Pediatric Minimally Invasive Surgery
Large Operations
Lap Hirschsprung’s
pull through
with
Tiny Incisions
Joseph A. Iocono, M.D.
Assistant Professor
Division of Pediatric Surgery
University of Kentucky
Children’s Hospital
8 weeks post-op
pull through
MIS-Advantages
* Cosmesis
− open operations often leave large, unsightly incisions
− with some laparoscopic instruments smaller than 2mm in size, it is
often difficult to see incisions postoperatively
* Analgesia
• Smaller incisions associated with less pain, lower analgesic use, and
quicker recovery.
− few controlled studies in children, especially in youngest patients
* Adhesions
• several studies suggest the formation of fewer intra-abdominal adhesions
after laparoscopic procedures
− reduces the risk of future postoperative bowel obstructions
− possibly reduces postoperative pain
* Decreased Ileus
− Nissen, Appendectomy, Pyloromyotomy, Bowel resection, Spleen
− Real or perceived?
Pediatric Surgery and MIS
Pediatric Surgeons—already “in the business”
• Small incisions--small scars
• Preemptive anesthesia--decreased pain med needs
• Short hospital stays
Holcomb (1991)
Newman (1991)
• Laparoscopic Cholecystectomy
Alain (1991)
• Laparoscopic Pyloromyotomy
• First true pediatric MIS procedure
Lobe (1992)
• Laparoscopic appendectomy
Rothenberg (1993)
Georgenson (1993)
• Laparoscopic Nissen Fundoplication
Holcomb (1993)
• Laparoscopic Splenectomy
MIS—What’s So Great?
* Why Bother?
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Additional expense
Prolonged procedures
Lack of tactile evaluation
Loss of depth perception
Complications specific to MIS
“After an advanced MIS case, the patient goes
home and the surgeon goes to the ICU”
Minimally Invasive Surgery
* Expense
• added costs are related to disposable instruments, expensive
equipment, and additional OR time
• use of non-disposable equipment reduces patient charges
• reduced hospital stay offsets some of additional expenses
* Length of Procedures
• learning curve is steep for laparoscopic procedures, especially
advanced techniques
− Learning curve improved with practice (simulator)
− OR time decreases to “nearly that” of open procedures with
increased experience and newer technology
From Curiosity to Standard of Care—How?
• Procedure Driven
−Modeled after successful techniques in adult population
• Patient (parent) Driven
−Population demanded use of minimally invasive techniques
• Technology Driven
−Smaller and smaller instruments continue to be developed
−Technology now allows better visualization than open
• Physician Driven
−Innovations in OR  career advancement
−No time for “small molecules"
• Care Driven --“re-think” care
−Myths about open procedures
−Myths about pre and post op care
Technology – Smaller and Better
Technology
1988
2004
Camera
Analog
Digital, 3D
Scope
10 mm 0º
2-3mm 30º
Monitors Rolling cart Integrated OR
Recorder VCR
Digital
Ligation Monopolar
Bipolar, harmonic
Instruments 10 mm
3 mm
(disposable) (reusable)
MIS – Indications
* General Indications
• Model from open techniques
• Improve open techniques
− to justify the performance of a minimally invasive technique,
The procedure must be as good or better than the open technique
- anything less is unacceptable. Improved cosmesis is not enough.
* New Procedures Developed Rapidly
Partial list of described MIS procedures in Children
Achalasia (1)
Adrenal Tumors (1)
Biliary Atresia
Chronic Abdominal Pain (2)
Crohn’s Disease (2)
Duodenal Atresia
Gastroesophageal Reflux (25)
Hirschsprung’s Disease (2)
Lung tumor (4)
Meckel’s Diverticulum
Ovarian Torsion and Cysts (2)
Pectus Excavatum (4)
Pyloromyotomy (32)
Splenic Pathology (5)
Undescended Testicle (6)
Urinary Reflux
Patent ductus arteriosus
Adhesive Small Bowel Obstruction
Appendicitis (25)
Cholelithiasis (5)
Chronic Constipation (ACE procedure) (5)
Diaphragmatic Hernia (1)
Empyema
Gastrostomy Tube Placement (20)
Benign Kidney Disease
Malrotation (1)
Mediastinal Pathology (1)
Pancreatic Pseudocyst
Placement of VP Shunt
Recurrent Pneumothorax (1)
Tracheoesophageal Fistula
Ulcerative Colitis (1)
Inguinal Hernia (recurrent) (1)
Peritoneal Dialysis access
Done at UK since July 2003 (>100)
MIS in Pediatric Surgery
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Cholecystectomy
Nissen Fundoplication
Appendectomy
Splenectomy
Intestinal Resection
VATS
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Inguinal Hernias
Pyloromyotomy
Hirschsprung’s Pull Through
Ladd’s Procedure
Pectus Excavatum-Nuss Procedure
Congenital Diaphragmatic Hernia
Indications
Procedure
Complications
Changes in Care
Controversies
Cholecystectomy--1991
* Indications
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Symptomatic cholelithiasis
Biliary dyskinesia
Cholecystitis
* Procedure
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Port placement and size of instruments
depends on size of child (5mm clip applier)
Modeled after adult procedure
* Complications
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Mirrors adult literature, duct injury 0.05%
Conversion to open higher 5%
* Changes to Care
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Faster return to normal activity
Less pulmonary complications
* Controversies
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Cholangiogram?
