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18 - MINIMAL ACCESS PEDIATRIC SURGERY
- Camran Nezhat, Stanford University School of Medicine, California, Farr Nezhat, Mount Sinai School of Medicine, New York, Ceana Nezhat
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- Book:
- Nezhat's Operative Gynecologic Laparoscopy and Hysteroscopy
- Published online:
- 23 December 2009
- Print publication:
- 07 July 2008, pp 509-515
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- Chapter
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Summary
The rapid co-evolution of instrumentation and surgical technique has allowed for an ever-growing number of pediatric procedures to be performed using minimal access surgery (MAS). Presently, patients of any size or age (i.e., from fetus to adolescent) can benefit from MAS. This chapter discusses current applications of MAS in infants and children and explores new developments and future directions in the field. Throughout this chapter, the term MAS is defined as procedures that are performed with tiny (≤12-mm) incisions, those performed percutaneously, or those performed endoluminally. It encompasses the field of robotic surgery and image-guided therapy. Common synonyms are laparoscopic surgery (abdominal MAS), thoracoscopic surgery (thoracic MAS), videoscopic surgery, and endosurgery.
WHY MINIMAL ACCESS PEDIATRIC SURGERY?
To date, there is only one randomized controlled trial of MAS in the pediatric population; however, many large retrospective studies in adults have demonstrated decreased postoperative pain, earlier return to feeds, shorter hospital stays, and improved cosmetic results when compared with open surgery. Despite these advantages, a number of concerns limited early widespread adoption of minimal access techniques in children. Appropriately sized instruments were slow to develop as the manufacturers focused on the adult population. The cost of these instruments was believed to be too high and the length of setup too long. Further, perioperative pain and stress have historically been underappreciated in children, and the benefit of smaller incisions was not seen to be substantial as many pediatric surgeons believed they had already made “small incisions.”
73 - Outcomes after maternal–fetal surgery
- from Part IX - Miscellaneous
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- By Preeti Malladi, Lucile Packard Children's Hospital at Stanford Medical Center, Department of Surgery, Division of Pediatric Surgery, CA, USA, Karl Sylvester, Lucile Packard Children's Hospital at Stanford Medical Center, Department of Surgery, Division of Pediatric Surgery, CA, USA, Craig T. Albanese, Lucile Packard Children's Hospital at Stanford Medical Center, Department of Surgery, Division of Pediatric Surgery, CA, USA
- Edited by Mark D. Stringer, Keith T. Oldham, Pierre D. E. Mouriquand
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- Book:
- Pediatric Surgery and Urology
- Published online:
- 08 January 2010
- Print publication:
- 09 November 2006, pp 966-1004
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- Chapter
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Summary
Until the 1980s, physicians had few options for parents of fetuses with congenital malformations; essentially, these were to terminate the pregnancy or continue and possibly modify the timing and/or method of delivery. Rapid advances in prenatal imaging and diagnosis over the last 20 years, coupled with increased understanding of the natural history of many fetal anomalies, has led to the identification of the fetus as a patient and to the burgeoning field of fetal surgery. An increasing number of selected fetal anomalies are amenable to prenatal intervention (Table 73.1), yet it has been difficult to demonstrate efficacy with regard to improved outcomes. With the exception of myelomeningocele and twin–twin transfusion syndrome, anomalies amenable to fetal repair yield only 2–5 cases per year at the busiest fetal treatment centers. Thus, the dearth of patient volume has dictated that outcome assessment be done over a long time often using historical controls. Also, anomalies in which no prenatal treatment reliably results in fetal death (e.g., lung lesion producing hydrops) cannot be ethically “randomized” for prospective study. Randomized prospective trials have been done for several “high” volume anomalies. To date, there are two completed randomized trials for congenital diaphragmatic hernia, and there are ongoing prospective randomized trials for myelomeningocele and twin–twin transfusion syndrome, each of which is illustrated below.
Risks and benefits
Assessing risks and benefits in fetal surgery is a complex task. Both the fetus and the mother must be considered.