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302 Pediatric Genitourinary Trauma
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Grade V injury is one in which the renal tissue is separated into multiple renal fragments
(“shattered kidney”). It can be dicult to determine which segments of tissue are poorly perfused as a result of severe contusion and which
segments have been completely devascularized.
Massive bleeding and extravasation within
Gerota’s fascia is common. Major hilar injury
leading to devascularization also constitutes a
grade V renal injury.
Management
e goals of care focus on preservation of renal
tissue and renal function while minimizing the
morbidity and risk of mortality posed by the
injury. Most blunt renal injuries can be managed
non-operatively, particularly since the majority are low grade (I–III). Conservative management usually involves bed rest until hematocrit
measurements have stabilized and hematuria
has resolved. Monitoring of vital signs is imperative to assess hemodynamic stability. Although
reevaluation with ultrasound can be used to
detect any expanding urinoma or hematoma,
CT imaging is indicated if there is deterioration
in the child’s clinical condition or hemodynamic
instability which might necessitate surgical intervention. Conservative management is highly successful in preventing long-term complications
such as hypertension, loss of renal function and
hydronephrosis.
Indications for surgery are frequently relative
and include:
●
Hemorrhage: Intervention may be required
to control active hemorrhage which is caus-
ing hemodynamic instability (e.g. pulsatile
hematoma on CT). Selective angioemboliza-
tion may be eective in stopping bleeding
of minor severity but surgical intervention
should be considered if this is unsuccess-
ful or the child is requiring repeated blood
transfusions.
●
Urinary extravasation: A minor degree
of contained urinary extravasation may
be managed conservatively and monitored
whereas larger and/or persistent collections
may require percutaneous drainage. Partial
disruption of the uretero pelvic junction
(UPJ) may be amenable to ureteral stent
placement whereas complete disruption
may require either percutaneous drainage
as a temporizing measure or immediate
surgical repair.
●
“Shattered kidney” (grade V injury): Even
in a hemodynamically stable patient, removal
of a non-functioning “shattered” kidney may
be justied to hasten recovery and reduce
long-term complications. In the presence
of other intra-abdominal injuries requiring
laparotomy, a “shattered” kidney should be
removed concurrently.
●
Hilar injury: e prospect of successful
revascularization is minimal when blood
supply is compromised and warm ischemia time exceeds one hour. However, this
relatively desperate attempt to conserve the
kidney may be justied in very rare circumstances, such as a solitary kidney or bilateral
renal injuries.
At the time of operation, the initial priority is
to gain vascular control of the renal pedicle and
aorta. Once hemostasis has been achieved, the
kidney and collecting system can be inspected,
devitalized tissue can be debrided and any defects
in the parenchyma closed and covered wherever
possible. In certain cases partial nephrectomy
may be a better way of preserving the remaining viable renal tissue. Urinary extravasation
can be managed with a ureteral stent or nephrostomy tube. As stated above, emergency repair of
a severe pedicle injury or thrombosis is unlikely
to result in preservation of the kidney since
the warm ischemic time will already have been
exceeded while the child was being evaluated and
resuscitated prior to surgery. Penetrating trauma
is most commonly the result of gunshot or stab
wounds and is, therefore, largely conned to the
older age group. Because these injuries tend to
be more severe and involve other organs there is
usually a greater requirement for blood transfusion and stronger likelihood of nephrectomy.
While stab wounds and low-velocity gunshot
wounds may cause localized injury, high-velocity
gunshot wounds are associated with blast eect
tissue damage, which may make it more dicult
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to determine the true extent of injury on initial
evaluation.
Outcomes and Complications
The most serious early complication of renal
trauma is acute bleeding, with the highest risk
being immediately following the injury. Even
if there is a low suspicion for severe injury
the child should be admitted for bed rest and
serial hemoglobin/hematocrit monitoring.
Secondary hematuria is not uncommon within
the first few days and weeks of the injury.
