1 History of Minimally Invasive Surgery Shawn D. St. Peter and George W. Holcomb III CHAPTER OUTLINE termed the Lichtleiter (light conductor) and used as a cystoscope and vaginoscope, is considered the fi rst true THE 19TH CENTURY endoscope (Fig. 1-1). Unfortunately, the medical com- munity’s reception of the Lichtleiter was tragically unfa- THE EARLY 20TH CENTURY vorable, which was perhaps predictable for such a giant THE DEVELOPMENT OF FIBEROPTIC leap. The instrument’s potential was not understood, TECHNOLOGY and it was condemned as “merely a magic lantern.” After a review by the medical faculty of the University THE LATE 20TH CENTURY in Vienna, Bozzini was punished. However, his contri- THE MODERN ERA butions fashioned the groundwork for others to make steady progress in the fi eld of endoscopy. Nearly 200 SELECTED REFERENCES years after his death, the concept of image projection on a screen would unlock the vast potential of minimally invasive surgery. The Lichtleiter and its modifi ed variants would be Hippocrates, the father of Western medicine, detailed used by others and would account for the endoscopic the use of a primitive anoscope to examine hemor- evolution over the next century. Pierre Salomon Segalas rhoids in 400 BC. In the ruins of Pompeii (AD 70), a introduced the urethro-cystique (a cystoscope), a varia- three-bladed speculum was identifi ed that is similar to tion of Bozzini’s instrument, to the Académie de Sci- one used today. An Arabian named Abulkasim improved ences in Paris in 1826. Simultaneously, the American on Hippocrates’ method around AD 1000 by refl ecting John Fisher was using a similar instrument clinically for light to examine the cervix. The dominant limitation to vaginoscopy in Boston. His development was driven by these fl edgling attempts at endoscopy was an adequate the necessity to evaluate the cervix of shy young women light source to illuminate the area exposed by the other for whom standard exposure would be traumatic. end of the instrument. Therefore, 15 centuries passed A French surgeon named Antoine Jean Desormeaux without a major advance in the fi eld, until 1585, when began using a technological modifi cation of the Licht- Tgulio Caesare Aranzi began focusing sunlight through leiter for urologic procedures in the mid 1800s. He is a fl ask of water and projecting the light into the nasal considered by some to be the father of endoscopy, and cavity. he is certainly the father of cystoscopy. He modifi ed Bozzini’s scope by changing the light source from a candle to the fl ame from a solution of alcohol and tur- THE 19TH CENTURY pentine. This solution produced a brighter and more condensable beam of light. Near the same time, in More than 200 years later, in 1806, Philip Bozzini pro- Dublin, Francis Cruise improved Desormeaux’s work by duced the fi rst endoscope with a light source. His revo- enhancing illumination with a paraffi n lamp. Cruise’s lutionary development involved a series of mirrors to instrument was more readily usable and was designed refl ect light from a burning wax candle inside an alumi- with attachments for examining the rectum, uterus, num device to the point of focus. His tool, which he auditory canal, pharynx, and larynx. In his writings, Ch001-X3373.indd 1 4/18/2008 10:55:31 AM 2 Atlas of Pediatric Laparoscopy and Thoracoscopy Figure 1-2. In 1901, the fi rst experimental laparoscopy was performed in an animal model by George Kelling. After insuffl ation of the peritoneal cavity with sterile air, he peered into the abdomen with a cystoscope, which he called a coelioskope. The insuffl ator he used is shown. Figure 1-1. In 1806, Philip Bozzini developed the fi rst endoscope with a light source. His instrument utilized a series of mirrors to refl ect light from a burning candle inside an aluminum device to the point of focus. He termed this tool the Lichtleiter, which means “light conductor.” This was considered the fi rst true endoscope and was used initially as a cystoscope and vaginoscope. Cruise mentioned that scopes might be modifi ed for examination of the esophagus and stomach. In 1869, Commander Pantaleoni used a modifi ed cystoscope to cauterize a hemorrhagic uterine growth. This procedure became the fi rst therapeutic hysteroscopy. Continuing along the same conceptual line with Figure 1-3. The fi rst clinical description of laparoscopy and further modifi cation, in 1877, a German physician, thoracoscopy is attributed to Hans Christian Jacobaeus. He used Maximilian Nitze, introduced the fi rst modern-style pneumoperitoneum and a light source on the distal end of his endoscope with a distal light source. His kystoskop was endoscope. He is seen peering through the lens of his laparoscope in this photograph. designed by Viennese instrument maker Joseph Leiter, who used an incandescent platinum wire loop to illu- minate the body cavity from inside, which allowed an image to be directed