Laparoscopic Appendicectomy in Children
Below the age of 1 year, the port for the telescope is inserted through the abdominal wall 1 cm to the left of the umbilicus. In small children, the umbilical ring is too loose to keep the trocar airtight. In older children, the umbilicus is chosen for the telescopic port. Before advancing the trocar, a skin incision is made slightly smaller than the trocar in order to secure gas-tight skin closure around the trocar shaft. A too-small incision is risky because it results in too forceful trocar insertion. A veress needle is inserted and CO2 is insufflated up to an intraabdominal pressure of 12 mm mercury. The smaller the child, the slow the insufflation flow rate should be. With practice, the pressure can be estimated by palpating the abdomen. Insufflation and pressure control are executed through valves at the trocars. A second and third trocar is inserted in the right lower hypochondria and left iliac fossa according to the baseball diamond concept. Its site is chosen by pressing the abdominal wall from outside. In pediatric age, the surgeon should try to stay lateral to the umbilical ligaments. Trocars may get caught in a ligament and may, therefore, be difficult to advance. The right trocar is used for the grasper forceps and also to take in the appendix for later removal. In children up to 8 to 10 years, the appendix will usually fit a 7.5 mm trocar. If the child is over 10, a 10 mm port suffices. A 5 mm trocar in the left lower abdomen will provide access for the cautery, scissors, and a second forceps. Expiratory capnography is mandatory for the anesthesiologist in all children. They are prepared to ventilate with decreased residual functional capacities, decreased tidal volumes, and increased frequencies during laparoscopy.
Urinary catheters and nasogastric tubes or drainages were never used. The fascia was approximated with a single absorbable suture. The appendix stump was simply ligated with a Roeder’s or Meltzer’s knot just like the adult patients. No purse string or Z suture is required. In the beginning, laparoscopy took considerably longer than an open approach (up to 90 min vs 25 min). Practice decreased the time consumed, which is now nearly identical to that required for open procedures (25 min).
Other Causes of Pain in the Abdomen in Pediatric Age Group
Hydatids can easily be exposed and removed laparoscopically. We have seen a few cases in the pediatric group that mimicked acute appendicitis. The ovaries can be trapped within dense adhesions; sometimes other additional signs of previous inflammatory processes are demonstrated as well. Such adhesions can be transacted laparoscopically, although we are not sure it is worth the trouble. A Meckel’s diverticulum can be identified and removed by laparoscopy. Congenital and acquired adhesions and ligaments are also found frequently in children. New aspects may be added to clinical symptoms. Laparoscopy can be used in children with incidentally discovered inguinal hernia.