Biomedical subjects
Publications and source records attributed to Mario Lima.
We report a 5-year-old child with pancreatic trauma from a blunt abdominal injury that was monitored with contrast-enhanced sonography. Unenhanced US failed to demonstrate the abnormality that was recognized by CT and MRI. The injury was well demonstrated by contrast-enhanced US which was therefore used for follow-up until its healing.
PURPOSE: We describe our three-year experience with the laparoscopically assisted anorectal pullthrough for high imperforate anus using laparoscopic muscle electrostimulation. MATERIALS AND METHODS: From March 2001 to January 2004, 7 patients with a diagnosis of high anorectal malformation underwent laparoscopically assisted anorectal pull-through. The patients, all males aged from 4 to 9 months (mean age, 5.8 months), presented with a rectourethral fistula. The associated malformations noted were sacral malformation, laryngeal stenosis, urethral duplication, multicystic kidney, nonpalpable testis, and esophageal atresia. All patients were treated with a colostomy in the newborn period followed by a delayed laparoscopically assisted anorectal pullthrough. Laparoscopy included stimulation of the puborectal muscle, using a modified Peña electrostimulator introduced through a trocar. All patients underwent a postoperative period of anal dilatation. RESULTS: In 6 cases the laparoscopically assisted anorectal pull-through was successful; there was 1 conversion to the open technique, due to strong tension from the colostomy. CONCLUSION: Although longer follow-up to evaluate continence is to come, laparoscopically assisted anorectal pull-through should be considered for the correction of the high imperforate anus and, according to our experience, it represents the gold standard. It offers the advantage of good visualization of the fistula and the surrounding structures and minimally invasive abdominal and perineal wounds. With the laparoscopic Peña stimulator the direct observation of the contraction of the puborectalis sling allows an evaluation of the functional contractility and an accurate colonic pullthrough in the center of the muscle complex.
PURPOSE: Diagnostic laparoscopy has changed the surgical approach to nonpalpable testes (NPT). The aim of this study was to determine the value of laparoscopy in managing patients with NPT and to suggest guidelines for the interpretation of laparoscopic findings. The authors report the results of a multicenter study of the Italian Society of Video Surgery in Infancy on laparoscopic management of NPT. METHODS: Between 1993 and 2001, the authors collected records of 364 patients with NPT who underwent laparoscopy, for a total of 388 testicular units. RESULTS: Intraabdominal testes were found in 124 (34%) cases, for a total of 137 testes; 83 testicular units were classified as low and 54 as high. A total of 155 (43%) patients had cord structures entering the internal inguinal ring, 79 (22%) had intraabdominal blind-ending cord structures, and 6 (1%) had testicular agenesia. CONCLUSIONS: Laparoscopy is a valuable tool in diagnosing and treating more than 50% of cases of NPT. The laparoscopic evaluation of abdominal testes can provide indications for the most suitable surgical technique; moreover, in 23% of patients, it makes abdominal exploration unnecessary. The value of laparoscopy is even greater if the anatomical aspect of the internal ring and spermatic cord structures is carefully evaluated.
BACKGROUND: Fetal and neonatal hepatic arteriovenous fistulas are rare and associated with a high mortality rate; they can be prenatally detected by ultrasonography. Management of these malformations can be a challenge for pediatric surgeons. METHODS: Two patients with a prenatal diagnosis of intrahepatic arteriovenous shunts were treated at our institution in the last 2 years. A hepatic complex arteriovenous malformation fed respectively by prominent branches of the hepatic artery and of the celiac trunk rising from dilated suprarenal aortae and draining into suprahepatic veins was detected. In the first case, an embolization was performed; in the second, the surgical resection of the vascular malformation was the treatment of choice. RESULTS: The first patient died after embolization and before surgery for hemodynamic complications. The second patient, at a follow-up of 16 months, is alive and doing well. CONCLUSION: Hepatic resection is the treatment of choice for localized intrahepatic arteriovenous malformation. Theoretically, embolization could be curative or reduce the size of a malformation, making consequent hepatic resection feasible. Results do not support this theory because of the high rate of complications recorded that brought in every case, ours included, to the death of the child.
Foreign body aspiration can produce serious pulmonary diseases. Timely diagnosis and appropriate treatment is important to prevent long-term complications in affected children. We report the case of a 15-month-old child with a 5-month history of regurgitation, vomiting, recurrent tracheobronchitis, and pneumonia. The diagnosis was gastroesophageal reflux. The laryngotracheal endoscopy revealed a rabbit vertebra partially obstructing the airway at the level of the cricoid cartilage. With a rigid bronchoscope and forceps equipped with a telescope, it was possible to disengage and extract the foreign body. Six months later endoscopic control revealed no residual alterations in the larynx and trachea.
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PURPOSE: Müllerian duct remnants (MDRs) are present in a male pseudohermaphroditic form characterized by failure of the müllerian duct to regress due to insufficient production or peripheral action of müllerian inhibiting substance. The MDR can be asymptomatic but it often results in infections, stones and voiding troubles. Furthermore, it may develop into a neoplasm. Therefore, surgery is mandatory for large MDRs and symptomatic patients. Laparoscopic removal is described. MATERIALS AND METHODS: Six males were treated from February 1998 to February 2003. Age at surgery was between 3 and 18 years (mean 8.6). All patients showed severe hypospadias and 2 had mixed gonadal dysgenesis with ambiguous genitalia. Three patients presented with urogenital infections and all had a large MDR. Laparoscopic procedures, which were preceded by cystoscopy, were performed using a 10 mm umbilical trocar for the camera and 3, 5 mm trocars for instruments placed in the suprapubic region and iliac fossa bilaterally. The remnants were ligated with endoscopic loops or an endoscopic GIA stapler and cut. RESULTS: Mean operative time was 2 hours. We noted no complications. In 2 cases there was deferential ectopia and in another of mixed gonadal dysgenesis bilateral gonadectomy was performed because of the risk of degeneration. Feeding started on postoperative day 1 and the patients were discharged home on day 5. After a followup of 8 months to 4 years all boys were healthy. CONCLUSIONS: Multiple approaches are used in traditional surgery, often leading to complications. Laparoscopy improves the view, decreases surgical risk and operative time, avoids large scars and allows more rapid hospital discharge.
PURPOSE: We evaluate the results and complications of laparoscopic urological procedures in children. MATERIALS AND METHODS: In a 3-year period 4,350 laparoscopic procedures were performed at 8 Italian centers of pediatric surgery. We analyzed only the data of urological procedures for a total of 701 laparoscopic operations on patients 1 month to 14 years old. The indications for surgery were cryptorchidism in 414 cases, varicoceles in 159, ambiguous genitalia in 37, total nephrectomy in 34, partial nephrectomy in 4, adrenalectomy in 3 and other diagnostic procedures in 50. We adopted a retroperitoneoscopic approach in 72 cases (10.3%) and a laparoscopic approach in 629 (89.7%). Patient records were analyzed to search for any complication that may have occurred during the laparoscopic procedure and assess how they were managed. RESULTS: We recorded 19 complications (2.7%) in our series, of which 6 required conversion to open surgery and 13 did not. There was no mortality. At a maximum followup of 4 years all children were alive and had no problems related to the laparoscopic complications. CONCLUSIONS: Our study shows that pediatric laparoscopic urological surgery has an acceptable rate of complications with no mortality. We believe that routine use of open laparoscopy in pediatric patients is a key factor to help avoid complications. Most complications can be avoided with surgeon and team experience, together with proper compliance with the indications for surgery.