Pediatric Laparoscopy - part 5 pps

101 Thoracoscopic Repair of Esophageal Atresia 10 10. Gilansz V, Boechat IM, Birnberg FA et al. Scoliosis after thoracotomy for esophageal atresia. AJR Am J Roentgenol 1983; 141:457-460. 11. Frola C, Serrano J, Cantoni S et al. CT findings of atrophy of chest wall muscle after thoracotomy: relationship between muscles involved and type of surgery. AJR Am J Roentgenol 1995; 164:599-601. 12. Goodman P, Balachandran, Guinto FC Jr. Postoperative atrophy of posterolateral chest wall musculature: CT demonstration. J Comput Assist Tomogr 1993; 17:63-66. 13. Carbognani P, Spaggiari L, Rusca M. Electromyographic evaluation of the spared serratus anterior after postero-lateral thoracotomy. J Cardiovasc Surg 1996; 37:529-530. CHAPTER 11 Pediatric Laparoscopy, edited by Thom E. Lobe. ©2003 Landes Bioscience. Laparoscopic Cholecystectomy George W. Holcomb, III In 1989, Reddick and Olsen in the United States and Dubois, et al in France published the first reports of the utilization of laparoscopy for cholecystectomy. 1,2 Soon thereafter, the technique of laparoscopic cholecystectomy became routine and the standard of care. In 1991 and 1993 the initial descriptions of laparoscopic cholecystectomy in children were published. 3-7 These reports described an initial experience of less than 10 patients at each center and demonstrated that the operation could be performed safely and effectively in pediatric patients. Although the appli- cation of laparoscopy for other conditions in children was slow to evolve, most pediatric surgeons began to apply this technique for cholecystectomy. Historically, children have required cholecystectomy for cholelithiasis due to hemolytic disease. However, over the past 20 years, there has been a changing pat- tern of disease as more and more patients have been diagnosed with idiopathic cholelithiasis rather than cholelithiasis due to spherocystosis or sickle cell disease. This increased awareness of children with cholelithiasis may be due to an increase in the development of gallstones, but may also be due to increased documentation with the widespread use of ultrasound for evaluation of children with abdominal pain. Laparoscopic Cholecystectomy Once the diagnosis of cholelithiasis or, occasionally, biliary dyskinesia has been made, the infant or child is scheduled for an elective procedure. Following induc- tion of general endotracheal anesthesia, an orogastric tube is introduced for gastric decompression and the bladder is emptied with a Credé maneuver in younger children. In older children, a urinary catheter is usually not required due to the brevity of the procedure. The patient is prepped and draped widely as for an open operation. The safest technique for placement of the initial cannula is direct incision of the umbilical skin and fascia with gentle introduction of a Veress needle and accompanying sheath into the abdominal cavity (Innerdyne, Sunnyvale, CA). Following establishment of a pneumoperitoneum, the Veress needle is removed and a 5 mm or 10 mm blunt cannula introduced into the abdominal cavity through the sheath. Diagnostic laparoscopy is then accomplished followed by introduction of accessory ports. Infants In children in less than 2 years of age, laparoscopic cholecystectomy can be readily accomplished. 8 However, placement of the auxiliary ports is different from the older patients in that an adequate working space must be created. Therefore, following 103 Laparoscopic Cholecystectomy 11 placement of the 5 mm umbilical cannula, a 3 mm or 5 mm cannula is positioned at the level of the right inguinal crease, a 3 mm cannula is introduced laterally near the right flank and a 5 mm port situated in the left mid-epigastrium. (Fig. 11.1) As Figure 11.1. This artist’s rendering depicts the port placements for an infant. It is important to widely space the cannulas so as to create an adequate intra-abdominal working space in a small patient. The most inferior right port can be placed in the inguinal crease region for cosmesis. Moreover, the epigastric port should be placed to the left of the midline for an efficient operation. 104 Pediatric Laparoscopy 11 most gallbladders in the age group can be extracted through a 5 mm umbilical incision, a 5 mm umbilical port is usually sufficient. Children Ages 2-12 The positioning of cannulas in this age group needs to be individualized according to the body habitus. For smaller children, the right lower port can be placed near the inguinal crease but should be closer to the level of the umbilicus in the larger patients. A 3 mm cannula positioned laterally in the right abdomen is usually sufficient in this age patient. The umbilical port should usually be 10 mm as the gallbladders are larger and require a larger umbilical incision for extraction. A 5 mm cannula is placed in the medial aspect of the left mid-epigastrium as a 5 mm endoscopic clip is usually sufficient for ligation of the cystic duct in this age patient. (Fig. 11.2) Figure 11.2. This diagram demonstrates the location of the ports for laparoscopic cholecystectomy in children between the ages of 3 and 12. The most inferior port should be positioned cephalad in the older child. 