Laparoscopy in children. That's why pediatric surgeons use little tricks when inserting instruments.
Chapter 1. Literature review. Laparoscopy in urgent abdominal surgery in young children: history, current state of the problem and development prospects.
Chapter 2. Materials and research methods.
2.1. General characteristics of patients.
2.2 General clinical examination of groups of patients.
2.3 Assessing the degree of surgical trauma.
2.4 General issues of laparoscopic intervention technique.
2.5. General issues of the technique of “open” laparotomy interventions.
2.6. Statistical data processing.
Chapter 3. Objectification of assessment of the degree of surgical trauma in children who have undergone emergency abdominal surgery
3.1. Correlation of the degree of surgical stress and homeostasis indicators.
3.2 Comparison of the severity of surgical stress in newborns after laparoscopic and traditional interventions.
3.3 Correlation of homeostasis indicators depending on the nature of the operation and the age of the patients.
Chapter 4. Treatment results for patients of the main group.
4.1. Complications.
4.2. Conversions during laparoscopic interventions.
4.3. Mortality.
Recommended list of dissertations in the specialty "Pediatric Surgery", 14.00.35 code VAK
Possibilities of minimally invasive technologies in the treatment of acute surgical diseases of the abdominal organs 2004, Doctor of Medical Sciences Semenov, Dmitry Yurievich
Video-assisted intestinal surgery in children. 2011, Candidate of Medical Sciences Vasilyeva, Ekaterina Vladimirovna
Endovideosurgical interventions for acute diseases and injuries of the abdomen 2009, Doctor of Medical Sciences Levin, Leonid Aleksandrovich
The influence of intra-abdominal pressure on the parameters of the cardiorespiratory system in children during laparoscopic operations 2013, Candidate of Medical Sciences Mareeva, Anastasia Aleksandrovna
Acute adhesive intestinal obstruction in children: diagnosis, treatment and the role of laparoscopy 2006, Doctor of Medical Sciences Kobilov, Ergash Egamberdievich
Introduction of the dissertation (part of the abstract) on the topic “Emergency laparoscopy in infants”
Relevance of the problem
Currently, there is a growing interest in the world in the introduction of endoscopic interventions in all areas of surgery. Despite advances in minimally invasive surgical technologies, the use of laparoscopy in children of an early age group and, especially, in newborns began relatively recently. Children during the neonatal period and the first months of life have a number of distinctive physiological and anatomical features that make it difficult to perform endoscopic operations on them and cause a higher risk of complications.
A particular difficulty in treating newborns is due to the fact that from 5% to 17% of children with surgical pathology are premature and children weighing less than 2,500 g. Moreover, the need for surgery arises in the first days of life against the background of a period of early adaptation and high sensitivity to surgical trauma and surgical stress: up to 42% of children require emergency surgical procedures (Ergashev N.Sh., 1999).
The need to perform traumatic laparotomies leads to a long stay in intensive care units, which increases the risk of infection and the degree of operational stress; necessitates long-term parenteral nutrition and ventilatory support after surgery, the administration of painkillers, taking into account the fact that the use of narcotic analgesics in newborns is undesirable due to the negative respiratory effects of the latter. Significant disadvantages of wide laparotomies are also the need to lengthen hospitalization and unsatisfactory cosmetic results.
These factors create the prerequisites for the use of gentle techniques using modern low-traumatic technologies in this age group. For example, in large foreign pediatric clinics, of all laparoscopic interventions, 38.1% are performed on children under 1 year of age (BaxN.M., 1999).
Studies reflecting the hemodynamic, respiratory and temperature effects of pneumoperitoneum in children in the first months of life are available only in foreign literature and are sporadic (Kalfa N. et all, 2005). At the same time, there were no works devoted to assessing the morbidity of laparoscopy from the standpoint of evidence-based medicine in acute surgical diseases in children of the first year of life in the literature available to us. One of the most reliable ways to assess the results of surgical interventions is the analysis of surgical aggression, which, when studied in patients with pyloric stenosis, convincingly proves the advantages of laparoscopy over open operations (Fujimoto T. et all., 1999).
In our country, despite many years of tradition and priority work in some areas on the use of laparoscopy in pediatric practice, only a few neonatal surgical centers have experience in endoscopic operations on newborns (Kotlobovsky V.I. et al., 1995, Gumerov A.A. et al. ., 1997, Sataev V.U. et al., 2002). Single reports have been published on the use of endoscopy for ulcerative necrotizing enterocolitis (UNEC) (Bushmelev V.A., 2002, Pierro A. Et all., 2004), intussusception, adhesive intestinal obstruction, acute appendicitis (Dronov A.F., Poddubny I.V., 1996), strangulated hernias (Shchebenkov M.V., 2002).
There are no works that comprehensively reflect the place and principles of application of this method in emergency neonatal surgery and surgery of infants. There are no criteria for objective assessment of the morbidity and safety of laparoscopy in newborns. In addition, the development of laparoscopic surgery in this age group requires a revision of indications and contraindications for operations, taking into account age, term, severity of the main and concomitant pathology.
Thus, the above circumstances, as well as our own experience of laparoscopic operations for various emergency surgical pathologies in children of neonatal and infant age, prompted us to conduct research in this direction.
Purpose of the work: to improve diagnosis and improve the quality of treatment of urgent abdominal pathology in newborns and infants through the use of minimally invasive laparoscopic interventions.
Research objectives:
1. prove the safety, feasibility and high effectiveness of laparoscopy in the diagnosis and treatment of urgent abdominal pathology in newborns and infants by studying the metabolic, hemodynamic and respiratory effects of CO2 pneumoperitoneum;
2. to develop a method for objective assessment of the surgical morbidity of laparoscopic interventions in newborns and infants;
3. conduct a comparative analysis of the morbidity and effectiveness of laparoscopic and traditional “open” surgical interventions for emergency surgical diseases of the abdominal organs in newborns and infants;
4. analyze intraoperative and postoperative complications, determine risk factors for complications during emergency laparoscopy in newborns and infants.
The position to be defended:
Laparoscopic interventions are less traumatic and more effective for emergency abdominal surgical pathology in children of the first year of life in comparison with laparotomic operations and have no age restrictions
Scientific novelty
For the first time, using a large clinical sample (157 patients under the age of 1 year), the results of introducing a whole range of minimally invasive laparoscopic surgical techniques into clinical practice were analyzed.
The influence of CC-pneumoperitoneum during emergency laparoscopic interventions in newborns and infants was studied.
A score assessment of the degree of surgical trauma in children in the first months of life, adapted to the use of laparoscopic interventions, is proposed. The objectivity of assessing the degree of surgical trauma based on widely used methods of intraoperative and postoperative monitoring has been proven.
Minimally invasive techniques such as laparoscopic and laparoscopic-assisted interventions for intussusception, perforated peritonitis of various origins, strangulated inguinal hernias, complicated forms of Meckel’s diverticulum, and severe forms of adhesive intestinal obstruction have been introduced into clinical practice in young children, including newborns.
The use of the described methods made it possible to achieve a significant improvement in the results of treatment of children with these types of pathologies - to reduce the number of postoperative complications, ensure a smoother course of the postoperative period, rapid restoration of activity, a significant reduction in the length of hospitalization of patients, excellent cosmetic results, and reduce treatment costs.
Implementation of results in healthcare practice
The results of the dissertation work were introduced into the practical activities of the departments of emergency and purulent surgery, neonatal surgery of the Children's City Clinical Hospital No. 13 named after N.F. Filatov (Moscow), the department of emergency purulent surgery of the Children's City Clinical Hospital No. 9 named after. G.N. Speransky (Moscow).
The materials of the work are used when giving lectures and at seminars on pediatric surgery for senior students and doctors of the Faculty of Internal Medicine of the Russian State Medical University.
Approbation of work
The dissertation was completed at the Department of Pediatric Surgery (headed by Professor A.V. Geraskin) of the Russian State Medical University, on the basis of Children's City Clinical Hospital No. 13 named after N.F. Filatov (chief physician - Doctor of Medical Sciences V.V. Popov). The main provisions of the dissertation are reported:
IV Russian Congress “Modern technologies in pediatrics and pediatric surgery. Moscow, October 16-19, 2005;
11th Moscow International Congress on Endoscopic Surgery, Moscow, April 18-20, 2007;
II Congress of Moscow Surgeons “Emergency and Specialized Surgical Care” Moscow, May 17-18, 2007;
15th International Congress of the European association for Endoscopic surgery (EAES), Athens, Greece, 14-18 June 2007;
XII Moscow International Congress on Endoscopic Surgery. Collection of abstracts. April 23-25, Moscow, 2008.
