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EDITORIAL |
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| Year : 2022 | Volume
: 27
| Issue : 2 | Page : 121-124 |
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The transition from open to minimal access pediatric surgery
Rasiklal Shamji Shah
Department Paediatric Surgery, SRCC Children's Hospital Managed by Narayana Health, Mumbai, Maharashtra, India
| Date of Submission | 18-Nov-2021 |
| Date of Acceptance | 23-Nov-2021 |
| Date of Web Publication | 01-Mar-2022 |
Correspondence Address:
Dr. Rasiklal Shamji Shah
SRCC Children's Hospital Managed by Narayana Health, K K Marg, Haji Ali, Mumbai - 400 034, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jiaps.jiaps_227_21
How to cite this article:
Shah RS. The transition from open to minimal access pediatric surgery. J Indian Assoc Pediatr Surg 2022;27:121-4 |
Dear Friends,
The transition from open to minimal access surgery (MAS) has happened over the decades. The MAS equipment and techniques have evolved over the entire century.[1],[2] There are several people, many known and some unknown, who have contributed to its progress to the present state. Thus, it would be unfair to credit a single person with all the development in the field of MAS. This Editorial highlights the significant milestones in MAS and in particular Minimal Access Pediatric Surgery (MAPS) at the national (global) and personal level.
Endoscopy preceded laparoscopic surgery by many years. In 1902, Georg Kelling from Dresden, Germany, performed the first laparoscopic surgery on a dog. In 1910, Hans Christian Jacobaeus from Sweden used the MAS approach to operate on a human. Kalk (1929), a German physician, introduced the forward oblique (135°) viewing lens systems; he advocated the usage of a separate puncture site for induction of pneumoperitoneum. John C. Ruddock (1934), an American surgeon, described laparoscopy as an advantageous diagnostic method. He considered it superior to an exploratory laparotomy. John C. Ruddock used an instrument consisting of built-in forceps with electrocoagulation capacity for diagnostic laparoscopy. Boesch of Switzerland is credited with the performance of the first laparoscopic tubal sterilization (1936). János Veres of Hungary developed a specially designed, spring-loaded needle (1938) to facilitate carboperitoneum. The rigid rod lens system was invented in 1953 by Professor Harold Hopkins, a British physicist who was nominated twice for the Nobel Prize. Kurt Semm, a German gynecologist, invented the automatic insufflator (1960). H. Coutnay Clarke was the first to employ a laparoscopic suturing technique for hemostasis (1972). Dekok performed the first laparoscopically-assisted appendectomy by exteriorizing the appendix and ligating it outside (1977). Kurt Semm devised the first use of endoloop for ligating structures in laparoscopic surgery (1977). He also performed the first laparoscopic appendectomy (1983). In 1985, Erich Mühe performed the first documented laparoscopic cholecystectomy in Germany.
The introduction of the computer chip television camera was an indispensable event in the development of laparoscopy. The procedure could then be performed while viewing a projected image of the abdominal contents. It also provided a magnified view of the internal anatomy. These collectively allowed free movement of the surgeon's hands, making it easier to perform complex procedures. Before the use of the camera system, the MAS approach was reserved only for diagnostic purposes and a few gynecological procedures such as tubectomy.
