| Abstract|| |
Aims: The laparoscopic "Spaghetti Maneuver" consists in holding an organ by its extremity with a grasper and rolling it up around the tool to keep the organ stable and facilitate its traction within a small space. We describe our experience with the "Spaghetti Maneuver" in some minimally invasive procedures. Materials and Methods: We successfully adopted this technique in 13 patients (5F : 8M) aged between 6 and 14 years (average age, 10) on whom we performed 7 appendectomies, 2 ureteral reimplantation and 4 cholecystectomies. In all cases, after the first steps, the appendix, the gallbladder and the ureter were rolled around the grasper and easily isolated; hemostasis was thus induced and the organ was mobilized until removal during cholecystectomy and appendectomy, and before the reimplantation in case of ureteral reimplantation. Results: We found that this technique facilitated significantly the acts of holding, isolating and removing, when necessary, the structures involved, which remained constantly within the visual field of the operator. This allowed a very ergonomic work setting, overcoming the problem of the "blind" zone, which represents a dangerous and invisible area out of the operator's control during laparoscopy. Moreover the isolation maneuvers resulted easier and reduced operating time. Conclusion: We think that this technique is easy to perform and very useful, because it facilitates the dissection of these organs, by harmonizing and stabilizing the force of traction exercised.
Keywords: Appendectomy, children, cholecystectomy, laparoscopy, pneumovesicoscopy
|How to cite this article:|
Marte A, Cavaiuolo S, Pintozzi L, Prezioso M, Nino F, Coppola S, Borrelli M, Parmeggiani P. "Spaghetti Maneuver": A useful tool in pediatric laparoscopy - Our experience. Afr J Paediatr Surg 2011;8:252-5
|How to cite this URL:|
Marte A, Cavaiuolo S, Pintozzi L, Prezioso M, Nino F, Coppola S, Borrelli M, Parmeggiani P. "Spaghetti Maneuver": A useful tool in pediatric laparoscopy - Our experience. Afr J Paediatr Surg [serial online] 2011 [cited 2020 Apr 3];8:252-5. Available from: http://www.afrjpaedsurg.org/text.asp?2011/8/2/252/86077
| Introduction|| |
Today, most surgical procedures involving pediatric patients can be performed by laparoscopy. Thanks to the technical progress and growing experience in this field, an increasing number of interventions, even complex ones, can be made by laparoscopy. Appendectomies  and cholecystectomies are among the most common surgical procedures. In fact, the laparoscopic technique in these specific cases is now the gold standard, even in the pediatric population, due to reduced recovery time and postoperative complications. ,,
Pneumovesicoscopic ureteral reimplantation is also an alternative minimally invasive procedure, effective and safe in both adult and pediatric patients with severe vesicoureteral reflux (VUR) and recurrent urinary tract infections (UTIs), especially in cases where a previous endoscopic correction has failed. It yields good results,  it is associated with less postoperative morbidities and a shorter hospital stay compared to the traditional open method,  and has a high success rate (92-95% of cases). 
Unfortunately, unlike in adults, in pediatric patients the laparoscopic workspace is rather limited, often making it difficult to isolate the anatomical structures involved, as well as dissection and knotting maneuvers.
In children, therefore, ergonomics as well as the development of techniques that allow the surgeon to work in small spaces, have an important role. To our knowledge, Martinez-Ferro  was the first to propose, during thoracoscopic repair of esophageal atresia, a technique known as "Spaghetti Maneuver", which consisted in rolling up the esophagus on the needle holder to better carry out the dissection of the upper segment of the esophagus from the trachea. Since then, this maneuver has also been used with other organs and structures, proving to be very effective.  We report our experience with the "Spaghetti Maneuver" in pediatric laparoscopy.
| Materials and Methods|| |
We report our experience in 13 patients (5F : 8M) aged between 6 and 14 years (average age, 10) in whom the "Spaghetti Maneuver" was successfully adopted from January 2009 to June 2010. We used this technique to perform 4 laparoscopic cholecystectomies in patients with idiopathic gallstone disease, 7 non-phlegmonous appendectomies, 2 Cohen's ureteric reimplantation for unilateral vesicoureteral reflux performed by pneumovesicoscopy. Children with preoperative evidence of perforated appendicitis were excluded from this study.
