>> THE FIRST STEP OF A LAPAROSCOPIC PROCEDURE,
THAT IS A MINIMALLY INVASIVE SURGERY IN THE ABDOMEN,
IS PLACEMENT OF THE TROCARS.
>> A TROCAR IS A HOLLOW TUBE.
IT HAS A VALVE AT THE TOP SO THAT GAS CAN'T LEAK
THROUGH IT.
IT HAS AN INSERTION IN THE MIDDLE WITH A SHARP POINT
SO THAT YOU CAN ACTUALLY INTRODUCE IT THROUGH
THE TISSUE, INTO THE ABDOMEN OR THE CHEST,
AND THEN YOU REMOVE THE INSERT,
AND THAT LEAVES YOU WITH A ONE-WAY VALVE THAT YOU CAN
PUT INSTRUMENTS IN AND OUT OF.
>> WE'LL PLACE THE FIRST ONE,
ALMOST ALWAYS, IN THE BELLY BUTTON,
AND THAT CREATES AN AIR LOCK SO THAT WE CAN INFLATE
THE ABDOMEN WITH CARBON DIOXIDE GAS.
THAT GIVES US ROOM TO WORK.
>> BY INSUFFLATING GAS, YOU CAN ACTUALLY RAISE THE
ABDOMINAL WALL AWAY FROM THE STRUCTURES YOU ARE
WORKING ON, AND IT ALLOWS YOU TO DO THE OPERATION.
>> CARBON DIOXIDE HAS A LOT OF VIRTUES.
HOWEVER, IT'S VERY DRY, AND THAT DRY GAS THAT'S
COLD CAN BE DANGEROUS TO THE BABY.
>> WE WANT THE BABY KEPT WARM,
NOT ONLY ON THE OUTSIDE, BUT ALSO ON THE INSIDE.
>> SO WE USE GENTLE, WARM, HUMIDIFIED CARBON DIOXIDE
IN THE BABIES.
AND THAT REALLY CUTS DOWN ON THEIR PAIN AND REMOVES
THE DANGER OF HYPOTHERMIA.
THE NEXT THING WE DO IS WE PLACE A TELESCOPE.
IT'S A METAL ROD WITH GLASS LENSES,
AND AT THE END OF THAT TELESCOPE
IS A HIGH-DEFINITION CAMERA.
RIGHT IN THAT TELESCOPE ARE FIBER OPTIC FIBERS THAT DRAW
LIGHT FROM AN EXTERNAL POWER SOURCE AND VERY
BRIGHTLY LIGHT UP THE ABDOMEN.
>> YOU NEED TO PUT IN YOUR PORTS IN APPROPRIATE SITES
SO YOU HAVE YOUR INSTRUMENTS AT THE CORRECT ANGLES
AND THE CORRECT POSITION TO DO THAT OPERATION.
>> WE'LL ACTUALLY LOOK UP AT THE ABDOMINAL WALL
WITH THE CAMERA AND WATCH THOSE TROCARS COME IN.
>> USUALLY, THERE ARE FOUR PORT SITES--
ONE AT THE BELLY BUTTON, TWO ON EACH SIDE ABOVE
THE LEVEL OF THE BELLY BUTTON, AND THEN OFTTIMES
A FOURTH PORT TO RETRACT THE LIVER.
>> AND WE CAN SEE WHAT THE CAMERA SEES BY WAY OF THESE
MONITORS THAT HANG DOWN RIGHT IN FRONT OF THE
PATIENT, AND WE CAN JUST LOOK RIGHT THERE,
SORT OF LIKE WATCHING HIGH-DEFINITION TELEVISION.
>> WE ALSO HAVE TO WATCH THE PRESSURES THAT WE USE
ON THE BABIES.
WE CAN'T USE ANYTHING LIKE THE KINDS OF PRESSURE
IN THE ABDOMEN THAT WE CAN IN AN ADULT.
>> THE PROBLEM WITH USING TOO MUCH PRESSURE IS THAT
YOU CAN INHIBIT BREATHING.
YOU CAN PUT PRESSURE ON THE DIAPHRAGM AND MAKE IT
HARDER TO VENTILATE THE PATIENT DURING SURGERY.
