Minimally invasive pediatric surgery: Increasing implementation in daily practice and resident’s training

Background In 1998, the one-year experience in minimally invasive abdominal surgery in children at a pediatric training center was assessed. Seven years later, we determined the current status of pediatric minimally invasive surgery in daily practice and surgical training. Methods A retrospective review was undertaken of all children with intra-abdominal operations performed between 1 January 2005 and 31 December 2005. Results The type of operations performed ranged from common interventions to demanding laparoscopic procedures. 81% of all abdominal procedures were performed laparoscopically, with a complication rate stable at 6.9%, and conversion rate decreasing from 10% to 7.4%, compared to 1998. There were six new advanced laparoscopic procedures performed in 2005 as compared to 1998. The children in the open operated group were significantly smaller and younger than in the laparoscopic group (p < 0.001 and p = 0.001, respectively). The majority (64.2%) of the laparoscopic procedures were performed by a trainee. There was no difference in the operating times of open versus laparoscopic surgery, or of procedures performed by trainees versus staff surgeons. Laparoscopy by trainees did not have a negative impact on complication or conversion rates. Conclusions Laparoscopy is an established approach in abdominal procedures in children, and does not hamper surgical training.     

微创肿瘤手术临床研究结果的启示与思考:如何提高微创外科手术的质量控制

以腹腔镜微创技术为代表的肿瘤微创外科发展已近30年。尽管手术技术及操作流程不断进步,但近来的临床研究结果显示:微创手术在部分恶性肿瘤中的肿瘤学疗效仍有争议。无论真相如何,手术的质量控制至关重要。严格把握手术指征,为肿瘤患者提供最合适的治疗方式有助于手术质量控制与风险降低。通过构建系统化培训体系,规范微创手术操作可保证肿瘤微创手术的质量。针对新兴微创手术技术,以严谨、审慎的态度加以开展,对于手术质量控制尤为重要。在微创外科高度发展的今天,除继续"保持速度",还应更好地"保证质量"才能使微创手术给更多的肿瘤患者带来获益。     

Neonatal laparoscopy

Until recently minimally invastive surgery was not performed in neonates. This was because of their small size and distinct physiological characteristics, neonates were not operated on using minimally invasive surgery until recently. Since the introduction of fine laparoscopic instruments, improvements in the surgical techniques and anaesthetic adjustments for laparoscopy, more complex operations are now being performed in neonates. While certain operations such as laparoscopic pyloromyotomy have become routine in many centres, some others require significant infrastructure and experience. Advantages of minimally invasive surgery seen in older children and adults, such as shortened hospital stay and less pain, also apply to neonates. There is no doubt that minimally invasive surgery for neonates is still in its infancy, and for many neonatal conditions requiring surgery, the benefits of minimally invasive surgery need to be established with well-designed studies.     

Robot-Assisted Cardiac Surgery

Recognition of the significant advantages of minimizing surgical trauma has resulted in the development of minimally invasive surgical procedures. Endoscopic surgery offers patients the benefits of minimally invasive surgery, and surgical robots have enhanced the ability and precision of surgeons. Consequently, technological advances have facilitated totally endoscopic robotic cardiac surgery, which has allowed surgeons to operate endoscopically rather than through a median sternotomy during cardiac surgery. Thus, repairs for structural heart conditions, including mitral valve plasty, atrial septal defect closure, multivessel minimally invasive direct coronary artery bypass grafting (MIDCAB), and totally endoscopic coronary artery bypass graft surgery (CABG), can be totally endoscopic. Robot-assisted cardiac surgery as minimally invasive cardiac surgery is reviewed.     

Minimally invasive surgery in the management of abdominal tumors in children

The application of minimally invasive surgical techniques to pediatric abdominal tumors is a controversial application towards the surgical management of childhood cancer. Although general pediatric surgeons practice minimally invasive surgery techniques in a vast array of abdominal cases, its role in pediatric oncology is still developing, with no consensus in North America about its use for pediatric solid abdominal tumors. The purposes of this article are to review the current literature about the use of minimally invasive surgery in pediatric abdominal oncology and to examine established indications, procedures and technologic advances.     

