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STATE-OF-THE-ART REVIEW ARTICLE |
Division of Pediatric Surgery, College of Physicians and Surgeons, Columbia University, New York, New York
ABSTRACT
Pediatric patients continue to benefit from the advances made in minimal-access surgery. Improvements in techniques and tools have made minimal-access procedures increasingly available to children. Growing popularity of laparoscopy and thoracoscopy has resulted in greater numbers of patients available for outcomes analysis. Randomized, controlled studies have been difficult to perform because of parent, patient, and physician selection bias.
Key Words: pediatric minimal-access surgery • laparoscopy • thoracoscopy
Abbreviations: MAS—minimal-access surgery • ONF—open Nissen fundoplication • LNF—laparoscopic Nissen fundoplication • LAGB—laparoscopic adjustable gastric banding
The field of minimal-access surgery (MAS) has secured a strong foothold in the discipline of pediatric surgery in a remarkably brief period of time. Barely 20 years ago, laparoscopy was just taking the first few stumbling steps from diagnostics into the world of therapy. Orthopedic surgeons, gastroenterologists, and urologists had long invaded closed spaces with small scopes to remove injured or pathologic tissues. Gynecologists developed the tools and techniques to perform basic operations such as cholecystectomy and tubal ligation. General surgeons took notice of the success of their gynecology colleagues. These first few steps opened the paths to explore additional MAS procedures. Appendectomies were possible, and biopsies could be performed. Fueled by industry, tools of the trade were developed and mass-produced, allowing surgeons to expose, dissect, ligate, cauterize, cut, and remove, replicating the same maneuvers performed during open operations. Stapling techniques used for open surgery became available for MAS, allowing surgeons to create anastomoses. Because most surgeons were more comfortable with sewn anastomoses and some anastomoses seemed better suited to sutures than staples, laparoscopic needle drivers and knot-tying devices were developed. If necessity is the mother of invention, imagination is the second parent.
Pediatric surgeons have been slower to adopt MAS, in part because the patients are smaller, the operations are often performed with minimal incisions, and many of the conditions that require surgery are rare. Nevertheless, several pioneering pediatric surgeons began to perform uncomplicated surgical procedures, demonstrating that children, too, could benefit from MAS techniques. Interest in pediatric MAS became contagious. In the Division of Pediatric Surgery at the Morgan Stanley Children's Hospital of New York Presbyterian, for example, laparoscopic appendectomies were performed in <10% of the cases in 1997; in 2005, >95% of the appendectomies were laparoscopic. Similar trends have been observed in numerous other pediatric surgical services.
Likewise, the breadth of cases now being performed laparoscopically continues to grow. Enthusiastic pediatric MAS proponents have learned how to apply techniques to perform more complex and complicated procedures. Industry recognizes the need to produce versions of their instruments that are shorter and smaller to allow MAS procedures to be offered to the smallest patients. Procedures once inconceivable as MAS operations (eg, repair of esophageal atresia, Kasai procedure) have been performed with successful outcomes.
The following paragraphs present an update of the current status of minimal-access procedures in a variety of areas in the field of pediatric surgery.
EMPYEMA
Early intervention to evacuate parapneumonic effusions and empyema results in decreased length of hospital stays. Layering fluid may be amenable to thoracentesis or closed drainage. Many patients will have fibropurulent exudate develop in the affected pleural space. Chen et al1 have shown that >70% of children with late presentation of empyema will eventually come to surgery and that video-assisted thoracoscopy is an effective and successful method of treatment.
GASTROESOPHAGEAL REFLUX DISEASE
Antireflux surgery for gastroesophageal reflux is a common laparoscopic procedure. Comparing open (ONF) and laparoscopic Nissen fundoplication (LNF), Diaz et al2 found LNF to have a significantly higher reoperation rate than ONF, although each procedure was successful without reoperation in >85% of the cases 2 years postoperatively. Somme et al3 reviewed 55 fundoplications performed in infants over a 1-year span. Operating times were longer with LNF (120 ± 24 minutes) than with ONF (91 ± 21 minutes). Feeds were started >1.5 days sooner after LNF, and time from initiation of feeding to full feeds was not significantly different. Recurrence was significantly more frequent in ONF (14.3%) than LNF (2.6%). Rothenberg4 reported a wrap failure rate of 4% in >1000 consecutive LNF procedures compared with failure rates as high as 13% reported for ONF.
