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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

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
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)
advances in mis3
Advances in MIS
  • Growth of IPEG
  • Development of good 3 mm instruments
  • Development of HD picture
  • Development of the stab incision technique
development of a surgical technique thoracoscopic repair ea tef lessons learned
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?
development of a surgical technique thoracoscopic repair ea tef lessons learned6
Development of A Surgical TechniqueThoracoscopic Repair EA/TEF – Lessons Learned

Oscillating Ventilator Helpful

development of a surgical technique thoracoscopic repair ea tef lessons learned7
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

development of a surgical technique thoracoscopic repair ea tef lessons learned8
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?
thoracoscopic repair ea tef results 104 patients
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
Thoracoscopic Repair EA/TEF(104 Patients)
  • Fistula Ligation
    • 37 pts: suture ligation
    • 67 pts: clip ligation

Ann Surg 242: 422-430, 2005

thoracoscopic repair ea tef results 104 patients12
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

thoracoscopic repair ea tef complications 104 patients
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

thoracoscopic repair ea tef conversion to open 5 pts
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
thoracoscopic repair ea tef 104 patients15
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

thoracoscopic repair ea tef16
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

ea tef
EA/TEF

Operative Approach

ThoracoscopyThoracotomy

thoracoscopic repair ea tef advantages of thoracoscopy
Thoracoscopic Repair EA/TEFAdvantages of Thoracoscopy
  • Avoidance of musculoskeletal sequelae
  • Superior visualization of anatomy
  • Easy to identify fistula for ligation
how to get started not the ideal case
How To Get StartedNot The Ideal Case
  • 2 - 2.5 kg
  • Very high upper pouch
  • Complex single ventricle physiology
  • Prostaglandin dependent
how to get started ideal case
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 technique thoracoscopic lobectomy lessons learned
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 technique thoracoscopic lobectomy lessons learned22
Development of a Surgical TechniqueThoracoscopic Lobectomy – Lessons Learned

Atlas of Pediatric Laparoscopy and Thoracoscopy

Holcomb, Rothenberg, Georgeson

development of a surgical technique ssuls
Development of a Surgical TechniqueSSULS
  • Why did it develop?
  • Who benefits patient or surgeon?
  • What operations are applicable?
  • Special equipment needed?
ssuls what operations are applicable
SSULSWhat Operations Are Applicable?
  • Appendectomy
  • Cholecystectomy
  • Splenectomy
  • Ileal or colonic resection (IBD or segmental lesion) – extra-corporeal anastomosis
  • Pyloromyotomy
ssuls special equipment
SSULSSpecial Equipment
  • SILS port

(Covidien, Inc.)

    • Cholecystectomy
    • Splenectomy
    • Segmental ileal or colonic resection
  • Long telescope (300, 450)
ssuls
SSULS

Appendectomy

refinement in technique lap fundoplication
Refinement in TechniqueLap. Fundoplication
  • Cautery in pts <4-5 yrs
  • Minimal esophageal dissection/mobilization
definition of perforated appendicitis
Definition of Perforated Appendicitis

Hole In appendix

Fecalith in abdomen

J Pediatr Surg 43:2242-2245, 2008

definition of perforated appendicitis32
Definition of Perforated Appendicitis

J Pediatr Surg 43:2242-2245, 2008

evidence based studies in mis laparoscopic vs open pyloromyotomy
Evidence Based Studies in MISLaparoscopic vs Open Pyloromyotomy

Ann Surg 244:363-370, 2006

evidence based studies in mis laparoscopic vs open pyloromyotomy34
Evidence Based Studies in MISLaparoscopic vs Open Pyloromyotomy

Ann Surg 244:363-370, 2006

thoracoscopic debridement vs fibrinolysis for empyema
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

thoracoscopic debridement vs fibrinolysis for empyema36
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

london prospective trial
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

evidence based studies in mis
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

slide40

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

mis studies in progress
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
slide43

The Use of Stab Incisions

PAPS, 2003

J Pediatr Surg 38:1837-1840, 2003

cost savings from stab incisions
Cost Savings from Stab Incisions

PAPS, 2003

J Pediatr Surg 38:1837-1840, 2003

questions
QUESTIONS

www.centerforprospectiveclinicaltrials.com

www.cmhcenterforminimallyinvasivesurgery.com