International Society of Paediatric Surgical Oncology (IPSO) Minimally Invasive Surgery (MIS) Guidelines

TL;DR

This paper presents guidelines for using minimally invasive surgery in pediatric oncology, emphasizing its benefits and proper application for various cancers.

Contribution

The paper introduces comprehensive MIS guidelines for pediatric oncology, tailored for both high- and low-income countries.

Findings

MIS offers benefits like faster recovery and reduced pain in pediatric oncology.

MIS is effective for specific tumors like neuroblastoma and Wilms tumor when used with proper protocols.

MIS requires strict adherence to oncological principles to avoid complications like tumor spillage.

Abstract

Paediatric oncology surgeons play a crucial role in diagnosing, staging, and treating malignant solid tumors. In recent years, many solid tumour protocols have advocated for a more tailored surgical approach to both the primary tumour site and metastatic disease. The integration of Minimally Invasive Surgery (MIS) into paediatric oncology practice has gained popularity over the past few decades. While the benefits of MIS are well established in non-oncologic surgery, its role in paediatric solid tumours is still evolving and, in many cases, lacks high-quality evidence. These IPSO-MIS guidelines guidelines aim to provide practical surgical recommendations for diverse clinical scenarios, addressing the needs of both High-Income Countries (HICs) and Low- and Middle-Income Countries (LMICs). The contributing authors represent both settings, ensuring a comprehensive and inclusive perspective. We hope that these guidelines will contribute to improving outcomes for children with cancer worldwide.

Israel Fernandez-Pineda, IPSO Education Committee Chair

Abdelhafeez H Abdelhafeez, IPSO Education Committee Member

Minimally invasive surgery (MIS) has become increasingly integrated into Paediatric Surgical Oncology (PSO), offering benefits such as faster recovery, reduced postoperative pain, earlier resumption of adjuvant therapy, lower blood loss and improved cosmetic outcomes. Despite these advantages, the safe application of MIS in oncology requires strict adherence to oncological principles to avoid complications such as tumour spillage, incomplete resections and staging errors, which may compromise survival outcomes. This article reviews the general principles, indications and contraindications for MIS in paediatric oncology, highlighting tumour- and histology-specific considerations. Commonly accepted MIS applications include selected cases of neuroblastoma, Wilms tumour following neoadjuvant therapy under SIOP protocols, thoracoscopic lung metastasectomy and resection of certain mediastinal, hepatic and adnexal masses. Contraindications include large or fragile tumours, high-risk neuroblastomas with vascular encasement and situations where surgeon experience or resources are insufficient. Technical aspects, patient selection and multidisciplinary coordination are emphasised as key to ensuring safety and efficacy. Establishing MIS guidelines in PSO may aid surgeons in decision-making and promote consistent standards of care.

Minimally invasive surgery (MIS) has become increasingly important in paediatric surgical oncology for the diagnosis and staging of solid tumours, due to its advantages in reducing morbidity, pain and hospitalisation times compared to traditional open surgery. While ultrasound-guided core needle biopsy (USCNB) typically remains the primary method for tissue sampling, MIS becomes essential in cases where USCNB is impractical or ineffective, such as with inaccessible tumour locations or where detailed staging information is required. Recent studies highlight the effectiveness of MIS in obtaining high-quality biopsy samples in neuroblastoma, thoracic tumours, hepatoblastoma and rhabdomyosarcoma, frequently outperforming open surgical methods regarding sample adequacy and complication rates. Video-assisted thoracoscopic surgery has demonstrated particular efficacy with minimal complications across various thoracic malignancies. Additionally, laparoscopic and robotic approaches for retroperitoneal lymph node dissection in rhabdomyosarcoma have proven beneficial by significantly reducing postoperative complications and hospital stays compared to open methods. Innovative adjunct technologies such as indocyanine green (ICG) fluorescence imaging have further advanced MIS by providing superior visualisation of tumour margins, metastases and lymphatic structures, enhancing the precision and safety of procedures. Overall, the integration of MIS techniques, supported by advanced imaging methods like ICG, represents a significant advancement in paediatric oncology, offering reliable diagnostic and staging options with reduced patient morbidity. These approaches provide critical clinical advantages, positioning MIS as an essential component of contemporary paediatric surgical oncology practice.

The use of minimally invasive surgery (MIS) for the diagnosis and treatment of neurogenic tumours has markedly increased over the past decade, evolving from a diagnostic and staging tool to a therapeutic option in carefully selected cases. The advantages of MIS—reduced postoperative pain, shorter hospital stay, and faster recovery—must be weighed against its technical challenges, including limited operative space, loss of tactile feedback and increased risk when image-defined risk factors are present. This chapter reviews current evidence, outlines practical indications and contraindications and proposes structured guidelines for MIS in paediatric neurogenic tumours to assist surgeons in safe adoption while maintaining oncologic integrity.

