Pediatr Transplantation 2014: 18: 163–165
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Pediatric Transplantation DOI: 10.1111/petr.12212
Is single-port laparoscopy feasible after liver transplant? Zani A, Paul A, Dhawan A, Desai A. Is single-port laparoscopy feasible after liver transplant?
Augusto Zani1, Anu Paul1, Anil Dhawan2 and Ashish Desai1 1
Abstract: The role of laparoscopy following liver transplant in children is debated. Herein, we report the first two cases of SIPES post-liver transplant. In both patients, SIPES access was carried out using Olympus TriPort. Patient 1 was an 11 yr old born with biliary atresia, who had four previous major laparotomies: Kasai portoenterostomy, followed by liver transplant and two laparotomies for lymph node biopsies for PTLD. The child was referred for suspected PTLD relapse due to enlarged nodes on CT scan. At SIPES, following adequate adhesiolysis, the lymph node biopsy was achieved successfully. Patient 2 was a five yr old with bilateral intra-abdominal testes who had undergone liver transplant aged two yr. He underwent a left one-stage orchidopexy and right first-stage Fowler–Stephen procedure at five yr of life, followed by a second stage Fowler–Stephen surgery on the right side, nine months later. All procedures were successfully performed by SIPES, and both patients were discharged home on first post-operative day. We conclude that SIPES could be safely carried out in patients who have had liver transplant. In case of diffuse intraperitoneal adhesions, SIPES is beneficial to create space by blunt and sharp dissection and decreases post-operative stay.
The role of laparoscopy after major laparotomy in children is debated. It is common knowledge that following major abdominal surgery extensive adhesions could develop and cause difficulties in case of later laparoscopic operations. This might occur especially after liver transplantation, where the incidence of post-operative adhesions could be high (1). For this reason, most surgeons would opt for an open laparotomy in children who underwent liver transplant and need further abdominal surgery. However, recently this view has been challenged by some authors, who do not consider laparoscopy after liver transplantation an absolute contraindication, but actually a possible indication in selected cases (2, 3). In the recent years, the world of minimally invasive surgery has incorporated a new approach that is now considered a possible alternative to conventional laparoscopy for some paediatric surgical diseases: SIPES (4). The number of surgical procedures performed with this Abbreviations: PTLD, post-transplant lymphoproliferative disease; SIPES, single-port endoscopic surgery.
Department of Paediatric Surgery, King′s College Hospital, London, UK, 2Paediatric Hepatology, Paediatric Liver, GI and Nutrition Centre, King’s College Hospital, London, UK
Key words: minimal invasive – SILS – LESS – OPUS Ashish P Desai, Department of Paediatric Surgery, King’s College Hospital, Denmark Hill, London SE5 9RS, UK Tel: +44 (0) 203 299 3350 Fax: +44 (0) 203 299 4021 E-mail: [email protected] Accepted for publication 22 November 2013
approach in the paediatric population is growing and includes pyloromyotomy (5), appendicectomy (6), cholecystectomy (7), splenectomy (8), and bowel resection (9). In the last three yr, at our institution, we have been successfully performing SIPES procedures on a wide range of paediatric surgical conditions. Because Kings College Hospital is one of the specialist centres for paediatric liver transplantation in the UK, we have decided to transfer our SIPES experience to post-liver transplant patients. Herein, we report the first two cases of SIPES in post-liver transplant children and discuss the feasibility of this approach. Patients and methods Between 2009 and 2012, 21 SIPES procedures have been performed by a single surgeon (AD). Among these, two children who had undergone liver transplant had a total of three SIPES procedures. In both patients, SIPES was performed using the Olympus TriPortTM Access system (Southend, UK), a 10-mm camera and two 5-mm straight instruments. Patient 1 was an 11-yr-old child who was born with biliary atresia. Before SIPES, he had had previous major
163
Zani et al. laparotomies. At five wk of age, once diagnosed with biliary atresia, he underwent a Kasai portoenterostomy. Due to failure to clear his jaundice at seven months of age, he underwent an orthotopic liver transplant. In the suspicion of PTLD, he underwent lymph node biopsy via laparotomy at two yr and at nine yr of age, respectively. After chemotherapy, the child was referred to us for suspected PTLD relapse given increased serum LDH levels and enlarged mesenteric lymph nodes on CT scan (Fig. 1). Following a multidisciplinary meeting with the Paediatric Hepatology team and parents, SIPES approach was planned. At surgery, there were dense adhesions between the small bowel and the abdominal wall around umbilicus, as well as between the bowel loops. The port was inserted through the umbilicus using the Hassan technique, after creating space via blunt finger dissection. Via SIPES approach, we were able to achieve adequate adhesiolysis and successfully obtain the mesenteric lymph node biopsy. The operative time was 92 min. The child tolerated the procedure well and was discharged home on post-operative day 1. At 25 months follow-up, the child is well with no evidence of PTLD. Patient 2 was a five-yr-old boy with