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Paediatric Laparoscopic Surgery

Ravindra Ramadwar
 

Historical Background
Laparoscopy was first attempted by Stephen Gans (1970) to diagnose contralateral hernia through the open hernial sac during herniotomy in children. In 1972 he reported on the role of diagnostic laparoscopy for intersex anomalies. Laparoscopy for undescended testis was popularized by Scott (1982).1 With the advent of CCD chip for camera the laparoscopy became easy and therapeutic laparoscopy became feasible. Therapeutic laparoscopy in children was attempted in early 90s and by late 90s almost all procedures were successfully carried out. With improvement in technology like availability of harmonic scalpel, smaller telescopes, smaller instruments and better light source, laparoscopic surgery is feasible in newborn, infants and older children.

Review of literature
Despite the acknowledged role of diagnostic laparoscopy and advent of laparoscopic cholecystectomy in adults, the first published reports of laparoscopic cholecystectomy in children appeared in 1991.2 The paediatric surgeons were unsure of applying the adult experience and were careful to evaluate the experiences in adult laparoscopy. The early nineties then saw rapid growth of therapeutic laparoscopy in children.

Laparoscopic fundoplication became a procedure of choice for gastro-oesophageal reflux. Rothenburgh reported on his experience of laparoscopic fundoplication in 220 patients by 1998.3 In 1995 Georgeson reported his experience of laparoscopic primary pullthrough for Hirschsprung’s disease questioning the way this condition was treated in multiple stages.4 In 2001 Thom Lobe discussed the issue of whether the laparoscopic surgery is better than open surgery in children.5 The current recommendation of the International Pediatric Endosurgery group are that laparoscopic surgery in children is a safe alternative in experienced hands if the laparoscopic operation is similar to the open procedure.

Indications of laparoscopy and retroperitoneoscopy
Laparoscopy can be performed in newborn, infants and older children for following indications:

A) Diagnostic

  1. Undescended nonpalpable testis
  2. Intersex anomalies
  3. Evaluation of contralateral hernia (hernioscopy)
  4. Chronic abdominal pain
  5. Abdominal Tuberculosis
  6. Gastrointestinal bleeding e.g. Meckel’s diverticulum
  7. Acute abdomen
  8. ntestinal obstruction
  9. Biopsy for tissue diagnosis e.g. liver biopsy, peritoneal biopsy, lymph node biopsy, biopsy of intra-abdominal masses

B) Therapeutic

  1. Upper gastrointestinal procedures like fundoplication, Heller’s cardiomyotomy, gastropexy for gastric volvulus, gastrostomy, correction of malrotation, pyloromyotomy, duodenal duplication cyst, hiatus hernia, congenital diaphragmatic hernia
  2. Hepatobiliary procedures like Cholecystectomy, choledochal cyst excision and roux-en-Y, Drainage of liver abscess, hydatid cystectomy, liver resection for benign cystic diseases of liver,
  3. Pancreatic procedures like cystogastrostomy for pseudocyst of pancreas, distal pancreatectomy, near total pancreatectomy for Nessidioblastosis,
  4. Splenectomy for haematological disorders,
  5. Small intestinal procedures like Meckel’s diverticulectomy, reduction of intussusception, stricturoplasty, adhesive intestinal obstruction, mesenteric cyst
  6. Large intestinal procedures like Appendicectomy, pull through for Hirschsprung’s disease, pull through for very high anorectal malformations, Antegrade colonic enema procedures for faecal incontinence, Rectopexy for chronic rectal prolapse, total colectomy for inflammatory bowel disease and polyposis coli
  7. Urological procedures like orchidopexy, nephrectomy, heminephrectomy, pyeloplasty, ureteric reimplantation, neurogenic bladder
  8. Gynaecological procedures like ovarian cystectomy, excision of mullerian remnant, hysterectomy
  9. Neonatal Surgical procedures like pyloromyotomy for pyloric stenosis, pull through for Hirschsprung’s disease, duodenal atresia repair, correction of malrotation, biliary atresia, ascites, repair of oesophageal atresia with tracheo-oesophageal fistula
  10. Other procedures like herniotomy, blocked VP shunt, CAPD catheter, omental cystectomy and, excision of tumours.

Contraindications
Contraindications for laparoscopic surgery in newborn, infants and children are the same as contraindications for any laparoscopic surgery. Severe cardio-respiratory instability, distended bowel loops, severe sepsis, bleeding disorders, lack of proper instruments or assistants or anaesthetist are general contraindications in children.

