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Pediatric Surgical Procedures – An Updated Guide – Volume I
111
Figure 17.
Left inguinal hernia after the cauterization.
Figure 18.
Bilateral inguinal hernia after the cauterization (a. right inguinal hernia; b. left inguinal hernia).
are sutured appropriately. If the stab incision remains very small and appears wholly
closed after removing the working instrument, it may not need to be sutured. At this
point, a subcutaneous injection of bupivacaine hydrochloride (.) helps reduce
postoperative pain.
. Intraoperative complications
Bleeding, bowel and urine bladder injury, and general surgical complications
are infrequent if the rules of laparoscopy are followed and the anatomy is taken into
consideration.
Laparoscopic Inguinal Hernia Repair Using the Burnia Technique
DOI: http://dx.doi.org/10.5772/intechopen.115067
112
. Postoperative care
The operated child may be discharged on the same day if no other indications are
observed, and analgesics such as paracetamol may also be administered. In the case
of older children, it is better to prevent the child from excessive physical activity until
the pain is relieved.
. Outcome
Postoperative complications are identical to those in all surgical interventions,
with a low recurrence rate.
. Discussion
Laparoscopic inguinal hernia repairs in children have many advantages. These
include less pain, the ability to intervene in bilateral inguinal hernias from the same
port, a good option for repairing recurrent and incarcerated hernias, excellent cosmetic results, and the ability to detect and repair femoral and direct hernias. However,
disadvantages include increased cost, long operating time, prolonged learning curve,
and recurrence []. A recent systematic review and meta-analysis focused on many
outcomes and concluded that [] concluded that the laparoscopic hernia repair is the
preferred method for managing inguinal hernia in pediatrics over open herniotomy
as it has a shorter operative time, lower risk of metachronous contralateral inguinal
hernia development, postoperative hydrocele, and postoperative scrotal edema, and its
major benefit is for the assessment of contralateral side of inguinal region to prevent
development of metachronous contralateral inguinal hernia. The study [] showed
that hernia recurrence is not less prevalent in open repair than in laparoscopic repair.
The correlation to which the laparoscopic approach is needed in further studies, as
many approaches are described is a limitation that needs extended study.
Laparoscopic techniques have some features shown in (Tabl e ) [–, , –].
Studies have shown that extracorporeal suturing is easier to learn and perform,
and has fewer complications []. For this reason, techniques involving intracorporeal suturing can be considered a disadvantage in inguinal hernia repair in children.
Moreover, these techniques appear to prolong surgery time. However, as experience is
gained, the operative time becomes shorter.
Single-port laparoscopic needle-assisted repair of inguinal hernia using a spinal
needle, a safe, reliable, and effective technique with high parent satisfaction, was
found compared to three port techniques [].
The Burnia technique has a shorter operating time due to the absence of intracorporeal and extracorporeal suturing and fewer ports. The learning curve is easier, and
recurrence due to peritoneal damage is reduced.
. Conclusion
The Burnia technique appears to be preferable for hernias in girls because of its
low recurrence rate and the advantages of laparoscopy. Additionally, this technique is
a safer intervention that may be taught easily in surgical assistance training.
Pediatric Surgical Procedures – An Updated Guide – Volume I
113
Study
[]
(minutes)
(unilateral);
. .±.
postoperative wound complications
[]
(bilateral)
.±.
No complications No recurrence ± (unilateral);
± (bilateral)
[]
(bilateral
.±.
(unilateral);
. ±.
inguinal swelling
Bleeding, surgical site infection,
. []
Torning of the flaps requiring
[]
(bilateral)
No recurrence . (unilateral;
vas deferens injury
postoperative scrotal edema
No intraoperative complications,
multiple sutures to close the defect,
[]
– []
in girls
No recurrence
infection
Mild scrotal edema, port-site
(unilateral);
±. (bilateral)
[]
– (bilateral)
Lateral port hernia No recurrence – (unilateral);
Devices Complications Recurrence Operative time
Two working ports No intraoperative complications and
Two working ports, requires
ligation
Laparoscopic inversion
Laparoscopic
techniques
Intraperitoneal
Needlescopic inversion
Two working ports,
intracorporeal suturing
modified polypectomy snare
,mm suture grasper device,
and snaring
internal ring
Suturing of the
Flip-Flap technique Two working ports,
Two working ports,
intracorporeal suturing
Disconnection of the
Two working ports Hematom No recurrence – []
intracorporeal suturing
ligation
sac and peritoneal
resection
sac, no ligation just
Disconnection of the
Reverdin needle No complications . .±.
intracorporeal suturing
Single-port
Muscular arch repair Two working ports,
intracorporeal knot
incision
tying
Burnia Single working port or stab
Laparoscopic Inguinal Hernia Repair Using the Burnia Technique
DOI: http://dx.doi.org/10.5772/intechopen.115067
114
[]
Study
[]
(minutes)
Devices Complications Recurrence Operative time
± (bilateral)
. . (unilateral);
. (bilateral)
postoperative hydrocele, iliac vessel
suture
puncture, palpating the subcutanous
Single working port No complication is given . No time is given []
Subcutenous
Laparoscopic
techniques
Extraperitoneal
approaches
endoscopically assisted
ligation (SEAL)
Single working port No complications No recurrence ± (unilateral);
Needlescopic hernia
repair
Single working port Omental evisceration, keloid scar,
Percutaneous internal
ring suturing (PIRS)
Table 1.
Some of laparoscopic inguinal hernia repair techniques.
Pediatric Surgical Procedures – An Updated Guide – Volume I
115
Acknowledgements
I would like to thank IPEG (International Pediatric Endosurgery Group), which has
stimulating meetings on minimally invasive interventions and inspired this study.
