Textbook The Sages Manual of Pediatric Minimally Invasive Surgery 1St Edition Danielle S Walsh Ebook All Chapter PDF
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Danielle S. Walsh
Todd A. Ponsky
Nicholas E. Bruns Editors
123
The SAGES Manual
of Pediatric Minimally
Invasive Surgery
Danielle S. Walsh • Todd A. Ponsky
Nicholas E. Bruns
Editors
v
vi Preface
with this in mind that these authors set out to educate ALL
surgeons, not just pediatric specialists, in the applications of
minimally invasive surgery to children through this
textbook.
The focus of this text is on the technical knowhow of these
minimally invasive techniques. There are larger resources for
detailed information on pathophysiology and others review-
ing each and every alternative technique for managing a
particular disorder. However, this publication is for providing
a safe way of technically approaching a particular problem
utilizing percutaneous or per-orifice methods in a concise
compendium. It is appropriate for the trained professional
looking for a refresher on a less commonly performed inter-
vention, an adult MIS surgeon with a pediatric emergency
unable to be transferred, or a surgical student or resident in
need of critical teaching points for understanding.
This coeditor team greatly appreciates the support we
have received from SAGES and Springer in making this
endeavor come to fruition. We applaud the authors, col-
leagues, staff, families, and patients who contributed to this
book through either time, effort, patience, or use of their
surgical journey to build the knowledge and content within
these pages. It is our hope that many a student of surgery will
benefit from the herein pearls of wisdom as they endeavor to
improve the care of a pediatric surgical patient.
vii
viii Contents
Index....................................................................................... 733
Contributors
xiii
xiv Contributors
Introduction
Laparoscopy and thoracoscopy have gained widespread acceptance
in the surgical approach to infants and children. Minimally invasive
procedures are routinely performed and often considered the standard of
care for common pediatric operations, such as appendectomy, pyloro-
myotomy, and fundoplication. Many pediatric surgeons employ laparos-
copy or thoracoscopy for advanced procedures including operations for
duodenal atresia, malrotation, anorectal malformations, Hirschsprung’s
disease, congenital diaphragmatic hernia, and tracheoesophageal fistula
[1, 2]. Additionally, there are case reports of minimally invasive pancre-
atectomy, hepatectomy, and resections for neuroblastoma and Wilms
tumor in children. The general trend in pediatric surgical practice has
been increased adoption of minimally invasive approaches.
Safe application of minimally invasive surgery in pediatric patients
necessitates a thorough understanding of the physiologic effects of
carbon dioxide (CO2) insufflation in this population. Regardless of the
operation being performed, two main effects produce the physiological
consequences of insufflation: (1) increased intra-abdominal or intratho-
racic pressure and (2) CO2 absorption through the visceral and parietal
peritoneum (Fig. 1.1). One series reported a 7 % rate of needing to stop
insufflation either transiently or permanently for children undergoing
laparoscopy [3, 4]. Patients who had insufflation-related incidents and
needed the procedure halted were younger with lower immediate preop-
erative body temperature, and the operations were longer and had higher
Fig. 1.1. Two major stimuli produce the observed physiologic changes during
abdominal insufflation for laparoscopy: (1) increased intra-abdominal pressure
(blue arrows), which impedes full lung expansion and can decrease flow through
the aorta and vascular system, and (2) enhanced CO2 absorption (red arrows) by
the visceral and parietal peritoneum, which increases the necessary minute ventila-
tion to maintain acid-base balance. Figure courtesy of Sarah Hua.
Preoperative Evaluation
As with any pediatric or neonatal operation, general fitness for a
planned minimally invasive operation is of paramount importance.
