Urologic Pediatric Laparoscopy-Physiology and Complications Pediatric GU Review UCSD Pediatric Urology George Chiang MD Sa...
Pneumoperitoneum <ul><li>Cardiac </li></ul><ul><li>Pulmonary </li></ul><ul><li>Renal </li></ul>
Cardiac <ul><li>Mechanical compression of IVC </li></ul><ul><li>Reduction in Preload </li></ul><ul><li>Decreased CO and po...
Cardiac <ul><li>Reverse trendelenburg makes effects worse, trendelenburg makes them better </li></ul><ul><li>Volume loadin...
Pulmonary <ul><li>Mechanical </li></ul><ul><li>Metabolic </li></ul>
Pulmonary-Mechanical <ul><li>Pneumo pushes on diaphragm </li></ul><ul><li>Increased intrathoracic pressure </li></ul><ul><...
Pulmonary-Metabolic <ul><li>Increased amount of CO2 gas that needs to be eliminated (children absorb more than adults) </l...
Renal <ul><li>Increased intra-abdominal pressure compressed renal vasculature and parenchyma </li></ul><ul><li>Reduction i...
Renal <ul><li>With desufflation of the abdomen, pressures return to normal </li></ul><ul><li>Diuresis may occur </li></ul>...
Recommendations <ul><li>Use lowest insufflation pressure possible to have adequate visualization </li></ul><ul><li>Infants...
Complications <ul><li>Access </li></ul><ul><li>Visceral Injury </li></ul><ul><li>Vascular Inury </li></ul><ul><li>Gas Embo...
Access/Trocars <ul><li>30% of complications happen upon initial access into the abdomen </li></ul><ul><li>76% of initial a...
Access <ul><li>However, reusable trocars have shown more injury than disposable (more force) </li></ul><ul><li>Safety shie...
Access-Anatomy <ul><li>Umbilicus is located at level of aortic bifurcation, and where left common iliac vein crosses the m...
Hasson Technique <ul><li>Direct open visualization layer by layer </li></ul><ul><li>Place trocar under direct visualizatio...
Optical Trocars <ul><li>Place port with clear end, through which camera can visualize the layers </li></ul><ul><li>With or...
Veress <ul><li>Small skin incision is made, veress inserted </li></ul><ul><li>Left sub-costal region has been used because...
Veress <ul><li>Two pops - fascia and peritoneum </li></ul><ul><li>Abdominal wall should be stabilized while veress needle ...
Access <ul><li>Most common vascular injury is injury to inferior epigastic artery </li></ul><ul><li>Attempt intra-abd caut...
Access <ul><li>Major vascular injury usually more common with blind trocar placement </li></ul><ul><li>Decrease with 45 de...
Access <ul><li>Injury to bowel, stomach or bladder can be more difficult to identify - high rate of late presentation </li...
Injury During Primary Access Journal of American College of Surgeons , 2001
Injury During Secondary Port Placement Journal of American College of Surgeons , 2001
Clinical Presentation Journal of Urology,  1999
Access <ul><li>Liver/Spleen injuries </li></ul><ul><li>Apply gentle pressure  - fan retractor </li></ul><ul><li>Argon beam...
Gas Embolism <ul><li>Rare </li></ul><ul><li>Direct insufflation into a vessel </li></ul><ul><li>Sudden decrease in end tid...
Pain <ul><li>Generally less than open surgery, but still significant </li></ul><ul><li>Shoulder pain felt to be from stret...
Subcutaneous Emphysema <ul><li>Crepitace under the skin </li></ul><ul><li>Generally not problematic </li></ul><ul><li>Insu...
Port Site Hernia <ul><li>Larger ports </li></ul><ul><li>Cutting vs dilating trocars </li></ul><ul><li>Midline vs lateral <...
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Pedi gu review laparoscopy

