Saundra Kay, MD, Pediatric Surgeon, Rocky Mountain Hospital for Children, talks about minimally invasive surgery on very small babies, and the new, even smaller than before, surgical instruments their team is using to perform these surgeries.
Interview conducted by Ivanhoe Broadcast News in January 2019.
You operate on older children too right?
Dr. Kay: Right. We operate on tiny little premature babies to 18 year olds. Big range.
Tell me a little bit about some of the some of the things that can go wrong, where babies would need surgery when they’re first born?
Dr. Kay: There are actually quite a few things that can happen to newborn babies, where they are born with things that are just not connected properly. It’s amazing actually that most babies are born with everything in the proper place and in functioning order. Some of the common things would be babies whose intestines or the esophagus isn’t connected or babies who are born with abnormalities in their lung or abnormal cysts next to the lung, esophagus or mouth, abnormal position of the intestines, things like that.
To be able to do surgeries on babies who have these conditions, to have something that’s not hooked up properly. What does that mean? Is this life saving, how does that impact them?
Dr. Kay: Well definitely if the esophagus or the intestine is not connected then the baby wouldn’t be able to eat and thrive. So it’s important. They cannot really go on living proper functioning lives without these surgeries to reconnect everything and make everything work properly.
When you hear about surgery; you have surgery and fix it, but that’s very different when you’re talking about a tiny little bean. Tell me about some of the challenges before some of these minimally invasive instruments came to be, some of the challenges that doctors faced around the world when trying to operate on babies this size?
Dr. Kay: Operating on a little baby is not the same as operating on a bigger person just because everything is on a much smaller scale. The intestines are smaller; the space that you have to work is much smaller. Surgeries were slowly developed, even in these young newborn babies, but they were involving larger incisions either in the chest or abdomen to be able to access everything and see everything well. At first when laparoscopy came to be, all the instruments were made for adults so they were way too big for these tiny little babies. There is just no room to work when you have a 10 millimeter (one centimeter) camera and instruments and so slowly they started developing smaller and smaller instruments. The team at Rocky Mountain Hospital for Children led by my partner Dr. Steve Rothenberg, has helped to pioneer smaller and smaller instruments to be able to do even the smallest little babies laparoscopically. We’re talking about five pounds and even less than that for some of the procedures that we do.
What are some of the risks or dangers of having these big scars and tiny babies before these instruments came to be?
Dr. Kay: When we’re talking about this, the chest is really one that I think the advantages are even more obvious than they are in the abdomen, although the abdomen has big advantages as well. You can imagine if you have a big incision cutting through muscle it’s much more painful for the babies. They may need more narcotics as they recover. And this is a lifelong scar, and the scars do tend to grow with the children when there are big scars. Certainly you can see some older adults that have had surgeries when they were young when they had a bigger incision done for their surgeries. It’s very apparent. Also, in the chest there is risk of developing, as they grow, some chest wall deformities. They may have abnormal growth of their spine or weakness in their shoulder muscles and things like that. So it really can have an impact on them long term when we do some of these big incisions.
These are different than what adults would have because these babies have to grow up?
Dr. Kay: For the chest yes.
Tell me about some of the instruments, an overview on when they first started coming in and what that’s done to surgery in babies?
Dr. Kay: Early on when the laparoscopic instruments came to be they were very large and as time went on they did start making them smaller and smaller. But you can imagine that it’s very difficult technically for these companies to make instruments that are going to function well at a smaller size. There’s a lot of logistics involved. And slowly they did manage to make a smaller scope and smaller instruments and even more recently they’ve been able to develop a small instrument, 3 millimeter that allows us to seal small blood vessels in these little babies. Even a very small stapler, a 5 millimeter stapler, for some of these procedures as well. That’s just made a huge difference because these smaller instruments allow us to do all sorts of surgeries on these tiny babies.
Were there ever things that we know we can’t operate on, we can’t do that and we can’t help this baby?
Dr. Kay: Years ago when the field of pediatric surgery started, a lot of babies died from some of these things. But this is a long time ago. Then they realized no, we can do open surgeries and they figured out OK yes we can actually reattach the intestine and things like that. So for babies, they were not dying from these things in the recent past by any means. They just were having open surgeries versus minimally invasive surgeries.
When you have an open surgery as compared to minimally invasive, is there a high risk of infection and post surgical complications?
