Scielo RSS <![CDATA[South African Journal of Surgery]]> vol. 49 num. 1 lang. en <![CDATA[SciELO Logo]]> <![CDATA[<b>Paediatric laparoscopic surgery issue</b>]]> <![CDATA[<b>'See one, practise on a simulator, do one' - the mantra of the modern surgeon</b>]]> Minimally invasive techniques are now well established in paediatric surgery. Training has traditionally been based on an apprenticeship model, as for open surgery. More recently the constraints of litigation, finance and restriction of doctors' working hours have led to a need to rethink this training. Simulation to learn and improve skills is by no means a new concept, but has been suggested as a way to address the above issues because it provides an ideal platform for acquiring the necessary skills for modern laparoscopic surgery. This paper explores some of the current issues of learning minimally invasive surgical skills in a simulated environment, and suggests that such simulation should not be seen in isolation but as a part of a wider and encompassing curriculum of learning for the 21st-century surgeon. <![CDATA[<b>Exciting times: Towards a totally minimally invasive paediatric urology service</b>]]> Following on from the first paediatric laparoscopic nephrectomy in 1992, the growth of minimally invasive ablative and reconstructive procedures in paediatric urology has been dramatic. This article reviews the literature related to laparoscopic dismembered pyeloplasty, optimising posterior urethral valve ablation and intravesical laparoscopic ureteric reimplantation. <![CDATA[<b>Overcoming the learning curve in hand-assisted laparoscopic live donor nephrectomy - a study in the animal model</b>]]> The demand for kidneys in South Africa is staggering. Only 38% of the kidney transplants done in 2008 were from related living donors. Laparoscopic living donor nephrectomy has been shown to have the advantages of decreased postoperative pain, better cosmesis and a quicker return to work when compared with the open technique. With limited surgical expertise, a realistic model was needed to overcome the learning curve. METHODS: A total of 21 nephrectomies were performed on 12 pigs. The transperitoneal hand-assisted laparoscopic technique was used. RESULTS: The median operative time was 75 minutes and the median warm ischaemic time 88 seconds. Three cases were aborted owing to major vascular injuries. DISCUSSION: The advent of laparoscopic techniques has been associated with an increase in morbidity and complications in donor and recipient during the initial learning curve. We found that with our porcine model, 21 nephrectomies were adequate in overcoming the learning curve. After 15 nephrectomies no complications were noted. <![CDATA[<b>Hand-assisted laparoscopic live donor nephrectomy - initial experience</b>]]> INTRODUCTION: The advantages of minimally invasive live donor nephrectomy have been well documented, with no adverse effect on graft function. Minimal access nephrectomy has now become the standard of care in many units. We have adopted the hand-assisted laparoscopic live donor (HALLDN) technique, and present our initial experience with the first 24 cases. MATERIAL AND METHODS: HALLDNs were performed trans-peritoneally. Primary outcomes included total operative time, warm ischaemic time, time to discharge, and postoperative complications. Warm ischaemic time was measured from the time of clamping the renal artery to the time of perfusing the kidney on the back table. RESULTS: Mean total operative time was 143 minutes and mean warm ischaemic time 188 seconds. A downward trend was displayed for operative times. Mean time to discharge was 60 hours. A right nephrectomy was performed in 2 cases. No surgical morbidity is reported. We describe one donor mortality. DISCUSSION: Our results compare favourably with those documented in the literature. Aberrant renal vascular anatomy had no adverse effect on operative or warm ischaemic times. HALLDN proved beneficial in patients with a high BMI. CONCLUSION: Surgical experience is vital when performing HALLDN. Overcoming the learning curve with an animal model is beneficial. <![CDATA[<b>Anaesthetic considerations for paediatric laparoscopy</b>]]> Children, infants and neonates represent an anaesthetic challenge because of age-specific anatomical and physiological issues. Apart from paediatric-specific anaesthetic considerations, the paediatric anaesthetist must understand the implications of laparoscopic surgery, and prevent and react appropriately to changes that will occur during these procedures. Pre-operative assessment is a multi-specialist