Although it is rarely of sufficient severity to
require active surgical intervention secondary
hematuria should be monitored carefully to
rule out the development of an arteriovenous
malformation or pseudoaneurysm. This risk is
highest in patients with higher grade trauma
who are managed conservatively. Infection is
another potential early complication, particularly if there is a significant urinoma and a
substantial amount of devitalized renal tissue.
Initially, it may be difficult to distinguish on
ultrasound between old blood products, resolving urinoma, and possible abscess formation
but serial imaging should enable this distinction to be made. Outcomes following penetrating injuries to the kidney are generally worse
than for blunt injury. The most significant
late complications of renal trauma are hypertension and loss of renal function. The risk
of hypertension is likely to be higher when a
significant amount of devascularized renal tissue has been left in place. The true incidence
of hypertension is difficult to assess because of
the lack of reliable long-term data but the available evidence indicates it is relatively rare with
an incidence of 1–2%. Nevertheless, monitoring of blood pressure is generally advisable in
view of the small risk of hypertension, which
might indicate late complications requiring
medical or surgical management.
Full recovery of function can usually
be expected following low-grade trauma
(grades I–III), whereas grade IV and V injuries are more likely to result in some permanent reduction in renal size and function.
Ureteric injury 303
Figure 22.3 A linear scar in the left kidney per-
sisting 3 months following a grade III injury.
Surprisingly, even segments or renal parenchyma in a shattered kidney may sometimes
retain their blood supply and viability and
become realigned in a functional configuration. However, the prognosis of severe injuries can be adversely affected by the presence
of persisting morphological changes including scars, cysts, or segmental hydronephrosis
(Figure 22.3). Nuclear medicine studies, such
as 99m Tc dimercaptoacetyltriglycine (MAG3)
or 99m Tc dimercaptosuccinic acid (DMSA) are
helpful in monitoring functional recovery over
time and in guiding a decision on whether to
perform reconstruction or nephrectomy in the
case of an injured kidney, which has been stabilized by nephrostomy drainage (Figure 22.4).
If the contralateral kidney is healthy, the
risk of post-traumatic renal failure is low.
Statistically, the risk of injuring a solitary kidney, even during contact sports, is extremely
low so there is little justification for restricting
normal activities and sports.
URETERIC INJURY
Injuries to the ureter are rare and usually result
from penetrating trauma or iatrogenic damage –
for example during ureteroscopy, tumor resection,
or laparoscopy.
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Figure 22.4 A 17-year-old boy experienced a
grade IV renal laceration with UPJ disruption
following a snowmobile accident. An indwelling ureteral stent could not be placed and a
nephrostomy tube was used as a temporizing
measure. Delayed MAG-3 test demonstrated
only 10% function and an elective laparoscopic
nephrectomy was performed.
Evaluation
Gross hematuria is not necessarily present even
aer a signicant ureteral injury. A high index of
suspicion must therefore be maintained to avoid
missing the diagnosis. Delayed computerized
tomography (CT) imaging with use of contrast
to visualize the entire collecting system is most
helpful in this regard.
ureteral repair is the creation of a tension free,
spatulated anastomosis. Devitalized segments
should be excised to ensure that healthy ureteral
tissue is used for the anastomosis. Depending
on the level and extent of the injury the options
include; spatulation with end-to-end anastomosis, psoas hitch and Boari ap. For more extensive
injuries ureteral substitution by ileal interposition may have to be considered.
Outcomes and Complications
If the injury is not recognized or is not correctly
managed the primary complication is urinary
extravasation into the retroperitoneum resulting
in urinoma or abscess formation. Long-term outcomes following repair are generally favorable –
although the published data are sparse.
BLADDER INJURY
Traumatic injuries to the bladder are rare in this
age group and are usually associated with other
severe injuries including pelvic fractures. Motor
vehicle accidents are the leading cause of blunt
pelvic trauma and bladder injury. By comparison to an adult, the bladder in a child is located
in a more vulnerable position which is higher
in the abdomen and less protected by the bony
pelvis. Penetrating injuries of the bladder are
exceedingly rare in children and are usually
iatrogenic, for example inadvertent damage to
the bladder wall during herniotomy or dicult
appendectomy.
