Evolving uses of laparoscopy in children.

As the technology evolves, the number of procedures that can be performed laparoscopically will continue to expand (Table 3). The impact on the field of pediatric surgery, which encompasses surgical oncology, gastrointestinal surgery, trauma, and gynecologic surgery, will be significant. There are several hurdles for the pediatric surgeon to overcome before beginning operative laparoscopy. The acquisition of the initial instrumentation is expensive, and the credentialing process may be time-consuming. And there remains a healthy suspicion on the part of many pediatric surgeons that these techniques represent a fad. We believe that operative laparoscopy has advantages and disadvantages. Some of the procedures require more time and are frequently tedious, thus trying the patience of the surgeon. It is difficult for experienced surgeons to subject themselves electively to the learning curve associated with a new procedure. While the benefits are mostly in the postoperative period, we believe exposure is vastly improved in obese patients. Patients appear to have less pain and postoperative ileus, and they may return to unrestricted activity sooner. We are still discovering which laparoscopic procedures can be done safely to the patient's advantage. Solving the dilemma of what procedures should be performed using laparoscopic techniques will require extensive experience and study, and minimally invasive surgery will be a subject of controversy and debate for many years. It is difficult to imagine that open cholecystectomy would once again become the standard. We predict that we will see a continued expansion in the types of procedures to be performed using minimal-access techniques. And in the future, we may have to justify our opening of a patient's abdomen when the procedure could have been performed laparoscopically, as is now the case for cholecystectomy in some areas of the country.