Scope and structure of the dissertation
The dissertation consists of an introduction, 5 chapters, practical recommendations and a list of references.
Conclusion of the dissertation on the topic “Pediatric Surgery”, Kholostova, Victoria Valerievna
104 Conclusions
1. In infants during laparoscopy, the effects of CO2-pneumoperitoneum are most significantly reflected in the state of the blood gas composition, especially in patients of the neonatal period. At the same time, laparoscopy-induced cardiorespiratory changes are comparable to those during “open” operations. The advantages of laparoscopic interventions over traditional ones are reflected in less pronounced levels of hypothermia, blood loss and changes in blood glucose levels - a marker of the hormonal-metabolic stress response to surgical aggression
2. The modified method of scoring surgical stress is an objective way to determine the morbidity of surgical interventions in newborns and infants and allows for a comparative analysis of laparoscopic and traditional “open” operations.
3. A comparative analysis of laparoscopic and traditional surgical interventions showed that laparoscopy is a less traumatic method of surgical treatment of emergency abdominal surgical diseases and has no age restrictions.
4. Complications of the intraoperative and postoperative periods after laparoscopic interventions are not specific and are less common compared to traditional “open” operations.
1. Laparoscopic surgery at the present stage is an integral part of pediatric surgery and has no age restrictions. In this regard, in leading children's surgical clinics it is advisable to organize the work of departments or clinical groups for endoscopic surgery, with the presence of a specialized operating room equipped with the necessary video endoscopic equipment and instruments intended for young children.
2. When performing laparoscopic interventions in children of an early age group, it is necessary to strictly adhere to a number of technical requirements:
The site of the first puncture of the abdominal wall should be removed from the projection of the umbilical vein, especially in newborns;
For the first puncture, use only atraumatic blunt trocars,
It is necessary to use tools of small diameter - no more than 3 mm,
All operations should be performed at low intra-abdominal pneumoperitoneum pressure not exceeding 6-8 mm Hg,
The carbon dioxide supply rate should not exceed 1-1.5 l/min,
A prerequisite is intraoperative monitoring of the main indicators of gas exchange, blood electrolyte composition, hemodynamic parameters, body temperature and diuresis.
3. In urgent surgery of newborns and infants with acquired “acute abdomen” syndrome, at present, almost all unclear cases are an indication for diagnostic laparoscopy. At the same time, the vast majority of cases of intestinal obstruction of various origins (adhesions, intestinal intussusception, etc.), acute appendicitis, Meckel's diverticulum, JNEC, etc., can not only be reliably diagnosed using laparoscopy, but also radically cured using minimally invasive laparoscopic surgery.
4. When developing and introducing minimally invasive technologies into pediatric surgical practice, it is necessary, from the standpoint of evidence-based medicine, to conduct comparative studies of surgical interventions, using a scoring method for surgical aggression based on objective criteria for the effectiveness and safety of operations.
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Laparoscopic pyeloplasty in children: experience of 250 patients.
Zakharov A.I. 1, Kovarsky S.L2, Tekotov A.N.², Sklyarova T.A1, Sottaeva Z.Z. 2, Petrukhina Yu.V. 2, Struyansky K.A.2
1 Children's City Clinical Hospital No. 13 named after. N.F. Filatov Moscow, 2 RNRMU named after. N.I. Pirogov, Moscow
In case of obstruction of the pyelourethral segment, a real alternative to open operations in recent years is laparoscopic disconnecting pyeloplasty, while the basic principles of surgical correction - resection of a part of the ureter within a healthy area with the application of ureteropyeloanastomosis - remain unchanged.
Methods: From 2008 to 2014. inclusive, in the urology department of the Filatov Children's Hospital, 256 operations were performed for simple hydronephrosis in 250 children (69 girls, 181 boys) aged from 2 months to 18 years (average age 2.8 years) using endoscopic technologies. 77 of them were less than 12 months old.
Indications for organ-preserving surgery were based on the results of ultrasound with Doppler ultrasound of the renal vessels, data from X-ray methods and static renography. If the size of the pelvis is significant (more than 30 mm), its drainage was previously (for 3-6 months) performed using puncture pyelostomy under ultrasound control (in our work - 18 patients) with delayed laparoscopic pyeloplasty. The remaining children underwent primary laparoscopic pyeloplasty using a transperitoneal or retroperitoneal approach. After installing 3 trocars - a 5 mm optic and two 3 mm manipulators, the pyeloureteral segment was mobilized and partial resection of the pelvis with longitudinal dissection of the ureter was performed (Anderson-Hynes principle). The pyeloureteral anastomosis was performed using a running suture using 5-0 or 6-0 PDS suture. Drainage was carried out by installing (antegrade or retrograde) an internal JJ stent. The duration of the operation was 120±40 minutes.
Results. All operations were completely laparoscopic and there were no conversions. No febrile infectious complications were recorded. The patients were discharged on postoperative days 3-7 under outpatient supervision of a urologist. During the primary operation, the ureteral stent was removed after 6 weeks; during surgery for recurrent hydronephrosis, 12 weeks after surgery. In 240 cases (96%) there was a reduction in the size of the pelvis, absence of urinary tract infection, improvement in intrarenal blood flow according to Dopplerography (1.6, 12 and 24 months after surgery. In 6 patients (4 after preliminary drainage of the pelvis) pyelectasia remained on the background of CKD, for which they received conservative therapy. 4 children were diagnosed with relapse of the disease, which served as an indication for repeated laparoscopic pyeloplasty.
Conclusion. The results of treatment of congenital hydronephrosis in children using laparoscopic pyeloplasty are comparable to the results of open operations, but its less invasiveness, low likelihood of infectious complications and the possibility of early activation of patients make this method of treatment the most optimal.
Our expert is a surgeon, head of the urology department of the Volgograd Clinical Hospital of Emergency Medicine, Sergey Bondarenko.
Not long ago, laparoscopic surgeries, which are performed through one or more tiny holes in the body, were science fiction. Something like the work of Filipino healers. Today, the indications for such operations are expanding day by day, and these interventions themselves are used not only in adults, but also in children.
Small access - big benefit
Once upon a time, doctors used the following phrase: “Big surgeon, big cut.” But this statement has long since lost its relevance. And all thanks to the introduction of so-called minimally invasive (that is, gentle) surgical methods. After all, such operations (as doctors say, with limited access) do not require large incisions, but are carried out through barely noticeable 3-4 punctures, which are made in the patient’s anterior abdominal wall. Through these holes, miniature manipulative instruments are inserted, which the surgeon uses to perform the operation. An optical device with a light source is inserted through another puncture. Modern optics are connected to a monitor screen, where a detailed and comprehensive image of the internal organ is displayed. You can view it in detail, and you can also use the image enlargement function. Naturally, an excellent overview of the surgical field is very convenient for the surgeon, which improves the quality of his work.
There are also benefits for the patient. Blood loss after laparoscopic operations is less, pain is lower, and the cosmetic result is better. Healing occurs faster, the rehabilitation period is simpler and shorter. And there are significantly fewer complications. Of course, at first glance, such operations represent a complete benefit for both the doctor and the patient. But is it really that simple?
Fundamental question
When using laparoscopic techniques, especially when it comes to pediatric surgery, some important principles must be observed. The main one is the principle of safety.
Passing optics and instruments into the patient's abdominal cavity is the most dangerous moment during the operation, since for the surgeon this process always occurs blindly. Doctors have to be especially careful if a small patient has anatomical anomalies - in this case, there is a higher risk of accidentally damaging important organs and tissues. And even the data from available studies (ultrasound, MRI) do not always guarantee safety. When performing laparoscopy in adults, air is pumped into the abdominal cavity - this is done in order to lift the abdominal wall and facilitate the insertion of instruments. But, alas, this method cannot be used for children, since for them the pressure in the abdominal cavity exceeds 7-8 mm Hg. Art., is harmful, it can have an extremely negative effect on the child’s cardiac activity, respiratory system and brain. Therefore, surgeons use different tricks when inserting instruments. For example, they use the “open port” technique - that is, before introducing instruments, they make a small incision (5-6 mm), through which all the anatomical details of interest will be clearly visible. The second way to ensure safety is to insert a Veress needle, a device that is a hollow needle with a spring inside and a cannula. After penetration into the cavity (usually the abdominal cavity), the protective part of this instrument extends and covers the needle tip, thereby protecting the organs and tissues located there from damage.
