Pediatric laparoscopy. Cut or puncture? What you need to know about pediatric laparoscopy

Our expert is a surgeon, head of the urology department of the Volgograd Clinical Hospital of Emergency Medicine, Sergei 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 incision.” 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.

The MedicaMente pediatric surgery clinic in Korolev (Moscow region) provides surgical treatment of inguinal hernia in children using laparoscopy (through punctures).

Laparoscopy of inguinal hernia: how is the operation performed?

Today, endoscopic methods using a miniature video camera and microsurgical instruments are increasingly used in pediatric surgery. Parents are interested in how such operations are performed, since in the professional hands of a surgeon the technique allows one to achieve an effective treatment result with a good cosmetic effect.

Laparoscopy of inguinal hernia in children is performed exclusively under general anesthesia. The duration of the operation is on average 40-50 minutes. Using a special laparoscope device, through minor punctures in the abdominal wall, the surgeon performs a full examination of the abdominal cavity, identifies the pathological process and takes the necessary measures to eliminate it.

Pediatric surgeons at MedicaMente have accumulated significant practical experience in the use of laparoscopic techniques, including in the treatment of inguinal hernia in children. The operating unit of our clinic is equipped with all the necessary medical equipment for laparoscopic operations, including the latest endoscopic equipment designed specifically for children.

The photo below shows the results of treating an inguinal hernia in a girl using laparoscopy.

Inguinal hernia in a girl. Laparoscopy

In the photo: the girl has an inguinal hernia on the left. Laparoscopic surgery. Sutures after laparoscopy of an inguinal hernia in a child (instrument width 11 mm)

Open surgery or laparoscopy for inguinal hernia in a child?

Open treatment:

• PRO: quickly 30-40 minutes, hardware-mask anesthesia,no pain in the abdomen.
• CONS: scar up to 2-5 cm (depending on the surgeon). A pediatric surgeon at the MedicaMente clinic in Korolev applies an intradermal suture that does not need to be removed. The child no longer experiences unpleasant procedures. After the operation, an inconspicuous scar, only 2 cm long, remains.

Laparoscopy:

• PROS: time about 45 minutes, no stitches with 3 mm instruments (there are also 6 mm ones), scar: from three 3 mm punctures. Possibility of performing hernia repair on both sides at once.
• CONS: the child is under endotracheal anesthesia, periodically there is pain in the abdomen, most often the high cost of surgical treatment (even in government agencies under the compulsory medical insurance policy).

The decision to choose a surgical method is made by a pediatric surgeon after a thorough examination of the patient, an assessment of his concomitant diseases and a conversation with his parents.

Laparoscopy of inguinal hernia: cost of surgery

Below are the prices for laparoscopic treatment of inguinal hernia in children. You can find out about the prices for inguinal hernia surgery in adults.

*Price includes:

• inpatient accommodation 1 day (double room with toilet, TV, cartoon channel)
• anesthetic aid: anesthetic Sevoran, implementation of local blockade - Naropin
• operation, all necessary operating supplies
• application of an intradermal cosmetic suture - no need to remove the suture
• constant telephone communication with the attending physician
• examination any day in the clinic within 30 days after surgery

The cost of the operation does not include:preoperative examination (tests can be taken at the clinic at your place of residence, in our medical center - the “For surgery” panel or in any commercial laboratory)

** This is not a public offer agreement. Check the cost of services on the day of your request.

Annual Congress of Perinatal Medicine Specialists
Modern perinatology: organization, technology, quality.
Report at the section – Current issues in neonatal surgery.
Authors: Shmyrov O.S., Vrublevsky S.G.
Moscow, September 23, 2014

Endosurgical resection pyeloplasty is currently considered the gold standard for surgical treatment of hydronephrosis in children. The advent of small-sized pediatric instruments, improved endoscopic visualization, accumulation of experience, and improved surgical skills have reduced the age limit for laparoscopic correction of ureteropelvic segment obstruction.

However, the feasibility and safety of using endosurgical techniques in young children is periodically questioned due to the small size of the operating area, the dangers of anesthesia in conditions of carboxyperitoneum, and the increase in the duration of the intervention compared to open operations.

