Minimally Invasive Surgery in Pediatric Surgery 三軍總醫院 小兒外科 朱志純 為恭紀念醫院   2007.9.4
Fewer and fewer kids   ---Quantity and Quality 1 2 3 4 5 民國 50 年 60 70 80 90 每 一 婦 女 平 均 生 育 數 2.46 3.71 1.72 5.59 人 6 1 2...
微創手術 Minimally invasive surgery  
近年來的新技術發展 <ul><li>微創手術  </li></ul><ul><li>Transumbilical extracorporeallaparoscope-assisted appendectomy (TELA,  經臍腹腔鏡輔助闌尾...
<ul><li>Minimally invasive surgery – </li></ul><ul><li>Tradition or Innovation? </li></ul>
Minimally invasive surgery—hernia repair
Minimally invasive surgery— pyloromyotomy for hypertrophic infantile pyloric stenosis
傳統切口及微創切口
Appendectomy 闌尾切除術 <ul><li>Open appendectomy </li></ul><ul><li>Laparoscopic appendecotmy </li></ul><ul><li>Laparoscope-ass...
All-in-1  Laparoscope  with working channel, air-inflation, irrigation & suction
 
 
 
 
 
Single umbilical-punctured laparoscope-assisted appendectomy Low cost Low infection rate No visible scar Short LOS
Vesicoureteric reflux <ul><li>Open methods </li></ul><ul><li>Extravesicle open method (detrussorrhaphy ) </li></ul><ul><li...
Anti-reflux procedure--- Intravesicle approach
Anti-reflux procedure--- Extravesicle approach
Submucosal injection of Deflux
Submucosal injection of Deflux
Submucosal Deflux injection Gr. VI No reflux
Pectus excavatum (funnel chest) <ul><li>Ravitch procedure— 傳統肋軟骨切除 </li></ul><ul><li>Nuss procedure— 支架頂出 </li></ul>
Preserve the perichondrum and remove all the deformed cartilage
Ravitch Procedure (removal deformed cartilage, fracture of the sternum)
 
Ravitch  手術  1943~ Ossification of the cartilage Scarring Blood loss
Scars
 
After sternum turn-over (Wada)
Dr. Donald Nuss
Nuss  Procedure
Dr. Park Hyung Joo
The pectus bar is supported by the ribs and the intercostal soft tissue.
Evaluation <ul><li>Haller index: A/B </li></ul><ul><li>Depression index: C/B </li></ul><ul><li>Asymmetric index: R/L </li>...
(Park, et al., 2004) saucer- shaped Asymmetric II funnel-shaped Symmetric I eccentric   unbalanced
Dr. Park
Pre-operative device remolding
 
 
Nuss procedure
 
 
Crane Technique
Nuss Procedure <ul><li>Is thoracoscopy really necessary? </li></ul><ul><li>Are stabilizers necessary? </li></ul><ul><li>Is...
 
 
STERNUM SUPPORTING  RIB
Stabilizer: avoids flipping of the bar
Kids are growing!
Funnel-shaped depression 手術前 手術後
Saucer-shaped depression
Asymmetric
Female
Re-do after Ravitch
 
 
Lung entrapment
<ul><li>2 days after operation </li></ul><ul><li>4 days after operation </li></ul><ul><li>7 days after operation </li></ul...
The future <ul><li>Key-hole surgery </li></ul><ul><li>Robot assisted surgery </li></ul><ul><li>70% of pediatric surgeries ...
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Mis20070904為恭紀念醫院

