PEDIATRICS Vol. 111 No. 6 June 2003, pp. 1239-1252
Current Concepts in Minimal Access Surgery for Children
Jeffrey L. Zitsman, MD
From the Children’s Hospital of New York Presbyterian, College of Physicians and Surgeons, Columbia University, New York, New York
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ABSTRACT
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Since the introduction of minimal access surgery to general surgeons in the 1980s, pediatric surgeons have been employing this innovative technology to perform surgery on children. Video technology and miniaturized instruments have brought the laboratory to the operating room; in many cases several small incisions are the only access necessary to perform complicated procedures that would otherwise require a large wound. Additional benefits of minimal access surgery may include reduced postoperative analgesic requirements, shortened length of stay, and faster resumption of normal activities. Increased operative costs offset some of these gains. The pediatric surgical community has embraced minimal access techniques for some operations; others remain controversial.
Key Words: laparoscopy • minimal access surgery • minimally invasive surgery • thoracoscopy
Abbreviations: MAS, minimal access surgery • CT, computerized tomography • LA, laparoscopic appendectomy • OA, open appendectomy • LC, laparoscopic cholecystectomy • CBD, common bile duct • LS, laparoscopic splenectomy • GERD, gastroesophageal reflux disease • LNF, laparoscopic Nissen fundoplication • ONF, open Nissen fundoplication • PEG, percutaneous endoscopic gastrostomy • OP, open pyloromyotomy • LP, laparoscopic pyloromyotomy • L-A, laparoscopically assisted • MD, Meckel’s diverticulum • ID, intestinal duplication
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INTRODUCTION
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Fifteen years ago minimal access procedures largely consisted of arthroscopy, endoscopy (eg, cystoscopy, esophagogastroscopy, colonoscopy), and gynecologic procedures. Several European gynecologists began to apply these techniques to remove gall bladders and appendices. The advantages of cholecystectomy using several small openings rather than a large upper abdominal incision were clear, and general surgeons worldwide rapidly learned the technique. With increased interest came increased demand for the specialized instruments necessary to perform the procedures; a multibillion-dollar industry was born. Pioneering surgeons began to explore additional applications for minimal access surgery (MAS), such as appendectomy and lysis of adhesions. Additional instruments were created to allow surgeons to divide major blood vessels, resect lung, and anastomose bowel. Surgeons devised ways to repair hernias "without incisions." Gradually, steadily, more and more procedures traditionally performed with major open exposures were tried with the laparoscope so that at present some operations are preferentially performed by MAS.
Pediatric surgeons trailed surgeons for adults in adopting minimal access procedures. Perhaps because smaller patients have smaller incisions, some felt that the benefit of MAS in children was less evident. Children recover from major procedures faster than adults, and analgesic requirement after surgery is less in children. Youngsters return to full activity quickly. Nonetheless, surgery in any patient is traumatic, and a few practitioners saw an opportunity to minimize the insult of operation in their young patients. Leaders such as Gans, Rodgers, Georgeson, and Lobe showed that MAS was certainly applicable to the pediatric patient. Initially their work was performed on older children since instruments were sized for adults. Technical demands of operating in a small area of an infant was out of the question until instrument makers began to manufacture smaller, shorter tools for pediatric use. Successful outcomes resulted in more pediatric surgeons and urologists using MAS.
"Minimal access surgery" contrasts with standard access whereby an operation on an internal organ requires the operator to make a larger incision. The techniques share certain principles. Each requires exposure; each requires lighting. In open operations exposure is accomplished by making an adequate incision in an appropriate location, then holding internal structures aside with retractors. Lighting comes from overhead lights and headlamps worn by the operating team. In laparoscopic and thoracoscopic surgery, access is obtained using ports (valved tubular devices passed through small incisions in the abdominal (or chest) wall (Fig 1). A measured amount of CO2 is pumped into the abdomen via a port; this allows the abdominal cavity to expand so that the surgeon has room to see and to work. A scope is passed through the port: the scope is attached to a minicamera externally so that the operating team can watch the procedure on a television monitor. Light from an external halogen lamp source passes through fiberoptic rods located within the scope to illuminate the field. After the initial port is placed and the scope is passed, additional ports for instruments are inserted to allow the surgery to proceed.
