John J. Meehan

Erosion of the Nuss bar into the internal mammary artery 4 months after minimally invasive repair of pectus excavatum

The minimally invasive repair of pectus excavatum has become increasingly popular. Life-threatening complications have included bleeding and cardiac perforation. There have been a number of delayed cases of bleeding, many of which never demonstrated a clear source. We present a case of a delayed acute bleed from the Nuss bar eroding into the internal mammary artery 4 months after bar placement.

Robotic resection of mediastinal masses in children.

PURPOSE Robotic surgery may be particularly well suited for solid chest masses. In this paper, we present our initial experience by using robotic surgery to resect mediastinal masses in children. METHODS Five pediatric patients with an average age of 9.8 years (range, 2-17) and an average weight of 41.5 kg (range, 13.9-70.5) underwent a robotic resection of a mediastinal chest mass using the da Vinci Surgical Robot (Intuitive Surgical, Sunnyvale, CA). RESULTS Operative time ranged from 44 to 156 minutes, with an average of 113 minutes. The pathology varied considerably and included a ganglioneuroma, ganglioneuroblastoma, teratoma, germ cell tumor, and a large inflammatory mass of unclear etiology. No complications or conversions occurred. Average length of hospitalization was 1.4 days. Follow-up averaged 2 years, with no evidence of recurrence in any patient. CONCLUSIONS Robotic surgery is safe and effective for resecting solid mediastinal chest masses. The articulating instruments are particularly helpful for dissecting around a solid mass within the rigid thoracic cavity.

Robotic surgery in small children: is there room for this?

Some pediatric surgeons may be reluctant to use robotic surgery for small patients because the only available surgical robot might seem too large for smaller patients. However, we have found this concern invalid. We have been successful in a wide variety of minimally invasive surgery procedures using robotics for general surgery applications in small children. However, several technical issues must be considered in order to optimize this technology for these children. In this article, we present a retrospective review of 45 patients of less than 10 kg who underwent robotic surgery and discuss the adjustments we made in order to adapt this technology to our small patients in a wide variety of general surgical procedures.

Ewing sarcoma/primitive neuroectodermal tumor arising from the adrenal gland in an adolescent†

We review the case of an adolescent who presented with flank pain, fatigue and a discrete nonfunctioning adrenal lesion which was found to be an adrenal Ewing sarcoma/primitive neuroectodermal tumor (ES/PNET). The patient was treated with a minimally invasive adrenalectomy as a component of multimodal therapy, including seven courses of chemotherapy and whole abdominal radiation. She is currently disease free 14 months after the operation and 3 months off therapy. Pediatr Blood Cancer 2011; 57: 691–692.

Robotic Repair of Congenital Diaphragmatic Anomalies

PURPOSE Congenital diaphragm anomalies, including eventration, Morgagni diaphragmatic hernias (M-CDH), and Bochdalek diaphragmatic hernias (B-CDH), have been successfully repaired by using minimally invasive surgery (MIS). However, some reports have shown a high recurrence rate for some defects, potentially due to difficulty associated with the rigid instruments. Robotic surgery may help close diaphragmatic anomalies more effectively. In this paper, we present a series of 8 consecutive patients with diaphragmatic anomalies who underwent robotic repair. METHODS We retrospectively reviewed patients with diaphragmatic anomalies. There were 2 patients with eventration, 5 with B-CDH, and 1 with M-CDH. All procedures were performed by using the Standard Da Vinci surgical robot (Intuitive Surgical, Sunnyvale, CA) with one camera arm (5-mm two-dimensional scope) and two instrument arms (5 mm). RESULTS Average age was 3.9 months (4 days to 12 months). Average weight was 3.6 kg (range, 2.2-10.5). Four B-CDH patients were approached through the chest and 1 from the abdomen. The patient with M-CDH had an abdominal repair, and both eventrations were performed from the chest. One B-CDH and 1 eventration were converted to thoracoscopic procedures. Average operative time was 1 hour and 20 minutes. One recurrence developed in a relatively large B-CDH repair that was closed primarily. Average follow-up was 20 months. CONCLUSIONS Robotic surgery is safe and effective for repairing diaphragm anomalies in small children. Although we prefer the thoracic approach for repairing the B-CDH, occasionally smaller newborns-perhaps those less than 2.5 kg-may do better with the abdominal approach, since the articulating instruments requiring a significant length in order to maneuver.

