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158
cd
S. Parkar and S.A. Clarke
a
b
Fig. 22.11 (a, b) Mobilizing appendix to hold at its base with soft bowel clamp. (c, d) Removing appendix through umbilical port under direct
vision
22 Laparoscopic Appendectomy
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159
22.5 Alternative Techniques
Single-incision laparoscopic surgery (SILS) was developed
in 1992 to further minimise the invasiveness of laparoscopic
surgery (Fig. 22.12). It is increasingly being used as an
a
approach for minimally invasive appendicectomy. Advantages
include better cosmesis, less postoperative pain, and an
earlier return to activities.
c
b
Fig. 22.12 (a) Wound protector prior to placement of a single-incision
laparoscopic surgery (SILS) port. A 5-mm camera port and two 5-mm
instrument ports are used in the same incision. Various devices are com-
mercially available. (b) The appendix can be removed via the gelport
without contacting the abdominal wall, thereby minimising postoperative wound infection. (c) No scar is visible on postoperative follow-up
Laparoscopy for Intussusception
Kate Cross
Abstract
Intussusception is a common abdominal emergency in infants and young children, with a
peak incidence between 5 and 7 months of age (70 % of cases present between 3 and 13
months). Treatment is reduction, usually by pneumatic or hydrostatic enema. However,
surgery is required when enema reduction fails or there is radiologic indication of doubt or
risk regarding reduction. Laparoscopy may be diagnostic, providing confirmation of reduction or persistent intussusception (where doubt exists), or it may be interventional, allowing
a minimally invasive approach to reduction. In the event that laparoscopic reduction is
unsuccessful, it also enables a focused and minimal incision for open surgery.
Keywords
Intussusception • Laparoscopy • Diagnosis • Reduction
23
23.1 General Information
Intussusception is a common abdominal emergency in
infants and young children, with a peak incidence between
5 and 7 months of age (70 % of cases present between 3
and 13 months). Treatment is reduction, usually by pneumatic or hydrostatic enema. However, surgery is required
when enema reduction fails or there is radiologic indication of doubt or risk regarding reduction. Laparoscopy
may be diagnostic, providing confirmation of reduction or
persistent intussusception (where doubt exists), or it may
be interventional, allowing a minimally invasive approach
to reduction. In the event that laparoscopic reduction is
K. Cross
Neonatal and Paediatric Surgery Department, Great Ormond Street
Hospital for Children NHS Foundation Trust, London, UK
unsuccessful, it also enables a focused and minimal incision for open surgery.
23.2 Working Instruments
• 5-mm Instruments (3-mm size can be used for a small
infants but may be more traumatic during reduction and
handling)
•
5-mm 30° Scope
• 5-mm Ports × 2
• 5-mm Johan graspers (atraumatic)
© Springer-Verlag Berlin Heidelberg 2017
M. McHoney et al. (eds.), Color Atlas of Pediatric Anatomy, Laparoscopy, and Thoracoscopy,
DOI 10.1007/978-3-662-53085-6_23
161
162
Screen
of intussusceptum
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K. Cross
23.3 Positioning, Port Siting,
Ergonomic Considerations
and
The patient should be placed with the feet at the end on the
table, and the laparoscopic screen should be on the patient’s
right side with the freedom to be moved from the head to feet
end of the table. This movement may be necessary, depending on the initial position and extent of the intussusceptum
Fig. 23.1 Patient positioning
(which may be as far as the sigmoid colon or rectum) to
allow ergonomic positioning for the initial reduction
(Fig. 23.1).
A 5-mm umbilical port position is used for the 30° telescope, and the two lateral 5-mm ports are placed in the right
upper quadrant (RUQ) and left lower quadrant (LLQ) of the
abdomen, opposite and perpendicular to the course of the
mesenteric base (Fig. 23.2).
Assistant
Possible position
Surgeon
23 Laparoscopy for Intussusception
5
5
163
Mesenteric
root
5
Fig. 23.2 A 5-mm umbilical port position is used for the 30° telescope,
and the two lateral 5-mm ports are placed in the RUQ and LLQ opposite
the course of the mesenteric base
164
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K. Cross
23.4 Relevant Anatomy
The intussusceptum may be on the patient’s left or right,
depending on the extent of the passage, and it must be identified as the initial step. When the intussusceptum is quite distal (descending colon), the operator should stand at the right
of the patient’s legs with the screen at the patient’s head to
initiate the reduction. As this progresses, the surgeon can
move below the patient’s feet and to the left-sided position
with the screen remaining opposite to complete the reduction
at ileocecal valve.
23.5 Surgical Technique
Visual confirmation of the intussusception and identification
of the distal point of the intussusceptum can be aided by walking the bowel and placing pressure distally on the collapsed
colon. Viability of the intestine can also be confirmed visually.
If there is evidence of necrotic or perforated bowel, conversion
to an open procedure should be performed at this time.
Reduction should commence with a combination of a distal and proximal approach. The “milking” or pushing action
similar to that of the open technique can be performed by
using the Johan grasper in the right hand immediately distal
to the mass with the jaws completely crossing the bowel and
gently squeezing.
