Evidence-based advances in minimally invasive surgery in infants with congenital gastrointestinal anomalies: a narrative review

Introduction

In the mid-1970s, thoracoscopy was first used for the exploration and biopsy of intrathoracic anomalies in infants (1). Later, pediatric surgeons began to publish their laparoscopic experience. By the 1990s, minimally invasive surgery (MIS) for the repair of congenital anomalies became fairly common practice (2). As sophisticated endomechanical devices (e.g., 5-mm diameter trocars and warmed CO₂ insufflators) were applied to infants and procedures were reported to be feasible for patients weighing less than 5 kg (3), a nascent subfield of neonatal MIS emerged.

Advantages of MIS include better cosmesis, less trauma, and faster recovery. However, experimental and clinical data have pointed out that several MIS-related effects/maneuvers such as CO₂ insufflation and decreased body temperature may significantly contribute to negative postoperative outcomes. These findings varied when examining different congenital anomalies and patient situations (4,5).

In this article, we reviewed the recent developments of MIS in infants with congenital gastrointestinal (GI) defects, aiming to assist surgeons in making decisions and improve patient outcomes. We present this article in accordance with the Narrative Review reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-23-611/rc).

Methods

We conducted a literature search for MIS-related studies with the strategy summarized in Table 1. Keywords included terms related to MIS (“thoracoscopy”, “laparoscopy”, etc.) and congenital GI anomalies (“esophageal atresia”, “anorectal malformations”, etc.). Literatures were supplemented by viewing the reference of relevant papers.

Congenital diaphragmatic hernia (CDH)

CDH is a congenital life-threatening condition in which the diaphragm fails to develop properly, allowing the abdominal contents to herniate into the thoracic cavity. Surgical intervention is required to repair the defect of the diaphragm. The most common type of CDH is the Bochdalek, which presents as a posterolateral defect. Among non-Bochdalek types of hernia, Morgagni hernia occurs most frequently and is characterized by the herniation of the abdominal organs into the thoracic cavity via a retrosternal diaphragmatic defect. The first thoracoscopic Bochdalek-type CDH repair was performed by Silen et al. in 1995 on a teenager, followed by the first Morgagni-type CDH repair in 1997 (6,7). However, a USA population-based report in 2019 revealed that CDH repair via thoracoscopy was attempted in only 18% (79/432) of infants, with a high rate of conversion to open surgery (32/79) (8).

The thoracoscopic approach has been more commonly used for Bochdalek-type CDH in previous reports, while the laparoscopic approach being reportedly more appropriate for Morgagni-type CDH hernias. For Bochdalek-type CDH patients, operative duration was longer for MIS, and postoperative ventilator time and postoperative mortality were higher after open surgery (9). The recurrence rate was reported to be higher after MIS than open repair when a patch was used; however, the authors claimed that it may be attributed to a selection bias as stable patients with milder defects are more likely to be selected for MIS, namely, severe infants undergoing open surgery may have died before recurrence could happen (9). In contrast to Bochdalek-type, in Morgagni-type CDH, laparoscopy is associated with shortened length of surgery and hospital stay, with comparable recurrence and complication rates to the open procedure (10,11).

No differences were found in the incidence of recurrence and other surgical outcomes when using either absorbable or nonabsorbable materials for patch repair (12). Comparison between primary repair and patch repair was hard to conduct due to selection bias as described above. It should also be noted that patch repair is frequently used for larger defects and is therefore often considered a surrogate marker for disease severity (13).

Intraoperative hypercapnia and severe acidosis were only observed during thoracoscopy for CDH but not for esophageal atresia (EA) in a randomized controlled trial (RCT) conducted by Bishay et al. (5). Since then, indications of MIS repair for CDH have been frequently discussed in the literature. Presently, there is no clear evidence in support of immediate surgical repair vs. late intervention, though both anatomical and physiological selection criteria for MIS surgery in CDH infants have been proposed by several researchers (14-18) (Table 2). Potential association between MIS surgery and increase risk of neurodevelopmental disorders in CDH patients need to be considered.

EA with or without tracheoesophageal fistula (TEF)

Defects in foregut separation during fetal life result in the formation of EA with or without TEF and require emergent surgical intervention after birth. Several decades after the first successful staged repair of this lesion by Ladd and Leven in 1939, thoracoscopic repair of a pure EA was reported in 1999, and the repair of an EA with distal TEF was completed 1 year later (19-21). Nowadays, apart from type III EA, the thoracoscopic approach has been shown to be safe and effective for non-type III EA and long-gap EA (22,23).