In 1987, the French physician Mouret performed the first laparoscopic cholecystectomy, using the camera on a human. The advantages of laparoscopic cholecystectomy led to its rapid acceptance by the general population. Many surgeries now use the principles of MAS. The MAS has been foremost among the surgical innovations of the 20th century. In 1971, Stephen Gans published “Advances in Endoscopy of Infants and Children” as a peritoneoscopy. The development of MAS in adults due to the innovation of camera chips paved the way for the performance of MAPS. Initially, only a handful of surgeons used this approach. These helped create a positive impact on the acceptance of laparoscopy: advances in the camera system, development of miniature hand instruments, understanding physiological effects of carboperitoneum in children, improvement in the anesthetic technique, etc. Perhaps, the most critical factor was the acceptance of MAPS by the patients and parents. This motivated surgeons to learn MAPS and adapt to the challenges. A fear of “missing the train” and potential loss of practice played an important role in motivating the surgeons to learn MAPS. This phenomenon was more prevalent in private practice as compared to public institutions. It took longer for the pediatric surgeons to embrace MAPS due to several challenges, some real and others perceived. These included: reduced abdominal space in children, differences in the anatomy and physiology as compared to adults, nonavailability of ergonomically designed, shorter hand instruments, the need for learning advanced skills of suturing for many procedures, and nonavailability of training centers. In the beginning, MAPS required longer operative time as compared to open surgery. Hence, many institutions with considerable workloads were reluctant to devote time to learn MAPS and offer it to their patients. In addition, many were skeptical about the results and kept postponing their decision to learn the principles of MAPS. The pediatric surgeons in private practice felt compelled to learn MAPS, as its demand increased rapidly not only for adults but even for children. Dr. Edward Kiely planted the seeds of learning MAPS in my mind during a discussion on December 06, 1992. Dr. Kiely had visited the Pediatric Surgery Department of Sir J. J. Group of Hospitals as the operating faculty during the live operative workshop organized to commemorate the silver jubilee of the department. In my interactions with him as a lecturer in the department, he pointed out that MAPS was the future of pediatric surgery and that I should make every effort to learn it. After a lot of personal deliberation and discussion with friends, I decided to take the United States Medical Licensing Examination. There were many hurdles to take the assessment and find a suitable place to work in the USA. However, with the blessings of God, I got a Fellowship position at the University of Tennessee, Memphis, Tennessee, guided by the program director Dr. Thom Lobe, one of the pioneers of MAPS in the USA. The USA was at the forefront in this developing field of MAPS. Appendectomy was probably the first indication to perform laparoscopic surgery in children. The development of technique to perform laparoscopic fundoplication in children led to the performance of many other complex surgeries using MAPS. With burgeoning experience, newer techniques were developed, perfected, and executed by pediatric surgeons worldwide. My fellowship in the pediatric surgery department under Dr. Lobe from November 1995 to June 1998 transformed me into a mature pediatric surgeon. My thought process changed from local to global. This association was instrumental in laying the foundations of MAPS for me. During fellowship, I performed various laparoscopic procedures: appendectomy, fundoplication, pyloromyotomy, empyema surgery, malrotation, hernia, pull-through surgery for Hirschsprung's disease, etc., In January 1996, I attended the first laparoscopic training course arranged at George Washington University in Washington, DC. Later in the year, I attended and presented a paper at the first IPEG conference in Vancouver, Canada. I participated as a faculty in the laparoscopic training courses organized at Medical Education and Research Institute, Memphis, USA. I authored few publications from the department.[3],[4],[5],[6],[7],[8],[9] In addition, I had the opportunity to work with Dr. Bhaskar Rao at St Jude Hospital for cancer in children, where apart from routine Pediatric Oncosurgery, I learned to perform thoracoscopic biopsies of pulmonary nodules. During my tenure, the department performed their first: laparoscopic pyloromyotomy, malrotation correction, nephrectomy, thoracoscopic ligation of patent ductus arteriosus, division of ligamentum in the vascular ring, etc. I returned to Mumbai in July 1998 with enthusiasm, added knowledge and skills to perform MAPS and oncosurgery but decided to focus on MAPS. In 1998, only a few general surgeons performed MAPS in India. This was limited to surgeries such as laparoscopic cholecystectomy. There was limited access to laparoscopic equipment and pediatric hand instruments. There were no local manufactures of pediatric hand instruments; the imported equipment was expensive. The two local manufacturers M/s Precious Surgicals and Om Surgicals agreed to make 3 mm hand instruments (as per my specifications). In December 1998, Precious Surgicals delivered the first set of hand instruments. I used these extensively to perform all advanced laparoscopic surgeries. Any advance or change goes through four stages: shock or denial, fear, acceptance, and transformation. These stages were present even during the transition from open to laparoscopic surgery. These phases often overlap. Furthermore, different parts of India and the world experienced distinct steps along the timeline of progress.
