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Rocky Mountain Hospital For Children

RMHC at P/SL

RMHC at Sky Ridge

RMHC at Rose

RMHC at North Suburban

RMHC at Aurora South

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Minimally Invasive Surgery: Pediatric Surgery 2.0

(How a few surgeons are replacing large incisions and long hospital stays with tiny incisions, short stays, and much less pain-all while increasing surgical precision.)

Surgery for children and babies has been undergoing a quiet revolution. Once, the prospect of an operation for a child raised the specter of big incisions, pain and disability, long hospital stays, and unsure outcomes. Over the last decade however, a few surgeons working mostly in the United States have perfected techniques and adapted new equipment to obviate these incisions. The surgeons at Rocky Mountain Pediatric Surgery are in the vanguard of this revolution.

"It's true that for some things, less really is more!". "For babies and kids, whenever we can, we try to make less scar, less pain, and less time in the hospital."

Minimally Invasive Surgery

The name of the revolution is Minimally Invasive Surgery (MIS). You may have heard it called laparoscopy, thoracoscopy, arthroscopy, minimal access surgery, keyhole surgery, or even "band-aid surgery". But these terms all refer parts of the larger field of minimally invasive surgery. More than a set of techniques or a "kit" of fancy equipment, MIS is a philosophy that aims to minimize the physiologic "costs" of an operation (like pain, deformity, stress response, and disability), while improving surgical precision.

Minimally invasive procedures have come a long way from the earliest bulky instruments and limited capabilities. It was once thought that only adults could withstand these procedures, and that only very simple procedures could be attempted. In contrast, small children have small delicate organs and tight spaces. Necessarily, pediatric surgery has to do with very small, very delicate structures confined to small spaces that leave little room in which to work, a situation that would seem to exclude minimally invasive approaches. But trocars and instruments have become smaller, finer, and more precise. Computers and high resolution charge-couple devices (video cameras) have made the visualization of tiny structures inside the body easier by remote than by direct (or even telescope/surgical loupe assisted) vision. These technological advances created a base from which new operations could be developed. But MIS is more than new gadgets.

Not every "minimally invasive" operation involves the use of fiber optic cameras and laparoscopic tools. Instead, it may involve a different kind of incision or other approach intended to diminish the trauma the child experiences. For example, in the repair of patent ductus arteriosus, many babies are premature and too small even for our smallest cameras and thoracoscopic instruments. In these children, however, we can still minimize the incision size and perform a muscle-sparing approach (moving rather than cutting the chest muscles[link to paper]), decreasing pain and potential shoulder girdle disability. Minimally invasive surgery is not technology; it is technique.

Minimally Invasive Surgery at Rocky Mountain Pediatric Surgery

The surgeons at Rocky Mountain Pediatric Surgery (RMPS) have invented many of the new MIS techniques, and have helped develop instruments now used by surgeons worldwide. For example, Dr. Rothenberg performed the world's first MIS repair of tracheo-esophageal fistula and duodenal atresia in newborns. Now his methods are used routinely in our practice to correct these and other problems. Babies with tracheo-esophageal fistula have three tiny incisions over the ribs instead of a large chest incision. Results have been excellent with fewer leaks and strictures in addition to much less incisional pain and deformity. Similarly, babies with duodenal atresia have three tiny abdominal incisions instead of a large incision across the abdomen, and shorter time to recover the ability to eat. Few other centers yet offer either of these approaches.

The surgeons at RMPS believe that any minimally invasive operation must produce technical results that are at least as good as the results of a standard open procedure-and must do so safely. In other words, since surgery is fundamentally a mechanical solution to a health problem, the manipulation and final state of the organs should be the same as that seen in a "standard" procedure. In some cases, like Nissen fundoplasty, our results are actually better [link to results] than nationally reported averages, probably because the enhanced visualization makes placement of the wrap and dissection of the esophagus more precise. Our results may also be better because our surgeons have so much experience. And that experience lets us create new techniques.

Procedures

New techniques are developed incrementally, using proven strategies from other established MIS procedures. For example, distal pancreatectomy-a rare operation-can be accomplished via the same approach and with many of the same instruments and maneuvers as the more common splenectomy. Meanwhile, we continuously work with producers of surgical instruments (including robotics), helping to invent new tools and to improve the old ones to make them safer and more reliable. In this way, more and more problems become amenable to an MIS solution.

A minimally invasive approach exists for many, if not most, procedures. Absolute bars to an MIS approach might include excision of very large tumors like neuroblastoma, or presence of scar tissue that precludes safe access to the chest or abdomen. But even in cases of severe internal scarring, an MIS approach may be possible and even preferable (because, for example, MIS produces much less new scar).

Below is a partial list of MIS procedures offered by Rocky Mountain Pediatric Surgery. Those that are highlighted have links to on-line procedure videos:

  • Adhesiolysis
  • Intussusception
  • Appendectomy
  • Ladd's Procedure for Malrotation
  • Bronchogenic Cyst
  • Lung Biopsy
  • Cystic Adenomatoid Malformation (CCAM)
  • Meckel's Diverticulum
  • Cholecystectomy
  • Ovarian Cyst
  • Choledochal Cyst Repair
  • Ovarian Torsion
  • Crohn's, bowel resection
  • Pancreatic pseudocyst
  • Diaphragmatic Hernia (bochdalek, morgagni, eventration)
  • Pulmonary Sequestration
  • Duodenal Atresia
  • Pyloric Stenosis
  • Duodenal duplication
  • Anti-Reflux and Hiatal Hernia Repair
  • Empyema
  • Roux-Y Gastric Bypass
  • Esophageal Duplication
  • Splenectomy and Splenic Cystectomy
  • Fallopian Tube Cyst
  • Tracheo-esophageal Fistula
  • Hirschprungs
  • Ulcerative Colitis
  • Imperforate Anus
  • Urachal Remnant
  • Inguinal Hernia

Not every patient with a surgical problem will be a candidate for MIS. For example, while nearly every child with appendicitis will be offered MIS, many children with diaphragmatic hernia may be too sick for this approach. Your surgeon can discuss the options in detail.

Still, no matter what your child needs, Rocky Mountain Pediatric Surgery brings the quiet revolution in surgery to your child.