IPEG’s 23rd Annual Congress for Endosurgery in Children Held in Conjunction with BAPS 61st Annual Meeting July 22-26, 2014 EDINBURGH INTERNATIONAL CONFERENCE CENTRE (EICC) EDINBURGH, SCOTLAND

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6325 Gunpark Drive, Suite G Boulder, CO 80301 6325 Gunpark(866) Drive, 683-1743 Suite G www.JustRightSurigcal.comBoulder, CO 80301 (866) 683-1743 www.JustRightSurigcal.com IPEG’s 23rd Annual Congress for Endosurgery in Children Held in Conjunction with BAPS 61st Annual Meeting July 22-26, 2014 EDINBURGH INTERNATIONAL CONFERENCE CENTRE (EICC) The Exchange, Edinburgh EH3 8EE, Scotland T: +44 (0) 131 300 3000 www.eicc.co.uk

International Pediatric Endosurgery Group (IPEG) 11300 W. Olympic Blvd, Suite 600 Los Angeles, CA 90064 T: +1 310.437.0553 F: +1 310.437.0585 E: [email protected]

Edinburgh skyline over East Princes Street Garden

WWW.IPEG.ORG | 1 DEAR COLLEAGUES,

Welcome to IPEG’s 23rd Annual Congress for Endosurgery in Children! IPEG is very pleased that this congress will be held in conjunction with the British Association of Paediatric Surgeons (BAPS) for the first time. Therefore, I would like to particularly welcome the President of BAPS, Rick Turnock and his team and to thank them for their efforts to ensure that this congress will be successful. The congress chairman of IPEG, Philipp Szavay and his co-chairs, Katherine Barsness, Go Miyano and Pablo Laje have set up an excellent program. Panels deal with hot topics and again, experts will teach their tips and tricks in the IPEG workshops. IPEG is a relatively young association with a strong innovative drive. BAPS has its tradition and unique standing within our paediatric surgical community. These differing perspectives give this inaugural joint congress the opportunity to offer unique joint sessions and discussions on pros and cons of endosurgical techniques in children. Numerous aspects of endoscopic surgery in children remain to be evaluated and a new generation of surgeons is ready to get involved. IPEG is a unique association with many opportunities for young surgeons. I am happy to invite you all to participate, to get involved with IPEG and to find new friends during this congress. Finally, don’t miss our main event which will be extraordinary fun. Enjoy the traditional Celeigh, an outrageous party and don’t forget to bring your dancing shoes. Welcome to Edinburgh! Benno Ure, MD, PhD 2014 IPEG President

TABLE OF CONTENTS Edinburgh Information 3 Commercial Bias Reporting Form 60 General Information 4 CME Worksheet 61 Meeting Hours 6 Faculty Disclosures 63 Accreditation 6 Presenter Disclosures 65 Program Chairs 7 Long Term Research Fund Donors 69 CME Chairs 10 New Membership 72 Meeting Leaders 12 Hotel Information 74 Meeting Faculty 14 Social Programs 74 Schedule-at-a-Glance 16 Oral Abstracts 75 Innovations Corner 18 Video Abstracts 157 Complete Schedule 24 Top Posters 171 Exhibitors & Exhibit Hall Floorplan 56 Poster Abstracts 201 Exhibitor Profiles 57

IPEG’s 23rd Annual Congress for Endosurgery in Children ■ July 22-26, 2014 | 2 Table of Contents Edinburgh Information

Scotland’s Inspiring capital city – is one of the most beautiful cities in Europe, where stunning cultural heritage fuses with the best of modern, dynamic World Heritage city. The city can be warm and pleasant during the summer although being close to the Firth of Forth means there can also be a cool coastal breeze and occasional mists (known locally as ‘haar’). From April to September, temperatures are mild and compare favourably with other European cities. Annual rainfall is the same as Frankfurt, New York and less than in Rome. Edinburgh Castle AIRPORT/TRAVEL INFORMATION Edinburgh Airport lies 8 miles (12 km) west of the city centre and is easy to reach thanks to reliable and frequent bus services. A range of taxi services and car hire options using major companies are also available. By Bus: The Airlink 100 express bus service operates a 24-hour shuttle service between Edinburgh Airport and Waverley Bridge (near Princes Street and the main rail and bus stations), with designated stops en route. The service is frequent - every 10 minutes at peak times – with a journey time of about 25 minutes. By Taxi: Official airport taxis, pre-booked private hire taxis and city black cabs are all available, each with separate ranks. Many taxis are wheelchair-accessible and the journey time is around 25 minutes (although this may be longer during rush hours). Car hire and driving: Vehicles can be hired from all major companies at Edinburgh Airport’s new car rental facility close to the main terminal building. Train and Tram: At present, there is no direct rail access between central Edinburgh and the airport. A high-quality, modern and efficient tram network is currently being built for Edinburgh and is scheduled to be running from the airport to the city centre from 2014.

VISA Information for International Attendees As part of the United Kingdom, Scotland has the same visa requirements. Visitors from the EU, rest of Europe and US, Canada, Australia and New Zealand can visit without a visa. Visitors from all other countries must have a valid visa to visit Scotland and details can be found at www.ukba.homeoffice.gov.uk.

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Why IPEG? Now is an excellent time to become an IPEG member. Join IPEG now and receive a substantial discount on the meeting registration by being an IPEG member! Your dues also include a subscription to the Journal of Laparoendoscopic & Advance Surgical Techniques (a $900 value is yours for FREE with your paid IPEG membership.)

Who Should Attend? The 23rd Annual Congress of the International Pediatric Endosurgery Group (IPEG) as elements that have been specifically designed to meet the needs of practicing pediatric surgeons, urologists, and other related specialties, physicians-in- training, GI assistants, and nurses who are interested in minimally invasive surgery in children and adolescents. The IPEG Program Committee recommends that participants design their own attendance schedule based on their own personal educational objectives.

2014 Meeting Objectives The objectives of the activity are to educate pediatric surgeons and urologists about developing techniques, to discuss the evidence supporting adopting these techniques, to provide a forum for discussions at a scientific level about the management principles regarding minimally invasive surgical techniques and to reveal scientific developments that will affect their patient population.

Specific Objectives include: 1. Presentation of new and developing minimally invasive surgical techniques in a scientific environment. 2. Interaction with experts in the fields of minimally invasive pediatric surgery and urology via panel discussions and informal networking. 3. Debates about controversial issues regarding indications, techniques and outcomes of minimally invasive surgery in infants and children. 4. Encourage and establish international networking in the management and minimally invasive surgical interventions for infants and children. At the conclusion of the activity, pediatric surgeons and urologists will be able to safely incorporate minimally invasive surgical techniques into their practice by applying the evidence-based medical knowledge and skills learned, recognizing pitfalls and monitoring patient outcomes.

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General Information CONTINUED

Best Science Award The Best Science Award will be a cash prize of US $1,000 to be presented on Saturday during the Awards Presentation Session. The Program Committee will select the Award recipient. The IPEG Executive Committee is committed to education and feels that this is a very concrete way to express that commitment.

IRCAD Award As a result of a generous grant provided by Karl Storz Endoscopy, the best resident abstract presenters will be selected by the IPEG Publications Committee to receive the 2014 IRCAD Award. The Award recipients will travel to Strasbourg France to participate in a course in pediatric minimally invasive surgery at the world famous European Institute of Telesurgery. This center at the University of Strasbourg is a state-of-the-art institute for instruction in all aspects of endoscopic surgery that is now providing a series of courses in pediatric surgery.

IPEG Member Benefits IPEG exists to support excellence in Pediatric Minimal Access Surgery and Endoscopy through education and research; to provide a forum for the exchange of ideas in Pediatric Minimal Access Surgery and Endoscopy; and to encourage and support development of standards of training and practice in Pediatric Minimal Access Surgery and Endoscopy. Benefits of membership include: ■■ Subscription to the Journal of Laparoendoscopic & Advance Surgical Techniques (a $900 value is yours for FREE with your paid IPEG membership.) ■■ Significant discounts on registration fees for the Annual Congress for Endosurgery in Children. (Note: registering for the IPEG Scientific Session, as a member, will save you the equivalent of one year’s dues) ■■ Affordable dues for surgeons and surgeons-in-training in any country. ■■ Opportunities to meet and discuss pediatric minimally invasive surgery with leaders and innovators in the field. For more information and applications, please go to: www.ipeg.org/member/memberapplication.

Event Dress Code Please note that the dress code for the entire conference is business casual. The average temperature is expected to be 19°C.

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Registration Hours Strathblane Hall Tuesday, July 22, 2014 12:00 pm – 5:00 pm Wednesday, July 23, 2014 6:30 am – 6:00 pm Thursday, July 24, 2014 6:30 am – 5:30 pm Friday, July 25, 2014 6:30 am – 5:30 pm Saturday, July 26, 2014 7:00 am – 12:00 pm Exhibit Dates & Times Cromdale Hall Wednesday, July 23, 2014 5:00 pm – 7:00 pm IPEG/BAPS Welcome Reception Thursday, July 24, 2014 9:30 am – 4:00 pm Top Posters 1-20: Digital Presentation 12:00 pm – 1:00 pm Friday, July 25, 2014 9:30 am – 4:30 pm Top Posters 21-40: Digital Presentation 12:00 pm – 1:00 pm Speaker Prep Hours Soutra Wednesday, July 23, 2014 6:00 am – 6:00 pm Thursday, July 24, 2014 6:00 am – 5:30 pm Friday, July 25, 2014 6:00 am – 5:30 pm Saturday, July 26, 2014 6:00 am – 12:00 pm Accreditation

The Activity has been planned and implemented in accordance with the Essentials and Standards of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and IPEG. SAGES is accredited by the ACCME to provide medical education for Physicians. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) designates this live activity for a maximum of 24.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Date Total Credits Tuesday, July 22, 2014 3.75 Thursday, July 24, 2014 8.25 Friday, July 25, 2014 9 Saturday, July 26, 2014 3.25

IPEG’s 23rd Annual Congress for Endosurgery in Children ■ July 22-26, 2014 | 6 Table of Contents 2014 Program Chairs PROGRAM CHAIR: Philipp O. Szavay, MD CO-CHAIR: Katherine A. Barsness, MD CO-CHAIR: Pablo Laje, MD CO-CHAIR: Go Miyano, MD

Philipp O. Szavay, MD Program Chair Children’s Hospital, Lucerne, Switzerland Philipp Szavay is currently Professor of Pediatric Surgery and Head of the Department of Pediatric Surgery at the Children’s Hospital in Lucerne, Switzerland. He attended Medical School at the University of Tuebingen, Germany from 1988-1995 and residency and fellowship at the Department of Pediatric Surgery at the Hannover Medical School in Hannover, Germany from 1995-2002. He then became Attending Surgeon at the Department of Pediatric Surgery at the University Children’s Hospital again in Tuebingen, Germany from 2002-2006. From 2006-2013 he was assigned to the Deputy Head of the Department. Dr. Szavay is particularly interested in minimally invasive pediatric surgery as well as in pediatric urology. He has a strong focus on surgical education especially in the field of minimally invasive techniques and directed numerous national and international courses respectively. He is a member of the Executive Board of the German Society of Pediatric Surgery as well as of several professional societies. Dr. Szavay has published more then 37 manuscripts, 3 book chapters and 2 DVD’s on minimally invasive pediatric urology and on thoracoscopy and presented over 120 abstracts.

IPEG 2014 CORPORATE SUPPORTERS Diamond Level Gold Level Stryker Endoscopy Karl Storz Endoscopy

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2014 Program Chairs CONTINUED

Katherine A. Barsness, MD Program Co-Chair Ann & Robert H Lurie Children’s Hospital, Chicago, Illinois Dr. Katherine A. Barsness received her cum laude B.S. degree in Biochemistry and her honors M.D. degree from the University of Tennessee. Dr. Barsness then went on to complete her internship and residency in general surgery, and a two-year basic science and trauma research program, at the University of Colorado. In 2007, Dr. Barsness completed her pediatric surgery fellowship at the University of Pittsburgh, and then joined the faculty at Northwestern University Feinberg School of Medicine, where she currently holds a joint appointment as an Assistant Professor in the Departments of Surgery and Medical Education. Dr. Barsness has received numerous teaching awards throughout her career, and is well recognized for her work in pediatric surgical education, both in the US and abroad. Dr. Barsness is the Director of Surgical Simulation for Ann and Robert H. Lurie Children’s Hospital of Chicago. Dr. Barsness was also recently appointed as the Director of Surgical Clinical Outcomes Research and an Associate Director of Surgical Translational Research for the Children’s Research Center at Lurie Children’s Hospital. She sits on the curriculum committee for simulation-based education, and serves as the Director of External Relations, for the Center for Education in Medicine in Northwestern University Feinberg School of Medicine. Dr. Barsness’ research focuses on the development and validation of educational tools and simulation models for use in pediatric surgical training. Dr. Barsness is a strong advocate for the advancement of surgical skills across the continuum of medical education, and remains committed to the growth and development of IPEG into a world-class organization, advancing the science of advanced minimally invasive surgical techniques for infants and children.

Pablo Laje, MD Program Co-Chair Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania Dr. Pablo Laje is currently Assistant Professor of Surgery at the University of Pennsylvania and Attending Surgeon at the Children’s Hospital of Philadelphia (CHOP), USA. He attended Medical School at the University of Buenos Aires and graduated in 1999. He trained in pediatric surgery at the JP Garrahan Pediatric Hospital in Buenos Aires, Argentina and obtained his Board Certification in 2005. Pursuing further training he went to CHOP in 2005 for a clinical/research fellowship in pediatric and fetal surgery. In 2011 he was appointed CHOP faculty.

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2014 Program Chairs CONTINUED

Dr. Laje has a particular interest in pediatric minimally invasive surgery and has conducted numerous basic science research projects to study the physiological implications of minimally invasive surgery on healthy and diseased organs. In 2008 he won the Best Basic Science Abstract Award at IPEG and obtained IPEG’s Research Grant for his work on biliary atresia. He has more than 30 publications on PubMed and has written multiple book chapters in the pediatric surgery literature.

Go Miyano, MD Program Co-Chair Juntendo University School of Medicine, Tokyo, Japan Go Miyano is currently an Associate Professor in the Department of Pediatric General and Urogenital Surgery at Juntendo University School of Medicine, and Chief Medical Officer in the Department of Pediatric Surgery at Shizuoka Children’s Hospital. He attended Juntendo University School of Medicine, Tokyo, Japan from 1995-2001 and completed his residency and fellowship in the Department of Pediatric General and Urogenital Surgery at Juntendo University Hospital under the supervision of Atsuyuki Yamataka from 2001-2006. He was a visiting research fellow in the Department of Pediatric Surgery at Blank Children’s Hospital under the supervision of Professor Thom E. Lobe from 2006-2007 and in the Department of Pediatric General and Thoracic Surgery at Cincinnati Children’s Hospital under the supervision by Professor Thomas H. Inge from 2007-2008. He has held his current position since 2009. He has a keen interest in the education of medical students and residents, and was voted the best tutor by his peers during his first year on faculty at Juntendo University School of Medicine and awarded. He has since been actively involved as a member of the Board of Directors for Medical Student Education at Juntendo University. He has a strong focus on minimally invasive pediatric surgery, and has published over 60 manuscripts in authoritative peer-reviewed journals, over 30 as first author. He has also given over 30 presentations at various international conferences.

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Celeste Hollands, MD St. John’s Children’s Hospital in Springfield, IL, USA University of South Alabama in Mobile, AL, USA Dr. Hollands is currently a Pediatric Surgeon at St. John’s Children’s Hospital in Springfield, Illinois and is Adjunct Associate Professor of Surgery at the University of South Alabama in Mobile, Alabama. Dr. Hollands completed medical school at the University of South Alabama and completed her surgical residency at The Graduate Hospital of the University of Pennsylvania. She completed a Pediatric Trauma fellowship at The Children’s Hospital of Philadelphia and a Pediatric Surgery Fellowship at Miami Children’s Hospital. She served on the surgical faculty as Assistant Professor of Surgery and Pediatrics at Louisiana State University Health Sciences Center in Shreveport, Louisiana where her research focused on developing pediatric robotic surgical procedures. She served on the faculty of the University at Buffalo, Women’s and Children’s Hospital of Buffalo as Associate Professor of Surgery and Pediatrics where she was Director of the Miniature Access Surgery Center and Director of Trauma. Dr. Hollands was Associate Professor of Surgery and Pediatrics at the University of South Alabama where she served as Chief of Pediatric Surgery and Director of Surgical Simulation. Dr. Hollands has published on topics that include: minimally invasive and robotic surgery, pediatric trauma, simulation, and faculty development. She serves on the Executive Committee of the American College of Surgeons Committee on Medical Student Education, on the American College of Surgeons and Association for Surgical Education Medical Student Core Curriculum Steering Committee, is Secretary of the Association of Women Surgeons, and is active in committee service in the International Pediatric Endosurgery Group, Society of American Gastrointestinal and Endoscopic Surgeons, and Association for Surgical Education. She serves on the editorial board of The American Journal of Surgery and The Journal of Laparoendoscopic and Advanced Surgical Techniques and is an ad hoc reviewer for several other journals. Her interests include advanced minimally invasive surgery and robotics, technical skills acquisition, surgical simulation and education

Holger Till, MD, PhD Medical University of Graz, Graz, Austria Professor Holger Till is currently Chair Professor and Director of the Department of Paediatric and Adolescent surgery at the Medical University of Graz. He attended Medical School at the University of Goettingen and the University of California in San Diego (UCSD). He also participated in a student exchange program with the Harvard Medical School and got fascinated by pediatric surgery while working with Professor Patricia Donahoe at the Massachusetts General Hospital in Boston.

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2014 CME Chairs CONTINUED

After graduation in 1989 he completed his residency in General Surgery and his fellowship in Pediatric Surgery at the Ludwig-Maximilians University of Munich. His career as a Pediatric Surgeon started at the Dr. von Hauner Children’s Hospital of the University of Munich. In 2004 he became an Assistant Professor of Pediatric Surgery at the Chinese University of Hong Kong with Professor Yeung. In 2006 he returned to Germany and accepted the Professorship for Pediatric Surgery in Leipzig until becoming the successor of Professor Michael Höllwarth in Graz in 2012. Professor Till has a special interest in pediatric minimal invasive surgery and was the director of the Single-Portal Laparoscopic Surgery (SPLS) training course at the IRDC (International Reference and Development Center for Surgical Technology) in Leipzig. He also chaired the training academy of the German Society of Pediatric Surgery. His present research introduces modern techniques like metabolomics and proteomics to malformations of the newborn as well as morbid obesity. He has published more than 130 scientific articles in national and international indexed journals and presented over 100 abstracts. Professor Till is a member of several professional societies and serves on the Editorial Board of many prestigious journals.

Suzanne M. Yoder, MD Pediatric Surgeon in Arizona and Kansas, USA Dr. Yoder graduated from Jefferson Medical College in Philadelphia and completed her surgical residency at the University of California San Diego. After spending one year at the Fetal Treatment Center at the University of California San Francisco Dr. Yoder completed a surgical critical care fellowship at Children’s Mercy Hospital in Kansas City and then her pediatric surgery fellowship at Yale. Dr. Yoder then joined the pediatric surgery practice at the Rocky Mountain Hospital for Children in Denver Colorado. After four years in Denver, Dr. Yoder moved back to California to pursue her interest in international surgical initiatives. Currently, Dr. Yoder works as a locum tenens pediatric surgeon in Arizona and Kansas while continue her involvement in various international surgery projects. She is an active member in the SAGES Global Affairs Committee having traveled to Mongolia four times to teach laparoscopic surgery in that country. Besides Mongolia, Dr. Yoder has participated in surgical outreach in Bolivia, Vietnam, Belize, Tanzania, and Haiti. Dr. Yoder remains active in the education committee and the CME committee of IPEG. Outside of surgery, Dr. Yoder enjoys surfing, skiing, hanging out with her dog and training for triathlons.

WWW.IPEG.ORG | 11 Table of Contents 2014 Meeting Leaders PROGRAM COMMITTEE Aayed R. Al-Qahtani, MD Philipp O. Szavay, MD Maria Marcela Bailez, MD ★ Hiroo Uchida, MD Katherine A. Barsness, MD Benno Ure, MD, PhD Ciro Esposito, MD Jean-Stephane Valla, MD Alan W. Flake, MD Kenneth Wong, MD James D. Geiger, MD Mark L. Wulkan, MD ★ Keith E. Georgeson, MD C.K. Yeung, MD Miguel Guelfand, MD Anna Gunnarsdottir, MD ★ Executive Committee Munther J. Haddad, FRCS Carroll M. Harmon, MD, PhD Ronald Hirschl, MD 2014 Pediatric Colorectal, George W. Holcomb III, MD Motility and Pelvic Celeste Hollands, MD ★ Reconstruction Conference Satoshi Ieiri, MD November 12-14, 2014 Saleem Islam, MD Nationwide Children’s Hospital Columbus, Ohio Tadashi Iwanaka, MD ★ Pablo Laje, MD Led by Program Directors, Marc Levitt, MD and Karen Diefenbach, MD, and experts in ★ Marc A. Levitt, MD GI and Urology, the conference will feature Long Li, MD ★ hands-on labs and case submissions from attendees. Visiting faculty will include Sean S. Marven, FRCS Drs. Georgeson, Langer, De la Torre, John J. Meehan, MD Teitelbaum and many others. Go Miyano, MD Oliver J. Muensterer, MD Todd A. Ponsky, MD ★ Steven Rothenberg, MD Atul J. Sabharwal, MD Shawn D. St Peter, MD

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2014 Meeting Leaders CONTINUED EXECUTIVE COMMITTEE PRESIDENT: Benno Ure, MD, PhD PRESIDENT-ELECT: Mark L. Wulkan, MD ◆ 1st VICE PRESIDENT: Maria Marcela Bailez, MD ◆ 2nd VICE PRESIDENT: David C. van der Zee, MD, PhD SECRETARY: Todd A. Ponsky, MD ◆ TREASURER: Marc A. Levitt, MD ◆ EDITOR: Daniel J. Ostlie, MD AMERICAS REPRESENTATIVE: Timothy D. Kane, MD EUROPE REPRESENTATIVE: Holger Till, MD, PhD WORLD-AT-LARGE REPRESENTATIVE: Edward Esteves, MD WORLD-AT-LARGE REPRESENTATIVE: Long Li, MD ◆ CME CHAIR: Celeste Hollands, MD ◆ PAST PRESIDENT: Tadashi Iwanaka, MD, PhD ◆

◆ Program Committee

PAST PRESIDENTS Tadashi Iwanaka, MD, PhD (2013)* Craig Albanese, MD (2003)* Carroll M. Harmon, MD, PhD (2012)* Vincenzo Jasonni, MD (2002) – Retired Gordon A. MacKinlay, OBE (2011)* – Peter Borzi, MD (2001)* Retired Steven Rothenberg, MD (2000)* Marcelo Martinez Ferro, MD (2010)* Juergen Waldschmidt, MD (1999) – George W. Holcomb III, MD (2009)* Deceased Jean-Stephane Valla, MD (2008)* Hock L. Tan, MD (1998) – Retired Atsuyuki Yamataka, MD (2007)* Takeshi Miyano, MD (1997) – Retired Keith Georgeson, MD (2006)* – Retired Steven Rubin, MD (1996) – Retired Klaas (N) M.A. Bax, MD (2005) – Retired Gunter-Heinrich Willital, MD (1995)* C.K. Yeung, MD (2004)*

*Active Past Presidents

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2014 IPEG Faculty *CONFIRMED

Hossein Allal, MD – Montpellier, France Aayed R. Al-Qahtani, MD – Riyadh, Saudi Arabia ◆ Georges Azzie, MD – Toronto, Canada Maria Marcela Bailez, MD – Buenos Aires, Argentina ◆ Katherine A. Barsness, MD – Chicago, IL, USA ◆ Simon Clarke, MD – London, United Kingdom Matthew S. Clifton, MD – Atlanta, GA, USA David C. G. Crabbe, MD – Leeds, United Kingdom ▲ Mark Davenport, MD – London, United Kingdom ▲ Dafydd A. Davies, MD – Halifax, Canada Karen A. Diefenbach, MD – Columbus, OH, USA Alex Dzakovic, MD – Chicago, IL, USA Simon Eaton, PhD – London, United Kingdom Peter Thomas Esslinger, MD – Lucerne, Switzerland Paula Flores, MD – Buenos Aires, Argentina Stefan Gfroerer, MD – Frankfurt, Germany Miguel Guelfand, MD – Santiago, Chile ◆ Carroll M. Harmon, MD, PhD – Buffalo, NY, USA ◆ George W. Holcomb III, MD – Kansas City, MO, USA ◆ Celeste Hollands, MD – Mobile, AL, USA ◆ Timothy D. Kane, MD – Washington, DC, USA Joachim F. Kuebler, MD – Hannover, Germany Martin Lacher, MD – Hannover, Germany Pablo Laje, MD – Philadelphia, PA, USA ◆ Andreas Leutner, MD – Dortmund, Germany Marc A. Levitt – Columbus, Ohio, USA ◆

Charles M. Leys, MD – Madison, WI, USA ◆ Program Committee Long Li, MD – Beijing, China ◆ ▲ BAPS Faculty

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2014 IPEG Faculty CONTINUED

Manuel Lopez, MD – Saint Etienne, France Tobias Luithle, MD – Tuebingen, Germany Gordon A. MacKinlay, OBE – Edinburgh, United Kingdom Maximillano Marcic, MD – Buenos Aires, Argentina Marcelo Martinez Ferro, MD – Buenos Aires, Argentina Sean S. Marven, FRCS – Sheffield, United Kingdom ◆ Milissa A. McKee, MD – Branford, CT, USA John J. Meehan, MD – Seattle, WA, USA ◆ Martin L. Metzelder, MD – Vienna, Austria Marc P. Michalsky, MD – Columbus, OH, USA Carolina A. Millan, MD – Buenos Aires, Argentina Go Miyano, MD – Tokyo, Japan ◆ Oliver J. Muensterer, MD – New York, NY, USA ◆ Daniel J. Ostlie, MD – Madison, WI, USA Agostino Pierro, MD – Toronto, Canada ▲ Todd A. Ponsky, MD – Akron, OH, USA ◆ Steven Rothenberg, MD – Denver, CO, USA ◆ Juergen Schleef, MD – Torino, Italy Shawn D. St. Peter, MD – Kansas City, MO, USA ◆ Philipp O. Szavay, MD – Lucerne, Switzerland ◆ Holger Till, MD, PhD – Graz, Austria Rick Turnock, MD – Liverpool, United Kingdom ▲ Benno Ure, MD, PhD – Hannover, Germany ◆ Reza M. Vahdad, MD – Bochum, Germany David C. van der Zee, MD, PhD – Utrecht, The Netherlands Mark L. Wulkan, MD – Atlanta, GA, USA ◆

CK Yeung, MD – Hong Kong, China ◆ ◆ Program Committee Suzanne M. Yoder, MD – Venice, CA, USA ▲ BAPS Faculty

WWW.IPEG.ORG | 15 Table of Contents Schedule-at-a-Glance PRE-MEETING COURSE Tuesday, July 22 Lowther 4:00 pm – 8:00 pm Postgraduate Lecture: MIS in Infants and Neonates IPEG’S 23rd ANNUAL CONGRESS Wednesday, July 23 Lennox 1 & 2 8:00 am - 11:00 am Hands On Lab: Critical Technical Skills for Neonatal and Infant Minimally Invasive Surgery 8:00 am – 11:00 am Simulator Hands On Lab: Advanced Neonatal High Fidelity Course for Advanced Learners 1:00 pm – 5:00 pm Simulator Hands On Lab: Innovations in Simulation- Based Education for Pediatric Surgeons 5:00 pm – 7:00 pm Joint IPEG/BAPS Opening Ceremony/Welcome Reception in the Exhibit Hall Thursday, July 24 Lennox 3 7:00 am – 8:00 am Morning Scientific Video Session I: Coolest Tricks, Extraordinary Procedures 8:00 am – 8:05 am Welcome Address 8:05 am – 9:00 am Scientific Session:Gastrointestinal 9:00 am – 9.30 am Presidential Address & Lecture: “Music, Endoscopic Surgery and IPEG” 9:30 am – 4:00 pm Exhibits/Posters Open 9:30 am – 10:00 am Break 10:00 am– 11:30 am Basic Science and Misc 11:30 am – 12:30 pm Lunch Break 12:00 pm – 1:00 pm Top Posters 1-20: Digital Presentation 1:00 pm – 5:50 pm IPEG & BAPS JOINT PROGRAMS Pentland, Sidlaw & Fintry Auditorium 1:00 pm – 3:00 pm IPEG/BAPS Presidential Debate: “Esophageal and Diaphragmatic Surgery – Thoracoscopic vs. Open” 3:00 pm – 3:30 pm Break 3:30 pm – 5:20 pm IPEG/BAPS Best Clinical Paper Session 5:20 pm – 5:50 pm Karl Storz Lecture: “Developing Neonatal MIS Surgery, Innovation, Techniques, and Helping an Industry to Change”

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Schedule-at-a-Glance CONTINUED IPEG’S 23rd ANNUAL CONGRESS Friday, July 25 Lennox 3 7:00 am – 8:00 am Morning Scientific Video Session II 8:00 am – 9:30 am Scientific Session:Urogenital 9:30 am – 4:30 pm Exhibits/Posters Open 9:30 am – 10:00 am Break 10:00am – 11:00 am Scientific Session:Gastrointestinal & Hepatobiliary II 11:00 am – 12:00 pm Scientific Session:Panel – “Laparoscopy in the Neonate and Infant: What’s New?” 12:00 pm – 1:00 pm Lunch Break 12:00 pm – 1:00 pm Top Posters 21-40: Digital Presentation 1:00 pm – 1:30 pm Keynote Lecture: “Lean Processes in the Hospital” 1:30 am – 2:30 pm Panel: Single Site Surgery 2:30 pm – 3:30 pm Scientific Session:Thorax 3:30 pm – 4:00 pm Break 4:00 pm – 5:00 pm Scientific Session:Bariatric, Robotics & Alternative Technologies 5:00 pm – 6:00 pm Panel: Live Surgery 7:00 pm – 11:30 pm Main Event Lennox 1 & 2 Celeigh and IPEG Dance Off – After Hours! Saturday, July 26 Lennox 3 8:00 am – 9:00 am Miscellaneous: Short Oral Papers 9:00 am – 9:30 am General Assembly: Presentation of the IPEG 2015 President 9:30 am – 9:45 am Awards: Coolest Tricks/Basic Science/IRCAD 9:45 am – 10:45 am Scientific Session:Single Site Surgery 10:45 am – 12:00 pm Saturday Movie Matinee: Complications – “My Worst Nightmare” – Complicated Cases, Pitfalls and Unusual Solutions 12:00 pm Closing Remarks

WWW.IPEG.ORG | 17 Table of Contents Innovations Corner ESOPHAGEAL ATRESIA MODEL A Training Model in Thoracoscopic Surgery for Esophageal Atresia

INTRODUCTION: Through time, the training and development of technical skills have been performed in the operating room. Clinical training using simulated environments may improve the efficiency and safety of laparoscopic surgery. We present a training model in laparoscopic surgery for esophageal atresia (EA).

MATERIAL & METHODS: To confine the training model, we divide it in three parts: A) Video surgery equipment. A video endoscopic unit with an image integrated module, three 3.5mm trocar, one 5.5 mm trocar, 3mm instruments. B) A doll is used, which simulated a term newborn having a longitudinal anterior and posterior opening of 10 cms long and 2cms wide, through which a separator is introduced. C). Rabbit tissue or synthetic material are used. We proceed to place the videosurgery unit just like a real procedure. Placing the optic, visualizes the first image of esophagus and trachea. Afterwards, performing a meticulous dissection the separation of the tracheoesophagean partition is done, a suture thread 5/0 is placed around the esophagus, making an intracorporeal knot. The same surgical technique, end to end anastomosis is performed.

CONCLUSION: Since the beginning of laparoscopy, the use of simulators have proven a great potential for training and acquiring skills , shortening the learning curve and the early use in real procedures. This model which perfectly simulates the environment of an EA has been used by pediatric surgeons in the unit, allowing them to acquire skills that could then be applied during surgery.

KEYWORDS: Training model, esophageal atresia.

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Innovations Corner CONTINUED ESPHAGEAL ATRESIA - COLEDOCO YEYUNO ANASTOMOSIS An Inanimate Model for Training Toracoscopic Repair of TEF/Esophageal Atresia

AIM: Present the evolution of a model developed for specific trainning in toracoscopic repair of TEF/ Esophageal atresia. MATERIAL & METHODS: The video starts showing the view of a complete repair using the final version of the model done with a 4mm lens, 3 mm instruments, 6/0 sutures and an HD camera. The procedure is being done by a postresidency fellow trained in open surgery who has never participated in a MIS TEF assisted by a senior MIS surgeon after being trained in basic inanimate models (PedFLS) and practising endoscopic suturing for 144 hours. Exercises consisted in dividing and suturing the fistula and doing an esophageal anastomosis with a transanastomotic tube. Extracorporeal and intracorporeal sliding knot tying were used. Aspects of the same model using 5mm instruments, 5/0 sutures and a 10mm lens inside the pediatric FLS trainer follows. This was the previous environment that we have used. Finally the domestic materials utilized are shown. We started with tubular balloons of 2 different colours to simulate the esophageal mucosal layer and a bended piece of for the traqueal simulation, always reproducing the view in an almost prone position. A small piece of wood was used as a support and half of a larger plastic corrugated tube (PVC) as a toracic posterior wall resembling ribs and intercostal spaces. A white plastic ribbon as the vagus nerve and, a half inflated round balloon as the lung were added and everything covered with an auto adhesive film as pleura. At the beginning we used it inside the Pediatric FLS trainer which was replaced by a plastic toy pink suitcase which can be perforated in the upper surface, making it easily portable. RESULTS: A pediatric surgeon with little experience in MIS and none in neonatal MIS was able to complete aTEF/ Esophageal atresia repair in the final version of the model in 70 minutes assisted by an experienced MIS surgeon. Cost of the matherials was less than 50 US$. DISCUSSION: A reproducible unexpensive inanimate model has been developed as an additional tool to facilitate the learning curve for MIS TEF surgery. Future validation is needed.

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Innovations Corner CONTINUED MAGNETIC ASSIST LAP TRAINER Simulation Model for the Training of Magnet-Assisted Laparoscopic Surgery

Magnet-Assisted laparoscopy is a novel surgical technique that requires additional training. In order to train surgeons with this technique, we have designed a model that simulates the outer and inner environment during magnet- assisted laparoscopy. With the aid of a local pediatric orthopedist, we built the core of the trainer with propylene (45 cm long x 28 cm wide x 18 cm thick). At the outer surface, we covered the center portion of the trainer with a 4-mm thick neoprene fabric (40 cm vertical axis x 50 cm wide) attached with Velcro. This system creates a hinge mechanism that allows for practical removal of surgical tools and simulated organs. So far, we have custommade several organs with foam rubber including liver-gallbladder (cystic duct and artery), uterus and most recently colon and appendix. During manufacture, we have taken into account several key factors: 1. To develop a trainer with optimal ergonomics. 2. To use simulated organs with similar appearance and consistency as the human tissue. 3. To use low cost of materials. 4. The model should require straightforward transportation. 5. The trainer should have smooth surfaces that enable optimal sliding of the magnetic instruments in the outer surface as well in the inside.

NEEDLESCOPIC SURGERY WITH STRYKER’S MINILAP

Stryker’s needlescopic instruments have the ability to eliminate ports without compromising proven safe surgical techniques. Because there are no trocars used, these 13 gauge percutaneous instruments may reduce trauma and may offer increased cosmetic benefits for all laparoscopic procedures, including hysterectomies and sacrocolpopexies

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Innovations Corner CONTINUED NEONATAL Neonatal Minimally Invasive Surgery Trainers

Scaled-neonatal trainers were designed to develop specific minimally invasive surgery skills. Initial measurements were taken of infants in the neonatal ICU between 2.5 and 3.5 kg with an average of 2.8 kg. Scaled training models were fabricated to simulate both laparoscopic and thoracoscopic procedures. Six models were developed in 2006 including the laparoscopic dexterity skills, laparoscopic running the bowel, laparoscopic suturing under tension, laparoscopic suturing of an anastomosis, thoracoscopic diaphragmatic hernia repair, and thoracoscopic esophageal atresia repair. The initial construct validity results were presented at IPEG in Buenos Aires at the 2007 meeting followed by expert testing at IPEG 2009 with benchmark results presented at the 2010 IPEG conference.

DA VINCI SURGICAL SKILLS SIMULATOR

The da Vinci Skills Simulator contains a variety of exercises and scenarios specifically designed to give users the opportunity to improve their proficiency with the da Vinci surgeon console controls. The case seamlessly integrates with an existing da Vinci® Si™ or Si-e™ surgeon console* and no additional system components are required. Built-in metrics enable users to assess skills, receive real-time feedback and track progress. Administrative tools let users structure their own curriculum to fit with other learning activities in their institution.

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Innovations Corner CONTINUED PEDIATRIC LAPAROSCOPIC SKILLS Pediatric Laparoscopic Surgery (PLS) simulator

The Pediatric Laparoscopic Surgery (PLS) simulator has been developed over several years, the emphasis being on tasks proven to benefit in the performance of Minimal Access Surgery (MAS) and for which construct validity (the ability to differentiate between novices, intermediates and experts) has been established. The model is a box trainer tailored to represent the size constraints (limited domain) faced by a pediatric surgeon. Performance with regard to time for completion and precision on individual tasks, as well as total score, allow one to discriminate between novice, intermediate and expert. The simulator’s simple design makes it very practical, whether using the validated tasks or a model of your choice. Further development using motion tracking of instruments within the PLS simulator may allow real time analysis of movement, and further improve the educational benefit.

TEF-CDH MODELS

Accurate measurements of ribs, thoracic space and scapulae for term neonates (50th% for age) were obtained from literature review. Solidworks 3D modeling software was used to design a rib cage with scapulae, replicating the exact dimensions of the thoracic cavity of a neonate. The rib cage was printed in ABS plastic on rapid prototyping machinery. The right side of the rib cage was printed for the esophageal atresia/tracheoesophageal fistula (EA/ TEF) model, while only the left side of the rib cage was printed for the diaphragmatic hernia (DH) model. Artificial tissue was modeled to recreate the anatomic abnormalities of EA/TEF and DH and secured to a base of platinum-cured silicon rubber. The entire apparatuses were then covered with synthetic silicon skin.

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Innovations Corner CONTINUED PYLORUS MODEL History of the UK pylorus model

When I arrived at the University of Kentucky in 2003, one of my senior partners expressed a desire to learn how to do a laparoscopic pyloromyotomy. However, he had very limited laparoscopic experience. We had a “dry lab” in the department that had MIS set-ups. We wanted to design an inexpensive model that would allow him to get used to the 2 dimensional world of laparoscopy as well as practice the key sequence of steps for a pyloromyotomy. We quickly realized that we could make a glove into a “stomach” very easily. Our first model used foam rubber for the muscularis and ioban drape for serosa. The glove itself is the mucosa. This is the model which we used to teach the cadence and the “feel” for lap pylorics. He successfully transitioned to laparoscopic pyloromyotomy but pointed out that the foam rubber did not feel the same when the spread was completed. The following year, I was approached by Stryker to use the model at an APSA meeting to get pediatric surgeons to try a pyloric spreader they were hoping to market. At that meeting we took the opportunity to get feedback from surgeons on both the instrument AND the model. The same issues with the foam came up. One day, I was thinking about fixing the model and the thought of using an olive came to mind. I made some trials and found that an green olive had the right “feel” for splitting the pylorus when stretched. A pitted green “queen” size olive is consistently 5mm thick and 15-20 mm long and when wrapped in ioban, has a feel that is very close to the inflamed muscle of pyloric stenosis The final change in the model occurred when the procedure switched in the OR form a cold knife to a bovie to cut the serosa. The ioban serosa is now pre cut and the bovie maneuver is not made with heat in the model. To date, over 300 learners have used the model and the feedback is good. A pilot study showing the results of training novices with the model showed good reliability and reproducibility was published in 2010. J Laparoendosc Adv Surg Tech A. 2010 Jul-Aug;20(6):569-73.

WWW.IPEG.ORG | 23 Table of Contents Complete Schedule TUESDAY, JULY 22 PRE-MEETING COURSE Tuesday, July 22 Lowther 4:00 pm – 8:00 pm POSTGRADUATE LECTURE: MIS in Infants and Neonates CHAIR: Katherine A. Barsness, MD DESCRIPTION: This course includes a series of didactic lectures that focus on the successful strategies for implementing neonatal minimally invasive surgery. Each speaker will discuss preoperative concerns, intraoperative set up and patient positioning, as well as tips and tricks for successfully overcoming any barriers to completing a neonatal MIS procedure. This course is designed for beginning and advanced MIS pediatric surgeons who are looking to expand their knowledge on the skills, techniques, and strategies for neonatal minimally invasive surgery. OBJECTIVES By the conclusion of the course, participants will be able to: • Articulate proper intra-operative set-up for a variety of neonatal MIS procedures • Describe appropriate patient positioning and port placement for a variety of neonatal MIS procedures • Describe common barriers to success for a variety of neonatal MIS procedures, and describe strategies to overcome these barriers • Understand how to add simulation-based educational strategies to the their current practice.

TIME TOPIC FACULTY 4:00 pm Duodenal Artresia Karen A. Diefenbach, MD 4:30 pm Tracheoesophageal Fistual Philipp O. Szavay, MD 5:00 pm Urology MIS Joachim F. Kuebler, MD 5:30 pm Break 5:45 pm Neonatal Robotics John J. Meehan, MD 6:15 pm Diaphragmatic Hernia Matthew S. Clifton, MD 6:45 pm Simulation-based Education Katherine A. Barsness, MD 7:15 pm Q&A All

IPEG acknowledges our Diamond Level Donor for their support of the course: Stryker Endoscopy

IPEG’s 23rd Annual Congress for Endosurgery in Children ■ July 22-26, 2014 | 24 Table of Contents Complete Schedule WEDNESDAY, JULY 23 IPEG’S 23rd ANNUAL CONGRESS Wednesday, July 23 Lennox 1 & 2 8:00 am - 11:00 am HANDS ON LAB: Critical Technical Skills for Neonatal and Infant Minimally Invasive Surgery CHAIR: Karen A. Diefenbach, MD CO-CHAIRS: Manuel Lopez, MD, Go Miyano, MD & David C. van der Zee, MD, PhD DESCRIPTION: Learn the critical skills necessary to safely perform operations in newborn infants, including instrument and suture selection, port placement, intracorporeal suturing, and instrument handling skills. Neonatal simulation models and 3 mm instruments will be used at all stations. Performance metrics will be assessed at the completion of the course. OBJECTIVES At the conclusion of this session, participants will be able to: • Choose appropriate instruments for neonatal and infant laparoscopy and thoracoscopy • Demonstrate improved instrument handling within the confines of a newborn chest or abdomen • Perform a successful intracorporeal knot. FACULTY: Alex Djakovic, MD; Peter Thomas Esslinger, MD; Stefan Gfroerer, MD; Joachim F. Kuebler, MD; Andreas Leutner, MD; Martin L. Metzelder, MD; Manuel Lopez, MD; Reza M. Vahdad, MD; and David C. van der Zee, MD, PhD IPEG acknowledges support for this course from: Karl Storz Endoscopy and Stryker Endoscopy

8:00 am – 11:00 am SIMULATOR HANDS ON LAB: Advanced Neonatal High Fidelity Course for Advanced Learners CHAIR: Katherine A. Barsness, MD CO-CHAIRS: Georges Azzie, MD & Pablo Laje, MD DESCRIPTION: This course is designed for advanced MIS pediatric surgeons who are about to begin, or have already begun, to introduce laparoscopic duodenal atresia repair, thoracoscopic diaphragmatic hernia repair (with and without a patch), thoracoscopic TEF repair, and/or thoracoscopic lobectomy. All participants must provide a Departmental Chief’s letter documenting expertise in basic MIS procedures, to be eligible to attend this course. Performance metrics will be assessed at the completion of the course.

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OBJECTIVIES At the conclusion of this session, participants will be able to: • Choose appropriate instruments for neonatal laparoscopy and thoracoscopy • Demonstrate improved instrument handling and knot tying skills within the confines of a newborn chest or abdomen • Demonstrate and describe port placement for common neonatal procedures. FACULTY: Georges Azzie, MD; Maria Marcela Bailez, MD; Simon Clarke, MD; Matthew S. Clifton, MD; Pablo Laje, MD; Tobias Luithle, MD; and Philipp O. Szavay, MD IPEG acknowledges support for this course from: Karl Storz Endoscopy and Stryker Endoscopy

1:00 pm – 5:00 pm SIMULATOR HANDS ON LAB: Innovations in Simulation- Based Education for Pediatric Surgeons CHAIR: Katherine A. Barsness, MD CO-CHAIRS: Karen A. Diefenbach, MD & Carolina A. Millan, MD DESCRIPTION: Practice your MIS skills and learn some new ones at the Innovations in Simulation-based educational course. Simulation-based instruction will include advanced surgical techniques for TEF, duodenal atresia, diaphragmatic hernia, choledochojejunostomy, pyloromyotomy, single incision surgical techniques, gastrostomy, technical skills models, and many more innovative models. Participants of all levels of MIS skill are encourage to attend the course. OBJECTIVIES At the conclusion of this session, participants will be able to: • Choose appropriate instruments for neonatal and infant laparoscopy and thoracoscopy • Demonstrate improved instrument handling and knot tying skills within the confines of a newborn chest or abdomen • Describe port placement for TEF and duodenal atresia operations. FACULTY: Hossein Allal, MD; Georges Azzie, MD; Maria Marcela Bailez, MD; Katherine A. Barsness, MD; Matthew S. Clifton, MD; Karen A. Diefenbach, MD; Paula Flores, MD; Pablo Laje, MD; Charles M. Leys, MD; Manuel Lopez, MD; Tobias Luithle, MD; Maximillano Marcic, MD; Marcelo Martinez Ferro, MD; Marc P. Michalsky, MD; Milissa A. McKee, MD; Carolina A. Millan, MD; Oliver J. Muensterer, MD; Shaw D. St Peter, MD; Philipp O. Szavay, MD; Holger Till, MD, PhD; and Suzanne M. Yoder, MD

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STATIONS/FACULTY STATION Hossein Allal, MD TEF doll Model Georges Azzie, MD PLS & Dafydd A Davies, MD Maria Marcela Bailez, MD, TEF trainer Maximillan Marcic, MD Duodenal atresia trainer & Paula Flores, MD Hepaticojejunostomy model Katherine A. Barsness, MD DH DA TEF Gastrostomy Tube Karen A. Diefenbach, MD Skills Intestine CDH Marc P. Michalsky, MD Ethicon band Model Olympus single port Applied medical single site Marcelo Martinez Ferro, MD, Magnet Model & Carolina Millan, MD Hybrid for single site cholecystectomy

IPEG acknowledges support for this course from: Karl Storz Endoscopy and Stryker Endoscopy

5:00 pm – 7:00 pm Joint IPEG/BAPS Opening Ceremony/Welcome Reception

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Thursday, July 24 Lennox 3 7:00 am – 8:00 am MORNING SCIENTIFIC VIDEO SESSION I: Coolest Tricks, Extraordinary Procedures CHAIRS: Miguel Guelfand, MD & Todd A. Ponsky, MD

7:00 am V001: LEFT UPPER LOBECTOMY FOR CPAM USING A 3MM TISSUE SEALING DEVICE; A STEP BY STEP APPROACH Stephen Oh, MD, Steven S. Rothenberg, MD, The Morgan Stanley Children’s Hospital, Columbia University 7:06 am V002: THORACOSCOPIC DIVISION OF H-TYPE TRACHEOESOPHAGEAL FISTULA Matthew S. Clifton, MD, Paul M. Parker, MD, Emory University/ Children’s Healthcare of Atlanta 7:12 am V003: THORACOSCOPIC RESECTION OF A BRONCHOGENIC CYST LOCATED AT THE THORACIC INLET Meghna V. Misra, MD, Tulio Valdez, MD, Anthony Tsai, MD, Brendan T. Campbell, MD, MPH, Connecticut Children’s Medical Center 7:18 am V004: THORACOSCOPIC APPROACH IN RECURRENT TRACHEOESOPHAGEAL FISTULA Ruben Lamas-Pinheiro, MD, Carlos Mariz, MD, Joaquim Monteiro, MD, Tiago Henriques-Coelho, MD, PhD, Pediatric Surgery Department, Faculty of Medicine, Hospital de São João, Porto, Portugal 7:24 am V005: A THORACOSCOPIC APPROACH TO AN UNUSUAL MEDIASTINAL MASS Victoria K. Pepper, MD, Peter C. Minneci, MD, Karen A. Diefenbach, MD, Nationwide Children’s Hospital 7:30 am V006: THORACOSCOPIC PERICARDIAL WINDOW FOR TREATMENT OF REFRACTORY PERICARDIAL EFFUSION AND TAMPONADE Oliver J. Muensterer, MD, PhD, Samir Pandya, MD, Matthew E. Bronstein, MD, Gustavo Stringel, MD, Suvro S. Sett, MD, Divisions of Pediatric Surgery and Pediatric Cardiac Surgery, New York Medical College 7:36 am V007: COMBINATION OF VALUABLE TECHNICAL RESOURCES FOR THE CORRECTION OF DIAPHRAGMATIC HERNIA (VIDEO) Carolina Millan, MD, Fernando Rabinovich, MD, Luzia Toselli, MD, Horacio Bignon, MD, Gaston Bellia, MD, Mariano Albertal, MD, Guillermo Dominguez, MD, Marcelo Martinez Ferro, MD, Private Children´s Hospital of Buenos Aires, Fundación Hospitalaria, Buenos Aires, Argentina 7:42 am V008: THORACOSCOPIC MANAGEMENT OF AN ESOPHAGEAL LUNG, REPORT OF A CASE Ivan Dario Molina, MD, Santiago Correa, MD, Ana Garces, MD, Mizrahim Mendez, MD, Edgar Alzate, MD, Fundación Hospital de la Misericordia, Universidad Nacional de Colombia

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7:48 am V009: TRANSCONTINENTAL TELEMENTORING WITH PEDIATRIC SURGEONS- PROOF OF CONCEPT AND TECHNICAL CONSIDERATIONS Todd A. Ponsky, MD, Marc H. Schwachter, MD, Ted Stathos, MD, Michael Rosen, MD, Robert Parry, MD, Margaret Nalugo, Steven Rothenberg, MD, Akron Children’s Hospital, Rocky Mountain Hospital for Children, University Hospitals Case Medical Center

8:00 am – 8:05 am Welcome Address Benno Ure, MD, PhD, 2014 President

8:05 am – 9:00 am SCIENTIFIC SESSION: Gastrointestinal CHAIRS: Marc A. Levitt, MD & Juergen Schleef, MD

8:05 am S001: MINIMALLY INVASIVE SURGERY FOR PEDIATRIC TRAUMA – A MULTI-CENTER REVIEW Hanna Alemayehu, MD, Diana Diesen, MD, Matt Santore, MD, Matthew Clifton, MD, Todd Ponsky, MD, Margaret Nalugo, MPH, Timothy Kane, MD, Mikael Petrosyan, MD, Ashanti Franklin, MD, George W Holcomb III, MD, MBA, Shawn D St. Peter, MD, The Children’s Mercy Hospital, Kansas City, MO; Children’s Medical Center, Dallas, TX; Children’s Healthcare of Atlanta at Egleston, Atlanta, GA; Akron Children’s Hospital, Akron, Ohio; Children’s National Medical Center, Washington, DC 8:10 am S002: OPEN VS. LAPAROSCOPIC MANAGEMENT OF APPENDICITIS PERITONITIS IN CHILDREN: CLINICAL TRIAL Fernando Rey, MD, Andres Perez, MD, William Murcia, MD, Fenando Fierro, MD, Ivan Molina, MD, Juan Valero, MD, Jorge R. Beltran, MD, Fundación HOMI Hospital de la Misericordia, Pediatric Surgery Unit, Universidad Nacional de Colombia, Bogotá (COL) 8:15 am S003: FEASIBILITY OF SINGLE INCISION 3 STAGE TOTAL PROCTOCOLECTOMY AND ILEAL POUCH ANAL ANASTOMOSIS Avraham Schlager, MD, Matthew T. Santore, MD, Ozlem Balci, MD, Drew A. Rideout, MD, Kurt F. Heiss, MD, Matthew S. Clifton, MD, Emory University/Children’s Healthcare of Atlanta 8:20 am S004: EVALUATION OF LIFE QUALITY OF CHILDREN AFTER LAPAROSCOPIC-ASSISTED TRANSANAL ENDORECTAL (SOAVE) PULL- THROUGH FOR HIRSCHSPRUNG’S DISEASE Bo Xiang, MD, Yang Wu, PhD, West Chian Hospital 8:25 am S005: SELECTIVE TRANSPERITONEAL ASPIRATION OF A DISTENDED BOWEL WITH A SMALL-CALIBER NEEDLE DURING LAPAROSCOPIC NISSEN FUNDUPLICATION: A PROSPECTIVE RANDOMIZED CONTROLLED TRIAL Carlos Garcia-Hernandez, MD, Lourdes Carvajal- Figueroa, MD, Sergio Landa-Juarez, MD, Adriana Calderon-Urrieta, MD, Hospital Star Medica Lomas Verdes, México

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8:30 am S006: LAPAROSCOPIC REPAIR OF MALROTATION. WHAT ARE THE INDICATIONS IN NEONATES AND CHILDREN? Go Miyano, MD, Keiichi Morita, MD, Masakatsu Kaneshiro, MD, Hiromu Miyake, MD, Hiroshi Nouso, MD, Masaya Yamoto, MD, Koji Fukumoto, MD, Naoto Urushihara, MD, Department of Pediatric Surgery, Shizuoka Children’s Hospital 8:35 am S007: LAPARSCOPIC REPAIR OF CONGENITAL DUODENAL OBSTRUCTION IN NEONATE Jinshi Huang, MD, Department of surgery, Jiangxi provincal Children’s Hospital 8:40 am S008: COMPLICATIONS AFTER LAPAROSCOPY FOR RECTOVESICAL FISTULA HamidReza Foroutan, Dr., Abbas Banani, Dr., Sultan Ghanem, Dr., Reza Vahdad, Dr., Laparoscopic research center, Shiraz university of Medical Sciences 8:45 am S009: LAPAROSCOPIC MESH RECTOPEXY FOR COMPLETE RECTAL PROLAPSE Cindy Gomes Ferreira, MD, Paul Philippe, MD, Isabelle Lacreuse, MD, Anne Schneider, MD, François Becmeur, PhD, MD, 1) Department of Paediatric Surgery, Clinique Pédiatrique, Centre Hospitalier Luxembourg, Luxembourg 2) Department of Paediatric Surgery, Hôpital de Hautepierre, Centre Hospitalier Universitaire de Strasbourg, France 8:50 am S010: SINGLE INCISION LAPAROSCOPIC SPLENECTOMY USING THE SUTURE SUSPENSION TECHNIQUE FOR SPLENOMEGALY IN CHILDREN WITH HEREDITARY SPHEROCYTOSIS Suolin Li, MD, Meng Li, MD, Weili Xu, MD, PhD, The Second Hospital of Hebei Medical University, Shijiazhuang, China 8:55 am S011: LAPAROSCOPIC GASTROSTOMY AND LAPAROSCOPIC NISSEN/ GT IN CHILDREN WITH COMPLEX CONGENITAL HEART DEFECTS V. Mortellaro, MD, J. Alten, MD, R. Russell, MD, R. Griffin, PhD, C. Martin, MD, S. Anderson, MD, D. Rogers, MD, E. Beierle, MD, M. Chen, MD, Children’s Hospital of Alabama

9:00 am – 9.30 am PRESIDENTIAL ADDRESS & LECTURE: “Music, Endoscopic Surgery and IPEG” Benno Ure, MD, PhD, 2014 President

9:30 am – 4:00 pm Exhibits/Posters Open

9:30 am – 10:00 am Break

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10:00 am – 11:30 am Basic Science and Misc CHAIRS: Aayed R. Al-Qahtani, MD & Daniel J. Ostlie, MD

10:00 am S012: ENDOSCOPIC SURGICAL SKILL VALIDATION SYSTEM FOR PEDIATRIC SURGEONS USING A REPAIR MODEL OF CONGENITAL DIAPHRAGMATIC HERNIA Satoshi Obata, MD, Satoshi Ieiri, MD, PhD, Munenori Uemura, PhD, Ryota Souzaki, MD, PhD, Noriyuki Matsuoka, Tamotsu Katayama, Makoto Hashizume, MD, PhD, FACS, Tomoaki Taguchi, MD, PhD, FACS, Department of Pediatric Surgery, Faculty of Medical Science, Kyushu University, Department of Advanced Medicine and Innovative Technology, Kyushu University Hospital, Kyoto Kagaku Co., Ltd 10:09 am S013: THE DEVELOPMENT AND PRELIMINARY EVALUATION OF A SYNTHETIC NEONATAL ESOPHAGEAL ATRESIA/ TRACHEOESOPHAGEAL FISTULA REPAIR MODEL Katherine A. Barsness, MD, MS, Deborah M. Rooney, PhD, Lauren M. Davis, BA, Ellen K. Hawkinson, BS, Northwestern University Feinberg School of Medicine; University of Michigan School of Medicine 10:18 am S014: VIDEO-BASED SKILL ASSESSMENT OF ENDOSCOPIC SUTURING IN A PEDIATRIC CHEST MODEL AND A BOX TRAINER Shinya Takazawa, MD, Tetsuya Ishimaru, MD, PhD, Kanako Harada, PhD, Yusuke Tsukuda, Naohiko Sugita, PhD, Mamoru Mitsuishi, PhD, Tadashi Iwanaka, MD, PhD, The University of Tokyo Hospital 10:25 am S015: ANATOMICAL VALIDATION OF AN INANIMATE MODEL FOR TRAINING THORACOSCOPIC REPAIR OF TRACHEO ESOPHAGEAL FISTULA/ESOPHAGEAL ATRESIA – TEF/EA Maximiliano A. Maricic, MD, Maria M. Bailez, MD, National Children’s Hospital S.A.M.I.C. “Prof. Dr. Juan P. Garrahan” 10:32 am S016: THE LAPAROSCOPIC DUODENO-DUODENOSTOMY SIMULATOR: A MODEL FOR CUSTOMIZABLE MINIMALLY INVASIVE SURGERY TRAINERS Joanne Baerg, MD, Nicole Carvajal, Danielle Ornelas, Candice Sanscartier, Diana Lopez, Cristine Cervantes, William Grover, PhD, Gerald Gollin, MD, Loma Linda University Children’s Hospital and University of California Riverside Biomedical Engineering Department 10:39 am S017: OPTIMIZING WORKING SPACE IN LAPAROSCOPY - CT MEASUREMENT OF THE INFLUENCE OF SMALL BODY SIZE IN A PORCINE MODEL J. Vlot, MD, Lme Staals, MD, PhD, Prof. RMH Wijnen, MD, PhD, Prof. RJ Stolker, MD, PhD, Prof. NMA Bax, MD, PhD, Erasmus MC: University Medical Center Rotterdam

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10:46 am S018: THE EFFECTS OF CO2-INSUFFLATION WITH 5 AND 10 MMHG DURING THORACOSCOPY ON CEREBRAL OXYGENATION AND HEMODYNAMICS IN PIGLETS Lisanne J. Stolwijk, MD, Stefaan H. Tytgat, MD, Kristin Keunen, MD, N. Suksamanapan, MD, Maud Y. van Herwaarden, MD, PhD, Petra M. Lemmers, MD, PhD, David C. van der Zee, Prof., Dr., Wilhelmina’s Children Hospital University Medical Center Utrecht 10:53 am S019: MAGIC (MAGNETIC ANTI-GLYCEMIC ILEAL CONDUIT) I: JEJUNAL- ILEAL MAGNETIC COMPRESSION ANASTOMOSIS CORRECTS INSULIN RESISTANCE IN DIABETIC PIGS Hilary B. Gallogly, MD, Elisabeth J. Leeflang, MD, Dillon A. Kwiat, Corey W. Iqbal, MD, Karyn J. Catalano, PhD, Kullada O. Pichakron, MD, Michael R. Harrison, MD, Department of Surgery, University of California, Davis, Departments of Pediatric Surgery and Obstetrics, Gynecology & RS, University of California, San Francisco, Department of Surgery, David Grant Medical Center, Travis Air Force Base 11:00 am S020: AMNIOSEAL I: A BIOMIMETIC POLYMER ADHESIVE TO PRESEAL THE AMNIOTIC MEMBRANE TO PREVENT PPROM AFTER FETOSCOPY Corey W. Iqbal, MD, Dillon A. Kwiat, BS, Stephanie Kwan, BS, Hoyong Chung, PhD, Robert H. Grubbs, PhD, Michael R. Harrison, MD, University of California San Francisco Fetal Treatment Center, Children’s Mercy Hospital Fetal Health Center 11:07 am S021: THE PEDIATRIC DEVICE CONSORTIUM: A MODEL FOR SURGICAL INNOVATION Elisabeth J. Leeflang, MD, Elizabeth A. Gress, Dillon A. Kwiat, Hanmin Lee, MD, Shuvo Roy, PhD, Michael R. Harrison, MD, Departments of Pediatric Surgery and Bioengineering and Therapeutic Sciences, University of California, San Francisco. 11:14 am S022: LONG TERM HEMODYNAMIC EFFECTS OF NUSS REPAIR IN PECTUS EXCAVATUM FOR VENTRICULAR FUNCTION BY “CARDIOVASCULAR MAGNETIC RESONANCE CINE-SSFP-IMAGING”, RESULTS OF BERLIN- BUCH NUSS-CARDIO-MRI STUDY K. Schaarschmidt, Prof., MD, Susanne Polleichtner, MD, A. Töpper, MD, A. Zagrosek, MD, M. Lempe, MD, F. Schlesinger, MD, J. Schulz-Menger, Prof., MD, Helios Center of Pediatric and Adolescent Surgery Berlin-Buch 11:21 am S023: 3-DIMENSIONAL VISION IMPROVES LAPAROSCOPIC SURGERY IN SMALL SPACES Xiaoyan Feng, MD, Anna Morandi, MD, Martin Boehne, MD, Tawan Imvised, MD, Benno Ure, MD, PhD, Joachim F. Kuebler, MD, Martin Lacher, MD, PhD, Center of Pediatric Surgery, Department of Pediatric Cardiology and Intensive Care Medicine, Hannover Medical School, Germany

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11:30 am – 12:30 pm Lunch Break

12:00 pm – 1:00 pm TOP POSTERS 1-20: Digital Presentation CHAIR: Oliver J. Muensterer, MD

12:00 pm T001: REDUCED PORT DISTAL PANCREATECTOMY FOR GIANT PANCREATIC NEOPLASM: BEYOND THE EVENT HORIZON AND BACK Samir Pandya, MD, Allison Sweny, MD, Oliver Muensterer, MD, New York Medical College / Maria Fareri Children’s Hospital 12:03 pm T002: LAPAROSCOPIC ADRENALECTOMY USING A SINGLE WORKING PORT: A CASE OF PRIMARY PIGMENTED NODULAR ADRENOCORTICAL DISEASE Neetu Kumar, Kathryn Evans, Imran Mushtaq, Great Ormond Street Hospital, London 12:06 pm T003: ROBOTIC-ASSISTED RESECTION OF A PYLORIC PANCREATIC REST WITH PERORAL ENDOSCOPIC REMOVAL AND RECONSTRUCTION BY PARTIAL GASTRODUODENOSTOMY Oliver J. Muensterer, MD, PhD, Samir Pandya, MD, Matthew E Bronstein, MD, Fouzia Shakil, MD, Aliza Solomon, DO, Michel Kahaleh, MD, Division of Pediatric Surgery and Pathology, New York Medical College, Division of Gastroenterology and Pediatric Gastroenterology, Weill Cornell Medical College 12:09 pm T004: LAPAROSCOPY FOR SMALL BOWEL OBSTRUCTION IN CHILDREN – AN UPDATE Hanna Alemayehu, MD, Bryan David, Amita A. Desai, MD, Corey W. Iqbal, MD, Shawn D. St. Peter, MD, The Children’s Mercy Hospital 12:12 pm T005: LAPAROSCOPIC TRANSDUODENAL DEROOFING OF THE PERIAMPULLARY DUODENAL DUPLICATION CYST IN AN INFANT Yu Sokolov, MD, PhD, Dm Donskoy, MD, A. Vilesov, MD, M. Shuvalov, MD, M. Akopyan, MD, Dm Ionov, MD, E. Fokin, MD, St. Vladimir Children Hospital, Moscow, Russia 12:15 pm T006: LAPAROSCOPIC ENUCLEATION OF TRUE PANCREATIC CONGENITAL CYST Mariana Borges-Dias, Manuel Oliveira, José Estevão- Costa, Miguel Campos, Pediatric Surgery Department, Faculty of Medicine, Hospital São João, Porto, Portugal 12:18 pm T007: BIMANUAL SUTURING - A NOVEL TECHNIQUE IN LAPAROSCOPIC REPAIR OF MORGAGNI HERNIA Kanika A. Bowen, MD, Dean M. Anselmo, MD, Nam X. Nguyen, Children’s Hospital Los Angeles, Los Angeles, CA 12:21 pm T008: ROBOTIC CHOLEDOCHAL CYST EXCISION Adam C. Alder, MD, Stephen M. Megison, MD, Children’s Medical Center Dallas

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12:24 pm T009: THE VACUUM BELL FOR CONSERVATIVE TREATMENT OF PECTUS EXCAVATUM: ASSESSMENT OF ITS EFFICACY WITH DISTANCE AND PRESSURE SENSORS Sergio B. Sesia, MD, Stefan Weiss, MSc, David Hradetzky, D. Eng., Frank-Martin Haecker, MD, University Children’s Hospital of Basel, Department of Paediatric Surgery, Basel, University of Applied Sciences and Arts Northwestern Switzerland, School of Life Sciences, Institute for Medical and Analytical Technologies, Muttenz, Switzerland 12:27 pm T010: OUTCOME OF LAPAROSCOPIC SUTURE RECTOPEXY IN PERSISTENT RECTAL PROLAPSE IN CHILDREN Karim Awad, MSc, MRCS, Amr Zaki, MSc, MD, Mohamed Eldebeiky, MSc, MD, MRCS, Ayman Alboghdady, MSc, MD, Tarak Hassan, MSc, MD, MRCS, Sameh Abdelhay, MSc, MD, ain Shams University Hospitals 12:30 pm T011: SURGICAL TECHNIQUES FOR LAPAROSCOPY-ASSISTED REPAIR OF MALE IMPERFORATE ANUS WITH RECTO-BULBAR FISTULA. COMPARISON WITH RECTO-PROSTATIC FISTULA Hiroyuki Koga, MD, Manabu Okawada, MD, Takashi Doi, MD, Go Miyano, MD, Hiroki Nakamura, MD, Takanori Ochi, MD, Shogo Seo, MD, Geoffrey J Lane, MD, Atsuyuki Yamataka, MD, Department of Pediatric General and Urogenital Surgery,Juntendo University School of Medicine 12:33 pm T012: DIAPHRAGMATIC EVENTRATION REPAIR: SHOULD WE USE A THORACOSCOPIC OR LAPAROSCOPIC APPROACH? Saidul Islam, Kirsty Brennan, Rajiv Lahiri, Anies Mahomed, Department of Paediatric Surgery,Royal Alexandra Children’s Hospital,Brighton,U.K. 12:36 pm T013: EVOLUTION OF MINIMALLY-INVASIVE TECHNIQUES WITHIN AN ACADEMIC SURGICAL PRACTICE AT A SINGLE INSTITUTION Shannon N. Acker, MD, Susan Staulcup, David A. Partrick, MD, Stig Somme, MD, Children’s Hospital Colorado 12:39 pm T014: ENDOSCOPIC CLOSURE OF PERSISTENT GASTROCUTANEOUS FISTULA IN CHILDREN Sandra M. Farach, MD, Paul D. Danielson, MD, Daniel McClenathan, MD, Nicole M. Chandler, MD, All Children’s Hospital Johns Hopkins Medicine 12:42 pm T015: INPATIENT ADMISSION IS NOT NECESSARY FOLLOWING SUCCESSFUL ENEMA REDUCTION OF INTUSSUSCEPTION IN CHILDREN Mohamed I. Mohamed, MBBS, Stephanie F. Polites, MD, Abdalla E. Zarroug, MD, Michael B. Ishitani, MD, Christopher R. Moir, MD, Division of Pediatric Surgery, Mayo Clinic, Rochester, MN, USA 12:45 pm T016: EVALUATION OF ENDOSCOPIC AND TRADITIONAL OPEN APPROACHES TO LOCAL ADRENAL NEUROBLASTOMA Wei Yao, Kuiran Dong, Kai Li, Yunli Bi, Gong Chen, Xianmin Xiao, Shan Zheng, Department of Pediatric Surgery, Children’s Hospital of Fudan University, Shanghai , China

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12:48 pm T017: COMPARISON OF MULTI-PORT AND SINGLE-PORT LAPAROSCOPIC INGUINAL HERNIORAPHY IN SMALL BABIES Yury Kozlov, MD, Vladimir Novozhilov, MD, Department of Neonatal Surgery, Municipal Pediatric Hospital, Irkutsk, Russia, Department of Pediatric Surgery, Irkutsk State Medical Academy of Continuing Education (IGMAPO), Irkutsk, Russia 12:51 pm T018: METAL-POLYMER COMPOSITE NUSS BAR FOR “MINIMALLY” INVASIVE BAR REMOVAL AFTER PECTUS EXCAVATUM TREATMENT Leonardo Ricotti, PhD, Gastone Ciuti, PhD, Marco Ghionzoli, MD, PhD, Arianna Menciassi, PhD, Antonio Messineo, MD, 1) The BioRobotics Institute, Scuola Superiore Sant’Anna, Pontedera (Pisa), Italy, 2) Department of Pediatric Surgery, Children’s Hospital A. Meyer, Florence, Italy 12:54 pm T019: SINGLE-INCISION THORACOSPCOPIC RESECTION FOR PEDIATRIC MEDIASTINAL NEUROGENIC TUMOR USING CONVENTIONAL INSTRUMENTS IN CHILDREN Jiangbin Liu, PhD, Professor, Department of Pediatric Surgery, Shanghai Children’s Hospital, Shanghai Jiao Tong University 12:57 pm T020: THORACOSCOPIC AORTOPEXY FOR TRACHEOMALACIA: DEMONSTRATING FEASIBILITY AND EFFICACY Avraham Schlager, MD, Ozlem Balci, MD, Matthew T. Santore, MD, Mark L. Wulkan, MD, Emory University School of Medicine/Children’s Healthcare of Atlanta

1:00 pm – 5:50 pm IPEG & BAPS JOINT PROGRAMS Pentland, Sidlaw & Fintry Auditorium

1:00 pm – 3:00 pm IPEG/BAPS PRESIDENTIAL DEBATE: “Esophageal and Diaphragmatic Surgery – Thoracoscopic vs. Open” CHAIRS: Benno Ure, MD, PhD (IPEG) & Rick Turnock, MD (BAPS) DESCRIPTION: This panel will discuss the pros and cons of thoracoscopic surgery for esophageal atresia and diaphragmatic hernia in the newborn. The discussion will include technical aspects, the pathophysiological responses of newborns and data on the outcome. OBJECTIVES At the conclusion of this session, participants will be able to: • Appropriately apply thoracosopic techniques for esophageal atresia and diaphragmatic hernia in newborns • Apply these techniques to relevant cases • Decide on when to convert to open surgery and how to monitor pathophysiological responses and to how to react appropriately.

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TIME TOPIC FACULTY 1:00 pm Pathophysiology and Intra-Operative Agostino Pierro, MD Physiology in OA-TOF/CDH 1:20 pm OA-TOF: Open Mark Davenport, MD 1:35 pm OA-TOF: Thoracoscopic Steven Rothenberg, MD 1:50 pm Q&A 2:10 pm CDH: Open David C G Crabbe, MD 2:25 pm CDH: Thoracoscopic Mark L Wulkan, MD 2:40 pm Q&A S024: MINIMALLY INVASIVE CDH REPAIR: EFFECTIVE FOR SELECT PATIENTS Tate Nice MD, Scott Anderson MD, Sebastian Pasara, Rafik M. Bous, Robert Russell MD, MPH, Carroll M. Harmon MD, PHD, Children's of Alabama, University of Alabama at Birmingham

3:00 pm – 3:30 pm Break 3:30 pm – 5:20 pm IPEG/BAPS Best Clinical Paper Session CHAIRS: Philipp O. Szavay, MD (IPEG) & Simon Eaton, MD (BAPS) INTRODUCTION: Gordon A. MacKinlay, OBE

3:30 pm S025: FURTHER EXPERIENCE WITH STAGED THORACOSCOPIC REPAIR OF A LONG GAP ESOPHAGEAL ATRESIA USING INTERNAL STATIC TRACTION SUTURE Dariusz Patkowski, Prof., MD, PhD, Wojciech Górecki, MD, PhD, Sylwester Gerus, MD, Anna Piaseczna-Piotrowska, Prof, MD, PhD, Piotr Wojciechowski, MD, PhD, A.I. Prokurat, Prof., MD, PhD, Przemyslaw Galazka, MD, PhD, Michal Blaszczynski, MD, PhD, Maciej Baglaj Prof, MD, PhD, Departments of Pediatric Surgery and Urology: Wroclaw, Krakow, Lodz, Poznan, Bydgoszcz 3:39 pm S026: B-TYPE NATRIURETIC PEPTIDE LEVELS CORRELATE WITH PULMONARY HYPERTENSION AND REQUIREMENT FOR EXTRACORPOREAL MEMBRANE OXYGENATION IN CONGENITAL DIAPHRAGMATIC HERNIA Emily A. Partridge, Lisa Herkert, Brian Hanna, Natalie E. Rintoul, Alan W. Flake, N. Scott Adzick, Holly L. Hedrick, William H. Peranteau, Children’s Hospital of Philadelphia Philadelphia, PA USA 3:48 pm S027: SINGLE INCISION LAPAROSCOPIC ILEAL POUCH-ANAL ANASTOMOSIS IN CHILDREN—HOW DOES IT COMPARE TO A TRADITIONAL LAPAROSCOPIC-ASSISTED APPROACH? Stephanie F. Polites, MD, Abdalla E. Zarroug, MD, Christopher R. Moir, MD, Donald D. Potter, MD, Mayo Clinic, Rochester, MN, University of Iowa, Iowa City, IA

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3:57 pm S028: CURRENT OPERATIVE STRATEGIES AND EARLY COMPLICATIONS OF DEFINITIVE SURGERY FOR HIRSCHSPRUNG’S DISEASE IN THE UK AND IRELAND: FINDINGS FROM A PROSPECTIVE NATIONAL COHORT STUDY Tim Bradnock1, Simon Kenny2, Paul Johnson3, Marian Knight4, Jenny Kurinczuk4, Gregor Walker1, 1Department of Paediatric surgery, Yorkhill hospital, Glasgow, UK, 2Department of Paediatric surgery, Alder Hey Children’s Hospital, Liverpool, UK, 3Department of Paediatric surgery, University of Oxford, Oxford, UK, 4National Perinatal Epidemiology Unit 4:06 pm S029: PRELIMINARY EVALUATION OF A NOVEL INFANT THORACOSCOPIC LOBECTOMY SIMULATOR Katherine A. Barsness, MD, MS, Deborah M. Rooney, PhD, Lauren M. Davis, BA, Ellen K. Hawkinson, BS, Northwestern University Feinberg School of Medicine, University of Michigan Medical School 4:15 pm S030: GASTROSCHISIS – THE ROLE OF BREAST MILK IN REDUCING TIME TO FULL FEEDS Deirdre Kriel1, Anne Aspin1, Jonathan Goring1, Robert West2, Jonathan Sutcliffe1, 1Leeds Teaching Hospitals NHS Trust, Leeds, UK, 2Leeds Institute of Health Sciences - University of Leeds, Leeds, UK 4:24 pm S031: ONCOLOGIC MIS SURGERY : ROLE OF IDRFS CRITERIA IN PATIENT SELECTION AND PLANNING * Claudio Vella, MD, *Camilla Viglio, MD, *Sara Costanzo, MD, **Salvatore Zirpoli, MD, **Marcello Napolitano, MD, ***Roberto Luksch, MD, *Giovanna Riccipetitoni, MD, *Pediatric Surgery Department, “V.Buzzi” Children’s Hospital ICP, **Pediatric Radiology and Neuroradiology Department “V.Buzzi” Children’s Hospital ICP, Milan – Italy,*** Pediatric Department , Fondazione IRCCS National Cancer Institute, Milan, Italy 4:33 pm S032: GLUTAMINE SUPPLEMENTATION IMPROVES MONOCYTE FUNCTION IN SURGICAL INFANTS REQUIRING PARENTERAL NUTRITION - RESULTS OF A RANDOMISED CONTROLLED TRIAL Mark Bishay1, Venetia Simchowitz2, Danielle Petersen2, Marlene Ellmer2, Sarah Macdonald2, Jane Hawdon4, Elizabeth Erasmus4, Kate MK Cross2, Joseph I Curry2, 1UCL Institute of Child Health, London, UK, 2Great Ormond Street Hospital, London, UK, 3Hospital for Sick Children, Toronto, Canada, 4University College Hospital, London, UK 4:42 pm S033: COMPARISON OF 30-DAY OUTCOMES BETWEEN THORACOSCOPIC AND OPEN LOBECTOMY FOR CONGENITAL PULMONARY LESIONS Justin Mahida, MD, MBA, Lindsey Asti, MPH, Victoria K. Pepper, MD, Katherine J. Deans, MD, MHSc, Peter C Minneci, MD, MHSc, Karen A. Diefenbach, MD, Nationwide Children’s Hospital, Columbus Ohio 4:51 pm S034: HIGH VOLUMES IMPROVE OUTCOMES - A NATIONAL REVIEW OF HYPOSPADIAS SURGERY IN ENGLAND 1999-2009 Patrick Green3,1 , David Wilkinson2,1, Shanthi Beglinger1, Rachel Hudson1, David Edgar1, Simon Kenny1,2, 1University of Liverpool, Liverpool, UK, 2Alder Hey Children’s Hospital NHS Foundation Trust, Liverpool, UK, 3Royal Liverpool and Broadgreen University Hospitals Trust, Liverpool, UK

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5:00 pm S035: TRANSUMBILICAL LAPAROENDOSCOPIC SINGLE SITE SURGERY WITH CONVENTIONAL INSTRUMENTS FOR CHOLEDOCHAL CYST IN CHILDREN: EARLY RESULTS OF 86 CASES Tran N. Son, MD, PhD, Nguyen T. Liem, MD, PhD, Vu X. Hoan, MD, National Hospital of Paediatrics, Hanoi, Vietnam 5:09 pm S036: SALINE VERSUS TISSUE PLASMINOGEN ACTIVATOR IRRIGATIONS AFTER DRAIN PLACEMENT FOR APPENDICITIS-ASSOCIATED ABSCESS: A PROSPECTIVE RANDOMIZED TRIAL Shawn St. Peter, Obinna Adibe, Sohail Shah, Susan Sharp, David Juang, Brent Reading, Brent Cully, Whit Holcomb III, Doug Rivard, Children’s Mercy Hospital, Kansas CIty, MO, USA

5:20 pm – 5:50 pm KARL STORZ LECTURE: “Developing Neonatal MIS Surgery, Innovation, Techniques, and Helping an Industry to Change” SPEAKER: Steven Rothenberg, MD Dr. Rothenberg is the Chief of Pediatric Surgery at the Rocky Mountain Hospital for Children at PSL in Denver, Co. He is also a Clinical Professor of Surgery at Columbia University College of Physicians and Surgeons. He is a world leader in the field of endoscopic surgery in infants and children and has pioneered many of the procedures using minimally invasive techniques.

Dr. Rothenberg completed medical school and general surgery residency at the University of Colorado in Denver. He then spent a year in England doing a fellowship in General Thoracic Surgery prior to returning to the states where he completed a two year Pediatric Surgery fellowship at Texas Children’s Hospital in Houston. He returned to Colorado in 1992 where he has been in practice for over the last 20 years.

Dr. Rothenberg was one of the founding members of the International Pediatric Surgical Group (IPEG) and is a past-president. He was also the Chair of the Pediatric Committee and on the Board of Directors for SAGES (The Society of American Gastr-intestinal Endoscopic Surgeons). He has authored over 180 publications on minimally invasive surgery in children and has given over 300 lectures on the subject nationally and internationally. He is also on the editorial board for the Journal of Laparoendoscopic Surgery and Advanced Surgical Technique, The Journal of Pediatric Surgery, and Pediatric Surgery International.

Dr. Rothenberg has been married to his wife Susan for over 30 years and has three children Jessica, Catherine, and Zachary. He is an avid outdoorsman and spends most of his free time in the mountains of Colorado skiing, hiking, biking, and fishing.

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Friday, July 25 Lennox 3

7:00 am – 8:00 am Morning Scientific Video Session II CHAIRS: Katherine A. Barsness, MD & Holger Till, MD, PhD

7:00 am V010: VAGINAL AGENESIS AND ATRESIA OF THE UTERINE CERVIX ASSOCIATED TO VESTIBULAR FISTULA Maria M. Bailez, MD, Lucila Alvarez, MD, Garrahan Children’s Hospital, Buenos Aires, Argentina 7:06 am V011: ENDOSCOPIC GASTROCUTANEOUS FISTULA CLOSURE USING AN OVER THE SCOPE CLIP James Wall, MD, MS, Lucile Packard Children’s Hospital Stanford 7:12 am V012: LAPAROSCOPIC RESECTION OF A NEUROENDOCRINE TUMOR OF THE COMMON BILE DUCT WITH HEPATICODUODENOSTOMY Steven S. Rothenberg, MD, The Rocky Mountain Hospital For Children 7:18 am V013: LAPAROSCOPIC RESECTION OF A LARGE RETROPERITONEAL GANGLIONEUROMA Bethany J. Slater, MD, Steven S. Rothenberg, MD, Rocky Mountain Hospital for Children 7:24 am V014: LAPAROSCOPIC LEFT PARTIAL ADRENALECTOMY IN A CHILD WITH VON HIPPEL-LINDAU AND RECURRENT PHEOCHROMOCYTOMA A. B. Podany, MD, A. Dash, MD, D. V. Rocourt, MD, Pennsylvania State Hershey Medical Center 7:30 am V015: LAPAROSCOPIC LATERAL PANCREATICOJEJUNOSTOMY- PEUSTOW PROCEDURE- IN A 4 YEAR OLD WITH PANCREATIC DUCTAL OBSTRUCTION Miller Hamrick, MD, Mikael Petrosyan, MD, Eric Jelin, MD, Timothy D. Kane, MD, Children’s National Medical Center 7:36 am V016: LAPAROSCOPIC CORRECTION OF COLORECTAL DUPLICATION AND VAGINOPLASTY Kanika A. Bowen, MD, Kevin Platt, BS, Alli Wu, BS, Kasper Wang, MD, Children’s Hospital of Los Angeles 7:42 am V017: LAPAROSCOPIC PROPHYLACTIC TOTAL GASTRECTOMY IN CHILDHOOD FOR THE PREVENTION OF HEREDITARY DIFFUSE GASTRIC CANCER Benjamin Zendejas, MD, MSc, Abdalla E. Zarroug, MD, Michael L. Kendrick, MD, Department of Surgery, Mayo Clinic, Rochester, MN, USA 7:48 am V018: LAPAROSCOPIC GASTRIC PLICATION IN ADOLESCENTS AND YOUNG ADULTS WITH SEVERE OBESITY: DESCRIPTION OF FIRST PATIENT ENROLLED IN PILOT STUDY Shannon F. Rosati, MD, Dan Parrish, MD, Poornima Vanguri, MD, Matthew Brengman, MD, FACS, Patricia Lange, MD, Claudio Oiticica, MD, David Lanning, MD, PhD, Children’s Hospital of Richmond at Virginia Commonwealth University Medical Center

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8:00 am – 9:30 am SCIENTIFIC SESSION: Urogenital CHAIRS: Martin L. Metzelder, MD & CK Yeung, MD

8:00 am V019: LAPAROSCOPIC PARTIAL NEPHRECTOMY FOR THE TREATMENT OF LARGE CYSTIC NEPHROMA IN CHILDREN Yujiro Tanaka, MD, PhD, Hiroo Uchida, MD, PhD, Hiroshi Kawashima, MD, Shinya Takazawa, MD, Takayuki Masuko, MD, PhD, Kyoichi Deie, MD, Hizuru Amano, MD, Michimasa Fujiogi, MD, Tadashi Iwanaka, MD, PhD, Prof, Department of Pediatric Surgery, Saitama Children’s Medical Center & The University of Tokyo

8:05 am S037: LAPAROSCOPIC FOWLER-STEVENS ORCHIOPEXY, A RANDOMIZED PILOT STUDY COMPARING THE PRIMARY AND 2-STAGE APPROACHES Daniel J. Ostlie, MD, Charles M. Leys, MD, Jason D. Fraser, MD, Charles L. Snyder, MD, Shawn D. St. Peter, MD, University of Wisconsin/American Family Children’s Hospital, Children’s Mercy Hospital and Clinics 8:11 am S038: LONG TERM FOLLOW UP OF MODIFIED LAPAROSCOPIC TRANSCUTANEOUS INGUINAL HERNIA REPAIR WITH HIGH SUTURE LIGATURE OF THE HERNIA SAC Matias Bruzoni, MD, FACS, Zachary J. Kastenberg, MD, Joshua D. Jaramillo, BA, James K. Wall, MD, Robert Wright, MA, Sanjeev Dutta, MD, MBA, Stanford University 8:17 am S039: LAPAROSCOPIC PYELOPLASTY IN INFANTS: SINGLE-SURGEON EXPERIENCE WITH 114 OPERATIONS Chandrasekharam Vvs, Dr., Rainbow Children’s Hospitals 8:25 am S041: LAPAROSCOPIC URETERO-PYELOLITHOTOMY IN CHILDREN Ana María Castillo-Fernández, MD, Sergio Landa-Juárez, MD, Ramón Esteban Moreno Riesgo, MD, Hermilo De La Cruz-Yañez, MD, Carlos Garcia-Hernández, MD, Hospital de Pediatria, Centro Médico Nacional SXXI. IMSS 8:29 am S042: EXPERIENCE OF LAPAROSCOPIC PYELOPLAST IN THE TREATMENT OF URETEROPELVIC JUNCTION OBSTUCTION IN INFANTS (<3 MONTHS) Aiwu Li, Jian Wang, Qiangye Zhang, Wentong Zhang, Hongchao Yang, Weijing Mu, Department of Pediatric Surgery, Qilu Hospital, Shandong University 8:35 am S043: LAPAROSCOPIC EXTRAVESICAL URETERAL REIMPLANTATION FOLLOWING LICH GREGOIRE TECHNIQUE. MEDIUM-TERM PROSPECTIVE STUDY Manuel Lopez, Eduardo Perez-Etchepare, MD, François Varlet, MD, PhD, Department of Pediatric Surgery, University Hospital of Saint Etienne

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8:41 am S044: ROBOTIC ASSISTED LAPAROSCOPIC MANAGEMENT OF DUPLEX RENAL ANOMALY IS FEASIBLE AND SAFE WITH EQUAL SHORT TERM SURGICAL OUTCOMES TO TRADITIONAL PURE LAPAROSCOPIC AND OPEN SURGERY Daniel B. Herz, MD, Paul A. Merguerian, MD, Venkata R. Jayanthi, MD, Seth A. Alpert, MD, Jennifer A. Smith, RN, Nationwide Children’s Hospital; Children’s Hospital at Dartmouth 8:47 am S045: TRANSRENAL STENTING IN LAPAROSCOPIC PYELOPLASTY IN INFANTS AND CHILDREN: A SAVE TECHNIQUE Tobias Luithle, MD, Florian Obermayr, MD, Joerg Fuchs, MD, Department of Pediatric Surgery and Pediatric Urology, University Children’s Hospital, Tuebingen, Germany 8:53 am S046: RETROPERITONEOSCOPIC PYELOPLASTY IN 134 CHILDREN Ravindra Ramadwar, Dr., Bombay Hospital, Hinduja Hospital & Joy Hospital, Mumbai, India 8:59 am S047: PREOPERATIVE COLOUR DOPPLER ULTRASOUND IN CHILDREN WITH PELVIURETERIC JUNCTION OBSTRUCTION AND SUSPECTED LOWER POLE CROSSING VESSELS – VALUE FOR THE LAPAROSCOPIC SURGEON? Nagoud Schukfeh, Martin Metzelder, Paul Andreas, Udo Vester, Division of Pediatric Surgery, Department of General-, Visceral- and Transplant Surgery, University Clinic Essen, Essen, Germany and Department of Pediatric Nephrology, University Clinic Essen, Essen, Germany 9:05 am S048: ONE TROCAR ASSISTED PYELOPLASTY IN CHILDREN Giovanni Cobellis, PhD, Fabiano Nino, MD, Carmine Noviello, PhD, Mercedes Romano, PhD, Francesco Mariscoli, MD, Lorenzo Rossi, MD, Ascanio Martino, MD, Pediatric Surgery Unit, Academic Children’s Hospital, Ancona 9:11 am S049: LAPAROSCOPIC WILMS’ TUMOUR NEPHRECTOMY Ewan M. Brownlee, Fraser D. Munro, Gordon A. MacKinlay, OBE, Hamish Wallace, Royal Hospital for Sick Children, Edinburgh

9:30 am – 4:30 pm Exhibits/Posters Open

9:30 am – 10:00 am Break

10:00 am – 11:00 am SCIENTIFIC SESSION: Gastrointestinal & Hepatobiliary II CHAIRS: Karen A. Diefenbach, MD & Long Li, MD

10:00 am S050: EVOLUTION OF MINIMALLY INVASIVE TREATMENT OF CHOLEDOCHOLITHIASIS (CL) IN PEDIATRICS. EXPERIENCE AT A SINGLE CENTER Mauro Capparelli, MD, Horacio Questa, MD, Maria M Bailez, MD, Garrahan Children’s Htal Buenos Aires; Argentina

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10:07 am S051: THE LEARNING CURVE ON THE LAPAROSCOPIC EXCISION OF CHOLEDOCHAL CYST WITH ROUX-EN-Y HEPATOENTEROSTOMY IN CHILDREN Jiangbin Liu, PhD, Zhibao Lv, Professor, Department of Pediatric Surgery, Shanghai Children’s Hospital, Shanghai Jiao Tong University and Department of Pediatric Surgery, Children’s Hospital of Fudan University, Shanghai, PR China 10:14 am S052: PERIOPERATIVE COMPLICATIONS OF LAPAROSCOPIC CHOLEDOCHAL CYST EXCISION Zhigang Gao, MD, Qixing Xiong, MD, Jinfa Tou, MD, Qiang Shu, Pro, Pediatric Surgery Department 10:21 am S054: LAPAROSCOPIC SIMPLE OBLIQUE DUODENO-DUODENOSTOMY IN MANAGEMENT OF CONGENITAL DUODENAL OBSTRUCTION IN CHILDREN Tran N. Son, MD, PhD, Nguyen T. Liem, MD, PhD, Hoang H. Kien, MD, National Hospital of Paediatrics, Hanoi, Vietnam 10:28 am S055: THREE-PORT TOTAL COLECTOMY AND SUBSEQUENT ROBOTIC PROCTECTOMY WITH ILEAL POUCH-ANAL ANASTOMOSIS IN FULMINANT ULCERATIVE COLITIS. INITIAL EXPERIENCE G. Elmo, MD, T. Ferraris, MD, D. Liberto, MD, M. Urquizo, MD, P. Lobos, MD, F. De Badiola, MD, Pediatric Surgery Hospital Italiano de Buenos Aires 10:35 am S056: WHAT HAPPENS BEYOND AN OPEN ANULUS INGUINALIS PROFUNDUS FOUND AT LAPAROSCOPIC PYLOROMYOTOMY IN INFANTS? - A JOURNEY INTO TERRA INCOGNITA Reza M. Vahdad, MD, Lars B. Burghardt, Matthias Nissen, MD, Svenja Hardwig, MD, Ralf B. Troebs, Prof, Dr., med, Tobias Klein, MD, Alexander Semaan, Thomas Boemers, Prof., Dr., med, Grigore Cernaianu, MD, 1) Department of Pediatric Surgery, Cologne, Germany, 2) Department of Pediatric Surgery, Ruhr-University Bochum, Germany, 3) Department of Pediatric Surgery, University Hospital Luebeck, Germany 10:42 am S057: LAPAROSCOPIC TRANSHIATAL GASTRIC PULL-UP IN 6 CHILDREN Nidhi Khandelwal, Dr., Ravindra Ramadwar, Dr., Bombay Hospital, Mumbai, India 10:49 am S058: THE SMALL BOWEL IN ITS HAMMOCK: HOW TO AVOID IRRADIATION THANKS TO THE SIGMOID Sabine Irtan, MD, PhD, Eric Mascard, MD, Stephanie Bolle, MD, Laurence Brugieres, MD, PhD, Sabine Sarnacki, MD, PhD, Department of pediatric surgery, APHP, Hopital Necker, Paris, France; Sorbonne Paris City University, Paris, France

IPEG’s 23rd Annual Congress for Endosurgery in Children ■ July 22-26, 2014 | 42 Table of Contents Complete Schedule FRIDAY, JULY 25

11:00 am – 12:00 pm SCIENTIFIC SESSION: Panel – “Laparoscopy in the Neonate and Infant: What’s New?” MODERATOR: David C. van der Zee, MD, PhD DESCRIPTIONS: This panel will provide an update of the most recent developments in neonatal minimally invasive surgery. OBJECTIVES At the conclusion of this session, participants will be able to: • Describe the technique for a safe anastomosis with low risk of postoperative leakage • Define the different steps of the procedure • Avoid using too high pressures in neonates.

TIME TOPIC PANELIST

11:00 am MIS in the Neonate and Infant: David C. van der Zee, MD, PhD What’s New - Introduction 11:05 am Approaches to Long Gap David C. van der Zee, MD, PhD Esophageal Atresia 11:20 am Thoracoscopy Indications and Timothy D. Kane, MD Techniques for Rare Conditions 11:35 am Laparoscopy in the Neonate - Milissa A. McKee, MD Indications, Techniques 11:50 am Round Table Discussion All

12:00 pm – 1:00 pm Lunch Break

12:00 pm – 1:00 pm TOP POSTERS 21-40: Digital Presentation CHAIR: Joachim F. Kuebler, MD

12:00 pm T021: THORACOSCOPIC IBIS HEAD REPAIR OF CONGENITAL PARTIAL DIAPHRAGMATIC EVENTRATION. A NEW ANATOMICAL RECONSTRUCTIVE CONCEPT Mohamed M. Elbarbary, MD, Ahmed E. Fares, MD, Haytham E. Tantawy, MD, Ayman H. Abdelsattar, MD, Mahmoud M. Marei, MD, Hamed M. Seleim, MD, Wissam M. Mahmoud, MD, Departments of Pediatric Surgery, Cairo University, Fayoum University, Tanta Univerity

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12:03 pm T022: IS LAPAROSCOPIC PERCUTANEOUS EXTRAPERITONEAL CLOSURE FOR INGUINAL HERNIA EFFECTIVE COMPARED WITH THE OPEN METHOD? –A SINGLE INSTITUTION EXPERIENCE OF OVER 1000 CASES Hiromu Miyake, Koji Fukumoto, Go Miyano, Masaya Yamoto, Hiroshi Nouso, Keiichi Morita, Masakatsu Kaneshiro, Naoto Urushihara, Shizuoka Children’s Hospital 12:06 pm T023: DEVELOPMENT OF MINIMALLY INVASIVE SURGERY (MIS) IN A MEDIUM-VOLUME PEDIATRIC SURGICAL CENTER: A TEN YEAR EXPERIENCE OF 1387 OPERATIONS Patrick Ho Yu Chung, MBBS, FRCS, Kenneth Kak Yuen Wong, PhD, Paul Kwong Hang Tam, MBBS, MS, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong 12:09 pm T024: HYBRID SIMULATION: A NOVEL CURRICULAR CHANGE FOR AN ESTABLISHED TRAINING COURSE Katherine A. Barsness, MD, MS, Deborah M. Rooney, PhD, Carroll M. Harmon, MD, PhD, Northwestern University Feinberg School of Medicine, University of Michigan Medical School, University of Buffalo School of Medicine 12:12 pm T025: LAPAROSCOPIC INTERRUPTED MUSCULAR ARCH REAPIR IN RECURRENT UNILATERAL INGUINAL HERNIA AMONG CHILDREN Sherif M. Shehata, PhD, Akram M. ElBatarny, MD, Mohamed A. Attia, MD, Ashraf A. AlAttar, MD, Abdel Ghani Shalaby, MD, Department of Pediatric Surgery, Tanta University Hospital, Tanta, Egypt 12:15 pm T026: LAPAROSCOPIC TREATMENT OF LIVER HYDATID DISEASE IN CASES OF CYST RUPTURE IN CHILDREN Sagidulla Dosmagambetov, Bulat Dzenalaev, Aitzan Baimenov, Vladimir Kotlobovskiy, Aslan Ergaliev, Aslbek Tusupkaliev, Ibatulla Nurgaliev, Roza Kenzalina, Kidirbek Altaev, Kuben Satibaldiev, Egor Roskidailo, Department of Laparoscopic Surgery, Regional Pediatric Hospital, Aktobe, Kazakhstan 12:18 pm T027: OUTCOMES OF SINGLE PORT SURGERY FOR PERFORATED APPENDICITIS IN CHILDREN: SINGLE SURGEON EXPERIENCE. Adesola C. Akinkuotu, MD, Paulette I. Abbas, MD, Shiree Bery, MD, Ashwin Pimpalwar, MD, Texas Children’s Hospital and the Division of Pediatric surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 12:21 pm T028: THORACOSCOPIC APPROACH OF BILATERAL CHYLOTHORAX: VIDEO Marcelo Martinez Ferro, MD, Fernando Rabinovich, MD, Carolina Millan, MD, Horacio Bignon, MD, Gaston Bellia, MD, Luzia Toselli, MD, Mariano Albertal, MD, Private Children´s Hospital of Buenos Aires, Fundación Hospitalaria, Buenos Aires, Argentina

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12:24 pm T029: THE USE OF ROBOTIC SURGERY ALLOWS FOR IMPROVED DEXTERITY AND VISUALIZATION DURING THORACOSCOPIC THYMECTOMY Shannon F. Rosati, MD, Dan Parrish, MD, Patricia Lange, MD, Claudio Oiticica, MD, David Lanning, MD, PhD, Children’s Hospital of Richmond at Virginia Commonwealth University Medical Center 12:27 pm T030: TREATMENT OF THE CHYLOPERICARDIUM THROUGH MINIMAL INVASIVE TECHNIQUES REPORT OF A PEDIATRIC CASE Carlos Garcia- Hernandez, MD, Lourdes Carvajal-Figueroa, MD, Adriana Calderon- Urreta, MD, Sergio Landa-Juarez, MD, Hospital Star Medica Lomas Verdes. México 12:30 pm T031: LAPAROSCOPIC URETEROVESICAL PLASTY FOR MEGAURETER`S TREATMENT Sergio Landa-Juárez, MD, Ana María Castillo-Fernández, MD, Angélica Alejandra Guerra-Rivas, MD, Arturo Medécigo Vite, MD, Hermilo De La Cruz-Yañez, MD, Carlos Garcia-Hernández, MD, Hospital de Pediatria, Centro Médico Nacional Siglo XXI. IMSS 12:33 pm T032: VIDEO ASSISTED EXTRACORPOREAL PYELOPLASTY Edgar Rubio Talero, MD, Fernando A. Escobar Rivera, MD, Clinica Saludcoop Tunja 12:36 pm T033: THE USE OF A 5-MM ENDOSCOPIC STAPLER FOR RECTAL TRANSECTION DURING LAPAROSCOPIC SUBTOTAL COLECTOMY Simone Frediani, MD, Silvia Ceccanti, MD, Romina Iaconelli, MD, Falconi Ilaria, MD, Debora Morgante, MD, Denis A Cozzi, MD, Policlinico Umberto I Hospital and Sapienza University of Rome, Rome, Italy 12:39 pm T034: THE CHARACTERIZATION OF PECTUS EXCAVATUM INCLUDING ITS ASYMMETRY Sergio B. Sesia, MD, Margarete M. Heitzelmann, Sabine Schaedelin, MSc, Olaf Magerkurth, MD, Frank-Martin Haecker, MD, University Children’s Hospital of Basel, Department of Pediatric Surgery and Department of Pediatric Radiology, Spitalstrasse 33, 4056 Basel, Switzerland; University of Basel, Clinical Trial Unit,Schanzenstrasse 55, 4031 Basel, Switzerland 12:42 pm T035: CURRENT PRACTICE AND OUTCOMES OF THORACOSCOPIC ESOPHAGEAL ATRESIA AND TRACHEOESOPHAGEAL FISTULA REPAIR: A MULTI-INSTITUTIONAL ANALYSIS IN JAPAN Hiroomi Okuyama, MD, PhD, Hiroyuki Koga, MD, PhD, Tetsuya Ishimaru, MD, PhD, Hiroshi Kawashima, MD, Atsuyuki Yamataka, MD, PhD, Naoto Urushihara, MD, Osamu Segawa, MD, PhD, Hiroo Uchida, MD, PhD, Tadashi Iwanaka, MD, PhD, Dept of Pediatric Surgery, Hyogo College of Med.; Juntendo University School of Med.; The University of Tokyo Hosp.; Saitama Children’s Hosp.; Shizuoka Children’s Hosp.; Tokyo Women’s Medical University; Nagoya University Graduate School of Med.

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12:45 pm T036: SINGLE-INCISION LAPAROSCOPIC ENDORECTAL PULL-THROUGH FOR HIRSCHSPRUNG’S DISEASE WITH TROCARLESS INSTRUMENT VIA AN ANOTHER STAB INCISION Shao-tao Tang, MD, Shi-wang Li, MD, Li Yang, Department of Pediatric Surgery, Union Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China 12:48 pm T037: AUDIT OF INITIAL EXPERIENCE OF LAPAROSCOPIC PYLOROMYOTOMY Helai Habib, MBBS, BSc, Mohamed Shalaby, FRCS, Paed, Surg, Philip Hammond, FRCS, Paed, Surg, Atul Sabharwal, FRCS, Paed, Surg, Royal Hospital for Sick Children, Yorkhill, Glasgow, UK 12:51 pm T038: OUTCOMES AFTER EARLY SPLENECTOMY FOR HEMATOLOGICAL DISORDERS Elizabeth Renaud, MD, Nirmal Gokarn, MD, Deepa Manwani, MD, Steven Borenstein, MD, Dominique Jan, MD, PhD, Montefiore. Medical Center 12:54 pm T039: BRINGING SURGEONS TOGETHER ACROSS THE WORLD: DIAGNOSIS AND MANAGEMENT OF ACUTE APPENDICITIS. Margaret Nalugo, MPH, Todd A. Ponsky, MD, George W. Holcomb III, MD, Akron Children’s Hospital, Children’s Mercy Hospital 12:57 pm T040: A NOVEL REPAIR OF A VAGINAL FORNIX LACERATION FOLLOWING INTERCOURSE Ulises Garza Serna, MD, David Bliss, MD, Nam Nguyen, MD, Kasper Wang, MD, University of Southern California, Children’s Hospital Los Angeles

1:00 pm – 1:30 pm KEYNOTE LECTURE: “Lean Processes in the Hospital” SPEAKER: Dirk Pfitzer, Porsche Consulting GmbH. Dirk Pfitzer is a partner at PORSCHE CONSULTING and responsible for the center of competence in the field of health care/pharmaceuticals/medical technique. He joined PORSCHE CONSULTING 9 years ago after 5 years working at a major consulting and strategy company. He studied business management at the University of Bayreuth, Germany and Madrid, Spain. PORSCHE CONSULTING is a 100% subsidiary of PORSCHE Corp. and belongs to the leading consulting companies for operative excellence. Dirk Pfitzer was in charge for a variety of projects regarding the improvement of efficiency and competitiveness in the field of health care providers. He and his team could successfully accomplish projects in more than 70 hospitals, either private or university hospitals. The spectrum of their activities comprises projects in order o reduce costs and increase proceeds as well as to implement improvements at a process level.

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1:30 pm – 2:30 pm PANEL: Single Site Surgery MODERATOR: Todd A. Ponsky, MD DESCRIPTIONS: Designed for practicing pediatric surgeons who have an interest in advanced laparoscopy. Specifically this session will address the pros and cons of single port laparoscopy in children. OBJECTIVES At the conclusion of this session, participants will be able to: • Identify situations where there is an increased risk of injury to the bowel or bile ducts from single site surgery in pediatric patients. (patient safety) • Articulate the application of single site surgery in children • Compare single site surgery to standard laparoscopy in children in regards to technical feasibility and patient outcome.

