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Principles of Laparoscopic and

Robotic Surgery in Children

Pasquale Casale

Questions

1.The benefits of minimally invasive surgery (MIS) in children include all of the following EXCEPT:

a.cosmesis.

b.decreased convalescence.

c.increased visualization.

d.increased control of cancer margins.

e.shorter hospital stay.

2.Strong contraindications to laparoscopic surgery in children include all of the following EXCEPT:

a.von Willebrand disease.

b.pulmonary hypertension.

c.sepsis.

d.malignancy.

e.hemophilia.

3.In regard to comparing the adult patient with the pediatric patient:

a.Half of the height in centimeters equals an eighth of the intraabdominal space in liters.

b.An eighth of the height in centimeters equals an eighth of the intraabdominal space in liters.

c.An eighth of the height in centimeters equals half of the intraabdominal space in liters.

d.Half of the height in centimeters equals half of the intra-abdominal space in liters.

e.Half of the height in centimeters equals a fourth of the intra-abdominal

space in liters.

4.Which of the following statements describes the difference between bipolar vessel sealing devices and ultrasonic shears?

a.Bipolar devices provided a more secure seal up to 8-mm vessels; however, the ultrasonic devices had less thermal spread and used less surgical time.

b.Bipolar devices provided a less secure seal up to 7-mm vessels; however, the ultrasonic devices had less thermal spread and used less surgical time.

c.Bipolar devices provided a more secure seal up to 7-mm vessels; however, the ultrasonic devices had less thermal spread and used less surgical time.

d.Bipolar devices provided a more secure seal up to 7-mm vessels; however, the ultrasonic devices had more thermal spread and used less surgical time.

e.Bipolar devices provided a more secure seal up to 7-mm vessels; however, the ultrasonic devices had less thermal spread and used more surgical time.

5.Nitrous oxide gas has the following effect on laparoscopy:

a.It is flammable.

b.It increases hypercarbia.

c.It decreases intracranial pressure.

d.It increases bowel distention.

e.It increases gastric emptying.

6.Insufflation of CO2 has the following hemodynamic effects:

a.The heart rate and mean arterial pressure increase, while the venous return and cardiac output decrease.

b.The heart rate and mean arterial pressure decrease, while the venous return and cardiac output decrease.

c.The heart rate and mean arterial pressure increase, while the venous return and cardiac output increase.

d.The heart rate and mean arterial pressure decrease, while the venous return and cardiac output increase.

e.The heart rate and mean arterial pressure stay constant, while the venous return and cardiac output decrease.

7.Renal effects of insufflation include all of the following EXCEPT:

a.decreased glomerular filtration rate (GFR).

b.decreased creatinine clearance.

c.decreased renal blood flow.

d.decreased urine output.

e.decreased long-term renal reserve.

8.Hypercarbia causes all of the following EXCEPT:

a.increased heart rate.

b.vasodilation.

c.increased cardiac contractility.

d.increased intracranial pressure.

e.pulmonary hypertension.

9.All of the following statements regarding the boundaries of the retroperitoneal space are true EXCEPT:

a.posteriorly: the paraspinous, psoas, and quadratus lumborum muscles, which are anatomically fixed structures.

b.laterally: the skin and subcutaneous fat.

c.anteriorly: the mobile posterior parietal peritoneum and its contents.

d.superiorly: the diaphragm.

e.inferiorly: contiguous with the extraperitoneal portions of the pelvis.

.If vascular entry of insufflation occurs:

a.Nothing needs to be done because it is completely reversible.

b.The patient should be placed in reverse Trendelenburg position with the right side up to trap the air embolus in the right atrium.

c.The patient should be placed in Trendelenburg position with the right side up to trap the air embolus in the right atrium.

d.The patient should be placed in reverse Trendelenburg position with the left side up to trap the air embolus in the right atrium.

e.The patient should be placed in reverse Trendelenburg position with the left side up to trap the air embolus in the left atrium.

Answers

1.d. Increased control of cancer margins. Laparoscopic surgery has gained widespread acceptance given the reliability and durability of outcomes. The proposed benefits of laparoscopic surgery versus the standard open approach include better cosmesis, increased magnification improving visualization, reduced postoperative pain, and shorter hospital stays. Its role in pediatric urologic oncology is in its infancy and limited data are available.