glycogen storage disorder type 4, who at two yr of age had undergone split liver transplant. Subsequently, he was also diagnosed with bilateral intra-abdominal testis. At five yr of life, a left one-stage orchidopexy and right first-stage Fowler–Stephen procedure (with division of testicular vessels) were performed. During surgery, adhesions were found around umbilicus. Intestinal loops were adherent to the abdominal wall at previous supraumbilical incision. Adhesions were not separated, as patient was asymptomatic from them. The post-operative course was uneventful. After nine months, the child had a second stage Fowler–Stephen surgery on the right side. The operative time for two procedures was 97 and 86 min, respectively. For both procedures, the child was discharged home on the first post-operative day. Patient was followed up in surgical clinic three months after surgery where two normal appearing testes were within scrotum. Both testes were of acceptable size and position.
Fig. 1. Contrast-enhanced CT scan (Patient 1), showing numerous mesenteric lymph nodes adjacent to the liver, raising the suspicion of post-transplant lymphoproliferative disease.
164
Discussion
The role of laparoscopy following solid organ transplant has changed over the years. Initially considered not suitable after transplantation, laparoscopy has acquired acceptance in kidneytransplanted patients first, given the extraperitoneal nature of the approach and the lower risk of thick intraperitoneal adhesions (2). Over time, minimally invasive procedures have been increasingly accepted also in liver-transplanted patients, including laparoscopic lymphocele drainage, laparoscopic adhesiolysis, and laparoscopic repair of incisional hernia (2, 10). In the paediatric literature, some authors have reported that prior surgery has a limited impact on the feasibility of laparoscopic surgery, and they consider minimal invasive surgery as the first-choice technique after previous laparotomy (11–13). Furthermore, laparoscopy has recently been advocated for intra-abdominal biopsy in transplanted patients with suspected PTLD: around 20% of paediatric PTLD patients require a biopsy that according to Metzelder et al. could be safely carried out with laparoscopy (3). Single-port surgery is a fascinating novel approach, introduced in the paediatric surgical practice in the last few years. The same technique is labelled in various ways, but in the present study, we used the term SIPES, first coined in 2010 by Muensterer to emphasize that this technique was specifically addressed to children (14). The popularity of SIPES in children has been steadily rising, thanks also to the improvement in instruments and technology. The most commonly reported SIPES operations in children are the common procedures of Paediatric Surgery, such as appendicectomy, inguinal hernia repair, pyloromyotomy, and fundoplication. (15). In the cases herein presented, the use of SIPES proved to be feasible. In the first case, it was actually very advantageous to achieve proper adhesiolysis by blunt and sharp dissection; a standard laparoscopic approach would have been impossible due to the widely distributed thick adhesions found all over the abdomen. Similarly, a conventional laparotomy would have required extensive adhesiolysis with potential risk to the bowel and blood loss. Conversely, minimizing the wounds to just one, SIPES proved to be useful to partially dissect and, when not possible, to get around the adhesions. No post-operative complications have occurred in this case. However, a trocar metastasis after laparoscopic biopsy of suspected PTLD has been reported in a child following cardiac transplant
Single-port surgery after liver transplant
(16). This complication might potentially occur also after SIPES. In the second case, thick intestinal adhesions were found at surgery, mainly in the upper abdominal quadrants and around the umbilicus. However, in this case, there was no need for adhesiolysis as the surgical field for the orchidopexy procedures was in the lower abdomen and pelvis. In both cases, SIPES resulted in a quick recovery and short post-operative hospital stay. The advantage of good cosmetic outcome that is usually associated with SIPES is lost in patients who had already undergone major laparotomy, and therefore herein, it was not taken into account. Our experience of SIPES in transplanted patients is limited just to the described procedures, but we envisage using the same approach in other post-transplant patients. We acknowledge that SIPES will not be feasible in all of them and indications for this approach have to be tailored to the patient’s past surgical history. In particular, we believe that SIPES following liver transplant should be reserved to procedures that involve the inframesocolic compartment, where adhesions are more likely to be less important, native anatomy can be preserved and no major structures have to be modified. Conversely, posttransplant SIPES in the supramesocolic compartment should be avoided due to potential hazards, such as the proximity to the transplanted liver graft, the presence of possibly thicker adhesions and the complexity of surgery to the upper abdominal quadrants. In conclusion, SIPES in expert hands is feasible and safe in patients who had liver transplant, at least for routine surgical procedures. In case of anticipated diffuse intraperitoneal adhesions, SIPES could be beneficial and should not be considered as a contraindication.