Jewelry work
The second important principle that is used today in pediatric laparoscopic surgery is the principle of minimal invasiveness. Doctors are confident that a small approach must be combined with minimally invasive (that is, gentle) surgery, then this justifies the essence of the method itself and guarantees the absence of postoperative injuries for the patient. Therefore, doctors performing laparoscopic operations on children try to work very carefully and literally with precision. This principle also implies the most gentle attitude when intervening to neighboring healthy organs and tissues. With an open operation, this is almost impossible to achieve, since the surgeon’s eyes cannot provide such a detailed image as a video camera can, showing the organ from all sides. In addition, manual manipulation is always more traumatic than working with thin instruments. In this regard, laparoscopic surgery provides great advantages.
Dangerous repetition
Repeated operations require special attention, the difficulty of which lies in the fact that the surgeon starting work does not fully know the severity of the scar process left in a small patient after the previous intervention. After all, any healing in the body occurs through the formation of scar tissue. However, the degree of scarring may vary. Therefore, the most difficult stage of such an operation is the isolation of the organ, since it is quite problematic to excise the surrounding scars, since they often include important tissues, for example, vessels that feed the organs. Therefore, few surgeons, even in the world, decide to perform repeated laparoscopic operations, which are difficult not only technically, but also physically and psycho-emotionally. However, if we talk about urology, the risk of losing a kidney with repeated open surgery is higher than with repeated laparoscopic intervention. That’s why doctors still resort to these complex methods. And they often achieve excellent results.
To apply sutures, two 5 mm instruments are required: a Szabo-Berci type needle holder (located in the right hand) and an atraumatic grabber (in the left).
The most commonly used are conventional surgical sutures with curved needles (Vicryl, PDS 4 0, 5 0).
The following types of seams are usually used:
1. Single sutures for suturing small defects of the peritoneum, suturing and ligating structures such as the ureter, urachus, etc., cecopexy, etc. The diagram for applying such a suture is shown in Fig. 4 8;
Rice. 4 8. Scheme of applying a single suture.
Features of operational technology
2. Continuous suture, mainly when closing fairly large peritoneal defects after extensive mobilizations of the colon (during kidney operations), during laparoscopic orchipexy, etc. (Fig. 4 9).
4.2. Final stages of intervention
Revision of the abdominal cavity 1. Thorough examination of the abdomen
cavity starting from the small pelvis to the upper floor of the abdominal cavity in order to detect previously undetected injuries to internal organs.
2. An inspection to detect bleeding sites is carried out after the intra-abdominal pressure has decreased to 5 mm Hg. Art., and venous bleeding resumes, which is tamponed at a pressure in the abdominal cavity of about 15 mm Hg. Art.
Abdominal sanitation
1. Complete removal of effusion from the abdominal cavity using endoscopic suction.
2. According to indications - targeted dosed rinsing of the entire abdominal cavity or its individual parts with physiological solution with the addition of heparin, followed by complete removal of the rinsing solution.
3. If necessary - dr-
Rice. 4 9. Scheme for applying a continuous suture.
lining the abdominal cavity with silicone drainage. Handset
it is precisely inserted into the desired part of the abdominal cavity under the control of a laparoscope. In our observations, the indication for drainage is most often the presence of peritonitis. After “pure” planned surgical interventions, abdominal drainage is usually not performed.
Laparoscopic surgery. General part
Trocar removal
1. First of all, 12 and 11 mm trocars are removed, always under endoscopic control of the place where they are located, in order to avoid possible bleeding (when using trocars with a conical stylet shape, this practically does not happen) or a strand of the omentum entering the peritoneal defect (this most often happens when the trocar removed after complete removal of pneumoperitoneum and the appearance of tension in the muscles of the anterior abdominal wall after the end of the action of muscle relaxants).
2. Layer-by-layer suturing of an 11 mm wound is also advisable to carry out until the pneumoperitoneum is completely removed and under optical control. The wound is closed in layers with mandatory suturing of the fascia (Vicryl 4 0) and skin.
3. After removing the pneumoperitoneum, 5 mm trocars are removed, and the skin wounds in the places where they are located are closed with adhesive plaster strips or one suture is applied.
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CHAPTER 5.
Laparoscopic surgical techniques place great demands on adequate anesthesia and intraoperative monitoring. Despite the accumulation of significant experience in ensuring adequate protection of the patient during surgery, when performing laparoscopic interventions, the anesthetic risk still remains significantly higher than the surgical risk.
In the middle of the 20th century, doctors paid serious attention to changes in the hemodynamic and gas exchange systems caused by the imposition of pneumoperitoneum. Laparoscopy turned out to be far from a safe procedure. Performing these operations is associated with the occurrence of minor and major surgical and anesthetic complications, to prevent and relieve which it is necessary to clearly understand the pathophysiological mechanisms of their development.
5.1. The effect of laparoscopic manipulation on ventilation and gas exchange
Currently, the vast majority of anesthesiologists note the danger of performing laparoscopic manipulations and operations against the background of spontaneous breathing, since the imposition of pneumoperitoneum limits the mobility of the diaphragm.
The application of pneumoperitoneum causes the following changes in the functioning of the child’s cardiovascular system:
1. The extensibility of the lung tissue decreases.
2. Atelectasis of areas of the lungs occurs.
3. The functional residual capacity of the lungs decreases, ventilation-perfusion disorders appear and progress, hypoventilation, hypercapnia and respiratory acidosis develop.
With an increase in the area of pulmonary shunting (i.e., areas of perf JnpyeMoft, but not ventilated lung tissue), hypoxemia increases, which is not corrected by increasing the percentage of oxygen in the inhaled mixture. This is reflected in a decrease in the value of such indicators as partial
real oxygen pressure in arterial blood (pa02) and hemoglobin oxygen saturation (S02). Typically, oxygen deprivation occurs in patients with underlying myocardial dysfunction and/or hypovolemia and is associated with the combined effects of reduced pulmonary compliance and reduced cardiac output (CO).
That is why, when performing laparoscopic procedures, there is a need for tracheal intubation, mechanical ventilation and total muscle relaxation. However, even against the background of mechanical ventilation in the normal ventilation mode with a complete muscle block, atelectasis of the alveoli and a decrease in pulmonary compliance occur.
Laparoscopic surgery. General part
tissue, a decrease in FOB, an increase in peak pressure and plateau pressure in the airways (on average by 40%). These changes are more pronounced during laparoscopic operations, which are performed in the Trendelenburg position and require maintaining high pressure in the abdominal cavity (5-14 mm Hg). Disturbances from the respiratory system are much less significant during laparoscopic cholecystectomies, during which a reverse Trendelenburg position is used and the pressure in the abdominal cavity does not exceed 10-14 mm Hg. Art.
Hypercapnia during laparoscopic procedures is caused not only by changes in ventilation parameters as a result of increased intra-abdominal pressure, but also by the absorption of carbon dioxide (CO2) from the abdominal cavity. CO2 is highly soluble in the blood and quickly diffuses through the peritoneum.
Factors that determine the intensity of CO2 entry into the blood:
1. Good solubility C0 2 in the blood, rapid diffusion through the peritoneum.
2. Abdominal pressure level.
3. Duration of surgery.
4. Absorption surface area (peritoneum).
Since the last parameter per unit of body weight in children is 2 times greater than in adults, a faster and more massive intake of CO2 into the blood can be expected in children. In adults, hypercapnia and respiratory acidosis usually develop no earlier than 15 minutes after the start of CO2 insufflation into the abdominal cavity, while in children these changes occur immediately after the application of pneumoperitoneum.
The absorption of CO2 into the blood when pneumoperitoneum is applied using CO2 is reflected in an increase in the concentration of CO2 at the end of expiration (ETC02), partial pressure of CO2 in arterial blood (pa CO2), the level of CO2 production by the lungs (VC02), and in the development of acidosis. In some patients, there is an increase in the difference between pa CO2 and ETC02; at the same time, the occurrence of uncontrollable acidosis is observed. An explanation for this fact is found in the presence of reduced CO and, as a consequence of this, increased venous shunting in the lungs and reduced splanchnic blood flow.
