Felix Schier, Salmai Turial (Auth.) - Laparoscopy in Children (2013, Springer-Verlag Berlin Heidelberg)

Felix Schier · Salmai Turial
Laparoscopy
in Children
Second Edition
123
Laparoscopy in Children
Felix Schier • Salmai Turial
Laparoscopy in Children
Second Edition
Authors
Felix Schier Salmai Turial
Emmetten Department of Pediatric Surgery
Schweiz University Medical Center Mainz
Mainz
Germany
ISBN 978-3-642-37637-5 ISBN 978-3-642-37638-2 (eBook)

DOI 10.1007/978-3-642-37638-2
Springer Heidelberg New York Dordrecht London
Library of Congress Control Number: 2013943014
© Springer-Verlag Berlin Heidelberg 2013

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Preface
Laparoscopy in children is special.

Children come in all sizes. The small size of children is an important technical
aspect. Also, there are characteristic paediatric indications for laparoscopy. The
most typical ones are described in this booklet.
This booklet is written for colleagues – adult and paediatric surgeons alike –
wishing to profit from the experience of authors who have performed numerous
laparoscopies in children of all sizes, many of them newborns.
The authors are aware of the fact that current medical progress may appear ridic-
ulous in 100 years. Laparoscopy in children began 20 years ago, and techniques are
constantly changing. Laparoscopic surgery may historically be the transition from
conventional “open” surgery to a surgery without scars. Reader should thus see our
comments as preliminary ones. Any suggestions for improvements would be very
welcome.
We also have omitted the “troubleshooting” section of the first edition. That sec-
tion was needed at the beginning of laparoscopic surgery, but not now anymore.
Humans have a natural inhibition about inserting sharp instruments into a small
child’s abdomen. However, once they have cut through the abdominal wall and can
find their bearings, surgeons usually feel comfortable.
This booklet contains no statistics and no comparisons with open approaches.
Instead, it concentrates on the practical steps involved.
Applying the techniques described, the reader may also master procedures not
mentioned here. The principles are covered in this booklet.
Do not use 10-mm instruments in children. Complete sets of instruments of 3 and
2 mm in diameter or even less are available. They enable us to operate virtually
without scars and can also be used in adults.
This 2nd edition covers more indications. They were still experimental at the
time of the 1st edition but have entered general practice in the meantime. It also
displays a different drawing style and reflects the fact that we have changed in the
meantime to optics of 2-mm diameters (in the 1st edition we were using 5-mm
optics).
Mainz, Germany Felix Schier

Salmai Turial
v
Contents
1 Equipment, Children, Anesthesia, Gas Embolism . . . . . . . . . . . . . . . 1

1.1 Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
1.2 Children . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
1.3 Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.4 Gas Embolism . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
2 Technical Basics: Insufflation, Trocar Insertion, Instruments, Needle

Insertion, Suturing, Ligating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
2.1 Insufflation (1) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
2.1.1 When Starting Insufflation with a 5-mm Trocar . . . . . . . . 12
2.2 Insufflation (2) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2.2.1 When Starting Insufflation with a 2-mm Trocar . . . . . . . . 14
2.3 Trocar Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
2.4 Instruments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
2.5 Needle Insertion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
2.6 Suturing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.7 Ligating . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
3 Thoracoscopic Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
3.1 Esophageal Atresia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
3.2 H-Fistula. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
3.3 Diaphragmatic Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
3.4 Lung Biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
3.5 Pneumothorax . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
3.6 Sympathectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
4 Upper Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
4.1 Achalasia (Heller Myotomy) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
4.2 Fundoplication (360° Nissen) . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
4.3 Eventration of the Diaphragm . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
4.4 Splenectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
4.5 Spleen Cyst (Technically Identical to Liver Cysts) . . . . . . . . . . . . 60
4.6 Liver Biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
vii
viii Contents
5 Right Upper Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

5.1 Pyloromyotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
5.2 Biliary Atresia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
5.3 Cholecystectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74
5.4 Cholecystotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76
5.5 Choledochal Cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78
5.6 Duodenal Atresia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88
6 Urogenital Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95
6.1 Cryptorchidism. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 96
6.2 Orchiopexy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100
6.3 Inguinal Hernia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
6.4 Varicocele . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 106
6.5 Urachal Cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
6.6 Pyeloplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
6.6.1 Purely Laparoscopic . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110
6.6.2 Laparoscopy Assisted . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112
6.7 Ovary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 114
7 Middle and Lower Gastrointestinal Tract . . . . . . . . . . . . . . . . . . . . . 121

7.1 Adhesiolysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122
7.2 Small Bowel Atresia. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126
7.3 Intussusception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
7.4 Meckel’s Diverticulum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
7.5 Appendectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
7.5.1 Classic Three-Trocar Technique . . . . . . . . . . . . . . . . . . . . 132
7.5.2 “Single-Trocar” Technique . . . . . . . . . . . . . . . . . . . . . . . . 132
7.6 Sigmoid Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
7.6.1 Laparoscopic Part . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136
7.6.2 Perineal Part . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138
7.7 Rectopexy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140
7.8 Anal Atresia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 147
Equipment, Children, Anesthesia,
Gas Embolism 1
Standard equipment is used: monitor, video equipment, insufflator, light source,

etc., as in adult patients.
Indeed, there is no difference to the equipment used for adult patients-except that
insufflators for adult patients insufflate at high rates, too high for small children.
They cannot go below 1 l/min.
All other technical characteristics of the minimally invasive technique are identi-
cal in adult and children.
Most procedures in children can be performed with 2- or 3-mm instruments.
Instruments do not need to be larger.
Children do not need urinary catheters. True, there is reduced intraabdominal
space, but most procedures do not need an empty bladder, except for sigmoid resec-
tions, rectopexies, and procedures at the inner genitalia.
Similarly, the anesthesia for minimally invasive procedures in children is not
significantly different from adults.
Surgeons and anesthesiologists should realize that the rare event of a gas embolus
will first be noticed by the anesthesiologist, not the surgeon.
F. Schier, S. Turial, Laparoscopy in Children, 1

DOI 10.1007/978-3-642-37638-2_1, © Springer-Verlag Berlin Heidelberg 2013
2 1 Equipment, Children, Anesthesia, Gas Embolism
1.1 Equipment
Two pieces of equipment need special attention:

• The insufflator has to be capable of delivering CO2 volumes of less than 0.5 l/
min. Some insufflators will deliver only rates of 1 l/min or more. A small child
may only have an abdominal capacity of 150 ml. In those children, insufflation
might be completed in seconds.
CO2 does not need to be heated. Temperature loss is only a concern if trocars
fall out and instruments are changed excessively often, which would require
re-insufflation with cool CO2.
• The light source needs to be powerful. As much as possible light needs to be
squeezed through narrow trocars.
All the remaining equipment is standard, as in adult laparoscopy.
The cautery is the piece of equipment that most often malfunctions.
The trolley should be placed on the other side of the patient, with the patient
between the surgeon and the trolley.
In contrast to conventional commercial arrangements, we place the monitor
low in order to close the angle between working and viewing directions (Fig. 1.1).
1.1 Equipment 3
Monitor
Insufflator
Light source
Fig. 1.1 Trolley with monitor placed low

1.2 Children
A urinary catheter is unnecessary, as a full bladder seldom obstructs the view. If it

does, a large needle can be inserted through the abdominal wall in order to empty
the bladder. Children should go to the toilet before laparoscopy.
Enemas are unnecessary. They will not necessarily empty the colon and may
even distend it.
Padding below the patient is risky, as it lifts up the endangered vessels and brings
the structures upward into the reach of the trocars (Fig. 1.2).
Laparoscopy is easier if the patient is fully relaxed.
The bowel is often dilated in small children, making visualization difficult. Wait
and continue dissecting, the situation will improve by itself.
The child should be prepared such that conversion to an open approach is pos-
sible at any time.
A neutral electrode is placed in order to save time if a conversion becomes nec-
essary.
The ether screen is adjusted to a low position in order to reach the pelvis with the
laparoscope.
Prior to introducing the first trocar, the laparoscope is readied in order to be able
to see immediately after the trocar is inserted. Furthermore, the cautery is checked
whether it is functioning properly by coagulating a wet sponge prior to inserting the
first trocar.
1.2 Children 5
Low ether
screen
Nasogastric
tube
Electrode
No padding
Fig. 1.2 No urinary catheter. Padding brings the aorta closer to the reach of the trocar tip
1.3 Anesthesia
The patient is premedicated with a parasympatholytic (this reduces the likelihood of

bradycardia and bronchial hypersecretion).
For monitoring, capnography, pulse oximetry, non-invasive blood pressure mea-
suring, and electrocardiography (ECG) are used (Fig. 1.3).
A nasogastric tube is inserted (this prevents trocar perforation and aspiration).
Volatile anesthetics are used. Remember the association between halothane and
arrhythmias in hypercapnia. Isoflurane or sevoflurane should be preferred (less
myocardial depression). Avoid nitrous oxide (thought to distend the bowel). Use
muscle relaxant.
Tracheal intubation and controlled ventilation are used. After CO2 insufflation
the position of the tracheal tube is checked again (when the diaphragm is elevated,
there is a relative downshift of the tube, producing a risk of unilateral intubation).
Mild hypercapnia tonicises blood vessels. This raises the heart preload (adequate
fluid management).
Ventilation is adjusted to the end-tidal CO2. Ventilation is increased up to 60 %
(mainly via the respiratory rate), and a positive end-expiratory pressure is main-
tained (PEEP) of 3–5 cm H2O (this prevents microatelectases and intrapulmonary
shunting).
1.3 Anesthesia 7
Heart Blood Pulse Temperature

rate pressure oximetry
NO2 Pressure PEEP Respiratory Airway

controlled rate pressure
ventilation
Sevoflurane Capnography
Fig. 1.3 Monitoring

1.4 Gas Embolism
This is a very rare event which the authors have never seen.
CO2 enters the venous system and the right ventricle, blocking the pulmonary
vasculature. This leads to right heart failure, dilated neck veins, hypotension, brady-
cardia, desaturation, CO2 retention (but low end-tidal CO2 pressure, PEtCO2), and a
rise in airway pressure.
Obviously, the surgeon will not notice a gas embolism! Only the anesthesiologist
will notice the first sign: A sudden fall of end-tidal PEtCO2!
Actions to be taken (Fig. 1.4):
1. Stop CO2 insufflation.
2. Stop nitrous oxide (this reduces bubble size) and administer 100 % O2
3. Perform Durant’s maneuver: left-sided head-down position (this shifts pulmo-
nary outflow, with gas bubbles accumulating above, and restores adequate car-
diac output).
Notice that it requires enormous amounts of intravascular CO2 to actually cause
a fatal threat to a patient. This is the reason why dangerous incidents with CO2
embolism are practically unheard of in children. In contrast, only a few ml of room
air is sufficient to cause a deadly incident. The connecting tubes from the insufflator
to the child contain 80–120 ml of room air. Thus, if the tubes are not flushed with
CO2 prior to starting intraabdominal insufflation, the room air contained within the
tube will be insufflated into the abdomen. Insufflation of room air into a major blood
vessel carries a deadly risk.
1.4 Gas Embolism 9
Stop
insufflation
Give O2
and stop NO2
Fig. 1.4 Actions to be taken in suspected gas embolism

Technical Basics:
Insufflation, Trocar Insertion, 2
Instruments, Needle Insertion,
Suturing, Ligating
The physical dimensions are smaller in children. The small spaces are quickly filled
with gas. The space within the CO2 tubing may suffice to fill the child’s abdomen;
it will be room air if the tubes are not flushed with CO2 prior to starting the
insufflation – with the incorrect assumption that CO2 is insufflated.
The distance from skin to aorta is short. We never start insufflation without prior
having checked with the laparoscope where the Veres needle tip is located.
Insufflation rates are smaller than in adult patients, although a number of pediat-
ric laparoscopists insufflate at rates of 1 l/min. In animal experiments, however,
such high insufflation rates have led to cardiovascular problems (and more so did
rapid desufflation).
It is an incorrect prejudice that 2-mm instruments bend and break easily. They
are sturdy enough, and 3-mm instruments are even sturdier. Two- and three-
millimeter instruments come in all varieties, just like 5- or 10-mm instruments.
Needle insertion is in small children mostly directly through the abdominal wall.
If a needle has to be removed at the end, it is removed together with the trocar – and
the trocar reinserted if needed.
Suturing and ligating are just as in “instrument knotting” in “open” surgery.

