Minimal access surgery MAS in the paediatric patient

1
Minimal access surgery (MAS) in the paediatric
patient

• MH Sheik Gafoor
• Department of Paediatric surgery
• IALCH

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History

• 1826 - Pierre Segalas (Paris) first demonstrated
  cystoscopy
• 1881 - Jan Mikulicz-Radecki (Vienna) performed
  the first gastroscopy
• 1910 Hans Christian Jacobäus in Stockholm
  performed peritonoscopy in 19 patients using air
  insufflation
• 1938 - Hungarian physician Janos Veress developed
  a needle for air insufflation

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Modern history

• development of videoendoscopy
• 1981 Kurt Semm performed the first appendesectomy
• 1985 Erich Mühe performed the first laparoscopic
  cholecystectomy
• French surgeons Philippe Mouret and Francois
  Dubois
• Jacques Perissats (Bordeaux) video demonstration
  of a laparoscopic chole 1989

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Minimally access surgery

• After 1989 adult surgeons took the lead and the
  was an explosion of laparoscopic procedures
• These procedures where often demanded by patients
• Industry also played a leading role
• However few studies to date have been subjected
  to critical analysis and results must be
  interpreted with caution

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Paediatric MAS

• Lagged behind adult surgery
• Instrumentation
• Common adult operation not so in children
• Mastery
• Costs
• recovery

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Learning curve

• Depth perception
• Loss of tactile sensation
• Instinctiveness
• Non wrist movement
• Smaller working space
• Lack of standard treatment

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Pros and cons

• Pros
• Decrease pain
• Earlier return of GI function
• Quicker return to work
• Improved magnification
• Decreased long term complications
• Cosmetic
• Physiological advantages
• Decrease in inflammatory cytokines and acute
  phase reactants
• Decrease immune response

• Cons
• Decreased degree of freedom
• No tactile information
• Steep learning curve
• Slow development of paediatric instrumentation
• Small working space
• Costs
• 2 dimensional images

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Anesthetic considerations

• Anesthetic management is made more complicated
• pneumoperitoneum
• systemic carbon dioxide absorption
• patient positioning
• venous gas embolization
• Possible surgical trauma to blood vessels or
  viscera resulting in major hemorrhage

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Respiratory effects

• CO2 absorption lead to hypercarbia if minute
  volume not compensated for
• increase in IAP - results in a decrease in FRC
  -increase in peak airway pressure and a reduction
  in thoracic compliance and subsequent V/Q
  mismatch
• Patient positioning and cephalad shift of the
  diaphragm

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Cardiovascular effects

• The cardiovascular physiology of infants is
  different from that of adults
• BP and SVR are lower HR, O2 consumption and CO
  are higher in infants
• CO2insufflation, hypercarbia and increased IAP
  consistently affect the cardiovascular function
  during laparoscopy
• End results are tachycardia, increases in SVR,
  hypotension and left to right shunting due to
  increased vascular resistance in lung

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Other effects

• Neurological
• Haemodynamic variations, patient positioning,
  alterations in PaCO2 and increased
  intra-abdominal and intrathoracic pressures can
  modify the increase cerebral perfusion ICP
• Renal
• Oliguria related to increased IAP
• Temp
• Hypothermia related to CO2 insufflation and
  length of procedures
• Musculoskeletal and nerve damage

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Hepatobiliary procedures

• Lap. Assisted Liver Biopsy
• Laparoscopy for biliary atresia
• Lap. Cholecystectomy
• Lap. Excision of Liver Cysts (Hydatid /
  Congenital)
• Lap. Spleenectomy
• Lap. Excision of Choledocal Cyst

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Liver biopsy and hydatid cyst
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Biary atresia and choledhocal cyst
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Lap. Spleenectomy
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Cholecystectomy
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Laparoscopic Meckels Diverticulectomy
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Laproscopic Fundoplication
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• Lap. Appendicectomy
• Lap. Hellers Cardiomyotomy
• Lap. Adhesiolysis
• Lap. Fundoplication
• Lap. Vagotomy
• Lap. assisted Meckels Diverticulectomy
• Lap. Intususception Reduction
• Lap. Pyloromyotomy
• Lap. Hemicolectomy / Total Colectomy
• Lap. Ladd Procedure for Malrotation
• Lap. Excision of Omental / Mesenteric/
  Duplication Cysts
• Lap. Pullthrough for Hirschprungs Disease
• Lap. Assisted Anorectoplasty for Anorectal
  Malformation (Imp. Anus)
• Lap. Biopsy (For deep seated lesions)
• Diagnostic Laparoscopy

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Lap. Intususception Reduction
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Ano rectal

• Imperforate anus
• High lesions
• Better visualization
• Long term??
• Hirschsprungs
• Used for biopsies and mobilization
• All described traditional procedures have been
  done

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Pyloromyotomy

• Periumbilical telescope 2 ports
• Various methods using retractable blade, cautery
  and spreaders
• ? Comparable to open procedure

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herniotomy

• Advantages
• Can assess contra lateral side
• Avoid damage to vas and vessels
• Disadvantages
• Intraperitoneal procedure
• Time
• ? Comparison to open procedure

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Intestinal atresia

• Avoid laparotomy
• Difficult in distal atresia and type IV
• Needs to compared to traditional open and
  periumbilical incisions

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Urology

• Urological procedures
• Lap. Surgery For Non Palpable Testis
• Lap. Inguinal Hernia Repair
• Lap. Nephrectomy
• Lap. Nephro-Ureterectomy
• Lap. Heminephrectomy
• Lap. Pyelolithotomy
• Lap. Adrenalectomy
• Lap. Assisted Pyeloplasty
• Lap. Ovarian Cystectomy
• Laparoscopy for Intersex Disorders
• Lap. Gonadectomy

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Ovarian
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Thoracoscopy

• Single lung ventilation may be required
• Thoracoscopic procedures
• Thoracoscopic Decortication for Empyema Thoracis
• Thoracoscopic Lung / Mediastinal / LN Biopsy
• Thoroacoscopic Repair of Diaphragmatic Hernia
• Thoracoscoplication for Eventration of Diaphragm
• Thoracoscopic Excision of Mediastinal masses
• Thoracoscopic Sympathetic Neurectomy
• Thoracoscopic Pulmonary Lobectomy

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Thoracoscopic diaphragmatic hernia
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thoracoscopy
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Oncology

• Problems
• Specimen retrieval
• Staging
• Port site metastasis
• Uses
• Biopsy of deep seated lesions
• Ablative therapy

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Future developments

• Robotics
• NOTES
• Fetoscopic surgery