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PEDIATRICS Vol. 111 No. 6 June 2003, pp. 1239-1252

REVIEW ARTICLE

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

	ABSTRACT

TOP ABSTRACT INTRODUCTION Appendicitis Cholecystectomy/Hepatobiliary Splenectomy Antireflux Procedures and... Achalasia Pyloric Stenosis Inguinal Hernia Intestinal Surgery Diagnostic Laparoscopy Undescended Testis Varicocele Other Intraabdominal Conditions Tumors Diaphragm Empyema Fetal Surgery and Congenital... Physiology Cost Pain Control Training Contraindications/Complications CONCLUSIONS REFERENCES

 
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

	INTRODUCTION

TOP ABSTRACT INTRODUCTION Appendicitis Cholecystectomy/Hepatobiliary Splenectomy Antireflux Procedures and... Achalasia Pyloric Stenosis Inguinal Hernia Intestinal Surgery Diagnostic Laparoscopy Undescended Testis Varicocele Other Intraabdominal Conditions Tumors Diaphragm Empyema Fetal Surgery and Congenital... Physiology Cost Pain Control Training Contraindications/Complications CONCLUSIONS REFERENCES

 
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.

View larger version (95K): [in this window] [in a new window]   Fig 1. Ports (3 mm) with pen for comparison.

 
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.

View larger version (80K): [in this window] [in a new window]   Fig 2. Pediatric laparoscopic instruments, 3 mm (top to bottom: scissors, grasper, dissector).

 

	Appendicitis

TOP ABSTRACT INTRODUCTION Appendicitis Cholecystectomy/Hepatobiliary Splenectomy Antireflux Procedures and... Achalasia Pyloric Stenosis Inguinal Hernia Intestinal Surgery Diagnostic Laparoscopy Undescended Testis Varicocele Other Intraabdominal Conditions Tumors Diaphragm Empyema Fetal Surgery and Congenital... Physiology Cost Pain Control Training Contraindications/Complications CONCLUSIONS REFERENCES

 
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.

	Cholecystectomy/Hepatobiliary

TOP ABSTRACT INTRODUCTION Appendicitis Cholecystectomy/Hepatobiliary Splenectomy Antireflux Procedures and... Achalasia Pyloric Stenosis Inguinal Hernia Intestinal Surgery Diagnostic Laparoscopy Undescended Testis Varicocele Other Intraabdominal Conditions Tumors Diaphragm Empyema Fetal Surgery and Congenital... Physiology Cost Pain Control Training Contraindications/Complications CONCLUSIONS REFERENCES

 
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

	Splenectomy

TOP ABSTRACT INTRODUCTION Appendicitis Cholecystectomy/Hepatobiliary Splenectomy Antireflux Procedures and... Achalasia Pyloric Stenosis Inguinal Hernia Intestinal Surgery Diagnostic Laparoscopy Undescended Testis Varicocele Other Intraabdominal Conditions Tumors Diaphragm Empyema Fetal Surgery and Congenital... Physiology Cost Pain Control Training Contraindications/Complications CONCLUSIONS REFERENCES

 
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 elevated^57,58 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.

	Antireflux Procedures and Gastrostomy

TOP ABSTRACT INTRODUCTION Appendicitis Cholecystectomy/Hepatobiliary Splenectomy Antireflux Procedures and... Achalasia Pyloric Stenosis Inguinal Hernia Intestinal Surgery Diagnostic Laparoscopy Undescended Testis Varicocele Other Intraabdominal Conditions Tumors Diaphragm Empyema Fetal Surgery and Congenital... Physiology Cost Pain Control Training Contraindications/Complications CONCLUSIONS REFERENCES

 
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.

	Achalasia

TOP ABSTRACT INTRODUCTION Appendicitis Cholecystectomy/Hepatobiliary Splenectomy Antireflux Procedures and... Achalasia Pyloric Stenosis Inguinal Hernia Intestinal Surgery Diagnostic Laparoscopy Undescended Testis Varicocele Other Intraabdominal Conditions Tumors Diaphragm Empyema Fetal Surgery and Congenital... Physiology Cost Pain Control Training Contraindications/Complications CONCLUSIONS REFERENCES

 
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

	Pyloric Stenosis

TOP ABSTRACT INTRODUCTION Appendicitis Cholecystectomy/Hepatobiliary Splenectomy Antireflux Procedures and... Achalasia Pyloric Stenosis Inguinal Hernia Intestinal Surgery Diagnostic Laparoscopy Undescended Testis Varicocele Other Intraabdominal Conditions Tumors Diaphragm Empyema Fetal Surgery and Congenital... Physiology Cost Pain Control Training Contraindications/Complications CONCLUSIONS REFERENCES

 
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.

