In the
last decade, advances in minimally invasive surgery have significantly impacted
the practice of pediatric surgery across a wide spectrum of disease processes.
Minimally invasive surgery is based on the premise that the abdominal or
thoracic cavity can be safely accessed with a telescope (sterile camera
connected to a television) and several small instruments to perform an operation
that is visualized on a screen. Both open and minimally invasive techniques have
the same surgical goal; the differences are primarily in the methods used to
access the anatomy of the disease process. The advantages to minimally invasive
surgery can include less surgical pain, earlier return of bowel function,
shorter postoperative hospital stay, more rapid return to routine physical
activities and decreased scarring.
In a variety of pediatric operations, comparative
studies are published on outcomes related to laparoscopic and traditional open
operations. Laparoscopic appendectomy in children is associated with decreased
length of stay,[1] less postoperative pain,[1] and an overall decrease in the
incidence of wound infection[2] compared to open appendectomy. Similarly,
laparoscopic splenectomy for hematologic disease is associated with shorter
lengths of stay, earlier first oral intake and less need for narcotic pain
medication compared to open splenectomy.[3]
However, in other disease processes, the benefit
to a laparoscopic approach may be only at the level of cosmesis. For example,
laparoscopic versus open pyloromyotomy for hypertrophic pyloric stenosis have
similar postoperative feeding and discharge outcomes with no difference in
complication rates. Therefore, the key difference between the laparoscopic and
open approach is in the cosmetic result. Interestingly, a recent study by
Haricharan et al.[4] evaluated the perceived benefit of laparoscopic
pyloromyotomy over open pyloromyotomy based on the appearance of the
postoperative scars. The study population included parents, college students and
first year medical students from a variety of different socioeconomic
backgrounds. After seeing photographs of laparoscopic and open pyloromyotomy
scars, 74% of the study population preferred the appearance of the scars after
laparoscopy. Up to 88% of respondents would pay an additional out-of-pocket
expense for their son or daughter to have the operation performed
laparoscopically. Based on this study of perceived value, cosmetic benefit is
important to current and potential parents with the overwhelming majority of
respondents preferring laparoscopic scars over open scars for their
children.
As pediatric surgeons have embraced minimally
invasive surgery for childhood conditions, the technological advances in
instrument miniaturization have broadened the application of minimal access
techniques to include procedures in neonates and infants as small as 1.5
kilograms. Many congenital malformations are particularly suited to minimal
access techniques given the benign nature of the disease processes.
Gastroesophageal reflux disease, Hirschsprung's disease, ovarian cysts and
congenital lung masses (cystic adenomatoid malformation and pulmonary
sequestration) are all routinely treated with minimally invasive approaches.
More recent advances in neonatal minimally invasive surgery include repair of
esophageal atresia with tracheoesophageal fistula, congenital diaphragmatic
hernia, and duodenal atresia. With specialized training, advanced minimally
invasive surgeons can now repair these complex anatomic anomalies with
equivalent outcomes as the traditional open procedures.
Esophageal atresia with distal tracheoesophageal fistula
Esophageal atresia, with or without
tracheoesophageal fistula, occurs in 1 out of 4500 live births in the
United
States. The most common anatomic variant of
esophageal atresia is the presence of a tracheal fistula to the distant remnant
of the esophagus. This type of tracheoesophageal fistula occurs in 85% of all
infants born with esophageal atresia. Other organ systems can also be affected
in up to 20% of infants born with esophageal atresia. The spectrum of associated
anomalies is frequently referred to by the acronym VACTERL, which includes
vertebral, anorectal, cardiac, tracheoesophageal, renal, and limb
abnormalities.
Diagnosis of esophageal atresia, with or without
tracheoesophageal fistula, is usually made after birth with symptoms of
respiratory distress, excess oral secretions, choking on attempted feeds and an
inability to pass an oro- or naso-gastric tube beyond 12 cm. The ultimate goal
of the surgical correction of esophageal atresia with distal tracheoesophageal
fistula is to restore esophageal continuity and ligate the tracheal fistula. The
traditional operation occurs via a right thoracotomy (large rib- and
muscle-splitting incision of the posterior and lateral chest wall) with
subsequent division/ligation of the tracheoesophageal fistula and anastomosis of
the proximal and distal esophageal segments. The thoracoscopic repair is
different from the traditional operation only in that the chest is accessed
through 3 incisions, 5 mm each, in the right chest.[5, 6] Early complications
include esophageal anastomotic leak, recurrent tracheoesophageal fistula,
gastroesophageal reflux, tracheomalacia and esophageal anastomotic stricture
formation. Late complications include progressive gastroesophageal reflux,
recurrent esophageal stricture formation and recurrent tracheoesophageal
fistula.
Holcomb et al.[7] reviewed the combined results of
104 neonates undergoing primary thoracoscopic repair of esophageal atresia with
tracheoesophageal fistula at 6 different institutions worldwide. The mean weight
at operation was 2.6 kg (+/-0.5) with a mean operative time of 129.9 minutes
(+/-55.5). Outcomes were compared to historical controls in infants undergoing
traditional thoracotomy repair. The esophageal anastomotic leak rate was 7.6%
(compared to 10%-21% historical) with a stricture rate of 3.8% (compared to 18%
historical). Recurrent tracheoesophageal fistulization rate is widely reported
to be between 2.2% to 12% in various historical reports. In this series, the
recurrent fistulization rate was 1.9%. Therefore, thoracoscopic repair of
esophageal atresia with distal tracheoesophageal fistula is feasible and can be
done with equivalent surgical outcomes to historical controls of the traditional
thoracotomy repair. However, the retrospective nature of this large series does
not allow for direct comparison of results between thoracoscopic and traditional
thoracotomy approaches. Without these direct data, comparative outcomes for
length of stay and postoperative pain are not yet available.