12 2 Technical Basics
2.1 Insufflation (1)
2.1.1 When Starting Insufflation with a 5-mm Trocar
A 4-mm transverse incision below the lower rim of the umbilicus is made so that the
incision is later hidden inside the umbilicus. This also may save a skin suture later
when withdrawing the trocar (Fig. 2.1).
The tissue is spread with small scissors down to the fascia (Fig. 2.2).
The Veres needle is inserted while lifting up the abdominal wall on both sides
(Fig. 2.3). There are two distinct snaps – both of them visible, audible and palpable
– when inserting the Veres needle. The second structure, the peritoneum, is the
tougher one.
It is preferable to stay inside the umbilicus, because there are fewer structures to
be crossed, and to go almost vertically down, not too obliquely because one may
end still within the abdominal wall layers. Do not aim toward the bladder.
The penetration depth of the Veres needle may be estimated by tilting it and pal-
pating for the tip (Fig. 2.4).
2.1 Insufflation (1) 13
Fig. 2.1 Scalpel incision at the lower aspect of Fig. 2.2 Spreading with scissors down to
the umbilicus for insertion of a 5-mm trocar the fascia
Fig. 2.3 Lifting the abdominal while inserting Fig. 2.4 Estimating the intraabdominal length
the Veres needle of the Veres needle
2.2 Insufflation (2)
First, physiologic saline is injected in order to rule out high resistance as one would
expect in intramuscular injection (Fig. 2.5). Intravascular placement is ruled out by
aspiration. When using a 2-mm trocar and a 2-mm laparoscope for checking the
correct placement, this maneuver is skipped.
The “hanging drop test” indicates correct needle placement: The Veres needle is
completely filled with physiologic saline until a meniscus builds on top of the nee-
dle (Fig. 2.6). Then the abdominal wall is lifted up: The saline will be sucked into
the abdomen (Fig. 2.7). This is considered proof that the needle tip is located intra-
peritoneally. Thereafter, insufflation is started (Fig. 2.8).
The following insufflating rates are used:
<1 year: 0.3 l/min, >1 year: 0.5 l/min, >5 years: 1 l/min.
We start with 0.5 l/min until we are sure that the needle tip is correctly located
intraperitoneally.
2.2.1 When Starting Insufflation with a 2-mm Trocar
The trocar together with the Veres needle is inserted directly through the skin within
the umbilicus, without a prior scalpel incision. The Veres needles are sharp enough.
Next, a 2-mm laparoscope is passed in order to check for correct placement within
the abdominal cavity. Lifting the abdominal wall enables visualization. Thereafter,
insufflation is initiated (with the laparoscope removed from the trocar, because it
will hamper insufflation due to its narrowing of the small trocar diameter).
Intraabdominal pressure will initially be −2 to +2 mmHg and will slowly increase.
We pull up the abdominal wall during insufflation (this prevents the occlusion of the
needle tip with the omentum). Initial pressures of 13–17 mmHg indicate that the
needle is in a wrong position (most likely outside the peritoneum and not deep
enough). In this case the Veres needle is withdrawn and reinserted.
The maximum pressure is 12 mmHg for all age groups. In children older than
10 years, 15 mmHg is acceptable, but this may result in postoperative shoulder pain.
Visualization will not be reduced when the pressure is lowered to 8 mmHg.
In animal experiments, piglets were killed by extremely rapid desufflation at the
end of the procedure.
2.2 Insufflation (2) 15
Fig. 2.5 Injecting to verify Fig. 2.6 Hanging drop test (1).
needle placement Veres needle is filled with saline
Fig. 2.7 Hanging drop test (2). Lifting the Fig. 2.8 Insufflation rate and pressure
abdominal wall will suck the saline into
the abdomen: correct needle placement
2.3 Trocar Insertion
• Two-mm trocars are inserted directly through the abdominal wall, without prior
skin incision. And the correct placement is checked with a 2-mm laparoscope.
• When a 5-mm trocar is inserted at the umbilicus, the valves should be closed and
the safety mechanism should be activated (if the valves are left open, the CO2
will escape immediately upon entering the abdominal cavity). The abdominal
wall is lifted and the forearm is guarded in order to prevent rushing in too quickly
and too deeply (Fig. 2.9).
The laparoscope is inserted and the correct trocar position is verified. If it is cor-
rect, insufflation is started.
The next trocars, the working trocars, are inserted at some distance from the
target organ, not directly on top of it. The line between the target organ, the trocar,
and the instrument should be considered as an extension of the surgeon’s forearm,
very much like eating with cutlery (Fig. 2.10).
Once the laparoscope has been inserted into the abdominal cavity, remember that
the space is small, that the bowel is dilated (especially in small children) and that the
view is close. All these factors may make the initial orientation difficult.
In most instances, the laparoscope is inserted through the umbilicus.
2.3 Trocar Insertion 17
Slightly
oblique
entry
Guard
elbow
Lift up
abdominal
wall
bilaterally
Fig. 2.9 Guarding of the elbow and lifting of the abdominal wall for 5-mm trocar insertion
Fig. 2.10 Working trocars are placed in a configuration similar to using cutlery while eating
2.4 Instruments
Since the last edition of the book, we have adopted 2-mm instruments and 2-mm
laparoscopes for most operations. They do not break and bend as easily as feared.
Previously we had used mostly 5-mm/0° laparoscopes. In the meantime the
2-mm laparoscopes have become much better. They also have the advantage that
they are exchanged easily from one 2-mm trocar to another for better visualization.
Unfortunately, the 2-mm laparoscopes pass less light. At the distance, the pictures
thus are darker. Photographs for documentation are not as good as with 5-mm lapa-
roscopes. And the 2-mm laparoscopes indeed do break more easily.
Thirty degree laparoscopes are more difficult to handle than 0°. But they have
advantages, for example, in fundoplications for the visualization of the esophagus’
left side.
Five millimeter instruments and trocars are relatively large for small children
(Figs. 2.11 and 2.12). Sets of 3-, 2- and even 1-mm instruments are available; 2-mm
instruments are easily bent and even broken, but 3-mm instruments are sturdy.
Trocars for 3-mm instruments are still rather large. Trocars for 2-mm instru-
ments are significantly smaller. Several types are commercially available (Fig. 2.13).
They may be replaced without hesitation intraoperatively, should the initial place-
ment prove inadequate since they leave virtually no scar. Also, they do not need any
suturing upon withdrawal; a bandage suffices.
Suction and irrigation is useful with 5-mm instruments. Suction is difficult with
2-mm instruments, as the fluid will be expressed through the cannula due to the
increased intraabdominal pressure.
The cosmetic results achieved with 2-mm instruments are superb, and there are
virtually no scars. Two-mm clips are not available, and tied ligatures have to be used
with 2-mm instruments.
Fogging can be reduced by increasing the light intensity to 100 % before insert-
ing the laparoscope. This heats the tip of the laparoscope. Antifogging solution
works well. Simply waiting until the laparoscope warms up works as well. Keeping
the laparoscope at distance from the target organ facilitates orientation.
At the end of the procedure, the 5-mm entry site at the umbilicus is closed with
an absorbable 4–0 fascia suture and skin sutures (Fig. 2.14). Two-mm entry sites are
only closed with Steri-Strips (Fig. 2.15).
2.4 Instruments 19
2 mm 5 mm 10 mm 2 mm 5 mm 10 mm
Fig. 2.11 Comparison of instrument sizes Fig. 2.12 Trocars of 2-mm, 5- and 10-mm
diameter
Fig. 2.13 Various 2-mm trocars Fig. 2.14 Fascia suture and skin suture at
5-mm trocar sites
Fig. 2.15 Steri-Strips only at 2-mm trocar

sites
2.5 Needle Insertion
• When using 5-mm trocars, the needle is inserted through the 5-mm trocar shaft,
with the needle tip covered within the jaws of a needle holder (Fig. 2.16). In anal-
ogy, the needle is removed eventually via the 5-mm trocar.
• When using 2-mm trocars, the needle is inserted directly through the abdominal
wall (Fig. 2.17). When the suturing is finished, the needle eventually is removed
together and in combination with the trocar (Fig. 2.18).
• 5-0, 6-0 or 7-0 sutures may be inserted via 2-mm trocars. The needles will scratch
along the inner trocar shaft, but they can be inserted and removed through the
same trocar several times until valve leakage occurs.
2.5 Needle Insertion 21
Fig. 2.16 Insertion of a needle within a 5-mm Fig. 2.17 Insertion of a 2-mm suture directly
trocar shaft, shielding the needle tip within through the abdominal wall
instrument jaws
Fig. 2.18 Removal of the suture together

with the trocar after completion of suture. The
trocar is reinserted immediately afterwards
2.6 Suturing
Initially, suturing is tedious and frustrating; practice helps. (Inguinal hernia is a

good practice procedure.) Intracorporeal knotting is familiar to most surgeons due
to its similarity to “open” instrument knotting.
We use two 2-mm needle holders. The second hand has a firmer grip with a nee-
dle holder. We use a ratched needle holder for the right hand and a non-ratched
needle holder for the left hand. Regular sutures for open surgery are used. 4-0 and
needle sizes of 18–20 mm are adequate for small children. To make the suture pass
through a 5-mm trocar more easily, the needle curve is bent open a bit. The total
length of the suture is cut to approximately 7 cm – depending on the size of the
abdominal cavity (the smaller the cavity, the shorter the suture). With the first stitch
done (Fig. 2.19), the free end of the thread is kept under visual control (in order to
keep it as short as possible, so short that it does not need to be cut later). The needle
is held in the left instrument, with the thread looking toward the surgeon. The instru-
ment in the right hand is rotated around the needle/thread connection of the left
hand so that the thread builds a double sling around the jaws of the right instrument.
Through the center of the slings, the jaws of the right instrument are advanced and
opened. They grab the free thread end – and close the knot (as in open instrument
knotting). The maneuver is repeated in the opposite direction (Fig. 2.20).
2.6 Suturing 23
Fig. 2.19 First step of intraabdominal Fig. 2.20 Second step, opposite direction
instrument knotting, as in “open” surgery
2.7 Ligating
Pre-tied pretied knots are most convenient.

Pass the pretied knots using an “introducer” through the trocar (otherwise the
loop bends and is difficult to maneuver inside).
Commercial pretied knots are available, but you can make your own by using the
guider from commercially available pretied knots and making the knot yourself.
The principle of the knot is easy to remember (Fig. 2.21).
2.7 Ligating 25
Fig. 2.21 Principle of the pretied knots

Thoracoscopic Procedures
3
Thoracoscopic procedures greatly profit first from good positioning of the patient
and second from single-lung ventilation if feasible.
The patient is so positioned that the affected lung faces the surgeon. The remain-
ing lung falls away by gravity.
Single-lung ventilation is feasible even in small children. It very much helps in
identifying the lesion.
We insert a 2-mm trocar (without prior incision, just like a cannula for drawing
blood), then insert a 2-mm laparoscope in order to make sure that the thorax is cor-
rectly entered, and start insufflation with 0.5 l/min up to 8 mmHg. In a newborn
with oesophageal atresia, we would insufflate at a rate of 0.3 l/min with a maximum
pressure of 8 mmHg.
Postoperative chest tubes are virtually never inserted (except that blood needs to
be drained). After all we do not cause a pneumothorax but rather a capnothorax by
CO2, which will be quickly absorbed.
When finished, the lung is insufflated until it almost prolapses into the trocar.
The fascia and the skin are sutured.

28 3 Thoracoscopic Procedures
3.1 Esophageal Atresia
The child lays with the right hemithorax up, with the right arm above the head, as in
open surgery. The position is 100°, i.e., with a slight tendency to fall forward
(Fig. 3.1).
In contrast to the “open” correction of an esophageal atresia (where the surgeon
stands at the back of the child), with the thoracoscopic approach, the surgeon stands
at the abdominal side.
Trocar position: The thoracoscope is inserted a bit anteriorly to the tip of the
scapula. Two further trocars are inserted in an oblique line to the left and right of the
scope.
Insufflation up to 8 mmHg.
It may take several minutes to wait until the lungs can be pushed aside and the
anatomy can be seen fully, just wait. But then the view is better than with the open
approach. The azygos vein is coagulated and transected, if required (Fig. 3.2).
3.1 Esophageal Atresia 29
Fig. 3.1 Patient and

trocar positioning for
esophageal atresia
Fig. 3.2 Coagulation of

the azygos vein
The vagus nerve is readily seen. The space between the fistula and the trachea is
dissected bluntly. Clipping the fistula is quicker but unfortunately requires a 5-mm
trocar. Using 2-mm or 3-mm trocars requires manual ligatures, which require extra
time. We apply an absorbable ligature (technically easier to tie the knot well) and a
nonabsorbable transfixing needle suture (a simple ligature might pop off). By then
one has a feel of how much tension is at the distal segment. If there is not too much
tension, the fistula is transected now (Fig. 3.3); otherwise, we postpone transection
until the upper pouch is exposed and opened.
In case the lung gradually enlarges in the meantime and obstructs view, we wait
a few minutes. The view will improve spontaneously.
The anesthesiologist pushes the nasogastric tube down. This helps to identify the
upper segment, just as in the open approach. A small opening is made into the
pleura at this area. The upper segment is grabbed with a forceps and bluntly freed
from the surrounding tissue. With a good bite, the upper pouch can be rolled up so
that the more cranial attachments can be visualized and transected more easily.
Usually there is a solid tissue bridge toward the trachea. This needs to be nicked
initially with the hook. The remainder can be pulled apart bluntly. We have twice
made a hole into the trachea at this stage. This is of little concern. The hole can be
sutured in X-like fashion with one single stitch.
The tip of the upper pouch is opened with scissors or perforated with the naso-
gastric tube (does not look as elegantly but has never made a difference in the final
anastomotic quality) (Fig. 3.4).
Fig. 3.3 Transection of the

fistula
Fig. 3.4 Opening of the upper

pouch with scissors
A large needle is inserted through the thorax wall near the site of the future anas-
tomosis. The needle will first be stitched through the upper segment and then the
lower segment and thereafter be brought out near the chest wall entry site to be
clamped outside. This maneuver approximates both segments and makes further
suturing easier (Fig. 3.5).
The first sutures are of the same kind as in open surgery. They are brought in
directly through the chest wall. If the first suture does not bring the ends fully
together, the knot is tied nevertheless. The second suture will accomplish the
approximation. Apply as many or as few sutures as you would do in open surgery.
Some surgeons close the back wall with running sutures and the anterior wall with
interrupted sutures (Fig. 3.6). Once one half is completed, the anesthesiologist will
further advance the nasogastric tube down into the stomach (Fig. 3.7). The sutures
of the anterior wall are relatively easy.
In case it appears impossible to bring the ends together (“long gap”), the fistula
is ligated as described above. Minimal tissue damage is attempted, since one has to
come back 3 months later, either again thoracoscopically or “open”. A laparoscopic
gastrostomy is added.
A thoracoscopy attempt for the second intervention is worthwhile. Some chil-
dren have massive adhesions, others have only few. We have applied traction sutures
for stimulating length growth, with mixed results (e.g. two abscesses). We distrust
that technique.
A chest drain is not necessary since this is only a rapidly absorbed capnothorax.
Fig. 3.5 Stay suture through the chest wall and Fig. 3.6 Back wall is sutured either running or
both esophagus segments aligning both seg- interrupted
ments (similar to duodenal atresia)
Fig. 3.7 Nasogastric tube and

front wall suture
3.2 H-Fistula
Most H-fistulae are best approached in the open technique via the neck.
A minority of H-fistulae can be reached from the thorax (the majority is too high
in the neck to be reached from below).
The child is positioned as in esophageal atresia.
The esophagus is easily identified because of the overlying vagal nerve. There is
a narrow space between esophagus and trachea. Blunt dissection between the two
structures, moving toward the patient’s head, will eventually reveal the solid con-
nection between them (Fig. 3.8). This is the fistula. It is completely developed
circumferentially with further blunt dissection and eventually ligated with two liga-
tures. (We use an absorbable suture because its knots can be closed more easily and,
in addition, a nonabsorbable suture in order to close the fistula permanently)
(Fig. 3.9). We do not transect the fistula, because we find that specific maneuver too
risky. Also, we fear that transection leads more frequently to tracheomalacia
(Fig. 3.10).
3.2 H-Fistula 35
Fig. 3.8 Blunt dissection between esophagus Fig. 3.9 Double ligature of the fistula, with
and trachea absorbable and nonabsorbable thread
Fig. 3.10 Fistula ligated but not transected

