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Safe laparoscopic access in pediatric patients
SURGEON'S W O R K S H O P
SAFE LAPAROSCOPIC ACCESS IN PEDIATRIC PATIENTS MICHAELJ. CONLIN, M.D. STEVEN J. SKOOG, M.D. From the Division of Urology, Oregon Health Sciences University, Portland, Oregon
ABSTRACT--The most serious complications of laparoscopy are attributable to gaining access to the peritoneal cavity. This has traditionally been performed with a closed technique utilizing the Verres needle and subsequently with a 5 to 10 mm trocar. The risks of blind peritoneal access are magnified in pediatric patients due to the smaller abdominal cavity and the closer proximity of the great vessels. Open techniques have been devised for adults but often require a larger incision with an undesirable cosmetic result in pediatric patients. We describe a safe, open technique for laparoscopic access to the pediatric peritoneal cavity.
laparoscopy in pediatric urology is ted for diagnostic and therapeutic variety of conditions, such as localaonpalpable gonad and characteriza:tal and gonadal anatomy in intersex is noninvasive technique is not with)ften the most challenging portion of : is the blind insertion of the Verres Ltial access to the peritoneum, and )car placement. The risks of this maa a g n i f i e d in c h i l d r e n b e c a u s e of size constraints, x,5 We have devised a :thod for laparoscopic access to the toneum. This utilizes a small incict, endoscopic visualization prior to the peritoneal cavity.
inferior margin of the umbilicus using a no. 11 scalpel blade. This incision is carried down to and through the fascia, which is secured with 2 fine hemostats. It is important that this incision remains at the level of the umbilicus, where the layers of the abdominal wall are most contiguous. The peritoneum is then grasped and elevated between 2 fine hemostats and a small peritoneotomy is then made with the no. 11 scalpel blade (Fig. 2A). This incision should be no bigger than the 4 m m endoscope tip.
TECHNIQUE is prepared in the usual manner for 7ith general anesthesia, skin preparafie draping. The bladder is drained al catheter. Nasogastric tube place:ation of gastric contents is optional. s in the supine position for initial peritoneum. The 4 m m endoscope, ~rt, and Surgigrip (United States Surtion) sleeve are assembled as shown ld video camera attached. The skin is :en 2 fine-toothed forceps and a small, "aumbilical incision is made along the !0, 1994, accepted: May 18, 1994
IC~OBER1994 I VOLU~'a~44, NUM~E~ 4
FIGURE 1.
The 4 rnrn endoscope, 5 rnrn Surgiport, and Surgigrip, unassernbled (above) and assembled (below).
579
FIGURE 2. (,4) A small peritoneotomy is made through an intraumbilical incision. The peritoneum is marked here with a skin hook. (B) The 4 mm endoscope, 5 mm laparoscopic port, and tissue screw assembly are inserted into the peritoneum under direct vision.
of varicoceles, and the evaluation orders. 1-5 Other applications may~ to this list. Although laparoscopy is consider, than open surgical treatment, it i risks.
The tip of the endoscope is inserted into the peritoneum and successful access is confirmed by visual inspection. All hemostats are removed. The 5 mm Surgiport is then used to dilate the fascia and peritoneum as it is advanced into the peritoneal cavity over the endoscope to an appropriate depth (Fig. 2B). The Surgigrip is then advanced over the Surgiport sleeve and secured into place with a twisting motion. This ensures an airtight seal. The patient is then placed in Trendelenburg position and the laparoscopic procedure performed. Additional ports can be placed as needed using standard techniques with continuous intraperitoneal visualization. At the conclusion of the procedure, the ports are removed "while the sites are inspected endoscopically for any bleeding, and the fascial and skin incisions are closed using appropriate absorbable suture. COMMENT L a p a r o s c o p y is b e i n g u s e d i n c r e a s i n g l y for both diagnostic and therapeutic p u r p o s e s in a wide variety of surgical conditions. Indications for laparoscopy in pediatric urologic patients include the evaluation and treatment of the nonpalpable testis, staged orchiopexy, gonadectomy, treatment 580
Oregon Health 3181 S W Sam Portland, {
