Minimally invasive surgery (MIS) has transformed the treatment of surgical disease in both adults and children. Concerns regarding length of hospital stay, pain and wound complications created the need and hence the beginnings of modern MIS. These techniques were initially developed by adult surgeons. Gradually this was accepted into infants and children practice as miniaturized endoscopic equipment became available through advancement in technology. Paediatric surgeons had to be convinced and assured that the procedures are safe and effective and that using these techniques would yield as good or better results compared to open surgery. By the turn of the century, the use of MIS in children became more widespread and mainstream in the west and developed countries. Over the last 10 years, advancement in surgical skills, allowed these techniques to be used for complex neonatal and paediatric surgical conditions.

MIS has come a long way from the earliest large instruments and limited capabilities. Trocars, instruments and cameras have become smaller, finer and more precise. The vast majority of minimally invasive surgery is performed using small endoscopic cameras and instruments that are inserted into the body cavity through natural body openings or “ports.” A port is a small cannula through which other small instruments are inserted into the body cavity in question. They range in size from 3 to 12 mm. Although larger ports often are utilized when it is necessary to remove a specimen, most ports are 5 mm or less in size. Alternatively, working instruments can be inserted directly into the body cavity without the use of a port, thus decreasing cost while making the incision more inconspicuous. In comparison to open surgery, MIS has several advantages: less pain, faster recovery time and improved cosmesis (much smaller incisions).

Minimally invasive surgery has become an important aspect of pediatric surgical practice and offers the potential to perform operations with less pain and quicker recovery. In Malaysia there are not many centres conducting Paediatric minimally invasive surgery. Certainly the advanced, complex paediatric surgical procedures like some of the ones described above are not regularly done in most Malaysian centres, either due to the lack of equipment or the lack of trained surgeons. Dr Nadarajan Sudhakaran is able to conduct these procedures and to train the masters trainee students in these techniques. Having completed all his training in the UK, including working at the world-renowned Great Ormond Street Hospital for Sick Children, London.

ABDOMINAL PROCEDURES

Laparoscopic cholecystectomies, pyloromytomies, appendicectomies and splenectomies are routinely performed in pediatric surgery. The more common applications are listed.

Abdominal operations performed and the common indications

  • Appendicectomy (appendicitis)
  • Pyloromyotomy (pyloric stenosis)
  • Cholecystectomy (gall stones, cholecystitis)
  • Inguinal hernia repair
  • Meckel’s diverticulectomy (symptomatic meckel’s)
  • Gastrostomy (feeding difficulties, failure to thrive)
  • Intestinal resection (Crohn disease)
  • Colectomy and J pouch (ulcerative colitis)
  • Nissen fundoplication (GO Reflux Disease)
  • Splenectomy (blood dyscrasias or tumors)
  • Endorectal pull through (Hirschsprung’s disease)
  • Heller myotomy (achalasia). ( link to chinese newspaper)
  • Adrenalectomy (tumor)
  • Ladd’s procedure (malrotation)
  • Orchidopexy (intrabdominal testis)
  • Ano –rectal Reconstruction (Ano-rectal malformation)

THORACIC PROCEDURES

Thoracic Procedures and Video Assisted Thoracoscopy (VATS). In the past, nearly all thoracic procedures involved a large thoracotomy that necessitated cutting the chest wall musculature. This typically resulted in a prolonged, painful hospital stay. By utilizing VATS the painful postoperative course associated with thoracotomy can be reduced markedly. A multitude of procedures are now performed using thoracoscopy (See List 2). One of the more common uses of VATS in children has been the treatment of parapneumonic effusion and empyema. In the past, children with parapneumonic effusion or empyema would linger in the hospital for several days, if not weeks, enduring multiple pleural taps and chest tube placements, and perhaps eventually requiring a decortication via a large incision. The great advantage of VATS is that it allows the surgeon to see the entire pleural cavity, effectively drain the pleural space and debride the exudate covering the pleural surface. Typically, two to three ports are used for the operation. Fluid surrounding the lung is suctioned, pleural debris is removed and the lung is allowed to re-expand. A small chest tube generally is placed through one of the port sites. Because adhesions in the pleural space become denser with each passing day, we generally recommend VATS be performed as early as possible in the disease process. Postoperatively, chest tube drainage typically subsides within 2 to 3 days and the tube is removed. The majority of children are home within 1 to 2 days following tube removal.

Thoracic operations performed and the common indications ( List 2)

  • Lung biopsy (lung mass)
  • Lobectom (CCAM, sequestration)
  • Drainage of empyema, parapneumonic effusion
  • Bullectomy (spontaneous pneumothorax)
  • Spinal exposure (correction of scoliosis)
  • TEF Repair
  • Thymectomy
  • Resection of bronchogenic cyst
  • Mediastinal tumor biopsy
  • Resection of esophageal duplication

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