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 Merrill McHoney
Edward M. Kiely
Imran Mushtaq Editors

Color Atlas of Pediatric

Anatomy, Laparoscopy,
and Thoracoscopy

123
Color Atlas of Pediatric Anatomy, Laparoscopy,
and Thoracoscopy
Merrill McHoney • Edward M. Kiely
Imran Mushtaq
Editors

Color Atlas of Pediatric

Anatomy, Laparoscopy, and
Thoracoscopy
Editors
Merrill McHoney Imran Mushtaq
Paediatric Surgery Great Ormond Street Hospital for Children
Royal Hospital for Sick Children Edinburgh London, United Kingdom
Edinburgh, United Kingdom

Edward M. Kiely
Great Ormond Street Hospital for Children
London, United Kingdom

ISBN 978-3-662-53083-2    ISBN 978-3-662-53085-6 (eBook)

DOI 10.1007/978-3-662-53085-6

Library of Congress Control Number: 2017930186

© Springer-Verlag Berlin Heidelberg 2017

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is
concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction
on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation,
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The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not
imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and
regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed
to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty,
express or implied, with respect to the material contained herein or for any errors or omissions that may have been
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Printed on acid-free paper

This Springer imprint is published by Springer Nature

The registered company is Springer-Verlag GmbH Germany
The registered company address is: Heidelberger Platz 3, 14197 Berlin, Germany
Foreword

This beautifully illustrated Atlas will, I believe, prove invaluable to paediatric surgeons at all
stages of their career. Those who are already proficient in minimal access surgery will find it
useful in planning a new procedure as well as rehearsing more familiar ones. Trainees will
benefit from it as they develop their surgical skills. Many paediatric surgeons have been slow
to adopt minimal access techniques, continuing to perform “conventional” open surgery for
most procedures. This book will hopefully stimulate those yet to be convinced, to ensure that
they acquire the appropriate skills and adopt these techniques.
The authorship of this Atlas is international, from the United States, Europe, the Far East,
and the United Kingdom, including, I am proud to note, several from Edinburgh, one of the
first paediatric centres in the United Kingdom to pioneer these techniques. The operative stages
of each procedure are clearly illustrated in a step-by-step sequence to aid understanding and
facilitate successful completion of the entire operative procedure endoscopically.
Endoscopic surgery, mainly laparoscopy and thoracoscopy, not only offers benefit to the
patient (improved cosmesis, less pain, less post-operative ileus, shorter hospital stay, faster
recovery, etc.), but it is also advantageous to the surgeon. The view of the operative site, as seen
in this Atlas, is usually far superior to that obtained through an open incision. The light is better
and the magnification of the image on the screen gives a much clearer view of the detailed
anatomy. I am certain that the next generation of paediatric surgeons will look back and say,
“Did they really make those large, unsightly and disfiguring incisions when the same proce-
dure can easily be performed using minimal access techniques?”
“In the 21st century it is unacceptable to perform any surgical procedure on a child by the
open route if it can be safely and easily be carried out through minimal access surgery”
(MacKinlay GA, BAPS Liverpool 1999). When I made this statement, it was considered heret-
ical, but increasingly in the past two decades, the minimally invasive approach has evolved into
routine paediatric surgical practice. This volume will likely become an essential component of
every paediatric surgical department.

Edinburgh, UK Gordon A. MacKinlay

v
Preface

We have been privileged to have worked with trainers and colleagues who have encouraged the
development of minimally invasive surgery in children. The popularity of minimally invasive
surgery in children is increasing, as well as the need for an atlas to help with the step-by-step
approach to common operations, not only for those who are learning but also more advanced
practitioners needing refreshing pictorial tips or reminders. This is not a textbook with details
of disease pathology, clinical presentation, or even indications for surgery for each procedure.
Instead, this atlas purely focuses on the operative steps once these steps have already been
achieved. The impetus to edit this book has come from our desire to help students, trainees, and
colleagues in developing minimally invasive surgery in children. We hope that this atlas will
be of value to those who are developing those skills.

vii
Contents

1 Introduction and General Principles ������������������������������������������������������������������������� 1

Merrill McHoney, Edward Kiely, and Imran Mushtaq
2 Equipment and Ergonomics����������������������������������������������������������������������������������������� 9
Alex C. H. Lee and Hugh W. Grant
3 Thoracoscopic Debridement of Empyema��������������������������������������������������������������� 27
Fraser D. Munro, Merrill McHoney, and Malcolm Wills
4 Spontaneous Pneumothorax ������������������������������������������������������������������������������������� 31
Merrill McHoney and Michael Singh
5 Thoracoscopic Lung Biopsy and Segmentectomy��������������������������������������������������� 39
Kokila Lakhoo
6 Thoracic Sympathectomy������������������������������������������������������������������������������������������� 45
Giampiero Soccorso and Michael Singh
7 Thymectomy ��������������������������������������������������������������������������������������������������������������� 49
Melissa Short and Dakshesh H. Parikh
8 Mediastinal Cysts ������������������������������������������������������������������������������������������������������� 55
Michael Singh
9 Thoracoscopic Nuss Procedure��������������������������������������������������������������������������������� 59
Joanna Stanwell and Robert Wheeler
10 Esophageal Atresia and Tracheoesophageal Fistula����������������������������������������������� 65
Merrill McHoney, Fraser Munro, Jimmy Lam, and Gordon MacKinlay
11 Thoracoscopic Aortopexy������������������������������������������������������������������������������������������� 75
Joanna Stanwell and Edward Kiely
12 Thoracoscopy for Congenital Lung Malformations ����������������������������������������������� 81
Fraser D. Munro
13 Thoracic Neuroblastoma ������������������������������������������������������������������������������������������� 89
Michael Singh and Giampiero Soccorso
14 Thoracoscopic Placation for Eventration of the Diaphragm ��������������������������������� 93
Ashok Daya Ram and Michael Singh
15 Laparoscopic Repair of Morgagni Hernia��������������������������������������������������������������� 97
Michael Singh
16 Primary Button Gastrostomy ��������������������������������������������������������������������������������� 103
Clarie Clark
17 Nissen Fundoplication ��������������������������������������������������������������������������������������������� 109
Merrill McHoney

ix
x Contents

18 Laparoscopic Thal Fundoplication������������������������������������������������������������������������� 119

Khaled Ashour, Alex C.H. Lee, and Hugh W. Grant
19 Pyloric Stenosis��������������������������������������������������������������������������������������������������������� 125
Merrill McHoney
20 Duodenal Atresia Repair ����������������������������������������������������������������������������������������� 133
Aimee Gibson and Nada Sudhakaran
21 Meckel Diverticulum������������������������������������������������������������������������������������������������� 143
Brian MacCormack and Philip Hammond
22 Laparoscopic Appendectomy����������������������������������������������������������������������������������� 147
Shabnam Parkar and Simon A. Clarke
23 Laparoscopy for Intussusception����������������������������������������������������������������������������� 161
Kate Cross
24 Laparoscopic Cholecystectomy������������������������������������������������������������������������������� 165
Augusto Zani and Niyi Ade-Ajayi
25 Laparoscopic Splenectomy��������������������������������������������������������������������������������������� 173
Khalid Elmalik and Sean Marven
26 Laparoscopic Surgery for Choledochal Cysts ������������������������������������������������������� 183
Nguyen Thanh Liem
27 Laparoscopic Colectomy ����������������������������������������������������������������������������������������� 189
Maurizio Pacilli and Hugh W. Grant
28 Laparoscopic Duhamels Pullthrough for Hirschprung Disease��������������������������� 201
Merrill McHoney
29 Laparoscopic-Assisted Soave Pullthrough for Hirschsprung Disease����������������� 211
Amanda J. McCabe
30 Laparoscopic-Assisted Swenson-Like Transanal Pullthrough
for Hirschsprung Disease����������������������������������������������������������������������������������������� 225
Michael Stanton, Bala Eradi, and Marc A. Levitt
31 Inguinal Hernia Repair ������������������������������������������������������������������������������������������� 235
Merrill McHoney
32 Undescended Testis: Laparoscopic Fowler-Stephens Orchidopexy��������������������� 241
Francisca Yankovic and Naima Smeulders
33 Laparoscopic Varicocelectomy ������������������������������������������������������������������������������� 253
Vassilis J. Siomos, Cole Wiedel, and Duncan T. Wilcox
34 Retroperitoneoscopic Adrenalectomy��������������������������������������������������������������������� 259
Imran Mushtaq and Francisca Yankovic
35 Laparoscopic Nephrectomy������������������������������������������������������������������������������������� 265
Pankaj Kumar Mishra and Abraham Cherian
36 Retroperitoneoscopic Nephrectomy/Heminephrectomy��������������������������������������� 271
Jimmy Lam
37 Pyeloplasty����������������������������������������������������������������������������������������������������������������� 279
Harish Chandran

Index����������������������������������������������������������������������������������������������������������������������������������� 291
Contributors

Niyi Ade-Ajayi Department of Paediatric Surgery, King’s College Hospital NHS Foundation
Trust, London, UK
Khaled Ashour Department of Paediatric Surgery, John Radcliffe Hospital, Oxford University,
Oxford, UK
Harish Chandran Department of Paediatric Surgery and Urology, Birmingham Children’s
Hospital, Birmingham, UK
Abraham Cherian Department of Paediatric Urology, Great Ormond Street Hospital,
London, UK
Melanie Claire Clark Royal Hosptial for Sick Children, Edinburgh, UK
Simon A. Clarke Department of Pediatric Surgery, Chelsea and Westminster NHS Foundation
Trust, London, UK
Kate Cross Paediatric Surgery Department, Great Ormond Street Hospital for Children NHS
Foundation Trust, London, UK
Khalid Elmalik Sheffield Children’s Hosptial, Sheffield, UK
Bala Eradi Department of Paediatric Surgery, Leicester Royal Infirmary, Leicester, UK
Aimee Gibson Paediatric Surgery, Gold Coast University Hospital, Queensland, Australia
Hugh W. Grant Department of Paediatric Surgery, John Radcliffe Hospital, Oxford University
Hospitals, Oxford, Oxfordshire, UK
Philip Hammond Royal Hosptial for Sick Children, Edinburgh, UK
Kokila Lakhoo Department of Paediatric Surgery, Oxford Children’s Hospital, Oxford
University Hospitals and University of Oxford, Oxford, UK
Jimmy Lam Department of Paediatric Surgery, Royal Hospital for Sick Children, Edinburgh,
UK
Alex C.H. Lee Department of Paediatric Surgery, Oxford University Hospitals NHS Trust,
Level 2, Oxford Children’s Hospital, John Radcliffe Hospital, Oxford, UK
Marc A. Levitt The Ohio State University, Columbus, OH, USA
Nationwide Children’s Hospital, Columbus, OH, USA
Nguyen Thanh Liem Vinmec International Hospital, Hanoi, Vietnam
Brian MacCormack Department of Paediatric Surgery, Royal Hospital for Sick Children,
Edinburgh, UK
Gordon A. MacKinlay Royal Hospital for Sick Children, Edinburgh, UK
Sean Marven Sheffield Children’s Hostpial, Sheffield, UK

