2004, vol.6, no.4, pediatric surgery

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I t was the best of times, it was the worst of times,it was the age of wisdom, it was the age of foolish-

ess, it was the epoch of belief, it was the epoch ofncredulity, it was the season of Light, it was the seasonf Darkness, it was the spring of hope, it was the winterf despair, we had everything before us, we had noth-ng before us.”

The eloquent prose of Charles Dickens in his Tale ofwo Cities appropriately describes how we, as inexperi-nced and neophyte journal editors (see right), felt whensked to embark on the educational endeavor known asperative Techniques in General Surgery. Dickens’ won-erful quote is, as well, an apt reflection on how we haveontinued to feel throughout this journey and how weow feel we as get ready to bid you, our trusted readers, a

ond adieu.As we say farewell, we ponder a number of seeming

mponderables. What made Ms. Livia Berardi decide weere up to the task of orchestrating this educational ex-erience? Only you know if she was correct or not in herelection. What we do know as fact, is that we have beenhe true beneficiaries by accepting her offer. We haveearned legions about all aspects of surgical techniquehat we really thought we knew something about (butidn’t!) and so much more about innovative techniquesmployed by experts in other surgical disciplines. Weave had the honor of relating to so many highly talenteduest editors, contributors, artists, and their support per-onnel. This relationship has indeed been “the best ofimes” and, on occasions, “the worst of times.” They haveiven to us, to Operative Techniques in General Surgery,nd to you, their most precious possession—theirIME—and for this, we are ever in their debt. We have

earned that there are “deadline keepers” and that therere those to whom deadlines are, and always will be,

© 2005 Elsevier Inc. All rights reserved.1524-153X/04/0604-0001$30.00/0

wdoi:10.1053/j.optechgensurg.2004.10.001

perative Techniques in General Surgery, Vol 6, No 4 (December), 2004

ythical. We have learned that surgeons are difficult toet in contact with and that voice mail is impersonal. Weave learned that publishers are becoming mega-publish-rs and, as such, they will have to strive, at all times, to tellhe left hand what the right hand is doing—not an easyask. We wonder about the future of surgical publica-ions—will surgical textbooks/journals and surgical at-ases such as Operative Techniques in General Surgery soone relegated to antiquity in this modern world of elec-ronic wizardry?

With obvious bias and quite unashamedly, we feel thathow to do it” illustrated atlases will always be needednd valued in our highly technical field. If you have eachf the 21 previous issues of Operative Techniques in Gen-ral Surgery on your bookshelf, you have in your posses-ion “General Surgery from A–Z” written by internationalxperts. Although some of these techniques may change,nd even though new techniques will come along (as theyhould), many will not change and these 22 separateournals will be utilized to the benefit of many, manyatients. How fortunate we feel to have made some of thisossible for you and for our patients.We collectively thank the large team, Marilyn Church-

ard in particular, for all the efforts that made this edu-

241: pp 241-242

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242 van Heerden and Farley

ational endeavor possible. More importantly, we thankou, our readers, who have been with us for part of, orerhaps all of, this educational journey. We feel it fittinghat this prefinal issue deals with pediatric surgery—ealing with patients who have their entire lives beforehem and who hold our future in their tiny and preciousands. It is also fitting that our guest editor for this issue

s Dr. Tom Krummel—gentleman extraordinaire.

“tan

Dickens’ prose goes on to state: “We were all goingirect to Heaven, we were all going direct the otheray. . .” You decide!

Jon A. van Heerden, MDDavid R. Farley, MD

Editors

I expect to pass through this world but once, Any goodhereforethat Icando,oranykindnessthat Icanshowtony fellow creature, let me do it now, let me not defer oreglect it, for I shall not pass this way again.”

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Thomas M. Krummel, MD, FACS, FAAP

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Guest Editor

his volume of Operative Techniques in General Surgeryis devoted to surgical problems and operative tech-

iques in children. We have included the types of proce-ures that, while frequently performed by pediatric sur-eons, may also be handled by general surgeons,epending on the nature of their practice. The discussionsre thorough, and the illustrations beautifully depict theechnical aspects of the operations.

Hernias, both umbilical and inguinal, are reviewed bothn their simple form and their complex form by Dr. Robert E.illey and Serene Shereef and by Drs. Tom Tracy and Arleturkchubasche, respectively. The problem of undescended

estes and its treatment with orchiopexy is authored by Rickonkalsrud and his colleagues, Drs. Dunn and Kawaguchi.r. Fonkalsrud has contributed significantly throughout his

areer to the thorough understanding of this problem andas provided us with a superb chapter.Dr. Christopher Moir has covered the various cyst,

inus, and fistula anomalies in the neck. A clear under-tanding of their embryological origins and the anatomi-ally appropriate excision is essential for success; Dr.oir has nicely covered these essentials.During my fellowship training at Pittsburgh, Dr. Mark

avitch opined that the operation for pyloric stenosis was

doi:10.1053/j.optechgensurg.2004.10.002

erhaps the greatest surgical advance of the 20th century,iven the frequency of the condition and the conversion of aatal problem to a complete solution with minimum se-uelae. Drs. Craig Albanese and Doug Miniati discuss theiagnosis and the operative techniques for both the opennd laparoscopic approaches.

Meckel’s diverticulum may present in a variety of ways,ncluding bleeding, intestinal obstruction, or chronic ab-ominal pain. Drs. Karl Sylvester and Denny Jenkins haveonderfully covered the embryology, the multiplicity of

natomic presentations, and the operative approach. Ap-endicitis is one of the most common surgical consulta-ions sought in children. Drs. Whit Holcomb and Danstlie have all of the permutations of appendicitis. Fi-ally, intussusception is presented by Drs. Baird Mallorynd Yale Popowich with very clear illustrations.

I am grateful to each of the authors, all of whom areuperb surgeons, teachers, and scientists. More impor-antly, I am privileged to consider them my friends. Forll of us who are privileged to provide surgical care forhildren, “the patient with no language but a cry” in theords of Willis Potts, it has been an honor to organize this

ssue. Finally, I wish to publicly express my gratitude toavid Farley and Jon van Heerden for this exceptionalpportunity.

Thomas M. Krummel, MD, FACS, FAAP

: p 243

Guest Editor

243

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mbilical Hernia Repair

obert E. Cilley, MD, and Serene Shereef, BS

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n contrast to the vital role played by the umbilicus inutero, it has minimal physiologic importance after

irth. It can be used as a convenient site for vascularccess in newborns; neonatologists use umbilical arterialnd umbilical venous catheters frequently. The umbilicusan be a portal for infection in newborns (omphalitis).he umbilicus is frequently used as an entry site for lapa-oscopic procedures. Its psychological importancehroughout life has been observed in individuals whoave had surgical loss of their umbilicus.1 Persistent um-ilical hernias are the most common umbilical problemncountered by surgeons.

NATURAL HISTORY

mbilical hernias are most often noted after separation ofhe umbilical cord remnant. There are no definitive pro-pective longitudinal studies of umbilical hernias fromirth to adulthood. It is therefore difficult to speculate aso the natural history of this process if hernia repair isithheld. Rupture of the hernia with evisceration is al-ost unheard of. Incarceration of visceral contents is

are. Most (80%) congenital umbilical hernias close spon-aneously within the first 3 years of life. However, umbil-cal hernias may continue to close into childhood. Her-ias with a diameter greater than 1.5 cm are less likely tolose on their own. “Proboscoid” hernias that turn inferi-rly as they protrude are less likely to resolve spontane-usly. Umbilical hernias usually disappear abruptly whenhe fascial defect can no longer admit visceral contents.

After spontaneous closure, the resultant umbilicussually has a natural concave appearance. Occasionally,etained material results in a protruding umbilical stalk.mall unrepaired umbilical hernias in girls may becomeymptomatic during pregnancy when the abdominal walltretches. There is a greater risk of incarceration in adultshan in children.2 Although used frequently in the past,opical applications, straps, trusses, and coins do not pro-ote closure of the umbilical ring and may be injurious.

From the Department of Surgery, Division of Pediatric Surgery, Pennsylvaniatate University College of Medicine, Hershey, PA.

Address reprint requests to Robert E. Cilley, MD, Division of Pediatric Surgery,ilton S. Hershey Medical Center, 500 University Drive, MC H113, Hershey, PA

7033.© 2005 Elsevier Inc. All rights reserved.1524-153X/04/0604-0003$30.00/0

tdoi:10.1053/j.optechgensurg.2004.10.003

44 Operative Techniq

ANATOMY/EMBRYOLOGY

isorders of the umbilicus are due either to the failure oflosure of the umbilical ring or because of the persistencef structures, which usually obliterate before birth. Theormation of the umbilicus takes place in early gestations a result of a fusion of the body stalk containing thembilical vessels and allantois with the extracoelomicolk stalk containing the vitelline (omphalomesenteric)uct and vessels. The fetal midgut normally returns to thebdominal cavity by 12 weeks’ gestation, and the abdom-nal wall closes. The umbilicus closes as mesoderm mi-rates in to form the abdominal wall. Failure of this clo-ure can lead to an omphalocele, hernia of the umbilicalord, or an umbilical hernia. An umbilical hernia is dis-inguished from a “hernia of the umbilical cord.” A herniaf the umbilical cord is similar to an omphalocele in thathere is a defect in the peritoneum as well as a fascialefect and the viscera herniate into the substance of theord itself. In a true umbilical hernia, the hernia protru-ion is composed of peritoneum adherent to the under-urface of the umbilical skin.

The umbilical ring continues to close until birth as theinea alba narrows and the rectus muscles approach the

idline. At birth, the contracted umbilical ring is nor-ally reinforced by the round ligament (umbilical vein),rachus, lateral umbilical ligaments (vestigial umbilicalrteries), and Richet’s umbilical fascia (a subumbilicalxtension of transversalis fascia). Incomplete develop-ent, imperfect attachment, or weak areas in either liga-entous or fascial structures may predispose to hernia-

ion at the umbilicus. The defect is usually noticed withinfew days or weeks after separation of the cord.3 As notedbove, the process of umbilical ring closure can continuefter birth for months or even years.

INCIDENCE

he true incidence of umbilical hernia is unknown becauseost umbilical hernias resolve spontaneously. Race and pre-aturity are predisposing factors with umbilical hernias

ound more commonly in children of African descent. Thencidence of umbilical hernias decreases with advancing age.here is a high familial incidence, but no genetic pattern of

nheritance has been identified. Umbilical hernia is com-only associated with a number of congenital malforma-

ions including thyroid dysgenesis, trisomy 18, trisomy 13,

ues in General Surgery, Vol 6, No 4 (December), 2004: pp 244-252

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245Umbilical Hernia Repair

risomy 21, Beckwith-Wiedemann syndrome, and Hurleryndrome.1

SURGICAL INDICATIONS

n umbilical hernia may cause considerable parental anx-ety and often results in requests for operative repair inarly infancy. Because most umbilical hernias will de-rease in size and close spontaneously, parents can beeassured and operation avoided in most children.4 Par-nts should be reminded not to apply straps, trusses, oroins to promote closure. Parents may associate abdomi-al pain and colic with the presence of an umbilical her-ia, however, an umbilical hernia rarely causes pain.Incarceration and strangulation are absolute indica-

ions for surgical repair. If incarceration occurs, it cansually be reduced manually and the hernia repaired elec-ively.1 Sedation may aid reduction of the hernia. Rupturend evisceration, although extremely rare, require imme-iate operation. Persistence of the hernia is the most com-on reason for operation. If the hernia persists as the

hild approaches school age (4-5 years of age), repair is a

ecommended. Earlier repair (at age 2-3 years) is war-anted if there is no reduction in the size of the herniaefect with serial observations. Fascial defects greaterhan 2.0 cm and “giant proboscoid hernias” should alsoe considered for earlier repair.

PERIOPERATIVE CARE

o preoperative testing is required in healthy children.efore the procedure, the child is kept without oral intakeccording to age and local pediatric anesthetic practices.perative repair is performed as an outpatient procedurender general anesthesia. Local anesthetic infiltration,araumbilical block, or a caudal epidural block can besed to minimize postoperative pain.2 Local/regional an-sthetic administration before the incision may be moreeneficial than at the time of closure. Oral analgesics areiven in the early postoperative period before the localnesthesia wears off. Acetaminophen with codeine maye used for pain control for 24 to 48 hours. Postopera-ively oral fluids can be offered when the patient is fully
wake and alert.

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246 Cilley and Shereef

SURGICAL TECHNIQUE

The incision. After appropriate skin preparation and application of sterile drapes, a curvilinear incision is marked in a naturalkin crease within or immediately below the umbilicus. The incision can often be hidden along or within the lower umbilical foldnd need not be placed conspicuously on the abdominal wall skin. Grasping the redundant umbilical skin and applying traction tohe abdominal wall facilitates the incision. The curved incision should not extend beyond 180°.

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Dissection of the hernia sac. The subcutaneous tissue is incised and bleeding points controlled with fine tip electrocautery. Aissection plane is present between the subcutaneous fat and the hernia sac that leads to the fascial ring at the level of the abdominalall. Any contents in the sac are reduced into the peritoneal cavity. With upward traction on the inner margin of the upper edge of

he incision, dissection is performed in this plane along the sac to the level of the anterior abdominal wall fascia. The sac is dissectedircumferentially by blunt dissection with a fine clamp. The plane of dissection is developed superiorly on either side of the sac untilhe sac is encircled. The sac is either transected or detached from the under-surface of the umbilical skin. It is important to avoidenestration of the skin at the base of the umbilicus. The dissection of the hernia sac is extended into the plane between thebdominal wall fascia and the subcutaneous tissue of the abdominal wall for a variable distance. The dissection is limited to theinimum distance that allows closure of the fascia without distortion of the periumbilical skin.

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Repair of the defect. (A) The hernia sac is elevated, opened (if not already done) and inspected. Occasionally other umbilicalbnormalities will be encountered such as urachal remnants or omphalomesenteric remnants and should be excised/repaired.


3 (B) The rim of the defect is identified and the sac incised to allow placement of sutures starting at one corner.

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(C) The remainder of the sac is excised and fascial sutures placed sequentially until the entire defect is controlled. Sutures areot initially tied to maintain control of the edge of the defect and avoid visceral injury. All of the sutures are then tied. Sutureaterial may be either absorbable or nonabsorbable and is chosen according to the size of the patient (3-0 for infants and young

hildren, 2-0 for older children and teenagers).

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Simple umbilicoplasty. Thembilicus is maintained in inversiony placement of sutures between theermis and the fascial closure. Thendersurface of the redundant um-ilical skin is tacked to the anteriorbdominal wall fascia with one orwo interrupted 4-0 absorbableutures.

