|Year : 2009 | Volume
| Issue : 5 | Page : 560-566
Challenges in Paediatric Laparoscopic Surgeries
Ruchi Gupta1, Saru Singh2
1 Prof & Head, Deptt. of Anaesthesia, Sri Guru Ram Das Institute of Medical Sciences & Research, Amritsar, India
2 Assistant Professor, Deptt. of Anaesthesia, Sri Guru Ram Das Institute of Medical Sciences & Research, Amritsar, India
|Date of Web Publication||3-Mar-2010|
314 A block, Ranjit Avenue, Amritsar – 143001, Punjab
Source of Support: None, Conflict of Interest: None
Today in the era of minimally invasive surgery, paediatric laparoscopy has become widely popular.The anaesthetic management in these cases poses special problems due to pneumoperitoneum created and extremes of position adopted in addition to the fact that paediatric anaesthesia itself is a challenge. Mostly the physiological as well as anaesthetic consideration are same except that child is not a small adult. The pressure of pnemoperitoneum needs to be kept between 6-12em H 2 O, flow of gas about 0.91, ventilation to be controlled, temperature monitoring being essential, use of atropine as premedicant, intravenous fluid management to be meticulous, induction with sevoflurane preferred as children may not allow i.v.puneture, intraoperative surgical complications being more, one needs to be very vigilant to diagnose and treat it. Using periumbilical area in paediatric age group should be avoided because the umbilical vessels have not imvoluted and can get punctured.Thus careful management in paediatric laparoscopic surgery will assume an important place in paediatric surgery.
Keywords: Paediatric Laparoscopy, Anaesthetic challenges
|How to cite this article:|
Gupta R, Singh S. Challenges in Paediatric Laparoscopic Surgeries. Indian J Anaesth 2009;53:560-6
| Introduction|| |
Paediatric laparoscopy has been first described in 1923 by Kelling but its use has increased since last decade. A laparoscopic approach offers several advantages over an open procedures; potentially reduces the surgical stress and fluid shifts that may accompany it; in addition there is less need forpostoperative analgesia, reduction of postoperative respiratory and wound complications; shortens postoperative convalescence, including an intensive care unit stay; rapid return to normal diet and decreased overall hospital stay  Laparoscopic procedures in children can be done for number of indications [Table 1] and anaesthesia for these procedures poses certain challenges which increase manifolds as the patients are children.
Physiologic changes during laparoscopic surgery in children is almost similarto adults. What makes anaesthesia challenging in these cases are related to positioning (Trendelenburg, reverse Trendelenburg) and creation of pneumoperitoneum. The magnitude of these changes is influenced bythe patient's age, underlying myocardial function and anaesthetic agents  . [Figure 1]
The gases that can be insufflated are CO2. N2O, air and helium. Out of these CO2 is the most commonly used gas because of its inabilityto support combustion, rapidly excreted high blood solubility and minimal effects of its irtravascular embolisation The creation& pneumoperitoeum with insufflated gas permits beter visualization and manipulation abdominal viscera. The volume of insufflating gas necessary for pneuceramoperitoneum is much lower in children than adults. Adults require 2.5L to 5L where as a 10 kg patient needs about 0.9L
Paediatric laparoscopic procedures are likely to cause an increase in pulmonary and systemic vascular resistance, sudden bradycardia during pneumoperitoneum because of raised intraabdominal pressure(IAP), the chances being much more than adults. Children have a high level of vagal tone and occasionally peritoneal stimulation by a blast of insufflated gas or penetration by trocars and laparoscopes can provoke bradycardia or asystole.,Intra Abdominal Pressure(IAP) is a critical determinant of cardiovascular stability during laparoscopyVarious cardiovascular effects have been slwumin [Table 2].
