Pediatric Annals

EDITORIAL 

A Pediatrician's View: Pediatric Endoscopic Surgeons: New Kids on the Block

Robert A Hoekelman, MD

Abstract

This issue of Pediatric Annals has as its Guest Editor George W. Holcomb, III, MD, Assistant Professor of Surgery and of Pediatrics at Vanderbilt University Medical Center. Dr Holcomb, who completed his pediatric surgical residency training just 5 years ago, is one of this country's pioneers of pediatric endoscopic surgery. This is not surprising, given that the techniques of performing pediatric endoscopic surgery have been taught only recently and then mostly to residents in training.

The subjects covered in the articles herein pertain to laparoscopic (peritonescopic) and thoracoscopic surgical procedures performed on children. I must confess, I was unaware of most of these procedures; I am sure that most of our readership is in the same boat. This is so for two reasons. First, Dr Holcomb estimates that, at best, only a third of our university medical centers currently perform these procedures; thus, most of us have not been exposed to them. (This represents tremendous growth; 5 years ago, only a handful of medical centers in this country performed laparoscopic and thoracoscopic surgery on children.) Second, essentially nothing has been published about these endoscopic surgical techniques in the books and journals that pediatricians usually read. None of the four major pediatric textbooks published since 1991 mention them,1'4 nor do any of the pediatric surgery textbooks published prior to 1993. Further, up to the year 1992, only one article about pediatric laparoscopic surgery had been published in all the pediatric journals usually read by pediatricians American Journal of Diseases in Children, Clinical Pediatrics, Contemporary Pediatrics, Journal of Pediatrics, Pediatric Annals Pediatrics, and Pediatrics in Review), and that article was published in 1992,5 (albeit a letter to the editor published in 1991 described a case of laparoscopic cholecystectomy performed under epidural anesthesia on an adolescent who had cystic fibrosis6). No articles have been published about pediatric thoracoscopic surgery in these journals. Much has been written about pediatric laparoscopic surgery in the Journal of Pediatric Surgery beginning in 1989, but nothing about thoracoscopic surgery. Since most of us don't subscribe to or read that journal, we have a lot to learn. This issue of Pediatric Annals and two pediatric surgical textbooks published this year,7,8 including one edited by Dr Holcomb, should help us.

Dr Holcomb and his coauthors tell us about performing appendectomies, cholecystectomies, splenectomies, gastrostomies, fundoplications, and pyloromyotomies laparoscopically. They also tell us of using laparoscopy to determine the presence or absence of a contralateral inguinal hernia, and the presence or absence of an undescended testicle, its location, and its operability, in terms of orchidopexy. Besides the diagnostic information gained laparoscopically about an undescended testicle, operative ligation of the testicular artery and vein as a first-stage procedure to allow for performing an orchidopexy later can be accomplished using this method. Laparoscopic repair of liver and spleen lacerations using fibrin glue also has been successful,9 as has detorsion of adnexa in a prepubertal girl.10 In addition to enabling these surgical procedures, laparoscopy has helped for many years diagnostically, allowing visualization of appendices, the liver, the biliary tree, and abdominal masses, and with it, biopsies and cholangiograms, when indicated.11

So, too, has thoracoscopy helped diagnostically, allowing visualization of the lungs, the pleural spaces, and the diaphragm, and biopsy of pulmonary and other intrathoracic lesions. Thoracoscopy-enabled surgical therapies include lysing adhesions, draining chylous fluid, sclerosing visceral and parietal pleural surfaces, removing intrathoracic tumors and cysts, performing sympathectomies, thymectomies, and pericardiectomies, as well as ligating patent ductus arterioses.

The use of endoscopy for diagnosis and treatment is not new to medicine. Laryngoscopy, bronchoscopy, esophagoscopy, gastroscopy, cystoscopy, colcoscopy, and sigmoidoscopy have been with us for many, many…

This issue of Pediatric Annals has as its Guest Editor George W. Holcomb, III, MD, Assistant Professor of Surgery and of Pediatrics at Vanderbilt University Medical Center. Dr Holcomb, who completed his pediatric surgical residency training just 5 years ago, is one of this country's pioneers of pediatric endoscopic surgery. This is not surprising, given that the techniques of performing pediatric endoscopic surgery have been taught only recently and then mostly to residents in training.

The subjects covered in the articles herein pertain to laparoscopic (peritonescopic) and thoracoscopic surgical procedures performed on children. I must confess, I was unaware of most of these procedures; I am sure that most of our readership is in the same boat. This is so for two reasons. First, Dr Holcomb estimates that, at best, only a third of our university medical centers currently perform these procedures; thus, most of us have not been exposed to them. (This represents tremendous growth; 5 years ago, only a handful of medical centers in this country performed laparoscopic and thoracoscopic surgery on children.) Second, essentially nothing has been published about these endoscopic surgical techniques in the books and journals that pediatricians usually read. None of the four major pediatric textbooks published since 1991 mention them,1'4 nor do any of the pediatric surgery textbooks published prior to 1993. Further, up to the year 1992, only one article about pediatric laparoscopic surgery had been published in all the pediatric journals usually read by pediatricians American Journal of Diseases in Children, Clinical Pediatrics, Contemporary Pediatrics, Journal of Pediatrics, Pediatric Annals Pediatrics, and Pediatrics in Review), and that article was published in 1992,5 (albeit a letter to the editor published in 1991 described a case of laparoscopic cholecystectomy performed under epidural anesthesia on an adolescent who had cystic fibrosis6). No articles have been published about pediatric thoracoscopic surgery in these journals. Much has been written about pediatric laparoscopic surgery in the Journal of Pediatric Surgery beginning in 1989, but nothing about thoracoscopic surgery. Since most of us don't subscribe to or read that journal, we have a lot to learn. This issue of Pediatric Annals and two pediatric surgical textbooks published this year,7,8 including one edited by Dr Holcomb, should help us.

