Operative Techniques in

General Surgery

Preface

t was the best of times, it was the worst of times,

I
it was the age of wisdom, it was the age of foolish-
ness, it was the epoch of belief, it was the epoch of
incredulity, it was the season of Light, it was the season
of Darkness, it was the spring of hope, it was the winter
of despair, we had everything before us, we had noth-
ing before us.
The eloquent prose of Charles Dickens in his Tale of
Two Cities appropriately describes how we, as inexperi-
enced and neophyte journal editors (see right), felt when
asked to embark on the educational endeavor known as
Operative Techniques in General Surgery. Dickens won-
derful quote is, as well, an apt reflection on how we have
continued to feel throughout this journey and how we
now feel we as get ready to bid you, our trusted readers, a
fond adieu.
As we say farewell, we ponder a number of seeming mythical. We have learned that surgeons are difficult to
imponderables. What made Ms. Livia Berardi decide we get in contact with and that voice mail is impersonal. We
have learned that publishers are becoming mega-publish-
were up to the task of orchestrating this educational ex-
ers and, as such, they will have to strive, at all times, to tell
perience? Only you know if she was correct or not in her
the left hand what the right hand is doingnot an easy
selection. What we do know as fact, is that we have been
task. We wonder about the future of surgical publica-
the true beneficiaries by accepting her offer. We have
tionswill surgical textbooks/journals and surgical at-
learned legions about all aspects of surgical technique
lases such as Operative Techniques in General Surgery soon
that we really thought we knew something about (but
be relegated to antiquity in this modern world of elec-
didnt!) and so much more about innovative techniques
tronic wizardry?
employed by experts in other surgical disciplines. We
With obvious bias and quite unashamedly, we feel that
have had the honor of relating to so many highly talented
how to do it illustrated atlases will always be needed
guest editors, contributors, artists, and their support per-
and valued in our highly technical field. If you have each
sonnel. This relationship has indeed been the best of
of the 21 previous issues of Operative Techniques in Gen-
times and, on occasions, the worst of times. They have eral Surgery on your bookshelf, you have in your posses-
given to us, to Operative Techniques in General Surgery, sion General Surgery from AZ written by international
and to you, their most precious possessiontheir experts. Although some of these techniques may change,
TIMEand for this, we are ever in their debt. We have and even though new techniques will come along (as they
learned that there are deadline keepers and that there should), many will not change and these 22 separate
are those to whom deadlines are, and always will be, journals will be utilized to the benefit of many, many
patients. How fortunate we feel to have made some of this
possible for you and for our patients.
2005 Elsevier Inc. All rights reserved.
1524-153X/04/0604-0001$30.00/0 We collectively thank the large team, Marilyn Church-
doi:10.1053/j.optechgensurg.2004.10.001 ward in particular, for all the efforts that made this edu-

Operative Techniques in General Surgery, Vol 6, No 4 (December), 2004: pp 241-242 241

242 van Heerden and Farley

cational endeavor possible. More importantly, we thank Dickens prose goes on to state: We were all going
you, our readers, who have been with us for part of, or direct to Heaven, we were all going direct the other
perhaps all of, this educational journey. We feel it fitting way. . . You decide!
that this prefinal issue deals with pediatric surgery
dealing with patients who have their entire lives before
them and who hold our future in their tiny and precious Jon A. van Heerden, MD
hands. It is also fitting that our guest editor for this issue David R. Farley, MD
is Dr. Tom Krummel gentleman extraordinaire. Editors

I expect to pass through this world but once, Any good

therefore that I can do, or any kindness that I can show to
any fellow creature, let me do it now, let me not defer or
neglect it, for I shall not pass this way again.
Unknown
Introduction
his volume of Operative Techniques in General Surgery
T is devoted to surgical problems and operative tech-
niques in children. We have included the types of proce-
dures that, while frequently performed by pediatric sur-
geons, may also be handled by general surgeons,
depending on the nature of their practice. The discussions
are thorough, and the illustrations beautifully depict the
technical aspects of the operations.
Hernias, both umbilical and inguinal, are reviewed both
in their simple form and their complex form by Dr. Robert E.
Cilley and Serene Shereef and by Drs. Tom Tracy and Arlet
Kurkchubasche, respectively. The problem of undescended
testes and its treatment with orchiopexy is authored by Rick
Fonkalsrud and his colleagues, Drs. Dunn and Kawaguchi.
Dr. Fonkalsrud has contributed significantly throughout his
career to the thorough understanding of this problem and
has provided us with a superb chapter.
Dr. Christopher Moir has covered the various cyst,
sinus, and fistula anomalies in the neck. A clear under-
standing of their embryological origins and the anatomi-
cally appropriate excision is essential for success; Dr.
Moir has nicely covered these essentials.
During my fellowship training at Pittsburgh, Dr. Mark
Ravitch opined that the operation for pyloric stenosis was
2005 Elsevier Inc. All rights reserved.
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doi:10.1053/j.optechgensurg.2004.10.002
Operative Techniques in General Surgery, Vol 6, No 4 (December), 2004: p 243
Thomas M. Krummel, MD, FACS, FAAP
Guest Editor
perhaps the greatest surgical advance of the 20th century,
given the frequency of the condition and the conversion of a
fatal problem to a complete solution with minimum se-
quelae. Drs. Craig Albanese and Doug Miniati discuss the
diagnosis and the operative techniques for both the open
and laparoscopic approaches.
Meckels diverticulum may present in a variety of ways,
including bleeding, intestinal obstruction, or chronic ab-
dominal pain. Drs. Karl Sylvester and Denny Jenkins have
wonderfully covered the embryology, the multiplicity of
anatomic presentations, and the operative approach. Ap-
pendicitis is one of the most common surgical consulta-
tions sought in children. Drs. Whit Holcomb and Dan
Ostlie have all of the permutations of appendicitis. Fi-
nally, intussusception is presented by Drs. Baird Mallory
and Yale Popowich with very clear illustrations.
I am grateful to each of the authors, all of whom are
superb surgeons, teachers, and scientists. More impor-
tantly, I am privileged to consider them my friends. For
all of us who are privileged to provide surgical care for
children, the patient with no language but a cry in the
words of Willis Potts, it has been an honor to organize this
issue. Finally, I wish to publicly express my gratitude to
David Farley and Jon van Heerden for this exceptional
opportunity.
Thomas M. Krummel, MD, FACS, FAAP
Guest Editor
243
Umbilical Hernia Repair
Robert E. Cilley, MD, and Serene Shereef, BS
n contrast to the vital role played by the umbilicus in
I utero, it has minimal physiologic importance after
birth. It can be used as a convenient site for vascular
access in newborns; neonatologists use umbilical arterial
and umbilical venous catheters frequently. The umbilicus
can be a portal for infection in newborns (omphalitis).
The umbilicus is frequently used as an entry site for lapa-
roscopic procedures. Its psychological importance
throughout life has been observed in individuals who
have had surgical loss of their umbilicus.1 Persistent um-
bilical hernias are the most common umbilical problem
encountered by surgeons.
NATURAL HISTORY
Umbilical hernias are most often noted after separation of
the umbilical cord remnant. There are no definitive pro-
spective longitudinal studies of umbilical hernias from
birth to adulthood. It is therefore difficult to speculate as
to the natural history of this process if hernia repair is
withheld. Rupture of the hernia with evisceration is al-
most unheard of. Incarceration of visceral contents is
rare. Most (80%) congenital umbilical hernias close spon-
taneously within the first 3 years of life. However, umbil-
ical hernias may continue to close into childhood. Her-
nias with a diameter greater than 1.5 cm are less likely to
close on their own. Proboscoid hernias that turn inferi-
orly as they protrude are less likely to resolve spontane-
ously. Umbilical hernias usually disappear abruptly when
the fascial defect can no longer admit visceral contents.
After spontaneous closure, the resultant umbilicus
usually has a natural concave appearance. Occasionally,
retained material results in a protruding umbilical stalk.
Small unrepaired umbilical hernias in girls may become
symptomatic during pregnancy when the abdominal wall
stretches. There is a greater risk of incarceration in adults
than in children.2 Although used frequently in the past,
topical applications, straps, trusses, and coins do not pro-
mote closure of the umbilical ring and may be injurious.
From the Department of Surgery, Division of Pediatric Surgery, Pennsylvania
State University College of Medicine, Hershey, PA.
Address reprint requests to Robert E. Cilley, MD, Division of Pediatric Surgery,
Milton S. Hershey Medical Center, 500 University Drive, MC H113, Hershey, PA
17033.
2005 Elsevier Inc. All rights reserved.
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doi:10.1053/j.optechgensurg.2004.10.003
244 Operative Techniques in General Surgery, Vol 6, No 4 (December), 2004: pp 244-252
ANATOMY/EMBRYOLOGY
Disorders of the umbilicus are due either to the failure of
closure of the umbilical ring or because of the persistence
of structures, which usually obliterate before birth. The
formation of the umbilicus takes place in early gestation
as a result of a fusion of the body stalk containing the
umbilical vessels and allantois with the extracoelomic
yolk stalk containing the vitelline (omphalomesenteric)
duct and vessels. The fetal midgut normally returns to the
abdominal cavity by 12 weeks gestation, and the abdom-
inal wall closes. The umbilicus closes as mesoderm mi-
grates in to form the abdominal wall. Failure of this clo-
sure can lead to an omphalocele, hernia of the umbilical
cord, or an umbilical hernia. An umbilical hernia is dis-
tinguished from a hernia of the umbilical cord. A hernia
of the umbilical cord is similar to an omphalocele in that
there is a defect in the peritoneum as well as a fascial
defect and the viscera herniate into the substance of the
cord itself. In a true umbilical hernia, the hernia protru-
sion is composed of peritoneum adherent to the under-
surface of the umbilical skin.
The umbilical ring continues to close until birth as the
linea alba narrows and the rectus muscles approach the
midline. At birth, the contracted umbilical ring is nor-
mally reinforced by the round ligament (umbilical vein),
urachus, lateral umbilical ligaments (vestigial umbilical
arteries), and Richets umbilical fascia (a subumbilical
extension of transversalis fascia). Incomplete develop-
ment, imperfect attachment, or weak areas in either liga-
mentous or fascial structures may predispose to hernia-
tion at the umbilicus. The defect is usually noticed within
a few days or weeks after separation of the cord.3 As noted
above, the process of umbilical ring closure can continue
after birth for months or even years.
INCIDENCE
The true incidence of umbilical hernia is unknown because
most umbilical hernias resolve spontaneously. Race and pre-
maturity are predisposing factors with umbilical hernias
found more commonly in children of African descent. The
incidence of umbilical hernias decreases with advancing age.
There is a high familial incidence, but no genetic pattern of
inheritance has been identified. Umbilical hernia is com-
monly associated with a number of congenital malforma-
tions including thyroid dysgenesis, trisomy 18, trisomy 13,
Umbilical Hernia Repair
trisomy 21, Beckwith-Wiedemann syndrome, and Hurler
syndrome.1
SURGICAL INDICATIONS
An umbilical hernia may cause considerable parental anx-
iety and often results in requests for operative repair in
early infancy. Because most umbilical hernias will de-
crease in size and close spontaneously, parents can be
reassured and operation avoided in most children.4 Par-
ents should be reminded not to apply straps, trusses, or
coins to promote closure. Parents may associate abdomi-
nal pain and colic with the presence of an umbilical her-
nia, however, an umbilical hernia rarely causes pain.
Incarceration and strangulation are absolute indica-
tions for surgical repair. If incarceration occurs, it can
usually be reduced manually and the hernia repaired elec-
tively.1 Sedation may aid reduction of the hernia. Rupture
and evisceration, although extremely rare, require imme-
diate operation. Persistence of the hernia is the most com-
mon reason for operation. If the hernia persists as the
child approaches school age (4-5 years of age), repair is
245
recommended. Earlier repair (at age 2-3 years) is war-
ranted if there is no reduction in the size of the hernia
defect with serial observations. Fascial defects greater
than 2.0 cm and giant proboscoid hernias should also
be considered for earlier repair.
PERIOPERATIVE CARE
No preoperative testing is required in healthy children.
Before the procedure, the child is kept without oral intake
according to age and local pediatric anesthetic practices.
Operative repair is performed as an outpatient procedure
under general anesthesia. Local anesthetic infiltration,
paraumbilical block, or a caudal epidural block can be
used to minimize postoperative pain.2 Local/regional an-
esthetic administration before the incision may be more
beneficial than at the time of closure. Oral analgesics are
given in the early postoperative period before the local
anesthesia wears off. Acetaminophen with codeine may
be used for pain control for 24 to 48 hours. Postopera-
tively oral fluids can be offered when the patient is fully
awake and alert.
246 Cilley and Shereef

SURGICAL TECHNIQUE

1 The incision. After appropriate skin preparation and application of sterile drapes, a curvilinear incision is marked in a natural
skin crease within or immediately below the umbilicus. The incision can often be hidden along or within the lower umbilical fold
and need not be placed conspicuously on the abdominal wall skin. Grasping the redundant umbilical skin and applying traction to
the abdominal wall facilitates the incision. The curved incision should not extend beyond 180.
Umbilical Hernia Repair 247

2 Dissection of the hernia sac. The subcutaneous tissue is incised and bleeding points controlled with fine tip electrocautery. A
dissection plane is present between the subcutaneous fat and the hernia sac that leads to the fascial ring at the level of the abdominal
wall. Any contents in the sac are reduced into the peritoneal cavity. With upward traction on the inner margin of the upper edge of
the incision, dissection is performed in this plane along the sac to the level of the anterior abdominal wall fascia. The sac is dissected
circumferentially by blunt dissection with a fine clamp. The plane of dissection is developed superiorly on either side of the sac until
the sac is encircled. The sac is either transected or detached from the under-surface of the umbilical skin. It is important to avoid
fenestration of the skin at the base of the umbilicus. The dissection of the hernia sac is extended into the plane between the
abdominal wall fascia and the subcutaneous tissue of the abdominal wall for a variable distance. The dissection is limited to the
minimum distance that allows closure of the fascia without distortion of the periumbilical skin.
248 Cilley and Shereef

3 Repair of the defect. (A) The hernia sac is elevated, opened (if not already done) and inspected. Occasionally other umbilical
abnormalities will be encountered such as urachal remnants or omphalomesenteric remnants and should be excised/repaired.
Umbilical Hernia Repair 249

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

3 (C) The remainder of the sac is excised and fascial sutures placed sequentially until the entire defect is controlled. Sutures are
not initially tied to maintain control of the edge of the defect and avoid visceral injury. All of the sutures are then tied. Suture
material may be either absorbable or nonabsorbable and is chosen according to the size of the patient (3-0 for infants and young
children, 2-0 for older children and teenagers).
Umbilical Hernia Repair 251

4 Simple umbilicoplasty. The

umbilicus is maintained in inversion
by placement of sutures between the
dermis and the fascial closure. The
undersurface of the redundant um-
bilical skin is tacked to the anterior
abdominal wall fascia with one or
two interrupted 4-0 absorbable
sutures.