REFERENCES 1. Peters CA: Laparoscopy in pediatri~ (Suppl 1) 41: 33-37, 1993. 2. Rogers DA, Lobe TE, and Schropp Kf laparoscopy in children. Surg clin North k 1992. 3. ElderJS: Laparoscopy and Fowler-St in the management of the impalpable testi Am i6: 399-411~ 1989. 4. Bloom DA, Ritchey ML, and Jord peritoneoscopy (laparoscopy). J Clin Pec 1993. 5. Kavoussi LR: Pediatric applications Ctayman RV, and Mcdougall EM (Eds): La St. Louis, Quality Medical Publishing, 199 6. Penfield AJ: How to prevent compl scopy,d Reprod Med 30: 660-663, 1985. 7. Winfield HN: Abdominal access: ir ment, in Clayman RV,and Mcdougall EM ( Urology, St. Louis, Quality Medical Put 38-52. 8. ByronJW, Fujiyoshi CA, and Miyaz', of the direct trocar insertion technique at t Gynecol 74:423-425 1989. UROI_OGY~ October 1994 / Vo
Markenson G, and Miyazawa K: A randoma of Verres needle and direct trocar insertion Surg Gynecol Obstet 177: 259-262, i993. EDITORIAL COMMENT s very timely since laparoscopic procedures ecoming more accepted by pediatric urolothe uncertainty associated with Mind punchild's abdomen with the Verres needle is well s article and it will probably contribute to the paroscopy by some hesitant traditional practistill feel uncomfortable about current methccess to the peritoneum. cess by open peritoneotomy is already being [ditional safety of direct simultaneous visualritoneal cavity offers advantages that may also
~ROLOCY ~' / OCZOBeR1994 / VOLUME44, NUM~S£~4
permit safer access to the peritoneal cavity of patients who have been previously explored. With regard to trocar size, I personally believe that it is safer to introduce the widest trocar compatible with the child's size, since this will allow the use of a larger telescope for the camera portal and achieve better overall visualization of the peritoneal cavity. Surrounding bowel loops do have a tendency to get too close to the operating field sometirnes, particularly if intra-abdominal pressure drops For any reason. Considering the relative space restriction in a child's abdomen, it does afford an additional degree of comfort to keep these lurking bowel loops at a safe distance.
Yves Homsy, M.D., ER.C.S.C. Montreal Children's Hospital and HOpital Ste. Justine 2300 Tupper Street Montreal, PQ H3H 1P3 Canada
581
SAFE LAPAROSCOPIC ACCESS IN PEDIATRIC PATIENTS MICHAELJ. CONLIN, M.D. STEVEN J. SKOOG, M.D. From the Division of Urology, Oregon Health Sciences University, Portland, Oregon
ABSTRACT--The most serious complications of laparoscopy are attributable to gaining access to the peritoneal cavity. This has traditionally been performed with a closed technique utilizing the Verres needle and subsequently with a 5 to 10 mm trocar. The risks of blind peritoneal access are magnified in pediatric patients due to the smaller abdominal cavity and the closer proximity of the great vessels. Open techniques have been devised for adults but often require a larger incision with an undesirable cosmetic result in pediatric patients. We describe a safe, open technique for laparoscopic access to the pediatric peritoneal cavity.
laparoscopy in pediatric urology is ted for diagnostic and therapeutic variety of conditions, such as localaonpalpable gonad and characteriza:tal and gonadal anatomy in intersex is noninvasive technique is not with)ften the most challenging portion of : is the blind insertion of the Verres Ltial access to the peritoneum, and )car placement. The risks of this maa a g n i f i e d in c h i l d r e n b e c a u s e of size constraints, x,5 We have devised a :thod for laparoscopic access to the toneum. This utilizes a small incict, endoscopic visualization prior to the peritoneal cavity.
inferior margin of the umbilicus using a no. 11 scalpel blade. This incision is carried down to and through the fascia, which is secured with 2 fine hemostats. It is important that this incision remains at the level of the umbilicus, where the layers of the abdominal wall are most contiguous. The peritoneum is then grasped and elevated between 2 fine hemostats and a small peritoneotomy is then made with the no. 11 scalpel blade (Fig. 2A). This incision should be no bigger than the 4 m m endoscope tip.
TECHNIQUE is prepared in the usual manner for 7ith general anesthesia, skin preparafie draping. The bladder is drained al catheter. Nasogastric tube place:ation of gastric contents is optional. s in the supine position for initial peritoneum. The 4 m m endoscope, ~rt, and Surgigrip (United States Surtion) sleeve are assembled as shown ld video camera attached. The skin is :en 2 fine-toothed forceps and a small, "aumbilical incision is made along the !0, 1994, accepted: May 18, 1994
IC~OBER1994 I VOLU~'a~44, NUM~E~ 4
FIGURE 1.
