Pediatric Endosurgery and Innovative Techniques

Thoracoscopy is now the preferred operative technique for many thoracic disorders in children, in part because of the development of better instrumentation. Reusable instruments are used increasingly to lower costs. There are few absolute contraindications to thoracoscopy in children, one of the few being complete pleural symphysis. Preoperative imaging is important for surgical planning and sometimes includes CT or MRI. The most effective anesthetic technique for the particular procedure is then selected; general anesthesia is used in most cases. Spontaneous breathing is desirable to facilitate maintenance of the pneumothorax. Proper positioning on the operating table is critical to success. Many thoracoscopic procedures are now possible in children, and pediatric surgeons must be familiar with its use.

Both primary and secondary spontaneous pneumothorax are significant clinical problems in the pediatric population. The majority of these patients will require active therapy, initially with a tube thoracostomy. Patients in whom primary therapy fails or patients with recurrent or bilateral pneumothoraces will require more aggressive, surgical, treatment. Thoracoscopy provides a minimally invasive technique that reproduces all of the traditional open surgical procedures used for treatment of pneumothorax with less morbidity. Chemical and mechanical pleurodesis, partial pleurectomy, and bleb resection may all be achieved by thoracoscopic techniques. These procedures may be performed under local or general anesthesia and require two or three thoracoscopic ports. In most reported series, the incidence of recurrent pneumothorax appears to be slightly higher after thoracoscopic treatment than after open treatment, especially in patients with secondary spontaneous pneumothorax. Between 1985 and 1997, we performed 27 thoracoscopic procedures in 21 patients for the treatment of pneumothorax. There have been two recurrences (7%) in patients with secondary spontaneous pneumothoraces, both of which were treated successfully with repeat thoracoscopy. Thoracoscopy is a safe and effective alternative to open thoracotomy for surgical management of both primary and secondary spontaneous pneumothorax in children.

Background: The treatment of patent ductus arteriosus (PDA) in infants and children has changed dramatically over the last 15 years. Open thoracotomy with surgical ligation has been largely replaced by transcatheter occlusive devices and thoracoscopic closure. Patients and Methods: Since 1994, the author has performed more than 60 thoracoscopic closures. Results: Only two procedures required conversion to open thoracotomy, and there was one incomplete closure, which necessitated a second procedure. The average operative time has dropped to 25 minutes during the last 30 cases; and the average hospital stay is less than 24 hours. Conclusion: Thoracoscopic closure of PDAs has proven to be a safe, effective, and cost-efficient method of dealing with persistent PDAs.

Background and Purpose: Thymectomy for myasthenia gravis is routinely performed by thoracoscopy in adults. To assess its safety and efficacy by the same route in children, we evaluated our experience. Patients and Methods: Eight girls and two boys aged 5 to 18 (mean 11.6) years were referred for thymectomy. Each had confirmed myasthenia gravis, none had thymomas, and all were maintained preoperatively on pyridostigmine bromide and prednisone. Four of the children had required plasmapheresis for severe symptoms. Single-lung anesthesia was maintained using right mainstem intubation or a bronchial blocker. The mediastinum was accessed through the left side of the chest. The telescope port (10 or 5 mm) was placed in the anterior axillary line in the fourth intercostal space. Two 3- or 5-mm working ports were placed lateral to the telescope port. Anterior to the phrenic nerve, the pleura was incised and the mediastinum opened. Visibility was excellent, and the pink-yellow and lobular appearance of the thymus was easy to distinguish from the surrounding fat. The entire mediastinum, from the thoracic inlet to the diaphragm, could be explored easily, and visibility of all major vessels and nerves was excellent. Dissection was done bluntly and with bipolar electocautery. All vessels were clipped before their division. The gland was removed intact through one of the ports. Chest tubes were not required. Results: The average operative time was 114 (range 70-150) minutes. There was no blood loss or complication. All patients were discharged on the first postoperative day. At 4 to 19 months' follow-up, all of the children are off medication and are symptom free. Conclusions: Thoracoscopic thymectomy for myasthenia gravis in this, the largest pediatric experience, was safe and effective.

Empyema has traditionally been managed by a combination of antibiotic therapy and chest drainage. Advanced cases have required surgical debridement of infected pleural debris. In the past, this was accomplished with a thoracotomy or minithoracotomy. Such procedures were often delayed in the hope that their morbidity could be avoided. However, advanced empyema carries its own morbidity. Moreover, resolution of empyema is usually hastened by aggressive surgical debridement of the pleural space if antibiotics and drainage have been unsuccessful. Thoracoscopy now allows surgical debridement with potentially less morbidity than traditional surgical procedures. This, in turn, may encourage earlier surgical debridement, thus avoiding the sequelae of advanced empyema. This review discusses thoracoscopy as treatment for empyema with illustrative case reports.

