Category Archives: Minimally Invasive Surgery

Infant surgery has changed massively during the past century. Access to misbehaving but buried parts is now often done using probes and without open surgery – so reducing all that comes with it. Welcome to the era of MIS or MAS (minimal access surgery).

Why are there so many kinds of scars from PS surgery?

As a boy growing up with a scar cluster front and centre on my belly, I found I had several fixations which have never really left me.

  1. I was desperate to know what caused this scar, left by pyloric stenosis (“PS”) surgery I had when just 10 days old.  Apart from my mother telling me several times that I had been “a little bit sick as a baby and a doctor had made me better” it wasn’t until much later in life that I pieced that puzzle together.
  2. I was also desperate to hide my belly from public view.  I shrank from people’s inquisitive stares and inevitable questions and felt deeply embarrassed because I couldn’t handle, let alone answer them.
  3. Whenever I saw people in beach or gym attire (and with a bare midriff) I was ravenous in my search for anyone with a scar similar to mine – but never found anybody like me in that way until in my adult life.

People02Only in recent years have I learnt that this somewhat bizarre cluster of phobias and fixations is by no means unusual for survivors of infant surgery.  As mentioned in a recent post, there are also many extroverts who totally escaped my problems – and often find them rather silly.

Obsession #3 has continued with me (and it seems with others in their more mature years).  In recent years I have seen quite a number of people with what look like being scars from PS operations, and this is largely because I have learnt that this “procedure” is done using a number of surgical techniques.  So my mind is now programmed to search for and recognize half a dozen scars!  Yes, weird and whacky!

The development of the internet has birthed several forum sites where people like me can network and break out of their feelings of isolation and self-flaggelation.  The web even allows us now to compare scars and to have many of our questions answered much more fully than my 1940s parents would ever have been able!

Recently Facebookers with an interest in their own or their child’s PS mentioned the sheer variety of scars from repairing PS, a fairly common condition remedied with a relatively simple technique.  My own research of this whole subject area enabled me to attempt an answer –

The pyloric ring muscle usually sits under and behind the right (and exit) end of the stomach, so below the right ribcage.  It can be fairly easily accessed from anywhere below the ribs and above the navel.

The navel (or umbilicus) itself is (or was once) often avoided as a point of access, especially if it hasn’t fully healed after the baby’s birth and as its folds are a haunt for germs.  The umbilical incision (“Tan Bianchi” after the surgeons who promoted it) is a semi-circle incision usually over the top of the navel, sometimes extended by one or both horizontals (making it an omega sign): through this the pylorus is worked on. The Tan Bianchi incision is now often used as it allows open access but (if done well) leaves a minimal scar.

The keyhole op (“minimal access surgery” or MAS) was introduced in the 1990s: a 5mm probe (tube or “port”) through or near the navel inflates the belly and adds light, and then two other probes (3mm) higher up allow instruments to enter and do the work on the pylorus. In recent years “single port MAS” has been introduced by which everything is done through the one port at the navel.  Special care with infection control is very important, and this technique comes with a higher number of infections, but it also leaves minimal scars and is therefore preferred by parents.  MAS requires a higher level of training and skill than open surgery, but experienced surgeons can use it with similar results and complication profiles.

The open incision was and is still the easy one for surgeons, but growing numbers of younger pediatric surgeons have now learnt the umbilical and/or MAS techniques.

Abdomen incisions1Open surgery involves cutting through layers of skin, fat, muscle, and the fine material that holds our abdominal bits and pieces in place, plus of course nerves and blood vessels.  There are several layers of muscle forming the wall of the abdomen, each running in different directions to enable them to do a variety of tasks and to add toughness.  Down the front and middle of the abdomen, running from the breastbone to the pubic region, is a strip of tough connective tissue called the “linea alba” or “white line”: it has less blood vessels and nerves and anchors the various muscle sheaths.

Conrad Ramstedt, who in 1912 pioneered and promoted the technique that is used to treat infant PS, used the median (or middle) incision down the linea alba that was and is still used for much (and especially major) abdominal surgery.  It gives good access, can be easily extended, and avoids the complex muscle layers on either side.

Other surgeons preferred to avoid this area for relatively short incisions, as the linea alba’s poor blood supply slowed healing and therefore increased the risk of wound rupture.  These doctors moved their vertical incision to the right, the “para-median” incision.

In the 1930s, two other incisions became popular for PS surgery.  Both avoided the vertical openings which it was claimed came with increased exposure of internal organs, and more wound complications.  By cutting through the several layers of muscle and repairing each separately, it was claimed that the wound was easier to control.  One of these incisions was angled just under the right ribcage, the Kocher or “gridiron” incision.  The other was transverse (“across”) and became the most popular one used for PS surgery to date.  Transverse incisions are placed wherever the surgeon likes or locates the pylorus: some are almost at navel level, other horizontal just under the ribcage, and most in between.