through lenses to the outside with Kelling, made a small incision in the abdomen of dogs, magnifi cation. Leiter used this instrument to inspect the insuffl ated the peritoneal cavity with sterile air, and urethra, bladder, and larynx. investigated the abdomen with a cystoscope. He created In 1868, Adolf Kussmaul viewed the esophagus and the term coelioskope for his visionary procedure. His stomach of a professional sword swallower. Although clinical goal was to stop intra-abdominal hemorrhage performed merely for demonstration and not clinically from diseases such as ruptured ectopic pregnancy and useful, it was very likely the fi rst esophagoscopy. There- pancreatitis. Although his work found little support, his fore, he is considered by some to be the father of the research established the importance of a sterile pneu- current fi eld. However, this arena was advanced more moperitoneum to allow visualization, an anchoring substantially by Johann Mikulicz, a surgeon in Vienna principle for future laparoscopy (Fig. 1-2). with a keen interest in the treatment of gastric cancer. Near the time of Kelling’s animal experiments, the He began performing clinically useful esophagoscopy in seeds of minimally invasive techniques in humans were 1881 in an attempt to discover gastric tumors at an being planted. Hans Christian Jacobaeus, an internist in earlier stage. A prolifi c surgeon, Mikulicz documented Stockholm, introduced the term laparothorakoskopie in 183 gastrectomies for gastric cancer during his relatively his unprecedented report on laparoscopy and thoracos- short career and became quite cognizant of its fatal copy in humans. This sentinel paper was published in nature. In fact, he died of gastric cancer at age 55. Münchener Medizinische Wochenschrift in 1911. He uti- lized a pneumoperitoneum and light source on the distal end of his endoscope (Fig. 1-3). Kelling took THE EARLY 20TH CENTURY exception to the article and issued a letter to the editor that appeared 2 months later disputing the assertion In 1901, the fi rst experimental laparoscopy was per- that Jacobaeus introduced the technique in humans. formed in an animal model. A German surgeon, George Kelling contended he had successfully performed two Ch001-X3373.indd 2 4/18/2008 10:55:32 AM History of Minimally Invasive Surgery 3 laparoscopic cases in humans between 1901 and 1910. In 1944, Raoul Palmer began examining the intra- Regardless of the merit in Kelling’s letter, his failure to abdominal reproductive organs of women in Paris. He publish his work in a timely manner will leave the used an umbilical port with insuffl ation and a rigid record attributing the fi rst clinical description of lapa- optic lighting system. Notably, his patients were placed roscopy and thoracoscopy to Jacobaeus. Interestingly, in in the Trendelenburg position to facilitate a view of the this paper, Jacobaeus reported thoracoscopy as a more pelvis by passively allowing air into this space. Palmer promising procedure than laparoscopy. monitored the intra-abdominal pressure during the pro- In 1911 as well, Bertram M. Berheim at Johns Hopkins cedure. Both of these concepts are now known to be performed the fi rst laparoscopy in the United States, important to modern laparoscopy. which he asserts was prior to any knowledge of Jacobaeus’s or Kelling’s work. He used a 1/-inch- 2 diameter proctoscope with a directed external light THE DEVELOPMENT OF and coined the term organoscopy, a misnomer because FIBEROPTIC TECHNOLOGY he was inspecting the inside of a cavity, not an organ. The enthusiasm Jacobaeus held for thoracoscopy over The greatest advance during the middle of the 20th laparoscopy resulted from the pressing medical needs century was not a surgical application but the techno- of his patients. He advocated an opposite working port logical discovery of fi beroptics. In 1954, two separate to perform pneumolysis in those patients with tubercu- articles describing imaging bundles appeared in Nature, losis, another founding principle in therapeutic thora- one by Abraham van Heel of the Technical University coscopy. This technique became widely practiced and in Delft, Holland, and the other by Harold H. Hopkins therefore represents the fi rst minimally invasive proce- and Narinder Kapany of Imperial College in London. dure to gain a reasonable level of acceptance. This initial Hopkins, an English physicist, produced the fi rst func- period of minimally invasive surgery ended in 1945 tional fi beroptic prototype in 1954. Van Heel, stimu- with the discovery of streptomycin. Now that this disease lated by a conversation with the American optical could be managed medically, the use of thoracoscopy physicist Brian O’Brien, subsequently covered the fi ber fell into a quiescent period. with a transparent layer having a lower refractive index. The fi rst large case series on the clinical use of lapa- This protected the