Pediatric Laparoscopy

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Hypertrophic pyloric stenosis occurs in 1 in 400 live births. This condition is characterized by hypertrophy of the pyloric smooth muscle, which results in gastric outlet obstruction. Typically, the condition presents as projectile, nonbilious emesis at approximately one month after birth. At first, the infant may regurgitate occasionally after a feeding. As the mehanical obstruction increases, however, the vomitting begins to occur after every feeding, resulting in significant dehydration and electrolyte and acid-base distrubances. Infants who have beeen symptomatic for many days may develop a slight jaundice and experience weight loss.

Pyloric stenosis is a medical emergency, not a surgical emergency. The initial treatment for pyloric stenosis is to rehydrate the patient with IV fluids for 24 to 48 hours and correct the metabolic alkalosis. Metabolic alkalosis occurs from depetion of chloride, sodium and potassium which are all found in gastric secretions.

The surgeon makes an umbilical incision and insufflates the abdomen with carbon dioxide, after which a laparoscope (telescope) is inserted through the umbilical incision. The surgeon then makes two small skin incisions one each in the upper right and upper left quadrants to accommodate a laparoscopic grasper and a retractable blade. The blade is used to make a longitudinal muscular incision in the pylorus, and the grasper is used to spread the muscle open. The incisions are closed and dermabond (liquid bandaid) is applied.

The diagnosis of CCAM can be made prenatally by ultrasound. The findings may reveal either a cystic mass or a solid lung tumor. A CCAM is classified into one of three categories: type I and type II CCAMs appear as cystic, fluid-filled masses, while a type III CCAM appears as a solid mass. Most CCAMs are manageable after the overall assessment and diagnosis are made. If the lesions are small and the infant is stable with no signs of respiratory distress, surgical intervention may not be needed immediately after birth. Surgical intervention may be arranted, however, if the mass is large and causing aireway obstruction or mediastinal shift.

Pediatric surgeons strive to perform these resections early to minimize the risk of infection and bleeding and to lessen the possibility of various types of cancers later in life if the CCAM is left unresected. Performing this procedure before the infant reaches six months of age decreases the chances of the CCAM growing, and thereby allows normal lung tissue to develop.

Initially, these procedures were performed through a small thoracotomy incision, which required muscle layers to be divided and the intercostal space to be entered. Currently, pediatric surgeons perform this procedure thoracoscopically as opposed to performing an open thoracotomy.

The patient lays on their side, with the affected side up. Single-lung ventilation is preferred. After placing a 5-mm trocar for use with a 4-mm telescope, the surgeon uses very low CO2 insufflation to help deflate the affected lung. The surgeon places two more trocars for working ports for use with the laparoscopic graspers. An Electrosurgical vessel sealing system is used to seal smaller vessels and larger vessels are tied intracorporeally with 3-0 silk ties and titanium clips. The surgeon brings the specimen out through one of the larger trocar sites. A chest tube is placed, usually for the first 24 hours. The incisions are closed and dermabond (liquid bandaid) is applied.

A pediatric patient may require a laparoscopic Nissen fundoplication if he or she has: gastroesophageal reflux, failed medical management to prevent the symptoms of reflux, neurological impairment, failure to thrive, esophagitis, an esophageal stricture or respiratory compromise.

In a fundoplication, the gastric fundus (upper part) of the stomach is wrapped around the lower part of the esophagus and stitched in place. Now, whenever the stomach contracts, it also closes off the esophagus instead of squeezing stomach acids into it. This prevents the reflux of gastric acid.

The surgeon inserts 5 3-mm and 5-mm trocars into the abdomen. The surgeon locates the stomach and esophagus. They completely wrap the fundus of the stomach around the esophagus and secures it with interrupted sutures. Many times, a g-tube is also placed during this procedure to allow adequate feeding and nutrition to the patient.

The incisions are then closed and dermabond (liquid bandaid) is applied.

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