5 Closure. A running fine absorb-able suture is used to close the der-mis. Skin sutures that require re-moval are avoided. Many pediatricsurgeons use flexible collodion todress the skin.5 A pressure dressingis applied and left in place for severaldays to prevent a wound hematoma.

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DISCUSSION

omplications are uncommon, but wound hematomand wound infection (1%) occasionally occur.4 Recur-ence is rare. Wound infection makes recurrence moreikely. The umbilicus may not have a perfectly naturalppearance after operation and some patients are dissat-sfied with the appearance. Supra-umbilical, epigastricernias may occur alone or in conjunction with an um-ilical hernia and should be repaired concurrently. A su-ra-umbilical incision allows both defects to be repaired.It is interesting to note that there is a wide range of

echnical variation in an operation that is performed soommonly. Some of the common technical alternativesre discussed below.

1. Closure of the fascia: The fascial closure can beerformed using a closed technique. The sac is sharplyetached from the umbilicus and inverted. The fasciadges are approximated without entry into the perito-eum and the sac is never opened. The dermis underlyinghe center of the umbilicus is secured to the fascia toestore the normal umbilical contour.

2. The distal sac can be left on the undersurface ofmbilical skin.3. A two-layer closure of the fascia may be performed

ither by imbricating the initial suture line or by overlap-ing the edges of the fascia.4. Fascia may be closed in either a horizontal or a

ransverse fashion. Either absorbable or nonabsorbable
uture material may be used. 5
5. The operation can be performed through the base ofhe umbilicus rather than through the traditional curvi-inear incision below the umbilicus. A supraumbilicalncision is also acceptable.

6. Excess or redundant skin can simply be ignored andhe base of the umbilicus tacked to the fascia. The naturalistory of such repairs is unknown. Redundant skin canlso be excised and a formal umbilicoplasty performedsing a variety of techniques. These techniques are par-icularly useful in the case of a large proboscoid hernia.

The true outcomes of umbilical hernia repair have noteen studied in a long-term, prospective manner. It is notnown whether any of the technical variations listedbove result in fewer complications or improved long-erm appearance.

REFERENCES. Cilley RE, Krummel TM: Disorders of the Umbilicus, in O’Neill JA,

Rowe MI, Grosfeld JL, et al (eds): Pediatric Surgery (ed 5, vol 2).Baltimore, MD, Mosby, 1998, pp 1029-1043

. Garcia VF: Umbilical, other abdominal wall hernias, in Ash-craft KW, Murphy JP, Sharp RJ, et al (eds): Pediatric Surgery(ed 3). Philadelphia, PA, W.B. Saunders Company, 2000, pp651-653

. Shaw A: Disorders of the umbilicus, in Welch KJ, Randolph JG,Ravitch MM, et al (eds): Pediatric Surgery (ed 4, vol 2). Chicago, IL,Year Book Medical Publishers, Inc, 1986, pp 731-739

. Grosfeld JL: Hernias in children, in Spitz L, Coran AG (eds): Rob &Smith’s Operative Surgery. Pediatric Surgery (ed 5). New York, NY,Chapman & Hall Medical, Lippincott Williams & Wilkins, 1995,pp 232-236

. Singh G: Technical Bulletin, Collodion: http://surgery.psu.edu

http://surgery.psu.edu

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rlet G. Kurkchubasche, MD, and Thomas F. Tracy, Jr, MD
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epair of the infant hernia is one of the principal opera-tions in pediatric surgery, requiring a meticulous and

tandardized technique. Although simple in concept, theepair is technically demanding as the surgeon attempts toinimize unnecessary trauma to ilio-inguinal and genito-

emoral nerves and the structures of the spermatic cord, allhile operating through small skin incisions and dissecting

ven finer structures. Expert pediatric surgeons will oftenerform the procedure with magnification for precision andontrol. While the technique of indirect hernia repair isonstant across the ages, the repair in the premature infantoses particular operative challenges because of the fragileature of the hernia sac and the short length of the inguinalanal. In the following series of diagrams, a technique isutlined in which a sequential series of interventions areerformed stepwise after identification of critical anatomicandmarks.

The principles of infant hernia repair are based on thenowledge that an indirect inguinal hernia develops as aonsequence of persistent patency of the processus vagi-alis. There is no associated defect in the fascia or mus-ulature related to the inguinal canal, therefore, high li-ation of the sac is essential and sufficient for repair.irect inguinal hernias and femoral hernias occur only

arely in children, and when encountered, are dealt withy applying standard adult repair techniques. A primaryepair for direct hernia, however, is typically accom-lished without the use of mesh in children.In view of the preponderance of indirect hernia, this dis-

ussion will focus on its operative management. The opera-ion can be approached via a 1 to 3 cm incision in an inguinalkin crease just superior to the palpated external ring. Theuperficial tissues that are exposed are mobile and can easilye retracted to expose the essential anatomic elements. Con-eptually, the operation proceeds by a combination of bluntnd sharp dissection through successive layers of fascia toeach the hernia sac and finally separate it from the remain-er of the spermatic cord structures.

From the Department of Surgery, Division of Pediatric Surgery, Brown Medicalchool, Providence, RI.

Address reprint requests to Thomas F. Tracy, Jr, MD, Department of Surgery,ivision of Pediatric Surgery, 593 Eddy Street, HCH 147, Providence, RI 02903.© 2005 Elsevier Inc. All rights reserved.1524-153X/04/0604-0004$30.00/0

tdoi:10.1053/j.optechgensurg.2004.10.004


DIAGNOSIS AND TIMING OF REPAIR

he diagnosis of infant hernia is made on the basis of theistory provided by the parent or pediatrician and physicalxamination. Asymmetry of the inguinal region with a re-ucible mass is diagnostic. In a boy, the physical examina-ion must also document whether there is an associatedydrocele and whether both testes are descended. The pres-nce of a noncommunicating or otherwise static hydrocele,n the absence of a hernia, does not require operative inter-ention until the hydrocele has demonstrated persistencehrough the age of 18 to 24 months. A communicating hy-rocele, defined by variation in scrotal size, a palpable thick-ning of the cord and a subtle “silk string sign” representinglarger patent processus, is best closed if it persists through

he first year. Occasionally a well-defined hydrocele of theord may mimic a hernia, presenting a diagnostic dilemmahat can be solved by manually verifying that the proximalanal is empty. Incomplete descent of the testis, particularlyn the premature infant, is usually associated with a herniand careful expectant management is often advised so as tovoid the potential complications associated with an orchi-opexy at this early stage.The timing of infant repair should generally occur within

everal weeks of diagnosis to minimize the risk of incarcer-tion which is greater in the first months postnatally. For theospitalized premature infant, repair is traditionally delayedntil the child approaches discharge. Even then, delay maye desirable if some of the comorbidities, particularly pul-onary compromise, are expected to substantially improve

r resolve within a period of months. However, once annfant or child presents with incarceration and a reduction isccomplished, prompt operative repair is recommended.he repair of the irreducible incarcerated infant hernia ishallenging, as the integrity of the sac and the identificationf the vas deferens and vessels is further compromised bynflammation and edema.

In the infant girl, incarceration can involve the ovaryather than the intestine. This diagnosis is made on pal-ation of a slippery almond shaped mass in the labiumajora. Despite this incarceration, these infants appear

linically well and can undergo a semielective repair, usu-lly the following day.

EVALUATION OF THECONTRALATERAL CANAL

en percent of childhood hernias are bilateral at presen-
ation. This number may vary with age with the highest
253: pp 253-268

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254 Kurkchubasche and Tracy

eports of bilaterality observed in preterm infants. Sur-eons have speculated that a routine exploration of theontralateral canal should yield a predictable incidence ofatent processus and undiagnosed hernias. With the ad-ent of laparoscopy, the technique for exploration be-ame a topic for controversy.1 Ultimately, a more practi-al perspective returned to focus on the true incidence ofetachronous hernia rather than asymptomatic patency

f the processus. For all but premature infants, this num-er has now been demonstrated to be 10% to 12% androvides a basis for justifying whether operative and an-sthetic risks are such that contralateral exploration,pen or laparoscopic, is even warranted.2

ANESTHETIC ANDPAIN MANAGEMENT

ernia repair in children is performed as an outpatientperation under general anesthesia. The airway may be
ontrolled by bag mask ventilation, laryngeal mask air- m
ay, or endotracheal intubation depending on the age,ize and comorbidities of the patient. Spinal anesthesia inome institutions is reserved for those premature infantsn whom pulmonary morbidity is such that intubationould be associated with prolonged postoperative depen-ency on mechanical ventilation.Techniques for optimizing perioperative analgesia in-

lude infiltration of lidocaine or bupivacaine to block thelioinguinal nerve and caudal blocks in children underne year of age. Acetaminophen or ibuprofen, with orithout codeine, is provided for postoperative analgesia

n the outpatient setting. Criteria for prolonged or over-ight observation are based on the risk for apnea and/orradycardia related to prematurity. The former prema-ure infant under 50 weeks corrected gestational age isenerally admitted for cardiac and respiratory monitor-ng. Term infants have minimal risk for post anestheticpnea beyond the 90 minutes of immediate postoperative
onitoring.

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255Inguinal Hernia/Hydrocele

SURGICAL TECHNIQUE

t is advisable to perform the operation wearing oper-ting loupes to provide adequate magnification

to visualize the critical elements in this opera-tion.

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(A) After induction of anesthesia, antiseptic skin preparatihould allow for access to the scrotum and to the abdomen foanal is palpated and the transverse incision is situated in thexternal ring. The length of the incision can vary from 1 to 3 c

completed encompassing the abdomen and genitalia. Drapinger approaches in cases of incarceration. The affected inguinalest skin fold immediately over the canal and superior to thepending on the patient’s size.

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(B) The subcutaneous tissues are separated bluntly using the Metzenbaum scissors, exposing Scarpas’s fascia which is graspedith atraumatic forceps and incised. Placement and spreading of the scissors in this opening then allows the insertion of retractors

o expose the external oblique fascia.

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This exposure is now maintained with the insertion of two pyloric, Senn, or similar retractors. The operating surgeon holds theateral retractor, while the assistant exerts gentle countertraction medially. Dissection over the anterolateral aspect of the externalblique exposes fine areolar tissue that is bluntly swept laterally with the Metzenbaum scissors, revealing the true lateral bordergroove) of the external oblique. By following the groove formed by the fascia distally, a point is reached at the external ring whereissue exiting from the external ring creates an acute angle toward the thigh. This landmark can be verified by pushing closed

etzenbaum scissors or a blunt instrument against the anterior fibers of the external oblique. Once this landmark has been defined,nly then is an incision made in the external oblique fibers. Occasionally, a skin incision made too medially or failure to determinehe lateral groove will result in dissection of the distal rectus fibers rather than the external oblique. This places the bladder and the
ransversalis at risk in a “lost dissection” via a small incision.

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After the external oblique incision is created with a #15 scalpel blade, the Metzenbaum scissors are again used to define theanal by passing the tightly closed blunt tip subjacent to the external oblique fascia into the scrotum or labia. This action also resultsn separating the ilioinguinal nerve from the undersurface of the fascia. The incision is extended distally with the Metzenbaum
cissors through the external ring, and then proximally to the level of the internal ring.

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Grasping the incised edges of the external oblique, the cremasteric fibers, hernia sac, and contents of the cord are exposed. The
lioinguinal nerve is visualized and dissected free.

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Using two atraumatic forceps, the surgeon now holds some cremasteric fibers while with the other forceps separates the fiberso reach deeper to elevate the hernia sac, vas and spermatic vessels. The sac is suspended by one or preferably two forceps, held by
n assistant, while another forceps sweeps the muscular fibers downwards allowing more sac to become visible.

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As the sac and cord structures are elevated, an inverted V-shaped aperture becomes evident under the canal contents. Forcepsr a hemostat can then be passed through this aperture to elevate all of the cord and keep the relevant structures at the skin woundevel for the retractors to be removed. Care must be taken to avoid injury to the floor of the inguinal canal, as the forceps are passed
nder the cord structures and hernia sac.

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The assistant continues to grasp the sac with two atraumatic forceps and suspends it on an incline toward the midline. By gentlyulling or scratching the tissue on the surface of the suspended sac with open atraumatic forceps, the surgeon searches for a smallad of fat that acts as a reliable landmark for the spermatic fascial plane separating the sac from the cord structures. The assistantontinues to maintain the sac on some traction in the medial position. Once identified, this fatty tissue is elevated laterally, openinghe fascial plane, which allows the surgeon to lift the cord structures off the surface of the sac. The spermatic vessels are the firsttructures identified on the lateral aspect of the sac and are often quite separate from the vas deferens that enters the canal from theosteromedial aspect at the internal ring. The assistant surgeon helps by regrasping more of the exposed hernia sac as it is dissected,hereby “rolling” it medially. Here the spermatic cord is simply draped over the surgeon’s finger for the purpose of demonstrating
he dissection plane.

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These spermatic cord elements are bluntly separated from the sac without ever grasping them with an instrument. Once theorceps have successfully passed between the sac and spermatic cord structures, a vessel loop, Allis clamp or other suitableetracting device encompasses the cord structures to deflect them inferiorly and laterally toward the ipsilateral knee. The distal endf the sac may now be evident and can be grasped with forceps or a hemostat. If the sac extends into the scrotum it is reasonable toivide the sac between clamps at this point, provided there is sufficient proximal and distal separation from the vessels and vaseferens. The spermatic cord and proximal portion of the sac are suspended vertically, allowing for the best visualization of the

nvesting spermatic fascia. The spermatic fascia has greater tensile strength than the sac at this level and is best divided withne-tipped scissors rather than by blunt dissection. The edge of the hernia sac and spermatic cord structures must be clearly
isualized during this sharp dissection.

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The proximal end of the sac is reflected toward the superior aspect of the wound, separating it from the cord structures thatontinue to be retracted laterally and toward the ipsilateral knee. This exposes the residual spermatic fascial investments of thepermatic cord and hernia. Note the diaphanous nature of the sac on its posterior aspect approaching the internal ring. Here it is theost vulnerable to disruption, which must be recognized promptly and controlled such that the final ligature is beyond or proximal

o a tear, to avoid a recurrence of the hernia. Division of this layer of tissue allows the sac to be completely separated from the vas
nd vessels at the level of the internal ring, recognized by the presence of preperitoneal fat.

1c


0 Proximal dissection of the sac to the internal ring may reveal either a very narrow neck or a wide base that must be carefully
onsidered as the dissection is completed.

