Children's laparoscopy. Laparoscopic operations in children and newborns
Annual Congress of Perinatal Medicine Specialists
Modern perinatology: organization, technology, quality.
The report on the sections is actual questions of neonatal surgery.
Authors: Smyrov OS, Vrublevsky S.G.
Moscow, September 23, 2014.
Endosurgery resectation pyeloplasty is currently being considered as a gold standard of surgical treatment of hydronephrosis in children. The appearance of small-sized pediatric tools, improving endoscopic visualization, accumulation of experience and, improvement of surgical skills made it possible to reduce the age limitations for laparoscopic correction of the obstruction of the rocker-ureteral segment.
Nevertheless, the feasibility and safety of the use of endosurgical techniques in young children is periodically raised due to the small size of the operating area, the hazards of the anesthesiological manual under carboxyperitoneum conditions, an increase in the duration of intervention compared to open operations.
In the Morozovsky Children's Hospital from November 2011 to September 2014, 44 pyeloplasty 43 children with hydronephrosis under the age of 1 year. Of these, 18 children aged 1 to 3 months. One child pyeloplasty is made consistently from 2 sides. Laparoscopic access operational intervention was completed 42 children. One girl is 11 months with hydrocephalus, VSH and transferred shunt infection, pyeloplasty is made of retroperitoneoscopic access.
The reason for the X-ray urological examination was the negative dynamics of pre and postnatal echographic indicators in 20 children, the identification of the expansion of the CHLS on the screening ultrasound examination of postnatally in 12 patients, echographic finds with episodes of concern and leukocytico in 11 children.
Standard examination included kidney WSDGs, excretory urography, mickeal cystography.
As additional diagnostic methods, diuretic sonography and CT with B \\ in contrasting were used.
An indication of the operational treatment was considered an increase in the dynamics of the sizes of the CLA during hydronephrosis of 2 degrees, hydronephrosis 3 and 4, and the corresponding classification of Society of Fetal Urology.
Three children with hydronephrosis 4 degrees in 2 months before the operation, the drainage of the collector kidney system was performed, followed by an estimate of its function.
Preoperative preparation included drugs that reduce gas formation in the intestine in Tech 2 days and microclides in the evening and in the morning before the operation.
Laparoscopic pyeloplasty technique is presented on slides. We used 5 mm optics and 3 mm laparoscopic tools. In most cases, access to the piiveuretheral segment was carried out by mobilizing the intestine loop. Classically lucca crossed in the oblique direction, the ureter in the longitudinal side of the opposing edge. Drainage was applied in various ways, it will stop a little later. In this case, the internal stent has failed to conduct an antitectural stent, and the drainage was carried out by the prescribed nephrostoy. In the formation of anastomosis, monofilament suture material of monocryl 6 \\ 0 was used. The high-definition image and 3mm tools allowed to create a hermetic anastomosis carefully, carefully comparing the edge of the jelly and the ureter.
The following video presents the technique of performing retroperitoneal endopeloplasty.
Optical 5 mm Troacar is installed near the retroperitoneal, the primary working cavity is formed using optics, then 3 mM MANIPULATION TROACARS is installed. Classical pyeloplasty was performed on Heins-Andersen, with the formation of a ureteropyelastomosis with a continuous seam of a thread of monocryl 6 \\ 0. Drainage is provided by intraoperative pyelostomy.
Currently, there is a discussion question about the optimal method of draining the pelvis. We have the experience of retrograde stenting, antegrade stenting, pyelostomy and preliminary puncture nephrostomy.
The ratio of the drainage methods of the collector system of the kidney in our patients is represented on the slide.
As can be seen from the presented data, most patients have been made by antegradial intraoperative drainage of Double Jay Statt.
The internal drainage system was established after the formation of one of the semi-rays anastomosis through a separate puncture of the abdominal wall or through a manipulative trocar. Pre-bladder was filled with an aqueous solution of indigocarmin. The receipt of the dye through the proximal department of the stent indicated its correct position.
The stent was removed after 1-1.5 months after the operation during cystoscopy. The duration of drainage was determined by the deadlines for the completion of reparative processes in the area of \u200b\u200bthe anastomosis.
The impossibility of antegradine stent is marked by us in 2 children. In both cases, the obstacle was localized at the level of the uretero-vesical segment.
For one child, the proximal department of the stent migrated to the distal ureter department without causing a violation of urine outflow. The attempt of intra-line removal of the stent was not crowned with success. After 4 months after the primary operation, laparoscopic pyelotomy and removal of the drainage system was performed.
Retrograde preoperative stenting in young children is not always successful due to the peculiarities of the pathological process in the field of piiveureteral segment. The impossibility of installing the stent in 3 patients and the punch of the ureter in the proximal department in one patient was forced us to further abandon such a technique.
Publications appeared on the use of V-shaped uretero-pyelonephrostomy drainage. The number of observations specified by the authors is small. The only marked complication is intraoperative parenchymal bleeding - demanded the removal of drainage and changing the drainage scheme.
The slide presents the comparative table of our idea of \u200b\u200bthe disadvantages of various variants of the drainage of the pelvis.
The disadvantage of the pyelostomomomomic drainage can be considered the elongation of the patient's patient's stay in the hospital and the lack of frame drainage zone of the anastomosis.
Also, the disadvantage of this method can be considered the impossibility of checking the patency of the anastomosis to the removal of ureteropelonephrosta.
As follows from the submitted data, the question of the optimal intraoperative drainage of the lochank remains a debate. In our opinion, the ideal way does not exist. We prefer antegradine introoperative stenting.
In the material presented, the duration of operational interventions was from 75 to 180 minutes.
There was no conversion.
Intra processing complications are not marked.
The recurrence of hydronephrosis is noted in one patient aged 7 months, which in the postoperative period has undergone heavy pyelonephritis of bacterial-fungal etiology, with extended internal stenting. Repeated laparoscopic pyeloplasty was performed successfully after 6 months.
