Small Wonder: Minimally Invasive Surgery Video

Minimally Invasive Surgery - Introduction

Tammy Maysonet, Mother: We have a two-year-old, Alexa, and we also have a 10 1/2-month-old, Ulysses.

Alex Maysonet, Father: When Alexa came along, it was kind of like a, well, a whole new level that we went to.

Tammy Maysonet, Mother: And it was just a whole new learning experience. Within a month she had only gained a few ounces. And she had actually started vomiting.

Alex Maysonet, Father: But it just kept getting worse, and we started noticing that she would turn really blue when she started crying.

Tammy Maysonet, Mother: She ended up getting admitted to CHOP, and they discovered that she had interstitial lung disease. That's when they started to talk about surgery.

N. Scott Adzick, MD: When a family is referred here and the child needs an operation, a big operation, that's an incredibly scary prospect, not only for the child, if they're old enough to understand this, but particularly for the parents.

Alan Flake, MD: One of the difficult things that we do is tell families and parents that their child needs a major operation. That, by its very nature, is a frightening thing.

N. Scott Adzick, MD: And if we can treat that child with a minimally invasive technique that will minimize scarring, minimize potential psychologic trauma, shorten the hospital stay -- you can see the sense of relief.

Alan Flake, MD: So what minimally invasive surgery does is, I think, it reduces that degree of fear of surgery.

Thane Blinman, MD: Being able to reassure the parents that their child is not going to have a huge scar, for example. That their child's not going to spend days and days in pain. That their child will, pretty much, look the way they looked when they started off really goes a long way to allaying those parents' fears.

Minimally Invasive Surgery - The Basics

Alan Flake, MD: Minimally invasive surgery could be defined as surgery that's less invasive than the old large-incision open surgery.

Susan Scully, RN: It's surgery that you do through tiny little holes with specialized equipment.

Alan Flake, MD: Very, very small incisions that we put scopes and instruments through to do the large operations that we used to do through big incisions.

Thane Blinman, MD: It's had all kinds of different names during history — thoracolaparoscopy, general endoscopic surgery, Band-Aid surgery, keyhole surgery, scarless surgery -- all kinds of different names for it. We call it minimally invasive surgery.

Alan Flake, MD: The two main types of minimally invasive surgery are laparoscopy, and that's were we operate in the abdominal cavity.

Thane Blinman, MD: So laparoscopy is looking inside the abdomen with a telescope.

Alan Flake, MD: And the other is thoracoscopy.

Thane Blinman, MD: Thoracoscopy means looking into the thorax, the chest.

Alan Flake, MD: There have been many principles in open surgery that have been developed over the years that really allow it to be done safely.

Thane Blinman, MD: All these principles that we've used count even more in minimally invasive surgery.

Alan Flake, MD: How you achieve those goals is what's different about minimally invasive surgery.

Thane Blinman, MD: That means, not that we replicate every step exactly the same way, but that the mechanical result is at least as good-and in many circumstances the result is a lot better.

Alan Flake, MD: There are many benefits to having minimally invasive operations.

Thane Blinman, MD: The first advantage, of course, is that the incisions are a lot smaller.

Alan Flake, MD: So you have less pain immediately after the procedure. You don't have the amount of muscle that you've divided and the large incisions that used to be very painful.

Thane Blinman, MD: We can do our operation with a great deal of precision, and that's the next thing.

N. Scott Adzick, MD: The optics and the magnification are a huge advantage for minimally invasive approaches. Frequently, when we do open operations in kids or in babies, we wear magnifying loupes that magnify things by a factor of usually three and a half to four.

Thane Blinman, MD: Minimally invasive techniques give us 20 or 30 times magnification. We can see a lot more, and we're not just looking from the top. We can see from the side. We can look underneath. We can go around corners. We can see things we never saw before on the open cases, and that lets us operate with a great deal of precision.

N. Scott Adzick, MD: Plus you're leaving organs in their natural position. You're not manipulating them to bring them in or out of the abdomen or things of that sort. So the optics are fantastic.

Alan Flake, MD: Certainly, if you have three little 5-millimeter incisions, you recover much more quickly than if you have a 12-inch-long incision. Not only do you have less pain in your recovery, but your intestine begins to work more quickly. You're functionally recovered much more quickly than you are with large incisions.

