laparoscopy in children

The ten commonest laparoscopic procedures, indecreasing order of frequency, performed in theDepartment of Paediatric Surgery and Urology atBirmingham Children’s Hospital between April 2008and March 2009 were:

C Gastrostomy

C Fundoplication

C Nephrectomy

C Partial nephrectomy

C Cholecystectomy

C Appendicectomy

C Splenectomy

C Orchidopexy for intra-abdominal testes

C Pyeloplasty

C Palomo procedure for varicocele

PAEDIATRIC SURGERY I

Laparoscopy in childrenJonathan Wells

Girish Jawaheer

AbstractTechnological advances combined with increasing surgical and anaes-

thetic expertise have broadened the range of laparoscopic procedures

presently being undertaken in children, from the neonatal period through

to adolescence. It is therefore essential for surgeons undertaking laparo-

scopic procedures in children to be equipped not only with technical

knowledge, but also to be familiar with the basic science which underpins

this practice. In this article, emphasis is placed upon physiology, anatom-

ical landmarks, the evidence base for laparoscopic procedures in children

and the mode of action of commonly used energy sources.

Keywords Anatomy; children; energy sources; laparoscopy; physiology;

pneumoperitoneum

Introduction

Increasing public awareness of the advantages of laparoscopy

such as cosmesis, reduced pain and shortened hospital stay is

driving demand. It is anticipated that an increasing range and

number of laparoscopic procedures will be performed in children

by more surgeons. This trend is reflected in the senior author’s

personal practice where the number of laparoscopic cases per-

formed has increased as shown in Figure 1. Training in laparo-

scopic surgery typically comprises exposure to operative steps in

a simulated or clinical environment. Often lacking is an under-

standing of the scientific basis of laparoscopic surgery. This

article emphasizes the fundamental principles rather than the

minutiae of the operations detailed in standard texts.

History

In1901,Kelling,agastroenterologist fromDresdenperformed thefirst

laparoscopicprocedureby insufflatingair into theabdomenofa living

dog and using a paediatric cystoscope to visualize the contents of the

peritoneal cavity. The chronology of innovative laparoscopic proce-

dures introduced subsequently is shown in Table 1.

The ‘laparoscopic stacking system’ in use today owes its

existence to several technological advances which are indicated

in Figure 2. It should be emphasized that one of the most

significant advances was the development of the three-chip

charged couple device (CCD) camera in 1985. Prior to this,

Jonathan Wells BMedSci MRCS is a Specialist Registrar in Paediatric

Surgery at Birmingham Children’s Hospital, Birmingham, UK. Conflicts

of interest: none.

Girish Jawaheer MD FRCS(Eng) FRCS(Paed) is a Consultant Paediatric

Surgeon at Birmingham Children’s Hospital, Birmingham, UK and is the

Lead for Laparoscopic Surgery. Conflicts of interest: none.

SURGERY 28:1 27

laparoscopy was essentially a diagnostic tool as the surgeon had

to hold the scope with one hand and look down it. Within 6 years

of this development, the majority of the now commonly per-

formed procedures had been introduced as shown in Table 1.

Laparoscopic procedures in children

In the senior author’s personal practice, 12% of procedures are

diagnostic. The commonest diagnostic procedure is laparoscopy

for impalpable testis. Twenty-two percent of therapeutic proce-

dures are performed on an emergency basis. The commonest

emergency procedure is appendicectomy. A study of all appen-

dicectomies performed in children in English NHS trusts between

1996 and 2006 showed that the percentage of laparoscopic cases

rose from 0.6% to 8.4%.

Evidence base for laparoscopic procedures

The best evidence comes from randomized controlled trials,

meta-analyses and systematic reviews. Thus far, the only lapa-

roscopic procedures assessed in this manner in children are:

� Pyloromyotomy for pyloric stenosis; the laparoscopic

approach is associated with a faster time to full enteral feeds

and a slightly shorter hospital stay, but more pyloromyoto-

mies may be inadequate. The adequacy of the myotomy as

a primary outcome measure has not been studied.

