The sages manual of pediatric minimally invasive surgery 1st edition danielle s. walsh download pdf
Danielle S. Walsh
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The SAGES Manual of Biliary Surgery Horacio J. Asbun
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Preface
…find though she be but little, she is fierce.—Shakespeare
More than once pediatric surgeons have heard general surgeons comment on their “fear” of caring for pediatric surgical patients. The diminutive size of the patient can intimidate, but those of us flourishing in the pediatric world recognize a well-kept secret—infants and children are fierce in their desire to live, handling the surgical insults that would cause many adults to give out, with determination of sometimes Olympic proportions. While they tolerate large incisions for invasive procedures with aplomb, showing their scars as badges of courage on the playground, we believe our kids deserve to reap the same benefits from minimally invasive techniques that the adult population embraces. This book was developed to help current and future surgeons in advancing their comfort in approaching children with laparoscopy, thoracoscopy, and endoscopy.
The mission of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) is to improve patient care through education, research, innovation, and leadership, principally in gastrointestinal endoscopic surgery. The pediatric surgery community within SAGES has been grateful that the leadership of SAGES has recognized the need to apply this mission to not only the adult general surgical population but to all patients, including our youngest and smallest. It is
with this in mind that these authors set out to educate ALL surgeons, not just pediatric specialists, in the applications of minimally invasive surgery to children through this textbook.
The focus of this text is on the technical knowhow of these minimally invasive techniques. There are larger resources for detailed information on pathophysiology and others reviewing each and every alternative technique for managing a particular disorder. However, this publication is for providing a safe way of technically approaching a particular problem utilizing percutaneous or per-orifice methods in a concise compendium. It is appropriate for the trained professional looking for a refresher on a less commonly performed intervention, an adult MIS surgeon with a pediatric emergency unable to be transferred, or a surgical student or resident in need of critical teaching points for understanding.
This coeditor team greatly appreciates the support we have received from SAGES and Springer in making this endeavor come to fruition. We applaud the authors, colleagues, staff, families, and patients who contributed to this book through either time, effort, patience, or use of their surgical journey to build the knowledge and content within these pages. It is our hope that many a student of surgery will benefit from the herein pearls of wisdom as they endeavor to improve the care of a pediatric surgical patient.
Greenville, NC, USA
Danielle S. Walsh Akron, OH, USA
Nicholas E. Bruns
Todd A. Ponsky Akron, OH, USA
Harveen K. Lamba, Nicholas E. Bruns, and Todd A. Ponsky
Alessandra Landmann, Juan L. Calisto, and Stefan Scholz
45 Laparoscopic Adrenalectomy in Children ............... 609
Craig A. Wengler, Heather R. Nolan, and Joshua Glenn
46
Celeste Hollands
47 Bariatric Surgery
Robert Michael Dorman, J. Hunter Mehaffey, and Carroll M. Harmon
48
Angela M. Hanna and Jose Alberto Lopez
49 Laparoscopic Management of Testicular Disorders: Cryptorchidism and Varicocele .............. 667
Armando Rosales, Gavin A. Falk, and Cathy A. Burnweit
50
51
Neel Parekh and Curtis J. Clark
Charlotte Wu and Hans G. Pohl
52
Ruchi Amin and Danielle S.
Contributors
Mohammad Ali Abbass Pediatric Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
Sophia Abdulhai General Surgery, East Carolina University, Greenville, NC, USA
Ruchi Amin General Surgery, East Carolina University, Greenville, NC, USA
Kelly Arps Emory University School of Medicine, Atlanta, GA, USA
Wesley Barnes General Surgery, Beaumont Health System, Royal Oak, MI, USA
Lilly Ann Bayouth General Surgery, East Carolina University, Greenville, NC, USA
Nicholas E. Bruns Pediatric Surgery, Akron Children’s Hospital, Akron, OH, USA
General Surgery, Cleveland Clinic, Cleveland, OH, USA
Cathy A. Burnweit Nicklaus Children’s Hospital, Miami, FL, USA
Juan L. Calisto Pediatric General and Thoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Julietta Chang Digestive Diseases Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
Richard Cheek General Surgery, Allegheny General Hospital, Pittsburgh, PA, USA
Curtis J. Clark Urology, Akron Children’s Hospital/ Northeast Ohio Medical University, Akron, OH, USA
Brian T. Craig Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN, USA
Domenic Craner Pediatric General Surgery, Akron Children’s Hospital, Akron, OH, USA
Barrett P. Cromeens General Surgery, East Carolina University, Greenville, NC, USA
Anthony L. DeRoss Pediatric Surgery, Cleveland Clinic Children’s, Surgery, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, USA
Diana L. Diesen Pediatric Surgery, Department of Surgery, Southwestern Medical, Children’s Health Dallas, Dallas, TX, USA
Robert Michael Dorman Pediatric Surgery, Women and Children’s Hospital of Buffalo, Buffalo, NY, USA
Ibrahim Abd el-shafy Pediatric Surgery, Cohen Children’s Medical Center, Queens, NY, USA
Meagan Elizabeth Evangelista Pediatric Surgery, East Carolina University, Greenville, NC, USA
Gavin A. Falk Nicklaus Children’s Hospital, Miami, FL, USA
Aaron P. Garrison Pediatric Surgery, Akron Children’s Hospital, Akron, OH, USA
James D. Geiger Pediatric Surgery, Mott Children’s Hospital, University of Michigan, Ann Arbor, MI, USA
Contributors
Sarah Gilmore University of Alabama School of Medicine in Birmingham, Birmingham, AL, USA
Ian C. Glenn Pediatric Surgery, Akron Children’s Hospital, Akron, OH, USA
Joshua Glenn Pediatric Surgery, Mercer University School of Medicine/The Medical Center – Navicent Health, Macon, GA, USA
Michael J. Goretsky Pediatric Surgery, Carolinas HealthCare System, Charlotte, NC, USA
Moriah M. Hagopian General Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
Angela M. Hanna Pediatric Surgery, Swedish Medical Center, Seattle, WA, USA
Carroll M. Harmon Pediatric Surgery, Women and Children’s Hospital of Buffalo, Buffalo, NY, USA
Celeste Hollands Surgery, University of South Alabama, Mobile, AL, USA
Anne-Sophie Holler Pediatric Surgery, University Medicine, Johannes Gutenberg University Mainz, Mainz, Germany
Zachary Hothem General Surgery, Beaumont Health System, Royal Oak, MI, USA
Sarah T. Hua Pediatric Surgery, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN, USA
Gretchen Purcell Jackson Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN, USA
Kevin N. Johnson Pediatric Innovation, Pediatric Surgery, Mott Children’s Hospital, University of Michigan, Ann Arbor, MI, USA
Folashade Adebisi Jose Pediatric Gastroenterology, East Carolina University, Greenville, NC, USA
Contributors
Timothy D. Kane Surgery and Pediatrics, Children’s National Medical Center, George Washington University School of Medicine, Washington, DC, USA
Harveen K. Lamba Pediatric Surgery, Akron Children’s Hospital, Akron, OH, USA
Alessandra Landmann General Surgery, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
Christine M. Leeper Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Thom E. Lobe Regeneveda, The Beverly Hills Institute of Cellular Therapy, Chicago, IL, USA
Shannon W. Longshore Surgery, East Carolina University, Greenville, NC, USA
Jose Alberto Lopez General Surgery, Swedish Medical Center, Seattle, WA, USA
Jeffrey Lukish Johns Hopkins University, Baltimore, MD, USA
Cristina Mamolea General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
Colin A. Martin University of Alabama at Birmingham, Birmingham, AL, USA
Laura Y. Martin Surgery, Johns Hopkins Hospital, Baltimore, MD, USA
Mark O. McCollum Pediatric Surgery, Akron Children’s Hospital, Akron, OH, USA
J. Hunter Mehaffey General Surgery, University of Virginia Medical Center, Charlottesville, VA, USA
Go Miyano Pediatric Surgery, Shizuoka Children’s Hospital, Shizuoka, Japan
Azmath Mohammed General Surgery, Beaumont Health System, Royal Oak, MI, USA
Contributors
Kevin P. Mollen Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
Oliver J. Muensterer Pediatric Surgery, University Medicine Mainz, Mainz, Germany
Heather R. Nolan General Surgery, Mercer University School of Medicine/The Medical Center – Navicent Health, Macon, GA, USA
Nathan Novotny Pediatric Surgery, Beaumont Health System, Oakland University William Beaumont School of Medicine, Royal Oak, MI, USA
