3rd International Neonatal MIS Symposium

Day 2Sat, Oct 17

1. 8:00 AM–8:30 AM
   Surgical Tips & Tricks in MIS in NewbornsBethany Slater, Division Chief of Pediatric Surgery; Dariusz Patkowski, Pediatric Surgeon and Urologist30 min · 6 highlights

   Bethany Slater presented an overview of minimally invasive surgery (MIS) in newborns, emphasizing the evolution from large open incisions to standard MIS, the importance of small instruments (35 mm versus 10 mm), specialized insufflators, and surgeon‑anesthesiologist communication. She detailed advantages such as reduced pain, infection, adhesions, shorter stays, and better visualization, and highlighted specific challenges in neonates—tiny working space, fragile tissues, high CO₂ absorption, and physiologic instability. Ergonomic considerations for surgeon, table height, monitor placement, and instrument length were discussed, as were patient positioning, trocar selection, and conversion criteria. Samir Pandya added practical tips on using reusable 3 mm trocars with caps to reduce clashes, the need for clear team communication, and a stepwise cultural shift to adopt neonatal MIS.…

   • MIS in neonates is now standard for many procedures, driven by small instruments and advanced insufflators.
   • Benefits include smaller incisions, less pain, lower infection risk, reduced adhesions, and quicker recovery.
   • Neonates require meticulous anesthetic management due to fragile tissues, high CO₂ absorption, and limited physiologic reserve.
   • Ergonomics: neutral surgeon posture, appropriate table/monitor height, short instruments, and strategic trocar placement improve outcomes.
   • Patient positioning and secure access for airway and lines are critical for safe neonatal MIS.
   • Reusable 3 mm trocars with caps minimize instrument clash in tiny spaces.
   • Effective communication with anesthesiology, scrub tech, and nursing teams is essential for success.
   • NICU surgery is limited to emergent cases; otherwise, operations should be performed in a dedicated OR.
   Watch
2. 8:35 AM–9:00 AM
   Neonatal MIS TrainingMaximiliano Maricic, Pediatric Surgeon25 min · 4 highlights

   Dr. Maximiliano Maricic presented a structured, high‑performance training program for neonatal minimally invasive surgery (MIS). He emphasized a progressive curriculum combining simulation labs, ergonomic models, and operating‑room practice, with continuous mentorship, debriefing, and team coordination. Simple low‑cost models are valuable early on, while higher‑fidelity simulations become essential as proficiency grows. The program aims to reduce operative time, improve patient safety, and sustain skills through train‑the‑trainer initiatives. Audience questions explored model fidelity, beginner pathways, and resident involvement, reinforcing the need for confidence, incremental skill acquisition, and collaborative, institution‑wide support.

   • High‑performance neonatal MIS training integrates simulation labs and OR practice with a clear, progressive curriculum.
   • Low‑cost simple models are suitable for foundational skills; higher fidelity models are used later for advanced detail.
   • Mentorship, continuous education, and team debriefing are central to skill acquisition and safety.
   • Train‑the‑trainer and sustainability are achieved by embedding the curriculum across institutions.
   • Program has reduced operative times and improved outcomes for esophageal atresia and other procedures.
   • Residents should be introduced gradually, only when surgeons feel confident and self‑assured.
   • Model fidelity matters more at advanced stages; basic maneuvers can be learned with simple models.
   • Recording and sharing procedures facilitate deliberate practice and collective learning.
   Watch
3. 9:10 AM–9:40 AM
   Congenital Diaphragmatic Hernia RepairArnaud Bonnard, Professor of Pediatric Surgery, Head of Pediatric Surgery Department30 min · 4 highlights

   The session reviewed current strategies for congenital diaphragmatic hernia (CDH) repair, emphasizing patient selection, minimally invasive surgery (MIS) techniques, and outcomes. Arnaud Bonnard highlighted selection criteria, classification of defect size, pre‑operative stabilization parameters (PCO₂ 95 %), and the advantages of thoracoscopic repair for low‑risk infants (recurrence ≈ 8.7% vs 1.6% open). He detailed operative steps, port placement, insufflation management, and suturing methods, including patch use for larger defects. Steve Rothenberg and others discussed ancillary issues such as patch material, muscle flap alternatives, and intra‑operative challenges. The panel concluded that careful patient selection and meticulous thoracoscopic technique can lower recurrence and morbidity, while acknowledging the need for conversion criteria and ongoing skill development.

