Minimally Invasive Surgery in the Neonate:
Review of Current Evidence
Keith E. Georgeson and Daniel J. Robertson
Minimally invasive surgery has been one of the most important surgical advances in the last 15
years. The development of smaller instruments has allowed pediatric surgeons to apply this
rapidly evolving technology to neonates. Congenital neonatal deformities including tracheoesophageal fistula, patent ductus arteriosus, duodenal atresia and anorectal malformations are now being
managed with minimally invasive surgery. This article summarizes the status of these techniques in
neonates.
© 2004 Elsevier Inc. All rights reserved.
he first reports of laparoscopic cholecystectomy in adults in the mid- 1980s stimulated
the advance of minimally invasive general surgery (MIS), one of the most important and dramatic surgical developments of the last century.
Minimally invasive techniques allow the surgeon
to complete major intracavitary operations without the postoperative morbidity and pain associated with larger incisions. In the past few years,
there has been an acceleration in the advancing
technology and clinical sophistication of endoscopic surgery. As a result, the scope and complexity of operations that are performed via
minimally invasive approaches has widened
substantially.
The development of MIS in the pediatric population has progressed more slowly than in
adults. The most obvious problem for the development of pediatric endoscopic surgery has
been instrument size and function. Instruments
manufactured for adults are too large for most
pediatric patients, especially neonates. Additionally, medical practitioners have often underestimated the degree of postoperative pain in neonatal and pediatric patients who are unable to
articulate their specific distress. The length of
incisions for open operations in neonates appear to be short, but are relatively as long as
corresponding incisions in adults. It has taken
the pediatric surgical community longer to ac-
T
From the Division of Pediatric Surgery, Children’s Hospital of Alabama, University of Alabama, Birmingham, AL.
Address reprint requests to Daniel J. Robertson, MD, 1600 7th Ave
S, Suite 300, Birmingham, AL 35233.
© 2004 Elsevier Inc. All rights reserved.
0146-0005/04/2803-0007$30.00/0
doi:10.1053/j.semperi.2004.03.008
212
cept decreased incision size as a benefit of MIS
in neonates.1 In addition, laparoscopic cholecystectomy is a relatively uncommon operation in
children. No similar single procedure has propelled the advance of minimally invasive techniques in pediatric patients.
With the development of smaller instruments
and an understanding of both the safety and
benefits of these techniques, there has been a
virtual revolution in pediatric surgery over the
last 5 to 10 years. Complicated neonatal problems including tracheoesophageal fistula, duodenal atresia, and pull-through for Hirschsprung’s disease can now be treated with MIS
techniques. This article outlines some of the
neonatal applications for endoscopic surgery
and summarizes the scant but growing evidence
supporting the use of minimally invasive techniques in neonates.2
Thoracoscopy
Thoracoscopy provides several potential advantages over thoracotomy for resection or repair of
intrathoracic neonatal abnormalities. Scoliosis
develops in up to 30% of neonates after thoracotomy.3 In addition, thoracoscopy appears to
be associated with decreased pain and better
pulmonary mechanics postoperatively and improved cosmesis when compared to thoracotomy.
For thoracoscopy to be successfully employed,
single-lung ventilation via mainstem intubation
is ideal for improved visualization. Insufflation
with CO2 into the pleural space can also help
create a larger intrathoracic working space. Neonates that have marginal pulmonary status and
Seminars in Perinatology, Vol 28, No 3 (June), 2004: pp 212-220
Minimally Invasive Surgery in the Neonate
poorly tolerate single-lung ventilation or an elevation in CO2 via pleural absorption may not be
good candidates for these techniques. Overall,
however, thoracoscopy is well tolerated in neonates and appears to offer both early and late
benefits.
Patent Ductus Arteriosus Ligation
As neonatal care has continued to improve,
more low-birth weight neonates with patent ductus arteriosus (PDA) are being cared for in the
NICU setting. Multi-institutional trials have demonstrated that diuretics and indomethacin are
often effective in inducing closure of the PDA,
leaving surgical ligation of the PDA for failure of
these medical therapies. Recent studies have reemphasized the effectiveness and the safety of
surgical ligation, particularly in very low birth
weight babies, who are prone to necrotizing enterocolitis and recurrence of the PDA after indomethacin therapy.4 From the time that Dr.
Robert Gross first successfully ligated a PDA in
1938 until 1991, the standard operative approach to this lesion was via a posterolateral
thoracotomy. In the early 1990s, both Burke5 in
Boston and Laborde6 in Paris independently developed thoracoscopic techniques for interrupting the PDA. Since that time, these techniques
have been used in multiple centers and in progressively smaller newborns. Burke7 in a recent
experience reports on 34 neonates with an average weight of 930 g, who underwent VATS PDA
ligation with no operative mortality, a 12% conversion rate to open, elimination of ductal flow
in all patients documented by echocardiogram,
and a 6% rate of trace ductal flow documented
during subsequent follow-up echocardiography.