xi
xii Contributors

Amanda J. McCabe Department of Paediatric Surgery, Royal Hospital for Sick Children,
Edinburgh, UK
Merril McHoney Department of Paediatric Surgery, Royal Hospital for Sick Children,
Edinburgh, UK
Pankaj Kumar Mishra Department of Paediatric Urology, Great Ormond Street Hospital,
London, UK
Fraser D. Munro Department of Paediatric Surgery, Royal Hospital for Sick Children,
Edinburgh, UK
Maurizio Pacilli Department of Paediatric Surgery, Oxford University Hospital, Oxford, UK
Dakshesh H. Parikh Department of Paediatric Surgery, Birmingham Children’s Hospital
NHS FT, Birmingham, UK
Shabnam Parkar Department of General Paediatric Surgery, Chelsea Children’s Hospital,
Chelsea and Westminster Hospital, London, UK
Ashok Daya Ram Department of Paediatric Surgery, Birmingham Children’s Hospital,
Birmingham, UK
Melissa Short Department of Paediatric Surgery, Birmingham Children’s Hospital,
Birmingham, UK
Michael Singh Department of Paediatric Surgery, Birmingham Children’s Hospital,
Birmingham, England
Vassilis J. Siomos Department of Surgery-Urology, University of Colorado Hospital,
Children’s Hospital Colorado, Aurora, CO, USA
Naima Smeulders Great Ormond Street Hospital for Children NHS Foundation Trust,
London, UK
Giampiero Soccorso Birmingham Children’s Hospital NHS Foundation Trust, Birmingham,
UK
Michael Stanton Department of Paediatric Surgery, G Level, Southampton Children’s
Hospital, Southampton, UK
Joanna Stanwell Department of Paediatric Surgery, University Hospital Southampton NHS
Foundation Trust, Southampton, UK
Nada Sudhakaran Paediatric Surgery, Gold Coast University Hospital, Queensland, Australia
Robert Wheeler University Hospital Southampton NHS Foundation Trust, Southampton,
Hampshire, UK
Cole Wiedel Department of Surgery-Urology, University of Colorado Denver School of
Medicine, University of Colorado Hospital, Children’s Hospital Colorado, Aurora, CO, USA
Duncan T. Wilcox Department of Pediatric Urology, Children's Hospital Colorado, Aurora,
CO, USA
Malcolm Wills Department of Cardiothoracic Surgery, Royal Infirmary of Edinburgh,
Edinburgh, UK
Francisca Yankovic Department of Paediatric Urology, Great Ormond Street Hospital NHS
Foundation Trust, London, UK
Augusto Zani Division of General and Thoracic Surgery, The Hospital for Sick Children,
Toronto, ON, Canada
 Introduction and General Principles
1
Merrill McHoney, Edward Kiely, and Imran Mushtaq

Abstract
Minimally invasive surgery (MIS) has become relatively commonplace in paediatric sur-
gery, and is becoming more popular. Paediatric surgeons perform laparoscopic and thoraco-
scopic surgery with the commonly held belief that MIS is associated with a dampened stress
response, more rapid postoperative recovery, and early discharge from hospital. There are
also long-term cosmetic advantages. Depending on the operation in question, some of the
potential advantages hold, but others do not, and we need to be conscious of potential dis-
advantages and difficulties when embarking on MIS.

Keywords
Minimally invasive surgery • Laparoscopy • Thoracoscopy • Retroperitonoscopy • Children

Minimally invasive surgery (MIS) has become relatively
commonplace in paediatric surgery, and is becoming more
popular. Paediatric surgeons perform laparoscopic and thora-
coscopic surgery with the commonly held belief that MIS is
associated with a dampened stress response, more rapid post-
operative recovery, and early discharge from hospital. There
are also long-term cosmetic advantages. Depending on the
operation in question, some of the potential advantages hold,
but others do not, and we need to be conscious of potential
disadvantages and difficulties when embarking on MIS.
As an introduction to the rest of this atlas, this chapter dis-
cusses some of these issues (albeit very briefly) in addressing
the “Why, When, Who, Where, and How” of MIS in children.
1.1  hy Minimally Invasive Surgery
W
in Children?
We can address the reasons for performing MIS surgery in
children by thinking of the advantages or benefits of MIS,
but we will also touch on the risks and potential downfalls.
There is evidence for some of the perceived benefits of MIS
in children, but some aspects lack substantial evidence at the
moment. The evidence base is increasingly being accrued
and investigated, however, and a few operations have been
evaluated in randomised controlled trials [1].
1.1.1 Potential Benefits

1.1.1.1 Postoperative Pain and Recovery

Both thoracoscopy and laparoscopy are associated with a
M. McHoney (*) significant reduction in the amount of tissue trauma and
Department of Paediatric Surgery, Royal Hospital for Sick
Children, Edinburgh, UK
thereby a reduction in postoperative pain. Studies have
shown varying reductions in postoperative pain after MIS
E. Kiely
Department of Paediatric Surgery, Great Ormond Street Hospital in both adults and children. Clinical evidence in adults
for Children NHS Foundation Trust, London, UK shows that laparoscopic surgery reduces postoperative
I. Mushtaq stay, respiratory complications, and postoperative pain
Department of Pediatric Urology, Great Ormond Street Hospital when compared with open surgery [2, 3]. The decreased
for Children NHS Trust, London, UK postoperative pain of tissue trauma after laparoscopy must
© Springer-Verlag Berlin Heidelberg 2017 1
M. McHoney et al. (eds.), Color Atlas of Pediatric Anatomy, Laparoscopy, and Thoracoscopy,
DOI 10.1007/978-3-662-53085-6_1
2 M. McHoney et al.
be balanced with the possibility of shoulder tip pain, per-
haps accounting for the fact that decreased postoperative
pain is not always proven. Laparoscopic surgery for mod-
erate to severely invasive operations has proven quicker
recovery in many studies. Thoracoscopy in children greatly
improves postoperative recovery [4, 5] and the minimisa-
tion of postoperative pain.
1.1.1.2 Cosmetic Advantages
The improved cosmesis after MIS is one of the hardest
advantages to quantify and report. The exchange of large
laparotomy and thoracotomy incisions for keyhole incisions
is undeniably beneficial. The minimisation of the visible scar
associated with the incisions in an important long-term
advantage to patients.
Reduction of physical deformity, especially on the chest
wall, is also very important. Long-term chest wall deformity
is minimised by MIS, and sometimes is eliminated com-
pletely. Winging of the scapula, kyphoscoliosis, pectus
deformities, and other deformities seen after thoracotomy
are reduced by thoracoscopy [6, 7]. Although most often
associated with chest wall incisions, such deformities also
can be associated with large abdominal wall incisions.
1.1.1.3 Blunting of the Metabolic Response
MIS is associated with minimisation of the degree of tissue
trauma (as the incisions into the body wall are smaller than
in the comparable open operation) and is of benefit in reduc-
ing some of the postoperative complications by blunting of
the metabolic and stress response. The cytokine response is
reduced after operations of a major magnitude performed by
MIS [8–10]. One of the major determinants of the metabolic
response to surgery is the magnitude of the operative stress
[11, 12]. Operations of greater magnitude are associated with
a greater metabolic response [13]. Therefore the benefit is
more pronounced when bigger operations are performed by
MIS.
1.1.1.4 T  hermoregulation and Energy
Metabolism
There is an important association between alteration in ther-
moregulation and the metabolic response. In the 1960s, it
was demonstrated that maintaining a 30 °C environmental
temperature blunted the metabolic response to trauma and
could therefore play an important role in determining the
postoperative metabolic response [14]. Morbidity and mor-
tality were also influenced by thermoregulation. Infants and
children are more susceptible to alterations in thermoregula-
tion and environmental temperature than adults. Physiological
differences in thermoregulation may be partially responsible
for differences between neonates, children, and adults in pat-
terns of metabolic response.
Because MIS is not associated with large open wounds,
heat loss and evaporative water loss are prevented, in turn
altering thermoregulation. Studies have shown maintenance
of core temperature and oxygen consumption in children
undergoing thoracoscopy [15, 16] and laparoscopy [17],
which was more marked in younger and smaller children.
Changes in intraoperative thermoregulation may alter post-
operative metabolism and changes in energy expenditure.
Luo et al. performed a trial in adults randomised to open
or laparoscopic cholecystectomy [18]. Rest energy expendi-
ture (REE), as measured by indirect calorimetry, was ele-
vated on postoperative day 1 in both groups, but the rise in
REE was significantly higher in the open group than in the
laparoscopic group. Postoperative energy metabolism is also
altered by laparoscopy in children, with a preservation of
energy metabolism in comparison with open surgery [19].
There are possible effects on postoperative protein metabo-
lism alongside these alterations. It seems, therefore, that MIS
is associated with preservation of homeostasis with regard to
energy expenditure.
1.1.1.5 Visualisation and Magnification
The visualisation obtained with MIS is often superior to
visualisation with open surgery. Access to many deep
recesses and folds can be improved with the use of the scope.
For instance, access to the oesophageal hiatus, pelvic struc-
tures, and apical areas of the lung is greatly facilitated with
MIS, compared with open surgery.
A much greater degree of magnification also can be
obtained using MIS. Structures that may be difficult to see
with the naked eye (e.g., the vagus nerve and its branches
during fundoplication and oesophageal atresia repair) are
often easily visible on the screen with the optical and digital
magnification allowed with MIS.
1.1.2 Potential Hazards of MIS
1.1.2.1 C  arbon Dioxide Absorption
from the Surgical Cavity
One of the new dimensions introduced by MIS is the creation
of a working space. This technique can involve abdominal wall
lifting, but the method most commonly used is insufflation of
CO2 to create a capnoperitoneum (or capnothorax). CO2
absorbed from the body cavity during MIS causes an increase
in CO2 elimination via the lungs. In adults undergoing laparos-
copy, there is typically a brief period of increased CO2 elimina-
tion, but after 10–30 min of insufflation, a plateau is usually
reached [20]. In children, the CO2 profile is different: there is a
continuous increase in CO2 elimination throughout intraperito-
neal insufflation of CO2 in children [21]. The increase in CO2
elimination was more marked in younger and smaller children,
1 Introduction and General Principles
suggesting that age modifies the intraoperative handling of
CO2, and the same difference was true for thoracoscopic sur-
gery [15]. The increased CO2 load has been calculated to be
approximately 16 % accounted for by absorption from the
abdomen in one study [22]. In the case of thoracoscopy, nearly
50 % of expired CO2 is absorbed from the thorax [22].
Neonates are particularly prone to acidosis during thora-
coscopic surgery owing to the markedly increased CO2 load,
the decreased respiratory elimination from lung collapse,
and exaggerated absorption in smaller children [15, 21].
Patients with congenital diaphragmatic hernia, for instance,
are also at risk of significant acidosis and secondary effects
[23–25]. Thoracoscopic surgery therefore should not be per-
formed without suitable expertise and monitoring, or if the
patient is unstable.
1.1.2.2 M  echanical Effects of Carbon Dioxide
Insufflation
Insufflation of CO2 used during laparoscopy increases intra-­
abdominal pressure. The optimal intra-abdominal pressure
for laparoscopy in children has been established to be
between 8 and 12 mm Hg [26], with neonates tolerating
lower pressures than older children. The increase in intra-­
abdominal pressure causes a rise in intrathoracic pressure,
which alters respiratory dynamics and leads to impaired
respiratory function, including reduced functional residual
capacity, increased airway pressure, and decreased lung
compliance. Absorption of CO2 from the abdomen seems to
peak about 30 min into surgery, with up to 20 % of expired
CO2 derived from absorption; it decreases back to preopera-
tive levels 30 min postoperatively [27]. During laparoscopy
in self-ventilating patients, this change translates into an
increase in end-tidal CO2 and arterial CO2 tensions [28] that
can lead to acidosis.
In children undergoing controlled ventilation during lapa-
roscopy, there is generally a good correlation between end-­
tidal CO2 and arterial CO2 pressures (PaCO2) [28, 29]. If
ventilation parameters are maintained at pre-insufflation val-
ues, both end-tidal CO2 and PaCO2 increase as intra-­
abdominal pressure increases. Occasionally, the increase in
PaCO2 is out of step with the increase in end-tidal CO2 [30].
A 20–30 % increase in minute ventilation is usually suffi-
cient to compensate for the increased CO2 load [31–33], thus
avoiding an increase in end-tidal CO2 or acidosis.
Intra-thoracic insufflation of CO2 has different mechani-
cal effects on respiratory dynamics than intra-abdominal
insufflation. Greater impaired respiratory capacity imposed
by lung collapse has significant implications for oxygenation
and CO2 excretion [34]. Thoracic insufflation of CO2 may
also have a different absorption profile than abdominal insuf-
flation, as it seems not to reach steady state within 30 min
[23]. A greater percentage (up to 30 %) of exhaled CO2 is
3
derived from absorption during thoracoscopy, compared
with 20 % during laparoscopy. The greater absorption of CO2
insufflated into the chest, coupled with the impaired ventila-
tion, can lead to a marked increase in arterial CO2 concentra-
tion, which is especially of concern in neonates and smaller
children, who have been shown to have greater CO2 increases
than bigger children [15]. Acidosis can be severe and pro-
longed in neonates undergoing thoracoscopy [23, 24]. The
ability to increase CO2 excretion in the face of the increased
load created by its absorption is crucial to safe thoracoscopy
in children. To avoid harm, the anaesthetist must anticipate,
monitor, and expertly manage this requirement. Therefore
thoracoscopic surgery in these circumstances should be per-
formed only in experienced centres and with good prospec-
tive monitoring and management of CO2 load.
1.1.2.3 Learning Curve
The impact of learning new tasks needed for MIS must be
taken account in embarking on such a venture. Many skills
are of course transferable between operations, but not always
between open and laparoscopic surgery. Intracorporeal sutur-
ing is a part of some MIS procedures and must be learned
before embarking on operations requiring this technique.
There is a role for learning these basic skills first on a form
of trainer (of which there are several types available), before
or while simultaneously attending a basic course. More
advanced courses teaching the combined steps and skills
for specific and advanced operations also can be used.
Many training models have been developed for specific
operations.
Whereas the learning curve can be measured in terms of
operative time and hospital stay, better measures are patient
safety outcomes such as complications and recurrence rates.
Many MIS operations can take significantly longer than the
corresponding open operation, especially during the learning
curve. This difference must be appreciated by the surgeon,
anaesthetist, and theatre staff (as well as patients and family,
of course), for good teamwork and success. For most sur-
geons with advancing skills, however, this difference in time
taken lessens and becomes clinically (and occasionally actu-
ally) insignificant.
There are various estimates of the number of MIS proce-
dures required to reach the peak of the learning curve. For
example, the number of procedures needed for laparoscopic
hernia repair is estimated to be between 10 and 30 cases [35,
36]. It must be remembered, however, that the learning curve
is both surgeon-specific and procedure-specific.
Being mentored at the outset of the MIS venture is one
means of quickly and safely negotiating the learning curve.
Inviting experienced operators to mentor surgeons at the
beginning of their venture should facilitate quick and safe
advancement up the learning curve.
4 M. McHoney et al.