Common duct exploration
* Gold Standard
2
3
4
1
Nissen Fundoplication--1998
* Indications
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Pulmonary complications of GERD
Refractory GERD
Neurologically impaired
Weight > 3kg
* Procedure
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Port placement and size of instruments
depends on size of child
4 -5 ports
* Complications
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Early- same or less than open
G-tube secured with temporary stitches
Recurrent GERD—as high as 25%
* Changes to Care
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Earlier feeding and discharge (outpatient?)
* Controversies
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Infants 3-10 kg and less than 3kg
Short gastric vessels?
No standard wrap procedure
5
4
3
2
1
Port size/use
1. 5mm--camera
2. 3mm--liver retractor
3. 5mm--dissection (G-tube)
4. 3mm--dissection
5. 3mm---retraction
(optional)
Appendectomy--1992
* Indications
• Female, Unsure of diagnosis,
obese
• Perforated?
• All appendectomies?
* Procedure
• 3 ports, locations vary
2 alt. site
* Complications
• Lower rate of wound infection
• Longer OR time
* Changes to Care
• Earlier feeding and discharge
* Controversies
• Indications
• Perforated appendicitis
• Expense of stapler or harmonic
1
2
Port size/use
1. 10-12mm-- stapler
dissection,
2. 5mm--camera or
dissection
3. 5mm--dissection
3
“Laparoscopic appendectomy is an
acceptable alternative in the treatment of
perforated appendicitis” –Surg End 1998.
“Laparoscopic appendectomy: An
unnecessary and expensive procedure in
children” --J Ped Surg, 2002.
Splenectomy--1998
* Indications
• SCD, Spherocytosis, ITP, Cysts
Port size/use
4
* Procedure
• Patient in partial lateral decubitus
* Complications
• No reported increase
2
1 3
1. 12mm--dissection, stapler,
bag
2. 5mm--dissection, HS
3. 5mm--dissection, HS
4. 5mm--dissection, HS
Camera moves around
* Changes to Care
• Hospital stay reduced 1-2 days
• Can perform chole at same time
• Partial splenectomy or cystectomy
* Controversies
• Large spleen
• OR time
• Inability to control major bleeding
Rescorla FJ, Breitfeld PP, West KW et al. A case controlled comparison of open and
laparoscopic splenectomy in children. Surgery 1998; 1224:670-676.
Intestinal Resection
* Indications
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IBD -- UC and Crohn’s
Meckel’s
Intussusception
FAP
* Procedure- 2 ways
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Total laparoscopic with intracorporeal
anastomosis
Lap assisted with extracorporeal
anastomosis
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5
4
1
2
* Complications
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OR time 3-4x open with initial cases
* Changes to Care
Dispelled myth of “can’t pull on
intussusception while reducing”
* Controversies
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Is Lap Assisted any better than open?
True lap still requires incision for
specimen
Role in CA?
Optional Incisions
Thoracoscopy-VATS
* Indications
• Empyema
• Wedge Biopsy
Blebs
Anterior Spine
• Mediastinal cysts Thymectomy
* Procedure
• 3 ports, low pressure CO2
* Complications
• Conversion rate high
* Changes to Care
• Insufflation better
• Faster recovery
• Start chemo earlier
* Controversies
• Ability to “feel’ lung
Inguinal Hernias
* Indications
• Any non-incarcerated hernia
* Procedure
• Different techniques
(Instruments 3mm or less)
* Complications
3
2
1
• Early--no change
* Changes to Care
• No removal of sac
* Controversies
• No single procedure-No mesh
• Hernia sac left behind
• Recurrence rate higher in
initial trials
Scheirer, et al Laparoscopic Inguinal Herniorrhaphy in Children: A Three-Center
Experience With 933 Repairs J of Pediatr Surg March, 2003.
Pyloromyotomy-1991
* Indications
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Newborn infant with HPS
* Procedure
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3 mm Instruments (2)
3 mm camera
1 3mm port (umbilicus)
2 mm meniscus knife
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2
1
* Complications
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Duodenal injury 1% vs 0.02%
Infection 0.2% vs 0.5%
Site hernia (1%)
* Changes to Care
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Feed 2hrs post-op
Home 18-24 hrs (36-48 open)
* Controversies
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Increased complication rate
Less scar, is this enough?
Vegunta , R Laparoscopic Pyloromyotomy: Safe, Cost-effective, and
Cosmetically Superior Ped Endo Surg, 2003
Pull-through for Hirschsprung’s--1995
* Indications
• Biopsy proven HD--not sick!
