Describe laparoscopic techniques used to repair inguinal hernias and the correction of pectus excavatum in pediatric patients and list their advantages over open surgery.

Explain the potential advantages and benefits (as well as limitations) of using the da Vinci robotic system in pediatric MIS.

Evaluate the limitations of laparoscopic restorative proctocolectomy.

Identify major categories of complications that are specific to MIS.

Predict specific complications associated with tools commonly used in MIS.

Laparoscopic Surgery in Children
Andre Hebra, MD, Professor of Surgery and Pediatrics, and Chief, Division of Pediatric Surgery, Medical University of South Carolina, Charleston

Laparoscopic hernia repair: pediatric surgeons have lagged behind general surgeons in adopting minimally invasive approach for repair of inguinal hernias (argued that standard repair could be done through very small incision, and therefore no real role for laparoscopy); however, according to 2006 study, laparoscopic needle-assisted repair in pediatric patients associated with only 3% rate of recurrence and 5% incidence of transient hydrocele; steps of laparoscopic repair are high ligation of hernia sac, using simple needle-assisted approach without large incisions; advantages of laparoscopic approach—safe; effective; leaves no visible scars; “tremendous” patient and family satisfaction; speaker’s experience— 92 cases (patients 3 wk to 10 yr of age); in first 10 patients, average operating time 40 min (now down to 10 min); among first 20 patients, 3 recurrences (current recurrence rate 0%); no complications; patient and family satisfaction extremely high; no information on long-term outcomes

Repair of pectus excavatum: Ravitch procedure gold standard; involves cartilage resection and sternal osteotomy, and requires broad exposure of anterior chest and sternum through midline or transverse incision; takes 5 hr; extremely invasive but very effective; introduction of minimally invasive technique for repair of pectus excavatum (Nuss, 1996)— convex steel bar inserted into chest under sternum; bar flipped into convex position so as to push outward on sternum, correcting deformity; requires just few small incisions on side where bar inserted; initially done without thoracoscopy; initial experience with very young patients (majority 5-10 yr of age) who tend to have very pliable chest wall (in older patients, eg, individuals 15-18 yr of age, who have fairly rigid chest wall, procedure not as easy to perform and stability of bar less predictable); in first major study of procedure, reported overall complication rate 20%; however, with subsequent modification of Nuss procedure (including incorporation of thoracoscopy), complications have essentially disappeared (only reported complications risk for bar displacement [very rare] and some epidural-related problems); pectus excavatum repair primarily cosmetic operation (although repair can improve pulmonary reserve, stamina, and exercise tolerance, physiologically, condition not considered life-threatening); however, speaker strongly believes patients should undergo surgery because of ability to positively influence body image and self-esteem

Robotic minimally invasive pediatric surgery: da Vinci robotic system lets surgeon control ≤4 operating arms; advantages of system—surgeon in charge of camera control; true 3-D visualization of surgical field; allows for correction from left or right as arms respond to (and mimic) surgeon’s movements within patient’s body; enables very fine movements (highly precise); provides greater range of motion; filters out tremors; enhances surgeon’s dexterity; restores degree of freedom; potential benefits in pediatric surgery—manufacturer argues that system can improve overall complication rates (however, impossible to prove); allows surgeons to expand applications of minimally invasive surgery (MIS); may increase referrals; limitations of system—expense; manufacturer working on development of smaller (5 mm) instruments for use in infants and children; lack of good feedback sensation; bulky, large, and complex (robotic arms take up space); requires set-up time and specialized training (but once personnel trained and accustomed to system, not a problem); number-one limitation that robot target-specific (ie, once robot docked and in position, arms working in one region and cannot travel to other areas of abdomen or chest

Controversies in Pelvic Pouch Surgery: Laparoscopic Pouch Surgery
Steven D. Wexner, MD, Professor of Surgery, Cleveland Clinic Foundation Health Sciences Center of Ohio State University College of Medicine; and Chief of Staff, Chair, Department of Colorectal Surgery, and Chair, Division of Research and Education, Cleveland Clinic Florida, Weston

