Teaching Impact in Pediatric Minimal Access Surgery: Personal Perspective from “Fellow”

Original Article

Teaching impact in pediatric minimal access surgery: Personal perspective from “Fellow”

Dragan Kravarusic Alberta Children's Hospital, Calgary, Alberta, Canada

Address for correspondence: Dragan Kravarusic, Alberta Children's Hospital, 1820 Richmond Road, SW, Calgary, Alberta, Canada T2T 5C7. E-mail: [email protected]

Abstract INTRODUCTION

The global objective of this paper is to review Ever since its entry more than two decades ago, from the “Fellow” perspective, the current status minimal access surgery (MAS) introduced a sweeping of pediatric minimal access surgery (MAS) in terms of teaching feasibility, safety and impact revolution in surgical practice. Worldwide, the on standard practice paradigms. In the pediatric volume of MAS procedures has rapidly increased in general surgery field, surgeons are dealing with recent years and consequently, recent general surgery a wide range of pathology that includes thoracic, graduates are seeking MAS fellowships in record abdominal, urological and gynecological numbers. The .com).field of pediatric surgery is no exception procedures. The learning curve is slow because of a relatively small volume of patients. However, and there are numerous patients who can benefit from gradually but steadily, a significant proportion of this approach.[1,2] the procedures traditionally performed, with major open exposures at present, are preferentially MAS is a natural extension of traditional surgical performed by minimal access. Currently, minimal .medknowtreatment, but the techniques and dexterity required access surgery training is incorporated into adult general surgery residency/fellowship programs to master these procedures are a separate set of skills. and teaching techniques of pediatric MAS are Currently, MAS training is incorporated into adult general available only as seldom international workshops.(www surgery residency programs and MAS fellowship Pediatric surgery fellowship programs with opportunities are feasible in well-established programs incorporated guidelinesThis PDF for MAS is training available are just forin free many download centers. In contrast, from teaching techniques of recently feasible in selecta site centers, hosted mostly by as Medknow Publications “self” established programs. In many other pediatric MAS are rarely available as international course pediatric surgery centers, teaching the “glamour” lectures (didactic or with animal models) or as of MAS is quite dependent on a program director’s broadcasting of specific case demonstrations used as vision. Integration of MAS training into the teaching opportunities. Pediatric surgery fellowship secondary residency/fellowship curriculum of programs with incorporated guidelines for MAS training pediatric surgeons is the inevitable goal. MAS- minded education and research through adequate are available only recently in select centers, mostly as training will pay dividends and “manufacture” “self ” established programs. In many other pediatric competent, contemporary trainees. National surgery centers, teaching the “glamour” of MAS is quite Pediatric Surgery Associations should be dependent on a program director’s vision. responsible for setting criteria that consider the MAS for accreditation with maintaining the MATERIALS AND METHODS international standards of these teaching programs. The global objective of this paper is to review from Key words: MAS, pediatric, teaching the “Fellow ” perspective, the current status of

