New procedures, devices, guidelines
By Susan Conova
Minimally Invasive Surgery for the Smallest Patients
|ILLUSTRATION CREDIT: Lauren Eaton Enochs
A decade ago, endoscopic, or “keyhole,” surgery in newborns and children was anything but minimally invasive. “Each instrument was half an inch wide, and when you multiplied the number of instruments needed by the size of each incision, in a child or a baby it often added up to more incision than for open surgery,” says Keith Kuenzler, M.D., assistant professor of surgery and director of minimally invasive pediatric surgery.
“Now I don’t know why I keep taking pictures,” he says as he flips through the “after” photos of his most recent patients. “There’s nothing to see.”
Today, nearly all non-cardiac operations at Morgan Stanley, even the most complicated, can be performed with endoscopic techniques that are truly minimally invasive. In the past few years the number of such cases has risen sharply as Dr. Kuenzler, an early adopter of complex endoscopic techniques, has introduced the procedures to other Columbia pediatric surgeons.
“The thing that parents are most excited about, of course, is the lack of scarring,” says Dr. Kuenzler. “But there are even more important benefits to the child.” Minimally invasive surgery causes less tissue trauma, and that leads to shorter recovery, less pain, and less need for narcotic painkillers that can have gastrointestinal and even temporary psychiatric effects. Less pain also can improve patient compliance with postsurgical therapy.
“Patients always do better when they participate in their own recovery.” Dr. Kuenzler says. “In the case of many chest procedures, patients need to cough after surgery to prevent pneumonia, and that’s hard to do when your ribs were spread apart by retractors and you’re in pain.”
Adults have enjoyed the benefits of “minimal access” surgery since the late 1980s, but its use in children has been slower to progress, in large part because the first instruments were too big for newborns or small children. And with only about 500 pediatric surgeons in the United States, demand for smaller instruments was not great.
One of the first surgeons to pioneer minimally invasive techniques in children, Steven Rothenberg, M.D., at Presbyterian/St. Luke’s Medical Center in Denver, says most pediatric surgeons were skeptical of the techniques. “There was a lot of resistance initially. People thought I was crazy, they didn’t believe we could do it, and they didn’t think it was safe. They were not convinced that smaller incisions would make much difference in reducing pain or recovery time.”
In the 1990s, Dr. Rothenberg, who now has an appointment as professor of clinical surgery at P&S, and others convinced surgical manufacturers to produce thinner and shorter child-friendly equipment. By the middle of this decade, simple minimal access procedures removing tissue for a biopsy or draining an abscess became widespread in operating rooms across the country, including Columbia’s.
In 2006, Dr. Kuenzler, upon completion of his pediatric surgical fellowship, felt that even more complex surgeries should be performed with minimally invasive techniques. He began a series of trips to Denver to train with Dr. Rothenberg.
One condition that has seen the biggest transition from open to minimally invasive is congenital diaphragmatic hernia CDH a disorder that Columbia doctors previously transformed from a routinely fatal condition to one with 90 percent survivorship. More than three quarters of CDH repairs at Columbia are now performed thoracoscopically, through five-millimeter chest incisions.
“For newborns with CDH, we need to move the intestines, spleen, and liver out of the chest and close the hole in the diaphragm using muscle or a prosthetic patch. “I feel very proud to be further advancing the care of CDH babies pioneered at Columbia in the 80s and 90s, particularly regarding the timing of surgery and ventilation techniques,” Dr. Kuenzler says. “The babies still need a ventilator after surgery, but we think that the minimally invasive techniques help in recovery by making it easier for these kids to breathe on their own in between ventilator breaths. That keeps their muscles strong, so they don’t start from zero when the ventilator is finally weaned.”
Minimally invasive surgery also may have important long-term benefits, Dr. Rothenberg adds. “Kids who have open surgeries often develop chest wall deformity, scoliosis, or shoulder weakness later in life because their muscles were cut when they were young,” he says. “With minimally invasive surgery, we may be able to avoid that morbidity.”
