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No 3

No 3 (28)

Antoine Liné, Francis Lefebvre, Aurélien Binet, Caroline François-Fiquet, Marie-Laurence Poli-Mérol

Department of Pediatric Surgery, American Memorial Hospital, Reims, France



Introduction: Minimally invasive surgery is more used in pediatric surgery and thoracoscopy is now the popular management of congenital diaphragmatic hernia. Closing method (diaphragmatic plication, suture, patch repair) is dependant of operative constatations. Necessary learning for new technical method is difficult especially as pathology is rare. We made the choice to evaluate our results, after 4 years experience.
Materials and methods: Retrospective study: 11 children (4 girls, 7 boys) with congenital diaphragmatic hernia (9 left, 2 right) managed by thoracoscopy since 2009. Perinatal and surgical data, comparison with anterior group managed by laparotomy and review of the literature.
Results: On arterial blood gases, acid pH was 7,18 and pCO2 was 68,4 mmHg. Length of intubation was 16 days (High Frequency Ocillation during 7 days, Synchronised Intermittent Mandatory Ventilation during 9 days). 7 children received exogenous surfactant, 9 received NO (during 16 days). Length of hospitalization in reanimatory ward was 30 days. 7 children were managed by direct suture and 4 had patch repair (Gore-Tex®). We noted 3 recurrence: 2 with patch and 1 suture. We also had 2 surgical management for occlusive syndrome.
Conclusion: In comparison to our anterior experience, thoracoscopic management of congenital diaphragmatic hernia led to more surgical complications, specially recurrence. However, mortality and length of hospitalization didn’t increase. We emphazise difficulties and our choice to manage by thoracoscopy this children 




Jean François Lecompte, Geraldine Hery, Pascal de Lagausie

Hopital Timone, Marseille, France



Background: Congenital diaphragmatic eventration needs a plication when it has an impact on respiratory function. During the last 10 years it’s done by thoracoscopy for reducing the surgical morbidity. Since then new tricks are surch to reach the best flattening of the diaphragm. We report 5 cases of plication using vascular clamp as technical tricks.
Material and Method: 5 patients, 1 girl and 4 boys, from 1 day to 15 months underwent thorascopic diaphragmatic plication for congenital diaphragmatic eventration. Selective ventilation was performed for 3 cases, and bipulmonary ventilation for 2 cases. A low insufflation allowed lung collapse. Diaphragmatic plication was done with four 5mm ports. The diaphragm was pinched by a clamp, introduced in the more distal ports hole, up to its base and complete abdominal viscera reintegration. A first hand-sew U-stitches suture was done at the base. Endostapler sac resection was done if the sac was too big. Then the sac was pulled and fixed in the lateral recess. A chest drain was placed at the end of the procedure.
Results: 2 had a sac resection with endostapler. The 5 were extubated immediately after surgery. Chest drains were removed between the 2nd and the 6th post-operative day. No additional thoracic surgery was needed. Chest radiographs showed good flattening of the diaphragm.
Conclusion: The clamp was good trick to facilitate diaphragmatic plication with a good tension and no additional surgery, even in newborns. 




Christian Pioplat¹, Yohann Robert¹, Ionella Nechifor¹, Hervé Testard¹, Blandine Fabre¹, Marie Parrens², Jérôme Duret¹, Corinne Alla¹, Dominique Plamtaz¹
¹Hôpital Couple Enfant, CHU de Grenoble, France, ²Groupe Hospitalier Haut Lévêque, CHU de Bordeaux, France