Introductory remarks: speaker and colleagues started doing laparoscopically assisted ileal pouch procedures in 1991; group’s initial study included 5 patients who underwent laparoscopically assisted total abdominal colectomy (L-TAC) and ileoproctostomy (IL) and L-TAC with ileo-anal reservoir (IAR); concluded that L-TAC technically feasible; 2 yr later, group updated series with larger patient population; results showed no significant gains in laparoscopic group and slightly higher morbidity; in 12 yr since speaker’s original pilot series, operative time for L-TAC with ileal pouch anal anastomosis (IPAA) has averaged ≤5 hr in most studies

Potential benefit of laparoscopic surgery: some recent comparisons of laparoscopic and open proctocolectomy with IPAA show that operative times often long in both groups; morbidity rate higher in laparoscopic group in some studies and lower in others; uncontested advantage is cosmesis (clearly better if pouch constructed laparoscopically through small incision); however, as shown in many recent series, even in hands of highly skilled laparoscopic surgeon with dedicated team, laparoscopic operation difficult to justify

Dutch study (Dunker et al): compared functional outcome, quality of life (QOL), body image, and cosmesis in patients after laparoscopic-assisted and conventional restorative proctocolectomy; patients well matched; functional outcome and QOL did not differ when compared to conventional IPAA, and better cosmesis single most important long-term advantage

Mayo Clinic Group study (Larson et al, 2006): 100 consecutive laparoscopic IPAA cases (75 laparoscopic-assisted, 25 hand-assisted) case-matched to 200 open IPAA patients by age, type of operation, sex, date of operation, and body mass index; patients well stratified; overall laparoscopic conversion rate, 6%; median operative time longer in laparoscopic group (3.5 hr); postoperative morbidity equivalent; while results significantly better than those seen in speaker’s pilot study, outcomes still not significantly better than with open operation; researchers concluded laparoscopic IPAA equivalent to open operation for safety and feasibility, and that it significantly improved short-term recovery outcomes

One-stage laparoscopic restorative proctocolectomy without ileostomy: study of 32 patients, 24-mo follow- up; postoperative morbidity similar to that in most literature on pouch procedures; 10% of patients required reoperation; median length of hospital stay, 6 days; procedure considered safe and effective

Laparoscopic-assisted colectomy and IPAA with and without protective ileostomy: 59 patients in study; ileostomy constructed only when operation difficult or anastomosis under tension; overall complication rate close to 50%, and rate of major complications requiring reoperation 4 times greater in group without ileostomy; concluded that laparoscopic approach probably does not reduce need for protective ileostomy

Meta-analysis by Tilney et al: evaluated short-term outcomes of laparoscopic vs open approaches to ileal pouch surgery; looked at 10 studies; 329 patients (50% underwent laparoscopic procedure); in laparoscopic group—operative time clearly longer; blood loss lower; duration of ileus not shorter; quicker time to normal diet; no overall difference in length of hospitalization between 2 groups; based on speaker’s review of published studies, no advantages to laparoscopic approach, at least in short term; results of meta-analysis suggest that current benefits of laparoscopic vs open surgery limited and evidence insufficient to support widespread adoption of this technique

Description of laparoscopic technique: patient placed in lithotomy position (stents optional; consider in patient who has had significant abdominal surgery in past); 4 working ports (2 placed on right side and 2 on left); can use Pfannenstiel incision but, in general, speaker prefers short vertical suprapubic incision; through ports and in number of different positions, left and right quadrants of colon are mobilized in the same manner as in standard open procedure (medial to lateral, or vice versa, depending on surgeon’s preference); speaker recommends using 5-mm blade harmonic scalpel for mobilization, and suggests using bipolar energy source for control of larger vessels; most challenging part of procedure dissection of greater omentum; speaker does not attempt high ligation; vascular ligation (must take all vessels) and pelvic dissection can be done intracorporeally through very small incision; speaker then divides terminal ileum and creates pouch extracorporeally; performs standard anastomosis