Susan Scully, RN: The worst thing is to see your child in pain. So, if we can do a surgery that would have caused a week of pain, and now they're only going to be in pain for two days, that has to be one of the best things for a parent to hear.

Alex Maysonet, Father: My mind is going years ahead of me. You know, and it's like -- Wow. Is this going to be, like, a really big surgery? Is she going to have huge scars? Is this something that she's going to be affected with psychologically?

N. Scott Adzick, MD: Than cosmetic result, the appearance, is dramatically better than, say, a big cut with a big scar in the abdomen. There's just no comparison.

Alan Flake, MD: And so I think the cosmetic benefits are real. And I think they're important psychologically for people as well as, to some degree, functionally.

Alex Maysonet, Father: I think she's had bigger scratches now than --

Tammy Maysonet, Mother: Than her incisions.

Alex Maysonet, Father: -- than her incisions.

Susan Scully, RN: To be able to do what they do in such a small space with very little pain and very little healing time for kids, I think, is what we're here to do.

Minimally Invasive Surgery - Step by Step

Thane Blinman, MD: The first step of a laparoscopic procedure, that is a minimally invasive surgery in the abdomen, is placement of the trocars.

Alan Flake, MD: A trocar is a hollow tube. It has a valve at the top so that gas can't leak through it. It has an insertion in the middle with a sharp point so that you can actually introduce it through the tissue, into the abdomen or the chest, and then you remove the insert, and that leaves you with a one-way valve that you can put instruments in and out of.

Thane Blinman, MD: We'll place the first one, almost always, in the belly button, and that creates an air lock so that we can inflate the abdomen with carbon dioxide gas. That gives us room to work.

Alan Flake, MD: By insufflating gas, you can actually raise the abdominal wall away from the structures you are working on, and it allows you to do the operation.

Thane Blinman, MD: Carbon dioxide has a lot of virtues. However, it's very dry, and that dry gas that's cold can be dangerous to the baby.

N. Scott Adzick, MD: We want the baby kept warm, not only on the outside, but also on the inside.

Thane Blinman, MD: So we use gentle, warm, humidified carbon dioxide in the babies. And that really cuts down on their pain and removes the danger of hypothermia. The next thing we do is we place a telescope. It's a metal rod with glass lenses, and at the end of that telescope is a high-definition camera. Right in that telescope are fiber optic fibers that draw light from an external power source and very brightly light up the abdomen.

Alan Flake, MD: You need to put in your ports in appropriate sites so you have your instruments at the correct angles and the correct position to do that operation.

Thane Blinman, MD: We'll actually look up at the abdominal wall with the camera and watch those trocars come in.

N. Scott Adzick, MD: Usually, there are four port sites -- one at the belly button, two on each side above the level of the belly button, and then oftentimes a fourth port to retract the liver.

Thane Blinman, MD: And we can see what the camera sees by way of these monitors that hang down right in front of the patient, and we can just look right there, sort of like watching high-definition television. We also have to watch the pressures that we use on the babies. We can't use anything like the kinds of pressure in the abdomen that we can in an adult.

Alan Flake, MD: The problem with using too much pressure is that you can inhibit breathing. You can put pressure on the diaphragm and make it harder to ventilate the patient during surgery.

Thane Blinman, MD: So we've had to modify our technique to use much lower pressures, much lighter instruments, lighter, thinner trocars, and even the way the surgeons hold their hands. You can't just rest things on the patient anymore. You've got to lift up. And that allows us to protect the baby and use those very low pressures.

When we're operating in the chest, the technique is a little different.

Alan Flake, MD: You have ribs. You have muscles of the chest wall. So you don't really have much mobility of your ports or your instruments once those ports are placed. And that's very different from laparoscopy, where you have much more mobility within the abdominal wall to move your instruments.

N. Scott Adzick, MD: Any operation in the chest is a bit more challenging because there's less space in the chest.

Thane Blinman, MD: The thoracic cage is rigid by design. And that means there's no inflating the thoracic cage to give us a little bit more elbow room.

Alan Flake, MD: So instead of that, what you have to do to make space is that you have to ventilate just one of the lungs, and that allows the other lung to decompress, or deflate. And that creates a tremendous amount of room in the thoracic cavity. The way that we do that is by placing the endotracheal tube, the tube that you breathe for the patient through, into either one bronchus or into the other bronchus depending on which lung you're working on.

