Minimally invasive surgery entered the world of pediatric care about 20 years ago. Since then, the field has advanced significantly, resulting in shorter recovery times for patients and new approaches to the treatment of conditions such as appendicitis.
“Johns Hopkins All Children’s Hospital was an early adopter of many of these advancements,” says Paul Danielson, M.D., chief of the pediatric surgery division at Johns Hopkins All Children’s. “The latest evolution of minimally invasive surgery is called single-port laparoscopy, which only requires one incision as opposed to multiple.”
Single-port laparoscopy typically takes place through the belly button—which hides the resulting scar—and can be used for multiple surgeries such as removal of the gall bladder, spleen or appendix. The adoption of single-port laparoscopy has allowed the team at Johns Hopkins All Children’s to discharge many appendicitis patients without an overnight stay at the hospital.
“By 2013, we were sending children home the same day after an appendectomy,” says Nicole Chandler, M.D., director of pediatric surgery research at Johns Hopkins All Children’s. “Our research fellows helped us determine that we save $750,000 annually because of this, and we’re improving the care for children at the same time. That’s a win-win.”
Allowing children to heal at home after appendectomies benefits both patients and their families. Patients have less anxiety since they don’t have to spend the night in an unfamiliar environment. Parents are able to take care of other familial responsibilities without taking extra time off from work.
Chandler began using the single-incision method in 2009 and has been a champion of the surgery ever since. Her adoption of the technique has resulted in fewer handoffs for appendectomy patients at Johns Hopkins All Children’s.
“Handoffs are the Achilles’ heel of modern health care,” Danielson says. “Our new approach eliminates between two and four handoffs compared to the old method. An appendectomy patient goes from the emergency department to the pre-op area, then to the operating room, the recovery room and, finally, home.”
In the past, patients would have to be admitted and readmitted to the hospital floor multiple times after being diagnosed and undergoing surgery. The new process lowers the chance of communication errors due to fewer handoffs.
“Our surgeons, led by Chandler and Danielson, were some of the first in the country to promote outpatient surgery for uncomplicated appendicitis,” says Paul Colombani, M.D., chairman of the surgery department at Johns Hopkins All Children’s. “More medical centers around the country are following their lead.”
Chest Wall Deformities Clinic
In the same way that appendectomies have been optimized for better patient results, the chest wall deformities clinic at Johns Hopkins All Children’s is streamlining the treatment of conditions such as a breastbone sunk into the chest (pectus excavatum), a protrusion of the sternum and ribs (pectus carinatum) and other congenital or acquired deformities of the chest.
“Chest wall deformities can cause issues with the lungs and heart,” Danielson says. “It’s important not to view the condition strictly from a surgical standpoint. Instead of having a patient visit a surgeon, then going to a cardiologist, and then transferring to a pulmonologist and so on, we’ve tried to formalize and include everything under one program.”
The chest wall deformities clinic serves as a one-stop shop for patients and their families. Oftentimes, an entire workup can be completed in one visit, with the surgery occurring during a subsequent trip to the hospital. In certain cases, both the workup and the surgery are completed in a single visit.
After surgery, the anesthesia department uses a new post-operative management paradigm to ensure patients can go home in two to three days as opposed to seven. Medications are given at carefully chosen times to better treat the pain, anxiety and nausea that can occur after surgery.
Colombani works with both Chandler and Danielson in the chest wall deformities clinic. Colombani is one of the most experienced chest wall deformity surgeons in the nation. Danielson learned the Nuss procedure—a minimally invasive treatment for pectus excavatum—from inventor Donald Nuss himself. All three physicians perform chest wall deformity surgery, with Chandler contributing research to the field.
“Johns Hopkins All Children’s is one of the few academic pediatric centers in the state,” Colombani says. “We are able to teach our research fellows how we manage patients, and they spread the word to other locations.”
This story first appeared in Leading Care magazine.