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Overview of laparoscopy in children and adolescents

Overview of laparoscopy in children and adolescents
Literature review current through: Jan 2024.
This topic last updated: Oct 21, 2022.

INTRODUCTION — Use of laparoscopic surgery in the pediatric population is common. Laparoscopy in children and adolescents bears marked similarities to adult procedures, but experience with adult surgery does not sufficiently translate to safe surgery in pediatric patients. Pediatric procedures must be performed with a full understanding of the relevant anatomic and physiologic differences between the pediatric and adult populations.

Unique aspects of laparoscopy in children and adolescents are reviewed here. General principles of laparoscopy and descriptions of specific laparoscopic surgical techniques in the pediatric population are discussed separately.

(See "Abdominal access techniques used in laparoscopic surgery".)

(See "Instruments and devices used in laparoscopic surgery".)

(See "Complications of laparoscopic surgery".)

BACKGROUND — Pediatric surgeons were initially slower to adopt laparoscopic techniques than surgeons for adults. This was due to several limiting factors, including the lack of availability of child or adolescent-size instrumentation, surgical learning curves, and limited case volumes for complex procedures. Subsequently, there have been marked advances in instrumentation, techniques, and training [1-3]. Minimally invasive approaches have become the standard of care for operations involving the thoracic and abdominal cavities for all ages, including newborn congenital anomalies. For example, one United States pediatric tertiary care center reported the proportion of appendectomies performed laparoscopically was fewer than 10 percent in 1997 and greater than 95 percent in 2005 [4]. As with adult procedures, pediatric laparoscopy offers advantages of fewer major wound-associated complications, less incisional pain, a shorter recovery, and improved cosmesis [5].

PREOPERATIVE EVALUATION AND PREPARATION

Informed consent — Informed consent must be obtained from the legal guardian of the patient for any pediatric or adolescent surgery. The age at which adult consent is required varies by jurisdiction and by whether the procedure is elective or an emergency and may change over time. Pediatric surgeons should be familiar with the appropriate laws. (See "Consent in adolescent health care".)

To make adolescent patients feel that they are part of the decision-making process, in our practice, we suggest, but do not require, that they also sign the consent form.

Evaluation — Pediatric patients should undergo appropriate preoperative evaluation for the planned procedure, as well as evaluation for comorbidities that may impact their ability to tolerate surgery. In this way, they do not differ from adults.

A focus of preoperative evaluation in some pediatric patients is the diagnosis and evaluation of congenital heart disease. This is important in several clinical contexts, including:

Neonatal laparoscopy – Newborn anomalies are often treated laparoscopically, and these are commonly associated with congenital heart disease.

Some of these children are exquisitely sensitive to decreases in ventricular preload. Care must be taken to identify children who are particularly dependent on venous return in order to identify those in whom insufflation of the abdomen may pose a greater risk.

The diagnosis and evaluation of congenital heart disease are discussed separately. (See "Suspected heart disease in infants and children: Criteria for referral".)

Antibiotic prophylaxis — The principles guiding antibiotic prophylaxis to prevent surgical site infection are the same for children as for adults. In laparoscopic procedures in which the bowel or vagina are not entered, we do not administer antibiotic prophylaxis (table 1). (See "Antimicrobial prophylaxis for prevention of surgical site infection in adults", section on 'Types of surgery'.)

Thromboprophylaxis — The principles guiding thromboprophylaxis are the same for children as for adults. Conditions that result in thrombosis are rare in children. In patients with conditions associated with hypercoagulability (eg, vascular anomalies, ulcerative colitis), in our practice, we treat with low molecular weight heparin.

OPERATIVE SET-UP

Measures to reduce anxiety — When a pediatric patient is brought into the operating room and positioned for surgery, every effort is made to avoid undue anxiety or discomfort. In many institutions, children are brought into the room with a parent or guardian. Initial anesthesia is often administered before placing an intravenous line, positioning the patient, and removing hospital clothing.

Patient positioning — Patients are positioned for surgery in a manner which is safe and allows the surgical team optimal access to the patient, as with adult patients. An additional consideration in pediatric laparoscopy is the small size of the patient relative to the surgeon. Depending upon the patient and procedure, adolescents who have reached the size of an average adult may often be positioned in the same way as adults.

Position of arms — Patient positioning for laparoscopic procedures is generally similar for pediatric and adult populations. In pelvic laparoscopy, it is often ideal to have the arm tucked next to the body on the side of the primary surgeon. If necessary, both arms may be tucked to allow the surgeons to stand at the level of the patient’s shoulders, which is the most ergonomic location for pelvic surgery.

