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Innovations in Minimally Invasive Surgery in Children

  • Todd A. PonskyEmail author
  • Gavin A. Falk
Living reference work entry
  • 227 Downloads

Abstract

This chapter provides an overview of recent innovations in pediatric minimally invasive surgery that have enabled pediatric surgeons to operate safely on their smallest patients through tiny incisions. The development of size appropriate laparoscopes and instruments has been key in the development of this specialty. We also discuss NOTES, telemedicine, and robotic surgery in our pediatric population.

The numerous MIS techniques, originally used in the adult population, have been successfully applied to our pediatric patients. MIS has become routine for the treatment of many pediatric surgical disease processes, due to the numerous benefits these techniques confer on the patient: decreased wound complications, shorter length of stay, and improved postoperative pain. Inherent in the application of these complex techniques to infants and children are many risks due to the size of these patients. Pediatric surgeons must be aware and understand these risks if they are to successfully and safely practice MIS.

MIS will continue to develop as long as industry is committed to developing pediatric equipment to provide better care for our patients. Surgical training must continue to evolve, to ensure that the next generation of surgeons is adequately trained in these complex techniques. The future of pediatric MIS is exciting for our patients and indeed the specialty of pediatric surgery.

Keywords

Minimally invasive surgery Inguinal hernias Laparoscopy NOTES Telemedicine Robotic surgery 

Introduction

The first known laparoscopic procedure was in 1901 when Kelling performed a celioscopy using a cystoscope on a dog. In 1985, Erich Muhe described the first laparoscopic cholecystectomy, which, within a decade, became the standard of care for the treatment of cholecystitis and symptomatic cholelithiasis. Since then laparoscopy has developed dramatically, and now surgical procedures that could only be achieved with large painful incisions are possible by minimally invasive techniques.

While initially slow to be widely accepted and adopted by pediatric surgeons because of the large instruments, laparoscopy has become the standard of care for many procedures. Pediatric surgeons continue to look for innovative technologies and methods to perform their operations while both minimizing incisions and maximizing patient safety.

This chapter provides an overview of recent innovations in pediatric minimally invasive surgery that have enabled pediatric surgeons to operate safely on their smallest patients through tiny incisions.

From Open to Laparoscopic in Pediatric Surgery

Laparoscopic surgery brought in an era of minimally invasive surgery, affording benefits such as decreased wound complications, shorter length of stay, and improved postoperative pain. While the benefits are certainly realized in the pediatric population, adopting laparoscopic techniques for infants and children comes with a unique set of costs and risks.

First, the size of the patient dictates the size of the working space, and the relationship is not a linear one (Blinman and Ponsky 2012). For example, a pediatric patient one half as tall as an adult patient leaves only one eighth of the working volume in either the chest or abdomen (Blinman and Ponsky 2012). The same principle extends to the increased risks of electrical energy injury from use of electrosurgical instruments, as well as increased proportion of non-visible space due to the close proximity of the laparoscopic or thoracoscopic camera.

Second, physiologic changes related to laparoscopic surgery also vary nonlinearly, often demanding exponential increases in attention to physiologic changes as size decreases. In particular, pediatric patients are at increased risk of developing hypothermia and hypercarbia from laparoscopic techniques. The CO2 generally used for insufflation, which is relatively cool and dry, leads to a large fraction of an infant’s metabolic rate being consumed by heat production, without a sufficient compensatory mechanism, which can result in subsequent hypothermia. Therefore, humidification of the gas and diligent adherence to reducing evaporative losses by minimizing leakage around the laparoscopic instruments is paramount, particularly for long cases. With appropriate humidification of the CO2 used for insufflation, the hypothermic side effect on an infant of the laparoscopic technique is virtually eliminated.

The reluctance of pediatric surgeons to adopt the minimally invasive techniques being used and developed by their adult colleagues was mostly due to technical factors. The equipment that had been developed for adults was not simply transferable to the pediatric patient. Innovation which led to the development of four key changes in equipment allowed the meteoric rise and widespread adoption of minimally invasive techniques in pediatric surgery, namely, laparoscopes, hand instruments, trocars, and insufflation devices.

Laparoscopes and Hand Instruments

In the early 1990s when a few pediatric surgeons began performing laparoscopy on small children, they had no choice but to use instruments designed for adult patients. These included 10 mm laparoscopes and cumbersome (5–10 mm) laparoscopic instruments , which made operating in the confines of a pediatric abdominal cavity very difficult. Eventually industry took note and developed smaller scopes allowing for the progression of pediatric minimally invasive surgery (MIS). In the mid-1990s, smaller instruments (2–3 mm) were developed, allowing pediatric surgeons to work more safely and with greater ease in the limited space of the pediatric abdominal cavity.

Trocars

In addition to the need for 5 mm or smaller trocars , pediatric patients have other unique characteristics that require special attention. The working space inside the pediatric peritoneal cavity is much smaller than in adults, and their abdominal wall much thinner. This can result in trocars being frequently dislodged during the case. The advent of radial expanding trocars or trocars with anchoring capabilities have somewhat mitigated this problem. Furthermore, these newer access systems offer cause less tissue trauma and a tighter fascial seal (Lam et al. 2000), which helps minimize tissue damage in small children with delicate tissues and a thin abdominal wall. In the very small patient, in which 3 mm instruments are used, many surgeons forgo the use of trocars and place the instruments directly through 3 mm stab incisions.

Insufflators

One of the major hurdles to the developmental pediatric laparoscopy was the standard adult insufflators. Recently, pediatric and even neonatal insufflators were developed. In contrast to adult insufflators, neonatal insufflators deliver CO2 in small, controlled puffs. This technology reduced the risk of over-insufflation that was often associated with using the oversized adult insufflators in small children. Over-insufflation can often be accompanied by a significant increase in end-tidal CO2, or the measurement of the amount of CO2 in the expired air. The anesthesiologist must adjust for this, as over-insufflation can lead to significant pulmonary complications in already fragile neonates (Kalfa et al. 2005). Close partnership with pediatric-trained anesthesiologists to ensure that insufflation pressures are kept low (8–10 mmHg) is of key importance in being able to safely perform laparoscopic surgery in even the smallest of infants (Blinman and Ponsky 2012; Lam et al. 2000; Kalfa et al. 2005; Fujimoto et al. 1999).