Dominic Papandria Pediatric General and Thoracic Surgery, Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
Neel Parekh Urology, Akron Children’s Hospital/Northeast Ohio Medical University, Akron, OH, USA
Shawn D. St. Peter Surgery, Children’s Mercy Hospital, Kansas City, MO, USA
Hans G. Pohl Urology and Pediatrics, Children’s National Medical Center, Washington, DC, USA
Todd A. Ponsky Surgery and Pediatrics, Pediatric Surgery, Akron Children’s Hospital, Akron, OH, USA
Ashwini S. Poola Surgery, Children’s Mercy Hospital, Kansas City, MO, USA
José M. Prince Pediatric Surgery, Cohen Children’s Medical Center of Northwell Health/Hofstra Northwell School of Medicine, New Hyde Park, NY, USA
Priya Rajdev General Surgery, Emory University, Atlanta, GA, USA
Eric J. Rellinger Pediatric Surgery, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, TN, USA
Robert L. Ricca Surgery, Naval Medical Center Portsmouth/ Uniformed Services University, Portsmouth, VA, USA
Contributors
J. Eli Robins Surgery, East Carolina University, Greenville, NC, USA
David Rodeberg Pediatric Surgery, East Carolina University, Greenville, NC, USA
Armando Rosales Nicklaus Children’s Hospital, Miami, FL, USA
Steven S. Rothenberg Pediatric Surgery, Rocky Mountain Hospital for Children, Denver, CO, USA
Melody R. Saeman Surgery, University of Texas Southwestern, Dallas, TX, USA
Lauren Salesi School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
Avraham Schlager Pediatric Surgery, Akron Children’s Hospital, Akron, OH, USA
Stefan Scholz Pediatric General and Thoracic Surgery, Children’s Hospital of Pittsburgh of UPMC, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
Federico G. Seifarth Pediatric Surgery, Kalispell Regional Healthcare, Kalispell, MT, USA
Bethany J. Slater Rocky Mountain Hospital for Children, Denver, CO, USA
Oliver Soldes Pediatric Surgery, Akron Children’s Hospital, Akron, OH, USA
Andrew T. Strong General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
Brandon VanderWel General Surgery, Swedish Medical Center, Seattle, WA, USA
John H.T. Waldhausen Division Chief Pediatric General and Thoracic Surgery, Seattle Children’s Hospital, Seattle, WA, USA
William Taylor Walsh General Surgery, South Pointe Hospital, Warrensville Heights, OH, USA
Contributors
Danielle S. Walsh Pediatric Surgery, East Carolina University, Greenville, NC, USA
Craig A. Wengler Surgery, Mercer University School of Medicine/The Medical Center – Navicent Health, Macon, GA, USA
Simon K. Wright Minimally Invasive Head and Neck Surgery, ENT Clinic of Iowa, West Des Moines, IA, USA
Charlotte Wu Urology, Yale–New Haven Hospital, Yale University School of Medicine, New Haven, CT, USA
Jingliang Yan General Surgery, Cleveland Clinic Foundation, Cleveland, CT, USA
Jeh B. Yung General Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
Jeh B. Yung Pediatric Surgery, Kalispell Regional Healthcare, Kalispell, MT, USA
David C. van der Zee Pediatric Surgery, University Medical Center Utrecht, Wilhelmina Children’s Hospital, Utrecht, The Netherlands
1. Physiologic Considerations for Minimally Invasive Surgery in Infants and Children
Brian T. Craig and Gretchen Purcell Jackson
Introduction
Laparoscopy and thoracoscopy have gained widespread acceptance in the surgical approach to infants and children. Minimally invasive procedures are routinely performed and often considered the standard of care for common pediatric operations, such as appendectomy, pyloromyotomy, and fundoplication. Many pediatric surgeons employ laparoscopy or thoracoscopy for advanced procedures including operations for duodenal atresia, malrotation, anorectal malformations, Hirschsprung’s disease, congenital diaphragmatic hernia, and tracheoesophageal fistula [1, 2]. Additionally, there are case reports of minimally invasive pancreatectomy, hepatectomy, and resections for neuroblastoma and Wilms tumor in children. The general trend in pediatric surgical practice has been increased adoption of minimally invasive approaches.
Safe application of minimally invasive surgery in pediatric patients necessitates a thorough understanding of the physiologic effects of carbon dioxide (CO2) insufflation in this population. Regardless of the operation being performed, two main effects produce the physiological consequences of insufflation: (1) increased intra-abdominal or intrathoracic pressure and (2) CO2 absorption through the visceral and parietal peritoneum (Fig. 1.1). One series reported a 7 % rate of needing to stop insufflation either transiently or permanently for children undergoing laparoscopy [3, 4]. Patients who had insufflation-related incidents and needed the procedure halted were younger with lower immediate preoperative body temperature, and the operations were longer and had higher
D.S. Walsh et al. (eds.), The SAGES Manual of Pediatric Minimally Invasive Surgery, DOI 10.1007/978-3-319-43642-5_1
B.T. Craig and G.P. Jackson
Fig. 1.1. Two major stimuli produce the observed physiologic changes during abdominal insufflation for laparoscopy: (1) increased intra-abdominal pressure (blue arrows), which impedes full lung expansion and can decrease flow through the aorta and vascular system, and (2) enhanced CO2 absorption (red arrows) by the visceral and parietal peritoneum, which increases the necessary minute ventilation to maintain acid-base balance. Figure courtesy of Sarah Hua.
insufflation pressures. Therefore, during minimally invasive operations, pediatric surgeons and anesthesiologists frequently contend with acute physiologic changes from abdominal or thoracic insufflation that may significantly change the course of the procedure. They should anticipate such changes and be prepared to manage them.
This chapter describes the effects of abdominal and thoracic insufflation on the cardiovascular, pulmonary, metabolic, and immune/inflammatory systems, with a special emphasis on neonates and infants, as these patients differ significantly from adults and older children both anatomically and physiologically. General principles for preoperative preparation and postoperative care are addressed. Physiologic sequelae of abdominal insufflation are discussed in context of the organ systems affected.
Preoperative Evaluation
As with any pediatric or neonatal operation, general fitness for a planned minimally invasive operation is of paramount importance. Appropriate history related to nutritional status and growth should be obtained for every patient, and any symptoms or signs that could suggest
cardiac or pulmonary impairment must be elicited. Anesthetic management plans need to be carefully formulated, especially in neonatal cases with extended procedures, reverse Trendelenburg positioning, and higher insufflation pressures [5]. General endotracheal anesthesia remains the standard for pediatric laparoscopic and thoracoscopic operations to allow the anesthesiologist to contend with the physiologic effects of hypercarbia and increased intra-abdominal or intrathoracic pressures [2].
Several specific comorbidities warrant special consideration in preoperative planning. Minimally invasive procedures are increasingly being performed in infants with congenital heart disease. These patients may be more susceptible to changes in preload due to impaired venous return or changes in systemic resistance associated with increased intra-abdominal pressure [6]. Laparoscopic and thoracoscopic operations can be done safely in these patients in experienced centers with dedicated pediatric cardiac anesthesia teams [6–8].
Underlying pulmonary disease is another important comorbidity to consider before undertaking a minimally invasive procedure in a child. Excretion of excess CO2 that is absorbed through the visceral and parietal peritoneum is a primary concern of the anesthesiologist managing the infant undergoing laparoscopic or thoracoscopic surgery. Increasing minute ventilation is the primary tool used to remove excess CO2. Any pulmonary condition that may limit the ability to increase minute ventilation or impair gas exchange could rapidly lead to a respiratory acidosis. If laparoscopy is to be undertaken in a patient with baseline pulmonary dysfunction, intensive postoperative monitoring should be utilized to limit risks of hypoventilation from retained hypercarbia. A related problem is portal hypertension, which has been shown to accelerate absorption of CO2 to a level twice that of the already increased absorption displayed in children [9]. Similar to the patient with pulmonary disease, patients with portal hypertension should be managed with increased vigilance to limit the negative effects of hypercarbia in the postoperative period.