Care should be taken to cushion pressure points on the arms, wrists, and hands when tucking the arms lest inadvertent nerve injury occur during the procedure. In addition, the surgeon and assistant must take care not to lean on the patient, thereby exerting pressure that could result in neuropathy. (See "Nerve injury associated with pelvic surgery", section on 'Avoid patient malposition'.)

Specific types of procedures — In this section, we describe the position we use for specific types of pediatric laparoscopic procedures.

Gynecologic procedures — During pediatric gynecologic laparoscopy, we minimize use of vaginal instruments or manipulation to avoid postoperative discomfort, hymenal disruption, cervical trauma, and uterine perforation.

We position children in the dorsal supine position. We utilize lithotomy position only when access to the vagina is needed for combined laparoscopic and vaginal surgery. These cases include complex anomalies of the vagina, cervix, or uterus.

Patients are sterilely prepared and draped as appropriate for the surgical position. For patients in the dorsal supine position, although vaginal preparation using iodine solutions can be performed with minimal trauma to the hymen using a 60 cc syringe, doing so is unnecessary and we routinely omit this step, unless it will significantly impact our ability to perform a given procedure. Preoperatively, we typically place the patient in a "frog leg" position to place a bladder catheter and then return the patient to a dorsal supine position for the remainder of the procedure.

In our practice, we do not use an intracervical uterine manipulator. In general, we have found that uterine manipulation is not necessary for successful completion of pediatric or adolescent gynecologic surgery. If necessary, we move the uterus with a suprapubic secondary port probe. Other experts have advised positioning all gynecologic pediatric patients who are large enough in Allen stirrups, allowing unencumbered access to the vagina and permitting the use of a gentle finger into the posterior fornix for uterine manipulation with gentle upward pressure [6,7].

General surgery procedures — Positioning of patients for general surgery procedures is dependent upon the location of the pathology. Lithotomy position is routinely used when performing procedures of the upper abdomen to treat gastric, colon, and pancreas pathology. Otherwise, various combinations of supine position are used, including flat supine and supine with one side elevated.

Infants and toddlers may be oriented transversely on the table for some procedures, such as imperforate anus repairs, congenital diaphragmatic hernia repairs and pyloromyotomies. With the patient positioned transversely at the foot of the table, three members of the surgical team can participate and the anesthesiologist has access to the side of the patient.

INCISION SITES — The abdomen is smaller in children than in adults, but it remains important to allow adequate space between trocars and instruments to provide sufficient working space. This is especially important when performing advanced laparoscopy with multiple instruments [8].

The dome of the pediatric bladder is often located superior to the position in an adult. Thus, the common teaching in adult laparoscopy, to place a suprapubic port "two finger breadths above the pubic symphysis," may not be appropriate in children. To avoid bladder injury, the bladder dome should be visualized with the laparoscope in all patients prior to placement of suprapubic ports.

There are several approaches to placing lower abdominal incisions to optimize cosmesis (ie, so that they are hidden by underwear or a two-piece bathing suit). For a suprapubic port, the skin incision may be made inferior to the planned path of the trocar. The trocar can then be angled cephalad and inserted, allowing for optimal peritoneal entry while at the same time allowing for a lower abdominal scar.

Another technique we use in pediatric and adolescent gynecology patients is to place the secondary ports in the suprapubic region. In general, we utilize 5 mm ports, but if a morcellator is needed to remove a large structure, such as an obstructed hemi-uterus, then a larger port can be placed in the midline in the suprapubic region. Gynecologic surgeons accustomed to a higher placement of ports may not be as facile at performing surgery from suprapubic ports, but we find that all gynecologic procedures can be performed through lower ports. Specific locations for incisions will, of course, depend on the laparoscopic procedure being performed and the comfort and experience of the surgeon.

PNEUMOPERITONEUM — Characteristics of the pediatric population that impact induction of pneumoperitoneum are discussed in this section. As adolescents approach adulthood, their physiology and physical characteristics approximate that of adults. Use of adult management techniques must be individualized, since there are no established size or age criteria for such management.

Insufflation pressure and volume — The abdominal wall in infants and prepubertal children is more pliable and the peritoneal cavity is smaller than in adults. Because of these characteristics, adequate visualization of intraperitoneal structures and expansion of the abdominal wall for operating space can typically be achieved with lower intraabdominal pressures and volumes than in adult laparoscopy.

