Minimally Invasive Surgery in Pediatric Surgery

三軍總醫院　小兒外科朱志純

為恭紀念醫院 2007.9.4

Fewer and fewer kids ---Quantity and Quality

1

2

3

4

5

民國 50年 60 70 80 90

每一婦女平均生育數 2.46

3.71

1.72

5.59人6

1

2

3

4

5

91

每一婦女平均生育數

1.40

2.46

3.71

1.72

5.59人6

1.34人1.24人92年

微創手術Minimally invasive surgery

　

近年來的新技術發展微創手術 Transumbilical

extracorporeallaparoscope-assisted appendectomy (TELA, 經臍腹腔鏡輔助闌尾切除手術 )

Nuss procedure for pectus excavatum(漏斗胸微創手術 )

Submucosal injection of Deflux for vesicoureteric reflux

Minimally invasive surgery –Tradition or Innovation?

Minimally invasive surgery—hernia repair

Minimally invasive surgery—pyloromyotomy for hypertrophic infantile pyloric stenosis

傳統切口及微創切口

Appendectomy闌尾切除術 Open appendectomy Laparoscopic appendecotmy Laparoscope-assisted

appendectomy Transumbilical extracorporeal

laparoscope-assisted appendectomy

All-in-1 Laparoscope with working channel, air-inflation, irrigation & suction

Single umbilical-punctured laparoscope-assisted appendectomy

Low cost

Low infection rate

No visible scar

Short LOS

Vesicoureteric reflux

Open methods Extravesicle open method

(detrussorrhaphy ) Submucosal injection of Deflux

Anti-reflux procedure---Intravesicle approach

Anti-reflux procedure---Extravesicle approach

Submucosal injection of Deflux

Submucosal injection of Deflux

Submucosal Deflux injection

Gr. VI No reflux

Pectus excavatum (funnel chest)

Ravitch procedure—傳統肋軟骨切除 Nuss procedure—支架頂出

Preserve the perichondrum and remove all the deformed cartilage

Ravitch Procedure(removal deformed cartilage, fracture of the sternum)

Ossification of the cartilage

Scarring

Blood loss

Ravitch 手術 1943~

Scars

After sternum turn-over (Wada)

Dr. Donald Nuss

Nuss Procedure

Dr. Park Hyung Joo

The pectus bar is supported by the ribs and the intercostal soft tissue.

Evaluation

Haller index: A/B Depression index:

C/B Asymmetric index:

R/L Eccentric index:

angles

(Park, et al., 2004)

saucer- shaped

Asymmetric

II

funnel-shaped

Symmetric

I

eccentric

unbalanced

Dr. Park

Pre-operative device remolding

Nuss procedure

Crane Technique

Nuss Procedure

Is thoracoscopy really necessary? Are stabilizers necessary? Is extrapleural approach possible?

Our way.

STERNUM

SUPPORTING RIB

Stabilizer: avoids flipping of the bar

Kids are growing!

Funnel-shaped depression

手術前 手術後

Saucer-shaped depression

Asymmetric

Female

Re-do after Ravitch

Lung entrapment

2 days after operation 4 days after operation 7 days after operation 10 days after operation 14 days after operation

The future

Key-hole surgery Robot assisted surgery 70% of pediatric surgeries will be

minimally invasive. UPJO, GERD, Hirschsprung’s disease.

Kasai’s procedure for biliary atresia, mediastinal tumor, lung decortication…