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Experience with the Exclusive Use of 5 mm Instruments for Paediatric Laparoscopy

Anies Mahomed, Stephen Adams
Department of Paediatric Surgery, Royal Alexandra Children’s Hospital, Brighton, United Kingdom

 

Correspondence 

Mr Anies Mahomed
Department of Paediatric Surgery
Royal Alexandra Children’s Hospital
Eastern Road, Brighton, BN2 5BE, United Kingdom
Tel: 01273 696955 / Fax: 01273 523120
E-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.  

 

Abstract

Background: For a paediatric surgical unit offering minimally invasive surgery it would seem essential to have both 3 and 5mm instruments. For a multitude of reasons a complete set of 3mm instruments was unavailable in our institution, for a period, thus making surgeons completely reliant on 5mm sets to deliver the service. Described are the technical modifications implemented to enable safe usage of 5mm sets in paediatric patients

Material and Method: Presented is a single surgeon’s experience between January 2004 and January 2008. Adaptations that were utilised, included amongst others: appropriate port placement and fixation to body wall using a sleeve designed from suction tubing, optimising CO2 insufflation pressure and utilising camera guided decompression of intra-abdominal cysts to increase operating space, utilising monopolar hook diathermy device with its fine tip for almost all dissection and diathermy control, use of external traction sutures to limit the number of ports and adjusting zoom control on the videocamera to improve the width of view.

Results: A total of 157 laparoscopic cases were performed during the period of review. These included 44 appendicectomies, 30 fundoplications, 18 cholecystectomies and 11 transperitoneal nephrectomies/heminephrectomies. Ages ranged from 2 months to 19 years (mean 9.05 years), weight from 3.1 to 120 kg and 8.3% of all cases were less than 1 year of age. In the 2 largest groups (appendicectomy and fundoplications) mean operating times were 45mins (range 35 -100 min. SD 17.23) and 124mins (range 60-315 min. SD 48.43) respectively. There was no mortality and no conversions. Two cases complicated, both these children made uneventful recoveries after further surgery.

Conclusions: In experienced hands 5mm instruments pose no impediment to safely undertaking a near comprehensive range of laparoscopic procedures across all ages in children. However there are limitations as is apparent by our lack of progress with advanced thoracic surgery such as that involving lung resection and tracheo-oesophageal fistula repair in infants. For almost all other surgery in children, with subtle modification, 5mm sets may be employed with relative safety.

Key words: laparoscopy, infant, paediatric, 5mm sets, adaptation of technique

 

Introduction

For a paediatric surgical unit offering minimally invasive surgery it would seem essential to have both 3 and 5mm instruments. For a multitude of reasons in our institution a complete set of 3mm instruments was unavailable thus making surgeons reliant on 5mm sets to deliver the service. Described are the technical modifications necessary to enable safe usage of 5mm sets in paediatric practice. We report our experience in the exclusive use of 5mm instruments for all paediatric laparoscopy over a 4 year period.

Also we reflect on what is achievable, to assess both poten- tial advantages and limitations in the exclusive use of 5mm instrumentation in paediatric practice.

Material and Method

Presented is a single surgeon’s experience between January 2004 and January 2008. Details of all cases performed were recorded prospectively in an MS Excel spreadsheet. Data were analysed for basic demographic parameters, range of procedures performed and outcome measures including: operating time, conversion rate and complications.

Technique

Adaptations in technique that were necessary included: appropriate port placement and fixation to body wall using a sleeve designed from suction tubing, regulation of intra-abdominal/thoracic extension of ports to maximise view and manoeuvrability and to minimise the fulcrum effect ( fig. 1), optimising CO2 insufflation pressure and utilising camera guided decompression of intra-abdominal cysts to increase operating space, use of external traction sutures instead of additional ports ( fig. 2), adjusting zoom control on the videocamera to improve the width of view, utilising a monopolar hook diathermy device with its fine tip for dissection and haemostasis, selective use of needle type and suture length to ease intracorporeal knotting and utilising a laparoscopic assisted technique to externalise bowel when complex and time consuming intra-corporeal procedures such as cre- ating anastamosis were anticipated ( fig. 3).