The volume of insufflating gas necessary to maintain pneumoperitoneum in adults is typically 2.5 to 5.0 L of carbon dioxide (CO2), while a 10 kg (22 lb) patient requires only 0.9 L [9]. The insufflation pressure used in adults is 15 mmHg; in infants and young children, insufflation pressures of 5 to 12 mmHg typically suffice [10]. Gas flow rates in infants are as low as 1 to 3 L per minute, while up to 40 L per minute is used in larger patients and when leaks of gas need to be overcome to maintain abdominal distention.

Managing adverse reactions to insufflation — In some pediatric patients, abdominal distension will induce a significant increase in vagal tone and an associated bradycardia, which may require abdominal desufflation [11]. Surgery may be resumed at a lower intraabdominal pressure once the patient recovers.

For pediatric patients with congenital heart defects or other conditions that may be impacted by increased intraabdominal pressure, laparoscopy may be performed with a plan to desufflate and potentially convert to laparotomy if there are hemodynamic derangements related to the insufflation pressure. In certain circumstances, decreasing the inflation pressure slightly may be enough to safely continue a laparoscopic approach. Management of these patients requires preoperative consultation with a pediatric cardiologist and intraoperative care by an anesthesiologist experienced in such conditions.

Absorption of carbon dioxide — In infants and prepubertal children, insufflated CO2 gas is more readily absorbed across the peritoneum than in adults. Uptake is more efficient, given the shorter distance between capillaries and peritoneum, as well as an increased absorptive area of peritoneum in relation to bodyweight [12]. Hypercapnia is thus more likely in pediatric laparoscopy. This can mandate an increased minute ventilation by as much as 60 percent to restore end-tidal CO2 back to baseline levels, as well as an increased requirement for ventilation postoperatively, given the need to clear excess CO2 [12].

The unique response of children to abdominal insufflation underscores the importance of having an anesthesia team well versed in pediatric laparoscopy and its associated impact on respiratory and cardiac physiology.

Laparoscopic entry protocols — This section details the protocols we use in our practice for laparoscopic entry.

Gynecologic procedures — In pediatric gynecology patients, in our practice, we use a Veress needle for initial entry. We initially use a carbon dioxide pressure of 12 mmHg and a gas flow rate of 4 L/min. After pneumoperitoneum is established, we insert a blunt dilating trocar. If a non-blunt trocar is utilized, then a higher intraabdominal pressure should be used to create the largest possible distance between the abdominal wall and the great vessels to avoid injury.

Once the initial trocar has been safely inserted into the peritoneal cavity, the insufflating pressure may be reduced based on the patient's habitus and age.

General surgery procedures — In pediatric general surgery, access is gained to the abdomen in a number of ways, including open or closed techniques and use of single or multiple ports. If Veress needle placement is used, some surgeons will confirm correct placement prior to insufflation with a saline drop test.

Abdominal access techniques for laparoscopy are described in detail separately. (See "Abdominal access techniques used in laparoscopic surgery", section on 'Initial port placement'.)

During insufflation, it is critical that the surgeon closely observes the flow rate and insufflation pressures. Insufflation pressures vary based on the goals of the operation and the size of the patient. As noted above, lower insufflation pressures may be used in small children due to increased abdominal wall compliance. As an example, in average size children who are between the ages of 2 and 12 years, we typically use 8 to 12 mmHg insufflation pressure and a 2 to 4 L/min flow rate, and then adjust these as needed. Lower flow rates are more critical for infants, particularly with cardiac conditions. For these patients, higher flow rates may cause unintended high insufflation pressure because the small peritoneal cavity can fill completely with CO2 within seconds.

For entry in newborns with an intact umbilical cord stump, great care must be taken to avoid initial trocar placement either within the umbilical vein remnant or into the side wall of the umbilical vein. There have been case reports of accidental insufflation into the umbilical vein remnants and umbilical vein injury that have resulted in large volume and fatal venous air embolism [13,14]. To reduce the risk of these complications, after initial trocar placement by open technique, we confirm proper position within the peritoneal cavity by camera view prior to insufflation. If there is concern for umbilical vein side wall injury during initial trocar placement because of bleeding, then strong consideration should be given to stopping the laparoscopic approach for the operation.

INSTRUMENTATION — A variety of trocars and other instruments has been specifically designed for use in pediatric laparoscopy. Available instruments include:

Small diameter ports and telescopes – Infant and toddler laparoscopy is commonly performed using reusable 3 and 4 mm metal port systems (5 and 10 mm scopes are typical for adult use). The metal construction of the ports allows for optimal wall strengths and minimal external diameter. This minimizes the skin incision required to accommodate the port.

