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Paediatric Laparoscopic Surgery

Ravindra Ramadwar
 

Historical Background
In 1910, a Swedish internist, Hans Jacobaeus, reported the use of Nitze’s lighted cystoscope in the pleural space under local anaesthesia using a heated wire to divide the adhesions. This intrapleural pneumolysis was quite successful in achieving pulmonary collapse, with a relatively low morbidity and mortality. This technique was soon adopted in Europe and in the USA. Jacobaeus reported the use of this technique to diagnose benign and malignant conditions of the pleura and lung parenchyma in 1921. Then with the advent of new antibiotics for tuberculosis, the role of surgery for lung and pleural disorders diminished. The popularity of the technique was then revived in the 1970s, when it was found to be an accurate method for obtaining lung biopsies for diagnosing Pneumocystis carinii pneumonia in immunocompromised children. Rogers was the earliest advocate of this technique for children in North America in 1976. The introduction of laparoscopic cholecystectomy in 1988 led to an explosive increase in the use of minimal access surgery for different conditions. There has been a true rebirth of thoracoscopy in the last ten to fifteen years, and it is now currently accepted and used by an increasing number of practicing paediatric surgeons for a variety of indications.

Indications for Thoracoscopy
VATS can be performed for the following conditions:

Diagnostic
Lung biopsy and wedge resection
    Interstitial lung disease (ILD)
    Biopsy of pulmonary nodule
    Metastatic disease
    Inflammatory disease
Biopsy and resection of mediastinal lesions
    Lymphoma
    Thymic and thyroid lesions
    Cystic hygromas
    Foregut duplications
    Ganglioneuromas and neuroblastomas
Therapeutic
Pleural conditions
    Spontaneous pneumothorax
    Empyema Thoracis (ET)
    Chylothorax
Extensive pulmonary resections, including segmentectomy and lobectomy for
    Infectious diseases
    Cavitatory lesions
    Bullous disease
    Sequestrations
    Lobar pneumonia
    Congenital adenomatoid malformations
    Neoplasms
Other advanced intrathoracic procedures
    Patent ductus arteriosus (PDA) closure
    Division of Ligamentum in the Vascular Ring
    Repair of hiatus hernia and other diaphragmatic defects
    Oesophageal myotomy for achalasia
    Anterior spinal fusion
    Repair of oesophageal atresia
    Excision of benign oesophageal tumours
    Repair of pectus excavatum
    Sympathectomy
    Pericardial window for pericardial effusion
    Trans-diaphragmatic adrenal surgeryContraindications
Contraindications
Late stages of empyema after the development of fibrosis with severe crowding of ribs (without any obvious space between ribs).
Densely adherent tumour infiltrating chest wall.

Preoperative Preparation
Most intrathoracic lesions require routine roentgenograms as well as CT scans. The CT scan defines the extent of disease precisely and helps in planning of surgery. Some procedures needs the specific measures preoperatively and are mentioned in the operative technique for the individual disease. In few patients’ ultrasound to know the contents whether solid or liquid and bronchoscopy may be required. The patients should be fully worked up for general anaesthesia with blood grouping and cross matching. The patients should be taught breathing exercises, which is continued post operatively to hasten the recovery.

Anaesthesia
The working space in thorax is created by giving collapsing the ipsilateral lung. There are many different modalities to collapse the ipsilateral lung, including placement of endotracheal tube in the contralateral main stem bronchus, use of double lumen tube, double lumen endobronchial tubes, use of bronchial blockers1 and use of low pressure CO2 insufflations. The application of general anaesthesia using single lung ventilation may be technically difficult in small children. The smallest double-lumen device is suitable for a child with a body weight of at least 30 to 35 kilograms. Alternative techniques like selective intubation of main stem bronchus with a cuffed or uncuffed tube can be used in small children. Insufflation of carbon dioxide under positive pressure can result in haemodynamic compromise and is not well tolerated by small infants. Tension pneumothorax decreases cardiac index, mean arterial pressure and left ventricular stroke index, and increases pulmonary artery and central venous pressures.2 In younger children, an intraoperative endobronchial blockage (using a Fogarty catheter) can be carried out to achieve the selective ventilation.1

Surgical Technique
For VATS in children, 5 mm and 10 mm telescopes are used. In small infants, 3.5 mm or the new 14-gauge endoscopic telescope may be useful. The standard trocars and hand instruments used in laparoscopy (10, 5 and 3 mm) can be used; however short trocars without valves and special instruments designed for VATS, which can be inserted through an open incision and have gentle “S” shaped curve to adapt to the shape of the thoracic cage can be used.