At the Morozov Children's Hospital, from November 2011 to September 2014, 44 pyeloplasties were performed on 43 children with hydronephrosis under the age of 1 year. Of these, 18 were children aged 1 to 3 months. For one child, pyeloplasty was performed sequentially on both sides. Surgical intervention was performed using laparoscopic access in 42 children. In one 11-month-old girl with hydrocephalus, HPS, and a history of shunt infection, pyeloplasty was performed using a retroperitoneoscopic approach.

The reason for conducting an X-ray urological examination was the negative dynamics of pre- and postnatal echographic indicators in 20 children, the detection of expansion of the maxillofacial area on a screening ultrasound examination postnatally in 12 patients, echographic findings with episodes of anxiety and leukocyturia in 11 children.

The standard examination included ultrasound of the kidneys, excretory urography, voiding cystography.

Diuretic sonography and CT with IV contrast were used as additional diagnostic methods.

The indication for surgical treatment was considered to be an increase in the dynamics of the size of the mandibular joint in hydronephrosis of the 2nd degree, hydronephrosis of the 3rd and 4th degrees, according to the classification of the Society of fetal urology.

Three children with grade 4 hydronephrosis underwent drainage of the renal collector system 2 months before surgery, followed by assessment of its function.

Preoperative preparation included drugs that reduce gas formation in the intestines for 2 days and microenemas in the evening and morning before surgery.

The technique of laparoscopic pyeloplasty is presented on the slides. We used 5 mm telescopes and 3 mm laparoscopic instruments. In most cases, access to the pyeloureteral segment was achieved by mobilizing a loop of intestine. Classically, the pelvis was divided in an oblique direction, the ureter in a longitudinal direction along the antimesenteric edge. Drainage was used in various ways, I will discuss this a little later. In this case, it was not possible to install an internal stent antegrade, and drainage was carried out by a previously installed nephrostomy tube. When forming the anastomosis, monofilament suture material monocryl 6\0 was used. High-definition images and 3mm instruments allowed us to create a tight anastomosis carefully, carefully aligning the edges of the pelvis and ureter.

The following video demonstrates the technique of performing retroperitoneal endopyeloplasty.

An optical 5 mm trocar is installed retroperitoneally, the primary working cavity is formed using optics, then 3 mm manipulation trocars are installed. Classical pyeloplasty according to Heins-Andersen was performed, with the formation of ureteropyeloanastomosis with a continuous suture using 6\0 monocryl thread. Drainage is provided by intraoperative pyelostomy.

Currently, the question of the optimal method of drainage of the pelvis remains controversial. We have experience in retrograde stenting, antegrade stenting, pyelostomy and preliminary puncture nephrostomy.

The relationship between the methods of drainage of the renal collecting system in our patients is presented on the slide.

As can be seen from the presented data, most patients underwent antegrade intraoperative drainage with a double-jay stent.

The internal drainage system was installed after the formation of one of the semicircles of the anastomosis through a separate puncture of the abdominal wall or through a manipulation trocar. The bladder was first filled with an aqueous solution of indigo carmine. The flow of dye through the proximal part of the stent indicated its correct position.

The stent was removed 1-1.5 months after surgery during cystoscopy. The duration of drainage was determined by the timing of completion of reparative processes in the area of ​​the anastomosis.

We noted the impossibility of antegrade placement of the stent in 2 children. In both cases, the obstruction was localized at the level of the ureterovesical segment.

In one child, the proximal part of the stent migrated to the distal part of the ureter without causing a disturbance in the outflow of urine. An attempt to remove the stent intraluminally was unsuccessful. 4 months after the initial operation, laparoscopic pyelotomy and removal of the drainage system were performed.

Retrograde preoperative stenting in young children is not always successful due to the characteristics of the pathological process in the area of ​​the pyeloureteral segment. The impossibility of installing a stent in 3 patients and perforation of the ureter in the proximal part in one patient forced us to subsequently abandon this technique.

Publications have appeared on the use of V-shaped uretero-pyelonephrostomy drainage. The number of observations reported by the authors is small. The only complication noted, intraoperative parenchymal bleeding, required removal of the drainage and changes in the drainage pattern.

The slide shows a comparative table of our understanding of the disadvantages of various options for drainage of the pelvis.

