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EDITORIAL |
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| Year : 2023 | Volume
: 28
| Issue : 6 | Page : 451-452 |
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Twenty-five Years (1998–2023) of advanced minimal access pediatric surgery in India
Rasiklal Shamji Shah
Department of Paediatric Surgery, SRCC Children's Hospital Managed By Narayana Health, Mumbai, Maharashtra, India
| Date of Submission | 15-Oct-2023 |
| Date of Acceptance | 15-Oct-2023 |
| Date of Web Publication | 02-Nov-2023 |
Correspondence Address:
Rasiklal Shamji Shah
Department of Paediatric Surgery, SRCC Children's Hospital Managed By Narayana Health, 1/1A, Haji Ali Chowk, K. K. Marg, Mumbai - 400 034, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jiaps.jiaps_217_23
How to cite this article:
Shah RS. Twenty-five Years (1998–2023) of advanced minimal access pediatric surgery in India. J Indian Assoc Pediatr Surg 2023;28:451-2 |
How to cite this URL:
Shah RS. Twenty-five Years (1998–2023) of advanced minimal access pediatric surgery in India. J Indian Assoc Pediatr Surg [serial online] 2023 [cited 2023 Dec 4];28:451-2. Available from: https://www.jiaps.com/text.asp?2023/28/6/451/389324 |
Endoscopic surgery has been established due to many innovations done over the last couple of centuries. Georg Kelling from Dresden, Germany, in 1902 performed the first laparoscopic surgery on dogs. In 1910, Hans Christian Jacobaeus from Sweden used the minimal access surgery (MAS) approach to operate on a human. In 1971, Stephen Gans had a landmark publication, “Advances in Endoscopy of Infants and Children,” as a peritoneoscopy.[1] The innovation of the camera chip opened the door for the performance of MAS in adults; this was soon followed by the application of the technique in children. The development of minimal access pediatric surgery (MAPS) lagged behind the MAS in adults. The reasons for this were related to less available space in the abdomen of children, nonavailability of ergonomically designed shorter hand instruments, differences in anatomy and physiology compared to adults, procedures needing advanced skills of suturing and nonavailability of training centers, etc., In 1998, very few companies made pediatric hand instruments (3 mm diameter and 20 cm length) at an international level, but none were available in India.
Before 1998, a few basic MAPSs were being carried out. These included laparoscopic cholecystectomy, appendicectomy, and orchiopexy. The surgeries were often done by adult general surgeons using adult instruments. Many senior pediatric and adult surgeons felt that there was no role for MAPS in children; most, unfortunately, ignored this burgeoning field. On December 20, 1998, I performed the first laparoscopic transanal pull-through for Hirschsprung's disease in India in a 1-year-old girl at BYL Nair Hospital, Mumbai, which was assisted by Dr. Sandesh Parelkar. This event should be considered a turning point and a milestone in MAPS in India. It changed the mindset of the medical fraternity, including pediatric and adult general surgeons. It was realized that advanced pull-through surgery for Hirschsprung's disease can be carried out even in small babies. Around this time, few pediatric surgeons in India decided to concentrate on this growing field.
In the beginning, MAPS required longer operative times than an open surgery. Hence, several institutes with busy workloads were not able to offer MAPS 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 had to learn MAPS as its demand increased rapidly, even in children.
For the first time, the Annual Conference of the Indian Association of Pediatric Surgery (IAPS), held in Kolkata in 1999, organized a separate session for MAS. Some 15–20 pediatric surgeons attended, where I presented two papers – one on laparoscopic surgery for undescended testis and the other on novel techniques to repair Morgagni's hernia. Google and YouTube were seldom used in the late 1990s and early 2000s. The surgeon had to visit institute libraries to keep abreast with the latest advances. It was a standard exercise before performing any new surgery using MAPS. One had to read and understand all the articles published in the journal; this was followed by modifying techniques as needed and carrying them out ideally in a given setting. Methods had to be devised for orchiopexy, appendicectomy, repair of Morgagni's and inguinal hernias, etc., as these were published later.