   • Selection criteria now include stable infants ≥2 kg, gestational age ≥35 weeks, and no ECMO or high‑frequency ventilation.
   • Defect classifications (A‑D) guide approach; types A/B suit thoracoscopy, C/D often need patches.
   • Thoracoscopic repair shows lower mortality and shorter hospital stay, but recurrence remains ~8.7%.
   • Pre‑operative targets: PCO₂ 34 mm Hg, SpO₂ 85‑95%, lactate 3 mmol/L, FiO₂ 50%.
   • Port placement: 5 mm laparoscope at scapular tip, 3 mm working ports along axillary line; insufflation 5 mm Hg.
   • Adequate muscle paralysis and nasogastric decompression are essential to reduce hypercapnia.
   • Patch repair for C/D defects should be oversized and anchored at least 2 mm from diaphragm edge.
   • Conversion to open surgery is advised for tension, poor visualization, or hemodynamic instability.
   Watch
4. 9:40 AM–10:10 AM
   Choledochal CystSamir Pandya, Professor of Surgery; Associate Chief, Pediatric Surgery30 min · 3 highlights

   Dr. Samir Pandya presented a comprehensive technical overview of choledochal cyst management, covering case presentation, pre‑operative imaging review, surgical planning, port placement, cyst excision techniques, anastomotic options (hepaticojejunostomy vs hepaticoduodenostomy), handling of small or accessory ducts, use of ICG, robotics versus laparoscopy, and postoperative outcomes. He emphasized multidisciplinary imaging review, team selection, and adaptable suturing strategies. Dr. Miguel Guelfand highlighted safe dissection on the anterior wall and answered audience questions about stent use and timing. Dr. Steve Rothenberg discussed MRCP optimization with Eovist. The session concluded that both anastomotic approaches are viable, with ongoing debate on long‑term reflux risk.

   • Choledochal cysts risk malignant transformation, mandating resection and biliary‑enteric reconstruction.
   • Pre‑op MRCP review with radiology, noting common channel length, vascular anatomy, and possible aberrant ducts.
   • Port positioning should be adapted for surgeon handedness; hitch sutures and cyst sling aid exposure.
   • For small or accessory ducts, ductoplasty or corral patch can replace multiple anastomoses.
   • Hepato‑choduodenostomy offers single anastomosis but may increase bile reflux; hepato‑cholangiostomy is shorter operative time.
   • Robotic and laparoscopic approaches reduce length of stay; robotics allows fully intracorporeal anastomoses.
   • Stents are optional but must not be sewn in; ICG can delineate biliary anatomy intra‑operatively.
   • Long‑term data show low stricture rates (~2%) and comparable outcomes between techniques.
   Watch
5. 10:10 AM–10:30 AM Coffee Break20 min
6. 10:30 AM–11:00 AM
   Duodenal ObstructionMiguel Guelfand, Section Head, Pediatric General & Thoracic Surgery30 min · 2 highlights

   Miguel Guelfand presented a detailed laparoscopic technique for duodenal obstruction in neonates, covering port placement, ergonomic considerations, and step‑by‑step execution of Kimura, duodeno‑duodenal, and duodeno‑jejunostomy anastomoses. He emphasized using percutaneous stay sutures to improve exposure, selecting appropriate suture size (usually 5‑0 PDS) based on patient weight, and the option of stapled side‑to‑side anastomoses for infants over 2 kg. He demonstrated handling of membranes and webs, and concluded with tips on leak testing and postoperative care. Questions addressed preference for duodeno‑duodenal repair and suture material, confirming 5‑0 PDS as standard.

   • Port placement below the umbilicus improves ergonomics and access
   • Percutaneous stay sutures aid exposure and precise anastomosis
   • Kimura technique is preferred for training and anatomical alignment
   • For infants 2 kg, a 5‑mm stapler can be used for side‑to‑side anastomosis
   • Use 5‑0 monofilament PDS; 6‑0 may be used in very small babies
   • Membrane resection should avoid papilla injury, targeting ~70% removal
   • Leak testing with air or fluid ensures anastomotic integrity
   • Open repair favors duodeno‑duodenal over duodeno‑jejunostomy when feasible
   Watch
7. 11:00 AM–11:30 AM
   MIS Inguinal HerniaJorge Correia-Pinto, Full Professor and Dean, School of Medicine30 min · 4 highlights

   Jorge Correia‑Pinto presented a minimally invasive laparoscopic approach for pediatric inguinal hernia repair, emphasizing lower testicular complications, reduced metachronous hernias, and comparable recurrence to open surgery. He described the Pierce technique, instrument choices, needle handling, and the importance of a gap‑free peritoneal purse‑string closure. He highlighted special considerations in girls, neonates, premature infants, and incarcerated or femoral hernias, and shared tricks to avoid infection and granuloma formation. The session concluded with a discussion on complications, recurrence management, and the feasibility of laparoscopy across all ages and weights, with a reported recurrence rate of about 1.5% in over 1,000 cases.

