Laparoscopic Portoenterostomy Research Articles

Prednisolone administration monitored by postoperative stool color achieves high jaundice clearance after laparoscopic portoenterostomy for biliary atresia.

Stool color (SC) for monitoring prednisolone use in biliary atresia (BA) patients after laparoscopic portoenterostomy (LPE) was reviewed. Subjects were 47 post-LPE BA patients given a reducing dose course of intravenous prednisolone. The course started at 4mg/kg/day and gradually reduced, ultimately reaching a final total dose (TD) of 31.5mg/kg. Normal SC indicated a course could progress until finished and was repeated until jaundice clearance (JC) was achieved. Abnormal SC persisting for two consecutive courses was the absolute indication for redo or liver transplantation (LTx). JC was achieved in 38/47 (80.9%) LPE cases and 4/6 redos to give an overall JC rate (JCR) of 42/47 (89.4%). Outcomes after one course (n = 5; JCR: 80.0%; median TD: 30.0mg/kg, interquartile range [IQR: 26.0-31.5]), two courses (n = 10; JCR: 90.0%; median TD: 62.5mg/kg [IQR: 60.8-66.0]), three courses (n = 13; JCR: 92.3%; median TD: 90.0mg/kg [IQR: 86.0-90.0]), four courses (n = 10; JCR: 80.0%; median TD: 120.0mg/kg [IQR: 116.7-123.3]), five courses (n = 7; JCR: 100%; median TD: 156.0mg/kg [IQR: 154.3-157.5]), six courses (n = 1; JCR: 100%; TD: 189.0mg/kg), ten courses (n = 1; JCR: 100%; TD: 308mg/kg). Indications for repeat prednisolone and timing of redo/LTx based on SC monitoring appeared effective based on high JCR and successful redo/LTx. III.

Laparoscopic versus open portoenterostomy for treatment of biliary atresia: a meta-analysis.

Our goal was to compare laparoscopic portoenterostomy versus open portoenterostomy for the treatment of biliary atresia. Using the databases EMBASE, PubMed, and Cochrane, we carried out a thorough literature search up to 2022. Studies comparing laparoscopic and open surgery for the treatment of biliary atresia were included. Twenty-three studies comparing laparoscopic portoenterostomy (LPE) (n = 689) and open portoenterostomy (OPE) (n = 818) were considered appropriate for meta-analysis. Age at surgery time was lower in the LPE group than OPE group (I2 = 84%), (WMD -4.70, 95% CI -9.14 to -0.26; P = 0.04). Significantly decreased blood loss (I2 = 94%), (WMD -17.85, 95% CI -23.67 to -12.02; P < 0.00001) and time to feed were found in the laparoscopic group (I2 = 97%), (WMD -2.88, 95% CI -4.71 to -1.04; P = 0.002). Significantly decreased operative time was found in the open group (I2 = 85%), (WMD 32.52, 95% CI 15.65-49.39; P = 0.0002). Weight, transfusion rate, overall complication rate, cholangitis, time to drain removal, length of stay, jaundice clearance, and two-year transplant-free survival were not significantly different across the groups. Laparoscopic portoenterostomy provides advantages regarding operative bleeding and the time to begin feeding. No differences in remain characteristics. Based on the data presented to us by this meta-analysis, LPE is not superior to OPE in terms of overall results.

Adding a spur valve to laparoscopic portoenterostomy for patients with biliary atresia can achieve a high jaundice clearance rate and lower the number of episodes of cholangitis