3.3 Diaphragmatic Hernia
For diaphragmatic hernia we have tried the approach from above (thoracoscopic)
and from below (laparoscopic). The thoracoscopic approach was easier.
The minimally invasive approach is suitable in otherwise healthy children. If,
however, the child is seriously compromised, an “open” subcostal approach is
quicker.
Trocar position: The patient lays on his healthy side, unfortunately. The thoraco-
scope is inserted high up in the thorax. Remember that the surgeon needs to work in
the lateral lower area of the thorax. So he stands just next to the anaesthesiologist.
Two additional trocars are inserted to the left and right for the surgeon’s hands.
Insufflation is up to 8 mmHg.
Initially only dilated bowel loops will we seen (Fig. 3.11). With increasing insuf-
flation and by exerting sufficient patience, more and more bowel loops can be
pushed down into the abdomen. The first movements will be blind. Once all the
bowel is down, it will stay down and the anatomy is clear (Fig. 3.12).
The first sutures (identical to the ones used in open surgery) are difficult to knot
because of the mechanical tension. If the tension is too high to overcome, the suture
might be knotted outside the thorax (Fig. 3.13). The suture is left long, brought in
and out through the same 2-mm trocar. Even without a knot, the trocar can be slided
down onto the diaphragm so that it closes the defect and facilitates the next sutures
and knots. The following sutures are easier (Fig. 3.14).
Placing a chest tube at the end has no advantages.
3.3 Diaphragmatic Hernia 37
Fig. 3.11 The surgeon’s view Fig. 3.12 When all bowel loops are down,
they will stay down
Fig. 3.13 With high tension, the first suture is

brought in and out through the chest wall and
closed by sliding down the trocar Fig. 3.14 Final closure
3.4 Lung Biopsy
The patient is positioned and tilted in such a way that gravity pulls the collapsed
lung away from the target area (Fig. 3.15). The first trocar for the 5-mm scope is
inserted like a chest tube (skin incision, spreading with scissors, blunt advance-
ment). The lung will collapse within a few minutes. Usually, we insufflate CO2 at
0.3 l/min up to 8 mmHg in order to speed up the collapsing. Insufflating conducted
too aggressively may result in bradycardia.
Biopsies at the lung periphery are easy. Biopsies of central parts of the lung are
better performed in the “open” technique.
Do not insert the thoracoscope exactly on top of the intended biopsy but a few
centimeters away in order to achieve not a direct on-top but an oblique view. Insert
two trocars at least 5 cm apart from the thoracoscope.
(a) The easiest technique is by using an pretied knots (Fig. 3.16). Use 5-mm tro-
cars. Insert an pretied knots through the right trocar. With the left hand, pull the
lung tissue through the loop and close the loop.
(b) Staplers are more expensive (Fig. 3.17): Use the required trocar for the stapler
on the right side (10 or 12 mm). Hold up the lung with a forceps.
The suture line looks better with staplers. However, metallic foreign bodies are
left behind for the child’s lifetime.
With pretied knots the stump looks crumbled, but it is safe.
3.4 Lung Biopsy 39
Fig. 3.15 Positioning for lung biopsy
Fig. 3.16 Lung biopsy with pretied knots Fig. 3.17 Lung biopsy with stapler
3.5 Pneumothorax
Position and tilt the patient in such a way that gravity pulls the collapsed lung away
from your target area, just as for a lung biopsy. Place the trocar for the 5-mm scope
like a chest tube (skin incision, spreading with scissors, blunt advancement). Wait a
few minutes for the lung to collapse. Usually, we insufflate CO2 at 0.3 l/min up to
8 mmHg in order to speed up the collapsing. Too aggressive insufflating may result
in bradycardia. The bullae are easily seen (Fig. 3.18). They most often located at the
cranial parts of the lung. Preoperative CTs usually inform precisely where they are
to be expected. The thoracoscope is inserted several centimeters further down
toward the diaphragm, not exactly on top of the bullae. Two further trocars are
inserted for the left and the right hand. The bullae are grabbed with the left hand and
exposed so that a stapler can comfortably include the complete bulla area and be
fired (Fig. 3.19). This is the most reliable technique.
We have also tried LigaSure® for that purpose but had recurrences.
3.5 Pneumothorax 41
Fig. 3.18 The bullae often are on top and easily seen
Fig. 3.19 The most reliable method: stapler

3.6 Sympathectomy
The patient is in supine position with both arms extended at 90°. The procedure can
be completed with 2- or 3-mm instruments and scopes exclusively. Insert a scope
5–7 cm below the axilla in the axillary line and one or two additional 2-mm trocars
laterally. Two trocars should suffice if the lung collapses well enough (with single-
lung ventilation). If not, a third 2-mm trocar is inserted in order to push the lung out
of the way (Fig. 3.20). Wait a minute for the lung to collapse. For hyperhidrosis of
the hands only, coagulate ganglia nr. 2 and 3. For the axilla, coagulate ganglion nr. 4.
We routinely coagulate ganglia 2–4 (Fig. 3.21). The ganglia are easily identified as
a white, cordlike structure crossing the anterior aspect of the paravertebral ribs.
Beware: destroying ganglion nr.1 results in Horner’s syndrome!
The ganglion is simply grabbed and coagulated on top of the rib. Destroy the
ganglion completely. Incomplete destruction may result in recurrence. Be careful
with the second rib because the heat of the coagulation may dissipate cranially and
cause damage to the first ganglion, resulting in temporary or permanent Horner’s.
Unfortunately, up to 40 % of patients will have “compensatory sweating” at the
back or the abdomen lasting for a few months.
3.6 Sympathectomy 43
Fig. 3.20 Trocar position
Fig. 3.21 The ganglia are coagulated on top of the ribs

Upper Abdomen
4
In some procedures at the upper abdomen, the view might be better if the laparo-
scope is not placed exclusively at the umbilicus but a few centimeters higher towards
the xiphoid (as in fundoplication) or to the left of the umbilicus (as in achalasia).
Nevertheless, we usually start at the umbilicus and see whether the view is okay
from there.
The liver is sometimes difficult to be held up sufficiently so that the hiatus or the
duodenum is seen well. Unfortunately, there are no efficient 2- or 3-mm liver retrac-
tors; however, the 5-mm variety is quite good (especially those which can be bent
inside). Also, in newborns, the liver can be held up with a needle holder, inserted at
the left upper abdomen and reaching transversely through the entire upper abdomen,
below the liver, over to the right side where it is attached to the inner abdominal wall
with the ratch closed, thereby holding up the liver. In duodenal atresia, for example,
this works quite well.

46 4 Upper Abdomen
4.1 Achalasia (Heller Myotomy)
The trocar position is as in fundoplication. The laparoscope is inserted halfway

between umbilicus and xiphoid (Fig. 4.1). However, a laparoscope position slightly
more to the left of the midline offers a better view of the myotomy. The esophagus
is exposed by lifting the liver up with a retractor, as in fundoplication. The serosa on
top of the esophagus is superficially incised. The muscles are bluntly spreaded with
a forceps (Fig. 4.2). This bleeds usually. The muscle layers are not as easily seen as
in adults.
Eventually, the mucosa is identified. Extending the spreading is a manoeuvre
similar to pyloromyotomy. A hook is entered into the divided muscle, and the mus-
culature is cut cranially by stepwise pulling back the hook. The vagus nerve is
identified and held out of the field. Its course is unpredictable in that area; its course
varies. The cutting is extended several centimeters up into the mediastinum. Six
centimeter suffices. Then the cutting is extended for three 3 cm down onto the stom-
ach. At the stomach more bleeding may occur because the fibers are crisscrossing.
The total length of incision is confirmed with a prepared thread of 10-cm length to
be laid onto the esophagus.
It is checked with esophagoscopy whether any residual fibers are left (Fig. 4.3).
Mucosa perforations do occur. In case this happens, the defect is closed with several
sutures. This is no reason to convert.
The procedure is completed with an anterior Dor fundoplication: First, the fun-
dus of the stomach is sutured with three sutures to the left margin of the myotomy
(Fig. 4.4). Then the remaining fundus is pulled over the myotomy defect over to the
right side. This covers the myotomy and prevents reflux. The fundus is also sutured
to the right crus with several sutures (Fig. 4.5).
Hook Forceps
Scissors
diathermy to hold
Fig. 4.1 Instruments and

trocar position. In bigger
children, the optic is placed
higher up, halfway between
umbilicus and xiphoid
4.1 Achalasia (Heller Myotomy) 47
6 cm
3 cm
Fig. 4.2 Superficial incision and blunt Fig. 4.3 Esophagoscopy checks for
dissection remaining fibers
Fig. 4.4 First step of Dor fundoplication. Fig. 4.5 Second step. Covers myotomy
Keeps myotomy open and prevents reflux
48 4 Upper Abdomen
4.2 Fundoplication (360° Nissen)
The laparoscope is inserted superior to the umbilicus (halfway to the xiphoid process).
A 30° laparoscope is better than a 0° because it can look around to the left side of the
esophagus. We use a 3-digit 5-mm liver retractor. The trocar for the liver retractor is
placed to the right or left of the xiphoid. There are good retractors available which can
be bent inside. Additional trocars are inserted in the left and right middle abdomen for
the surgeon’s hands. The surgeon’s position is at his discretion (right, left, between
legs); we prefer a position on the right (Fig. 4.6). The monitor is placed across.
Two millimeter instruments are adequate only in small children. In older children
the mechanical forces are bigger; therefore, 3- or 5-mm instruments are better.
Through an additional trocar in the left lower abdomen, the stomach is pulled
down with a ratched instrument.
The transverse colon is dilated in many children. It will collapse later spontaneously.
Obtain overview of the patient’s anatomy: identify and expose the hiatus and
right limb of the diaphragmatic crus (Fig. 4.7). The beginner finds it difficult to
identify the soft space between the right crus and the esophagus. It is found by prob-
ing and spreading the area with a forceps.
4.2 Fundoplication (360° Nissen) 49
Fig. 4.6 Position of the

surgeons and trocars
Assistant 2
Laparoscope
Surgeon
Assistant 1
Esophagus
Right
Fig. 4.7 Identification of crus
esophagus and phrenoesoph- Left
crus
ageal ligament
50 4 Upper Abdomen
The stomach is pulled downward with an instrument inserted at the left lower
abdomen. The phrenesophageal ligament is stretched, coagulated and transsected
(Fig. 4.8). The arising opening is left small because it may contain the left hepatic
artery or hepatic branches of the vagus nerve. A small opening may also subse-
quently stabilize the wrap.
Directly underneath the opening is the right limb of the crus. The muscle is not
fully exposed since sutures may later cut through more easily without its coverage.
There is a slitlike, narrow space between the crus and esophagus, filled with
loose tissue. That space is identified first by palpation and then gradually widened
by blunt dissection. Eventually the space can be opened wide enough to look into
the mediastinum and see the left crus. That retroesophageal window needs to be
sufficiently wide to accommodate the wrap later. Now, the esophagus is shifted to
the right. The left crus is exposed, again by blunt and sharp dissection.
Positioning a sling, as in open surgery, improves the anatomic exposure.
The crura are approximated with 2–3 sutures, using the same suture material as in
the open procedure (Fig. 4.9). These sutures are the only difficult steps in fundoplica-
tion because they are difficult to be placed behind the esophagus. A large esophageal
bougie is inserted during placement of these sutures. If the knots are placed too high,
they narrow the esophagus. The result is dysphagia. If the sutures are placed too
wide, there is a risk of herniation of the stomach into the mediastinum.
Fig. 4.8 Widening the soft tissue space between the right crus and the esophagus
Bougie
Fig. 4.9 Approximating the crura

52 4 Upper Abdomen
While the stomach is pulled around posteriorly of the esophagus, the bougie is
removed. With the stomach pulled around, apply the “shoeshine” test in order to
check whether the stomach will remain spontaneously in the plicated position
(Fig. 4.10). If not, the retroesophageal window needs to be made wider. The bougie
is again advanced into the stomach. Three loose sutures are placed, one from fundus
to fundus (to hold the wrap in place), another one from fundus to the diaphragm and
back (to prevent the wrap from sliding up and down), and a last one from the left
fundus through the anterior esophagus and the right fundus (to hold the wrap in
place) (Fig. 4.11).
Fig. 4.10 Checking whether the window is wide enough. “Shoeshine test”: will the wrap stay
without suture? Or will it slip back?
Fig. 4.11 The three sutures of fundoplication, yielding a loose and slim wrap
54 4 Upper Abdomen
4.3 Eventration of the Diaphragm
Birth trauma and previous heart surgery were our most frequent referral causes for
paralytic diaphragms.
Thoracoscopic and laparoscopic approaches are equivalent. We prefer laparos-
copy because with thoracoscopy one never can be sure that no intraabdominal
organs are unintentionally injured with a suture.
The laparoscope is inserted at the umbilicus. A further trocar is inserted at the
left and third trocar at the right upper abdomen (Fig. 4.12). The diaphragm is pulled
down and plicated with several nonabsorbable sutures. It usually requires more
sutures than initially assumed until eventually the diaphragm is fully pulled down to
a flat dome (Fig. 4.13).
4.3 Eventration of the Diaphragm 55
Fig. 4.12 Trocar

position and initial
pulling down of
the relaxed
diaphragm
Fig. 4.13
Plication of the
diaphragm with
multiple sutures
until eventually a
flat dome results
56 4 Upper Abdomen
4.4 Splenectomy
The patient is placed in a semilateral position with a 30–40° tilt of the left side. The
table is flexed 20–30° and elevated in a 30° anti-Trendelenburg position. The left
arm is fixed in an overhead position.
Surgeon and assistant stand on the right side of the patient, the scrub nurse on the
left. One monitor is placed opposite the surgeon, the second one opposite the scrub
nurse (Fig. 4.14).
A 10–15-mm trocar is inserted at the umbilicus (it will be used at the end of the
procedure for passing an Endobag into the abdominal cavity).
Near the xiphoid a liver retractor is inserted. There are no good liver retractors of
2- or 3-mm diameter. The best retractors are those of 5-mm diameter which can be
bent inside the abdomen. They also may be used to elevate the spleen from under-
neath or by encircling the stalk of the spleen.
If this is insufficient, an additional 2- or 3-mm instrument is inserted also at the
xiphoid in order to further elevate the lower pole of the spleen. This stretches any
adhesions between the lower pole and the omentum.
Further trocars for the surgeon’s hands are inserted in the left and right middle or
lower abdomen, depending of the spleen’s size. We use a 3-mm trocar for the left
and a 5-mm trocar for the right hand, 5-mm in order to pass the LigaSure® (Fig. 4.15).
4.4 Splenectomy 57
Surgeon
Laparoscope
Assistant
Fig. 4.14 Surgeons’ and patient’s positions
Straight Curved
forceps forceps Scissors Stapler
Flexible
Hook retractor Clips Endobag
Fig. 4.15 Instruments for splenectomy