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1 The sac is held perpendicular to the wound and is then doubly ligated with a simple tie proximally and suture ligature distallysing suture material of the surgeon’s choice, typically silk or vicryl (polyglactin 910). Although some surgeons opt to twist the sacefore placing the ligature, this maneuver can inadvertently pull the vas deferens into the ligature. The excess sac is then transectedell above the ligature and the sutures are cut resulting in complete retraction of the hernia stump to the level of the peritoneum

djacent to the internal ring. This provides further confirmation that a high ligation was achieved. Closure of the internal ring is notecessary unless there is a large aperture in a premature infant with a very short inguinal canal. In the repair of a hernia in female

nfants, it is important to realize that the extension of the suspensory ligaments into the sac can bring the fallopian tube close to thenternal ring, placing it at risk with blind high ligation of the sac. A Potts-Goldstein flap type repair using a prolene pursestringuture is often advisable and the internal ring is then tightened or closed completely.

The distal portion of the sac is now separated to the extent possible from the distal structures taking care to avoid the pitfall ofserpentine vas deferens. If incompletely resected, the edges of the sac are grasped and examined for any bleeding points requiringinimal cautery. The vessel loop retracting the cord structures is released and the cord structures are returned into the canal by

lacing traction either directly on the testes or indirectly via the gubernaculum from the scrotal skin. It is important to assure that
he testis is correctly situated within the scrotum beyond the pouch of Dennis Browne to avoid postoperative cryptorchidism.

1waww


2 The pyloric retractors are re-inserted and the previously prepared edges of the external oblique fascia are reapproximatedith interrupted absorbable suture material. If a preoperative ilioinguinal nerve block was not performed, the block can be

dministered under direct vision either at the time of opening the external oblique or on closure. Scarpas’s fascia is reapproximatedith a single buried suture and skin is closed with a subcuticular stitch. Mastisol or benzoin is applied before covering the incision
ith steristrips. Alternatively the wound is sealed with collodion or other dressing.

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VARIATIONS AND PITFALLS INOPERATIVE TECHNIQUE

Female infant hernia repair. Once the sac israsped between the internal oblique fibers, it is elevatednd will expose an artery on its posterior surface. Thisessel should be carefully separated from the sac to avoidemorrhage on transection of the sac. If the sac is empty,hen the distal end can be clamped and transected withlectrocautery, releasing it from its ligamentous attach-ents to the labia. Alternatively the sac can be divided

etween clamps. The proximal extent of the sac is dis-ected to the level of the internal ring. Care should beaken to avoid overzealous traction on the proximal sac ashis can bring the adnexal structures, particularly theallopian tube, close to the level of ligation. It is advisableo visually inspect the interior of the sac at the level ofigation. If the round ligament is very prominent at thisevel no attempt should be made at separation of this fromhe sac. If the fallopian tube is found to be present, then itust be dissected along its borders from the posterior sac.his flap is then turned in allowing for a Potts-Goldsteinepair performed using a fine prolene pursestring sutureo the remainder of the sac. The internal ring should beightened or closed to prevent hernia recurrence in thisnstance.

Another pitfall in the repair in girls is that bilateralernias may be encountered with the androgen insensi-ivity syndrome (Testicular Feminization Syndrome).his diagnosis can be excluded by either visualizing thevary or fallopian tube at the time of hernia repair or moreimply by verifying the presence of a palpable cervix via aectal examination under anesthesia.

Incarcerated hernia repair. If reduction of the in-arcerated intestine does not occur spontaneously withnduction of anesthesia, then the intestine should not beeduced manually so as to allow for visual inspection ofecrosis or significant ischemia of the bowel. The overly-

ng soft tissues are typically edematous and friable. Sinceircumferential control of the sac is often impossible, the
dges of the opened sac are grasped with fine hemostats as
t is opened on its medial aspect to inspect the incarcer-ted intestine. Once reduced, the sac is then dissectedrom the cord structures and controlled more proximallyor a standard high ligation. It is very important to exam-ne and document the viability of the testis in the scenariof incarceration, as it may have undergone ischemic ne-rosis from venous congestion. If the intestine reducesnto the abdomen before complete inspection, one mayncounter chylous or bloody fluid from the abdomen.his finding in isolation does not mandate laparotomy,owever, close observation of the patient for obstructionr peritonitis is advisable. Surgeons should be comfort-ble with the need for other abdominal incisions in theidline or right lower quadrant (Laroque maneuver) to

id in manual reduction of incarcerated intestine.

CONCLUSION

epair of infant and childhood hernia can be accom-lished with little morbidity and mortality. Complica-ions such as bleeding and infection are expected to occurith less than 1% incidence. Recurrence rates are quoted

n the context of the age at repair. In the preterm neonatehis may approach 5% when additional comorbiditiesuch as bronchopulmonary dysplasia are present. In theealthy infant or child, it is expected to occur less than 1%f the time. It is standard procedure in many institutionso send the sac for pathologic examination, this serves as

method for screening for injury to the vas deferens.owever, injury is recognized by the experienced sur-eon at the time of operation and allows for expert con-ultation for the potential for microanastomosis. Occa-ionally a child without a vas deferens is identified. Thishould prompt a medical evaluation for cystic fibrosis.

REFERENCES. Miltenburg DM, Nuchtern JG, Jaksic T, et al: Laparoscopic evalua-

tion of the pediatric inguinal hernia: a meta-analysis. J Pediatr Surg33:874-879, 1998

. Tackett LD, Breuer CK, Luks FI, et al: Incidence of contralateralinguinal hernia: A prospective analysis. J Pediatr Surg 34:684-687;
discussion 687-688, 1999

U

Ja

Scsrpdtoch

At

SC

O

ndescended Testes/Orchiopexy

ames C.Y. Dunn, MD, PhD,1 Akemi L. Kawaguchi, MD,2

nd Eric W. Fonkalsrud, MD1

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tsetrusai

urgical management of the undescended testis is per-formed to prevent the potential complications of

ryptorchidism. When feasible, surgical correctionhould be performed at 1 to 2 years of age because laterepair commonly results in increasingly more severe im-airment of seminiferous tubular development and re-uced spermatogenesis. Although orchiopexy increaseshe potential for fertility, it does not restore the spermat-genesis to normal levels and does not abolish the in-reased risk of developing testicular cancer.1 Orchiopexy,owever, does allow for earlier detection of neoplasms by

From the 1Department of Pediatric Surgery, UCLA School of Medicine, Losngeles, CA; and 2Department of Surgery, Massachusetts General Hospital, Bos-

on, MA.Address reprint requests to Eric W. Fonkalsrud, MD, Professor, Department of

urgery, Emeritus Chief of Pediatric Surgery, UCLA School of Medicine, 10833 Leonte Avenue, Room 72-126, Los Angeles, CA 90095.© 2005 Elsevier Inc. All rights reserved.1524-153X/04/0604-0005$30.00/0

idoi:10.1053/j.optechgensurg.2004.10.005


elf-examination of the testicles. Other problems associ-ted with cryptorchidism include inguinal hernia and,ccasionally, testicular torsion. The success of treatmentepends on the position of the testis at diagnosis withuch better results being achieved with testes located in

he low inguinal canal. Laparoscopic approaches to diag-osis and repair may hold the promise of improved out-omes for high positioned testes.2,3

The most significant complication of orchiopexy is tes-icular atrophy. Injury to the spermatic vessels, or exten-ive downward traction during repair, can cause postop-rative venous congestion or ischemia with resultantesticular atrophy. Although this is a rare complication ofoutine orchiopexy, published reports indicate an 8% fail-re rate of orchiopexy, even in the distally situated unde-cended testis, and failure of more than 25% for intra-bdominal testes. Other infrequent complicationsnclude ascent of the testis requiring a second orchiopexy,
nfection, and bleeding.
269: pp 269-280

1fTv

270 Dunn et al

INGUINAL ORCHIOPEXY: SURGICAL TECHNIQUE

For undescended testes that are palpable, orchiopexy is performed through an inguinal incision slightly longer than that used
or inguinal herniorrhaphy. Because the length of the spermatic vessels is shorter than normal, the descent of the testis is limited.he objective of the repair is to change the course of the spermatic vessels such that they extend from their origin near the renal ascular pedicle to the scrotum, instead of the triangular course through the internal inguinal ring and the inguinal canal.

2o

271Undescended Testes/Orchiopexy

With the patient lying in the supine position, an oblique skin incision is made through the lowermost abdominal skin crease
ver the inguinal ligament.

3iii

272 Dunn et al

The undescended testis is usually positioned at or near the external ring and may extend through the ring into the superficialnguinal pouch. The external oblique fascia is exposed and incised from the external ring along the direction of the fibers to thenternal ring. The testis and its tunica vaginalis are mobilized from the gubernaculum and attachments to the pubis up to the
nternal inguinal ring.

4Trfn


The cremaster muscle is dissected from the spermatic vessels and the vas deferens is mobilized to the level of the internal ring.he internal oblique is divided just lateral to the internal ring, and the transversalis fascia is opened widely to expose theetroperitoneum. The inferior epigastric vessels are ligated and divided. The accompanying indirect inguinal hernia sac is separatedrom the spermatic vessels and the vas. This maneuver may be facilitated by injecting a small amount of saline through a 26-gauge
eedle between the hernia sac and the cord structures.

5abu

274 Dunn et al

A high ligation of the sac is performed with a transfixion suture. The testicle and epididymis are carefully examined for anybnormalities. The remaining tunica is closed loosely over the testis. The mobilization is continued into the retroperitoneal spacey elevating the peritoneum using blunt dissection. The lateral spermatic fascia is divided, and the spermatic vessels are mobilized
p near their origin high in the retroperitoneal space.

6smoiita


The scrotum is stretched by inserting a blunt clamp, and then a finger through the wound into the lowest portion of thecrotum. A small incision is made through a scrotal skin crease in the most dependent position, and a space between the dartosuscle and the scrotal skin is developed to accommodate the testis. An opening is then made in the dartos layer to allow the passage

f the untwisted spermatic cord and testis into the newly created space. The upper edge of the tunica is anchored to the dartos fascian a circumferential manner with interrupted nonabsorbable sutures to minimize the risk of retraction or torsion. The scrotal skins closed with fine absorbable sutures. The transversalis fascia is closed, leaving a small opening adjacent to the pubis to serve as bothhe internal and external inguinal rings, and to allow the passage of the spermatic cord. The internal and external oblique muscles
re re-approximated in layers in the same manner as used for inguinal herniorrhaphy.

7atiaptsl

276 Dunn et al

LAPAROSCOPIC ORCHIOPEXY: SURGICAL TECHNIQUE

For a nonpalpable testis, laparoscopy is useful for both diagnosis and treatment. Laparoscopy can be utilized to locate the testiss well as to facilitate orchiopexy or ligation of vessels. If the nonpalpable testis is not located in the abdomen, it is likely that theestis has vanished secondary to prenatal torsion. With the patient lying in the supine position, an umbilical port is inserted to allownsufflation of the abdomen. The testis is usually found within 1 cm of the internal ring. If the testis is absent and the vas and vesselspproach the internal ring, then the testis has atrophied. If neither the vas nor vessels are seen, then additional ports should belaced to locate the testis higher up in the abdomen. If the testis is deemed too high to be brought down in a single stage procedure,hen the spermatic vessels may be ligated to allow for neovascularization of the testis in the next 6 months in preparation for the
econd stage of a Fowler-Stephens orchiopexy. After locating the testis with the laparoscope, two additional ports are placed at the evel of the umbilicus along the mid-clavicular line.

8ts


The gubernacular attachment is grasped and transected to begin mobilization of the testis. The dissection is carried medially tohe bladder, incising the peritoneum well above the vas, and laterally the peritoneum is incised along the pelvic wall along the
permatic vessels.

9cAl

278 Dunn et al

This peritoneal release provides additional length for the testis to reach the scrotum and leaves a broad strip of peritoneum inase the division of spermatic vessels is needed. An incision is then made in the scrotum to develop a space over the dartos muscles.

scrotal port that goes from the dartos pouch to the abdominal wall near the pubic tubercle, medial to the median umbilical
igament, is used to bring the mobilized testis down to the scrotum.

1s


0 The internal ring is usually small and will close spontaneously. The testis is anchored to the dartos fascia with interrupted
utures circumferentially. The scrotal skin is approximated with fine sutures.

1

2

3

280 Dunn et al

REFERENCES

. Jordan GH, Winslow BH: Laparoscopic single stage and staged
orchiopexy. J Urol 152:1249-1252, 1994
. Hadziselimovic F: Cryptorchism, its impact on male fertility. EurUrol 41:121-123, 2002

. Holcomb GW III: Diagnostic laparoscopy for contralateral patentprocessus vaginalis and nonpalpable testes. Semin Pediatr Surg
7:232-238, 1998

ND

C

Ustrdflo1occset

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S

O

eck Cysts, Sinuses, Thyroglossaluct Cysts, and Branchial Cleft Anomalies

hristopher R. Moir, MD

aw

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ddpidmrswumia

TS

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CT

nlike benign masses in other locations where simpleexcision is often the preferred method of diagnosis,

uch an approach in the neck may result in chronic infec-ion and draining tracts. The surgical approach to pediat-ic neck masses requires a thorough understanding of theiagnostic possibilities and the anatomic implications be-ore making the incision. Sistrunk understood this di-emma after observing high recurrence rates with removalf thyroglossal duct cysts. His operation, published in928,1 was based on the anatomic and embryologic factsf thyroid descent through or around the hyoid bone. Theombination of accurate preoperative diagnosis and spe-ific anatomic knowledge remains the standard for neckurgery today. Fortunately, the preoperative diagnosticvaluation is straightforward, and when followed, opera-ive outcomes are excellent.2

PREOPERATIVE EVALUATION

ediatric neck masses are conveniently classified as mid-ine or lateral (Table 1). Branchial cleft and thyroglossaluct anomalies are found with equal frequency in chil-ren and make up about half of all surgically excised neckasses.2 Occasionally, a cyst may appear on the border of

he other’s territory requiring additional differentiatingeatures of the history and physical examination plus ul-rasound.3 Indications for operation are increasing size,nfection, diagnostic uncertainty, and prevention of infec-ion or cancer.4

idline Neck Massesn the upper midline, thyroglossal duct cysts are the mainoncern, directing all investigations to its diagnosis.here is always a concern for the rare lingual thyroid;owever, the typical cyst is an isolated anomaly residinglose to the hyoid bone. Other masses close by includeubmental lymph nodes found higher in the neck justeneath the chin, and dermoid cysts that can be anywhere

From the Division of Pediatric Surgery, Mayo Clinic, Rochester, MN.Address reprint requests to Christopher R. Moir, MD, Division of Pediatric

urgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.© 2005 Elsevier Inc. All rights reserved.1524-153X/04/0604-0006$30.00/0

mdoi:10.1053/j.optechgensurg.2004.10.010


long the midline including below the thyroid cartilagehere thyroglossal duct cysts are very rare.Warning signs for unusual thyroglossal anomalies in-

lude a history of other congenital head and neck disorders,ysphagia, voice changes, or hypothyroidism. Any of theseigns mandate further studies including direct laryngoscopynd thyroid scans.5 In the absence of such concerns physicalxamination of the head, neck, mouth, and pharynx is suf-cient. Most children willingly tilt their heads back to dis-lay a prominent smooth round mass near the hyoid bonehat moves with swallowing. Unless infected, it is usually notender or erythematous. Parents may discover the cyst asheir child begins to grow and the neck assumes a morechool-age appearance at two or 3 years of age. Ultrasoundvaluation is simple and straightforward, confirming theystic nature of the mass and excluding more problematicssues such as ectopic thyroid tissue.3,5

Dermoid cysts in the upper midline may not be easilyifferentiated from thyroglossal duct anomalies. Mostermoids are found close to the deep cervical fascia andresent as smooth round masses that move with swallow-ng. Movement with tongue protrusion may be a helpfulifferentiating finding. If all investigations fail to deter-ine which is which, the surgical guidelines follow thy-

oglossal duct cyst excision. Although it may seem exces-ive, a Sistrunk procedure is recommended as the safestay to excise the cyst.3 At operation, dermoid cysts aresually yellow-orange, firm, disc-like masses that lookuch different than the typical thyroglossal duct cyst, but

f infected or for other reasons not easily identified, theyre removed in continuity with the hyoid bone.