Some authors note an increased release of CO2 by the lungs even after removal of pneumoperitoneum. Values of VC02, ETC02, and Pa CO2 that exceed the normal level can be observed during the first 30–180 minutes of the postoperative period. This occurs because 20-40% of absorbed CO2 remains in the patient's body after CO2 is removed from the abdominal cavity.
Possible ways to prevent and correct emerging ventilation and gas exchange disorders:
1. Use of endotracheal anesthesia against the background of total muscle relaxation.
2. Ventilation in hyperventilation mode (at 30-35% more than normal). In this case, mechanical ventilation can continue after the end of surgery until ETC02 and CO2 pa are normalized.
3. Using CPAP (Continuous Positive Airway Pressure Expiratory Pressure) modes.
Features of pain relief during laparoscopic operations
It must be remembered, however, that in cases where the progression of acidosis is partially associated with a decrease in peripheral perfusion, hyperventilation may not provide a pronounced compensatory effect, since it itself can cause a decrease in CO. Probably the most rational option for mechanical ventilation is high-frequency injection mechanical ventilation, which reduces the negative impact of carboxyperitoneum on central hemodynamics, gas exchange and respiratory function.
If progressive hypercapnia, acidosis, hypoxemia occurs against the background of hyperventilation, the following measures are performed sequentially until the desired effect is achieved:
1. Ventilation 100% Og
2. Maintenance of cardiac output and peripheral perfusion by various methods.
3. Return the patient to a horizontal position.
4. Removal of CO 2 from the abdominal cavity.
5. Transition from laparoscopy to laparotomy.
5.2. The influence of laparoscopic manipulations on hemodynamics
An increase in pressure in the abdominal cavity when applying pneumoperito neum can influence the CO value in two ways: contribute, on the one hand, to the “squeezing out” of blood from the abdominal organs and the inferior vena cava to the heart, on the other, to the accumulation of blood in the lower extremities with a subsequent natural decrease in venous return. The prevalence of one or another effect depends on many factors, in particular on the magnitude of intra-abdominal pressure. It has been noted that the position opposite to the Trend Elenburg position contributes to the development of more serious hemodynamic changes, since in this case the influence of high intra-abdominal pressure is combined with the gravitational effect on the return of blood to the heart with the natural development of venous stagnation in the periphery and a pronounced decrease in preload for the left ventricle , and SV. The Trendelenburg position, on the contrary, is favorable for maintaining proper CO values, as it helps to normalize venous return and thereby increase the central blood volume in conditions of pneumoperito-cheum.
The application of pneumoperitoneum helps to increase peripheral vascular resistance due to external compression of arterioles, in particular the splanchnic basin. Pressure in the abdominal cavity increased to a certain level can cause compression of the aorta. Renal blood flow is also significantly affected.
Along with the above factors, hypoxemia, hypercapnia and respiratory acidosis have a certain effect on hemodynamics. On the one hand, CO2, directly affecting the vascular wall, causes vasodilation, compensating for the increase in peripheral vascular resistance. On the other hand, both hypoxemia and a decrease in blood pH stimulate the sympathetic adrenal system, thereby promoting mass
Laparoscopic surgery. General part
strong release of catecholamines. All this can lead to an increase in CO, peripheral vascular resistance, blood pressure, the development of tachycardia, cardiac arrhythmias, and even cardiac arrest.
If severe disturbances occur in the circulatory system, all experts recommend removing pneumoperitoneum and switching to laparotomy.
An increase in intra-abdominal pressure during laparoscopic operations creates the prerequisites for the occurrence of gastroesophageal regurgitation with subsequent aspiration of acidic gastric contents. The risk of developing this complication is especially high in patients with gastroparesis, hiatal hernia, obesity, pyloric gastric obstruction, outpatients and children (due to the lower pH of gastric contents and the higher ratio of the latter to body weight). Perhaps the high probability of gastroesophageal reflux with subsequent aspiration limits the use of the laryngeal mask, which is currently widely used during laparoscopic surgical interventions.
The following measures to prevent regurgitation are suggested:
1. Preoperative use of metoclopramide (10 mg per os or intravenously)
rivenno), which increases the tone of the cardiac sphincter of the stomach, and H2 blockers, which reduce the acidity of gastric contents.
2. Preoperative gastric lavage followed by insertion of a gastric tube (after tracheal intubation); the presence of a probe in the stomach, in addition, prevents injury to the stomach when pneumoperitoneum is applied and improves visualization of the surgical field for surgeons.
3. Tracheal intubation is mandatory, and it is desirable that the endotracheal tube have a cuff.
One of the most dangerous, potentially fatal complications of paw-
roscopic surgery is gas embolism. CO2 is quickly absorbed through the peritoneum and absorbed into the splanchnic vessels. Since it is highly soluble in the blood, the entry of a small amount into the blood
the current passes without visible complications. Massive absorption of CO2 leads to gas embolism.
Prerequisites for the development of CO2 embolism:
1. Reduced splanchnic blood flow, which is observed with high intra-abdominal pressure.
2. The presence of gaping venous vessels as a result of surgical trauma. Clinical signs of gas embolism are a significant decrease in blood pressure, cardiac dysrhythmias, the appearance of new cardiac murmurs, cyanosis,
pulmonary edema, increased ETC02 levels, i.e. There is a picture of the development of right ventricular heart failure against the background of pulmonary hypertension and hypoxemia. Early diagnosis of this complication requires careful monitoring of ECG, blood pressure, heart sounds and ETC02.
When diagnosing gas embolism, it must be remembered that collapse can also be observed with bleeding, pulmonary embolism, myocardial infarction, pneumothorax, pneumomediastinum, high intra-abdominal pressure, and pronounced vagal reflexes.
Features of pain relief during laparoscopic operations
5.3. Selection of anesthetic aid
Anesthesiologists working with children point out the need for a thorough history taking in patients undergoing laparoscopic surgery. An absolute contraindication to such operations is fibrous dysplasia of the lungs.
Contraindications for emergency laparoscopy in children:
1. Coma.
2. Decompensated heart failure.
3. Decompensated respiratory failure.
4. Severe bleeding disorders (Quick test value below 30%, significant increase in bleeding time).
5. Borderline conditions in which laparoscopy can cause the above complications.
The use of various techniques of local anesthesia with preserved spontaneous breathing in adults is still under debate. In pediatric practice, this method is unacceptable, since it is impossible and impractical to perform epidural anesthesia or bilateral intercostal block in a conscious child. The use of epidural anesthesia as part of combined anesthesia, despite some advantages, is often accompanied by hemodynamic disorders and does not prevent irritation of the phrenic nerve (C1P-Cv), nausea and vomiting in the postoperative period.
Advantages of general endotracheal anesthesia:
1. Improving working conditions for surgeons with total muscle relaxation and the presence of a gastric tube. Deep sedation of the patient makes it easy to give him the desired position.
2. Tracheal intubation ensures a clear airway and prevents aspiration (when the endotracheal tube cuff inflates).
3. Cardiopulmonary changes caused by CO2 injection 2 into the abdominal cavity can be eliminated by maintaining proper levels of minute ventilation, oxygenation and circulating blood volume (CBV).
For general endotracheal anesthesia, different specialists offer a wide variety of schemes, which, as a rule, differ little from the methods of general anesthesia for conventional surgical interventions. The accumulated experience and research conducted on the characteristics of pain relief for laparoscopic operations in children allow us to formulate the following practical recommendations for conducting anesthesia in a pediatric clinic.
Premedication. For the purpose of premedication, children are administered intramuscularly with 0.1% atropine at a rate of 0.01 mg/kg, 0.5% relanium 0.35 mg/kg for children aged 1-3 years, 0.3 mg/kg for children aged 4- 8 years and 0.2-0.3 mg/kg for older patients. The differentiation is due to the weaker sensitivity of patients in the younger age group to ataracts. If there is a history of allergies, premedication includes diphenhydramine or Rastin soup at a dose of 0.3-0.5 mg/kg.