� Appendicectomy; one trial reported less pain and shortened

hospital stay and another reported no difference when

compared with the open approach.

� Palomo procedure for varicocele with mass ligation of

testicular artery and veins in the retroperitoneum with

sparing of lymphatics. The laparoscopic approach was asso-

ciated with superior outcomes. In addition, lymphatic sparing

is associated with a lower incidence of hydrocele formation.

� Inguinal herniotomy. Recurrence rate was not studied. One

trial found the laparoscopic approach to be associated with

less pain, faster recovery and better satisfaction with cosm-

esis, whereas another trial reported increased operating time

and more pain in the laparoscopic group.

� 2010 Elsevier Ltd. All rights reserved.

There has been a trend towards an increased number of procedures being performed in children in recent years

Year

Nu

mb

er

of

the

rap

eu

tic

pro

ced

ure

s

90

80

70

60

50

2003 2004 2005 2006 2007 20080

40

30

20

10

Figure 1


Anatomical landmarks

The introduction of the laparoscope into the child’s insufflated

abdomen offers the surgeon a view which is markedly different

to that seen at open surgery. In neonates and infants, the peri-

toneal cavity is small and in children with adhesions, the

anatomy may be confusing. It is therefore mandatory for the

surgeon to be familiar with anatomical landmarks in order to

practise safe surgery (Figures 3 and 4).

Physiology of laparoscopy

Patient homeostasis is influenced by three factors which are

intrinsic to the laparoscopic technique:

The chronology of innovation in laparoscopy

Year Innovation Name

1910 First publication

of a clinical

series of laparoscopic cases

Jacobeus

1976 Diagnosis of an undescended

intra-abdominal testis

Cortesi

1983 Gynaecologist performs

first appendicectomy

Semm

1985 Cholecystectomy Muhe

1991 Nissen fundoplication Dallemagne

1991 Splenectomy Delaitre

1991 Nephrectomy Clayman

1991 Laparoscopic-assisted colectomy Jacobs & Sclinkert

1992 Adrenalectomy Gagner

Table 1

SURGERY 28:1 28

1. Hypercarbia, resulting from the presence of carbon dioxide

(CO2) within the peritoneal cavity

2. Positive pressure pneumoperitoneum

3. Changes in patient position.

Hypercarbia

Hypercarbia causes:

� Myocardial depression, which leads to a decrease in stroke

volume and cardiac output.

� A reflex systemic vasodilatation causing raised intracranial

pressure (ICP) which triggers a neuro-endocrine mechanism

resulting in catecholamine release, systemic vasoconstriction

and hypertension.

� Impaired macrophage function within the peritoneal cavity.

Positive pressure pneumoperitoneum

In children, insufflation pressures of 5e15 mmHg are generally

used and the principle is to use the lowest pressure which allows

the procedure to be completed safely. The effects are manifested

in several systems:

Cardiovascular: the cardiovascular changes are similar to those

observed in adults (Figure 5) with one exception, namely

a reduction in cardiac preload in children.

Respiratory: raised intra-abdominal pressure (IAP) causes

splinting of the diaphragm, decreased lung expansion and

compliance and reduced vital capacity and functional residual

volume. As a result, CO2 elimination is impaired and respiratory

acidosis ensues.

Renal: acute transient oliguria is noted in healthy subjects but

may result in acute renal failure in patients with impaired renal

function.

Endocrine: a neuro-endocrine stress response has been demon-

strated in adults undergoing laparoscopic and open procedures.

An increase in adrenocorticotropic hormone (ACTH), cortisol,

norepinephrine, epinephrine, insulin and glucose concentration

is seen in both sets of patients, but in the laparoscopic group

levels return to normal sooner. The increase in antidiuretic

hormone seen after laparoscopic cholecystectomy is not seen

after open cholecystectomy.

Metabolic: an increase in metabolic rate, as measured by

increased oxygen consumption and core temperature, has been

observed in children undergoing laparoscopy. The younger the

child, the more marked the effect and this observation was

absent in children having open procedures and in adults under-

going laparoscopic surgery.