This study aimed to evaluate the efficacy of adding a spur valve to laparoscopic portoenterostomy for patients with biliary atresia. We retrospectively reviewed the records of all patients diagnosed with biliary atresia (BA) who underwent laparoscopic portoenterostomy (Lap-PE) between 2013 and 2021. The patients were divided into two groups: Lap-PE with a spur valve (spur group) and without it (control group). Perioperative management was the same in both groups. We compared patient backgrounds and clinical outcomes, including jaundice clearance and the number of postoperative cholangitis episodes. Of 63 patients reviewed, 16 received a spur valve. There were no statistically significant differences in the patient backgrounds between the groups. All patients in the spur group achieved jaundice clearance. The number of postoperative cholangitis episodes one year after surgery was significantly lower in the spur group than in the control group (1 [0-3] vs. 3 [0-9], p = 0.04). The jaundice-free survival rate with the native liver at one year after surgery was significantly higher in the spur group (100% vs. 53%, p = 0.01). Adding a spur valve during Lap-PE significantly lowered the number of cholangitis episodes 1year after surgery.

Laparoscopic revision of Kasai portoenterostomy after initial laparoscopic portoenterostomy in patients with biliary atresia: a limited but positive effect on native liver survival.

It is important for patients with biliary atresia (BA) to retain the native liver after Kasai portoenterostomy (PE). Laparoscopic PE (Lap-PE) is standard, whereas laparoscopic revision of PE (Lap-revision) is performed as needed. We report the medium-term outcomes of Lap-revision. We retrospectively reviewed the demographics and outcomes of 63 patients who underwent Lap-PE between 2013 and 2021. Indications for revision included recurrent jaundice, repeat cholangitis, and persistent jaundice with temporary biliary excretion following the initial PE. We compared liver transplantation (LT) data of patients who underwent Lap-revision with those of patients who did not. Lap-revision was performed in 20 patients. Of those 17 (excluding the two who were jaundice-free before the age of 1, and the one who underwent open conversion for bleeding), 11 (65%) were jaundice-free 1year after Lap-revision. The surgical parameters of LT did not differ between patients who underwent Lap-revision and those who did not. Lap-revision for patients with BA had a limited but positive effect on native liver survival and did not adversely affect subsequent LT. Therefore, Lap-revision could be second-line standard therapy in patients with BA who have demonstrated biliary drainage at least once after initial PE.

Laparoscopic Kasai portoenterostomy can be a standard surgical procedure for treatment of biliary atresia.

BACKGROUNDBiliary atresia (BA) is a rare pediatric disease.AIMTo compare the outcomes of laparoscopic portoenterostomy (Lap-PE) with those of laparotomy (Open-PE) at a single institution. METHODSThe surgical outcomes of PE were retrospectively analyzed for patients with a non-correctable type of BA from 2003 to 2020.RESULTSThroughout the assessment period, 119 patients received PE for BA treatment, including 66 Open-PE and 53 Lap-PE cases. Although the operation duration was longer (medians: for Open-PE, 242 min; for Lap-PE, 341 min; P < 0.001), blood loss was considerably less (medians: for Open-PE, 52 mL; for Lap-PE, 24 mL; P < 0.001) in the Lap-PE group than in the Open-PE group. The postoperative recovery of the Lap-PE group was more favorable; specifically, both times to resume oral intake and drain removal were significantly shorter in the Lap-PE group. Complete resolution of jaundice was observed in 45 Open-PE cases and 42 Lap-PE cases, with no statistically significant difference (P = 0.176). Native liver survival rates were >80% for both groups for the first half year post surgery, followed by a gradual decrease with time; there were no statistically significant differences in the native liver survival rates for any durations assessed.CONCLUSIONLap-PE could be a standard therapy for BA.

Laparoscopic vs open portoenterostomy in biliary atresia: a systematic review and meta-analysis.

Hepatoportoenterostomy remains the cornerstone of treatment for biliary atresia. Current employed techniques include laparoscopy and open surgery. This study aims to determine if either method provides an advantage. Following PRISMA guidelines, a systematic review was conducted. Nineteen studies were included. Mean operative time 34.98 (95% CI 20.10, 49.85; p ≤ 0.00001) was longer in laparoscopic while bleeding volumes -16.63 (95% CI -23.39, -9.86; p ≤ 0.00001) as well as the time to normal diet -2.42 (95% CI -4.51, -0.32; p = 0.02) were lower in the laparoscopic group. No differences were observed in mean length of stay -0.83. Similar complication, transfusions, postoperative cholangitis 0.97, and transplant free survival rates 1.00 (0.63, 1.60; p = 0.99) were seen between groups. Laparoscopic portoenterostomy provides advantages on operative time and bleeding as well as to normal diet when compared to open procedures. Both procedures showed no differences in length of stay, complications, cholangitis, and importantly, native liver survival. Level of evidence: III.