Surgery is a corner stone of treatment in children with nephroblastoma. Over recent years, the evolution of surgical guidelines has added to the improvement of treatment results in affected children. Minimally invasive surgery (MIS) has been described as part of this evolution. The present article summarises the current recommendations for MIS in nephroblastoma based on the relevant global treatment protocols.

Minimally invasive surgical techniques are increasingly adopted for the management of hepatic masses in children. Laparoscopic liver biopsy can be used to obtain tissue diagnosis while avoiding the risks of open surgery and providing improved cosmesis. Laparoscopic or robotic liver resection has more gradually been adopted in children than in adults but can be utilized for appropriately located tumours as long as oncologic principles are maintained. Patient size is a factor when choosing whether to perform liver resection via a minimally invasive approach. Laparoscopic radiofrequency ablation offers an alternative strategy to surgery for paediatric patients with small masses or can serve as a bridge to transplant.

The role of minimally invasive surgery (MIS) in paediatric pulmonary metastasectomy is evolving, reflecting advances in imaging, localisation and instrumentation. Compared with thoracotomy, thoracoscopy offers benefits of reduced postoperative pain, shorter recovery and easier reoperation. However, limitations include anaesthetic challenges in smaller children and lack of manual palpation, which may miss subpleural nodules, which is particularly important in chemoresistant tumours such as osteosarcoma and nonrhabdomyosarcoma soft tissue sarcoma. MIS is most suitable for limited disease, peripheral nodules and histologies where complete manual exploration is unnecessary. Indications depend on tumour type, number and location of lesions, as well as patient stability and institutional expertise. Advances in nodule localization—such as wire or coil marking, fluorescence imaging and radiotracers—have improved thoracoscopic precision. Wedge resection remains preferred for peripheral nodules, with anatomic resection reserved for central or larger lesions. MIS contraindications include extensive disease, inability to tolerate single-lung ventilation or lack of required resources. Optimal outcomes depend on experienced multidisciplinary teams and readiness to convert to open surgery when needed. Overall, thoracoscopy is a safe, effective option in selected paediatric patients, providing therapeutic benefit while minimising morbidity when applied judiciously to tumour biology and disease extent.

The role of minimally invasive surgery (MIS) for ovarian neoplasms in paediatric patients depends on multiple factors. First, it is important to consider the risk of malignancy, which can be difficult to assess, especially in the setting of torsion. Second, when possible ovarian sparing surgery (OSS) should be performed. In certain settings MIS to perform OSS may carry a higher risk of tumour or cyst spillage. MIS can also play a role in diagnosis, via staging or biopsy. When performed, MIS can offer improved visualization of the contralateral ovary and other abdominal structures. Overall, MIS for ovarian neoplasms offers improved visualization of pelvic structures and decreased risk of adhesions in addition to the traditional benefits of MIS. However, these advantages should not supersede the need to achieve complete oncologic resection and to minimize the risk of capsule rupture.

The Role of Minimally Invasive Surgery (MIS) in Paediatric Mediastinal Masses and Thoracic Tumours. MIS has transformed paediatric surgical oncology. This chapter explores the pivotal role of MIS in managing thoracic and mediastinal tumours in children, emphasising diagnostic and therapeutic advancements. Video-assisted thoracoscopic surgery has demonstrated significant utility, allowing for precise tumour resections and reduced morbidity. The techniques' feasibility and efficacy are underscored across a range of tumour types, including thymic, neurogenic and germ cell tumours, with promising outcomes in both high-resource and low- and middle-income countries (LMICs). The chapter pretends to be a practical guide for surgeons treating children with mediastinal and thoracic tumours, describing types of neoplasms, diagnostic approaches and treatment principles and options, with particular focus on surgical nuances and intraoperative advice. Despite its benefits, the chapter highlights critical challenges, including the limitations posed by large, invasive tumours and resource constraints in LMICs. The role of MIS in pulmonary metastases, particularly in osteosarcoma, is also discussed, with a focus on the balance between minimally invasive approaches and open surgeries for complete resection. Key principles for patient selection, surgical planning and the integration of advanced imaging and technology are emphasised, aiming for optimal outcomes. The chapter also addresses contraindications, different surgical techniques, anaesthetic considerations and the importance of global collaboration to expand access to MIS. It concludes with a call for continued innovation and equitable distribution of minimally invasive technologies worldwide, ensuring that the benefits of these techniques are accessible to all children with cancer, irrespective of geographical and economic barriers.