1.2  hen Should MIS Be Used

W and this should be the first intention. But in other opera-
in Children? tions, the outcome is equivalent even though the classic
steps of an open operation are not performed laparoscopi-
1.2.1 Indications and Contraindications cally. The key consideration is whether the efficacy and
outcome of the laparoscopic approach have been shown
More and more operations are being performed by MIS in to be equal to those of the open approach.
children. Indications for each specific operation are beyond
the scope of this book. Some general indications and contra-
indications can be given. 1.2.3 Clinical Status

Patients being considered for MIS should be specifically clini-

1.2.2 Specific Operations
Some operations lend themselves nicely to MIS. Operations
that are particularly suitable for MIS may have the following
characteristics:
• A small, focused area of interest that would otherwise
require a large incision for access (e.g., the oesophageal
junction for myotomy or fundoplication)
• Access to areas that are relatively difficult to reach (e.g.,
deep recesses) but are suitable for access with a scope
(e.g., operations around the oesophageal hiatus or pelvis)
• Operations that have incisions associated with poor cos-
metic outcome (e.g., chest wall deformity) but that can be
improved with MIS
• Operations in which diagnostic uncertainty exists or when
MIS offers opportunity for diagnostic benefit not easily
available with open surgery (e.g., assessment of contralat-
eral inguinal ring and pelvic organs in hernia surgery, and
investigation of impalpable testis)
cally evaluated for the potential physiological changes dis-
cussed previously. In general, they should have achieved some
physiological stability, if not normality. Emergency operations
in unstable patients are associated with higher rates of compli-
cations. Active bleeding is a relative contraindication for MIS,
as bleeding will severely obscure visualisation in the cavity
being explored. Furthermore, blood itself causes difficulty by
light absorption, thereby further decreasing visibility.
There is no age or weight limit for the application of MIS
in children. Even preterm neonates can be candidates for
diagnostic and therapeutic interventions, and even opera-
tions requiring advanced MIS skills are being performed in
younger and smaller children.
There are some contraindications:
• Inability to tolerate the additional challenges of MIS sur-
gery and the CO2 load required, as shown by evaluation
• Active bleeding (relative)
• Physiological instability—a relative contraindication but
an important parameter that may prevent MIS

Some operations may pose a relative or absolute contrain-

dication to MIS, but absolute contraindications are becoming
fewer with advancing experience, instrumentation, and inno-
vation. Contraindications are suggested by the following
considerations:

• If the MIS approach is associated with higher complica-

tion rates, it is contraindicated.
• The MIS approach can be sanctioned for cancer surgery
only if the cancer surgery principles can be adhered to
(e.g., nodal sampling or clearance, wide tumour margins,
and intact tumour retrieval without rupture).
• If MIS ports do not allow safe organ or specimen retrieval,
open surgery may be needed. Often hybrid techniques are
possible, however (e.g., see Splenectomy chapter), using
alternative innovations or techniques or a more appropri-
ate abdominal incision.
• The need to alter the steps of the “classic” open operation
is often cited as a contraindication for laparoscopic sur-
gery—an idea both correct and incorrect. Often various
innovations in instrumentation and technique allow the
MIS operation to be performed using the classic steps,
1 Introduction and General Principles
1.3 Who Should Perform MIS in Children?
1.3.1 Training and Competence
Not all surgeons may suit advanced MIS surgery and the
skill sets that are required, but with adequate training, nearly
every surgeon can perform simple MIS procedures or opera-
tions. Many models of training exist and a combination of
some or all is usually employed in a stepwise fashion.
• Simple box trainers allow the novice MIS surgeon to test,
evaluate, and develop the skills required. Simple box train-
ers may also employ a manual or electronic scoring system
to allow documentation (and audit) of the developing psy-
chomotor skills. An example of a simple box trainer used in
one of our centres is shown in Fig. 1.1. Box training has
been shown to successfully contribute to laparoscopic
competence [37].
• Complex box trainers allow the trainee to develop the
sometimes more complex mix of the many different skills
and techniques required during MIS. Acquisition of data
regarding developing skills is again possible.
• Specific training models for specific operations also exist,
simulating the steps required for the completion of an
operation from start to finish. For example, box trainers
exist for operations such as repair of inguinal hernia,
pyloric stenosis, diaphragmatic hernia, or oesophageal
atresia and tracheo-oesophageal fistula. These models can
use a combination of simulated reconstructions and real-
istic body cavities with simulated tissue.
• Training courses are a very good means of gaining expo-
sure to MIS surgery. Courses are available at a variety of
levels, from those targeted at the novice and most junior
trainee to advanced courses for established MIS surgeons.
Some of the advanced courses allow realistic exposure to
Fig. 1.1 A simple box trainer used in one of our centres
5
animal tissue or models (including live operating) with
expert tutorship and teaching.
• Clinical exposure is the most realistic and eventually the
most appropriate means of training, but the need for clini-
cal training and clinical governance must be balanced
with patient safety and outcome. Therefore some form of
training with the means described above is used prior to
and alongside clinical exposure.
1.3.2 Mentorship
This can be seen as the final training step for those wishing
to embark on MIS who have not acquired full training in
MIS or in a specific operation. An expert can mentor a senior
surgeon in the acquisition of the final stages of the needed
skill and experience. This mentorship allows for a good mix
of training, governance, and safety.
1.3.3 Continued Development
Even experts in MIS needs to continually develop and mod-
ify techniques and skills, keeping abreast of advances in the
field. This development is often best done by attending large
international conferences that either focus on MIS (e.g.,
International Pediatric Endosurgery Group/Society of
American Gastrointestinal and Endoscopic Surgeons, IPEG/
SAGES) or include MIS in their programme (e.g., British
Association of Paediatric Surgeons/British Association of
Urological Surgeons, BAPS/BAUS), often with manual
training running alongside academic sessions.
It is also prudent to audit and frequently evaluate the out-
come of MIS cases to document and evaluate outcomes that
may need addressing or can help direct continued profes-
sional development. Presenting such data at conferences is
also a means of peer review and feedback, which can help
continued professional development.
6 M. McHoney et al.
1.4  here Should MIS in Children Take
W 1.4.3
Place?
1.4.1 Centres
If embarking on MIS in children for the first time, it may be
advantageous to be in a centre that performs MIS in adults,
to allow for some mentorship and sharing of experience
between surgeons and teams. It also cuts down on setup cost
if most of the basic equipment is already available.
Dedicated paediatric anaesthetists, who appreciate the dif-
ferent physiological changes incurred by MIS, are crucial in
allowing safe anaesthesia for children undergoing MIS. The
respiratory management is especially challenging in thoraco-
scopic operations in smaller children; an experienced anaes-
thetist is needed. There are also different cardiovascular
changes introduced by MIS. A dedicated team of personnel
(scrub nurses, managers) interested in development and sup-
port is needed for the success of MIS in children.
1.4.2 Research
It is also helpful to have some interest in research (both clini-
cal and basic science) and development of MIS in the centre.
Although not essential, the research interest will help with
the development of personal governance and can assist with
input into the general evidence base to inform and consoli-
date the case for MIS in children.
Operating Rooms
Most regular operating room (ORs) that are functional and
suited for paediatric surgery are easily transformed into a
suitable MIS suite for most routine procedures by the addi-
tion of a simple MIS stack. Commercially available start-up
sets are available from well-known companies with a track
record in paediatric MIS (e.g., Storz and Olympus). The
basic stack and a very simple basic tray (see individual chap-
ters) may suffice for operations like pyloromyotomies, her-
nia repairs, and appendectomies.
More advanced, integrated MIS suites are being used in
centres that perform high volume and/or high-complexity
MIS operations. Collaboration between hospitals and endo-
scopic companies like Storz and Olympus have allowed
development of integrated theatre suites (OR1™ and
ENDOALPHA™), which combine advanced concepts of
MIS to include controls by a common sterile interface for
operating lights, insufflators, and electrosurgical equipment;
“built-in” LCD monitors; “all-in-one” camera heads; and
other advanced solutions for integration. These impressive
suites come at a cost but are worth the investment for those
doing high volume and dedicated MIS procedures.
1 Introduction and General Principles 7