Advantage of Using 8K Ultra-High-Definition Television System for Kasai Portoenterostomy for Biliary Atresia

Kasai portoenterostomy (KPE) is currently the first-line treatment for biliary atresia. Many pediatric surgeons have reported that the dissection of the fibrous remnant at the porta hepatis is one of the most important components of this procedure. Furthermore, laparoscopic portoenterostomy is being increasingly used to treat biliary atresia.An advantage of laparoscopic surgery is that surgeons can more easily identify microbiliary ducts, owing to the magnification. We report the case of a 61-day-old girl on whom we performed an exploratory laparotomy and diagnosed type III biliary atresia using intraoperative cholangiography. For the first time, we performed an open KPE using an 8K ultra-high-definition television system. This allowed us to clearly view the porta hepatis and to successfully perform the portoenterostomy.

Modifications to Expose Porta Hepatis for Laparoscopic Portoenterostomy Easier in Biliary Atresia

BackgroundLaparoscopic Kasai portoenterostomy (LKPE) is generally regarded to have a poorer outcome for surgical treatment of uncorrectable biliary atresia. We herein described our initial experience of some modifications to make LKPE easier in the treatment of type III biliary atresia (BA). MethodsDuring the period July 2012-October 2016, a total of 25 infants with type III BA were treated with a modified LKPE technique. A percutaneous suture was introduced just below the xiphoid process to snare the round ligament and retract the liver; other percutaneous stay sutures were then introduced to the fundus and neck of the gallbladder to elevate the liver and expose the porta hepatis. In 15 cases, part of the hepatic lobus quadratus was removed laparoscopically to expose the porta hepatis. The two elastic rubber bands were put around the portal vein and hepatic artery, and the porta hepatis was exposed by stretching the two rubber bands laterally to facilitate laparoscopic portoenterostomy. ResultsPatients were divided into two groups according to their ages at operation: group I: age between 30 and 75 days (n = 18), and group II: age between 76 and 85 days (n = 8). There were no operative deaths, but two patients died of repeated cholangitis and liver failure. Blood loss during operation was minimal and no blood transfusions were required. Operating times varied from 210 to 270 min (mean 232.4 ± 19.0 min). Among the two groups, there were no differences in blood loss (P > 0.05), but there were differences in operating time (P < 0.05). All patients survived the surgery without any intraoperative complications, and the median follow-up time was 25.3 months. Total bilirubin dropped to normal in 18 patients with an additional 5 patients showing a significant overall drop after surgery. ConclusionsWith the original concepts of Kasai portoenterostomy, perfect laparoscopic skills and some key modifications to expose the porta hepatis, our LKPE can be performed safely and successfully with improved outcome for infants with type III BA.

Laparoscopic portoenterostomy for biliary atresia: single-center experience and review of literatures.

