Basic MIS-Behavior:

Mechanical Advantage in Pediatric Minimally Invasive Surgery

Thane A. Blinman, MD Division of General, Thoracic and Fetal Surgery Childrens Hospital of Philadelphia 34th and Civic Center Blvd Philadelphia, PA 19104 215.590.4510 blinman@email.chop.edu

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ABSTRACT

In pediatric minimally invasive surgery (MIS), the

advantages of expert technique are demonstrable, but moving from novice to expert often seems more the product of fortune than intent. Meanwhile, the modern residency is being driven away from unlimited hours of direct experience and toward formal curricula, more didactics, lessons on simulators, and learning metrics. Advocates and critics of these changes probably can agree: We need to teach more efEiciently. That is, each trainee must make more progress toward expertise (however deEined) in less time. In pediatric MIS, that need seems magniEied, but safe surgical methodology hinges less on contrived core competencies than on sound principles and heuristics. This essay describes teachable principles designed to improve mechanical advantage in any MIS procedure. Pediatric surgical residents who learn these principles exhibit easier, faster, and safer minimally invasive technique.
KEY WORDS: laparoscopy, thoracoscopy, minimally invasive surgery, surgical education, resident training, heuristics

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INTRODUCTION

As to methods there may be a million and then some, but principles are few. The man who grasps principles can successfully select his own methods. The man who tries methods, ignoring principles, is sure to have trouble. Ralph Waldo Emerson Minimally invasive surgery (MIS) is hard to teach. To begin with, it is hard to learn(1). The skills needed for successful MIS are grounded in good open surgical technique, but expert ability to perform a given operation using open technique is only the First prerequisite to endoscopic expertise. Successful MIS requires a superset of skills to perform complex procedures in small spaces with long tillers via remote visualization. MIS is not a replacement for good surgical habits and techniques, but is a very powerful extension of surgical technique. Despite some skepticism of MIS in pediatric surgery (2, 3), the potential beneFits to patients are plain: smaller incisions create far less morbidity. Nevertheless, clumsy laparoscopic technique is not minimally invasive. Ad hoc practices and imprecise maneuvers lead to long operating and anesthetic times, poor mechanical results, and return trips to the operating room. These risks are ampliFied in children: The variety of cases is broader, including cases in the chest, abdomen, and pelvis associated with a very wide variety of malformations and other problems. The scope of required expertise is very broad. The patients are much more delicate, and have much smaller structures. Therefore, precise movement of instruments within body cavities is essential for safe tissue manipulation and good surgical results. Scaling effects of biomechanical structures and essential physiology create new surgical constraints. For example, the abdominal wall of a baby is relatively similar in thickness compared to that of a lean adult, but its absolute thickness is much smaller, dramatically reducing its ability to hold a trocar in place. Technique must be speciFically adapted to accommodate the thin abdomen. Similarly, round structures (such as esophagus, etc) must be perfectly approximated during repair, lest nonlinear increases in resistance at small diameters lead to poor outcomes. The patients are much more sensitive to hypothermia than adults because of their diminished metabolic capacity, diminished reserve, and physical characteristics allowing greater heat loss. Poor endoscopic technique can actually
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place small patients at increased risk of hypothermia compared to open technique, as long operating times and poor instrumentation choices force high insufFlation Flows to maintain visualization. The energy required to heat and humidify high-Flow insufFlation gas can easily be twice the basal metabolic rate of a baby. The instruments are shorter, narrower, and more delicate. Relatively few tools are specially adapted for pediatric use. The stakes from a misadventure can be much higher (e.g. In an adult, 90mL of blood loss is trivial; in a 3 kg child it is 1/3 of the total blood volume), and complications seem to be somehow more tragic in children than in adults. For all of these reasons, the margin for error in small patients is disproportionately small. The objective of this essay is to set out discrete principles of good pediatric minimally invasive surgical technique beyond simple exercises (4, 5). The heuristics listed here are intended to maximize the surgeons mechanical advantage at all times, in all cases. Maximum mechanical advantage fosters precision and spares the surgeon unnecessary fatigue, keeps him away from avoidable blunders, creates options for recovering from slips or unexpected anatomical challenges, increases, shortens operating time, and protects the patient.

Surgery is a physical art. Surgery is the art of applying mechanical solutions to medical problems. As such, surgical interventions lead to the best results when those medical problems have a mechanical basis. Some examples for which surgery is the best intervention include: repairing the damage from a stab incision; removing a tumor; relieving an intestinal blockage; reconnecting the esophagus; restoring the insertion of the ureter on the bladder; repairing a meniscal tear. These, and many other problems all have a mechanical problem as their source, and a mechanical solution is demanded. However, surgery sometimes is used for diseases that are not strictly mechanical, but more physiological, some disorder at the cellular level. For example, ulcerative colitis may be treated by colectomy, but this is more palliation than cure: the surgeon has not repaired a biomechanical problem, only removed an organ afFlicted with an inFlammatory disease that we dont really understand. The same may be said for obesity surgery. Observe that as a general rule, the results for mechanical interventions to mechanical problems are superior to those for physiological ones: repairing a

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duodenum damaged by a handle-bar is better than removing the antrum of the stomach to prevent ulcers in the duodenum. In this way, surgery is a kind of engineering. In order to achieve the best results, surgeons must know about their tools, their materials, the raw substrate they are manipulating, and what the mechanical objective is that they are trying to achieve. Try to state the purely mechanical objectives of: fundoplasty diaphragmatic plication appendectomy gunshot wound inguinal hernia repair

