In patients with clinical stage I lung cancer, VATS lobectomy
for cancer affords several proven advantages over open thoracotomy,
which include less postoperative pain, shorter hospitalization,
and faster return to full activity. Tumors less than 5 cm.
which do not encroach on the hilum, invade the chest wall,
have central airway spread, and appear to not have nodal
involvement, regardless of which lobe they arise, are suitable
for VATS lobectomy. The VATS lobectomy achieves the same
result as open lobectomy. The lobe with the adjacent lobar
lymph nodes is removed. (Figure 3)
Fig. 3:
The blood vessels and bronchus to the right middle lobe
have been ligated. During the dissection, surrounding lymph
nodes have been removed, thoroughly determining the pathologic
stage.
Complete staging of the cancer is done by sampling lymph
nodes at various anatomical sites, similar to intraoperative
staging when performing open lobectomy. The patient is placed
in a lateral decubitus position. A 1-cm. incision is made
for the camera, a 6-cm utility incision through which the
dissection is performed, and a 3-cm subcostal incision through
which the stapling instruments are passed. The individual
vessels are controlled in the hilum and the fissure, and
the bronchus to the lobe is isolated and stapled. The lobe
is placed in a bag to deliver it through the chest wall
to prevent potential seeding of the tumor in the incision.
At no time are the ribs spread or is strain placed on the
intercostals nerve bundles. (Figure 4)
Fig. 4:
Incisions used to perform a VATS lobectomy. The utility
incision is strategically placed to perform the dissection,
and to extract the lobe. Rib retraction is avoided to minimize
postoperative pain.
This is critical if post thoracotomy pain syndrome is to
be prevented. Improving video technology and instrumentation
has allowed development of advanced thoracoscopic procedures.
In the past year we performed 35 VATS lobectomies for lung
cancer. There was a predominance of lower lobectomies in
our early experience. The average length of stay was 3.7
days, which is significantly less than our average stay
following open lobectomy. (Figure 5)
Fig. 5:
The VATS incision approximately 6 weeks after surgery. As
no muscles are divided, patients recover rapidly from surgery.
Several publications have compared the survival after VATS
lobectomy with open lobectomy. Comparing patients with equal
stages, there is no detrimental effect on 5-year survival
by VATS lobectomy; and in fact survival may be enhanced
by a minimally invasive approach. In a randomized study
from Japan, the 5-year survival after VATS lobectomy in
stage I lung cancer was 90%, not significantly different
from the 85%, 5-year survival following open thoracotomy.
We continue to recommend VATS lobectomy in select patients
with lung cancer.
- Landreneau RJ, Mack MJ, Dowling RD, et al. The
Role of Thoracoscopy in Lung Cancer Management. Chest
1998; 113:6S-12S.
- Walker WS. Video-Assisted Thoracic Surgery (V A
TS) Lobectomy: The Edinburgh Experience. Seminars in
Thoracic and Cardiovascular Surgery, Vol. 10, 291-99,
1998.
- McKenna RJ, Wolf RK, Brenner M, et al. Is Lobectomy
by Video-Assisted Thoracic Surgery an Adequate Cancer
Operation? Ann Thorac Surg 1998; 66:1903-8.
- Sugi K, Yoshikazu K, Esato K. Video- Assisted Thoracoscopic
Lobectomy Achieves a Satisfactory Long-term Prognosis
in Patients with Clinical Stage IA Lung Cancer. World
J. Surg. 24, 27-31, 2000.
Michael Argenziano, M.D.
Assistant Professor of Surgery
Columbia University College of Physicians and Surgeons
Director, Robotic Cardiac Surgery
New York Presbyterian Hospital Columbia-Presbyterian Medical
Center
In the past decade, the face of cardiac surgery has been
changed by a number of technologic advances, most notably
the development of less invasive techniques, including
minimally invasive direct coronary artery bypass (MIDCAB),
off-pump coronary artery bypass (OPCAB), and minimal access
valve surgery. However, each of these procedures has had
a limited impact on the general practice of cardiac surgery
for a number of reasons.
