Children's laparoscopy. Laparoscopy in children - the advantages of laparoscopic operations with newborns and children older

Laparoscopic pyeloplastic in children: experience 250 patients.

Zakharov A.I. 1, Covarsky S.L2, Tekototov A.N.², Sklyarova T.A1, Sottale Z.Z. 2, Petrukhina Yu.V. 2, Rushed K.A.2

1 DGKB number 13. N.F. Filatova Moscow, 2 Rnim. N.I. Pirogov Moscow

When obstruction of the piiveuretral segment with a real alternative to open operations in last years is a laparoscopic separating pyeloplastic, while the basic principles surgical correction - resection of the portion of the ureter within a healthy area with the imposition of ureteropyelastomosis - remain unchanged.
Methods: from 2008 to 2014. Including in the department of urology of the Philatian kids hospital, 256 operations were performed about simple hydronephrosis in 250 children (69 girls, 181 boys) aged 2 months to 18 years (average age of 2.8 years) using endoscopic technologies. Age 77 of them were less than 12 months.

Indications for organophing operations were based on ultrasound results with dopplerography of renal vessels, data x-ray methods and static renography. With significant sizes of pellets (more than 30 mm), it was pre-(for 3-6 months) with the help of puncture pyelostomy under the control of the ultrasound (in our work - 18 patients) with a delayed laparoscopic pyeloplasty. The rest of the children made primary laparoscopic pyeloplasty with transperitoneal or retroperitoneal access. After installing 3 trocars - 5 mm optics and two manipulators 3 mm, the piiveuretheral segment was mobilized and a partial resection of a locher with longitudinal dissection of the ureter was performed (the Anderson-Hynes principle). Peliuretheral anastomosis was superimposed with a continuous seam of PDS 5-0 or 6-0 thread. The drainage was carried out by installing (antite or retrograd) internal JJ - stent. The duration of the operation was 120 ± 40 minutes.

Results. All operations were completely laparoscopic, there was no conversion. Fabry infectious complications are not registered. Patients are discharged by 3-7 postoperative days under outpatient observation urologist. The ureteral stent during the primary operation was removed after 6 weeks, with surgery over the recurrence of hydronephrosis 12 weeks after the operation. In 240 cases (96%), a reduction in the size of the CHLS is noted, the absence of urinary tract infection, improving intravenous blood flow according to Doppler data (after 1.6, 12 and 24 months after surgery. In 6 patients (4 - after the preliminary drainage of the pellek), pyelectasia was maintained The background of the HBS, about which they were held conservative therapy. In 4 children were diagnosed by the recurrence of the disease, which was indicated to re-laparoscopic pyeloplasty.

Conclusion. The results of the treatment of congenital hydronephrosis in children using laparoscopic pyeloplasty are comparable to open operations, but smaller invasiveness, the low probability of infectious complications and the possibility of early intensification of patients make this treatment method most optimal.

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The study in all cases is carried out in the operating system under general anesthesia with artificial ventilation of the lungs, since the pneumoperitoneum can significantly limit the movements of the diaphragm, especially in children early age.

Before starting manipulation in all cases, a thorough deep palpation is carried out abdominal cavity Under the anesthesia, which often allows you to more clearly determine the presence and location of bloated interstitis, tumor-like formations, inflammatory infiltrates, invaginate, etc. In addition, during palpation is controlled by the sufficiency of the gastric emptying and bladder.

For the initial entry into the abdominal cavity, we widely use a special direct puncture method with a stupid trochar. Skin cut is performed with a length of slightly less than the diameter of the trocar, which is supposed to be introduced in this place (as a rule, 5.5 mm, with peritonitis -11 mm) - more often in the area of \u200b\u200bthe umbilical ring along its upper edge (Figure 7A). Then the surgeon in young children with his left hand lifts the front abdominal wall. Through the specified incision, a sharp clamp of the Mosquito type, which disseminates fascia and aponeurosis without opening the abdominal cavity (Figure 7B). In the same position, but already with the help of a stupid clamp (type "bilrot"), the peritone (Figure 7B) is revealed.

