IPEG 2015 - EXPERT PANEL: MIS Revisional Surgery

The session is on revisional surgery. And, um, we'll go ahead and get started. It, it's probably be better to, uh, ask questions after the uh presentations on the, the topics rather than waiting to the end. So, uh, we'll allow some time for, uh, questions, but we need to go on and move through the program so we get finished on time. So our first two presenters, uh, will be, uh, Doctor Lahi and, uh, Doctor Harmon, and they're gonna talk about revisional, uh, fundoplacation surgery. All right, good morning. OK. Laparoscopic fun application is, is a very, very common procedure, at least in the United States, and that is mostly driven by an increasing population, a constantly increasing population of premature neonates with chronic lung disease. The surgical technique for funduplication for different types of funduplication in in theory is well standardized. However, uh, when we look into the literature regarding the failure rates and outcomes in general, um, the results are quite heterogeneous and, and the, and, you know, the, you know, all those outcomes that are quite dissimilar even though the surgery, like I said, is supposed to be standardized. Um, when we try to evaluate the outcomes of, um, patients after fund application, there, there's a number of issues or, or, or problems that don't allow us, uh, to do clear analysis of the data. Uh, first of all, the, the population that receives the surgery is very heterogeneous, from the premature baby with chronic Lyme disease to the maybe teenager with, uh, developmental delay. Um, there's also no standard follow up path, um, for after the surgery. In some centers we do studies routinely after the operation just to see what's going on in other centers we just follow patients clinically, um, so there's no clear path on, uh, you know, how, how to evaluate what happens afterwards. And there's also not a very clear definition of failure. Um, what is a failure of the of the fund duplication is something just an image? Is it, um, it has to have a clinical impact, um, is it a failure only when it needs surgery? Um, so there's no clear definition of any of these things. Uh, in our opinion, um, at, at least at our center, we believe that a failure of a duplication is, uh, has to fulfill two conditions. Um, first, the patient has to in a way go back to what it was before. It has to have, uh, failure to thrive or inability to gain weight, um, and or. Have again respiratory problems or being unable to protect the airway because of reflux with clinically obvious reflux, but together with this in our opinion, we must have an abnormal contrast study showing that there is an anatomical issue that should not be there and that is the reason why the symptoms have recurred. Um, and we highlight this because, um, we commonly receive patients, uh, in, in our clinic that are referred to us for a possibly redo, um, because they have, for instance, wretching or they have feeding intolerance, and people, uh, or practitioners not very familiar with, uh, with surgery may believe that all of these things are because the wrap has failed. Uh, when in reality is issues related to the feeding technique or the feeding regimen or the formula that the the patients are being given, etc. So in our opinion there must be an anatomical issue together with recurrent of symptoms. And even in those cases, um, we believe that the first step in general could be uh medical management um and if that fails only then we believe the surgery might be indicated. Um A very controversial topic in the literature is the list of things that would predispose, uh, uh, you to a failure of the funduplication and uh in general I would just say by memory, um, neurodevelopmental delay, uh, younger age of surgery, all those things. Now when you look deeper into the literature I assure you that for any and each of these um. Uh, conditions that are supposedly associated with a higher failure rate, there are papers towards that and papers against that, and these are just a list of, uh, a few papers, um, that, um, for instance, on the first one, patients that have neurological impairment in general, people tend to think that the results are worse. However, there's plenty of literature saying the opposite, and the same is true for patients with prematurity and ch chronic lung disease, um, or patients who undergo surgery at a younger age. Uh, patients who undergo open surgery or laparoscopic surgery. There's plenty of papers out there saying that laparoscopic is worse and plenty of others saying that the open is worse, um. And one of probably the the the the the one that is there's less controversy on is the fact that patients who require dilatations after the initial fund application may be at risk for failure. But what I, what I wanted to point out with this um Um Graphic it was is what does this tell you? In our opinion, when the literature is so controversial and so contradictory, it tells us, at least we think that when the surgery fails it's just because of a technical problem, at least in general I'm sure there's some truth to the risk factors, uh, but we cannot neglect the fact that the technical errors are probably, uh, the stronger predictor of problems. Um, this graph shows, uh, roughly the things that can happen, uh, after a phone duplication that would make, uh, make it not work. Uh, on the upper, um, left, uh, you can see a complete disruption, you can see the stitches that are left behind, uh, on the upper right, um, you can see that the the wrap just migrated down. Um, on the lower left, you can see that the actual wrap was built on the, uh, body of the stomach. It's like a corpoplasty. That would never work. Um, and on the upper, uh, right, um, you can see that somehow the hiatus was left too big, um, and the entire thing just migrated up. Um, and again, you can blame the patient all, all you want, um, and try to come up with explanations, but in reality, we believe that at least in, in a strong part, um, this is just the result of technical or, or not paying attention to details. We are all very familiar with this awesome study that came out a few years ago, um, uh, in which the authors showed, um, that dissecting the esophagus off the diaphragm, um, was strongly associated with worse results. In the past, the tendency was to just to undo the whole, uh, you know, esophago, uh, phrenic unit, and that I think came from adults that needed to dissect the esophagus esophagus a lot to gain length, but in kids it's a different story. And these studies showed very clearly that in patients, uh, um, that the patients who did not undergo a very extensive dissection, uh, did a lot better, and that is purely a technical, uh, issue. There's not much, uh, to, to, it doesn't have much to do with the patient quality or, or, or demographics or anything. It's just a technical issue. So now I think the vast majority of that of, of us pay attention to, to these detail, and the results are better in general. You can see here that the incidence of redo was 3% roughly, at least at that time of the follow-up in the patients who did have a minimal dissection versus almost 20% in those who have a maximum dissection. Another, um, technical issue is that, um, the um esophageal hiatus has to be tightened, and we believe that there's a tendency, uh, to leave that not tight just for the fear of, um, you know, causing, um, you know, stricture and the, the esophagus. So we're strong believers that, uh, the, the hiatus needs to be tight, and, uh, even if it looks too tight on the image, um, this is critical to avoid, uh, the, the wrap from migrating up. And another thing that we see quite often is that when uh people put the uh the stitches to build the fundoplication they grab the left side of the uh fundus and the right side of the fundus bypassing the wall of the esophagus. So for some time the esophagus will be able to slip in, in, in between the the the wrap. So we actually believe that this should not be done and and the stitches need to get a big and strong, strong bite of the esophageal wall so that this remains as a big unit and, and the wrap cannot migrate up or down. Um, and when, when you fail to pay attention to these details, that's what happens, uh, in this, uh, image we can clearly see the wrap, but some somehow the hiatus was left, uh, too redundant, and a part of the upper part of the stomach just, uh, herniated up. Um, in this one, for instance, we can see, uh, the, um, that the phone application was built in the, in the body of the stomach, you know, there's the typical image of the wrap is just not there. Uh, this one we can see the wrap, which is the, the area of the defect of contrast, and somehow a good portion of the stomach just either migrated up or the wrap was built, uh, in the incorrect spot. And in this last one again, the hiatus must have been left too redundant and the entire unit just migrated up into the chest. Um, so when it comes to technical details that usually goes associated with, uh, the question, OK, so if you do more of these and you get more proficient with the technique, does that have an impact on your outcomes? And in, in general, if you read the literature, the studies that have higher, uh, recurrence rates have short, uh, smaller series in, in, uh, in their groups. So this is just to say that in our opinion, as in probably every, uh, surgery, you know, the more you do, the better you get at it and the better results you have. And this also tells you that maybe it's not so much about the patients as we tend to believe, but as, um, it's, it's about us and how, how, you know, good we are and how much attention we pay to those small details that uh will will make all the difference. Um, we did a retrospective study in our center, um, uh, during 6 years we reviewed about 500 