1.5  he “How” of Laparoscopic Surgery

T Secondary ports also come in various forms. An initial stab
in Children: Techniques incision can be used at the intended site. This incision can be
superficial if an introducer is being used with the port. The com-
The bulk of the rest of this book deals with the techniques monest introducers are pyramidal or conical (sharp or blunt), or
involved in specific MIS operations in children. Precise, ports with a retractable blade. The introduction is always per-
step-by-step approaches to common operations are outlined formed under laparoscopic vision, pointing the tip away from
in individual chapters, but the individual skills required to viscera and vital structures (point into space). If blunt introduc-
put these techniques together are not the subject of this atlas, ers are being used or instruments are to be inserted directly
as important and fundamental as they are. Many intuitive through the abdominal wall without ports, the stab incision is
steps during open surgery are not as intuitive during laparo- through all layers with direct laparoscopic vision.
scopic surgery; sometimes a complete change in the thought Tips and tricks for port insertion:
process is required. Others need to be learned in the context
of laparoscopy. Familiarity with the equipment unique to • Local anaesthetic can be used to infiltrate the incision site
MIS is also required; some is addressed in chapters on ergo- prior to incising.
nomics and equipment. • Ensure that there is sufficient intra-abdominal pressure to
Laparoscopic training sets (both commercial and individ- give counter-pressure during insertion. (The pressure can
ualised) are available for practise and to familiarise the sur- always be temporarily increased if necessary and
geon with the techniques such as triangulation, ligation, possible.)
clipping, and intracorporeal and extracorporeal suturing. • A direct cut-down of the secondary ports is also possible
These sets are a worthwhile investment for training and if desired.
building up of necessary skills.
Ergonomics is covered in Chap. 2. Appreciating and mas-
tering some of the ergonomic challenges of laparoscopy is 1.5.2 Converting to an Open Approach
essential to the safe and efficient performance of individual
tasks to construct a successful operation. During MIS, it sometimes becomes necessary to convert to
an open approach. This need is not in itself a complication.
Converting to an open approach may indeed avoid complica-
1.5.1 Port Insertion tions in situations where it is difficult to carry on using MIS,
such as equipment problems, poor visualisation, or bleeding.
Most primary port insertions tend to be at the umbilicus Many of the techniques used during MIS and open surgery
(either infraumbilical or supraumbilical depending on the are transferable (e.g., operative principles, tissue handling,
operation and patient size). Primary ports can be inserted and operative steps), whereas others are not (suturing, haem-
either by open cut-down technique or blind insertion (e.g., orrhage control, and organ extraction). The surgeon should
Veress needle). Given the small size of many paediatric be familiar with the corresponding techniques and skills for
patients and the inherent safety provided by the cut-down the open operation. Usually this is not difficult, as most sur-
technique, that is the method used and recommended. geons have been exposed to both the open and laparoscopic
A small stab incision is made and tissue planes sequen- techniques during training. But as more and more operations
tially dissected onto muscle fascia. This can be stabilised are being done laparoscopically, this difficulty may increase.
between stay sutures or clips and then incised down to the For instance, very few appendectomies are primarily being
peritoneum, which is then opened under direct vision. done by open surgery, so trainees may not routinely gain
Various port types are available, with various ways to fix exposure to these open techniques.
them in place after insertion. Some ports have been designed Now that most surgeons in training are being taught MIS
to prevent migration once inserted (e.g., screwing-in shaft, procedures without much exposure to the open operation for
radially expanding sheath, inflatable balloons). A Hasson-­ comparison and reference, the challenge of familiarity with
type port is commonly used, and allows for fixation and seal- open techniques is not easily addressed. Continued exposure
ing in its mechanism. Specialised ports with a transparent to open operations—even if not the same operation as the
trocar tip that allows insertion of an endoscope to visualise one being converted—can keep the repertoire of open tech-
entry during insertion are also available, and may be suitable niques in the forefront of the surgeon’s mind and psychomo-
for the older age group. tor skills.
8 M. McHoney et al.

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 Equipment and Ergonomics
2
Alex C.H. Lee and Hugh W. Grant

Abstract
Minimal access surgery (MAS) differs from traditional open surgery in that it accesses and
visualizes the operative field via small skin incisions. The small access points minimize the
morbidity and unsightly scars caused by larger open wounds. The endoscopic visualization
can also offer additional views by reaching deeper within the body cavity. The procedure
can still be invasive and traumatic, and therefore it is more appropriate to describe the
approach as “minimal access” instead of “minimally invasive.”

Keywords
Ergonomics • Operative field • Task performance

A.C.H. Lee, MB ChB, PhD, FRCSEd (Paed Surg), FRCS (*)

H.W. Grant, MB ChB, MD, FRCSEd, FRCS
Department of Paediatric Surgery, Oxford University Hospitals
NHS Foundation Trust, Oxford Children’s Hospital, John Radcliffe
Hospital, Oxford, UK

© Springer-Verlag Berlin Heidelberg 2017 9

M. McHoney et al. (eds.), Color Atlas of Pediatric Anatomy, Laparoscopy, and Thoracoscopy,
DOI 10.1007/978-3-662-53085-6_2
10
2.1 General Information
Minimal access surgery (MAS) differs from traditional open
surgery in that it accesses and visualizes the operative field
via small skin incisions. The small access points minimize
the morbidity and unsightly scars caused by larger open
wounds. The endoscopic visualization can also offer addi-
tional views by reaching deeper within the body cavity. The
procedure can still be invasive and traumatic, and therefore it
is more appropriate to describe the approach as “minimal
access” instead of “minimally invasive.”
The three interrelated performance-enhancing elements
in optimizing operative surgery are technology, ergonomics,
Fig. 2.1 Three interrelated performance enhancing elements
A.C.H. Lee and H.W. Grant
and training (Fig. 2.1). The innate abilities of the surgeon
and patient factors also influence surgical outcomes. The
interaction ergonomics and psychomotor skills are even
more evident in pediatric MAS, where there is often a lim-
ited operative workspace.
In this chapter we provide an overview of the basic equip-
ment used in pediatric MAS, the ergonomic constraints, and
optimization strategies.
Specific requirements in operative procedures and devel-
opments in techniques such as single incision laparoscopic
surgery (SILS) and robotic surgery are described in other
chapters.
Ergonomics
Technology Training
2 Equipment and Ergonomics 11

2.2 Working Instruments
The equipment and instruments used in pediatric MAS are
mostly the same as those used in adult MAS with some spe-
cifically designed for surgery in infants. It is important for
the surgeon to understand how the equipment works and to
know how to trouble-shoot basic problems.
poses a problem in small infants because each pulse of insuf-
flation (if set at a high rate) could result in a pressure surpass-
ing the set pressure before the negative feedback occurs that
stops further insufflation. This can be particularly dangerous
when insufflation is used in the neonatal chest. The initial
pressure and flow rate settings should be at low levels to start
(e.g., a pressure of 6–8 mmHg and a flow rate of 1 L/min).

2.2.1 Creation of the Operative Workspace

An insufflator is used to create, maintain, and control an ade-

quate operative workspace during MAS. The machine regu-
lates and monitors the flow rate, volume, and pressure of CO2
transported into the body cavity from the CO2 cylinder. A fil-
ter is used to prevent back flow of fluid from the patient. The
ambient air within the tube should be purged and filled with
CO2 prior to connecting it to the patient. The desired pressure
and flow rate can be set by the user (Fig. 2.2). The insuffla-
tions are given in short pulses and not continuously (although
set as liters per minute). When the measured pressure is less
than the set pressure, another pulse of insufflation is given,
and the process is repeated until the set pressure is reached.
Most machines are designed for adult use. In a large body
Fig. 2.2 Insufflator displaying preset and measured pressure and flow
cavity, leakage can be easily compensated for by setting the rate. Some machines only display the preset values temporarily after
machine at a higher flow rate to maintain pressure. Leakage adjustments are made
12 A.C.H. Lee and H.W. Grant

2.3 Visualization of the Operative Field

It is crucial that the surgeon understands the imaging chain

(Fig. 2.3). Any disruption of this chain results in suboptimal
visualization.

Fig. 2.3 Imaging chain. A clear understanding of this

Light Light
interlinked chain would allow trouble-shooting when the source cable
displayed image is absent or poor
Light

OBJECT

Image

Camera Connecting
Telescope Camera head Monitor
processor cables
2 Equipment and Ergonomics 13

2.3.1 Light

Most modern light sources use 300 watt xenon bulbs that
emit white light transmitted via a fiberoptic light cable to the
light post of the endoscope. Problems arise if there is a size
mismatch between the light cable and the endoscope size,
loose connections, or plus or minus broken fibers within the
light cable (Fig. 2.4). Light is transmitted along the optical
fibers within the endoscope, which provides illumination
from its tip. These were called “cold” light sources because
of the color temperature of 5000–6500 K. They generate a
significant amount of heat, which can cause thermal damage
to tissue; the temperature at the distal end of the tip of the
endoscope can reach up to 95 °C.
Fig. 2.4 Broken fibers in the light cable are shown as black dots on
close inspection
14
2.3.2 Optical Image
The traditional endoscope, the Hopkins rod lens endoscope,
contains optical lenses in the center and illumination fiberop-
tics in the periphery. The endoscopes come in various sizes
and lengths, with a viewing angle of 0–70°. Generally,
smaller endoscopes have lower optical resolution, lower
light transmission, and greater distortion compared with
larger ones (Fig. 2.5a, b). The optical image at the eyepiece
of the endoscope is captured by the camera head, which con-
tains the charge coupled device (CCD). It converts the opti-
cal information into electrical signals for processing in the
camera box. Single chip cameras have been replaced by
three-chip cameras, which have one channel for each of the
three primary colors. Some cameras are also equipped with a
parfocal zoom, which allows enlargement of the image with-
out moving the endoscope. However, zooming results in less
resolution, illumination, and perception of depth.
Prior to use, white balancing should be performed by keep-
ing a white object in front of the endoscope and ­activating
a b
Fig. 2.5 (a, b) Barrel distortion is less marked using a larger endoscope
A.C.H. Lee and H.W. Grant
the appropriate button on the camera box or ­camera head.
This is used as a white reference to adjust to the three pri-
mary colors.
With advances and miniaturization of imaging technol-
ogy, some manufacturers place the CCD at the tip of the
endoscope (“chip-at-tip”) rather than at the eyepiece end
without the need of Hopkins rod lenses. This construction
also allows pivoting at the tip in larger endoscopes.
Whatever type of endoscope is used, the processed elec-
tronic signal of the image is then transmitted to the viewing
monitor. Previously large cathode-ray tube (CRT) monitors
were placed on top of other equipment in the MAS tower.
Most hospitals now use flat panel monitors attached to the
MAS tower or suspended from the ceiling; they are usually
adjustable to allow changes in position. High definition
(HD) camera systems and monitor displays are increasingly
used in the operating theater. It is important to note that a
compatible processor connecting cables and monitor is
essential for the superior imaging from three-chip CCD or
HD cameras.
2 Equipment and Ergonomics 15

2.4 Instruments sheath, or the Hasson port (Fig. 2.8). In small children and
infants, instruments can be inserted without a port, especially
Instruments are available in disposable or reusable forms. if frequent instrument changes are unlikely, such as in a
Disposable instruments are always new, clean, sterile, and pyloromyotomy. The incision needs to be small and tight
work well as manufactured. However, they are expensive. around the instrument to minimize the leakage of gas.
Reusable instruments are generally more economical but Commonly used working instruments in MAS include
have to be cleaned, sterilized, packed, and serviced. It is graspers/dissectors, scissors, retractors, clippers/staplers,
essential that the cleaning/sterilization department knows the ligature placing devices, suction/irrigation devices, energy
exact requirements of each instrument. supplying devices, and tissue retrieving bags. Some of these
Instrument access into a body cavity in MAS is usually instruments are only available in disposable form (e.g., sta-
via a port that consists of the cannula and trocar. The cannula plers). Several manufacturers have modular design instru-
is also commonly referred to as the port. There are various ments to allow interchangeable handles (e.g., various
types of trocar tips (Fig. 2.6), the commonest being pyrami- ratchets) with different tips. The diameter of the shaft is usu-
dal, conical (sharp or blunt), or with a retractable blade. ally 3 mm or 5 mm. Generally, 3-mm instruments are prefer-
Insertion using a pyramidal or blade tip should avoid any able in patients weighing less than 10 kg.
twisting action in order to minimize tissue damage.
Specialized ports such as those used for bariatric surgery
have a bladeless trocar with a transparent trocar tip, allowing
for insertion of an endoscope to visualize entry during inser-
tion. Disposable radially expandable sheath ports are popular
with some surgeons.
The size of the port depends on the instruments to be
used. Most ports have a side stopcock for insufflation and an
internal valve to prevent gas leakage when the instrument is
removed (Fig. 2.7); some allow instruments of different sizes
to be used without the need for adaptors/reducers. The ­rubber
bung at the outer end maintains the gas seal when the instru-
ment is inserted.
The length of the port is important: Long ones are heavy
and can limit the surgeon if they are inserted too deeply into
the body cavity. On the other hand, short ports increase the
risk of dislodging owing to the thin body wall of infants.
There are various ways to fix a port after insertion into the
body, and some ports have been designed to prevent slip- Fig. 2.6 Trocars with conical (10 mm) and pyramidal (5 mm) tips are
page, such as the screwing-in shaft, the radially expanding shown
16 A.C.H. Lee and H.W. Grant

a b

Fig. 2.7 Internal valve mechanisms when an instrument is inserted. (a) Silicon valve. (b) Metal valve

