Journal of Pediatric Surgery VOL 26, NO 10
OCTOBER
1991
EDITORIAL
Laparoscopy
in Pediatric
A
LTHOUGH laparoscopy has been an accepted treatment modality since first described by Kelling’ and Ott,2 efforts to incorporate this approach into general surgery have largely been fruitless. Over the years, a number of investigators, including Ruddock,3 Berci et al: and Cuschieri,’ proselytized this approach to intraabdominal problems. However, the surgical community was resistant until the introduction and wide dissemination of laparoscopic cholecystectomy. The use of this endoscopic approach is not new to pediatric&’ and it is of interest to see several reports in this issue dedicated to the use of the laparoscope for pediatric disease. As enthusiasm for laparoscopy builds, it is vital that certain safeguards are maintained. First, we must ensure that those using Iaparoscopy are appropriately trained. Obviously, as it becomes a more accepted treatment, it will be incorporated into residency training programs, but until such time, practicing surgeons must attend well-structured courses and it is incumbent upon the societies of each specialty to ensure the appropriate endorsement is given.* We must also ensure that we only perform laparoscopitally, operations that make sense when carried out by the open route, and that because something can be done does not mean it should be done. Due to the enthusiastic response demonstrated by the surgical community in welcoming laparoscopy into their armamentarium, it is only natural that clinicians should wish to be the first to describe new procedures in the literature. However, for Iaparoscopy to become an enduring item, it must not be discredited by being too widely adopted without careful and diligent prospective assessment and peer review. This is not to say that every new laparoscopic indication should be subjected to critical dissection by institutional review bodies and double-blind, prospective, clinical trials, because very often we are looking at merely changing the route of entry for well-known diagnostic and therapeutic procedures such as, for instance, pyloromyotomy for hypertrophic pyloric stenosis.
Journal of Pediatric Surgery, Vol26, No 10 (October), 1991:
pp 7145-l
147
Surgery
Of course, this raises interesting philosophical dilemmas, for what exactly is experimental surgery and when should we be pleased to perform the first laparoscopic operation of a given category and when should we rely on an ethical committee’s stipulations? Obviously, the surgeon’s intelligence, integrity, and conscience should provide guidance in most circumstances, but the pressure to publish and be the first in a field is quite intense, especially in today’s competitive and rapidly moving medical marketplace. Perhaps it would be appropriate to accept that if the operation under consideration is routinely performed by the open route and that the laparoscopic approach will change nothing, this could merely be called a minimal access approach with, effectively, just the difference in incision. However, if a markedly different method of surgery or different equipment is used and the technique has not been published in the peer review literature or presented at an appropriate scientific meeting, then this may be called experimental or investigational. It is vital for the good name of laparoscopy that such a rationale be strictly followed and that we police ourselves as a profession, for certainly, if we do not, others may do this for us. The article by Drs Holcomb et al9 is an important contribution by known leaders in the field. They correctly stress the importance of the tests of needle positioning including aspiration, injection, and the hanging drop technique. These tests, in concert with careful observation of the insufflator, are vital if the potentionally fatal complication of gas embolism is to be avoided. There is no doubt that the insertion of the Veress needle is one of the most challenging parts of any laparoscopic procedure and a careful inspection for intestinal or other intraabominal injuries is also vital, because there have been a number of injuries when the surgeon’s attention was immediately directed to the gallbladder rather than checking to ascertain that no injury had occurred. There has been a great deal of controversy about whether laser or electrocautery is vital for this opera1145
JONATHAN