In diaphragmatic plication for example, there are two objectives: increase functional residual capacity of the ipsilateral lung, and provide a less compliant medial border to the contralateral hemidiaphragm so to increase its deFlection for the same muscular contraction. Compare mechanical objectives like this with palliative objectives in, for example, colectomy for ulcerative colitis, or pancreatectomy for hyperinsulinism. In each of these later cases, the basis of the treatment isnt biomechanical, but simply to remove the dysfunctional organ, trading a diseased physiology to some lesser dysfunction. In indirect inguinal hernia repair, the objective is to permanently close the internal ring (while avoiding damage to the spermatic cord structures). What approach most likely achieves this? Laparoscopic repairs allow the surgeon to visualize the ring at around 8x magniFication decreasing the probability of damaging the cord. But early results showed a disappointingly high recurrence rate. This problem vanished when permanent suture was used instead of the more traditional absorbable suture used in open technique. It appears that while the mechanical objective (permanently close the internal ring) of open and laparoscopic repairs is the same, the method may be different--one technique disconnects the sac, one does not--and so different materials must be used. Still, whatever the details of the method, the mechanical objective is the same, and must be achieved for a successful repair regardless of whether the approach is open or laparoscopic. The ten principles here increase the chances that the mechanical objectives of a given procedure will be achieved.

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#1 Perfect Operations Begin With Perfect Tools

If I had 8 hours to cut down a tree, I would spend 6 hours sharpening my axe. Abe Lincoln. The right toolscamera, ports, instruments, scopesmake the difference between a safe operation performed smoothly under conditions of excellent visualization and a Flail. In this way, patient safety is seen to begin with (but not end with) well-chosen and perfectly maintained tools. MIS instrument maintenance and replacement is often neglected in hospitals even though the instruments have a far shorter usable lifetime than those used in open procedures. A stainless steel Kocher clamp will work reliably for generations; a Fine 3mm endoscopic needle-driver will be sprung in a few years or less and endoscopic scissors may not last more than a single operation. Operating room budgets must reFlect these shorter useful lifetimes and plan for constant replacement of defective instruments. Clever operating rooms partner with vendors to maintain the instruments on a constant basis, vastly extending these tools working lives. An operating room staff that holds out a standard of like new operation for every instrument for every case protects both its own bottom line and its patients. Put more simply, tools that are not good enough for use on your own child are not good enough. It is the surgeons job to insist on this standard. Perfect operations are performed with tools that have smooth, low-resistance working parts, precision approximation at the tip, reproducible and predictable action. An expert wields these tools, the long reach from hand to organ hardly noticed. In contrast, poorly functioning tools can be deadly. While an experienced surgeon will be irritated and slowed by sticky instruments, the novice will be thoroughly Flummoxed, operating with jerky moves and halting over- corrections. The delicate infant liver, Fine sutures, and ephemeral tissue planes become inevitable casualties. Then, disrupted anatomy and bloody, obscured views makes the operation even harder, producing a feed-forward spiral to sub-optimal results at least, and disaster at worst. Well chosen, well functioning tools must be regarded and budgetedas indispensable contributors to patient safety. An important corollary here is that the expert knows how all his tools work. He knows how the tools Fit together, how feedback is measured by the insufFlator, how Flow relates to hypothermia, how the various energy sources work and what their limits and liabilities are. A novice is bafFled by poor insufFlation; an expert knows how to track and dispose of problems instantly, from the CO2 source, to the insufFlator, to
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the tubing, to the trocars, to the instruments, to the level of anesthesia. The expert chooses hook, or spatula, or hot scissors, or Harmonic Scalpel (Ethicon, Endosurgery, Cincinnati, OH), or Ligasure (ValleyLab, Boulder, CO) according to the way they deliver energy, how the shape of the business end Fits his surgical Field, and what problems are minimized by choosing one over the other. The novice has one tool and tries to use it everywhere. A novice blames the tools; the experts tools serve his technique. In other words, MIS is not technology; it is technique. Surgeons like technology. The number and variety of instruments and devices for use in the operating room runs into the thousands. With the spread of endoscopic methods, vendors have hugely expanded the available tools. Certainly technological progress in charge-couple devices, electronics, optics, and materials has helped spur the broad application of MIS methods, and ongoing advances (especially in optics) will continue to aid technique and help patients. But a large number of these are mere gadgets, engineered solutions to non-problems. For example, suture assist devices exist in order to bridge a deFicit of sewing and tying skill. Vendors have marketed all manner of devices that hold in common only that they are complex, expensive, and totally unnecessary to the expert endoscopic surgeon. The tools never do the operation. For example, the surgical robot is really a telemanipulator (or a waldo), and cannot make a novice endoscopic surgeon into an expert one. Even suture assist devices that use ski-needles are not an asset but a liability in babies: The large size of these needles makes them clumsy instruments, better suited to inadvertently damaging the liver or spleen than allowing accurate suture placement. In any case, endoscopic gadgets are rarely designed for very small patients, and trying to force these devices (e.g. trying to squeeze even a small stapler into an infants chest) is no route to better outcomes. The wrong tools weaken the surgeon and endanger the patient. On the other hand, the expert surgeon has attended to developing robust and general skills with basic endoscopic instruments. He exhibits suture technique as precise as open technique. He understands and can troubleshoot the equipment. He can safely and rapidly perform a very wide number of procedures at least as well as (and in many cases better than) using open technique. Use of gadgets fosters shortcuts and poor methods, compromising outcomes and lending MIS an air of risk. In cases of trouble, the surgeon, and his patient, are better served by reliable technique than by technology. One problem with medical and surgical devices is the problem of implied use, the cues on the device itself that imply how the think is intended to be used. These cues are sometimes called affordances.
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Rarely are surgeons given instruction on the elements of how devices are designed, and user manuals are an early casualty of a busy operating room, even if the surgeon was interested. Instead, surgeons during their training typically receive some lessons as memes or lore, often passed from a senior resident, a lesson they will pass to their own trainees. Often, those lessons are little more than someones workaround when trying to use the device for a certain purpose (e.g. a malecot drain repurposed as a gastrostomy tube, now virtually standard of care in pediatric surgery). Other times, the use is simply a misunderstanding of a design that implies, by its shape or structure, that it should be used a particular way (e.g. the suture holes on many gastrostomy tubes which are in fact merely ventilation holes, and not designed or intended for securing a tube). Sometimes, these hints for use are accurate, but often not, and the novice may have no basis on which to tell the difference. For example, novice operators very commonly pick up instruments and hold them in thumb and index Finger, a grip that puts the user at a disadvantage in terms of torque and precision. The surgeon must pay attention to how devices were actually engineered to be used, but hemust go further: he must understand when the design does not quite serve his need, and beware of how these shortcomings can increase risks. For example, it is common for surgical staplers to require a very strong grip in order to Fire. A surgeon with smaller hands may be at a mechanical disadvantage and struggle with the Firing, which can translate to jarring or shaking at the business end of the stapler. One way around this is to turn the handle upside down which acts to lengthen the moment arm, thereby decreasing the force required to exert the same torque on the Firing mechanism. Expert minimally invasive surgery is technology wielded according to proFicient technique.