Physiologic Effects of Pneumoperitoneum by
System
Cardiovascular System
Several studies have examined the cardiovascular effects of pneumoperitoneum in children. Direct measurement of flow in the thoracic aorta by transesophageal echocardiography (TEE) in healthy 6- to 30-month-old
B.T. Craig and G.P. Jackson
infants and children undergoing laparoscopic assisted orchiopexy for undescended testicles with a maximum insufflation pressure of 10 mmHg showed significantly decreased flow, decreased stroke volume, and increased systemic resistance. However, these changes resolved completely after desufflation of the abdominal cavity. Significant changes in mean arterial pressure (MAP) or end-tidal CO2 were not observed during these relatively short procedures, nor were any clinically important sequelae [10]. In another study of healthy 2- to 6-year-old children undergoing laparoscopic inguinal herniorrhaphy, an initial insufflation to an abdominal pressure of 12 mmHg decreased cardiac index (CI) as measured by TEE [11]. Interestingly, CI returned to baseline with a decrease in insufflation pressure to 6 mmHg and did not decrease with a subsequent increase in abdominal pressure to 12 mmHg, suggesting an adaptation to the change in afterload induced by abdominal insufflation. A recent study exposed neonatal and adolescent piglets to 180 min of abdominal insufflation, which caused a decrease in CI and MAP that persisted well into the recovery period after insufflation ended. This effect was more pronounced in the neonates [12]. The extended response to the pressure stimulus suggests a need for vigilant monitoring in the postoperative period to ensure that hypotension does not ensue. Prolonged exposure to higher insufflation pressures (>8–10 mmHg) may also induce capillary microcirculatory changes and impair venous return [1]. In contrast, a study using low-pressure insufflation no greater than 5 mmHg combined with reverse Trendelenburg positioning in children ages 6 to 36 months undergoing laparoscopic fundoplication actually increased CI, heart rate, and MAP [13].
In summary, in the otherwise healthy infant or child, abdominal insufflation pressures of 12 mmHg or less for short- to medium-length procedures may cause changes in CI, MAP, or systemic resistance when specifically measured but rarely (3.2 % of cases) produce clinically significant effects requiring intervention [4]. The location of monitoring may not affect the accuracy of blood pressure measurements. In a piglet model, no difference was found between measured carotid and femoral arterial blood pressures with up to 24 mmHg abdominal insufflation, a level nearly twice that of the highest commonly used clinically [14].
Pulmonary System
The pulmonary effects of pneumoperitoneum in pediatric patients are the result of anatomic and physiologic differences between adults and children. The alveolar surface area to body surface area ratio in
infants and children is smaller than that of adults. Therefore, children have a significantly higher minute ventilation and oxygen consumption (up to twice that of an adult) even at baseline to maintain PaCO2 in the normal range [1]. In patients younger than 1 year of age, the spaceoccupying effects of abdominal insufflation lead to increased peak inspiratory pressure, reduced tidal volume, and decreased compliance [15]. These changes in turn produce decreased functional residual capacity (FRC), increased pulmonary vascular resistance, and increased shunt fraction, which in combination with the increased CO2 absorption can lead to hypercarbia if the minute ventilation is not increased concomitantly [15].
Hypercapnia is a significant concern in minimally invasive surgery, especially in children with underlying pulmonary disease. In one series of laparoscopic and thoracoscopic procedures performed in neonates (i.e., <1 month of age), hypercapnia >45 mmHg was reported in 2.3 % of cases [4]. The degree of hypercapnia depends on insufflation pressure and duration of pneumoperitoneum. In piglet models, PaCO2 has been shown to increase 25 % with stepwise increases in insufflation pressure with associated increases in mortality from CO2 embolism [16]. In a study of low-pressure (i.e., maximum 5 mmHg) insufflation for fundoplication, CO2 rose 28 % on average when patients up to 3 years of age were exposed for more than an hour [17]. Careful monitoring for hypercapnia is warranted for all pediatric minimally invasive procedures, and laparoscopic insufflation pressures should be limited, with a maximum recommended pressure of 12 mmHg for neonates [15].
An important consideration for respiratory monitoring is that a gradient will develop between the PaCO2 and the end-tidal CO2 after abdominal insufflation because of an increased CO2 and diminished functional residual volume. This gradient has been documented to increase significantly in adults during the first 60 min of insufflation for laparoscopic colorectal surgery but to stabilize or decrease thereafter [18]. In young children with cyanotic congenital heart disease undergoing laparoscopic fundoplication, the gradient increased by a factor of nearly 2.5 soon after initial insufflation of the abdomen [19]. This gradient was shown to be as high as 8 mmHg in one study of laparoscopic fundoplication in children without underlying cardiac or respiratory disease; as in other studies, the gradient decreased with longer insufflation stimulus [20]. Measuring CO2 elimination has also been used to monitor this process. End-tidal CO2 increases disproportionately for younger patients compared to older children with the same insufflation pressures and duration, and it remains elevated even after
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the conclusion of the procedure [15]. For these reasons, postoperative monitoring of respiratory rate is critical to safely performing laparoscopy in infants and neonates.
Another potential problem in infants undergoing laparoscopy is hypoxemia. In neonates and infants, there is a close relationship between functional residual capacity (FRC) and airway closing pressure. When FRC decreases in response to the increased intra-abdominal pressure, airway closure will exacerbate right-to-left intrapulmonary shunt and can lead to hypoxemia [5].
Inflammatory/Immune System
In children, data from a study of procedures for acute abdominal pain suggested that laparoscopic compared to open operations did not result in differences in major inflammatory mediators such as cortisol and IL-6 [21]. However, several subsequent studies have demonstrated a lesser degree of increase in inflammatory mediators including IL-6, CRP, TNF-α, and cortisol with laparoscopy compared to open approach for a variety of operations [22–25]. Cellular responses are also affected by laparoscopy, in a manner similar to the cytokine responses. Both macrophages and neutrophils are recruited to the peritoneal cavity with insufflation, though the numbers are lower with CO2 insufflation compared to air [26].
Other
Compared with adults, children have a greater body surface area to volume ratio [27] and thus are at increased risk for hypothermia. During minimally invasive surgical procedures in infants and children, hypothermia is reported to occur in 1.8 % of cases [4]. Temperature monitoring is especially important in newborns. Dry CO2 insufflation on continuous flow of 5–8 L/min will lead to massive evaporative losses relative to body size, and the accompanying heat loss can approach 40 % of a neonate’s metabolic power capacity, despite their higher-per-kilogram power capacity compared to adults [3]. Additionally, gas leaks around port sites in a neonate can result in a much greater loss of insufflation gas, thereby requiring higher flow rates and potentially exacerbating hypothermia if non-humidified CO2 is used.
Reversible anuria during laparoscopy is a consistent observation in the literature, occurring in 88 % of neonates and 14 % in older children. Up to one-third of older children will experience oliguria [28]. Interestingly, these decreases in urine output are not responsive to volume challenge and do not reflect decreases in renal blood flow. Thus, intraoperative fluid resuscitation during laparoscopic procedures should not be governed by urine output alone.
Finally, potential catastrophic events can occur during laparoscopy, and some of these severe complications may be more likely in children. Venous air embolism due to cannulation and insufflation of a patent umbilical vein has been reported in several instances and has sometimes led to cardiac arrest [1]. CO2 pneumothorax is another rare complication that has been reported in children. In one case, it was discovered at the end of the procedure when the infant did not resume spontaneous respirations with reversal of anesthesia, although the child eventually recovered with no reported long-term effects [29].
Thoracoscopic Surgery Considerations
Many of the major pediatric thoracic operations have been performed thoracoscopically, including resection for congenital pulmonary airway malformation, repair of congenital diaphragmatic hernia, and repair of esophageal atresia with and without concomitant tracheoesophageal fistula [1]. Thoracoscopy is routinely employed in pediatric surgical practice for other procedures such as decortication, sympathectomy, and lung biopsies or resections. A knowledge of the physiology of minimally invasive chest procedures is essential for their safe application.