Operative manipulations include division and dissection of tissues, establishing hemostasis, repair of structures, and removal of tissue. Laparoscopic instruments have been developed which allow the surgeon to perform each of the above (Fig 2). In pediatric procedures most instruments used are either 3 or 5 mm in diameter. Specialized graspers permit fragile tissue such as bowel to be handled without trauma. Scissors and dissectors have been designed to permit all of the maneuvers possible with "standard" operating instruments. Irrigation and suction devices allow the workers to keep the operative field clear. Hemostasis is achieved using ligatures, clips, cautery, stapling devices, and ultrasonic coagulation tools. Suturing can be performed internally. Specimens may be removed directly through a port or after first being placed into a protective bag device.
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Appendicitis
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Appendectomy is the most common emergency operation performed by pediatric surgeons. Treatment of appendicitis includes intravenous antibiotics and removal of the appendix. Drainage of an associated abscess may be warranted. Occasional cases of appendicitis present days into the process; intestinal loops, omentum, bladder, or pelvic organs have walled off the appendix and associated pus. These patients often are over the acute phase of the illness but have continued abdominal pain and fever. Other patients seeming to have appendicitis turn out to have a normal appendix at exploration; although frequent use of computerized tomography (CT) imaging has increased the accuracy of diagnosis, other pathology accounts for a significant number of these cases.
Open appendectomy (OA) is performed through a single right lower quadrant abdominal incision. Muscles are separated ("muscle-splitting") rather than divided to reduce trauma. The peritoneal cavity is entered and the appendix is located by digital examination. The appendix is delivered into the wound. The blood supply is controlled and divided, and then the appendix is removed. Many surgeons wash the abdomen with sterile saline before closing the incision. In cases where there has been gross spillage of purulent material, some surgeons choose to leave the skin open, packing the wound with gauze for several days then approximating the edges with strips. In adults, wound infections appear to be less frequent with this technique than with primary closure.
Laparoscopic appendectomy (LA) requires 3 incisions in most cases. One port is placed to accommodate the laparoscope; the other ports allow the surgeon to use instruments to manipulate the appendix and its attachments. Usually the umbilicus is used for the camera/lens port; small incisions in the left lower quadrant and the suprapubic region afford access to the right lower quadrant and upper pelvis. The appendix is identified and isolated. Most surgeons separate the appendix and its blood supply, then secure each either with ligatures, clips, stapling devices, or a combination. The amputated organ may be removed directly through a port, through the largest incision, or placed in a protective plastic bag and removed in either of these fashions.
The abdomen may be irrigated and suctioned if desired, and a drain may be placed and brought out of the abdomen through a lower port site. The fascia of the larger wounds is closed; that of smaller wounds is optional. Umbilical wounds may be packed or closed. Port sites other than the umbilicus are closed with plastic surgical technique.
LA provides the surgeon and the assistant visual access to a large part of the abdominal cavity. The appendix can be located in retrocecal, retroperitoneal, or pelvic positions. Rupture of the appendix may result in extrusion of an appendicolith into the pelvis. The limits of an abscess may be identified laparoscopically. Other causes of abdominal pain can be evaluated, and incidental findings may be noted or treated.1
Meguerditchian et al2 reviewed 391 appendectomies performed over a 3-year period. A total of 126 patients were treated with laparoscopy (LA), 262 by laparotomy (OA), and 3 were converted to OA. Although comparable rates of complications and narcotic use were noted, LA was associated with shorter hospitalization (2.38 days vs 2.94 days). Operative time for LA was slightly longer (45.7 minutes vs 40.6 minutes). Interestingly, rates of negative appendectomy were higher with laparoscopic procedures (21.4% vs 22.5%), but both figures seem excessive. Blakely et al3 reviewed published literature comparing OA and LA. They determined that LA offered a slight advantage over OA in most studies, noting that perforated appendicitis resulted in more complications regardless of the technique.
Krisher et al4 found the occurrence of intrabdominal abscess following appendectomy for perforated appendicitis 24% for patients undergoing LA and 4.2% after OA. Paya et al5 had 89 minor and 11 major complications in a group of 500 consecutive appendectomies (362 OA, 138 LA). All major complications (wound infections, intrabdominal abscess, ileus, others) occurred in the OA group. The same group studied 75 patients prospectively, all of whom had perforated appendicitis. Minor wound complications or postoperative fever occurred in 10% and 50% of the LA group and 14% and 15%, respectively, in OA. Major complications requiring intervention occurred only in the OA group (10%).6
Tan et al7 performed LA in 50 children using a 5-mm bipolar forceps to cauterize and strip the mesoappendix, reducing operative time and instrument expense. Schier8 has performed LA with 1.7-mm instruments, resulting in virtually no scar.