There has been a rapid growth of MAPS in India over the last 25 years (from 1998 to 2023). There is an increase in the number of pediatric surgeons and the number of institutes offering MAPS to their patients. At the same time, MAPS is being offered for an expanded spectrum of diseases. It is heartening to know that many pediatric surgeons in tier II and III cities also offer advanced MAPS to their patients (personal communications).
The reasons for this growth include the availability of dedicated MAPS training courses, the teaching of MAPS in many teaching institutes, easy availability of 3 mm short-length instruments manufactured by local companies at very competitive rates, advances in technology, and annual MAPS workshops organized by the Paediatric Endoscopic Surgeons of India section of IAPS. In addition, MAPS videos on YouTube made it easier for pediatric surgeons, even in smaller towns in India, to understand and undertake advanced laparoscopic surgeries. I started my YouTube channel in 2012; it helped many pediatric surgeons worldwide offer MAPS to their patients. The technological advancements have helped pediatric surgeons to carry out advanced MAPS for their patients. These included the availability of high-definition camera systems, ultrasonic shears, and bipolar vessel sealing devices. Even today, the latter two gadgets, available as larger diameter and long-length instruments, are primarily designed for use in adults. It is high time that companies start manufacturing and/or marketing 3-mm ultrasonic shears and bipolar vessel sealing devices. It will be interesting if an Indian company manufactures these equipment under the banner “MAKE IN INDIA.” It may reduce the cost of making as well as using these disposable hand instruments. The most significant driving factor for MAPS has been the demand from the families of children undergoing surgery. In the last 25 years, the level of education in the community and awareness of paediatric surgical conditions has improved significantly. Also per capita income of Indians families have increased and many families are able to offer advance care for their children in private setup. Today, many families acquire information on the Internet before choosing a surgeon and institute.
The short-term advantages of MAPS include less pain, early recovery, decreased length of hospital stay, and reduced incidence of pneumonia and adhesive intestinal obstruction. Multiple studies have proved these short-term benefits. It is the time that Indian surgeons published their long-term results for every condition. Pediatric surgeons in India have extensive experience and workload; they should take the lead in publishing their long-term experience and results. The challenge is to acquire authentic data due to known difficulties in contacting the patients' families. It was very pleasing when some of these patients operated during the early phase between 1998 and 2005 returned with exceptional long-term results. A few of my Hirschsprung's disease patients have given me surprise calls and/or visits to say that they were doing well. These incidences bring immense joy and satisfaction to the operating pediatric surgeon and a sense of fulfillment and energy to continue.
There are many advantages of laparoscopic surgery over open surgery. However, single-incision laparoscopic surgery has not added any significant advantage as compared to standard laparoscopic surgery. Hence, it is not extremely popular. Robotic surgery is favorable for surgeons as it offers complex wrist movements. However, there are relatively few takers due to the larger size of the incisions and prohibitive cost. Once the cost of robotic surgery comes down and dedicated robotic instrumentation for use in pediatric patients becomes available, it is likely to become the preferred approach.
Many MAPS surgeons end up with neck pain and discomfort due to the monitor being placed at a level higher than eye level of surgeons.[2] Similarly, laparoscopic surgeons are more prone to shoulder pain due to the abduction of the shoulder, backache, finger and wrist pain, tenosynovitis, burning eyes, stress exhaustion, and hand muscle injury.[3] It is possible to prevent these complications by understanding the ergonomics of the operating room, using pediatric hand instruments, and improving personal physical fitness.
To summarize at the end of 25 years of advanced laparoscopic surgery in India, we need to publish long-term results for pediatric surgical conditions and to understand ergonomics well to prevent long-term physical issues which can happen to operating surgeons. The institutes where it is possible to acquire authentic data should take the initiative to publish long-term results.
 References | |  |
| 1. | Shah RS. The transition from open to minimal access pediatric surgery. J Indian Assoc Pediatr Surg 2022;27:121-4.  [Full text] |
| 2. | Kant IJ, de Jong LC, van Rijssen-Moll M, Borm PJ. A survey of static and dynamic work postures of operating room staff. Int Arch Occup Environ Health 1992;63:423-8. |
| 3. | Berguer R, Forkey DL, Smith WD. The effect of laparoscopic instrument working angle on surgeons' upper extremity workload. Surg Endosc 2001;15:1027-9. |
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