58 4 Upper Abdomen
Retract the colon downward and dissect the splenocolic ligament with the
LigaSure® all the way up to the hilum. By opening the lesser omental sac, the splenic
vessels are displayed. The vein is usually lying anterocaudal from the artery. The
vessels are divided with the LigaSure® (Fig. 4.16). The jaws of the LigaSure® tend
to stick to the vessel walls after they have been “burnt” and transsected. A cautious
rocking movement will separate the jaws from the vessel wall. It has happened sev-
eral times that a bleeding occurred when the jaws were opened after the transsec-
tion. Immediate reclosure and additional “burning” on both sides stopped the
bleeding in all cases. No conversion was ever necessary.
The remaining short gastric vessels are burnt and transsected step by step until
finally only the dorsal peritoneal attachments remain to be severed and the spleen is
free.
The optic is now moved to the right trocar where the LigaSure® had been.
The Endobag is passed via the 10–15-mm trocar at the umbilicus. We open the
ring on top of the spleen and scoop the spleen with a movement from laterally to
medially (Fig. 4.17). The final catching of the spleen is often described as tedious
and frustrating.
After the spleen is within the sac, the suture around the sac is pulled and the sac
is moved to the umbilicus.
We first use large clamps to break and fragment the spleen. Thereafter, a finger is
used (Fig. 4.18). Initially it is time-consuming to remove the first bits of paren-
chyma and blood. The last few pieces can be removed rather quickly.
In case of additional cholelithiasis, the table may be turned over to the left to give
adequate exposure of the right subcostal area. An additional trocar in the right upper
abdomen might become necessary for either a cholecystotomy with stone removal
or for a regular cholecystectomy.
Fig. 4.16 LigaSure transsects

vessels and ligaments from below
upward
4.4 Splenectomy 59
Fig. 4.17 Catching the spleen with

an Endobag
Fig. 4.18 Fracturing the spleen

within the bag
60 4 Upper Abdomen
4.5 Spleen Cyst (Technically Identical to Liver Cysts)
Place the patient with its left side 45° elevated.

The laparoscope is inserted at the umbilicus. Two further trocars are inserted to
the left and right of this trocar. First, with a long needle inserted through the abdom-
inal wall, the cyst fluid is aspirated (Fig. 4.19). The cyst collapses. The configura-
tion of the remaining spleen parenchyma is easily seen. Sometimes the cyst wall has
adhesions to the lateral abdominal wall. They are transsected (Fig. 4.20).
The cyst is opened with scissors. The cyst wall is resected with a LigaSure®
including some neighboring spleen parenchyma (Fig. 4.21). Cautery or other tissue
transsecting techniques might work quite as well. We find the LigaSure® quick and
efficient. Finally, the omentum is pulled over the remaining inner wall in order to
cover its surface. The omentum is attached with several sutures to the parenchymal
margin of the spleen (Fig. 4.22).
The excised wall is removed through the 10-mm trocar for the LigaSure®.
The same technique applies to liver cysts.
Unfortunately, spleen cysts as well as liver cysts (or “persistencies”) recur in up
to 40 % of cases, no matter whether they were operated on with the open or the lapa-
roscopic technique. A really definitive cure is only partial splenectomy.
Fig. 4.19 Trocar position. Aspiration of the Fig. 4.20 Transsection of adhesions
cyst
4.5 Spleen Cyst (Technically Identical to Liver Cysts) 61
Fig. 4.21 Resection of cyst wall with LigaSure®
Fig. 4.22 Covering the surface with omentum

62 4 Upper Abdomen
4.6 Liver Biopsy
Two trocars suffice. The laparoscope is inserted at the umbilicus, and a second
5-mm trocar is added to the left of the umbilicus. No further trocars are needed
(Fig. 4.23).
Scissors, a forceps with teeth and a bipolar coagulation forceps are all that is
needed.
First, the open scissors is held against the margin of the liver, and the liver is
lightly pushed to the left (Fig. 4.24). In this position the scissors makes the first cut
and lets go, so that the liver moves back to its original position (Fig. 4.25). The
second incision is made so that an inverted “V” results (Fig. 4.26).
A small tissue bridge is left. The forceps with teeth will disrupt the last small
tissue bridge and exteriorize the specimen (Fig. 4.27). The bipolar forceps coagu-
lates the bleeding parenchyma (Fig. 4.28). Livers with storage diseases appear to
bleed less than normal livers.
Surgeon
Laparoscope

4.6 Liver Biopsy 63
Fig. 4.24 The open scissors pushes the liver to Fig. 4.25 Cut and let go
the left
Fig. 4.26 Second cut Fig. 4.27 Removing the specimen
Fig. 4.28 Coagulation

Right Upper Abdomen
5
This includes a series of procedures at the pylorus, duodenum, and bile ducts. They
all have the monitor at the right upper side of the patient, as in cholecystectomy.
Duodenal atresia, choledochal cyst, and biliary atresia are considered to be
technically demanding because they demand suturing skills. Duodenal atresia is
facilitated by placing a stay suture through the abdominal and the upper as well as
the lower duodenal stump, after the anatomy is cleared. The rest is then
straightforward.
Choledochal cyst is time-consuming but not really difficult. It is easier than
anticipated to get around the cyst, especially behind, once the peritoneum in front is
incised and the cyst wall is followed along that plane all the way around.
Biliary atresia is no longer being operated on with the laparoscopic approach at
several centers because they found that the laparoscopic approach results in a higher
subsequent transplant rate.

66 5 Right Upper Abdomen
5.1 Pyloromyotomy
The monitor is placed at the right side of the child’s head (as in cholecystectomy).
The surgeon stands on the left side, opposite the monitor (Fig. 5.1). A 2- or 5-mm
laparoscope is inserted at the umbilicus. Using a 2-mm laparoscope is more elegant,
first, because it can be inserted directly through the first 2-mm trocar (just through
the skin, without prior incision) and, secondly, because it can be removed at the end
of the procedure without suturing; Steri-Strips suffice. This makes the procedure
more rapid. A 2-mm forceps with teeth is inserted at the right upper abdomen; it
holds the duodenum and rotates it forward, thereby exposing an avascular segment
of the pylorus.
5.1 Pyloromyotomy 67
Surgeon
Assistant
Laparoscope
Forceps Spreader Knife, cuts

to hold and coagulates
Fig. 5.1 (a) Position of surgeons and trocars. (b) Instruments

The pylorus is incised with a 2-mm monopolar scalpel which coagulates while
cutting (Duffner/Tuttlingen/Germany) (Fig. 5.2). The knife is inserted through the
left upper abdomen at the lateral margin of the rectus muscle. If its insertion is too
lateral, a shallow incision results. If the incision is too medial, the knife tip cuts in
dangerously steep. The lateral margin of the rectus muscle is a good area. There are
knives specially designed for pyloromyotomy (Storz/Tuttlingen). Some surgeons
use knives originally designed for arthroscopy.
There are no 2-mm spreaders on the market. Commercially available spreaders
(Storz/Tuttlingen) have 3-mm diameter (Fig. 5.3). They are inserted directly through
the abdominal wall, without a trocar.
Do not stop during spreading. Carry on without delay, because soon blood ooz-
ing will set in and obscure the view onto the mucosa. Spread slowly and steady. The
spreaders tend to dig laterally between the thickened muscle and the mucosa. This
has never led to a mucosa lesion.
Most surgeons initially have a slightly higher perforation rate with laparoscopic
rather than “open” pyloromyotomy. As in the open approach, most perforations are
likely to occur at the distal end. If it happens, one 4-0 PDS suture is placed over the
mucosa, a nasogastric tube is left for 24 h and thereafter regular feedings are started.
More cautious surgeons would place two sutures, roll the duodenum further and
make a new, parallel incision cranially. We have managed the few perforations we
had without a second incision.
5.1 Pyloromyotomy 69
Fig. 5.2 Coagulating knife
Fig. 5.3 Spreader penetrates in between hypertrophied muscle and mucosa

5.2 Biliary Atresia
Remember that several pediatric centers have abandoned the laparoscopic approach
in biliary atresia. The reason: The laparoscopic dissection of the scar conus at the
liver is suspected to be not as controlled as in the open approach. Furthermore,
coagulation at the level of the transsection is blamed to cause unwanted scarring
(which might be true), but also the lateral extent and the imperfect flush excision are
considered responsible for the disadvantage. However, recently the old, original
videos by Kasai himself were reviewed. They demonstrated that the objections
raised today against laparoscopy might be applied also to Kasai’s original, open
technique at that time.
The trocar position is identical to choledochal cyst (Fig. 5.4). Refer to the chole-
dochal cyst chapter. Also, the first step of preparing the Roux-en-Y loop and open-
ing a window in the mesocolon is identical as in choledochal cyst. There is one
difference, however: The loop should be 40 cm for biliary atresia and for chole-
dochal cyst only 20 cm. So we are told by our Asian colleagues. One 5-mm trocar
is needed for subsequently inserting a 5-mm instrument with sponge tissue for
exerting pressure onto the transsected area at the liver porta. It will bleed, but coagu-
lation is not permitted there.
The surgeon stands to the patient’s left, as in cholecystectomy. A 10-mm trocar
is inserted at the umbilicus because later small bowel will be exteriorized at the
umbilicus for the small bowel anastomosis which will be performed outside the
abdominal cavity. The remaining instruments are of the 2- or 3-mm variety.
First, the extrahepatic bile ducts are exposed by lifting up the – usually small –
gallbladder (Fig. 5.5).
5.2 Biliary Atresia 71
Fig. 5.4 Surgeons’ position
Fig. 5.5 Exposing the

extrahepatic bile ducts
The gallbladder is dissected from its bed. Initially, the gallbladder is used as a
handle. The cystic duct and the hepatic duct are followed cranially until the duct
enlarges at the hilum into the conus (Fig. 5.6). The conus is exposed and followed
laterally, in order to include into the excision also some of the more lateral surface
tissue. There are two small veins originating from below into the conus. With 2-mm
instruments they are identified and coagulated without damage to the nearby liver
parenchyma. In Japan, even a LigaSure® is used for this step. With scissors inserted
laterally, the conus area is excised flush to the assumed parenchymal surface. Our
Asian colleagues maintain that it is more important to excise in a shallow manner
rather than excising too far laterally.
The specimen (includes gallbladder and fibrotic cystic plus hepatic ducts) is
stored on top of the liver in order to be removed – and not forgotten – at the end of
the procedure.
The Roux-en-Y loop, fashioned as described in the choledochal cyst chapter, is
pulled nearby. A small opening is made with the hook. The opening is made smaller
than anticipated because it gradually will become larger while the anastomotic
sutures are placed. 6-0 sutures are used. They are passed through the 5-mm trocar.
For the back wall the needle is passed through the remaining scar tissue (Fig. 5.7).
One should not stitch too far laterally at 02:00 and 10:00 positions (as being sug-
gested by our colleagues from Japan).
5.2 Biliary Atresia 73
Fig. 5.6 The scar conus is excised at the level of the liver parenchyma
Fig. 5.7 Placing the sutures in the scar tissue

5.3 Cholecystectomy
The laparoscope is inserted through the umbilicus. The surgeon stands either
between the patient’s legs or on the left side (Fig. 5.8).
The procedure is quicker when using 5-mm instruments, and clips may be used
with this size of instruments.
We dislike the use of clips in children in principle and prefer to ligate the vessels
with 4-0 absorbable ligatures. Also, we prefer using 2-mm instruments for cosmetic
reasons.
The fundus of the gallbladder is grasped and pushed cranially (Fig. 5.9). The
neck of the bladder is pulled to the right. The peritoneum is opened longitudinally
(Fig. 5.10) and the vessels are exposed, ligated and transsected (Fig. 5.11). The
gallbladder is gradually freed from its bed by pulling and transsecting the remaining
attachments (Fig. 5.12). Finally, the gallbladder is aspirated to reduce its volume
and is removed through the umbilicus.
Surgeon
Assistant
Laparoscope
Fig. 5.8 Surgeons and trocar position