The wrong hold. It can seem like the right way to grasp the instrument, but this hold destroys control at the tip and leaves the user unable to spin the shaft.

#2 Face the Organ

Positioning the patient properly begins with positioning the surgeon. For any endoscopic procedure, the surgeon must stand facing the organ of interest. Too often, surgeons are seen operating backwards, stricken by paradoxical action of their tools on the screen. Precision motion is impossible when the surgeon cannot even intuit right and left, up and down. Of course, its not funny if the surgeon is you. Meanwhile, operating in poor position is very tiring to the surgeon. As the surgeon fatigues, the muscles responsible for Fine movements fail First. In this way, fatigue hugely compromises precision. For example, a surgeon who attempts to operate on a spleen from the left side of the table not only has a poor angle of attack and
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Stand up. No one can maintain precise technique if hunched over, twisted, or awkwardly positioned. The surgeon is the rst surgical instrument, and must be used properly like all the others.

some paradoxical motion to contend with, but awkward body position that quickly leads to fatigue. If you are shaking and sore after an endoscopic procedure, your set-up was probably suboptimal. Perfect position allows the surgeon to operate with little effort. The most important principle for good position is for the surgeon to face the organ he is operating on. In other words, the surgeon should place the monitor (ideally mounted on the ceiling, but the practice can be maintained with towers) in a line with himself, the camera, and the organ of interest. A good mnemonic that some surgeons teach is S-C- O-P, or surgeoncameraorganpicture(6). For example, with appendectomy, the surgeon stands to the patients left, facing the right lower quadrant with the screen on the patients right. If the surgeon is operating on the GE junction, he should stand at the foot of the bed (with babies frog-legged at the end of the bed, larger patients in low lithotomy position) facing the epigastrium, with the monitor hung directly over the patients chest. This is the First principle that allows the surgeon to use all available degrees of freedom. Implicit in this rule is knowing what the organ is. For example, when performing a thoracoscopic lobectomy, the organ is not the lung or the lobe, but the major Fissure, the place where most of the Fine dissection occurs (see Figure 1, above), and the surgeon should stand in line with it. Similarly, in laparoscopic pullthrough for Hirschprungs, the area where the Fine dissection occurs is the rectum, and the surgeon should stand at the babys head. One mental barrier to face the organ is the implicit rule that a surgeon and his assistant must operate opposite each other. In nearly every open procedure surgeon and assistant face each other, and any other arrangement seems wrong, even taboo. But what brings advantage in open cases may bring disadvantage in endoscopic cases. It is absurd for either surgeon or assistant to struggle with paradoxical motion, but this foolish practice is tolerated because of the belief that an operator must stand on each side of the patient regardless of the surgical objective. Face the organ goes for surgeon and assistant, even if both stand on the same side of a patient (as they often should). Only when facing the organ can the other aspect of good positioning be employed, the Pianist Position. Virtuoso pianists hold their arms loose at the shoulder, arms bent at the elbow, wrists loose and Fingers on the keys. Virtuoso endoscopic surgeons operate with the bed at a level that allows them the same position: head upright and level with the screen, shoulders relaxed, elbows bent at 90 120degrees, wrists loose, and action on the instruments controlled with Fingertips. The novice can be seen with back bent, arms abducted, elbows askew, wrists stiff, instruments held in a death grip. The comfortable surgeon attends to surgical detail; the uncomfortable surgeon thinks about his sore back.
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In lobectomy, the organ is not the lobe being removed, but the ssure. The surgeon gets best advantage by aligning tools and his body along its axis.

