open operations often leave large, unsightly incisions ..

1
Pediatric Minimally Invasive Surgery
Large Operations with Tiny Incisions
Lap Hirschsprungs pull through
8 weeks post-op pull through

• Joseph A. Iocono, M.D.
• Assistant Professor

Division of Pediatric Surgery University of
Kentucky Childrens Hospital
2
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?

3
Pediatric Surgery and MIS

• Pediatric Surgeonsalready 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

4
MISWhats So Great?

• Why Bother?
• 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
5
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

6
From Curiosity to Standard of CareHow?

• 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

7
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 Bipola
  r, harmonic
• Instruments 10 mm 3 mm
• (disposable) (reusable)

8
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

9
Partial list of described MIS procedures in
Children
Achalasia (1) Adhesive Small Bowel
Obstruction Adrenal Tumors (1) Appendicitis
(25) Biliary Atresia Cholelithiasis (5)
Chronic Abdominal Pain (2) Chronic
Constipation (ACE procedure) (5) Crohns Disease
(2) Diaphragmatic Hernia (1) Duodenal
Atresia Empyema Gastroesophageal Reflux
(25) Gastrostomy Tube Placement
(20) Hirschsprungs Disease (2) Benign Kidney
Disease Lung tumor (4) Malrotation
(1) Meckels Diverticulum Mediastinal Pathology
(1) Ovarian Torsion and Cysts (2) Pancreatic
Pseudocyst Pectus Excavatum (4) Placement of VP
Shunt Pyloromyotomy (32) Recurrent Pneumothorax
(1) Splenic Pathology (5) Tracheoesophageal
Fistula Undescended Testicle (6) Ulcerative
Colitis (1) Urinary Reflux Inguinal Hernia
(recurrent) (1) Patent ductus arteriosus Perito
neal Dialysis access
Done at UK since July 2003 (gt100)
10
MIS in Pediatric Surgery

• Cholecystectomy
• Nissen Fundoplication
• Appendectomy
• Splenectomy
• Intestinal Resection
• VATS

• Inguinal Hernias
• Pyloromyotomy
• Hirschsprungs Pull Through
• Ladds Procedure
• Pectus Excavatum-Nuss Procedure
• Congenital Diaphragmatic Hernia

• Indications
• Procedure
• Complications
• Changes in Care
• Controversies

11
Cholecystectomy--1991

• Indications
• Symptomatic cholelithiasis
• Biliary dyskinesia
• Cholecystitis
• Procedure
• Port placement and size of instruments depends
  on size of child (5mm clip applier)
• Modeled after adult procedure
• Complications
• Mirrors adult literature, duct injury 0.05
• Conversion to open higher 5
• Changes to Care
• Faster return to normal activity
• Less pulmonary complications
• Controversies
• Cholangiogram?
• Common duct exploration
• Gold Standard

12
Nissen Fundoplication--1998

• Indications
• Pulmonary complications of GERD
• Refractory GERD
• Neurologically impaired
• Weight gt 3kg
• Procedure
• Port placement and size of instruments depends on
  size of child
• 4 -5 ports
• Complications
• Early- same or less than open
• G-tube secured with temporary stitches
• Recurrent GERDas high as 25
• Changes to Care
• Earlier feeding and discharge (outpatient?)
• Controversies
• Infants 3-10 kg and less than 3kg
• Short gastric vessels?
• No standard wrap procedure

Port size/use 1. 5mm--camera 2. 3mm--liver
retractor 3. 5mm--dissection (G-tube) 4.
3mm--dissection 5. 3mm---retraction (optional)
13
Appendectomy--1992

• Indications
• Female, Unsure of diagnosis, obese
• Perforated?
• All appendectomies?
• Procedure
• 3 ports, locations vary
• 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

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.
14
Splenectomy--1998

• Indications
• SCD, Spherocytosis, ITP, Cysts
• Procedure
• Patient in partial lateral decubitus
• Complications
• No reported increase
• 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

Port size/use 1. 12mm--dissection,
stapler, bag 2. 5mm--dissection, HS 3.
5mm--dissection, HS 4. 5mm--dissection, HS Camera
moves around
Rescorla FJ, Breitfeld PP, West KW et al. A case
controlled comparison of open and laparoscopic
splenectomy in children. Surgery 1998
1224670-676.
15
Intestinal Resection

• Indications
• IBD -- UC and Crohns
• Meckels
• Intussusception
• FAP
• Procedure- 2 ways
• Total laparoscopic with intracorporeal
  anastomosis
• Lap assisted with extracorporeal anastomosis
• Complications
• OR time 3-4x open with initial cases
• Changes to Care
• Dispelled myth of cant pull on intussusception
  while reducing
• Controversies
• Is Lap Assisted any better than open?
• True lap still requires incision for specimen
• Role in CA?

16
Thoracoscopy-VATS

• Indications
• Empyema Blebs
• Wedge Biopsy 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

17
Inguinal Hernias

• Indications
• Any non-incarcerated hernia
• Procedure
• Different techniques (Instruments 3mm or less)
• Complications
• 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.
18
Pyloromyotomy-1991

• Indications
• Newborn infant with HPS
• Procedure
• 3 mm Instruments (2)
• 3 mm camera
• 1 3mm port (umbilicus)
• 2 mm meniscus knife
• Complications
• Duodenal injury 1 vs 0.02
• Infection 0.2 vs 0.5
• Site hernia (1)
• Changes to Care
• Feed 2hrs post-op
• Home 18-24 hrs (36-48 open)
• Controversies
• Increased complication rate
• Less scar, is this enough?

Vegunta , R Laparoscopic Pyloromyotomy Safe,
Cost-effective, and Cosmetically Superior Ped
Endo Surg, 2003
19
Pull-through for Hirschsprungs--1995

• Indications
• Biopsy proven HD--not sick!
• Procedure
• 3mm instruments
• Serial biopsies for level
• Take down mesentery
• Anal dissection
• Colo-anal anastomosis
• Complications
• Recurrent Hirschsprungs
• Changes to Care
• Elimination of colostomy in select
  patients--single stage
• Controversies
• Laparoscope necessary?

Coran, A et al. Recent Advances in the
Management of Hirschsprungs Disease. Am J
Surgery 2000
20
Ladds Procedure for Malrotation--1997

• Indications
• Malrotation without volvulus
• Older patient (gt 1 yo)
• Procedure
• 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

21
Nuss Procedure for Pectus Excavatum --1995

• Indications
• Pectus excavatum with CT scan index gt 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
22
Diaphragmatic Hernia

• Indications
• Any late presenting CDH
• Infant CDH not on ECMO
• Procedure
• Bochdalek-- VATS
• Morgagni-- laparoscope
• Complications
• Much longer OR time
• Changes to Care
• Ideal for Morgagni hernias
• Controversies
• ? 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.
23
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.

24
Teaching Minimally Invasive Surgery

• Education
• Techniques--taught in standard Halsted fashion
• See one, do one, teach one.
• You cant break anything that I cant 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
• 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

25
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

26
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

27
Future Directions

• Ready for Pediatric MIS? Yes 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

28
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 patientsSeveral pediatric
surgeons are involved with experimentation and
development with robotic surgeryCertainly, 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
29
Pediatric Surgery at University of Kentucky

• Contact Information
• Andrew Pulito, M.D.
  arpuli_at_uky.edu
• Joe Iocono, M.D. jiocono_at_uky.edu
• UK MDs 1-800-333-8874
• Office 859-323-5625
• FAX [phone]
• Clinic Appointments 859-257-3253

30
Pediatric Minimally Invasive Surgery

• Questions