In 1 of the earlier retrospective series, el Ghoneimi et al9 demonstrated the safety and success of LA in 1379 patients, ranging in age from 2 to 16 years. Hospital course was marked by fewer complications from infection or adhesions; children were discharged sooner and returned to normal activities at 7 days.
Dronov et al10 report an initial experience of 205 cases of children who underwent LA. All children had LA performed successfully; 6 developed complications and 4 of these were treated laparoscopically. Canty and colleagues11 report their experience with 1128 appendectomies over a 6-year period. A total of 653 underwent LA, and 173 underwent OA. Perforated appendicitis represented one third of the LA group and half of the OA patients. Postoperative abscess rates and bowel obstruction did not differ between LA and OA. LA yielded shorter hospitals stays, required less postoperative pain medication, and achieved better cosmetic results. A decade ago Gilchrist et al12 studied a small prospective series of patients undergoing appendectomy. Although comparable in weight, age, hospital cost, and complications, patients undergoing LA spent fewer days in the hospital and returned to normal activities sooner. In many cases, the appendix and mesoappendix can be secured and divided with a single endoscopic stapler, reducing time, difficulty, and expense of LA.13 Hay14 reported LA required longer operative time but resulted in less postoperative pain, fewer wound complications, quicker return to normal activities, and a more desirable cosmetic result when compared with a similar group of patients undergoing OA. Increase in operating room cost, accounted for by time and use of disposable instruments, is balanced by the shorter hospital stay.
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Cholecystectomy/Hepatobiliary
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Laparoscopic cholecystectomy (LC) has replaced open cholecystectomy in adults as the technique of choice for removal of the gall bladder. Pioneering work of Holcomb and others demonstrates that it is the preferred technique in children as well.15–21 Infants can be successfully treated with LC.22,23 In the pediatric population, the procedure is performed most often in adolescents with cholecystitis. Gall stone formation associated with hemolytic disease accounts for a significant proportion of cases. Common duct stones are far less frequent in children than in adults, but pancreatitis secondary to passage of a small stone is not uncommon. Long-term parenteral nutritional therapy, short gut syndrome, and a variety of medications have been associated with gall bladder disease in pediatric patients.
The laparoscopic approach to the gall bladder usually requires 4 ports. An umbilical port is placed for the scope, then a second port is placed in the lateral aspect of the right subcostal region. The fundus of the gall bladder is grasped and retracted cephalad through this port. Two working ports are then placed in the right subcostal area at the midclavicular line and near the xyphoid process. With the proximal portion of the gall bladder exposed, the peritoneum is opened and the cystic duct and cystic artery are identified. Great care must be taken to identify the junction of the cystic duct with the common bile duct (CBD) so that injury to the latter (or an anomalous hepatic duct) does not occur. The duct is clipped and divided, then the artery is similarly divided. The gall bladder is then dissected from medial to lateral using cautery to minimize bleeding and bile leak. The freed gall bladder is then placed into a plastic bag and removed through a large port site. Drains are not used routinely.
CBD stones may be present in children with cholelithiasis. Although clinical evidence of CBD stones were present (clinical picture, ultrasound, laboratories) in 20 of 100 patients undergoing LC, Waldhausen found stones by intraoperative cholangiography in 15 of that group as well as 3 additional patients who had no clinical evidence of stones. Intraoperative cholangiography was successful in 55 of 63, and endoscopic retrograde cholangiopancreatography was avoided in patients with no stones visualized.24 Mattioli et al25 reported 58 patients under the age of 10 years who underwent LC for stone disease. All but 1 was completed laparoscopically. Transcystic common duct exploration has been performed by Shah et al26 using either a rigid 7F cystoscope or flexible 10F fiber-optic cystoscope. Endoscopic retrograde cholangiopancreatography can be used to extract retained stones before or following cholecystectomy.27 Reduced postoperative stay is confirmed by numerous authors.28–34 LC can be performed in patients who have undergone prior abdominal surgery.35
Several authors note the benefit of laparoscopic examination of the liver in jaundiced infants to distinguish between neonatal hepatitis and biliary atresia.36,37 Laparoscopic cholecystocholangiography can be used to evaluate the jaundiced infant for biliary atresia.38
Laparoscopically directed liver biopsy may be more reliable than blind percutaneous biopsy.39
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Splenectomy
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The anatomy of the spleen makes it very amenable to laparoscopic removal. Blood supply enters the spleen at the central hilum; there is occasionally a lower pole artery, and short gastric vessels are always present. Indications for removing the spleen in children include spherocytosis, hypersplenism, refractile thrombocytopenia, symptomatic splenomegaly, storage diseases, and tumor.