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Pedi gu review laparoscopy

  1. 1. 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)
  2. 2. Pneumoperitoneum <ul><li>Cardiac </li></ul><ul><li>Pulmonary </li></ul><ul><li>Renal </li></ul>
  3. 3. Cardiac <ul><li>Mechanical compression of IVC </li></ul><ul><li>Reduction in Preload </li></ul><ul><li>Decreased CO and possibly BP </li></ul><ul><li>CO2 is a direct cardiovascular depressant </li></ul>
  4. 4. Cardiac <ul><li>Reverse trendelenburg makes effects worse, trendelenburg makes them better </li></ul><ul><li>Volume loading prior to pneumoperitoneum can reduce effects (dehydration reduces preload) </li></ul><ul><li>Consider SCD’s in older pt, longer cases, in reverse trendelenburg </li></ul><ul><li>Those with cardiac history may need invasive monitoring during the case </li></ul>
  5. 5. Pulmonary <ul><li>Mechanical </li></ul><ul><li>Metabolic </li></ul>
  6. 6. Pulmonary-Mechanical <ul><li>Pneumo pushes on diaphragm </li></ul><ul><li>Increased intrathoracic pressure </li></ul><ul><li>Observe increased peek expiratory airway pressure, decreased functional residual capacity </li></ul><ul><li>All effects worse while in trendelenburg </li></ul><ul><li>Trachea can be displaced anteriorly resulting in right bronchial intubation in infants </li></ul>
  7. 7. Pulmonary-Metabolic <ul><li>Increased amount of CO2 gas that needs to be eliminated (children absorb more than adults) </li></ul><ul><li>Managed by increasing minute ventilation </li></ul><ul><li>Tight chest taping can further magnify thoracic problems </li></ul><ul><li>Those with pulmonary disease may retain CO2 longer and require post-op intubation and ventilation to clear the CO2 </li></ul>
  8. 8. Renal <ul><li>Increased intra-abdominal pressure compressed renal vasculature and parenchyma </li></ul><ul><li>Reduction in renal blood flow and perfusion </li></ul><ul><li>Negligible when intra-abdominal pressure is less than 10 mmHg </li></ul><ul><li>When greater than 15 mmHg, RBF, GFR, UOP all decrease </li></ul>
  9. 9. Renal <ul><li>With desufflation of the abdomen, pressures return to normal </li></ul><ul><li>Diuresis may occur </li></ul><ul><li>NSAID increase medullary vasoconstriction and increase these effects </li></ul><ul><li>Important not to fluid overload based on oliguria alone (not indicator of intravascular volume), could cause potential pulmonary edema or CHF </li></ul>
  10. 10. Recommendations <ul><li>Use lowest insufflation pressure possible to have adequate visualization </li></ul><ul><li>Infants~8 mmHg </li></ul><ul><li>Children~12mmHg </li></ul><ul><li>Adolescents~15mmHg </li></ul>
  11. 11. Complications <ul><li>Access </li></ul><ul><li>Visceral Injury </li></ul><ul><li>Vascular Inury </li></ul><ul><li>Gas Embolism </li></ul><ul><li>Pain/Nausea/Vomiting </li></ul><ul><li>Conversion is not a complication </li></ul>
  12. 12. Access/Trocars <ul><li>30% of complications happen upon initial access into the abdomen </li></ul><ul><li>76% of initial access injuries are to bowel or vascular structures </li></ul><ul><li>There is no great literature to support one form of access over another </li></ul>
  13. 13. Access <ul><li>However, reusable trocars have shown more injury than disposable (more force) </li></ul><ul><li>Safety shields are not safe </li></ul>
  14. 14. Access-Anatomy <ul><li>Umbilicus is located at level of aortic bifurcation, and where left common iliac vein crosses the midline </li></ul><ul><li>AP distance from umbilicus to aorta can be as close as 1cm in thin/sm patient </li></ul><ul><li>Lift abdominal wall </li></ul>
  15. 15. Hasson Technique <ul><li>Direct open visualization layer by layer </li></ul><ul><li>Place trocar under direct visualization </li></ul><ul><li>Disadvantages - gas leak, increased incision size, increased time for placement </li></ul>
  16. 16. Optical Trocars <ul><li>Place port with clear end, through which camera can visualize the layers </li></ul><ul><li>With or without veress insufflation </li></ul><ul><li>Decreased skin incision and air leakage </li></ul><ul><li>Disadvantage - difficulty in recognizing the layers (reports of major vascular injury with this technique) </li></ul>
  17. 17. Veress <ul><li>Small skin incision is made, veress inserted </li></ul><ul><li>Left sub-costal region has been used because rarely adhesions, counter-traction </li></ul><ul><li>Umbilicus is the thinnest region of the body, even in obese people </li></ul>
  18. 18. Veress <ul><li>Two pops - fascia and peritoneum </li></ul><ul><li>Abdominal wall should be stabilized while veress needle placed </li></ul><ul><li>Draw back, inject, drop test </li></ul><ul><li>Insufflation system that sounds with high pressure - extra peritoneal </li></ul><ul><li>Do not use reusable veress needles - dull </li></ul>
  19. 19. Access <ul><li>Most common vascular injury is injury to inferior epigastic artery </li></ul><ul><li>Attempt intra-abd cautery, compression with cannula, foley with balloon up to tamponade, box-stitch (Carter-Thompson device) </li></ul>
  20. 20. Access <ul><li>Major vascular injury usually more common with blind trocar placement </li></ul><ul><li>Decrease with 45 degree insertion angle </li></ul><ul><li>Recognize with aspiration of blood through veress needle or blood on initial visualization </li></ul><ul><li>Need prompt recognition and laparotomy </li></ul>
  21. 21. Access <ul><li>Injury to bowel, stomach or bladder can be more difficult to identify - high rate of late presentation </li></ul><ul><li>If identified immediately, can repair intracorporally </li></ul><ul><li>Always inspect abdomen fully upon entering </li></ul>
  22. 22. Injury During Primary Access Journal of American College of Surgeons , 2001
  23. 23. Injury During Secondary Port Placement Journal of American College of Surgeons , 2001
  24. 24. Clinical Presentation Journal of Urology, 1999
  25. 25. Access <ul><li>Liver/Spleen injuries </li></ul><ul><li>Apply gentle pressure - fan retractor </li></ul><ul><li>Argon beam </li></ul><ul><li>Sealants </li></ul>
  26. 26. Gas Embolism <ul><li>Rare </li></ul><ul><li>Direct insufflation into a vessel </li></ul><ul><li>Sudden decrease in end tidal CO2 and blood pressure </li></ul><ul><li>Trap gas in right ventricle (trendelenburg, left lateral decubitus) </li></ul>
  27. 27. Pain <ul><li>Generally less than open surgery, but still significant </li></ul><ul><li>Shoulder pain felt to be from stretching peritoneum during insufflation </li></ul><ul><li>Reduction in pain score with: </li></ul><ul><li>Lower pressures, removal of gas at end of procedure, reducing size of trocars, local at port sites, irrigation of abdomen </li></ul>
  28. 28. Subcutaneous Emphysema <ul><li>Crepitace under the skin </li></ul><ul><li>Generally not problematic </li></ul><ul><li>Insufflation outside of peritoneum with initial access or trocar leak </li></ul>
  29. 29. Port Site Hernia <ul><li>Larger ports </li></ul><ul><li>Cutting vs dilating trocars </li></ul><ul><li>Midline vs lateral </li></ul><ul><li>Close 10mm or greater in adults </li></ul><ul><li>Close 5mm or greater in peds </li></ul><ul><li>? Close 3mm in infants </li></ul>

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