Defining digital surgery: a SAGES white paper.

BACKGROUND: Digital surgery is a new paradigm within the surgical innovation space that is rapidly advancing and encompasses multiple areas. METHODS: This white paper from the SAGES Digital Surgery Working Group outlines the scope of digital surgery, defines key terms, and analyzes the challenges and opportunities surrounding this disruptive technology. RESULTS: In its simplest form, digital surgery inserts a computer interface between surgeon and patient. We divide the digital surgery space into the following elements: advanced visualization, enhanced instrumentation, data capture, data analytics with artificial intelligence/machine learning, connectivity via telepresence, and robotic surgical platforms. We will define each area, describe specific terminology, review current advances as well as discuss limitations and opportunities for future growth. CONCLUSION: Digital Surgery will continue to evolve and has great potential to bring value to all levels of the healthcare system. The surgical community has an essential role in understanding, developing, and guiding this emerging field.

Thoracoscopic lobectomy for type I pleuropulmonary blastoma in an infant.

Pleuropulmonary blastoma (PPB) is a rare, aggressive, intrathoracic mesenchymal neoplasm associated with cystic lung lesions. The authors describe an 8-month-old male who underwent thoracoscopic left upper lobectomy for a cystic lung lesion initially diagnosed as congenital pulmonary airway malformation. Pathology revealed type I PPB.

Congenital lung malformations.

Congenital lung malformations (CLMs) are rare developmental anomalies of the lung, including congenital pulmonary airway malformations (CPAM), bronchopulmonary sequestration, congenital lobar overinflation, bronchogenic cyst and isolated congenital bronchial atresia. CLMs occur in 4 out of 10,000 live births. Postnatal presentation ranges from an asymptomatic infant to respiratory failure. CLMs are typically diagnosed with antenatal ultrasonography and confirmed by chest CT angiography in the first few months of life. Although surgical treatment is the gold standard for symptomatic CLMs, a consensus on asymptomatic cases has not been reached. Resection, either thoracoscopically or through thoracotomy, minimizes the risk of local morbidity, including recurrent infections and pneumothorax, and avoids the risk of malignancies that have been associated with CPAM, bronchopulmonary sequestration and bronchogenic cyst. However, some surgeons suggest expectant management as the incidence of adverse outcomes, including malignancy, remains unknown. In either case, a planned follow-up and a proper transition to adult care are needed. The biological mechanisms through which some CLMs may trigger malignant transformation are under investigation. KRAS has already been confirmed to be somatically mutated in CPAM and other genetic susceptibilities linked to tumour development have been explored. By summarizing current progress in CLM diagnosis, management and molecular understanding we hope to highlight open questions that require urgent attention.

Thoracoscopic Lobectomy in Infants and Children.

Indications for pulmonary lobectomy in infants and children include cystic pulmonary adenomatoid malformation, congenital lobar emphysema, chronic infection, and malignancy. These procedures can now all be done thoracoscopically avoiding the short- and long-term morbidity of an open thoracotomy. In this article we describe the technique of thoracoscopic lobectomy as well as the preoperative and postoperative care.

Division of the mesoappendix with electrocautery in children is safe, effective, and cost-efficient.

INTRODUCTION: Laparoscopic appendectomy is one of the most common procedures performed in children. There are several techniques available for dividing the mesoappendix including the using an endostapler, a LigaSure (Covidien, Boulder, CO), a harmonic scalpel (Ethicon Endosurgery, Cincinnati, OH), or electrocautery. Although it is the least expensive approach, many feel that electrocautery is an unsafe method of dividing the mesoappendix. Here we present our experience with the use of solely electrocautery to divide the mesoappendix. METHODS: Over a period of 12 years, a total of 442 laparoscopic appendectomies were logged into our database. Each appendectomy was performed by coagulating and dividing the mesoappendix with a Maryland dissector or in some cases a hook electrocautery. Three 0-PDS Endoloops (Ethicon Endosurgery, Cincinnati, OH) were then used to ligate the base of the appendix, two proximal and one distal. Patient weight, age, operative time, perforated versus nonperforated, and intraoperative and postoperative complications were queried. RESULTS: Of the 442 cases, 71 were perforated (16%). The mean time for nonperforated appendectomies was 26 minutes and 38 minutes for perforated. There was one case of postoperative bleeding managed nonoperatively in a patient with previously undiagnosed factor VIII deficiency. The cost of each endoloop was $22. CONCLUSION: Although some have questioned the safety of using electrocautery alone to divide the mesoappendix for fear that it may not be adequate to seal the appendiceal artery, may take excessive time, or may cause collateral tissue injury, this has not been our experience. Therefore, the use of more costly instruments to divide the mesoappendix such as the endostapler, LigaSure, or harmonic scalpel seems unwarranted. This study demonstrates that electrocautery for the mesoappendix and endoloops for the appendix is safe, effective, and cost-efficient.