Four ports are used routinely. The umbilical port is used for the scope. A 12-mm port is placed in the left lower quadrant to retract the spleen during initial dissection, then to pass the endoscopic stapler. Ports are placed in the xyphoid region and left upper quadrant, and the surgery is primarily performed using instruments through these sites. To avoid spillage of splenic tissue (which may result in port site implantation40), the mobilized spleen is passed into a large endoscopic pouch. Accessory spleens are sought and removed. The spleen may then be removed piecemeal through the left lower quadrant incision, or by enlarging that incision to extract the organ.41 Drains are not used.
In a study comparing open splenectomy and laparoscopic elective splenectomy (LS), Reddy et al42 found that LS resulted in longer operative times but significant reduction in hospital stay, time to initial oral intake, and use of postoperative narcotics. Complications were rare with either technique. Other groups have reported similar results.43–51 Esposito et al52 feel that the size of the spleen may affect the success of LS; they advocate preoperative ultrasound to measure the size of the spleen. Should the organ be very large, an open technique may be preferable. Introduction of the ultrasonic scalpel53 and the large, wide-rimmed endoscopic pouch have contributed to making the technique of LS easier.54 Numerous authors report that experience with LS resulted in a decrease in operative time.55,56 Cost of hospitalization was elevated57,58 or similar59 in some early studies but reduced in later reports.42
Splenic cyst is an unusual lesion that can be treated laparoscopically.60,61 These lesions, which may be congenital or acquired, can be treated with drainage, partial splenectomy, or splenectomy. The ultrasonic scalpel (a cutting and coagulating instrument that does not damage adjacent tissue) has made endoscopic decapsulization possible.62
"Wandering" spleen is a rare condition that predisposes the organ to torsion and infarction. Attributed to lax ligamentous attachments, treatment is directed toward stabilizing the position of the spleen. Hirose et al63 successfully performed laparoscopic splenopexy with mesh.
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Antireflux Procedures and Gastrostomy
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Gastroesophageal reflux disease (GERD) is a common problem in the pediatric population. Most children can be managed successfully with feeding regimens and medication, but children whose reflux fails to respond become surgical candidates. Antireflux procedures are commonly performed as an adjunct to gastrostomy in neurologically compromised individuals. GERD patients who have had aspiration or "near miss" sudden infant death syndrome episodes are also appropriate children in whom an antireflux operation may play an important role.
Laparoscopic Nissen fundoplication (LNF) as described by Nissen64 is the procedure most commonly performed for GERD. The principles of the operation include increasing the amount of intrabdominal esophagus, creating a valve-like mechanism at the gastroesophageal junction by wrapping a portion of the gastric fundus around the esophagus at that location, and creating a wrap sufficiently loose to allow the patient to relieve gastric distention by belching. Kawahara and colleagues65 document success of LNF in increasing lower esophageal sphincter postprandial resting pressure and maintaining significant residual lower esophageal sphincter pressure during relaxation without inducing esophageal dysmotility. Access to the abdomen is obtained through an umbilical port; a scope with a 30° viewing angle allows good visualization of the esophagus at the hiatus. A port is placed in the right upper quadrant to retract the left lobe of the liver, and another is placed in the left upper quadrant for traction on the stomach and to aid dissection. Ports are then placed in the epigastric and left subcostal region to be used in dissection; the latter may be the future site of a gastrostomy. After dissection and mobilization of the esophagus, the fundus is mobilized and wrapped posteriorly around the esophagus. Care is taken to avoid trauma to the vagus nerves (which could delay gastric emptying). A large dilator is passed through the esophagus and the wrap is sewn in place with nonabsorbable sutures. Atraumatic laparoscopic instruments have been manufactured to allow these structures to be grasped and manipulated without injury. Sutures are placed with endoscopic needle drivers; knots may be tied using intracorporeal or extracoporeal technique. Infants can undergo successful LNF thanks to the availability of 3-mm instruments.66
Alternate antireflux procedures such as those described by Toupet67 and Thal68 employ a partial wrap. Dissection of the esophagus and stomach are the same as for fundoplication, but rather than bringing the stomach 360° around the esophagus and sewing it to itself (incorporating the esophagus), the stomach is sewn directly to esophagus, creating a wrap of 270°. The gastroesophageal angle is also recreated.69 Van der Zee and coworkers70 described successful 180° Thal wraps in 96 of 100 patients. Four required conversion to complete wraps. A total of 88% showed clinical improvement, but pH studies showed evidence of persistent reflux in 25%.71 Georgeson72 converted 5 of 201 children treated with Toupet fundoplication to a complete wrap. Schleef73 performs laparoscopically assisted (L-A) anterior gastropexy in children with GERD. Tovar et al74 found similar improvement with LNF, noting an overall failure rate in 14%, equivalent to open Nissen fundoplication (ONF).
