advances in pediatric mis over the past decade george w. holcomb, iii, m.d., mba surgeon-in-chief...
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Advances in Pediatric MIS Advances in Pediatric MIS Over The Past DecadeOver The Past Decade
George W. Holcomb, III, M.D., MBA
Surgeon-in-Chief
Children’s Mercy Hospital
Kansas City, Missouri
Advances in MIS1. Development of Surgical Technique
Thoracoscopic lobectomy Thoracoscopic repair EA/TEF Single site umbilical laparoscopic surgery (SSULS)
2. Refinement in Surgical Technique Laparoscopic fundoplication Laparoscopic pyloromyotomy
3. Definition of Perforated Appendicitis
4. Evidence Based Studies in MIS
5. Consensus B/W Drs. Pena & Georgeson regarding laparoscopy for anorectal atresia with a fistula above the prostatic urethra (IPEG 2009)
Advances in MIS
6. Growth of IPEG
7. Development of good 3 mm instruments
8. Development of HD picture
9. Development of the stab incision
technique
Development of A Surgical TechniqueThoracoscopic Repair EA/TEF –
Lessons Learned
• Baby should ideally be >2.5 kg
• Bronchoscopy to identify fistula to gauge distance
• Oscillating ventilator helpful
• Is metal clip good for ligating TEF?
• When to convert?
• How to train staff and residents?
Thoracoscopic Repair EA/TEF
Oscillating Ventilator Helpful
Development of A Surgical TechniqueThoracoscopic Repair EA/TEF –
Lessons Learned
Is the metal clip appropriate for ligating the TEF?
Can a recurrent TEF be prevented?
J Laparoendosc Adv Surg Tech 17:380-382, 2007J Laparoendosc Adv Surg Tech 17:380-382, 2007
Development of A Surgical TechniqueThoracoscopic Repair EA/TEF –
Lessons Learned
• When to convert? After ligation & division of TEF - if the gap
is too large (2 -3 cm)?
• How do we train staff and residents?
Development of A Surgical TechniqueThoracoscopic Repair EA/TEF –
Lessons Learned
Thoracoscopic Repair EA/TEFResults
(104 Patients)
Mean Age (days) 1.2 (± 1.1)
Mean Wt (kg) 2.6 (± 0.5)
Mean Operative Time (min) 129.9 (± 55.5)
Mean Days Ventilation 3.6 (± 5.8)
Mean Hospitalization (days) 18.1 (± 18.6)
Thoracoscopic Repair EA/TEF(104 Patients)
• Fistula Ligation
37 pts: suture ligation
67 pts: clip ligation
Ann Surg 242: 422-430, 2005Ann Surg 242: 422-430, 2005
Thoracoscopic Repair EA/TEFAssociated Anomalies
(104 Patients)Cardiac Renal
ASD/VSD 15 Horseshoe kidney 3 Right aortic arch 6 Unilateral agenesis 2 Tetralogy of Fallot 3 Crossed fused ectopia 1 Dextrocardia 3 VUR > Grade 3 1 PDA (ligation) 2 Duplex kidney 1 DORV 1 Ectopic kidney 1 Tricuspid atresia 1
Gastrointestinal Other
High imperforate anus 7 Vertebral anomalies 6 Duodenal atresia 4 Radial aplasia 3 Low imperforate anus 3 Tethered cord 1 Cloaca 1 Hydromyelia 1 Choanal atresia 1
Syndromes
VACTERL (>2 anomalies) 10 CHARGE 3 Down 3
Thoracoscopic Repair EA/TEFResults
(104 Patients)
• Fundoplication 26(22 Nissen, 4 Thal)
• Aortopexy 7( 6 thoracoscopic)
• Duodenal atresia 4(4 laparoscopic)
• Imperforate anus 10(7 high, 3 low)
• Cardiac operations 5( other than VSD/ASD)
Ann Surg 242: 422-430, 2005Ann Surg 242: 422-430, 2005
Thoracoscopic Repair EA/TEFComplications (104 Patients)
• Recurrent fistula 2( 3 mos, 8 mos)
• Mortality 3 7 mo old - NEC 10 day old – CHD 21 day old with
esophageal disruption at intubation
Ann Surg 242: 422-430, 2005Ann Surg 242: 422-430, 2005
Thoracoscopic Repair EA/TEFConversion to Open
5 Pts
