Basic Paediatric Laparoscopic Surgery Sanjay Oak, Sandesh Parelkar
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  1. Why Minimal Access Surgery (MAS) in Children?
  2. Role of a Preceptor and Training in Paediatric MAS
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Why Minimal Access Surgery (MAS) in Children?1

“Creativity is finding new things…or expressing old things in new ways.”
 
MERITS OF MAS IN CHILDREN
  1. Reduction in morbidity related to access.
  2. Reduction in hypertrophy of scars (Figs 1.1 and 1.2).
  3. Reduction of keloid formations.
  4. Reduction in paresthesia.
  5. Reduction in hematoma, infection, wound dehiscence.
  6. Reduction in neurapraxia.
  7. Reduction in hypothermia and desiccation of tissues.
  8. Advantage of magnification and good illumination.
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    Fig. 1.1: Hypertrophic scar following laparotomy
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    Fig. 1.2: Hypertrophic scar of thoracotomy
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  9. Superior in costophrenic region and in pelvic cavity in children.
  10. Convenient for staged repairs of congenital anomalies.
  11. Safer for surgeon as it reduces the chances of contact with patient's tissue fluids.
  12. Scars in children are known to grow and disturb them cosmetically in adolescence (Figs 1.3 and 1.4).
  13. Quicker recovery, early ambulation in the ward, quicker return to normal diet, school and sports.
  14. Thoracoscopy in children allows direct access to the pleural space and mediastinal structures.
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Fig. 1.3: Scoliosis—Delayed complication of open thoracotomy
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Fig. 1.4: Small scars of VATS
 
POTENTIAL RISKS IN MAS
However one must also take the cognizance of the potential risks of MAS in abdominal procedures in children: The use of CO2 as a gas for insufflation may cause profound local and general acid-base and hemodynamic changes: Prolong insufflation can lead to compartment syndrome in abdomen: High flow can lead to drying of tissues and if the gas is not pre-warmed, hypothermia may set in:
 
FUTURE FRONTIERS
  • Simulators.
  • Tactile sensors on the hand instruments.
  • Computer-assisted surgery.
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  • MR-guided surgery.
  • 3-D reconstruction in dissection.
  • Endoscopic image + MR image (4th dimension).
  • Virtual reality applications in surgery.
  • Robotics-augmented reality:
  • MR-guided thermotherapy ablators.
  • Development of transformer instruments which are linear during insertion into body cavities but undergo internal transformation into useful robotic tools working in six directions as human wrist.
  • Devices or glues for rapid and precise tissue approximation.
  • Specimen removal systems allowing resection of large intracorporeal organs.
  • Biologically active agents which can be safely endoscopically injected for closure of inguinal hernial sacs.
  • Comparable advances of MAS in pediatric neurosurgery, cardiac surgery, orthopedic surgery, otolaryngology and plastic surgery.