Immune function: in a randomized controlled trial comparing

the inflammatory responses following open and laparoscopic

fundoplication in children, no differences were found between

the two groups.

Splanchnic blood flow: a reduction in splanchnic blood flow is

reported. This is relevant for the surgeon contemplating


Cold light, introduced byForestier in 1952 reduces risk ofintraperitoneal burns

Automated insufflationdevice introduced bySemm, 1970s

Hopkins introduced fibre-optictechnology in 1953. It doubled light-carrying capacity of laparoscope

Charge- coupled devicethree-chip camera invented in 1985

Figure 2 Technological advances which have contributed to the modern-day laparoscopic stacking system.


a laparoscopic procedure in a child with a compromised

mesenteric circulation. Laparoscopy has been described in infants

with necrotizing enterocolitis (NEC), but this may not be

appropriate.

Peritoneal fluid resorption: peritoneal fluid is currently believed to

be absorbed through stomata situated between the lateral borders of

peritoneal mesothelial cells. It then enters the lymphatic system and

reaches the blood stream through the thoracic duct. Raising IAP

Figure 3 Anatomical landmarks in the lower abdomen.

SURGERY 28:1 29

increases the surface area of the peritoneum and increases the

pressure gradient, both of which increase the absorption of fluid. In

the presence of intra-abdominal infection, it is postulated that

increased absorption of bacteria and toxins from the peritoneum

may predispose to an increased risk of bacteraemia and sepsis.

Changes in patient position

The Trendelenberg position is often used in lower abdominal and

pelvic surgery. Its effects are:

Figure 4 Anatomical landmarks in the upper abdomen.



� Decreased lung expansion and atelectasis at lung bases.

� Promotion of regurgitation, especially in children with gastro-

oesophageal reflux with increased risk of aspiration.

� Raised intracranial pressure and cerebral perfusion pressure.

Whilst the presence of a ventriculo-peritoneal shunt inserted

for the treatment of hydrocephalus is not a definite contra-

indication to the laparoscopic approach, it is important for the

surgeon to weigh up the risks and to keep IAP at its lowest

and to avoid the Trendelenberg position to prevent neuro-

logical sequelae.

The reverse Trendelenberg position used for upper abdominal

procedures such as fundoplication predisposes to reduced

venous return from the legs and stasis. Even though deep venous

thrombosis (DVT) is rare in childhood, the need for DVT

prophylaxis should be considered during long procedures,

especially in overweight children and adolescents.

Patient selection

Laparoscopy should be used with caution in the following

patients:

� Premature infants: Babies born prematurely are susceptible

because until 6 months of age, they have reduced left

Cardiovascular effects of raised intra-ab

↓ Spinal blood flow

↓ Venous return

↓ Cardiac preload

↓ Cardiac output ↑ Systemic vascu

↑ Mean arterial blood pressure

↑ Intrathoracic pressure

↑ Right atrial pre

Positive pressure pneumoperitoneum

Figure 5

SURGERY 28:1 30

ventricular relaxation, functional residual capacity of their

lungs and diaphragmatic function.

� Trauma victims: The elevation of intracranial pressure by raised

IAP and the Trendelenberg position shouldbe taken into account.

� Children with impaired renal, cardiac or respiratory function.

Intra-operative management

Anaesthesia

The standard technique comprises general anaesthesia with

tracheal intubation and controlled ventilation. It is important to

note the following:

� End-tidal CO2 (PetCO2 ) is not a reliable indicator of systemic

partial pressure of CO2 (PaCO2) because of the metabolic

effect of insufflated CO2.

� When IAP is not excessive, the choice of anaesthetic agent has

a minimal effect on respiratory and cardiovascular parameters.

� Use of nitrous oxide is controversial. When used as an anaes-

thetic agent, it diffuses rapidly into hollow organs such as the

small bowel and colon and causes their distension. Its effect on

thevolumeof theoperativefieldhasnotbeenobjectively studied.