• 1 Pt: R aortic arch (despite negative ECHO)
• 3 Pts: Intraoperative desaturation, relatively long gap
• 1 Pt: 1.2 kg baby – only 1 port placed – too small
Thoracoscopic Repair EA/TEF104 Patients
Waterston A: > 5.5 lb with no significant associated problemsWaterston B: 4-5.5 lbs. or higher weight with moderate pneumonia or congenital anomalyWaterston C: weight < 4 lb or higher weight with severe pneumonia or congenital anomaly
Waterston A 62 Patients
Waterston B 30 Patients
Waterston C 12 Patients
Operation converted 2 2 1
Operation staged 1 - -
Esophageal anastomotic leak 2 3 3
Stricture (on initial esophagram) 3 1 -
Patients needing only 1 dilation 7 5 -
Patients needing 2 dilations 9 1 2
Patients needing 3 dilations - 3 1
Patients needing >3 dilations 3 2 -
Recurrent tracheoesophageal fistula 1 1 -
Fundoplication 19 6 1
Imperforate anus operations 4 4 2
Duodenal atresia repairs - 2 2
Aortopexy 6 1 -
Death 1 - 2
Thoracoscopic Repair EA/TEF
N.R.: Not reportedA: 87% are Gross Type CB: Stricture is defined as a significant narrowing on the initial esophagramC: Stricture in this paper is defined as requiring > 4 dilationsD: Stricture in this paper is defined as requiring > 2 dilations
Current Engum, et al (1971-93)
Spitz, Kelly (1980-84)
Randolph, et al (1982-88)
Manning, et al (1977-85)
Number of Patients
104 174 148A
39 63
Mean length of hospitalization (days)
18.1
(6-120)
N.R. N.R. N.R. 24 (9-174)
Anastomotic leak 7.6% N.R. 21% 10.2% 17%
Anastomotic stricture
3.8%B
32.7%C
17.7% 33.3% 4.3%D
Patients requiring at least 1 dilation
31.7% 32.7% N.R. 33.3% N.R.
Anastomotic revision
1.9% 0.9% 2.7% 5.1% N.R.
Fundoplication 24.0% 25.2% 18% 15.3% 16.9%
Aortopexy 6.7% N.R. 16% N.R. 4.7%
Mortality Related EA/TEF Not Related
0.9% 1.9% 2.8%
4.5% (overall)
14.8% (overall)
0% 7.6% 7.6%
3.1% 11.1% 14.2%
Recurrent fistula 1.9% 2.2% 12% 5.1% 6.4%
EA/TEFOperative Approach
Thoracoscopy Thoracotomy
• Transpleural • Extrapleural/Transpleural
• Longer operative time • Shorter operative time
• Better visualization • Adequate visualization
• Anesthesia important • Anesthesia standard
Thoracoscopic Repair EA/TEFAdvantages of Thoracoscopy
• Avoidance of musculoskeletal sequelae
• Superior visualization of anatomy
• Easy to identify fistula for ligation
How To Get StartedNot The Ideal Case
• 2 - 2.5 kg
• Very high upper pouch
• Complex single ventricle physiology
• Prostaglandin dependent
How To Get StartedIdeal Case
• Baby – 2.5-3 kg; no other anomalies
• Esophageal segments close together (CXR, Bronchoscopy)
• Start thoracoscopically – Go as far as comfortable
• Try it again
Development of a Surgical TechniqueThoracoscopic Lobectomy – Lessons Learned
• Upper lobes are very difficult, esp. if training residents
• Middle & lower lobes are easier b/c are “end organs”
• Single lung ventilation very helpful – need good anesthesiologist
• For prenatally discovered CPAM, better to wait until baby is 6-9 mos of age (assuming asymptomatic)
Development of a Surgical TechniqueThoracoscopic Lobectomy – Lessons Learned
Atlas of Pediatric Laparoscopy and Thoracoscopy Atlas of Pediatric Laparoscopy and Thoracoscopy
Holcomb, Rothenberg, GeorgesonHolcomb, Rothenberg, Georgeson
Development of a Surgical TechniqueSSULS
• Why did it develop?
• Who benefits patient or surgeon?
• What operations are applicable?
• Special equipment needed?
SSULSWhat Operations Are Applicable?
