1. 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

2. 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?

3. 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

4. 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”

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 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

7. Technology – Smaller and Better
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)

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)
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)

10. 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

11. 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

12. 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

13. 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
mm-- 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.

14. 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:

15. 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

16. 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

17. 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.

18. 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 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

19. 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

20. Ladd’s Procedure for Malrotation--19973 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

21. 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

22. 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.

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 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

25. 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, , 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 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

29. Pediatric Surgery at University of Kentucky
Contact Information
Andrew Pulito, M.D.
Joe Iocono, M.D.
UK MDs
Office
FAX
Clinic Appointments

30. Pediatric Minimally Invasive Surgery
Questions