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216 CMYK Kravarusic D: Teaching impact in pediatric pediatric minimal access surgery in terms of teaching Table 1: The spectrum of MAS procedures with comparison feasibility, safety and impact on standard practice to relevant conventional “open” procedures during the same period of time. paradigms of a single institution. The Alberta MAS OPEN Children’s Hospital is a pediatric tertiary care facility for patients from the neonatal period, to late Thoracoscopic adolescence. This report is a retrospective review of Type of procedure No. Conversions Lung biopsy/wedge 18 0 4 all MAS procedures performed in the pediatric general Mediastinal biopsy 4 1 0 surgery department, from June 2004 to June 2005. Drainage and debridement for empyema 11 0 0 Excisions of benign tumor/cyst 2 0 0 The selection of patients and procedures in this series Aortopexy 1 0 2 was highly individualized between staff surgeons with Blebectomy for recurrent pneumothorax 6 0 0 consideration regarding patient/parent preference, Nuss operation 14 0 0 Laparoscopic surgeon’s experience, complexity of the procedure Appendectomy 56 4 242 and the patient’s medical condition. All surgeries were Cholecystectomy 24 0 0 performed by the single pediatric surgery fellow, with Splenectomy 4 1 1 Fundoplication 42 0 7 close supervision by the attending staff surgeon. Heller myotomy 4 0 0 Absolute contraindications included hemodynamic Pyloromyotomy 3 0 12 Adhesiolysis 8 1 14 instability, severe cardiac diseases, pulmonary Gastrostomy 31 0 15 insufficiency and malignancy. Cecostomy 6 1 1 Excision of mesenteric cystic mass 1 0 1 Liver biopsy 2 0 2 RESULTS Excision of urachal cyst 1 0 3 Retroperitoneal biopsy/lymph node A total of 314 MAS procedures were performed in sampling .com). 2 0 6 Bowel resection’s for Crohn’s/FAP 6 2 5 311 patients, of which 56 were thoracoscopic and Pull through for Imperforated anus 2 1 4 258 laparoscopic [Table 1]. The range included 28 High ligation for varicocele 12 0 0 different procedures with an overall conversion rate Fowler-stephens operation 1st stage 18 0 0 Exploration for contralateral hernia 22 0 0 of 3.5% (1.78% in thoracoscopic and 3.87% in Ovarian cyst drainage/resection 9 0 0 laparoscopic procedures). .medknowOvarian detorsion 1 0 0 Nephrectomy 4 0 2 Total 314 11 321 The great majority (90.32%) of relevant thoracic MAS: Minimal access surgery procedures were performed thoracoscopically(www. Lung biopsy was the most common performed procedure variable percentage (45%). (In total, 258 from 573 (18 cases) with excellentThis results PDFa andsite isa zer hostedavailableo conversion by forMedknowprocedures.) free download Publications All 24 fromcholecystectomies were rate. Minimal access repair of pectus excavatum (nuss performed as laparoscopic (100%) and of the 49 operation) was performed in 14 children with good fundoplications, 42 were performed laparoscopically cosmetic results, without complications and (85.71%). These two procedures have already become conversions. Drainage of empyema with debridement the “gold standard” in pediatric surgery practice. The was done in 11 cases and this modality is especially insertion of gastrostomy tube only or as part of anti- suitable for children where general anesthesia is reflux procedures for patients with feeding difficulties, unavoidable. Thoracoscopic aortopexy was very was done in 31 cases. This technique provided very challenging, but the low volume of these procedures good visualization and was especially important for prevents us from reading valid conclusions of this choosing “the right place” for a G-tube. Of the 5 approach. For solitary, simple, cystic lung lesions, splenectomy cases, 4 were done by laparoscopy the MAS approach seems to be a very comfortable (80.0%), with 1 open evacuation of the large spleen. and safe option. During this period of time, 298 appendectomies were performed, of which 56 were done by laparoscopy From selected routine abdominal surgery, (18.79%), with 4 conversions (7.14%) for perforated laparoscopic procedures replaced open surgery in appendicitis with diffuse purulent peritonitis.

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CMYK217 Kravarusic D: Teaching impact in pediatric

Selection for laparoscopic appendectomy was focused MAS training programs. Computer-generated virtual to a certain group of patients (obesity, female reality systems allow sensory interaction and provide adolescents and patients with uncertain diagnosis) “hand-eye coordination” models which are especially who were especially suitable for such a modality. useful for self-assessment in simulation-based surgical Laparoscopic cecostomy for bowel management of skills training.[3,4] The reliability and validity of this incontinent or severely constipated patients (mostly modality in teaching has been confirmed in numerous spina bifida group) were performed in 6 cases. This studies.[5-8] MAS in animal laboratories has been approach is very well-established at this hospital, with recognized as well as a method of teaching, long term follow-up and documentation of improved developing and refining surgical techniques which quality of life. From six laparoscopic bowel resections contribute to a beneficial outcome in patients.[9] (4 for Crohn’s disease and 2 total colectomies for However, pediatric MAS workshops are quite rare and familial adenomatous polyposis syndrome) with attendance at a 1 or 2 day workshop does not extracorporal anastomosis, we had conversion in 2 translate into expert practice and is not sufficient to cases (33.3%) due to insufficient visualization and be considered as credentialing activity. So the only probably lack of experience. However, the general way to reach competency in pediatric MAS, is the departmental approach is to continue with acquisition and safe performance of sufficient volume performing these procedures in selected, suitable and a range of relevant procedures. An operation can patients, to overcome pitfalls and maintain progress be reduced to its component steps, which can be in MAS. Laparoscopic pull-through for imperforate learned and mastered over a number of separate anus was done in two cases, after diverting colostomy operations on different patients.[10] Supervised was performed in the postnatal period. One case was operating with structured objective assessment and converted after a time- consuming attempt to release feedback remains.com). an essential part of surgical training, severe adhesions, in a child who previously had a V- because it includes all of the variables encountered P shunt for hydrocephalus. The other child had an in surgery.[11,12] uneventful surgery and this result encouraged us to continue with this modality in suitable cases of high The intent of this discussion is to acquaint how imperforate anus with fistula. Laparoscopic high .medknowimportant it is to teach trainees, what can and should ligation for varicocele (12 cases) and Fowler-Stephens be done via MAS in the pediatric population. Today’s operation (18 cases) for undescended, intra- parents are bringing their children in for surgical abdominal testicle, were routine MAS procedures(www that consultation after profound “search” on the internet replaced almost all “open” approaches for such for a specific problem. They are well informed about pathology. From Thisthe so PDF-calleda site is “gynecological hostedavailable by forMedknowtherapeutic free download Publicationsoptions and from require the best possible procedures”, all cases were done as “urgent” cases of medical care. An important issue that must be kept acute abdominal pain with peritoneal signs and in mind, is that just because a procedure can be done uncertain diagnosis. Nine cases of ovarian cysts technically, does not mean that it is better for the (ruptured or hemorrhagic) and one case of ovarian patient. The MAS technique must be at the very least torsion were successfully treated in a timely manner. and as safe and effective as the procedure it purports Laparoscopic hand-assisted bilateral nephrectomy to replace. performed for persistent post transplant polyuria in 2 patients with juvenile nephronophthisis was safe, The surgeon must be fluent with conventional surgical was tolerated very well and allowed out-patient methods in situations when the MAS approach is not follow-up of these patients who were otherwise feasible or results in problems that require rapid dependent on intravenous infusion. conversion to “open” operation. Nevertheless, there is a learning curve and the potential for a higher DISCUSSION complication rate is one of the most uncomfortable facts that teaching staff have to face, especially when Various workshops have been developed in adult this is judged against the excellent results of many

