Current status of minimal access surgery in children


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Minimal Access Surgery (MAS) in children though late to start compared to adult MAS has
Received 1 October 2013 now reached widespread application. Currently most of the surgeries are being carried out
Accepted 13 November 2013 by -scopy surgeries, viz: laparoscopy, thoracoscopy, neuroendoscopy, etc. Newer advances
Available online 15 December 2013 continue to be incorporated into pediatric surgery and include Robotic and Single Incision
Laparoscopic surgeries. This article reviews the various applications and present status of
MAS in children.

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Current status of minimal access surgery in children

  1. 1. Current status of minimal access surgery in children
  2. 2. a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 6 0 e2 6 4 Available online at ScienceDirect journal homepage: Review Article Current status of minimal access surgery in children Anand Alladi*, Deepti Vepakomma Department of Paediatric Surgery, Apollo Hospitals, Bannerghatta Road, Bangalore, Karnataka 560075, India article info abstract Article history: Minimal Access Surgery (MAS) in children though late to start compared to adult MAS has Received 1 October 2013 now reached widespread application. Currently most of the surgeries are being carried out Accepted 13 November 2013 by -scopy surgeries, viz: laparoscopy, thoracoscopy, neuroendoscopy, etc. Newer advances Available online 15 December 2013 continue to be incorporated into pediatric surgery and include Robotic and Single Incision Laparoscopic surgeries. This article reviews the various applications and present status of Keywords: MAS in children. Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved. MAS Laparoscopy Thoracoscopy Children 1. Introduction The concept of Minimal Access Surgery or MAS as it is called was established in the early 80s amongst General Surgeons and took some time in being adopted and adapted to the pediatric population. The reasons might have been many, including special, smaller more expensive instrumentation, smaller optics, technically more demanding in view of smaller working space, etc. However once popularized, both the applications and indications increased widely to reach the present state where most surgeries are being done by MAS starting from laparoscopy, thoracoscopy, neuroendoscopy, endourology, etc. Robotic surgery has also come to vogue in children. Newer modification and advances in adult surgery continue to be modified and adopted in children with Single Incision Laparoscopic Surgery (SILS) being the latest addition to the armamentarium. This article will go through the various applications of MAS in children and advances in the same. The obvious benefits of MAS are smaller wounds, less postoperative pain, faster recovery and shorter hospitalization, better access and visualization of deep structures, etc. The disadvantages mentioned are generally overcome over a period of time and include longer operating times during the learning curve, loss of 3D view and more expensive instrumentation. 2. Discussion Minimal access surgery in children has a wide range of applications, which include diagnostic and therapeutic procedures. A discussion of the various indications system wise follows (Tables 1 and 2). MAS are carried out by creating working space using CO2 gas that is easily absorbed. The * Corresponding author. Senior Consultant, Paediatric Surgery, Apollo Hospitals, Bannerghatta Road, Bangalore, Karnataka 560075, India. Tel.: þ91 9845064069. E-mail address: (A. Alladi). 0976-0016/$ e see front matter Copyright ª 2013, Indraprastha Medical Corporation Ltd. All rights reserved.
  3. 3. a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 6 0 e2 6 4 Table 1 e Some common indications for laparoscopy. Diagnostic Evaluation of pain abdomen Biopsy for Hirschsprung’s Liver biopsy Operative cholangiogram Non-palpable UDT Intersex disorders Tumor biopsy Therapeutic Appendicectomy Cholecystectomy Pyloromyotomy Ladd’s procedure Choledochal cyst surgery Excision of cysts, tumors Pull through for ARM Pull through for ARM Pyeloplasty Orchidopexy optical trocar is usually inserted by an open technique unlike in adults. The pressure range used is from 4 mm to 14 mm depending the age and the site used for. The flow rate varies between 0.8 L and 2 L/min. The ports used are generally 5 mm and 3 mm depending on the age. The hand instruments in addition to being of smaller diameter compared to those used in adults are also of smaller lengths. There are certain transient circulatory and ventilatory changes that take place during MAS that include interference with lung expansion and increase pulmonary vascular pressures. Most of these can be managed by altering the ventilatory techniques and proper use of post op analgesia. The absorption of CO2 causes transient hypercarbia, which lasts about 3 h post op. The advantages of MAS in children are more or less the same as in adults and include smaller incisions, faster recovery and less pain. The only limitations are the smaller cavities limiting working space and the higher costs of smaller instruments. 