Mattioli et al75 report a comparison of laparoscopic and open approaches to fundoplication. Measuring children between 1 and 14 years of age, 17 patients were treated with open fundoplication while 49 underwent laparoscopic Nissen. The latter group averaged 22 minutes less intraoperatively and 5 days less in the hospital.
Somme and colleagues76 found that LNF took half an hour longer than ONF. In their series hospital stays were similar, and ONF had a significantly higher incidence of recurrence.
Rothenberg77 noted the steep learning curve necessary to perform expeditious and successful LNF in infants and children. Allal78 reported experience with 142 consecutive laparoscopic antireflux procedures. The authors noted a decrease in operating time of 30 minutes after the first 60 cases, and had no complications in the last 79 cases. Esposito79 recorded 25 complications in 289 patients who underwent antireflux surgery. Fifteen had intraoperative events including pleural perforation, vagus nerve injury, esophageal perforation, gastric perforation, and pericardial perforation. They described 10 postoperative complications: 1 undetected esophageal perforation, 5 cases of fat herniated into port sites, 3 cases of dysphagia (all of which resolved), and 1 case of delayed gastric emptying that required surgery. Hopkins and Stringel80 report 25 consecutive patients in whom LNF was completed without significant complication. Time to feeding, analgesic requirements, and length of stay were decreased when compared with traditional surgery. Georgeson81 reported similar findings. Meehan and Georgeson82 reported that 64% of their patients were discharged by postoperative day 3. They report a complication rate of 7.4%, including 1 death attributable to a misplaced gastrostomy. Fundoplication has been performed successfully in patients with prior percutaneous endoscopic gastrostomy (PEG).83 Patients with familial dysautonomia who require antireflux surgery tolerate LNF well.84 Scoliosis is not a contraindication to LNF.85 Many children are unable to feed and receive a gastrostomy for enteral nutrition. PEG placement is a widely accepted technique with a low incidence of complications.86 In patients undergoing fundoplication in whom gastrostomy is desired, the stomach is secured to the anterior abdominal wall and using either PEG technique87 or with laparoscopic assistance,88 exiting through the left subcostal incision. Tomicic et al89 reported successful placement of a gastrostomy button in 51 patients using a single umbilical port and a left upper quadrant button site. All patients began feedings the day after surgery. Eighteen patients had concomitant LNF. Two patients required reoperation for tube dislodgement.
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Achalasia
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Achalasia is an uncommon abnormality in children. Treatment usually consists of esophageal dilatation, with surgery being reserved for those who fail in this approach. Rothenberg90 has performed both thoracoscopic and laparoscopic esophageal myotomy, preferring the latter because of better results and a shorter convalescence. Others have used laparoscopic approach to achalasia, but the incidence of mucosal perforation is significant.91,92
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Pyloric Stenosis
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Many pediatric surgeons perform division of the hypertrophic pyloric muscle laparoscopically. Using an umbilical incision to access the abdomen to perform open pyloromyotomy (OP) has eliminated the often-sizable traditional right upper quadrant incision. Which technique is better? Fujimoto93 reviewed the cases of 60 infants with pyloric stenosis performed over a 3-year period. Half underwent OP and half were done laparoscopically (laparoscopic pyloromyotomy; LP). Operating times were equally long or longer in the LP patients. LP patients reached full feeding much sooner than OP patients (38 hours vs 64 hours). Emesis after surgery was lower in the LP group (3% vs 25%). LP patients had a shortened hospital stay, and only 1 required conversion to OP because of mucosal perforation. Sitsen,94 however, reports that while LP may produce a better cosmetic result, cause less postoperative pain, and lead to earlier discharge, LP has a higher rate of mucosal perforation than OP and takes longer.