Laparoscopic Inguinal Hernia Repair Using the Burnia Technique
DOI: http://dx.doi.org/10.5772/intechopen.115067
116
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Thymectomy in Children
119
Chapter 6
GüngörKaragüzel and Ku
tayBahadır
Abstract
Surgical diseases of the thymus are rare in childhood. Although thymic hyperplasia, myasthenia gravis (MG), and ectopic thymic cysts/tissues are relatively
more frequent among these ones, thymectomy is commonly performed during
congenital cardiac surgery and for thymoma. The indication and timing for
thymectomy in thymic hyperplasia and non-thymomatous MG is controversial
due to their unpredictable course. Such complex cases should be evaluated by a
multidisciplinary team at a tertiary center. In thymic hyperplasia and MG, as a
general management policy, thymectomy is recommended when all conservative
approaches fail. Excision is the first option in symptomatic ectopic thymic cysts or
tissues. There are three basic access routes for thymectomy: (I) transsternal, (II)
transcervical, and (III) endoscopic (thoracoscopic/robotic). Additionally, when the
extent and limits of the excision procedure are considered, the surgical techniques
can be further classified in three groups: (I) simple/standard thymectomy, (II)
extended thymectomy, (III) radical/maximal thymectomy. Most of the thymic
disorders in children are treated with simple thymectomy, which can be performed
through thoracoscopic approach. Transsternal access is usually preferred for a large
thymus or advanced thymomas. Available literature supports that thymectomy can
make a significant contribution to relieving generalized symptoms in selected cases
of thymic hyperplasia and MG. Morbidity after thymectomy in children is minimal
and mortality is negligible.
Keywords: children, myasthenia gravis, thymectomy, thymic cyst, thymic hyperplasia,
thymomas, thymus
. Introduction
Thymectomy is the basic surgical procedure in the treatment of disorders
affecting the morphologic structure of the thymus gland. In order to understand better the surgical philosophy of thymectomy, first, it will be useful to mention briefly
basic embryogenesis, anatomy and physiology of the thymus gland, and the history
of thymectomy.
In the 5th intrauterine week, the thymic buds begin to differentiate as a diverticulum from the ventral surface (endodermal) of the third branchial pouches on the
right and left sides, in close relationship with the inferior parathyroid glands’ ducts.
Later, the buds that migrate dorsally and inferiorly around the thyroid gland, leaving the thymopharyngeal canal behind, merge and settle in the anterior–superior
Pediatric Surgical Procedures – An Updated Guide – Volume I
120
mediastinum. Meanwhile, the thymopharyngeal duct undergoes involution, and the
relationship between the thymus and the pharynx disappears [1, 2].
Anatomically, the thymus is an organ located in the anterior mediastinum,
posterior to the sternum, anterior to the trachea, main vascular structures and pericardium, consisting of two lobes and surrounded by a fibrocollagenous capsule.The
right lobe is slightly larger and is joined in the middle by a loose areolar tissue.
However, it might show significant variations in terms of shape, size, and borders [3].
Their size decreases significantly with puberty. The cortex and medulla of each lobe
contain thymocytes (lymphocytes), stromal (epithelial, dendritic) cells, and Hassall’s
corpuscles. The thymus is often fed by the internal mammary artery and inferior
thyroid artery. Although the venous drainage of the gland is usually to the brachiocephalic and internal thoracic veins, it may also connect with the superior vena cava on
the right side. Lymphatic drainage is in the direction of the anterior mediastinal and
hilar lymph nodes [1, 3]. It is important to know the anatomical areas where ectopic
thymic tissues may be found during thymectomy. The rate of ectopic thymic tissues
located outside the anatomical capsule can reach up to 70%. The most common
ectopic locations are cervical and mediastinal fatty tissues and the aortopulmonary
window. Additionally, it has been reported that there may be ectopic thymic tissue
within the thyroid gland [4].
The thymus gland has an important role in the development and functioning of
T lymphocytes, especially in the first years of life. Because of this role, it is an important component of the immune system, especially in children. This role gradually
decreases in parallel with the volume loss that occurs with adolescence [5].
The first thymus surgery in modern medicine is attributed to Ludwig REHN (a
German surgeon) in 1896 [6]. He performed transcervical thymopexy on a patient
whose thymus was enlarged and caused choking attacks. Until the 1930s, the principal access route for thymic surgery was the transcervical approach. The first successful transsternal thymectomy was performed by Alfred BLALOCK in 1936 via upper
median sternotomy in a patient with MG and a large anterior superior mediastinal
tumor [7]. Subsequently, median sternotomy became a standard method for accessing
the thymus gland, and transcervical procedures followed sternotomy. Thoracoscopic
thymectomy was first described in an adult population in 1995 and in a pediatric
population in 2000 [8].
Thymectomy is an uncommon surgical procedure in children but it is performed
throughout childhood, starting from the neonatal period. Despite its lower incidence
and prevalence in children, the diseases originating from the thymus and requiring
surgical intervention have a broader spectrum when compared to adults. Among these
diseases, acquired ones are more common, and congenital ones are less common.
Therefore, adult experiences are prioritized in thymus-related surgical interventions
in children. This situation gains importance especially in the care of pediatric patients
with lymphoid hyperplasia, refractory MG, and thymoma which is more common
in older ages [9]. In this chapter, surgical treatment of thymic disorders in children,
specifically thymectomy, will be reviewed taking into account emerging pediatric
management strategies as well as the data obtained from adult patients.
. Indications for thymectomy
While there is remarkable debate about the necessity of thymectomy in some
cases, there is a certain consensus in the literature in other cases. In this context, it
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