1. Advances in Pediatric MIS Over The Past Decade George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital Kansas City, Missouri

2. Advances in MIS 1.Development of Surgical Technique  Thoracoscopic lobectomy  Thoracoscopic repair EA/TEF  Single site umbilical laparoscopic surgery (SSULS) 2.Refinement in Surgical Technique  Laparoscopic fundoplication  Laparoscopic pyloromyotomy 3.Definition of Perforated Appendicitis 4.Evidence Based Studies in MIS 5.Consensus B/W Drs. Pena & Georgeson regarding laparoscopy for anorectal atresia with a fistula above the prostatic urethra (IPEG 2009)

3. Advances in MIS 6.Growth of IPEG 7.Development of good 3 mm instruments 8.Development of HD picture 9.Development of the stab incision technique

4. Development of A Surgical Technique Thoracoscopic Repair EA/TEF – Lessons Learned Baby should ideally be >2.5 kg Bronchoscopy to identify fistula to gauge distance Oscillating ventilator helpful Is metal clip good for ligating TEF? When to convert? How to train staff and residents?

5. Thoracoscopic Repair EA/TEF

6. Oscillating Ventilator Helpful Development of A Surgical Technique Thoracoscopic Repair EA/TEF – Lessons Learned

7. Is the metal clip appropriate for ligating the TEF? Can a recurrent TEF be prevented? J Laparoendosc Adv Surg Tech 17:380-382, 2007 Development of A Surgical Technique Thoracoscopic Repair EA/TEF – Lessons Learned

8. When to convert?  After ligation & division of TEF - if the gap is too large (2 -3 cm)? How do we train staff and residents? Development of A Surgical Technique Thoracoscopic Repair EA/TEF – Lessons Learned

9. Thoracoscopic Repair EA/TEF Results (104 Patients) Mean Age (days)1.2 (± 1.1) Mean Wt (kg)2.6 (± 0.5) Mean Operative Time (min)129.9 (± 55.5) Mean Days Ventilation3.6 (± 5.8) Mean Hospitalization (days) 18.1 (± 18.6)

10. Thoracoscopic Repair EA/TEF (104 Patients) Fistula Ligation  37 pts: suture ligation  67 pts: clip ligation Ann Surg 242: 422-430, 2005

11. Thoracoscopic Repair EA/TEF Associated Anomalies (104 Patients)

12. Thoracoscopic Repair EA/TEF Results (104 Patients) Fundoplication26 (22 Nissen, 4 Thal) Aortopexy7 ( 6 thoracoscopic) Duodenal atresia4 (4 laparoscopic) Imperforate anus10 (7 high, 3 low) Cardiac operations5 ( other than VSD/ASD) Ann Surg 242: 422-430, 2005

13. Thoracoscopic Repair EA/TEF Complications (104 Patients) Recurrent fistula2 ( 3 mos, 8 mos) Mortality 3  7 mo old - NEC  10 day old – CHD  21 day old with esophageal disruption at intubation Ann Surg 242: 422-430, 2005

14. Thoracoscopic Repair EA/TEF Conversion to Open 5 Pts 1 Pt:R aortic arch (despite negative ECHO) 3 Pts:Intraoperative desaturation, relatively long gap 1 Pt:1.2 kg baby – only 1 port placed – too small

15. Thoracoscopic Repair EA/TEF 104 Patients Waterston A: > 5.5 lb with no significant associated problems Waterston B: 4-5.5 lbs. or higher weight with moderate pneumonia or congenital anomaly Waterston C: weight < 4 lb or higher weight with severe pneumonia or congenital anomaly

16. Thoracoscopic Repair EA/TEF N.R.:Not reported A:87% are Gross Type C B:Stricture is defined as a significant narrowing on the initial esophagram C:Stricture in this paper is defined as requiring > 4 dilations D:Stricture in this paper is defined as requiring > 2 dilations