Figure 7. Stages of the front entry into the abdominal cavity by the method of right puncture with a stingy trocar in young children

The moment of penetration into the abdominal cavity is usually clearly felt by the surgeon. At the same time, it is almost always possible to note the characteristic sound of the "suction" of the air into the abdominal cavity. Without changing the position of the left hand, lifting the front abdominal wall, a stupid trocar (Figure 7g) is introduced through incision. In older children, especially with a pronounced subcutaneous fatty cell, helps to raise the front abdominal wall also an assistant surgeon (Figure 8).

Figure 8. The input of primary entry into the abdominal cavity in older children

The correct position of the Troacar is always controlled using a 5 mm telescope introduced into it with a 30 ° C angle with a miniature endovideo camera. Careful compliance with all listed rules for the first puncture of the abdominal cavity allows you to avoid serious complications - billings or injuries internal organs. Making advocating in the correct arrangement of the Troacar, the insoflation of C0 2 begins using an electronic insoflet. The volume of gas used is 1-1.5 liters in small children, up to 3-5 liters in adolescents. The level of intra-abdominal pressure ranges from 5-8 mm Hg. Art. In newborns and infants to 10-14 mm Hg. Art. At older age.

The second trocar (3-5.5 mm) is introduced in the left iliac region already under the control of the endovideosystem. With the help of the videoParoscope and the palpatira probe (or the atraumatic clamp), administered through the trocar sleeve in the left iliac region (Figure 9), the abdominal cavity is carried out. First of all, the place of entry into the abdominal cavity of the manipulator is examined, which, if necessary, is released from the strand of the gland. Then a panoramic examination of the entire abdominal cavity is made, during which the availability of traffic, the state of intestinal loops and peritoneum is estimated.

Figure 9. Operating access to diagnostic laparoscopy. The place of introduction of trocharov:
1 - trocar 5.5 mm (for palpator); 2- Throacar 5.5 mm (for laparoscope 5 mm, 30 o)

The revision begins with the search for the dome of the blind intestine. In early age children, the dome is usually located above, in the right lateral channel, sometimes under the right lobe of the liver. There is also an increased mobility of a blind intestine - in these cases its dome can be detected medially, among loops thin gut On the middle floor of the abdominal cavity. It is often found a long blind intestine with the localization of the dome in the area of \u200b\u200bthe small pelvis in such a way, if there is no blind intestine in the right iliac hole, and there are difficulties in its detection, the inspection is advisable to start from the cross-colon.

Sequentially moving the laparoscope along the triumph in the direction to the ileocecular corner, using the manipulator and the change of the patient's body position, determine the localization of the dome of the blind intestine. The removal in the field of view of a worm-like process when using a manipulator does not represent difficulties. Some difficulties may occur if there are congenital adhesions in the Ileocecal region, this is a bunch of lein, fixing the distal loop of the ileum to the ileum-lumbar muscle. In this case, Appendix can be located behind the ileum. It makes it difficult to inspect the Jackson membrane, which is a plenized trample, fixing the blind and rising intestine to the parietal peritoneum of the right lateral canal. With the severity of these adhesions in the area of \u200b\u200bthe dome of the blind intestine, the black-shaped process can be located in a narrow retrocecore pocket.

In case of difficulties of this kind, you must turn the patient on the left side, to find the base of the process, and, carefully pushing it with a manipulator (or capturing a soft clip), make it easy traction. Usually in this position it can be displayed in sight.

After the detection of a worm-like process, it is inspected. Normal worm-shaped process movable, easily shifted by a manipulator, a serous shell is shiny, the color is pale pink (Figure 10). The presence or absence of inflammation in it is judged by direct and indirect features. To indirect signs, we assume the presence of mudding in the immediate vicinity of the process, the peritoneum reaction in the form of hyperemia, the disappearance of its natural shine, the presence of fibrin raids.

Figure 10. Endoscopic picture of an unchanged duct-like process

Direct signs are detected with the immediate inspection of a heart-shaped process. We include the injection of the seroza, its hyperemia, the disappearance of the natural brilliance of the serosine, the change in its natural color, both in certain areas and in general, infiltration of both the walls of the process and its mesenter, the presence of fibrin raids. It is possible to "proper" the voltage of the process and observe its rigidity (Figure 11). Inflammatory changes are more often pronounced in the di steel process. In addition, it is often possible to detect the presence of loose adhesions and between the process and the surrounding tissues. In some cases, in the presence of gangrenous changes in the wall of the process, a perforative hole is detected.