3.3 2009-5-1

Fig. 1. Siting ports well away the target organ. In this case dressings indicate where ports were placed in a 5 kg baby undergoing a fundoplication procedure.

3.3 2009-5-2 3.3 2009-5-3
Fig. 2. This stenotic segment (arrowed) in an infant was delivered through a discreet Pfannensteil incision prior to resection, primary anastamosis and return to the abdominal cavity. Fig. 3. Duodenotomy being held open by percutaneous stay sutures during performance of a congenital web resection.

Results

A total of 157 laparoscopic cases were performed during the study period. These included 44 appendicectomies, 30 fundoplications (including 3 Heller myotomies), 18 cholecystectomies and 11 transperitoneal nephrectomies/heminephrectomies. Miscellaneous cases (table 1) totalled 54 patients and included 18 different procedures, almost all therapeutic, ranging from thoracoscopic to neonatal surgery. Ages ranged from 2 months to 19 years (mean 9.05 years), weight from 3.1 to 120 kg and 8.3% of all cases were less than 1 year of age. In the 2 largest groups (appendicectomy and fundoplications) mean operating times were 45mins (range 35 -100 min. SD 17.23) and 124mins (range 60-315 min. SD 48.43) respectively. There was no mortality and no conversions. Two cases complicated and were taken back to theatre; a 15 year old with 32 previous laparotomies developed delayed ileal perfo- ration following cholecystectomy and a 2 year old with omental prolapse through an umbilical camera port site following fundoplication. Both these children made an uneventful recovery.

Table 1: Miscellaneous conditions 

Procedure

Number

Palomo Procedure

Impalpable Testes: Fowler Stevens

Vanishing Testes

Cystectomy

Cyst Decapsulation

Thoracoscopic Empyema Drainage

Adhesiolysis/Small Bowel Obstruction

Rectopexy

Resection Omental Torsion

Bilateral Thoracoscopic Sympathectomy

Diagnostic Abdominal Pain

Meckels Diverticulectomy

Abdominal Wall Hernia

Gastropexy

Small Bowel Resection

Small Bowel Biopsy

Urachal Cyst Excision

Duodenal Web Resection

16

11

4

1

3

3

2

2

2

1

1

2

1

1

1

1

1

1

Total

54

 

Discussion

When limited by the availability of solely 5mm laparoscopy sets in a paediatric environment, several technical adaptations have to be made to allow for minimally invasive surgery to be undertaken safely. Most of the changes are subtle and are especially applicable to surgery in infants because of their smaller dimensions. Space is perhaps the greatest limiting factor to safe performance of laparoscopic surgery in the very young, but this can be optimised in several ways.

CO2 insufflation of the abdominal cavity can be maximised. Due to the pliability of the paediatric abdominal wall higher inflation pressure translates into increased intra-cavity gas volume and additional operating space. We found that incremental inflation pressure increases up to 12mmHg can be employed in infants with no clinically untoward effect on venous return, respiratory or metabolic status [1, 2].

In certain situations such as giant cysts (ovarian, splenic and miscellaneous) additional operating space is created by percutaneous decompression of these structures under laparoscopic guidance prior to placement of working ports. The same principle can be applied to massively distended gas filled loops of bowel which may obscure the view [3]. However, in this context, puncture sites need to be comprehensively closed with an intra-corporeal stitch.

Employing external traction sutures increases both internal and external working space by reducing the number of working ports. If strategically placed these are unobtrusive, help reduce instrument clutter and free up hands. These are also less traumatic to the skin and can be adjusted to deliver the appropriate amount of traction.