Initial attempts to perform cardiac operations through
small incisions were hindered by the absence of appropriate
accessory technology, such as visualization systems, retractors,
stabilizers, and alternate methods of vascular cannulation
and cardiopulmonary bypass. With the development of these
technologies, surgeons have been increasingly able to
perform complex cardiac procedures, including coronary
artery bypass, mitral and aortic valve replacement, and
atrial septal defect (ASD) closure, through smaller -than-traditional
incisions. Nonetheless, in many cases, the extent to which
incision size has been reduced by these minimally invasive
approaches has been matched by a corresponding increase
in technical difficulty and operative time, due to the
constraints imposed by limited or incomplete cardiac exposure.
For example, MIDCAB, in which a single vessel bypass to
the anterolateral surface of the heart is achieved through
a small anterior mini-thoracotomy, requires internal mammary
artery graft harvesting by thoracoscopy, which even in
the most experienced hands, is time consuming and technically
challenging. Furthermore, the decreased visualization
through small thoracotomy incisions has led to a significant
incidence of complications with this procedure.
With the development of new technologies, surgeons have
been increasingly able to perform complex cardiac procedures
through smaller-than-traditional incisions.
With respect to valvular surgery and other open-heart
procedures (such as ASD repair), advances in the area
of peripheral cardiopulmonary bypass access and endoaortic
balloon technology ("port-access") have allowed
these procedures to be performed through smaller-than-usual
(but not necessarily small) incisions. The development
of these procedures has required the adaptation of surgical
instruments and techniques to the challenge of operating
"in a deep hole," with less than optimal visualization.
For these and other technical reasons, these procedures
have been performed predominantly at selected centers,
and have not gained widespread popularity.
The minimally invasive cardiac surgical movement has recently
been propelled by the introduction of a new category of
technologic achievement: the computerized telemicromanipulator.
Utilizing this device, also known as the surgical robot,
surgeons can manipulate small instruments, which are inserted
through small chest incisions, in tight spaces, achieving
many of the technical maneuvers previously possible only
with open exposure. Since May 2001, cardiac surgeons at
New York-Presbyterian Hospital have begun to utilize this
technology, and are currently involved in several exciting
clinical protocols testing the Da Vinciª Surgical
System, manufactured by Intuitive Surgical, Inc. (Mountainview,
CA) for a variety of cardiac surgical operations.
Dr. Argenziano prepares a patient
for insertion of robotic instrument arms.
The minimally invasive cardiac surgical movement has
recently been propelled by the introduction of a new category
of technologic achievement: the computerized telemicromanipulator.
The Da Vinci Surgical Systemª consists of two primary
components: the surgeon's viewing and control console
and the surgical arm unit that positions and maneuvers
detachable surgical EndoWrist instruments. These pencil-sized
instruments (with tiny, computer-enhanced mechanical wrists)
are designed to provide the dexterity of the surgeon's
forearm and wrist at the operative site through entry
ports less than 1 cm. This enables the surgeon to enter
the chest through keyhole incisions and perform closed
chest heart and lung surgery. One port allows access for
the endoscope, a tiny camera that is attached to a fiber-optic
cable. The other two ports provide access for surgical
tools. Instead of the surgeon holding the tools, the robots
wrists do -bending back and forth, side to side, and rotating
in a full circle - thereby providing greater range of
motion than humanly possible. The wrists of the robot
mimics the motions made by the physician, who sits at
a console outside the operating room. The surgeon peers
through an eyepiece that provides high-definition, full-color,
magnified, 3-D images of the surgical site provided by
the endoscope. The physician moves his hands, which are
attached to manipulation controls and the robot follows
along. An important element of this technology is that
the built-in computer enhances the surgeon's hand movement
and renders it more precise with less tremors - an important
element in refining delicate bypass and valve surgery.