 Shock | |  |
An introduction of change releases a reaction of shock and denial; people try to ignore it. The moment of shock started before 2000; pediatric surgeons had limited knowledge about what was happening around the globe. This era was before the boom of the Internet. The only way to acquire knowledge was by attending conferences and visiting pediatric surgery departments. In 1998, four MAPS workshops were organized in India. In these workshops, pediatric surgeons learned some basic surgeries and laparoscopic surgical exercises. These workshops were instrumental in generating interest among the few pediatric surgeons in this developing field. The first advanced MAPS: a pull-through for Hirschsprung's disease in a 1-year-old girl, was carried out at BYL Nair Hospital, Mumbai (December 20, 1998). I performed the surgery, assisted by Dr. Sandesh Parelkar. This surgery will be remembered as a vital milestone in the history of MAPS in India. It changed the thought process of pediatric surgeons and others, i.e., even advanced major surgeries can be carried out using MAPS. There was a separate session for MAPS for the first time at the Indian Association of Pediatric Surgeons (IAPS) annual conference (Kolkata, 1999). It was conducted in an adjoining room and attended by around 15–20 pediatric surgeons. I had presented two papers: one on laparoscopic surgery for undescended testis and the second one on novel techniques to repair Morgagni's hernia laparoscopically. In 1999, I carried out my first laparoscopic surgery for nonpalpable undescended testis. I visited the library at Sir J. J. Group of Hospitals and read about all available literature on laparoscopic orchiopexy. I devised my technique with the information and still use it to date, barring some minor modifications. There was no literature available on a laparoscopic method to perform Morgagni's hernia. Therefore, I devised my technique, also published in JIAPS.[10] Similarly, the procedure for the laparoscopic repair of inguinal hernia was also devised by me similar to the open surgery. This was published later on in JMAS as an IDES technique to repair an inguinal hernia in males.[11] MAPS requires teamwork; it is crucial to have a good camera person, especially during the initial years. I had teamed with Dr. Deepraj Bhandarkar, a general laparoscopic surgeon; we assisted each other for most of our cases in the first 10 years and later on for challenging cases. This doubled our experience and kept us busy too. Together, we have devised techniques to perform: laparoscopic gastropexy, retrograde removal of the appendix, single-port laparoscopic cholecystectomy, etc. All these techniques have been published in peer-reviewed journals.[12],[13],[14] In addition, I had teamed up with Dr. Ketan Parikh, a pediatric surgeon, to perform MAPS. The annual conference of IAPS in 2002 took place at Trivandrum, where I was the convener of the symposium on “Role of Thoracoscopy in Empyema.” This symposium was instrumental in spreading the knowledge of thoracoscopic pediatric surgery in India.
| Fear | | |
In the phase of fear, people come to grips with reality, though many react negatively. This fear develops as people start thinking about being left behind due to new developments. It is a normal reaction, but it can hinder acceptance of the change. In the context of MAPS in India, this stage probably lasted between 1998 and 2005. Many workshops drew pediatric surgeons toward MAPS. In 2000, Dr. Sanjay Oak appointed me as a Visiting Pediatric Surgeon at BYL Nair Hospital to teach MAPS. This teaching experience sharpened both my knowledge and skills in MAPS. The department set up workshops on MAPS which provided me with the additional impetus to spread the knowledge of this developing field.
| Acceptance | | |
After fears have been expressed and understood, people begin to calm down and accept the situation. This is the real turning point-the change initiative may be out of danger, but people will continue testing the boundaries and exploring what it means. It is essential to lay a good foundation for this stage. Moreover, ensure that people are well trained and have early opportunities to experience what the changes will bring. Productivity may drop a bit at this point as people begin dipping their toes in deeper waters. This stage started somewhere in 2005 with the establishment of Pediatric Endoscopic Surgeons of India (PESI). Later, PESI became a section of the IAPS. The formation of PESI was a landmark milestone in the history of MAPS in India. It facilitated the transfer of knowledge and skills to those interested in learning MAPS. Dr. Kishore Panjwani organized the first PESICON (Agra, 2006). The PESI-IAPS conference is now an annual popular event. This meeting saw a variety of MAPS demonstrated by pediatric surgeons from all over India and the world.
| Transformation | | |
In this stage, people have accepted the reality and explored the novelty. They are ready to be more productive and efficient. The positive effect of the change is apparent and has become a part of life. This stage probably started in 2012 onward. It was easy for pediatric surgeons to learn MAPS by either attending the annual workshops conducted during PESICON or joining the training courses. The training courses were conducted in Mumbai by our team or at Bangalore by Dr. S. Ramesh. The Centre of Excellence of Minimal Access Surgery Training (CEMAST), Mumbai, was started by Dr. T. E. Udwadia with an educational grant from Karl Storz, Germany. Dr. Udwadia invited me to join the institute as a Course Director for MAPS courses. At CEMAST, the four types of programs offered were Intensive or Basic, Advanced Gastrointestinal, Advanced MAP Urology and Endourology, and Advanced Thoracoscopic surgery. These courses enhanced the transfer of skills from experienced MAP surgeons to novice surgeons. These courses gave immense confidence to the participating surgeons; they also reduced the rate of complications. More than 400 pediatric surgeons have benefitted from these courses. Under the banner of CEMAST, we also started to offer 1-month fellowship programs to teach MAPS. In the fellowship program, the pediatric surgeons were able to visit the operating room, and in their spare time, they could practice at CEMAST. All these innovative efforts helped the pediatric surgeons to learn advanced skills in MAPS. At present, many pediatric surgeons can offer advanced techniques even in peripheral centers in India.
