Minimally invasive surgery in neonates and infants

Advancements in surgical education: exploring animal and simulation models in fetal and neonatal surgery training

Introduction

Surgical education is undergoing a transformation, moving away from traditional models towards more modern approaches that integrate experiential and didactic methods. This shift is particularly pertinent in the realm of fetal and neonatal surgery, where specialized training is crucial. Historical training methods, such as cadaveric dissection, have been prevalent for centuries, but newer innovations, including animal and non-animal simulation models, are gaining prominence. This manuscript aims to explore the use of both animal and non-animal models in surgical education, with a specific focus on fetal and neonatal surgery.

Animal models

The use of animal models in surgical training has a long history, dating back to Halsted's introduction in 1889. These models, often utilizing large animals like swine and dogs, offer valuable insights into fetal and neonatal surgeries. They allow for the study of long-term outcomes and the simulation of various diseases and anomalies, providing essential training experiences not readily available in human surgeries. However, there are notable limitations, including anatomical and physiological differences from humans, ethical considerations, and substantial infrastructure and maintenance costs.

Simulation models

Simulation-based training offers several benefits, including standardized and safe learning environments without risks to real patients. Bench models, using synthetic materials or non-living animal tissue, provide cost-effective options for skills development. Virtual reality and 3-D printing technologies further enhance simulation experiences, allowing for the replication of complex clinical scenarios and patient-specific anatomies. While these models offer significant advantages, they lack the complexity of biological systems found in animal models.

Conclusion

In conclusion, both animal and non-animal simulation models play crucial roles in enhancing surgical education, particularly in fetal and neonatal surgery. While advancements in non-animal technologies are important for ethical reasons, the continued necessity of animal models in certain areas should be acknowledged. By responsibly integrating these models into training programs, surgical education can be further enriched while upholding ethical standards and ensuring optimal patient outcomes.

A pilot study to determine the incidence, type, and severity of non-routine events in neonates undergoing gastrostomy tube placement

BACKGROUND

Non-routine events (NRE) are defined as any suboptimal occurrences in a process being measured in the opinion of the reporter and comes from the field of human factors engineering. These typically occur well up-stream of an adverse event and NRE measurement has not been applied to the complex context of neonatal surgery. We sought to apply this novel safety event measurement methodology to neonates in the NICU undergoing gastrostomy tube placement.

METHODS

A prospective pilot study was conducted between November 2016 and August 2020 in the Level IV NICU and the pediatric operating rooms of an urban academic children's hospital to determine the incidence, severity, impact, and contributory factors of clinician-reported non-routine events (NREs, i.e., deviations from optimal care) and 30-day NSQIP occurrences in neonates receiving a G-tube.

RESULTS

Clinicians reported at least one NRE in 32 of 36 (89%) G-tube cases, averaging 3.0 (Standard deviation: 2.5) NRE reports per case. NSQIP-P review identified 7 cases (19%) with NSQIP-P occurrences and each of these cases had multiple reported NREs. One case in which NREs were not reported was without NSQIP-P occurrences. The odds ratio of having a NSQIP-P occurrence with the presence of an NRE was 0.695 (95% CI 0.06-17.04).

CONCLUSION

Despite being considered a "simple" operation, >80% of neonatal G-tube placement operations had at least one reported NRE by an operative team member. In this pilot study, NRE occurrence was not significantly associated with the subsequent reporting of an NSQIP-P occurrence. Understanding contributory factors of NREs that occur in neonatal surgery may promote surgical safety efforts and should be evaluated in larger and more diverse populations.

LEVEL OF EVIDENCE

IV.

Laparoscopy-Assisted Cutaneous Ureterostomy in Children: Early Experience

OBJECTIVE

Laparoscopy-assisted cutaneous ureterostomy (LA-CU) is a minimally invasive approach for temporary urinary diversion in children. We describe the technique, its feasibility, potential advantages, and outcomes in 12 children treated for a variety of conditions.

METHODS

Three trocars were used transperitoneally, one transumbilical, and another placed at the later stoma site. In the semilateral position, with a panoramic view, the ureter of interest is easily identified, mobilized, and exteriorized for stoma creation. We retrospectively reviewed our experience at two tertiary-care centers and included both refluxing and end ureterostomies. The study period was between October 2014 and February 2017. Renal function and growth curves were noted at follow-up.

RESULTS

Twelve children underwent LA-CU: 3 end and 9 refluxing ureterostomy. Mean age was 18.75 ± 17.60 months. Mean operating time was 94.44 ± 34.86 minutes. Follow-up ranged from 10 to 38 months. No major postoperative complications occurred. Renal function and growth curves improved in the majority of children.

CONCLUSIONS

Primary surgical correction of obstructive or refluxing uropathy is the gold standard; however, temporary urinary diversion is useful in specific scenarios. In these patients, laparoscopic assistance may offer better and direct visualization, achieves accurate and rapid identification of ureter, and provides adequate mobilization, tension-free exteriorization, and excision of redundant ureter in some to optimize drainage. One trocar at the eventual stoma site minimizes scarring.

