This document discusses laparoscopy in children. It begins with a brief history of laparoscopy from the 5th century BC to modern developments. The basic principles of laparoscopy are then explained, including how instruments are inserted and the use of carbon dioxide gas. Common laparoscopic instruments and techniques for pediatric surgery are outlined. Applications in pediatric urology and recent modernizations like single-incision laparoscopy and robotic surgery are also summarized. The conclusion emphasizes that laparoscopy is becoming increasingly popular due to patient benefits but requires experienced surgeons, and residents should learn its basic principles.

1. Laparoscopy in Children
Dr shirish silwal
Phase B year 1
Resident, Paediatric Surgery
BSMMU

2. 1. Introduction
2. History
3. Basic Principle
4. Instrument
5. Laparoscopic Paediatric Surgery
6. Paediatric Urology
7. Modernizations
Content

3.  Laparoscopic surgery, also called minimally
invasive surgery (MIS), band-Aid surgery, or keyhole surgery, is a
modern surgical technique in which operations are performed far
from their location through small incisions (usually 0.5–1.5 cm)
elsewhere in the body.
Introduction

4. 460-375 B.C. – First speculum
1806 – Lichtlieter
1901 – First Laparoscopy
1920- Benefit of CO2 Gas Vs atmospheric gas/Nitrogen
1938 – Veress Needle
1953 – Hopkins Rod System
1960 – Automatic Insufflator
1978- Trocar Used
1980 Laparoscopic procedure in UK.
1983 – 1st Lap Appendectomy, 1987 – 1st Lap Chole
History

5.  Paediatric laparoscopy has been first described in 1923 by Kelling.
 The first case of laparoscopy in pediatric surgery was reported by
Stephen Gans in 1971, in his landmark publication, “Advances in
Endoscopy of Infants and Children,” as a peritoneoscopy.

7.  Laparoscopy (Gr: Laparo-abdomen, scopein-to examine) is the art
of examining the abdominal cavity and its contents.
 It requires insertion of a cannula through the abdominal wall,
distention of the abdominal cavity with gas or air
(pneumoperitoneum), and visualization and examination of the
abdomen’s contents with an illuminated telescope.
Principle

8.  CLOSED ENTRY (CLASSIC) LAPAROSCOPY
 OPEN LAPAROSCOPIC ENTRY OR HASSON TECHNIQUE

10. Why Carbon dioxide is preferred ?
 Availability
 It does not support combustion.
 It is very soluble which reduces the risk of gas embolism.
 Cheap.
Other gas Air, nitrous oxide, helium, argon.

11.  Air Pressure – (12-18)mm of Hg
 Insufflation rates
< 1 year: 0.3 liter / minute·
> 1 year: 0.5 liter / minute·
> 5 years: 1.0 liter / minute·

12.  Decrease venous return due to venacaval compression leading to:
• Increased chance of DVT (Deep vein thrombosis of calf)
• Hidden cardiac ischemia can precipitate due to decrease cardiac output.
 Decrease tidal volume due to diaphragmatic excursion
 Increase risk of air embolism due to venous intravasation
 Increased risk of surgical emphysema.
Increased Air pressure

14.  Wound infection at the umbilicus is similar to that at other site.
 Postoperative ventral hernia at the umbilicus is similar to that at
other site.
 The central location and ability to camouflage scar make it
attractive primary trocar site.
Is umbilicus safe for primary port
??

17. Ideal angles!
1. Manipulatation angle: 60 degree
2. Azimuth angle: Equal/30 degree each
3. Elevation angle: 60 degree

19. INSTRUMENT

20. Maryland dissector Endo babcock

21.  Hunter bowel grasper  Crocodile graspers

22.  Scissors  Hook scissors

23.  Bullet nose grasper
 Dorsey intestinal grasper

24.  Raptor grasper  Needle holder

25.  Harmonic scalpel:

26.  Surgitie  Knot pusher

27.  Clip applicator:

28.  Suction –irrigator:  Nezhat-Dorsey suction tips

29.  In the early 1990s, it was unclear whether there would be further
benefits to an already faster healing process and recovery time.
 The small intra-abdominal working space in infants and young
children makes the operations more difficult and time consuming.
 Children seem to recover more rapidly than adults.
Laparoscopic Pediatric Surgery

30.  Smaller chest and abdomen in infants make access and exposure
more problematic.
 The relatively large sized liver and spleen in young kids can
compromise the running space.
 The umbilical vein may remain patent in the infant gas embolism.

