Minimally invasive surgery (MIS) allows surgeons to perform complex procedures on some of the smallest patients through the smallest incisions possible, which makes it the future not only of pediatric surgery, but surgery in general, according to pediatric surgeon Dr. G. Ashaini Knowles.
According to Dr. Knowles, who is affiliated with Doctors Hospital and the Princess Margaret Hospital and who spoke at the recent Doctors Hospital Distinguished Lecture Series, MIS, which is also called keyhole surgery, results in less surgical trauma, less pain and a shorter recovery period for the pediatric patient.
"Keyhole surgery is a method of carrying out an operation without having to make a large incision as is done in open surgery. If done laparoscopically, it's an abdominal surgery with video assistance; thoracoscopic surgery means doctors enter the patient via the chest," said Dr. Knowles.
The doctor said there are probably 10 to 15 standard operations that are done via keyhole incisions in neonates and young infants -- fundoplication, ovarian pathology, OA/TOF (tracheo-oesophageal fistula), biliary atresia, malrotation, bowel atresia, CDH, diagnostic and lung biopsy.
Fundoplication, he said, is a common keyhole surgery that is done for kids who have severe reflux, like kids with cerebral palsy where they have reflux and it damages their lungs. In the surgery, the stomach is wrapped around where the children have to swallow to decrease regurgitation.
Dr. Knowles, who returned home just three months ago, said during his training at least every other call was to perform a fundoplication surgery.
"You can do it open, but the problem with doing this surgery open is that these kids are malnourished, so you have these big scars with malnourished kids and the wounds don't heal well. But if you do it laparoscopically with chopsticks, as we call it, you have little wounds that would take no time to heal."
He said a lot of laparoscopic surgery is also done on children born with ovarian cysts.
Laparoscopy has also been used on children with malrotation (twisted bowels from which death can result) and studies have shown the advantages to include a decrease in time to full feeds and decreased hospital stay.
Dr. Knowles said the problem is that it has a 25 percent conversion rate, meaning doctors have started laparoscopically and then go open, and 19 percent of patients will have a reoperation rate.
"So it depends on the institution and you have to sit down with the ethical board and decide if you're going to do it or not," said the pediatric surgeon.
Children with biliary atresia are born without the part of the intestine or liver that drains bile to break down fats. Most children born with the condition in The Bahamas die, according to Dr. Knowles. Those who can be fixed, he said, will need liver transplants. It's a surgery that is hard to do as an open surgery, due to its difficulty. Having the surgery laparoscopically has advantages that include being able to see well, less adhesions and shorter hospital stays. But the learning curve on the operation is steep, and, according to Dr. Knowles, doctors should be careful about pushing the limits and putting kids at risk.
Advantages
The advantages to keyhole surgery include recovering more quickly, a reduction in hospital stay, less scarring and the minimization of adhesions. In MIS surgery, doctors use three-millimeter instruments on neonatals (some doctors go as small as two millimeters); five millimeter-instruments are used on older children, with 10 millimeter instruments being used on adults.
"The big thing is adhesions where internal organs stick together and form bands of scar tissue, which can be painful and cause obstruction," said the doctor.
One day after doing two laparoscopic appendix surgeries, Dr. Knowles said he was able to discharge both of his patients. If the surgeries had been done open, he said it would have been between three to four days before he would have been able to discharge the patients.
He said most operations last between 30 minutes and four hours, a time that has been significantly reduced since the procedure was introduced into medicine.
"When laparoscopy and thoracoscopy came out you had guys who were trying to do these surgeries, but taking hours and hours...six, seven hours to do an operation you could do open in an hour, but with training and the modules and the importance of setting up these units, that's really decreased the time people take to do these operations," he said.
When training today, doctors have to show on a simulator that they can do an operation that can be done in 90 minutes within that time frame before they are allowed to do the operation on a patient.
Risks
According to Dr. Knowles, every anesthetic carries a risk of complication. He also said that occasionally the tools used to carry out the operation may damage internal organs in the chest or abdomen, but with the development of ports to which a video can be attached, the risk of damage has been reduced. When using the ports, the patient's abdomen has to be inflated using CO2; according to Dr. Knowles, there hasn't been any evidence to show that doctors should not be using CO2 as an inflator. But, he said, with laparoscopic surgery, the risk of infection is much smaller, because the wound is smaller.
Patient positioning
During laparoscopic surgery, Dr. Knowles said patient positioning is important and that doctors do not want to put their patient in the wrong position, to then have to struggle to keep repositioning them during the surgery. He also said that patient security is of utmost importance.
"Mostly in neonates and small kids we go right through the belly button, so when you're done and you stitch up the belly button, you never even knew they had a surgery. Whereas in the adult, we make our incisions further down because the camera is bigger so you can't use the umbilicus. And we're very cautious when we do it, because as you go in there are bowels and internal organs that you can damage, so we're very cautious, because the big issue with small kids is space. In adults you have bigger abdomens, but with kids it's a very small space, so you have to be cognizant of this."
As a surgeon he said before the surgery, they have to know the steps and position themselves and their team in position so that everything is a smooth transition during the procedure.
Alternatives
"All operations carried out as keyhole surgery can also be carried out using open surgery, with a larger incision," said the doctor. "Or we do this freaky thing -- robotics. You never think of robotics until you see it or do it. And a lot of people are doing it -- especially in Hong Kong, Singapore and the United States. Robotics is like laparoscopic surgery, but it's more precise. Unfortunately, the robot is $1 million dollars and it's still patented."
Dr. Knowles who was exposed to robotics at Boston Children's Hospital in pediatric urology said the robot's dexterity makes it precise.
MIS is not new to medicine and certainly not to The Bahamas. The technique has been available in North American in the last 20 years, and was brought to the country approximately 15 years ago by doctors Charles Diggiss and Locksley Munroe. The procedure took off with adult patients, according to Dr. Knowles, but he said it was not really sought in children. He is hoping that with obtaining the necessary instrumentation that they can start doing minimally invasive surgery in children.
Dr. Knowles has trained with world leaders in MIS surgery at King's College in London, at the Red Cross War Memorial Children's Hospital in Cape Town, South Africa and in Germany.
He said MIS is a developing field and that as technology improves, he said they will get better.
"I think it is safe. It is effective on most operations ... there are some that require a lot of training and we should not be cowboys just because we feel we're surgeons. We should not be putting kids' lives at risk. But we need the expertise and experience, so hopefully in a few years, we have a lab where we're training young surgeons to do these," he said.
During Dr. Knowles' training he said before he did any complex minimally invasive surgery that he went into a lab to warm up for about an hour or two, which he said helped a lot and allowed him and the other doctors to be more aware.
"You don't do it [warm up] too long so you get tired, but you do it so you remember the steps and you remember the tough steps so when you actually go with the real child, you know what you're doing," he said.
"I think laparoscopic and robotic surgery is the future -- you're seeing it more and more -- no one does an open appendisectomy anymore, except where you can't afford to purchase the equipment. I think it's the future not of pediatric surgery, but surgery in general," said Dr. Knowles.
"Surgery is very difficult open, and very difficult thoracoscopically, it's a steep learning curve, but once you get it the view is so good, you won't go back to doing open surgery. When you do open surgery, you can only see what's in front of view, but when you do laparoscopic surgery, you can actually see what's behind as well," he said.

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