#3 Triangulate the Ports

Positioning the ports well also contributes to the surgeons comfort and precision. Camera and working hands should form a triangle, like the broad end of a kite where the organ of interest is the pointed tail (Figure 2). In general, the camera is in the center (but not always, see below). Even in small patients the kite allows wide enough separation between ports that the operator will not cross the streams and impede his own work. Equal spacing allows both hands to contribute similarly (see Principle #6). Notice that triangulation allows maximum motion through all available degrees of freedom (DOF). Degrees of freedom in mechanics are the parameters required to specify an objects position in space. In MIS, there are 6: (1) Side to side (2) Up and down (3) In and out through the trocar (4) Rotation of the instrument (5) Opening/Closing the instrument (e.g. a marylands working tip) (6) Translation of the body wall (what CO2 insufFlation gives) Even if four or more ports are needed, the position of all the ports is determined by the working triangle, and the priniciple of maximizing all available degrees of freedom. Notice that poor triangulation destroys a DOF. For example, trocars positioned too close together, or too far from the organ will make the instruments work nearly in parallel, constraining the #1. It is nearly impossible to tie sutures in this circumstance. Similarly, putting trocars too lateral (where the body wall begins to curve back down toward the bed), or bumping the patients legs up both can impede #2, making anterior anatomy impossible to reach, or awkward to handle. More familiarly, when CO2 insufFlation is inadequate from leaks or poor settings or a bucking patient, #6 is constrained, destroying the surgeons view and making progress impossible. But any reduction of DOF (such as forgetting the available instrument rotation, #4) seriously degrades the surgeons ability to move freely and with precision. Good mechanical results cannot be attained this way. Centering the camera also keeps paradoxical motion to the minimum. Paradoxical motion is attempting to operate when the image is reversed, from the surgeons perspective. It is the opposite of face the organ. For example if the camera was looking toward the appendix, but the surgeon was standing on the patients right, he would

In general, trocars should be placed so that right and left hand instruments approach the organ of interest separated by approximately 90 degrees. Meanwhile, the camera port should (usually) be oset from the two main working ports such that the three ports form a triangle, not a line. These four pointsthe three main ports and the organform a kite shape, a conguration that generally allows the best view, comfort, and maneuverability.

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be working paradoxically. All moves would feel backwards, and unintuitive. No one can operate with precision this way. But rigidly keeping the camera in a center port is disadvantageous. Occasionally, operations are better performed (at least in part) by placing the camera to one side, as an outrigger camera. For example, in appendectomy, it may be easier to place the camera at the umbilicus and work through suprapubic and left-lower- quadrant ports. In thoracoscopic diaphragmatic hernia repair with the patient in decubitus position, it may be advantageous to have the camera (and the camera operator) in the port nearest the patients back and the operator using the ports in the mid and anterior axillary lines. In other cases, the peculiarities of the anatomy (e.g. some thoracic masses) may require the camera to occupy any of the ports as the procedure progresses. Observe that when using the outrigger camera technique, advantage can be gained by using an angled scope which allows the viewing angle to approach (if not perfectly achieve) a centered view. Triangulating the ports allows the freedom to move the camera whenever needed, without creating distortions in working mechanical advantage.

Surgery is the application of mechanical solutions to medical problems.

#4 Do The Same Operation

Some have the impression that endoscopic methods are not as reliable, safe, or effective as open technique, that somehow the results are less robust and the patients well being less well in hand. Certainly the novice feels unnaturally constrained by the tools and the visualization, and often is confused by the orientation. Struggles with the anatomy and with basic skills such as endoscopic suturing can lead some surgeons into doing an operation that is pretty close, nearly as good, a fair approximation, etc. Stitches are placed, workaround methods with clips or other gadgets are employed, and dissections are fudged in ways that the same surgeon would never accept were the case being done in standard open fashion. Who could be surprised then when outcomes are not as good, especially early in a surgeons experience? Do the same operation means: Perform an operation with at least as good a mechanical result as would be achieved with classic open technique. This does not mean that every step used in an open procedure should be replicated endoscopically. Instead, one is aiming at the same Final mechanical product: Use the same suture. If you are repairing duodenal atresia, and you would perform the duodenoduodenostomy with a series of Fine interrupted monoFilament sutures in a double- d i a m o n d a n a s t o m o s i s , d o t h e s a m e a n a s t o m o s i s

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laparoscopically. Alternatively, if you would never use a braided 2-0 on a ski needle for this anastomosis, dont use it laparoscopically simply because that is the only suture you can use with the scope. Do the same dissection. For example, if you carefully isolate and visualize the splenic vessels and clearly visualize the tail of the pancreas during splenectomy, you should do the same laparoscopically rather than Firing a stapler semi-blindly across the splenic hilum. Complete at least the same mechanical repair. If you stick- tie the appendiceal base during open appendectomy, you should do this (or a mechanical equivalent, like staples) in a laparoscopic appendectomy. If you would place a stitch in that serosal tear in an open case, put a suture in laparoscopically too. If you would mobilize the colon more to decrease tension during an open pull-through, you should mobilize it precisely the same amount when performing the procedure laparoscopically.

The idea is to perform at least as good an operation. In skilled hands of course, endoscopic procedures may produce superior results: a laparoscopic Nissen done well will have afforded a better view of the vagus nerves and a better, safer wrap; a laparoscopic pyloromyotomy is faster; a laparoscopic duodenoduodenostomy allows the anastomosis do be done largely in situ, decreasing the amount of dissection needed and possibly leading to faster resolution of gastric ileus; a thoracoscopic esophageal atresia repair allows less dissection of the distal segment and dissection under very high magniFication apparently leading to measurably lower stricture and leak rate(7). Better visualization can certainly allow the endoscopic expert to do a superior procedure. But the essential principle is a cognitive commitment to doing the same excellent operation one would do using open technique.