5.3 Cholecystectomy 75
Fig. 5.9 Gallbladder pushed up Fig. 5.10 Longitudinal opening of the

peritoneum
Fig. 5.11 Ligation of vessels Fig. 5.12 Excision of the gallbladder

from its bed
5.4 Cholecystotomy
We have also opened the gallbladder, removed a single stone and closed the bladder
with a running suture in several children. This appears justified in children without
a history of metabolic disturbances and a risk of formation of new stones (Fig. 5.13).
Blindly “fishing” with a forceps in the opened gallbladder leads to gall spillage.
We lost the stone twice in the bladder when trying to extract it. We suggest placing
a small sponge (inserted through the 5-mm trocar at the umbilicus) below the blad-
der opening, preventing the stone from falling between the bowel loops.
An easier technique is the “laparoscopy-assisted” technique. The gallbladder is
identified laparoscopically. A 5-mm trocar is inserted above the gallbladder. The
gallbladder is grabbed through this trocar and pulled up to the abdominal wall sur-
face. There it is opened and the stone removed. The gallbladder is sutured and
dropped back.
5.4 Cholecystotomy 77
Fig. 5.13 Cholecystotomy, removing the stone while leaving the gallbladder
5.5 Choledochal Cyst
The laparoscope is of 10-mm diameter. This is unusual for pediatric laparoscopy,

but it yields great pictures. The reason: A wide opening will be needed later because
the small bowel will be pulled out at the umbilicus for the Roux-en-Y anastomosis.
Two 2-mm trocars (or 3-mm) are inserted into the left and right abdomen for the
hands of the surgeon. A third trocar is inserted at the right upper abdomen, grabs the
gallbladder and pushes it up toward the head of the patient. This exposes not only
the full length of the gallbladder but also the anterior surface of the choledochal
cyst. A fourth trocar is inserted at the left subcostal margin for a needle holder
which is passed below the liver to the right side. It holds the liver up. It also grabs
the right abdominal wall inside. When the ratchet is closed, the instrument stays
without being held (Fig. 5.14).
The cystic duct and the cystic artery of the gallbladder are exposed and trans-
sected, like an incomplete cholecystectomy. The fundus of the gallbladder, however,
is left in situ since, for the rest of the procedure, the gallbladder is used as a handle
in order to push up the liver and expose the liver hilum (Fig. 5.15).
5.5 Choledochal Cyst 79
Fig. 5.14 Surgeons’

and trocar positioning
Pushes up Holds up
gallbladder liver
Surgeon
Assistant
Laparoscope
Fig. 5.15
Transsection of cystic
duct and vessels
The serosa on top of the choledochal cyst is lifted and incised. This plane is used
to proceed around the cyst until it is fully encircled. It is not difficult to find the
plane between the cyst and the underlying vessels (Fig. 5.16). A large thread might
be passed behind the cyst now in order to hold up the cyst. Our colleagues from Asia
transsect the cyst at this point instead of encircling it. So the cyst falls into a caudal
and a cranial half.
The distal part of the cyst is followed and freed from surrounding connective tis-
sue until the pancreatic tissue is approached. It will bleed in this area. The distal part
of the cyst is ligated and transsected (Fig. 5.17). This distal segment of the duct does
not necessarily be ligated. It may be left unligated. We place a suture ligature at the
cyst end because a simple ligature had slid off previously when the cyst was pulled
up with the ligature.
Fig. 5.16 Just below the peritoneum is the plane to proceed around the cyst
Fig. 5.17 Ligature of the distal duct

The cyst is lifted up and the back side of the cyst is freed step by step from the
connective tissue until the bifurcation of the bile ducts is reached (Fig. 5.18).
The ligament of Treitz is searched and the small bowel is followed distally for
10 cm. At this distance a characteristic three-point mark is applied with the cautery.
This serves to distinguish later the oral from the aboral limb of the bowel. The
marked small bowel segment is pulled out through the umbilicus (Fig. 5.19).
Fig. 5.18 Dissection of the cyst, up to the bifurcation
Umbilicus
Fig. 5.19 Three-point mark 10 cm distal to the ligament of Treitz. The segment is pulled out at the
umbilicus
After the mark is identified, the bowel transsected and reanastomosed in the fash-
ion of a Roux-en-Y loop (Fig. 5.20). Our colleagues from Asia find that a loop of
20 cm suffices in choledochal cysts (in contrast to biliary atresia). We prefer a
slightly oblique anastomosis with the intention to invite the bowel contents to pro-
ceed aborally, not back up into the loop. The blind end is closed. The last suture is
left long (5 cm). All the bowel is brought back into the abdominal cavity, the trocar
is inserted again and insufflation resumed. The long thread makes is easier to find
the blind end among all the bowel loops.
The right mesocolon is exposed. With blunt dissection a window is opened into
the mesocolon, just large enough to allow passage of the bowel loop. The bowel
loop is pushed through so that the end is positioned somewhere near the liver hilum
(Fig. 5.21).
20 cm
Fig. 5.20 Roux-en-Y loop. A long thread at the blind end makes it easier to find the loop
laparoscopically
Fig. 5.21 Mesocolon opened bluntly. Roux loop positioned near the hilum. Bile ducts cut
The bile duct is transsected.

The specimen is pushed up in order to further expose the liver porta. A small
opening is made at the side of the blind end of the bowel loop with the cautery (not
exactly at the end but slightly to the side where there are no sutures). The opening is
made relatively small because it will enlarge during manipulations while the anasto-
mosis to the bile duct is created (Fig. 5.22). 6-0 PDS sutures are used for the anasto-
mosis, first the back wall, then the front wall. Since leaks of the anastomosis are not
uncommon, a drain is placed with the tip nearby. Any leak will close spontaneously.
Eventually the gallbladder is completely excised and removed together with the
rest of the specimen via the umbilicus.
Fig. 5.22 Biliodigestive anastomosis and removal of specimen

5.6 Duodenal Atresia
The laparoscope is inserted at the umbilicus. Additional trocars are inserted at the
left middle and another one at the right lower abdomen, at quite a distance from the
duodenum, for the surgeon’s left and right hand (Fig. 5.23). If the duodenum is not
well exposed, a third trocar is inserted at the left subcostal margin, through which a
needle holder reaches below the liver over to the right side where it grabs the inner
abdominal wall. This needle holder lifts up the liver. The needle holder stays by
itself after the ratchet is closed (Fig. 5.24).
Gradually the duodenum is exposed with the hook until the anatomy is clear.
Also the duodenal surface areas immediately adjacent to the future anastomosis are
cleared.
5.6 Duodenal Atresia 89
Laparoscope
Fig. 5.23 Trocar positions
Anular
pancreas
Fig. 5.24 Needle holder as liver retractor. Exposure of both duodenal segments with the dia-
thermy hook
A suture with a large needle is inserted through the abdominal wall above the
liver, near the gallbladder. It is first passed through the oral part of the duodenum
(just next to the stenosis or to a pancreas anulare), then passed through the aboral
part of the duodenum and exteriorized again through the abdominal wall next to the
entry site. The suture is slightly pulled up and clamped outside (Fig. 5.25). This
manoeuver lifts up both parts of the duodenum, brings them close together and
exposes the area of the future suturing.
Using the hook, a transverse incision is made into the oral part and a longitudinal
incision into the aboral part of the duodenum (Fig. 5.26). Unfortunately this imme-
diately leads to an eversion of the duodenal mucosa which may look confusing
while suturing the back wall.
Fig. 5.25 Transabdominal stay suture. Brings ends together
Fig. 5.26 Transverse incision proximally. Longitudinal incision distally

The back wall is sutured first with several interrupted (or running) sutures. The
anesthesiologist advances the gastric tube which is grabbed laparoscopically and
inserted into the aboral segment deep enough to prevent immediate coiling back
(Fig. 5.27). Then the anterior wall is sutured (Fig 5.28).
The stay suture holding the anastomosis up is released. The anastomosis area
falls back in its final position.
When a duodenal membrane is suspected, a urinary catheter is inserted through
the abdominal wall directly into the aboral segment, without a trocar. The balloon is
filled and the catheter gradually pulled back. If a membrane is present, it will stretch
itself on top of the balloon (Fig. 5.29). The membrane is incised carefully in its
lateral aspect, hoping not to injure a bile or pancreatic duct.
Fig. 5.27 Suture of the posterior wall and passage of nasogastric tube
Fig. 5.28 Suture of anterior wall is easier
Fig. 5.29 A membrane stretches on top of balloon

Urogenital Procedures
6
This chapter includes also cryptorchidism, inguinal hernia, and varicocele – a group
of diagnoses which usually not strictly and uniformly are subsumed under “urol-
ogy”: We are aware of this. They represent the everyday procedures of pediatric
surgery, and they are good indications for practising the characteristic techniques of
laparoscopy in children, namely, trocar insertion and intraabdominal suturing.
Laparoscopic orchiopexy has not replaced its “open” approach. Laparoscopic
inguinal hernia repair, however, is our everyday approach. It is faster and has an
undoubted diagnostic advantage. “Open” inguinal hernia repair has become a rarity
in our practise. Direct and femoral inguinal hernias are quite often missed in open
surgery. Laparoscopically they are easy to see. A technical difference is only that a
direct hernia cannot be simply closed with a suture (as is the technique in the com-
mon indirect hernia), but it needs to be closed in two layers, after resection of the
hernia sac and the underlying lipoma.
A varicocele is a questionable indication in principle. Laparoscopically, how-
ever, it is easier than with any other techniques.
An intraabdominal pyeloplasty, including intraabdominal suturing, requires sutur-
ing skills, just as in the correction of atresias. If a surgeon prefers to perform the
anastomosis outside the abdomen, he is welcome to do so by first mobilizing the
ureteropelvic junction laparoscopically, then pull the junction outside the abdomen
and drop it back after completion of the anastomosis.
Finally, pediatric surgeons are regularly confronted with lesions of the ovary,
often in newborns. Below a diameter of 4 cm, they are followed up by ultrasonog-
raphy. If they are larger, they are opened (“fenestrated”).

96 6 Urogenital Procedures
6.1 Cryptorchidism
Statistically, surgeons will encounter the following situations. These are only approxi-
mative figures, given in order to prepare surgeons for what they should expect.
All undescended testes
80 % palpable 20 % impalpable
On exploration: 50 % intracannalicular 30 % intraabdominal 20 % absent
70 % vanishing 30 % agenesis
(blind ending cord (absence of epi-
structures) didymis and vas)
60 % inguinal canal 23 % intraabdominal 14 % deep inguinal ring 3 % scrotum
Shadowed area: Laparoscopic approach

The laparoscope is inserted at the umbilicus. The monitor is placed at the affected
side, opposite the surgeon (Fig. 6.1).
An open inner inguinal ring usually signifies that a testis will be found some-
where nearby or in the canal (Fig. 6.2). If in doubt, a small trocar is inserted at the
lateral abdominal wall, ipsilateral to the affected side. The testicle will be found
inside the inguinal canal.
A closed processus, however, usually indicates an absent or “vanishing testis”
(Fig. 6.3). We excise the blind end of the blind-ending structure in order to send it
for histology.
6.1 Cryptorchidism 97
Fig. 6.1 Surgeons’ and

trocar position
Laparoscope
Assistant
Surgeon
Fig. 6.2 Open inner inguinal ring means there Fig. 6.3 Closed inner ring means no testis
is a testis somewhere
In that case, an additional trocar is inserted. In right-sided cryptorchidism, for

example, one trocar is inserted just above the bladder and another lateral to the right
rectus sheath. The peritoneum is incised above the structure. The vessels (blood
vessels and vas) are followed to the blind ending (Fig. 6.4). The nubbing is resected
and sent for obtaining a histology. If the blind end cannot be followed to the very
end with laparoscopic means alone, we convert to an open inguinal exploration in
order to find it. We would not leave it behind.
If, however, there is a testis present, and it is in a low intraabdominal position,
we check with a laparoscopic instrument whether the testis can be mobilised to the
contralateral inner ring using forceps (Fig. 6.5), because if this can be done, the
testicle most likely can be transferred down into the scrotum, although quite often
not fully. If an open processus vaginalis is present, which is often the case, a laparo-
scopic orchiopexy is added. For this, a scrotal incision is made and a laparoscopic
forceps advanced from there up into the inguinal canal for pulling down the testicle.
An open orchiopexy is done for this second step if the anatomy of the inguinal canal
is not clear laparoscopically.
In high intraabdominal testis before puberty, and in cases with bilateral high
intraabdominal testis, laparoscopic ligation of the testicular vessels is performed
(Fig. 6.6). This is followed 3–6 months later by laparoscopic transsection (Fig. 6.7)
and conventional orchiopexy (called “staged Fowler-Stephens”). The ligature should
remain cranial, i.e. at some distance, from the testis. Some surgeons do not wait sev-
eral months. They transsect immediately. The testis will spontaneously descend to
the internal ring where it may be fetched and brought down through a conventional
groin incision or a laparoscopic approach through the scrotum now or later (without
a second laparoscopy).
We dislike clips and ligate with absorbable suture material.
In high intraabdominal testis after puberty with normal contralateral scrotal testis
or with poor testicular quality, a laparoscopic orchiectomy is performed. If there is
only one testis, microvascular transfer may be carried out.
For the diagnoses “vanishing testis” and “agenesis testis”, compare vessels to the
contralateral side. No further exploration is required, and the procedure is finished.
6.1 Cryptorchidism 99
Fig. 6.4 Blind end of a vas as in “vanishing Fig. 6.5 If the testis can be brought to the
testis” contralateral side, it might as well be brought
down into the scrotum
Fig. 6.6 Fowler-Stephens I Fig. 6.7 Fowler-Stephens II

6.2 Orchiopexy
The laparoscope is inserted at the umbilicus and two further trocars in the left and
right lower abdomen (as in inguinal hernia). If the inner inguinal ring is closed, we
are reluctant to perform a laparoscopic orchiopexy (blunt and blind preparation of
the inguinal canal all the way down into the scrotum appears unsafe to us). If the
inner inguinal ring is open, the procedure is executed laparoscopically and is rela-
tively easy.
The testis is pulled back from the inguinal canal into the abdominal cavity. The
gubernaculum distally of the testis is transsected with hook and scissors until the
testis can be pulled back freely. The peritoneum surrounding the inner inguinal ring
is incised so that the testis becomes fully mobile and may even be transferred to the
contralateral inner inguinal ring. This serves to estimate whether enough length is
provided in order to bring the testicle fully down.
From abdominally, an instrument is introduced into the inguinal canal until it is
palpated within the scrotum from outside. The scrotum is incised at this site. The
instrument is further inserted until it is seen from outside. A second forceps is
inserted from outside into the scrotal pouch and advanced upward via the inguinal
cannel until it enters the abdominal cavity (Fig. 6.8). The testicle is grabbed at the
former gubernaculum site and pulled all the way down into the scrotum (Fig. 6.9).
There it is sutured into a pouch in the conventional Shoemaker technique.
6.2 Orchiopexy 101
Fig. 6.8 Forceps from scrotum into abdomen
Fig. 6.9 Pulling down of testicle