Critical also to task performance in all cases but particularly so in infants is maintenance of an appropriate intra to extra corporeal instrument shaft ratio. Due to the fulcrum effect, if more than 50% of the instrument passes beyond the body wall then any movement of the hands externally will produce exaggerated but less forceful movements of the tip. Conversely if less than 50% of the instrument is internal then the tip movements will be reduced but will have greater force than the hand movements. Also directly relevant to this is the degree of port extension into the body cavity which can be regulated by the manner of fixation of this device to the body wall. For this purpose a plastic sleeve fashioned from suction tub ing is very useful as it limits both internal and external excursion of the ports. Limited internal extension allows for the camera to be held further from the target organ and if set at its maximum zoom out capability makes a significant difference to the field of view. Furthermore a fixed movement of the camera subtends a small angle in the visible field if the movement occurs at a distance and a large angle if close to the object. Thus appropriate zoom adjustment when working within a confined space could have a substantial impact on task performance.

Port fixation is particularly pertinent to infant surgery as the body wall is very thin and extrusion is a common problem. Ports should be placed to achieve a manipulation angle of between 45 o and 70 as execution of complex tasks such as intra-corporeal knotting is eased. o The monopolar hook diathermy device with its fine tip is ideally suited to undertake dissection in confined spaces. In this series, mesoappendiceal and perioesophageal dissection for appendicectomy and fundoplication were exclusively performed using hook diathermy, irrespective of size of patient. In our experience it is safe and since reusable, integral to cost saving.

Intracorporeal suturing can be tedious particularly in smaller infants. Cutting sutures to an appropriate length to match the size of the patient facilitates the speed of knotting as does selection of an appropriate needle. In some contexts it is sensible to use a curved rather than a ski needle as the former has a narrower transverse diameter [3]. We have found curved needles to be less harmful to the caudate lobe of liver when completing an anterior fundoplication and would elect to use these in preference to sutures mounted on ski needles in infants. Another useful procedure in infants is utilising a laparoscopic assisted technique to externalise the bowel when undertaking resective surgery and anastamosis [4]. Convenient for this purpose is extension of the transumbilical optical port-site to enable delivery of the bowel. A judicious repair of this site should leave no noticeable scar as would a discreet Pfannensteil incision [5].

Whilst adaptation to technique is necessary when using 5mm instruments in infants, there are some clear advantages. For instance, we have managed cost savings by sharing a centralised consumables procurement process with adult services as suppliers tended to offer greater discounts on bulk purchase [6]. At a practical level, passage of suture mounted needles into body cavities is uncomplicated and there is rarely a need for direct passage through the anterior wall or for placement of larger ports. Most ski needles readily pass down a 5mm port as do some curved needles. Another practical advantage to 5mm instruments is their wider grasp which allows for superior manipulation and retrieval of internal structures such as the appendix. Smaller instruments are limited by the excursion of the jaws making the execution of certain tasks more difficult. In addition use of 5 mm sets allow for a wider choice of instrumentation particularly haemostatic devices such as liga clip applicators, ultrasonic dissectors and bipolar devices, many of which are currently not available in a 3mm size. Finally, proficiency in applying 5mm instruments to the paediatric context translates into improved standardisation and streamlining of laparoscopic sets which generally aids theatre efficiency. 

Conclusion

In experienced hands 5mm instruments pose no impediment to safely undertaking a near comprehensive range of laparoscopic procedures across all ages in children. However there are limitations as is apparent by our lack of progress with advanced thoracic surgery such as that involving lung resection and tracheo-oesophageal fistula repair in infants. For almost all other surgery in children, with subtle modification, 5mm sets may be employed with relative safety.

 

References 

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  3. MacKenzie RK, Mahomed AA: The benefits of a curved suture needle in laparoscopic partial fundoplications in infants.. Paediatric Surgery International 2004 Jun; 20(6):474-5.
  4. Simon T.,Orangio G.,Ambroze et al. : Laparoscopic-assisted bowel resection in pediatric/adolescent inflammatory bowel disease: Laparoscopic bowel resection in children. Diseases of the Colon and Rectum, Oct 2003, vol./is. 46/10(1325-1331)
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