While much has been published detailing the tools available in the pediatric surgeon’s toolbox (Blinman and Ponsky 2012; Lam et al. 2000; Krpata and Ponsky 2011, 2013; Ponsky 2009), the area needs continued attention from industry to allow full realization of minimally invasive techniques in the pediatric population. In particular, development needs to focus on designing stiffer 2 and 3 mm instruments, ultrasonographic instruments in pediatric sizes, and improving optics for smaller cameras.

Neonatal Laparoscopy

The development of smaller laparoscopic combined with the development of pediatric surgeons’ skills enabled operations to be performed on smaller and smaller children. When these laparoscopic techniques were applied to infants 28 days old or less, and weighing up to 5,000 g, the subspecialty of neonatal laparoscopy was created. The laparoscopic and thoracoscopic approaches to many neonatal surgical problems have been successfully carried out.

Needlescopic Surgery

As with many fields in surgery, necessity has been the driving force of innovation. With the availability of 2 or 3 mm laparoscopic instruments, surgeons can now operate with even smaller incisions on even smaller children (Krpata and Ponsky 2013). The use of these “needle-sized” instruments is frequently called either needlescopic surgery or minilaparoscopy.

While the hidden scar of single-incision surgery is desirable, its technical difficulty along with the potential increase in postoperative pain has forced surgeons to seek other options. The 2–3 mm needlescopic instruments have been available for many years, but many surgeons felt they were too flimsy for use in larger patients. However, with the increased emphasis on cosmesis and hiding the scars, combined with development of stronger, more versatile, minilaparoscopic instruments, many surgeons have added these to their toolbox even for larger patients. A 5 mm trocar and instrument used to be the standard-sized instrument used in a cholecystectomy, yet current reports show it can be done safely with 2 and 3 mm instruments (Franklin et al. 2006; Tagaya et al. 2007; Lee et al. 2005).

While the advantage of a 3 mm scar over a 5 mm scar may not be readily apparent, there are two main advantages: while 5 mm scars are smaller than 10 mm scars, a 3 mm scar is essentially invisible, making it almost impossible to notice that the patient underwent a major operation. The second advantage is that with 3 mm laparoscopy, the insertion of instruments is essentially percutaneous, meaning that muscle fibers are spread rather than cut, and this helps to minimize pain.

In addition to the development of more sturdy, versatile minilaparoscopic instruments, there are many new devices that have recently entered the marketplace or are in the pipeline. Companies are also working with different materials to develop novel 2–3 mm instruments with the strength and functionality of the currently available 5 mm instruments.

Laparoscopic Inguinal Hernia Repair

The laparoscopic inguinal hernia repair deserves special attention as it has recently emerged as a very popular technique. Laparoscopic repair of inguinal hernias offers many proposed and proven advantages over the open repair. While some studies report improved postoperative pain and cosmesis, and decreased risk of recurrence, the current authors feel that the primary benefit is the ease of repair in difficult hernias such as a recurrent hernia, meaning less chance of injury to the floor, and “no-touch” of the cord structures. Additionally, in the case of possible bilateral inguinal hernias, laparoscopic repair permits exploration of the contralateral groin without an additional incision. A high percentage of open inguinal hernia repair recurrences are direct hernias, which are either missed at initial repair or caused by the open hernia repair. The laparoscopic repair should eliminate this frequent cause of open hernia repair recurrence.

There are two basic laparoscopic approaches for inguinal hernia repair – intracorporeal and extracorporeal. The authors use the percutaneous, extracorporeal approach, which involves passing a circumferential suture percutaneously around the patent processus vaginalis between the peritoneum and the cord structures. This is done after bupivacaine or saline has been used to hydro-dissect the peritoneum away from the spermatic cord, thereby avoiding injury to delicate cord structures when ligating the defect. The authors obtained very convincing data from their rabbit hernia model, that intentionally causing iatrogenic injury to the anterior hernia sac with a scissors or electrocautery leads to a more durable repair than if sutures alone were used (Blinman and Ponsky 2012; Blatnik et al. 2012). Consequently the hernia sac is cauterized from the 3 to 9 o’clock position anteriorly prior to percutaneous repair. The authors have also demonstrated in their rabbit model that braided, nonabsorbable, suture results in a more durable repair than a monofilament suture.

Other techniques involve the placement of an intracorporeal, purse-string stitch. Some experts argue that the defect can also be repaired intracorporeally by resecting the hernia sac without ligation (Lam et al. 2000; Riquelme et al. 2010).

Hiding the Scars

Single-Incision Laparoscopy

Initial opponents of laparoscopy stated that instead of one larger scar, patients were now having multiple smaller scars. Despite multiple studies showing that laparoscopic surgery resulted in less pain, shorter hospital stays, and improved cosmesis, there was still a drive for advancement. This led to the advent of single-incision laparoscopic surgery as an approach to limit the number of incisions required to complete laparoscopic procedures. This technique involves placing all of the instruments through a single small incision hidden within the umbilicus.

This minimization of incision quantity is achieved in one of two ways. First, multiple companies have developed single, multiport trocars that have three or four working ports for instruments (Blinman and Ponsky 2012; Krpata and Ponsky 2011; Kalfa et al. 2005). These trocars require a 2 cm incision in the skin and fascia, usually located in the base of the umbilicus. Alternatively, multiple small trocars can be placed through separate fascial openings but hidden in one incision in the skin. With this option, at the completion of the procedure, the holes in the fascia are connected and then closed in a traditional manner. By placing the single skin incision in the umbilicus, the surgeon enables the patient to have no visible scar.

