Advances in Pediatric Minimal Access Therapy: a Cautious Journey from Therapeutic Endoscopy to Transluminal Surgery Based on the Adult Experience

Introduction

Since the introduction of laparoscopic surgery by Kelling in 1901, minimal access surgery has developed into a safe and clinically comparable alternative to open surgery of the abdomen. It brings substantial benefits to patients, both adult and pediatric, including less pain, reduced risk of local and systemic complications (eg, ventral herniation, wound infection, adhesion formation), faster recovery, and superior cosmesis ⁽¹⁾.

In recent years, therapeutic endoscopy has entered the realm of minimal access surgery, motivated by the goal of further minimizing the invasiveness of abdominal access. With the focus mainly on gastroesophageal reflux disease (GERD), several innovative endoscopic tools have been developed in the attempt to replicate 1 or more of the features of a surgical fundoplication. The Wilson-Cook Endoscopic Sew-Right suturing device, the Bard EndoCinch, and the NDO full-thickness plicator are examples of devices now in clinical use. Alternatively, procedures such as the Stretta exploit the use of energy sources, in this case radiofrequency ablation, to bolster the lower esophageal valve mechanism.

This article explores the confluence of pediatric minimal access surgery and therapeutic endoscopy in a novel modality called transluminal surgery, or NOTES. The limitations of conventional pediatric minimal access surgery are briefly discussed, and existing therapeutic endoscopic procedures are reviewed. The concept of transluminal surgery, with its future directions and challenges, is introduced, and the emergence of a new type of minimal access surgical specialist is proposed. The goal is to raise awareness of these “fringe” technologies so that practitioners can understand better what the future may hold for pediatric minimal access therapy.