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Inguinal Hernia
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Repair of inguinal hernia is one of the most common procedures performed by pediatric surgeons. Controversy exists over whether a child with a hernia on a single side should undergo surgical exploration of the "silent" side. Generations of pediatric surgeons have been taught to explore the contralateral groin, but this practice results in a significant number of "negative" explorations. A 1996 survey of members of the Surgical Section of the American Academy of Pediatrics noted that 65% of respondents explored the contralateral side of males 
2 years of age and 84% explore females up to 4 years old.95 Uncomfortable with performing these procedures, surgeons have sought less invasive ways to evaluate the opposite side. Minimally invasive techniques have been adapted to accommodate this purpose. The author performs exploration of the "silent" side in selected patients: children whose hernia presents at age 2 years, children <36 weeks at birth, children with clinical suggestion of a contralateral hernia, and children who are high risk for anesthesia in whom a second separate procedure would pose significant risk. After isolating the hernia sac on the known side, the sac is opened and a small port is inserted. CO2 is insufflated to distend the abdomen, then an angled laparoscope is passed and focused on the opposite internal ring. The absence or presence of a patent processus vaginalis on that side is determined; the devices are removed and repair of the known side is completed. If laparoscopic inspection of the opposite groin revealed no evidence of hernia, the operation ends. If a patent processus vaginalis was found, a mirror-image incision is made and hernia repair is conducted. Fuenfer et al96 have described a technique whereby a small puncture is made in the abdominal wall of the contralateral side and a 14-gauge intravenous catheter is inserted. A 1.2-mm scope is passed through this catheter and the groin is visualized. Gardner et al97 use a flexible cystoscope to evaluate the opposite side. Visualization of the opposite groin reveals a variety of anatomic configurations.98,99 Probing the contralateral processus vaginalis may be helpful to confirm patency and determine its length.100 Numerous reports reveal the contralateral processus vaginalis to be closed in 52% to 78% of cases, suggesting that contralateral exploration without imaging is no longer appropriate.101–110 Meta-analysis by Miltenberg et al111 determined laparoscopic evaluation of contralateral hernia to have a specificity of 99.4% and sensitivity of 99.5%, based on their analysis of published studies.
Laparoscopy provides useful information in patients with recurrent inguinal hernias.112 Direct inguinal hernias and femoral hernias are far less common in children than indirect inguinal hernias. Laparoscopy for hernia repair allows confirmation of these diagnoses, and repair can be performed using laparoscopic technique.113–117
Laparoscopic repair of indirect inguinal hernias has been performed in a relatively small number of pediatric patients. Long-term outcomes are not yet available.
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Intestinal Surgery
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Many intestinal operations can be performed successfully using laparoscopic techniques. Gauderer118 has described a technique to insert a PEG-type gastrostomy tube for colonic irrigations in patients with chronic evacuation difficulties. Intestine can be readily assessed in patients with suspected Crohn’s disease in whom radiographic studies are inconclusive.119 Diamond and Langer120 compared open and L-A techniques in ileocolic resection for Crohn’s disease. They noted no significant differences in analgesic requirement or return to a regular diet, but found that patients who underwent successful L-A resection were discharged 2 days sooner. Hirschsprung’s disease has been treated successfully by numerous authors.121–124 Georgeson et al125 argue that L-A primary endorectal pull-through is the new standard treatment for Hirschsprung’s disease. Intestinal biopsy can be performed using L-A technique.126,127 Robotic technology may permit small lumen anastomoses to be performed with precision.128 Intestinal duplication (ID) and Meckel’s diverticulum (MD) are amenable to laparoscopic resection.129–131 Intestinal malrotation and heterotaxy syndrome have been corrected laparoscopically.132–135
The role of laparoscopy in the patient with intussusception is unclear. Van der Laan136 found that only 3 of 10 patients in whom laparoscopic reduction was attempted had a successful outcome. Of these failures, 5 were reduced after conversion to open surgery and 2 required resection. Hay137 used laparoscopy to monitor intraoperative saline enema reduction. Schier138 reported successful reduction in approximately half of his patients. Experimental L-A pneumatic reduction was successful in 94.5%.139 Others have reported successful outcomes.140–142
Georgeson143 has used MAS in place of posterior sagittal anorectoplasty in patients with high imperforate anus. Seven underwent initial colostomy with subsequent pull-through, whereas 4 underwent primary correction. Long-term follow-up is not yet available.
