P&S Journal: Fall 1994, Vol.14, No.3
Gallstone removal. Tumor biopsy. Appendectomy. Pneumothorax correction. Traditionally, these have been open surgical procedures in babies and children, but now they are among the operations routinely being done laparoscopically and thoracoscopically by Dr. Steven Stylianos, assistant professor of surgery and director of the new pediatric laparoscopy and thoracoscopy program in pediatric surgery at Babies and Children's Hospital.
Since the program started in July 1993, Dr. Stylianos and his colleagues have performed more than 40 abdominal and 20 thoracic procedures in young patients. "The benefits to the children have been dramatic," he says. "Compared to open surgery, convalescence has been dramatically shortened; kids return to school and to normal activities quicker; and the amount of narcotics to treat pain has been drastically reduced."
In laparoscopy and thoracoscopy, surgeons manipulate 10-cm.-long, thin, tube-shaped devices placed in either the abdomen or the chest. Through the tube's shaft, surgeons put slender rod-shaped instruments carrying either fiber optic cables or attachments that can cut, excise, cauterize, or suture tissue. To perform surgery, surgeons watch video monitors hooked to the fiber optic cables to see inside the body. Manual controls to the inner instrument are outside the patient.
"Endoscopic surgery has been compared to a video game," says Dr. Stylianos. "It takes getting used to. You are doing surgery without feeling tissue with your hands, not seeing tissue directly."
Surgeons have done laparoscopic and thoracoscopic procedures in adults for the past 10 years, but pediatric surgeons originally resisted because smaller devices were not available. "Initially, surgeons used adult-sized instruments in children," says Dr. Stylianos.
Dr. Stylianos worked with manufacturers to test and refine new laparoscopic devices tailored to smaller patients. The youngest laparoscopy patient treated was a 7-week-old with an abdominal tumor. "We were identified as a center in this area. Suppliers used us as consultants. As a result we got experience in the field, giving us a jump over other hospitals."
In fact, the program is one of the first dedicated pediatric laparoscopic and thoracoscopic practice in the metropolitan area. "There are other surgeons doing these procedures in children," Dr. Stylianos explains, "but they are generally done by 'adult' surgeons with laparoscopy expertise. Here we have a dedicated team of pediatric professionals. All I do is pediatric surgery. The anesthesiologists specialize in children, as do the nurses." The majority of the abdominal procedures have been gallbladder removals and appendectomies. The children treated range from being otherwise healthy to having sickle cell disease to having undergone organ transplants.
The most dramatic results with these methods, says Dr. Stylianos, have been for pneumothorax, which may result from an injury or weakness to the lung and causes air to leak out of the lungs. Blisters called blebs form on the lung and can cause otherwise healthy teen-agers to get sudden chest pains. Through the thoracoscope, Dr. Stylianos removes the diseased lung without making a major chest incision. "The children can go home the next day rather than stay in the hospital several days as with open surgery. They do not need days and days of narcotics."
Pediatric laparoscopic and thoracoscopic procedures also can be used in undescended testes, chronic abdominal pain, ovarian cysts and torsion, abdominal tumor biopsy and staging, gastroesophageal reflux, pleural effusion/empyema, VP shunt insertions, peritoneal dialysis catheter insertion, liver biopsy, and abdominal trauma.
The cost of these procedures still surpasses traditional surgery, but the ultimate cost of treatment is less because hospital stays are shorter. Originally, disposable instruments incurred additional costs. "Now we successfully employ reusable devices, which helps control costs." Dr. Stylianos predicts laparoscopic and thoracoscopic device prices will decrease as more manufacturers compete in this burgeoning industry.