Download Minimally Invasive Surgery: From Adult to

Minimally Invasive Surgery: From Adult to Neonatal Applications
Author: Dr. Steven Rothenberg, MD
IPEG (International Pediatric Endosurgery Group) Past-President
Published in International Hospital Equipment & Solutions
Volume 27, Issue #7, November, 2001, Page 54
Over the last decade there has been a dramatic revolution in surgical practice with the
wide spread acceptance of minimally invasive surgery. This is abdominal (laparoscopic)
and chest (thoracoscopic) surgery that is performed through a number of small incisions
with special instruments and cameras, rather than the large incisions previously used. The
pioneering procedure in adults was the laparoscopic cholecystectomy, which was first
performed in the U.S. in 1989. Since that time the instruments and techniques have been
adapted so that a majority of procedures can now be performed this way. The advantages
are many including decreased post-operative pain and recovery time, shorter
hospitalizations, and a superior cosmetic result. While this technology was quickly
assimilated in the care of adults the process was much slower in children and especially
in small neonates and infants.
The obstacles were many for the application of minimally invasive surgery (MIS)
inchildren. The initial instrumentation was too large and awkward to use in children,
there was a significant resistance among pediatric surgeons to adopt these new
techniques, and the benefits to pediatric patients were not as clear. However, over the last
decade there have been significant advancements made in both technology and technique
that now allow even the most complicated neonatal procedures to be performed using
MIS.
The International Pediatric Endosurgical Group (IPEG) has fostered much of this
development. IPEG started as a small group of pediatric surgeons from around the world
who shared an interest in developing MIS techniques in children. They believed that
infants and children would benefit from the same decrease in post-operative pain and
quicker recovery as adults, with the added benefit that decreased scarring would result in
fewer long-term complications. This group has pioneered many of the procedures
performed in infants today and helped develop the instrumentation necessary to make
these procedures possible. The group has rapidly expanded and now comprises over 350
surgeons in over 30 countries. Through these advances MIS has become much more
prevalent in the pediatric population.
Minimally invasive surgery is performed through a number of small ports, which allow
the introduction of special instruments and telescopes. The ports have valves, which
allow for the insufflation of CO2, which expands the abdominal cavity and creates a
dome like environment in which to work. The picture, now digital in most cases, is
viewed on monitors placed over the patient and the surgeon operates while looking at the
monitor.
Over the last 5 years smaller instrumentation and scopes (2 & 3mm) have been developed
that now allow very complicated procedures to be performed in even small premature
infants only 1000 gms in size. Below is a list of procedures which are now commonly
performed in infants under 5 kg.
Nissen fundoplication
PDA ligation
Pyloromyotomy
Lung biopsy
Pull-through procedure
Lobectomy
CDH repair
Esophageal duplication
Imperforate Anus repair Thoracic Duct ligation
Duodenal Atresia repair TEF repair
Ovarian cystectomy
Diaphragmatic plication
NEC resection
Aortopexy
Intestinal duplication
Bronchogenic Cyst
Malrotation
Sequestration
These procedures when performed using MIS techniques have resulted in significantly
lower morbidity and much shorter hospital stays. For example, patients undergoing a
fundoplication for gastro-esophageal reflux would often be hospitalized for up to a week
after surgery. Now that the procedure is done laparoscopically the average hospital stay is
one day and the incisions are barely visible after 2 to 3 months. The post-operative
complications, especially respiratory problems such as pneumonia, have significantly
decreased. It also appears that long-term problems from adhesion formation will be much
less. This is extremely important when considering the entire lifespan of an infant.
Thoracic procedures can also be performed avoiding the necessity of a painful and
relatively morbid thoracotomy. It has been well documented that infants and children
undergoing thoracotomies have a higher incidence of scoliosis and shoulder girdle
weakness later in life. The ability to perform procedures such as Patent Ductus Arteriosus
ligation, Tracheo-esophageal Fistula repair, and lung resections for congenital lesions,
thoracoscopically, should significantly diminish these long-term complications.
These new techniques have become so sophisticated that they are now being applied to
pre-natally diagnosed lesions. Fetoscopic surgery is now being used in a number of
centers to evaluate and in some cases intervene when there are life-threatening anomalies
present. The ability to safely reach the fetus in the womb and perform surgical therapy
threw a few tiny incisions may someday change standard therapy for a number of
congenital or inherited diseases.
Whether it be the treatment of common surgical diseases such as appendicitis or complex
congenital anomalies like tracheoesophageal fistula, MIS has made a dramatic impact on
the surgical care of infants and children, and future developments promise only to further
expand the applications and benefits.