Dr. Kay: Certainly when you do an open surgery, there are more potential complications. If you’re in the abdomen for example, the more manipulation of the intestines tends to lead to more adhesions – which is scar tissue inside – which can lead to development of intestinal blockages, obstructions, down the road. That is definitely minimized with the laparoscopic approach. Also, if you have a big incision as opposed to a small incision, there is a greater chance that the incision could start to open or develop an infection. A larger incision will often cause more pain because you are dividing muscle as opposed to when you’re making just a small incision. Even the way our instruments work is we’re not really dividing, but instead kind of separating the muscle fibers when we’re putting in our trocars (the part that goes in so that we can pass our instruments in and out with minimal trauma to the tissues).
The family that we are interviewing today, can you tell me about their situation?
Dr. Kay: CPAM stands for Congenital Pulmonary Airway Malformation. This used to be better known as CCAM which is Congenital Cystic Airway Malformation. CPAM is an abnormal development of a portion of the lung that happens early on in gestation. Now, with the excellent prenatal ultrasounds that we have, we tend to pick up these lesions prenatally whereas in the past, this wasn’t discovered until children developed recurrent infections always in the same spot. So people said wait a minute, maybe there’s an abnormality there. But now, with prenatal ultrasounds these are often picked up early on in gestation. Therefore, the moms and babies can be followed to watch what’s happening with these abnormal portions of the lung. This abnormal portion of the lung is really separate from the lung in the sense that it doesn’t exchange air like the rest of the lung. It will not go away as time goes on; this abnormal portion of the lung is abnormal for life. It’s not like it can develop into normal lung down the road. So what happens is when this is found, the obstetricians are following this very closely because it definitely can increase in size and does tend to increase in size until about 28 weeks gestation and it does have some potential complications depending on its size. If it starts to grow very large it can cause shifting of the whole heart, main airway and esophagus. This can cause compression of the esophagus, causing the mom to develop increased amniotic fluid and it can even then affect the return of blood flow to the heart and lead to heart failure for the baby. When that happens in utero, the baby develops what’s called hydrops, which is very dangerous for the baby and is associated with a high mortality. There is a high chance of death in the baby when this happens as there is accumulation of fluid in the tissues around the heart and around the lungs, in the tissues themselves, underneath the skin and things like that. And even when the baby develops this, the mom is at risk as well, with the mirror syndrome; the mom mirrors the disease of the baby. Then even if the baby is delivered at that point the mom may remain sick for some time.
Ok so this is serious. How common is this?
Dr. Kay: It certainly can be serious. It occurs about one in 4,000 births. It used to be thought to occur much less frequently, but now that we’re picking it up so well on prenatal ultrasounds we see that it’s actually more common than we thought it was in the past.
You know this is there when the mom is pregnant. How soon do you operate?
Dr. Kay: The surgery itself is less important at the beginning. As soon as it’s developed, the high risk obstetricians will really be following the moms very closely to make sure that there’s no development of hydrops. That accumulation of the fluid is really a sign of heart failure in the baby. If that happens, they do have some tricks to try to decrease the size of the lesion or really try to reverse or prevent the hydrops from worsening. If it’s a big cystic lesion in the lung, then they can drain it. If it’s a little more solid sometimes just steroids may help and they can try to prevent the progression of the hydrops and allow the baby to continue to grow and not be ill and then be born well and healthy.
But even if they’re born, even if they prevent that, this still needs to be operated on?
Dr. Kay: Right, we’ve just talked about how this can lead to hydrops but the vast majority of them don’t do that. The vast majority of them will either stay the same once they’re diagnosed or they will slowly decrease in size. When that happens sometimes it will even look on prenatal ultrasounds like the lesion has gone away completely. But when the babies are born it’s really important that they do get a chest X-ray just to see if we can see the lesion. Even if we don’t see the lesion, these babies should get a CT scan to look for an abnormality in their lung because most of the time it’s still there. These children will need surgery, but as long as they’re born and the vast majority of them are born breathing well, happy babies, it’s no problem. They can go home with mom and then come back and have their surgeries. We usually recommend doing the surgery at a month or greater.
When you do the surgery can you tell me the before and after of how difficult this surgery is and was?