total-refl ection surface from contami- roscopy appeared in 1920. An internist from Chicago, nation and greatly reduced interfi ber contamination. B. H. Orndoff, described 42 cases of diagnostic perito- The next step was made by Lawrence Curtiss, an neoscopy. He described the use of a sharp pyramidal undergraduate at the University of Michigan working trocar for an access port. The next substantial step under physician Basil Hirschowitz and physicist C. occurred in 1929 when Heinz Kalk, a German gastroen- Wilbur Peters. Curtiss covered the optical fi bers in glass. terologist, developed a 135-degree lens system and This glass-encased fi berscope, built as a gastroscope, described the addition of a working port. He used lapa- made its clinical debut in 1957 in Ann Arbor. For the roscopy effectively in the diagnosis of hepatobiliary fi rst time, the image was suffi cient for photographs. disease. Ten years after his invention, demonstrating Bergein F. Overholt, also working in Ann Arbor as a remarkable confi dence in his instrumentation, Kalk trainee at the time, helped develop the fi rst fl exible published a series of 2000 liver biopsies under local fi beroptic sigmoidoscope-colonoscope in 1963. After he anesthesia without any mortality. During this time, in presented his experience to the American Society of Gas- 1934, John C. Ruddock, an American internist, claimed trointestinal Endoscopy in 1967, the idea of colonos- laparoscopy to be a diagnostic technique superior to copy was offi cially embraced. laparotomy. His work produced an important instru- ment in modern minimally invasive surgery: forceps with electrocoagulation capacity. THE LATE 20TH CENTURY Another modern tool of laparoscopy was introduced in 1938 when Hungarian Janos Veress developed a Now that technology had progressed enough to enable spring-loaded blunt-tipped needle for draining ascites clear visualization of body cavities, the next opportunity and evacuating fl uid and air from the chest. His innova- for advancement rested in the hands of the surgeons. tion was used to create a therapeutic pneumothorax for Few surgeons have had a more infl uential role in the tuberculosis. Although he did not foresee application of development of minimally invasive surgery than Kurt this tool in minimally invasive surgery, the Veress needle Semm of Kiel, Germany. His story refl ects the plight has become an indispensable instrument for many lapa- assumed by original thinkers when they begin to trans- roscopic surgeons. Although the device was, and still is, form ideas into action. He began publicizing his work considered unsafe by some surgeons, an alternative with presentations at German, Austrian, and Swiss gyne- approach, using the cut-down technique, would later be cologic meetings in the early 1960s. A trained toolmaker published in 1971 by H. M. Hasson, a gynecologist in as well as a physician, he developed an electronic carbon Chicago. dioxide insuffl ator, producing a clear shift in the previ- Ch001-X3373.indd 3 4/18/2008 10:55:32 AM 4 Atlas of Pediatric Laparoscopy and Thoracoscopy ous concept of air pneumoperitoneum. He also began lished in 1987, and in 1988, the annual World Congress to develop specifi c endoscopic tools with a designated on Surgical Endoscopy made its debut in Berlin. function such as a uterine manipulator, a high-volume irrigation and aspiration device, knot-tying instruments, and a tubal patency testing device. Understanding the THE MODERN ERA overwhelming potential of laparoscopy, he urged the general surgeons at Kiel University to perform a laparo- Meanwhile, the technical key to Pandora’s box was scopic cholecystectomy in the late 1970s, more than a found in 1982 when a real-time, high-resolution video decade before general surgeons considered this a viable camera was developed that could be attached to the approach. Of course, his suggestion was ridiculed. endoscope. This miniature electronic camera (4 × 4 mm) Despite this skepticism, he performed the fi rst laparo- had a charge-coupling device (CCD) that could convert scopic appendectomy in 1981. After presentation of the the incoming optical image into electrical impulses that technique at a surgical meeting in Germany, the Presi- could be sent to a monitor, a recording device, or else- dent of the German Surgical Society wrote a letter to the where. This development allowed a clear magnifi ed Board of Directors of the German Gynecological Society image of the entire operating fi eld to be shown on a requesting suspension of Semm’s privileges. Apprehen- monitor. Up to this point, the surgeon was hunched sion, fear, and unfounded resistance should be antici- over, peering into the scope, with limited vision. Once pated by pioneers. Overcoming these prejudices is a a high-resolution, magnifi ed intracorporeal image could necessary step for advancement. be viewed on a monitor, the surgeon could stand upright The