Robotic pulmonary resections in children: series report and introduction of a new robotic instrument.

Thermal sealing devices, such as the LigaSure (ValleyLab-Tyco Healthcare; Boulder, CO) or Gyrus PK (Gyrus ACMI, Maple Grove, MN) are minimally invasive instruments that can be used to seal the pulmonary parenchyma in pediatric lung resections. But these devices were only available in laparoscopic form, and no robotically similar instruments were manufactured. This handicaps the surgeon at the console, because these nonrobotic instruments must be manipulated and used by the bedside assistant instead of the console surgeon. In July 2006, the robotic Gyrus PK was introduced for the da Vinci Surgical Robot (Intuitive Surgical, Sunnyvale, CA). In this paper, we present our initial experience in performing robotic pulmonary resections in infants and children, including all cases before and after the robotic Gyrus PK was introduced.

The robotic Gyrus PK: a new articulating thermal sealing device and a preliminary series report.

Before 2006, thermal sealing devices, such as the LigaSure (ValleyLab-Tyco Healthcare, Boulder, CO) and the Gyrus (Gyrus ACMI, Maple Grove, MN), were not available for use with the Da Vinci Surgical Robot (Intuitive Surgical, Sunny Vale, CA). Surgeons had to incorporate standard nonarticulating handheld laparoscopic devices into their operations by having the bedside assistant use these devices. This took a significant portion of the procedure out of the hands of the operating surgeon. However, a new pulse-modulating device, the robotic Gyrus PK (RG-PK), has been manufactured specifically for the Da Vinci. We present our initial experience with this new device in 12 patients, all but 1 of which were children.

Robotic lateral pancreaticojejunostomy (Puestow)

A lateral pancreaticojejunostomy (LPJ), also known as the Puestow procedure, is a complex procedure performed for chronic pancreatitis when the pancreatic duct is dilated and unable to drain properly. Traditionally, these procedures are performed with open surgery. A minimally invasive approach to the LPJ using rigid handheld nonarticulating instruments is tedious and rarely performed. In fact, there are no prior laparoscopic case reports for LPJ in children and only a small handful of cases in the adult literature. This lack of laparoscopic information may be an indication of the difficulty in performing this complex operation with nonarticulating laparoscopic instruments. The advantages of robotic surgery may help overcome these difficulties. We present the first robotic LPJ ever reported in a 14-year-old child with idiopathic chronic pancreatitis. This case demonstrates the utility of this advanced surgical technology and may lead to a new minimally invasive option for both adults and children with chronic pancreatitis requiring surgical intervention.

Spontaneous Clostridium perfringens myonecrosis: Case report, radiologic findings, and literature review.

The utility of computed tomography (CT) has not been studied in the initial evaluation of a patient with suspected spontaneous Clostridial myonecrosis. Here, we present a patient with acute lymphoblastic leukemia (ALL) and neutropenia who developed spontaneous Clostridium perfringens myonecrosis after induction chemotherapy. Although suspected, the patient’s symptoms and physical exam findings were not specific for Clostridial myonecrosis. CT confirmed the diagnosis and helped direct surgical intervention.

Pediatric Robotic Surgery

Pediatric minimally invasive surgery (MIS) has expanded tremendously in recent years. Much of the advance can be attributed to equipment improvements and the downsizing of standard MIS instruments as manufacturers began making pediatric specific instrumentation. However, the non-articulating MIS instruments are limited in the ability to provide detailed precision. Moreover, several procedures have demonstrated questionable outcomes using non-articulating handheld instruments and two-dimensional optics. Robotic technology may help overcome these obstacles. In this chapter, we will discuss the advantages and disadvantages of the current robotic technology as it applies to children and describe pediatric robotic applications in detail. Operative issues for each procedure including patient positioning, port location, and critical steps will be described. Finally, we will outline areas, which will need improvement if robotic surgery is to gain further momentum in pediatric thoracic surgery.