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Mis20070904為恭紀念醫院

  1. 1. Minimally Invasive Surgery in Pediatric Surgery 三軍總醫院 小兒外科 朱志純 為恭紀念醫院 2007.9.4
  2. 2. Fewer and fewer kids ---Quantity and Quality 1 2 3 4 5 民國 50 年 60 70 80 90 每 一 婦 女 平 均 生 育 數 2.46 3.71 1.72 5.59 人 6 1 2 3 4 5 91 每 一 婦 女 平 均 生 育 數 1.40 2.46 3.71 1.72 5.59 人 6 1.34 人 1.24 人 92 年
  3. 3. 微創手術 Minimally invasive surgery  
  4. 4. 近年來的新技術發展 <ul><li>微創手術 </li></ul><ul><li>Transumbilical extracorporeallaparoscope-assisted appendectomy (TELA, 經臍腹腔鏡輔助闌尾切除手術 ) </li></ul><ul><li>Nuss procedure for pectus excavatum( 漏斗胸微創手術 ) </li></ul><ul><li>Submucosal injection of Deflux for vesicoureteric reflux </li></ul>
  5. 5. <ul><li>Minimally invasive surgery – </li></ul><ul><li>Tradition or Innovation? </li></ul>
  6. 6. Minimally invasive surgery—hernia repair
  7. 7. Minimally invasive surgery— pyloromyotomy for hypertrophic infantile pyloric stenosis
  8. 8. 傳統切口及微創切口
  9. 9. Appendectomy 闌尾切除術 <ul><li>Open appendectomy </li></ul><ul><li>Laparoscopic appendecotmy </li></ul><ul><li>Laparoscope-assisted appendectomy </li></ul><ul><li>Transumbilical extracorporeal laparoscope-assisted appendectomy </li></ul>
  10. 10. All-in-1 Laparoscope with working channel, air-inflation, irrigation & suction
  11. 16. Single umbilical-punctured laparoscope-assisted appendectomy Low cost Low infection rate No visible scar Short LOS
  12. 17. Vesicoureteric reflux <ul><li>Open methods </li></ul><ul><li>Extravesicle open method (detrussorrhaphy ) </li></ul><ul><li>Submucosal injection of Deflux </li></ul>
  13. 18. Anti-reflux procedure--- Intravesicle approach
  14. 19. Anti-reflux procedure--- Extravesicle approach
  15. 20. Submucosal injection of Deflux
  16. 21. Submucosal injection of Deflux
  17. 22. Submucosal Deflux injection Gr. VI No reflux
  18. 23. Pectus excavatum (funnel chest) <ul><li>Ravitch procedure— 傳統肋軟骨切除 </li></ul><ul><li>Nuss procedure— 支架頂出 </li></ul>
  19. 24. Preserve the perichondrum and remove all the deformed cartilage
  20. 25. Ravitch Procedure (removal deformed cartilage, fracture of the sternum)
  21. 27. Ravitch 手術 1943~ Ossification of the cartilage Scarring Blood loss
  22. 28. Scars
  23. 30. After sternum turn-over (Wada)
  24. 31. Dr. Donald Nuss
  25. 32. Nuss Procedure
  26. 33. Dr. Park Hyung Joo
  27. 34. The pectus bar is supported by the ribs and the intercostal soft tissue.
  28. 35. Evaluation <ul><li>Haller index: A/B </li></ul><ul><li>Depression index: C/B </li></ul><ul><li>Asymmetric index: R/L </li></ul><ul><li>Eccentric index: angles </li></ul>
  29. 36. (Park, et al., 2004) saucer- shaped Asymmetric II funnel-shaped Symmetric I eccentric unbalanced
  30. 37. Dr. Park
  31. 38. Pre-operative device remolding
  32. 41. Nuss procedure
  33. 44. Crane Technique
  34. 45. Nuss Procedure <ul><li>Is thoracoscopy really necessary? </li></ul><ul><li>Are stabilizers necessary? </li></ul><ul><li>Is extrapleural approach possible? </li></ul><ul><li>O ur way. </li></ul>
  35. 48. STERNUM SUPPORTING RIB
  36. 49. Stabilizer: avoids flipping of the bar
  37. 50. Kids are growing!
  38. 51. Funnel-shaped depression 手術前 手術後
  39. 52. Saucer-shaped depression
  40. 53. Asymmetric
  41. 54. Female
  42. 55. Re-do after Ravitch
  43. 58. Lung entrapment
  44. 59. <ul><li>2 days after operation </li></ul><ul><li>4 days after operation </li></ul><ul><li>7 days after operation </li></ul><ul><li>10 days after operation </li></ul><ul><li>14 days after operation </li></ul>
  45. 60. The future <ul><li>Key-hole surgery </li></ul><ul><li>Robot assisted surgery </li></ul><ul><li>70% of pediatric surgeries will be minimally invasive. </li></ul><ul><li>UPJO, GERD, Hirschsprung’s disease. Kasai’s procedure for biliary atresia, mediastinal tumor, lung decortication… </li></ul>

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