Initial experience with surgical telementoring in pediatric laparoscopic surgery using remote presence technology.

PURPOSE: To evaluate the efficacy of remote presence technology in surgical mentoring. METHODS: A self-propelled robot, which is controlled from a wireless remote control station (Laptop computer)and provides two-way audio and visual communication, was used to allow an experienced endoscopic surgeon to provide mentoring during three unique laparoscopic cases. This first was a laparoscopic exploration in a 9-month-old child with clinical evidence of intermittent obstruction but nondiagnostic imaging studies.The second was a 4-day-old, 3-kg infant with a congenital diaphragmatic hernia, and the third was a 1-day-old child with duodenal atresia. The robot was used to visualize the patient and radiologic studies, telestrate suggestions for trocar placement, visualize the laparoscopic procedure, and provide advice during the procedure.In the second case, another surgeon at a remote site control station watched the surgery and asked questions. RESULTS: The procedures were completed successfully in 90, 30, and 90 minutes. The first case included identification of the obstructing lesion (internal jejunal polyp) and intestinal resection and anastomosis. The second case involved resection of the hernia sac and repair of the congenital diaphragmatic hernia. The third consisted of identification of the site of atresia and identification of the site for the proximal and distal enterotomy. The robot allowed excellent visualization of the procedures and direct communication between the surgeon and mentor was uninterrupted throughout the case. Both surgeon and mentor felt the telementoring assisted in the case. CONCLUSIONS: While this is a limited series, the initial evaluation of this remote presence technology in the operating room suggests that it may be extremely usefully in adding surgical experience and expertise in minimally invasive surgery.

Experience with a new energy source for tissue fusion in pediatric patients.

INTRODUCTION: Options for effective techniques for vessel and tissue sealing in infants and children are limited because of the size and limited intracorporeal space of many pediatric patients. We evaluated a new energy source, the ForceTriad (Covidien, West Windsor, NJ) LigaSure, which delivers both mono- and bipolar energy in a 5-mm format and allows for tissue fusion and vessel sealing and division. This report documents our experience with this device. METHODS: A database review was performed, looking for all cases that were performed in children using the ForceTriad LigaSure as the main source of hemostasis and tissue fusion. Two different handpieces were used a fine Maryland dissector-type instrument with no cutting blade, and a sealer/cutter, both in a 5-mm format. RESULTS: A total of 60 cases were performed in children from September 2006 to September 2007, using the ForceTriad. The two most common cases were Nissen fundoplication (40 cases; weight: 8.5-95 kg [average,40.7]; operating room [OR] time: 15-70 min [average, 32]; average days to full feeds: 2) and lung lobectomy (11)cases (weight: 4.6-63 kg [average, 27.3]; OR time: 60-180 min [average, 123]; average hospital days: 3.1). Other procedures included, excision of choledochal cyst (3), aortopexy, closure of bronchopleural fistula, nephrectomy(1), thymectomy (1), parathyroid adenoma excision (1), total colectomy (2), and intestinal duplication resection(2). There were no failures of vessel or tissue fusion and no operative complications. A delayed hydropneumothorax developed in 1 lung resection and spontaneously resolved. CONCLUSION: The ForceTriad provides a safe, effective energy source in a 5-mm format. As compared to previous versions of the LigaSure, there was less sticking, a quicker seal, and no tissue-fusion failures.

Thoracoscopic lobectomy for severe bronchiectasis in children.