Appropriate history related to nutritional status and growth should be
obtained for every patient, and any symptoms or signs that could suggest
1. Physiologic Considerations for Minimally Invasive Surgery… 3
Pulmonary System
The pulmonary effects of pneumoperitoneum in pediatric patients
are the result of anatomic and physiologic differences between adults
and children. The alveolar surface area to body surface area ratio in
1. Physiologic Considerations for Minimally Invasive Surgery… 5
Inflammatory/Immune System
In children, data from a study of procedures for acute abdominal pain
suggested that laparoscopic compared to open operations did not result
in differences in major inflammatory mediators such as cortisol and
IL-6 [21]. However, several subsequent studies have demonstrated a
lesser degree of increase in inflammatory mediators including IL-6,
CRP, TNF-α, and cortisol with laparoscopy compared to open approach
for a variety of operations [22–25]. Cellular responses are also affected
by laparoscopy, in a manner similar to the cytokine responses. Both
macrophages and neutrophils are recruited to the peritoneal cavity with
insufflation, though the numbers are lower with CO2 insufflation com-
pared to air [26].
Other
Compared with adults, children have a greater body surface area to
volume ratio [27] and thus are at increased risk for hypothermia. During
minimally invasive surgical procedures in infants and children, hypo-
thermia is reported to occur in 1.8 % of cases [4]. Temperature moni
toring is especially important in newborns. Dry CO2 insufflation on
continuous flow of 5–8 L/min will lead to massive evaporative losses
relative to body size, and the accompanying heat loss can approach 40 %
of a neonate’s metabolic power capacity, despite their higher-per-kilogram
power capacity compared to adults [3]. Additionally, gas leaks around
port sites in a neonate can result in a much greater loss of insufflation
gas, thereby requiring higher flow rates and potentially exacerbating
hypothermia if non-humidified CO2 is used.
1. Physiologic Considerations for Minimally Invasive Surgery… 7
these changes are greater in younger patients and larger than those
observed during laparoscopy [30]. The data on these two responses are
far from conclusive, and more work is needed to identify specific situa-
tions that will produce clinically important changes in CO2 level and
acid-base status.
Postoperative Care
The most important consideration in the postoperative care of children
undergoing minimally invasive procedures is respiratory monitoring in
the first several hours after abdominal desufflation, when residual hyper-
carbia may be present and the potential for hypoventilation persists. This
risk is especially important in neonates, infants, and young children, and
we recommend these patients be monitored with continuous pulse oxim-
etry for at least the first several hours after laparoscopy. Further work will
be needed to accurately determine if a predefined, mandatory length of
stay in the anesthesia recovery area or in a monitored hospital unit is
necessary to prevent life-threatening hypoventilation.
Summary
• Laparoscopy is physiologically safe and effective approach in pediat-
ric patients of all ages and for many pediatric abdominal surgical
procedures.
• Increased intra-abdominal pressure leading to impaired pulmonary
mechanics and increased CO2 absorption are the two primary stimuli
that lead to the array of physiologic sequelae during and after
laparoscopy.
• Cardiac index, mean arterial pressure, and aortic blood flow decrease
during abdominal insufflation but rarely with important clinical
consequences.
• Increased minute ventilation must be achieved during minimally inva-
sive surgery, especially in neonates, to prevent hypercarbia and subse-
quent acidosis.
• Reversible anuria and oliguria occur with laparoscopy, and this effect
is more pronounced in younger patients.
• Increases in inflammatory mediators and cellular responses are decreased
during laparoscopic compared to open operations in children.
• Vigilant postoperative monitoring for neonates should be employed
as CO2 retention may persist after abdominal desufflation.
1. Physiologic Considerations for Minimally Invasive Surgery… 9
References
1. Lacher M, Kuebler JF, Dingemann J, Ure BM. Minimal invasive surgery in the new-
born: current status and evidence. Semin Pediatr Surg. 2014;23(5):249–56.
2. Ponsky TA, Rothenberg SS. Minimally invasive surgery in infants less than 5 kg:
experience of 649 cases. Surg Endosc. 2008;22(10):2214–9.
3. Blinman T, Ponsky T. Pediatric minimally invasive surgery: laparoscopy and thoracos-
copy in infants and children. Pediatrics. 2012;130(3):539–49.
4. Kalfa N, Allal H, Raux O, et al. Multicentric assessment of the safety of neonatal
video surgery. Surg Endosc. 2007;21(2):303–8.
5. Means LJ, Green MC, Bilal R. Anesthesia for minimally invasive surgery. Semin
Pediatr Surg. 2004;13(3):181–7.