Congenital diaphragmatic hernia
Approximately 1000 infants per year in the
United
States are born with a congenital diaphragmatic
hernia. The diaphragmatic defect occurs in the left chest in 80% of all cases.
Associated anomalies can occur, with skeletal defects in up to 32% of infants
and cardiac anomalies in 24% of infants with diaphragmatic hernia. Syndromes
commonly associated with diaphragmatic hernia include trisomy 21 and 18, Frey's
syndrome, Beckwith-Wiedemann syndrome and Goldenhar's syndrome.
The pathophysiology of diaphragmatic hernia is
based overwhelmingly on the hypoplastic development of both the ipsilateral and
contralateral lungs. The hypoplasia occurs at the level of bronchial branching
and also has effects on pulmonary vascular development. The end result is
limitation in oxygenation and ventilation, with associated pulmonary
hypertension. The majority of diaphragmatic hernias are diagnosed prenatally
with ultrasonographic identification of intestine in the fetal chest. Delivery
of infants with diaphragmatic hernia usually occurs at specialized neonatal
centers to initiate immediate optimal respiratory support of the
newborn.
After stabilization of the ventilatory and
oxygenation status of the neonate, the surgical management includes reduction of
the bowel out of the ipsilateral chest, followed by repair of the diaphragmatic
defect either primarily or with the aid of a synthetic patch. The traditional
open operation occurs via an ipsilateral transverse abdominal incision with
direct repair of the diaphragmatic defect with or without a patch. The minimally
invasive approach has been successfully completed both through the abdominal and
thoracic cavities,[8, 9] with the thoracic approach more widely accepted.[10,
11] The minimally invasive approach differs from the open approach only in the
method of access to the anatomy. Both primary and patched diaphragmatic repairs
can safely be completed using minimally invasive approaches. (See Figures
1–3.)
Early experience with minimally invasive diaphragmatic repair as reported by
Arca et al.[12] suggested complications in up to 50% of all patients. However,
subsequent studies have documented both the safety and efficacy of minimally
invasive repair of diaphragmatic hernias. Yang et al.13 sought to define
criteria for successful outcomes after minimally invasive diaphragmatic hernia
repair. These criteria include preoperative nasogastric tube in an
intraabdominal location (stomach in abdominal cavity and not up in chest),
ventilatory peak inspiratory pressure less than 24 mm Hg and no clinical
evidence of pulmonary hypertension. Using these criteria, these authors were
able to successfully repair the diaphragmatic defect in 30 neonates by minimally
invasive techniques. These repairs were accompanied by low morbidity and no
mortality. As experience with minimally invasive repair of diaphragmatic hernia
continues to accumulate, advanced centers are now easily performing even complex
patch repairs of large diaphragmatic defects using minimally invasive
techniques.[8, 14]
Duodenal atresia and duodenal web
Congenital obstruction of the duodenum occurs in
approximately 1 out of 6000 live births. Nearly 30% of these obstructions will
occur in association with trisomy 21. A complete obstruction is frequently
diagnosed prenatally by the classically described "double bubble" visualized on
a prenatal ultrasound. The 2 bubbles visualized on the ultrasound represent the
obstructed stomach and proximal duodenum filled with swallowed amniotic fluid.
The obstruction is confirmed by a double bubble on plain abdominal radiograph
after birth. The presentation of a partial obstruction caused by a membranous
web may be delayed if the aperture of the web is sufficiently wide to allow
passage of milk or formula. However, the majority of infants with a duodenal web
will fail to tolerate diet advances to solid foods.
The goal of the operation is to restore intestinal
continuity. The traditional repair of duodenal obstruction is performed via a
right upper quadrant laparotomy incision with mobilization of the proximal and
distal duodenal segments and subsequent creation of a duodenoduodenostomy
(surgical connection of the proximal and distal duodenal segments). The
laparoscopic repair differs from the traditional operation only in the manner of
access to the abdominal cavity. Instead of a right upper quadrant incision, 4
incisions, 3 mm each, spaced out across the abdomen and flank are used to
perform the operation.
Beginning with the first report in 2001, there have been
3 different case descriptions of laparoscopic repair of duodenal obstruction in
the neonatal population. Bax et al.[15] successfully repaired a complete
duodenal atresia in a 3.2 kg infant. Rothenberg[16] reported successful
laparoscopic repair of 3 duodenal atresias and 1 duodenal web. All 4 infants
were on full enteral feeds within 7 days of the procedure and subsequent upper
gastrointestinal imaging show no evidence of stricture or obstruction. A more
recent report by Valusek et al.[17] describes the use of a metallic tissue
approximation device to aid in laparoscopic suturing for the duodenoduodenostomy
in 1 infant. There were no adverse events reported in any of the case series of
laparoscopic duodenal atresia repair. Larger studies comparing traditional open versus laparoscopic repair
of duodenal atresia have not yet been published.
Summary
Dramatic advancement in the miniaturization of
minimally invasive instruments and optics has provided the background for
innovative applications of minimally invasive techniques to correct some of the
most challenging congenital anomalies. Early studies in esophageal atresia with
tracheoesophageal fistula, duodenal atresia, and diaphragmatic hernia have
demonstrated that minimally invasive repairs are safe and effective. Ongoing
direct comparison studies are eagerly anticipated with respect to length of
stay, return of bowel function, postoperative narcotic use, and cosmesis.
Similar to other minimally invasive pediatric procedures, it is possible that
minimally invasive techniques for specific congenital anomalies will become the
preferred approach for operative repair.
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