Summary

For many years, pediatric surgeons did not feel there was an advantage to minimally invasive surgery in children, although it was introduced to the general surgery population in 1987[1] and became common for many abdominal and thoracic surgeries in adults. In the 1990s, the leaders in pediatric minimally invasive surgery began performing laparoscopic procedures, such as cholecystectomy and appendectomy. These procedures were first performed in older children due to limitations of equipment, but over time manufacturers began making shorter and smaller instruments so that minimally invasive surgery could be performed on even the smallest infants. The following discussion will focus on current uses of minimally invasive surgery for common conditions in pediatrics.

Educational objectives

At the conclusion of this activity, participants will be able to:

• Recognize the common pediatric conditions that may be treated with minimally invasive surgery
• Explain the advantages of minimally invasive surgery vs. open surgery
• Explain the basics of minimally invasive surgery to their patients and families

CME credit

This is an article from The Child's Doctor, Fall 2005 issue. You may take the quiz for learning purposes, but credits are no longer valid.

Author disclosures

Dr. Madonna has no industry relationships to disclose and does not refer to products that are still investigational or not labeled for the use in discussion.

Dr. Reynolds has no industry relationships to disclose and does not refer to products that are still investigational or not labeled for the use in discussion.

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Principles of minimally invasive surgery

Minimally invasive surgery relies on access to the cavity of interest (eg, abdomen, chest) with the placement of ports that are long, thin valved tubular devices. Carbon dioxide is insufflated into the cavity through the ports to expand it, allowing adequate visualization and working space. A scope is attached to a camera so that the procedure is watched on a television monitor by the surgeons and all others in the room, or even at remote sites. Light is obtained with a halogen light source through fiber optics attached to the scope. Laparoscopic instruments are also long and thin and placed through additional ports (working ports). There are instruments available to retract, dissect, cauterize, and suture tissues. Hemostasis is obtained by a variety of techniques, including ligation, clips, stapling devices, cautery, and ultrasonic coagulation. Specimens are removed directly through the ports or after placement in a protective bag to avoid contamination. If needed, a port incision can be slightly enlarged to allow removal of the specimen. There are now 3 mm ports available with similarly sized instruments so that these procedures can be routinely performed in 2 kg to 3 kg babies.

Despite the advances in technology, there is still some controversy about the advantages of laparoscopy in children. The advantages described in the early reports of minimally invasive surgery in adults included a shorter postoperative course, less pain and scarring, and no muscular damage from the standard open incisions. Resistance to this approach in children was mainly because open surgery requires small incisions in children as a rule, analgesic requirements are minimal for children, and they recover from major procedures and return to full activity quickly even with open procedures.[2]

In a paper by Rangel, et al,[3] the 3 most common laparoscopic procedures performed in children were reviewed, namely appendectomy, fundoplication, and splenectomy. They found that due to the retrospective nature of the reports available, improvement in outcomes could not be proven in the pediatric population. They did note that the benefits have been definitely proven in adult patients through the use of randomized trials and meta-analysis. They felt that if these types of papers were available, the benefits in children might be proven as well.

Laparoscopic appendectomy

Appendicitis is the most common abdominal condition requiring surgery in children, accounting for over 320 000 operations per year in the United States.[4] Despite improved access to medical care, a significant portion of these patients present with advanced disease and therefore incur increased morbidity. This is especially true of the youngest patients.

Antibiotic therapy and appendectomy have been the mainstays of treatment for many decades. Ure[5] reported the first laparoscopic appendectomy in a child in 1991. A decade later in a survey of North American pediatric surgeons,[6] 31.3% of surgeons used the laparoscopic technique frequently or always and an additional 29.4% used it occasionally.

Open appendectomy is performed using a right lower quadrant incision and splitting the muscles of the abdomen. The appendix is then brought into the incision, the blood supply ligated, and the appendix removed. The laparoscopic approach generally uses 3 small incisions ranging from 5 mm to 12 mm with 1 of the small incisions being concealed in the umbilicus. The appendix and blood supply are separated, then ligated with a stapling device, clips or cautery. The appendix is then brought out through a port, usually in a protective bag to prevent contamination with bacteria.