critically revised the article; Ashish Desai designed and critically revised the article.
References 1. BLACHAR A, FEDERLE MP. Bowel obstruction following liver transplantation: Clinical and CT findings in 48 cases with emphasis on internal hernia. Radiology 2001: 218: 384–388. 2. LAI Q, PINHEIRO RS, LEVI SANDRI GB, et al. Laparoscopy in liver transplantation: The future has arrived. HPB Surg 2012: 2012: 148387. 3. METZELDER ML, SCHOBER T, GRIGULL L, et al. The role of laparoscopic techniques in children with suspected post-transplantation lymphoproliferative disorders. J Laparoendosc Adv Surg Tech A 2011: 21: 767–770. 4. BLANCO FC, KANE TD. Single-port laparoscopic surgery in children: Concept and controversies of the new technique. Minim Invasive Surg 2012: 2012: 232347. 5. HARMON CM. Single-site umbilical laparoscopic pyloromyotomy. Semin Pediatr Surg 2011: 20: 208–211. 6. OSTLIE DJ. Single-site umbilical laparoscopic appendectomy. Semin Pediatr Surg 2011: 20: 196–200. 7. HOLCOMB GW 3rd. Single-site umbilical laparoscopic cholecystectomy. Semin Pediatr Surg 2011: 20: 201–207. 8. BRUZONI M, DUTTA S. Single-site umbilical laparoscopic splenectomy. Semin Pediatr Surg 2011: 20: 212–218. 9. ST PETER SD. Single-site umbilical laparoscopic segmental small bowel resection. Semin Pediatr Surg 2011: 20: 219–223. 10. KRAJEWSKI E, SORIANO IS, ORTIZ J. Laparoscopy in transplantation. JSLS 2006: 10: 426–431. 11. METZELDER ML, JESCH N, DICK A, et al. Impact of prior surgery on the feasibility of laparoscopic surgery for children: A prospective study. Surg Endosc 2006: 20: 1733–1737. 12. ESPOSITO C, BECMEUR F, CENTONZE A, et al. Laparoscopic reoperation following unsuccessful antireflux surgery in childhood. Semin Laparosc Surg 2002: 9: 177–179. 13. TAN S, WULKAN ML. Minimally invasive surgical techniques in reoperative surgery for gastroesophageal reflux disease in infants and children. Am Surg 2002: 68: 989–992. 14. MUENSTERER OJ. Single-incision pediatric Endosurgical (SIPES) versus conventional laparoscopic pyloromyotomy: A single-surgeon experience. J Gastrointest Surg 2010: 14: 965–968. 15. PONSKY TA, KRPATA DM. Single-port laparoscopy: Considerations in children. J Minim Access Surg 2011: 7: 96–98. 16. METZELDER M, URE B. Port-site metastasis after laparoscopic biopsy of a posttransplant Burkitt lymphoma in a child. Eur J Pediatr Surg 2009: 19: 126–127.