TIME TOPIC PANELIST 1:30 pm Current Practice with Impact on Routine Martin Lacher, MD 1:45 pm How Far Can We Go? Carroll M. Harmon, MD, PhD 2:00 pm A Critical Appraisal Shawn D. St. Peter, MD 2:15 pm Q&A All

2:30 pm – 3:30 pm SCIENTIFIC SESSION: Thorax CHAIRS: Timothy D. Kane, MD & Pablo Laje, MD

2:30 pm S059: EXTENDED NUSS FOR 146 RECURRENCES OF PECTUS EXCAVATUM K. Schaarschmidt, Prof, MD, S. Polleichtner, MD, M. Lempe, MD, F. Schlesinger, MD, U. Jaeschke, MD, Helios Center of Pediatric & Adolescent Surgery Berlin-Buch 2:38 pm S060: 100 INFANT THORACOSCOPIC LOBECTOMIES: LEARNING CURVE AND A COMPARISON WITH OPEN LOBECTOMY Pablo Laje, MD, Erik G. Pearson, MD, Tiffany Sinclair, MD, Mohamed A. Rehman, MD, Allan F. Simpao, MD, David E. Cohen, MD, Holly L. Hedrick, MD, N. Scott Adzick, MD, Alan W. Flake, MD, The Children’s Hospital of Philadelphia 2:46 pm S061: TWO DECADES EXPERIENCE WITH THORACOSCOPIC LOBECTOMY IN INFANTS AND CHILDREN, STANDARDIZING TECHNIQUES FOR ADVANCED THORAOCSOCPIC SURGERY Steven Rothenberg, MD, William Middlesworth, MD, Angela Kadenhe-chiweshe, MD, The Morgan Stanley Children’s Hospital, Columbia University; The Rocky Mountain Hospital For Children

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2:54 pm S062: THORACOSCOPIC THORACIC DUCT LIGATION FOR CONGENITAL AND ACQUIRED DISEASE Bethany J. Slater, MD, Steven S. Rothenberg, MD, FACS, FAAP, Rocky Mountain Hospital For Children 3:02 pm S063: COMPARISON OF THORACOSCOPIC AND OPEN DIAPHRAGMATIC PLICATION IN NEONATES AND INFANTS Yury Kozlov, MD, Vladimir Novozhilov, MD, Department of Neonatal Surgery, Municipal Pediatric Hospital, Irkutsk, Russia; Department of Pediatric Surgery, Irkutsk State Medical Academy of Continuing Education (IGMAPO), Irkutsk, Russia 3:10 pm S064: THORACOSCOPIC LEFT CARDIAC SYMPATHETIC DENERVATION IN CHILDREN WITH MALIGNANT ARRHYTHMIA SYNDROMES Ryan Antiel, MD, Aodhnait Fahy, BMBCh, PhD, J. Martijn Bos, MD, PhD, Abdalla Zarroug, MD, Michael Ackerman, MD, PhD, Christopher Moir, MD, Mayo Clinic 3:18 pm S065: DIAPHRAGMATIC EVENTRATION IN CHILDREN; LAPAROSCOPY VERSUS THORACOSCOPIC PLICATION Go Miyano, MD, Masaya Yamoto, MD, Masakatsu Kaneshiro, MD, Hiromu Miyake, MD, Keiichi Morita, MD, Hiroshi Nouso, MD, Manabu Okawada, MD, Hiroyuki Koga, MD, Geoffrey J Lane, MD, Koji Fukumoto, MD, Atsuyuki Yamataka, MD, Naoto Urushihara, MD, Department of Pediatric Surgery, Shizuoka Children’s Hospital, Department of Pediatric General & Urogenital Surgery, Juntendo University of Medicine. 3:26 pm S097: THORACOSCOPIC CDH REPAIR – A SURVEY ON OPINION AND EXPERIENCE AMONG IPEG MEMBERS Martin Lacher, MD, PhD, Shawn D St. Peter MD, Paolo Laje MD, Benno M Ure MD, PhD, Caroll M Harmon MD, PhD, Joachim F Kuebler MD, Hannover Medical School (on behalf of the IPEG Research Committee)

3:30 pm – 4:00 pm Break 4:00 pm – 5:00 pm SCIENTIFIC SESSION: Bariatric, Robotics & Alternative Technologies CHAIRS: John J. Meehan, MD & Holger Till, MD, PhD

4:00 pm S066: LEARNING CURVE ANALYSIS IN PEDIATRIC SURGERY USING THE CUMULATIVE SUM (CUSUM) METHOD – A STATISTICAL PRIMER AND CLINICAL EXAMPLE Thomas P. Cundy, Nicholas E. Gattas, Alan White, Guang-Zhong Yang, Ara Darzi, Azad Najmaldin, Imperial College London, UK. Leeds General Infirmary, UK

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4:06 pm S067: MAN VS. MACHINE: A COMPARISON OF ROBOTIC-ASSISTED VS. LAPAROSCOPIC SLEEVE GASTRECTOMY IN SEVERELY OBESE ADOLESCENTS Victoria K. Pepper, MD, Terrence M. Rager, MD, MS, Karen A. Diefenbach, MD, Wei Wang, MS, MAS, Mehul V. Raval, MD, MS, Steven Teich, MD, Ihuoma Eneli, MD, Marc P. Michalsky, MD, Nationwide Children’s Hospital 4:12 pm S068: INTERNATIONAL ATTITUDES OF EARLY ADOPTERS TO CURRENT AND FUTURE ROBOTIC TECHNOLOGIES IN PEDIATRIC SURGERY Thomas P. Cundy, Hani J. Marcus, Archie Hughes-Hallett, Azad Najmaldin, Guang-Zhong Yang, Ara Darzi, Imperial College London 4:18 pm S069: LAPAROSCOPIC SLEEVE GASTRECTOMY IN CHILDREN AND ADOLESCENTS: THE TECHNIQUE AND THE STANDARDIZED PERI- OPERATIVE CLINICAL PATHWAY Aayed R. Alqahtani, MD, FRCSC, FACS, Mohamed O. Elahmedi, MD, Department of Surgery and Obesity Chair, King Saud University 4:24 pm S070: COMORBIDITY RESOLUTION IN MORBIDLY OBESE CHILDREN AND ADOLESCENTS UNDERGOING SLEEVE GASTRECTOMY Aayed R. Alqahtani, MD, FRCSC, FACS, Mohamed O. Elahmedi, MD, Awadh R. Al Qahtani, MD, FRCSC, Department of Surgery and Obesity Chair, King Saud University 4:30 pm S072: EVALUATION OF THE SAFETY OF LAPAROSCOPIC GASTROSTOMY IN PEDIATRIC PATIENTS WITH HYPOPLASTIC LEFT HEART SYNDROME USING INTRAOPERATIVE TRANSESOPHAGEAL ECHOCARDIOGRAPHY Hanna Alemayehu, MD, E. Marty Knott, DO, Jason D. Fraser, MD, William B. Drake, MD, Shawn D. St. Peter, MD, Kathy M. Perryman, MD, David Juang, MD, Children’s Mercy Hospital 4:36 pm S073: A COMPARATIVE STUDY OF OUTCOME OF SIMPLE PURSE STRING SUTURE LAPAROSCOPIC HERNIA REPAIR IN CHILDREN Mairi Steven, Miss, Stephen Bell, Dr., Peter Carson, Dr., Rebecca Ward, Dr., Merrill McHoney, Mr., Royal Hospital for Sick Children, Edinburgh, UK 4:42 pm S074: VERTICAL SLEEVE GASTRECTOMY: PRIMARY VERSUS REVISIONAL WEIGHT LOSS SURGERY IN ADOLESCENTS AND YOUNG ADULTS Jeffrey Zitsman, MD, Melissa Bagloo, MD, Beth Schrope, MD, PhD, Aaron Roth, MD, Miguel Silva, MD, Mary DiGiorgi, PhD, Marc Bessler, MD, Columbia University Medical Center

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5:00 pm – 6:00 pm PANEL: Live Surgery CHAIR: Marcelo Martinez Ferro, MD DESCRIPTION: This panel will discuss the current status and the real value of Live Surgery as an education tool for Pediatric Minimally Invasive Surgeons. OBJECTIVES At the conclusion of this session, participants will be able to: • Identify special settings needed to perform live case demonstrations • Develop a “Live case Surgical Time Out” a specific “Check list” for live case demonstrations to enhance patient safety • Recognize the real educational value of live case demonstrations in their practice • Recommend specific “IPEG Live case demonstrations guidelines”.

TIME TOPIC PANELIST 5:00 pm Introduction Marcelo Martinez Ferro, MD 5:02 pm State of the Art Steven Rothenberg, MD 5:14 pm Ethical Implications Go Miyano, MD 5:26 pm Pitfalls and Complications Maria Marcela Bailez, MD 5:38 pm IPEG Survey George W. Holcomb III, MD 5:50 pm Q&A All

7:00 pm – 11:30 pm MAIN EVENT: Celeigh and IPEG Dance Off – After Hours! (Black Tie and Kilts Optional)

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Saturday, July 26 Lennox 3 8:00 am – 9:00 am MISCELLANEOUS: Short Oral Papers CHAIRS: Celeste Hollands, MD and Sean S. Marven, MD

8:00 am S075: A ROBOTIC APPROACH TO MEDIAN ARCUATE LIGAMENT SYNDROME Victoria K. Pepper, MD, Karen A. Diefenbach, MD, Andy C. Chiou, MD, David L. Crawford, MD, University of Illinois School of Medicine at Peoria, Order of Saint Francis Medical Center, Nationwide Children’s Hospital 8:04 am S076: LAPAROSCOPIC EXCISION OF PERIPANCREATIC TUMOR AND MESENTERIC CYST Thai Lan N. Tran, MD, Nam X. Nguyen, MD, University of California, Irvine Medical Center 8:08 am S077: HIDING THE SCARS. EVOLUTION OF THE PEDIATRIC LAPAROSCOPIC CHOLECYSTECTOMY - THE 2X2 HYBRID TECHNIQUE Jeh Yung, MD, Georgios Karagkounis, MD, Gavin Falk, MD, Todd Ponsky, MD, FACS, Akron Children’s Hospital; Cleveland Clinic 8:12 am S078: FETOSCOPY AND LASER: A GOOD THERAPEUTIC ALLIANCE IN MINIMALLY-INVASIVE FETAL SURGERY Alan Coleman, MD, Jose Peiro, MD, Foong-Yen Lim, MD, Cincinnati Children’s Hospital Medical Center 8:16 am S079: IMPACT OF CUSTOMIZED PRE-BENDED BAR IN SURGICAL TREATMENT OF PECTUS EXCAVATUM Ruben Lamas-Pinheiro, MD, Pedro Correia-Rodrigues, Jaime C Fonseca, PhD, João L Vilaça, PhD, Jorge Correia-Pinto, MD, PhD, Tiago Henriques-Coelho, MD, PhD, Pediatric Surgery Department, Faculty of Medicine, Hospital de São João, Porto, Portugal 8:20 am S080: SINGLE INCISION LAPAROSCOPIC SURGERY FOR PERFORATED APPENDICITIS: DOES OBESITY AFFECT OUTCOMES ? Adesola C. Akinkuotu, MD, Paulette I. Abbas, MD, Ashwin Pimpalwar, MD, Texas Children’s Hospital and the Division of Pediatric Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 8:24 am S081: DIAGNOSTIC LAPAROSCOPY FOR INTRA-ABDOMINAL EVALUATION AND VENTRICULOPERITONEAL SHUNT PLACEMENT IN CHILDREN Sandra M. Farach, MD, Paul D. Danielson, MD, Nicole M. Chandler, MD, All Children’s Hospital Johns Hopkins Medicine 8:28 am S082: RISK OF REDO LAPAROSCOPIC FUNDOPLICATION IN CHILDREN: BEWARE THE RESPIRATORY PHYSICIAN? Edward Gibson, MBBS, Warwick J. Teague, DPhil, FRACS, Sanjeev Khurana, MS, FRCSI, FRACS, Department of Paediatric Surgery, Women’s and Children’s Hospital, Adelaide, Australia

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8:32 am S083: THORACOSCOPIC REPAIR ON THE CONGENITAL DIAPHRAGMATIC EVENTRATION IN CHILDREN?CONTINUOUS OR INTERRUPTED SUTURE FOR PLICATION Jiangbin Liu, PhD, Professor, Zhibao Lv, Professor, Department of Pediatric Surgery, Shanghai Children’s Hospital, Shanghai Jiao Tong University and Department of Pediatric Surgery, Children’s Hospital of Fudan University, Shanghai, PR China 8:36 am S084: VALIDATION OF A NOVEL PARAMETER FOR THE EVALUATION OF PECTUS EXCAVATUM: THE KANSAS CITY CORRECTION INDEX Gaston Bellia, MD, Mariano Albertal, MD, Luzia Toselli, MD, Carolina Millan, MD, Horacio Bignon, MD, Giselle Corti, Javier Vallejos, MD, Marcelo Martinez Ferro, Private Children´s Hospital of Buenos Aires, Fundación Hospitalaria, Buenos Aires, Argentina 8:40 am S085: SPONTANEOUS PNEUMOTHORAXES: A SINGLE-INSTITUTION RETROSPECTIVE REVIEW Victoria K. Pepper, MD, Terrence M. Rager, MD, MS, Wei Wang, MS, MAS, Dennis R. King, MD, Karen A. Diefenbach, MD, Nationwide Children’s Hospital 8:44 am S086: LAPAROSCOPIC RESECTION OF ABDOMINAL NEUROBLASTOMA WITH RENAL PEDICLE INVOLVEMENT Paula Flores, MD, Martin Cadario, MD, Yvonne Lenz, MD, Garrahan Hospital. Buenos Aires. Argentina. 8:48 am S087: LOWER ESOPHAGEAL BANDING IN EXTREMELY LOW BIRTH WEIGHT PREMATURE INFANTS WITH OESOPHAGEAL ATRESIA AND TRACHEO-ESOPHAGEAL FISTULA IS A LIFE SAVING PRACTICE FOLLOWED BY A SUCCESSFUL DELAYED PRIMARY THORACOSCOPY RECONSTRUCTION Manuel Lopez, MD, Eduardo Perez-Etchepare, François Varlet, MD, PhD, Department of Pediatric Surgery, University Hospital of Saint Etienne

9:00 am – 9:30 am General Assembly Presentation of the IPEG 2015 President

9:30 am – 9:45 am Awards Coolest Tricks, Basic Science and IRCAD

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9:45 am – 10:45 am SCIENTIFIC SESSION: Single Site Surgery CHAIR: Martin L. Metzelder, MD

9:45 am S088: DEVELOPMENT OF BLIND AREA VISUALIZATION SYSTEM IN MAGNIFIED FIELD OF VIEW USING AN AUGMENTED REALITY IN PEDIATRIC ENDOSURGERY ~AMAZING SEE-THROUGH NEEDLE DRIVER~ Satoshi Ieiri1,2, MD, PhD, Yuya Nishio3, Satoshi Obata1, MD, Ryota Souzaki1,2, MD, PhD, Yo Kobayashi3, PhD, Masakatsu Fujie3, PhD, Makoto Hashizume2, MD, PhD, FACS, Tomoak, 1Department of Pediatric Surgery, Faculty of Medicine, Kyushu University, 2Department of Advanced Medicine and Innovative Technology, Kyushu University Hospital, 3The faculty of science and engineering, Waseda University 9:51 am S089: IS SINGLE INCISION APPENDECTOMY SUPERIOR TO TRADITIONAL LAPAROSCOPY IN CHILDREN? Stephanie F. Polites, MD, Shannon D. Acker, MD, James T. Ross, David A. Partrick, MD, Abdalla E. Zarroug, MD, Kristine M. Thomsen, Donald D. Potter, MD, Mayo Clinic, Rochester, MN; Children’s Hospital Colorado, Aurora, CO; University of Iowa, Iowa City, IA 9:57 am S090: IMPACT OF EXPERIENCE ON QUALITY OUTCOMES IN SINGLE- INCISION LAPAROSCOPY FOR SIMPLE AND COMPLEX APPENDICITIS IN CHILDREN Sandra M. Farach, MD, Paul D. Danielson, MD, Nicole M. Chandler, MD, All Children’s Hospital Johns Hopkins Medicine 10:03 am S091: CAN HYPERTROPHIC PYLORIC STENOSIS BE TREATED WITH NATURAL ORIFICE TRANSESOPHAGEAL SURGERY APPROACH USING A NOVEL ENDOLUMINAL CATHETER DEVICE? EX-VIVO VALIDATION OF A NEW RABBIT MODEL FOR PYLORIC STENOSIS Carolyn T. Cochenour, BS, Timothy Kane, MD, Axel Krieger, PhD, Peter Kim, MD, PhD, Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Health System, Washington, DC, USA 10:09 am S092: ROUTINE UTILIZATION OF SINGLE-INCISION PEDIATRIC ENDOSURGERY (SIPES): A FIVE YEAR INSTITUTIONAL EXPERIENCE Aaron D. Seims, MD, Tate R. Nice, MD, Vincent E. Mortellaro, MD, Martin Lacher, MD, PhD, Muhammad E. Ba'ath, MD, Scott A. Anderson, MD, Elizabeth A. Beierle, MD, Colin A. Martin, MD, David A. Rogers, MD, Carroll M. Harmon, MD, PhD, Mike K. Chen, MD, Robert T. Russell MD, MPH, Children's of Alabama 10:15 am S093: SILS APPROACH TO INFLAMMATORY BOWEL DISEASE Claudio Vella, MD, Sara Costanzo, MD, Giorgio Fava, MD, Luciano Maestri, MD, Giovanna Riccipetitoni, MD, Pediatric Surgery Department, “V.Buzzi” Children’s Hospital ICP, Milan – Italy

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10:21 am S094: CLIPPED VERSUS STAPLED SIPES (SINGLE INCISION PEDIATRIC ENDOSURGERY) APPENDECTOMY: PATIENT OUTCOME, ECONOMIC CONSIDERATIONS, AND ENVIRONMENTAL IMPACT Hayden W. Stagg, MD, Oliver Muensterer, MD, PhD, Samir Pandya, MD, Matthew Bronstein, MD, Lena Perger, MD, McLane Children’s at Scott and White, Texas A&M,Temple TX, USA; Maria Fareri Children’s Hospital at Westchester Medical Center New York Medical College, Valhalla NY, USA 10:27 am S095: INITIAL EXPERIENCE OF MINIMALLY INVASIVE LAPAROSCOPIC SURGERY ASSISTED BY PERCUTANEOUS INSTRUMENTS ASSEMBLED IN OPERATIVE FIELD Ryosuke Satake, MD, Keisuke Suzuki, MD, Tetsuro Kodaka, PhD, Kan Terawaki, PhD, Makoto Komura, PhD, Saitama Medical University, Department of pediatric surgery 10:33 am S096: INTERNATIONAL OPINION ON THE FUTURE OF MINIMALLY INVASIVE SURGERY - FROM A(BESECON) TO Z(AGREB) Roland W. Partridge, Paul M. Brennan, Mark M. Hughes, Iain A. Hennessey, Royal Hospital for Sick Children, Edinburgh, UK, Alder Hey Children’s Hospital, Liverpool, UK

10:45 am – 12:00 pm SATURDAY MOVIE MATINEE: Complications: “My Worst Nightmare” – Complicated Cases, Pitfalls and Unusual Solutions Popcorn and soft drinks will be provided CHAIRS: Philipp O. Szavay, MD & Mark L. Wulkan, MD DESCRIPTION: This session is designed to show videos of operations where a complication occurred. The causes and strategies to prevent those complications will be discussed. OBJECTIVES At the conclusion of this session, participants will be able to: • Identify strategies to decrease conversion rates due to complications occurring during MIS. • Describe techniques to manage complications safely and appropriately (patient safety). • Identify technical strategies to manage complications. • Apply techniques learned in the situation of a complication. • Predict cases, where a complication might be anticipated (patient safety).

12:00 pm Closing Remarks

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WWW.IPEG.ORG | 55 Table of Contents Exhibitors & Exhibit Hall Floorplan

EXHIBITORS B. Braun Aesculap Booth #10 Richard Wolf UK Ltd. Booth #3 JustRight Surgical Booth #13 Shire Booth #6 Cardica Inc. Booth #9 Stryker Endoscopy Booth #8 Karl Storz Endoscopy Booth #1 Surgical Innovations Booth #4 LaproSurge Ltd Booth #7 Vygon (UK) Ltd. Booth #5 RADistribution Booth #11 Wisepress Medical Bookshop Booth #14

IPEG’s 23rd Annual Congress for Endosurgery in Children ■ July 22-26, 2014 | 56 Table of Contents Exhibitor Profiles

AUS SYSTEMS/LAPROSURGE Cardica Inc. Booth #7 Booth #9 73a High Road 900 Saginaw Drive Bushey Heath WD23 1EL Herts Redwood City, CA 94063 Germany T: 1.650.364.9975 T: 0208 950 8662 F: 1.650.364.3134 www.laprosurge.com www.cardica.com The rbi2 suction rectal biopsy system Cardica's MicroCutter is the world’s is easy to use, providing consistent first and only 5mm stapler that and controlled suction and delivering articulates to 80°. The MicroCutter uniform sub mucosa specimens for XCHANGE 30 is a cartridge-based pathological examination for the surgical stapling system available in diagnosis of Hirschsprung’s Disease. selected European countries for use Offering superior efficacy, proven in a wide variety of open, laparoscopic performance and a reduction in costs, and thoracoscopic surgical procedures the system includes a fully assembled including appendectomies, intestinal, single-use capsule packaged for lung and liver resections, and pediatric convenience in a sterile procedure pack. procedures for congenital disease.

B. BRAUN AESCULAP JUSTRIGHT SURGICAL Booth #10 Booth #13 Am Aesculap-Platz 6325 Gunpark Dr., Suite G 78532 Tuttlingen Boulder, CO 80301 Germany T: 720.287 7130 T: +49746195256 F: 720.287.7135 F: +497461952072 www.justrightsurgical.com www.bbraun.com JustRight Surgical is moving the B. Braun Sharing Expertise benefits of minimally invasive surgery into the pediatric surgical arena. We Through exchanging knowledge with its design, develop and market precision customers, B. Braun helps to improve instrumentation for the pediatric treatments and working procedures in surgical community. With our devices hospitals and medical practices and to we expect to foster advancements in increase the safety of patients, doctors surgical approaches that reach beyond and nursing staff. With useful products what traditional instruments have and process-oriented advice Aesculap, allowed. a B. Braun company is pursuing a goal: to improve therapies and make processes more efficient.

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KARL STORZ GMBH & CO. KG RICHARD WOLF UK LTD. Booth #1 Booth #3 Mittelstr. 8 Waterside Way 78532 Tuttlingen Wimbledon, London, SW17 0HB Germany United Kingdom T: +49 (0) 7461 7080 T: 020 8944 7447 F: +49 (0) 7461 708105 F: 020 8944 1311 www.karlstorz.com www.richardwolf.uk.com KARL STORZ is a renowned Richard Wolf UK Ltd is proud to provide manufacturer that is well established the highest quality surgical products in all fields of endoscopy. The still and with a focus on innovation and family held company has grown to excellence, we are thrilled to announce one with a worldwide presence and the launch of the Texas Paediatric 6700 employees. KARL STORZ offers Bronchoscope in August 2014. Please a range of both rigid and flexible speak to a staff member about this endoscopes for a broad variety of exciting development. applications. SHIRE PHARMACEUTICALS (UK) OCEANA THERAPEUTICS LTD. Booth #6 Booth #11 Hampshire International Business Park Sandyford Industerial Estate Lime Tree Way Q House, 76 Furze Road, Suite 602 Chineham, Basingstoke Sandyford Dublin 18 Hampshire RG24 8EP T: +353 12930153 United Kingdom www.deflux.com T: +44 (0)1256 894000 www.radistribution.com F: +44 (0)1256 894708 www.shire.com Deflux™ by Oceana Therapeutics is the only FDA approved bulking Shire enables people with life-altering agent for the treatment of conditions to lead better lives. Our Vesicoureteral Reflux and is also strategy is to focus on developing indicated for the treatment of Stress and marketing innovative specialty Urinary Incontinence. Deflux™ medicines to meet significant unmet gel is composed of dextranomer patient needs. We provide treatments microspheres and stabilized in Neuroscience, Rare Diseases, hyaluronic acid of non-animal origin Gastrointestinal and Internal Medicine (NASHA™). Deflux™ is represented by and we are developing treatments for its distributor RADistribution symptomatic conditions treated by specialist physicians in other targeted therapeutic areas.

IPEG’s 23rd Annual Congress for Endosurgery in Children ■ July 22-26, 2014 | 58 Table of Contents Exhibitor Profiles

STRYKER VYGON (UK) LTD. Booth #8 Booth #5 5900 Optical Ct, San Jose CA 95138 The Pierre Simonet Building T: 408.754.2000 V-Park, Gateway North www.stryker.com Latham Road Swindon SN25 4DL Stryker is a leading medical technology United Kingdom company and together with our T: (01793) 748800 customers, we are driven to make F: (01793) 748899 healthcare better. Stryker offers www.vygon.co.uk innovative reconstructive, medical, surgical, neurotechnology, spine and We are a leading supplier of medical robotic arm assisted technologies and surgical devices with a reputation to help people lead more active, for delivering high quality products satisfying lives. We are committed to and excellent customer service, enhancing quality of care, operational helping healthcare professionals effectiveness and patient satisfaction. offer best practice solutions to their patients. Our products cover many SURGICAL INNOVATIONS therapeutic specialties, including Booth #4 vascular access, IV management, Clayton Wood House neonatology and enteral feeding. Unit 6, Clayton Wood Bank Leeds LS16 6QZ UK WISEPRESS MEDICAL BOOKSHOP Booth #14 T: +44 (0)113 230 7597 www.surginno.com 25 High Path, Merton Abbey London, SW19 2JL, UK Surgical Innovations (SI) specialises T: +44 20 8715 1812 in the design and manufacture of F: +44 20 8715 1722 creative solutions for minimally www.wisepress.com invasive surgery (MIS). Designed and manufactured in the UK, our medical Wisepress are Europe’s principal devices are pioneering, ergonomic, conference bookseller. We exhibit easy to assemble and easy-to-use. the leading books, sample journals Our Resposable® products – made up and digital content relevant to this of reusable and disposable elements meeting. Books may be purchased – have been specifically designed at the booth, and we offer a postal to offer hospitals high quality, cost- service. Visit our online bookshop for effective solutions. We have recently special offers and follow us on Twitter launched a pioneering range of 3mm for the latest news @WisepressBooks. ‘Ultra MIS’ technologies.

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IPEG 2014 ANNUAL MEETING Commercial Bias Reporting Form You are encouraged to… 1. Document (on this form) any concerns about commercially-biased presentations/ materials during educational sessions, and 2. Immediately take your completed form to the IPEG staff at Meeting Registration Desk Your feedback will be shared with a members of the Executive Committee, who will make the faculty and course chair(s) aware of these concerns.

COMMERCIAL BIAS The International Pediatric Endosurgery Group (IPEG) has an obligation to the medical profession and society as a whole to elucidate bias in order to protect the objectivity, scientific integrity and quality of its continuing medical education (CME) programs and to provide CME in an ethical and impartial manner. Bias is defined when a preference or predisposition exist toward a particular perspective or result that interferes with an individual’s ability to be impartial, unprejudiced or objective in order to further personal gain and disregard for data. Particular preferences may be favorable or unfavorable. When bias exists, impartial judgment and neutrality may be compromised. Bias may be minimized through a declaration of conflict of interest or commercial interests, an evaluation of peer-reviewed evidence-based medicine with an integration of clinical expertise and/or experience, and an assertion of published sources for evidence- based reporting. IPEG requires presenters at all educational events to specifically avoid introducing bias, commercial or otherwise, into their presentations. Presentation: (eg session name, etc)

Commercial Bias by: (ie faculty name, company rep)

Promotion via: (eg handouts, slides, what they said, actions)

Commercial Bias about: (check all that apply) ££ Patient treatment/management recommendations weren’t based on strongest levels of evidence available. ££ Emphasis was placed on one drug or device versus competing therapies, and no evidence was provided to support its increased safety and/or efficacy. ££ Trade/brand names were used. ££ Trade names versus generics were used for all therapies discussed. ££ The activity was funded by industry and I perceived a slant toward the grantors. ££ The faculty member had a disclosure and I perceived a slant toward the companies with which he/she has relationships. ££ Other (please describe): Please return this form to Vanessa Cheung at [email protected] or fax to 310-437-0585.

IPEG’s 23rd Annual Congress for Endosurgery in Children ■ July 22-26, 2014 | 60 Table of Contents CME Worksheet 2014 Meeting

CREDITS HOURS TIME ACTIVITY AVAILABLE ATTENDED TUESDAY, JULY 22, 2014 4:00 pm – 8:00 pm Postgraduate Lecture: MIS in Infants 3.75 and Neonates TOTAL CREDITS AVAILABLE FOR TUESDAY 3.75 WEDNESDAY, JULY 23, 2014 8:00 am – 11:00 am Hands On Lab: Critical Technical Skills for Neonatal and Infant 0 Minimally Invasive Surgery 8:00 am – 11:00 am Simulator Hands on Lab: Advanced Neonatal High Fidelity Course for 0 Advanced Learners 1:00 pm – 5:00 pm Simulator Hands On Lab: Innovations in Simulation-Based Education for 0 Pediatric Surgeons 5:00 pm – 7:00 pm Joint IPEG/BAPS Opening Ceremony/ 0 Welcome Reception TOTAL CREDITS AVAILABLE FOR WEDNESDAY 0 THURSDAY, JULY 24, 2014 7:00 am – 8:00 am Morning Scientific Video Session I: Coolest Tricks, Extraordinary 1.0 Procedures 8:05 am – 9:00 am Scientific Session: Gastrointestinal 1.0 9:00 am – 9:30 am Presidential Address & Lecture: 0.5 “Music, Endoscopic Surgery and IPEG” 10:00AM – 11:30AM Basic Science and Misc 1.5 12:00 pm – 1:00 pm Top Posters 1-20: Digital 0 Presentation 1:00 pm – 3:00 pm IPEG/BAPS Presidential Debate: “Esophageal and Diaphragmatic 2.0 Surgery-Thoracoscopic vs Open” 3:30 pm – 5:20 pm IPEG/BAPS Best Clinical Paper Session 1.75 5:20 pm – 5:50 pm Karl Storz Lecture: “Developing Neonatal MIS Surgery, Innovation, 0.5 Techniques, and helping an Industry to Change” TOTAL CREDITS AVAILABLE FOR THURSDAY 8.25 CONTINUED }

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CME Worksheet 2014 Meeting CONTINUED

CREDITS HOURS TIME ACTIVITY AVAILABLE ATTENDED FRIDAY, JULY 25, 2014 7:00 am - 8:00 am Morning Scientific Video Session II 1.0 8:00 am - 9:30 am Scientific Session: Urogenital 1.5 10:00 am - 11:00 am Scientific Session: Gastrointestinal & 1.0 Hepatobiliary II 11:00 am - 12:00 pm Scientific Session: Panel – “Laparoscopy in the Neonate and 1.0 Infant: What’s New?” 12:00 pm – 1:00 pm Top Posters 21-40: Digital 0 Presentation 1:00 pm - 1:30 pm Keynote Lecture: “Learn Processes in 0.5 the Hospital” 1:30 pm - 2:30 pm Panel: Single Site Surgery 1.0 2:30PM-3:30 pm Scientific Session: Thorax 1.0 4:00 pm - 5:00 pm Scientific Session: Bariatric, Robotics 1.0 and Alternative Technologies 5:00 pm - 6:00 pm Panel: Live Surgery 1.0 TOTAL CREDITS AVAILABLE FOR FRIDAY 9.0 SATURDAY, JULY 26, 2014 8:00 am – 9:00 am Miscellaneous: Short Oral Papers 1.0 9:00 am – 9:30 am General Assembly 0 9:30 am – 9:45 am Awards 0 9:45 am – 10:45 am Scientific Session: Single Site Surgery 1.0 10:45 am – 12:00 pm Saturday Movie Matinee: Complications-“ My Worst 1.25 Nightmare” – Complicated Cases, Pitfalls and Unusual Solutions” 12:00 pm – 1:00 pm Closing Remarks 0 TOTAL CREDITS AVAILABLE FOR SATURDAY 3.25 TOTAL POSSIBLE CREDITS 24.25

To receive a CME Certificate for this meeting, please complete the on-line survey at www.research.net/s/2014ipeg. If you have questions about this CME section, please email Vanessa Cheung/IPEG CME Department at [email protected]. AN ADDITIONAL CHARGE OF US$25.00 WILL BE ASSESSED FOR REQUESTS RECEIVED AFTER SEPTEMBER 30, 2014

IPEG’s 23rd Annual Congress for Endosurgery in Children ■ July 22-26, 2014 | 62 Table of Contents Faculty Disclosures

The following faculty, IPEG Program and Executive Committee Members provided information indicating they have a financial relationship with a proprietary entity producing health care goods or services, with the exemption of non-profit or government organizations and non-health care related companies. (Financial relationships can include such things as grants or research support, employee, consultant, major stockholder, member of speaker's bureau, etc.)

Commercial What Was What Was Faculty Disclosure Interest Received the Role Hossen Allal Nothing to Disclose Aayed Al-Qahtani ◆ Nothing to Disclose George Azzie Nothing to Disclose Marcela Bailez ★ ◆ Nothing to Disclose Katherine Barsness ◆ Nothing to Disclose Matthew Clifton Nothing to Disclose David Crabbe Nothing to Disclose Mark Davenport Nothing to Disclose Dafydd A. Davies Nothing to Disclose Alex Dzakovic Nothing to Disclose Karen A. Diefenbach Nothing to Disclose Simon Eaton Nothing to Disclose Peter Thomas Esslinger Nothing to Disclose Paula Flores Nothing to Disclose Justin Gerstle Nothing to Disclose Stefan Gfroerer Nothing to Disclose Miguel Guelfand ◆ Nothing to Disclose Carroll M. Harmon ◆ Nothing to Disclose George W. Holcomb JustRight Ownership Advisory III ◆ Surgical Interest Committee JustRight Ownership Consultant Surgical Interest Celeste Hollands ★ Nothing to Disclose Timothy Kane ★ Nothing to Disclose Joachin Kuebler Aesculap AG Expense Speaking/ allowance for Teaching being tutor of a MIC Course Aesculap Reimbursement Speaking/ Academy for teaching Teaching in workshop: Minimal Invasive Pediatrc Surgery Martin Lacher Nothing to Disclose Pablo Laje ◆ Nothing to Disclose

★ Executive Committee ◆ Program Committee

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Faculty Disclosures CONTINUED

Commercial What Was What Was Faculty Disclosure Interest Received the Role Andreas Leutner Nothing to Disclose Marc A. Levitt ★ Nothing to Disclose Charles Leys Nothing to Disclose Long Li ★ ◆ Nothing to Disclose Manuel Lopez Nothing to Disclose Tobias Luithle Nothing to Disclose Gordon MacKinlay Nothing to Disclose Maximillano Marcic Nothing to Disclose Marcelo Martinez Nothing to Disclose Ferro Sean Marven ◆ Nothing to Disclose Milissa McKee Nothing to Disclose John J. Meehan Nothing to Disclose Martin Metzelder Nothing to Disclose Mac P. Michalsky Nothing to Disclose Carolina A. Millan Nothing to Disclose Go Miyano Nothing to Disclose Oliver Muensterer ◆ Nothing to Disclose Daniel Ostlie ★ Nothing to Disclose Dirk Pfitzer Nothing to Disclose Agostino Pierro Nothing to Disclose Todd A. Ponsky ★ ◆ GlobalCastMD Ownership Owner Steven Rothenberg JustRight Ownership Consultant Surgical Interest Juergen Schleef Nothing to Disclose Shawn D. St Peter ◆ Nothing to Disclose Philipp O. Szavay ◆ Nothing to Disclose Holger Till ★ Nothing to Disclose Rick Turnock Nothing to Disclose Benno Ure ★ ◆ Braun Honoraia Independent Aesculap Contractor Rezza Vahdad Nothing to Disclose David C. van der Zee ★ Nothing to Disclose Mark L. Wulkan ★ ◆ Nothing to Disclose CK Yeung ◆ Nothing to Disclose Suzanne Yoder Nothing to Disclose

★ Executive Committee ◆ Program Committee

IPEG’s 23rd Annual Congress for Endosurgery in Children ■ July 22-26, 2014 | 64 Table of Contents Presenter Disclosures

What Was What Was Presenter Disclosure Company Received the Role Shannon N. Acker, MD Nothing to Disclose Adam C. Alder, MD Nothing to Disclose Hanna Alemayehu, MD Nothing to Disclose Aayed R. Alqahtani, MD, Nothing to Disclose FRCSC, FACS ◆ Ryan Antiel, MD Nothing to Disclose Karim Awad, MSc, MRCS Nothing to Disclose Joanne Baerg, MD Nothing to Disclose Maria M. Bailez, MD ◆ Nothing to Disclose Katherine A. Barsness, Nothing to Disclose MD, MS ◆ Mark Bishay Nothing to Disclose Mariana Borges-Dias Nothing to Disclose Kanika A. Bowen, MD Nothing to Disclose Tim Bradnock Nothing to Disclose Kirsty Brennan Nothing to Disclose Ewan M. Brownlee Nothing to Disclose Matias Bruzoni, MD, Nothing to Disclose FACS Ana Maria­ Castillo- Nothing to Disclose Fernandez, MD Patrick Ho Yu Chung, Dr. Nothing to Disclose Matthew S. Clifton, MD Nothing to Disclose Giovanni Cobellis, PhD Nothing to Disclose Alan Coleman, MD Nothing to Disclose Santiago Correa, MD Nothing to Disclose Thomas P. Cundy Nothing to Disclose Kuiran Dong, MD Nothing to Disclose Mohamed M. Elbarbary, Nothing to Disclose MD Akram M. Elbatarny, Nothing to Disclose MD, MRCSEd Gaston Ricardo Elmo, Nothing to Disclose MD Sandra M Farach, MD Nothing to Disclose Xiaoyan Feng, MD Nothing to Disclose Paula Flores, MD Nothing to Disclose HamidReza Foroutan, Nothing to Disclose Dr. Simone Frediani, MD Nothing to Disclose

◆ Program Committee

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Presenter Disclosures CONTINUED

What Was What Was Presenter Disclosure Company Received the Role Zhigang Gao, MD Nothing to Disclose Carlos Garcia- Nothing to Disclose Hernandez, MD Cindy Gomes Ferreira, Nothing to Disclose MD Jonathan Goring Nothing to Disclose Patrick Green Nothing to Disclose Helai Habib, MBBS, BSc Nothing to Disclose Michael Harrison, MD Nothing to Disclose Daniel B. Herz, MD Nothing to Disclose Jinshi Huang, MD Nothing to Disclose Satoshi Ieiri , MD, PhD Nothing to Disclose Corey W. Iqbal, MD Nothing to Disclose Sabine Irtan, MD, PhD Nothing to Disclose David Juang, MD Nothing to Disclose Timothy D. Kane, MD Nothing to Disclose Nidhi Khandelwal, Dr Nothing to Disclose Vladimir Kotlobovskiy, Nothing to Disclose Prof. Yury Kozlov, MD Nothing to Disclose Neetu Kumar Nothing to Disclose Pablo Laje, MD ◆ Nothing to Disclose Ruben Lamas-Pinheiro, Nothing to Disclose MD Sergio Landa-Juarez, Nothing to Disclose MD Suolin Li, MD Nothing to Disclose Aiwu Li Nothing to Disclose Jiangbin Liu, PhD, Nothing to Disclose Professor Manuel Lopez, MD Nothing to Disclose Tobias Luithle, MD Nothing to Disclose Justin B. Mahida, MD, Nothing to Disclose MBA Maximiliano Alejo Nothing to Disclose Maricic, MD Marcelo Martinez Ferro, Nothing to Disclose MD Antonio Messineo, MD Nothing to Disclose Martin Metzelder Nothing to Disclose

◆ Program Committee

IPEG’s 23rd Annual Congress for Endosurgery in Children ■ July 22-26, 2014 | 66 Table of Contents

Presenter Disclosures CONTINUED

What Was What Was Presenter Disclosure Company Received the Role Carolina Millan, MD Nothing to Disclose Meghna V Misra, MD Nothing to Disclose Hiromu Miyake Nothing to Disclose Go Miyano, MD ◆ Nothing to Disclose Vincent Mortellaro, MD Nothing to Disclose Oliver J. Muensterer, MD, Nothing to Disclose PhD ◆ Nam X Nguyen, MD Nothing to Disclose Tate Nice, MD Nothing to Disclose Satoshi Obata, MD Nothing to Disclose Stephen Oh, MD Nothing to Disclose Manabu Okawada, MD Nothing to Disclose Hiroomi Okuyama, MD, Nothing to Disclose PhD Daniel J. Ostlie, MD Nothing to Disclose Samir Pandya, MD Nothing to Disclose Roland W. Partridge 1 Disclosure esSurgical Ltd Ownership Management “Simulator” Interest Position Emily A. Partridge Nothing to Disclose Dariusz Patkowski, Prof, 1 Disclosure Bbraun Honoraria Speaking/ MD, PhD Teaching Victoria K Pepper, MD Nothing to Disclose Lena Perger, MD Nothing to Disclose Ashwin Pimpalwar, MD Nothing to Disclose Abigail B. Podany, MD Nothing to Disclose Stephanie F Polites, MD Nothing to Disclose Todd Ponsky, MD, FACS 4 Disclosures Stryker Honoraria Speaking/ ◆ Teaching GlobalCastMD Ownership Management Interest Position Storz Honoraria Consultant Covidian Honoraria Consultant Ravindra Ramadwar, Dr. Nothing to Disclose Elizabeth Renaud, MD Nothing to Disclose Fernando Rey, MD Nothing to Disclose Shannon F. Rosati, MD Nothing to Disclose Steven Rothenberg, 2 Disclosures Karl Storz Consulting Fee Consultant MD ◆ Just Right Ownership Consultant Surgical Interest ◆ Program Committee

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Presenter Disclosures CONTINUED

What Was What Was Presenter Disclosure Company Received the Role Edgar Rubio Talero, MD Nothing to Disclose Ryosuke Satake, MD Nothing to Disclose K. Schaarschmidt, Prof., Nothing to Disclose MD Avraham Schlager, MD Nothing to Disclose Aaron D. Seims, MD Nothing to Disclose Sergio B. Sesia, MD Nothing to Disclose Bethany J. Slater, MD Nothing to Disclose Yu. Sokolov, MD, PhD Nothing to Disclose Tran N. Son, MD, PhD Nothing to Disclose Shawn St. Peter ◆ Nothing to Disclose Mairi Steven, Miss Nothing to Disclose Lisanne J. Stolwijk, MD Nothing to Disclose Shinya Takazawa, MD Nothing to Disclose Yujiro Tanaka, MD, PhD Nothing to Disclose Shao-tao Tang, MD Nothing to Disclose Warwick J. Teague, DPhil, Nothing to Disclose FRACS Reza M. Vahdad, MD Nothing to Disclose Claudio Vella, MD Nothing to Disclose J. Vlot, MD, PhD Nothing to Disclose Chandrasekharam Vvs, Nothing to Disclose Dr. James Wall, MD, MS 2 Disclosures Cardica Consulting Fee Consultant Magnamosis Ownership Advisory Interest Committee Bo Xiang, MD Nothing to Disclose Benjamin Zendejas, MD, Nothing to Disclose MSc Jeffrey Zitsman, MD Nothing to Disclose ◆ Program Committee

SAVE THE DATE! For IPEG’s 24th Annual Congress for Endosurgery in Children, April 14-18, 2015, held at Gaylord Resort & Convention Center, Nashville, Tennessee, in conjunction with the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).

Abstract submission open in Summer 2014.

IPEG’s 23rd Annual Congress for Endosurgery in Children ■ July 22-26, 2014 | 68 Table of Contents Long Term Research Fund Donors

In an effort to further IPEG’s mission of education, research and improved patient care, the IPEG Executive Committee formed the IPEG Long Term Research Fund (LTRF). The primary goal of the LTRF is to award an annual research grant to IPEG members. This grant is meant to stimulate and support high-quality original research from IPEG members in basic science. The IPEG Research Grant is made possible by the donations of numerous IPEG members. Without your promotion and financial support of this grant, this award would not be possible. Thank you to all those who have donated! $1200+

Steven Rothenberg, MD $500-1199

Todd A. Marcelo Timothy D. Go Miyano, MD Karen Ponsky, MD Martinez Kane, MD Diefenbach, MD Ferro, MD $100-300 Soo Min Ahn, MD Celeste Hollands, MD Aayed R. Al-Qahtani, MD Satoshi Ieiri, MD Dayang A. Abdul Aziz, MD Tadashi Iwanaka, MD, PhD Katerine A. Barsness, MD Colin Kikiros, MD Bonnie L. Beaver, MD, FACS Pablo Laje, MD Yoon-Jung Boo, MD Sherif M.K.A. Mebed Brendan T. Campbell, MD Samir R. Pandya, MD Simon A. Clarke, FRCS Rajeev Prasad, MD Carlos Garcia-Hernandez, MD C.K. Yeung, MD Munther J. Haddad, MD Jeffrey Zitsman, MD Carroll M. Harmon, MD, PhD

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Long Term Research Fund Donors CONTINUED $30-99 Maria Marcela Bailez, MD Olga G. Mokrushina, MD Abderrahman Sadok El Kadhi, MD Carlos A.H. Peterson, MD Peter Thomas Esslinger, MD Ravindra H. Ramadwar MS Edward Esteves, MD Jeffrey J. Runge, DVM Fernando Fierro, MD Klaus Schaarschmidt, MD Miguel Guelfand, MD Sergio Sesia Anna Gunnarsdottir, MD, PhD Heriberto L. Solano, MD Tiago Henriques-Coelho, MD Henri Steyaert, MD G.M. Irfan Kan Suzuki, PhD Hiroyuki Koga, MD Philipp O. Szavay, MD Vladamir Kotlobovsky, MD Edgar Rubio Talero, MD Suolin Li, MD Holger Till, MD Pierre Lingier, MD Hiroo Uchida, MD Manuel Lopez, MD Kees P. van de Ven, MD Sergio Melo Claudio Vella, MD Martin L. Metzelder, MD $20-29 Mari Arai, MD Sherif G. Emil, MD Joanne Baerg Ciro Esposito, MD, PhD Julio Justo Baez, MD Stephen M. Evans, MD Robert Bergholz, MD Naomi R. Golonka, MD Sanja Besarovic, MD B.J. Hancock, MD Marcos Bettolli, MD Jafrul Hannan, MS, MD Meltem Bingol-Kologlu, MD Akira Hatanaka, MD Christopher J. Bourke, MD Andrew J.A. Holland, PhD Charles W. Breaux, MD, FACS Andrew R. Hong, MD Marybeth Browne, MD Jeffrey Horwitz, MD Allen F. Browne, MD Olajire Idowu, MD Andreana Butter, MD Michael S. Irish, MD Anthony Chung-ning Chin, MD Tetsuya Ishimaru Kelvin L. Choo, MD, FRACS Ashish Jiwane, MD Matthew S. Clifton, MD Michael Josephs, MD C. Eric Coln, MD Shoko Kawashima, MD Catherine M. Cosentino, MD Richard Keijzer, MD Benjamin Del Rio Hernandez, MD Karim Khelif, MD Anthony Dilley, MD Toan Khuc, MD Michael W. Dingeldein, MD Evan R. Kokoska, MD John E. Dinsmore, MD Keith A. Kuenzler, MD

IPEG’s 23rd Annual Congress for Endosurgery in Children ■ July 22-26, 2014 | 70 Table of Contents

Long Term Research Fund Donors CONTINUED

$20-29 continued… Jean-Martin Laberge, MD Henrik Steinbrecher, MD Vinh T. Lam, MD Gustavo Stringel, MD Jacob C. Langer, MD Wendy T. Su, MD Colin Lazarus, MD Makoto Suzuki, MD , PhD Manuel Lopez, MD Paul K.H. Tam PhD Tobias Luithle Yuk Him Tam, MD Francois I. Luks, MD Paul K.H. Tam PhD Maurício Macedo, PhD Xavier Tarrado, MD Claudia Marhuenda Irastorza, MD Kristine Jane Thayer, MD Thomas McGill, MD Paul Thorne, MD Elizabeth J. McLeod, MD Michael V. Tirabassi, MD David P. Meagher Jr., MD Salmai Turial, MD Clemens-Magnus Meier, MD Hiroo Uchida, MD Hector Melgarejo Sadashige Uemura, PhD Antonio Messineo, MD Benno Ure, MD, PhD Carolina A. Millan, MD Patricia Valusek, MD Rodrigo Mon, MD David C. Van der Zee, MD, PhD Don Moores, MD Martin Van Niekerk, MD Fraser D. Munro, MD Robert J. Vandewalle, MD Sadasivam Muthurajan, MD Ravindra Vegunta, MD Masaki Nio, MD John Vlot, MD Robert L. Parry, MD Kenneth K. Wong, MD Bhavesh Patel, MD Makoto Yagi, MD Dariusz Patkowski, MD Atsuyuki Yamataka, MD J. Duncan Phillips, MD Suzanne M. Yoder, MD Mark Powis, MD Jyoji Yoshizawa, MD Horacio A. Questa, MD Matthew S. Clifton, MD Daniel J. Robertson, MD Joachim F. Kuebler, MD David H. Rothstein, MD Sang Lee, MD Matthew T. Santore, MD Ivan Molina, MD Ryosuke Satake Douglas Y. Tamura, MD Masahito Sato, MD Baran Tokar, MD Matthias B. Schaffert, MD Robertine Van Baren, MD Robert Schlechter, MD Jian Wang, MD Axel Schneider, MD Jeong-Meen Seo, MD Hideki Soh, MD Oliver S Soldes, MD Amy B. Stanfill, MD

WWW.IPEG.ORG | 71 Table of Contents New Membership

Hanna Alemayehu, MD Alexander Dzakovic, MD The Children’s Mercy Hospital Loyola Univ Med Ctr USA USA Hashim Al Ghamdi, MD Gavin A. Falk, MD Asir Central Hospital, Abha, Cleveland Clinic Foundation Children and Mat USA SAUDI ARABIA Sandra Farach, MD Fuad Alkhoury, MD All Children’s Hospital Joe Dimaggio Children’s Hospital USA USA Alexander Feliz, MD William Cody Allen, BS ULPS Division of Pediatric Surgery University of Utah USA USA Paula Flores, MD Noora Al-Shahwani, MD Garrahan Hospital Hamad Medical Corp ARGENTINA QATAR Oleg Godik, MD Zaki Assi, MD National Specialized Children’s Hospital Schneider children’s Medical Center of “OHMATDET” Israel UKRAINE ISRAEL Julia Grabowski, MD Laura A. Boomer, MD Rady Children’s Hospital USA USA Christine Burgmeier, MD Frank-Martin Haecker, MD University Medical Center Ulm University Children’s Hospital GERMANY SWITZERLAND Gemana Casaccia, MD Nicholas Hamilton, Fellow Pediatric Hispotal, Cesare Arriogo Oregon Health and Sciences University ITALY USA Alan Coleman, MD Mikihiro Inoue, MD Texas Tech University Health Sciences Mie University Graduate School of Center Medicine USA JAPAN Dafydd Davis, MD Sunghoon Kim, MD Iwk Health Centre UCSF Benioff Children’s Hospital Oakland CANADA USA Jose Ribas M. De Campos, PhD Gaye Knowles, MD Hospital das Clinicas Princess Margaret Hospital BRAZIL BAHAMAS Carsten Driller, MD Andreas Leutner, MD Klinikum Brememn Mitte Kinderchirgische Klinikum Dortmund, gGmbH Klinik GERMANY Germany

IPEG’s 23rd Annual Congress for Endosurgery in Children ■ July 22-26, 2014 | 72 Table of Contents

New Membership CONTINUED

Christian Lorenz, MD Hans K. Pilegaard, MD Klinikum Bremen-Mitte Aarhus University Hospital, Skejby GERMANY DENMARK Jeffrey Lukish, MD Drew Rideout, MD John Hopkins University USA USA Avraham Schlager, MD Brian MacCormack, MD Children’s Healthcare of Atlanta Royal Hospital For Sick Children Edinburgh USA UNITED KINGDOM Franz Schnekenburger, MD Justin Mahida, MD Klinikum Kassel Nationwide Children’s Hospital GERMANY USA Aaron Seims, Endosurgery Fellow Maximiliano Maricic, MD Children’s of Alabama Garrahan Children Hospital USA ARGENTINA Valerie Soroutchan, MD Jarod McAteer, MD, MPH National Med Uni of O.O. Bogomolets Univesity of Washington UKRAINE USA Dylan Stewart, MD Vincent Mortellaro, MD Johns Hopkins School of Medicine Children`s hospital of Alabama USA USA Xu Ke Tao, MD Anja Neugebauer, MD Affiliated Hospital School of Medicine University Hospital Charite Berlin CHINA GERMANY Xavier Tarrado, MD Tate Nice, MD Hospital de Sant Joan de Déu Children’s of Alabama SPAIN USA Iyampillai Thurkkaram, MD Satoshi Obata, MD Vitebsk State Medical University Kyushu University BELARUS JAPAN Indravadan Vyas, MD, FRCS Manabu Okawada, MD Golisano Children Hospital of SW Florida Juntendo University School of Medicine USA JAPAN Chin-Hung Wei, MD Hyung Joo Park, MD Mackay Memorial Hospital Seoul St. Mary’s Hospital TAIWAN KOREA Mustafa Yuksel, MD Rodrigo Pereira, MD Marmara University, TURKEY Hospital Infantil Sao Camilo Jonah Zitsman, MD BRAZIL Columbia University Medical Center USA

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To access the below hotels’ reservation links, please visit our website: www.ipeg.org/accommodations

Hilton Edinburgh Grosvenor Grosvenor Street Haymarket, Edinburgh EH12 5EF, United Kingdom T: (44) 131 527 1401 n F: (44) 131 220 2387

Waldorf Astoria Hotel – The Caledonian Princes Street, Edinburgh, EH1 2AB, United Kingdom T: (44) 131 222 8890 n F: (44) 131 222 8889

The Point Hotel Edinburgh – A Converting to DoubleTree by Hilton Hotel 34 Bread Street, Edinburgh, EH3 9AF, United Kingdom T: (44) 131 221 5555 n F: (44) 131 221 9929

SOCIAL PROGRAMS IPEG/BAPS Opening Ceremony MAIN EVENT: Celeigh and IPEG Welcome Reception Dance Off – After Hours! Black Tie and Kilts Are Optional Cromdale Hall Lennox 1 & 2 Wednesday, July 23, 2014 5:00 pm – 7:00 pm Friday, July 25, 2014 7:00 pm – 11:30 pm

IPEG’s 23rd Annual Congress for Endosurgery in Children ■ July 22-26, 2014 | 74 Table of Contents Oral Abstracts

S001: MINIMALLY INVASIVE SURGERY FOR Indications for the MIS approach included PEDIATRIC TRAUMA – A MULTI-CENTER penetrating injury (n=53), peritonitis REVIEW Hanna Alemayehu, MD, Diana (n=30), free fluid with abdominal pain Diesen, MD, Matt Santore, MD, Matthew in the setting of blunt trauma (n=24), Clifton, MD, Todd Ponsky, MD, Margaret pneumoperitoneum (n=15), and other Nalugo, MPH, Timothy Kane, MD, Mikael indications (n=77). Of the 110 procedures Petrosyan, MD, Ashanti Franklin, MD, completed without conversion, 60 George W Holcomb III, MD, MBA, Shawn D. (55%) were diagnostic, while the St. Peter, MD, The Children’s Mercy Hospital, remaining were therapeutic. The most Kansas City, MO; Children’s Medical Center, common therapeutic procedure was Dallas, TX; Children’s Healthcare of Atlanta laparoscopic or laparoscopic assisted at Egleston, Atlanta, GA; Akron Children’s repair of bowel injuries (n=19), followed Hospital, Akron, Ohio; Children’s National by various laparoscopic repairs (n=12), Medical Center, Washington, DC laparoscopic distal pancreatectomy (n=5), thoracoscopic evacuation of hemothorax INTRODUCTION: Although minimally (n=4), other thoracoscopic interventions invasive surgery (MIS) has been used in the (n=4), laparoscopic splenectomy (n=2), management of pediatric trauma for over and laparoscopic repair of traumatic three decades, the literature remains sparse. abdominal wall hernias (n=2). Procedures The purpose of this study is to characterize that required conversion were also most the role of MIS in pediatric trauma. commonly for bowel injury (n=54). Patients METHODS: After obtaining Institutional with peritonitis and pneumoperitoneum Review Board approval at each were most likely to require conversion institution, a retrospective review was to an open procedure (76.6% and 60% conducted on children who underwent respectively). Reasons for conversion thoracoscopy or laparoscopy for the included technical difficulty (n=66), management of trauma over the past hemorrhage (n=16), or hemodynamic 13 years. Five pediatric regional trauma instability (n=3), and some patients had centers in the United States participated. more than one reason for conversion. Data included patient demographics, Mean time to a regular diet was 4.6 ±9 mechanism of injury, indication for days, and mean hospital stay was 6.7 ± 6.6 operative intervention, conversion to days. Complications occurred in 19 patients open procedure, complications, and post- and included intra-abdominal abscess operative course. (n=5), pancreatic pseudocyst (n=2), wound RESULTS: There were 175 patients with a infection (n=2), small bowel obstruction mean age of 9.1 (1.0-17.3) years and 71% were (n=2), and others (n=9). Long-term male. Blunt trauma occurred in 65% with sequelae following their traumatic injuries the most common mechanism of injury occurred in 10 patients, and permanent being all-terrain vehicle or motor vehicle disability was found in 2 patients. crash (40%). Laparoscopy performed in CONCLUSION: Laparoscopy and 164 (94%), thoracoscopy in 7 (4%), and 4 thoracoscopy hold utility for a wide (2%) patients had both. Conversion to open variety of traumatic injuries in stable occurred in 39%, although no additional children and can be used to accomplish procedure was necessary after conversion the goals of the operation without in 4 cases. Median operative time was conversion in the majority of cases. 84(16-369) minutes.

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S002: OPEN VS. LAPAROSCOPIC (21-168) vs (20-120) p: 0.64)) respectively MANAGEMENT OF APPENDICITIS for open and laparoscopic surgery. Mean PERITONITIS IN CHILDREN: CLINICAL surgical time was 43.78 minutes for open TRIAL Fernando Rey, MD, Andres Perez, surgery and 75.11 for the other one (range MD, William Murcia, MD, Fenando Fierro, (20-86) vs (32-175) p: 0.0001). Pain was MD, Ivan Molina, MD, Juan Valero, MD, rated by patients at 24 after surgery with Jorge R. Beltran, MD, Fundación HOMI postoperative analog pain scale, a mean Hospital de la Misericordia, Pediatric of 2.67 points for open approach and 1.94 Surgery Unit, Universidad Nacional de points to laparoscopic (range (1-4) vs. (1-3) Colombia, Bogotá (COL) p: 0.0094). SUMMARY: The minimally invasive Patients with complications had longer surgical treatment for perforated time of abdominal pain before surgery appendicitis and peritonitis in children than those did not complicated, 76.53 and has taken an important place in the 54.48 hours respectively (range (48 - 168) management of this condition. Questions vs (20 - 126) p: 0.0033) regarding the comparative results of open There was no statistical difference in and laparoscopic approach in this disease the mean postoperative hospital days are under investigation. The literature (8.21 days to 9.94 days open and the currently lacks evidence to come to new laparoscopic). All patients were free of conclusions on this issue. symptoms at five months follow-up. STUDY DESIGN: Randomized clinical CONCLUSIONS: For patients with trial of the surgical approach of patients appendicitis with peritonitis without with appendicitis and peritonitis, from signs of shock, the laparoscopic October 2010 to March 2011. A 18-month approach requires more operative time, postoperative follow up is also included. but provides better results in terms Demographic data, symptoms, surgical of postoperative pain. Laparoscopic results and postoperative data were approach seems to have a trend of lower recorded. rate of reoperation; however this is not RESULTS: 46 patients were included, 28 significant statistically. For other variables patients managed with open surgery and there are not statistical significant 18 with laparoscopy. There were no deaths differences. in either group. We had 6 reinterventions S003: FEASIBILITY OF SINGLE INCISION in the open group and none in the 3 STAGE TOTAL PROCTOCOLECTOMY laparoscopic one (p=0.06), with an AND ILEAL POUCH ANAL ANASTOMOSIS average of 1.32 porc and 1 respectively, Avraham Schlager, MD, Matthew T. 6 surgical site infections in the open Santore, MD, Ozlem Balci, MD, Drew A. approach and 5 in the laparoscopic. A Rideout, MD, Kurt F Heiss, MD, Matthew S. total of 6 bowel obstruction in the open Clifton, MD, Emory University/Children’s approach and 2 in laparoscopic, the Healthcare of Atlanta average age for both groups was 8.72 and 9.46 years (confidence interval [CI] BACKGROUND: Total proctocolectomy 8.04-10.88 vs 95% 7.07 - 10.37) (p: 0.4); (TPC) and ileal pouch anal anastomosis the average time in hours of abdominal (IPAA) is the standard of care for patients pain at the time of the assessment by the with ulcerative colitis refractory to surgeon was 60.71 and 60.72 hours (range medical care. Safety and efficacy have

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Oral Abstracts CONTINUED been demonstrated for both the two and of 4.6 ± 2.4 days. Median length of stay three stage laparoscopic approach. We was 6 days (range 3-18). There were two present a 3 stage single-site laparoscopic surgical complications after TPC, both TPC and IPAA series and discuss potential of which required ileostomy revision; advantages of this technique. one following a conventional 5-port laparoscopic resection and the other after METHODS: We retrospectively reviewed a single-site resection. all patients who underwent single-site three-stage TPC and IPAA for ulcerative Mean operating time for IPAA using colitis at our institution. Primary the single-site approach was 283 ± 50 outcomes included operative time, time minutes. Mean time to tolerance of clear to oral intake, time to stoma function, liquids was 1.0 ± 0.5 days and regular time to cessation of intravenous opiates, diet was 3.3 ± 1.1 days. Stoma function length of stay, and post-operative returned on average at 1.6 ± 0.5 days. surgical complications. The Gelpoint Postoperative intravenous opioid use advanced access platform (Applied lasted an average of 3.3 ± 1.4 days. Median Medical, Santa Margarita, CA) was used length of stay was 4 days (range 3-9 days). in at least one stage of all cases. This Surgical complications following IPAA device facilitated open division of major included one anastomotic leak at the arterial vessels, extraction of the colon, J-pouch (which closed spontaneously) and and extracorporeal construction of the another patient who developed a mucosal J-pouch. bridge in the J-pouch staple line requiring surgical division. RESULTS: A total of 8 patients were identified that had undergone single- CONCLUSION: Single-site TPC-IPAA using site surgery with the Gelpoint advanced the Gelpoint advanced access platform is access platform for at least one both feasible and safe. In addition to the component of their TPC-IPAA. Six of improved cosmetic result, the single-site 8 underwent single-site TPC and all 8 access point offers added advantages underwent single-site IPAA followed by of wound protection, ease of ligation standard ileostomy closure. No single- for major arterial vessels, extraction of site patient required additional port the specimen, as well as extracorporeal placement or conversion to open surgery. J-pouch construction. Median age at TPC was 14 years (range 10-17 years). Five patients were female. S004: EVALUATION OF LIFE QUALITY Overall median follow up time was 20 OF CHILDREN AFTER LAPAROSCOPIC- months (range 5-45 months) from the ASSISTED TRANSANAL ENDORECTAL first operation and 6 months (range 1-12 (SOAVE) PULL-THROUGH FOR months) from the time of ileostomy HIRSCHSPRUNG’S DISEASE Bo Xiang, MD, closure. Yang Wu, PhD, West Chian Hospital Mean operating time for TPC was 227 PURPOSE: To assess the life quality of ± 41 minutes. Mean time until patients patients two years after laparoscopic- tolerated clear liquid diet was 1.3 ± 0.5 assisted transanal endorectal (Soave) days and 4.1 ± 2.6 days until tolerating a pull-through for Hirschsprung’s disease regular diet. Stoma function returned on (HD) and compare with that of traditional average at 1.75 ± 0.71 days. Post-operative Duhamel procedures in the same center. intravenous opioid use lasted an average

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METHODS: A total of 297 cases of HD CONCLUSIONS: Our present 2-year data from January, 2007 to December, 2010 limited to the normal – segment type had been diagnosed in our hospital. revealed that life quality of children And 245 of them belonged to the receiving laparoscopic-assisted transanal normal-segment type which were endorectal (Soave) pull-throughs did included in our study. 173 of them had not significantly differ from those who received laparoscopic-assisted transanal receiving traditional Duhamel procedures. endorectal (Soave) pull-throughs and Meanwhile traditional Duhamel 72 had traditional Duhamel procedures. procedures might be more beneficial Post-surgical anal dilations lasted for 6 regarding to RAIR recovery. months. Anorectal manometry had been TABLE 1: Life Quality Scoring 2 year after performed regularly at 3, 6, 12 and 24 surgery months after operations. We adopted the Wenxer scores, Fecal Incontinence Quality Life Quality Scoring of Life (FIQL) questionnaire, and Self- rated Health Measurement Scale Version 80~ 60~80 ~60 Total (good) (moderate) (poor) 1.0 (SRHMS) scores to evaluate life quality after surgery for Hirschsprung’s Lap- Soave 23 28 7 58 disease. Chilren with 2-year follow-ups Tra – Duhamel 13 12 2 27 and more had been included in this study. Those younger than five at the time of Total 36 40 9 85 investigations were excluded. t test, p=0.22

RESULTS: Effective 2-year follow-ups Lap - Soave: laparoscopic-assisted transanal were carried out and clinical data had endorectal (Soave) pull-through been retrieved among 85(58 laparoscopic Soave , 27 traditional Duhamel ) of those Tra – Duhamel: traditional Duhamel procedures 103 children (82.5%) older than three at TABLE 2: Recto-anal inhibitory reflex (RAIR) 2 the time of surgery. year after surgery 1. Life quality scoring: Classified as RAIR Lap- Soave Tra – Duhamel Total ~60(poor), 60~80(moderate) and occurrence 80~(good), the average scores for laparoscopic Soave group and traditional Positive 9 9 8 Duhamel group were 75.43±13.01 and Negative 49 18 67 79.00±10.77 respectively(t test, p=0.22) with no statistical significance.(Table 1) Total 58 27 85

2. Anorectal manometry: recovery chi-square p=0.06 of recto-anal inhibitory reflex (RAIR) occurred in nine of 58(15.5%) of Lap - Soave: laparoscopic-assisted transanal laparoscopic Soave patients and nine of endorectal (Soave) pull-through 27(33.3%) of traditional Duhamel patients Tra – Duhamel: traditional Duhamel procedures (chi-square p=0.06). The occurrence rates were higher in the traditional Duhamel group though there was no statistical difference. (Table 2)

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S005: SELECTIVE TRANSPERITONEAL advanced the needle into the transverse ASPIRATION OF A DISTENDED BOWEL colon at its anti-mesenteric border WITH A SMALL-CALIBER NEEDLE and continued with gentle aspiration. DURING LAPAROSCOPIC NISSEN In case of suboptimal result after first FUNDUPLICATION: A PROSPECTIVE attempt, aspiration could be performed RANDOMIZED CONTROLLED TRIAL at other sites if required. Afterwards, the Carlos Garcia-Hernandez, MD, Lourdes procedure proceeded as planned. In the Carvajal-Figueroa, MD, Sergio Landa- control group, the operators performed Juarez, MD, Adriana Calderon-Urrieta, conventional maneuvers such as deviating MD, Hospital Star Medica Lomas Verdes, downwards the dilated loop using surgical México tools and/or placing the patient on a high Fowler´s position. BACKGROUND/PURPOSE: Anecdotal reports have demonstrated the We performed 403 Nissen procedures feasibility of needle aspiration to deflate laparoscopically, 102 were in infants ≤6 a distended bowel loop during open months old, while only 44 presented surgery, but we are not aware of any severe transverse colonic distension. prospective study that has evaluated SAMPLE SIZE: STAB facilitated the surgical the safety and efficacy of this technique procedure and drastically reduced during laparoscopic surgery. Therefore, surgical time. Thus, we calculated our we designed a randomized controlled sample size with use of the following study to evaluate the use of the selective inputs: 90% power, a critical p value of transperitoneal needle aspiration of a 0.05, and 50% reduction in surgical time. bowel loop (STAB) in infants undergoing This resulted in a necessary sample size of laparoscopic Nissen Fundoplication. 21 subjects per group, for a total required METHODS: The study was conducted sample size of 42 subjects. between January 2010 and December RESULTS: We performed STAB in 23 2013. Candidates were patients of less patients and conventional measures in 21. than 6 months of age, scheduled for STAB attempts were 45: 8 (36.4%) patients laparoscopic Nissen fundoplication, required one puncture, 8 (36.4) required in which severe colonic distention was two punctures and 7 (27.3%) required observed during the surgery. three. Mean age was 66.9±38.1 days in We randomized the patients to the the STAB group and 64.7±36.2 days in study drug or placebo in a 1:1 mode. The the control group, p=NS. Mean operative treatment group received STAB, while the time was shorter in the STAB group than control group was subject to conventional in controls (34.6±6.1vs. 70.8±7.1minutes, maneuvers discretionally by the surgeon. p<0.001), which constituted a 50.7±9.1% absolute reduction. Open conversion PROCEDURE: In both groups, we (N=3, 14.3%) only occurred in the performed the Nissen Technique open group. There were no additional according to standard laparoscopic intraoperative or postoperative approach. The presence of severe colonic complications. distention was identified after placing all ports. We introduced a 30-gauge DISCUSSION: We proposed the use hypodermic needle into the abdominal of STAB as alternative therapy to wall in a perpendicular fashion. We decompress a dilated large-bowel

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Oral Abstracts CONTINUED loop during laparoscopic surgery. This lap-Ladd; 11 open-Ladd) and 12 cases in maneuver is simple and efficient and has group C (6 lap-Ladd; 6 open-Ladd). None no clinical complications. Future studies of the cases in our series had suspected are required to evaluate its role in the diagnoses of ischemic or necrotic bowel subset of other patients or procedures, preoperatively. Mean age and mean body as well as the safety of STAB in dilated weight at surgery were higher in lap-Ladd small-bowel loops. Nonetheless, the than open-Ladd but differences were present study may be considered not significant. Intestinal volvulus was hypothesis generating for other surgical confirmed at surgery in 3/3 lap-Ladd and settings. 9/11 open-Ladd in group N and in 5/6 lap-Ladd and 6/6 open-Ladd in group C S006: LAPAROSCOPIC REPAIR OF (p=ns). No cases required bowel resection MALROTATION. WHAT ARE THE in our series. Mean operating time was INDICATIONS IN NEONATES AND significantly longer in lap-Ladd (130.7 CHILDREN? Go Miyano, MD, Keiichi minutes) versus open-Ladd (81.1 minutes) Morita, MD, Masakatsu Kaneshiro, MD, in group N, as well as in lap-Ladd (119.2 Hiromu Miyake, MD, Hiroshi Nouso, MD, minutes) versus open-Ladd (74.2 minutes) Masaya Yamoto, MD, Koji Fukumoto, MD, in group C. The rate of conversion of Naoto Urushihara, MD, Department of lap-Ladd to open-Ladd was 1/3 (33.3 %) in Pediatric Surgery, Shizuoka Children’s group N and 1/6 (16.7 %) in group C. There Hospital was 1 case each of bowel obstruction AIM: To present our experience of treating (1/11, 9.1%) in open-Ladd in group N and malrotation with laparoscopy to more chylorrhea from mesentery (1/6, 16.7%) in clearly define its role in neonates and open-Ladd in group C both necessitating children and to compare outcome of open laparotomy. Recurrence of signs and repair with outcome of laparoscopic repair symptoms of malrotation occurred in with respect to age at the time of surgery. 1/3 (33.3%) lap-Ladd in group N. Mean time taken to recommence feeding in MATERIALS & METHODS: We conducted group N was shorter for lap-Ladd (3.7 a retrospective analysis of all Ladd’s days) versus open-Ladd (4.1 days) as it procedures performed at our institution was also in group C; lap-Ladd (2.6 days) between 2007 and 2012. In order to versus open-Ladd (3.0 days), but these compare postoperative outcome, we differences were not significant (p=0.73 divided our subjects into 2 groups for group N; p=0.64 for group C). Length according to age at the time of surgery. of hospitalization was similar for all group The neonate group (N) comprised N cases (lap-Ladd: 13.7 days; open-Ladd: subjects who had surgery up to and 13.9 days), but shorter for lap-Ladd (6.6 including day 30 of life, and the child days) compared with open-Ladd (8.2 days) group (C) comprised subjects who had in group C, which was not statistically surgery from day 31 of life onwards. significant (p=0.94 for group N; p=0.28 for RESULTS: There were 26 Ladd’s group C). procedures performed during the study CONCLUSION: Our data confirm that lap- period. Of these, 9 were laparoscopic Ladd is a safe procedure, but we do not (lap-Ladd) and 17 were open (open-Ladd). recommend lap-Ladd for the treatment When categorized according to age at of malrotation in patients 30 days of age surgery, there were 14 cases in group N (3 or less.

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S007: LAPARSCOPIC REPAIR OF anorectal malformation. The traditional CONGENITAL DUODENAL OBSTRUCTION procedure of PSARP, Laparatomy and IN NEONATE Jinshi Huang, MD, then pull-through is the treatment of Department of Surgery, Jiangxi Provincal choice. With the advances in Laparoscopic Children’s Hospital surgery in small children, it seemed that laparoscopic assisted anorectoplasty OBJECTIVE: To evaluate the curative would be an accepted alterative. effect of laparoscopic surgery treatment of congenital duodenal Here we present the intermediate term obstruction(CDO),such as web or annular results of 3-7 years for these patients panctreasl, in neonate. METHODS AND MATERIALS: Eleven METHODS: Thirty-eight neonates with patients with rectovesical fistula were CDO who underwent laparoscopic operated on laparoscopically during surgery were analyzed retrospectively the last 7 years. All of these patients from September 2009 to August 2013(22 had diverting colostomy at newborn with web,and 16 with annular panctreas), age and had laparoscopic assisted Outcomes of interest were operative time, anorectoplasty at the age of 3-6 months. postoperative leaks, and postoperative The operations were performed in supine full time of feeding. position and the external sphincter was localized with muscle stimulator. The RESULTS: The laparoscopic procedures patients were followed for 3-7 years w ere completed without intraoperative postoperatively. Anorectal manometry, complication in 38 neonates, Conversion MRI, endosonography were performed. to open surgery was required in 2 patients (5.3 %).Average operating time was RESULTS: Eleven patients were followed. 102±19 minutes. There were no duodenal Three were continent with very occasional anastomotic leaks. time to initial feeding soilage. Five patients had frequent bowel 5.7±2.8 days, and time to full oral intake movement with soilage. Three patients 8.7±2.0 days. Average hospitalization had severe perineal dermatitis, one of time was 10.7±3.2 days.Follow-up upper whom had sigmoid pull through due to gastrointestinal tests show no evidence of very short rectum. Three patients had stricture or bstruction. constipation. Two patients had dribbling. All had good weight gain. Most patients CONCLUSION: The laparoscopic surgery had decreased sphincter tone. MRI treatment of CDO is safe and efficacious. showed well positioning of the sphincter. INDEX WORDS: Laparscopic ,congenital, CONCLUSION: Laparoscopic assisted duodenal obstruction anorectoplasty is feasible and S008: COMPLICATIONS AFTER intermediate term follow up showed LAPAROSCOPY FOR RECTOVESICAL relatively high complications. Some FISTULA HamidReza Foroutan, Dr., modifications of the procedure can Abbas Banani, Dr., Sultan Ghanem, Dr., improve the results Reza Vahdad, Dr., Laparoscopic Research Center, Shiraz University of Medical Sciences INTRODUCTION: Rectovesical fistula is one of the challenging cases of

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S009: LAPAROSCOPIC MESH RECTOPEXY and efficient treatment of persistent FOR COMPLETE RECTAL PROLAPSE complete RP in children. To avoid post- Cindy Gomes Ferreira, MD, Paul Philippe, operative constipation, it is important to MD, Isabelle Lacreuse, MD, Anne perform a tension-free mesh rectopexy. Schneider, MD, François Becmeur, PhD, S010: SINGLE INCISION LAPAROSCOPIC MD, Department of Paediatric Surgery, SPLENECTOMY USING THE SUTURE Clinique Pédiatrique, Centre Hospitalier SUSPENSION TECHNIQUE FOR Luxembourg, Luxembourg, Department of SPLENOMEGALY IN CHILDREN WITH Paediatric Surgery, Hôpital de Hautepierre, HEREDITARY SPHEROCYTOSIS Suolin Centre Hospitalier Universitaire de Li, MD, Meng Li, MD, Weili Xu, MD, PhD, Strasbourg, France The Second Hospital of Hebei Medical AIM: To describe the operative technique of University, Shijiazhuang, China the treatment of complete rectal prolapse BACKGROUND: Laparoscopic splenectomy (RP) through minimal invasive approach in has become a gold standard in the children presenting recurrent RP. treatment of spleen disorders related to MATERIAL AND METHODS: We present hematologic diseases. With increasing an operating technique inspired from laparoscopic surgery experience and the Orr-Loygue-Cerbonnet operating improved new vessel sealing equipment, technique modified for laparoscopy. The single incision laparoscopic splenectomy operative steps are: diagnosis (presence (SILS) has emerged as an alternative to of a peritoneal hernia in the Douglas), multiport laparoscopy, but the application peritoneal opening of the Douglas, of SILS to massive splenectomy is still posterior rectal dissection, tension-free challenging due to technical difficulties. mesh rectopexy, peritoneal closure. The aim of this study was to describe the Operative treatment was proposed after suture suspension technique contributing complete work-up excluding cystic to SILS for the treatment of hereditary fibrosis and medullar anomalies, for spherocytosis with splenomegaly. persistent RP despite well conducted METHODS: A retrospective review medical treatment during 6 months at was conducted to evaluate all SILS least. Low-fibre diet was prescribed for for splenomegaly performed by a the first 2post-operative weeks. single surgeon between June 2010 RESULTS: Since 2001, eight patients and December 2013. On preoperative (3M/5F) with a median age of 6, 5years ultrasonography, the spleen size index (2-17years) benefitted from laparoscopic ranged from 0.67 to 0.82 (the normal treatment of RP. Mean operative time was spleen index should be <0.2). A 2-3 98minutes (range 80-125). There were no cm umbilical incision was used for the conversion, nor operative complications. placement of a multichannel single- Mean hospital stay was 3.5days (range port. A needle with a 1-0 suture was 2-5). No post-operative constipation, percutaneously introduced from the left nor recurrence were reported during the hypochondriac region at the midaxillary mean follow-up period of 4.1years. line into the abdomen, then penetrated out from the anterior chest wall at the CONCLUSION: The modified Orr-Loygue- midclavicular line for suspending the Cerbonnet laparoscopic operating massively enlarged spleen. Pulling technique is a simple, reproducible the suture both ends could provide

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Oral Abstracts CONTINUED excellent exposure of the splenic hilum. described. The goal of this paper was Dissection was facilitated by the use of to describe intraoperative physiology, a 5-mm curved reusable grasper and a estimate intraoperative physiologic 5-mm conventional Harmonic scalpel, stability, and report operative outcomes and splenic vessels were ligated at the during laparoscopic gastrostomy tube hilum with a 5-mm Hem-o-lok clips. (GT), and laparoscopic fundoplication The resected spleen was placed in an with gastrostomy tube in patients with endosurgical bag, morcellated, and complex congenital heart defects. removed from the abdomen via the METHOD: An IRB approved retrospective umbilical incision. chart review of all children with complex RESULTS: Nine children with hereditary congenital heart defects who underwent spherocytosis underwent SILS during the GT or Nissen with GT from January study period without conversion to an 2010 to January 2014 was conducted. open procedure or requiring additional Data collection included patient ports. The suture suspension technique demographics, intraoperative physiologic was successfully used in all patients and parameters, and postoperative outcomes. markedly improved the exposure of the All procedures were performed splenic hilum. The median operative in the cardiovascular operating time was 122.6±31.2 min, and the median rooms, with cardiovascularly trained extracted spleen weight was 562±74.5 anesthesiologists. Statistical analysis g (range, 420-1260 g). No intraoperative consisted of descriptive statistics, and or postoperative complications were non-parametric analysis. recorded. The umbilical incision healed RESULT: 28 patients were identified, 16 well with a satisfactory cosmetic effect. male and 12 female, with a mean age CONCLUSIONS: Our preliminary of 115 days (range 20 – 1173 days). The experience shows the the suture mean weight at operation was 4.2kg suspension technique that enables safe (range 2.2 – 12.5kg). Cardiac defects and feasible SILS for the management of included hypoplastic left heart syndrome splenomegaly in children with hereditary (n=6), complex single ventricle (n=7), spherocytosis. More experience is needed tetralogy of Fallot (n=6), AV Canal (n=1), to assess advantages and disadvantages aortic arch hypoplasia/interruption compared with the standard laparoscopic (n=3), ventriculoseptal defects (n=3), approach. pulmonary vein hypoplasia (n=1) and large patent ductus arteriosum (n=1). There S011: LAPAROSCOPIC GASTROSTOMY were 21 laparoscopic GTs placed and 7 AND LAPAROSCOPIC NISSEN/GT IN laparoscopic Nissen/GTs performed. The CHILDREN WITH COMPLEX CONGENITAL mean operative time was 35min (range HEART DEFECTS V. Mortellaro, MD, 12 – 63min) for GT, and 71min (range J. Alten, MD, R. Russell, MD, R. Griffin, 62 – 200min) for Nissen/GT. The mean PhD, C. Martin, MD, S. Anderson, MD, D. blood loss was 1mL (0 – 2mL) for GT, Rogers, MD, E. Beierle, MD, M. Chen, MD, and 2mL (range 2 – 10mL) for Nissen/ Children’s Hospital of Alabama GT. There were no conversions to an BACKGROUND: In children with complex open procedure for either procedure. congenital heart defects, the effect of Intraoperatively the mean minute laparoscopy on cardiac physiology and ventilation was 1.3L (range 0.1 – 2.3L) with the resultant morbidity are not well a mean intervention rate of 4 changes per

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Oral Abstracts CONTINUED case in patients who underwent GT. The PURPOSE: Pediatric surgeons require mean minute ventilation was 1.4L (range both basic and, highly advanced 0.2 – 2.2L) with a mean intervention rate endoscopic surgical skills because of of 9 changes per case in patients who the various operations and different underwent Nissen/GT. The mean end tidal physical sizes of patients. The Japanese CO2 was 35 (range 28 – 45) for GT and 45 Society for Endoscopic Surgery range (range 41 – 45) for Nissen/GT. The developed an endoscopic surgical mean FiO2 was 50% (range 20 – 100%) skill qualification(ESSQ) system for for GT with a mean of 4 interventions all surgical fields, including pediatric per case. The mean FiO2 was 47% (range surgery. However, it is difficult to evaluate 27 – 100) for Nissen/GT with a mean of 7 quantitative endoscopic skills using this interventions per case. The mean sPO2 ESSQ system. We therefore developed was 87% (range 77 – 100%) for GT and a validation system for objective 92% (range 71 – 100%) for Nissen/GT. endoscopic surgical skills for pediatric The mean temperature was 36.0C (range surgeons based on a disease model. 32.8 – 37.9C) for GT, and 35.4C (range The aim of this study is to verify the skill 33.0 – 37.7C) for Nissen/GT. There was quality for pediatric endoscopic surgery. one intraoperative complication due to METHODS: We developed a thoracic hypothermia resulting in cardiac shunting repair model of congenital diaphragmatic and the need for ECMO. There were no hernia mimicking a new born case(body postoperative complications. weight:3 kg, diaphragm defect:1.5 x 1.0 CONCLUSION: The increased CO2 cm, Fig. 1, 2). The examinees divided into introduced via laparoscopic insufflation two groups, 10 experts and 19 trainees(all does not appear to adversely affect right handed). They performed 2 tasks; patient stability and can be adequately Task 1 was a reduction of the herniated managed with intraoperative ventilation. small intestine(5 mm diameter, length The performance of laparoscopic GT 30 cm) from the thoracic space to the and Nissen/GT can be achieved safely in abdomen (Fig 3a); Task 2 was to perform 3 patients with complex congenital heart suture ligatures of the diaphragm defect defects. using an intracorporeal knot tying(Fig. 3b). The evaluation points were the time S012: ENDOSCOPIC SURGICAL SKILL required to complete Task 1, the time VALIDATION SYSTEM FOR PEDIATRIC score calculated using the residual time SURGEONS USING A REPAIR MODEL OF from 900 seconds(time limit:15 min) CONGENITAL DIAPHRAGMATIC HERNIA for Task 2, the number of complete Satoshi Obata, MD, Satoshi Ieiri, MD, PhD, full-thickness sutures, maximum air Munenori Uemura, PhD, Ryota Souzaki, pressure tolerance, degree of diaphragm MD, PhD, Noriyuki Matsuoka, Tamotsu deformation, and residual defect areas Katayama, Makoto Hashizume, MD, PhD, after suturing. This model improved FACS, Tomoaki Taguchi, MD, PhD, FACS, using the Suture Simulator Instruction Department of Pediatric Surgery, Faculty Evaluation Unit(Kyoto Kagaku Co., Ltd). of Medical Science, Kyushu University, Additionally, we evaluated the total Department of Advanced Medicine and path length and velocity of each tip Innovative Technology, Kyushu University of the forceps using a 3-dimensional Hospital, Kyoto Kagaku Co., Ltd position measurement instrument with an electromagnetic tracking

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Oral Abstracts CONTINUED system(AURORA; Northern Digital Inc. Canada) to assess bi-hand coordination. All data were expressed as the mean ± standard deviation. A statistical analysis was performed using the two tail paired and unpaired t test and p<0.05 was considered statistically significant. RESULTS: Table 1 shows the results of the time of Task 1(p=0.0074), time score(p=0.0118), numbers of complete full-thickness suture(p=0.0056), maximum air pressure tolerance(p=0.0119), degree of diaphragm deformation(p=0.0109), and defect residual areas(p=0.1573). In the time of Task 1, time score, the number of complete full-thickness sutures, maximum air pressure tolerance, and degree of diaphragm deformation, experts were significantly superior to the trainees. Tables 2 and 3 compare the total path length and velocity of tip of the forceps between the left and right hand in tasks 1 and 2. In trainees(Table2), the total length and velocity of the left forceps were inferior to those of the right forceps in both Tasks(p<0.05, respectively). Conversely, no significant differences were seen among experts between both forceps(Table3)(p>0.05, respectively) for both tasks. CONCLUSIONS: This study revealed that experts possessed quick and accurate skills. Experts have excellent bi-hand coordination and they can use both hands equally compared to trainees. Our model validated the quality of endoscopic surgical skills between experts and trainees of pediatric surgeons. We next plan to develop effective training models for novice pediatric surgeons.

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S013: THE DEVELOPMENT AND repair and were ranked as undesignated. PRELIMINARY EVALUATION OF A All comparative data between expert SYNTHETIC NEONATAL ESOPHAGEAL and novice participants excluded the ATRESIA/TRACHEOESOPHAGEAL undesignated group. Participants FISTULA REPAIR MODEL Katherine A. completed a self-report, six-domain, Barsness, MD, MS, Deborah M. Rooney, 24-item instrument consisting of PhD, Lauren M. Davis, BA, Ellen K. twenty-three 5-point rating [D2]scales Hawkinson, BS, Northwestern University (1=not realistic to 5=highly realistic) and Feinberg School of Medicine; University of one 4-point Global rating scale. Content Michigan School of Medicine validity was evaluated using the many- Facet Rasch model and estimating inter- BACKGROUND: Thoracoscopic esophageal rater consistency was estimated using atresia/tracheoesophageal fistula (EA/ iIntra-class correlation (ICC) for items TEF) repair is technically challenging. We relevant to simulator characteristics. have previously reported our experiences with a high-fidelity hybrid model for RESULTS: A review of the participants’ simulation-based educational instruction ratings indicates there were no overall in thoracoscopic EA/TEF, including the differences across sites (IPEG vs. WOFAPS, high cost of the tissue for these models. p=0.84), or experience (Expert vs. The purposes of this study were to 1) to Novice, p=0.17). The highest observed create a low-cost synthetic tissue EA/ averages were 4.4 (Value of Simulator as TEF repair simulation model and 2) to a Training Tool), 4.3 (Physical Attributes- evaluate the content validity of the chest circumference, chest depth and synthetic tissue simulator. intercostal space) and 4.3 (Realism of Experience-fistula location). The lowest METHODS: Review of the literature and observed averageOA’s were 3.5 (Ability to computed tomography images were Perform-closure of fistula) and 3.7 (Ability used to create Computer-aided drawings to Perform-Acquisition target trocar (CAD) for a synthetic, size appropriate EA/ sites), 3.8 (Physical Attributes-landmark TEF tissue insert. The inverse of the CAD visualization), 3.8 (Ability to Perform- image was then printed in six five different anastomosis and dissection of upper sections to create a mold that could be pouch) and 3.9 (Realism of Materials- filled with platinum-cured silicone. The skin). The Global Rating was 2.9, coinciding silicone EA/TEF insert was then placed with a response of “this simulator can be in a previously described neonatal considered for use in neonatal TEF repair thorax and covered with synthetic skin. training, but could be improved slightly”. Following IRB-exempt determination, 47 participants performed some or all of a CONCLUSIONS: We have successfully simulated thoracoscopic EA/TEF during created a low-cost synthetic EA/ two separate international meetings (IPEG TEF tissue insert for use in a neonatal and WOFAPS). X[D1]Fourteen participants thoracoscopic EA/TEF repair simulator. were identified as “experts”, having Analysis of the participants’ ratings of 6-50 self-reported thoracoscopic EA/ the synthetic EA/TEF simulation model TEF repairs, and thirty “novice”, having indicate that it has value and can be used 0-5 self-reported thoracoscopic EA/TEF to train pediatric surgeons to performn repairs. Three participants did report prior thoracoscopic EA/TEF repair, with minor experience with thoracoscopic EA/TEF revisions. Areas for improvement were

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Oral Abstracts CONTINUED identified, and these areas will be the or slightly worse than the expert group focus for future modifications to this in the box trainer. In contrast, the novel synthetic EA/TEF repair simulator. performance of the expert group was significantly better than the intermediate S014: VIDEO-BASED SKILL ASSESSMENT group in the pediatric chest model. OF ENDOSCOPIC SUTURING IN A Significant specific differences between PEDIATRIC CHEST MODEL AND A BOX the expert and trainee groups in the TRAINER Shinya Takazawa, MD, Tetsuya pediatric chest model were observed in Ishimaru, MD, PhD, Kanako Harada, PhD, some checklist items related to the ability Yusuke Tsukuda, Naohiko Sugita, PhD, to keep the needle in view at all times, the Mamoru Mitsuishi, PhD, Tadashi Iwanaka, knot-tying technique, and techniques for MD, PhD, The University of Tokyo Hospital avoiding possible tissue damage. PURPOSE: Pediatric minimally-invasive CONCLUSIONS: The expert group showed surgery requires special surgical skills significantly better suturing performance because of the small working space and than either the intermediate or trainee tissue fragility. We previously reported groups in the pediatric chest model, a pediatric chest model developed for suggesting that this method can better the training and assessment of specific assess the pediatric-specific expert skills pediatric surgical skills. This paper presents obtained by performing many clinical a video-based method for assessing skills procedures. Therefore, we conclude that for endoscopic suturing in the pediatric the pediatric chest model together with a chest model compared with a box trainer. training program for the identified pediatric- METHODS: A commercial suture pad was specific skills is a good endoscopic surgical placed in a rapid-prototyped pediatric training and assessment platform for chest model of a one year-old patient pediatric surgeons. to simulate a suture required in the thoracoscopic repair of esophageal atresia type C. Twenty-eight pediatric surgeons (9 experts, 9 intermediates, and 10 trainees) each completed an endoscopic intracorporeal suturing and knot-tying task both in the pediatric chest Median values (interquartile model and in a box trainer. The tasks were range);*p<0.05 vs Trainee, #p<0.05 vs video-recorded and rated by two blinded Intermediate(Mann-Whitney U) observers using two evaluation methods: S015: ANATOMICAL VALIDATION OF the 29-point checklist method and the AN INANIMATE MODEL FOR TRAINING error assessment sheet method. The THORACOSCOPIC REPAIR OF TRACHEO experimental protocol was approved by ESOPHAGEAL FISTULA/ESOPHAGEAL the Ethics Committee. ATRESIA – TEF/EA Maximiliano A. Maricic, RESULTS: The suturing performance of MD, Maria M., Bailez, MD, National the three groups is shown in Table 1. In all Children’s Hospital S.A.M.I.C. “Prof. Dr. metrics for both setups, the expert group Juan P. Garrahan” performed significantly better than the INTRODUCTION: We present the results trainee group. The overall performance of anatomical validation of an inanimate of the intermediate group was similar model created for training thoracoscopic

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Oral Abstracts CONTINUED repair of esophageal atresia with lower in relation to external and endoscopic trachea esophageal fistula (EA/TEF) appearance (visual environment), dimensions, esophageal anatomy and MATERIALS & METHODS: This model has double layer anastomosis; 91% (15/16) been previously presented in IPEG 2013. in relation to instruments positioning, It is made of a piece of wood used as a internal dimensions and appearance support, 3 corrugated plastic tubes of of work area esophageal dimensions, different diameters (50mmø, 25mmø, ligation and section of TEF and upper and 15mmø) simulating ribs, intercostal pouch dissection; 82% (14/16) regarding spaces, trachea and spine and tubular latex anatomical appearance (pleura, ribs, balloons as the acigos vein and esophagus, trachea, Azygos vein, nerve, lung), with a thin self-adhesive transparent film trans anastomotic tube, placement and that fixed all structures as the parietal and positioning of trocars and 73% (13/16) mediastinal pleura, all introduced into a refering to dissection of the esophagus plastic container with a lid that simulates and azygos vein. the thoracic cavity of a newborn. The cost of materials is less than 50U$. All respondents believe that the simulator can generate skills in use of 3mm A compact system monitor, light source Instrumental; 91% of them in handling and endocamera, a 4mm lens and 3mm camera and 82% in dissection, suturing instruments are used to reproduce all and tissue handling. steps of the procedure. DISCUSION: The process of functional Initial validation consisted of a anatomical validation is a necessary step Liker type survey completed by 16 before its validation as a training method. international experts and pediatric After survey results we are in the process of surgeonsfrom different countries (Brazil, improving the items that had a lower rate France, Luxemburg, Switzerland and to develop a more accurate and reliable Argentina),already trained in MIS TEF model for example including it into a doll to repair. We define 4 categories depending improve similarity with port positioning and on their experience in MISTEF/AE repair: a) including a tubular acigos vein. beginners (less than 5) b) intermediate (5- 20) c) seniors (20-30) d) experts (+30). S016: THE LAPAROSCOPIC DUODENO- DUODENOSTOMY SIMULATOR: A MODEL The survey included 18 questions FOR CUSTOMIZABLE MINIMALLY regarding different aspects related to INVASIVE SURGERY TRAINERS Joanne similarity with real surgery with 5 possible Baerg, MD, Nicole Carvajal, Danielle answers graded from non to high degree Ornelas, Candice Sanscartier, Diana Lopez, of similarity, and “not serve to generate Cristine Cervantes, William Grover, PhD, skills” to “can generate the vast majority Gerald Gollin, MD, Loma Linda University of skills” Children’s Hospital and University RESULTS: Seven respondents were of California Riverside Biomedical experts, 4 intermediate, 3 beginners and Engineering Department 2 seniors. INTRODUCTION: Simulator training is One hundred percent of them felt that an important step toward proficiency the model has a high degree or good in minimally invasive surgery (MIS) for likeness of similarity (grade 5 and 4) pediatric surgeons. MIS repair of duodenal

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Oral Abstracts CONTINUED atresia requires suturing skills that are modeled small intestine, duodenum difficult to acquire. We sought to develop and stomach were placed in the bottom a prototype of an inexpensive, synthetic, frame and the liver was placed inside the and customized MIS simulator for top frame of the body cavity. A silicone laparoscopic duodeno-duodenostomy. rubber sheet covered the top frame. The simulated duodeno-duodenostomy was METHODS: Two pediatric surgeons, judged to be realistic by the surgeons who in cooperation with a University trialed the simulator. The material was Bioengineering Department, designed and durable and did not tear or deform after developed a synthetic model to simulate multiple anastomoses. laparoscopic duodenal atresia repair in an infant. CONCLUSION: An inexpensive, life- sized and durable synthetic simulator RESULTS: The simulator was constructed for MIS duodeno-duodenostomy was in three parts: organ construction, training constructed. This serves as an initial box construction and assembly. proof of concept that customizable Organ construction: Solid molds of small simulators of pediatric MIS procedures intestine, duodenum, stomach and liver can be constructed using 3-D printing were designed in SolidWorks software technology and latex to construct organs. in acrylonitrile butadiene styrene using The development of operation-specific a 3D printer. The size of each mold was simulators has the potential to speed designed to be dimensionally accurate to the safe and efficient integration of rare life-sized infant organs. Premium liquid pediatric MIS procedures into practice. latex rubber was then dispersed over the plastic molds to construct the organs. The duodenal segments included a layer of thin gauze sandwiched between layers of latex. Training box construction: The box was modeled after the body cavity of an infant, from the lower neck to the top of the thighs. The interior volume mimics the pneumoperitoneum of an infant abdomen during laparoscopic S017: OPTIMIZING WORKING SPACE IN surgery. After constructing a Styrofoam LAPAROSCOPY - CT MEASUREMENT OF top and bottom frame template that THE INFLUENCE OF SMALL BODY SIZE simulated the top and bottom of the IN A PORCINE MODEL J. Vlot, MD, Lme infant body, fiberglass resin was painted Staals, MD, PhD, Prof. RMH Wijnen, MD, over the template to construct the PhD, Prof. RJ Stolker, MD, PhD, Prof. NMA body cavity. Three holes designating the Bax, MD, PhD, Erasmus MC: University placement of a grasper, a needle driver Medical Center Rotterdam and an endoscope were cut from the INTRODUCTION: In our continuing top frame. Top and bottom frames were research into the determinants of secured to each other. A reusable rubber laparoscopic working space, the influence grip was secured over the top frame so of small body size was investigated. the laparoscopic instruments could be placed through it. Assembly: Organs METHODS: In eight 6-kg pigs, were secured in the box with Velcro. The the effects of intra-abdominal

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CO2pneumoperitoneum pressure (IAP), S018: THE EFFECTS OF CO2- pre-stretching of the abdominal wall, INSUFFLATION WITH 5 AND 10 MMHG and neuromuscular blockade (NMB) DURING THORACOSCOPY ON CEREBRAL on laparoscopic working space volume OXYGENATION AND HEMODYNAMICS and distances were studied. Computed IN PIGLETS Lisanne J. Stolwijk, MD, tomography was used to measure working Stefaan H. Tytgat, MD, Kristin Keunen, space during two stepwise abdominal MD, N Suksamanapan, MD, Maud Y. van insufflation-runs up to an IAP of 15 Herwaarden, MD, PhD, Petra M. Lemmers, mmHg. Results were compared with data MD, PhD, David C. van der Zee, Prof., Dr., from earlier experiments in 20-kg pigs. Wilhelmina’s Children Hospital University Medical Center Utrecht RESULTS: In 6-kg pigsworking-space dimensions werefive times smaller than in AIMS: An increasing percentage of surgical 20-kg pigs. Cardiorespiratory parameters interventions in neonates is performed by were stable up to an IAP of 8-10 mmHg. minimal invasive techniques. Near infrared Working-space volume, anteroposterior spectroscopy is a non-invasive method (AP) diameter and symphysis-diaphragm that can be used to assess changes in distance increased linearly up to an IAP cerebral oxygenation, an estimator of of 8 mmHg. Above 8 mmHg, compliance cerebral perfusion, by monitoring regional decreased. Eighty percent of the total cerebral oxygen saturation (rScO2). volume (618 ml) and of AP diameter (3 Values below 40% are related with brain cm) at 15 mmHg had been achieved at damage. rScO2can be influenced by an IAP of 10 mmHg. Pre-stretching by a mean arterial blood pressure (MABP), first insufflation resulted in a statistically mean airway pressure, arterial saturation significant increase in working space (SaO2) and pCO2. Recently, concerns volume and in AP-diameter during the have been raised regarding a decrease second insufflation. This effect was of cerebral oxygenation in neonates significantly larger than in 20-kg pigs. during thoracoscopy as a result of CO2- Neuromuscular blockade did not have a insufflation (Bishay 2013). significant effect on working space. METHODS: Piglets were anaesthetized, CONCLUSIONS: Working space in growing intubated, ventilated and surgically individuals is very limited. Eighty percent prepared for CO2-insufflation and of the working space created by an insertion of a trocar in the right IAP of 15 mmHg was already achieved hemithorax took place. Insufflation at 10 mmHg, while cardiorespiratory was done with 5 or 10 mmHg CO2during side effects at an IAP of 8-10 mmHg one hour. Physiologic parameters SaO2, seem acceptable. Pre-stretching of the heart rate (HR), MABP and rScO2were abdominal wall significantly increased monitored. cFTOE, an estimator of working space, even more so than in cerebral oxygen extraction ((SaO2 - 20-kg pigs. As in 20-kg pigs, NMB had no rScO2) / SaO2)) was calculated. Arterial significant effect on laparoscopic working blood gases were drawn every 15’: space. Pre-stretching of the abdominal pre(T0), during(T1-T4) and after CO2- wall is a promising cheap, safe and easy insufflation(T5). strategy to increase laparoscopic working space, lessening the need for prolonged RESULTS: Ten piglets (4kg) were high-pressure pneumoperitoneum. randomized for 5(P5) and 10(P10) mmHg CO2-insufflation.

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Two P10 piglets needed resuscitation PURPOSE: Bariatric after insufflation, none P5. surgery corrects insulin resistance independent P5 showed stable SaO , HR and MABP 2 of weight loss, possibly during the entire procedure. pCO2(mmHg) through enterokine increased from 36±4 at T0 to 70±19 at T4 signaling pathways. (p<0.05) and rScO (%) from T0 42±3 to 2 We hypothesize that a 57±1 at T5 (p<0.001). Magnetic Anti-Glycemic P10 showed a decrease of MABP (mmHg) Ileal Conduit (MAGIC), from 84±8 at T0 to 54±21 at T3 (p<0.05). created with a magnetic compression HR increased from T0152±18 to 218±9 at anastomosis between the proximal jejunum and distal ileum, corrects insulin T3 (p<0.05), pCO2(mmHg) from 35±6 at T0 to 74±8 at T3 (p=0.01), rScO2(%) from 37±4 resistance. at T0 to T5 50±5 (p=0.05). METHODS: Yucatan mini pigs (n = 12) cFTOE in P10 compared to P5 was higher received a high fat diet for 3 months to at all time points and significant at induce insulin resistance. Animals were T5(p<0.05)(fig 1). randomly assigned to 4 groups (n=3). Baseline intravenous glucose tolerance CONCLUSION: Insufflation of CO during 2 tests (IVGTT) were performed in fat-fed thoracoscopy with 10 mmHg caused more pigs and one farm pig as a control. Eight severe hemodynamic instability compared animals underwent the MAGIC procedure to 5 mmHg. Although higher CO -levels 2 using either 23 mm (n=3) or 17 mm are related with higher brain perfusion diameter (n=5) magnets. Four animals by cerebral vasodilation insufflation of underwent sham operation. Groups were 10 mmHg seemed to be related with survived for 2, 4, 8 or 12 weeks, at which a decrease of cerebral perfusion as points IVGTTs were repeated to assess represented by a higher oxygen extraction. changes in insulin sensitivity. Plasma glucose and serum insulin by ELISA was CO2-Insufflation of 5 mmHg for thoracoscopy seems to be safe for measured (n=8). Animals were euthanized cerebral oxygenation. and the anastomosis procured for histology. S019: MAGIC (MAGNETIC ANTI- GLYCEMIC ILEAL CONDUIT) I: JEJUNAL- RESULTS: Baseline insulin resistance was ILEAL MAGNETIC COMPRESSION confirmed in fat-fed pigs versus control ANASTOMOSIS CORRECTS INSULIN (Insulin area under the curve normalized RESISTANCE IN DIABETIC PIGS Hilary B. to weight [AUC]: 0.330 ± 0.206 vs 0.053, p Gallogly, MD, Elisabeth J. Leeflang, MD, < .005). Insulin sensitivity improved by 2 Dillon A. Kwiat, Corey W. Iqbal, MD, Karyn weeks in animals after MAGIC treatment J. Catalano, PhD, Kullada O. Pichakron, compared with sham (AUC: 0.169 ± 0.098 MD, Michael R Harrison, MD, Department vs 0.382 ± 0.30, p < 0.005). While animals of Surgery, University of California, Davis. with 23 mm magnets experienced Departments of Pediatric Surgery and excessive weight loss (>25%) observed by Obstetrics, Gynecology & RS, University 4 weeks, this was ameliorated in pigs with of California, San Francisco. Department 17 mm magnets (48% ± 3 vs 18% ± 14). of Surgery, David Grant Medical Center, No anastomotic leaks or strictures were Travis Air Force Base. observed in any animals. All animals took

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Oral Abstracts CONTINUED liquids on the day of surgery and were RESULTS: Eighty-seven rabbit fetuses tolerating solids on POD 1. Two animals were studied. Direct evidence of had diarrhea that abated, but none membrane leakage was present in 36% required supplements or TPN. of Amnioseal treated animals and 67% of saline treated animals (p=0.03). The CONCLUSION: MAGIC jejunal-ileal bypass membrane was completely disrupted in may be an effective treatment for insulin 43% of the saline group compared to 15% resistance and the metabolic syndrome, with Amnioseal (p=0.03). Mean lung-to- with the potential for an outpatient body weight ratio was lowest (suggesting minimally invasive procedure. oligohydramnios) in the saline control S020: AMNIOSEAL I: A BIOMIMETIC group (0.026±0.001) while the Amnioseal POLYMER ADHESIVE TO PRESEAL THE group (0.030±0.002) was closer to the AMNIOTIC MEMBRANE TO PREVENT untreated group (0.0.32±0.002). PPROM AFTER FETOSCOPY Corey W. CONCLUSIONS: Amnioseal was effective Iqbal, MD, Dillon A. Kwiat, BS, Stephanie in reducing membrane rupture as Kwan, BS, Hoyong Chung, PhD, Robert measured by direct membrane H. Grubbs, PhD, Michael R. Harrison, MD, assessment and fetal lung-to-body University of California San Francisco weight ratio. This may be a useful Fetal Treatment Center; Children’s Mercy strategy to prevent PPROM after Hospital Fetal Health Center fetoscopy. PURPOSE: Preterm premature rupture S021: THE PEDIATRIC DEVICE of membranes (PPROM) is a common CONSORTIUM: A MODEL FOR SURGICAL problem after fetoscopy and remains the INNOVATION Elisabeth J. Leeflang, “Achilles Heel” of fetal therapy. MD, Elizabeth A. Gress, Dillon A. Kwiat, HYPOTHESIS: We hypothesize that Hanmin Lee, MD, Shuvo Roy, PhD, presealing the amniotic membrane with Michael R. Harrison, MD, Departments a biomimetic polymer adhesive that of Pediatric Surgery and Bioengineering works in an aqueous environment, similar and Therapeutic Sciences, University of to that produced by the mollusk, prior to California, San Francisco amniotomy will prevent PPROM. The Pediatric Device METHODS: With IACUC approval, Consortium (PDC) has pregnant rabbits underwent celiotomy served for 4 years as with exposure of the uterus. Fetuses a platform for open were randomly assigned (by position brainstorming, creating in the uterine horns) to either (1) no solutions through intervention, (2) Amnioseal injection a multidisciplinary between the myometrium and amnion approach and completing the cycle followed by needle puncture or (3) saline of device innovation from concept to injection between the myometrium and commercialization. amnion followed by needle puncture. The consortium’s twice weekly One week postoperatively, the integrity meetings afford a venue for iteration of the amniotic sac was assessed for of its 13 active projects and support for leak by injection of methylene blue and people with new ideas at any stage of oligohydramnios was assessed indirectly development. These meetings are a by fetal lung-to-body weight ratio.