Patients with normal cardiovascular function tolerate variations in preload and afterload well, but those with cardiovascular disorders, anemia or hypovolemia require meticulous attention to volume loading, positioning and insufflation pressures. For this restriction of the IAP to 6mmhg in infants and to 12mmHg in older children has been recommended. These pressures have minimal effects on cardiac index.,
Various pulmonary effects include reduced diaphragmatic excursion& cephalad shift; reduced thoracic compliance& functional residual capacity; early closure of smaller airways& increased peak airway pressures; thus leading to ventilation perfusion mismatch. Other problems occuring during laparoscopy include endobronchial intubation, subcutaneous emphysema, pnuemothorax, pneumomediastinum, massive CO2 embolism, bronchospasm, bronchial hypersecretion and atelectasis. 
These pulmonary effects depend on age, weight, preoperative pulmonary functions, degree of trendelenburg position, anaesthetic agents, and ventilation technique. In order to reduce these effects neuromuscular blockade, endotracheal intubation, adjustment in mechanical ventilation (PCV) and PEEP are recommended. 
Central Nervous System:
Hypercapnia, high systemic vascular resistance and head low position combine to elevate intracranial pressure.  The induction of pneumoperitoneum itself increases muddle cerebral artery blood flow velocity in young children, even when CO 2 reactivity is normal  Avoiding above factors may help reduce intracranial pressure.
Increased intraabdominal pressure increases the risk of regurgitation. This is more so if regional anaesthesia with sedation or GA with mask ventilation is given.  So the use of acid aspiration prophylaxis has been recommended in all patients.
Increased IAP may leadto increasedvenous stasis thus causing deep vein thrombosis especially when surgery is prolonged,  so deep vein thrombosis prophylaxis should be done in such patients.
and acute phase responses (glucose, leucocytosis, C-reactive protein) and interleukin were less after laparoscopy compared to laparotomy , But reduction in splanchnic, hepatic, and renal blood flow and increase in the plasma concentrations of catecholamines, cortisol, insulin, epinephrine, prolactin, growth hormone, and glucose levels have been reported with carbon dioxide pneumoperitoneum . 
Laparoscopic surgery involves the intr peritoneal or extraperitoneal insuftlation of carbon dioxide through averess needle. Avariable-flow insufflator terminates flow at a preset intra-abdominal pressure which is decided according to the age group ofpatients. Once the abdomen is filled with carbon dioxide, the veress needle is replaced by a cannulathrough which a video laparoscope is inserted. Additional ports are placed according to the surgical procedure undertaken.  In infants less than 5 kg weight, periumbilical area should not be used for port access because of risk of puncture of umbilical vessels.  Aftertracheal intubation, the stomach is suctioned with an orogastric tube and bladder catheterization is done in order to decrease the risk of visceral injury during trocar insertion.
Although regional anaesthesia has been used in adults& older children, general anaesthesia is nearly always used for laparoscopic procedures in infants& children. 
Detailed history and physical examination should be conducted in all elective as well as emergency procedures. Investigations should be ordered according to the requirement of the procedure(type, urgency) and co existing diseases. 
Children younger than 9 months do not suffer separation anxiety and require no sedatives however older children may be given oral midazolam 0.5-0.75mg.kg -1 15-30 min preoperatively. Other drugs include antacids, H L antagonists, gastrokinetic agents, opioids and ketamine. Anticholinergic (atropine 20µg.kg -1 i.m.) is associated with decreased incidence of cardiovascular and airway complications perioperatively. It also helps in preventing vasovagal reflexs occurring during peritoneal penetration. 
Venous access can be performed with minimal discomfort using EMLA, prilocaine gel and should be secured above the level of diaphragm, so as to permit rapid fluid resuscitation inthe case of accidental vascular injury. A fluid bolus of 20 ml.kg -l can be used to offset hemodynamic effects when pnuemoperitoneum is created.  Induction of GA can be done in children by inhalational agents (sevoflurane or halothane, air and oxygen) or by intravenous route if venous access has already been secured. Tracheal intubation which is a gold standard in children, provides secure airway, allows good muscle relaxation, optimal surgical conditions and controlled ventilation.  The laryngeal mask airways (LMA) or mask ventilation for airway maintenance for short-term laparoscopic urologic procedure has been used. For inguinal hemion aphy, orcheopexy, or orchiectomy; it is a suitable and safe alternative to endotracheal intubation.  Mask ventilator is beneficial in asthmatic patients where intubation needs to be avoided. In case of pulmonary disease, spontaneous ventilation using mask has the added advantage of decreasing ventilation perfusion mismatch. 