missions done uh in kids younger than 2 years on a maximum follow up of 5 years and we had a pretty low um recurrence rate, at least at that time. Um, which was, uh, around, uh, just about 3% or a little less than that, which is a pretty good number. It was a very homogeneous population. We don't have long-term, uh, outcomes, but, um, the the the point of the study is that it was a large amount of patients done just by a few surgeons and all with the same same technique. Um, so, in our opinion, to conclude, um, we believe that the failure of a phone application should be a quite rare event, um. And we believe that rather than the patient's characteristics, even though there might be some truth to it, in general, when things fail are because uh of technical errors and um we also believe that higher volume um is usually associated with better results. Thank you. Yes. Uh, it's just to reiterate, uh, uh, Pablo's comments that one man's fundoplication or one surgeon's fundoplication is not another surgeon's fundoplications. Any time you're talking about, uh, uh, recurrent reflux and what do you do about it, you have to take into consideration the anatomy is, uh, quite different after these operations. Uh, most literature would say that there's a recurrence rate of somewhere between 10 and 25%. I congratulate Pablo's results at 3% or less. Uh, this is what it used to look like. We used to mobilize the esophagus, uh, aggressively to get adequate intraabdominal length. This was, uh, now known to be a risk factor for recurrent disease, uh, and the same pictures that Pablo showed about minimal mobilization. So what do we do when you get recurrent reflux? So just a hands up in your institution, who, who, uh, who gets a gastrojainnostomy tube if your fundo fails. Nobody, your gastroenterologists don't wanna do that. Yeah, a few hands go up. So, uh, who, who we saw a beautiful, uh, laparoscopic esophagogastric disconnection in the video section this morning that looked like a big deal operation, right? So, uh, a redo fundo is an obvious option in this case, and we can argue about how many redos you do before you give up and do something else, but a redo fundo is reasonable. So indications from my point of view for consideration of redo fundo are listed here. Uh, for the sake of time, I'm just showing one X-ray that shows the traditional what you had happened to you after you did the aggressive mobilization and you had recurrence. You also had a big hiatal hernia. So some technical points for the for the revision laparoscopic fundoplication, uh, careful access to the umbilicus. There's oftentimes a loop of bowel stuck up right there. Uh, I like using the telescope just to do blunt dissection to push down loops of bowel and adhesions in order to get more trochars in. Try to use your old sites if you can, and interestingly, you don't typically have to take down your gastrostomy tube to do this operation. You can work around it. Some other technical points, um. I like having a bougie in place for this, uh, procedure, sharp dissection, find the cura, reduce the hiatal hernia. Again, in the old days, I would say you most of the time had to completely undo the wrap and then redo the wrap, close the hiatus, and an interesting debate will be about whether you put a patch in at your first or second redo. Whit may comment on that later. Uh, now if you've done the minimal mobilization, your chance of recurrent reflux is lower, but it's not zero. But when you re-explore those patients for a redo fundo, usually the wrap is just loosened, it's undone, and you can do less dissection to mobilize it enough to re-approximate your previous fundo, and it's less of an operation. So, um, Uh, a video of, uh, a redo fundo boy that does not look like the first time you did a fundo, right? Uh, this, uh, is a lot of adhesions. The first thing you notice is the liver is always stuck to the stomach. Uh, and, uh, uh, you have to take that down. I'm an advocate of using, uh, sharp scissor dissection for that, uh, rather than a hook cautery or other things. Um, As you work your way up, uh, the stomach toward the hiatus, uh, we'll eventually see that, uh, you can find the hiatal hernia. Oftentimes the anatomical left side of the stomach toward the spleen is not as stuck as, uh, this part of the stomach. Once you mobilize that enough, you can, you can see the G tube is still in place. That's the stomach tenting up. You can get another trochar in and uh nice liver retractor there. That your assistant helps you with, but it's really a one person. Operation for the most part. Now Steve and Whitt have both done an awful lot of fundos. Um I'm not sure that Steve has ever had to redo one of his fundos, but I know Witt has had some experience with this, so if they wanna make comments, uh, during the video, that would be fine. So now you can see the hiatus over on the left side and the, the stomach is going up through the hiatus. You can see the left cruise and again, uh, this is a common finding back in the days when we did aggressive mobilization of the esophagus. Uh, here's a little video clip of, uh, freeing up the, the hiatus enough to reduce the stomach, uh, which is herniated up into the chest. Uh, hook cautery is a little bit more helpful here. If I could speed it up, I would, but I can't. operates Operate slow. Uh, I'm, I'm helping someone, prob maybe someone in this room. It was, this was a long time ago. Uh, minimal mobilization has lessened this operation. Yeah, I apologize. I need to speed up. Almost. There's a microphone. It's a lot more scar tissue than this. I mean, this is, this, this was obviously probably a redo of a lap fundo initially, right? So the big hiatus and then closing the currow behind. I agree, Steve, that was not a lap redo of an open fundo. That good point, um. Uh, after you've done that mobilization, you can need to do the re-wrap, still shoot for a loose, uh, short wrap. Uh, I like the stitches to put the wrap over at the 10 or 11 o'clock position. I think we tend to all do that, not exactly sure about the data behind it. So if we look at outcomes of redo fundopplacations, uh, number one, the complications of a laparoscopic redo are less than open redos. That's been well established. I do think you have more chances for bleeding both intraoperatively and post-op from that dissection. Uh, people always worry about an esophageal tear in the second operation that you don't worry so much about in the first operation. Uh, dysphagia certainly can happen if you make your wrap too tight or too long, and unfortunately, the, the, despite the idea that we can technically do that and it may be better than an esophagogastric disconnection or a GJ tube, which drives the family crazy, there's still a recurrence rate after the second fundo. And if you do a 3rd fundo, there's a recurrence rate after that too. Ask me how I know. So my conclusions uh are that uh initial laparoscopic fundoplication can be helpful in many children and and help for quite a long time. However, no fundoplication that I'm aware of is perfect, and there's a real rate of recurrent reflux disease, as Pablo said. How we define that's a little bit tricky, but that really does happen. Um, except to Steve, laparoscopic fundoplications, um, a redo is very feasible and can have very good results in my opinion. However, again, the redo is not perfect and also has recurrent disease, and you have to have a strategy for what you do next. So, um, I'll stop there and, and we can entertain any questions. Thank you. Uh, Pablo and Mac, thank you so much. Nice presentations. Uh, many of you know that our center has been interested in fundoplication and, and really how, how to do an operation, uh, without having to do a second operation. Uh, personally, I think that the fundoplication is the best treatment for symptomatic, uh, gastroesophageal reflux disease. And if we can make it an operation that doesn't have complications and you don't need to do a second time. Then I think more and more gastroenterologists will, uh, feel that way, uh, and send their patients to us to get, uh, get that operation. So let's open up the, uh, uh, conversation for some questions. Uh, Yama, do you have a question? Yeah, thank you for showing a nice video, but you didn't mention about how many percent are neurologically impaired and how many percent had a gastrostomy at the time of the redo, because some cases have a severe scoliosis. So, uh, what, how many percent are neurologically impaired and how many percent are severe scoliosis when you are redoing, so the actual the percent of kids that are neurologically impaired kids. That get recurrent reflux disease is controversial. There are papers that say it's a risk factor, and others say it's not a risk factor, but when they do get it, they often do have scoliosis and positioning them on the table and where you stand and where you put trocars, as you understand, are very, very different than a, a non, uh, distorted, you know, body habitus like that. So have you done the redo Nissan? In the patient who had a gastrostomy tube, who's had a what? gastrostomy. Gastrostomy. Yes, yes, all the time. This one was so you you you've taken down the so I leave it and work around it. But I, I think that's an important point. I think it depends on whether you did the gastrostomy and where the gastrostomy was put, because I think if, if the gastrostomy was not put in a good position and you can't get adequate mobilization so that you have a, a floppy wrap, that you should take down the gastrostomy. You can get by, you can be fooled, but I think that. You need to be very carefully evaluate where that gastrostomy is before you make that decision. If it's, if I'm redoing one of my fundos, I know that the gastrostomy is in a position that, that allows for an adequate loose wrap. But if you're, I've