Two potential effects of thoracoscopic surgery merit consideration. First, single-lung ventilation produces ventilation/ perfusion (V/Q) mismatch, which is most pronounced in neonates. Several factors make neonates particularly susceptible to V/Q mismatch: a narrower window between FRC and residual volume, a compliant chest wall, a lateral decubitus positioning, and a neuromuscular blockade [5]. The end result is hypoxia.
Second, there is a widely held belief that CO2 absorption is greater during thoracoscopy compared to laparoscopy, which could lead to metabolic acidosis, as reported during congenital diaphragmatic hernia repair [1]. In support of this hypothesis, end-tidal CO2 has been shown to increase significantly after chest insufflation and persist after desufflation, and
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these changes are greater in younger patients and larger than those observed during laparoscopy [30]. The data on these two responses are far from conclusive, and more work is needed to identify specific situations that will produce clinically important changes in CO2 level and acid-base status.
Postoperative Care
The most important consideration in the postoperative care of children undergoing minimally invasive procedures is respiratory monitoring in the first several hours after abdominal desufflation, when residual hypercarbia may be present and the potential for hypoventilation persists. This risk is especially important in neonates, infants, and young children, and we recommend these patients be monitored with continuous pulse oximetry for at least the first several hours after laparoscopy. Further work will be needed to accurately determine if a predefined, mandatory length of stay in the anesthesia recovery area or in a monitored hospital unit is necessary to prevent life-threatening hypoventilation.
Summary
• Laparoscopy is physiologically safe and effective approach in pediatric patients of all ages and for many pediatric abdominal surgical procedures.
• Increased intra-abdominal pressure leading to impaired pulmonary mechanics and increased CO2 absorption are the two primary stimuli that lead to the array of physiologic sequelae during and after laparoscopy.
• Cardiac index, mean arterial pressure, and aortic blood flow decrease during abdominal insufflation but rarely with important clinical consequences.
• Increased minute ventilation must be achieved during minimally invasive surgery, especially in neonates, to prevent hypercarbia and subsequent acidosis.
• Reversible anuria and oliguria occur with laparoscopy, and this effect is more pronounced in younger patients.
• Increases in inflammatory mediators and cellular responses are decreased during laparoscopic compared to open operations in children.
• Vigilant postoperative monitoring for neonates should be employed as CO2 retention may persist after abdominal desufflation.
References
1. Lacher M, Kuebler JF, Dingemann J, Ure BM. Minimal invasive surgery in the newborn: current status and evidence. Semin Pediatr Surg. 2014;23(5):249–56.
2. Ponsky TA, Rothenberg SS. Minimally invasive surgery in infants less than 5 kg: experience of 649 cases. Surg Endosc. 2008;22(10):2214–9.
3. Blinman T, Ponsky T. Pediatric minimally invasive surgery: laparoscopy and thoracoscopy in infants and children. Pediatrics. 2012;130(3):539–49.
4. Kalfa N, Allal H, Raux O, et al. Multicentric assessment of the safety of neonatal video surgery. Surg Endosc. 2007;21(2):303–8.
5. Means LJ, Green MC, Bilal R. Anesthesia for minimally invasive surgery. Semin Pediatr Surg. 2004;13(3):181–7.
6. Watkins SC, Morrow SE, McNew BS, Donahue BS. Perioperative management of infants undergoing fundoplication and gastrostomy after stage I palliation of hypoplastic left heart syndrome. Pediatr Cardiol. 2012;95:204–11.
7. Slater B, Rangel S, Ramamoorthy C, Abrajano C, Albanese CT. Outcomes after laparoscopic surgery in neonates with hypoplastic heart left heart syndrome. J Pediatr Surg. 2007;42(6):1118–21.
8. Cribbs RK, Heiss KF, Clabby ML, Wulkan ML. Gastric fundoplication is effective in promoting weight gain in children with severe congenital heart defects. J Pediatr Surg. 2008;43(2):283–9.
9. Bozkurt P, Kaya G, Yeker Y, et al. Arterial carbon dioxide markedly increases during diagnostic laparoscopy in portal hypertensive children. Anesth Analg. 2002;95(5): 1236–40.
10. Gueugniaud PY, Abisseror M, Moussa M, et al. The hemodynamic effects of pneumoperitoneum during laparoscopic surgery in healthy infants: assessment by continuous esophageal aortic blood flow echo-Doppler. Anesth Analg. 1998;86(2):290–3.
11. Sakka SG, Huettemann E, Petrat G, et al. Transoesophageal echocardiographic assessment of haemodynamic changes during laparoscopic herniorrhaphy in small children. Br J Anaesth. 2000;84:330–4.
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13. De Waal EEC, Kalkman CJ. Haemodynamic changes during low-pressure carbon dioxide pneumoperitoneum in young children. Paediatr Anaesth. 2003;13(1):18–25.
14. Aksakal D, Hückstädt T, Richter S, et al. Comparison of femoral and carotid blood pressure during laparoscopy in piglets. J Pediatr Surg. 2012;47(9):1688–93.
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18. Tanaka T, Satoh K, Torii Y, Suzuki M, Furutani H, Harioka T. Arterial to end-tidal carbon dioxide tension difference during laparoscopic colorectal surgery. Masui. 2006;55(8):988–91.
19. Wulkan ML, Vasudevan SA. Is end-tidal CO2 an accurate measure of arterial CO2 during laparoscopic procedures in children and neonates with cyanotic congenital heart disease? J Pediatr Surg. 2001;36(8):1234–6.
20. Sanders JC, Gerstein N. Arterial to endtidal carbon dioxide gradient during pediatric laparoscopic fundoplication. Paediatr Anaesth. 2008;18(11):1096–101.
21. Bozkurt P, Kaya G, Altintas F, et al. Systemic stress response during operations for acute abdominal pain performed via laparoscopy or laparotomy in children. Anaesthesia. 2000;55(1):5–9.
22. Ure BM, Niewold TA, Bax NMA, et al. Peritoneal, systemic, and distant organ inflammatory responses are reduced by a laparoscopic approach and carbon dioxide vs air. Surg Endosc. 2002;16(5):836–42.
23. Wang L, Qin W, Tian F, et al. Cytokine responses following laparoscopic or open pyeloplasty in children. Surg Endosc. 2009;23(3):544–9.
24. Montalto AS, Bitto A, Irrera N, et al. CO2 pneumoperitoneum impact on early liver and lung cytokine expression in a rat model of abdominal sepsis. Surg Endosc. 2012; 26(4):984–9.
25. Papparella A, Noviello C, Romano M, et al. Local and systemic impact of pneumoperitoneum on prepubertal rats. Pediatr Surg Int. 2007;23(5):453–7.
26. Moehrlen U, Ziegler U, Boneberg E, et al. Impact of carbon dioxide versus air pneumoperitoneum on peritoneal cell migration and cell fate. Surg Endosc. 2006;20(10): 1607–13.
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2. Pediatric Laparoscopic and Thoracoscopic Instrumentation
Sarah Gilmore and Colin A. Martin
Early Experience
Pediatric minimally invasive surgery (MIS) has lagged behind its adult counterpart. In 1973, a report in the Journal of Pediatric Surgery by Gans and Berci described 16 early laparoscopic pediatric cases [1]. These early advances were possible in part by the Hopkins rod-lens optical system (Fig. 2.1). However, widespread adoption of pediatric laparoscopy was initially met with criticism. The first adult laparoscopic cholecystectomy was performed in 1985 [2] and was widely regarded as experimental and dangerous. There has been no single procedure that has propelled the advance of MIS in pediatric patients the way laparoscopic cholecystectomies did with adult MIS. Training modules for teaching laparoscopic cholecystectomy to adult surgeons were not well suited for teaching the advanced skills required for pediatric surgery [3]. This procedure was not considered standard of care in pediatrics until many years later. However, great strides have been made within the last 20 years. Today, it is common practice for neonates to undergo minimally invasive surgery. A study conducted by Rothenberg et al. over a 51-month period with 183 infants weighing 1.3–5.0 kg who underwent 195 procedures using minimally invasive techniques “demonstrates that advanced endosurgical techniques in infants is safe, effective, and associated with the same benefit as that seen in older patients” [4].