3. Appendicectomy Laparoscopic pyloromyotomy (Fig. 1) has replaced open pyloromyotomy in most centers doing Laparoscopic pediatric surgery. The various reports, both prospective and retrospective, as well as meta-analyses have reported comparable results with open pyloromyotomy with the benefits of earlier feeding and shorter hospitalization. They however also report about a slightly increased incidence of perforation and incomplete pyloromyotomy during the learning curve, which stabilizes with experience.2 3.3. Fundoplication Gastro esophageal reflux disease with near SIDS, recurrent pneumonias and failed medical therapy require surgical intervention. Antireflux surgery is also done as a part of feeding gastrostomy in the neurologically impaired. Different techniques have been described, Nissen’s, Toupet’s and Thal’s fundoplications to name 3 of the commonly used procedures. The outcomes in all three are nearly the same. The large series of Laparoscopic fundoplications reported have all noted a steep learning curve like any other procedure done laparoscopically, but once overcome faster recover and lesser complications.3 Many gastrointestinal tract surgeries are performed by Laparoscopic techniques and the list of indications continues to increase and has progressed from resectional to reconstructive surgeries. These include insertion of feeding devices like gastorstomy or jejunostomy, resections of Meckel’s diverticulum, excisions of cysts and tumors in the abdomen, intestinal resection for different congenital and acquired diseases and correction of intestinal malrotation and others (Fig. 2). Gastro intestinal system 3.1. 261 4. Appendicectomy as in adults was one of the earliest surgeries to be carried out laparoscopically. Over a period of time it has now become the standard approach for acute appendicitis. There are enough literature which prove Laparoscopic appendicectomy is comparable to open appendicectomy regarding complications but with the added advantage of small incision, faster recovery, shorter hospital stay, etc. Even with perforated and gangrenous appendicitis the incidence of complications is not increased.1 3.2. Hepatobiliary system & spleen 4.1. Cholecystectomy The indications for cholecystectomy are much fewer unlike adults, where it’s a commonly performed surgery, and include Pyloromyotomy Idiopathic pyloric stenosis is a common condition seen in children and pyloromyotomy is the treatment of choice. Table 2 e Some common indications for thoracoscopy. Diagnostic Lung biopsy Tumor biopsy Therapeutic Decortication Lobectomy Excision of mediastinal masses Repair of diaphragm Repair of esophageal atresia Esophageal replacement Fig. 1 e Laparoscopic pyloromyotomy showing completed myotomy.
  4. 4. 262 a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 6 0 e2 6 4 Fig. 3 e Laparoscopic splenectomy. Fig. 2 e Laparoscopic Trichobezoar excision. gall stones associated with hemolytic anemias. Even infants can be managed by Laparoscopic cholecystectomy.4 In addition Laparoscopic cholangiogram and guided liver biopsies are the other applications in gall bladder surgery especially in evaluation of infantile cholestases.5 Laparoscopic excision of liver hydatid cyst, a common problem encountered in tropical and subtropical countries have been reported since the 90s. Though there is a theoretical increased risk of spill and anaphylaxis, the reports do not mention any significantly increased risk. Laparoscopic choledochal cyst excision and reconstruction though a complex and long surgery can also be carried out laparoscopically with published reports showing definite benefits after the long operating time during the initial surgeries.6 4.2. Splenectomy Anatomically spleen is a very convenient organ to remove by laparoscopy. The limiting factor is however the size requiring an additional small incision or a morcellator to remove it piecemeal. The indication for Laparoscopic splenectomy is ideally pathology like Idiopathic thrombocytopenic purpura where the size is small (Fig. 3). However spleens with other pathologies like thalassemia, spherocytoses, etc are also removed laparoscopically.7 Splenic cysts can also be managed laparoscopically by drainage, excision or splenectomy.8 Complications with Laparoscopic splenectomy are rare and benefits are obvious. 