done other ones where it was very clear that I could not get a good wrap, in which case I think you should take down the gastrostomy. I agree. Over here. So what I was gonna make a quick comment about uh uh Mac about the, uh, esophagogastric disconnect. You made a, you sort of dismissed it and said that, you know how many redo fundos do you have to do before you do one. What I can tell you is if you do the disconnect after multiple redo fundos, it is a real bear. I've had, so I had one family. In whom I did a gastroesophageal disconnect and a completely neurologically devastated child, which I think it's a good, it's, I think it's a good operation as a first operation, as a first operation. Well, the, the, well, one kid I did as this is a foster family who kept adopting neurologically impaired kids, the first one I did after a failed fundo, after that, they had two more children that they begged me to do it as a primary operation. And as a primary operation it actually goes very smoothly, but for redos, I do think that we ought to consider it for the severely neurologically impaired kid. I think trying a fundo once, but I don't know if you'll comment or if you guys have any experience with doing the disconnect. It's, it's, it's the second operation. It's not a bad option for. Redo. Coming about the patch with since that that was real controversial for a bit, you advocated a patch after the first. Right, um, I used to think that, uh, the patch was really important. I'm not sure it's that important. Uh, I started putting a, a surgicis patch in after when I had to do my only 3rd time fundal placation because I did not want to have to go and do a 4th 1, uh, and that seemed to work. And then I, I put, uh, a number of patches in. For, um, the first redo and that seemed to work. Other colleagues, uh, at our hospital were not putting a patch in and they seem to have good results. So I think as a general statement that's sort of fallen off. Uh, however, having said that, I have not had to do a redo fundo in a child that I uh that I put a patch in at the second time. So I was pleased, uh, pleased with that. We've got one, let's have one final question in the back and then we'll move to our next topic. It's at the front. That's you. That's you. Oh, OK. I'm sorry. Go ahead. Uh, thank you, Sanjeev Khurana from Adelaide. Question to all panelists. I personally think that the siting of the gastrostomy at the timing of the first fundoplication has a huge bearing on how that fundoplication will play out. So, would you like to tell us how you, what technical tips you have for siting the first gastrostomy? And secondly, when you go in the second time, and you find that there is a bit of a stretch between the gastrostomy and the fun and the funders. Would you consider taking down the greater momentum on the greater curve and perhaps resiting the gastrostomy on the posterior wall? Do you ever have to do that? Thank you. Well, I think Steve's point is right that if your G tube is hurting your second fundo, take it down, you know, by whatever means and put it someplace better. I agree with that. Uh, completely in terms of where you site your first G tube, it, it, I don't know if we'll all say the same thing. You don't want it too close to the pylorus. I want it along the greater curvature. I don't want it to put tension on the fundo. To me it's a visual intraoperative decision, you know, based on the anatomy. Um, What I tend to do is to look and see where, uh, the crow's foot comes in on the lesser curve and draw a diagonal down to the greater curve and sight it at that point. At least that's what I try to teach our, our residents and fellows. And it seems like it's, it's a good spot. It's not too close to the pylorus and it's not too high up. Uh, but certainly, if the gastrostomy is placed higher on the stomach, you'd likely will have to, to take it down. I, I would, you do need to be careful that you're not too close to the gastric outlet because I've had to redo a number of fundos that were done at other institutions where the, the gastrostomy balloon was put too close to the outlet causing a partial outlet obstruction, which is what I think led to the recurrent reflux because the kids gagged and wretched all the time because their stomach wasn't emptying and, and we realized that the button was too close. Um, so you do, you do need, I sort of use, uh, 1/3, 2/3 up along the greater curve to, to determine that site, but, um, you know, it, it really is a visual thing and you just, um, you need to be aware of it. All right, let's, uh, move on. Before we move on, uh, is Marcella here? She got back there. OK, great. Thank you. All right, our, uh, our next topic is gonna be recurrent uh, congenital diaphragmatic hernia, uh, laparoscopic versus thoracoscopic, and, uh, Mark Wolan's gonna give us, uh, the. Which perspective are you giving, Mark? I'm thoracoscopic, thoracoscopic, but we'll see this, yes. It's hard to, so. Yeah, so we're gonna talk about, we're gonna, I'm gonna get you all familiar with all the world's literature on recurrent diaphragmatic hernia. And we'll talk about maybe how to prevent them and what to do, and maybe some technical points. So, the world's literature. I searched high and low. And that's what I found. Now, the neat thing is, a couple of points about this. Is one, that it was a 2016 IPEG paper. And 2, it was by one of my former fellows, Abby Schlager. And it was a survey, which I'm sure many of you actually participated in. And the bottom line was the only evidence for whether we go thoracoscopic or laparoscopic for redo hernias. Is this survey which says that most of us go thoracoscopic. So that's about it. So we could stop right there. Or we can talk. Um, you know, there's a couple of things I wanna talk about because I think it's most important to prevent recurrences in the first place. Um, so all of you know that you have a an obligate pneumothorax, you put a chest tube in. We always leave them to water seal. Sometimes I don't even leave a tube. I think sometimes you suck on that, you're gonna pull, especially with a tenuous repair, you might pull on things. Uh, you don't wanna do that. This, I think, is a very important point. And I think that when we started doing thoracoscopic repairs of diaphragmatic hernias, um, a lot of us had more recurrences early in the, uh, learning curve. And I think you can get things together from the chest and not appreciate how much tension they're on. And you really don't want to leave that flat diaphragm, because I think that puts too much tension on the repair, and could lead to recurrence. You want to have a nice domed diaphragm. Uh, one of the other things that you can, uh, That you want to pay attention to is how you get that lateral stitch, cause where do, where do these recur? They mostly recur or laterally. Uh, occasionally they'll recur medially by the esophagus if you have a big defect. But here I'm actually put a stitch. Through the chest wall. Uh, around the diaphragm and around the rib, then you bring it back out, and this is the, the seesaw technique. Actually, Han Min Lee, uh, I guess, described it as such. So basically, if you saw that, uh, you end up with one suture and one tiny little stab wound, and you can tie it on down and hide that suture. And this kid actually had an interesting defect and that there was plenty of diaphragm to unfurl, and I did multiple of these around the ribs. And at the end of the operation, the kid looked like he was hit maybe by a shotgun with all these little dots, but you actually could not find them about six months later, it all healed up very nicely. But that's a nice little technique. You don't want to skimp. You know, if you're open, uh, we always talk about putting that stitch around the rib. So if you're going thoracoscopic or even if you're going laparoscopic, you don't want to skimp on that. Uh, in our series, though, I, I know that we've talked, you know, last, last time we were with Babs, I actually got up here and almost got into a fistfight with Mark Davenport over this, but fortunately, we made up and had a pint. Um, but, uh, We, we were debating open versus thoracoscopic or minimally invasive congenital diaphragmatic hernia repair as a primary repair. Uh, and, and Mark's argument, and legitimately so, there are several papers in the literature that showed that there was a higher recurrence rate or a, or a high recurrence rate with thoracoscopic repair. Again, I think some of that was technical and learning curve. You can't make it too tight. Uh, you have to put in enough stitches. Uh, you can see some people, you know, it's, if you're, if you're not comfortable sewing stitches and tying them down, uh, you tend to put less. You want to make sure you put enough. In our own series, we had a, uh, which we've presented, we presented at the BAPS, I think it was the, several years ago. Uh, we had a recurrence rate of, uh, with primary thoracoscopic repair of somewhere around 12%. But ever since we started doing this is putting in a, uh, mesh underlay, which I'm gonna show you in a minute. Uh, basically, if you, when you get to the edge there, you can Lay down a mesh in here, uh, next slide. Uh, you can lay a mesh underlay of, uh, we usually use a biologic, we usually use surgesis. Lay that down there and then, uh, suture over that. Underneath the primary repair, our recurrence rate actually dropped to 1.3. It was 1 out of 31. Uh, so it's, uh, it, it really, I think that dramatically reduced our recurrence rate. So here's actually evidence that you can do a redo, repair thoracoscopically. Uh, it's actually not, it's, it's, it's usually not too bad. The adhesions in the chest aren't too terrible. This, this poor guy had, uh, did have more adhesions than, uh, than most of them do. And you can see the defect there. And that defect was