Traumareduktion durch MIC aus der Sicht der Kinderchirurgie

Reduced insufflation pressure during laparoscopy in pediatric surgery can contribute considerably to reducing postoperative pain. Technical innovations in high-grade instruments and thin optics have led to increased diversification of minimally invasive surgery and reduced the strain on patients. The minimally invasive approach is particularly advantageous when the large surgical approaches of conventional procedures can be avoided. The reduction of postoperative adhesions with minimally invasive surgery is a very important factor. The tendency toward decreased infections of surgical wounds is beneficial as well as the improved cosmetic results. The duration of hospital stays and need for analgesics in pediatric surgery have not evidenced any significant differences from conventional procedures. In cases of larger intra-abdominal interventions, it becomes apparent that these small patients can receive oral alimentation at an earlier time.     

Minimally invasive pediatric nephrectomy

PURPOSE OF REVIEW: Since the first laparoscopic pediatric nephrectomy was performed in 1992, many articles have reported the feasibility of minimally invasive nephrectomy, heminephrectomy, and nephroureterectomy in children. This article reviews the literature related to minimally invasive nephrectomy, including robot-assisted surgery, and its complications published between November 2002 and November 2004. RECENT FINDINGS: The retroperitoneoscopic approach to nephrectomy and nephroureterectomy continues to prove successful in the pediatric population, although the transperitoneal approach is beneficial in combined upper and lower tract procedures. Initial reports on bilateral transperitoneal nephrectomy for nephrotic syndrome and laparoscopic nephrectomy for Wilms tumor are presented. Comparison studies between laparoscopic nephrectomy and open procedures are reviewed. Robot-assisted procedures are possible in children but little information is available on their pediatric use at the present time. Laparoscopy in children appears to have a similar complication rate to that in adults. SUMMARY: More studies are needed to compare the outcomes of minimally invasive procedures with those of open procedures. Robot-assisted surgery offers promise but expense currently limits its use.     

Transoral diverticulostomy with a modified Endo-Gia stapler: results after 4 years of experience

Background The incidence of Zenker’s diverticulum is low (2/100,000). Standard surgical treatment is cricopharyngeal myotomy with diverticulectomy. Various minimally invasive surgical approaches pursued recently have treated Zenker’s diverticulum adequately. The functional minimally invasive therapy is performed alternatively using an Endo-Gia stapler inserted transorally to perform an esophageal diverticulostomia, or using thermal coagulation applied by a carbon dioxide (CO₂) or argon plasma laser. The key to a successful procedure is adequate exposure of the diverticulum by insertion of a pharynx spreader before the surgery. Methods Since 1996, 31 patients who underwent minimally invasive diverticulostomies performed in our clinic have been included prospectively in the current study. All the patients were examined endoscopically before and after surgery. Furthermore, the intraesophageal and intragastric pressure was examined by transesophageal manometry, and the pH in the esophagus and stomach was determined by pH-metry. A barium swallow was performed to exclude leakage at the stapler suture line as proof of sufficient anastomoses. Manometry showed that the upper esophageal sphincter functioned normally before and after surgery. The results were compared with those of patients undergoing conventional procedures. Results The median follow-up period after resection of the diverticulum was 46 months. Both the Gastrointestinal Quality-of-Life Index (GQLI) (p < 0.001) and the modified dysphagia score (GHDS) increased significantly, indicating that the operations were successful. The minimally invasive procedure is faster than cricopharyngeal myotomy and significantly safer. It is better tolerated by patients, and they are discharged earlier. Conclusion Transoral esophagodiverticulosomy has become the standard procedure for Zenker’s diverticulum in the authors’ department. The endoscopic minimally invasive approach proved to be safer than standard surgical procedures. It offers a significantly shorter operation time and postoperative hospital stay (p < 0.001). An erratum to this article can be found at     