Thane Blinman, MD: Of course, the baby is still breathing with the other lung, and humans have enough reserve so that using just one lung for the time of the operation is really no problem.

Alan Flake, MD: Our anesthesia teams at CHOP are very, very experienced with single-lung ventilation in infants, and it's a very, very safe procedure to be done in the right hands.

Thane Blinman, MD: We'll put the trocars in the same way. But when we place the first trocar, we've got to use a modification of that technique so that the trocar is very blunt because we don't want that to damage the lungs we're placing in there. After we've placed that first one, we do still use a little carbon dioxide gas, but not nearly as much as we would use in the abdomen. Because we can't squeeze on the chest organs the same way we can squeeze a little bit on the abdominal organs.

Alan Flake, MD: We position the baby on its side, and we turn the front of the baby downward so that the lung will drop forward. We put in three ports. We put the scope port up above the two instrument ports at the appropriate level of the chest wall placing the ports between the ribs, and that allows us to look down on our instruments and look down on the field while we're operating just like you would if you were looking down on your hands in an open operation. If you have everything set up correctly, then you're in a perfect position, perfect alignment, to do the operation as well as you could possibly do it using open techniques.

Thane Blinman, MD: We're routinely operating inside of volumes that are the size of a matchbox or a child's medicine cup.

Alan Flake, MD: So that's a very small area to work in, and it requires a different instrumentation and actually a different technical approach to do those operations.

N. Scott Adzick, MD: We can sew and cut and tie knots and all those things through those ports.

Thane Blinman, MD: The tiny little tools that we use in the babies and the children are far more delicate than other surgical tools.

Alan Flake, MD: The laparoscopic instruments or thoracoscopic instruments are really patterned after the instruments we use in open surgery, and those have been perfected for centuries by surgeons. You put your hands into the rings of the instrument, and you, basically, can open and close the instrument, dissect with the instrument based on these handles that you have outside of the abdomen or the chest.

Susan Scully, RN: We have cameras in the lights so that you can watch the procedure. We have the camera on the screen that is imperative for the surgeon because that's all he looks at is the screen.

Alan Flake, MD: It's a remote-controlled sort of a system that's very different from actually being inside the abdomen or inside the chest and directly applying the instrument, and it takes a little getting used to. Everyone in the room is familiar with both the minimally invasive approach for a particular operation as well as the open approach.

Thane Blinman, MD: It is routine at CHOP now to set up the room with the instruments we need for both methods.

Alan Flake, MD: So, if we have to convert an operation from minimally invasive to open, everyone there is appropriately trained to do the procedure. And it's an easy transition, and one that's safe for the child.

N. Scott Adzick, MD: When the operation is finished, all those -- the instrumentation is all removed, and you have these little tiny 3-, 4-, 5-millimeter sites, just a fraction of an inch, that can then be closed with a plastic surgical-type closure so there's no stitch on the outside. We use numbing medicine, local anesthesia, at the beginning for each of those port sites.

Thane Blinman, MD: Because we've learned that if we numb up the skin and the subcutaneous tissues before placing the trocar, the pain after the baby wakes up is a lot less.

Minimally Invasive Surgery - Tools, Technique

Thane Blinman, MD: When we first started minimally invasive surgery at CHOP, we could pretty much do appendectomies, pyloromyotomies for pyloric stenosis, and maybe a few other minor things.

N. Scott Adzick, MD: We now do everything that can be done in a proper manner with a minimally invasive approach.

Thane Blinman, MD: We can take out defective lobes of the lung. We can repair the esophagus. We can remove duplication cysts. We can fix reflux disease. In fact, CHOP offers over 100 different procedure codes for minimally invasive procedures alone.

Alan Flake, MD: In the old days we would think about doing a procedure open. Now we always think about, "Can we do this minimally invasively?"

Thane Blinman, MD: Having a team is critical to making this work the right way.

Susan Scully, RN: Teamwork is the most important thing that we do here.

Thane Blinman, MD: The reason that we can do all those different procedures in the daytime and the nighttime, on the weekday or on a weekend is that all the nurses are very, very well trained in these techniques.

Susan Scully, RN: Without the instruments and without the things that we put in place, they couldn't do their surgery. So basically, as the specialty nurse, I have to make sure that the instruments we have are functional, and that we have the instruments that each different doctor needs for each different surgery that he does.