Laparoscopic surgery. General part
The choice of anesthetic remains with the anesthesiologist. Traditionally, inhalation anesthesia using fluorothan (halothane, narcotan) is widely used in children's clinics. This halogen-containing anesthetic is so popular due to its rapid induction into general anesthesia and rapid awakening, ensuring sufficient depth and controllability of anesthesia. Ftorotan is used according to the traditional scheme, adhering to the minimum sufficient concentrations of the anesthetic in the inhaled mixture. The use of a combination with nitrous oxide (N02) is permissible only at the stage of induction of anesthesia. In the future, taking into account the ability of N2 0 to actively accumulate in the physiological and pathological cavities of the body and its potentially hypoxic effect, ventilation should be carried out with 100% O2
The pronounced cardiodepressive effect of ftorotan is manifested by a decrease in CO, a slowdown in atrioventricular conduction, and a decrease in blood pressure. Of the modern and available drugs for anesthesia, diprivan and midazolam were chosen as alternative drugs to fluorothane that do not give such pronounced side effects.
Midazolam, synthesized in 1976, is one of the many representatives of the benzodiazepine group. It has the ability to quickly bind to GABAergic and benzodiazepine receptors. As a result, a few (5-10) minutes after intramuscular administration, the patient develops rapid psychomotor inhibition, and upon completion of the administration, he quickly returns to normal activity. It is necessary to note the pronounced anxiolytic, sedative and anticonvulsant effects and low allergenicity inherent in midazolam,
A also the fact that when using it there is a significant antero
And retrograde amnesia. This drug compares favorably with ftorotan due to its minimal effect on the cardiovascular and respiratory systems. Induction of anesthesia is carried out by intravenous administration of midazolam(0.3-0.4 mg/kg for children 1-3 years old, 0.2-0.25 mg/kg for children 4-8 years old, 0.1-0.15 mg/kg for children 9-14 years old) in combinations with intravenous fractional administration of fentanyl and muscle relaxant comrade. The maintenance period is a constant infusion of midazolam 0.3-0.4 mg/kg per hour in combination with intravenous fractional administration of fentanyl and miorelak santov. The administration of midazolam is stopped 8-12 minutes before the end of anesthesia.
Diprivan (propofol) has a mechanism of action similar to benzodiazepine drugs. Its advantages include:
1. Rapid onset of hypnotic effect.
2. High metabolic rate.
3. Mild recovery period.
These properties ensure that Dipriv is becoming increasingly widespread in clinical practice. Like most anesthetic agents, diprivan affects respiratory function, causing depression of spontaneous breathing during the induction stage of anesthesia. The drug can cause hypotension due to a decrease in total peripheral resistance. The administration of diprivan in a clinically effective dose is usually accompanied by a decrease in heart rate, which is explained by the vagotonic effect of the drug and blood pressure.
Features of pain relief during laparoscopic operations
is treated with preemptive administration of atropine or metacin. Induction of anesthesia is carried out by intravenous administration of 2.5 mg/kg diprivan. The maintenance period is a constant infusion of diprivan 8-12 mg/kg per hour in combination with fractional administration of fentanyl and muscle relaxants. The administration of diprivan is stopped 6-10 minutes before the end of anesthesia.
5.4. Artificial ventilation, infusion therapy
and monitoring
Ventilation Ensuring adequate gas exchange is possible only when using mechanical ventilation in hyperventilation mode. In the intermittent positive pressure ventilation mode, the tidal volume is calculated using the Radford nomogram. The respiratory rate corresponds to the age norm. The inspiratory pressure is set for each patient depending on age and individual characteristics in the range of 14-22 mbar. Expiratory pressure 0. After pneumoperitoneum is applied, the minute volume of ventilation increases by 30-35%, due to an increase in both tidal volume and respiratory rate.
All patients after tracheal intubation are recommended to insert a tube into the stomach and catheterize the bladder. This not only prevents dangerous complications (aspiration of gastric contents, perforation of hollow organs with a trocar), but also improves visualization of the surgical field by surgeons.
Infusion therapy. The use of a forced infusion load regime makes it possible to prevent the development of hemodynamic disorders caused by the state of relative hypovolemia provoked by pneumoperitoneum. Intravenous infusion therapy can be carried out with crystalloid solutions (for example, Inosteril from Frisenius). If it is necessary to correct intraoperative blood loss, infusion transfusion therapy is performed. In these cases, single-group fresh frozen plasma, plasma protectors (reopolyglucin, polyglucin), polyionic crystalloid solutions, and 5-10% glucose solutions are used. When Hb is less than 100 g/l and W is less than 30%, transfusion of single-group red blood cells is recommended.
Studies have shown that, regardless of the anesthetic chosen, standard infusion therapy (8-10 ml/kg per hour during planned operations and 12-14 ml/kg per hour during emergency operations) does not prevent the development of a state of relative hypovolemia caused by the redistribution of blood to the periphery with a decrease venous return, a drop in CO and stroke volume after the application of pneumoperitoneum. To correct this condition, the following infusion therapy regimen is used. From the moment of catheterization of the peripheral vein in the operating room until the moment of pneumoperitoneum is applied, the infusion rate should be 10-15 ml/kg per hour during planned operations and 15-28 ml/kg per hour during emergency operations. After gas insufflation into the abdominal cavity, it is advisable to reduce the infusion rate to 10-12 ml/kg per hour.
As a manuscript
Kholostova Victoria Valerievna
Emergency laparoscopy in infants
Dissertations for an academic degree
Candidate of Medical Sciences
Moscow - 2008
The work was carried out at the State Educational Institution of Higher Professional Education "Russian State Medical University of the Federal Agency for Health and Social Development".
Scientific supervisor:
Honored Scientist of the Russian Federation,
Doctor of Medical Sciences, Professor ^ Anatoly Fedorovich Dronov
Official opponents:
Doctor of Medical Sciences, Professor, Vladimir Georgievich Geldt
Moscow Research Institute of Pediatrics and Pediatric Surgery of Roszdrav
Doctor of Medical Sciences, Professor, ^ Alexander Evgenievich Mashkov
Moscow Regional Research Clinical Institute
Them. M.F. Vladimirsky
Lead institution:
GOU DPO "Russian Medical Academy of Postgraduate Education of Roszdrav"
The defense of the dissertation will take place on November 17, 2008 at 14.00 at a meeting of the dissertation council D 208.072.02 at the Russian State Medical University at the address: 117997, Moscow, st. Ostrovityanova, 1.
The dissertation can be found in the library of the Russian State Medical University at the address: 117997, Moscow, st. Ostrovityanova, 1.
Scientific secretary of the dissertation council
Doctor of Medical Sciences, Professor N.P. Kotlukova
General characteristics of the work.
Relevance of the problem
Currently, there is a growing interest in the world in the introduction of endoscopic interventions in all areas of surgery. Despite advances in minimally invasive surgical technologies, the use of laparoscopy in children of an early age group and, especially, in newborns began relatively recently. Children during the neonatal period and the first months of life have a number of distinctive physiological and anatomical features that make it difficult to perform endoscopic operations on them and cause a higher risk of complications.
A particular difficulty in treating newborns is due to the fact that from 5% to 17% of children with surgical pathology are premature and children weighing less than 2,500 g. Moreover, the need for surgery arises in the first days of life against the background of a period of early adaptation and high sensitivity to surgical trauma and surgical stress: up to 42% of children require emergency surgical procedures (Ergashev N.Sh., 1999).
The need to perform traumatic laparotomies leads to a long stay in intensive care units, which increases the risk of infection and the degree of operational stress; necessitates long-term parenteral nutrition and ventilatory support after surgery, the administration of painkillers, taking into account the fact that the use of narcotic analgesics in newborns is undesirable due to the negative respiratory effects of the latter. Significant disadvantages of wide laparotomies are also the need to lengthen hospitalization and unsatisfactory cosmetic results.
These factors create the prerequisites for the use of gentle techniques using modern low-traumatic technologies in this age group. For example, in large foreign pediatric clinics, of all laparoscopic interventions, 38.1% are performed on children under 1 year of age (Bax N.M., 1999).