However, single-incision laparoscopy has a number of inherent mechanical disadvantages that have limited its use. Because they are so close together, instruments tend to clash and the classic “triangulation” of the instruments is lost. While instruments that can articulate (i.e., bend and flex) overcome some limitations, they require the surgeon to work backward and with reduced degrees of freedom (Blinman and Ponsky 2012; Krpata and Ponsky 2011; Fujimoto et al. 1999). These constraints increase operating time and restrict the complexity of case type that can be successfully performed. In addition the umbilical incision must be relatively large to fit the port and multiple instruments, which may lead to increased risk for herniation in the future.

In the pediatric patient, single-incision laparoscopic surgery has found daily use in multiple procedures. The first reported use of single-incision laparoscopy in children was in 2009 when an initial experience of 72 single-incision laparoscopic procedures was reported and showed to be a safe alternative to traditional laparoscopy and open surgery (Ponsky et al. 2009). Many pediatric surgeons around the world now perform many procedures by a single-incision approach, including splenectomy, adrenalectomy, pyloromyotomy, cholecystectomy, appendectomy, and gastrostomy tube placement (Ming et al. 2016; Ponsky and Krpata 2011; Ponsky 2009; Rothenberg et al. 2009; Agrawal et al. 2010).

Studies in pediatric single-incision laparoscopy have shown equivalent results to standard laparoscopic techniques with regard to both cost and outcomes (Saldaña and Targarona 2013; Islam et al. 2012), and a recent long-term follow-up from a prospective randomized controlled trial (RCT), which compared single-incision laparoscopic surgery to standard four-port laparoscopic cholecystectomy in 60 pediatric patients, found that single-incision laparoscopic surgery patients perceived a superior scar assessment at long-term follow-up compared with the four-port cohort (Ostlie et al. 2013). Despite this, widespread adoption has not occurred, likely due in part to the inherent technical challenges of the technique, with the only proven benefit when compared to standard laparoscopy being aesthetics due to decreased visible scarring.

For this reason, we have strongly stood by the mantra that single-incision laparoscopy, and, for that matter, standard laparoscopy, should be attempted only when the approach is able to be performed safely and effectively without compromising the completeness and accuracy of the surgery. Conversion from a single-incision to a standard laparoscopic approach or an open approach should not be viewed as a failure, but rather as a necessary step for certain difficult cases to ensure the safety of the patient.

Single-Incision Laparoscopic Techniques in Pediatric Patients

Given the vast breadth of cases described in infants and children using single-incision laparoscopic techniques, this chapter will look at three relatively common single-port minimally invasive procedures that highlight specific modifications that enable an improved operative experience in our unique patient population: cholecystectomy, appendectomy, and gastrostomy.

For several years, single-incision techniques for cholecystectomies have been used successfully in children. This section will look at how the standard single-incision procedure has been adapted successfully for the pediatric population. A newer alternate approach, the “2×2” method, will then be outlined which uses an amalgamation of needlescopic techniques with single-incision techniques to offer a scarless cholecystectomy. Extracorporeal appendectomy using a small umbilical incision will then be outlined, a procedure widely performed daily on patients of all ages and body types. The section concludes with a method for single-incision gastrostomy tube placement, successfully used in the smallest of patients.

Single-Port Laparoscopic Cholecystectomy: Considerations in Children

Standard laparoscopy utilizes a 10–12 mm umbilical port and either three 5 mm ports or two 5 mm ports and a 10 mm port at the subxiphoid location. In classic single-incision laparoscopic surgery, all three working ports are brought to the umbilicus, and a multiport system is used. In the pediatric patient, the various single-port systems are often too large and cumbersome to be feasibly employed. In addition, the decreased intra-abdominal working space leads to increased frequency of instrument and hand collisions without dedicated solutions to increase extracorporeal freedom. For these reasons, modifications used include separate umbilical ports that are then connected for extraction of the specimen and a 50 cm long laparoscope with 90° angled video cord adapter. The technique allows the surgeon to take advantage of single-incision benefits without being limited to a single-product system while freeing up working space for the surgeon’s hands.

Various techniques for single-incision laparoscopic cholecystectomy have been described, including 3-trocar techniques, 3-trocar and a gallbladder stitch, use of curved versus purely straight instruments, and use of an operative laparoscope. Many techniques may add complexity to the case, lead to collisions of the hands, not be easily reproducible by other surgeons, and not be easily performed by residents in a training environment. The technique described here is cost-effective, learned quickly, and easily reproducible and results in no bumping of the hands and relatively short operative times. The technique has been quickly learned and performed by over 150 surgeons and trainees with good success.

Key Steps

  1. 1.

    The patient is placed supine on the operating table.

     
  2. 2.

    Following induction of general anesthesia, the patient is prepped and draped in the usual sterile fashion, and pre-incision local anesthetic is injected.

     
  3. 3.

    A 1.5 cm curvilinear umbilical incision is made along the inferior umbilical stalk.

     
  4. 4.

    A Veress needle is used for insufflation of the abdomen.

     
  5. 5.

    A 5 mm umbilical trocar is placed.

     
  6. 6.

    Inspection of abdominal contents is performed to assure safe entry was achieved and no adhesions or abdominal contents are obstructing entry of a second 5 mm port at the umbilicus. A 50 cm long laparoscope (5 mm, 30°scope) with a right-angle light cord adapter is used to ensure the assistant’s hands are behind and away from the operating surgeon’s hands.

     
  7. 7.

    The second and third umbilical trocars are introduced into the abdomen.

     
  8. 8.

    The trocars are situated at the 10 o’clock, 2 o’clock, and 5 o’clock positions. The depth of each port is adjusted so that the heads are all at different levels, maximizing working degrees of freedom.

     
  9. 9.

    The mini-lap gator which is both a grasper and trocar is inserted into the inferior aspect of the incision and does not require its own trocar.