very tight, so we decided to go ahead and close it with a piece of mesh. And This is a little trick. Getting the mesh into the chest can be somewhat difficult, especially if you're trying to push it in. So, I pass from one trochar, take an instrument from one hand, pass it out the other trochar, and then pull the mesh in. And then you can sew it on down. And we basically use a biologic underlay with PTFE on top. So, if you're bridging a gap, This, you know, this has a much, for us, this has a lower recurrence rate. Than if you are using a primary piece of PTFE and certainly if you're using primary biologic. Uh, again, this is an example of, uh, laying that mesh underlay, where you put it underneath your suture line and close it on up. And then there's still a little gap there. So we put the, uh, PTFE on top of that. So What can we say about this? You know, it's, it's, again, there's clearly thoracoscopic approach is better because that's what we do. Uh, that's not even expert opinion. I guess that's crowdsource opinion, is that right? So, but seriously, there's really no data, so I guess I can, you know, we can talk about our expert opinions. Uh, I think that as far as the approach, I don't think it matters much. Um, posterior recurrences, I think, are easier to approach from the chest. So if it's a posterior lateral recurrence, just because of the angles and if you're going from the belly, especially on the left side, getting up over the spleen can be difficult and can be challenging. And I think, uh, my next presenter is gonna show you a video of, uh, or at least a, uh, a, a picture of a pretty, uh pretty socked in belly there. So sometimes that can be difficult, sometimes for the chest, I think it's actually a little bit easier. Uh, however, if it's anterior, I think it's actually easier to get the stitches in sometimes. And I think that sometime that's, it's probably just as easy to do laparoscopically. Uh, and which way you go. And I've had, you know, we all have, how many of you have a patient who like Every once in a while we get these patients that keep recurring. They're usually very large defects. Every time they have a growth, growth spurt, something happens. And so some of those I've gone like on the chest one time, then the next time I go back on the belly. Hopefully, there's not a next time, but I guess I'd go back to the chest. So You know, really the. Biggest thing that I can say is just to do all you can do to prevent recurrences. And hopefully we'll have some lively discussion after all this. Oh, thank you. Thanks, Mark. Now, uh, everybody knows Darius Darius is going to present, uh. The laparoscopic. View. Uh, thank you very much for inviting me to come here. There are 2 experts, so probably we will have 2 different opinions. So let's start my presentation. May I ask you? I have nothing to disclose, so the question we are discussing, which way is better, laparoscopic versus trachoscopic approach. We know all the advantages of endoscopic surgery repair. However, still, there is a lot of discussion when you look at the papers, and people who are against endoscopic repair for CDH, they always say there is increased risk of recurrence. But maybe this is a pessimistic point of view. Maybe we should look at it this way that there is. It doesn't work. Yes, there is increased recurrent risk, but we have a lot of benefits, a lot of advantages using endoscopic surgery for this condition. So if you try to define the risk factors for CDH recurrence, most of them are related to the size of the defect, using the patch repair, endoscopic technique, disease severity, ECM treatment, and also the most important endoscopic surgical skills and learning curve. Some of these risks we can overcome. They are on our side besides, some of them are independent from us, and probably such a learning center like today may help us to improve our endoscopic surgical skills and to decrease the recurrence rate for CDH. So my experience is not so great, but if you look, we started in 2007, right now it's 36 cases operated by endoscopic surgery. So we are happy we had only 3 recurrences. That's what is very interesting. It was just at the beginning of our experience. And after that we introduced also a patch repair for endoscopic technique. So right now we have no recurrence, of course, probably it will happen, but right now we are happy. It's almost the same like that is cited that about the risk for recurrence is about 8% for endoscopic. Some papers show us even 20%. So. Which way to take if we have a recurrence, it's very difficult to give you any good explanation how to do it, having only 3 cases of recurrence. But what we should take when we are discussing the right approach for this complication, we should think about the type of the defects, size of this defect, also the complication. And previous surgical procedures we have done. This is a very simple protocol that we have at our department, which way to use for which kind of defects. So we always do a thorachoscopic approach for primary repair of posterolateal hernia in all newborns and also in infants in children that had uncomplicated posterolateal hernia. And the laparoscopic approach is for retrosternal hernia. Infants and children that had very complicated posterolateral hernia and also for recurrent diaphragmatic hernia. So it's a little bit different than Mark showed us because This is, of course, very small clip. May I ask you to clip the video? Probably this is a case of right. Right diaphragmatic hernia with the liver inside the chest. Probably what most of you would like to do it by abdominal approach, but we started with thoracoscopic approach. This is just to show you how it is difficult sometimes to make a decision which approach is better. Look at this video. Probably this is the fastest reposition of the liver into the abdomen. That you can watch because this is a real video. It's not shortened. Look, we were thinking at the beginning to convert the case when we found this liver inside the chest, but suddenly with only one movement it went down into the abdomen. So for this case. The Thoracoscopic approach was better than using laparoscopic approach. Probably it would be difficult to take the liver down with laparoscopic approach. Now, right now it was very easy to repair the defect, even without any patch. The next case is, may I ask you to clip the video? This is the 2 year old boy who was admitted to a hospital with bowel obstruction and the right chest CDH. So in this case, probably most of my team wanted to do an open surgery because of the bowel strangulation. It was supposed that it was the bowel strangulation because of the X-ray. However, as you can see, it was very easy to put all the bowels down, and there was no injury to the bowel. The bowels were. With a very good circulation. There was no adhesions and the defect was very small in the posterior lateral diaphragm, so it was very easy to repair it. The video is very short, so as you can see right now, very small defect. And this is the case that we have with recurrent CD. It was one of our first cases, so as you can see, the defect was in the posterolateral aspect of the diaphragm just near the thoracic wall. It was really very difficult to transect all the adhesions you can see even the suture. And it was repaired using single interrupted sutures without any patch, and it was doing fine. However, the other case, we started with a laparoscopic approach and you can see also the recurrence is just near the chest wall. With a lot of adhesions that I couldn't manage it. And after Trying to dissect it, I decided to convert and to do it by open procedure, and even with an open approach, it was really very difficult to do it. So the question which access is better probably it's not very easy to answer. It depends on the case. It depends on your on your experience, but What is very interesting is that we are not asking about laparosco laparotomy, about thoracotomy, but we are discussing about endoscopic approach. So this is the sign of our times. We are very happy to to use endoscopic surgery. Thank you very much and please come to another meeting that we will have in this year. Thank you. Um, thank you, Darius. I, I think these are difficult and, and complex cases, and I think the approach may be somewhat dependent on, on where the recurrences and, and how the child's doing, but are there any questions? Yes, hi, I'm Lucia Toceli from Argentina and I was wondering maybe. If there is a bias in selection of patients because we are not always talking about the characterization of the patients, I mean there are um more severe clinical cases that probably do not undergo endoscopic surgery in the first time or in the second time clinicians asked us to perform an open surgery, so I don't know if you can comment on that. So, so let me ask Mark and, and Darius, so if the initial procedure was done open, would you consider doing the recurrence horoscopically or laparoscopically? So the, the answer to your question, your question, Steve, is, is yes, uh, if the, if the initial operation is open and most of the time that's through a laparotomy, then I'll go through the chest because usually those kids have a lot of intraabdominal adhesions and you can avoid all that by going through the chest and we've been successful with that. Um, as far as your question about the stratification of the patients, you're right, if you look at the patients that are initially done. Thoracoscopically or laparoscopically, uh, overall, in most series they are, they are better than the patients that are done open for places that do both. We tend to put a scope in everybody, but you're right, there are some patients that have, that are, that are very, uh, you know, relatively unstable. But we, you know, even if someone's been on ECMO, we'll still