Indications for Laparoscopy in Neonates CIPESUR Meeting November 2011 George W. Holcomb, III, M.D., MBA Children’s Mercy Hospital Kansas City, Missouri

Neonatal (< 3 mo) Laparoscopy

Hirschsprung’s Disease High Imperforate Anus Duodenal Atresia Malrotation (no volvulus) Pyloromyotomy Fundoplication/Gastrostomy Choledochal Cyst NEC/Stricture - ?

Small Intestinal Atresias - ?

Access Issues

• •

Umbilical access Thin, pliable abdominal wall

Hirschsprung’s Disease

Hirschsprung’s Disease

•

Initial trans abdominal biopsy with frozen section is important in determining what surgical option is best for each patient

•

Biopsy can be performed through umbilicus easily

Hirschsprung’s Disease

Mobilization of Rectum

Hirschsprung’s Disease Colo-anal Anastomosis

Hirschsprung’s Disease

Extent of Disease Rectosigmoid Descending colon Transverse colon Rt colon; ileum Optimal Surgical Option Laparoscopic-assisted (Transanal -?) Laparoscopic-assisted Two-stage approach Two-stage approach Ileal pullthrough (? Laparoscopic)

Hirschsprung’s Disease

Personal Approach

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Laparoscopic directed biopsy thru umbilicus

•

For rectosigmoid disease, laparoscopic assisted pullthrough



Tension free relocation of ganglionic colon to anus



Already in abdomen for laparoscopic directed biopsy

Hirschsprung’s Disease

Transanal Approach

• •

If used, best suited for low rectosigmoid disease Concern is tension on vasculature as it is brought to anus

• •

Need transabdominal biopsy to define extent of disease

•

If biopsy done, why not mobilize laparoscopically?

If no biopsy, must be ready to do transverse colon or ileal pullthrough in newborn period

Children’s Mercy Hospital Results 2000 – 2001 15 Pts Primary Lap Pullthrough (8 pts) Colostomy + Open Pullthrough (7 pts) Total Postop Hospitalization(D) 3.7

(3-7) Total Cost ($) $38,489 (21,040 - 71,034) 3.4 + 3.5

(2-19) (2-4) $70,858 (20,087 - 165,642)

Duodenal Atresia

Duodenal Atresia

Liver Retraction

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Suture around Falciform ligament

•

Retraction



3 mm liver retractor



Instrument

Visualization

Anastomosis

Diamond shaped duodenoduodenostomy

Anastomosis

•

Interrupted



Sutures



U-clips (S-60)

•

Running



Anterior, posterior or both

Surgical U-Clips

• • • •

Designed for small vascular anastomoses Easily and quickly placed – reduced operative time Allows for interrupted anastomosis (same as open operation) Approved for tissue approximation in esophageal, small intestinal, gastric, and mesenteric closures Needle Braided Flexible Member Transition Release Trigger (Black) Squeeze Area U-Clip© Device Surg Endosc 21:1023-1024, 2007

Laparoscopic Repair

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Results CMH Experience

• • • • •

January 2003 – July 2007 29 CDO operations 15 laparoscopic (11 atresia, 3 stenosis) 14 open (11 atresia, 4 stenosis) No difference in birth wt., age at operation, incidence of heart disease or chromosomal abnormalities J Pediatr Surg. 43:1002-1005, 2008

CMH Experience

Outcome Variable Operative Time Open Approach (N=14) 96.3 min Laparoscopic Approach (N=15) P value 126.7 min 0.06

Length of Postoperative Hospitalization Time to Initial Feeding Time to Full Oral Intake 20.1 days 11.3 days 16.9 days 12.9 days 5.4 days 9.0 days 0.01

0.002

0.007

J Pediatr Surg. 43:1002-1005, 2008

CMH Experience Postoperative Outcome

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1 stenosis in each group



Open revision

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Balloon dilation

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No leaks in either group

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UGI studies

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Laparoscopic – All pts (day 2-11)



Open - 4/14 pts (day 6-27) J Pediatr Surg. 43:1002-1005, 2008

Postoperative Upper GI Study

Associated Jejunal Atresia?