• Appendectomy
• Cholecystectomy
• Splenectomy• Ileal or colonic resection (IBD or segmental
lesion) – extra-corporeal anastomosis
• Pyloromyotomy
SSULSSpecial Equipment
• SILS port(Covidien, Inc.)• Cholecystectomy• Splenectomy• Segmental ileal or
colonic resection
• Long telescope (300, 450)
SSULSCholecystectomy
SSULS
Appendectomy
SSULS Appendectomy
Refinement in TechniqueLap. Fundoplication
• Cautery in pts <4-5 yrs
• Minimal esophageal dissection/mobilization
Refinement in TechniqueLap Pyloromyotomy
Definition of Perforated Appendicitis
Hole In appendix Fecalith in abdomen
J Pediatr Surg 43:2242-2245, 2008J Pediatr Surg 43:2242-2245, 2008
Definition of Perforated Appendicitis
Impact of Strict Definition of Perforation on Abscess Rate
Before definition After definition
Abscess rate (%) Abscess rate (%)
Acute appendicitis 1.7 0.8
Perforated appendicitis 14.0 18.0
J Pediatr Surg 43:2242-2245, 2008J Pediatr Surg 43:2242-2245, 2008
Evidence Based Studies in MISLaparoscopic vs Open Pyloromyotomy
Preoperative Data
Open
(n = 100)
(mean +/- SE)
Laparoscopic
(n = 100)
(mean +/- SE)
P
value
Age (wk) 5.24 +/- 0.25 5.33 +/- 0.21 0.77
Preoperative pyloric thickness (mm)
4.17 +/- 0.08 4.16 +/- 0.09 0.88
Preoperative pyloric length (mm)
19.51 +/- 0.26 19.38 +/- 0.27 0.74
Admission chloride level (mmol/L)
99.36 +/- 0.79 99.76 +/- 0.76 0.72
Admission bicarbonate level (mmol/L)
28.18 +/- 0.51 27.86 +/- 0.47 0.65
Ann Surg 244:363-370, 2006Ann Surg 244:363-370, 2006
Evidence Based Studies in MISLaparoscopic vs Open Pyloromyotomy
OutcomesOpen
(n = 100)
(mean +/- SE)
Laparoscopic
(n = 100)
(mean +/- SE)
P
value
Operating time (minutes:seconds)
19:28 +/- 0:41 19:34 +/- 0:46 0.93
Postoperative emesis (no.) 2.61 =/- 0.32 1.85 +/- 0.15 0.05*
Time to full feeds (hours:minutes)
21:01 +/- 1:17 19:30 +/- 1:22 0.43
Doses of analgesia (no.) 2.23 +/- 0.18 1.59 +/- 0.15 0.008*
Length of stay after operation (hours:minutes)
33:10 +/- 1:35 29:38 +/- 1:36 0.12
Ann Surg 244:363-370, 2006Ann Surg 244:363-370, 2006
Patient Variables at ConsultationPatient Variables at Consultation
WBC WBC 20.820.8 19.719.7 0.71 0.71
Weight (kg) Weight (kg) 24.624.6 20.720.7 0.52 0.52
Age (Years) Age (Years) 4.8 4.8 5.2 5.2 0.770.77
Days of SymptomsDays of Symptoms 9.0 9.0 10.610.6 0.320.32
VATSVATS tPAtPA P ValueP Value
O2 support (L/min)O2 support (L/min) 0.81 0.81 0.79 0.79 0.96 0.96
Thoracoscopic Debridement vs Fibrinolysis for Empyema
ER/PCP visits ER/PCP visits 2.9 2.9 2.7 2.7 0.69 0.69 J Pediatr Surg 44:106-111, 2008J Pediatr Surg 44:106-111, 2008
OutcomesOutcomes
16.6% failure rate for fibrinolysis16.6% failure rate for fibrinolysis
VATSVATS tPAtPA P ValueP Value
PO Fever (Days)PO Fever (Days) 3.1 3.1 3.8 3.8 0.46 0.46
O2 tx (Days) O2 tx (Days) 2.25 2.25 2.33 2.33 0.89 0.89
LOS (Days)LOS (Days) 6.89 6.89 6.83 6.83 0.960.96
Patient ChargesPatient Charges $11,660 $11,660 $7,575$7,575 0.010.01
Analgesic dosesAnalgesic doses 22.322.3 21.421.4 0.90 0.90
Thoracoscopic Debridement vs Fibrinolysis for Empyema
J Pediatr Surg 44:106-111, 2008J Pediatr Surg 44:106-111, 2008
London Prospective TrialVATS v Fibrinolysis w/UrokinaseVATS v Fibrinolysis w/Urokinase
• No difference in LOS (6 v 6 days)
• No difference in 6 month CXR
• VATS more expensive ($11.3K v $9.1K)
• 16 % failure rate for fibrinolysis
Am J Respir Crit Care Med 174:221-227, 2006Am J Respir Crit Care Med 174:221-227, 2006
Current Management Algorithm
Treatment algorithm for empyema in children based on level 1 evidence.
