Pediatric laparoscopy
- 1. Pediatric Laparoscopy : Spectrum and Current Applications Mosad El Behery Professor of Surgery, Ain Shams Univ., Cairo
- 3. Laparoscopy is currently successful in young children, neonates and even in pre-terms. Gans, 1971 showed the safety of the procedure Two issues surface - Procedural issues - The significant advantages of laparoscopy procedures over the conventional operative approach
- 4. ANATOMIC CONSIDERATIONS * Larger diameter of umbilical vessels. * Urinary bladder (with the urachus) is an abdominal organ till 3 ys. Of age. * Processus vaginalis may be re-opened by insufflation. * Wider, displayed rectus abdominis muscles ( epigastric vessels injury ). * Insufflation P. - Infants 6 – 8 mm Hg - Children 8 – 10 mmHg - Older children 10 – 12 mm Hg
- 5. Eessentials of Pediatric Laparoscopy - Rod lens telescope ( 2-10 mm ). - Light weight video camera. - Smaller, shorter trocar / cannula sets ( about 2 cm long ) with expandable flinges or adhesive rings. Difficulties : Thin, elastic abdominal wall - Misdirection of the needle and trocars. - Injury of the abdominal viscera. - Limited mobility of the instruments.
- 6. Advantages of Pediatric Laparoscopy - Less parietal complications. - Shorter hospitalization. - Less psychological trauma. ? Cost effective ? Operative time ? Training programs
- 7. Laparoscopic Procedures in Infants and Children I – Excision for Internal Organs Diseases * Cholecystectomy * Appendectomy * Nephrectomy * Adrenalectomy * Splenectomy * Cyst ecxision 2- Diagnostic procedures * Neonatal jaundice * Acute abdomen * Impalpable testis ( also therapeutic ) * Intussusception ( after hydrostatic reduction ) * LN & tumors guided biopsy * Intersex
- 8. 3- Reconstructive procedures • Fundoplication * Biliary surgery • Pyeloplasty * Pyloromyotomy • GI anastomosis * Rectopexy 4- Dissection • Adhesiolysis * LA ERPT • LA APPT
- 9. Optimum table height should position of laparoscopic instrument handles close to surgeon’s elbow. This is 64 to 77 cm above floor level
- 10. Manipulation angle should be as near as possible to 60 degree (Ergonomically the best)
- 11. Elevation angle should be between 15 to 30 degree 30 degree
- 13. Center of the monitor should be placed 20 degree lower than the eye This position corresponds with the normal resting position of occulomotor muscle
- 14. Distance of Monitor should be 5 times of diagonal length of screen
- 18. * A good modality for training on handling tissues laparoscopically. Laparoscopic Appendectomy
- 19. Control of mesoappendix 1. Endo GIA 2. Sutures 3. Endo loops 4. Surgical clips 5. Laser 6. Laparoscopic assisted
- 22. Contrary to the previously mentioned view, our experience showed that laparoscopic appendectomy is especially valuable in cases of perforated appendicitis as this permits copuous irrigation and meticulous suction of the irrigation fluid from the pelvis.
- 24. Laparoscopic Cholecystectomy 80% idiopathic. 15% hemolytic anemia ( Sickle cell disease ). 5% TPN, hypercholesterolemia.
- 25. Trocar sites
- 29. IDIOPATHIC INTUSSUSCEPTION Results Pts with intussusceptionn Initial surgery contraindication for hydrostatic reduction Barium HR Fluoroscopic control reduced failed (laparoscopy) reduced reduced (HSR) surgical reduction
- 30. Nissen Fundoplication - Laparoscopic Nissen fundoplication is now a standard procedure for GERD in children. Advantages: - Less wound complications & pulmonary atelectasis particularly in mentally retarded children.
- 31. Essential Steps : - Approximation of the diaphragmatic crura. - 360° fundoplication. - Gastrostomy is a complementary procedure. - Results: Comparable to the open method.
- 32. Trocar sites
- 34. Laparoscopic Rectopexy Principles 1- Deep posterior rectal dissection. 2- Bilateral dissection down to the lateral ligaments. 3- Bilateral suture fixation of the rectum to the presacral fascia 4- Ensuring no perforation or narrowing of the rectum.
- 36. Neonatal Jaundice - Laparoscopy has become a conclusive method if diagnosis is still uncertain. - Value: Direct exploration of the extra hepatic biliary ducts. - permits radiological control and liver biopsy. - Allows irrigation of the G.B.
- 37. Laparoscopic exploration (or mini-laparotomy) GB is found No GB Laparoscop. (or open) cholang. GB lumen No GB lumen Hepatic porto- Patent BDs Atretic BDs jejunostomy close the abd. ( Kasai )
- 39. Abdominal Undescended testes * 5 years periods : 92 patients with 135 impalpable testes underwent laparoscopic exploration. * Diagnosis is confirmed by examination under anaesthesia. * The patient is not labelled to have anorchia except after laparoscopic exploration.
- 41. Laparoscopic classification and management Pediatr Surg Int (1999) 15:570-572 TYPE I : No testis - VD &SV end blindly at IR : No ttt NO TESTIS - VD & SV entering the ring : Inguinal Exploration
- 42. Type II : Testis at IR-loopin of VD&SV: LAO Type III : Testis at IR-no looping of VD&SV Type IV : Testis not related to IR III&IV : Lap clipping of SV & LAO after 6 ws
- 45. Laparoscopic assisted techniques The intra-abdominal portion of the laparoscopic technique is not different from that of open primary pull-through. Three ports are usually used in the upper abdomen . A right lower quadrant port can be used for colon manipulation, especially when performing the Duhamel or Swenson procedures. Initial dissection consists of mobilizing the sigmoid colon down to and opening the peritoneal reflection.