	Inguinal Hernia

TOP ABSTRACT INTRODUCTION Appendicitis Cholecystectomy/Hepatobiliary Splenectomy Antireflux Procedures and... Achalasia Pyloric Stenosis Inguinal Hernia Intestinal Surgery Diagnostic Laparoscopy Undescended Testis Varicocele Other Intraabdominal Conditions Tumors Diaphragm Empyema Fetal Surgery and Congenital... Physiology Cost Pain Control Training Contraindications/Complications CONCLUSIONS REFERENCES

 
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.

	Intestinal Surgery

TOP ABSTRACT INTRODUCTION Appendicitis Cholecystectomy/Hepatobiliary Splenectomy Antireflux Procedures and... Achalasia Pyloric Stenosis Inguinal Hernia Intestinal Surgery Diagnostic Laparoscopy Undescended Testis Varicocele Other Intraabdominal Conditions Tumors Diaphragm Empyema Fetal Surgery and Congenital... Physiology Cost Pain Control Training Contraindications/Complications CONCLUSIONS REFERENCES

 
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

	Diagnostic Laparoscopy

TOP ABSTRACT INTRODUCTION Appendicitis Cholecystectomy/Hepatobiliary Splenectomy Antireflux Procedures and... Achalasia Pyloric Stenosis Inguinal Hernia Intestinal Surgery Diagnostic Laparoscopy Undescended Testis Varicocele Other Intraabdominal Conditions Tumors Diaphragm Empyema Fetal Surgery and Congenital... Physiology Cost Pain Control Training Contraindications/Complications CONCLUSIONS REFERENCES

 
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

	Undescended Testis

TOP ABSTRACT INTRODUCTION Appendicitis Cholecystectomy/Hepatobiliary Splenectomy Antireflux Procedures and... Achalasia Pyloric Stenosis Inguinal Hernia Intestinal Surgery Diagnostic Laparoscopy Undescended Testis Varicocele Other Intraabdominal Conditions Tumors Diaphragm Empyema Fetal Surgery and Congenital... Physiology Cost Pain Control Training Contraindications/Complications CONCLUSIONS REFERENCES

 
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.

	Varicocele

TOP ABSTRACT INTRODUCTION Appendicitis Cholecystectomy/Hepatobiliary Splenectomy Antireflux Procedures and... Achalasia Pyloric Stenosis Inguinal Hernia Intestinal Surgery Diagnostic Laparoscopy Undescended Testis Varicocele Other Intraabdominal Conditions Tumors Diaphragm Empyema Fetal Surgery and Congenital... Physiology Cost Pain Control Training Contraindications/Complications CONCLUSIONS REFERENCES

 
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

	Other Intraabdominal Conditions

TOP ABSTRACT INTRODUCTION Appendicitis Cholecystectomy/Hepatobiliary Splenectomy Antireflux Procedures and... Achalasia Pyloric Stenosis Inguinal Hernia Intestinal Surgery Diagnostic Laparoscopy Undescended Testis Varicocele Other Intraabdominal Conditions Tumors Diaphragm Empyema Fetal Surgery and Congenital... Physiology Cost Pain Control Training Contraindications/Complications CONCLUSIONS REFERENCES

 
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

	Tumors

TOP ABSTRACT INTRODUCTION Appendicitis Cholecystectomy/Hepatobiliary Splenectomy Antireflux Procedures and... Achalasia Pyloric Stenosis Inguinal Hernia Intestinal Surgery Diagnostic Laparoscopy Undescended Testis Varicocele Other Intraabdominal Conditions Tumors Diaphragm Empyema Fetal Surgery and Congenital... Physiology Cost Pain Control Training Contraindications/Complications CONCLUSIONS REFERENCES

 
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.