Submental lymph nodes typically occur in groups and

Table 1. Classification of Pediatric Neck Masses

Midline Lateral

hyroglossal duct anomaly Branchial cleft anomalyubmental lymphadenopathy Lymphatic/vascular

malformationermoid and epidermoidcysts

Lymphadenopathy

ervical cleft Thyroid noduleeratoma Thymic cyst

LaryngoceleBenign soft tissue tumorsSialadenitis

ay be associated with an intercurrent illness. The nodes are

281: pp 281-295

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282 Christopher R. Moir

ocated directly beneath the chin and do not move withwallowing. They are smooth, round, rubbery, mobile nod-les that have a typical appearance on ultrasound imaging.ubmental lymphadenitis comes and goes relatively quickly,aking observation an excellent approach when the diag-osis is suspected. Persistent lymphadenopathy may lead toxcisional biopsy especially if a chronic infection such astypical mycobacteria is considered.

ateral Neck Masseshe lymphatic system is responsible for the vast majorityf normal and abnormal lateral neck masses.5 There isormal but sometimes alarming lymph node prominence

n preschoolers whose necks have slimmed down withrowth spurts. These nodes are not matted or fixed, butay be quite sizable nearing 2 cm in diameter on average.ystic hygromas or other lymphoid malformationsresent during infancy in the lateral neck, most classicallyn the posterior cervical triangle. Infectious lymphade-opathy in childhood becomes problematic during theoddler years while malignant infiltration with lymphomaccurs later in childhood or adolescence. Metastatic dis-ase with neuroblastoma and soft tissue sarcomas canccur early but there are usually other features that lead tohe diagnosis. History and physical examination differen-iate most lymphatic conditions, open biopsy is indicatedor persistent enlarging, matted, fixed, or chronically in-ected lesions.

Branchial cleft anomalies, while much less commonhan lymphadenopathy, occur with about equal fre-uency to thyroglossal duct lesions and excite the mostnterest as lateral neck masses.2 The second branchialleft is responsible for almost 90% of lesions, arising as astula in young children or as a cyst in the older child anddolescent.5 Parents point out a small punctate openingn the anterior border of the sternomastoid muscle in theower one-third of the neck, noting daily drainage andntermittent inflammation. Physical examination is use-ul to confirm this finding and the absence of any otherbnormalities. The tract may be palpable as the childtretches their neck. Such branchial cleft fistulas may beafely excised up to the root at the tonsillar fossa. Younghildren do well with just one small neck incision anduture ligation at the internal opening site. When exci-ion is contemplated the younger child fares better forase of operation, complete excision, and cosmetic place-ent of the incision.Before operation in the lower lateral third of the neck,

hyroid tumors and the rare thymic and parathyroid cystsust be ruled out. Again, ultrasound is a helpful adjunct

o physical examination. Fine needle aspiration is usuallyeserved as a second-line option for children who regarduch investigations as equivalent to surgery. Neverthe-ess, great care should be taken to make the diagnosis
efore operation. If a cystic lesion is still in doubt at the m
ime of excision, the surgeon performs a careful search fortract and, if discovered, follows the expected anatomic

ine based on its presumed embryologic origin.First branchial clefts may present as a fistula coursing

hrough the parotid gland in close association with theacial nerve. These make up less than 10% of the branchialnomalies. Branchial cysts may be confused with parotidumors but both require superficial parotidectomy andacial nerve dissection for control. The key is to rememberhe internal connection to the auditory canal.6

The rare third branchial cleft anomalies are found inhe same general location as second cleft cysts but on theeft side close to the upper pole of the thyroid. Whennfected these are the lesions that masquerade as suppu-ative thyroiditis. If an external opening is present it islose to the second cleft. There may be a fourth branchialleft anomaly as well and its cystic anlage also resides inhe lower one-third of the neck. Other branchial cleftnomalies in the low neck are seen in the sternal notchnd at the head of the clavicle. These are usually skin andartilage remnants with small, short sinus tracts that dis-ppear in the mediastinum without major connection ton epithelial-lined surface.3

Torticollis is an infiltrating fibrotic condition of theternocleidomastoid muscle that presents as a hard, solid,ery worrisome mass in the young infant. By examinationt has every aspect of an infiltrating sarcoma, but theseumors are benign and resolve with physical therapy.onfirmation of torticollis includes the discovery nearirth of a sternocleidomastoid mass that is associated withpsilateral plagiocephaly and the classic head position: theace is turned to the contralateral side while the ear andhoulder on the ipsilateral side are preferentially heldlose together. When these signs are present, the diagno-is is made on physical examination alone. The childrenre best treated with physical therapy. Occasionally, fullesolution of the mass leaves behind a tight tendinoustricture of the muscle belly. When this fails to respond tohysical therapy, operative division of the sternomastoiduscle is recommended. The procedure can be safely

erformed through a short transverse low-neck incisiono fully divide the sternomastoid muscle above its sternalnd clavicular heads. Excellent results have been ob-ained with complete division and dissection of the endsombined with postoperative physical therapy.7

ANATOMIC CONSIDERATIONS

irst and second branchial clefts are responsible for al-ost all surgically important congenital lesions in the

ateral neck. Each cleft is a depression on the outside ofhe developing head and neck (Fig 1A). The externalctodermally lined cleft is associated with an internalndodermally lined pouch that is a similar depression onhe wall of the developing pharynx (Fig 1B). When the
embrane between these two indentations dissolve, gills

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283Pediatric Neck Masses

re formed. Although this does not happen in the humanmbryo, tiny perforations may develop in the closingembrane that give rise to the sinuses and fistulae of the

ranchial anomalies. The location of the internal orifice isirectly correlated with the pouch of origin: firstranchial anomalies originate from the external auditoryanal, second sinuses and fistulas are found at the tonsil-ar fossa and third openings are through the pyriform

The first four branchial arches have clinical significance.ions between each arch form clefts on the external surface of thay lead to fistulae or sinus tracts.

inus (Fig 2). With descent and fusion of the third and c

ourth pouches, the as yet unreported fourth branchialleft fistula would also originate from the pyriform fossa.8

Knowledge of the branchial sinus internal opening ismportant to prevent recurrence. Suture ligation shouldccur close to these origins. The course of each fistulaust be well understood (Fig 2). For example, second

nd third branchial cleft cysts are found in the lower thirdf the neck, but their tracts differ in relationship to the

ing development, the second arch predominates (A). Indenta-bryo (B) and pharyngeal pouches internally. Incomplete fusion

Dure em

arotid artery and thyroid gland. These anatomic rela-

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Branchial cleft fistula. The uncommon first anomaly originates in the auditory canal, traverses the parotid gland and exits nearhe mandible. The typical second cleft has an external opening on the lower one-third of the neck near the anterior border of theternomastoid muscle. The tract bisects the carotid near its origin at the tonsillar fossa. The rare third anomaly opens near the
econd but traverses between the thyroid and carotid, passing posteriorly to its origin at the pyriform sinus.

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ions are important landmarks for surgical excision, highigation, and to avoid nerve injury. In particular, the firstranchial cleft anomalies may come close to branches ofhe facial nerve requiring full nerve dissection for success-ul excision. Surgery on the second cleft must avoid theypoglossal and glossopharyngeal nerves. Dissection ofhird fistulas may injury the vagus or hypoglossal nerves.

The branchial cleft/pouch combinations discussedbove reside between six branchial arches. The first fourrches are of clinical significance (Fig 1B). Each is com-osed of three embryologic layers that give rise to anssociated nerve (ectoderm), artery, muscle and cartilagemesoderm), and glands (endoderm). The first archorms the apparatus of the ear while the second is associ-ted with the styloid process and hyoid bone as well as theoot of the tongue and foramen cecum. The third arch haso muscle or cartilage but its pouch forms the inferiorarathyroid glands and the pyriform fossa. The ventralortion is associated with the thymus gland. Similarly, theourth arch again has no muscle or cartilage associations,ut the pouch forms the superior parathyroid glands andportion of the thymus as well as the ultimobranchial

ody. Knowledge of the particular muscle and cartilagessociations is of less importance than the internal open-ng of the fistulas and sinus tracts. Nevertheless, this in-ormation is of interest to pediatric and endocrine sur-eons.

Thyroglossal duct anomalies occur when there is in-omplete resolution of thyroid descent. The thyroid glandegins at the base of the tongue (foramen cecum) as a
iverticulum that descends down the midline of the neck t
o its eventual home on the thyroid cartilage. Because theecond branchial arch is busy forming the hyoid bone athe same time as the thyroid is descending through therea; the tract may travel in front, behind or actuallyhrough the midpoint of the bone. It was this knowledgehat led Sistrunk to advocate excision of the thyroglossaluct with the midportion of the hyoid bone and the softissue on either side.1 Cysts may be present anywherelong the tract from the pyramidal lobe of the thyroid,tself a remnant of descent, to the foramen cecum. Fistulasccur only after surgical drainage of infected thyroglossaluct cysts.2

Very rarely the thyroid gland itself fails to descend inhe neck, remaining at the foramen cecum. Typically, thiss discovered early after birth because of hypothyroidismr dysphagia and aspiration. Occasionally euthyroid pa-ients will have portions of the thyroid gland along theract descent. Differentiation of these masses is critical tovoid surgical excision of functioning thyroid tissue.gain, ultrasound is very helpful to make this determina-

ion. If there is any question, a thyroid scan completes thenvestigation.3

Midline dermoid cysts are thought to represent ecto-ermal inclusions formed during midline fusion of thembryo. These benign cysts are filled with ectodermallements that proliferate and can become infected. Be-ause they are at the site of fusion, their attachments maye deep but are always benign. Malignant degenerationas been described, but the typical indication for opera-
ion is a slowly growing mass that may become infected.

3a


OPERATIVE TECHNIQUE

Thyroglossal Duct Cyst

The patient is positioned supine with the neck extended. A shoulder roll is necessary, particularly in smaller children to achievedequate extension of the neck. The disparity of a large head and a small body must be accounted for in small children.

3n


Before extension of the neck, a transverse skin incision is marked in an appropriate skin crease. An elliptical incision is
ecessary if there has been previous infection or a fistula that is adherent to the skin.

4eio


Dissection continues directly onto the cyst where it is gently freed from surrounding tissue. The cyst may initially be locatedccentrically but always narrows down to the midpoint of the hyoid bone. The lateral horns of the hyoid are identified as they fusen the midline. The lateral musculature is freed just medial to the site of fusion on each site. The midpoint of the hyoid is grasped
n either side of the suspected tracts with strong clamps. The bone is excised with Mayo scissors or light bone cutters.

5csfrio


The mass is mobilized inferiorly along the suprathyroid fascia, leaving any suspected tracts with the midpoint of the bone. Oncelear inferiorly, the anterior and superior muscles are gradually divided. As the last remnants of muscle are divided, care is taken touture-ligate all possible accessory tracts leading to the base of the tongue. At this point, the anesthesiologist may help elevate theoramen cecum further into the incision. The tract is then suture-ligated with absorbable suture (inset). The muscles aree-approximated transversely in several layers using interrupted stitches. The bone is not re-sutured. The remainder of the wounds closed in layers with absorbable suture. Generally no drains are placed unless there has been previous infection or a large amount
f dissection has created significant dead space.

6aieb


Second Branchial Cleft Anomaly

the head.

The external opening of the branchial cleft anomaly is almtransverse elliptical incision in line with a previously marked

ncision is sufficient for complete removal of the tract. The younxcision. If the child is older and the neck longer, a secondifurcation. The site is marked before extension and turning of

ost always located in the lower third of the neck. It is excised usingskin crease. Depending on the age and size of the child, a single

ger the child, the better to achieve to the most cosmetic and reliableincision is planned further up the neck directly over the carotid

7mmcfiw


A small probe or suture may be advanced through the tract to help with palpation and visualization of the tract. Injection ofethylene blue is messy and spillage obscures operative detail. Dissection of the tract begins inferiorly and laterally, graduallyobilizing the fistula from its subcutaneous attachments and the platysma. Once the tract has been well identified, the division

ontinues anteriorly and superiorly. Some tracts appear lined with circular muscle which aids in full visualization and allows forrm traction to take place. Generally with traction and counter-traction, the investments of the tract into the surrounding tissue are
ell visualized and divided sharply or with electrocautery.

8Toascn


Cephalad retraction on the skin incision may allow for visualization of the carotid bifurcation and subsequent tract ligation.his maneuver is aided by digit pressure from the anesthesiologist on the appropriate tonsillar fossa. If dissection continues directlyn the tract, all nerves are avoided. Inflammation or prior infection increases the chance of risk to the hypoglossal nerve that liesnteriorly. Care must be taken during retraction to very carefully elevate the tissues around the nerve to avoid damage. Dissectiontays below the posterior belly of digastric as the bifurcation is reached. The base of the tract is suture-ligated with Vicryl. Woundlosure is simple with re-approximation of the platysma, subcutaneous tissues and skin using absorbable suture. Drainage is usually
ot required unless there has been extensive dissection or prior infection.