5 Closure. A running fine absorb-

able suture is used to close the der-
mis. Skin sutures that require re-
moval are avoided. Many pediatric
surgeons use flexible collodion to
dress the skin.5 A pressure dressing
is applied and left in place for several
days to prevent a wound hematoma.
252
DISCUSSION
Complications are uncommon, but wound hematoma
and wound infection (1%) occasionally occur.4 Recur-
rence is rare. Wound infection makes recurrence more
likely. The umbilicus may not have a perfectly natural
appearance after operation and some patients are dissat-
isfied with the appearance. Supra-umbilical, epigastric
hernias may occur alone or in conjunction with an um-
bilical hernia and should be repaired concurrently. A su-
pra-umbilical incision allows both defects to be repaired.
It is interesting to note that there is a wide range of
technical variation in an operation that is performed so
commonly. Some of the common technical alternatives
are discussed below.
1. Closure of the fascia: The fascial closure can be
performed using a closed technique. The sac is sharply
detached from the umbilicus and inverted. The fascia
edges are approximated without entry into the perito-
neum and the sac is never opened. The dermis underlying
the center of the umbilicus is secured to the fascia to
restore the normal umbilical contour.
2. The distal sac can be left on the undersurface of
umbilical skin.
3. A two-layer closure of the fascia may be performed
either by imbricating the initial suture line or by overlap-
ping the edges of the fascia.
4. Fascia may be closed in either a horizontal or a
transverse fashion. Either absorbable or nonabsorbable
suture material may be used.
Cilley and Shereef
5. The operation can be performed through the base of
the umbilicus rather than through the traditional curvi-
linear incision below the umbilicus. A supraumbilical
incision is also acceptable.
6. Excess or redundant skin can simply be ignored and
the base of the umbilicus tacked to the fascia. The natural
history of such repairs is unknown. Redundant skin can
also be excised and a formal umbilicoplasty performed
using a variety of techniques. These techniques are par-
ticularly useful in the case of a large proboscoid hernia.
The true outcomes of umbilical hernia repair have not
been studied in a long-term, prospective manner. It is not
known whether any of the technical variations listed
above result in fewer complications or improved long-
term appearance.
REFERENCES
1. Cilley RE, Krummel TM: Disorders of the Umbilicus, in ONeill JA,
Rowe MI, Grosfeld JL, et al (eds): Pediatric Surgery (ed 5, vol 2).
Baltimore, MD, Mosby, 1998, pp 1029-1043
2. Garcia VF: Umbilical, other abdominal wall hernias, in Ash-
craft KW, Murphy JP, Sharp RJ, et al (eds): Pediatric Surgery
(ed 3). Philadelphia, PA, W.B. Saunders Company, 2000, pp
651-653
3. Shaw A: Disorders of the umbilicus, in Welch KJ, Randolph JG,
Ravitch MM, et al (eds): Pediatric Surgery (ed 4, vol 2). Chicago, IL,
Year Book Medical Publishers, Inc, 1986, pp 731-739
4. Grosfeld JL: Hernias in children, in Spitz L, Coran AG (eds): Rob &
Smiths Operative Surgery. Pediatric Surgery (ed 5). New York, NY,
Chapman & Hall Medical, Lippincott Williams & Wilkins, 1995,
pp 232-236
5. Singh G: Technical Bulletin, Collodion: http://surgery.psu.edu
Inguinal Hernia/Hydrocele
Arlet G. Kurkchubasche, MD, and Thomas F. Tracy, Jr, MD
epair of the infant hernia is one of the principal opera-
R tions in pediatric surgery, requiring a meticulous and
standardized technique. Although simple in concept, the
repair is technically demanding as the surgeon attempts to
minimize unnecessary trauma to ilio-inguinal and genito-
femoral nerves and the structures of the spermatic cord, all
while operating through small skin incisions and dissecting
even finer structures. Expert pediatric surgeons will often
perform the procedure with magnification for precision and
control. While the technique of indirect hernia repair is
constant across the ages, the repair in the premature infant
poses particular operative challenges because of the fragile
nature of the hernia sac and the short length of the inguinal
canal. In the following series of diagrams, a technique is
outlined in which a sequential series of interventions are
performed stepwise after identification of critical anatomic
landmarks.
The principles of infant hernia repair are based on the
knowledge that an indirect inguinal hernia develops as a
consequence of persistent patency of the processus vagi-
nalis. There is no associated defect in the fascia or mus-
culature related to the inguinal canal, therefore, high li-
gation of the sac is essential and sufficient for repair.
Direct inguinal hernias and femoral hernias occur only
rarely in children, and when encountered, are dealt with
by applying standard adult repair techniques. A primary
repair for direct hernia, however, is typically accom-
plished without the use of mesh in children.
In view of the preponderance of indirect hernia, this dis-
cussion will focus on its operative management. The opera-
tion can be approached via a 1 to 3 cm incision in an inguinal
skin crease just superior to the palpated external ring. The
superficial tissues that are exposed are mobile and can easily
be retracted to expose the essential anatomic elements. Con-
ceptually, the operation proceeds by a combination of blunt
and sharp dissection through successive layers of fascia to
reach the hernia sac and finally separate it from the remain-
der of the spermatic cord structures.
From the Department of Surgery, Division of Pediatric Surgery, Brown Medical
School, Providence, RI.
Address reprint requests to Thomas F. Tracy, Jr, MD, Department of Surgery,
Division of Pediatric Surgery, 593 Eddy Street, HCH 147, Providence, RI 02903.
2005 Elsevier Inc. All rights reserved.
1524-153X/04/0604-0004$30.00/0
doi:10.1053/j.optechgensurg.2004.10.004
Operative Techniques in General Surgery, Vol 6, No 4 (December), 2004: pp 253-268
DIAGNOSIS AND TIMING OF REPAIR
The diagnosis of infant hernia is made on the basis of the
history provided by the parent or pediatrician and physical
examination. Asymmetry of the inguinal region with a re-
ducible mass is diagnostic. In a boy, the physical examina-
tion must also document whether there is an associated
hydrocele and whether both testes are descended. The pres-
ence of a noncommunicating or otherwise static hydrocele,
in the absence of a hernia, does not require operative inter-
vention until the hydrocele has demonstrated persistence
through the age of 18 to 24 months. A communicating hy-
drocele, defined by variation in scrotal size, a palpable thick-
ening of the cord and a subtle silk string sign representing
a larger patent processus, is best closed if it persists through
the first year. Occasionally a well-defined hydrocele of the
cord may mimic a hernia, presenting a diagnostic dilemma
that can be solved by manually verifying that the proximal
canal is empty. Incomplete descent of the testis, particularly
in the premature infant, is usually associated with a hernia
and careful expectant management is often advised so as to
avoid the potential complications associated with an orchi-
dopexy at this early stage.
The timing of infant repair should generally occur within
several weeks of diagnosis to minimize the risk of incarcer-
ation which is greater in the first months postnatally. For the
hospitalized premature infant, repair is traditionally delayed
until the child approaches discharge. Even then, delay may
be desirable if some of the comorbidities, particularly pul-
monary compromise, are expected to substantially improve
or resolve within a period of months. However, once an
infant or child presents with incarceration and a reduction is
accomplished, prompt operative repair is recommended.
The repair of the irreducible incarcerated infant hernia is
challenging, as the integrity of the sac and the identification
of the vas deferens and vessels is further compromised by
inflammation and edema.
In the infant girl, incarceration can involve the ovary
rather than the intestine. This diagnosis is made on pal-
pation of a slippery almond shaped mass in the labium
majora. Despite this incarceration, these infants appear
clinically well and can undergo a semielective repair, usu-
ally the following day.
EVALUATION OF THE
CONTRALATERAL CANAL
Ten percent of childhood hernias are bilateral at presen-
tation. This number may vary with age with the highest
253
254
reports of bilaterality observed in preterm infants. Sur-
geons have speculated that a routine exploration of the
contralateral canal should yield a predictable incidence of
patent processus and undiagnosed hernias. With the ad-
vent of laparoscopy, the technique for exploration be-
came a topic for controversy.1 Ultimately, a more practi-
cal perspective returned to focus on the true incidence of
metachronous hernia rather than asymptomatic patency
of the processus. For all but premature infants, this num-
ber has now been demonstrated to be 10% to 12% and
provides a basis for justifying whether operative and an-
esthetic risks are such that contralateral exploration,
open or laparoscopic, is even warranted.2
ANESTHETIC AND
PAIN MANAGEMENT
Hernia repair in children is performed as an outpatient
operation under general anesthesia. The airway may be
controlled by bag mask ventilation, laryngeal mask air-
Kurkchubasche and Tracy
way, or endotracheal intubation depending on the age,
size and comorbidities of the patient. Spinal anesthesia in
some institutions is reserved for those premature infants
in whom pulmonary morbidity is such that intubation
would be associated with prolonged postoperative depen-
dency on mechanical ventilation.
Techniques for optimizing perioperative analgesia in-
clude infiltration of lidocaine or bupivacaine to block the
ilioinguinal nerve and caudal blocks in children under
one year of age. Acetaminophen or ibuprofen, with or
without codeine, is provided for postoperative analgesia
in the outpatient setting. Criteria for prolonged or over-
night observation are based on the risk for apnea and/or
bradycardia related to prematurity. The former prema-
ture infant under 50 weeks corrected gestational age is
generally admitted for cardiac and respiratory monitor-
ing. Term infants have minimal risk for post anesthetic
apnea beyond the 90 minutes of immediate postoperative
monitoring.
Inguinal Hernia/Hydrocele 255

SURGICAL TECHNIQUE

It is advisable to perform the operation wearing oper- to visualize the critical elements in this opera-
ating loupes to provide adequate magnification tion.

1 (A) After induction of anesthesia, antiseptic skin preparation is completed encompassing the abdomen and genitalia. Draping
should allow for access to the scrotum and to the abdomen for other approaches in cases of incarceration. The affected inguinal
canal is palpated and the transverse incision is situated in the lowest skin fold immediately over the canal and superior to the
external ring. The length of the incision can vary from 1 to 3 cm depending on the patients size.
256 Kurkchubasche and Tracy

1 (B) The subcutaneous tissues are separated bluntly using the Metzenbaum scissors, exposing Scarpass fascia which is grasped
with atraumatic forceps and incised. Placement and spreading of the scissors in this opening then allows the insertion of retractors
to expose the external oblique fascia.
Inguinal Hernia/Hydrocele 257

2 This exposure is now maintained with the insertion of two pyloric, Senn, or similar retractors. The operating surgeon holds the
lateral retractor, while the assistant exerts gentle countertraction medially. Dissection over the anterolateral aspect of the external
oblique exposes fine areolar tissue that is bluntly swept laterally with the Metzenbaum scissors, revealing the true lateral border
(groove) of the external oblique. By following the groove formed by the fascia distally, a point is reached at the external ring where
tissue exiting from the external ring creates an acute angle toward the thigh. This landmark can be verified by pushing closed
Metzenbaum scissors or a blunt instrument against the anterior fibers of the external oblique. Once this landmark has been defined,
only then is an incision made in the external oblique fibers. Occasionally, a skin incision made too medially or failure to determine
the lateral groove will result in dissection of the distal rectus fibers rather than the external oblique. This places the bladder and the
transversalis at risk in a lost dissection via a small incision.
258 Kurkchubasche and Tracy

3 After the external oblique incision is created with a #15 scalpel blade, the Metzenbaum scissors are again used to define the
canal by passing the tightly closed blunt tip subjacent to the external oblique fascia into the scrotum or labia. This action also results
in separating the ilioinguinal nerve from the undersurface of the fascia. The incision is extended distally with the Metzenbaum
scissors through the external ring, and then proximally to the level of the internal ring.
Inguinal Hernia/Hydrocele 259

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

5 Using two atraumatic forceps, the surgeon now holds some cremasteric fibers while with the other forceps separates the fibers
to reach deeper to elevate the hernia sac, vas and spermatic vessels. The sac is suspended by one or preferably two forceps, held by
an assistant, while another forceps sweeps the muscular fibers downwards allowing more sac to become visible.
Inguinal Hernia/Hydrocele 261

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

7 The assistant continues to grasp the sac with two atraumatic forceps and suspends it on an incline toward the midline. By gently
pulling or scratching the tissue on the surface of the suspended sac with open atraumatic forceps, the surgeon searches for a small
pad of fat that acts as a reliable landmark for the spermatic fascial plane separating the sac from the cord structures. The assistant
continues to maintain the sac on some traction in the medial position. Once identified, this fatty tissue is elevated laterally, opening
the fascial plane, which allows the surgeon to lift the cord structures off the surface of the sac. The spermatic vessels are the first
structures identified on the lateral aspect of the sac and are often quite separate from the vas deferens that enters the canal from the
posteromedial aspect at the internal ring. The assistant surgeon helps by regrasping more of the exposed hernia sac as it is dissected,
thereby rolling it medially. Here the spermatic cord is simply draped over the surgeons finger for the purpose of demonstrating
the dissection plane.
Inguinal Hernia/Hydrocele 263

8 These spermatic cord elements are bluntly separated from the sac without ever grasping them with an instrument. Once the
forceps have successfully passed between the sac and spermatic cord structures, a vessel loop, Allis clamp or other suitable
retracting device encompasses the cord structures to deflect them inferiorly and laterally toward the ipsilateral knee. The distal end
of the sac may now be evident and can be grasped with forceps or a hemostat. If the sac extends into the scrotum it is reasonable to
divide the sac between clamps at this point, provided there is sufficient proximal and distal separation from the vessels and vas
deferens. The spermatic cord and proximal portion of the sac are suspended vertically, allowing for the best visualization of the
investing spermatic fascia. The spermatic fascia has greater tensile strength than the sac at this level and is best divided with
fine-tipped scissors rather than by blunt dissection. The edge of the hernia sac and spermatic cord structures must be clearly
visualized during this sharp dissection.
264 Kurkchubasche and Tracy