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Oral Abstracts CONTINUED sounding board for potential devices, S022: LONG TERM HEMODYNAMIC project updates and future directions. EFFECTS OF NUSS REPAIR IN PECTUS The interactive web portal provides EXCAVATUM FOR VENTRICULAR resources for education, collaboration FUNCTION BY “CARDIOVASCULAR and communication. The organization MAGNETIC RESONANCE CINE-SSFP- consists of a program administrator, IMAGING”, RESULTS OF BERLIN- principal investigators, partner programs, BUCH NUSS-CARDIO-MRI STUDY K. and specialists in product development, Schaarschmidt, Prof., MD, Susanne regulatory affairs, and intellectual Polleichtner, MD, A. Töpper, MD, property. Residents, engineers and A. Zagrosek, MD, M. Lempe, MD, F. students from a variety of disciplines Schlesinger, MD, J. Schulz-Menger, work on physical devices and are Prof., MD, Helios Center of Pediatric and surrounded by a diverse technological Adolescent Surgery Berlin-Buch pool. OBJECTIVE: Exercise intolerancein The model of the PDC has contributed pectus excavatum is known,but true to over 30 pediatric devices, with 3 physiological impairment is difficult to projects in the clinical stages and one prove. Controversial is, whether Nuss commercially available device. Fifteen improvescardio-pulmonary performance articles have been published in peer- althoughcardiac relief was reported reviewed medical and engineering 2006 by Colnecho-cardiographically journals and research presented at and in 2013 by Maagaard clinically. over 20 conferences. Meetings attract Cardiac nuclear magnetic resonance 12-20 people on average from different imaging(CMRI)has low inter-observer backgrounds. To accelerate the adoption variance but shows severeinterferences of pediatric devices into the market, by ferro-magnetic Nuss bars and the PDC has facilitated 5 partnerships investigation capacities are limited. between innovators and existing companies and has helped launch 6 METHODS: 7/2009- 11/2011 53 PE start-ups around technologies born in patients of 12.8-42.9y (21.1±8.6) with the PDC. The PDC has raised more than a Haller of 9.9± 5.7 (4.3-18.1) and $11 million as an impressive return on BMI of 20.8±3.6 entered the study the Food and Drug Administration’s $2 and37series(30 male /7 female) free of million investment. artifacts allowed complete evaluation. This ongoing prospective studyquantifies Momentum continues to gather in the right +left ventricular function by CMR newly formed Surgical Innovations Group before, 2 weeks, 3months, 1 year after - encompassing all surgical specialties, Nuss and finally 3 years postop after bioengineering and a multicenter bar removal. The use of titanium bars incubator, a device accelerator for (13´-17´) in all patients avoided bar funding devices and the Innovation interferences in CMR. Cardiac function Pathway for researchers. What began was assessed by Cine-SSFP-imaging as a free forum has grown into an covering the left ventricle (LV) as short innovation powerhouse with name axis and the right ventricle (RV) axial recognition and clinical solutions. orientation in axial orientationWe quantified the enddiastolic and endsystolic volumes of LV and RV: and

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Oral Abstracts CONTINUED calculated the ejection fractions (EF) and S023: 3-DIMENSIONAL VISION stroke volumes (SV) using CMR42 (circle IMPROVES LAPAROSCOPIC SURGERY cvi, Canada). IN SMALL SPACES Xiaoyan Feng, MD, Anna Morandi, MD, Martin Boehne, MD, Tawan Imvised, MD, Benno Ure, MD, PhD, Joachim F. Kuebler, MD, Martin Lacher, MD, PhD, Center of Pediatric Surgery, Department of Pediatric Cardiology TABLE 1: Change of cardiac function in and Intensive Care Medicine, Hannover pectus excavatum after Nuss repair Medical School, Germany RESULTS: Haller index was significantly AIM OF THE STUDY: Three-dimensional improved after Nuss surgery (pre: 9.9± 5.7 (3D) cameras, a recent technical vs. post: 2.8± 0.5, p <0.001) indicating a innovation in laparoscopic surgery, have successful repair in all patients. The right been postulated to enhance depth ventricle lies anteriorly and to the right perception and to facilitate operations. and is predominantly compromised by However, they have not been tested in pectus excavatum. Thus right ventricular conditions where the focus is close to the ejection fraction (RVEF) and stroke optical system. Thus, it is unclear whether volumes of both ventricles (RVSV and 3D cameras could improve laparoscopic LVSV) are highly significantly increased 2 surgery in neonates and infants. We wk, 3 mo and 1 year after Nuss (see table tested the advantages of 3D vs 2D vision 1), while LVEF just reaches significance during laparoscopic surgery in rabbits, with p of 0.05. mimicking the size of a neonatal patient. CONCLUSIONS: Cardiovascular MATERIALS & METHODS: Cadaver New improvement by Nuss repair has been Zealand white rabbits (mean weight 2800 suspected for a long time due to g) were operated by two experienced decreased palpitations and exercise heart laparoscopic surgeons. All animals rates but could never be measured in a underwent 6 surgical procedures: Nissen strictly reproducible way.Although this fundoplication, small bowel anastomosis is an early report and still a small series and closure of a diaphragmatic hernia it shows hemodynamic improvement using 2D and 3D systems (3D: 0°, 10mm after Nuss repair significantly and laparoscope; 2D: 30°, 10mm laparoscope, consistently in all control scans. Karl Storz, Tuttlingen, Germany). The Cine-volumetric CMR measurement sequence of the three cases and visual shows preoperative impairment technique (2D vs 3D) was changed every in PEand significant postoperative time. Primary endpoint was operation improvement of the most important (OR) time. Secondary endpoints were right and left functional parametersafter measured to exclude confounders and severalpostoperativeperiods following included the hemodynamic response of Nuss repair and may become a new the surgeon (heart rate, blood pressure, standard for PE evaluation in the future. cardiac output assessed by noninvasive electrical velocimetry Aesculon®) as well as the assessment of the psychomental stress level (measurement of concentration by a “bp-test”, reaction

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Oral Abstracts CONTINUED time (seconds) and performance in a PURPOSE: Minimally invasive approaches video game (Score; Pac-man). Finally, to congenital diaphragmatic hernia subjective data were assessed with (CDH) repair were once hailed for their questionnaires on a 0–4 scale after each perceived benefits. However, increased operation. recurrence rates have been frequently reported, demonstrating that a minimally RESULTS: 42 procedures were completed invasive approach may be less effective in 7 rabbits with a total of 21 2D- and 21 than conventional open repair. The 3D-operations. The mean cumulative OR purpose of this study was to examine the time for all three operations in the 3D outcomes of infants selectively chosen group was significantly shorter compared for minimally invasive repair compared to to the 2D group (3D: 23.0 min vs 2D: 29.5 infants who underwent open repair with min, p<0.01). This effect could be shown special attention to recurrence. for all three operations independently (Nissen fundoplication: mean time METHODS: A retrospective review of 3D 8.9min vs 2D 11.6min, p=0.02; patients with CDH repair at our institution Diaphragmatic reconstruction: mean was performed from June 1999 to June time 3D 7.5 min vs 2D 9.7 min, p=0.0009; 2012. (IRB #X130829007). Only Bochdalek Intestinal anastomosis: mean time 3D CDH repairs were included. Participants 6.6 min vs 2D 8.2 min, p=0.014). There were excluded for repair after 6 months were no differences in the cardiovascular of age or death. Infants were then response of the surgeon comparing 3D grouped based on repair type: open repair and 2D (heart rate, blood pressure, cardiac (laparotomy or thoracotomy), endoscopic output) as well as psychomental stress repair (thoracoscopic or laparoscopic), levels (concentration, reaction time and or conversion (starting endoscopic and performance in the Pac-man video game). converting to an open procedure). Repair Subjective evaluation of the surgical type was chosen based on surgeon’s performance revealed that 3D offers a assessment of patient’s condition and better perception of the depth. organ involvement. Demographic data (gestational age, birth weight, Apgar scores CONCLUSION: The use of 3D laparoscopy at 1, 5, and 10 minutes) and treatment in small spaces using a rabbit model is data (repair day of life, patch use) were associated with faster operation times. collected. Hernia data included side and This finding was independent of the organ involvement. Outcome measures overall shape of the surgeon assessed included length of stay, ventilator days, by hemodynamic and psychomental follow-up length, and hernia recurrence. measurements. 3D may therefore Hernia recurrence was based on chest facilitate reconstructive minimal invasive x-ray, CT scan, or need for recurrent hernia surgery in small children. surgery. The three patient groups were S024: MINIMALLY INVASIVE CDH compared using analysis of variance and REPAIR: EFFECTIVE FOR SELECT the Freeman-Halton extension of Fisher’s PATIENTS Tate Nice, MD, Scott Anderson, exact test for continuous and categorical MD, Sebastian Pasara, Rafik M. Bous, variables, respectively; non-parametric Robert Russell, MD, MPH, Carroll M. statistics were used when deemed Harmon, MD, PHD, Children’s of Alabama, appropriate. An intention-to-treat analysis University of Alabama at Birmingham was also performed comparing open to the aggregate group of endoscopic and conversion repairs.

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RESULTS: Sixty-four infants underwent S025: FURTHER EXPERIENCE WITH open repair and 26 underwent STAGED THORACOSCOPIC REPAIR OF A endosurgical repair, 7 of which were LONG GAP ESOPHAGEAL ATRESIA USING converted to open during the study INTERNAL STATIC TRACTION SUTURE period. Demographically the groups differ Dariusz Patkowski, Prof, MD, PhD, only by APGAR scores at 1 minute of Wojciech Górecki, MD, PhD, Sylwester life (Open:5, Endoscopic:7, Conversion:7, Gerus, MD, Anna Piaseczna-Piotrowska, p= 0.025) and ECMO requirement Prof, MD, PhD, Piotr Wojciechowski, (Open:37.5%, Endoscopic:5.3%, MD, PhD, A.I. Prokurat, Prof, MD, PhD, Conversion:14.3%, p= 0.011). While hernia Przemyslaw Galazka, MD, PhD, Michal side and patch use were not statistically Blaszczynski, MD, PhD, Maciej Baglaj different between repair groups, organ Prof, MD, PhD, Departments of Pediatric involvement differed significantly [Table Surgery and Urology: Wroclaw, Krakow, 1]. Ventilator days were decreased in the Lodz, Poznan, Bydgoszcz endoscopic group, however length of stay was not significantly different. Median BACKGROUND: Repair of long gap follow-up in days was similar between esophageal atresia (EA) is a challenge. groups. There were 11 (17.2%) recurrences Several different techniques have been in the open group, none (0%) in the invented. Most of them require staged endoscopic group, and 1 (14.3%) in the procedures with negative consequences conversion group (p= 0.114). The intention- of rethoracotomy. Three years ago, we to-treat analysis confirmed no statistical presented our initial experience with difference in recurrence between the endoscopic technique using internal static open (17.2%) and endoscopic/conversion traction suture for management of long repair (3.8%) (p= 0.169). gap esophageal atresia (EA). CONCLUSION: By selectively utilizing OBJECTIVE: To evaluate the safety and minimally invasive techniques rather than efficacy of repetitive thoracoscopic applying to all patients, effective repairs technique using static internal traction of Bochdalek CDH can be obtained with suture for repair of long gap EA. a low recurrence rate. Overall patient METHOD: Between June 2010 and January condition, need for ECMO, and organ 2014, fourteen infants (7 girls, 7 boys) involvement should factor into the repair with long gap EA (no distal tracheo- technique decision. Hernia recurrence is esophageal fistula - TEF), were managed similar between open and endoscopic by a thoracoscopic approach in 5 different repairs as long as minimally invasive hospitals. The first author was involved repairs are utilized selectively. in all chest procedures except two. All the children had a feeding gastrostomy. The thoracoscopic procedure was preceded by bronchoscopy to exclude a proximal fistula. Thoracoscopy was performed in right semi-supine position using 3 ports around the right scapula. The azygos vein was not divided. Both esophageal ends were mobilized and the proximal TEF present in four newborns was closed. Non-absorbable 2-0 suture

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Oral Abstracts CONTINUED was advanced to the proximal and distal because of heart defect. Six children esophagus and with the aid of sliding required calibration/dilatation of the knot; both ends were approximated and anastomosis for a mild and treatable left under the tension. At the subsequent stricture. One case had antireflux endoscopic approach, under favorable surgery. conditions, a definite anastomosis over CONCLUSION: We believe our technique an 8F nasogastric tube by single stitches is an alternative option for the repair of of 5-0 absorbable braided suture was long gap esophageal atresia, and offers constructed. Otherwise, new traction functional native esophagus in early suture was applied. infancy. Thoracoscopic approach allows RESULTS: The first stage thoracoscopic for avoiding negative consequences of surgery was performed between 2 and 51 open thoracotomy for a growing child. days of life. The esophageal anastomosis Repetitive thoracoscopy does not hinder was completed in 12 infants between the exposure for dissection in posterior 31 and 175 days of life: 10 infants mediastinum. were managed only by thoracoscopic approach, one baby was converted in S026: B-TYPE NATRIURETIC PEPTIDE the last procedure and the other one LEVELS CORRELATE WITH PULMONARY had the last procedure performed in an HYPERTENSION AND REQUIREMENT open fashion by intention. Two infants FOR EXTRACORPOREAL MEMBRANE are still awaiting a definitive procedure. OXYGENATION IN CONGENITAL All infants had 37 procedures performed DIAPHRAGMATIC HERNIA Emily A. (35 thoracoscopies, 1 thoracoscopy Partridge, Lisa Herkert, Brian Hanna, with conversion, 1 thoracotomy). The Natalie E. Rintoul, Alan W. Flake, N. number of procedures to complete Scott Adzick, Holly L. Hedrick, William the anastomosis was between 2 and 5 H. Peranteau, Children’s Hospital of (mean: 2.86). The traction suture caused Philadelphia ,Philadelphia, PA USA esophageal perforation in one case AIM OF THE STUDY: B-type natriuretic that required thoracoscopic closure. peptide (BNP), an established biomarker The other baby had probably hidden of ventricular pressure overload, is used perforation that resulted in pleural cavity in the assessment of disease severity obliteration and required conversion and treatment guidance in children during esophageal anastomosis. In other with pulmonary hypertension (PH). PH cases, we experienced no difficulties is commonly observed in congenital with repetitive approach to the pleural diaphragmatic hernia (CDH) and cavity, as well as exposition, dissection represents the most frequent indication and suture of esophagus after the for the initiation of extracorporeal previous procedures. membrane oxygenation (ECMO) therapy. In 12 children with anastomosed However, the use of BNP levels to guide esophagus, a contrast study was treatment in this patient population has performed 5-7 days postoperatively. not been well defined. We investigate Anastomotic healing was satisfactory in BNP levels in a large cohort of CDH each case. Oral feeding was progressively patients treated at a single institution started replacing the gastrostomy route. and correlate them with clinical There was late mortality in one case outcomes

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METHODS: We retrospectively reviewed PURPOSE: Laparoscopic ileal pouch-anal charts of all CDH patients enrolled in anastomosis (IPAA) has been associated our pulmonary hypoplasia program with decreased complications when from 2004-2013. PH was assessed by compared to open IPAA in children. echocardiography using defined criteria, Though single incision laparoscopic (SIL) and patients were further stratified into IPAA has been shown to be feasible and the following cohorts: no PH, short-term safe, outcomes have not been compared PH (requiring nitric oxide but no additional to those of traditional laparoscopic- vasodilatory therapy), long-term PH assisted (LA) procedures. The purpose (requiring continued vasodilatory therapy of this study was to compare the two post-discharge), and ECMO (requiring techniques to determine if benefits to the ECMO therapy). BNP levels prior to CDH single incision approach exist in children repair and/or ECMO cannulation from with ulcerative colitis (UC) and familial each patient cohort were analyzed by adenomatous polyposis (FAP). Mann-Whitney t-test (p<0.05). METHODS: All children ≤18 who RESULTS: One hundred and eleven underwent SIL and LA IPAA between 2000 patients were studied. BNP levels were and 2013 at our institution were identified significantly lower in patients with from a prospectively maintained database normal pulmonary pressures compared of surgical procedures. Single incision to patients with PH (p<0.0001) [Table 1]. laparoscopic IPAA was first performed in Those patients who went on to require 2010 and utilized a modified glove port ECMO therapy had significantly higher with a wound protector/retractor. Many BNP levels compared to patients with SIL procedures required one accessory no PH (p=0.0341). BNP levels were also port and traditional LA procedures significantly increased in both ST-PH and often used a 5-cm Pfannenstiel incision LT-PH patients compared to those with no for proctectomy and IPAA following PH. Although not statistically significant, laparoscopic colon mobilization. there was a trend towards higher BNP Demographic, preoperative, operative, levels in patients with LT-PH compared to and postoperative information was ST-PH (p=0.0696). obtained retrospectively from patients’ medical records and compared between CONCLUSION: Plasma BNP levels SIL and LA approaches usingt-tests for correlate with pulmonary hypertension continuous variables and chi square and requirement for ECMO in CDH or fisher exact tests for discrete patients. Monitoring of serial BNP levels variables. Results for operative time and may provide a useful prognostic tool in postoperative length of stay (LOS) were the management of CDH. stratified by number of stages (one, two, S027: SINGLE INCISION LAPAROSCOPIC or three) and postoperative complications ILEAL POUCH-ANAL ANASTOMOSIS IN were stratified by diagnosis (UC or FAP). CHILDREN—HOW DOES IT COMPARE TO A RESULTS: Children who underwent SIL TRADITIONAL LAPAROSCOPIC-ASSISTED IPAA (n=19) and LA IPAA (n=62) were not APPROACH? Stephanie F. Polites, MD, significantly different in age, gender, Abdalla E. Zarroug, MD, Christopher R. diagnosis, biologic use (UC patients Moir, MD, Donald D. Potter, MD, Mayo only), staged approach, and stapled Clinic, Rochester, MN; University of Iowa, vs. mucosectomy with hand sewn Iowa City, IA

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Oral Abstracts CONTINUED anastomosis (Table 1). An accessory S028: CURRENT OPERATIVE STRATEGIES port was used in 53% of SIL procedures AND EARLY COMPLICATIONS and a Pfannenstiel incision in 87% of LA OF DEFINITIVE SURGERY FOR procedures.Single incision laparoscopic HIRSCHSPRUNG’S DISEASE IN THE IPAA had equivalent mean operative UK AND IRELAND: FINDINGS FROM times to LA for two (353 vs. 385 minutes, A PROSPECTIVE NATIONAL COHORT p=.32) and three stage (316 vs. 339 STUDY Tim Bradnock1,Simon Kenny2, minutes, p=.60) procedures but operative Paul Johnson3, Marian Knight4, Jenny time for one stage procedures was Kurinczuk4, Gregor Walker1, 1Department shorter with SIL (308 vs. 355 minutes, of Paediatric surgery, Yorkhill hospital p<.001). Median LOS was shorter following Glasgow UK;2Department of Paediatric SIL for all patients (4 vs. 7 days, p<.001) Surgery, Alder Hey Children’s Hospital and, specifically, for two stage patients Liverpool UK;3Department of Paediatric (4 vs. 6 days, p=.009). Patients with CUC surgery, University of Oxford Oxford UK;4 had more unplanned returns to the operating room following LA IPAA (40% AIM OF STUDY: 1) To describe operative vs. 13% for SIL, p=.07) and more bowel strategies and early complications obstructions (18% vs. 7% for SIL, p=.43); for a national cohort of infants with however, these differences were not Hirschsprung’s Disease (HD) and 2) significant. Occurrence of pelvic abscess, investigate factors associated with anastomotic leak, and revision of IPAA surgical complications. was also equivalent between SIL and LA METHODS: Between October 2010 - for both UC (7 vs. 11%, p=.99) and FAP September 2012, each paediatric surgical (25% vs. 24%, p=.99) but these results are centre in the UK and Ireland prospectively limited by small sample size. identified infants presenting before 6 months of age with histologically- proven HD. Data including demographics, operative approach and complications (anastomotic leak/stricture, infection, TABLE 1: Characteristics of children who perianal excoriation, enterocolitis, and underwent IPAA unplanned operations) in the first 28 days were recorded. CONCLUSIONS: Single incision laparoscopic IPAA is a safe alternative to Univariate analysis using Mann-Whitney traditional laparoscopic-assisted IPAA for tests for numerical variables and chi- children with UC or FAP and may reduce squared tests for categorical variables postoperative LOS without affecting short were used to investigate factors term postoperative morbidity. Additional predictive of any complication. Variables studies are needed to determine if there significant at 5% level were used for are long term benefits. multivariate logistic regression analysis to determine independent predictors of complications. All analyses were done using Minitab (v16) at P<0.05. RESULTS: In 2 years, there were 317 reported cases of HD and data were available for 287/317(91%). 260 infants

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Oral Abstracts CONTINUED had definitive surgery (180 primary the potential to improve these skills and 80 staged pull-throughs). Colonic without patient risk. Although validity mobilization was laparoscopic, open evidence exists for an “adult” simulator, and exclusively transanal in 113(43.5%), none exists for a pediatric simulator. The 108(41.5%) and 39(15%) cases respectively. study purpose was to 1) create a size- Rectal dissection technique was appropriate infant scale lobectomy model submucosal, posterior and perirectal and 2) evaluate validity evidence for in 137(52.7%), 96(36.9%) and 26(10%) performance measures on the simulator. respectively. METHODS: IRB exempt pilot study. A size The overall early complication rate was appropriate rib cage for a 3-month old 96/260(36.9%). Independent predictive infant was created from literature and CT factors of complications were any image review. Fetal bovine tissue injected additional anomaly (OR=2.32, 95% C I with a blood substitute completed 1.19-4.51, p=0.013) and rectal dissection the model. Thirty-three participants technique (table 1). Compared to performed the simulated thoracoscopic submucosal dissection, complications lobectomy during a national course. were more likely with posterior (OR=1.93, Participants completed a self-report, 95% C I 1.11-3.36, p=0.02) and perirectal six-domain, 26-item instrument dissection (OR 2.87, 95% C I 1.21-6.81=, consisting of 4-point rating scales (1=Not p=0.017). Factors not significantly realistic to 4=Highly realistic). Using predictive of complications were self-reported thoracoscopic lobectomy age, weight, primary/staged surgery, experience, we categorized participants aganglionosis length, abnormal as “experienced” (n=11) or “novice” (n= proximal resection margin, and colonic 20). Content validity was evaluated mobilization technique. Case fatality by examining the rating differences was 8/287(2.8%). No infant died after using the many-Facet Rasch model and definitive surgery. estimating inter-rater consistency using Intraclass correlation (ICC). CONCLUSIONS: This national cohort study delineates current operative strategies RESULTS: Table 1. Experienced surgeons for HD in the UK and Ireland. Early (Observed Average (OA)=3.6) had slightly complications are common and appear higher overall ratings than novice related to coexisting anomalies and rectal (OA=3.4), p = .001. The highest combined dissection technique. observed averages were for Chest circumference and depth (both OA = 3.8), S029: PRELIMINARY EVALUATION OF while the lowest ratings were Realism A NOVEL INFANT THORACOSCOPIC of mediastinum, (OA = 3.3), and Realism LOBECTOMY SIMULATOR Katherine A. resistance-trocar placement (OA = 3.2). Barsness, MD, MS, Deborah M. Rooney, Averaged global opinion rating was 2.9, PhD, Lauren M Davis, BA, Ellen K. indicating the simulator can be considered Hawkinson, BS, Northwestern University for teaching thoracoscopic lobectomy, Feinberg School of Medicine, University of but could be improved slightly. Inter-rater Michigan Medical School reliability was high [ICC(1,k)α=.91]. PURPOSE: Thoracoscopic lobectomy CONCLUSIONS: With comments/ratings requires advanced minimally invasive consistent with high physical attributes and skills. Simulation-based education has realism, we successfully created an infant

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Oral Abstracts CONTINUED lobectomy simulator. Simulator ratings (26 days) and FM (31 days) (p=0.024) (figure from novice and experienced participants 1). The mean cost of treating patients in the were high, indicating it was realistic, BM group was £17,615 and the mean cost relevant to clinical practice and valuable as for patients fed C M and FM was £28,556. a learning tool. In spite of high ratings, the (p < 0.001). If all patients had been fed simulator requires minor improvements exclusively with BM, then there would have and evaluation of additional validation been a reduction in cost of £49,230 per evidence prior to implementation as an year. educational and testing tool. CONCLUSION: Our data demonstrate S030: GASTROSCHISIS – THE ROLE that breast milk significantly reduced the OF BREAST MILK IN REDUC ING TIME time to full feed in our population and TO FULL FEEDS Deirdre Kriel1, Anne was associated with a reduction in bed Aspin1,Jonathan Goring1,Robert West2, occupancy and cost. We recommend that Jonathan Sutcliffe1, 1Leeds Teaching breast milk is the feed of choice for all Hospitals NHS Trust, Leeds UK;2Leeds children with simple gastroschisis where it Institute of Health Sciences - University is practically available. of Leeds, Leeds UK S031: ONCOLOGIC MIS SURGERY : AIM OF STUDY: Gastroschisis is increasingly ROLE OF IDRFS CRITERIA IN PATIENT common and is associated with prolonged SELECTION AND PLANNING *Claudio hospital stay and cost. This study aimed Vella, MD,*Camilla Viglio, MD,*Sara to examine the effect of feed type on the Costanzo, MD,**Salvatore Zirpoli, MD, time to full enteral nutrition in infants with **Marcello Napolitano, MD,***Roberto simple gastroschisis. Luksch, MD,*Giovanna Riccipetitoni, MD, *Pediatric Surgery Department, “V.Buzzi” METHODS: In this prospective study, data Children’s Hospital ICP,**Pediatric were collected for all neonates born Radiology and Neuroradiology with simple gastroschisis between April Department “V.Buzzi” CHILDREN’S 2007 and May 2011. Information obtained Hospital ICP, Milan – Italy,***Pediatric included patient demographics, feed type Department, Fondazione IRCCS National and rate of feed advancement. Patients Cancer Institute, Milan, Italy were divided into 3 groups: Group A – exclusively breast milk fed (BM), Group INTRODUCTION: Minimally invasive B - combination of breast and formula surgery (MIS) in solid tumors is reserved feeds (C M) and Group C - formula milk for selected patients according to (FM). Time to full feed was calculated for morphological criteria and cancer each patient. Cost of hospitalisation was protocols. The availability of high- estimated for each group using current resolution imaging techniques and the Healthcare Resource Group (HRG) codes. application of Image-Defined Risk Factors (IDRFs) for neuroblastoma allows to MAIN RESULTS: 50 patients were born with select cases of solid tumors that could be gastroschisis during the 210 week study submitted to MIS procedures. period of which 38/50 were “simple”. The number of patients in each group were: BM MATERIAL AND METHODS: Records n=20, C M n=8 and FM n=10. A significant of patients affected by solid tumors, difference in the median time to full feed diagnosed and treated in our centre in the was observed between BM (19 days), C M last 6 years were reviewed.

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For the diagnostic findings: CT oncologic surgery. This classification is angiography, MR angiography with of utmost importance not only for the multiplanar reconstruction technique morphological assessment of the mass with maximum intensity projection (MIP) but also as a guidance for patients’ and volume rendering (VR) to define the selection and planning in MIS surgery. anatomical features, vascular supply, relationships of the tumor with vital S032: GLUTAMINE SUPPLEMENTATION structures were used to determine an IMPROVES MONOC YTE FUNC TION IDRFs classification for the surgical risk IN SURGIC AL INFANTS REQUIRING in solid masses. The multidisciplinary PARENTERAL NUTRITION - RESULTS OF A RANDOMISED CONTROLLED approach involving surgeon, radiologist, 1 2 oncologist and pathologist allowed us to TRIAL Mark Bishay ,Venetia Simchowitz , Danielle Petersen2, Marlene Ellmer2, identify cases eligible for a MIS procedure: 2 4 biopsy or surgical excision, according to Sarah Macdonald , Jane Hawdon , 4 2 IDRFs, staging and biology of the tumor. Elizabeth Erasmus , Kate MK Cross , Joseph I Curry2, Edward M Kiely2, Paolo RESULTS: In the period of study a total De Coppi1,2, Nigel Klein1,2, Agostino Pierro3, of 221 patients with solid tumor (aged 3 Simon Eaton1, 1UCL Institute of Child months-14 years) were surgically treated. Health, London UK;2Great Ormond Street 50 of them met the criteria for MIS Hospital, London UK;3Hospital for Sick approach. 25 patients underwent a MIS Children, Toronto Canada;4University diagnostic biopsy : 3 hepatoblastoma, College Hospital, London UK 2 hepatocellular carcinoma, 1 focal nodular hyperplasia, 4 lymphoma, 2 BACKGROUND: Our aim was to determine Castleman disease, 5 neuroblastoma, whether, in surgical infants requiring 2 rhabdomyosarcoma, 2 germ cell parenteral nutrition (PN), parenteral tumors, 1 pulmonary blastoma, 1 and enteral glutamine supplementation retroperitoneal osteosarcoma and influences monocyte HLA-DR expression, 2 renal neoplasms. Primary surgical a marker of monocyte activation and exicision was planned in 25 patients: 6 immune function. neuroblastoma, 2 ganglioneuroblastoma, METHODS: This was an ethically-approved 3 ganglioneuroma, 1 pheochromocytoma, prospective double-blind randomised 1 adrenal lymphangioma, 4 ovarian controlled trial in surgical infants (corrected cystadenoma, 5 ovarian teratoma, 1 gestational age <3 months) receiving PN granulosa tumor, 1 presacral teratoma for at least five days for congenital or , 1 chest teratoma,. All the procedures acquired intestinal anomalies (July 2009 were successfully completed with MIS - March 2012). Infants were randomised technique. A good hemostasis was always using weighted minimisation to receive achieved. No secondary localizations either parenteral plus enteral glutamine at trocarsites or local recurrences were supplementation ((total 400mg/kg/day) or observed. The median hospital stay isonitrogenous control. Monocyte HLA-DR was 48 hours for patients undergone a expression was assessed (as a secondary diagnostic biopsy and 5 days for patients outcome measure) at enrolment, after five submitted to primary surgery. days, and on reaching full enteral feeds (or CONCLUSIONS: The extension of prior to transfer to another centre). Data IDRFs criteria to the vast majority are given as mean±SEM and compared by of solid tumors can be effective in unpaired t-test with Welch’s correction.

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MAIN RESULTS: Sixty infants (35 boys, congenital pulmonary lesions using a 25 girls) were enrolled in the study. The validated national database. median age at enrolment was 6 days METHOD: We identified all lobectomies (range 0-95), corrected gestational age performed on patients with congenital 37 weeks (24-49), and weight 2.3 kg pulmonary lesions in the 2012 National (0.6-4.6). The underlying diagnoses were: Surgical Quality Improvement Program 25 patients had congenital/neonatal Pediatric (NSQIP Pediatric) database and intestinal obstruction, 19 had anterior compared demographic, clinical, and abdominal wall defects, 13 had necrotising 30-day outcome characteristics between enterocolitis, and 3 had other causes of patients who underwent an open or intestinal dysfunction. Glutamine and thoracoscopic lobectomy. Patients who control groups had similarly low HLA-DR underwent an emergent operation or had expression at enrolment/surgery, which a resection associated with a diagnosis slowly increased in each group during the of cancer were excluded. Minor and study (Figure). However, the postoperative major complications were defined as any restoration in HLA-DR expression was occurrence of the complications listed faster in infants receiving glutamine so in the table within 30 days of surgery. A that HLA-DR expression was significantly multivariable regression model was fit to higher after five days and at the end determine the risk-adjusted effect of a of the study. HLA-DR expression was thoracoscopic approach on postoperative significantly lower during episodes of length of stay (LOS) after adjusting for clinical sepsis (51±4 vs. 64±2; p=0.008). factors associated with open resection on CONCLUSION: Parenteral plus enteral univariable analysis. glutamine supplementation in infants RESULTS: Of the 102 patients who receiving PN after gastrointestinal surgery underwent a non-emergent lobectomy significantly increases monocyte activation, for a congenital pulmonary lesion, reflecting improved immune function. 40 (39%) underwent thoracoscopic S033: COMPARISON OF 30-DAY lobectomy. In comparison to patients OUTCOMES BETWEEN THORACOSCOPIC undergoing thoracoscopic lobectomy, AND OPEN LOBECTOMY FOR patients undergoing open lobectomy CONGENITAL PULMONARY LESIONS were less likely be admitted from Justin Mahida, MD, MBA, Lindsey Asti, MPH, home on the day of surgery (82% vs. Victoria K Pepper, MD, Katherine J. Deans, 97%, p=0.02), and were more likely to MD, MHSc, Peter C. Minneci, MD, MHSc, be classified as American Society of Karen A. Diefenbach, MD, Nationwide Anesthesia (ASA) class 3 or greater (47% Children’s Hospital, Columbus Ohio vs. 15%, p=0.001), to receive oxygen support prior to surgery (13% vs. 0%, INTRODUCTION: Multiple single- p=0.021), to have other congenital institution studies have demonstrated anomalies (50% vs. 30%, p=0.046), and feasibility and safety of thoracoscopic to have cardiac risk factors (26% vs. 5%, resection for congenital pulmonary p=0.007). Both groups had similar total lesions. The purpose of this study was operative time (open vs. thoracoscopic, to compare postoperative length of p-value) (144 vs. 173 minutes, p=0.196), stay and 30-day outcomes between duration of time in the operating room thoracoscopic and open lobectomy (252 vs. 271 minutes, p=0.397), and performed non-emergently for

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Oral Abstracts CONTINUED duration of anesthesia from induction to S034: HIGH VOLUMES IMPROVE recovery (316 vs. 283 minutes, p=0.598). OUTCOMES - A NATIONAL REVIEW OF In comparison to patients undergoing HYPOSPADIAS SURGERY IN ENGLAND thoracoscopic lobectomy, patients 1999-2009 Patrick Green3,1, David undergoing open lobectomy had Wilkinson2,1, Shanthi Beglinger1, Rachel significantly longer postoperative LOS (4 Hudson1, David Edgar1, Simon Kenny1,2, vs. 3, p=0.002) and more often received 1University of Liverpool, Liverpool an intraoperative or postoperative UK;2Alder Hey Children’s Hospital NHS transfusion within 72 hours of surgery Foundation Trust, Liverpool UK;3Royal (12% vs. 0%, p=0.003) (Table). The Liverpool and Broadgreen University difference in LOS was not significant in the Hospitals Trust, Liverpool UK multivariable analysis. AIMS: A review of outcomes following CONCLUSION: This NSQIP Pediatric study hypospadias surgery reveals a wide represents the largest multi-institutional disparity in reported outcomes. This compilation of patients undergoing may in part be explained by variations non-emergent lobectomy for congenital in surgical technique, caseload and the pulmonary lesions using validated data with availability of specialist perioperative standardized definitions of postoperative care. Having previously reported outcomes. This study suggests that patients preliminary data from specialist paediatric undergoing thoracoscopic lobectomy centres in England, we sought to have fewer comorbidities at baseline and determine outcomes from all centres receive fewer perioperative transfusions performing hypospadias surgery in and have a shorter postoperative length England to identify whether there is a of stay. Accrual of additional patients direct relationship between caseload and within the NSQIP Pediatric database will surgical outcome. allow for further risk-adjusted analyses of outcomes to control for differences in METHODS: All children undergoing baseline characteristics between patients hypospadias surgery in English NHS undergoing open and thoracoscopic trusts were identified using the Hospital resections. Episode Statistics database (1999- 2009). Patient demographics, institution type and associated diagnostic (IC D10) and treatment codes (OPC S4.6) were collected for both primary repairs and postoperative complications. The unique patient identifier allows all operative complications to be tracked irrespective of the centre to which they present. Analysis was performed on the whole cohort with separate subgroup analysis for those cases with severity of hypospadias recorded. Statistical analysis included linear regression and Mann-U Whitney for non-parametric data with p<0.05 taken as significant.

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RESULTS: 18357 primary operations for incision. Excision of ChC and hepatico- hypospadias were performed in England intestinal anastomosis were performed between 1999 and 2009 at a median age using conventional straight laparoscopic of 24.5months. Hypospadias operations instruments. were carried out at a total of 60 different RESULTS: 86 patients (64 girls, 22 boys) centres each carrying out between 1 and were identified with median age 24.5 144 cases/year. The overall, non-adjusted months (range: 1 month - 11 years). The complication rate for low (<20cases/year) most common clinical manifestations volume centres was 18.1% falling to 12.2% were abdominal pain – 67.4%, vomiting in high (>20cases/year) volume centres – 51.2%, jaundice – 26.7 %. The median (odds ratio 1.6, 95%C I 1.4-1.8, p<0.0001). diameter of ChC was 3 cm (range: 1.5 – 12 CONCLUSIONS: There appears to cm). The ChC was successfully excised be a significantly increased risk of by TULESS in all cases. Ladd procesdure complications following primary for associated intestinal malrotation hypospadias surgery performed in centres was carried out at the same time in one operating on less than 20 cases per year. patient. Hepaticoplasty was performed Population-level HES data provides a in 12 cases (13.9%) with hepatic duct valuable resource to determine outcomes diameter less than 5mm. Hepatico- for conditions such as hypospadias which jejunostomy was performed in 84 cases are treated in a range of centres and by (97.7%) and hepatico-duodenostomy different surgical specialties. in 2 cases (2.3%). Anastomosis with an aberrant bile duct was performed in 5 S035: TRANSUMBILICAL patients. Additional trocars were needed LAPAROENDOSCOPIC SINGLE SITE in just one case (1.2%). There was no SURGERY WITH CONVENTIONAL conversion to open surgery. The median INSTRUMENTS FOR CHOLEDOCHAL operative time was 195 minutes (range: CYST IN CHILDREN: EARLY RESULTS OF 150 minutes to 400 minutes). Abdominal 86 CASES Tran N. Son, MD, PhD, Nguyen T. drain was used in 8 patients (9.3%) in the Liem, MD, PhD, Vu X. Hoan, MD, National early period and no drain was used in the Hospital of Paediatrics, Hanoi, Vietnam remaining 78 patients (90.7%). There was INTRODUCTION: Reported experience with no anastomotic leakage. Mild umbilical trans-umbilical laparo-endoscopic single infection was noted in 2 patients (2.3%). site surgery (TULESS) for choledochal cyst The median postoperative hospital stay (ChC) in children is still limited. The aim of was 5 days (range 3-9 days). At a median this study is to present our early results of follow up of 6 months (range: 1 – 14 TULESS for childhood ChC. months), one patient (1.2%) from the early period suffered from hepaticojejunal METHODS: Medical records of all children anastomotic stenosis with cholangitis and undergoing TULESS for ChC at our center needed a redo surgery; all other patients from September, 2012 to December, 2013 were in good health. The postoperative were reviewed. Our TULESS operations cosmesis was excellent as all TULESS started with a z-shaped umbilical skin patients were virtually scarless. incision and placement of three 3-5mm ports at separate points in the same CONCLUSIONS: TULESS with conventional incision site. Roux-en-Y loop was created laparoscopic instruments for ChC in extracorporally through the umbilical children is feasible, cost effective, with

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Oral Abstracts CONTINUED excellent postoperative cosmesis. The abscess number, admission temperature, early outcome is promising and TULESS admission white blood cell count or can be a viable option for scarless duration of symptoms. There was no surgical management of childhood ChC at difference in duration of hospitalization experienced centers. after drainage (Table). One patient could not tolerate tPA secondary to pain with S036: SALINE VERSUS TISSUE flushes. PLASMINOGEN ACTIVATOR IRRIGATIONS AFTER DRAIN PLACEMENT FOR CONCLUSION: There are no advantages APPENDICITIS-ASSOCIATED ABSCESS: to routine tPA flushes in the treatment A PROSPECTIVE RANDOMIZED TRIAL of abdominal abscess secondary to Shawn St. Peter, Obinna Adibe, Sohail perforated appendicitis in children. Shah, Susan Sharp, David Juang, Brent S037: LAPAROSCOPIC FOWLER-STEVENS Reading, Brent Cully, Whit Holcomb III, ORCHIOPEXY, A RANDOMIZED PILOT Doug Rivard, Children’s Mercy Hospital, STUDY COMPARING THE PRIMARY AND Kansas City, MO USA 2-STAGE APPROACHES Daniel J. Ostlie, BACKGROUND: Emerging data suggest MD, Charles M. Leys, MD, Jason D. Fraser, instillation of tissue plasminogen MD, Charles L. Snyder, MD, Shawn D. activator (tPA) is safe and potentially St. Peter, MD, University of Wisconsin/ efficacious in the treatment of intra- American Family Children’s Hospital, abdominal abscesss. To date, prospective Children’s Mercy Hospital and Clinics comparative data are lacking in children. BACKGROUND: Intra-abdominal testes Therefore, we conducted a prospective, that lack sufficient vessel length to randomized trial comparing abscess perform an orchiopexy require division irrigation with tPA to irrigation with saline of the testicular vessels. Historically, the alone. vessels are divided at the initial operation METHODS: After IRB approval, children and the orchiopexy is then performed as with an abscess secondary to perforated a 2-stage procedure with the assumption appendicitis who had a percutaneous that development of neovascularization drain placed for treatment were occurs along the vas deferens during randomized to twice daily instillation the interim. Recent reports suggest the of 13ml of 10% tPA or 13 ml of normal orchipexy may be performed primarily at saline. All patients were treated with the time of vessel division. However, these once daily dosing of ceftriaxone and strategies have not been prospectively metronidazole throughout their course. compared. Therefore, we conducted a The primary outcome variable was randomized pilot trial to examine the role duration of hospitalization after drain for a larger comparative study. placement. Utilizing a power of 0.8 and an METHODS: After IRB approval, all patients alpha of 0.05, a sample size of 62 patients undergoing laparoscopic orchiopexy for a was calculated. Data was analyzed on non-palpable testis were considered for intention to treat basis. enrollment. This study was designed as a RESULTS: 62 patients were enrolled pilot study to evaluate testicular survival between 1/2009 and 2/2013. There were at 6 months follow-up. After obtaining no differences in age, weight, body mass consent, computer randomization index, gender distribution, abscess size, was used to determine a primary or

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2-stage orchiopexy. All procedures were the contralateral groin. Recurrence performed by 5 surgeons and allotment rates remain a concern. In 2011, our had no affect on surgeon selection. institution described a modification of the laparoscopic transcutaneous technique RESULTS: Between October 2007 and that replicates high transfixation ligation September 2013, 112 patients were of the hernia sac with the aim of inducing enrolled in the study. Twenty-nine more secure healing, preventing suture patients met criteria for randomization slippage, and distributing tension across based on inability to bring the testis to two suture passes. We now describe the contralateral internal ring. There was our long-term follow-up of patients no difference in the approach between undergoing this novel repair. surgeons. Data was complete in 27 cases. Outcome data is shown in table 1. METHODS: After obtaining IRB approval, a retrospective chart review and phone CONCLUSION: Approximately 70% of follow-up was performed of all patients patients with a non-palpable testis will that underwent this procedure between not require vascular division. This study October 2009 and November 2013. suggests that when vascular division is Data collection included demographics, required, the primary orchiopexy may laterality of hernia, evidence of recurrence, be equivalent to the traditional 2-stage complications, and time to follow-up. with testicular survival with potential advantages in total operative time and RESULTS: Three surgeons (0 – 10 years charges. These data provide evidence experience) performed 207 laparoscopic for sufficient equipoise to proceed transfixation suture ligature repairs on with the development of a large multi- 146 patients.Demographics were as institutional trial comparing these two follows: mean age 29.8 months (range approaches. 1-192 mo); male 66.4% and female 33.6%; 59% of the neonates (n=61) were premature infants (<37 weeks GA). Repairs were bilateral in 41.8% of patients, right sided in 34.2%, and left sided in TABLE 1 24%. 31% of preoperatively diagnosed unilateral hernias were found to have a S038: LONG TERM FOLLOW UP contralateral defect. Mean follow-up OF MODIFIED LAPAROSCOPIC was 24.1 months (range 2-50 mo). One 2 TRANSCUTANEOUS INGUINAL HERNIA month old syndromic patient with severe REPAIR WITH HIGH SUTURE LIGATURE congenital heart disease recurred twice OF THE HERNIA SAC Matias Bruzoni, MD, while another patient recurred after repair FACS, Zachary J. Kastenberg, MD, Joshua post incarceration. Overall recurrence rate D. Jaramillo, BA, James K. Wall, MD, Robert was 1.4%. The complication rate was 1.9% Wright, MA, Sanjeev Dutta, MD, MBA, (3 hydroceles and 1 inguinal hematoma; Stanford University all resolved spontaneously). BACKGROUND: Laparoscopic inguinal CONCLUSION: The laparoscopic hernia repair in children may reduce transcutaneous high transfixation post-operative pain, improve cosmesis, ligature technique can be performed allow for less manipulation of the cord by surgeons of varying experience and structures, and offer easy access to produce recurrence rates comparable to

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Oral Abstracts CONTINUED the standard open repair, with the added to report the results our large single- benefits of laparoscopy. surgeon experience with transperitoneal laparoscopic pyeloplasty in infants with a minimum of 6-month follow-up. METHODS: The records of all infant laparoscopic pyeloplasties over a 4.5-year period (109 babies, 114 kidneys, mean age 3.8 months, mean weight 5.3 kg) were analyzed. Preoperative evaluation included renal ultrasound and diuretic renogram (using Tc 99m DTPA) in all children. The indications for pyeloplasty was severe hydronephrosis (SFU grade 4 and/or AP diameter > 20mm) with obstructed drainage on DTPA renogram and a differential function of <40% in the affected kidney. Transperitoneal laparoscopic pyeloplasty was performed in all babies with 3 ports. Double J stent was used in 102 kidneys. Follow-up renal ultrasound (114 kidneys) was done at 3-6 months and diuretic renogram (76 patients) at 6-12 months after the surgery; data were compared using statistical software (medcalc). RESULTS: There were 104 unilateral and 5 bilateral pyeloplasties. The mean operating time was 106 min (70-145) and median hospital stay was 2 days (2-8). There were no major intraoperative complications. There was one intraoperative cautery injury to the appendix; appendicectomy was done in S039: LAPAROSCOPIC PYELOPLASTY the same sitting. One child (1%) developed IN INFANTS: SINGLE-SURGEON urinary leak that spontaneously resolved. EXPERIENCE WITH 114 OPERATIONS Four (5%) children had port-site infections Chandrasekharam Vvs, Dr., Rainbow  which were managed conservatively. children’s hospitals At a mean follow-up of 18 months, all AIM: Laparoscopic pyeloplasty is a children are asymptomatic; ultrasound technically demanding operation, demonstrated significant reduction especially in infants. To our knowledge, in the anteroposterior diameter of till date, there are only 5 published series renal pelvis in all children (mean pre- of laparoscopic pyeloplasty specifically operative diameter 34.4 +/- 13.4 mm in infancy, with a combined total of versus mean postoperative diameter 94 patients. The aim of this paper is 10.6 +/- 5.7mm, p< 0.0001). On Follow-up

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Oral Abstracts CONTINUED renogram, all renal units demonstrated RESULTS: Eleven procedures were improved drainage.There was a significant performed in 10 patients, 9 peritoneal and improvement in the differential function one retroperitoneal approach, because of the operated kidney in unilateral one of the patients had bilateral lithiasis cases (preoperative 22.1 +/- 8.6 % versus disease. postoperative 35.6 +/- 11.4 %, p< 0.0001) Ipsilateral additional ureterolithotomy CONCLUSIONS: To our knowledge, this is was necessary in 3 patients for embedded the largest series of infant laparoscopic stones in proximal uréter (27.2%). The pyeloplasty reported till date. Laparoscopic mean operative time in abdominal pyeloplasty could be safely and successfully procedures was 196 min (range 75-355 performed even in small infants, with min) and 170 min in the retroperitoneal minimal complications and good results. approach. The blood loss volume was Significant reduction in hydronephrosis & 59.3 ml (range 3-250 ml) and 10 ml improvement in differential function can be respectively. One patient had urinary expected in the majority of children. tract infection and urinary fistula which closed spontaneously. Opioid analgesic S041: LAPAROSCOPIC URETERO- was required in 5 patients (45.4%) for 2.4 Ana PYELOLITHOTOMY IN CHILDREN  days (range: 1-3 days ). The mean hospital María Castillo-Fernández, MD, Sergio stay was 5.2 days (range 2-13 days). Stone Landa-Juárez MD, Ramón Esteban disease free condition was ensured by Moreno Riesgo MD, Hermilo De La Cruz- pyeloscopy in all patients before finishing Yañez MD, Carlos Garcia-Hernández MD, the procedure (Fig. 2). Hospital de Pediatria, Centro Médico Nacional SXXI. IMSS PURPOSE: To evaluate laparoscopic uretero-pyelolithotomy as a feasible and safe procedure in children. PATIENTS & METHODS: We conducted a descriptive study (case series) from January 2011 to December 2013, including patients 2 to 13 years old with pyelic and FIG 2: Pieloscopy superior ureteral lithiasis, who underwent laparoscopic pyelolithotomy (Fig.1) by peritoneal or retroperitoneal approach with additional ureterolithotomy when necessary.

FIG 3: Removal of calculus CONCLUSIONS: Laparoscopic uretero- pyelolithotomy by either peritoneal or retroperitoneal approach is a feasilble and safe alternative treatment in the FIG 1: Pielotomy pediatric population. In our experience

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Oral Abstracts CONTINUED all patients with stone free condition (Fig. wall. Clinical data was collected and 3). The promising results of this series, compared between laparoscopy group encourages further clinical trials. and open group, such as operation time, intraoperative blood loos, postoperative S042: EXPERIENCE OF LAPAROSCOPIC blood transfusion, postoperative hospital PYELOPLAST IN THE TREATMENT stay and postoperative complication. OF URETEROPELVIC JUNCTION OBSTUCTION IN INFANTS (<3 MONTHS) RESULTS: In laparoscopy group the Aiwu Li, Jian Wang, Qiangye Zhang, operation time was 123.1±34.8 minutes Wentong Zhang, Hongchao Yang, Weijing which were similar to that of open Mu, Department of Pediatric Surgery, Qilu procedure (P > 0.05); intraoperative Hospital, Shandong University blood loss was 4.2±1.7 ml, which was much lower than that of open procedure BACKGROUND: Although early detection (16.8±2.5ml) (P < 0.05); the postoperative and early therapy are important to the hospital stay was 8.1±2.3 days, which treatment of Ureteropelvic Junction was obviously lower than that of open Obstuction (UPJO) and laparoscopic procedure.(14.4±2.8 days) (P < 0.05); pyeloplast has been widely applied in no conversions to open surgery and older children patients with UPJO, related no postoperative blood transfusion reports are still less in the treatment were required; no incision infection, of infants (< 3 months) patients with retroperitoneal hematoma, double J tube UPJO up to now. The aim of this study shifting or anastomotic leakage was in was to summarize the therapeutic this group besides 1 urinary infection efficacy and our operative experience of case. In the open group there were 3 transperitoneal laparoscopy pyeloplasty retroperitoneal hematoma cases, 2 in infants (< 3 months) with UPJO. incision infection cases, 2 double J tube PATIENTS & METHODS: From Jan 2010 to shifting cases, 1 anastomotic leakage case Dec 2013, 40 infants patients (54.45±5.72 and 2 0.5U erythrocyte concentrated days, from 20 to 88 days) with UPJO cases. Compared with the long incision of were treated with transperitoneal abdominal wall (8.5±1.3cm) in open group, laparoscopy pyeloplasty, and 22 infants 3 5-mm trocars were much more artistic patients (57.61±6.32 days, from 22 to for infants in the laparoscopy group. After 90 days) with UPJO were treated with a follow-up period from 6 months to 2 open pyeloplasty. Three-hole method years, all the infants patients recovered was used in laparoscopy pyeloplasty well and no cases in the two groups had and 3 5-mm trocars were punctured at obstruction of ureter or vesicoureteral umbilical, middle point between umbilical reflux by the imaging examination such as and anterior superior iliac spine and the magnetic resonance hydrography (MRU) intersection point of costal margin at or computed tomography hydrography midclavicular line respectively. Ultrasonic (CTU). scalpel was used to discover the renal CONCLUSION: As a well minimally pelvis. Suspension with silk thread of renal invasive surgical method, transperitoneal pelvis was applied for a better suture and laparoscopic-assisted pyeloplasty a easier insertion of double J tube into the brings less injury to both order children ureteral. Double J tube was inserted easily patients and infants(< 3 months) patients with the help of a pneumoperitoneum with UPJO. According to our operative puncturing through the abdominal

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Oral Abstracts CONTINUED experience and the analysis of clinical The mean hospital stay was 27 hours. data, this operative method is safe, The overall Vesicoureteal reflux reliable and effective in the treatment resolution was 96.5%. Three renal units of UPJO of infants(< 3 months) patients, were downgraded to unilateral grade 2 which should be generalized on the basis Vesicoureteral reflux were considered of qualified endoscopic techniques. to have failure treatment. Two of them underwent subsequent sub-ureteral S043: LAPAROSCOPIC EXTRAVESICAL injection therapy and one underwent redo URETERAL REIMPLANTATION open procedure. The follow-up period FOLLOWING LICH GREGOIRE was 27 months. TECHNIQUE. MEDIUM-TERM PROSPECTIVE STUDY Manuel Lopez, CONCLUSION: Laparoscopic Extravesical Eduardo Perez-Etchepare, MD, François Ureteral Reimplantation following Lich- Varlet, MD, PhD, Department of Pediatric Gregoir technique is an effective procedure Surgery, University Hospital of Saint in unilateral, bilateral and Duplex Collector Etienne System with Vesicoureteral reflux and obstructive megaureter. When refluxing OBJECTIVES: to evaluate medium terms Duplex Collector System is associated results of Laparoscopic Extravesical with obstruction, and total deterioration Ureteral Reimplantation, following Lich- of upper polar function; hemi-nephro- Gregoir Technique in the treatment of ureterectomy with excision of ureterocele Vesico Ureteral Reflux and obstructive can be safely and effectively performed in megaureter. a single-stage. Laparoscopic Extravesical METHODS: Between August 2007 and Ureteral Reimplantation permits shorter November 2013, 115 renal units in 89 hospital stay, decreased postoperative patients, 113 with VUR and Two with discomfort, reduced recovery period obstructive Megaureter with deterioration with success rates similar to the open of renal function were treated by technique. Laparoscopic Extravesical Ureteral S044: ROBOTIC ASSISTED Reimplantation. 24 patients had Duplex LAPAROSCOPIC MANAGEMENT OF Collector System;in five cases were DUPLEX RENAL ANOMALY IS FEASIBLE associated to obstruction: three with AND SAFE WITH EQUAL SHORT TERM complete deterioration of upper polar SURGICAL OUTCOMES TO TRADITIONAL function.6 Patients presented recurrence PURE LAPAROSCOPIC AND OPEN of VUR after endoscopic ureteral SURGERY Daniel B. Herz, MD, Paul A. injection. Merguerian, MD, Venkata R. Jayanthi, MD, RESULTS: Laparoscopic Extravesical Seth A. Alpert, MD, Jennifer A. Smith, RN, Ureteral Reimplantation was feasible Nationwide Children’s Hospital; Children’s in all cases. Mean age was 52 month; Hospital at Dartmouth mean surgical time was 70 minutes in OBJECTIVE: The surgical management unilaterals, 144 minutes in bilateral of duplex renal anomalies is as varied Vesicoureteral reflux and 135min in as their presentation. Traditionally, open Obstructive megaureter. In one-stage: or Laparoscopic Heminephrectomy with three laparoscopic hemi-nephro- partial ureterectomy (HN), upper to ureterectomy with excision of ureterocele lower ureter ureteroureterostomy (UU), and one nephrectomy were performed. common sheath ureteroneocystostomy

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(UN), or a combination is employed in 8 and persisted in 2 children after based on renal moiety function, and/or common sheath UN. VUR developed in 10 presence or absence of vesicoureteral lower ureters after RAL upHN (Grade II-III reflux (VUR). In children, Robot Assisted in 8 and Grade IV in 2). Of these, 5 were Laparoscopy (RAL) adds value because successfully treated endoscopically, 1 with it allows renal moiety removal and/ RAL UN, and 4 resolved spontaneously. or ureteral reconstruction in situ with Of those who had RAL UU, VUR was excellent visualization and the ability to present pre-operatively in the recipient suture in a confined space. ureter in 4 (29%, Grade I-III) and all resolved spontaneously within 2 years of METHODS: IRB approved retrospective post-operative observation. A total of 4 analysis of all children with duplex (7.7%) complications occurred: ureteral renal anomalies that had robot assisted leak (1), ureteral obstruction (1), vascular laparoscopic surgery between 2008 injury to lower renal moiety (1), and port- and 2013 was performed. All children site herniation (1). There were no open had either RAL HN, RAL UU, or RAL UN conversions. Hypertension either improved based on renal moiety function, degree or was cured in 3 of 4 children with this of ureteral obstruction, and/or the pre-operative co-morbidity. presence or absence of vesicoureteral reflux. Data collection included CONCLUSIONS: RAL surgical management demographics and diagnosis at the time of duplex renal anomaly is safe and of RAL surgery, type of RAL surgical effective, and has similar outcomes and intervention, immediate RAL surgical complication rates to open and pure outcomes and complications, as well as laparoscopic surgery. However, our report renal outcomes at 2 years post-surgery. shows that RAL can be used for pelvic reconstruction in this population which, if RESULTS: A total of 55 children (57 renal more widely accepted and applied, could units) were treated. Twenty-eight (29) obviate the need for open surgery. children had RAL HN, 14 had RAL UU, and 10 had RAL UN. Forty (73%) children were S045: TRANSRENAL STENTING IN female and 15 (27%) male. Ages were 4 LAPAROSCOPIC PYELOPLASTY IN months to 14.8 years (Average = 4.2 years) INFANTS AND CHILDREN: A SAVE at the time of surgery. Diagnoses were TECHNIQUE Tobias Luithle, MD, Florian Duplex Ureterocele (n=28), Duplex Ectopic Obermayr, MD, Joerg Fuchs, MD, Ureter (n=23), and High Grade Secondary Department of Pediatric Surgery and VUR (n=4). RAL ureteral tailoring was Pediatric Urology, University Children’s required in 7 children, 4 during UU for Hospital, Tuebingen, Germany mismatched donor and recipient ureteral caliber, and 3 during common sheath UN. INTRODUCTION: Laparoscopic Of the children who had HN, the moiety dismembered pyeloplasty is increasingly removed was upper pole (upHN) in 26 becoming the standard treatment for and lower pole (lpHN) in 3, and the mean ureteropelvic junction obstruction in differential function of the excised moiety infants and children. As in the open was 9% (range = 2-13%). Of the children approach various techniques for who had UU or common sheath UN, the temporary ureteral stenting have been upper moiety differential renal function proposed. We present our experience was 31% (range = 17-44%). VUR was cured with transrenal transanastomotic stenting via a transperitoneal approach.

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METHODS: A retrospective analysis was CONCLUSION: Laparoscopic transrenal performed on a consecutive series of transanastomotic stenting is safe and 161 patients (166 renal units, RU) who easy to perform. Placement under direct underwent a laparoscopic pyeloplasty vision reduces the risk of bleeding. using a transperitoneal laparoscopic Stent associated complications are low approach at our institution between and rarely requiring major secondary March 2004 and December 2013. In intervention. Stent removal without the 150 patients (155 RU) a silicon ureteral necessity of cystoscopy and therefore catheter (Dirocath®, Braun, Germany) additional anesthesia is a major advantage was used for stenting the anastomosis. compared to double-J stent placement. The catheter was fixed on a curved metal spear which was introduced S046: RETROPERITONEOSCOPIC Ravindra transabdominally via a renal calix under PYELOPLASTY IN 134 CHILDREN  laparoscopic vision and led out through Ramadwar, Dr., Bombay Hospital, Hinduja the flank. Two additional holes were cut in Hospital & Joy Hospital, Mumbai, India the catheter draining the renal pelvis. No AIM: Retroperitoneoscopic pyeloplasty was perirenal drainage was inserted routinely. performed in 134 patients since January Eleven patients were excluded (no stent 2005 to January 2014. The aim of the study (n=4), double-J-ureteral stent (n=3), was to identify all the parameters that percutaneous nephrostomy (n=4)). helped in reducing the operative time. RESULTS: 104 boys and 46 girls with a median METHOD: All patients who underwent age of 22 months (range: 1-214 months) retroperitoneoscopic pyelopasty since underwent laparoscopic transabdominal January 2005 were enrolled in the study. pyeloplasty. An aberrant lower-pole Data were collected prospectively and vessel was evident in 24 cases. Associated results were analyzed. anomalies were horseshoe kidney (n=2) and a duplex system with lower pole obstruction RESULTS: 134 patients (Age 4 weeks (n=2). Stent size was 4 French in 7, 6 French -18 years) (right side 63, left side 71) in 130 and 8 French in 17 RU. Stents were underwent retroperitoneoscopic removed without anesthesia after 7 days Anderson Hynes pyeloplasty since January (median, range: 3-21 days) 2005 to January 2014. Mean operative time was 122 minutes. A balloon was Stent associated complications occurred used to open retroperitoneal space in in 11 patients (7,3 %). The stent dislocated 87 procedures and open insertion of in 6 RU. 2 Stents were repositioned, trocar with CO2 insufflation was used a percutaneous nephrostomy was to open the retroperitoneal space in 47 introduced in1 and a double-J stent in procedures. Movement of kidney and 2 RU, respectively. Stent obstruction pelvis during ventilation added to the occurred in 3 RU, and was treated difficulty in suturing in 81 procedures. conservatively in 2 RU and with early Addition of trans-abdominal suture removal and double-J stent placement on pelvis in 53 procedures reduced the in one. Leakage along the catheter in movements and mean operative time one RU and percutaneous leakage after decreased significantly (93 min vs. 158 stent removal in two RU was treated min). 12 patients had UTI preoperatively conservatively. Transrenal stenting was and 4 patients had preoperative insertion not associated with relevant blood loss. of DJ stent. In 14 patients cystoscopy,

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Oral Abstracts CONTINUED retrograde pyelography and insertion to intraoperative misinterpretation of of stent or guide wire was performed anatomic findings. just before pyeloplasty. Mean operative AIM: To evaluate sensitivity and specifity time for these patients with preoperative of CD with regard to intraoperative stenting was 168 minutes. Antegrade findings in children with suspected LCV stenting was performed in 84 patients causing PUJO. and pelvi-ureteric stent was kept in 32 infants below 6 months of age. METHODS: Between November, 2012, to Pyeloplasty sutures were interrupted in February, 2014, 13 consecutive children (5 initial 16 procedures and continuous in 116 male, 8 female; mean age 9.8 years, range procedures. Mean operative time reduced 2 - 17 years) with unilateral PUJO ( 9 left, significantly (189 min vs. 100 min). 4 right-sided) underwent laparoscopic transabdominal dismembered pyeloplasty CONCLUSION: Open insertion of and were prospectively studied. All had trocar and CO 2 insufflation opens usual criteria with need for surgery. the retroperitoneal space adequately Preoperative CD was applied to investigate in children. There is no need to use a the presence of LCV and films were linked balloon for this purpose. Placement of to the surgeon for a detailed briefing. trans-abdominal stay suture, ante-grade stenting and continuous suturing reduced RESULTS: CD was correct in 12 out of the operative timings significantly. 13 (92%). LCV was found at CD in 9 and in 10 cases at surgery, whereas 3 cases S047: PREOPERATIVE COLOUR without LCV were proven to be absent DOPPLER ULTRASOUND IN CHILDREN intraoperatively. A very thin LCV was WITH PELVIURETERIC JUNCTION found at surgery in 1 case but not at CD. OBSTRUCTION AND SUSPECTED LOWER CD had a sensitivity, specifity, positive POLE CROSSING VESSELS – VALUE predictive, and negative predictive FOR THE LAPAROSCOPIC SURGEON? value of 90%, 100%, 100% and 75%, Nagoud Schukfeh, Martin Metzelder, Paul  respectively. Attending preoperative Andreas, Udo Vester, Division of Pediatric CD by the surgeon was extremely Surgery, Department of General-, helpful, due to precise one-to-one Visceral- and Transplant Surgery, transformation of ultrasonographic into University Clinic Essen, Essen, Germany intraoperative findings. and Department of Pediatric Nephrology, University Clinic Essen, Essen, Germany CONCLUSION: CD is of high value for the laparoscopic surgeon, due to high BACKGROUND: Lower pole crossing sensitivity and specifity as well as vessels (LCV) are known to be present highly accurate to detect the position in about 15 to 45% of pediatric patients of LCV and main renal vessels to avoid with pelviureteric junction obstruction misinterpretation, due to the variety of (PUJO). Colour Doppler ultrasound LCV anatomy. Thus, laparoscopic surgeons (CD) is a reliable non-invasive tool to should attend CD prior to laparoscopic identify LCV especially in older children, pyeloplasty especially in older children when hydronephrosis is symptomatic with renovascular hydronephorisis to and/or intermittent. However, the increase the patient`s safety. caliber of LCV varies as well as their position and distance differs to main renal hilar vessels, which might lead

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S048: ONE TROCAR ASSISTED 1, 23% in group 2 (p>0.05 vs G1) and 60% PYELOPLASTY IN CHILDREN Giovanni in group 3 (p<0.05 vs G1; p <0.05 vs G2). Cobellis, PhD, Fabiano Nino, MD, Carmine Mean hospital stay was 3.5 days in all Noviello, PhD, Mercedes Romano, PhD, groups. One recurrent UPJO was observed Francesco Mariscoli, MD, Lorenzo Rossi, in group 1. Cosmetic results were MD, Ascanio Martino, MD, Pediatric excellent in all patients. Surgery Unit, Academic Children’s DISCUSSION: In our experience OTAP is Hospital, Ancona a safe and effective minimally invasive INTRODUCTION: Anderson-Hynes technique, easily reproducible, with fast dismembered pyeloplasty is considered learning curve, low operative time, low the gold standard in the surgical costs and good cosmetic results. In case treatment of ureteropelvic junction of inadequate exposure of the pelvis the obstruction (UPJO) in children. Minimally procedure can be easily completed with invasive approaches have been an extension of the incision. The OTAP proposed but all presents technical could be considered the procedure of difficulties. Retroperitoneoscopic choice in early childhood. approach is limited by the small working S049: LAPAROSCOPIC WILMS’ TUMOUR space, while the laparoscopic one NEPHRECTOMY Ewan M. Brownlee, convert an extraperitoneal surgery in Fraser D. Munro, Gordon A. MacKinlay, transperitoneal. The techniques based OBE, Hamish Wallace, Royal Hospital for on the use of robots still have high costs Sick Children, Edinburgh and are not adequately widespread. Aim of the study was to evaluate the efficacy AIM OF THE STUDY: Since 2002, Wilms’ of the One Trocar Assisted Pyeloplasty tumour nephrectomies have been (OTAP) in pediatric age. performed laparoscopically in our centre where possible. We planned to review MATERIALS & METHODS: Between May the outcomes of our initial 10 years’ 2006 and June 2013 a total of52 children experience with this approach. underwent OTAP for UPJO. Patients were divided in three groups according METHODS: A retrospective review of case to age at intervention. Group 1: 30 notes and local electronic databases patients (range 1 month - 2 years; mean was performed examining all patients 9 months); Group 2: 13 patients (range undergoing laparoscopic Wilms’ tumour 2 - 6 years; mean 4,1 years); Group 3: 9 nephrectomies at a single centre from patients (range 6 - 14 years; mean age 2002 to 2011 inclusive. 11 years). Intraoperative complications, operative time, conversion rate, length MAIN RESULTS: 12 patients were identified of hospitalization, recurrence and the with median age at surgery of 43 months cosmetic results were considered. (IQR 25-47). SIOP protocol was followed with tumours initially biopsied (either RESULTS: There were no intraoperative laparoscopic-assisted or image-guided) complications. Mean operative time was then neo-adjuvant chemotherapy 127 minutes (range 85 - 213) in group 1, administered. 2 of the first 3 procedures 107 minutes (range 90 - 195) in group 2 required conversion to open procedures (p>0,05 vs G1) and 156 minutes (range due to large size of tumour preventing 95 - 215) in group 3 (p<0.05 vs G1; p <0.05 access to renal vessels. Since then, no vs G2). Conversion rate was 21% in group further conversions have been required,

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Oral Abstracts CONTINUED although one procedure required insertion of this study is to show the evolution of an extra port. Of the 10 patients in the diagnosis and treatment of this successfully undergoing laparoscopic disease in a single center and propose a resection, median operative time was 180 diagnostic and therapeutic algorithm. mins (IQR 176-210). Pathological staging MATHERIAL & METHODS: A retrospective was: Stage I – 4 patients; Stage II – 4 analysis of the medical records of patients; Stage III – 1 patient; Stage IV – 1 patients with suspected CL, assisted patient. Histology confirmed complete between December 1992 and June 2013, resection of all tumours except the was performed. Patients were divided Stage III tumour which had widespread into 2 groups, based on the inclusion of peritoneal deposits. The resected Stage nuclear magnetic cholangioresonance III tumour showed 99% necrosis and the (NMCR) and endoscopic retrograde patient responded well to further post- cholangiopancreatography (ERCP) in 2009. operative chemotherapy, not requiring any The suspicion of CL was compared with radiotherapy. The patient with Stage IV the subsequent confirmation by ERCP or Wilms had a Stage I tumour pathologically, intraoperative cholangiography (IOC) . but had pulmonary metastases which were treated successfully with RESULTS: Group 1: CL was suspected radiotherapy. One patient with a Stage in 61 patients among 443 undergoing I tumour had recurrence of disease, laparoscopic cholecystectomy (LC) presenting 9 months post-operatively (13,8%), Only 24.5% (15/61) had CL during with ascites. This renal bed and peritoneal the IOC, requiring instrumentation of the recurrence was biopsied and treated with bile duct (BD) through initial trans-cystic chemotherapy and radiotherapy, and the approach (TCA) with 9 failures. Of these, patient has now been disease free for 7 were converted to open surgery and 59 months since. All other patients are 2 were resolved by postoperative ERCP. disease-free at follow up to a median of 61 Group 2: From a total of 270 patients months (range 39-122). undergoind cholecystectomy, CL was suspected in 101. Of these, 31(30,6%) CONCLUSION: Laparoscopic approach for required instrumentation of the BD: Wilms’ tumour nephrectomy can achieve 23 preoperative ERCP (only 1 required similar results to open nephrectomy. subsequent TCA) and 9 TCA, with 4 There seems to be a learning curve for this failures, which underwent postoperative procedure although this was not reflected ERCP.There were no conversions to in a trend in operative times. All patients open surgery.Overall 69.3 to 75.5% of have disease-free survival to date. patients,in whom CL was suspected, S050: EVOLUTION OF MINIMALLY did not require any instrumentation of INVASIVE TREATMENT OF the BD.The presence of jaundice and CHOLEDOCHOLITHIASIS (CL) IN CL at ultrasonography (US), had a high PEDIATRICS. EXPERIENCE AT A SINGLE percentage of CL detected by IOC or ERCP CENTER Mauro Capparelli, MD, Horacio (60%), whereas pancreatitis and dilated Questa, MD, Maria M. Bailez, MD, bile duct (DBD) on US, only 10.8 and Garrahan Children´s Htal Buenos Aires; 22%, respectively. CRNM showed a 100% Argentina specificity and 95.8%.sensitivity . INTRODUCTION: Sequence of treatment CONCLUSIONS: 1) There is a high of CL in children is controversial. The aim percentage of spontaneous resolution

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Oral Abstracts CONTINUED of CL in pediatric patients. 69.3 to 75.5% April 2009 to September 2010, 17 cases; of patients,in whom CL was suspected, group B, from November 2010 to May did not require any instrumentation of 2012, 31 cases; group C, from June 2012 to the BD. 2) NMCR and ERCP are useful September 2013, 25 cases. All the surgical tools and, used selectively, have lowered procedure were finished by one surgeon conversion rate to open surgery in our The following factors such as average serie (0% in Group 2). 3) We propose this operative time, conversion rate, volume diagnostic and therapeutic algorithm: a) of bleeding, postoperative hospital stay, In patients with a pancreatitis background and postoperative complications were without CL or DBD in US we propose: LC analyzed among the 3 groups. without neither previous NMCR nor ERCP RESULTS: The average operative time in . b) In those presenting with jaundice group A (6.7±1.9 hours ) was longer than and CL in US we propose a NMCR. In the those of group B( 3.5±0.7 hours) and presence of CL in this study, we indicate C(3.7±0.5 hours, and all P values < 0.01) an ERCP. If it is successful, we performed respectively. And also the conversion LC without IOC. In the presence of normal rate of group A (5/17, 29.4%) was higher BD at CRNM we propose LC without CIO, than those of group B(3/31, 9.6%) and while the finding of DBD without CL in this C(2/25, 8%, all P values < 0.01). Volume study, we indicate IOC during LC. of bleeding (32.5±12.2ml) was larger S051: THE LEARNING CURVE ON than those of group B (18.5±9.4ml) THE LAPAROSCOPIC EXCISION OF and C(19.5±5.7ml, all P vales <0.05). CHOLEDOCHAL CYST WITH ROUX-EN-Y But the postoperative hospital stay or HEPATOENTEROSTOMY IN CHILDREN postoperative complications in all the 3 Jiangbin Liu, PhD, Zhibao Lv, Professor, groups were nearly same. And there were Department of Pediatric Surgery, no difference between group B and group Shanghai Children’s Hospital, Shanghai C on the upper 5 factors. Jiao Tong University and Department of CONCLUSION: The learning curve on the Pediatric Surgery, Children’s Hospital of laparoscopic cyst excision of choledochal Fudan University, Shanghai, PR China cyst with Roux-en-Y hepatoentemstomy AIMS & OBJECTIVES: To review the in children is extremely steep before 15 experience from the two major children’s cases for surgeon. After that, the average hospital of Shanghai city in China on the operative time, conversion rate and laparoscopic cyst excision with Roux-en-Y volume of bleeding declined dramatically. hepatoenterostomy for choledochal cyst in children and to establish the learning S052: PERIOPERATIVE COMPLICATIONS curve for surgeons. OF LAPAROSCOPIC CHOLEDOCHAL CYST EXCISION Zhigang Gao, MD, Qixing MATERIAL & METHODS: from April Xiong, MD, Jinfa Tou, MD, Qiang Shu, Pro, 2009 to September 2013, 73 cases of Pediatric Surgery Department choledochal cyst were performed by OBJECTIVE: To investigate perioperative laparoscopic cyst excision with Roux-en-Y complications of laparoscopic chiledochal hepatoenterostomy in Shanghai Children’s cyst excision and the hepatic-jejunum Hospital, Shanghai Jiao Tong University and Roux-en-Y anastomosis. Children’s Hospital of Fudan University2. All the patients were divided into 3 METHODS: March 2012- December groups chronologically. group A, from 2013 , 72 cases of chiledochal cyst were

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Oral Abstracts CONTINUED performed laparoscopic chiledochal cyst from postoperative bile leakage. One excision and the hepatic-jejunum Roux- case found bile from drainage. 21 days en-Y anastomosis including 9 males and after surgery the bile disappeared. The 63 female cases, 55 cases of cystic type other case got abdomen pain and fever and spindle type of 17 cases. after 5 days of surgery. Ultrasound show encapsulated fluid around the liver RESULTS: 72 cases of choledochal with diameter about 10cm. Peritoneal cyst were successfully completed drainage was performed, after 3 under laparoscopic procedure, average weeks of drainage bile leakage cured operation time 3.5h (2.5-5.5 h). and the drainage tube was removed. INTRAOPERATIVE COMPLICATIONS: 1) 3) Anastomotic stenosis: Obstructive Right hepatic duct injury: one case jaundice was found in one case after suffered right hepatic duct injury from 2 weeks of cholangioenterostomy. the sharp separation process because Laparoscopic procedure found right hepatic duct adhesion to the neck cholangioenterostomy anastomotic of gallbladder. We find bile leak from the stenosis. Recholangioenterostomy right bile duct. Interrupted suture with was performed by laparoscopic 5-0 PDS-2 line repair was performed procedure.4) Pancreatitis: Pancreatitiswas directly. No postoperative bile leakage found in one case after 6 days surgery was found. 2) Hepatic duct separation: 1 , sudden abdominal pain started in case suffered hepatic duct separation. this case. Blood amylase increased The diameter of the cyst is 8cm. MRCP significantly suggesting pancreatitis. After can not show the right and lefthepatic 4 weeks nasal tubes feeding the baby duct clearly. When separate the common was cured. All 72 cases of patients were bile duct. The diameter of the left followed up for 1-19 months. No long- hepatic duct is about 1.5cm. So we take term complications were found. left hepatic duct as common bile duct CONCLUSIONS: Laparoscopic choledochal and take right hepatic duct as the neck cyst excision and hepatic-jejunal Roux- of the gallbladder. During separate the en-Y anastomosis is a complex, high-risk right side of the duct we found we make procedure, it need skilled laparoscopic a mistake. At last intraoperative two techniques. Precise intraoperative cholangioenterostomy was performed. skills help to reduce intraoperative and No postoperative bile leakage was found. postoperative complications. POSTOPERATIVE COMPLICATIONS: 1) S054: LAPAROSCOPIC SIMPLE OBLIQUE Bleeding: 2 cases suffered postoperative DUODENO-DUODENOSTOMY IN bleeding when one case had laparotomy MANAGEMENT OF CONGENITAL 8 hours after laparoscopic procedure. DUODENAL OBSTRUCTION IN CHILDREN 600ml continuous blood transfusion Tran N. Son, MD, PhD, Nguyen T. Liem, MD, can not stable the blood pressure. PhD, Hoang H. Kien, MD, National Hospital Bleeding lies the bed of cyst, continue of Paediatrics, Hanoi, Vietnam suture of cyst bed was performed and bleeding stopped. The other bleeding INTRODUCTION: The technique of case had conservative treatment after diamond-shape duodeno-duodenostomy continuous blood transfusion. This is usually recommended for surgical repair case had postoperative bleeding about of congenital duodenal obstruction (CDO). 400ml. 2) Bile leakage: 2 cases suffered The aim of this report is to present our

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Oral Abstracts CONTINUED technique of laparoscopic simple oblique (range 1 - 48 months), all the patients were duodeno-duodenostomy (LSOD) and its asymptomatic. results in management of CDO in children. CONCLUSIONS: The technique of LSOD METHODS: Medical records of patients is safe, efficacious and can be a viable with diagnosis CDO undergoing LSOD option in management of selected cases at our center from March, 2009 to of CDO in children at experienced centers. December, 2013 were reviewed. For the LSOD, one infra- or trans-umbilical S055: THREE-PORT TOTAL COLECTOMY 5mm port for camera and two 3mm AND SUBSEQUENT ROBOTIC ports for instruments were used. After PROCTECTOMY WITH ILEAL POUCH- mobilization of the distant part of the ANAL ANASTOMOSIS IN FULMINANT duodenum, two 5.0 PDS seromuscular ULCERATIVE COLITIS. INITIAL G. Elmo, MD, T. Ferraris, MD, sutures were placed on the duodenal wall EXPERIENCE  D. Liberto, MD, M. Urquizo, MD, P. Lobos, proximal and distal to the obstruction MD, F. De Badiola, MD, Pediatric Surgery and tacked to the anterior abdominal wall Hospital Italiano de Buenos Aires for traction. The lower duodenum was incised longitudinally distal to the traction SUMMARY: INTRODUCTION: Three-stage suture. The upper duodenum incision was total colectomy with ileal pouch-anal placed away from the traction suture anastomosis is indicated in patients and extended downward obliquely. The with fulminant ulcerative colitis (UC) in duodeno-duodenostomy was performed which medical treatment fails or suffer as a “simple” anastomosis. complications such as toxic megacolon or intestinal perforations due to RESULTS: 48 patients were identified (23 chemotherapy. boys, 47.9%) with median age at operation 11 days (ranged 1 day – 4 years, 42 patients The purpose of this paper is to present (87.5%) were neonates). The median our initial surgical experience in pediatric weight at operation was 2600 g (ranged patients with fulminant UC which 1600g to 10kg). . Type I atresia, annular underwent total laparoscopic colectomy pancreas and type III atresia were found in using three ports only and subsequent 31 (64.5%), 9 (18.8%) and 8 (16.7%) patients, robotic proctectomy. respectively. The median operative time MATERIALS & METHODS: We analyze was 90 minutes (ranged 60 - 150 minutes). pediatric patients with UC treated There was no conversion to open surgery, at Hospital Italiano de Buenos Aires no anastomotic leakage or stenosis. The Gastroenterology service since January median time from the operation to initial 2010 until December 2013. We only oral feeding was 3 days. Postoperative included patients tested and treated complications were documented in because of fulminant UC. 2 patients (4.2%): severe ventilator- associated pneumonia causing death at Three stage surgery correspond to: postoperative day17 in one patient with Three-port total colectomy as the first bodyweight 1700g and gastrointestinal stage, robotic proctectomy as the second, bleeding due to decreased prothrombin and finally ileostomy closure. treated successfully in another. All other RESULTS: All five patients underwent patients were discharge in good health with total colectomy with only three ports a median postoperative hospital stay of 7 without intraoperatory complications days. At a median follow-up of 18 months or conversion to laparotomy. One

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Oral Abstracts CONTINUED patient was explored because of partial This prospective study was done to bowel obstruction, with enterolysis and analyze the incidence of metachronous subsequent full recovering. inguinal hernia (MIH) after identification of Every patient improved and normalized an asymptomatic open anulus inguinalis laboratory variables leaving corticosteroid profundus (OAIP) during laparoscopic therapy. pyloromyotomy (LP) in infants. We deliberately used this term instead of Three of this patients underwent robotic patent processus vaginalis (PPV) as the proctectomy with ileal pouch-anal latter implies intraoperative information anastomosis without complications and about length, width and diameter of the good postoperative evolution. The other processus vaginalis. This term suggests two patients are waiting for surgery. that MIH is almost obligate. Instead, Following time is an average of 17 months. this information is not provided by most They didn’t present pouchitis and present studies and exact data about MIH after approximately 5 to 8 stools per day with LP is rare. good anal continence. METHODS: We prospectively analyzed CONCLUSION: Although this is our initial the incidence of OAIP at LP and MIH in experience, we can infer that: 80 infants (68 boys, 12 girls, m:f = 5.6:1) who underwent LP at one institution Patients with fulminant UC must be between February 2007 and October hospitalized and stabilized clinically. Total 2012. The incidence of MIH after LP was laparoscopy colectomy with three ports additionally compared retrospectively and Hartmann’s closure of the rectum can between all infants who underwent LP be easily performed, reaching nutritional (92) and 141 infants who underwent open recovering of these patients. pyloromyotomy (OP) between February Once the patient is stabilized and 2004 and August 2012 at the same corticosteroid therapy is finished, robotic institution. proctectomy and J ileal pouch seems to be RESULTS: OAIP was prospectively a feasible alternative to open proctectomy evaluated and encountered in 32/80 or laparoscopic proctectomy in patients (40%) of infants (1 girl and 31 boys, Table with fulminant UC. 1). MIH after LP developed only in 8/32 S056: WHAT HAPPENS BEYOND (25%) of infants (1 girl and 7 boys) in this AN OPEN ANULUS INGUINALIS group. Retrospectively, MIH developed PROFUNDUS FOUND AT LAPAROSCOPIC in 8/92 of all LP and in 2/141 of OP, being PYLOROMYOTOMY IN INFANTS? - A more frequent (P=.016, Fisher exact test) JOURNEY INTO TERRA INCOGNITA Reza after LP. The median follow-up period was M. Vahdad, MD, Lars B. Burghardt, Matthias 22.5 months (range: 4 – 52 months) for Nissen, MD, Svenja Hardwig, MD, Ralf B. LP and 73 months (range: 6 – 108 months) Troebs, Prof., Dr., med, Tobias Klein, MD, for OP. Alexander Semaan, Thomas Boemers, CONCLUSION: OAIP during LP was a Prof., Dr., med, Grigore Cernaianu, MD, frequent finding, but only one quarter of 1Department of Pediatric Surgery, Cologne, infants with OAIP developed MIH. MIH Germany,2Department of Pediatric developed significantly more often after Surgery, Ruhr-University Bochum, LP comparing to OP. Germany,3Department of Pediatric Surgery, University Hospital Luebeck, Germany

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Oral Abstracts CONTINUED

Prognostic factors for the identification disorder of MIH after OAIP are lacking. Since it is METHOD: Six children (age 1- 5 years) a frequent finding, further standardized were selected for laparoscopic transhiatal laparoscopic parameters for the gastric pull-up. Four patients had measurement of the PPV are needed. A had oesophageal atresia with feeding system that laparoscopically quantifies gastrostomy and oesophagostomy. One a PPV and correlates with MIH remains patient patient had a caustic oesophageal to be developed. Further studies with stricture requiring dilatation every this aim are needed. Until such a system two weeks for more than one year. has been established and validated, we Sixth patient had severe dilatation of recommend that the surgeon should oesophagus with respiratory distress with record the presence of an OAIP, but aperistaltic oesophagus on manometry. not proceed with prophylactic repair of All patients underwent laparoscopic asymptomatic OAIP. transhiatal gastric pull-up. In five patients The increased incidence of MIH after LP feeding jejunostomy was also performed. compared to OP needs to be validated by In two patients oesophagectomy was further studies. performed under vision upto arch of aorta. The cervical and upper thoracic oesophagus was dissected easily from neck incision on right side. The posterior mediastinal dissection was done under vision to create adequate space for stomach. RESULTS: All children withstood the procedure very well. The mean operative time was 140 min (range 120- 190 min). Posterior mediastinal dissection was bloodless and none of the patients require blood transfusion. Postoperatively S057: LAPAROSCOPIC TRANSHIATAL five patients were electively ventilated GASTRIC PULL-UP IN 6 CHILDREN Nidhi for 24 hours and in them jejunostomy Khandelwal, Dr., Ravindra Ramadwar, Dr., feeding was commenced after 48 hours. Bombay Hospital, Mumbai, India One patient with large dilated oesophagu was extubated on table and nasogastric INTRODUCTION: Oesophageal feeding was commenced after 72 hours. replacement for oesophageal atresia and In the same child oral feeding was caustic oesophageal strictures involves commenced on 5th postoperative day and major dissection in abdomen, chest was on soft diet on 7th postoperative day. and neck. To minimise surgical trauma, Contrast study was performed on postop laparoscopic transhiatal gastric pull up day 7 in all patients. Four patients had appeared to be a good alternative. minor leak which resolved spontaneously AIM: To evaluate the feasibility and safety within 14 days of surgery. In these patients of laparoscopic transhiatal gastric pull- oral fluids were introduced on 7th day up in children with oesophageal atresia, after contrast study. Five patients were caustic oesophageal stricture and motility on full oral feeds by 15th postop day.

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Jejunostomy was removed after one MATERIALS & METHODS: Three patients, month. In one patient anastomotic one male and two females, aged 13.1, ulcer blleding occurred on 21st postop 5.7 and 12.9 years were respectively day. He had carotid blow out which was diagnosed with metastatic Ewing embolized. He needed thoractomy and sarcoma of the right iliac branch, revision of his gastric pull up in staged localized MPNST of the left sciatic operation. He ws on jejunstomy feeds notch and localized BECOR tumor of the for 8 months and then was successfully left hemisacrum. All three underwent weaned of to oral feeding. At follow-up neoadjuvant chemotherapy according (1-7 years) there was significant weight to leading protocols. A hemisacrectomy gain and no major feeding issues. under S2 was performed for the two female patients while no orthopedic CONCLUSION: Laparoscopic transhiatal surgery was required for the male gastric pull-up with dissection of posterior patient due to excellent local response mediastinum under vision appears to be to chemotherapy. A 54 Gy intensity- feasible and safe. modulated radiotherapy of the posterior S058: THE SMALL BOWEL IN part of the pelvis was intended for ITS HAMMOCK: HOW TO AVOID all patients either after surgery or IRRADIATION THANKS TO THE SIGMOID neoadjuvant chemotherapy. Sabine Irtan, MD, PhD, Eric Mascard, MD,  RESULTS: The laparoscopy procedure was Stephanie Bolle, MD, Laurence Brugieres, performed the same day as the orthopedic MD, PhD, Sabine Sarnacki, MD, PhD, surgery. It consisted in the fixation of Department of pediatric surgery, APHP, the sigmoid to the anterior parietal Hopital Necker, Paris, France; Sorbonne wall, the anterior transposition of the 2 Paris City University, Paris, France. ovaries and of the rectum associated to BACKGROUND: Irradiation is the a colostomy for the two female patients, cornerstone treatment of bone cancers the anterior fixation of the uterus in one of the pelvic rim, either Ewing sarcoma female patient and the dissection of left or Malignant peripheral nerve sheath iliac vessels to move them anteriorly in tumors (MPNSTs). High doses exceeding the other female patient. For the male 50 Gy may be required causing early or patient, only the fixation of the sigmoid to late damages to the surrounded organs. the anterior parietal wall was performed. The small bowel is particularly sensitive Three ports were used for each procedure, to high dose radiotherapy with functional one 10-mm optic umbilical port and two and anatomical side effects such as 5-mm working ports in the right and left malabsorption, diarrhea, stricture or flanks. Fixation was done with resorbable fistula formation. Several surgical or sutures. The loop of sigmoid was moved non-surgical methods have already been to the right, fixed to the anterior parietal described to displace the bowel out of the wall on a transversal line two centimeters radiotherapy field with various results. below the umbilicus. Stomas were placed in the right iliac fossa and complete the AIM: We hereby described the use of hammock to prevent slippage of the small laparoscopy to perform a hammock intestine in the pelvis. If needed, sutures with the sigmoid to avoid small bowel were added between the mesocolon of irradiation and following consequences. the right colon and those of the sigmoid. The post-operative course was uneventful

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Oral Abstracts CONTINUED in all patients. Stomas were closed 5 Lennard, 2 Sulama, 1 bilateral free gluteal and 7 months after completeness of the flaps. 7 were our own recurrences (4 Nuss, radiotherapy course, associated with the 3 Willital). 17 had a preschool repair and replacement of the uterus, ovaries and an asphyxiating chondrodystrophy and 21 colon. With a mean follow-up of 7, 29 and presented with severe instability. 61 were 30 months, all patients are alive without referred from German Hospitals, 85 from any recurrences or symptoms. European countries and abroad. As a rule existing Ravitch incisions were extended CONCLUSION: The laparoscopic laterally but not opened in the midline, “hammock technique” is an efficient and previous Nuss scars were used sometimes safe approach not only to protect the extended. Very extensive pleurolysis of small bowel from irradiation by using both lungs was required in 80% of the the sigmoid but also to ease and secure patients, particularly in the 28 patients the orthopedic procedure done only who had more than one previous chest by posterior approachby displacing the repair. The majority of patients required abdominal organs forward. 2 Nuss bars (12-17 inch), 11 required 3 S059: EXTENDED NUSS FOR 146 Nuss bars, 4 patients >3 bars up to 8 RECURRENCES OF PECTUS EXCAVATUM bars (3 Nuss + 5 longitudinal Willital). 37 K. Schaarschmidt, Prof., MD, S. patients required multiple sternal and Polleichtner, MD, M. Lempe, MD, F. rib osteotomies, 9 patches (surgisis). 9 Schlesinger, MD, U. Jaeschke, MD, Helios patients were referred with persisting Center of Pediatric & Adolescent Surgery pericardial effusions mostly caused by Berlin-Buch displaced Nuss bars, in 2 thoracoscopic pericardial windows had to be performed OBJECTIVE: Nuss procedure for primary in 2 pericardial cyst were resected during pectus excavatum repair in adolescents Redo Nuss. has stood the test of time. The difficult cases are recurrences after Ravitch + Nuss RESULTS: In 146 patients recurrent or or multiple previous repairs particularly resudual deformities could be corrected at an advanced age, asphyxiating to very near normal from the Nuss chondrodystrophy and floating sternum. accesses. In 7 Patients existing midline In many patients additional procedures incision were partly opened in addition like longitudinal bars, patches for closure to fix sternal deformities, fractures or of chest wall defects and lung hernias pseudoarthroses. Meanwhile in 113/146 or repair of excessive rib flare have to be patients the bars are removed: 98 rated added to standard Nuss procedure all of their result as excellent, 12 as good, 3 which we call “Extended Nuss”. as fair; 2 of the latter had a second redo Nuss (second high bar) meanwhile. METHODS & PROCEDURES: Under epidural PCA 146/1429 adolescents and CONCLUSION: In our hands Extended adults had a redo Nuss repair in Berlin- Nuss is a very reliable Method to repair Buch (age 13-54 years, mean 19.3 +/- 8.7 y; all sorts of recurrences regardless of the 129 male / 17 female. Previous Operations method previously used. It seems to be an were 53 Ravitch (14 with floating sternum), advantage to approach the sternum from 29 Nuss (11 with massive bar dislocation, a new access (laterally) after failed Ravitch 6 with secondary pectus carinatum), 17 type surgery. Very often the bilateral Ravitch+ Nuss, 11 multiple operations thoracoscopic view gives valuable clues (3-6), 13 Willital, 7 Rehbein, 4 Brunner, 3 why the previous surgery failed

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S060: 100 INFANT THORACOSCOPIC time in the thoracoscopic group was LOBECTOMIES: LEARNING CURVE AND A significantly longer: 185 minutes (103 to COMPARISON WITH OPEN LOBECTOMY 515; median: 174 - SD = 64) compared to Pablo Laje, MD, Erik G. Pearson, MD, 111 minutes (56 to 272; p < 0.001; median Tiffany Sinclair, MD, Mohamed A. 101 - SD = 42 minutes) in the open group. Rehman, MD, Allan F. Simpao, MD, David However, the operative time decreased E. Cohen, MD, Holly L. Hedrick, MD, N. markedly with increasing thoracoscopic Scott Adzick, MD, Alan W. Flake, MD, The experience from 208 to 175 minutes Children’s Hospital of Philadelphia (mean) for the first and last thirds of the thoracoscopic series, respectively. This was OBJECTIVE: To assess the learning curve despite the primary surgeon increasingly and outcomes for 100 consecutive assuming a teaching role for the second attempted infant thoracoscopic half of the series. Similarly, the conversion lobectomies by a single surgeon for rate to open lobectomy decreased with asymptomatic, prenatally diagnosed lung increasing experience from 10 to 2 during lesions and to compare the outcomes to a the first and second thirds of the series contemporaneous series of age-matched respectively, with no cases converted in patients undergoing open lobectomy. the final third (total conversion rate: 12%). METHODS: The medical records of all Three cases were converted for bleeding patients undergoing lung lobectomy and the remainder for fused fissures or between March 2005 and January abnormal lobulation. There was 1 major 2014 at a prenatal referral center were hemorrhage in the thoracoscopic group retrospectively reviewed. Included in the early in the series and no other major study were asymptomatic infants less complications in either group. There were than 4 months of age with congenital 9 minor postoperative complications in lung lesions who underwent: 1) attempted the thoracoscopic group (9%) and 9 in the thoracoscopic lobectomy, or 2) open open group (4.8%); p = 0.248. There were lobectomy. Patients older than 4 4 prolonged air leaks in the thoracoscopic months, patients undergoing emergent group (4%) and 6 in the open group (3.2%); lobectomy for symptomatic disease, p = 0.984. From an anesthetic perspective, and patients with isolated extralobar at equivalent minute ventilation volumes bronchopulmonary sequestrations were the mean end-tidal CO2 was higher in the excluded. thoracoscopic group: 51.7 mmHg versus 38.6 mmHg (p < 0.001). However, with RESULTS: The first 100 attempted appropriate ventilator management, this thoracoscopic lobectomies by a single value plateaued and did not progressively surgeon were compared with 188 open increase during the operation. lobectomies performed in asymptomatic infants younger than 4 months of age CONCLUSION: Infant thoracoscopic with prenatally diagnosed lung lesions. lobectomy is a technically challenging There were no significant differences in procedure with a noteworthy learning mean age (7.2 vs. 7.9 weeks), mean weight curve. In centers with high prenatal at surgery (4.8 vs. 5.0 kg), mean interval referral volumes, the learning curve can to chest tube removal (1.5 vs. 1.5 days), be rapidly overcome and the procedure and mean hospital stay (2.9 vs. 3.1 days) can be safely performed with comparable between the thoracoscopic and open outcomes and superior cosmetic results groups, respectively. The mean operative to open lobectomy.

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S061: TWO DECADES EXPERIENCE and efficacious technique. With proper WITH THORACOSCOPIC LOBECTOMY mentoring it is an exportable technique, IN INFANTS AND CHILDREN, which can be performed by pediatric STANDARDIZING TECHNIQUES FOR surgical trainees. The procedures are safe ADVANCED THORAOCSOCPIC SURGERY and effective even when performed in Steven Rothenberg, MD, William the first 3 months of life. Early resection Middlesworth, MD, Angela Kadenhe- avoids the risk of later infection and the chiweshe, MD, The Morgan Stanley small but real risk of malignancy. Children’s Hospital, Columbia University; The Rocky Mountain Hospital For Children S062: THORACOSCOPIC THORACIC DUCT LIGATION FOR CONGENITAL AND OBJECTIVES: This study evaluates the ACQUIRED DISEASE Bethany J. Slater, MD, safety and efficacy of thoracoscopic Steven S. Rothenberg, MD, FACS, FAAP, lobectomy in infants and children. Rocky Mountain Hospital For Children METHODS: From January 1994 to PURPOSE: Congenital and acquired November 2013, 346 patients underwent chylothorax presents a unique video assisted thoracoscopic lobe management challenge in neonates and resection at 2 institutions (RMHC/ infants. A failure of conservative therapy CHONY). All procedures were performed requires surgical ligation to prevent by or under the direct guidance of a continued fluid and protein losses. This single surgeon. Ages ranged from 1 day paper exams a 15-year experience with to 18 years and weights from 2.8 to 78 thoracoscopic ligation of the thoracic kg. Pre-operative diagnosis included duct. sequestration/congenital adenomatoid METHODS: From June 1999 to December malformation (CPAM) -306, severe 2013, 20 patients presented with chronic bronchiectasis -24, congenital lobar chylothoracies refractory to conservative emphysema -13, and malignancy -3 management. 16 patients were s/p cardiac RESULTS: 341 of 346 procedures were procedures, 1 patient was s/p TEF repair, completed thoracoscopically. Operative 1 patient was s/p ECMO for meconieum times ranged from 35 minutes to 240 aspiration, and 2 cases had congenital minutes (avg. 115 minutes). Average chylothoracies. Ages ranged from 3 operative time when a trainee was the weeks to 3 years old and weights ranged primary surgeon was 160 minutes. There from 2.6 to 12.7 Kg. All procedures were were 80 upper, 25 middle, and 241 lower performed in the right chest with 3 ports. lobe resections. There were 4 intra- Initially a 5 mm port was needed to insert operative complications (1.1%) requiring a 5mm tissue sealing device but the last conversion to an open thoracotomy. 2 procedures were performed with 3mm The post-operative complication rate ports as a 3mm sealer became available. was 3.3%, and 3 patients required re- All cases consisted of sealing of the duct exploration for a prolonged air leak. at the level of the diaphragm with the Hospital stay (LOS) ranged from 1 to 16 tissue sealer and or sutures, a mechanical days (avg 2.4) at RMHC and 4.2 at CHONY. pleurodesis, and insertion of tissue glue at In patients < 5kg and < 3 months of the level of the diaphragm. A chest tube age the average operative time was 90 was left in all cases. The chyle leak was minutes and LOS 2.1 days. CONCLUSIONS: noted to significantly diminish during the Thoracoscopic lung resection is a safe procedure in all cases.