   • Laparoscopic repair offers lower testicular complications and fewer metachronous hernias without increasing recurrence.
   • The Pierce technique with a 30‑degree 5 mm scope is the department’s standard method.
   • Avoiding gaps in the peritoneal purse‑string is critical, especially in girls where folds can cause recurrence.
   • Needle choice evolves from blunt aspiration to cutting Avocat needles as experience grows.
   • Complications such as infection are managed by removing the stitch; granuloma is minimized by soaking sutures in betadine.
   • Laparoscopy is suitable for infants, premature neonates, incarcerated hernias, and even femoral hernias.
   • Recurrence rate reported is about 1.5% after 1,000 cases performed.
   • No strict age or weight limits were set for laparoscopic hernia repair.
   Watch
8. 11:30 AM–12:15 PM Sponsored Lunch45 min
9. 12:15 PM–12:45 PM
   Fetoscopic Repair of MyelomeningoceleJose Luis Peiro, Director, NYU Langone Advanced Fetal Care Center; Professor of Surgery30 min · 1 highlight

   Dr. Peiro presented his extensive experience with fetoscopic repair of myelomeningocele, describing the pathophysiology, animal models, surgical technique, and clinical outcomes of minimally invasive fetal surgery. He compared it to open prenatal repair, highlighting reduced prematurity, comparable Chiari reversal, lower shunt rates, and improved motor function. He discussed patch materials, future regenerative approaches, and training programs. Q&A addressed gestational timing, case selection, and urological/ bowel outcomes, confirming a 23‑26 week optimal window and no strict size limits. The session concluded that fetoscopic repair is a safe, effective alternative to open surgery, with ongoing innovations and international collaboration.

   • Fetoscopic repair aims to protect the spinal cord from amniotic fluid damage and CSF leak.
   • Animal studies showed progressive neuroinflammation and neuron loss in untreated models.
   • Clinical series (≈108 cases) achieved ~90% Chiari reversal and 32% CSF diversion, with deliveries at 36‑37 weeks.
   • Motor improvement seen in 30% of infants; 50% walk independently without aid.
   • Patch material from umbilical cord shows anti‑inflammatory properties and good integration.
   • Optimal surgery window is 23‑26 weeks; most cases performed around 25 weeks.
   • No strict lesion size limit; exclusion criteria include major maternal/fetal anomalies.
   • Collaboration, training courses, and future stem‑cell/patch innovations were emphasized.
   Watch
10. 12:45 PM–1:15 PM
    MIS in Neonatal Bowel PerforationAdel Al Jneibi, Consultant Pediatric Surgery & Pediatric Urology, Head of Department30 min · 3 highlights

    Dr. Adel Al Jneibi presented a comprehensive overview of minimally invasive surgery (MIS) for neonatal bowel perforation, covering clinical presentation, diagnostic imaging, operative techniques, and postoperative considerations. He emphasized the importance of team coordination, proper patient selection, and mastering advanced laparoscopic skills, including suturing and intracorporeal anastomosis. The session concluded that MIS is safe for low‑birth‑weight infants when performed by an experienced multidisciplinary team, with conversion to open surgery considered a valid Plan B.

    • Neonatal bowel perforation presents with apnea, bradycardia, feeding intolerance, high gastric output, and bile vomiting.
    • Radiologic signs include pneumoperitoneum and the ‘football sign’ indicating free air.
    • MIS offers combined diagnostic and therapeutic benefits, requiring careful patient positioning and trocar placement.
    • Primary closure with few stitches is feasible for fresh, small perforations in stable infants.
    • Large defects or unstable patients may need ileostomy or staged repair.
    • Conversion to open surgery is acceptable and should be planned as a backup option.
    • Successful MIS depends on skilled suturing, team collaboration, and dedicated training.
    • Overall, MIS is safe in low‑birth‑weight neonates when patient selection and expertise are optimal.
    Watch
11. 1:15 PM–2:15 PM ICG Symposium: ICG and On Target in Newborn and Pediatric SurgerySteve Rothenberg, Chief of Pediatric Surgery; Manuel Lopez, Pediatric Surgeon; Visiting Professor of Surgery; Gloria Gonzalez, Pediatric Surgeon; Visiting Professor of Surgery; Miguel Guelfand, Section Head, Pediatric General & Thoracic Surgery1 h · 7 highlightsWatch
12. 2:15 PM–2:35 PM Coffee Break20 min
13. 2:35 PM–3:05 PM
    25 Years of FETO for Severe CDHJose Luis Peiro, Director, NYU Langone Advanced Fetal Care Center; Professor of Surgery30 min · 4 highlights

    Dr. Jose Luis Peiro reviewed 25 years of fetal endoscopic tracheal occlusion (FETO) for severe congenital diaphragmatic hernia (CDH). He explained CDH pathophysiology, the rationale for tracheal occlusion, technical evolution from open surgery to percutaneous balloon placement, and outcomes showing survival improvement from 8% to 55% in Europe and 40% to 83% in the U.S. He highlighted challenges such as balloon availability, the need for early removal, and ongoing trials of magnetic valves and stem‑cell adjuncts. The session concluded that FETO is now a consolidated therapy with clear survival benefit in severe CDH, though moderate cases remain debated and further innovation is anticipated.

