Surgical Innovations

Pediatric Surgery Division Focuses on Minimal Access Surgery

(top) Shinjiro Hirose, MD (right) and Keith Kuenzler, MD (left) feed Carlos Mordan his first bottle at one week of age, after thoracoscopic repair of esophageal atresia with tracheoesophageal fistula.
(bottom) At two weeks after surgery, Carlos' scars are virtually undetectable.

As most people are probably aware, surgeons have been migrating from open to laparoscopic surgery during the last two decades. The shift was slower to begin in pediatrics than in adult surgery, however, in large part because the first laparoscopic instruments were developed for adults, and child-size devices were simply not available at first. Manufacturers soon closed that gap, however, and newly trained surgeons began viewing laparoscopic surgery as the preferred standard. In the treatment of children, laparoscopy has essentially replaced open surgery in a basic set of procedures, including removal of the gallbladder, the spleen, and the appendix, as well as biopsies of abdominal tumors or the lung, and the treatment of lung infections. But surgeon Keith A. Kuenzler, MD, recognized the benefits of doing more complex minimally invasive procedures in infants and children — and was determined to deliver this new level of care.

As a pediatric surgical fellow at Children's Hospital of NewYork-Presbyterian Hospital/Columbia from 2004 to 2006, Dr. Kuenzler was aware that a few surgeons were applying laparoscopic and thoracoscopic techniques to more complicated, less commonly performed procedures as well as the common ones. He believed that Nissen fundoplication (to correct gastroesophageal reflux), pyloromyotomy, colon procedures for Hirschprung's disease, and other procedures should be done laparoscopically in children and even the smallest of infants, affording them the advantages of less pain, reduced scarring, and faster recovery. Beyond these procedures, he envisioned the application of minimally invasive techniques to the most complicated infant chest surgeries such as lung resections and esophageal reconstructions. At that time, no one at NewYork- Presbyterian, and indeed few surgeons anywhere, were attempting to perform such procedures thoracoscopically in children.

Erin Lobovsky, (left) pictured two weeks after thoracoscopic surgery for the treatment of congenital cystic adenomatoidmalformation (CCAM). At six months, (right) her scars are virtually invisible.

One expert was doing so, however: Steven S. Rothenberg, MD, Chief of Pediatric Surgery at Presbyterian/St. Luke's Medical Center in Denver, who performed laparoscopic surgery since its inception and worked closely with device manufacturers to develop the instrumentation and methodology for children. As such, Dr. Rothenberg has been widely recognized as the nation's top expert in minimal access pediatric surgery. Under the leadership of Charles J. H. Stolar, MD, Chief, Division of Pediatric Surgery, a partnership was born. Dr. Kuenzler trained with Dr. Rothenberg in Denver, and soon brought his knowledge back to his colleagues in New York. "Dr. Kuenzler's job was to learn from him, and then teach the rest of our surgeons," explains Dr. Stolar.

The plan met with terrific success. Morgan Stanley's pediatric surgery program now has the expertise to perform the most complicated minimally invasive pediatric procedures, including operations for pyloric stenosis, duodenal atresia, and Hirschprung's disease, even in the very youngest of newborns. "Half the battle with these operations is the setup: knowing how to position the child and where to place the camera and instruments," says Dr. Kuenzler. Some of these procedures take slightly longer to complete than their open counterparts, but the extra operative time may reduce hospital stay by several days. "The most dramatic difference between minimal access and open surgery is apparent in thoracic procedures," says Dr. Stolar. "Traditionally, thoracic operations require a large incision, but with minimal access surgery, children are left with just three or four small dots on the chest. They are hospitalized for a much shorter time, and have far fewer long-term complications after minimal access surgery."

In short order Dr. Rothenberg accepted a joint appointment at Morgan Stanley Children's Hospital, so that he now maintains appointments in both New York and Denver and splits his time between the two centers. "We are extremely fortunate to have Dr. Rothenberg as part of our division," says Dr. Kuenzler. "We've been able to benefit from his 14 years of experience to ramp up our program in a very short time. The pediatric surgery program at Morgan Stanley Children's Hospital now stands as one of only a few in the U.S. with expertise in minimal access surgery for children with tracheoesophageal fistulas, congenital cystic adenomatoid malformation (CCAM), bronchopulmonary sequestrations (BPS), achalasia, and more.