Management
Management of ureteral injuries in children
generally mirrors the management in adults
and should be individualized according the site
and nature of the injury. Prompt surgical repair
is indicated for injuries which are recognized
immediately or shortly aer they have occurred.
However, a period of temporizing nephrostomy
drainage is preferable when the diagnosis is
delayed by > 1 week, with denitive repair being
delayed for a few months. e key principle of
Evaluation
e hallmark signs of bladder and urethral injury
are suprapubic pain, tenderness, inability to urinate, gross hematuria, and blood at the urethral
meatus. Indications for bladder imaging include
gross hematuria and/or urinary retention in conjunction with a pelvic fracture.
e initial CT scan may not be adequate to
completely characterize bladder injury, although
delayed imaging aer bladder lling may be
helpful when looking for possible extravasation.
Urethral injury / Management 305
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Other imaging modalities which may be useful include cystography or intravenous pyelography. CT cystography is sensitive and specic
but involves signicant radiation exposure and
should be used judiciously.
Management
Free leakage of urine into the peritoneum is
indicative of an intraperitoneal injury for which
surgical intervention is required in the majority
of cases. However, non-operative management
can be used successfully for small, isolated bladder injuries. Extraperitoneal perforation, with
extravasation conned to the perivesical space,
can usually be managed by a period of continuous catheter drainage. However, if there are other
concurrent injuries requiring surgical intervention this may be an opportunity to close the bladder defect and hasten recovery.
Outcomes and Complications
Early complications include persistent gross
hematuria, clot retention, and pelvic abscess.
Hematuria is typically self-limiting but may
require intermittent or continuous irrigation.
Abscess or urinoma can be drained percutaneously. Large intraperitoneal injuries may be
complicated by peritonitis, paralytic ileus and
metabolic disturbance, such as hyponatremia,
hypokalemia, and elevated serum urea and creatinine. Late complications are uncommon but can
include urinary stula, persistent lower urinary
tract symptoms or persistent incontinence.
URETHRAL INJURY
ese are generally conned to males and can
result from either direct blunt trauma to the urethra or injuries associated with pelvic fracture. In
adults, the posterior urethra is supported by the
prostate but in boys the prostate has not yet developed so that when the pelvic ring is disrupted,
shear forces can disrupt the pelvic oor and drag
the membranous urethra apart from the bladder
and prostate. Straddle injuries typically result
from falls on bicycles, playground equipment and
bars, and fences. e mechanism of injury occurs
when the urethra and surrounding corpus spongiosum are crushed against the pubic rami.
Evaluation
e signs of urethral injury are an inability to
urinate, gross hematuria, and blood at the urethral meatus.
A retrograde urethrogram is widely regarded
as the best imaging study for visualizing the urethra. Oblique views are necessary to look for posterior extravasation and demonstrate complete
continuity of the urethra.
Management
Initial management of urethral injury involves
bladder drainage and radiological evaluation.
A Foley catheter may be placed into the bladder
under radiographic guidance if the urethra is
intact with only a small tear. Alternatively, if the
patient has already voided and examination does
not suggest urethral injury, a urethral catheter
can be placed immediately without a retrograde
study. If a catheter has been placed previously, it
should not be removed. In such cases, an infant
feeding tube can be introduced alongside the
catheter in order to facilitate the urethrogram
and assess injury.