>> SO WE'VE HAD TO MODIFY OUR TECHNIQUE TO USE MUCH
LOWER PRESSURES, MUCH LIGHTER INSTRUMENTS,
LIGHTER, THINNER TROCARS, AND EVEN THE WAY
THE SURGEONS HOLD THEIR HANDS.
YOU CAN'T JUST REST THINGS ON THE PATIENT ANYMORE.
YOU'VE GOT TO LIFT UP.
AND THAT ALLOWS US TO PROTECT THE BABY AND USE
THOSE VERY LOW PRESSURES.
WHEN WE'RE OPERATING IN THE CHEST,
THE TECHNIQUE IS A LITTLE DIFFERENT.
>> YOU HAVE RIBS.
YOU HAVE MUSCLES OF THE CHEST WALL.
SO YOU DON'T REALLY HAVE MUCH MOBILITY OF YOUR PORTS
OR YOUR INSTRUMENTS ONCE THOSE PORTS ARE PLACED.
AND THAT'S VERY DIFFERENT FROM LAPAROSCOPY,
WHERE YOU HAVE MUCH MORE MOBILITY WITHIN
THE ABDOMINAL WALL TO MOVE YOUR INSTRUMENTS.
>> ANY OPERATION IN THE CHEST IS A BIT MORE
CHALLENGING BECAUSE THERE'S LESS SPACE IN THE CHEST.
>> THE THORACIC CAGE IS RIGID BY DESIGN.
AND THAT MEANS THERE'S NO INFLATING THE THORACIC CAGE
TO GIVE US A LITTLE BIT MORE ELBOW ROOM.
>> SO INSTEAD OF THAT, WHAT YOU HAVE TO DO TO MAKE SPACE
IS THAT YOU HAVE TO VENTILATE JUST ONE OF THE
LUNGS, AND THAT ALLOWS THE OTHER LUNG TO DECOMPRESS,
OR DEFLATE.
AND THAT CREATES A TREMENDOUS AMOUNT OF ROOM
IN THE THORACIC CAVITY.
THE WAY THAT WE DO THAT IS BY PLACING THE ENDOTRACHEAL
TUBE, THE TUBE THAT YOU BREATHE FOR THE PATIENT
THROUGH, INTO EITHER ONE BRONCHUS OR INTO THE OTHER
BRONCHUS DEPENDING ON WHICH LUNG YOU'RE WORKING ON.
>> OF COURSE, THE BABY IS STILL BREATHING WITH THE
OTHER LUNG, AND HUMANS HAVE ENOUGH RESERVE SO THAT USING
JUST ONE LUNG FOR THE TIME OF THE OPERATION IS REALLY
NO PROBLEM.
>> OUR ANESTHESIA TEAMS AT CHOP ARE VERY,
VERY EXPERIENCED WITH SINGLE-LUNG VENTILATION
IN INFANTS, AND IT'S A VERY, VERY SAFE PROCEDURE TO BE
DONE IN THE RIGHT HANDS.
>> WE'LL PUT THE TROCARS IN THE SAME WAY.
BUT WHEN WE PLACE THE FIRST TROCAR,
WE'VE GOT TO USE A MODIFICATION OF THAT
TECHNIQUE SO THAT THE TROCAR IS VERY BLUNT BECAUSE WE
DON'T WANT THAT TO DAMAGE THE LUNGS WE'RE PLACING
IN THERE.
AFTER WE'VE PLACED THAT FIRST ONE,
WE DO STILL USE A LITTLE CARBON DIOXIDE GAS,
BUT NOT NEARLY AS MUCH AS WE WOULD USE IN THE ABDOMEN.
BECAUSE WE CAN'T SQUEEZE ON THE CHEST ORGANS THE SAME
WAY WE CAN SQUEEZE A LITTLE BIT ON THE ABDOMINAL ORGANS.
>> WE POSITION THE BABY ON ITS SIDE,
AND WE TURN THE FRONT OF THE BABY DOWNWARD SO THAT
THE LUNG WILL DROP FORWARD.
WE PUT IN THREE PORTS.
WE PUT THE SCOPE PORT UP ABOVE THE TWO INSTRUMENT
PORTS AT THE APPROPRIATE LEVEL OF THE CHEST WALL
PLACING THE PORTS BETWEEN THE RIBS,
AND THAT ALLOWS US TO LOOK DOWN ON OUR INSTRUMENTS AND
LOOK DOWN ON THE FIELD WHILE WE'RE OPERATING JUST LIKE
YOU WOULD IF YOU WERE LOOKING DOWN ON YOUR HANDS
IN AN OPEN OPERATION.