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Preauricular Sinuses

This condition is not related to first branchial cleft anomalies. The area is often infected with Staphylococcus aureus that requires
reatment before surgical excision. If resected during a time of active inflammation or infection, recurrence rates are high. Anlliptical skin incision or a skin flap are the best approaches for identification of sometimes multiple glands in the subcutaneousissue over the zygomatic arch. Full visualization and excision of the glands is necessary to prevent recurrence. Although thepening may be small, the incision is sometimes out of proportion to the expected removal. Care must be taken to explain to the amily the surgical procedure involved for these small masses.

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Torticollis

0 Patients are positioned as for branchial cleft excision. A short transverse incision is marked in a skin crease before full patientositioning. Dissection continues through subcutaneous tissue to identify the lower third of the sternomastoid muscle just above

ts sternal and clavicular heads. With gentle dissection, the tendinous tissue is dissected free from the underlying carotid sheath andivided with cautery. The deep cervical fascia is similarly divided to achieve full and complete separation of the muscle. If the

ncision is placed slightly lower, care must be taken to divide both the sternal and clavicular heads. The cut ends of muscle are left
ree as the platysma, subcutaneous tissue and skin are closed in layers with absorbable suture. Generally no drains are placed. hysical therapy begins immediately after operation.

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EXPECTED OUTCOME

xcellent outcomes can be expected when the surgicalrinciples of complete excision occurs during a timehen there is no inflammation or infection. Generally,

he younger the patient, the more successful the excisionnd improved cosmetic results. Perioperative antibioticsre helpful especially when excising fistulas becauseany of the wounds are contaminated with oral flora or

kin organisms. If the incision is placed in a skin crease,he wound heals almost without trace. Recurrence ofranchial cleft or thyroglossal duct anomalies resultsrom incomplete excision or inadequate suture ligation ofhe tract. Recurrence is generally heralded by infectionnd wound break down. The ensuing drainage is allowedo settle with local wound care, warm soaks and systemicntibiotics as necessary. Generally, at least 6 weeks to 3onths should be allowed to pass before re-excision. A

areful evaluation for a third branchial anomaly usingirect laryngoscopy may be helpful for recurrences ofuspected second clefts. Most thyroglossal duct cysts re-ur when the midpoint of the hyoid bone has not beenxcised; however, rare recurrences can be found whenmall accessory ducts escape detection at the first opera-ion.

CONCLUSIONS

enign head and neck masses can be classified into mid-
ine or lateral. Congenital anomalies require a thorough
nderstanding of the anatomic and embryologic originsor complete excision without recurrence or nerve injury.reviously infected lesions require antibiotics, needle as-iration or drainage before surgical excision. Ample timehould be given for the infection to settle down beforeefinitive surgery. In general, excellent results can bechieved for almost all excisions of benign neck masses inhildren.

REFERENCES. Sistrunk WE: Technique of removal of cyst and sinuses of the

thyroglossal duct. Surg Gynecol Obstet 46:109-112, 1928. Roback SA, Telander RL: Thyroglossal duct cysts and branchial

cleft anomalies. Semin Pediatr Surg 3:142-146, 1994. Faerber EN, Swartz JD: Imaging of neck masses in infants and

children. Crit Rev Diagn Imaging 31:283-314, 1992. Girvigian MR, Rechdouni AK, Zeger GD, et al: Squamous cell car-

cinoma arising in a second branchial cleft cyst. Am J Clin Oncol27:96-100, 2004

. Burton DM, Pransky SM: Practical aspects of managing non-malig-nant lumps of the neck. J Otolaryngol 21:398-403, 1992

. Triglia JM, Nicollas R, Ducroz V, et al: First branchial cleft anom-alies: The study of 39 cases and a review of the literature. ArchOtolaryngol Head Neck Surg 124:291-295, 1998

. Tang SF, Hsu KH, Wong AM, et al: A longitudinal follow-up studyof ultrasonography in congenital muscular torticollis. Clin Or-thoped Related Res 403:179-185, 2002

. Moore KL, Persaud TVN: The pharyngeal (branchial) apparatus, inThe Developing Human: Clinically Orientated Embryology (ed 6).
Philadelphia, PA, WB Saunders, 1998, pp 215-256

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2

yloric Stenosis

ouglas N. Miniati, MD, and Craig T. Albanese, MD

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ypertrophic pyloric stenosis was first described byHirschsprung in 1888.1 It affects approximately 4

er 1000 live births.2 Infants that are affected are usuallyetween 2 and 8 weeks old, and it rarely occurs in prema-ure infants. Both familial and environmental factors areelieved to be causative. Infants whose mothers had py-oric stenosis are more likely to develop pyloric stenosistypically the first-born male), and having a child withhis disorder results in an increased incidence of pylorictenosis in one’s future children. Despite these hereditaryies, both barium swallow and ultrasound studies havergued against a congenital defect. Of over 2000 babiesound to have no pylorus abnormalities at birth, someent on to develop pyloric stenosis.3,4 The male:female

atio is approximately 5:1, Caucasians are affected morehan African-Americans and Asians, and babies who arereast fed are more likely to be affected.While the narrowing of the pyloric channel is primarily

ecause of hypertrophy of the inner circular muscle layer,he precise etiology of this hypertrophy is unknown. Sev-ral mechanisms have been suggested, including alter-tions in the pyloric muscle relaxation because of changesn the numbers and structural qualities of pyloric gan-lion cells, elevations in various gastrointestinal hor-ones (gastrin, substance P, secretin, enteroglucogon,eurotensin), and deficiencies of vasoactive intestinalolypeptide and nitric oxide.5

DIAGNOSIS

nfants typically present with progressively forceful, non-ilious vomiting. With prolonged emesis, lethargy be-ause of dehydration can occur, but infants otherwiseppear healthy. Differential diagnoses to consider includeylorospasm, gastroesophageal reflux, over-feeding, ele-ated intracranial pressure, metabolic disorders (salt-los-ng adrenogenital syndrome, certain aminoacidurias as-ociated with electrolyte derangements), antral web, andyloric duplication.

From the Department of Surgery, Stanford University School of Medicine,tanford, CA; and the Division of Pediatric Surgery, Lucile Packard Children’sospital, Stanford, CA.Address reprint requests to Craig T. Albanese, MD, 780 Welch Road, Suite

206, Stanford, CA 94305-5733© 2005 Elsevier Inc. All rights reserved.1524-153X/04/0604-0007$30.00/0
doi:10.1053/j.optechgensurg.2004.10.006 t

Experienced hands can make the diagnosis by palpat-ng an “olive” in the right upper quadrant. Careful phys-cal examination includes administering 5% dextrose wa-er or using a pacifier, covering the abdomen and legsith a blanket, and flexing the trunk with the hands over

Transverse (top) and longitudinal (bottom) views of an ab-ominal ultrasound. Cursor markers demonstrate a 4.9 mm wall
hickness (top) and 16.2 mm length (bottom) of pyloric channel.

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297Pyloric Stenosis

he baby’s thighs to help the baby relax the abdominaluscles. In addition, suctioning the stomach before ex-

mining the upper abdomen increases the chances ofaking the diagnosis. Even with these maneuvers, the

ypertrophied pylorus may be missed, especially if it isnder the liver edge.For patients in whom the pylorus is not palpable, ul-

rasonography is the imaging modality of choice (Fig 1).he ultrasonographic criteria for the diagnosis of pylorictenosis are a muscle wall thickness that is 4 mm or morend a pyloric channel length that is 14 mm or more. Theiameter of the hypertrophied pylorus is usually greaterhan 12 mm. In instances when the diagnosis cannot beade by physical examination and when ultrasound isot available, or when pyloric stenosis is considered less

ikely, a contrast upper gastrointestinal (GI) examinations indicated (Fig 2). The diagnosis is suggested by dem-nstrating an elongated pyloric channel, “shouldering” ofhe pyloric muscle against the gastric antrum, and thestring sign” of contrast traversing the narrow channelnto the duodenum. In contrast to ultrasonography,hich can only rule in or exclude the diagnosis of pyloric

tenosis, an upper gastrointestinal (GI) examination canlso diagnose other entities in the differential diagnosisuch as pylorospasm, gastroesophageal reflux, web, oruplication.Prolonged vomiting may result in a hypokalemic, hy-

Upper gastrointestinal series depicting the contrast-filledtomach (S), hypertrophied pylorus (P), and the “string sign”arrow).

ochloremic, metabolic alkalosis because of loss of hy- w

rogen and chloride ions with emesis. Paradoxical acid-ria is a late finding when the kidneys compensate for aontracted volume by reabsorbing sodium at the expensef hydrogen. Mild indirect hyperbilirubinemia occurs in% but resolves spontaneously within 5 to 7 days afteryloromyotomy.

PREOPERATIVE PREPARATION

ral feedings are discontinued as soon as the diagnosis isuspected. An important feature of pyloric stenosis is thatt is not a surgical emergency. Accordingly, proper fluidnd electrolyte resuscitation is of particular importance invoiding anesthetic and surgical complications. Bolusesf 20 mL/kg over 1 hour than a maintenance rate of 150L/kg/day with a solution containing 5% dextrose and

.45% saline corrects all underlying electrolyte abnormal-ties. Potassium is not added to the intravenous fluid untiln adequate urine output is established. Lactated Ringerolution is contraindicated because of the potential toorsen the patient’s metabolic alkalosis. Surgery is con-

idered safe if the following are achieved: a urine outputreater than 1 mL/kg/hr, a serum chloride level of greaterhan 100 mEq/L, a serum bicarbonate level of less than 25Eq/L, and a normal serum potassium level. Nasogastric

ecompression is not indicated because gastric secretionsre usually tolerated and the alkalosis could be worsenedith drainage of the gastric acid.

CHOICE OF OPERATIVE TECHNIQUES

lassically, a pyloromyotomy has been performed asescribed by Ramstedt6 via a transverse incision in theight upper quadrant, transecting the rectus abdomi-us muscle. Muscle-sparing techniques and a su-raumbilical approach have also been advocated. Sincehe mid-1990s, the operation has been performed lapa-oscopically. Multiple studies have compared laparo-copic and open techniques, and the latest consensus ishat laparoscopic pyloromyotomy can be performed asafely as the open pyloromyotomy at similar cost withossibly a marginal decrease in length of hospitaliza-ion, but with an improved cosmetic outcome.7-9 Also,here is less postoperative emesis after the laparoscopicpproach since the stomach and the duodenum areinimally manipulated as opposed to the open ap-

roach, which can cause a gastric ileus from extensiveanipulation during delivery of the pylorus into the
ound.

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298 Miniati and Albanese

SURGICAL TECHNIQUE

wptieict

pen Pyloromyotomyoth the open5,10 and the laparoscopic11 techniques will beeviewed. One dose of cefazolin (25 mg/kg intravenously)nd rectal acetaminophen (30 mg/kg) are given preopera-ively. The general anesthetic is the same for both techniquesxcept that it is not necessary to administer a narcotic for theaparoscopic approach since it is relatively quick, there is noarge incision, and the wounds are preemptively infiltrated

epict the fascial incision.

ith a long-acting local anesthetic. The abdomen is pre-ared from the nipple line to the pubic region for bothechniques. However, diligent cleaning of the umbilicus (us-ng a cotton-tipped applicator or clamp and alcohol) is nec-ssary before the laparoscopic technique to avoid an umbil-cal wound infection. In those with a persistent umbilicalord stump, an inferior circumumbilical incision used forhe port placement.

Incision. A transverse right upper quadrant incision (A) is performed and the rectus abdominus muscle and fascia areransected with cautery. Alternatively, the fascia can be incised transversely, the muscle dissected from the undersurface of thenterior sheath, and then retracted laterally exposing the posterior sheath, which is similarly incised transversely. If the perium-ilical incision is performed (B), the midline skin is undermined and the linea alba is incised to enter the peritoneum; the skinncision is sometimes extended laterally to make an “omega” shape to accommodate the deliver of the large pylorus. Dashed lines

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299Pyloric Stenosis

Pylorus delivered into the wound. Regardless of the incision used, the pylorus is delivered into the wound. This is accom-lished by gently grasping the stomach with a Babcock clamp, delivering the stomach to the wound where it can be grabbedroximal to the pylorus with a moist sponge in the surgeon’s hand. One should “rock” the pylorus into and out of the wound. If thetomach cannot be located, the tip of a moist sponge is inserted into the abdomen and withdrawn slowly. The omentum will sticko the sponge and then the omentum can be used as a guide to the greater curvature of the stomach. The pylorus is incised on itsvascular surface starting form 1 mm proximal to the pyloroduodenal junction (located by a change in color, texture, and a
rominent pyloric vein) and extending onto the antrum.

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Completion of myotomy. The muscle is “split” using the back of the knife handle and then spread using a Benson spreader,xposing (but not breaching) the underlying mucosa. When completed, the upper and lower muscle edges appear askew and cane moved side-to-side independently. It is important to stop just short of the duodenum because of the fornix created by its mucosa,aking mucosal perforation risky at this location. Once the myotomy is completed, the wound is inspected for hemostasis and any

ile or gastric fluid leak. The anesthesiologist then passes an orogastric catheter and insufflates the stomach with 60 mL of air whilehe duodenum is gently compressed. With the stomach fully distended, the myotomy wound is carefully inspected under salinerrigation for evidence of air leaking (bubbles) through a mucosal perforation. If a perforation is encountered, it is closed with a “U”titch of absorbable suture. Alternatively, a large perforation is treated by suture closure of the myotomy, rotation of the pyloruspproximately 45° in either direction, and a fresh myotomy performed. A short myotomy (not extending far enough onto thentrum) or one that is poorly spread may lead to an “incomplete myotomy” and persistent symptoms. The fascia and theubcuticular skin are closed with absorbable suture. Steri-strips® (3M Health Care, St. Paul, MN) are applied to the skin incision;
o other dressing is needed.

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LAPAROSCOPIC PYLOROMYOTOMY

Patient and equipment positioning. The child is positioned transversely on the bed; if the patient is too long, his or her headr feet can be placed on an arm board that is folded against the bed. One monitor is used and it is placed directly over the patient’sead. Both the surgeon and the assistant stand on the same side, at the patient’s feet. To perform a “slice and pull” laparoscopicyloromyotomy,11 two instruments and a small telescope are required; a 3 mm laparoscopic Babcock grasper, a 3 mm sheathedrthroscopy knife (Linvatec Corporation, Largo, FL), and a 2.7 mm 30° lens telescope. Some prefer to use an additional instrument,3 mm laparoscopic pyloric spreader. Only one 3 mm trocar is necessary and it is used for the telescope.