The disadvantage of pyelostomy drainage can be considered the lengthening of the patient's stay in the hospital and the lack of frame drainage of the anastomosis area.

Another disadvantage of this method is the impossibility of checking the patency of the anastomosis before removing the ureteropyelonephrostomy.

As follows from the presented data, the issue of optimal intraoperative drainage of the pelvis remains controversial. In our opinion, there is no ideal method yet. We give preference to antegrade intraoperative stenting.

In the presented material, the duration of surgical interventions ranged from 75 to 180 minutes.

There were no conversions.

No intraoperative complications were noted.

Relapse of hydronephrosis was noted in one patient at the age of 7 months, who in the postoperative period suffered severe pyelonephritis of bacterial and fungal etiology, with prolonged internal stenting. Repeated laparoscopic pyeloplasty was performed successfully after 6 months.

The remaining patients showed positive echographic signs of resolution of obstruction, in the form of a reduction in the renal collector system, an increase in the thickness of the parenchyma and an improvement in the parameters of parenchymal blood flow. There were no signs of recurrent UTI.

Thus, in our opinion, endosurgical pyeloplasty in young children with hydronephrosis appears to be an effective and safe method for correcting the defect, corresponding to the principles of minimally invasive surgery. A necessary condition for the high effectiveness of the technique is sufficient experience and professional skills of the operator and the use of high-quality endosurgical instruments.

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The study in all cases is carried out in the operating room under general anesthesia with artificial ventilation, since pneumoperitoneum can significantly limit the movements of the diaphragm, especially in young children.

Before starting the manipulation, in all cases, a thorough deep palpation of the abdominal cavity under anesthesia is carried out, which often makes it possible to more clearly determine the presence and location of swollen intestinal loops, tumor-like formations, inflammatory infiltrates, intussusception, etc. In addition, during palpation the sufficiency of gastric emptying and bladder.

For initial entry into the abdominal cavity, we widely use a special method of direct puncture with a blunt-pointed trocar. A skin incision is made with a length slightly less than the diameter of the trocar that is supposed to be inserted in this place (usually 5.5 mm, in the presence of peritonitis - 11 mm) - most often in the area of ​​the umbilical ring along its upper edge (Figure 7a). Then, in young children, the surgeon lifts the anterior abdominal wall with his left hand. A sharp “mosquito” type clamp is inserted through this incision, with which the fascia and aponeurosis are separated without opening the abdominal cavity (Figure 7b). In the same position, but with the help of a blunt clamp (Billroth type), the peritoneum is opened (Figure 7c).

Figure 7. Stages of pericial entry into the abdominal cavity using the method of right puncture with a blunt trocar in young children

The moment of penetration into the abdominal cavity is usually clearly felt by the surgeon. In this case, you can almost always notice the characteristic sound of air being “sucked” into the abdominal cavity. Without changing the position of the left hand, which lifts the anterior abdominal wall, a blunt-ended trocar is inserted through the incision (Figure 7d). In older children, especially with pronounced subcutaneous fat, the surgeon's assistant also helps to raise the anterior abdominal wall (Figure 8).

Figure 8. Stage of primary entry into the abdominal cavity in older children

The correct position of the trocar is always controlled using a 5 mm telescope inserted into it with a viewing angle of 30° with a miniature endovideo camera. Careful observance of all the listed rules for performing the first puncture of the abdominal cavity allows you to avoid serious complications - bleeding or injuries to internal organs. Having ensured that the trocar is correctly positioned, C0 2 insufflation begins using an electronic insufflator. The volume of gas used is 1-1.5 liters for small children, up to 3-5 liters for teenagers. The level of intra-abdominal pressure ranges from 5-8 mm Hg. Art. in newborns and infants up to 10-14 mm Hg. Art. at an older age.

The second trocar (3-5.5 mm) is inserted in the left iliac region under the control of the endovideo system. Using a video laparoscope and a palpatir probe (or an atraumatic clamp) inserted through the trocar sleeve in the left iliac region (Figure 9), an inspection of the abdominal cavity is performed. First of all, the place where the manipulator enters the abdominal cavity is inspected, which, if necessary, is freed from the strands of the omentum. Then a panoramic examination of the entire abdominal cavity is performed, during which the presence of effusion, the condition of the intestinal loops and peritoneum are assessed.