The technique was implemented as follows: As to the cholecystectomy, after ligating and sectioning the cystic duct and artery with the standard technique, the "Spaghetti Maneuver" was performed rolling the infundibulum of the gallbladder and progressively sectioning it from the liver bed until its complete excision [Figure 1] and [Figure 2]. No lateral or upward/downward traction was applied.
|Figure 1: Laparoscopic cholecystectomy: the figures show the "Spaghetti technique", where the gallbladder is held to facilitate its removal|
Click here to view
|Figure 2: Laparoscopic cholecystectomy: the figures show the "Spaghetti technique", where the gallbladder is held to facilitate its removal|
Click here to view
In case of the appendectomy, the adhesions were lysed and the appendix was mobilized. After fixing its apex to a Maryland, the appendix was then coiled around the tool [Figure 3] and [Figure 4]. During this part of the procedure, hemostasis was induced and, after reaching the basis of the appendix, we proceeded to suture and cut it with an endo-GIA. The ureteroneocystostomies were performed according to Cohen's technique; in particular, the ureter was first isolated with a circular incision of the meatus using a hook electrode and was then progressively isolated by rolling the distal ureter around a needle holder and pulling it out [Figure 5] and [Figure 6]. After preparing the trans-trigonal tunnel, the ureter was rolled out and reimplanted.
|Figure 3: Laparoscopic appendectomy: the "Spaghetti technique" facilitates the exposure of the appendiceal base keeping all the organs under visual control.|
Click here to view
|Figure 4: Laparoscopic appendectomy: the "Spaghetti technique" facilitates the exposure of the appendiceal base keeping all the organs under visual control.|
Click here to view
|Figure 5: Pneumovesicoscopic reimplantation: The ureter is first isolated by circular incision around the meatus; the "Spaghetti technique" allows the isolation and traction of the ureter under constant visual control.|
Click here to view
|Figure 6: Pneumovesicoscopic reimplantation: The ureter is first isolated by circular incision around the meatus; the "Spaghetti technique" allows the isolation and traction of the ureter under constant visual control.|
Click here to view
| Results|| |
No major perioperative or postoperative complications were recorded. No patient was converted to open technique.
All cholecystectomies have been performed with three-trocar technique. Only a minimum leakage occurred in one patient during the isolation of gallbladder due to a small tear of the lateral wall. As regards the appendectomies, the mean operative time was 29.5 min (range 25-60 m) and was shorter, but not significant, than the similar standard laparoscopic technique (mean, 35 min; range 30-80 min). Also the ureteral isolation resulted easy and fast thanks to the progressive rolling traction. On the whole, we found that this technique facilitated significantly the acts of holding, isolating and removing, when necessary, the structures involved, which remained constantly within the visual field of the operator. This allowed a very ergonomic work setting, overcoming the problem of the "blind" zone, which represents a dangerous and invisible area out of the operator's control during laparoscopy. Moreover the isolation maneuvers resulted easier and, in most cases, reduced the operating time.
| Discussion|| |
In laparoscopy, it is sometimes complicated to operate on a mobile and/or elongated structure, as its isolation may be difficult for the surgeon, also due to limited space of the operative field, and to the instability of the structure itself. Holding the organ by its extremity with a grasper and rolling it up around the tool confers greater stability and better traction. In case of an appendectomy, this technique also ensures better control of the appendix, even if it is shorter, and allows easier access to its base thus facilitating excision. Moreover, the "Spaghetti Maneuver" allows the surgeon to control the entire organ in the laparoscopic field, given the better visualization and exposure of the mesoappendix. Similarly, during a cholecystectomy, the action of rolling-up the organ improves its stability and facilitates its dissection from the liver bed, at the same time allowing exposure and removal of possible adhesions, as well as the cauterization of any bleeding areas in the bed liver. Moreover, as in our cases, the traumatic action of the grasper or needle holder is applied to an area that will be subsequently removed, and thus does not cause any damage.
According to the literature, this technique has been applied so far only to laparoscopic cholecystectomies and appendectomies.  In our experience, the "Spaghetti Maneuver" has been employed also to perform a ureteral reimplantation using pneumovesicoscopy.  In fact the isolation of the ureter is facilitated by the act of rolling-up the organ on the grasper or needle-holder, which allows a more stable traction and makes it easier to peel off the lining of the bladder trigone. With this technique the surgeon is able to achieve more quickly and safely the most suitable length to reimplant the ureter in the submucosal tunnel.