Port sites for laparoscopic pyloromyotomy. A long-acting local anesthetic is infiltrated preemptively into the port sites. Aertical incision is made directly into the base of the umbilicus. Commonly there is a small umbilical fascial defect that makes portntry safe and easy. An open or a Veress technique can be used to insufflate and insert the 3 mm umbilical port that willccommodate the telescope. If an umbilical cord remnant persists, an inferior circumumbilical incision is used. The abdomen isnsufflated to 10 torr pressure via the umbilical port. Under direct laparoscopic visualization, bilateral 2 to 3 mm stab incisions are

ade with a #11 blade scalpel, slightly medial to the midclavicular lines and midway between the costal margin and the umbilicus.hese incisions should be high enough such that the shaft of the instruments can retract the liver cephalad if the liver is overlying

he pylorus. They should also be slightly smaller than the instruments so that they have to be stretched a little—this will guardgainst gas leakage from the incisions. If a leak occurs, the flow rate on the insufflator should be increased to a level that maintains
n adequately pressured pneumoperitoneum.

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The laparoscopic Babcock grasper is inserted through either incision, depending on surgeon preference. Most, however, prefero use the Babcock in their left hand to gently hold the duodenum while the pylorus is incised. The sheathed arthroscopy knife isnserted through the other incision with the blade fully retracted. It should enter the abdomen at virtually a right angle to the

idportion of the pylorus. For this reason, it is recommended that the stab wounds in the upper abdomen are not created until the
elescope is inserted to ensure accurate placement of the instruments.

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303Pyloric Stenosis

The knife blade is extended one click (a length of 2 mm), and the full 2 mm length is inserted into the avascular portion of theylorus, and a standard seromuscular incision is made as described for the open procedure (inset). Any bleeding that occurs with
his incision is venous and should stop once the myotomy is completed.

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0 The knife blade is retracted and its shaft is used to break the remaining pylorus muscle fibers by twisting the instrumentithin the myotomy wound. The Babcock grasper and the sheathed arthroscopy knife may be used together to separate the

emaining muscular fibers by distracting the two instruments in opposite directions (arrows). Alternatively, one may use aaparoscopic pyloric spreader to break the muscle fibers, as described for the open procedure. The principles used to avoid duodenalerforation and incomplete myotomy are the same for both the laparoscopic and open techniques. The abdomen is exsufflated viahe umbilical port. Once all of the gas is removed, the instruments are removed from the stab wounds. Omental herniation has beenescribed when the instruments are removed from the stab wounds before exsufflating the abdomen. The stab incisions are closedith steri strips alone or with interrupted subcuticular absorbable sutures, based on the surgeon’s preference. The fascia of the
mbilical port site is closed with a simple absorbable suture and its skin is closed with a simple plain gut suture.

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305Pyloric Stenosis

OSTOPERATIVE MANAGEMENT ANDOMPLICATIONSarious refeeding regimens have been suggested from im-ediate postoperative ad libitum oral intake to waiting up to

2 hours to start feeding with an escalating scale of volumend concentration of feeds. Recent evidence indicates thataiting for approximately 4 hours postoperatively results in

ess postoperative emesis and a more rapid advancement toutritional goals.12 It is no longer deemed necessary to ad-

ust the concentration of the formula administered postop-ratively. Full-strength formula (or breast milk) can be ad-inistered ad libitum as tolerated.Potential complications include mucosal perforation

0.5-3%), and incomplete pyloromyotomy requiring reop-ration (up to 2%). Mucosal perforation, if not promptlyecognized, can be a life-threatening complication. An in-omplete myotomy is suspected when a child does not tol-rate feeds after 7 to 10 days postoperatively. If stronglyuspected, reoperation is required. There is no reliable im-

11 Completed laparoscopic pyloromy

ging study that can be used in the workup for incomplete

yotomy because, after a perfect myotomy, an upper GIeries will be consistent with pyloric stenosis for severalonths postoperatively.

REFERENCES1. Hirschsprung H: Falle von angeborener pylorus stenose. Jb

Kinderheilk 27:61, 18882. Mitchell LE, Risch N: The genetics of infantile hypertrophic pylo-

ric stenosis. Am J Dis Child 147:1203, 19933. Rollins MD, Shields MD, Quinn RJ, et al: Pyloric stenosis: congen-

ital or acquired? Arch Dis Child 64:138, 19894. Wallgren A: Preclinical stage of infantile hypertrophic pyloric

stenosis. Am J Dis Child 72:371, 19465. Schwartz MZ: Hypertrophic pyloric stenosis, in O’Neill JA, Row

MI, Grosfeld JL, et al (eds): Pediatric Surgery. St. Louis, MO,Mosby-Year Book, Inc, 1998, pp 1111-1117

6. Ramstedt C: Operation der angeborenen Zpylorus stenose. MedKlinik 8:1702, 1912

7. Caceres M, Liu D: Laparoscopic pyloromyotomy: Redefining the

y. Inset demonstrates bulging mucosa.

advantages of a novel technique. JSLS 7:123-127, 2003

1

1

1


8. Greason KL, Allshouse MJ, Thompson WR, et al: A prospective,randomized evaluation of laparoscopic versus open pyloromyot-omy of infantile hypertrophic pyloric stenosis. Pediatr EndosurgInnov Tech 1:175-179, 1997

9. Yagmurlu A, Barnhart DC, Vernon A, et al: Comparison of theincidence of complications in open and laparoscopic pyloromyo-tomy: A concurrent single institution series. J Pediatr Surg 39:292-
296, 2004
0. Benson CD: Infantile hypertrophic pyloric stenosis, in Welch KJ,Randolph JG, Ravitch MM, et al (eds): Pediatric Surgery. Chicago,IL, Year Book Medical Publishers, 1986

1. Rothenberg SS: Laparoscopic pyloromyotomy: The slice andpull technique. Pediatr Endosurg Innov Tech 1:39-41, 1997

2. Van Der Bilt JD, Kramer WL, Van Der Zee DC, et al: Early feedingafter laparoscopic pyloromyotomy: The pros and cons. Surg En-
dosc 18:907-909, 2004

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eckel’s Diverticulum

. Denison Jenkins, MD, and Karl G. Sylvester, MD

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eckel’s diverticulum is the most common congenitalmalformation of the gastrointestinal tract, occur-

ing in 1 to 2% of the population.1 It is a remnant of themphalomesenteric duct, an embryologic structure con-ecting the primitive yolk sac to the midgut in the devel-ping fetus (Fig 1). Also known as the vitelline duct, themphalomesenteric duct is usually obliterated by the 5thr 7th week of gestation2,3; failure of this structure tolose completely results in a continuum of pathology,anging from an umbilical-enteric fistula, to an umbilicalinus or cyst, to a Meckel’s diverticulum (Fig 2).3 Fur-hermore, up to 25% of Meckel’s diverticuli are tetheredo the abdominal wall via a fibrous remnant of the ompha-omesenteric duct.4 Ectopic tissue, commonly gastric mu-osa, is present in about 50% to 60% of Meckel’s diver-iculi.5 In adults, the majority of these congenital lesionsre clinically silent, discovered incidentally when a pa-ient requires an abdominal operation for another cause.n children less than 2 years of age, a Meckel’s diverticu-um generally presents as lower gastrointestinal bleeding;therwise it is infrequently diagnosed preoperatively.hile overall gender predominance does not exist for the

resence of a Meckel’s diverticulum, males are three toourfold more likely to present with symptoms.5,6 Thereatment of a diverticulum found incidentally in thelder patient is controversial, whereas a symptomatic le-ion is resected using either an open or laparoscopic ap-roach.7

PREOPERATIVE EVALUATION

Meckel’s diverticulum may manifest a wide variety ofymptoms in children, including gastrointestinal bleed-ng, peritonitis, small bowel obstruction, and chronic ab-ominal pain. Ultimately, preoperative evaluation de-ends on the patient’s presentation. Acid secretion fromctopic gastric tissue within a Meckel’s diverticulum can

From the Department of Surgery, Stanford University School of Medicine,tanford, CA.

Address reprint request to Karl G. Sylvester, MD, Department of Surgery,ivision of Pediatric Surgery, Stanford University School of Medicine, 780 Welchoad, Suite 206, Stanford, CA 94305-5733




ead to mucosal ulceration and painless bleeding in ahild. In these patients, a Tc-99m pertechnetate scintig-aphy, also known as Meckel’s scan, is commonly used todentify the suspected diverticulum (Fig 3). Acid-secret-ng cells absorb pertechnetate, whereas the kidneys rap-dly excrete it; consequently, the stomach and bladder areisualized on Tc-99m pertechnetate scintigraphy. Aeckel’s diverticulum with acid-producing ectopic gas-

ric mucosa will also take up the radiotracer, and gener-lly will be identified on the nuclear scan. A false negativeesult may occur with a Meckel’s diverticulum with annsufficient volume of ectopic gastric mucosa. Figure 3emonstrates a Meckel’s scan, with radiotracer uptake inhe stomach, bladder, and a Meckel’s diverticulum. A

eckel’s scan has low negative predictive value in chil-ren presenting with both hematochezia and anemia,eading some to argue in favor of early diagnostic laparos-opy.8

When a Meckel’s diverticulum is inflamed or perfo-ates, the child will likely present with peritonitis, leadingo laparotomy. In such circumstances, a child is ofteniagnosed with appendicitis preoperatively. A Meckel’siverticulum may also manifest as a small bowel obstruc-ion. In these situations, the lesion usually acts either ashe lead-point for an intussusception or a fibrous cordcts as the axis of a volvulus. Most children in theseituations are diagnosed during laparotomy or laparos-opy. For equivocal cases, or for children with chronicbdominal pain, a computed tomography scan may facil-tate the diagnosis. Most commonly, a Meckel’s divertic-lum is an incidental finding during an operation fornother reason.

PREOPERATIVE PREPARATION

owel preparation is not necessary before resection of anown Meckel’s diverticulum. The patient is placed su-ine on the operating room table and general endotra-heal anesthesia is induced. Prophylactic antibiotics aredministered depending on the operative indication andurgeon preference. The abdomen is prepared and drapedn a standard fashion. If using laparoscopy, an orogastricube is placed and the bladder emptied via catheterizationo minimize the risk of visceral injury associated with
nitial access.
307: pp 307-316

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308 Jenkins and Sylvester

Patent omphalomesenteric duct in a developing embryo. From: TS Cullen. Embryology, Anatomy, and Diseases of thembilicus, 1916. Illustration by Max Brödel. Reprinted with permission from Elsevier.

309Meckel’s Diverticulum

Potential Pathology Resulting from Omphalomesenteric Duct Remnants

2 (A) Ulceration. (B) Fibr
ous band. (C) Duct. (D) Cysts.

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2 (E) Vitalline sinus. (F) Fibrous cord.

Meckel’s scan showing radiotracer uptake in stomach, bladder, and a Meckel’s diverticulum (from K.G. Sylvester, Stanfordniversity).

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SURGICAL TECHNIQUES

ither anopenor laparoscopic techniquemaybeused toexciseMeckel’s diverticulum. The traditional method to remove a

Thetraditionalopentechniqueisperformedthrougheitheratransverse right lower or a low midline laparotomy. Once aMiCidtaTui

eckel’s diverticulum is a segmental bowel resection, espe-ially in thesettingofgastrointestinalbleeding.Classic teachingtates that the mucosal ulceration may be located in adjacentmall bowel, and not within the actual diverticulum, thus man-ating segmental resection. However, with increased use ofaparoscopy, simple amputation with an endoscopic stapler—ven in a child with a history of a bleeding distal mucosallcer—is being increasingly performed by experienced pediat-ic laparoscopic surgeons, with favorable outcomes and no re-orted postoperative recurrences.

Laparoscopic port site placement: To perform a laparoscop

eckel’s diverticulum has been identified, a window is createdn the mesentery approximately 2 cm proximal to the lesion.lamps are placed, and the bowel is divided. A second window

s opened in the mesentery 2 cm distal to the lesion, and theistal segment is divided. The lesion is resected off the mesen-eric remnant using electrocautery, and a hand-sewn bowelnastomosis is created in a single layer using absorbable suture.he mesenteric defect is then closed with absorbable suturesing a running stitch; the fascia and abdominal wall are closed

n the standard fashion.

imple diverticulectomy, pneumoperitoneum is established to 8
ic so 12 torr, depending on the child’s size. A 5 to 12 mm Step radically expanding trocar is placed through the umbilicus, and a 5 mm0-degree laparoscope is advanced into the abdomen. Two 3 to 5 mm working ports are placed under direct visualization, the firstn the low mid-line, just cephalad to the pubic symphysis and clearing the dome of the decompressed bladder.

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Laparoscopic excision of fibrous cord: After the abdomen has been explored, the ileocecal junction is identified, and thentestine is run proximally. A Meckel’s diverticulum is usually found within 2 feet of the ileocecal valve, located on the antimes-nteric side of the small bowel. If tethered to the abdominal wall, the fibrous cord is either ligated between clips or cautiouslyivided with electrocautery, as the cord may contain a persistent vitelline artery.

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Simple diverticulectomy: A recognizable vessel extending from the mesentery to the apex of the diverticulum is frequentlyncountered. This is generally controlled simultaneously during the resection of the diverticulum. The distal end of the divertic-lum is grasped with an atraumatic instrument placed through the suprapubic port, and an EndoGIA-30 with a vascular load (USurgical, Norwalk, CT) introduced via the 5 to 12 mm umbilical port is applied to the base of the diverticulum. The lesion is thenmputated and removed. If performing a laparoscopic segmental resection, a window is created in the mesentery using electrocau-ery approximately 2 cm proximal to the lesion, and the bowel divided with an EndoGIA-30. A second window is created 2 cm distalo the lesion, and the distal bowel divided with another EndoGIA-30. The lesion is then resected off the mesentery usinglectrocautery in the very small infant, or using an additional vascular stapler in the older child. A stapled bowel anastomosis is thenreated, and the mesenteric defect closed. Alternatively, a hybrid technique may be used, if necessary (Fig 7).

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(A) Hybrid technique for excision of a Meckel’s diverticulum: This is accomplished by removing the umbilical trocar, andxtending the fascial opening while remaining within the confines of the umbilical skin, and therefore not altering overall cosmesis.he Meckel’s diverticulum and adjacent intestine can then be exteriorized, and either a simple diverticulectomy or a segmentalesection performed.

