9
Anaesthetic considerations for laparoscopic surgery in neonates and infants: a practical review

https://doi.org/10.1016/j.bpa.2003.10.002Get rights and content

Abstract

Minimally invasive surgery is being applied to an increasing number of neonates and infants undergoing abdominal surgeries. Knowledge of specific implications, patient's health status and pathophysiological changes induced by the surgery allow the anaesthesiologist to provide safe anaesthesia to these high-risk patients. This chapter describes the specific pathophysiological effects, peri-operative management, major complications and contraindications related to endoscopic procedures.

Section snippets

General physiological considerations of laparoscopy

To achieve a pneumoperitoneum, CO2 is insufflated within the abdominal cavity at pressures ranging from 10 to 15 mmHg. This increased abdominal pressure leads to a decrease in total lung compliance and functional residual capacity (FRC) resulting in increased airway pressures, atelectasis and ventilation/perfusion (V/Q) mismatches.

In addition, the CO2 insufflated causes an increase in CO2 absorption and elimination and this increased CO2 elimination continues for up to 10 minutes after deflation

Incidence of surgical techniques

With the development of new equipments and increased experience, minimally invasive surgery is being applied in more instances to neonates and infants. To reduce the risk of puncturing blood vessels or abdominal viscera, particularly the liver which lies partly below the lower ribs in infants, an open ‘cut down’ technique is used for gas insufflation.9., 10.

The ‘ideal’ gas to be used should have specific characteristics, ideally:

  • •

    Limited absorption

  • •

    No physiological effects

  • •

    Incapability of

Pathophysiological effects of laparoscopic surgery in neonates and infants

Pathophysiological changes during laparoscopic surgery are mainly related to the increased intra-abdominal pressure (IAP) associated with CO2 insufflation of the abdomen, patient's positioning (head-up or head-down tilt) and CO2 absorption. Pneumoperitoneum in infants and neonates has a major impact on cardiac volumes and function. Increased IAP induces a mechanical cephalad displacement of the diaphragm that reduces the pulmonary compliance, total lung volume, vital capacity and FRC.

Pre-operative evaluation and investigations

As for open surgery, neonates and infants presenting for laparoscopy should be managed in the same way as for open laparotomy. The scenarios can vary from an elective procedure in a healthy infant to an emergency laparoscopy for an acute abdomen in a premature neonate. A thorough pre-operative history should be taken and a complete physical examination should be performed to identify any underlying medical condition and, specifically, heart murmurs. Routine pre-operative laboratory evaluation

Major complications of laparoscopic surgery

In large centres, the complication rate, excluding subcutaneous emphysema and pre-peritoneal insufflation, ranges from 1 to 2%, with an overall complication rate of 5.8%.59., 60.

There are well documented learning curves and skills in paediatric laparoscopic surgery61., 62., 63. and the complication rates are inversely correlated with laparoscopic experience. Most complications are technique-related. Unintentional injuries to major vessel and viscera are decreased by 50% with the use of an open

Contraindications

Laparoscopy should be avoided in patients with severe cardiac disease, pulmonary insufficiency, bleeding disorders or unstable haemodynamic status. It is more hazardous in patients who have had repeated abdominal surgeries or have abdominal sepsis and remains controversial in malrotation and intussusception.68

Conclusion

Some paediatric laparoscopic procedures will become routine aspects of paediatric surgery. Infants present a technical challenge due to the small size of the structures and the small workspace available. The gasless laparoscopic technique avoids using any gas insufflation and relies on an abdominal wall lift to create an intra-abdominal space. This new technique avoids the problems attributed to increased IAP.69

The use of virtual reality models allows surgeons to perfect their laparoscopic

Acknowledgements

The author thanks Mrs Madeleine Tremblay for her excellent secretarial assistance.

References (71)

  • A.J Kirsch et al.

    The renal effects of CO2 insufflation: oliguria and acute renal dysfunction in a rat pneumoperitoneum model

    Urology

    (1994)
  • A.D Walder et al.

    Role of vasopressin in the haemodynamic response to laparoscopic cholecystectomy

    British Journal of Anaesthesia

    (1997)
  • C.A Shaw et al.

    Comparison of the incidence of complications at induction and emergence in infants receiving oral atropine vs no premedication

    British Journal of Anaesthesia

    (2000)
  • M.L Wulkan et al.

    Is end-tidal CO2 an accurate measure of arterial CO2 during laparoscopic procedures in children and neonates with cyanotic congenital heart disease?

    Journal of Pediatric Surgery

    (2001)
  • C.A Peters

    Complications of pediatric urologic laparoscopy: results of a survey

    Journal of Urology

    (1996)
  • S.S Rothenberg et al.

    Experience with minimally invasive surgery in infants

    American Journal of Surgery

    (1998)
  • A.M Firilas et al.

    Minimally invasive surgery: the pediatric surgery experience

    Journal of the American College of Surgeons

    (1998)
  • W.D.A Ford et al.

