advances in pediatric mis over the past decade george w. holcomb, iii, m.d., mba surgeon-in-chief...

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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