9 The proximal end of the sac is reflected toward the superior aspect of the wound, separating it from the cord structures that
continue to be retracted laterally and toward the ipsilateral knee. This exposes the residual spermatic fascial investments of the
spermatic cord and hernia. Note the diaphanous nature of the sac on its posterior aspect approaching the internal ring. Here it is the
most vulnerable to disruption, which must be recognized promptly and controlled such that the final ligature is beyond or proximal
to a tear, to avoid a recurrence of the hernia. Division of this layer of tissue allows the sac to be completely separated from the vas
and vessels at the level of the internal ring, recognized by the presence of preperitoneal fat.
Inguinal Hernia/Hydrocele 265

10 Proximal dissection of the sac to the internal ring may reveal either a very narrow neck or a wide base that must be carefully
considered as the dissection is completed.
266 Kurkchubasche and Tracy

11 The sac is held perpendicular to the wound and is then doubly ligated with a simple tie proximally and suture ligature distally
using suture material of the surgeons choice, typically silk or vicryl (polyglactin 910). Although some surgeons opt to twist the sac
before placing the ligature, this maneuver can inadvertently pull the vas deferens into the ligature. The excess sac is then transected
well above the ligature and the sutures are cut resulting in complete retraction of the hernia stump to the level of the peritoneum
adjacent to the internal ring. This provides further confirmation that a high ligation was achieved. Closure of the internal ring is not
necessary unless there is a large aperture in a premature infant with a very short inguinal canal. In the repair of a hernia in female
infants, it is important to realize that the extension of the suspensory ligaments into the sac can bring the fallopian tube close to the
internal ring, placing it at risk with blind high ligation of the sac. A Potts-Goldstein flap type repair using a prolene pursestring
suture is often advisable and the internal ring is then tightened or closed completely.
The distal portion of the sac is now separated to the extent possible from the distal structures taking care to avoid the pitfall of
a serpentine vas deferens. If incompletely resected, the edges of the sac are grasped and examined for any bleeding points requiring
minimal cautery. The vessel loop retracting the cord structures is released and the cord structures are returned into the canal by
placing traction either directly on the testes or indirectly via the gubernaculum from the scrotal skin. It is important to assure that
the testis is correctly situated within the scrotum beyond the pouch of Dennis Browne to avoid postoperative cryptorchidism.
Inguinal Hernia/Hydrocele 267

12 The pyloric retractors are re-inserted and the previously prepared edges of the external oblique fascia are reapproximated
with interrupted absorbable suture material. If a preoperative ilioinguinal nerve block was not performed, the block can be
administered under direct vision either at the time of opening the external oblique or on closure. Scarpass fascia is reapproximated
with a single buried suture and skin is closed with a subcuticular stitch. Mastisol or benzoin is applied before covering the incision
with steristrips. Alternatively the wound is sealed with collodion or other dressing.
268
VARIATIONS AND PITFALLS IN
OPERATIVE TECHNIQUE
Female infant hernia repair. Once the sac is
grasped between the internal oblique fibers, it is elevated
and will expose an artery on its posterior surface. This
vessel should be carefully separated from the sac to avoid
hemorrhage on transection of the sac. If the sac is empty,
then the distal end can be clamped and transected with
electrocautery, releasing it from its ligamentous attach-
ments to the labia. Alternatively the sac can be divided
between clamps. The proximal extent of the sac is dis-
sected to the level of the internal ring. Care should be
taken to avoid overzealous traction on the proximal sac as
this can bring the adnexal structures, particularly the
fallopian tube, close to the level of ligation. It is advisable
to visually inspect the interior of the sac at the level of
ligation. If the round ligament is very prominent at this
level no attempt should be made at separation of this from
the sac. If the fallopian tube is found to be present, then it
must be dissected along its borders from the posterior sac.
This flap is then turned in allowing for a Potts-Goldstein
repair performed using a fine prolene pursestring suture
to the remainder of the sac. The internal ring should be
tightened or closed to prevent hernia recurrence in this
instance.
Another pitfall in the repair in girls is that bilateral
hernias may be encountered with the androgen insensi-
tivity syndrome (Testicular Feminization Syndrome).
This diagnosis can be excluded by either visualizing the
ovary or fallopian tube at the time of hernia repair or more
simply by verifying the presence of a palpable cervix via a
rectal examination under anesthesia.
Incarcerated hernia repair. If reduction of the in-
carcerated intestine does not occur spontaneously with
induction of anesthesia, then the intestine should not be
reduced manually so as to allow for visual inspection of
necrosis or significant ischemia of the bowel. The overly-
ing soft tissues are typically edematous and friable. Since
circumferential control of the sac is often impossible, the
edges of the opened sac are grasped with fine hemostats as
Kurkchubasche and Tracy
it is opened on its medial aspect to inspect the incarcer-
ated intestine. Once reduced, the sac is then dissected
from the cord structures and controlled more proximally
for a standard high ligation. It is very important to exam-
ine and document the viability of the testis in the scenario
of incarceration, as it may have undergone ischemic ne-
crosis from venous congestion. If the intestine reduces
into the abdomen before complete inspection, one may
encounter chylous or bloody fluid from the abdomen.
This finding in isolation does not mandate laparotomy,
however, close observation of the patient for obstruction
or peritonitis is advisable. Surgeons should be comfort-
able with the need for other abdominal incisions in the
midline or right lower quadrant (Laroque maneuver) to
aid in manual reduction of incarcerated intestine.
CONCLUSION
Repair of infant and childhood hernia can be accom-
plished with little morbidity and mortality. Complica-
tions such as bleeding and infection are expected to occur
with less than 1% incidence. Recurrence rates are quoted
in the context of the age at repair. In the preterm neonate
this may approach 5% when additional comorbidities
such as bronchopulmonary dysplasia are present. In the
healthy infant or child, it is expected to occur less than 1%
of the time. It is standard procedure in many institutions
to send the sac for pathologic examination, this serves as
a method for screening for injury to the vas deferens.
However, injury is recognized by the experienced sur-
geon at the time of operation and allows for expert con-
sultation for the potential for microanastomosis. Occa-
sionally a child without a vas deferens is identified. This
should prompt a medical evaluation for cystic fibrosis.
REFERENCES
1. Miltenburg DM, Nuchtern JG, Jaksic T, et al: Laparoscopic evalua-
tion of the pediatric inguinal hernia: a meta-analysis. J Pediatr Surg
33:874-879, 1998
2. Tackett LD, Breuer CK, Luks FI, et al: Incidence of contralateral
inguinal hernia: A prospective analysis. J Pediatr Surg 34:684-687;
discussion 687-688, 1999
Undescended Testes/Orchiopexy
James C.Y. Dunn, MD, PhD,1 Akemi L. Kawaguchi, MD,2
and Eric W. Fonkalsrud, MD1
urgical management of the undescended testis is per-
S formed to prevent the potential complications of
cryptorchidism. When feasible, surgical correction
should be performed at 1 to 2 years of age because later
repair commonly results in increasingly more severe im-
pairment of seminiferous tubular development and re-
duced spermatogenesis. Although orchiopexy increases
the potential for fertility, it does not restore the spermat-
ogenesis to normal levels and does not abolish the in-
creased risk of developing testicular cancer.1 Orchiopexy,
however, does allow for earlier detection of neoplasms by
From the 1Department of Pediatric Surgery, UCLA School of Medicine, Los
Angeles, CA; and 2Department of Surgery, Massachusetts General Hospital, Bos-
ton, MA.
Address reprint requests to Eric W. Fonkalsrud, MD, Professor, Department of
Surgery, Emeritus Chief of Pediatric Surgery, UCLA School of Medicine, 10833 Le
Conte Avenue, Room 72-126, Los Angeles, CA 90095.
2005 Elsevier Inc. All rights reserved.
1524-153X/04/0604-0005$30.00/0
doi:10.1053/j.optechgensurg.2004.10.005
Operative Techniques in General Surgery, Vol 6, No 4 (December), 2004: pp 269-280
self-examination of the testicles. Other problems associ-
ated with cryptorchidism include inguinal hernia and,
occasionally, testicular torsion. The success of treatment
depends on the position of the testis at diagnosis with
much better results being achieved with testes located in
the low inguinal canal. Laparoscopic approaches to diag-
nosis and repair may hold the promise of improved out-
comes for high positioned testes.2,3
The most significant complication of orchiopexy is tes-
ticular atrophy. Injury to the spermatic vessels, or exten-
sive downward traction during repair, can cause postop-
erative venous congestion or ischemia with resultant
testicular atrophy. Although this is a rare complication of
routine orchiopexy, published reports indicate an 8% fail-
ure rate of orchiopexy, even in the distally situated unde-
scended testis, and failure of more than 25% for intra-
abdominal testes. Other infrequent complications
include ascent of the testis requiring a second orchiopexy,
infection, and bleeding.
269
270 Dunn et al

INGUINAL ORCHIOPEXY: SURGICAL TECHNIQUE

1 For undescended testes that are palpable, orchiopexy is performed through an inguinal incision slightly longer than that used
for inguinal herniorrhaphy. Because the length of the spermatic vessels is shorter than normal, the descent of the testis is limited.
The objective of the repair is to change the course of the spermatic vessels such that they extend from their origin near the renal
vascular pedicle to the scrotum, instead of the triangular course through the internal inguinal ring and the inguinal canal.
Undescended Testes/Orchiopexy 271

2 With the patient lying in the supine position, an oblique skin incision is made through the lowermost abdominal skin crease
over the inguinal ligament.
272 Dunn et al

3 The undescended testis is usually positioned at or near the external ring and may extend through the ring into the superficial
inguinal pouch. The external oblique fascia is exposed and incised from the external ring along the direction of the fibers to the
internal ring. The testis and its tunica vaginalis are mobilized from the gubernaculum and attachments to the pubis up to the
internal inguinal ring.
Undescended Testes/Orchiopexy 273

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

5 A high ligation of the sac is performed with a transfixion suture. The testicle and epididymis are carefully examined for any
abnormalities. The remaining tunica is closed loosely over the testis. The mobilization is continued into the retroperitoneal space
by elevating the peritoneum using blunt dissection. The lateral spermatic fascia is divided, and the spermatic vessels are mobilized
up near their origin high in the retroperitoneal space.
Undescended Testes/Orchiopexy 275

6 The scrotum is stretched by inserting a blunt clamp, and then a finger through the wound into the lowest portion of the
scrotum. A small incision is made through a scrotal skin crease in the most dependent position, and a space between the dartos
muscle and the scrotal skin is developed to accommodate the testis. An opening is then made in the dartos layer to allow the passage
of the untwisted spermatic cord and testis into the newly created space. The upper edge of the tunica is anchored to the dartos fascia
in a circumferential manner with interrupted nonabsorbable sutures to minimize the risk of retraction or torsion. The scrotal skin
is closed with fine absorbable sutures. The transversalis fascia is closed, leaving a small opening adjacent to the pubis to serve as both
the internal and external inguinal rings, and to allow the passage of the spermatic cord. The internal and external oblique muscles
are re-approximated in layers in the same manner as used for inguinal herniorrhaphy.
276 Dunn et al

LAPAROSCOPIC ORCHIOPEXY: SURGICAL TECHNIQUE

7 For a nonpalpable testis, laparoscopy is useful for both diagnosis and treatment. Laparoscopy can be utilized to locate the testis
as well as to facilitate orchiopexy or ligation of vessels. If the nonpalpable testis is not located in the abdomen, it is likely that the
testis has vanished secondary to prenatal torsion. With the patient lying in the supine position, an umbilical port is inserted to allow
insufflation of the abdomen. The testis is usually found within 1 cm of the internal ring. If the testis is absent and the vas and vessels
approach the internal ring, then the testis has atrophied. If neither the vas nor vessels are seen, then additional ports should be
placed to locate the testis higher up in the abdomen. If the testis is deemed too high to be brought down in a single stage procedure,
then the spermatic vessels may be ligated to allow for neovascularization of the testis in the next 6 months in preparation for the
second stage of a Fowler-Stephens orchiopexy. After locating the testis with the laparoscope, two additional ports are placed at the
level of the umbilicus along the mid-clavicular line.
Undescended Testes/Orchiopexy 277

8 The gubernacular attachment is grasped and transected to begin mobilization of the testis. The dissection is carried medially to
the bladder, incising the peritoneum well above the vas, and laterally the peritoneum is incised along the pelvic wall along the
spermatic vessels.
278 Dunn et al

9 This peritoneal release provides additional length for the testis to reach the scrotum and leaves a broad strip of peritoneum in
case the division of spermatic vessels is needed. An incision is then made in the scrotum to develop a space over the dartos muscles.
A scrotal port that goes from the dartos pouch to the abdominal wall near the pubic tubercle, medial to the median umbilical
ligament, is used to bring the mobilized testis down to the scrotum.
Undescended Testes/Orchiopexy 279

10 The internal ring is usually small and will close spontaneously. The testis is anchored to the dartos fascia with interrupted
sutures circumferentially. The scrotal skin is approximated with fine sutures.
280 Dunn et al