31.  The bladder is an intra-abdominal organ in the younger pediatric
population limit exposure and be at risk of injury during trocar
placement.
 The closer proximity of organs and associated structures such as
blood vessels and nerves requires careful identification and
dissection to avoid injury.

32. Reasons behind Increasing
Popularity
 Procedure Driven
Modeled after successful techniques in adult population
 Patient (parent) Driven
Population demanded use of minimally invasive techniques
 Technology Driven
Smaller and smaller instruments continue to be developed
Technology now allows better visualization than open
 Physician Driven
Innovations in procedure  career advancement

33. Positive Effects of Laparoscopic
Surgery
 Pulmonary function better maintained
 Less acute phase stress response
 Inflammatory response is dampened
 Less immunosuppression
 Decreased intra-abdominal adhesions
 Quicker GI tract recovery
 Decrease in wound complications

34. 1.Diagnostic
2.Operative
• Adrenalectomy
• Appendectomy
• Cholecystectomy
• Diaphragmatic hernia repair
• Fundoplication
• Gastrostomy
• Herniorraphy
• Intestinal Procedure
• Urological Procedure
INDICATION

35.  Localization and evaluation of impalpable undescended testicles
 Gonadal examination and biopsy in patients with intersex disorders
 Orchiectomy for undescended testicles
 Diagnosis and treatment of pediatric inguinal hernias
 Staged orchiopexy
Paediatric Urology

36.  Spermatic vein ligation in patients with a varicocele.
 Nephrectomy
 Nephroureterectomy
 Pyleoplasty.

37.  Nephrectomy
 Pyeloplasty
 Adrenalectomy
 Pyelolithotomy
 Uretero- lithotomy
 Retroperitoneal lymph node dissection
Procedure done
Retroperitoneoscopy

39.  Flow Rate-0.5 lt/min
 CO2 Volume – 0.5- 2 liters
 Air pressure – Diagnostic (10mm of hg) ,
Complex 12 to 15 mm of hg
 Umbilical 10mm Trocar
 5mm port placed in lateral position
 10mm trocar in midline
 Length of instrument 28 cm and in adult 34 cm
Operative technique

40. Visceral Injuries
 Incidence of Injury of Hollow Viscus
• Small bowel (2.7%)
• Large bowel (0.15%)
• Bladder (0.5%)
• Stomach (0.02%).
 Solid Organs
• Liver & Spleen
Complication

41. Vessel Injury
 Inferior epigastric
 Omental
 Mesenteric vessels
 Aorta
 Inferior vena cava.
Other Complications
 Gas embolism
 Pneumo-omentum
 Surgical emphysema
 Pneumomediastinum

42.  What man kind can dream, and technology can achieve.
C. Walton Lillehei (1918-1999). The father of open heart surgery

43.  SINGLE-INCISION LAPAROSCOPIC SURGERY
 MINILAPAROSCOPIC INSTRUMENTS
 ROBIOTIC SURGERY
Modernization

48. Robotic Surgery

50.  With Advancement of laparoscopic surgery around the globe and Patient
Benefit it popularity is increasing day by day.
 Robotic surgery have already established its foundation in neighbor
country India.
 Laparoscopic Surgery need experienced hand for better outcome and
uneventful surgery.
 With its increasing popularity soon it will be the heart of surgery thus
every Resident must have a basic knowledge about it .
CONCLUSION

52.  Textbook of Practical Laparoscopic Surgery, 3E (2013) [PDF]
[UnitedVRG]
 Mastery of Endoscopic and Laparoscopic Surgery, 4E (2014) [PDF]
[UnitedVRG]
 Dr R.K Mishra Lecture
 http://laparoscopy.blogs.com/prevention_management_3/2010/11/la
paroscopic-pediatric-surgery.html
 http://www.ciperj.org/imagens/pediatriclaparoscopy.pdf
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2900088/
Bibliography