    The learning curve for laparoscopic pyloromyotomy

    Journal of Pediatric Surgery

    (1997)
  • C.R Voyles et al.

    Education and engineering solutions for potential problems with laparoscopic mono electrosurgery

    American Journal of Surgery

    (1992)
  • M Sfez

    Anesthesia for laparoscopic surgery in pediatrics

    Annales Françaises f'Anestheie et Reanimation

    (1994)
  • Poddoubnyi et al.

    Laparoscopy in the treatment of intussusception in children

    Journal of Pediatric Surgery

    (1998)
  • F.I Luks et al.

    Gasless laparoscopy in infants: the rabbit model

    Journal of Pediatric Surgery

    (1995)
  • K.G Parr et al.

    Anesthetic implications of the addition of an operative robot for endoscopic surgery: a case report

    Journal of Clinical Anesthesia

    (2002)
  • W.J Brampton et al.

    Arterial to end-tidal carbon dioxide tension difference during laparoscopy. Magnitude and effect of anaesthetic technique

    Anaesthesia

    (1990)
  • G.P Joshi

    Abdominal surgery

  • J.L Shifran et al.

    Asystolic cardiac arrest: a rare complication of laparoscopy

    Obstetrics and Gynecology

    (1992)
  • M.A Cheong et al.

    Paroxysmal tachycardia and hypertension with or without ventricular fibrillation during laparoscopic adrenalectomy: two case reports in patients with non-catecholamine secreting adrenocortical adenomas

    Journal of Laparoendoscopic and Advanced Surgical Techniques

    (1999)
  • D.C Van der Zee et al.

    Laparoscopic approach to intestinal obstruction in children

  • P.E Greilich et al.

    Intra-abdominal fire during laparoscopic cholecystectomy

    Anesthesiology

    (1995)
  • G.G Neuman et al.

    Laparoscopic explosion hazards with nitrous-oxide

    Anesthesiology

    (1993)
  • F.S Bongard et al.

    Helium insufflation for laparoscopic operation

    Surgery, Gynecology and Obstetrics

    (1993)
  • B.M Ure et al.

    Laparoscopic surgery in children and adolescents with suspected appendicitis: results of medical technology assessment

    European Journal of Pediatric Surgery

    (1992)
  • S.Y Liu et al.

    Prospective analysis of cardiopulmonary responses to laparoscopic cholecystectomy

    Journal Laparoendoscopic Surgery

    (1991)
  • F Reinoso-Barbero et al.

    Physiopathologic implications of the anesthesiologic management of pediatric laparoscopic surgery

    Revista Espanola de Anesthesiologia y Reanimacion

    (1995)
  • M Sfez

    Coeliachirurgie en pédiatrie: le point de vue de l'anesthésiste

    Cahiers d'Anesthésiologie

    (1993)

    • Cited by (28)

    • Paediatric minimally invasive abdominal and urological surgeries: Current trends and perioperative management

      2018, Anaesthesia Critical Care and Pain Medicine
      Citation Excerpt :

      The indications were the same as those practiced in adults and encompassed cholecystectomy, Nissen fundoplication and splenectomy [4,12,14,15]. Laparoscopy was extended to younger children and for a wide variety of pathologies, from congenital anomalies to acquired ones [16–18]. In neonates, this approach is currently used for numerous patients either for congenital anomalies or as a diagnostic tool.

    • Advanced minimal access surgery in infants weighing less than 3 kg: A single center experience

      2018, Journal of Pediatric Surgery

    • Minimally Invasive Surgery in the Management of Anorectal Malformations

      2017, Clinics in Perinatology
      Citation Excerpt :

      Contraindications, aside from anatomic variants not amenable to or necessitating abdominal exposure, are determined by conditions of general physiology. Pending hospital capabilities and surgeon and anesthesiologist comfort levels, patients with severe cardiac disease, bleeding disorders, significant hemodynamic instability, or pulmonary insufficiency may be suboptimal candidates for laparoscopy.24 As in any surgical procedure, preoperative planning and patient selection are paramount to a successful operation.

    • Assessment of dynamic variables of fluid responsiveness to predict desufflation-induced hypotension during paediatric laparoscopic surgery

      2017, British Journal of Anaesthesia
      Citation Excerpt :

      During pneumoperitoneum, hypovolaemia is usually masked by the increased systemic vascular resistance as a result of elevated intra-abdominal pressure and centrally mediated increases in cardiac output as a result of hypercarbia. Static indices of preload change and central venous pressure are unreliable for the detection of hypovolaemia because of the increased cardiac filling pressure.16 18 This study shows that high ΔPOP can predict hypotension after desufflation.

    • Effects of carbon dioxide insufflation on regional cerebral oxygenation during laparoscopic surgery in children: A prospective study

      2016, Brazilian Journal of Anesthesiology

    • Intraoperative Management of the Neonate

      2011, Assisted Ventilation of the Neonate
    View all citing articles on Scopus
    View full text
    Copyright © 2003 Elsevier Ltd. All rights reserved.