* Procedure
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3mm instruments
Serial biopsies for level
Take down mesentery
Anal dissection
Colo-anal anastomosis
3
2
1
* Complications
• Recurrent Hirschsprung’s
* Changes to Care
• Elimination of colostomy in select
patients--single stage
* Controversies
• Laparoscope necessary?
Coran, A et al. Recent Advances in the Management of Hirschsprung’s
Disease. Am J Surgery 2000
Ladd’s Procedure for Malrotation--1997
* Indications
• Malrotation without volvulus
• Older patient (> 1 yo)
* Procedure
4
• 4 ports, all 5 mm
* Complications
• Same as open short term
* Changes to Care
• No improvement in LOS in
younger patients
* Controversies
• Desire to induce adhesions
• No pexy of bowel
• Need increased follow-up to
assess durability of procedure
2
3
1
Nuss Procedure for Pectus Excavatum --1995
* Indications
• Pectus excavatum with CT scan
index > 4
* Procedure
• 1-2 ports (just used to watch
first pass of bar)
* Complications
• Infection 1-2% (bar out, redo)
• Bar shifts 5% (OR to adjust)
• Failure of procedure 1%
* Changes to Care
• Increase in number of
procedures performed
• Use of VATS increased safety and
decrease OR time
* Controversies
• Need for scope?
Croitrou, Experience and Modification Update for the Minimally Invasive
Nuss Technique for Pectus Excavatum Repair in 303 Patients. J PS 2002
Diaphragmatic Hernia
* Indications
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Any late presenting CDH
Infant CDH not on ECMO
* Procedure
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Bochdalek-- VATS
Morgagni-- laparoscope
Bochdalek
* Complications
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Much longer OR time
* Changes to Care
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Ideal for Morgagni hernias
* Controversies
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? On ECMO, babies in NICU
Arca, et al Early Experience With Minimally Invasive Repair of Congenital
Diaphragmatic Hernias: Results and Lessons Learned. J Peds Surg Nov 2003.
Morgagni
Pediatric Minimally Invasive Surgery
* Conclusions
• Surgeon must decide whether a minimally invasive
approach is the safest and most appropriate procedure.
• Must convert to an open procedure at any time that the
risks are greater than those of the open technique.
• Must increase his/her repertoire of MIS cases as skills
improve.
• Must stay informed about new techniques, tools, and
indications and complete CME in order to gain needed
training.
Teaching Minimally Invasive Surgery
* Education
• Techniques--taught in standard Halsted fashion
− “See one, do one, teach one.”
− “You can’t break anything that I can’t fix.”
• Difficulty with this system
− “Teacher” has same or less experience than the “student”
− Procedures are developed or modified in the OR
− Technology changes quickly
* Solution--basic skills need to be mastered
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Establish baseline skill levels before exposure to “live” OR
Implement within the constraints of 80 hour work week
Homework and skills lab
Build on basics with OR experience
Who gets CATS Procedures and
When do I refer to Pediatric Surgery?
* Who?
• Techniques--List of procedures grows constantly
− Unique pathology in infants and children
− Advanced skills set in place, applications grow with
experience of entire team
* When?
− Standard referral patterns --no change for MIS
− Exception--patient size, age decreasing with technology
* How?
− Phone, Email, FAX
Future Directions
* Limitations of current MIS technology
• No wrist
− Motions are limited to 3 degrees of freedom
− Limits suture techniques
• 2-dimensional images
− Lack of depth perception
• Distance from operative field
− Image is in opposite direction from where
surgeon is working
* Solution---daVinci operative system
• Robot arm with 5 degrees of freedom
• True 3-dimensional images
• Work station allows “total immersion”
Future Directions
* Ready for Pediatric MIS? Yes
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Infant MIS? Not quite
Instruments are still 8 mm and scope is 11 mm
Robotic arms cumbersome on smallest patients -- infants?
Developing new techniques to utilize newer technology as it emerges.
Where daVinci helps most--small operative field with little maneuverability
Final Thoughts
“Five years ago it would have been unthinkable that an [entire] issue of Seminars
in Pediatric Surgery would be discussing intracorporeal anastomoses after
intestinal resections and laparoscopic pull-through for high imperforate anus. Yes
it is likely that we are only in the infancy of the development of laparoscopic
surgery in our patients…Several pediatric surgeons are involved with
experimentation and development with robotic surgery…Certainly, it will make
intestinal anastomoses easier and make [more complicated] procedures such as
portoenterostomy [Kasai procedure] more feasible.”
George W. Holcomb, MD
November, 2002
Seminars in Pediatric Surgery
Pediatric Surgery at University of Kentucky
Contact Information
Andrew Pulito, M.D.
[email protected]
Joe Iocono, M.D.
UK MDs
Office
FAX
Clinic Appointments
[email protected]
1-800-333-8874
859-323-5625
859-323-5289
859-257-3253
Pediatric Minimally Invasive Surgery
Questions