Savagely sliding into home plate, 15-year-old Tatum mentally prepared for the inevitable impact.

Cuts and bruises come with high-school-softball territory. Even her mom winced from the stands, as she watched the play. But bruises aside, neither one was prepared that day for an Emergency Center visit and a ruptured cyst on her spleen.
 
Fortunately for Tatum, Nicole Chandler, M.D., and her team at Johns Hopkins All Children’s Hospital, get kids back in the game faster with single-incision, minimally invasive pediatric surgery.

Chandler, director of pediatric surgery research at Johns Hopkins All Children’s, has been championing—and improving—the technique since she first started using it for surgeries, including appendectomies and splenectomies in 2009.

Already, the technique saves an average of $4,100 per patient by sending them home sooner.

“By 2013, we were sending kids home the same day after an appendectomy,” Chandler says. “Our research fellows helped us determine that that saves us $750,000 per year—and it is improving the care for the child at the same time. That’s a win-win.”

Constantly Fine-tuning Success

Chandler adopted the technique shortly after it was introduced for pediatric patients. With the help of her clinical and research surgical fellows, she investigates ways to improve the surgery, which offers fewer scars, faster recovery and less time for pediatric patients to be under anesthesia.

The procedure involves a single incision most commonly hidden within the belly button. The size depends on the type of surgery. In Tatum’s case, the incision was about a half inch long, which is standard. The spleen was broken up into small pieces inside the abdomen and extracted through the small incision.

Through her study of the technique over the years, Chandler knew Tatum—whose sports injury and ruptured spleen left her sore, swollen and filled with a liter of fluid—was a better candidate for minimally invasive surgery if she first took a few days to heal.

“With Tatum, if we had operated on the first visit with all of that fluid, it would have been harder to see what was going on and we likely would have needed a much larger incision,” Chandler explains. “The recovery time would have been greater, which would have affected getting her back to sports.”

Chandler’s research on combating infections in single-incision minimally invasive surgery soon will be published in the Journal of Pediatric Surgery, and she frequently speaks nationally and internationally on her findings. Her team began applying antibiotic powder to the incision area in 2015, resulting in no infections since then.

“Once we saw the numbers, rather than abandoning this otherwise great technique, we wanted to discover how we could reduce the percentage of infections at the incision site,” Chandler recalls.

She would next like to introduce the technique in training environments. “We’re looking at things like, ‘How many surgeries a fellow would need to do in order to be considered competent,’” she explains. “These fellows then graduate, move on and take the technique to their new practices. From an educational standpoint, we are training the next wave of pediatric surgeons in this skill set, which they can now offer to their own patients.”

Chandler’s team also works closely with the Johns Hopkins School of Engineering Center for Bioengineering Innovation & Design (CBID) in Baltimore on designing surgical tools to improve the technique even further.

“Closing the belly button can take twice as long as the actual surgery because this tiny incision is really at the bottom of a tunnel,” she explains, smiling at her own analogy. “We take these problems to the students and ask them to come up with a solution.”

Fellows Increase the Opportunity for Research

Chandler, who also is the associate program director of the Pediatric Surgery Fellowship Program, is using the help of her fellows in several other surgery-related studies. For instance, pectus excavatum is a specific chest wall deformity that presents as a sunken chest. Children, mostly boys, who have this deformity can have breathing issues and be limited in sports, but mostly it creates social anxiety. The treatment is called the Nuss procedure and involves making small incisions to allow a stainless steel bar to be inserted to support the chest.

Chandler and her fellows are working on testing an alternate measurement system that can be done during an office visit for less time and cost to the family as they prepare for surgery. “Currently, most insurance companies require a CT or MRI scan of the chest, which can cost families several thousand dollars, in addition to an additional trip to the hospital to have the test done. By eliminating this test, we are talking about a significant cost savings to families. Following the operation, we have developed care plans that reduce the number of blood and radiology tests, get patients up and moving right after surgery, and provide better pain control. We are doing everything we can to streamline this procedure so that we see fewer side effects, they can go home sooner and they are more informed.”

For Chandler, anything she can do to make these procedures safer, faster, less expensive and provide an easier, less painful recovery is a win for her and her patients.

Tatum’s mom agrees. “I can’t tell you how thrilled we were after Tatum’s surgery. There is no scar and she was able to get back to playing ball in a few short weeks. It was amazing,” recalls Tatum’s mom, Nicole. “We are so grateful to Dr. Chandler and everyone at the hospital for everything they did for Tatum.”

“I was so bored without sports,” Tatum adds. “It was really nice to get back to it so quickly.”