In a study of 103 children,[7] laparoscopic appendectomy was feasible in all stages of acute appendicitis, including perforation. The laparoscopic technique took slightly longer and there was an increased operative cost. There were fewer overall complications and infectious complications in the laparoscopic group. A single blinded randomized clinical trial comparing the 2 techniques for non-perforated appendicitis in 61 children found that pain scores were lower and the length of stay was shorter in the laparoscopic group.[8]

In another report comparing laparoscopic and open appendectomies in 391 children,[9] there was no statistically significant difference in post-operative pain medication usage, operative, or post-operative complications. The length of hospitalization was significantly shorter in the laparoscopic group.

In the largest pediatric report to date including 1379 children treated laparoscopically, El Ghoneimi et al,[10] found an incidence of 2.1% of intraoperative complications, such as insufflation of the omentum, visceral perforation, and appendiceal rupture. Post-operative complications were also very low (1.5%) and included bowel obstructions, wound infection and abscesses. When he further reviewed the data these complications occurred only in the group of patients with perforated appendicitis, and are comparable, if not lower, than with open appendectomy for perforated appendicitis.

Laparoscopic pyloromyotomy

Infantile hypertrophic pyloric stenosis is a common condition causing vomiting in infancy, with an incidence of 1 to 3 per 1000 live births.[11] The operation still used today was described by Ramstedt in the early 1900s.[12] The hypertrophic muscle is split leaving the mucosa intact and allowing gastric emptying. This operation has been performed countless times with a high rate of success, low rate of complications, and short operative time. In the early 1990s a laparoscopic alternative to this procedure was described by Alain.[13] This approach uses the same principles as the Ramstedt procedure, but uses an arthroscopic knife to split the muscle and 2 additional 3 mm ports. The laparoscopic approach offers improved cosmesis.

Hall, et al,[14] did a retrospective comparison of the open and laparoscopic approaches at their institution and concluded that there were similar complication rates and recovery times, but no clear benefit of either approach over the other. In a large series of 457 patients from a single institution,[15] there was an equal overall complication rate with a higher degree of mucosal perforation (3.6% vs. 0.4%) in the open group and a higher incidence of incomplete pyloromyotomy in the laparoscopic group (0 vs. 2.2%). Hall, et al,[16] also performed a meta-analysis of the literature available on the 2 approaches, which included 595 patients and showed no difference in mucosal perforation rates, but a higher incomplete pyloromyotomy rate in the laparoscopic group (1.6% vs. 0.2%). There was a significantly shorter time to full feeds and length of stay in the laparoscopic group.

At present, the laparoscopic approach seems to be an option for treatment of this disease, but without a distinct advantage. This is in contrast to the next procedure described.

Laparoscopic splenectomy

Splenectomy is indicated in children with spherocytosis, refractile thrombocytopenia, storage diseases, hereditary anemias, and tumor. In the standard approach for splenectomy a midline or left upper abdominal incision is used in order to gain access to the blood supply to the spleen. This involves cutting the abdominal muscles. The anatomy of the spleen makes it quite amenable to the laparoscopic approach, thereby avoiding the more painful open incision. Four ports are routinely used and the blood supply is controlled most commonly using a stapling device. A protective bag is used to remove the spleen in piecemeal fashion to prevent spillage of the contents and possible splenosis. Accessory spleens are searched for in either approach to assure a complete operation.

In a comparison between the 2 approaches in 51 children who underwent splenectomy,[17] 35 patients were treated laparoscopically and the remainder by the open technique. There was no difference in blood loss during the procedures or in hospital costs, but the laparoscopic group had a significantly shorter hospital stay.

In a case controlled study, Rescorla, et al,[18] found that the laparoscopic group had less narcotic use and shorter length of stay with a comparable complication rate, and therefore in a subsequent study[19] concluded that laparoscopic splenectomy is the gold standard in children.

Laparoscopic fundoplication for gastroesophageal reflux

Gastroesophageal reflux disease (GERD) is a common problem in the pediatric population. Carré[20] noted the natural history of GERD in children in a retrospective study. Most children are managed with medication and feeding changes, but those who fail these therapies may be considered for surgical intervention. In addition, those with more serious sequelae, such as aspiration pneumonia, "near" sudden death episodes, wheezing, or choking may be considered for early surgical treatment.