Computer-assisted laparoscopic splenectomy with the da Vinci surgical robot

Laparoscopic splenectomy has become the standard of care for the surgical treatment of idiopathic thrombocytopenic purpura (ITP). The minimally invasive approach to splenic disorders such as ITP clearly results in the same benefits to the patients as have been demonstrated with the laparoscopic cholecystectomy techniques. New technologies in minimally invasive surgery have resulted in the development of robotic devises that assist the surgeon during the procedures. Robotic surgery is in its infancy at this point in time. Herein, we report a splenectomy performed with the assistance of the da Vinci surgical robot. With advancement of technology, robotic systems will play an integral role in future minimally invasive surgery.     

Single-site versus conventional laparoscopic appendectomy: comparison of short-term operative outcomes

Background  

Recent developments in minimally invasive surgery have introduced scarless surgeries such as natural orifice transluminal endoscopic surgery (NOTES) and single-site laparoscopic surgery. Among surgical procedures, the appendectomy is one of those targeted for early adoption of new minimally invasive surgical techniques. To date, however, only a limited number of case series have been reported. Thus, the current study aimed to evaluate the safety and feasibility of single-site laparoscopic appendectomy (SSLA) compared with conventional laparoscopic appendectomy (CLA).     

Anaesthesia for minimally invasive surgery in children

There continues to be an increase in the applications of minimally invasive surgical techniques in infants and children. This increase includes their use for new surgical procedures as well as their application in younger patients including neonates. As with any new surgical procedure, specific modifications of the anaesthetic technique may be necessary. This chapter reviews (1) the pre-operative evaluation of infants and children scheduled for minimally invasive surgery; (2) techniques for pre-medication and anaesthetic induction; (3) intra-operative anaesthetic implications of laparoscopy, including the cardiorespiratory consequences of CO2 pneumoperitoneum; (4) intra-operative anaesthetic implications of thoracoscopy, including techniques for one-lung ventilation (OLV); and (5) post-operative issues, including pain management and monitoring of cardiorespiratory function as they apply to the patient of paediatric age.     

微创外科技术在中央型肺癌治疗中的应用

微创手术有助于减少手术创伤和疼痛,帮助患者康复,改善生活质量。包括胸腔镜和机器人在内的微创肺切除术目前主要用于早期周围型肺癌的外科治疗,中央型肺癌由于肿瘤位置、淋巴结转移和治疗模式等原因,手术难度较大、技术要求较高,尤其是袖状切除术和全肺切除术,大多需要开胸手术切除。随着微创手术技术的不断进步,近年来临床上开始尝试将其应用于中央型肺癌的外科治疗,其可行性和安全性已得到初步结果证明,代表了微创胸肺癌外科的发展方向。但仍需要更多研究结果证实其功能优越性和肿瘤学效果,让更多肺癌患者从外科技术的进步中获益。     

Minimally invasive cardiac surgery

Cardiac surgery has been the last of the surgical specialties to embrace the principles of minimal invasiveness. The complexity and invasiveness of the procedures have presented both a problem and an opportunity to make the procedures less invasive. Beginning with initial attempts at coronary artery bypass surgery through limited access with and without robotics, a number of other cardiac procedures currently are being performed by minimally invasive approaches. These include mitral valve repair, transapical aortic valve implant, limited access, and totally endoscopic pulmonary vein isolation for the treatment of atrial fibrillation and the treatment of aortic aneurysmal disease by thoracic endografting. The experience with less invasive surgery in other specialties has served as cross-fertilization for minimally invasive cardiac surgery.     

Traumareduktion durch minimal invasive Chirurgie

Minimally invasive surgery has become a viable alternative to conventional surgery. The technical advantages of minimally invasive surgery can be translated into clinical benefits for the patients, i.e., less postoperative pain and impairment of lung function, better cosmetic results, shorter hospitalization, and earlier convalescence. Laparoscopic operations have replaced a significant proportion of open surgical procedures and are now routinely used. While the role of laparoscopic surgery has been generally accepted for the management of benign disorders, there is ongoing debate regarding the adequacy of this technique in surgical oncology. There is evidence that minimally invasive surgery can reduce perioperative morbidity in cancer patients. However, definite validation of these procedures for tumor surgery is not yet available due to the lack of prospective randomized trials providing reliable long-term data on disease-free survival and overall survival. It seems likely that minimally invasive procedures will play an important role for the treatment of preneoplastic lesions and tumors of limited size.     

