It’s the pits: New approach is turning surgery inside out
The instruments used in the subcutaneous surgical approach.
During this young patient’s neck surgery, endoscopes, inserted in the armpits and chest, emit light, seen here glowing pink through the skin at the throat.
BY KRISTA CONGER
Take it from the ancient Egyptians: Unsightly scarring can be a real drag.
After all, who wants to show up in the afterlife with obvious mummy marks?
But if you think preparing for an eternity of kibitzing with the gods is tricky, just try operating on the face or neck of a prom-bound teenager.
"For children, there is a strong psychological component to having scars," said Sanjeev Dutta, MD, a pediatric surgeon at Lucile Packard Children's Hospital. "People tend to think it's not a big deal and that they should just work through it, but it's much more complicated than that. The last thing we want to do is to put them at a social disadvantage."
Negative cosmetic side effects can be devastating, confirmed Michelle Brown, PhD, a psychologist at the hospital. "Children and adolescents may withdraw from social activities or avoid school for fear of being teased, and their self-esteem may drop if they take to heart the cruel comments made by their peers."
Egyptian embalmers relied on natural openings such as the nostrils to remove the brain and small abdominal incisions to remove other organs with the least amount of disfigurement. But Packard Children's pediatric surgeons have them beat in the scar-avoidance department. They can remove lesions or perform surgery with endoscopic tools, burrowing under the skin from tiny incisions in what until now has been an under-appreciated body part.
"Finally, armpits have a purpose," joked Dutta. "Not only are they a great place to hide surgical scars, but they also provide access to many areas of the body."
Although places like the sides, back, chest, neck and head can be reached from under the arms, it's rare for pediatric surgeons to use them for this purpose, known as subcutaneous endoscopy.
Dutta's muse was a 7-year-old boy from Guadalajara, Mexico, with torticollis, or wryneck. Congenital torticollis can be caused by birth trauma or a uterine position that causes neck muscles to contract abnormally. Caught early, it can be treated with gentle, regular neck stretches.
"Unfortunately, this had developed a significant deformity," said Dutta. "His eyes had begun to shift position to compensate for his tilted head." His neck muscle had thickened into a fibrous, inflexible band that needed to be severed to allow normal movement and head position.
Such surgery typically leaves a large scar on the patient's neck. Although Dutta and Packard's chief of pediatric surgery, Craig Albanese, MD, had previously used a subcutaneous approach to remove a cyst from the forehead of a teen-age girl through incisions hidden in her scalp, reaching the neck from the scalp is more difficult.
"We were really trying to think about this in a different way," said Dutta.
He decided to try inserting endoscopic tools in three small incisions in the boy's armpit. Once that was accomplished, he threaded the tools just below the skin up into his neck. After blowing carbon dioxide into the area to make more room to work, he was able to perform the operation without damaging the neck skin.
"We saw the results immediately," said Dutta. "His father was overwhelmed. He had never seen his son hold his head up straight before."
"This approach is very cool," said Albanese. "It will definitely catch on."
The surgeons have now performed several subcutaneous procedures, including removing lymph nodes, cysts and other benign lesions.
Some procedures benefit from using both armpits, which allows surgeons to approach the surgical site from either side and gives them more room to maneuver. They can also insert tools at the base of the breastbone for a three-pronged approach.
"Endoscopic instruments are basically like long, motorized chopsticks with swappable ends," said Thomas Krummel, MD, professor and chair of surgery at Stanford and the Susan B. Ford Surgeon-in-Chief at Packard. "It's necessary to have a good angle between them to be effective. It's very different in an open operation where our angle and approach are basically unlimited."
The subcutaneous layer of the skin is basically loose connective tissue. Threading surgical tools from the incision to the surgical site, though it might seem traumatic, causes no lasting damage as long as major nerves are avoided.
Dutta tracks the tools by watching and feeling them move just beneath the skin. The light at the endoscope's tip also marks its position by shining through the body's surface. Once in place, the surgeons pump in carbon dioxide to puff up the skin and create a cavity in which to work.
"Now that we're more confident with it, we're fired up to do all sorts of things," said Dutta. "This procedure can be used on both adults and kids to address problems all over the body."
Dutta is already imagining ways to modify the tools to make the job easier. Although minimal-access surgery makes a surgeon's job more complicated, the benefits to patients offer great inspiration to develop and master the technique.
"People tend to say that these kids should just tough it out," said Dutta. "I think that my patients have plenty of time to learn how to be tough later in life."
This story was adapted from an article in the fall issue of Stanford Medicine. To read the complete version, visit http://mednews.stanford.edu/stanmed/