put a scope in because you never know. And a lot of those they, they seem to tolerate it very well, and you can still still do those primarily with a scope. Uh, if you go back to the survey that, uh, that Avi, uh, did, Avi, you're in the audience somewhere here. I've seen you earlier. Uh, he, he actually looked at, uh, how people would approach a, uh, patient who had a recurrence after an open procedure, and there was a good number of people about how it was split half and half between redoing it open and redoing it with a scope. If you ask Steve what to do if the first procedure was open procedure, if we have a redo procedure, we always start with an endoscopic approach because you always can convert it. So this is just a chance to do such a procedure. If you start with an open procedure, there is no chance given, yeah. OK, thank you. No. Yeah, and I'm Wayne from Los Angeles. I have a couple of questions. One is, um, there was a mention, um, it's easier if you go to the belly if it's medial defect, and it's all easier to do it, going to the chest, if it's lateral, posterior lateral. The question though is how can you tell based on the chest X-ray? You just cannot tell. It's a, it's a recurrence of recurrence. And secondly is, my, oftentimes the recurrence is a very small defect, and you have a bowel up in the chest, what is the trick for you to be able to reduce it and able to do it successfully? So, you know, it is hard to tell, but uh sometimes, if you, you know, again, you look at your original op note, if it was just a posterolateral defect, you're not gonna be recurring uh medially. What I have seen on a couple of kids though, is a large paraesophageal hernia after a diaphragmatic hernia repair. And you have to watch out for that cause that's gonna be best done through the belly. Uh, as far as reducing it, from the chest, I think the insufflation really helps you. And it helps you push down and you just slowly push it down. From the belly, I've had a couple where I've had to actually, you know, where I've just sort of taken the defect and just snipped it a little bit to make it a little bit bigger to bring, to bring stuff down. But that's very unusual and that's usually if there's some adhesions up there on a recurrence. Yeah, I, I, my experience is one of the hardest things to do. You got a whole belt, a whole chest full of bowel. It's very difficult to the tiny the defect, and so. I think for the primary repairer, the thoracoscopy is our first choice because thorax is a natural. Big operating space so we don't have even to create it, you know, so it's for instance, when we do it in a renewable period, our problems with CO2 are almost not like in literature because we are not using any pressure almost after the position of the power we stop insufflation so we don't have the problems with the CO2 as it is seated in literature. Philip, thanks Philip Salva from Lucerne, Switzerland, uh, thanks Mark and Darius, both great talks, um, but should we not aim in the case of recurrence to have a more liberal use of a, of using a patch for repair that in general. Yeah, I think, I mean just uh we're gonna have to cut it short, but I think that one of the points is, is that one of the reasons we may have more recurrences initially thoracoscopic is technical details, but I think it's also because we, we lack the sense of how tight the repair is that we might have when we do it open and so I think it's probably better to err on the side of putting a patch, um, and certainly when you're doing a recurrence, I think that's reasonable. Sorry, we're gonna have to cut the discussion off and get the next, but you can find the presenters, um, at the break. OK. Our, uh, next presentation is on, um, Uh, management of, uh, recurrent cholidocal cyst, uh, and also on bile duct injuries. Uh, Navi, uh, Alizai is going to, uh, give us a talk. Unfortunately, uh, Long Lee was not able to join us at this meeting. Thanks, thank you. Um, OK, so the plan was that, uh, Le Long and myself, we will show, uh, videos and some, uh, talk and then discuss some, uh, tips and tricks at the end. But unfortunately, there was some problem with processing of the visa, so we couldn't come. He sent his talk, uh, which we just uploaded, and then there's a video at the end, uh, which I'll, is not embedded in the talk, but I'll show you the video at the end. So he's probably got the largest experience uh uh of dealing with the problems, uh, post-op problems with uh hepaticodenostomies because not only his own work, he gets, uh, patients referred from all over China and from other parts of the other countries as well. So he's got quite big experience. Now, he, uh, just, uh, this is his talk, so I'm just, uh, reading out to you. So, uh, in, in literature, there is a suggestion that there is a problem with the hepaticosinoscopy in 0 to 10% um cases, uh, which for various reasons. So this is both for open and laparoscopic. Uh, and, in, in, in the picture, you can see the hepatocogenostomy and the stricture and the dilated proximal ducts. Um, they have done a huge number of cases, as you can see, nearly 1500 cases. So after 360 cases, they went on to single port and now they do single port only. Uh, and, and they've had very good result with that and, and, and skin to skin, uh, time, it just takes 2, 2.5 hours. Uh, so, in their own case series, they've had 5 children, uh, who had a stricture of hepaticogenostomy. He does not do hepatochodenostomy. He does hepaticogegenostomy. So 5 children had, which is fairly low and quite impressive. Um, I think this is slides of work, uh, moving on their own. So can that, can we stop that, please, sir? Um, so, and then they get, uh, patients referred from a, is it possible to, uh, yeah. Thank you. So, so they had 58 patients in total. Uh, 5 of them were their own. The rest were referred from other centers, and many of them had surgery as an open surgery, and then 16 had laparoscopic pedagogydenostomies. So out of these, they found 3 different reasons why there was a problem with the drainage. In 30 cases it was anastomotic stricture at the hepaticgedenostomy level, and in 15, looking at the previous scans, they thought that the reason was the pre-existing strictures, but some of them may have happened even after the procedure, and that's probably because of cholangitis. And, and there's a very high percentage of children, 13 cases out of those 58, in which the right hepatic artery was in front of what he means common hepatic duct, uh, so just the upper end of the common hepatic duct where the left and right ducts join. Uh, I've only had one case in which, uh, the situation was like that, but that's a very big number. And, and so if that's recognized at the beginning, so then it can be sorted out. So, The anastomotic strictures in 30 cases. So, uh, in, in, in this patient, uh, you can see the pre-op and the post-op, uh, uh, MRCP, uh, with biliary dilatation just proximal to the, uh, anastomosis. One thing which, uh, uh, in fact, if, uh, if there's only Maybe I'll tell you one message. There's a few messages, so maybe one message is that even in this situation where there's quite tight stricture, the bilirubin would be normal, so we can't rely on the serum bilirubin levels. Even a very small bit of drainage will give color in the poo, and the bilirubin will be normal. So you have to sometimes treat the scans, not the patient, which is not what we normally say. Um, now, so the video is working. That's great. Uh, so this is, uh, This is procedure, and this is single port procedure in which he's dissecting the strictures and then remove the sludge and the stone. And then wash it out. And um If there are any more stones or strictures inside, you need to deal with them as well. Now, the hepatoconoscopy that Li Long does is PDS, a continuous suture. One continuous suture for the posterior wall and one for the interior wall. And even with that, uh, they have a very, very low leak rate and only 5 cases out of 1500 who are strictured. Now these are the cases in which there was, I think was a stricture which pre-existed, and had that been picked up preoperatively, they may have dealt with it. So, and there are 15 patients who presented with this problem. Uh, these are just some photos of, uh, what is there a marker anywhere, no. Um, so the right hepatic duct stricture and just There's no marker here. It's a pointer. OK. Fine. Um Now in this one, we've got pointers there to show the anastomosis and the stricture, and there's another photo after this you'll be able to see the artery which is lying almost in front of the upper end of the hepatic duct. This is another scan which shows the dilated ducts and the pointer is at the hepatic artery. On this one, you can see on the top left-hand corner, the hepatic duct above and below the arteries, so the arteries in front of it. And then in the second photo, they dissect it out, so the artery is pushed posteriorly, posterior to the upper hepatic duct, uh, and then the anastomosis is created in front of the right hepatic duct. Uh, this video is not going to work. Now, so the, the results in the lab redo out of 53 patients who came from other centers and 58 patients total, in 53, they managed to do it laparoscopically, but in 5 for various reasons, they had to convert. None of these patients had any further strictures of bile leak or cholangitis. And these are just the results before and after surgery, so everything gets better. So this is just a message that if there's anastomotic leak, that's because of technical reasons. I totally agree with him, but if there are other reasons like aberrant artery or preexisting strictures, then it depends whether you ought to know about them and you need to look for them and maybe have Close a chat with the radiologist to see if they can pick them up, uh, before you operate. Uh, that's