The further growth in MAPS happened when the teaching institutions started adapting to MAPS. In addition, MAPS videos on YouTube made pediatric surgeons comfortable undertaking advanced laparoscopic surgeries in smaller towns of India. I started my YouTube channel in 2012. It has helped many pediatric surgeons worldwide to offer MAPS to their patients.
There are immense advantages of laparoscopic surgery over open surgery. Single-incision laparoscopic surgery is not as popular as its advantages over laparoscopic surgery are limited. Robotic surgery is beneficial for surgeons as it offers complex wrist movements, but it has disadvantage of larger size of the incisions and prohibitive cost. Once the cost of robotic surgery and the diameter of hand instruments decreases, it may become a preferred approach in children.
It is fascinating to witness how the transition from open to laparoscopic surgery has unfolded. Laparoscopic surgery is here to stay. In the incoming decade, there will be a further transformation in its application. This will result in a decrease in morbidity and mortality for surgical procedures.
| References | | |
| 1. | Vecchio R, MacFayden BV, Palazzo F. History of laparoscopic surgery. Panminerva Med 2000;42:87-90.  |
| 2. | Nagy AG, Poulin EC, Girotti MJ, Litwin DE, Mamazza J. History of laparoscopic surgery. Can J Surg 1992;35:271-4. |
| 3. | Shah RS, Neto PN. An Innovative Technique for Laparoscopic Cannula Stabilization and Fixation. Paed Endo & Inno Tech 1997;1:59-62. |
| 4. | Shah R, Chen MK, Gross E, Rao BN, Schropp KP, Lobe TE. The Role of Laparoscopic Lymph Node Sampling in Children. Paed Endo and Inno Tech 1997;1:33-38. |
| 5. | Merry C, Varela PJ, Shah RS, Blakely ML. Gasless Laparoscopy with Standard Instrumentation: Initial Experience with Tenckhoff Catheter Placement. Paed Endo and Inno Tech 1997;1:197-201. |
| 6. | Bufo AJ, Merry C, Shah R, Cyr N, Schropp KP, Lobe TE. Laparoscopic pyloromyotomy: A Safer technique. Pediatr Surg Int 1998;13:240-2. |
| 7. | Bufo AJ, Shah R, Lobe TE, Smoot CE. Laparoscopic Transposition of the Omentum for Reconstructive Surgery. Paed Endo and Inno Tech 1997;1:217-21. |
| 8. | Merry CM, Bufo AJ, Shah RS, Schropp KP, Lobe TE. Early definitive Treatment in Paediatric Empyema. J of Paed Surg 1999;33:178-81. |
| 9. | Bufo AJ, Chen MK, Shah R, Gross E, Cyr N, Lobe TE. Analysis of Cost of Surgery for Hirschsprung's Disease: One Stage Laparoscopic pull through vs Two-Stage Duhamel's Procedure. Clinical Pediatrics 1999;38:593-6. |
| 10. | Shah RS, Sharma PC, Bhandarkar DS. Laparoscopic repair of Morgagni's hernia – An innovative approach. J Indian Assoc Paediatr Surg 2015;20:68-71. |
| 11. | Shah R, Arlikar J, Dhende N. Incise, dissect, excise and suture technique of laparoscopic repair of paediatric male inguinal hernia. J Minim Access Surg 2013;9:72-5. |
| 12. | Bhandarkar DS, Shah R, Dhawan P. Laparoscopic gastropexy for chronic intermittent gastric volvulus. Indian J Gastroenterol 2001;20:111-2. [ PUBMED] |
| 13. | Bhandarkar D, Shah R. A novel technique for extraction of the appendix in laparoscopic appendectomy. Surg Laparosc Endosc Percutan Tech 2002;12:117-8. |
| 14. | Bhandarkar D, Mittal G, Shah R, Katara A, Udwadia TE. Single-incision laparoscopic cholecystectomy: How I do it? J Minim Access Surg 2011;7:17-23. |
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