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(B) Hand sewn bowel anastomosis: If necessary, a hand-sewn anastomosis in a single layer using absorbable suture may beerformed. At the completion of the procedure, trocars are sequentially removed under direct visualization, and the port sites closedith absorbable suture.

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1

2

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POSTOPERATIVE CARE

he orogastric tube placed preoperatively is removed athe completion of the operation. The patient is kept NPOnil per orum) until bowel function returns, which gen-rally occurs rapidly. Pain medications may be adminis-ered either intravenously, or rectally, depending on theedication, and the child’s age.

REFERENCES. Matsagas MI, Fatouros M, Koulouras B, et al: Incidence, complica-

tions, and management of Meckel’s Diverticulum. Arch Surg 130:143-146, 1995

. Synder CL: Meckel’s diverticulum, in Ashcraft KW, Murphy JP,

Sharp RJ, et al (eds): Pediatric Surgery (ed 3). Philadelphia, W.B.Saunders, 2000, pp 541-544

. Vane DW, West KW, Grosfeld JL: Vitelline duct abnormalities.Arch Surg 122:542-547, 1987

. Moore GP, Burkle FM Jr: Isolated axial volvulus of a Meckel’sdiverticulum. Am J Emerg Med 6:137-142, 1988

. St-Vil D, Brandt ML, Panic S, et al: Meckel’s diverticulum in chil-dren: A 20-year review. J Pediatr Surg 26:1289-1292, 1991

. Androulakis JA, Gray SW, Lionakis B, et al: The sex ratio of Meck-el’s diverticulum. Am Surg 35:455-460, 1969

. Teitelbaum DH, Polley TZ Jr, Obeid F: Laparoscopic diagnosisand excision of Meckel’s diverticulum. J Pediatr Surg 29:495-497,1994

. Swaniker F, Soldes O, Hirschl RB: The utility of technetium 99mpertechnetate scintigraphy in the evaluation of patients with Meck-
el’s diverticulum. J Pediatr Surg 34:760-764, 1999

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aparoscopic Appendectomy

aniel J. Ostlie, MD, and George W. Holcomb, III, MD, MBA

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ppendicitis is a common cause of abdominal pain inthe pediatric patient. Moreover, suspected appendi-

itis is one of the most common surgical consultationsbtained in the outpatient or emergency room setting.his disease occurs in all age groups, but has a higher

ncidence in those children between 5 and 14 years of age,ith a second peak incidence in the elderly population.he exact etiology of appendicitis is unknown; however,

t is generally agreed that obstruction of the appendicealumen is the precipitating event. The obstruction may beresult of an appendicolith or other factors such as lym-hoid hyperplasia, infectious agents, or, rarely, a carci-oid tumor. Following obstruction of the appendiceal

umen, there is appendiceal dilation/distention with in-reased luminal pressure across the appendiceal wall.his leads to decreased vascular perfusion with break-own of the mucosal barrier and necrosis.1 As the appen-ix harbors colonic flora, it is understandable that infec-ion ensues, unless appendectomy is performed, andventually leads to perforation with either localized oreneralized peritonitis and/or abscess formation.

DIAGNOSIS

s with most patients under evaluation for surgical pa-hology, a careful history and physical examination areritical to early diagnosis and intervention, limiting theomplications associated with perforation. The classicresentation is abdominal pain that initially begins peri-mbilically and migrates to the right lower abdominaluadrant (RLQ) at McBurney’s point over the ensuing 12o 24 hours. There is associated anorexia and occasionallyne or two episodes of vomiting. More frequent vomitinghould cause the evaluating physician to consider gastro-nteritis. Classically, the vomiting ensues after the onsetf the pain. If the vomiting occurs before the pain, gastro-nteritis is a distinct possibility. Once the pain has movedo the RLQ, it remains constant and will worsen as theisease progresses. The local signs caused by the appen-iceal inflammation/obstruction is the result of peritonealrritation in the vicinity of the appendix. Because of vari-

From the Department of Surgery, Children’s Mercy Hospital, Kansas City, MO.Address reprint requests to George W. Holcomb, III, MD, MBA, Department of

urgery, Children’s Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108© 2005 Elsevier Inc. All rights reserved.1524-153X/04/0604-0009$30.00/0



bility in appendiceal location, the pain is not alwaysocated exactly at McBurney’s point. If the diagnosis ofcute appendicitis is not made early, the pain willrogress over 36 to 48 hours at which time there may be audden decrease in pain which indicates when perfora-ion likely occurred. This diminution in pain will be fol-owed by generalized peritonitis, unless the perforation isnclosed within the omentum, small bowel, or cecum (inretrocecal appendix) in which case an abscess may de-elop.

Children can present often with urinary complaintsuch as dysuria, frequent urination, and urgency becausef bladder inflammation related to the appendicitis. Arinalysis is generally obtained in all patients with sus-ected appendicitis to eliminate a urinary tract infections an etiology for the abdominal pain. Fever is commonlyssociated with appendicitis. Generally, the fever is mild38-38.5°C), unless perforation and peritonitis areresent, in which case it can be quite high (39-39.5°C).The physical examination of a child with suspected

ppendicitis can be both straightforward and difficult athe same time. The earlier a patient is examined, the easiert is to get a “true” examination. Tenderness over McBur-ey’s point and the presence of a Rovsing’s sign (pain inhe RLQ with palpation of the left lower quadrant) areallmarks of appendicitis. There may be mild abdominalistention; however, this is not present early in the dis-ase process. As the appendicitis worsens, there will beore evidence of peritoneal irritation with rebound ten-

erness and guarding. Eventually, generalized peritonitisill develop as a result of perforation and intestinal spill-

ge causing severe peritoneal irritation.Laboratory analysis in the presence of appendicitis

hould be used as confirmatory evidence for appendicitisather than to establish the diagnosis. The most commonnding is a leukocytosis with an associated left shift. The

eukocytosis is usually less than 20,000 WBC/mL in thecute phase. However, it can be much higher with perfo-ation.2 Moreover, leukopenia may be present in severeases of peritonitis with associated sepsis. There are gen-rally no electrolyte abnormalities unless there is signifi-ant dehydration. It is not uncommon to encounteryuria that is the result of bladder inflammation at theime of the urinalysis. The presence of bacteria in therine should lead to a diagnosis of urinary tract infection

n almost all instances.

317: pp 317-329

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318 Ostlie and Holcomb

Regarding imaging studies, a computerized tomogra-hy (CT) scan of the abdomen and pelvis is often ob-ained before obtaining a surgical consult. We do notecommend that all patients being evaluated for appendi-itis undergo CT of the abdomen and pelvis, but rathereserve this test for those patients in whom the diagnosiss in question (Fig 1). With this study, the presence ofLQ inflammation and/or appendiceal enlargement lendsupport to the diagnosis of appendicitis with an overallensitivity of greater than 95%. Less commonly, an ab-ominal ultrasound will be used in a confirmatory fash-on. If the appendix is visualized and found to be dilatedo greater than 1 cm, this finding is highly suggestive ofppendicitis. If the appendix is not visualized or it is lesshan 1 cm in diameter, the examination does not aidignificantly in the differential diagnosis. Plain radio-raphs of the chest or abdomen generally are not usefuluring the evaluation of acute appendicitis, and we rec-mmend their use only for select cases, such as patientsith a possible renal stone or intestinal obstruction.3 The

linical presentation of the child with appendicitis variesarkedly depending on the stage of the disease. Four

linical scenarios will be described.

ACUTE,NONPERFORATED APPENDICITIS

he most common and least morbid clinical presentationf appendicitis occurs in the child that presents with

A CT scan can be helpful in those patients in whom theiagnosis is in question. The presence of right lower quadrantbdominal inflammation, appendiceal enlargement, or theresence of a fecalith lends support to the diagnosis of appen-icitis with an overall sensitivity of � 95%. In this 18 monthld, the infant presented with vague abdominal complaints, butid have some lower abdominal discomfort. The CT scan showsfecalith (arrow). This child underwent uneventful laparo-

copic appendectomy and was discharged the following day.

arly, acute, nonperforated appendicitis. In this scenario, t

he appendix may be acutely inflamed or suppurative, buterforation has not occurred The typical presentation andonfirmatory signs have been presented previously in theext. When this clinical scenario is encountered, we rec-mmend immediate operation for appendectomy. If thexploration is negative for acute appendicitis, we suggestvaluation of the abdomen for any other pathology thatay be present, such as Meckel’s diverticulitis or mesen-

eric adenitis. Although a normal appendix may be foundn up to 15% of cases, we recommend the removal of allppendices that are explored for acute appendicitis,hereby limiting the difficulties associated with a repeatvaluation of a patient with recurrent abdominal painuspicious for appendicitis in whom the appendix haseen left behind at a previous operation for appendicitis.4

NONCOMPLICATEDPERFORATED APPENDICITIS

hen a patient presents with significant peritoneal irri-ation, temperature �39°C, or leukocytosis �20,000

BC/mL or a history of symptoms greater than 48 hours,erforated appendicitis should be considered. The preop-rative management of these children should include ad-quate resuscitation and the administration of appropri-te antibiotics. We favor either traditional triple antibioticoverage (ampicillin, gentamicin, and clindamycin/agyl) or, more recently, ceftriaxone and flagyl. If theatient is stable and the symptoms have been present foress than 3 or 4 days, we favor proceeding with appendec-omy rather than trying to treat nonoperatively followedy interval appendectomy later. Often an early abscessill be identified and omentum has walled off the puru-

ent fluid. The main advantage of the laparoscopic ap-roach in this clinical scenario is a markedly reducedncidence of postoperative wound infection comparedith the traditional RLQ open approach.

PERFORATED APPENDICITISWITH ABSCESS AND STABLE PATIENT

third clinical scenario can be seen in patients withppendicitis complicated by perforation and the forma-ion of a well-defined abscess cavity. The duration of theerforation is important in that these patients usuallyave symptoms for 1 week or longer. Typically, they haven initial 24 to 48 hours of symptoms suggestive of ap-endicitis, but then begin feeling better which is when theerforation likely occurs. Following a short interval ofeeling better, they begin to feel worse. These patients areften teenagers, but we have seen an occasional youngeratient with this scenario. The patients are febrile andave a well-delineated right lower abdominal mass. How-ver, there is no evidence of small bowel obstruction orther signs of toxemia. A CT scan is performed and reveals aell-defined abscess. There is no evidence of bowel obstruc-

ion on the abdominal films or the CT scan (Fig 2).

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319Laparoscopic Appendectomy

In the above clinical scenario, initial nonoperativeanagement is favored. The abscess cavity is drained

ercutaneously and a PICC (percutaneous intravenousentral catheter) line is introduced for home antibioticdministration. If the patient stabilizes and is able to tol-rate a regular diet, he/she can be discharged and thentibiotics continued for 10 days. The patient is usuallyeen in the outpatient setting approximately 1 week fol-owing the drainage procedure and a repeat CT scan per-ormed. If there is no evidence of a residual abscess cavitynd the patient is clinically improving, the drain is re-oved. The patient is often continued on oral antibiotics

or another week or two with plans for an interval lapa-oscopic appendectomy 6 weeks following the initial

In select cases, patients with a long-standing history consibscess cavity, but may not be toxic from this disease. On the lefwell defined and localized abscess cavity (arrow). On the ri

ntestinal obstruction from the abscess. In this type of patienercutaneous drainage of the abscess cavity followed by 10 to 1e accomplished at home. If the abscess resolves and the patienor a laparoscopic interval appendectomy.

rainage procedure. M

It should be emphasized that patients managed inhis fashion comprise a select group. Very few (�5%)f all patients who have presented to our hospital withppendicitis have been managed in this fashion. Also,here is some controversy about whether or not thenterval appendectomy needs to be performed. How-ver, in our experience, we have seen several patientsith a long, tubular appendix at the time of the interval

aparoscopic procedure with a fecalith found in thepecimen (Fig 3). This operative finding leads us toelieve that these patients are at risk for developingnother episode of appendicitis. Thus, we believe thathe interval laparoscopic appendectomy is an impor-ant part of the overall treatment plan of these patients.

t with perforated appendicitis may present with a well defined, the abdominal/pelvic CT scan is seen from such a patient with(B), the patient’s plain abdominal film shows no evidence ofually a teenager, nonoperative management is initiated withs of intravenous antibiotics. Most of the antibiotic therapy canains stable, the patient then returns at approximately 6 weeks

stent (A)ghtt, us4 dayt rem

ost of the patients that we have managed in this

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ashion have been ready for discharge on either the firstr second day following their interval laparoscopic

This operative photograph shows a long, tubular appendix inpatient who had previously undergone nonoperative manage-ent for perforated appendicitis and abscess. At the time of the

nterval appendectomy 6 weeks following the development of thebscess, the appendix was removed. It is not unusual to find aather significant residual appendix at the time of the laparoscopicnterval appendectomy that leads us to believe that all patientsreated in this manner should undergo interval appendectomy torevent a second episode of acute appendicitis.

rocedure although one patient had a prolonged post- s

perative course of 5 days because of unexplained nau-ea and vomiting.

PERFORATED APPENDICITIS INAN UNSTABLE AND TOXIC PATIENT

nce or twice a year, we find a patient with perforatedppendicitis who is in critical condition requiring aassive amount of intravenous fluid, nasogastric suc-

ion and, on some occasions, vasopressive medication.hese patients represent the extreme result of un-bated perforated appendicitis with generalized perito-itis. In such patients, following stabilization, an ex-loratory laparotomy is performed through a loweridline incision, the appendix is removed and inter-

oop abscesses manipulated and drained. Usually, 4 orliters of saline are used to irrigate and cleanse the

bdominal cavity in these patients. Drains are placedlong each lateral colonic gutter and exteriorizedhrough the lower aspect of the incision. Also, a pelvicrain is often placed. It is not unusual for these patientso require 10 to 14 days, or even longer in some in-tances, of hospitalization as they are quite ill and slowo recover. Occasionally, they will also develop anotherntra-abdominal abscess that requires percutaneousrainage. However, over the last 5 years, we have notad any mortality in this patient population and no
ignificant morbidity.