the conclusion, laparoscopic correction is possible. And I think, uh, what I'll do, I'll go straight on to, uh, the next talk, which is quite a brief talk, uh, should be under my name, Alizai. That's, you've already seen this video, so. Thank you. I'll, I'll pass the message on to him. So, but we'll discuss, uh, let me show the talk as well, and then we'll discuss that. Is it the next talk, yeah, my talk. Thank you. So, um, this is a very brief, just a few slides because the plan was that we'll discuss it. But, uh, so I'm going to show you a video of, uh, another stricture and how I dealt with it. And, um, also there is, uh, just a bit about trauma because we're supposed to talk about trauma as well. So it's, it's, we don't do a lot of, um, uh, laparoscopic or robotic trauma surgery, but, uh, sometimes we do. Um, now, this patient, um, had a cholodocal cyst. Again, I don't have a pointer, but I wanted to show you that, uh, there's something which I missed, uh, on, on the scan, uh, which was that, uh, the left and right hepatic ducts were opening separately into the top of the cholodocal anomaly. Now, the two ducts that you can see is the left one and that's the middle one. The right one, you can't see. You can just see a bubble there, uh, but that is actually the right one. So, so when, uh, this child came in for surgery, uh, she was about 10 months old, and when we operated on her, uh, one option was to leave a cuff of, Colodo cyst and do a single anastomosis with the jeinum, but we don't want to leave any abnormal tissue, so we dissect it at the surface of the liver. That's where we dissect and we separated the two ducts and we joined them together. Uh, and then we did the anastomosis. Uh, so, Post-operatively, she came back with the cholangitis, six weeks later. Now, if there's one message I want you, I want you to take from this talk is that If you've done a cholodo cyst excision, whether it's open or laparoscopic, if a child has cholangitis, that's because of stricture, that's because of poor drainage. If drainage is good, they do not get infections. So if any child comes to you with cholangitis after surgery for a choco cyst, look out for stricture, they may still have, as I said, they will have a normal colored poop. They probably will have a normal bilirubin, but they'll have dilated ducts, and the chances are they'll need something doing. You can dilate it percutaneously or you can. redo it. So in this one, she presented 6 weeks later, and we scanned her and her ducts were dilated. There were 6 at that time, the intrahepatic ducts, both left and right. Then, we treated the infection with antibiotics and the plan was that we're going to reassess in 6 weeks' time, which we did, and the ducts were slightly 1 millimeter more dilated. And then we arranged a percutaneous. Stretch balloon dilatation. Um, and when we did um this um Procedure, we noticed that the left and right ducts were not communicating with each other. They had separated. So you can see the one on the left side, there's a guide wire in there. That's in the left duct, and there's the middle hepatic duct which is opening on the left side and the separate guide wire and the tube is on the right side, and they were not communicating with each other. They were, um, there was some way through when we did, when we injected some contrast, there was some way through into the, from the right duct, but nothing from the left one. So I decided to take the patient to the theater. There are always some adhesions, uh, so that's the rule loop that you can see. You can see some staples. This is the top of the staple rule loop, and this is the actual. Uh anastomosis, you can see the right hepatic duct. Which was just behind so we need to go dissect the separated completely. So the bit above my forceps, this bit is the anastomosis which had strictured. Um, when we do robotically for this procedure, I sometimes use mono, but mostly bipolar if I'm close to ducts. Now, is it possible to pause the video at this point, please? No, OK. So, yeah, great. So, then, uh, at As you can see, everything looked blurred. It wasn't clear. It's not clear when you go back. This was 6 months after surgery. When you go back and you can't make out where is the duct and where is the vessel. Vessel, yes, you can see it pulsating, but everything else looks the same, so it's quite difficult to see where to cut. So at that time, at that point, we have 3 options, 3 or 4 options. One option is What we did in this case, uh, I inserted a needle, aspirated it, and that was based on by looking at the scans because I knew where the duct was in relation to the left and right and where the hepatic artery was because I knew when we operated the right hepatic artery was just behind the anastomosis, and we could see a bulge there on, on, on the left side, but the right one wasn't visible at all. Um, the other option would have been to do an ultrasound, uh, laparoscopic ultrasound, or we could also have done a percutaneous cholangiogram at that time, but we decided to use the needle and it worked. And then I opened this duct, so I'm looking, you can see the left duct. You can run the video again, please. Thank you. And so now this is looking for the right duct, which was more difficult to see. So we inserted the needle, we could aspirate the bile, and then I cut it. When you cut it, you won't go straight into the duct. There'll be a lot of thick tissue in front, uh, and you can see that a tiny little hole in the duct, and I'm going to stretch it. It's not in this video, but I do open both sides quite a bit, and there was a gap of about 0.5 centimeter between those two. The left and right were separated by half. 1 centimeter of quite thick and inflamed edematous tissue. Didn't need to, uh, refashion the, uh, rule loop because it was healthy, uh, and we, there was a little hole in it which, uh, I just, uh, extended. Uh, and, uh, we try to make it as big as possible, but, uh, as long as it's is the same size as the two ducks. Um, and then, uh, after that, uh, I just did the anastomosis. I usually use vicral interrupted sutures. I don't do continuous, uh, and in this one, I did one long anastomosis, but both of the ducts, uh, I kept them separately. I didn't join them together. I think that was probably a technical mistake, uh, because there was, uh, the gap was probably too long between the two ducts, so they just. Pulled apart. When we take bites, we do take quite big bites, uh, uh, just to make sure both on the bowel and on the duck, and this is the last stitch which is at the front wall. Uh, and the instruments, as you can see, they are still quite bulky as compared to the tissues that we deal with. But for this patient who was just over one year old, they were fine enough for us to Do this procedure. So, uh Now, so that was uh uh the corido. Now just quickly uh show you. Um, so this was, um, about trauma. The eight year old girl, uh, had a road traffic accident, quite serious injury to, uh, liver and had a lot of bleeding. And my colleague may may be in this room, he was sitting on the ward all night thinking, should he take her to theater or not. Anyway, she settled. But then a week later, she had a bile leak. Uh, and we managed it by doing ERCP. Uh, we aspirated first, but she collected again. So we did ERCP and stent. Now, she was 8 and the stent, uh, that we had was about 10 centimeter long. Uh, and so they had to cut it. Uh, and so the bile leak got sorted and she came back and she didn't have any symptoms. So then we had to remove the stent. So we took her to theater and, uh, endoscoped her. Uh, and there was no stent to be seen because it had migrated into the duct. So we had to, and then abandon and take her back to theater. So, for redo surgery on this occasion. Again, we did robotically. So we explored the common bile duct and, uh, we removed the stent. This was a 4 French, uh, originally 7 centimeter long stand. Uh, and then we did, uh, interrupted vicral anastomosis. So that was redo surgery just because of, uh, stent migration. Uh, and, uh, she's, this was, uh, about 6 years ago, and she's, has not had any problems since, and she doesn't have any dilatation. Thank you. So, We may have time for one question if anyone has one. Is that Go ahead. Uh, Doctor Kololo from Ankara, Turkey, thank you for your presentation. Uh, my question is, why did you choose to connect two ducks, uh, because it's not, uh, wise to connect them when the gap is too long. Uh, the tension would, uh, make them close, uh, if you, uh, connect them. Yeah, so when I said the gap was too long, I think I was being, was being a bit harsh on myself. Uh, they were lying together. They were, they were not that far apart from, so the options I had was to do two separate. Anstomosis or join them together and I decided to join them together in the past I have done two separate anastomosis and that patient has been fine. So yeah, it's just a learning thing. Maybe if you want to do one anastomosis when you have two ducts, maybe you can just grab from the bubble and the tissue between two ducts so you won't pull two ducts together and abstract them. That's what I did the second time around. Yeah, that would be better. Thank you. Thank you. Thanks. Yeah, you have a quick question. Yeah, thank you for a nice, uh, video, uh, but I'm afraid I don't think aberrant right hepatic artery will not cause the, uh, stenosis according to my experience. Because of the presence of the right hepatic artery, then anosmosis technically difficult. I think that's the cause of postoperative anassmosis. And as your case, I always cystoscope to the Cortical cyst to see that whereas right and left he backed, then we can prevent separation, separate the anastomosis. Yeah, yeah, I know, because what we do is we cut it very low, so I knew they were separate. I found