Aims: Solid tumors of the spleen are extremely rare in children. Sclerosing angiomatoid nodular transformation of the spleen (SANT) is an exceptional etiology.
Case report: A 14-years old girl experienced asthenia and was treated for urinary tract infection. She was addressed following sonographic finding of a 70 mm in diameter, heterogeneous, vascularized splenic solid tumor.
Biology has found anemia. CT and MRI confirmed enhancement of the central portion after injection. Several hypotheses have been advanced (vascular malformation? hamartoma?) but malignancy could not be ruled out. Laparoscopic total splenectomy was undertaken, the spleen was then placed in a retrieval bag and extracted without fragmentation by a suprapubic incision. Follow-up was uneventful. Histology has suggested the diagnosis of sclerosing angiomatoïd nodular transformation of the spleen (SANT). The decline since the intervention is 9 months.
Discussion: Described for the first time by Martel in 2004, SANT is exceptional. 97 cases have been detailed by Falk in 2012 and only 3 cases involved children. The lesion is often asymptomatic and discovered incidentally by imaging, more rarely symptomatic. Some MRI characteristics have been described. Diagnostic biopsy may allow avoiding surgery, but exposes to complications (intraperitoneal bleeding, swarming if malignancy). Laparoscopic splenectomy is not contrindicated but it seems preferable, to not fragment the spleen and to extract it via a cosmetic incision in an extraction bag. In case of non-central tumors partial splenectomy is possible without taking a risk of tumor rupture. Differential diagnoses are vascular lesions of the spleen: hemangioma, coastal cell angioma, hemangioendothelioma and inflammatory myofibroblastic tumor. Immuno-histo-chemical characteristics are helpful.
Conclusion: SANT should be kept in mind in children in cases of solid vascular splenic tumors. Imaging may be suggestive but is rarely sufficient to avoid splenectomy. Laparoscopic splenectomy, respecting the rules of oncological surgery, led to the diagnosis and brings healing.



Jean François Lecompte, Geraldine Hery, Guillaume Gorincour, Nicole Philip, Pascal de Lagausie

Hopital Timone Enfant, Marseille, France



Purpose: Cystic lesions are common findings during prenatal ultrasonography but their pre- and post-natal prognosis is difficult to establish since some regress spontaneously. The purpose of this study was to identify putative criteria to predict regression of partially or completely cystic lesions detected by prenatal ultrasound.
Methods: Prenatal ultrasound features of thoracic or abdominal cystic lesions were retrospectively analyzed. Ovarian and urological lesions were not included in this study.
Results: A total of 57 cystic lesions were studied. Thirty-six lesions including 10 abdominal (43.5%) and 26 thoracic (76.5%) lesions required surgical resection (p=0.02). Ten persistent lesions after birth were only monitored. Eleven lesions including 8 abdominal (34.7%) and 3 thoracic (8.8%) regressed prenatally (p=0.02). Regressing abdominal lesions consistently presented as solitary lesions with a homogenous aspect. Only one abdominal lesion showed a multilobulated aspect. Two regressing thoracic lesions were purely cystic and one presented a heterogeneous aspect.
Conclusion: Regression of cystic lesions detected by prenatal ultrasound scan was more likely for lesions in abdominal (mainly adrenal or splenic lesions) than thoracic locations. The likelihood of regression was highest for purely cystic abdominal lesions.






Manuel Lopez¹, Jean Michel Prades² & Francois Varlet¹ ¹Department of Pediatric Surgery, and ²Otorhinolaryngology University Hospital of Saint Etienne, France
Manuel Lopez, Jean Michel Prades, Francois Varlet
Department of Pediatric Surgery, Saint Etienne, France



Objective: Open repair with a second thoracotomy is technically challenging and has a high risk of complications for the treatment of a recurrent tracheoesophageal fistula (RTEF). Therefore, less invasive endoscopic techniques have been developed. We report our initial experience with trichloroacetic acid chemocauterization for recurrent trachea-esophageal fistula by endoscopy. 

Methods: Two patients who had an open repair with thoracotomy for congenital tracheoesophageal fistula and were diagnosed with large RTEF. Rigid ventilating bronchoscopy with telescopic magnification was used to evaluate and manage the RTEF. After identification of the fistula opening, a 50% TCA-soaked small cotton ball was applied in the opening 3 times during each session, in day surgery.
Results: The mean number of procedures was 2, and the fistulae were closed in both cases. Closure of the fistula was confirmed by esophagogram and/or bronchoscopy. There were no postoperative complications.
Conclusion: The results of this initial experience showed that chemocauterization with TCA can be safe and effective for the management of RTEF.




