Pediatric Surgery and Minimally Invasive Techniques
Guest: Dr. Chris Streck – Department of Surgery, MUSC
Host: Dr. Linda Austin – Psychiatrist, MUSC
Dr. Linda Austin: Dr. Chris Streck is Assistant Professor of Pediatric Surgery; Pediatric Surgery in the Department of General Surgery. Dr. Streck, you have a very wonderful and interesting specialty, which is minimally invasive surgery of pediatric patients. I think we’re used to thinking about that for adults, but this is really a new service offered here in South Carolina, is that right?
Dr. Chris Streck: It really is. The nice thing about children is there’s such a broad spectrum of diseases and problems that we encounter, and for a long time surgeons have been resistant to move forward and try minimally invasive techniques in children. Part of that, I think, are just technical limitations: the size of the instruments, the size of the scopes, getting good optics from the children. But from a technological standpoint, we’re able to do many of the things that we do in adults, now, in children.
Dr. Linda Austin: So, what are some of the most common minimally invasive procedures you do in children?
Dr. Chris Streck: Overall, the most common is the laparoscopic appendectomy. However, recently, we have really applied the same techniques to treat other pediatric problems that until recently were treated, always, with open surgery. That would include inguinal hernias; hernias in the groin, and problems like pyloric stenosis, which is a thickening of the stomach muscle that babies can encounter. So, we’re able to operate in children that are even less than 3 kilograms using these minimally invasive techniques.
Dr. Linda Austin: Three kilograms is what, six and a half pounds? So, these are little, itty-bitty babies that you’re doing this on?
Dr. Chris Streck: Yes.
Dr. Linda Austin: Why might it be particularly important in such a small child to do minimally invasive, rather than the traditional open approach with a larger incision?
Dr. Chris Streck: I think there are a lot of benefits of the minimally invasive technique. Obviously, one, I’m a parent, and this is something I always think about as a parent: What will the incision look like? I think there’s a huge cosmetic benefit to making smaller incisions, particularly in children, because the scars that they have will become proportionally longer as they grow. But I think the benefits go much further than just cosmesis alone. With smaller incisions, less cutting of the abdominal wall, or chest wall, we think the children have much less pain. Obviously, pain is bad for anyone, but particularly in children, we think pain is not well-controlled. It can set off a cascade of other problems. Beyond just hurting the child, there can be some physiologic consequences.
And then, importantly, I think the visualization we get as surgeons helps us to do the best operation; to do the right operation. The scopes that we use have magnification. So, if you’re using a scope in a very small baby and dealing with a very tiny organ, or a tiny problem, the added visualization you get from 20x magnification can be very helpful. And, often, we can look into places that we otherwise couldn’t see with the help of a scope.
Dr. Linda Austin: For those who’ve never seen a scope; actually, I don’t think I’ve ever seen a scope, what does it look like? What do you mean when you say a scope?
Dr. Chris Streck: The scope, just to look at it from the outside, looks like a long thin cylinder. The diameter of some of the scopes we use is as small as 3 millimeters. The most common one we use is 5 millimeters, so half a centimeter in size would be the actual width of the scope. That allows us to put the camera; the scope is actually a camera, inside the abdomen or chest through a very small incision.
Dr. Linda Austin: So that’s about the width of a piece of fat macaroni, right?
Dr. Chris Streck: Pretty much.
Dr. Linda Austin: Something like that.
Dr. Chris Streck: Yeah.
Dr. Linda Austin: And so then it magnifies it so that you can actually see better in teeny-tiny areas than you could with a big open incision, is that correct?
Dr. Chris Streck: That’s correct. And often what we do is, with the ports that we use; a port is an instrument that allows you to take the scope in or out of the abdomen, or other small instruments; it’s a channel, or cannula, that we put in, inject air into the abdomen to fill up the abdomen, or fill up the chest. That expands the area we’re working in. So, in addition to the magnification, we often have a little more space to work with.
Dr. Linda Austin: So, you’ve mentioned a couple of things: the appearance over time, less pain and trauma, and stress, to a baby, or a child. How about healing time with these procedures, compared to regular surgery?
Dr. Chris Streck: That’s a great question. We feel that the children often heal much quicker. I’ve had parents call me later the same afternoon, or the next day, and say that their child is running around, playing on the playground; on the monkey bars, and ask if that’s a problem. And, you know, we always recommend that children take it easy after any operation. But the reality is, when you’re dealing with a three or four-year-old child, or even an older child, once they’ve decided they’re going to go out and do something, it’s really hard to hold them back. And that, typically, is not a problem. It demonstrates how well children often recover from these laparoscopic procedures.
Dr. Linda Austin: What is the smallest child you’ve operated on?
Dr. Chris Streck: The smallest child I’ve operated on was probably about 500 grams.
Dr. Linda Austin: Now, in pounds; for lay people?
Dr. Chris Streck: That’s about one pound.
Dr. Linda Austin: Oh, my goodness.
Dr. Chris Streck: Probably, the smallest child that I’ve done a laparoscopic procedure on would be five or six pounds. Those might be patients that had a hernia or pyloric stenosis.
Dr. Linda Austin: One last question: tell us about your training. This sounds to me like years and years of advanced training to master surgery, pediatric surgery, and now very specialized techniques. How did you learn to do this?
Dr. Chris Streck: Sure. The standard training that all pediatric surgeons go through is a five-year general surgery residency. Most of us spend a year or two beyond that in a lab. I spent two years at St. Jude doing research in Children’s Oncology. Then, beyond that, most surgeons do at least two years of fellowship.
What’s different now about general surgery training, as opposed to ten years ago, as we discussed, adult surgeons are commonly doing laparoscopic procedures. So, we get, I think, a very good background to develop fundamentals of laparoscopy during our general surgery training. Then, we really learn how to operate on small babies during the two years of fellowship.
One of the great things about MUSC is that we have a number of pediatric surgeons that have special skills in laparoscopy. So I feel like my training is never done. We’re always working together, bouncing ideas off of each other. Often on the difficult cases involving babies that have rare or complex problems, we’ll have two surgeons in the room, feeding off of each other, helping each other, and ensuring that the best operation is being done.
Dr. Linda Austin: Is this the only place in South Carolina where minimally invasive, or laparoscopic, surgery is done on children?
Dr. Chris Streck: I think, to some degree, all surgeons have learned laparoscopic techniques, so some procedures are probably being done all over the state. However, if you took the most common problems that we deal with: appendicitis, hernias, pyloric stenosis, I would say that, at MUSC, we probably have the highest volume of patients being treated with minimally invasive techniques in the entire state.
Dr. Linda Austin: Very exciting. Congratulations on the great work you do.
Dr. Chris Streck: Thank you.
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