Thane Blinman, MD: She had to learn how every single one of those things worked and then teach that to all the other nurses in the operating rooms.

N. Scott Adzick, MD: So that we can have that sort of quality 24 hours a day, 7 days a week.

Alan Flake, MD: Minimally invasive surgery is a very technical endeavor. You're dependent on high technology to do the procedures.

N. Scott Adzick, MD: You need an industry partner here on site to help you solve these problems in real time.

Thane Blinman, MD: And that's where Lem comes in. Lem is like a secret weapon. Lem is like our ace up the sleeve.

Lemuel White, On-site Endoscopic Specialist: Where the nurse is concerned with the patient, my job is to be concerned with that room. It's a unique position. There's not too many on-site technicians in the country.

Alan Flake, MD: Like any complex electronically driven system, you can have breakdowns in that system. You can have glitches that occur, and they can during surgery or before or after surgery.

Lemuel White: Once the rooms are up and running, we then move on to the instruments.

Thane Blinman, MD: Our instruments have tiny little moving pieces. Very, very fine action at the tips, and they're -- they're just delicate. They don't last nearly as long as the open kind of tools do. And, as a consequence, we've got to really pay attention to make sure that the tools that we're using are still in good working order.

Lemuel White: You're constantly cleaning, oiling, maintaining, adjusting, tightening all these instruments, and making sure this equipment, every case, is just like new.

Thane Blinman, MD: Porsche perfect for every procedure, for every baby, every single time. Very often we find that the tools we use don't work exactly the way we want it to. Some of the things were designed perfectly for the babies, but most of the things weren't designed for children. And we've adapted their use, but even those will have problems.

N. Scott Adzick, MD: You have to get industry to play along because they have the horsepower to make the things that you need. So we generate the ideas. They generate the instruments.

Thane Blinman, MD: And we can give them very specific recommendations. Your tool would help us if it did this.

Lemuel White: Having that innovation done here translates out into the field in all the other hospitals.

Susan Scully, RN: Kids wouldn't survive as well, or do as well, if we didn't have the teams that we have and if we didn't communicate the way we do.

Thane Blinman, MD: There are nine general surgeons on the staff here and all of them use minimally invasive techniques in their practices. Moreover, some of the urologists are now using these methods, including the robot. Some of the neurosurgeons use some of these techniques, even using minimally invasive surgery in the head. The ear, nose and throat doctors have always used different scopes, but now they have different tools that they use. And, of course, the orthopedic doctors are using arthroscopy, or looking into the joint, that way. So, essentially, this has become a very normal part of what we do at CHOP.

Minimally Invasive Surgery - What's Ahead?

Alan Flake, MD: It's a very challenging proposition to educate young surgeons, teach young surgeons to do these minimally invasive procedures.

N. Scott Adzick, MD: We're fortunate to be able to attract a world talent pool of trainees.

Thane Blinman, MD: CHOP now has a real unique combination of expertise when it comes to disease and expertise when it comes to technique that allows us to take care of common diseases and rare diseases using really innovative methods.

N. Scott Adzick, MD: In my experience, many of the new ideas and innovations come from determined, smart folks who come from around the world to train here.

Thane Blinman, MD: Once they've become experts in minimally invasive technology, well it's very easy to marry that knowledge of these rare diseases to these new techniques and not just anyone can do that. It takes practice, and it takes familiarity with not what goes right, but what can go wrong.

Tammy Maysonet, Mother: I actually had the same surgery as Alexa 30 years ago. It was nothing compared to what it is now. My incisions are there to stay, and they're very big. Alexa and Ulysses' incisions you'll barely see when they grow up. But the biggest one, they'll never have.

N. Scott Adzick, MD: Minimally invasive approaches are going to play a bigger and bigger role in things that we do every day.

Alan Flake, MD: We do most procedures now, at least some proportion of them, by minimally invasive technique. But what's, I think, going to happen in the future with minimally invasive surgery is we'll learn to do it better.

Thane Blinman, MD: It's appropriate that these more advanced methods for minimally invasive surgery are being done here.

N. Scott Adzick, MD: CHOP is one such place to serve as the platform for future innovation and creative developments to enhance the care of children using minimally invasive techniques. With persistence and imagination, we can accomplish virtually anything.