The minimally invasive surgery and regenerative medicine: clinical and experimental aspects

The field of pediatric surgery has undergone numerous changes throughout the past few years. First of all the laparoscopic surgery, introduced with reluctance because many of the instruments were not appropriate for their tiny patients. Finally, the often quoted benefits of smaller scars, less pain, and shorter hospital stays had not been shown to be true in the pediatric patient. However, in the mid 1990s, surgeons began to publish their laparoscopic pediatric cases, showing laparoscopy to be a potential alternative for these patients. When pediatric surgeons began to perform laparoscopic procedures on small children and neonates, they were often forced to use instruments designed for adult patients. In the mid 1990s, 2- and 3-mm instruments were developed, which allowed surgeons to work with greater ease in confined spaces. Around the same time, a neonatal insufflator was also developed. In contrast to adult insufflators, neonatal insufflators deliver CO2 in small, controlled puffs. This technology reduced the risk of over-insufflation that was often associated with using the oversized adult insufflators in small children. Over-insufflation can often be accompanied by a significant increase in end-tidal carbon dioxide, or the measurement of the amount of carbon dioxide in the expired air. If this is not adjusted for by the anesthesiologist, overinsufflation can lead to significant pulmonary complications in already fragile neonates. With these advances, more pediatric surgeons are expanding their repertoire of minimally invasive operations. Not only are they increasing the number of cases that can be performed laparoscopically, but they are also showing that they can be safely performed on neonates weighing 5 kg and less. In parallel the regenerative medicine was a relatively new field. This combining tissue engineering and cell transplantation, with the aim of replacing damaged tissues and organs using living cells. The regenerative medicine could lead to new ways of repairing or replacing injured organs, even during fetal development and therefore even children could benefit from this exciting field. Moreover, particularly in the field of tissue engineering, there has been a remarkable contribution from academic pediatric surgeons such as Anthony Atala and Joseph Vacanti. Congenital malformations are major causes of disease and death during the first years of life and most of the time functional replacement of the missing or damaged organ (or tissue) remains an unmet clinical need. Tissue engineering led by advances in two specific fields, cell biology and materials science, has combined to create the perfect biological substitution, while materials science and polymer generation, both of natural and synthetic origin, have had constant evolution. This thesis reports the results obtained during my PhD course in “Human, Reproduction, Development and Growth” (XXV Cycle) from 2009 to 2012. During the past 3 years I have been focused my research in these main fields following 3 lines of research: - Evaluation of changes of intestinal adaptation in animal model of short bowel syndrome and the possibility to increase the intestinal surface used a 3D scaffold as guide for the lengthening of the intestinal wall until complete absorption of the same scaffold - Study of the possibility of increase of the bladder and urethral surface used an animal model and a 3D scaffold as guide until complete absorption of the same scaffold in bladder - The standardization of laparoscopic techniques in pediatric patients by multicentric study

Current trends in the management of pediatric patients with perineal groove.

Objective: Perineal groove is an uncommon congenital anomaly of the perineum, affecting young girls. We report our experience in the treatment of this pathology. Design: Retrospective review of patients operated in our institution for a perineal groove between 1999 and 2007. Setting: Multidisciplinary clinic for young girls with perineal groove at the Department of Pediatrics, “Federico II” University, Naples, Italy. Participants: Six young girls (aged between 2 and 7 years) with perineal groove. Interventions: In the first three patients, who were operated on before 2004, the procedure consisted in resecting the groove and closing the perineal defect using interrupted sutures; in the last three, the skinwas closed with similar approach and then covered with a chemical glue to impermeabilize and protect the suture. Results: At a long-term follow-up, two of the three patients operated before 2004 experienced dehiscence of the perineal skin due to urine and feces contamination; in the last three patients in whom the sutures were covered with glue there was no skin dehiscence, and the postoperative course was uneventful. Conclusions: A perineal groove is a rare anomaly in young girls. Treatment consists in the surgical excision of the groove, generally after two years of age. On the basis of our experience it is preferable to cover the suture with a chemical glue to impermeabilize the suture line and protect the skin from infections

Laparoscopy-assisted jejunostomy in neurological patients with chronic malnutrition and GERD. Technical considerations and analysis of the results.