Fig. 2.8 Hassan port system for port fixation. It can be secured at vari-
able internal lengths
2 Equipment and Ergonomics
2.5 Energy Devices
Electrosurgical devices are used extensively for hemosta-
sis and dissection in MAS. Minor bleeding can obscure
the view and reduce light reflection within the operative
field. The general principles of monopolar and bipolar dia-
thermy are the same as those for open surgery and are con-
trolled by a foot pedal. Extra care must be taken when
using monopolar diathermy to avoid hazards caused by
insulation failure, capacitive coupling, and inadvertent
direct (coupling) touching of another metal instrument
within the operative field. All plastic or all metal port sys-
tems can be used but avoid ports that are made from a
combination of materials (i.e., hybrid ports). The hook
monopolar diathermy instrument is most commonly used
for dissection. Bipolar diathermy uses special forceps
without the need for use of the patient return plate in
monopolar diathermy. In general, bipolar instruments are
preferable because the ­electrical circuit passes between
the tips of the instruments, not through the patient’s body.
Ultrasonic scalpels (e.g., the harmonic scalpel and
Sonosurg [Olympus America, Center Valley, NJ]) convert
ultrasonic vibrations into energy for precision cutting and
coagulation without the need for an electrical circuit through
the patient. Beware of collateral injury caused by thermal
spread by the heated instrument tip during or after use.
Vessel-sealing technology (e.g., LigaSure [Medtronic,
Minneapolis, MN]) uses an optimized combination of pres-
sure and energy to create seals by denaturing the collagen
and elastin in vessel walls. It seals vessels up to 7 mm in
diameter. When the seal is complete, the computer-controlled
feedback ceases the energy. Some hand-held devices also
come with a knife mechanism for division of tissue that has
just been sealed.
17
2.6  ther Equipment Considerations
O
in Pediatric MAS
• The Nathanson retractor (Cook Medical; Bloomington,
IN, USA) is very useful for liver retraction in upper
abdominal surgery in place of a second assistant (e.g.,
fundoplication). There are other hand-held endoscopic
retractors that open up once inserted into the body cavity
into snake or fan shapes.
• Pretied surgical loops (e.g., Endoloops [Ethicon, Medline
Industries. Mundelein, IL]) are useful for resection proce-
dures such as appendicectomy.
• Specimen retrieval bags of various sizes and designs are
available to avoid contamination during organ/tissue
removal. These are usually too large for use in infants.
• Knot pushers of various designs are used in extracorpo-
real knot tying.
• Suction-irrigation devices are useful when there is spillage
in the operative field. They can also be used in blunt dissec-
tion. They require pressurized fluid for irrigation. A speci-
men trap can be set up for collection of the suctioned fluid.
• Stapling devices are bulky and suitable for older children
only.
• Titanium clips for ligating vessels are available in 5 mm.
• A pyloromyotomy spreader has serrations in the outer and
inner surfaces of the instrument tip; the tip comes in
straight or hockey-stick configurations, depending on the
surgeon’s preference.
• Veres needles are used by some surgeons routinely. There
is a greater risk of collateral injury in children because of
their more elastic abdominal walls. The risk of such injury
is avoided by the “open” or “Hassan” entry method. The
authors prefer to use the open technique for initial entry in
children in all cases.
18 A.C.H. Lee and H.W. Grant

2.7 Ergonomic Considerations optimizing ergonomics plays a crucial role for safe and effi-
in Pediatric MAS cient deployment. The ergonomic challenges in the operat-
ing room have become more evident and critical with
2.7.1 Definition advances in surgical technology.

The word ergonomics comes from the Greek words ergos

(work/labor) and nomos (natural law). Ergonomics is the scien- 2.7.2  rgonomic Constraints in Minimal
E
tific study of the interaction between humans and their working Access Surgery
environment. It aims to achieve the optimum outcome by fitting
the job to the worker and the product to the user (Table 2.1). MAS carries a set of mechanical and visual constraints in the
There are many mental and physical similarities between execution of surgical tasks that cause degraded task perfor-
surgery and safety-critical industries such as aviation, where mance and surgeon discomfort.