e management of injuries to the bulbar
or anterior urethra is typically straightforward
and consists of either observation or urethral
catheter drainage alone. e primary risk is the
later development of a urethral stricture. e
initial management of posterior urethral injuries is more complex. If possible, placement of a
urethral catheter will help to align the urethra
as well as providing bladder drainage. However,
this may not be feasible if there is complete disruption and the urethra is no longer in continuity. As in adults, the management of these
severe injuries is controversial. e options
include prolonged suprapubic tube drainage followed by delayed urethroplasty or, alternatively,
immediate exploration with debridement and
306 Pediatric Genitourinary Trauma
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primary realignment. If a delayed repair strategy is employed, continuous drainage should be
maintained for at least 6–8 weeks before urethroplasty is attempted. Injuries to the urethra
which involve the bladder neck and/or prostate
require immediate intervention to minimize
the risk of long-term complications, such as
stricture, incontinence, and stula. Fortunately,
such injuries are very uncommon. Traumatic
injuries of female urethra are extremely rare
because of the shorter length of the urethra
and the more protected location. ese injuries typically occur in conjunction with severe
pelvic fractures and vaginal injury and may
consist of either transverse disruption or a longitudinal tear. Conservative management can
be employed if the bladder neck is intact and a
urethral catheter can be passed into the bladder. However, immediate surgical repair is indicated if the bladder neck is transected or the
vagina is also involved in the injury. In some
cases, the preferred management may comprise
a period of suprapubic catheterization followed
by delayed repair. Long-term outcomes are generally poor because a traumatic force which is of
sucient severity to cause damage to the female
urethra usually causes extensive damage to the
tissues supporting the urethra as well as causing
pelvic fractures.
INJURIES TO THE EXTERNAL
GENITALIA
In the neonatal period, penile injuries are usually
iatrogenic and related to circumcision. In older
boys, the penis or prepuce may become trapped
in a zipper – with resultant contusion or pressure
necrosis of the prepuce. Other forms of penile
injury include dog bites and high-ow priapism
associated with a traumatic arteriovenous stula
secondary to perineal trauma.
e testis may be injured as a result of a bicycle
crossbar injury in which the testis is compressed
against the pubic ramus, causing disruption of
the tunica albuginea. Other causes include kicks
to the scrotum during sporting activity or rough
play and ghts. Traumatic genital injuries are
rare in girls and typically result from straddle
injuries. Because of the proximity of the urethra
and vagina, traumatic injuries of the external
genitalia or urethra should prompt an evaluation for associated vaginal injuries. A high index
of suspicion of possible sexual abuse is required
whenever a girl presents with a genital injury,
particularly if the nature of the injury seems discordant with the history.
Evaluation and Management
Outcomes and Complications
Stricture formation is the most significant
complication following urethral injuries.
Experience with urethral stricture and urethroplasty in children is limited, but the management options are similar to those in adults.
Optical urethrotomy may be appropriate for
short, well defined strictures. For more extensive strictures the choice usually lies between
stricture resection and end to end anastomosis
or urethroplasty utilizing onlay grafts of buccal
mucosa or other materials. A perineal approach
usually provides optimal exposure. Injuries to
the posterior urethra which involve the bladder neck, prostatic urethra, and sphincteric
complex, carry a high risk of serious long-term
complications, notably urinary incontinence
and impotence.
Excessive removal of penile skin due to neonatal
circumcision can be managed conservatively in
the majority of cases but later reconstructive surgery (including the use of free skin gras) may
occasionally be required if there has been extensive excision of penile sha skin. Circumcision
injuries involving the glans or urethra are rare
but may require complex reconstruction.
Supercial penile contusions and lacerations
can typically be managed with topical antibiotic
ointments, but may require minor debridement
and skin approximation depending on the mechanism and severity of the injury. Zipper injuries
usually occur in uncircumcised boys and may be
treated using mineral oil to release the trapped
skin from the zipper or dividing the zipper with
bone cutters. Genital injuries caused by animal
bites should be assessed under anesthesia to fully
assess the extent of trauma and broad spectrum
Injuries to the external genitalia / Complications 307
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antibiotics and tetanus prophylaxis should be
administered. High-ow priapism may be managed non-operatively because of the likelihood of
spontaneous resolution within days to weeks aer
injury. If conservative measures fail, embolization
with autologous clot is the preferred treatment.