Simultaneously a pulling technique on the proximal intussuscipiens with the alternate Johan grasper should be used.
The use of 5-mm instruments allows a broader coverage of
the bowel diameter and less trauma during this process.
Unlike the open procedure, more emphasis may be needed
on the pulling action than on the milking technique, and both
graspers may be used proximally to allow better traction.
The movements should be slow and gradual to avoid serosal
tearing of the intussuscepted bowel. These actions can be
repeated until complete reduction is performed and seen.
The reduced bowel should then be gently examined to
exclude the presence of a lead point such as a Meckel diverticulum that may require a laparoscopic-assisted resection
(via the umbilical port).
Port sites can be closed externally under laparoscopic
vision, followed by the umbilicus with an absorbable suture
and tissue glue applied to the skin.
Postoperatively the child should remain on nothing by
mouth until the return of gut function, which is dependent on
the duration, extent, and damage to the intestinal mucosa by
the intussusception rather than the operative technique.
Analgesia should be intravenous until oral fluids are
tolerated.
23.6 Alternatives
In a small infant 3-mm instruments can be used; however,
they tend to have shorter and sharper jaws, which may
increase the chance of iatrogenic injury to the already compromised bowel with minimal cosmetic benefit.
23.7 Highlights and Pitfalls
• Slow gentle movements are necessary to avoid iatrogenic
damage.
The pulling technique usually results in better success (as
•
opposed to the open technique).
• Gentle probing between the intussuscipiens and the intussusception with the blunt end of the Johan grasper may
release fibrinous adhesions and pressure between the
opposing bowel walls, which may prevent reduction.
• If conversion becomes necessary, this can be achieved by
extending the umbilical incision laterally to the right or
alternatively by a minimal focused incision placed to provide optimal access, depending on the laparoscopic
findings.
Suggested Reading
Bonnard A, Demarche M, Dimitriu C, Podevin G, Varlet F, François M,
et al. Indications for laparoscopy in the management of intussusception: a multicenter retrospective study conducted by the French
Study Group for Pediatric Laparoscopy (GECI). J Pediatr Surg.
2008;43:1249–53.
Hannon E, Williams R, Allan R, Okoye B. UK intussusception audit: a
national survey of practice and audit of reduction rates. Clin Radiol.
2014;69:344–9.
Pierro A, Donnell SC, Paraskevopoulou C, Carty H, Lloyd
DA. Indications for laparotomy after hydrostatic reduction for intussusception. J Pediatr Surg. 1993;28:1154–7.
Sklar CM, Chan E, Nasr A. Laparoscopic versus open reduction of
intussusception in children: a retrospective review and metaanalysis. J Laparoendosc Adv Surg Tech A. 2014;24:518–23.
Laparoscopic Cholecystectomy
Augusto Zani and Niyi Ade-Ajayi
Abstract
Cholelithiasis in the paediatric population is typically secondary to haemolytic disorders,
structural biliary tract anomalies, or previous illness/medical interventions of infancy and
early childhood. A proportion of cases are idiopathic. More recently, an increasing incidence of stone disease has been reported outside these traditional groups. This may reflect
easier access to abdominal sonography and other diagnostic tools such as magnetic resonance cholangio-pancreatography (MRCP) as well as an increase in childhood obesity, particularly in adolescent girls [1]. There is no good evidence for the treatment of asymptomatic
gallstones in otherwise well children as complication rates are low [2]. Surgery for a diagnosis of biliary dyskinesia is controversial and incidental cholecystectomy during another
procedure is inappropriate in the paediatric population. Conversely, symptomatic patients
with background conditions such as sickle cell disease and spherocytosis have a high risk
of complications and should, in general, be offered laparoscopic cholecystectomy (LC),
which has become the gold standard for intervention where the infrastructure and expertise
are available.
24
Keywords
Laparoscopic • Cholecystectomy • Gall bladder • Bile duct
24.1 General Information
Cholelithiasis in the paediatric population is typically secondary to haemolytic disorders, structural biliary tract anomalies, or previous illness/medical interventions of infancy
and early childhood. A proportion of cases are idiopathic.
More recently, an increasing incidence of stone disease has
been reported outside these traditional groups. This may
reflect easier access to abdominal sonography and other
diagnostic tools such as magnetic resonance cholangio-
A. Zani
Division of General and Thoracic Surgery, The Hospital for Sick
Children, Toronto, ON, Canada
N. Ade-Ajayi (
Department of Paediatric Surgery, King’s College Hospital NHS
Foundation Trust, London, UK
*)
pancreatography (MRCP) as well as an increase in childhood
obesity, particularly in adolescent girls [1]. There is no good
evidence for the treatment of asymptomatic gallstones in
otherwise well children as complication rates are low [
Surgery for a diagnosis of biliary dyskinesia is controversial
and incidental cholecystectomy during another procedure is
inappropriate in the paediatric population. Conversely,
symptomatic patients with background conditions such as
sickle cell disease and spherocytosis have a high risk of complications and should, in general, be offered laparoscopic
cholecystectomy (LC), which has become the gold standard
for intervention where the infrastructure and expertise are
available.
