Minimal Access Pediatric Surgery

 

In 1973, Drs Gans and Berci were the pioneers in pediatric laparoscopy. Next many surgeon performed pediatric laparoscopic surgery. Drs Gans and Berci initially performed laparoscopy (ie, peritoneoscopy) on 16 children (aged 1 d to 14 y), mainly for diagnostic purposes as well as for obtaining biopsies.

Adult surgeons sought the smaller telescopes and instruments that were produced for pediatric MAS. Once the intra-abdominal volume exceeds the ability of the peritoneal cavity to grow with no significant rise in abdominal pressure, increase in pressure results in detrimental physiologic effects. This is also true when the cavity is small, as with children. Ale the abdominal cavity to support a rise in pressure depends on the pressure applied and also the period of time during which the pressure is maintained.

A long lag period in pediatric MAS had occurred since its evolution. Poor-quality pediatric laparoscopic instruments and telescopes which were not small enough were probably the most hindering in pediatric laparoscopy advancement. Many of the advances produced in pediatric laparoscopy have subsequently been used in adults.

Under normal physiology, the intra-abdominal pressure can be as high as 200 mm Hg during a coughing and defecation episode. During peritoneal dialysis, the pressures may rise to 2-8 mm Hg, without any demonstrable adverse affect. Increased intra-abdominal pressure interferes with infradiaphragmatic venous and arterial blood flow, especially to the kidneys.

The ventilatory and circulatory changes can be appreciated within 5 minutes from the start of insufflation of gas. Pressures in excess of 15 mm Hg are related to significant pathophysiologic effects but they are reversible on the 2-hour period. In infants and children, no hemodynamic effects are observed at a pressure of 10 mm Hg for under Fifteen minutes. On the other hand, at insufflation pressures of 12 mm Hg, peak airway pressure increases by 40%, and compliance decreases by 47% without any change in dead space. Pediatric surgeons and pediatric anesthesiologists must interact to insufflate adequately yet maintain normal physiologic parameters.

It may also displace the diaphragm into the chest cavity, decreasing total lung capacity and functional residual capacity, contributing to the acid-base disturbance. An increase in intra-abdominal pressure effectively acts as a venous tourniquet. Blood circulation from the lower limbs and abdomen is decreased as the arterial perfusion is intact. Cardiac output is decreased with rise in the ventricular stroke work and the heart rate. Pressure around the abdominal aorta also increases pressure in the upper body. In children with preexisting decreased cardiac output, increased intra-abdominal pressure can lead to acute cardiac failure.

Minimal Access Surgery benefits are carried out by surgeons adults long before admission to the pediatric community. Initially, the execution of MAS in the pediatric population was recorded for the following reasons:

• The widespread belief that children do not know pain.

• The cost of laparoscopy is considered too high.

• Abdominal Cavity was not small enough.

• MAS considered too difficult and too difficult to learn.

• It is believed that cases take too long to implement and execute.

Many surgeons believe that laparoscopic procedures are not really applicable to children, and the need for cholecystectomy was relatively rare in children.

• Pediatric surgeons already had the ability to work with small cuts.

• Many believed that the MAS was not sure, but its effectiveness has not been proven.

In 1973, Gans and Dr. Bercy performed a laparoscopy mainly for diagnostic purposes and to biopsy. The long latency period of pediatric MAS happened of its development. Pediatric laparoscopic instruments of poor quality and telescopes that are not small enough are perhaps the most advance laparoscopic pediatric obstruction. In a comparative study of five years, the results of 211 children who had autism were compared with age-matched with similar diagnoses who underwent open surgery control. We have detected significant differences in mortality or morbidity. However, the hospital stay was smaller for children who undertook laparoscopic cholecystectomy, appendectomy, nephrectomy, splenectomy and intra-abdominal testicular surgery compared to open surgery. In addition, all parents prefer cosmetic results MAS. Many of the advances in pediatric laparoscopy then used in adults. Surgeons adults looked small telescopes and instruments have been developed for pediatric MAS.