Authors’ contributions Augusto Zani performed data collection and analysis, drafting the article; Anu Paul collected the data; Anil Dhawan
165
© 2013 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Pediatric Transplantation DOI: 10.1111/petr.12212
Is single-port laparoscopy feasible after liver transplant? Zani A, Paul A, Dhawan A, Desai A. Is single-port laparoscopy feasible after liver transplant?
Augusto Zani1, Anu Paul1, Anil Dhawan2 and Ashish Desai1 1
Abstract: The role of laparoscopy following liver transplant in children is debated. Herein, we report the first two cases of SIPES post-liver transplant. In both patients, SIPES access was carried out using Olympus TriPort. Patient 1 was an 11 yr old born with biliary atresia, who had four previous major laparotomies: Kasai portoenterostomy, followed by liver transplant and two laparotomies for lymph node biopsies for PTLD. The child was referred for suspected PTLD relapse due to enlarged nodes on CT scan. At SIPES, following adequate adhesiolysis, the lymph node biopsy was achieved successfully. Patient 2 was a five yr old with bilateral intra-abdominal testes who had undergone liver transplant aged two yr. He underwent a left one-stage orchidopexy and right first-stage Fowler–Stephen procedure at five yr of life, followed by a second stage Fowler–Stephen surgery on the right side, nine months later. All procedures were successfully performed by SIPES, and both patients were discharged home on first post-operative day. We conclude that SIPES could be safely carried out in patients who have had liver transplant. In case of diffuse intraperitoneal adhesions, SIPES is beneficial to create space by blunt and sharp dissection and decreases post-operative stay.
The role of laparoscopy after major laparotomy in children is debated. It is common knowledge that following major abdominal surgery extensive adhesions could develop and cause difficulties in case of later laparoscopic operations. This might occur especially after liver transplantation, where the incidence of post-operative adhesions could be high (1). For this reason, most surgeons would opt for an open laparotomy in children who underwent liver transplant and need further abdominal surgery. However, recently this view has been challenged by some authors, who do not consider laparoscopy after liver transplantation an absolute contraindication, but actually a possible indication in selected cases (2, 3). In the recent years, the world of minimally invasive surgery has incorporated a new approach that is now considered a possible alternative to conventional laparoscopy for some paediatric surgical diseases: SIPES (4). The number of surgical procedures performed with this Abbreviations: PTLD, post-transplant lymphoproliferative disease; SIPES, single-port endoscopic surgery.
Department of Paediatric Surgery, King′s College Hospital, London, UK, 2Paediatric Hepatology, Paediatric Liver, GI and Nutrition Centre, King’s College Hospital, London, UK
Key words: minimal invasive – SILS – LESS – OPUS Ashish P Desai, Department of Paediatric Surgery, King’s College Hospital, Denmark Hill, London SE5 9RS, UK Tel: +44 (0) 203 299 3350 Fax: +44 (0) 203 299 4021 E-mail: [email protected] Accepted for publication 22 November 2013
approach in the paediatric population is growing and includes pyloromyotomy (5), appendicectomy (6), cholecystectomy (7), splenectomy (8), and bowel resection (9). In the last three yr, at our institution, we have been successfully performing SIPES procedures on a wide range of paediatric surgical conditions. Because Kings College Hospital is one of the specialist centres for paediatric liver transplantation in the UK, we have decided to transfer our SIPES experience to post-liver transplant patients. Herein, we report the first two cases of SIPES in post-liver transplant children and discuss the feasibility of this approach. Patients and methods Between 2009 and 2012, 21 SIPES procedures have been performed by a single surgeon (AD). Among these, two children who had undergone liver transplant had a total of three SIPES procedures. In both patients, SIPES was performed using the Olympus TriPortTM Access system (Southend, UK), a 10-mm camera and two 5-mm straight instruments. Patient 1 was an 11-yr-old child who was born with biliary atresia. Before SIPES, he had had previous major
163
Zani et al. laparotomies. At five wk of age, once diagnosed with biliary atresia, he underwent a Kasai portoenterostomy. Due to failure to clear his jaundice at seven months of age, he underwent an orthotopic liver transplant. In the suspicion of PTLD, he underwent lymph node biopsy via laparotomy at two yr and at nine yr of age, respectively. After chemotherapy, the child was referred to us for suspected PTLD relapse given increased serum LDH levels and enlarged mesenteric lymph nodes on CT scan (Fig. 1). Following a multidisciplinary meeting with the Paediatric Hepatology team and parents, SIPES approach was planned. At surgery, there were dense adhesions between the small bowel and the abdominal wall around umbilicus, as well as between the bowel loops. The port was inserted through the umbilicus using the Hassan technique, after creating space via blunt finger dissection. Via SIPES approach, we were able to achieve adequate adhesiolysis and successfully obtain the mesenteric lymph node biopsy. The operative time was 92 min. The child tolerated the procedure well and was discharged home on post-operative day 1. At 25 months follow-up, the child is well with no