Arnaud Bonnard, Ahmed Kheniche, Marie Noelle Lebras, Dominique Berrebi, Alaa El Ghoneimi

Robert Debré Children University Hospital, Paris, France



Introduction: Surgery for pulmonary malformation can be complicated by ventilatory troubles, residual pneumothorax and pleural effusion. The aim of the study was to collect the post-operative radiographic findings looking for a correlation with the pulmonary status after surgery.
Patients and method: chest x ray at day post operative 2 (DPO 2) and 30 (DPO 30) of patients operated on for thoracoscopic pulmonary resection related to a congenital malformation between 2007 and 2012 were retrospectively reviewed. Only patients with congenital lobar emphysema (CLE), congenital cystic adenomatoid malformation (CCAM) and Intra lobar sequestration (ILS) were included. A post-operative finding’s classification in 4 grades of gravity (0,1,2 et 3) was built.
Results: 55 patients were operated on, 35 were included (26 CCAM, 8 CLE et 1 ILS). At DPO 2, 6 patients have lesions grade 0 and 1, 26 patients grade 2 and 3 patients grade 3. At DPO 30, 24 patients have stable grade 2 lesions (68.6%), while 10 were downgrading (28.6%) and only one upgrading (2.8%). Mean hospital stay was not different between patients classified in grade 0,1 or 2 (3,4 and 3 days respectively). Only patients classified as grade 3 on DPO2 have a longer hospital stay (8 days). With a median follow up of 23.5 months, 4 children (3 grade 2 and 1 grade 3) have a medical treatment for an asthma or recurrent bronchitis (11.4%).
Conclusions: Post-operative chest x ray is rarely normal after thoracoscopic pulmonary resection for pulmonary malformation. In two third of cases, it doesn’t improve at DPO 30. However, the mean hospital stay for grade 0,1 or 2 are quite similar meaning that the chest x ray in not an indication for prolonged hospital stay. Furthermore, lesions are not predictive of post-operative medical treatment requirement. 




Emilie Eyssartier¹, Jean Bréaud², Hubert Lardy³, Jérome Berton¹, Jean-Claude Granry¹, Guillaume Podevin¹

¹CHU Angers, Angers, France, ²Faculté de médecine, Nice, France, ³CHRU de Tours, Tours, France



Introduction: Paediatric surgery is a generalist surgery, and deals with rare pathologies (frequency from 1/2000 to 1/5000). Effective skills acquisition in the operating room is becoming increasingly difficult with larger numbers of residents to be trained, and the existing system still lacks well-defined structured training programs.
Aims of the study: The aim of this study was to determine if medical or surgical simulation is used to teach paediatric surgery in France. 

Method: Paediatric surgery residents, and young practitioners working in paediatric surgery units in France were requested to fill in a questionnaire sent by e-mail. This questionnaire was sent to all recipients of the ACPF mailing list (Association des Chirurgiens Pédiatres en Formation).
Results: Out of 128 paediatric surgeons having received the questionnaire, only 48 answered, who were working in 19 different centers. Simulation had been compulsory for 7 of these surgeons. Simple operative skills using surgical simulation were taught to 27 surgeons. Three people had practiced more than 10 hours, and 1 more than 20 hours. More elaborated virtual reality was used by 21 surgeons, 5 had practiced more than 10 hours, and 1 more than 20 hours. 6 residents had taken part in high fidelity simulation sessions.
Conclusion: Training programs using surgical simulation are not much developed. It seems that paediatric surgery residents are not much interested in training by surgical simulation. We believe that a compulsory program should be developed, starting at undergraduate study level. 




Hossein Allal

CHU Lapeyronie Structure de Chirurgie Viscérale Pédiatrique, Montpellier, France



Introduction: Through time, the training and development of technical skills have been performed in the operating room. Clinical training using simulated environments may improve the efficiency and safety of laparoscopic surgery. We present a training model in laparoscopic surgery for esophageal atresia (EA).
Material and methods: To confine the training model, we divide it in three parts: A) Video surgery equipment. A video endoscopic unit with an image integrated module, three 3.5mm trocar, one 5.5 mm trocar, 3mm instruments. B) A doll is used, which simulated a term newborn having a longitudinal anterior and posterior opening of 10 cms long and 2cms wide, through which a separator is introduced. C). Rabbit tissue or synthetic material are used. We proceed to place the videosurgery unit just like a real procedure. Placing the optic, visualizes the first image of esophagus and trachea. Afterwards, performing a meticulous dissection the separation of the tracheoesophagean partition is done, a suture thread 5/0 is placed around the esophagus, making an intracorporeal knot. The same surgical technique, end to end anastomosis is performed.
Conclusion: Since the beginning of laparoscopy, the use of simulators have proven a great potential for training and acquiring skills, shortening the learning curve and the early use in real procedures. This model which perfectly simulates the environment of an EA has been used by pediatric surgeons in the unit, allowing them to acquire skills that could then be applied during surgery 




