, which included minor bile leakage, anastomotic stricture, and intestinal obstruction.Conclusion: LHJ is as effective as OHJ for the treatment of choledochal cysts irrespective of the presence of HHDS and the need for hepatic ductoplasty.

This study presents a modified surgical approach to laparoscopic myotomy for achalasia using stepped dilation with a Rigiflex balloon and contrast medium under image guidance. A 10-year-old boy with persistent dysphagia and vomiting had ingested only liquids for 3 months, losing >10 kg in body weight. Barium swallow and esophageal manometry diagnosed esophageal achalasia with mild esophageal dilatation. After failed pneumatic dilatation, laparoscopic Heller myotomy with Dor fundoplication was performed. Prior to surgery, a Rigiflex balloon dilator was placed within the esophagus near the diaphragmatic hiatus. A four-port technique was used, and mobilization of the esophagus was limited to the anterior aspect. A 5-cm Heller myotomy was performed, extending another 2 cm onto the anterior gastric wall. During myotomy, the Rigiflex balloon was serially dilated from 30 to 50 mL, and filled with contrast medium under fluoroscopic image guidance in order to maintain appropriate tension on the esophagus to facilitate myotomy, and to confirm adequate myotomy with sufficient release of lower esophageal sphincter by resecting residual circular muscle fibers. Residual circular muscle fibers can be simultaneously visualized under both fluoroscopic image guidance and direct observation through the laparoscope, and they were cut precisely until the residual notch fully disappeared. Dor fundoplication was completed. The operative time was 180 minutes, and oral intake was started after esophagography on postoperative day 1. As of the 12-month follow-up, the patient has not shown any symptoms, and his postoperative course appeared satisfactory.

A 15-year-old girl was found to be hypertensive (230–270/140–170 mm Hg) without any subjective symptoms. Magnetic resonance imaging confirmed the presence of a well-defined 22 mm hypodense lesion in the lower pole of the left kidney, located close to the renal hilum. Plasma rennin activity was elevated (75 ng/mL/h), and reninoma was diagnosed. Retroperitoneoscopy-assisted nephron-sparing surgery was planned. The retroperitoneum was accessed through a 4 cm left pararectal upper abdominal incision. Following blunt dissection, the abdominal wall was elevated with a lifting bar and lifting retractor, inserted below the 12th rib in the anterior axillary line to create sufficient working space in the retroperitoneal cavity without the need for pneumoperitoneum. Three 5 mm trocars were introduced above the superior iliac crest for the camera and the assistant. Gerota's fascia was opened and the kidney exposed. The surgeon dissected the left kidney through the minilaparotomy incision under both direct vision and using the magnified view on the monitor, which was particularly effective for the lateral and posterior sides of the kidney. The posterior peritoneum was incised intentionally next to the diaphragm to allow further mobilization of the kidney. Diathermy was used to remove the tumor and a layer of surrounding normal parenchymal tissue at least 0.5 cm thick. The histopathologic diagnosis was reninoma. Ischemia time was 14 minutes. Postoperatively, both plasma rennin activity and blood pressure were normal (1.9 ng/mL/h and 90–110/70–80 mm Hg, respectively). After follow-up of 12 months, there is no evidence of recurrence.

Introduction: We report a case of a 1.8‐kg infant who had laparoscopic Toupet fundoplication (LTF) using the AirSeal Intelligent Flow System and Anchor Port (AP).Materials and Surgical Technique: Our case had severe gastroesophageal reflux in association with genetic and cardiac anomalies. Despite the patient being continuously fed, persistent vomiting caused failure to thrive, and LTF was performed at 4 months of age when he weighed 1.8 kg. The AirSeal Intelligent Flow System is a novel laparoscopic CO₂ insufflation system that improves the visual field by constantly evacuating smoke and providing a more stable pneumoperitoneum. The AP is a recently developed, stretchable, elastomeric, low‐profile cannula. Three 5‐mm AP were inserted: one subumbilically for the scope and one in both the right and left upper abdomen for the surgeon. A 5‐mm AirSeal trocar was inserted in the left lower abdomen for the assistant. The gastrosplenic ligament was dissected free, and the intra‐abdominal esophagus was prepared. A posterior hiatoplasty was performed, followed by the 270° fundoplication. During the fundoplication, the esophagus was fixed to the crus and then the right and left wraps were fixed to the esophagus. Pneumoperitoneum was maintained stably throughout the LTF procedure, with optimal operative field. Total operating time for LTF was 90 min. Body temperature dropped from 37.4°C to 35.7°C during pneumoperitoneum but resolved once pneumoperitoneum was ceased. Postoperative progress was uneventful, and an upper gastrointestinal study on postoperative day 2 showed no residual gastroesophageal reflux.Discussion: We believe the AirSeal Intelligent Flow System and AP contributed to the successful completion of LTF in a 1.8‐kg infant.