Technical Challenges: Avoiding Laparoscopic Complications
Steven D. Schwaitzberg, MD, Chief of Surgery, Department of General Surgery, Division of Minimally Invasive Surgery, Cambridge Hospital, Cambridge, MA

Complications of access: trocar injuries—overall incidence 3% (of these, 0.1% major vascular injuries, 1% bowel injuries; 80% of patient injuries caused by initial trocar insertion); placing trocar toward pelvis riskiest type of blind puncture; abdominal wall hemorrhage—fairly common; caused when vessel in abdominal wall punctured by trocar; can be managed many ways (speaker prefers using very small Bovie electrocautery tip to coagulate small peritoneal bleeding; notes that use of Foley catheter and clamp should be abandoned [replaced by direct suturing of abdominal wall, which is surest way to control port- site bleeding]); trocar-site hernia (trocars >10 mm, particularly those placed below umbilicus, should be sutured closed at end of case); controversy about which technique best for trocar insertion (options include Veress needle, optical trocar, open technique, direct trocar insertion, and radial expanding trocar); optical trocars do not prevent injuries; vigilance imperative (always assume you can create an injury)

Complications of physiology: cardiac complications—in general, most minimally invasive operations performed utilizing pneumoperitoneum; pneumoperitoneum causes decrease in preload and increase in afterload; arrhythmias and bradycardia secondary to vagal stimulation seen regularly; such complications always worse in patients who are hypovolemic; in early 1990s, significant concerns about effects of pneumoperitoneum on high-risk cardiac patients; however, many series show that MIS can be performed in these patients with good clinical results; carbon dioxide (CO2 ) embolism—incidence 2 to 15/100000 cases; classic symptom initial sharp rise in end-tidal carbon dioxide, followed by sharp fall; mill wheel murmur characteristic; placing patient in Trendelenburg position with right side up (Durrant’s position) helps to trap gas bubbles in right atrium; aspiration of foamy blood from right ventricle “absolutely” diagnostic; if patient placed on 100% oxygen (O2 ), CO2 absorption rapid enough that patient likely to survive; however, when poorly treated, mortality at least 30%; deep venous thrombosis—can result from venous stasis induced by pressure from pneumoperitoneum; all patients undergoing laparoscopic surgery should get ≥1 form of prophylaxis (higher risk patients should receive 2 or 3 forms); CO2 retention—common; not problematic (resolves in 30 min); carbothorax—common after operations involving the chest; usually does not require chest tube placement (unless there is major loss of lung volume)

Complications of specific MIS tools: ultrasonic coagulator associated with 11% failure rate; ultrasonic harmonic scalpel (downside that blade hot; even with power off, blade hot enough to burn bowel); tools can break (surgeons have reported losing parts in abdomen); numerous reports of sealing failure with LigaSure vessel sealing system; fatal argon embolism leading to death has occurred with laparoscopic argon beam coagulator; cases in which endoscopic staples cut vessels but do not actually staple; wide variation in holding strengths with surgical clips; laparoscopic tacks problematic because they can migrate; reports of patient burns from laparoscopes; with cautery devices, inadvertent burns associated with defects in insulation (even bipolar cautery device can send errant current through “outer loop” phenomenon)

Complications of MIS-specific techniques: laparoscopic suturing—studies show that knot security and precision of suturing done during MIS procedures not quite as good as those done in their open counterparts

Complications of technology dependence: important for surgeons to utilize education and training to master necessary laparoscopic tools (and avoid dependence on technicians)

Complications of surgical techniques modified for MIS approaches: modification of traditional open operations has led to, eg, laparoscopic ventral hernia repair associated with rise in occurrence of seromas; development of laparoscopic gastric bypass associated with dramatic rise in incidence of Peterson’s hernia

Complications of MIS environment: environment complex and overwhelming; response to crisis different from response in open OR; studies show more experienced individuals perform better and that training through simulated crisis scenarios improves treatment in the laparoscopic environment

Complications for surgeon: surgeons subject to complications resulting from operating in MIS environment; no protections against MIS-associated hazards in surgeon’s workplace (eg, surgeons have no unions, very few standards for surgical equipment, no governmental protection)