Figure 9. Operating approaches for diagnostic laparoscopy. Trocar insertion sites:
1 - trocar 5.5 mm (for palpator); 2-trocar 5.5 mm (for laparoscope 5 mm, 30 o)

The audit begins with a search for the dome of the cecum. In young children, the dome is usually located higher, in the right lateral canal, sometimes under the right lobe of the liver. There is also increased mobility of the cecum - in these cases, its dome can be found medially, among the loops of the small intestine in the middle floor of the abdominal cavity. A long cecum with a dome localized in the pelvic area is often found. Thus, if the cecum is absent in the right iliac fossa and there are difficulties in detecting it, it is advisable to begin the examination with the transverse colon.

Consistently moving the laparoscope along the tenia towards the ileocecal angle, using a manipulator and changing the position of the patient’s body, the localization of the dome of the cecum is determined. Bringing the appendix into view when using a manipulator is not difficult. Some difficulties may arise in the presence of congenital adhesions in the ileocecal region. This is Lane's ligament, which fixes the distal loop of the ileum to the iliopsoas muscle. In this case, the appendix may be located behind the ileum. The Jackson's membrane, which is a membranous cord that fixes the cecum and ascending colon to the parietal peritoneum of the right lateral canal, also makes inspection difficult. If these adhesions are pronounced in the area of ​​the dome of the cecum, the appendix may be located in a narrow retrocecal pouch.

In case of difficulties of this kind, it is necessary to turn the patient on his left side, find the base of the process, and, carefully prying it up with a manipulator (or grabbing it with a soft clamp), apply slight traction. Usually in this position it is possible to bring it into view.

After detecting the appendix, it is examined. The normal vermiform appendix is ​​mobile, easily moved by a manipulator, its serous membrane is shiny and pale pink in color (Figure 10). The presence or absence of inflammation in it is judged by direct and indirect signs. We include the presence of a cloudy effusion in the immediate vicinity of the appendix, a reaction of the peritoneum in the form of hyperemia, the disappearance of its natural luster, and the presence of fibrin deposits as indirect signs.

Figure 10. Endoscopic picture of an unchanged appendix

Direct signs are detected by direct examination of the appendix. To these we include the injection of the serosa, its hyperemia, the disappearance of the natural shine of the serosa, a change in its natural color both in individual areas and as a whole, infiltration of both the wall of the appendix and its mesentery, the presence of fibrin deposits. In this case, it is possible to “palpate” the tension of the process and observe its rigidity (Figure 11). Inflammatory changes are more often expressed in the distal part of the process. In addition, it is often possible to detect the presence of loose adhesions between the process and surrounding tissues. In some cases, in the presence of gangrenous changes in the wall of the process, a perforation hole is detected.

Figure 11. Endoscopic picture of a phlegmonous changed appendix

The greatest difficulties arise in the differential diagnosis of the initial stages of destructive inflammation and superficial inflammation of the appendix. In this case, of all the described signs, it is possible to detect only mild hyperemia of the serosa and its injection by blood vessels. The only differential diagnostic feature that allows us to distinguish the initial stage of destructive inflammation in the appendix from a superficial inflammatory reaction is its rigidity.

Using this sign, it is possible to identify destructive inflammation in the appendix even in its early stages. This sign is defined as follows: the vermiform appendix is ​​raised by a manipulator placed under it in the middle third. If at the same time the vermiform appendix sagged, as if falling from the manipulator, this sign was considered negative (Figure 10). If it holds the shape of the rod either in its entirety or on a separate one area, this sign is considered positive (Figure 11).

It should be noted that this sign is the most reliable of all existing ones and is used by us as a pathognomonic endoscopic symptom.

Significant difficulties arise in the differential diagnosis of pronounced secondary changes in the appendix from truly destructive changes in it. Thus, with primary pelvioperitonitis, severe mesadenitis or another source of inflammation of the abdominal cavity, secondary changes in the appendix are detected.