The 4 rnrn endoscope, 5 rnrn Surgiport, and Surgigrip, unassernbled (above) and assembled (below).
579
FIGURE 2. (,4) A small peritoneotomy is made through an intraumbilical incision. The peritoneum is marked here with a skin hook. (B) The 4 mm endoscope, 5 mm laparoscopic port, and tissue screw assembly are inserted into the peritoneum under direct vision.
of varicoceles, and the evaluation orders. 1-5 Other applications may~ to this list. Although laparoscopy is consider, than open surgical treatment, it i risks.
The tip of the endoscope is inserted into the peritoneum and successful access is confirmed by visual inspection. All hemostats are removed. The 5 mm Surgiport is then used to dilate the fascia and peritoneum as it is advanced into the peritoneal cavity over the endoscope to an appropriate depth (Fig. 2B). The Surgigrip is then advanced over the Surgiport sleeve and secured into place with a twisting motion. This ensures an airtight seal. The patient is then placed in Trendelenburg position and the laparoscopic procedure performed. Additional ports can be placed as needed using standard techniques with continuous intraperitoneal visualization. At the conclusion of the procedure, the ports are removed "while the sites are inspected endoscopically for any bleeding, and the fascial and skin incisions are closed using appropriate absorbable suture. COMMENT L a p a r o s c o p y is b e i n g u s e d i n c r e a s i n g l y for both diagnostic and therapeutic p u r p o s e s in a wide variety of surgical conditions. Indications for laparoscopy in pediatric urologic patients include the evaluation and treatment of the nonpalpable testis, staged orchiopexy, gonadectomy, treatment 580
Oregon Health 3181 S W Sam Portland, {
REFERENCES 1. Peters CA: Laparoscopy in pediatri~ (Suppl 1) 41: 33-37, 1993. 2. Rogers DA, Lobe TE, and Schropp Kf laparoscopy in children. Surg clin North k 1992. 3. ElderJS: Laparoscopy and Fowler-St in the management of the impalpable testi Am i6: 399-411~ 1989. 4. Bloom DA, Ritchey ML, and Jord peritoneoscopy (laparoscopy). J Clin Pec 1993. 5. Kavoussi LR: Pediatric applications Ctayman RV, and Mcdougall EM (Eds): La St. Louis, Quality Medical Publishing, 199 6. Penfield AJ: How to prevent compl scopy,d Reprod Med 30: 660-663, 1985. 7. Winfield HN: Abdominal access: ir ment, in Clayman RV,and Mcdougall EM ( Urology, St. Louis, Quality Medical Put 38-52. 8. ByronJW, Fujiyoshi CA, and Miyaz', of the direct trocar insertion technique at t Gynecol 74:423-425 1989. UROI_OGY~ October 1994 / Vo
Markenson G, and Miyazawa K: A randoma of Verres needle and direct trocar insertion Surg Gynecol Obstet 177: 259-262, i993. EDITORIAL COMMENT s very timely since laparoscopic procedures ecoming more accepted by pediatric urolothe uncertainty associated with Mind punchild's abdomen with the Verres needle is well s article and it will probably contribute to the paroscopy by some hesitant traditional practistill feel uncomfortable about current methccess to the peritoneum. cess by open peritoneotomy is already being [ditional safety of direct simultaneous visualritoneal cavity offers advantages that may also
~ROLOCY ~' / OCZOBeR1994 / VOLUME44, NUM~S£~4
permit safer access to the peritoneal cavity of patients who have been previously explored. With regard to trocar size, I personally believe that it is safer to introduce the widest trocar compatible with the child's size, since this will allow the use of a larger telescope for the camera portal and achieve better overall visualization of the peritoneal cavity. Surrounding bowel loops do have a tendency to get too close to the operating field sometirnes, particularly if intra-abdominal pressure drops For any reason. Considering the relative space restriction in a child's abdomen, it does afford an additional degree of comfort to keep these lurking bowel loops at a safe distance.
Yves Homsy, M.D., ER.C.S.C. Montreal Children's Hospital and HOpital Ste. Justine 2300 Tupper Street Montreal, PQ H3H 1P3 Canada
581