The aim of this report was to present the laparoscopic portoenterostomy (LapPE) procedure developed by the Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine (JLapPE). We also attempted to obtain an understanding of the current status of laparoscopic portoenterostomy in the world as reported in the English literature to compare with our experience. There were 22 BA patients who had JLapPE between 2009 and 2016. BA classification was type III (n = 19) and type II (n = 3). There was 1 case of syndromic BA and 1 case was positive for cytomegalovirus. A systematic search in PubMed of all BA patients treated by LapPE in the English literature was conducted. Jaundice clearance (JC) and survival with the native liver (SNL) were compared. Mean age at JLapPE was 67.1days (range 29-119). Mean postoperative follow-up was 4.6years (1.3-8.3). Mean operative time was 514min (240-662) and mean blood loss was 13.4g (3-21). Postoperative JC (Total bilirubin ≤ 1.5mg/dL) was 77.3% (17/22) at 3months and 90.9% (20/22) at 6months. SNL at 6months of age was 90.9% (20/22); at 1year of age was 77.3% (17/22), at 2years of age was 73.7% (14/19); and at 3years of age was 81.3% (13/16). Despite recent reports that outcome of LapPE for BA may be unfavorable compared with the conventional open portoenterostomy, our results would suggest that JLapPE can be performed successfully, because it is performed exactingly according to a standard protocol. JLapPE will continue to be our procedure of choice for treating BA.

Biliary Atresia: Laparoscopic Kasai Portoenterostomy

Introduction: Biliary atresia is an obliterating disease of the extrahepatic biliary system that must be corrected surgically through a hepatoportoenterostomy. This procedure was developed by Dr. Morio Kasai in the 1950s and was classically performed as an open surgery.1 In 2002, the first laparoscopic portoenterostomy was reported.2 This approach is described in this video. Materials and Methods: This video shows a laparoscopic Kasai procedure done in a 6-week-old female infant who presented with jaundice and acholic stools. A 10 mm trocar was introduced into the scar of the umbilicus using a modified Hasson technique. Pneumoperitoneum was established using 5 L/min of carbon dioxide under 10 mm Hg of pressure. A 30° telescope camera was inserted into the peritoneal cavity for proper observation. Two 3 mm ports were placed in the right side of the abdomen, whereas 3 and 5 mm ports were placed in the left side. The atretic gallbladder was observed. The grasper was used to retract the fundus of the gallbladder while the area was dissected with hook diathermy. The lymph node at the neck of the gallbladder was dissected and removed so the cystic duct could be followed to its entry into the common bile duct. The atretic gallbladder was then released from the liver bed and used as a retractor while the atretic common bile duct was dissected out to the point it entered the duodenum and divided at its lowest point of entry. The area beneath the duct was further dissected up to the portal plate and carried out on either side until we identified the first branch of the right hepatic artery on the right side and the umbilical point on the left side (where the umbilical vein enters the left branch of the portal vein). The atretic common hepatic duct was excised flat with the liver. Bile was observed flowing from the cut surface. Next, the ligament of Treitz was identified. The small bowel was followed distally to a length of ~25 cm. A 25 cm Roux-en-Y loop was constructed extracorporally after pulling the bowel out through the umbilical incision, then reduced back into the peritoneal cavity. A window was made behind the colon so the Roux limb could be placed in a retrocolic direction. Anastomosis of the Roux limb was then made with the biliary plate. The defect in the colon mesentery was closed, the peritoneal cavity was desufflated, and ports were withdrawn and closed with 2-0 vicryl on UR-6 needles. The skin was reapproximated with Dermabond glue. Total operative time was ~4.5 hours. Results and Conclusions: There were no postoperative complications. The patient started to tolerate oral feeds on post-operative day #4 and was discharged on post-operative day #7 after passing yellow stools. At her 3-month follow-up visit, she was tolerating feeds and passing yellow stools and had normal liver laboratories with a decrease in conjugated bilirubin from 6.6 to 1.8 mg/dL. No competing financial interests exist. Runtime of video: 5 mins 26 secs

Comprehensive assessment of prognosis after laparoscopic portoenterostomy for biliary atresia.

