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Document6 min read·Published May 2026

Yuri 2017

Part of Lectures, Courses and Honors 15 items

Document · May 2026 · 6 min read

In brief

Comprehensive review of two decades of minimally invasive surgical techniques in neonates, including 219 procedures in infants under 2.5kg. Covers laparoscopic and thoracoscopic approaches for conditions including TEF repair, CDH, duodenal atresia, and PDA ligation, with detailed discussion of instrumentation, patient selection criteria, and outcomes demonstrating safety and efficacy in extremely low birth weight infants.

MIS is feasible in neonates <2.5kg using specialized 3mm instruments, low-flow insufflation (10-15mmHg lap, 4-8mmHg thoracic), and careful monitoring.
Thoracoscopic TEF repair evolved over 12 years: operative time decreased (95→75min), leak rate dropped (7%→0%), stricture rate fell (28.5%→9.5%).
Laparoscopic duodenoduodenostomy in neonates averages 76min operative time, feeds start POD#5, with no strictures at 2-month follow-up.
Single-lung ventilation for thoracoscopy uses bronchial blockers or mainstem intubation; accept mild hypercapnia and increase minute ventilation.
CDH candidates for thoracoscopic repair: not on ECMO, FiO2 <60%, no pressors; patch feasibility depends on defect size and surgeon experience.

Written by the GCMD Library team from the document.

Dr. Steve Rothenberg

Surgical content by Dr. Steve Rothenberg — Lectures & Presentations

Full text

Minimally Invasive Surgery in Neonates Are There LimitsSteven Rothenberg M.D.Denver, Colorado WOFAPS 2016

Disclosures Justright Surgical: Medical director/ ownership interest

Evolution Over Two DecadesMinimizing Morbidity

Does instrumenta:on limit us?

Instrumenta:on Scopes - 4mm and 3mm short (20cm) 30 degree Instruments: 3mm short Trocars: short 50-75mm Camera: digital/HD Vessel sealing technology 3-5mm staples and clips

Laparoscopic Procedures in Neonates and Infants Fundoplication Gastrostomy tube Pyloromyotomy Ladd’s procedure Cholecystectomy Cholangiogram Liver biopsy Duodenal atresia repair Retroperitoneal mass excision Kasai procedure Pancreatectomy Diaphragmatic plication CDH repair Bowel resection Nephrectomy Pull-through procedure Imperforate anus repair Inguinal hernia repair Ovarian cystectomy Urachal cyst excision CAPD catheter Choledochal Cyst Ponsky TA, Rothenberg SS. Minimally invasive surgery in infants less than 5 kg: experience of 649 cases. Surg Endosc. 2008 Oct 22(10) 2214-9

Thoracoscopic Procedures in Neonates and Infants Lung Biopsy Lobectomy Sequestration resection Cyst excision Decortication Forgut duplication resection Diagnostic PDA Ligation Thoracic Duct Ligation Esophageal atresia repair TEF repair Aortopexy Mediastinal mass excision Pleurodesis

Evaluate the safety and efficacy of MIS techniques in neonates< 2.5 Kg January 1994 – August 2012 Laparoscopic and Thoracoscopic procedures Weight 1.1 – 2.5 Kg 219 procedures

MIS Suite

Insuﬄator Low flow/ heated circuit Pressures Laparoscopy 10-15 Thoracoscopy 4-8 Single lung ventilation +/ If you can’t see it , you can’t fix it!

Insufflator Low flow/ heated circuit Pressures Laparoscopy 10-15 Thoracoscopy 4-8 Single lung ventilation +/Hypoxia, hypercapnia, hypotension, acidosis, renal hypoperfusion, CO2 embolism, Hypothermia If you can’t see it , you can’t fix it!

Procedures:219 TEF Repair PDA ligation Duplication cyst Lung biopsy Thoracic duct ligation Lobectomy Pull-through procedure: Hirschsprung’s Disease /Imperforate anus Nissen +/- G button Pyloromyotomy Duodenal atresia Jejunal atresia Ladd’s procedure Pull-through procedure Bowel resection (NEC/duplication) CDH repair Plication Inguinal hernia repair

Pyloromyotomy Hall NJ, Pacilli M, Eaton S, Reblock K, Gaines BA, Pastor A, Langer JC, Pierro A.Lancet. 2009 Jan 31 Air embolism, hypotension, acidosis

Fundoplica:on 1.2Kg Rothenberg SS. Two Decades Experience with Laparoscopic Nissen Fundoplication in Infants and Children; a Critical Evaluation of Indications, Technique , and Results. J Laparoendosc Adv Surg Tech A. 2013 Sep;23(9):791-4

