Single-incision pediatric endosurgery: lessons learned from our first 224 laparoendoscopic single-site procedures in children

To identify technical difficulties during single-incision pediatric endoscopic surgery (SIPES) cases and to highlight solutions. After IRB approval, all SIPES cases were prospectively collected, and the surgeons involved were polled for technical difficulties encountered and their operative solutions. Over a period of 13 months, 224 pediatric SIPES cases were performed in 223 pediatric patients (92 female, 131 male) aged 3 weeks to 19 years. Among these were 130 appendectomies, 32 pyloromyotomies, 32 cholecystectomies, 11 inguinal hernia repairs, 6 Nissen fundoplications and 4 laparoscopic-assisted endorectal pullthrough procedures. Eighteen procedures (8%) employed a primary extra-umbilical instrument in addition to the transumbilical trocar(s). Thirty procedures (13%) begun via a single-site technique required additional trocars for completion. None required laparotomy. Intraoperative complications are discussed. The main challenges of SIPES are: (1) variable umbilical anatomy, (2) large size of current proprietary multitrocar devices, (3) trocar crowding, (4) intra-abdominal exposure, (5) fewer degrees of freedom, (6) clashing instruments, (7) in-line endoscope viewing, and (8) limited number of working ports. We discuss coping strategies to address these issues. Many of the drawbacks of SIPES can be overcome by specific techniques, which can make SIPES procedures more broadly feasible and applicable within pediatric endosurgery.