105 Laparoscopic Cholecystectomy 11 Teenagers In these older pediatric patients, placement of the ports mirrors that of the adult patient with the right lower cannula being situated at the level of the umbilicus and the epigastric cannula positioned either just to the left or right of the midline. The umbilical port should be 10 mm and the epigastric port can either be 5 mm or 10 mm depending on the size of the endoscopic clip required to ligate the cystic duct. The other two accessory cannulas can be either 3 mm or 5 mm. (Fig. 11.3) Technique Following introduction of these accessory ports, the patient is rotated to the left and into reverse Trendelenburg to allow the colon to fall away from the gallbladder. A grasping forcep is introduced through the right lower cannula and the dome of the gallbladder secured. It is rotated superiorly and ventrally over the liver which exposes the triangle of Calot. A grasping forcep is then placed through the right lateral port and the infundibulum is retracted laterally, creating a 90˚ angle between Figure 11.3. In the teenager, the location of the ports mirrors that in adult. The epigastric cannula can be situated either to the right or the left of the midline. In addition, a 10 mm umbilical port is usually required to extract the gallbladders in these older children. 106 Pediatric Laparoscopy 11 the cystic and the common bile ducts to prevent misidentification of these two structures. (Fig. 11.4) Through the primary working port in the epigastrium, a scis- sor with attached cautery is used to lyse adhesions which may have developed from inflammation. The cystic duct is then identified and skeletonized. It is at this point that cholangiography can be performed if desired. Cholangiography The primary indication for cholangiography in children is correct identification of the cystic and common bile ducts. Most children have had a recent preoperative ultrasound which has documented the cholelithiasis and the likely absence of common bile duct dilatation or stones. Therefore, an intraoperative cholangiogram to document the absence of stones is rarely needed. However, injury to the common bile duct can be such a significant complication that it is imperative to identify correctly the anatomy of the cystic and common bile ducts to prevent injury to the common bile duct. For this reason, if the anatomy is unclear, cholangiography should be performed. There are several techniques possible for cholangiography. In addition to lateral incision of the cystic duct and introduction of a small cholangiocatheter into the cystic duct, percutaneous introduction of a needle into the gallbladder with Figure 11.4. It is important to retract the infundibulum laterally to create a 90∞ angle between the cystic and common ducts to prevent misidentification of these two structures. 107 Laparoscopic Cholecystectomy 11 subsequent instillation of dye is also possible. I prefer to use the Kumar Pre-view cholangiography clamp (Nashville Surgical Instruments, Springfield, TN) technique in which an atraumatic clamp is placed through one of the ports (usually the inferior one) and positioned across the infundibulum of the gallbladder. 9 Through a side channel in the clamp, a cholangiography catheter with a 19 g needle is introduced into the infundibulum. (Fig. 11.5) Contrast is then instilled into the infundibulum and cystic duct. (Fig. 11.6) This is easily accomplished in most patients. However, if there is a stone at the junction of the cystic duct and infundibulum, the cholangiogram will not be successful. Also, if there is significant inflammation of the gallbladder due to cholecystitis, the cholangiogram may also be unsuccessful. The atraumatic clamp is placed across the infundibulum distal to the needle to prevent filling of the gallbladder with dye. Moreover, if the gallbladder is distended and tense, it can be decompressed with the catheter and needle as well. Figure 11.5. The Kumar preview cholangiography clamp technique is optimal in pediatric patients. An atraumatic clamp is placed across the infundibulum of the gallbladder. Through the side arm in the clamp, a 19 gauge needle attached to a cholangiography catheter is directly introduced into the infundibulum proximal to the occlusive clamp. With this technique, cannulation of a small cystic duct is not required. 