The rest of the patients noted positive echographic signs of the obstruction resolution, in the form of a reduction in the collector kidney system, increasing the thickness of the parenchyma and improving the parameters of parenchymal blood flow. There were no signs of recurrence.
Thus, in our opinion, endosurgical pyeloplastic in young children with hydronephrosis seems to be an effective and safe way of correction of vice corresponding to the principles of minimally invasive surgery. A prerequisite for the high efficiency of the technique is sufficient experience and professional operator skills and the use of high-quality endosurgery intrumeintary.
Today, laparoscopy in childhood belongs to one of the leading methods of treatment, due to its undoubted advantages in comparison with conventional intervention. Operations using punctures, with the introduction of tool in the cavity, even complex operations with minimal injury to tissues and blood loss are carried out. Today, laparoscopy helps in eliminating the majority of malfunctions and acute surgical pathology in children of different ages, ranging from newborns and ending with adolescents. But, this branch of surgery does not stand still, developing all new and new techniques, applying increasingly secure methods of seams and stop bleeding.
To date, more and more surgeons in the treatment of surgical pathologies in children prefer laparoscopy operations. These techniques have proven themselves in gynecological and urological practice, with intestinal and biliary operations. In addition, the laparoscopy operation helps to eliminate the newborn many malformations, while it gives small injury to tissues and allows children to quickly and actively recover after intervention. However, when the question arises about the treatment of certain diseases with the operation, parents are always worried - whether it will help that this intervention will help completely eliminate the disease, is such interference?
The operation of laparoscopy in childhood is carried out only under general anesthesia, but the duration of the operation in comparison with the traditional method (incision of the scalpel) is usually much shorter, on average, from half an hour to several hours. The duration largely depends on the pathology and the volume of operation, as well as the planned operation or emergency. A decrease in the duration of intervention significantly reduces the risks of the negative effect of anesthesia and complications after the operation.
Intervention is carried out with minimal fabric damage. To carry out operation with laparoscopy, several small cuts are made in the front abdominal wall area for the introduction of tools. It is usually 2-3 punzes with dimensions up to 3-5 mm. Through them, surgeons are injected with a camera, tools and fed air to stretch the abdominal cavity and facilitate access to affected organs. Data from the camera is transmitted to the monitor, according to which the doctor monitors all the manipulations inside the abdomen and conducts operation.
Depending on the volume of intervention, after the operation, children can be in the hospital from several hours to 2-3 days.
It would be wrong to say that this operation is completely bloodless and painless. Although cuts and punctures and small size, but the seams after laparoscopy are still superimposed. First of all, it will be the inner seams after laparoscopy, which are performed during the injury or when conducting manipulations. They are performed by special materials that do not cause rejection, inflammation and other reactions of the body. Sovki gradually, as tissues are healing, they are absorbed, you do not need to remove them. For each type of surgery, surgeons select their types of materials and methods of overlaying seams. In addition, after removing the tools from the abdominal cavity, the seams after laparoscopy also apply in the area of \u200b\u200bskin cuts. They require proper processing and are usually removed in a few days, when visiting the surgeon.
Also separately it is worth talking about pain after laparoscopy. Naturally, any operation, even with minimal cuts and seams, leads to damage to the tissues and nerves, which gives pain after laparoscopy. However, in comparison with the strip operations, the period of soreness and the degree of severity of sensations is much lower. To facilitate the state of children after surgery, painkillers are used, and the pains after laparoscopy are eaten after 2-3 days, leaving only light pain and discomfort in the field of healing wound. Due to these features, children carry such operations are much easier.
All children without exception are operated on with laparoscopic interventions only under general anesthesia. This is usually endotracheal anesthesia. Use any other methods of anesthesia in this case is not possible, since the operation in the abdominal cavity is introduced gas, which gives up a diaphragm at the bottom and, including, leads to the impossibility of independent pulmonary respiration. Alone, the method of anesthesia is not fundamentally different from such in conventional, extensive operations. Children are preparing for surgery and anesthesia just like with ordinary interventions - after 18 pm (if the operation for morning) is prohibited from eating food, before the operation itself, it is impossible to drink water in the morning. In the presence of indications for emergency operation, the preparation is minimal, but also the risks of complications above, which doctors know and follow the condition of small patients.
Today, children are operated on using the safest and high-quality drugs for anesthesia, which reduces the risks of the reaction unfavorable. After the operation, an early exit from anesthesia is provided with a small probability of such side effects as dizziness with nausea or vomiting.
If there are no contraindications, doctors always prefer to laparoscopic interventions. Such operations children are transferred much easier, they have good cosmetic effects, they have little injured fabrics, and the blood is lost much less. The complications of laparoscopy are much less likely than when extensive operationand the risk of recurrences is also reduced to the minimum. However, there are certain states and clinical situations where laparoscopic intervention can be contraindicated. Then a traditional operation is carried out with a scalpel. However, the final decision on the method of surgical treatment of a small patient is made by a doctor in conjunction with parents, given all the arguments for and against.
Two 5 millimeter tools are required to overlay the seams: a "Szabo-Berci" type needle holder (located in the right hand) and atraumatic grasper (in the left).
Most often used conventional surgical threads with curved needles (Vicryl, PDS 4 0, 5 0).
Usually apply the following types of seams:
1. Single seams when embeding small peritoneal defects, flashing and dressing such structures as a ureter, urahow, etc., tsekoplexia, etc. The layout of such a seam is presented in Fig. 4 8;
Fig. 4 8. Single seam overlay scheme.
Features of operational machinery
2. Continuous seam, mainly when closing sufficiently large peritoneal defects after extensive colon mobilization (with kidney operations), during laparoscopic orchipexia, etc. (Fig. 4 9).
4.2. Finishing stages of intervention
Audit of the abdominal cavity 1. Careful examination of the abdominal
noah cavity ranging from a small pelvic to the upper floor of the abdominal cavity in order to detect previously noticed damage to the internal organs.