it out on the table, so I knew they were separate, but I had, I didn't want to leave any choloiddocosis behind, so that's why I separated them. Yeah. All right, thank you very much. Thank you. It's a great presentation. Thanks for Fully and closely. So our next topic is um reoperative surgery for anorectal malformations, uh, and, uh, Marcela Baez is going to lead us off. Thank you for the opportunity of sharing this experience with you. I have nothing to disclose. Here we go, we will talk about anorectal malformations and their anomalies. The indications of redo surgery in anorectal malformations, mostly of reconstruction, are perenal fibrosis because of infection and ischemia, incomplete treatment of cloaca or fistula in boys like a persistent genital sinus or fistula, and hematometra or genital occlusion because of associated anomalies. I am excluding complications related to colostomy which are also high. If we look at perinal fibrosis, of course we know that MIS has not a role, but sometimes, uh, we, we usually treat this kind of cloacas where the anus is pulled, has been pulled through, but there's a your genital sinus left and video please. We, we start. With a perennial approach, you see there's a lot of fecal. Like You all know it can be in lithotomy or prone position and there is a session of the operation where we need abdominal help even with very good X-ray or pre-op X-ray so I think laparoscopy has a role. In helping diagnosis. With endoscopy and laparoscopy, even with very good X-rays, MRI, or everything, we don't need to deny that role, and those tools have to be in our or all the time. I will, I will give you some examples because, as, as Mark said, I couldn't find any. Bibliography talking about the redo MIS in these operations. So for example, this is a 12-year-old girl born with cloaca. She had a transverse colostomy in other institutions, recurrent urinary tract infections, and she was seen at 9 years for the first time. And you will see that the cloaca was not treated. She had a flat perineun. But that's the sacer ratio. The calligraphy, we saw a very dilated rectum proximal to the ostomy. Which was a transverse one and she has she became very sick when we started distal colostomy washing she had abdominal pain, vomiting, and fever and we need to do colostomy revision open colostomy revision because she was very sick, creating a sigmoid divertic dysfunctional colostomy and resecting proximal colon so she had open surgery. And of course we did a cystoscopy to to see the cochle channel and here we have what we ended up having. A patient with an open surgery and the need of reconstruction so. Video please can we reconstruct these patients after open surgery? Why not? Sometimes we have these surprises. Even the surgery, open abdominal surgery was huge. We can still have a clean abdomen. We can treat that's the stitch that we put to hold the uterus up and I will not show the whole operation, but. MIS is not a one way road. So in some of these patients we don't deny starting with MIS and combining with, uh, as I tell you, cystoscopy and perennial approach, and that's the end of the case where you can see the urethra and the vagina from the lithotomy position in a perennial approach. So redo surgery for stenosis, ischemia, and infection if it is, if the rectum is near the skin, we won't use MIS from the abdominal approach, but it can help diagnosis and in some cases, as you have seen, we have the tool to give if we have genital obstruction hematometra which is usually associated with these anomalies. Why 63% of our clockas has a double uterus and the message is don't forget to look for these anomalies video please because they look different at the very beginning and they can come later with this kind of obstructed AI structures that in the early assessment. We were not able to understand what they were maybe they they get stuck in in the pelvis uh behind the colostomy most of the time and so this kind of reoperations are tricky and we need to avoid using energy near of course the artery and and and the nerves in the pelvis. Another case, this is a 13 year old girl. She had a transverse colostomy in another institution, a vasicostomy, and she came, she had a reconstruction with a combined SAP and a lab in our institution at one age. You can see the video, and she came at 13 years old with after reconstruction Ammirofanov and a child. This is, I looked for the video. This is a 12 year old video. To see because she had pain and she had a mass on the left side, there is the rectum. And you see the left. Hemi uterus which at that time we were not so able to understand what was happening because the vagina was pulled down but that uterus was left and now we are having a 114 year old girl with a microfanov. With this complex left adnexal mass and which ended up to be a left hematometra because she has she had menses through the vagina and she had a right uterus then so. Video please Should we deny this girl? An MIS approach and that's the question because of the scars we started using a scar far away from the from the umbilical and sometimes we have this kind of surprises that uh I would want to share with you of course we do an open approach we don't want to have another complication and even. With the stoma and with the bladder augmentation we can go around the bladder augmentation to get to the point which was the left side and the left severe hemattotra and adnexal mass that she had that in this case we decided to remove because she had the normal right uterus that you are seeing now. And This girl has other problems like uh renal insufficiency, chronic renal. So that's the normal right uterus and the left one that we were not able to assess well at the early stage. I think these patients are the ones that benefit with redo MIS video. I'm This is another girl with a mitrofanov and a bladder augmentation and of course an stenosis of the of the vaginal outlets than elsewhere. What we did in this case is we entered through the umbilicus very carefully. That's another way of doing. We have now 5 patients that we have been able to go open with a very, very small chokers like the 404 millimeters or 3 millimeters and then. Go ahead and do the same procedure as you have seen in this case we we only. Drain one M structure to keep it. This is a different case, but you see that we can keep after taking away additions, we can keep the augmented bladder and the mitrofanov much better than with an open midline incision that that's the obstructed it in this case it was preserved. It was drained, preserved, and then a redo to connect also laparoscopically so. 2 more cases and we finish with a conclusion. This was a girl born with cloacal atrophy. 17 years old, multiple procedures including the closure of the abdominal defect with a mesh. And persistent atrophy you say they exist they exist in many parts of the world and we we have a we have a um. Like, uh, a paper that we made about quality of life in these patients, and we can't believe they, they are doing better than we think so we need to help them and so this girl came and was waiting for bladder augmentation and she had pain, but she had a vagina and she had menses that was a uh bladder. Spectrum extrophy was a clockar extrophy in the spectrum. The vaginas were outside, but she developed this mass that you see there, a complex cyst in left pelvis, multiple septums, and the left ovary was not identified. Markers were negative. She had an annexal mass, and this is the abdomen video. If you see the abdomen, you see the scar because she had a mesh. And we needed to go down that scar so we went away we said there was no bladder augmentation here is this is what she needs she had a she still has a piece of of atrophy there she's incontinent so we decided it was better to go laparoscopically. And we had a surprise that as you can see it's a little more difficult, but all the additions from the midline of the mesh were taken down easily easier than we thought and then we treated them that Nexon mass in the way we usually do. The only trick that we use in these cases is to use a needle with grasper capabilities as a left hand uh. Which is not disposable it's a reusable needle that you can use where you find a place you put the needle as you see there. This that's the left hand with a with a bipolar sealer. It's you need to have a bipolar sealer and that there's where the needle is used to help. Of course you can use another troker when when there's no space this needle with grasper capabilities is very useful and so it's the trick. Augmented bladder atrophy. Same thing with uterine prolapse. Can you move the video? It's a seconds. Uterine prolapse is a complication of these spectrums of bladder atrophy and bladder atrophy and clockar atrophy patients. In this case she had bladder augmentation. So what we did, we put a stitch to the uterus going from the left side and we fixed it to the anterior abdominal wall. And we're having a a lot of surprises every time we decide to go MIS instead of saying no with those scars just go open. Residual rectal polyposis. This was a a rec uh a rectal cuff that was left there because of complications during the surgery and then she was sent and so we decided to go laparoscopically and you see how even. With additions you can dissect better than open because the vision in an adolescent or a big child retro uterine vision that you are seeing it's impossible to have an open surgery. So Of all our Cloacas. Only 32 have been treated with MIS, and there are 5 that were redo cloacas. All of them had mitrofannov. These are only cloaca patients, not extratrophy or trophy cloacas. So we think. That coming to the conclusion. This is a video. And, uh, no voice, no voice. You can find this case. I, no, no, no volume please. Can you put it on. You can read and