Todd A. Ponsky

Pediatric Minimally Invasive Surgery: Laparoscopy and Thoracoscopy in Infants and Children

This article discusses the potential benefits and challenges of minimally invasive surgery for infants and small children, and discusses why pediatric minimally invasive surgery is not yet the surgical default or standard of care. Minimally invasive methods offer advantages such as smaller incisions, decreased risk of infection, greater surgical precision, decreased cost of care, reduced length of stay, and better clinical information. But none of these benefits comes without cost, and these costs, both monetary and risk-based, rise disproportionately with the declining size of the patient. In this review, we describe recent progress in minimally invasive surgery for infants and children. The evidence for the large benefits to the patient will be presented, as well as the considerable, sometimes surprising, mechanical and physiological challenges surgeons must manage.

Single Port Laparoscopic Cholecystectomy in Adults and Children: Tools and Techniques

g s v o l l ith the advent of laparoscopic surgery a compromise was ade: one large incision for several small incisions. For the ost part, several small incisions are a better cosmetic alernative than the open incision. In addition, several small ncisions typically cause less pain and fewer complications han one large incision. But with the development of more dvanced technology there may be a better alternative to ultiple incision surgery. In the last several years the develpment of natural orifice translumenal endoscopic surgery NOTES) has created a great deal of excitement as a less nvasive alternative to laparoscopy. But this technology ecessitates a visceral injury. Recently, perhaps a safer but qually as cosmetic approach to minimally invasive surgery as developed: single port laparoscopic surgery. Single port urgery allows for advanced laparoscopic procedures to be erformed through one incision, usually in the umbilicus. lthough this technique should closely replicate the tradiional laparoscopic alternative, modifications of instruentation and technique must be made. Because this echnique is still in its infancy, there are few data conirming the benefits of this approach. But literature is merging demonstrating the safety and efficacy of single ort laparoscopy. We describe a suggested technique and nstrumentation that make single port laparoscopic surgery easible. We have performed this operation in both adults nd children as young as 4 years of age, with weights rangng from 17.1 kg to 125.5 kg. The intention here is to ention the most commonly used products available for ingle port surgery and present opinions of their pros and ons.

Laparoscopic treatment of pancreatic pseudocysts in children.

BACKGROUND Pancreatic pseudocysts are problematic sequelae of pancreatitis or pancreatic trauma causing persistent abdominal pain, nausea, and gastric outlet obstruction. Due to the low volume of disease in children, there is scant information in the literature on the operative management of pseudocysts with minimally invasive techniques. We conducted a multi-institutional review to illustrate several technical variations utilized in achieving laparoscopic cystgastrostomy in the pediatric population. METHODS A retrospective review was conducted of all patients who underwent laparoscopic cystgastrostomy in five institutions. Patient data, operative techniques, and postoperative course were analyzed. RESULTS There were 13 patients with a mean age of 10.4 years and mean weight of 52.1 kg. The etiologies of pancreatitis included: trauma (4), gallstones (3), chemotherapy (2), hereditary (1), and idiopathic (3). Preoperative radiographic measurements of the maximal cyst diameter averaged 11.7 cm. Cystgastrostomy was approached by using transgastric exposure in 5 cases and intragastric ports in 8 cases. An average of four ports were used to complete these operations. Mean operative time was 113 minutes. There were no conversions in this series. Cystgastrostomy was performed by using an endoscopic stapler (average 3.8 loads) in 6 cases, sutures in 6 cases, and 1 was formed solely with the Harmonic Scalpel (Johnson and Johnson). Gastrotomy sites were closed by using a stapler in 4 cases and suture techniques in 9. Mean time to initial and goal feeds was 3 and 4 days, respectively. Postoperative imaging revealed persistent pseudocyst in 1 patient, who was treated with a distal pancreatectomy. Therefore, 92% required no further operative intervention and remained asymptomatic upon recovery from their pancreatitis. CONCLUSION A laparoscopic approach to pancreatic cystgastrostomy for chronic pseudocyst proved to be safe and effective in this five-institution survey. Techniques varied, but 92% had complete resolution with minimal morbidity and rapid recovery. Laparoscopic cystgastrostomy should be considered as an appropriate first-line treatment for chronic pseudocysts in children.

