Since the last edition of the Handbook of Pediatric Urology, advancements in robotic-assisted surgery have led to an exponential increase in pediatric laparoscopic surgery particularly for upper tract reconstruction. The laparoscopic approach has the advantages of smaller incisions, less pain, shorter hospitalization, and reduced convalescence for adults undergoing abdominal surgery. Infants and children benefit also but the advantages over open surgery probably decrease with the size of the patient. Since a child’s bladder and kidneys are much closer to the surface and smaller, they can be repaired or removed through small (2- to 5-cm) open incisions with less division of muscle. Yet, the combination of excellent exposure and vision via the laparoscope with improved fine motor control via the robot has challenged the superiority of many pediatric open urologic procedures.

Having the abdomen insufflated with CO2 under pressure creates unique physiologic changes distinct from open surgery. Laparoscopic surgery is generally performed at pressures between 10 mm Hg and 15 mm Hg, which cause decreases in diaphragmatic movement and pulmonary capacity. The absorption of CO2 (hypercarbia) with the pressure can lead to cardiopulmonary changes that the surgeon and anesthesiologist have to follow and prepare to compensate. These include decreased cardiac output, increased heart rate, lower urine output, and increased intracranial pressure. Long-duration surgeries and/or cardiopulmonary comorbidities may prevent some patients from having laparoscopic surgery.

Laparoscopic telescopes are available in 2- to 12-mm sizes. The initial port placement can be done blindly with a Veress needle, through an open incision, or with trocars that allow direct vision. It is very important to ensure an empty bladder prior to placing the first port. One to four more ports are then placed under direct laparoscopic vision. Most pediatric procedures are performed with 3.5- or 5-mm working instruments. A full array of instruments is available including dissectors, graspers, needle-drivers, cautery, and suction devices. Coagulation and division of tissue can be performed with similar instruments as open surgery such as scissors, mono- or bipolar cautery, and ultrasonic devices. Ligation of vessels and tissue can be accomplished with suture, clips, and staplers. Most surgeons prefer the robot if there is a reconstructive component to the surgery with suturing. Morcellators and bags may be used for specimen removal.

The laparoscope provides magnification, but the instruments and port angles often limit the surgeon’s dexterity and movement. Robotics can
obviate these problems. As mentioned previously, advantages of the laparoscopic approach decrease inversely with patient size. The working space in small children and infants limits distance between ports and movement of instruments. Single-site (port) surgery that allows the use of up to three instruments through one incision is gaining popularity in adults but will probably have limited utility in small children.

Most laparoscopic procedures are performed within the peritoneum. Some surgeons employ a retroperitoneal approach for kidney procedures. Operating within the peritoneal space has the advantage of more working space, but there is a risk of injuring bowel or the theoretical risk of inducing bowel adhesions. Retroperitoneoscopy is hindered by a smaller working area, but the renal hilum is easier to expose without bowel, liver, or spleen obstructing the view.