see this case in JL. It's published. It was presented in 2014. I will not show the video, but this case, it has everything. It's an anorectal anomaly. Had colostomy, had PSAP. She had a vaginal genesis and a uterine cervix a genesis that was not recognized and came back with pain later and everything was done. With minimally invasive, but we need to avoid these cases so the conclusion of the session. Is even there's no available data in this topic. To conclude, MIS is not a one way road. Avoiding an incision in the mess of that these patients have might prevent complications. Why not give a chance? Prevent the need of a redo surgery. So think that all these anorectals have associated anomalies and they had to be assessed before reconstruction to prevent reduced surgeries, which is the the best message and I. Encourage everyone that has these cases to make data together so we can put that data to encourage other people to use more MIS in these redo surgeries. Thank you. So our next speaker is uh Professor Till. I think he's gonna talk to us about redo uh surgery for UPJ obstruction. Thanks Steve. Sorry ladies and gentlemen to keep you from uh the well deserved lunch break, but I'll be brief. Well, the story of no literature continues. And for pediatric MAS at the upper urinary tract, there may be one very simple explanation. And that is that most of our MIS procedures in the upper urinary tract are very, very successful and must be successful. I'll try to lead you through that within the next 10 minutes anyway. Nephrectomy and heminephrectomy, why would you fail on these? Pyeloplasty with a success rate of 95%, how do you dare to fail on these, and your urethral reimplant. What's the better option? Uh, well, the standard of heminephrectomy is well established, so the, the standard for redo heminephrectomy may be as well established as well. Why would you do it? Um, Maya and, uh, the team from Ches Positive and many others, uh, in a multi-center study have collected, uh, their and our data and we found that there's one major reason, maybe you conclude on that yourself. There's one major reason for that, and that is urinoma and then renal cysts. I guess we all agree in the room that those renal cysts which are asymptomatic are not a target of redo operations. Only a few then become symptomatic, and if you just want to apply the same technique as you do for heminephrectomies, you're doing fine. The better example is the ureter. Open surgery with a flank incision of whatever you do usually does not reach all the way down to the bladder. And in any reflexing system. Good pediatric urology teaching tells you you need to dissect the ureter all the way down to the bladder to the dome. So if open surgery fails, here is a good example that laparoscopically surgery is superior. Those ureteric stumps, which always are in the literature, are the perfect target for you as pediatric urologists to do it MIS wise, transabdominally, transsexually, and on the left side you see a picture. Where the ureter still remaining crosses the iliac artery, reaches down to the bladder. You don't go by that. You go even further and on the right hand side you see a rudder slings at the ureter, which is already retracted. And once you cut that, it zooms down all the way to the bladder. So, the postoperative complications of nephrectomy and heminephrectomy to sum summarize this urinoma renal cysts and the remaining ureteric stump, and your solution, laparoscopic resection of the renal cyst is feasible. Laparoscopic resection of the urotech stump is advisable, and again, there's hardly any literature for that. These are just simple cases here and there. Pyloplasty, a more difficult topic. Remember, the open pyeloplasty, um, and Babs we'll discuss this at 2 o'clock next door and fight me for that, uh, is an extremely high standard with a success rate of about 95%. So primary laparoscopic pyeloplasty must be successful, otherwise you can't justify it. Redo pyeloplasty is very scarce. Here is one study that is from Hong Kong, that is from the Queen Mary Hospital, and interestingly, um, they reported about 42 children. With 46 primary laparoscopic Anderson Heinz pyoplasties and 10 cases, which is an extraordinary higher number, and required re-intervention, but let's learn from these cases and let's rethink about how successful redo surgery may be. And if you take a look at their data, 6 required the actual laparoscopic redo 4 they did endopyelotomies. I'll come to that in a minute, and those 6 were all. Significantly favorable for the child in terms of tracer clearance, and that's the only thing that counts, drainage after redo. So their conclusion, if you want to tackle a redo pyeloplasty, go ahead and laparoscopic pyeloplasty is quite successful. Do we know about the long term results of of that? Yes. Again, a very small study, 13 patients only, um, with history of prior surgical interventions, um, all of their redo, um, laparoscopic Edison Heinz plastic, they completed successfully, mean operative time is longer than the open ones. Um, primary operation 183 minutes, the redo is, um, almost 4 hours. That's a significant long operating time, but success rate as successful as open. 97% after mean follow-up of 40 months. So this is a clear justification for all of us doing it to do the redo laparoscopically and not convert to open primarily for the redo. Of course, there is no pediatric ur urological talk without robots. That's a must for any MIS talk in pediatric urology. So what's the the role of the robot for failed pyeloplasty? Again, there's one study. Um, available, um, that's, uh, try to demonstrate the feasibility and safety of the robot assisted 153 patients that primary underwent a laparoscopic Anderson Heinz plus the 9 of them had a recurrence of the UPJO 5 underwent primary repair by the robot, and of course all of these 5 cases were successful, otherwise he probably wouldn't have published. Yeah, is there an alternative which is even less invasive? Uh, what can I pick? What can we learn from the urologist? Oh, there is good news, end of urology. Maybe in our hands, come in soon too, meaning that you don't go through the abdominal cavity transabdominally to reach the pathology, but you primarily go via cystoscopy or transrenally, and that's a good idea uh for these 11 children for redo and uh pyeloplast after failed pyeloplasties with an endoscopic plootomy. Pyotomy. 10 of these SEPs were percutaneous, 1 retrograde cystoscopically, mean follow-up of 20 months, 7 with complete drainage, but again, no trauma, neither to the kidney. And 4 units and you can redo the redo as an SEP. That's the conclusion of this paper. And finally, a couple of words um to my fine experience with CK in Hong Kong and what can we do for the lower, for the lower urinary tract for the ureter close to the bladder. Uh, two things. One is of course the redo ureteric reimplant, and one, I'll still mention this is going for the remaining ureteric stump. Um, here's one case, 4 year old boy. Um, bilateral reflux nephropathy and at the age of 8 months he underwent open nephrectomy on the right side. At that age of 4 years, you can clearly see on the right side this substantial remaining ureteric stump refluxing and of course he had multiple infections in that. Also he had a grade 3 VUR on the left hand side. So why not go pneumo vesicoscopically? Why not combine a redo procedure for the ureotech stump with a primary colon transvesicle. Um, operation and it was a real pleasure seeker to do that with you. Um, here are two examples. Uh, on the left and upper side, you see the vasicoscopic aspect, um, the left ureter, which, um, is on the left hand side of the picture. Again, you look from above into the bladder outlet, uh, is already prepared for the, um, uh, replantation with the cone's procedure and the right hand side shows the stent in the to be resected ureter. The right picture on the right side shows how nicely you can mobilize the remaining ureter into the bladder. And just, uh, resect the adhesions and then you close the detrusor above it and swing, um, the two reimplanted ureter across with a good outcome. In summary, ladies and gentlemen, I think, um, the pediatric urology, uh, is a perfect target for redo operations for the benefit of the child. You must, of course, understand the complications and the variety of the urinary tract. With a variety of pathologies, um, limited evidence, uh, as mentioned is available, but those causalistics we all have heard may justify in any way that we do it. It's a definitely, it's a fine field to be developed. Thank you for your attention. Thank you, Holger. Um, it was a great talk. Uh, if there's one quick question, we can take it. A a beautiful talk, um, you haven't mentioned deflux. So my experience in uh the refluxing stump in an incomplete heminephrectomy could be I've done in some patients where you discuss with the family, we can do deflux procedure if that, if that is successful, we don't have to do redo laparoscopic surgery where you have to go down to the bladder and may injure the nerve supply to the bladder. Do you see any role of of deflux in redo surgery? Perfect question Martin, but never forget defflux only works or usually only works in a normal inserting ureter, any ectopic ureter, and most of the duplex systems have some kind of pathology, uh, of the ostium. You can try deflux, but if you have a urethrocele, if you have a bifidus ureter, and many, many other ectopic things, deflux is a nice try. You don't harm or anything, but it's probably not not very conclusive. All right. Well, I'd like to thank all the speakers for their excellent talks. Um, we're now on a lunch break. Please take time to visit the exhibits and I thank all the exhibitors for being here. Again, we rely on their support and we'll start up again at 1:30. Come