Abstract
Background:
In the scientific nomenclature, “incidentaloma” is the medical term to describe incidentally found asymptomatic tumors. We adapted the term “incidentaloma” to describe the finding of additional pathology during laparoscopic surgery conducted for a different indication. This study aimed to highlight the role of laparoscopy in identifying and addressing hidden concurrent conditions, thereby preventing the need for further surgical interventions.
Methods:
Five hundred ninety-five patients undergoing laparoscopic procedures from January 2018 to January 2023 were enrolled. Patients were divided in 4 groups according to the primary pathology or anatomical district: G1 included 331 children undergoing unilateral inguinal hernia laparoscopic repair, G2 included 115 children receiving laparoscopic varicocelectomy, G3 included 40 children undergoing laparoscopic exploration for non-palpable testis, G4 included 109 children undergoing laparoscopic abdominal procedures (53 appendectomies, 10 ovarian cystectomies, 14 renal surgeries, 28 cholecystectomies, 4 esophageal surgeries).
Results:
A total of 170 incidentalomas were found intraoperatively (28.6%). In G1, 126/331 (38.1%) had contralateral patent peritoneal-vaginal duct (PPVD), and 2/331 (0.6%) had ovarian cyst (n = 1) and paratubaric cyst (n = 1). In G2, incidentaloma was found in 2/115 (1.7%), including PPVD (n = 1) and omphalomesenteric duct remnant (n = 1). In G3, PPVD was discovered in 11/40 (27.5%). In G4, 19/109 (17.4%) concomitant adnexal pathologies, 4/109 (3.7%) PPVD, 2/109 (1.8%) pelvic masses, 2/109 (1.8%) subhepatic appendices, 1/109 (0.9%) Meckel’s diverticulum, 1/109 (0.9%) urachal sinus were discovered intraoperatively. The incidentalomas were treated during the same surgeries in 168/170 cases (98.8%). The postoperative course was uneventful in all patients, and no postoperative complications were observed.
Conclusions:
Laparoscopy may be helpful to detect intraoperatively concomitant asymptomatic and unknown pathologies. Our results demonstrated that the incidence of incidentalomas was not negligible (28.6%) in the pediatric population. Laparoscopy allows their early treatment in most cases, thereby preventing the need for reintervention or emergency operation in case of acute onset.
Introduction
The advent of laparoscopy has brought several benefits to both surgeons and patients, with particularly notable advantages in the pediatric field. 1 Specifically, the use of millimeter-sized surgical incisions is linked to reduced postoperative pain, shorter hospital stay, and quicker recovery time when compared to the traditional open surgical approach. 2
Another benefit compared to open surgery is that laparoscopy enables surgeons to have a visual perspective inside the patient’s body. 3 This capability not only aids in addressing the primary disease but also potentially allows for the detection of any concurrent pathologies that may not be clinically evident.
In the scientific nomenclature, incidentaloma is the medical term to describe incidentally found asymptomatic tumors. 4 We re-adapted this term to define the occasional finding of coexisting pathology during laparoscopic surgery performed for other indications.
This study aimed to highlight the role of laparoscopy in identifying and addressing hidden concurrent conditions, thereby preventing the need for further surgical interventions.
Materials and Methods
All patients undergoing laparoscopic procedures from January 2018 to January 2023 in our Pediatric Surgery unit were enrolled. Inclusion criteria were all patients aged from 0 to 18 years who were operated via laparoscopic approach. Exclusion criteria were previous open or laparoscopic surgery, preoperative evidence of secondary concomitant pathologies, and diffuse peritonitis preventing the exploration of the abdominal cavity.
Patients were divided in four groups according to the primary pathology or anatomical district of interest.
Parameters evaluated in each patient group were the incidence of incidentaloma, the type of incidentaloma, and the related management.
Each laparoscopic procedure was performed under general anesthesia, and the pneumoperitoneum was achieved by using Hasson technique in all patients. Once the first access port was introduced under direct vision, necessary working ports were placed.
The parents or legal guardians of each patient signed specific informed consent prior to surgery. In the consent form, a detailed description of the primary surgery was firstly given. Thereafter, further information regarding the possible intraoperative finding of concomitant diseases and the possibility to treat them accordingly was indicated.