6.3 Inguinal Hernia
Since the last edition, two major different techniques have evolved for the repair of
inguinal hernias.
One technique does the suturing and knotting intraabdominally (purely laparo-
scopically), while the other introduces the thread through the abdominal wall,
directs the tip around the inner inguinal ring under laparoscopic control, pulls it out
again, and does the knotting outside. Of all paediatric surgeons performing mini-
mally invasive inguinal hernia repairs at present, it seems that 2/3 use the fully
intraabdominal and 1/3 the extraabdominal knotting technique, and it also appears
that the outside-knotting technique (branded with several different names) has
slightly less recurrences.
Routine urinary catheters are unnecessary in both techniques.
1. Laparoscopic inguinal hernia repair with fully intraabdominal suturing and
knotting is described first.
The only instruments needed are two needle holders and a pair of scissors.
The monitor is placed across the surgeon, on the side of the hernia. The laparo-
scope is inserted at the umbilicus. Two additional trocars are inserted at the mid-
abdomen, at the level of the umbilicus, lateral to the rectus muscle (Fig. 6.10).
A regular nonabsorbable 4-0 suture with a cutting needle is shortened to approxi-
mately 7 cm. Cutting needles have a better grip than round ones in the needle
driver. The needle is inserted through the abdominal wall directly on top of the
inner inguinal ring and pulled inside with a laparoscopic needle driver.
The suture is placed in an “N”-shaped fashion (Figs. 6.11a–c). On top also
some underlying musculature is included, not merely the peritoneum. Inferiorly,
however, we stay more shallow (more or less only peritoneum) out of fear to
injure nerves and vessels.
Recurrences almost exclusively occur medially, immediately adjacent to the
epigastric vessels. Therefore, that area needs to be closed with extra care. We
regularly include some tissue being pulled over from the medial to the epigastric
vessels and inferiorly from the area between the vas and the testicular vessels.
The surgeon changes sides for bilateral hernias so that he stands opposite the
hernia side. Contralateral sides are (unexpectedly) open in 15–30 %. We close
them in the same technique.
The thread is cut and pulled out together with a trocar.
6.3 Inguinal Hernia 103
Laparoscope
Surgeon
Assistant
Fig. 6.10 Surgeons’ and trocar position
a b
Figs. 6.11 Steps of suture closure of the internal ring (a–c)

2. The technique of circumnavigating the internal ring with a needle from outside
and extracorporeal knotting.
We do not have own experience with this technique. A laparoscope is intro-
duced at the umbilicus. A hollow needle is inserted through the abdominal wall,
on top of the inner inguinal ring. It aims toward the lateral aspect of the inner
inguinal ring. Before it perforates the peritoneum, the needle tip is manipulated
over the testicular vessels and the vas medially. There, the needle with the thread
inside perforates the peritoneum.
The thread is left in place, the needle is withdrawn. It is again inserted through
the same skin opening, but now it aims towards the medial aspect of the inner
ring. A thin forceps is passed through the hollow needle into the abdomen. It
grabs the thread and pulls it outside. The thread is knotted outside. The knot is
hidden below the skin incision.
With laparoscopic techniques, up to ten times more direct hernias and femoral
hernias can be expected, approximately 2 % each, far more than the text books say.
They are especially frequent in recurrences from open surgery. Surgeons therefore
need to be prepared what to do in these cases. These hernias cannot simply be
closed with a single suture, as described above. This would result in recurrence.
Instead, an excision of the hernia sac and closure in two layers is required. For ana-
tomical orientation, see Fig. 6.12. For the anatomy of direct hernias, see Fig. 6.13.
In case of a direct or femoral hernia, we pull the hernia sac back and excise it
circumferentially with a hook cautery (Fig. 6.14). This includes the lipoma often
found just underneath. Thereafter, the top rim of the defect is clearly seen. This
applies for direct and for femoral hernias. The rim is seen and palpated with a nee-
dle holder. We close the muscle defect with several nonabsorbable sutures
(Fig. 6.15). In a femoral hernia the rim is best seen on top. Laterally comes the
femoral vein (cannot be used for suturing) and inferiorly there is only relatively
loose tissue of minor mechanical strength. We still approximate the stabile upper
rim with that loose tissue. Finally we close the peritoneum on top of these sutures
with several sutures. This technique has virtually eliminated recurrences.
In addition there are simultaneous indirect and direct hernias, indirect and femo-
ral hernias and combinations of all three hernias. A combination of a direct and a
femoral hernia, however, we have never seen.
6.3 Inguinal Hernia 105
Direct
hernia Indirect
hernia
Femoral
hernia
Fig. 6.12 Anatomy of inguinal hernias. The

epigastric vessels separate indirect and direct
hernias. Femoral hernias are below the inguinal
ligament Fig. 6.13 Direct hernias are just medially of
indirect hernias, of the other side of the epigas-
tric vessels
Fig. 6.14 Pulling back and excision of the her- Fig. 6.15 Closure of the defect in two steps,
nia sac hernia defect plus peritoneum
6.4 Varicocele
Most varicoceles are on the left side. Therefore, the monitor will be placed near the
left thigh of the patient. The surgeon stands to the right of the patient (Fig. 6.16).
A 2- or 5-mm laparoscope is placed through the umbilicus. A 2-mm trocar is
inserted at the level of the umbilicus at the lateral margin of the rectus muscle. This
is a relatively avascular area. Going through the rectus muscle itself carries a risk of
bleeding. A second 2-mm trocar is inserted above the bladder, in an area likely to be
covered later by pubic hair.
The ectatic veins are easily seen, even with an intraabdominal pressure of
12 mmHg. Comparison with the contralateral side confirms the diagnosis. Often, in
varicoceles, there is an adhesion of the sigmoid colon to the peritoneum covering
the varicocele. Transsecting or pulling off the adhesion results in small bleedings
rendering the picture unclear.
We incise the peritoneum in the shape of a “T” (Fig. 6.17). Often, the artery is
buried below a bundle of veins. When touched with a forceps, the artery tends to
become spasmic and subsequently is impossible to distinguish from the veins. Be
careful to avoid even the smallest bleedings when dissecting the veins. Bleedings
render it impossible to identify the artery later. Then, the only consequence is to
ligate the whole bundle, artery together with veins (Fig. 6.18). We, however, try to
preserve the artery. In probably 30 % it is impossible to identify the artery despite
Doppler sonography and pharmacologic agents applied. We are uncertain which
technique is best. If the artery is preserved, there are less hydroceles but possibly
more recurrences. If the artery is transsected, there are possibly less recurrences but
more hydroceles.
We ligate the vessels with nonabsorbable ligatures. Clips – used by many lapa-
roscopists because they are quickly applied – require at least 5-mm trocars. In some
patients we have transsected the vessels after ligating, in others we have not.
In several patients we have coagulated the vessels after ligature. In two patients,
postoperatively, a zone of hypesthesia or hyperesthesia at the thigh was noted
(“meralgia”) which subsided after several weeks. Obviously an underlying nerve
was damaged while coagulating.
6.4 Varicocele 107
Fig. 6.16 Surgeons and trocars
Surgeon
Laparoscope
Assistant
Fig. 6.17 T-shaped incision of the

peritoneum
Fig. 6.18 (a) Testicular artery

preserved. (b) All vessels
transsected
6.5 Urachal Cyst
The patient is positioned elevated on underlying pads, because the operation will
take place “at the ceiling” of the abdominal cavity.
A urinary catheter is placed and left postoperatively for 4 days because the dome
of the bladder will be ligated and sutured. The urinary catheter takes the tension off
these sutures which cannot be avoided with a fully distended bladder.
All trocars (we use exclusively 2-mm instruments for the procedure) are inserted
at the left lateral lower abdomen, the laparoscope in the center, at the level halfway
between the dome of the urinary bladder and the umbilicus, all at the lateral margin
of the rectus sheath (Fig. 6.19). Insufflation is initiated at the trocar which will be
used for the laparoscope. The trocars for the surgeon’s hands are then inserted to the
right and the left of the scope.
An omphaloenteric duct is readily seen, ligated, and transsected.
A urachal cyst or fistula may be more difficult to see with this lateral approach
because they might be hidden behind an umbilical ligament (Fig. 6.20). When it is
finally identified, the duct is ligated and transsected below the umbilicus.
The cyst or fistula is dissected free from the abdominal wall towards the bladder
with blunt or sharp manoeuvres. There it is ligated with a simple ligature and in
addition with a stitch in order to prevent popping off of the ligature once the bladder
is full and under tension (Fig. 6.21).
For the removal of a cyst, an incision is made at the umbilicus.
When removing a urachal cyst, remember that in several patients adenocarcino-
mata developed decades later at the bladder dome, where the cyst had entered the
bladder previously.
6.5 Urachal Cyst 109
Fig. 6.19 Patient and trocars
Fig. 6.20 The urachal duct is Fig. 6.21 Ligature and transsection
hidden behind the umbilical
ligament
6.6 Pyeloplasty
Initially, we started with pure laparoscopic pyeloplasties and later changed to

“laparoscopy-assisted” pyeloplasties. Both approaches are described below.
“Laparoscopy-assisted” appeals to those colleagues who dislike intraabdominal
laparoscopic suturing and who prefer to do all the suturing outside, in the “open”
fashion.
We have no experience with the retroperitoneal approach. Here, only the trans-
peritoneal approach is described.
We do use stents. And we find “double-J” stents most convenient, especially when
they are inserted cystoscopically before the procedure. We also inserted stents
through the abdominal wall directly into the renal pelvis. A purse-string suture (of
short-time absorbable threads) would secure the stent. The stent is removed approxi-
mately 10 days later after it has been demonstrated radiologically that the outflow is
unobstructed. This results in a leak, which will close spontaneously. Laparoscopically
inserted stents occasionally will not pass all the way down into the bladder.
6.6.1 Purely Laparoscopic
Trocar position: The affected side of the patient is elevated by 45° (Fig 6.22). The
trocar for the laparoscope is inserted at the suspected level of the kidney. On each
side of that trocar, a further trocar is inserted for the left and for the right hand. The
ureteropelvic junction is exposed by blunt and sharp dissection. One or two stay
sutures are inserted through the abdominal wall in order to better expose the renal
pelvis (Fig. 6.23). The remainder of the procedure is identical to the open approach.
The ureter is spatulated. The sutures of the corners are brought in and out through
the abdominal wall. This exposes the area to be sutured. Only at the corners several
interrupted sutures are placed. The posterior and anterior walls are closed with run-
ning sutures.
A stent (of your choice) is inserted through the abdominal wall, through a sepa-
rate stab incision into the cranial pelvis and passed over the anastomosis prior to
suturing the anterior wall (Fig. 6.24). We leave these stents for 10 days. The rest of
the procedure is as in open surgery (Fig. 6.25).
6.6 Pyeloplasty 111
Fig. 6.22 Trocar position Fig. 6.23 Stay sutures at the pelvis
a b
Catheter c
d
Fig. 6.24 Passage of stent Fig. 6.25 Principle of anastomosis as in open

surgery (a–d)
6.6.2 Laparoscopy Assisted
The patient is elevated 45°. Initially, a laparoscope is inserted at the umbilicus. This
serves to identify the position of the kidney pelvis (the exact anatomical position
varies in different patients). With two additional trocars to the left and right, the
pelvis of the kidney is fully exposed until the stenotic ureteropelvic obstruction is
fully mobile.
A 10-mm trocar is inserted exactly above the renal pelvis (Fig. 6.26). The pelvis
is grabbed via this trocar with a 10-mm dissector and pulled outside the abdominal
cavity (Fig. 6.27). In a small child this is not difficult. This is also possible in older
children if the abdominal wall is pushed down by the assistant while the anastomo-
sis is completed.
The resection of the ureteropelvic stenosis, insertion of a stent (if desired) and
the suturing is done in the conventional “open” fashion. Once the anastomosis is
completed, it is dropped back into the peritoneal cavity.
6.6 Pyeloplasty 113
Fig. 6.26 Trocar for exteriorization
Fig. 6.27 Ureteropelvic junction brought out

6.7 Ovary
Ovarian cysts in newborns usually decrease in size spontaneously with time. If a

cyst of more than 4-cm diameter remains unchanged or appears to enlarge, we sug-
gest laparoscopic fenestration.
The laparoscope is inserted through the umbilicus. Additional trocars are ad-
vanced as required (Fig. 6.28).
In a newborn, the first view of the cyst may be confusing because the laparoscope
may be too close for orientation.
The cyst color is different from the remaining small bowel, either brownish or
whitish (brown means blood content; whitish/blueish means hormones/steroids)
(Fig. 6.29).
6.7 Ovary 115
Laparoscope
Assistant
Surgeon
Fig. 6.29 Brown means blood. Bluish means hormones

Two 2- or 3-mm instruments are inserted laterally to the umbilicus (or even
slightly more cranially) and the cyst is aspirated or incised. It collapses and permits
better anatomic orientation (Fig. 6.30).
In newborns it suffices to simply cut a window into the cyst wall and to pull or
tear the window wide open. The cyst wall consists of two layers (Fig. 6.31), although
the two layers cannot easily be distinguished in newborns. The older the girl is, the
easier it is to separate the two layers. Gynecologists say that leaving the inner layer
leads to recurrence of a cyst and therefore advocate removal of the inner layer even
in small children. In newborns we only tear the cyst wide open and never remove the
inner layer and still never had a recurrence. In older children the cyst wall is incised.
A two-layered wall structure becomes visible, and the inner layer can be separated
from the outer layer and removed without much difficulty.
6.7 Ovary 117
Fig. 6.30 Cyst aspiration for

better view
Fig. 6.31 Cysts have two

layers
Torsions are readily detected (Fig. 6.32). We suggest first to cut a window into
the cyst, detorque it, remove the inner layer (Fig. 6.33) and wait and see whether the
blood perfusion of the adnexa is sufficiently well enough to leave the organ intact.
The inner layer is removed in order to prevent recurrence (Fig. 6.34). If in doubt we
would return for a second laparoscopic look in approximately 3 days (which in fact
we never did) or check by ultrasonography whether the previously malperfused
organ has recovered. Most ovaries will have recovered by then and may be left in
place. We are afraid to have removed too many ovaries in the past.
If the ovary looks histologically suspicious, we convert to an adequate incision
in the lower abdomen and retrieve the specimen in the “open” technique.
In older girls, blood in the pelvis and hemangioma-like lesions at the bladder wall
or bowel wall may indicate endometriosis. The affected area needs to be excised with
a safety margin.
6.7 Ovary 119
Fig. 6.32 Torsion
Fig. 6.33 Open a window and the

cyst collapses
Fig. 6.34 Removal of inner cyst

layer
Middle and Lower Gastrointestinal Tract
7
This chapter contains diagnoses which usually require placement of the monitor at
the feet of the patient (with the exception of adhesiolysis where the visible scar on
the abdomen may indicate where the adhesions might be expected).
The chapter contains an everyday indication like appendectomy (which might
become less frequent in the future with antibiotics therapy alone) and classical pedi-
atric surgical procedures like sigmoidectomy for Hirschsprung’s disease or anal
atresia. Both have profited from the advent of laparoscopic techniques. But also the
treatment of a Meckel’s diverticulum or a small bowel atresia has profited. Both are
identified laparoscopically, are then pulled out through the umbilicus and resected
outside the abdominal cavity using conventional open suturing techniques. It is
astonishing how much bowel can be pulled out through the umbilicus in a child
without any additional incision. The younger the child the easier it is, and the
approach leaves no scars although it is only a “laparoscopy-assisted” technique.

