The importance of minimal invasive pediatric surgery

The importance of minimal invasive pediatric surgery explained by a doctor who has performed thousands of such procedures

Professor Burak Tander, a doctor with a huge pediatric surgery experience, is known for very difficult cases he manages to solve through minimal invasive surgery techniques. Out of almost 10.000 surgeries performed so far in his career, he has done half with a minimal invasive approach. What are the benefits of this type of surgery and when it can be used – we find the answers from the ACIBADEM Atakent expert, in the following material.

Professor Tander, tell us a little more about the minimal invasive pediatric surgery, like a definition.

Prof. Dr. Burak Tander: As pediatric surgeons, we operate all chest, abdomen and urogenital systems in diseases which require some surgical intervention. And, in time, the advanced pediatric surgery domain created the minimal invasive surgery. What does it mean? This is endoscopic surgery in children. There are many examples for minimal invasive operations such as laparoscopy, thoracoscopy, but also bronchoscopy, esophagoscopy, gastroscopy, cystoscopy, rectoscopy, colonoscopy. So, every hole or space in the body can be accessed through endoscopic way, therefore, if an operation is possible by endoscopy, then we do it by endoscopy.

What are the benefits these minimal invasive surgery methods in pediatry?

Prof. Dr. Burak Tander: There are many benefits. First, there is a cosmetic benefit. There is almost no scar on the body. The second one, but the most important one, the child can return home earlier, can be fed earlier, can go to school earlier. Also, there is less pain after minimal invasive surgery - the pain management is very important after surgeries, and when the child is operated by endoscopic manner, through a minimal invasive manner, the post-operative pain is diminished.

Is it more difficult to manage a minimal invasive surgery in a child than in an adult?

Prof. Dr. Burak Tander: Yes, absolutely yes! The main problem with children is the difficulty of the endoscopic minimal invasive operations because the space in children’s bodies, the space in which we should operate is sometimes too small to make the surgery and therefore we have special instruments, very small size instruments and also special, different methods. And the learning curve - the rate of a person's progress in gaining experience or new skills - for these operations is very long in children. Fortunately, we have quite a good experience in minimal invasive surgery and almost all operations which can be managed by minimal invasive methods are operated by our team here in ACIBADEM Atakent Hospital.

You have mentioned the experience importance - what are the risks of performing a minimal invasive operation in a medical center with less experience?

Prof. Dr. Burak Tander: The complications’ management in a surgery is much more challenging in minimal invasive methods. I can give you an example. If you operate a child by laparoscopy and a sudden bleeding happens, you cannot manage this bleeding easily when compared to open surgery. In open surgery, you put a finger and press the bleeding point and the bleeding stops. But in minimally invasive surgery it is impossible. Therefore, you need some experience. First, an experienced minimal invasive pediatric surgeon does not cause bleeding problems easily, and, secondly, if there is a bleeding, an experienced surgeon can manage it. And therefore, we always say that experience is the most important thing in minimal invasive pediatric surgery.

Let’s also talk about different diseases, diagnosis, which the minimal invasive surgery can be an approach for, and for the ones that can’t.

Prof. Dr. Burak Tander: In theory, almost 90% of surgical problems can be treated by endoscopic surgery. But this is only in theory. Some tumors cannot be managed by endoscopic surgery such as neuroblastomas, most of neuroblastomas, because, as I have said before, these are more invasive on the tissues area and therefore there are too many blood vessels and they bleed a lot if you use endoscopic surgery. But some neuroblastomas can be managed by laparoscopy. In small infants, in babies less than 1 year of age, and if the neuroblastoma is not too large, I can perform it by laparoscopy.

Some traumas cannot be managed by laparoscopy, especially bleeding traumas, traumas of spleen and liver mostly cannot be managed by laparoscopy. Many inborn defects, congenital digestive system anomalies either can’t be managed by laparoscopy or can be managed by laparoscopy only, but through the so-called laparoscopy assisted open surgery. Actually, I can list the surgical problems which we use mostly laparoscopy or thoracoscopy. When we start at the chest, congenital problems of the chest, for example esophageal atresia, it can be managed by thoracoscopy or cannot, we need to decide on a patient, on the patient status. Mediastinal cysts, also congenital cysts, can be managed by thoracoscopy. Two weeks ago, I performed a large mediastinal cyst by thoracoscopy in a small infant; the empyema thorax system, infection at the thorax, can be managed by thoracoscopy. Some tumors can be managed by thoracoscopy, also some small neuroblastomas, some benign tumors can be managed by thoracoscopy and congenital diaphragmatic hernia, especially Morgagni type hernia, the retro-sternal hernia can be managed by thoracoscopy or laparoscopy.

In abdomen, appendicitis, gastroesophageal reflux, intussusception, invagination of the bowel, the small bowel, into the large bowel, can be managed by laparoscopy. All ovarian cysts and tumors can be managed by laparoscopy, some tumors are managed by laparoscopy and insertion of peritoneal catheters, all peritoneal catheters, not just dialysis catheters, also ventricular peritoneal shunt catheters can be inserted by laparoscopy. Some bowel problems, bowel resections can be managed by laparoscopy, also bariatric surgery, surgery for obesity are managed by laparoscopy, some liver problems are also treated by laparoscopy, some liver cysts, liver biopsies, diagnosis for liver problems and also biliary problems, especially cholecystectomies, gall bladder stones are managed always by laparoscopy and splenectomies, removal of the spleen, is performed by laparoscopy. Exploration of the undescended testes, abdominal testes, is a good indication for laparoscopy. Yes, the most common problems which are managed by endoscopy are these problems, but also some vesical-urethral reflux, reflux of the urine from the urinary bladder to the kidney, this can be also managed by laparoscopy in some methods. Also, diagnostic laparoscopy is important sometimes, even when abdominal pain cannot be managed, cannot be diagnosed by any laboratory or imaging studies and the only way to find a diagnosis is through laparoscopy.

What about inguinal hernia? Do you recommend a laparoscopic intervention in this diagnosis?

Prof. Dr. Burak Tander: There is a big debate on the management of the inguinal hernia repair. Some pediatric surgeons prefer laparoscopic management, some do not. I do not prefer it. Why not? Because of the risks of the laparoscopy, because there is almost no risk for the open surgery on inguinal hernia. Almost no risk. But there are some risks of the laparoscopy, especially trauma on the spermatic cord, funiculus spermaticus, that is a risk of laparoscopic surgery. The second reason why I do not use laparoscopy in inguinal hernia is the invasiveness of the procedure. What’s the reason for “laparoscopy”? Minimal invasive surgery, arguably. And then we should ask the question: is laparoscopic repair of inguinal hernia more invasive than the open repair method? I think laparoscopic repair is more invasive. Why? Because in laparoscopic repair we make an invasion to the abdominal space, in the peritoneal cavity. But in open repair, we just make an invasion of subcutaneous tissue, under the skin. Therefore, I think open repair is less invasive in inguinal hernia in children. Because of these reasons, I don't prefer laparoscopic repair of inguinal hernia. And also, there is almost no cosmetic advantage of laparoscopic surgery of inguinal hernia repair because the open repair of inguinal hernia causes just one-centimeter scar, and in laparoscopic surgery you have a similar size scar.

So, there are some cases in which open surgery is less invasive than laparoscopy.

Prof. Dr. Burak Tander: Yes, this is actually a philosophic discussion, but more pediatric surgeons repair the inguinal hernias through an open access.

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