Minimally Invasive Surgery

Minimally invasive surgery (MIS) is surgery done through small incisions using miniaturized surgical tools and cameras or telescopes. MIS usually results in less scarring and a quicker recovery time compared to open procedures.

• A common form of MIS is laparoscopic surgery, where small instruments guided by a small telescope are passed through the body wall. The instruments are held and manipulated by the surgeon who controls their movements, while watching them on a video screen. This form of MIS has been used widely in adults and more recently in children. It usually involves operations in the abdomen including surgery of the stomach, gall bladder, intestines, kidneys, and bladder.
• Another form of MIS is endosurgery (in Urology it is termed endourology). It involves operating on the internal structures of the urinary tract by passing small instruments with a light and telescope up the natural passages of the urinary tract, the urethra, or through a small puncture in the bladder or kidney. This procedure is used mostly to diagnose and remove stones in the kidney, ureter, or bladder. These methods can be used to deal with obstructions, but this has not been as successful as other methods. These methods include cystoscopy (looking inside the bladder), ureteroscopy (looking inside the ureter), and percutaneous nephroscopy (looking inside the kidney by way of a puncture through the skin).
• Cystoscopy is used for vesicoureteral reflux to inject a biodegradable material under the ureter to correct the reflux. The success rate is about 75 to 80 percent, and more study is being carried out to determine the value of this approach.
• Robotic surgery is one of the most exciting and promising areas in the field of minimally invasive surgery. Advances in robotic technology make it ideally suited for use in a number of complex pediatric surgeries, and physicians at Boston Children's are pioneers in the field.
• Endoscopic strip craniectomy is a common form of MIS to treat craniosynostosis, a condition where the sutures in the skull fuse too early during an infant’s development. Endoscopic strip craniectomy, also called endoscopic release surgery, works to release the fused sutures, helping restore the shape of your baby’s head and face, and giving their brain enough room to grow safely.

Minimally invasive surgery offers the potential to perform operations with less pain and quicker recovery, but it is not appropriate for all surgeries. Your surgeon will be able to tell you in which cases it may be the best choice.

Surgeons who perform this type of surgery also know how to perform the same operations with alternative methods, if necessary. New technologies, such as robotic-assisted surgery, offers the potential for minimally invasive surgery to continue to improve and offer even more benefits to pediatric patients in the future.

Laparoscopy

Laparoscopy is the most common MIS procedure for major operations on the kidney and bladder. It may be performed from the front of the body, the side, or the back, depending upon the operation needed and the surgeon's preferences.

Operations most commonly performed using these techniques include:

• Diagnostic operations for testicles in the abdomen
• Orchiopexy (bringing a testis from the abdomen)
• Nephrectomy (removing the kidney)
• Partial nephrectomy (removing part of the kidney)
• Pyeloplasty (correction of kidney obstruction near the kidney)
• Removal of kidney cysts
• Removal of some kinds of stones
• Removal of the ureter along with the kidney, if it is also diseased
• Bladder surgery, particularly for vesicoureteral reflux

Robotic surgery

Laparoscopy may also be performed with the assistance of a surgical robotic system. This system is performed in a similar way as laparoscopy with small punctures in the abdomen to place instruments with a lighted telescope to see the operation. The instruments, however, are controlled by the surgeon working through a complex computer that permits the movements to be more natural, smooth, and delicate.

The surgeon is able to see the operation with a three-dimensional image, while sitting at a console manipulating the instruments in the patient. The surgeon is in control at all times; the robot simply makes the movements more precise and smooth. This has permitted surgeons to perform very delicate reconstructive operations even in very small children, that would have otherwise been very difficult using conventional laparoscopy.

Laser surgery

Many people ask about "laser" surgery, which is simply the use of laser power for some form of surgery. It may be confused for laparoscopic surgery. Lasers are used to break stones when used in an endourological procedure such as ureteroscopy. They may also be used to cauterize blood vessels in special cases within the urinary tract.

The advantages of MIS include very small scars, which are difficult to see after several months, less pain after surgery, and usually a shorter hospital stay. In younger children this advantage is less noticeable because young children recover easier from even major surgery. In school-age and adolescent children, however, the difference is very noticeable. In many cases children can go home in one to two days instead of three to four days. They will be able to return to their normal activities more quickly as well. This will depend upon the particular operation, but even after a kidney operation it can be possible to be back to normal activity in seven days instead of two or three weeks.

There are relatively few disadvantages to MIS methods as long as the surgeon is experienced in them. More surgeons are being trained in these methods and it is becoming a routine part of training in many centers. In rare cases, the operation will not be able to be finished laparoscopically, due to unusual anatomy, bleeding, or complications from the procedure. In these cases the operation will nearly always be finished by traditional methods of "open" surgery with an incision.

However, there are many procedures which MIS is not appropriate for. Technical limitations of MIS equipment — such as lack of dexterity of the tools — make it unsuitable for many pediatric procedures.

The overall safety of MIS techniques appears to be equivalent to open surgery in both children and adults. As with all surgery, the experience of the surgeon and the center where it is being performed is very important to the outcome of the operation.