In cases of scrotal trauma, ultrasound is an
excellent investigation to assess any testicular injury. Early scrotal exploration should be
undertaken if there is clinical or ultrasound evidence of testicular rupture or a signicant tear in
the tunica albuginea (Figure 22.5). In rare cases
of penetrating scrotal injury a detailed examination is required to determine the depth of
penetration prior to treatment by cleansing and
debridement.
Operative management is seldom required
for uncomplicated genital trauma in young
girls. However, sexual abuse or assault is implicated in up to 25% girls presenting with genital injuries. In these circumstances cystoscopy,
vaginoscopy, and rectal examination should
be performed to fully evaluate any associated
injuries. For more extensive vaginal lacerations,
primary repair should be performed if possible
to reduce the rate of vaginal stenosis and urethrovaginal stulae.
Complications
Acute complications of penile trauma include
bleeding and infection, particularly in cases of
animal bites. Late complications of penile injury
include penile entrapment (cicatrix), meatal stenosis, and unsatisfactory cosmetic outcomes.
e outcome of circumcision injuries is generally excellent, although a very small proportion
will require further surgery to provide adequate
skin coverage of the penile sha. Penetrating
scrotal injuries pose a risk of infection but this
can be considerably reduced by adequate cleansing, debridement, and the use of broad-spectrum
antibiotics. Inadequate surgical management of a
signicant injury to the testis may lead to a prolonged recovery and convalescence.
e most signicant complication following
vaginal trauma is stricture – although this is usually conned to severe injuries. Follow-up into
puberty is essential to exclude possible stenosis or
hematocolpos, especially in patients with extensive urethrovaginal injuries.
Figure 22.5 A 12-year-old boy experienced a
straddle injury with signicant scrotal pain and
hematoma. Testicular ultrasound suggested
a rupture and exploration is demonstrating a
1 cm tear in the tunica albuginea. 4-0 PDS was
used to reapproximate the edges and there was
no atrophy on follow-up.
KEY POINTS
●
Potentially serious renal trauma can
occur in children aer seemingly
innocuous injury.
●
All children with suspected renal
trauma should be admitted for observation, imaging, and evaluation.
●
Most cases of renal trauma can be
managed conservatively, but grade
IV–V injuries are more likely to require
intervention.
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●
After recovery from the acute injury,
blood pressure should be monitored.
●
The risk of significant injury to a
solitary kidney is extremely low and
does not usually justify any restrictions on everyday life or sporting
activity.
●
Extraperitoneal bladder injuries can
be managed conservatively with catheter drainage whereas intraperitoneal
injury is an indication for surgical
repair.
●
Surgical management of post-traumatic
urethral strictures should only be
undertaken by an experienced pediatric or reconstructive urologist.
●
e possibility of sexual abuse should
always be considered in any child presenting with an injury to the external
genitalia.
FURTHER READING
Americal Urological Association Guidelines on
UroTrauma. 2017. https://www.auanet.org/
guidelines/urotrauma-guideline#x3296
Buckley JC, McAninch JW. Pediatric renal inju-
ries: management guidelines from a 25-year
experience. J Urol. 2004;172(2):687–690,
discussion 90.
Buckley JC, McAninch JW. The diagnosis, man-
agement, and outcomes of pediatric renal
injuries. Urol Clin North Am. 2006;33(1):33–
40, vi.
McAleer IM, Kaplan GW, LoSasso BE.
Congenital urinary tract anomalies in pediatric renal trauma patients. J Urol. 2002;168(4,
Pt 2):1808–1810, discussion 10.
Santucci RA, McAninch JW, Sar M, Mario
LA, Service S, Segal MR. Validation of the
American Association for the Surgery of
Trauma Organ Injury Severity Scale for the
Kidney. J Trauma. 2001;50(2):195–200.