Although the rolling-up maneuver is extremely practical and attractive, it cannot be implemented in all cases. For example, in case of a phlegmonous appendix, it might cause the fracture of the organ. In addition, if there is mucocele or if the organ is swollen, this maneuver is not recommended. In case of a complicated cholecystectomy, this maneuver is possible although an excess of traction can cause breakage of the organ and subsequent distribution of bile and stones within the peritoneum.
One of the most interesting advantages of this technique, in our opinion, is the fact that the isolated structure remains within the operator's visual field; this avoids what in laparoscopy is defined as the "blind zone", i.e.., the lack of the operator's visual control of the work space. In fact, the dissection, ligation or induction of hemostasis, especially in case of a long organ, requires traction, which inevitably brings both the laparoscopic forceps and the organ itself outside the visual field of the operator, which can represent a danger given the absence of visual control by the operator.
| Conclusions|| |
In conclusion, despite the quite small study population, we found that the "Spaghetti Maneuver" is easy to perform and very useful, because it can facilitate the dissection and/or resection of an organ, harmonizing the strength of the traction and maintaining its stability. Our experience has also demonstrated its great usefulness in pneumovesicoscopic ureteral reimplantation where the surgeon is obliged to operate in a little room. Moreover we think that this maneuver can be useful also in a larger number of laparoscopic procedures and can be considered an effective technical device. However, a larger number of patients and applications are needed for better evaluation.
| References|| |
|1.||Humes DJ, Simpson J. "Acute appendicitis." BMJ 2006;333:530-4. |
|2.||Sandhu T, Yamada S, Ariyakachon V, Chakrabandhu T, Chongruksut W, Ko-Iam W. "Low-pressure pneumoperitoneum versus standard pneumoperitoneum in laparoscopic cholecystectomy, a propspective, randomized clinical trial". Surg Endosc 2009;23:1044-7. |
|3.||Rezola E, Villanueva A, Garay J, Sunol M, Arana J, Intxaurrondo MI, et al. "Laparoscopic appendicectomy after the learning curve". Cir Pediatr 2008;21:167-72. |
|4.||Billingham MJ, Basterfield SJ. "Pediatric surgical technique: Laparoscopic or open approach? A systematic review and meta-analysis." Eur J Pediatr Surg 2010;20:73-7. |
|5.||Kawauchi A, Naitoh Y, Soh J, Hirahara N, Okihara K, Miki T. "Transvesical laparoscopic cross-trigonal ureteral reimplantation for correction of vesicoureteral reflux: Initial experience and comparisons between adult and pediatric cases." J Endourol 2009;23:1875-8. |
|6.||Chung PH, Tang DY, Wong KK, Yip PK, Tam PK. "Comparing open and pneumovesical approach for ureteric reimplantation in pediatric patients- A preliminary review." J Pediatr Surg 2008;43:2246-9. |
|7.||Valla JS, Steyaert H, Griffin SJ, Lauron J, Fragoso AC, Arnaud P, et al. "Transvesicoscopic Cohen ureteric reimplantation for vesicoureteral reflux in children: A single-centre 5-year experience." J Pediatr Urol 2009;5:466-71. |
|8.||Martinez-Ferro M. "Thoracoscopic repair of esophageal atresia without fistula." In: Bax KM, Georgeson KE, Rothenberg SS, Valla JS, Yeung CK, editors. Endoscopic surgery in infants and children. Vol. 28. Berlin, Heidelberg: Springer-Verlag; 2008. p. 207-19. |
|9.||Durai R, Ng PC. "Spaghetti Technique"-Novel Technique to facilitate Laparoscopic Appendicectomy and Cholecstectomy. J Laparoendosc Adv Surg Tech A 2009;19:667-8. |
|10.||Marte A, Sabatino MD, Borrelli M, Nino F, Prezioso M, Pintozzi L, et al. Pneumovesicoscopic correction of primary Vesicoureteral Reflux (VUR) in children. Our Experience. Eur J Pediatr Surg 2010;20:366-70. |
Via S. Pansini 5, 80131, Naples
Source of Support: None, Conflict of Interest: None
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]