Because the Da Vinci robotic surgical system allows for
3-D visualization and wrist-like dexterity and control
of fine instruments that can be placed in the chest through
post-sized incisions, this technology has the potential
to impact the practice of cardiac surgery in three important
ways:
1. Make existing MIS operations easier: Surgical procedures
routinely performed today using MIS techniques will be
performed more quickly and easily with the increased dexterity
and control provided by robotic assistance.
2. Make difficult MIS operations routine: Surgical procedures
that today are performed only rarely using MIS techniques
may someday be achieved routinely with robotic assistance.
Some procedures have been adapted for port-based techniques
but are extremely difficult and are currently performed
by a limited number of highly skilled surgeons. With the
availability of robotic assistance, more surgeons at more
institutions will be able to perform these procedures.
3. Make new surgical procedures possible: A number of
procedures that are currently not feasible by minimally
invasive techniques may eventually be preformed through
small incisions with the help of robotic technology.
In the United States, Intuitive Surgical, Inc. has received
clearance from the FDA for use of the Da Vinciª Surgical
System in laparoscopic surgical procedures such as cholecystectomy
and Nissen Fundoplication and general non-cardiac thoracoscopic
surgical procedures such as internal mammary artery mobilization.
In addition, New York Presbyterian surgeons are involved
in several FDA-sanctioned clinical trials to assess the
Da Vinci Robotic System for mitral valve repair, coronary
artery bypass and ASD (atrial septal defect) closure.
New York Presbyterian has two Da Vinci robotic systems
- one at the Columbia-Presbyterian campus, and one at
the Weill-Cornell campus. The Columbia program is directed
by Michael Argenziano, M.D., and Featured here is the
Da Vinci robotic surgical system. The robotic system is
ready for use in the operating room. Potential Impact
of Robotic Technology: Make existing MIS operations easier
Make difficult MIS operations routine Make new surgical
procedures possible. The Weill-Cornell program by Charles
Mack, M.D.
The Columbia-Presbyterian team has performed over 30 internal
mammary artery (IMA) harvests with the Da Vinci system,
serves as an IMA harvesting training site, and has utilized
Da Vinci for several minimally invasive direct coronary
artery bypasses (MIDCAB), in which a bypass is performed
on the beating heart, through a 2 to 3 inch incision on
the left side of the chest. The Weill-Cornell team has
performed over 20 IMA harvests.
The Columbia-Presbyterian team is one of nine centers
in the FDA-sanctioned robotic mitral valve repair trial.
Dr. Craig R. Smith, Jr. serves as the site principal investigator,
and leads a team that has performed 11 such procedures
to date.
Dr. Argenziano is the principal investigator of the single-center
robotic ASD trial, and with Dr. Mehmet C. Oz, performed
the first totally endoscopic open-heart operation in the
U.S. on July 24, 2001. The Columbia-Presbyterian team
currently has the world's largest experience with this
operation (12 procedures performed), and serves as the
training site for the multicenter robotic ASD trial.
Dr. Argenziano is the principal investigator of the FDA
multicenter totally endoscopic coronary artery bypass
(TECAB) trial, and with Dr. Smith, performed the first
totally endoscopic (closed chest) coronary bypass operation
in U.S. history on January 15, 2002. The Columbia team
will train other centers that will participate in the
trial. Dr. Mack and the W eill-Cornell team will also
participate in the TECAB trial.
The New York-Presbyterian Hospital team has performed
over 100 left atrial isolation procedures for atrial fibrillation,
using a variety of energy sources. Recently, Drs. Argenziano,
Oz, and Williams have developed a totally endoscopic,
robotic operation for atrial fibrillation. The Columbia-Presbyterian
team will perform the world's first totally endoscopic
human cases in the spring of 2002.