D.S. Walsh et al. (eds.), The SAGES Manual of Pediatric Minimally Invasive Surgery, DOI 10.1007/978-3-319-43642-5_2
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people; and no doubt they have been seeking him ever since they learned that he was the murderer of Sasaku. Also, unquestionably, they would shadow the men with whom he was associated; and thus, through Minowsky’s coming here this afternoon, they learned of his hiding place.
“But come,” he urged, laying a hand on Cato’s arm. “Let us hurry after them. We still may be in time to prevent bloodshed. They will certainly desist if we tell them that Simmons has decided to give himself up to the authorities.”
Indeed, considering that they had been trussed up for over fifteen hours, it was really remarkable how quickly they made their way to the shore. Through the tall weeds they plunged breathlessly, never thinking of the danger they ran in possibly being mistaken for the fugitive.
As a matter of fact, though, they were led astray from the actual chase by a chance pig, which, stirred up from its comfortable wallow at their approach, drew them considerably to the north under the delusion that they were following the footsteps of Simmons, or one of his pursuers.
So, when they finally came out on the river bank, it was to see Simmons emerge from the bushes fully four hundred yards below them, and, in frenzied flight, dash down to the water’s edge.
There he hesitated a second, glancing back over his shoulder; but evidently seeing the avengers hard upon his heels, threw aside his coat, and splashed into the shallows with the manifest intention of trying to escape by swimming.
A dozen steps he took, the water rising above his waist; then, just as he was about to throw himself forward and strike out, he stopped suddenly with a peculiar gesture, seemed to struggle unavailingly, and, half turning toward shore, threw up his arms with a wild scream for help.
“Great heavens!” exclaimed Grail. “He’s struck quicksand!” And immediately he and Cato started to run down the shore. But before they had covered half the distance they saw that they would be too late. With fearful rapidity the victim was being drawn down. Already the water was up to his chin.
A little knot of the pursuers stood on the bank, but they stirred neither hand nor foot to tender aid. In absolutely stolid silence they watched the tragedy being enacted before them. Grail tried to call to them, to explain; but they either failed to hear or declined to heed him.
So the end came. There was one last awful, gurgling cry; then silence. By the time that Cato and Grail came panting to the spot, the Japanese had disappeared, departed as quickly and silently as though they had evaporated into air. Only a few bubbles floating on the surface of the muddy river remained to give a sign of what had happened.
CHAPTER XXVI.
THE DAMPENED LETTER.
Shocked and shaken by the terrible fate which had overtaken Simmons, Grail and his companion could only stand staring silently at the flowing waters; but very shortly they aroused themselves from their stunned apathy.
Primarily it behooved them to make good their escape; for the Russians might return at any moment, and, finding them gone from the hut, set afoot a search, which, so long as they remained so near at hand, could not fail to result in their recapture.
With the possibility of such an encounter, they decided not to risk going back through the bottoms, but since the skiff that they had used the night before was close at hand, to take it, and row across the river.
Quickly they launched it, therefore, and Grail, who took the oars, forgot, under the desire for speed, how stiff and sore his arms were.
As he thought of what might have happened to Colonel Vedant while he lay a prisoner—nay, more, of what might have happened to Meredith, recalling Simmons’ interrupted disclosure—he set his teeth in grim determination, and pulled away so furiously that Cato was constrained to protest.
“Here, captain,” he urged, “you’ll wind yourself before we are halfway across. Take it easier.”
But Grail only shook his head, and dug at the water harder than ever. Nevertheless, the swift, eddying current of the river is a thing to test the mettle of any rower, and, despite all that Grail could do, the landing that they finally effected was far downstream.
A passing trolley car, however, afforded them quick means of returning to the city, and, boarding it, they rode until Grail sighted the signboard of a public telephone station, and leaped off to call up with fast-beating heart the home of Mrs. Schilder.
The voice of the French maid answered, and as she repeated his name it seemed to him that there was a distinct flutter of surprise in her tone.
However, he was too absorbed to pay any heed to that. “Is Miss Vedant there?” he inquired breathlessly.
“Mees Vedant? No.” Grail’s heart seemed to stop beating in the pause. “She and madame ’ave just gone out in ze automobile.”
He drew a long breath, and the icy hand which seemed to have been clutching at his throat relaxed. His fears and misgivings, then, in regard to Meredith had all been in vain; she was safe.
What he would have thought if he had known that Marie lied when she said that Meredith was not in, and that immediately on leaving the phone Marie hastened wide-eyed to her mistress, is another question.
Also, he might have indulged in some reflection, if he had known that immediately on receiving the maid’s news, Mrs. Schilder herself hurried to the instrument and called up a number not listed in the book, but recorded at the office as belonging to Dabney.
Ignorant of all this, he went out almost buoyantly to rejoin Cato, and catch the next car headed for town. They had to wait a little for it to come along; so, with one thing and another, it was three-quarters of an hour before they arrived at the fort.
The evening had settled down early with a lowering sky, from which fell every now and then a spatter of raindrops, and the thunder was growling sullenly away in the distance; so, although it was still hardly sunset, darkness had practically fallen, and the sentinel at first failed to recognize them as, muddy and bedraggled, they approached the entrance.
At the sound of Grail’s voice, however, he stared in incredulous surprise, and seemed about to say something; then recovered himself and gave the salute.
“There was a note came for you, sir,” he stammered, “just about five minutes ago; but I didn’t know if—didn’t know when you were coming back, so I told the boy to take it over to the guardhouse.”
“Thank you,” replied the adjutant, and, stopping on his way to his quarters, possessed himself of the missive.
It was slightly damp to the touch, he noticed, but he thought nothing of that on account of the rainy evening. Tearing it open, and holding it up to the light when he reached his rooms, he pursed his lips as he read:
“D G : I am dictating this to you at Schilder’s office, where I have just received some astounding information which completely exonerates you from the unjust suspicions some of us have entertained toward you, and also points the way toward the speedy recovery of Colonel Vedant.
“Should you return to the post before eight o’clock, will you not accept our apologies, and come at once to Mr. Schilder’s residence to join the officers in a conference we are holding there, to decide on how best to use the intelligence at hand to Vedant’s advantage? Faithfully yours,
A .”
Grail studied the letter. There seemed no reason to doubt the genuineness of the bold signature; it was Appleby’s in every line and flourish. Neither could he question that the thing had been typed at Schilder’s office. The chipped “m” and blurred “D” spoke for themselves.
Then he smelled and tasted of the paper on which it was written, but an incipient head cold, as a result of his night spent out on the bottoms, had somewhat blunted those senses, and he could not be sure of the results. The letter seemed, on the face of it, to be straight.
Still, to make certain, he called in his “striker,” and asked if he knew where Major Appleby could be found.
“I understand, sir,” said the man, “that he and all the other officers at liberty have gone out to Mr. Schilder’s.”
Grail turned to Cato. “That seems to settle it,” he announced. “As soon as we can get brushed up a bit, we’ll call a taxi and be off.”
TO BE CONTINUED.
EXCEEDINGLY CAUTIOUS.
A gentleman once told a strange story, one that, like so many other true stories, was difficult to believe.
His auditors showed by their manners that they doubted, and so he appealed to another gentleman who had been present at the time to confirm the truth of his statement.
To his amazement, this man replied stiffly, and said:
“I regret that I do not remember the circumstances to which you allude.”
The next day both these persons met, and the first gentleman said:
“But can’t you really remember those extraordinary circumstances?”
“Oh, yes,” replied the second.
“Then why the dickens did you say you didn’t, when I asked you about them before?” inquired Mr. One indignantly.
“Ah,” replied Mr. Two, “I saw that the company, all of them took you for a liar, and I wasn’t going to be taken for another!”
LOST AMONG THE ALLIGATORS.
Many years ago I was journeying by steamboat up one of the many bayous or creeks in the southern part of the State of Louisiana.
In the course of the morning the steamboat drew up at a wooding station to take in a supply of fuel, and, led by curiosity, I went ashore with a lad about my own age.
Growing tired of watching the negroes carrying the split wood on board, we yielded to the temptation to venture a little way into the forest.
A squirrel crossed our path. We gave chase, and the frisky little animal led us on till we found ourselves out of hearing of the hissing of the steam and the voices of the negroes at the woodpile.
Suddenly a bell rang; this we knew to be the signal for the steamer’s departure, and were horrified to note how faint and far-off the sound appeared. However, shouting at the top of our voices, we turned back.