Acute colonic pseudoobstruction in a child with sickle cell disease treated with neostigmine

Sickle cell disease is a disorder that produces significant morbidity and mortality. Vaso-occlusive pain crises are the most common presenting symptom associated with sickle cell patients. A rare, yet important to recognize, complication of sickle cell disease is acute colonic pseudoobstruction, also known as Ogilvies syndrome. These patients may present with symptoms that are difficult to distinguish from other etiologies of abdominal pain, but a thorough diagnostic workup can provide important clues. Furthermore, there is no agreement on optimal treatment of pseudoobstruction. We report the first pediatric case of acute pseudoobstruction secondary to sickle cell disease that was treated successfully with neostigmine. Early recognition of this phenomenon is important as it alters patient management, can be treated medically, and may avoid unnecessary surgical intervention.

Use of operative laparoscopes in single-port surgery: The forgotten tool

Single-port surgery is an emerging advancement in the field of minimally invasive surgery. Several different techniques and tools have been developed to decrease the invasiveness of various operations. Amongst these new developments, many general surgeons have overlooked an important tool, the operative laparoscope. These telescopes reduce the number of ports placed during minimally invasive operations by providing both visualization and operative channels to accommodate instruments. We have described several simple techniques that employ the operative laparoscope to reduce the number of incisions in laparoscopic surgery with good outcomes. Single-port surgery has been shown to be safe and effective and may someday replace traditional laparoscopy in the performance of minimally invasive operations.

Urachal remnant small bowel obstruction : Report of two adult cases

This report describes two separate cases of adult patients with intestinal obstruction caused by an urachal remnant. While reports of infected urachal cysts causing intra-abdominal pathology are not uncommon, intestinal obstruction caused by urachal remnants is exceedingly rare in the pediatric population and has never been described in adults. Both of these patients required surgical intervention with excision of the urachal remnant and subsequent resolution of the small bowel obstruction.

Advances in Minimally Invasive Surgery

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The first endoscopic retrograde pancreatogram

In 1968, a group of physicians published the first report documenting the initial clinical application of endoscopic retrograde cholangiopancreatography (ERCP). These physicians included Drs. McCune and Shorb from the George Washington University Medical Center (GW) and Dr. Moscovitz, who practiced mainly at the Washington Hospital Center. Their work was predicated on hours of canine research followed by patience and determination in the operating room. Approximately 10 years ago, one of the initial ERCP collaborators, Dr. Paul Shorb, retired from clinical practice. Shortly after retiring, Dr. Shorb began the arduous task of reviewing 50 years of surgical acumen that had accumulated in closets, drawers, and desks. During one cleaning endeavor, Dr. Shorb found the original endoscope embedded under a stack of radiographs in the back of a closet. Interestingly, a 1998 editorial from Dr. Sivak noted that the original ERCP endoscope ‘‘[had] been lost’’[1]. Contrary to this statement, Dr. Shorb had donated the original instrument to the Department of Surgery at GW. Upon donating this instrument, Dr. Shorb described the initial experience with the instrument and many of the confounding factors associated with his early encounters. This report reviews the original endoscope used for retrograde pancreatography and recounts the initial clinical experience as described by Dr. Paul Shorb.

Minimally Invasive Management of Pediatric Malignancies

Minimally invasive surgery (MIS) is becoming an increasingly important component of the work-up and treatment of pediatric solid tumors. Today, MIS is important in the exploration, diagnosis, staging, palliation, resection, and surveillance of oncologic disease. The development of laparoscopic technology designed specifically for children in the 1990s led to an increased use of MIS in pediatric surgery. As experience grows and technology advances, criteria are developed to carefully select patients. Minimally invasive techniques are being used increasingly to treat solid pediatric malignancies. Over the past decade, experience in MIS has increased to the point where laparoscopy and thoracoscopy have become acceptable treatment modalities for the work-up and treatment of pediatric solid tumors. MIS has been shown to be a useful method to obtain tissue for both the initial diagnosis of suspicious masses in the peritoneal and thoracic cavities and the diagnosis of recurrent or metastatic disease in patients who have completed initial therapy for malignant disease. This chapter covers some malignancies unique to the pediatric patient and explains indications and gives a step-by-step overview of the different procedures.