Laparoscopic or thoracoscopic applications that can be performed in adults and children can also be performed in the neonatal period, thanks to the development of technology and industry, the increase in the experience of the surgeon and the anesthesiologist and the miniaturization of endoscopic instruments.
Usage Areas of Laparoscopy in Newborns
Laparoscopy Assisted Cholangiography
If biliary atresia is suspected in a newborn with prolonged jaundice, cholangiography is the gold standard for diagnosis. After detecting the presence of the gallbladder by laparoscopy, unnecessary laparotomy can be avoided by showing the patency or absence of the bile ducts by performing cholangiography with a needle advanced into the gallbladder percutaneously and transhepaticly.
Laparoscopic Pyloromyotomy
Pyloromyotomy is an intervention that requires a lot of experience in laparoscopy and the learning curve is quite high. In the meta-analysis of Oomen et al., in which they evaluated the complication rates in open and laparoscopic pyloromyotomy, a total of 502 cases were reviewed in 4 separate studies. While the complication rate was 11% in open pyloromyotomy, the complication rate in laparoscopic pyloromyotomy was 10.5%. There was no statistical difference in complications after both methods. Considering the advantages of minimally invasive surgery, laparoscopic pyloromyotomy may be preferred in experienced hands.
Ovarian cysts- Laparoscopy
Ovarian cysts can be seen in the fetal and neonatal period. Depending on the size of the cyst, it is decided whether or not to operate. Cysts larger than 4 cm in size may cause ovarian torsion, hemorrhage or intestinal obstruction and require surgical intervention. Laparoscopic intervention is preferred because the diagnosis and treatment are together, it takes a short time, the post-op care is short, the pain is less, and the incision scar is less. If ovarian tissue with debris-filled, calcified or hyperechoic structures is detected in postnatal ultrasonography, torsioned and necrotic ovary can be considered. While the necrotic ovary is removed, if there is no necrosis, ovarian detorsion can be performed and cyst aspiration or resection can be performed. Detorsion and ovarian fixation with laparoscopy can be performed according to the surgeon's preference.
Anorectal malformations-Laparoscopy
Georgeson first described laparoscopy-assisted anorectal malformation correction surgery in 2000. Pena, on the other hand, started the discussion on the need to select cases for laparoscopy-assisted correction. In the neonatal period, performing a colostomy first and then planning a definitive surgery is the generally accepted treatment for high-type atresia.
Uses of Thoracoscopy in Newborns
Thoracoscopy is preferred because it has less postoperative pain, is cosmetically satisfactory, has a short hospital stay, does not have abnormal rib union after thoracotomy, and therefore does not have shoulder drop that may occur in the future, and scoliosis is less. Indications for thoracoscopy in the neonatal period are very rare. The most popular indication is esophageal atresia repair.
Thoracoscopic Esophageal Atresia and Tracheoesophageal Fistula Repair
Thoracoscopic esophageal atresia repair was performed for the first time in 1999 and is a minimally invasive approach that is currently accepted. In a meta-analysis conducted in 2012, thoracoscopy and thoracotomy repairs were compared and it was shown that the incidence of postoperative complications, anastomotic leaks or strictures was not statistically different. Various methods have been described in long-range esophageal atresia. Although the thoracoscopic approach does not cause cosmetic or postural scoliosis, the rate of scoliosis in newborns who underwent thoracotomy is 30%.
Congenital Pulmonary Malformation
Cystic diseases of the lung (congenital pulmonary malformation, lobar emphysema, sequestration) diagnosed by prenatal ultrasound usually have indications for surgery when they are symptomatic. They are very rarely symptomatic in the neonatal period. In some studies, it is said that the surgery is easier with the thoracoscopic method without being symptomatic, that is, without recurrent infections. In the meta-analysis review; No difference was found between the duration of surgery and complications after interventions in congenital lung lesions, whether thoracoscopic or thoracotomy.
Congenital diaphragmatic hernia
Congenital diaphragmatic hernia repair can be performed both laparoscopically and thoracoscopically. In the thoracoscopic approach, the gas introduced into the thorax provides an advantage in surgical technique due to the progression of the intestines filling the thorax into the abdomen, and it also causes a possible malrotation to be overlooked. In Landsdale's meta-analysis, it was determined that open surgery is more advantageous because the duration of the thoracoscopic approach is longer and the recurrence rate is high(15). In addition, neurotoxic side effects due to carbon dioxide absorption in thoracoscopic intervention, long-lasting hypercapnia and acidosis make open surgery preferred. In neonatal minimally invasive applications (including infants under 5 kg), the most common conversion rate to open surgery is 15% and is seen in diaphragmatic hernia repair.
Conclusion
The advantages of minimally invasive methods such as being more cosmetic than open surgery, short hospital stay and less postoperative analgesic requirement are known. Almost all surgeries in adults can be performed with an endoscopic approach. After the development of technology, the experience of the surgeon and the anesthetist, regardless of age and weight, whether it is a newborn or an infant under 5 kg, many operations performed with open surgical technique can be performed safely and successfully with minimally invasive method.