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SURGICAL TECHNIQUE

e utilize a three instrument technique for laparo-copic appendectomy. A broad spectrum antibiotic

the patient urinate before their transfer to the operatingroom. For smaller children, a Credè maneuver is em-pndc

such as cefoxitin) is given to cover Gram-negativerganisms and anaerobic bacteria. The operation is ini-iated with the patient in the supine position after thenduction of general anesthesia. If possible, we have

Following a vertical incision in the center of the umbilical skinip Step (US Surgical, Norwalk, CT) cannula is introduced into thetep cannula is placed in the umbilicus because the 10 mm endoscngled telescope is then introduced through the umbilical cannu

isualized, and a 5 mm Step cannula is inserted just above the peritone

loyed to obtain bladder decompression, thus elimi-ating the need for bladder catheterization. If the blad-er is distended and cannot be emptied, urinaryatheterization is performed.

cautery is used to incise the fascia and peritoneum. A 12 mm blunttoneal cavity and the abdomen is insufflated with CO2. (A 12 mmstapler is too large for a 10 mm Step cannula.) A 5 mm 70 degree5 mm Step cannula is inserted through a left lower abdominal

, theperiopicla. A

ncision, lateral to the inferior epigastric vessels. The craniocaudal position of this cannula is determined by the size of the child, but aeneral guideline is to position this cannula approximately one-half the distance from the symphysis pubis to the umbilicus. The thirdnstrument is placed in the left suprapubic location. With the telescope inserted through the umbilical port, the collapsed bladder is

al reflection of the bladder and to the left of the patient’s midline.

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After insertion of the three cannulas, the abdomen is fully inspected, including the RLQ for signs of appendicitis (inflammation,mental adhesions, appendiceal injection, or perforation, purulent peritoneal fluid), the gallbladder and liver, and the terminalleum for evidence of a Meckel’s diverticulum (especially in the face of a normal appearing appendix). In adolescent females, thevaries and fallopian tubes are visualized to eliminate a gonadal etiology for the abdominal pain. If an abscess has developed, thealls are gently separated and the purulent fluid suctioned to prevent contamination of the rest of the peritoneal cavity. If the

ppendix is retrocecal, the lateral peritoneal attachments to the cecum are incised to mobilize the cecum and appendix. This
issection is usually performed sharply.


6 After incising the peritoneal attachments, the rest of the cecal mobilization can be accomplished bluntly.

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Once the appendix is mobilized, an opening is made in the mesoappendix just distal to the junction between the appendix andhe cecum. Using the two instruments (a Maryland dissecting instrument and an atraumatic grasper) through the two 5 mm
annulas, this window is made large enough to accommodate a 35 mm endoscopic stapler.

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The telescope is then rotated to the left lower quadrant 5 mm cannula and the stapler is introduced into the abdomen throughhe 12 mm umbilical cannula. In many instances, it is easier to staple the base of the appendix before proceeding with division of
he mesoappendix.

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However, in some cases, it is more advantageous to proceed with mesoappendiceal division before appendiceal division.egardless of the order, a vascular load is utilized to perform the mesoappendiceal ligation and division, and a gastrointestinal load

s used to perform the appendiceal division.

1a


0 In cases of acute, nonperforated appendicitis, we do not routinely use an endoscopic retrieval bag for removal of the
ppendix, but rather grasp the stapled base of the appendix with the stapler and remove it through the 12 mm umbilical cannula.

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1 However, if perforation has occurred or if the appendix is too large to permit its removal through the 12 mm cannula, it islaced into an endoscopic bag, which is inserted through the umbilical cannula. The cannula and bag are exteriorized along withhe appendix through the umbilical incision. Following local, but not generalized, irrigation, the instruments are removed underirect vision and the subcutaneous tissues are infiltrated with 0.25% bupivocaine. The umbilical cannula is removed, the fascia islosed with an absorbable suture, and the umbilical skin is approximated with absorbable suture such as plain catgut. If possible,he fascia of the other two instrument sites is closed with an absorbable suture and the skin is closed in a subcuticular fashion. Aasogastric tube is usually not needed and the patient is advanced to a regular diet as tolerated. The antibiotic is continued for 24ours for nonperforated appendicitis. For perforated appendicitis, broad spectrum coverage is utilized and is continued for at least
days or until the patient is afebrile with a normal leukocyte count.5

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CONCLUSION

he laparoscopic approach for appendicitis is advanta-eous in a number of clinical scenarios. For the child withimple, acute appendicitis, the operation is well toleratedith reduced postoperative discomfort and a short post-perative hospitalization. Moreover, the incidence ofostoperative wound infections approaches zero.Patients, especially children, can present with perfo-

ated appendicitis in a wide variety of clinical scenarios.nfortunately, approximately 30% to 40% of children

een with appendicitis have already developed perfora-ion. For those patients with acute appendicitis withather recent perforation, the laparoscopic approach istilized. The main advantages for this approach center onhe ability to directly suction all purulent material underisualization and lyse small intestinal adhesions formedy the inflammatory response. Also, the greatest advan-age of the laparoscopic over the open approach for thisatient population with early perforation is the almostonexistent incidence of wound infections. Moreover,he incisions do not need to be left open and, should aound infection develop which requires drainage, inci-

ion and drainage can easily be accomplished in the out-atient setting under local anesthesia. However, there isikely not a significant reduction in hospital stay with the
aparoscopic approach for these patients with perforated
ppendicitis as the patient still requires recovery from anleus and the prolonged instillation of intravenous antibi-tics.For the patient with perforation and a well-defined

bscess of relatively long-standing duration, initial non-perative management followed by interval laparoscopicppendectomy has been a very efficient approach in amall segment of patients. Also, for patients who are crit-cally ill from perforated appendicitis, laparotomyhrough a lower midline incision affords the surgeon theest chance for evacuating the purulent material and abat-ng the significant peritonitis in these patients.

REFERENCES. Wangensteen OH, Dennis C: Experimental proof of obstructive

origin of appendicitis in man. Ann Surg 110:629, 1939. Samuel M: Pediatric appendicitis score. J Pediatr Surg 37:877-881,

2002. Garcia Pena BM, Cook EF, Mandl KD: Selective imaging strategies

for the diagnosis of appendicitis in children. Pediatrics 113:24-28,2004

. DeCou JM, Gauderer MW, Boyle JT, et al: Diagnostic laparoscopywith planned appendectomy: An integral step in the evaluation ofunexplained right lower quadrant pain. Pediatr Surg Int 20:123-126, 2004

. Meier DE, Guzzetta PC, Barber RG, et al: Perforated appendicitis inchildren: Is there a best treatment? J Pediatr Surg 38:1520-1524,
2003

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ntussusception

aird Mallory, MD,1 and Yale Popowich, MD2

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n children 3 months to 3 years of age intussusception isone of the most common causes of a distal small bowel

bstruction. It is often associated with intermittent painccompanied by a characteristic knees-to-chest position,omiting, and passage of bloody “currant jelly” stools. Asausage shaped mass in the right upper quadrant” isore often described than palpated (Fig 1). In this age

roup, intussusception is thought to occur secondary toiral infection inflaming Peyer’s patches or, perhaps, theppendix—either of which may then act as the “leadoint” of the intussusceptum that invaginates or “tele-copes” downstream into the intussuscipiens. It is liter-lly as though the downstream bowel has mistaken thepstream bowel for stool and is trying to propel it forwardoward the anus. This typically occurs just proximal tohe ileo-cecal valve and so is called “ileo-cecal” intussus-eption.

When intussusception occurs outside of this age group,n most cases there will be a pathologic lead point includ-ng:

● lymphoma● carcinoid tumor● adenocarcinoma● Meckel’s diverticulum● mural hematoma from Henoch-Schonlein purpura

or trauma● polyp● duplicationIntussusception may also occur after operations, par-

icularly those involving the retroperitoneum, althoughn this circumstance it may occur further up in the smallowel. At this location these intussusceptions, called “il-al-ileal,” are difficult to diagnose or treat with contrastnemas. They are best diagnosed by a computed tomog-aphy (CT) scan (ultrasonography may be successful inery experienced hands) and treated by operation. Expe-ienced laparoscopists will note that intussusceptions oc-ur in nonpathologic states: during operations for prob-ems nonenteric, small bowel may be observed to

From the 1Department of Pediatric Surgery, Packard Children’s Hospital attanford, Stanford, CA; and 2Department of General Surgery, Stanford Universityedical Center, Stanford, CA.Address reprint requests to Baird Mallory, MD, 780 Welch Rd, Suite 206,

tanford, CA 94305-5733.© 2005 Elsevier Inc. All rights reserved.1524-153X/04/0604-0010$30.00/0

ldoi:10.1053/j.optechgensurg.2004.10.009


ransiently intussuscept into itself and then return to aormal anatomic state without causing postoperativeymptoms.

Diagnosis of ileo-cecal intussusception is ideally doney ultrasound but is also possible by CT scan or wateroluble contrast enema. In the latter case the procedureay also be therapeutic: a bag of contrast is hung 3 feet

bove the patient and a catheter (with or without bal-oon—the author prefers with) is securely taped into thehild’s rectum. Nothing is more important than the com-ination of catheter and taping—if this is not hermetic itill be impossible to apply sufficient pressure via any of

he nonsurgical reduction techniques. It is probably wiseo give one dose of antibiotics with Gram-negative andnaerobic coverage (Cefotetan®). All nonoperative at-empts should be aborted and the patient transferred tohe operating room (after resuscitation) if he or she has orevelops an acute abdomen.Water soluble contrast (in other cases either water or

ir may be used) is infused under radiologic visualizationith which one can watch the intussusceptum being re-uced back out of the intussuscipiens.1 Although the

ntussusceptum may actually start physically coming outhe anus, it is more usually found in the ascending, trans-erse or descending colon from which it reduces in a lefto right direction. When air is used this may take as muchs 130 to 140 Torr for periods of 5 minutes at a time.2

here is always swelling at the ileo-cecal valve but onlyuid/air refluxing back up into the small bowel (throughn incompetent ileo-cecal valve) is proof positive of suc-ess.

When successful, the patient may soon begin fluids andhen solids followed by discharge in about 24 hours. Al-hough fever during the first 24 hours after reduction isot uncommon (thought to occur secondary to bacterialranslocation), there is experience in Sweden with actualatient dismissal directly from the radiology suite. Occa-ionally high reduction pressures expose an inguinal her-ia. Rarely these pressures cause bowel rupture—either

n the cecum (because of transmitted pressure) or rectumbecause of catheter balloon pressure). As long as air orater soluble fluid has been used there is typically little

ontamination of the abdomen during the operation thatccurs rapidly after patient stabilization. Barium, in thisircumstance, is disastrous and may be associated with
ife-threatening infection.

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331Intussusception

Nonoperative reduction fails in 40% to 50% of patients,epending on the timing of presentation and aggressive-ess of the radiologists. Unsuccessful reductions may re-

ate to inadequate taping of the buttocks to establish suf-cient intraluminal pressure. When skilled radiologistsre unsuccessful, commonly the intussusceptum will be
artially dead and resection will be required. When less b
SURGICAL TE

he open approach is performed through an R-transversencision just above or below the umbilicus.4,5 The bowel

isp

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ggressive efforts have been made, operative reductionithout need for small bowel resection will be more com-on. The approach may be open or laparoscopic al-

hough the former may enable one to more effectivelysqueeze” the distal bowel (often compared with squeez-ng a tube of toothpaste) while pulling on the proximal
owel.3
CHNIQUE

ty it served as a lead point and to prevent future confu-

s exteriorized, demonstrating an engorged colon con-aining intussuscepted ileum (Fig 2). Squeezing on theolon while pulling on the ileum has been found moreuccessful than pulling alone (Fig 3). A successful reduc-ion is usually possible with viable bowel, although ery-hema and edema, and occasional discoloration, may in-icate a period of warming and waiting before assumingiability (Fig 4). This is a good time to remove the appen-ix (Fig 5), which is usually done because of the possibil-

Child in supine position showing position of masscross-hatched) and planned incision. Note that the incisionust be made near the level of the umbilicus, either just

bove or below it.

ion about a scar near McBurney’s point. The incision isrimarily closed (Fig 6).If the intussusceptum is dead it will be difficult, if not

mpossible, to reduce, indicating that resection is neces-ary. At this point it is very important to realize the intus-uscipiens is alive and some of the intussusceptum maye as well. Therefore, after aggressive manual reductionttempts, one makes a circular incision around the mostroximal portion of colon available; this enables exterior-zation of the intussusceptum and estimation of its viabil-ty and usually there is a portion which can be preservedor anastamosis. More than one operator has mistakenlyxcised the entire sausage of ileum-containing colon, sac-

Exteriorized cecum, appendix, and ileum. Note ileum (in-ussusceptum) invaginated into cecum (intussuscipiens)auses cecum to appear bulky. Appendix has been reduced byir enema.

332 Mallory and Popowich

3 The combined method of squeezing the distal bowel (colon) while pulling on the proximal bowel (ileum) is demonstrated.

333Intussusception

4 Reduced bowel demonstrates hyperemia and edema; this is mild compared with many other cases.

5 Appendectomy is performed in case the appendix has served as a “lead point.”

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334 Mallory and Popowich

ificing more bowel than necessary. This is not of greatignificance in the usual cases involving the ileo-cecalalve, but sometimes the segment is much longer—in thisase excess excision of small bowel and colon may lead to

When the operation is complete, the skin is primarilylosed.

hort gut syndrome.

The laparoscopic approach involves ports (3) placedhrough the umbilicus, right lower quadrant and supra-ubic region, after the usual precautions. One attempts touplicate the maneuvers used in the open operation. Onedditional maneuver includes pulling the colon intussus-ipiens over the surface of the intussusceptum (distally)s surrogate for squeezing the colon like a tube of tooth-aste. If resection is necessary, the subsequent anastamo-is may be performed intracorporeally or extra-corpore-lly through an enlarged umbilical incision, dependingn surgeon preference. Laparoscopic reduction may beugmented by rectally applied reduction pressure al-hough the subsequent swelling of the colon with air maybscure the surgeon’s view.There are few long-term complications other than re-

urrence (�10% following nonoperative reduction), ad-esive small bowel obstruction (more common followingpen reduction) and stenosis when ischemic bowel is notesected.

REFERENCES. Goldstein AM, Cho NL, Massiotti MV, et al: Pneumatically assisted

laparoscopic reduction of intussusception. Pediatr Endosurg InnovTech 1:33-37, 2003

. Guo JZ, Ma XY, Zhou QH: Results of air pressure enema reductionof intussusception: 6,396 cases in 13 years. J Pediatr Surg 21:1201-1203, 1986

. Schier F: Experience with laparoscopy in the treatment of intussus-ception. J Pediatr Surg 32:1713-1714, 1997

. Wright VM: Intussusception, in Spitz, L (ed): Rob and Smith’sOperative Surgery: Pediatric Surgery. London, UK, Chapman &Hall, 1995, pp 396-401

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2004, vol.6, no.4, pediatric surgery

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