Port insertion

A safe method for the insertion of the primary port is based upon an

open technique describedbyHasson in1971. It comprisesa cut-down

dominal pressure

↑ Intracranial pressure

↑ Cerebrospinal volume

Catecholamine release

Systemic vasoconstriction

lar resistance

↓ Cerebral venous drainage

ssure



methodat theumbilicus to insert theprimaryportunderdirect vision,

with the aim of reducing the risk of vascular and bowel injury.

Neonates and infants have a relatively compliant abdominal

wall and secondary port insertion can be challenging. An inno-

vative technique uses two stay sutures through the abdominal

wall to provide counter-traction during port insertion. This

method is simple and safe and avoids the need for open

secondary port insertion (Figure 6).

Understanding port sizes

Drain sizes are usually expressed in French gauge, which refers

to the circumference in mm.

What is the largest size drain which can be inserted through

a 5 mm port?

Port size ¼ Diameter (d) in mm

Drain size¼ Circumference of drain

¼ 2pr ðwhere r is the radiusÞ ¼ pd

¼ p� 5¼ 3:14� 5¼ 15:7 mm:

The largest drain which can be inserted through a 5 mm port

is a 16 Fr drain.

Choice of insufflation gas

Several gases have been considered for inducing pneumo-

peritoneum, namely carbon dioxide, nitric oxide, helium, argon

and nitrogen. The ideal gas should be:

� highly soluble in blood to prevent the potentially lethal

complication of gas embolism

� chemically inert

� non-combustible

� readily available and inexpensive.

Helium, argon and nitrogen have low plasma solubility and

hence a risk of gas embolism. Nitric oxide carries only a slight

Figure 6 Traction on stay sutures during secondary port insertion.

SURGERY 28:1 31

risk of gas embolism, but has a more significant risk of inducing

intraperitoneal combustion. At present therefore, CO2 is the gas

of choice because it satisfies all the above criteria except for its

undesirable metabolic effect of plasma acidaemia.

Energy sources

Monopolar electrosurgery: an alternating current is applied to

tissues via an instrument such as the diathermy hook. Electrons

bombard cells and transfer energy to ions which collide and

release energy as heat. A rise in temperature within the cell

causes the volume and pressure of intracellular gases to increase

and the cell explodes, hence the cutting effect. The most effective

cutting effect is produced when a current in the form of a pure

sine wave is delivered to the tissues 100% of the time. The

coagulative effect is obtained when the electrical wave is present

10e80% of the time that the device is activated. The intracellular

temperature rises when current passes, but then falls before the

next passage of current. The temperature rise is enough to

produce protein denaturation and coagulation, but not high

enough to cause cellular explosion and cutting.

Risks

� Direct coupling occurs when the activated device comes into

contact with a metallic object such as a port, clip or staple

line. Electricity is conducted to living tissue causing necrosis.

It is therefore considered bad practice to divide a clipped

vessel using monopolar diathermy.

� Capacitive coupling: When two electrical conductors are

separated by an insulator, electrical energy is stored. When

the capacitively stored charge is subsequently discharged it

can cause problems. Capacitive coupling, for example, may

happen when an active electrosurgical cable is wrapped

around a towel clip.

� Diathermy plate burns.

� Thermal injury: The gaseous environment has a low heat

capacity and consequently cooling of the instruments is not as

rapid as at open surgery. The risk of thermal damage is

therefore high even when the instrument is not active.

Bipolar electrosurgery: examples of instruments which utilize

a bipolar circuit are bipolar scissors and the LigaSure (Tyco,

USA). The active and indifferent electrodes are very close to each

other and current travels a very small distance. Bipolar instru-

ments are therefore safer.

Ultrasonic coagulation and cutting: an ultrasound wave is

a longitudinal wave with a frequency above that of audible sound

waves which stimulate hearing in the 20e20,000 Hz range. Such

waves are produced by applying electromagnetic energy to either

a piezoelectric or magnetostrictive transducer which transforms

the energy to mechanical vibration which is propagated to an

active blade element through a rod.