122 7 Middle and Lower Gastrointestinal Tract
7.1 Adhesiolysis
The child is placed in an elevated position with padding since the surgery will be
performed “at the ceiling” (Fig. 7.1).
Stay away from the scar of previous surgery with the first trocar. In adhesions, we
prefer the “open” Hasson technique in order to ensure that we do not perforate ad-
herent bowel (in all other cases we use the Veres needle approach).
Keep the laparoscope as far away as possible from anticipated adhesions. The
extent and density of adhesions are difficult to evaluate if they are immediately in
front of the optic (Fig. 7.2).
7.1 Adhesiolysis 123
Fig. 7.1 Elevated position
Forceps Forceps to Scissors

to hold coagulate

The size of the scar does not give any indication of the extent of adhesions. Some
adhesions are very limited and easy to transsect, while others are widespread and
densely adherent. If a straightforward transsection is not feasible, we have no hesi-
tation to convert and reopen the old scar. There is no point in insisting on a mini-
mally invasive technique if there is already a scar.
We coagulate the bands before performing transsecting (Fig. 7.3). The majority
of the bands contain blood vessels. Beginners risk incising too close to the abdomi-
nal wall, thereby removing the peritoneum over extended areas (Fig. 7.4). Most
laparoscopists have perforated bowel during an adhesiolysis at some stage of their
career, including the author (Fig. 7.5).
7.1 Adhesiolysis 125
Fig. 7.3 Coagulation
Fig. 7.4 Cutting
Fig. 7.5 Bowel perforation

7.2 Small Bowel Atresia
The laparoscope is introduced at the umbilicus. A 10-mm trocar is inserted and a

5-mm laparoscope with a coaxial working channel (like the one depicted in the
appendectomy chapter, see below) is introduced. Two additional trocars are inserted
to the right and left, for the surgeon’s hands. These two ancillary trocars are of
2-mm diameter (Fig. 7.6). The site of the atresia is identified, seized with a forceps,
and pulled out from the abdominal cavity at the umbilicus, along, and together with
the 10-mm trocar (Fig. 7.7). The umbilicus usually does not need to be enlarged by
an incision. It will accommodate any single loop of bowel. The atresia is corrected
in the conventional open technique (Fig. 7.8). The bowel segment is dropped back
into the abdomen.
It is astonishing how easily the bowel can be exteriorised in a small child through
the umbilicus if there is only a 10-mm opening. However, pull out as little bowel as
possible, just enough to complete the anastomosis. Pulling out too much will lead to
edema, making it difficult to bring the bowel back through the umbilicus, it looks
just like an incarceration.
This is the technique we also use for a Meckel’s diverticulum.
Umbilicus
Fig. 7.6 Trocars

7.2 Small Bowel Atresia 127
Fig. 7.7 Atresia pulled out at the

umbilicus
Fig. 7.8 Anastomosis outside the

abdomen
7.3 Intussusception
Laparoscopy is performed in those intussusceptions which are incompletely or

questionably reduced by an enema. In children with distended abdomen or peritoni-
tis, however, or in those children with long segments of intussuscepted bowel reach-
ing into the transverse colon or further, we would prefer the conventional, open
approach.
Prior to prepping the patient, we insert a large urinary catheter into the rectum in
order to instillate physiologic saline during the laparoscopy. This might help to
further reduce the intussusception during laparoscopy.
The 5-mm laparoscope is inserted at the umbilicus (Fig. 7.9). Two 2-mm trocars
are advanced through the left middle abdomen and the lower mid-abdomen (the
position of 2-mm trocars is irrelevant; their position may be changed any time since
they leave virtually no scars).
Some intussusceptions will have spontaneously reduced upon laparoscopy. In
contrast to conventional teaching, we pull (Fig. 7.10). Completeness is documented
and the procedure terminated (Fig. 7.11). If pulling and pushing with 2-mm instru-
ments is unsuccessful, we give it a trial with 5-mm instruments. In addition, we
repeat the enema with the laparoscopy still going on. If this all fails, we convert.
7.3 Intussusception 129
Fig. 7.9 Trocars

Laparoscope
Assistant
Surgeon
Fig. 7.10 Pulling at the terminal ileum
Fig. 7.11 Complete reduction

7.4 Meckel’s Diverticulum
With the clinical suspicion of a Meckel’s diverticulum, we do not perform anymore

a “Meckel’s scan” but rather proceed directly to laparoscopy.
A Meckel’s diverticulum might be overlooked during the first run. We therefore
retrogradually check the small bowel two or three times, starting from the ileocecal
area, in order not to miss a diverticulum.
Trocars are inserted as in appendectomy (Fig. 7.12).
A narrow-based Meckel’s diverticulum may be ligated similar to an appendix,
leaving an everted stump. This can be done with 5-mm instruments and pretied
knots alone (Fig. 7.13).
A broad-based Meckel’s diverticulum may also be removed with a stapler.
Staplers require 12-mm trocars, and they leave metallic deposits in the abdomen for
life. Both these aspects made us refrain from staplers.
Quite as well, and this is our preferred technique now, the Meckel’s diverticulum
may be identified laparoscopically and pulled out at the umbilicus with a forceps to
be resected outside, very much as in small bowel atresia (see the Sects. on 7.2 and
7.5.2, where the special coaxial working laparoscope is depicted).
7.4 Meckel’s Diverticulum 131
Fig. 7.12 Trocars and

surgeons
Fig. 7.13 Endoloop

for small-based
diverticulum
7.5 Appendectomy
We use two different techniques, the “classic” three-trocar technique and the single-
trocar technique. The “single-trocar” technique is preferable for uncomplicated
appendectomies.
7.5.1 Classic Three-Trocar Technique (Fig. 7.14)
A 5-mm/0° laparoscope is inserted at the umbilicus. Two further trocars are

inserted in the right and left lower or middle lower abdomen. The left trocar is either
2 or 5 mm in diameter, and the right trocar is 5 mm for a 5-year-old child and a
10 mm for a 10-year-old child.
7.5.2 “Single-Trocar” Technique (Fig. 7.15)
A 10-mm trocar is inserted at the umbilicus. The angulated laparoscope (origi-

nally used for thoracoscopy) with an inbuilt 5-mm working channel is inserted.
Long and short versions are available, but only the short version can be used for
regular 5-mm instruments. The long version of a coaxial laparoscope requires “extra
long” 5-mm instruments. In addition, the pretied knots can only be used in the short
version.
To manipulate and expose the appendix, an additional (or two additional) 2-mm
instrument is inserted in the suprapubic area, an area which is likely to be covered
later by pubic hair. This helps to hold the appendix and place the pretied knots.
7.5 Appendectomy 133
a b
Figs. 7.14 Three-trocar technique (a, b)
a b
Figs. 7.15 Single-trocar technique (a, b)

The intraabdominal steps are identical in both techniques.

Eventually the appendix is removed via the umbilical trocar.
The tip of the appendix is seized, pulled up and rotated in such a way that the
mesoappendix is facing the surgeon. The mesocolon is coagulated toward the base
in several steps (Fig. 7.16). Each step is followed by cutting with scissors (Fig. 7.17).
Do not cut into the uncoagulated tissue, bleeding will surely ensue.
The skeletised appendix is ligated with three polydioxanone (PDS) pretied knots
(Fig. 7.18). The first is placed near the base, and the appendix is then coagulated
distally at the level of subsequent transsection. An additional pretied knots is placed
at the base and a third one more distally. The appendix is cut in between and removed
through the trocar (Fig. 7.19). The stump is coated with Betadine solution.
Recently we have replaced both, pretied knots and cautery, by using the LigaSure®
exclusively, for all steps, i.e. for coagulating and also transsecting the meso of the
appendix and the appendix itself. A 10-mm LigaSure® will transsect the appendix
base without leakage, and it withstands very high bursting pressures. The technique
is not inexpensive but the most rapid we know of.
• Retrocecal appendices are also removed laparoscopically. It is feasible, but it
takes time.
• We would advise against laparoscopic appendectomy in appendiceal “masses”.
Nonsurgical therapy with antibiotics yields better results. It is not really neces-
sary to come back later for a second look because in almost all cases the appendix
will look virtually normal 3 months later. In several instances we have seen trace
of the former inflammation.
• In perforated appendicitis a thorough irrigation is easier laparoscopically than
with an open technique. We irrigate with at least 1 liter.
• Fecaliths are easily lost and difficult to find laparoscopically. Also, they break
easily.
7.5 Appendectomy 135
Fig. 7.16 Coagulation of the meso Fig. 7.17 Cutting
Fig. 7.18 Ligating Fig. 7.19 Coagulating, ligating, and transsection

7.6 Sigmoid Resection
7.6.1 Laparoscopic Part
The complete lower body is prepped and taped, including the abdomen and the
perineum. A towel at the anus controls intraoperative stool spillage. The monitor is
placed near the left leg. The surgeon stands on the right, the assistant on the left side.
The laparoscope is inserted at the right upper abdomen (not at the umbilicus),
because the meso of the sigmoid is better seen from the right. We now use a 2-mm
laparoscope for cosmetic reasons. Further trocars are inserted through the umbilicus
(for the left hand) and the above the cecum (for the right hand) (Fig. 7.20). A suture
with a relatively large needle is inserted through the left upper abdominal wall (near
the spleen). It seizes the wall of the proximal sigmoid and is exteriorised through the
abdominal wall near the entry site. It serves to pull the sigmoid up and to stretch the
full length of the mesosigmoid.
The table is tilted to head down. A biopsy is taken with forceps and scissors
(Fig. 7.21). We insert the suture prior to taking the biopsy and place it nearby so that
the defect can be closed immediately, in case the mucosa is opened.
While waiting for the histology, the mesosigmoid is coagulated and opened with
a hook. The sigmoid is pulled up towards the spleen in order to spread its meso
(Fig. 7.22). We pull the hook towards us in order to stay away from the iliac vessels
hidden behind the mesosigmoid. First, we open a window for anatomic orientation.
We stay a few millimeters away from the bowel wall proximally and also try to
preserve the marginal artery along the bowel wall. Further down we approach the
bowel wall more closely. At the rectum we begin with the posterior wall of the rec-
tum. There is no need to proceed too deeply at the anterior aspect of the rectum
(1–2 cm beyond the peritoneal reflection suffices).
This concludes the abdominal part. While waiting for the result of the frozen
section, the perineal part is started.
7.6 Sigmoid Resection 137
Fig. 7.20 Trocar position and instruments
Fig. 7.21 Biopsy Fig. 7.22 Opening a window into the meso
7.6.2 Perineal Part
The anus is pulled open with several radial sutures (2-0). The sutures go through the
dentate line and are arranged in a radial fashion either directly to the skin or to the
base plate of a colostomy (Fig. 7.23). This exposes the inside of the anal canal. With
the lateral stitches, we stay 4 cm away from the anus itself. No sutures are placed in
the midline. A total of 6 stay sutures are used.
Inside the anal canal, a circumferential line is marked with the cautery tip at a
level of 0.5–1 cm above the dentate line. The line is incised first with the cautery,
then with scissors. The idea is to separate the mucosa from the serosa. The mucosa
is seized with 4-0 stay sutures and slowly and gradually pulled out from the anus.
Four sutures or more are used. With the first caudal stitches, also, a bit of muscula-
ture is included for a better grip. Moving orally, the mucosa is isolated step by step,
alternatively by cutting or by blunt dissection. This step of the procedure is slow and
tedious (Fig. 7.24). If a muscle fiber sticks to the mucosa, it is cut with scissors until
further pulling is possible. If proceeding in the correct plane, there is little
bleeding.
When approximately 7 cm of mucosa is dissected and pulled out from the anus,
the transition from normally vascularized to less perfused bowel is discerned. The
posterior deflection line is grabbed with two Allis clamps. Cut along the line
between clamps with electrocautery. This opens the abdominal cavity. Insert a fin-
ger for orientation. Complete the transsection circumferentially with scissors.
Thereafter, the full-length large bowel, which was mobilized before laparoscopi-
cally, can be pulled out from the anus until the biopsy site is seen.
The musculature on the back side of the tunnel is incised 1 or 2 cm in order to
provide more space for the pulled-through bowel.
The anterior part of the bowel is transsected. The anastomosis is started with 4-0
in a water-tight fashion, then the posterior part is completed.
The stay sutures are cut. The anus retracts and covers the anastomosis.
Finally, check laparoscopically for torsion or bleeding before closing the
procedure.
7.6 Sigmoid Resection 139
Fig. 7.23 Pulling open the anus
Fig. 7.24 Gradually dissecting and pulling out the mucosa. The completed anastomosis retracts
into the anus
7.7 Rectopexy
Among all the procedures we have tried for anal prolapse (pararectal injection,
inserting a constricting thread around the anus and rectopexy), laparoscopic recto-
pexy was the most successful. We usually started with injection and, if that failed,
proceeded to laparoscopic rectopexy.
The laparoscope (a 2-mm laparoscope suffices) is inserted to the right of the
umbilicus, not at the umbilicus, because a lateral view onto the mesocolon facili-
tates the procedure. A further 2- or 3-mm instrument is inserted at the left middle or
upper abdomen in order to lift the rectosigmoidal colon just over the promontorium
ossis sacri. A third instrument of 5-mm diameter is inserted at the right lower abdo-
men (Fig. 7.25). A window is opened into the mesocolon over the promontory. The
opening reaches down to the bone and exposes its surface to about 1 cm2 (Fig. 7.26).
It requires a strong, cutting needle and also a strong 5-mm needle holder to pass the
needle through the surface of the bone. At both sides, the suture passes also through
the bowel wall in such a way that it stretches the rectum as much as necessary. Two
sutures suffice, one on the right and one on the left side of the bowel (Fig. 7.27).
Assistant
Laparoscope
Surgeon
Fig. 7.25 Position of trocars and surgeons