tion. It would seem at this stage that either is suitable, but electrocautery is so much less expensive and is readily familiar to all surgeons. Therefore, it is interesting to see the authors’ comments on the significance of the increased expense of the KTP laser device. Cholangiography, as an adjunct to laparoscopic cholecystectomy, has many other significant factors. During open cholecystectomy one may assess the common duct and feel for stones, and obviously this is not as readily possible laparoscopically. Also, the length of cystic duct available for clipping, the presence of anomalies (such as an aberrent right hepatic duct), and the detection of iatrogenic injuries are also vital considerations.” In addition, if the surgeon performs this procedure routinely, he or she will become adept at it and, therefore, able to perform it in the cases in which it is needed. It also prepares the surgeon for transcystic duct stone extraction.” The importance of moving the scope at the end of the procedure to the subxiphisternal portal allows the surgeon one last opportunity to check for any missed intestinal injury. Other useful maneuvers are to anesthetize the peritoneum under direct vision at the end of the procedure to ensure adequate analgesia of this pain-sensitive structure. It is also useful to fully discharge the pneumoperitoneum to limit the amount of shoulder-tip pain experienced by the patient. Another potentially contentious area is that of simultaneous appendectomy. Certainly, in the older age group in whom there is more experience with laparoscopic cholecystectomy, this is not justified because the risks of infection and obstruction far outweigh the risk of subsequent appendicitis.” However, as experience grows in pediatric cholecystectomy, this may become appropriate and certainly deserves observation. Dr Newman and his associates13 make some fascinating additional statements to point out the value of carefully selecting trocar sites. As in open surgery, exposure and retraction are key principles. Because we rely on the lever principle in laparoscopic surgery, a great deal of thought must be given to trocar placement. These investigators suggest that endoscopic retrograde cholangiopancreatography may be suitable for dealing with choledocholithiasis, but we must have concerns about using this in such young children, and perhaps the cystic duct route will prove to be more suitable. The article by Dr Sigman et all4 also makes valid points about trocar placement, but I do have concerns about early discharge from hospital. We have already made rapid advances in sending patients home within a day or so of surgery rather than the 5 or 6-day usual average for open cholecys-
M. SACKER
tectomy. However, I believe it will prove useful to keep patients in hospital overnight, which will allow any potential problems at surgery, such as an injured viscus or a slipped hemoclip, to become obvious. If such patients are to be discharged then the problem might not become obvious until they are at home with potentially disasterous consequences. It is also interesting to postulate just why patients are so much better after laparoscopic surgery, because the lengths of several small incisions do not seem to add up to the physical insult of one larger incision. We may postulate on the biochemical mechanism for this, but it would certainly seem that the emotional stress is reduced, which is particularly pertinent to young children. Laparoscopy has been used for the diagnosis of adnexal lesions in adult gynecological patients and also for the treatment of many such lesions. Its application by Dr Shalev et all5 for the detorsion of adnexae in childhood demonstrates what can be performed laparoscopically, but other questions are raised, such as will torsion occur again and should a fixation procedure have been performed. It would also be important to exclude teratoma in such a case. The article by Dr Alain et all6 describing using laparoscopy to perform an extramucosal pyloromyotomy is a logical extension and this procedure is also being done in the adult as part of the Taylor”,” procedure for peptic ulcer disease. Obviously, safeguards have to be followed to make sure that perforation does not occur and careful follow-up will demonstrate whether there is, in fact, any advantage over the widely known and practiced open approach. The final point that needs to be strongly made is that should the laparoscopic approach to surgery prove difficult or impossible, the surgeon should be discouraged from perserving and should convert to open surgery. Laparoscopic cholecystectomy has only been with us about 3 years,‘9z20but open cholecystectomy has been a known procedure since first performed by Langenbuch in 1882.*’ Conversion to open cholecystectomy in case of difficulty, anomolous anatomy, or unsuspected pathology represents sound surgical judgement and is a testimony to a surgeon’s conservative and safe approach. With judgement, self-assessment, and, above all, imagination, an exciting and stimulating time exists in the future for surgeons incorporating laparoscopy into their clinical practice. Jonathan M. Sackier, MD, FRCS
Department of Surgery Cedars-Sinai Medical Center Los Angeles, CA
LAPAROSCOPY
1147
IN PEDIATRIC SURGERY