development of medical therapy for tuberculosis and work with two operating hands without handling lessened physicians’ interest in thoracoscopy. In the the camera. Moreover, additional assistants could then 1960s, there were occasional case reports describing its join the procedure with an equal view. Surgeons would use, but there were no real accepted applications. Medi- no longer need to scrub to teach an operation, trainees astinoscopy for evaluating resectability of pulmonary could watch without being close to the fi eld, and opera- carcinomas became useful in the 1960s, as this proce- tions could easily be recorded and transmitted to sepa- dure did not depend on advanced visualization or rate sites. The limitation to minimally invasive surgery lighting systems and the instrumentation needed was was instantly shifted to the imagination and willingness rudimentary. In the early 1970s, thoracoscopy reemerged of the surgeons. as a useful diagnostic technique. Brad Rodgers and Jim Five years after this critical innovation, the revolution Talbert at the University of Virginia used thoracoscopy in minimally invasive surgery began. The fi rst laparo- in children to visualize lung pathology and obtain biop- scopic cholecystectomy was reported in 1987 by Philippe sies. Around the same time, several small series of adult Mouret in Lyon, France. The news of this surgical patients undergoing thoracoscopy in a similar manner triumph spread, and the next calendar year witnessed began to appear in the world literature. The use of fi ber- laparoscopic cholecystectomies performed by several optics for these procedures allowed expansion of this surgeons including Dubois (Paris), Perissat (Bordeaux), technology beyond gynecology and set the stage for the Nathanson and Cuschieri (Scotland), McKernan and coming era of minimally invasive surgery. Saye (Georgia), Reddick and Olsen (Tennessee), Groitl In the late 1970s, an inspired obstetrician and scien- and Troidl (Germany), Katkhouda (France), Klaiber tist in Bristol, England, Patrick C. Steptoe, used a lapa- (Switzerland), and others. On the surface, it appears roscopic technique to harvest oocytes to perform in that few advances in the history of surgery have become vitro fertilization for infertile couples. With the help of so widely accepted so quickly. However, given the long Robert Edwards, a physiologist at Cambridge Univer- struggle against resistance that minimally invasive sity, the fi rst “test tube” baby, Louise Joy Brown, was surgery incurred initially, these early laparoscopic cho- born on July 25, 1978. A landmark in minimally inva- lecystectomies represent the breaking points that led to sive surgery, the birth of this 5-pound, 12-ounce baby the modern era of minimally invasive surgery. The evo- girl with blue eyes and blond hair was also the birth of lution toward laparoscopy and thoracoscopy was a a new fi eld in medicine. monumental shift in surgical capacity akin to the advent The political climate in medicine began a gradual of general anesthesia and antiseptic agents. In the 5 shift in the late 1970s that would strengthen the push years that followed, surgeons from every subspecialty toward modern minimally invasive surgery. In Hamburg, began applying the surgical principles found in those Germany, the Surgical Study Group on Endoscopy and original cholecystectomies. Shortly thereafter, laparos- Ultrasound (CAES) was created in 1976. In 1981, the copy became routinely used for colectomy, splenec- Society of American Gastrointestinal Endoscopic Sur- tomy, nephrectomy, adrenalectomy, appendectomy, geons (SAGES) was conceived. The same year, the small bowel resections, explorations, and more. Thora- American Board of Obstetrics and Gynecology made coscopy became standard for decortication and wedge laparoscopy a requirement for residency training. The resections. This explosion of surgical advancement fi rst issue of the journal Surgical Endoscopy was pub- pressed commercial producers of surgical equipment to Ch001-X3373.indd 4 4/18/2008 10:55:32 AM History of Minimally Invasive Surgery 5 an infl ection point of technological improvement. Sta- tance; And as brave ones not to whimper if it should plers, clip devices, endoloops, ultrasonic shears, Liga- prove less than we had supposed.” Mindful of the well- sure technology (Covidien, Mansfi eld, MA), endoscopic founded surgical principles handed down from our ultrasound probes, and many innovative devices pro- predecessors, our role now is to continue to challenge vided surgeons with fertile ground for advancing the dogmatic assumptions with the goal of easing the fi eld of minimally invasive surgery. burden and stress that operations have on our patients In the late 1990s, minimally invasive surgery experi- and their families. enced dueling processes of advancement. One was the use of a robot to push the technical limits of human laparoscopy. However, laparoscopy