7.7 Rectopexy 141
Fig. 7.26 Meso window at

the promontory
Fig. 7.27 Two sutures

7.8 Anal Atresia
“Low” anal atresias are best approached using the Peña approach (Figs. 7.28, 7.29,
and 7.30). A laparoscopic approach does not make sense in these lesions.
However, an anal atresia with a recto-vesical fistulae, or higher forms of recto-
vaginal fistulae in girls, or recto-bulbar or recto-vesical fistulae in boys or high
forms of cloacae are better being approached in the laparoscopic technique.
At present, it is unclear whether those cases in between – recto-prostatic or recto-
bulbar fistulae – are better treated laparoscopically or with the open approach.
a b Peña
Fig. 7.28 Girls. (a, b)

Recto-perineal and recto-
vestibular fistulae are better
approached in the Peña
technique. (c, d) Higher
forms of recto-vaginal fistula
are better approached in the c d Lap-assisted
laparoscopic technique
7.8 Anal Atresia 143
Fig. 7.29 Boys. (a, b) Recto-

perineal are best approached in the
Peña technique. Recto-bulbar
fistulae may be tried
laparoscopically, but may be
technically difficult if the fistula
is too deep in the pelvis
a b Peña
c d
Lap-assisted
a Peña
b c
Fig. 7.30 Any cloaca profits

d e
from a primary laparoscopic
approach Lap-assisted
In any case, the principle is to follow the bowel downwards until the fistulae are
identified and either clipped or ligated (Fig. 7.31).
In contrast to the Peña approach, in laparoscopy the patient is positioned on his
back with the feet angulated at the hip and the knee joints, just as in laparoscopic
sigmoid resection. Also the trocar placement is as in sigmoid resection: The laparo-
scope is inserted a few centimeters to the right of the umbilicus. This offers a better
lateral view of the distal colon.
The bladder is lifted up by a suture with a large needle, which is passed through
the abdominal wall. It grasps the bladder and pulls it out of the pelvis for a better
view. The suture is clamped outside (Fig. 7.32).
Technically the easiest cases are anal atresias with recto-vesical fistulae. The
colon is followed from proximally to distally until it turns up and enters the bladder.
The fistula between the distal colon and the bladder is relatively easily identified. The
fistula is clipped or ligated and transsected. The bowel will immediately fall out of
the pelvis and pull back into the abdomen, thereby fully exposing the pelvis. Perineal
muscle stimulation from outside (at the perineal skin) or from inside (with a laparo-
scopic electric probe) clearly shows the center of muscle contractions inside.
Once the center of muscle contractions is identified outside and inside, an inci-
sion is made at the perineum which is gradually dilated step by step with trocars up
to the size of a 12-mm trocar. Whether the dilatations are in the center of the mus-
cles is easily controlled laparoscopically. A 5-mm grasper is inserted through the
12-mm trocar at the perineum (Fig. 7.33). The most distal part of the colon/rectum
is grasped and pulled outside behind the 12-mm trocar. This step will cause CO2
loss via the neo-anus. The pulled-through bowel is sutured to the perineum as in
sigmoid resection (Fig. 7.34).
Before placing all perineal sutures, it is checked laparoscopically whether the
bowel is not torqued inside.
The deeper the fistula within the pelvis, the more difficult it is to be exposed.
Recto-prostatic fistulae do not enter the urethra as directly as the recto-vesical ones.
They insert obliquely and, unfortunately, in the same axis as the laparoscopic view.
To ligate them laparoscopically is more demanding, if not impossible sometimes.
We hesitate to use clips because they stay in situ for life. It has been shown repeat-
edly that the ligation of a recto-urethral fistula is not really necessary as long as a
bladder catheter is in place. The defect will close spontaneously within 10 days.
In girls we have even closed recto-vestibular fistulae laparoscopically, especially
if the girl is older. We would suggest in all cases (except the rectoperineal fistulae of
course) to see first whether they cannot be performed laparoscopically. For most
recto-prostatic fistulae, we find the classic Peña approach technically easier than the
laparoscopic technique.
7.8 Anal Atresia 145
Suture
Clip
Fig. 7.31 Principle of the laparo- Fig. 7.32 Pulling up the bladder
scopic approach
Fig. 7.33 Pulling the bowel through Fig. 7.34 Perineal sutures
Index
A E
Achalasia, 45–47 ECG. See Electrocardiography (ECG)
Adhesiolysis, 121–125 Electrocardiography (ECG), 6
Agenesis of the testis, 98 Endobag, 56, 58, 59
Anal atresia, 121, 142–145 Endoloop, 24, 25, 38, 39, 130–132, 134
Anesthesia, 1–9 End-tidal carbon dioxide, 6, 8
Appendectomy, 121, 126, 130, Enema, 4, 128
132–135 Equipment, 1–9
Appendiceal masses, 134 Esophageal atresia, 27–34
Ether screen, 4
Eventration of the diaphragm, 54–55
B
Biliary atresia, 65, 70–73, 84
Bladder full, 4, 108 F
Blood pressure, 6, 7 Fecaliths, 134
Bowel distension, 6 Femoral hernia, 104, 105
Bullae of the lung, 40, 41 Finger fracture, 58, 59
Fogging, 18
Fowler-Stephens orchidopexy, 98, 99
C Fundoplication, 18, 45–53
Cables (light, CO2), 2, 3
Capnography, 6, 7
Carbon dioxide (CO2), 2, 6, 8, 11, 16, 27, G
38, 40, 144 Gas embolism, 1–9
Cautery, 2, 4, 60, 82, 86, 104,
134, 138
Cholecystectomy, 58, 65, 66, 70, H
74–75, 78 Hanging drop test, 14, 15
Cholecystotomy, 58, 76–77 Hasson technique, 122
Choledochal cyst, 65, 70, 72, 78–87 Heating of CO2, 2
Compensatory sweating, 42 Heller myotomy, 46–47
Conversion, 4, 58 Hirschsprung’s disease, 121
Cryptorchidism, 95–99 Hypercapnia, 6
Hyperhidrosis, 42
D
Diaphragmatic hernia, 36–37 I
Direct hernia, 95, 104, 105 Impalpable testis, 96
Duodenal atresia, 33, 45, 65, 88–93 Indirect hernia, 95, 104, 105
Durant’s maneuver, 8 Inguinal hernia, 22, 95, 100, 102–105
F. Schier and S. Turial, Laparoscopy in Children, DOI 10.1007/978-3-642-37638-2 147

© Springer-Verlag Berlin Heidelberg 2013
148 Index
Instruments, 1, 2, 11–25, 42, 47, 48, 50, 56, PEEP See Positive end-expiratory
57, 67, 70, 72, 74, 78, 98, 100, 102, pressure (PEEP)
108, 116, 128, 130, 132, 137, 140 Pneumothorax, 27, 40–41
Insufflation pressure, 15, 27 Positive end-expiratory pressure
Insufflation rate, 11, 15 (PEEP), 6
Insufflator, 1, 2, 8 Premedication, 6
Intraabdominal testis, 98 Pull-through for anal atresia, 142, 144, 145
Intracorporeal knotting, 22 Pull-through in Hirschsprung’s
Intubation, 6 disease, 121
Intussusception, 128–129 Pulse oximetry, 6
Pyeloplasty, 95, 110–113
Pyloromyotomy, 46, 66–69
L
Ligating, 11–25, 106, 135
Light source, 1, 2 R
Liver biopsy, 62–63 Rectopexy, 140–141
Liver cyst, 60–61 Retrocecal appendices, 134
Lung biopsy, 38–40
S
M Shoeshine test, 52, 53
Meckel’s diverticulum, 121, 126, 130–131 Sigmoid resection, 1, 136–139, 144
Monitor, 1–3, 48, 56, 65, 66, 96, 102, 106, Single lung ventilation, 27, 42
121, 136 Single-trocar technique, 132–135
Monitoring, 6, 7 Small bowel atresia, 121, 126–127, 130
Spleen cyst, 60–61
Splenectomy, 56–60
N Suturing, 11–25, 32, 65, 66, 90, 95, 102,
Nasogastric tube, 6, 30, 32, 33, 68, 93 104, 110, 112, 121
Needle holders, 20, 22, 45, 78, 88, 89, 102, Sympathectomy, 42–43
104, 140
Neutral electrode, 4
Nitrous oxide, 6, 8 T
Thoracoscopy, 32, 54, 132
Thoracoscopy and anesthesia, 30, 32
O Trocar insertion, 11–25, 95
Open processus vaginalis, 98 Trolley, 2, 3
Orchiectomy, 98
Orchiopexy, 95, 98, 100–101
Ovarian cyst, 114 U
Ovarian torsion, 118, 119 Urachal cyst, 108–109
Ovary, 95, 114–119 Urinary bladder, 108
Urinary catheter, 1, 4, 5, 92, 102, 108, 128
P
Padding, 4, 5, 122 V
Patient, 1, 2, 4, 6, 8, 11, 27, 29, 34, 36, 38, 40, Vanishing testis, 96, 98, 99
42, 48, 56, 57, 60, 65, 70, 74, 78, Varicocele, 95, 106–107
106, 108–110, 112, 121, 128, 142 Veres needle, 11–15, 122

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Felix Schier · Salmai Turial

ISBN 978-3-642-37637-5 ISBN 978-3-642-37638-2 (eBook)

Library of Congress Control Number: 2013943014

© Springer-Verlag Berlin Heidelberg 2013

Printed on acid-free paper

Springer is part of Springer Science+Business Media (www.springer.com)

Laparoscopy in children is special.

Mainz, Germany Felix Schier

1 Equipment, Children, Anesthesia, Gas Embolism . . . . . . . . . . . . . . . 1

2 Technical Basics: Insufflation, Trocar Insertion, Instruments, Needle

5 Right Upper Abdomen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

7 Middle and Lower Gastrointestinal Tract . . . . . . . . . . . . . . . . . . . . . 121

Standard equipment is used: monitor, video equipment, insufflator, light source,

F. Schier, S. Turial, Laparoscopy in Children, 1

Two pieces of equipment need special attention:

Fig. 1.1 Trolley with monitor placed low

A urinary catheter is unnecessary, as a full bladder seldom obstructs the view. If it

The patient is premedicated with a parasympatholytic (this reduces the likelihood of

Heart Blood Pulse Temperature

NO2 Pressure PEEP Respiratory Airway

Fig. 1.3 Monitoring

1.4 Gas Embolism

Fig. 1.4 Actions to be taken in suspected gas embolism

F. Schier, S. Turial, Laparoscopy in Children, 11

2.1 Insufflation (1)

2.1.1 When Starting Insufflation with a 5-mm Trocar

2.2 Insufflation (2)

2.2.1 When Starting Insufflation with a 2-mm Trocar

2.3 Trocar Insertion

Fig. 2.15 Steri-Strips only at 2-mm trocar

2.5 Needle Insertion

Fig. 2.18 Removal of the suture together

Initially, suturing is tedious and frustrating; practice helps. (Inguinal hernia is a

Pre-tied pretied knots are most convenient.

Fig. 2.21 Principle of the pretied knots

F. Schier, S. Turial, Laparoscopy in Children, 27

3.1 Esophageal Atresia

Fig. 3.1 Patient and

Fig. 3.2 Coagulation of

Fig. 3.3 Transection of the

Fig. 3.4 Opening of the upper

Fig. 3.7 Nasogastric tube and

Fig. 3.10 Fistula ligated but not transected

3.3 Diaphragmatic Hernia

Fig. 3.13 With high tension, the first suture is

3.4 Lung Biopsy

Fig. 3.15 Positioning for lung biopsy

Fig. 3.19 The most reliable method: stapler

Fig. 3.20 Trocar position

Fig. 3.21 The ganglia are coagulated on top of the ribs

F. Schier, S. Turial, Laparoscopy in Children, 45

4.1 Achalasia (Heller Myotomy)

The trocar position is as in fundoplication. The laparoscope is inserted halfway

Fig. 4.1 Instruments and

4.2 Fundoplication (360° Nissen)

Fig. 4.6 Position of the

Fig. 4.9 Approximating the crura

4.3 Eventration of the Diaphragm

Fig. 4.12 Trocar

Fig. 4.14 Surgeons’ and patient’s positions

Fig. 4.15 Instruments for splenectomy

Fig. 4.16 LigaSure transsects

Fig. 4.17 Catching the spleen with

Fig. 4.18 Fracturing the spleen