Minimal access surgery (MAS) has
gradually become available for children for selective surgeries
in limited centers. Few retrospective studies without follow up
data have been reported from our country [1-3]. Minimal access
surgery is far more demanding in children due to the small size
of peritoneal cavity, higher risk of iatrogenic injuries,
smaller blood volume, anesthetic risks and majority of the
operations being reconstructive. We report the first prospective
study from our country on minimal access surgery in children
with a minimum 12 month follow up.
Methods
All consecutive babies and children who
underwent minimal access surgery between 2005-2010 were
recruited into the study. Children older than three weeks and
upto 14 year of age who required surgery for the clinical
diagnosis of impalpable/intra-abdominal testis, symptomatic or
non-resolving gall stone disease, acute appendicitis, focal
small bowel pathology, Hirschsprung’s disease of rectosigmoid,
non-functioning kidney with secondary pathology, focal
mesenteric pathology, tubo-ovarian pathology, early empyema
thoracis, small mediastinal mass or lung biopsy and Not
Otherwise Specified (NOS) lesion were included. Any patient with
major reconstructive procedure, risk of intra-abdominal
adhesions, and more than ASA (American Society of
Anaesthesiology) grade 1, was excluded.
Each one of them was offered the option of
open versus minimally invasive approach and an informed consent
was obtained. All the surgeries were video recorded for future
reference. Age matched controls of patients undergoing
laparotomy or thoracotomy for similar disease in the same period
were compared in terms of mortality and morbidity, length of
stay, postoperative pain based on duration and dose of morphine
infusion and cosmetic outcome. Standard statistical methods were
used to compare results between the two groups.
Results
During the study period, 211 babies and
children were recruited into the study. All patients who were
recruited into study reported back for at least two follow up
visits in the outpatients until 12 months after surgery (Table
I). There was no mortality among the babies recruited
for minimal access surgery. There was no patient taken back to
theatre following MAS in the follow up period. During minimal
access surgery 10 patients were converted to open surgery. These
included appendicular perforation with dense intestinal
adhesions-3, Meckel’s diverticulum with volvulus-1, ovarian
tumour with torsion-1, nephrectomy-2, empyema-2, congenital
diaphragmatic hernia-1. During the early period of study,
laparoscopic hernia repair was discontinued due to an early
recurrence, higher reported recurrence rate and excellent
existing outcome of open hernia repair.
TABLE I Minimal Access Surgery in Children 2005–2010 (N = 211)
Surgery |
Number |
Mean time in
|
Mean stay |
Morbidity minimum |
Mean age
|
|
|
minutes |
in days |
follow up 12 months |
in years
|
Appendectomy |
32 |
(45-90) 60
|
(2-4) 2.5
|
Nil |
5.5
|
Cholecystectomy
|
21 |
(45-100) 60
|
(1.5-3) 2.0
|
Nil |
4
|
Splenectomy |
5 |
(50-120) 75
|
(2-5) 3.0
|
Nil |
5
|
Diaphragmmatic hernia repair |
02 |
(75-105) 90
|
(1-3) 2.0
|
Nil |
4
|
* Inguinal hernia repair
|
12 |
(40-70) 50
|
(0.5-2) 01
|
02 |
3.5
|
Orchidopexy, Single stage
(intra-abdominal testis)
|
42 |
(55-90) 75
|
(0.5-3) 1.5
|
01 |
2.5
|
Orchidopexy, two stage
(intra-abdominal testis)
|
15 |
(50-90) 70
|
(0.5-2) 1.5
|
Nil |
2.5
|
Oopheropexy / oopherectomy / Biopsy |
07 |
(30-100) 60
|
(0.5-2) 01
|
Nil |
2.5
|
Nephrectomy
|
10 |
(105-150) 120
|
(1.5-4) 02
|
Nil |
4
|
Nephroureterectomy/Excision ureterocele |
04 |
(100-160) 120
|
(1-3) 02
|
Nil |
4.2
|
Panhysterectomy for Congenital
Adrenal Hyperplasia (CAH)/others |
03 |
(90-120) 100
|
(1.5-3) 02
|
Nil |
3.1
|
Small bowel resection Meckel’s 5,
tumour 2, mesenteric cyst 2, Segmental
dilatation 1, TB stricture 1, traumaperforation 1, hemangioma
1,hemicolectomy2
|
15 |
(80-140)100
|
(6-9)07
|
Nil |
3.5
|
Hartmann’s operation/colostomy, reduction
ileocolo/colic intussusception
|
08 |
(30-120) 70
|
(2-5)3.5
|
Nil |
4
|
Abdomino perineal pull thru |
04 |
(100-150) 120
|
(4-7) 05
|
Nil |
6 wks |
Others (Tenchkoff catheter, peritonitis,
trauma gastrostomy,ambiguous external
genitalia, feeding jejunostomy, mesenteric
node Bx,etc) |
23 |
(45-90) 70
|
(1-7) 03
|
Nil |
4.5
|
Video Assisted Thoracic Surgery
(VATS)Early empyema, lung biopsy,
excision mass, exposure for anterior
spine surgery |
08 |
(50-120) 90
|
(3-6) 04
|
Nil |
6
|
*Discontinued in the middle of the study period. |
There were 32 children who underwent
laparoscopic appendectomy; 1 of them had normal appendix at
exploration and underwent appendectomy, all others had various
stages of the disease and 3 with perforation were converted to
open procedure. There was no morbidity, unexpected prolonged
stay, or a significant difference in analgesic requirement and
complications from the laparotomy group. Table II compares the
hospital stay duration between the minimal access and laparotomy
groups.