Laparoscopic Paediatric Urology
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KARLY ZAHER, SARA LOBO and IMRAN MUSHTAQ
Topics covered
23
Overview of benets and limitations of
laparoscopic surgery in paediatric urology
Robotic surgery – Benets and limitations
Patient selection
Fundamentals of technique: Robotic and
non-robotic
Procedures, indications and outcomes
INTRODUCTION
e role of laparoscopy in paediatric urology was
initially limited to diagnostic indications, such
as the investigation of impalpable testes. In 1976,
Cortesi was the rst to report the use of laparoscopy to perform a therapeutic procedure – in the
treatment of crypthorchidism. e well-established benets of minimally invasive surgery
(MIS) have been further enhanced by the introduction of single site surgery. Innovations in
robotics have helped to overcome diculties
of working in limited spaces, permitted more
eective intracorporeal suturing and provided
three-dimensional (3D) visualisation and technology to eliminate manual tremor during
operative manoeuvres. These and other developments now enable the surgeon to operate
with far greater precision. The advent of MIS
Nephrectomy
Heminephrectomy
Pyeloplasty (including robotic pyeloplasty)
Adrenalectomy
Reconstructive surgery
Others
and robotics has provided new insights into the
anatomy of the urogenital tract and the conditions which affect it. It has also created challenging opportunities for minimally invasive
paediatric urologists to develop and introduce
innovative techniques for reconstructive surgery of the lower urinary tract.
BENEFITS AND LIMITATIONS
e acknowledged benets of laparoscopic
surgery in children include; reduced postoperative pain, shorter hospital stay, earlier return
to normal activities, improved cosmesis and
fewer wound complications. e smaller size
of the paediatric patient has the great advantage of allowing access to both the upper and
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lower urinary tract through the same port sites.
Laparoscopy also provides superior access to the
pelvis when operating, for example, on Müllerian
duct remnants, intra-abdominal testes and cloacal anomalies.
Paediatric urology encompasses a wide
spectrum of conditions (including a variety of
congenital anomalies and benign and malignant tumours) in patients ranging in age and
size from neonates to adolescents. In addition,
minimally invasive paediatric urologists face
the challenge of having to overcome the technical diculties inherent in operating in relatively
conned anatomical spaces (as in the retroperitoneoscopic [RP] approach). However, these
have been largely addressed by advances in camera technology and instrumentation. One of the
main drawbacks of laparoscopic surgery relates
to the high nancial costs of the technology and
equipment. Although these additional costs may
be partially oset by the economic advantage of
a reduced duration of hospital stay this consideration is of less importance in children than
adults. e complications of laparoscopic surgery in children, however, are broadly similar to
those in adults.
Robotic Surgery – Benets and
Limitations
Robotic surgery oers the benets of a minimally invasive approach whilst overcoming
some of the limitations of laparoscopic surgery.
Robotic surgery provides better visualisation
(with 3D, magnied images), superior ergonomics, tremor ltration and improved dexterity than traditional laparoscopy. However, a
major limitation of the Da Vinci robotic system
is the lack of tactile feedback – which requires
the operating surgeon to rely far more on visual
information. Another disadvantage is the large
capital outlay for the robot and ongoing costs
of consumables. ere are also risks which are
unique to the robotic system, such as human
error in operating the robot and problems arising from mechanical failure and malfunction
of the system. Despite recent modications and
upgrades, the bulky equipment still demands a
sizeable space for storage.
SCOPE OF MINIMALLY INVASIVE
SURGERY IN PAEDIATRIC UROLOGY
MIS now fulls a key role in paediatric urology
and used for a wide range of procedures including;
●
Nephrectomy and partial nephrectomy
●
Pyeloplasty
●
Adrenalectomy
●
Excision/marsupialisation of renal cysts
●
Pyelolithotomy and ureterolithotomy
●
Ureteric surgery including; excision of
ureteric stump aer partial nephrectomy,
ureteroureterostomy, ureterocalicostomy
●
Ureteric reimplantation
●
Investigation and management of impalpable
testis
●
Treatment of varicocele
●
Investigation and treatment of disorders of
sex development (DSD), e.g. gonadal biopsy.