2.d. Malignancy. Contraindications to laparoscopy in infants, children, and adolescents are the same as for any other surgical procedure, except for evidence of limited pulmonary reserve, which may be considered a relative contraindication. If the patient is septic, in shock, or exhibits a coagulopathy, these should be corrected before MIS is contemplated. If surgery is deemed essential under these circumstances, then it probably should be performed by using open techniques.

3.a. Half of the height in centimeters equals an eighth of the intraabdominal space in liters. Whereas an adult pneumoperitoneum will typically provide a 5-to 6-L working space, a 1-year-old boy will present a 1- L intra-abdominal space. A good rule of thumb is that half of the height in centimeters is equivalent to an eighth of the intra-abdominal space in liters.

4.c. Bipolar devices provided a more secure seal up to 7-mm vessels; however, the ultrasonic devices had less thermal spread and used less surgical time. Mischra performed a meta-analysis of the literature comparing these devices. The analysis found that bipolar devices provided a more secure seal up to 7-mm vessels; however, the ultrasonic devices had less thermal spread and used less surgical time. Based on the data, he concluded that it seemed to depend on the surgeon's experience to decide which energy source to use for each particular part of a specific procedure.

5.d. It increases bowel distention. Nitrous oxide gas increases bowel distention, potentially bringing the peritoneum closer to the area of dissection for retroperitoneal procedures and decreasing working space in transperitoneal procedures.

6.a. The heart rate and mean arterial pressure increase, while the venous return and cardiac output decrease. While gas is placed in the closed space of the operative field, the pressure rises and cardiovascular, pulmonary and renal effects occur. The heart rate and mean arterial pressure increase while the venous return and cardiac output decrease. These parameters are seen even when pressure is set at a standard working level of 10 mm Hg. Above a level of 15 mm Hg, more profound hemodynamic alterations are expected to occur, with further decrease in cardiac output.

7.e. Decreased long-term renal reserve. Renal effects occur secondary to gas insufflation, manifested by decreased glomerular filtration rate and urine output. Animal studies have shown that gas insufflation causes renal vein compression inducing decreased renal blood flow, decreased urine output and diminished creatinine clearance. These effects do not

appear to cause renal damage in humans, however.

8.e. Pulmonary hypertension. The hemodynamic effects of hypercarbia are increased heart rate, vasodilation, increased cardiac contractility, and increased intracranial pressure. Although in healthy children there is little if any added cardiorespiratory risk from laparoscopic procedures, children with cardiopulmonary compromise require close and careful monitoring.

9.b. Laterally: the skin and subcutaneous fat. The boundaries of the retroperitoneal space are: (1) posteriorly and laterally: the paraspinous, psoas, and quadratus lumborum muscles, which are anatomically fixed structures;

(2) anteriorly: the mobile posterior parietal peritoneum and its contents; (3)

superiorly: the diaphragm; and (4) inferiorly: contiguous with the extraperitoneal portions of the pelvis.

.b. The patient should be placed in reverse Trendelenburg position with the right side up to trap the air embolus in the right atrium. Vascular entry of insufflation can be catastrophic. If vascular entry is noted after insufflation has started, the patient should be placed in reverse Trendelenburg position with right side up to trap the air embolus in the right atrium. The air can then be retrieved with catheterization aided by transesophageal ultrasound.

Chapter review

1.Gastric distention following intubation should be immediately decompressed because of the rapid gastric emptying time in children—if this is not done, air may enter the small bowel, causing bowel distention.

2.The distance from the abdominal wall to vital structures may be very small in children; for example, the great vessels may be as little as 5 cm from the anterior abdominal wall.

3.Bipolar devices provide a more secure seal in vessels 7 mm or less when compared with ultrasonic devices; however, the latter have less thermal spread.

4.Nitrous oxide gas inhalation increases bowel distention,

5.Intraperitoneal gas insufflation causes renal vein compression, inducing decreased renal blood flow, decreased urine output, and diminished creatinine clearance.

6.If vascular entry is noted after insufflation has started, the patient should be placed in reverse Trendelenburg position with the right side up to trap the air embolus in the right atrium.

SECTION C

Upper Urinary Tract Conditions