3. Laparoscopy is currently successful in young
children, neonates and even in pre-terms.
Gans, 1971 showed the safety of the procedure
Two issues surface
- Procedural issues
- The significant advantages of laparoscopy
procedures over the conventional operative
approach
4. ANATOMIC CONSIDERATIONS
* Larger diameter of umbilical vessels.
* Urinary bladder (with the urachus) is an abdominal organ
till 3 ys. Of age.
* Processus vaginalis may be re-opened by insufflation.
* Wider, displayed rectus abdominis muscles ( epigastric
vessels injury ).
* Insufflation P. - Infants 6 – 8 mm Hg
- Children 8 – 10 mmHg
- Older children 10 – 12 mm Hg
5. Eessentials of Pediatric Laparoscopy
- Rod lens telescope ( 2-10 mm ).
- Light weight video camera.
- Smaller, shorter trocar / cannula sets ( about 2 cm
long ) with expandable flinges or adhesive rings.
Difficulties : Thin, elastic abdominal wall
- Misdirection of the needle and trocars.
- Injury of the abdominal viscera.
- Limited mobility of the instruments.
6. Advantages of Pediatric Laparoscopy
- Less parietal complications.
- Shorter hospitalization.
- Less psychological trauma.
? Cost effective
? Operative time
? Training programs
7. Laparoscopic Procedures in Infants and Children
I – Excision for Internal Organs Diseases
* Cholecystectomy * Appendectomy
* Nephrectomy * Adrenalectomy
* Splenectomy * Cyst ecxision
2- Diagnostic procedures
* Neonatal jaundice * Acute abdomen
* Impalpable testis ( also therapeutic )
* Intussusception ( after hydrostatic reduction )
* LN & tumors guided biopsy * Intersex
8. 3- Reconstructive procedures
• Fundoplication * Biliary surgery
• Pyeloplasty * Pyloromyotomy
• GI anastomosis * Rectopexy
4- Dissection
• Adhesiolysis * LA ERPT
• LA APPT
9. Optimum table height should position of laparoscopic
instrument handles close to
surgeon’s elbow. This is 64 to 77 cm
above floor level
10. Manipulation angle should be as near as possible
to 60 degree (Ergonomically the best)
13. Center of the monitor should be placed 20 degree
lower than the eye
This position corresponds with the normal resting
position of occulomotor muscle
14. Distance of Monitor should be 5 times of
diagonal length of screen
15.
16.
17.
18. * A good modality for training on handling tissues laparoscopically.
Laparoscopic Appendectomy
19. Control of mesoappendix
1. Endo GIA 2. Sutures
3. Endo loops 4. Surgical clips
5. Laser
6. Laparoscopic assisted
22. Contrary to the previously mentioned
view, our experience showed that
laparoscopic appendectomy is
especially valuable in cases of
perforated appendicitis as this permits
copuous irrigation and meticulous
suction of the irrigation fluid from the
pelvis.
30. Nissen Fundoplication
- Laparoscopic Nissen fundoplication is now a
standard procedure for GERD in children.
Advantages:
- Less wound complications & pulmonary
atelectasis particularly in mentally retarded
children.
31. Essential Steps :
- Approximation of the diaphragmatic crura.
- 360° fundoplication.
- Gastrostomy is a complementary procedure.
- Results: Comparable to the open method.
34. Laparoscopic Rectopexy
Principles
1- Deep posterior rectal dissection.
2- Bilateral dissection down to the
lateral ligaments.
3- Bilateral suture fixation of the rectum to the
presacral fascia
4- Ensuring no perforation or narrowing of the
rectum.
35.
36. Neonatal Jaundice
- Laparoscopy has become a conclusive method if
diagnosis is still uncertain.
- Value: Direct exploration of the extra hepatic
biliary ducts.
- permits radiological control and liver biopsy.
- Allows irrigation of the G.B.
37. Laparoscopic exploration (or mini-laparotomy)
GB is found No GB
Laparoscop. (or open) cholang.
GB lumen No GB lumen Hepatic porto-
Patent BDs Atretic BDs jejunostomy
close the abd. ( Kasai )
39. Abdominal Undescended testes
* 5 years periods :
92 patients with 135 impalpable testes underwent
laparoscopic exploration.
* Diagnosis is confirmed by examination under
anaesthesia.
* The patient is not labelled to have anorchia
except after laparoscopic exploration.
41. Laparoscopic classification and management
Pediatr Surg Int (1999) 15:570-572
TYPE I :
No testis - VD &SV end
blindly at IR : No ttt
NO TESTIS - VD & SV
entering the ring :
Inguinal Exploration
42. Type II : Testis at IR-loopin
of VD&SV: LAO
Type III : Testis at IR-no looping
of VD&SV
Type IV : Testis not related to IR
III&IV : Lap clipping of SV & LAO
after 6 ws
45. Laparoscopic assisted
techniques
The intra-abdominal portion of the laparoscopic
technique is not different from that of open primary
pull-through. Three ports are usually used in the
upper abdomen .