However the role of LMA in upper abdominal procedures is limited due to increased chances of regurgitation. More favorable ventilation and a reduction in inadvertent gastric insufflation have been reported withthe LMA-ProSeal. 
Maintenance of Anaesthesia
Anaesthesiais maintained with a volatile agent in oxygen and air. Both isoflurane and halothane have been used successfully.  However, there is increased chances of arrhythmias occurring with halothane in spontaneously breathing patients due to hypercarbia.  Moreover there is a risk of halothane hepatotoxicity due to decreased hepatic blood flow.  Isoflurane has been associated with excessive secretions and bronchospasm.  Total intravenous anaesthesia (TIVA) using a propofol infusion has also been successfully employed.Minute ventilation needs lobe increased by 20% or more to maintain nonnocapnia.  Nitrous oxide is generally not used as it can increase bowel distension, nausea and vomiting.
Intraoperative pain management can be done by parenteral, spinal, epidural and caudal route using local anaesthetics, NSAIDS& opioids and this can continue in postoperative period.
Small children have a high body surface area to mass ratio and little subcutaneous fat or body hair to retain heat. Continuous insufflation of large volumes of cold, non-humidified C02 directly into the abdominal cavity also contributes to a major risk of hypothermia. Awarming mattress, heated humidifier or a convective forced air warmer might be used if available. Hypothermia is avoided by warming the insufflating gas and/or maintaining insufflating flows of less than 2 L/min. 
Apart from the mandatory monitoring which includes pulse oximetry, NIBP, ECG capnography and temperature; precordial or oesophageal stethoscope should be used especially for early detection of endobronchial intubation. , Precordial doppler probe and transoesophageal echocardiographyhave been recommended in normal patients for the detection of gas embolism and assessment of preload& cardiac contractility in children with cardiac disease ,, CVP may be indicated where there are more chances of embolism as embolised gas can be aspirated.
The table position itself may need to be changed repeatedly during the operation; both the trendelenburg andthe reverse trendelenburg positions are often used. Infants may be placed near the foot end of the table. Accordingly, care must be taken to secure the patient to the table (e.g., using rolls of gauze and tape). Well padding of extremities should be ensured. 
Reversal / Extubation
Reversal and extubation is done after ensuring adequate orogastric suction and empting of pneumoperitonem. Bilateral air entry should be checked at the end of anaesthesia.
Nausea Vomiting (PONY):
The incidence of PONY following laparoscopy can be reduced by administrating a combination of drugs including ondansetron(100 rg.kg -1 ), dexamethsone (150µg.kg -1 ), droperidol(25 tg.kg -1 ). Other maneuvers that prevent post operative nausea vomiting are; use of propofol as an induction agent and avoidance of nitrous oxide.
Additional CO 2 load can persist into the post operative period resulting in increase in the ventilatoty requirement, especially when the ability to increase ventilation is impaired by residual anaesthetic drugs, diaphragmatic dysfunction and parenteral narcotics. 
Pain following laparoscopy is due to rapid distension ofperitoneum, visceral manipulation, initation and traction of vessels and phrenic nerves, presence of residual gas and inflamatoiy mediators , Normal presentation in adults is abdominal discomfort and shoulder tip pain but in children shoulder tip pain is less.