REFERENCES 2. Hadziselimovic F: Cryptorchism, its impact on male fertility. Eur

Urol 41:121-123, 2002
3. Holcomb GW III: Diagnostic laparoscopy for contralateral patent
1. Jordan GH, Winslow BH: Laparoscopic single stage and staged processus vaginalis and nonpalpable testes. Semin Pediatr Surg
orchiopexy. J Urol 152:1249-1252, 1994 7:232-238, 1998
Neck Cysts, Sinuses, Thyroglossal
Duct Cysts, and Branchial Cleft Anomalies
Christopher R. Moir, MD
nlike benign masses in other locations where simple
U excision is often the preferred method of diagnosis,
such an approach in the neck may result in chronic infec-
tion and draining tracts. The surgical approach to pediat-
ric neck masses requires a thorough understanding of the
diagnostic possibilities and the anatomic implications be-
fore making the incision. Sistrunk understood this di-
lemma after observing high recurrence rates with removal
of thyroglossal duct cysts. His operation, published in
1928,1 was based on the anatomic and embryologic facts
of thyroid descent through or around the hyoid bone. The
combination of accurate preoperative diagnosis and spe-
cific anatomic knowledge remains the standard for neck
surgery today. Fortunately, the preoperative diagnostic
evaluation is straightforward, and when followed, opera-
tive outcomes are excellent.2
PREOPERATIVE EVALUATION
Pediatric neck masses are conveniently classified as mid-
line or lateral (Table 1). Branchial cleft and thyroglossal
duct anomalies are found with equal frequency in chil-
dren and make up about half of all surgically excised neck
masses.2 Occasionally, a cyst may appear on the border of
the others territory requiring additional differentiating
features of the history and physical examination plus ul-
trasound.3 Indications for operation are increasing size,
infection, diagnostic uncertainty, and prevention of infec-
tion or cancer.4
Midline Neck Masses
In the upper midline, thyroglossal duct cysts are the main
concern, directing all investigations to its diagnosis.
There is always a concern for the rare lingual thyroid;
however, the typical cyst is an isolated anomaly residing
close to the hyoid bone. Other masses close by include
submental lymph nodes found higher in the neck just
beneath the chin, and dermoid cysts that can be anywhere
From the Division of Pediatric Surgery, Mayo Clinic, Rochester, MN.
Address reprint requests to Christopher R. Moir, MD, Division of Pediatric
Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905.
2005 Elsevier Inc. All rights reserved.
1524-153X/04/0604-0006$30.00/0
doi:10.1053/j.optechgensurg.2004.10.010
Operative Techniques in General Surgery, Vol 6, No 4 (December), 2004: pp 281-295
Table 1. Classification of Pediatric Neck Masses
Midline Lateral
Thyroglossal duct anomaly Branchial cleft anomaly
Submental lymphadenopathy Lymphatic/vascular
malformation
Dermoid and epidermoid Lymphadenopathy
cysts
Cervical cleft Thyroid nodule
Teratoma Thymic cyst
Laryngocele
Benign soft tissue tumors
Sialadenitis
along the midline including below the thyroid cartilage
where thyroglossal duct cysts are very rare.
Warning signs for unusual thyroglossal anomalies in-
clude a history of other congenital head and neck disorders,
dysphagia, voice changes, or hypothyroidism. Any of these
signs mandate further studies including direct laryngoscopy
and thyroid scans.5 In the absence of such concerns physical
examination of the head, neck, mouth, and pharynx is suf-
ficient. Most children willingly tilt their heads back to dis-
play a prominent smooth round mass near the hyoid bone
that moves with swallowing. Unless infected, it is usually not
tender or erythematous. Parents may discover the cyst as
their child begins to grow and the neck assumes a more
school-age appearance at two or 3 years of age. Ultrasound
evaluation is simple and straightforward, confirming the
cystic nature of the mass and excluding more problematic
issues such as ectopic thyroid tissue.3,5
Dermoid cysts in the upper midline may not be easily
differentiated from thyroglossal duct anomalies. Most
dermoids are found close to the deep cervical fascia and
present as smooth round masses that move with swallow-
ing. Movement with tongue protrusion may be a helpful
differentiating finding. If all investigations fail to deter-
mine which is which, the surgical guidelines follow thy-
roglossal duct cyst excision. Although it may seem exces-
sive, a Sistrunk procedure is recommended as the safest
way to excise the cyst.3 At operation, dermoid cysts are
usually yellow-orange, firm, disc-like masses that look
much different than the typical thyroglossal duct cyst, but
if infected or for other reasons not easily identified, they
are removed in continuity with the hyoid bone.
Submental lymph nodes typically occur in groups and
may be associated with an intercurrent illness. The nodes are
281
282
located directly beneath the chin and do not move with
swallowing. They are smooth, round, rubbery, mobile nod-
ules that have a typical appearance on ultrasound imaging.
Submental lymphadenitis comes and goes relatively quickly,
making observation an excellent approach when the diag-
nosis is suspected. Persistent lymphadenopathy may lead to
excisional biopsy especially if a chronic infection such as
atypical mycobacteria is considered.
Lateral Neck Masses
The lymphatic system is responsible for the vast majority
of normal and abnormal lateral neck masses.5 There is
normal but sometimes alarming lymph node prominence
in preschoolers whose necks have slimmed down with
growth spurts. These nodes are not matted or fixed, but
may be quite sizable nearing 2 cm in diameter on average.
Cystic hygromas or other lymphoid malformations
present during infancy in the lateral neck, most classically
in the posterior cervical triangle. Infectious lymphade-
nopathy in childhood becomes problematic during the
toddler years while malignant infiltration with lymphoma
occurs later in childhood or adolescence. Metastatic dis-
ease with neuroblastoma and soft tissue sarcomas can
occur early but there are usually other features that lead to
the diagnosis. History and physical examination differen-
tiate most lymphatic conditions, open biopsy is indicated
for persistent enlarging, matted, fixed, or chronically in-
fected lesions.
Branchial cleft anomalies, while much less common
than lymphadenopathy, occur with about equal fre-
quency to thyroglossal duct lesions and excite the most
interest as lateral neck masses.2 The second branchial
cleft is responsible for almost 90% of lesions, arising as a
fistula in young children or as a cyst in the older child and
adolescent.5 Parents point out a small punctate opening
on the anterior border of the sternomastoid muscle in the
lower one-third of the neck, noting daily drainage and
intermittent inflammation. Physical examination is use-
ful to confirm this finding and the absence of any other
abnormalities. The tract may be palpable as the child
stretches their neck. Such branchial cleft fistulas may be
safely excised up to the root at the tonsillar fossa. Young
children do well with just one small neck incision and
suture ligation at the internal opening site. When exci-
sion is contemplated the younger child fares better for
ease of operation, complete excision, and cosmetic place-
ment of the incision.
Before operation in the lower lateral third of the neck,
thyroid tumors and the rare thymic and parathyroid cysts
must be ruled out. Again, ultrasound is a helpful adjunct
to physical examination. Fine needle aspiration is usually
reserved as a second-line option for children who regard
such investigations as equivalent to surgery. Neverthe-
less, great care should be taken to make the diagnosis
before operation. If a cystic lesion is still in doubt at the
Christopher R. Moir
time of excision, the surgeon performs a careful search for
a tract and, if discovered, follows the expected anatomic
line based on its presumed embryologic origin.
First branchial clefts may present as a fistula coursing
through the parotid gland in close association with the
facial nerve. These make up less than 10% of the branchial
anomalies. Branchial cysts may be confused with parotid
tumors but both require superficial parotidectomy and
facial nerve dissection for control. The key is to remember
the internal connection to the auditory canal.6
The rare third branchial cleft anomalies are found in
the same general location as second cleft cysts but on the
left side close to the upper pole of the thyroid. When
infected these are the lesions that masquerade as suppu-
rative thyroiditis. If an external opening is present it is
close to the second cleft. There may be a fourth branchial
cleft anomaly as well and its cystic anlage also resides in
the lower one-third of the neck. Other branchial cleft
anomalies in the low neck are seen in the sternal notch
and at the head of the clavicle. These are usually skin and
cartilage remnants with small, short sinus tracts that dis-
appear in the mediastinum without major connection to
an epithelial-lined surface.3
Torticollis is an infiltrating fibrotic condition of the
sternocleidomastoid muscle that presents as a hard, solid,
very worrisome mass in the young infant. By examination
it has every aspect of an infiltrating sarcoma, but these
tumors are benign and resolve with physical therapy.
Confirmation of torticollis includes the discovery near
birth of a sternocleidomastoid mass that is associated with
ipsilateral plagiocephaly and the classic head position: the
face is turned to the contralateral side while the ear and
shoulder on the ipsilateral side are preferentially held
close together. When these signs are present, the diagno-
sis is made on physical examination alone. The children
are best treated with physical therapy. Occasionally, full
resolution of the mass leaves behind a tight tendinous
stricture of the muscle belly. When this fails to respond to
physical therapy, operative division of the sternomastoid
muscle is recommended. The procedure can be safely
performed through a short transverse low-neck incision
to fully divide the sternomastoid muscle above its sternal
and clavicular heads. Excellent results have been ob-
tained with complete division and dissection of the ends
combined with postoperative physical therapy.7
ANATOMIC CONSIDERATIONS
First and second branchial clefts are responsible for al-
most all surgically important congenital lesions in the
lateral neck. Each cleft is a depression on the outside of
the developing head and neck (Fig 1A). The external
ectodermally lined cleft is associated with an internal
endodermally lined pouch that is a similar depression on
the wall of the developing pharynx (Fig 1B). When the
membrane between these two indentations dissolve, gills
Pediatric Neck Masses 283

1 The first four branchial arches have clinical significance. During development, the second arch predominates (A). Indenta-
tions between each arch form clefts on the external surface of the embryo (B) and pharyngeal pouches internally. Incomplete fusion
may lead to fistulae or sinus tracts.

are formed. Although this does not happen in the human
embryo, tiny perforations may develop in the closing
membrane that give rise to the sinuses and fistulae of the
branchial anomalies. The location of the internal orifice is
directly correlated with the pouch of origin: first
branchial anomalies originate from the external auditory
canal, second sinuses and fistulas are found at the tonsil-
lar fossa and third openings are through the pyriform
sinus (Fig 2). With descent and fusion of the third and
fourth pouches, the as yet unreported fourth branchial
cleft fistula would also originate from the pyriform fossa.8
Knowledge of the branchial sinus internal opening is
important to prevent recurrence. Suture ligation should
occur close to these origins. The course of each fistula
must be well understood (Fig 2). For example, second
and third branchial cleft cysts are found in the lower third
of the neck, but their tracts differ in relationship to the
carotid artery and thyroid gland. These anatomic rela-
284 Christopher R. Moir

2 Branchial cleft fistula. The uncommon first anomaly originates in the auditory canal, traverses the parotid gland and exits near
the mandible. The typical second cleft has an external opening on the lower one-third of the neck near the anterior border of the
sternomastoid muscle. The tract bisects the carotid near its origin at the tonsillar fossa. The rare third anomaly opens near the
second but traverses between the thyroid and carotid, passing posteriorly to its origin at the pyriform sinus.
Pediatric Neck Masses
tions are important landmarks for surgical excision, high
ligation, and to avoid nerve injury. In particular, the first
branchial cleft anomalies may come close to branches of
the facial nerve requiring full nerve dissection for success-
ful excision. Surgery on the second cleft must avoid the
hypoglossal and glossopharyngeal nerves. Dissection of
third fistulas may injury the vagus or hypoglossal nerves.
The branchial cleft/pouch combinations discussed
above reside between six branchial arches. The first four
arches are of clinical significance (Fig 1B). Each is com-
posed of three embryologic layers that give rise to an
associated nerve (ectoderm), artery, muscle and cartilage
(mesoderm), and glands (endoderm). The first arch
forms the apparatus of the ear while the second is associ-
ated with the styloid process and hyoid bone as well as the
root of the tongue and foramen cecum. The third arch has
no muscle or cartilage but its pouch forms the inferior
parathyroid glands and the pyriform fossa. The ventral
portion is associated with the thymus gland. Similarly, the
fourth arch again has no muscle or cartilage associations,
but the pouch forms the superior parathyroid glands and
a portion of the thymus as well as the ultimobranchial
body. Knowledge of the particular muscle and cartilage
associations is of less importance than the internal open-
ing of the fistulas and sinus tracts. Nevertheless, this in-
formation is of interest to pediatric and endocrine sur-
geons.
Thyroglossal duct anomalies occur when there is in-
complete resolution of thyroid descent. The thyroid gland
begins at the base of the tongue (foramen cecum) as a
diverticulum that descends down the midline of the neck
285
to its eventual home on the thyroid cartilage. Because the
second branchial arch is busy forming the hyoid bone at
the same time as the thyroid is descending through the
area; the tract may travel in front, behind or actually
through the midpoint of the bone. It was this knowledge
that led Sistrunk to advocate excision of the thyroglossal
duct with the midportion of the hyoid bone and the soft
tissue on either side.1 Cysts may be present anywhere
along the tract from the pyramidal lobe of the thyroid,
itself a remnant of descent, to the foramen cecum. Fistulas
occur only after surgical drainage of infected thyroglossal
duct cysts.2
Very rarely the thyroid gland itself fails to descend in
the neck, remaining at the foramen cecum. Typically, this
is discovered early after birth because of hypothyroidism
or dysphagia and aspiration. Occasionally euthyroid pa-
tients will have portions of the thyroid gland along the
tract descent. Differentiation of these masses is critical to
avoid surgical excision of functioning thyroid tissue.
Again, ultrasound is very helpful to make this determina-
tion. If there is any question, a thyroid scan completes the
investigation.3
Midline dermoid cysts are thought to represent ecto-
dermal inclusions formed during midline fusion of the
embryo. These benign cysts are filled with ectodermal
elements that proliferate and can become infected. Be-
cause they are at the site of fusion, their attachments may
be deep but are always benign. Malignant degeneration
has been described, but the typical indication for opera-
tion is a slowly growing mass that may become infected.
286 Christopher R. Moir

OPERATIVE TECHNIQUE
Thyroglossal Duct Cyst

3 The patient is positioned supine with the neck extended. A shoulder roll is necessary, particularly in smaller children to achieve
adequate extension of the neck. The disparity of a large head and a small body must be accounted for in small children.
Pediatric Neck Masses 287

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

4 Dissection continues directly onto the cyst where it is gently freed from surrounding tissue. The cyst may initially be located
eccentrically but always narrows down to the midpoint of the hyoid bone. The lateral horns of the hyoid are identified as they fuse
in the midline. The lateral musculature is freed just medial to the site of fusion on each site. The midpoint of the hyoid is grasped
on either side of the suspected tracts with strong clamps. The bone is excised with Mayo scissors or light bone cutters.
Pediatric Neck Masses 289

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

Second Branchial Cleft Anomaly

6 The external opening of the branchial cleft anomaly is almost always located in the lower third of the neck. It is excised using
a transverse elliptical incision in line with a previously marked skin crease. Depending on the age and size of the child, a single
incision is sufficient for complete removal of the tract. The younger the child, the better to achieve to the most cosmetic and reliable
excision. If the child is older and the neck longer, a second incision is planned further up the neck directly over the carotid
bifurcation. The site is marked before extension and turning of the head.
Pediatric Neck Masses 291

7 A small probe or suture may be advanced through the tract to help with palpation and visualization of the tract. Injection of
methylene blue is messy and spillage obscures operative detail. Dissection of the tract begins inferiorly and laterally, gradually
mobilizing the fistula from its subcutaneous attachments and the platysma. Once the tract has been well identified, the division
continues anteriorly and superiorly. Some tracts appear lined with circular muscle which aids in full visualization and allows for
firm traction to take place. Generally with traction and counter-traction, the investments of the tract into the surrounding tissue are
well visualized and divided sharply or with electrocautery.
292 Christopher R. Moir