Intestinal adhesions may be treated successfully using MAS in selected patients.144,145 MAS can be used to evaluate and treat ingested foreign bodies.146,147 Release of the ligament of Treitz laparoscopically has corrected the symptoms of superior mesenteric artery syndrome.148 Gastric volvulus has been pexed with laparoscopic assistance.149
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Diagnostic Laparoscopy
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Many authors have employed MAS techniques to diagnose and treat intrabdominal pathology. Exploration for abdominal pain has uncovered adhesions, ovarian torsion, appendicitis, MD, inguinal hernia, urachal cyst, parafallopian tube cyst, and lymphadenopathy.1,150 Lee et al151 managed 17 children with gastrointestinal bleeding using laparoscopy. Endoscopic examinations showed no bleeding source. Technetium pertechnetate scan was positive in 6: 4 had a MD, 1 had ID, and 1 had lymphoid hyperplasia (LH). Of the negative scans, 3 patients had MD, 1 had ID, 1 had LH, 1 had Henoch-Schoenlein purpura, and 4 had normal laparoscopy. One patient who underwent laparoscopy without a prior scan proved to have MD. Laparoscopic surgical resection was successful in all but the Henoch-Schoenlein Purpura patient, whose disease was considered too extensive for laparoscopic resection. Swaniker and coworkers152 argued that the low negative predictive value of technetium pertechnetate scan in patients suspicious for MD (lower gastrointestinal bleeding, hemoglobin <11.0) are better served by laparoscopy rather than scintigraphy. Abdominal pain caused by omental infarction can be diagnosed and treated laparoscopically.153 Gurkan154 used laparoscopy to assist in the diagnosis of tuberculous peritonitis. Appendicovesicular fistula was diagnosed at laparoscopy in a 21-month-old child with recurrent urinary tract infection and negative workup of ultrasound, CT scan, barium enema, and cystogram.155 Diagnostic laparoscopy may be valuable in evaluating suspected Crohn’s disease.156 A role is emerging for laparoscopy in the diagnosis and management of blunt abdominal trauma in children.157–160
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Undescended Testis
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Successful outcome for the male with undescended testis depends on several factors, not least of which is the position of the testis. The gonad position can be anywhere from the internal inguinal ring to the kidney, and the testis may have vanished. Laparoscopy has come to play an important role in the management of the child whose testis cannot be palpated. For patients whose testis is palpable in the internal ring, laparoscopy may serve a role if short testicular vessels are the limiting factor to completion of the orchidopexy. When the testicle cannot be palpated, laparoscopy allows both visualization of the gonad and access to the vessels (which can be divided laparoscopically) and surrounding tissues for dissection. Inguinal ultrasound may eliminate the need to perform laparoscopy in some patients with a nonpalpable testis.161 Laparoscopy is more sensitive than nuclear magnetic resonance in detecting a nonpalpable testis.162 Numerous authors report successful outcomes using MAS technique for boys with a nonpalpable testis.163–169 Staged techniques are preferred by several authors, who report an initial laparoscopy with division of the vessels, then subsequent surgery to deliver the testicle into the scrotum.170–172 L-A autotransplantation of the testis has been successfully performed.173 Ferro et al174 examined 2 groups of patients with nonpalpable testes prospectively randomized to undergo laparoscopic surgery then open orchidopexy or open surgery alone. They found no significant difference in anatomic findings, recurrences, or testicular volume between the 2 groups. Cost and operative time was significantly higher in the MAS group.
