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    Pint-sized surgery

    All Children's Hospital in St. Petersburg has new equipment that makes less invasive surgery possible for pint-sized patients.

    [Times photo: Bill Serne]
    Dr. Andre Hebra, director of the new minimally invasive surgery program at All Children's Hospital in St. Petersburg, shows the OR1, a machine that uses a voice-controlled video system called Aesop to help direct laparoscopic surgery.

    By WES ALLISON, Times Staff Writer
    © St. Petersburg Times
    published April 5, 2002


    ST. PETERSBURG -- The smallest patients need the tiniest surgical tools.

    All Children's Hospital unveiled new equipment Thursday that will let doctors perform major operations on children through minor incisions in the abdomen or chest.

    The technique, called minimally invasive surgery, is designed to hasten the patient's recovery and reduce damage to muscle and other tissue. It has become increasingly common for adults in recent years, but its use on children has evolved much more slowly, experts say.

    Because children -- especially infants and toddlers -- are so much smaller than adults, the equipment needs to be smaller too. That means making already tiny adult tools even tinier.

    "Many companies didn't feel it was worth it to make smaller equipment. It's very expensive," said Dr. Andre Hebra, director of the new minimally invasive surgery program at All Children's. "But in my mind, the people who would most benefit are kids."

    A common adult laparoscope, which is used to carry a camera or tools into an incision, is 10 millimeters in diameter, a bit larger around than a pencil. The child's version, which Hebra can use on a newborn as young as 1 day old, is just 2 millimeters, as thin as a plastic coffee stirrer.

    Many pediatric hospitals, including Tampa Children's Hospital at St. Joseph's, use minimally invasive techniques for a limited number of procedures, including appendectomies, gall bladder removal and hernia repair.

    All Children's new equipment is part of a $1-million operating suite where surgeons can perform a wider array of minimally invasive procedures, Hebra said. It was built by Karl Stortz Endoscopy, one of several companies that designs such suites, and gives the hospital one of the most advanced pediatric surgery programs in the nation.

    Also Thursday, St. Joseph's announced it had bought a robot that will be used to perform minimally invasive surgery on adults, beginning in May. Later the hospital plans to use it on children as well, a hospital spokeswoman said.

    Minimally invasive surgery is called laparoscopy when it's performed in the abdomen, such as to remove an appendix or tinker with the gastrointestinal system. It's called thoracoscopy when used in the chest.

    Hebra learned the technique on children at two places that have pioneered it, the Medical University of South Carolina in Charleston and Children's Hospital at the University of Pennsylvania in Philadelphia.

    All Children's hired him in February to launch the minimally invasive program here. Eventually, the hospital plans to establish a training program so doctors from other hospitals can come to St. Petersburg to learn the technique.

    Laparoscopic and thoracoscopic surgeries carry about the same risk as traditional open surgeries, but they offer several key advantages, experts say. Making tiny incisions damages less muscle and tissue, and they don't hurt as badly after surgery. The patient also spends about half the time in the hospital, or less, and can resume daily activities much sooner.

    Hebra can make as many incisions as he needs to insert hunter-grabbers, staplers and other tiny tools. Small tissue samples or organs, such as the appendix, can be dropped into a tiny bag held at the end of a laparoscope, then pulled through the incision. Bigger pieces, such as an enlarged spleen, can be cut up inside the body, then removed in pieces.

    A voice-activated video system, called Aesop, shows him where to go and what to cut. The lens fits on the end of a tiny laparoscope, and allows him to see even more than he could if he had made a larger incision.

    Hebra said it's commonly used to remove the appendix, gall bladder or spleen, as well as to repair stomach blockages in newborns. Sunken chests, or pectus excavatum, another common but dangerous problem, now can be repaired by using tiny scopes to insert a steel rod that reforms the sternum, rather than the massive, open chest operation usually required.

    The technique also makes for easier exploratory surgeries -- to determine how large or involved a tumor is, for example -- and biopsies.

    The hardest change for the surgeon is learning to operate two-dimensionally, as it appears on the video screen, rather than in real-life 3-D.

    On Thursday, Hebra used the board game Operation to demonstrate. The game was covered by blue surgical cloth, but it showed clearly on the video screen over the bed.

    "Aesop, move down," Hebra told the camera. "Stop. Move left. Stop. Move up. Stop. Right. Move right."

    With a grabber, he snagged the Adam's apple from the neck, then dropped it into the hole for the broken heart.

    For Mark Johnson, 14, who needed an emergency appendectomy at All Children's last month, the new equipment meant five days in the hospital, rather than as long as two weeks.

    And to show for it, Mark, who lives in Largo, has just three small marks between his breast and waist, not the 6-inch scar one of his friends has. He was back at track practice two weeks later.

    "I thought it was pretty neat that all this equipment was used on me, and that it's so advanced," he said.

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