108 Pediatric Laparoscopy 11 Completion of Cholecystectomy If cholangiography has been performed, the cholangiocatheter is removed. If it has not been performed, then ligation and division of the cystic duct is accomplished. The two endoscopic clips are placed on the cystic duct near, but not at, the junction of the cystic and common bile ducts. Another clip is placed at the junction of the cystic duct and infundibulum. The cystic duct is divided leaving two clips on the cystic duct stump. In a similar fashion, the cystic artery is also doubly clipped and divided. (Fig. 11.7) The gallbladder is then dissected from the liver bed in a retrograde fashion using the cautery. Although I utilize the hook cautery, others prefer the spatula cautery. (Fig. 11.8) Prior to almost completely detaching the gallbladder from the liver bed, the area of dissection is inspected for hemostasis. Once hemostasis is assured, the gallbladder is completely freed and extracted through the umbilicus. In younger patients, it is often possible to deliver the gallbladder through the cannula. However, in older patients, and especially those with an inflamed gallbladder, it is usually necessary to remove the umbilical cannula and deliver the gallbladder through the fascial incision. Occasionally, it is necessary to incise further the fascial opening to extract a large and inflamed specimen. After the gallbladder has been removed, the area of dissection is again inspected to ensure hemostasis. Once hemostasis is assured, the ports are removed and Bupivacaine is instilled into the incisions for postoperative analgesia. The umbilicus is closed with a 2-0 or 3-0 absorbable suture depending on the patient’s size. The Figure 11.6. In this 2 1/2-year old patient, cholangiography is easily performed. The cystic duct is seen entering the common duct with passage of dye into the duode- num without evidence of obstruction. In addition, the correct anatomy is confirmed. 109 Laparoscopic Cholecystectomy 11 umbilical skin is closed with 4-0 or 5-0 plain catgut suture placed in an interrupted fashion. The other incisions are secured with subcutaneous 5-0 absorbable suture. Sterile dressings are applied and anesthesia is terminated. The patients are usually discharged the next day. If the operation was performed early in the day, an occasional patient may be ready for discharge the evening of the procedure. The patients are evaluated in two weeks and thereafter as needed. Rou- tine laboratory studies or ultrasounds are not performed unless indicated. Choledocholithiasis The management of children with choledocholithiasis is complex, as the management decisions are dependent on the availability of an experienced endoscopist for endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy. For this reason, I prefer to know preoperatively whether or not such an individual is available and if stones are definitely located in the common bile duct. 10,11 For patients with documented or suspected choledocholithiasis on ultrasonography, I prefer to ask an endoscopist to perform ERCP, sphincterotomy and extraction of the stones, if they are documented. The rationale for this is that, at the time of laparoscopic cholecystectomy 24 hours later, I know whether or not a laparoscopic choledochal exploration will be required. This approach is somewhat different than in adults in which there is almost routine availability of such an endoscopist. Therefore, many adult laparoscopic surgeons will complete the laparoscopic cholecystectomy and have Figure 11.7. The cystic duct has been doubly clipped with 2 clips visualized on the cystic duct stump. In a similar fashion, the cystic artery is being clipped and divided. 110 Pediatric Laparoscopy 11 their endoscopic colleague perform an ERCP with extraction of the stones the following day. In children, however, such endoscopic availability is not as routine and the surgeon needs to know whether or not open or laparoscopic choledochal exploration will be necessary at the time of the cholecystectomy. If stones are not suspected preoperatively, but noted at the time of cholangiography, then choledochal exploration is not advisable if an experienced endoscopist is available. The disadvantage of not performing the choledochal exploration and relying on the endoscopist to extract the stones is that the child will require another operation if the endoscopist is not successful in extracting the stones. It is for this reason that I prefer to know preoperatively whether or not stones are lodged in the common bile duct. Technique Two approaches are possible for laparoscopic choledochal exploration. The first approach is through a cystotomy in the cystic duct with subsequent dilation of the cystic duct to a point where a flexible choledochoscope can be advanced through the cystotomy into the common duct. Extraction of the stone is then possible using a basket technique through the choledochoscope. If it is not possible to perform the choledochoscopy through the cystic duct, choledochoscopy is possible through a vertical incision in the common bile duct following placement of stay sutures on either side planned of the choledochotomy. Again, the choledochoscope is introduced into the common bile duct and the stones Figure 11.8. The gallbladder is dissected free from the liver bed using the hook cautery. [...]