Through brambles and briers, thorns and thickets, climbing over fallen logs and splashing through marshy places, we scrambled and leaped.
Then we distinctly heard the coughing of the steam and the dash of the paddle wheels. The boat had started! The sound grew more indistinct, and our hearts sank as we heard them rapidly die away in the distance.
We thought it would be an easy thing to find the river; yet our efforts were utterly in vain.
After a time, no river appearing, we realized the fact that we were lost!
An hour or two passed, and we became sensible of the pangs of hunger. We searched our pockets, and discovered that one biscuit was our entire stock of provisions. This we divided and gloomily ate.
An incident now occurred which showed that our position had its positive dangers. A fallen tree lay before us.
Upon mounting the log, I espied, coiled in many folds, with its rattle erect in the center, a huge rattlesnake.
Just as I was about to leap down, my eye caught its villainous glance. Fortunately I knew enough of serpent lore to recognize this formidable enemy, and, with a shout and gesture, prevented my companion climbing the log.
Nor were we a moment too soon. The creature had evidently observed us, for, as we fled, we heard his warning rattle, and momentarily expected him to spring over the log, in pursuit.
As the sun drew westward, we busied ourselves with picking out a tree suitable for camping purposes.
I helped my companion to mount one, which was thick and bushy, in the branches of which he soon lay down.
I stayed below to watch for a last chance. It seemed a useless thing to do; yet, though hoarse with shouting, I once more lifted up my voice.
Was it a fancy that there was a reply? We could not be mistaken, for both of us heard a faint, far-off response.
We waited with intense anxiety the approach of the stranger.
At length a gun barrel emerged from a great bank of rushes, followed by a rough, hunter-looking man.
“Who are you?” he asked.
“We came ashore from the Abeille at the wooding station, and have lost our way.”
“Whew!” he whistled, and rested on his gun; then scanned us both narrowly, for by this time my companion had slidden down from his post among the branches.
“Guess you had better come with me,” he said; and, shouldering his rifle, he turned and pushed his way through the reeds.
Soon we saw through the branches the glitter of water, and came out upon the bank of a river, smaller than that up which we had passed in the steamboat in the morning.
Here, concealed in the rushes, was a canoe, which he quickly launched, swinging the head round to where we were standing.
Without speaking, he motioned us to get into the frail craft, then followed himself, laying down his gun and taking up a paddle. With a few strokes he drove the canoe out into mid-channel.
Very soon the night fell, and the fireflies darted among the bushes on the shore. We now heard the barking of dogs, deep-toned and long-continued.
Ten minutes more and the canoe was laid alongside a shelving bank, some five or six feet high. Our boatman, quickly leaping ashore, fastened the chain of the canoe to a stump near the water’s edge, and bade us disembark.
We followed our protector as best we could in spite of the growing darkness, till, after traveling a few hundred yards, as far as one might judge in such a blind journey, we halted before a dimly visible log house.
The man unfastened the door, whereupon two huge deerhounds leaped out, frisking and barking, and, in their canine fashion, expressing the height of joy upon the return of their master.
Upon perceiving us, they showed signs, lively and unpleasant, of doubt and animosity, till they were roared down by the deep voice of our conductor.
A match was struck and a pine knot kindled. Heaping some dry wood upon the hearth, the hunter speedily had a blazing fire, whose ruddy glow showed up distinctly the rough interior of the house.
One of the first acts of our protector was to unroll a bundle from the corner and spread upon the floor a buffalo robe, upon which he bade me sit.
From the blazing fire he lit a rude lamp, which he hung upon the roof. Then he produced his iron pot, and sharpening his knife, with the pot in one hand and the knife in the other, went out into the darkness.
He soon returned with water from the river in the pot, and in his hand a piece of deer meat.
The pot was set upon the fire; the meat, cut into pieces and powdered with salt, put into it, and a handful of meal added, making a savory compound, which to us hungry boys seemed a delicious supper.
The serving of the meal was primitive. There was but one plate in the establishment; this the owner relinquished to his visitors, after having heaped it with smoking food, himself feeding leisurely from the pot.
We learned that our entertainer was an Englishman, who, in consequence of liberal views on poaching matters, had thought it more prudent to put the
broad Atlantic between himself and his native village.
Here, deep in the backwoods, he lived a Robinson Crusoe kind of life, miles away from human habitation, supporting himself with his gun.
During the course of the evening we had been conscious of a growing babel of sounds, which arose on all sides in the great, dark, outside world, and which deepened in intensity as the night wore on.
Every now and then a hoarse bellow as of some mammoth bull that, slumbering, had been awakened by intolerable agony, came from the alligators that abounded in the surrounding swamp.
We had noticed that the door of the hut was a crazy concern, loosely hasped, and with an unfastened padlock on the outside. Inside, its only protection was a wooden bar, which shot so smoothly in its grooves as to suggest that a strong-snouted animal could easily nose the door off its hinges.
Upon communicating our fears to our host, we produced upon his grim visage the nearest approach to a smile that we had yet observed.
He seemed entirely at his ease.
He had strange tales, such as that one day he came home and found an old alligator asleep on his hearth; how that rattlesnakes had frequently crept in through the interstices of the logs; and how that almost every evening after dusk, at certain times of the year, wolves prowled around.
Then our protector informed us that we must be stirring with the dawn. He would take us in his canoe a distance of ten miles, whence, by crossing a narrow tongue of land, we might reach a steamboat landing.
With lively interest we watched his preparations for the night. He tried the wooden bar placed across the doorway. The logs were put together on the hearth. He then bade us wrap ourselves as well as we could in our buffalo robe; put out the lamp, and then lay full length on the floor, near the hearth, and was soon fast asleep.
Wearied as I was, I could not sleep. The external noises grew louder and louder. The alligators waddled up and down the acclivity upon which the house stood.
At one time no fewer than four of these ugly reptiles were prowling around our little sanctuary.
Meantime, our host had fallen into the profoundest of slumbers, the audible proofs of which had in them some obscure consolation, for I could not but reason that a man who could sleep under such circumstances, and sleep so soundly, could not but be assured that there was no real ground for alarm.
So the event proved. Confused thoughts of rattlesnakes, alligators, wolves, steamboats that devoured, and rattlesnakes that coughed and paddled, clouded my brain until I fell off into an uneasy slumber, gradually deepening into utter unconsciousness.
When we awoke our host was standing in the open doorway, drying himself with a strip of canvas, after his matutinal wash in the river.
He had put a can of water over the fire, and, bruising some coffee berries between two stones, he made us a not unacceptable beverage. Biscuits, coffee—without either sugar or milk—and the considerate relics in the iron pot from his last night’s supper, made our breakfast.
We were soon on board the canoe, and were rapidly drifting downstream. The distance was quickly accomplished, and connection with civilization rapidly made; but I shall never forget that night spent among the alligators.
A NEW MOSQUITO TRAP.
He had the appearance of having traveled a good deal and was very talkative.
I incidentally touched upon the subject of mosquitoes.
“Mosquitoes!” he said; “why, my dear sir, up the Kongo I’ve seen them as big as bumblebees. One night, I remember particularly, they were out on the warpath, seeking whom they might devour, and were so outrageously lost to all sense of respect for me, that I was compelled to take refuge under the mosquito bar or curtain, although it was only just after dinner time and I wasn’t a bit sleepy. There were two candles burning on the table, so that I could see pretty clearly through the thin muslin bar, and by and by I noticed one of the indefatigable gray cusses, in prospecting around, had discovered a hole about the size of a shilling in the bar. He hummed joyously and then sailed away and triumphantly broke the news to all his friends and relatives, and in five minutes the whole community had clustered round the hole. They marched in silently and formed up in battalions, awaiting the signal to fall to. I had been imitating the sailor’s parrot by thinking a good deal, and superior
intellect prevailed; for, as the last of the procession entered, I slipped out from underneath, took a cork from the brandy bottle, stopped up the hole, and slept outside. The way those penned-up insects raved and swore when they saw themselves circumvented was simply bloodcurdling. Fact, sir. What! going so soon? Well, I hope to meet you again some day. Good-by.”
THE CAP FITTED ALL.
“You told me that you were going to a spiritualistic séance last week,” said young Hepburn to his chum, McCabe. “Did you go?”