A right lower quadrant port can be used for colon
manipulation, especially when performing the
Duhamel or Swenson procedures. Initial dissection
consists of mobilizing the sigmoid colon down to
and opening the peritoneal reflection.
46. Laparoscopic assisted
techniques
Further dissection into the pelvis can be
done, as in the Swenson or Duhamel
approach, but is not necessary for the
Soave endorectal approach.
Great care should be taken to avoid
collateral structures, especially the left ureter
and the vas deferens.
53. Currently, we use laparoscopy :
- To detect the level of aganglionosis
- To do more colonic mobilization
& gain more length.
- To save time ( synchronous dissection )
- To prevent over-stretch of the anal ring
while prolapsing the huge rectum transanally
54. Adhesiolysis for Intestinal Obstruction
* Principles:
- Open laparoscopy
- Adhesions between loops of small bowel &
anterior abdominal wall are divided first.
- Run the whole bowel from the ligament of Tritz
to ileocaecal valve till the point of obstruction.
58. Principles:
- Pre-operative vaccination with polyvalent
vaccine against Hemophilus influenzae &
Pneumococus
- Fixation of the spleen.
- Start with G/S ligament & short gastric vessels.
- Division of the hilar vessels.
- A lap Sac & Morcellator are used to remove the
spleen.
- Search for accessory spleens.
67. Advantages of
PSARP
Perfect exposure
Defining the muscle complex accurately
Strict positioning of the rectum within the
muscle complex
Tailoring of the dilated rectal pouch
Less incidence of prolapse due to fixation of
the rectum
Accepted cosmetic results of the perineum
Cutting of fistula flush with the bladder neck
68. PSARP with Laparotomy
Longer operative time
Changing the position of the patient
Cutting the levator ani with the risk of
disruption or improper re-closure
Abdominal incision
69. Indications Of Laparoscopic
assisted APP
Whenever laparotomy is indicated.
1)Recto-vesical fistula.
2)recto-prostatic fistula.
3)High confluence cloaca
4)Recto uterine fistula.(rare)
The majority has poor
prognosis as regards
continence.
70. Steps
Abdominal part:
1. Abdominal exploration
2. Release of adhesions
3. Evaluation of the site of
colostomy
4. Mobilization of the rectum
5. Exposure of the fistula
6. Ligation of fistula
7. Exposure of the levator ani
71. Perineal part
1. Defining & marking the external sphincter.
2. Midline division of the sphincter (2cm incision)
3. Deepening of the incision for 2-3 cm
4. Passing no 6 hegar dilator from the perineal side to exit
in the midline in front of the levator and behind the
urethra.
5. Dilatation of the pathway using hegar dilators till no 14.
6. Insertion of a backcock forceps to grasp the rectum
7. Anal anastomosis
72. Laparoscopy in chronic pelvic pain
in childhood
* A challenging problem ? Persistant lower abdominal pain
> 6 mo & multiple visits to the physian
* Primary : No obvious cause ( NSAP )
* Secondary : Obvious cause, look for them laparoscopically
- GIT: Chronic constipation & Regional ileitis &
- Genito-urinary: Recurring cystitis, endometriosis,
oophritis, congenital uterine
anomalies, functional ovarian cysts
- postoperative adhesions
73.
74. Laparoscopy in acute abdominal
pain
- Medium or severe abdominal pain with
Duration of less than 7 days
- Laparoscopy is indicated after a complete
Diagnostic work-up.
- Causes
Non specific abdominal pain
Acute biliary disease
Diverticulitis
Bowel obstruction
75. Laparoscopic liver resection
Lap US
The line of transection on the liver surface.
The hepatic parenchyma transection and the
main blood vessels and bile ducts: clips or
staples.
The resected liver is enclosed in a bag and
removed through a small incision.
Haemostasis of the transection line.
Hand-assisted laparoscopic liver resection.
? For benign swellings only
76. Laparoscopic management of
hepatic cysts
Laparoscopic management of hepatic
cysts has become the new gold
standard, associated with minimum
morbidity and good long-term outcome
( marsupialization, cyst wall resection
Or segmental hepatic resection )
77. Laparoscopic hepatic hydatid
surgery is a safe and effective
method in selected patients
•Limitations
•Intraparenchymal location
•of the cyst
•Multiple cysts
•Cysts with thick & calcified walls
78. Surgical Tipss
- Gauzes soaked with 10% povidone iodine solution are
placed around the cyst
- Injection of scolecidal agents is controversial
(possible sclerosing cholangitis)
•-If cystic fluid bile stained, suggesting biliary rupture
choledochotomy and T-tube drainage
•- Proper removal of the germinative membrane
wide-bore suction catheter (without valvular system)
•- Management of the cavity
83. NOTES is Dying SILS is progressing due to high
patient Acceptance
84. Conclusion
Pediatric laparoscopy is a useful tool
in the pediatric surgical practice and
should be one of the armamentarium
of the pediatric surgeons.