The potential significance of robotic technology in the
practice of cardiac surgery is great. Cardiovascular disease
remains the top killer of Americans, and over 750,000
cardiac surgical procedures are performed in the U.S.
each year. The annual cost of this care, including hospital
costs, treatment of complications and disability, and
lost productivity and quality of life, has been estimated
at several billions of dollars. Despite efforts to curb
these expenditures, the costs of medical care, and especially
of surgical procedures, continue to increase. Despite
improved diagnostics and medical treatments over the last
decade, the incidence of cardiac disease, cardiac surgery,
and death due to cardiovascular causes has continued to
increase. A potential explanation for continued increases
in cardiovascular disease, procedures, and costs may be
the changing demographics of the population.
Shown above is the Da Vinci three-dimensional
endoscopic camera.
A sampling of 8-mm wristed robotic
surgical instruments is displayed here.
The nation is getting older, and it is estimated that
by the year 2050, nearly a third of the U.S. population
will be over 65 years of age. Older patients present with
more complex cardiac disease, suffer higher complication
rates, and thus may benefit most from less traumatic,
minimally invasive approaches, with decreased recovery
times and hospital costs. For these reasons, the development
of reliable minimally invasive cardiac surgical procedures
can be expected to make a significant impact on the quality
of medical care as well as the economics of health care
delivery, resulting in increased access to care, especially
for elderly patients.
Despite the enthusiasm generated by our early experience
with robotics in cardiac surgery, we realize that we still
have much to accomplish. The technology we have available
today is just an initial iteration of what is sure to
be a complex developmental process. The continued evolution
of robotic technology, toward the goal of widespread applicability,
will require many mechanical and engineering refinements.
However, as important to the eventual success of this
technology will be the development of adjunctive technology,
such as facilitated anastomotic devices, endoscopic retractors
and stabilizers, and cardiovascular support devices. Robots
have given us a previously unimaginable degree of thoracoscopic
visualization and instrument dexterity - the next step
is to develop facilitating technology to fully utilize
this newfound access to the heart.
Dr. Argenziano performs robotic
heart surgery while seated at the Da Vinci console.
Jeffrey L. Zitsman, M.D. Director, Minimal Access Surgery
Children's Hospital of New York Presbyterian
Assistant Clinical Professor of Surgery College of Physicians
and Surgeons, Columbia University
Terry Buchmiller Crair, M.D.
Assistant Attending
New York Presbyterian Hospital-Weill Cornell Medical Center
Assistant Professor of Surgery Weill Medical College of
Cornell University
The field of pediatric surgery is gradually incorporating
minimal access technology. Following the lead of our general
surgical colleagues, pediatric surgeons are seeking ways
to substitute less invasive techniques without sacrificing
safety or success rates. The first pediatric surgeons
practicing minimal access surgery (MAS) were taught by
general surgeons; logically, the first procedures performed
were cholecystectomy and appendectomy (the procedures
first learned by the instructors). Initial limitations
were imposed by the absence of instruments suitable for
use in children. Minimal access surgery in children in
the United States grew from the work of Stephen Gans,
who brought instruments from Europe where pediatric endoscopy
was common. Interestingly, the initial experience developed
in diagnostic thoracoscopy through the work of Bradley
Rodgers. As MAS became more widespread, innovators such
as Thom Lobe in Memphis and Keith Georgeson in Birmingham
described techniques for more complicated procedures.
In part pushed forward by the rapid advances of our colleagues
in general surgery, pediatric surgeons have become more
engaged in using MAS techniques to help care for their
patients. 1
Initially dismissed by some as a mere gimmick, minimal
access techniques are now routinely applied to diagnose
and treat pediatric surgical problems. Tumor biopsies,
lymph node dissections, and tumor resections are often
amenable to MAS. Intestinal resection, both small and
large bowel, can be performed using MAS. Evaluation of
chronic abdominal pain, second-look operations for staging
malignancy, and lysis of adhesions can be performed. Ovarian
cysts and tumors can be treated, and boys with a nonpalpable
testis can undergo both minimally invasive diagnosis and
treatment for the aberrant gonad. Lung resection is readily
performed, as is resection of mediastinal masses. In addition
to the above, antireflux surgery, splenectomy, and the
provision of exposure for orthopedic surgeons who perform
scoliosis repairs are just some of the ways that MAS is
being used at the Children's Hospital of New York Presbyterian
(CHONY). Our pediatric surgical staff has performed over
300 laparoscopic and thoracoscopic procedures in the last
2 years. In this brief report, 2 of the operations that
we commonly perform are described.