“Oh, yes,” replied the other; “I went.”
“Well,” said his friend inquiringly, “anything out of the way happen?”
“Well, rather,” said McCue. “We had spirit rapping and table moving and other things, besides, and the whole affair went off splendidly until the medium went into a trance, and then announced that he was the spirit of a man who had had his umbrella stolen, and that the thief was in the room.”
“And what happened then?” queried Hepburn.
“Well,” replied his chum, “the whole party made a dash for the door, and I was afraid that if I stayed behind I might be taken for the thief, so I retreated with the rest.”
THE
NEWS OF ALL NATIONS.
Forks Save Keeper Clawed by Lion.
Attendants armed with pitchforks saved the life of Carl Wilson, an animal tamer, when Prince, a Nubian lion owned by the Levitt & Meyerholz circus, leaped at him as he was putting the beast through its paces at Jersey City.
Wilson was rehearsing four lions when Prince became enraged. As the trainer advanced to the corner of the cage where it crouched, the beast sprang, Wilson fell backward, and the lion clawed his face and tore his arm.
The lion was growling over the prostrate trainer, when attendants, standing outside of the bars, prodded the animal with long-handled forks.
Prince turned on them, giving Wilson opportunity to crawl to a door on the opposite side of the cage. He was taken to the Jersey City Hospital.
Prince has a reputation as a bad lion. Six other trainers have met with more or less serious injuries at his teeth and claws.
Scottish Officers Make Ammunition.
One hundred members of the Glasgow Officers’ Training Corps have begun a self-imposed task of making shells, in response to the appeal from Earl Kitchener for unlimited amounts of ammunition. These volunteers belong to the best families of Glasgow, and most of them will go to the shell factory in their own automobiles. They have undertaken to work six-hour shifts after a preliminary course of training.
Hamilton’s Oath Sold.
The original oath taken by Alexander Hamilton on his admission to practice as attorney and counselor in the supreme court and as solicitor and counselor in the court of chancery in New York, a one-page folio, dated Albany, July 12, 1783, brought the top price at the opening session of the sale at the Anderson Galleries of Part V. of the library of the late Adrian H. Joline, of New York. George D. Smith paid $125 for the document.
The same buyer gave $100 for the original manuscript petition of Colonel John Brown to “Horatio Gates, in the Army of the United States of America, commanding at Albany,” requiring General Arnold’s arrest on thirteen charges. Mr. Smith also gave sixty dollars for a four-page letter written by Washington Irving.
Auto Puts Engine Out by a Blow.
A great, overgrown Erie express train near the Garfield, N. J., railroad crossing struck a poor, little, aluminum-bodied automobile with all its might —and the Erie locomotive was put out of business and had to be hauled back to the repair shops.
That was all there was to this New Jersey incident, except for the fact that two men who were seated in the automobile don’t know just how they escaped injury.
Antonio Parapeto, of Monroe Street, Garfield, N. J., and John Russo, 430 Midland Avenue, also of Garfield, climbed into the touring car “to take a little spin.” While approaching the Erie Railroad crossing at Garfield, the autoists failed to see No. 9 Erie Express, bound for Chicago, until they were only thirty feet from the tracks. Both men jumped.
The automobile went ahead and was smashed to splinters.
The locomotive came to a halt very soon. The metal work of the automobile had cut a steam pipe near the locomotive’s pilot and rendered it helpless. Traffic on the line was tied up for an hour.
Parisians Lionize Pau.
An incident in Paris illustrates the popular regard for General Pau, who has been spending some time in that city since returning from his political mission to Petrograd and the Balkan capitals. Persons who saw the general enter the Red Cross branch in the Place Madeleine, waited in the street to see him come out. A crowd soon collected. A young girl borrowed a hat and quickly collected enough money in the crowd to buy for the general a huge bouquet of red, white, and blue flowers.
General Pau appeared to be deeply moved on receiving the flowers, and kissed the girl. The crowd cheered him, and as he drove off in his motor car he responded by shouting: “Vive la France!”
Husband Rued His Bargain.
Belmar, N. J., women want to know the name of the wife who obtained from her husband funds for a new Easter bonnet and two dollars, besides, as a church contribution.
Women of one of the borough’s church societies each undertook to earn a dollar. They were to tell how they made it. Some baked cakes and one earned her share by deciphering a tombstone. The prize went to the woman who bargained with her husband for a dollar to trim her own Easter hat.
The husband gave her a dollar not to wear the hat and bought her a new hat besides.
Girl Arrests Hat Critics.
Miss Hannah Goldstein, of 1841 Prospect Place, East New York, chased two young men whom she accused of criticizing her hat into a candy store near her home, and there, after her screams had brought a crowd, exercised the right of any citizen to make arrests.
She took both into custody with the support of the onlookers, and escorted them to the Brownsville station, where they were booked on a charge of disorderly conduct.
The prisoners said they were Louis Markowitz, of 1589 Prospect Place, and Murray Zepkin, of 1858 Prospect Place.
Boy in Storage Three Days.
While the police of New York searched three days for James Kelly, the fourteen-year-old foster son of Mrs. Thomas Riley, of 158 Kent Street, Williamsburg, the youngster was locked in the subbasement of the building in which he lived. A workman for a storage warehouse, which occupies the lower floors, found him unconscious.
A general alarm was sent out for the boy, and it was only by accident that the subbasement was opened, as goods had been placed there to remain several months.
At the Williamsburg Hospital, where the boy was revived, he said he went to the cellar to look for something, and found the door closed when he attempted to leave. He screamed and beat upon the walls until he became unconscious, he said. The vault was so far below the ground that his signals were unheard.
England Aids Belgians
The English National Committee for the Relief of Belgium, organized as an auxiliary of the American Relief Fund, has made an excellent start. Although its appeal was issued a few days ago, $400,000 has already been subscribed.
Many Anglo-Americans have contributed, among them Countess Strafford, who sent $500. The success which the appeal has met is regarded in London as a wonderful tribute to the American organization.
Land French Boy’s Valor.
Jacques Goujon, seventeen years old, has been mentioned in military orders, and a military medal has been given him. The youth killed two German sentinels, blew up, with the aid of bombs, two quick-firers of the enemy, was captured, but succeeded in escaping, carrying with him at the same time a machine gun of the Germans to the French lines. Later, during a German counter-attack, Goujon’s right arm was blown off by a shell.
The military authorities at Lyons, Goujon’s home city, had refused to accept him for military duty on account of his age. He went to Paris, where he was accepted because of his robust constitution.
Weds Invalid Rescuer.
Frank A. Seabert, seventy-seven, former superintendent of the Delaware, Lackawanna & Western Railroad, has fulfilled what he declared was a debt of honor, when he married Miss Jeannette A. Thomas, forty-seven, the woman who saved his life recently. The ceremony occurred in the Pasadena Hospital, Pasadena, Cal.
Recently Miss Thomas threw herself upon a discharged employee of Seabert’s in the Seabert mansion at Sierra Madre, who had attempted to kill her employer. She was shot in the spine, and physicians say she is paralyzed for life. For five years Miss Thomas had been Mr. Seabert’s private secretary. The first Mrs. Seabert died four years ago.
Hen Hatches Turtle Brood.
Thomas Warren, a fox hunter, of Winsted, Conn., who recently found a nest of turtles’ eggs in a field, placed them under a setting hen as an experiment. Seven of the eggs hatched. The hen’s unusual offspring still nest among the feathers.
Gave Three Sons to France
Three of the four sons of Charles Legrand, who entered the army, have been killed in action.
M. Legrand, who was formerly president of the chamber of commerce and was active in the project for exchanges of commercial students between Harvard University and the French Commercial University, has been notified that the third of his sons had been killed.
Use Name of Spy to Spy on Germans.
Anton Kuepferle, the American citizen of German birth who is held for trial in London on a charge of supplying Germany with information concerning the movements of English troops and ships, is said to have been the means of affording English detectives much inside information concerning the workings of the German spy system, with headquarters in Holland.
