Presentation on theme: "Pediatric Minimally Invasive Surgery"— Presentation transcript:
1 Pediatric Minimally Invasive Surgery Large OperationswithTiny IncisionsLap Hirschsprung’spull through8 weeks post-oppull throughJoseph A. Iocono, M.D.Assistant ProfessorDivision of Pediatric SurgeryUniversity of KentuckyChildren’s Hospital
2 MIS-Advantages * Cosmesis * Analgesia * Adhesions * Decreased Ileus open operations often leave large, unsightly incisionswith some laparoscopic instruments smaller than 2mm in size, it is often difficult to see incisions postoperatively* AnalgesiaSmaller incisions associated with less pain, lower analgesic use, and quicker recovery.few controlled studies in children, especially in youngest patients* Adhesionsseveral studies suggest the formation of fewer intra-abdominal adhesions after laparoscopic proceduresreduces the risk of future postoperative bowel obstructionspossibly reduces postoperative pain* Decreased IleusNissen, Appendectomy, Pyloromyotomy, Bowel resection, SpleenReal or perceived?
3 Pediatric Surgery and MIS Pediatric Surgeons—already “in the business”Small incisions--small scarsPreemptive anesthesia--decreased pain med needsShort hospital staysHolcomb (1991) Newman (1991)Laparoscopic CholecystectomyAlain (1991)Laparoscopic PyloromyotomyFirst true pediatric MIS procedureLobe (1992)Laparoscopic appendectomyRothenberg (1993) Georgenson (1993)Laparoscopic Nissen FundoplicationHolcomb (1993)Laparoscopic Splenectomy
4 MIS—What’s So Great? * Why Bother? Additional expense Prolonged proceduresLack of tactile evaluationLoss of depth perceptionComplications specific to MIS“After an advanced MIS case, the patient goes home and the surgeon goes to the ICU”
5 Minimally Invasive Surgery * Expenseadded costs are related to disposable instruments, expensive equipment, and additional OR timeuse of non-disposable equipment reduces patient chargesreduced hospital stay offsets some of additional expenses* Length of Procedureslearning curve is steep for laparoscopic procedures, especially advanced techniquesLearning 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 Care—How? Procedure DrivenModeled after successful techniques in adult populationPatient (parent) DrivenPopulation demanded use of minimally invasive techniquesTechnology DrivenSmaller and smaller instruments continue to be developedTechnology now allows better visualization than openPhysician DrivenInnovations in OR career advancementNo time for “small molecules"Care Driven --“re-think” careMyths about open proceduresMyths about pre and post op care
7 Technology – Smaller and Better Camera Analog Digital, 3D Scope 10 mm 0º 2-3mm 30ºMonitors Rolling cart Integrated ORRecorder VCR Digital Ligation Monopolar Bipolar, harmonicInstruments 10 mm 3 mm(disposable) (reusable)
8 MIS – Indications * General Indications Model from open techniques Improve open techniquesto 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 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 EmpyemaGastroesophageal Reflux (25) Gastrostomy Tube Placement (20)Hirschsprung’s Disease (2) Benign Kidney DiseaseLung 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 accessDone at UK since July 2003 (>100)
10 MIS in Pediatric Surgery CholecystectomyNissen FundoplicationAppendectomySplenectomyIntestinal ResectionVATSInguinal HerniasPyloromyotomyHirschsprung’s Pull ThroughLadd’s ProcedurePectus Excavatum-Nuss ProcedureCongenital Diaphragmatic HerniaIndicationsProcedureComplicationsChanges in CareControversies
11 Cholecystectomy--1991 * Indications * Procedure * Complications Symptomatic cholelithiasisBiliary dyskinesiaCholecystitis* ProcedurePort placement and size of instruments depends on size of child (5mm clip applier)Modeled after adult procedure* ComplicationsMirrors adult literature, duct injury 0.05%Conversion to open higher 5%* Changes to CareFaster return to normal activityLess pulmonary complications* ControversiesCholangiogram?Common duct exploration* Gold Standard1234
12 Nissen Fundoplication--1998 * IndicationsPulmonary complications of GERDRefractory GERDNeurologically impairedWeight > 3kg* ProcedurePort placement and size of instruments depends on size of child4 -5 ports* ComplicationsEarly- same or less than openG-tube secured with temporary stitchesRecurrent GERD—as high as 25%* Changes to CareEarlier feeding and discharge (outpatient?)* ControversiesInfants 3-10 kg and less than 3kgShort gastric vessels?No standard wrap procedurePort size/use1. 5mm--camera2. 3mm--liver retractor3. 5mm--dissection (G-tube)4. 3mm--dissection5. 3mm---retraction (optional)12345