To confirm reflux, the gold standard is the pH probe, which documents the reflux events. In addition, most surgeons would like an upper gastrointestinal study prior to any operative intervention to confirm normal anatomy. GERD must be differentiated from the normal "spitting up" that occurs in most infants. Endoscopy, esophageal manometry and gastric emptying studies may also be used to guide therapy.

Reflux disease is caused by failure of the lower esophageal sphincter, a short intraabdominal esophagus and/or an abnormal angle of His. A fundoplication, which wraps a portion of the fundus of the stomach around the esophagus, creates an artificial anti-reflux valve. The Nissen fundoplication is a 360º wrap. The open technique requires either an upper midline incision, or a left upper transverse incision. The laparoscopic procedure uses 5 small incisions. The fundoplication is fashioned with sutures and intracorporeal knot tying. A diaphragmatic crural repair is also performed to prevent the wrap from migrating into the chest causing a hiatal hernia.

In a study by Ostlie and Holcomb,[21] 154 children who had laparoscopic Nissen fundoplication were studied. Only 2 patients had recurrent symptoms and only 1 required reoperation. The adult literature reports satisfaction rates of 85% to 100% after laparoscopic Nissen fundoplication and only one-third of failures require a second operation. In a long-term follow-up study of children undergoing a laparoscopic Nissen fundoplication, 66% of patients had complete relief, 26% had considerable improvement and only 2% had documented recurrent reflux with a median follow-up of 3 years. In addition, 92% of parents surveyed were happy with the results and would have their child undergo the procedure again.[22] In comparison, Subramaniam[23] studied the long term outcome in children undergoing the open fundoplication and found 3.5% early recurrence. Most families felt the results were good and some were delighted, but there was no follow-up on 40% of the patients.

Laparoscopic pull-through procedures for Hirschsprung disease

Hirschsprung disease is a functional distal bowel obstruction caused by aganglionosis in the rectum and a variable length of proximal bowel. Patients were previously treated with colostomy, as the etiology of the disease was unknown. In 1948, Swenson performed the first operation for definitive treatment of Hirschsprung disease and reported on 50 cases.[24] Two subsequent open procedures – the Soave and the Duhamel – are commonly performed today.

These procedures were initially staged (diverting colostomy first) and then performed as a 1-stage procedure through a left lower abdominal incision with a transanal anastamosis. To spare the lower abdominal incision, 3 or 4 ports (3 mm to 5 mm) may be used in the neonate to dissect the colon and ligate the blood supply to the aganglionic bowel that is to be removed. The transanal anastamosis is performed as before.

In 1995,[25] the first 1-stage laparoscopic pull-through procedure was reported. Raffensperger published the first report of a Swenson procedure performed laparoscopically at Children's Memorial Hospital in 1996.[26] In this report 8 laparoscopic procedures were compared to 10 open procedures, and there was decreased time to oral intake and discharge in the laparoscopic group.

Georgeson, et al,[27] have the largest report of the laparoscopic endorectal (Soave) pull-through to date with 80 patients. There were 4 patients that required diversion at a later time for enterocolitis or anastomotic leak. Only 20 patients were old enough to assess continence and of those 18 were continent and 2 had overflow incontinence.

Summary

With advances in technology, minimally invasive surgery is a viable option for many procedures in our smallest patients. In addition to those procedures discussed here, laparoscopic options are available for lung resections, pancreas and adrenal surgery, esophageal and bowel surgery and almost limitless other areas. Most surgeons who perform minimally invasive surgery feel that it is an equal or better option for the patient and in most cases has been associated with shorter hospital stays, lower analgesic requirements, more rapid return to activity, and better cosmesis.

REFERENCES

[1.] Mouret P. From the first laparoscopic cholecystectomy to the frontiers of laparoscopic surgery: The future prospectives. Dig Surg 1991;8:124.

[2.] Zitsman JL. Current concepts in minimal access surgery for children. Pediatrics 2003;111:1239-1252.

[3.] Rangel SJ, Henry MC, Brindle M, Moss L. Small evidence for small incisions: Pediatric laparoscopy and the need for more rigorous evaluation of novel surgical therapies. Journal of Pedatr Surg 2003;38(10):1429-1433.

[4.] Addiss DG, Shaffer N, Fowler BS, et al. The epidemiology of appendicitis and appendectomy in the United States. Am J Epidemiol 1990;132:910-925.