Alexis P Arnaud, Juliette Hascoet, Audrey Guinot, Edouard Habonimana, Olivier Azzis, Benjamin Fremond

Department of General Paediatric Surgery, University Hospital, Rennes, France



Aim: Evaluation of the single port trans-umbilical laparoscopic assisted appendectomy (TULAA) performed in children for non-complicated appendicitis and appendicular peritonitis.
Method: A retrospective cohort study of children operated on using the TULAA technique between 1 January 2008 and 1 January 2013 was performed. TULAA is a minimally invasive surgery using a 10mm single port and a 5mm laparoscopic grasper through a 10mm sidearm viewing telescope. The appendix is exteriorized through the umbilical incision, a conventional appendectomy is then performed extra corporeally. Data collected were: demographics, type of appendicitis, need to convert, operative time, per and postoperative complications. Data are given in median (range).
Results: TULAA was performed in 282 children. Patients were 10,3 years old (1.6; 17.8). There were 233 non-perforated appendicitis (83%) and 49 peritonitis (17%). TULAA completed the procedure in 255 cases (90.5%). Conversion to multiport surgery was required in 26 cases (9%): 14 appendicitis (6%) and 12 peritonitis (24%). Number of added port was: 1 in 15 cases (9 appendicitis and 6 peritonitis) and 2 in 11 cases (5 appendicitis and 6 peritonitis). One conversion to open surgery was needed for peritonitis. Peroperative rupture happened in 8 cases during exteriorization of the appendix. Operative time was 60 minutes (21; 205). Postoperative complications included 1 umbilical wound infection that required debridement under general anaesthesia and 7 intra-abdominal abscesses. The latter complication was treated conservatively in 5 cases, but 2 needed general anaesthesia: 1 for radiological drainage and 1 for a rectotomy. Hospital stay was 2 days
(0; 14) in non complicated appendicitis and 5 days (2; 14) in peritonitis.
Conclusion: TULAA is a feasible technique that can be used safely regardless of the perforation status with a high success rate and an excellent cosmetic result. This procedure should be recommended as a first approach in paediatric population. 




Guillaume Podevin¹, Cynthia Garignon², Francois Bastard¹, Emilie Eyssartier¹, Francoise Schmitt¹

¹Pediatric Surgery Department, CHU, Angers, France, ²Pediatric Surgery Department, St Brieuc, France



Aims: recent advances in laparoscopic surgery lead to use umbilicus as a unique access to perform all the surgical procedure. We report here our first experience in such approach.
Methods: Twenty-five procedures were performed in the last two years. Patients were ranged from 5 months to 16 years old (median 11 y). Procedures types were cholecystectomy (9), splenectomy (6: total 3, splenic cyst unroofing 2, partial 1), bowel resections (3: Crohn diseases 2, pseudo-inflammatory tumour 1), total nephrectomy (4), pyeloplasty (2), and ovarian cyst (1). In 6 young patients, we used a small Alexis wound retractor® (Applied Biomedical) equipped with a glove, 3 to 4 trocars being inserted in the fingers of the glove. For the others 19 patients, we used Gelport® device in 16 cases and Octoport® device in 3 cases.
Results: Operative median time was 93 mn (from 52 to 195 mn) and patients were discharged after 2 days (from 1 to 12 d). Two procedures were converted to classical multi-trocars laparoscopic approach, and we added one 5 mm trocar during 3 others procedures. We didn’t observe any adverse event during the follow up. All parents and old children were happy with the cosmetic result.
Conclusion: This new single access laparoscopic approach, first described in adult surgery, was easily transferred in our hands of paediatric surgeons, even in young children, mainly to removed pathologic abdominal organs. We didn’t observed any specific complications or longer operative time than in classical laparoscopic procedures. 




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