Recurrent laryngeal nerve injury was seen in
2.9% of patients. These figures are consistent
with other published literature on thoracoscopic
PDA ligation and are comparable to rates of
recurrence and recurrent nerve injury for open
techniques.
Tracheoesophageal Fistula
Successful ligation and repair of tracheoesophageal fistula via a thoracoscopic approach has
been accomplished in the last several years and
illustrates the potential that can be achieved
with minimally invasive surgery in neonates. The
213
first entirely thoracoscopic repair was reported
by Lobe et al8 in 1999 and described repair of
pure atresia in an 8-month-old patient. Rothenberg has subsequently reported on a series of 8
neonates with esophageal atresia and distal fistula9; Bax et al from the Netherlands also has
reported a series of 8 patients.10 Several neonatal centers have successfully performed more
than 20 esophageal atresia repairs.11
The procedure is completed using 3 endoscopic ports ranging in size from 3 to 5 mm in
diameter. Low flow CO2 insufflation into the
right hemithorax (or left if the patient has a
right-sided aortic arch) is used to retract the
lung. In addition to the benefits of avoiding
thoracotomy, the surgeons who report on this
technique cite improved exposure and visualization as well as dissection under magnification as
potential advantages (Fig 1). In addition, CO2
insufflation may cause less pulmonary compromise during the operation when compared to
standard mechanical retraction. Suturing the
anastomosis in a small space is technically demanding. The incidence of leakage and stricture
may be increased during the learning curve for
this technique, but appear to be equivalent after
experience is gained.
Pulmonary Resection
Thoracoscopic wedge resection of lung lesions
has been used widely in both adults and children, but thoracoscopic lobectomy is relatively
new. Neonatal lung diseases most amenable to
VATS techniques include cystic congenital adenomatoid malformation (CCAM) and pulmonary sequestration. These congenital lesions are
commonly diagnosed on prenatal ultrasound;
they may enlarge and cause mediastinal compression and fetal hydrops; they may remain
stable or they may regress in size.12 Even when
these lesions regress and cannot be detected by
subsequent ultrasound, they are usually apparent on postnatal CT scan of the chest.13 Sequestration and CCAMs require resection due to the
risk of recurrent pulmonary infection and progressive enlargement of the pulmonary cysts
leading to ventilatory compromise (Fig 2). Several reports document VATS pulmonary lobectomy in neonates and infants. Gluer et al reported on the resection of an extralobar
pulmonary sequestration in a 22 day old.14 Al-
214
Georgeson and Robertson
Figure 1. Thoracoscopic repair of esophageal atresia.
Note the clip on the divided
tracheoesophageal fistula.
banese et al15 recently reported on 14 patients
with prenatal diagnoses of lung lesions who underwent thoracoscopic resection between the
ages of 4 and 35 months with an average operating time of 110 minutes, a postoperative hospital stay of 3 days with no serious complications
and no conversions.
Figure 2. Thoracoscopic resection of an intralobar pulmonary sequestration with a
clear view of the extraanatomic feeding vessels prior to
ligation.
Diaphragmatic Hernia/Eventration
Neonates can be afflicted with diaphragmatic
eventration and phrenic nerve paralysis as either
a result of a difficult delivery or as an iatrogenic
problem after neonatal cardiac surgery. The
goal of diaphragmatic plication in these patients
Minimally Invasive Surgery in the Neonate
is to improve respiratory mechanics to allow for
bilateral lung expansion, which is critically important in neonates due to their cylindrical
chest, recumbent position and small airways.16
Thoracoscopy is ideally suited for eventration,
because it allows for successful plication of the
diaphragm without a large abdominal wall incision, which can decrease pulmonary compliance
in the early postoperative period. Several studies
in adults document marked improvement of
PFTs postoperatively17,18; no similar studies to
date have been performed in children. From a
technical standpoint, either interrupted or running sutures or endoscopic staplers have been
used for plication. The authors prefer interrupted sutures.
Congenital diaphragmatic hernia in the neonate is one of the most challenging problems
faced by the pediatric surgeon. Mortality rates
for this condition are under dispute but range
from 20% to 60%. While there are a number of
reports in the literature that describe repair of
both Morgagni hernias and Bochdalek hernias
in children and adults, MIS in neonates with life
threatening Bochdalek hernias is controversial.
Repair of asymptomatic CDH may be performed
laparoscopically or thoracoscopically.19 Endoscopic placement of diaphragmatic patches has
also been successfully performed in our hospital.
