Pediatric Laparoscopic Surgery Research Articles

Anesthetic considerations in pediatric laparoscopic and thoracoscopic surgery.

Minimally-invasive surgery does not equate with minimally-invasive anesthesia in children undergoing laparoscopic and thoracoscopic surgery. Knowledge of the associated pathophysiological changes, appropriate monitoring and good planning allow the safe provision of anesthesia for children subjected to these otherwise advantageous surgical techniques.

A new technique applicable to pediatric laparoscopic surgery: Abdominal wall ‘area lifting’ with subcutaneous wiring

Background: Recently, the authors developed a unique method of laparoscopic surgery without pneumoperitoneum: “area lifting of the abdominal wall with subcutaneous wiring.” Methods: In this gasless procedure, the anterior abdominal wall is pulled upward by a pair of wires placed subcutaneously and held by thick sutures for “hanger lifting.” Simultaneous lifting of a pair of subcutaneous wires across the abdomen, produces a wide, roof-shaped intraabdominal space sufficient for laparoscopic surgical procedures. The practical aspects of this gasless technique, as well as the authors' limited experience with this method in 24 children, ranging from 8 days to 15 years of age is presented. These children have had various pathologies including splenomegaly, rectal prolapse, ovarian cyst, gall stone, adrenal neuroblastoma, and abdominal wall abscess. Conclusions: Gasless laparoscopic surgery with double subcutaneous wiring is safe for children including neonates and those with respiratory compromise because all operative procedures are performed under normal abdominal pressure. Because of the highly elastic abdominal wall musculature inherent in children, this selective area lifting of abdominal wall creates a relatively larger peritoneal volume than in adults.

Trocar fixation during endoscopic surgery in infants and children.

The slipping of trocars is a major problem, especially in pediatric laparoscopic surgery. Although the suturing of a trocar, along with its valve housing, to the fascia or skin is common, this technique only serves to prevent the trocar from being pulled out. We have found that the simple procedure of winding a +/- 1-cm broad tape several times around the base of the trocar, which has been sutured to the fascia or skin, will prevent the trocar, from being pushed in, even during lengthy operations. The tape that we use is derived from sterile disposable drapes and is therefore not only readily available but also an inexpensive solution to a chronic problem.

Complications of pediatric laparoscopic surgery.

Surgical complications of laparoscopy most often occur during Veress needle or primary trocar placement. Veress needle punctures are insignificant and require no further treatment, whereas trocar-induced vascular injuries can be catastrophic. The frequency of vascular and viscus injuries is difficult to calculate because several complications are not reported in the literature. During a 10-year-period (1984-1995), at the Division of Pediatric Surgery at "Federico II" University of Naples, 430 laparoscopic procedures were performed in 395 children with a mean age of 5 years. The incidence of complications related to laparoscopy was 1.8% with eight complications, one of which was rather severe. The complications included one abdominal wall hematoma, two perforations of abdominal viscus (stomach, ovary), one umbilical scar complication, one postoperative hydrocele, one subcutaneous emphysema, and one pneumothorax during a Nissen procedure. The only severe complication occurred in a young girl with neurologic problems and a kyphoscoliosis operated on via laparoscopy for a gastroesophageal reflux. She suffered injuries of both right common iliac vessels and several intestinal perforations due to blind introduction of the first umbilical trocar. In this case rapid conversion, complex vascular reconstruction, and multiple intestinal sutures were performed. The Nissen fundoplication with pyloroplasty was performed traditionally and the patient left the hospital free of symptoms after 20 days. The other seven complications were resolved without any problem intra- or postoperatively. The authors believe that the open approach with a blunt trocar is most important in helping to avoid complications in pediatric laparoscopy.