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RESULTS: All cases were completed METHODS: We reported the data of 35 successfully thoracoscopically. Operative small babies who underwent standard time ranged from 20 to 55 minutes. There posterolateral thoracotomy (18 patients – were no intra-operative complications. Group I) and video-assisted thoracoscopic One patient with congenital bilateral surgery for diaphragmatic plication (17 chylothoracies required a second patients – Group II). The two groups were procedure with a left partial pleurectomy. compared for patients demographics, The chest tube duration post-procedure operative report and postoperative ranged from 4 to 14 days. Two patients parameters. failed the ligation and required a second RESULTS: The groups were similar procedure, a thoracoscopic pleurectomy in terms of demographics and in one, and a chemical pleurodesis in the preoperative parameters. There other. was significant difference in mean CONCLUSION: Thoracoscopic thoracic operative time between open and duct ligation is a safe and effective thoracoscopic procedure (71,67 min vs procedureeven in sick post-cardiac 51,76 min; p<<0,05). Duration of care surgery patients. The site of the leak in neonatal intensive unit and length can be identified in the majority of cases of hospital stay were significantly and tissue sealing technology appears shorter in the Group II (5,89 d vs 3,23 d; to be effective in sealing the duct. p<0,05 and 13,06 d vs 9,88 d; p<0,05). The minimally invasive nature of the Early postoperative complications procedure has hastened the request from (hemothorax, pneumothorax) were the PICU and cardiac services to perform frequent in thoracotomy group (16,67% the operative to avoid the often chronic vs 0%; p=0,229). Rate of the reccurences and debilitating fluid and protein losses was dominated in the thoracotomy group associated with a major chyle leak. (11,11% vs 0%; p=0,486). S063: COMPARISON OF THORACOSCOPIC CONCLUSION: Thoracoscopic plication of AND OPEN DIAPHRAGMATIC PLICATION the diaphragm in infants of the first three IN NEONATES AND INFANTS Yury months of the life demonstrated results Kozlov, MD, Vladimir Novozhilov, MD, better than open surgery. Department of Neonatal Surgery, Municipal Pediatric Hospital, Irkutsk, S064: THORACOSCOPIC LEFT CARDIAC Russia; Department of Pediatric Surgery, SYMPATHETIC DENERVATION Irkutsk State Medical Academy of IN CHILDREN WITH MALIGNANT Ryan Antiel, Continuing Education (IGMAPO), Irkutsk, ARRHYTHMIA SYNDROMES  MD, Aodhnait Fahy, BMBCh, PhD, J. Martijn Russia Bos, MD, PhD, Abdalla Zarroug, MD, BACKGROUND: Thoracoscopic plication Michael Ackerman, MD, PhD, Christopher of the diaphragm is an alternative Moir, MD, Mayo Clinic to conventional surgical treatment BACKGROUND: Long QT syndrome (LQTS) of diaphragmatic evisceration via and catecholaminergic polymorphic thoracotomy in neonates and infants. ventricular tachycardia (CPVT) can lead The aim of this study is to compare of to ventricular arrhythmias and sudden these two groups of patients for the last death. Video-assisted thoracoscopic 11 years. left cardiac sympathetic denervation

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(LCSD) surgery provides another viewed as curative, prophylactic LCSD treatment option for patients with either offers a safe, minimally invasive pharmacologic therapy resistance/ treatment option for patients with intolerance or those with a particularly sudden-death-predisposing conditions. severe arrhythmic phenotype. Failure to recognize and remove anatomic variations of the sympathetic chain could METHODS: Retrospective evaluation of all result in a suboptimal denervation. pediatric patients who underwent LCSD surgery at our institution between January S065: DIAPHRAGMATIC EVENTRATION 2005 and May 2013. IN CHILDREN; LAPAROSCOPY VERSUS THORACOSCOPIC PLICATION Go Miyano, RESULTS: 79 patients (37 female, MD, Masaya Yamoto, MD, Masakatsu mean age 9.8 years) underwent LCSD; Kaneshiro, MD, Hiromu Miyake, MD, 77 patients (97.5%) underwent a Keiichi Morita, MD, Hiroshi Nouso, MD, thoracoscopic approach, while 2 patients Manabu Okawada, MD, Hiroyuki Koga, (2.5%) underwent an open approach. MD, Geoffrey J Lane, MD, Koji Fukumoto, LCSD was performed on 14 patients (18%) MD, Atsuyuki Yamataka, MD, Naoto for high-risk LQTS, 33 (42%) required Urushihara, MD, Department of Pediatric additional protection, 19 (24%) for beta- Surgery, Shizuoka Children’s Hospital. blocker intolerance, and 13 (16%) for a Department of Pediatric General & break through cardiac event. Sixty-two Urogenital Surgery, Juntendo University of percent of these patients (49/79) were Medicine. classified clinically as high risk of fatal arrhythmias. Pathology confirmed AIM: To determine what is the most successful removal of sympathetic appropriate minimally invasive surgical chain in all cases. Anatomical chain approach for performing diaphragmatic abnormalities were noted in 31 patients plication; thoracoscopy or laparoscopy. (39%), with split trunk or bifid chain being MATERIALS & METHODS: We the most commonly identified variant. retrospectively reviewed the medical The average operation time was 48.6 records of children diagnosed with ± 21 minutes. One thoracoscopic case congenital diaphragmatic eventration was converted to an open approach at Shizuoka Children’s Hospital and due to hemorrhage. Thirty-five Juntendo University Hospital between patients (44%) had a radiographically 2007 and 2012. Thoracoscopic plication detected, hemodynamically insignificant (TP) is performed under general pneumothorax post-LCSD. Only 5 (6%) anesthesia using single lung ventilation patients had a pneumothorax that with three 5mm ports; pneumothorax required chest tube placement. There was is established at a pressure of 4mmHg, no significant difference noted between and plication is performed using the average preoperative QTc value (490 interrupted 4-0 nonabsorbable sutures. ± 68 ms) and postoperative QTc values Laparoscopic plication (LP) is performed (478 ± 56 ms). The average time from with three or four 5mm trocars with operation to dismissal was 2.6 days (range pneumoperitoneum at a pressure of 1-17 days). 8mmHg; plication is performed with 4-0 CONCLUSION: We present the largest nonabsorbable sutures, and the initial single center series of pediatric patients line of plication is sutured to the anterior who underwent LCSD. Although not abdominal wall for stability. Choice

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Oral Abstracts CONTINUED of procedure, whether laparoscopic CONCLUSION: Both TP and LP appear to or thoracoscopic was based on each be safe and beneficial for treating small operating surgeons’ preference. children with diaphragmatic eventration. Although we found a statistically higher RESULTS: We treated 20 cases of incidence of recurrence of eventration diaphragmatic eventration by LP (n=13) after LP, there is no consensus about and TP (n=7). Etiology in LP was phrenic the role of TP for treating eventration in nerve injury secondary to cardiac surgery patients who need further cardiac surgery. (n=9) and mediastinal tumor resection (n=2), and congenital muscular deficiency S066: LEARNING CURVE ANALYSIS of the diaphragm (n=2). Etiology in TP IN PEDIATRIC SURGERY USING THE was phrenic nerve injury secondary to CUMULATIVE SUM (CUSUM) METHOD – cardiac surgery (n=1) and congenital A STATISTICAL PRIMER AND CLINICAL muscular deficiency of the diaphragm EXAMPLE Thomas P. Cundy, Nicholas E. (n=6). In LP, eventration was left-sided Gattas, Alan White, Guang-Zhong Yang, in 9 cases, right-sided in 2 cases, and Ara Darzi, Azad Najmaldin, Imperial bilateral in 2 cases. In TP, eventration was College London, UK, Leeds General left-sided in 4 cases, and right-sided in Infirmary, UK. 3 cases. Respiratory distress developed BACKGROUND: Cumulative sum (CUSUM) in all cases and preoperative ventilator analysis is recognized as a preferred support was required in 6 LP cases and 3 statistical method for evaluating TP cases. Mean age at the time of surgery outcomes following introduction was 18.3 months (range: 0 – 45) in LP and of any newly implemented surgical 25.1 months (range: 0 – 75) in TP. Mean technique or technology, and particularly weight at the time of surgery was 8.0kg for monitoring individual surgeons’ (range: 2.7 – 15.9) in LP and 9.7kg (range: performance. Despite its ostensive 2.2 – 27) in TP. Mean operating time was virtues, the CUSUM method remains 155.6 minutes (range: 90 - 290) in LP and under-utilized in the surgical literature in 167.0 minutes (range: 122 – 303) in TP general, and is described in only a small (p=NS). Mean intraoperative end-tidal number of publications within the field CO2 was 41.9mmHg (range: 35 – 52) in of pediatric surgery. This study aims to LP and 36.9mmHg (range: 33 - 41) in TP introduce the CUSUM analysis technique (p=.01). One TP case required conversion and apply this statistical method to to thoracotomy (p=NS). Mean duration evaluate the learning curve for pediatric of postoperative ventilator support robot-assisted laparoscopic pyeloplasty was 1.2 days (range: 0 - 5) in LP and 1.3 (RP). days (range: 0 - 5) in TP (p=NS). Mean time taken to recommence feeding METHODS: Intra-operative and post- postoperatively was 1.6 days (range: 1 - operative clinical data were prospectively 4) in LP and 1.6 days (range: 1 - 4) in TP recorded for consecutive pediatric RP (p=NS). Atelectasis occurred in 1 case in cases performed by a single-surgeon each of LP and TP (p=NS) and while there (ASN) between March 2006 and October were 6 cases of recurrence in LP, there 2013. CUSUM charts and tests were were none in TP (p=.04). Mean duration of generated to quantitatively investigate follow-up, 2.7 years for LP and 2.4 years the learning curve for set-up time, for TP, were not statistically different. docking time, console time, operating time, total operating room time, and post-

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Oral Abstracts CONTINUED operative complications. Conversions were attributed to surgical assistant and avoidable operating room delay were inexperience or error (39%), equipment separately evaluated with respect to case unavailability or malfunction (29%), experience. Comparisons between case nursing scrub staff inexperience or error experience and time-based outcomes (22%), anesthesia issues (7%), and robot were assessed using the Student’s t-test malfunction (3%). There was no significant and one-way ANOVA for bi-phasic and difference between case experience and multi-phasic learning curves respectively. avoidable delay (P = 0.48). Comparison between case experience CONCLUSIONS: The CUSUM method and complication frequency was assessed has a valuable role for learning curve using the Kruskal-Wallis test. evaluation and outcome quality RESULTS: A total of 90 RP cases were monitoring in pediatric surgery. In evaluated. The youngest patient in applying this statistical technique to the the series was 1 month of age, and the largest reported single-surgeon series of smallest patient weighed 4.1 kilograms. pediatric RP, we demonstrate numerous The median duration of follow up was distinctly shaped learning curves and 3.9 years (range 0.6 – 7.9 years). Multi- well-defined learning phase transition phasic learning curves were observed for points. set-up and docking time, and bi-phasic learning curves for all other operating S067: MAN VS. MACHINE: A room time variables. The learning curve COMPARISON OF ROBOTIC-ASSISTED VS. transitioned beyond the learning phase at LAPAROSCOPIC SLEEVE GASTRECTOMY cases 10, 15, 42, 57, and 58 for set-up time, IN SEVERELY OBESE ADOLESCENTS Victoria K. Pepper, MD, Terrence M. Rager, docking time, console time, operating  MD, MS, Karen A. Diefenbach, MD, Wei time, and total operating room time Wang, MS, MAS, Mehul V. Raval, MD, MS, respectively. All comparisons of mean Steven Teich, MD, Ihuoma Eneli, MD, Marc operating times between the learning P. Michalsky, MD, Nationwide Children’s phase and subsequent phases were Hospital statistically significant (P = <0.001 – 0.01). No significant difference was observed PURPOSE: Coupled with the rising between case experience and frequency prevalence of childhood obesity, the of post-operative complications (P concomitant increase in obesity- = 0.125), although the CUSUM chart related comorbid diseases, including demonstrated a directional change cardiovascular disease, type 2 diabetes, in slope for the last 12 cases in which dyslipidemia, obstructive sleep apnea there were high proportions of more and hypertension, poses new challenges complicated re-do cases and patients for both the current and future health < 6 months of age. Two cases were care systems. While accumulating converted to open procedures (2.2%, evidence demonstrates the safety and Cases 8 and 86). Three cases required efficacy of weight loss surgery in the repeat procedures for PUJO recurrence treatment of severely obese adolescents, (3.4%, Cases 28, 52 and 79). We regard the application of operative robotic the overall success rate of this series as technology has not been explored in 96.7%. Avoidable delay was recorded in this emerging surgical population. The 53% of cases with mean delay time of aim of this study was to determine the 26.6 ± 12.3 minutes. The causes of delay safety and efficacy of robotic-assisted

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Oral Abstracts CONTINUED laparoscopic sleeve gastrectomy in the greater ($41,006 (ROB) vs. $31,824 (LAP), treatment of severe adolescent obesity. In p=0.0016). On initial analysis of the total addition, we compared 30-day outcomes hospital charges, the robotic cohort and associated total operative and was less compared to the laparoscopic hospital charges among robotic-assisted group ($57,836 (ROB) vs. $64,541 (LAP), versus laparoscopic vertical sleeve p=0.0366). Following the exclusion of gastrectomy at the same institution. outliers however, (n=3 LAP, n=0 ROB), total hospital charges in the robotic group METHODS: A retrospective analysis were higher compared to the laparoscopic of 14 consecutive robotic (ROB) and group ($57,836 (ROB) vs. $47,587 (LAP), 14 consecutive laparoscopic (LAP) p=0.0004). adolescent patients undergoing sleeve gastrectomy by one surgeon at a single institution was conducted. Data collection included age, gender, body mass index (BMI), ethnicity, obesity- related comorbidities, hospital length of stay (LOS), operative time, post- operative complications and 30-day clinical outcomes and readmission rates. The total operative and hospital charges were also examined. Subjects with a LOS greater than seven days were considered outliers for the purpose of analysis. A CONCLUSIONS: Robotic-assisted sleeve comparative analysis was performed gastrectomy is both safe and efficacious using nonparametric Wilcoxon two- within the adolescent population and sample test or t-test as appropriate. demonstrates results similar to the RESULTS: Analysis between groups laparoscopic approach. The charges for demonstrated no difference in age, sleeve gastrectomy are currently higher gender, BMI, ethnicity, and associated when performed using robotic assistance. comorbidities. In addition, there This difference appears to be driven was no difference in post-operative almost entirely by operative charges, complications, 30-day readmission but may be partially offset by shorter rates (n=1 LAP, n=1 ROB), or weight loss post-operative length of stay. Additional between groups. While the operative prospective studies are warranted. time was significantly longer within the S068: INTERNATIONAL ATTITUDES OF robotic group (ROB 136 minutes vs. LAP EARLY ADOPTERS TO CURRENT AND 99 minutes, p = 0.0006), the LOS was FUTURE ROBOTIC TECHNOLOGIES IN significantly less on initial analysis (ROB PEDIATRIC SURGERY Thomas P. Cundy, 67.5 hours vs. LAP 115.1 hours, p = 0.0094). Hani J. Marcus, Archie Hughes-Hallett, Following exclusion of outliers (n=3 LAP, Azad Najmaldin, Guang-Zhong Yang, Ara n=0 ROB), the reduction in hospital LOS Darzi, Imperial College London still approached statistical significance (ROB 67.5 vs. LAP 76.1 hours, p = 0.052). BACKGROUND: Perceptions toward Analysis of the operative charges for surgical innovations are critical to the the robotic group were significantly social processes that influence an individual’s innovation-decision process

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Oral Abstracts CONTINUED and drive the technology’s overall rate In comparing responses between expert of adoption. Cross-sectional surveys and non-expert sub groups, significant are therefore important tools for differences were found only for the understanding and tracing the diffusion feature of motion scaling with experts of an innovation such as robotic surgery. being less agreeable that this was of This focused survey study aims to benefit (P = 0.008). The most highly rated capture international attitudes of early limitations were capital outlay expense, adopter pediatric surgeons to current instrument size, and consumables/ and future robotic technologies in order maintenance expenses. Statistically to 1) examine what specific features are significant differences in responses driving its appeal and enthusiasm, 2) to between expert and non-expert groups explore attitudes toward limiting factors were observed only for haptic feedback to adoption that are acting as barriers to loss (P = 0.023), with experts being less diffusion, and 3) to investigate opinions agreeable that this was a limitation. toward future robotic technologies for The most preferred instrument and pediatric surgery and the detailed needs scope diameter sizes were 3mm and of this technology end-user community. 5mm respectively. The majority of respondents (51%) felt a price of METHODS: An electronic survey was €500,000 - €1.0 million was reasonable distributed to pediatric surgeons with for a new robotic system. When asked, “is personal experience or exposure there is a future role for robot-assisted in robotic surgery. The survey was minimally invasive surgery in children?”, distributed over one calendar month 72% (34/47) responded “definitely”, 26% between June and July 2013. Surveys (12/47) responded “probably”. Future were circulated in the following three technologies that respondents were settings; 1) personal approach of most interested in were microbots, recognized experts attending the 22nd image guidance, and flexible snake IPEG Annual Congress, 2) delegates and robots (mean aggregated 5-point level faculty attending the Inaugural European of interest Likert scale scores 4.43 ± 0.62, Paediatric Robotic Surgery Workshop at 4.30 ± 0.75, and 4.30 ± 0.72 respectively). the 6th Hamlyn Symposium on Medical Robotics, and 3) personal email invitation CONCLUSIONS: Existing features of to corresponding authors of relevant putative benefit and limitation in robotic publications in the field identified surgery are perceived with widely varied during a recent systematic review. weightings. Insight provided by these Participants were classified as experts responses will help to inform relevant or non-experts for further sub-group clinical, engineering, and industry groups analysis. Coded Likert scale responses such that unambiguous goals and are analyzed using the Friedman test or priorities may be assigned for the future. Mann-Whitney test. In general, the early adopter cohort of pediatric surgeons sampled seem RESULTS: A total of 48 responses were most receptive towards future robotic received (22 experts, 26 non-experts), technology that is smaller, less expensive, with 14 countries represented. The more intelligent and flexible. most highly rated benefits of robot- assistance were wristed instruments, stereoscopic vision, and magnified view.

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S069: LAPAROSCOPIC SLEEVE CONCLUSIONS: Applying a standardized GASTRECTOMY IN CHILDREN AND clinical pathway in LSG for pediatric ADOLESCENTS: THE TECHNIQUE AND patients results in safe and effective THE STANDARDIZED PERI-OPERATIVE outcomes with low complication rates, CLINICAL PATHWAY Aayed R. Alqahtani, maximum co-morbidity resolution, and MD, FRCSC, FACS, Mohamed O. Elahmedi, minimum morbidity as well as improved MD, Department of Surgery and Obesity follow-up compliance. Chair, King Saud University S070: COMORBIDITY RESOLUTION BACKGROUND: In the presence of IN MORBIDLY OBESE CHILDREN AND growing concerns about bariatric surgery ADOLESCENTS UNDERGOING SLEEVE in children and adolescents, knowledge GASTRECTOMY Aayed R. Alqahtani, MD, regarding peri-operative management FRCSC, FACS, Mohamed O. Elahmedi, and standardized care are lacking. This MD, Awadh R. Al Qahtani, MD, FRCSC, study establishes a pediatric bariatric Department of Surgery and Obesity Chair, surgery clinical pathway, utilizing our King Saud University current largest-to-date experience in BACKGROUND: Bariatric surgery is Laparoscopic Sleeve Gastrectomy (LSG) in becoming important for the reversal this age group. of co-morbidities in children and METHODS: This study reviews the adolescents. We previously reported details of the clinical pathway including the safety and efficacy of laparoscopic preoperative workup and planning, sleeve gastrectomy (LSG) in the pediatric intraoperative and in-hospital population. However, evidence pertaining management, and postoperative care and to the effect of LSG on co-morbidities in follow-up. Results attained by patients this age group is scarce. on whom this protocol was applied were OBJECTIVE: To assess the remission reported and improvement of co-morbidities RESULTS: Up to December 2013, (dyslipidemia, hypertension, diabetes, and 273 patients underwent LSG (50.4% obstructive sleep apnea (OSA)) after LSG females) with standardized care. Mean in children and adolescents. age was 14.4 ± 4.0 years (Range: 5 to SETTING: Data extracted from King 21 years). Median preoperative BMI Saud University Obesity Chair Research (interquartile range) was 46.5 (41.56 – Database for all pediatric patients under 52.63). Median excess weight loss at 1, the age of 21 years who underwent LSG 2, and 3 postoperative years was 61.7%, between March 2008 and December 2013. 62.8%, and 68.9% respectively. There were minor complications in 9 patients METHODS: Anthropometric changes, whom were all managed conservatively, complications, remission and improvement and there were no mortalities, leaks or in comorbidities were assessed over reoperations. At 3 postoperative years, 3 years. OSA was diagnosed using the compliance to follow-up dropped to Pediatric Sleep Questionnaire (PSQ) and 22%. Applying the protocol increased polysomnography. Diabetes, prediabetes, the compliance rate to 73.6%, bringing hypertension, prehypertension and the overall compliance during the study dyslipidemia were assessed using standard period to 90.3%. pediatric-specific definitions.

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RESULTS: The review yielded 273 S072: EVALUATION OF THE SAFETY patients. 94 patients were prepubertal OF LAPAROSCOPIC GASTROSTOMY IN (5-12 years of age, mean: 9.8 ± 2.3), 139 PEDIATRIC PATIENTS WITH HYPOPLASTIC adolescents (13-17 years of age, mean: LEFT HEART SYNDROME USING 15.4 ± 1.7), and 40 were young adults INTRAOPERATIVE TRANSESOPHAGEAL (18-21 years of age, mean: 19.1 ± 0.8). ECHOCARDIOGRAPHY Hanna Alemayehu, Overall mean age was 14.4 ± 4.0 years MD, E. Marty Knott, DO, Jason D. Fraser, (range: 4.94 – 20.99), and 50.4 % were MD, William B. Drake, MD, Shawn D. St. females. Mean Body Mass Index (BMI) Peter, MD, Kathy M. Perryman, MD, David and BMI z-score were 48.2 ± 10.1 kg/m2 Juang, MD, Children’s Mercy Hospital and 2.99 ± 0.35 respectively. Mean BMI z-score at 1, 2 and 3 years postoperative INTRODUCTION: Patients with single was 2.01 ± 0.87, 2.00 ± 1.1, and 1.65 ± ventricle physiology (SVP), specifically, 0.65, respectively with no significant hypoplastic left heart syndrome (HLHS) difference observed across age groups. frequently need long-term enteral Mean preoperative height was 158.0 ± access, however they are at an extremely 15.1 cm, and at one, two, and three years high operative risk. Nothing has been postoperative it was 160.3 ± 13.5, 161.4 published on the physiologic impact on SV ± 14.1, and 163.2 ± 11.0, respectively. function during laparoscopy in this patient The highest height gain was observed population. Therefore, we performed in prepubertal children (11.6 ± 5.5 cm). intraoperative echocardiography (TEE) All patients at different age groups to study the physiologic effects of experienced normal growth velocity laparoscopic surgery in these patients. between the 3rd and 97th centile for METHODS: After IRB approval patients height. Within two years of follow-up, with SVP undergoing laparoscopic 90.3% of comorbidities were in remission gastrostomy were studied with or improved, 64.9% of which were within intraoperative TEE. Patients were the first three months postoperatively. separated into those with HLHS and No further improvement or remission others with SVP. Data is reported as mean was observed beyond two years, and +/- standard deviation. Student’s T-test there was no recurrence up to 3-years in was used for continuous variables. those patients who were seen in follow- up. The lost to follow-up in each of the RESULTS: From 8/2011 – 2/2013 a total three years was 4.2%, 7.6%, and 15.3% of 11 patients with SVP underwent respectively. laparoscopic gastrostomy, including 6 with HLHS. One of the 6 HLHS and CONCLUSIONS: LSG performed on 1 of the SVP underwent concurrent children and adolescents results in fundoplication. All patients were post- remission or improvement of more than first stage palliation. Average follow-up 90% of comorbidities within 2 years after was 335 +/- 163 days. There was no 30 day bariatric surgery, with few complications, mortality. TEE data is in found in Table 1. no mortality and normal growth. Depression in fractional shortening was found to be statistically significant in HLHS during insufflation( P= 0.03). CONCLUSIONS: There was a statistically significant depression in cardiac function

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Oral Abstracts CONTINUED in children with HLHS with initiation of suture. Patient demographics were pneumoperitoneum, which resolves collected and outcomes compared with desufflation. Overall, the children including operation time, length of stay tolerated pneumoperitoneum. TEE allows and complication rate. Groups were for real-time assessment of ventricular compared using independent t test or function and volume and may improve Mann Whitney test as appropriate with safety during longer procedures. a p value <0.05 deemed significant. 95% confidence intervals (CIs) are given. MAIN RESULTS: 103 patients (23F: 80M) underwent LH over four years compared to 151 (25F:126M) OH in the first two years. Median age in the LH group was 0.56 years (range 0.04 to 14.7) compared to 0.52 years (range 0.04 to 13.47) in the OH group (p=0.81). The median weight in the LH group was 7.8 kilograms (2-58.2) compared to 7.6 kilograms (2.06-48.4) in the OH group (p=0.84). In the OH group there were 8 bilateral herniae and 143 unilateral of which 3 had contralateral explorations. In the LH group the intended operation was bilateral in 18 (17.4%) and 85 were clinically unilateral but at operation a contralateral patent processus vaginalis was repaired in26 i.e. S073: A COMPARATIVE STUDY OF 30.5%. The median operative time was 50.5 OUTCOME OF SIMPLE PURSE STRING minutes (range 20-95 minutes) in the LH SUTURE LAPAROSCOPIC HERNIA REPAIR group and 20 minutes (range 10-90) in the IN CHILDREN Mairi Steven, Miss, Stephen OH cohort (p<0.0001). Same day discharge Bell, Dr., Peter Carson, Dr., Rebecca Ward, was possible in 56 % who had LH and in 33% Dr., Merrill McHoney, Mr., Royal Hospital who had OH (p=0.0002). No intraoperative for Sick Children, Edinburgh, UK complications were encountered during LH AIM OF THE STUDY: To compare surgical and the procedure was well-tolerated. The outcomes for a simple purse string comparative post-operative complications method of laparoscopicinguinalhernia are shown in the table. repair (LH), with a traditional open inguinal hernia repair (OH) in children in a single centre. METHODS: Following institutional ethical approval, a retrospective review of all children undergoing LH from January 2010 to December 2013 was compared to a historic cohort of all OH between January 2010 and December 2011. LH was performed by a simple purse string technique using non-absorbable braided

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CONCLUSION: LH yields similar results were recorded as were co-morbid to OH, however, the operation time is conditions and complications. significantly longer. All complication RESULTS: Mean pre-operative weight rates were statistically similar on balance. and BMI were 139.0 kg and 49.2 kg/ The differencein metachronous hernia m2 , respectively, in Group 1, and rates is tending to significance owing to 154.0kg and 55.2 kg/m2 in Group 2 (p the concurrent detection and repair of a = .104). All procedures were completed contralateral patent processus vaginalis laparoscopically without intraoperative at laparoscopy. complication. Mean operating time was S074: VERTICAL SLEEVE GASTRECTOMY: 128 minutes in Group 1 and 197 minutes PRIMARY VERSUS REVISIONAL WEIGHT in Group 2 (p < .0001). One patient in LOSS SURGERY IN ADOLESCENTS AND each group underwent laparoscopic YOUNG ADULTS Jeffrey Zitsman, MD, cholecystectomy concurrently. One Melissa Bagloo, MD, Beth Schrope, MD, patient in each group stayed in the PhD, Aaron Roth, MD, Miguel Silva, MD, hospital an additional day for pain control. Mary DiGiorgi, PhD, Marc Bessler, MD, No patient experienced significant Columbia University Medical Center vomiting or abdominal pain in follow- up of 2-36 months. One patient (Group INTRODUCTION: Laparoscopic vertical 1) experienced mesenteric venous sleeve gastrectomy (VSG) is becoming thrombosis in the second week post-op. the preferred weight loss operation for BMI decreased an average of 10.0+4.1 morbidly obese adolescents and young kg/m2 at 6 months post-op in Group 1 adults. The procedure has been used and 7.0+2.6 kg/m2 (p=0.033). All patients both as a primary procedure as well as were able to tolerate a regular diet. a secondary procedure following failed Comorbidities improved with weight loss laparoscopic adjustable gastric banding following VSG. (LAGB). We retrospectively reviewed our case series to date to compare early CONCLUSION: Early results demonstrate post-operative outcomes in patients who successful weight loss in adolescents underwent VSG as a primary weight loss and young adults following VSG used as procedure with those who underwent either a primary or secondary weight loss VSG as a secondary procedure following procedure. previous LAGB. S075: A ROBOTIC APPROACH TO MEDIAN METHODS: Between June, 2010 and ARCUATE LIGAMENT SYNDROME Victoria January, 2014, 50 consecutive patients K. Pepper, MD, Karen A. Diefenbach, MD, (range 12.7 to 22.7 yr, mean 17.3 yr) Andy C. Chiou, MD, David L. Crawford, MD, underwent VSG to treat morbid obesity University of Illinois School of Medicine under an IRB-approved protocol. 40 at Peoria, Order of Saint Francis Medical patients underwent VSG as a primary Center, Nationwide Children’s Hospital weight loss procedure (Group 1) while INTRODUCTION: Median arcuate ligament 10 underwent conversion for failure syndrome (MALS) is an uncommon and to lose weight following LAGB (Group controversial disease. The syndrome is 2). All patients were evaluated by a characterized by a triad of postprandial multidisciplinary team. Data collected abdominal pain, an epigastric bruit which included age, gender, and ethnicity. increases with expiration, and a > 50% Weight and body mass index changes

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Oral Abstracts CONTINUED extrinsic compression of the celiac artery feasibility of the procedure within the on vascular imaging. Patients can have pediatric population as well as the significant history of weight loss and potential improvement in visablity and this weight loss is a positive prognostic range of motions offered by the robotic indicator for surgical intervention. While instruments. most frequently seen in females ages 40-50, we present a case of MALS in an S076: LAPAROSCOPIC EXCISION 18-year-old female. OF PERIPANCREATIC TUMOR AND MESENTERIC CYST Thai Lan N. Tran, METHODS: An 18-year-old female MD, Nam X. Nguyen, MD, University of was referred to vascular surgery after California, Irvine Medical Center extensive work-up for post-prandial pain The patient is a 13 year-old previously and weight loss. The patient underwent healthy male who presented with CTA with inspiratory and expiratory an acute onset of epigastric pain. He phases which revealed compression of underwent extensive workup, which the celiac axis. The patient was scheduled revealed a cystic mass at the root of for robotic median arcuate ligament the mesentery abutting the SMA. In release. After induction of anesthesia, addition, there weretwo solid lesions insufflation of the abdomen was locating within the body of the pancreas, performed via a Verus needle. Five trocars straddling between the splenic vein and were placed including a 12-mm trocar the portal vein. The patient was brought just left and superior of the umbilicus, a to the operating room and placed supine second 12 mm trocar in the left lateral on the split leg table. Four 5 mm trocars abdomen, and three 8 mm trocars (left were inserted in the following locations: upper quadrant, right lateral abdomen, infraumbilical, left subcostal, andtwo and right upper quadrant). After division on either side of the umbilicus at the of the gastrohepatic ligament, the right midclavicular line. crus of the diaphragm was identified and freed from the esophagus. This dissection We began the operation by taking down was continued inferiorly until the left the gastrocolic ligaments and entering the gastric artery was identified and isolated. lesser sac. Two stay sutures were placed Dissection was continued proximally through and through the abdominal wall until the celiac trunk and common and tacking the posterior aspect of the hepatic artery were identified. The bands stomach up to the abdominal wall in order composing the median arcuate ligament to expose the retroperitoneal space. were divided, releasing and straightening We noticed a solid tumor locating within celiac axis. the body of the pancreas. The mass was abutting against the portal vein to the right RESULTS: The patient tolerated the and the splenic vein inferiorly. We began procedure well and was discharged post- taking down the retroperitoneal tissues operative day 3. The patient had complete and meticulously dissect the tumor using a resolution of symptoms with weight gain combination of Harmonic scalpel and hook and is currently 1 year post-op. electrocautery. After peeling the tumor CONCLUSIONS: Robotic-assisted median away from the surrounding tissues, we arcuate ligament release has been noticed that this is actually a bilobar tumor, shown to be safe and feasible in previous with the inferior lobe extended underneath studies. This video demonstrates the the pancreas towards the inferior border

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Oral Abstracts CONTINUED of the pancreas. With tedious dissection, laparoscopic surgery (SILS) has arguably we were able to circumferentially remove reached that goal; technical limitations both lobes without any injuries to the are, however, preventing it from replacing major blood vessels. traditional multiport laparoscopic surgery (MLS). Lack of instrument triangulation Next, we turned our attention to the and inconvenient proximity between the cystic lesion by first reflecting the colon surgeon’s and the assistant’s ports result superiorly. We noticed that the tumor in prolonged operative time and a steeper is located at the root of the mesentery. learning curve. Our hybrid method We began by scoring the overlying intends to combine the benefits of both peritoneum and dissected out the surface MLS and SILS through a 2x2 approach, in of the cyst. As we nearly complete the which two umbilical ports are combined circumferential dissection, we opened the with two 3 mm subcostal access points. cyst and looked inside to confirm this is Thanks to this configuration, instrument the cyst with a previously placed pigtail triangulation is possible, the surgeon drain. With careful dissection, we were and the assistant can work comfortably able to dissect the cyst off of the SMA in tandem and the cosmetic result is and shell the cyst out of the root of the excellent, with a scarless abdominal wall mesentery. after healing. Furthermore, the steps of Postoperative course was uncomplicated the operation parallel those of traditional and the patient was sent home on POD MLS, which facilitates its adoption by 3. Final pathology revealed benign experienced laparoscopic surgeons. hamartoma. S078: FETOSCOPY AND LASER: A In conclusion, we showed in this GOOD THERAPEUTIC ALLIANCE IN patientthat laparoscopic approach is MINIMALLY-INVASIVE FETAL SURGERY feasible for complex abdominal masses. Alan Coleman, MD, Jose Peiro, MD, Foong- Yen Lim, MD, Cincinnati Children’s Hospital S077: HIDING THE SCARS. EVOLUTION Medical Center OF THE PEDIATRIC LAPAROSCOPIC CHOLECYSTECTOMY - THE 2X2 HYBRID INTRODUCTION: Fetoscopy is becoming TECHNIQUE Jeh Yung, MD, Georgios more widely utilized in the diagnosis Karagkounis, MD, Gavin Falk, MD, Todd and treatment of a variety of prenatal Ponsky, MD, FACS, Akron Children’s conditions. The indications and uses are Hospital; Cleveland Clinic also expanding with further innovation of techniques and equipment. In some cases Cholecystectomy has evolved such as twin-twin transfusion syndrome impressively in the past 30 years. (TTTS), fetoscopic laser photocoagulation From traditional open to mini-open to has become the therapy of choice in laparoscopic and now single-incision, treating prenatal disorders. We will incisions have become gradually smaller, review our outcomes with fetoscopic significantly improving injury to the laser interventions for various indications patient, length of stay, postoperative pain and discuss the current literature on the and cosmesis. This evolution has been subject. of particular importance for pediatric surgery due to the higher expectations for METHODS: We retrospectively reviewed cosmetic outcome, with the ideal being a all patients who underwent fetoscopic truly scarless operation. Single-incision interventions with laser therapy from

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2004 – 2014. Diagnoses included TTTS, become more prevalent with improved amniotic band syndrome (ABS), and giant outcomes compared initial descriptions. chorioangioma. Indications for laser Further innovation and experience will intervention and complications were only lead to an increase in the indications recorded. Outcomes included mortality treated with fetoscopy and laser and rate of complications. We reviewed interventions. the literature for current outcomes and further indications. S079: IMPACT OF CUSTOMIZED PRE- BENDED BAR IN SURGICAL TREATMENT RESULTS: We performed over 730 OF PECTUS EXCAVATUM Ruben Lamas- interventions with fetoscopic laser from Pinheiro, MD, Pedro Correia-Rodrigues, 2004 – 2014. Among the diagnoses Jaime C. Fonseca PhD, João L. Vilaça treated were TTTS (n=714), ABS (n=14), PhD, Jorge Correia-Pinto MD, PhD, Tiago and chorioangioma (n=3). In those Henriques-Coelho MD, PhD, Pediatric treated for TTTS, 5 patients had two Surgery Department, Faculty of Medicine, consecutive laser treatments and 35 Hospital de São João, Porto, Portugal patients had incomplete delivery data. INTRODUCTION & AIMS: Pre-surgical Of the remaining 674 interventions, automatic and personalized bar bending 33 pregnancies were triplets and 641 for pectus excavatum (PE) allows a pregnancies were twins. In our twin correct size and shape of the bar using CT cases, both twins survived to delivery in scan information. In the present study, 70% (n=446/641) of cases and at least we reviewed the experience in PE surgical one twin in 90% (n=560/624) of cases. treatment at a tertiary center comparing Among our ABS patients, we performed the Nuss procedure performed using release of amniotic bands involving the pre-bended (i3D) with manual bended umbilical cord in 64% (n=9/14) of cases (MB) bars. and isolated compromised extremities in the remaining 36% (n=5/14). Laser MATERIAL & METHODS: Patients therapy was utilized in conjunction submitted to NP from January of 2000 with other modalities in 3 cases of to December 2013 were included. Clinical chorioangioma that led to high output files were retrospectively reviewed for cardiac states. In reviewing the literature, demography, previous PE correction, we also found other indications anesthetic and operative details. Patients for laser therapy not currently in submitted to surgery with the new widespread use including posterior i3DExcavatum system pre-bended bars urethral valve ablation in bladder outlet were compared to those where classic obstruction, cord coagulation in twin manual bar bending was performed. reversed arterial perfusion sequence, fetoscopic balloon decompression/ RESULTS: During 14 years, 139 patients deflation for tracheal occlusion release were operated, 98 males (78%), with in congenital diaphragmatic hernia, a mean age of 14.9±3.2 years. Eight and decompressive laryngotomy for patients had been previously submitted congenital high airway obstruction to Ravitch procedure. Since 2007, the syndrome. i3D pre-bended bar was used in 96 patients (69%). The i3D and MB groups CONCLUSIONS: Minimally invasive were identical for gender, but the fetoscopic laser interventions have patients in MB were younger (median

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13.9 vs. 14.7 years, p=0.024) and had compared to non-obese children a superior Haller index (mean 4.2 vs. undergoing SILS appendectomy for 3.4, p=0.002). In i3D group, surgery last acute, perforated appendicitis. less time (median 72 vs. 120 minutes, METHODS: We reviewed the records of p<0.001), the hospital stay was shorter all pediatric patients who underwent (median 5 vs. 7 days, p<0.001) and SILS appendectomy for acute, there were less complication (7% vs. perforated appendicitis, performed by 43%, p<0.001). Complications were a single surgeon, between 2008 -2013. mainly skin erosion (i3D - 0 vs. MB - 6), The diagnosis of acute, perforated pneumothorax (i3D - 1 vs. MB - 5), lung appendicitis was based on pathology atelectasis (i3D - 1 vs. MB - 1) and wound results. Patient characteristics including infections (i3D - 2 vs. MB - 1). There was age, body weight, gender and outcomes no mortality in both groups. The bar was were compared between both obese removed later in the i3D group: median and non-obese children.Body weight period with the bar was 32 months percentiles were calculated based on versus 28 months (p<0.001). age-appropriate growth charts.Obesity DISCUSSION: The introduction of was defined as body weight greater than i3DExcavatum system improved the 95th percentile. outcomes. Since the bar is bended before RESULTS: 70 patients underwent SILS surgery, a clear reduction in operative time appendectomy for acute, perforated was achieved. However, we cannot exclude appendicitis. 26 of these were obese. Of the learning curve in the first years of these patients, 35(48.6%) were male. implementation of the NP in our center. None of the patients in either group were S080: SINGLE INCISION LAPAROSCOPIC converted to conventional laparoscopic SURGERY FOR PERFORATED or open appendectomy. There was APPENDICITIS: DOES OBESITY AFFECT no difference in length of operation OUTCOMES? Adesola C. Akinkuotu, MD, (69.2±25.1vs.65.6±25.8 minutes; p=0.57), Paulette I Abbas, MD, Ashwin Pimpalwar, length of hospital stay (6.0±3.9vs.5.1±3.1 MD, Texas Children’s Hospital and the days; p=0.32) or time to full diet Division of Pediatric surgery, Michael E. (2.9±2.0vs2.6±2.1 days; p=0.55) between DeBakey Department of Surgery, Baylor obese and non-obese children.Obese College of Medicine, Houston, TX patients had a higher incidence of post- operative wound infection than non- INTRODUCTION: In children with acute obese children (26.9%vs.4.7%; p=0.02). appendicitis, obesity has been linked There were no differences in other post- with worse post-operative outcomes operative complications such as intra- in open and conventional laparoscopic abdominal abscess, wound seroma and appendectomy. Improvements in post-operative ileus (Table 1). laparoscopic surgery have led to the use of single incision laparoscopic CONCLUSION: Obese children treated surgery (SILS) for surgical procedures with SILS appendectomy for acute, including appendectomies. At our perforated appendicitis appear to have institution, SILS appendectomies are similar outcomes when compared to non- performed routinely by a single surgeon. obese children except for a higher wound We hypothesize that obese children infection rate. have worse post-operative outcomes

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TABLE 1: Outcomes of obese and March 2013 was performed. Patient non-obese children undergoing demographics and outcomes were SILS appendectomy for perforated analyzed, including age at diagnostic appendicitis laparoscopy, gender, diagnosis or indication for shunt placement, previous shunt placement, prior abdominal operations or procedures, cause of shunt failure, shunt revisions, and length of shunt patency. RESULTS: During the four year study period, a total of 27 patients underwent diagnostic laparoscopy for ventriculoperitoneal shunt placement at a mean age of 7.7 ± 6.8 years. Medical indications for shunt placement included: hemorrhagic hydrocephalus (40.7%), congenital hydrocephalus (22.2%), spina S081: DIAGNOSTIC LAPAROSCOPY FOR bifida (18.5%), myelomeningocele (11.1%), INTRA-ABDOMINAL EVALUATION AND and arachnoid cyst (7.4%). Twenty five VENTRICULOPERITONEAL SHUNT patients who underwent laparoscopy had PLACEMENT IN CHILDREN Sandra M. previous shunts placed in the peritoneum Farach, MD, Paul D. Danielson, MD, Nicole (mean number of prior shunts placed M. Chandler, MD, All Children’s Hospital was 1.6 ± 0.8), while two underwent Johns Hopkins Medicine initial shunt placement. Sixteen patients (59%) had undergone previous non- BACKGROUND: Studies have shown that shunt related abdominal operations. laparoscopic assistance for the placement Indications for shunt externalization of ventriculoperitoneal (VP) shunts is a prior to diagnostic laparoscopy included: safe, effective, and minimally invasive infection (n=10), malfunction (n=10), and approach for distal peritoneal shunt pseudocyst (n=5). Twenty three (85%) placement. A relative contraindication patients had successful peritoneal shunt to abdominal shunt placement is a placement. There were four patients history of peritonitis or prior abdominal (15%) in whom peritoneal shunt could surgery. In an effort to reduce the need not be placed at the time of laparoscopy for ventriculoatrial shunt placement, secondary to extensive adhesions. Of laparoscopy can be used for diagnosis the 23 patients who had successful and intervention. The purpose of our peritoneal shunt placement, 13 (57%) did study was to review our experience with not require further shunt intervention, diagnostic laparoscopy for VP shunt 5 (22%) underwent conversion to a placement in patients with a potential ventriculoatrial shunt, 4 (17%) underwent hostile abdomen. re-externalization, and 1 (4%) required METHODS: After Institutional Review distal shunt revision (Figure 1). Of the four Board approval, a retrospective analysis patients who required externalization, of all patients who underwent diagnostic 3 underwent a second diagnostic laparoscopy for ventriculoperitoneal laparoscopy procedure with successful shunt placement from March 2009 to peritoneal shunt placement. Mean length

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Oral Abstracts CONTINUED of follow up after diagnostic laparoscopy mobilisation as a cause of surgical was 1.6 ±1.1 years. Two patients (7.4%) were failure due to wrap transmigration. We lost to follow up. however, have neither adopted minimal oesophageal mobilisation nor perceived CONCLUSIONS: Utilization of diagnostic a preponderance of wrap transmigration laparoscopy eliminated the need for at redo fundoplication. This study aimed initial ventriculoatrial shunt placement in to determine the incidence of wrap 85% of patients. Sixty percent of patients transmigration in children requiring redo- required no further shunt revision and fundoplication, and to quantify the risk of this resulted in an overall long term shunt hypothesised alternative antecedents for patency of 70%. Laparoscopic assisted redo surgery. peritoneal shunt insertion in pediatric patients is a safe and minimally invasive METHODS: A single-centre retrospective technique with the additional benefit of study was performed of all children exploration and adhesiolysis to determine undergoing primary laparoscopic suitability of shunt placement. fundoplication between 2008 and 2012 inclusive. Primary outcome was need for redo-fundoplication. Data were also collected regarding demographics, medical history, referral details, investigations and operative approach. Relative risk of redo-fundoplication was calculated for each hypothesised antecedent with Cox regression; p<0.05 significant. MAIN RESULTS: 95 children underwent primary laparoscopic fundoplication; 1/95 was followed up interstate and so excluded from analysis. 15/94 (16%) S082: RISK OF REDO LAPAROSCOPIC children required redo-fundoplication and FUNDOPLICATION IN CHILDREN: a further 2/94 died. 3/15 required >1 redo. BEWARE THE RESPIRATORY PHYSICIAN? Indications for redo-fundoplication were: Edward Gibson, MBBS, Warwick J. Teague, 5/15 too tight wrap, 10/15 GOR recurrence. DPhil, FRACS, Sanjeev Khurana, MS, 4/15 (27%) had wrap transmigration. FRCSI, FRACS, Department of Paediatric The risk of redo-fundoplication was Surgery, Women’s and Children’s Hospital, significantly increased if referral for Adelaide, Australia fundoplication was by a respiratory physician (vs. gastroenterologist; HR 19.9, AIM OF THE STUDY: The success CI 95% 2.7-145.2, p=0.003). However, and shortcomings of laparoscopic neurological status, indication for fundoplication in children with primary fundoplication, and presence complicated gastro-oesophageal reflux of a gastrostomy were not significantly (GOR) remains a matter of scrutiny associated with redo surgery; see table. and debate. Redo-fundoplication presents challenges for the patient and surgeon alike. Recent literature has emphasied extensive oeosphageal

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Shanghai Children’s Hospital, Shanghai Jiao Tong University and Children’s Hospital of Fudan University. There were 9 boys and 12 girls, average age 1.5±0.9 years(range 0.4-4.5 years). The patients were divided into 2 groups according to different suture in the thoracoscopic repair and duplication. Group 1, the diaphragm were repaired by interrupted suture. 8 cases. Group 2, the repair on the diaphragm were treated by continuous suture, 13 cases. The following factors such as average operation time, volume CONCLUSIONS: This, like other series, of bleeding, drainage, postoperative reports a concerning incidence of redo hospital stay and postoperative fundoplication. However, even if wrap complications were analyzed. transmigration were eliminated, our RESULTS: The age, body weight of redo surgery rate remains >10%. The patients, symptoms or signs and the association of redo-fundoplication numbers of eventrated intercostal space with referral by a respiratory physician of diaphragm were no difference between is thought-provoking. This may reflect 2 groups. The average operation time in the severity of GOR sequelae and/or group 1 and group 2 was different (75±21 superadded strain on the fundoplication vs 33±17min, P < 0.01). The volume of wrap in the most respiratory-impaired bleeding, postoperative stay in hospital, children. and drainage in the two groups were S083: THORACOSCOPIC REPAIR ON nearly same, There was no mortality in THE CONGENITAL DIAPHRAGMATIC operation and the patients were followed EVENTRATION IN CHILDREN? up from 0.45 to 3.3 years, and only 1 case CONTINUOUS OR INTERRUPTED of recurrence was found in group 1. SUTURE FOR PLICATION Jiangbin Liu, CONCLUSIONS: Thoracoscopic repair PhD, Professor, Zhibao Lv, Professor, on the diaphragmatic eventration by Department of Pediatric Surgery, continuous suture is a safe, reliable, Shanghai Children’s Hospital, Shanghai convenient and effective procedure for Jiao Tong University and Department of plication, which can take the place of Pediatric Surgery, Children’s Hospital of interrupted suture. Fudan University, Shanghai, PR China KEY WORDS: Eventration of diaphragm; OBJECTIVES: To review the experience and Congenital;Diaphragm/Malformation; compare the results of the continuous Diaphragm/Surgery;Thoracoscopy or interrupted suture on the congenital diaphragmatic eventration in children by thoracoscopic repair. METHODS: From January 2010 to September 2013, 21 children with congenital diaphragmatic eventration were repaired by thoracoscopic repair in

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S084: VALIDATION OF A NOVEL two lines (D1 and D2) is the amount of PARAMETER FOR THE EVALUATION OF defect the patient has in their chest. KCI PECTUS EXCAVATUM: THE KANSAS CITY formula was as follows: D2-D1/D2*100. CORRECTION INDEX Gaston Bellia, MD, RESULTS: The mean age was similar Mariano Albertal, MD, Luzia Toselli, MD, between groups (19.5±9.3 years old for PE Carolina Millan, MD, Horacio Bignon, MD, and 22±2.9 years old for controls, p=0.92). Giselle Corti, Javier Vallejos, MD,Marcelo Thetableillustrates the HI and KCI values Martinez Ferro, Private Children´s Hospital from our study and St. Peters et al. In our of Buenos Aires, Fundación Hospitalaria, study, 10/87 (11.4%) patients with PE had Buenos Aires, Argentina overlapped with controls (area under the INTRODUCTION: The Haller index (HI) ROC curve 0.48, p=0.67) compared to 47% is the ratio of the distance between the in St. Peters et al. Using the KCI, only 2/87 anterior spine and posterior sternum (2.3%) patients overlapped (area under to the widest transverse diameter of ROC curve 0.99, p<0.001), while no overlap the chest. Although the HI remains was reported in St. Peters et al. the most commonly used parameter to determine surgical candidacy in patients with pectus excavatum (PE), it cannotdiscriminate between PE and controls. Recently, a group of investigatorsfrom Kansas introduced a new PE index, the correction index (St Peter SD et al.A novel measure for CONCLUSION: 1) Similat to St. Peters et PE: thecorrectionindex, J Pediatr Surg. al.KCI resulted in less overlap thanHI. 2) 2011 Dec;46 (12):2270-3.) The Kansas Overlapwith HI was low in our study, likely correctionindex (KCI) expresses the due to greater PE severity compared to St. percentage of thoracic depression Peters et al. represented by the sternal defect, demonstrating optimum discrimination S085: SPONTANEOUS between PE and controls. In order to PNEUMOTHORAXES: A SINGLE- confirm those results, we aim to report INSTITUTION RETROSPECTIVE REVIEW our experience with the KCI for the Victoria K. Pepper, MD, Terrence M. Rager, assessment of PE severity. MD, MS, Wei Wang, MS, MAS, Dennis R. King, MD, Karen A. Diefenbach, MD, METHODS: Retrospective analysis of Nationwide Children’s Hospital prospectively collected chest computed tomographic data in PE (N=87) and PURPOSE: Previous studies have controls (N=24). We calculated HI in a evaluated the management of standard fashion. For the KCI, we drew spontaneous pneumothorax in the a horizontal line across the anterior pediatric population, but no standard spine and measured two distances: the of care has emerged with regard to the minimum distance between the posterior timing of surgical management. While sternum and the anterior spine (D1) and some surgeons opt for a “conservative” the maximum distance between the line approach with either observation or placed on the anterior spine and, the inner chest tube placement initially, others margin of the most anterior portion of the proceed with surgical intervention on chest (D2). The difference between these the first occurrence. The purpose of this

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Oral Abstracts CONTINUED study was to review the management There was no difference in LOS between of spontaneous pneumothorax by patients treated with immediate surgery multiple surgeons in a single institution (8.6 days) versus those converted in order to compare the outcomes of to surgery from either chest tube initial conservative and early operative management (9.9 days, p=0.3013) or treatment. observation (11 days, p=0.4152). METHODS: A retrospective review of all Of the 59 occurrences which did not patients at a single institution between undergo surgical management on the October 2008 and October 2013 was first admission, 19 developed a recurrent performed. The diagnosis code for pneumothorax (32.2%). Fifteen of these “pneumothorax” was used to identify patients (78.9%) received immediate all possible study candidates. Exclusion surgical management. Of the remaining criteria included underlying pulmonary 4 patients, one (25%) was converted pathology, iatrogenic pneumothorax, to surgery. Of the three patients traumatic pneumothorax, and age who did not have surgery after their less than 10 years. Data was collected second occurrence, two (66.7%) had a regarding age, race, gender, weight, and third episode. Both of these patients comorbidities. The initial management, underwent surgery during their third any alterations in management, and admission. length of stay (LOS) were examined for Of the total number of patients each occurrence of pneumothorax. undergoing surgical management (n=41), RESULTS: A total of 72 patients with 82 7 (17.1%) had a recurrent ipsilateral occurrences of initial pneumothorax pneumothorax post-operatively, and one were identified (10 patients had bilateral child developed a contralateral lesion disease). Of the 82 occurrences, seven after bilateral pleurodesis. (8.54%) were treated at the outset SUMMARY: While the timing of with surgery (SM). Thirteen (17.3%) of surgery in patients with spontaneous the patients initially managed with pneumothoraxes is a controversial conservative treatment (CM) were subject, most surgeons agree that surgical converted to surgical treatment during management should be performed after their first admission and an additional the first or second occurrence. With a 3 patients underwent elective surgical total postoperative recurrence rate of management after initial discharge. 19.5% post-operatively, 32.2% after the There was no significant difference first occurrence, and 66.7% after the in age, gender, race, or comorbidities second episode, our data would suggest between those treated successfully that patients may best benefit from conservatively versus those managed surgical intervention after the second with surgery. There was a predominance occurrence of pneumothorax. of left-sided pneumothoraces in both subgroups (CM = 60.4% vs. SM = 65%). S086: LAPAROSCOPIC RESECTION OF There was a significant difference ABDOMINAL NEUROBLASTOMA WITH between the average length of stay (LOS) RENAL PEDICLE INVOLVEMENT Paula in patients treated conservatively versus Flores, MD, Martin Cadario, MD, Yvonne those with surgical management (CM Lenz, MD, Garrahan Hospital. Buenos = 3.9 days vs. SM = 9.7 days, p<0.0001). Aires. Argentina.

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Neuroblastoma is the most common reduction of kidney estimated dimension extracranial solid malignancy in was found and the patients present childhood, accounting for 8% to 10% of normal blood pressure at the time of the all cancers in the pediatric population. analysis. Almost half of the patients have The INRG classification system was disseminated disease. Patients with developed to facilitate the comparison local compromise will have a better of risk-based clinical trials conducted in prognosis, although some will develop different regions of the world by defining either local or disseminated relapse. One homogenous pretreatment patient of the factors that determine treatment cohorts. However, there are patients strategy is the tumor resectability. The that will benefit with primary surgery, International Neuroblastoma Risk Group although the presence of IDRF. In our (INRG) classification is a pretreatment experience, there are some tumors staging system based on tumor imaging. with vessel encasement that can be The goal is to reduce the surgery- bluntly resected founding the correct related complications in those patients surgical dissection plane. Some tumors undergoing primary surgical treatment. considered “unresectable” according According to the INRG classification, to current protocols, are amenable abdominal tumors invading one or to complete laparoscopic resection both renal pedicles are considered as despite vessel involvement. Minimal “image defined risk factors” (IDRF), invasive surgery allows an effective local and neoadyuvant chemotherapy is control. In order to benefit from this de- highly recommended. On the other escalation therapy strategy, the patients hand, complete resection of localized have to be strictly selected. neuroblastoma would be the best option to spare chemotherapy in selected S087: LOWER ESOPHAGEAL patients who will not benefit with it. BANDING IN EXTREMELY LOW BIRTH We present 2 patients aged 11 WEIGHT PREMATURE INFANTS months and 3 years old with localized WITH OESOPHAGEAL ATRESIA AND neuroblastoma with renal pedicle TRACHEO-ESOPHAGEAL FISTULA IS invasion. Tumor location and size were A LIFE SAVING PRACTICE FOLLOWED determined by preoperative CTscan. BY A SUCCESSFUL DELAYED PRIMARY The mean tumor volume was 18 cc. THORACOSCOPY RECONSTRUCTION Manuel Lopez, MD, Eduardo Perez- A complete macroscopic resection  Etchepare, François Varlet, MD, PhD, was achieved in both cases with no Department of Pediatric Surgery, perioperative morbidity. The mean University Hospital of Saint Etienne operative time was 190 minutes and the patients’ hospital stay was 2 INTRODUCTION: In extremely low birth days. Pathological exams confirmed weight infants (ELBW<1000 g), several neuroblastoma with favorable biological abnormalities are associated making factors in both cases. During the follow- surgical treatment a real challenge. High up period (19 months and 27 months), the morbidity is associated with primary patients did not receive any additional repair in these patients. Here, we report therapy. Both patients are alive and our experience with three cases of ELBW with no evidence of disease. Kidneys babies with EA. size was calculated by ultrasound. No

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MATERIAL & METHODS: From september Kyushu University,2Department of 2012 to January 2013, Three low birth Advanced Medicine and Innovative weight infants with EA and TEF born Technology, Kyushu University prematurely with severe respiratory Hospital,3The faculty of science and distress,the mean gestational age was engineering, Waseda University 26(25-27) weeks,the median birth weight BACKGROUND & AIM: In pediatric was 690 gr (500-790)were treated with endosurgery, surgeons receive much initial banding of the gastroesophageal benefit of magnified visual filed even for juncture followed by a gastrostomy. ARM small bady patients. On the other hand, was associated in one of them. the more visual filed was magnified, RESULTS: One baby died in the the more blind area of the forceps postoperative period because became bigger. In the previous study, intracerebral hemorrhage at 7 days we developed augmented reality (AR) after initial surgery. In one of them a navigation system and applied pediatric ligation without section of the TEF with laparocopic splenectomy (Ieiri S, et al., removal of lower esophageal band Pediatr Surg Int, 2012) and oncologic was performed by thoracoscopy at surgery (Souzaki R et al., J Ped Surg,2013). 30 days and 1100 gr. The esophageal Therefore we developed the blind area reconstruction and section of fistula was visualization system to resolve these done by thoracoscopy at 70 and 80 days demerits using AR technique for pediatric and 2100gr and 2200 gr. with uneventful endosurgery. In this study, we verify an course. None early complication. The effectiveness of this system for pediatric follow-up was 12 months, one baby surgeons. presented a small stricture requiring only METHODS: Developed system was one dilation of lower esophageal with composed of two cameras. One is for unevenful course usual view point of surgeon, and the CONCLUSION: LEB is a life saving other is for compensation of blind area practice in premature ELBW babies. The of forceps. Image of blind area of forceps esophagus can tolerate the ligation even was fused with a real-time endoscopic with a thread without having a long time image of the operative field, providing stricture complication. Thoracoscopic a transparent forceps for the surgeon reconstruction of the esophagus is (Fig.1a).Surgeons can get “See-Through possible in these babies. Needle Driver” using this augmented reality technique (Fig.1b). We examined S088: DEVELOPMENT OF BLIND AREA the effectiveness of this system VISUALIZATION SYSTEM IN MAGNIFIED by backhand needle driving (Fig.2). FIELD OF VIEW USING AN AUGMENTED Examinees were 17 pediatric surgeons REALITY IN PEDIATRIC ENDOSURGERY and they were divided into 2 groups, 3 ~AMAZING SEE-THROUGH NEEDLE experts and 14 trainees. They had to Satoshi Ieiri1,2, MD, PhD, Yuya DRIVER~  perform 3 backhand needle driving in the Nishio3, Satoshi Obata1, MD, Ryota box with(Fig.2a) or without this system Souzaki1,2, MD, PhD, Yo Kobayashi3, (Fig.2b). The tip of the needle was hidden PhD, Masakatsu Fujie3, PhD, Makoto by shaft of forceps. Such being the case, Hashizume2, MD, PhD, FACS, Tomoaki this task was setup. Evaluation points Taguchi 1, MD, PhD, FACS, 1Department of were time and accuracy. Accuracy was Pediatric Surgery, Faculty of Medicine, calculated by measuring of deviation

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Oral Abstracts CONTINUED of exertion error. Statistical analysis was performed Mann-Whitney U test and p<0.05 was considered statistically significant. RESULTS: All 17 participants completed the evaluation task. There was no significant difference between with and without system for time, in experts and trainees, respectively. Figure 3 showed the results of needle driving accuracy. Exertion error of experts with and without system was 0.63 ± 0.43 and 1.40 ± 2.33 (p=0.001158) (Fig.3a), respectively. Exertion error of trainees with and without system was 0.63 ± 0.43 and 1.40 ± 2.33 (p=0.843972) (Fig.3b), respectively. Experts improved the backhand needle driving accuracy using this system. CONCLUSIONS: The results revealed that the experts made skillful use “See-Through Needle Driver” using an AR technique. They would receive the maximum merit of this system for the S089: IS SINGLE INCISION magnified view of small working space. APPENDECTOMY SUPERIOR TO Next step, we must refine this system for TRADITIONAL LAPAROSCOPY IN in-vivo experiments. In the near future, CHILDREN? Stephanie F. Polites, MD, this system would be applied for clinical Shannon D. Acker, MD, James T. Ross, use of advanced pediatric endosurgery, David A. Partrick, MD, Abdalla E. Zarroug, espscially for small neonate and infant MD, Kristine M. Thomsen, Donald D. patients. Potter, MD, Mayo Clinic, Rochester, MN; Children’s Hospital Colorado, Aurora, CO; University of Iowa, Iowa City, IA INTRODUCTION: Laparoscopic appendectomy (LA) has largely become the standard of care for children with acute appendicitis, and some institutions are now moving to single incision laparoscopic appendectomy (SILA). Data comparing SILA and LA is limited, and existing data originate from single institutions that select patients based on if they are best suited for SILA or LA. We aimed to compare SILA and traditional LA for acute appendicitis in children

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Oral Abstracts CONTINUED by comparing outcomes between two confirmed by multivariable analysis institutions which each use SILA or LA (p<.001). Postoperative LOS was shorter preferentially. We hypothesized that SILA following SILA for both perforated (4.2 and LA would have at least equivalent vs. 5.0 days, p=.11) and nonperforated outcomes. (1.0 vs. 1.5 days, p<.001) appendicitis. Extended postoperative LOS (>2 days) METHODS: We performed a was more likely following LA (30.0% vs. retrospective review of all children 12.7%, OR=3.3, 95% CI: 1.9-5.8, p<.001) 18 who underwent SILA at a single ≤ on multivariable analysis. Rate of institution between July 2010 and July unplanned readmission (4.3% SILA group 2013 for acute appendicitis. Each SILA vs. 1.9% LA group, p=0.10), superficial patient was matched to 2-3 patients wound infections (1.6% vs. 0.2%, p=.07) who underwent LA at a second and intra-abdominal abscess (4.3% vs. institution during the same time period. 2.1%, p=.11) were similar in both groups; Patients were matched based on age, however, on multivariable analysis, sex, weight, and perforation status. SILA was predictive of infectious Demographic information, preoperative complications (OR=3.6, 95% CI: 1.4-10.0, clinical information, operative time, p=.012). Other complications were rare. and outcomes were collected. Linear regression was used to compare operative time and postoperative LOS and logistic regression was used to compare extended length of stay (>75th percentile) for nonperforated appendicitis and infectious complications (superficial wound infections and intra-abdominal abscess). Multivariable analyses controlled for preoperative LOS and preoperative antibiotic use to adjust for differences between institutions. TABLE: Comparison of outcomes of single incision and traditional laparoscopic RESULTS: A total of 184 children appendectomy underwent SILA and were matched to 478 children who underwent LA. There CONCLUSION: Operative outcomes were no clinically significant differences for single incision laparoscopic in age (mean 11.8 vs. 11.2 years), sex appendectomy are similar to traditional (52.2% vs. 54.8% male), weight (mean laparoscopic appendectomy for 50.5 vs. 46.3 kg), or perforation status perforated and nonperforated acute (22.8% vs. 24.7% perforated) between appendicitis in children. Traditional LA the cohorts. Conversion to traditional was associated with shorter operative LA was required in 2 SILA patients. times and reduced risk of infectious Conversion to open appendectomy was complications as compared to SILA. Single required in 2 SILA patients and no LA incision laparoscopic appendectomy was patients. On univariate analysis (Table), associated with a shorter hospital stay. mean operative time was significantly Both techniques have an acceptably low greater for SILA (64.1 vs. 45.9 minutes, complication rate; thus, the choice of p<.001) as compared to LA and this was procedure can be surgeon dependent.

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S090: IMPACT OF EXPERIENCE ON a single center. Mean age for all patients QUALITY OUTCOMES IN SINGLE- was 11.8 ± 4 (0-21.5) years and mean weight INCISION LAPAROSCOPY FOR SIMPLE was 47.5 ± 20.4 (9.8-134) kilograms. The AND COMPLEX APPENDICITIS IN population consisted of 61% males. Four CHILDREN Sandra M. Farach, MD, Paul hundred eleven (58.5%) patients were D. Danielson, MD, Nicole M. Chandler, diagnosed with acute appendicitis and MD, All Children’s Hospital Johns Hopkins 292 (41.5%) with complex appendicitis. Medicine Prior to the start of our training program, 357 patients and 248 patients underwent BACKGROUND: Single incision appendectomy for acute and complex laparoscopy (SIL) has been performed appendicitis, respectively. Surgical by more than 70% of pediatric surgeons. trainees were involved in 54 and 44 However, evolving surgical technology appendectomies for acute and complex is often adapted without rigorous appendicitis, respectively. Quality scientific investigation. Single incision measures are summarized in Table 1. There appendectomy has been shown to be was a significant decrease in operative an effective treatment in appendicitis time between early and late groups for in children, but factors that impact both simple appendicitis (p<0.05) and outcomes are not well understood. We complex appendicitis (p<0.05). There was report our large experience with SIL, a significant increase in operative time focusing on the impact experience may following introduction of surgical trainees play on quality outcomes. compared to the late group (p<0.05), but METHODS: At the inception of our SIL not compared to the early group for simple program, all patients were entered appendicitis. There was no difference in into a prospective database for quality operative times following the introduction monitoring. After Institutional Review of trainees for complex appendicitis. Board approval, a retrospective review of There were no significant differences patients who underwent SIL from August in complications or readmission 2009 to November 2013 was performed. rates between any of the groups. No A total of 919 patients were reviewed. conversions occurred in patients with Patients who underwent appendectomy simple appendicitis, while two conversions were grouped by early experience without (0.7%) occurred in patients with complex trainees (first consecutive 100 cases), late appendicitis. experience without trainees, and late CONCLUSION: The adoption of new experience with surgical trainees. Our technology requires a significant training program began in October 2012. learning curve even for the experienced Each cohort was further stratified into laparoscopist. There is the potential for simple (acute) appendicitis and complex significantly decreased operative times appendicitis. Quality measures including once experience is obtained. Surgical operative time, conversion to multi-port trainees with laparoscopic experience or open, and 30-day complications were likely perform similar to attendings when analyzed. introducing new technology. While there RESULTS: A total of 703 patients may be an appreciated increase in overall underwent SIL appendectomy during operative time with the introduction of the study period. All procedures were trainees, this does not impact quality performed by two attending surgeons at outcomes.

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pylori. Furthermore we hypothesize that we can effectively dilate the obstruction restoring flow through the pyloric channel using our novel balloon device. METHODS: Five adult rabbit (4-5kg) cadaver pylori were excised and reserved for testing. Each pylorus was held vertically while 2cc of infant formula was poured into the antrum and the time for formula to exit the duodenum was recorded. Cross-linked hyaluronic acid (HA) dermal filler was S091: CAN HYPERTROPHIC PYLORIC injected subcutaneously with a 25G needle STENOSIS BE TREATED WITH NATURAL to bulk the pyloric muscle circumferentially. ORIFICE TRANSESOPHAGEAL On average 1.28cc was injected per pylorus SURGERY APPROACH USING A NOVEL over 23 injection sites. Flow through the ENDOLUMINAL CATHETER DEVICE? bulked pylorus was measured using the EX-VIVO VALIDATION OF A NEW RABBIT same method as for the normal pylorus. MODEL FOR PYLORIC STENOSIS Carolyn The balloon catheter was advanced through T. Cochenour, BS,Timothy Kane, MD, Axel the lumen of the bulked pylori. The balloon Krieger, PhD, Peter Kim, MD, PhD, Sheikh was inflated to 10atm for approximately Zayed Institute for Pediatric Surgical 30 seconds, deflated and inflated for a Innovation, Children’s National Health second cycle. The balloon was deflated System, Washington, DC, US and removed from the pylori. Flow through the dilated pylorus was measured using the AIM OF THE STUDY: Hypertrophic pyloric same method as for the normal pylorus. stenosis (HPS) is a common foregut The samples were fixed in formaldehyde obstruction in the neonatal period for 24 hours and embedded in paraffin for requiring surgery. Laparoscopic or open gross histological analysis. Measured pyloric pyloromyotomy currently provides emptying times were converted to flow (cc/ effective relief of gastric outlet obstruction. second) and compared in the unbulked state Both approaches require trans-abdominal (normal), bulked state (simulated-HPS) and access as well as myotomy which may dilated state (treated HPS) (see Figure 1). lead to complications associated with the invasive nature used to treat this condition RESULTS: Flow through the unbulked such as wound infection, perforation, and samples were 0.24±0.08cc/s (n=5). hernias. We have specifically designed a Flow through the bulked samples was novel catheter-based device to isolate and completely obstructed in 3/5 samples dilate the hypertrophied area in a controlled and slowed the flow to 0.11±0.06cc/s safe manner using a natural orifice in the other 2 samples (p=0.008). The transesophageal surgery (NOTES) approach. balloon catheter was able to anchor in the duodenum while isolating and dilating In the absence of any clinically relevant the bulked pyloric region. In the dilated animal model to test the approach, herein samples, flow was restored to 1.48±0.63cc/s we report a novel ex vivo validation of HPS (p=0.001) (n=5). Figure 1 shows that gross using a rabbit model. We hypothesize that histology revealed no breach in mucosal we could create a functional and repeatable or muscular integrity (n=5). No transmural obstruction as measured by flow in rabbit perforation was noted.

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CONCLUSION: We report a novel NOTES- METHODS & PROCEDURES: This is an IRB based catheter device for potential approved (FWA00005960) retrospective treatment of HPS. In addition, we describe analysis of prospectively collected data. a new clinically relevant rabbit model of All SIPES cases performed at a tertiary HPS using HA based dermal filler injection children’s hospital from March 2009 creating an effective obstruction of the to December 2013 were included. Our pylorus mimicking HPS. Ex vivo validation prospective database includes standard of our approach using the endoluminal demographics, procedure types, operative catheter resulting in an effective relief of duration, estimated blood loss, instances pyloric obstruction confirms the potential of added ports or conversion to an open for our non-invasive approach. procedure, intraoperative and postoperative complications and duration of follow-up. Statistical analysis was performed using JMP® Software. RESULTS: During the study period, 1322 SIPES operations were performed. Cases performed were: appendectomy (66.2%), cholecystectomy (15.9%), pyloromyotomy (4.3%), splenectomy (3.2%), intestinal procedure (3.0%), gynecologic operation (2.7%), inguinal hernia repair (2.6%) and miscellaneous procedure (2.1%). Miscellaneous operations included Nissen fundoplication (N=12), diagnostic S092: ROUTINE UTILIZATION OF SINGLE- laparoscopy (N=6), laparoscopic assisted INCISION PEDIATRIC ENDOSURGERY biopsy (N=4), Ladd’s procedure (N=2), hiatal/ (SIPES): A FIVE YEAR INSTITUTIONAL epigastric hernia repair (N=2), duodenal EXPERIENCE Aaron D Seims, MD, Tate R web resection (N=1) and peritoneal dialysis Nice, MD, Vincent E Mortellaro, MD, Martin catheter repositioning (N=1). Table 1 Lacher, MD, PhD, Muhammad E Ba'ath, MD, presents data regarding median operative Scott A Anderson, MD, Elizabeth A Beierle, time, comparative multi-port operative MD, Colin A Martin, MD, David A Rogers, MD, times, need for additional ports and Carroll M Harmon, MD, PhD, Mike K Chen, conversion to open for each procedural MD, Robert T Russell MD, MPH, Children's of category. 871 (66%) patients were seen in Alabama follow-up, with a median duration of 26 INTRODUCTION: Single-Incision Pediatric days. 53 (6.1%) children experienced post- Endosurgery (SIPES) is a technical operative complication. 42 (4.8%) of these innovation that allows procedures to were surgical site infections, of which only be performed through a single access four required incision and drainage. This site, which replaces the multiple ports compares favorably to published traditional traditionally utilized. Large series evaluating laparoscopic wound infection rates of 3-6%. the versatility of SIPES in the pediatric Less frequent post-operative complications population are not abundant in the that required operative intervention include literature. The purpose of this study is recurrent inguinal hernia (N=4), umbilical to review our long term experience with hernia (N=3), intra-abdominal abscess (N=1), routine SIPES use. bleeding (N=1), abdominal compartment

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Oral Abstracts CONTINUED syndrome (N=1), bowel obstruction (N=1), challenge and a further step compared stitch granuloma (N=1) and pain (N=1). to conventional video assisted therapies. We report our recent experience with CONCLUSIONS: SIPES can be safely the application of SILS technique in IBD integrated into the routine of a busy patients. operative practice for most traditional multi-port procedures. Operative times MATERIALS & METHODS: Over the last and complication rates for SIPES are 22 months, 13 procedures were carried comparable to prior reported multi- out in 5 IBD patients using SILS technique. port laparoscopic series in the pediatric Demographics, clinical presentation and population. Future investigations may diagnostic details are briefly described. need to compare patient satisfaction with In all cases, a preformed SILS port was cosmesis and differences in post-operative used, inserted into the abdomen through a pain between SIPES and traditional skin incision of approximately 2.5 cm. The laparoscopic methods. ileocecal segment in Crohn’s disease (CD) and the colon in ulcerative colitis (UC) were mobilized using articulating instruments and Ligasure ™ device. In all CD patients, the affected bowel was exteriorized through the umbilical SILS port to perform resection, anastomosis and stricturoplasty when needed. Total colectomy in UC patients was performed using a SILS access in the right lower quadrant, employing the portsite to pack the terminal ileostomy. During further reconstructive procedures, the SILS was introduced at the level of the previous ileostomy to perform dissection of the rectal stump, J-pouch creation , assistance of the ileoanal anastomosis. Then the SILS access became the site of protective ileostomy S093: SILS APPROACH TO INFLAMMATORY BOWEL DISEASE Claudio Vella, MD, Sara RESULTS: Three males and 2 females, aged Costanzo, MD, Giorgio Fava, MD, Luciano 7-14 years, were treated, 3 for Crohn’s diseas Maestri, MD, Giovanna Riccipetitoni, MD, (CD) and 2 for ulcerative colitis (UC). The 3 Pediatric Surgery Department, “V.Buzzi” CD cases presented with ileocecal stenosis, Children’s Hospital ICP , Milan – Italy in 1 case associated with six further ileal stenoses. The 2 UC patients presented with INTRODUCTION: Patients affected by hemorrhagic colitis resistant to medical chronic inflammatory bowel diseases (IBD) treatment. A total of 13 procedures were may require numerous surgical procedures performed using the SILS: 4 procedures during lifetime. For this group of patients, in UC (2 colectomy + ileostomy and 2 J laparoscopic surgery represents the gold pouch ileoanalanastomosis + protective standard, allowing to perform major ileostomy), 9 procedures in CD ( 3 procedures with minimal invasiveness ileocecal resections + 6 stricturoplasties). and rapid remission. The single incision The operative time ranged from 180 to laparoscopic technique (SILS) is the ultimate

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360 minutes. All the SILS procedures METHODS: We performed a retrospective were completed without conversion. analysis of SIPES appendectomies No intraoperative nor postoperative performed using the sterilizable complications occurred. The oral nutrition polyethylene clip applier and compared started 4 days after surgery in all cases. No them to a same size control group of our adhesions were detected during procedures most recent stapled appendectomies, even after colectomy in complicated UC. done before transitioning to the clip technique. Patient demographics, CONCLUSIONS: Our preliminary experience operative time, training level of operating suggests that the SILS technique can be surgeon, blood loss, complications, and safely performed on patients with IBD. patient outcomes were recorded. We This approach permits a surprisingly rapid calculated the cost of the disposable recovery of the patient with limited pain and items necessary for an appendectomy excellent cosmetic results. The laparoscopic using either the traditional stapler or approach, avoiding multiple laparotomies, the novel polyethylene clip method. We reduces the risk of adhesions, facilitating also measured the amount of paper, further surgical procedures if needed. plastic, and metal trash generated using a S094: CLIPPED VERSUS STAPLED disposable stapler or polyethylene clips. SIPES (SINGLE INCISION PEDIATRIC RESULTS: A total of 20 patients per group ENDOSURGERY) APPENDECTOMY: were included. In the clipped group, there PATIENT OUTCOME, ECONOMIC were 13 simple, 4 complex, and 3 interval CONSIDERATIONS, AND ENVIRONMENTAL appendectomies, and in the stapled group Hayden W. Stagg, MD, Oliver IMPACT  there were 17 simple, 2 complex, and1 Muensterer, MD, PhD, Samir Pandya, MD, interval. The average operating time was Matthew Bronstein, MD, Lena Perger, MD, 51.6 (31-87) minutes in clipped versus 47.4 McLane Children’s at Scott and White, (26-96) minutes in stapled. All procedures Texas A&M,Temple TX, USA; Maria Fareri were performed by general surgery Children’s Hospital at Westchester Medical residents (PGY 1-4) and in some cases Center New York Medical College, Valhalla included other concomitant interventions NY, USA (resection of a vitelline artery, removal BACKGROUND: In our practice, single- of endometrial implants, mesenteric incision pediatric endosurgical (SIPES) lymph node biopsy) Mean estimated appendectomy has been performed with a blood loss (EBL) was 4.3 (0-10) ml, and linear cutting endosurgical stapler. Recently, mean length of stay (LOS) was 1 (0-6) day we transitioned to applying a series of in clipped group. In the stapled group polyethylene clips around the base with mean EBL was 5.2 (2-10) ml, and mean a reusable, sterilizable clip applier, and LOS was 0.8 (0-3) days. There were no subsequently cutting the appendix with complications in either group. Between the endoscopic shears, leaving one to three two institutions involved in the study, costs clips in situ. for the disposable items were US$ 32 for a cartidge of 6 polyethylene clips, versus a OBJECTIVE: This study compares the total of US$ 291-338 for the endosurgical polyethylene clip technique to stapled stapler (cost saving of US$ 259-306 per technique in terms of peri-operative case). Using clips generated 0.4g of paper variables, patient outcome, costs, and and 9.8g of plastic trash, while using the amount of trash generated. disposable stapler generated 12.9g of

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Oral Abstracts CONTINUED paper, 381g of plastic, and 582g of metal puncture method. The abdominal inner- trash (54x more trash than with clips). side tip of shaft is pulled out through the laparoscopic trocar. And the forceps shaft CONCLUSIONS: The performance of of 5 mm in diameter is connected to the laparoscopic appendectomies with tip of the shaft and the other outside tip of polyethylene clips appears just as safe and the shaft is attached to the handle in the efficient as using endosurgical staplers, but operative field. We used Endo ReliefTM is more economical, and environmentally in 1 case each of oophorocystectomy, friendlier. ovarian hemostasis, splenectomy, and right S095: INITIAL EXPERIENCE OF hemicolectomy and 4 cases of pediatric MINIMALLY INVASIVE LAPAROSCOPIC appendectomy in minimally invasive SURGERY ASSISTED BY PERCUTANEOUS surgery since 2013. A retrospective review of INSTRUMENTS ASSEMBLED IN chart and Operative reports was performed OPERATIVE FIELD Ryosuke Satake, MD, on all laparoscopic surgeries using Endo Keisuke Suzuki, MD, Tetsuro Kodaka, PhD, ReliefTM at Saitama Medical University, Kan Terawaki, PhD, Makoto Komura, PhD, Saitama, in Japan. Saitama Medical University, Department of RESULTS: In all cases but the first case, the pediatric surgery required time for assembly of instruments BACKGROUND: Needlescopic surgery is was less than 2 minutes without problem. defined as minimally invasive surgery with Oophorocystectomy was performed instruments that are 3 mm in diameter by single-incision laparoscopic surgery or less and is sometimes referred to as (TANKO) and the percutaneous instrument. minilaparoscopy. The major limitation of Ovarian hemostasis was performed with needlescopic surgery is the instruments 2 ports and the percutaneous instrument. themselves. The strength and durability The instrument was inserted from the of the instruments may limit tissue lower-side abdomen to reach the ovary. manipulation. Trocar-less instruments Splenectomy was performed by TANKO may also be useful to reduce abdominal and the percutaneous instrument. The trauma. Recently, the US Food and Drug instrument was inserted from the left- Administration approved the Percutaneous side abdomen to reach the splenic hilum. Surgical Set (Ethicon), which is designed Right hemicolectomy was performed to be assembled and disassembled by TANKO and two percutaneous inside the body with limitations. We used instruments. They were inserted at the percutaneous instruments assembled in lower abdomen and at the supraumbilical the operative field for minimally invasive region as grasping forceps for the bowel. laparoscopic surgery. The Needle Forceps Appendectomy with strong adhesion in - Endo ReliefTM was made by Hirata the 4 cases was performed by TANKO Precisions Co., Ltd. and was approved by and percutaneous instruments. Two the Ministry of Health and Welfare of Japan. percutaneous instruments were inserted in The purpose of this study was to evaluate 2 cases, and one instrument was inserted operative outcomes and ergonomics using in the other 2 cases. The instruments new percutaneous instruments assembled did not malfunction in any operation. in the operative field. No operation was converted to open surgery. The strength and durability of the METHODS: The Endo ReliefTM shaft of percutaneous instruments were sufficient 2.4mm in diameter was inserted by the for tissue manipulation, blunt dissection

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Oral Abstracts CONTINUED and coagulation. Wound infection at was strong. 91% favour mandatory the insertion point was not observed in simulator training during surgical any patient. In addition, the wound by residency and 79% advocate compulsory percutaneous instruments leaves minimally demonstration of basic competency prior visible scars. to trainees being allowed to operate on patients. 76% believe there is a role for CONCLUSION: Percutaneous instruments ‘take-home’ MIS simulators to be used could be simply assembled in the outside normal working hours. Amongst operative field with safety and certainty. Pediatric Surgeons these figures were This instrument had enough force for 95%, 79% and 73% respectively. Access to grasping tissues and organs. It may make an simulators was poor however, with only 32% important contribution to shorten operative having access to a simulator during working duration. Also, it ultimately limited tissue hours, falling to 18% outside working hours trauma and minimized the visibility of scars. (Pediatric Surgeons: 42% and 15%). S096: INTERNATIONAL OPINION ON The Pediatric Surgery group did not THE FUTURE OF MINIMALLY INVASIVE differ significantly from other specialties SURGERY - FROM A(BESECON) TO regarding warm-up, SiMIS and Robotic Roland W. Partridge, Paul Z(AGREB)  surgery, thus these are presented as overall M. Brennan, Mark M. Hughes, Iain A. results. ‘Informal mental’ warm-up, such as Hennessey, Royal Hospital for Sick Children, thinking though the steps of an operation, Edinburgh, UK, Alder Hey Children’s is practiced by 79%. 22% regularly perform Hospital, Liverpool, UK a ‘formal mental’ warm-up, eg. revising a AIMS: Minimally Invasive Surgery (MIS) procedure on a smartphone application. is now performed worldwide. This study 13% practice ‘informal physical’ warm-up, quantifies the use of simulators, pre- eg. placing a smaller case on a list before operative ‘warm-up’, single incision MIS a major MIS procedure, and 5% regularly (SiMIS) and robotic MIS in Pediatric Surgery perform ‘formal physical’ warm-up eg. and other surgical specialties globally. using a MIS simulator prior to an operating list. Significantly, 83% stated they would use METHOD: An online survey was a MIS simulator to warm-up before some or generated using a web-based survey all cases if they had regular access to one. tool (SurveyGizmo.com, Survey Gizmo, Boulder, USA). The authors invited contacts 44% have SiMIS equipment in their they have establish on the ‘professional department but it is used infrequently, with media’ network LinkedIn.com (LinkedIn only 13% having performed more than 25 Corporation, California, USA).A total of 1314 SiMIS cases in their careers to date. Only operating clinicians throughout the world 25% have access to Robotic MIS equipment were contacted. and just 7% have performed more than 25 Robotic MIS cases in their career so far. RESULTS: 257 responses were received from There was greater enthusiasm for Robotic 145 different cities ranging alphabetically MIS than SiMIS, with 49% (vs SiMIS: 42%) from Abesecon to Zagreb and spanning 63 hoping to undertake more of this type countries. 25% were Pediatric Surgeons. of MIS in the future. Perceived risks and The responders are an experienced group benefits of robotic and SiMIS are reported. (86% fully qualified specialists) with 63% performing more than 50 MIS cases per CONCLUSION: This study provides a unique year. Support for the use of MIS simulators international perspective, presenting a

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Oral Abstracts CONTINUED snapshot of the current global ‘state- (42%), right sided hernia (15%), liver in chest of-the-art’ of minimally invasive surgery (32%), weight < 2.5kg (35%), and persistent and surgeons’ aspirations for the future. R-to-L shunting (50%). 72% of participants It demonstrates that the global use of indicated that recent reports on significant simulators, pre-operative ‘warm-up’, hypercapnia and severe acidosis during single incision MIS (SiMIS) and robotic thoracoscopic CDH repair have changed MIS in Pediatric Surgery is similar to that their management. 52% of participants in other surgical specialties worldwide. It said that during thoracoscopy they would highlights strong support for the use of MIS tolerate any pH. In contrast, 48% indicated simulators, but that access to these devices that they would only tolerate pH/pCO2 remains poor. levels down/up to 7.2/80mmHg (range pH:6.9-7.3; pCO2:55-100mmHg). In cases S097: THORACOSCOPIC CDH REPAIR – A where a patch is needed 39% of participants SURVEY ON OPINION AND EXPERIENCE said they would continue thoracoscopically, Martin Lacher MD, AMONG IPEG MEMBERS 31% would convert and 31% stated that PhD, Shawn D St. Peter MD, Paolo Laje MD, the decision would be based on the size Benno M Ure MD, PhD, Caroll M Harmon of the defect. In case of conversion, 26% MD, PhD, Joachim F Kuebler MD, Hannover would convert to thoracotomy and 74% to Medical School (on behalf of the IPEG laparotomy. 56% of participants reported Research Committee) recurrences after thoracoscopic repair. Of BACKGROUND: Thoracoscopic repair of the last 5 thoracoscopic CDH repairs of each congenital diaphragmatic hernia (CDH) has participant, the following recurrence rates become popular among pediatric surgical were reported: 0/5 (44%), 1/5 (35%), 2-4/5 centers. Given the fact that there is an (6%), 5/5 (none). Recurrences occurred ongoing discussion on whether the benefits early (less than 6 months after surgery) in of the thoracoscopic repair outweigh 43% of the cases, late (more than 6 months the potential side effects, we aimed to after surgery) in 37%, and early AND late in investigate the opinion and experience of 20% of the cases. Overall, 50% of surgeons the members of IPEG on this topic. stated that CDH can be repaired equally by thoracoscopy and open thoracotomy and METHODS: An online based survey was 50% disagreed with this statement. conducted between 10/2013 a 12/2013 on behalf of the IPEG Research Committee. CONCLUSION: Thoracoscopic CDH repair All IPEG members were contacted is currently being performed by 89% of by email and asked to complete an all participating IPEG members. ECMO (at anonymous questionnaire that included the time of surgery or prior to the surgery) personal background and 28 items on the and persistent R-to-L shunting are the management of CDH. Trainees/fellows were main contraindications to thoracoscopic excluded from the study. repair. CDH recurrence after thoracoscopic repair has occurred to 56% RESULTS: 159 attending pediatric surgeons of participants at least once. The fact that (consultants), who perform thoracoscopic only 50% of surgeons stated that CDH CDH repair routinely (40%), occasionally can be repaired equally by thoracoscopy (49%), or never (11%), completed the and open surgery suggests that future questionnaire. Contraindications to studies should focus on identifying the thoracoscopic repair included: patient on appropriate patient population. ECMO (78%), preoperative need for ECMO

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V001: LEFT UPPER LOBECTOMY FOR V002: THORACOSCOPIC DIVISION CPAM USING A 3MM TISSUE SEALING OF H-TYPE TRACHEOESOPHAGEAL DEVICE; A STEP BY STEP APPROACH FISTULA Matthew S. Clifton, MD, Paul M. Stephen Oh, MD, Steven S Rothenberg, Parker, MD, Emory University/Children’s MD, The Morgan Stanley Children’s Healthcare of Atlanta Hospital, Columbia University INTRODUCTION: H-type PURPOSE: This video demonstrates a tracheoesophageal fistula repairs have step by step method for performing a historically been approached from thoracoscopic lobectomy in an infant. The either a low cervical or high thoracic anterior approach and the use of a 3mm incision, both of which are associated tissue dissector/ vessel sealer facilitates with attendant problems. Chief amongst the case in the small chest cavity of an these is adequate identification and infant. isolation of the fistula; it is commonly located at the level of the thoracic inlet. METHODS: A 3 month old female with The thoracoscopic approach provides a a pre-nataly diagnosed LUL CPAM magnified, improved view of the relevant underwent elective left upper lobectomy. anatomy, and pulls the operative field to The procedure was performed through 3 a site remote from the recurrent laryngeal trocars, a 4mm for the 30 degree 4mm nerve. telescope and 2 -3 mm ports. One of the 3mm ports was changed top a 5 mm port RUN TIME: 4 minutes 54 seconds at the end of the procedure to apply a METHODS: A 3 day-old 2.2 kg baby girl was 5mm clip to the bronchus and remove the referred for repeated coughing with feeds specimen. The 3 mm sealer was used to and an esophagram which demonstrated dissect out and seal all pulmonary vessels an H-type tracheoesophageal fistula. as well as complete the major fissure. Echocardiogram identified an atrial RESULTS: The procedure took 65 minutes. septal defect. In the operating room, rigid There were no failed seals, no intra- bronchoscopy showed a normal airway operative bleeding, and no airleak post- with the exception of a fistula in the operatively. The chest tube was removed posterior wall of the trachea; a #3 Fogarty on day 2 and the patient was discharged balloon catheter was inserted through on day 3. the fistula and the balloon inflated. Traction on the catheter wedged it into CONCLUSIONS: The use of the anterior the esophageal lumen at the position of approach and a 3mm sealer allows for the fistula. Flexible bronchoscopy was safe and effective lobectomy, even in used to perform a left mainstem bronchus the small chest cavity of an infant. The intubation. The child was positioned in anterior approach provides the greatest an exaggerated left lateral decubitus space between the instrument insertion position. A right thoracoscopic approach and the mediastinum. The 3 mm sealer was used with 3mm equipment. Dissection works more efficiently and ergonomically commenced cephalad to the azygous vein, in this small cavity then previously used below the level of the fistula. The position 5mm devices, improving the ease of the of the Fogarty balloon in the esophagus operation. was identified and followed to isolate the fistula. The fistula was isolated with a silicone vessel loop and then the Fogarty

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Video Abstracts CONTINUED withdrawn. The tracheal side of the fistula METHODS: The patient is a 9 month-old was closed with two 5mm Hem-o-lok female who presented to the Emergency clips, the esophageal side tied off with size Department with progressive stridor for 0 braided absorbable suture twice, and 3 weeks. Her symptoms did not improve the fistula divided. At the completion of despite trying a regimen of antibiotics the operation, an 8 French feeding tube and steroids. A chest Xray and neck Xray was guided through the esophagus and a showed significant tracheal deviation. 12 French chest tube placed into the right Bronchoscopy revealed tracheal hemithorax. compression by an external source. CT scan confirmed a mass at the thoracic RESULTS: Operative time for inlet. thoracoscopic division of the H-type tracheoesophageal fistula was 90 RESULTS: The decision was made to minutes. Nasogastric feeds were approach the mass thoracoscopically. One initiated with return of bowel function. 5mm port was used for the camera, one An esophagram on postoperative day 5 mm port, one 3 mm port, and one 3 7 showed no leak and no stricture. Oral mm stab incision were used for exposure feeds were started and the thoracostomy and dissection. Upon placing the camera tube removed. Repeat esophagram at 14 in the chest, a bulge from the cyst was months showed no evidence of stricture. seen lying posterior to the subclavian vessels and anterior to the aorta. Once CONCLUSION: We demonstrate the the cyst was exposed, a combination of thoracoscopic approach to repair of blunt and sharp dissection was performed an H-type tracheoesophageal fistula. to mobilize the cyst. The cyst was This approach utilizes placement of an decompressed to ease the dissection. As intraluminal balloon catheter to identify medial dissection of the cyst proceeded, the location of the fistula. Caudal attachment to the cricopharyngeus traction on the fistula down into the muscle was visualized. Dissection chest minimizes the risk of injury to the proceeded through a translucent plane recurrent laryngeal nerve. between the cyst and the esophagus until V003: THORACOSCOPIC RESECTION the cyst came off of it completely. Once OF A BRONCHOGENIC CYST LOCATED the cyst was removed, the trachea and AT THE THORACIC INLET Meghna V. the esophagus were clearly seen at the Misra, MD, Tulio Valdez, MD, Anthony medial dissection plane. These structures Tsai, MD, Brendan T. Campbell, MD, MPH, appeared grossly intact. Connecticut Children’s Medical Center CONCLUSION: The patient did well BACKGROUND: Bronchogenic cysts are overall postoperatively. Her course was a type of foregut duplication cyst. They complicated by development of an can appear in several different locations asymptomatic esophageal diverticulum in the mediastinum. Controversy exists and a left recurrent laryngeal nerve traction over the best method by which to excise injury. She recovered from both of these cysts that are located at the thoracic inlet. injuries completely. Complete thoracoscopic This is the first case report on complete excision of bronchogenic cysts at the thoracoscopic excision of a bronchogenic thoracic inlet can be performed safely. cyst located at the thoracic inlet. However, complications can happen with any type of resection that is performed at

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Video Abstracts CONTINUED this location. Expectations should be set TIPS: Its possible to apply the accordingly with family members regarding thoracoscopic approach in the treatment possible complications. of recurrent fistulisation after TEF repair. The use of a mesh or a tissue to separate V004: THORACOSCOPIC APPROACH IN the esophagus from the trachea is highly RECURRENT TRACHEOESOPHAGEAL recommended. FISTULA Ruben Lamas-Pinheiro, MD, Carlos Mariz, MD, Joaquim Monteiro, V005: A THORACOSCOPIC APPROACH MD, Tiago Henriques-Coelho, MD, PhD, TO AN UNUSUAL MEDIASTINAL MASS Pediatric Surgery Department, Faculty Victoria K. Pepper, MD, Peter C. Minneci, of Medicine, Hospital de São João, Porto, MD, Karen A. Diefenbach, MD, Nationwide Portugal Children’s Hospital INTRODUCTION: Recurrent fistulisation PURPOSE: We present a thoracoscopic after tracheoesophageal fistula (TEF) resection of an unusual mediastinal cystic repair can be a complication of difficult mass in a 2-year-old boy. management. There is very few data on METHODS/FINDINGS: A previously- thoracoscopic reintervention. The authors healthy 2-year-old male presented to present a video of a thoracoscopic the emergency room with cough. On approach in a recurrent fistula after TEF chest x-ray, he was found to have a repair by thoracotomy. mediastinal widening and subsequent CASE: A child with 20 months of life was chest CT revealed a cystic mediastinal diagnosed with a recurrent fistula by mass. The patient was taken to the OR bronchoscopy. The boy had a history of for thoracoscopic excision. A 5-mm port recurrent respiratory symptoms after a was inserted in the mid-axillary line. surgical correction of esophageal atresia Two 5-mm ports were placed in the 4th with TFE by thoracotomy. A right side and 8th intercostal spaces. Although thoracocopy was performed: three trocars pre-operative imaging suggested a were used (two 5mm and one 3mm). thymic cyst, the thymus was visualized Right upper lobe adhesions from previous and no mass was associated with it. surgery were divided with electrocautery. Inspection revealed that the mass The azygus vein was identified and was intrapericardial. After opening the preserved. The TEF was identified just pericardium, the mass was noted to be above the azygus vein, dissected and adherent to the aortic root. It was freed isolated, two titanium clips were applied from the aorta with careful dissection. The and the fistula was then divided. The patient did well post-operatively and was clips were reinforced with endoloops®. A discharged home on post-operative day 3. prolene® mesh was interposed between Final pathology revealed a mature cystic the trachea and the esophagus. There teratoma. were no postoperative complications. CONCLUSION: While intrapericardial The nasogastric tube was removed in teratomas are rare, they should be a the first postoperative day and the child part of the differential in an abnormally was discharged in the second day after presenting anterior or middle mediastinal starting oral feeding. Currently, the child mass. While care must be taken both is followed in outpatient clinic and he is with patient selection and intraoperative otherwise healthy. management, thoracoscopic resection

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Video Abstracts CONTINUED of these lesions is feasible, and has the RESULTS: The procedure was potential benefits of smaller incisions, well tolerated by the patient, and less post-operative pain, a shorter length hemodynamics improved immediately. of stay, and a quicker return to normal The operative time was 36 minutes and activity. blood loss was minimal. The chest tube was removed on postoperative day 8, V006: THORACOSCOPIC PERICARDIAL at which time the cardiac silhouette WINDOW FOR TREATMENT OF had normalized (Figure C). A chest CT REFRACTORY PERICARDIAL EFFUSION performed one month later for worsening AND TAMPONADE Oliver J. Muensterer, pulmonary status showed no recurrent MD, PhD, Samir Pandya, MD, Matthew pericardial or pleural effusion (Figure D). E. Bronstein, MD, Gustavo Stringel, MD, Suvro S. Sett, MD, Divisions of Pediatric CONCLUSIONS: Pericardial windows can Surgery and Pediatric Cardiac Surgery, be performed safely via a thoracoscopic New York Medical College approach in children with symptomatic chronic pericardial effusions. The BACKGROUND: Chronic pericardial procedure is simple, quick, and normalizes effusions may present with a spectrum cardiac function immediately. The surface of symptoms. When the volume of fluid area of the pleura seems to be adequate in the pericardium increases briskly, it for resorption of the pericardial fluid in may compromise cardiac function. In this case. such cases, urgent pericardiocentesis for short term management is indicated. A V007: COMBINATION OF VALUABLE more permanent solution is the creation TECHNICAL RESOURCES FOR THE of a pericardial window. In children, this is CORRECTION OF DIAPHRAGMATIC mostly performed through a subxiphoid HERNIA (VIDEO) Carolina Millan, MD, open approach. Fernando Rabinovich, MD, Luzia Toselli, MD, Horacio Bignon, MD, Gaston Bellia, OBJECTIVE: We describe a thoracoscopic MD, Mariano Albertal, MD, Guillermo technique for creation of a pericardial Dominguez, MD, Marcelo Martinez Ferro, window in a toddler. MD, Private Children’s Hospital of Buenos CASE: A 2 year old girl with Down syndrome Aires, Fundación Hospitalaria, Buenos with acute myeloid leukemia treated Aires, Argentina with bone marrow transplant developed The surgical management of anterolateral a large, chronic pericardial effusion as a diaphragmatic hernia can pose a result of graft-versus host disease (Figure challenge to surgeons. In this video we A). Several attempts of ultrasound-guided shown several technical resources used to pericardiocentesis were performed, with overcome limitations during laparoscopic re-accumulation of the fluid and signs correction of a left anterolateral of cardiac tamponade within a few days. diaphragmatic hernia. After stabilization, she was taken to the operating room where a pericardial window anterior to the right phrenic nerve was created thoracoscopically using ultrasound shears (Figure B). An 8F Jackson-Pratt drain was placed as a chest tube.

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Video Abstracts CONTINUED

V008: THORACOSCOPIC MANAGEMENT V009: TRANSCONTINENTAL OF AN ESOPHAGEAL LUNG, REPORT TELEMENTORING WITH PEDIATRIC OF A CASE Ivan Dario Molina, MD, SURGEONS- PROOF OF CONCEPT AND Santiago Correa, MD, Ana Garces, MD, TECHNICAL CONSIDERATIONS Todd A. Mizrahim Mendez, MD, Edgar Alzate, MD, Ponsky, MD, Marc H. Schwachter, MD, Ted Fundación Hospital de la Misericordia, Stathos, MD, Michael Rosen, MD, Robert Universidad Nacional de Colombia Parry, MD, Margaret Nalugo, Steven Rothenberg, MD, Akron Children’s Hospital, Esophageal lung is a rare Rocky Mountain Hospital for Children, broncopulmonary foregut malformation, University Hospitals Case Medical Center in which the main stem bronchus arises from the esophagus. Since the description New skill acquisition poses a challenge by Keely et al. in 1960, less than 20 for post-graduate practicing surgeons. cases have been reported. We present Current methods for skill acquisition a case of a 4-month-old female, who include practicing on simulation models was referred to our institution after 2 and attending courses. However, these months of management for respiratory are probably not adequate for true skill recurrent infections. Contrast studies acquisition. The true skill acquisition were performed during the evaluation model for postgraduate surgeons most and a right broncography was identified likely involves developing a relationship in the esophagogram. Bronchoscopy was with an expert in which the mentee visits performed confirming the atresic right the mentor and vice versa. However, bronchus. Complementary imaging and for this to be realistic there must be cardiology evaluation confirmed the ongoing mentorship which can only absence of major vascular anomalies, be accomplished realistically with especially a pulmonary artery sling that Telementoring. The concept of Tele has been described in relation with this mentoring has been discussed and even entity. Due to the hypoplastic lung in the piloted in other areas of medicine. Here absence of major vascular anomalies, we show proof of concept and technical thoracoscopic pneumonectomy was considerations for Telementoring in deemed possible. Procedure was pediatric surgery. We describe the logistics performed with four ports and 3 mm and technical details of six transcontinental equipment was used. Special attention pediatric surgery telemonitoring cases was made identifying and dissecting between an expert in the less experienced the vascular structures first, and then pediatric surgeon. the arising esophageal bronchus was dissected. The hypoplastic lung was V010: VAGINAL AGENESIS AND ATRESIA extracted through a small incision inferior OF THE UTERINE CERVIX ASSOCIATED TO to the axilla. As for our knowledge this is VESTIBULAR FISTULA Maria M. Bailez, MD, the first case reported of thoracoscopic Lucila Alvarez, MD, Garrahan Children’s management of this pathology, and we Hospital, Buenos Aires, Argentina consider that due to the hypoplastic lung Uterovaginal anomalies are a spectrum of and vessels, the thoracoscopic approach anomalies, which are often associated with is safe and feasible for the management renal and sometimes anorectal anomalies. of the esophageal lung and even for de esophageal bronchus in the absence of AIM: Show a succesful staged laparoscopic major vascular anomalies. treatment of a patient previously

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Video Abstracts CONTINUED operated for an ARM with a non diagnosed entity. It is often associated with associated vaginal agenesis and atresia of absence of the vagina. Although there the uterine cervix. is general agreement that if the cervix is absent, without any cervical stroma, CASE: A 13 years old female presented hysterectomy is advisable to prevent with severe acute pelvic pain .She had ovarian endometriosis and pelvic undergone an anorectoplasty through a infections, preservation of the uterus posterior sagital approach for a vestibular may be intented in selected patients.We fistula at the age of 2. She had never had have previously treated 4 patients with menses yet. No vaginal opening was found vaginal associated to cervix agenesis using at perineal exam. Ultrasonography showed a combined laparoscopic and perineal an hematomethra and a left complex approach Laparoscopy was useful to adnexal mass. An initial laparoscopic define the anomaly and to complete approach showed a single uterus with hysterectomy after the evidence of total an hematomethra and a left ovarian cervix aplasia and to perform a sigmoid endometrioma that was removed. With vaginal replacement. This is our first no evidence of associated hematocolpos, patient undergoing a long term successful a cervical atresia associated to vaginal laparoscopic assisted sigmoid vaginal agenesis was suspected and a drain replacement, cervical canalization and was placed in the fundus . Menses were uterovaginal anastomosis even after inhibited using , allowing psycological previous abdominal and perineal surgery support .An MRI confirmed atresia of (sigmoid colostomy and PSARP). the cervix. A combined laparoscopic and perineal approach to enable sigmoid 2) The diagnosis of a uterovaginal anomaly vaginal replacement,cervical canalization is a common misleading finding in patients and a uterovaginal anastomosis followed. with vestibular fistula . A meticulous perineal exam is mandatory in newborns Three working ports were used . Bowel with this anomaly to plan combined vaginal adhesions secondary to colostomy take and anorectal reconstruction avoidiing down were freed . A 15 cm long distal redo surgery and sequela related to sigmoid was isolated. Dissection between obstructive functional mullerian ducts theurethra and rectum followed.Linear q.We have previously reported a combined staplers were inserted from this approach endoscopic and laparoscopic initial to transect the colon.The uterine cervix area assesment as a less invasive and time was dissected preserving its vascular supply. consuming approach for atypical ARM like Recanalization of its lumen was achieved. the one presented. Enlarging the suprapubic port entry was used to facilitate suturing of the proximal V011: ENDOSCOPIC GASTROCUTANEOUS end of the neovagina around the cervix. FISTULA CLOSURE USING AN OVER THE SCOPE CLIP James Wall, MD, MS, Lucile RESULTS: Operative time was 210 minutes. Packard Children’s Hospital Stanford The patient presents irregular menses without clinical and ultrasonographic BACKGROUND: Gastrocutaneous fistula evidence of infection or obstruction after a closure is commonly required for long- 38 months follow up period term gastrostomy sites. Standard surgical repair can be complicated in cases of DISCUSSION: 1) Agenesis or atresia local skin excoriation or extensive prior of the cervix uteri is an uncommon abdominal operations. Endoscopic

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Video Abstracts CONTINUED methods have been described for INTRO: This video demonstrates the closing a variety of enteric fistulas. laparoscopic resection of a neuroendocrine Shape memory metal (Nitinol) clips that tumor of the common bile duct (CBD) with fit over an endoscope have recently a hepaticoduodenostomy been approved for several endoscopic METHODS: A 15 year old female presented purposes including closure of the with evidence of acute cholangitis and intestinal wall. Such over the scope clips evidence of biliary obstruction. Total enable circumferential closure of larger bilirubin was 2.4 and an ultrasound showed defects than standard endoscopic clips a markedly dilated common hepatic passed through the working channel. duct and a question of a large intra- METHODS: We report a series of 4 hepatic stone. An ERCP was performed patients who underwent endoscopic and the obstructing mass was found to gastrocutaneous fistula closure using be extra-luminal. A transductal biopsy gold probe cauterization of the fistula failed to obtain tissue for diagnosis. An tract followed by placement of an over intraductal stent was placed to relieve the the scope clip. Ages ranged from 6 to obstruction. A CT scan was obtained and 21 years old. The patients were selected showed a 2.5 x 2.5 x 2.4 mass adjacent to for this intervention based on persistent and compressing the CBD. A laparoscopic skin excoriation around the fistula site biopsy was performed for diagnosis or history of extensive prior abdominal primarily to rule out lymphoma. operations. A laparoscopic resection was then RESULTS: The procedure was technically performed using 3 - 5mm ports. The feasible in all cases with an average specimen was removed thru an enlarged operative time of 18 minutes. There were umbilical incision intact inside a specimen no failures at 1-month follow-up. One bag. Proximal and distal margins were patient reported mild throat pain for 2 checked for tumor by frozen section. weeks following the procedure. A hepaticoduodenostomy was then CONCLUSION: Endoscopic performed to reconstruct the bile drainage gastrocutaneous fistula closure using over system. the scope clips is technically feasible in the RESULTS: The surgery was completed pediatric population with promising initial successfully laparoscopically in 140 results. The size of the current endoscopic minutes. The patient was started on po caps required to deliver these clips may feeds on the 4th post-operative day and not be suitable for very small children. The discharged on day 5. The final pathology existing caps may additionally contribute showed a Grade 1 neuroendocrine to oropharyngeal trauma resulting in post- neoplasm with papillary features. There operative dysphagia. was no evidence of local or distant V012: LAPAROSCOPIC RESECTION invasion. OF A NEUROENDOCRINE TUMOR At 2 week follow-up all lab values had OF THE COMMON BILE DUCT WITH returned to normal. A complete metastatic HEPATICODUODENOSTOMY Steven S. work-up was negative. Rothenberg, MD, The Rocky Mountain Hospital For Children CONCLUSION: This case presents a rare finding of a primary bile duct tumor.