8 Cephalad retraction on the skin incision may allow for visualization of the carotid bifurcation and subsequent tract ligation.
This maneuver is aided by digit pressure from the anesthesiologist on the appropriate tonsillar fossa. If dissection continues directly
on the tract, all nerves are avoided. Inflammation or prior infection increases the chance of risk to the hypoglossal nerve that lies
anteriorly. Care must be taken during retraction to very carefully elevate the tissues around the nerve to avoid damage. Dissection
stays below the posterior belly of digastric as the bifurcation is reached. The base of the tract is suture-ligated with Vicryl. Wound
closure is simple with re-approximation of the platysma, subcutaneous tissues and skin using absorbable suture. Drainage is usually
not required unless there has been extensive dissection or prior infection.
Pediatric Neck Masses 293

Preauricular Sinuses

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

Torticollis

10 Patients are positioned as for branchial cleft excision. A short transverse incision is marked in a skin crease before full patient
positioning. Dissection continues through subcutaneous tissue to identify the lower third of the sternomastoid muscle just above
its sternal and clavicular heads. With gentle dissection, the tendinous tissue is dissected free from the underlying carotid sheath and
divided with cautery. The deep cervical fascia is similarly divided to achieve full and complete separation of the muscle. If the
incision is placed slightly lower, care must be taken to divide both the sternal and clavicular heads. The cut ends of muscle are left
free as the platysma, subcutaneous tissue and skin are closed in layers with absorbable suture. Generally no drains are placed.
Physical therapy begins immediately after operation.
Pediatric Neck Masses
EXPECTED OUTCOME
Excellent outcomes can be expected when the surgical
principles of complete excision occurs during a time
when there is no inflammation or infection. Generally,
the younger the patient, the more successful the excision
and improved cosmetic results. Perioperative antibiotics
are helpful especially when excising fistulas because
many of the wounds are contaminated with oral flora or
skin organisms. If the incision is placed in a skin crease,
the wound heals almost without trace. Recurrence of
branchial cleft or thyroglossal duct anomalies results
from incomplete excision or inadequate suture ligation of
the tract. Recurrence is generally heralded by infection
and wound break down. The ensuing drainage is allowed
to settle with local wound care, warm soaks and systemic
antibiotics as necessary. Generally, at least 6 weeks to 3
months should be allowed to pass before re-excision. A
careful evaluation for a third branchial anomaly using
direct laryngoscopy may be helpful for recurrences of
suspected second clefts. Most thyroglossal duct cysts re-
cur when the midpoint of the hyoid bone has not been
excised; however, rare recurrences can be found when
small accessory ducts escape detection at the first opera-
tion.
CONCLUSIONS
Benign head and neck masses can be classified into mid-
line or lateral. Congenital anomalies require a thorough
295
understanding of the anatomic and embryologic origins
for complete excision without recurrence or nerve injury.
Previously infected lesions require antibiotics, needle as-
piration or drainage before surgical excision. Ample time
should be given for the infection to settle down before
definitive surgery. In general, excellent results can be
achieved for almost all excisions of benign neck masses in
children.
REFERENCES
1. Sistrunk WE: Technique of removal of cyst and sinuses of the
thyroglossal duct. Surg Gynecol Obstet 46:109-112, 1928
2. Roback SA, Telander RL: Thyroglossal duct cysts and branchial
cleft anomalies. Semin Pediatr Surg 3:142-146, 1994
3. Faerber EN, Swartz JD: Imaging of neck masses in infants and
children. Crit Rev Diagn Imaging 31:283-314, 1992
4. Girvigian MR, Rechdouni AK, Zeger GD, et al: Squamous cell car-
cinoma arising in a second branchial cleft cyst. Am J Clin Oncol
27:96-100, 2004
5. Burton DM, Pransky SM: Practical aspects of managing non-malig-
nant lumps of the neck. J Otolaryngol 21:398-403, 1992
6. Triglia JM, Nicollas R, Ducroz V, et al: First branchial cleft anom-
alies: The study of 39 cases and a review of the literature. Arch
Otolaryngol Head Neck Surg 124:291-295, 1998
7. Tang SF, Hsu KH, Wong AM, et al: A longitudinal follow-up study
of ultrasonography in congenital muscular torticollis. Clin Or-
thoped Related Res 403:179-185, 2002
8. Moore KL, Persaud TVN: The pharyngeal (branchial) apparatus, in
The Developing Human: Clinically Orientated Embryology (ed 6).
Philadelphia, PA, WB Saunders, 1998, pp 215-256
Pyloric Stenosis
Douglas N. Miniati, MD, and Craig T. Albanese, MD

ypertrophic pyloric stenosis was first described by Experienced hands can make the diagnosis by palpat-
H Hirschsprung in 1888.1 It affects approximately 4
per 1000 live births.2 Infants that are affected are usually
ing an olive in the right upper quadrant. Careful phys-
ical examination includes administering 5% dextrose wa-
between 2 and 8 weeks old, and it rarely occurs in prema- ter or using a pacifier, covering the abdomen and legs
ture infants. Both familial and environmental factors are with a blanket, and flexing the trunk with the hands over
believed to be causative. Infants whose mothers had py-
loric stenosis are more likely to develop pyloric stenosis
(typically the first-born male), and having a child with
this disorder results in an increased incidence of pyloric
stenosis in ones future children. Despite these hereditary
ties, both barium swallow and ultrasound studies have
argued against a congenital defect. Of over 2000 babies
found to have no pylorus abnormalities at birth, some
went on to develop pyloric stenosis.3,4 The male:female
ratio is approximately 5:1, Caucasians are affected more
than African-Americans and Asians, and babies who are
breast fed are more likely to be affected.
While the narrowing of the pyloric channel is primarily
because of hypertrophy of the inner circular muscle layer,
the precise etiology of this hypertrophy is unknown. Sev-
eral mechanisms have been suggested, including alter-
ations in the pyloric muscle relaxation because of changes
in the numbers and structural qualities of pyloric gan-
glion cells, elevations in various gastrointestinal hor-
mones (gastrin, substance P, secretin, enteroglucogon,
neurotensin), and deficiencies of vasoactive intestinal
polypeptide and nitric oxide.5

DIAGNOSIS
Infants typically present with progressively forceful, non-
bilious vomiting. With prolonged emesis, lethargy be-
cause of dehydration can occur, but infants otherwise
appear healthy. Differential diagnoses to consider include
pylorospasm, gastroesophageal reflux, over-feeding, ele-
vated intracranial pressure, metabolic disorders (salt-los-
ing adrenogenital syndrome, certain aminoacidurias as-
sociated with electrolyte derangements), antral web, and
pyloric duplication.

From the Department of Surgery, Stanford University School of Medicine,

Stanford, CA; and the Division of Pediatric Surgery, Lucile Packard Childrens
Hospital, Stanford, CA.
Address reprint requests to Craig T. Albanese, MD, 780 Welch Road, Suite
#206, Stanford, CA 94305-5733
2005 Elsevier Inc. All rights reserved.
1 Transverse (top) and longitudinal (bottom) views of an ab-
1524-153X/04/0604-0007$30.00/0 dominal ultrasound. Cursor markers demonstrate a 4.9 mm wall
doi:10.1053/j.optechgensurg.2004.10.006 thickness (top) and 16.2 mm length (bottom) of pyloric channel.

296 Operative Techniques in General Surgery, Vol 6, No 4 (December), 2004: pp 296-306

Pyloric Stenosis
2 Upper gastrointestinal series depicting the contrast-filled
stomach (S), hypertrophied pylorus (P), and the string sign
(arrow).
the babys thighs to help the baby relax the abdominal
muscles. In addition, suctioning the stomach before ex-
amining the upper abdomen increases the chances of
making the diagnosis. Even with these maneuvers, the
hypertrophied pylorus may be missed, especially if it is
under the liver edge.
For patients in whom the pylorus is not palpable, ul-
trasonography is the imaging modality of choice (Fig 1).
The ultrasonographic criteria for the diagnosis of pyloric
stenosis are a muscle wall thickness that is 4 mm or more
and a pyloric channel length that is 14 mm or more. The
diameter of the hypertrophied pylorus is usually greater
than 12 mm. In instances when the diagnosis cannot be
made by physical examination and when ultrasound is
not available, or when pyloric stenosis is considered less
likely, a contrast upper gastrointestinal (GI) examination
is indicated (Fig 2). The diagnosis is suggested by dem-
onstrating an elongated pyloric channel, shouldering of
the pyloric muscle against the gastric antrum, and the
string sign of contrast traversing the narrow channel
into the duodenum. In contrast to ultrasonography,
which can only rule in or exclude the diagnosis of pyloric
stenosis, an upper gastrointestinal (GI) examination can
also diagnose other entities in the differential diagnosis
such as pylorospasm, gastroesophageal reflux, web, or
duplication.
Prolonged vomiting may result in a hypokalemic, hy-
pochloremic, metabolic alkalosis because of loss of hy-
297
drogen and chloride ions with emesis. Paradoxical acid-
uria is a late finding when the kidneys compensate for a
contracted volume by reabsorbing sodium at the expense
of hydrogen. Mild indirect hyperbilirubinemia occurs in
2% but resolves spontaneously within 5 to 7 days after
pyloromyotomy.
PREOPERATIVE PREPARATION
Oral feedings are discontinued as soon as the diagnosis is
suspected. An important feature of pyloric stenosis is that
it is not a surgical emergency. Accordingly, proper fluid
and electrolyte resuscitation is of particular importance in
avoiding anesthetic and surgical complications. Boluses
of 20 mL/kg over 1 hour than a maintenance rate of 150
mL/kg/day with a solution containing 5% dextrose and
0.45% saline corrects all underlying electrolyte abnormal-
ities. Potassium is not added to the intravenous fluid until
an adequate urine output is established. Lactated Ringer
solution is contraindicated because of the potential to
worsen the patients metabolic alkalosis. Surgery is con-
sidered safe if the following are achieved: a urine output
greater than 1 mL/kg/hr, a serum chloride level of greater
than 100 mEq/L, a serum bicarbonate level of less than 25
mEq/L, and a normal serum potassium level. Nasogastric
decompression is not indicated because gastric secretions
are usually tolerated and the alkalosis could be worsened
with drainage of the gastric acid.
CHOICE OF OPERATIVE TECHNIQUES
Classically, a pyloromyotomy has been performed as
described by Ramstedt6 via a transverse incision in the
right upper quadrant, transecting the rectus abdomi-
nus muscle. Muscle-sparing techniques and a su-
praumbilical approach have also been advocated. Since
the mid-1990s, the operation has been performed lapa-
roscopically. Multiple studies have compared laparo-
scopic and open techniques, and the latest consensus is
that laparoscopic pyloromyotomy can be performed as
safely as the open pyloromyotomy at similar cost with
possibly a marginal decrease in length of hospitaliza-
tion, but with an improved cosmetic outcome.7-9 Also,
there is less postoperative emesis after the laparoscopic
approach since the stomach and the duodenum are
minimally manipulated as opposed to the open ap-
proach, which can cause a gastric ileus from extensive
manipulation during delivery of the pylorus into the
wound.
298 Miniati and Albanese

SURGICAL TECHNIQUE
Open Pyloromyotomy
Both the open 5,10 11
and the laparoscopic techniques will be
reviewed. One dose of cefazolin (25 mg/kg intravenously)
and rectal acetaminophen (30 mg/kg) are given preopera-
tively. The general anesthetic is the same for both techniques
except that it is not necessary to administer a narcotic for the
laparoscopic approach since it is relatively quick, there is no
large incision, and the wounds are preemptively infiltrated
with a long-acting local anesthetic. The abdomen is pre-
pared from the nipple line to the pubic region for both
techniques. However, diligent cleaning of the umbilicus (us-
ing a cotton-tipped applicator or clamp and alcohol) is nec-
essary before the laparoscopic technique to avoid an umbil-
ical wound infection. In those with a persistent umbilical
cord stump, an inferior circumumbilical incision used for
the port placement.

3 Incision. A transverse right upper quadrant incision (A) is performed and the rectus abdominus muscle and fascia are
transected with cautery. Alternatively, the fascia can be incised transversely, the muscle dissected from the undersurface of the
anterior sheath, and then retracted laterally exposing the posterior sheath, which is similarly incised transversely. If the perium-
bilical incision is performed (B), the midline skin is undermined and the linea alba is incised to enter the peritoneum; the skin
incision is sometimes extended laterally to make an omega shape to accommodate the deliver of the large pylorus. Dashed lines
depict the fascial incision.
Pyloric Stenosis 299

4 Pylorus delivered into the wound. Regardless of the incision used, the pylorus is delivered into the wound. This is accom-
plished by gently grasping the stomach with a Babcock clamp, delivering the stomach to the wound where it can be grabbed
proximal to the pylorus with a moist sponge in the surgeons hand. One should rock the pylorus into and out of the wound. If the
stomach cannot be located, the tip of a moist sponge is inserted into the abdomen and withdrawn slowly. The omentum will stick
to the sponge and then the omentum can be used as a guide to the greater curvature of the stomach. The pylorus is incised on its
avascular surface starting form 1 mm proximal to the pyloroduodenal junction (located by a change in color, texture, and a
prominent pyloric vein) and extending onto the antrum.
300 Miniati and Albanese

5 Completion of myotomy. The muscle is split using the back of the knife handle and then spread using a Benson spreader,
exposing (but not breaching) the underlying mucosa. When completed, the upper and lower muscle edges appear askew and can
be moved side-to-side independently. It is important to stop just short of the duodenum because of the fornix created by its mucosa,
making mucosal perforation risky at this location. Once the myotomy is completed, the wound is inspected for hemostasis and any
bile or gastric fluid leak. The anesthesiologist then passes an orogastric catheter and insufflates the stomach with 60 mL of air while
the duodenum is gently compressed. With the stomach fully distended, the myotomy wound is carefully inspected under saline
irrigation for evidence of air leaking (bubbles) through a mucosal perforation. If a perforation is encountered, it is closed with a U
stitch of absorbable suture. Alternatively, a large perforation is treated by suture closure of the myotomy, rotation of the pylorus
approximately 45 in either direction, and a fresh myotomy performed. A short myotomy (not extending far enough onto the
antrum) or one that is poorly spread may lead to an incomplete myotomy and persistent symptoms. The fascia and the
subcuticular skin are closed with absorbable suture. Steri-strips (3M Health Care, St. Paul, MN) are applied to the skin incision;
no other dressing is needed.
 LAPAROSCOPIC PYLOROMYOTOMY