Swelling of the serous membrane is noted, its vessels are full-blooded, dilated, and appear in the form of a network enveloping the appendix. Unlike primary inflammation, there is no rigidity (deep layers are not involved in the process), and there is also no uniform hyperemia and compaction of the process. Thus, visible secondary changes in the appendix represent serositis and are a consequence of contact with an inflammatory effusion.

If there is no destructive inflammation in the appendix, a careful gentle inspection of the abdominal organs is performed using the following method.

Since the patient is in the Trendelenburg position with a turn on the left side during examination of the appendix, it is first convenient to examine the ileocecal angle and the mesentery of this section of the intestine (Figure 12). In childhood, a common cause of abdominal pain is acute mesenteric lymphadenitis. In the mesentery of the ileocecal angle, in the mesentery of the small intestine, enlarged, swollen and hyperemic lymph nodes are detected.

Figure 12. Position of the patient on the operating table when examining the ileocecal angle and appendix

Sometimes enlarged lymph node packets resemble “bunches of grapes”. Then the ileum is examined retrogradely at a distance of at least 60-80 cm from the ileocecal angle. In this case, we use a palpator probe, examining the small intestine loop by loop. This allows us to identify a wide variety of pathologies: Meckel's diverticulum. angiomatosis. inflammatory diseases, neoplasms, etc.

By increasing the angle of the table in the Trendelenburg position. The pelvic organs are examined, where in girls attention is drawn to the uterus and appendages. First, the right appendage is examined, then, with the table tilted sideways, but maintaining the Trendelenburg position, the left appendage is examined.

In the same position, the internal rings of the right and left inguinal canals are examined. Attention is drawn to their consistency; in addition, in boys, a testicle is sometimes found in these areas, indicating the presence of an abdominal form of cryptorchidism. Here the vas deferens and vessels of the testicles are examined.

Then the patient is given the Fowler position with a turn on the left side, in which the right lobe of the liver, the gallbladder, the area of ​​the hepatoduodenal ligament, the pyloric part of the stomach, the duodenal bulb, and the contours of the lower pole of the right kidney are examined. Having eliminated the lateral rotation of the table, but maintaining the Fowler's position, examine the left lobe of the liver, the round and falciform ligaments of the liver, the anterior wall of the stomach, the area of ​​the lesser omentum and the gastrocolic ligament.

It is more difficult to examine the spleen, which is located high under the diaphragm and is covered by the omentum, and in small children it is also covered by the left lobe of the liver. The patient must be turned on his right side and the head end of the table raised. By displacing the omentum and intestinal loops with a manipulator, the spleen is brought into view. Its mobility depends on the severity of the ligamentous apparatus, however, it is usually possible to clearly see the anterior end, upper edge, diaphragmatic surface and hilum area. Normally, the area of ​​the left kidney is not visible. The inspection of the upper and middle floors of the abdominal cavity ends with an examination of the loops of the small intestine. Using a manipulator, you can methodically examine the entire intestine, its mesentery, the abdominal part of the aorta, and the place of its bifurcation.

A gentle laparoscopy technique that takes into account age-related characteristics in children, and the use of modern pediatric models of laparoscopes allow a fundamentally new approach to the diagnosis of appendicitis. The use of puncture laparoscopy in case of questionable results of other research methods allows not only to accurately determine the presence or absence of inflammation in the appendix, but also, when excluding the diagnosis of acute appendicitis, to conduct a gentle examination of the abdominal organs and in more than 1/3 of patients to identify the true cause of abdominal pain syndrome. Most often, nonspecific mesadenitis, gynecological diseases in girls, cryptogenic pelvioperitonitis, diseases of the biliary system and ileocecal angle are detected.

Analyzing the data obtained from diagnostic laparoscopy, the following options for further tactics can be identified:

1. The study ends at the diagnostic stage, and no pathology is detected.

2. The study ends at the diagnostic stage, which reveals pathology of the abdominal organs that requires conservative treatment.

3. As a result of the diagnostic stage of laparoscopic intervention, diseases of the abdominal organs are identified, the treatment of which can be carried out using laparoscopic interventions.

4. At the diagnostic stage of laparoscopic intervention, diseases are identified that cannot be treated laparoscopically. These patients undergo laparotomy.

D.G. Krieger, A.V. Fedorov, P.K. Voskresensky, A.F. Dronov