The general principles for performing a laparoscopic operation have not changed significantly since the laparoscopic revolution began in the late 1980s. Prior to the laparoscopic procedure, a preoperative conference should be held with the parents and the patient (if the age is appropriate) to discuss the nature of the laparoscopic operation and the risks and benefits of this approach. The benefits include reduced discomfort, reduced hospitalization, and faster return to routine activities (such as school or sporting activities) as well as early return to normal activities, such as work, for the family members. In addition, there is a definite cosmetic advantage for this approach, although there is minimal data available. Finally, there appears to be a definite reduction in the risk of adhesive postoperative small bowel obstruction with the laparoscopic approach. Risks include a small (generally 1%) chance of conversion to an open operation, usually because of unclear anatomy and sometimes because of adhesions from previous open operations. In addition, as with the open technique, there is a small but definite incidence of injury to other structures, or of bleeding requiring transfusion. For thoracoscopic procedures the benefits are the same as for laparoscopy, but there is the added advantage of minimizing the risk of scoliosis, chest wall deformity, and shoulder girdle weakness, which has been reported in up to 40% of patients undergoing a thoracotomy as an infant.
Contraindications for the minimally invasive approach are few. The laparoscopic technique has been used for every general surgical procedure in children. Its primary contraindication is a situation in which an adequate pneumoperitoneum cannot be created or a lung cannot be collapsed for a thoracic operation. Fortunately, this rarely occurs. Adhesions from previous procedures precluding adequate visualization are occasionally found. Bleeding that cannot be readily controlled may develop, but this is rare. Finally, because of chronic lung disease or uncorrected congenital cardiac disease, the patient may not be able to tolerate creation of a pneumoperitoneum for an abdominal operation or lung collapse for a thoracic procedure. Any patient with a congenital cardiac defect that is adversely affected by an increase in systemic vascular resistance is susceptible to increased cardiac complications from creation of a pneumoperitoneum. Included in this group of patients are those with hypoplastic left syndrome, unrepaired septal defects, palliative cardiac defects with passive pulmonary blood flow such as those who have undergone a Glenn or Fontan procedure, and babies with complete atrioventricular canal. However, at the same time, a well-trained team with a good cardiac anesthesiologist can usually safely navigate these patients laparoscopically without untoward effects.
We know that a number of newborns have died or developed significant neurological impairment following CO 2 insufflation, and this knowledge has led many pediatric surgeons not to do a cutdown procedure through the center of the umbilicus in newborns. The premise is that the insufflated CO 2 gains entry into the umbilical vein and courses to the heart and into the lungs as a gas embolus. This has been documented in both the open Hassan approach and the Veress needle technique. The concept that the “natural defect” in the center of the umbilicus is a safe access point is not true in newborns and infants (up to 2 months of age). We strongly recommend an infraumbilical ring approach in these patients ( Fig. 1-1 ). The cosmetic result is the same, and this approach should avoid unrecognized injury to the umbilical vein.
The preoperative evaluation and preparation of the patient undergoing a laparoscopic operation are the same as those required for the comparable open operation. A patient who is undergoing an elective colonic procedure and needs preoperative bowel preparation can be admitted before the operation for this purpose, if needed. Patients with sickle cell disease who require laparoscopic procedures should be transfused to a hemoglobin of 10 g/dL. Preoperative admission for hydration of these patients is not believed to be as necessary as it was in the past, but transfusion continues to be a mainstay of the preoperative preparation.
General Principles
Although it is possible to effect collapse of the ipsilateral lung through a variety of measures when performing thoracoscopy, insufflation is necessary to create an adequate working space in the abdomen. We have used inflating pressures of 12 to 15 mm Hg in numerous infants without deleterious effects. The primary reason to reduce this pressure is the presence of underlying heart or lung disease. If there is underlying lung disease, an elevated insufflation pressure may raise the hemidiaphragms, which can be followed by a corresponding reduction in tidal volume, ventilation, and oxygenation. In an infant with chronic heart disease who is volume dependent, the higher inflating pressures may reduce venous return to the heart, with a corresponding reduction in cardiac output. Other than these two areas, insufflation of 12 to 15 mm Hg can be used routinely in most patients. A final caveat centers on the lack of an adequate working space despite a high intra-abdominal pressure and adequate flow. In such an instance, the surgeon should evaluate whether the patient is adequately paralyzed. If the patient is not paralyzed, it may not be possible to create an adequate working space despite high flows and high inflating pressures.