REFERENCES 1. Kelling G: Zur coelioskopie. Arch Klin Chir 126:226-229, 1923 2. Ott D: Die direkte Beleuchtung der Bauchhole, der Harnblase, des Dickdarms und des Uterus zu diagnostichen Zwecken. Rev Med Tcheque (Prague) 2:27-30, 1909 3. Ruddock JC: Peritoneoscopy surgery. Gynecol Obstet 65:523539, 1937 4. Berci G, Shore JM, Parrish J, et al: The evaluation of a new peritoneoscope as a diagnostic aid to the surgeon. Ann Surg 178:37-39, 1973 5. Cuschieri A: Value of laparoscopy in hepatobiliary disease. Br J Surg 61:318-319. 1974 6. Gans SL, Berci G: Advances in endoscopy of infants and children. J Pediatr Surg 6:199-234, 1971 7. Gans SL, Berci G: Peritoneoscopy in infants and children. J Pediatr Surg 8:399-405,1973 8. Society of American Gastrointestinal Endoscopic Surgeons (SAGES): Guidelines on privileging and credentialling: Standards of practice and continuing medical education of laparoscopic cholecystectomy. Am J Surg 161:324-325, 1991 9. Holcomb GW III, Olsen DO, Sharp KW: Laparoscopic cholecystectomy in the pediatric patient. J Pediatr Surg 26:11861190,199l 10. Phillips EH, Berci G, Carroll B, et al: The importance of intraoperative cholangiography during laparoscopic cholecystectomy. Am Surg 56:729-795, 1990 11. Sackier JM, Berci G. Paz-Partlow M: Laparoscopic transcystic choledocholithotomy as an adjunct to laparoscopic cholecystectomy. Am Surg 57:323-326. 1991
12. Ludbrook J, Spears GF: The risk of developing appendicitis. Br J Surg 52:856-858, 1965 13. Newman KD, Marmon LM, Attorri R, et al: Laparoscopic cholecystectomy in pediatric patients. J Pediatr Surg 26:1184-l 185, 1991 14. Sigman HH, Laberge J-M, Croitoru D, et al: Laparoscopic cholecystectomy: A treatment option for gallbladder disease in children. J Pediatr Surg 26:1181-1183. 1991 15. Shalev E, Mann S, Roman0 S, et al: Laparoscopic detorsion of adnexa in childhood: A case report. J Pediatr Surg 26:1193-1194, 1991 16. Alain JL, Grousseau D, Terrier G: Extramucosal pylorotomy by laparoscopy. J Pediatr Surg26:1191-1192.1991 17. Taylor TV, Macleod DAD, Gunn AA, et al: Anterior lesser curve seromyotomy and posterior truncal vagotomy in the treatment of chronic duodenal ulcer. Lancet 2:848-848, 1982 18. Hunter JG, Becker JM, Lee RG, et al: Anterior lesser curvature laser seromyotomy with posterior truncal vagotomy: A potential treatment of peptic ulcer disease. Br J Surg 76:949-952, 1989 19. Dubois F, Berthelots G, Levard H: Cholecystectomy par coelioscopi. Presse Med 18:980-982, 1989 20. Berci G, Sackier JM, Paz-Portlow M: A new endoscopic treatment for symptomatic gallbladder disease. Gastrointest Endose Clin North Am 1:191-203, 1991 21. Langenbuch C: Ein Fall von Exstirpation der Gallenblase wegen chronischer Cholelithiasis: Heliungo. Klin Wschr 19:725727,1882
OCTOBER
1991
EDITORIAL
Laparoscopy
in Pediatric
A
LTHOUGH laparoscopy has been an accepted treatment modality since first described by Kelling’ and Ott,2 efforts to incorporate this approach into general surgery have largely been fruitless. Over the years, a number of investigators, including Ruddock,3 Berci et al: and Cuschieri,’ proselytized this approach to intraabdominal problems. However, the surgical community was resistant until the introduction and wide dissemination of laparoscopic cholecystectomy. The use of this endoscopic approach is not new to pediatric&’ and it is of interest to see several reports in this issue dedicated to the use of the laparoscope for pediatric disease. As enthusiasm for laparoscopy builds, it is vital that certain safeguards are maintained. First, we must ensure that those using Iaparoscopy are appropriately trained. Obviously, as it becomes a more accepted treatment, it will be incorporated into residency training programs, but until such time, practicing surgeons must attend well-structured courses and it is incumbent upon the societies of each specialty to ensure the appropriate endorsement is given.* We must also ensure that we only perform laparoscopitally, operations that make sense when carried out by the open route, and that because something can be done does not mean it should be done. Due to the enthusiastic response demonstrated by the surgical community in welcoming laparoscopy into their armamentarium, it is only natural that clinicians should wish to be the first to describe new procedures in the literature. However, for Iaparoscopy to become an enduring item, it must not be discredited by being too widely adopted without careful and diligent prospective assessment and peer review. This is not to say that every new laparoscopic indication should be subjected to critical dissection by institutional review bodies and double-blind, prospective, clinical trials, because very often we are looking at merely changing the route of entry for well-known diagnostic and therapeutic procedures such as, for instance, pyloromyotomy for hypertrophic pyloric stenosis.