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

7 Port sites for laparoscopic pyloromyotomy. A long-acting local anesthetic is infiltrated preemptively into the port sites. A
vertical incision is made directly into the base of the umbilicus. Commonly there is a small umbilical fascial defect that makes port
entry safe and easy. An open or a Veress technique can be used to insufflate and insert the 3 mm umbilical port that will
accommodate the telescope. If an umbilical cord remnant persists, an inferior circumumbilical incision is used. The abdomen is
insufflated to 10 torr pressure via the umbilical port. Under direct laparoscopic visualization, bilateral 2 to 3 mm stab incisions are
made with a #11 blade scalpel, slightly medial to the midclavicular lines and midway between the costal margin and the umbilicus.
These incisions should be high enough such that the shaft of the instruments can retract the liver cephalad if the liver is overlying
the pylorus. They should also be slightly smaller than the instruments so that they have to be stretched a littlethis will guard
against gas leakage from the incisions. If a leak occurs, the flow rate on the insufflator should be increased to a level that maintains
an adequately pressured pneumoperitoneum.
302 Miniati and Albanese

8 The laparoscopic Babcock grasper is inserted through either incision, depending on surgeon preference. Most, however, prefer
to use the Babcock in their left hand to gently hold the duodenum while the pylorus is incised. The sheathed arthroscopy knife is
inserted through the other incision with the blade fully retracted. It should enter the abdomen at virtually a right angle to the
midportion of the pylorus. For this reason, it is recommended that the stab wounds in the upper abdomen are not created until the
telescope is inserted to ensure accurate placement of the instruments.
Pyloric Stenosis 303

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

10 The knife blade is retracted and its shaft is used to break the remaining pylorus muscle fibers by twisting the instrument
within the myotomy wound. The Babcock grasper and the sheathed arthroscopy knife may be used together to separate the
remaining muscular fibers by distracting the two instruments in opposite directions (arrows). Alternatively, one may use a
laparoscopic pyloric spreader to break the muscle fibers, as described for the open procedure. The principles used to avoid duodenal
perforation and incomplete myotomy are the same for both the laparoscopic and open techniques. The abdomen is exsufflated via
the umbilical port. Once all of the gas is removed, the instruments are removed from the stab wounds. Omental herniation has been
described when the instruments are removed from the stab wounds before exsufflating the abdomen. The stab incisions are closed
with steri strips alone or with interrupted subcuticular absorbable sutures, based on the surgeons preference. The fascia of the
umbilical port site is closed with a simple absorbable suture and its skin is closed with a simple plain gut suture.
Pyloric Stenosis
11 Completed laparoscopic pyloromyotomy. Inset demonstrates bulging mucosa.
POSTOPERATIVE MANAGEMENT AND
COMPLICATIONS
Various refeeding regimens have been suggested from im-
mediate postoperative ad libitum oral intake to waiting up to
12 hours to start feeding with an escalating scale of volume
and concentration of feeds. Recent evidence indicates that
waiting for approximately 4 hours postoperatively results in
less postoperative emesis and a more rapid advancement to
nutritional goals.12 It is no longer deemed necessary to ad-
just the concentration of the formula administered postop-
eratively. Full-strength formula (or breast milk) can be ad-
ministered ad libitum as tolerated.
Potential complications include mucosal perforation
(0.5-3%), and incomplete pyloromyotomy requiring reop-
eration (up to 2%). Mucosal perforation, if not promptly
recognized, can be a life-threatening complication. An in-
complete myotomy is suspected when a child does not tol-
erate feeds after 7 to 10 days postoperatively. If strongly
suspected, reoperation is required. There is no reliable im-
aging study that can be used in the workup for incomplete
305
myotomy because, after a perfect myotomy, an upper GI
series will be consistent with pyloric stenosis for several
months postoperatively.
REFERENCES
1. Hirschsprung H: Falle von angeborener pylorus stenose. Jb
Kinderheilk 27:61, 1888
2. Mitchell LE, Risch N: The genetics of infantile hypertrophic pylo-
ric stenosis. Am J Dis Child 147:1203, 1993
3. Rollins MD, Shields MD, Quinn RJ, et al: Pyloric stenosis: congen-
ital or acquired? Arch Dis Child 64:138, 1989
4. Wallgren A: Preclinical stage of infantile hypertrophic pyloric
stenosis. Am J Dis Child 72:371, 1946
5. Schwartz MZ: Hypertrophic pyloric stenosis, in ONeill JA, Row
MI, Grosfeld JL, et al (eds): Pediatric Surgery. St. Louis, MO,
Mosby-Year Book, Inc, 1998, pp 1111-1117
6. Ramstedt C: Operation der angeborenen Zpylorus stenose. Med
Klinik 8:1702, 1912
7. Caceres M, Liu D: Laparoscopic pyloromyotomy: Redefining the
advantages of a novel technique. JSLS 7:123-127, 2003
306
8. Greason KL, Allshouse MJ, Thompson WR, et al: A prospective,
randomized evaluation of laparoscopic versus open pyloromyot-
omy of infantile hypertrophic pyloric stenosis. Pediatr Endosurg
Innov Tech 1:175-179, 1997
9. Yagmurlu A, Barnhart DC, Vernon A, et al: Comparison of the
incidence of complications in open and laparoscopic pyloromyo-
tomy: A concurrent single institution series. J Pediatr Surg 39:292-
296, 2004
Miniati and Albanese
10. Benson CD: Infantile hypertrophic pyloric stenosis, in Welch KJ,
Randolph JG, Ravitch MM, et al (eds): Pediatric Surgery. Chicago,
IL, Year Book Medical Publishers, 1986
11. Rothenberg SS: Laparoscopic pyloromyotomy: The slice and
pull technique. Pediatr Endosurg Innov Tech 1:39-41, 1997
12. Van Der Bilt JD, Kramer WL, Van Der Zee DC, et al: Early feeding
after laparoscopic pyloromyotomy: The pros and cons. Surg En-
dosc 18:907-909, 2004
Meckels Diverticulum
D. Denison Jenkins, MD, and Karl G. Sylvester, MD
eckels diverticulum is the most common congenital
M malformation of the gastrointestinal tract, occur-
ring in 1 to 2% of the population.1 It is a remnant of the
omphalomesenteric duct, an embryologic structure con-
necting the primitive yolk sac to the midgut in the devel-
oping fetus (Fig 1). Also known as the vitelline duct, the
omphalomesenteric duct is usually obliterated by the 5th
or 7th week of gestation2,3; failure of this structure to
close completely results in a continuum of pathology,
ranging from an umbilical-enteric fistula, to an umbilical
sinus or cyst, to a Meckels diverticulum (Fig 2).3 Fur-
thermore, up to 25% of Meckels diverticuli are tethered
to the abdominal wall via a fibrous remnant of the ompha-
lomesenteric duct.4 Ectopic tissue, commonly gastric mu-
cosa, is present in about 50% to 60% of Meckels diver-
ticuli.5 In adults, the majority of these congenital lesions
are clinically silent, discovered incidentally when a pa-
tient requires an abdominal operation for another cause.
In children less than 2 years of age, a Meckels diverticu-
lum generally presents as lower gastrointestinal bleeding;
otherwise it is infrequently diagnosed preoperatively.
While overall gender predominance does not exist for the
presence of a Meckels diverticulum, males are three to
fourfold more likely to present with symptoms.5,6 The
treatment of a diverticulum found incidentally in the
older patient is controversial, whereas a symptomatic le-
sion is resected using either an open or laparoscopic ap-
proach.7
PREOPERATIVE EVALUATION
A Meckels diverticulum may manifest a wide variety of
symptoms in children, including gastrointestinal bleed-
ing, peritonitis, small bowel obstruction, and chronic ab-
dominal pain. Ultimately, preoperative evaluation de-
pends on the patients presentation. Acid secretion from
ectopic gastric tissue within a Meckels diverticulum can
From the Department of Surgery, Stanford University School of Medicine,
Stanford, CA.
Address reprint request to Karl G. Sylvester, MD, Department of Surgery,
Division of Pediatric Surgery, Stanford University School of Medicine, 780 Welch
Road, Suite 206, Stanford, CA 94305-5733
2005 Elsevier Inc. All rights reserved.
1524-153X/04/0604-0008$30.00/0
doi:10.1053/j.optechgensurg.2004.10.007
Operative Techniques in General Surgery, Vol 6, No 4 (December), 2004: pp 307-316
lead to mucosal ulceration and painless bleeding in a
child. In these patients, a Tc-99m pertechnetate scintig-
raphy, also known as Meckels scan, is commonly used to
identify the suspected diverticulum (Fig 3). Acid-secret-
ing cells absorb pertechnetate, whereas the kidneys rap-
idly excrete it; consequently, the stomach and bladder are
visualized on Tc-99m pertechnetate scintigraphy. A
Meckels diverticulum with acid-producing ectopic gas-
tric mucosa will also take up the radiotracer, and gener-
ally will be identified on the nuclear scan. A false negative
result may occur with a Meckels diverticulum with an
insufficient volume of ectopic gastric mucosa. Figure 3
demonstrates a Meckels scan, with radiotracer uptake in
the stomach, bladder, and a Meckels diverticulum. A
Meckels scan has low negative predictive value in chil-
dren presenting with both hematochezia and anemia,
leading some to argue in favor of early diagnostic laparos-
copy.8
When a Meckels diverticulum is inflamed or perfo-
rates, the child will likely present with peritonitis, leading
to laparotomy. In such circumstances, a child is often
diagnosed with appendicitis preoperatively. A Meckels
diverticulum may also manifest as a small bowel obstruc-
tion. In these situations, the lesion usually acts either as
the lead-point for an intussusception or a fibrous cord
acts as the axis of a volvulus. Most children in these
situations are diagnosed during laparotomy or laparos-
copy. For equivocal cases, or for children with chronic
abdominal pain, a computed tomography scan may facil-
itate the diagnosis. Most commonly, a Meckels divertic-
ulum is an incidental finding during an operation for
another reason.
PREOPERATIVE PREPARATION
Bowel preparation is not necessary before resection of a
known Meckels diverticulum. The patient is placed su-
pine on the operating room table and general endotra-
cheal anesthesia is induced. Prophylactic antibiotics are
administered depending on the operative indication and
surgeon preference. The abdomen is prepared and draped
in a standard fashion. If using laparoscopy, an orogastric
tube is placed and the bladder emptied via catheterization
to minimize the risk of visceral injury associated with
initial access.
307
308 Jenkins and Sylvester

1 Patent omphalomesenteric duct in a developing embryo. From: TS Cullen. Embryology, Anatomy, and Diseases of the
Umbilicus, 1916. Illustration by Max Brdel. Reprinted with permission from Elsevier.
Meckels Diverticulum 309

Potential Pathology Resulting from Omphalomesenteric Duct Remnants

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

310 Jenkins and Sylvester

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

3 Meckels scan showing radiotracer uptake in stomach, bladder, and a Meckels diverticulum (from K.G. Sylvester, Stanford
University).
Meckels Diverticulum 311

SURGICAL TECHNIQUES
Either an open or laparoscopic technique may be used to excise
a Meckels diverticulum. The traditional method to remove a
Meckels diverticulum is a segmental bowel resection, espe-
cially in the setting of gastrointestinal bleeding. Classic teaching
states that the mucosal ulceration may be located in adjacent
small bowel, and not within the actual diverticulum, thus man-
dating segmental resection. However, with increased use of
laparoscopy, simple amputation with an endoscopic stapler
even in a child with a history of a bleeding distal mucosal
ulceris being increasingly performed by experienced pediat-
ric laparoscopic surgeons, with favorable outcomes and no re-
ported postoperative recurrences.
The traditional open technique is performed through either a
transverse right lower or a low midline laparotomy. Once a
Meckels diverticulum has been identified, a window is created
in the mesentery approximately 2 cm proximal to the lesion.
Clamps are placed, and the bowel is divided. A second window
is opened in the mesentery 2 cm distal to the lesion, and the
distal segment is divided. The lesion is resected off the mesen-
teric remnant using electrocautery, and a hand-sewn bowel
anastomosis is created in a single layer using absorbable suture.
The mesenteric defect is then closed with absorbable suture
using a running stitch; the fascia and abdominal wall are closed
in the standard fashion.