evidence of PTLD. Patient 2 was a five-yr-old boy with glycogen storage disorder type 4, who at two yr of age had undergone split liver transplant. Subsequently, he was also diagnosed with bilateral intra-abdominal testis. At five yr of life, a left one-stage orchidopexy and right first-stage Fowler–Stephen procedure (with division of testicular vessels) were performed. During surgery, adhesions were found around umbilicus. Intestinal loops were adherent to the abdominal wall at previous supraumbilical incision. Adhesions were not separated, as patient was asymptomatic from them. The post-operative course was uneventful. After nine months, the child had a second stage Fowler–Stephen surgery on the right side. The operative time for two procedures was 97 and 86 min, respectively. For both procedures, the child was discharged home on the first post-operative day. Patient was followed up in surgical clinic three months after surgery where two normal appearing testes were within scrotum. Both testes were of acceptable size and position.
Fig. 1. Contrast-enhanced CT scan (Patient 1), showing numerous mesenteric lymph nodes adjacent to the liver, raising the suspicion of post-transplant lymphoproliferative disease.
164
Discussion
The role of laparoscopy following solid organ transplant has changed over the years. Initially considered not suitable after transplantation, laparoscopy has acquired acceptance in kidneytransplanted patients first, given the extraperitoneal nature of the approach and the lower risk of thick intraperitoneal adhesions (2). Over time, minimally invasive procedures have been increasingly accepted also in liver-transplanted patients, including laparoscopic lymphocele drainage, laparoscopic adhesiolysis, and laparoscopic repair of incisional hernia (2, 10). In the paediatric literature, some authors have reported that prior surgery has a limited impact on the feasibility of laparoscopic surgery, and they consider minimal invasive surgery as the first-choice technique after previous laparotomy (11–13). Furthermore, laparoscopy has recently been advocated for intra-abdominal biopsy in transplanted patients with suspected PTLD: around 20% of paediatric PTLD patients require a biopsy that according to Metzelder et al. could be safely carried out with laparoscopy (3). Single-port surgery is a fascinating novel approach, introduced in the paediatric surgical practice in the last few years. The same technique is labelled in various ways, but in the present study, we used the term SIPES, first coined in 2010 by Muensterer to emphasize that this technique was specifically addressed to children (14). The popularity of SIPES in children has been steadily rising, thanks also to the improvement in instruments and technology. The most commonly reported SIPES operations in children are the common procedures of Paediatric Surgery, such as appendicectomy, inguinal hernia repair, pyloromyotomy, and fundoplication. (15). In the cases herein presented, the use of SIPES proved to be feasible. In the first case, it was actually very advantageous to achieve proper adhesiolysis by blunt and sharp dissection; a standard laparoscopic approach would have been impossible due to the widely distributed thick adhesions found all over the abdomen. Similarly, a conventional laparotomy would have required extensive adhesiolysis with potential risk to the bowel and blood loss. Conversely, minimizing the wounds to just one, SIPES proved to be useful to partially dissect and, when not possible, to get around the adhesions. No post-operative complications have occurred in this case. However, a trocar metastasis after laparoscopic biopsy of suspected PTLD has been reported in a child following cardiac transplant
Single-port surgery after liver transplant
(16). This complication might potentially occur also after SIPES. In the second case, thick intestinal adhesions were found at surgery, mainly in the upper abdominal quadrants and around the umbilicus. However, in this case, there was no need for adhesiolysis as the surgical field for the orchidopexy procedures was in the lower abdomen and pelvis. In both cases, SIPES resulted in a quick recovery and short post-operative hospital stay. The advantage of good cosmetic outcome that is usually associated with SIPES is lost in patients who had already undergone major laparotomy, and therefore herein, it was not taken into account. Our experience of SIPES in transplanted patients is limited just to the described procedures, but we envisage using the same approach in other post-transplant patients. We acknowledge that SIPES will not be feasible in all of them and indications for this approach have to be tailored to the patient’s past surgical history. In particular, we believe that SIPES following liver transplant should be reserved to procedures that involve the inframesocolic compartment, where adhesions are more likely to be less important, native anatomy can be preserved and no major structures have to be modified. Conversely, posttransplant SIPES in the supramesocolic compartment should be avoided due to potential hazards, such as the proximity to the transplanted liver graft, the presence of possibly thicker adhesions and the complexity of surgery to the upper abdominal quadrants. In conclusion, SIPES in expert hands is feasible and safe in patients who had liver transplant, at least for routine surgical procedures. In case of anticipated diffuse intraperitoneal adhesions, SIPES could be beneficial and should not be considered as a contraindication.