A wide variety of mediastinal masses occur in children. Traditionally, biopsy or resection of such masses has required open thoracotomy, minithoracotomy, a Chamberlin procedure, or sternotomy. As thoracoscopic techniques and equipment have evolved and improved, most mediastinal masses may now be surgically approached and managed using minimally invasive methods. This review discusses the general principles of the management of mediastinal masses in children and how thoracoscopy plays a role in this management.

Background: Repair of esophageal atresia (EA) with or without tracheoesophageal fistula (TEF) is a major operation for newborn infants, who often are premature and small for gestational age. In an effort to minimize perioperative stress, recent technologic advances have been applied that permit certain traditional open operations to be performed using minimally invasive techniques. This article provides an update on our experience with endosurgical techniques to repair various types of EA. Patients and Methods: The records of 10 neonatal infants having thoracoscopy to repair EA either with and without TEF were reviewed. Outcome measures included operative time, intraoperative complications, leak, empyema, and stricture formation. Results: Nine of the procedures were completed using thoracoscopy, and no intraoperative complications were encountered. Two babies had mild salivary leaks that resolved spontaneously within 48 hours of onset. Three patients required bougienage for relief of mild strictures. All babies are alive and thriving on oral feeding. Conclusion: Thoracoscopic repair of EA with or without TEF not only is technically feasible but provides a safe alternative to classic open thoracotomy that is as successful and less physiologically stressful.

Thoracoscopy in children was originally described for biopsy of diffuse pulmonary infiltrates. The application of these techniques to other pulmonary parenchymal lesions is now a well-established, reliable alternative to traditional open thoracotomy. The technique has been used successfully for diagnosis of diffuse and localized infiltrates of uncertain etiology. Diagnostic biopsies may be obtained safely and accurately with minimal morbidity and at comparable or lower overall cost than thoracotomy. Discrete parenchymal nodules, either solitary or multiple, are also amenable to thoracoscopic resection. The literature reports complete evaluation and resection of selected lung lesions with equivalent follow-up results. Hospital stay and duration of chest tube drainage are shorter for thoracoscopy than for open thoracotomy, and therefore, the overall cost is lower. Although thoracoscopy may be limited somewhat by patient size and ability to tolerate unilateral ventilation, it has become the procedure of choice in suitable patients undergoing lung biopsy or resection of nodules.

The management of chylothorax has undergone a series of changes in the past decade. Current practice includes nonoperative treatment with low-fat dietary manipulation, pleuroperitoneal shunting procedures, and the direct operative approach to the thoracic duct. Medical management should be used initially but should not be continued for extended periods of time. We have felt that after 1 week of medical therapy, the risks of sepsis and malnutrition outweigh the risk of intervention. The shunting procedures have been successful in managing conditions that are associated with widespread lymphatic leak such as postoperative chylothorax with wide mediastinal dissection and lymphangiomatosis. Thoracoscopic procedures are most successful in the management of the discrete thoracic duct injury, including posttraumatic injuries and congenital chylothorax. The thoracoscopic approach to chylothorax appears to be as effective as thoracotomy, while offering the benefits of minimally invasive procedures.

Background and Purpose: Traditional repair of pectus excavatum (PE) has required a long and complex procedure with multiple rib resections and a large sternal scar. A minimally invasive procedure (the Nuss procedure) has recently been reported as an alternative method for PE repair. This operation involves blind passage of a clamp and rigid bar across the mediastinum, subjecting the patient to potential injury. The addition of thoracoscopy to this procedure is described in this report. Patients and Methods: During the 15 months from September 1998 to January 2000, we performed 32 PE repairs using the minimal access technique with thoracoscopic assistance. The thoracoscope is inserted into the right side of the chest for viewing during the repair. In three cases, bilateral thoracoscopy was performed. The patients ranged in age from 5 to 18 (average 10.7) years. Results: Thirty-one patients had one bar inserted under thoracoscopic guidance. One patient required two bars. The average operative time was 68 minutes (range 40-85 minutes). The average length of hospital stay was 4.7 days (range 3-8 days). There were no procedure-related complications. Two older patients have had pain with specific activity, but follow-up of 3 to 18 months has revealed no significant complications. Conclusions: Thoracoscopically assisted PE repair is a safe technique, decreasing the risk of cardiothoracic injury and other potential complications. This addition to the Nuss procedure does not lengthen the operative time, alter the cosmetic result, or increase the cost to the patient. Using thoracoscopic guidance also can facilitate learning and promoting the Nuss technique of PE repair.

