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Children's Hospital offers minimally invasive surgery


by Heather Woolwine
Public Relations
MUSC’s Children’s Hospital is among the few hospitals nationwide with the expertise to perform laparoscopic and thoracoscopic procedures in neonatal intensive care unit (NNICU) patients. It is the only hospital able to perform them in the state.
 
Brandon Demiress, now 1 month old, was the first patient to receive a minimally invasive procedure to correct his esophageal atresia (EA) and tracheoesophageal fistula (TEF). The devastating effects of EA/TEF strike one out of every 4,000 children. Born with an obstructed proximal esophagus, children like Brandon cannot ingest milk. Instead of connecting all the way to the stomach, the proximal esophagus stops like a dead end street. At the other end, the distal esophagus is incorrectly connected to the trachea. This causes gastric fluid to reflux into the lungs, which can be fatal. Diagnosis of the condition usually comes when the infant spits up all nourishment, or aspirates it into the lungs.
 
Traditionally, surgically repairing EA/TEF involved disconnecting the distal esophagus from the trachea and reconnecting the two sections via a thoracotomy. This was done with a large chest incision extending from the nipple back toward the spine. The resulting incision caused significant pain, a cosmetically unappealing scar and potential long-term musculoskeletal problems such as scoliosis or other chest wall deformities.
 
Advanced surgical methods used at MUSC have eliminated these negative outcomes.
 
“We’ve been able to rapidly advance our abilities in minimally invasive surgery performed on newborn patients, joining the few centers around the world that are routinely performing these advanced procedures upon NNICU patients,” said Edward Tagge, M.D., Division of Pediatric Surgery director. “The thoracoscopic EA/TEF repair is one of the most technically demanding operations, requiring advanced endosurgical skills and specialized equipment. There are only a handful of children’s hospitals in this country that are repairing EA/TEF thoracoscopically, and MUSC is the first in South Carolina.”
 
The new, minimally invasive treatment that Brandon received requires three incisions, each about the size of a bug bite. The procedure is performed with instruments 3mm in diameter. The result is virtually no scarring; there is minimal pain, and recovery time is faster. However, in order to have a successful outcome, all involved clinicians must work as a team. “The procedure requires great cooperation between the surgeon and anesthesiologist, as it is essential to collapse one of the child’s lungs in order to provide enough room to repair the esophagus,” Tagge said. “Equally as important to the team are the surgical residents and operating room nurses, who make enormous contributions intra-operatively, the neonatal nurse who accompanies the child to the operating room, and the entire neonatal team which is actively involved in the important post-operative period.”
 
Brandon’s mother, Olga Garcia, said that she also felt a part of the team working to change his future.
 
“I want to thank the hospital, the whole team, the NNICU, and especially Dr. Tagge,” she said. “He explained everything very well. He explained both procedures to us, and he was very confident that he could do it. He felt good about it, and that made us very relieved and thinking it was the right thing.” 
 
Tagge emphasized that performing these  complex procedures is possible because of increased clinical experience with other complex cases, in conjunction with the development of miniaturized equipment designed especially for newborns. He also felt that the family understood the weight of their decision. “Brandon’s parents were very supportive. We told them that this hadn’t been done at this hospital before, and thus offered them the choice between the minimally invasive procedure and a standard thorocotomy. They seemed to feel very strongly that the minimally invasive procedure was the choice they preferred,” he said. “Prior to the surgery, Brandon’s father bathed my hands in holy water and essentially gave his blessing. They were eager to do what they felt was best for their son.”
 
Brandon’s surgery went very well, and he was soon home, tolerating breast milk without a problem. According to Garcia, he has slept through the night, from about midnight to 6 or 7 a.m. each night. She said she knows that she’s a lucky mom, and wants her family’s experience to serve as a message to others. “We want everyone to know that if you do something like this, you are helping everyone by helping to improve medical care,” she said. “That’s the only way it progresses.”

Minimally invasive procedures set MUSC Children’s Hospital apart

In most surgical specialties, a limited number of procedures are frequently performed. Unlike many other surgeons, pediatric surgeons perform more than 150 different procedures, and most of them only occasionally due to their low incidence, said Edward Tagge, M.D., professor of surgery and pediatrics. Therefore, accumulating experience to perform advanced minimally invasive procedures takes time, and that expertise must be matched with specifically-designed instrumentation and technology. Teamwork is essential, and is perhaps the primary component to perform an advanced minimally invasive procedure successfully.
  Up to this point, minimally invasive techniques in the NNICU have been limited to laparoscopic fundoplication in large babies: laparoscopic-assisted pull through for Hirschsprungs disease; and laparoscopic visualization of opposite side during inguinal hernia surgery.
 
In the last six months, however, Tagge and his team have performed a remarkable number of advanced minimally-invasive procedures on newborn infants, including the EA/TEF repair mentioned in the adjoining story. In fact, several of these procedures had never been performed in South Carolina.
 
“These cases are all considered advanced laparoscopic cases due not only to the small size of the child (and thus small working space), but also to the difficulty of the technical maneuvers required and the delicate nature of the infant’s cardio-respiratory physiology,” Tagge said.
 
In addition to the thoracoscopic EA/TEF repair procedures, Tagge has performed:
  • Thoracoscopic repair of a congenital diaphragmatic hernia (CDH) in a 3-week-old child. The child went home the day after surgery.
  • Combined laparoscopic and thoracoscopic repair of an incarcerated CDH in a 6-week-old patient.
  • Laparoscopic repair of a high imperforate anus in a 2-month-old. This procedure required no division of the sphincter mechanism, which is usually done.
  • Laparoscopic repair of a variant of duodenal atresia in a 2-week-old.
  • Laparoscopic fundoplication in a premature infant weighing 1.8 kg.
  • Laparoscopic fundoplication in an infant with hypoplastic left heart syndrome.
 
Tagge said the minimally invasive management of this varied group of patients in such a short period of time was the result of several circumstances. “We’ve been able to achieve these results because of improved instrumentation; improved anesthesia facility with effects of insufflation on neonatal physiology; active involvement of the NNICU team; and ever-increasing aggressiveness of our surgery team to apply minimally invasive techniques,” he said. “In these and in future cases, minimally invasive techniques offer major advantages versus open surgery in terms of immediate recovery from surgery, less pain, the lack of long-term sequelae and the improved cosmetic appearance.”

   

Friday, July 13, 2007
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