     
  10. 10.

    The gallbladder is grasped at its dome, twisted 90°, and retracted cephalad toward the patient’s right shoulder.

     
  11. 11.

    The mini-lap is secured to the drapes and covered by a towel so that it is out of the way of the surgeon’s hands.

     
  12. 12.

    A reticulating endograsper is used to grasp the infundibulum of the gallbladder. The handle is reticulated to the patient’s left and handed off to the assistant. The assistant manages the camera and this grasper.

     
  13. 13.

    The operating surgeon performs the dissection of the triangle of Calot. The critical view is identified, and the cystic duct ligated with endoclips and divided.

     
  14. 14.

    The cystic artery is identified, ligated with endoclips and divided.

     
  15. 15.

    The gallbladder is taken off of the cystic plate and the gallbladder fossa.

     
  16. 16.

    Once free, the umbilical port sites are connected using electrocautery, and the specimen is removed via the umbilicus.

     
  17. 17.

    The fascia is closed with figure-of-eight stitches, and the skin closed using monofilament suture.

     

“2×2” Laparoscopic Cholecystectomy: Scarless Surgery in Children

Ponsky et al. have evolved their thinking with regard to minimally invasive techniques applied to gallbladder surgery and currently endorse a mixed single-incision and needlescopic approach in the pediatric patient, which they call the “2×2” technique. This technique aims to adhere to the principles set forth by single-incision pioneers while improving the safety and working mechanics of cholecystectomy. In the pediatric population, the technical difficulties of four instruments sited at the umbilicus are formidable. While the procedure has been performed safely for several years, the amount of infundibular and dome retraction is limited given the physics of a central fulcrum. The difficulties of gaining adequate exposure and retraction without the instruments contesting each other, given the space constraints of a pediatric patient, have been a driving force leading to nominal adoption of this technique.

Needlescopic surgery is technically defined as minimally invasive surgery with instruments that are 3 mm in diameter or less, sometimes also referred to as minilaparoscopy. Over time, 3 mm incisions tend to be nearly invisible and have significant cosmetic benefits over 5 mm incisions. Moving from 10 to 5 mm incisions decreases the risk of herniation due to the physics of incision strength, but moving from 5 to 3 mm incisions decreases scars from noticeable to practically invisible. Gagner and Garcia-Ruiz described a series of 60 needlescopic cholecystectomies and showed improved postoperative analgesia and cosmesis over standard laparoscopy (Gagner and Garcia-Ruiz 1998). The “2×2” hybrid technique adopted and further modified these techniques to make them applicable to infants and children; the steps of the procedure are outlined below. Of note, a 50 cm long camera with an angled light cord adapter is utilized, as well as an access insertion needle built into 3 mm instruments that allow for trocar-less insertion of our alligator graspers. The alligator graspers are curved, allowing them to be far left of the working space, even in pediatric patients. The “2×2” hybrid technique combines the triangulation advantages of standard laparoscopic techniques with the cosmetic benefits of single-incision techniques. The result is essentially scarless surgery and a clear sphere of working space for safe removal of the gallbladder.

Key Steps

  1. 1.

    The patient is placed supine on the operating table.

     
  2. 2.

    Following induction of general anesthesia, the patient is prepped and draped in the usual sterile fashion, and injection of pre-incision local anesthetic is performed.

     
  3. 3.

    A curvilinear umbilical incision is used along the inferior umbilical stalk.

     
  4. 4.

    A Veress needle is used for insufflation of the abdomen.

     
  5. 5.

    A 5 mm umbilical trocar is placed.

     
  6. 6.

    Inspection of abdominal contents is performed to assure safe entry was achieved, and no adhesions or abdominal contents are obstructing entry of a second 5 mm port at the umbilicus. A 50 cm long laparoscope (5 mm, 30°) with a right-angle (90°) light cord adapter.

     
  7. 7.

    A second 5 mm umbilical trocar is placed.

     
  8. 8.

    A 2 mm stab incision in the right hemiabdomen, two fingerbreadths below the costal margin and at dome of the gallbladder, is made, and a 3 mm straight alligator grasper is inserted under direct visualization. This grasper is used to retract the dome of the gallbladder cephalad toward the patient’s right shoulder.

     
  9. 9.

    A second 2 mm stab incision in the inferior-lateral position is made, and a second 3 mm alligator grasper is introduced into the abdomen under direct visualization. This grasper is used to retract the infundibulum of the gallbladder laterally.

     
  10. 10.

    Dissection of Calot’s triangle is accomplished via the umbilical port with identification of the cystic duct and artery. The critical view of safety can be seen clearly using this technique.

     
  11. 11.

    A ductotomy can be performed for intraoperative cholangiogram via the umbilical port, and an additional port or incision is not needed.

     
  12. 12.

    The gallbladder is dissected off of the cystic plate using electrocautery.

     
  13. 13.

    Before removing the gallbladder completely, the gallbladder fossa is inspected for bleeding or biliary leak, and the clips are inspected to ensure they are secured.

     
  14. 14.

    The last attachments between the gallbladder and cystic bed are ligated.

     
  15. 15.

    Before extraction of the gallbladder, the two 5 mm umbilical port sites are connected to form one incision.

     
  16. 16.

    The fascia of the umbilical incision is closed with a figure-of-eight stitch, and all skin incisions are closed using monofilament subcutaneous stitches.

