Current Trends in Minimal Access Surgery for Neonates
Minimal access surgery (MAS) is a milestone development in the history of surgery. Several small puncture wounds are used to perform surgical procedures that would otherwise require a large incision. The benefits of MAS have been well documented in adults. With advances in miniaturized instruments, video technology, new surgical techniques and anaesthesia, MAS is increasingly performed in infants and neonates. Currently, it has been used in both neonatal chest and abdominal conditions. However, further clinical studies are required to document the benefit of MAS in neonates in the long term.
Keyword : Laparoscopy; Minimal access surgery; Neonatal surgery; Thoracoscopy
Minimal access surgery (MAS) is an important milestone development in the history of surgery. However, its use is not new to paediatric surgeons. The laparoscope was used for diagnostic purpose in children as early as the 1970s but its use had been confined to such.1 Since the early 1990s, there has been an explosive expansion of laparoscopic surgery in adults and the potential advantages have been well documented.2,3 Its use in children, however, was initially confined to a few centres only. With advances in miniaturised instruments, video technology, surgical techniques and anaesthesia, MAS is being increasingly applied in children in all areas. Over the last 10 years, the application of MAS techniques to neonates has progressed rapidly and is used in many chest and abdominal conditions.
General Principles of Minimal Access Surgery
In laparoscopic and thoracoscopic surgery, access is achieved via ports inserted through small puncture wounds in the abdominal or chest wall. Carbon dioxide (CO2) insufflation is used to expand the abdominal or thoracic cavity to allow enough room to work. A scope attached to a camera is passed through a port so that the procedure can be watched on a monitor. Light from an external source passes through fibreoptic rods within the scope and provides illumination to the operating field. Laparoscopic or thoracoscopic instruments are then passed through the ports for operative manipulations. These instruments are specially designed to allow maneuvers similar to standard open operative instruments. For thoracoscopy, single lung ventilation either by intubation of contralateral main stem bronchus or bronchial blocker of ipsilateral lung is the usual technique used to partially collapse the ipsilateral lung.4 A low-flow (<1 L/min) and low-pressure infusion (<4 mmHg) of CO2 is often needed to provide further compression of the partially collapsed lung in order to allow more room to work. For laparoscopy, the intra-abdominal pressure is usually maintained below 10 mmHg in neonates and proportionally higher in children. Meticulous control of the pressure is essential as carbon dioxide pneumoperitoneum may have profound physiological effects in neonates resulting in hypercapnia and respiratory acidosis.5 This can be compensated for by slight hyperventilation.6 Cardiovascular compromise may result from compression of the inferior vena cava leading to decreased venous return and hypotension.7
In general, neonates who have an unstable haemodynamic status with severe cardio-pulmonary compromise, bleeding disorders, severe abdominal sepsis or gross abdominal distension are not suitable for laparoscopic/ thoracoscopic surgery.
A number of abdominal operations using laparoscopic approach have been performed in neonates. In some conditions, laparoscopy has virtually replaced open surgery as the operation of choice while in others it may be a good alternative.
Fundoplication and Gastrostomy
Fundoplication with or without feeding gastrostomy is a common procedure performed in neonates. Indications include gross oesophageal reflux, recurrent aspiration, and profound neurological impairment with failure to thrive. Laparoscopic approach has virtually replaced open surgery. The operation can be performed using 3 to 4 ports and consists essentially of mobilisation of the distal oesophagus, approximation of the crura behind the oesophagus and loose wrapping of the distal oesophagus with the fundus. For those with feeding problem, a laparoscopic guided gastrostomy button is often inserted in the same setting.8 Indeed laparoscopic gastrostomy is often used as an alternative to percutaneous endoscopic gastrostomy as it allows accurate selection of the site for gastrostomy and also avoidance of accidental injury to nearby structures during creation of the gastrostomy.
Pull-through for Hirschsprung's Disease
The management of Hirschsprung's disease has gone through revolutionary changes from the traditional open two to three stage procedure to the open one stage procedure, and more recently to the laparoscopic-assisted or trans-anal one stage pull-through. All the traditional techniques of Swenson, Duhamel and Soave can be applied laparoscopically but the Soave (endorectal) technique is most commonly performed.9 The procedure involves laparoscopic localisation with histological confirmation of the transitional zone, mobilisation of the colon, trans-anal sub-mucosal dissection, pull-through of the colon and anastomosis of the colon proximal to the transition zone to the anal region. Early result of the procedure has been satisfactory. 9,10 Although further studies are necessary to determine the long-term outcome, it is likely that laparoscopic-assisted pull-through procedure is going to stay and will become increasingly popular.