#5 Operate with Two Hands

Humans almost always do tasks with a dominant hand. When learning a new task, the natural tendency is to focus on the dominant hand, unconsciously neglecting the non-dominant hand. If the task is very new and very difFicult, this unilateral neglect almost seems to approach that of stroke patients. Even the dexterity of the dominant hand suffers(8). When doctors attempt laparoscopy for the First time, nearly all exhibit unilateral neglect (and it is not conFined to laparoscopic surgery; everyone tends to ignore the non-dominant hand when First learning open suturing). All attention seems to be focused
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on the unusual tiller-action-at-a-distance that is laparoscopic manipulation, channeling and truncating attention into narrow tunnel vision. Novice operators struggle to manipulate a needle or cautery one-handedly, when they could easily help themselves with their non- dominant hand. Instead, the instrument held in the non-dominant hand drifts out of view, is lost, begins grasping with a white-knuckled death grip, etc. Nearby organs and structures are at great, but unrecognized, risk from instrument clutched in the neglected hand. Good teachers will stress non-dominant hand awareness, boring their students with the refrain What is your other hand doing? Only by repeatedly redirecting attention to both hands can one learn to use both hands effectively, and automatically. Even seasoned surgeon need to explicitly remind themselves. Non-dominant hand awareness is important not only for speed and efFiciency, but because humans are more coordinated in Fine motor tasks when both hands appear in their visual Field, even if one hand is not participating in the action(9). You can verify this yourself; try cutting suture with one hand on your chest versus with both hands in the Field. With both hands in view, the cutting hand will be smoother and more precise. The same effect holds in MIS. Endoscopic methods always impose constraints on manipulation, since the number of hands in the Field are always one fewer than the number of trocars (unless one has an experimental camera/manipulator combination instrument). So, one must maximize what he can do with what he has. Neglecting the non-dominant hand halves an already-restricted dexterity (by removing degrees of freedom granted by that hand). Some may boast that they can operate with one hand tied behind their back, but this is no road to precision and accuracy for the rest of us. Precision endoscopy is a two-handed proposition. This discussion brings up one common but very poor practice. In general surgery, training cases (like cholecystectomy, appendectomy, or even splenectomy) are commonly set up in such a way that the attending manipulates organs with one instrument, and has the trainee try to operate with the dominant while the non- dominant hand moves the camera. There are natural reasons for this: Attending surgeons tire of (and are notoriously unskilled at) running the camera (see #8, below), they are nervous about the dexterity of the trainee, feel the need to have a hand in the action as a means of exerting control, and they worry that the trainee is not skillful enough to use both hands. However, this practice always puts the trainee (and thus the patient) at a disadvantage since he is forced to divide attention between two very different tasks, camera work and Fine dissection. Meanwhile, removing the non-dominant hand from view degrades the
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coordination of the operating hand as described above. Finally, no degree of simpatico between teacher and student will allow good coordination between two different operators single hands. This attempted coordination almost always resembles fencing more than operating. Instead, the teacher is always better having the learner operate with two hands from their First case, just as we teach in open cases. If the teacher feels he needs more control, the solution is to add a port (see #7 below) and an instrument, not to take one away from the learning operator. But there is more to the skillful use of two-handed surgery than merely remembering to use two hands. The skillful operator moves his instruments the way a geisha walks, with small, even mincing, but highly-controlled steps. The tips of the instruments remain in view of the camera (reducing the need to rely on #9, below), and each move is slow, smooth, controlled. Furthermore, the skilled endoscopic surgeon is ambidextrous. There will be times when it is better to have the energy source enter from a left-handed port, and a retractor from the right. One should be able to readily switch instruments from hand to hand, always keeping the highest possible mechanical advantage. Those Fine, measured movements also apply to the use of energy sources like monopolar electrosurgery (the bovie). Energy sources in babies not only require lower power settings, but the manner of applying these instruments is different. In particular, when using the hook cautery, energy should never be engaged unless in contact with the tissue to be divided or fulgurated (Swinging the activated hook around like a lightsaber risks cautery injury). Also, it is bad practice to work in a hole; keeping a wide working front maximizes visualization and minimizes collateral damage. All energy sources certainly perform better if the operator avoids getting greedy, e.g. taking large bites of tissue to divide, a practice that leads to excess char, incomplete hemostasis, and broad collateral burns. Finally, and most importantly, precision technique beneFits from a light foot on the pedal. Most division and coagulation can be achieved with Fine taps of the pedal, whereas long continuous burns produce char and a wide penumbra of thermal damage. Of course, no cutting can occur without proper tension on the tissue. Perhaps the most important role of the non-dominant hand is creation of tension on whatever area is to be cut. Without good tension applied to it, the tissue will merely contract and char when energy is applied. It will not separate, but thermal spread will take over as the operator vainly applies more electricity. In small spaces, unintended tissue damage becomes inevitable. Novices often cannot see that while they may be creating tension in the tissue, the focus of the tension is away from where it is that they want to be cutting. But careful
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Put tension where you are cutting; cut where the tension is.

attention to tension lines combined with an unconstrained use of the non-dominant hand will allow the operator to recognize where the tissue tension lies within the tissue plain. Moreover, the non- dominant hand must continue to adjust to bring new tension to the working plane as attachments are cut and tension is released. In general, the principle is: Put tension where you are cutting, and cut where the tension is. This sounds hilariously obvious, but is notoriously difFicult to apply in practice without an explicit effort. Such dainty use of energy usually seems odd at First, but these habits lower energy settings, no lightsabers, no holes, no greediness, no Bovie pedal lead foot, and attention to tension translate into Fine, efFicient dissection with less smoke, less char, less bleeding, and less risk of unintentional damage. The surgeon who always operates with two hands has the fullest possible control over the surgical Field.