2. Audit to detect bleeding places is carried out after a decrease in intra-historical pressure to 5 mm RT. Art., In this case, venous bleeding is resumed, which is tremored at a pressure in the abdominal cavity of about 15 mm Hg. Art.
Sanitation of abdominal cavity
1. Complete disposal of the abdominal cavity with endoscopic suction.
2. According to the testimony - aiming dosage of the entire abdominal cavity or its individual sections with a physiological solution with the addition of heparin, followed by a complete removal of the washing solution.
3. If necessary -
Fig. 4 9. Scheme of overlaying continuous seam.
the neutrition of the abdominal cavity with silicone drainage. Tube
aimiciously introduced into the desired department of the abdominal cavity under the control of laparoscope. An indication for drainage in our observations is most often the presence of peritonitis. After "net" planned operational interventions, the drainage of the abdominal cavity is usually not carried out.
Laparoscopic surgery. a common part
Removal of trocharov
1. First of all, 12 and 11 mm millimeter trocars are removed under the endoscopic control of the place of their standing to avoid possible bleeding (when using trocars with a conical style of the stylet, it practically does not happen) or walking the peel to the peristine defect (this is most often happening when Trocar Remove after the complete removal of the pneumoperitoneum and the appearance of the tension of the muscles of the anterior abdominal wall at the end of the actions of the Miorosanta).
2. The layer stamp of 11 millimeter wounds is also advisable to carry out the complete removal of the pneumoperitoneum and under the control of optics. Wound closed in a layer with mandatory fascia (Vincons 4 0) and leather.
3. After removal of the pneumoperitoneum, 5 millimeter trocars are removed, and skin wounds in the places of their standing are closed with leucoplasty strips or impose one seam.
Literature
1. Emelyanov S., Matveev N.L., Fedenko V.V., Evdoshenko V.V. Manual seam in laparoscopic surgery // Endoscope, Hir. - 1995. - №2-3. -
P. 55 62.
2. BOX N.M.A., Georgeson K.E., Najmaldin A., Valla J.S.Endoscopic Surgery in Children. Berlin; HEIDELBERG: Springer Verlag, 1999. P. 145.
3. Nathanson L.K., Nethanson p.d., Cuscheri A.Safety of Vessel Ligatuon in Laparoscopic Surgery // Endoscopy. - 2001. - Vol. 23. - P.206-209.
4. Sabo Z, Hunter J. G., Litwin D.T., Berci G. TRAINING FOR ADVANCED LAPAROSCOPIC SURGICAL SKILLS. - San Francisco: Surgical Universal Medical Press, 1994. - P. 118-
5. Zucker K.A., Bailey R.W., Graham L. et al.TRAINING FOR LAPAROSCOPIC SURGERY // WORLD J. SURG. 1993. Vol. 17. No. 1. P. 3 7.
Chapter 5.
Laparoscopic surgical techniques impose large requirements for adequate anesthesiological benefits and to intraoperative monitoring. Despite the accumulation of significant experience to ensure adequate protection of the patient during surgery, when conducting laparoscopic interventions, anesthesiological risk is still significantly higher than the risk of surgical.
In the middle of the 20th century, doctors paid serious attention to changes in hemodynamic and gas exchange systems caused by the imposition of pneumoperitoneum. Laparoscopy was far from a safe procedure. The implementation of these operations is associated with the occurrence of small and large surgical and anesthesiological complications, to prevent and relieve which it is necessary to clearly represent the pathophysiological mechanisms for their development.
5.1. The effect of laparoscopic manipulations on ventilation and gas exchange
Currently, the absolute majority of anesthesiologists note the danger of laparoscopic manipulations and operations against the background of spontaneous respiration, since the imposition of the pneumoperitoneum limits the aperture of the diaphragm.
The imposition of pneumoperitoneum causes the following changes in the work of the child's cardiovascular system:
1. The tensile light of the pulmonary fabric is reduced.
2. Atelectases of lung plots arise.
3. The functional residual lung capacity decreases, ventilation perfusion violations appear and progress, ventilation, hypercapnia and respiratory acidosis are developing.
With an increase in the area of \u200b\u200bpulmonary shunting (i.e., the jnpyemoft perifractions, but not ventilated tissue of the lung) increases hypoxemia, which is not corrected by increasing the percentage of oxygen in the inhaled mixture. This is reflected in the reduction of the values \u200b\u200bof such indicators as in
the oxygen pressure in arterial blood (Ra 02) and the saturation of hemoglobin oxygen (S02). As a rule, oxygen insufficiency takes place in patients with source dysfunction of myocardium and / or hypovole Mia and is associated with the combined effect of the reduced pulmonary computers and reduced cardiac output (SV).
That is why when carrying out laparoscopic procedures, there is a need for intubation of trachea, IVL and total muscle relaxation. However, on the background of the IVL in normal fusion mode with the full muscular block, the alvetol atelectasiya occurs, the decrease in the complix is \u200b\u200bliguous
Laparoscopic surgery. a common part
tissue, reducing FOB, raising peak pressure and pressure plateau in respiratory tract (on average by 40%). These changes are more pronounced in laparoscopic operations, which are carried out in the Trendelenburg position and require the maintenance of high pressure in the abdominal cavity (5-14 mm Hg. Art.). Disturbances from the respiratory system are much less significant at laparoscopic cholecystectomy, during which the converse position of trendelenburg is used and the pressure in the abdominal cavity does not exceed 10-14 mm RT. Art.
Hypercapnia under laparoscopic manipulations is due not only to the change in ventilation parameters as a result of an increase in intra-penetration pressure, but also absorption of carbon dioxide (C02) from the abdominal cavity. C02 is well soluble in blood, quickly diffuses through the peritoneum.
Factors defining the intensity of the intake of C02 in blood:
1. Good solubility C0.2 in the blood, fast diffusion through peritoneum.
2. Pressure level in the abdominal cavity.
3. Duration of operational intervention.
4. Square of the suction surface (peritoneum).
Since the last parameter per unit body weight in children is 2 times more than in adults, children can be expected faster and massive intake of C02 to blood. In adults, hyperkapinia and respiratory acidosis usually develop no earlier than 15 minutes after the start of C02 insufflation into the abdominal cavity, while in children these changes occur immediately after the imposition of the pneumoperitoneum.