Table 2.1 Ergonomics can be broadly considered in three domains: physical, cognitive, and organizational
Domain
Physical ergonomics
Cognitive ergonomics
Organizational ergonomics
Considerations Relevance/Applications
Anatomic, anthropometric, physiologic, and Work postures
biomechanical characteristics Workplace layout
Equipment handling
Work-related musculoskeletal disorders in surgeon
Mental processes: Decision-making
Perception Mental workload
Memory Skill performance
Reasoning Human-computer interaction
Motor response Human reliability
Training
Organizational structures, policies, and processes Communication
Teamwork
Team resource management
Design of roster and work patterns
2 Equipment and Ergonomics
2.7.3 Mechanical Constraints
Each degree of freedom (DOF) of movement allows the
instrument to move in an independent direction (Fig. 2.9). In
MAS, there are four DOFs of movement, namely, across in
the X axis, up and down in the Y axis, in and out in the Z
axis, and rotational movements. This compares unfavorably
to the 36 DOFs of movement in open surgery, where all
joints of the upper limbs from shoulder to finger tips provide
movement. The movements of MAS instruments are
restricted by the entry point in the body wall, and the r­ esulting
fulcrum effect leads to paradoxical movements, such as
when the surgeon’s hand moves to the right, the instrument
tip moves to the left.
Direct tactile feedback is lost in MAS, and indirect tactile
feedback from the instrument’s tip to the handles is reduced.
Proprioceptive feedback and the ability to identify the nature
of tissue components and planes are therefore diminished.
MAS instruments were adapted from equivalent instru-
ments used in open surgery with modifications to enable
them to be inserted into the body cavity. The diameter of the
endoscopic instruments is limited by the size of the access
port. Long thin instruments have poor mechanical advan-
tage, and the narrow distal tip may cause damage to tissues.
Because of the extracorporeal shaft length, the use of a long
instrument will result in a large external arc of arm move-
ment by the surgeon when the corresponding intracorporeal
shaft length is short.
The locations of the ports are determined by the surgeon
according to the available space on the surface of the body.
These are known to have crucial effects on task performance.
The manipulation angle is defined as the angle between the two
instruments (active and assisting) (Fig. 2.10). The ­elevation
19
angle is the angle of the instrument against the horizontal
plane. The best task performance is obtained when the manip-
ulation angle is between 45 and 75°, the ideal being 60°. Wide
manipulation angles necessitate wide elevation angles for
optimal performance and task efficiency. Generally elevation
angles of 45–60° are most suitable.
Most MAS instruments are not well suited for their use;
they often require flexion and ulnar deviation at the wrist
(which decrease maximum grip force); the handle configura-
tion often requires the surgeon to use opposing thenar and
hypothenar muscles for gripping rather than the more power-
ful deep flexor muscles of the forearm; the muscle contrac-
tion force for MAS grasping is three to five times higher than
that for open instruments. The inefficient transfer of the
mechanical force from the handles to the tip of the instru-
ment causes further discomfort and fatigue. Many laparo-
scopic instruments are not designed to accommodate the
fingers comfortably and can cause neuropraxia.
Surgeons have limited freedom of movement to adjust
their body posture and arm positions as a result of the fixed
point of insertion through the body wall. In addition, pro-
longed shoulder abduction is necessary, especially when the
table height is not suitably lowered. The presence of the
assistant holding the camera in front of the surgeon may fur-
ther prevent the surgeon as well as the assistant from adopt-
ing a comfortable posture. Surgeons often adopt static
postures for prolonged periods during MAS; in particular,
there is reduced mobility of the head and neck regions and
anteroposterior weight shifting. The restricted posture limits
the natural posture changes that occur in open surgery. This
is worsened when MAS is performed from the side of the
patient, requiring rotation of the surgeon along the head-­
neck spine axis.
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reputation of being great drunkards. The Houssa caravans pass
close to the north side of the town, but seldom halt here. It was
deserted last year, when Edrisi was driven here with his army; the
inhabitants flying to Ingastrie in Youri, and to the province of Wawa;
but are now mostly returned.
Sunday, 16th.—I was visited by the sirtain fada this morning, who
had just returned from seeing the Fellatas safe out of Koolfu: he told
me that the Benin people, before the civil war began, came here to
trade; that the Quorra ran into the sea, behind Benin, at Fundah; that
the Nyffe people and those of Benin were the same people; that
Benin paid tribute to Nyffe—(this is common with all negroes, to exalt
their native country above all others, in their accounts to strangers).
He said they got their salt from a town called Affaga, near the sea:
this is the Laro or Alaro of Yourriba, and in possession of the
Fellatas. In the evening an eunuch, a messenger, arrived from the
king, to take me to the Sanson, or gathering-place, where he was;
and to stop the taya.
Monday, 17th.—This morning a messenger of the king of Youri
arrived, bringing me a present of a camel, to assist in carrying my
baggage to Kano. He said the king, before he left Youri, had shown
him two books, very large, and printed, that had belonged to the
white men, that were lost in the boat at Boussa; that he had been
offered a hundred and seventy mitgalls of gold for them, by a
merchant from Bornou, who had been sent by a Christian on
purpose for them. I advised him to tell the king, that he ought to have
sold them; that I would not give five mitgalls for them; but that if he
would send them, I would give him an additional present; and that he
would be doing an acceptable thing to the king of England by
sending them, and that he would not act like a king if he did not. I
gave him for his master one of the mock-gold chains, a common
sword, and ten yards of silk, and said I would give him a handsome
gun and some more silk, if he would send the books. On asking him
if there were any books like my journal, which I showed him, he said
there was one, but that his master had given it to an Arab merchant
ten years ago; but the merchant was killed by the Fellatas on his way
to Kano, and what had become of that book afterwards he did not
know. He also told me, that the fifteen men whom I had seen at
Wawa belonging to Dahomey were slave-merchants; that they had
bought a hundred slaves at Youri; that they also bought small red
beads that came from Tripoli; that at Wawa they were to get a
hundred more slaves, when they would return to Dahomey; that
these people bring cloths, earthen ware, brass and pewter dishes,
and sell them in Houssa, Nyffe, and Youri, for slaves and beads.
Wednesday, 19th.—Dull and cloudy this morning. The eunuch
came with his horse ready saddled, but without one for me. I told him
I was all ready, but would not go until he brought me a horse. He
then pretended that he was going, and asked if I had no present to
send to the king. I said I had, but should give it myself when I saw
him; not until then. He then departed; when a Fellata, calling himself
a messenger from Bello, residing with the king, came and said he
would make the eunuch stop, and removed my baggage and myself
to a good and quiet house, as the one I was in was much disturbed
by women and children; and it is settled that I am to go with him to
the king to-morrow. I have offered two hundred thousand cowries to
have my baggage carried, but I cannot even get a letter conveyed to
Kano; either so jealous are they of me, or they have an eye to my
baggage, about which they have formed anxious conjectures. I had a
present from the king’s sister of a sheep, for which she modestly
requested a dollar and some beads. My new house is very snug and
comfortable. I have three rooms for myself and servants, with
houses for my horse and mare, an old man and his wife to look after
it, and I can keep out all idle persons.
Thursday, 20th.—Morning clear and warm. I had to remain to-day
also, as my guide and messenger, the black eunuch, is gone to the
Koolfu market again. At sunset he and Omar Zurmie (or Omar the
Brave), the messenger of Bello, waited on me, and told me that they
would leave this for the Sanson, or camp, in the course of the night,
if I was ready, and that Zurmie had a horse ready for me. I said I was
ready at a moment’s notice, and had been the last four days. In the
night we had a tornado, with thunder, lightning, and rain.
Friday, 21st.—This morning I left Tabra in company of Omar the
Brave, a black eunuch, and Mohamed Ben Ahmet, the Morzukie, as
my interpreter and servant; and having travelled twenty-seven miles,
came to a village called Kitako, where we passed the night.
Saturday, 22d.—At 1.30 A.M. left Kitako. The moon through the
thick clouds just enabling us, by the assistance of two Amars
(spearmen) who went a-head, to thread our way through the thick
woods, and over some of the most ticklish wooden bridges that ever
man and horse passed over. The morning was raw and cold, and the
path slippery and wet. At 4.30 I got so unwell and unable to bear the
motion of the horse, that I dismounted, and lay down on the wet
ground without covering, or any thing underneath me; for there are
times when a man, to get rid of his present sickness, will try any
remedy, whatever may be the after consequences: this was my
case, and I lay until six, when I rose much better of my sickness, but
with severe pains in the bones. A short while after starting, I crossed
over the wall of a ruined town called Jinne, or Janne, through
plantations of indigo and cotton, choked up with weeds. The morning
was raw and cloudy. A few of the ragged inhabitants were up; two or
three of the most miserable starved horses I ever saw were tied to
stakes close to the few huts that were rebuilt, their backs dreadfully
lacerated, the skin being nearly off from the shoulder to the rump,
and their eyes running with matter. Only for the verdure of the trees
at this season, and a beautiful stream of clear water, whose banks
were planted with plantain and palm-oil trees, this would have been
one of the most miserable scenes I ever saw in my life. After passing
the stream twice, without bridges, whose banks were very steep and
slippery, with several deep round holes, as man traps, on each side
the road, I ascended the plain above, from whence I saw the ruins of
several other towns and villages along the banks of the ravine. At
eight passed the ruins of another town; and at nine I met, attended
by a great rabble, armed with pickaxes, hoes, and hatchets,
Mohamed El Magia, or the would-be king, mounted on horseback,
and halted under a tree. When they told me there was the Magia
waiting to receive me, I rode up and shook hands with him. He asked
me after my health, and how I had fared on the road, and then told
the eunuch who was with me to take me to his house; he then rode
past, as I was informed, to complete the ruin of the last, as I thought
already ruined, town I had passed through. He was mounted on a
good bay horse, whose saddle was ornamented with pieces of silver
and brass; the breastpiece with large silver plates hanging down
from it, like what is represented in the prints of Roman and eastern
emperors’ horses. He is a tall man, with a sort of stupid expression
of countenance, having a large mouth and snagged teeth, with which
he makes himself look worse when he attempts to smile, and looks
indeed like any thing but a king or a soldier. He wore a black velvet
cap, with two flaps over the ears, and trimmed with red silk, a blue
and white striped tobe, red boots, part of leather and part red cloth,
in rags; in his hand he had a black staff, with a silver head; his
slaves were carrying a coast-made umbrella and his sword. I paid
him every decent respect, and put on as many smiles as I was able,
as I know that those ragged and dirty rogues, when they have power,
have more pride than a real king, and expect a great deal more
respect, and cannot bear a man to look serious. At ten I arrived at
the Sanson, or camp, where I was lodged in the eunuchs’ part,
having a small unoccupied hut separated from the rest allotted for
me to live in. Here I was left to myself until 3 P.M., when the eunuch
came and told me the king had arrived, and wished to see me. I went
directly, taking a present, which I displayed before him. When the
articles were taken away by an eunuch, I told him who and what I
was, where I was going, and that I wanted his assistance and
protection to the governors of Guari or Zegzeg, in Houssa; that I had
been well treated by every king and governor between Badagry on
the sea-coast, to Tabra in his dominions, and I hoped for the same
favourable reception from him. He said it was easy to do all that I
had asked, and he would do it.
Sunday, 23d.—This morning I was much better, having shut my
little straw hut up as close as possible, so that I was as if in a steam
bath all night. I have ever found this and fasting a good cure for most
disorders.
The king went through the camp, attended by a great rabble, a
slave carrying the umbrella I had given him over his head. He paid
me a visit, and began, as soon as he had seated himself, to show
me his staff of authority, a black stick, about four feet long, with a
silver head. He said I had got some of the same kind, and he wanted
one. I said I could not indulge him with one, unless I gave him that
intended for Bello. He then begged my travelling knife and fork. I
said, “What, then, I am to go without, and eat with my fingers! he had
better go to Tabra, and take all I had.” He observed he would
certainly not do that; that he would send me to Kano, and that I
should go in five or six days after this. He then went home, and sent
me, as a present, a small country horse, which will do well enough
for Pascoe to ride. I have now two horses and a mare.
The Sanson, or camp, is like a large square village, built of small
bee-hive-like huts, thatched with straw, having four large broad
streets, and with a square or clear place near the huts of the king.
Only for the number of horses feeding, and some picketed near the
huts, and the men all going armed, and numbers of drums beating, it
would pass for a well-inhabited village. Here are to be seen weavers,
taylors, women spinning cotton, others reeling off, some selling foo-
foo and accassons, others crying yams and paste, little markets at
every green tree, holy men counting their beads, and dissolute
slaves drinking roa bum.
Monday, 24th.—Morning cool and cloudy. In the early part of the
morning I went to take leave of the king, whom I found in his hut,
surrounded by Fellatas, one of whom was reading the Koran aloud
for the benefit of the whole; the meaning of which not one of them
understood, not even the reader. This may seem odd to an
Englishman; but it is very common for a man, both in Bornou and
Houssa, to be able to read the Koran fluently, and not understand a
word in it but “Allah,” or able to read any other book. They left off
reading when I came in; and as soon as the compliments of the
morning were over, the king begged me to give him my sword, which
I flatly refused, but promised to give him the five dollars, the staff,
and the pistol, whenever I was permitted to leave this for Kano,
which he promised I should do, and pointed out a person whom he
said he would send with me as a messenger; and that a merchant
from Koolfu would come and agree about the price he was to have
for carrying my baggage. I thanked him, and took my leave. He is
one of the most beggarly rogues I have yet met with; every thing he
saw or heard that I was possessed of he begged, not like a person
that wished to have them because they were scarce or rare, but with
a mean greediness that was disgusting. Though I had given him a
better present than he had ever got in his life before, he told me that
I said “No, no,” to every thing he asked for. He has been the ruin of
his country by his unnatural ambition, and by calling in the Fellatas,
who will remove him out of the way the moment he is of no more use
to them; even now he dares not move without their permission. It is
said that he has put to death his brother and two of his sons.
Through him the greater part of the industrious population of Nyffé
have either been killed, sold as slaves, or fled from their native
country. To remove him now would be charity; and the sooner the
better for his country.
At 8.30 in the morning I left the Sanson, and riding on ahead of
old Malam Fama, the Morzukie, I halted under a tree at eleven to let
the horses feed, and the Malam to come up with the sheep. At noon,
Mahomed having joined, I started with a plundering party who were