Reading the journal articles that advocate the writers’ incision preference has led me to conclude that a surgeon’s choice seems to depend more on their classroom or craft training than on truly decisive benefits or hazards.

The development of the umbilical and MAS techniques has occurred only since 1990, urged on by the cosmetic benefits which are usually and typically urged on conservative and technique-oriented doctors by the concerned parents of unknowing babies.

Postscript

Since writing this post I came across a website under the title of Common Abdominal Incisions.  It sets out in (what I find) fascinating detail and in generally understandable English the various considerations, benefits and hazards regarding the incisions used for many of the commonly used abdominal surgeries, and what each incision involves.  In the past I have sometimes found it necessary to “translate” the information given on a medical website, but in this case that seemed quite unnecessary.

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Pyloric stenosis surgery – “somewhat improved”

Has the treatment of infant pyloric stenosis (“PS”) improved with the years?

Yes!  In a recent post I listed many of the clear and obvious ways it has.

Adults struggling with IBS, adhesions, or PTSD may well doubt that; any and all of these can at times be linked with their infant surgery.

The mother I read about recently must surely also doubt that much has been learnt: she was diagnosed with PTSD a few months after suffering with her newborn through several weeks of slow and shoddy diagnosis followed by “last minute, life-saving” PS surgery.

And the continuing avalanche of parents’ posts on social forum sites like Facebook and BabyCenter show this hapless mother is far from alone.

However, what I wrote in the above-mentioned post stands: it is beyond doubt that, thank God and thanks to the medical community, infant surgery including the treatment of PS has made huge progress.

Infant surgery03Last year I read the summary of a 2014 report that supports the claim that the actual surgery to remedy PS has also improved – but only marginally.  The survey evaluates the records of 791 little PS patients of a pediatric surgeon over a 35 year period (1969-2003).

Most of the results reported in the Abstract of this article (sadly, all that is publicly available) merely confirm the usual facts about PS, information that will not surprise those who know something about this condition.

  • 82% of the patients were male and 18% were female.
  • The average age (presumably at surgery) was 38 days and ranged from 7 days to 10 months.
  • Only 5% were not Caucasian.
  • 10% had a family history.
  • 15 babies (3.1%) were premature at the time of diagnosis (so in fact, many more).
  • 9% had other conditions or abnormalities.
  • 10 babies (1.2%) developed PS after surgery for another condition.
  • 13 (1.7%) were treated medically and avoided surgery.
  • All the pyloromyotomy operations were done by open surgery: the incisions used were sub-costal, transverse, or upper midline.
  • 14 babies (1.7%) had other surgical work done (presumably including herniation).
  • 87 of the operations (10%) were followed by complications: 1.1% happened during the surgery, and 9% post-operatively.
  • 2 babies died.
  • Other evaluation results showed some areas of improvement.
  • When ultrasound imaging was used, the age at diagnosis was reduced by about 10 days.
  • All the operations were done using general anesthesia and endotracheal intubation (breathing tube).
  • From 1982, precautionary antibiotics were given before surgery and this resulted in wound infections being reduced to 3.9%.

This surgeon was also responsible for correcting the inadequacy of the work of some non-pediatric surgeons, and these statistics make grim reading:

  • There were 13 such little patients, 12 of them transferred from non-pediatric surgeons.
  • These 13 accounted for 16 complications including one death.
  • 5 of the babies needed further surgery: 4 for an incomplete pyloromyotomy and the other for a perforation of the pyloric canal.

The report drew these conclusions:

  • IHPS should be considered in any vomiting infant.
  • Ultrasound examination allows earlier diagnosis.
  • Serious complications are uncommon and avoidable, but recognizable and easily corrected.
  • Surgeons who do more than 14 pyloromyotomies per annum see fewer complications.

This report (as stated above) deals only with the actual surgical treatment of PS, and not the complaints of many about the total management of this condition.  The report featured does not survey the standard of the diagnosis of PS, nor the often uninformed, sweeping, and simplistic reassurances given about the possible short- and long-term after-effects of PS and its surgical treatment, about which so many doctors and parents seem to be quite “in the dark” (or possibly in denial).

RUQ PLM-3This blogsite and the social media posts of countless parents and patients express gratitude for the survival of almost every PS baby, ever since the Ramstedt pyloromyotomy (surgical operation) rapidly became the standard treatment after 1912.

It is often remarked that the Ramstedt pyloromyotomy is one of the few surgical techniques that has continued as the standard and virtually unchanged since it was introduced.  It is relatively quick and simple to perform, and almost always immediately effective (as much as can be expected of any surgical procedure).