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218 CMYK Kravarusic D: Teaching impact in pediatric

pediatric procedures achieved by open surgery. Some prospective studies will allow determination of senior pediatric surgeons are reluctant to promote standard guidelines for MAS teaching in the pediatric MAS skills when they are already highly proficient in population. open surgery. REFERENCES Without open-minded and supporting staff/ consultants as leaders, surgical residents/fellows are 1. Bax NM. Laparoscopic surgery in infants and children. Eur J Pediatr Surg 2005;15:319-24. unable to gain skills and make any progress, unless 2. Zitsman JL. Current concepts in minimal access surgery for every potential MAS procedure is evaluated. MAS children. Pediatrics 2003;111:1239-52. should be appraised not merely on its feasibility or 3. Moorthy K, Munz Y, Sarker K, Darzi A. Objective assessment of technical skills in surgery. BMJ 2003;327:1032-7. by the enthusiasm or euphoria of personal ego or 4. Aggarwal R, Moorthy K, Darzi A. Laparoscopic skills training and achievement, but rather as a pragmatic clinical assessment. BMJ 2004;91:1549-58. 5. Gallagher AG, Smith CD, Bowers SP, Seymour NE, Pearson A, McNatt teaching process, as it applies to the pediatric S, et al. Psychomotor skills assessment in practicing surgeons population. experienced in performing advanced laparoscopic procedures. J Am Coll Surg 2003;197:479-88. 6. MacDonald J, Williams RG, Rogers DA. Self-assessment in The scene is fast moving and only encouraging simulation based surgical skills training. Am J Surg 2003;185:319­ programs with established training of MAS techniques 22. will “manufacture” competent, contemporary trainees 7. Grantcharov TP, Kristiansen VB, Bendix J, Bardram L, Rosenberg J, Funch-Jensen P. Randomized clinical trial of virtual reality who are under close supervision of their teachers, simulation for laparoscopic skills training. Br J Surg 2004;91:146­ through education and research, constantly 50. challenging the order of criterions for MAS procedures 8. Scheeres DE, Mellinger JD, Brasse BA, Davis AT. Animate advanced laparoscopic .com).courses improve resident operative performance. in modern surgery. This is especially important in Am J Surg 2004;188:157-60. the pediatric general surgery field where surgeons 9. Kirlum HJ, Heinrich M, Tillo N, Till H. Advanced paediatric laparoscopic surgery: Repetitive training in a rabbit model are dealing with a wide range of pathology that provides superior skills for live operations. Eur J Pediatr Surg include thoracic, abdominal, urological and 2005;15:149-52. gynecological procedures, where the learning curve 10. Lin E, Szomstein S, Addasi T, Galati-Burke L, Turner JW, Tiszenkel .medknowHI. Model for teaching laparoscopic colectomy to surgical is slower because of the relatively small volume of residents. Am J Surg 2003;186:45-8. patients. Adequate training will pay dividends and 11. Schijven MP, Berlage JT, Jakimowicz JJ. Minimal-access surgery national pediatric surgery associations should be training in the Netherlands - A survey among residents-in-training (www for general surgery. Surg Endosc 2004;18:1805-14. responsible for setting criteria that consider MAS for 12. Vincent C, Moorthy K, Sarker SK, Chang A, Darzi AW. Systems accreditation with maintaining international approaches to surgical quality and safety: From concept to standards of teachingThis programs PDFa site and is courses. hostedavailable by forMedknow freemeasurement. download Publications Ann Surg 2004;239:475-82.from

Integration of MAS training into the secondary Cite this article as: Kravarusic D. Teaching impact in pediatric minimal residency/fellowship curriculum of pediatric surgeons access surgery: Personal perspective from “Fellow”. J Min Access Surg is the inevitable goal. Interaction through 2006;2:216-9. International Pediatric MAS groups is very welcome Date of submission: 07/06/06, Date of acceptance: 19/07/06 Source of Support: Nil, Conflict of Interest: None declared. among trainees and hopefully multi-institutional

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