Editorials

1. Minimally Invasive Surgery: From Adult to Neonatal Applications
(added 03-13-2002)

Minimally Invasive Surgery: From Adult to Neonatal Applications

Author: Dr. Steven Rothenberg, MD
IPEG Past-President and Membership Committee Chair
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) in children. 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.

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 tracheo-esophageal 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.

:: Join IPEG in 2010 and discover more about our annual congress and Big Island of Hawaii, USA

:: View available Support & Exhibit Opportunites for the 2010 Meeting

:: View the 2008 Meeting Program Book & Abstracts

:: Join IPEG today!

:: Get more info about IPEG's official journal

:: Members log in for access to more benefits

:: IPEG Clinical Guidelines are available.