Childhood cancers represent approximately 1% of all malignancies, with improved therapeutic strategies leading to an 80% long-term survival rate. However, these advancements come with potential long-term sequelae, among which fertility impairment is a major concern. Gonadotoxic treatments, including chemotherapy, radiotherapy and mutilating surgery, significantly impact reproductive potential, necessitating fertility preservation strategies. Minimally invasive surgery (MIS) plays a crucial role in preserving fertility in paediatric patients. Ovarian and genital tract-sparing surgery should be prioritised for benign ovarian tumours, which constitute 90% of childhood ovarian lesions, to avoid unnecessary loss of ovarian reserve. Ovarian transposition is recommended for patients requiring pelvic radiotherapy, relocating the ovaries outside the radiation field to mitigate ovarian damage. Additionally, uterine transposition has been explored to protect reproductive organs from radiation exposure. Ovarian tissue cryopreservation remains a promising option, particularly for prepubertal patients undergoing gonadotoxic treatments. Cryopreserved ovarian fragments can later be used for autografting or in vitro maturation, though the risk of malignant cell transmission remains a challenge. MIS contraindications are limited, primarily related to tumour size and the risk of rupture during laparoscopic procedures. A multidisciplinary approach involving oncologists, surgeons, radiotherapists and fertility specialists is essential for optimising outcomes. This chapter discusses the indications, techniques and challenges associated with MIS in fertility preservation, emphasising its role in ensuring reproductive potential while maintaining oncological safety in paediatric cancer patients.

The aim of this guidance is to discuss the advantages of utilising adjunct technologies in minimally invasive surgery and to mitigate risks associated with these technologies in paediatric cancer surgery.

A literature search was conducted, focusing on robotics, single-site and image-guided surgical approaches in paediatric cancer.

The findings indicate significant improvements in surgical precision, reduced morbidity and enhanced recovery times. Technologies such as robotics, single-site and image-guided surgical approaches have shown promising results in improving the precision of tumour resection.

Integrating advanced technologies into paediatric cancer surgery offers the potential for improved surgical outcomes and quality of life for patients. However, ongoing research and careful implementation are necessary to ensure safety and efficacy.

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Disclaimer

The document, IPSO-MIS Guidelines, and the information it contains are for authorised use by surgeons. IPSO cannot accept any liability and responsibility for any claims, loss or damage arising from the use of this document and its contents.

Contents

IPSO-MIS GUIDELINES

Abstract

Disclaimer

Contributing Authors

General principles of MIS in PSOThe role of MIS in Paediatric Cancer Diagnosis and StagingRole of MIS in neurogenic tumorsMIS in Paediatric NephroblastomaThe Role of MIS in the Management of Paediatric Liver TumorsRole of MIS in Paediatric Pulmonary Metastatic DiseaseOvarian Neoplasms-The Role of MISThe Role of MIS in Paediatric Mediastinal Masses and Thoracic TumoursRole of MIS in Fertility PreservationNew technologies in MIS in Childhood Cancer Surgery

General Principles of MIS in PSO 1

Introduction 1

Indications 2

Contraindications 3

Surgical Approach 4

Conclusions 4

The Role of MIS in Paediatric Cancer Diagnosis and Staging 6

Introduction 6

MIS Indication for Diagnosis and Staging 7

Summary of MIS Indications 8

Summary of MIS Contraindications 8

Surgical Approach 8

Conclusions 10

Role of MIS in Neurogenic Tumors 12

Introduction 12

Advantages and Disadvantages of MIS 13

Feasibility, safety and outcomes 13

Indications and contraindications 14

Robotic-assisted MIS 15

Surgical Approach 17

Conclusions 20

MIS in Paediatric Nephroblastoma 23

Introduction 23

Indications-contraindications 24

Surgical Approach 24

The Role of MIS in the Management of Paediatric Liver Tumors 27

Introduction 27

Minimally Invasive Procedures for Liver Biopsy 27

MIS for Liver Resection 28

MIS for Radiofrequency Ablation 32

Conclusions 34

Role of MIS in Paediatric Pulmonary Metastatic Disease 38

Introduction 38

MIS Indications 39

MIS Contraindications 39

Surgical Approach 40

Conclusions 41

Ovarian Neoplasms-The Role of MIS 43

Introduction 43

Indications for MIS 44

MIS Contraindications 45

Surgical Approach 45

Tips and Pitfalls 46

Conclusions 46

The Role of MIS in Paediatric Mediastinal Masses and Thoracic Tumours 50

Introduction 50

MIS Indications in Paediatric Solid Tumours 51

Feasibility and Outcomes of MIS in Mediastinal Tumours in Children 51

Feasibility and Outcomes of MIS in Paediatric Patients with Lung Metastases 52

Open versus thoracoscopic approach for pulmonary lesions in Osteosarcoma 53

MIS Contraindications 55

Surgical Approach 55

Outcomes in LMICs 59

MIS in Global Paediatric Surgical Oncology 59

Conclusions 59

Role of MIS in Fertility Preservation 62

Introduction 62

MIS Indications 64

MIS Contraindications 65

Surgical Approach 66

Ovarian Transposition 67

Ovarian Harvesting for Cryopreservation 67

Conclusions 68

New Technologies in MIS in Childhood Cancer Surgery 71

Introduction 71

Robotic-Assisted Surgery 72

Discussion 74

Conclusions 76

Contributing authors

1. General principles of MIS in PSO

1. Israel Fernandez-Pineda

Department of Paediatric Surgery, Children’s Health Ireland at Crumlin, Dublin D12 N512, Ireland