Studies reflecting the hemodynamic, respiratory and temperature effects of pneumoperitoneum in children in the first months of life are available only in foreign literature and are sporadic (Kalfa N. et all, 2005). At the same time, there were no works devoted to assessing the morbidity of laparoscopy from the standpoint of evidence-based medicine in acute surgical diseases in children of the first year of life in the literature available to us. One of the most reliable ways to assess the results of surgical interventions is the analysis of surgical aggression, which, when studied in patients with pyloric stenosis, convincingly proves the advantages of laparoscopy over open operations (Fujimoto T. et all., 1999).
In our country, despite many years of tradition and priority work in some areas on the use of laparoscopy in pediatric practice, only a few neonatal surgical centers have experience in endoscopic operations on newborns (Kotlobovsky V.I. et al., 1995, Gumerov A.A. et al. ., 1997, Sataev V.U. et al., 2002). Single reports have been published on the use of endoscopy in ulcerative necrotizing enterocolitis (UNEC) (Bushmelev V.A., 2002, Pierro A. Et all., 2004), intussusception, adhesive intestinal obstruction, acute appendicitis (Dronov A.F., Poddubny I.V., 1996), strangulated hernias (Shchebenkov M.V., 2002).
There are no works that comprehensively reflect the place and principles of application of this method in emergency neonatal surgery and surgery of infants. There are no criteria for objective assessment of the morbidity and safety of laparoscopy in newborns. In addition, the development of laparoscopic surgery in this age group requires a revision of indications and contraindications for operations, taking into account age, term, severity of the main and concomitant pathology.
Thus, the above circumstances, as well as our own experience of laparoscopic operations for various emergency surgical pathologies in children of neonatal and infant age, prompted us to conduct research in this direction.
Purpose of the work:
Improving diagnosis and improving the quality of treatment of urgent abdominal pathology in newborns and infants through the use of minimally invasive laparoscopic interventions.
Research objectives:
To prove the safety, feasibility and high efficiency of laparoscopy in the diagnosis and treatment of urgent abdominal pathology in newborns and infants by studying the metabolic, hemodynamic and respiratory effects of CO2 pneumoperitoneum;
To develop a method for objective assessment of the surgical morbidity of laparoscopic interventions in newborns and infants;
To conduct a comparative analysis of the morbidity and effectiveness of laparoscopic and traditional “open” surgical interventions for emergency surgical diseases of the abdominal organs in newborns and infants;
To analyze intraoperative and postoperative complications, to determine risk factors for complications during emergency laparoscopy in newborns and infants.
The position to be defended:
Laparoscopic interventions are less traumatic and more effective for emergency abdominal surgical pathology in children of the first year of life in comparison with laparotomic operations and have no age restrictions
Scientific novelty
For the first time, using a large clinical sample (157 patients under the age of 1 year), the results of introducing a whole range of minimally invasive laparoscopic surgical techniques into clinical practice were analyzed.
The influence of CO2 pneumoperitoneum during emergency laparoscopic interventions in newborns and infants was studied.
A score assessment of the degree of surgical trauma in children in the first months of life, adapted to the use of laparoscopic interventions, is proposed. The objectivity of assessing the degree of surgical trauma based on widely used methods of intraoperative and postoperative monitoring has been proven.
Practical value
Recommendations are given on the technique and general features of emergency laparoscopic interventions in newborns and infants, recommendations on compliance with the parameters of pneumoperitoneum in the age aspect.
Minimally invasive techniques such as laparoscopic and laparoscopic-assisted interventions for intussusception, perforated peritonitis of various origins, strangulated inguinal hernias, complicated forms of Meckel’s diverticulum, and severe forms of adhesive intestinal obstruction have been introduced into clinical practice in young children, including newborns.
The use of the described methods made it possible to achieve a significant improvement in the results of treatment of children with these types of pathologies - to reduce the number of postoperative complications, ensure a smoother course of the postoperative period, rapid restoration of activity, a significant reduction in the length of hospitalization of patients, excellent cosmetic results, and reduce treatment costs.
Implementation of results in healthcare practice
The results of the dissertation work were introduced into the practical activities of the departments of emergency and purulent surgery, neonatal surgery of the Children's City Clinical Hospital No. 13 named after N.F. Filatov (Moscow), the department of emergency purulent surgery of the Children's City Clinical Hospital No. 9 named after. G.N. Speransky (Moscow).
The materials of the work are used when giving lectures and at seminars on pediatric surgery for senior students and doctors of the Faculty of Internal Medicine of the Russian State Medical University.
Approbation of work
The dissertation was completed at the Department of Pediatric Surgery (headed by Professor A.V. Geraskin) of the Russian State Medical University, on the basis of Children's City Clinical Hospital No. 13 named after N.F. Filatov (chief physician - Doctor of Medical Sciences V.V. Popov). The main provisions of the dissertation were presented: at the IV Russian Congress “Modern technologies in pediatrics and pediatric surgery. Moscow, 2005; X All-Russian Congress on Endoscopic Surgery, Moscow, 2006; 11th Moscow International Congress on Endoscopic Surgery, Moscow, 2007; II Congress of Moscow Surgeons “Emergency and Specialized Surgical Care” Moscow, 2007; 15th International Congress of the European association for Endoscopic surgery (EAES), Athens, Greece, 2007.
Scope and structure of the dissertation
The dissertation consists of an introduction, 5 chapters, practical recommendations and a list of references. The text part of the dissertation is presented on pages of typewritten text, illustrated with 48 drawings and 25 tables. The bibliography index contains links to 68 domestic and 239 foreign sources.
Materials and methods of research.
General characteristics of patients.
The work was carried out at the clinical base of the Department of Pediatric Surgery of the Russian State Medical University in the Department of Emergency and Purulent Surgery and the Department of Neonatal Surgery of Children's Clinical Hospital No. 13 named after. N.F. Filatova from 1996 to December 2007
The work is based on a retro- and prospective study of medical histories of 157 patients aged 0 to 12 months with emergency surgical diseases of the abdominal organs who underwent laparoscopic interventions (group 1 - main group). Study group 2 (control) consisted of 84 patients who underwent surgical interventions through laparotomy access. In each group, 2 subgroups were identified according to the age of the patients.
^1 A group. Laparoscopy for emergency indications was performed in 26 neonatal patients with symptoms of dynamic intestinal obstruction due to somatic pathology (2), due to JNEC (11), with perforation and necrosis of hollow organs (6), acute appendicitis (1), mesenteric thrombosis ( 4), Hirschsprung's b. (1), meconium ileus (1), postoperative complications (1), strangulated inguinal hernia (1), complicated by Mekel's (1). The following were performed: diagnostic laparoscopy, sanitation and drainage of the abdominal cavity (15), laparoscopic-assisted minilaparotomy (8), appendectomy (1), hernia repair (1), Meckle resection (1).
The average age of the children was 7±2.79 days. There were 10 girls (38.5%), 16 boys (61.5%). The average gestational age was 32.6±1.8 weeks, 20 patients (76.9%) had some degree of prematurity. The weight of the children at the time of surgery was 2374±485.4g. At birth, the average Apgar score was 5.8±0.73 / 7.06±0.58.
At the time of surgery, 10 patients (53.8%) were breathing independently, 5 (19.2%) were on supportive ventilation, and 11 (42.3%) children were on mechanical ventilation (Fig. 2.3). Concomitant conditions and developmental defects were observed in 24 (92.3%) children.
^1 B group. Laparoscopic interventions for emergency indications were performed on 131 children aged from 29 days to 12 months with intussusception (88), adhesive intestinal obstruction (14), strangulated inguinal hernia (12), complicated by Meckel's hernia (6), acute appendicitis (6) , perforated peritonitis of non-appendiceal origin (5). There were 3.7 times more boys than girls (103 and 28, respectively).
The average age of the patients was 6.8±2.3 months. At the time of surgery, the condition of the majority of children was assessed as moderate in 100 patients (76.3%), satisfactory in 21 (16.1%), severe in 10 (7.6%) patients. Concomitant pathological conditions and diseases were noted in 41 patients (31.3%).
^ Control group. The control group consisted of 84 patients aged 0 to 12 months, including 29 children of the neonatal period (34.5%) (group 2A), who underwent traditional surgical interventions through laparotomy access: exploratory laparotomy (2), resection of the small intestine with stoma removal (16), suturing of hollow organ perforation (2), colonic stoma (3), herniolaparotomy, hernia repair (2), Meckel resection (3).