Total bilirubin (T-bil) is used universally for monitoring post-portoenterostomy (PE) biliary atresia (BA) patients although other biochemical markers [BM; AST/ALT and platelet count (PC)] are also prognostic. We compared open PE (OPE) with laparoscopic PE (LPE) using T-bil, AST/ALT, and PC (3BM) as more comprehensive indicators of postoperative clinical status. Subjects were 31 PE cases (LPE: n=17; OPE: n=14). BA classification was type III (n=16), type II (n=1) in LPE and type III (n=12), type I (n=1), type II (n=1) in OPE. Mean ages and weights at PE were similar: 65.5days, 4.4kg (LPE) versus 69.3days, 4.1kg (OPE); and mean follow-up was 2.5years for both LPE and OPE. Jaundice clearance (T-bil ≤1.2mg/dL) was achieved in 16/17 (94.1%) after LPE versus 10/14 (71.4%) after OPE (p=NS), but 3BM were closer to normal after OPE. At the time of review, 13/17 LPE cases (76.5%) were alive with native livers and 4/17 had received LTx (23.5%) and 10/14 OPE cases (71.4%) were alive with native livers and 4/14 had received LTx (28.6%). Although JC was better after LPE, 3BM were better after OPE. Further follow-up will prove the comprehensive prognostic value of 3BM.

Does pneumoperitoneum adversely affect growth, development and liver function in biliary atresia patients after laparoscopic portoenterostomy?

We assessed the effect of high partial pressure of arterial carbon dioxide (PaCO2) due to pneumoperitoneum (PP) on growth (height/weight) and development (gross/fine motor function, receptive/expressive communication, and social interaction), by comparing outcome after portoenterostomy (PE) for biliary atresia (BA) using laparoscopic PE (LPE: n = 13) and open PE (OPE: n = 13) cases performed between 2005 and 2014. Our PE is based on Kasai's original PE. All data were collated prospectively. Differences in duration of follow-up (LPE: 38.8 months; OPE: 38.1 months), jaundice clearance (LPE: 12/13 = 92.3 %; OPE: 9/13 = 69.2 %), survival with the native liver (LPE: 10/13 = 76.9 %; OPE: 9/13 = 69.2 %), incidence of cholangitis, hypersplenism, and incidence of esophageal varices were not significant. Mean intraoperative PaCO2 was significantly higher in LPE (LPE: 50.1 mmHg; OPE: 40.7 mmHg, p < 0.05). Liver function impairment was not statistically different, although LPE results were slightly worse. There was no overall delay in growth observed, although height/weight gain was more consistent in LPE. The pattern of developmental delay observed was similar for LPE and OPE suggesting that developmental delay is not PE-related; in other words, PP is not implicated in developmental delay. PP during LPE would appear to have no adverse effects on overall growth/development and liver function in BA patients.

From laparoscopic to open Kasai portoenterostomy: the outcome after reintroduction of open Kasai portoenterostomy in infant with biliary atresia

Apparently superior result was observed after open Kasai portoenterostomy in infant with biliary atresia. Our institute stopped performing laparoscopic portoenterostomy since 2007. We aimed to investigate the outcome after reintroduction of open portoenterostomy. 27 non-syndromic infants underwent open Kasai portoenterostomy from 2007 to 2012. The age and the sex of the patient, the bilirubin level before the operation, the early clearance of jaundice (total bilirubin <20 μmol/L within 6 month of portoenterostomy), the native liver survival at 2 years after the operation were reviewed. The results were retrospectively compared with all 16 infants who underwent laparoscopic Kasai portoenterostomy before 2007. All infants had type III biliary atresia. No statistical difference was observed regarding the age at operation and the pre-operative bilirubin level. The early clearance of jaundice rate was 81% (22/27) after open operation and was 50% (8/16) after laparoscopic operation (p = 0.03). At 2 years after the operation, the native liver survival was 81% (22/27) after open operation and was 50% (8/16) after laparoscopic operation (p = 0.03). Reintroduction of open Kasai portoenterostomy was associated with superior early clearance of jaundice rate and 2-year native liver survival rate.