Dr. Kuenzler is quick to credit Columbia’s extensive adoption of minimally invasive techniques to Dr. Rothenberg, “who had the courage to start without any blueprints.” But Dr. Kuenzler also has done his part as his own trainees spread the procedures to other renowned children’s hospitals: Last year’s pediatric surgery fellow performed the first minimally invasive CDH repair for an infant at Cincinnati Children’s Hospital, considered one of the best children’s hospitals in the world. “It’s really rewarding as an educator to know that what we’ve done here at Columbia not only benefits our own patients, but is also benefiting patients around the country.”
For more information about pediatric minimally invasive surgery, go to www.childrensnyp.org or call 212-342-8586.
Shattered Elbow: Orthopedic Surgeons Break from the Past
A fundamental part of any surgery is getting from the outside to the inside without hurting other things along the way.
But for many broken elbows, that principle is often violated. Orthopedic surgeons routinely saw off the point of the elbow to see and repair fractures in the joint’s humerus bone. “The down side of that method is you have to fix a bone that was perfectly fine before. The elbow is made of complex parts and is hard to reassemble. If both fractures are not repaired well, you may double the problem,” says Melvin Rosenwasser, M.D., the Robert E. Carroll Professor of Hand Surgery.
For nearly 15 years, Dr. Rosenwasser has been using a different method he devised to repair broken elbows without breaking the ulna. “How these fractures are initially treated can affect the ultimate outcomes, and this way of exposing the elbow may reduce complications and improve results.”
Elbow fractures are common Columbia surgeons see one or more every day but they do not heal as well as breaks in the femur, tibia, or bones in the forearm. The fracture reassembly is hard enough but the iatrogenic osteotomy or fracture of the ulna for surgical exposure can lead to its own set of complication and poor results. Sometimes the hardware used to repair the surgically broken ulna loosens and causes pain. Sometimes the bone displaces and results in joint deformity resulting in stiffness and often leads to premature traumatic arthritis. In short, it is not always a trivial exercise to break a bone to fix a bone.
“When you see master surgeons perform the standard olecranon osteotomy technique for surgical exposure and get less than the expected result one has to look to the technique, not the surgeon.”
“The elbow is quite important in positioning the hand, and even if the elbow is injured in trivial ways the resulting elbow stiffness can greatly impact everyday life and activities, such as eating or bathing,” Dr. Rosenwasser says. “‘Fix it and it’ll be fine,’ i.e., returned to normal, doesn’t apply to the elbow, and many patients must accept some limitations after surgery. It can create a permanent functional disability in many cases.”
Many orthopedic surgeons have been searching for ways to predictably improve outcomes while minimizing surgical complications. To Dr. Rosenwasser, part of the problem is rooted in the surgical approach to the elbow joint.
“When you see master surgeons perform the standard olecranon osteotomy technique for surgical exposure and get less than the expected result one has to look to the technique, not the surgeon,” he says.
The new method avoids breaking the ulna but still permits excellent visualization of the joint anatomy and the fracture fragments. One incision with two muscle interval or windows are created through the posterior arm and triceps muscle. “These two windows, one lateral and one medial, along with capsulotomy and minimal ligament release allow access for reassembly of the fracture fragments thus putting humpty together again,” says Dr. Rosenwasser, “all this without creating an iatrogenic fracture through the unbroken bone which requires its own repair at the end of the case.” Dr. Rosenwasser presented the technique at the 24th annual American Shoulder and Elbow Surgeons meeting in 2007, which resulted in a full-length manuscript describing better patient mediated outcomes with regard to function and satisfaction. This triceps preservation method can lead to stronger elbow extension, less hardware pain and secondary surgery, and equivalent mobility to the gold standard olecranon osteotomy exposure.
Other nonosteotomy techniques have been published but Dr. Rosenwasser’s two windows approach maintains the triceps continuity best while still allowing surgeons the potential conversion to the osteotomy if the fracture reassembly cannot be adequately realized.
“Surgical anatomy is always being refreshed by practicing surgeons and they rely on the technique they have been taught and practiced for this type of injury. Imperfect results or frequent complications drive the discovery of new approaches which need to be confirmed by clinical trials and then taught and gradually adopted by the majority of practicing orthopedic surgeons,” he says. “This technique once understood and practiced can afford surgeons another important tool in their armamentarium for improving patient outcomes in complex elbow fractures involving the distal end of the humerus.”
For more information, contact Melvin Rosenwasser at 212-305-8036 or firstname.lastname@example.org.