Pediatric Minimally Invasive Surgery Large Operations with Tiny Incisions Lap Hirschsprung’s pull through 8 weeks post-op pull through Joseph A. Iocono, M.D. Assistant Professor Division of Pediatric Surgery University of Kentucky Children’s Hospital

MIS-Advantages * Cosmesis * Analgesia * Adhesions * Decreased Ileus 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? 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 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) Adhesive Small Bowel Obstruction Adrenal 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 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 Peritoneal Dialysis access Done at UK since July 2003 (>100)

MIS in Pediatric Surgery 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 Indications Procedure Complications Changes in Care Controversies

Cholecystectomy--1991 * Indications * Procedure * Complications 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 1 2 3 4

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

Appendectomy--1992 * Indications * Procedure * Complications 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 Port size/use 1. 10-12mm-- stapler dissection, 2. 5mm--camera or dissection 3. 5mm--dissection 1 3 2 2 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.

laparoscopic splenectomy in children. Surgery 1998; 1224:670-676. 3 2 4 1 * 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; 1224:670-676.

Intestinal Resection * Indications * Procedure- 2 ways * Complications 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? 3 2 4 1 5 Optional Incisions

Thoracoscopy-VATS * Indications * Procedure * Complications 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 * Procedure * Complications 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 2 3 1 Scheirer, et al Laparoscopic Inguinal Herniorrhaphy in Children: A Three-Center Experience With 933 Repairs J of Pediatr Surg March, 2003.

Pyloromyotomy-1991 * Indications * Procedure * Complications 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? 3 2 1 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 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? 3 2 1 Coran, A et al. Recent Advances in the Management of Hirschsprung’s Disease. Am J Surgery 2000

Ladd’s Procedure for Malrotation--1997 3 2 4 1 * 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

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 * Procedure * Complications 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 Morgagni Bochdalek Arca, et al Early Experience With Minimally Invasive Repair of Congenital Diaphragmatic Hernias: Results and Lessons Learned. J Peds Surg Nov 2003.

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? 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, MD November, 2002 Seminars in Pediatric Surgery

Pediatric Surgery at University of Kentucky 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 Minimally Invasive Surgery Questions