The Experience and Technique in Laparoscopic Portoenterostomy for Biliary Atresia

The laparoscopic Kasai operation has been under debate for a long time. In this study, we described our experience in laparoscopic portoenterostomy for biliary atresia The operative experience in 25 cases of laparoscopic portoenterostomy for biliary atresia since January 2011 was reviewed. For the procedure, operative cholangiography was first performed for diagnosis. Laparoscopic Kasai portoenterostomy was performed as in the open manner. Electrocoagulation hemostasis was avoided at the porta, where bleeding was controlled with direct compression only. The Roux loop was fashioned outside of the abdominal cavity through the umbilical incision, and portoenterostomy was performed with absorbable sutures. All cases underwent the operation successfully without conversion to open surgery. The average time of operation was 180-285 minutes (mean, 208 minutes), and the blood loss was 15-30 mL. Twenty-two (88%) patients had bile drainage postoperatively as indicated by their stool color. Jaundice was alleviated in 21 (84%) patients, with total bilirubin decreased by a third. Follow-up extended from 3 months to 2 years after the operation. Jaundice had completely subsided in 14 (56%) cases, with a normal level of bilirubin. Seven patients had an initial decrease in bilirubin, but jaundice returned because of cholangitis. Two patients died because their parents refused liver transplantation. Two cases underwent successful liver transplants. Laparoscopic portoenterostomy for biliary atresia is safe and feasible. It has the advantage of clearer vision, precise operation, and less operative trauma. In our experience, the outcome of this surgery is as good as open surgery if the surgeons are well experienced.

Laparoscopic Kasai portoenterostomy for biliary atresia

Minimally invasive surgery requires mastery of complex skills and exhaustive knowledge of anatomic variations but the patient benefits from excellent cosmesis, less requirement for analgesia and respiratory support, and a reduced incidence of postoperative morbidity, such as bowel adhesions and incisional hernias. Laparoscopic portoenterostomy is being performed with encouraging results after the open extended portoenterostomy procedure currently performed was revised to more closely resemble the original procedure developed by Kasai in the 1950s. Thus, the risk for damage to micro bile ducts around the porta hepatis is minimized because deep suturing and extensive dissection are eliminated.

Laparoscopic versus open Kasai portoenterostomy in infant with biliary atresia: a retrospective review on the 5-year native liver survival

Laparoscopic Kasai portoenterostomy was reported to be a safe and feasible procedure in infant with biliary atresia. We aimed to investigate the long-term results after laparoscopic portoenterostomy as such data in the literature are lacking. Sixteen infants underwent laparoscopic Kasai portoenterostomy from 2002 to 2006. The age and the sex of the patient, the bilirubin level before the operation, the early clearance of jaundice (total bilirubin <20 μmol/L within 6 months of portoenterostomy), the native liver survival at 2 and 5 years after the operation were reviewed. The results were retrospectively compared with 16 consecutive infants who underwent open Kasai portoenterostomy before 2002. All infants had type III biliary atresia. The early clearance of jaundice rate at 6 months was 50 % (8/16) after laparoscopic operation and was 75 % (12/16) after open operation (p = 0.144). Two years after the operation, the native liver survival was 50 % (8/16) in the laparoscopic group and was 81 % (13/16) in the open group (p = 0.076). Five years after the operation, the native liver survival rate was 50 % (8/16) in the laparoscopic group and was 81 % (13/16) in the open group (p = 0.076). The jaundice-free native liver survival rate at 5 years was 50 % (8/16) in laparoscopic group and was 75 % (12/16) in the open group. In the laparoscopic group, all patients with early clearance of jaundice survived and remained jaundice freed 5 years after the operation. The 5-year native liver survival rate after laparoscopic portoenterostomy was 50 %. Apparently superior result was observed in the open group (81 %) although the figures did not reach statistical difference because of the small sample size. A larger scale study is required to draw a more meaningful conclusion.