Figure 11.Endoscopic pattern of phlegmosno changed Cell-shaped process

The greatest difficulties occur when differential diagnosis The initial stages of destructive inflammation and surface inflammation of a heart-shaped process. In this case, of all the described features, it is possible to identify only the easy hyperemia of the serosine, the injection of its vessels. The only differential diagnostic sign that allows us to distinguish statiya Destructive inflammation in the process from the surface inflammatory reaction is its rigidity.

With this feature, it is possible to identify destructive inflammation in draw-shaped process Even in its early stages. This feature is determined as follows: a worm-shaped process is lifted by a manipulator supplied under it in an average third if the Cell-shaped process saved, no matter how falling from the manipulator, this feature It was considered negative (Figure 10) if it holds the shape of the rod or the whole, or in a separate section, this feature is considered positive (Figure 11).

It should be noted that the specified feature is the most reliable of all existing and we are used as a pathognomonic endoscopic symptom.

Significant difficulties arise in the differential diagnosis of pronounced secondary changes in a worm-like process against truly destructive changes in it. Thus, with primary pelvioperitonite, expressed mesadenite or another source of inflammation of the abdominal cavity detects secondary changes in the heart-shaped process.

Even is noted serous shell, Its vessels are full, extended, presented in the form of a network, enveloping the process. Unlike primary inflammation, there is no rigidity (deep layers are not involved in the process), there is also no uniform hyperemia and the sealing of the process. Thus, visible secondary changes in the heart-shaped process are servers and are a consequence of contact with inflammatory flow.

If there is no destructive inflammation in a heart-shaped process, a thorough gentle audit of the abdominal cavity organs is carried out according to the following procedure.

Since the patient during the inspection of a draft-like process is in the Trendelenburg position with a turn to the left side, then first of all it can be conveniently inspecting the ileocecal angle and the mesentery of this intestinal department (Figure 12). IN childhood frequent cause Abdominal pain is acute mesenteric lymphadenitis. In the mesentery of the ileocecal angle, in the mesentery of the small intestine, increased, edema and hyperemic lymph nodes are revealed.

Figure 12. Patient position on the operating table when examining an ileocecal angle and a heart-shaped process

Sometimes enlarged Lymph node packs resemble a "bunch of grapes". Then there is a retrograde ileum at a distance of at least 60-80 cm from the ileocecal angle. At the same time, we use the palpator probe, looking at the loop of the loop of the small intestine. This allows you to identify the most diverse pathology: Mekkel diverticulus. Angiomatosis. inflammatory diseases, neoplasms, etc.

Having increased the angle of inclination of the table in the Trendelenburg position. The bodies of the small pelvis are viewed, where the girls are drawn to the uterus with appendages. First, the right appendage is examined, then by setting the side tilt of the table, but, while maintaining the position of the Trendelenburg, the left appendage of the uterus is examined.

In the same position inspecting the inner rings of the right and left inguinal channels. Attention is drawn to their consistency, in addition, the boys in these areas sometimes discovered an egg showing the presence of abdominal form of cryptorchism. Seed-withdrawing docks and egg vessels are examined here.

Then the patient is attached to the position of the foller with a turn to the left side in which it is examined right share liver, gall-bubble, region of hepatic duodian ligament, pylorial diversity of stomach, bulbs duodenal gut, the contours of the lower pole of the right kidney. By removing the side turn of the table, but, while maintaining the position of the foller, inspect left share Liver, round and sickle ligaments of the liver, the front wall of the stomach, the area of \u200b\u200bthe small gland and gastrointestinal bundle.

More complex examination of the spleen, which is located high under the diaphragm covered with the gland, and in small children - also the left lodge of the liver. The patient must be rotated to the right side and lift the head end of the table. Shooting the manipulator the gland and intestinal loops, in the field of view, remove the spleen. Its mobility depends on the severity of the ligament, however, it is usually possible to clearly consider the front end, the top edge, the diaphragm surface and the area of \u200b\u200bthe gate. Normally, the region of the left kidney is not visible. The revision of the upper and middle floors of the abdominal cavity is completed by the inspection of the loop of the small intestine. Using a manipulator, you can manipitate the entire intestine, my mesenter, abdominal part Aorts, place of her bifurcation.

