Recent Advances in Pediatric Surgery
By Dr Prof Iftikhar Jan
Pediatric surgery is a rapidly advancing specialty. Over the past few decades the whole spectrum of management of pediatric surgical patients has changed. The improvement has been in diagnosis, surgical management and operative care. This has resulted in the excellent outcome of most pediatric surgical conditions. The advances in pediatric surgery have helped to improve the results of common & complex pediatric surgical conditions like hernia, Undescended testes, cleft lip, cleft palate, hypospadias, intestinal surgery, thoracic surgery, urological surgery. Etc.
Circumcision is the commonest procedure performed by pediatric surgeons. Several studies have now proved without doubt that early circumcision before one month gives the best results. Use of Plastibell device for circumcision has made the procedure extremely simple. It involves placing a bell like device in the foreskin, which is tightly tied around the foreskin. The skin and device usually shed off spontaneously after 5-7 days leaving a neat scar. The procedure is performed under local anesthesia with an average operative time of 5 minutes. No dressing is required and baby can have diapers as nothing has been done. The procedure shall be avoided in children over one year as the bell may get impacted and cause problem.
Inguinal hernia repair is the second most common pediatric surgical procedure. It is considered a surgical urgency due to the chances of strangulation of an inguinal hernia. The smaller the baby the more are the risks for strangulation and irreducibility. This can cause serious damage to the intestine or other contents of the hernial sac. Surgery in babies was considered to be a high-risk procedure and thus delayed in very small babies till they achieve good weight. This resulted in many babies getting strangulation and serious consequences. Now the anesthesia and pri-operative care has become very safe for surgery on small babies therefore when the diagnosis of a hernia is made in a baby, he is admitted for surgery at first available list. Similarly the management of undescended testes has also become more standardized. For testes, which are palpable, a simple orchiopexy is required and can safely be performed as a day case. Now it is possible to perform trans-scrotal orchiopxey, which avoids a scar on the lower abdomen and equally good results. For patients who have high testis in the abdomen laparoscopy is now the gold standard to visualize the testis, evaluate their size and morphology and first stage procedure can be performed to bring down the testes at a lower position and then in second stage usually after 6 moths the testes are brought and fixed in the scrotum. If done properly and if testes are developmentally normal, this can give 70-80 percent success to have a functional testis in its place.
Hypospadias is a condition where the urethral opening is in abnormal position on the penis. The opening may be at variable places along the shaft of the penis or even in the perineum. The surgery for hypospadias used to be a nightmare for the treating surgeons and the families, due to high incidence of breakdown and failure of surgery. During the last decade management of hypospadias has been standardized with excellent results. Now most surgeons can achieve a success rate of 85 to 95% if done properly. This has been possible due to the availability of fine sutures, better operative techniques and better wound care and stents. Surgery for hypospadias may be performed as a single stage procedure or in 2-3 stages depending upon the nature of the pathology however the goal of surgery is to achieve a functional penile tissue with a straight non-obstructive urinary stream.
The most important advances in pediatric surgery have been the use of minimally invasive (MIS) techniques, which includes, laparoscopy, thoracoscopy, other endoscopic procedures and use of robotics in pediatric surgery. Laparoscopy did not gain much importance initially but in the last two decades the use of minimally invasive techniques has become a gold standard for most pediatric surgical procedures. The beauty of minimally invasive surgery is that the surgery is performed in a baby or child from very small incisions for the MIS instruments, which are usually less than 5mm in diameter. The procedures is performed using high definition cameras giving a very high quality enlarged images of the body structures. This helps in minimizing the tissue damage and better surgical outcome. MIS techniques also causes least tissue trauma therefore the recovery after surgery is quick and leaves minimal scarring which ensures early mobilization and least post operative squeal. In Pakistan unfortunately MIS has not been developed as in other developed countries. Procedures like appendectomy, diagnostic laparoscopy, thoracoscopy, treatment of mal-rotation, removal of gall bladder, surgery for Gastro esophageal reflux, pyeloplasty for obstructed kidneys, thoracic biopsies are some of the procedures, which are performed routinely in most centers. Good centers also perform procedures like esophageal atresia repair, lung resections, treatment of choledochal cyst etc. The important issue when opting for minimally invasive procedures in developing countries will be the expertise of the surgeon, availability of proper equipment and cost effectiveness. One very important concern will be proper sterilization of the laparoscopy equipment. As most components of laparoscopy are reusable, improper sterilization techniques can cause transmission of serious diseases like hepatitis. Therefore one must ensure that the equipment use is properly sterilized otherwise an open surgery is as good option unless the MIS is performed in proper institute with adequate facilities.
Robotic surgery has shown promising results in Pediatric surgery. At present facilities for robotics surgery are not available in Pakistan. The basic principle of robotic surgery is same as of laparoscopy. The Laparoscopy equipment is installed as in any Laparoscopy procedure. This is then connected to the robotic arm while surgeon is sitting at a distance and performing the procedure with the remote controlled arms. The advantage of robotics surgery is the high precision of the equipment and minimization of unnecessary movements by the robot. It also has a shorter learning curve thus surgeon can be trained easily for robotic surgery. The disadvantage is the cost and a long setup time. For some procedures like pyeloplasty, fundoplication, etc. the robotic surgery has proved to be an excellent technique.
Medical sciences are in rapid evolution and many innovations and advances are happening daily to improve patient’s care. The parents however must realize that the old gold standard procedures are still the basis of modern surgery. The aim of all surgical procedures is to achieve a cure from a surgical condition safely with minimal complications. Just because laparoscopy or robotic surgery is a new modality of management it may not necessary be good for the patient. One must balance between the nature of the pathology and the limitations of modern techniques like MIS, Cost effectiveness and above all any added risk to the patient. Sometimes there is an over enthusiastic attempt by the surgeons to perform MIS procedures. The main driving forces are the good cosmetic appearance, prestige of the surgeons and financial benefits. Luckily most surgeons understand their limitation and will work ethically to give the best results and therefore it is always wise to discuss with the treating surgeons the pros and cons in detail about the procedure before opting for MIS procedures.