Paediatric LC is predominantly carried out in the elective
setting following biochemical and radiological investigations to exclude bile duct stones. Cholecystitis, cholangitis,
gall stone pancreatitis, and other acute presentations are
2].
© Springer-Verlag Berlin Heidelberg 2017
M. McHoney et al. (eds.), Color Atlas of Pediatric Anatomy, Laparoscopy, and Thoracoscopy,
DOI 10.1007/978-3-662-53085-6_24
165
166
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A. Zani and N. Ade-Ajayi
generally managed conservatively with the aim of delayed
surgery. This may be preceded by diagnostic/therapeutic
endoscopic retrograde cholangio-pancreaticography
(ERCP). LC has been described in the outpatient setting for
children and, in expert hands, overall morbidity is low.
24.2 Working Instruments
• 10 mm Hasson port
• 5 mm ports × 3
• 30° 5-mm telescope
• 5 mm bowel graspers × 2
• 5 mm hook diathermy
• 5 mm Maryland forceps
• 5 mm Liga or polymer locking clips
• 5 mm scissors
• 10 mm retrieval bag
24.3 Positioning, Port Siting,
Ergonomic Considerations
and
The patient is positioned supine and secured to the operating
table (Fig. 24.1). There are two widely used setups to perform this operation: the French (Dubois) and the American
(Reddick Olsen) positions. In the French position, the patient
lies in the lithotomy position, the operating surgeon stands
between the patient’s legs, the assisting surgeon is on the
patient’s left side, and the scrub nurse on the right. In the
American position, the patient lies supine with arms in
abduction, the operating surgeon stands on the patient’s left
side with the scrub nurse to his left, and the surgical assistant
is on the patient’s right. From an ergonomic perspective,
there is little difference between the two approaches in a
modern dedicated minimally invasive surgery suite [
authors favour a modification of the American position: the
patient is supine with arms down on either side with one surgical assistant to the left of the operating surgeon for the
camera and another (or a robot arm) to the right of the patient
for gallbladder retraction.
Port position depends on various factors including
patient age and size, liver size, and gallbladder location
and, importantly, surgeon preference (Fig. 24.2a, b). A
trans- or infraumbilical port is placed using the open technique. In adolescents with a high body mass index, an optical trocar inserted in a suitable peri-umbilical position may
facilitate safe access. Once the port is inserted and the camera introduced, the surgeon can judge where to place the
working ports. The authors favour three port “subcostal”
placement: two ports are positioned in the right subcostal
position; the most lateral for gallbladder retraction over the
liver to expose the operating field. Medial to that, the surgeon’s left-hand operating port and finally an epigastric
port, to the left of the falciform ligament for the right operating hand.
3]. The
monitor
Assistant
24 Laparoscopic Cholecystectomy
Main
monitor
167
Anaesthetic
equipment
and team
Slave
Surgeon
Scrub
nurse
Camera
assistant
Instruments
Fig. 24.1 Operating room set-up
168
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a b
Fig. 24.2 (a) Illustration of port positions. (b) Digital image of port positions
A. Zani and N. Ade-Ajayi
24.4 Relevant Anatomy
The safety of laparoscopic cholecystectomy depends on the
correct identification and interpretation of the relevant anatomy (Fig. 24.3a, b). The most important structures to identify are related to Calot’s triangle, also known as the
hepatobiliary or cystohepatic triangle. This is an anatomic
space bordered by the common hepatic duct medially, the
cystic duct laterally, and the upper aspect of the cystic artery/
inferior border of the liver superiorly. It is the key landmark
to ensure safety during LC. Dissection of Calot’s enables the
surgeon to identify the cystic artery as it crosses the triangle
from medial to lateral sides. The blood supply of the common bile duct is usually derived from cystic and pancreaticoduodenal artery branches. It is therefore prudent to ligate the
cystic artery at its gallbladder end rather than too close to the
right hepatic artery.
Calot’s triangle also contains a lymph node, called
Mascagni’s or Lund’s node, that can be enlarged in patients
who had cholecystitis or cholangitis, and can be safely
removed during cholecystectomy if required for a clear view
24.4).
(Fig.
Variations in vascular anatomy are common. These
include a right hepatic artery (RHA) arising from the superior mesenteric artery and a left hepatic artery (LHA) from
the left gastric artery. Other variations include an accessory
right hepatic artery, a particularly tortuous right hepatic or
common hepatic artery that could be mistaken for the cystic
artery.
Variations in ductal anatomy are also frequent with leftsided anatomy being more consistent than the right; low
insertion of the right posterior sectoral duct in which the
right hepatic duct may be absent. The right posterior sectoral
duct may go behind the right anterior and join the left anterior sectoral duct. It may also insert into the neck of the gallbladder. The cystic duct may join the right hepatic or right
sectoral duct. The cystic duct may run behind the common
bile duct, entering on the left, rendering the common bile
duct vulnerable to injury.
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