Duodenal Atresia

Duodenal Atresia 1.2 Kg

ResultsnAll completed successfully laparoscopicallynOperative times: 60-90 minutes (avg. 76)nFeeds started POD# 5 in 36 neonates FF POD#8 (6), POD#10 (1) discharged POD# 10,12, 14, &23nFeeds started POD#3 in 1nNo complicationsKay S, Yoder S, Rothenberg S. Laparoscopic duodenoduodenostomy in the neonate. J Pediatr Surg. 2009 May;44(5):906-8

Follow-upnUGI at 2 months: nNo stricture or obstructionnAll tolerating ad lib feedsn4 patients on anti-reflux medicationsnNo post-op

Intestinal Atresia St Peter SD, Little DC, Barsness KA, Copeland DR, Calkins CM, Yoder S, RothenbergSS, Islam S, Tsao K, Ostlie DJ. Should we be concerned about jejunoileal atresia during repair of duodenal atresia? J Laparoendosc Adv Surg Tech A. 2010 Aug 11

Necrotizing EnterocolitisStricture 2.0Kg

Laparoscopic treatment of Post NEC colonic strictures. . J Laparoendosc Adv Surg Tech A. 2010 Jun;20(5):477-80.Martinez-Ferro, Rothenberg SS, St Peters S, Bignon H, Holcomb G.

Neonatal Hypoglycemia

Congenital DiaphragmaEc Hernia

CDH Not on ECMO Not on high FIO2 (>60%) Not on Pressors Patch repair : yes but dependent on size of defect and surgeon experience

Thoracoscopic Procedures in Neonates and Infants <2.5 Kg Lung Biopsy Lobectomy Sequestration resection Cyst excision Decortication Forgut duplication resection Diagnostic PDA Ligation Thoracic Duct Ligation Esophageal atresia repair TEF repair Aortopexy Mediastinal mass excision Pleurodesis

Anesthesia Single lung ventilation: Double lumen tube Bronchial blocker Mainstem intubation Tracheal intubation w/ CO2 insufflation Increase in PCO2/ Increase minute ventilation Less analgesia , easier to extubate, can better monitor surgeon”s progress

PDA Ligation Smallest 800 gmAll cases over 1 Kg

Vascular Rings

TEF Repair

Thoracoscopic TEF RepairMarch 2000 Rothenberg SS: Thoracoscopic Repair of Tracheoesophageal Fistula in a Newborn. Ped Endosurg Innovative Tech. (4) 289-294. 2000 1.2 Kg

Thoracoscopic TEF Repair 61 cases (March 2000 –Sept 2012) 1.2 – 3.8 kg (mean 2.6) 21 associated anomalies 19 congenital heart defects (3 right arch) 4 imperforate anus/ 1 cloacca 9 pure esophageal atresia Operative time: 50 – 120 minutes (average 85) 1 conversion (esophageal stenosis) 3 H-type, 3 recurrent TEFs, Resection of giant tracheal pouch, Resection of congenital and acquired esophageal strictureRothenberg SS. Thoracoscopic Repair of Esophageal Atresia and Tracheo-Esophageal Fistula in Neonates: Evolution of a Technique.. J Laparoendosc Adv Surg Tech A. 2012 March 22 (2) 195-9

Thoracoscopic TEF Repair 3 leaks: Treated conservatively 1 pt with TEF, leak day 4, resolved day 9 2 pt with pure EA, leak day 5, resolved day 10 Oral feeds started day 4 or 5 all other patients 12/61 required dilation : 1-9 (20%) 18 required Nissen fundoplication 1 aortopexy No recurrent fistula

March 2000-March 2010First 5 yearsSecond ﬁve years 28 pts Average time 95 2 leaks 1 conversion 8/28 required dilation (28.5%) 0 recurrent fistula 21 patients Average time 75 0 leaks 0 conversion 2/21 required dilatation (9.5%) 0 recurrent fistula

DOUBLE ARCH & TEF

CPAM 3 day old: 2.4 Kg Two Decades of Experience with Thoracoscopic Lobectomy in Infants and Children: Standardizing Techniques for Advanced Thoracoscopic Surgery Steven S.Rothenberg, William Middlesworth, Angela Kadennhe-Chiweshe, Gudrun Aspelund, Keith Kuenzler, Robert Cowles, Lawrence Bodenstein, Saundra Kay, Kristin Shipman, CathrynRothenberg, Charles Stolar, Steven Stylianos. J Laproendosc Adv Surg Tech A 2015 May; 25(5) 423-8

Advanced Procedures in NICU CLE

Results 216/219 completed successfully endoscopically 1994-1995: insufflator over pressure encountered every case in patients<5kg Intra-operative complication: 2.7% Post-operative: 5.7% No deaths related to MIS approach