Pull-through for Imperforate Anus
High type of imperforate anus has been traditionally managed with an initial defunctioning colostomy followed later by pull-through procedure using an abdominal perineal approach or posterior sagittal anorectoplasty. Laparoscopic-assisted pull-through for a high anomaly has been described.11 The fistula is first dissected and ligated using laparoscopic approach. The site of the sphincteric muscle complex is identified by muscle stimulation on the perineum. A tract is then made through the muscle complex into the pelvic cavity as guided by the laparoscope. This tract is then dilated and the large bowel is pulled through to the perineum and a neo-anus reconstructed. Short-term result has been promising though the long-term outcome of continence needs further study. One stage primary pull-through without initial defunctioning colostomy has been reported.11 This has the advantage of saving multiple operations, avoiding the problems of colostomy and the potential neural developmental superiority of the infant stooling through the anus soon after birth. However, primary pull through in newborn is technically difficult, and long-term data is lacking.
Ramstedt's pyloromyotomy has been regarded as the gold standard for the management of hypertrophic pyloric stenosis. In order to have a better cosmetic effect, approach using peri-umbilical incision has been described with successful outcome.12 Laparoscopic pyloromyotomy gives equally good result13 with excellent cosmetic effect and is becoming an increasingly popular alternative.
The repair of intestinal atresia is possible using laparoscopic approach. Laparoscopic repair for duodenal atresia has been reported14 although cases with associated severe cardiac anomaly may limit its use. The proximal and distal segments are mobilised and then joined together using intracorporeal sutures. For more distal intestinal atresia, the dilated bowel loops may render laparoscopic approach more difficult and technically demanding.
Malrotation and Volvulus
Malrotation with or without volvulus has been repaired using laparoscopic approach.15,16 The volvulus is untwisted and a Ladd's procedure performed. For cases with equivocal findings, laparoscopy can provide a diagnostic tool.16 In those cases with significant bowel ischaemia and dilatation, laparoscopic approach may be difficult and an open approach is preferable.
Laparoscopic herniotomy has been reported.17 Advantages include the detection of contralateral hernia allowing repair in the same setting, and the avoidance of potential injury to the vas deferens and cord vessels that might be associated with the conventional open repair while the hernia sac is being stripped off the vas and vessels.
Intussusception is a common cause of intestinal obstruction in infants but less so in neonates. Non-operative treatment using pneumatic or hydrostatic reduction usually suffices for 80-90% of cases. Laparoscopy may have a role in those cases with equivocal complete reduction or unsuccessful non-operative treatment.18
Laparoscopy has been used in operative cholangiogram19 and liver biopsy in cases of prolonged jaundice. Sporadic cases of laparoscopic-assisted repair of biliary atresia and choledochal cysts have been reported.20 However the long-term results of these cases are not available and laparoscopic repair should only be used in selected cases.
Ovarian and Pelvic Disorders
Laparoscopy has been used in the treatment of ovarian cysts in neonates21 and in the dissection of the pelvic portion of sacrococcygeal teratoma.22
The application of laparoscopic surgery in paediatric urology is beginning to accelerate. Indications have expanded from diagnostic to ablative and recently to reconstructive procedures. The current status of its application includes orchidopexy for high undescended testis, varicocelectomy, total or partial nephrectomy, dismembered pyeloplasty, adrenal surgery and ureteric re-implantation etc.23 However, these procedures are seldom required to be performed in the neonatal period. Instead, endo-urology may be required for ablation of posterior urethral valve and for provision of external or internal drainage in cases of obstructive uropathy.
Necrotising enterocolitis (NEC) is the most common gastrointestinal emergency in neonates affecting mainly premature infants. Lack of specific indications for surgical intervention is occasionally encountered in critically ill babies with suspected NEC. Laparoscopy has been used in these cases either confirming the diagnosis or reviewing the extent of the disease, which can guide the subsequent management.24
Thoracoscopy is not as commonly used as laparoscopy in neonates. It can be used for diagnostic purpose such as biopsy of lung lesions.4 Resections of thoracic lesions like cystadenomatoid malformations, sequestrations, mediastinal masses25 can be performed via thoracoscopy.
The management of oesophageal atresia has gone through revolutionary changes. One of the recent advancement is the use of thoracoscopy to clip and divide the tracheo-oesophageal fistula and to join the proximal and distal oesophageal segments.26 Apart from the minimal wound pain and the excellent cosmetic effect, there is the avoidance of the potential musculoskeletal weakness that may result from the conventional open thoracotomy. However, thoracoscopy may not be applicable in babies who are premature or small for dates and with associated severe cardiac and pulmonary anomalies.
