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Pediatric Update

 
Spring 2008

Less Invasive Surgeries Increasingly Performed in Children

04/24/2008

Minimally invasive pediatric surgeries have increased dramatically at major academic centers such at UCLA in recent years—both in the breadth of surgeries in which minimally invasive techniques such as laparoscopy and thoracoscopy are being used, and in the proportion of patients for whom these techniques, in which pediatric surgeons operate through tiny incisions in the abdomen or chest, are employed.

 “A high percentage of the operations we do are now using these techniques,” says Stephen Shew, M.D., UCLA pediatric surgeon. He notes that as pediatric surgeons have gained more experience with the minimally invasive approach, clear advantages over traditional open surgery have emerged, most notably in the area of cosmetics.

After minimally invasive techniques were first used in adults in the late 1980s, demand for the procedures skyrocketed among the adult population in the 1990s, Dr. Shew notes, as benefits such as less pain, shorter length of hospital stay and faster recovery time became apparent. Pediatric surgery has lagged behind the trend for several reasons. Perhaps most significantly, given that children represent a small segment of the overall surgery population, the manufacture of instruments tiny enough to enable pediatric surgeons to operate within the limited confines of a child’s abdomen or chest was slower in developing. Once that occurred, and as the number of pediatric surgeons trained in minimally invasive surgery grew, the trend took hold. Dr. Shew notes that widespread publicity about the procedures has greatly increased demand among parents, accelerating the shift.

Certain benefits may be less pronounced in children. For example, since pediatric patients tend to recover significantly more rapidly than adult patients after open surgery, the reduction in recovery time is likely less among children after minimally invasive procedures than for adults. It is believed that children, like adults, enjoy shorter length of hospital stay and less need for pain medicine following minimally invasive operations, though these observations have yet to be confirmed in randomized prospective trials.

The indisputable benefit of the tiny incisions necessitated by minimally invasive surgery is the smaller scars that result. “Children tend to have a better body image after minimally invasive procedures,” says James Dunn, M.D., UCLA pediatric surgeon. He recently saw two brothers who had both had appendectomies, one laparoscopic and one open. “The differences were pronounced,” Dr. Dunn says.

He notes that smaller scars are particularly important for children given that the scar grows along with the child. “A one-inch scar for an infant may expand to several inches by the time that infant is an adult,” says Dr. Dunn. The faster recovery time—even if it’s not as big a difference as in adults—means that children are able to resume normal activities more rapidly after minimally invasive surgeries than after open procedures, typically within two to three weeks, he adds.

Nissen fundoplication, appendectomy, intestinal pull-through procedures (such as for Hirschsprung’s disease and ulcerative colitis) and lung surgeries have been most affected by the move toward minimally invasive surgery, but virtually every type of operation can be done with the new approaches, says Daniel DeUgarte, M.D., UCLA pediatric surgeon.

Certain patients may not be good candidates, including patients with severe heart or lung deficits, who may not be able to tolerate the inflation of air into the abdomen. “We always tell parents there is a possibility that we won’t be able to proceed in the minimally invasive way and will have to switch to the traditional surgery,” Dr. Shew says. “But those are rare cases. There are few surgeries that can’t be done using minimally invasive techniques.”





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