itself was advancing SELECTED REFERENCES as experience and skills grew, allowing surgeons to over- come previous contraindications and limitations. The 1. Gans SL: Historical development of pediatric endoscopic once unthinkable minimally invasive operations being surgery. In Holcomb GW III (ed): Pediatric Endoscopic mastered at some centers included gastric bypass, hepa- Surgery. Norwalk, CT, Appleton and Lange, pp 1-7, toportoenterostomy (Kasai procedure), total abdominal 1994 colectomy with ileal pouch–anal anastomosis, and 2. Spaner SJ, Warnock GL: A brief history of endoscopy, lapa- esophageal atresia repair. The notion of using tools to roscopy, and laparoscopic surgery. J Laparoendosc Adv lessen injury to the patient was having effects in multi- Surg Tech 7:369-373, 1997 ple fi elds. During this time, technological advances of 3. Litynski GS: Kurt Semm and the fi ght against skepticism: expandable stents and percutaneous endovascular tools Endoscopic hemostasis, laparoscopic appendectomy, and revamped the fi elds of vascular and cardiothoracic Semm’s impact on the “laparoscopic revolution.” JSLS surgery. As the century turned, hospitals began building 2:309-313, 1998 4. Georgeson KE, Owings E: Advances in minimally invasive operating suites specifi cally designed for minimally surgery in children. Am J Surg 180:362-364, 2000 invasive operations. 5. Himal HS: Minimally invasive (laparoscopic) surgery. Surg Today, we bear witness to an emerging phenomenon Endosc 16:1647-1652, 2002 of proven effi cacy. We stand beyond the point of no 6. Modlin IM, Kidd M, Lye KD: From the lumen to the lapa- return as the surgical fi elds have irreversibly moved into roscope. Arch Surg 139:1110-1126, 2004 the minimally invasive era. The scientist John Tyndall 7. Harrell AG, Heniford BT: Minimally invasive abdominal said, “We are truly heirs of all the ages; But, as honest surgery: Lux et veritas past, present, and future. Am J Surg men, it behooves us to learn the extent of our inheri- 190:239-243, 2005 Ch001-X3373.indd 5 4/18/2008 10:55:32 AM SECTION 1: GASTROINTESTINAL 2 Principles of Laparoscopic Surgery George W. Holcomb III CHAPTER OUTLINE trolled may develop, but this is rare. Finally, because of chronic lung disease or uncorrected congenital cardiac GENERAL PRINCIPLES disease, the patient may not be able to tolerate creation of a pneumoperitoneum for an abdominal operation or SAFETY AND CONCERNS FOR CHILDREN lung collapse for a thoracic procedure. The preoperative evaluation and preparation of the patient undergoing a laparoscopic operation are the same as those required for the comparable open opera- The general principles for performing a laparoscopic tion. A patient who is undergoing an elective colonic operation have not changed signifi cantly since the procedure and needs preoperative bowel preparation laparoscopic revolution began in the late 1980s. Prior should be admitted before the operation for this to the laparoscopic procedure, a preoperative confer- purpose. Patients with sickle cell disease who require ence should be held with the parents and the patient (if laparoscopic procedures should be transfused to a the age is appropriate) to discuss the nature of the lapa- hemoglobin of 10 g/dL. Preoperative admission for roscopic operation and the risks and benefi ts of this hydration of these patients is not believed to be as nec- approach. The benefi ts include reduced discomfort, essary as it was in the past, but transfusion continues to reduced hospitalization, and faster return to routine be a mainstay of the preoperative preparation. activities (such as school or sporting activities). In addi- tion, the cosmetic advantage of this approach is becom- ing increasingly appreciated. Finally, there appears to be GENERAL PRINCIPLES a defi nite reduction in the risk of adhesive postopera- tive small bowel obstruction with this approach. Risks Although for thoracoscopy, it is possible to effect include a small (generally 1%) chance of conversion to collapse of the ipsilateral lung through a variety of an open operation, usually because of unclear anatomy measures, insuffl ation is necessary to create an adequate and sometimes because of adhesions from previous working space in the abdomen. I have used infl ating open operations. In addition, as with the open approach, pressures of 12 to 15 mm Hg in numerous infants there is a small but defi nite incidence of injury to other without deleterious effects. The primary reason to structures, or of bleeding requiring transfusion. reduce this pressure is the presence of underlying The contraindications for the laparoscopic approach heart or lung disease. If there is underlying lung disease, are few. The laparoscopic technique has been used for an elevated pressure may raise the hemidiaphragms, every general and thoracic surgical procedure in chil- which can be followed by a corresponding reduction dren. Its