    • CDH severity correlates with defect size, liver herniation, and lung hypoplasia.
    • Tracheal occlusion restores intrapulmonary fluid, promoting lung growth before birth.
    • Percutaneous balloon FETO (26‑28 weeks) replaced open fetal surgery, but placement is technically demanding.
    • Survival rose from 8% to 55% in Europe and 40% to 83% in the U.S. after FETO.
    • Early balloon removal improves outcomes by reducing airway inflammation.
    • Magnetic‑valve balloons and stem‑cell/exosome therapies are under development.
    • Balloon supply issues hinder European use; FDA approval drives U.S. availability.
    • Training courses now teach FETO techniques, making it a standard, not experimental, therapy.
    Watch
14. 3:05 PM–3:35 PM
    MIS for Lung LesionsSteve Rothenberg, Chief of Pediatric Surgery30 min · 3 highlights

    Steve Rothenberg presented a comprehensive overview of minimally invasive lung resections in infants, emphasizing safety, anatomy, and standardized techniques. He described his preferred anterior‑to‑posterior, layer‑by‑layer approach, optimal port placement, and use of CO₂ for lung collapse. Vessel sealing, incremental cutting, and avoidance of combined energy‑clip methods were highlighted to prevent catastrophic bleeding. He advocated early surgery (first three months) to avoid infection, use of 3‑mm and 5‑mm sealers and staplers, and incorporation of ICG imaging for better segmental delineation. Q&A covered multi‑lobe disease, segmentectomy strategies, and resource‑limited settings. He concluded that with proper tools and technique, thoracoscopic lobectomy can be safe, efficient, and widely adoptable.

    • Rothenberg stresses understanding segmental lung anatomy to safely navigate arteries, bronchi, and veins.
    • Standard anterior‑to‑posterior, layer‑by‑layer dissection with mid‑axillary scope port improves exposure.
    • Uses CO₂ insufflation and single‑lung ventilation to create operative space; prefers main‑stem intubation over bronchial blockers.
    • Applies vessel sealing with incremental cutting; avoids simultaneous seal‑and‑cut devices on vessels larger than 1 mm.
    • Early thoracoscopic lobectomy (≤3 months) reduces infection risk and supports normal pulmonary development.
    • Incorporates ICG (inhaled or IV) to visualize vascular anatomy and guide segmentectomy.
    • Prefers 3‑mm sealers in smaller infants, 5‑mm devices in larger babies; uses staplers for bronchial and vascular control.
    • Advocates standardized, reproducible technique to minimize conversion and improve outcomes.
    Watch
15. 3:35 PM–4:05 PM
    Long Gap Esophageal AtresiaDariusz Patkowski, Pediatric Surgeon and Urologist30 min · 4 highlights

    The session on long‑gap esophageal atresia highlighted the rarity of true long‑gap cases (approximately one case per 10 years per surgeon) and emphasized the need for centralized expertise. Dariusz Patkowski presented his thoracoscopic technique, focusing on type A and B gaps, avoiding emergency surgery, and using staged internal traction with meticulous suturing and clipping to prevent leaks. He reported nearly 500 thoracoscopic repairs, most completed within the first two weeks of life, with low complication rates and no need for esophageal replacement in his experience. Discussion addressed management of type C gaps, the role of fistula ligation, and the importance of careful postoperative care and potential centralization of care.

    • Long‑gap esophageal atresia is extremely rare, seen about once per 10 years per surgeon.
    • Only type A and B gaps are true long‑gap cases; type C/D are different malformations.
    • Patkowski’s preferred approach is thoracoscopic repair with staged internal traction and careful clipping to avoid leaks.
    • Surgery should be planned, not emergent; refer to high‑volume centers for best outcomes.
    • His center achieved ~90 % thoracoscopic repairs with most cases completed within the first two weeks of life.
    • Complications included rare stomach migration and severe leaks, but no esophageal replacement was needed.
    • Consensus was to centralize care and standardize the thoracoscopic technique for long‑gap cases.
    • Future discussions will include sham feeding practices and minimal‑invasive strategies for related neonatal surgeries.
    Watch
16. 4:05 PM–5:05 PM Complex Cases: Tips, Tricks and New Ideas (Expert Panel)1 h
17. 5:05 PM–5:35 PM All Faculty Q&A30 min