There were 57 patients who underwent
laparoscopic orchidopexy. In six patients no testis was found
intra-abdominally or on inguinal exploration. In 15 patients the
gonadal vessels were short and they were subjected to two stage
Fowler- Stephens orchidopexy. There was testicular atrophy in
three out of 15 patients. Single stage orchidopexy was possible
in 42 patients and there was no testicular loss. In five
patients the result was unsatisfactory with the testis outside
abdomen but high up at the root of scrotum.
There were 21 laparoscopic cholecystectomies
during the study period. There was no conversion to open
surgery. Majority were girls, the youngest child being a two
year old boy. There was no difference in analgesic requirement,
morbidity and complications. There was no significant difference
between mortality, morbidity, re-exploration rates between MAS
and open surgery. All parents preferred the cosmetic outcome of
laparoscopic surgery.
Discussion
Our study is on a controlled pediatric
population who have undergone laparoscopic surgery in specific
conditions where there is a clearly established benefit in
favour of MAS in the adult population. Follow up to twelve
months after surgery in each child, gave an opportunity to
evaluate for several well known delayed complications which do
not manifest in early post-operative period i.e. ischemic bile
duct stricture after laparoscopic cholecystectomy.
The benefit reported in our study in favour
of minimal access surgery for acute appendicitis has been
reported by other authors and now the standard of care in
children [4-6]. Our results were equally encouraging with
laparoscopic cholecystectomy. There were no conversions to open
cholecystectomy and no late complications. The open approach for
cholecystectomy for children should be adopted only in the rare
circumstance if laparoscopic assessment reveals dense adhesions
[7].
Laparoscopic exploration of small bowel
allows confirmation of diagnosis of focal small bowel pathology
of some typical focal lesions like Meckel’s diverticulum,
mesenteric cyst, tubercular strictures, and rarely tumours. In
the 14 cases treated, it was possible to localize these lesions,
dissect and decompress whenever necessary and exteriorize the
small bowel segment bearing the pathology through the umbilical
port. The segmental resection of small bowel and extracorporeal
end to end anastomosis could be done easily and the loop dropped
back into the peritoneal cavity as reported previously [8].
The largest experience of laparoscopic hernia
repair has revealed a recurrence rate of 4.1% versus a reported
recurrence rate of less than 0.5% in the open technique [9]. We
had one recurrence and another boy had a hydrocele develop early
in postoperative period among the first few operated. This was
not an acceptable outcome for hernia repair at our centre, and
hence at this stage we discontinued laparoscopic hernia repair.
There may be a role for laparoscopic repair in a girl or
bilateral hernia. However, the scientific benefit to such an
attitude is yet to be shown [10].
Laparoscopy can also easily localize presence
or absence of testis beyond any doubt. In 42 children, single
stage orchidopexy was done with no testicular loss. However,
although there was no testicular atrophy, five (10%) had
unsatisfactory position of testis at the root of scrotum. Among
15 children who had short gonadal vessels, two stage
Fowler-Stephens orchidopexy was done with testicular atrophy in
three cases (20%).This is comparable to the previously published
data with postoperative follow-up [11].
TABLE II Mean Duration of Hospital Stay in Days
Surgery |
MAS |
Age matched control* |
Cholecystectomy# |
(1.5-3) 2 |
(3-5) 4 |
Appendectomy# |
(2-4) 2.5 |
(2-6) 4.5 |
Splenectomy# |
(2-5) 3 |
(3-6) 5 |
Orchidopexy (impalpable testis)#
|
(0.5-3) 1.5 |
(2-4) 3 |
Nephrectomy# |
(1.5-4) 2 |
(3-6) 4 |
Small bowel resection |
(6-9) 7 |
(6-9) 7 |
VATS† |
(3-6) 4 |
(3-7) 5 |
*Age matched controls undergoing laparotomy for
comparable diagnosis; †VATS- Video assisted
thoracoscopic surgery;# P <0.01. |
In diseases like Hirschsprung’s disease,
laparoscopy offers the chance to identify the transition zone
and perform Hartmann’s procedure or single stage laparoscopic
abdominoperineal surgery with frozen section control. The single
stage approach is feasible on short segment disease without
massive proximal dilatation. Our experience is still very early
and numbers are small to make any definite conclusion on this
approach.
Laparoscopic paediatric renal surgery has
become an attractive alternative to open surgery and is being
done in several centers [12]. In our patients the indications
for laparoscopic nephrectomy were symptomatic multicystic
dysplastic kidneys (MCDK) and non functioning kidneys secondary
to pelviureteric junction obstruction or reflux nephropathy and
laparoscopic pyelolithotomy for a pelvic stone with large
extrarenal pelvis. Even complex conditions like poorly
functioning kidney with ureterocele have been managed in one
stage laparoscopic surgery. In this study there has been low
threshold for conversion to avoid morbidity.
Laparoscopic splenectomy is an attractive
option in children with small spleen, typically those who have
early diagnosis of hemolytic anemia like hereditary
spherocytosis [13]. Those with large spleen like portal
hypertension of Thalassemia continue to be removed by open
surgery. We have followed both approaches with selective use of
laparoscopic approach and no morbidity.
Our results suggest that MAS can be done in
children without lowering the bar of quality outcomes in
surgery.
Contributors: Both authors are
responsible for conduct of the study and draft of the
manuscript.
Funding: None; Competing interests:
None stated.
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