The average age of the children was 8.3±2.4 days. There were 9 girls (30.1%), 20 boys (68.9%). The average gestational age was 34.3±1.6 weeks, 16 patients (55.2%) had some degree of prematurity. The weight of children at the time of surgery averaged 2758±389g. At birth, the average Apgar score was 5.7±0.57 / 7.1±0.78. At the time of surgery, 7 patients (24.1%) were breathing independently, 13 (44.8%) were on supportive ventilation, and 9 (31.1%) children were on mechanical ventilation. Concomitant conditions and developmental defects were observed in 21 (72.4%) children.
^2 B group. Open operations were performed on 55 patients aged from 29 days to 12 months for intussusception (28), adhesive intestinal obstruction (6), strangulated inguinal hernia (8), acute appendicitis (3), complicated by Meckel's disease (3), perforated peritonitis (7).
The average age of the patients was 5.9±1.8 months. There were 2.2 times more boys than girls (38 and 17, respectively). At the time of surgery, the condition of the majority of children was assessed as moderate in 42 patients (76.3%), satisfactory in 2 (3.6%), severe in 11 (20%) patients. The nature of the pathology that required emergency laparotomy is reflected in Table 2.6.
Concomitant pathological conditions and diseases were noted in 13 patients (23.6%): acute respiratory disease in 6 children (10.9%), intestinal infection in 3 (5.5%), anemia of various origins in 4 (7, 3%), concomitant congenital malformations – in 5 (9.1%) children.
^ General clinical examination of groups of patients
History of life and illness
The general characteristics of the study groups were assessed on the basis of a clinical examination (study of life history, complaints, medical history and clinical symptoms).
^ Laboratory research
A biochemical blood test assessed glucose levels. In the analysis of the acid-base and gas composition of the blood, the following indicators were assessed: pH; pO2; pCO2; SO2; BE. Measurements of indicators were made before surgery, at the end of surgery, 12 and 24 hours after surgery. The blood CRP level was determined before surgery and on days 1 and 4 of the postoperative period.
^ Hemodynamic parameters were measured during surgical interventions by monitoring heart rate (HR); systolic blood pressure (SD); diastolic blood pressure (DD); SO2 – blood saturation.
^ Assessing the degree of surgical trauma
To determine the degree of invasiveness and trauma of laparoscopic interventions in infants, a scoring scale for surgical trauma was used, which was based on the scoring method proposed by K. Anand and A. Aynsley-Green. This method was adapted taking into account the characteristics of laparoscopic operations in children under 1 year of age and was supplemented by us with the following indicators: severity of intra-abdominal hypertension syndrome, hypothermia, body weight at the time of surgery, the presence of concomitant cardiovascular and respiratory failure, level of intra-abdominal pressure pneumoperitoneum and postural positions of the patient during surgery (Table 1). The validity of using the modified scale was proven by confirming the correlation between the severity of surgical injury and the severity of hemodynamic, biochemical and acid-base constants of the body. Based on the sum of points, the level of surgical stress was classified as mild (1-12 points), moderate (13-22 points), severe (over 22).
Table 1
Score method for assessing surgical stress
Indicators
1. Level of blood loss
2. Area of intervention
Superficial, intra-abdominal, intrathoracic
3. Level of superficial damage (skin, muscles, etc.)
4. Volume of visceral damage
5. Duration of operation
6. Severity of intra-abdominal hypertension syndrome (SIAH)
7. Additional stressors
(a) Hypothermia
(b) Local infection
Generalized infection (JNEC, sepsis, etc.)
(c) Prematurity
(d) Associated defects and conditions
Cardiovascular failure
Respiratory failure
Dr. defects and pathological conditions
(e) Body weight
8. Intra-abdominal pressure when applying pneumoperitoneum
9. Postural positions during surgery
^ General issues of laparoscopic intervention technique
Indications for emergency laparoscopy in children of the study groups were: acquired intestinal obstruction, acute inflammatory diseases of the abdominal organs, incl. complicated by peritonitis; abdominal complications after previous surgical interventions.
Contraindications to laparoscopy were: a state of extreme severity due to multiple organ failure and extreme prematurity; severe intestinal paresis against the background of diffuse peritonitis and late admission of patients; repeatedly undergone surgical interventions with a clearly pronounced adhesive process in the abdominal cavity.
^ Primary entry into the abdominal cavity was performed using the “open laparoscopy” technique. In children in the first three months of life, a skin incision was made 1 cm up and 1.5 cm to the left of the umbilical ring to prevent damage to the umbilical vessels. In older children, the skin incision was made supraumbilical. When performing laparoscopic interventions, endosurgical instruments with a diameter of 3 mm and 5 mm were used. Laparoscopic operations were performed according to generally accepted clinical methods of diagnostic laparoscopy, laparoscopic disinvagination, adhesiolysis, appendectomy, diverticulectomy and hernioplasty.
^ Parameters of pneumoperitoneum. When performing laparoscopic interventions, the greatest importance was attached to compliance with the parameters of pneumoperitoneum:
Intra-abdominal pressure did not exceed 5-6 mm Hg; in children aged 6-12 months, gas pressure did not exceed 6-8 mm Hg;
The volume of injected gas was 1-1.5 liters.
The rate of gas injection into the abdominal cavity in children of the first three months was 1-1.5 l/min, in older children - up to 2-2.5 l/min.
General issues of laparotomy intervention technique.
Traditional “open” surgical interventions were performed in accordance with the generally accepted canons of pediatric surgery. Minilaparotomy was performed in the most advantageous area of the anterior abdominal wall - directly above the most altered loop of the small intestine. The size of the cutaneous incision was 1.5-2 cm, through which only the pathologically altered loop of the small intestine was exteriorized and the necrotic section of the intestine was resectioned. The operation was completed with the placement of an intestinal stoma.
Clinical trial results
Based on the use of a modified scale for assessing operational stress, all children were divided into three groups according to the severity of the latter: 35.8% suffered mild operational stress, 23.1% suffered moderate stress, 41% suffered severe stress (Fig. 1).
The level of surgical stress clearly correlated with changes in blood glucose levels at the end of the operation (0.05>p>0.01) and 12 hours after surgery (0.05>p>0.01); with a change in the level of blood saturation, partial pressure of blood carbon dioxide and the level of blood acidity - by the end of the operation (0.05>p>0.01). The level of stress also correlated with the change in the basic blood alkalinity at the end of the operation (0.05>p>0.01) and 12 hours after the operation (0.05>p>0.01), as well as with the tachycardia indicator at the end of the first days after surgery (0.001>p>0.0001) and changes in diuresis in the early postoperative period (0.001>p>0.0001).
^ Changes in blood glucose levels
When analyzing blood glucose levels in children from different groups according to the severity of operational stress, it was noted that a significant increase in concentration was detected immediately after surgery: in group 1 - 1.8 times, in group 2 - 1.5 times, in 3rd – 2.3 times. Differences between groups in changes in blood glucose concentration were detected at the end of surgery (0.05>p>0.01) and 12 hours after surgery (0.05>p>0.01). 12 hours after the intervention, normalization of sugar levels was noted in children of the 1st group; in the 2nd group of patients, the sugar level remained without significant changes, in the 3rd group it significantly decreased and exceeded the initial one by 1.6 times. By the end of the 1st day after the intervention, in all groups of patients the blood sugar level normalized and was below 6 g/l.
^ Changes in acid-base balance indicators
Differences between groups in changes in blood pH levels were revealed by the end of the operation (0.05>p>0.01): immediately after the operation there was a tendency to acidosis in the 2nd and, especially, in the 3rd group of patients (average level 7 ,1). In the next 12 hours, there were no significant differences in the pH level in all 3 groups of patients and was close to the normal level.
All children had pronounced changes in BE before surgery - the tendency to acidosis was -8.4; -7.9 and -8.9 respectively. Differences between groups in changes in blood BE levels were identified at the end of the operation (0.05>p>0.01) and 12 hours after surgery: immediately after the intervention in children of the 2nd and 3rd groups, changes in BE progressed and amounted to - 8.7 and -9.9, while in children of group 1 the signs of acidosis decreased to -4.95. 12 hours after the operation, the trend towards a decrease in acidosis in all children continued; by the end of the first day, the BE indicator was: - 4.3; -5.7 and -7.6 respectively.