responsibility. Predicting the effects on each organ system, planning the strategy required and maintaining open communication within the team ensure the success of the operation and limit peri-operative morbidity. <![CDATA[<b>Neonatal laparoscopy</b>]]> Until recently minimally invasive surgery was not performed in neonates. This was because of their small size and distinct physiological characteristics. Since the introduction of fine laparoscopic instruments, improvements in the surgical technique and a better understanding of the unique anaesthetic requirements of laparoscopy, more complex operations have been performed. While certain operations such as laparoscopic pyloromyotomy have become routine in many centres, others require significant infrastructure and experience. Advantages of minimally invasive surgery seen in older children and adults, such as shortened hospital stay and less pain, also apply to neonates. There is no doubt that minimally invasive surgery for neonates is still in its infancy. For many neonatal conditions requiring surgery, the benefits of minimally invasive surgery have yet to be established with well-designed studies. <![CDATA[<b>Oesophageal atresia without tracheo-oesophageal fistula and an anorectal malformation: Advantages of a primary laparoscopically assisted anorectal pull-through</b>]]> We report on a primary laparoscopically assisted anorectal pull-through (LAARP) performed in a neonate with pure oesophageal atresia and imperforate anus with recto-bulbo-urethral fistula, representing a unique case for the LAARP approach owing to the undistended nature of the bowel and sterile meconium. Further evaluation of the applicability of LAARP in the management of infants with anorectal malformations is needed, but in this case it held major advantages for the patient. A laparoscopically assisted gastrostomy was facilitated during the same procedure, while avoidance of a colostomy and its associated complications also facilitated preservation of the left colon for subsequent use in oesophageal replacement. Long-term outcome remains to be assessed. <![CDATA[<b>Paediatric thoracoscopy: State of the art</b>]]> Brad Rogers reported the first significant use of thoracoscopy in children in the late 1970s. Over the past two decades there has been an exponential growth and expansion of this technique. Many advanced procedures, including lobectomy, repair of tracheo-oesophageal fistula, excision of mediastinal tumours and diaphragmatic hernia repairs, are being done routinely in paediatric surgery centres around the world. This article reviews the state of the art of thoracoscopic surgery in children. The author selected five procedures which in his opinion are most relevant for this discussion. The thoracoscopic technique seems to offer a favourable alternative to open surgery, but more clinical research is necessary to confirm the benefits of minimal access surgery. <![CDATA[<b>A survey on the current status of laparoscopic training in paediatric surgery in South Africa</b>]]> OBJECTIVES: To document the current status of laparoscopic training of paediatric surgical registrars in South Africa. METHODS: An anonymous questionnaire was distributed. Participants were asked to document their involvement in a number of index laparoscopic procedures during the preceding year, as well as additional non-operative training they received and their satisfaction with their training thus far. RESULTS: All registrars (N=16) completed the questionnaire. Registrars were from the Universities of KwaZulu-Natal, Cape Town, Stellenbosch, Pretoria, the Witwatersrand, and Walter Sisulu University. The ratio of consultants proficient in paediatric laparoscopy to registrars was between 0.6 and 1. Junior registrars were more likely to assist with, and senior registrars more likely to perform, procedures. Registrar satisfaction varied greatly across institutions, with 44% of registrars satisfied with their training. CONCLUSIONS: The consultant-to-registrar ratio is favourable, and high patient load provides opportunity for laparoscopic education. However, there are a number of obstacles to adequate training. These include the feasibility of after-hours laparoscopic surgery and the availability and use of training aids. The introduction of a structured training programme across all institutions will improve laparoscopic proficiency and satisfaction among paediatric surgical registrars in South Africa. <![CDATA[<b>A comparison of laparoscopic-assisted (LAARP) and posterior sagittal (PSARP) anorectoplasty in the outcome of intermediate and high