going the same road. They told me they were going to seize some
villagers who had returned to build up their ruined huts and sow a
little millet without first praying for leave to the Magia. On crossing
one of the small rivers and ascending the steep and slippery bank,
the chief of this band checked his horse, and both horse and rider
fell souse into the water. He was close behind me, but I left his
companions to pick him up. On the 25th we once more reached
Tabra.
I have observed more people with bad teeth and the loss of the
front teeth in Nyffé than any other country in Africa, or indeed any
other country. The males mostly are those who lose their teeth.
Whether it may arise from the universal custom of chewing snuff
mixed with natron or not, I do not pretend to say. The white of the
eye in the black population is in general bilious-looking and
bloodshot. There is scarcely one exception, unless it be in those
below eighteen or twenty years of age.
Tuesday, May 2.—This morning I left Tabra, and travelling along
the banks of the May-yarrow, passed the walled village of Gonda.
Having crossed a stream coming from the north, and running into the
May-yarrow, I entered the walled town of Koolfu, the greatest market
town in this portion of Nyffé, and resorted to by trading people from
all parts of the interior. I was provided with a good house; and the
head man of the town, a plausible fellow, was very officious, but at
the same time giving broad hints for a present. Mohamed Kalu, the
madagoo or head man of the goffle from Bornou, has to remain here
until after the Rhamadan. I was visited by all the principal people in
the place, as a matter of curiosity, though many of them had seen
me at Tabra.
Monday, 8th.—Clear and cool. The house in which I live is one of
the best in Koolfu. I have three separate coozies parted off from the
rest of the house, and a place for my stud, which now amounts to
two horses and a mare. My landlady is a widow, large, fat, and deaf,
with an only child, a daughter, about five years old; a spoiled child.
The widow Laddie, as she is called, is considered to be very rich.
She is a merchant; sells salt, natron, and various other articles: but
what she is most famed for is her booza and roa bum, as the palm
wine is called; and every night the large outer hut is filled with the
topers of Koolfu, who are provided with music as well as drink, and
keep it up generally until the dawn of morning separates them. Their
music consists of the drum, erbab, or guitar of the Arabs, the Nyffé
harp, and the voice. Their songs are mostly extempore, and allude to
the company present. The booza is made from a mixture of doura, or
Guinea corn, honey, Chili pepper, the root of a coarse grass on
which the cattle feed, and a proportion of water: these are thrown in
equal proportions into large earthen jars, open at top, and are
allowed to ferment near a slow fire for four or five days, when the
booza is fit to drink, and is put into earthen jars. It is a very fiery and
intoxicating beverage; but, whether Mohamedan or pagan, they all
drink, and agree very well together when in their cups. At first neither
I nor my servants could sleep for their noise, but now I have got used
to it. This night the new moon was seen, and Mohamedan and
pagan joined in the cry of joy. My landlady had thirteen pieces of
wood, on each of which was written by the Bornou malem the word
“Bismillah,” the only word he could write. These boards she then
washed and drank the water, and gave to her family to drink. She
offered some of it to me; but I said I never drank dirty water: and I
thought that if she and her servants had taken a comfortable cup of
booza or bum it would have done them more good than drinking the
washings of a board written over with ink; for the man was a rogue
who had made her pay for such stuff. “What!” says she, “do you call
the name of God dirty water? it was good to take it.” These rogues,
who call themselves malems, impose on the poor ignorant people
very much; and the pagans are as fond of having these charms as
the Mohamedans. These dirty draughts are a cure for all evils,
present and to come, and are called by the people dua. Some of
their fighting men will confine themselves to their houses for thirty or
forty days, fasting during the day, and only drinking and washing with
this dirty stuff. If a man is fortunate, or does any feat above the
common, it is attributed to the dua, or medicine: neither his wit nor
the grace of God gains a man any thing.
Tuesday, 9th.—Clear and warm. The new moon having been
seen last night put an end to the fast of the Rhamadan; and this day
is kept throughout the northern interior by Mohamedan and Kafir.
Every one was dressed in his best, paying and receiving visits,
giving and receiving presents, parading the streets with horns,
guitars, and flutes; groups of men and women seated under the
shade at their doors, or under shady trees, drinking roa bum or
booza. I also had my share of visitors: the head man of the town
came to drink hot water, as they call my tea. The chief of Ingaskie,
the second town in Youri, only a day’s journey distant, sent me a
present of a sheep, some rice, and a thousand gora nuts, for which
he expects double the amount in return. The women were dressed
and painted to the height of Nyffé perfection; and the young and
modest on this day would come up and salute the men as if old
acquaintances, and bid them joy on the day; with the wool on their
heads dressed, plaited, and dyed with indigo; their eyebrows painted
with indigo, the eyelashes with khol, the lips stained yellow, the teeth
red, and their feet and hands stained with henna; their finest and
gayest clothes on; all their finest beads on their necks; their arms
and legs adorned with bracelets of glass, brass, and silver, their
fingers with rings of brass, pewter, silver, and copper; some had
Spanish dollars soldered on the back of the rings. They, too, drank of
the booza and roa bum as freely as the men, joining in their songs,
whether good or bad. In the afternoon, parties of men were seen
dancing: free men and slaves all were alike; not a clouded brow was
to be seen in Koolfu; but at nine in the evening the scene was
changed from joy and gladness to terror and dismay; a tornado had
just began, and the hum of voices and the din of people putting their
things under cover from the approaching storm had ceased at once.
All was silent as death, except the thunder and the wind. The
clouded sky appeared as if on fire; each cloud rolling towards us as
a sea of flame, and only surpassed in grandeur and brightness by
the forked lightning, which constantly seemed to ascend and
descend from what was now evidently the town of Bali on fire, only a
short distance outside the walls of Koolfu. When this was
extinguished a new scene began, if possible worse than the first.
The wind had increased to a hurricane; houses were blown down;
roofs of houses going along with the wind like chaff, the shady trees
in the town bending and breaking; and, in the intervals between the
roaring of the thunder, nothing heard but the war-cry of the men and
the screams of women and children, as no one knew but that an
enemy was at hand, and that we should every instant share in the
fate of Bali. I had the fire-arms loaded when I learned this, and
stationed Richard and Pascoe at the door of each hut, and took the
command of my landlady’s house, securing the outer door, and
putting all the fires out. One old woman roasting ground nuts, quite
unconcerned, made as much noise as if she had been going to be
put to death when the water was thrown over her fire. At last the rain
fell: the fire in Bali had ceased by its being wholly burnt down. In our
house we escaped with the roof blown off one coozie, and a shed
blown down. All was now quiet; and I went to rest with that
satisfaction every man feels when his neighbour’s house is burnt
down and his own, thank God! has escaped.
Sunday, 14th.—Mohamed, the Fezzanie, whom I had hired at
Tabra, and whom I had sent to the chief of Youri for the books and
papers of the late Mungo Park, returned, bringing me a letter from
that person, which contained the following account of the death of
that unfortunate traveller: that not the least injury was done to him at
Youri, or by the people of that country; that the people of Boussa had
killed them, and taken all their riches; that the books in his
possession were given him by the Imam of Boussa; that they were
lying on the top of the goods in the boat when she was taken; that
not a soul was left alive belonging to the boat; that the bodies of two
black men were found in the boat chained together; that the white
men jumped overboard; that the boat was made of two canoes
joined fast together, with an awning or roof behind; that he, the
sultan, had a gun, double-barrelled, and a sword, and two books that
had belonged to those in the boat; that he would give me the books
whenever I went to Youri myself for them, not until then.
Monday, 15th.—I am still very weak; Richard worse. I had a letter
from the learned Abdurahman, of Kora, a noted chief of banditti, and
who once, with his followers, overran Nyffé, and held possession of
the capital six months. He now keeps the town of Kora, a day’s
journey to the north-east, and is much feared by Mohamedan and
Kafir. He is a native of Nyffé. He is particularly anxious that I should
visit him, as he wants my acquaintance, and begs I will give him the
Psalms of David in Arabic, which he hears I have got. His letter was
written on part of the picture of the frontispiece of an European book,
apparently Spanish or Portuguese. He says he has something to
communicate to me, which cannot be done but by a personal
interview; but unless he come to Koolfu I told his messenger, I could
not see him.
Tuesday, 23d.—Cool and cloudy. A large caravan arrived from
Yourriba. They had come through Borgoo, where they sold what
natron they had remaining after they left Yourriba. They were in
Katunga when I was there; but were forbidden to hold any
communication with us, on pain of having their throats cut. They told
me that my friend the fat eunuch had endeavoured to hire a man to
assassinate me, but that they were all afraid. There are strong
reports of a war between the Sheik El Kanami and the Fellatas. They
say the sheik has taken the city of Hadija, and that the governor of
Kano is gone out to meet him, as he is advancing upon Kano.
Whether it is a report to please the Nyffé people, who cannot bear
the Fellatas, or not, I do not know. We had a number of such reports
when in Bornou last journey. In the evening a messenger from the
sultan of Boussa arrived, bringing me a present of a beautiful little
mare. The messenger of the sultan was accompanied by another
person from the midaki, a female slave, bringing me rice, yams, and
butter. He brought a message from the sultan desiring me to kill a
she-goat, and distribute the flesh amongst the inhabitants of Koolfu
the day before I left it; that he had distributed gora nuts and salt for
me at Boussa, which would do for Koolfu. I was also desired not to
eat any meat that came cooked from the west, and which would be
sent by the Magia’s female relations from Tabra, as they intended to
take away my life by poison. Through the night continual rain,
thunder, and lightning.
Thursday, 25th.—Sent Sheeref Mohamed to Raba, a town
possessed by the Fellatas, three days south of this, on the banks of
the Quorra, with a message to the late Imam of Boussa, who, he
says, has got some of the books belonging to the late Mungo Park:
one, he tells me, was carried to Yourriba by a Fellata, as a charm
and preservative against musket balls. He is either to buy them, or I
will give him Arabic books for them in exchange.
Friday, June 17th.—This evening I was talking with a man that is
married to one of my landlady’s female slaves, called her daughter,
about the manners of the Cumbrie and about England; when he
gave the following account of the death of Park and his companions,
of which he was an eye-witness: He said that when the boat came
down the river, it happened unfortunately just at the time that the
Fellatas first rose in arms, and were ravaging Goober and Zamfra;
that the sultan of Boussa, on hearing that the persons in the boat
were white men, and that the boat was different from any that had
ever been seen before, as she had a house at one end, called his
people together from the neighbouring towns, attacked and killed
them, not doubting that they were the advance guard of the Fellata
army then ravaging Soudan, under the command of Malem
Danfodio, the father of the present Bello; that one of the white men
was a tall man with long hair; that they fought for three days before
they were all killed; that the people in the neighbourhood were very
much alarmed, and great numbers fled to Nyffé and other countries,
thinking that the Fellatas were certainly coming among them. The
number of persons in the boat was only four, two white men and two
blacks: that they found great treasure in the boat; but that the people
had all died who eat of the meat that was found in her. This account I
believe to be the most correct of all that I have yet got; and was told
without my putting any questions, or showing any eagerness for him
to go on with his story. I was often puzzled to think, after the
kindness I had received at Boussa, what could have caused such a
change in the minds of these people in the course of twenty years,
and of their different treatment of two European travellers. I was
even disposed at times to flatter myself that there was something in
me that belonged to nobody else, to make them treat me and my
people with so much kindness; for the friendship of the king of
Boussa I consider as my only protection in this country.
Koolfu, or, as it is called by many, Koolfie, is the principal town for
trade in Nyffé at present; and at all times a central point for trade in
this part of the interior. It is situated on the north bank of the river
May-yarrow; and it is surrounded by a clay wall about twenty feet
high, and has four gates. It is built in the form of an oblong square,
having its longest diameter from east to west; there is a long
irregular street runs through it, from which lead a number of smaller
streets. There are two large open spaces near the east and west
ends of the town, in which are booths, and large shady trees, to
protect the people from the heat of the sun, when attending the
markets, which are daily held in those places: there are, besides the
daily markets, two weekly markets on Mondays and Saturdays,
which are resorted to by traders and people inhabiting the sea coast.
Ajoolly and the other towns in Yourriba, Cubbi, Youri, Borgoo,
Sockatoo, and Zamfra on the north, Bornou and Houssa on the east,
and, before the civil war, people from Benin, Jabbo, and the southern
parts of Nyffé, used to resort to this town as a central point of trade,
where the natives of the different countries were sure to get a ready
sale for their goods; either selling them for cowries, or exchanging
them for others by way of barter. Those who sold their goods for
cowries attend the market daily, and when they have completed their
sale, buy at once the goods or wares they want, and return home.
Such is the way of the small traders, who are nine out of ten women,
and are principally from the west part of the Quorra, even as far off
as Niki: they carry their goods on their heads in packages, from sixty
to eighty and a hundred pounds weight. The goods these people
bring from the west are principally salt, and cloths worn by the
women round their loins, of about six yards in length and two in
breadth, made of the narrow striped cloth, in which red silk is
generally woven, and a great deal of blue cotton; this is called
Azane, and the best are worth about three thousand to five thousand
cowries, or two dollars:—Jabbo cloths, which are about the same
length as the others, and about the breadth of our sail-cloth, are
worn by slaves, and have a stripe or two of blue in them; the poor
classes also wear them, men and women:—Peppers, called
monsoura, shitta, and kimba; monsoura is like our East India pepper;
shitta is the malagetta pepper of the coast; kimba is a small thin
pepper, growing on a bush, near the sea coast, in Yourriba, of a red
colour, like Chili pepper:—Red wood from Benin, which is pounded
to a powder and made into a paste; women and children are rubbed
with this, mixed with a little grease, every morning; and very
frequently a woman is to be seen with a large score of it on her face,
arms, or some part of her body, as a cure for some imaginary pain or
other:—A small quantity of calico or red cloth is sometimes brought,
which is of European manufacture. They take back principally
natron, beads made at Venice of various kinds, and come by the way
of Tripoli and Ghadamis, and unwrought silk of various colours,
principally red, of about one ounce in weight, and is sold here at
three thousand cowries; it and natron are as good as cowries.
The caravans from Bornou and Houssa, which always halt here a