HERNIAS
Laparoscopically facilitated repair of inguinal hernias, a common practice in adults, has been performed in sufficient numbers to allow comparison to traditional open repair. Chan et al5 assigned consecutive patients with inguinal hernias to undergo either laparoscopic (N = 42) or open (N = 41) repair. Patients who underwent laparoscopically facilitated repair required fewer postoperative analgesics and had more contralateral hernias detected at surgery (11 vs 0). Five patients in the open-repair group subsequently had contralateral hernias appear. Spurbeck et al6 have shown that MAS is a safe technique for inguinal hernia repair, although Gorsler and Schier7 have reported a recurrence rate of 2.7% with laparoscopic repair, a figure slightly higher than reported with open repair. Recent laboratory studies demonstrate success using tissue adhesives injected into the hernia sac(s) under laparoscopic guidance.8
Routine contralateral groin exploration in a child with a unilateral inguinal hernia at presentation is becoming less common. Laparoscopic evaluation of the contralateral groin is now practiced by 37% of pediatric surgeons, a sixfold increase over a dozen years.9
PYLORIC STENOSIS
Pyloromyotomy is a common pediatric surgical procedure. More that a century of experience has demonstrated the Ramstedt pyloromyotomy to be safe and effective. Technical nuances of the laparoscopic procedure are learned with experience, reflected by Kim et al.10 A meta-analysis of laparoscopic versus open pyloromyotomy found laparoscopic pyloromyotomy to be associated with a higher complication rate (mucosal perforation, incomplete pyloromyotomy) and similar operating times but shorter recovery times.11
INTESTINAL SURGERY: SMALL INTESTINE
Laparoscopic bowel resection and anastomosis can be performed in children and adolescents for such conditions as Crohn disease, Meckel diverticulum, and duplication cyst.12 Intestinal malrotation is amenable to correction by MAS, although the presence of volvulus may make the laparoscopic technique less desirable than open laparotomy because most pediatric surgeons will require more time to perform the procedure laparoscopically. Laparoscopic-assisted procedures have also gained popularity, allowing the surgeon to carry out the dissection laparoscopically and then deliver the loops of intestine through a small incision to perform an anastomoses outside of the abdominal cavity.13 Pediatric surgeons have used MAS techniques to reduce intussusception.14,15
APPENDICITIS
A recent survey of the members of the American Pediatric Surgical Association revealed that 31% of respondents used a MAS technique to remove the appendix frequently (including "always," 11%), and an additional 29% reported that they used MAS occasionally. Almost 40% rarely or never treated appendicitis laparoscopically.16 Selected patients with uncomplicated appendicitis may be treated as same-day surgery patients,17 as may patients for whom antibiotic therapy followed by interval appendectomy is the selected treatment.18 Ikeda et al19 confirm that laparoscopic appendectomy shortens hospital stay in uncomplicated appendicitis but not in complicated appendicitis. Operating time was 50% longer with laparoscopic appendectomy, and overall hospital costs were 26% higher in their early experience with the operation.
INTESTINAL SURGERY: COLORECTAL DISORDERS
As with small-bowel abnormalities, colon resections may be conducted by using MAS. For more than a decade, pediatric surgeons have used laparoscopy to assist with endorectal pull-through for Hirschsprung disease.20 Similar techniques are used to perform total colectomy for ulcerative colitis and familial polyposis.21 Georgeson et al22 have successfully performed correction of high imperforate anus using laparoscopic assistance.