6. Watkins SC, Morrow SE, McNew BS, Donahue BS. Perioperative management of
infants undergoing fundoplication and gastrostomy after stage I palliation of hypo-
plastic left heart syndrome. Pediatr Cardiol. 2012;95:204–11.
7. Slater B, Rangel S, Ramamoorthy C, Abrajano C, Albanese CT. Outcomes after lapa-
roscopic surgery in neonates with hypoplastic heart left heart syndrome. J Pediatr
Surg. 2007;42(6):1118–21.
8. Cribbs RK, Heiss KF, Clabby ML, Wulkan ML. Gastric fundoplication is effective in
promoting weight gain in children with severe congenital heart defects. J Pediatr Surg.
2008;43(2):283–9.
9. Bozkurt P, Kaya G, Yeker Y, et al. Arterial carbon dioxide markedly increases during
diagnostic laparoscopy in portal hypertensive children. Anesth Analg. 2002;95(5):
1236–40.
10. Gueugniaud PY, Abisseror M, Moussa M, et al. The hemodynamic effects of pneumo-
peritoneum during laparoscopic surgery in healthy infants: assessment by continuous
esophageal aortic blood flow echo-Doppler. Anesth Analg. 1998;86(2):290–3.
11. Sakka SG, Huettemann E, Petrat G, et al. Transoesophageal echocardiographic assess-
ment of haemodynamic changes during laparoscopic herniorrhaphy in small children.
Br J Anaesth. 2000;84:330–4.
12. Metzelder ML, Kuebler JF, Huber D, et al. Cardiovascular responses to prolonged
carbon dioxide pneumoperitoneum in neonatal versus adolescent pigs. Surg Endosc.
2010;24(3):670–4.
13. De Waal EEC, Kalkman CJ. Haemodynamic changes during low-pressure carbon diox-
ide pneumoperitoneum in young children. Paediatr Anaesth. 2003;13(1):18–25.
14. Aksakal D, Hückstädt T, Richter S, et al. Comparison of femoral and carotid blood
pressure during laparoscopy in piglets. J Pediatr Surg. 2012;47(9):1688–93.
15. Bannister CF, Brosius KK, Wulkan M. The effect of insufflation pressure on pulmo-
nary mechanics in infants during laparoscopic surgical procedures. Paediatr Anaesth.
2003;13(9):785–9.
16. Beebe DS, Zhu S, Kumar MVS, et al. The effect of insufflation pressure on CO(2)
pneumoperitoneum and embolism in piglets. Anesth Analg. 2002;94(5):1182–7.
17. McHoney M, Corizia L, Eaton S, et al. Carbon dioxide elimination during laparoscopy
in children is age dependent. J Pediatr Surg. 2003;38(1):105–10.
10 B.T. Craig and G.P. Jackson
Early Experience
Pediatric minimally invasive surgery (MIS) has lagged behind its
adult counterpart. In 1973, a report in the Journal of Pediatric Surgery
by Gans and Berci described 16 early laparoscopic pediatric cases [1].
These early advances were possible in part by the Hopkins rod-lens opti-
cal system (Fig. 2.1). However, widespread adoption of pediatric lapa-
roscopy was initially met with criticism. The first adult laparoscopic
cholecystectomy was performed in 1985 [2] and was widely regarded as
experimental and dangerous. There has been no single procedure that has
propelled the advance of MIS in pediatric patients the way laparoscopic
cholecystectomies did with adult MIS. Training modules for teaching
laparoscopic cholecystectomy to adult surgeons were not well suited for
teaching the advanced skills required for pediatric surgery [3]. This pro-
cedure was not considered standard of care in pediatrics until many
years later. However, great strides have been made within the last 20
years. Today, it is common practice for neonates to undergo minimally
invasive surgery. A study conducted by Rothenberg et al. over a 51-month
period with 183 infants weighing 1.3–5.0 kg who underwent 195 proce-
dures using minimally invasive techniques “demonstrates that advanced
endosurgical techniques in infants is safe, effective, and associated with
the same benefit as that seen in older patients” [4].
Language: English
PHILADELPHIA
GEORGE W. JACOBS & CO.
PUBLISHERS
Copyright, 1902,
By George W. Jacobs & Co.
Published July, 1902.
Contents
CHAPTER. PAGE.