BACKGROUND/PURPOSE: Lung resection should be considered for severe, localized bronchiectasis causing recurrent infections in patients with cystic fibrosis (CF) and other diseases. This series represents our experience and results with thoracoscopic lobectomy for the treatment of severe bronchiectasis confined to a single lobe. METHODS: Nineteen thoracoscopic anatomic lobectomies were performed between July 1994 and August 2008. Patient age at the time of surgery ranged from 14 months to 22 years. Left lower lobectomy was the most frequently performed procedure (n = 9). Eight patients suffered from CF, 5 had chronic pneumonia, 2 had chronic aspiration, and 3 had other diagnoses. RESULTS: Mean operative time was 162 minutes (range, 65-300), and no cases required a conversion to thoracotomy. The mean duration of postoperative chest tube drainage was 3.2 days (range, 1-9). The mean postoperative length of stay was 3.6 days (range, 1-12). One patient had a prolonged air leak lasting 9 days, which resolved with the placement of a second chest tube. Another had a small hydropneumothorax, which persisted after chest tube removal but resolved spontaneously. CONCLUSIONS: Thoracoscopic lobectomy for severe lobar bronchiectasis with recurrent infection is technically challenging, but appears to be safe and effective. Avoidance of a thoracotomy, in this group of patients, allows for earlier mobilization, less postoperative pain with cough and chest physiotherapy, and faster recovery. There appear to be significant benefits in these patients with chronic respiratory illnesses.

Thoracoscopy in children: is a chest tube necessary?

PURPOSE: Historically, a chest tube or drain has been left following a thoracic operation to allow drainage of air or fluid in the postoperative period. However, in patients undergoing thoracoscopy, the tube is often the greatest source of postoperative pain. We began excluding chest tubes several years ago and therefore are reviewing our experience to evaluate the safety and efficacy of this approach. METHODS: A retrospective review of the medical record was performed on patients undergoing thoracoscopy at two centers from 1993 to 2007. Patients who left the operating room without a chest tube were included in this series. Patient demographics, type of operation, and outcome were recorded. RESULTS: A total of 333 thoracoscopic procedures were performed at the two institutions without the use of a chest tube. Ages ranged from 1 week to 39 years. Weight ranged from 1.3 kg to 117 kg. The cases performed included aortopexy, congenital diaphragmatic repair, excision of a bronchogenic cyst, exploratory thoracoscopy, lung biopsy, resection extralobar sequestration, Nuss procedure, patent ductus arteriosus ligation, resection/biopsy of mediastinal lesions, resection of esophageal duplication, excision of parathyroid adenoma, hiatal hernia repair, esophagomyotomy, and thymectomy. Within this group of thoracic operations, 176 patients underwent lung biopsy. Pulmonary lobectomy or segmentectomy patients were excluded. All patients had a chest radiograph in the recovery room. Only one developed a postoperative pneumothorax, which occurred on postoperative day 2 following reintubation for respiratory failure. This patient required repeat thoracoscopy. CONCLUSIONS: The use of routine chest tubes following thoracoscopy in children appears to be unnecessary as the absence of a chest tube in our series resulted in an intervention in one patient (0.3%). Elimination of the chest tube will allow for a much more tolerable postoperative course in most children.

Culture of safety and error traps in pediatric thoracoscopy.

Growing adoption of thoracoscopy by pediatric surgeons has resulted in increasingly complex operations being performed. Although common complications of these procedures have decreased with experience, surgeons are still at risk to fall into error traps where routine practice in uncommon situations results in unanticipated complications. A background culture of safety that rewards multidisciplinary communication, teamwork, openness and standardization of care can assist surgeons to recognize, address and report error traps when they arise. This article serves to encourage a culture of safety and raise awareness of error traps in pediatric thoracoscopy to minimize potential harm and improve quality of care.

Minimally invasive surgery in infants less than 5 kg: experience of 649 cases.