4 Laparoscopic port site placement: To perform a laparoscopic simple diverticulectomy, pneumoperitoneum is established to 8
to 12 torr, depending on the childs size. A 5 to 12 mm Step radically expanding trocar is placed through the umbilicus, and a 5 mm
30-degree laparoscope is advanced into the abdomen. Two 3 to 5 mm working ports are placed under direct visualization, the first
in the low mid-line, just cephalad to the pubic symphysis and clearing the dome of the decompressed bladder.
312 Jenkins and Sylvester

5 Laparoscopic excision of fibrous cord: After the abdomen has been explored, the ileocecal junction is identified, and the
intestine is run proximally. A Meckels diverticulum is usually found within 2 feet of the ileocecal valve, located on the antimes-
enteric side of the small bowel. If tethered to the abdominal wall, the fibrous cord is either ligated between clips or cautiously
divided with electrocautery, as the cord may contain a persistent vitelline artery.
Meckels Diverticulum 313

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

7 (A) Hybrid technique for excision of a Meckels diverticulum: This is accomplished by removing the umbilical trocar, and
extending the fascial opening while remaining within the confines of the umbilical skin, and therefore not altering overall cosmesis.
The Meckels diverticulum and adjacent intestine can then be exteriorized, and either a simple diverticulectomy or a segmental
resection performed.
Meckels Diverticulum 315

7 (B) Hand sewn bowel anastomosis: If necessary, a hand-sewn anastomosis in a single layer using absorbable suture may be
performed. At the completion of the procedure, trocars are sequentially removed under direct visualization, and the port sites closed
with absorbable suture.
316
POSTOPERATIVE CARE
The orogastric tube placed preoperatively is removed at
the completion of the operation. The patient is kept NPO
(nil per orum) until bowel function returns, which gen-
erally occurs rapidly. Pain medications may be adminis-
tered either intravenously, or rectally, depending on the
medication, and the childs age.
REFERENCES
1. Matsagas MI, Fatouros M, Koulouras B, et al: Incidence, complica-
tions, and management of Meckels Diverticulum. Arch Surg 130:
143-146, 1995
2. Synder CL: Meckels diverticulum, in Ashcraft KW, Murphy JP,
Jenkins and Sylvester
Sharp RJ, et al (eds): Pediatric Surgery (ed 3). Philadelphia, W.B.
Saunders, 2000, pp 541-544
3. Vane DW, West KW, Grosfeld JL: Vitelline duct abnormalities.
Arch Surg 122:542-547, 1987
4. Moore GP, Burkle FM Jr: Isolated axial volvulus of a Meckels
diverticulum. Am J Emerg Med 6:137-142, 1988
5. St-Vil D, Brandt ML, Panic S, et al: Meckels diverticulum in chil-
dren: A 20-year review. J Pediatr Surg 26:1289-1292, 1991
6. Androulakis JA, Gray SW, Lionakis B, et al: The sex ratio of Meck-
els diverticulum. Am Surg 35:455-460, 1969
7. Teitelbaum DH, Polley TZ Jr, Obeid F: Laparoscopic diagnosis
and excision of Meckels diverticulum. J Pediatr Surg 29:495-497,
1994
8. Swaniker F, Soldes O, Hirschl RB: The utility of technetium 99m
pertechnetate scintigraphy in the evaluation of patients with Meck-
els diverticulum. J Pediatr Surg 34:760-764, 1999
Laparoscopic Appendectomy
Daniel J. Ostlie, MD, and George W. Holcomb, III, MD, MBA
ppendicitis is a common cause of abdominal pain in
A the pediatric patient. Moreover, suspected appendi-
citis is one of the most common surgical consultations
obtained in the outpatient or emergency room setting.
This disease occurs in all age groups, but has a higher
incidence in those children between 5 and 14 years of age,
with a second peak incidence in the elderly population.
The exact etiology of appendicitis is unknown; however,
it is generally agreed that obstruction of the appendiceal
lumen is the precipitating event. The obstruction may be
a result of an appendicolith or other factors such as lym-
phoid hyperplasia, infectious agents, or, rarely, a carci-
noid tumor. Following obstruction of the appendiceal
lumen, there is appendiceal dilation/distention with in-
creased luminal pressure across the appendiceal wall.
This leads to decreased vascular perfusion with break-
down of the mucosal barrier and necrosis.1 As the appen-
dix harbors colonic flora, it is understandable that infec-
tion ensues, unless appendectomy is performed, and
eventually leads to perforation with either localized or
generalized peritonitis and/or abscess formation.
DIAGNOSIS
As with most patients under evaluation for surgical pa-
thology, a careful history and physical examination are
critical to early diagnosis and intervention, limiting the
complications associated with perforation. The classic
presentation is abdominal pain that initially begins peri-
umbilically and migrates to the right lower abdominal
quadrant (RLQ) at McBurneys point over the ensuing 12
to 24 hours. There is associated anorexia and occasionally
one or two episodes of vomiting. More frequent vomiting
should cause the evaluating physician to consider gastro-
enteritis. Classically, the vomiting ensues after the onset
of the pain. If the vomiting occurs before the pain, gastro-
enteritis is a distinct possibility. Once the pain has moved
to the RLQ, it remains constant and will worsen as the
disease progresses. The local signs caused by the appen-
diceal inflammation/obstruction is the result of peritoneal
irritation in the vicinity of the appendix. Because of vari-
From the Department of Surgery, Childrens Mercy Hospital, Kansas City, MO.
Address reprint requests to George W. Holcomb, III, MD, MBA, Department of
Surgery, Childrens Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108
2005 Elsevier Inc. All rights reserved.
1524-153X/04/0604-0009$30.00/0
doi:10.1053/j.optechgensurg.2004.10.008
Operative Techniques in General Surgery, Vol 6, No 4 (December), 2004: pp 317-329
ability in appendiceal location, the pain is not always
located exactly at McBurneys point. If the diagnosis of
acute appendicitis is not made early, the pain will
progress over 36 to 48 hours at which time there may be a
sudden decrease in pain which indicates when perfora-
tion likely occurred. This diminution in pain will be fol-
lowed by generalized peritonitis, unless the perforation is
enclosed within the omentum, small bowel, or cecum (in
a retrocecal appendix) in which case an abscess may de-
velop.
Children can present often with urinary complaints
such as dysuria, frequent urination, and urgency because
of bladder inflammation related to the appendicitis. A
urinalysis is generally obtained in all patients with sus-
pected appendicitis to eliminate a urinary tract infection
as an etiology for the abdominal pain. Fever is commonly
associated with appendicitis. Generally, the fever is mild
(38-38.5C), unless perforation and peritonitis are
present, in which case it can be quite high (39-39.5C).
The physical examination of a child with suspected
appendicitis can be both straightforward and difficult at
the same time. The earlier a patient is examined, the easier
it is to get a true examination. Tenderness over McBur-
neys point and the presence of a Rovsings sign (pain in
the RLQ with palpation of the left lower quadrant) are
hallmarks of appendicitis. There may be mild abdominal
distention; however, this is not present early in the dis-
ease process. As the appendicitis worsens, there will be
more evidence of peritoneal irritation with rebound ten-
derness and guarding. Eventually, generalized peritonitis
will develop as a result of perforation and intestinal spill-
age causing severe peritoneal irritation.
Laboratory analysis in the presence of appendicitis
should be used as confirmatory evidence for appendicitis
rather than to establish the diagnosis. The most common
finding is a leukocytosis with an associated left shift. The
leukocytosis is usually less than 20,000 WBC/mL in the
acute phase. However, it can be much higher with perfo-
ration.2 Moreover, leukopenia may be present in severe
cases of peritonitis with associated sepsis. There are gen-
erally no electrolyte abnormalities unless there is signifi-
cant dehydration. It is not uncommon to encounter
pyuria that is the result of bladder inflammation at the
time of the urinalysis. The presence of bacteria in the
urine should lead to a diagnosis of urinary tract infection
in almost all instances.
317
318
1 A CT scan can be helpful in those patients in whom the
diagnosis is in question. The presence of right lower quadrant
abdominal inflammation, appendiceal enlargement, or the
presence of a fecalith lends support to the diagnosis of appen-
dicitis with an overall sensitivity of 95%. In this 18 month
old, the infant presented with vague abdominal complaints, but
did have some lower abdominal discomfort. The CT scan shows
a fecalith (arrow). This child underwent uneventful laparo-
scopic appendectomy and was discharged the following day.
Regarding imaging studies, a computerized tomogra-
phy (CT) scan of the abdomen and pelvis is often ob-
tained before obtaining a surgical consult. We do not
recommend that all patients being evaluated for appendi-
citis undergo CT of the abdomen and pelvis, but rather
reserve this test for those patients in whom the diagnosis
is in question (Fig 1). With this study, the presence of
RLQ inflammation and/or appendiceal enlargement lends
support to the diagnosis of appendicitis with an overall
sensitivity of greater than 95%. Less commonly, an ab-
dominal ultrasound will be used in a confirmatory fash-
ion. If the appendix is visualized and found to be dilated
to greater than 1 cm, this finding is highly suggestive of
appendicitis. If the appendix is not visualized or it is less
than 1 cm in diameter, the examination does not aid
significantly in the differential diagnosis. Plain radio-
graphs of the chest or abdomen generally are not useful
during the evaluation of acute appendicitis, and we rec-
ommend their use only for select cases, such as patients
with a possible renal stone or intestinal obstruction.3 The
clinical presentation of the child with appendicitis varies
markedly depending on the stage of the disease. Four
clinical scenarios will be described.
ACUTE,
NONPERFORATED APPENDICITIS
The most common and least morbid clinical presentation
of appendicitis occurs in the child that presents with
early, acute, nonperforated appendicitis. In this scenario,
Ostlie and Holcomb
the appendix may be acutely inflamed or suppurative, but
perforation has not occurred The typical presentation and
confirmatory signs have been presented previously in the
text. When this clinical scenario is encountered, we rec-
ommend immediate operation for appendectomy. If the
exploration is negative for acute appendicitis, we suggest
evaluation of the abdomen for any other pathology that
may be present, such as Meckels diverticulitis or mesen-
teric adenitis. Although a normal appendix may be found
in up to 15% of cases, we recommend the removal of all
appendices that are explored for acute appendicitis,
thereby limiting the difficulties associated with a repeat
evaluation of a patient with recurrent abdominal pain
suspicious for appendicitis in whom the appendix has
been left behind at a previous operation for appendicitis.4
NONCOMPLICATED
PERFORATED APPENDICITIS
When a patient presents with significant peritoneal irri-
tation, temperature 39C, or leukocytosis 20,000
WBC/mL or a history of symptoms greater than 48 hours,
perforated appendicitis should be considered. The preop-
erative management of these children should include ad-
equate resuscitation and the administration of appropri-
ate antibiotics. We favor either traditional triple antibiotic
coverage (ampicillin, gentamicin, and clindamycin/
flagyl) or, more recently, ceftriaxone and flagyl. If the
patient is stable and the symptoms have been present for
less than 3 or 4 days, we favor proceeding with appendec-
tomy rather than trying to treat nonoperatively followed
by interval appendectomy later. Often an early abscess
will be identified and omentum has walled off the puru-
lent fluid. The main advantage of the laparoscopic ap-
proach in this clinical scenario is a markedly reduced
incidence of postoperative wound infection compared
with the traditional RLQ open approach.
PERFORATED APPENDICITIS
WITH ABSCESS AND STABLE PATIENT
A third clinical scenario can be seen in patients with
appendicitis complicated by perforation and the forma-
tion of a well-defined abscess cavity. The duration of the
perforation is important in that these patients usually
have symptoms for 1 week or longer. Typically, they have
an initial 24 to 48 hours of symptoms suggestive of ap-
pendicitis, but then begin feeling better which is when the
perforation likely occurs. Following a short interval of
feeling better, they begin to feel worse. These patients are
often teenagers, but we have seen an occasional younger
patient with this scenario. The patients are febrile and
have a well-delineated right lower abdominal mass. How-
ever, there is no evidence of small bowel obstruction or
other signs of toxemia. A CT scan is performed and reveals a
well-defined abscess. There is no evidence of bowel obstruc-
tion on the abdominal films or the CT scan (Fig 2).
Laparoscopic Appendectomy 319

2 In select cases, patients with a long-standing history consistent with perforated appendicitis may present with a well defined
abscess cavity, but may not be toxic from this disease. On the left (A), the abdominal/pelvic CT scan is seen from such a patient with
a well defined and localized abscess cavity (arrow). On the right (B), the patients plain abdominal film shows no evidence of
intestinal obstruction from the abscess. In this type of patient, usually a teenager, nonoperative management is initiated with
percutaneous drainage of the abscess cavity followed by 10 to 14 days of intravenous antibiotics. Most of the antibiotic therapy can
be accomplished at home. If the abscess resolves and the patient remains stable, the patient then returns at approximately 6 weeks
for a laparoscopic interval appendectomy.

In the above clinical scenario, initial nonoperative
management is favored. The abscess cavity is drained
percutaneously and a PICC (percutaneous intravenous
central catheter) line is introduced for home antibiotic
administration. If the patient stabilizes and is able to tol-
erate a regular diet, he/she can be discharged and the
antibiotics continued for 10 days. The patient is usually
seen in the outpatient setting approximately 1 week fol-
lowing the drainage procedure and a repeat CT scan per-
formed. If there is no evidence of a residual abscess cavity
and the patient is clinically improving, the drain is re-
moved. The patient is often continued on oral antibiotics
for another week or two with plans for an interval lapa-
roscopic appendectomy 6 weeks following the initial
drainage procedure.
It should be emphasized that patients managed in
this fashion comprise a select group. Very few (5%)
of all patients who have presented to our hospital with
appendicitis have been managed in this fashion. Also,
there is some controversy about whether or not the
interval appendectomy needs to be performed. How-
ever, in our experience, we have seen several patients
with a long, tubular appendix at the time of the interval
laparoscopic procedure with a fecalith found in the
specimen (Fig 3). This operative finding leads us to
believe that these patients are at risk for developing
another episode of appendicitis. Thus, we believe that
the interval laparoscopic appendectomy is an impor-
tant part of the overall treatment plan of these patients.
Most of the patients that we have managed in this
320
3 This operative photograph shows a long, tubular appendix in
a patient who had previously undergone nonoperative manage-
ment for perforated appendicitis and abscess. At the time of the
interval appendectomy 6 weeks following the development of the
abscess, the appendix was removed. It is not unusual to find a
rather significant residual appendix at the time of the laparoscopic
interval appendectomy that leads us to believe that all patients
treated in this manner should undergo interval appendectomy to
prevent a second episode of acute appendicitis.
fashion have been ready for discharge on either the first
or second day following their interval laparoscopic
procedure although one patient had a prolonged post-
Ostlie and Holcomb
operative course of 5 days because of unexplained nau-
sea and vomiting.
PERFORATED APPENDICITIS IN
AN UNSTABLE AND TOXIC PATIENT
Once or twice a year, we find a patient with perforated
appendicitis who is in critical condition requiring a
massive amount of intravenous fluid, nasogastric suc-
tion and, on some occasions, vasopressive medication.
These patients represent the extreme result of un-
abated perforated appendicitis with generalized perito-
nitis. In such patients, following stabilization, an ex-
ploratory laparotomy is performed through a lower
midline incision, the appendix is removed and inter-
loop abscesses manipulated and drained. Usually, 4 or
5 liters of saline are used to irrigate and cleanse the
abdominal cavity in these patients. Drains are placed
along each lateral colonic gutter and exteriorized
through the lower aspect of the incision. Also, a pelvic
drain is often placed. It is not unusual for these patients
to require 10 to 14 days, or even longer in some in-
stances, of hospitalization as they are quite ill and slow
to recover. Occasionally, they will also develop another
intra-abdominal abscess that requires percutaneous
drainage. However, over the last 5 years, we have not
had any mortality in this patient population and no
significant morbidity.
Laparoscopic Appendectomy 321

SURGICAL TECHNIQUE
We utilize a three instrument technique for laparo-
scopic appendectomy. A broad spectrum antibiotic
(such as cefoxitin) is given to cover Gram-negative
organisms and anaerobic bacteria. The operation is ini-
tiated with the patient in the supine position after the
induction of general anesthesia. If possible, we have
the patient urinate before their transfer to the operating
room. For smaller children, a Cred maneuver is em-
ployed to obtain bladder decompression, thus elimi-
nating the need for bladder catheterization. If the blad-
der is distended and cannot be emptied, urinary
catheterization is performed.