The outcome of laparoscopic portoenterostomy for biliary atresia in children

There were only a few reports on laparoscopic portoenterostomy for biliary atresia in children. We report our experience on laparoscopic Kasai operation for biliary atresia. A retrospective review of all children who had biliary atresia underwent laparoscopic portoenterostomy from January 2002 to September 2006 were included and analyzed. Sixteen children (five boys and eleven girls) with a mean age of 66 days (range 47-106 days) at operation were included in this study. All patients had type III biliary atresia. There was no conversion to open procedure. The operative time ranged from 193 to 435 min (mean 292 min). At a median follow-up of 72 months (range 33-89 months), eight patients were free of jaundice with bilirubin level <20 μmol/L and did not require liver transplantation. Seven patients underwent liver transplantation. One patient who had persistent elevated bilirubin defaulted follow-up. One patient complicated with volvulus of intestine post-operatively. All patients survived except one patient who had combined liver and intestine transplantation. Laparoscopic portoenterostomy in children with biliary atresia is technically feasible. 50% of children who had type III biliary atresia were free of jaundice and did not require liver transplantation. A longer follow-up is required to assess the long-term outcome.

Early outcomes of laparoscopic surgery for biliary atresia

Aim The aim of the study was to present early outcomes of the laparoscopic technique for biliary atresia with some technical modifications. Materials and Methods We reviewed charts of all patients with biliary atresia who underwent laparoscopic portoenterostomy from July to December 2008. There were 11 patients with biliary atresia, including 5 boys and 6 girls. The operation was carried out using 4 trocars. The liver was elevated by 2 transcutaneous stay sutures: one on the round ligament and the other on the gallbladder remnant. The left and right hepatic arteries and portal veins were dissected and retracted laterally by 2 transcutaneous sutures to expose the liver hilum. A stay suture was placed on fibrotic tissue at the liver hilum to facilitate its maximal removal. A jejunal end-to-side anastomosis was constructed extracorporeally. Portoenterostomy was carried out laparoscopically. Results Mean operative time was 245 ± 31 minutes. No patient required conversion. There were no operative deaths. Blood loss during operation was minimal. One patient died on day 65 after operation because of intractable hepatic liver. Follow-up after discharge from 10 to 16 months revealed that 6 patients still survived and 4 patients died. One patient died because of milk aspiration at 12 months of age. Three patients died because of repeated cholangitis and liver failure at 10, 10, and 14 months, respectively. Conclusion With a modified laparoscopic technique, good early outcomes of laparoscopic surgery for biliary atresia were achieved.

Minimal Access Surgery in the Neonate

After completing this article, readers should be able to: 1. Review physiologic, anatomic, and technical issues related to minimal access surgery in the neonate. 2. Describe conditions in which minimal access surgery can be used in neonates. Historically, pediatric surgeons were slow to adapt to minimal access surgery (MAS) techniques compared with the adult surgical community. However, MAS now is widely established in infants and children. Differences in size and physiology have necessitated a number of surgical and technological modifications to apply MAS techniques to this population. This review outlines the important differences between children and adults with respect to MAS and provides examples of the use of MAS for diseases seen in infants. ### Physiologic Issues The physiologic response to pneumoperitoneum in children is more pronounced than in adults. Peritoneal insufflation with carbon dioxide has been shown to cause hypercarbia, acidemia, and decreased oxygenation in the pediatric piglet model. (1) In infants, however, there is no detrimental effect on blood pressure, heart rate, or oxygen saturation during short periods of pneumoperitoneum, and elevations in end-tidal CO2 can be counteracted readily by increasing the minute ventilation. (2) Hypercarbia-induced pneumoperitoneum in infants is associated with changes in cerebral blood flow and cardiac output. Nevertheless, laparoscopic procedures have been performed safely with proper anesthetic management in children who have even severe congenital cardiac abnormalities such as hypoplastic left heart syndrome. (3) Hypothermia also can be a concern due to rapid insufflation of unwarmed CO2 gas, mandating the moderation of flow rates. (4) ### Anatomic Issues A number of anatomic factors set children apart from adults and must be accounted for when performing laparoscopic surgery in this age group. Young children and infants have thinner abdominal walls than adults, so extreme care must be exercised when placing trocars. Due to the small size of the abdomen, the working …