17. EA/TEF Operative Approach ThoracoscopyThoracotomy TranspleuralExtrapleural/Transpleural Longer operative timeShorter operative time Better visualizationAdequate visualization Anesthesia importantAnesthesia standard

18. Thoracoscopic Repair EA/TEF Advantages of Thoracoscopy Avoidance of musculoskeletal sequelae Superior visualization of anatomy Easy to identify fistula for ligation

19. How To Get Started Not The Ideal Case 2 - 2.5 kg Very high upper pouch Complex single ventricle physiology Prostaglandin dependent

20. How To Get Started Ideal Case Baby – 2.5-3 kg; no other anomalies Esophageal segments close together (CXR, Bronchoscopy) Start thoracoscopically – Go as far as comfortable Try it again

21. Development of a Surgical Technique Thoracoscopic Lobectomy – Lessons Learned Upper lobes are very difficult, esp. if training residents Middle & lower lobes are easier b/c are “end organs” Single lung ventilation very helpful – need good anesthesiologist For prenatally discovered CPAM, better to wait until baby is 6-9 mos of age (assuming asymptomatic)

22. Development of a Surgical Technique Thoracoscopic Lobectomy – Lessons Learned Atlas of Pediatric Laparoscopy and Thoracoscopy Holcomb, Rothenberg, Georgeson

23. Development of a Surgical Technique SSULS Why did it develop? Who benefits patient or surgeon? What operations are applicable? Special equipment needed?

24. SSULS What Operations Are Applicable? Appendectomy Cholecystectomy Splenectomy Ileal or colonic resection (IBD or segmental lesion) – extra-corporeal anastomosis Pyloromyotomy

25. SSULS Special Equipment SILS port (Covidien, Inc.) Cholecystectomy Splenectomy Segmental ileal or colonic resection Long telescope (30 0, 45 0 )

26. SSULS Cholecystectomy

27. SSULS Appendectomy

28. SSULS Appendectomy

29. Refinement in Technique Lap. Fundoplication Cautery in pts <4-5 yrs Minimal esophageal dissection/mobilization

30. Refinement in Technique Lap Pyloromyotomy

31. Definition of Perforated Appendicitis Hole In appendixFecalith in abdomen J Pediatr Surg 43:2242-2245, 2008

32. Definition of Perforated Appendicitis Impact of Strict Definition of Perforation on Abscess Rate Before definitionAfter definition Abscess rate (%) Acute appendicitis 1.70.8 Perforated appendicitis 14.018.0 J Pediatr Surg 43:2242-2245, 2008

33. Evidence Based Studies in MIS Laparoscopic vs Open Pyloromyotomy Preoperative Data Open (n = 100) (mean +/- SE) Laparoscopic (n = 100) (mean +/- SE) P value Age (wk)5.24 +/- 0.255.33 +/- 0.210.77 Preoperative pyloric thickness (mm) 4.17 +/- 0.084.16 +/- 0.090.88 Preoperative pyloric length (mm) 19.51 +/- 0.2619.38 +/- 0.270.74 Admission chloride level (mmol/L) 99.36 +/- 0.7999.76 +/- 0.760.72 Admission bicarbonate level (mmol/L) 28.18 +/- 0.5127.86 +/- 0.470.65 Ann Surg 244:363-370, 2006

34. Evidence Based Studies in MIS Laparoscopic vs Open Pyloromyotomy Outcomes Open (n = 100) (mean +/- SE) Laparoscopic (n = 100) (mean +/- SE) P value Operating time (minutes:seconds) 19:28 +/- 0:4119:34 +/- 0:460.93 Postoperative emesis (no.)2.61 =/- 0.321.85 +/- 0.150.05* Time to full feeds (hours:minutes) 21:01 +/- 1:1719:30 +/- 1:220.43 Doses of analgesia (no.)2.23 +/- 0.181.59 +/- 0.150.008* Length of stay after operation (hours:minutes) 33:10 +/- 1:3529:38 +/- 1:360.12 Ann Surg 244:363-370, 2006