A complication of some pneumonias is the development of
an effusion, or fluid outside the lung in the pleural
space. (Figure 1)
Fig. 1:
Parapneumonic effusion with empyema secondary to pneumonia.
As the fluid accumulates it reduces the available space
into which the lung can expand, impairing respiratory
function. Sometimes the fluid will be reabsorbed, but
at other times it will thicken, form adhesions, and interfere
with lung movement. This condition, known as empyema,
further compromises respiratory effort in a sick child.
A CT scan can reveal a dramatic degree of lung compromise.
(Figure 2)
Fig. 2: Parapneumonic effusion
with empyema secondary to pneumonia (CT Scan).
Empyema is often infected; children typically have fevers
and may require supplemental oxygen.
In 1989 Hoff and co-workers at Vanderbilt 2 published
the results of treatment of 3 groups of pediatric patients
with parapneumonic effusion and empyema. All children
were treated with antibiotics. Group 1 was treated with
aspiration of fluid (thoracentesis) followed by antibiotics
alone. Group 2 underwent aspiration of fluid, followed
by placement of a tube to drain the pleural cavity. Group
3 underwent decortication, a surgical cleaning out of
the pleural space. This required a chest incision in order
to remove the inflammatory material around the lung. The
result of these treatments showed a marked improvement
of those patients with more severe infections (e.g., longer
period of illness, loculated pleural fluid, persistent
fevers) manifested by rapid radiographic improvement,
earlier defervescence, and a shortened hospital stay.
Nevertheless, the need for a large chest incision and
a major operation dampened enthusiasm among pediatricians
for this procedure. Minimal access surgical techniques
have made decortication a much less onerous prospect in
the care of these children.
The procedure is performed in the operating room using
general anesthesia. After confirming the site of the empyema
the patient is anesthetized, then turned onto his side
with the affected lung up. A small-bore needle is introduced
into the chest cavity through the chest wall at about
the 7th intercostal space to confirm the presence of fluid.
A small incision is made and, with blunt dissection, the
pleural space is entered. A port equipped with an adapter
to allow insufflation of CO 2 is inserted and the pleural
space is inspected.
Under direct vision a second incision is made and working
access to the pleural space is achieved. All fluid is
evacuated and as much inflammatory exudate is removed
as possible. A variety of instruments can be used to accomplish
this including laparoscopy graspers, sponge forceps, Kelly
clamps, and biliary stone forceps. Irrigation is liberally
employed, and one or two chest tubes are inserted through
the port sites. (Figure 3)
Fig. 3: Chest x-ray following
thoracoscopic evacuation of effusion and empyema.
Numerous authors have discussed the clinical course of
patients treated with empyema. 3 Chan 4 reported 47 cases
from the Montreal Children's Hospital over a 26-year period.
Eighty-two percent having either fibropurulent empyema
with or without loculations responded to antibiotics and
drainage. Seven required formal decortication. The average
stay of the former group was 23 days; the operative group
stayed an average of 40 days. This contrasts with the
Vanderbilt data wherein patients treated with decortication
had their hospital stay lessened by approximately one
week. Rodriguez 5 from New Orleans reported that patients
who underwent decortication required a chest tube for
less time than those undergoing drainage alone (2-5 days
vs. 8-37 days). Those patients undergoing video assisted
thoracoscopic surgery (VATS) to evacuate the empyema were
discharged on the average 5.8 days after the procedure
(range 3-19 days). Kercher 6 reports similar reduction
in hospital stays. The emerging data matches our experience
at CHONY and supports the use of MAS in children with
empyema.
