A Color Atlas of Minimal Access Surgery in Children Sanjay Oak, Prakash Agarwal, Sandesh V Parelkar
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1Infrastructure and Instrumentation
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Why Minimal Access Surgery in ChildrenCHAPTER 1

In case of surgery of children, the principle of “Doing least, and that too only if and when MUST”, provides the necessary background for promotion of Minimally Invasive Surgery. It is morally preferable, if possible, to avoid, invading into the body of a patient (van Willinenburg 1995). Refinements in anesthesia and technical innovations in instrumentations have made minimally invasive access safer in younger age groups. Conventional open surgery believes in wide exposures and exteriorization of the latent problems. It would indeed be a pity to subject coelomic walls to operative insult when they have done no wrong. Body wall related complications then follow, including dehiscence, abscesses and incisional hernia. A surgical trauma can be further classified as
  • Access trauma
  • Disease related
In case of certain benign procedures in children, the postoperative morbidity is solely and largely contributed by the access trauma rather than the disease related one. The larger the open wound, the more the fascia, muscles and nerves are transected and more morbidity can be expected. Long-term morbidity after a classical posterolateral thoracotomy is well known. Hypertrophic scars are not only important from a cosmetic point of view but also in terms of morbidity. These scars later become painful and limit the movement. Some paresthesia and feelings of discomfort may remain.
If one tries to perform open surgery through smaller incisions, the amount of retraction required is more and this can lead to parietal hematoma, neuropraxia, postoperative paresthesia.
Wide opening of the body cavity results in loss of water and heat. Drying out of the tissues and handling of the tissues causes trauma to them and impaired healing. Hypothermia and drying out of the tissues, however, can also happen during endoscopic surgery when a high flow is used for a longer period.
Due to magnification and good illumination endoscopic surgery gives a much better view than open surgery. This is particularly true in surgery in the pelvis and in the costophrenic region. The MAS surgeon over a period of time acquires skills making him more refined, meticulous and less traumatic than an open surgeon.
Laparoscopic surgery elicits fewer adhesions than an open one and this is particularly important in pediatric abdomens, which are smaller in size, and capacity. Moreover some of the congenital problems need staged approaches and in an open procedure the subsequent stages make intra-abdominal access more tedious.
Endoscopic surgery is safer for the surgeon as there is reduced chance of contact between the patient's body fluids and him.
Scars in children are not liked by the parents and hated by the children themselves. These scars grow along with the children. MAS can minimize the scarring and does not disturb the cosmesis.
Lesser surgical trauma, quicker is the recovery, early ambulation in the ward, quicker return to normal diet, school and sports.
Introduced for Lung Biopsy in 1976, Pediatric thoracoscopy has become far more widely used in the past 4decade. Thoracoscopy in children allows direct access to the pleural space and mediastinal structures. Visibility is excellent and approximates the exposure during an open thoracic procedure. With the refinement in the instruments, application of one lung ventilation techniques and safer anesthesia, the indications in pediatric thoracic procedures are increasing.
However, one must also take the cognizance of the potential risks of MAS in abdominal procedures in children. The use of CO2 as a gas for insufflation causes profound local and general acid-base and hemodynamic changes. Prolong insufflation can lead to compartment syndrome in abdomen. High flow can lead to drying of tissues and if the gas is not prewarmed, hypothermia may set in.
  • Simulators.
  • Tactile Sensors on the hand instruments.
  • Computer assisted surgery.
  • MR guided surgery.
  • 3-D reconstruction in dissection.
  • Endoscopic image + MR image (4th dimension).
  • Virtual reality applications in surgery.
  • Robotics—Augmented reality.
  • MR guided thermotherapy ablators.
  • Development of transformer instruments which are linear during insertion into body cavities but undergo internal transformation into useful robotic tools working in six directions as human wrist.
  • Devices or glues for rapid and precise tissue approximation
  • Specimen removal systems allowing resection of large intracorporeal organs.
  • Biologically active agents which can be safely endoscopically injected for closure of inguinal hernial sacs.
  • Comparable advances of MAS in pediatric neurosurgery, cardiac surgery, orthopedic surgery, otolaryngology and plastic surgery.
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FIGURE 1.1: Hypertrophic scar following laparotomy
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FIGURE 1.2: Hypertrophic scar following thoracotomy
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FIGURE 1.3: Scoliosis—Delayed complication of open thoracotomy
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FIGURE 1.4: Small scars of VATS