Dr Holcomb and his coauthors tell us about performing appendectomies, cholecystectomies, splenectomies, gastrostomies, fundoplications, and pyloromyotomies laparoscopically. They also tell us of using laparoscopy to determine the presence or absence of a contralateral inguinal hernia, and the presence or absence of an undescended testicle, its location, and its operability, in terms of orchidopexy. Besides the diagnostic information gained laparoscopically about an undescended testicle, operative ligation of the testicular artery and vein as a first-stage procedure to allow for performing an orchidopexy later can be accomplished using this method. Laparoscopic repair of liver and spleen lacerations using fibrin glue also has been successful,9 as has detorsion of adnexa in a prepubertal girl.10 In addition to enabling these surgical procedures, laparoscopy has helped for many years diagnostically, allowing visualization of appendices, the liver, the biliary tree, and abdominal masses, and with it, biopsies and cholangiograms, when indicated.11

So, too, has thoracoscopy helped diagnostically, allowing visualization of the lungs, the pleural spaces, and the diaphragm, and biopsy of pulmonary and other intrathoracic lesions. Thoracoscopy-enabled surgical therapies include lysing adhesions, draining chylous fluid, sclerosing visceral and parietal pleural surfaces, removing intrathoracic tumors and cysts, performing sympathectomies, thymectomies, and pericardiectomies, as well as ligating patent ductus arterioses.

The use of endoscopy for diagnosis and treatment is not new to medicine. Laryngoscopy, bronchoscopy, esophagoscopy, gastroscopy, cystoscopy, colcoscopy, and sigmoidoscopy have been with us for many, many years and have served us well, entering the lumens of organs with minimal risk and invasiveness. The same may not yet be said for many thoracoscopic and laparoscopic surgical procedures. In both instances, closed cavities - the abdomen and the thorax - are entered, endoscopically, under general anesthesia; great skill in manipulating the new instruments used must be applied. Those who perform such procedures must be trained adequately and certified to conduct them. Appropriate prospective analyses of their relative safety, vis-à-vis laparotomy and thoracotomy to accomplish the same ends, must be conducted and must show that there are definitive advantages and no disadvantages to using the newer methods. So far, the advantages for most procedures include reduction in the length of hospitalization, costs, and postoperative pain, faster recovery and return to full activity, and improved cosmetic results. No disadvantages, save for expensive operative equipment and, for some procedures, increased intraoperative and anesthesia time, have been identified. But, as with any new kids on the block, we will have to wait and see how, over the long run, our endoscopic surgeons, with their new "toys" and "games," fit in. I believe they will do quite well and will expand the scope of this new form of pediatric surgery even wider.

REFERENCES

1. Oski FA, DeAngelis CD, Fergin RU Warshaw JB. Principles and Practice of Pediatrics. Philadelphia, Pa: JB Lippincott Co; 1990.

2. Rudolph AM, Hoffman JIE, Rudolph CD. Rudolph's Pediatrics. I9th ed. Norwalk, Conn: Appleton & Lange; 1991.

3. Behrman RE, Kliegman RM, Nelson NE, Vaughn VC. Nelson Textbook of Pediatrics. 14th ed. Philadelphia, Pa: WB SaundetsCo; 1992.

4. Hoekelman RA, Friedman SB1 Nelson NM, Seidel HM. Primer? Pediatric Care. 2nd ed. St. Louis, Mo: Mosby Year Book; 1992.

5. Ware RE. Kinney TR, Casey ]R, Pappas TN, Meyers WC. Laparoscopic cholecystectomy in young patients with sickle hemoglobinopathies. ) Pediatr. 1992; 1 20:58-6 1 .

6. Edelman DS. Laparoscopic cholecystectomy under continuous epidural anesthesia in patients with cystic fibrosis. Am 7 Dis Child. 1991;145:723-724- Utter.

7. Ashcraft KW1 Holder TM. ftdietrie Surgery. 2nd ed. Philadelphia. Pa: WB Saunders Co; 1993.

8. Holcomb GW III. Pediatric Endoscopic Surgery. Nnrwalk, Conn: Appleton & Lange; 1993.

9. Fibrin glue application to liver and spleen lacerations from blunt abdominal trauma. J Pediatr Surg. 1989;24:867-871.

10. Shalev E, Mann S, Rahely D. Laparoscopic detorsion of adnexa in childhood: a case report. J Pediatr Surg. 1991 ;26: 1 193-1 194.

11. Leape LL, Ramenofsky ML. Laparoscopy in children. Pediatrics. 1980;66:215-220.

10.3928/0090-4481-19931101-04

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