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Advances in Pediatric MIS Over The Past Decade

Advances in Pediatric MIS Over The Past Decade. George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri. Advances in MIS. Development of Surgical Technique Thoracoscopic lobectomy Thoracoscopic repair EA/TEF

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Advances in Pediatric MIS Over The Past Decade

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  1. Advances in Pediatric MIS Over The Past Decade George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri

  2. Advances in MIS • Development of Surgical Technique • Thoracoscopic lobectomy • Thoracoscopic repair EA/TEF • Single site umbilical laparoscopic surgery (SSULS) • Refinement in Surgical Technique • Laparoscopic fundoplication • Laparoscopic pyloromyotomy • Definition of Perforated Appendicitis • Evidence Based Studies in MIS • Consensus B/W Drs. Pena & Georgeson regarding laparoscopy for anorectal atresia with a fistula above the prostatic urethra (IPEG 2009)

  3. Advances in MIS • Growth of IPEG • Development of good 3 mm instruments • Development of HD picture • Development of the stab incision technique

  4. 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?

  5. Thoracoscopic Repair EA/TEF

  6. Development of A Surgical TechniqueThoracoscopic Repair EA/TEF – Lessons Learned Oscillating Ventilator Helpful

  7. 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, 2007

  8. 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?

  9. 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)

  10. Thoracoscopic Repair EA/TEF(104 Patients) • Fistula Ligation • 37 pts: suture ligation • 67 pts: clip ligation Ann Surg 242: 422-430, 2005

  11. Thoracoscopic Repair EA/TEFAssociated Anomalies(104 Patients)

  12. 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, 2005

  13. 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, 2005

  14. Thoracoscopic Repair EA/TEFConversion to Open5 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

  15. Thoracoscopic Repair EA/TEF104 Patients Waterston A: > 5.5 lb with no significant associated problems Waterston B: 4-5.5 lbs. or higher weight with moderate pneumonia or congenital anomaly Waterston C: weight < 4 lb or higher weight with severe pneumonia or congenital anomaly

  16. Thoracoscopic Repair EA/TEF N.R.: Not reported A: 87% are Gross Type C B: Stricture is defined as a significant narrowing on the initial esophagram C: Stricture in this paper is defined as requiring > 4 dilations D: Stricture in this paper is defined as requiring > 2 dilations

  17. EA/TEF Operative Approach ThoracoscopyThoracotomy

  18. Thoracoscopic Repair EA/TEFAdvantages of Thoracoscopy • Avoidance of musculoskeletal sequelae • Superior visualization of anatomy • Easy to identify fistula for ligation

  19. How To Get StartedNot The Ideal Case • 2 - 2.5 kg • Very high upper pouch • Complex single ventricle physiology • Prostaglandin dependent

  20. 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

  21. 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)

  22. Development of a Surgical TechniqueThoracoscopic Lobectomy – Lessons Learned Atlas of Pediatric Laparoscopy and Thoracoscopy Holcomb, Rothenberg, Georgeson

  23. Development of a Surgical TechniqueSSULS • Why did it develop? • Who benefits patient or surgeon? • What operations are applicable? • Special equipment needed?

  24. SSULSWhat Operations Are Applicable? • Appendectomy • Cholecystectomy • Splenectomy • Ileal or colonic resection (IBD or segmental lesion) – extra-corporeal anastomosis • Pyloromyotomy

  25. SSULSSpecial Equipment • SILS port (Covidien, Inc.) • Cholecystectomy • Splenectomy • Segmental ileal or colonic resection • Long telescope (300, 450)

  26. SSULSCholecystectomy

  27. SSULS Appendectomy

  28. SSULS Appendectomy

  29. Refinement in TechniqueLap. Fundoplication • Cautery in pts <4-5 yrs • Minimal esophageal dissection/mobilization

  30. Refinement in TechniqueLap Pyloromyotomy

  31. Definition of Perforated Appendicitis Hole In appendix Fecalith in abdomen J Pediatr Surg 43:2242-2245, 2008

  32. Definition of Perforated Appendicitis J Pediatr Surg 43:2242-2245, 2008

  33. Evidence Based Studies in MISLaparoscopic vs Open Pyloromyotomy Ann Surg 244:363-370, 2006

  34. Evidence Based Studies in MISLaparoscopic vs Open Pyloromyotomy Ann Surg 244:363-370, 2006

  35. Thoracoscopic Debridement vs Fibrinolysis for Empyema Patient Variables at Consultation VATS tPA P Value Age (Years) 4.8 5.2 0.77 Weight (kg) 24.6 20.7 0.52 WBC 20.8 19.7 0.71 O2 support (L/min) 0.81 0.79 0.96 Days of Symptoms 9.0 10.6 0.32 ER/PCP visits 2.9 2.7 0.69 J Pediatr Surg 44:106-111, 2008

  36. Thoracoscopic Debridement vs Fibrinolysis for Empyema LOS (Days) 6.89 6.83 0.96 O2 tx (Days) 2.25 2.33 0.89 PO Fever (Days) 3.1 3.8 0.46 Analgesic doses 22.3 21.4 0.90 Patient Charges $11,660 $7,575 0.01 Outcomes VATS tPA P Value 16.6% failure rate for fibrinolysis J Pediatr Surg 44:106-111, 2008

  37. London Prospective Trial VATS 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, 2006

  38. Treatment algorithm for empyema in children based on level 1 evidence. Current Management Algorithm

  39. Evidence Based Studies in MIS Initial Laparoscopic Appendectomy vs Initial Non-operative Management for Patients Presenting with Appendicitis and Abscess APSA, 2009 J Pediatr Surg 45:236-240, 2010

  40. Evidence Based Studies in MIS Initial Laparoscopic Appendectomy vs Initial Non-operative Management for Patients Presenting with Appendicitis and Abscess APSA, 2009 J Pediatr Surg 45:236-240, 2010

  41. 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

  42. Development of the Stab Incision Technique

  43. The Use of Stab Incisions PAPS, 2003 J Pediatr Surg 38:1837-1840, 2003

  44. Cost Savings from Stab Incisions PAPS, 2003 J Pediatr Surg 38:1837-1840, 2003

  45. What Advances Will Be Made in the Next Decade?

  46. QUESTIONS www.centerforprospectiveclinicaltrials.com www.cmhcenterforminimallyinvasivesurgery.com

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