	Diaphragm

TOP ABSTRACT INTRODUCTION Appendicitis Cholecystectomy/Hepatobiliary Splenectomy Antireflux Procedures and... Achalasia Pyloric Stenosis Inguinal Hernia Intestinal Surgery Diagnostic Laparoscopy Undescended Testis Varicocele Other Intraabdominal Conditions Tumors Diaphragm Empyema Fetal Surgery and Congenital... Physiology Cost Pain Control Training Contraindications/Complications CONCLUSIONS REFERENCES

 
Diaphragmatic abnormalities have been corrected with MAS techniques. Paraesophageal hernia may be closed laparoscopically.²⁰⁷ Morgagni hernias have been repaired successfully,²⁰⁸ as have posttraumatic hernia²⁰⁹ and congenital diaphragmatic hernia in a 6-month-old.²¹⁰

	Empyema

TOP ABSTRACT INTRODUCTION Appendicitis Cholecystectomy/Hepatobiliary Splenectomy Antireflux Procedures and... Achalasia Pyloric Stenosis Inguinal Hernia Intestinal Surgery Diagnostic Laparoscopy Undescended Testis Varicocele Other Intraabdominal Conditions Tumors Diaphragm Empyema Fetal Surgery and Congenital... Physiology Cost Pain Control Training Contraindications/Complications CONCLUSIONS REFERENCES

 
Treatment of empyema as a complication of bacterial pneumonia is based on the principles of antibiotic therapy and clearing of the pleural cavity of fluid and exudates. The latter can be accomplished by aspiration or by inserting a chest tube when the exudate is in a liquid state. In time the exudates congeals, making surgical evacuation the only option. Previously, this was only accomplished by open surgery. Minimal access techniques enable the surgeon to accomplish drainage with far less trauma.

General anesthesia is required. The patient is rotated so that the affected side is elevated. After standard skin preparation, the pleural cavity is accessed via a small incision and blunt dissection. Local anesthesia is often used as a supplement. Once the chest cavity is entered, a blunt-tipped port is introduced and the lung is cleared from the parietal pleura. CO₂ is often infused at low pressure to "push" the lung away. A second incision is made when sufficient space has been cleared to allow safe entry; a port may be introduced, or instruments may be placed directly through the opening. All fluid and exudates is cleared. One or 2 chest tubes are inserted through these openings and attached to closed suction drainage.

Merry et al²¹¹ reported results in 19 patients who underwent thoracoscopy to evacuate fibrous exudates of empyema. Resolution of fever and days to discharge from hospital compared favorably with open thoracotomy. Similar results were reported by Gandhi and Stringel.²¹²

	Fetal Surgery and Congenital Anomalies

TOP ABSTRACT INTRODUCTION Appendicitis Cholecystectomy/Hepatobiliary Splenectomy Antireflux Procedures and... Achalasia Pyloric Stenosis Inguinal Hernia Intestinal Surgery Diagnostic Laparoscopy Undescended Testis Varicocele Other Intraabdominal Conditions Tumors Diaphragm Empyema Fetal Surgery and Congenital... Physiology Cost Pain Control Training Contraindications/Complications CONCLUSIONS REFERENCES

 
Laparoscopic procedures performed in utero are described as "fetoscopic" surgery. Numerous procedures have been performed, including bladder decompression in posterior urethral valves,²¹³ laser coagulation of vascular anastomoses in severe twin-twin transfusion syndrome,²¹⁴ temporary tracheal occlusion in the fetus with diaphragmatic hernia, division of amniotic bands, access to fetal vessels, and drainage of fetal hydrothorax.²¹⁵ Early experience with fetoscopic surgery suggests a reduction in the risk of preterm delivery when compared with open fetal surgery.²¹⁶

Interest in pediatric laparoscopic surgery has created a market demand for smaller, shorter instruments that allow infant and newborn procedures to be completed successfully. Worldwide, pediatric surgeons are venturing into the realm of newborn MAS to treat congenital defects. Pioneers such as Rothenberg, Lobe, and Georgeson have brought the tools and skills of MAS to the youngest patients. Laparoscopic correction of intestinal malrotation by Ladd’s procedure is readily accomplished; controversy exists as to whether the technique is appropriate for the patient with midgut volvulus.¹³⁵ Georgeson¹²⁶ has popularized L-A pull-through for Hirschsprung’s disease. Langer¹²⁴ has gone a step farther and eliminated the laparoscopic part of the procedure in many cases.