"Short" instruments – These are shorter and lighter weight than standard laparoscopic instruments.

Standard 5 mm ports and instruments – Deflectable tip 5 mm laparoscopes are being used for single incision and standard laparoscopy.

One of the most commonly used infant and toddler telescopes for pediatric general surgeons is a 4 mm 30° laparoscope. Smaller scope sizes (1 to 2 mm, also called "needle laparoscopes") are available for very small neonates, including those weighing less than 1 kg. Additionally, 5 mm 30° and 45° Hopkins rod-lens telescopes are commonly used. Zero degree laparoscopes may be used for pediatric gynecologic laparoscopy.

For a 4 mm laparoscope, the associated 3 mm instrumentation can be passed through either the 3 or 4 mm metal ports. The full range of effective and functional standard 5 mm instruments is also now available in 3 mm instrument sets. Advances in material science are making 2 mm instruments with adequate physical characteristics for laparoscopy a reality.

Alternatively, some pediatric surgeons avoid the use of ports altogether and place their instruments through stab incisions. The compliant infant and toddler abdominal wall adequately seals around the instruments to retain the pneumoperitoneum. When this technique is used, instrument exchanges should be minimized since it is a little more difficult to replace instruments through stab incisions. For laparoscopic suturing, stab incisions permit use of sutures with any type and size needle because the needle does not have to fit through a trocar.

COMPLICATIONS — The types of complications associated with pediatric laparoscopy are similar to those for adult procedures. These include vascular or visceral injury, hemorrhage, and infection. Studies of 500 or more procedures have reported a rate of complications of 1 to 2 percent [15,16]. (See "Complications of laparoscopic surgery".)

Vascular or visceral injury — Vascular, bowel, or bladder injury are the most serious complications of pediatric laparoscopy. These occur almost exclusively during initial entry into the abdomen or subsequent placement of trocars, as with adult laparoscopy [17,18]. A survey of pediatric urologic surgeons who had performed a total of 5400 cases reported a rate of significant complications (excluding preperitoneal insufflation and subcutaneous emphysema) of 1.2 percent; 0.4 percent of complications required surgical repair (vascular or visceral injury) [15]. (See "Complications of laparoscopic surgery", section on 'Vascular injuries'.)

There is no high quality evidence regarding the best choice laparoscopic entry technique in children or adolescents. The few available data are inconsistent regarding the risk of complications with use of the Veress needle compared with an open technique [15,19]. Further studies are needed to address this issue. In the pediatric and adolescent population, the small anatomy and short distance between the umbilicus and the large vessels must be kept foremost in mind when using either an open or closed laparoscopic entry technique. (See 'Insufflation pressure and volume' above.)

General principles of laparoscopic entry and associated complications are discussed separately. (See "Abdominal access techniques used in laparoscopic surgery".)

Port site hernia — The incidence of postoperative hernia at port (trocar) sites following pediatric laparoscopy varies widely by study (0.2 to 3.2 percent) [15,20,21]. Due to the relatively recent introduction of laparoscopy in children, the long-term port site complication rates remain unknown and deserve further study. (See "Complications of laparoscopic surgery", section on 'Trocar site hernia'.)

Young age appears to be an important risk factor for developing a port site hernia. A retrospective series of 293 laparoscopic procedures in children (ages zero to 18 years) reported trocar site hernia in significantly more children 5 years of age and younger (3 of 54; 5.6 percent) compared with the older group (0 of 240) [21]. Similarly, in a series of 218 pediatric urologic laparoscopy patients (ages zero to 19 years), the seven port site hernias that occurred were all in children under the age of 5 years [20].

Small port size does not appear to eliminate the risk of herniation. This is likely because the abdominal wall is thin, the abdominal muscles are weak, and the bowel and omentum are proportionally smaller in relation to the abdominal incisions in the pediatric patient. Cases of omental or bowel herniation through 3 to 5 mm incisions in children have been reported [22-24]. In the pediatric urology series described in the preceding paragraph, hernias occurred with similar frequency at port sites <5 mm compared with >10 mm [20].

Fascial closure — In adult laparoscopy, it is common practice to close the fascia of trocar sites that are 10 mm or greater, since herniation of bowel or omentum is unlikely through smaller incisions [25-27]. Practice in pediatric surgery varies by specialty. For children who are 5 years of age or younger, we suggest fascial closure for laparoscopic incisions that are 5 mm or larger. This is consistent with our approach in our pediatric gynecology practice. On the other hand, in our pediatric general surgery practice, in this age group, we close the fascia in all laparoscopic incisions, regardless of incision size. For children who are older than 5 years and for adolescents, we suggest fascial closure for incisions that are 8 mm or larger.

