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Minimal Access Surgery in Pediatrics

Background

Minimal access surgery (MAS) has been in existence since the early 19th century. In the form of laparoscopy, MAS has been used by gynecologists since the 1960s. Its application to general surgery began when Muhe performed the first laparoscopic cholecystectomy in 1985. In 1987, Mouret and Dubois helped popularize this procedure, and laparoscopic cholecystectomy soon became the standard of care.
Since then, MAS has been applied to numerous other procedures both in the abdomen (laparoscopy) and in the chest (thoracoscopy), with good results.

The advantages of MAS were realized by surgeons operating on adults long before this approach was accepted in the pediatric community. Initially, performing MAS in the pediatric population was resisted for the following reasons:

It was widely believed that children did not experience pain as adults did

The cost of laparoscopy was believed to be too high

The available equipment was not small enough

MAS in children was regarded as too demanding to perform and too difficult to learn

The cases were thought to take too long to set up and to perform

Many surgeons believed that laparoscopic approaches did not really apply to children, and the need for cholecystectomy was relatively uncommon in children

Pediatric surgeons already prided themselves on their ability to work with small incisions

Many believed that MAS was not safe and that its efficacy was not proved

In 1973, Gans and Berci were the pioneers in pediatric laparoscopy.
They performed laparoscopy (ie, peritoneoscopy) on 16 children aged 1 day to 14 years, mainly for diagnostic purposes and for obtaining biopsy specimens. After that initial experience, however, there was a long lag period before pediatric surgeons in Europe and the United States picked up the torch in the early 1990s, after which point expertise in abdominal 
 and thoracic operations
 started growing rapidly and began to be disseminated widely. 

Poor-quality pediatric laparoscopic instruments and telescopes that were not small enough were perhaps the most significant barriers to the advancement of pediatric MAS.

In a comparative 5-year study, the outcomes of 211 children who underwent MAS were compared with age-matched controls with similar diagnoses who underwent open surgery.
No significant differences in mortality or morbidity were found. However, the hospital stay was shorter for children who underwent laparoscopic cholecystectomy, appendectomy, nephrectomy, splenectomy, and surgery for intra-abdominal testis than for those who underwent open surgery. In addition, all parents favored the cosmetic results of MAS.

Additional procedure-specific trials yielded equivocal results for laparoscopic appendectomy
 and demonstrated similar or superior results for laparoscopic urologic procedures,
 whereas laparoscopy was found to be advantageous in the correction of inguinal hernias
and hypertrophic pyloric stenosis.

Subsequently, robotic-assisted laparoscopy and thoracoscopy have been adopted for use in children at numerous centers, though this transition has been constrained by the issues surrounding the adaptation of such approaches to smaller patient anatomies.

Refinements and innovations in adult surgical practice have frequently been adapted for use in infants and children; however, many of the advances made in pediatric laparoscopy have also migrated back into adult laparoscopy. As the smaller telescopes and instruments developed for pediatric MAS became more broadly available, they were rapidly adopted by adult surgeons.

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