The absorption of C02 in the blood under the imposition of pneumoperitoneum using C02 is reflected in increasing the concentration of C02 at the end of the exhalation (ETS02), the partial pressure of C02 in arterial blood (RA C02), the production level of C02 light (VC02), in the development of acidosis. In some patients, there is an increase in the difference between the RA C02 and ETS02; In this case, there is also an occurrence of unmanaged acidosis. An explanation of this fact is available in the presence of reduced BC and as a result of this increased venous shunting in light and reduced gllanger bleeding.
Some authors note the increased allocation of C02 light and after removing the pneumoperitoneum. Excess the normal level of VC02, ETC02, Ra C02 may be observed during the first 30,180 min of the postoperative period. This comes due to the fact that 20-40% of the absorbed C02 remains in the patient's body after removing C02 from the abdominal cavity.
Possible ways of prevention and correction of emerging ventilation and gas exchange disorders:
1. The use of an endotracheal anesthesia method against the background of total muscle relaxation.
2. IVL in hyperventilation mode (on30-35% more norm). At the same time, the IVL can continue after the end of surgery up to normalization of ETS02 and RA C02.
3. Using Cup (Continuous Positive Airway Pressure Expiratory Pressure).
Features of anesthesia with laparoscopic operations
It must be remembered, however, in cases where the progression of acidosis is partly associated with a decrease in peripheral perfusion, hyperventilation may not give a pronounced compensatory effect, as it can cause a decrease in CV. Probably the most rational version of the IVL is the high-frequency injection IVL, which reduces the negative effect of carboxyperitoneum on central hemodynamics, gas exchange, and external respiratory function.
In the event of progressive hyperkapinia, acidosis, hypoxemia against the background of hyperventilation in series, before achieving the desired effect, the following activities are performed:
1. Ventilation 100% o g
2. Maintaining various methods of sv and peripheral perfusion.
3. Returning the patient in a horizontal position.
4. Removing C0 2 from the abdominal cavity.
5. Transition from laparoscopy to laparotomy.
5.2. The effect of laparoscopic manipulations on hemodynamics
Increased pressure in the abdominal cavity when imposing pneumoperito, it may be bobbly to influence the value of CR: to promote, on the one hand, the "squeezing" of blood from the abdominal cavity organs and the lower hollow vein to the heart, on the other - blood cluster in the lower limbs with the subsequent natural decrease in venous Return. The prevalence of one or another effect depends on many factors, in particular from the value of intra-abdominal pressure. It is observed that the position, the inverse position of the Trend elastkun, contributes to the development of more serious hemodynamic changes, since the gravitational impact on the return of blood to the heart with the natural development of venous stagnation on the periphery and a pronounced decrease of venous stagnation for the left ventricle and St. The situation of Trendelenburg, on the contrary, is favorable to maintain the proper values \u200b\u200bof CV, since it contributes to the normalization of venous return and thereby an increase in the central volume of blood under the conditions of pneumoperite Cherum.
The imposition of the pneumoperitoneum contributes to an increase in peripheral vascular resistance due to the surveillance of the arteriole, in particular the splashing basin. The pressure in the abdominal cavity increased to a certain level can cause the aorta compression. Renal blood flow is largely suffering.
Along with the above-mentioned factors, hypoxemia, hypercapnia and respiratory acidosis have a certain impact on hemodynamics. On the one hand, C02, directly affecting the vascular wall, causes vasodilation, compensating for an increase in peripheral vascular resistance. On the other hand, both hypoxemia and a decrease in blood pH stimulate a sympathetic adrenal system, thereby contributing to Mas
Laparoscopic surgery. a common part
sivan emission of catecholamines. All this can lead to an increase in SV, peripheral vascular resistance, blood pressure, development of tachycardia, heart arrhythmias and even to a heart stop.
In case of severe violations in the circulatory system, all experts recommend that the pneumoperitoneum is removed and the transition to laparotomy.
Increased intra-abdominal pressure during laparoscopic operations creates prerequisites for the occurrence of gastroelectric instrument of gurgitation, followed by aspiration of acidic gastric content. The risk of developing this complication is especially high in patients with gastroparesis, hernias of the esophageal hole of the diaphragm, obesity, obstruction of the sawmill of the stomach, in ambulatory patients and children (due to the lower pH of the gastric content and a higher ratio of the latter to the mass of the body). Perhaps the high probability of occurrence of gastrointestinal piped reflux, followed by aspiration limits the use of a laryngeal mask, widely used at present during laparoscopic surgical interventions.
The following regurgitation prevention measures are proposed:
1. Preoperative use of metoclopramid (10 mg per OS or internal
rivenly), increasing the tone of the cardiac sphincter of the stomach, and H2 of the tori block that reduces the acidity of gastric content.
2. Preoperative stomaching of the stomach with the subsequent installation of the gastric probe (after the trachea intubation); The presence of a probe in the stomach, in addition, warns the injury of the stomach when imposing pneumoperitoneum and improves the visualization of the surgeon's surgeon.
3. The tracheal intubation is required, while it is desirable that the endotrache does not have a cuff.
One of the most dangerous, threatening fatal outcome of the complications of the lap-
roscopic surgery is a gas embolism. C02 is quickly absorbed through the peritoneum and is absorbed into the splash vessels. Since it is well soluble in the blood, the flow of a small amount in blood
the current passes without visible complications. The massive absorption of C02 leads to the gas embolism.
Embolia C02 Development Prerequisites:
1. Reduced splashing blood flow, which is observed at high intra-abdominal pressure.
2. The presence of gaping venous vessels as a result of surgical injury. Clinical signs Gas embolism are a significant decrease in blood pressure, hearty dieselmia, the emergence of new heart noise, cyanosis,
email swelling, increasing level of ETS02, i.e. There is a picture of the development of the right-hand heart failure against the background of pulmonary hypertension and hypoxemia. For early diagnosis of this complication, careful monitoring of ECG, Hell, cardiac tones is needed, and ETS02.