35. Patient Variables at Consultation WBC 20.819.70.71 Weight (kg) 24.620.70.52 Age (Years) 4.8 5.20.77 Days of Symptoms 9.010.60.32 VATStPA P Value O2 support (L/min) 0.81 0.790.96 Thoracoscopic Debridement vs Fibrinolysis for Empyema ER/PCP visits 2.9 2.70.69 J Pediatr Surg 44:106-111, 2008

36. Outcomes 16.6% failure rate for fibrinolysis VATStPA P Value PO Fever (Days) 3.1 3.80.46 O2 tx (Days) 2.25 2.330.89 LOS (Days) 6.89 6.830.96 Patient Charges $11,660$7,5750.01 Analgesic doses22.321.40.90 Thoracoscopic Debridement vs Fibrinolysis for Empyema J Pediatr Surg 44:106-111, 2008

37. London Prospective Trial VATS v Fibrinolysis w/Urokinase No difference in LOS (6 v 6 days) No difference in 6 month CXR VATS more expensive ($11.3K v $9.1K) 16 % failure rate for fibrinolysis Am J Respir Crit Care Med 174:221-227, 2006

38. Current Management Algorithm Treatment algorithm for empyema in children based on level 1 evidence.

39. Evidence Based Studies in MIS Initial Laparoscopic Appendectomy vs Initial Non-operative Management for Patients Presenting with Appendicitis and Abscess Patient Characteristics at the Time of Admission Initial operation (n = 20) Initial non-operative management (n = 20) P value Age (y)10.1 +/- 4.28.8 +/- 4.2.31 Weight (kg)37.0 +/- 16.237.1 +/- 20.8.98 Body mass index (kg/cm 2 )18.0 +/- 4.519.5 +/- 5.5.39 White blood cell count17.4 +/- 6.616.9 +/- 6.8.84 Maximum temperature37.8 +/- 1.037.7 +/- 0.9.95 Maximum axial area of abscess (cm 2 )29.2 +/- 29.726.2 +/- 21.1.75 APSA, 2009 J Pediatr Surg 45:236-240, 2010

40. Evidence Based Studies in MIS Initial Laparoscopic Appendectomy vs Initial Non-operative Management for Patients Presenting with Appendicitis and Abscess Initial operation (n = 20) Initial non-operative management (n = 20) P value Operation time (min) 62.1 +/- 38.742.0 +/- 45.5.06 Total length of hospitalization (d) 6.5 +/- 3.86.7 +/- 6.6.92 Recurrent abscess after initial treatment 20%25%1.0 Doses of narcotics 9.7 +/- 4.07.1 +/- 15.8.47 Total health care visits 2.8 +/- 1.14.1 +/- 1.0<.001 No. of CT scans 1.5 +/- 0.72.1 +/- 1.10.4 Total charges $44,195 +/- $19,384 $41,687 +/- $18,483.68 APSA, 2009 J Pediatr Surg 45:236-240, 2010

41. MIS Studies in Progress SSULS Appendectomy vs 3-Port Lap Appendectomy SSULS Cholecystectomy vs 4-Port Lap Cholecystectomy SSULS Splenectomy vs 4-Port Laparoscopic Splenectomy Irrigation/Suction vs Suction Only During Lap. Appendectomy for Perforated Appendicitis Epidural vs PCA for Post-operative Pain Mgmt. Following Nuss Repair

42. Development of the Stab Incision Technique

43. The Use of Stab Incisions PAPS, 2003 J Pediatr Surg 38:1837-1840, 2003

44. Cost Savings from Stab Incisions PAPS, 2003 J Pediatr Surg 38:1837-1840, 2003

45. What Advances Will Be Made in the Next Decade?

46. QUESTIONS www.centerforprospectiveclinicaltrials.com www.cmhcenterforminimallyinvasivesurgery.com