Gentle method of laparoscopy taking into account age features In children, the use of modern Pediatric Laparoscope models allow fundamentally to approach the diagnosis of appendicitis in a new way. The use of puncture laparoscopy with dubious results of other research methods allows not only to accurately establish the presence or absence of inflammation in a worm-like process, but also when the diagnosis is excluded acute appendicitis Conduct a gentle audit of the abdominal organs and more than 1/3 of patients to identify the true cause of pain abdominal syndrome. Most often, nonspecific mesadenitis, gynecological diseases in girls, cryptogenic pylvioperitonitis, diseases of the biliary system and Ileoceclane are found.

Analyzing the obtained data of diagnostic laparoscopy, you can allocate the following options for further tactics:

1. The study ends at the diagnostic stage, while no pathology is detected.

2. The study ends at the diagnostic stage, while the pathology of the abdominal organs, requiring conservative treatment, is revealed.

3. As a result of the diagnostic stage of laparoscopic intervention, diseases of the abdominal organs are detected, the treatment of which can be made using laparoscopic interventions.

4. At the diagnostic stage of laparoscopic intervention, diseases are detected, the treatment of which is impossible to produce laparoscopically. These patients are subjected to laparotomy.

D.G. Kriger, A.V. Fedorov, P.K.Voskreshensky, A.F.Dronov

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 malformations 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?

Operation Laparoscopy in childhood is carried out only under general anesthesia, but the duration of the operation in comparison with traditional method (The cut 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 output from anesthesia is provided with a small probability of such side Effectslike 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 surgical treatment A small patient is accepted by a doctor together with parents, given all the arguments for and against.

In its development, the minimum invasive surgery in children has passed the way from adapting to pediatric practice of such common in adult operations, as, before the use of laparoscopy and for conducting, which are found only in children's surgery, for example, the reconstruction of the atresia of the esophagus and trachene-esophagus fistula. This article is devoted to pediatric variants of operations commonly carried out in adults, as well as some neonatal operations that are performed by children's surgeons - a wide profile specialists.

Children have specific anatomical and physiological features, which is important to keep in mind when carrying out laparoscopic operations. In newborns and young children abdominal wall The elastic and the top of the bladder is located intraperitoneally, which makes the introduction of trocars potentially dangerous. Most newborn and many children have upholstered herniawhich can become convenient locally For access to the abdominal cavity, and after the operation you can carry out the hernia. The liver of the newborn usually has proportionally large sizes, and even a small injury can lead to profuse bleeding, which is difficult to stop. All laparoscopic ports in newborns need to be installed significantly below the level of the rib arc, and when resting the liver should be particularly careful.

Available for use of short endoscopic ports with a diameter of 3.4 and 5 mm, both disposable and reusable. Children often have the need to install ports in the distance from each other and at points that do not match with the points of installation of trocars during adults in operations in order to avoid the "duel" of the tools in the small operating field of the child. Many children perform operations through cuts on the stomach, and not through ports, with the exception of the ports for the camera or large tools. Wide spectrum Operations on the gastrointestinal tract, biliary paths, adrenal glands, spleen and organs gOOD SYSTEM It can be safely carried out without the use of ports, which considerably saves financial resources. Laparoscopic chambers and energy sources for electrosurgery have a diameter of from 3 to 5 mm, but ultrasonic coagulators usually have a diameter of at least 5 mm, and an endoscopic stapler requires the installation of a 10mm port. The size of these tools sometimes limits the minimum invasiveness, which it would be possible to achieve newborns.

Children are usually strengthened by mechanical and physiological effects of pneumoperitoneum, insufflation pleural cavity and ventilation of one lung. In the state of the pneumoperitoneum in children, the children are absorbed in proportion to the larger amount of carbon dioxide than in adults, and the absorption and removal of carbon dioxide depends on age. Inside insufflation for laparoscopic operations, newborn has a decrease in systemic arterial pressurewhich is usually possible to proceed with an increase in fluid infusion, but increasing the maximum concentration of CO 2 at the end of a calm exhalation is often impossible to return to the norm by enhancing ventilation, so it is supported before the operation is completed. In newborns with immaturity or violation of work of cardio-vascular system The risk of side effects during a long period of insufflation is particularly elevated, and they have a thorough monitoring in the peripheral period. Pneumoperitoneum causes reversible Anuria by almost all newborns and oliguria in many children, and these changes in urinary depends on the volume of intraoperative infusion. Thus, in children while maintaining pneumoperitoneum infusion therapy It should not be strictly focused on the volume of allocated urine. Fortunately, the elastic abdominal wall allows many abdominal operations with an insufflation pressure of 5-10 mm Hg, and many thoracic operations do not require insufflation at all. In all cases, insufflation pressure must be limited, with a maximum pressure of 12 mm Hg. In babies with a body weight less than 5 kg.