Diagnosing a gas embolusion, it is necessary to remember that the collapse may also be observed when bleeding, pulmonary artery embolism, myocardial infarction, pneumothorax, pneumomediastine, high intra-abdominal pressure, expressed vagal reflexes.
Features of anesthesia with laparoscopic operations
5.3. Choosing anesthesiological manual
Anesthesiologists working with children indicate the need to carefully collect anamnesis in patients who planrate laparoscopic intervention. Absolute contraindication to such operations is fibrous lung dysplasia.
Contraindicationsto conduct emergency laparoscopy in children:
1. Coma
2. Decompensated heart failure.
3. Decompensated respiratory failure.
4. Heavy blood coagulation disorders (the value of the Kwick sample is below 30%, a significant increase in bleeding time).
5. Border states in which laparoscopy can cause the above complications.
The use of various methods of local anesthesia with preserved spontaneous breathing in adults is still discussed. In pediatric practice, this method is unacceptable, since it is impossible and inappropriate to carry out peridural anesthesia or a bilateral intercostal block in a child who is in consciousness. The use of epidural anesthesia in the composition of the combined anesthesia, despite some advantages, is often accompanied by hemodynamic disorders, does not prevent the infrared nerve irritation (C1P -CV), nausea and vomiting in the postoperative period.
Advantages of general endotracheal anesthesia:
1. Improving the working conditions of surgeons with total muscle relaxation and presence of a gastric probe. The patient's deep sedation makes it easy to give it the desired position.
2. Trachee intubation provides free permeability respiratory tract And warns aspiration (when inflating the endotracheal tube cuff).
3. Cardiopulmonal changes caused by injection C02 In the abdominal cavity, can be eliminated by maintaining at the proper level of minute ventilation, oxygenation and volume of circulating blood (OCC).
For general endotracheal anesthesia, different specialists offer a wide variety of schemes, as a rule, a little different from general anesthesia techniques in conventional surgical interventions. The accumulated experience and studies of the features of pain relief of laparoscopic operations in children make it possible to formulate the following practical recommendations for the anesthetic manual in the pediatric clinic.
Premedication. In order to premix children intramuscularly introduce 0.1% atropine at the rate of 0.01 mg / kg, 0.5% relainium 0.35 mg / kg children aged 1-3 years, 0.3 mg / kg children aged 4- 8 years and 0.2-0.3 mg / kg - more older patients. The differentiation is due to the weaker sensitivity of the patients of the younger age group to the atractic. If there is a history of instructions on allergies into premedication, they include diphyderol or vegetation soup in a dose of 0.3-0.5 mg / kg.
Laparoscopic surgery. a common part
The choice of anesthetic remains behind the anesthesiologist. Traditionally, inhalation anesthesia is used in children's clinics using fluoro tana (galotan, narcotan). This halogen-containing anesthetic is so popular due to the rapid introduction into general anesthesia and rapid awakening, ensuring sufficient depth and controllability of anesthesia. Fluorochny is used according to the traditional scheme, adhering to the minimum sufficient concentrations of anesthetic in the inhaled mixture. The use of a combination with nitrogen (N02) is permissible only at the stage of introductory anesthesia. In the future, given the ability of N2 0 to actively accumulate in the physiological and pathological cavities of the organism and its potentially hypoxic effect, the ventilation should be carried out 100%
The pronounced cardiodepressive effect of fluorotan is manifested by a decrease in the SV, slowing down of the obtricular conduction, decreased blood pressure. Of the modern and affordable drugs for anesthesia, Dip Rivan and Midazolam were chosen as alternative fluorotan drugs that do not give such pronounced side effects.
Midazolas, synthesized in 1976, is one of the numerous representatives of the group of benzodiazepines. It has the ability to quickly bind to gamkergic and benzodiazepine receptors. As a result of this, after several (5-10) minutes after intramuscular administration, fast psychomotor braking of the patient develops, and at the end of the introduction, it occurs rapid return to normal operation. It is necessary to note the pronounced anxolytic, sedative and relations, and low allergicness inherent in mydazolam,
but also the fact that there is significant antero when used
and retrograde amnesia. From fluorotan, this drug is beneficial to the minimum effect on the cardiovascular and respiratory system. Introductory anesthesia is carried out by intravenous administration of Midazolam(0.3-0.4 mg / kg children for 1-3 years, 0.2-0.25 mg / kg children 4-8 years, 0.1-0.15 mg / kg children 9-14 years old) Combinations with intravenous fractional administration of fentanyl and Miorolaxan Tov. The maintenance period is a constant infusion of Midazolam 0.3-0.4 mg / kg per hour in combination with intravenous fractional administration of fentanyl and Miorolac Santans. The introduction of Midazolam ceases 8-12 minutes before the end of the anesthesia.
The diprivan (propofol) on the mechanism of action is similar to the drugs of the benzo diazepine series. Its advantages include:
1. Rapid offensive hypnotic effect.
2. High speed metabolism.
3. Soft recovery period.
These properties provide an increasing distribution of the dipriva on clinical practice. Like most means for anesthesia, the diprivan affects the respiratory function, causing oppression of independent respiration at the stage of introductory anesthesia. The drug is able to cause hypothen zei, due to a decrease in overall peripheral resistance. The introduction of a diprivan in a clinically effective dose is usually accompanied by a decrease in heart rate, which is explained by the vagotonic effect of the drug and
Features of anesthesia with laparoscopic operations
write by the proactive assignment of atropine or metacine. Introductory anesthesia is carried out by intravenous administration of 2.5 mg / kg of diprivan. The period of maintenance is the constant infusion of the diprivan of 8-12 mg / kg per hour in combination with fractional administration of fentanyl and muscle relaxants. The introduction of the diprivan is stopped for 6-10 minutes before the end of the anesthesia.