Inguinal hernia repair is among the most common surgical
procedures performed by pediatric surgeons. Traditional
teaching has held that double (bilateral) hernias are
common; many pediatric surgeons were taught to explore
the opposite side to identify and (if present) repair
the hernia on the "silent" side. Robert Gross,
deemed by many to have been the greatest force in the
development of pediatric surgery as a specialty, wrote
in his classic 1953 text that exploration of the opposite
side, in competent hands, was probably warranted. 7 Experience
has shown, however, that a hernia is actually present
(or potentially present) in only about 1 of every 6 children
with a single-sided groin hernia. Perhaps Gross felt that,
in those days, a second incision and careful exploration
by a competent pediatric surgeon was safer than a second
anesthetic. Nevertheless, groin exploration for a "silent"
hernia requires a second incision and exposes the child
to the risks of infection, bleeding, and injury to the
inguinal structures.
Since these writings pediatric surgeons have tried to
reconcile this high percentage of negative explorations
with the decreasing risk of anesthesia. Various clinical
features have been identified that may be associated with
a greater likelihood of finding a hernia on the opposite
side; these include female gender, left-sided presentation
of the initial hernia, young age, and prematurity. Techniques
have been used to try to identify a hernia on the opposite
side. These include radiographic "herniograms,"
ultrasonography, probing the opposite side from within
the hernia sac at surgery, and filling the abdomen with
air to see if the opposite side inflates. None of these
criteria or techniques is sufficiently reliable to reduce
the negative exploration rate.
With the advent of laparoscopy and miniaturized equipment,
a new set of tools to evaluate a child for a contralateral
inguinal hernia has become available. Owings and Georgeson
8 described a technique whereby a 14-gauge intravenous
catheter is introduced into the abdominal cavity. CO 2
is insufflated and using a 1.2-mm end-viewing laparoscope,
the internal ring of the side opposite the hernia is evaluated.
The downside of this technique, of course, is that it
employs another puncture and puts the intestine and other
abdominal structures at risk.
An alternative technique uses a laparoscope with an angled
lens. Modifying a technique described by Chu 9, we use
a 4-mm diameter scope with a lateral viewing angle to
inspect the opposite groin.
Inguinal hernia exposure of the side known to have a hernia
is carried out. After isolating the vas deferens and cord
vessels, the hernia sac is divided. The proximal portion
is dissected to the level of the internal ring. Small
clamps are placed on the edges of the cut sac and the
sac is opened. A 4.5-mm port is carefully introduced into
the abdomen. The sac is tightened around the port with
a vessel loop to prevent escape of the insufflated gas.
The CO2 is then pumped into the abdomen to a preset pressure
level. On occasion the opposite groin inflates, confirming
the presence of a patent processus vaginalis. A 90o 4-mm
scope is then passed through the port and across the lower
pelvis until the landmarks of the opposite internal ring
are identified. (Figure 4). The processus vaginalis is
observed to be either open or closed. On average this
technique adds only 2 minutes to the operative time. If
there are other intrabdominal questions to answer, laparoscopic
exploration is directed appropriately. Upon completion
of inspection, the gas is released, the port and scope
are removed, and a high ligation of the sac is performed.
If a patent processus vaginalis was found, the opposite
side is then repaired with a routine open technique.
In 1993, one of us (JZ) began performing this procedure.
As an initial series 10 45 consecutive patients with inguinal
hernias were evaluated. Two patients had bilateral inguinal
hernias on examination and needed no further investigation.
Laparoscopic evaluation of the opposite groin was attempted
in the remaining 43 and was successfully completed in
41. These patients were divided into 2 groups based on
age. Twenty-one patients were 2 years or older; 20 were
less than 2 years. In the former group, only 1 had a patent
contralateral processus vaginalis. Of the younger group
9/20 were found to have an open processus. From this small
series the author felt confident in concluding that, since
most patients do not have the potential for a hernia developing
on the "silent" side, routine open exploration
had no place, regardless of age. Furthermore, even though
about 3 of the 9 positive patients in the <2 year group
would develop a hernia (16%), the high risk group was
readily extractable from the children with a hernia cohort
by using transinguinal laparoscopy. Meta-analysis of subsequent
studies using laparoscopy to evaluate the "silent"
side has confirmed the value of the technique. 11
Fig. 4: Right internal inguinal
ring with hernia as viewed from within using a 90-¼
scope.
