Minimally Invasive Surgery Now Possible in Pediatrics
Medical Robot Part of Surgical Team

"AESOP, move right," says a voice from behind a surgical mask.

The robotic arm recognizes the voice as that of surgeon Martin Blakely, and responds by following the command.

AESOP®, which stands for Automated Endoscopic System for Optimal Positioning, actually assists Dr. Blakely during laparoscopic surgery, a type of minimally invasive surgery performed in the abdominal area.

Misty Dowdell and her children (from left) Kathlynn, Frank and Steven at a recent visit with Dr. Blakely following Frank's surgery.

During the procedure, a slender instrument called a laparoscope is inserted into the abdomen through small incisions. This instrument allows the surgeon to examine the area by displaying images on a video screen. The robotic arm plays the key role of steadying this "camera" and maneuvering it at the surgeon's command, which is given through a voice-activated headset.

How can AESOP tell who is speaking? The robot responds to Dr. Blakely's voice because a voice card has been inserted with the surgeon's commands recorded on it, thereby preventing confusion between Dr. Blakely's words and those of any other voice in the operating room.

While laparoscopic procedures are not new to surgical teams operating on adults, Dr. Blakely is taking the minimally invasive techniques, including the use of AESOP, and applying them to pediatric patients.

"These are techniques that are done in adults on a regular basis," says Dr. Blakely, assistant professor of pediatric surgery at The University of Texas-Houston Medical School. "But because kids are so small, it has needed to wait on better instruments being made. The instruments required are so much smaller that it requires an entirely different set up. That is partly why it has lagged behind adults.

"The reason we're using this robot is that some of these babies are so small that getting precise movements of the camera and keeping it still is very important," says Dr. Blakely. "He [AESOP] very precisely, in centimeter increments, goes exactly where you tell him to, which gives the surgeon better control over the operating room environment."

Dr. Blakely, who recently came to Houston from Le Bonheur Children's Medical Center and the University of Tennessee in Memphis, says that advanced minimally invasive surgeries in pediatrics are being performed in a few centers around the country, citing Memphis, Denver and Birmingham. He is now a partner with Texas Pediatric Surgical Associates. Since arriving to Houston, the majority of these operations have been performed at Memorial Hermann Children's Hospital.

Misty Dowdell of Porter, Texas, knew something was wrong when her 3-month-old son, Frank, stopped breathing while being fed. Frank had a condition known as gastroesophageal reflux disease (GERD). Children with GERD may experience difficulty with growth because they are not getting the food they need. The condition can also lead to esophagitis - when stomach acid refluxes into the esophagus - or could result in pneumonias caused by food refluxing into the lungs.

If medication fails to treat the reflux, a surgery known as fundoplication may be considered. While the surgery has traditionally been performed with an open incision, Dr. Blakely says that due to improved instruments and technique, it can now be done laparoscopically in children and infants.

"In adults, this procedure has been studied a lot. For this particular operation, it has been shown that the hospital stay is shorter, requirements for pain medication are lower, and they tolerate feedings better," says Dr. Blakely. "For kids, there's not a lot of data out there because it's a very new field. In any one center, you may do 20-30 a year, so it's not like you can get a whole lot of patients to study."

The goal of minimally invasive fundoplication is the same as that of the surgery performed with an open incision. The surgeon creates an avenue for food to go down into the stomach by wrapping a portion of the stomach known as the fundus around the esophagus. A small tube is often placed into the stomach (a button gastrostomy) to assist with feedings.

"When the baby tries to reflux, it is blocked and goes down the correct way," says Dr. Blakely. "In little babies, this prevents air or formula from refluxing."

Frank Dowdell underwent a minimally invasive fundoplication to correct his reflux in August. "I always like less stiches and less infection," said Misty Dowdell, at a doctor's visit in September. "He's doing good, he has gained a pound and feedings are easier. It used to take an hour to feed him and now it takes 30 minutes." Dowdell's insurance covered the procedure.

According to Dr. Blakely, in addition to fundoplication, minimally invasive techniques can be used in other procedures traditionally performed through open surgery in pediatric patients, like appendectomies and hernia operations.

"We're basically applying techniques that have been done elsewhere but we are applying them to kids, which is going to be done more and more everywhere because there are advantages, even if, for some operations, it's only cosmetic," Dr. Blakely says. "For families, that is very important. It does make a difference if there is a big scar or not.

"I think it is going to really change how kids are treated," he says.

As for his robotic assistant, Dr. Blakely plans to conduct studies of AESOP and other medical robots to determine how they can further assist in the operating room.

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©2006 Texas Medical Center

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