5.4. Artificial lung ventilation, infusion therapy
and monitoring
IVL. Ensuring adequate gas exchange is possible only when using IVL in hyperventilation mode. In IVL mode with intelligent positive pressure, the respiratory volume is calculated by the Radford nomogram. The frequency of breathing corresponds to the age norm. The inspiration pressure is set for each patient depending on the age and individual features in the interval of 14-22 mbar. Exemption pressure 0. After overlaying the pneumoperitoneum, the minute volume of ventilation increases by 30-25%, and by increasing and respiratory volume, and respiratory frequency.
All patients after the intubation of the trachea, it is recommended to install a probe in the stomach and catheterize the bladder. This not only allows you to prevent hazardous complications (aspiration of gastric content, perforation of hollow organs by Troacar), but also improves the visualization of the operational field surgeons.
Infusion therapy.Using the mode of the forced infusion load allows you to prevent the development of hemodynamic disorders due to the state of relative hypovolemia provoked by the pneumoperitoneum. Intravenous infusion therapy can be carried out by crystalloid solutions (for example, Inosteril FRISENIUS). If necessary, the correction of intraoperative blood loss is carried out infusionally transfusion therapy. In these cases, a single-logular fresh frozen plasma is used, plasmoprotectors (CIN, polyglyukine repeating), polyionic crystalloid solutions, 5-10% glucose solutions. At least, less than 100 g / l and w, less than 30%, transfusion of a single-line erythrocytic mass is recommended.
Studies have shown that independently of the selected anesthetic maintaining standard infusion therapy (8-10 ml / kg per hour with planned operations and 12-14 ml / kg per hour with emergency) does not prevent the development of the state of relative hypovolemia caused by the redistribution of blood to the periphery with a decrease venous return, falling sv and shock volume after the imposition of pneumoperitoneum. To correct this state, the following diagram of infusion therapy is used. On the moment of catheterization of the peripheral veins in the operating room until the imposition of the pneumoperitoneum, the rate of infusion should be 10-15 ml / kg per hour with planned operations and 15-28 ml / kg per hour with emergency. After insufflation of gas into the abdominal cavity, the infusion rate is advisable to reduce to 10-12 ml / kg per hour.
Chapter 1. Review of literature. Laparoscopy in urgent abdominal surgery in young children: history, the current state of the problem and development prospects.
Chapter 2. Materials and research methods.
2.1. general characteristics patients.
2.2 Generally clinical examination of groups of patients.
2.3 Evaluation of the degree of operating injury.
2.4 General issues of laparoscopic interventions.
2.5. General issues of the technique of "open" laparotomic interventions.
2.6. Statistical data processing.
Chapter 3. Opportization of the evaluation of the degree of operational injury in children who have undergone emergency abdominal surgery
3.1. Correlation of the degree of surgical stress and levels of homeostasis.
3.2 Comparison of the severity of surgical stress in newborns after laparoscopic and traditional interventions.
3.3 Correlation of homeostasis indicators depending on the nature of the operation and age of patients.
Chapter 4. The results of the treatment of patients of the main group.
4.1. Complications.
4.2. Conversion with laparoscopic interventions.
4.3. Mortality.
Recommended list of dissertations in the specialty "Children's Surgery", 14.00.35 CIFRA WAK
The possibilities of minimally invasive technologies in the treatment of acute surgical diseases of the abdominal organs 2004, Doctor of Medical Sciences Semenov, Dmitry Yuryevich
Video trained intestinal operations in children. 2011, Candidate of Medical Sciences Vasilyeva, Ekaterina Vladimirovna
Endovideosurgical interventions in acute diseases and abdominal injuries 2009, Doctor of Medical Sciences Levin, Leonid Aleksandrovich
The effect of intra-historical pressure on the cardiorespirator system in children with laparoscopic operations 2013, Candidate of Medical Sciences Mareeva, Anastasia Aleksandrovna
Acute adhesive intestinal obstruction in children: diagnosis, treatment and role of laparoscopy 2006, Doctor of Medical Sciences Kobilov, Ergash Egamemberdievich
The dissertation (part of the author's abstract) on the topic "Emergency laparoscopy in breast-age"
The relevance of the problem
Currently, the world has an increasing interest in the introduction of endoscopic interventions in all areas of surgery. Despite the achievements in the field of mini-invasive surgical technologies, the use of laparoscopy in children of the early age group and, especially, the newborn began relatively recently. Children of the neonatal period and the first months of life have a number of distinctive physiological and anatomical features that make it difficult to perform endoscopic operations and determine the higher risk of developing complications.
Special difficulty in the treatment of newborns is related to the fact that from 5% to 17% of children with surgical pathology are premature and children with a body weight of less than 2,500 g. At the same time, the need for operation occurs in the first days of life against the background of the early adaptation period and high sensitivity Operating injury and operational stress: up to 42% of children need emergency operational benefits (Ergashev N.Sh., 1999).
The need to perform traumatic laparotomy leads to a long stay in conditions of resuscitation and intensive therapy, which increases the risk of infection, the degree of operational stress; It necessitates long-term parenteral nutrition and fan support after surgery, introducing painkillers, taking into account the fact that the use of narcotic analgesics in newborns is undesirable due to the negative respiratory effects of the latter. The need to lengthen the terms of hospitalization and unsatisfactory cosmetic results are also substantial distension of broad laparotomy.
These factors create prerequisites for the use of gentle techniques using modern small-scale technologies in this age group. For example, in large foreign pediatric clinics from all laparoscopic interventions, 38.1% are carried out in children under the 1st year (Baxn.m., 1999).
Research reflecting hemodynamic, respiratory and temperature effects of pneumoperitoneum in children of the first months of life is available only in foreign literature and are of a single character (Kalfa N. et al, 2005). At the same time, the works devoted to the assessment of laparoscopy traumaticity from the standpoint of evidence-based medicine during acute surgical diseases in children of the first year of life in the literature accessible to us did not meet. One of the most reliable ways to evaluate the results of operational interventions is the analysis of surgical aggression, which, when studying in patients with pylorostenosis, convincingly proves the benefits of laparoscopy over open operations (Fujimoto T. et al., 1999).
