Of course prevention of a complication should be the highest priority and involves several important elements. One should always be aware of the possible risks for particular surgery in a particular patient. One should anticipate the possibility of complications both in the procedure as a whole, as well as in particular parts of the procedure that may be more prone to problems. A key element of this is to recognize the complication prone situation. This can occur during access where there are any difficulties in initially obtaining what should be routine access or in the child with prior abdominal surgery where there may be adhesions. Situations in which there is limited vision either due to the anatomy, proximity or due to fogging, also increase the potential for inadvertent injuries. Any case in which there is prior surgical or inflammatory scarring also increases the potential for inadvertent injury, particularly vascular injury. In children, unusual anatomy is typically the basis for surgery and one should always be anticipating and alert for variations in normal structure. This can be particularly the case in duplication anomalies where identification and localization of the various components, both ureteral and renal, are very important. Renal ectopia , particularly pelvic kidney with malrotation, poses challenges as well, and one should always be cognizant of the potential for complex vascular anomalies in these children. This is also the situation with horseshoe kidneys.

In all steps of any procedure, safe technique should be followed. This is certainly very important with access, using either the Veress needle, although no technique is truly risk-free [1, 2]. During dissection, the practice of touching a cold instrument with an electrified instrument to provide for tissue cautery is risky, particularly if one cannot see all of the electrified elements of the cold instrument. Inadvertent burn injuries to bowel or vascular structures then become more possible.

Just as with open surgery, the surgeon must always be aware of their surroundings from an anatomic perspective. A three-dimensional mental image of the surroundings of the operative field should always be maintained in the surgeon’s mind. If there is uncertainty as to the orientation or proximity, a brief pause to reassess location and context is useful. In dissecting the right renal pelvis, for example, the close proximity of the duodenum and IVC should always be in mind.

In pediatric practice of both laparoscopy and robotics, the largest fraction of complications occur during access. This occurs in both open and Veress needle techniques . During open technique one should never attempt cannula insertion until the open space of the peritoneum has been visualized. If pre-placed fascial sutures are to be used, they should not be passed until after the peritoneum is opened and the cavity visualized. Pre-placed fascial sutures have a significant advantage particularly in children, because they provide for counter-traction as the cannula is being placed through the abdominal wall. The natural resistance of the child’s abdominal wall is limited and without counter-traction it is possible, even with a blunt cannula, to injure peritoneal or retroperitoneal structures.

If the Veress needle technique is being used, strict adherence to safe steps and practices is important. The author still strongly recommends the saline test with aspiration to ensure that the bowel or a vascular structure has not been inadvertently entered. The drop test confirming intraperitoneal placement, while not definitive, is certainly reassuring. If there is any uncertainty as to the placement of the needle, insufflation should not be started. With the initial passage of the needle it is important to avoid vigorous pressure and potential past pointing, with the risk for inadvertent puncture of an intra-abdominal structure.