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KEYHOLE SURGERY IN CHILDREN
By Mr Niall Jones MD FRCSI(Paed) Consultant Paediatric Surgeon and Honorary Clinical Senior Lecturer Centre for Paediatrics Barts and the London NHS Trust and The Portland Hospital for Women and Children
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Article last updated: September 2nd 2009
Synopsis
Mr Niall Jones is one of a few highly skilled surgeons trained to perform surgery on babies. He is expert in the use of keyhole (laparoscopic) surgical methods which avoid the baby needing open, more complicated invasive surgery. The use of tailor-made, smaller instruments means the surgeons can:
get easier access to baby’s organs; make smaller incisions which in turn means tiny cuts for the baby instead of one large scar from an invasive procedure; avoid complications from large scarring which can leave troublesome adhesions and require future surgery. As a result, the babies recover more quickly and normal family life can resume.
In his article, ‘Keyhole surgery in children’, Niall Jones explains how these skills can be applied to treating a range of disorders in children
Keyhole surgery in the abdomen is known as laparoscopy. This involves operating through tiny incisions with the help of a telescope and TV monitor. Over the last 20 years laparoscopy has replaced many traditional ‘open’ operations. This is due to the distinct advantages laparoscopy has for patients, such as:
a) less pain after surgery
b) quicker discharge from hospital , and
c) quicker return to normal daily activities.
While keyhole surgery is now readily available to adult patients for these reasons, it is not so readily available to children and infants, even though the advantages are just as relevant to this population. The surgery is technically demanding and takes patience, time and determination to master. Some surgeons have not been trained in this technique or have not learned the necessary skills and a small number of surgeons do not have the required hand-eye co-ordination.
However, thanks to developments in training and equipment almost all surgical conditions in the abdomen in children can be treated by keyhole surgery. Procedures that are appropriate for this type of minimally invasive approach range from common conditions such as inguinal hernia repair, to rarer conditions such as fundoplication for acid reflux. In this article I will discuss several conditions that can, and some that should only, be treated by keyhole surgery and describe the associated advantages to the child.
1) Inguinal herniaBoth boys and girls often present with groin swellings known as inguinal hernias. A hernia is the protrusion of an organ such as the intestine or ovary through the abdominal muscles, and an inguinal hernia appears as a bulge in the groin. To fix the hernia by keyhole surgery involves a small incision at the umbilicus which acts as the entry point for the camera and two tiny cuts on each flank. The umbilical incision is for the miniaturized camera / telescope and the two side incisions are for the working instruments, in this case a forceps and a needle-holder. The hernia defect is closed with a stitch, somewhat like closing the top of a purse by pulling the string. Sometimes there is a potential hernia on the other side, which has not yet developed in to a groin swelling, and this can be proactively ‘fixed’ at the same time. The older, traditional operation for inguinal hernia involves a larger cut in the groin skin and muscle. The hernia is then peeled from the sperm duct and vessels of the testicle (in boys) and sutured closed. So, the advantages of the new, keyhole technique include the following:
a) skin and muscle incisions are small so there is less pain and scarring
b) the sperm duct and testicular vessels are not handled and therefore not at risk of being damaged
c) if there is a potential hernia on the other side then it can be fixed at the same time.
2) Undescended testicleAgain, this is quite a common occurrence in babies. When the testicle is easily palpated, but is not in the scrotum, then a routine ‘orchidopexy’ can be performed, which involves fixing the testicle in the scrotum. However, if the testicle is not palpable, then laparoscopy is the best investigation. By looking inside the abdomen with the telescope, I can seen where the testicle is, or indeed, if it is present at all. No other investigations even including ultrasound, gives this level of diagnostic accuracy. In those cases where the testicle is present I can go on to reposition and fix it in place by passing it through the muscles and placing it in a little pocket in the scrotum.
3) Acute appendicitisThis is the commonest reason for emergency surgery in children. Treatment consists of antibiotics and surgery - appendicectomy. Laparoscopy allows the surgeon to confirm the diagnosis and remove the inflamed appendix. Traditional ‘open’ surgery involves a bigger incision in the abdominal wall with resulting discomfort and potential for infection.
4) Gallbladder stonesThese are not as common in children as in adults and tend to be associated with blood disorders such as Sickle Cell disease. The gold standard operation for removing the gallbladder (and stones) is laparoscopic cholecystectomy, whereby the gallbladder is dissected from it’s bed in the liver and removed from the body. Again, this minimally invasive approach allows quicker recovery and leaves only tiny scars rather than bigger, unsightly scars associated with traditional surgery.
5) SplenectomyIn certain cases it is necessary to remove the spleen in children with blood disorders. Laparoscopic splenectomy is safe and has all the usual advantages of keyhole surgery.
6) FundoplicationChildren occasionally have very severe vomiting (gastro-oesophageal reflux), which causes chest infections and failure to thrive. Mostly, this can be treated with medicines, but an operation is sometimes needed. The operation is called a fundoplication and the safest option is to perform this procedure using keyhole surgery. The operation involves wrapping the top of the stomach (fundus) around the oesophagus to create a valve. The resulting structure prevents the reflux of acid from the stomach.
ConclusionMinimal access surgery, such as the laparoscopic procedures mentioned above, is now accepted as the best and safest way to operate on babies and children. This special group of patients has their whole lives ahead of them and there is no longer any need for them to have to live with the scars of ‘open’ operations performed in their childhood.
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