Examples of ultrasonic-activated instruments are:

Instrument

� 2010 Elsevi

Frequency (kHz)

Sonosurg, Olympus
23.5
Harmonic Scalpel, Ethicon Endo-Surgery
55.5
Autosonix, U.S. Surgical Corporation
55.5
er Ltd. All rights reserved.


Ultrasonic devices use mechanical vibration to transfer energy to

tissues. Heat is generated from internal tissue friction and protein

is denatured and tissue coagulated. Cutting is produced by the

mechanical effect of a blade vibrating at 23,500e55,000 times per

second over a distance of 50e200 hm.

Post-operative considerations

Hypoxia: it has been demonstrated that 25% children under-

going laparoscopic Nissen fundoplication experience hypoxia in

the first 4 hours following the procedure. During the subsequent

24 hours, neither hypoxia nor atelectasis was noted. Since

neonates and infants have a lower functional residual capacity

the beneficial effect of laparoscopy on post-operative atelectasis

is an advantage.

Pain management: it is customary in paediatric practice to

administer opioids via a patient or nurse-controlled device. In

our experience, this negates the benefits of laparoscopic

surgery by increasing hospital stay. The administration of oral

analgesia can provide equally effective pain control. At our

institution, the favoured analgesic regimen comprises a combi-

nation of paracetamol, codeine and a non-steroidal anti-

inflammatory agent.

In a randomized trial of open versus laparoscopic appendi-

cectomy in children, the incidence and severity of post-operative

pain was similar in the two groups but shoulder tip pain was

2.5 times more common in the latter group.

Post-operative nausea and vomiting (PONV): this is a major

challenge for the laparoscopic surgeon and is seen in up to 50%

of children undergoing laparoscopic cholecystectomy. Our

current protocol includes adequate intra-operative hydration,

intra-operative anti-emetics, minimization of the use of long-

acting intravenous opioids and a strict dietary regime which

includes light meals.

The future

Bariatric surgery: there are early reports of sleeve gastrectomy,

gastric banding and Roux-en-Y gastric bypass in morbidly obese

adolescentswithgoodearly results.However, long-termgrowthand

development and psychosocial outcomes are not available. The role

of bariatric surgery in morbidly obese children is yet to be defined.

Single Port Laparoscopic Surgery (SILS): a newer generation

of laparoscopic ports allows all instruments to enter the

SURGERY 28:1 32

abdominal cavity through a single incision. There are reports of

gastrostomy, appendicectomy, cholecystectomy and splenec-

tomy having been performed using SILS in children. The theo-

retical benefits of SILS are improved cosmesis, less tissue

trauma and pain. However, these benefits remain to be

demonstrated.

Needlescopic surgery: a needlescopic procedure is one where all

ports and instruments are 3 mm or smaller. It has been used

successfully for the following procedures in children:

� reduction of incarcerated inguinal herniae

� orchidopexy

� thoracic sympathectomy for palmar hyperhidrosis

� appendicectomy

� AndersoneHynes dismembered pyeloplasty.

This form of surgery is yet to gain favour amongst paediatric

surgeons as objective outcomes have not been proven to be

better.

Robotic surgery: a wide range of procedures has been performed

using robotic surgery in children and good clinical outcomes

have been reported. However, this modality has not gained wide

acceptance mainly due to cost, reliance on relatively large port

sizes and increased operating time.

Robotics offers the exciting prospect of telesurgery where the

surgeon can perform the procedure from a remote location and

teleconsultation where the surgeon may request assistance from

another surgeon in another part of the world.

Natural Orifice Translumenal Endoscopic Surgery (NOTES): In

a further attempt to improve cosmesis, procedures have been

performed using natural orifices. The procedures of transgastric

and transvaginal cholecystectomy, transvaginal sleeve gastrec-

tomy for morbid obesity and transvaginal splenectomy have

been reported in adults. These procedures remain controversial

and have not been performed in children. A

FURTHER READING

Najmaldin A, ed. Operative endoscopy and endoscopic surgery in infants

and children. 1st edn. Edward Arnold, 2005.

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