Pain can be controlled using a multimodal approach such as local anaesthetics, opioids, NSATDS and adjuncts like clonidine. This can be achieved by instilling local anaesthetic with laparoscope, use of caudal and epidural catheter and bilateral rectos sheath block.  Analgesiacan be given as fentanyl 2-5 meg.kg -1 bolus, followed by infusion at 2 mcg.kg -1 .hour -1 ; or codeine phosphate 1-2 mg.kg -1 intramuscularly given at the end of the procedure, or an infusion ofremifentanil 0.1-1 meg.kg -1 .min' followed by morphine 0.1-0.2 mg.kg -1 . At the end of surgery, paracetamol 15-20 mg.kg -1 or diclofenac 1-2 mg.kg -1 , if not contraindicated, can be administered rectally
Diagnostic Laparoscopy in Portal Hypertensive Child ren(PHT)
The PaCO ` increased remarkably in children with PHT undergoing laparoscopy. Absorption of CO, is enhanced by enlarged and tortuous collateral vessels over parietal and visceral peritoneal surfaces, angiomatous channels over liver, increased plasma volume, hyperdynamic circulation and increased cardiac output. Moreover, pulmonary dysfunction and difficulty in ventilation due to enlarged spleen or liver explain the high PaCO 2 and significantly low PaO 2 . Limiting the duration of CO 2 pneumoperitoneum and intraabdominal pressure, application of high Fi02 (50%) and adjustment of ventilatory variables is important in such cases. 
LaparoscopicAdrenalectomy for Pheochromocvtoma in a Pediatric Patient
Critical events in laparoscopic adrenlectomy occur during intubation, induction of pneumoperitoneum and tumor manipulation. The intravenous infusions of sufentanil, esmolol, and nicardipine should be carefully titrated to attenuate the wide fluctuations in hemodynamics . 
MgSO 4 has been used as an adjunct to nicardipine in pediatric laparoscpoic adrenalectomy which acts by inhibitingthe release of catecholamines, blocks catecholamine receptors directly, dilating action on vessel walls andhas an antiarrhythmic effect onthe heart. ,
Laparoscopic Nissen's Fundoplicaton
Patients undergoing laparoscopic Nissen's fundoplicaton have preexisting respiratory disease seeondaryto chronic aspiration; and interference with diaphragmatic function during fundoplication lead to post operative hypoxemia. At high TAP levels dissection of esophageal hiatus may even permit the passage of insufflated gas across the diaphragm leading occasionally to pneumothorax and pnemomediastinum.This necessitates routine post operative chest X-ray. These patients may develop hypotension and bradycardia during reverse trendelenburgposition; volume loading and administration ofvagolytic drugs helps preventing this problem. 
Laparoscopic Renal Surgery in Infants
In a study on 17 patients less than 10 kg weight, laparoscopic renal surgery (nephrectomy, partial nephrectomy, nephroureterectomy) was done. All operations had minimal estimated blood loss, less operative time, reduced hospital stay, low morbidity and rapid recoveiy.lnthese patients diaphragmatic injury is common which needs immediate diagnosis and repair. 
A new technique known as gasless laparoscopy eliminates the risks of pneumoperitoneum by using mechanical retraction and is therefore appealing for patients with severe heart and pulmonary disease  . Reduced visualization is associated with this technique and its applicationto pediatrics remains uncertain.
- Preoperative optimization of patients with co existing diseases (eg.PHT, gastrooesophageal reflux, pheochromocytoma) and those posted for emergency surgery.
- Intraoperative diagnosis and treatment of effects of carboperitoneum; maintenance of TAP between 6-12 mmHg. Vigilant observation of its effects and tailoring the management accordingly is the keyto successful management.
- Monitoring ECG NIBP, Pulse oximetry, Capnography, PNS and Temperature forthe early detection ofhypotension, bradycardia, anythmias, venous air embolism, endobrochial intubation, pneumothorax and hypothermia is mandatory
- Post operative care for observation and management of nausea vomiting, inadequacy ofventilation due to residual carbon dioxide load and pain which includes cautious selection of drugs and their routes so as to avoid enhancement of above problems.
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[Table 1], [Table 2]