Regarding statistical analysis, descriptive data were reported as absolute numbers and percentages for qualitative variables. Quantitative variables were described using median and range. The study protocol was reviewed and approved by the Ethics Committee of the University of Naples Federico II, Naples, Italy.
Results
Five hundred ninety-five patients, who received laparoscopic surgery over the study period, were included. Group 1 (G1) included 331 children undergoing unilateral inguinal hernia laparoscopic repair, Group 2 (G2) included 115 children receiving laparoscopic Palomo varicocelectomy, Group 3 (G3) included 40 children undergoing laparoscopic exploration for non-palpable testis, Group 4 (G4) included 109 children undergoing laparoscopic abdominal procedures (53 appendectomies, 10 ovarian cystectomies, 14 renal surgeries, 28 cholecystectomies, 4 esophageal surgeries).
A total of 170 incidentalomas out of the 595 operated patients (28.6%) were found intraoperatively. In G1, 126/331 (38.1%) patients had contralateral patent peritoneal-vaginal duct (PPVD), and 2/331 (0.6%) had ovarian cyst (n = 1) and paratubaric cyst (n = 1). In G2, incidentaloma was found in 2/115 (1.7%) patients, including PPVD (n = 1) and omphalomesenteric duct remnant (n = 1). In G3, PPVD was discovered in 11/40 (27.5%) patients. In G4, 19/109 (17.4%) concomitant paratubaric/paraovaric cysts, 4/109 (3.7%) PPVD, 2/109 (1.8%) pelvic masses, 2/109 (1.8%) subhepatic appendices, 1/109 (0.9%) Meckel’s diverticulum, 1/109 (0.9%) urachal sinus were discovered intraoperatively.
The incidence of incidentalomas found in each group is reported in Figure 1.
Incidence of incidentalomas found in each group.
The incidentalomas were treated during the same surgeries in 168/170 cases (98.8%). Contralateral PPVD was repaired using either purse-string or N-shaped nonresorbable suture. Paratubal and/or ovarian cysts were excised using electrocautery or a sealing device, according to the cyst’s size and surgeon’s preference. The subhepatic appendices were dissected and ligated using two polyglactin endoloops and divided. The urachal remnant was isolated as distally to the bladder as possible, ligated, and divided. The Meckel’s diverticulum and omphalomesenteric duct remnant were dissected and exteriorized through the umbilical port and divided using a stapler device.
In 1 patient undergoing primary laparoscopic appendectomy, a massive extraperitoneal mass displacing the bladder was unexpectedly encountered. Due to strong suspicion of neoplastic origin, a postoperative MRI was performed to confirm the mass and its anatomical landmarks. Thereafter, a secondary laparoscopy was carried out, leading to the complete removal of the mass. Pathology confirmed the diagnosis of pelvic ganglioneuroma.
In another patient who underwent primary laparoscopic appendectomy, a large extraperitoneal mass was discovered within the pelvic space. Following the appendectomy, an MRI was performed, and due to high suspicion of myelomeningocele, the patient was referred to the neurosurgery division and properly treated.
The postoperative course was uneventful in all patients, and no postoperative complications were observed.
Patient demographics and outcomes are reported in Table 1.
Patient Demographics and Outcomes
Discussion
Minimally invasive surgery has become a valuable tool for surgeons over the last three decades. Minimally invasive approaches are now considered the standard of care for many indications in different anatomical districts. Particularly in the pediatric population, the debate about the best approach between open surgery and laparoscopy is still ongoing for some indications.1–3
The most reported advantages of laparoscopy, such as fewer wound-associated complications, less incisional pain, improved cosmesis, and faster recovery, are well known. 1
This study explored a previously unexamined advantage of the laparoscopic approach, namely the potential to discover concurrent unidentified pathologies that can be treated simultaneously with the primary procedure.
The term “incidentaloma” is commonly used in the medical field to describe the unexpected discovery of a lesion of neoplastic nature, typically on the adrenal gland. 4 In this study, we adopted the broad term “incidentaloma” to specifically define the occasional identification of a concurrent pathology while conducting laparoscopic surgery for a different primary indication.
The results of our study showed an incidence of incidentaloma of 28.6%. The most common finding was the patency of the peritoneal-vaginal duct that represented 83.5% of all incidentalomas.