Angled telescopes are essential for safety and adequate visualization. There are currently very few indications for a 0-degree telescope. A 0-degree telescope may be used for a laparoscopic cholecystectomy and for initial diagnostic laparoscopy. However, to see around the corners of the abdominal viscera, use of an angled telescope is paramount. For most of the operations, either a 30-degree, a 45-degree, or a 70-degree angled 3-mm, 4-mm, or 5-mm telescope is used. For fundoplication or cholecystectomy, a 45-degree angled telescope is employed. For a pyloromyotomy, a splenectomy, a laparoscopic pull-through, or an appendectomy, a 70-degree angled telescope is helpful. In addition, for evaluation of the contralateral inguinal region in a child with a known unilateral inguinal hernia, a 70-degree angled telescope is essential for adequate visualization of the contralateral inguinal ring.
Although some authors feel that a 3-mm telescope can be useful for laparoscopic operations, there is no advantage to using the smaller telescope in the umbilicus. A 5-mm port inserted in the center of the umbilicus results in the same cosmetic appearance as a 3-mm port, as the umbilicus is composed of scar and heals quite nicely. Therefore, there is no advantage to using a 3-mm telescope, even in infants. One disadvantage of using a 3-mm cannula and telescope is that there is often inadequate space in the cannula around the telescope to allow adequate insufflation.
Over the past 10 years, several new vessel-sealing devices have been developed. The Harmonic Scalpel (Ethicon Endosurgery, Cincinnati, OH) was developed in the late 1990s. Coagulation occurs when the blade, vibrating at 55,000 Hz, couples with protein and denatures it to form a coagulum that seals small vessels. However, there can be significant thermal spread with this device. The Ligasure (Medtronic, Minneapolis, MN) is useful as well and works by melting the collagen and elastin in the vessel wall and re-forming it into a permanent seal. These instruments are also helpful for splenectomy and thoracic procedures and other pediatric applications, and both come as 5-mm instruments. However, their size precludes safe use in smaller infants and neonates. A 3-mm vessel sealer (Bolder Surgical, Louisville, CO) that uses bipolar technology is now available. It can safely seal blood vessels up to 5 mm with almost no collateral heat spread and is perfect for working in the smaller chest and abdominal cavities of infants and small children.
As a general statement, the largest and usually the initial cannula is placed in the umbilicus. Again, the reasoning is that the umbilicus is composed mainly of scar and it is quite easy to hide a large incision at this site. For children undergoing laparoscopic appendectomy or splenectomy, a 12-mm port is often placed in the umbilicus and the resulting scar is often quite pleasing.
Finally, at Children’s Mercy Hospital, the surgeons use a stab incision technique in infants and young children almost exclusively. With this approach, an initial cannula is placed in the umbilicus and insufflation is achieved through this cannula. A stab incision using a #11 Bard Parker (Becton-Dickinson, Franklin Lakes, NJ) blade is then used to create the tract through which instruments are passed ( Fig. 1-2 ). This stab incision technique is employed for all operations in infants and young children, and can even be applied to some adolescents. As an example, for a fundoplication, one 5-mm cannula is placed in the umbilicus and four stab incisions are used. For a laparoscopic splenectomy, a 12-mm port is placed in the umbilicus and a 5-mm port is placed in the midline epigastrium. Two stab incisions are then used ( Fig. 1-3A ). For a laparoscopic cholecystectomy, the two right-sided instruments are often introduced through stab incisions rather than ports unless the patient is extremely hefty ( Fig. 1-3B ). In general, this technique is ideal for instruments that do not need to be exteriorized and then reinserted on a regular basis. The only operation in which this stab incision technique is not used currently at Children’s Mercy is an appendectomy, for which a 12-mm port is placed in the umbilicus and two 5-mm cannulas are introduced in the left midabdomen and left lower quadrant.