Laparoscopy
In order to perform laparoscopy, pneumoperitoneum using insufflation with CO2needs to be
established for adequate visualization. Neonates
are particularly sensitive to absorption of CO2
and can develop respiratory acidosis, which is
almost always correctable by increasing the neonate’s minute ventilation. Increased intraabdominal pressure can also compromise venous
return causing hypotension, and intraabdominal pressures greater than 10 mm Hg are sometimes poorly tolerated by the neonate.20
Several unique problems are encountered
when performing laparoscopy in the neonate. In
pediatric patients, the largest trocar is usually
inserted through the umbilicus for cosmesis and
to exploit an existing small umbilical hernia.
Many neonates have retained umbilical stumps,
and access in this age group is generally made
through an umbilical fold below the umbilicus.
The abdominal wall of neonates is relatively
215
thin. Techniques have been developed to secure
trocars to the abdominal wall to keep them from
slipping in and out when instruments are placed
through them. In general, incisions and trocars
between 2 and 4 mm are used in neonates.
The volume of gas required for pneumoperitoneum in neonates is small and current insufflators, designed primarily for adults, deliver
large volumes of gas fairly rapidly. Flow on these
insufflators must be kept low, and a small intentional leak from a laparoscopy trocar is often
helpful in controlling pressure overshoot.
Duodenal Atresia
Congenital duodenal obstruction is usually
treated with duodenoduodenostomy using open
methods with excellent long-term results. Only
recently has MIS been applied to this condition.
Unlike many neonatal bowel obstructions, which
present technical problems for the laparoscopic
surgeon due to the dilated bowel making visualization difficult, duodenal atresia is favorable for
treatment via laparoscopy. The distal bowel is
decompressed (due to the duodenal obstruction) allowing for space to identify the nature of
the lesion and the performance of a successful
repair. Recent reports describe successful treatment for both atresias and webs.21-23 Operating
time is not significantly different between open
and laparoscopic techniques. Return to feeding
may be more rapid after laparoscopic duodenoduodenostomy than after its open counterpart,
although patient numbers are too small to make
definitive conclusions. Infusing saline through a
spinal needle inserted through the abdominal
wall and into the proximal jejunal lumen is used
to assess the lumenal continuity through the
entire small bowel.
Malrotation
Malrotation of the intestine can be a life-threatening surgical emergency due to the risk of midgut volvulus with subsequent infarction of the
small intestine. This problem occurs most commonly in neonates, although children and adolescents have also presented with acute volvulus
as the initial presentation of malrotation. Surgical treatment of malrotation was first described
by Ladd in 1932 and includes detorsion of the
associated volvulus, placement of the proximal
216
Georgeson and Robertson
small intestine in the right side of the abdomen,
placement of the colon in the left side of the
abdomen, and broadening of the base of the
mesentery by incising the anterior peritoneum
of the mesentery. Incidental appendectomy is
usually recommended due to the abnormal position of the appendix in these neonates.
The spectrum of nonrotation to malrotation
of the intestine varies substantially and the more
narrow the base of the mesentery, the more
unstable the midgut. Stability of the gut is best
assessed by surgical exploration. Laparoscopy allows the surgeon to assess the exact character of
the malrotation and to perform detorsion of the
bowel and completion of Ladd’s procedure.
Laparoscopic treatment of this problem was first
published in 199524 and has subsequently been
reported in roughly 50 patients ranging in age
from several days to adulthood.25-29 One potential disadvantage to laparoscopic Ladd’s procedure is that postoperative adhesion formation
may be less than in the open operation, leaving
the bowel unstable. However, raw surfaces are
left after a laparoscopic Ladd’s procedure,
which usually form adhesions. There have been
no published reports of midgut volvulus after
laparoscopic Ladd’s procedure.
Endorectal Pull-Through for
Hirschsprung’s
Swenson was the first to report a successful surgical correction for Hirschsprung’s disease in
1948. Since that time, several operations have
been developed which differ in technical detail
from Swenson’s procedure, but adhere to the
basic principles he advocated. Successful repair
of Hirschsprung’s disease includes resection of
the distal aganglionic bowel with reanastomosis
of the neorectum to the anus while sparing the
anal sphincter and avoiding injury to the genitourinary tract. The operations described by Duhamel and Soave were developed to minimize
anterior pelvic dissection to prevent problems
with urinary continence and reproductive function. Classically, a diverting ostomy was initially
performed followed by subsequent resection of
the aganglionic segment.
In 1980, So et al30 first reported successful
primary pull-through without diverting ostomy.
In most patients with Hirschsprung’s disease,
primary pull-through can be performed in the
neonatal period with results equivalent or superior to multi-stage procedures and with the benefit of avoiding the morbidity associated with an
ostomy and secondary surgeries.31
Laparoscopy has been used to enhance the
primary surgical management of this disease in
several ways. Endoscopic seromuscular biopsies
can be obtained from various levels in the colon
which are then evaluated by frozen section to
determine the level of the transition zone. The
intraabdominal aganglionic colon is mobilized
laparoscopically. After this mobilization, a
transanal submucosal dissection is carried out to
complete removal of the aganglionic colon. The
transanal submucosal dissection is performed to
spare nerves to both the bladder and reproductive organs and the nerves and muscular fibers
of the anal sphincters. After the resection of the
aganglionic segment, normally ganglionic colon
is brought down just proximal to the dentate
line and secured there (Fig 3). Finally, laparoscopy is also used to ensure that the pull-through
segment has not been twisted on its mesentery
after it is pulled through.