Evidence Based Studies in MISInitial Laparoscopic Appendectomy vs Initial Non-operative Management for Patients Presenting with Appendicitis and
Abscess
Patient Characteristics at the Time of AdmissionInitial
operation
(n = 20)
Initial non-operative management (n = 20)
P
value
Age (y) 10.1 +/- 4.2 8.8 +/- 4.2 .31
Weight (kg) 37.0 +/- 16.2 37.1 +/- 20.8 .98
Body mass index (kg/cm2) 18.0 +/- 4.5 19.5 +/- 5.5 .39
White blood cell count 17.4 +/- 6.6 16.9 +/- 6.8 .84
Maximum temperature 37.8 +/- 1.0 37.7 +/- 0.9 .95
Maximum axial area of abscess (cm2) 29.2 +/- 29.7 26.2 +/- 21.1 .75
APSA, 2009APSA, 2009J Pediatr Surg 45:236-240, 2010J Pediatr Surg 45:236-240, 2010
Evidence Based Studies in MISInitial Laparoscopic Appendectomy vs Initial Non-operative Management for
Patients Presenting with Appendicitis and Abscess
Initial operation
(n = 20)
Initial non-operative management
(n = 20)
P value
Operation time (min) 62.1 +/- 38.7 42.0 +/- 45.5 .06Total length of hospitalization (d)
6.5 +/- 3.8 6.7 +/- 6.6 .92
Recurrent abscess after initial treatment
20% 25% 1.0
Doses of narcotics 9.7 +/- 4.0 7.1 +/- 15.8 .47Total health care visits 2.8 +/- 1.1 4.1 +/- 1.0 <.001No. of CT scans 1.5 +/- 0.7 2.1 +/- 1.1 0.4Total charges $44,195 +/-
$19,384$41,687 +/- $18,483 .68
APSA, 2009APSA, 2009J Pediatr Surg 45:236-240, 2010J Pediatr Surg 45:236-240, 2010
MIS Studies in Progress
• SSULS Appendectomy vs 3-Port Lap Appendectomy
• SSULS Cholecystectomy vs 4-Port Lap Cholecystectomy
• SSULS Splenectomy vs 4-Port Laparoscopic Splenectomy
• Irrigation/Suction vs Suction Only During Lap. Appendectomy for Perforated Appendicitis
• Epidural vs PCA for Post-operative Pain Mgmt. Following Nuss Repair
Development of the Stab Incision Technique
The Use of Stab IncisionsProcedure (n) Used/case Saved/case Nissen (209) 1 4
Nissen (14) 2 3
Heller Myotomy (7) 2 3
Appendectomy (102) 2 1
Meckel’s Diverticulum (2) 2 1
Pyloromyotomy (77) 1 2
Cholecystectomy (31) 2 2
Pullthrough (20) 2 1
Splenectomy (21) 2 2
Adrenalectomy (6) 2 2
UDT (15) 1 2
Varicocele (5) 1 2
Ovarian (2) 1 2
Totals (511) 714 1337 PAPS, 2003PAPS, 2003
J Pediatr Surg 38:1837-1840, 2003J Pediatr Surg 38:1837-1840, 2003
Cost Savings from Stab IncisionsProcedure (n) Step Pt./Instit. Savings ($) Ethicon Pt./Instit. Savings ($) Nissen (209) 117,040 / 51,832 76,912 / 4,276 Nissen (14) 5,880 / 2,604 3,864 / 1,722 Heller (7) 2,940 / 1,302 1,932 / 861 Appy (102) 14,280 / 6,324 9,384 / 4,182 Meckel’s (2) 280/ 124 184 / 82 Pyloric (77) 21,560 / 9,548 14,168 / 6,314 Chole (31) 8,680 / 3,844 5,704 / 2,542 Pullthrough (20) 2,800 / 1,240 1,840 / 820 Spleens (21) 5,880 / 2,604 3,864 / 1,722 Adrenal (6) 1,680 / 744 1,104 / 492 UDT (15) 4,200 / 1,860 2,760 / 1,230 Varicocele (5) 1,400 / 620 920 / 410 Ovarian (2) 560 / 248 368 / 164 Total = 511 $187,180/$82,894 $123,004/$54,817
PAPS, 2003PAPS, 2003J Pediatr Surg 38:1837-1840, 2003J Pediatr Surg 38:1837-1840, 2003
What Advances Will Be Made in the Next Decade?
QUESTIONS
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