primary contraindication is a situation in which in tidal volume, ventilation, and oxygenation. In an an adequate pneumoperitoneum cannot be created or infant with chronic heart disease who is volume depen- a lung cannot be collapsed for a thoracic operation. dent, the higher infl ating pressures may reduce venous Fortunately, this rarely occurs. Adhesions from previous return to the heart, with a corresponding reduction procedures precluding adequate visualization are occa- in cardiac output. Other than these two areas, insuffl a- sionally found. Bleeding that cannot be readily con- tion of 12 to 15 mm Hg has been used routinely in Ch002-X3373.indd 9 4/18/2008 10:55:59 AM 10 Atlas of Pediatric Laparoscopy and Thoracoscopy all patients at my institution. A fi nal caveat centers on Ligasure (Covidien, Mansfi eld, MA) has been developed the lack of an adequate working space despite a high over the past 5 years and is useful as well for ligation intra-abdominal pressure and adequate fl ow. In such and division of mesenteric vessels or short gastric an instance, the surgeon should evaluate whether the vessels in older patients requiring fundoplication. patient is adequately paralyzed. If the patient is not It works by melting the collagen and elastin in the vessel paralyzed, it may not be possible to create an adequate wall and re-forming it into a permanent seal. Moreover, working space despite high fl ows and high infl ating these instruments are also helpful for splenectomy pressures. and for thoracic procedures. Both of them come as 5- Angled telescopes are essential for safety and adequate mm instruments and are well suited for pediatric visualization. There are currently very few indications application. for a 0-degree telescope. A 0-degree telescope may be As a general statement, the largest and usually the used for a laparoscopic cholecystectomy and for initial initial cannula is placed in the umbilicus. Again, the diagnostic laparoscopy. However, to see around the reasoning is that the umbilicus is composed mainly of corners of the abdominal viscera, use of an angled tele- scar and it is quite easy to hide a large incision at this scope is paramount. For most of the operations at my site. For children undergoing laparoscopic appendec- institution, either a 45-degree angled 5-mm telescope or tomy or splenectomy at my institution, a 12-mm port a 70-degree angled 5-mm telescope is used. For fundo- is placed in the umbilicus and the resulting scar is quite plication or cholecystectomy, a 45-degree angled tele- pleasing. scope is employed. For a pyloromyotomy, a splenectomy, Finally, my colleagues and I use a stab incision tech- a laparoscopic pull-through, or an appendectomy, a 70- nique in infants and young children almost exclusively. degree angled telescope is employed. In addition, for With this approach, an initial cannula is placed in evaluation of the contralateral inguinal region in a child the umbilicus and insuffl ation achieved through this with a known unilateral inguinal hernia, a 70-degree cannula. A stab incision using a #11 Bard Parker (Becton- angled telescope is essential for adequate visualization Dickinson, Franklin Lakes, NJ) blade is then used to of the contralateral inguinal ring. Although some create the tract through which instruments are passed authors feel that a 3-mm telescope can be useful, there (Fig. 2-1). This stab incision technique is employed for is no advantage to using the smaller telescope in the all operations in infants and young children and can umbilicus. A 5-mm port results in the same cosmetic even be applied to some adolescents. As an example, for appearance as a 3-mm port inserted in the center of the a fundoplication, one 5-mm cannula is placed in the umbilicus, as the umbilicus is scar and heals quite umbilicus and four stab incisions are used. For a lapa- nicely. Therefore, in my mind, there is no advantage to roscopic splenectomy, a 12-mm port is placed in the using a 3-mm telescope, even in infants. A disadvantage umbilicus and a 5-mm port is placed in the midline of using a 3-mm cannula and telescope is that there is epigastrium. Two stab incisions are then used (Fig. 2- often inadequate space in the cannula around the tele- 2A). For a laparoscopic cholecystectomy, the two right- scope to allow adequate insuffl ation. sided instruments are usually placed through stab Over the past 10 years, a couple of vessel-sealing incisions rather than ports unless the patient is extremely devices have been developed. The Harmonic Scalpel hefty (see Fig. 2-2B). In general, this technique is ideal (Ethicon Endosurgery, Cincinnati, OH) was developed for instruments that do not need to be exteriorized and in the late 1990s. Coagulation occurs when the blade, then reinserted on a regular basis. The only operation vibrating at 55,000 Hz, couples with protein and dena- in which this stab incision technique is not