Dr. Kay: Of course you are operating still on a small chest and the chest is a very confined area. All the babies in the past would have definitely had an open surgery which involves an incision on the chest and then opening the chest. And it’s really a matter of usually removing a whole lobe of the lung. Most of the time these CPAMs are isolated to one lobe of the lung, and we remove that lobe. We know that the lung can continue to grow until the children are eight years of age. So even if they lose a lobe of lung when they’re very young they will have normal lung function the vast majority of the time as they grow older. Now, we can do this surgery with three small incisions.
When you say a lobe of the lung, how much is that?
Dr. Kay: On the right side there are three lobes of the lung while on the left there’s actually two, so you are losing a big portion of your lung. It sounds like you’d be very concerned about how that child would be in the future, even in terms of exercise tolerance down the road. But this surgery is actually very well tolerated by these little babies and because they have that continued lung growth they usually have normal lung function down the road.
So with the development of these new tools, does this tool have a name?
Dr. Kay: It’s a sealer device. There are other sealer devices that the adults use that are just too big for the little ones.
Tell me about the development of these newer instruments and how this changed the surgery?
Dr. Kay: The smaller instruments that have been developed have allowed us to instead of making the big incisions on these babies, use a minimally invasive approach, which means making a few very small incisions. One to place our small camera, and usually two other little incisions for instruments to work. And with those little instruments and just that small little area we’re able to take the blood vessels, little airway to the abnormal lung and take the lung out; just stretching one of the incisions slightly to be able to take the lung out. So instead of having a larger incision with its potential complications and increased pain, the babies do better.
So this doesn’t stop the removal of part of the lung? You still need to remove a lobe?
Dr. Kay: So the smaller instruments allow us to do the same surgery with smaller incisions. The idea should be and has always been, when you’re approaching something laparoscopically, you don’t want to invent a new surgery. The surgeries we have are good. What we want to do is we want to do the same surgery but in a minimally invasive fashion. So the same surgery but with smaller incisions and so you have the same result with smaller incisions less pain less potential complications.
So when you say this, instead of opening the chest, you’re making very small incisions?
Dr. Kay: Three little incisions and generally you can hardly see them as the children are growing older. They’re all positioned on the side of the chest really.
Can you do just about any surgery now using these new tools?
Dr. Kay: We can do a large number of surgeries now, even on the little babies. We do chest surgeries, surgeries on the esophagus, on the lungs, abdominal surgeries … The times when you can’t really use that technique is if you have for example no room to work. I told you about the intestines, and if that’s not connected. If that happens really low down in the intestine, then all the intestines above are going to be so dilated. There’ll be no room to work. You can’t do that. But higher up you certainly can use all your laparoscopic instruments. In this practice, we definitely approach every situation by asking ‘Can I do this in a minimally invasive fashion?’ And we do it if we think we can.
Do most major children’s hospitals have this ability or is this something that needs to spread more?
Dr. Kay: Well more and more as time has gone on and as the instrumentation has gotten better, people have tried to learn the minimally invasive techniques on the smaller children. More and more centers are starting to use laparoscopy for the neonates as well. But there’s still room for expanding that even more because I think it’s the way to go and I think that a lot of these surgeries should only be done minimally invasively at this point when appropriate.
Is there anything you still need?
Dr. Kay: I think it’s really more a matter of the surgeons feeling more and more comfortable operating in a minimally invasive fashion on these smaller and smaller babies. I think this is what we need more than new instruments now, because now we have a lot of things at our disposal to be able to do pretty much anything we want to do. With the development of the little 3-millimeter sealer and the 5-millimeter stapler, these things really expanded our capabilities.
And you guys have people coming from other states and countries to come?
Dr. Kay: Yes.
Tell me a little bit about that, what is it here that makes people come here?
Dr. Kay: Rocky Mountain Hospital for Children is really a center of excellence for minimally invasive surgery. My senior partner, Dr. Steve Rothenberg, is known all over the world and has developed many of these techniques and so he is traveling all over the world to teach these techniques, trying to spread his knowledge so that all the children around the world can benefit from these techniques.
And doctors are also coming here to learn these techniques, and babies are being recommended and sent over here?
Dr. Kay: Right. Because of what we’ve been able to accomplish at Rocky Mountain Hospital for Children, patients and their families definitely seek out our hospital to have their surgeries done. And there have been patients from around the world that have come for their surgeries. Hopefully as more and more centers are able to do this, the families will not have to travel so far and every baby will be able to have minimal invasive surgery at their own center.
END OF INTERVIEW
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