Imperforate anus with bladder neck fistula or prostatic/bulbar urethra has now been approached laparoscopically. Advocates of this technique feel that a single-stage pull-through placed in the identified center of the muscular complex may allow the patient to be continent and can avoid the morbidity of laparotomy and, in some cases, colostomy.¹⁴⁴

Lobar emphysema other pulmonary malformations can be resected as indicated, particularly with the advent of endoscopic staplers. Patent ductus interruption is accomplished with clips.²¹⁷ Diaphragmatic hernia and eventration can be repaired using MAS techniques. In the former, a patch is sewn into place after reducing the herniated intestine.²¹⁸ Eventration is treated by tightening the floppy diaphragmatic muscle with several rows of endoscopically placed sutures. Long-term results are not yet available, and to date few cases have been reported.

Repair of esophageal atresia and tracheoesophageal fistula typically requires thoracotomy in the newborn period, which has been associated with scoliosis and restricted chest development in some children. Several authors have now reported early success with thoracoscopic repair of esophageal atresia with or without tracheoesophageal fistula.^219,220

	Physiology

TOP ABSTRACT INTRODUCTION Appendicitis Cholecystectomy/Hepatobiliary Splenectomy Antireflux Procedures and... Achalasia Pyloric Stenosis Inguinal Hernia Intestinal Surgery Diagnostic Laparoscopy Undescended Testis Varicocele Other Intraabdominal Conditions Tumors Diaphragm Empyema Fetal Surgery and Congenital... Physiology Cost Pain Control Training Contraindications/Complications CONCLUSIONS REFERENCES

 
Laparoscopic procedures performed with CO₂ experimentally do not result in transient decrease in cell-mediated immunity that is seen by laparotomy.²²¹ Inflammatory response as measured by interleukin-1, interleukin 6, tumor necrosis factor-, polymorphonuclear cells, and macrophage counts showed an increased response for laparotomy as compared with laparoscopy.²²² Menoza-Sagaon and coworkers,²²³ however, found no significant difference in stress response in pigs undergoing open or LC. The risk of intestinal ischemia can be controlled by monitoring intrabdominal pressure.²²⁴ Liem and colleagues²²⁵ found that the use of CO₂ insufflation in a piglet model caused acidosis and hypercarbia when compared with helium insufflation. Experimental evidence in piglets revealed increased end-tidal CO₂ through insufflation, suggesting increased ventilatory dead space.²²⁶ These findings were refuted in a rabbit model.²²⁷ Clinically, measurable increase in end-tidal CO₂ appears to have no effect on patient hemodynamic stability.²²⁸ Intrabdominal exposure by abdominal wall-lifting technique may circumvent this potential problem.^229,230 Cerebral blood flow is increased with pneumoperitoneum, but cerebral vasoreactivity remains intact.²³¹

	Cost

TOP ABSTRACT INTRODUCTION Appendicitis Cholecystectomy/Hepatobiliary Splenectomy Antireflux Procedures and... Achalasia Pyloric Stenosis Inguinal Hernia Intestinal Surgery Diagnostic Laparoscopy Undescended Testis Varicocele Other Intraabdominal Conditions Tumors Diaphragm Empyema Fetal Surgery and Congenital... Physiology Cost Pain Control Training Contraindications/Complications CONCLUSIONS REFERENCES

 
Many laparoscopic procedures cost more than their traditional open counterparts. MAS procedures may take longer and use disposable equipment, increasing operating room expenses. These costs are often offset by avoiding ICU stays and by reducing lengths of stay.²³² Using reusable instruments can further decrease costs.²³³

	Pain Control

TOP ABSTRACT INTRODUCTION Appendicitis Cholecystectomy/Hepatobiliary Splenectomy Antireflux Procedures and... Achalasia Pyloric Stenosis Inguinal Hernia Intestinal Surgery Diagnostic Laparoscopy Undescended Testis Varicocele Other Intraabdominal Conditions Tumors Diaphragm Empyema Fetal Surgery and Congenital... Physiology Cost Pain Control Training Contraindications/Complications CONCLUSIONS REFERENCES

 
Techniques for control of postoperative pain are the same for MAS as for open surgery. Infiltration of bupivicaine at port sites and intraperitoneal lidocaine reduces early postoperative discomfort.²³⁴ Patient-controlled analgesia works well in both groups and provides a measure by which the degree of postoperative pain of MAS and open surgery can be compared.²³⁵

	Training

TOP ABSTRACT INTRODUCTION Appendicitis Cholecystectomy/Hepatobiliary Splenectomy Antireflux Procedures and... Achalasia Pyloric Stenosis Inguinal Hernia Intestinal Surgery Diagnostic Laparoscopy Undescended Testis Varicocele Other Intraabdominal Conditions Tumors Diaphragm Empyema Fetal Surgery and Congenital... Physiology Cost Pain Control Training Contraindications/Complications CONCLUSIONS REFERENCES

 
MAS is a natural extension of traditional surgical therapy, but the techniques and dexterity required to master MAS is a separate set of skills. Training is incorporated into all surgical residency programs, and fellowships are available. Many didactic courses are offered with animal models to use for learning technique. More complicated procedures often require the surgeon to practice in a laboratory setting. DeCou and colleagues²³⁶ developed a computer-based virtual reality model with which to practice LP. The model allowed them to identify weak areas in the procedure, then make corrections before patient use that result in success once the technique was introduced clinically.

