Pediatric Minimally Invasive Surgery Joseph A. Iocono, M.D. Assistant Professor Division of Pediatric Surgery University of Kentucky Children’s Hospital Large Operations with Tiny Incisions Lap Hirschsprung’s pull through 8 weeks post-op pull through
30
Embed
Pediatric Minimally Invasive Surgery Joseph A. Iocono, M.D. Assistant Professor Division of Pediatric Surgery University of Kentucky Children’s Hospital.
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
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
* 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.
23
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
3 2
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
3
21
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
3
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