What the report implies but fails to acknowledge is that many older surgeons continue to perform Ramstedt’s pyloromyotomy using the old and often disfiguring open incisions.  Other recent statistics show that the new and cosmetically superior laparoscopic surgery is now used in over half of PS operations.  Understandably but sadly, many older surgeons resist mastering current best practice.

What then is clear from the material collected and reviewed in the two posts (this one and the linked post)?

  • The overall management of PS has seen huge progress.
  • The actual surgery for PS has changed little in a century, but continues to be marginally and slowly improved on.
  • There remain several areas of immediate and significant concern to PS patients and their parents which the medical community is loathe to recognise, let alone seriously tackle.

And therefore numerous PS parents and patients will continue to speak up, network – and post!

Pyloric stenosis – surgery or medical therapy? (2)

When I wrote this post there had been only one response to the question I posed at the end of my previous post: If you were the parent of a baby dying with pyloric stenosis (“PS”), and you knew of the choice you could make between surgical and medical treatment, what would you ask, choose and why?

Since then my web searching and reading have yielded two more sources which are worth considering.

RubyOne is from Michelle, who wrote a forum post about her infant daughter’s hemangioma (“strawberry birthmark”) and the very different responses to this by two mothers who had also had a child with a facial birthmark.  One had opted for prompt surgery and the other had waited and seen her child’s blemish almost disappear by age 7.  Neither child had ever shown being bothered by the surgery or growing up with the birthmark.

Michelle set these two quite different stories next to her own, as she had been “really self-conscious … particularly as a teenager” about the disfiguring scars from the PS operation she had had as a baby.

Three different people and three different reactions to a very personal issue!

The second document I found was a Spanish powerpoint about PS surgery – which I was able to get translated.  Further to what I stated in my previous post, Dr Christian Pérez Pulgar actually presented in a fair way the alternative way of treating PS: by a course of medical therapy.  The careful attention he devoted to this was of much interest to me –

  • Before the widespread use of Pyloromyotomy, hypertrophic pyloric stenosis was treated medically with atropine.
  • However, the excellent results associated with the Ramstedt procedure [pyloromyotomy] have led to a virtual abandonment of the non-surgical treatment.
  • According to theory, the [drug] Atropine temporarily suppresses muscle contractions and decreases gastrointestinal peristalsis, and therefore breaks the cycle that caused the symptoms.

The key details of the most recent article advocating the value of the medical treatment alternative (and published in 2005 by a team of Japanese doctors) follow on the next screen –

  • Atropine Sulfate injectn1Dr H Kawahara used atropine intravenously (0.01 mg / kg / day) in 19 patients 6 times a day, 5 minutes before feeding.
  • Treatment with atropine was successful in 17 of the 19 patients.
  • The total average hospital stay was 13 days, the range being 6-20 days.
  • The duration of the intravenous and later oral atropine therapy was 7 and 44 days respectively.

Sadly, Dr Pulgar does not give us his personal evaluation or comment.  However, from his first screen (as above) and the further content of his document, we may conclude that he concurs with the strong advocacy of surgery for all but the mildest of PS cases.

Where does all this leave the parents of a PS baby?

  • As my blogging colleague Wendy Williams suggests, most parents of a PS baby will not have the time or tranquil mind to dig up the facts, weigh up what they discover, and then muster the confidence to discuss these matters with a time-pressed and typically single goal-oriented and controlling doctor.
    However, up to about 20% of PS babies have a parent or close family member who has been through PS surgery and these parents will be far better prepared than most – and also well able to guess at how their child is likely to handle the future wearing surgical scars.
  • 110908 sick bub1My years of researching this subject have shown very clearly that while the majority of those who carry a surgical scar were troubled by self-consciousness and self-hatred in their growing years, and many of these people still don’t like it, there is also (what seems) a minority who profess never to have been bothered by being scarred in their infancy.  And then there seem to be just a small minority (as far as I can assess that) who have significant to major ongoing effects from their surgery and/or the way their closest relatives failed to manage it well.
  • Laparoscopic (or “keyhole” or “minimal access”) surgery can in theory greatly reduce scarring from surgery.  However,
    (1) not every baby has access to this, as it requires considerably training for the surgeon and team, is more costly, and not available in every hospital; and
    (2) because scars resulting from infant surgery grow with the patient, the already disfiguring pitlike scars left by laparoscopic surgery will usually become at least 3 times larger and more obvious and disfiguring.

My conclusion?

We are each very different and unique. And we know ourselves best.

Therefore if parents have reason to think that their baby may in time be significantly affected by the scars they inherit from their battle to survive, they should (if they can) seriously consider pressing their doctor to support them in trying the medical therapy alternative to surgery.  It will take longer and will cost them more patience and perseverance, and perhaps some more money.  But they can be assured that in about 80% of cases (see Dr Pulgar above and also my previous post) they will be successful, they may well save their child trauma and other emotional pain, and their child will probably thank them one day in a most wholehearted way!