- 46. Laparoscopic assisted techniques Further dissection into the pelvis can be done, as in the Swenson or Duhamel approach, but is not necessary for the Soave endorectal approach. Great care should be taken to avoid collateral structures, especially the left ureter and the vas deferens.
- 47. Trocar sites
- 48. Laparoscopic Pull-Through Procedures 1- Duhamel 0peration - Main value : Mobilization of the colon. - All the procedure can be done laparoscopically. - Controversy : time - consuming.
- 53. Currently, we use laparoscopy : - To detect the level of aganglionosis - To do more colonic mobilization & gain more length. - To save time ( synchronous dissection ) - To prevent over-stretch of the anal ring while prolapsing the huge rectum transanally
- 54. Adhesiolysis for Intestinal Obstruction * Principles: - Open laparoscopy - Adhesions between loops of small bowel & anterior abdominal wall are divided first. - Run the whole bowel from the ligament of Tritz to ileocaecal valve till the point of obstruction.
- 56. Laparoscopic Splenectomy Indications Hereditary Spherocytosis Thalassemia (major) Autoimmune hemolytic anemia I.T.P. Thromboticytopenic Purpura Cysts Abscess Hodgkin’s (staging) AIDS Trauma
- 58. Principles: - Pre-operative vaccination with polyvalent vaccine against Hemophilus influenzae & Pneumococus - Fixation of the spleen. - Start with G/S ligament & short gastric vessels. - Division of the hilar vessels. - A lap Sac & Morcellator are used to remove the spleen. - Search for accessory spleens.
- 61. Laparoscopic Nephrectomy Indications - Dysplastic kidney - Multicystic nonfunctioning kidney - Recepient nephrectomy before transplantation Advantages Better pedicle and ureteric exposure
- 64. Laparoscopic Adrenalectomy - Advanced Laparoscopic skills - Selective Indications: ( Valla et al, 2001) 1- Well defined lesions 2- Smaller than 5 cm 3- ? Benign lesions e.g., adenoma, hyperplasia, c.pheochromocytoma ganglioneuroma, lipoma, teratoma
- 67. Advantages of PSARP Perfect exposure Defining the muscle complex accurately Strict positioning of the rectum within the muscle complex Tailoring of the dilated rectal pouch Less incidence of prolapse due to fixation of the rectum Accepted cosmetic results of the perineum Cutting of fistula flush with the bladder neck
- 68. PSARP with Laparotomy Longer operative time Changing the position of the patient Cutting the levator ani with the risk of disruption or improper re-closure Abdominal incision
- 69. Indications Of Laparoscopic assisted APP Whenever laparotomy is indicated. 1)Recto-vesical fistula. 2)recto-prostatic fistula. 3)High confluence cloaca 4)Recto uterine fistula.(rare) The majority has poor prognosis as regards continence.
- 70. Steps Abdominal part: 1. Abdominal exploration 2. Release of adhesions 3. Evaluation of the site of colostomy 4. Mobilization of the rectum 5. Exposure of the fistula 6. Ligation of fistula 7. Exposure of the levator ani
- 71. Perineal part 1. Defining & marking the external sphincter. 2. Midline division of the sphincter (2cm incision) 3. Deepening of the incision for 2-3 cm 4. Passing no 6 hegar dilator from the perineal side to exit in the midline in front of the levator and behind the urethra. 5. Dilatation of the pathway using hegar dilators till no 14. 6. Insertion of a backcock forceps to grasp the rectum 7. Anal anastomosis
- 72. Laparoscopy in chronic pelvic pain in childhood * A challenging problem ? Persistant lower abdominal pain > 6 mo & multiple visits to the physian * Primary : No obvious cause ( NSAP ) * Secondary : Obvious cause, look for them laparoscopically - GIT: Chronic constipation & Regional ileitis & - Genito-urinary: Recurring cystitis, endometriosis, oophritis, congenital uterine anomalies, functional ovarian cysts - postoperative adhesions
- 74. Laparoscopy in acute abdominal pain - Medium or severe abdominal pain with Duration of less than 7 days - Laparoscopy is indicated after a complete Diagnostic work-up. - Causes Non specific abdominal pain Acute biliary disease Diverticulitis Bowel obstruction
- 75. Laparoscopic liver resection Lap US The line of transection on the liver surface. The hepatic parenchyma transection and the main blood vessels and bile ducts: clips or staples. The resected liver is enclosed in a bag and removed through a small incision. Haemostasis of the transection line. Hand-assisted laparoscopic liver resection. ? For benign swellings only
- 76. Laparoscopic management of hepatic cysts Laparoscopic management of hepatic cysts has become the new gold standard, associated with minimum morbidity and good long-term outcome ( marsupialization, cyst wall resection Or segmental hepatic resection )
- 77. Laparoscopic hepatic hydatid surgery is a safe and effective method in selected patients •Limitations •Intraparenchymal location •of the cyst •Multiple cysts •Cysts with thick & calcified walls
- 78. Surgical Tipss - Gauzes soaked with 10% povidone iodine solution are placed around the cyst - Injection of scolecidal agents is controversial (possible sclerosing cholangitis) •-If cystic fluid bile stained, suggesting biliary rupture choledochotomy and T-tube drainage •- Proper removal of the germinative membrane wide-bore suction catheter (without valvular system) •- Management of the cavity
- 79. Single Incision Laparoscopic Surgery
- 83. NOTES is Dying SILS is progressing due to high patient Acceptance
- 84. Conclusion Pediatric laparoscopy is a useful tool in the pediatric surgical practice and should be one of the armamentarium of the pediatric surgeons.