Gonadectomy
●
Ovarian harvest for cryopreservation
●
Excision of Müllerian remnants
●
Lower urinary tract reconstruction including; bladder reconstruction (augmentation)
Monti/Mitrofano procedures, bladder neck
reconstruction and Sling procedure
Contraindications
Almost all conditions in paediatric urology are amenable to a minimally invasive approach and there are
very few contraindications. e use of MIS has also
been extended to the treatment of Wilms tumour. In
carefully selected patients the results of laparoscopic
total nephrectomy and lymphadenectomy are comparable to those of open surgery. With increasing
experience it is likely that large and more complex
Wilms tumours may prove to be amenable to MIS.
For the time being, however, most oncology centres
continue to favour open surgery for Wilms tumour.
Absolute contraindications to the use of MIS
include:
●
Signicant comorbidity (e.g. cardiac, respiratory disease)
●
Uncorrectable coagulopathies
●
Sepsis
Fundamentals of technique / Access 311
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FUNDAMENTALS OF TECHNIQUE
Anaesthesia
Anaesthesia for MIS procedures in children
requires endotracheal intubation and the use of
volatile and/or intravenous anaesthetic agents.
Because respiration in infants and young children is predominantly diaphragmatic, abdominal insuation during transperitoneal (TP)
surgery may compromise diaphragmatic excursion. Insuation pressures are therefore kept low
in infants and children. Younger children absorb
proportionately more CO2 than other age groups
during pneumoperitoneum formation and may
also experience greater transient elimination of
CO2 postdesuation. For this reason small children warrant particularly close monitoring during laparoscopy and the immediate postoperative
period. Underbody/overbody warming mats are
used routinely in children because they are at signicant risk of developing hypothermia during
laparoscopic surgery, especially with prolonged
operating times and a high gas ow.
Instrumentation
Laparoscopic instruments are available in a wide
range of sizes (2, 2.5, 3 and 5 mm) – although a
5 mm 30° laparoscope provides optimum visualisation for most procedures. e Hasson cannula,
which is used for the initial access, is available in
5 mm and 10 mm sizes. For diagnostic and reconstructive procedures (e.g. pyeloplasty), the 5 mm
cannula is sucient. However, a 10 mm cannula
is required when an Endopouch retrieval device is
required for specimen extraction. A wide assortment of reusable or disposable instrument trocars
are available. Bladeless trocars are generally safer
for use in children, in whom the abdominal wall
is more compliant and less muscular.
abdominal wall. However, the Hasson technique is
the preferred method for establishing a pneumoperitoneum in children. is is an ʻopenʼ proce-
dure in which the needle is inserted under direct
vision. A stab incision is made in the supraumbilical skin crease, and is enlarged along Langer’s
line. e underlying linea alba is then grasped and
opened transversely with scissors or a scalpel. e
peritoneum is opened in a similar manner and the
Hasson cannula introduced into the peritoneal
cavity and secured in place with a skin suture.
Because of the limited working space and relatively
large size of the liver, spleen and bladder in children, the insertion of trocars and instrumentation
should always be performed under direct vision
to avoid iatrogenic complications. For retroperitoneoscopic (RP) procedures a blunt approach is
used to access the retroperitoneum (Figure 23.1).
In common with traditional laparoscopic surgery, robotic surgery utilises small incisions and
insuation of the anatomical operative space
with CO
are inserted through access ports and are manipulated remotely by the operating surgeon seated at a
console. e system has three major components:
the robot (mobile tower with three or four arms,
including a camera arm and instrument arms),
the bedside cart (image processing equipment and
light source) and the console (where the surgeon
performs the surgery with two handpieces aided
by the use of two binocular lenses, which magnify
and create a 3D image) (Figure 23.2).
most widely – with instruments available in
. e robotic camera and instruments
2
e Da Vinci robotic surgical system is used
Access
ere are two methods of accessing the peritoneum: in the blind technique a Veress needle is
inserted into the peritoneal cavity via the skin
adjacent to the umbilicus through all layers of the
Figure 23.1 Port placement for a transperito-
neal laparoscopic nephrectomy.
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