Journal of Pediatric Surgery, Vol26, No 10 (October), 1991:
pp 7145-l
147
Surgery
Of course, this raises interesting philosophical dilemmas, for what exactly is experimental surgery and when should we be pleased to perform the first laparoscopic operation of a given category and when should we rely on an ethical committee’s stipulations? Obviously, the surgeon’s intelligence, integrity, and conscience should provide guidance in most circumstances, but the pressure to publish and be the first in a field is quite intense, especially in today’s competitive and rapidly moving medical marketplace. Perhaps it would be appropriate to accept that if the operation under consideration is routinely performed by the open route and that the laparoscopic approach will change nothing, this could merely be called a minimal access approach with, effectively, just the difference in incision. However, if a markedly different method of surgery or different equipment is used and the technique has not been published in the peer review literature or presented at an appropriate scientific meeting, then this may be called experimental or investigational. It is vital for the good name of laparoscopy that such a rationale be strictly followed and that we police ourselves as a profession, for certainly, if we do not, others may do this for us. The article by Drs Holcomb et al9 is an important contribution by known leaders in the field. They correctly stress the importance of the tests of needle positioning including aspiration, injection, and the hanging drop technique. These tests, in concert with careful observation of the insufflator, are vital if the potentionally fatal complication of gas embolism is to be avoided. There is no doubt that the insertion of the Veress needle is one of the most challenging parts of any laparoscopic procedure and a careful inspection for intestinal or other intraabominal injuries is also vital, because there have been a number of injuries when the surgeon’s attention was immediately directed to the gallbladder rather than checking to ascertain that no injury had occurred. There has been a great deal of controversy about whether laser or electrocautery is vital for this opera1145
JONATHAN
tion. It would seem at this stage that either is suitable, but electrocautery is so much less expensive and is readily familiar to all surgeons. Therefore, it is interesting to see the authors’ comments on the significance of the increased expense of the KTP laser device. Cholangiography, as an adjunct to laparoscopic cholecystectomy, has many other significant factors. During open cholecystectomy one may assess the common duct and feel for stones, and obviously this is not as readily possible laparoscopically. Also, the length of cystic duct available for clipping, the presence of anomalies (such as an aberrent right hepatic duct), and the detection of iatrogenic injuries are also vital considerations.” In addition, if the surgeon performs this procedure routinely, he or she will become adept at it and, therefore, able to perform it in the cases in which it is needed. It also prepares the surgeon for transcystic duct stone extraction.” The importance of moving the scope at the end of the procedure to the subxiphisternal portal allows the surgeon one last opportunity to check for any missed intestinal injury. Other useful maneuvers are to anesthetize the peritoneum under direct vision at the end of the procedure to ensure adequate analgesia of this pain-sensitive structure. It is also useful to fully discharge the pneumoperitoneum to limit the amount of shoulder-tip pain experienced by the patient. Another potentially contentious area is that of simultaneous appendectomy. Certainly, in the older age group in whom there is more experience with laparoscopic cholecystectomy, this is not justified because the risks of infection and obstruction far outweigh the risk of subsequent appendicitis.” However, as experience grows in pediatric cholecystectomy, this may become appropriate and certainly deserves observation. Dr Newman and his associates13 make some fascinating additional statements to point out the value of carefully selecting trocar sites. As in open surgery, exposure and retraction are key principles. Because we rely on the lever principle in laparoscopic surgery, a great deal of thought must be given to trocar placement. These investigators suggest that endoscopic retrograde cholangiopancreatography may be suitable for dealing with choledocholithiasis, but we must have concerns about using this in such young children, and perhaps the cystic duct route will prove to be more suitable. The article by Dr Sigman et all4 also makes valid points about trocar placement, but I do have concerns about early discharge from hospital. We have already made rapid advances in sending patients home within a day or so of surgery rather than the 5 or 6-day usual average for open cholecys-
M. SACKER