Anesthetic concerns Pneumoperitoneum complicated pneumomediastinum causing cardiovascular deterioration in a low-body-weight premature infant during laparoscopic Nissen fundoplication. Lin MC1, Lee CL2, Chen CY2, Rau RH2. Acta Anaesthesiol Taiwan. 2013 Dec;51(4):177-9. doi: 10.1016/j.aat.2013.10.003. Epub 2013 Dec 19. Influence of laparoscopic carbon dioxide pneumoperitoneum on neonate circulation and respiration. Li LW, Zhang W, Ai YQ, Li L, Peng ZQ, Wang HW. . J Int Med Res. 2013 Jun;41(3):889-94. doi: 10.1177/0300060513481922. Epub 2013 May 17 Carbon dioxide embolism in a 3-week-old neonate during laparoscopic pyloromyotomy: a case report. Fischler M. J Pediatr Surg. 2009 Sep;44(9):1864; author reply 1864. doi: 10.1016/j.jpedsurg.2009.05.017. No abstract available. Tolerance of laparoscopy and thoracoscopy in neonates. Kalfa N1, Allal H, Raux O, Lopez M, Forgues D, Guibal MP, Picaud JC, Galifer RB.Pediatrics. 2005 Dec;116(6):e785-91. The effect of insufﬂation pressure on pulmonary mechanics in infants during laparoscopic surgical procedures. Bannister CF1, Brosius KK, Wulkan M.

Hypercapniaandacidosisduringopen andthoracoscopicrepairof congenital diaphragmatichernia andesophagealatresia: resultsof a pilot randomizedcontrolledtrial.Bishay M1, Giacomello L, Retrosi G, Thyoka M, Garriboli M, Brierley J, Harding L, Scuplak S, Cross KM, Curry JI, Kiely EM, De Coppi P , Eaton S, Pierro A. Ann Surg. 2013 Dec;258(6):895-900.

The effect of CO₂-insufflation with 5 mmHg on the cerebral oxygenation in thoracoscopic repair of oesophageal atresia in neonates, L.J. Stolwijk, S.H.A.J. Tytgat, K. Keunen, M.J.N.L. Benders, J.C. de Graaff, D.C. van der Zee, P .M.A. Lemmers, M.Y .A. van Herwaarden, Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands 14 neonates GA 36.9 [30.6-41.9] BW 2358 [1395–4490] Arterial saturation (%) (%) * (mmHg) Arterial CO2 * (mmHg) Mean arterial blood pressure

The effect of CO₂-insufflation with 5 mmHg on the cerebral oxygenation in thoracoscopic repair of oesophageal atresia in neonates, L.J. Stolwijk, S.H.A.J. Tytgat, K. Keunen, M.J.N.L. Benders, J.C. de Graaff, D.C. van der Zee, P .M.A. Lemmers, M.Y .A. van Herwaarden, Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands rScO₂ (%) Cerebral oxygenation 5 mmHg SaO₂ ↓ 96.3% to 92.5% paCO₂ ↑ 47±6.9 to 58±13 mmHg MABP remained stable rScO₂ remained stable

Thoracoscopy versus Thoracotomy forEsophageal Atresia and TracheoesophagealFistula Repair: Review of the Literature andMeta-analysisFrancesca Astra Borruto, Pietro Impellizzeri, Angela Simona Montalto, Pietro Antonuccio, Emanuela Santacaterina, Gianfranco Scalfari, Francesco Arena, Carmelo Romeo1Department of Medical and Surgical Pediatric Sciences, Unit ofPediatric Surgery, University of Messina, Messina, ItalyEur J Pediatr Surg 2012;22:415–419. Conclusions: The effectiveness of the endoscopic technique for EA/TOF repair is indicated with outcomes not different from open surgery.

ComparaGve studies

Annals Thoracic Surgery 2009Thoracoscopy Versus Thoracotomy ImprovesMidterm Musculoskeletal Status and Cosmesis inInfants and ChildrenTaiwo A. Lawal, MBBS, Jan-H. Gosemann, Joachim F. Kuebler, MD,Sylvia Glüer, MD, PhD, and Benno M. Ure, MD, PhDDepartment of Pediatric Surgery, Hannover Medical School, Hannover, Germany Scoliosis 54 vs 10% Significant difference in chest wall dimensions in open vs VATS group Cosmesis: Manchester score: 13.8 vs 7.5

Thoracotomy

Needs Met Better more sensitive insufflators Modified instrumentation: 3mm bowel clamp, needle driver, modified suture Better reusable and disposable 3 mm trocars Suturing skills: Expertise developed quickly with experience

Needs Alternate energy sources 3 mm clips Anastomotic device: U clips/stapler/ tissue fusion (magnets) Neonatal Trainers

Conclusions: MIS in small neonates is safe and effective down to 1Kg Current instrumentation is effective but continued refinement is necessary Suturing is still the most difficult skill to acquire but can be effectively mastered even in the smallest neonates Certain insufflators are not sensitive enough and can cause repeated over inflation which can hinder venous return and respiratory effort Pneumoperitoneum and pneumothorax is tolerated in most neonates Careful coordination with and support of anesthesia is critical to success

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