     

Single-Incision Laparoscopic Gastrostomy: Utilizing an Operative Hysteroscope

Numerous methods are published for placement of a gastrostomy tube, including open Stamm gastrostomy, open Janeway gastrostomy, percutaneous endoscopic gastrostomy (PEG), laparoscopic gastrostomy, and radiologically guided gastrostomy. PEG tube placement is the standard technique utilized in children; however, PEG requires blind placement of the tube through the peritoneal cavity. The maneuver creates opportunity for injury to the surrounding viscera that could be avoided using techniques that allow for direct visualization. Furthermore, in children and infants with severe micrognathia, foregut anomalies, macroglossia, or prior abdominal surgeries, PEG placement may be difficult to perform. In these situations, most surgeons default to an open gastrostomy with gastropexy or to a standard three- to four-port laparoscopic technique. A minimally invasive approach is to perform a single-incision laparoscopic technique utilizing an operative laparoscope. The procedure can be performed quickly and safely and has a very short learning curve. The procedure is also applicable to adults and has been used successfully on patients of all ages and body habitus.

In infants, a 4 mm Storz operative hysteroscope, which comes with a 3 mm, zero-degree camera and two working ports, can be utilized. Wire instruments can be inserted into the working channel and a biopsy forceps used for this procedure. The external diameter of the scope is 5 mm, which easily fits down a 5 mm trocar.

Key Steps

  1. 1.

    The patient is placed supine on the operating table.

     
  2. 2.

    Following induction of anesthesia, the patient is prepped and draped in the usual sterile fashion, and injection of pre-incision local anesthetic is performed at the site deemed suitable for gastrostomy, usually just below the costal margin, midclavicular line.

     
  3. 3.

    A 5 mm stab incision is created at this site.

     
  4. 4.

    A Veress needle is inserted, and the abdomen is insufflated.

     
  5. 5.

    A 5 mm short step trocar is placed.

     
  6. 6.

    The operative laparoscope is inserted. Because the scope occupies the entire channel of the trocar, the CO2 insufflation is moved to the operative hysteroscope.

     
  7. 7.

    The stomach is visualized and is inflated and deflated via the patient’s nasogastric tube (NGT) by anesthesia to confirm the anatomy.

     
  8. 8.

    The stomach is grasped on the greater curvature.

     
  9. 9.

    The abdomen is desufflated, and the stomach is pulled up through the incision site.

     
  10. 10.

    The stomach is grasped using an Adson forceps or a hemostat.

     
  11. 11.

    A stay suture is placed to maintain traction on the stomach.

     
  12. 12.

    A purse-string suture is placed.

     
  13. 13.

    Lateral and then medial fascial-gastric stitches are placed.

     
  14. 14.

    Inferior and superior fascial-gastric stitches are placed.

     
  15. 15.

    A needle is placed through the middle of the purse-string.

     
  16. 16.

    Electrocautery is used over the needle to create the gastrotomy.

     
  17. 17.

    The gastrotomy is dilated by a hemostat.

     
  18. 18.

    The button is placed using the Veress needle as an obturator.

     
  19. 19.

    A 3–5 cc of sterile water is instilled into the balloon.

     
  20. 20.

    Betadine solution is injected through the button and is aspirated via the NGT by anesthesia to confirm intragastric placement of the button.

     
  21. 21.

    The sutures are tied down.

     
  22. 22.

    The button is secured with steri-strips, serving a dual function of decreasing the chance of button dislodgement, as well as increasing granulation tissue formation by decreasing button movement.

     

Appendectomy

Standard laparoscopic appendectomy is performed with a 10 mm umbilical port for the laparoscope and introduction of the stapler with two 5 mm working ports. The two additional ports are classically super-pubic and left lower quadrant, with additional ports added as needed. The ligation of the appendiceal vessels and the appendix is performed intra-abdominally using laparoscopic staplers, and the specimen is extracted through the umbilicus, usually with a collection bag. The size of the umbilical port is limited by the need for a 10–12 mm port for introduction of a stapler device.

Single-port appendectomy is performed according to one of two conceptual techniques: intracorporeal versus extracorporeal ligation of the appendiceal stump. The intracorporeal technique follows the exact same steps as standard laparoscopic appendectomy but utilizes a single-port system. Extracorporeal ligation has been performed on pediatric patients of all sizes, including obese patients. In this approach, the appendix is identified and brought up to the umbilical incision using a 5 mm laparoscope and 3 mm instrument, both introduced through the umbilicus. The appendix is ligated and returned to the abdomen as in the classic open appendectomy performed through a right lower quadrant incision. The technique utilizes the benefits of laparoscopic visualization and umbilical entry but obviates the need for additional laparoscopic working ports and a 10–12 mm umbilical port. The technique is well established and has been tested in a randomized controlled trial by St. Peter and colleagues (2011). The single-incision appendectomy approach was shown to have no difference regarding morbidity and mortality outcomes with some question of increased costs when compared to standard laparoscopy likely related to equipment charges. Importantly, there was no increased risk of surgical site infection with the single-site technique.

Key Steps

  1. 1.

    The patient is placed supine on the operating table (hands tucked or along the patient’s side, based on size).

     
  2. 2.

    Following induction of general anesthesia, the patient is prepped and draped in the usual sterile fashion, and injection of pre-incision local anesthetic is performed.

     
  3. 3.

    A curvilinear umbilical incision is used along the inferior umbilical stalk.

     
  4. 4.

    A Veress needle is used for insufflation of the abdomen.

     
  5. 5.

    A 5 mm umbilical trocar is placed.

     
  6. 6.

    Inspection of abdominal contents is performed to assure safe entry was achieved, and diagnosis is confirmed.

     
  7. 7.

    The patient is rotated left and put in Trendelenburg.

     
  8. 8.

    A 3 mm trocar-less bowel grasper is introduced directly into the abdomen immediately inferior to the umbilical trocar along the midline and within the same skin incision.

     
  9. 9.

    The appendix is grasped, elevated, and brought to the umbilical port site.

     
  10. 10.

    The abdomen is desufflated, and a hemostat is placed on the appendix.

     
  11. 11.

    The appendix is fully elevated out of the umbilical port, and clamps and scissors are used to take the appendiceal vessels which are tied in bulk.

     
  12. 12.

    The base of the appendix is identified and suture ligated.

     
  13. 13.

    The cecum is returned to the abdomen, the trocar replaced, and the abdomen inspected once more.

