LAPAROSCOPY IN CHILDREN – REVIEW OF OUR EXPERIENCE

1. LAPAROSCOPY IN CHILDREN – REVIEW OF OUR EXPERIENCE Hemraj, RAMESH BABU S Pediatric urology unit SRI RAMACHANDRA MEDICAL COLLEGE AND RESEARCH INSTITUTE CHENNAI

2. INTRODUCTION • Laparoscopy has become the mainstay of treatment for many conditions in adult urology. • Diagnostic laparoscopy was done 30 years ago in pediatric urology for diagnosing non palpable testes1. • Era of therapeutic laparoscopy began with introduction of clipping for 1st stage Fowler-Stephens operation in 19912 and laparoscopic orchidopexy was performed in 19943. • 1. Cortesi N, Ferrari P, Zambarda E, et al: Diagnosis of bilateral abdominal cryptorchidism by laparoscopy. Endoscopy 1976;8:33.2. Bloom DA: Two-step orchiopexy with pelviscopic clip ligation of the spermatic vessels. J Urol 1991;145:1030–1033. • 3. Jordan GH: Will laparoscopic orchiopexy replace open surgery for the nonpalpable undescended testis? [editorial; comment]. J Urol 1997;158:1956.

3. Introduction • Development of laparoscopy in pediatric urology was slower when compared to adults. • With availability of expertise and equipments, more centers have started using laparoscopic approach for management of pediatric urological problems.

4. MATERIALS AND METHODS • All the children who underwent laparoscopy for various paediatric urological problems from July 2006 to June 2008 were included in the study.

5. General principles • Open Hassan’s technique was used for umbilical port in all the cases • Transperitoneal approach was adapted in all the cases • Ports • 10 mm and 5 mm ports were used • Two lateral ports and one umbilical port were used • Whenever indicated a fourth port was used • Intra abdominal pressure • Was always kept low at about 8 – 10 mmHg

6. Port placement 05mm 0 10mm 05mm 05mm 010mm 010mm 05mm 010mm Right nephrectomy Left nephrectomy

7. Procedures • Lap orchidopexy 6 • Lap Ureterolysis 1 • Lap assisted nephrectomy 3 • Lap nephrectomy 7 • Lap assisted pyeloplasty 3 • Lap pyeloplasty 1 Total 21

9. RESULTS • The mean operating time was 3 hours ( 2 – 3.5 hours ) • The operating time was higher in the initial cases (3.5 hours) • With the learning curve, the current operating time has come down further

10. Results • Conversion rate • 3/21 procedures (14%) • 1 nephrectomy; 2 pyeloplasty • Intra operative problems (during early stages) • Bowel distension (avoid nitrous oxide, Pre op enema) • Hyper carbia (using low pressures, intermittent deflation) • Duration of hospital stay • Mean duration 4.5 days (3-8 days) • Main reason to stay was to establish feeds, IV antibiotics etc

11. Paediatric Laparoscopy Vs Adult • Advantages • Well defined tissue planes • Thin abdominal wall • Smaller vessels, amenable to clips / diathermy • Limitations • Limited space, Ports clash • Size of the instruments • Complications such as bowel injury

12. DISCUSSION • Laparoscopy offers reduced hospital stay, reduced complications and superior cosmetic results in children • More complex procedures can be performed with ease • Multiple problems can be tackled with planning ports • With experience, the operating time is significantly reduced nearing to that of a open procedure.

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