5. Urology Pediatric urology has seen a tremendous advance as far as minimally invasive surgery is concerned from laparoscopy for impalpable testes to now laparoscopic pyeloplasty and ureteric reimplantation. Laparoscopy is now the gold standard for impalpable testes, which constitute about 20% of undescended testes and enables to locate, assess and plan a single or two-staged orchidopexy. It also helps in confirming atrophic or ‘vanishing’ testes by identifying following the vas and testicular artery to their logical termination. The applications for laparoscopy in Pediatric urology also has gone through the journey from simpler resectional surgeries like nephrectomy, heminephrectomy for non-functioning kidneys to reconstructive surgeries like pyeloplasty, ureteric reimplantations and even bladder reconstructions. With the establishment of Robotic surgery many of the reconstructive surgeries are done faster, cleaner and more precisely with minimum complications.9 5.1. Inguinal hernia Inguinal hernia repair is a very controversial subject where the opinion is vertically split between advocates of routine Laparoscopic hernia repair and those who believe that inguinal hernia repair is better done by open technique and that laparoscopy unnecessarily violates a virgin abdominal cavity. The middle path is followed by many surgeons who routinely carry out open inguinal hernia repair and reserve the Laparoscopic approach for specific situations like recurrence following open repair, females with suspicion of disorder of sexual differentiation,10 etc. 6. Thoracic surgery Thoracoscopy was initially used for management of empyemas which continue to be the most common indication for Video Assisted Thoracoscopic Surgery (VATS). Most units nowadays advocate primary VATS in the treatment of Empyema (Fig. 4) and this has resulted in a dramatic decrease in morbidity and faster recovery of these patients. Again with better instrumentation and gain in expertise more complicated procedures were attempted and currently the surgeries carried out by VATS include simple lung biopsies, thoracic duct ligation, excision of cysts, major surgeries like aortopexy, sympathectomy, PDA ligation, mediastinal masses (Fig. 5) and thymectomies and more
  5. 5. a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 6 0 e2 6 4 Fig. 6 e Thoracoscopic excision of neuroblastoma. Fig. 4 e VATS Empyema decortication. complex surgeries in neonates like esophageal atresiatracheoesophageal fistula repair, repair of diaphragmatic hernia and eventration.11 7. Oncology Fear of breach of principles of Oncosurgery and spill causing recurrences delayed the application of MAS in pediatric oncology. However starting off with biopsies for diagnosis gradually the surgeries for resection of tumors have been done thoracoscopically (Fig. 6) or laparoscopically and even major resectional surgeries like Nephrectomies for Wilms tumor and Hepatic resections have successfully been carried out with no major increase in complications.12 The recent addition to the armamentarium of MAS in children has been Robotic surgery and Single Incision Laparoscopic Surgery (SILS).13 In SILS instead of multiple port incision, a large single umbilical port incision is made and Fig. 5 e Thoracoscopic resection of sequestration. 263 special hinged and rotation instruments are used through the same port site. This is being used in older children. 8. Summary Over a period of time MAS in children has progressed from simple diagnostic procedure to very complex reconstructive surgeries in neonates and has had equal or better results than the corresponding open surgeries and definite benefits of faster recovery, cosmesis, and shorter hospitalization. Conflicts of interest All authors have none to declare. references 1. Mequerditchian Ari-Nareq, Prasil Pascale, Cloutier Raymond, et al. Laparoscopic appendectomy in children: a favorable alternative in simple and complicated appendicitis. J Pediatr Surg. 2002;37:695e698. 2. Hall Nigel J, Van Der Zee Jill, Tan Hock L, et al. Meta-analysis of laparoscopic versus open pyloromyotomy. Ann Surg. 2004;240:774e778. 3. Rothenberg SS. Experience with 220 consecutive laparoscopic Nissen fundoplications in infants and children. J Pediatr Surg. 1998;33:274e278. 4. Papandreou Evangelos, Gentimi Fotini, Baltogiannis Nikolaos, et al. Laparoscopic cholecystectomy in children: a 5-year experience. Pediatrics. 2008;121:S163. 5. Hay SA, Soliman HE, Sherif HM, et al. Neonatal jaundice: the role of laparoscopy. J Pediatr Surg. 2001;36:464e465. 6. Liuming H, Hongwu Z, Gang L, et al. The effect of laparoscopic excision vs open excision in children with choledochal cyst: a midterm follow-up study. J Pediatr Surg. Apr 2011;46(4):662e665. 7. Reddy VS, Phan HH, O’Neill JA, et al. Laparoscopic versus open splenectomy in pediatric population: a contemporary single centre experience. Ann Surg. 2001;67:859e864.
  6. 6. 264 a p o l l o m e d i c i n e 1 0 ( 2 0 1 3 ) 2 6 0 e2 6 4 8. Sheshadri PA, Poenaru D, Park A. Laparoscopic splenic cystectomy: a case report. J Pediatr Surg. 1998;33:1439e1440. 9. Kim Christina, Docimo Steven G. Use of laparoscopy in pediatric urology. Rev Urol. 2005;7(4):215e223. 10. Schier F. Laparoscopic surgery of inguinal hernia in children e initial experience. J Pediatr Surg. 2000;35:1331e1335. 11. Rothenberg Steven S. Thoracoscopy in infants and children: the state of the art. J Pediatr Surg. 2005;40:303e306. ´ 12. Duarte RJ, Denes FT, Cristofani LM, Srougi M. Laparoscopic nephrectomy for Wilms’ tumor. Expert Rev Anticancer Ther. 2009 Jun;9(6):753e761. 13. de Armas IA, Garcia I. Pimpalwar laparoscopic single port surgery in children using Triport: our early experience. Pediatr Surg Int. 2011;27(9):985e989.
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