Many modern open operations Characterized by acceptable cosmetic and excellent functional results. The advantages of laparoscopic and thoracoscopic operations in newborns and children must be assessed by modern criteria and take into account the shortcomings of laparoscopic operations that can occupy more time, be more expensive and lead to undesirable physiological effects. As technology complicates and the growth of surgeons in the implementation of laparoscopic operations, many laparoscopic and thoracoscopic operations will most likely become routine in children's surgery.

The article has prepared and edited: a surgeon doctor

Laparoscopic operations in children Percentwhile: their list includes appendectomy, herniance with groin hernia, fondoplikation, splenectomy and kingctomy. Compared to laparotomy, laparoscopic intervention is less traumatic, and recovery after it takes less time. At the same time, the operation may be long.

It is very important to properly put the patient on the operating table. Typically patients operated in the back position. It is important to negotiate with the surgeon in advance, where it will rise and how monitors will be located.
Filling in the abdominal cavity of the gas (for example, C02) and the lowered head end limit the movement of the diaphragm, the gas exchange is worsen and can reduce the venous refund.
Nitrogen is not used.

Complications: suction C02 in the bloodstream, unintentional blowing of C02 under the skin or extra-barnishly, injury to the adjacent organs and tissues with trockers and laparoscopes, hidden bleeding.
To facilitate postoperative pain, solutions of local anesthetics infiltrate the zones of the introduction of trocarians, use NSAIDs, paracetamol, sometimes a morphine infusion.
Monitoring body temperature is needed, since sometimes hyperthermia can develop during a long operation.

Operation with groin hernia, hydrocele and twist eggs in children

These are common operations with similar anesthesiological strategy. They are performed through a small incision at the bottom of the abdomen. In the absence of concomitant diseases, these interventions are carried out in a day hospital.

W. newborn, especially in premature, hernias are found very often. Interventions about hernia in newborns in day hospital are not performed. Inguinal hernia Usually painless and easily busted. Unfficred hernia is fraught with grown of the intestine, which may require emergency intervention.

Orchisexia Showing at the location of the testicles in the abdominal cavity or in the upper part of the scrotum, since true cryptorchism increases the risk malignant tumors Eggs.
Inhalation or V / in introductory anesthesia.
Providing passability respiratory tract With a facial or laryngeal mask.
Young children may need intubation of trachea and IVL.
Before the operation of the operation (in the ward or after introductory anesthesia), it is advisable to assign NSAIDs or paracetamol to the proactive anesthesia.
Local pain relief: blockade of iliac-inguinal nerve, sacral blockade or infiltration anesthesia.

If bilateral intervention is planned, the sacred blockade is preferred: it is easily executed and well managed.
During orchipexia, the peritonean traction can cause reflex bradycardia.
With orchisexia, the iliac-groove blockade may be insufficient for the pain relief of the scrotum skin, so it is necessary to infiltrate the area of \u200b\u200bthe solution with a solution of local anesthetic.
When the egg is located in the abdominal cavity, the operation is performed in two stages. The first stage of the Egg is lowered to the inguinal ring, and the next time it is reduced to the scrotum.
Laparoscopic operations are increasingly carried out in children of all age groups. Features of anesthesia with laparoscopic operations are described above.

Twisted eggs Sometimes it is found in newborns, but more often - in children older. You can smash irreversible damage to the egg, and the operation is carried out in an emergency order.
It should be processed from the fact that the evacuation of gastric content is slowed down (full stomach).
Conduct fast serial introductory anesthesia.
Intubate the trachea and conduct IVL.
Anesthesia is carried out in the same way as with orchisexia.