tectomy. However, I believe it will prove useful to keep patients in hospital overnight, which will allow any potential problems at surgery, such as an injured viscus or a slipped hemoclip, to become obvious. If such patients are to be discharged then the problem might not become obvious until they are at home with potentially disasterous consequences. It is also interesting to postulate just why patients are so much better after laparoscopic surgery, because the lengths of several small incisions do not seem to add up to the physical insult of one larger incision. We may postulate on the biochemical mechanism for this, but it would certainly seem that the emotional stress is reduced, which is particularly pertinent to young children. Laparoscopy has been used for the diagnosis of adnexal lesions in adult gynecological patients and also for the treatment of many such lesions. Its application by Dr Shalev et all5 for the detorsion of adnexae in childhood demonstrates what can be performed laparoscopically, but other questions are raised, such as will torsion occur again and should a fixation procedure have been performed. It would also be important to exclude teratoma in such a case. The article by Dr Alain et all6 describing using laparoscopy to perform an extramucosal pyloromyotomy is a logical extension and this procedure is also being done in the adult as part of the Taylor”,” procedure for peptic ulcer disease. Obviously, safeguards have to be followed to make sure that perforation does not occur and careful follow-up will demonstrate whether there is, in fact, any advantage over the widely known and practiced open approach. The final point that needs to be strongly made is that should the laparoscopic approach to surgery prove difficult or impossible, the surgeon should be discouraged from perserving and should convert to open surgery. Laparoscopic cholecystectomy has only been with us about 3 years,‘9z20but open cholecystectomy has been a known procedure since first performed by Langenbuch in 1882.*’ Conversion to open cholecystectomy in case of difficulty, anomolous anatomy, or unsuspected pathology represents sound surgical judgement and is a testimony to a surgeon’s conservative and safe approach. With judgement, self-assessment, and, above all, imagination, an exciting and stimulating time exists in the future for surgeons incorporating laparoscopy into their clinical practice. Jonathan M. Sackier, MD, FRCS
Department of Surgery Cedars-Sinai Medical Center Los Angeles, CA
LAPAROSCOPY
1147
IN PEDIATRIC SURGERY
REFERENCES 1. Kelling G: Zur coelioskopie. Arch Klin Chir 126:226-229, 1923 2. Ott D: Die direkte Beleuchtung der Bauchhole, der Harnblase, des Dickdarms und des Uterus zu diagnostichen Zwecken. Rev Med Tcheque (Prague) 2:27-30, 1909 3. Ruddock JC: Peritoneoscopy surgery. Gynecol Obstet 65:523539, 1937 4. Berci G, Shore JM, Parrish J, et al: The evaluation of a new peritoneoscope as a diagnostic aid to the surgeon. Ann Surg 178:37-39, 1973 5. Cuschieri A: Value of laparoscopy in hepatobiliary disease. Br J Surg 61:318-319. 1974 6. Gans SL, Berci G: Advances in endoscopy of infants and children. J Pediatr Surg 6:199-234, 1971 7. Gans SL, Berci G: Peritoneoscopy in infants and children. J Pediatr Surg 8:399-405,1973 8. Society of American Gastrointestinal Endoscopic Surgeons (SAGES): Guidelines on privileging and credentialling: Standards of practice and continuing medical education of laparoscopic cholecystectomy. Am J Surg 161:324-325, 1991 9. Holcomb GW III, Olsen DO, Sharp KW: Laparoscopic cholecystectomy in the pediatric patient. J Pediatr Surg 26:11861190,199l 10. Phillips EH, Berci G, Carroll B, et al: The importance of intraoperative cholangiography during laparoscopic cholecystectomy. Am Surg 56:729-795, 1990 11. Sackier JM, Berci G. Paz-Partlow M: Laparoscopic transcystic choledocholithotomy as an adjunct to laparoscopic cholecystectomy. Am Surg 57:323-326. 1991
12. Ludbrook J, Spears GF: The risk of developing appendicitis. Br J Surg 52:856-858, 1965 13. Newman KD, Marmon LM, Attorri R, et al: Laparoscopic cholecystectomy in pediatric patients. J Pediatr Surg 26:1184-l 185, 1991 14. Sigman HH, Laberge J-M, Croitoru D, et al: Laparoscopic cholecystectomy: A treatment option for gallbladder disease in children. J Pediatr Surg 26:1181-1183. 1991 15. Shalev E, Mann S, Roman0 S, et al: Laparoscopic detorsion of adnexa in childhood: A case report. J Pediatr Surg 26:1193-1194, 1991 16. Alain JL, Grousseau D, Terrier G: Extramucosal pylorotomy by laparoscopy. J Pediatr Surg26:1191-1192.1991 17. Taylor TV, Macleod DAD, Gunn AA, et al: Anterior lesser curve seromyotomy and posterior truncal vagotomy in the treatment of chronic duodenal ulcer. Lancet 2:848-848, 1982 18. Hunter JG, Becker JM, Lee RG, et al: Anterior lesser curvature laser seromyotomy with posterior truncal vagotomy: A potential treatment of peptic ulcer disease. Br J Surg 76:949-952, 1989 19. Dubois F, Berthelots G, Levard H: Cholecystectomy par coelioscopi. Presse Med 18:980-982, 1989 20. Berci G, Sackier JM, Paz-Portlow M: A new endoscopic treatment for symptomatic gallbladder disease. Gastrointest Endose Clin North Am 1:191-203, 1991 21. Langenbuch C: Ein Fall von Exstirpation der Gallenblase wegen chronischer Cholelithiasis: Heliungo. Klin Wschr 19:725727,1882