SPLENIC DISORDERS
Laparoscopic splenectomy allows the patient to have the spleen removed without having the morbidity of a large, painful incision. Most surgeons perform the procedure with 3 small access ports and a larger port through which the spleen is eventually removed. More than 85% of the spleens removed laparoscopically are removed to treat hematologic disorders.23 In those children in whom gall bladder disease may be associated, laparoscopic cholecystectomy may be added to the procedure. Open splenic salvage is preferred for treating splenic injuries. Partial splenectomy may be conducted in selected patients, particularly in those who have a solitary nonparasitic splenic cyst.
BILIARY DISEASES
Laparoscopic cholecystectomy is the standard of therapy in patients of all ages. Advances in laparoscopic suturing and stapling devices have made it possible to perform biliary anastomoses for such conditions as biliary atresia and choledochal cyst. Laparoscopy has also been used for guided liver biopsy as well as cholangiography.
GONADAL ABNORMALITIES
Much has been written in support of MAS to treat male children with a nonpalpable testicle. A multicenter analysis of treatment for nonpalpable testicle confirmed improved results and better testicular salvage with laparoscopic techniques.24 Varicocele is now routinely corrected laparoscopically with successful outcomes and low complication rates.25 Ovarian torsion can often be treated laparoscopically with detorsion and pexy, resulting in a salvaged ovary in most instances.26 Templeman et al27 argue in favor of the use of laparoscopy to evaluate and treat ovarian cysts, the most common ovarian mass requiring operative intervention. I have removed twisted paraovarian cysts while performing laparoscopy for chronic abdominal pain.
TUMORS
In addition to gonadal tumors, other masses in the abdomen and chest have been biopsied or removed by using MAS. A multitude of biopsies have been performed for mediastinal, pulmonary, abdominal, and retroperitoneal tumors, with satisfactory results in most. Laparoscopic adrenalectomy is appropriate for selected patients; successful resection of virilizing tumors, pheochromocytomas, and neuroblastoma has been reported.28 Biopsy is appropriate for some tumors, whereas complete resection may be performed on selected neoplasms.29–31
OBESITY SURGERY
Bariatric surgeons are interested in developing programs for obese adolescents.32 Both laparoscopic gastric bypass and laparoscopic adjustable gastric banding (LAGB) have proven to be effective procedures to help obese and superobese patients lose excess weight in numerous studies.33,34 Current opinion calls for patients to be cared for in multidisciplinary programs that include medical specialists, dieticians, psychologists, exercise therapists, and surgeons.35 Gastric bypass is the most common bariatric procedure performed in the United States, but irreversibility and concern regarding chronic malabsorption have led bariatric surgeons to consider LAGB. At present, few centers are approved for LAGB; Food and Drug Administration–regulated studies are underway at 3 sites to determine the efficacy and applicability of LAGB in adolescents.
CONCLUSIONS
Smaller incisions, shorter hospital stays, and a more rapid return to preoperative activities continue to make MAS appealing to patients. Instruments now available enable surgeons to perform most operations wielding scopes rather than scalpels. Parents regularly reference Internet sites to help them make informed decisions regarding how appropriate MAS might be for their child's condition. Searching the Web for medical information may lead to incomplete or misleading information; thus, Web sites of the American Pediatric Surgical Association (www.eapsa.org) and the International Pediatric Endosurgery Group (www.ipeg.org) provide guidelines for pediatric MAS in several topics.36,37
Still lacking from the pediatric endosurgical literature are controlled studies that compare open and minimal-access procedures. The enthusiasm generated by patients who undergo MAS (and their parents) and the surgeons who perform these operations are hurdles to overcome to obtain truly objective and significant results. Clinical trials organized both at individual institutions and on a multicenter level will be important to validate or challenge the presumed benefits of MAS in children and adolescents.
FOOTNOTES
Accepted Feb 6, 2006.
Address correspondence to Jeffrey L. Zitsman, MD, Minimal Access Surgery, Morgan Stanley Children's Hospital of New York Presbyterian, 3959 Broadway, New York, NY 10032. E-mail:jlz2{at}columbia.edu
The author has indicated he has no financial relationships relevant to this article to disclose.
REFERENCES
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