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Laparoscopy was a safe and effective entrance from the vertebral column. The technique for resecting the tumor infraumbilical port site was changed to and avoided the morbidity of a large a 10mm trocar and an EndoCatch bag laparotomy without compromising the was inserted. The specimen was placed cancer operation. into the bag, morcelated sharply, and brought out in a piecemeal fashion. The V013: LAPAROSCOPIC RESECTION patient did well post-operatively and OF A LARGE RETROPERITONEAL was discharged home on POD # 3 with GANGLIONEUROMA Bethany J. Slater, no complications. The final pathology MD, Steven S. Rothenberg, MD, Rocky revealed ganglioneuroma, and no further Mountain Hospital for Children treatment was required. A 4 year old female presented with V014: LAPAROSCOPIC LEFT PARTIAL recurrent UTIs. An ultrasound was ADRENALECTOMY IN A CHILD WITH obtained for workup and demonstrated VON HIPPEL-LINDAU AND RECURRENT a 5 cm mass solid mass near the porta PHEOCHROMOCYTOMA A. B. Podany, hepatis. A subsequent MRI showed MD, A. Dash, MD, D. V. Rocourt, MD, a 5.8x4.9x4.8 cm heterogenous Pennsylvania State Hershey Medical retroperitoneal mass compressing Center the inferior vena cava and displacing the second and third portions of the PURPOSE: Patients with Von Hippel- duodenum. Laboratory values were Lindau are at high risk of developing unremarkable. A laparoscopic biopsy of recurrent pheochromocytoma. In this the mass was performed with pathology 13 year-old patient status post right consistent with a ganglioneuroma. adrenalectomy with recurrence on the MIBG scan confirmed the localized left, we hypothesized that a laparoscopic mass with no evidence of metastatic left partial adrenalectomy would be safe disease. The patient was then taken to and effective at removing the tumor, the operating room for laparoscopic while preserving native adrenal function. resection of the retroperitoneal tumor. METHODS: Though asymptomatic, A 4 mm infraumbilical trocar was used due to the patient’s prior history of for the camera, and a 3mm trocar in the pheochromocytoma, preoperative alpha right mid quadrant and 5 mm trocar in blockade was undertaken. He presented the left mid quadrant were inserted. electively on the day of surgery and The gallbladder was retracted superiorly underwent a laparoscopic left partial with a suture through the abdominal adrenalectomy. Key portions of the wall. The transverse colon was mobilized procedure include mobilization of the inferiorly. The duodenum, which was splenic flexure, circumferential dissection densely adherent to the tumor, was of the tumor with preservation of the dissected medially. The tumor was renal vein, renal artery, and the adrenal then carefully mobilized from the vein, and separation of the tumor from surrounding tissues including the inferior normal residual adrenal gland. vena cava. There was a feeding vessel from the inferior vena cava which was RESULTS: Final pathology demonstrated sealed and divided using the Ligasure complete resection and was consistent device. There were also two nerve roots with a 2.6x2.3x1.9 cm pheochromocytoma identified which were divided near their with intact capsule. Postoperatively,

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Video Abstracts CONTINUED the patient recovered well, with no ERCP. On MRCP, she was found to have complications and no requirement for a diffusely dilated main pancreatic duct cortisol replacement. He was discharged (6-9 mm) distal to a large stone which home on postoperative day number two. was located at a strictured area of the He will continue to be followed by his main pancreatic duct. The accessory duct endocrinologist for annual screening. was draining the uncinate process and non-dilated. ERCP was performed and CONCLUSIONS: The technique for small pancreatic stone fragments were laparoscopic partial left adrenalectomy removed but the large stone could not be described here has utility in the pediatric accessed. She was referred for operative population to preserve adrenal function intervention. during years of growth. Patients with Von Hippel-Lindau are at high risk RESULTS: At 4 years 9 months of age, of recurrence and need continued the child underwent a laparoscopic surveillance. This patient will continue to cholecystectomy, pancreatic duct benefit from preserved native adrenal stone clearance, and Roux-en-Y function for months to years before pancreaticojejunostomy (Peustow) potential recurrence. anastomosis. The child weighed 17.9 kg at the time of operation which took V015: LAPAROSCOPIC LATERAL 235 minutes and there were no intra- PANCREATICOJEJUNOSTOMY- PEUSTOW operative complications. This video shows PROCEDURE- IN A 4 YEAR OLD WITH the Peustow portion of the procedure. PANCREATIC DUCTAL OBSTRUCTION Five trocars were used. One 12 mm trocar Miller Hamrick, MD, Mikael Petrosyan, in the umbilicus; and 4 x 5mm trocars MD, Eric Jelin, MD, Timothy D. Kane, MD, in the left upper abdomen, left lower Children’s National Medical Center abdomen (periumbilical), right upper BACKGROUND: Pancreatic ductal quadrant, and right lateral abdomen obstruction leading to ductal dilation (periumbilical). The lesser sac was and recurrent pancreatitis is uncommon entered after taking down the gastrocolic in children. This is a video of a 4 year old omentum and utilizing trans-abdominal girl who presented at 10 months of age stay sutures to elevate the stomach with high grade duodenal obstruction, anteriorly to expose the pancreas. A 10 gastric pneumatosis, pneumobilia, and mm laparoscopic ultrasound probe was gas within a dilated pancreatic duct used to identify the main pancreatic on abdominal computed tomography duct and cautery used to perform the scan with presumed annular pancreas pancreatotomy. A 3 cm longitudinal or pancreatic head enlargement or incision in the pancreatic duct was created mass. At that time, she had undergone and duct was irrigated clear of debris a laparoscopic duodenoduodenostomy and protein plugs. A 3 French Fogarty and had symptomatic relief for 2 years. catheter was used to remove the large She returned at 3 years of age with stone from the proximal duct. A Roux- pancreatitis on 3 separate occasions, en-Y jejunojejunostomy was created 20 once requiring hospital admission. At 4 cm from the ligament of Treitz extra years of age, she had 3 more episodes corporeally using an endostapler and the of pancreatitis and was admitted to Roux loop limb was passed retrocolic undergo magnetic resonance imaging into the lesser sac. Stay sutures and a cholangiopancreatography (MRCP) and running 4-0 PDS non-absorbable suture

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Video Abstracts CONTINUED were used to complete the side to side performed. At 13 months of age, after pancreaticojejunostomy anastomosis. A having accomplished adequate anal drain was left in the lesser sac. dilations, a colostomy takedown was performed. However, four weeks later, CONCLUSION: Indication for lateral the patient was noted to be passing pancreaticojejunostomy or Puestow stool per vagina as well as per rectum. procedure is rare in children and even She was taken back to the operating less often performed using laparoscopy. room where a rectovaginal fistula was The use of laparoscopic ultrasound was again identified within the introitus, and a critical in identifying the dilated pancreatic diverting colostomy was re-established. duct and enabled the performance of A subsequent postoperative contrast the procedure. Only 4 other laparoscopic enema also visualized the fistula. At 18 Peustow procedures have been reported months, the patient returned to the OR in children (ages 6-12), in addition to 1 for a planned ligation of the rectovaginal robotic-assisted Puestow operation in a fistula via a posterior sagittal approach. 14 year old. The rarity of this anomaly as In the prone position, the fistulous well as the complexity of performing the connection could not be identified. Thus, operation laparoscopically likely impacts a laparoscopic exploration was performed this observation. whereupon a colorectal duplication with V016: LAPAROSCOPIC CORRECTION two distinct blood supplies, starting OF COLORECTAL DUPLICATION AND approximately 4 cm distal to the mucus VAGINOPLASTY Kanika A. Bowen, MD, fistula, was identified. One lumen Kevin Platt, BS, Alli Wu, BS, Kasper Wang, communicated with the vagina and the MD, Children’s Hospital of Los Angeles other lumen connected to the anus. Proximally the two lumens coalesced INTRODUCTION: Tubular colorectal to form a single lumen just distal to the duplications are rare congenital anomalies mucus fistula. The rectovaginal fistula was with widely varied presentations. These divided laparoscopically. The duplicated anomalies are often misdiagnosed lumens were made into a single channel until discovered intra-operatively. by using a laparoscopic stapler passed Here, we present a case of an unusual distally through the mucus fistula under colorectal duplication which we repaired laparoscopic guidance, and the PSARP laparoscopically. was revised. A subsequent postoperative CASE DESCRIPTION: An 8-month-old contrast enema demonstrated no leak. girl with a suspected cloaca, status CONCLUSION: An imperforate anus with a post creation of a diverting colostomy colorectal duplication terminating in dual and mucus fistula was referred from rectovaginal fistulae has not previously an outside hospital. The child also had been reported. This case illustrates an associated cleft lip/palate, a small the difficulty in diagnosing colorectal ventricular septal defect, and hydroureter. duplications and the utility of laparoscopy On physical examination, the patient in the treatment of these duplications. was thought to have an imperforate anus with a rectovestibular fistula. In the operating room, a rectovaginal fistula was instead identified, and a posterior sagittal anorectoplasty (PSARP) was

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V017: LAPAROSCOPIC PROPHYLACTIC The duodenocolic ligament was incised, TOTAL GASTRECTOMY IN CHILDHOOD and the first portion of the duodenum was FOR THE PREVENTION OF HEREDITARY cleared circumferentially and transected DIFFUSE GASTRIC CANCER Benjamin 2 cm distal to the pylorus. The right and Zendejas, MD, MSc, Abdalla E. Zarroug, left gastric vessels were divided. The MD, Michael L. Kendrick, MD, Department gastroesophageal junction was cleared of Surgery, Mayo Clinic, Rochester, MN, circumferentially. An esophagogastroscopy USA was performed to localize and mark the Z-line and the distal esophagus was INTRODUCTION: Mutations in the divided with a stapler. A Roux limb was E-cadherin (CDH1) gene confer an created dividing the proximal jejunum 50 80% lifetime risk of hereditary diffuse cm distal to the ligament of Treitz. A 150- gastric cancer (HDGC).1Due to unreliable cm limb was measured, and a side-to-side screening modalities, prophylactic total enteroenterostomy was created with a gastrectomy (PTG) is recommended for linear stapler. A window was made in the individuals at risk for HDGC.2-3Due to left mesocolon, and 20-cm of Roux limb genetic anticipation (cancer occurring was passed through this window into the at an earlier age with each successive lesser sac. A hand-sewn, two-layered end- generation), the age at which PTG is to-side esophagojejunostomy was created. recommended is not clearly defined, An air leak test was performed, no air leaks but generally recommended before 20 were identified. The gastrectomy specimen years of age.4We present the case of an was removed and no intra-operative asymptomatic 15 year old male, positive complications occurred. for CDH1 mutation, with a strong family history of HDGC (father and paternal RESULTS & CONCLUSIONS: Operative time uncle, both died from biopsy-proven was 117 minutes, estimated blood loss was diffuse gastric cancer at ages 42 and 40 milliliters, and the patient tolerated 15, respectively), who underwent a the procedure well. A water soluble laparoscopic PTG for the prevention of contrast esophagogram was performed HDGC. the following morning which showed no contrast extravasation. His diet was MATERIALS AND METHODS: Pre- advanced and he left the hospital without operative evaluation included genetic, sequelae. Pathologic evaluation of the psychological, endocrine, nutritional and specimen revealed no invasive cancer. surgical evaluations; the patient essentially With a mean follow-up of 6 months, no went through our adolescent bariatric perioperative complications have been surgery program. Upper gastrointestinal identified. In conclusion, laparoscopic PTG endoscopy was unremarkable. His can be safely and successfully performed comorbidities included obesity (body mass in childhood kindreds at risk for hereditary index 34kg/m2), asthma, and depression. diffuse gastric cancer. Until more is known A laparoscopic PTG with Roux-en-Y about when these patients develop esophagojejunostomy reconstruction was gastric cancer, strong consideration planned. Intraoperatively, with patient in should be given to perform prophylactic the supine position, 5 working ports were gastrectomy during mid-teenage years placed. The gastrocolic ligament was in patients with a family history of early divided and mobilized to the angle of His gastric cancer. with division of the short gastric vessels.

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REFERENCES: Harmonic scalpel, which was also used to 1. Guilford P, et. al. Nature. ligate the short gastric blood vessels up to 1998;392(6674):402. the angle of His as well as the vessels into the antrum, just inside the gastroepiploic 2. Huntsman DG, et. al. N Engl J Med. artery to approximately 4-cm above the 2001;344(25):1904 pylorus. Cautery injury to the stomach 3. Hebbard PC, et. al. Ann Surg Oncol. was carefully avoided. Four 2-0 polyester 2009;16(7):1890. sutures were placed in an interrupted 4. Cisco RM, et. al. Cancer. 2008;113(7 fashion along the greater curvature, as Suppl):1850. well as at the incisura, and one on the antrum. Each of these sutures included a V018: LAPAROSCOPIC GASTRIC small portion of the posterior stomach as PLICATION IN ADOLESCENTS AND well as the anterior stomach to imbricate YOUNG ADULTS WITH SEVERE OBESITY: in the greater curvature. A 35-cm 2-0 DESCRIPTION OF FIRST PATIENT polypropylene running suture was then ENROLLED IN PILOT STUDY Shannon F. started just inferior to the angle of His and Rosati, MD, Dan Parrish, MD, Poornima further plicated the greater curvature and Vanguri, MD, Matthew Brengman, antrum. Flexible esophagogastroscopy MD, FACS, Patricia Lange, MD, Claudio confirmed that the plication was initiated Oiticica, MD, David Lanning, MD, PhD, in a satisfactory manner. A shorter second Children’s Hospital of Richmond at Virginia polypropylene suture was used to further Commonwealth University Medical Center imbricate the antrum of the stomach. A INTRODUCTION: Laparoscopic Gastric final running 2-0 polypropylene suture Plication (LGP) is a novel restrictive bariatric further imbricated the greater curvature operation that has had some success in from the angle of His to below the incisura. the adult patients with weight loss and Care was taken to ensure that the diameter improvement in associated comorbidities. of the incisura was not compromised. We are currently conducting a prospective Final esophagogastroscopy confirmed research study, IRB # HM14809, entitled good apposition of the plicated stomach “A Pilot Study of Laparoscopic Gastric mucosa along the entire course of the Plication in Adolescents and Young Adults” lesser curvature without evidence of and have included the details from our first obstruction. The port sites were closed in case in this abstract. standard fashion. The patient tolerated the procedure well with minimal blood PATIENT: This 17 year old girl is followed loss and no perioperative complications. in our multidisciplinary weight loss She was discharged home on the third program. While she had been adherent postoperative day on a liquid diet. At her to the program, she was only able to lose two week follow up, she was noted to have approximately 7 pounds over 6 months no nausea or pain, was advanced onto her (preop BMI was 42.5) and had several pureed diet, and had lost ten pounds. comorbidities. CONCLUSION: This report details the TREATMENT: Three 5-mm and one 12- perioperative results of the first patient mm trocars were placed across the upper enrolled in a new pilot study examining portion of her abdomen and a Nathanson LGP in morbidly obese adolescents and liver retractor in the epigastrium. The fat young adults. As the LGP is purported pad over the cardia was excised with a to be reversible and some parents are

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Video Abstracts CONTINUED hesitant to consent to gastric bypass CASE 2: Another 9-month-old boy or sleeve resection for their child, this was referred to our department for operation may be a reasonable alternative intussusception, and a left upper polar for young patients that have not been renal multilocular cystic mass was successful with nonoperative treatment incidentally detected by abdominal of their morbid obesity. ultrasound. CT showed a well- circumscribed 5.2 × 4.3 × 3.5 cm mass, V019: LAPAROSCOPIC PARTIAL occupying three-fourths of the kidney. NEPHRECTOMY FOR THE TREATMENT OF LARGE CYSTIC NEPHROMA IN In both cases, CN or CPDN was suspected, CHILDREN Yujiro Tanaka, MD, PhD, Hiroo but differential diagnosis was not possible Uchida, MD, PhD, Hiroshi Kawashima, MD, without surgical resection. Shinya Takazawa, MD, Takayuki Masuko, PROCEDURE: After inserting a ureteral MD, PhD, Kyoichi Deie, MD, Hizuru Amano, catheter to the pelvis, the affected kidney MD, Michimasa Fujiogi, MD, Tadashi was approached transperitoneally. The Iwanaka, MD, PhD, Prof, Department precise area of the lesion was detected of Pediatric Surgery, Saitama Children’s using a laparoscopic ultrasound probe, Medical Center & The University of Tokyo and the vessels of the affected part were BACKGROUND: Cystic nephroma (CN), also identified, dissected and excised. After called multilocular cyst of the kidney, is a clamping the renal artery with a hemostat, rare benign renal neoplasm. The differential the parenchyma of the affected part diagnosis of cystic partially differentiated was dissected out and divided using a nephroblastoma (CPDN) is only possible Harmonic Scalpel™. The partly cut pelvis based on pathological findings. Therefore, was closed by monofilament sutures. surgical resection is necessary to diagnose The resected stump was coated with lesions suspected to be CN. Because CNs Beriplast™ P, covered with Surgicel™, are usually well-demarcated and have and finally covered with the pediculate a good prognosis, partial nephrectomy peritoneum, which was used for hemostat without preoperative chemotherapy sealing and fixation of the remaining is recommended for their treatment. kidney. However, to our knowledge, laparoscopic RESULTS: Laparoscopic partial nephrectomy treatment of CN has not been reported. In was performed at 11 months (Case 1) and the present report, we describe two cases of 10 months (Case 2) of age. Operative time large CN, which were successfully treated by for Cases 1 and 2 was 460 min and 415 min, laparoscopic partial nephrectomy. and total warm ischemia time was 63 min CASE HISTORY: and 28 min, respectively. The lesion was not CASE 1: A 9-month-old boy was referred exposed during the operation in both cases, to our department because of a lower and the microscopic features were cysts polar multilocular cystic mass of the right lined by cuboidal cells separated by fibrous kidney, which was incidentally detected septae without any sign of malignancy, by abdominal ultrasound during the consistent with CN. Although some fluid follow-up of slight ureteropelvic junction accumulation was detected at the resection stenosis of the left kidney. Computed stump, it diminished in a month. The tomography (CT) showed a well- residual renal function was good and no circumscribed 4.3 × 3.7 × 3.8 cm mass, residual tumor was found in both cases over occupying two-thirds of the kidney. a year.

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DISCUSSION: Laparoscopic partial covering the stump with hemostatic nephrectomy is a feasible approach to agents and pediculate peritoneum treat large CNs occupying more than half is feasible. However, this procedure the kidney, and preserve residual renal must be considered because, in CPDN, function. When it is difficult to close the intraoperative tumor spill will result in a resection stump by parenchymal suturing, higher tumor stage.

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T001: REDUCED PORT DISTAL vein. The specimen was removed via PANCREATECTOMY FOR GIANT the umbilicus and resulting cosmesis PANCREATIC NEOPLASM: BEYOND excellent. THE EVENT HORIZON AND BACK Samir CONCLUSION: Single incision distal Pandya, MD, Allison Sweny, MD, Oliver pancreatectomy with splenic preservation Muensterer, MD, New York Medical for large tumors is technically very College, Maria Fareri Children’s Hospital demanding with straight instruments. Early BACKGOUND: Giant pancreatic masses addition of a port at a proposed drain site in the pediatric population are managed can facilitate the dissection significantly. with resection when feasible. When Reduced port surgery however may still located in the distal pancreas, a distal have a role in select cases. pancreatectomy with splenic preservation T002: LAPAROSCOPIC ADRENALECTOMY is typically the ideal approach. Multiport USING A SINGLE WORKING PORT: A CASE laparoscopic surgery has been successful OF PRIMARY PIGMENTED NODULAR in small to moderate sized lesions. ADRENOCORTICAL DISEASE Neetu OBJECTIVE: We report a reduced port Kumar, Kathryn Evans, Imran Mushtaq, approach to a giant neoplasm at the Great Ormond Street Hospital, London tail of the pancreas treated with distal Primary Pigmented Nodular Adrenocortical pancreatectomy and splenic preservation. Disease (PPNAD) is a rare condition of METHOD & MATERIALS: A 15-year-old the adrenal glands. It is associated with otherwise healthy male with left upper adrenocorticotrophin hormone (ACTH) quadrant fullness, nausea and vomiting. independent cushing syndrome. It is A CT scan and MRI showed a 10cm mass characterised by multiple small nodules at the tip of the pancreas. Tumor markers (<1cm in diameter) in a small or normal were negative. The patient had already sized adrenal gland. We present a case undergone an open appendectomy with PPNAD that was treated with bilateral previously and was very concerned about adrenalectomy: the video showing the cosmesis. A single incision approach was right-sided adrenalectomy completed therefore employed for the resection. laparoscopically using a single working Straight stick laparoscopic instruments port. and a vessel sealing device were used. A two and a half year old girl presented RESULT: Intraoperatively, the mass was with weight gain over 6 months, densely adherent to the surrounding cushingoid appearance, behavioural structures. The dissection of the distal changes and androgen hair. Biochemically splenic vein and artery proved to she had ACTH independent disease. be extremely challenging using this Radiological investigations did not show approach. An additional 5mm port was a tumour/mass in the adrenals and was placed in the left lower quadrant, which inconclusive. Adrenal venous sampling improved triangulation and facilitated showed excessive cortisol secretion from completion of the procedure. The site was the left adrenal but studies on the right subsequently used for a flat suction drain. side were inconclusive. Laparoscopic left A distal pancreatectomy was successfully adrenalectomy was performed using a performed along with complete single working port. preservation of the splenic artery and

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Post operatively she recovered well T003: ROBOTIC-ASSISTED RESECTION but was noted to have persistent OF A PYLORIC PANCREATIC REST WITH cortisol secretion indicative of right PERORAL ENDOSCOPIC REMOVAL adrenal disease. 3 weeks later, the AND RECONSTRUCTION BY PARTIAL patient underwent laparoscopic right GASTRODUODENOSTOMY Oliver J adrenalectomy. This again was performed Muensterer, MD, PhD, Samir Pandya, MD, with a single working port. Histology Matthew E Bronstein, MD, Fouzia Shakil, showed appearances in keeping with MD, Aliza Solomon, DO, Michel Kahaleh, bilateral PPNAD. MD, Division of Pediatric Surgery and Pathology, New York Medical College, The accompanying video demonstrates Division of Gastroenterology and Pediatric laparoscopic right adrenalectomy Gastroenterology, Weill Cornell Medical performed in the prone position. Retroperitoneal space was created using College the ‘finger glove’ balloon dissection BACKGROUND: Gastric pancreatic rests method. A 5mm camera port was inserted consist of ectopic pancreatic tissue within just lateral to the erector spinae muscle the stomach wall and exhibit a typical in between the 12th rib and iliac crest. The endoscopic appearance. They frequently second port was placed anterior to the are asymptomatic, but can cause pain, camera. Gerotas fascia was opened, the erosions, and depending on their location, kidney mobilised and the right adrenal gastric outlet obstruction. Symptomatic gland identified. Using the spread and pancreatic rests should be resected dissect method the vessels were divided surgically. with ligasure and the adrenal gland was removed. No assistant was required OBJECTIVE: We report the first robotic- for this technique and the procedure assisted resection of a pyloric pancreatic completed within an hour. rest with endoscopic removal of the tumor through the pharynx and subsequent The treatment of choice for PPNAD is reconstruction of the gastric outflow tract bilateral adrenalectomy. The laparoscopic by partial gastroduodenostomy. approach is much preferred to the open one. Various techniques have been CASE: A 10 year old girl presented with described in the literature including the several months of worsening abdominal traditional 3 port, single port and robotic pain and nonbilious emesis. An upper procedures. However, the single working gastrointestinal endoscopy showed a large port technique is a very efficient and pancreatic rest adjacent to and obstructing safe way of dealing with such cases. With the pylorus (Figure, A), confirmed by just 2 small incisions bilaterally, the child endoscopic ultrasound. The patient was recovered very well and was discharged scheduled for robotic-assisted resection without any complications. We propose of the tumor. Intraoperatively, resection this technique as an additional novel of the mass with part of the pylorus was approach for benign adrenal conditions performed (B). To avoid augmenting one like PPNAD. of the robotic trocar sites for removal of the tumor, the mass was pushed into the stomach and retrieved endoscopically via the esophagus and pharynx (C). The Pylorus was reconstructed robotically by transverse gastroduodenostomy using

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Top Poster Abstracts CONTINUED interrupted sutures in 2 layers (D). The T004: LAPAROSCOPY FOR SMALL BOWEL operative time was 320 minutes. OBSTRUCTION IN CHILDREN – AN UPDATE Hanna Alemayehu, MD, Bryan RESULTS: The patient tolerated the David, Amita A Desai, MD, Corey W Iqbal, procedure well, advanced on her diet MD, Shawn D St. Peter, MD, The Children’s without difficulties, and was discharged Mercy Hospital home on postoperative day 3. Histopathology confirmed the diagnosis. INTRODUCTION: We previously reviewed She remained asymptomatic, and an upper our institutional experience with gastrointestinal contrast study 3 months laparoscopic management of small bowel later showed normal passage of contrast obstruction (SBO) in children. The purpose from the stomach into the duodenum. of this study was to evaluate the evolution She remains asymptomatic at 8 months of minimally invasive surgery (MIS) for follow-up. these patients, and compare our current outcomes with a historical control. CONCLUSIONS: Symptomatic pyloric pancreatic rests require careful excision METHODS: After obtaining Institutional with precise reconstruction of the Review Board approval, a retrospective gastric outflow tract, and therefore lend review of patients undergoing MIS for themselves to a robotic-assisted approach. the management of acute SBOs was Endoscopic removal through the mouth as performed over a five-year period from a natural orifice allows for removal without 2008 to 2013. MIS was defined as a augmenting one of the trocar sites and completely laparoscopic procedure, a thereby minimizes visible scars. If careful laparoscopic-assisted procedure, or a resection and reconstruction is achieved, laparoscopic procedure converted to open. the outcome is excellent. Patients with chronic obstructions, colonic obstructions, or acute intussusceptions FIGURE: On the initial endoscopy (A), were excluded. Patients with inflammatory the pancreatic rest (asterisk) partially bowel strictures were included only if obstructing the pylorus (arrow) is seen. they presented with acute SBO. Data The mass (arrows) was resected robotically was collected; both descriptive and (B) and removed through the mouth by comparative analysis was performed. endoscopy (C). After resection, the pyloric Additionally, this study population was channel (D) was reconstructed by partial compared to a historical control including gastroduodenostomy. patients from 2001 to 2008. All means reported ± standard deviation. RESULTS: There were 71 patients that were managed with MIS for SBO during the study period, of which 35 were male and 36 were female. 62 children underwent laparoscopy for their first episode of SBO, and 12 underwent laparoscopy for recurrent SBO, accounting for 74 episodes of SBO managed with MIS. The mean age at time of MIS for SBO was 10.2 ± 5.8 years, with a mean weight of 36.0 ± 20.4 kg. 55.3% (n=42) of these had previous

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Top Poster Abstracts CONTINUED abdominal surgery, with a mean number of 1.4 ± 0.7 surgeries prior to MIS for SBO. The mean time from a previous operation to undergoing MIS for SBO was 28.6 ± 48.1 months. The most common etiology of SBO was adhesions (n=40), followed by Crohn’s disease (n=10), other causes (n=8), Meckel’s diverticulum, (n=5), perforated appendicitis (n=5), volvulus (n=4), internal T005: LAPAROSCOPIC TRANSDUODENAL hernia (n=2) and anastamotic strictures DEROOFING OF THE PERIAMPULLARY (n=2). 50% (n=37) of SBOs were managed DUODENAL DUPLICATION CYST IN completely laparoscopically, 27% (n=20) AN INFANT Yu. Sokolov, MD, PhD, Dm with laparoscopic assisted procedures Donskoy, MD, A Vilesov, MD, M Shuvalov, and 23% (n=17) converted to open MD, M Akopyan, MD, Dm Ionov, MD, E procedures. The most common procedure Fokin, MD, St Vladimir Children Hospital, performed was adhesiolysis only (n=28), Moscow, Russia followed by bowel resection with primary INTRODUCTION: Duodenal cysts anastomosis (n=19). Post-operatively the constitute about 5% of all gastrointestinal mean number of days of nasogastric tube duplications with an incidence of less (NGT) decompression was 2.2 ± 3.4 days, than 1 per 100,000 birth. In extremely rare mean time to a regular diet was 5.0 ± 4.2 instances, duodenal duplication cysts can days, and mean length of stay was 9.6 ± communicate with pancreaticobiliary ducts. 19.1 days. Laparoscopy is associated with a Here, we report a case of the periampullary shorter time of NGT decompression and duodenal duplication cyst communicating time to regular diet (Table 1). There were with the biliary system in an infant, which 8 post-operative complications; intra- was treated with laparoscopic approach. abdominal abscess (n=3), anastomotic stricture (n=2), anastomotic leak (n=1), MATERIAL & METHODS: A 2-year-old bowel obstruction (n=1), and respiratory girl presented with 2-week history of failure (n=1). intermittent epigastric abdominal pain and bilious vomiting associated with failure Compared to the historical control there to gain weight. Physical examination were similar outcomes: mean number of showed diffuse abdominal tenderness days of NGT use was 1.6 ± 1.6 vs. 2.2 ± 3.4 in the right upper quadrant. Laboratory in the current study (p=0.42), mean length studies were normal. The initial imaging of stay was 12.5 ± 20.2 days vs. 9.6 ± 19.1 with ultrasonography and CT showed 3 cm days (p=0.53), mean complication rate cystic mass, which was located within the was 14.7% vs. 10.8% (p=0.45), and mean duodenal wall in continuity with the head conversion rate to open was 30.8% vs. of the pancreas thereby causing some 23.0% (p=0.59). degree of duodenal obstruction. MRCP CONCLUSION: Laparoscopy continues to be also revealed the cyst in the second part of a safe and vital diagnostic and therapeutic duodenum, which occupied more then half tool in the management of pediatric small of the duodenal circumference and was bowel obstructions secondary to a wide adjacent to the confluence of the common variety of etiologies. bile duct and pancreatic duct. Upper GI endoscopy showed the large submucosally located duodenal mass close to the

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Top Poster Abstracts CONTINUED ampulla of Vater, considerably protruding laparoscopic thansduodenal deroofing of in the duodenal lumen. Laparoscopy was this lesion is safe and feasible technique performed utilizing 5mm umbilical optical even in small children. port and two 5mm working ports. After mobilization of the hepatic flexure of the T006: LAPAROSCOPIC ENUCLEATION OF colon and duodenum the temporary stay TRUE PANCREATIC CONGENITAL CYST sutures brought through the abdominal Mariana Borges-Dias, Manuel Oliveira, José wall were then placed on the duodenal wall. Estevão-Costa, Miguel Campos, Pediatric A 2.5-cm longitudinal duodenotomy was Surgery Department, Faculty of Medicine, then made on the antimesenteric lateral Hospital São João, Porto, Portugal portion of the descended duodenum. INTRODUCTION: True solitary pancreatic The intraduodenal submucosal cyst, cysts are rare entities, since 80% to 90% of 3.0x2.0x2.0cm in size, was thus exposed. Its benign pancreatic cysts are pseudocysts. inferior border was observed to be involving In recent years, its incidence has increased and displacing the Vater ampulla. The cyst due to the generalized use of CT and was opened with the help of diathermy MRI and a better accuracy thereof. Most hook and it was found that the cyst was congenital pancreatic cysts are multiple filled with viscous and bile stained material. and associated with diseases such as Cystic The anterior wall of the cyst was excised, Fibrosis, the Von Hippel-Lindau Syndrome leaving the posterior one intact. Hemostasis or Polycystic Kidneys. was assured with monopolar diathermy. Extreme care was taken not to cause CASE REPORT: We present a clinical case of any damage to the papilla of Vater. The a 7-years-old girl, asymptomatic, followed duodenum was then closed in a transverse as an outpatient at a pediatric nephrologist fashion using extracorporeal interrupted due to repeated pyelonephritis, without sutures PDS 5-0. other relevant history. In a routine ultrasound, a cystic lesion with about 4 cm RESULTS: The procedure was successfully larger diameter, in close relation with the completed. Operative time was pancreatic tail was detected. In order to 100 minutes. The patient recovered better characterize the lesion an MRI was uneventfully and was discharged on the performed. The images showed a “Cystic, 7th postoperative day and remained simple lesion of 41x40mm, centered on asymptomatic at follow up at intervals the tail of the pancreas, unilocular, well- up to 1 year. No evidence of the cyst circumscribed, thin-walled and regular, recurrence was demonstrated on US. with no areas of contrast uptake, in intimate Pathological evaluation of the cyst sac relation with the left renal vein (...)”. The showed inner mucosal lining with well authors present in the following video a formed villi and also well developed laparoscopic enucleation of the pancreatic muscular coat, confirmed features of the cyst with pancreas and spleen preservation. intestinal duplication cyst. No relevant post-op complications CONCLUSION: The imaging, intra-operative occurred. Histology revealed a cavitary and pathology findings in this patient lesion lined by cuboid and simple columnar appeared to be consistent with a very rare epitheliums of ductal type, without atypia. periampullary duodenal duplication cyst These aspects were compatible with communicating with the biliary system. congenital pancreatic cyst.Nowadays she is We believe that, the therapeutic mode of monitored in Pediatric Surgery and Pediatric Gastroenterology consults.

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COMMENTS: This case study aims to CONCLUSION: Bimanual suturing technique document a rare, usually asymptomatic facilitates closure of anterior defects and and incidentally diagnosed entity, that provides better cosmetic outcomes. was treated successfully by laparoscopic technique, as shown in the video T008: ROBOTIC CHOLEDOCHAL CYST Adam C Alder, MD, Stephen M presentation. EXCISION  Megison, MD, Children’s Medical Center T007: BIMANUAL SUTURING - A NOVEL Dallas TECHNIQUE IN LAPAROSCOPIC REPAIR This video highlights the technical aspects OF MORGAGNI HERNIA Kanika A. Bowen, of choledochal cyst excision using a MD, Dean M. Anselmo, MD, Nam X. surgical robot platform. The technique Nguyen, Children’s Hospital Los Angeles, illustrated includes: confirmation of Los Angeles, CA the suspected pathology, creation of a INTRODUCTION: Laparoscopic approach has roux-en-y enteroenterostomy, isolation become a preferred technique in Morgagni of the anterior wall of the choledochal diaphragmatic hernia repair. However, cyst, opening of the duct to allow for the laparoscopic suturing of the anterior defect safe dissection of the posterior wall of is technically challenging. Many surgeons the common duct, proximal and distal place sutures through-and-through the dissection of the abnormal common bile anterior abdominal wall in order to secure duct, ligation of the distal duct remnant, the hernia closure. This method leads to creation of a hepaticojejunostomy to the undesirable cosmetic results. We present a roux limb, cholecystectomy. The video novel technique using “bimanual suturing” highlights the advantages of the robotic to overcome this dilemma. platform: 10x magnification, 3D viewing, wristed instrumentation, natural motion METHOD: The patient is placed in a supine with tremor dampening. position at the far end of the table. The operation is performed using three 5 mm T009: THE VACUUM BELL FOR ports (one at the umbilicus and one on CONSERVATIVE TREATMENT OF each side of the umbilicus along the mid- PECTUS EXCAVATUM: ASSESSMENT clavicular line) with the operating surgeon OF ITS EFFICACY WITH DISTANCE AND standing at the patient’s feet. The hernia sac PRESSURE SENSORS Sergio B Sesia, MD, is completely excised. The defect is then Stefan Weiss, MSc, David Hradetzky, D, closed with interrupted 3.0 Ethibond® RB-1 Eng, Frank-Martin Haecker, MD, University (Ethicon, Cincinnati, OH) sutures. During Children’s Hospital of Basel, Department the suturing, the surgeon’s left hand is of Paediatric Surgery, Basel; University of pushing down on the anterior abdominal Applied Sciences and Arts Northwestern wall allowing big bites on the fascia. The Switzerland, School of Life Sciences, needle is then passed through the edge of Institute for Medical and Analytical the diaphragm, and the knots are secured Technologies, Muttenz, Switzerland extra-corporally using a knot pusher. BACKGROUND: The conservative RESULT: Postoperative chest X-ray shows a treatment of a pectus excavatum (PE) by complete resolution of the hernia. At three using the vacuum bell (VB) represents a month follow-up, a chest X-ray shows an valid alternative to the surgical minimally intact hernia repair, and the patient has invasive repair (MIRPE) technique by Nuss no scars other than those from the trocar for selected patients. incisions.

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The objective assessment of its efficacy T010: OUTCOME OF LAPAROSCOPIC (elevation of the sternum) is still a SUTURE RECTOPEXY IN PERSISTENT challenge. RECTAL PROLAPSE IN CHILDREN Karim Awad, MSc, MRCS, Amr Zaki, MSc, MD, So far, there is no method for a Mohamed Eldebeiky, MSc, MD, MRCS, quantitative measurement of the Ayman Alboghdady, MSc, MD, Tarak improvement of PE, nor a method to Hassan, MSc, MD, MRCS, Sameh Abdelhay, evaluate the applied pressure during the MSc, MD, ain Shams University Hospitals VB therapy. The aim of our study was to evaluate the reliability of a three-sensor BACKGROUND: Rectal prolapse is a tool to assess the improvement of the PE relatively common problem, specially during the VB application. in developing countries with high rates of Gastroenteritis, parasitic infestations PATIENTS & METHODS: Based on a three- and malnourishment. Despite absence point distance measurement, a device with of accurate statistical studies regarding three sensors was developed to assess the its prevalence, yet it is frequently seen in distance between the window of the VB outpatient clinic. and the sternum as well as the differential pressure in the VB. The differential pressure The majority of the cases are managed depending on the sternum elevation can conservatively, yet intervention is be calculated in relation to a reference mandatory in some cases. pressure. The clinical application was started after the institutional review board Hundreds of approaches have been used approval and written consent was obtained. in management of full thickness prolapse The patient in supine position fixed the with variable degrees of success, we device on the top of its own VB and started aim to evaluate the laparoscopic suture to create a vacuum in order to elevate rectopexy (LSRP) as regards safety and the sternum. The data were recorded recurrence rate in children with persistent continuously and send via USB-cable to full thickness rectal prolapse. a computer. The raising of the sternum as PATIENTS AND METHODS: during period well as the pressure in the VB over the time from August 2011 till January 2014, patients and the pressure in relation to the raising of who presented with rectal prolapse the sternum were assessed have been screened as regards history RESULTS: 17 patients were included. of prolapse and predisposing factors, all The elevation of the sternum increases have been examined and investigated with diminishing pressure. This relation is with stool analysis, barium enema in non-linear. The elevation of the sternum addition to colonoscopy and EMG as continued during the application of the VB needed. Cases who failed to respond to while the pressure was kept constant. The conservative measures were corrected younger a patient is, less pressure is needed using (LSRP).The procedure was done to reach the same elevation of the sternum. under general anesthesia and completed with laparoscopic approach with fixation of CONCLUSION: Sensor-based measurement the mobilized rectum to sacral promontory represents a reliable tool to assess the by multiple non absorbable sutures. efficacy of the use of the VB. Statements to the flexibility of the chest and the After discharge, all patients were asked duration of therapy become possible. to visit outpatient clinic for clinical assessment and their data were recorded.

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RESULTS: Seventy four patients presented PURPOSE: Laparoscopically assisted to our outpatient clinics during this period, anorectoplasty (LAARP) is now considered 47 patients where successfully managed to be the radical surgical treatment of conservatively. Twenty seven failed to choice for male imperforate anus (MIA) respond to conservative measures and 20 with recto-vesical, recto-prostatic, or of them were managed by LSRP. absent fistula in many centers. However, only a few centers treat recto-bulbar Their age ranged from 2 to 11 years with fistula (RBF) which is the most challenging mean 5.3 years, duration of conservation type to treat laparoscopically. We introduce ranged from 6 weeks to 72 months with our current treatment techniques including mean 15.3 months, operative time ranged technical refinements and some novel from 25 to 150 minutes with mean of 80 procedures of LAARP for MIA with RBF. minutes, no intraoperative complications were encountered other than the need for SURGICAL TECHNIQUES: Scope and conversion to open in one case. Feeding Trocar positions:Dissecting the rectum toleration was achieved between Day 0 laparoscopically in MIA with RBF can be to Day 4. Patients were discharged home so difficult that surgeons are tempted Day 0 to Day 5, all were followed up for to abandon dissection early, leaving the a period ranging from 6 to 26 months most distal part of the RBF behind with with mean of 14.5 months.one patient great likelihood of it becoming a posterior (5%) developed recurrence requiring redo urethral diverticulum. To overcome such surgery and one patient suffered partial frustration with dissection, surgeons would thickness prolapse (5%) which improved benefit from: (1) refining trocar placement spontaneously on follow up. in RBF cases by placing the right and left trocars much closer to the laparoscope, CONCLUSION: LSRP is a minimally invasive compared with the trocar positions in procedure for children with full thickness recto-prostatic fistula (RPF) cases, so that rectal prolapse, it has the advantage of their ends can reach the distal end of the being safe, having low recurrence rate, RBF. (2) Using an adjustable scope with short hospital stay and minimal post- fixed-rod rotating lens. This device allows operative discomfort. When expertise the laparoscope to be adjusted from 0 available, it can be done as a day case to 120 intraoperatively, eliminating the procedure. However longer follow up is need to choose a type of laparoscope needed to detect any further recurrence. in advance or be limited to a fixed view. T011: SURGICAL TECHNIQUES FOR Deep exposure of the pelvis:Insertion of a LAPAROSCOPY-ASSISTED REPAIR OF suprapubic catheter into the bladder with MALE IMPERFORATE ANUS WITH RECTO- continuous suction of urine to decompress BULBAR FISTULA. COMPARISON WITH the bladder improves exposure of the RECTO-PROSTATIC FISTULA Hiroyuki distal part of the RBF located deep in the Koga, MD, Manabu Okawada, MD, Takashi pelvis. This catheter is not needed for the Doi, MD, Go Miyano, MD, Hiroki Nakamura, RPF.Measurement of the fistula:The RBF MD, Takanori Ochi, MD, Shogo Seo, MD, is dissected carefully close to the urethra Geoffrey J Lane, MD, Atsuyuki Yamataka, and opened. A fine catheter with 10mm MD, Department of Pediatric General and calibrations is inserted by the laparoscopic Urogenital Surgery,Juntendo University surgeon until it is seen to emerge into the School of Medicine urethra by another surgeon performing cystoscopy. The laparoscopic surgeon

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Top Poster Abstracts CONTINUED then measures the distance from the operation ranged from 0.2-84 months point where dissection was ceased at ( mean 15.7 months). A thoracoscopic the rectal end to the urethral orifice. The approach was used in 70 patents (85 %) RBF can then be dissected distally with with four patients requiring conversion confidence without any risk for injury to to open (co2 insufflation not tolerated, genitourinary structures for exactly the high diaphragm reducing operative field, length measured, tied, and excised. mobile intra-thoracic kidney following previous diaphragmatic hernia repair, CONCLUSIONS: Our refinements during inadequate operative field). A laparoscopic LAARP would appear to provide excellent approach was performed in 12 patents exposure for dissecting RBF and facilitate (15%) with no cases converted to open complete excision of RBF, improving the surgery. Right sided eventration was accuracy of treatment and minimizing more common (48/82, 59%) and 45/48 complications. (94%) were performed thoracoscopically. T012: DIAPHRAGMATIC EVENTRATION Interestingly, a laparoscopic approach was REPAIR: SHOULD WE USE A more common in left sided eventration THORACOSCOPIC OR LAPAROSCOPIC (10/19, 53%). In 15 cases, laterality was APPROACH? Saidul Islam, Kirsty Brennan, not specified. Rajiv Lahiri, Anies Mahomed, Department CONCLUSION: Case series predominate of Paediatric Surgery,Royal Alexandra in the literature with regard to minimally Children’s Hospital,Brighton,U.K. invasive approaches to diaphragmatic AIMS: Minimally invasive surgery has eventration. There is a predilection permeated through paediatric surgery. We towards a thoracoscopic approach in performed a systematic review to identify published series, especially in right sided the preferred minimally invasive approach diaphragmatic eventration. However, for diaphragmatic eventration repair. laparoscopic diaphragmatic eventration repair is feasible, and should be considered METHODS: A systematic review of the when operative field in chest is reduced. A online literature using Embase and randomised control trial comparing both Medline was performed. The initial search approaches is required to delineate the criteria of ‘Diaphragmatic Eventration possible advantages of either approach. repair in children‘ was further narrowed down to select only thoracoscopic or T013: EVOLUTION OF MINIMALLY- laparoscopic cases. We included two INVASIVE TECHNIQUES WITHIN AN cases of laparoscopic eventration repair ACADEMIC SURGICAL PRACTICE AT A from the author’s institution. The number SINGLE INSTITUTION Shannon N Acker, of patents, age at operation, type of MD, Susan Staulcup, David A Partrick, procedure, conversion rate and laterality MD, Stig Somme, MD, Children’s Hospital (right or left) were noted. Colorado MAIN RESULTS: The initial search for AIM: We aimed to better understand how diaphragmatic eventration repair in changes in surgical techniques are being children identified 20 publications which transferred into surgical practice. We included 236 patients. After excluding hypothesize that as the use of minimally open cases and including two cases invasive surgical techniques (MIS) have from our institution, 15 publications increased, the integration of these with 82 patients were included. Age at techniques into a pediatric surgical practice

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Top Poster Abstracts CONTINUED is dependent on the hiring of junior partners with extensive training in MIS who can then transfer their knowledge to senior surgeons. METHODS: We reviewed the operative techniques used to perform six different general pediatric surgical procedures from 1999-2013. Procedures evaluated include appendectomy (average 238/year), fundoplication (129/year), gastrostomy tube placement (102/year), pyloromyotomy (56/year), colectomy CONCLUSIONS: The hiring of junior (8/year), and lobectomy - lung (7/ surgeons with MIS training was associated year). Records were obtained from both with an increase in adoption of MIS the hospital’s surgical database and techniques by the entire surgical group. the department’s billing records. The Trends in procedures that were early percentage of cases performed with in the MIS era demonstrate a gradual MIS was calculated for each procedure rise towards uniform adoption of MIS annually. Our group is comprised of 4-7 techniques. More advanced and recently pediatric general surgeons at any time. adopted MIS techniques demonstrate a Three surgeons completed training in the rapid rise to uniform adoption. era of MIS and were hired in 2001, 2007, T014: ENDOSCOPIC CLOSURE OF and 2009. PERSISTENT GASTROCUTANEOUS RESULTS: In 1999 a median of 16.7% of FISTULA IN CHILDREN Sandra M Farach, these six procedures were performed MD, Paul D Danielson, MD, Daniel with MIS. This increased to 85.3% in 2013 McClenathan, MD, Nicole M Chandler, (P<0.05). Figure 1 depicts the changes MD, All Children’s Hospital Johns Hopkins in MIS use for each procedure over Medicine time. Three procedures: appendectomy, BACKGROUND: The literature has reported pyloromyotomy, and fundoplication, the incidence of persistent gastrocutaneous demonstrate early adoption and uniform fistula (GCF) after removal of gastrostomy use of laparoscopy (>85% laparoscopy tubes in pediatric patients to be up to by 2007). Gastrostomy tube placement 44%. The use of endoscopy may spare the reached 90% laparoscopy utilization in patient the potential morbidity associated 2009. Lung lobectomy and colectomy with surgical approaches to this problem. also reached >80% use of MIS in 2009 and The purpose of our study was to review the 2010 respectively. From 2000 to 2013, the outcomes of GCF closure by an endoscopic rate of MIS use for pyloromyotomy among technique that utilizes a combination of senior surgeons with no formal MIS training cautery and endoclips. increased from 0% to 96% (p<0.0001) and from 24% to 96% (p<0.0001) for G-tube METHODS: After Institutional Review placement. Board approval, a retrospective analysis of pediatric patients who underwent endoscopic treatment for persistent GCF following gastrostomy tube removal from January 2010 to September 2013

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Top Poster Abstracts CONTINUED was performed. This technique utilized with endoscopy. The mean length of follow esophagogastroduodenoscopy with up from the first endoscopic procedure cauterization of the fistula track and was 1.1 ± 1.1 (0.1-3.5) years. endoclip closure of the gastric mucosa. CONCLUSIONS: Benefits of endoscopic Demographics and outcomes recorded closure of gastrocutaneous fistulas include included age, diagnosis, duration of the potential for a more minimally invasive gastrostomy tube presence, number of intervention that can be performed as an interventions, and length of follow up. outpatient procedure. While endoscopy RESULTS: A total of 21 patients underwent with cautery and endoclipping proves to endoscopic treatment for persistent GCF be a safe method for fistula closure, many following gastrostomy tube removal. Five patients require multiple procedures and patients had inadequate follow up and may require eventual surgical closure. were excluded from analysis. Techniques Patient selection and refinement of this for gastrostomy tube placement included technique may improve outcomes. percutaneous endoscopic gastrostomy in 75%, surgical gastrostomy in 12.5%, and unknown in 12.5%. Indications for gastrostomy tube placement included: neurological dysfunction (37.5%), mechanical feeding difficulty (25%), congenital/genetic disease (12.5%), gastrointestinal disease (12.5%), and congenital heart disease (12.5%). The mean age at the time of endoscopic treatment was 7.5 ± 5.5 (1.1-17) years. Females comprised 56% of the group. Gastrostomy tubes were in place for a mean of 5.5 ± 5.2 (0.5-14.2) years prior to removal. The average time from gastrostomy tube removal to first endoscopic clipping was 6.7 ± 9 (0.7-28.9) months. Seven patients (44%) had successful closure after their first endoclipping procedure. Six patients underwent a second endoclipping T015: INPATIENT ADMISSION IS procedure, with three successful closures. NOT NECESSARY FOLLOWING A total of 4 patients (25%) required SUCCESSFUL ENEMA REDUCTION surgical closure for persistent fistulas and OF INTUSSUSCEPTION IN CHILDREN 2 patients (13%) have continued drainage Mohamed I Mohamed, MBBS, Stephanie F (Figure 1). Seven (44%) patients underwent Polites, MD, Abdalla E Zarroug, MD, Michael more than one intervention for treatment B Ishitani, MD, Christopher R Moir, MD, of a persistent GCF. Fifteen (94%) patients Division of Pediatric Surgery, Mayo Clinic, had the endoscopic clipping procedure Rochester, MN, USA. performed on an outpatient basis. A total of ten patients (63%) had definitive GCF BACKGROUND: Following successful enema closure after endoscopic clipping alone. reduction of intussusception in children, There were no complications associated the need for admission is controversial.

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Many institutions are moving towards early (range) duration of 3 (1-21) hours. No discharge after brief observation in the recurrence was observed in this group. emergency department. The concern is that The overall recurrence rate was 10% with a intussusception may recur following early median (range) time to recurrence from 2 discharge. The purpose of this study was days (0 days- 10 months). All recurrences to evaluate patterns of management and were successfully managed non-surgically. recurrence at a tertiary care center over two CONCLUSION: Recurrence of decades. intussusception following successful enema METHODS: We performed a retrospective reduction or spontaneous reduction is review of all patients ≤18 years who were infrequent and does not result in surgical treated for intussusception at our institution management. Ambulatory monitoring from January, 1992 to October, 2013. of children following successful enema Patient clinical data and outcomes were reduction of intussusception appears to be analyzed with a focus on recurrence of a safe and feasible option. intussusception and time to recurrence. T016: EVALUATION OF ENDOSCOPIC AND RESULTS: We identified 109 children with TRADITIONAL OPEN APPROACHES TO intussusception over 21 years. Patients’ LOCAL ADRENAL NEUROBLASTOMA Wei ages ranged from 3 months to 16 years; Yao, Kuiran Dong, Kai Li, Yunli Bi, Gong Chen, however, 62 % were <2 years. The most Xianmin Xiao, Shan Zheng, Department frequent presentation was abdominal pain of Pediatric Surgery, Children’s Hospital of (87%) and the classic triad of abdominal Fudan University, Shanghai, China pain, abdominal mass and rectal bleeding was only present in 6%. Abdominal OBJECTIVE: To investigate and compare radiographs (65%) and ultrasound (57%) long term oncologic outcomes in were the primary initial diagnostic tools. children undergoing laparoscopic or Nine (8%) patients required emergent open adrenalectomy for local adrenal surgery and did not receive enemas. Enema neuroblastoma. reduction was attempted in 100(92%) METHODS: A retrospective review was patients, including pneumatic enemas conducted of 43 children with local adrenal (93%) and barium enemas(25%) . In 5 (5%) neuroblastoma treated between July 2005 patients, the enema failed to identify the and July 2013 in Children’s Hospital of Fudan intussusception and no further intervention University. These patients met inclusion was required. Reduction was successful in criteria for having adrenal neuroblastoma 48(44%) patients. Surgery was required in and undergoing operative resection. a total of 56 (51%) patients including 9 who required emergent surgery and did not RESULTS: The local adrenal neuroblastoma have an enema, 43 (39%) who failed enema cases included 19 males and 14 females, reduction, 2 who recurred immediately aged 5 days -158 months, mean 32.44 after enema reduction, and 2 for which months. Left adrenal lesions was in 14 the diagnosis could not be confirmed cases, the right in 29 cases. According to via enema. Surgery was laparoscopic in 7 INSS staging system, there were 27 cases patients. Meckel’s diverticulum was the lead of stage I, 10 of stage II, 6 of stage IVs. point in 7 patients. Post successful enema Open adrenalectomy was peformed in 28 reduction, 22 patients were observed in patients. Laparoscopic adrenalectomy was the emergency department for a median peformed in the other 15 patients, two of whom were converted to open surgery

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Top Poster Abstracts CONTINUED because of adhesions to renal vessels RESULTS: We did’t investigate the and diaphragmatic rupture. There was no difference in operative time, number difference in tumor size (3.92 & 5.22cm) and doses of the analgesia and duration of operative time (141.33 & 137.68min) between the hospital stay in patients of compared laparoscopic and open surgery except groups. The mean operative time blood loss (P = 0.033). All patients were (summarized duration of mono- and followed up for 2-93 months, mean 34.47 bilateral repair) in Group I was 16 min. months. There were two recurrence cases in In contrast, the mean duration of the open surgery, but there was no recurrence operation in the Group II was 15,73 min. in laparoscopic surgery. The overall 5-year The number of the doses of postoperative survival rate of open and laparoscopic analgesia was 1,19 and 1,22. The length surgery were 88.5 % and 100 % (P = 0.348). of hospital stay in Group I was 8,12 hours and 8,27 hours in Group II. No differences CONCLUSIONS: Laparoscopic resection of between groups were registrated in follow- adrenal neuroblastoma is feasible and can up periode – recidive (0:0) and hydrocele be performed with equivalent recurrence formation (0:1). and mortality rates in open resection. For tumor size <6cm, absence of vascular CONCLUSION: We must conclude similar encasement, the adrenal neuroblastoma functional results in treatment of inguinal may be preferred laparoscopic surgery. hernia in babies of the first 3 months of the life with using single- and multi-port T017: COMPARISON OF MULTI-PORT AND laparoscopy and demonstrated scarless SINGLE-PORT LAPAROSCOPIC INGUINAL cosmetic results in group of single-incision HERNIORAPHY IN SMALL BABIES laparoscopic surgery. Yury Kozlov, MD, Vladimir Novozhilov, MD, Department of Neonatal Surgery, T018: METAL-POLYMER COMPOSITE NUSS Municipal Pediatric Hospital, Irkutsk, Russia; BAR FOR “MINIMALLY” INVASIVE BAR Department of Pediatric Surgery, Irkutsk REMOVAL AFTER PECTUS EXCAVATUM State Medical Academy of Continuing TREATMENT Leonardo Ricotti, PhD, Education (IGMAPO), Irkutsk, Russia Gastone Ciuti, PhD, Marco Ghionzoli, MD, PhD, Arianna Menciassi, PhD, Antonio BACKGROUND: The aim of this study was Messineo, MD, 1 – The BioRobotics Institute, the comparison of single-port and multi- Scuola Superiore Sant’Anna, Pontedera port laparoscopic methods of the treatment (Pisa), Italy. 2 – Department of Pediatric of inguinal hernia in children of the first 3 Surgery, Children’s Hospital A. Meyer, months of life. Florence, Italy. MATERIALS AND METHOD: Between January BACKGROUND: The insertion in the chest of 2002 and December 2012 children were a metallic implant and the need to remove performed 260 laparoscopic operation it after years represent the main drawback in neonates and infants with diagnosis of for the Nuss “mini-invasive” procedure In inguinal hernia. Surgical procedures were the Pectus Excavatum (PE) patients. The idea single-port endoscopic hernioraphy (Group of using an entirely reabsorbable bar was I – 180 patients) and multi-port laparoscopic hypothesized but soon abandoned because hernioraphy (Group II – 80 patients). The of concerns about its mechanical stability two groups were compared for patient’s due to the strong forces at work in the chest. demographics, operative report, early and Accounting these limits, we developed and late postoperative outcomes. patented an innovative approach for the

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Top Poster Abstracts CONTINUED treatment of PE which is based on a metal RESULTS: FEM simulations performed on and polymer composite bar. the composite structures (Figure 1) revealed that metal/polymer composite bars can MATERIAL & METHODS: We designed a new be developed by using a few combinations configuration of bar with dimensions similar of metal and polymers. When stainless to a Nuss bar, composed by internal metals steel (AISI316L) has been considered, we element and an external biodegradable discovered that only metal sheet-based polymeric shell in order to facilitate bars embedded in PLLA, PHB and PBPA the removal intervention. Two different are mechanically stable. For titanium geometries for the metal elements to be alloy (Ti-6Al-4V) matrices, instead, both embedded in the polymeric matrix were configurations are mechanically stable (leaf tested: in the former thin metal sheet, in or rod). Moreover, metal component can the latter cylindrical metal reinforcing rods be further scaled down in comparison to were considered. Finite element method stainless steel, still assuring bar integrity and simulations (FEM) were performed applying mechanical stability. Similar results were a force on the bar of 250 N and by varying obtained when Tungsten has been used as metal sheet thickness or rod diameter metal element. for different material combinations. The maximum stresses and strains of the CONCLUSIONS: FEM simulations were bar were figured out and the optimal able to establish the adequate compound configuration for the PE treatment was proportions to ensure bar integrity and identified for a composite bar. mechanical stability. The insights herein reported should serve as guidelines for the design of advanced composite bars for the correction of chest wall deformities, as well as for the development of other load- bearing implanted and partly reabsorbable composite devices. T019: SINGLE-INCISION THORACOSPCOPIC RESECTION FOR PEDIATRIC MEDIASTINAL NEUROGENIC TUMOR USING CONVENTIONAL INSTRUMENTS IN CHILDREN Jiangbin Liu, PhD, Professor, Department of Pediatric Surgery, Shanghai Children’s Hospital, Shanghai Jiao Tong University AIMS AND OBJECTIVES: to review the experience on the thoracoscopic resection of mediastinal neurogenic tumors using conventional instruments in children. METHODS: 5 children with mediastinal FIGURE 1: Example of FEM simulation tumors treated by single-incision with performed on a metal-polymer composite thoracoscopic resection using conventional bar. Stress distribution, elastic strain and instruments between July 2010 and total deformation of the composite bar are October 2013.. Medical charts were shown.

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Top Poster Abstracts CONTINUED reviewed for collection of data on age, sternum as a method of treatment for sex, histological type of tumor, clinical severe tracheomalacia. Although many manifestations, tumor size, duration of approaches have been described, left thoracic drainage, surgical complications, anterior thoracotomy remains the most tumor recurrence, and mortality. common surgical approach. Recent case reports of have demonstrated the RESULTS: 3 males and 2 females were feasibility of a thoracoscopic approach in studied. Median age was 22 months selected cases. We present our experience (range, 18.5-85 months), 3 children with thoracoscopic aortopexy describing had ganglioneuroma, 1 child had our technique as well as our outcomes. ganglioneuroblastoma and the another 1 had neuroblastoma,. The median METHODS: We performed a retrospective time of the operation was 75 minutes review of all patient who underwent (range, 45-120minutes) with complete thoracoscopic aortopexy for tracheomalacia thoracoscopic resection in all cases and at our institution. Primary outcomes no conversion to 3 ports or opening. No included operative time, number, type and children developed Horner syndrome but 1 location of stitches, comparative caliber got chylothorax postoperatively, the child change at post-operative bronchoscopy, recovered by TPN administration after 3 time until extubation, length of stay weeks. The duration of thoracic drainage following surgery, recurrence requiring was 7.5 days (range, 3.5-21.5 days), No revision and long term dependence deaths were reported, and no recurrence on respiratory support. Intra-operative was noted during a median follow-up bronchoscopy performed at the conclusion period of 21 months (range, 3-40 months) of each case was used to document the effectiveness of the procedure. CONCLUSIONS: Based on our experience, single-incision thoracospcopic resection RESULTS: A total of 6 patients were for pediatric mediastinal neurogenic tumor identified that underwent thoracoscopic using conventional instruments could be aortopexy. The median follow up time completed successfully in children. More was 7.5 months (2 months to 72 months). data are needed to fully assess the benefit Pre-operative bronchoscopy reported of this technique. The major advantages of severe or near complete obstruction in this approach are cosmetic improvement all 6 patients. The median age and weight and minimal scars. at the time of surgery was 5 months (3kg to 33 kg) and 5.1 kg ( 3.9 kg to 14.5 KEY WORDS: Single-incision, kg). The procedure was performed using thoracospcopic mediastinal, neurogenic, left thoracoscopy in five cases and right conventional instruments, children thoracoscopy in one case. The median T020: THORACOSCOPIC AORTOPEXY FOR operative time was 102 minutes (82 TRACHEOMALACIA: DEMONSTRATING minutes to 105 minutes). Four of the FEASIBILITY AND EFFICACY Avraham aortopexies were performed using 3 Schlager, MD, Ozlem Balci, MD, Matthew stitches into the aorta, one using 4 stitches T Santore, MD, Mark L Wulkan, MD, Emory and the final case using five stitches University School of Medicine/Children’s distributed between the pericardium Healthcare of Atlanta and the aorta. The pexy was performed using 3-0 PDS in two of the patients, BACKROUND: Aortopexy refers to the 3-0 prolene in another two and 3-0 silk surgical suspension of the aorta to the

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Top Poster Abstracts CONTINUED in the remaining two. Post-operative BACKGROUND: Congenital partial bronchoscopy demonstrated near- diaphragmatic eventration describes an complete resolution or markedly improved antrolateral defect in the diaphragm. The caliber in five patients and approximately defect boundaries can be clearly defined 50 percent improvement in the final thoracoscopically. The anterolateral edge is patient. The two of the six patients that formed by the costal margin, whereas, the were not ventilator-dependent at the postromedial edge is formed by a relatively time of surgery were extubated in the longer elevated “C-shaped” muscle. We operating room following the case. hereby describe a simple tension free Of the remaining four that had been thoracoscopic technique for its repair. ventilator-dependent prior to surgery, METHODS: The Ibis is a sacred Egyptian one patient was extubated in the PACU, bird with a peculiar sickle shaped peak one on post-operative day number 4, one and head. Using three 5-mm ports, patient on post-operative day number 8 several rib-anchoring stitches (plicating and the final patient remainedventilator- the fibroelastic membrane) are inserted dependent until he died of unrelated to reorient the postromedial C-shaped causes 6 months following surgery. Of the diaphragmatic muscle edge into an five surviving patients, the median hospital Ibis head sickle shaped repair. This stay following surgery was 6.5 days (2 reorientation creates two limbs: one lateral days to 72 days). One patient experienced between the costal margin and the muscle recurrent bronchoscopic compression 2 and the other vertical where the muscle months following surgery necessitating is sutured to itself. In a five year period, 31 open aortopexy via right thoracotomy. patients were treated using this technique. All five of the surviving patients have been discharged home off all respiratory RESULTS: The age range was from 8 support. months to 3 years. The side of diaphragm eventration was on left in 26 and on the CONCLUSION: Future studies directly right in five cases. There was no procedure- comparing thoracoscopic to the open related major complications or mortality. aortopexy are needed to ascertain their The repair was completed in all case comparative effectiveness. In this small thoracoscopically using 2/0 Ethibond Excel series, thoracoscopic aortopexy proved ® Polyester stitches. Prolonged ileus was to be both a feasible and an effective noticed in 3 patients, reflux symptoms in 7 treatment for tracheomalacia refractory to patients, buried stitches caused discomfort non-operative management. in two patients and chest deformity was T021: THORACOSCOPIC IBIS HEAD reported in one patient. No recurrences REPAIR OF CONGENITAL PARTIAL were reported in any of the patients. DIAPHRAGMATIC EVENTRATION. A CONCLUSION: Thoracoscopic Ibis-head NEW ANATOMICAL RECONSTRUCTIVE repair offers a tension free repair of CONCEPT Mohamed M Elbarbary, MD, late presenting antrolateral congential Ahmed E Fares, MD, Haytham E Tantawy, diaphragamticdefects An added benefit MD, Ayman H Abdelsattar, MD, Mahmoud is the elimination of use of synthetic M Marei, MD, Hamed M Seleim, MD, material. Wissam M Mahmoud, MD, Departments of Pediatric Surgery, Cairo University, Fayoum University, Tanta Univerity

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these 29 patients were excluded from this study. Mean follow-up period was 95 months with OR and 35 months with LPEC (p<0.001). In consideration of this difference in follow-up, log-rank testing was used to analyze long-term results. RESULTS: Mean age at operation was 3.72 years with OR and 3.75 years with LPEC (p=0.81). Mean body weights were 14.73 kg and 14.72 kg, respectively (p=0.98). Male:female ratios were 617:433 and 561:456, respectively (p=0.10). Preoperative Fig shows the c-shaped diaphragmatic laterality of hernia (right/left/bilateral) was muscle edge after reorientation 546/319/113 and 534/319/92, respectively resembling the Ibis -head (p=0.42). All operations were performed T022: IS LAPAROSCOPIC PERCUTANEOUS under general anesthesia. With LPEC, an EXTRAPERITONEAL CLOSURE FOR asymptomatic contralateral internal ring INGUINAL HERNIA EFFECTIVE was routinely observed, and when a patent COMPARED WITH THE OPEN METHOD? processus vaginalis (PPV) was confirmed, – A SINGLE INSTITUTION EXPERIENCE prophylactic surgery was performed OF OVER 1000 CASES Hiromu Miyake, Koji regardless of the size of patency. In the Fukumoto, Go Miyano, Masaya Yamoto, LPEC group, of 908 patients preoperatively Hiroshi Nouso, Keiichi Morita, Masakatsu diagnosed as unilateral (excluding cases Kaneshiro, Naoto Urushihara, Shizuoka in which contralateral surgery had already Children’s Hospital been performed), 379 patients (41.7%) were confirmed with contralateral PPV BACKGROUND: Laparoscopic percutaneous and underwent prophylactic LPEC. Mean extraperitoneal closure (LPEC) for pediatric operative times for unilateral surgery in inguinal hernia has recently been gaining OR and LPEC were 28.5 min and 21.2 min, popularity. However, few reports have respectively (p<0.001). Mean operative times compared LPEC with traditional open for bilateral surgery were 52.3 min and 25.4 repair (OR) using a certain level of cases min, respectively (p<0.001). Mean operative and follow-up. The aim of this study was time was significantly shorter for bilateral to compare LPEC with OR performed in a LPEC than for unilateral OR (p<0.001). The single institution. frequency of postoperative recurrence METHODS: This was a retrospective was 0.52% in OR (6/1158 sides) and 0.27% study in one institution. Our institution in LPEC (3/1109 sides; p=0.53, log-rank started LPEC for essentially all patients test). The frequency of postoperative with inguinal hernia in July 2008. This contralateral metachronous inguinal hernia study compared LPEC with OR using (CMIH) was 6.48% in OR (57/879) and 0.33% 1050 patients who underwent OR from in LPEC (3/908; p<0.001, log-rank test). No July 2003 to June 2008 and 1017 patients postoperative testicular atrophy, iatrogenic who underwent LPEC from July 2008 to cryptorchism or serious complications were June 2013. From July 2008, 29 patients encountered in either group. Among the underwent OR for reasons such as history 6 patients who underwent repeated LPEC of peritonitis and associated cryptorchism; due to recurrence or CMIH, none showed

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Top Poster Abstracts CONTINUED intraabdominal adhesions during second RESULTS: Results of 1387 operations surgery. were reviewed. Overall, 339 cases (24.4%) were operated by trainees. The youngest CONCLUSION: In our institution, both OR patient was operated on day 2 of life with and LPEC obtained satisfactory results body weight 2.2kg (thoracoscopic repair from the perspective of recurrence rate of esophageal atresia). MIS advanced and complications. In our series, operative remarkably in volume (n=952; 68.6%) time was shorter for bilateral LPEC than for and complexity (neonatal, thoracic) in unilateral OR. This shows that prophylactic the second 5-year period. Statistical contralateral LPEC is useful for preventing improvement was seen in operative CMIH without prolonging operative time durations in four procedures (pyeloplasty, compared with OR. Of course, some splenectomy, fundoplication and resection controversy remains regarding long-term of CCAM, 25-40% reduction in operative effects of LPEC, including fertility. Midterm time, p=ns) and in complication/recurrence safety and efficacy of LPEC are yet to be in two procedures (hernioplasty and proven, and lifelong assessment remains appendicectomy, 50-75% reduction in an outstanding issue with LPEC. complications or recurrences, p = ns). T023: DEVELOPMENT OF MINIMALLY Proportion of trainees and young fellows INVASIVE SURGERY (MIS) IN A MEDIUM- performing I and II operations increased VOLUME PEDIATRIC SURGICAL CENTER: significantly in recent years. A TEN YEAR EXPERIENCE OF 1387 CONCLUSIONS: MIS can be developed OPERATIONS Patrick Ho Yu Chung, MBBS, safely and comprehensively in a medium- FRCS, Kenneth Kak Yuen Wong, PhD, Paul volume centre. Mastering the technique Kwong Hang Tam, MBBS, MS, Department of common procedures fast-tracks the of Surgery, Li Ka Shing Faculty of Medicine, development of rare, complex operations. The University of Hong Kong MIS skills are transferrable across different OBJECTIVE: A major challenge to the procedures and among surgeons, and can development of minimally invasive be effectively incorporated in a surgical surgery (MIS) in paediatric surgery is the training program. wide spectrum of rare diseases. Here, we T024: HYBRID SIMULATION: A present our institutional experience in its NOVEL CURRICULAR CHANGE FOR development as a model for medium- AN ESTABLISHED TRAINING COURSE volume comprehensive service and Katherine A Barsness, MD, MS, Deborah M training centers. Rooney, PhD, Carroll M Harmon, MD, PhD, METHODS: We reviewed our single- Northwestern University Feinberg School centered MIS program in 2003-2012. of Medicine, University of Michigan Medical Eleven index operations were selected School, University of Buffalo School of and categorized into I, II and III according Medicine to increasing technical demands BACKGROUND: For more than 20 years, (simple dissection/suturing to major the annual minimally invasive surgery reconstruction). Experience of surgeons (MIS) fellows’ course maintained a basic ranged from trainees, young fellows to structure of morning lectures and an senior surgeons. Comparison between afternoon animate porcine laboratory skills early (2003 - 2007) and late (2008-2012) session. In 2012, a hybrid simulation model developmental periods was made. (inanimate tissue with synthetic surround)

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Top Poster Abstracts CONTINUED for esophageal atresia was introduced. evidence supports continued use of hybrid Based on data from 2012 evaluations simulation during pediatric surgery training. (“more access to simulation models” and “less time with [live animals]), the 2013 T025: LAPAROSCOPIC INTERRUPTED course was converted from an animate MUSCULAR ARCH REAPIR IN RECURRENT porcine lab to a fully hybrid simulation UNILATERAL INGUINAL HERNIA AMONG laboratory session, eliminating the animate CHILDREN Sherif M Shehata, PhD, Akram porcine laboratory. We present our M ElBatarny, MD, Mohamed A Attia, MD, subsequent evaluation results. Ashraf A AlAttar, MD, AbdelGhani Shalaby, MD, Department of Pediatric Surgery, METHODS: IRB-exempt study. Fifty-two Tanta University Hospital, Tanta, Egypt previously described hybrid simulation models (13 each: esophageal atresia/ INTRODUCTION: Laparoscopy became tracheoesophageal fistula [TEF], duodenal widely used in the management of atresia [DA], diaphragmatic hernia [DH] and pediatric inguinal hernia (PIH) especially [Lobectomy]) were surgically modified/ in recurrent cases as we approach virgin assembled. Thirty-seven pediatric surgery field with many advantages. In unilateral residents performed MIS procedures on cases, many cases can be repaired by the four hybrid models. The student to herniorraphy. faculty member ratio was 3:1. At course AIM: We present a procedure with suturing conclusion, participants were asked to the transverse abdominal fascial arch to the evaluate the course across six domains ileopubic tract laparoscopiccally in order to (29 items) using 5-point rating scales (1=no repair recurrent unilateral inguinal hernia. value, 5=extremely valuable). Ratings were evaluated using the many-Facet Rasch PATIENTS & METHODS: Twenty model, reported as observed averages (OA). consecutive children with recurrent unilateral PIH were treated along 5 years RESULTS: Table 1. The highest observed period in a tertiary academic center. All average (OA) was for Relevance to cases were subjected to laparoscopic participants’ personal educational needs exploration followed by laparoscopic (OA=4.9). Didactic sessions had an overall hernia repair as a day case surgery. Sutures OA of 4.7 [4.4-4.86]. Hybrid models OAs were placed on from the fascial arch to were 4.7 (DH), 4.6 (DA), 4.3 (TEF) and the ileopubic tract avoiding the spermatic 4.3 (Lobectomy). The global course OA vessels and duct in interrupted manner was 3.3, with 3=continue the course for using 2/0 Prolene or Vicryl sutures. In pediatric surgery training as is, with slight some cases, a purse string suture is added improvements and 4=continue to use the to narrow the internal ring. The knot is tied course, no changes. either intra corporeally or extra corporeally CONCLUSIONS: With the availability of according to surgeon’s preference. The high fidelity hybrid simulation models needle removed transabdominally. relevant to pediatric surgical training, we Operative findings and post operative have successfully converted a previously results and complications were assessed. exclusive animate porcine educational The patients were followed for a period course to a fully simulated course. ranged between 6 and 52 months. Additional validity evidence for the use of RESULTS: We have 18 boys and two girls. hybrid simulation models as educational Operative age ranged between 18 months tools are still required, but preliminary and 15 years. Three or four sutures

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Top Poster Abstracts CONTINUED were placed in either case. In 4 cases, brain, in 3 (0,8%) – in retroperitoneal space, additional purse string suture was added. in 2 (0,5%) - in mussels, in 2 (0,5%) - in Operative time ranged between 35 & 70 pancreas. There were 12 (5,1%) urgent cases min in unilateral cases without conversion. of liver cysts rupture. In 9 (75%) cases the Scrotal edema reported in 4 cases, 2 cyst rupture was associated with trauma. cases of port infection were reported In 3 (25%) - it happened spontaneously. and treated conservatively. One case of Abdominal ultrasonography, CT, MRI recurrence among boys was reported performed as a diagnostic procedures and no case of testicular atrophy was before surgery. In 11 (91,6%) patients we reported in the follow up period. Cosmetic performed laparoscopic approach for outcomes were excellent. treatment of th?se complicated cases, in 1 (8,4%) – open surgery. Four trocar (10, 6, CONCLUSION: This procedure is helpful 6, 22 mm) approach was performed. Free in the functional reconstruction of the hydatid fluid was identified and aspirated inguinal canal in recurrent cases of from abdomen cavity. In 8 (72,7%) cases unilateral inguinal hernia. Laparoscopic ruptured cysts were located in a right lobe, inguinal herniorraphy by this technique in 3 (27,3%) – in a left. We used 22 mm is feasible and safe. Consequently, there trocar for vacuum extraction of endocyst. is lower risk of injury to the spermatic Abdomen cavity was irrigated by saline duct or vessels than the conventional solution. We performed betadine solution herniorrhaphy. Larger studies and long- for the processing of fibrous capsule. term follow up are needed to support our One tube used for draining of residual encouraging results. cavity. One, or two - for draining of the T026: LAPAROSCOPIC TREATMENT OF abdominal cavity. All patients accepted LIVER HYDATID DISEASE IN CASES OF 10 mg/kg of albendazolum during 6 CYST RUPTURE IN CHILDREN Sagidulla weeks postoperatively. Operation time, Dosmagambetov, Bulat Dzenalaev, Aitzan conversion rate, complications rate, length Baimenov, Vladimir Kotlobovskiy, Aslan of hospital stay were analyzed. Ergaliev, Aslbek Tusupkaliev, Ibatulla RESULTS: It was no mortality. Duration Nurgaliev, Roza Kenzalina, Kidirbek of operation time was 61.3+-13.6 min. It Altaev, Kuben Satibaldiev, Egor Roskidailo, was 1 (8,4%) case of billiary peritonitis, Department of Laparoscopic Surgery, associated with billiary fistula. Laparoscopic Regional Pediatric Hospital, Aktobe, suturing of billiary fistula was performed Kazakhstan on a third day after primary procedure. AIM: Evaluation of efficiency of Duration of the hospital stay was 9.8+-1.5 laparoscopic treatment of liver hydatid days. It was 1 (8,4%) case of recurrence disease in cases of cyst rupture in children. with dissemination of the process in an abdomen cavity. MATERIALS: Since 1993 till February 2014 375 children ranging from 4 to 14 years CONCLUSION: Laparoscopic approach could of age with hydatid disease underwent be successfully performed for treatment of surgery. In 236 (62,9%) cases hydatid liver hydatid disease in cases of cyst rupture. located in liver, in 83 (22,1%) cases – in It demonstrates good post-operative lung, in 36 (10,9%) – in kidney, in 6 (1,6%) – results, low rate of complications and in omentum, in 2 (0,5%) – in uterine tubes, recurrence, short duration of operation time in 3 (0,8%) – in spleen, in 2 (0,5%) – in and hospital stay.

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T027: OUTCOMES OF SINGLE PORT effective and has comparable outcomes SURGERY FOR PERFORATED APPENDICITIS to traditional approaches for perforated IN CHILDREN: SINGLE SURGEON appendicitis in historical literature. EXPERIENCE Adesola C Akinkuotu, MD, THORACOSCOPIC APPROACH Paulette I Abbas, MD, Shiree Bery, MD, T028: OF BILATERAL CHYLOTHORAX: VIDEO Ashwin Pimpalwar, MD, Texas Children’s Marcelo Martinez Ferro, MD, Fernando Hospital and the Division of Pediatric surgery, Rabinovich, MD, Carolina Millan, MD, Michael E. DeBakey Department of Surgery, Horacio Bignon, MD, Gaston Bellia, MD, Baylor College of Medicine, Houston, TX. Luzia Toselli, MD, Mariano Albertal, MD, INTRODUCTION: Advances in laparoscopic Private Children´s Hospital of Buenos Aires, surgery have led to the use of single- Fundación Hospitalaria, Buenos Aires, incision/port laparoscopy surgery (SILS) Argentina for general surgical operations including The development of chylothorax is a appendectomies. At our institution, a relatively common complication after single surgeon routinely performs SILS pediatric cardiac surgery. The resolution appendectomies for acute appendicitis. of this complication poses a significant There is limited data in literature for challenge to surgeons and there is no outcome of SILS in perforated appendicitis. consensus for the most appropriate PURPOSE: To report outcomes for SILS in therapeutic strategy.In this video, we shown children with acute perforated appendicitis. thethoracoscopic correction of a bilateral chylothorax on a 2-month old baby. METHODS: We reviewed the records of all pediatric patients who underwent T029: THE USE OF ROBOTIC SURGERY SILS appendectomy for acute, ALLOWS FOR IMPROVED DEXTERITY perforated, appendicitis, performed by AND VISUALIZATION DURING a single surgeon, between 2009 -2013. THORACOSCOPIC THYMECTOMY Shannon Appendectomy was performed using the F Rosati, MD, Dan Parrish, MD, Patricia single port (Olympus Triport) by single Lange, MD, Claudio Oiticica, MD, David incision through center of the umbilicus Lanning, MD, PhD, Children’s Hospital (keeping within the limits of the umbilicus) of Richmond at Virginia Commonwealth completely intra-corporeally by using University Medical Center conventional laparoscopy equipment. INTRODUCTION: Myasthenia gravis (MG) is RESULTS: 72 patients underwent SILS for an autoimmune neuromuscular disease, acute, perforated, appendicitis. Age of the effects of which can be improved patients undergoing SILS was (Median of or alleviated by thymectomy in young 8.7±3), length of operation was (median, patients. However, median sternotomies 58(36-140) minutes and length of hospital or thoracotomies have a high degree stay was (Median 5.5±3.4days). Only of morbidity, especially when already one patient was converted to traditional weakened from their MG. A thoracoscopic laparoscopy. Post-operative complications approach allows for a minimally-invasive included wound infection 9/71 (12.7%), intra- approach but it can be technically abdominal abscess formation 12/71 (16.9%), challenging to completely remove all of and post-operative ileus 15/72 (20.8%). the thymic tissue in the contralateral chest and lower neck, especially in the smaller CONCLUSION: SILS for perforated children that typically have larger glands. appendicitis in children is safe and

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The robotic-assisted approach allows for that had been placed through the slightly the use of articulating instruments and 3D widened 8-mm trocar defect. The lungs visualization were fully inflated prior to the fascia being closed at all port sites without placing a PATIENT: This patient is a three year old boy chest tube. No pneumothorax was seen on who had been suffering from generalized the postoperative chest xray. The patient MG. Due to disease progression that was tolerated the procedure well without any only partially controlled by medications, his postoperative complications, had minimal neurologist referred him for thymectomy. blood loss, and was discharged home the After a lengthy conversation with his following day. parents, the decision was made to proceed with a robotic-assisted left thoracoscopic CONCLUSION: The use of robotic- thymectomy. assistance in thoracoscopic thymectomies with its articulating instruments and 3D TREATMENT: The patient was placed in visualization has allowed for this approach the supine position on the operating room to be offered to younger and smaller table. Through a transverse incision in the patients despite having a larger thymus. left axilla, a 5-mm XCEL trocar was placed This approach allows these patients to in the ? interspace, and pneumothorax benefit from an earlier thymectomy while was created with a pressure of 4 mmHg. avoiding the morbidity from a sternotomy One additional 5-mm robotic trocar was or large thoracotomy. placed in the left mid-clavicular line in the 6th interspace, and an additional 8mm T030: TREATMENT OF THE trocar was placed in the 6th interspace in CHYLOPERICARDIUM THROUGH MINIMAL the anterior axillary line. The XCEL trocar INVASIVE TECHNIQUES REPORT OF A was replaced with a 5mm robotic trocar. At PEDIATRIC CASE Carlos Garcia-Hernandez, this point, the robot was docked, and the MD, Lourdes Carvajal-Figueroa, MD, 8-mm camera and 30 degree scope was Adriana Calderon-Urreta, MD, Sergio placed in the central trocar. Hook cautery Landa-Juarez, MD, Hospital Star Medica and a Maryland grasper were used to Lomas Verdes. Mexico dissect the gland off of the heart. The left lateral aspect of the thymus was lateral to INTRODUCTION: The chylopericardium is the left phrenic nerve, which was identified a rare entity in pediatrics. There are few and preserved. Dissection was continued publications about the occurrence of in a caudad direction to free up the entire this disorder in children, and most of the left lobe of the gland and carried over available reports are related to cases in toward the right chest. A small hole was cardiovascular surgeries. The objective of made in the right pleura to prevent tension this paper is to present the case of a child pneumothorax from developing. At this that developed chylopericardium without point, the dissection was carried around an apparent cause, its diagnostic, as well as the right lobe of the thymus with care its successful resolution through a ligature taken to preserve the right phrenic nerve. of the thoracic conduct and the creation of Dissection was continued to free the gland a pericardial window using approach. from the heart as well as both superior CASE PRESENTATION: Male patient of horns that extended well into the lower 6 years of age, started with symptoms neck. Once the organ was dissected free, (cervical and thoracic pain) 3 weeks it was placed into a 10-mm Endocatch bag before admission to hospital after

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Top Poster Abstracts CONTINUED falling from his own height. The it is rather believed that such occurrence is x-ray showed cardiomegaly and the a consequence of a leakage in the insertion echocardiogram demonstrated the of the thoracic conduct in the superior cava existence of a pericardial effusion. After vein. When the medical treatment happens 300 ml. of a white liquid were drained to fail it must be solved through surgery, through pericardiocentesis, a pericardial as demonstrated in the above mentioned catheter was placed. The aspired liquid case. The best option is to perform a presented 1910 mg/dl of triglycerides ligature of the conduct with the creation and chylomicrons of 21.3. Treatment of a pericardial window. Performing this was initiated using NPT, octreotide and surgery through thoracoscopic approach diet with mid-chain triglycerides. With results in the well-known advantages of magnetic resonance lymphatic anomalies minimum invasive procedures in terms of were discarded. Upon failure of the recovery, in addition to the magnification medical treatment, due to an increase of images that allows us to locate and link in expenditures, surgery was performed the thoracic conduct safely, immediately using a thoracoscopic approach through controlling the chilothorax and avoiding the right. The thoracic conduct was future complications. dissected upon entry to the thorax and linked with a 2-0 silk, the pericardia was T031: LAPAROSCOPIC URETEROVESICAL incised to create a window ranging from PLASTY FOR MEGAURETER`S the diaphragm until the union of the TREATMENT Sergio Landa-Juárez, MD, superior cava and the auricular, resulting in Ana María Castillo-Fernández MD, an engrossed pericardia. Oral feeding after Angélica Alejandra Guerra-Rivas MD, 24 hours without increasing the pleural Arturo Medécigo Vite MD, Hermilo De La expenditure and catheter was removed Cruz-Yañez MD, Carlos Garcia-Hernández after 72 hours; patient was discharged on MD, Hospital de Pediatria, Centro Médico the fourth day. Follow up after 6 months Nacional Siglo XXI. IMSS without complications, with normal PURPOSE: The ureterovesical junction echocardiographic and radiological control. stenosis is a distal ureteral obstructive DISCUSION: The chylopericardium anomaly which causes megaureter. When in children occurs most of the time surgical reconstruction is necessary the after cardiovascular surgery. The megaureter is traditionally detached, the aforementioned case could be stenotic segment resected and in some considered idiopathic as the traumatism cases tailoring is recommended. This paper was reduced and the event provoked proposes an alternative laparoscopic an x-ray that marked the beginning treatment for obstructive and obstructive- of the study. Disregarding the volume refluxing megaureter sparing the of the accumulated liquid, as well as uterovesical junction (UVJ). for an unknown reason, the patients PATIENTS AND METHODS: 7 patients with with this disorder can have severe febrile urinary tract infection were studied tamponed symptoms or otherwise be with ultrasound, cystogram, excretory asymptomatic as in the reported case. In urography and MAG3 renal scan. Six were the idiopathic cases the physiopathology diagnosed with obstructive and one with of the accumulation of the chylo in the obstructive-refluxing megaureter. The pericardium rather than in the pleural diameters varied between 8 to 10mm. space has yet been thoroughly studied, and Laparoscopic ureterovesical plasty

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Top Poster Abstracts CONTINUED consisted in a longitudinally incision on the The patient with febrile urinary tract anterior ureteral wall above and through infection after surgery was tested with the stenotic segment including vesical renal scan reporting improvement from mucosa maintaining the ureter´s posterior preoperative to postoperative conditions. wall attached to the bladder (Fig. 1). Cystourethrogram study was done for study purposes only. Six of seven patients with no reflux reported. The remaining patient without cistourethrogram moved from country residence and the study has not been considered necessary by new physician. CONCLUSIONS: Laparoscopic approach FIG. 1 allows a good ureteral stenotic segment Then a transverse ureter to bladder identification and combined with mucosa anastomosis was peformed to Lich Gregoir and Heineke-Mickulicz relieve obstruction (Fig. 2). ureterorraphy of stenotics segments at ureterovesical junction is a novel, simple and speedy technique for megaureter treatment. Further more, allows to calculate the need for detrusotomy extension when needed to ensure antireflux mechanisms. T032: VIDEO ASSISTED FIG. 2 EXTRACORPOREAL PYELOPLASTY Edgar RESULTS: From a total of 7 cases, 2 were Rubio Talero, MD, Fernando A Escobar women and 5 men aged between 5 Rivera, MD, CLINICA SALUDCOOP TUNJA months and 3 years old. The operative time Dismembered Pyeloplasty is still the “Gold ranged from 90-120 minutes with a 48- Standard” in the treatment of obstructive hour hospital stay. Urethral catheter and hydronephrosis. double “pig” tail stent were used for 48 hours and six weeks respectively. Antibiotic What has changed in recent years is the was used in therapeutic doses for 7 days approach to perform this operation. and prophylactic doses for 8 weeks. The Robotics and Laparoscopy have average follow-up was 17.7 months. demonstrated to be good surgical resources to solve Uretero-Pelvic- One female patient developed febrile Junction (UPJ) obstruction. Nevertheless, urinary tract infection a week from surgery. the complexity of robotic surgery, Thereafter she remained asymptomatic, the unaffordable that it is to most of with normal urinalysis, as did the remaining the patients around the world and patients. the advanced skills that has to have a Ultrasound and excretory urography at laparoscopic surgeon, working in limited six months from surgery demonstrated space, make these techniques too improvement in ureteral and pyelocaliceal demanding and not always reproducible. diameters. This makes sound the idea of combine the

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Top Poster Abstracts CONTINUED benefits of laparoscopic approach and T034: THE CHARACTERIZATION OF the agility of the open surgery suturing. PECTUS EXCAVATUM INCLUDING This is the case of VIDEO ASSISTED ITS ASYMMETRY Sergio B Sesia, MD, EXTRACORPOREAL PYELOPLASTY. Margarete M Heitzelmann, Sabine Schaedelin, MSc, Olaf Magerkurth, MD, The aim of this Video presentation is Frank-Martin Haecker, MD, University to review step by step this technique, Children’s Hospital of Basel, Department highlighting the tricks and maneuvers of Pediatric Surgery and Department of to get success and improve the results Pediatric Radiology, Spitalstrasse 33, 4056 in the management of obstructive Basel, Switzerland; University of Basel, hydronephrosis Clinical Trial Unit,Schanzenstrasse 55, 4031 T033: THE USE OF A 5-MM ENDOSCOPIC Basel, Switzerland STAPLER FOR RECTAL TRANSECTION BACKGROUND: The Haller-Index (HI) > DURING LAPAROSCOPIC SUBTOTAL 3.25 by computed tomography (CT) is the COLECTOMY Simone Frediani, MD, Silvia main criterion to indicate surgical repair Ceccanti, MD, Romina Iaconelli, MD, in patients with pectus excavatum (PE). Falconi Ilaria, MD, Debora Morgante, MD, However, the level along the sternum Denis A Cozzi, MD, Policlinico Umberto I in which the HI is measured, is not Hospital and Sapienza University of Rome, standardized. Commonly, the deepest Rome, Italy point of the sternum is considered. This video depicts a 9.5-year-old boy with Additionally, the HI alone is unable to longstanding ulcerative colitis resistant describe asymmetric deformities of the to maximal medical therapy. Following anterior chest wall. unsuccessful split ileostomy performed The aim of this study was to propose an elsewhere, he was then elected for Asymmetry-Index (AI) in addition to the laparoscopic subtotal colectomy. HI for a more objective characterization The procedure entailed a 12-mm of both the depth of the PE and its transumbilical port for the camera and asymmetry and to evaluate its impact in three 5-mm working ports. Dissection the surgical indication. and hemostasis were achieved utilizing a single vessel sealing device throughout METHODS: After institutional review board the procedure. The present video focuses approval, the HI of 43 PE-patients and on the transection of the rectosigmoid of 33 children of the control group from junction, which was carried out utilizing the University Children’s Hospital of Basel a newly devised 5-mm endoscopic (UKBB) was measured retrospectively articulating linear stapler. The specimen at three different levels (HI1, HI4, HI5). was easily extracted via the distal stoma Sensitivity and specificity of the HI in these site. Given the patient’s poor general levels were compared. Furthermore, an health status, clinical improvement was asymmetry index was calculated at the slow but progressive. Ultimate cosmetic same three levels (AI1, AI4, AI5). All the results were excellent. We believe that measurements were based on CT scan. the above described 5-mm endoscopic Validity was assessed using McNemar and stapler has the potential for wide scope exact McNemar tests. and application in pediatric minimally RESULTS: There is a moderate higher invasive surgery. sensitivity of the HI when measured at

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Top Poster Abstracts CONTINUED level 4 instead of level 1 or 5. The AI at MATERIALS & METHODS: A survey was level 1 has a higher sensitivity than at sent to the seven institutes regarding the level 4 and 5. Combining HI4 and AI1, the operative indications, surgical technique, sensitivity significantly increases compared postoperative management and outcomes to HI4 alone. of thoracoscopic repair of EA/TEF. CONCLUSIONS: Our study showed that RESULTS: All institutes responded to the HI evaluated at level 4 combined with AI survey. A low birth weight (five institutes), at level 1 increases the accuracy of the associated anomalies (three institutes) and description of the chest wall deformity compromised physiologic status (three compared to HI4 alone. Additionally, HI institutes) were identified as common at level 4 combined with A1 at level 1 exclusion criteria for thoracoscopic increases the accuracy of the indication to repair. The operation was uniformly surgical repair of the PE. performed via an intrapleural approach in the 0~45?prone position. Preoperative T035: CURRENT PRACTICE AND bronchoscopy was routinely performed OUTCOMES OF THORACOSCOPIC in six (85.7%) institutes, and single lung ESOPHAGEAL ATRESIA AND ventilation was performed in two (28.6%) TRACHEOESOPHAGEAL FISTULA REPAIR: institutes. The TEF was occluded with suture A MULTI-INSTITUTIONAL ANALYSIS ligature in four (57.1%) institutes and clips IN JAPAN Hiroomi Okuyama, MD, PhD, in the remaining three (42.9%) institutes. Hiroyuki Koga, MD, PhD, Tetsuya Ishimaru, Anastomosis was performed using the MD, PhD, Hiroshi Kawashima, MD, Atsuyuki extracorporeal knot-tying technique Yamataka, MD, PhD, Naoto Urushihara, using 5-0 to 6-0 absorbable sutures in MD, Osamu Segawa, MD, PhD, Hiroo four institutes and the intracorporeal Uchida, MD, PhD, Tadashi Iwanaka, MD, technique in three institutes. In order to PhD, Dept of Pediatric Surgery, Hyogo facilitate anastomosis, stay sutures were College of Med.; Juntendo University used in three (42.9%) institutes. During School of Med.; The University of Tokyo surgery, chest and transanastomotic tubes Hosp.; Saitama Children’s Hosp.; Shizuoka were placed in all institutes. Patients were Children’s Hosp.; Tokyo Women’s Medical routinely left intubated and paralyzed for University; Nagoya University Graduate three to seven days postoperatively in four School of Med. institutes.A total of 58 patients underwent BACKGROUND: The optimal surgical thoracoscopic repair of EA/TEF at the seven treatment of infants with esophageal institutes. Fifty-two (89.7%) of the patients atresia and tracheoesophageal fistula underwent successful thoracoscopic repair. (EA/TEF) remains controversial. In order Six (10.3%) operations were converted to better understand the current practice to open thoracotomy due to a long gap and outcomes of thoracoscopic repair (4), right aortic arch (1) and intraoperative of EA/TEF, a multi-institutional analysis instability (1). One operation was staged was conducted among seven Japanese due to the patient’s low birth weight. The institutes that perform advanced body weight at operation ranged from 1.2 laparoscopic and thoracoscopic procedures to 4.6 kg, while the age ranged from 0 to in infants and children. All of the co- 194 days and the operative time ranged authors belong to these institutes. from 115 to 428 minutes. There were no major intraoperative complications. The gap distance between the proximal and

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Top Poster Abstracts CONTINUED distal esophagus for anastomosis ranged risk of impaired defecation function in from zero to four vertebral bodies. Eleven long term follow-up. Single-incision patients (19.0%) suffered from anastomotic laparoscopic endorectal pull-through leakage, which healed following (SILEP) was technically feasible and safe conservative management. Twenty-eight in selected HD patients offering better patients (48.3%) developed anastomotic cosmesis and less postoperative pain in stricture, all cases of which responded comparison with conventional laparoscopic successfully to endoscopic dilatation. One procedures. However, it is stressful for the patient died during the postoperative period surgeons in view of its low manipulability due to an unrelated disease. Recurrent and poor visualization because clashing of TEF developed in three infants (5.2%). instruments. We applied the technique of Thirteen patients (22.4%) later required SILEP using a trocarless instrument via an fundoplication. another abdominal stab incision to obtain further improvement of SILEP. CONCLUSIONS: Considerable variability was observed among the seven institutes with METHODS: Between August 2010 and July respect to the operative indications, surgical 2013, 32 patients with HD were performed technique and postoperative management SILEP with a trocarless instrument. There of thoracoscopic repair of EA/TEF, which were 24 males and 8 females, with a can be safely performed with less surgical mean age of 3.6 months. Under general trauma by experienced endoscopic anesthesia, a single transumbilical vertical surgeons. However, postoperative stricture incision was made. Two 5.0 mm trocars was common in this series, although there were inserted into the peritoneal cavity were no major intraoperative complications. at horizontal ends of umbilical incision. A The identification of variance in this survey 3.0 mm instrument was inserted through is the first step to conducting future studies the left abdominal stab incision. After to identify best practices. Standardizing obtaining the critical view, two or three the surgical technique and postoperative seromuscular leveling biopsies of the management may reduce the incidence of rectum and colon were obtained to identify complications after thoracoscopic repair for the transitional zone. Rectum and colon EA/TEF. were mobilized 5 cm proximal to the normal colon by elevating the mesentery T036: SINGLE-INCISION LAPAROSCOPIC using a 3 mm grasping forceps and ENDORECTAL PULL-THROUGH FOR dissecting it using the ultrasonic scalpel, HIRSCHSPRUNG’S DISEASE WITH until the colon pedicle was long enough TROCARLESS INSTRUMENT VIA AN to reach deep into the pelvis without ANOTHER STAB INCISION Shao-tao tension. The dissection was continued to Tang, MD, Shi-wang Li, MD, Li Yang, the peritoneal reflection of the rectum. Department of Pediatric Surgery, Union Rectal mucosa dissection was performed Hospital of Tongji Medical College, transanally by the electrocautery Huazhong University of Science and technique. The aganglionic and dilated Technology,Wuhan 430022, China segments were resected and coloanal BACKGROUND: Transanal endorectal anastomosis was performed. pull-through for HD was a relatively safe RESULTS: 10 patients with the transitional and feasible procedure. However, over zone in the rectum, 17 patients in the stretching on anal sphincter and mesentery sigmoid colon and 5 patients in the of sigmoid colon might cause potential

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Top Poster Abstracts CONTINUED descending colon. All procedures were the laparoscopic group, median age at performed without adding another ports presentation was 5 weeks (range: 2-9weeks), or conversion to open approach. The mean gender (31 male, 78%), mean weight 3.9kg operative time was 116 min. There was no (range: 2.5-5.3kg) and 3 had positive family major intraoperative complications. In history. Complications were noted in 5 regard to early postoperative complications, patients (13%); 3 had duodenal perforation mainly perianal excoriation occurred in 9 (site of perforation; 2 at site of grasper and patients. No anastomotic leak occurred. 1 at site of pyloromyotomy) repaired with Postoperative enterocolitis occurred in one open conversion, 1 further patient had open patient, who was relieved by transfusion and conversion due to technical difficulty, 1 colon irrigations requiring rehospitalization. had open re-do pyloromyotomy 4 weeks There was no recurrent constipation. later for inadequate pyloromyotomy, 1 had Clashing between the laparoscope and the port-site infection requiring oral antibiotics, instruments was reduced by changing the and 1 had epigastric port-site omental hernia insertion site of forceps. Follow-up for 6 requiring surgical repair. months to 3 years in all patients showed CONCLUSION: Laparoscopic excellent cosmetic appearance. pyloromyotomy is a feasible treatment CONCLUSION: Our procedure is feasible for pyloric stenosis although technical and safe for performing SILEP in selected challenges should be appreciated. Our HD patients, and the improved results are experience highlights the importance attributable to the introduction of a 3 mm of gentle grasping of the duodenum forceps through the left abdominal stab for stabilisation during pyloromyotomy incision. and ensuring clear visualization whilst spreading the pyloric muscle. T037: AUDIT OF INITIAL EXPERIENCE OF LAPAROSCOPIC PYLOROMYOTOMY Helai T038: OUTCOMES AFTER EARLY Habib, MBBS, BSc, Mohamed Shalaby, SPLENECTOMY FOR HEMATOLOGICAL FRCS, Paed, Surg, Philip Hammond, FRCS, DISORDERS Elizabeth Renaud, MD, Nirmal Paed, Surg, Atul Sabharwal, FRCS, Paed, Gokarn, MD, Deepa Manwani, MD, Steven Surg, Royal Hospital for Sick Children, Borenstein, MD, Dominique Jan, MD, PhD, Yorkhill, Glasgow, UK Montefiore.Medical Center AIM: Laparoscopic pyloromyotomy has PURPOSE: Acute splenic sequestration recently been introduced at our institution. crisis is a potentially life threatening Our aim was to audit this initial experience, complication of sickle cell disease which focusing on complications. can require prophylactic splenectomy. Historically, splenectomy before age 5 METHODS: Patients who had laparoscopic was avoided due to fear of overwhelming pyloromyotomy between 2005 and 2014 post-splenectomy sepsis. Recently, inclusive were identified retrospectively splenectomy has been performed as early from the theatre database. These as age 2, but the safety of this approach is case notes were reviewed regarding unknown. This study compared outcomes demographics, presentation, operative of splenectomy performed in patients details and post-operative course. under 5 to those 5 years and older. RESULTS: During the study period 605 METHODS: A retrospective chart review pyloromyotomies were performed, 40 of patients registered in a children’s attempted laparoscopically (7%). For

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Top Poster Abstracts CONTINUED hospital hematology database was INTRODUCTION: Appendicitis is one of performed to examine intra-operative, the most common surgical emergencies post-operative, and long-term outcomes in the pediatric population. Despite this, after splenectomy. Statistical data analysis there is still a great deal of debate among included Chi-Square test and Fisher’s pediatric surgeons regarding the workup exact tests for categorical variables and and treatment of this condition. The the Non-Parametric Median test for introduction of virtual broadcasts has continuous variables. The Institutional created a forum where surgeons all over Review Board approved this study. the world can discuss various controversial topics without being in one physical RESULTS: From 1997 to 2013, 30 sickle cell location. A case in point is appendicitis. patients underwent splenectomy. At time While there is an immense body of of surgery, 18/30 patients were under age 5 literature relating to the management of (group1) and 12/30 patients were 5 years or appendicitis, the literature is often varied older (group2). Mean age at splenectomy and so are common practices, especially was 34.2 months for group1 and 83.6 internationally. During a live, virtual, months for group2. Almost all procedures consensus conference in September were laparoscopic, and there was no of 2013, we polled pediatric surgeons difference between groups in frequency of from around the world regarding their laparoscopic or open splenectomy (group1, preferences in the management of 18 laparoscopic; group2, 9 laparoscopic appendicitis. Results are reported here. and 1 open). There was no difference in the operative time, rate of conversion METHODS: During the interactive from laparoscopic to open procedure, or broadcast session, questions about frequency of intra-operative complications. diagnosis and management of appendicitis The median length of stay was 4 and 6 days were displayed on the screen. World- for group1 and group2 respectively. Both renowned faculty and pediatric surgeon groups had similar lengths of follow up audience members were then asked to (median of 62.5 months group1, 63 months respond to the poll questions. group2). No portal vein thromboses or RESULTS: Questions asked were in the post-splenectomy sepsis events occurred in form of clinical scenarios. These included: either group. A 12 –year old boy with classic history CONCLUSIONS: While the statistical and exam for appendicitis. Is imaging power of this study was limited, there needed? Majority (69.2%) reported no was no evidence that the incidence imaging, 26.9% - Ultrasound, none chose of complications was higher after CT scan. When a question was asked splenectomy at a younger age. A large, about acute, non-ruptured appendicitis multi-center study is needed to further to be treated non-operatively, 7.1% said evaluate the safety of this practice. they would treat non-operatively with antibiotics whereas the majority (92.9%) T039: BRINGING SURGEONS TOGETHER said they would operate.For suspected, ACROSS THE WORLD: DIAGNOSIS AND acute, non-ruptured appendicitis at 11pm, MANAGEMENT OF ACUTE APPENDICITIS when would you operate? The majority Margaret Nalugo, MPH, Todd A Ponsky, (65%) reported that they would operate MD, George W Holcomb III, MD, Akron the next day, the rest reported that they Children’s Hospital, Children’s Mercy would operate that night. Regarding Hospital

WWW.IPEG.ORG | 199 Table of Contents Poster Abstracts technique the majority (56.8%) preferred INTRODUCTION: Vaginal and cervical standard 3- port laparoscopy for non- avulsions after sexual intercourse are perforated appendicitis, 37.8% preferred very rare in healthy female patients. The single-incision appendectomy and the rest standard approach for such lacerations preferred open appendectomy. Regarding utilizes a tenaculum to pull the cervix out antibiotic doses after appendectomy more superficially in order to facilitate for acute, non–ruptured appendicitis repair. There is one reported case in the and length of stay, the majority (56.67%) literature of laparoscopic intraabdominal preferred one more dose of antibiotic repair of a vaginal rupture with evisceration and discharge 24hours postoperatively, after intercourse. Here we describe a 16.67% preferred no further antibiotic transvaginal endoscopic repair of a deep and discharge 24hours postoperatively, vaginal laceration. 20% preferred no further antibiotic and DESCRIPTION: An otherwise healthy 17 discharge from recovery room or soon year-old girl presented with a one week thereafter , while 6.67% preferred one history of heavy vaginal bleeding after her more dose of antibiotics and discharge first sexual intercourse encounter. The after the dose. Regarding return to patient described using 4 to 5 pads per full activity following laparoscopic day with evacuation of large blood clots. appendectomy; Majority of the surgeons No external trauma was observed so the (33.3%) reported after two weeks, 16.67% patient was emergently scheduled for and 16.67% reported after three and examination under anesthesia. 4 weeks respectively, 20% reported after one week and 13.33% reported no The patient was placed in a lithotomy restrictions. position. Using a speculum, we visualized an actively bleeding partial cervical If on postoperative day 10 the child is not avulsion due to a deep partial thickness clinically well and still has a low grade laceration in the posterior vaginal fornix. fever; 56.25% of the surgeons would get a Repair using standard surgical instruments CT scan, the rest would get an ultrasound was unsuccessful. Given the risk of and none would continue intravenous (IV) completely avulsing the cervix if pulled antibiotics without any studies. outward using a tenaculum for repair, CONCLUSION: The use of virtual broadcasts we opted to use a 5 mm, 30 degree affords a unique opportunity for surgeons laparoscope and laparoscopic instruments around the world to share their practice including a knot pusher to repair the strategies with each other and gauge if laceration cervix. Hemostasis was they practice significantly different than accomplished and the patient recovered the majority of others. This is especially uneventfully thereafter. suited for topics such as appendicitis were CONCLUSION: We describe the successful diagnosis and treatment can be widely use of laparoscopic instruments to varied. repair a deep vaginal laceration in lieu T040: A NOVEL REPAIR OF A VAGINAL of maneuvers to pull the cervix out FORNIX LACERATION FOLLOWING superficially. This technique is simple and INTERCOURSE Ulises Garza Serna, MD, should be considered to avoid worsening David Bliss, MD, Nam Nguyen, MD, existing tears that may occur with Kasper Wang, MD, University of Southern manipulating the anatomy. California, Children’s Hospital Los Angeles

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Top Poster Abstracts CONTINUED

P001: THE INFLUENCE OF OPEN P002: LAPAROSCOPIC MANAGEMENT OF APPENDECTOMY AND LAPAROSCOPIC POSOPERATIVE BOWEL OBSTRUCTION APPENDECTOMY ON CD14, MD-2 AND IN CHILDREN Fernando Rey, MD, William TLR4 SIGNAL PATHWAYS IN CHILDREN Murcia, MD, Andrés Pérez, MD, Nidia WITH PERFORATED APPENDICITIS Jian Vera, MD, David Díaz, MD, Clinica Infantil Wang, MD, Jie Zhu, MD, Children’s Hospital Colsubsidio Bogotá, Colombia of Soochow University INTRODUCTION: Peritoneal adhesions are BACKGROUND: The inflammatory process a major cause of postoperative intestinal in the post-appendectomy period is not obstruction in children, the surgical well characterized. This study aimed to treatment is considered in cases where compare the inflammatory response the non-surgical management does not during open appendectomy (OA) and work or when there are signs of intestinal laparoscopic appendectomy (LA) and ischemia . Historically, the open release of the underlying Toll-like receptor (TLR)- peritoneal adhesions was the conventional mediated signal transduction pathways. treatment for this pathology; in recent years, laparoscopic management has MATERIAL & METHODS: We examined showed lower recurrence of adhesions, 17 children with perforated appendicitis less postoperative pain and shorter undergoing OA and 19 children undergoing postoperative hospitalization. The objective LA. Monocytes at different time points of this study is to describe our experience before and after surgery were evaluated. in the management of adhesive intestinal TLR4, CD14, and MD-2 expression, LPS- obstruction in a children’s hospital. mediated inflammatory response, and TLR signaling pathways were examined. OBJECTIVE: To describe the results of laparoscopic management of adhesions RESULTS: The expression of TLR4 and in children with postoperative intestinal MD-2 is increased in LA group, while there obstruction. is no difference in CD14, TLR4, and MD-2 expression in OA group. LPS stimulated RESULTS: 6 patients with postoperative ex vivo production of inflammatory intestinal obstruction were managed with cytokines was not affected in LA group, adhesiolysis by laparoscopy, the mean but the diminished TNF-a was found after age was 11.6 years (range 3-17 years), surgery in OA group. The phosphorylation 67% female and 33 % male, all patients of STAT3 and ERK1/2 in monocytes after were studied with abdominal X-ray, LPS stimulation was also suppressed in OA evidencing signs of mechanical intestinal group, while no difference was found in LA obstruction. They were initially managed group. with nasogastric tube between 1 and 5 days without improvement, so they CONCLUSIONS: LA, rather than OA, could were taken to surgery. All patients had protect monocyte-mediated inflammatory had peritonitis secondary to perforated response upon LPS stimulation, which appendicitis, 2 patients had been operated may help reduce the risk of postoperative by Rockey Davis incision, and 4 patients infection in children with perforated by median laparotomy, one of which had appendicitis. two previous surgeries for the same via for previous intestinal obstruction. The average operative time was 71 minutes (range 45-100 min), the procedure was

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Poster Abstracts CONTINUED performed by 3 ports in all patients, only 1 effect of pre-stretching of the abdominal case required reoperation by laparoscopy wall by a previous abdominal insufflation for drainage of postoperative residual was found to be significant. collection, non intestinal resection was CONCLUSIONS: NMB does not influence performed. The averaged time of oral laparoscopic working space. Studies feeding was 48 hours (range 24-96). There dealing with working space during were not intraoperative or postoperative laparoscopy should take note of pre- complications, nether conversion to open stretching bias. surgery. CONCLUSIONS: Laparoscopic adhesiolysis P004: LAPAROSCOPIC MANAGEMENT was safe in these patients; it is an FOR VENTRICULAR PERITONEAL SHUNT alternative management that could be COMPLICATION IN TWO PATIENTS WITH consider the best treatment in children CEREBROSPINAL FLUID PSEUDOCYST Fernando Rey, MD, William Murcia, MD, with these pathology, even in the first  Andres Perez, MD, David Diaz, MD, Nidia episode of postoperative intestinal Vera, MD, Faber Pelaez, MD, Clinica Infantil obstruction. Colsubsidio Bogotá, Colombia P003: OPTIMIZING WORKING SPACE INTRODUCTION: Peritoneal pseudocysts IN LAPAROSCOPY - CT MEASUREMENT of cerebrospinal fluid and intestinal OF THE EFFECT OF NEUROMUSCULAR obstruction due to adhesions are common BLOCKADE AND ITS REVERSAL IN A complications in ventriculo peritoneal PORCINE MODEL J. Vlot, MD, Pac Specht, shunt in hydrocephalus. Recently, BSc, Prof. RMH Wijnen, MD, PhD, Eg laparoscopic drainage of collections Mik, MD, PhD, Prof. NMA Bax, MD, PhD, and release of peritoneal adhesions Erasmus MC: University Medical Center shows favorable results with less Rotterdam intestinal manipulation, shorter ileus and BACKGROUND: Conflicting results on postoperative hospitalization time. the effect of neuromuscular blockade Two patients with hydrocephalus and (NMB) on laparoscopic working space are ventricular peritoneal derivation consulted found in literature. Studies are limited by for abdominal pain, associated with signs the absence of objective assessment of of partial intestinal obstruction. working space or use surrogate outcomes. We investigated this issue in a porcine CASE 1: 11 Year old male with multiple model using an objective method for ventricular peritoneal shunts for non- evaluating working space. communicating hydrocephalus, and previous liberation ofadhesions by METHODS: In a standardized porcine laparotomy, consulted with abdominal laparoscopy model, laparoscopic working- distension and tense mass at palpation, space dimensions with and without NMB abdominal pain and vomiting. The were investigated in 16 animals using abdominal x ray showed absence of computed tomography at intra-abdominal intestinal gas and round center radiopaque pressures of 0, 5, 10 and 15 mmHg during image. In the ultrasound and abdominal multiple runs of abdominal insufflation. scanography a round pseudocyst was RESULTS: No statistically significant effect displayed in the center of the abdomen of NMB on laparoscopic working-space surrounded by bowels. The patient dimensions was found. In contrast, the was managed by laparoscopy draining

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Poster Abstracts CONTINUED a pseudocyst of 1000 cc clear fluid. Due to development endovideosurgery Peritoneal adhesions of the bowel loops it became possible to perform difficult to the abdominal wall were released. 12 reconstructive surgeries on the biliary tract hours after surgery the gastric tube was by the aid of laparoscopy. removed, and in the third day, the patient The main goal of our work was to compare was released with adequate oral intake. the results of surgical treatment in two CASE 2: 4 Year old girl with hydrocephalus patient groups: “open surgery” and and ventricle peritoneal shunt, consulted “endovideosurgery” patients. for abdominal pain and distention, Since 2008, 26 patients with choledochal vomiting, and liquid stools. Abdominal cyst have been treated at National ultrasound showed ascites without Research Center for Mother and Child evidence of abdominal pseudocyst. At Health. Eight of them had complaints 72 hours of consultation, the abdominal on pain at epigastrium, three children – pain increased in association with transitory jaundice, and six patients had no tense abdomen and fever, a diagnostic clinical symptoms. All the children passed laparoscopy was performed, finding CT and ultrasound investigation. multiple collections of clear liquid. Collections were drained and the catheter We applied endovideosurgery in 11 exteriorized. Postoperative abdominal children. Roux-en-Y hepaticojejunostomy scanography showed underlying were performed after laparoscopic pseudocyst in the posterior aspect of choledochocystectomy had been the abdomen, another laparoscopy was completed. First two cases were a kind of performed after 4 days of the first surgery, open surgery with laparoscopic assistance. with appropriated drainage of pseudocyst. Roux-en-Y hepaticojejunostomy in these The externalized catheter was removed. patients were performed through arciform The patient did not require nasogastric incision at umbilicus. tube and the release was at 24 hours. In remained nine cases all the stages of CONCLUSIONS: Laparoscopic asses of intervention have been completed by abdominal pseudocyst was safe in both the aid of laparoscopic surgery. Affected patients, achieving appropriated drainage choledoch was incised very close (0.5cm) of the collections and early postoperative to the left and right hepatic ducts oral intake. This approach is a useful in the conjunction. While performing Roux-en-Y treatment of ventricular peritoneal shunts hepaticojejunostomy extracorporeal ties complications in pediatric age. were used. P005: ENDOVIDEOSURGERY FOR The similar open surgery was perfomed in TREATMENT OF CHOLEDOCHAL CYST 15 patients of control group. IN CHILDREN Damir Jenalayev, National Research Center for Mother and Child At postoperative period we used Health standard antibacterial treatment (wide spectrum antibiotics), parenteral nutrition The surgical treatment of congenital biliary within three days, and painkillers. No disorders is one of the tough issues in complications during the intra- and pediatric surgery. Choledochal cysts are postsurgery period were noticed. also of a current interest. For comparative assessment of body’s postagressive response to laparoscopic

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Poster Abstracts CONTINUED and traditional types of operations we performed undergeneral endotracheal studied: the state of stressful hormones anesthesia with muscle relaxation. (cortisol, prolactin) and several biochemical The patient was in the supine position. blood parameters, reflecting the functional Pneumoperitoneum was established with state of the suprarenal glands and liver, an open technique by introducing a 2.5- or the balance of carbohydrate and protein 5-mm reusable trocar through a transverse metabolism. incision at the lower part of umbilicus. The analysis of the comparative evaluation Insufflation pressure was between of body’s postagressive response to 8–10 mm Hg, based on the patient’s laparoscopic and traditional surgeries age. The size of the trocar depends on has showed that laparoscopic surgery is the size of the telescope. Two sizes of less invasive, less traumatic, less durable telescope diameter may be used: either surgical intervention which is characterized 2.5-mm 5-degree, or 5-mm 5-degree to have more favorable postoperative or 25-degree. The whole peritoneal period. cavity is inspected. Any hernia is reduced manually or with the aid of the telescope Taking into consideration our experience of tip. All needle movements are performed laparoscopic surgery for choledochal cysts from outside the body cavity under endovideosurgery could become a method camera control. To choose the location of choice for correction of external biliary for the needle puncture, the position ducts disorders. of the internal inguinal ring is assessed P006: PERCUTANEOUS INTERNAL by pressing the inguinal region from the RING SUTURING: MINIMALLY INVASIVE outside with the tip of a Pean the needle TECHNIQUE FOR INGUINAL HERNIA into the thread loop and the needle is REPAIR IN CHILDREN Damir Jenalayev, withdrawn. Next, the thread loop is pulled Omar Mamlin, Bulat Jenalayev, Dulat out of the abdomen with the thread end Mustafinov, National Research Center for caught by the loop. In this way the thread Mother and Child Health is placed around the inguinal ring under the peritoneum and both ends exit the Since January 2013, 47 patients , from 1 skin through the same puncture point. month to 16 years old with inguinal hernia The knot is tied to close the internal ring have been treated by PIRS (Percutaneuos and is placed under the skin. If an open Inguinal Ring Suturing) at National inguinal ring is found contralaterally, it is Research Center for Mother and Child closed during the procedure, regardless of Health. There were 26 boys with 33 hernias its diameter. The umbilical wound is closed (27% bilateral) and 21 girls with 30 hernias with absorbable stitches and covered with (43% bilateral). In 3 of 7 (42, 8%) boys and pressure dressing to prevent hematoma 6 of 9 (66, 6%) girls with bilateral hernias, formation. The skin puncture point in the the diagnosis was made preoperatively. inguinal region is left without any ressing. The other children with bilateral hernias had an open contralateral inguinal canal There were no conversions in our series. diagnosed perioperatively that was The mean time under anesthesia for regarded as a hidden hernia. PIRS was 42± 12.35 minutes. The mean operative time was 17.34±6.30 minutes for All apparatus introduced into the body unilateral hernia and 25.20±6.56 minutes cavity were manufactured by Karl Storz for bilateral hernias, from the beginning of (Germany). The PIRS procedure was

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Poster Abstracts CONTINUED cleaning the operative field to dressing the bead transfer task, 6 beads were lifted umbilicus. The cosmetic results after PIRS from pegs by one operator and passed were excellent, with no scars in the inguinal to the other operator, who placed them region and an almost invisible scar in the on opposite pegs. In the experimental umbilicus. There were not intraoperative group, both operators controlled their own complications in our experience. instrument-centered image. There were two controls: 1) static, wide-angle view of CONCLUSION: The PIRS method seems all the pegs, and 2) single moving camera to be a simple and effective minimally allowing close-up and tracking of the bead invasive procedure with excellent as it was transferred. Each team of two cosmetic results and a complication rate operators performed every test at least comparable to other laparoscopic once; the order in which the tests were techniques of inguinal hernias repair in performed was randomly assigned. Time children. According to our experience, PIRS to completion and number of bead drops should be taken into consideration as an were recorded. alternative technique. RESULTS: Thirty-six individual sessions P007: INTERACTIVE INSTRUMENT- were performed by pairs of surgical DRIVEN IMAGE DISPLAY IN residents in their second-through-fifth LAPAROSCOPIC SURGERY Austin Y. Ha, post-graduate year. Average total time Eleanor A. Fallon, MD, Derek L. Merck, PhD, for bead transfer was 127.3 ± 21.3 s in Sean S. Ciullo, MD, Francois I. Luks, MD, the Experimental group, 139.1 ± 27.8 s Alpert Medical School of Brown University in Control 1 and 186.2 ± 18.5 s in Control 2 (P=0.034, ANOVA). Paired analysis BACKGROUND: A significant limitation (Wilcoxon Signed Rank Test) showed that of minimally invasive surgery (MIS) is the the Experimental group was significantly dependence of the entire surgical team faster than the Control 1 group (P=0.035) on a single endoscopic viewpoint. We have and the Control 2 group (P=0.004). developed an individualized, instrument- driven image display system that allows CONCLUSIONS: An image navigation all members of the surgical team to system that allows two (or more) simultaneously control their view of the simultaneous, independent image displays operative field. We tested its efficacy in centered on each laparoscopic instrument vitro using a modified Fundamentals in allows intuitive and significantly faster Laparoscopic Surgery (FLS®) bead transfer laparoscopic task performance than task. either the standard, static FLS® camera view or a single tracking close-up image METHODS: An image navigation program of the field. Specifically, it offers higher was custom-written in Python, numpy and resolution images and the possibility of OpenGL to allow zooming and centering multi-tasking. In addition, the instrument- of the image window on two specific color driven tracking system guarantees that the signals, each one attached near the tip close-up image is always centered on the of a different laparoscopic grasper. The laparoscopic target. Further development navigation router receives the image signal of robust prototypes will allow the from a stationary camera via USB interface transition of this in vitro system into clinical and splits it into the respective daughter application. windows (one monitor per user). In the modified, two-operator FLS® endotrainer

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Poster Abstracts CONTINUED

P009: THE GONZALEZ HERNIA REVISTED: DISCUSSION: The ischiorectal fat pad is USE OF THE ISCHIORECTAL FAT PAD TO easily visualized and mobilized, either via AID IN THE REPAIR OF RECTOVAGINAL a posterior sagittal or transanal approach, AND RECTOURETHRAL FISTULAE Marc providing excellent coverage with native, Levitt, Sebastian King, Andrea Biscoff, well-vascularized tissue, in an area that is Shumyle Alam, G Gonzalez, Alberto difficult to heal. It is an excellent option Pena, Nationwide Children’s Hospital, The for recurrent rectovaginal and rectovaginal Royal Children’s Hospital, Morgan Stanley fistulaeand may have other additional Children’s Hospital creative applications. This approach when the rectum requires mobilization already, INTRODUCTION: During the development may be less invasive than a laparoscopic of the posterior sagittal approach to omental mobilization. anorectal malformations a vital technical challenge was a precise midline dissection, P010: THE INITIAL RESULTS OF which if off, allowed for the ischiorectal LAPAROSCOPIC-ASSISTED DUHAMEL fat pad to bulge into the wound. This OPERATION IN TOTAL COLONIC occurrence became affectionately known AGANGLIONOSIS Tri T. Tran, MD, Pediatric as a “Gonzalez hernia”, after a trainee Hospital No 2 of Dr Pena’s. For both traditional PSARP BACKGROUND: Total colonic aganglionosis and the laparoscopic approach (ideal for (TCA) is the rarest type of Hirschsprung’s rectobladderneck and high rectoprostatic disease. and has been traditionally fistulae), this technical aspect of managed by enterostomy and various staying precisely in the midline remains different techniques of pull-through paramount. With a twist of this idea, we operation. Since Jan 2012, laparoscopic- have put this fat pad to use, and have assisted Duhamel operation has been found that it can be an effective structure performed in our hospital. to aid in the repair of acquired rectovaginal and rectourethral fistulae. The aim of this study was to evaluate the initial results of laparoscopic-assisted METHODS: Patients with recurrent Duhamel operation in TCA at Children’s vaginal or urethral fistulae were selected Hospital 2. for review. The ischiorectal fat pad was deliberately mobilized, (via a posterior METHODS: Case series reports from Jan sagittal or transanal approach) and used to 2012 – June 2013. buttress the repair of the posterior vagina or urethra. RESULTS: There were 6 TCA children underwent the laparoscopic-assisted RESULTS: The ischiorectal fat pad Duhamel operation. Mean age was 20.3 (13 technique was used in 9 patients. All had -36) months, mean operating time was 5.4 (3, an acquired fistula (6 rectovaginal fistula, 6-7) hours. No intraoperative complications. 3 rectourethral fistulas). We used the No conversion to open surgery. In 5 posterior sagittal approach in 7 and in 2 the successful cases, mean time of oral feeding transanal approach. 6 patients had had at was 5.6 (4-8) days and the average length least two prior attempts at fistula repair. 6 of hospital stay was 11.2 (10-13) days. There patients had a stoma, and 3 did not. There was one case of failure due to postoperative were no recurrences in greater than six adhesive intestinal obstruction and month follow-up. anastomotic stenosis. This case was operated 8 months after first operation.