     
  14. 14.

    The umbilical port site is closed with a figure-of-eight stitch in the fascia and subcutaneous monofilament suture for the skin.

     

Natural Orifice Endoluminal Surgery (NOTES)

In the past decade, many centers have gone a step further than single-incision surgery and have started to perform “incisionless surgery.” With the development of natural orifice transluminal endoscopic surgery (NOTES), surgeons have found a way to utilize the endoscope to perform surgery without any incisions in the abdominal wall. With the use of multichannel endoscopes, the peritoneal or thoracic cavity is accessed through a natural orifice – the mouth, vagina, urethra, or anus, and then, by passing instruments through the working channels, basic procedures can be performed.

In the adult literature, this technique has been described in the literature for numerous surgical procedures including appendectomies and cholecystectomies and recently even a transanal NOTES total mesorectal excision with retroperitoneal sigmoid mobilization and coloanal side-to-end anastomosis (Leroy et al. 2013).

Although NOTES has not won overwhelming support throughout the pediatric surgery community, the technique has been applied successfully in some specific instances. A recent report by Velhote et al. described combining a NOTES technique with transanal endorectal pull-through (TAEPT) surgery for a patient with Hirschsprung’s disease (Velhote and Velhote 2009). This alleviated the need for the abdominal incision that is usually required to mobilize the sigmoid safely.

Transoral incisionless fundoplication (TIF) has been used as an alternative to the standard surgical treatment of laparoscopic Nissen fundoplication for gastroesophageal reflux disease (GERD). This minimally invasive technique shows promise in treating patients who are neurologically impaired or perhaps requiring a re-operative procedure due to failure of their fundoplication. A special designed endoscopic device is inserted transorally, full-thickness plications are created, and then fasteners are placed approximately 270° around the gastroesophageal junction (Cadière et al. 2008a, b). In adults, the recently reported 3-year results of a multicenter prospective study of TIF recently showed long-term safety and durability of the procedure (Muls et al. 2013).

Surgeons are doing “hybrid NOTES” procedures – techniques combining NOTES with laparoscopy or needlescopic surgery to perform basic procedures within the peritoneal cavity (Shih et al. 2007). Improved retraction in NOTES procedures has been described with the use of noninvasive techniques, such as with magnets. The magnetic anchoring and guidance system has been used for visceral retraction and manipulating the telescope in single-site surgery (Dominguez et al. 2009; Park et al. 2007; Padilla et al. 2011). This technology uses magnetic intracorporeal graspers and an extracorporeal magnet that is manipulated over the abdominal wall to adjust and control the instruments and has been used to perform single-site (Dominguez et al. 2009) and transvaginal NOTES cholecystectomy in adults (Scott et al. 2007). Recently, initial experience using these magnetic instruments to perform appendectomy in a pediatric population was published.

Of 23 patients who underwent this procedure, there were no conversions to an open procedure, and just four cases required an additional 5 mm trocar placed. The authors note that magnetic instruments provide excellent triangulation, improve the ergonomics of single trocar surgery, and can be used to perform single-site surgery without the aid of a surgical assistant (Padilla et al. 2013). The current authors are using an animal model to develop a new technique using hybrid NOTES to repair esophageal atresia.

Although NOTES has developed relatively quickly, continued investigation with long-term results will be required to determine whether it will be a technique that provides improved care and outcomes to patients. It is difficult to assess and remains to be seen if the risk of creating an intentional visceral injury is worth the cosmetic benefit of incisionless surgery (Mintz et al. 2008; Pearl and Ponsky 2008).

Other Innovations

Robotic Surgery

When robotic surgery was first introduced, it was with great expectations that it would change the way surgeons operate. Robotic surgery uses the basic techniques of laparoscopic surgery; however, these techniques are used through robotic arms, which are designed to mimic more accurately the motion and dexterity of human hands. The operating surgeon sits at a remote console and uses a 3D viewer to direct the robot through hand and finger controls. Because of its significant cost, widespread use of robotic surgery is limited. The first robotic surgical procedure in a child was a Nissen fundoplication in 2000 (Meininger et al. 2001), and the first robotic urological procedure was performed in 2002 (Lee et al. 2006; Peters 2004).

There have been reports of pediatric procedures performed with the assistance of robotics. Albassam et al. reported on 50 children who were in need of Nissen fundoplication. Twenty-five children had the procedure performed in the standard laparoscopic method, while the other 25 underwent robotic Nissen fundoplication. The results showed no significant differences in postoperative complication rates, postoperative analgesic requirements, or lengths of hospital stay between the groups. They concluded that robotic surgery is feasible and safe but, given the significant cost, should be limited to specific cases. With further investigation, robotic surgery may allow operations on neonates who at one time were thought to be too small to undergo laparoscopic surgery.

A recent systematic review was conducted looking at all reported cases of robotic surgery in the literature from the first reported case in 2001 to 2012 (Cundy et al. 2013). One hundred thirty-seven articles were included in the review, reporting 2,393 procedures in 1,840 patients. The most common gastrointestinal, genitourinary, and thoracic procedures performed were fundoplication, pyeloplasty, and lobectomy, respectively. There was an obvious trend of increasing number of publications over the period reviewed. The net overall reported conversion rate was 2.5 % and the rate of reported robot malfunctions or failures was low at just 0.5 %. There were however no RCTs for inclusion in the study, and the authors conclude that future evolution and evaluation should occur simultaneously so that wider uptake may be led by higher quality and level of evidence (Cundy et al. 2013).

Technical Benefits of Robotic Surgery

The advocates of robotic MIS systems claim many inherent useful feature magnification (up to 10×), stereoscopic vision, operator-controlled camera movement, and the elimination of the fulcrum effect when compared to conventional laparoscopy (Bruns et al. 2015). The wristed laparoscopic instruments used in robotic surgery provide seven degrees of freedom. For the surgeon, these features may allow for more precise dissection with increased magnification and visibility. The intuitive controls of the robot are purported as providing the ability to perform laparoscopic procedures in an “open” fashion. In pediatric surgical procedures, these technical abilities may have the potential to surpass the physical capabilities of human performance in the tight operative fields encountered in children (Bruns et al. 2015).