Kuepferle’s arrest was kept a secret for nearly two months. Meantime it is reported that Scotland Yard men were using the prisoner’s name as a means of communicating with German officials in Holland. In Kuepferle’s baggage, sheets of paper used for invisible ink were found. Imitating Kuepferle’s handwriting, the detectives were said to have written letters to German spy chiefs, between the lines of which they traced in invisible ink all sorts of questions asking further instructions. A rapid-fire correspondence is reported to have continued for many weeks.
The prisoner is charged with having visited many English and Irish ports to investigate shipping and report to Germany the movements of transports. Dublin, Liverpool, and Belfast are said to be centers where he was active. His capture took place the day following the declaration of the German submarine blockade, February 18th.
New Record Made by Wireless Phone.
A new distance record for wireless telephony was established when P. N. Place, superintendent of the Scranton division of the Lackawanna Railroad, spoke from Scranton, Pa., to Frank Cizek, superintendent of the Syracuse division, who was in Binghamton, N. Y. The messages traversed sixty-three miles through a mountainous country.
The achievement was made more notable by the fact that the messages exchanged were not brief greetings, but business communications, regarding the movement of trains. The Lackawanna trains between Scranton and Binghamton moved for several hours according to orders sent and received by the wireless telephone.
Every word transmitted by the wireless was heard distinctly, according to L. B. Foley, superintendent of telephone, telegraph, and wireless of the Lackawanna, who was in charge of the experiment. Mr. Foley was jubilant
over the achievement. Experiments with wireless telegraph and telephone have been conducted by the Lackawanna under his direction for more than a year.
The more recently recorded demonstration previous to this was on February 9th last, when wireless-telephone conversations were carried on between the station at Binghamton and a moving train at Lounsberry, N. Y., twenty-six miles away. The immediate object of the Lackawanna’s experimenters now is to increase the distance between a fixed station and a moving train to fifty miles, and that between two fixed stations to 150 miles, the distance between Hoboken and Scranton.
“I firmly believe,” Mr. Foley said, “that we shall be talking from our station in Hoboken to our station in Scranton within the next three or four weeks.”
The Lackawanna has constructed wireless stations at Hoboken, Scranton, Binghamton, and Buffalo, and the ultimate object of its experiments is to have all points of the entire line between Hoboken and Buffalo in constant communication by wireless telephone. Simultaneously with the experiments in talking between fixed stations, progress is being made in the development of wireless telephony between a fixed station and a moving train. The experiments are being conducted by the Lackawanna’s own men working independently of other agents. They use the Marconi receiver and a transmitter devised and constructed by themselves.
The Lackawanna began with experiments in wireless telegraphy from a moving train to a fixed station, and this was developed until the wirelessequipped train was always in communication with one of the fixed stations along the line, but with the advance of wireless telephony the development of this branch of communication was appreciated, and the efforts of the Lackawanna were bent to its perfection.
The value of wireless telephony has been proved on the occasion of every blizzard that has destroyed or impaired communication by wire along the railroad lines west of New York. In several instances the Lackawanna has succeeded in getting its trains in operation many hours ahead of other railroads because of the efficiency of its wireless.
Owes Life to Albert.
A wounded soldier in the Nantes Hospital tells how King Albert saved the life of a French officer. During a furious bayonet charge, a lieutenant ventured too far into the German lines, and was brought down by a rifle shot. He was grievously wounded, and evidently was thought by the Germans to be dead. The scene of the conflict shifted, and though the officer was very weak from loss of blood, he dragged himself out of the range of fire and then fainted.
On regaining consciousness, he saw two Belgian officers beside him, one with a lantern and the other dressing his wounds. They carried him to a motor car in the road. Arriving at the field hospital, near the general headquarters of the Belgian army, he got a better view of the two officers. One of them he recognized, saluted, and started to speak, but the king hushed him.
“All right, my brave hero,” he said; “save your strength; the world can’t afford to lose men like you.”
Woman, 100, Leads in Dance; Blesses Sturdy Ancestors.
Doubtless, as she says, Mrs. Emily Mayhew Osborne’s sturdy health heritage from New England ancestry has something to do with her century’s lease on life. “I have lived to enjoy vigorous old age because of the clean, moral life of my forefathers,” she said.
Nevertheless, when the orchestra tuned up for the one-hundredth-birthday celebration at 660 East 164th Street, New York recently, Mrs. Osborne led her fifteen descendants in a tango step. Four grandchildren and nine greatgrandchildren joined in the applause which greeted this skillful attempt to reconcile Puritan ancestry with modern liberalism.
One hundred years rest lightly on the shoulders of this direct descendant of Thomas Mayhew, the first governor of Martha’s Vineyard, who received a royal grant of Nantucket Island in 1641. She is hale and hearty, takes a long walk every day, and sews several hours at a stretch.
“Yes, I use glasses,” commented Mrs. Osborne, anticipating the next question, “but understand, now, that I don’t have to use them. They rest my eyes—that’s all.”
When she came to New York City from Columbia County, a woman of one and twenty, Manhattan Island above Fourteenth Street was mostly pasturage. “Yes, Broadway was nothing but a pathway for cattle, and
Fourteenth Street was a little lane!” she exclaimed, in a flash of reminiscence.
After the death of her first husband, John Wilson Higgins, Mrs. Osborne married Samuel Osborne, who died many years ago. Of the eight children she has borne, two are living, Miss Emily Higgins and Mrs. Victor Smith.
Beginning in the afternoon, Mrs. Osborne’s birthday party lasted into the evening, with friends and neighbors dropping in to leave flowers and extend congratulations.
Respirator Appeal Swamps British.
One day’s appeal through the London press has given the English army all the respirators needed, and the press bureau issued the following notice:
“Thanks to the magnificent response already made to the appeal in the press for respirators for the troops, the war office is in a position to announce that no further gifts of respirators need be made.”
“It looks,” says The Daily News, “as though every woman in England who could find time for it made respirators. No doubt reports from soldiers who had suffered from fumes had a tremendous effect in prompting the instant answer to the appeal of the army, but the response was of such an extraordinary nature as to set up a record.”
Great Waste in Potatoes.
Doctor Carl L. Alsberg, chief of the bureau of chemistry in the department of agriculture, said, in a talk to the New York Society of Chemical Industry at Rumford Hall, 50 East Forty-first Street, New York, that millions of dollars’ worth of potatoes and grain were destroyed by excessive moisture in this country every year, when they could be utilized for making alcohol and other purposes.
The United States, he said, had relied on Germany for a supply of potato dextrin used as an adhesive, when it could easily be obtained here by simple processes from the potatoes which are annually allowed to rot in the Pacific coast States.
America Leader in Tobacco Trade.
The United States holds first rank among the nations of the world as producer, exporter, importer, and consumer of tobacco. Our production of leaf of all sorts averages somewhat more than 1,000,000,000 pounds a year, having a value to the producers of about $100,000,000.
An enormous quantity is exported—considerably more than a third of the production in normal years—and the sales of tobacco abroad are excelled by only seven other products. They exceed in value such items as cotton manufactures, electrical machinery, paper and paper products, and leather and leather manufactures.
Taking the export figures of the department of commerce for the eight months ended with February this year, the exports of leaf tobacco amounted to 221,129,872 pounds, valued at $28,077,684, and of manufactured tobacco were valued at $4,209,054.
The dislocation of trade resulting from the war has had its effect on tobacco sales, however, as on most other businesses. Unmanufactured leaf has suffered most. It is practically impossible to ship leaf to some of the belligerents, while factories in the warring countries that are accessible are not taking their usual supply because of insufficient labor. Manufactured tobacco is holding its own, due to the increased demands from the Far East and Oceania. In the actual war zone the increased consumption by the men in the field is more than offset by the economies that must be practiced by noncombatants.
Oldest Circus Man Dead.
Charles H.—“Pop”—Baker, seventy-nine years old, known as the oldest circus man in the world, died recently at the county infirmary in Toledo, Ohio, from the infirmities of old age. Baker brought out George Primrose, the minstrel, and twelve famous side-show curiosities.
Baker was born in Buffalo. He was an intimate friend of President Cleveland. He was in the circus business fifty-nine years.
Triplets Ride in Baskets.
Doctor George G. Hartzel, of 1460 Bryant Avenue, and Doctor Edward C. Joyce, of 1926 Clinton Avenue, New York, took to Bellevue Hospital a set of triplets. The little ones were born to Mrs. D. C. Attridge, of 826 East