INTRODUCTION: With the development of advanced skills and the introduction of miniature laparoscopic tools, endoscopic procedures in infants and small children have become possible. This report documents our experience in minimally invasive surgery (MIS) in infants under 5 kg. METHODS: A retrospective database review was performed from September 1993 to September 2007. All children weighing 5 kg or less that underwent a laparoscopic or thoracoscopic procedure were included. RESULTS: A total of 649 cases were attempted. 43 different procedures were performed, the most common being Nissen fundoplication (310 cases, average operating room (OR) time 43 min, average time to full feeds 2 days), pyloromyotomy (104 cases, average OR time 12.5 min, average hospital days<1), patent ductus arteriosum (PDA) ligation (26 cases, average OR time 31 min, average hospital days<1), tracheoesophageal fistula (TEF) repair (22 cases, average OR time 83 min, average time to full feeds 7.8 days), duodenoduodenostomy (20 cases, average OR time 76 min, average time to full feeds 8.6 days), colonic pull-through for Hirschsprung's disease (18 cases, average OR time 109.6 min, average time to full feeds 3 days), colonic pull-through for imperforate anus (10 cases, average OR time 103 min, average hospital days 2), lung resection (12 cases, average OR time 66.8 min, average hospital days 1.75), congenital diaphragmatic hernia repair (10 cases, average OR time 62.5 min, average time to full feeds 4.75 days). There were no surgery-related deaths. The conversion rate to open was 1.2% (n=8). There were six intraoperative complication rate (0.9%) and the overall complication rate was 3% (20 complications overall). CONCLUSIONS: The development of modern low-flow CO2 insufflators, smaller instruments and telescopes, as well as advanced techniques, has made MIS in neonates feasible and safe. The greatest challenge remains performing intestinal anastomosis in these confined spaces, and further technical advances will be required to make these techniques universally adopted.

Thoracoscopic lung biopsy in infants and children with endoloops allows smaller trocar sites and discreet biopsies.

BACKGROUND: Thoracoscopy is replacing open lung biopsies because it is less invasive. However, most surgeons obtain biopsies with an endostapler, which requires a 12-mm trocar and a minimum of 4.5 cm of intrathoracic space to open, making its use in patients less then 10 kg impractical. This report describes the use of the Endoloop (Ethicon Endosurgery, Cincinnati, OH) in small pediatric patients undergoing thoracoscopic lung biopsies. MATERIALS AND METHODS: From 1993 to February 2007, 69 patients underwent thoracoscopic lung biopsy for diagnosis and therapy. Ages ranged from 2 weeks to 4 years and weight from 2 to 22 kg. One 5- and two 3-mm trocars were used in all cases. In all cases, two Endoloops were placed proximal to the segment of lung being biopsied and the lung was divided sharply distal to the Endoloops. The specimen was removed through the 5-mm trocar site. The lung was reexpanded and no chest drains were left in postoperatively. RESULTS: All 69 procedures were successfully completed thoracoscopically. Two biopsy specimens were obtained, in most cases. Operative time ranged from 10 to 35 minutes (average, 20). There were no intraoperative complications. One patient required reintubation and ventilator support on postoperative day 1 and developed a pneumothorax on postoperative day 2, requiring a chest tube. There were no other complications. CONCLUSIONS: The thoracoscopic approach to lung biopsy is the preferred method of obtaining lung tissue for diagnosis. The use of the Endoloop technique is a safe, effective technique in small pediatric patients, avoiding problems with the limited size of the chest cavity in patients less than 10 kg, and avoids the use of large incisions in a small child.

Use of the 5-mm Endoscopic Stapler for Ligation of Fistula in Laparoscopic-Assisted Repair of Anorectal Malformation.

OBJECTIVE: Laparoscopic anorectoplasty (LARRP) for the treatment of select anorectal malformations has gained popularity due to enhanced visualization of the fistula and the ability to place the rectum within the sphincter complex while minimizing division of muscles and the perineal incision. However, given the technical challenges and reported complications of ligation, a number of techniques have been described, including using clips, suture ligation, endoloops, or division without closure. We aimed to evaluate fistula closure and division for high imperforate anus using a 5-mm stapler (JustRight Surgical, Boulder, CO). MATERIALS AND METHODS: A retrospective chart review was performed on patients who underwent LAARP for imperforate anus between March 2015 and December 2016. RESULTS: Four patients underwent LAARP with division of the fistula using the 5-mm stapler. The average age was 3.2 months and average weight was 4.5 kg. The location of the fistula was rectoprostatic in 3 cases and rectobladder neck in 1 case. There were no complications. CONCLUSION: Division of a fistula at or above the level of the prostate can safely and effectively be performed with the 5-mm stapler. The stapler allows for division flush with the urethra or bladder ergonomically and quickly.

Thoracoscopic pulmonary surgery.