Robotic lateral pancreaticojejunostomy (Puestow)

A lateral pancreaticojejunostomy (LPJ), also known as the Puestow procedure, is a complex procedure performed for chronic pancreatitis when the pancreatic duct is dilated and unable to drain properly. Traditionally, these procedures are performed with open surgery. A minimally invasive approach to the LPJ using rigid handheld nonarticulating instruments is tedious and rarely performed. In fact, there are no prior laparoscopic case reports for LPJ in children and only a small handful of cases in the adult literature. This lack of laparoscopic information may be an indication of the difficulty in performing this complex operation with nonarticulating laparoscopic instruments. The advantages of robotic surgery may help overcome these difficulties. We present the first robotic LPJ ever reported in a 14-year-old child with idiopathic chronic pancreatitis. This case demonstrates the utility of this advanced surgical technology and may lead to a new minimally invasive option for both adults and children with chronic pancreatitis requiring surgical intervention.     

Laparoscopic fundoplication for gastroesophageal reflux disease in infants and children

The number and types of minimally invasive surgical procedures being performed in children have increased exponentially in the last 15 years. Laparoscopic fundoplication is commonly performed for gastroesophageal reflux disease (GERD), although the population of patients who undergo this procedure is different in adults and children. In Japan, laparoscopic fundoplication has become a standard procedure, even for children with neurological impairment; however, its indications remain controversial. In this article we review the status of laparoscopic antireflux surgery for infants and children, looking at its indications, the procedures available, the complications, and the training required to perform the procedure safely and effectively.     

Value analysis of minimally invasive spine surgery

The purpose of this article is to acquaint readers with the current methodology and evidence on outcome assessment and economic value for minimally invasive spinal surgical procedures. This article will review the standardized outcome measures, calculations of direct and indirect costs, quality-adjusted life years, and economic comparisons of spinal surgical procedures. The available literature suggests that minimally invasive spine surgery is cost effective; however, further research is needed to better assess the longer-term outcomes and cost–utility benefits of minimally invasive spinal interventions in comparison to open surgical approaches.     

An update on minimally invasive surgery

Minimally invasive surgery is a highly technological specialty of surgical practice, and requires training and retraining for traditional surgeons. The development of new instruments and new technologies during the last few years has allowed complex procedures that were previously considered unsuitable for minimally invasive surgery, but it has to be recognized that training, accreditation, and case load are fundamental for programs in advanced procedures. This article reviews some of these items including innovative surgical technologies related to minimally invasive surgery.     

The ALIF concept

The terms ‘minimally invasive’ or ‘less invasive surgery’ have been used recently to describe surgical approaches or operations that are performed with less trauma to anatomical structures on the way to or surrounding the surgical ‘target area’. These types of surgical procedures are usually performed with the help of ‘high-tech’ instruments such as surgical endoscopes or surgical microscopes, modern video techniques and automated instruments. Within the last 10 years, such techniques have been developed in the field of spinal surgery. The application of minimally or less invasive procedures has concentrated predominantly on anterior approaches to the thoracic and lumbar spine. This article describes two anterior approach techniques for performing anterior lumbar interbody fusion (ALIF) through a minimally invasive retroperitoneal or transperitoneal approach. The technical principles are microsurgical modifications of traditional anterior approaches to the lumbar spine. Through small (4-cm) skin incisions, the target area can be exposed. Preliminary results suggest decreased peri - and postoperative morbidity, less blood loss, earlier rehabilitation and acceptable complication rates. The technique is currently used by the author for all patients requiring anterior lumbar interbody fusion.