[5.] Ure BM, Spangenberger W, Hebebrand D, et al. Laparoscopic surgery in children and adolescents with suspected appendicitis: Results of medical technology assessment. Eur J Pediatr Surg 1992;2:336-340.

[6.] Muehlstedt SG, Pham TQ, Schmeling DJ. The management of pediatric appendicitis: A survey of North American pediatric surgeons. J Pediatr Surg 2004;39(6):875-879.

[7.] Vegunta RK, Ali A, Wallace LJ, et al. Laparoscopic appendectomy in children technically feasible and safe in all stages of acute appendicitis. The American Surgeon 2004;70:198-202.

[8.] Lintula H, Kokki H, Vanamo K. Single-blind randomized clinical trial of laparoscopic versus open appendectomy in children. Brit J Surg 2001;88:510-514.

[9.] Meguerditchian A, Prasil P, Cloutier R, et al. Laparoscopic appendectomy in children: A favorable alternative in simple and complicated appendicitis. J Pediatr Surg 2002;37(5):695-698.

[10.] El Ghoneimi A, Valla JS, Limonne B, et al. Laparoscopic appendectomy in children: Report of 1379 cases. J Pediatr Surg 1994;29(6):786-789.

[11.] Grant GA, McAleer JJ. Incidence of infantile hypertrophic pyloric stenosis. Lancet 1984;1(8387):1177.

[12.] Ramstedt C. Zur operation der angeborenen pylorus stenose. Med Klin 1912;26:1191-1192.

[13.] Alain JL, Grousseau D, Terrier G. Extramucosal pyloromyotomy by laparoscopy. J Pediatr Surg 1991;26:1191-1192.

[14.] Hall NJ, Ade-Ajayi N, Al-Roubaie, et al. Retrospective comparison of open versus laparoscopic pyloromyotomy. Brit J Surg 2004;91:1325-1329.

[15.] Yagmurlu A, Barnhart DC, Vernon A, et al. Comparison of incidence of complications in open and laparoscopic pyloromyotomy: A concurrent single institution series. J Pediatr Surg 2004;39(3):292- 296.

[16.] Hall NJ, Van Der Zee J, Tan HL, Pierro A. Meta-analysis of laparoscopic versus open pyloromyotomy. Ann Surg 2004;240(5):774-778.

[17.] Minkes RK, Lagzdins M, Langer JC. Laparoscopic versus open splenectomy in children. J Pediatr Surg 2000;35(5);699-701.

[18.] Rescorla FJ, Breitfeld PP, West KW, et al. A case controlled comparison of open and laparoscopic splenectomy in children. Surgery 1998;124:670-676.

[19.] Rescorla FJ, Engum SA, West KW, et al. Laparoscopic splenectomy has become the gold standard in children. Amer Surg 2002;68:297-301.

[20.] Carré IJ. The natural history of partial thoracic stomach (hiatus henia) in children. Arch Dis Child 1959;34:344-353.

[21.] Ostlie DJ, Holcomb III GW. Laparoscopic fundoplication and gastrostomy. Seminars in Pediatr Surg 2002;11(4):196-204.

[22.] Bourne MC, Wheeldon C, MacKinlay GA, Munro FD. Laparoscopic Nissen fundoplication in childen: 2-5 year follow-up. Pediar Surg Int 2003;19:537-539.

[23.] Subramaniam R, Dickson AP. Long-term outcome of Boix-Ochoa and Nissen fundoplication in normal and neurologically impaired childen. J Pediatr Surg 2000;35(8):1214-1216.

[24.] Shim WK, Swenson O. Treatment of congenital megacolon in 50 infants. Pediatrics 1966;38(2):185-193.

[25.] Georgeson KE, Fuenfer MM, Hardin WD. Primary laparoscopic pull-through for Hirschsprung's disease in infants and children. J Pediatr Surg 1995;30:1-7.

[26.] Curran TJ, Raffensperger JG. Laparoscopic Swenson pull-through: A comparison with the open procedure. J Pediatr Surg 1996;31(8):1155-1157.

[27.] Georgeson KE, Cohen RD, Hebra A, et al. Primary laparoscopicassisted endorectal colon pull-through for Hirschsprung's disease: A new gold standard. Ann Surg 1999;229(5);678-683.