anorectal malformations</b>]]> INTRODUCTION: Laparoscopic-assisted anorectoplasty (LAARP) has gained popularity since its introduction in 2000. Further evidence is needed to compare its outcome with the gold standard of posterior sagittal anorectoplasty (PSARP). METHOD: A retrospective review of patients presenting with anorectal malformation (ARM) in the period 2000 - 2009. Demographics, associated abnormalities, and operative and post-operative complications were assessed. The functional outcome in children older than 3 years was assessed, applying the Krickenbeck scoring system and, where possible, by interviewing parents. Patients with cloacal abnormalities were excluded. Patients with a LAARP were compared with those managed by PSARP. RESULTS: Seventy-three patients with ARM were identified during the study period. Male to female ratio was 1.6:1. All 32 low ARMs (perineal and vestibular fistulae) were excluded. Thirty-nine had levator or supra-levator lesions. Twenty males presented with recto-bulbar, 3 with recto-prostatic, and 1 with a recto-vesical fistula; 2 had no fistula; and in 2 the data were insufficient to determine the level. Among the females, 6 had recto-vaginal fistulae, 4 had cloacas and 1 had an ARM without fistula. There were 3 syndromic ARMs (2 trisomy 21 and 1 Baller-Gerold syndrome). One neonate with a long-gap oesophageal atresia had a successful primary LAARP. Seventy-five per cent of all patients had VACTERL associations. Two early deaths after colostomy formation were related to a cardiac anomaly and an oesophageal atresia. In both groups, mean age at anoplasty was 8 months. Twenty of the intermediate/high lesions were treated with LAARP, and 19 by PSARP. There were slightly more complications in the LAARP group; intra-operative injury to the vas deferens and urethra occurred once each. Post-operatively, 2 port-site hernias and 1 case of pelvic sepsis occurred. A poorly sited colostomy caused difficulty in 2 patients. Two patients were converted to laparotomy: severe adhesions in one and a poorly sited stoma in another. Five patients required redo-anoplasty for mucosal prolapse, anal stenosis, incorrect placement of the anus, retraction of the rectum and an ischaemic rectal stricture. Complications in the PSARP group included 2 wound dehiscences, 1 anal stenosis, 3 mucosal prolapses, 1 recurrent fistula and 2 incorrect anal placements requiring redo surgery. The Krickenbeck questionnaire was used in 70% of PSARPs (mean age 5.9 years) and LAARPs (mean age 5.5 years) for a functional assessment. Both groups showed voluntary bowel movements in 14%. Soiling and overflow incontinence was a significant problem. Grade III constipation was less common in the LAARP (14%) than PSARP (21%) group. Four patients in the LAARP group were reliant on regular rectal washouts compared with 6 in the PSARP group. CONCLUSION: Both LAARP and PSARP can successfully treat ARM but have specific associated problems. <![CDATA[<b>Laparoscopically inserted button colostomy as a venting stoma and access port for the administration of antegrade enemas in African degenerative leiomyopathy</b>]]> African degenerative leiomyopathy (ADL) is a rare incurable disorder seen in African children, predominantly in southern and south-eastern Africa. ADL presents as chronic intestinal pseudo-obstruction. Management is traditionally conservative, with surgery restricted to the management of complications. We have placed Malone antegrade continence enema (MACE) stomas in the grossly dilated colon to vent accumulated gas and administer antegrade bowel enemas. This is done mainly for relief of gaseous distension and constipation in an attempt to provide symptomatic relief and improve quality of life. In this article, we present our preliminary results of laparoscopically assisted technique to insert a Mic-Key gastrostomy device as a 'button colostomy' in 8 patients over the past 6½ years. <![CDATA[<b>Laparoscopic treatment of type III para-oesophageal hernia</b>]]> Type III congenital para-oesophageal hernia is a rare condition in children and is characterised by the herniation of both a substantial portion of the stomach and the gastro-oesophageal junction into the chest. This report describes the laparoscopic repair of 4 para-oesophageal hernias in children between 2002 and 2010. All hernias were treated successfully using the laparoscopic method. There were no recurrences. The laparoscopic repair of a para-oesophageal hernia is technically challenging, but is feasible and safe in the hands of paediatric surgeons familiar with laparoscopic anti-reflux surgery.