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Paediatric laparoscopic surgery

Posted Dec 21 2011 9:22am

Modern technology means that abdominalRelating to the abdomen, which is the region of the body between the chest and the pelvis. surgery for infants has improved and can mostly avoid the need for invasive surgery. This article provides information on the new laparoscopicA keyhole surgical procedure. techniques used to treat hernias and other complications in young children.

The use of tailor-made, smaller instruments in laparoscopic (keyhole) surgery means the surgeons can:

  • Get easier access to the baby’s organs
  • Make smaller incisions which in turn means tiny cuts for the baby instead of one large scar from an invasive procedure
  • Avoid complications from large scarring which can leave troublesome adhesionsAn abnormal connection between two surfaces of the body. and require future surgery. As a result, the babies recover more quickly and normal family life can resume

Keyhole surgery in the abdomenThe part of the body that contains the stomach, intestines, liver, gallbladder and other organs. is known as laparoscopyKeyhole surgery that uses an instrument called a laparoscope to examine the abdominal or pelvic organs.. This involves operating through tiny incisions with the help of a telescope and TVtrichomonal vaginosis monitor. Over the last 20 years laparoscopy has replaced many traditional ‘open’ operations. This is due to the distinct advantages laparoscopy has for patients, such as:

  • Less pain after surgery
  • Quicker discharge from hospital
  • Quicker return to normal daily activities

While keyhole surgery is now readily available to adult patients for these reasons, it is not so readily available to children and infants, even though the advantages are just as relevant to this population. The surgery is technically demanding and takes patience, time and determination to master. Some surgeons have not been trained in this technique or have not learned the necessary skills and a small number of surgeons do not have the required hand-eye co-ordination.

However, thanks to developments in training and equipment almost all surgical conditions in the abdomen in children can be treated by keyhole surgery. Procedures that are appropriate for this type of minimally invasive approach range from common conditions such as inguinalRelating to the area around the groin. hernia repair, to rarer conditions such as fundoplication for acid refluxBackflow of a bodily fluid in the wrong direction. In this article I will discuss several conditions that can, and some that should only, be treated by keyhole surgery and describe the associated advantages to the child.

Both boys and girls often present with groin swellings known as inguinal hernias. A hernia is the protrusion of an organ such as the intestineThe section of gut, or gastrointestinal tract, from the stomach to the anus. or ovary through the abdominal muscles, and an inguinal hernia appears as a bulge in the groin. To fix the hernia by keyhole surgery involves a small incision at the umbilicus which acts as the entry point for the camera and two tiny cuts on each flank. The umbilical incision is for the miniaturized camera / telescope and the two side incisions are for the working instruments, in this case a forceps and a needle-holder. The hernia defect is closed with a stitch, somewhat like closing the top of a purse by pulling the string. Sometimes there is a potential hernia on the other side, which has not yet developed in to a groin swelling, and this can be proactively ‘fixed’ at the same time. The older, traditional operation for inguinal hernia involves a larger cut in the groin skin and muscle. The hernia is then peeled from the spermA mature male sex cell. duct and vessels of the testicle (in boys) and sutured closed. So, the advantages of the new, keyhole technique include the following:

  • Skin and muscle incisions are small so there is less pain and scarring
  • The sperm duct and testicularRelating to the testicles. vessels are not handled and therefore not at risk of being damaged
  • If there is a potential hernia on the other side then it can be fixed at the same time

Again, this is quite a common occurrence in babies. When the testicle is easily palpated, but is not in the scrotumThe sac that contains the testes., then a routine ‘orchidopexyAn operation to bring a testicle down into the scrotum.’ can be performed, which involves fixing the testicle in the scrotum. However, if the testicle is not palpable, then laparoscopy is the best investigation. By looking inside the abdomen with the telescope, I can seen where the testicle is, or indeed, if it is present at all. No other investigations even including ultrasoundA diagnostic method in which very high frequency sound waves are passed into the body and the reflective echoes analysed to build a picture of the internal organs – or of the foetus in the uterus., gives this level of diagnostic accuracy. In those cases where the testicle is present I can go on to reposition and fix it in place by passing it through the muscles and placing it in a little pocket in the scrotum.

This is the commonest reason for emergency surgery in children. Treatment consists of antibioticsMedication to treat infections caused by microbes (organisms that can't be seen with the naked eye), such as bacteria. and surgery - appendicectomy. Laparoscopy allows the surgeon to confirm the diagnosisThe process of determining which condition a patient may have. and remove the inflamed appendix. Traditional ‘open’ surgery involves a bigger incision in the abdominal wall with resulting discomfort and potential for infectionInvasion by organisms that may be harmful, for example bacteria or parasites..

These are not as common in children as in adults and tend to be associated with bloodA fluid that transports oxygen and other substances through the body, made up of blood cells suspended in a liquid. disorders such as Sickle Cell disease. The gold standard operation for removing the gallbladder (and stones) is laparoscopic cholecystectomyThe surgical removal of the gallbladder., whereby the gallbladder is dissected from it’s bed in the liverA large abdominal organ that has many important roles including the production of bile and clotting factors, detoxification, and the metabolism of proteins, carbohydrates and fats. and removed from the body. Again, this minimally invasive approach allows quicker recovery and leaves only tiny scars rather than bigger, unsightly scars associated with traditional surgery.

In certain cases it is necessary to remove the spleenAn organ situated on the left side of the abdomen that filters out worn-out red blood cells and other foreign bodies from the bloodstream. in children with blood disorders. Laparoscopic splenectomy is safe and has all the usual advantages of keyhole surgery.

Children occasionally have very severe vomitingExpusion of the contents of the stomach through the mouth. (gastro-oesophageal reflux), which causes chest infections and failure to thrive. Mostly, this can be treated with medicines, but an operation is sometimes needed. The operation is called a fundoplication and the safest option is to perform this procedure using keyhole surgery. The operation involves wrapping the top of the stomachthe organ or the body where food is stored and broken down (fundusThe appearance of the retina when viewed through an opthalmoscope.) around the oesophagusThe gullet, the part of the gastrointestinal system that extends down from the mouth cavity to the stomach. to create a valveA structure that allows fluid to flow in one direction only, preventing backflow.. The resulting structure prevents the reflux of acid from the stomach.

Minimal access surgery, such as the laparoscopic procedures mentioned above, is now accepted as the best and safest way to operate on babies and children. This special group of patients has their whole lives ahead of them and there is no longer any need for them to have to live with the scars of ‘open’ operations performed in their childhood.
 

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