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Poster Abstracts CONTINUED

Mean follow-up time is 9.2 months with left abdominal quadrant. To confirm the good functional outcome. 5 of 6 cases had suspicion of hereditary pancreatitis a biopsy 3 to 6 bowel movements per day and the was performed. But the result was not clear. remaining case had 10 times per day. One year later the ultrasound follow-up showed the spleen lying in the small pelvis CONCLUSIONS: This is a safe operation above the bladder. Also a mild pancreatitis with good results, and highly aesthetic. The was still existent. A few months later, the laparoscopic-assisted Duhamel procedure patient came back to the hospital with an is our procedure of choice in total colonic exacerbation of the abdominal pain. The aganglionosis. physical examination resulted in an acute KEYWORDS: laparoscopic-assisted abdomen. The ultrasound examination Duhamel operation, total colonic presented a torsion of the greatly enlarged aganglionosis, Hirschsprung’s disease. spleen (20cm) lying above the bladder surrounded by ascites. Via contrast gain, P011: WANDERING SPLEEN - a very slow tide and two areas cutted out LAPAROSCOPIC SPLENOPEXY Sonja Kern, were detected. Immediately, an emergency Julia Syed, P. Lux, Dr., R. T. Carbon, Prof., Dr., laparoscopy was performed. The pedicle Pediatric Surgery Department of University was twisted about 240 degrees. Now Hospital Friedrich-Alexander University of the spleen was turned back and brought Erlangen-Nuremberg into the normal position in the upper left BACKGROUND: A wandering spleen is a abdominal quadrant. After a few minutes, very rare clinical condition associated with the spleen was reperfused. Splenopexy was a high risk of splenic torsion along the mandatory and was realized by gluing with vascular pedicle leading to splenomegaly fibringlue. The inferior pole was positioned and infarction. The incidence is about into a peritoneal pouch sutured out of the 0.2%. The suspected etiology is the lack peritoneum of the abdominal wall. After one of suspensory ligaments and laxity of the week of bed rest, a planned second-look peritoneal fixation resulting from a fusion laparoscopy was performed. The spleen was anomaly of the dorsal mesogastrium of found still in place with a little overturning the spleen. The predominant symptoms at the top. Further fixation was applied with vary from an asymptomatic incidental two stripes of vicryl-net anchored to the finding to an abdominal mass, recurrent diaphragm and the abdominal wall. abdominal pain, intestinal obstruction, RESULT: The postoperative course was hemoperitoneum or in the case of uneventful. Mobilization and defecation infarction even the acute abdomen. were without problems. The clinical and CASE REPORT: We report a case of a ultrasonic follow-up showed the spleen 17-year-old girl presenting with recurrent fixed in anatomical position. Since then, abdominal pain for a year and a half. no pancreatic problems appeared. A Interestingly, the 13-year-old sister of our light elevation of the diaphragm was patient had a wandering spleen with total evident without breathing impairment. torsion and necrosis of the organ one year Laparoscopic splenopexy by forming a before with consecutive splenectomy. peritoneal pouch and inserting a vicryl-net The blood test resulted in an increase fashioned around is feasible, less invasive of the pancreatic enzymes. In the first and does not diminish splenic function. examinations the spleen was minimally It is a safe and effective treatment for enlarged and positioned in the upper symptomatic wandering spleen.

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P012: LAPAROSCOPIC REPAIR OF the duodenum. The suspension stitch CONGENITAL DUODENAL OBSTRUCTION facilitated completion of the anastomosis Brian J. MacCormack, Mr., Jimmy P. Lam, with excellent visualisation and minimal Mr., Royal Hospital For Sick Children manipulation of the tissues. Edinburgh RESULTS: Of the three cases, one was a BACKGROUND: Congenital duodenal duodenal web, while the other two were obstruction (CDO) occurs in 1 in 6000 live duodenal atresias. All three cases were births and is often associated with other successfully managed by laparoscopic anomalies including trisomy 21 and cardiac duodenoduodenostomy. The operative malformations. Laparoscopic repair of CDO duration was between 170 and 195 has become popularised over the past mins. There were no conversions to an decade, however the variable anatomy and open procedure, no intra-operative small operating space poses a challenge complications and no anastomotic leaks for surgical repair utilising minimally observed. Enteral feeds were initiated on invasive techniques. It has therefore been post-operative day 3, once nasogastric suggested that laparoscopic treatment tube output had decreased. Full feeds of CDO should be restricted to a limited were established between 10 and 14 days. number of designated centres of expertise. Post-operatively one patient developed After gaining extensive experience with chylous acities, which was successfully intracorporeal suturing in other procedures managed conservatively with medium we evaluated the feasibility of this chain triglyceride (MCT) feed for 4 weeks. approach in a single centre. CONCLUSIONS: Laparoscopic METHODS: Three consecutive cases of duodenoduodenostomy is a technically CDO were approached laparoscopically. challenging procedure which involves The gestational age at operation was delicate intracorporeal suturing. The between 35 and 37 weeks, and the weight published results have been reported by between 1.7 and 2.6 kg. In each case a 5 very experienced paediatric endoscopic mm 30° telescope was inserted through surgical groups. This has led to the the inferior umbilical fold, using a open conclusion that laparoscopic treatment of Hassan technique. Pneumoperitoneum CDO should be restricted to a few centres to 8 mmHg with CO2 was established. of expertise. This series demonstrates Two 3.5 mm working ports were inserted; that laparoscopic duodenoduodenostomy one in the right iliac fossa, and one in can be safely and successfully performed the left flank. In the first case a side to with excellent short-term outcome. We side anastomosis was performed. In the found that suspension stitches facilitate subsequent two cases, after transverse the complex anastomosis by allowing enterotomy of the dilated proximal excellent visualisation. We conclude that duodenum, and longitudinal enterotomy if experience of intracorporeal suturing of the collapsed distal duodenum, a has been attained in other areas that diamond-shaped Kimura anastomosis laparoscopic duodenoduodenostomy can with interrupted 6 - 0 Vicryl sutures be safely and successfully performed in was performed. A 4-0 PDS suture was small preterm neonates, even in lower placed through the abdominal wall, volume centres. through the proximal duodenum, and back out the abdominal wall to display

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Poster Abstracts CONTINUED

P013: LAPAROSCOPIC SPLENECTOMY P014: ENDOSCOPIC REMOVAL OF IN CHILDREN WITH BENIGN SHARP OBJECTS IN THE UPPER HEMATOLOGICAL DISEASES: LEAVING GASTROINTESTINAL TRACT Burak NOTHING BEHIND POLICY Mohammad Tander, MD, Unal Bicakci, MD, Mithat Gharieb, PhD, Departement of Pediatric Gunaydin, MD, Riza Rizalar, MD, Ender Surgery. Facullty of Medicine. Tanta Ariturk, MD, Ferit Bernay, MD, Ondokuz University Mayis University, Department of Pediatric Surgery, Samsun, Turkey INTRODUCTION: Laparoscopic splenectomy (LS) is considered the standard approach AIMS: Removal of ingested sharp objects for the treatment of children with non is challenging in children, when they malignant hematological diseases due are stuck in the upper gastrointestinal to the advances in minimal invasive tract. We evaluated the role of flexible surgery over conventional splenectomy endoscopy and the snare as a removing (CS). Different techniques are involved instrument on patients with ingested sharp in the operation to secure the hilum. We objects. assessed the value of bipolar sealing device METHODS: Within the last four years, (LigasureTM ) as a safe, effective and less eight patients with a history of sharp time consuming with less complication rate. object swallowing were admitted. The PATIENTS & METHODS: Sixty chidren (33 primary diagnostic tool was a direct with thalassemia, 20 with ITP, and 7 with X-ray of the upper body. The foreign spherocytosis) were operated upon in bodies were removed by flexible Tanta University Hospital. These children esophagogastroduodenoscopy and its had undergone LS using bipolar sealing associated instruments. devices (LigasureTM). We excluded RESULTS: Four of the foreign bodies were cases with mean splenic span <16cm. We lodged in the esophagus, three in the evaluated the overall operative time, total stomach and one in the duodenum. There amount of blood loss and the occurance of were six open safety pins and two jewels any other complications. with sharp tips. Three were lodged in the RESULTS: Sixty children (37 girls and esophagus one of them with the pin’s 23 boys) with mean age 10.2 years had open end pointed caudally; it was held undregone LS using LigasureTM with with the endoscopic forceps by its tail mean operative time 85 minutes. There end and removed, two of them had the were no mortality, two cases converted open end with cranially pointed; they were to convensional open splenectomy due pushed into stomach rotated, grasped by to difficulty to complete the procedure. their blunt end and taken out. One sharp Two cases had postoperative subphrenic tipped jewel was in the upper esophagus collection resolved with conservative and it was removed similarly. Another measures. No complications related to sharp tipped jewel was in the stomach and injury of adjacent strctures. it was grasped by the snare used in the “percutaneous endoscopic gastrostomy”. CONCLUSION: Laparoscopic splenectomy An open safety pin lodged in the distal using bipolar vessel sealing device is part of duodenum was also removed by techniqually safe, less time consuming the same snare. The last foreign body with less complications compared with was an open safety pin in the stomach. It other techniques. was noticed that the object had already

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Poster Abstracts CONTINUED passed into the jejunum after induction of between both groups. In LAP group, mean anesthesia. It left the gastrointestinal tract OP time was significantly longer (70.4 ± spontaneously within 3 days. 37.7 vs. 47.3 ± 15.1 mins, p< 0.01); mean PO time (1.57 ± 0.83 vs. 2.23 ± 0.97 days, p< CONCLUSIONS: Open surgery or other 0.01) and LOS (3.34 ± 1.19 vs. 4.37 ± 1.59 invasive removal methods are mostly days, p= 0.01) were significantly shorter. not necessary in children with sharp One surgical recurrence occurred in object ingestions. The best way to extract each group occurring (4.3% vs. 2.8%, p= the sharp objects from the esophagus, 0.76). In comparison of IP (n= 15) and NIP stomach or duodenum is using a flexible (n= 8), there is no significant difference endoscopic device and a powerful snare. on recurrence rate and OP time. The P016: IDIOPATHIC INTUSSUSCEPTION IN overall conversion rate was 13.0% (6.8% CHILDREN: EFFICACY OF LAPAROSCOPY vs. 25%, p= 0.21). The conversion rate AND ILEOPEXY Chin-Hung Wei, MD, was significantly higher in cases with Yu-Wei Fu, MD, Nien-Lu Wang, MD, the intussusceptum to transverse and PhD, Yi-Chen Du, MD, Mackay Memorial descending colon than to ascending colon Hospital (p< 0.05). With the exclusion of conversion, OP time was significantly shorter in NIP (p= PURPOSE: This study aims to compare the 0.01). results of laparoscopy and open surgery for idiopathic intussusception in children as CONCLUSION: Laparoscopy should be well as evaluate the efficacy of ileopexy. considered the primary modality for radiologically irreducible idiopathic METHODS AND MATERIALS: Between intussusception in children. Ileopexy January 2007 and July 2013, children provides no benefit on recurrence aged < 18 years who were operated for prevention but longer OP time. intussusception in our institution were reviewed. Patients were classified into P017: BILIARY-ENTERIC two groups, laparoscopy (LAP) and open RECONSTRUCTION WITH (OPEN). LAP group was further divided into HEPATICOJEJUNOSTOMY (HJ) VERSUS two subgroups, ileopexy (IP) and non- HEPATICODUODENOSTOMY (HD) ileopexy (NIP). Parameters investigated FOLLOWING LAPAROSCOPIC EXCISION OF included age, gender, operative indication, CHOLEDOCHAL CYST IN CHILDREN Fanny surgical procedure, type of intussusception, Yeung, MBBS, Patrick Chung, FRCSEd, Ivy level of intussusceptum, presence of Chan, FRCSEd, Paul K. Tam, ChM, FRCSEd, spontaneously reduced intussusception Kenneth K Wong, MD, PhD, The University and pathologic lead points, operative time of Hong Kong (OP time), time to oral intake (PO time), BACKGROUND: With the advent of length of postoperative hospital stay (LOS), laparoscopic surgery, more choledochal surgical recurrence. cysts are excised laparoscopically. In this RESULTS: There were 23 and 35 cases study, we compared the outcomes from in LAP and OPEN group respectively. laparoscopic hepaticojejunostomy (HJ) and No significant difference was found hepaticoduodenostomy (HD) for biliary- on age, operative indication, surgical enteric reconstruction performed in our procedure, type of intussusception, level early era. of intussusceptum, and presence of spontaneously reduced intussusception

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METHODS: A retrospective analysis of P018: INTRAOPERATIVE patients who had undergone laparoscopic ESOPHAGOGASTRODUODENOSCOPY FOR choledochal cyst excision between LAPAROSCOPIC-ASSISTED DUODENAL February 2005 and May 2013 was WEB RESECTION IN THE PEDIATRIC performed. Demographic data and surgical POPULATION Paul M. Jeziorczak, MD, MPH, outcomes were analysed using SPSS Jill S. Whitehouse, MD, Kevin P. Boyd, DO, Statistics 21.0. Alfonso Martinez, MD, John C. Densmore, MD, Medical College of Wisconsin/ RESULTS: A total of 38 patients were Children’s Hospital of Wisconsin identified, with initial 28 patients underwent HJ. The most recent 10 PURPOSE: To demonstrate the benefit of patients underwent HD. The first 8 METHODS: This is a 13 m.o. female with a patients of the HJ series were excluded as prolonged history of intermittent vomiting it was deemed to be the learning curve of undigested food. An UGI study was period. Overall, there were no significant concerning for a proximal small bowel differences in terms of demographics. stenosis or web. She was taken electively Mean operative time was significantly to the operating room for intraoperative shorter in HD group (269 vs 403 minutes, EGD with laparoscopic assisted resection of p= 0.004) with lower conversion rate (0% her enteric obstruction. vs 35%, p=0.033). Although postoperative A 1cm vertical incision was made through enteral feeding was initiated later in the umbilicus and a 5mm trocar was HD group (5.2 vs 4.7 days, p=0.026), placed and the abdomen was insufflated. postoperative stay in intensive care Upon inspection of the abdominal unit (ICU) (0.8 vs 2.35 days, p=0.011) contents using a laparoscope, a very and overall hospital stay (9 vs 10 days, dilated duodenum was immediately p=0.248) favoured HD group. There was observed. The normal-caliber transverse no perioperative mortality. One patient colon was draped over the duodenum. In in HJ group had postoperative cholangitis the distal duodenum, a very clear transition related to anastomotic stricture whereas point was visualized. At this point, a 2nd no cholangitis noted in HD group. trocar was placed in the left mid-abdomen Although four patients in HD group under direct visualization. An intraoperative had asymptomatic biliary reflux, none EGD was performed to identify the etiology required reoperation while five patients of the obstruction. A stenotic web was in HJ group required second operation for located directly at the point of transition, complications and residual diseases. which was visualized endoscopically as well CONCLUSIONS: Laparoscopic as laparoscopically. The transition point excision of choledochal cyst with was grasped and brought out through the hepaticoduodenostomy reconstruction umbilical incision. is safe and feasible with shorter The bowel was opened longitudinally operative time, lower conversion rate through the transition point where a web and shorter ICU stay. It is not inferior to was found with a 3mm central opening. hepaticojejunostomy in terms of various The web was excised and the mucosal postoperative outcomes. defect was closed with a running chromic suture. The duodenum was closed transversely in a Heineke-Mikulicz fashion.

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RESULTS: She did well after surgery, no down into the abdominal cavity, pulled fevers, appetite is better than before back into the posterior mediastinum surgery, no emesis, stooling 1-3 times per simply when the stomach was detached. day-soft, back to usual activity. The vessel at the lesser omentum was damaged when the assistant held and CONCLUSIONS: Intraoperative endoscopic pulled the stomach strained in one examination during laparoscopic case. The hernia sac consisted of a exploratory laparotomy is useful to identify thickened phrenoesophageal ligament. the etiology and location of proximal small Resection of the sac at posterior site of bowel enteric obstructions and to rule out the stomach is relatively difficult, and a windsock deformity more proximal to the it’s troublesome to dissect it from lesser transition point. omentum (hepatogastric ligament). The P019: LAPAROSCOPIC MANAGEMENT important procedure is to expose crura OF PARAESOPHAGEAL HERNIA WITH firmly, not to excise the sac. Insufficient INTRATHORACIC STOMACH IN INFANT : dissection of the crura brought type2 PITFALLS IN THE TREATMENT FROM OUR hiatal hernia recurrence in one case. 3 CASE EXPERIENCES Kan Suzuki, PhD, The abdominalesophagus was wrapped Akira Nishi, PhD, Hideki Yamamoto, PhD, with the mobilized fundus in a 2- to Tetsuya Ishimaru, PhD, Tadashi Iwanaka, 3-cm floppy Nissen fundoplication in PhD, Gunma Children’s Medical Center all cases. An anchoring, wrapping cuff was approximated to the anterior edge PURPOSE: The aim of this report was of the diaphragmatic crura in all cases. to analyze pitfalls in the laparoscopic Stamm gastrostomy was added to double management of type3 paraesophageal as gastropexy in one case. Transient hernia in infant. dysphagia was found in 2 cases after METHODS: Between 2009 and 2013, operation. The solid was got blocked in the the records of 3 infants with type3 case of 1 y/o and needed to remove. The paraesophageal hiatal hernia were esophageal passage was improved in all retrospectively reviewed for age, cases two months after the operation. presenting symptoms, operative findings CONCLUSIONS: The opportunity of and approaches, and outcomes. operation is recommended before starting RESULTS: All cases (1 male, 2 female) the baby food. Laparoscopic intervention had right-sided type3 paraesophageal of hiatal hernia with intrathoracic stomach hiatal hernia. Diagnosed until neonatal is a safe and feasible method in infantile period in two cases, their symptom was patients. Management consists of retrieval only intermittent vomiting and they of the intrathoracic stomach, closure of had good weight gain. We conducted the hiatus and subsequent antireflux the operation before the baby food procedure. In our experiences, perfect start. The other patient had clinical excision of the sac is relatively difficult, features of chest infection and anemia and firm exposure of the crura and precise at 9 months, she underwent electively closure of the hiatus is the most important. operation at 1 y/o. Surgical procedures The method of antireflux procedure leaves were conducted with laparoscopy, and room for discussion. open conversion was not required in any case. At the operation, though the intrathoracic stomach was easily pulled

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P020: LAPAROSCOPIC CORRECTION OF contrast fluoroscopy may help in cases of DUODENAL WIND-SOCK ATRESIA WITH intraluminal obstruction; other procedures ASSOCIATED MALROTATION Ruben than diamond shaped anastomosis can be Lamas-Pinheiro, MD, Tiago Henriques- performed in the correction of this type of Coelho, MD, PhD, Hospital de São João, duodenal atresia. Porto, Portugal P021: THE FEASIBILITY OF EMERGENCY INTRODUCTION: The most complex LAPAROSCOPIC COLECTOMY FOR neonatal procedures have already CHILDREN WITH ACUTE COLONIC been performed by minimal invasive PERFORATIONS AND FIBROPURULENT approaches. The authors present a video PERITONITIS Yu-Tang Chang, Jui-Ying Lee, of a challenging laparoscopic correction Chi-Shu Chiu, Jaw-Yuan Wang, Kaohsiung of type I duodenal atresia (Wind-sock) Medical University Hospital associated with intestinal malrotation and BACKGROUND: Several studies have volvulus. demonstrated that laparoscopic surgery CASE: Preterm female newborn, 34 is safe and effective for urgent and weeks gestation with prenatal diagnosis emergent colectomy in adulthood. The aim of duodenal atresia. A postnatal of this study was to evaluate the feasibility roentgenogram confirmed the diagnosis. of laparoscopic colectomy for children in The neonate was submitted to laparoscopy emergent settings. at D1: one 5 mm trocar was placed in METHODS: Between March 2008 and the umbilicus and two 3 mm trocars August 2011, 10 consecutive children were placed in both flanks. The liver was with acute colonic perforations and suspended using a percutaneous stich. fibropurulent peritonitis secondary to An intestinal volvulus was identified and infectious colitis received emergency reduced. Ladd bands were divided and the laparoscopic colectomy. Simultaneously, mesentery was widened. As there was no we reviewed and recorded the same data visible duodenal atresia, an intra-operative of another consecutive 10 patients who contrast study was performed and a Wind- underwent standard laparotomy between sock atresia was revealed. The duodenum November 2004 and February 2008. The was incised, the membrane was partially two groups were compared regarding excised and a duodenoplasty (Heineke- operation time, length of hospital stay Mikulicztype) was performed. There were (LOS), and complications. no intra- or post-operative complications. The child started enteral feeding on 6th RESULTS: The gender, age, body weight, post-operative day, suspended parenteral serum C-reactive protein, number of feeding on the 13th and was discharged involved bowel segment, operation time on the 15th. Currently she is followed in and LOS were not significantly different outpatient without symptoms and with an (P = 0.36, 0.50, 0.33, 0.62, 0.81, 0.14 and excellent cosmetic result. 0.23, respectively). Of the laparoscopy group, one patient was converted to TIPS: This video presents possible open surgery because of extensive bowel difficulties during duodenal correction involvement and another with solitary and ways to overcome them with safety colonic perforation required reoperation and assertiveness: laparoscopic volvulus for anastomostic leakage. However, reduction is safe and less difficult in the patients receiving laparotomy had a higher absence of bowel dilatation; intraoperative

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Poster Abstracts CONTINUED incidence of later complications, including respectively. All patients had concurrent wound infection, incisional hernia and laparoscopic gastrostomy. The average adhesion ileus (P = 0.03, 0.06 and 0.03, operative time was shorter in group I (157 ± respectively), and thus required more 55 minutes vs 169 ± 52 minutes, p = 0.66). additional unplanned operations (P = 0.05). Both groups had minimal blood loss only. The surgical outcomes in both groups were CONCLUSIONS: Emergency laparoscopic comparable in terms of recurrence (0% surgery is technically feasible in most vs 3%, p = 0.105) and complications (9.5% children with acute colonic perforations vs 6%, p = 0.275). The median follow up and fibropurulent peritonitis. However, duration for group I and group II were 23 extensive intestinal involvement with months and 40 months respectively. multiple perforations should be an indication for converting to open surgery. CONCLUSION: Laparoscopic Nissen fundoplication can be safely performed P022: LAPAROSCOPIC NISSEN in infants with outcomes comparable to FUNDOPLICATION FOR older patients and a shorter operative GASTROESOPHAGEAL REFLUX DISEASE duration. Should infants develop GERD, Jessie Leung, MRCSEd, Patrick IN INFANTS  this operation should be performed early Chung, FRCSEd, Ivy Chan, FRCSEd, Eugene in order to avoid chronic lung disease due Lau, MRCSEd, Kenneth Wong, MD, PhD, to recurrent aspiration pneumonia. Paul Tam, ChM, FRCSEd, Department of Hong Kong, The University of Hong Kong P023: THE USE OF LAPAROSCOPY FOR PEDIATRIC LIVER BIOPSIES: A INTRODUCTION: Data on laparoscopic REVIEW OF A SINGLE INSTITUTIONAL Nissen fundoplication for EXPERIENCE Dan Parrish, MD, Shannon gastroesophageal reflux disease (GERD) in F. Rosati, MD, Michael Poppe, BS, Karen infants remains limited. We describe our Brown, BA, Patricia Lange, MD, Claudio experience with this operation in children Oiticica, MD, David Lanning, MD, PhD, and in particularly, infants younger than 12 Children’s Hospital of Richmond at Virginia months old. Commonwealth University Medical Center METHODS: Medical records of all BACKGROUND: Percutaneous liver biopsy paediatric patients who had laparoscopic (PLB) is an important tool for diagnosing fundoplication done for GERD from 1998 to liver diseases, especially in the pediatric 2013 were reviewed. Patients were divided population. Most PLB protocols require into two groups based on age: group I: 0 - a period of observation following the 12 months, and group II >12 months. Data procedure that may be extended should on indications, patient’s demographics, complications arise in addition to post- operative time, blood loss, conversions, procedure blood work. While it is often complications, recurrences and duration of performed effectively and safely, it is hospitalization were studied. not without its complications. Most RESULTS: A total of 86 patients were studies report minor complications reviewed (group I = 21, group II = 65). While (mild perihepatic hemorrhage, mild the mean age and body weight for group hemoperitoneum, pain, etc.) at rates I were 8 months (range 2.6 to 12 months) of 6-10% and major complication and 6 kg (range: 3.6 to 11 kg), the values for (perforation, large hemoperitoneum, etc.) group II were 84 months (range 17 to 228 rates of 1-3%. months) and 18 kg (range: 6.2 to 64.5 kg)

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METHODS: We retrospectively reviewed 24 with only 5% of symptomatic patients of our pediatric patients who underwent being in this age group. The aim of this laparoscopic-assisted liver biopsy between study was to evaluate the efficacy and April 2006 and May 2013. This group was safety of laparoscopic esophagomyotomy analyzed for length of stay, duration of with adjunctive intra-operative operation, labs obtained, repeat biopsy esophagoscopy to treat children with rate, and complication rate. Statistical achalasia. analysis was not performed due to the METHODS: Following ethical approval, small sample size and the retrospective we reviewed the medical charts of 10 nature of the design. children (7 male; 3 female) submitted to RESULTS: Of the 24 patients reviewed, laparoscopic esophagomyotomy to treat the average length of stay was 5.8 ± 2.95 achalasia. Median age at surgery was 12 hours, average duration of operation was years (9-13.8). Surgeries were performed 43.7 ± 10.73 minutes, no complications at a single tertiary hospital between were observed, no repeat biopsies January 2001 and December 2013. Anterior were needed, and no preoperative or myotomy was performed with five trocars postoperative labs were obtained. under intraoperative esophagoscopy. The distal part of the myotomy was extended CONCLUSIONS: Laparoscopic-assisted liver over the esophagogastric junction, and a biopsy allows for patients to be discharged Dor fundoplication was done after the end as soon as they have recovered from their of myotomy. anesthetic without the need for lab work or a prolonged period of observation. This RESULTS: Median operating time was 2.4 study suggests that laparoscopic-assisted hours (2-5). Median myotomy length liver biopsy is a viable option for diagnosing was 6 cm (5-8). One child had a mucosal liver disease that may be a safer and more perforation that was sutured before reliable alternative to PLB and should the Dor fundoplication. Two others had be further studied with a prospective, dysphagia after surgery, one of which had a randomized trial. redo surgery 6 months later. No conversion to open surgery was necessary, and there P024: LAPAROSCOPIC HELLER were no deaths. At a median follow-up of MYOTOMY WITH INTRAOPERATIVE 2.4 years (7 months-11.2 years), weight had ESOPHAGOSCOPY AND DOR improved in all children. Seven (70%) were FUNDOPLICATION FOR CHILDREN WITH symptom-free, whereas 2 (20%) presented Jose Carlos ESOPHAGEAL ACHALASIA  intermittent retrosternal pain, and 1 (10%) Fraga, MD, PhD, FAAP, Samanta S. Silva, had mild dysphasia. MD, Cristiane Hallal, MD, Cristina T. Ferreira, MD, PhD, Daltro L. Nunes, MD, Helena A. CONCLUSIONS: Laparoscopic Goldani, MD, PhD, Paola B. Santis-Isolan, esophagomyotomy associated with Dor MD, PhD, Pediatric Surgery Service¹ and fundoplication is a safe and effective Pediatric Gastroenterology Unit², Hospital treatment for pediatric esophageal de Clinicas of Porto Alegre, Federal achalasia. Myotomy should be long and University of Rio Grande do Sul, Brazil. extend through the esophagogastric junction. Intraoperative esophagoscopy PURPOSE: Achalasia is a functional disorder is very important to ensure adequate with abnormal motility of the esophageal myotomy and to reduce the incidence of body and incomplete relaxation of the mucosal perforation. lower sphincter. It rarely occurs in children,

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P025: ILEOCECAL RESECTION IN discharge was 7 days. The follow-up CROHN’S DISEASE – COMBINED showed a normal course. The patient LAPAROSCOPIC APPROACH J. Syed, does not need to take medication since S. Kern, M. Besendoerfer, Rt Carbon, operation. Pediatric Surgery Department of University CONCLUSION: Minimally invasive Hospital Friedrich-Alexander University of procedures gain standard for bowel Erlangen-Nuremberg resection, and by using appropriate BACKGROUND: As the number of patients technology (ultrasonic devices) it is suffering from chronic inflammatory easily practicable. The combination of bowel disease constantly increases, laparoscopy with an umbilical BIANCHI operative treatment will gain more and approach for retrieving specimen offers an more significance. Ileocecal resection elegant possibility. Advantages compared with primary anastomosis represents the with open surgery are: earlier reset of definitive management for drug – resistant digestion, shorter length of stay, earlier Crohn’s disease. recovery, smaller wounds, less pain, better cosmetic results, less adhesions with less CASE REPORT: We report a case of a 14 long term digestive problems, better year old boy with ileal Crohn’s disease. overview during operation. His dad suffered from ulcerative colitis, his mum from Crohn’s disease as well. P026: COMPARISON OF INFLAMMATION Because of a clinical relevant ileal VALUE AND INTRAABDOMINAL ABSCESS obstruction with recurrent fistula, abscess FORMATION AFTER LAPAROSCOPIC AND and probably perforation as well as severe OPEN APPENDECTOMIES IN TREATMENT growth disturbance, the indication for OF PERFORATED APPENDICITIS FOR operation was justified. We purposed CHILDREN Zai Song, PHD, Shan Zheng, a combination of minimally invasive PHD, Children’s Hospital of Fudan procedures – laparoscopical and umbilical University access. The ileocecal region was mobilized AIM: Now, laparoscopic appendicetomy(LA) by using ultrasonic device (Ultracision) and is an accepted alternative to the open the inflamed segment has been resected appendicetomy(OA) in children. However, by stapling device. Resected specimen was in treatment of perforated appendicitis, it retrieved via the umbilical approach which has been suggested that there is a higher was prepared (BIANCHI). After enlarged incidence of intraabdominal abscesses mobilization of the bowel the anastomosis (IAAs) and increased inflammation due (ileoascendostomy, single sutures) was to carbon dioxide pneumoperitoneum. performed extracorporeally. After the Our aim is to determine the incidence of mesenteric sutures the reposition of IAAs and the level of inflammation in both the anastomosis succeeded without techniques with perforated appendicitis. any difficulty. Peritoneal lavage and placement of a peritoneal drainage were METHODS: 62 patients and 71patients with administered. Umbilical reconstruction perforated appendicitis received LA and OA worked tension-free. respectively in out hospital from January to June, 2013. PH value and the value of RESULT: Operation time was 90 minutes. blood lactate(Lac) during the operation, The postoperative process was uneventful, as well as the value of proca lcit ionin(PCT) defecation set in after 2 days and and C-reactive protein(CRP) before alimentation could be started. Time to

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Poster Abstracts CONTINUED operation , during operation and 2 days surgery for gastrointestinal bleeding with after operation, were recorded. Incidence negative Tc-99m Meckel’s s diverticulum of wound infection and IAA also studied in canning. this study. METHODS: During the period from RESULTS: During the operation, the value Dec 2006 to October 2013, 13 cases of PH value and value of Lac show no with gastrointestinal bleeding and significant difference between LA and hypoalbuminemia were underwent OA group. (PH value:7.36±0.7 VS 7.39±0.5, DBE and laparoscopic surgery in the p=0.271, >0.05;value of Lac:1.3±0.4 VS department of pediatric surgery, Shanghai 1.4±0.7 , p=0.376>0.05). The value of Children’s Hospital, Shanghai Jiao Tong PCT and CRP also indicate no significant University and Children’s Hospital of Fudan different difference between LA and University. All the patients got Tc-99m OA group. In LA group, incidence of Meckel’s diverticulum scanning but failed wound infection is much lower than that to find positive spot. With the aid of a of OA group (4/62 6.4% VS 16/71 22.5, specially designed DBE, with the alternate p=0.017<0.05). However, comparing with inflation and deflation of the balloons at OA group, LA group did not reduced the the tip of the endoscope, the enteroscope incidence of IAAs (10/62, 16.1% VS 16.9%, was advanced into small intestine under 12/71, p=0.072>0.05) . total anesthesia. If Meckel’s diverticulum or other surgical disease was found, a CONCLUSION: In this study, we found that single umbilical incision were performed in treatment of perforated appendicitis in and then the laparoscopic surgery such as children, the technique of appendectomy ileoileostomy was followed at the same does not appear to affect the incidence of time. IAAs and value of inflammation. Children with LA seem to have a lower incidence of RESULTS: 8 patients of the final wound infection. clinicopathological diagnosis was Meckel’s diverticulum, duplication of P027: THE COMBINATION OF DOUBLE intestine was 4 cases and hemagiomas BALLOON ENTEROSCOPY WITH in 1. No complications such as aspiration LAPAROSCOPIC SURGERY FOR THE pneumonia, perforation or hemorrhage GASTROINTESTINAL BLEEDING occurred, and all the patients well WITH NEGATIVE TC-99M MECKEL’S tolerated during the procedure. No DIVERTICULUM SCANNING IN CHILDREN recurrence of bleeding was noted during Jiangbin Liu, PhD, Professor, Department  a median follow-up period of 21 months of Pediatric Surgery, Shanghai Children’s (range, 3-60 months). Hospital, Shanghai Jiao Tong University and Department of Pediatric Surgery, Children’s CONCLUSION: DBE is a useful and feasible Hospital of Fudan University, Shanghai, PR procedure in the pediatric patients, China especially for the gastrointestinal bleeding with negative Tc-99m Meckel’s AIMS AND OBJECTIVES: Double balloon diverticulum scanning, and combination enteroscopy (DBE) is widely practiced in with laparoscopic surgery at the same time adults but rare in children. The study aimed could make good results to review the experience on the application of double balloon enteroscopy (DBE) in children, and to combine laparoscopic

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P028: LAPROSCOPIC OPERATION FOR months ago. He had been ill with severe TREATMENT OF COMPLICATIONS IN cholangitis accompanied by intrahepatic CHOLEDOCHOCYST Zhaozhu Li, MD, bile ducts dilatation, we found stenosis of Qingbo Cui, MD, Dapeng Jiang, MD, Bo Xu, biliary-intestinal anastomosis by PTC. PhD, Department of Pediatric Surgery, the RESULTS: Two girls ill with perforation 2nd Affiliated Hospital of Harbin Medical of choledochocyst were treated by University laparoscopic drainage and irrigation of OBJECTIVE: Choledochal cysts are peritoneal cavity for emergency therapy. congenital cystic dilatations of the The patients were better in 7-10 days extrahepatic or intrahepatic portion of and went home. One month later they the biliary tree. Complete excision of came to hospital again for laparoscopic choledochal cysts is currently regarded as choledochal cyst excision with Roux-en-Y the gold standard treatment. Laparoscopic hepatico-jejunostomy and recovery. Two operation for choledochocyst is becoming boys ill with stenosis of biliary-intestinal popular. The complications may be anastomosis were operated by redo occurred in preoperative and postoperative laparoscopic hepatico-jejunostomy. The periods. Perforation of choledochocyst, procedure included splitting adhesions, cholangitis, pancreatitis, and malignant enlarging anastomotic stoma, and calculus may occur because of delay treatment. removed ect. The two boys recovered Stenosis of biliary-intestinal anastomosis, well and were hospital stay for 10 and cholelithiasis and infection of biliary tree 14 days, respectively. All patients were may also occur in post-operation. Here we followed 6 months to 2 years and no more treated 4 patients with the complications complications occurred. associated with choledochocyst by CONCLUSIONS: Laparoscopic operation for laparoscopic technique. complication treatment of choledochocyst METHODS: Total 4 children were treated is suitable and not difficult. Because in our hospital from June 2010 to June laparoscopic drainage and irrigation 2013. Two girls were ill with perforation of of peritoneal cavity for perforation of choledochocyst. Of them one girl was 3 choledochocyst are easy, it can rinse years old and had been diagnosed with peritoneal cavity thoroughly and the wall choledochocyst before. Another girl was of perforative bile duct can heal by itself 8 months old and was first attacked with quickly. It will be convenient and safe for abdominal pain, fever and abdominal the subsequent laparoscopic cyst excision. distension. We found her dilated common For hepaticojejunostomy stricture and bile duct by ultrasound exam and CT. intrahepatic stone formation, it will be Two boys were ill with stenosis of biliary- very important preoperative and operative intestinal anastomosis. Of them one boy cholangiography. It is not difficult to was 12 years-old and had been treated by separate adhesion of omentum and open choledochal cyst excision with Roux- intestine carefully. When the stoma site is en-Y hepatico-jejunostomy 6 years ago. recognized, hepaticojejunostomy need to He had been ill with reoccured cholangitis redo. and cholelithiasis for one year. Another boy KEY WORDS: Choledochocyst; was 6 years-old, he had been operated Laparoscopic operation; Complications by laparoscopic choledochal cyst excision with Roux-en-Y hepatico-jejunostomy 3

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P029: SIGMOID VOLVULUS. We consider that endoscopic devolvulation VIDEOASSISTED SIGMOIDECTOMY AS followed by an early videoasisted AN OPTION FOR MANAGEMENT IN sigmoidectomy is the ideal technique for PEDIATRIC POPULATION S. Castañeda, the management of this patients. MD, I. Molina, MD,P. Jaimes, MD, J. Beltran, MD, J. Valero, MD, F. Fierro, MD, P030: REDUCED PORT LAPAROSCOPIC Universidad Naccional de Colombia, RESTRATIVE PROCTOCOLECTOMY WITH Fundación Hospital de la Misericoridia ILEAL POUCH-ANAL ANASTOMOSIS IN PEDIATRIC PATIENTS Mikihiro Inoue, Sigmoid volvulus is one of the most MD, Junichiro Hiro, MD, Keiichi Uchida, frecuent causes of acute large bowel MD, Hiroyuki Fujikawa, MD, Yuhki Koike, obstruction. In children, it is a rare cause of MD, Yoshiki Okita, MD, Kohei Otake, MD, bowel obstruction with an incidence that Toshimitsu Araki, MD, Masato Kusunoki, varies from 3 to 5%. MD, Department of Gastrointestinal and Pediatric Surgery, Mie University Graduate A redundant sigmoid with a shortened School of Medicine mesentery (Dolichosigmoid) is necessary for the formation a volvulus. In the Restorative proctocolectomy with ileal pediatric population the cause of a pouch-anal anastomosis is the treatment dolicohsigmoid may be an abnormal of choice for most patients with ulcerative fixation that causes a widened mesentery colitis (UC) and familial adenomatous with a small base . Other causes are history polyposis (FAP). Technical feasibility and of anorectal malformation , Prune Belly safety for conventional laparoscopic syndrome, intestinal malrotation and approaches to this procedure have been Hirschsprung Disease. established since 1992 mostly in adult settings. Recently, not only short term but We report a series of 4 patients managed also long term benefits including reduced in our service with Sigmoid volvulus. Each postoperative adhesion and increased patient was taken to endoscopic reduction pregnancy rate have become evident in of the volvulus and latterly taken to the laparoscopic procedure compared with videoassisted sigmoidectomy. This case open surgery. Meanwhile, reduced port series is composed by 4 patients between laparoscopic surgery including single- 9 and 14 years. One of the patients had to incision laparoscopic surgery has been be taken to a second reduction of volvulus developed as an option for minimally before sigmoidectomy during hospital invasive laparoscopic procedures for stay. Another patient that initially rejected better cosmesis in the past few years. We sigmoidectomy, had a recurrence of the report four pediatric cases that underwent volvulus requiring a second endoscopic reduced port laparoscopic restorative reduction. There were no intraoperative proctocolectomy (RPL-RPC) with ileal complications, and patients have been pouch-anal anastomosis using single-port followed up for at least 6 months . During device in the different ways. this time, one of the patients required reintervention ; this patient had a diagnosis Three of four cases with ulcerative of an intestinal miopathy: Inflamatory colitis were planned to perform 2-stage Leiomiocytis which is a predisposition for procedure and underwent RPL-RPC as the intestinal obstruction. first operation. At operation, single-port device (Lap protectorTM and oval shaped EZ-access, Hakko CO.,LTD., Nagano, Japan)

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Poster Abstracts CONTINUED was positioned through the intra-umbilical P031: A CASE SERIES OF LAPAROSCOPIC longitudinal 30 mm incision and two 5 DUODENOJEJUNOSTOMY FOR THE mm ports were placed in the umbilical TREATMENT OF PEDIATRIC SUPERIOR device. A 12 mm port was used at the MESENTERIC ARTERY SYNDROME site of ileostomy in the right iliac fossa. A Fredrick J. Bohanon, MD, Lance W. Griffin, 5 mm port was also placed at the drain MD, Laila Rashidi, MD, Sam Hsieh, MD, insertion site in the left iliac fossa. Colonic Geetha L. Radhakrishnan, MD, Ravi S. mobilization and mesenteric division Radhakrishnan, MD, MBA, FACS, FAAP, was firstly achieved antegradely from University of Texas Medical Branch terminal ileum to splenic flexture and then Superior mesenteric artery (SMA) retrogradely from sigmoid colon to splenic syndrome is a rare debilitating clinical flexture. Division of the mesenteric vessels condition caused by compression of was performed using ENSEAL G2 Tissue the third portion of the duodenum by Sealers (Ethicon Endo-Surgery, Ohio, US) the SMA. It is often associated with without ligation. Terminal ileum was divided scoliosis corrective surgery, anorexia by endoscopic linear stapler through the 12 nervosa, rapid growth, and dramatic mm port. Colonic specimen was removed weight loss. Prevalence rates are through the umbilical incision and ileal J reported to vary between 0.01 – 0.08%. pouch was created extracorporeally at the Common symptoms include intermittent same site. Hand-sewn ileal pouch-anal postprandial abdominal pain, nausea, anastomosis was performed transanally. weight loss, bilious vomiting and Remaining one case with familial obstruction. SMA syndrome is also adenomatous polyposis underwent 1-stage associated with pancreatitis of unknown RPL-RPC without ileostomy. Same single- etiology. Here we present a case series port device was used transumbilically and a of three patients with SMA syndrome 5 mm port was placed at the drain insertion that were treated with laparoscopic site in the right iliac fossa. Additional 3 mm duodenojejunostomy. forceps for retraction was directly inserted Patients were female between 12-17 in the left upper abdomen. Division of the years old. One patient presented post- terminal ileum was performed through a scoliosis corrective surgery, one patient glove that was temporally exchanged from with anorexia nervosa, and one patient EZ-access. with rapid weight loss after pneumonia. All procedures were successfully All patients underwent a successful completed without any perioperative laparoscopic duodenojejunostomy after complications. Operative time ranged 385 imaging suggested SMA syndrome. Mean to 490 min. There were two long term time to feedings after surgery was 4.00 ± adverse events, including one afferent 1.15 days (mean ± SEM). Mean length of limb syndrome and one acute pouchitis. stay after surgery was 8.6 ± 2.7 days. One patient presented with pancreatitis (Lipase Our RPL-RPC to optimize the umbilicus 4432 U/L) that resolved after surgery. and the essential incisions is technically One patient developed acute pancreatitis comparable and cosmetically superior (Lipase 2220 U/L) on post-operative day 9 to conventional laparoscopy. This requiring readmission and treatment. One procedure can be an alternative for the patient didn’t develop pancreatitis. pediatric patients in needs of restorative proctocolectomy.

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SMA syndrome remains a complex disease IRB exempt determination, 23 participants to diagnose and treat. Once suspected performed the simulated laparoscopic DA current therapy consists of either non- repair during a national pediatric surgery surgical or surgical intervention. Post- conference. All participants completed obstructive placement of nasojejunal a self-report, six-domain, 24-item feeding tubes and total parental nutrition instrument consisting of 4-point rating allow for adequate nutritional intake scales (1=Not realistic, 4=Highly realistic). and decompression, but often require Content validity was evaluated using the prolonged hospitalization and increased many-Facet Rasch model and estimating costs. Reported hospital length of stay inter-rater consistency using Intra-class is between 21 days and 4 months in a correlation (ICC) for items relevant to small series. Surgical management mainly simulator characteristics. consists of open lysis of the ligament RESULTS: The highest observed averages of Trietz or duodenojejunostomy with (OA) were for Value as a training and possible risk of complications. Here we testing tool (both OAs = 3.9), while the demonstrate that laparoscopic treatment lowest ratings associated with simulator of SMA syndrome is a safe treatment characteristics were Palpation of liver, option and is associated with early initiation (OA = 3.3), and Realism of skin (OA = 3.2), of enteral feeds and a short hospital stay which aligned with “adequate realism, after surgery. but could be improved.” The Global P032: THE DEVELOPMENT AND opinion rating was 3.2, indicating the PRELIMINARY EVALUATION OF A NOVEL simulator can be considered for use as is, LAPAROSCOPIC DUODENAL ATRESIA but could be improved slightly. Validity REPAIR SIMULATOR Katherine A. Barsness, evidence relevant to internal structure was MD, MS, Deborah M. Rooney, PhD, Lauren supported by high inter-rater agreement M. Davis, BA, Ellen K. Hawkinson, BS, [ICC(1,k)α=.88]. Northwestern University Feinberg School CONCLUSIONS: We have successfully of Medicine, University of Michigan Medical created a size appropriate, high fidelity School laparoscopic DA simulator. Participants BACKGROUND: Laparoscopic duodenal agreed that the simulator was relevant atresia (DA) repair is a relatively uncommon to clinical practice and valuable as a pediatric operation requiring advanced learning/testing tool, but it may require minimally invasive skills. Currently, there minor improvements. Comments were are no commercial simulators available consistent with the Value ratings. Prior to that address surgeons’ needs while refining implementing this simulator as a training skills associated with this procedure. The tool, minor improvements should be purposes of this study were 1) to create an made, with subsequent evaluation of anatomically correct, size relevant model additional validation evidence. and 2) to evaluate the content validity of the simulator. P033: ENDOVIDEOSURGERY FOR TREATMENT OF HIRSCHPRUNG DISEASE METHODS: Review of literature and IN CHILDREN Bulat Jenalayev,Damir X-ray/CT images were used to create an Jenalayev, Omar Mamlin, National abdominal domain, size consistent with a Research Center for Mother and Child full-term infant. Fetal bovine tissue was Health used to complete the simulator. Following

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Hirschprung disease possesses the No perioperative complications were second place (after pylorostenosis) by noticed. Blood loss during surgery didn’t frequency among the disorders leading exceed 20.0-30.0 ml and didn’t require to gastrointestinal obstruction in children transfusion. In all cases the gastrointestinal that require surgical treatment. There were contents appeared within 12-18 days 17 cases of Hirschprung disease treatment after surgery, since that moment enteral by the aid of laparoscopic assistance. The feeding has been extended. These patients age of patients were between 3 and 14. were under observation of outpatient The rectosigmoidal form of Hirschprung department at late postoperative period disease were revealed in all the cases while and received anal bougienage by dilators X-ray examination. of sizes according to the age. There were no symptoms of stenosis. One of the Surgeries were performed under patients had high body temperature endotracheal narcosis and consisted of the and difficulty of defecation at 7th day following stages: after surgery. A cavern of 3.0x4.0 cm Stage I – laparoscopic. After insertion of with liquid content was revealed while three troacars the left side of abdomen rectal examination and ultrasound were visually investigated. Further, examination. In the result of puncture transition fold of peritoneum was through the posterior wall of the rectum dissected and rectum was mobilized about 30.0 ml of rheumic content with circularly deep in small pelvis. In order to fibrin was aspirated. The cavern was assess the adequacy of mobilization and rinsed by insertion irrigating catheter the degree of tension of the mesentery a under ultrasound scan control. After trial traction of a mobilized colon toward these manipulations the cavern have the anus was conducted. been closed up and infiltration nearby diminished. The patient was discharged Stage II - perineal. Anal orifice was in 15 days after the surgery. The other extended, tack-up sutures were patients were discharged in 8-9 days after performed around the anus. Dissection surgery. Control observation in 6 month and mobilization of rectal mucous coat showed good condition of all the patients. was performed for 5.0 – 6.0 cm starting 0.5 There were no complaints, abdominal cm from linea serrata. distention, encopresis or obstipation. Then, the colon was resected and brought Conclusion. Laparoscopic surgery by K. down to perineum through demucousized Georgson for surgical treatment of colon channel. This step was conducted under aganglionosis in children is considered to laparoscopic visual control while the be both radical and minimally traumatic; correct performance could be seen. The following the principles of preoperative coloanal anastomosis was completed by examination and treatment, following separate absorbable sutures. the steps and specific aspects of surgery III stage - laparoscopic revision and allows to minimize the risk of intra- and sanitation of the pelvis, restoring the perioperative complications, to achieve transitional fold of peritoneum, elimination significant improvement the results of of the “window” in the colon mesentery the treatment reducing trauma, severity were performed through the abdominal or postoperative period, length of stay, cavity. providing quick recovery along with good cosmetic effect.

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P034: SINGLE-INCISION p<0.01). All patients resumed feeding on LAPAROSCOPIC-ASSISTED postoperative day 1. The median follow- ANORECTOPLASTY FOR HIGH up period was 20 months. No injuries of AND INTERMEDIATE ANORECTAL vessels, urethral or vas deferens occurred MALFORMATIONS: COMPARISON WITH in operations. No mortality or morbidities CONVENTIONAL LAPAROSCOPIC- of wound infection, rectal retraction, ASSISTED ANORECTOPLASTY recurrent fistula, urethral diverticulum, AND POSTERIOR SAGITTAL anal stenosis, or rectal prolapse was ANORECTOPLASTY Mei Diao, MD, PhD, encountered. Overall complication rate Long Li, MD, PhD, Mao Ye, B., Med, MPhil, in high ARM group was comparable to Department of Pediatric Surgery, Capital that of our historical CLAARP group Institute of Pediatrics, Beijing, P. R. China (12.5%, p=0.15), and lower than that of our historical PSARP group (35.3%, p<0.01). BACKGROUND: The current study aims to evaluate the safety and efficacy of CONCLUSIONS: SILAARP is safe, single-incision laparoscopic-assisted feasible and effective for both high and anorectoplasty (SILAARP) for children intermediate ARMs. One-stage SILAARP with high and intermediate anorectal or combined transumbilical colostomy malformations (ARM). and 3-stage SILAARP offers a viable alternative treatment for children with METHODS: Children with high and high and intermediate ARMs. intermediate ARMs who underwent SILAARP between May 2011 and P035: LAPAROSCOPIC CARDIOMYOTOMY December 2012 were reviewed. The ARM AND FUNDOPLICATION IN A 2-MONTH- patients who had poor-developed pelvic OLD INFANT WITH ACHALASIA: A CASE muscles on magnetic resonance images REPORT Shin-Young Kim, MD, Hye Kyung were excluded. The operative time, early Chang, MD, PhD, Myung Duk Lee, MD, postoperative and follow-up results were PhD, Departmenf of Surgery, Seoul St. compared with our historical controls who Mary’s Hospital, The Catholic University of underwent conventional laparoscopic- Korea College of Medicine assisted anorectoplasties (CLAARP) INTRODUCTION: Achalasia is an and posterior sagittal anorectoplasties uncommon condition in children. The (PSARP). purpose of the study is to report a case RESULTS: Thirty-one patients (high vs. of an infant with achalasia treated with intermediate ARM: 15/16) successfully laparoscopic Heller’s cardiomyotomy and underwent SILAARPs without conversions. Nissen’s fundoplication. Mean ages at operation were similar in 2 CASE REPORT: Two-month-old boy groups (high vs. intermediate ARM: 4.94 presented with projectile vomiting months vs. 5.67 months, p=0.46). Average for one month. Ultrasonographic operative time in intermediate ARM finding was not remarkable. Upper GI children was 1.94 hours, which did not study showed passage disturbance at differ from 1.78 hours in high ARM children esophagogastric junction with suspicious (p=0.39). The mean operative time in high esophageal motility disorder and ARM group was comparable to that in combined gastroesophageal reflux with our historical CLAARP group (1.62 hours, relaxation of lower esophageal sphincter. p=0.12), and significantly shorter than that Endoscopic findings were decreased in our historical PSARP group (2.13 hours,

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Poster Abstracts CONTINUED esophageal peristalsis and narrowing of oesophageal dilatation for eosinophilic esophagogastric junction with proximal oesophagitis between 2008 and 2013 esophageal dilation. Symptoms were was performed. Demographics, symptom not relieved by medical treatment duration, medical therapies, endoscopy of gastroesophageal reflux. He was findings, dilatation technique, post underwent Heller’s cardiomyotomy and dilation endoscopic findings and response Nissen’s fundoplication laparoscopically. to treatment were analysed. Using two 5mm working ports, liver RESULTS: Three patients of a cohort retractor and 5mm endoscope, distal of circa 30 patients with eosinophilic esophagus around the hiatus was oesophagitis underwent bougienage dissected, and longitudinal esophageal dilatation of an oesophageal stricture. myotomy was performed on the anterior Median age at dilatation was 16 (range 14- side of distal esophagus about 5 cm in 16). All patients presented with symptoms length. Nissen’s fundoplication was done. of dysphagia and odynophagia. Time of The postoperative progress was not referral from paediatric gastroenterology remarkable without complication. Feeding to oesophageal dilatation was between 4 with adequate amount of milk became and 8 months. All patients had endoscopy tolerable in a week without vomiting. and passage of a guidewire into the CONCLUSION: Laparoscopic Heller’s stomach followed by serial dilatation cardiomyotomy and Nissen’s with savary-guilliard© dilators and check fundoplication was successfully endoscopy. In all cases dilatation was performed in 2-month-old infant with noted to be traumatic with deep linear achalasia resulting complete relief of fractures of the oesophageal mucosa vomiting. (figure 1). All patients remained well after dilatation with no evidence of perforation P036: EOSINOPHILIC OESOPHAGITIS: on chest radiograph. All patients reported THE TRUTH ABOUT DILATATION immediate symptom relief and on Kirsty Brennan, Saidul Islam, Michael  maintenance medical treatment none has Hii, Assad Butt, Anies Mahomed, required further endoscopic evaluation or Department of Paediatrics & Paediatric repeat dilatation. Surgery,Royal Alexandra Children’s Hospital,Brighton,U.K. CONCLUSIONS: Our experience suggests that the diffuse nature of the AIM: Eosinophilic oesphagitis is a inflammation in eosinophilic oesophagitis debilitating condition with significant is associated with long strictures which associated morbidity. Dilatation is respond to tangential dilatation. We reserved for patients with strictures suspect it is the degree of mucosal resistant to medical therapy. Strictures inflammation with relatively normal are commonly long and difficult to underlying serosa that leads to impressive assess with radiological imaging. We aim mucosal trauma without perforation. to investigate whether endoscopy and The presented series supports tangential tangential bougienage dilatation is a safe bougienage dilatation for paediatric and effective treatment. eosinophilic oesophageal stricture that METHODS: Retrospective analysis fails to respond to medical therapy. of prospectively collected database savary-guilliard© Cook Medical of patients undergoing tangential

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FIGURE 1 and descending colon is grasped and exteriorized identifying the attachments to left retroperitoneum and his progression distally to Douglas. Division of the colon is performed outside and the distal colon is displaced to the port in the midline. Both stomas are then fixed without wound in between, being the distal intentionally small (mucous fistula). RESULTS: Two patients with ARM were Long Linear fracture in Anterior wall operated this way. No complications were seen during and after the procedure. P037: 2 PORT LAPAROSCOPIC Oral intake was achieved before the first COLOSTOMY FOR ANORECTAL 24 hours. Colostomy bag was placed MALFORMATIONS IN NEWBORNS Carlos immediately after surgery. In one case, an Gine, MD, Saioa Santiago, MD, Nerea anomaly of internal genitalia was identified Vicente, MD, Jesus Broto, MD, Javier Bueno, and recorded. Time of procedure was less PhD, Hospital Vall d’Hebron. Barcelona than 1 hour. INTRODUCTION: Standard colostomy DISCUSSION: This technique allows in anorectal malformations (ARM) is rigorous inspection of internal genitalia, a descending colostomy in separate eliminates the wound infection possibility stomas, leaving the distal stoma as a because the are no scars, colostomy bag is mucous fistula. Oblique laparotomy in left easily and painlessly managed immediately lower quadrant (LLQ) is needed leaving after surgery, twisted colostomy is less the stomas at each edge of the wound. probable because it is checked during This procedure may quite often lead to surgery, the procedure is not technically minor complications as skin infection demanding and better cosmetic result are of the surgical wound and discomfort achieved by transversal scars in colostomy during management of the colostomy closure. bag immediately after the surgery. Rarely, wound infection and evisceration can P038: THE DOGMA OF ARTERIO-VENOUS occur. We describe a 2 port laparoscopic FISTULA AFTER SPLENECTOMY: STILL colostomy for ARM in descending colon RELEVANT WITH LAPAROSCOPIC JOINT and separate stomas without other SEALING OF SEGMENTAL SPLENIC incisions than those created to place the ARTERY AND VEIN? Sara Silvaroli, MD, stomas. We emphasize the advantages of Marianne De Montalembert, MD, Valentine this technique. Brousse, MD, Sabine Irtan, MD, PhD, Department of pediatric surgery, Necker METHODS: First port is located in LLQ Hospital, Paris, France. equally distant from the umbilicus and iliac crest, where proximal stoma should BACKGROUND: Splenectomy in be. This incision is circular and ballooned children is nowadays widely performed trocar is needed. Inspection of internal by laparoscopy. Either by anterior or genitalia is then achieved. Supra-pubic 5 lateral approach, the splenic vessels are mm trocar is placed next in the midline separately dissected and divided at the where we would like the mucous fistula left upper part of the pancreas before their to be. Camera is introduced in this port division in the splenic hilum according to

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Poster Abstracts CONTINUED the princeps technique aiming to prevent cholecystectomy was performed in 12 arterio-venous fistula. children. A fourth port was added in 7 patients. The mean operative time was 115 AIM: We hereby describe a new technique mn (49-240). No operative bleeding or of vascular control in splenectomy thanks conversion was noticed. The postoperative to the development of new laparoscopic course was uneventful, except for one coagulation devices. female patient presented an isolated MATERIALS AND METHODS: The fever 2 days after the procedure treated laparoscopic splenectomy was performed by IV antibiotics in fear of occult infection. by a lateral approach with the left side The mean postoperative hospital stay was of the patient elevated 30 to 45 degrees 2,25 days (2-8). No venous thrombosis thanks to a small roll under the back. or arterio-venous fistulas were found at The 10-mm optic port was placed in the postoperative ultrasound scan with a mean umbilicus via an open approach for a 0° follow-up of 15,5 months (8-42,5). laparoscope. Two 5-mm working ports CONCLUSION: With the introduction of new were placed in the left lower quadrant and technology, the joint sealing of segmental in the right upper part of the abdomen splenic artery and vein appeared safe and near the midline. An additional port efficient in laparoscopic splenectomy, was placed in the epigastrium to ease without any increased risk of operative the dissection if needed or in case of bleeding or postoperative arterio-venous cholecystectomy. All the procedure was fistula. performed with the LigaSure (Valleylab, Tyco Healthcare Group, Boulder, CO). The P039: LAPAROSCOPIC MANAGEMENT OF dissection began at the lower pole of the CHOLEDOCHAL CYST – OUR EXPERIENCE spleen with the division of the splenocolic OF 62 CASES Ravindra Ramadwar, Dr., ligament. Short gastric vessels were Nidhi Khandelwal, Dr., Bombay Hospital, divided allowing access to the splenic Mumbai, India hilum. Each segmental splenic vessel was INTRODUCTION: Laparoscopic dissected at the lower, middle and upper excision of choledochal cyst with part of the spleen. They were then divided hepaticodochoenterostomy is an without individualizing the artery from the alternative to open operation in children. vein. Progressing from bottom to top, the The aim of the study was to evaluate our splenophrenic ligament was sectioned experience of laparoscopic management allowing complete mobilisation of the of choledochal cyst and assess the spleen. The specimen was exteriorized medium term results. through an enlarged umbilical incision after finger fragmentation in a retrieval METHOD: We reviewed 62 patients who pouch. had undergone laparoscopic surgery for choledochal cyst since January 2003 to RESULTS: Thirty patients aged 6.36 January 2014. The data were analysed years (2-15.6) have been operated on for operative approach, intraoperative in our institution from 2009 to 2013. problems, postoperative complications The indications of splenectomy were and postoperative follow up. sickle cell anemia (n=18), hereditary spherocytosis (n=9), hemolytic anemia RESULTS: Since January 2003, 62 patients (n=1), idiopathic thrombocytopenic purpura have undergone laparoscopic surgery (n=1) and hystiocytosis (n=1). An additional for choledochal cyst. Mean age was 6

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Poster Abstracts CONTINUED years (6 weeks – 18 years), mean weight INTRODUCTION: Persistent was 12 kg (3.5 kg - 52 kg). 57 patients hyperinsulenemic hypoglycemia of infancy had type I and 5 patients had type IV (PHHI) is one of the most common cause A choledochal cyst. In 39 patients the of persistent neonatal hypoglycemia. cyst diameter was more than 5 cms. Management of PHHI involves use In 3 patients the posterior segmental of medical agents and its failure is an duct was opening directly into the cyst. indication for surgical intervention. PHHI Preoperative ERCP and stenting was done in infants requiring surgery is rare and in 2 patients. Mean operative time was traditionally an open pancreatectomy 175 minutes (115 – 290 minutes). Mean was the gold standard surgical approach. intraoperative blood loss was 25 ml (10 – But recently trend has shifted towards 45 ml). Lilly’s technique of mucosectomy use of laparoscopy. We describe a case was performed in 41 patients. 44 patients of PHHI managed by laparoscopic spleen underwent Roux-en-y hepaticodocho- preserving near total pancreatectomy in a jejunostomy and 18 patients had 2month old infant. hepaticodocho-duodenostomy. The METHODS: A 2 month old male child mean time taken for intra-corporeal diagnosed with PHHI with failure of hepaticodocho-enterostomy was 60 medical therapy. A laparoscopic near total minutes (45-100 minutes). Conversion spleen preserving pancreatectomy was to open surgery was required in 1 patient done. Laparoscopic pancreatectomy was with recurrent pancreatitis. Bile leak was performed using a 5-mm cannula at the seen in 4 patients, three were treated umbilicus, one 5mm and two additional conservatively and one patient required 3mm cannula sites. The stomach was percutaneous placement of stent. Mean retracted and lesser sac opened. The entire hospitalisation was 6 days (4 – 14 days). At pancreas was exposed. The pancreas was mean follow-up of 4 years (6 months – 11 resected from the splenic hilum to the years) one patient had recurrent sub-acute mesenteric vessels. The splenic vein was obstruction and 2 patients had cholangitis. dissected from the under surface of the 60 patients have normal liver function pancreas using harmonic scalpel, and tests and ultrasonography. 2 patients with the spleen was easily preserved. Leaving recurrent cholangitis had abnormal liver behind a small rim of pancreatic head function tests during cholangitis which along the C- loop of duodenum, a near reverted to normal after antibiotic therapy. total pancreatectomy was done by using HIDA scan in these patients show good Ligasure. Surgery time was 90 min, and drainage with no stasis. minimal blood loss occurred. The specimen CONCLUSION: Laparoscopic excision of was extracted in a bag. Drains were kept choledochal cyst with hepaticodocho- in pancreatic bed and pelvis. The patient enterostomy is a safe alternative to open tolerated the procedure well and the surgery and has satisfactory results. post operative recovery was uneventfull. Histopathology showed evidence of islet P040: LAPAROSCOPIC NEAR TOTAL cell adenoma with the background of PANCREATECTOMY FOR PERSISTENT nessidioblastosis in the entire pancreas. HYPERINSULENEMIC HYPOGYCEMIA OF INFANCY Ravindra Ramadwar, Dr., Vrajesh RESULT: The patient has remained Udani, Dr., Soonu Udani, Dr., Hinduja euglycemic for ten months now after the Hospital, Mumbai procedure and currently is not on any

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Poster Abstracts CONTINUED medication. The extent of pancreatectomy RESULTS: Medical treatment was effective was 95%. No postoperative complications in 2 patients with liver hydatid cysts less were noted. than 4cms. The deep seated liver cyst responded well to ultrasound guided CONCLUSION: The magnification afforded aspiration of cyst fluid and instillation of by laparoscopic vision allows for safe scolicidal agent(hypertonic saline 3%). dissection of pancreas. Laparoscopcic near Rest of the 21 cases(87.5%) with cyst size total pancreatectomy is safe and feasible more than 5cms underwent minimal approach for infants with PHHI with failure access surgery. None of these patients had of medical management with minimal postoperative complications (including blood loss and lesser wound morbidity. recurrence) requiring reoperation. The P042: EVALUATION OF ROLE OF MINIMAL overall long-term results were good. ACCESS SURGERY IN TREATMENT OF CONCLUSIONS: Hydatid cysts with sizes G. M. HYDATID DISEASE IN CHILDREN  exceeding 5cm in diameter should be Irfan, MS, MRCSEd, MCh, P. S. Reddy, MS, treated surgically and minimal access MCh, Vinod Kumar, MS, MCh, Niloufer surgery seems to be more effective and Hospital, Institute for Woman and Child has almost nil complications with less Health.Hyderabad AP India morbidity to the patient. Also use of PURPOSE: Hydatid disease is not so antihelmenthic agents for 2weeks prior to commom in children even in endemic surgery may decrease recurrence. areas but has serious complications if P043: LAPAROSCOPIC-ASSISTED not treated properly. There are various PANCREATICODUODENECTOMY IN A methods for treatment of this disease CHILD WITH A GASTRINOMA Hiroo Uchida, both medically and surgically. The aim of MD, Yasuyuki Ono, MD, Naruhiko Murase, this prospective study is to present our MD, Satoshi Makita, MD, Kazuki Yokota, experience in the management of hydatid MD, #Hiroshi Kawashima, MD, #Yujiro disease in children by minimal access Tanaka, MD, #Kyoichi Deie, MD, #Hizuru surgery and its efficacy. Amano, MD, Department of Pediatric MATERIAL & METHODS: Over a 3-year Surgery, Nagoya University Graduate period (2010 - 2013), 24 children with School of Medicine, Nagoya 466-8550, abdominal and pulmonary hydatid disease Japan. # Department of Pediatric Surgery, (ECHINOCOCCUS) were treated at our Saitama Children’s Medical Center, Saitama department of paediatric surgery. The 339-8551, Japan anatomical location of the parasite was BACKGROUND: Zollinger–Ellison as follows: liver 17, lungs 4 spleen 2, and syndrome is very rare in children. Ninety mesentery 1 case. Medical treatment with percent of gastrinomas are located in the oral antihelminthic agents was given to all pancreaticoduodenal region referred to patients for two weeks before taking up for as the gastrinoma triangle. Prompt and surgery so as to make them less infective. complete removal of the gastrinoma Only medical management was used for is necessary in patients with Zollinger– 2 cases of liver hydatid cysts less than Ellison syndrome, even in patients with 5cms and in one case of deep seated liver negative imaging findings, because a hydatid cyst while rest of the 21 cases(87.5 long delay in surgery may cause liver %) underwent minimal access surgery metastases and disease-related deaths. (laparoscopic or thoracoscopic procedure). We performed laparoscopic-assisted

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Poster Abstracts CONTINUED pancreaticoduodenectomy (LAPD) in treated a grade A pancreatic fistula. He a child with a biochemical diagnosis of was discharged in a healthy condition 20 gastrinoma but negative imaging findings. days after surgery and biochemical tests Although LAPD has not been reported in confirmed the absence of gastrinoma 1 a child until now, we believe it is safe and year after surgery. feasible in children. DISCUSSION: The optimal surgical CASE: A 9-year-old boy with Down procedure for resecting a gastrinoma is syndrome presented at an outpatient unclear, but aggressive resection following clinic complaining of weight loss and its accurate localization with a selective vomiting. Upper gastrointestinal images arterial secretagogue injection test with and endoscopy showed severe stenosis calcium was biochemically curative. of the duodenal bulb because of a The complications associated with a semicircular ulcer. His symptoms did pancreatic fistula mean that laparoscopic not improve following treatment with a PD is technically challenging for pediatric proton pump inhibitor. His gastrin level surgeons. Our LAPD approach should was very high (834 pg/ml; normal range: enable pediatric surgeons to perform 37–137 pg/ml). A peripheral vein calcium pancreaticojejunostomy as confidently injection test was positive for gastrinoma. as open PD because it can be performed However, imaging studies did not reveal a under direct vision through a small gastrinoma. Injection of a selective arterial laparotomy. LAPD is a minimally invasive secretagogue revealed a tumor within and reproducible procedure. the gastroduodenal arterial zone. The clinical course of the patient was poor as P044: LAPAROSCOPIC SURGERY FOR he intermittently felt well and nauseous HIATAL HERNIA ASSOCIATED WITH intermittently. The patient and his parents MICROGASTRIA IN ASPLENIA SYNDROME Takeo Yonekura, MD, PhD, Yuji Morishita, opted for surgery at 11 years of age.  MD, PhD, Masafumi Kamiyama, MD, PhD, OPERATIVE PROCEDURE & Katuji Yamauti, MD, PhD, Tomohiro Ishii, POSTOPERATIVE COURSE: The patient Md, PhD, Dep. of Pediatric Surgery, Nara was placed in a supine position with his Hosp., Kinki Univ. Sch. Med. legs apart. The surgeon stood between INTRODUCTION: Hiatal hernia associated the patient’s legs. A 12 mm camera port with microgastria in asplenia syndrome was introduced via the umbilicus while 12 is a rare but well-described congenital and 5 mm ports were inserted into the anomaly. Surgical treatment is technically left and right abdomen. A 4 cm incision difficult due to associated anatomical and was made directly above the pancreatic cardiovascular anomalies. stump to remove the resected tissue. After minilaparotomy, which was covered by a METHODS: Four out of 22 infants with wound retractor and a sealed cap, LAPD asplenia syndrome had had hiatal hernia was performed with child Roux-en-Y and microgastria for the last 10 years. One reconstruction. Pancreaticojejunostomy infant underwent open hiatal repair due to and gastrojejunostomy were done under associated severe cardiorespiratory failure. direct vision, while hepaticojejunostomy Another infant had VATS, which resulted in was done laparoscopically. The operative residual gastric herniation. The 2 remaining time was 694 minutes. Oral intake infants underwent laparoscopic repair was started on postoperative day 3. of the hiatal hernia and anti-reflux with The surgical procedure conservatively microgastria in asplenia syndrome. Herein,

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Poster Abstracts CONTINUED we review these 2 latter infants and discuss BACKGROUND: Percutaneousendoscop- the role of laparoscopic procedures. icgastrostomy(PEG) is widely accepted as the preferred procedure to establish RESULTS: Case 1: A 3-month-old male long-term enteral feeding in children. Sur- infant who had underwent PA banding for prisingly, various published series suggest SASV showed melena due to herniation conflicting morbidity rates differing from of the microgastria and colon through 5-33% associated with PEG procedure the esophageal hiatus near the left-sided in children. Therefore, we reviewed our IVC. Laparoscopic surgery confirmed experience with children who underwent a preduodenal portal vein and large PEG placement to find out the complica- esophageal hiatus located in the deep tion rates and long-term outcomes of this cranial portion of the subhepatic recessus. procedure. He underwent crural repair after reduction of the herniated stomach, pancreas, and METHODS: The records of the patients colon. However, he still showed GERD with who underwent PEG placement between failed anti-reflux surgery due to severe January 2008 and December 2012 were microgastria. reviewed. The patients were called to evaluate their latest situation. The CASE 2: A-four-month-old female infant procedure was performed with the received an antenatal diagnosis of hiatal standard pull technique under general hernia with asplenia syndrome. After anesthesia. Prophylactic antimicrobial placing an arterial-pulmonary shunt drugs were not used. Tube feeding was for PA stenosis and SASV, she received begun 12 hours after the PEG placement. laparoscopic surgery at 2 months of age. The patients were visited regularly by Laparoscopy revealed a preduodenal an experienced nurse in their homes portal vein and large esophageal hiatus and evaluated in terms of potential located in the deep cranial portion of the complications. subhepatic recessus. She underwent hiatal repair and partial fundoplication. RESULTS: A total of 40 pediatric patients (22 males and 18 females), with a mean CONCLUSION: Accurate preoperative age of 5.6±4.1 years (17 day old to 14 evaluation of cardiovascular and years), underwent 41 PEG placement. The anatomical anomalies is extremely mean weight of the patients during the important in asplenia syndrome. MIS procedure was 13.7±10.2 kg. The underlying is warranted for hiatal repair; however, diseases of the patients were neurological complications resulting from microgastria dysfunction (n=34), metabolic disorders and cardiovascular abnormalities still (n=4), total intestinal aganglionosis (n=1) remain. and cleft palate (n=1). There was no early P045: DETERMINATION OF complication. Mean follow-up time of PERCUTANEOUS ENDOSCOPIC the patients was 2 ±1.2 years. The late GASTROSTOMY COMPLICATION RATES IN complications were stoma infection CHILDREN Gonul Kucuk, MD, Gulnur Gollu, which was managed conservatively in MD, Meltem Bingol-Kologlu, Prof., Aydin three children (7.5%), buried bumper in Yagmurlu, Prof., Murat Cakmak, Prof., Tanju one (2.5%) and gastroesophageal reflux Aktug, Prof., Huseyin Dindar, Prof, Ankara disease which required laparoscopic University School of Medicine Department Nissen fundoplication in one (2.5%). Three of Pediatric Surgery patients died because of their underlying

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Poster Abstracts CONTINUED disease The PEG tube was removed performed and lower esophageal sphincter permanently in four patients because they was seen firm even with air insufflations resumed an adequate oral intake. and did not opened. Endoscopic balloon dilatation was performed all 5 patients CONCLUSION: PEG is a minimal invasive, and botox injection was performed to easy, safe and reusable route for long one. They did not get benefit, and Heller term enteral feeding. Rates of PEG myotomy and fundoplication to prevent complications observed in this study are reflux were performed. Postoperative third low and are generally minor. Observed week videofluoroscopy was performed and rates of PEG-specific complications are no reflux or stricture were seen. In 7-24 lower than previous reports. Therefore months follow ups, (median 10 months) it should be first preferred choice of especially fluid need of swallowing firm procedure in children who require long food was detected and videofluoroscopy term enteral feeding. was performed. Increased esophagus P046: PATIENT COMFORT DOES NOT calibration, no strictures of lower ALWAYS GET BETTER WITH SURGICAL esophageal sphincter and tertiary INTERVENTION IN ACHALASIA Gulnur contractions were seen all of the patients. Gollu1, MD,Ergun Ergun1, MD, Gonul CONCLUSION: Achalasia, a rare motor Kucuk1, MD, Numan Demir2, Tanju disease of esophagus. Esophagus that Aktug1, Prof., Huseyin Dindar1, Prof., Aydin diagnosed late and dilated or tortiosed, Yagmurlu1, Prof., 1Ankara University School surgical interventions may not be able to of Medicine Department of Pediatric prevent dysphagia even there was no lower Surgery,2Hacettepe University, Swallowing esophageal sphincter stricture. Disorders Application and Research Center P047: LAPAROSCOPIC MANAGEMENT PURPOSE: Achalasia, an esophageal IN ACUTE DUODENAL PERFORATION IN motility disease which is characterized with AN ADOLESCENT GIRL Gulnur Gollu, MD, absence of relaxation of lower esophageal Gonul Kucuk, MD, Bilge Turedi, MD, Nil Y. sphincter. Dilatation, botox injection, and Tastekin, MD, Aydin Yagmurlu, Prof, Ankara for the last chance, surgical intervention University School of Medicine Department are among treatment choices. The of Pediatric Surgery dysmotilities of patients who had surgical operations because of achalasia is aimed Duodenalulcerperforationis an to evaluate. uncommon entity in pediatric age group and it is not usually considered in the METHODS: Patients who had been differential diagnosis of acute abdomen operated between 2006- 2012 and in these patients. A thirteen-year old who had swallowing disorder reviewed who had abdominal pain and vomiting retrospectively. Three girls and two boys had prominent abdominal tenderness. were brought to the hospital with swallow Abdominal X-ray revealed free gas under trouble. diaphragm. She had a history of non- RESULTS: Videofluoroscopy was performed steroidal anti-inflammatory drug ingestion five children for having troubles of four days ago because of tooth pain. After swallowing firm food.” Bird beak” deformity fluid resuscitation, laparoscopy revealed at the lower esophagus and dilatation free bilious fluid in the abdomen. A discrete of upper segments had seen. Upper perforation was found on the anterior gastrointestinal tract endoscopy was wall of the first part of duodenum. Simple

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Poster Abstracts CONTINUED closure was performed laparoscopically. RESULTS: Among all patients, 16 were The aim of this video presentation is to male, 9 were female. Age at admission show the technical details of this minimal ranged from 2 h to 1 d.Ten patients were invasive surgery. preterm (gestational age 34w~37w) and 12 were low birth weight (1580g~2450g). P048: LAPAROSCOPIC The duodenal obstruction was due to GASTRODUODENOSTOMY IN A malrotation (n=11), atresia (n=4), web (n=5), Gulnur NEWBORN WITH PYLORIC ATRESIA  and annular pancreas (n=5). Laparoscopic Gollu, MD, Gonul Kucuk, MD, Bilge Turedi, procedure was performed in all the cases MD, Hakan Tuzlali, MD, Aydin Yagmurlu, by 3 to 4 trocars. During operation, 2 Prof, Ankara University School of Medicine to 3 sutures for lifting were performed Department of Pediatric Surgery in the cases who needed anstamosis Pyloric atresia is a very rare condition (atresia, web and annular pancreas), and with an incidence of 1:100000 newborns. abdominal drainage was performed in A 2500g boy who had non-projectile these cases. The operation time was and non-bilious vomiting had single 60-180 min(mean, 85min). Twenty-three gastric bubble with no air in distal cases were accomplished by LP surgery, segments in abdominal X-ray. He had two cases with malrotation shifted to open no associated anomalies. Laparoscopic procedure due to volvulus more than 720°. gastroduodenostomy was performed. One case suffered anastomotic leakage The aim is to present technical details by and recurred 2w later with conservative showing video of the surgery. treatment of fasting and drainage. For the other 24 patients, full feeding started P049: LAPAROSCOPIC PROCEDURE FOR on postoperative day 4-11 (mean, 6.2), NEONATAL DUODENAL OBSTRUCTION IN and discharged from hospital on the 25 CASES : A RETROSPECTIVE ANALYSIS postoperative day 7-21(mean, 12). The IN A SINGLE CENTER Jinfa Tou, PhD, Qixing follow-up ranged from 1 to 24 months, all Xiong, MD, Zhigang Gao, MD, Jinhu Wang, cases grew up healthily. PHD, Shoujiang Huang, PHD, Qiang Shu, PHD, The Children’s hospital Zhejiang CONCLUSION: In treatment of neonatal University School of Medicine, Hangzhou, duodenal obstruction, laparoscopic China. procedure performed by skilled surgeon is a safely and effective technique with BACKGROUND: Laparoscopic (LP) surgery satisfactory outcomes. for neonatal congenital duodenal obstruction have been reported recently. To P050: USE OF FULLY COVERED SELF- summarize the experiences and advantages EXPANDABLE METAL STENTS FOR of laparoscopic surgery for neonatal BENIGN OESOPHAGEAL DISORDERS IN duodenal obstruction, here we report a CHILDREN Bettina Lange, MD, Rainer series or 25 cases in our single center. Kubiak, MD, Lucas M Wessel, MD, Georg Kähler, MD, Department of Paediatric METHODS: Twenty-five neonates with Surgery, Central Interdisciplinary congenital duodenal obstruction were Endoscopy treated with LP procedure in Children’s hospital Zhejiang University School of BACKGROUND: There is a lack of Medicine between Jan 2012 and Dec 2013. experience withfully covered self- The clinical data were retrospectively expandable metal stents (SEMSs) for analyzed. benign oesophageal disorders in children.

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PATIENTS AND METHODS: Eleven P051: LAPAROSCOPIC HEPATIC children (6M, 5F) with a median age of PORTOJEJUNOSTOMY FOR FETALLY 30.5 months (range, 1 month - 11 years), DIAGNOSED CYSTIC BILIARY ATRESIA who underwent treatment with a SEMS Hiroyuki Koga, MD, Takashi Doi, MD, for a benign oesophageal condition Manabu Okawada, MD, Tadanori Ochi, MD, between February 2006 - January 2014 Shiho Yoshida, MD, Hiroki Nakamura, MD, were recruited to this retrospective study. Geoffrey J. Lane, MD, Atsuyuki Yamataka, Aetiologies included: oesophageal atresia MD, Department of Pediatric General and with postoperative stricture (n=5) and/ Urogenital Surgery, Juntendo University orrecurrent fistula (n=1), anastomotic School of Medicine leakage (n=1); iatrogenic perforation of PURPOSE: To present a case of the oesophagus following endoscopy hepatic portojejunostomy performed (n=3)or laparoscopic fundoplication (n=1). laparoscopically (LapPE) for fetally As part of an interdisciplinary approach diagnosed cystic biliary atresia (cystic BA). patients were jointly managed from the Department of Paediatric Surgery and CASE: Cystic BA was initially suspected Central Interdisciplinary Endoscopy at our on routine fetal ultrasonography and was institution. confirmed after birth by clinical signs, diagnostic imaging, and blood biochemistry. RESULTS: Median duration of individual LapPE was performed on day 37 of life; stenting was 29 days (range, 17-91 days). weight was 3.6kg. On examination of the In4 casesup to four differentSEMSs abdominal cavity after insertion of the initial were placed over time. There were no trocar, the gall bladder was found to be complications noted on stent placement small but not atrophied, the liver was mildly or removal. Follow-up showed successful cirrhotic, and the bile duct was cystic-in treatment in 6 patients (55%). Minor shape and 1.5 x 1.5cm in size. Intraoperative stent-related complications occured in5 cholangiography confirmed cystic BA type cases, mainly attributed to mild gastro- III. The gall bladder, cystic duct, and the oesophageal reflux and silent stent thickened fibrous cystic-shaped common displacement. In two children each (18%) bile duct were dissected and the common one single dilatation wasperformed after bile duct transected distal to the point of stent removal. Three patients (27%) did not confluence with the cystic duct. Next, full- improve following stenting and required thickness dissection of the duodenal side of further surgery. the cyst was commenced but about a third CONCLUSION: SEMS placement for of the way through, an elliptical area of benign oesophageal disorders in children lumenal mucosa within the cyst separated can be used safe and effective either spontaneously together with the mucosa as an emergency procedure or as an from the lower two thirds of the cyst. This additive treatment further to endoscopy elliptical area appeared like waxed paper or previous surgery. Establishment of a macroscopically and on histopathology standardized approach in the paediatric was found to be composed entirely of population is mandatory. fibrous tissue with no mucosal epithelial structure. Because of this spontaneous separation, there was no mucosa left on the duodenal side of the cyst to dissect; i.e., there was no need to proceed further

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Poster Abstracts CONTINUED with dissection on the duodenal side. Thus, PURPOSE: Percutaneous endoscopic full-thickness dissection of the portal gastrostomy (PEG) is a commonly used side was commenced. Once the fibrotic technique for establishing enteral feeding. biliary remnant was exposed adequately Many complications of the procedure are on the portal side it was transected. After known, especially in children. The aim of transecting the fibrotic biliary remnant at this study was to review the indications the porta hepatis a 3mm diameter hepatic and the results of the PEG procedure in duct was identified almost in the center Icelandic children. of the transected biliary remnant which METHODS: A retrospective review of all meant that LapPE could be executed children (0-18 years) who received PEG at by placing 2 sutures to the center of the Landspitali University Hospital of Iceland in posterior wall of the common hepatic duct, the years 1999-2010. Their medical records one suture to the center of the anterior were reviewed with regards to indication wall, and other sutures superficially to the for the procedure, age, pre-operative use liver parenchyma and connective tissue of nasogastric tube, the result of operation, around the transected biliary remnant at complications (major and minor) one year the porta hepatis. A drain was placed in from insertion of PEG, length of hospital the Pouch of Winslow and the trocar site stay and weight gain after the procedure. was closed. Operating time was 8 hours 38 minutes. From the 3rd postoperative day RESULTS: 98 children (51 girls and 47 boys) bile colored feces began to be passed, and received PEG during the study period. jaundice clearance was achieved on the 72% received enteral feeding through 33rd postoperative day after 3 courses of nasogastric tube prior to the operation. corticosteroids. At follow-up of 6 months, The median age was 2 years (range 1 mo she remains jaundice-free, current total -17 y). The most common indication for bilirubin is 0.5mg/dL, and there have PEG insertion was failure to thrive due to been no episodes of cholangitis. The neurological disease (56%). Median length classification of BA was reviewed to be II-d of stay after PEG insertion was 4 days (cystic )-α. (range 1 - 189 days). None of the extented length of stay was in relation with the PEG CONCLUSION: Fetally diagnosed cystic procedure. BA should be included as an indication for LapPE. Median body mass index (BMI) before surgery was 14,5 (range 9,8 – 20,8) and P052: PERCUTANEOUS ENDOSCOPIC median BMI-for-age z-score was -1,4 GASTROSTOMY IN CHILDREN. A (range -5,9 – 3,0). Median BMI one year POPULATION BASED STUDY FROM after surgery was 15,3 (range 11,2 – 22,1) ICELAND 1999-2010 Margret Brands and median BMI-for-age z-score was Viktorsdottir, MD, Kristjan Oskarsson, -0,5 (range -5,1 – 3,8). The median weight MD, Luther Sigurdsson, MD, Anna increased significantly in one year by 1,0 Gunnarsdottir, MD, PhD, Dpt of Surgery SD (P<0,0001, 95% CI -1.4820 to -0.7387). and Dpt of Pediatric Surgery, Landspitali Height and weight 12 months after PEG University Hospital, Iceland. Dpt of procedure was documented for 54 Pediatrics, University of Wisconsin, USA. children. Dpt of Pediatric Surgery, Astrid Lindgren Children Hospital, Karolinska University 166 complications were registrated in Hospital, Sweden. 65 children of which 96% were minor.

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The most common complications were group 5 had an underlying diagnosis granuloma formation (19%) and superficial of oesophageal atresia. 0.5mg/ml of skin infection (25%). The incidence of Mitomycin-C was endoscopically applied infection was not statistically different under direct vision to the stricture between those who received pre-operative following balloon dilatation. The rate and antibiotics vs. no antibiotics. Major need for subsequent stricture dialatation complications were 4% and included three were assessed. Out comes for this group children with peritonitis due to gastric leak were compared with oesophageal atresia from the gastrostomy site, one child with patients who did not receive adjuncts/ esophageal tear, one child with buried Mitomycin-C for management of post bumper and in one case malposition of the operative strictures at our institution. gastrostomy tube. Median follow up time RESULTS & CONCLUSION: There were was 47 months (range 1-152). 14 children no complications following application died (1 mo - 3 y) after PEG insertion of Mitomycin C in any of our patients. and none of the deaths were related to Demonstrated reduction in frequency PEG insertion. 27 children were without of stricture dilatation were statistically gastrostomy at follow up. compared. The rate of post-operative CONCLUSION: According to our results oesophageal stricture are affected by the PEG procedure is a safe technique for meticulous technique, aggressive acid establishing enteral feeding in children. suppression and tensison at time of Gastrostomy is sometimes temporary. anastomosis. The use of Mitomycin C Complication rate is high but the majority may be helpful in selective patients for of complications are minor og easily management of refractory oesophageal treatable. Enteral feeding through PEG in strictures. children causes significant weight gain in one year. P054: LAPAROSCOPIC SURGERY FOR PEDIATRIC ESOPHAGEAL HIATUS HERNIA P053: THE ROLE OF MITOMYCIN-C IN Lishuang Ma, MD, Ning Dong, BA, Capital THE MANAGEMENT OF OESOPHAGEAL institue of Pediatrics STRICTURES SECONDARY TO BACKGROUND AND PURPOSE: Esophageal OESOPHAGEAL ATRESIA E. Achimugu, hiatus hernia mostly need surgical Miss, M. Thompson, MBChB, DCH, FRCP, procedure. As the development of FRCPCH, MD, R. M. Lindley, Mr., The laparoscope surgery, esophageal hiatus Children’s Hospital Sheffield hernia repair and fundoplication under Local application of the anti-fibroblastic laparoscope have become the leading agent Mitomycin-C, has been reported treatment of esophageal hiatus hernia. We as an alternative treatment of refractory herewith explore the safety and effectivity oesophageal strictures in children. We to of laparoscopic surgery for esophageal our knowledge, present the largest case hiatus hernia. series assessing efficacy of Mitomycin MATERIALS & METHODS: We treated 29 c in refractory oesophageal strictures cases with esophageal hiatus hernia by secondary to oesophageal atresia. laparoscopic esophageal hiatus hernia METHOD: All patients prescribed repair between Sept. 2007 and Oct. 2012. Mitomycin-C for Oesophageal Strictures Of the patients, 21 were male and 8 were at our centre were identified. Of this female. They were aged 7 days to 5.5

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Poster Abstracts CONTINUED years(average,1.2 years) . Of the patients, P055: THE PRETZELFLEX™, A KINDER 9 were neonates. 25 cases presented with LIVER RETRACTOR FOR CHILDREN D. intermittent vomiting, among which one Dass, Mr., K. Elmalik, Mr., J. Rae, Dr., R. case was accompanied by haematemesis Sahay, Miss, S. Marven, Mr., Sheffield and melena, and 6 accompanied by Children’s Hospital noticeable malnutrition and delayed Laparoscopic liver retractors in children growth. 4 cases presented with cough are hazardous. Nathanson liver retractor and dyspnea. According to Barrett typing has steadily supplanted others for use in standard, 6 cases belonged to type I fundoplication in all ages. Association with (sliding hernia), which still suffered from liver ischaemia and parenchymal injury is recurrent vomiting after conservative well recognised; the retractors are typically treatment for 3 months~1 year; 18 inserted via stab incision which may result were type II and 5 type III. All pantiets in contemporaneous bleeding and gas underwent LP esophageal hiatus hernia leakage. The smallest Nathanson retractor repair and Nissen fundoplication. The (5mm) has a hook height of almost 70mm Surgical procedures carried out as follow: ? making the device arduous to deploy in Exposure of esophageal hiatus , ? Incision small children. of hernia sac. ? Dissociation of esophagus. ? Contraction of esophageal hiatus. ? AIM: To evaluate the use of 3mm re- Fundoplication. useable organ and tissue retractor, PretzelFlexTM (Surgical Innovations), RESULTS: One of 29 patients, 2 patients during laparoscopic fundoplication. was transferred to open surgery due to severe abdominal adhesion. 27 METHODS: Fundoplication was performed patients completed laparoscopic in four children using 3mm laparoscopic repair of esophageal hiatus and Niseen instruments. fundoplication successfully. The average time of surgery was 147min (90~390min); The 3mm PretzelFlex retractor device was intraoperative bleeding was 5mL on inserted via stab incision using a 69 blade average (1~10mL); All cases began to drink (Swann-Morton Ltd) in one patient. water 24~48h later after surgery, and A 3mm YelloPort+plus™ (Surgical backed to preoperative diet on the 4th- Innovations) was used in the latter three 5thday; hospital stay lasted for 4~12 days patients; the first placed in the right upper after surgery, 6.5 days on average. 25 cases quadrant (RUQ) and the latter two in the were followed up for 1 month to 5 years. infra-Xiphisternal position. The 1-year follow-up after surgery showed no evidence of recurrence. The retractor was stabilised using Fast ClampTM (Surgical Innovations). CONCLUSIONS: Laparoscopic surgery for pediatric esophageal hiatus hernia RESULTS: At procedure, patients weighed had more advantages than traditional 5 kg, 12 kg, 14.7 kg and 18kg. Deployment opening surgery, such as minor injury, of PretzelFlex within the abdomen was rapid recovery. The procedure is safety prompt and uncomplicated. Whilst key and efficiency, and the clinical effect was in providing optimal view of the hiatus, satisfactory. no evidence of liver injury was noted. The breadth of retraction likely reduced transfer of pressure across the large retractor-tissue interface.