Combined outcomes from 80 patients operated in 6 pediatric surgery centers over 5 years
have been summarized by Georgeson et al.32 Of
these 80 patients, only 1 required blood transfusion, blood loss averaged less than 10 mL, average operating time was 147 minutes, and time to
ad lib feedings averaged 28 hours. The disease
was confined to the rectosigmoid in 86% of
these patients, although one patient had total
colonic Hirschsprung’s disease. Almost 90%
were less than 6 months of age and mean time to
hospital discharge was 3.7 days after operation.
Two cases were converted to open operations, 6
patients had early enterocolitis, 6 patients had
chronic diarrhea, and 2 patients had anastomotic leaks. There were no anastomotic strictures, bowel obstructions, or wound complications.
In summary, MIS techniques allow for treatment of Hirschsprung’s disease without laparotomy. By using laparoscopy prior to the transanal
endorectal dissection, the transition zone can be
gauged precisely. Long segment Hirschsprung’s
disease can be recognized before the endorectal
dissection so that colectomy can be based on
permanent section analysis.
Figure 3. (A) The aganglionic colon is mobilized laparoscopically. (B) The mucosa is cored out. (C) The
aganglionic colon is removed through the anus. (D) Normally innervated colon is attached to the anus.
218
Georgeson and Robertson
Anorectal Malformation
Laparoscopic assisted anorectal pull-through
(LAARP) for repair of high anorectal malformations has replaced the more invasive open approach in many newborn centers. While low
anorectal malformations are best operated on
via a perineal approach, laparoscopy allows good
visualization of the deep pelvis for dissection and
division of rectourethral, rectocystic or rectovaginal fistulae in high anorectal abnormalities.
After using external electrostimulation to identify the proper location for the anus, the perineal dissection is initiated inside the anal sphincters. A trocar is passed inside the anal sphincter
into the pelvis under laparoscopic surveillance
(Fig 4). The rectal fistula is pulled down through
the anal sphincters.33,34
LAARP affords excellent visualization of the
pelvic anatomy in children with high anorectal
anomalies and allows the operating surgeon to
Figure 4. (A) The rectourethral fistula is divided laparoscopically and the pelvic floor muscles are viewed from
above. (B) The external sphincter muscles are identified and a plane is developed inside the sphincters via the
perineum. (C) An expandable trocar is passed from below through the sphincters using laparoscopic surveillance from above. (D) The fistulous end of the rectum is attached to the anal skin, which is tethered upward and
held in position by hitch stitches.
Minimally Invasive Surgery in the Neonate
avoid division of the anal sphincter and pelvic
floor musculature as is necessary in the posterior
sagittal anorectoplasty, the usual procedure used
to correct these anomalies.35 In addition,
LAARP has been reported as a one-stage operation in the neonatal period, avoiding the need
for a colostomy in selected patients.36 As the
technique has been developed only recently, follow-up will be necessary to determine whether
this minimally invasive approach ultimately improves the rate of fecal continence, which is only
25% to 30% in open approaches for high anorectal anomalies.
Inguinal Hernia
Repair of congenital indirect inguinal hernia is
one of the most common operations performed
by pediatric surgeons. The necessity of open
exploration of the contralateral groin for bilateral hernia has been debated by pediatric surgeons for years. In the last decade, laparoscopic
exploration of the contralateral groin for hernia, either via the existing hernia sac or via the
umbilicus, has become standard practice in most
centers. More recently, laparoscopic repair of
inguinal hernia has been reported, allowing for
exploration of both sides and repair of existing
hernias all via a minimally invasive approach.
Ligating the hernia sac in this manner spares the
extensive dissection required to separate the
spermatic cord structures from the often adherent hernia sac, and may decrease the incidence
of infertility, particularly in cases of bilateral hernia. The techniques are too new to allow for
long-term data regarding fertility and recurrence.
Summary
Minimally invasive surgery has been one of the
major surgical advances in the last several decades. New technology has allowed the application of these advances to the neonate. While
early data collected to this point has been based
on relatively small numbers of patients, the techniques are promising.37 Potential advantages of
these techniques are the development of less
adhesions and scar tissue, less postoperative
pain, less disruption of anatomy and function
and better cosmesis. Continued technical advances in the manufacture of the smaller equip-
219
ment will allow continued advances in endoscopic neonatal surgery.
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