Applications and challenges of using 3D printed implants for the treatment of birth defects

Pediatric implants are a special subclass of a vast number of clinically used medical implants, uniquely designed to address the needs of young patients who are at the onset of their developmental growth stage. Given the vulnerability of the implant receiver, it is crucial that the implants manufactured for small children with birth-associated defects be given careful considerations and great attention to design detail to avoid postoperative complications. In this review, we focus on the most common types of medical implants manufactured for the treatment of birth defects originating from both genetic and environmental causes. Particular emphasis is devoted toward identifying the implant material of choice and manufacturing approaches for the fabrication of pediatric prostheses. Along this line, the emerging role of 3D printing to enable customized implants for infants with congenital disorders is presented, as well as the possible complications associated with prosthetic-related infections that is prevalent in using artificial implants for the treatment of birth malformations.

Minimal Access Surgery in Neonates

Despite the significant advancement of minimally invasive surgery (MIS) in the adults and even in pediatric population, its role as the standard of care in the neonates has not yet been established among the pediatric and neonatal surgeons universally. Lots of controversies still arise though several advanced centers in the world having very experienced surgeons performing MIS for neonatal surgical conditions with promising outcomes. The unique physiological characteristics of a neonate make MIS quiet a challenging subject among these tiny babies. We have tried to look into the recent literature on the issues related to the use of MIS for the surgical management of neonates.

Laparoscopy-assisted cutaneous ureterostomy at suprapubic creaseline facilitates subsequent reimplantation

BACKGROUND:

Cutaneous ureterostomy is still practiced despite a trend towards primary surgical correction for obstructive or refluxive uropathy. For future open reimplantation, ureterostomy can be created by minimal invasive technique at the end(s) of the suprapubic creaseline.

MATERIALS AND METHODS:

From 1 January 2009 to 31 July 2012, seven children were treated with laparoscopy-assisted cutaneous ureterostomy followed by ureteric reimplantation. Indications were primary obstructive megaureter 3, hugely dilated ureters with reflux 3 and posterior urethral valve with poor general health 1. The distal manoeuverable part of tortuous ureter was pulled to the surface at either end of suprapubic creaseline to create the stoma. During reimplantation, this stoma was dismembered and brought inside urinary bladder obviating the need for stoma-site repair.

RESULTS:

Mean age was 4.6 ± 2.8 years with six males. There were three bilateral cases with total 10 lesions. Mean operating time was 39.8 ± 12.5 minutes. Mean follow-up was 1.7 ± 0.8 years and except for peri-stomal excoriations no major complication occurred. All these were reimplanted 6-12 months after ureterostomy and faring well except in one case.

CONCLUSIONS:

Laparoscopy-assisted cutaneous ureterostomy can be fashioned at suprapubic creaseline to facilitate future reimplantation without much jeopardy and extra scar.

Retrospective study of prenatal diagnosed pulmonary sequestration

PURPOSE

To describe the prenatal findings, treatments and outcomes of fetuses with pulmonary sequestrations (PS), which were retrospectively studied.

METHODS

From May 2010 to January 2013, 292 women were referred to the Guangdong Women and Children Hospital, Guangzhou because obstetric ultrasound had demonstrated fetal lung lesions. In 68 fetuses, the echogenic lung masses were pulmonary sequestrations deriving arterial blood supply from clearly identifiable systemic arteries rather than the pulmonary artery. We examined records of the 68 fetuses and measured the lesions and congenital cystic adenomatoid malformation volume ratio (CVR), provided prenatal counseling and treatment, documented the CVR, location of lesion, gestational age at diagnosis, need for fetal intervention, perinatal clinical course (including the development of hydrops, effusions, and neonatal respiratory distress), gestational age at delivery, postnatal ultrasound and CT, operation treatment, survival and pathology.

RESULTS

There were 68 PS in our study. All of 56 cases with CVR ≤ 1.6, survived without prenatal hydrops or postnatal respiratory symptoms. In 12 cases with CVR >1.6, 7 cases (58.3 %, 7/12) had hydrops, 10 cases (83.3 %, 10/12) survived, 2 cases (16.7 %, 2/12) of induced abortion, 8 cases (66 %, 8/12) were postnatal symptomatic. There was statistical significant difference in the incidence rate of hydrops and postnatal respiratory symptoms between the PS with CVR ≤ 1.6 and that with CVR >1.6. 66 cases postnatal survived, two cases of induced abortion. 64 cases had no prenatal treatment, two cases underwent thoracoamniotic shunt. The mean gestational age at birth was 38 weeks (range 34-40 weeks). 21 asymptomatic cases had no surgery. 45 cases (8 symptomatic and 37 asymptomatic) underwent surgical resections, 43 cases without postoperative complications, two cases of postoperative pneumothorax, no wound infection. Postoperative follow-up showed good growth in all surgery cases.

CONCLUSION

PS specific absence of hydrop was a congenital disorder with an excellent prognosis. CVR >1.6 was associated with fetal hydrops and postnatal symptoms. However, absolute CVR value cannot be used to select fetuses for fetal treatment before the development of hydrops. Surgery of PS in neonates or infants presented a good outcome.