#6 Gravity is the Third Hand

Gravity can be a tremendous hindrance if ignored. On the other hand, using gravity to ones advantage can dramatically improve visibility, decrease the need for manipulating the organs, and cut anesthetic time. For example, when operating in the pelvis, the worst possible position would be reverse-Trendelenberg; all of the small bowel would slide to the pelvis, hopelessly obscuring all other structures. On the other hand, when operating in the upper quadrants, especially, for example, during a fundoplasty or a gastric bypass, reverse-Trendelenberg is crucial to pull the colon and fatty omentum out of the way. Even routine cases such as appendectomy beneFit from simple positioning changes: rolling the patient to the left, and placing him in slight Trendelenberg elevates the cecum and allows the ileum to fall down and back from the Field of view. In all of these cases, gravity is like a third hand holding a retractor for the surgeon, keeping other organs out of the Field of view. This is always a better method than constantly trying to sweep the bowel or omentum away so one can see the operative Field. But to use gravity effectively, one must plan the positioning carefully. In particular, one has to keep in mind two strategies: Set up the trocar and patient positions so that gravity can be used. For example, one would not want to approach the posterior left lower lobe with a patient supine since no amount of turning the table will allow the lung to fall away from the chest wall. On the other hand, anterior mediastinal masses are best approached with the patient supine since in this position the lung is already pulled down and away from the

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operative target by gravity. Obviously, part of this set-up depends on Principle #2: Face the organ. Secure and pad the patient properly to restrain gravity. For example, one of the most common positions when operating on babies is to place them at the foot of the table, with legs frog-legged, and the monitor hanging above the patients head or chest (lower picture). This position is excellent for Nissen, Ladds, duodenal atresia repair, abdominal approach to CDH/eventration, Morgagni hernia repair, choledochal cyst excision, etc. But the same gravity that pulls the omentum down can pull the whole patient down as well. Indeed, in a baby, even a short slide down the table, say 1-2 cm, is enough to dislodge the endotracheal tube, creating unintended extubation. To avoid this kind of problem, careful padding and taping are essential. In addition, the use of a small bump under the abdomen acts as a kind of skid-stop to retard sliding. The pictures show two well-positioned patients, top, for laparoscopic right nephrectomy, and, bottom, for laparoscopic fundoplasty (or duodenal atresia, or choledochal cyst, or others). Observe that there is no stretch on the extremities that could produce nerve injuries, and that good padding is placed everywhere. No undercrossing lines or tubes snake beneath the body or limbs (these could quickly create pressure injuries in children). Also, note that tape with adequate tensile strength is used; it is a common blunder in pediatric surgery to rely on clear plastic or paper tape in an attempt to be gentle. But there is nothing gentle about falling off the operating table.

Using gravity well also means protecting from gravity. These patients are properly padded and secured.

#7 Add a Port
It is an error to sacriFice precision, mechanical advantage, and speed in the name of making fewer port incisions. Occasionally, a perverse sort of macho ethic sneaks into a surgeons mental habits, like the s u r g e o n w h o r a c e s t h r o u g h laparoscopic cholecystectomies aiming for personal best skin-to-skin times. Here the error is to replace effect as cause: It is from precision and efFiciency that a speedy operation results. Focusing on speed will not improve precision, but precision always brings speed. A stitch in time really does save nine. Similarly, adding
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b b>>a

a port in a case where exposure or counter-tension is difFicult can dramatically improve the overall precision of the case, and allow its L = LENGTH 0 L T = NORMAL TENSION completion speedily. Regarding the addition of a trocar as some sort of failing, as a loss in some kind of Name That Tune type of numerical TO GET THE TOTAL TENSION, FIND THE contest (I can take out that spleen with only three trocars Well I can AREA UNDER THE CURVE (DOTTED LINE): do it with only two!) does not serve the patient. L/2 L = LENGTH L One of the worries about adding trocars is that the addition T= mL (dL) could add signiFicantly to the morbidity of the operation. However, a 2C 0 fourth or Fifth 3 or 5 mm trocar will not contribute substantially to a patients pain or scarring. Experience shows that the extra trocar site SOLVING, GIVES: THEN T(L) = NORMAL TENSION AT adds trivially to the patients pain. But if the operative time is EACH LENGTH POINT L2 shortened from 3 hours of struggle with grasping and regrasping the , Cm $ T 4 bowel to a smooth 1 hour case with the least amount of manipulation necessary, the patient is plainly well served. A TROCAR OF DIAMETER D... Consideration of trocar incision lengths brings us to one of the prime fallacies in endoscopic surgery. It is inevitable that one hears DEVELOPMENT OF TENSION D 250 the argument that ACROSS THE INCISION CAN surgical technique is not improved if an open BE APPROXIMATED BY A e done through a linear incision whose length is similar operation can b 200 LINEAR FUNCTION: length of all trocar site incisions. For example, it is argued ...REQUIRES AN INCISION to the sum OF LENGTH 150 that a 2.5 cm incision is no different than Five 5 mm incisions, with the L T (L) = CmLthat the endoscopic method is somehow a fancy waste. implication 100 D However, it is not true that the lengths of trocar incisions sum to L=r 2 50 similar open incision lengths in terms of pain, scar, disability, etc. For OR ONE HALF THE example, it is intuitively obvious that 00 incisions distributed around the 5 3 6 9 12 15 CIRCUMFERENCE! abdomen have a very low or zero risk of dehiscence, but a 2.5-3cm linear incision is vulnerable to this complication. Furthermore, the Good trocar placement requires making a precisely sized trocar incision. The outer mathematics of wound tension show that the total tension across an diameter of a 5mm trocar is usually just over incision varies as a function of the square of its length, so the total 7 mm, but the incision needs to be a little tension of a long incision is greater than the summed tensions across larger. This formula suggests an incision of several very small incisions of the same aggregate length (10). Pain 11mm for a 7mm OD trocar, but because the skin has a small amount of elasticity, the real and scarring plainly depend on tension(11). The smaller tensions value is the formula, minus a little bit, or across trocar incisions are the origin of the minimally invasive closer to 9mm. If it is too small, the trocar moniker, but there is no reason for the surgeon to endure a minimal will crush the skin edges, and the surgeon may damage underlying structures while he access disadvantage. struggles to insert it. Conversely, a trocar in Dont struggle. Add a port.

too large an incision will slide in and out with the instruments, easily falling out, etc.