Diaphragmatic Hernia and Eventration
Thoracoscopic or laparoscopic approach has been used in the repair of diaphragmatic hernia in stable infants.27,28 Symptomatic eventration of the diaphragm can be plicated using a thoracoscopic technique.
Patent Ductus Arteriosus
A patent ductus arteriosus can be clipped using thoracoscopic means preserving the recurrent laryngeal nerve.29
Potential Benefits and Complications of Minimal Access Surgery
Despite the exponential growth of MAS in children in the past few years, its application in neonates should not be considered as a direct transposition of techniques used in older children.30 Because of the much reduced working space and the potential effects of carbon dioxide pneumoperitoneum and pneumothorax on an immature neonatal cardiopulmonary system, neonatal MAS is rendered more difficult.31 Most of the reports on the feasibility of MAS in neonates are case reports or small clinical series, and there is hardly any multicentric study on the complications and cardiorespiratory effects of neonatal MAS.32 A multicentric assessment of the safety of neonatal MAS was reported recently.33 There was no mortality but a significant morbidity (19.2%) including both surgical (7.5%) and anaesthetic incidents (12%). The majority of the surgical incidents was minor and was likely to be related to the learning curve of the surgeons. The anaesthetic incidents occurred during insufflations including desaturation, transient hypotension, hypercapnia, hypothermia and metabolic acidosis. It was possible to limit these respiratory, haemodynamic and thermic imbalances in 42% by ventilatory adjustments, vascular expansion and external warming. Insufflations had to be temporarily (35%) or definitively (23%) stopped, and conversion to open surgery was required in the latter. The significant risk factors for an insufflation-related incident were young age, low body temperature, thoracic insufflation, high pressure and flow of insufflation, and length of surgery. The overall rate of conversion to open surgery was 15%. This study stresses the importance of thorough preoperative evaluation and close surveillance of the haemodynamic and ventilatory status during insufflation. A pressure of 8 mm of Hg appears to be the limit beyond which the risk of insufflation-related incident tends to increase. The advances in specifically designed instruments for neonates and the growth in the experience of the surgeons will decrease the incidence of the surgical complications and the need for conversion to open surgery.
The benefits of MAS are evident with less adhesion, less postoperative pain, better cosmetic result and less length of hospital stay.34 It seems that the limit of MAS for neonates is not the technical feasibility but rather the right selection of those who would benefit.
State of Development in Hong Kong
In Hong Kong, MAS has been adopted in children as early as the 1990s but the rapid expansion occurred since 1998. Rapidly it is being used in all the paediatric surgical centres, and currently, all of the aforementioned procedures can be performed. As these procedures require the close co-operation of multi-disciplines, they can only be performed in recognised paediatric surgical centres. Indeed Hong Kong has become one of the leading centres in laparoscopic surgery with new pioneers and innovations. These innovative procedures on complex anomalies have been presented and subsequently published. International and regional conferences on paediatric MAS take place regularly, and prove to be of great help in its development.
Minimal access surgery has grown remarkably over the last twenty years and is continuing to expand. A lot of surgical operations in neonates can now be performed with minimal access surgery with good reported results. However few studies to date have been subjected to critical analysis and results must be interpreted with caution. With further advances and refinement in technology and technique, minimal access surgery should continue to expand and will be seen as a major changing trend in neonatal surgery.
1. Gans SL, Berci G. Peritoneoscopy in infants and children. J Pediatr Surg 1973;8:399-405.
2. Tittel A, Schippers E, Anurov M, Titkova S, Ottinger A, Schumpelick V. Shorter postoperative atony after laparoscopic-assisted colonic resection? An animal study. Surg Endosc 2001;15:508-12.
3. Velanovich V. Comparison of symptomatic and quality of life outcomes of laparoscopic versus open antireflux surgery. Surgery 1999;126:782-8.
4. Rothenberg SS. Thoracoscopy in infants and children. Semin Pediatr Surg 1998;7:194-201.
5. Fujimoto T, Segawa O, Lane GJ, Esaki S, Miyano T. Laparoscopic surgery in newborn infants. Surg Endosc 1999;13:773-7.
6. Tobias JD. Anesthetic considerations for laparoscopy in children. Semin Laparosc Surg 1998;5:60-6.
7. Gueugniaud PY, Abisseror M, Moussa M, et al. The hemodynamic effects of pneumoperitoneum during laparoscopic surgery in healthy infants: assessment by continuous esophageal aortic blood flow echo-Doppler. Anesth Analg 1998;86:290-3.