critically revised the article; Ashish Desai designed and critically revised the article.
References 1. BLACHAR A, FEDERLE MP. Bowel obstruction following liver transplantation: Clinical and CT findings in 48 cases with emphasis on internal hernia. Radiology 2001: 218: 384–388. 2. LAI Q, PINHEIRO RS, LEVI SANDRI GB, et al. Laparoscopy in liver transplantation: The future has arrived. HPB Surg 2012: 2012: 148387. 3. METZELDER ML, SCHOBER T, GRIGULL L, et al. The role of laparoscopic techniques in children with suspected post-transplantation lymphoproliferative disorders. J Laparoendosc Adv Surg Tech A 2011: 21: 767–770. 4. BLANCO FC, KANE TD. Single-port laparoscopic surgery in children: Concept and controversies of the new technique. Minim Invasive Surg 2012: 2012: 232347. 5. HARMON CM. Single-site umbilical laparoscopic pyloromyotomy. Semin Pediatr Surg 2011: 20: 208–211. 6. OSTLIE DJ. Single-site umbilical laparoscopic appendectomy. Semin Pediatr Surg 2011: 20: 196–200. 7. HOLCOMB GW 3rd. Single-site umbilical laparoscopic cholecystectomy. Semin Pediatr Surg 2011: 20: 201–207. 8. BRUZONI M, DUTTA S. Single-site umbilical laparoscopic splenectomy. Semin Pediatr Surg 2011: 20: 212–218. 9. ST PETER SD. Single-site umbilical laparoscopic segmental small bowel resection. Semin Pediatr Surg 2011: 20: 219–223. 10. KRAJEWSKI E, SORIANO IS, ORTIZ J. Laparoscopy in transplantation. JSLS 2006: 10: 426–431. 11. METZELDER ML, JESCH N, DICK A, et al. Impact of prior surgery on the feasibility of laparoscopic surgery for children: A prospective study. Surg Endosc 2006: 20: 1733–1737. 12. ESPOSITO C, BECMEUR F, CENTONZE A, et al. Laparoscopic reoperation following unsuccessful antireflux surgery in childhood. Semin Laparosc Surg 2002: 9: 177–179. 13. TAN S, WULKAN ML. Minimally invasive surgical techniques in reoperative surgery for gastroesophageal reflux disease in infants and children. Am Surg 2002: 68: 989–992. 14. MUENSTERER OJ. Single-incision pediatric Endosurgical (SIPES) versus conventional laparoscopic pyloromyotomy: A single-surgeon experience. J Gastrointest Surg 2010: 14: 965–968. 15. PONSKY TA, KRPATA DM. Single-port laparoscopy: Considerations in children. J Minim Access Surg 2011: 7: 96–98. 16. METZELDER M, URE B. Port-site metastasis after laparoscopic biopsy of a posttransplant Burkitt lymphoma in a child. Eur J Pediatr Surg 2009: 19: 126–127.
Authors’ contributions Augusto Zani performed data collection and analysis, drafting the article; Anu Paul collected the data; Anil Dhawan
165