To present the medium to long-term outcome of the largest pediatric series of laparoscopic Toupet fundoplications (LTF) performed at a single institution. Subjects were 131 neurologically impaired children (81 M, 50 F) who underwent LTF between 2003 and 2013. Our LTF involves full dissection of the crus of the diaphragm to allow the intraabdominal esophagus to be mobilized at least 3–4 cm. Preoperative mean fraction time for pH n = 4; 3.0 %) including full-thickness perforation (n = 1; 0.8 %). Postoperative complications included pyloric stenosis (n = 4; 3.0 %), dysphagia (n = 1; 0.8 %), incisional hernia (n = 1; 0.8 %), hemorrhage requiring transfusion (n = 1; 0.8 %), recurrence (n = 3; 2.3 % at 11, 13, and 48 months, respectively), and gastrostomy site infection (n = 7; 5.3 %). Mean operative time decreased significantly with experience from 180.8 min for the first quarter of subjects to 150.6 (2nd quarter), 128.6 (3rd) and 109.2 min (4th). Our LTF would appear to be safe for treating GERD in children because of reliable outcome and low recurrence.

In children with choledochal cysts (CC), obstruction of the discharge of bile or pancreatic juice is frequently observed, and biliary perforation and severe pancreatitis may occur. In such cases, temporary drainage is necessary to stabilize these patients. We employed laparoscopic cholecystostomy followed by laparoscopic cyst excision in cases with complicated CC.Between 2009 and 2013, emergency laparoscopic cholecystostomy for bile drainage was performed in seven girls with complicated CC in whom conservative treatment failed to ameliorate abdominal pain, vomiting, and jaundice; among these seven patients included two with biliary perforation, one with a huge cyst, and four with peribiliary edema suggestive of impending biliary rupture. Protein plugs in the common channel or the terminal portion of the cyst were present in six patients.Amelioration of symptoms, such as abdominal pain and jaundice, was achieved in all patients after laparoscopic cholecystostomy. Saline irrigation of the bile duct via cholecystostomy was commenced 2 days postoperatively. All patients underwent laparoscopic cyst resection after improvement of their general condition and detailed evaluation of the intrahepatic and extrahepatic bile ducts and pancreaticobiliary maljunction. Impacted protein plugs or gallstones were eliminated in all patients by the time of laparoscopic cyst excision.Laparoscopic cholecystostomy followed by laparoscopic cyst excision is a useful and safe procedure for the treatment of complicated CC. This technique is also favorable from a cosmetic viewpoint because the resultant wound can be reused as the trocar insertion site at the time of laparoscopic cyst excision.

We report herein an adolescent case of Duchenne muscular dystrophy (DMD) with idiopathic gastric perforation, in which emergency surgical repair was performed laparoscopically. A 14-year-old nonambulatory boy with DMD was brought to our emergency department with sudden onset of severe abdominal pain and distention. Plain radiograph and computed tomography confirmed the presence of free intraperitoneal air and intrapelvic effusion. The patient elected to undergo laparoscopic inspection with 4 trocars, revealing a focal perforation, 3-4 cm in diameter, on the upper gastric body near the diaphragm. The stomach was also found to have a thin wall without evidence of peptic ulcer disease or other abnormalities. An interrupted suture was placed using 4-0 PDS. The abdomen was extensively irrigated, and multiple J-Vac drains were left in situ. Total operation time was 90 min, and no intraoperative complications were encountered. Enteral feeding through a nasogastric tube was started on postoperative day 7. The postoperative course has been uneventful as of the 12-month follow-up. Pediatric surgeons should be aware of the increased risk of gastric perforation associated with DMD, and that laparoscopic repair can be safely performed even in emergency settings.