	Contraindications/Complications

TOP ABSTRACT INTRODUCTION Appendicitis Cholecystectomy/Hepatobiliary Splenectomy Antireflux Procedures and... Achalasia Pyloric Stenosis Inguinal Hernia Intestinal Surgery Diagnostic Laparoscopy Undescended Testis Varicocele Other Intraabdominal Conditions Tumors Diaphragm Empyema Fetal Surgery and Congenital... Physiology Cost Pain Control Training Contraindications/Complications CONCLUSIONS REFERENCES

 
Laparoscopic surgery can be performed safely in patients with ventriculoperitoneal shunt.^237,238 MAS technique does not lower the risk of acute chest syndrome in sickle cell patients undergoing abdominal surgery.^239,240

Serious vascular injury is a rare but potentially devastating complication of laparoscopy. Most injuries occur during placement of the initial port at the umbilicus.^241,242 Injury to the inferior epigastric vessels during port placement may also occur. Conversion to open surgery to control bleeding is preferred in most instances.

Most complications of laparoscopic surgery occur during initial entry into the abdomen or subsequent port placement. Vascular injury, intestinal perforation, and solid organ injury have all been described.²⁴³ Trocar site herniation and infection have occurred.²⁴⁴ Herniation may occur at port sites as small as 5 mm. Laparoscopic correction and repair can be performed.²⁴⁵ A survey of pediatric urologists revealed that the best predictor of complication rate was laparoscopic experience.²⁴⁶ Adhesions form after all intrabdominal operations. Moore et al²⁴⁷ found that <10% of patients who underwent second-look urological procedures had formed significant adhesions, and that the extent of dissection correlated with the severity of adhesion formation.

	CONCLUSIONS

TOP ABSTRACT INTRODUCTION Appendicitis Cholecystectomy/Hepatobiliary Splenectomy Antireflux Procedures and... Achalasia Pyloric Stenosis Inguinal Hernia Intestinal Surgery Diagnostic Laparoscopy Undescended Testis Varicocele Other Intraabdominal Conditions Tumors Diaphragm Empyema Fetal Surgery and Congenital... Physiology Cost Pain Control Training Contraindications/Complications CONCLUSIONS REFERENCES

 
The field of MAS has grown remarkably over the past 2 decades. The imaginations and creativity of operating physicians worldwide has led to a broad array of surgeries that can now be performed without large incisions. Most authors report results of MAS equal to or better than that of standard open surgery, with MAS showing shorter hospital stays, less analgesic requirement after surgery, more rapid return to work or school, and cosmetic satisfaction. MAS clearly has a steep learning curve, and complications with MAS do occur. Often MAS procedures are more expensive in the operating room, but less costly for the hospital room.

Laparoscopy or open surgery—which is better? Few studies in children have been subjected to critical analysis, so outcomes to date must be interpreted with caution. As MAS moves forward, the task of practitioners is to pursue careful prospective, randomized clinical studies with the goal to provide answers to this important question.

	FOOTNOTES

 
Received for publication Nov 4, 2002; Accepted Dec 10, 2002.

Reprint requests to (J.L.Z.) Division of Pediatric Surgery, Children’s Hospital of New York Presbyterian, 3959 Broadway, New York, NY 10032. Email: jlz2{at}columbia.edu

	REFERENCES

TOP ABSTRACT INTRODUCTION Appendicitis Cholecystectomy/Hepatobiliary Splenectomy Antireflux Procedures and... Achalasia Pyloric Stenosis Inguinal Hernia Intestinal Surgery Diagnostic Laparoscopy Undescended Testis Varicocele Other Intraabdominal Conditions Tumors Diaphragm Empyema Fetal Surgery and Congenital... Physiology Cost Pain Control Training Contraindications/Complications CONCLUSIONS REFERENCES

 

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