Technical Limitations of Robotic Surgery

Many of the most c hallenging and complex procedures, where robotic MIS may hold the most potential, are performed in newborns. It might be assumed that the surgical robot would be very useful in the small operative spaces encountered in pediatrics. However, its technical requirements can make it cumbersome or not feasible for smaller patients. The manufacturer of the da Vinci surgical robot recommends an 8 cm distance between each port, which is difficult if not impossible to achieve in many neonatal cases. The size and length of the instruments can also be an issue. Neonatal surgical procedures are often performed with 3 mm instruments and endoscopes, which are smaller than the smallest instruments and endoscopes available currently for robotic surgery.

Currently, there are two endoscopes available for the da Vinci Surgical System: 12 mm 3D and 8.5 mm 3D scope. The 8.5 mm scope may be more versatile for smaller children, but it is still large for the intercostal space of a small child (Meehan 2013).

Instruments are available in two sizes: 8 and 5 mm. The 8 mm instruments articulate with a pitch-roll-yaw mechanism, whereas the 5 mm instruments articulate in a snakelike manner (Berlinger 2006).

The difference in articulation results in the 5 mm instruments being longer than their 8 mm counterparts, losing workspace within a small body cavity. For infants and toddlers, 3 mm instruments are routinely used for many basic and advanced laparoscopic procedures. The lack of commercially available 3 mm instruments is a significant limitation of the current robotic surgical platforms and a disincentive for their use in small children. There are a limited number of instruments from which to choose; there are forty 8 mm instruments and twelve 5 mm instruments. For many pediatric surgeons, creating the smallest possible incision is a major advantage of laparoscopic procedures. The absence of 3 mm and the few options for 5 mm instruments may limit the use of the robots in infants and toddlers.

Patient Benefits of Robotic Surgery

The patient benefits of robotic surgery are thought to be essentially the same as conventional laparoscopy: decreased length of stay, decreased blood loss, decreased pain, quicker return to work, and improved cosmetic result through smaller incisions (Mattei 2007). In pediatric urology, there is evidence that robot-assisted pyeloplasty may be superior to open and laparoscopic approach with decreased length of stay, decreased narcotic use, and decreased operative times (Lee et al. 2006; Yee et al. 2006). In an analysis of the Nationwide Inpatient Sample that compared robotic to laparoscopic and open surgery, among most procedure types, there was a significant decrease in the length of stay and likelihood of mortality for the robotic surgery group when compared to the open and conventional laparoscopic surgery groups (Anderson et al. 2012).

However, the effect was significantly diminished when comparing robotic to laparoscopic surgery alone. In the robotic surgery group, the length of stay was 0.6 days shorter with increased charges of $1,300 (Meehan 2013). A recent RCT in adults comparing open to robotic surgery showed no difference between the groups in terms of complication rate and length of hospital stay for radical prostatectomy (Bochner et al. 2014). There was a significant difference in operative time: the open group was 2 h shorter. These findings suggest some potential benefits to robotic surgery, but additional study is needed to verify the benefits, especially with respect to laparoscopic surgery. There are no RCTs in the pediatric population.

Costs

Robotic surgery has higher costs than open and laparoscopic procedures. This is due to the high costs of purchasing and maintaining a robot, increased operative time, and costs of disposable surgical supplies (Geller and Matthews 2013). In a retrospective analysis of 368,239 patients from the Nationwide Inpatient Sample database, there was an increase in total charges of $1,309 per robotic-assisted case (Anderson et al. 2012). The da Vinci Surgical Systems typically cost between $1.0 and $2.3 million and require an additional maintenance contract of $100,000–$170,000 per year in addition to variable disposable instrument costs. In the US medical system of reimbursement, these extra costs may result in robotic procedures being financially unfeasible given the slim operating margins (<1 %) on patient care of most US hospitals.

Safety

The overall reported conversion-to-open-procedure rate is low. It has been reported as 2.5% in a meta-analysis of robotic pediatric surgery (Cundy et al. 2013). When broken into subgroups, it was 3.9%, 1.3%, and 10% in gastrointestinal, genitourinary, and thoracic cases, respectively (Cundy et al. 2013). This is comparable to the conversion rate in conventional pediatric minimally invasive surgery (Adikibi et al. 2012). However, the real conversion rate for robotic pediatric surgery may be higher due to citation bias. There has been evidence of underreporting of complications following robotic surgery in both the media and medical literature. Over a 12-year period, a review that cross-referenced device-related complication databases with the FDA revealed eight cases that were either unreported or incorrectly reported (Cooper et al. 2015). This is especially concerning because the true incidence of device-related complication is unknown.

Learning Curve

Laparoscopy has been adopted for advantages that include decreased adhesion formation, improved cosmesis, decreased postoperative pain, and shorter recovery times (Mattei 2007). A skilled laparoscopic surgeon may see no additional benefit when compared to robotic surgery. In a study comparing novice and expert surgeons that completed tasks on laparoscopic and robotic simulators, there was a significant improvement in speed and smoothness of performance in the novice group when using the robot that was not replicated in the expert group (Chandra et al. 2010). This suggests that the novice laparoscopist may realize the greatest benefit of robotic surgery. There is evidence that a learning curve is encountered when adopting robotic surgery as demonstrated by decreasing operative times as case volumes increased. This learning curve may be more difficult to surpass for the most complex neonatal congenital surgical cases such as tracheoesophageal fistula repair where even the busiest pediatric surgeons do only a handful of such cases per year due to the low incidence of the condition.