^ Changes in blood gas parameters
Differences between groups in changes in blood pCO2 levels were identified at the end of the operation (0.05>p>0.01). Statistically significant changes were detected in patients of group 3. Almost all children in group 3 experienced hypercapnia after surgery; the average pCO2 level was 48.9. However, already 12 hours after the operation, the pCO2 level in all groups approached normal and no statistically significant differences were noted between the groups of patients.
Differences between groups in changes in So2 levels were detected at the end of the operation (0.05>p>0.01). In children who experienced mild postoperative stress, there were no changes in saturation before and after surgery; its average level was 95.6. In patients of groups 2 and 3, immediately after surgery, saturation increased by 3.8 and 2.2%, respectively. The increase in saturation continued 12 hours after the intervention, reaching 87.5 and 87.2, respectively. Despite the difference in the dynamics of So2, the average level of this indicator under mild surgical stress was significantly different from that under moderate and severe stress, regardless of the time elapsed after surgery.
^ Correlation of the degree of surgical stress and diuresis parameters
Differences between groups in changes in diuresis levels were detected at the end of the operation (0.001>p>0.0001). The average level of diuresis during surgery and during the first day of the postoperative period in children with a mild degree of surgical stress was 0.0786±0.04 ml/kg/min, with a moderate level of stress - 0.0448±0.01 ml/ kg/min, for severe cases – 0.0152±0.01 ml/kg/min.
^ Correlation of the degree of surgical stress and pro-inflammatory factors
The level of C-reactive protein (CRP) was determined in 7 newborns with a clinical picture of complicated enterocolitis - intestinal perforation (3a), intestinal necrosis (3), destructive appendicitis (1). Before surgery, there were wide fluctuations in CRP levels: from 0 to 96 units. In the postoperative period, no patterns of changes in its concentration were revealed; in 4 children there was an increase in its concentration (from 23 to 35 units), in the rest there was a decrease (from 18 to 24 units). At the same time, no dependence of changes in the CRP indicator on the type of surgical intervention was identified. On the 3rd day of the postoperative period, the majority of children (5 patients) showed a decrease in the concentration of CRP, and in 2 patients it continued to increase.
Comparison of the severity of surgical stress in newborns after laparoscopic and traditional interventions
When assessing the severity of surgical stress using our modified scale, it was revealed that after laparoscopy only mild (35.8%) and moderate (11.6%) stress was noted, after open interventions - moderate (11.6%) and severe (41%) stress (Fig. 2). The average severity score of surgical stress after laparoscopy was 13.3 points, after open operations – 24.6 points.
^ Comparison of the main indicators of homeostasis in newborns, depending on the nature of the surgical intervention
Blood saturation (SO2)
An assessment of the dynamics of changes in blood saturation (SO2) showed that in the postoperative period there was a significant deterioration in blood saturation by 9.56 times in group 1A and 8.18 times in group 1B. During the 1st day after surgery, these changes remain high and decrease slowly, and by the end of the 24-hour period after surgery they are 4.97 and 7.3 times, respectively.
^ Blood hemoglobin (D Hb)
Statistically significant changes in hemoglobin levels were observed only in children after laparotomy immediately after surgery, 12 and 24 hours after surgery.
Changes in hemoglobin levels after laparoscopy immediately after surgery were 1.52 times lower than after open interventions, after 12 hours – 2.18 times lower, after 24 hours – 3.42 times lower (Fig. 3). After open operations within 24 hours, despite blood transfusions in 100% of children in the control group, there was a further drop in hemoglobin levels. After laparoscopy, by the end of the day, the hemoglobin level increased, approaching preoperative values.
^ Body temperature ((D t0C)
78.5% of children had changes in body temperature of varying severity (Fig. 4). Statistically significant changes in body temperature were observed in children who underwent open surgery: immediately after surgery and during the 1st day of the postoperative period. After surgery, changes in body temperature are 5.13 times higher after open operations, after 12 hours – 1.97 times, after 24 hours – 3.34 times.
^ Heart rate ( HR)
Changes in the heart rate level were clearly pronounced in children, regardless of the nature of the operation: by 24.5 and 28 beats. per minute higher (p>0.1), and remained at the end of the first day: after laparoscopy by 8.75, and after open operations by 23.25 beats. per minute. Over time, in children after open operations, hemodynamic disorders worsen, while after laparoscopy, by 12 hours after surgery, tachycardia decreases by 2.12 times.
^ Blood pressure (SD, DD, MeanP)
In children after laparoscopy, statistically significant changes in DM were observed at the end of the operation and 12 hours after surgery, changes in MAP – after 12 and 24 hours. After open operations, changes in DM were noted 12 and 24 hours after surgery, DD – immediately after the intervention, after 12 and 24 hours, and MAP – after 12 and 24 hours. After open operations, all blood pressure indicators (DM, DD and MAP) change more significantly. By the end of the 1st day, in newborns who underwent laparoscopy, all blood pressure indicators do not differ from the initial ones by more than 5 mm Hg. While, after laparotomies, SD exceeds the initial figures by more than 20 mm Hg, DD – by 15 mm Hg, and SD – by 13 mm Hg.
^ Severity of children's condition
When assessing the severity of the condition of newborn children in dynamics before and after surgery, it was revealed that the average total score of the severity of the condition of children who underwent only laparoscopic interventions was 16.28 on the SNAPPE II scale and 6, 14 points on the TRIP score (14 and 4 .6 points in the control group). Statistically significant changes in the severity of the condition were noted in patients of group 2A: according to the SNAPPE II scale - immediately after surgery, according to the TRIP scale - after surgery and after 12 hours (Fig. 5 and 6).
When assessing the absolute indicators of the dynamics of severity (p>0.1), the most significant deterioration in condition was noted immediately after surgery, and with open interventions the changes were 2.58 (SNAPPE II scale) and 3.59 (TRIP scale) times greater, than with laparoscopic ones.
Results of treatment of patients of the main group.
Complications
Most complications in patients of groups 1A and 2A arose intraoperatively and were of an anesthetic nature: after laparotomy operations they developed 1.8 times more often (p<0,01). Десатурация крови встречалась также чаще в контрольной группе (11,5% и 13,8%) (p>0.05). Hypercapnia did not have statistically significant differences in groups 1A and 2A (11.5% and 10.3%). Hypothermia was noted only in children of the control group 2A – 17.2%. Metabolic acidosis also developed more often in the control group: 3.9% and 10.3%, respectively.
Complications in group B were exclusively surgical in nature and occurred 3.9 times more often in children who underwent laparotomy. Repeated interventions were also performed 4.8 times more often in children in the control group. In the main group, inflammatory complications occurred in 1 newborn, while in the control group they occurred in 6 (3.8%) children. Complications of adhesive nature were noted in 1 child of group 1B (0.8%) and 2 children of group 2B (3.6%), requiring re-operation in 1 case.
^ Conversions during laparoscopic interventions
Conversion to laparotomy was performed in 3 patients in the neonatal period (11.5%): with massive intestinal necrosis, Hirschsprung's disease and meconium ileus. All three cases required extensive bowel resection and intestinal stoma. Laparoscopically-assisted minilaparotomies were performed in 8 patients of group 1A. We do not classify laparoscopic-assisted minilaparotomies as conversions, since the total assessment of the degree of surgical stress was 13.5 points, which corresponds to a moderate degree of severity.
Among patients older than the neonatal period, conversion was performed in 23 (17.5%) cases. The vast majority of conversion cases occurred in patients with intussusception (21 patients), of which 7 children (33.3%) had forms complicated by necrosis. In 14 children with intussusception, the laparoscopic technique was ineffective; they underwent open disinvagination (10.7%). Laparoscopically-assisted minilaparotomies were performed in 3 patients of group 1B with peritonitis due to perforation by a foreign body, the average degree of surgical aggression was 11.6 points (mild and moderate-severe surgical stress).
Mortality
Cases of death were observed only among patients in the neonatal period (groups 1A and 2A). Among patients in group 1A, mortality was 3.8%. The child died due to total intestinal necrosis incompatible with life. Among patients in group 2A, mortality was 10.3%. Three children died with severe JNEC and mesenteric thrombosis. However, all children died in the postoperative period due to sepsis and the development of severe purulent-septic complications.
Conclusion
“Acute abdomen” syndrome in children is one of the most complex medical and social problems and the most common reason for emergency surgical interventions in children.