used cur- tures it to form a coagulum that seals small vessels. The rently is an appendectomy, for which a 12-mm port is A B Figure 2-1. The stab incision technique can be used to introduce instruments in infants and young children. A, A stab incision using a #11 blade is used to create the tract through which the instrument is passed. B, After removal of the knife, the instrument is passed through the skin and soft tissue tract. Ch002-X3373.indd 10 4/18/2008 10:55:59 AM Principles of Laparoscopic Surgery 11 A B Figure 2-2. The stab incision technique can be used for many operations, including some in older children with relatively thin abdominal walls. A, For a laparoscopic splenectomy, a 12-mm port is placed in the umbilicus and a 5-mm port is placed in the midline epigastrium where the telescope is inserted. Two stab incisions are then used cephalad to the 5-mm cannula. B, For a laparoscopic cholecystectomy, the two right-sided instruments can often be placed through stab incisions rather than ports unless the patient is extremely hefty. In general, this technique is ideal for instruments that do not need to be exteriorized and then reinserted on a regular basis for the operation. Table 2-1 Savings to the Patient and to the Hospital, Realized by Using Stab Incision Technique Savings with Step Savings with Ethicon System ($) System ($) Cannulas Used Cannulas Saved Procedure (No.) per Patient per Patient Patient Institution Patient Institution Nissen (209) 1 4 117,040 51,832 76,912 34,276 Nissen (adolescent) (14) 2 3 5,880 2,604 3,864 1,722 Appendectomy (102) 2 1 14,280 6,324 9,384 4,182 Pyloromyotomy (77) 1 2 21,560 9,548 14,168 6,314 Cholecystectomy (31) 2 2 8,680 3,844 5,704 2,542 Splenectomy (21) 2 2 5,880 2,604 3,864 1,722 Pull-through (20) 2 1 2,800 1,240 1,840 820 Ligation of testicular 1 2 4,200 1,860 2,760 1,230 vessels (AT) (15) Esophagomyotomy (7) 2 3 2,940 1,302 1,932 861 Adrenalectomy (6) 2 2 1,680 744 1,104 492 Varicocele (5) 1 2 1,400 620 920 410 Ovarian (2) 1 2 560 248 368 164 Meckel diverticulum (2) 2 1 280 124 184 82 511 operations 714 1324 $187,180 $82,894 $123,004 $54,817 AT, abdominal testis. placed in the umbilicus and two 5-mm cannulas are $123,004 to the patient and $54,817 to the institution introduced in the left mid abdomen and left lower if Ethicon cannulas were used (Table 2-1). Moreover, quadrant. these are small incisions and are usually closed only Our group recently looked at the fi nancial implica- with Steri-Strips. Finally, only one patient has returned tions of the stab incision technique in 511 operations. with a possible complication related to the stab incision If the stab incision technique was used, a savings of technique. In this patient, there was concern that a piece $187,000 in patient charges and $82,894 in institu- of omentum might have herniated into the incision tional charges were realized if the Step cannula system tract. However, this soft tissue enlargement resolved (Covidien, Mansfi eld, MA) was used. The savings were with observation. Ch002-X3373.indd 11 4/18/2008 10:56:00 AM 12 Atlas of Pediatric Laparoscopy and Thoracoscopy SAFETY AND CONCERNS FOR CHILDREN or needle should be directed transversely across the abdominal cavity and not toward the underlying viscera Because of the small size of the pediatric patient, a (Fig. 2-3). With this technique, injury to underlying number of safety considerations are peculiar to this age structures should be minimized. group. Insertion of a urinary catheter is not generally For most operations, the initial cannula is introduced required unless a prolonged procedure is anticipated. in the umbilicus. We prefer the cutdown approach However, operations in which bladder decompres- although others use the Veress needle technique. With sion is helpful include laparoscopic pull-through for the cutdown technique, a vertical incision is made in Hirschsprung’s disease and for imperforate anus. For the center of the umbilicus and carried down to the other operations, it is quite easy to manually empty the fascia. The fascia is then incised with the cautery and bladder in children if bladder decompression is required. the Step cannula system is used. However, instead of Gastric decompression with an orogastric tube remains introducing the Veress needle and expandable sleeve important for upper abdominal procedures. directly in the abdominal cavity, only the expandable Because the child’s abdominal cavity is much smaller sleeve is introduced gently into the abdominal cavity, than an adult patient’s cavity, it is important to widely followed by insertion of the cannula with a blunt-tip space the ports and instruments to allow adequate stylet through the expandable sleeve (Fig. 2-4). In this working space. An effi cient procedure is not possible if way, it is extremely unlikely that the underlying viscera the instruments are situated too close together. This can will be injured