#8 Tai Chi Camera

Ironically, camera work, one of the tougher tasks, is often delegated to the least experienced person around the table. The camera operator must keep an upright image centered on the action with the right zoom and least movement at all times. Often, the intern or medical student is asked to run the camera and has no idea how the operation is done, what needs to be seen, or even exactly what he is
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seeing. When stern orders are barked (Look left! NO! Left! And DOWN!) the result is a dizzying jumpy picture like a bad 1980s music video. But everyone must learn camera work sometime. Fortunately, a few simple ideas can vastly help the learner mentally picture what it is he needs to do. First, take one minute to show (or to learn) the camera controls, lens connection, and light hook up. Explain the use of the extra degree of freedom one gains with an angled telescope, and how to use it to advantage (for example, twist the scope so the objective points upward when placing trocars, etc.). Demystify it, so that the camera operator will not be distracted by apprehension. Next, the learner must understand that the image must always be centered on the action, and kept upright. Novices tend to allow the camera to drift away from center, and off kilter. If you Find yourself trying to look around the corner of the screen, or are tilting your head, check your cameraman. Most learners need to be reminded of this multiple times. Even seasoned surgeons can be pulled into this tendency to look around corners of a two-dimensional image, but a good camera operator will not tempt the operator. Not only should the camera be centered on the action, but the picture must be kept upright. It is a matter of simple demonstration that task precision radically degrades if the image tilts relative to the surgeons sense of up and down. It is possible (although not optimal) to work semi-paradoxically, that is with ones body oriented up to nearly 90 degrees off the line between camera and organ of interest (that is, partially violating the rule to face the organ being operate on). This position allows an assistant to work well from the patients side when the operator is at the foot, for example. It also make the outrigger camera a viable strategy. But even a slight change in tilt destroys the surgeons ability to move because of human reliance on an absolute z- axis. For both surgeon and assistant, the up and down must remain a consistent reference frame in which to work. Novices also tend to jerk the camera around, making small, brisk movements with multiple overcorrections. Humans are known to perform better at new skills if they can mentally link the new action to an imagined action or image that they know. Martial arts teachers have known this for centuries: Bend like the reed in the wind or Stand like an iron horse. The images do not need to be an action that the novice has already done (although that is helpful), but evocative in a way that pre-Fires the cerebellum in a particular way. In this spirit, teach the new camera operator to move the camera as if she were doing Tai Chi. Everyone can picture the slow, graceful, highly controlled and Fluid motion of some old master practicing Tai Chi. Holding this image in mind predisposes the novice to relax, breathe, and move the camera slowly, precisely. The image will be better than in response to the
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order Move slower! The novice learns faster when primed than when bullied. The Tai Chi camera is always centered, upright, and deliberate.

#9 Use Bifocals for Spatial and Situational Awareness.

It is very easy to lose oneself during an endoscopic procedure. The perspective is different, the anatomy disorienting, and the angle of approach of ones instruments to the surgical objective may be awkward. Instruments leave the visual frame whenever one does not practice Geisha walk movements, when the non-dominant hand is neglected, or whenever an instrument must be changed or cleaned. One hand can easily get lost, leaving the operator Flailing around in an attempt to bring the instrument back into view of the camera. In a baby, these gross, blind moves can damage bowel, liver or lung. Even without damage, these struggles waste time. Fortunately, one can see more than just what is on the screen. One can see the patient as well. A lost instrument can easily be found if one looks at the patient to see where the camera is pointing and simply aims the instrument for that region. In essence, one tries to focus alternately between the virtual image on the screen, and the real image of the actual Field. Calling this method bifocals gives the technique a name, making the method easier to remember. Bifocals also improve situational awareness. It means that not only must the surgeon be able to focus on the images inside the operating cavity, but must be attuned to what is happening outside the operating Field as well. Is the anesthesiologist acting worried? Is the pulse ox drifting? Is the end-tidal CO2 oddly high? Did someone just call for blood? Have you primed the scrub nurse or tech to have the right stitch or critical endomechanical device ready for the next move, and the move after that? Awareness of these things helps you smooth the procedure and protect the patient. Humans cannot really multitask. True multitasking is a myth; humans that attempt to do two jobs at once end up doing two jobs poorly. Instead, apparent multitasking depends on at least two skills. First, the appearance of multitasking is really the quick Flit of attention among different objects, just the way someone wearing bifocals quickly adjusts his focal length by peering through different portions of the glasses. For example, the aware surgeon may quickly sample the sounds around him periodically--the pulse ox, the heart monitor, the conversations. This Flitting sample takes milliseconds, but yields lots of information.

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 The second skill is the ability to ignore details. This skill is familiar to anyone who has learned the automatic, unconscious movements of driving a car. At First, every single move requires deliberate thought--clutch, signal, turn, gas, clutch, brake, gas....The new driver must pay so much attention to the mechanics of the car that he will not see that truck, that pedestrian, or that pothole. But with practice, the driver, and the surgeon, moves automatically, freeing the mind for other focus. In this way, practice is really a way of removing distractions. Somewhat paradoxically, being more mindful is the art of attending to less. Expertise is not the ability to attend to more things, but the ability to be more selective in attention. The expert automatically pays attention to the important stuff and neglects the unimportant. Being an expert means being able to tell the difference.

