Pediatric Minimally Invasive Surgery

Joseph A. Iocono, M.D.Assistant Professor

Division of Pediatric SurgeryUniversity of Kentucky

Children’s Hospital

Large Operations with

Tiny IncisionsLap Hirschsprung’s

pull through8 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 MISPediatric 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?• 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

1988 2004Camera Analog Digital, 3DScope 10 mm 0º 2-3mm 30º Monitors Rolling cart Integrated ORRecorder VCR DigitalLigation Monopolar Bipolar,

harmonic Instruments 10 mm 3 mm

(disposable) (reusable)

Technology

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) Adhesive Small Bowel ObstructionAdrenal Tumors (1) Appendicitis (25)Biliary Atresia Cholelithiasis (5) Chronic Abdominal Pain (2) Chronic Constipation (ACE procedure) (5)Crohn’s Disease (2) Diaphragmatic Hernia (1)Duodenal Atresia Empyema Gastroesophageal Reflux (25) Gastrostomy Tube Placement (20)Hirschsprung’s Disease (2) Benign Kidney Disease Lung tumor (4) Malrotation (1)Meckel’s Diverticulum Mediastinal Pathology (1)Ovarian Torsion and Cysts (2) Pancreatic PseudocystPectus Excavatum (4) Placement of VP ShuntPyloromyotomy (32) Recurrent Pneumothorax (1)Splenic Pathology (5) Tracheoesophageal FistulaUndescended Testicle (6) Ulcerative Colitis (1)Urinary Reflux Inguinal Hernia (recurrent) (1)Patent ductus arteriosus Peritoneal Dialysis access

Done at UK since July 2003 (>100)

MIS in Pediatric Surgery

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

• Cholecystectomy

• Nissen Fundoplication

• Appendectomy

• Splenectomy

• Intestinal Resection

• VATS

• Inguinal Hernias

• Pyloromyotomy

• Hirschsprung’s Pull Through

• Ladd’s Procedure

• Pectus Excavatum-Nuss Procedure

• Congenital Diaphragmatic Hernia

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

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2

34

Nissen Fundoplication--1998* Indications

• Pulmonary complications of GERD• Refractory GERD• Neurologically impaired• Weight > 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 GERD—as 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

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5

Port size/use1. 5mm--camera2. 3mm--liver retractor3. 5mm--dissection (G-tube)4. 3mm--dissection5. 3mm---retraction

(optional)

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.

Port size/use1. 10-12mm-- stapler

dissection,

2. 5mm--camera or

dissection3. 5mm--dissection

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3

2

2 alt. site

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

Rescorla FJ, Breitfeld PP, West KW et al. A case controlled comparison of open andlaparoscopic splenectomy in children. Surgery 1998; 1224:670-676.

Port size/use1. 12mm--dissection, stapler,

bag2. 5mm--dissection, HS3. 5mm--dissection, HS4. 5mm--dissection, HSCamera moves around

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4

1

Intestinal Resection* Indications

• IBD -- UC and Crohn’s• Meckel’s• 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 “can’t pull on intussusception while reducing”

* Controversies• Is Lap Assisted any better than open?• True lap still requires incision for

specimen• Role in CA?

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1

5

Optional Incisions

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

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.

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1

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

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1

Pull-through for Hirschsprung’s--1995

* Indications• Biopsy proven HD--not sick!

* Procedure• 3mm instruments• Serial biopsies for level• Take down mesentery• Anal dissection • Colo-anal anastomosis

* 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

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Ladd’s Procedure for Malrotation--1997

* Indications• Malrotation without volvulus• Older patient (> 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

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2

4

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• 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.

Bochdalek 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− 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 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, MDNovember, 2002Seminars in Pediatric Surgery

Contact Information Andrew Pulito, M.D. arpuli@uky.edu

Joe Iocono, M.D. jiocono@uky.edu

UK MDs 1-800-333-8874

Office 859-323-5625

FAX 859-323-5289

Clinic Appointments 859-257-3253

Pediatric Surgery at University of Kentucky

Questions

Pediatric Minimally Invasive Surgery