Decortications for Empyema Thoracis
Early intervention of emyema prevents chronicity of the disease. In the exudative stage (48-72 hours) (7-10 days) the management with intercostal drain is adequate. However, in the fibrino-purulent stage ICD is not adequate to evacuate empyema completely and VATS should be performed. The advantage of VATS in empyema thoracis includes determining stage of the disease, breaking of all loculi, evacuation of thick pus and fibrinopurulent material, reduction in bacterial load and insertion of ICD in the dependant position. As thick pus and fibrinopurulent material is removed thoroughly, the fever resolves quickly (usually 48-72 hours), ICD is required for short duration (usually 48-72 hours) and post procedure hospitalisation can be reduced to 6-7 days.3-4 In addition trauma of insertion of ICD under local anaesthesia is avoided. The disadvantages are need of general anaesthesia, operating room with

video camera and team of experienced anaesthetists and endoscopic surgeon. The author recommends conservative management for patients who present early (< 7 days), primary VATS for those who present late (> 7 days) or has definite loculations on imaging studies and an open surgery for chronic disease. The patients in whom empyema fails to resolve conservatively in 72 hours as decided on X-ray and USG of chest should undergo secondary VATS.

Pulmonary Parenchymal Biopsy
Pulmonary biopsies for either diffuse or localized processes are common indications for thoracoscopy. In patients with diffuse processes, preoperative imaging with postero-lateral and lateral chest roentgenograms is usually sufficient. In patients with localized disease processes, preoperative imaging with high resolution CT scans is useful. Thoracoscopic sampling of pulmonary tissue gives a very high yield and results are encouraging.5,6

Mediastinal Disease
Mediastinal lymphnodes biopsy and excision of other mediastinal lesions can be performed easily. Extensive surface biopsy specimens can be done using cup forceps, while deeper tissue can be obtained with a transthoracic, visually guided, true-cut needle. Thymus gland is located in the superior mediastinum and its excision is indicated in some of the patients with Myasthenia Gravis. The techniques of VATS can be safely applied in these patients to decrease the morbidity of the thoracotomy.7

Diaphragmatic Eventeration and Hernia
The repair of the diaphragmatic hernia and eventeration is relatively straight forward operations even in small children. The recovery is rapid with removal of ICD in 48 hours with early discharge from the hospital.8

Other conditions
The division of PDA can be performed using VATS.9 Similarly it is possible to clip and divide the ligamentum of the vascular ring using VATS. Spontaneous pneumothorax in young adults is caused by apical bullae and primary VATS with the stapling can be performed.10 Benign oesophageal tumours like leiomyoma cab be removed using VATS with good results.12 The VATS application has been used successfully with good results in newborn with oesophageal atresia and tracheo-oesophageal fistula.13,14

Summary
VATS is a useful for the diagnosis and treatment of many intrathoracic conditions for which in past conventional thoracotomy was performed. The same results can be achieved without thoracotomy with less surgical trauma, reduced hospitalization and speedier return to normal physical activities.

