Pediatric Gynecology

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Dr. Larry Demco: "I’m reporting from the World Congress of Gynecological Endoscopy here in Tel Aviv, Israel and I’d like to interview Dr. Ronald Levine who’s been a leader in laparoscopic surgery and has a program in his institution for adolescent gynecology. This is a new field and it sounds very exciting. Dr. Levine, could you just give us a little overview of the focus for pediatric and adolescent laparoscopy?"

Dr. Ronald Levine: "First of all, there are only two institutions in the United States that offer fellowships in pediatric-adolescent gynecology and the University of Louisville is one of them. That’s under the directorship of Dr. Sally Pearlman and Dr. Paige Hertweck, it had originally been started by Dr. Joseph Sanfilippo. This fellowship in this field covers the use of laparoscopy in these patients. This field of laparoscopy in pediatrics and adolescent patients really was under the realm prior to these fellowships of the pediatric surgeons, however, we now are working in conjunction with them particularly in the fields of the newborn patients and the pre-pubertal patients."

Dr. Larry Demco: "What conditions in this age group tend to lead to a laparoscopic intervention?"

Dr. Ronald Levine: "We literally divided off into three areas, the neonatal period and frequently in these patients in whom a mass is detected by ultrasound pre-natally now that most of the patients, particularly in the United States, have an ultrasound somewhere along the line. Then these patients will often be followed after birth with a mass being discovered. Usually within three months most of these masses, about 90%, will reverse, however, if they’re large or complicated masses, they probably will not. So this is the type of patient in whom there’s surgical intervention by laparoscopy and what happens is because getting symptoms out of these patients are really very little because they may just be off on their feeding. They may be irritable but that’s very hard to discern from symptoms so there’s usually something that’s either picked up by ultrasound and then followed by ultrasound and so this is in that group. And then in the pre- pubertal group of patients that develop tumors, they often are teratomas and sometimes torsion on these patients that present with pain in the abdomen, and they have a torsed ovarian mass so these are the types of tumors that they usually have. In the newborns the incidence of a malignancy is very, very, very low. It starts to rise at about age ten and so after age ten we have to be very careful in screening these patients other than the usual techniques but we also can remove a mass in toto and then have frozen sections on it so that can be done. As we get into the older group, this is where the more traditional gynecologist usually handles the post-pubertal patient, the early teenage patients that can get either PID and have ovarian masses, again, here where occasionally ovarian tortion occurs and occasionally ectopic pregnancy and such like that."

Dr. Larry Demco: "Dr. Levine, operating on a newborn would be a very technical challenge, what size of instruments are you currently using in your choice of laparoscopic instruments?"

Dr. Ronald Levine: "Our pediatric-adolescent gynecologists are using 3 mm instruments, of course, a couple of the little tricks is the anesthesia is very important, the anesthesiologist must really know how to take care of these patients. One has to realize that we use a lot different pneumoperitoneum than we do in adults with a maximum of about 8-9 mm of mercury pressure as opposed to our usual 16 mm or so of mercury pressure. The instrument placement is different and the entry is different. All open laparoscopy is used on all of these patients and it’s important to identify the often times patent umbilical vessels, and they have to be identified and tied off. So if they’re not identified and tied off, one may get bleeding. To put in the open laparoscopy, it’s the complete opposite of what we as gynecologists have been trained. Instead of going the lower abdomen ancillary ports of course have to be placed high into the upper abdomen because of the space. Also with the gas that’s used it’s extremely important in these patients to use warm humidified gas because these patients would certainly be very susceptible to hypothermia."

Dr. Larry Demco: "Has there been any work involved in interuterine laparoscopy?"

Dr. Ronald Levine: "I’m not aware of it, it may be but I don’t particularly have any experience. By the way, I forgot kind of rushing along with this that one of the big things that we’re interested in in the adolescent patients are the patients who have problems with non-development of the vagina and where we’re doing neovagina surgery. We’re particularly interested in doing two laparoscopic approaches, one of them is the Vecky-eddie approach, which we have tried but some of this equipment isn’t FDA approved yet. We’re very interested in working with the Davidoff procedure which comes out of Russia, Aleda Dameon is probably done 300 of these and it’s really a great procedure because the patient has a useable vagina within literally days of the surgery. It’s really not a very difficult operation to perform using both external techniques and laparoscopic technique."

Dr. Larry Demco: "Dr. Levine, one of my own residents is extremely interested in pediatric and adolescent laparoscopy and gynecology so I think that this is an up and coming field. I’m glad you shed some light into this new field, and I thank you very much."