Pedi gu review laparoscopy

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Urologic Pediatric Laparoscopy-Physiology and Complications Pediatric GU Review UCSD Pediatric Urology George Chiang MD Sara Marietti MD Outlined from The Kelalis-King-Belman Textbook of Clinical Pediatric Urology 2007 (not for reproduction, distribution, or sale without consent)

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  • 1. Urologic Pediatric Laparoscopy-Physiology and Complications Pediatric GU Review UCSD Pediatric Urology George Chiang MD Sara Marietti MD Outlined fromThe Kelalis-King-Belman Textbook of Clinical Pediatric Urology 2007 (not for reproduction, distribution, or sale without consent)

2. Pneumoperitoneum

  • Cardiac
  • Pulmonary
  • Renal

3. Cardiac

  • Mechanical compression of IVC
  • Reduction in Preload
  • Decreased CO and possibly BP
  • CO2 is a direct cardiovascular depressant

4. Cardiac

  • Reverse trendelenburg makes effects worse, trendelenburg makes them better
  • Volume loading prior to pneumoperitoneum can reduce effects (dehydration reduces preload)
  • Consider SCDs in older pt, longer cases, in reverse trendelenburg
  • Those with cardiac history may need invasive monitoring during the case

5. Pulmonary

  • Mechanical
  • Metabolic

6. Pulmonary-Mechanical

  • Pneumo pushes on diaphragm
  • Increased intrathoracic pressure
  • Observe increased peek expiratory airway pressure, decreased functional residual capacity
  • All effects worse while in trendelenburg
  • Trachea can be displaced anteriorly resulting in right bronchial intubation in infants

7. Pulmonary-Metabolic

  • Increased amount of CO2 gas that needs to be eliminated (children absorb more than adults)
  • Managed by increasing minute ventilation
  • Tight chest taping can further magnify thoracic problems
  • Those with pulmonary disease may retain CO2 longer and require post-op intubation and ventilation to clear the CO2

8. Renal

  • Increased intra-abdominal pressure compressed renal vasculature and parenchyma
  • Reduction in renal blood flow and perfusion
  • Negligible when intra-abdominal pressureis less than 10 mmHg
  • When greater than 15 mmHg, RBF, GFR, UOP all decrease

9. Renal

  • With desufflation of the abdomen, pressures return to normal
  • Diuresis may occur
  • NSAID increase medullary vasoconstriction and increase these effects
  • Important not to fluid overload based on oliguria alone (not indicator of intravascular volume), could cause potential pulmonary edema or CHF

10. Recommendations

  • Use lowest insufflation pressure possible to have adequate visualization
  • Infants~8 mmHg
  • Children~12mmHg
  • Adolescents~15mmHg

11. Complications

  • Access
  • Visceral Injury
  • Vascular Inury
  • Gas Embolism
  • Pain/Nausea/Vomiting
  • Conversion is not a complication

12. Access/Trocars

  • 30% of complications happen upon initial access into the abdomen
  • 76% of initial access injuries are to bowel or vascular structures
  • There is no great literature to support one form of access over another

13. Access

  • However, reusable trocars have shown more injury than disposable (more force)
  • Safety shields are not safe

14. Access-Anatomy

  • Umbilicus is located at level of aortic bifurcation, and where left common iliac vein crosses the midline
  • AP distance from umbilicus to aorta can be as close as 1cm in thin/sm patient
  • Lift abdominal wall

15. Hasson Technique

  • Direct open visualization layer by layer
  • Place trocar under direct visualization
  • Disadvantages - gas leak, increased incision size, increased time for placement

16. Optical Trocars

  • Place port with clear end, through which camera can visualize the layers
  • With or without veress insufflation
  • Decreased skin incision and air leakage
  • Disadvantage - difficulty in recognizing the layers (reports of major vascular injury with this technique)

17. Veress

  • Small skin incision is made, veress inserted
  • Left sub-costal region has been used because rarely adhesions, counter-traction
  • Umbilicus is the thinnest region of the body, even in obese people

18. Veress

  • Two pops - fascia and peritoneum
  • Abdominal wall should be stabilized while veress needle placed
  • Draw back, inject, drop test
  • Insufflation system that sounds with high pressure - extra peritoneal
  • Do not use reusable veress needles - dull

19. Access

  • Most common vascular injury is injury to inferior epigastic artery
  • Attempt intra-abd cautery, compression with cannula, foley with balloon up to tamponade, box-stitch (Carter-Thompson device)

20. Access

  • Major vascular injury usually more common with blind trocar placement
  • Decrease with 45 degree insertion angle
  • Recognize with aspiration of blood through veress needle or blood on initial visualization
  • Need prompt recognition and laparotomy

21. Access

  • Injury to bowel, stomach or bladder can be more difficult to identify - high rate of late presentation
  • If identified immediately, can repair intracorporally
  • Always inspect abdomen fully upon entering

22. Injury During Primary Access Journal of American College of Surgeons , 2001 23. Injury During Secondary Port Placement Journal of American College of Surgeons , 2001 24. Clinical Presentation Journal of Urology,1999 25. Access

  • Liver/Spleen injuries
  • Apply gentle pressure- fan retractor
  • Argon beam
  • Sealants

26. Gas Embolism

  • Rare
  • Direct insufflation into a vessel
  • Sudden decrease in end tidal CO2 and blood pressure
  • Trap gas in right ventricle (trendelenburg, left lateral decubitus)

27. Pain

  • Generally less than open surgery, but still significant
  • Shoulder pain felt to be from stretching peritoneum during insufflation
  • Reduction in pain score with:
  • Lower pressures, removal of gas at end ofprocedure, reducing size of trocars, local at port sites, irrigation of abdomen

28. Subcutaneous Emphysema

  • Crepitace under the skin
  • Generally not problematic
  • Insufflation outside of peritoneum with initial access or trocar leak

29. Port Site Hernia

  • Larger ports
  • Cutting vs dilating trocars
  • Midline vs lateral
  • Close 10mm or greater in adults
  • Close 5mm or greater in peds
  • ? Close 3mm in infants