#10 Build Versatility by Analogy

Innovative new procedures are created the same way that the learner adds to his repertoire. The skills and lessons from other cases are carried over to new applications. For example, when considering the repair of duodenal atresia, one can reuse the setup for pyloromyotomy. Later, familiarity with the right upper quadrant allows better exposure and understanding of the twisted duodenum seen in correction of malrotation. Similarly, when confronting the biopsy of a pelvic mass, one can re-use the set-up for laparoscopic rectal pull through. Or, if one needs to repair a Morgagni or Bochdalek hernia from the abdomen, familiarity with the setup and manipulation of the upper abdomen and diaphragm as in a Nissen can be brought to bear. Each surgeon becomes more versatile by reusing discrete skills from other operations to build a new one (even if merely new to him). Another way to say this is If you can make a pizza, you can make a calzone. Versatility allows the surgeon to operate better in several ways. The ability to adapt analogous methods to new circumstances allows the surgeon to get out of trouble (possibly avoiding conversion to open technique). It also allows the surgeon to apply old techniques to new problems. Finally, movement analogy helps reinforce the skills he uses for whatever procedure he is doing right then: moves are well- practiced and less dangerous when used in many contexts. For example, easy facility with an endo-loop type device for common procedures like appendectomy extends that facility to unfamiliar contexts with rare cases like choledochal cyst.

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 Explicitly noting the reused movement objects (the small moves from which more complex actions are built) in different cases allows the surgeon to move up learning curves much more quickly. Every endoscopic case reinforces the others, even the easy onesif good principles are always followed. For example, safe trocar placement, non-dominant hand attention, camera movement, and use of gravity for retraction are used in every laparoscopic or thoracoscopic case, and the lessons and skills built here are actually more critical in harder cases. In this way, as cases are built from skill blocks (like classes in object-oriented computer programming), the learner discovers that there are no hard cases, only cases with a greater number of easy moves.

Conclusion
The principles described here can be applied in any pediatric MIS case. They are intended to help maximize the surgeons mechanical advantage anywhere minimally invasive methods are used. Each of these is intended to deal with the scaling problems of small patients, to help the surgeon wield rather than simply use the devices, to promote precision by maximizing available degrees of freedom, or to work with (or overcome) inherent human strengths (and weaknesses):
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Perfect tools are perfectly maintained...and understood Face the organ Triangulate the ports Do the same operation Operate with two hands Gravity is the third hand Add a port Tai Chi Camera Bifocals for Spatial and Situational Awareness Analogy builds versatility

The learning curve: prociency with any skill requires practice. But it is not true that each new operation starts the surgeon at the bottom of the curve. Instead, specic abilities--good set-up, two handed action, small moves, comfortable facility with electrosurgical devices, etc--are all objects that port easily to new procedures. But the surgeon must see the analogies to apply old methods to new circumstances!

Maximizing mechanical advantage aids precision, speed, and safety in MIS, a technological extension of surgery that, perhaps ironically, presents several mechanical disadvantages (and some advantages, of course) to the surgeon. Struggling with these disadvantages puts the patient at unnecessary risk, risk that is magniFied in babies and children. Fortunately, practiced application of the heuristics here can help the surgeon create the superset of skills needed to obviate common hazards. But principles can go too far. Regarding the principles presented here as rigid or exhaustive misses the principle behind principles: Principles are to be used, not blindly obeyed. TAB

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1. Morgenstern, L. Warning! Dangerous curve ahead: the learning curve. Surgical innovation 12: 101-103, 2005. 2. Rangel, S. J., Henry, M. C., Brindle, M., and Moss, R. L. Small evidence for small incisions: pediatric laparoscopy and the need for more rigorous evaluation of novel surgical therapies. Journal of pediatric surgery 38: 1429-1433, 2003. 3. Rogers, D. A., Lobe, T. E., and Schropp, K. P. Evolving uses of laparoscopy in children. The Surgical clinics of North America 72: 1299-1313, 1992. 4. Madan, A. K., and Frantzides, C. T. Prospective randomized controlled trial of laparoscopic trainers for basic laparoscopic skills acquisition. Surgical endoscopy 21: 209-213, 2007. 5. Van Sickle, K. R., Ritter, E. M., McClusky, D. A., 3rd, Lederman, A., Baghai, M., Gallagher, A. G., and Smith, C. D. Attempted establishment of prociency levels for laparoscopic performance on a national scale using simulation: the results from the 2004 SAGES Minimally Invasive Surgical Trainer-Virtual Reality (MIST-VR) learning center study. Surgical endoscopy 21: 5-10, 2007. 6. Najmaldin, A. (Ed.) Operative Endoscopy and Endoscopic Surgery in Infants and Children. New York: Oxford University Press, 2005. 7. Holcomb, G. W., 3rd, Rothenberg, S. S., Bax, K. M., MartinezFerro, M., Albanese, C. T., Ostlie, D. J., van Der Zee, D. C., and Yeung, C. K. Thoracoscopic repair of esophageal atresia and tracheoesophageal stula: a multi-institutional analysis. Annals of surgery 242: 422-428; discussion 428-430, 2005. 8. Desrosiers, J., Bourbonnais, D., Bravo, G., Roy, P. M., and Guay, M. Performance of the 'unaected' upper extremity of elderly stroke patients. Stroke; a journal of cerebral circulation 27: 1564-1570, 1996. 9. Georgopoulos, A. P., and Grillner, S. Visuomotor coordination in reaching and locomotion. Science (New York, N.Y 245: 1209-1210, 1989.

10. Blinman T Incisions do not simply sum. Surg Endosc. 2010 Jul;24(7): 1746-51. Epub 2010 Jan 7. 11. Burgess, L. P., Morin, G. V., Rand, M., Vossoughi, J., and Hollinger, J. O. Wound healing. Relationship of wound closing tension to scar width in rats. Archives of otolaryngology--head & neck surgery 116: 798-802, 1990.

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