Thoracoscopy in infants and children has undergone a dramatic evolution in the last 30 years. From its infancy in the mid-1970s, limited procedures such as biopsy and pleural lysis, were pioneered by Rogers and others, and in the late 1990s, the most delicate of procedures, a tracheo-esophageal fistula repair, was performed thoracoscopically for the first time. During the last 20 years, it has become clear that the most commonly performed thoracic procedures in the pediatric age group, lung biopsy and resection, are clearly best performed using these advanced thoracoscopic techniques. New instrumentation and advanced skills now make thoracoscopic lung resection the preferred approach and help avoid the significant morbidity associated with thoracotomy in the pediatric age group.

Experience with 144 consecutive pediatric thoracoscopic lobectomies.

OBJECTIVE: The early experience with the technique and short-term outcomes after pediatric thoracoscopic lobectomy were independently reported by the authors several years ago. This paper updates their combined experience, evaluating the safety, efficacy, and long-term outcomes. METHODS: From January 1995 to May 2005, 144 consecutive patients underwent a thoracoscopic lobectomy. Preoperative diagnoses included cystic adenomatoid malformation/sequestration (n = 112), bronchiectasis (n = 19), lobar emphysema (n = 10), and malignancy (n = 3). Ages ranged from 2 days to 18 years, and weight ranged from 2.8 to 78 kgs. Three or four valved ports were used with a controlled pneumothorax. Single-lung ventilation was used in all cases. Follow-up ranged from 1 to 10 years. RESULTS: All but three procedures were completed thoracoscopically; one was converted to repair an injured upper lobe bronchus during a lower lobectomy, one resulting from bleeding, and another caused by what was believed to be a potentially inadequate margin during the resection of a large tumor. The operating time ranged from 35 to 220 minutes (median, 125). There were 110 lower, 24 upper, and 10 middle lobe resections. There was one intraoperative complication--the compromise of a left upper lobe bronchus. There were four postoperative complications: pneumonia, pneumothorax, empyema, and prolonged chest tube drainage. There were no reoperations. The median duration of hospital stay was 2.8 days. A long-term follow-up revealed no cases of musculoskeletal deformity or weakness. CONCLUSIONS: The current techniques and equipment allow for the complete thoracoscopic resection of pulmonary lobes in any age or size of a child, with low morbidity and no mortality. Long-term outcomes support the efficacy of this technique that spares growing children a thoracotomy that has the potential for late musculoskeletal morbidity.

Thoracoscopic management of non-type C esophageal atresia and tracheoesophageal atresia.

PURPOSE: This study evaluates the results of thoracoscopic management of complex, non-type C, EA and TEF in infants. METHODS: From March 2000 to February 2017, 23 patients were treated for Type A N=13, Type B N=4, and Type E N=6. Patients diagnosed with EA had G-tube feeds for a period of 4-9weeks. All procedures were performed thoracoscopically. EA gaps were between 4 and 7 1/2 vertebral bodies. RESULTS: All surgeries were completed thoracoscopically. Average operative time was 95min for Type A, 115min for Type B, and 50min for Type E. Two patients with long gaps had small leaks which resolved with conservative management. One patient with an H-type was re-intubated causing a partial disruption of the tracheal repair. This required thoracoscopic re-exploration with repair and placement of an intercostal muscle flap. No patient has any clinical evidence of fused ribs, chest wall asymmetry, shoulder girdle weakness, or winged scapula. CONCLUSION: Thoracoscopic repair of complex EA and TEF is safe and effective. The excellent visualization of the thoracic inlet allows for extensive mobilization creating sufficient length for long gaps and safely managing high fistulas. This may limit injury to adjacent structures and avoid a neck incision and chest wall deformity. LEVEL OF EVIDENCE: IV.

Fundoplication.

Gastroesophageal reflux disease (GERD) is a common condition in infants. Symptoms from pathologic GERD include regurgitation, irritability when feeding, failure to thrive, and respiratory problems. Treatment typically starts with dietary modifications and postural changes. Antireflux medications may then be added. Indications for operative management in neonates and infants include poor weight gain, failure to thrive, acute life-threatening events, and continued respiratory symptoms. Laparoscopic Nissen fundoplication has become the standard of care for surgical treatment of children with GERD. In this procedure, the fundus of the stomach is wrapped 360° posteriorly around the lower esophagus.

Gastroesophageal reflux.