... 4 5 6 Collins JB 3rd, Georgeson KE, Vicente Y et al Comparison of open and laparoscopic gastrostomy and fundoplication in 120 patients J Pediatr Surg 19 95; 30:106 5- 1 070 Georgeson KE, Owings EP Surgical and laparoscopic techniques for feeding tube placement Gastroint Endo Clin of NA 1998; 8(3) :58 1 -5 92 Duh QY, Way LW Laparoscopic gastrostomy using T-fasteners as retractors Surg Endosc 1993; 7(1):6 0-6 3... Surg Endoscopy 1989; 3:13 1-1 33 Dubois F, Berthelot G, Levard H Cholecystecomie par colelioscopie La Presse Medicale 1989; 13:98 0-9 82 Holcomb GW III, Sharp KW, Olsen DO Laparoscopic cholecystectomy in the pediatric patient J Pediatr Surg 1991; 26:118 6-1 190 Newman KD, Marmon LM, Attorri R et al Laparoscopic cholecystectomy in pediatric patient J Pediatr Surg 1991; 26:118 4-1 1 85 Sigman HH, Laberge JM, Croitoru... et al Laparoscopic gastrostomy using four-point fixation Amer J Surg 1994; 167(2):27 3-2 76 Murayama KM, Johnson TJ, Thompson JS Laparoscopic gastrostomy and jejunostomy Amer J Surg 1996; 172 (5) :59 1 -5 94 Sampson LK, Georgeson KE, Winters DC Laparoscopic gastrostomy as an adjunctive procedure to laparoscopic fundoplication in children Surgic Endosc 1996; 10(11):110 6-1 110 Gastrostomy 117 Figure 12.3 A needle... trocar (Tyco) 30 degree scope (3, 4, or 5 mm depending on size) Red rubber catheter for stabilization Metzenbaum scissors (3 or 5 mm depending on size of child) Grasping forceps (3 or 5 mm) Babcock 5 mm Hook 3 -5 mm electrocautery Needle driver Ski needles (Ethicon) 13 120 Pediatric Laparoscopy Figure 13.2 Optional port stabilization The working ports are stabilized by passing them through a section of red... Surg 1991; 2 6-1 18 1-1 183 Moir CR, Donohue JH, van Heerden JA Laparoscopic cholecystectomy in children: Initial experience and recommendations J Pediatr Surg 1992; 27:106 6-1 070 Davidoff AM, Branum GD, Murray EA et al The technique of laparoscopic cholecystectomy in children Ann Surg 1992; 2 15: 18 6-1 91 Holcomb GW III, Naffis D Laparoscopic cholecystectomy in infants J Pediatr Surg 1994; 29:8 6-8 7 Holzman... placement of the instruments Instrumentation A single 3 mm or 5 mm trocar is used in the umbilicus In most instances, a 3 mm scope allows adequate visualization for the procedure The instruments needed include: Scope 0 degree, 3 mm Trocar, 3 .5 mm, x2 Grasper, 3 mm U-stitch Needle with guidewire Graduated dilators, x4 (Cook dilator set # C-JCDS-100-CHB PO Box 489, Bloomington, IN 47402 ) Catheter or balloon... (use one for liver retraction) Pediatric Laparoscopy, edited by Thom E Lobe ©2003 Landes Bioscience Pediatric Laparoscopic Fundoplication 119 Figure 13.1 Port placement The camera is placed in the umbilical port The open circles denote the placement of trocars in small infants Large Children 5 mm trocars x 5 All Patients Innerdyne trocar (Tyco) 30 degree scope (3, 4, or 5 mm depending on size) Red rubber... the procedure The installation of bupivicaine hydrochloride 0. 25 with epinephrine or large volumes of dilute xylocaine with epinephrine into the trocar sites helps with postoperative pain management Pediatric Laparoscopy, edited by Thom E Lobe ©2003 Landes Bioscience 114 Pediatric Laparoscopy Patient Positioning Patients under the age of 5 years can usually be positioned at the end of the table with... secured to the undersurface of the diaphragm with 2 or 3 non-absorbable sutures to prevent migration of the wrap into the chest A partial wrap is constructed by attaching the right side of the fundus to the right crus with a running 2-0 or 3-0 nonabsorbable suture The fundus is secured to the right side of the esophagus with a running 2-0 or 3-0 nonabsorbable suture The fundus to the left of the esophagus... our patients 13 124 Pediatric Laparoscopy 13 Figure 13 .5 Toupet fundoplication The fundoplication is a 270 -3 00˚ wrap secured to the esophagus with running sutures The fundoplication is stabilized by suturing it to the diaphragm on both sides Selected Readings 1 2 Bell RCW, Hanna P, Powers B et al Clinical and manometric results of laparoscopic partial (Toupet) and complete (Rosetti-Nissen) fundoplication . evaluation of the spared serratus anterior after postero-lateral thoracotomy. J Cardiovasc Surg 1996; 37 :52 9 -5 30. CHAPTER 11 Pediatric Laparoscopy, edited by Thom E. Lobe. ©2003 Landes Bioscience. Laparoscopic. patients. J Pediatr Surg 19 95; 30:106 5- 1 070. 2. Georgeson KE, Owings EP. Surgical and laparoscopic techniques for feeding tube placement. Gastroint Endo Clin of NA 1998; 8(3) :58 1 -5 92. 3. Duh QY, Way. JS. Laparoscopic gastrostomy and jejunostomy. Amer J Surg 1996; 172 (5) :59 1 -5 94. 6. Sampson LK, Georgeson KE, Winters DC. Laparoscopic gastrostomy as an adjunctive procedure to laparoscopic