There are several advantages of the thoracoscopic approach over open repair which include superior cosmetic results, faster recovery, and avoidance of posterior-lateral thoracotomy which has been shown to be associated with growth deformities of the thorax, shoulder, and spine (24). Miyano et al. also found that EA patients who had a thoracoscopic repair demonstrated lower quality of life scores at 1 year, but the score evened out at the time of starting school (25). Additionally, the 5 mm titanium clips have been shown to be simple and effective with no evidence of tracheal leak or recurrent fistula, which may be preferred by surgeons who encounter the technical hurdle of anastomotic sutures in the small working space (26). However, a meta-analysis showed that there were no significant differences in anastomotic leak rate and formation of esophageal strictures following anastomoses between the open and thoracoscopic approaches (27).

When evaluating surgical outcomes, several factors or findings warrant attention. A meta-analysis revealed the superiority of laparoscopic repair performed with preservation of azygos vein, in terms of the incidence of postoperative chest infection (28). However, prophylactic extrapleural chest tube drainage failed to decrease the early postoperative respiratory complications and mortality rates in newborns with EA (29). Additionally, a meta-analysis concentrated on use of transanastomotic feeding tube (TAFT) demonstrated that the use of TAFT significantly increased the risk of stricture, but it was not associated with other complications (30).

Choledochal cyst (CC)

CC is one of the most common causes of jaundice in infants. Surgical intervention is required for all patients and consists of excision of the dilated bile duct and the formation of either a hepaticoduodenostomy or Roux-en-Y hepaticojejunostomy. In contrast to the laparoscopic Kasai procedure, laparoscopic CC excision and related reformation have been widely accepted as a therapeutic option since they were first reported by Farello et al. in 1995 (31,32).

Large multicenter series have reported lower complication rate and excellent cosmetic results in children with laparoscopic treatment, which is comparable or even superior to open procedure (33). Even with the different level of tolerance, retrospective analyses of neonates came to a similar conclusion (33-37) (Table 3). The application of new technologies such as three-dimensional (3D) laparoscopy have been reported to provide better outcomes for neonates (38).

It is generally agreed on by researchers that earlier detection and operation decreases the complication risk for CC patients. However, the best operation time for asymptomatic patients within 1 year remains controversial. van den Eijnden et al. and Chan et al. recommended delaying surgery until the weight of about 6 kg or age of about 3 months because of the lower rate of postoperative morbidity and complication seen in retrospective reviews (39,40). However, Diao et al. recommended surgery within 1 month after birth as the incidence of hepatic fibrosis was significantly increased after 1 month of age in an RCT (41). Retrospective analysis conducted by Guan et al. revealed that cyst size of length >5.2 cm and width >4.1 cm suggested that clinical symptoms might appear and reached a similar conclusion—surgery should be carried out as soon as possible, even in the neonatal period (42).

There are some significant findings in CC children which are noteworthy but need further confirmation in neonates. A meta-analysis conducted by Narayanan et al. compared the two most commonly performed methods of reconstruction after excision and concluded that hepaticoduodenostomy has a higher postoperative reflux or gastritis but shorter hospital stays than Roux-en-Y hepaticojejunostomy (43). For hepaticojejunostomy, Diao et al. reported that an individualized short Roux-loop length is as effective as the conventional Roux-loop length and may prevent Roux-loop obstruction and reflux (44). Diao et al. also presented that no drainage is needed after laparoscopic Roux-en-Y hepaticojejunostomy for the majority of CC children, which minimizes postoperative pain and complications, and facilitates recovery (45).

Hypertrophic pyloric stenosis

Pyloric stenosis is an acquired condition caused by hypertrophy of the pyloric muscle, resulting in gastric exit obstruction. The first pyloromyotomy procedure was reported in 1912 by Ramstedt (46), which is quite early among neonatal surgeries. In 1986, Tan and Bianchi reported the use of a “circumumbilical incision” for this procedure (47), and the laparoscopic approach was described later by Alain in 1991 (48).

Several studies have compared the difference between open and laparoscopic approaches to pyloromyotomy. The laparoscopic approach was recommended as the first choice by large retrospective studies and RCTs (49-51). However, a meta-analysis conducted by the Cochrane Gut Group involving seven RCTs failed to show a significant increase in complications for the open approach, partly due to limitations in study design, imprecision, and inconsistency (52). Given that mucosal perforation and incomplete myotomy are the two most concerning complications of pyloromyotomy, the decision to opt for a single-incision laparoscopic approach should be made cautiously. It is still unclear whether this approach has a higher perforation rate compared to the conventional laparoscopic method (53-55).