13 Appendectomy--1992 * Indications * Procedure * Complications Female, Unsure of diagnosis, obesePerforated?All appendectomies?* Procedure3 ports, locations vary* ComplicationsLower rate of wound infectionLonger OR time* Changes to CareEarlier feeding and discharge* ControversiesIndicationsPerforated appendicitisExpense of stapler or harmonicPort size/usemm-- stapler dissection,2. 5mm--camera or dissection3. 5mm--dissection1322 alt. site“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 laparoscopic splenectomy in children. Surgery 1998; 1224:670-676. 3241* IndicationsSCD, Spherocytosis, ITP, Cysts* ProcedurePatient in partial lateral decubitus* ComplicationsNo reported increase* Changes to CareHospital stay reduced 1-2 daysCan perform chole at same timePartial splenectomy or cystectomy* ControversiesLarge spleenOR timeInability to control major bleedingPort size/use1. 12mm--dissection, stapler,bag2. 5mm--dissection, HS3. 5mm--dissection, HS4. 5mm--dissection, HSCamera moves aroundRescorla FJ, Breitfeld PP, West KW et al. A case controlled comparison of open andlaparoscopic splenectomy in children. Surgery 1998; 1224:
15 Intestinal Resection * Indications * Procedure- 2 ways * Complications IBD -- UC and Crohn’sMeckel’sIntussusceptionFAP* Procedure- 2 waysTotal laparoscopic with intracorporeal anastomosisLap assisted with extracorporeal anastomosis* ComplicationsOR time 3-4x open with initial cases* Changes to CareDispelled myth of “can’t pull on intussusception while reducing”* ControversiesIs Lap Assisted any better than open?True lap still requires incision for specimenRole in CA?32415Optional Incisions
17 Inguinal Hernias * Indications * Procedure * Complications Any non-incarcerated hernia* ProcedureDifferent techniques (Instruments 3mm or less)* ComplicationsEarly--no change* Changes to CareNo removal of sac* ControversiesNo single procedure-No meshHernia sac left behindRecurrence rate higher in initial trials231Scheirer, et al Laparoscopic Inguinal Herniorrhaphy in Children: A Three-Center Experience With 933 Repairs J of Pediatr Surg March, 2003.
18 Pyloromyotomy-1991 * Indications * Procedure * Complications Newborn infant with HPS* Procedure3 mm Instruments (2)3 mm camera1 3mm port (umbilicus)2 mm meniscus knife* ComplicationsDuodenal injury 1% vs 0.02%Infection 0.2% vs 0.5%Site hernia (1%)* Changes to CareFeed 2hrs post-opHome hrs (36-48 open)* ControversiesIncreased complication rateLess scar, is this enough?321Vegunta , R Laparoscopic Pyloromyotomy: Safe, Cost-effective, and Cosmetically Superior Ped Endo Surg, 2003
19 Pull-through for Hirschsprung’s--1995 * IndicationsBiopsy proven HD--not sick!* Procedure3mm instrumentsSerial biopsies for levelTake down mesenteryAnal dissectionColo-anal anastomosis* ComplicationsRecurrent Hirschsprung’s* Changes to CareElimination of colostomy in select patients--single stage* ControversiesLaparoscope necessary?321Coran, A et al. Recent Advances in the Management of Hirschsprung’s Disease. Am J Surgery 2000
20 Ladd’s Procedure for Malrotation--1997 3241* IndicationsMalrotation without volvulusOlder patient (> 1 yo)* Procedure4 ports, all 5 mm* ComplicationsSame as open short term* Changes to CareNo improvement in LOS in younger patients* ControversiesDesire to induce adhesionsNo pexy of bowelNeed increased follow-up to assess durability of procedure
21 Nuss Procedure for Pectus Excavatum --1995 * IndicationsPectus excavatum with CT scan index > 4* Procedure1-2 ports (just used to watch first pass of bar)* ComplicationsInfection 1-2% (bar out, redo)Bar shifts 5% (OR to adjust)Failure of procedure 1%* Changes to CareIncrease in number of procedures performedUse of VATS increased safety and decrease OR time* ControversiesNeed 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 * Procedure * Complications Any late presenting CDHInfant CDH not on ECMO* ProcedureBochdalek-- VATSMorgagni-- laparoscope* ComplicationsMuch longer OR time* Changes to CareIdeal for Morgagni hernias* Controversies? On ECMO, babies in NICUMorgagniBochdalekArca, 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 * ConclusionsSurgeon 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 * EducationTechniques--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 ORTechnology changes quickly* Solution--basic skills need to be masteredEstablish baseline skill levels before exposure to “live” ORImplement within the constraints of 80 hour work weekHomework and skills labBuild on basics with OR experience
25 Who gets CATS Procedures and When do I refer to Pediatric Surgery? Techniques--List of procedures grows constantlyUnique pathology in infants and childrenAdvanced skills set in place, applications grow with experience of entire team* When?Standard referral patterns --no change for MISException--patient size, age decreasing with technology* How?Phone, , FAX
26 Future Directions * Limitations of current MIS technology No wristMotions are limited to 3 degrees of freedomLimits suture techniques2-dimensional imagesLack of depth perceptionDistance from operative fieldImage is in opposite direction from where surgeon is working* Solution---daVinci operative systemRobot arm with 5 degrees of freedomTrue 3-dimensional imagesWork 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 mmRobotic 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 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
29 Pediatric Surgery at University of Kentucky Contact InformationAndrew Pulito, M.D.Joe Iocono, M.D.UK MDsOfficeFAXClinic Appointments