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Use without a port caused bending of endoscope -“one stop” for obscure the retractor. Some external clashing of massive gastrointestinal bleeding from Jan instruments was noted when placed in the 2011 to December 2013 was performed. RUQ position. RESULTS: In our series, a total of 11 patients CONCLUSIONS: Used with YelloPort+plus, with obscure massive gastrointestinal the 3mm PretzelFlex offers the following bleeding were included. There were 7 potentials: males and 4 females with a median age of • reduced liver trauma 3.5 years, the most common etiologies of • improved view obscure massive gastrointestinal bleeding • less bleeding were Meckel’s Diverticulum (MD; 72.7%), • minimal gas leak perforation of duodenal ulcer (DU; 18.2%) • improved cosmesis and unknown cause (UC; 9.1%). All of Meckel’s Diverticulum were successfully Though our early paediatric experience has treated, including 8 cases (72.7%) of shown PretzelFlex is safe and may present laparoscopic Meckels diverticulectomy a new standard in laparoscopic liver and enteroenterostomy. The other two retraction for infants and toddlers, further of perforation of duodenal ulcer were experience is warranted to qualify this. successfully treated by Subtotal Gastrectomy P056: GASTROINTESTINAL ENDOSCOPE (Billroth ?Method). One child died for failing COMBINES LAPAROSCOPY FOR OBSCURE to treat in time in early stage (ten months old MASSIVE GASTROINTESTINAL BLEEDING boy, failed to timely diagnosis). Bian M. Hongqiang, IN CHILDREN  CONCLUSION: Though rare, massive Gastrointestinal Endoscope Combines hemorrhage of gastrointestinal tract lapa, Wuhan Medical & Health Center for can present with several lifethreatening Women and Children, General Surgery, complications that mandates immediate Wuhan, 430016 China surgery. While the surgical procedure BACKGROUND: Gastrointestinal (GI) bleeding may be technically simple, achieving is a common medical problem associated the accurate preoperative diagnosis with significant morbidity and mortality is often fraught with challenges. The in children. Although most patients stop implementation of “one stop” to bleeding spontaneously without intervention manage patients with obscure massive and most do not re-bleed, a small number gastrointestinal bleeding will evidently have obscure massive gastrointestinal shorten the patients rescuing time. bleeding (OMGI) that may require acute KEYWORDS: Children Gastrointestinal surgical intervention to prevent shock and bleeding Gastrointestinal endoscope coagulopathy. Many choices are available in Laparoscopy managing such patients. The clinician faces decisions regarding the timing and nature of P057: LAPAROSCOPIC PROCEDURE FOR investigations and treatment options. The CHILDREN WITH CYSTIC LESION IN aim of this study is to analyse the impact of ABDOMEN Shuli Liu MD, Long Li MD, Jun a protocol to improve clinical practice in this Zhang MD, Xu Li MD, Capital Institute of area. Pediatrics METHODS: A retrospective review of BACKGROUND AND PURPOSE: Cystic 11 patients who underwent surgery in lesion in abdomen mostly require laparoscopy combines gastrointestinal surgical excision for histological

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Poster Abstracts CONTINUED diagnosis, symptom relief, and to prevent PURPOSE: To find a cost effective, safe, complications,preferably before the onset and easy alternative for primary retrograde of complication. It has become feasible to gastrostomy button placement. accomplish the excision Laparoscopically METHODS: Gastroscopy is performed with in children. We herewith reviewed our the Olympus flexible endoscope. After experience of laparoscopic procedure for transillumination and digital indentation children with cystic lesion in abdomen. an 18-French spinal tap needle with a #0 To summarize the effectiveness and polydioxanone loop is transcutaneously principles of laparoscopic procedure for advanced into the stomach. A second cystic lesion in abdomen. Materials and needle is introduced 1.5cm more distally. Methods:160 patients, 91girls and 56 boys, Through the second needle, a #0 suffered cystic lesion were involved in this polydioxanone is advanced through the group, from 2002 to 2013. Their ages ranged previously introduced polydioxanone loop. from 3 months to 16 years (average, 8±3.5y). The loop snares the single polydioxanone The average diameter of lesions were 5.5 strand and is pulled out. This creates cm (ranged, from 3 to 17 cm). Three trocars a U-stitch. Another U-stitch is placed were utilized with 3 to 5mm instruments. using identical technique, medially to the Under laparoscopic guidance a transfixion first one. Mild traction is applied to the pin was prick into cyst. Then the fluid in the U-stitches apposing the gastric wall to the cyst was aspiration through the pin. The bulk peritoneum. In between the U-stitches, an of the cyst contracted. Then decompression incision is made and a 16-French needle procedure, internal drainage procedure, is directed into the stomach; a guide-wire resection or dissection procedure were is advanced through the needle. Dilations applied according cystic character. to 22-French are performed over the guide-wire. The abdominal wall thickness RESULTS: Average duration of operation is measured and a gastrostomy button was 1.5 hours (range, from 0.6 to 3.2 hours) placed. Correct placement is confirmed without intraoperative complications, by endoscopy. The previously placed intraoperative bleeding was 5 to 10 ml U-stitches are tied around the G-tube and without necessity for blood transfusion. left in place for one week. Return of oral food intake postoperative was 12 hours (range, from 6 to 48 hours). RESULTS: N=10. Age 3 months to 21 years The postoperative course was uneventful old. 40% Females (n=4) , 60% males (n=6). in all patients with hospital stay 6.8days Mean weight 22.01kg ±6.31, BMI 17.08±1.31. (range, from 1 to 9 days) after the Mean operative time 22±3.49 min. Two operation. There was no postoperative cases were performed in a combined complication during followed-up visits. procedure. No intra- or postoperative complications. 4 patients experienced CONCLUSIONS: Laparoscopic procedure for irritation around sutures. Tubes sizes 12-14 children with cystic lesion in abdomen is Fr, ranging from 1.2 to 3 cm length. safe and effective. CONCLUSION: This endoscopic technique P058: ENDOSCOPIC GASTROSTOMY is a save and cost effective alternative for BUTTON PLACEMENT WITH primary retrograde gastrostomy button TRANSCUTANEOUS LASSO U-STITCH placement with high patient satisfaction - Alfredo D. Guerron, MD, Jose S. Lozada,  without the need for placement of more MD, Federico Seifarth, MD, Cleveland Clinic expensive T fasteners or blind needle Foundation

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Poster Abstracts CONTINUED sweeps. The PDS sutures are absorbable RESULTS: Wearing Glass throughout the day and there is no risk for potential gastric for the study interval was well tolerated. erosion/abscess formation from retained Colleagues, staff, families and patients foreign bodies from T-fasteners. overwhelmingly had a positive response Endoscopy allows proper intraluminal to Glass. Useful applications for Glass was placement confirmation. hands-free photo-/videodocumentation, making hands-free telephone calls, looking P059: GOOGLE GLASS IN PEDIATRIC up billing codes, and internet searches for SURGERY: TESTING ITS APPLICABILITY unfamiliar medical terms or syndromes. Oliver J. Muensterer, MD, PhD, Martin  Drawbacks encountered with the current Lacher, MD, PhD, Christoph Zoeller, MD, equipment were low battery endurance, Matthew E. Bronstein, MD, Joachim Kübler, data protection issues, poor overall audio MD, Division of Pediatric Surgery, New York quality, as well as long transmission latency Medical College, NY, USA; Department of combined with interruptions and cut-offs Pediatric Surgery, Medizinische Hochschule during internet videoconferencing. In the Hannover, Hannover, Germany transatlantic vision test, all characters 8mm INTRODUCTION: Personal portable or larger were correctly identified. None of information technology is advancing at a the characters 3 mm or smaller were legible breathtaking speed. Google has recently via the transatlantic link (see figure below). introduced Glass, a device that is worn like Glass is an excellent tool for teaching conventional glasses, but that combines complex tasks such as endotracheal a computerized central processing unit, intubation, and has some applicability touch pad, display screen, high-definition to show the user realtime radiographic camera, microphone, bone-conduction information during procedures. transducer, and wireless connectivity. CONCLUSION: Glass has the some clear We have obtained a Glass device utility in the clinical setting. However, through Google’s Explorer program and before it can be recommended universally have tested its applicability in our daily for physicians and surgeons, substantial pediatric surgical practice and in relevant improvements to the hardware are experimental settings. required, issues of data protection must METHODS: Glass was worn daily for be solved, and specialized medical 4 consecutive weeks in a University applications (apps) need to be developed. Children’s Hospital. A daily log was kept, and activities with a potential applicability were identified. Performance of Glass was evaluated for such activities. In-vitro experiments were conducted where further testing was indicated, including, for example, a standard Snellen vision test using Glass over a transatlantic internet connection, with the Glass camera positioned 50 cm away from the letter chart. Glass was also tested as a training tool for teaching intubation, and for evaluating radiographic images in real- time.

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P060: FIRST REPORT OF THORACOSCOPIC patient. An initial 5mm optical trocar was LEFT UPPER PULMONARY LOBECTOMY placed 1cm below the angle of the scapula USING FISSURELESS TECHNIQUE IN in the posterior axillary line (AL) using a A SMALL CHILD Hiroki Nakamura, MD, closed technique. Four other trocars were Kenji Suzuki, MD, PhD, Hiroyuki Koga, MD, placed. 1. Fourth intercostal space (IS) Manabu Okawada, MD, Takashi Doi, MD, slightly posterior to the anterior axillary Kinya Nishimura, MD, PhD, Eiichi Inada, line (AAL) for the telescope; 2. Third IS in MD, PhD, Geoffrey J. Lane, MD, Atsuyuki the AAL for the surgeon’s left hand; 3. Sixth Yamataka, MD, PhD, Department of IS in the AAL for the surgeon’s right hand; Pediatric Surgery and Urogenital Surgery, 4. Eighth IS in the mid AL for a retractor Juntendo University School of Medicine; or stapler. On examination, the major Department of General Thoracic surgery, fissure was tightly fused. Firstly, the LUL Juntendo University School of Medicine; was retracted posteriorly and superiorly Department of Anesthesiology, Juntendo to expose the hilum, allowing the apical/ University School of Medicine anterior/posterior branches (A1+2, A3) and mediastinal lingular branches (A4, A5) of BACKGROUND: Pulmonary lobectomy the left pulmonary artery to be divided involves ligating branches of the using hemo-clips and Ligasure. Then, the pulmonary artery, the pulmonary vein, pulmonary veins to the LUL (V1-3, V4, and bronchus. The pulmonary artery is V5) were encircled, clipped, and divided, exposed at a fissure by dividing the lung exposing the LUL bronchus which was then parenchyma overlying the artery using divided using an endo-stapler and the cut- electrocautery or sharp/blunt dissection end retracted superiorly and posteriorly that causes air/fluid leakage that prolongs to expose the left pulmonary artery trunk chest tube drainage and hospitalization. clearly. Branches of the pulmonary artery Recently, vessel/tissue sealing devices (A6, A8) to the left lower lobe (LLL) were (Ligasure, Harmonic scalpel, Enseal) are identified and left intact, and branches to being used to seal lung parenchyma the lingular lobe (interlobar A4, A5) of the and fissure surfaces, especially during LUL where identified and divided. A stapler thoracoscopic lobectomy. However, in was then inserted and used to grasp the cases where a fissure is fused so tightly lung parenchyma gently while retracting that it cannot be identified, air leakage can the LUL superiorly, inferiorly, posteriorly, occur even with sealing devices. We used and anteriorly to confirm that the stapler fissureless lobectomy, a novel technique did not include arterial branches to the for preventing parenchymal injury to the LLL and that alignment with the proposed lung during thoracoscopic lobectomy in major fissure was “correct”. The stapler children for the first time. was then fired and the LUL divided and CASE: Thoracoscopic left upper lobe (LUL) separated. Blood loss was 1mg. There lobectomy was performed on a 2-year-old was no air leak from the chest tube girl with prenatally diagnosed congenital postoperatively and minimal fluid leakage. pulmonary airway malformation (CPAM) The chest tube was removed the next day of the LUL. She was positioned in the right after surgery. She is currently symptomless lateral decubitus position under general and well after follow-up of 10 months. anesthesia with single lung ventilation. CONCLUSION: Thoracoscopic fissureless The surgeon and scopist stand in front of lobectomy is safe and feasible even in the patient and view a monitor behind the small children.

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P061: COMBINED LAPAROSCOPICALLY distance from the urethra. A minimal ASSISTED AND ANTERIOR SAGITTAL anterior sagittal incision was made, and ANORECTOPLASTY FOR IMPERFORATE a ligature passer was inserted from the ANUS WITH RECTOBULBAR URETHRAL center of the external anal sphincter FISTULA Tetsuya Ishimaru, MD, PhD, to the center of the puborectalis under Masahiko Sugiyama, MD, Mari Arai, MD, laparoscopic vision. The ligature was pulled PhD, Jun Fujishiro, MD, PhD, Chizue Uotani, out from the abdominal cavity, and a MD, PhD, Kyohei Miyakawa, MD, Tomo pull-through route was formed by cutting Kakihara, MD, Tadashi Iwanaka, MD, PhD, the midline of the external sphincter Department of Pediatric Surgery, The muscle and vertical fibers along the thread University of Tokyo Hospital using a muscle stimulator. The fistula was identified from the perineum by pulling BACKGROUND: Laparoscopically the thread, and resected close to the assisted anorectoplasty (LAARP) was urethra. The rectum was pulled through introduced in 2000, and the number of and anchored to the muscle fibers. The hospitals adopting it for the treatment muscles were closed to surround the of high-type anorectal malformation rectum and anocutaneous anastomosis (rectovesical or rectoprostatic fistula) is was performed. The post-operative course increasing. However, the application of was uneventful. The stoma was closed LAARP for rectobulbar urethral fistula is one month after the anorectoplasty. controversial, because precise division MRI performed at one year after the of the fistula in the deep pelvic cavity anorectoplasty showed the rectum at is difficult and there is a potential risk the center of the sphincter muscle and of posterior urethral diverticulum. We no residual fistula. Although he is still herein introduce a novel procedure for an administered a daily enema, a couple of imperforate anus with a rectobulbar fistula voluntary bowel movements are seen involving precise ligation of the fistula and every day. appropriate placement of the rectum in the center of the sphincter using combined CONCLUSIONS: Combined laparoscopically laparoscopically assisted and anterior assisted and anterior sagittal sagittal approaches. anorectoplasty for an imperforate anus with a rectobulbar urethral fistula was CASE REPORT: A boy weighing 2,220 g feasible and advantageous for the precise was born at a gestational age of 37 weeks, division of the fistula. and diagnosed with a imperforate anus immediately after birth. No associated P062: PERCUTANEOUS SUTURING malformations, including neurological TECHNIQUE AND SINGLE SITE UMBILICAL abnormalities and sacral deformities, LAPAROSCOPIC REPAIR OF A MORGAGNI were noted. Initially, a loop colostomy HERNIA: REVIEW OF 3 CASES Mohamed was placed at the right transverse colon. Jallouli, Mahdi Ben Dhaou, Souhir Mefteh, Distal colostography and urethrography Hayet Zitouni, Salwa Ammar, Riadh Mhiri, showed a rectobulbar urethral fistula. Department of Pediatric Surgery. Hedi Anorectoplasty was performed at the age Chaker Hospital. Sfax Tunisia University of of 4 months (5.8 kg) Sfax. Tunisia PROCEDURE: Rectal dissection was INTRODUCTION: Morgagni hernias are performed laparoscopically, and the uncommon and account to only 1-5 % fistula was ligated and resected at a short of all congenital diaphragmatic hernia.

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Although most are asymptomatic, surgical years of age. In the absence of peritonitis, treatment is recommended to prevent initial treatment is either hydrostatic or possible future complication. Minimal pneumatic reduction. If these measures invasive surgery is today the gold standards fail, operative intervention is required. In treatment. We present our technique using non-reducible cases, we propose the use percutaneous suturing technique and of intraoperative hydrostatic enema to single site umbilical laparoscopic repair of achieve or confirm reduction. Morgagni hernias in 3 children. METHODS: We performed intraoperative PATIENTS & METHODS: In 2013 three boys’ hydrostatic enema reduction in seven ages nine, sixteen and eighteen month children ages 4 months to 2 years. All respectively were referred to our institution patients had ileocolic intussusception for repair of their Morgagni hernia. that failed initial reduction by radiographic enema. Under general anesthesia, A 2- cm longitudinal incision was made in saline enema was facilitated by direct the umbilicus. A homemade single-port laparoscopic visualization. device with a wound retractor and surgical gloves was introduced. A 5–mm 0 angle RESULTS: In two of the seven cases, scope was used. The herniated bowel was intussusception reduction was visually easily reduced into the abdomen using confirmed in real time. In these two a grasper. The posterior diaphragmatic cases only a laparoscopic camera port rim was clearly visualized. The defect was required. In one case, the bowel was repaired using entirely 2-0 prolene was extensively dilated requiring mini- percutaneous sutures. laparotomy for visualization; however, the enema reduced the intussusception RESULTS: The total operative time was without any need for bowel manipulation. respectively 100, 60 and 50 minutes. In the remaining four cases, minimal Recovery was uneventful in all 3 patients. laparoscopic manipulation was required, There were no recurrence and the chest and enema confirmed reduction. No child radiograph stayed normal during the required bowel resection. postoperative follow-up. CONCLUSIONS: Intraoperative hydrostatic CONCLUSION: Percutaneous suturing enema is a safe and valuable addition to technique and single site umbilical laparoscopic reduction of intussusception. laparoscopic repair of a Morgagni hernia This technique gives the advantage of is an easy and effective alternative to the little or no bowel manipulation and can be standard laparoscopic repair. accomplished via a single port. P063: THE UTILITY OF INTRAOPERATIVE P064: LAPAROSCOPICALLY ASSISTED HYDROSTATIC ENEMA DURING REPAIR FOR FEMALE LOW TYPE PEDIATRIC LAPAROSCOPIC IMPERFORATE ANUS Manabu Okawada, Cristina INTUSSUSCEPTION REDUCTION  MD, Takashi Doi, MD, Hiroyuki Koga, MD, N. Budde, MD, Thomas Sims, MD, Andrew Geoffrey J Lane, MD, Atsuyuki Yamataka, Zigman, MD, Oregon Health and Science MD, Juntendo University School of University & Kaiser Permanente Northwest Medicine BACKGROUND/PURPOSE: Intussusception OBJECTIVE: In recent years, laparoscopic is the most common cause of bowel intersphincteric resection for low rectal obstruction in children 3 months to 3 cancer has been offered and performed

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Poster Abstracts CONTINUED successfully in adult patients, indicating distal fistula, 3-5 mm in length, was ligated that laparoscopic manipulation can now with an endoloop suture. At this stage, reach deep into the pelvic cavity, in other the surgeon moved to the perineum site words, as far as the perineum. Because to perform mucosectomy of the residual this revolutionary procedure would also fistula and close it with interrupted sutures. improve chances of external sphincter Electrostimulation was used to define the preservation, the authors were persuaded center of the anal dimple, and a 10mm skin to perform laparoscopically-assisted repair incision was made. Minimal blunt dissection of female low-type imperforate anus using of the perineum using a pair of mosquito this technique. forceps with transillumination from the laparoscope as a guide was commenced SURGICAL TECHNIQUE: A 12-month- to create a pull-through canal. Once an old 8.1kg girl was diagnosed with ano- adequate route for the pull-through canal vestibular fistula at birth. She was prepared was established, dilatation was commenced for laparoscopically assisted repair by passing a series of dilators. The rectum (LAR) according to our standard bowel with proximal ano-vestibular fistula was preparation protocol involving colonic then pulled-through, its distal end biopsied irrigation, probiotics and insertion of a to confirm normoganglionosis and the central venous catheter the day before coloanal anastomosis completed. If the surgery. The principles of LAR are dissection distal end was not normoganglionotic, it of the fistula laparoscopically as distally was cut back and rebiopsied until it was as possible up to the perineum using four normoganglionotic to prevent intractable ports, division of the fistula laparoscopically, postoperative constipation. Operating time followed by mucosectomy of the was 175 minutes. The postoperative course approximately only 4-5mm long residual was uneventful. fistula from the perineum. For laparoscopic dissection of the fistula, a newly developed CONCLUSION: Minimally invasive surgery 10-mm fixed-rod rotating scope was used, can now be considered actively for treating which allows the direction of view to be female low-type imperforate anus adjusted from 0° to 120° as required. This following our successful application of scope was introduced through an umbilical LAR. Long-term follow-up is required to trocar, and three additional 3 or 5mm evaluate fecal continence. trocars were inserted as working ports. All 3 additional trocars were placed medial to the P065: A COMPARISON OF TWO rectus abdominis, similar to single incision TECHNIQUES FOR THE DELIVERY AND laparoscopy, in contrast to conventional FIXATION OF EXTRACORPOREAL KNOTS trocar placement for imperforate anus DURING LAPAROSCOPY: KNOT-PUSHER repair in males with recto-prostatic or WITH INTEGRATED CUTTER VERSUS Carolina recto-vesical fistula where the tips of the CONVENTIONAL SUTURING  Millan, MD, Guillermo Dominguez, MD, endoscopic instruments do not need to Luzia Toselli, MD, Yolanda Martinez, MD, reach deep into the pelvis that is narrow. Fernando Rabinovich, MD, Horacio Bignon, Using these trocar positions, the rectum MD, Gaston Bellia, MD, Albertal Mariano, and ano-vestibular fistula were dissected MD, PhD, Marcelo Martinez Ferro, MD, from the vaginal wall easily, and dissection Private Children´s Hospital of Buenos Aires, of the ano-vestibular fistula progressed Fundación Hospitalaria, Buenos Aires, to the level of the perineum. The fistula Argentina was then divided and the tiny residual

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INTRODUCTION: the use of knot-pusher CONCLUSION: the use of KP reduced (KP) with integrated cutter simplifies the tasktime required for tying and cutting the delivery and fixation of extracorporeal knot compared to CS and it was associated knots to an intracorporeal surface with a short learning curve, mainly in less and constitutes a technical alternative experienced operators. to conventional knot sliding suturing technique (CS). This study test the hypothesis that KP shortens the time require for tying and cutting a knot compare to CS. METHODS: Three surgeons (one expert, one semi-expert and one fourth-year pediatric surgeon resident) performed 10 P066: INTRAABDOMINAL PARTITIONING knots each (five with KP and five with CS) OF THE LAPAROSCOPIC SLEEVE using a laparoscopic abdominal trainer with GASTRECTOMY REMNANT OPTIMIZES its own visual output. Surgical tools used THE SPECIMEN EXTRACTION were as follows: 1) 10-mm 30ºlaparoscope ERGONOMICS AND POSTOPERATIVE and 5-mm conventional surgical tools PAIN AND IS AN ATTRACTIVE TECHNIQUE (Meryland, scissors). 2) KP with 5-mm IN TEENAGE PATIENTS Piotr Gorecki, integrated cutter.3) 2 trocars (11-mm MD, Josue Chery, MD, Jennifer Lee, and 5-mm). 4) 0, 40 mm Nylon (length Anthony Tortolani, Wojciech Gorecki, 75 cm). 5) 0.5-mm Nelaton catheters MD, Department of Surgery, New York (length 7cm). All bows (10 per operator) Methodist Hospital, Brooklyn, NY, USA were tight into the Nelaton catheters at INTRODUCTION: Laparoscopic Sleeve the bottom of the simulator and both free Gastrectomy (LSG) becomes increasingly ends exteriorizedthrough the 5-mm trocar. popular bariatric procedure worldwide. The In this manner, all sutures had the same high failure rate of adjustable gastric band length prior to tying and cutting the knot. and the magnitude of the gastric bypass In order control for differences in skills make this option even more appealing regarding knot design, only one operator when adapted to pediatric patient designed all 30 knots. We evaluated the population. The fear of complications time required to deliver and fix the knot and the postoperative pain and recovery into the Nelaton catheter (from outside remain the significant factors when the simulator up its fixation and cut inside considering wider application of surgery the trainer). in the treatment of morbid obesity in RESULTS: Overall task time was lower with pediatric patients. KP than with CS (20.9±5.5 versus 39.39±5.9 CASE REPORT: A 16 year old girl with the seconds, p<0, 01), which translated into weight of 359 Lbs and BMI of 55 kg/m2 an absolute difference of 18.4±6 seconds suffering from severe metabolic syndrome, (88.2% reduction). This reduction in task type II diabetes, hypertension and fatty time was observed across all operators liver disease underwent uneventful (table). Improvement in task time from laparoscopic sleeve gastrectomy and first to the fifth knot was larger with KP liver biopsy . The procedure time was than with CS,but only in less experienced 65 min (specimen extraction time was 7 operators (table). min). Her recovery was uneventful and

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Poster Abstracts CONTINUED she was discharged home on a second with conservative therapies for morbidly postoperative day. Her mean in hospital obese patients and further improvement visual analog pain scores with the in the safety and perioperative morbidity utilization of standard PCA pump were 3.2 remain the main factors determining the on a day of surgery, 1.7 on postoperative future growth of bariatric surgery. In this day 1 and 0 on a postoperative day 2. After abstract we describe the novel technique the discharge from the hospital, she did that may contribute to further reduction not require any postoperative analgesics of perioperative morbidity and therefore and returned to normal activities in 7 contribute to wider acceptance of LSG. days. On a 1, 3 and 6-month follow up Detailed technique and the photographs she has shown all the benefits of weight will be presented in the poster. Prospective loss and associated improvement in comparison study will be designed to metabolic parameters and quality of life further evaluate the benefits of this as determined by the laboratory tests (Hb extraction technique. A1C 6.5% preoperatively vs 4.7% at three months after surgery, off hypoglycemic P067: LEFT THORACOSCOPIC agents) and SF-36 questionnaire (bodily ESOPHAGEAL ATRESIA REPAIR: TIPS FOR Drew A. Rideout, MD, Avraham pain score 45 preoperatively vs 67 at 1 SUCCESS  Schlager, MD, Amina M. Bhatia, MD, MS, month after surgery). At 1, 3 and 6 month Children’s Healthcare of Atlanta/Emory after surgery her weight loss was 30, 49 University, Atlanta, Georgia; All Children’s and 99 Lbs respectively. The patient and Hospital/Johns Hopkins Medicine, St. her family were also very satisfied with Petersburg, Florida the decision to undergo the bariatric procedure. INTRODUCTION: Right aortic arch (RAA) is present in 5% of patients with esophageal EXTRACTION TECHNIQUE: A sleeve atresia with or without tracheoesophageal gastrostomy specimen containing fistula (EA/TEF). Repair of EA/TEF in gastric body and fundus and containing the newborn with RAA adds technical approximately 80 % of the stomach challenges and hence the surgical volume has been partitioned longitudinally approach has been controversial. We intracorporealy with endoshears, which present a newborn with the prenatal allowed its extraction in one partitioned diagnosis of congenital heart disease, who fragment via a 15-mm port site without underwent a repair of EA/TEF through a the need for increasing the length of the left thoracoscopic approach. incision, stretching of the fascia opening, need for closure of the fascia or utilization CASE PRESENTATION: The patient was of the Endocatch device. This technique born by elective C-section at 38 weeks resulted in minimizing postoperative gestation, weighing 3.5 kg and with the pain, reducing the operative costs and prenatal diagnosis of congenital heart minimizing the likelihood of would disease. An orogastric tube was placed infection. and found to be curled in the proximal esophagus, consistent with the diagnosis CONCLUSION: General application and the of EA/TEF. Postnatal ECHO showed double selection of the type of bariatric procedure outlet right ventricle with VSD, ASD, and in pediatric patient populations remains RAA with mirror image branching. Vertebral a controversial and widely discussed anomalies were also present, consistent topic. The hope for improved outcomes with the diagnosis of VACTERL association.

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FISH analysis for the 22q deletion was but no such study has been published normal. Because of the presence of RAA, in children. We report our experience a left thoracoscopic approach was chosen. with laparoscopic self-adherent mesh On the first day of life he underwent left hernioplasty in adolescent children. thoracoscopy with repair of a type C EA/ RESULTS: Six patients who underwent TEF utilizing high frequency oscillator laparoscopic hernioplasty with self- ventilation. A suspension suture between adherent mesh by a single surgeon at our the bulbous proximal pouch and small institution during one year were included. distal esophagus was used to elevate the All patients were males with a median age esophagus out of the posterior thorax and of 15.4 years (14 - 16 years) and median BMI facilitate construction of the anastomosis. of 24.9 (19.8-32.6). Five patients presented Because of the left-sided approach and with complaints of unilateral painless size discrepancy between the proximal “groin bulge” while one had intermittent pouch and distal esophagus, left- severe pain, but no patient had obstructive handed suturing proved advantageous. symptoms or signs of incarceration. One An esophagram on postoperative day patient presented with a recurrent hernia 6 showed a persistent size discrepancy while the remaining five patients had no between the proximal and distal previous hernia repairs. Patients were esophagus but no leak or anastomotic taken electively to the operating room. stricture. Five patients had unilateral inguinal CONCLUSION: Left thoracoscopy is a hernias and one patient was found to have feasible approach in the newborn with bilateral inguinal hernias intra-operatively. EA/TEF, congenital heart disease, and All patients had the self adherent mesh RAA. Technical pearls include use of placed without difficulty and without injury oscillator ventilation for optimal exposure, to bowel or conversion to open. Median a suspension suture to facilitate the operative time was 97 minutes (63 - 146 anastomosis, and left-handed suturing. min). All patients tolerated the procedure well and were discharged on the same day. P068: INNOVATIVE SELF- Five patients had postoperative follow up. ADHERENT (VELCRO) PROLINE Three patients were seen in clinic 149 days, MESH FOR LAPAROSCOPIC INGUINAL 24 days, and 29 days after the operation; HERNIOPLASTY IN ADOLESCENT one patient had a telephone follow up 314 Paulette I. Abbas, MD, Adesola CHILDREN  days after the operation. At time of follow C. Akinkuotu, MD, Ashwin Pimpalwar, MD, up, no patient had signs of recurrence, Texas Children’s Hospital and the Michael surgical site infection, or chronic post- E. DeBakey Department of Surgery, Baylor operative pain. The last patient was seen in College of Medicine, Houston, Texas the ED for concern of scrotal swelling and INTRODUCTION: Laparoscopic hernia repair pain and was ultimately diagnosed with a with mesh has been reported in adolescent scrotal hematoma; he was instructed to children. The mesh generally requires return to clinic and has since been lost to suturing or tacking on the abdominal wall follow up. to secure it in place. Tacking or suturing in CONCLUSION: Laparoscopic hernioplasty the groin area has been reported to cause with the innovative self-adherent mesh chronic pain. An innovative self-adherent is feasible and safe with good short to mesh has been used as an alternative mid term results. None of our patients with good results in the adult population,

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Poster Abstracts CONTINUED had chronic postoperative pain previously CONCLUSIONS: TSSLPEC and TEC are reported with mesh tacking technique. Our both reliable in treatment of hernia in series is small and larger numbers would children, TEC procedure are trending be needed to confirm our results. more acceptable by patients because less postoperation pain at the puncture P069: SINGLE-SITE LAPAROSCOPIC location and more satisfied with the PERCUTANEOUS TOTALLY operation. EXTRAPERITONEAL CLOSURE FOR HERNIA IN CHILDREN Li GuiBin, Qiu Yun, P070: OUTCOME AFTER NUSS The 5th Central Hospital of TianJin China PROCEDURE WITH DIAGONAL BAR PLACEMENT: AN UPDATE ON TECHNIQUE BACKGROUND: Single site laparoscopic Bethany J. Slater, MD, Sara C. Fallon, MD, percutaneous extraperitoneal closure for Jed G. Nuchtern, MD, Darrell L. Cass, MD, hernia is accepted by pediatric surgeons Mark V. Mazziotti, MD, Texas Children’s for its reliable effect, simple procedure, Hospital, Division of Pediatric Surgery, cosmetic result. However there is an issue Baylor College of Medicine, Houston, TX about this method is that the knot was left in the subcutaneous tissue, and cause BACKGROUND: The correction of pectus the postoperation pain at the puncture excavatum in pediatric patients allows location, occasionally suture reaction for improvement of both lung physiology occurred. We modified the procedure of and significant aesthetic concerns that the operation as totally extraperitoneal can affect patient quality of life. At our closure (TEC) : Firstly, puncture epidural institution, since 2003 we have routinely needleand free half of processus vaginali. used the minimally invasive Nuss Secondly, put the guide line and silk into procedure for surgical correction with peritoneal through the needle. Thirdly, excellent results. However, some patients’ remove the needle. Following putting the deformities do not lend themselves to needle to peritoneal at the same place we adequate correction with this procedure, had reached before, and accomplished during which the pectus bar is placed at a totally extraperitoneal closure. horizontal angle and secured to the same rib space bilaterally. Recently, we have METHODS: 115 patients who accepted the begun to employ a technical modification single-site laparoscopic percutaneous of the traditional Nuss procedure for these extraperitoneal closure procedure in our difficult anatomical deformities by placing hospital between July 2011 and January the pectus bar at an angle, securing the 2014 were analyzed retrospectively. bar bilaterally at different rib spaces. The Postoperation pain of puncture location and goal of this study was to evaluate the suture reaction were targeted to compare. surgical outcomes of these patients with RESULTS: 65 patients who underwent challenging anatomic deformities who traditional single-site laparoscopic underwent the modified Nuss procedure percutaneous extraperitoneal with a diagonal bar, as opposed to the closure(TSSLPEC),50 patients were given traditional horizontal bar, and determine if TEC operation. Postoperation pain of this modification is an effective operative puncture location after operation was 10 technique. (15.4%,TSSLPEC) to 3( 6.0%,TEC). Suture METHODS: After institutional review board reaction was 1(TSSLPEC) to 0(TEC). There is approval, a retrospective review of patients no recurrence in either group. who underwent a modified Nuss procedure

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Poster Abstracts CONTINUED at Texas Children’s Hospital was performed P071: ENDOSCOPIC MANAGEMENT OF from Dec 2010 to May 2012. Patients were RECURRENT TRACHEOESOPHAGEAL identified through the surgical record, and FISTULA WITH TRICHLOROACETIC ACID the post-procedure chest radiographs CHEMOCAUTERIZATION: A PRELIMINARY of all patients who underwent a Nuss REPORT Manuel Lopez, MD, Eduardo procedure by the three surgeons (JGN, DLC, Perez-Etchepare, MD, François Varlet, MD, MVM) who use this technical modification PhD, Department of Pediatric Surgery, were reviewed for diagonal bar placement. University Hospital of Saint Etienne Patients with the traditional placement OBJECTIVE: Open repair with a second were excluded from further review. thoracotomy is technically challenging Patient data including Haller index, patient and has a high risk of complications demographics, bar-related complications, for the treatment of arecurrent and cosmetic outcome were systematically tracheoesophageal fistula(RTEF). extracted from the medical record. Therefore, less invasive endoscopic RESULTS: We identified 12 patients who techniques have been developed. underwent the Nuss procedure with a We report our initial experience with diagonal bar. The median length of follow- trichloroacetic acid chemocauterization for up was 10 months (range from 1 mo to recurrent trachea-esophageal fistula by 28 months). Two patients did not have endoscopy. stabilizers placed at the time of operation; METHODS: Two patients who had despite an increased risk for bar migration, an open repair with thoracotomy neither of these patients has experienced for congenitaltracheoesophageal a complication. All patients reported fistulaand were diagnosed with large satisfaction with their post-operative RTEF were included in this study. Rigid cosmetic outcome to date. One patient ventilating bronchoscopy with telescopic with pyoderma gangrenosum developed magnification was used to evaluate and a wound dehiscence that required re- manage the RTEF. After identification of operation for debridement and closure. thefistulaopening, a 50% TCA-soaked CONCLUSIONS: Our data demonstrate small cotton ball was applied in the that positioning the pectus bar diagonally opening 3 times during each session , in during the minimally invasive Nuss day surgery. procedure is feasible and leads to good RESULTS: The mean number of procedures cosmetic outcomes with a minimal early was 3, and the fistulae were closed in both complication profile; however, long-term cases. Closure of thefistulawas confirmed outcomes until after bar removal occurs by esophagogram and/or bronchoscopy. remain unknown in this series. Diagonal There were no postoperative bar placement should be considered in complications. patients with asymmetric defects, where placing the bar in different interspaces CONCLUSION: The results of this study allows for proper sternal alignment. showed that chemocauterization with TCA can be safe and effective for the management of RTEF.

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P072: RETROGRADE DILATATION VIA complete anastomotic stricture and the GASTROSTOMY OF AN ANASTOMOTIC stricture was unable to be traversed using STRICTURE IN A NEONATE WITH a guide wire. REPAIRED OESOPHAGEAL ATRESIA Brian Further attempts were abandoned and MacCormack, Jimmy Lam, Fraser Munro, a Stamm gastrostomy was created Royal Hospital For Sick Children Edinburgh and retrograde dilatation through the Anastomotic stricture is the most gastrostomy was performed. A guide wire common complication following repair was passed through the gastrostomy and of oesophageal atresia, occurring in 18% by repeated probing through the stricture - 50% of patients. Balloon dilatations and into the proximal oesophagus in a remain the treatment of choice for retrograde direction. The wire was then symptomatic oesophageal strictures. If retrieved from the mouth and a 5.5Fr this fails re-operation is needed.Combined Accustick dilator passed down the wire, oesophagoscopy and transgastrostomy allowing the stricture to be dilated using a gastroscopy is a well established method 4mm balloon. A nasogastric tube was then of dilating post-radiotherapy oesophageal passed over the wire and left in-situ. strictures in adults. The retrograde The gastrostomy was removed at 3 approach to dilate oesophageal strictures months. The patient required one in neonates is not well described. This subsequent balloon dilatation following report highlights the efficacy of this this procedure, and has had no recurrence technique in dilating an anastomotic of the stricture since. stricture at the time of gastrostomy placement and therefore avoiding This report highlights that retrograde potentially difficult re-do surgery. dilatation should be considered when performing a gastrostomy following A male infant, born at term with a birth failure of traditional antegrade methods. weight of 3kg, presented with oesophageal Traversing a stricture in a retrograde atresia and a distal tracheo-oesophageal direction appears to be easier, due to the fistula. On day 2 of life, the fistula was progressive narrowing of the stricture. This ligated throacoscopically. The procedure has been previously noted in both adults was converted to open due to poor view with post-radiotherapy strictures and in and the repair of oesophageal atresia children following fundoplication. Our completed without difficulty. The patient case report demonstrates that retrograde was discharged home at 1 week post- dilatation is possible in neonates and operatively, following a normal contrast should be considered when performing study. He was tolerating full oral feeds, and a gastrostomy so as to avoid potentially on maximal anti-reflux therapy. difficult re-do surgery. At 2 weeks post-operatively the patient was re-admitted with intolerance to P073: ESOPHAGO-BRONCHIAL FISTULA feeds. A contrast study confirmed a near- (EBF) AFTER PREVIOUS TEF (TRACHEO- complete anastomotic stricture. This was ESOPHAGEAL FISTULA) REPAIR: REPAIR unable to be traversed using a guide-wire USING A THORACOSCOPIC APPROACH Ashwin Pimpalwar, Dr., Texas Children’s despite multiple attempts. The decision  Hospital1 and the Division of Pediatric was therefore made to allow the oedema surgery, Michael E. DeBakey Department to settle and re-attempt dilatation. 5 of Surgery, Baylor College of Medicine, days later oesophagoscopy confirmed a Houston, TX

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AIM: To report the thoracoscopic technique two suture lines. A chest tube was placed, for repair of esophago-bronchial fistula. ports were withdrawn under vision and port sites were closed with sutures and glue. MATERIAL & METHODS: The chart of a 4 year old girl who presented with EBF was RESULTS: The child recovered well from retrospectively reviewed. the procedure and underwent a contrast esophagogram on the 5th postoperative CASE: A 4 year old female presented day which did not show a leak. The chest with chronic coughing during feeding and tube was removed and the child was failure to thrive. She had a past history allowed to feed orally. She was discharged of TEF repair at an outside hospital. on the 6th postoperative day on full Esophagogram revealed an esophago- regular diet. At 3 weeks follow-up the child bronchial fistula (between a right sided was asymptomatic and was tolerating diet peripheral bronchus and esophagus). well with no coughing. Esophagoscopy cauterization of the fistula and fibrin glue injection was successful CONCLUSION: The thoracoscopic in occluding the fistula but was followed technique is a minimally invasive approach by recurrence at 3 months which was that could be successfully used in the managed by thoracoscopic repair. management of esophago-bronchial fistula following previous repair of TEF in TECHNIQUE: The child was laid in supine children. position and a guide wire was passed through the fistula using the flexible P074: PIGGY-BACK (PARALLEL TO Pentax pediatric esophagoscope and PORT) NEEDLE INSERTION FOR ENDO- taped to the mouth. The child was turned SUTURING Ketan P. Parikh, Dr., Tara into a semi-prone position with the right Neo-Surg Hospital, Jaslok Hospital, L H side elevated. The first 5mm STEP port Hiranandani Hospital, Seven Hills Hospital. was introduced 1 cm below the angle of Endosuturing has become an integral scapula. The second port was introduced part of advanced laparoscopic surgeries. 3-4 rib spaces below in the mid-axillary Laparoscopic surgeries in small children line. Placement of the third port required or mini-laparoscopic procedures in older extensive adhesiolysis. It was placed in children are performed using thin cannulae the axilla, 2 rib spaces above the first (2-3mmin diameter) to minimise the port, in the mid-axillary line. Using a hook trauma related to ports. Every puncture diathermy, adhesions between the chest on the abdominal wall is independently wall, esophagus and the lung were taken capable of producing pain in the post- down. operative period (including a puncture of a The esophagus was dissected above and surgical needle). below the site of the fistula and a sling Needle insertion for the purpose of was placed around the lower esophagus to endosuturing is traditionally achieved help dissection. The fistula was identified either by straightening a curved surgical by the previously placed guide wire, needle (converting to ski needle) and divided and the bronchial and esophageal insertion through these thin ports or ends were closed with interrupted Vicryl direct insertion through the abdominal sutures. A pleural patch was designed wall. The former is likely to lead to a mild from the lateral chest wall and laid on the distortion of the needle making it more esophageal anastomosis to separate the unsuitable for suturing tissues where an

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Poster Abstracts CONTINUED appropriate curve of the needle would unstable or have peritoneal signs. be preferred and at tiimes even make the Ultrasound and CT scans were performed needle more prone for rotation within the in both patients with identification of needle-holder. In the latter method, 2 abdominal wall hernias containing bowel in needle pricks (entry and exit) are made the absence of other injuries. Laparoscopic for every insertion, thus adding to the repair were performed uneventfully in both potential post-operative pain and at times patients with interrupted nonabsorbable a significant extra time for this manoeuvre. multifilament suture with 2 and 3 ports respectively. Oral intake was initiated one Over the past 15 years, we have been day after surgery and both patients were following a simple manoeuvre for needle- discharged home the second day after insertion (and even retrieval) by which surgery. In the follow-up visit patients were surgical needles of any size, diameter, asymptomatic and no signs of abdominal length, shape and cross-section(cutting/ wall hernias were found. round-bodied) can be inserted into the abdominal or chest cavity parallel to Laparoscopic repair of blunt traumatic an existing trocar (without making any abdominal wall hernias is safe and additional punctures). We feel that this technically possible in children, and should technique is easily reproducible and be considered as the standard initial laparoscopic surgeons should add this to approach in the stable patient. their technical skills for appropriate use with an added advantage of preserving the P076: LAPAROSCOPIC SUBTOTAL shape of the needle and not increasing the PANCREATIC RESECTION IN INFANTS potential of post-operative pain. WITH CONGENITAL HYPERINSULINEMIA? COMPLICATIONS AND TREATMENT Kuiran P075: TRAUMATIC ABDOMINAL WALL Dong, MD, Gong Chen, MD, Wei Yao, MD, HERNIA FROM HANDLEBAR INJURY, Xianming Xiao, Prof, Gongbao Liu, MD, LAPAROSCOPIC REPAIR – REPORT OF Children’s Hospital of Fudan University TWO CASES Santiago Correa, MD, Juan PURPOSE: To report the experience Valero, MD, Jorge Beltran, MD, Fundación of laparoscopic subtotal pancreatic Hospital de la Misericordia, Univerdidad resection in infants with congenital Nacional de Colombia. hyperinsulinemia(ICHI) in our hospital, the Although rare, traumatic abdominal wall laparoscopic technic, resection range , the hernia associated with handlebar injury complication and treatment is discussed. is a well-described entity in the pediatric METHOD: Retrospective chlinical data population with about 40 cases and of 9 cases of laproscopic subtotal only one laparoscopic repair reported in pancreatic resection in infant congenital children. We present two cases of male hyperinsulinemia which operated in Mar patients who were 9 and 13 years old, 2001~Jun 2013. evaluated in our emergency room after blunt abdominal trauma associated with RESULTS: Preoperative: The age of 9 cases handlebar injury. Both patients presented was from 17days to 6 months,. There were with the handlebar sign in the abdominal 6 males and 3 females. The diagnosis of wall, one had a painful mass, and the persistent hyperinsulinemic hypoglycemia other one had intermittent pain in the area were made by our endocrinology team. of trauma without palpable mass. None Their fasting plasma glucose were of the patients were hemodinamically 0.5~5.1mmol/L, insulin levels of the

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Poster Abstracts CONTINUED fasting test were 4.1~50.1u lU/ml. All hyperplasia. There are 2 cases were normal these patients were failed in the Diazoxide morphology. medical therapy. Glucagon treatment and FOLLOW UP: Patients were followed up for continuous hypertonic intravenous glucose 6~10 months. The fasting plasma glucose treatment were needed all the time. CT were 2.2~12mmol/L. Two patients still and MRI showed normal pancreatics. had symptoms of hypoglycemia required Since 2013, three cases of CHI underwent steroid therapy. Three cases have low genetic testing, two of them prompted fasting blood glucose, but can turn to KATP channel gene mutations (ABBC8 and normal after eating. The other 4 cases KCNJ11). have well controlled blood glucose. SURGICAL APPROACH: Three holes DISCUSSION: The main type of the CHI laparoscopic technique were used in the in infant is diffuse type. The genomics procedure. The pancreatic tail was the detect may take place of PET-CT. The first mobilized from the spleen hila, and uncinate part resection is an important sent for the frozen pathology. When the step to reach the 95% range during the focal lesion was excluded, the pancreas laparoscopic operation. Complication rate was mobilized from the tail to the head, of laparoscopic pancreatic resection is when the right edge of the superior 22%. The pancreatic short vessels is the mesenteric vein was reached, then pull main reason of spleen vein damage and out the uncinat part and separated it from bleeding. Althought bile duct injury is one the back of SMV. Along the left edge of of the complications of this operation; the the biliary duct, the subtoltal resection chlodochol cyst is a rare event. was performed by the harmonica, the total amount of the resection was 95%. P077: LAPAROSCOPIC TREATMENT OF COMPLICATIONS AND TREATMENT: FALLOPIAN TUBE TORSION SECONDARY Claudia M. All 9 patients were completed surgery, TO HYDATIDS OF MORGAGNI  Mueller, PhD, MD, Sandra Tomita, MD, no operative mortality. Intra and Stanford University School of Medicine, postoperation complication happened in New York University School of Medicine 2 cases(22.2%). One case has spleen vein injury during operation, the hemolocker PURPOSE: Hydatids of Morgagni, which has to be used for hemostasis. After six are pedunculated cystic structures arising months follow-up, the child developed from the fimbriated end of the fallopian splenomegaly but no esophageal tubes, are embryologic remnants of the and gastric varices or gastrointestinal mullerian duct. Torsion of the fallopian bleeding. Another case appeared jaundice tube involving hydatids of Morgagni, is a and liver function damage at 3 month rare cause of acute pelvic pain in young postoperatively; MRI showed the biliary girls and can pose significant risks to future was unobstructed but a choledochal fertility. In addition, it may present as a cyst. The hepatic duct jejunal Roux-Y diagnostic dilemma since the ovary itself operation was then performed, and the usually appears normal on ultrasound, liver function returned to normal 1 month and the cystic hydatid may be incorrectly postoperatively. recognized as a simple ovarian cyst. Thus, surgical intervention can be delayed which PATHOLOGY: The pancreases of all 9 may lead to worsening necrosis and result cases have no atrophy; 2 cases have islet in the need for resection of the affected hyperplasia, 5 cases have partial islet cell

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Poster Abstracts CONTINUED tube. Laparoscopy is an effective way meatus. Both testes were non-palpabl. to both diagnose and treat this unusual There was scrotal hyperpigmentation. USG condition in a rapid fashion. did not detect any testicular tissue. MRI revealed no testicules. A retrovesically METHODS: We review two cases of located uterus of 48×22×15 mm, bilateral fallopian tube torsion associated with ovaries and a 10 mm wide and 5 cm long large hydatids of Morgagni in adolescent vagina extending to the posterior urethra females. were present. The karyotype was 46XX. RESULTS: Both patients were Psychosexual evaluation revealed male perimenarchal (ages 10 and 13) and dominancy and endocrinologic studies a presented with acute pelvic pain. virilizing congenital adrenal hyperplasia Ultrasound showed a normal ovary with a due to 21-OHase deficiency. Committee paratubal cyst in both cases. Both patients on “Sexually Development Disorders” underwent diagnostic laparoscopy and evaluated the patients as a male. After were found to have adnexal torsion approval of the parents, the patient with large hydatids of Morgagni. In both underwent a total histero-salphyngo- cases, the fallopian tube was detorsed oofero-vaginectomy. No surgical laparoscopically and preserved. The cyst complication has been detected. There was excised in one case and marsupialized were no postoperative hematuria no in the other. voiding problems. The patient discharged at postoperative 5th day. CONCLUSIONS: Prompt recognition and operative management of this relatively CONCLUSION: Laparoscopy is a safe and uncommon disease entity may prevent effective procedure for the removal of unnecessary tubal resection and improve internal genitalia in phenotypic male long-term fertility in young women. patients with intersex. Minimally-invasive surgical procedures can P079: LAPAROSCOPIC TOUPET be used to safely and efficiently diagnose FUNDOPLICATION IN A 1.8KG INFANT and treat this gynecologic emergency. USING AIR SEAL INTELLIGENT FLOW P078: LAPAROSCOPIC TOTAL HISTERO- SYSTEM AND ANCHOR PORT. A SALPHYNGO-OOFERO-VAGINECTOMY TECHNICAL REPORT. Go Miyano, MD, Unal Bicakci, MD, Ferit Bernay, MD, Dilek Keiichi Morita, MD, Masakatsu Kaneshiro, Demirel, MD, Beytullah Yagiz, MD, Burak MD, Hiromu Miyake, MD, Hiroshi Nouso, Tander, MD, Selim Nural, MD, Cengiz MD, Masaya Yamoto, MD, Koji Fukumoto, Kara, MD, Riza Rizalar, MD, Ondokuz MD, Naoto Urushihara, MD, Department Mayis University, Department of Pediatric of Pediatric Surgery, Shizuoka Children’s Surgery, Radiology, Endocrinology Samsun, Hospital Turkey AIM: Laparoscopic fundoplication has been We present here a laparoscopic total refined because of the development of histero-salphyngo-oofero-vaginectomy in improved instruments and equipment. We a patient with intersex. report the case of a 1.8kg infant who had laparoscopic Toupet fundoplication (LTF) Fourteen years old phenotypic male for severe gastroesophageal reflux (GER) patient was admitted with hematuria. using the Air Seal Intelligent Flow System Physical examination revealed 8 cm (ASIFS) and Anchor Port (AP). long phallus, normal positioned urethral

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CASE REPORT: Our case had GER in LTF procedure, with optimum operative association with genetic and cardiac field. Total operating time for LTF was 90 anomalies, and despite continuous minutes. During pneumoperitoneum, body feeding, persistent vomiting caused failure temperature dropped from 37.4 to 35.7, to thrive. At 4 months of age our case but recovered immediately after cessation weighed 1.8kg and LTF was performed of pneumoperitoneum. Postoperative using 4 trocars and 3mm instruments. progress was uneventful, and an upper The ASIFS is a novel laparoscopic CO2 gastrointestinal study on postoperative day insufflation system composed of the 2 showed no residual GER. Air Seal IFS control, the Air Seal valve- CONCLUSIONS: The AFIFS and AP less trocar and the Air Seal Mode contributed to the successful outcome Evacuation Tri-lumen Filter Tube Set that of LTF in a 1.8kg infant. However, decreases camera smudging, improves there would appear to be a risk for the visual field by constant evacuation hypothermia in neonates and small infants of smoke, and provides a more stable during insufflation for laparoscopic or pneumoperitoneum. In addition, the AP is a thoracoscopic procedures that requires recently developed elastomeric low profile constant vigilant monitoring. cannula that is stretchable thus allowing its laparoscopic footprint to be minimized P080: A SAFE AND EASY TECHNIQUE both inside and outside the body. A 5mm TO POSITION A GASTROSTOMY TUBE AP was inserted subumbilically using the AFTER LAPAROSCOPIC FUNDOPLICATION blunt obturator supplied with the scope. Michimasa Fujiogi, Yujiro Tanaka, Hiroshi After sufficient insufflation to establish Kawashima, Miki Toma, Takayuki Masuko, pneumoperitoneum, a second and third Hiroyuki Kawashima, Kyouichi Deie, Hizuru 5mm AP were inserted in the right and Amano, Hiroo Uchida, Tadashi Iwanaka, left upper abdomen as the surgeon’s Saitama Children’s Medical Center,The working ports, a 5mm Air Seal trocar was University of Tokyo Hospital inserted in the left lower abdomen for the assistant, and a Nathanson retractor INTRODUCTION: Severely handicapped was also placed in the mid epigastrium. children with gastroesophageal reflux The gastrosplenic ligament was dissected disease commonly undergo gastrostomy free and the intraabdominal esophagus with fundoplication. Although there are was prepared by thorough dissection of many procedures, an optimal method is the hiatus mediastinal paraesophageal awaited. Conventionally, we sutured the ligament. A posterior hiatoplasty using stomach to peritoneum under direct vision two 4-0 non-absorbable sutures was by port hole expansion. The expanded performed to repair the large hiatus hernia wound was closed after gastrostomy tube that was present before the tension- insertion. free 270 degree fundoplication was However, with a 3-cm wound, infection and performed by fixing the anterior wall of the external leakage risks were high. In 2011, esophagus to the crus of the diaphragm we devised a new technique not requiring a with two sutures followed by two sutures 3-cm wound. We report this technique. each to fix the right and left wraps to the esophagus. All eight sutures were tied METHOD: In fundoplication, we use 3 ports: extracorporeally. Pneumoperitoneum was one is placed in the umbilicus as a camera maintained stably throughout the whole port, and the two other are in the left and right flanks as working ports. We use 2

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Poster Abstracts CONTINUED port-less forceps (PLF) (3-mm) for liver NP group: Age ranged from 3 months to 23 elevation and stomach traction. One PLF years (median: 42.5 months); bodyweight insertion site is used for the gastrostomy ranged from 3.7 to 42 kg (median: 11.75). tube. Age and bodyweight of the groups did not differ (P=0.88 & 0.98, respectively). After fundoplication, the anterior stomach wall is grasped by PLF. Three 3-0 vicryl NP group complications were rare: 2 sutures are placed around it at the cases of external leakage around the seromuscular layer laparoscopically. gastrostomy, 1 of internal leakage, and no Ends of sutures are pulled through the infection. Infection was significantly lower abdominal wall using a laparoscopic in the NP compared to CP group (n=0 percutaneous extraperitoneal closure vs. n=4, respectively; p=0.04). External (LPEC) needle. The LPEC needle is leakage was lower in the NP compared percutaneously inserted from the to CP group (n=2 vs. n=5, respectively; same point and takes different routes p=0.24), with no other significant subcutaneously to catch the ends of differences. sutures. DISCUSSION: Effective fixation is possible The LPEC needle pierces the peritoneum at by triangular suturing of the stomach intervals equivalent to the distance of the and abdominal wall. Since the PLF hole is stitch. This is repeated for each stitch. used, no additional incision is necessary. This procedure is applicable even for A triangle is made with three sutures. Its small infants. Since this technique is center is the gastrostomy, and the three simple with less infection, we recommend sides are formed by the sutures. it for gastrostomy after laparoscopic We remove PLF at the site of gastrostomy, fundoplication and insert the electrocautery needle from P081: MINIMALLY INVASIVE REPAIR OF the same site to penetrate the stomach MORGAGNI HERNIA – A MULTICENTRIC wall under laparoscopic vision. NATIONAL STUDY R. Lamas-Pinheiro, MD, We flatten the cutting area by holding J. Pereira, MD, F. Carvalho, MD, P. Horta, the two nearest points of the triangle MD, A. Ochoa, MD, M. Knoblich, MD, J. and pulling the opposite suture. Then, a Henriques, MD, T Henriques-Coelho, MD, balloon-type gastrostomy tube is inserted. PhD, J. Correia-Pinto, MD, PhD, P. Casella, MD, J. Estevao-Costa, MD, PhD, Pediatric After insufflation, the 3 stitches are pulled Surgery Departments of: Hospital Sao Joao, toward the abdominal wall and tied Porto; Centro Hospitalar do Porto; Hospital extracorporeally. The LPEC needle pierces Pediátrico de Coimbra; Hospital Dona the same skin surface for each stitch, so Estefania, Lisboa, Portugal the knot goes under the skin. INTRODUCTION: Morgagni hernia (MH) is RESULTS: We compared complications extremely rare, representing less than 6% between the new procedure (NP) group of all congenital diaphragmatic defects from January 2011 to January 2014 (n=36; repaired at pediatric age. Children may 20 males, 16 females) and conventional benefit from the application of minimally procedure (CP) group from January 2008 invasive surgery (MIS) in the correction to December 2010 (n=37; 26 males, 11 of these defects, but larger studies are females). needed to evaluate such potentiality.

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The present study aims to evaluate the P082: TWO-PORT LAPAROSCOPIC outcomes of the MIS through a national HERNIOTOMY: A NOVEL WAY TO PROVIDE multicentric study. BETTER COSMETIC RESULTS WITHOUT INCREASING THE TECHNICAL DIFFICULTY MATERIAL & METHODS: All national IN PEDIATRIC INGUINAL HERNIA Yoon- institutions that used MIS in the treatment Jung Boo, MD, Ji-Sung Lee, PhD, Eun-Hee of MH were included in a retrospective Lee, MD, Division of Pediatric Surgery, transversal study. Demographic data, co- Department of Surgery, Korea University morbidities, clinical presentation, operative College of Medicine details and follow-up were analyzed. BACKGROUND: We previously have RESULTS: Between December 2006 and reported that laparoscopic hernia sac June 2013, thirteen patients (6 males) transection and intracorporeal ligation were submitted to correction of MH can be a safe alternative for conventional by MIS (using similar percutaneous pediatric herniotomy. We modified our stitches technique), in 4 tertiary centers. previous technique and used reduced The children were operated at a mean number of ports (two-port) to produce age of 21.6 months (4.8-56.5 months). better cosmetic results with less technical Six patients had chromosomopathies difficulty. The aim of this study was to (46.2%), including five children with evaluate the outcome of this two-port Down syndrome (38.5%). The most technique compared to the previous common presentation was respiratory three-port technique. symptoms (53.8%) and 5 patients (38.5%) had previous admissions for different METHODS: Between 2008 and 2013, 410 causes. The procedure last, in mean, records of children with inguinal hernia 95±23 minutes (range 40-120). There treated by laparoscopy were reviewed. Of were no intra-operative complications; in them, 63 patients were treated by two-port none of the patients the hernia sac was laparoscopic herniotomy and 347 patients removed; prosthesis was never used. In were treated by three-port laparoscopic the immediate post-operative period, 4 herniotomy. For two-port laparoscopic patients (36%) were admitted to intensive herniotomy, we introduced one globe care unit due to co-morbidities (all port through the umbilicus and inserted presented Down syndrome); the remaining a 3mm assistant port at the suprapubic patients started enteral feeding within area. We calculated the learning rate of the first 24 hours. With a mean follow- the two-port technique and compared this up of 17.5 months, there have been two to the result of the three-port method to recurrences (18%) on the same institution; evaluate technical difficulty. one of the recurrences was the only case in RESULTS: There was no significant which an absorbable suture was used. difference in operation time between the CONCLUSION: The application of MIS in the two-port group and three-port group MH repair is effective even in the presence (25.2±7.0 minutes vs. 24.8±9.6 minutes: of comorbidities such as Down syndrome; p=0.75). Learning rate analysis showed the latter influenced only the immediate that there was no difference between postoperative recovery. Removal of hernia the two-port and three-port technique sac is not necessary. The use of absorbable (6.02 % vs. 10.60 %: p=0.23). No intra- or suture is not recommended. postoperative complications were found in two-port group. In the three-port group,

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Poster Abstracts CONTINUED we had two cases of recurrence (0.58 %) P083: LAPAROSCOPIC INFANT INGUINAL and one metachronous hernia (0.28 %) HERNIA REPAIR: 5 YEAR EXPERIENCE IN during the follow-up period (mean 28.5 A SINGLE CENTRE Joshua Rae, Caroline months). Smith, S. S. Marven, G. V. Murthi, R. M. Lindley, J. P. Roberts, Sheffield Children’s CONCLUSION: The two-port laparoscopic Hospital herniotomy can be used as a safe treatment option providing better AIM: Laparoscopic inguinal hernia repair cosmetic results without increasing the in infancy is still a contentious issue. The technical difficulty of the operation. purpose of this study was to look at the outcomes of laparoscopic inguinal hernia repair in children under one year of age in terms of demographics, detection of contralateral patent processus vaginalis (PPV), length of post operative stay, post operative complications and rate of recurrence. METHODS: A retrospective case note review of 150 patients under the age of 12 months who underwent a laparoscopic hernia repair at our institution between November 2008 and November 2013 was conducted. Mean time to first follow up was 3 months. Median follow up was 6 months (0 – 24 months). RESULTS: All operations were completed laparoscopically. There were 118 (79%) hernia repairs in males and 32 (21%) in females. Mean Post conceptual age was 51.6 weeks. Mean weight at operation was 5.2 Kg. The rate of detection of contralateral PPV was 40%. Median length of stay was 1 day (range 0-10 days). There were 3 patients who required prolonged post operative oxygenation and oral antibiotics for lower respiratory tract infections. There were 6 recurrences (4%) in the time period, of these 4 had presented originally as an emergency. Mean time to recurrence was 8.5 months, median time to recurrence was 2 ½ months (2 days – 24 months). There were no instances of testicular atrophy. 3 patients developed testicular ascent requiring orchidopexy.

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No patients developed metachnronous full-thickness neck of the hernia and the hernias during the study period. inguinal ligament and at the same time minimized the suture line tension. The CONCLUSION: Laparoscopic infant hernia technique was used for IHR in 72 selected repair is safe and our recurrence rate patients aged from12 months to 14 years. is within the reported range. Repair of All procedures were carried out in the inguinal hernia laparoscopically allows minilaporoscopy mode. The total number inspection of both internal rings and avoids of IHR’s, including the contralateral readmission for repair of a metachronous metachronous hernias was 96. The patient hernia. outcomes were followed up at intervals of P084: A POTENTIALLY MORE DURABLE one, three, six months, 1 and 1.5 years. The MIS REPAIR FOR PEDIATRIC INGUINAL patient data were summarized. Anatole Kotlovsky, MD, PhD, HERNIA  RESULTS: All procedures were Sergei Bondarenko, MD, PhD, Alexander successfully completed without any Lepeev, MD, PhD, Vitaly Ovchinnikoff, complication encountered. The operative MD, Oleg Chernogoroff, MD, Alexey time ranged between 10 – 35 minutes for Ryazantzev, MD, Solntzevo Clinical the unilateral hernias and 25 – 45 minutes Research Center of Medical Care for for the bilateral. All patients made prompt Children, Moscow, Central Children’s uneventful recovery with only minimal Hospital in Oryol Region, Oryol, Russian requirement for analgesia. No evidence Federation of hernia recurrence was found at the BACKGROUND: Certain advantages of MIS follow-up intervals. Patient/parent techniques for the inguinal hernia repair satisfaction with the treatment was stated (IHR) in children have been demonstrated. in all cases. However, the fact of higher recurrence CONCLUSION: IHR with the use of TMTF/ rates following the MIS repair vs the RT appears to be effective in preventing/ conventional open procedure points to minimizing risk of hernia recurrence. For the desirability for further development. the further evaluation a randomized To enhance the potential durability of the comparative study of the TMTF/RT vs the laparoscopic repair we have modified the open technique will be warranted. technique of transperitoneal closure of the hernia defect, following the principles P085: LAPAROSCOPIC PARTIAL of mass and tension free/reduced SPLENECTOMY AND EXTROPERITONEAL suturing. SPLENOPEXY FOR TORSION OF WANDERING SPLEEN Chi Sun, MD, Suolin OBJECTIVE: This study represents a Li, MD, Department of Pediatric Surgery, preliminary report of the proposed The Second Hospital of Hebei Medical transperitoneal mass, tension free/ University, Shijiazhuang, China reduced technique (TMTF/RT) for pediatric IHR. BACKGROUND: Wandering spleen is a rare condition in which the spleen lacks PROCEDURE & PATIENTS: The key its usual peritoneal attachments and elements of the TMTF/RT entailed supporting ligments, thus its vascular closure of the hernia defect while using pedicle can twist resulting in ischemia differentially, depending on the defect and infarction. Although splenectomy size, combinations of various types of has traditionally been used for this suturing that incorporated parts of the

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Poster Abstracts CONTINUED condition, splenopexy is increasingly This is a video presentation of laparoscopic used in the pediatric population to resection of posterior gastric wall tumor anchor the spleen and preserve splenic in a 12 year old boy. He was found to have function. We describe a laparoscopic a transmural tumor of the gastric wall, partial splenectomy and extroperitoneal extending into the lesser sac. The tumor splenopexy of the remaining spleen for was excised laparoscopically. The resulting torsion of a wandering spleen in a child. gastrotomy was repaired using continuous full-thickness single layer suture using 2-0 CASE REPORT: The patient was a absorbable, glycolic acid, barbed suture 3-year-old girl with a month history of device. intermittent abdominal pain. Abdominal ultrasonography and axial computed Unidirectional barbed sutures like V-Loc tomography demonstrated a wandering (Covidien, Mansfield, MA) allow easier spleen with partial infarction in the left placement of continuous sutures during mid-abdomin and the whirl appearance open and minimally invasive procedures. of the splenic vessels. On laparoscopic This does not require knots at the exploration the spleen was found to lack beginning or at the completion of the its normal attachments and had made 3 suture. Neither does it need maintenance complete clockwise rotations around its of tension on the material while suturing. mesentery and there were signs of vascular Use of this device allowed for expeditious occlusions and infarction of the spleen. The and secure closure of the gastric spleen was detorsed around its mesentery defect. The child recovered well without and then the partial splenectomy and complications and remained asymptomatic extroperitoneal pocket splenopexy of the six months after the procedure. remaining spleen were performed. The postoperative course was uneventful and P087: FIRST CASE REPORT OF the well-perfused remaining spleen had PERCUTANEOUS TRANS-ESOPHAGEAL maintained its position during a 2-year GASTRO-TUBING PERFORMED IN A follow-up period. CHILD Hideto Oishi, MD, Katsunori Kouchi, MD, Fumi Maeda, MD, Takeshi Ishita, MD, CONCLUSION: Wandering spleen should Masayuki Ishii, MD, Takuya Satou, MD, be considered in cases of acute abdominal Takayuki Iino, MD, Hidekazu Kuramuchi, pain, and laparoscopic partial splenectomy MD, Shunsuke Onizawa, MD, Eiichi Hirai, with splenopexy is technically feasible and MD, Mie Hamano, MD, Tutomu Nakamura, safe, based on the well-known advantages MD, Tatsuo Araida, MD, Shingo Kameoka, that the minimally invasive approach MD, Division of Gastroenterological offers, and should be considered the Surgery, Division of Pediatric Surgery, treatment of choice for this rare condition, Dept of Surgery, Yachiyo Med Ctr, Tokyo with the goal of preservation of the organ Women's Med Univ whenever possible. OBJECTIVE: We report the first P086: KNOTLESS REPAIR OF percutaneous trans-esophageal gastro- GASTROTOMY USING UNIDIRECTIONAL tubing (PTEG) procedure performed BARBED SUTURE FOLLOWING EXCISION in a child. We developed PTEG in 1994 OF GASTRIC LEIOMYOMA Ravindra K. for patients in whom percutaneous Vegunta, MBBS, Cardon Children’s Medical endoscopic gastrostomy (PEG) would be Center, Mesa, AZ and University of Arizona difficult. In 1997, we invented a rupture- College of Medicine, Phoenix, AZ

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Poster Abstracts CONTINUED free balloon (RFB) to aid the PTEG P088: MULTI-MODAL ASSESSMENT procedure. In Japan, PTEG is usually used STRATEGY FOR ADVANCED MINIMAL for gastrointestinal decompression and, ACCESS PAEDIATRIC SURGEON like PEG, for enteral nutrition. It has proven SELECTION Simon Clarke, Mr., Munther to be as useful as PEG. Of the 16,000 PTEG Haddad, Mr., Giuseppe Retrosi, Tom Cundy, procedures performed in Japan to date, Chelsea and Westminster Hospital NHS 285 were performed by us. However, all Foundation Trust ; Imperial College London patients were adults; the procedure was The selection process for appointment not performed in children. We recently of consultant paediatric surgeons is a performed the PTEG procedure in a child highly competitive process. In an effort to and report our experience herein. improve transparency and objectiveness MATERIALS & METHODS: The patient was of this process for an advanced minimal a 9-year-old girl with cerebral palsy who access post, a multi-modal assessment required enteral nutrition. Transperitoneal approach was designed utilizing the dialysis was anticipated in this case; thus, resources of an established paediatric PEG was not possible. PTEG was selected surgery simulation laboratory. and carried out under general anesthesia. AIMS: to assess the process and outcome The PTEG procedure was performed in two for two sets of consultant interviews using steps. The first step was esophagostomy, validated and non-validated surgical skill which was accomplished by direct puncture tests. under ultrasonographic guidance. We began by inserting an RFB into the cervical METHODS: Consultant selection took esophagus via the nose, and we inflated place on two separate occasions. 10 the RFB to keep the esophageal lumen prospective candidates took part and open for puncture. The second step was were rotated through three assessment tube placement via the esophagostomy stations consisting of 1) validated Pediatric under fluoroscopic guidance. An indwelling Laparoscopic Surgery (PLS) simulator PTEG button catheter, 15 Fr x 90 cm, was peg transfer task, 2) neonatal box placed in the patient’s jejunum via the trainer intracorporal suture task, and 3) cervical fistula. structured interview with senior faculty. An independent observer moderated the RESULT: We encountered no technical technical skills task stations. This observer complication. Surgical antibiotic was assigned to mitigate candidates being prophylaxis prevented infection. Enteral distracted in their task performance and nutrition was begun on postoperative to avoid uncontrolled bias. Candidates day 1, and the patient was discharged on consented to live video and audio postoperative day 2. being transmitted to an adjoining room EXPECTATION: With the effectiveness of where faculty were able to observe PTEG already confirmed in adults, we were the assessment stations via tele-feed. able to show that it is likely to be feasible Results for each assessment station were and safe in children. PTEG might be broadly scored and then pooled for an aggregate applicable in pediatric cases for which PEG candidate score. Results were fed back to would be difficult or is contraindicated. the appointments committee after their preferred candidates had been named.

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RESULTS: All candidates completed all (SonoSite, Inc.,Bothell, Washington). tasks. The median unnormalized PLS peg The packaged 0.025 inch diameter (ID) J transfer score was 125 (range 76 – 62). wire within the set was used in all infants The validated task coincided with all three weighing greater than 2.5 kg. A 0.018 ID preferred candidates. The non-validated angled glidewire (Radiofocus® glidewire, task scores coincided with 2 of 3 preferred Boston Scientific Inc., Natick, MA) was used candidates. Feedback from candidates in infants less than 2.5 kg. The average was variable and most felt the task did not size of the internal jugular vein was 4.0 demonstrate their ability on the day. mm (range of 3.5 to 5.0 mm). Twenty infants underwent 21 UG CVC placements CONCLUSION: Pre selection is increasingly (mean weight 2.45 kg., range 1.4 to 3.4 being used at interview in medical kg.). Vascular CVC placement occurred specialities. We found those who at the following access sites: 16 infants performed well at interview correlated well underwent 17 placements via the right with task performance. Further validation internal jugular (RIJ) vein, 3 infants via the studies are planned to enable this to be left internal jugular vein (LIJ). One infant used with more confidence at future had inadvertent removal of the UG CVC appointments panels. in the RIJ on post operative day 7. This P089: ULTRASOUND GUIDED infant returned to the OR and underwent PERCUTANEOUS CENTRAL VENOUS a successful UG CVC in the same RIJ. ACCESS IN INFANTS Seth Goldstein, MD, (infant weight 2.8 kg). There were no other Howard Pryor, MD, Dylan Stewart, MD, complications in the group. Fizan Abdullah, MD, PhD, Paul Colombani, CONCLUSIONS: The UG CVC approach is MD, Jeffrey Lukish, MD, Johns Hopkins a safe and efficient approach to central University venous access in infants as small as 1.4 PURPOSE: The insertion of tunneled kg. Our experience support the use of central venous access catheters (CVC) in an ultrasound guided percutaneous infants can be challenging. The use of the technique as the initial approach in infants ultrasound guided approach (UG) to CVC who require central venous access. placement has been reported in adults and P090: HOW TO IMPACT DELIVERY children but there is minimal information OF PEDIATRIC SURGICAL CARE IN A regarding these techniques in infants. DEVELOPING COUNTRY—START A METHODS: From August 2012 to FELLOWSHIP TRAINING PROGRAM Novemeber 2013, retrospective analyses Stephanie F. Polites, MD, Abdelbasit Ali, were carried out on the charts of MBBS, Diyaeldinn Y Mohammed, MBBS, infants that were 3 kilograms or less Osman Taha, MBBS, Abdalla E. Zarroug, who underwent attempted UG CVC MD, Mayo Clinic, Rochester, MN; Soba placement. Data retrieval included infant Hospital, University of Khartoum, Sudan; weight, vascular access site, diameter of University of Gezira, Wad Madani, Sudan cannulated vein in mm, and complications. INTRODUCTION: Providing pediatric RESULTS: All infants underwent UG CVC surgical care in Sudan is difficult due to placement utilizing a standard 4.2 Fr or 3.0 a shortage of surgeons and facilities. As Fr CVC system. (Bard Access Systems, INC., of 2010, it is believed that only 7 pediatric Salt Lake City, Utah). UG was performed surgeons practiced in Sudan and South on all infants with the Sonosite M-Turbo® Sudan (Sudan) and no studies have been

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Poster Abstracts CONTINUED published regarding manpower in Sudan. the median reported wait time for patients To address the manpower issue, a 2 year decreased from >9 months to 6-9 months. pediatric surgery fellowship program was Three participants (33%) were worried started. The first participants graduated about graduating surgeons taking business in January, 2012. The purpose of this study from their practice and 6 (67%) were not was to establish current workforce issues worried. All participants felt the fellowship and evaluate the impact of the training was important for children in Sudan and program on delivery of pediatric surgical that additional pediatric surgeons were care in Sudan. needed, with 6 (67%) who felt that 4-10 more were needed. METHODS: In February, 2013, all practicing pediatric surgeons (7 surgeons before CONCLUSIONS: A 2 year pediatric surgery the fellowship and 7 surgeons after the training program has been positively fellowship) in Sudan received a previously received in Sudan and has doubled the published modified questionnaire about number of surgeons, resulting in increased training and delivery of pediatric surgical access to care as evidenced by a decreased care. Results were analyzed in aggregate. wait time for children. We believe this can serve as a model for others to have a RESULTS: Surveys were returned by 9 of long-term impact on the care of children 14 (64%) surgeons. Most participating in developing countries by training local surgeons received training in Africa (78%), physicians in their environment. Pediatric while one trained in Europe and one in surgeons in developed nations should Asia. Previous general surgery training support such fruitful efforts. was variable, as 3 particpants reported 3 years of training, 3 reported 4 years, P091: A ROBOTIC-ASSISTED APPROACH and 3 reported >4 years. The majority TO SLEEVE GASTRECTOMY IN A (78%) reported practicing in a city with a MORBIDLY OBESE ADOLESCENT population of 1,000,000-10,000,000. The POPULATION Victoria K. Pepper, MD, median (range) of pediatric surgeons at Karen A. Diefenbach, MD, Terry M. participants’ hospitals was 2 (1-3). The most Rager, MD, MS, Marc P. Michalsky, MD, common pediatric surgical service offered Nationwide Children’s Hospital was urology (100%), followed by general PURPOSE: While minimally invasive pediatric surgery, oncology, neurosurgery surgery is an expanding field within (all 89%), trauma (78%), orthopedics and pediatric surgery, robotic techniques minimally invasive surgery (both 22%). A have not been widely applied within this patient age limit of < 13 years was reported population. Robotic techniques for adult by 3 (33%) surgeons and 6 (67%) reported bariatric surgery have been explored by an age limit of <16 years. All (100%) many investigators. Our purpose was to participants reported inadequate pediatric demonstrate a robotic-assisted approach surgery facilities, manpower, support to a sleeve gastrectomy within the facilities, and anesthesia as problems adolescent population. impacting care. Only 4 (44%) reported having access to pediatric anesthesiology METHODS/RESULTS: The procedure is services. Five (56%) of the 9 participants initiated by insertion of a 5-mm Visiport reported involvement in training future in the left lateral abdomen, which is later pediatric surgeons. When asked about the exchanged for an 8-mm robotic port. impact of the fellowship training program, A 12-mm camera port is inserted at the

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Poster Abstracts CONTINUED umbilicus, while a 15-mm assistant port Blood tests and tumor markers were is inserted in the right upper quadrant. unremarkable. An 8-mm port is inserted in the lateral MRI demonstrated a 20 cm large cyst at right upper quadrant, while a second the abdominal left upper quadrant. 8-mm port is inserted in the left upper quadrant. After docking the robot, the The patient was then scheduled for procedure is initiated by measuring a 6 resection. cm distance proximal to the pylorus. The greater curvature of the stomach is freed SURGICAL TECHNIQUE: by division of the gastrocolic ligament. This Four throcars were used, 3 of 5 mm and dissection is continued up to the hiatus. one of 12mm at the umbilical site using a 5 Once the greater curvature is freed, the mm 30 degree laparoscope. stomach is divided with a reinforced endo- stapler along a 34 French Bougie, creating Evidence of the 20 cm cyst arising from the the gastric sleeve. The gastric sleeve is spleen was done on the first inspection. insufflated endoscopically to inspect for Aspiration of the cyst was done using and any leak, which also allows inspection endoscopic needle aspirator obtaining of the suture line intraluminally. The around 11 liters of cyst fluid. gastric remnant is then removed and the procedure is completed with closure of the Splenophrenic ligament was taken down port sites. and then the short gastric vessels were taken down using a combination of CONCLUSION: Robotic-assisted monopolar cautery and a vessel sealing laparoscopic sleeve gastrectomy is instrument. safe in the adolescent population, and demonstrates many advantages Once freed, thespleenpoleswere over traditional laparoscopic surgery, demarcated for resection and divided using including enhanced visualization, multiple endoscopic staplers. increased articulation and mobility of Splenopexy was done from the splenocolic the instruments, and increased operator ligament to the lower pole of the spleen control. using interrupted vycril sutures. P092: TOTAL LAPAROSCOPIC PARTIAL The cyst was extracted using a 15 mm SPLENECTOMY AND SPLENOPEXY AS endocatchbag and morcerated. A MANAGEMENT OF AN EXTREMELY LARGE SPLENIC CYST Ulises Garza Serna, Patient was sent home two days after MD, Shin Miyata, MD, Aaron Jensen, MD, surgery. Michael Zobel, BS, Nam Nguyen, MD, Final path showed a benign epithelial cyst. Children’s Hospital Los Angeles, University of Southern California P093: COMPARING THE KINECT™ AND MOUSE AS INTERACTION DEVICES FOR INTRODUCTION: This is a 15 year old MANIPULATING TISSUE DENSITY IN girl, who had a left flank mass found on VOLUME-RENDERED MEDICAL IMAGES routine physical exam by pediatrician. The Bethany Juhnke, Kenneth Hisley, PhD, patient was unable to lose weight and the David Eliot, Joseph Holub, Eliot Winer, PhD, abdominal girth increased over several Iowa State University and Touro University months.

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Poster Abstracts CONTINUED

Volume-rendered medical images have entire study. Ten tasks were selected by an changed the way medical professionals anatomy professor to ensure participant diagnose and treat patients. These three- knowledge. Each participant performed dimensional (3D) representations enable five of the tasks then repeated those non-invasive viewing inside a patient from tasks with a short break in-between. The any angle. Volume-rendering technologies participant was then given the other five are being integrated into every step of the tasks, a break, and then repeated those healthcare process from classrooms to same five tasks. Tasks and interaction patient’s rooms, including operating rooms devices were randomized to prevent (OR) where sterility is critical. To maintain bias. Participants were given a pre and OR sterility, commercial off-the-shelf post study survey to obtain relevant (COTS) devices like Microsoft’s Kinect™ are demographic and personal experience being used to provide computer interaction information as well as qualitative data without the need for physical contact. It about their experience during the study. is important to research what benefits The qualitative results showed participants or drawbacks are associated with using enjoyed using the Kinect™ more than the Kinect™ for manipulating volume- the mouse, which was opposite from rendered medical images especially in the first study. This may be attributed terms of the usability of the device and to the novelty of the device; something the accuracy associated with using it for commented on by multiple participants. medical diagnoses. While the results confirmed the Kinect™ This research builds upon a previous study still had issues with window width precision, attempting to quantify the differences this did not appear to impact performance. in using a Kinect™ versus a tradition Both the mouse and the Kinect™ results computer mouse for changing tissue showed no statistical difference in accuracy densities (windowing) of a medical image. with approximately 75% accuracy for both The results of the first study were not devices. The big difference was the task positive for the Kinect™ with participants completion time where the Kinect™ held indicating that they did not enjoy the a 2 minute advantage over the mouse device and felt self-conscious while using which was statistically significant to a 99% it. The participant’s performance with confidence. The results of the participant’s the Kinect™ showed inefficiencies with general experience and performance precision manipulations. indicate that the Kinect™ has the potential for effectively manipulating medical data. A new study was conducted to further explore the previous study’s results. P094: ENDOSCOPIC TREATMENT OF Specifically, the study was designed to AIRWAY MASSES AND OTHER LESIONS evaluate the user’s experience when using IN A DEVELOPING COUNTRY Satish K. the Kinect™ as well as their performance Aggarwal, Professor, Shandip K. Sinha, Dr., compared with a traditional mouse. 32 Simmi K Ratan, Dr., G. R. Sethi, Professor, participants with a median age of 28 Anju Bhalotra, Professor, anaesthesiology, volunteered for this study. Most were in Maulana Azad Medical College New Delhi, their first or second year of medical school India. at Touro University. Participants used AIM: To Assess the role of Bronchoscopy either the Kinect™ or a traditional mouse for treatment of tracheobronchial masses to manipulate the tissue density for the and acquired stenotic lesions in children.

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MATERIAL & METHODS: Records of cases Polyp and granulomas were removed using that underwent bronchoscopic treatment a combination of cautery, Pulse Diode of tracheobronchial masses and acquired Laser, and physical retrieval by forceps. stenotic lesions over 3 years (2011-2013) Hemangioma was partially ablated by at a tertiary care Paediatric Surgery Holmium Laser. Dilatation was performed department were retrospectively reviewed by using Balloon dilator on a guide wire with reference to demographics, clinical under direct vision. The endobronchial presentation, pre op work up and surgical retention cyst was de-roofed with cautery. management. Innovations in techniques Patients with endobronchial TB were and instrumentation were recorded. already on ATT when they presented with obstructive symptoms. Endoscopic RESULTS: Twelve patients (M: F-9:3) with removal of granuloma was successful in median age of 6 years (range: 3 months- 18 relieving obstructive symptoms. years) underwent therapeutic bronchoscopy for excision of mass lesions (7), dilatation of All mass lesions were completely excised foreign body (FB) induced bronchial stenosis in the first attempt except the subglottic (4), and for excision of post tracheoplasty hemangioma. suture granuloma and dilatation of a COMPLICATIONS: Recurrent Histiocytosis recurrent stenosis (1). Mass lesions included which was also excised. It recurred again Histiocytosis X (1), foreign body granuloma twice and excised twice. In the Hemangioma following TEF repair (1), Endobronchial case a gauge piece which was used to protect tubercular granuloma (3), subglottic the tracheostomy tube was dislodged distal hemangioma (1), and Endobronchial cyst (1). to tracheostomy and required retrieval. Diagnostic evaluation was done with flexible Transient collapse of lung was seen in 4 bronchoscopy. Rigid bronchoscopy (using cases. One case with bronchial stenosis Storz operating bronchoscope) was used required re dilatation after 6 weeks. One case for therapeutic intervention. All procedures in which dilatation was successful but the were performed under general anaesthesia lung had chronic collapse and did not inflate. using either conventional or jet ventilation. She required pneumonectomy later. Energy sources used were Electro cautery and Lasers. Salient features in technique CONCLUSION: Endoscopic management were: of mass lesion is feasible in children with acceptable morbidity. Innovative use • Using ureteric catheter with metallic of urological equipment comes handy. obturator, and Bugabee electrode for Team approach with input from Paediatric cautery. pulmonologist and anaesthesiologist is • Using 3mm laparoscopy dithery hook for necessary. cauterising granuloma in an older child. P095: COMPLICATIONS OF LONG • Using MLS (Micro Laryngeal surgery) set STANDING FOREIGN BODY IN THE up for direct access to the lesion. AIRWAY AND THEIR OUTCOMES AFTER ENDOSCOPIC MANAGEMENT: AN • Using Ureteric Balloon Dilators (Bard) for EXPERIENCE OF 20 CASES Satish K. bronchial dilatation Aggarwal, Shandip K Sinha, Dr., G. R. Sethi, • Improvising an optical forceps by Director, Professor, of, Paediatrics, Anjan introducing telescope and an ordinary Dhua, Dr., Simmi Ratan, Dr., Nitin Pant, Dr., forceps together through the sheath. Maulana Azad Medical College New Delhi, India.

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AIM: To study the complications of long for chronic erosion of bronchial wall standing foreign body in the airway and by a battery, and the other died during the outcomes after their endoscopic bronchoscopy because of dislodgement of management. FB into the opposite normal bronchus. MATERIAL & METHODS: Records of cases Of the 16 who had successful retrieval, that underwent treatment of chronic foreign 11 recovered completely with full lung body bronchus over 6 years 2008-2013 at a expansion after mean duration of three tertiary care Paediatric Surgery department months. Four had persistent collapse were retrospectively reviewed with reference due to residual granulation and / or to demographics, clinical presentation, bronchial stenosis as diagnosed on flexible pre op work up and management. The bronchoscopy. They underwent rigid techniques for management and tips and bronchoscopy again and the granulations tricks to prevent complications are presented were cauterised and stenoses dilated using through this paper. Outcomes were assessed balloon dilators. All of them recovered in terms of removal of FB, expansion of lung, on follow up with full lung expansion. need for further treatment and resolution of One patient required a pneumonectomy symptoms. because of persistent collapse despite removal of FB and dilatation. RESULTS: Twenty patients (M: F-16:4) with mean age of 7 years (range: 10 months- In summary of the 20 cases, 11recovered 12 years) who underwent therapeutic completely after first removal of FB. Four bronchoscopy and or thoracotomy needed follow up procedure for dilatation for management of problem related or removal of granulation – and recovered. to chronic foreign body in the airway. Two required pneumonectomy and one Most cases initially presented to the patient died. Paediatric pulmonologist (GRS) as referrals CONCLUSION: Long standing FB in airway for evaluation of chronic respiratory should be suspected if there are chronic symptoms. Diagnostic work up included respiratory symptoms even if there is no flexible bronchoscopy. If a FB was definite history and flexible bronchoscopy suspected on flexible bronchoscopy the should be offered for diagnosis. case was sent to Paediatric Surgery for rigid Bronchoscopic removal leads to reversal of bronchoscopy and removal. lung changes in most cases. Tracheotomy The diagnosis was made on flexible should be considered while removing large bronchoscopy in 14 whereas in 6 it was impacted FBs with chronic lung damage. evident from a radio opaque FB on chest X-ray. Chest CT scan was done in 6 cases P096: PARAESOPHAGEAL HERNIA IN Aaron Garrison, MD, Todd foe evaluation of lung parenchyma. Rigid 2.7 KG INFANT  Ponsky, MD, Robert L. Parry, MD, Akron bronchoscopy (Storz) was performed in all Children’s Hospital cases under GA with conventional or jet ventilation. In 16 the FB could be retrieved A 2.7kg infant was evaluated for significant successfully (tracheotomy required in 2). In gastroesophageal reflux. Pre-operative 2 cases there was a tracheo oesophageal floroscopy showed reflux to the thoracic fistula resulting from eroding FB in the inlet along with a small hiatal hernia. At oesophagus – both these cases required operation for a Nissen fundoplication, a open surgery for removal of FB and repair of large paraesophageal hernia was noted oesophagus and trachea. Of the remaining and repaired. two cases one required pneumonectomy

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Poster Abstracts CONTINUED

P097: LAPAROSCOPIC INGUINAL We have been performing laparosopic HERNIOTOMY – MIMICKING THE herniotomy since the past 15 years. The PRINCIPLES OF OPEN INGUINAL essential therapeutic stepsof the open HERNIOTOMY FOR COMPARABLE (inguinal) herniotomy involve dissecting RESULTS Ketan Parikh, MD, Jaslok hospital, away the processus vaginalis protrusion L H Hiranandani Memorial Hospital, Tara from the vas and vessels especially at Neo-Surg hospital. the neck of the hernia sac and effective disconnection of the herniated procesus Laparoscopy has been well accepted as vaginalis from the parietal peritoneum a superior modality for most surgical (principles of high ligation of sac). procedures in children. In contrast, Over these years, we have evolved a laparoscopic herniotomy in children technique which closely mimics the continues to be a controversial issue. One inguinal herniotomy in all its principles of the main objections to the herniotomy and employs the principles of MAS. In by the laparoscopic approach has been the contrast to our earlier surgical techniques, relatively higher incidence of recurrences we have achieved effective adherence by the laparoscopic method. Whereas the to these principles in our laparoscopic surgical technique for inguinal herniotomy procedure over the past 10 years and has been fairly well standardised, attribute ournear-zero recurrence rate for laparoscopic herniotomy has the dubious laparoscopic herniotomy in children. distinction of being performed by perhaps the largest variety of methods described in P100: TRANSUMBILICAL ONE-PORT literature. LAPAROSCOPIC- ASSISTED TECHNIQUE FOR INGUINAL HERNIA REPAIR IN We feel that since the ‘open’ (inguinal) CHILDREN Shiwang Li, MD, PhD, Shuai Li, herniotomy has been so fairly standardised Guoqing Cao, Yong Wang, Yongzhong Mao, with minimal complication rate and Shaotao Tang, Department of pediatric recurrences, its evolved (laparosopic) surgery, Tongji Medical College, Huazhong counterpart should mimic the steps University of Science and Technology, of the ‘open’ procedure as closely as Wuhan, China, 430022 possible to aim at comparable results. Basic principles of the dynamics of BACKGROUND AND PURPOSE: Since inguinal canal function also need to be laparoscopic hernia repair was reported a remembered and respected.The intactness few decades ago, many techniques have and the integrity of the posterior wall of been developed. Single-port endoscopic- the inguinal canal, the maintenance of the assisted percutaneous extraperitoneal shutter mechanism of the inguinal canal closure of inguinal hernia with variable and the maintenance of the mobility of the devices is a novel technique in minimal- spermatic cord within the inguinal canal are access surgery for pediatric inguinal integral to the physiology of the inguinal hernias. In this study, we introduced a canal which are well preserved during the new method, Transumbilical one-port procedure of inguinal herniotomy. The laparoscopic- assisted technique (TOPLAT), laparoscopic benefits of visualisation of and evaluated the safety and feasibility of the contralateral deep inguinal ring and this method. the superior visualisation of the vas and PATIENTS & METHODS: One hundred vessels during their dissection can only be and sixty-eight patients who accepted fully justified if the recurrence rates do not the TOPLAT procedure in our hospital betray the final outcome.

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Poster Abstracts CONTINUED from November 2009 to Octoberr 2013 BACKGROUND: Gastrostomy tube insertion were analyzed retrospectively. During the in children can be accomplished via TOPLAT procedure, a laparoscope was open surgery, laparoscopy, endoscopy, placed through a Transumbilical incision. or fluoroscopy. Clinicians should use an Epidural puncture needle and Non- approach that is safe, minimally invasive, absorbable 2-0 Prolene sutures (Ethicon provides adequate visualization, and products ) were used to close the hernia does not require tube exchanges post- extraperitoneally. operatively. This study describes our experience with a recently developed RESULTS: A total of 210 inguinal repairs technique for the placement of skin-level were performed in 168 children (age device (Mic-Key) in a single procedure. range, 3 months to 12 years; median, 6.8 years; 145 boys, 23 girls). All operations METHODS: We identified 92 children were completed successfully by TOPLAT. and young adults who underwent The mean operating time was 18 minutes laparoscopic-assisted percutaneous (range, 10-25 minutes). In this group endoscopic gastrostomy (LAPEG) tube of patients no postoperative bleeding, insertion by one of three surgeons hydrocele, or scrotal edema was found, no between October 2009 and June 2013. known cases of postoperative testicular The steps of this procedure include upper atrophy or hypotrophy nor hernia endoscopy, followed by single-port recurrence on the symptomatic side. laparoscopy, gastropexy via percutaneous Five months after the operation, most T-fasteners, and percutaneous endoscopic patients had no obvious signs of a previous Mic-Key placement using an introducer operation. and tear-away sheath. CONCLUSIONS: The preliminary results showed satisfactory outcomes with TOPLAT in the treatment of inguinal hernia in children, which enclose the hernia defect without upper subcutaneous tissues. This technique appeared to be safe, effective, reliable, and had excellent cosmetic results and aid in the achievement of a near-zero recurrence rate. P101: LAPAROSCOPIC-ASSISTED PERCUTANEOUS ENDOSCOPIC GASTROSTOMY (LAPEG) IN CHILDREN: INSERTION OF A SKIN-LEVEL DEVICE IN A SINGLE PROCEDURE Michael H. Livingston, MD, Daniel Pepe, BMSc, Andreana Bütter, MD, FRCSC, Neil H. Merritt, MD, FRCSC, Children’s Hospital of Western Ontario, London Health Sciences Centre, London, Ontario, Canada RESULTS: Mean age was 3.7 years (range 3 weeks to 25 years) and mean weight was

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11.2 kilograms (range 2.8 to 54 kilograms). site surgeries (LESS).All procedures were Median procedural time was 20 minutes performed by a homemade single-port (range 12 to 76 minutes). Total operative device with a wound retractor and surgical time for the most recent 25 procedures gloves. A prospective study was performed (median 62 minutes) was lower compared to to evaluate the outcomes. the first 25 procedures (median 79 minutes) RESULTS: Our study includes 15 girls and 75 (p=0.004). Significant complications were boys; their ages range from 4 to 14 years. observed in 4 patients (4.3%). These We used LESS on 78 appendectomies, one included one intra-abdominal abscess and unilateral impalpable testis, one inguinal one leak that required surgical repair, one hernia, three varicocelectomy and four retained T-fastener that was assessed via Morgagni-Larrey hernia. A conversion upper endoscopy, and one dislodged tube to open surgery was necessary in three that required replacement by interventional patients. The time required to assemble radiology. No major complications have the transumbilical glove port was 4 been observed in the most recent 50 minutes. The mean operative time was 55 procedures. minutes. The average hospital stay was 3 CONCLUSIONS: LAPEG tube insertion is a days. The cosmetic results were excellent viable option for infants and children of all with no post- operative complications. ages. This approach allows for immediate CONCLUSIONS: This homemade use of a Mic-Key without the need for transumbilical port offers a safe, reliable, additional upsizing. The complication rate flexible, and cost-effective access for and operative time with LAPEG are low LESSprocedure. This technique may be and appear to improve with increased an alternative for current specialized port experience. This technique provides systems. excellent visualization and no visceral injuries have been observed. P103: EARLY EXPERIENCE WITH A NEW 3 MM TISSUE AND VESSEL SEALING DEVICE P102: PEDIATRIC HOMEMADE Steven S. Rothenberg, MD, FACS, FAAP, TRANSUMBILICAL PORT: INITIAL Saundra M. Kay, MD, Kristin Shipman, EXPERIENCE WITH 90 CASES M. MD, William Middlesworth, MD, Angela Ben Dhaou, S. Mesbehi, M. Jallouli, H. Kadenhe-chiweshe, MD, Bethany Slater, Zitouni, S. Mefteh, A. Kotti, R. Mhiri, MD, Stephen Oh, MD, Rocky Mountain Department of pediatric surgery, Hedi Hospital For Children, Columbia University Chaker Hospital,Sfax,Tunisia. University of College of Physicians and Surgeons Sfax,Tunisia PURPOSE: To evaluate the functionality BACKGROUND: Single-port laparoscopic of a new 3mm vessel and tissue sealing surgery is a new surgical technique. Some device in neonates and children. initial studies on adults have already been published all over the world. METHODS: Over a 4 week divided test period 23 patients underwent laparoscopic This paper describes our initial and thoracoscopic procedures using a new pediatric experience with an innovated 3 mm tissue sealing device. The device is a transumbilical port for 90cases. 3mm instrument with a 1 cm Maryland style MATERIALS & METHODS: Between January grasper/dissector capable of sealing vessels 2013 and December 2013, we performed up to 5mm in diameter. The generator uses consecutive laparoendoscopic single low bipolar RF output, which limits collateral

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Poster Abstracts CONTINUED tissue damage. Ages ranged from 7 days One hundred and sixty-eight patients to nine years and weight from 1.1 kg to who accepted the Transumbilical one- 30kg. Procedures included Thoracoscopic port laparoscopic- assisted technique lobectomy (7), Fundoplication (4), Thoracic (TOPLAT) procedure in our hospital from Duct ligation (2), Lap assisted pull-thru (2), November 2009 to Octoberr 2013. During Choledochocyst excisiopn (1), Malrotation the TOPLAT procedure, a laparoscope (1), PDA ligation (2), Colectomy for NEC was placed through a Transumbilical stricture (1), Splenectomy (1), TEF repair (1), incision. Epidural puncture needle and Appendectomy (1). Non-absorbable 2-0 Prolene sutures (Ethicon products ) were used to close the RESULTS: All procedures were completed hernia extraperitoneally. A total of 210 successfully endoscopically. The device inguinal repairs were performed in 168 was used in all cases for tissue grasping, children (age range, 3 months to 12 years; dissection, and to seal all blood vessels median, 6.8 years; 145 boys, 23 girls). All taken during the procedure. The number operations were completed successfully of seals performed ranged from 10 to 140 by TOPLAT. The mean operating time was seals. There were no failed vessel seals 18 minutes (range, 10-25 minutes). In when the device cycled properly. In one this group of patients no postoperative case the device was exchanged after 80 bleeding, hydrocele, or scrotal edema was seals because of a fault in the device. The found, no known cases of postoperative second device performed properly. The testicular atrophy or hypotrophy nor hernia device was easily inserted through a 3mm recurrence on the symptomatic side. re-usable trocar. Five months after the operation, most CONCLUSION: A new 3mm vessel and patients had no obvious signs of a previous tissue sealer using a lower more efficient operation. energy profile and RF bipolar technology, P105: SINGLE SITE VERSUS MULTIPORT works safely and effectively in a wide LAPAROSCOPIC SURGERY FOR PEDIATRIC range of cases. The 3mm shaft and 1 COMPLICATED AND NON-COMPLICATED cm jaw design allow for excellent tissue APPENDICITIS: IS ONE BETTER? Charles J. manipulation and dissection in even Aprahamian, MD, Nerina M. DiSomma, BA, small premature infants, and allows entry Edmund Y. Yang, MD, Carl V. Asche, PhD, through a 3mm trocar limiting the number Jinma Ren, PhD, Angela M. Kao, BS, Jeremy of larger ports needed. The design limits S. McGarvey, MS, Sharon A. Kauzlarich, MA, the number of instrument changes as Richard H. Pearl, MD, Division of Pediatric all dissection and tissue sealing can be Surgery, Children’s Hospital of Illinois, done with a single instrument. Further University of Illinois College of Medicine at evaluation is necessary to determine the Peoria full range and application of the device BACKGROUND: Current literature supports P104: TRANSUMBILICAL ONE-PORT that single incision laparoscopy (S-LA) and LAPAROSCOPIC- ASSISTED TECHNIQUE conventional multiport laparoscopic (M- FOR INGUINAL HERNIA REPAIR IN LA) techniques have comparable outcomes Shiwang Li, MD, PhD, CHILDREN  for treatment of appendicitis, although Department of pediatric surgery, Tongji some reports express concern that S-LA Medical College, Huazhong University of causes more pain postoperatively. This Science and Technology, Wuhan, China, study evaluates the outcomes and cost of 430022

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S-LA as compared to M-LA for treatment 5%, p=0.42), or abscess rates (8% vs. 7%, of both complicated and non-complicated p=0.63) between S-LA and M-LA groups. appendicitis in a single institution over a Procedure time was significantly shorter concurrent time frame. in S-LA as compared to M-LA (30 vs. 40 minutes, p<0.001). Direct cost of hospital METHODS: An Institutional Review stay for S-LA was significantly less than Board–approved retrospective chart M-LA ($3736 vs. $5486, p <0.001). review was performed for all laparoscopic appendectomies with a preoperative CONCLUSION: Our data demonstrates diagnosis of appendicitis at the Children’s comparable clinical outcomes between Hospital of Illinois from September S-LA and M-LA, regardless of type of 2010 through December 2013. Interval appendicitis. However, S-LA has shorter appendectomies were excluded. Patient procedure time and a lower cost when demographics, type of laparoscopic compared to M-LA in both acute and appendectomy, intraoperative complicated appendicitis. Therefore the complications, duration of surgery, hospital use of S-LA is supported for surgeons stay, pain score, antibiotic use, narcotic use, comfortable with this technique. postoperative complications, and direct cost were collected and compared by statistical P106: COMPARATIVE STUDY BETWEEN analysis for the S-LA and M-LA populations. SINGLE-INCISION LAPAROSCOPIC The M-LA group was defined by patients INGUINAL HERNIA REPAIR AND who had appendectomy using 3 disposable CONVENTIONAL INGUINAL HERNIA Li GuiBin, Wang Li, trocars placed in different locations in the REPAIR IN CHILDREN  The 5th Centrial Hospital of TianJin China abdomen. For the S-LA group, patients who had an appendectomy through a single OBJECTIVE: To discuss the clinical umbilical incision were grouped together. application value of single-incision These were either performed with individual laparoscopic inguinal hernia repair and trocars or proprietary multiport device. conventional inguinal hernia repair in the Direct hospital costs were computed from treatment of children’s inguinal hernia. hospital charges using a cost to charge ratio (total annual direct costs divided by total METHODS: From Mon.2012 to Oct.2013,the annual charges) and converted to 2013 clinical data of 110 children with inguinal dollar costs using data from the Consumer hernia who underwent processus vaginalis Price Index. high ligation were analyzed retrospectively. Among them, there were 50 cases of RESULTS: A total of 341 patients underwent single-incision laparoscopic inguinal hernia laparoscopic appendectomies at our repair, 60 cases of conventional inguinal institution: S-LA (n=175) and M-LA (n=166). hernia repair. Type of procedure was determined by surgeon preference. According to the RESULTS: All the operations were surgeon’s diagnosis, 22% of patients successful. There is no significant had complicated appendicitis and difference in mean operative time, 76% non-complicated. There were no intraoperative blood loss, the duration of statistical differences in appendicitis type, hospital stay, hospital total cost between intraoperative complications, hospital stay, both groups, and no intraoperative or narcotic use, antibiotic use, pain score (3.4 postoperative complications are observed vs. 2.9, p=0.08), wound infection (7% vs. in both groups. Postoperative cosmetic outcome of laparoscopic group is better.

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Conclusions:The present study shows RESULTS: None of the patients were that single-incision laparoscopic inguinal underwent conversion from single- hernia repair is feasible, safe, and more site laparoscpy to open approach or aesthetically pleasing than conventional conventional laparoscopic surgery.The operation. operational time was 35.15±6.68 minutes. 23%of the unilateral inguinal hernia was P107: TRANSUMBILICAL SINGLE-SITE found contralateral inguinal hernia.The LAPAROSCOPIC INGUINAL HERNIA patients were discharged the day after INVERSION AND LIGATION IN GIRLS operation.Follow-up with all cases in 7 Hongwei xI, Shanxi Children’s Hospital,  months showed no recurrence and no Taiyuan, Shanxi, China incision complication. Objectives:Transumbilical single-site CONCLUSION: Transumbilical single-site laparoscopic inguinal hernia inversion and laparoscopic inguinal hernia inversion and ligation is a new approach for girls.We have ligation is a reliable, safe, and cosmetic done 13cases in our hospital since May herniorrhaphy for girls with inguinal hernia. 2013. P108: TO REMOVE ABDOMINAL Methods:13 girls with inguinal hernia, BENIGN TUMOR BY LAPAROSCOPIC aged from 6 months to 10years old(mean OPERATION Zhaozhu Li, MD, Dapeng 3.92±2.60 years) ,were performed with Jiang, MD, Shengyang Guan, MD, Mowen transumbilical single-incision laparoscopy. Yang, Master, Bo Xu, PhD, Department Operation steps: Endotracheal of Pediatric Surgery, the 2nd Affiliated anesthesia was conducted in all cases Hospital of Harbin Medical University in trendelenburg position. A 5-mm OBJECTIVES: Common abdominal benign incision was made on the right side of mass include: ovarian cysts or teratoma, the umbilicus and laparoscope (0°or 30° cyst of mesentery and omentum majus, Storz Germany)was introduced through enlarged mesenteric lymph node, the incision after pneumoperitoneum adrenal gland neoplasms, retroperitoneal (pressure 9-12mm Hg) established. A 3mm lymphangioma. To summarize the or 5mm incision was made on the left side advantage, experience, technique of of the umbilicus for regular needle holder. laparoscopic operations (LO). Under the direction of the laparoscope, it could be checked whether both internal METHODS: We analyzed the clinical rings have been closed. Then the bottom findings, histologic diagnosis, and surgical of the hernia sac was twisted and inversed outcomes in children. Before operation into the peritoneal cavity and hung by the patient who was suspect of abdominal the suture from the skin projection of mass had been examined by ultrasound, the internal ring. The final portion of the CT or MRI. We also exam tumor immunity operation is the ligation and resection of marker and selected the mass wasn’t the hernia sac.The hernia sac was removed shown malignant for LO. The patients had from the Trocar on the right side of the been general anaesthesia, and first trocar umbilicus.The suture was cut off after the was inserted through umbilicus. After needle penetrated out of the abdominal. found the mass, we select one or three The pneumoperitoneum and trocar were trocar technique to remove the tumor. removed. The umbilical incision was RESULTS: From January 2010 to June 2013, subcuticularly sutured with 5-0 absorbable 24 cases (10 girls, 14 boys) were treated. thread and adhered with medical adhesive.