2. Simone de Campos Vieira Abib

Pediatric Oncology Institute, GRAACC, Federal University of São Paulo, São Paulo, SP 04021-001, Brazil

2. The role of MIS in Paediatric Cancer Diagnosis and Staging

1. Tristan Boam

Department of Paediatric Surgery, Children’s Health Ireland at Crumlin, Dublin D12 N512, Ireland

2. Diego Aspiazu Salinas

Department of Paediatric Surgery, Clínica San Felipe, Clinica Angloamericana, Clinica Internacional, Lima 15073, Perú

3. Role of MIS in Neurogenic Tumours

1. Samer Michael

Department of Paediatric Surgery, Hadassah University Medical Center, Kiryat Hadassah, Jerusalem 91120, Israel

2. Justin Ted Gerstle

Department of Surgery, Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10065, USA

4. MIS in Paediatric Nephroblastoma

1. Steven Warmann

Department of Pediatric Surgery and Pediatric Urology, Charité University Hospital Berlin, 13353 Berlin, Germany

2. Jorg Fuchs

Department of Pediatric Surgery and Pediatric Urology, University of Tuebingen, Tübingen 72076, Germany

5. The Role of MIS in the Management of Paediatric Liver Tumours

1. Alyssa Stetson

Division of Paediatric General and Thoracic Surgery, Cincinnati Children Hospital Medical Center, Cincinnati OH 45229, USA

2. Gloria Gonzalez

Department of Paediatric General and Thoracic Surgery, Cleveland Clinic Children's Hospital, Cleveland OH 44106, USA

3. Greg Tiao

Division of Paediatric General and Thoracic Surgery, Cincinnati Children Hospital Medical Center, Cincinnati OH 45229, USA

6. Role of MIS in Paediatric Pulmonary Disease

1. Timothy B. Lautz

Division of Paediatric Surgery, Ann & Robert H Lurie Children’s Hospital of Chicago, Chicago, IL 60611, USA

2. Rodrigo Chaves Ribeiro

Department of Paediatric Surgery. Children’s Cancer Hospital, Barretos Cancer Hospital, Barretos 14784058, Brazil

7. Ovarian Neoplasms-The Role of MIS

1. Alyssa Stetson

Division of Paediatric General and Thoracic Surgery, Cincinnati Children Hospital Medical Center, Cincinnati OH 45229, USA

2. Roshni Dasgupta

Division of Paediatric General and Thoracic Surgery, Cincinnati Children Hospital Medical Center, Cincinnati OH 45229, USA

8. The Role of MIS in Paediatric Mediastinal Masses and Thoracic Tumours

1. Jaime Shalkow-Klincovstein

ABC Cancer Center, Sur 136 No 116, Mexico City 01120, Mexico

2. Cristian Puerta

Division of Cardiothoracic Surgery, University of California, San Diego, 9300 Campus Point Drive, La Jolla, CA 92093, USA

3. Andrew M. Davidoff

Department of Surgery, St Jude Research Hospital 262 Danny Thomas Place. MS133, Memphis, TN 38105, USA

9. Role of MIS in Fertility Preservation

1. Marianna Cornet

Department of pediatric surgery, urology and transplantation, Necker Enfants-Malades Hospital, AP-HP, Paris, 75015, France

2. Julien Grosman

Department of pediatric surgery, urology and transplantation, Necker Enfants-Malades Hospital, AP-HP, Paris, 75015, France

3. Aurore Pire

Department of pediatric surgery, urology and transplantation, Necker Enfants-Malades Hospital, AP-HP, Paris, 75015, France

4. Sabine Sarnacki

Department of pediatric surgery, urology and transplantation, Necker Enfants-Malades Hospital, AP-HP, Paris, 75015, France

10. New Technologies in MIS in Childhood Cancer Surgery

1. Thomas Blanc

Department of pediatric surgery, urology and transplantation, Necker Enfants-Malades Hospital, AP-HP, Paris, 75015, France

2. Abdelhafeez H. Abdelhafeez

Division of Pediatric Surgery, Department of Surgery, Golisano Children's Hospital, Rochester, NY 14627, USA