In our country, despite the long-term traditions and priorities in some areas of work on the use of laparoscopy in pediatric practice, only single neonatal surgical centers have experiences of endoscopic operations in newborns (Kotlobovsky V.I. et al. And Sovat, 1995, Gmerov A.A. et al ., 1997, Sataev V.U. et al., 2002). Published single messages on the use of endoscopy with ulcer-necrotic enterocolite (Yaek) (Bushmelev V.A., 2002, Pierro A. et al., 2004), intestinal invagination, adhesive intestinal obstruction, acute appendicitis (Dronov A.F., Poddubny I.V., 1996), disadvantaged hernias (crushed stone M.V., 2002).
There are no work, comprehensively reflecting the place and principles of the application of this method in emergency neonatal surgery and child-child surgery. There is no criteria for an objective assessment of injury and safety of laparoscopy in newborns. In addition, the development of laparoscopic surgery in this age group requires revision of the testimony and contraindications to operations, taking into account the age, donidity, gravity of the main and related pathology.
Thus, the above circumstances, as well as their own experience of laparoscopic operations with a variety of emergency surgical pathology in children of newborn and chest period, prompted us to conduct research in this direction.
Objective: Improving the diagnosis and improving the quality of treatment of urgent abdominal pathology in newborn and breast-age children by using mini-invasive laparoscopic interventions.
Research tasks:
1. Prove the safety, feasibility and high efficiency of laparoscopy in the diagnosis and treatment of urgent abdominal pathology in newborn and breast-age, through the study of metabolic, hemodynamic and respiratory influences of the Sog-pneumoperitoneum;
2. Develop a method for objective assessment of surgical traumaticity of laparoscopic interventions in newborns and breast-age children;
3. Conduct a comparative analysis of the injuries and the effectiveness of laparoscopic and traditional "open" operational interventions in emergency surgical diseases of the abdominal organs in newborns and breast-age;
4. Analyze intraoperative and postoperative complications, determine the risk factors of complications in emergency laparoscopy in newborns and breast-age.
Protection Position:
Laparoscopic interventions are less traumatic and more effective in emergency abdominal surgical pathology in children of the first year of life in comparison with laparotomic operations and have no age limit
Scientific novelty
For the first time on a large clinical material (157 patients under the age of 1st year), the results of the introduction into the clinical practice of a whole complex of minimally invasive laparoscopic surgical techniques were analyzed.
The effects of SS-pneumoperitoneum are investigated during emergency laparoscopic interventions in newborns and breast-age.
A clear assessment of the degree of operating injury in children of the first months of life, adapted to the use of laparoscopic interventions. The objectivity of an assessment of the degree of operational injury based on widely used methods of intraoperative and postoperative monitoring is proved.
We have been introduced into clinical practice in young children, including newborns, such minimally invasive techniques, such as laparoscopic and laparoscopic-assisted interventions with intestinal invincation, perforated peritonitis of various genesis, infrained inguinal hernias, complicated forms of meckage diverticula, severe forms of adhesive intestinal obstruction.
The use of the described techniques made it possible to achieve a significant improvement in the results of the treatment of children with the specified types of pathology - the amount of postoperative complications, to ensure a smoother course of the postoperative period, the rapid restoration of activity, a significant reduction in the time of hospitalization of patients, excellent cosmetic result, reduce treatment costs.
Introduction of results into health practice
The results of the dissertation work were introduced into the practical activity of the departments of urgent and purulent surgery, surgery of newborns of DGKB No. 13 named after N.F. Filatova (Moscow), separation of emergency purulent surgery of DGKB No. 9. G.N. SPEARSky (Moscow).
Materials of the work are used when reading lectures and at seminars on children's surgery in high school students and physicians of Fow RGMU.
Approbation of work
The dissertation was performed at the Department of Children's Surgery (Head of Prufessor A.V. Gerasskin) RGMU, on the basis of DGKB No. 13 named after N.F. Filatov (Chief Doctor - Doctor of Medical Sciences V.V. Popov). The main provisions of the dissertation reported:
IV Russian Congress "Modern technologies in pediatrics and children's surgery. Moscow, October 16-19, 2005;
11th Moscow International Congress on Endoscopic Surgery, Moscow, April 18-20, 2007;
II Congress of Moscow surgeons "Emergency and Specialized Surgical Help" Moscow, May 17-18, 2007;
15th International Congress of The European Association for Endoscopic Surgery (EAES), Athens, Greece, 14-18 June 2007;
XII Moscow International Congress on Endoscopic Surgery. Collection of theses. April 23-25, Moscow, 2008.
Thesis and structure of the dissertation
The thesis consists of administration, 5 chapters, practical recommendations and a literature of literature.
Conclusion of dissertation on the topic "Children's Surgery", Holodova, Victoria Valerievna
104 Conclusions
1. In breast-age children, when conducting laparoscopy, the effect of C02-pneumoperitoneum is most significantly reflected in the state of the gas composition of blood, especially in the patients of the newborn period ™. At the same time, laparoscopy induced cardio-respiratory changes are comparable to those when conducting "open" operations. The advantages of laparoscopic interventions before traditional are reflected in the less pronounced levels of hypothermia, blood loss and changing blood glucose - marker of a hormonal-metabolic stress response to surgical aggression
2. The modified method of a ball validation of surgical stress is an objective way to determine the traumaticity of surgical interventions in newborns and breast-age and makes a comparative analysis of laparoscopic and traditional "open" operations.
3. A comparative analysis of laparoscopic and traditional surgical interventions showed that laparoscopy is a less traumatic method for the operational treatment of emergency abdominal surgical diseases and has no age limit.
4. Complications of intraoperative and postoperative periods After laparoscopic interventions are not specific and are less common in comparison with traditional "open" operations.