Purpose: To assess our experience with postoperative pain and analgesia requirements associated with the minimally invasive repair of pectus excavatum in children. Patients and Methods: a retrospective review of the charts of patients operated on between July 1998 and December 1999 was conducted, and all patients and parents were contacted by phone for interviews. Results: Thirty-one patients (8 girls and 23 boys) aged 3 to 18 years (median 9 years) were identified. The average length of stay was 4.7 days. In 29 children, continuous thoracic epidural infusions were initiated, and they were the mainstay of analgesia in 22 children (mean duration of infusion 65 hours). The remaining nine children required a combination of therapies for pain relief. Two patients required oral analgesia for >3 weeks after discharge, one of whom subsequently required surgical revision. Pain assessment using the Wong-Baker nonverbal scoring system showed that on any given day after surgery, children in the 3- to 10-year age group consistently scored lower than those in the 11- to 18-year age group. Conclusions: The length of stay and duration of continuous epidural infusions required after the minimally invasive repair of pectus excavatum in children is similar to that reported for the traditional open repair. Younger children (3-10 years) appeared to tolerate the procedure better than older children (11-18 years).

Background and Purpose: Infants with an elevated hemidiaphragm secondary to eventration or paralysis from birth trauma may have significant pulmonary compromise. Many require prolonged ventilation and are difficult to wean. Plication of the diaphragm has been considered a therapeutic adjunct to improve pulmonary function but often necessitates a thoracotomy. This report describes a technique of laparoscopic plication that avoids the morbidity of an open thoracotomy and the limitations imposed by the rib cage in a thoracoscopic approach. Patients and Methods: Three patients aged 8 to 14 weeks who had elevation of the right hemidiaphragm and could not be weaned from the ventilator were referred for plication. The patients' weights ranged from 1.7 to 3.4 kg, and the gestational age at the time of surgery was 38 to 48 weeks. The surgery was performed under general anesthesia using 3-mm instruments and trocars. Results: Two procedures required three trocars and one required five. The operative time ranged from 25 to 60 minutes. This last case also included a fundoplication and button. There were no operative complications. The patients were weaned off their ventilators at 2, 3, and 14 days. Chest radiographs at 1 month showed the repair to be intact. Conclusion: This report demonstrates that laparoscopic plication of the diaphragm is a safe and effective technique. A laparoscopic approach affords excellent visibility and exposure and avoids the limitations of a thoracic approach.

Purpose: To introduce a suture needle (Endoneedle) designed for laparoscopic extraperitoneal closure of patent processus vaginalis (PPV). Methods: The Endoneedle consists of 19-gauge hollow needle with a notch near the tip and 2-0 nonabsorbable suture and a plastic sheath. The procedures are performed with the help of a 5-mm telescope inserted through the umbilicus, and a 2-mm Endograsp placed below the umbilicus. Results: Since July 1998, this procedure has been carried out in 61 girls aged 3 months to 14 years. There have been no postoperative complications, and no recurrent hernia. The surgical wounds completely disappeared. In the most recent 10 cases, the mean operative time was 21 minutes for unilateral and 28 minutes for bilateral closure. Conclusion: This procedure is easy and safe, and it has excellent cosmetic results.

Duplication of the diaphragm is a rare congenital anomaly that typically results in recurrent pulmonary infections. Open thoracotomy and surgical resection of the accessory diaphragm is curative and may prevent future complications associated with chronic inflammation. We describe a case in which thoracoscopy was used to diagnose and resect an accessory diaphragm and an associated extralobar pulmonary sequestration in a 9-year-old boy. We feel that thoracoscopy offers superior diagnostic capability and permits resection of accessory diaphragm with or without associated extralobar pulmonary sequestration.

We report the case of a 2-year-old boy affected by a Morgagni-Larrey hernia discovered accidentally. The hernia was large, and it contained an accessory hepatic lobe. The repair was performed easily utilizing a laparoscopic approach. On the basis of our experience, we can affirm that laparoscopic correction of Morgagni-Larrey hernia is not a difficult operation. In our opinion, the minimally invasive procedure may be the first-choice treatment for this kind of diaphragmatic defect.

Aortopexy, typically performed via thoracotomy, is the procedure of choice for severe tracheomalacia leading to life-threatening episodes of apnea and bradycardia. We report a technique of thoracoscopic aortopexy, in which the aortic sutures were passed directly through the sternum and then tied extracorporeally. This procedure, which follows the surgical principles of an open aortopexy, was effective in a 1-year-old child. This minimally invasive approach may prove to be associated with decreased morbidity.

Anorectal abnormalities are classified into supralevator, intermediate, and infralevator types. According to the morphologic findings, different operative procedures are required for reconstruction. For a high anorectal abnormality, an abdominoperineal pull-through is often necessary. A 1-year-old girl with a high anorectal malformation was treated by laparoscopy. The rectal pouch and rectovaginal fistula were dissected, and the pull-through was done under visual control. The anastomosis was preformed extrabdominally at the perineum. There were no postoperative complications, and so far, continence is as good as that seen after conventional procedures.