Future

Over time, there are more higher-level-of-evidence studies being completed in the area of pediatric robotic surgery (Cundy et al. 2013). The largest RCT completed, to date, showed no benefit for robotic surgery for radical prostatectomy (Bochner et al. 2014). However, there is a need for additional randomized trials comparing robot-assisted surgery to open or traditional laparoscopic surgery. In a survey of 117 pediatric surgeons, the majority felt that robotic surgery has a future role, although over 80% of respondents had no personal experience with robotic surgery (Jones and Cohen 2008). Robotic surgery has established itself in the adult population, but due to technical and financial limitations specific to pediatrics, it may be some time before we see the same popularity in pediatric surgery.

Telemedicine

The advances in telecommunication over the last century have enabled us to overcome our logistical constraints and communicate with others over any distance. In surgery, new technologies have made possible long-distance mentoring, proctoring/teaching, consultation, and even remote procedures. The term “telemedicine” is an umbrella term for the use of audiovisual technology to facilitate patient care, administration, or education related to the field of medicine (Tsuda 2012). There are many different subcategories of telemedicine but there are a number which have important and exciting applications to surgery, namely, teleproctoring, telementoring, teleeducation, and telesurgery (Rosser et al. 2007).

Teleproctoring is the term applied to the use of audiovisual technology at any distance to conduct examinations or certifications between proctors and students, while telementoring applies the same technology to provide mentoring or teaching (Tichansky et al. 2012; Tsuda 2012). An example of telementoring is an expert pediatric laparoscopic surgeon in the USA, using videolink to guide a less experienced surgeon in another country, through a single-incision cholecystectomy. However, while great advances have been made in technology and surgical technique, there is still a lag behind in skills transfer. In other words, the optimal method for surgeons with advanced technical skills such as MIS to teach others their unique skill has yet to be identified. The technology is available to support the development of telementoring; however, medicolegal and financial constraints have slowed progress. There has been recent collaboration between surgeons, medical device companies, and legal teams to address the existing constraints and move toward making telementoring a reality.

The Internet has enabled the development of surgical teleeducation through live telesymposia, during which surgeons from around the world discuss, learn, and share ideas on current topics in their field of interest. These telesymposia have allowed surgeons to circumvent the geographic or financial barriers to education that they would otherwise have faced. The authors have conducted many virtual symposiums, mainly in the field of pediatric surgery in which surgeons and allied professionals discuss contemporary management of complex diseases. Well over 1,000 pediatric surgeons typically join each symposium, making this one of the largest avenues for surgical education in existence.

The term telesurgery is given to the act of actually operating on a patient from a distance, usually through robotic technology. One of the first demonstrations of this was by Marescaux et al. when they performed a robotic-assisted laparoscopic cholecystectomy on a 68-year-old woman in Strasbourg, France, while sitting at a console in New York (Marescaux et al. 2002). Even using the high-speed connection of the time, which seems somewhat slow and antiquated to us now, the operation was a performed in 54 min (Marescaux et al. 2002).

The most obvious application of telemedicine is allowing access to expert consultation where none is available. Previous barriers to expert surgical treatment, such as geographic constraints, or limited surgical expertise no longer have to limit patients’ choices. Through the use of new technology, a patient can receive the best operation for their condition, such as new minimally invasive technique. The potential implications of this on healthcare in developing countries are exciting, where healthcare is often provided by volunteers who are generalists, lacking expertise in many areas of medicine and surgery.

As MIS techniques continue to develop rapidly, surgical trainees’ work hours are limited, and patients demand the highest quality of healthcare, there will continue to be an expanding role for teleproctoring, telementoring, teleeducation, and telesurgery.

Gastric Stimulators

Gastroparesis is a disorder defined by symptoms and evidence of gastric retention or delayed gastric emptying in the absence of any structural or mechanical obstruction (Parkman et al. 2004; Park and Camilleri 2006). This disorder can be caused by either impaired motor activity or impaired myoelectrical activity. Standard therapies used to treat gastroparesis are dietary modifications, and medications to increase gastric contractility thereby accelerate gastric emptying. Some patients however do not get symptom relief from dietary modifications and prokinetic therapy and are termed drug refractory (Forster et al. 2001).

A new technology that is gaining popularity is the use of gastric electrostimulation (GES) to treat this drug refractory gastroparesis. It has been shown that high-frequency, low-energy gastric stimulation is an effective treatment for gastroparesis (Abell et al. 2002), and in an adult population, that short-term placement of an electrode with GES is predictive of long-term response to GES (Islam et al. 2008; Hyman et al. 2009; Ayinala et al. 2005). The electrical stimulator device is implanted in the abdominal wall and then connected to the stomach by wires. It is unclear exactly how the stimulator relieves symptoms, but many believe it is due to improved receptive relaxation of the stomach, or improved gastric motility. Some institutions first perform endoscopic temporary stimulation for several weeks to assess symptomatic relief prior to surgically implanting the permanent device.

Conclusion and Future Directions

The numerous MIS techniques discussed above, originally used in the adult population, have been successfully applied to our pediatric patients. MIS has become routine for the treatment of many pediatric surgical disease processes, due to the numerous benefits these techniques confer on the patient: decreased wound complications, shorter length of stay, and improved postoperative pain. Inherent in the application of these complex techniques to infants and children are many risks due to the size of these patients. Pediatric surgeons must be aware and understand these risks if they are to successfully and safely practice MIS.

MIS will continue to develop as long as industry is committed to developing pediatric equipment to provide better care for our patients. Surgical training must continue to evolve, to ensure that the next generation of surgeons is adequately trained in these complex techniques. The future of pediatric MIS is exciting for our patients and indeed the specialty of pediatric surgery.

Cross-References

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Copyright information

© Springer-Verlag GmbH Germany 2016

Authors and Affiliations

  1. 1.Division of Pediatric SurgeryAkron Children’s HospitalAkronUSA
  2. 2.Division of Pediatric SurgeryMiami Children’s HospitalMiamiUSA

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