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Age was 3 months to 12 years old. Of them, CASE: The patient was born with Eight mass were found in ovarian(6 cystic esophageal atresia and distal tumor , 2 teratoma); Intra-abdominal cystic tracheoesophageal fistula (EA/TEF), masses were found 3 in greater omentum, cloacal malformation, cross-fused 4 in mesentery, and in retroperitoneum, right renal ectopia, as well as vertebral 2 in cystic duplication of intestine, 2 in anomalies. She underwent thoracoscopic mega-cyst of hydrocele; Other mass were EA/TEF repair on day of life 1, along with 2 enlarged mesenteric lymph node and a proximal sigmoid colostomy. At 10 1 bilatera adrenal gland neoplasms. All months of age, we addressed the cloacal patients had been removed tumor or mass malformation by performing a total by LO and recovery. Operation time was urogenital mobilization in combination 0.5-3h. less blood lost. Follow up for 3-6 with a SIPES-assisted pull-through of the months, no complications occurred. rectum with anorectoplasty. One of the challenges of the case was the dissection CONCLUSIONS: LO for removing abdominal of the presacral tissue creating sufficient benign tumor has more advantage, space for the pull-through without injuring especially for cystic tumor. Complete the newly reconstructed vagina (figure A, excision was possible in almost all cases below). The rectum was pulled down to the despite the size, bringing a favorable anus using a large Foley catheter to gently outcome. guide the structures into place (figure P111: REPAIR OF CLOACAL B), facilitating a coloanal anastomosis MALFORMATION USING SINGLE- separate from the urogenital incision INCISION PEDIATRIC ENDOSURGERY AND (figure C). TOTAL UROGENITAL MOBILIZATION IN A RESULTS: The patient was discharged Allison PATIENT WITH VATER SYNDROME  home on postoperative day 3 and started Sweny, MD, Ariella Friedman, MD, Joseph a dilation program of the neorectum and J. Lopez, MD, Matthew E. Bronstein, MD, vagina 2 weeks later. The colostomy was Richard N. Schlussel, Oliver J. Muensterer, taken down at 6 weeks, at which time her MD, PhD, Divisions of Pediatric Surgery perineum had healed nicely (Figure D). She and Pediatric Urology, New York Medical continued to do well with spontaneous College, Maria Fareri Children’s Hospital bowel movements 3-5x a day. At 2 BACKGROUND: Single-incision months follow up, the dilation program pediatric endosurgery (SIPES) is usually had been weaned to once a week, and the performed for routine operations such patient had excellent functional as well as as appendectomy or nephrectomy. The cosmetic results. approach is less often used for complex CONCLUSION: Children with complex procedures requiring interdisciplinary syndromes including VATER and cloacal reconstructive surgery. To our knowledge, malformation can be managed with a SIPES-assisted cloacal repair has not advanced minimalinvasive techniques, been reported previously. including single-incision endosurgery. OBJECTIVE: To present the first cloacal When combining SIPES imperforate anus repair in a patient with VATER syndrome repair with urogenital reconstruction using a SIPES-assisted pullthrough and in the setting of cloacal malformation, urogenital mobilization technique. care must be taken not to injure the neovagina during the presacral dissection

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Poster Abstracts CONTINUED and the pull-through maneuver. Using to the right 13th rib. The cryptorchidectomy an interdisciplinary approach, excellent was performed using graspers, a bipolar outcome can be achieved despite the vessel sealing device and a 300 telescope. complexity of the malformation. RESULTS: 22 dogs and 3 cats that had a SPLC with a SILS port (15), TriPort (8) or Endocone (2) were included in the study. Median patient age was 365 days (range, 166-3285 days). Median weight was 18.9kg (range, 1.3-70kg). Median surgical time was 38 minutes (range, 15-70 minutes). Thirty- two testicles were removed (12 left, 6 right, and 7 bilateral). Four patients had one other abdominal surgical procedure performed concurrently during the SPLC. No intra- operative or post-operative complications were encountered in any of the patients. P112: SINGLE PORT LAPAROSCOPIC CRYPTORCHIDECTOMY IN DOGS AND CONCLUSIONS AND CLINICAL RELEVANCE: CATS: A MULTICENTER ANALYSIS OF 25 SPLC is a safe, feasible procedure that can CASES (2009-2014) Jeffrey J Runge, DVM, be performed on a wide range of patient DACVS, Philipp D Mayhew, BVMS, , DACVS, J. sizes and can be combined concurrently Brad Case, DVM, MS, DACVS, Ameet Singh, with other elective surgical procedures. DVM, DACVS, Kelli N Mayhew, VMD, DACVS, This technique provides an efficient, low William T Culp, VMD, DACVS, University morbidity and potentially less invasive of Pennsylvania, School of Veterinary alternative to the traditional open and Medicine, University of California at Davis, multi-port laparoscopic techniques School of Veterinary Medicine, College of described for the treatment canine and Veterinary Medicine, University of Florida, feline cryptorchidism. Gainesville, FL. Ontario Veterinary College, University of Guelph, Guelph P113: SINGLE-INCISION LAPAROSCOPIC INGUINAL HERNIOPLASTY IN GIRLS Mario OBJECTIVE: To describe the operative Mendoza-Sagaon, MD, Flurim Hamitaga, technique and evaluate the clinical MD, Natalia M Voumard, MD, Ospedale outcome for dogs and cats that underwent Regionale di Bellinzona e Valli single port laparoscopic cryptorchidectomy (SPLC) INTRODUCTION: Several laparoscopic procedures continue to evolve to DESIGN: Retrospective case series achieve minimal tissular damage, less post-operative pain and discomfort, ANIMALS: 25 client-owned dogs & cats and better esthetics. Laparoscopic METHODS: Dogs and cats that underwent inguinal hernioplasty in children is gaining a SPLC using 3 different commercially popularity, however, controversy still available single port devices were exist regarding its benefits and the rate retrospectively identified. A single port of recurrence. In this study we report our device was placed through a 1.5-3.0 cm technique of single-incision laparoscopic abdominal incision at either the region of hernioplasty in girls and analyze the the umbilicus or a 2-3 cm incision caudal results.

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METHODS: The files of all girls operated CONCLUSION: Single-incision laparoscopic by single-incision laparoscopic inguinal herniotomy in girls is a feasible hernioplasty in our institution were and safe technique with an excellent reviewed. Surgical technique: Briefly, post-operative outcome and esthetics. a vertical transumbilical incision Moreover, it allows to diagnose and to was performed. An 8 mmHg CO2 treat an asymptomatic contralateral pneumoperitoneum was achieved using patent processus vaginalis (incidence a small catheter with a stopcock valve. of 58% in this study) through a small A 5-mm 30o telescope and 3-mm umbilicalsingle-incision. instruments were used for the procedure. The patent processus vaginalis (PPV) P114: SINGLE-PORT LAPAROSCOPIC Alejandra was grasped and twisted with a 3mm ANORECTAL PULL-THROUGH  Parilli, MD, Gregory Contreras, MD, José Babcock clamp and ligated with a 00-PDS Gregorio Mejías, MD, Lisbeth Medina, MD, Endo-loop. Finally the tip of the sac was Hospital de Clínicas Caracas cauterized with a monopolar hook. This is 21 month old male infant, referred RESULTS: Since 2010, we have operated from another center, with anorectal 48 PPV in 29 girls, range of age was malformation and rectourethral fistula, from 11 months to 12 years (median carrying two mouths colostomy and 4-5 years). Pre-operatively, 19 patients 10kg weight. At physical examination presented clinicallyaright inguinal hernia, intergluteal cleft are evident, had a 8 a left inguinal hernia and in 2 patients good anal fovea and coccyx is palpable. was bilateral. Per-operatively, 17 girls In the distal colostrogram, the distance with a pre-operative unilateral inguinal between the rectum and anus is 2,7 cm hernia, presented a contralateral PPV approx. Was undergoing to single-port associated. Duration of surgery was laparoscopic anorectal pull-through, initially 40 minutes for a single PPV and using the Mini Gelpoint to umbilical after the first 10 cases decreased to 10 level and an accessory port level 3mm to15 minutes. All patients weretreated in left upper quadrant. Dissection of the the out-patient unit. No per-operative distal part and section of the fistula complications were recorded. There was with a white cartridge Echelon 45mm 1 recurrence in the 5th patient operated and 10mm Hemolock was performed for an unilateral right inguinal hernia because this was at the level of the and 6 months after surgery she was re- membranous urethra, 5mm trocar was operated using the same technique with placed at the level of the fovea anal and an excellent outcome. In the majority rectum decreased. The surgery last about of the cases return to normal physical 3 hours and the patient was discharged activity was achieved around the 2nd to on the third hospital day, progressing 4th post-operative day and analgesic satisfactorily. The single-port laparoscopic therapy was necessary only in the first two anorectal pull-through seems to be an postoperative days. Patients and parents efficient method that allows adequate were very satisfied with post-operative visualization and tissue manipulation in esthetics. Follow up is from 3 months to these patients. 3.5 years. To date, all patients are doing very good and no late recurrences have been reported.

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P115: SINGLE-PORT ACCESS major complications were encountered in LAPAROSCOPIC APPENDECTOMY IN the two groups. PEDIATRIC PATIENTS: A COMPARISON CONCLUSION: Postoperative outcome of STUDY WITH CONVENTIONAL SLA doesn’t seem to be superior to that LAPAROSCOPIC APPENDECTOMY Tae A. of CLA in pediatric populations. Safety and Kim, Jung Rae Cho, Won Me Kang, Soo feasibility of SLA in pediatric population, Min Ahn, Pediatric Surgery Clinic, Hallym however, are comparable with CLA. University Sacred Heart Hospital, Hallym University College of Medicine P116: LAPAROSCOPIC AND ROBOTIC- INTRODUCTION: Currently single-port ASSISTED GASTROESOPHAGEAL laparoscopic appendectomy became DISSOCIATION FOR RECURRENT popular in adult population. We sought to GASTROESOPHAGEAL REFLUX DISEASE Dan Parrish, MD, Shannon F. Rosati, MD, investigate the essential prerequisites for  Claudio Oiticica, MD, Patricia Lange, applying single-port access laparoscopic MD, David Lanning, MD, PhD, Children’s appendectomy (SLA) to children. Hospital of Richmond at Virginia MATERIALS & METHODS: Prospective Commonwealth University Medical Center non-randomized consecutive data INTRODUCTION: Laparoscopic Nissen collection was performed in children fundoplication has become a very who had undergone SLA or conventional important tool for controlling severe laparoscopic appendectomy (CLA) gastroesophageal reflux disease (GERD) from September 2009 to June 2013. in the pediatric population. However, Preoperative diagnosis was confirmed some patients, especially those that are by ultrasonography for all patients. The neurologically-impaired, may develop preoperative patient characteristics recurrent GERD that is refractory to and surgical outcomes were compared continued medical management. between the groups in terms of age, sex, BMI, leukocytosis, CRP, operation time, BACKGROUND: This is a 3 year old hospital stay, frequency of postoperative child with Cornelia de Lange syndrome intravenous painkiller usage, and and severe developmental delay who perioperative complications. underwent a laparoscopic Nissen fundoplication at 1 year of age. After RESULTS: SLA and CLA were completed in initially doing well, he began to have total of 120 patients; 60 patients in both repeated episodes of aspiration groups irrespectively. Both group showed pneumonia and severe reflux symptoms. no difference of demographics and While his fundoplication was intact, it had disease severity. Overall anesthesia time migrated into his mediastinum. was longer in SLA (m ± sd, 88.7 ± 21.5 min vs. 101.4 ± 27.4 min; p = 0.005) compared METHODS: The case began to CLA, whereas there was no differences laparoscopically with placement of a in operation time between groups 12-mm trocar in the umbilicus, and (60.8 ± 22.0 min vs. 68.4 ± 28.3 min; p 8-mm robotic trocars were placed in the = 0.098). There were no differences in right and left mid-abdomen using his postoperative hospital stay (3.1 ± 1.4 vs. 2.7 old surgical scars. An additional 8-mm ± 1.4 day; p = 0.114), pain killer usage (2.7 robotic trocar was placed just medial to ± 2.2 vs. 2.4 ± 1.7; p = 0.404) and medical the gastrostomy tube site for the robotic cost (p > 0.05) between the groups. No camera. Lysis of adhesions and repair

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Poster Abstracts CONTINUED of the hiatal hernia were performed CONCLUSIONS: For neurologically- with preservation of the gastrostomy impaired patients with recurrent reflux tube site, anterior and posterior vagus symptoms following fundoplication, nerves, as well as a large replaced left especially those that take most of their hepatic artery. Once the hiatus was feeds via a feeding tube, gastroesophageal closed, the jejunum was measured dissociation may be a reasonable about 30-cm distal to the ligament of alternative to performing multiple Treitz and was brought out through the fundoplications. By utilizing the da umbilical defect. It was marked in a way Vinci surgical robot with its articulating to delineate orientation then divided instruments and 3D visualization to with the Endo-GIA stapler. A side-to- perform the esophagojejunostomy, we side jejunojejunostomy was created were able to ensure precise placement of 30-cm distal to the tip of the Roux limb sutures while preserving the vagus nerves, with an Endo-GIA stapler. The bowel avoiding the need for a pyloroplasty, was then returned to the abdomen with maintaining the replaced hepatic artery, as the Roux limb passed in a retrocolic well as the gastrostomy site. position toward the hiatus. The Petersen defect was reapproximated with multiple P117: ROBOTIC-ASSISTED RESECTION interrupted 4-0 polyglactin sutures. An OF A LARGE POSTERIOR MEDIASTINAL Dan Parrish, MD, Shannon F. Endo-GIA stapler was fired across the GE MASS  Rosati, MD, Patricia Lange, MD, Claudio junction just above the fundoplication, Oiticica, MD, David Lanning, MD, PhD, again preserving the vagus nerves. At Children’s Hospital of Richmond at Virginia this point, the da Vinci robot was docked Commonwealth University Medical Center and the esophagojejunostomy was performed with multiple 4-0 polyglactin INTRODUCTION: Ganglioneuromas are rare, sutures in a single-layered anastomosis typically benign, tumors that arise from in an end to side manner after the tissues that have a neural crest cell origin. esophageal staple line was excised. The They typically occur in patients ranging in age esophagojejunostomy was confirmed from 10 to 40 years and are classically found to be airtight via a nasoenteric tube that in the adrenal glands. Ganglioneuromas are was left in place postoperatively as well frequently asymptomatic and discovered as a 10-mm Jackson-Pratt drain near this incidentally while another condition is being anastomosis. investigated. RESULTS: The patient returned to the BACKGROUND: An 18 year old woman pediatric intensive care unit and on who was being followed for scoliosis was postoperative day two, he underwent found to have a large left chest mass on contrast studies through the gastrostomy a chest x-ray. A chest CT scan revealed a and nasoenteric tubes, which 10 x 7.5 x 6.5-cm mass in the left upper demonstrated both anastomoses to chest, consistent with a bronchogenic cyst. be intact. His tube feeds were gradually She had no reports of fever, shortness advanced and he was discharged on of breath or chest pain, although she did postoperative day 6 tolerating gastrostomy endorse frequent feelings of left chest/ feeds at goal. On follow up, his reflux shoulder tightness. In an attempt to symptoms have resolved and his avoid a large thoracotomy or sternotomy, respiratory has improved. we proceeded with a robotic-assisted resection of the large mass.

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METHODS: The patient was laid supine CONCLUSIONS: Robotic-assisted thoracic with the left chest slightly elevated and surgery provides great 3D visualization her left arm extended above her head. and articulating instruments that can be She was intubated with a Carlens tube used to dissect large intrathoracic tumors for single lung ventilation. With the left and possibly avoid a large thoracotomy or lung deflated, an 8-mm robotic trocar sternotomy. was placed in the left midaxillary line, just below the axilla, and two 8-mm robotic P118: ESSENTIAL ELEMENTS IN trocars were placed in left anterior axillary PLANNING AND IMPLEMENTING A line and left midclavicular line, all in the MULTI-SPECIALTY PEDIATRIC ROBOT left inframammary fold. An additional ASSISTED SURGERY PROGRAM AT A Daniel 5-mm step trocar was placed as an LARGE CHILDREN’S HOSPITAL  B. Herz, MD, Karen A. Diefenbach, MD, assistant port, lower left midchest in the Jennifer A. Smith, RN, Joeseph D. Tobias, midaxillary line. Using hook cautery and MD, Christopher T. McKee, DO, Nationwide graspers with bipolar cautery, the tumor Children’s Hospital; Children’s Hospital at was dissected free from the surrounding Dartmouth tissues and the blood vessels cauterized. The mass seemed to arise from the left PURPOSE: Robotic assisted surgery (RAS) sympathetic ganglia chain, which had is growing tremendously in pediatric to be sacrificed for tumor removal. The surgery and urology. Program success, tumor extended into the apex of the left sustainability, and safety are dependent on chest and into the lower part of the left infrastructure. Currently there is a paucity neck just behind the head of the clavicle. of specific information about how to Once the tumor was dissected free from establish and maintain a safe and efficient the surrounding structures, an additional multi-specialty pediatric robotic surgery 2 x 2-cm mass was noted between the program. We discuss what we consider first and second rib and removed. The are key factors for building a safe and anterior axillary line trocar was removed successful multi-specialty pediatric RAS and widened to approximately 5 cm to program. allow specimen removal in an endocatch bag and a 28-French chest tube was METHODS: In the fall of 2012, the purchase placed. Final pathology revealed a of a robotic surgical system was approved ganglioneuroma. by a steering committee consisting of nursing, surgery, and finance hospital RESULTS: She was admitted to the step leadership. By December 2012, a robotic down unit postoperatively with PCA surgery director and nursing coordinator pain control. She was transitioned to were named, and a dedicated team was PO pain medicine with a general diet on identified and trained. Where appropriate, postoperative day one. Her chest tube children considered candidates for was removed and she was discharged minimally invasive surgery were referred on postoperative day two. She was seen to a RAS program surgeon. Multi-specialty in clinic the following month with some proctoring and credentialing guidelines left arm numbness and slight symptoms were established. All nursing team of Horner’s syndrome (left eye ptosis members were trained in circulating, when tired and left eye miosis). Eight scrub, and bedside assistant roles. Specific months later her Horner’s syndrome had emergency and communication protocols significantly improved. were established. A multifactorial strategy

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Poster Abstracts CONTINUED with surgical training and simulation, by premeditated implementation of the resident/fellow integration, pre-surgery above key essential elements. There is a case-specific practical training, pre- modest initial cost increase associated with operative huddles, robot-specific time use of the robot. out, intra-operative video and time stamp recording, post-operative case P119: THE USE OF ROBOTIC SURGERY review and mentoring, weekly team IN THORACIC SURGERY: PATIENT meetings to discuss quality improvement SATISFACTION IN CHILDREN AND ADULT was employed. A longitudinal robotic POPULATIONS IN A SINGLE INSTITUTION Shannon F. Rosati, MD, Dan database is recorded. Case-by-Case EXPERIENCE  Parrish, MD, Michael Poppe, BS, Karen review of reposable and disposable robotic Brown, BA, Patricia Lange, MD, Claudio equipment with quarterly cost data is Oiticica, MD, Anthony Cassano, MD, David reviewed for comparative effectiveness Lanning, M., PhD, Children’s Hospital of to identical open or purely laparoscopic Richmond at Virginia Commonwealth procedures. University Medical Center RESULTS: From January to December 2013, BACKGROUND: Many thoracic surgeries are 136 robot assisted laparoscopic surgeries maximally invasive procedures, requiring were performed. 135 were technically thoracotomies or median sternotomies to successful with 1 open conversion. remove large thymomas, or mediastinal Ninety-Two operations were performed masses. Due to the associated morbidity by 2 pediatric urologists, and Forty-Two of these procedures, the use of robotic by 3 pediatric surgeons. At the outset, surgery in both the pediatric and adult one pediatric urologist proctored and thoracic surgery populations is being credentialed the 4 other robotic surgeons. increasingly utilized. Due to the rarity Surgery types were: Dismembered of pediatric thoracic tumors, the use of Pyeloplasty, Ureteroneocystostomy with robotic thoracic surgery, performed in and without ureteral tapering, ipsilateral conjunction with adult thoracic surgeons, Ureteroureterostomy, Nephrectomy/ allows for additional experience and Heminephrectomy, Partial Nephrectomy, collaboration. We review our experience Continent Urinary Diversion, Bladder in robotic thoracic surgery, which we have Neck Reconstruction with and without performed in both adults and children Bladder Neck Sling, Gastric Sleeve, over the past five years, and reviewed the Cholecystectomy, Nissen Fundoplication, satisfaction of both the patients and the and Ileocecectomy/Colectomy. No parents of children who have undergone major robot-specific complications robotic thoracic surgery. were recorded. Four (3.7%) surgical complications were managed successfully. METHODS: We conducted a retrospective Two near miss events identified during the review of our adult and pediatric thoracic robot-specific time out were recorded. robotic surgery cases over the past An average increase of 12% in the charges five years. Additionally, we conducted associated with the use of the robot was telephone interviews with the patients recorded over a 12 month period. and the parents of the pediatric patients to ascertain their experience with robotic CONCLUSION: A multispecialty pediatric surgery. After obtaining verbal consent RAS program at large children’s hospital over the phone, we inquired about their can be successful, safe, and sustainable overall satisfaction with robotic surgery,

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Poster Abstracts CONTINUED their post operative pain, if they were surgeons work together on these cases satisfied with the cosmetic appearance can increase their robotic experience and of their scars, and if they would undergo complement both programs. robotic surgery again. P120: ROBOTIC-ASSISTED RESULTS: Forty-two patients have SINGLE-INCISION LAPAROSCOPIC undergone robotic thoracic surgery, CHOLECYSTECTOMY IN A PEDIATRIC 27 adults and 15 children. Only one of PATIENT; FROM MULTI-PORT TO SINGLE- these procedures was unsuccessful and PORT WITH INCREASED CONFIDENCE required an additional operation. None Terrence M. Rager, MD, MS, Victoria K. of the remaining 41 operations had to be Pepper, MD, Marc P. Michalsky, MD, Karen converted to open procedures. Twenty- A. Diefenbach, MD, Nationwide Children’s three patients had thymectomies (8 Hospital, Columbus, Ohio children, 15 adults), 14 had mediastinal PURPOSE: Single-port laparoscopic masses or cysts (4 children, 10 adults), cholecystectomy has been reported 1 pediatric patient had a left upper in both the pediatric and adult surgical lobectomy, 1 pediatric patient had a populations. However, its widespread resection of a diaphragm tumor, 1 patient adoption has been limited in part by had the insertion of a LV lead, and 1 patient a steep learning curve due to well- had a LIMA takedown. 23 patients and described technical limitations. These parents could be contacted. All 23 patients limitations include instrument collision, stated they were pleased with the cosmetic poor visualization, a loss of ability to appearance of their incisions or their triangulate, and paradoxical instrument child’s incisions. Also, 22/23 responded control due to crossing of instruments that they would undergo robotic surgery as they traverse the single incision. We again, or have their child undergo robotic demonstrate a robotic-assisted single surgery again. Satisfaction with their incision laparoscopic cholecystectomy overall experience or their child’s overall in a pediatric patient performed in the experience on a numbered scale from 1-10, absence of these technical limitations. with 10 being the most satisfied ranged The increasing availability of robotic- from 4-10, with an average of 8.3. Patients assistance may lead to increased adoption rated their post operative pain or the post of robotic-assisted single-incision pediatric operative pain of their child on a scale from endosurgery (R-SIPES). 1-10 with 10 being the worst pain ranged from 0-9, with an average of 6.2. METHODS: A four-port robotic-assisted laparoscopic (R-L/S) cholecystectomy CONCLUSIONS: Robotic surgery performed was performed using two 5mm, one 8 in both adults and children allows for mm, and one 12 mm ports. An R-SIPES increased control and mobility when cholecystectomy was performed using a performing operations in small, confined single multi-lumen port placed through spaces, as is the case for thymectomy a 2.5 cm umbilical incision. Video of the and mediastinal mass resection. Patients intra-abdominal portions of each surgery appear to be satisfied with their overall was recorded and are presented for visual outcomes. Robotic surgery represents an comparison. The placement and removal alternative to VATS or open procedures of the multi-lumen port used in the in the adult and pediatric populations. R-SIPES case was also recorded and is Lastly, having pediatric and adult thoracic presented.

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Poster Abstracts CONTINUED

RESULTS: Side-by-side comparison RESULTS: 201 children underwent a rigid demonstrates that both robotic-assisted bronchoscopy for a suspected FBA (133 surgical techniques allow the surgeon to M, 68 F). The mean age was 2.83 years have nearly equivalent triangulation ability (1-17). 64 patients had a FB in right main and anatomic visualization. Advances in bronchus, 62 in left main bronchus and robotic instrumentation and software have 18 in the trachea. Remaining 57 patients also eliminated the technical limitations with bronchoscopy had no FB. The main of instrument collision as well as the symptom was cough. The aspirated paradoxical and counter-intuitive hand- FBs are organic materials (nuts, seeds, instrument movements that are often other food material) in 123 and inorganic associated with single incision laparoscopic subjects (jewels, toy parts etc) in 21 cases. surgery. The main symptoms were cyanosis in 26, stridor in 47, dyspnea in 59, fever CONCLUSION: Using cholecystectomy, in 6 and cough in 67 patients. Cyanosis we demonstrate that the application of and dyspnea were significantly more robotic-assistance to SIPES eliminates in patients with tracheal FBA. Organic many of the limitations associated with FBs causes significantly more dyspnea laparoscopic single incision surgery, which and cough than the inorganics. The may result in increased utilization of single mean age of the patients with organic incision laparoscopic surgeries in the FBA is significantly less than those with future. inorganic FBA (2.3 vs 6.7). 63 patients with P121: BRONCHOSCOPIC REMOVAL OF bronchoscopy resided (49 with FBA) in FOREIGN BODIES: FACTORS AFFECTING urban, 67 in suburban (43 with FBA) and THE MANAGEMENT Burak Tander, MD, 63 in rural (49 with FBA) areas. Only one Dilek Demirel, MD, Bahar Önaksoy, MD, patient needed a re-bronchoscopy for Mithat Gunaydin, MD, Unal Bicakci, MD, Riza failed FB removal (0.4%). Rizalar, MD, Ender Ariturk, MD, Ferit Bernay, CONCLUSION: Rigid bronchoscopy is the MD, Ondokuz Mayis University, Department method of choice for both diagnosis and of Pediatric Surgery, Samsun, Turkey treatment of patients with suspected FBA. AIM: In children, foreign body aspiration The failure rate of removal is extremely (FBA) is common. It is not clear yet, which low. The radiologic images are frequently demographic and clinic factors are more non-informative. Therefore, in case of prominent in the FBA and indication for doubt, bronchoscopic examination is bronchoscopy. necessary. Residence of the patients seems to have no effect on likelihood of METHODS: In children with FBA; gender, FBA. Younger children are more likely to age, symptoms, type of residence aspirate organic FBs. (urban vs rural), localization and type of foreign body, the radiologic appearance, P122: THORACOSCOPIC ESOPHAGEAL outcome were evaluated. In all cases, a RESECTION AND ANASTOMOSIS IN AN rigid bronchoscopy was performed and INFANT WITH CONGENITAL ESOPHAGEAL all foreign bodies were removed with an STENOSIS Burak Tander, MD, Ogunc optic or regular bronchoscopic forceps. Apaydin, MD, Ferit Bernay, MD, Ondokuz Descriptive tests and ANOVA were made to Mayis University, Department of Pediatric analyze the determining factors on foreign Surgery, Samsun-Turkey body ingestion.

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Poster Abstracts CONTINUED

AIM: We report a 1 year old infant with children. The safety and effectiveness of congenital esophageal stenosis treated by thoracoscopic diaphragmatic plication a thoracoscopic esophageal resection and for diaphragmatic eventration in such end-to-end anastomosis. patients remain unclear because of possible concerns about serious CASE REPORT: One year male infant complication such as intraoperative was admitted with emesis and failure circulatory or respiratory failure and air to thrive to the Department of embolism caused by right to left shunt. Pediatric Gastroenterology. His upper The aim of the study was to clarify the gastrointestinal contrast study revealed a role of thoracoscopic diaphragmatic 2.5 cm stenosis at the distal portion of the plication for diaphragmatic eventration esophagus. At thoracoscopy, the stenosis after surgery for CHD in children. was identified at the distal part. The stenotic segment was resected. The two PATIENTS & METHODS: Retrospective ends of the esophagus was dissected and chart review was conducted in pediatric freed. An end-to-end anastomosis was patients who underwent thoracoscpic performed with interrupted sutures by diaphragmatic plication for diaphragmatic means of intracorporeal suture tying and eventration after surgery for CHD from extracorporeal knot-pushing techniques. 2008 to 2013 at our department. No complication was encountered. The RESULTS: Five patients, 4 boys and 1 girl, postoperative course was uneventful were identified during the study period. and the patient was discharged at 12th Median age and body weight of the postoperative day. The patient is doing patients at thoracoscopic diaphragmatic well three years after surgery with normal plication were 7.6 (1.8-17.9) months and grow up and no swallowing difficulty. 6.6 (3.0-7.1) kg. All patients had left side CONCLUSION: Thoracoscopic esophageal diaphragmatic eventration. Associated resection and anastomosis is safe and CHDs are pulmonary artery atresia in effective in infants with in congenital 3 patient, and truncus arteriosus and esophageal stenosis. double outlet right ventricle in 1 patient, respectively. Two patients received P123: THORACOSCOPIC DIAPHRAGMATIC previous ipsilateral thoracotomy for PLICATION FOR DIAPHRAGMATIC Blalock-Taussig shunt. Three patients EVENTRATION AFTER SURGERY had right to left shunt after Glenn FOR CONGENITAL HEART DISEASE operation at thoracoscopic diaphragmatic Jun Fujishiro, MD, PhD, IN CHILDREN  plication. Four of 5 patients needed Tetsuya Ishimaru, MD, PhD, Masahiko mechanical respiratory supports before Sugiyama, MD, PhD, Mari Arai, MD, thoracoscopic diaphragmatic plication. PhD, Chizue Uotani, MD, PhD, Mariko Median duration between previous Yoshida, MD, Kyohei Miyakawa, MD, Tomo CHD operation and thoracoscopic Kakihara, MD, Tadashi Iwanaka, MD, PhD, diaphragmatic plication were 56 (15-169) Department of Pediatric Surgery, Faculty days. At thoracoscopic diaphragmatic of Medicine, The University of Tokyo plication, 3 of 5 patients attempted OBJECTIVE: Diaphragmatic eventration one-lung ventilation using bronchial caused by phrenic nerve palsy is a rare blocker and all received CO2insufflation but serious complication after surgery (4 mmHg) for ipsilateral lung collapse. for congenital heart disease (CHD) in Thoracoscopic diaphragmatic plication

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Poster Abstracts CONTINUED was performed using 3 or 4 ports. P124: THORACOSCOPIC RESECTION OF A Sufficient operative field was kept by VERY RARE EXTRA-LOBAR PULMONARY CO2insufflation in all patients regardless SEQUESTRATION IN A 2-YEAR-OLD BOY of one-lung ventilation, and no patients Kazuto Suda1, Hiroyuki Koga1, Manabu were converted to open operation. Okawada1, Takashi Doi1, Kenji Suzuki2, Intraoperative arterial blood pH and Ryohei Kuwatsuru3, Atsushi Arakawa4, PCO2were 7.29 (7.22-7.39) and 51 (44.5- Atsuyuki Yamataka1, 1Department 67) mmHg. In one patient, dislodgement of Pediatric Surgery,2Department of of bronchial blocker resulted in severe General Thoracic Surgery,3Department respiratory and circulatory failure just of Radiology,4Department of Human before starting the operation. While Pathology of Juntendo University School of this patient needed intraoperative NO Medicine, Tokyo, Japan inhalation, the patient also underwent AIM: We report the thoracoscopic resection thoracoscopic diaphragmatic plication of a very rare case of right extra-lobar after stabilization. Postoperatively, one pulmonary sequestration. patient was extubated at the operating room, 2 were on the day of operation, CASE REPORT: A solid mass was identified and 2 were on 1 and 2 postoperative days, in the right mediastinum of a male respectively. One patient experienced fetus at 30 weeks’ gestation on fetal minor pneumothorax and pleural magnetic resonance imaging (MRI). effusion, which resolved spontaneously At 2 months old, a right pulmonary without drainage. Air embolism was not sequestration comprising a hypervascular observed in any patient. No recurrence racemous angiomatous arterial-venous of diaphragmatic eventration was malformation (RAVM) with a feeding experienced in these 5 patients after the artery coming from the thoracic aorta thoracoscopic plication. was diagnosed on enhanced computed tomography (CT). The sequestration CONCLUSIONS: Our results show that was initially considered to be intra- thoracoscopic diaphragmatic plication lobar since it drained into the inferior is safe and effective procedure for right basal pulmonary vein rather than diaphragmatic eventration after surgery the inferior vena cava or azygos vein as for CHD in children. Considering the extra-lobar sequestrations usually do. serious complication of bronchial When referred for further management, blocker dislodgement and the sufficient he was well and asymptomatic, however, operative field kept by CO2insufflation his cardiothoracic ratio (CTR) on chest without one-lung ventilation, bronchial radiography was elevated as a result of blocker is unnecessary for this procedure. systemic drainage from the RAVM in With safety and good outcome of the sequestration overloading the left the procedure, early thoracoscopic atrium. Thoracoscopic resection was diaphragmatic plication is a good option performed when 2 years old. Briefly, for pediatric patients with symptomatic conventional thoracoscopy under general diaphragmatic eventration after surgery anesthesia with single lung ventilation for CHD. was performed with the patient placed laterally. The sequestration was confirmed to be extra-lobar, was located in the right inferior mediastinum between

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Poster Abstracts CONTINUED the right diaphragm and the inferior lobe history of vomiting , regurgitation , and was found to drain into the inferior dysphagia , and weight loss . Studies right basal pulmonary vein, as shown on included , esophagoscopy, barium preoperative CT. The sequestration was esophagogram, contrast tomography retracted gently posteriorly and elevated with subclavian reconstruction . An with endoscopic peanut swabs without Aberrant retroesophageal subclavian the use of endoscopic Kelly retractors as artery was diagnosed. Patient was taken to they may potentially cause injury to the thoracoscopic ligation of the artery without lung parenchyma and cause hemorrhage, complications. After the procedure, the which would be impossible to control. The patient was completely relieved from feeding artery from the thoracic aorta symptoms , tolerated oral alimentation and the drainage vein were very close without obstructive symptoms , and right but with great caution, were successfully arm perfussion was preserved. separated, hemo-clipped and divided. Surgical management of ARSA includes The sequestration was extracted through ligation of the artery with or without one of the trocar sites. No chest tube reimplantation through thoracotomy or was inserted. Postoperatively, CTR sternotomy. Thoracoscopic ligation of the improved from a preoperative 53% to ARSA can show similar results compared 47%. Histopathology showed that the with the open approach. sequestration comprised increased abnormal thick and thin walled arteries P126: THORACOSCOPIC RESECTION OF and veins. A DISTAL OESOPHAGEAL DUPLICATION Leel CONCLUSION: This is the first report CYST IN A 10-MONTH-OLD INFANT  Nellihela, Mr., M. Agrawal, Ms., D. Drake, of an extra-lobar sequestration with Mr., N. Bouhadiba, Mr., Evelina London hypervascularity due to an increase of Children’s Hospital, Guy’s and St Thomas’ abnormal vessels being excised safely NHS Foundation Trust, UK using thoracoscopy. Postoperative recovery was uneventful and cardiac load AIM: Literature related to thoracoscopic was decreased. excision of oesophageal duplication cyst (ODC) are rare and so far not being P125: THORACOSCOPIC MANAGEMENT reported in the UK. We are reporting the OF ABERRANT RIGHT SUBCLAVIAN successful a full thoracoscopic resection ARTERY: CASE REPORT I. Molina, MD, F. ODC in a ten month old infant. Fierro, MD, S. Castañeda, MD, P. Jaimes, MD, Universidad Naccional de Colombia, METHOD: A baby boy weighing 2.8Kg Fundación Hospital de la Misericoridia was born at 38 week gestation. Prenatal ultrasonography had shown an intra- Aberrant retroesophageal subclavian thoracic cystic lesion. The ultrasonography artery (ARSA) is a type of vascular ring that on day 2 of life suggest a possible rarely produces symptoms , the majority bronchogenicor duplication cyst. of cases reported in the literature present Upper GI contrast at 3 month of age with dysphagia and vomiting due to showed an extrinsic indentation of the esophagic compression. Other symptoms distal oesophagus by the cyst but no may include apnea, cyanosis, and syncope . communication with the oesophageal We present the case of an 8-year-old lumen. MRI scan at the age of 6 month girl that presented with a 2 month confirm anODC.

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Poster Abstracts CONTINUED

At 10 month, under general anaesthesia We would like to introduce our first thoracoscopy was performed with experience of pectus excavatum 5mm three-port system. A camera was treatment applying minimal invasive Nuss inserted via a 5-mm trocar at the sixth procedure. intercostal space, between mid-axillary Patients with pectum excavatum that to posterior axillary line. The other two underwent thoracoscope-assisted Nuss 5-mm trocars were positioned at the fifth procedures in our department from and seventh intercostal spaces, in the January 2013 were analyzed retrospectively. mid axillary line. Cystic mass was found Surgical technique, operation duration and at the distal oesophagus to right side of blood loss were analyzed. Postoperative the oesophagus. Complete resection of complication, hospital stay length and the cyst was carried out without damaging recovery were evaluated. the oesophagus using hook and scissors. The vagus nerve were clearly identified There were 32 cases, 17 boys and 15 girls, and preserved, the cyst was excised from 4 to 16 years old. With the guidance completely and intact, muscular defect of thoracoscope, all procedures were was closed with 4 0 vicryl continuous completed smoothly without occurrence stich. Cystic fluid was aspirated to allow of pericardium, heart, great vessels or retrieval. 10Fr chest drain inserted and lung injury. All patients were kept stable connected to an underwater seal. vital sings during operation. The operative times ranged from 45 to 75 minutes and 5 RESULTS: The patient was discharged ml to 15 ml blood loss were recorder. The on the third postoperative day without postoperative pain was most severe on the complications. The pathology confirmed first postoperative day and alleviated as the diagnosis of foregut duplication cyst the time passed. On the third postoperative with no evidence of neoplasia. The video day, the pain alleviated significantly. No film is presented. postoperative pneumonia, pleural effusion CONCLUSION: We recommend or other complication occurred. Patients thoracoscopic approach to resect ODC. It discharged from hospital 4 to 6 days after provides a good access, better visualisation operation. All patients did well in the short of the cyst by magnification. Patient have term follow-up with obvious improvement a shorter hospital with good cosmetic in chest shape. outcome. CONCLUSIONS: Thoracoscopy-assisted P128: FIRST EXPERIENCE WITH Nuss operation has many advantages MINIMALLY INVASIVE NUSS REPAIR including small and masked incision, short OF PECTUM EXCAVATUM IN CHILDREN operative time, minimal blood loss, fast Damir Jenalayev, Bulat Nagimanov, Agabek recovery, less trauma, and satisfactory Chikinayev, Vladislav Orlovsky, National outcomes of repair. Nuss is a safe and Research Center for Mother and Child reliable technique for repair of pectus Health excavatum. Pectus excavatum - is the most common defect in development of the chest and is more than 90% of all deformities of the chest.

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Poster Abstracts CONTINUED

P129: THORACOSCOPIC CHEST WALL MASS CONCLUSION: Minimally invasive resection EXCISION IN A FORMER PREMATURE of a benign chest wall mass is a safe INFANT Jeffrey Zitsman, MD, Jeffrey technique that allows limited rib resection Gander, MD, Julie Monteagudo, MD, Steven to minimize chest wall instability and may Rothenberg, MD, Morgan Stanley Children’s reduce risk for respiratory compromise and Hospital of New York Presbyterian, spinal deformity post-op. Columbia University Medical Center, New York, NY, USA; Rocky Mountain Hospital for P130: THORACOSCOPIC Children at Presbyterian/St. Luke’s Medical SEGMENTECTOMY OF INTRALOBAR Center, Denver, CO, USA SEQUESTRATIONS THROUGH DYE DELIMITATION X. Tarrado, MD, L. Saura, INTRODUCTION: Mesenchymal hamartoma MD, Bejarano M., MD, J.M. Ribó MD, M. (MH) of the chest wall in the newborn is a Castañón MD, Hospital Sant Joan de Déu. rare tumor of infancy notable for distinct Universitat de Barcelona. Barcelona radiographic findings. MH is usually benign PURPOSE: The surgical resection of but may cause respiratory compromise due congenital lung lesions has evolved with to extension into the pleural cavity. Surgical the minimal invasive and the parenchyma- excision is standard therapy for MH. preserving techniques. Although these METHODS: On routine ultrasound a child in lesions are usually small and its limits can utero was noted to have a left intrathoracic be suspected by direct vision or palpation, mass. MRI suggested mass was arising there is not a clear anatomic landmark from rib tissue. The child was delivered to resect them. We present a new at 27 weeks gestation after her mother technique that helps to define the limits suffered premature rupture of membranes. of intralobar sequestrations (ILS) leading CPAP was administered for mild respiratory to a safe and anatomic segmentectomy distress. CXR confirmed the mass, arising thoracoscopically. from the left 6th rib posteriorly. Surgery PATIENTS & METHODS: We have was deferred to allow the baby to grow. A retrospectively reviewed this thoracoscopic approach was planned. segmentectomy technique on four cases PROCEDURE: At age 4 months the patient (two boys and two girls) the last two underwent thoracoscopic resection of the years. Three cases had a mean age of 10 left posterior chest wall mass. 3 ports were months and the last one was 15 years- used (4mm x 2, 5mm x 1). Frozen section old. Preoperative diagnosis were ILS in biopsy confirmed the diagnosis. The mass three and an hybrid lesion in one. After was resected with a limited section of rib. dissecting the aberrant arterial vessel, a The mass was morcellated from within a dye was injected through it to stain the 10mm retrieval bag and removed. The free sequestration. Then it was marked with rib laterally was fixed to the chest wall. A monopolar cautery and resected with an 12Fr chest tube was left in the pleural space. endostapler. RESULTS: All gross hamartoma was RESULTS: In three cases we obtained resected, along with a limited segment of a good delimitation of the ILS so the rib. The hospital course was uneventful procedure was carried out as described. and the patient was discharged to home In one case the artery was so thin that we on POD #4. She developed RSV 3 weeks could not inject through it properly. All post-op and was hospitalized for 48hrs but cases were completed throracoscopically, is well 3 months post op. with a mean operative time of 120’. Mean

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Poster Abstracts CONTINUED thoracic drainage time was 2,5 days starting the conservative treatment using and mean discharge day was the 3rd the vacuum bell. The device was used for POD. There where no intraoperative or 30 minutes twice a day. postoperative complications and with RESULTS: 6 patients were included. The a mean follow-up time of 16 months 3D-phtography enabled an objective they are all asympthomatic and control assessment of the elevation of the CT scans 1 year postoperatively show no sternum, which was improved in the residual disease. median up to 16,8 mm. CONCLUSIONS: In our experience dyeing CONCLUSION: 3D photography represents of ILS is a safe and effective technique a valuable alternative to thoracal CT-scan to define the limits of intralobar to assess the degree of PE. It is a radiation- sequestrations leading to a anatomic free, reliable and a high qualitative tool to resection thoracoscopically. track the clinical course of the conservative P131: THE VACUUM BELL FOR treatment of PE by the vacuum bell. CONSERVATIVE TREATMENT OF PECTUS P132: MANAGEMENT OF PEDIATRIC EXCAVATUM: ASSESSMENT OF ITS PRIMARY SPONTANEOUS EFFICACY BY THREE-DIMENSIONAL PNEUMOTHORAX IN A TERTIARY PHOTOGRAPHY Sergio B. Sesia, MD, José Branco-Salvador, Ruben Matthias Kreutz, MD, Frank-Martin CENTER  Lamas-Pinheiro, MD, Catarina Ferraz, Haecker, MD, University Children’s Hospital MD, Luisa G Vaz, MD, Inês Azevedo MD, of Basel, Department of Paediatric Surgery, PhD, Tiago Henriques-Coelho MD, PhD, Basel, Switzerland; University of Basel, Pediatric Surgery Department & Pediatric Department of Craniomaxillofacial Surgery, Department, Faculty of Medicine, Hospital Basel, Switzerland de São João, Porto, Portugal BACKGROUND: The conservative INTRODUCTION: Treatment of Pediatric treatment of pectus excavatum (PE) Primary Spontaneous Pneumothorax (PSP) using the vacuum bell represents a can be achieved conservatively, through valid alternative to surgical minimally oxygen therapy, chest tube drainage or invasive repair (MIRPE) technique by thoracocentesis, or surgically, by using Nuss for selected patients. The objective video-assisted thoracic surgery (VATS). assessment of its efficacy (elevation of the The best therapeutic algorithm for PSP sternum) is still a challenge. Until today, continues to be sought, as well as the role accurate measurement of the degree of PE of thoracic Computed Tomography (CT) is only ensured by a computer tomography in its management. The aim of this study of the chest. This study was performed was to review the approach to pediatric to evaluate the reliability and quality of patients with PSP in a tertiary center. the three-dimensional (3D) photography to assess the improvement of the funnel MATERIAL & METHODS: Observational chest under the vacuum bell therapy. Study, with retrospective analysis of 25 pediatric patients with a diagnosis of PSP, PATIENTS & METHODS: After institutional admitted in the first episode and treated in review board approval and written a third level care Hospital, between January consent, the chest of six children with 1st 2006 and December 31st 2012. Data pectus excavatum was analysed by 3D was obtained from clinical processes of photography before and 6 month after the selected patients and were analyzed

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Poster Abstracts CONTINUED by demographic, diagnosis, treatment and were carried out before surgery, and then follow-up perspective. followed with thoracoscopic resection of esophageal stricture, esophageal RESULTS: PSP occurred mainly in the anastomosis without conversion to male gender at the left hemithorax. laparotomy . Initial episodes were treated with oxygenotherapy alone (n=8), chest tube RESULTS: All 8 patients performed drainage (n=12) and VATS (n=5). Chest typical symptoms with repeated sickness drainage had a failure rate of 25% in the without gastric juice and bile, especially first episode and 100% in the recurrence with complementary feeding. Patients group. The method that presented higher began to appear typical clinical symptoms therapeutic success was VATS (100%). on average 6 months after birth and Patients with blebs in CT were those that generally affect healthy development. significantly recurred more frequently. With Barium meal examination, 3 among 8 Apical resection with mechanical patients showed a typical “pendulum sign pleurodesis was the preferred surgical “ performance, 2 showed thin line change technique. between the esophagus and cardia , and others suspected achalasia 3 cases were CONCLUSION: The best treatment for first performed esophagoscopic examinations PSP in pediatric patients seems to be non- in surgerys, all showed a sudden expansion surgical, namely thoracocenthesis or chest of esophageal stenosis and without passing drainage. VAST is the best option for the the stenosis segment. Patients take the recurrent episodes. The role of CT in the left side of the prone position during the management of these patients appears operations, a rigid and inflexible mass to be crucial in identifying patients with in the narrow section were detected on blebs. The using of VATS in asymptomatic the esophageal wall, which located lower patients with blebs in CT is still a matter of esophagus away from the cardia about2.0 debate. ~ 4.0cm. The narrow section is about 0.5 P133: THORACOSCOPIC ESOPHAGECTOMY ~ 1.0cm in length, and about 0.2 ~ 0.4cm FOR CHILDREN`S CONGENITAL in diameter. Diameter of the esophagus TRACHEOBRONCHIAL CARTILAGE near terminal expansion is about 2.0 ~ REMNANTS OF ESOPHAGUS Shuli Liu, 3.0cm, distal esophageal diameter is 1.0 KaoPing Guan, Long Li, Capital Institute of ~ 1.2cm. We resected stenosis segment, Pediatrics, interrupted full-thickness esophageal anastomosis with 5-0 PDS and reserve an OBJECTIVE: To investigate the clinical indwelling gastric tube 10. Among them, 4 manifestation, diagnostic characteristics patients appeared dysphagia after 1 month and to evaluate the thoracoscopic surgery, esophageal graphy showed the esophagectomy for congenital lower esophageal stricture, and symptoms tracheobronchial cartilage remnants of were mitigated after esophageal balloon esophagus . dilatation. METHODS: A retrospective study of 8 cases CONCLUSIONS: Vomiting history while between 1.1 to 4 years old with congenital complementary feeding and pendulum tracheobronchial cartilage remnants symptoms and thread-like changes of esophagus were collected in our between the esophagus and cardia by department since Mar, 2008 to september, barium meal examination could be 2013. Preoperative imaging or endoscopy

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Poster Abstracts CONTINUED regarded as preoperative diagnosis of upper lobe, the middle lobe as well as congenital tracheobronchial cartilage segments S7 and S10 in the lower lobewere remnants of esophagus. Esophagoscopic free of disease. examination would help the diagnosis. The child was operated at the age of Surgery is the only reliable way for 4 months, with a weight of 5.3 kg. A treatment, and the patient nutrition thoracoscopy, under lung exclusion and condition should be adjusted before CO2 pneumothorax, was performed surgery. Thoracoscopic resection of with a 5mm telescope and three 5 mm esophageal stricture could get a clear instruments ports. The greater fissure surgical field, less bleeding, light chest was incomplete and the malformation wall injury, little effect on the lungs and clearly seen bridging S6 and S3, whose reducing the chance of postoperative segmental artery arouse from A6. Using pneumonia. The children would got a the 3D reconstruction as a map, the various quickly recovery after the thoracoscopic segmental arteries and corresponding surgery for less trauma in both bronchi were dissected and divided consciousness and chest. respectively with a tissue sealing device P134: 3D RECONSTRUCTION and clips, thus allowing the resection of AIDED THORACOSCOPIC S3 from the upper lobe, S6,8and 9 from MULTISEGMENTECTOMY AS A LUNG- the lower, using the tissue sealing device SPARING PROCEDURE IN A CASE OF to divide the parenchyma. S3, S6 and the MULTILOBAR PULMONARY CCAM Paul basal segments were divided individually to Philippe, MD, Cindy Gomes Ferreira, facilitate exposure of the next segments, MD, Luc Soler, PhD, Miriam Raffel, MD, and extracted at the end of the procedure Jerry Kieffer, MD, Brigitte Crochet, MD, through an enlarged port-site. A good Clinique Pédiatrique, Centre Hospitalier reexpansion of the remaining segments S1, de Luxembourg, Luxembourg and IHU, 2 and 7 and middle lobe was documented, IRCAD,Strasbourg,France S10 (postero-lateral segment) being non functional. This extensive procedure lasted Congenital Pulmonary Malformations are 5 hours. Blood loss was moderate during the most common reason for pulmonary the dissection, and the child received a resection in children. If most of them have 10cc/kg transfusion. The post-operative been treated by lobectomies, there is a course was uneventful, with no air leak trend toward limited resections such as allowing for chest tube could removal anatomical segmentectomies. We present on POD 2and the child discharged on a case of antenatally diagnosed cystic POD 4. She has been asymptomatic adenomatoid malformation involving both since. A CTScan at 6 month confirms the upper and lower lobes of the right the completeness of the resection and lung, for which a bilobectomy would have the viability of the preserved segments. sacrificed a huge amount of normal lung Pathology confirmed a Stocker type 1 tissue, thus enforcing the indication of a CCAM. multisegmentectomy. In order to asses the anatomy of the malformation and define 3D rendering provideda clear anatomical the various segments involved, a three delineation of the anomaly and the dimensional reconstruction using a specific lung segments, allowing the planning software was used. The reconstruction of a lung-sparing procedure. Multiple showed that segments S1 and S2 in the segmentectomies arepossible with

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Poster Abstracts CONTINUED meticulous thoracoscopic dissection of of sweeping the lung free from the chest the hilar elements. The delineation of wall in empyema. the anomaly was not easy to identify CONCLUSION: attention to how best to macroscopically, and the knowledge of the modify the type of ventilation, selection 3 dimensional expected limits proved very of the best location for the working ports, important to ensure complete resection and decompression of hyperinflated lung as well as maximum lung preservation. lesions, facilitates the ease and safety Progresses in our ability to finely dissect of thoracoscopic surgery in infants and the anatomy minimally invasively and children improved imaging might improve our ability to preserve functional lung tissue P137: ENDOSCOPIC DIAPHRAGMATIC while assuring the completeness of the HERNIA REPAIR BY USING MESH FIXED resection. WITH TITANIUM SPIRAL TACKS Gulnur Gollu, MD,Gonul Kucuk, MD, Meltem P136: ROOM TO MOVE: HOW TO CREATE Bingol-Kologlu, Prof, Aydin Yagmurlu, Prof, ADEQUATE WORKING SPACE IN Huseyin Dindar, Prof, Ankara University THORACOSCOPIC SURGERY FOR LUNG School of Medicine Department of RESECTION AND EMPYEMA Spencer Pediatric Surgery W. Beasley, MD, Mark D. Stringer, MD, Nadeem Haider, MD, Kiki Maoate, MD, Primary closure is not always possible Department of Paediatric Surgery, in thoracoscopic or laparoscopic Christchurch Hospital, and University of diaphragmatic hernia repair. It is difficult Otago to use sutures in approximating the mesh especially near chest wall – rib / sternum. INTRODUCTION: One of the limitations of thoracoscopy in small children requiring The aim is to present three cases of lung resection or debridement of Bochdalek and one case of Morgagni empyema is the surgical exposure and the hernia whose defects were large and not working space that can be achieved. suitable for primary closure. Dura mesh was used in all of the three patients. METHODOLOGY: A review, including video Diaphragmatic rims were approximated analysis, of 113 thoracoscopic procedures to mesh by using extracorporeal sutures. (including 37 for empyema) in children Since the diaphragmatic rims were too aged 2 months to 17 years, to evaluate narrow at sternum and anterior chest wall, the potential advantages and limitations titanium spiral tacks were used to stabilize of various techniques to improve the mesh. There wasn’t any complication exposure and operative working space. during the operations however one of RESULTS: Measures that can improve the children died because of pulmonary vision and enhance the working space hypertension. Remaining patients include: selective bronchial intubation, the recovered well and are doing well in two- use of bronchial blockers, determination year follow-up. of the best location for working ports Titanium spiral tacks which are more to facilitate exposure and optimize routinely used in adults in incisional and ergonomics, adjustment of insufflation inguinal hernia repairs can also be used in pressure, “popping” major cysts in CCAMs Pediatric Surgery by confirming with larger and deflating CLEs, selective use of an further reports. additional working port, and the technique

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Poster Abstracts CONTINUED

P138: THORACOSCOPIC REPAIR OF operating time, simplicity and feasibility. DIAPHRAGMATIC HERNIA IN NEONATES It may be preferable to intracorporeal AND CHILDREN: A NEW SIMPLIFIED suturing and knot tying for the repair of TECHNIQUE WITH SYRINGE NEEDLE Bing the posterolateral defects and worth Li, Bing W. Chen, Qing S. Wang, Huai’an introduced. Women and Children’s Hospital, Jiangsu, 223002, P. R. China P139: EARLY EXPERIENCE WITH PEDIATRIC THORACOSCOPIC LOBECTOMY PURPOSE: New techniques with minor / SEGMENTECTOMY IN ISRAEL Dragan modifications are evolving every day. The Kravarusic, MD, Steven Rothenberg, MD, objective of this study was to describe and Enrique Freud, MD, Schneider Children’s assess our initial experience by using a new Medical Center of Israel , Tel Aviv, Israel simplified technique with syringe needle OBJECTIVE: In our community in thoracoscopic repair of diaphragmatic for symptomatic congenital lung hernia in neonates and children. malformations open surgery is a common METHODS: A retrospective review of a new practice. For asymptomatic cystic simplified technique with syringe needle adenomatoid malformations / pulmonary in thoracoscopic repair of diaphragmatic sequestrations , discovered on routine hernia in 6 cases from March 2013 to pre / postnatal imaging, management is December 2013 was performed. The three controversial. This report evaluates the neonates that underwent thoracoscopic safety and efficacy of thoracoscopic lung repair were physiologically stable with resections in pediatric patients. minimal to moderate ventilatory support. METHODS: During the 2013, eleven In the procedure of elective thoracoscopic patients underwent thoracoscopic repair, a syringe needle with nonabsorbable lobectomy / segmentectomy. Patients 2-0 sutures was used to insert between ages ranged from 8 months to 7 years. the edges of the posterolateral defects. Preoperative diagnosis included congenital The technique will be described in detail. cystic adenomatoid malformation (n = 4) , pulmonary sequestration (n = 5), RESULTS: A total of 6 neonates and bronchogenic cyst (n = 1) and complex children with CDH were repaired bronchiectasis (n = 1). Four patients were successfully using this new technique. symptomatic with previous lung infections There were 4 males and 2 females with a and seven others were asymptomatic. mean age of 4.94 months (range, 2 days–17 Single lung ventilation was desired but not months). All the cases were left-sided. The accomplished in 3 patients. Three ports 3–5 mean operative time was 85 min (range, mm were used with controlled pressure 65–125 min) for each CDH repair. No cases pneumothorax. A ligasure sealing device required closure with a synthetic patch and was the mode for tissue dissection / vessel conversion to open surgery, blood loss was ligation and bronchi were closed either by minimal. The 6 cases were followed up for stapling device or by interrupted sutures. 2–11 months (mean, 6.2 months), with no deaths, and no single case of recurrence. RESULTS: All the procedures were completed thoracoscopically. Operating CONCLUSION: The new technique with times ranged from 70 to 200 min syringe needle had all the advantages (remarkable longer in patients with of thoracoscopy in children combined previous infections ). We performed with the advantages of reduced

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Poster Abstracts CONTINUED seven lobectomies and four segmental site intracorporeal purse string suture lung resections. We had no intraoperative using a needle-holder (IP group), and 100 complications, chest tubes were left for patients by single-port extracorporeal one day in all but two cases of extralobar knotting using an epidural needle with sequestration. Hospital stay ranged from preperitoneal hydrodissection (EK group). 1 to 3 days and only one patient required Technical difficulties, operation time, ICU admission post operatively. intra- and postoperative complications, and recurrence rate were studied. CONCLUSIONS: Supervised mentorship in thoracoscopic approached surgeries for RESULTS: All patients could be completed congenital lung malformations changed successfully without any serious our paradgm of practice. Thoracoscopic complications. The operation time was lobectomy / segmentectomy in selected significantly longer in the IP group than patients is feasible and safe technique. in the EK group (unilateral: 23.7 vs. 15.4 There is a clear difference in dissection minutes; bilateral: 38.1 vs. 21.2 min; P<0.01). complexity in patients with previous There were two recurrences (2.63%) in the infectious complications. Decreased IP group while none in the EK group. The postoperative pain, shorter hospital stay postoperative pain, functional recovery, and better cosmetic results are definite hospital stay and satisfaction were similar. advantages. There was no obvious scaring visible in any patients after treatment. P141: SINGLE-SITE INTRACORPOREAL PURSE-SUTURING VERSUS SINGLE- CONCLUSIONS: Both IP and EK are safe PORT EXTRACORPOREAL KNOTTING and feasible LESS. Accompanied by the LAPAROSCOPIC HERNIORRHAPHY: A method of preperitoneal hydrodissection, COMPARATIVE EVALUATION Suolin Li, single-port laparoscopic EK herniorrhaphy MD, Lin Liu, MD, Meng Li, MD, The Second would be superior to single-site IP repair Hospital of Hebei Medical University, with regard to prevention of recurrence. Shijiazhuang, China It is easy to perfect and to perform and therefore is a worthy choice for PIH. BACKGROUND: Laparo-endoscopic single-site or single-port surgery (LESS) P142: INTRODUCING NEW is a rapidly evolving field, which offers LAPAROSCOPIC TECHNIQUES - THE cosmetic advantage over standard FIRST TWENTY CASES MATTER Christian multiple-access laparoscopic surgery. The Lorenz, Prof., Dr., Carsten Driller, Dr., objective of this study was to compare Department of Pediatric Surgery and the surgical and functional outcomes Urology, Klinikum Bremen-Mitte, Bremen of single-site (transumbilical two-port) BACKGROUND AND OBJECTIVES: intracorporeal purse-suturing (IP) and Minimally invasive laparoscopic techniques single-port extracorporeal knotting (EK) (MILT) replace well established open for pediatric inguinal hernia (PIH) repair. procedures. Practical aspects of this METHODS: Between May 2008 and trend are best resembled by the learning December 2011, the medical records of curve, a term undergoing a change of 176 children undergoing laparoscopic meaning - away from sole feasibility of a inguinal herniorrhaphy by a single pediatric procedure to the point, that a major team surgeon were retrospectively reviewed. Of of surgeons will be enabled to practice them, 76 patients were treated by single- MILT comparably.

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Poster Abstracts CONTINUED

PATIENTS & METHODS: We retrospectively procedure the most challenging one to compared three groups (G) of patients in teach since it needs skilled and cautious whom the first 20 MILT were performed preparation in a short operative time for inguinal hernia in girls (G1/2006-2007: frame. herniorrhaphy), dysplastic upper pole and CONCLUSIONS: Introducing MILT for megaureter in duplex kidneys (G2/2008- standard pediatric surgical conditions 2013: heminephroureterectomy), needs a limited group of skilled surgeons and pyloric stenosis (G3/2012-2013: and close follow-up at least for the pyloromyotomy). The various operations first 20 cases. On the basis of these were performed by just 3 experienced data performing the procedure may be pediatric surgeons. We questioned if basic spread among either skilled specialists or surgical parameters, complications, and doctors in advanced training. Again, close outcome in short term are in such a way supervision is needed to keep or improve consistent, that a wider circle of surgeons the results of the first series. may get involved in processing these operations under close supervision. P143: THE LIMITS OF LAPAROSCOPY: RESULTS: G1: mean age at surgery 43 INFLAMMATORY MYOFIBROBLASTIC months (range 5-79), mean operation time TUMOR OF THE SMALL BOWEL 33 minutes (range 15-65, bilaterally in 3 MESENTERY MASQUERADING AS Christopher patients), postoperative stay in hospital PERFORATED APPENDICITIS  D. Hughes, MD, MPH, Ioanna Mazotas, MD, 6-24 hours, observations/complications: Anthony Tsai, MD, Abby Theriaque, APRN, 3/3 events. G2: 5/15 patients (boys/girls), Richard G. Weiss, MD, Department of mean age at surgery 33 months (9-216), Surgery, University of Connecticut School mean operation time 144 minutes (80-240, of Medicine; Department of Surgery, bilaterally in one), mean postoperative stay Connecticut Children’s Medical Center in hospital 4,6 days (3-7), observations/ complications: 7/0. G3: 17/3 (boys/girls), INTRODUCTION: Inflammatory mean age at surgery 5,6 months (range pseudotumor, or inflammatory 3-9), mean postoperative stay in hospital myofibroblastic tumor (IMT), is a rare lesion 3,8 days (2-8), observations/complications: among pediatric patients. It is a unique 1/2. pathologic entity that is histologically benign, but it can behave like a malignant Operative time in all groups converges tumor, with local invasion and even to that in open surgery (G1/G3) or metastasis. Symptoms vary depending values reported in recent literature on the tumor’s location, and diagnosis (G2), Events (6/7/3 – 30/35/15%) and can often prove challenging. Traditional true complications among them (3/0/3 laparoscopic approaches may prove -17,6/0/10%) occurred in the first 3 to be inadequate for effective surgical quarters of these periods with an overall treatment. rate of 10% (6/60). Some of them could be solved easily by changing suture material METHOD(S): We present a unique case to prevent recurrent hernia(G1) or by study of a three-year-old girl who administering antibiotics postoperatively presented with abdominal pain and in light of the risk of fever (G2). Awareness symptoms consistent with perforated of the risk of mucosal perforation or appendicitis. incomplete myotomy in G3 makes this

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RESULTS: The patient was brought to ventilation support with BPAP (Bilevel the operating room for a laparoscopic Positive Airway Pressure) during early appendectomy. Upon inspection with the postoperative period. operating laparoscope, we discovered Eight years- old male patient with hemoperitoneum and a necrotic segment cerebral palsy and oxygen dependency of small intestine that suggested a more was admitted for frequent lower complex pathology (Figure 1). We then respiratory tract infections and severe converted to laparotomy where we growth deficiency (<3% percentile) Upper discovered a large, dense mass at the gastrointestinal tract fluoroscopy and 24 base the patient’s small bowel mesentery hours pH monitorization had revealed that had separated from the edge of the gastroesophageal reflux. Laparoscopic bowel wall resulting in a necrotic segment Nissen Fundoplication and feeding of proximal jejeunum (Figure 2). After gastrostomy was decided and performed resection, the patient was reanastomosed, without complications. The patient and she subsequently recovered following required non invasive mask ventilation- an uneventful postoperative hospital BPAP during early postoperative period course. Pathology revealed the lesion to be because respiration problems. Enteral an inflammatory pseudotumor (Figure 3). feedings were started from gastrostomy CONCLUSION(S): The diagnosis of IMT tube on postoperative day 3. Gastrostomy can be challenging secondary to its site cellulitis and subcutaneous rarity and its variable presentation. Our crepitations of the abdominal wall report of an IMT presenting as perforated became evident on postoperative day appendicitis is unique in the small body of 6. X-Ray imaging of abdomen revealed literature on these tumors. Laparoscopy disseminated subcutaneous emphysema, was helpful in the diagnostic process as dilated stomach and the spread of the well as determining where to place the opaque given from gastrostomy tube to laparotomy incision. Knowing when to the abdominal wall. Laparotomy was done change course during an operation remains and a leak between the stomach and critical. abdominal wall was found. Gastrostomy site of the stomach was enlarged. P144: EARLY DISLODGEMENT OF Gastrostomy revision was done and the LAPAROSCOPIC GASTROSTOMY IN patient discharged after an uneventful A PATIENT WHO REQUIRED NON- postoperative course. In 18 months of INVASIVE MASK VENTILATION DURING follow up, there were no problems. EARLY POSTOPERATIVE PERIOD Ergun Ergun1, MD, Gulnur Gollu1, MD, Farid Fundoplication and gastrostomy are Khanmammadov1, MD, Gonul Kucuk1, life saving options for children with MD, Tanil Kendirli2, Prof., Meltem Bingol- neurological disorders. But unexpected Kologlu1, Prof., 1Ankara University School complications can be seen if positive of Medicine, Department of Pediatric pressure applied to the gastrointestinal Surgery,2Pediatric Intensive Care Unit tract. In patients who underwent gastrostomy procedure and require non- The aim of this case report is to present invasive mask ventilation, feeding from an unusual complication of laparoscopic gastrostomy tube should be delayed and gastrostomy in a patient who was treated gastric decompression should be done by Laparoscopic Nissen Fundoplication and during early postoperative period. gastrostomy and required non-invasive

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Poster Abstracts CONTINUED

P145: THORACOSCOPIC TRACTION P146: A CASE REPORT :LAPAROSCOPIC SUTURES FOR LONG-GAP OESOPHAGEAL NEPHRON-SPARING SURGERY ON ATRESIA MAY CAUSE SEVERE SOLITARY KIDNEY OF A 2 YEARS-OLD COMPLICATIONS Martin L. van Niekerk, GIRL Hua Xie, Yichen Huang, Yiqing Lv, Prof., University of Pretoria Fang Chen, Shanghai Children’s Hospital , Shanghai Jiao Tong University INTRODUCTION: Long-gap oesophagus atresia is a challenging problem for A 2 years-old girl, who was admitted to our surgeons. Thoracoscopically placed hospital because a mass was discovered traction sutures is one of the recent on the mid polar of her right kidney by approaches to manage this problem. ultrasonography. The girl was diagnosed One of the reasons preventing the wide with Willm’s Tumor on her left kidney one spread acceptance of this approach is the year ago. She underwent nephrectomy problem of sutures cutting through tissue. and half year of chemotherapy. She was We present two patients with isolated followed up by ultrasonography and a oesophagus atresia who developed year later, a mass was discovered on the severe complications following this mid polar of her right kidney. Further CT procedure. indicated a enhanced tumor on the ventral part of left kidney(Fig1). Laparoscopic PATIENTS & METHOD: Thoracoscopic nephron-sparing surgery was performed. traction sutures were placed in two Three 5mm trocar were used, one beneath babies with long gap oesophageal atresia, the umbilicus, the other two on the lateral weighing 3.2 and 2.8 kg respectively. The margin of the rectus of right abdomen. first patient was operated primarily at our The tumor is 2*2*2cm with a clear margin. institution. The other patient was referred The opertion took 90 min. Pathology from another institution after traction indicated clear cell carcinoma. The girl sutures resulted in a leak. Both patients was discharged from hospital 3 days after developed a leak of the distal poach, 9 surgery. She was followed up every 2 and 5 days respectively after placement months for half a year by ultrasonography of traction sutures. Both patients and no reccurence of the tumor has been underwent two further operations to discovered yet. manage this problem. Currently these babies are doing well, and are awaiting P147: LAPAROSCOPIC PERITONEAL oesophageal replacement procedures. DIALYSIS CATHETER IMPLANTATION IN CHILDREN: A PRIMARY EXPERIENCE CONCLUSION: Thoracoscopically placed Yichen Huang, Yiqing Lv, Fang Chen, Hua traction sutures may lead to severe Xie, Shanghai Children’s Hospital , Shanghai complications. Jiao Tong University Thoracoscopic placement of sutures in OBJECTIVES: To assess the feasibility and the thin wall of the smaller distal poach is complications of laparoscopic placement a surgical challenge. of peritoneal dialysis catheters in pediatric This procedure is not recommended for patients. small babies. METHODS: A total of 3 patients underwent laparoscopic peritoneal dialysis catheter insertion in our institution in 2013.They were all males, with the age of 7, 8 and 8

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Poster Abstracts CONTINUED years old respectively. 2-cuff Tenckhoff The upper moiety is frequently dilated or catheters with arc bend in the intercuff dysplastic, while ureteropelvic junction segment were used. The operation started obstruction (UPJO) in lower unit of with three 5-mm trocars placed beneath duplex kidney is rare and preservation is the umbilicus and on the lateral margin recommended when it is not significantly of the rectus sheath on each side. Partial impaired. Laparoscopic reconstruction with Omentectomy was performed till the lower pole preservation is presented as an omentum couldn’t reach the pelvic cavity. alternative treatment. The catheter was inserted through the left PATIENTS & METHODS: Three patients incision with the deep cuff placed within with UPJO in lower unit of duplex kidney, a peritoneal tunnel underneath the left two presenting with abdominal pain and rectus muscle and the superficial cuff the other with no symptoms, were treated upon the muscle. The catheter tip was by laparoscopic ureteropyeloanastomosis. positioned in the left iliac fossa with the Patients’ records were analyzed exit site oriented downward. retrospectively for operative details and RESULTS: The median operating time postoperative complications. was 43 min. Peritoneal dialysis could be RESULTS: Severe hydronephrosis, thin performed just after the surgery. The parenchyma and the presence of UPJO patients were followed up for 3, 5 and 6 in lower moiety could be shown on CT months respectively. Complications such urography. The upper moiety had normal as infection, leakage, dislodgement or function without hydronephrosis.The obstruction were not observed. ureters were fused in a “Y” shape to CONCLUSIONS: Laparoscopic peritoneal form a single ureteral orifice without any dialysis catheter implantation is feasible dilation. According to the length between and safe in children. Laparoscopic the fused ureter and UPJO, patients were procedure allows for careful assessment classified to group 1(1 case,≤3cm) and of the abdominal cavity, recognition and group 2 (2 cases, >3cm). In group 1, surgical treatment of intra-abdominal diseases procedure envolved laparoscopic end- such as inguinal hernias, accurate partial to-side ureteropyeloanastomosis of the omentectomy which is important to lower pelvis to the fused ureter. The two prevent catheter obstruction, and precise patients in group 2 underwent laparoscopic placement of catheter in the pelvic cavity. pyeloplasty of lower moiety. Surgical time varied from 100 to 150 minutes, with P148: LAPAROSCOPIC minimal blood loss in all cases. Follow- URETEROPYELOANASTOMOSIS IN up varied from 6 months to 2 years, with THE TREATMENT OF URETEROPELVIC resolution of the clinical symptoms and JUNCTION OBSTRUCTION IN LOWER preservation of the lower moiety function. MOIETY OF DUPLEX KIDNEY Rongde Wu, Prof, Wei Liu, PhD, Department of Pediatric CONCLUSION: Laparoscopic Surgery, Provincial Hospital Affiliated to ureteropyeloanatomosis is a feasible Shandong University, Jinan, China and safe minimally invasive option in the treatment of duplex kidneys associated to BACKGROUND: Duplex kidney is one of a functioning lower moiety with UPJO. the most common congenital anomalies of the urinary tract. Anatomical and clinical presentation determines its treatment.

IPEG’s 23rd Annual Congress for Endosurgery in Children ■ July 22-26, 2014 | 296 Table of Contents

Poster Abstracts CONTINUED

P149: LAPAROSCOPIC RADICAL inchildrenforWilms’tumoror renal cancer NEPHRECTOMY OF WILMS’ TUMOR can be safely performed laparoscopically. AND RENAL CANCER IN CHILDREN: For trained laparoscopic surgeons, by small PRELIMINARY EXPERIENCE FROM tumors under about 10cm in diameter, TWO-CENTERS STUDY IN EAST CHINA especially without crossing the lateral edge Jiangbin Liu, PhD, Professor, Department of the vertebra on the CT scan at the time of Pediatric Surgery, Shanghai Children’s of surgery. Hospital, Shanghai Jiao Tong University1 and KEY WORDS: Laparoscopic, nephrectomy, Department of Pediatric Surgery, Children’s wilms’ tumor, renal cancer, children Hospital of Fudan University2 OBJECTIVE: To review the preliminary P150: TRANSVESICAL ENDOSCOPIC experience from two-centers study and EXCISION OF REDUNDANT URETERAL Baran Tokar, MD, Surhan Arda, MD, to evaluate the laparoscopic radical STUMP  Umut Alici, MD, Eskisehir OGU Medical nephrectomy inchildrenwith wilms’ tumor School, Department of Pediatric Surgery, and renal cancer. Section of Pediatric Urology, Eskisehir, \MATERIAL & METHODS: From January Turkey 2010 to October 2013, medical recordings In children, transvesical endoscopic on 7 caseswho underwent a laparoscopic approach was described mainly for radical nephrectomy for wilm’s tumor vesicoureteral reflux and diverticulum. and renal cancer in the department of This video shows the surgical technique of pediatric surgery, Shanghai Children’s pneumovesicoscopic resection of a long Hospital, Shanghai Jiao Tong University and and refluxing distal redundant ureteral Children’s Hospital of Fudan University stump in a nephrectomized patient. were included in this study. Video presentation:10 years old boy was RESULTS: Three underwent chemotherapy admitted to our clinic with a history right before operation according the COG nephrectomy performed in another (Children’s Oncological Group) protocol hospital. The patient had frequent urinary and all could be treated bylaparoscopy; tract infections (UTI) in his postoperative the biggest tumoral size was 10cm follow up. We showed a refluxing stump without crossing the lateral edge of the with a 4 mm stone in it preoperatively and vertebra. The median hospital stay was 8.5 performed cystoscopy. During cystoscopy, days (6-11). The pathologic investigation a 5 cm long distal redundant ureteral showed 5Wilms’ tumors, 1 rhabdoid stump with 1 cm diameter was determined tumor and 1 renal cell carcinoma. With a on the right side. Debris of suture and median follow-up of 26months (range stone in the stump was removed. He 3 and 48 months) after laparoscopic did not have UTI following the removal radical nephrectomy, all the childrenhad of the debris and excision of the stump no oncological complications (port site was planned for the future. Transvesical recurrence, pulmonary metastasis) and excision of the stump was done by without intraoperative tumoral rupture, pneumovesicoscopy 6 months later. A 5 except the patients with rhabdoid tumor mm port was introduced from the bladder had a local recurrence dome, and 2 three mm ports were inserted CONCLUSIONS: From our own preliminary into the lateral sides of the bladder. experience, the radical nephrectomy With a 12 mmHg insufflation pressure,

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Poster Abstracts CONTINUED refluxing distal redundant ureteral stump P152: POSTERIOR URETHRAL VALVE: was removed by transvesical endoscopic OUR EXPERIENCE IN VIET NAM Van Thao technique. Muscular and mucosa defect Tran, MD, Ngoc Thach Pham, MD, Duc Tri was repaired by 5/0 monofilament Nguyen, MD, Children hospital number 2 in suture. The patient was discharged on Ho Chi Minh city postoperative 2nd day. PURPOSE: to evaluate the results of CONCLUSION: Pneumovesicoscopy could endoscopic valve ablation at Children be considered as one of the options for hospital No 2 in Viet Nam. intravesical ureteral surgery in children. METHODS: We retrospectively reviewed P151: LAPAROSCOPY- ASSISTED EXCISION the records of 25 consecutive patients OF RENAL MATURE CYSTIC TERATOMA with posterior urethral valves from January Baran Tokar, MD, Huseyin Ilhan, MD, 2008 to December 2012. On the basis of Surhan Arda, MD, Umut Alici, MD, Cigdem the initial renal function and radiologic Arslan, MD, Eskisehir OGU Medical School, findings, patients were divided into three Department of Pediatric Surgery, Section groups: group 1, normal renal function and of Pediatric Urology, Eskisehir, Turkey radiologically normal upper tracts; group 2, normal renal function with hydronephrosis Extragonadal teratoma predominantly and/or reflux; and group 3, azotemia with appears along the midline of the body. hydronephrosis or reflux. Renal teratoma is very rare pathology. In this video, laparoscopic assisted excision of RESULTS: All 11 patients in group 1 were a renal teratoma is presented. treated with valve ablation. After a mean follow-up of 32 months, these VIDEO PRESENTATION: An 11 year-old children had normal renal function and female patient was admitted with a right no evidence of upper tract deterioration. abdominal mass. Radiological investigation All 6 patients in group 2 were also treated showed a 13 cm cystic mass on the right with valve ablation. The radiologic upper quadrant just under the liver and abnormalities (hydronephrosis, reflux) above the right kidney. A mass related resolved in 50% of cases, with an average to the upper pole of the right kidney was follow-up of 28 months. Of the 8 patients found by laparoscopic exploration. The in group 3, 5 underwent valve ablation mass was totally excised with laparoscopy after catheterisme and 3 underwent -assisted technique. The histopathology urinary diversion. Urinary diversion showed that the mass was a mature cystic was performed in patients with renal teratoma. deterioration and severe hydronephrosis CONCLUSION: Differential diagnosis, and/or high-grade reflux. Renal function dissection and excision of an returned to normal in all patients who intraabdominal large cystic mass could underwent valve ablation except one; be performed by laparoscopy-assisted renal function returned to normal in only techniques. Teratoid Wilms’ tumor and 1of 3 patients who underwent urinary other renal cystic lesions should be diversion. Radiologically, the severity considered in the differential diagnosis in of the hydronephrosis and reflux was that location. downgraded in patients who underwent valve ablation but not in the diverted group.

IPEG’s 23rd Annual Congress for Endosurgery in Children ■ July 22-26, 2014 | 298 Table of Contents

Poster Abstracts CONTINUED

CONCLUSIONS: endoscopic valve ablation CONCLUSIONS: Nephrostomy external is the mainstay of treatment for patients drainage was associated with lowest rates with posterior urethral valves. of postoperative complications after laparoscopic pyeloplasty. However, three P155: COMPARISON DIFFERENT urine drainages have their own indication. DRAINAGES IN LAPAROSCOPIC The most suitable urine drainages could be Xing Liu, MD, Dawei He, PYELOPLASTY  selected by actual situation. Zedong Bian, De-ying Zhang, Tao Lin, Children’s Hospital of Chongqing Medical P156: OUR EXPERIENCE OF University, Chongqing, China THE SURGICAL TREATMENT OF CRIPTORCHISM IN CHILDREN Damir OBJECTIVE: To evaluate the benefits, Jenalayev, Esmurat Nartbayev, Ardak drawbacks and indication of different Ainakulov, National Research Center for pelvis urine drainages after laparoscopic Mother and Child Health pyeloplasty. The purpose of this study was a comparative METHODS: A total of 105 patients (112 evaluation the results of treatment of sides) who had undergone laparoscopic children with cryptorchism, operated by pyeloplasty between January 2010 and “open” and endovideosurgical ways. October 2013 were divided into nephrostomy external drainage group(66 sides), long-term Since August 2007, 61 patients with various double J catheter internal drainage group forms of cryptorchism have been treated (29 sides) and short-term double J catheter in the urology department of National internal drainage group (17 sides). Research Center of Mother and Child Health. RESULTS: The incidence of postoperative gross hematuria in nephrostomy external Age of patients ranged from one year to 14 drainage group was lower than long- years. Endovideosurgery has been applied term double J catheter internal drainage in the treatment of 43 patients (study group (P<0.01) and short-term double J group). The operation consisted of the catheter internal drainage group (P<0.05). following steps: diagnostic laparoscopy in The total incidence of postoperative order to clarify the level of retention, visual complications in nephrostomy external evaluation of the testis, its blood vessels drainage group was lower than long-term and the fixing apparatus, the intersection double J catheter internal drainage group Gunter`s cord, the mobilization of the and short-term double J catheter internal vascular bundle and ductus defferens, drainage group (P<0.01). The incidence of forming a channel from the abdomen into urinary infection in nephrostomy external the scrotum, bringing down the testis and drainage group was lower than long-term fixation it in the scrotum. double J catheter internal drainage group The “open” brining down and fixation of (P<0.05). The incidence of drainage tube the testis by Petrivalskij-Schumaker has blockage and omentum prolapsus in been performed in 18 patients (control nephrostomy external drainage group was group). lower than short-term double J catheter internal drainage group (P<0.05). And For comparative assessment of body’s there was no significant difference of postagressive response to laparoscopic anastomosis obstruction incidence and and traditional types of operations for postoperative successful rate in three cryptorchism we studied: the state of groups (P>0.05).

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Poster Abstracts CONTINUED simpaticoadrenalic system (in circadian spermatic vessels offers a low recurrence excretion of adrenaline and noradrenaline) rate but with the risk of postoperative and several biochemical blood parameters, hydrocele in 10% short term and up to 30% reflecting the functional state of the with extended follow-up. We present our suprarenal glands and liver, the balance of experience with dye-assisted lymphatic- carbohydrate and protein metabolism. To sparing laparoscopic varicocelectomy assess the state of the testis we conducted (LSLV) to prevent postoperative hydrocele ultrasound and Doppler exams of gonads in children. We contribute novel insights in the preoperative period, on the 3rd and 6 regarding the number of lymphatic vessels month of postoperative period. There were which need to be preserved. no complications in the immediate and MATERIALS & METHODS: Five consecutive late postoperative period. LSLVs were performed over a period of The analysis of the comparative evaluation three years on children with a mean age of body’s postagressive response to of twelve years. The varicocele grade was laparoscopic and traditional operations has three in one case and grade 2 in four cases, showed that laparoscopic surgery is less respectively. Indications of operation invasive, less traumatic, less durable surgical were testicular volume asymmetry of intervention, which is characterized to have greater than 20% in one patient (a grade more favorable postoperative period. 3 varicocele) , scrotal pain or discomfort in three patients and family preference in one More expressive positive dynamics, patient. A left subdartos injection of 2ml concluded in the growth of gonads of Indigo carmine dye was done using a and the normalization of blood flow 25-gauge needle at ten minutes before an parameters while ultrasound and Doppler operation. Stained lymphatics were easily study, has been in patients undergone seen running alongside the spermatic endovideosurgical interventions. artery and vein. We intentionally spared Thus, this study shows clear advantages one or two lymphatics and the rest of the of endovideosurgical treatment of spermatic vessels were clipped and divided cryptorchism in children and calls for RESULTS: Lymphatic-sparing was their widespread introduction into clinical accomplished in all cases. No peri- practice. operative complication was noted. We P157: HOW MANY LYMPHATIC spared one lymphatic channel in one VESSELS NEED TO BE PRESERVED patient (20%) and two channels in four IN DYE-ASSISTED LYMPHATIC- patients (80%). There were no cases SPARING LAPAROSCOPIC PALOMO of hydrocele or residual varicocele. VARICOCELECTOMY IN CHILDREN? Hiroki No testicular atrophy was observed at Ishibashi, MD, PhD, Hiroki Mori, MD, PhD, follow-up. Three patients who presented Keigo Yada, MD, Mitsuo Shimada, MD, PhD, with scrotal pain or discomfort achieved FACS, Department of Pediatric Surgery and complete resolusion of their symptoms. Pediatric Endoscopic Surgery, Tokushima CONCLUSION: Dye-assisted LSLV is easily University Hospital accomplished with an excellent surgical BACKGROUD: The ideal method for outcome and preserving one or two varicocelectomy in children remains lymphatics appears to be sufficient to controversial. The Palomo method of avoid secondary hydrocele. retroperitoneal mass ligation of the

IPEG’s 23rd Annual Congress for Endosurgery in Children ■ July 22-26, 2014 | 300 Table of Contents

Poster Abstracts CONTINUED

P158: RETROPERITONEOSCOPIC REDO were placed along the line of the erector PYELOPLASTY AFTER AN UNSUCCESSFUL spinae muscle to free adhesions and create OPEN PROCEDURE Manabu Okawada, MD, an adequate working space. A fourth port Hiroyuki Koga, MD, Takashi Doi, MD, Go was placed in the mid-axillary line for Miyano, MD, Kazuto Suda, MD, Geoffrey peritoneal retraction and assistance during J Lane, MD, Atsuyuki Yamataka, MD, the pyeloplasty procedure.After releasing Juntendo University School of Medicine dense adhesions of the left ureter and area where the UPJO was suspected to PURPOSE: Laparoscopic pyeloplasty (LP) be, we found the ureter was being kinked and retroperitoneoscopic pyeloplasty (RP) by an aberrant artery to the inferior pole have become widely accepted for treating of the kidney that was located in front ureteropelvic junction obstruction (UPJO) of the ureter, causing UPJO. Adhesions using minimally invasive surgery (MIS). between the ureter and the aberrant However, for re-do procedures, extensive artery were dissected carefully and the adhesions can make LP or RP technically ureter transected at the site of kinking. challenging. Here we report the use of RP The ureter was thickened and extremely for re-do pyeloplasty. fragile because of chronic inflammation CASE: A 16-year-old girl with left UPJO associated with prolonged insertion of was referred following unsuccessful open the double J stent and recurrent urinary surgery elsewhere. Other than the ureter tract infections and was re-anastomosed being noted to be narrow and the narrow in front of the aberrant artery using 5/0 portion being excised and the ureter absorbable interrupted sutures over the re-anastomosed, no further details were double J stent. Thus, the aberrant artery available. However, a double J stent had came to lie behind the anastomosis, in been inserted in the left ureter 2 years a position that would not compress the earlier to treat recurrent urinary tract ureteropelvic junction. The anastomosis infections and episodes of left flank pain. was complicated by suturing under tension Both the patient and her mother requested and tissue fragility. Postoperative recovery the old scar be used for open re-do and if was uneventful. She was discharged 3 days not possible, MIS re-do. However, the old after surgery. The stent was removed 6 scar was so low that we doubted whether weeks postoperatively, and she is currently the UPJO could be visualized adequately so well after follow-up of 2 years with no RP was recommended for re-do as our MIS urinary symptoms or recurrence of UPJO. procedure of choice. CONCLUSIONS:This case demonstrates RP: A 5mm optical trocar was used to reach that our RP technique is safe and effective the left retroperitoneal space. As we were even in cases complicated by severe anxious about adhesions around the scar retroperitoneal adhesions due to previous from previous open surgery being dense, surgery. we placed the first port 2cm inferior to its P159: LAPAROSCOPIC PERCUTANEOUS conventional position at the costovertebral INTERNAL RING SUTURING FOR angle. Although there were adhesions INGUINAL HERNIA REPAIR IN CHILDREN between the scar and the retroperitoneal OF DIFFERENT AGES Oleg Godik, MD, space, blunt dissection was possible initially Vasil Prytula, MD, Valerie Soroutchan, MD, using the tip of the scope, whereupon two Igor Mirochnik, MD, Roman Zhezhera, MD, additional ports (one at the costovertebral National Specialized Childrens’ Hospital angle and the other above the iliac crest) “OHMATDET”

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Poster Abstracts CONTINUED

BACKGROUND: laparoscopic treatment of (10.6%) patients. In 6 (2.4%) cases the inguinal hernias is a popular procedures inguinal hernias were diagnosed during in pediatric surgery. Many techniques are simultaneous operations (3 laparoscopic used in laparoscopic inguinal hernia repair appendectomies, 1 laparoscopic in children. We present PIRS (Percutaneous cholecystectomy, 1 varicocelectomy, Internal Ring Suturing) technique that was 1 pieloplastics in a PUJ obstruction ). introduced by a polish surgeon Dariusz The average time of the operation was Patkowski. The aim of this study was to 15±5 minutes for unilateral hernias, and evaluate the efficacy of PIRS for inguinal 25±5 minutes for bilateral hernias. The hernia repair in children of different ages. average hospital stay was from 6 hours to 1 day. There were 4 (1.6%) cases with an MATERIALS AND METHODS: A review intraoperative complication, in which the of all PIRS procedures in children from iliac vessels were accidentally punctured 28 days- 18 years, with a time period during the ring suturing process, and from March 2010 to December 2013. The required no treatment. There were such procedures were performed under general post operative complications: 9 (3.5%) endotracheal anesthesia. For the PIRS patients experienced mild pain in the method we used a 5 mm camera through place of the puncture for up to 2-3 a transumbilical port, a curved 18 gauge months that stopped with no treatment, injection needle with a non- absorbable 3 (1.2%) hydrocele that also required no filament inside the barrel of the needle. treatment, and 6 (2.4%)hernia recurrences With the injection needle we made a that were all reoperated with the PIRS puncture through the abdominal wall in method. the place of the internal inguinal ring. By moving the needle the thread passed CONCLUSION: The PIRS method showed under the peritoneum around the entrance to be a safe, effective, and reliable for into the hernia sac. Two semi- circular inguinal hernia repair in children. The PIRS sutures were made around the ring and the method showed that it can be used in knot was tightened form the outside and different child ages from 28 days to 18 placed into the subcutaneous region. year. There was a low recurrence rate and great cosmetic result. RESULTS: Over the above years 254 children with 329 hernias underwent P161: IMPORTANCE OF ‘ADEQUATE AND the PIRS procedure, 86 (33.9%) of them PROPER MATERIAL SUBSTANCE FOR THE were girls and 168 (66.1%) were boys. The ENDOSCOPIC TREATMENT OF REFLUX. average age of the children was 3 years 7 OUR EXPERIENCE IN THE LAST FIVE months. There were 179 (70.5%) unilateral YEARS Luciano Sangiorgio, MD, Claudio hernias and 75 (29.5%) cases presented Carlini, MD, Franco Rotundi, MD, Rossella with bilateral inguinal hernias. Unilateral Arnoldi, MD, Pediatric Urology, * Pediatric hernias consisted of 132 (73.7) right sided Surgery. A.O. “SS: Antonio e Biagio e C. hernias and 47 (26.3%) left sided hernias. Arrigo” Alessandria Italy. Out of the bilateral hernias in 65 (25.6%) INTRODUCTION & OBJECTIVES: the aim of cases a contralateral processus vaginalis this paper is to emphasize the ‘importance was diagnosed during the operation, and of a’ proper substance and a proper only in 10 (3.9%) cases were the bilateral material for the endoscopic treatment of hernias diagnosed prior to the operation. reflux, in order to obtain a good success. Incarcerated hernias appeared in 27

IPEG’s 23rd Annual Congress for Endosurgery in Children ■ July 22-26, 2014 | 302 Table of Contents

Poster Abstracts CONTINUED

MATERIALS & METHODS: in the last five impurities that could be included in the years, we observed 232 patients with VUR thickness of bladder wall, the latter have (354 units refluxing ureters). Twenty- found healing from VUR through a third one cases were suffering from urinary injection of the polymer, using Deflux double district (unilateral or bilateral). again. The remaining two patients with One hundred twenty-six (54.31%) were recurrent VUR and suffering from urinary male and one hundred and six (45.68%) double district were subjected to surgery. females. We evaluated the radiological CONCLUSIONS: it is stressed that the grade of reflux, the presence in the past endoscopic treatment with a stable co of episodes of acute pyelonephritis, the - polymer dextranomer and hyaluronic scars on the static renal scintigraphy. acid (Deflux) offers the same chance Forty-two patients were undergoing of recovery from VUR compared to surgery according to the technique of surgical treatment, definitely the choice Cohen, one hundred and ninety performed of a substance stable and valid material the endoscopic treatment of reflux. The ensures a great eventually find. treatment consisted of the endoscopic injection, below the ureteral meatus, using P162: TRANSPERITONEAL LAPAROSCOPIC and comparing two different co - polymer HEMINEPHRECTOMY FOR DUPLEX of the same substance: dextranomer KIDNEYS IN INFANTS AND CHILDREN and hyaluronic acid (Deflux and Dexell), Stephane Thiry, MD, Delphine DEMEDE, using the same technique by needle drive, MD, Jacques Birraux, MD, Pierre lifting the bladder mucosa with the needle Mouriquand, PhD, Pierre-Yves Mure, PhD, itself, so as to favor the detachment Department of Pediatric Urology, Hôpital and thus the elongation of the junction Femme, Mère, Enfant, 59 Boulevard Pinel, uretero – bladder and the creation of an Université Claude Bernard Lyon1. 69677 appropriate niche for the wheal of organic Bron, France. material - compatible. (Nicola Capozza Technique), however, always using two sub OBJECTIVE: To study the feasibility, safety, ureteral meatal injections amounts being and results of transperitoneal laparoscopic of a material of between 0.7 ml and 1 ml. heminephrectomy (TLHN) for non- for injection. Were detected six cases of functional moiety in duplex kidneys. persistent reflux to the second injection MATERIAL AND METHOD: Between 2008 (two treated with Deflux and all patients and January 2013, 34 TLHN were performed treated with Dexell). Those treated with in 33 patients (18 girls, 15 boys), median Deflux had urinary district, but there was age was 20 months (range 7-107). Twenty- persistence of the wheal which was not six upper poles were removed and eight sufficient to ensure a good valvular effect, lower pole. The mean follow up was 11 instead those treated with Dexell were months (range 2-32). In a subgroup of 19 suffering from reflux of single district and patients, pre and post operative nuclear there was no trace of the wheal at the level investigations were compared to correlate of the ureteral meatus, in addition, during the predicted and the real loss of function. the injection of the second substance, occurred in a case, breakage of the plunger RESULTS: TPLHN was feasible in all of the syringe and in another case the patients without any conversion. The needle was not properly milled for which median operating time was 130 min (range were present in the tip of the metallic 75 – 210 min) and the median hospital stay was four days (range 3-29). No major blood

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Poster Abstracts CONTINUED loss was observed. Two complications were were selected, either after initial open or observed: a persistant secreting moiety laparoscopic repair. A phone interview was and a ureteral injury requiring open surgical conducted with the parents of identified repair. The subgroup with post operative patients. All patients with recurrences nuclear studies showed a loss of function had clinical follow-up. In boys, testicular corresponding to the predictive value of volume and echogenic texture were the preoperative isotopic renographies with evaluated by ultrasound. a median difference of 2% (mean 3.17%, RESULTS: Between December 2003 and range 0-8%). December 2011, 1187 children underwent CONCLUSION & DISCUSSION: LHN inguinal hernia repair, 1087 in a minimally using a transperitoneal approach for invasive fashion and 100 children by a duplex kidney is feasible, safe, and traditional groin exploration. From a effective. Laparoscopic retroperitoneal total of 1547 laparoscopic inguinal hernia heminephrectomies has long been repairs, 71 laparoscopic evaluations were favoured as it reproduced the classical performed for suspected inguinal hernia retroperitoneal approach used in open recurrences. In 11 children, a suspected surgery. Our clinical experience suggests recurrence was not confirmed and the that laparoscopic heminephrectomy using procedure was completed. 60 children a transperitoneal approach for duplex (43 boys and 17 girls) underwent 67 kidneys is a safe and efficient procedure laparoscopic inguinal hernia repairs for leading to a low rate of complication. recurrences (53 unilateral and 7 bilateral Fears regarding potential intra-abdominal recurrences). Of all recurrences, 35 children organ injury appear to be hypothetical. (58.3%) had laparoscopic repairs and 25 Furthermore, transperitoneal approach (41.7%) had traditional open herniotomies. seems to be easier to perform due to a Of those 25 patients, five underwent larger working space and a direct vision on multiple groin explorations (two vascular pedicles. explorations (3) and three explorations (2), respectively) prior to the final laparoscopic P163: LOW (RE-) RECURRENCE RATE repair. Of those, three patients had direct AFTER LAPAROSCOPIC REPAIR OF (2) and femoral (1) hernias. The overall Salmai RECURRENT INGUINAL HERNIA  recurrence rate in children after initial Turial, MD, Ralph Hornung, Department of laparoscopic hernia repair in this cohort pediatric surgery, university medical center was 1.3%. A second recurrence was noted Mainz, Germany in one patient (0.06%). PURPOSE: The aim of this study is to The median follow-up was 3.4 years. No identify the incidence of (re-) recurrence testicular atrophy was noted in patients after laparoscopic repair of recurrent after repair of a recurrent inguinal hernia. inguinal hernias after initial laparoscopic or open repair. CONCLUSION: The risk of (re-) recurrence remains low after laparoscopic METHODS AND PATIENTS: We performed herniorrhaphy for recurrent inguinal a retrospective analysis of the surgical hernias. Laparoscopic evaluation of the charts of children who underwent inguinal groin can reveal previously unrecognized hernia repair at our department. All inguinal hernias as well as unusual cases children, who underwent laparoscopic of presumed hernias. Open redo groin repair of a recurrent inguinal hernia, explorations can be prevented in cases

IPEG’s 23rd Annual Congress for Endosurgery in Children ■ July 22-26, 2014 | 304 Table of Contents

Poster Abstracts CONTINUED where a closed processus vaginalis is grade was I in 4, II in 24, III in 26, IV in 18 laparoscopically found. From a technical and V in 2 ureters. Within a follow-up of perspective, the laparoscopic approach 48 months (1-66 months), 49 patients had for recurrent inguinal hernias seems to be no postoperative VCUG, and none of them less demanding, especially in cases after showed febrile UTI or recurrent non-febrile multiple previous groin explorations. UTIs. 1 boy with bilateral VUR grade IV and 1 girl with VUR III in a duplex ureter had a P164: IS A POSTOPERATIVE VOIDING febrile UTI 6 months and 36 months, resp., CYSTURETHROGRAM STILL INDICATED after ET. Further VCUG revealed recurrent AFTER ENDOSCOPIC TREATMENT OF VUR, and both patients underwent a Frank-Martin Haecker, MD, Martina VUR?  second ET. Frech, MD, Sergio Sesia, MD, Christoph Rudin, MD, Department of Pediatric CONCLUSION: In this series, we could Surgery, University Children’s Hospital confirm our follow-up protocol that postoperative VCUG is considered only BACKGROUND: The management of for selected patients. A larger prospective follow-up for patients who underwent study is necessary to evaluate this endoscopic treatment (ET) using Dx/HA approach. for primary vesicoureteral reflux (VUR), is controversially discussed. Recent studies P165: PAPILLARY UROTHELIAL reveal different opinions concerning NEOPLASM OF LOW MALIGNANT the necessity of a postoperative voiding POTENTIAL (PUNLMP) IN A 13 YEAR-OLD cysturethrogram (VCUG). Additionally, PATIENT: CASE REPORT AND REVIEW OF Stenberg and Läckgren reported in THE LITERATURE Frank-Martin Haecker, 2007 on the experience of patients and MD, Elisabeth Bruder, MD, Sergio Sesia, the perception of parents with regard MD, Johannes Mayr, MD, Department of to different diagnostic and treatment Pediatric Surgery, University Children’s modalities, with VCUG mentioned as Hospital, Basel, Switzerland the worst intervention. We sought to PURPOSE: Urothelial carcinoma of the determine whether a postoperative VCUG bladder occurs rarely in the first two is still necessary. decades of life. We report a case of a 13 METHODS: A retrospective study year-old boy who presented with urothelial evaluating 164 patients who underwent neoplasm of low malignant potential ET from 2002 to present was performed. (PUNLMP). In a subgroup of 51 patients, one week METHODS: We describe clinical after ET, prophylactic antibiotics were presentation and diagnostic procedures discontinued and patients were followed as well as treatment and follow-up of up clinically including periodical urinalysis our patient. A review of the literature was and renal ultrasound. Patients did not performed to analyze recommendations undergo further VCUGs unless febrile UTI concerning diagnostic staging, treatment or recurrent non-febrile UTIs developed. and follow-up examinations as well as RESULTS: 51 children with a total of surveillance of urothelial carcinoma in the 95 ureters underwent ET. Additional pediatric population. malformations were: duplex ureters (15 RESULTS: Urothelial tumors in the first two patients), posterior urethral valves (1 decades of life are distinctly unusual, with patient) and dicerticulum (1 patient). VUR most described in case reports and small

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Poster Abstracts CONTINUED series. Most of the small series describe METHODS: We made a retrospective these tumors as being characteristically analysis of 28 patients with malformation superficial and low grade. As in our patient, of ureterovesical junction from January silent macrohematuria is the predominant 2009 to November 2013. 9 cases were clinical symptom. Abdominal ultrasound male and other 19 cases were female. revealed a papillary mass measuring 1.5cm, Their average age was 3.3y(4Mo-10.4y). and abdominal CT scan showed no evidence All cases accepted examination such of additional tumor manifestations. as Ultrosound, MRU, MCU, etc, and Therapy included cystoscopy and hydronephrosis with ureteral dilatation transurethral resection of the tumor. were found in all of them. Of which 17 Histologic examination confirmed the patients were obstruction of ureterovesical diagnosis of a PUNLMP. Three months later, junction, 11 patients were believed to have control cystoscopy including fluoroscopy VUR with grade IV-V. These patients were demonstrated no residual tumor in the divided into two groups. In group A, from bladder. Within the next 36 months, the January 2009 to October 2011, 18 cases clinical course was uneventful. were operated by open procedure. Of which 6 cases were male, 12 cases were CONCLUSIONS: Urothelial tumors in the female. Their average age was 3.7y(4Mo- first two decades of life are unusual, 10.4y). In group B, from November 2011 to with most described in case reports. November 2013, 10 cases were operated Regarding the tumor characteristics, by pneumocystoscopic Cohen ureteric transurethral local resection is the therapy reimplantation. Of which 3 cases were of choice, followed by control cystoscopy male, 7 cases were female. Their average including fluoroscopy. General treatment age was 3.1y(5Mo-9.2y). Operative time, protocols including recommendations for blood loss, postoperative hospital stay, staging, tumor markers, and follow-up complications and therapeutic efficacy examinations are not available for this were analyned. tumor entity. RESULTS: 10 cases were performed P166: COMPARATIVE STUDY OF pneumocystoscopic Cohen ureteric PNEUMOCYSTOSCOPIC COHEN reimplantation, of which 1 case gave up URETERIC REIMPLANTATION AND laparocopic procedure because the trocar OPEN SURGERY FOR MALFORMATION was out of work and the gas leaked into OF URETEROVESICAL JUNCTION IN the abdominal cavity .The remaining CHILDREN: EXPERIENCE AT A SINGLE 9 cases were accepted successful Chang Tao, BA, Daxing Tang, MD, CENTER  surgery. The mean operative time was Shan Xu, BA, Dehua Wu, BA, Yong Huang, (177.3±47.5 minutes) longer than open BA, Department of Urology Children’s procedure(114.3±24.2minutes),(P<0.05). Hospital Zhejiang University School of The mean blood loss was (4.4±1.1 ml) Medicine lower than open procedure (12.8±4.3 OBJECTIVE: To compare the results ml), (P<0.05). The average postoperative of open and pneumocystoscopic hospital stay was (9.2±2.4 d) lower than Cohen ureteric reimplantation for open procedure(14.6±3.7 d), (P<0.05). malformation of ureterovesical junction Postoperative follow-up was 2 ~ 38 in children and review the experience months. In group A , 5 cases with UTI of pneumocystoscopic Cohen ureteric were cured after antibiotic therapy. 1 reimplantation . patient got cut-infection and 1 patient

IPEG’s 23rd Annual Congress for Endosurgery in Children ■ July 22-26, 2014 | 306 Table of Contents

Poster Abstracts CONTINUED got extravasation of urine. In group ectopia with bilateral inguinal hernias, B, 3 cases got UTI , 1 case of a female and identifying the remnant Mullerian children complained abdominal pain two structures and a common vas deferens. months later after operation. Ultrasonic Under laparoscopic guidance both testicles examination clew: ureteral calculi. The were brought into the left internal ring and stone disappeared after spasmolysis, a trans-septal orchidopexy was performed alkalize urine and abdominal pain relief. followed by bilateral laparoscopic inguinal Postoperative ultrasonic examination of hernia repairs. To our knowledge this all cases showed hydronephrosis with is the first reported case of complete ureteral dilatation were better than before. laparoscopic management of transverse The therapeutic efficacy of two group was testicular ectopia in conjunction with coincident. a common vas deferens, persistent Mullerian duct syndrome, and bilateral CONCLUSIONS: Pneumocystoscopic Cohen inguinal hernias. Challenges encountered ureteric reimplantation as a well minimally included clear identification of the invasive surgery with a small incision, less vas deferens as it merged at the base bleeding, small trauma, rapid recovery, of the uterine remnant, the decision unconspicuous scar was safe and reliable. to leave the remnant Mullerian duct It could achieve good clinical effects like structures, and the approach to correction open surgery. It could take the place of of the inguinal hernias. Based on this open surgery if surgeon had proficient experience, we advocate a laparoscopic laparoscopic technique. approach in the treatment of transverse P167: LAPAROSCOPIC MANAGEMENT testicular ectopia as it enables clear OF TRANSVERSE TESTICULAR ECTOPIA identification of testicular anatomy and IN CONJUNCTION WITH BILATERAL associated anomalies, thereby minimizing INGUINAL HERNIAS, PERSISTENT unnecessary dissection and diagnostic MULLERIAN DUCT SYNDROME AND A uncertainty, while facilitating management. COMMON VAS DEFERENS Kathryn Martin, MD, Kyle Cowan, MD, PhD, Children’s Hospital of Eastern Ontario, University of Ottawa Transverse testicular ectopia is a rare congenital anomaly in which both testicles descend into the same inguinal canal. This condition has been associated with contra-lateral inguinal hernias, persistent Mullerian duct syndrome, common vas deferens, seminal vesicle cysts, seminomas and renal anomalies. We present the case of an 11-month-old male infant with a left inguinal hernia and a right non- palpable testicle. Clinical examination and ultrasound located the right and left testes within the left inguinal canal. Laparoscopy was instrumental in confirming the presence of transverse testicular

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Save the Date! IPEG’s 24th Annual Congress for Endosurgery in Children Held in Conjunction with the Society of American Gastrointestinal and Endoscopic Surgeons

April 14-18, 2015 GAYLORD OPRYLAND RESORT & CONVENTION CENTER NASHVILLE, TENNESSEE Society of American Gastrointestinal and Endoscopic Surgeons April 15-18, 2015Nashville, TN SAGES 2015 www.sages.org @SAGES_Updates www.facebook.com/SAGESSurgery SurgicalSpring Week Program Co-Chair: Michael Holzman,MD Program Michael Co-Chair: Program Aurora Chair: Pryor, MD • www.sages2015.org

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