Special Considerations in Newborn, Infants and Older Children
The pressures (8 – 10 mm of Hg) and flow rates (0.5 – 2 lpm) for CO2 insufflation of the peritoneal cavity in children are much lower compared to adults. Retroperitoneoscopy can cause mediastinal and subcutaneous emphysema. Hence the insufflation pressure is set at 6-8 mm of Hg. Low temperatures in operation theatre complex can cause hypothermia due to cold CO2. The instruments are smaller and telescopes are thinner making them prone for accidental breakage. The handling of instruments and tissues need to be very gentle. Energy sources like monopolar or bipolar electrocautery should be used very carefully in smaller children. As mentioned above in indications the laparoscopic procedures in newborn, infants and children can be complex. Hence the assistants must be properly trained and experienced in paediatric surgery. As the working spaces are smaller and the tissues thinner the paediatric laparoscopic surgeon needs to be very highly skilled and properly trained.

Anaesthesia can be very tricky in smaller children undergoing laparoscopic procedures. Hence the Paediatric Anaesthetist should be trained for anaesthesia for laparoscopic procedures. End tidal CO2 monitoring must be done in all paediatric cases. During retroperitoneoscopy the anaesthetist must watch for subcutaneous emphysema in the neck as it suggests mediastinal emphysema. There is a possibility of pneumothorax and therefore any difficulty in ventilation must be reported immediately.

Postoperative course
Most of the procedures are very well tolerated by newborns, infants and older children. The recovery is faster, feeding can be commenced early and analgesia requirement is less reducing the hospital stay. The rest of the postoperative care is similar to open procedures and depends on the surgical procedures.

Laparoscopic versus other alternative procedures
Diagnostic tests like USG, CT and MRI have shown certain benefits however diagnostic laparoscopy remains a gold standard for many conditions like nonpalpable undescended testis, intersex anomalies. Tissue diagnosis can be better performed by laparoscopic guidance than blind biopsies for liver pathology, tuberculosis. Therapeutic laparoscopy has an alternative of open surgery. Visualization of pelvis and subdiaphragmatic spaces is better in laparoscopy. There is minimal access trauma compared to open surgery. Due to minimal handling the post operative ileus, pain, chest complications and hospital stay is reduced in laparoscopic surgery compared to open procedures. This reduces the economic burden on the family as parents can go back to work quickly. The cosmetic benefits are immense as in open surgery many scars would stretch or migrate as the child grows.

Current Status
Laparoscopic surgery in newborn, infant and older children has gained wider acceptance through out the world. As mentioned in the list of indications most of the procedures are being carried out in children laparoscopically. The training and experience of the surgeon, the availability of better equipment, and access to harmonic scalpel, endovascular staplers will determine the ability of the surgeon to perform laparoscopic surgery in newborn, infants and older children. At the Bombay hospital we have performed more than 200 laparoscopic operations in newborn, infants and children in last 3 years and almost all the above mentioned procedures mentioned in the list of indications were performed with no mortality and excellent results. We feel that any operation that requires laparotomy or thoracotomy can be performed by thoracoscopic, laparoscopic or retroperitoneoscopic approach.

References

  1. Gans SL, Berci G. Peritoneoscopy in infants and children. J Pediatr Surg 1973; 8 : 399.
  2. Siegman HH, Laberge JM, Croitoru D, et al. Laparoscopic Cholecystectomy: A treatment option for gall bladder disease in children. J Pediatr Surg 1991; 26 : 1181-3.
  3. Rothenburgh SS. Experience with 220 consecutive laparoscopic Nissen fundoplications in infants and children. J Pediatr Surg 1998; 33 : 274-8.
  4. Georgeson K, Fuenfur M, Hardin WD. Primary laparoscopic pullthrough for Hirschsprung’s disease in infants and children. J Pediatr Surg 1995; 30: 1017-22.
  5. Lobe TE. Laparoscopic surgery in children: Is it better than open surgery? Pediatric Endosurgery and Innovative Techniques 2001; 5 : 1-2.

 

CHRONIC LOW BACK PAIN : SURGERY ISN’T CONCLUSIVELY BETTER.....

Surgery does not clearly achieve better results than an intensive rehabilitation programme for treating patients with chronic low backpain, and the potential risk of surgery also need to be considered. Fairbank and colleagues randomised 349 patients who had had low back pain for at least one year before recruitment to lumbar spine fusion or to an intensive rehabilitation programme that included exercises and cognitive behaviour therapy. After two years, all patients reported improvement and the researchers found no significant differences in outcomes between the groups, except for a marginally better score on the Oswestry disability index in favour of surgery (P = 0.045).

BMJ, 2005; 330 : 1233.

Honorary Consultant Paediatric Surgeon, Bombay Hospital, Mumbai 400 020.
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