Fascial closure in children can be performed through the skin incision using traditional instruments. Direct closure is more easily accomplished in children than in adults, given the thinner abdominal wall in the pediatric population. Alternatively, a laparoscopic endo-fascial closure needle can be employed to perform a laparoscopic-assisted closure.

TRAINING — Depending upon the complexity of the procedure, performing 5 to 10 procedures is typically required to achieve competence [15,16,28,29]. The majority of complications associated with pediatric laparoscopy occur while a surgeon is in the early learning phase of pediatric laparoscopy, as is the case with most surgical procedures [15]. Training programs in pediatric minimally invasive surgery and use of simulation programs help surgeons to acquire skills in pediatric laparoscopy within a protected environment. Nevertheless, vigilance should be employed by the operative team whenever a new procedure is incorporated into practice.

For pediatric gynecologic surgery, experience in adult laparoscopy does not suffice to safely perform procedures in children. Surgeons should gain familiarity with pediatric anatomy and experience in pediatric surgery. In urgent situations, it may be prudent for a gynecologic surgeon to operate with a pediatric surgeon.

ADVANCES IN PEDIATRIC MINIMALLY INVASIVE SURGERY — Advances in minimally invasive surgical (MIS) techniques for both adults and children include single incision laparoscopic approaches (as opposed to multiport laparoscopy) and robot-assisted laparoscopic and thoracoscopic operations [30-34]. The combination of these two approaches (robotic single incision laparoscopy) is likewise on the rise [35].

Single incision – Single-incision approaches are most common for laparoscopy utilizing an umbilical trocar. Specialized multi-instrument trocars are available, and multiple trocars within the same incision can also be employed. Both cameras and instruments have been developed with articulation and deflectable tips to facilitate these single-port approaches. Appendectomy and cholecystectomy are the most common indications.

Robot assisted – Robotic platforms, by which the surgeon controls minimally invasive instruments remotely from a console and include specialized three-dimensional optics and "wristed" instruments, are also growing in popularity and use at many major children's hospitals. Operations with complex angles of approach and suturing are facilitated by these systems.

Combination – Single-port options are commonly employed with these robotic systems as well. Adult urology and, subsequently, pediatric urology were the primary pioneers for these robot-assisted operations, which are now utilized by many specialties including gynecology, general surgery, and thoracic surgery.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Laparoscopic and robotic surgery".)

SUMMARY AND RECOMMENDATIONS

Use of laparoscopy in children and adolescents is common. Minimally invasive approaches have become the standard of care for many abdominal and pelvic procedures. Laparoscopy offers advantages of fewer major wound-associated complications, less incisional pain, a shorter recovery, and improved cosmesis. (See 'Introduction' above.)

Patients are positioned for surgery in a manner which is safe and allows the surgical team optimal access for patient care. An additional consideration in pediatric laparoscopy is the variable size of the patient. Depending upon the patient and procedure, adolescents who have reached the size of an average adult may often be positioned in the same way as adults. (See 'Patient positioning' above.)

The location of incisions in children and adolescents must be chosen carefully to provide adequate operating space, avoid injury, and optimize cosmesis. (See 'Incision sites' above.)

For children who are 5 years of age or younger, we suggest fascial closure for laparoscopic incisions that are 5 mm or larger (Grade 2C). In this age group, closing the fascia in all laparoscopic incisions is also a reasonable option. For children who are older than 5 years and for adolescents, we suggest fascial closure for incisions that are 8 mm or larger (Grade 2C). (See 'Fascial closure' above.)

Lower insufflation pressures and volumes are required to create an adequate working space in pediatric patients, given the small size of the abdomen and laxity of the abdominal walls. (See 'Insufflation pressure and volume' above.)

In children, insufflated carbon dioxide gas is more readily absorbed across the peritoneum than in adults, and the risk of hypercapnia is higher. An anesthesia team experienced in pediatric laparoscopy is required for these procedures. (See 'Absorption of carbon dioxide' above.)

Complications of pediatric laparoscopy occur in 1 to 2 percent of procedures. The types of complications are similar to those for adult laparoscopy, including vessel or visceral injury, port site hernia, and infection. (See 'Complications' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Dr. Bradley C Linden, who contributed to earlier versions of this topic review.

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Topic 14187 Version 21.0

References

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