Preface

Article Outline

• Copyright

This issue of Seminars in Pediatric Surgery deals with a number of advanced endoscopic surgical procedures in children. Over the last 15 years, endoscopic surgery has become well established, albeit at a slower rate in pediatric surgery when compared with endoscopic surgery in adults. An endoscopic surgical variant has been developed of almost any operation that was previously classically performed open, eg, repair of esophageal atresia, anorectal anomalies, treatment of malrotation, etc. One of the major problems in pediatric surgery is the limited number of conditions and their complexity, so that controlled studies comparing open with endoscopic surgical repair are rare. However, there is not much reason to believe why these procedures, when performed endoscopically, should not be equally effective and also result in a smoother postoperative recovery, better cosmesis, and fewer adhesions.

This issue of Seminars in Pediatric Surgery focuses on a selection of advanced endoscopic surgical procedures in children. As CO₂ insufflation is used in most of these often prolonged procedures, an overview of the physiologic responses to endoscopic surgery in children is presented by Ure and coworkers. It is clear that the use of CO₂ in endoscopic surgery has a profound influence on child physiology. Pediatric anesthesiologists have learned how to deal with these changes, and the general conclusion is that the use of CO₂ in children during endoscopic surgery is clinically well tolerated. The physiologic alterations that occur leave no doubt that the lower the CO₂ pressure employed, the better it is for the patient.

Performing an open thoracotomy for whatever procedure has always been considered as major trauma with considerable and long-lasting morbidity. Even when a muscle-sparing incision is used, wound problems are considerable, at least in adults. Spreading the ribs is undoubtedly a major contributing factor. Reports concerning complicated procedures, such as thoracoscopic correction of esophageal atresia, and complex lung surgery, such as lobectomy, are still scanty. One of the largest single-center series on thoracoscopic correction of esophageal atresia, of over 50 cases, is reported by van der Zee and Bax from the Wilhelmina Children’s Hospital in Utrecht. Thoracoscopic aortopexy for tracheomalacia is a rather simple procedure, and although the indication for any operation should be sound, it is always a compromise between the result to be expected and the magnitude of morbidity. As morbidity with a thoracoscopic approach is certainly less, the incidence of aortopexy may rise. Rothenberg reports on his extensive experience with endoscopic lung surgery in children.

Whether a congenital diaphragmatic hernia should be approached thoracoscopically or laparoscopically is a matter of debate. The balance seems to be in favor of a thoracscopic correction, but as with many discussions in surgery, dogmatism should be avoided. Moreover, sometimes a combination of a thoracoscopic with a laparoscopic approach or vice versa may be optimal, as explained by Becmeur and coworkers.

Open access to the pancreas, especially in children, who are organomegalic as a result of high glucose intake to control hyperinsulinemic hypoglycemia, requires a wide incision for access. Such large-access wounds may cause considerable postoperative problems, especially if there is a postoperative pancreatic leak. Minimal access pancreatic surgery avoids these problems. Due its magnification, the endoscopic approach allows for meticulous exploration of the pancreas, which is especially useful in detecting focal form of hyperinsulinism. Reoperative pancreatic surgery may be necessary in hyperinsulinism. Although this is usually quite difficult when using an open approach, much fewer adhesions are seen when the first operation has been performed endoscopically. Bax and van der Zee provide an overview of the endoscopic surgical approach of hyperinsulinism in children.

Fundoplication is one of the most commonly performed operations in children and, as can be expected, a number of these operations fail irrespective of whether an open or endoscopic surgical approach has been chosen. The same arguments for why the operation should be performed endoscopically in the first place apply for reoperative surgery: fewer adhesions, less postoperative pain, quicker recovery, and better cosmesis. Ostlie and Holcomb report on their experience regarding 30 reoperative endoscopic procedures in a series of 370 laparoscopic Nissen fundoplications. They show that reoperative fundoplication is feasible with low morbidity and good functional results. They consider fixation of the esophagus to the crura of paramount importance in avoiding intrathoracic wrap migration. Moreover, in case of a wide hiatus, the use of a Surgisis patch is advocated.

The use of an endoscopic surgical approach in childhood cancer is still controversial. The behavior of the various solid tumors in childhood is different so that no uniform rules apply. For this reason, only one particular tumor is considered here. Iwanaka reports on his experience with endoscopic surgical techniques in neuroblastoma.

Whether anorectal anomalies should be approached in an endoscopic surgical manner is still a matter of discussion. Georgeson starts his contribution by stating that the current standard of surgical care for high anorectal malformations is posterior sagittal anorectoplasty, but concludes that there appears to be less scarring in the pelvic floor and less injury to the muscles with the laparoscopic technique as compared with the posterior sagittal technique.

The discussion as to whether the adrenal glands, kidneys, and ureters should be approached retroperitoneally or transperitoneally has not yet been settled. Valla puts the retroperitoneal approach into perspective and gives a balanced view of the possibilities and impossibilities.

The last contribution is by Bailez on the use of endoscopic surgical techniques in the treatment of uterovaginal anomalies in children. The era of pure ablative endoscopic surgery has moved to more innovative methods of reconstructive surgery, eg, vaginal reconstruction using bowel.

As the defaults of pediatric surgery seem to have been reset, I would like to invite each of you to collaborate in multicenter trials to reset the standards as well.

It has been a great privilege for me to serve as guest editor of this issue of Seminars in Pediatric Surgery, and I would like to thank each of the contributors for their help and Dr. Grosfeld for the opportunity.