When focusing solely on the laparoscopic inguinal hernia repair (G1), the occurrence of contralateral PPVD was determined to be 38.1%. This observation aligned with the previous findings of the pediatric literature, which reported a PPVD rate of up to 39.61%. 5 Closing the patency during the same procedure mitigated the risk of contralateral metachronous hernia without introducing additional postoperative morbidity or prolonging the recovery period.6–9
Although contralateral PPVD is a known condition, its incidental nature during surgery performed for a different primary indication justifies its inclusion. We believe that excluding it from our analysis would lead to an underestimation of the diagnostic value of laparoscopy in real-world practice, where even simple findings may carry clinical relevance and therapeutic consequences.
The second most prevalent discovery was concurrent adnexal pathology, constituting 12.3% of all incidentalomas. Most of the adnexal pathology consisted of paratubal cysts of different size, accounting for 80.9% of cases. The decision to address them concurrently was made to mitigate the risk of cyst torsion or its potential enlargement, which could serve as a triggering factor for adnexal torsion. 10
We decided to surgically remove the subhepatic appendix identified in 2 patients to reduce the potential risk of misdiagnosis associated with the atypical clinical presentation of appendicitis in this anatomical variant.
Although pathologies like Meckel’s diverticulum, urachal sinus, and omphalomesenteric duct remnant may remain silent for a lifetime, we opted for their treatment due to the documented risk of long-term complications, including inflammation, bleeding, infection, intussusception, or, more rarely, malignancy.11–13
In all cases the main reason to treat the incidentaloma during the same surgery was to avoid a possible reintervention, thus eliminating the necessity for a second anesthesia, additional hospitalization, associated costs, and the resulting discomfort for both patients and their families.
Furthermore, the benefit to manage these conditions during elective surgery, avoiding the challenges of treating them in an acute setting, should be additionally considered.
All incidentalomas were managed in laparoscopy. In each case, the initial port position was found to be suitable, even when treating concurrent pathologies, and there was no need for additional ports.
It is advisable to communicate to parents the potential for incidental finding of concurrent pathologies and the potential need for their treatment during the same procedure. This information should be included in the informed consent process.
The only contraindication to simultaneous treatment encountered in our experience was the presence of two masses of unknown origin. In such a situation, the suspected neoplastic nature prompted us to schedule a comprehensive diagnostic evaluation and defer any surgical interventions. Another possible contraindication is the presence of diffuse peritonitis, which might negate the meticulous exploration of the abdominal cavity and compromise the potential advantages of addressing concurrent pathologies.
In our institution, and in line with widely adopted pediatric protocols, second-level imaging (CT/MRI) is reserved for cases with specific clinical or laboratory features suggestive of atypical pathology. Since none of the patients presented such indicators, no advanced imaging was performed preoperatively, which explains why the extraperitoneal lesions were not detected beforehand. This reinforces the relevance of laparoscopy as a diagnostic adjunct in pediatric surgery, particularly when unexpected findings arise.
The main limitations of this study are its retrospective design, the heterogeneity of the study population, and the absence of a control group. As a consequence, the actual risk associated with untreated incidentalomas cannot be reliably assessed. An additional limitation is that extraperitoneal masses are rarely investigated preoperatively with second-level imaging in standard pediatric practice, unless specific clinical red flags are present. As a result, the absence of systematic CT or MRI limits the ability to characterize these lesions preoperatively and to assess the potential implications of leaving them untreated.
In conclusion, laparoscopy, besides being currently the gold standard for minimally invasive treatment of many pediatric pathologies, may be helpful to detect intraoperatively concomitant asymptomatic and unknown pathologies. Our results demonstrated that the incidence of incidentalomas was not negligible (28.6%) in the pediatric population. Laparoscopy allows their early treatment in most cases, thereby preventing the risk of reintervention or emergency operation in case of acute onset.
Footnotes
Authors’ Contributions
C.D.M.: Conceptualization (lead); writing—original draft (lead); formal analysis (lead); writing—review and editing (equal); M.E.: Conceptualization (lead); writing—original draft (supporting); formal analysis (supporting); writing—review and editing (lead); G.E.: Methodology (lead); writing—review and editing (equal); A.C.: Software (lead); writing—review and editing (equal); C.E.: Conceptualization (supporting); writing—original draft (supporting); writing—review and editing (lead).
Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.