While there is an ongoing debate about the optimal feeding regimen following laparoscopic pyloromyotomy, there is consensus that ad libitum feeding is highly effective (56-58). This is because ad libitum feeding helps decrease the time required to reach goal feeding. Even though the frequency of postoperative emesis may be increased, it does not appear to significantly increase hospital readmission.

Intestinal atresia

Congenital blockage of the intestine is a relatively common developmental defect in the newborn and may be complete or partial and intrinsic or extrinsic. Surgery to establish intestine continuity is the treatment. The first laparoscopic duodenoduodenostomy in a newborn was reported by Bax et al. in 2001 (59), followed by Rothenberg et al. in 2002 who described their initial experience with this novel procedure (60). Yamataka et al. were the first to apply a combination of laparoscopy and transumbilical laparotomy in this procedure and did intestine anastomosis after exteriorization via the umbilical incision site (61).

There are no clear criteria for surgical procedure (open or laparoscopic) in previous reports. The decision seems to be subjective, based on the tolerance of pneumoperitoneum and surgeon’s preference (62). Advantages of laparoscopy included lower morbidity, reduced time for initiation and completion of full enteral feeds, reduced need for postoperative pain medication, shorter length of stay, and cosmesis; notable however, several studies reported the need for a longer operative duration with the laparoscopic approach (63-65).

A report by van der Zee et al. in 2011 gave rise to the discussion about the best anastomotic approach in laparoscopy procedures. The abandoned laparoscopic duodenal atresia repair was largely abandoned in infants because of unacceptably high rates of leaks and other complications, but was then reintroduced when there was adequate experience and appropriate adjustment of technique (66). Anastomosis methods now include U-clips, side-to-side fashion, diamond-like fashion, parallel fashion with traction on two sides, and can be done either intracorporeally or after exteriorization (63-65,67-71) (Table 4). No significant differences directly related to anastomosis were found compared to open procedure when the same method was applied (64,70,71).

Rothenberg was the first to report that laparoscopy had a possible disadvantage in evaluating distal bowel (60). Miscia et al. reported that the incidence of associated intestine atresia in duodenal atresia infants is low, but the risk of missing it is higher by laparoscopy than by laparotomy (72). However, whether the missed atresia will cause adverse events, and whether there is value in conducting more careful inspections laparoscopically, are still unclear.

Malrotation

Incomplete or abnormal midgut rotation during early fetal development increases a child’s susceptibility to conditions like midgut volvulus, intestinal obstruction, or mesenteric artery occlusion, all of which may require surgical intervention. The classical surgical approach to malrotation was first described by Ladd in 1936 (73), and the laparoscopic procedure was first published by van der Zee and Bax in 1995 (74).

Age at surgery is a key factor to consider when dealing with malrotation. This is due to the higher risk for recurrence and conversion to open procedure in neonates compared with older children. Miyano et al. noted that laparoscopy should not be recommended for the treatment of malrotation in neonates (75). Skertich et al. also noted that younger age is associated with an increased risk of conversion to open procedures (76).

In addition to benefits like shorter hospital stays, fewer incision infections, and better cosmetic outcomes, research suggests that laparoscopy may be valuable in both symptomatic and asymptomatic cases where radiological findings are inconclusive (77,78). Hsiao et al. reported that about 37% of patients had equivocal or inconclusive imaging studies in their institution, and six out of 19 patients were prevented from having potentially devastating intestinal ischemia from midgut volvulus by laparoscopic inspection (79).

A systematic review conducted by da Costa et al. indicated that the presence of volvulus is associated with recurrence and conversion (80). Due to the limited effectiveness of the laparoscopic approach in neonates with suspected volvulus, Hsiao et al. recommended urgent laparotomy in these patients to quickly access the bowel and minimize the risk of bowel necrosis (81). A comparative study conducted by Zhu et al. concluded that recurrent volvulus occurs primarily after laparoscopic Ladd’s procedure, whereas adhesive intestinal obstruction occurs after both open and laparoscopic Ladd’s procedures (82). There was no difference in reoperation rate between the two approaches noted. The high rate of conversion in neonates with a suspected volvulus needs to be taken into consideration when deciding on the surgical approach, and the difference in outcomes is crucial in determining the best approach for the patient.

Hirschsprung’s disease (HD)

HD is a motility defect caused by failure of ganglion cell migration during fetal life. The aganglionic segment is functionally obstructed after birth. The goals of surgical treatment for HD are to remove the aganglionic segment and reconstruct the intestinal tract while preserving normal functionality of defecation. Several open procedures were described and popularized in the 1940s, including Swenson, Soave, and Duhamel, with similar results in long-term studies (83). Georgeson was the first to apply laparoscopic techniques via pull-through surgery in the early 1990s (84). The transanal Soave procedure, which was first described by De la Torre-Mondragón et al. in the late 1990s enabled the perineal dissection to be performed safely without laparoscopic dissection, completely from below (85). The totally transanal procedure represented a new era for pull-through surgery.