4 Following a vertical incision in the center of the umbilical skin, the cautery is used to incise the fascia and peritoneum. A 12 mm blunt
tip Step (US Surgical, Norwalk, CT) cannula is introduced into the peritoneal cavity and the abdomen is insufflated with CO2. (A 12 mm
Step cannula is placed in the umbilicus because the 10 mm endoscopic stapler is too large for a 10 mm Step cannula.) A 5 mm 70 degree
angled telescope is then introduced through the umbilical cannula. A 5 mm Step cannula is inserted through a left lower abdominal
incision, lateral to the inferior epigastric vessels. The craniocaudal position of this cannula is determined by the size of the child, but a
general guideline is to position this cannula approximately one-half the distance from the symphysis pubis to the umbilicus. The third
instrument is placed in the left suprapubic location. With the telescope inserted through the umbilical port, the collapsed bladder is
visualized, and a 5 mm Step cannula is inserted just above the peritoneal reflection of the bladder and to the left of the patients midline.
322 Ostlie and Holcomb

5 After insertion of the three cannulas, the abdomen is fully inspected, including the RLQ for signs of appendicitis (inflammation,
omental adhesions, appendiceal injection, or perforation, purulent peritoneal fluid), the gallbladder and liver, and the terminal
ileum for evidence of a Meckels diverticulum (especially in the face of a normal appearing appendix). In adolescent females, the
ovaries and fallopian tubes are visualized to eliminate a gonadal etiology for the abdominal pain. If an abscess has developed, the
walls are gently separated and the purulent fluid suctioned to prevent contamination of the rest of the peritoneal cavity. If the
appendix is retrocecal, the lateral peritoneal attachments to the cecum are incised to mobilize the cecum and appendix. This
dissection is usually performed sharply.
Laparoscopic Appendectomy 323

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

7 Once the appendix is mobilized, an opening is made in the mesoappendix just distal to the junction between the appendix and
the cecum. Using the two instruments (a Maryland dissecting instrument and an atraumatic grasper) through the two 5 mm
cannulas, this window is made large enough to accommodate a 35 mm endoscopic stapler.
Laparoscopic Appendectomy 325

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

9 However, in some cases, it is more advantageous to proceed with mesoappendiceal division before appendiceal division.
Regardless of the order, a vascular load is utilized to perform the mesoappendiceal ligation and division, and a gastrointestinal load
is used to perform the appendiceal division.
Laparoscopic Appendectomy 327

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

11 However, if perforation has occurred or if the appendix is too large to permit its removal through the 12 mm cannula, it is
placed into an endoscopic bag, which is inserted through the umbilical cannula. The cannula and bag are exteriorized along with
the appendix through the umbilical incision. Following local, but not generalized, irrigation, the instruments are removed under
direct vision and the subcutaneous tissues are infiltrated with 0.25% bupivocaine. The umbilical cannula is removed, the fascia is
closed with an absorbable suture, and the umbilical skin is approximated with absorbable suture such as plain catgut. If possible,
the fascia of the other two instrument sites is closed with an absorbable suture and the skin is closed in a subcuticular fashion. A
nasogastric tube is usually not needed and the patient is advanced to a regular diet as tolerated. The antibiotic is continued for 24
hours for nonperforated appendicitis. For perforated appendicitis, broad spectrum coverage is utilized and is continued for at least
7 days or until the patient is afebrile with a normal leukocyte count.5
Laparoscopic Appendectomy
CONCLUSION
The laparoscopic approach for appendicitis is advanta-
geous in a number of clinical scenarios. For the child with
simple, acute appendicitis, the operation is well tolerated
with reduced postoperative discomfort and a short post-
operative hospitalization. Moreover, the incidence of
postoperative wound infections approaches zero.
Patients, especially children, can present with perfo-
rated appendicitis in a wide variety of clinical scenarios.
Unfortunately, approximately 30% to 40% of children
seen with appendicitis have already developed perfora-
tion. For those patients with acute appendicitis with
rather recent perforation, the laparoscopic approach is
utilized. The main advantages for this approach center on
the ability to directly suction all purulent material under
visualization and lyse small intestinal adhesions formed
by the inflammatory response. Also, the greatest advan-
tage of the laparoscopic over the open approach for this
patient population with early perforation is the almost
nonexistent incidence of wound infections. Moreover,
the incisions do not need to be left open and, should a
wound infection develop which requires drainage, inci-
sion and drainage can easily be accomplished in the out-
patient setting under local anesthesia. However, there is
likely not a significant reduction in hospital stay with the
laparoscopic approach for these patients with perforated
329
appendicitis as the patient still requires recovery from an
ileus and the prolonged instillation of intravenous antibi-
otics.
For the patient with perforation and a well-defined
abscess of relatively long-standing duration, initial non-
operative management followed by interval laparoscopic
appendectomy has been a very efficient approach in a
small segment of patients. Also, for patients who are crit-
ically ill from perforated appendicitis, laparotomy
through a lower midline incision affords the surgeon the
best chance for evacuating the purulent material and abat-
ing the significant peritonitis in these patients.
REFERENCES
1. Wangensteen OH, Dennis C: Experimental proof of obstructive
origin of appendicitis in man. Ann Surg 110:629, 1939
2. Samuel M: Pediatric appendicitis score. J Pediatr Surg 37:877-881,
2002
3. Garcia Pena BM, Cook EF, Mandl KD: Selective imaging strategies
for the diagnosis of appendicitis in children. Pediatrics 113:24-28,
2004
4. DeCou JM, Gauderer MW, Boyle JT, et al: Diagnostic laparoscopy
with planned appendectomy: An integral step in the evaluation of
unexplained right lower quadrant pain. Pediatr Surg Int 20:123-
126, 2004
5. Meier DE, Guzzetta PC, Barber RG, et al: Perforated appendicitis in
children: Is there a best treatment? J Pediatr Surg 38:1520-1524,
2003
Intussusception
Baird Mallory, MD,1 and Yale Popowich, MD2
n children 3 months to 3 years of age intussusception is
I one of the most common causes of a distal small bowel
obstruction. It is often associated with intermittent pain
accompanied by a characteristic knees-to-chest position,
vomiting, and passage of bloody currant jelly stools. A
sausage shaped mass in the right upper quadrant is
more often described than palpated (Fig 1). In this age
group, intussusception is thought to occur secondary to
viral infection inflaming Peyers patches or, perhaps, the
appendix either of which may then act as the lead
point of the intussusceptum that invaginates or tele-
scopes downstream into the intussuscipiens. It is liter-
ally as though the downstream bowel has mistaken the
upstream bowel for stool and is trying to propel it forward
toward the anus. This typically occurs just proximal to
the ileo-cecal valve and so is called ileo-cecal intussus-
ception.
When intussusception occurs outside of this age group,
in most cases there will be a pathologic lead point includ-
ing:
lymphoma
carcinoid tumor
adenocarcinoma
Meckels diverticulum
mural hematoma from Henoch-Schonlein purpura
or trauma
polyp
duplication
Intussusception may also occur after operations, par-
ticularly those involving the retroperitoneum, although
in this circumstance it may occur further up in the small
bowel. At this location these intussusceptions, called il-
eal-ileal, are difficult to diagnose or treat with contrast
enemas. They are best diagnosed by a computed tomog-
raphy (CT) scan (ultrasonography may be successful in
very experienced hands) and treated by operation. Expe-
rienced laparoscopists will note that intussusceptions oc-
cur in nonpathologic states: during operations for prob-
lems nonenteric, small bowel may be observed to
From the 1Department of Pediatric Surgery, Packard Childrens Hospital at
Stanford, Stanford, CA; and 2Department of General Surgery, Stanford University
Medical Center, Stanford, CA.
Address reprint requests to Baird Mallory, MD, 780 Welch Rd, Suite 206,
Stanford, CA 94305-5733.
2005 Elsevier Inc. All rights reserved.
1524-153X/04/0604-0010$30.00/0
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330 Operative Techniques in General Surgery, Vol 6, No 4 (December), 2004: pp 330-334
transiently intussuscept into itself and then return to a
normal anatomic state without causing postoperative
symptoms.
Diagnosis of ileo-cecal intussusception is ideally done
by ultrasound but is also possible by CT scan or water
soluble contrast enema. In the latter case the procedure
may also be therapeutic: a bag of contrast is hung 3 feet
above the patient and a catheter (with or without bal-
loonthe author prefers with) is securely taped into the
childs rectum. Nothing is more important than the com-
bination of catheter and tapingif this is not hermetic it
will be impossible to apply sufficient pressure via any of
the nonsurgical reduction techniques. It is probably wise
to give one dose of antibiotics with Gram-negative and
anaerobic coverage (Cefotetan). All nonoperative at-
tempts should be aborted and the patient transferred to
the operating room (after resuscitation) if he or she has or
develops an acute abdomen.
Water soluble contrast (in other cases either water or
air may be used) is infused under radiologic visualization
with which one can watch the intussusceptum being re-
duced back out of the intussuscipiens.1 Although the
intussusceptum may actually start physically coming out
the anus, it is more usually found in the ascending, trans-
verse or descending colon from which it reduces in a left
to right direction. When air is used this may take as much
as 130 to 140 Torr for periods of 5 minutes at a time.2
There is always swelling at the ileo-cecal valve but only
fluid/air refluxing back up into the small bowel (through
an incompetent ileo-cecal valve) is proof positive of suc-
cess.
When successful, the patient may soon begin fluids and
then solids followed by discharge in about 24 hours. Al-
though fever during the first 24 hours after reduction is
not uncommon (thought to occur secondary to bacterial
translocation), there is experience in Sweden with actual
patient dismissal directly from the radiology suite. Occa-
sionally high reduction pressures expose an inguinal her-
nia. Rarely these pressures cause bowel rupture either
in the cecum (because of transmitted pressure) or rectum
(because of catheter balloon pressure). As long as air or
water soluble fluid has been used there is typically little
contamination of the abdomen during the operation that
occurs rapidly after patient stabilization. Barium, in this
circumstance, is disastrous and may be associated with
life-threatening infection.
Intussusception
Nonoperative reduction fails in 40% to 50% of patients,
depending on the timing of presentation and aggressive-
ness of the radiologists. Unsuccessful reductions may re-
late to inadequate taping of the buttocks to establish suf-
ficient intraluminal pressure. When skilled radiologists
are unsuccessful, commonly the intussusceptum will be
partially dead and resection will be required. When less
SURGICAL TECHNIQUE
The open approach is performed through an R-transverse
incision just above or below the umbilicus.4,5 The bowel
is exteriorized, demonstrating an engorged colon con-
taining intussuscepted ileum (Fig 2). Squeezing on the
colon while pulling on the ileum has been found more
successful than pulling alone (Fig 3). A successful reduc-
tion is usually possible with viable bowel, although ery-
thema and edema, and occasional discoloration, may in-
dicate a period of warming and waiting before assuming
viability (Fig 4). This is a good time to remove the appen-
dix (Fig 5), which is usually done because of the possibil-
1 Child in supine position showing position of mass
(cross-hatched) and planned incision. Note that the incision
must be made near the level of the umbilicus, either just
above or below it.
331
aggressive efforts have been made, operative reduction
without need for small bowel resection will be more com-
mon. The approach may be open or laparoscopic al-
though the former may enable one to more effectively
squeeze the distal bowel (often compared with squeez-
ing a tube of toothpaste) while pulling on the proximal
bowel.3
ity it served as a lead point and to prevent future confu-
sion about a scar near McBurneys point. The incision is
primarily closed (Fig 6).
If the intussusceptum is dead it will be difficult, if not
impossible, to reduce, indicating that resection is neces-
sary. At this point it is very important to realize the intus-
suscipiens is alive and some of the intussusceptum may
be as well. Therefore, after aggressive manual reduction
attempts, one makes a circular incision around the most
proximal portion of colon available; this enables exterior-
ization of the intussusceptum and estimation of its viabil-
ity and usually there is a portion which can be preserved
for anastamosis. More than one operator has mistakenly
excised the entire sausage of ileum-containing colon, sac-
2 Exteriorized cecum, appendix, and ileum. Note ileum (in-
tussusceptum) invaginated into cecum (intussuscipiens)
causes cecum to appear bulky. Appendix has been reduced by
air enema.
332 Mallory and Popowich

3 The combined method of squeezing the distal bowel (colon) while pulling on the proximal bowel (ileum) is demonstrated.
Intussusception 333

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

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

334
6 When the operation is complete, the skin is primarily
closed.
rificing more bowel than necessary. This is not of great
significance in the usual cases involving the ileo-cecal
valve, but sometimes the segment is much longerin this
case excess excision of small bowel and colon may lead to
short gut syndrome.
Mallory and Popowich
The laparoscopic approach involves ports (3) placed
through the umbilicus, right lower quadrant and supra-
pubic region, after the usual precautions. One attempts to
duplicate the maneuvers used in the open operation. One
additional maneuver includes pulling the colon intussus-
cipiens over the surface of the intussusceptum (distally)
as surrogate for squeezing the colon like a tube of tooth-
paste. If resection is necessary, the subsequent anastamo-
sis may be performed intracorporeally or extra-corpore-
ally through an enlarged umbilical incision, depending
on surgeon preference. Laparoscopic reduction may be
augmented by rectally applied reduction pressure al-
though the subsequent swelling of the colon with air may
obscure the surgeons view.
There are few long-term complications other than re-
currence (10% following nonoperative reduction), ad-
hesive small bowel obstruction (more common following
open reduction) and stenosis when ischemic bowel is not
resected.
REFERENCES
1. Goldstein AM, Cho NL, Massiotti MV, et al: Pneumatically assisted
laparoscopic reduction of intussusception. Pediatr Endosurg Innov
Tech 1:33-37, 2003
2. Guo JZ, Ma XY, Zhou QH: Results of air pressure enema reduction
of intussusception: 6,396 cases in 13 years. J Pediatr Surg 21:1201-
1203, 1986
3. Schier F: Experience with laparoscopy in the treatment of intussus-
ception. J Pediatr Surg 32:1713-1714, 1997
4. Wright VM: Intussusception, in Spitz, L (ed): Rob and Smiths
Operative Surgery: Pediatric Surgery. London, UK, Chapman &
Hall, 1995, pp 396-401
5. Young DG: Intussusception, in ONeill JA (ed): Pediatric Surgery.
St. Louis, MO, Mosby, 1998, pp 1185-1198