•

Escobar et al – J Pediatr Surg 39:867-871, 2004 Indiana – 1972-2001 (29 yrs)

• •

169 pts - 1 missed second mucosal web - no mention other multiple atresias/stenoses

•

Millar, Rode, Cywes – Pediatric Surgery 4 th p 418,419

•

Edition, Red Cross Children’s Hospital – 1954-2003 (44 yrs)

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187 infants – 3 siblings with multiple atresias and immunodeficiency syndromes (J Pediatr Surg 31:1733, 1996)

Associated Jejunal Atresia

Multi-Institutional Report

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7 institutions; 1998 – 2010

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408 patients

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28% Trisomy 21

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Jejunal atresia – 2 patients (0.5%)

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Both Type IIIb IPEG 2010 JLAST 20: 773-775, 2010

Malrotation

(No Volvulus)

•

Laparoscopy ideal for unclear UGI study

Malrotation

(No Volvulus)

Laparoscopic Pylormyotomy

Patient Positioning

• • • • • •

Baby placed across operating table Table tilted toward surgeon Monitor in front of surgeon Assistant/camera holder to right of surgeon Scrub nurse opposite assistant Red rubber catheter in stomach

Equipment

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5 mm umbilical cannula – 4 mm, 70 o telescope

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Atraumatic grasping forcep

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Pyloric spreader

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Bovie needle and spatula tip

Tips and Tricks

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Use cautery to incise serosa and muscle to 2 mm

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Use blunt cautery tip to bluntly separate muscle

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Insert pyloric spreader – Gently separate pyloric muscle fibers as you view the submucosa

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Measure length – know length of stenosis on ultrasound

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Distend stomach with 45-60 cc air Place omentum over myotomy

Complications

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Incomplete myotomy

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Mucosal perforation

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Wound infection

Laparoscopic Pyloromyotomy

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Open Versus Laparoscopic Pyloromyotomy For Pyloric Stenosis: A Prospective Randomized Trial Shawn D. St. Peter George W. Holcomb III Casey M. Calkins Walter S. Andrews J. Patrick Murphy Charles L. Snyder Ronald J. Sharp George K. Gittes Daniel J. Ostlie The Center for Prospective Clinical Trials Children’s Mercy Hospital Kansas City, MO

Results Upon Presentation OPEN

(n = 100)

(Mean +/- S.E.) LAP (n = 100) ( Mean +/- S.E.) P Value Age (weeks) 5.24 +/- 0.25 Thickness (mm) 4.17 +/- 0.08 Length (mm) Cl (mmol/L) 19.51 +/- 0.27 99.36 +/- 0.78 HCO3 (mmol/L) 28.18 +/- 0.51 5.33 +/- 0.22

4.16 +/- 0.09

19.38 +/- 0.27

99.76 +/- 0.79

27.86 +/- 0.49

0.77

0.88

0.74

0.72

0.65

Results Outcomes OR time (mins) OPEN (n = 100) LAP (n = 100) P Value (Mean +/- S.E.) ( Mean +/- S.E.) 19:28 +/- 0.60 19:34 +/- 0.78 0.93

Emesis Full Feeds (hrs) LOS (#) (hrs) Tylenol ( doses) 2.61 +/- 0.27 21:01 +/- 2.16 33:10 +/- 1.63 2.23 +/- 0.18 1.84 +/- 0.23 0.05

19:30 +/- 1.46

0.43

29:38 +/- 1.69

0.12

1.59 +/- 0.16

0.01

Results Complications

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1 mucosal perforation in the open group

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1 incisional hernia in the open group

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1 laparoscopic case was converted to open

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4 wound infections in the open group compared to 2 wound infections in the laparoscopic group (P = 0.68)

Results Cosmetic Outcome OPEN LAP

High Imperforate Anus

Other Neonatal Conditions

Fundoplication/ Gastrostomy NEC Stricture

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2005 – 2008 – 11 neonates

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LERA – 4 pts

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LIRA – 7 pts

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No complications, no recurrent strictures (JLAST 20: 477-480, 2010)

QUESTIONS

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