Gastroesophageal reflux disease (GERD) is a very common condition and affects approximately 7-20% of the pediatric population. Symptoms from pathological GERD include regurgitation, irritability when feeding, respiratory problems, and substernal pain. Treatment typically starts with dietary modifications and postural changes. Antireflux medications may then be added. Indications for operative management in the pediatric population include failure of medical therapy with poor weight gain or failure to thrive, continued respiratory symptoms, and complications such as esophagitis. Laparoscopic Nissen fundoplication has become the standard of care for surgical treatment of children with GERD. The key technical aspects of laparoscopic Nissen fundoplication include creation of an adequate intra-abdominal esophagus, minimal dissection of the hiatus with exposure of the right crus to identify the gastroesophageal junction, crural repair, and creation of floppy, 360° wrap that is oriented at the 11 o׳clock position.

Two-Site Appendectomy in Children: Description of Technique and Outcomes.

PURPOSE: Laparoscopic appendectomy is one of the most common operations. Single-site appendectomy has been gaining popularity; however, it has certain disadvantages. The purpose of this study was to review the results of an essentially scarless laparoscopic appendectomy technique. METHODS: A retrospective review of all patients who underwent two-site appendectomy for appendicitis between January 2015 and February 2016 was performed. For all cases, a 4 mm trocar and a 5 mm trocar were placed through an infraumbilical incision and a 3 mm trocar was placed in the suprapubic region. RESULTS: Fifty patients underwent appendectomy using this technique. The average age was 9.7 years (5-16 years) and average weight was 40 kg (15.7-73.3 kg). The classifications of appendicitis consisted of 32 simple, 5 suppurative, 4 gangrenous, and 8 perforated. The average operative time was 29 minutes (6-53 minutes) and average length of stay was 1.9 days (1-6 days). There were three minor complications, and all cases were completed with this technique, including in obese patients and for perforated appendicitis. All patients reported satisfaction with their postoperative cosmetic outcome. CONCLUSIONS: This technique allows for the main incision to be hidden at the umbilicus, creating an essentially scarless cosmetic result. The addition of a 3 mm suprapubic port leads to increased maneuverability of the instruments and better retraction of the appendix. It is also feasible in obese children and cases of perforated appendicitis.

Outcomes of Laparoscopic Cholecystectomy for Biliary Dyskinesia in Children.

PURPOSE: To determine the outcomes of laparoscopic cholecystectomy as a treatment for biliary dyskinesia in children. METHODS: With ethics approval, a retrospective chart review was performed on children (<21 years) at a single center diagnosed with biliary dyskinesia (defined as gallbladder ejection fraction [EF] <35% and/or pain with cholecystokinin [CCK] on cholescintigraphy, in the absence of gallstones or cholecystitis on ultrasound) and treated with laparoscopic cholecystectomy between March 2010 and February 2016. Demographic, medical history, diagnostic imaging, pathology, and outcome data were collected and analyzed based on degree of symptom resolution. RESULTS: Laparoscopic cholecystectomy was performed in 215 children with biliary dyskinesia (156/215 [72.6%] female, age 13.8 ± 3.4 years, body mass index [BMI] 22.3 ± 6.3 kg/m2). 181/206 (87.9%) had EF <35%. CCK reproduced symptoms in 149/177 (84.2%). 34/215 (15.8%) were lost to follow-up. Median follow-up time was 2.7 weeks. Pain improved in 162/181 (89.5%). Chronic cholecystitis was found in 183/213 (85.9%) and unexpected cholelithiasis in 4/213 (1.9%) on pathology. Postoperatively, 6/181 (3.3%) had wound infections and 8/181 (4.4%) required common bile duct stents for the following indications: 6 sphincter of Oddi dysfunction, 1 choledocholithiasis, and 1 stricture. Virgin abdomen (odds ratio [OR] 4.03, confidence interval [95% CI] 1.12-14.53, P = .0460) and follow-up <6 months (OR 7.35, 95% CI 2.68-20.21, P = .0002) were associated with better outcomes. CONCLUSIONS: Laparoscopic cholecystectomy is safe and effective in symptom resolution for biliary dyskinesia in children. Virgin abdomen and follow-up <6 months were associated with better outcomes. Prospective long-term studies comparing surgical and nonoperative management of biliary dyskinesia are required to determine the utility of cholecystectomy.