Minimal access approaches (both laparoscopic and transanal procedures) have shown less pain, shorter time to feeding, shorter hospital stay, and improved cosmetic results in comparison to open surgery, with no difference in short or long-term complication rates (86). Additionally, single-incision laparoscopy seems to serve better cosmetic results and shorter operation duration compared to the conventional laparoscopic approach (87,88).

Current discussions center on the necessity of laparoscopic assistance during transanal procedures. Meta-analyses have shown similar outcomes between transanal endorectal pull-through (TERPT) and laparoscopically assisted TERPT (LTERPT) to correct classic segment HD. In addition, TERPT offers a shorter operative duration and leaves no visible scars (89,90).

Nevertheless, transanal pull-through procedures of long segment cases were almost all performed with the assistance of laparoscopy due to the vital ability for inspection and mobilization (91,92). This is particularly important as approximately 10% of neonates show mismatch between radiographic transition zone and level of aganglionosis (93). As a result, for any case with confirmed or suspected non-classic segment HD, the use of laparoscopic assistance seems to be required (94).

Anorectal malformations (ARM)

ARM includes various types of anomalies that are described as low, intermediate, or high, according to the space between supralevator muscle complex and the distal rectum. The posterior sagittal anorectoplasty (PSARP) has been considered the mainstream therapy for ARM since it was first described by Pena in the 1980s (95). However, surgical outcomes after PSARP are not satisfactory, as only 38% of patients totally achieve continence (96). In 2000, laparoscopic-assisted anorectal pull-through (LAARP) was introduced by Georgeson et al. with the aim of accomplishing a correction without mid-sagittal division of any muscles related to continence (97). LAARP has allowed patients to have a new surgical option especially in patients with high or intermediate ARM (98).

Laparoscopy is most commonly indicated as a substitute for laparotomy when a high to intermediate ARM defect is suspected, or when abdominal entry is required for malformation repair. In a meta-analysis conducted by Han et al., shorter hospital stays, less wound infection/dehiscence, higher anal canal resting pressure, and a lower incidence of grade 2 or 3 constipation were obtained after LAARP compared with the PSARP group (99).

It should be noted however that one of the most concerning complications, namely incontinence, remains poorly controlled with the laparoscopic approach even though theoretically it should be lessened due to reduced damage to the neuromuscular system (100). Standardized guidance for follow-up is needed to confirm the differences between LAARP and PSARP and will hopefully enable frequent assessments and possible improvement for incontinence.

Conclusions

Better cosmetic result, less postoperative pain, and an accelerated recovery have been shown to be common advantages of MIS relative to open approaches, and the use of thoracoscopy has significantly reduced the long-term sequelae caused during surgical procedures, including a reduction in shoulder movement impairment, rib fusions, and scoliosis. In addition, advanced technologies such as the combination of robotic assistance with single-incision approaches and 3D endoscopy have made more precise manipulations and better outcomes possible. Surgical evolution consists of technical invention and expanded application and should continue to be emphasized and updated by the surgical community.

There are however some technical hurdles that may appear while applying minimally invasive techniques in large part due to the limited working space, unfamiliarity with instruments, and difficult manipulations. Surgical skills such as exteriorization anastomosis can be quite helpful, and surgeons should proactively seek to learn and become familiar with such techniques. Surgeons should be mindful of the metabolic disturbances caused by CO₂ during MIS and coordinate closely with anesthesiologists. They should also prioritize long-term follow-up, especially focusing on neurodevelopmental outcomes where relevant. In cases constrained by technical limitations or patient tolerance, surgeons should not hesitate to opt for an open approach.

Lastly, it is important that surgeons understand that current operative techniques are inherently imperfect and continue to develop. Some factors associated with quality of life such as fecal continence may not be corrected using by the use of laparoscopic or minimally invasive techniques. Furthermore, the difficulty for infants and young children to express their true feelings calls for systematic and objective assessment tools for surgical outcome evaluations in this patient population. Prospective multicenter studies and prospective databases are also in demand, especially in the neonatal age group.

Acknowledgments

Funding: This work was supported by the National Children Medical Center Discipline Leader Training Program (No. EKXDPY202307), the Fujian Key Discipline Project (Nos. FKS-2023-NE-06 and FKS-2023-PS-MDT-06), and the Open Fund of Xiamen Key Laboratory of Pediatric Surgical Diseases (No. CHP-2023-XKL-006).

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-23-611/rc

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-23-611/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-23-611/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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