BACKGROUND: Feeding difficulties and gastroesophageal reflux (GER) are major problems in severely neurologically impaired children. Many patients are managed with a simple gastrostomy, with or without fundoplication. Unfortunately, fundoplication and gastrostomy are not devoid of complications, indicating the need for other options in the management of these patients. METHODS: Between January 2002 and June 2010, ten patients (age range, 18 months-14 years) have been treated by creating a jejunostomy with the laparoscopic-assisted procedure. The procedure was performed using 2-3 trocars. The technique consists of identifying the first jeujnal loop, grasping it 20-30 cm away from the Treitz ligament, and exteriorizing it to the trocar orifice under visual guide. The jejunostomy was created outside the abdominal cavity during open surgery. At the end of the jejunostomy, the correct position of the intestinal loops was evaluated via laparoscopy. RESULTS: Surgery lasted 40 min on average, the laparoscopic portion about 10 min. Hospital stay was 3 or 7 days for all patients. At the longest follow-up (8 years), all patients had experienced a significant weight gain. One patient died 1 year after the procedure of unknown causes. As for the other complications: 4/10 patients experienced peristomal heritema, 2/10 device's dislocation and 1 patient a peristomal granuloma. CONCLUSIONS: Laparoscopic-assisted jejunostomy is a safe and effective procedure to adopt in neurologically impaired children with feeding problems and GER. We advocate the use of this procedure in neurologically impaired patients with feeding problems and reflux due to its overall practicability and because there is minimal surgical trauma. The improvement in the quality of life of these children after the jejunostomy seems to be the major advantage of this procedure. However the management of jejunostomy can be difficult for parents above all in the first postoperative months

A modified approach for feminizing genitoplasty

Purpose We reported the use of the mucosal layer of preputial skin to give extra length to penile Xaps on vaginal introitus and labia minora reconstruction in children with congenital adrenal hyperplasia. Materials and methods Since November 1999, 14 patients (average age 16 months, range 6 months–4 years) have undergone early one-stage reconstruction of external genitalia. All patients were classiWed according to Prader’s classiWcation (from III to V degree) with clitoral size of 3 § 1.5 cm. The perineal sagittal approach is followed by careful dissection and partial mobilisation of the urogenital sinus. Subcutaneous reduction clitoroplasty has been performed. The mucosal layer of the prepuce, developed as an extended Xap on the end of the phallic shaft skin used for labia minora, is ideally placed for reconstruction of the vestibulae and distal vagina. Results The vagina was calibrated, the main vaginal calibre was 10 Hegar (range 6–14). With one exception, the urethral meatus was situated in the vestibulae and easily accessible. One distal vaginal stenosis was observed in a case with high conXuence. No urinary incontinence was noted. The appearance of external genitalia was very satisfactory. Conclusions The described genitoplasty provides a good cosmetic appearance. As most of our patients have not yet reached the age of sexual activity and child bearing, the functional results of this operation will need longer-term evaluation

Technical Standardization of Laparoscopic Direct Hernia Repair in Pediatric Patients.

Background: The aim of this article is to standardize the laparoscopic technique to treat direct inguinal hernia in pediatric patients. Patients and Methods: In the last 3 years we treated laparoscopically 163 patients with a diagnosis of inguinal hernia. In 7 patients we discovered laparoscopically a direct inguinal hernia. This study is focused on the management of these 7 cases (4 girls and 3 boys; median age 4.6 years). They presented a right defect in 4 cases and a left defect in 3 cases. Six of 7 patients had been already operated for an inguinal hernia and presented a recurrence of the hernia. We used three trocars, 5-mm 0 degree optic, and two 3-mm instruments. In each case, after the resection of the lipoma using the hook cautery, the defect was closed by means of separated stitches. In every case we used the vesical ligament as an autologous patch to reinforce the closure of the defect. Results: The average operative time was 35 minutes. All the procedures were performed in a day-hospital setting. We had neither conversions nor complications in our series. With a minimum follow-up of 1 year, we had no recurrence. Conclusions: Laparoscopic identification and repair of direct inguinal hernia in children is a safe and effective procedure to adopt. The key points of the technique are the resection of the lipoma, the closure of the defect using separated, nonabsorbable sutures, and the use of the vesical ligament to reinforce the suture. We believe that in case of recurrence of inguinal hernias after inguinal approach, laparoscopy is the gold standard technique to identify and treat the cause of the recurrence itself

Topical steroid application versus circumcision in pediatric patients with phimosis: a prospective randomized placebo controlled clinical trial

OBJECTIVES: Topical steroids have been advocated as an effective alternative treatment to circumcision in boys with phimosis. We evaluated the effectiveness of topical steroid therapy compared to a placebo neutral cream in 240 patients with phimosis. METHODS: A prospective study was carried out over a 24-months period, on an out-patient basis on two groups of patients with phimosis. One-hundred twenty patients applied a steroid cream twice a day for 4 weeks, and another group of 120 pts used a placebo cream twice a day for 4 weeks. Patients were assigned to either group by a computer-generated random choice. RESULTS: All patients in our series completed the two treatment periods without interruption. At a median follow-up of 20 months (6-30 months) therapeutic success was obtained in 43.75% (99/240) of cases, independently of the protocol. In particular, therapeutic success was obtained in 65.8% (79/120) of cases in the steroids group and in 16.6% (20/120) of cases in the placebo group, the difference being statistically significant (P < 0.0001, Mann-Withney test). CONCLUSION: Our study shows that topical steroids represent a good alternative to surgery in case of phimosis. Steroid therapy using monometasone furoate 0.1% in our series gave better results that placebo with an overall efficacy of 65.8%. In patients where a phimotic ring persist after steroid therapy, circumcision is mandatory