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Varicocele
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Many surgeons have employed laparoscopy to treat young men with varicocele. Barqawi et al175 found that previous groin surgery (hernia repair, orchidopexy) was not a contraindication to laparoscopic Palomo varicocelectomy (ligation of both spermatic artery and vein proximal to the internal inguinal ring). Sun and coworkers176 found no difference in testicular volume after laparoscopic clipping of these vessels in 14 patients. In a large series, the authors from Magna Graecia University reported no incidence of testicular atrophy in 211 children who underwent laparoscopic varicocelectomy. Complications occurred in 9%; these included ipsilateral hydrocele, scrotal emphysema, and umbilical wound granuloma. Recurrence of varicocele was <5%.177 Excellent results have been reported by many other groups.178–181
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Other Intraabdominal Conditions
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Laparoscopy has been valuable in detecting the site of leakage from abnormal lymphatic ducts in patients with chylous ascites.182 Lessin et al183 used laparoscopic technique to introduce peritoneal dialysis catheters into pediatric patients. Although resulting in early catheter use, early hospital discharge, and controlled catheter placement, complications were common. Two thirds of the group had good long-term catheter function. Ventriculoperitoneal shunts that malfunction secondary to intraabdominal processes (adhesions, pseudocyst) are readily salvaged using MAS technique.184 Excision of a mesenteric cyst associated with a gastric volvulus and pexy of the stomach has been reported.185 Oophorectomy for torsion and for teratoma is discussed below; removal of streak gonads in patients with Turner’s syndrome or other intersex conditions is readily accomplished.186 Laparoscopic technique has been used successfully to diagnose and remove aberrant gonadal tissue in testicular feminization syndrome187 and hermaphrodism.188
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Tumors
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MAS offers a valuable tool to use in evaluating and treating selected tumors. Tumor masses that previously would require open surgical biopsy can now be accessed through laparoscopy and thoracoscopy. Occasional tumors occurring in those organs that lend themselves to laparoscopic resection—kidney, adrenal, spleen, ovary—can be removed in their entirety. Lymph node biopsy from the abdomen or the chest is commonly performed. Tumor nodules metastatic to lung can be resected. Partial resection of isolated lesions of the kidney and liver may be possible, but selection is essential. Iwanaka189 reviewed 37 children with abdominal neuroblastoma. Those with advanced disease underwent laparoscopic biopsy, open biopsy, or second-look procedures. Those with early disease underwent either open or laparoscopic resection. Patients undergoing laparoscopic procedures had shorter lengths of stay and time to postoperative feeding but no difference in operative times or blood loss. Neuroblastoma detected on mass screening can be excised laparoscopically.190,191 A successful resection of a subdiaphragmatic epidermoid cyst and diaphragmatic repair has been reported.192 Waldhausen et al193 used MAS techniques to biopsy patients with thoracic or subdiaphragmatic lesions and achieved 100% diagnostic accuracy. Others confirm the high diagnostic accuracy rate.194,195 Recently, Holcomb196 surveyed experts in pediatric surgical oncology and experts in MAS by providing case scenarios to determine which would be applicable to MAS. Participants generally agreed that thoracoscopy or laparoscopy was safe and adequate for biopsies of tumors. Tumor resection could be performed in some cases when the surgeon had an appropriate skill level. Biopsy of peripheral pulmonary nodules was endorsed in patients with malignancies other than osteogenic sarcoma (participants felt palpation of the entire lung was important to resect all nodules). The respondents felt that open excision of solid organ tumors was preferable with the exception of a well-defined thoracic neuroblastoma. Laparoscopic ultrasound may prove a useful adjunct for detecting lymph nodes and tumors during exploration.197 Tumor implantation at a port sites is a concern in MAS for malignancy. In a murine model, Iwanaka et al198 showed that administration of chemotherapeutic agent on postoperative days 0 and 3 effectively prevented port site recurrence.
Benign intrathoracic lesions (bronchogenic cyst, foregut duplication) have been successfully excised using MAS techniques.199
Ovarian pathology has long been approached laparoscopically. Cystic teratomas can be resected using ovary-sparing techniques known to open surgery. Spillage rates are higher with MAS, but long-term outcomes are excellent.200 Simple cysts and ovarian torsion have also been treated successfully with laparoscopic technique.201,202 Newborn ovarian cysts have been successfully removed by Esposito et al.203 Pelvic inflammatory disease can be diagnosed and treated using MAS.204 Adolescent females with chronic abdominal pain not responsive to standard therapy may have endometriosis; laparoscopy may reveal subtle findings and allow therapy to be directed appropriately.205 As an adjunct to cancer treatment, Heloury et al206 have performed laparoscopic adnexal transposition before directed radiotherapy.
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ABSTRACT
INTRODUCTION