References

  1. Shah RS, Varela P J, Merry C M. Selective Ventilation Using A Fogarty Balloon Catheter as A Bronchial Blocker: An Essential Technique for Paediatric Thoracoscopic Surgery. Paediatric Endosurgery and Innovative Techniques 1997; 1 : 147-50.
  2. Hill RC, Jones DR, Vance RA, Kalantarian B. Selective lung ventilation during thoracoscopy: Effects of insufflation on haemodynamics. Ann Thorac Surg 1996; 61 : 945-48.
  3. Shah RS. Empyema Thoracis - Recent Trends in the Management. Indian J Practical Pediatrics 2004; 6 : 21-6.
  4. Merry CM, Bufo AJ, Shah RS, Schropp K P, Lobe TE. Early definitive Treatment in Paediatric Empyema. J Paediatric Surgery 1999;33: 178-81.
  5. Piolanti M, Coppola F, Papa S, Pilotti V, Mattioli S, Gavelli G. Ultrasonographic localization of occult pulmonary nodules during video-assisted thoracic surgery. Eur Radiol 2003.
  6. Blakely ML, Shah R, Lakshman S, Lezamme P, Lobe TE. “Pediatric Thoracoscopy”, In: Atlas of Videothorascopic Surgery. Di Falco G (Ed.) 1998. Milan : Masson.
  7. Bufo AJ, Shah R, Wheeler T, Fachinni S, Lobe TE. Video Assisted Thymectomy in children with Myasthenia Gravis. Accepted for publication in Paediatric Endosurgery and Innovative Techniques.
  8. Hwang Z, Shin JS, Cho YH, Sun K, Lee IS. A simple technique for the thoracoscopic plication of the diaphragm. Chest 2003; 124 : 376-8.
  9. Nezafati MH. Closure of patent ductus arteriosus by video-assisted thoracoscopic surgery; minimally invasive, maximally effective: report of 600 cases. Heart Surg Forum 2003; 6 : S28.
  10. Galbis Caravajal JM, Mafe Madueno JJ, Benlloch Carrion S, Baschwitz Gomez B, Rodriguez Paniagua JM. Video-assisted thoracoscopic surgery in the treatment of pneumothorax: 107 consecutive procedures. Arch Bronconeumol 2003; 39 : 310-3.
  11. Hazama K, Akashi A, Shigemura N, Nakagiri T. Less invasive needle thoracoscopic laser ablation of small bullae for primary spontaneous pneumothorax. Eur J Cardiothorac Surg 2003; 24 : 139-44.
  12. Samphire J, Nafteux P, Luketich J. Minimally invasive techniques for resection of benign esophageal tumors. Semin Thorac Cardiovasc Surg 2003; 15 : 35-43.
  13. Krosnar S, Baxter A. Thoracoscopic repair of esophageal atresia with tracheoesophageal fistula: anesthetic and intensive care management of a series of eight neonates. Paediatr Anaesth 2005; 15 : 541-6.
  14. Aziz GA, Schier F. Thoracoscopic ligation of a tracheoesophageal H-type fistula in a newborn. J Pediatr Surg 2005; 40 : 35-6.

 

OBESITY HOLDS BACK WOMEN, BUT NOT MEN

Women with obesity persisting from childhood to adulthood are half as likely to be gainfully employed and to have a partner than women who are not obese; in men, obesity is not associated with any adverse social outcomes. Viner and Cole analysed self reported socioeconomic, educational, psychological, and social outcomes for 8490 participants from the 1970 British birth cohort who were followed up at ages 10 and 30 years. Obesity that was limited to childhood had little impact on adult outcomes in both sexes.

BMJ, 2005; 330 : 1354.


CELECOXIB SEEMS TO BE THE CHOICE FOR CONGESTIVE HEART FAILURE

Celecoxib currently seems to be the safest choice for treating elderly patients with congestive heart failure. Hudson and colleagues undertook a retrospective cohort study that included more than 2000 patients aged 66 or more who were prescribed celecoxib, rofecoxib, or a non-steroidal anti-inflammatory drug (NSAID) at their index admission for congestive heart failure. The combined risk of death and recurrent congestive heart failure was higher in patients prescribed NSAIDs or rofecoxib than in those prescribed celecoxib (hazard ratios 1.26 and 1.27, respectively).

BMJ, 2005; 330 : 1370.


BACK PAIN

`Brief pain management techniques... offer an alternative to physiotherapy incorporating manual therapy and could provide a more efficient first-line approach'.
The importance of early attention to psychosocial factors is emphasised in clinical guidelines for the management of low back pain. E M Hay and colleagues compared a brief pain management programme with physiotherapy incorporating manual therapy for patients consulting primary care with subacute low back pain. At 12 months, the groups had similar clinical outcomes.

Lancet, 2005; 1987, 2024.

*Hon. Paediatric and Laparoscopic Surgeon, P.D. Hinduja National Hospital and Sir H. N. Hospital, Mumbai. **Ex-Associate Consultant; ***Hon. GI and Laparoscopic Surgeon, P. D. Hinduja National Hospital, Mumbai and Sir H. N. Hospital, Mumbai.
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