Small Wonder - Minimally Invasive Surgery Videos

Transcript: Step by Step

Transcripts in This Video Series
Introduction The Basics Step by Step Team, Tools, Technique What's Ahead?

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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 ofttimes 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.