1. Laparoscopic surgery at the present stage is an integral part of children's surgery and has no age limit. In this regard, in leading children's surgical clinics it is advisable to organize the work of departments or clinical groups on endoscopic surgery, with the presence of specialized operating room, equipped with the necessary video-endoscopic equipment and tools intended for young children.
2. When performing laparoscopic interventions in children of an early age group, it is necessary to strictly adhere to a number of technical requirements:
The place of the first puncture of the abdominal wall should be removed from the projection of the umbilical veins, especially in newborns;
At the first puncture, only atraumatic stupid trocaciers,
It is necessary to use small diameter tools - no more than 3 mm,
All operations must be performed at low intraabdomominal pressure of the pneumoperitoneum not exceeding 6-8 mm RT Art,
Carbon dioxide feed rate should not exceed 1-1.5 l / min,
The prerequisite is to carry out intraoperative monitoring of the main indicators of gas exchange, the electrolyte composition of blood, hemodynamic parameters, body temperature and diurea.
3. In the Urgent Surgery of Newborn and Child Children in the syndrome of the acquired "acute abdomen" at present, almost all unclear cases are an indication of diagnostic laparoscopy. At the same time, the overwhelming majority of intestinal obstruction cases of various genes (adhesive, intestinal invagination, etc.), acute appendicitis, meckleel diverticulus, Yaek, etc., may not only be significantly diagnosed with laparoscopy, but also radically cured by methods of minimally invasive laparoscopic surgery.
4. When developing and implementing mini-invasive technologies in children's surgical practice, it is necessary from the standpoint of evidence-based medicine to conduct comparative studies of operational interventions, using the method of a ball valuation of operational aggression, based on objective criteria for the efficiency and safety of operations.
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Please note the scientific texts presented above are posted for familiarization and obtained by recognizing the original texts of theses (OCR). In this connection, they may contain errors associated with the imperfection of recognition algorithms. In PDF the dissertation and the author's abstracts that we deliver such errors.
Our expert is a surgeon, head of the urological department of the GUZ "Clinical Hospital of Emergency Medical Aid" of Volgograd Sergey Bondarenko.
More recently laparoscopic operations that are conducted through one or more tiny holes in the body were fantastic. Something like the work of Filipino chielars. Today, the testimony for such operations is married day by day, and these interventions themselves are applied not only in adults, but also in kids.
Small access - big benefits
Once upon a time, physicians had such a phrase in the go: "A large surgeon is a big cut." But for a long time, this statement has lost its relevance. And all thanks to the introduction of so-called minimally invasive (that is, gentle) surgical methods. After all, such operations (as doctors say, with small access) do not require large cuts, and are carried out through barely noticeable 3-4 punctures that are made in the front abdominal wall of the patient. Through these holes are introduced miniature manipulators, which surgeon conducts operation. An optical device with a light source is inserted through another puncture. Modern optics are connected to the monitor screen, where the detailed and comprehensive image of the internal organ is displayed. It can be considered in all details, in addition, you can use the image zoom function. Naturally, a great overview of the operating field is very convenient to a surgeon, which improves the quality of his work.
The patient is also some advantages. The blood loss after laparoscopic operations is smaller, painful syndrome - below, cosmetic result is better. Healing occurs faster, the rehabilitation period is easier and shorter. Yes, and complications are less than several times. Of course, at first glance, such operations are solid benefit for both the doctor and for the patient. But is it simple?
Principled question
When using laparoscopic technology, especially if we are talking about children's surgery, some important principles must be observed. The main one is the principle of security.
Conducting optics and tools into the patient's abdominal cavity - the most dangerous moment during the operation, because for the surgeon, this process always takes blind. Special care doctors have to be exercised if there is anatomical anomalies in a small patient - in this case, the risk is accidentally damaged important organs and fabric. And even the data of existing research (ultrasound, MRI) do not always guarantee security. When carrying out laparoscopy in adults in the abdominal cavity, air is injected - this is done in order to lift the abdominal wall and facilitate the introduction of tools. But for children this method, alas, it is impossible to apply, since for them the pressure in the abdominal cavity exceeding 7-8 mm Hg. Art., Harmful, it can extremely negatively affect heart activities, respiratory system and a child's brain. Therefore, surgeons when entering tools use different tricks. For example, apply the "open port" technique - that is, before entering the tools, make a small incision (5-6 mm), through which all interested in the anatomical details will be clearly visible. The second way to ensure security is the needle of the versal, the device, which is a hollow needle with a spring inside and cannula. After penetrating the cavity (most often abdominal), the protective part of this tool is advanced and covers the needle's edges, thereby protecting the organs and tissues from damage.
Jewelry work
The second important principle, which is used today in children's laparoscopic surgery, is the principle of low invasiveness. Doctors are confident that small access must be combined with a minimally invasive (that is, gentle) surgery, then it justifies the essence of the method itself and guarantees the lack of postoperative injuries in the patient. Therefore, doctors conducting laparoscopic operations in children try to work very carefully and literally jewelry. This principle also implies the most gentle attitude when interfering with neighboring healthy organs and tissues. With an open operation, it is almost unrealistic, since the surgeon's eyes cannot give such a detailed image that the video camera is capable of showing the organ from all sides. In addition, manipulation with hands is always more traumatic than working with subtle tools. In this regard, laparoscopic surgery gives great advantages.
Dangerous repetition
Special attention is required by repeated operations, the difficulty of which is that a surgeon starting to work is not fully known for the severity of the scarsing process remaining in a small patient after the previous intervention. After all, any healing in the body goes through the formation of scar tissue. However, the degree of scarring may be different. Therefore, the most difficult stage of such an operation is the allocation of the organ, since the surrounding scars are rather problematic, as important tissues, such as vessels, feeding organs are often included in them. Therefore, few surgeons, even in the world, are solved on repeated laparoscopic operations, which are complex not only technically, but also physically, and psycho-emotional. Nevertheless, if we talk about urology, the risk of losing the kidney during re-open operation is higher than when re-laparo-copic intervention. Therefore, doctors still go to these complex methods. And often achieve excellent results.