Improvements in infant surgery (1) – Minimally Invasive Surgery

Almost two years ago I wrote a post about the improvements in infant surgery since I had my own life-saving pyloric stenosis operation (“PS”) in 1945.  If these changes for the better are of any interest to you, the reader, you will find the post via this link.

In this post I want to pass on how one pediatric surgeon regards one of these improvements: the increasing use of minimally invasive or laparoscopic surgery (“MIS”) rather than open surgery (“OS”).  Dr George W Holcomb is (or was then) the Surgeon-in-Chief at the Mercy Children’s Hospital in Kansas, Missouri, and his powerpoint presentation gives some telling insights into the medical mind.

Dr Holcomb’s opening definition of innovation in medical science is the “creation of more effective health care technologies, processes, or medicines that are accepted by doctors, payors [sic] and patients.”

He then lists as the three most impactful medical-surgical innovations of the last 60 years

  • the heart-lung machine (1953),
  • total parenteral nutrition (TPN, 1960s) or feeding a patient totally intravenously when the gut is unable to process food, and
  • laparoscopy and thoracoscopy (1988), by which surgeons work inside the abdomen or chest by inserting narrow tubes through which they can see or work with miniaturized instruments.

Holcomb discusses the last these, which he says has almost overnight “revolutionized” the model for much surgery, resulting in less pain, faster recovery, and reduced scarring for the patient.

PLM Lap 52 CO2 off1At first, MIS was used mainly in surgery on adults, as the miniaturized instruments and skills required for infant surgery took some time to be developed.  I was fascinated and grateful for the revealing insight Dr Holcomb gave into how MIS was received before 1995.  He reports that “organized surgery” (presumably meaning medical schools and professional leaders and associations) at first regarded it as a passing fad.

Interestingly, I have on file several journal articles which still (more recently) question the benefits of MIS.  While I am well aware that MIS has some disadvantages, risks, and possible negative consequences, open surgery also has its share of these.

Holcomb reports that support for the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) rose at this time – presumably due to their interest in and support level for MIS.  Howver, the numbers of those who attended the meetings and conferences of the American College of Surgeons (ACS, presumably a more time-honoured, august and conservative body) fell, while “device manufacturers flocked to SAGES – and felt welcome”.  Ah, when novelty, modernity and commercial interests unite!

The presentation goes on to report that after about 1995, ACS began to realise that MIS was no passing fad, but SAGES nevertheless continued to grow and attract business.

TerryB PLM 061203

This baby’s mother expressed her upset at the size of this PS wound

Dr Holcomb then directs his attention to infant surgery, focusing on PS, the most common reason for it.  He says that in 1990 pediatric surgeons who began to use MIS were seen as “cowboys” – young and daring but reckless.  He also tells us that many “open surgery” pediatric surgeons regarded the size of their incision as a reflection of their skill!  He adds with obvious feeling that it was commonly felt that a large scar looks impressive on a baby “but we [surgeons] don’t see these patients as teenagers or adults”.  How absolutely true!  Nor do many surgeons seem to realize the emotional pain and damage these patients and their parents may suffer as a result of their insensitive treatment and care.  Holcomb comments succinctly and with some understatement that these people “have no appreciation for the benefits if MIS”.

The good doctor then continues to discuss MIS.

It is not easy to learn, he says.  I have read that it usually takes some 30 or so “tries” to learn the techniques involved in a pyloromyotomy by MIS.  At first it also takes longer to do and results in more morbidity (mistakes, complications and unwanted effects and extra care).

Dr Holcomb continues by mapping real progress since about 2000.

  • Some general surgeons trained in MIS also specialized in pediatric surgery and started to teach in medical schools.
  • Schools began to recruit trainees from recognized MIS pediatric surgery programs.
  • Appreciation of the benefits of pediatric and adult MIS developed: reduced pain, shorter hospital stays, faster recovery, and an earlier return to normal routines.
  • MIS procedures for many conditions reported reduced operating times, especially due to less time being needed for wound closure.

Also of interest to readers will be Dr Holcomb’s notes on the present situation.

  • Most practising MIS surgeons are young, or 2-3 generations removed from the “founding fathers” of pediatric surgery.
  • Because there are so few schools teaching pediatric and MIS surgery, “the opinions of a few affect the masses”.
  • In pediatric surgery, apart from PS, there is “a wide variety of rare cases” which makes it hard to gather objective and meaningful statistics and treatment data.

Regarding PS however, I have seen a considerable amount of data which tends to underline, or at least show equivalence to, the value of MIS on technical, cost and treatment grounds.  And of course this disregards the studies which have established the huge preference for PS surgery by MIS whenever parents of the infant patients were consulted.