with the blunt-tip trocar. Often, espe- be especially true when performing an advanced lapa- cially in young children, there is an umbilical hernia, so roscopic procedure in an infant. this approach can be quite easy. Again, when introduc- The abdominal wall of young children, and especially ing the blunt-tip cannula and trocar, it is important to infants, is very pliable. When introducing cannulas or a try to insert the trocar and cannula away from the Veress needle with an attached expandable sleeve, it is underlying viscera so as not to injure them. very important to watch for inadvertent injury to the Another important consideration centers on the use underlying viscera. Once the sharp trocar of the cannula of endoscopic retrieval bags. Although these are required or Veress needle has pierced the peritoneum, the trocar for entrapment and subsequent morcellation of solid A B C D Figure 2-3. The abdominal wall of young children, and especially infants, is very pliable. When introducing cannulas with sharp trocars or a Veress needle with an attached expandable sleeve, it is important to watch for inadvertent injury to underlying viscera. After identifi cation of the site for introduction of the cannula (A), the sleeve and Veress needle pierce the peritoneum (B). Once the trocar or needle has pierced the peritoneum, it should be directed transversely across the abdominal wall and not toward the underlying viscera (C and D). With this technique, injury to the underlying structures should be minimized. Ch002-X3373.indd 12 4/18/2008 10:56:01 AM Principles of Laparoscopic Surgery 13 A B Figure 2-4. The umbilical site is usually where the initial cannula is introduced. We prefer the Step cannula system because of its safety; with this system, a vertical incision is made in the umbilical skin and carried down to the fascia. After incision in the peritoneum with the cautery, the expandable sleeve is introduced without the Veress needle (A). In this way, it is extremely unlikely that underlying viscera will be injured when the blunt-tipped trocar and cannula are inserted (B). HERMES A B Figure 2-5. If the endoscopic staple misfi res, massive hemorrhage may result. To minimize the complications of stapler malfunction during a laparoscopic splenectomy, we clip the splenic artery early in the operation (A). If there is stapler malfunction when it is fi red across the hilum (B), bleeding should be from the splenic vein and should be more readily controllable than from the divided splenic artery. The arrows point to the clips on the splenic artery. organs such as the spleen, they are also useful for remov- tomy (Fig. 2-5). There are two advantages to early clip- ing malignant lesions to prevent seeding of the tract and ping of the splenic artery. First, the spleen should decrease for infectious etiologies such as acute appendicitis. in size because of autotransfusion through the splenic Regarding acute appendicitis, if the specimen cannot be vein. Second, if there is a stapler malfunction, the bleed- extracted intact through the umbilical port, then an ing is from the splenic vein and should be more readily endoscopic retrieval bag is usually introduced, and the controllable than from the divided splenic artery. specimen and bag are exteriorized through the umbili- A fi nal concern regards closure of the fascial incisions. cal fascial incision after removal of the port. When mor- With the use of the Step cannula system with radial cellation of the specimen in the bag is required, it is expansion of the abdominal wall muscles as the cannula important not to morcellate too vigorously, as rupture and blunt trocar are inserted, most 3- and some 5-mm of these bags with subsequently spillage of the contents fascial incisions (other than the umbilicus) do not need has been described. The endoscopic stapler is often used closure. However, with a thin patient, we usually close in advanced minimally invasive surgical operations and the anterior sheath of the 5-mm incisions. Ten-mm inci- is useful for ligation and division of the mesoappendix sions (especially in thin patients) should always be and the appendix when performing an appendectomy, closed to prevent fascial herniation. and for ligation and visualization of the splenic hilum Complications with introduction of the Veress needle when performing a splenectomy. However, malfunction and cannulas have markedly diminished over the past of these staplers has occurred in this latter setting with 15 years. However, some abdominal wall vessels, espe- subsequent rapid hemorrhage. To minimize the com- cially the inferior epigastric vessels, can be injured if plications of stapler malfunction, we clip the splenic they are pierced by either a sharp trocar, a Veress needle, artery early in the course of the laparoscopic splenec- or a #11 blade. In a thin patient, these vessels can often Ch002-X3373.indd 13 4/18/2008 10:56:04 AM