With the advent of laparoscopy and miniaturized equipment,
a new set of tools to evaluate a child for a contralateral
inguinal hernia has become available.
Minimal access surgery is a remarkable technical advance
that benefits patients of all ages. The development of
smaller and shorter instruments has made techniques once
limited to larger patients now available for even newborns.
There is every reason to believe that the 21st century
will offer new techniques and novel methods for using
MAS to care for the pediatric surgical patient. Additional
information about minimal access surgery at Children's
Hospital of New York Presbyterian is available at our
website: www.babysurg.org.
- Lobe TE, Schropp KP. Pediatric Laparoscopy and
Thoracoscopy. WB Saunders Company, Philadelphia, 1994.
- Hoff SJ, Neblett WW 3rd, Heller RM, Pietsch JB,
Holcomb GW Jr, Sheller JR, Harmon TW. Postpneumonic
empyema is childhood: selecting appropriate therapy.
J Pediatr Surg1990; 25:1307.
- Davidoff AM, Hebra A, Kerr J, Stafford PW. Thoracoscopic
management of empyema in children. J Laparoendosc Surg
1996; 6 Suppl 1:S51-4.
- Chan W, Keyser-Gauvin E, Davis GM, Nguyen LT, Laberge
JM. Empyemathoracis in children: 1 26-year review of
the Montreal Children's Hospital experience. J Pediatr
Surg 1997;32:870-2.
- Rodriguez, JA, Hill CB, Loe WA Jr, Kirsch DS, Liu
DC. Video-assisted thoracoscopic surgery for children
with stage II empyema. Am Surg 2000; 66:596-72.
- Kercher KW, Attorri RJ, Hoover JD, Morton D Jr.
Thoracoscopic decortication as first-line therapy for
pediatric parapneumonic empyema. A case series. Chest2000;
118:24-7.
- Gross RE. The Surgery of Infants and Children.
WB Saunders Company, Philadelphia, 1953.
- Owings EP, Georgeson KE. A new technique for laparoscopic
exploration to find contra lateral patent processus
vaginalis. Surg Endosc2000; 14:114-6.
- Chu C, Chou C, Tsu H, et al: Intraoperative laparoscopy
in unilateral hernia repair to detect a contralateral
patent processus vaginalis. Pediatr Surg Int1993;8:385-388.
- Zitsman JL. Transinguinal diagnostic laparoscopy
in pediatric inguinal hernia. J Laparoendosc Surg1996;
6 Suppl 1:S15-20.
- Miltenberg DM, Nuchtern JG, JaksicT, Kozineitz
C, Brandt ML.Laparoscopic evaluation of the pediatric
inguinal hernia-a meta-analysis. J Pediatr Surg1998;33:874-879.
Minimal Access Surgery Center
New York-Presbyterian Hospital
525 East 68th Street New York, NY 10021
Dennis L. Fowler, M.D. Director
(212) 746-5599
Richard L. Whelan, M.D.
Site Director
Columbia Presbyterian Medical Center
(212) 305-0577
The Minimal Access
Surgery Center at New York-Presbyterian Hospital offers
the latest advances in minimally invasive surgical and
diagnostic techniques for a wide range of conditions.
Minimally invasive surgical services are particularly
applicable in the fields of general surgery, gynecology,
urology, cardiothoracic surgery, pediatric surgery, colorectal
surgery, and neurosurgery. Surgeons in all of these disciplines
at both campuses of the Hospital have expertise in minimal
access techniques and are available for elective or emergent
consultation.