IF YOU HAVE EVERYTHING SET UP CORRECTLY,
THEN YOU'RE IN A PERFECT POSITION,
PERFECT ALIGNMENT, TO DO THE OPERATION AS WELL
AS YOU COULD POSSIBLY DO IT USING OPEN TECHNIQUES.
>> WE'RE ROUTINELY OPERATING INSIDE OF VOLUMES THAT
ARE THE SIZE OF A MATCHBOX OR A CHILD'S MEDICINE CUP.
>> SO THAT'S A VERY SMALL AREA TO WORK IN,
AND IT REQUIRES A DIFFERENT INSTRUMENTATION AND ACTUALLY
A DIFFERENT TECHNICAL APPROACH TO DO THOSE
OPERATIONS.
>> WE CAN SEW AND CUT AND TIE KNOTS AND ALL THOSE
THINGS THROUGH THOSE PORTS.
>> THE TINY LITTLE TOOLS THAT WE USE IN THE BABIES
AND THE CHILDREN ARE FAR MORE DELICATE THAN OTHER
SURGICAL TOOLS.
>> THE LAPAROSCOPIC INSTRUMENTS
OR THORACOSCOPIC INSTRUMENTS ARE REALLY
PATTERNED AFTER THE INSTRUMENTS
WE USE IN OPEN SURGERY, AND THOSE HAVE BEEN
PERFECTED FOR CENTURIES BY SURGEONS.
YOU PUT YOUR HANDS INTO THE RINGS OF THE INSTRUMENT,
AND YOU, BASICALLY, CAN OPEN AND CLOSE THE INSTRUMENT,
DISSECT WITH THE INSTRUMENT BASED ON THESE HANDLES THAT
YOU HAVE OUTSIDE OF THE ABDOMEN OR THE CHEST.
>> WE HAVE CAMERAS IN THE LIGHTS SO THAT YOU CAN WATCH
THE PROCEDURE.
WE HAVE THE CAMERA ON THE SCREEN THAT IS IMPERATIVE
FOR THE SURGEON BECAUSE THAT'S ALL HE LOOKS AT
IS THE SCREEN.
>> IT'S A REMOTE-CONTROLLED SORT OF A SYSTEM THAT'S VERY
DIFFERENT FROM ACTUALLY BEING INSIDE THE ABDOMEN
OR INSIDE THE CHEST AND DIRECTLY APPLYING THE
INSTRUMENT, AND IT TAKES A LITTLE GETTING USED TO.
EVERYONE IN THE ROOM IS FAMILIAR WITH BOTH THE
MINIMALLY INVASIVE APPROACH FOR A PARTICULAR OPERATION
AS WELL AS THE OPEN APPROACH.
>> IT IS ROUTINE AT CHOP NOW TO SET UP THE ROOM
WITH THE INSTRUMENTS WE NEED FOR BOTH METHODS.
>> SO, IF WE HAVE TO CONVERT AN OPERATION FROM MINIMALLY
INVASIVE TO OPEN, EVERYONE THERE IS APPROPRIATELY
TRAINED TO DO THE PROCEDURE.
AND IT'S AN EASY TRANSITION, AND ONE THAT'S SAFE
FOR THE CHILD.
>> WHEN THE OPERATION IS FINISHED,
ALL THOSE-- THE INSTRUMENTATION
IS ALL REMOVED, AND YOU HAVE THESE LITTLE TINY
3-, 4-, 5-MILLIMETER SITES, JUST A FRACTION OF AN INCH,
THAT CAN THEN BE CLOSED WITH A PLASTIC SURGICAL-TYPE
CLOSURE SO THERE'S NO STITCH ON THE OUTSIDE.
WE USE NUMBING MEDICINE, LOCAL ANESTHESIA,
AT THE BEGINNING FOR EACH OF THOSE PORT SITES.
>> BECAUSE WE'VE LEARNED THAT IF WE NUMB UP THE SKIN
AND THE SUBCUTANEOUS TISSUES BEFORE PLACING THE TROCAR,
THE PAIN AFTER THE BABY WAKES UP IS A LOT LESS.