8. Chung DH, Georgeson KE. Fundoplication and gastrostomy. Semin Pediatr Surg 1998;7:213-9.
9. Georgeson KE, Cohen RD, Hebra A, et al. Primary laparoscopic-assisted endorectal colon pull-through for Hirschsprung's disease: a new gold standard. Ann Surg 1999;229:678-82.
10. Wong BPY, Chao NSY, Leung MWY, et al. Primary laparoscopic-assisted endorectal pull-through for Hirschsprung's disease; our early experience. Asian J Surg 2004;1(1 Suppl):38S.
11. Georgeson KE, Inge TH, Albanese CT. Laparoscopically assisted anorectal pull-through for high imperforate anus--a new technique. J Pediatr Surg 2000;35:927-30.
12. Tan KC, Bianchi A. Circumumbilical incision for pyloromyotomy. Br J Surg 1986;73:399.
13. Downey EC Jr. Laparoscopic pyloromyotomy. Semin Pediatr Surg 1998;7:220-4.
14. Rothenberg SS. Laparoscopic duodenoduodenostomy for duodenal obstruction in infants and children. J Pediatr Surg 2002;37:1088-9.
15. Bass KD, Rothenberg SS, Chang JH. Laparoscopic Ladd's procedure in infants with malrotation. J Pediatr Surg 1998;33:279-81.
16. Gross E, Chen MK, Lobe TE. Laparoscopic evaluation and treatment of intestinal malrotation in infants. Surg Endosc 1996;10:936-7.
17. Schier F, Montupet P, Esposito C. Laparoscopic inguinal herniorrhaphy in children: a three-center experience with 933 repairs. J Pediatr Surg 2002;37:395-7.
18. van der Laan M, Bax NM, van der Zee DC, Ure BM. The role of laparoscopy in the management of childhood intussusception. Surg Endosc 2001;15:373-6.
19. Senyuz OF, Yeilda E, Emir H, et al. Diagnostic laparoscopy in prolonged jaundice. J Pediatr Surg 2001;36:463-5.
20. Martinez-Ferro M, Esteves E, Laje P. Laparoscopic treatment of biliary atresia and choledochal cyst. Semin Pediatr Surg 2005;14:206-15.
21. Mahomed A, Jibril A, Youngson G. Laparoscopic management of a large ovarian cyst in the neonate. Surg Endosc 1998;12:1272-4.
22. Bax NM, van der Zee DC. Laparoscopic clipping of the median sacral artery in huge sacrococcygeal teratomas. Surg Endosc 1998;12:882-3.
23. Peters CA. Laparoscopy in pediatric urology. Curr Opin Urol 2004;14:67-73.
24. Pierro A, Hall N, Ade-Ajayi A, Curry J, Kiely EM. Laparoscopy assists surgical decision making in infants with necrotizing enterocolitis. J Pediatr Surg 2004;39:902-6.
25. Dillon PW, Cilley RE, Krummel TM. Video-assisted thoracoscopic excision of intrathoracic masses in children: report of two cases. Surg Laparosc Endosc 1993;3:433-6.
26. Rothenberg SS. Thoracoscopic repair of tracheoesophageal fistula in newborns. J Pediatr Surg 2002;37:869-72.
27. Shah AV, Shah AA. Laparoscopic approach to surgical management of congenital diaphragmatic hernia in the newborn. J Pediatr Surg 2002;37:548-50.
28. Taskin M, Zengin K, Unal E, Eren D, Korman U. Laparoscopic repair of congenital diaphragmatic hernias. Surg Endosc 2002;16:869.
29. Rothenberg SS, Chang JH, Toews WH, Washington RL. Thoracoscopic closure of patent ductus arteriosus: a less traumatic and more cost-effective technique. J Pediatr Surg 1995;30:1057-60.
30. Wurst H, Schulte-Steinberg H, Finsterer U. Pulmonary CO2 elimination in laparoscopic cholecystectomy: a clinical study. Anaesthesist 1993;42:427-34.
31. Bozkurt P, Kaya G, Yeker Y, Tunali Y, Altintas F. The cardiorespiratory effects of laparoscopic procedures in infants. Anaesthesia 1999;54:831-4.
32. Rangel SJ, Henry MC, Brindle M, Moss RL. Small evidence for small incisions: pediatric laparoscopy and the need for more rigorous evaluation of novel surgical therapies. J Pediatr Surg 2003;38:1429-33.
33. Kalfa N, Allal H, Raux O, et al. Multicentric assessment of the safety of neonatal videosurgery. Surg Endosc 2007;21:303-8.
34. Georgeson KE, Robertson DJ. Minimally invasive surgery in the neonate: review of current evidence. Semin Perinatol 2004;28:212-20.