considerable time, bring horses, natron, unwrought silk, beads, silk
cords, swords that once belonged to Malta, exchanged for bullocks
at Bengazie, in the regency of Tripoli, sent to Kano and remounted,
and then sold all over the desert and the interior; these swords will
sell for ten or twenty dollars a piece or that value, and sometimes
more; cloths made up in the Moorish fashion; looking-glasses of
Italian manufacture from about a penny a piece to a shilling in Malta;
tobes or large shirts undyed, made in Bornou; khol or lead used as
blacking for the eye-lids; a small quantity of ottar of roses, much
adulterated; sweet smelling gum from Mecca; a scented wood also
from the East; silks the manufacture of Egypt; turbans; red Moorish
caps with blue silk tassels; and sometimes a few tunics of checked
silk and linen made in Egypt: the last are generally brought by Arabs.
A number of slaves are also brought from Houssa and Bornou, who
are either sold here or go further on. The Bornou caravans never go
further than this place, though generally some of their number
accompany the Houssa merchants to Agolly in Yourriba, Gonja, and
Borgoo, from which they bring Kolla or Gora nuts, cloth of woollen,
printed cottons, brass and pewter dishes, earthenware, a few
muskets, a little gold, and the wares mentioned before as brought
from Yourriba. They carry their goods on bullocks, asses, and mules;
and a great number of fine women hire themselves to carry loads on
their heads; their slaves, male and female, are also loaded. The
Bornou merchants, during their stay, stop in the town in the houses
of their friends or acquaintances, and give them a small present on
their arrival and departure, for the use of the house. The Houssa
merchants stop outside the walls in little straw huts or leathern tents,
which they erect themselves. They sell their goods and wares in their
houses or tents; the small wares they send to the market and round
to the different houses by their slaves to sell; there are also a
number of male and female brokers in the town, whom they also
intrust. The pedlers or western merchants always live in the houses
of the town, and attend the markets daily, employing their spare time
in spinning cotton, which they provide themselves with on their
arrival, and support themselves by this kind of labour. There have
been no fewer than twenty-one of these mercantile women living in
my landlady’s house at one time, all of them from Yourriba and
Borgoo: these women attend the markets at the different towns
between this and their homes, buying and selling as they go along.
The caravans from Cubbi, Youri, and Zamfra, bring principally slaves
and salt, which they exchange for natron, Gora nuts, beads, horses,
tobes dyed of a dark blue, having a glossy and coppery tinge. The
slaves intended for sale are confined in the house, mostly in irons,
and are seldom allowed to go out of it, except to the well or river
every morning to wash; they are strictly guarded on a journey, and
chained neck to neck; or else tied neck to neck in a long rope of raw
hide, and carry loads on their heads consisting of their master’s
goods, or his household stuff; these loads generally from fifty to sixty
pounds weight. A stranger may remain a long time in a town without
seeing any of the slaves, except by accident, or making particular
inquiry. The duties which traders pay here are collected by the
people of Tabra, who take twenty cowries from every loaded person,
forty for an ass, and fifty for a loaded bullock.
The inhabitants may amount to from twelve to fifteen thousand,
including all classes, the slave and the free; they are mostly
employed in buying and selling, though there are a great number of
dyers, tailors, blacksmiths, and weavers, yet all these are engaged in
buying and selling; few of these descriptions ever go on distant
journeys to trade, and still fewer attend the wars, except it be to buy
slaves from the conquerors. I have seen slaves exposed for sale
here, the aged, infirm, and the idiot, also children at the breast,
whose mothers had either fled, died, or been put to death. The
domestic slaves are looked upon almost as the children of the family,
and if they behave well, humanely treated: the males are often freed,
and the females given in marriage to freemen, at other times to the
male domestic slaves of the family; when such is the case a house is
given to them, and if he be a mechanic, he lives in the town, and
works at his trade; if not, in the country, giving his owner part of the
produce, if not made free; in both cases they always look upon the
head of such owner’s family as their lord, and call him or her father
or mother.
The food of the free and the slave is nearly the same; perhaps the
master or mistress may have a little fat flesh, fish, or fowl, more than
their slaves, and his meat is served in a separate place and dish; but
the greatest man or woman in the country is not ashamed at times to
let their slaves eat out of the same dish, but a woman is never
allowed to eat with a man. Their food consists of ground maize,
made into puddings or loaves, and about half a pound each, sold at
five cowries each in the market; of flummery, or, as they call it in
Scotland, sowens, made from the ground millet, which is allowed to
stand covered with water, until it gets a little sour; it is then well
stirred and strained through a strainer of basketwork into another
vessel, when it is left to settle, and the water being strained off, it is
dried in the sun; when perfectly dry, it is broken into lumps and kept
in a sack or basket; when used it is put into boiling water, and well
stirred, until of a sufficient thickness; this makes a very pleasant and
healthy breakfast with a little honey or salt, and is sold in the market
at two cowries a pint every morning, and is called Koko. They have a
pudding made of ground millet, boiled in the ley of wood ashes,
which gives a red colour; this is always eaten with fat or stewed
meat, fish, or fowl. They always stew or grill their meat: when we
have it in any quantity it is half grilled and smoked, to preserve until it
is wanted to be used. Boiled beans made up in papers of a pound or
a half pound each, and wrapped in leaves, sold for two cowries
each, and called waki. Beans dried in the sun sold at one cowrie a
handful. Small balls of boiled rice, mixed with rice flower, called
Dundakaria, a cowrie a piece, mixed with water, and serves as meat
and drink. Small balls of rice, mixed with honey and pepper, called
Bakaroo, sold at five cowries each. Small balls made from bean
flowers, fried in fat, like a bunch of grapes. Their intoxicating
draughts are the palm wine called roa bum, bouza, and aquadent,
very much adulterated and mixed with pepper.
At daylight the whole household arise: the women begin to clean
the house, the men to wash from head to foot; the women and
children are then washed in water, in which the leaf of a bush has
been boiled called Bambarnia: when this is done, breakfast of cocoa
is served out, every one having their separate dish, the women and
children eating together. After breakfast the women and children rub
themselves over with the pounded red wood and a little grease,
which lightens the darkness of the black skin. A score or patch of the
red powder is put on some place where it will show to the best
advantage. The eyes are blacked with khol. The mistress and the
better looking females stain their teeth and the inside of the lips of a
yellow colour with gora, the flower of the tobacco plant, and the bark
of a root: the outer part of the lips, hair, and eye-brows, are stained
with shuni, or prepared indigo. Then the women who attend the
market prepare their wares for sale, and when ready go. The elderly
women prepare, clean, and spin cotton at home and cook the
victuals; the younger females are generally sent round the town
selling the small rice balls, fried beans, &c. and bringing a supply of
water for the day. The master of the house generally takes a walk to
the market, or sits in the shade at the door of his house, hearing the
news, or speaking of the price of natron or other goods. The weavers
are daily employed at their trade; some are sent to cut wood, and
bring it to market; others to bring grass for the horses that may
belong to the house, or to take to the market to sell; numbers, at the
beginning of the rainy season, are employed in clearing the ground
for sowing the maize and millet; some are sent on distant journeys to
buy and sell for their master or mistress, and very rarely betray their
trust. About noon they return home, when all have a mess of the
pudding called waki, or boiled beans, and about two or three in the
afternoon they return to their different employments, on which they
remain until near sunset, when they count their gains to their master
or mistress, who receives it, and puts it carefully away in their strong
room. They then have a meal of pudding and a little fat or stew. The
mistress of the house, when she goes to rest, has her feet put into a
cold poultice of the pounded henna leaves. The young then go to
dance and play, if it is moonlight, and the old to lounge and converse
in the open square of the house, or in the outer coozie, where they
remain until the cool of the night, or till the approach of morning
drives them into shelter.
Their marriages are the same amongst the Mohamedans as they
are in other countries, where they profess that faith. The pagan part
first agree to go together, giving the father and mother a present,
and, if rich, the present is sent with music, each separate article
being borne on the head of a female slave. The Mohamedans bury
in the same manner as they do in other parts of the world. The
pagans dig a round hole like a well, about six feet deep, sometimes
in the house, sometimes in the threshold of the door, and sometimes
in the woods: the corpse is placed in a sitting posture, with the wrists
tied round the neck, the hams and legs close to the body: a hole is
left at the mouth of the grave, and the relations and acquaintances
leave tobes, cloth, and other articles at the small round hole, and
telling the dead persons to give this to so and so: these things are
always removed before the morning by the priest. The majority of the
inhabitants of Koolfu profess to be Mahometans, the rest Pagans,
whose mode of worship I never could learn, except that they, like the
inhabitants of the other towns in Nyffé, attended once a year in one
of the southern provinces, where there was a high hill, on which they
sacrificed a black bull, a black sheep, and a black dog. The figures
on their houses of worship are much the same as in Yourriba: the
lizard, crocodile, the tortoise, and the boa-serpent, with sometimes
men and women. Their language is a dialect of the Yourriba, but the
Houssa tongue is the language of the market. Their houses and
court are kept very clean, as also the court-yard, which is sprinkled
every morning with water, having the shell of the bean of the mitta
tree boiled in it, which stains it of a dark brown colour; and each side
of the doors of the coozies or huts are stained with indigo and
ornamented with figures. The women have the stone for grinding the
corn, pepper, &c. raised on a clay bench inside the house, so that
they can stand upright while they grind the corn; an improvement to
be seen in no other part of the interior, or in Fezzan, the women
having to sit on their knees when grinding corn. Their gourd dishes
are also of the first order for cleanliness, neatness, and good carving
and staining, as also their mats, straw bags, and baskets.
They are civil, but the truth is not in them, and to be detected in a
lie is not the smallest disgrace, it only causes a laugh. They are also
great cheats. The men drink very hard, even the Mahometans; and
the women are generally of easy virtue. Notwithstanding all this
against them, they are a people of a natural good disposition; for
when it is considered that they have been twice burnt out of the town
by the enemy within the last six years, and that they have had a civil
war desolating the country for the last seven years, and been subject
to the inroads of the Fellatas during twenty years, and having neither
established law nor government but what a present sense of right
and wrong dictates, I am surprised that they are as good as they are.
I witnessed while here several acts of real kindness and goodness
of heart to one another. When the town of Bali was burnt down,
every person sent next day what they could spare of their goods, to
assist the unfortunate inhabitants. My landlady, who has given away
a number of her female slaves to freemen for wives, looks upon
them as her own children, attending them when sick; and one who
had a child while I was here, at the giving it a name, she sent
seventy different dishes of meat, corn, and drink, to assist at the
feast on that occasion. In all my dealings with them they tried and
succeeded in cheating me, but they had an idea that I was
possessed of inexhaustible riches; and besides, I differed with them
in colour, in dress, in religion, and in my manner of living. I was
considered therefore as a pigeon for them to pluck. Had they been
rogues, indeed, they might have taken all I had; but, on the contrary,
I never had an article stolen, and was even treated with the most
perfect respect and civility they were masters of.
I believe it is generally considered in England, that when a negro
slave is attached to his master, he will part with his life for him.
Instances of this kind are not so common as they ought to be, when
it is considered that all of these slaves are brought up from their
childhood, and know no other parent or protector; and if they were to
run away, or behave so ill as to cause him to sell them, they would
never be so well off as they were before. Those who are taken when
grown-up men or women, and even boys and girls, run whenever an
opportunity offers, and, whenever they can, take their owner’s goods
or cattle to assist them on their journey. Instances of this kind
happened every night.
They have very few bullocks, sheep, or goats, in the country; but
that is owing to the desolating war. Corn they have in abundance, as
that cannot be driven away by plundering parties. The surrounding
country is a level plain, well cultivated, and studded with little walled
towns and villages, along the banks of the May-yarrow, and another
little river running into it from the north. It is subject to the Majia, but
never visited by him or his people, except to attend the market, or
collect the duties from the traders. The town of Kufu, at a short
distance (not a mile), has a quarrel with another little town about half
a mile from it, called Lajo, the latter having taken the wife of a man,
whom they thought they had killed and left for dead, and selling her;
hence arose a regular system of retaliation; and they take and sell
one another whenever they have an opportunity. Every other night
almost the war-cry was raised about stealing asses, oxen, or murder;
and sometimes the inhabitants of Koolfu would join in the fray,
always siding with Kufu.
Monday, 19th.—Having been detained thus long at Koolfu, by my
own and my servant Richard’s illness, we left it this morning,
accompanied by the head man and the principal inhabitants of
Koolfu, who went with me as far as the walled and warlike village of
Kufu, where I stopped for the night. Here the head man of Koolfu
introduced me to the head man of Kufu, who provided me with a
good house, and made me a present of a sheep and some cooked
meat. I had also presents of meat sent me by the principal
inhabitants. The people of Kufu, not satisfied with having frequently
seen me and my servants at Koolfu, are in the habit of mounting
some trees growing on a small hill close to and overlooking my
house and court-yard, to get another and a last look: party came
after party until sunset, when they went away.
My landlady, the widow Laddie, also accompanied me to Kufu,
where she remained all night. I thought it had been out of a great
regard for me; but I was soon let into the secret, by five of her slaves
arriving with booza and bum, which she began selling in my court-
yard to the different merchants, bullock-drivers, and slaves
assembled here, who are going to the eastward.
The village of Kufu is walled, and only about two musket shots
from the other walled village, which is to the south, and with whom
they are at heavy war. The space between is generally occupied by
the caravans bound to the eastward, who usually halt here for a
week to complete their purchases at the market of Koolfu before they
start. The country around has a rich and clay soil, planted with
indigo, cotton, Indian corn, and yams.
Tuesday, 20th.—Having given the head man of Kufu thirty Gora
nuts, with which he was well pleased, and loaded the bullocks,
horse, ass, and camel, at 6 A.M. left Kufu. The path, or road, through
a woody country: the trees consisting mostly of the micadania, or
butter tree, which does not grow to a large size; the largest only
about the size of our apple trees in Europe, and this only seldom:
their girth is not above two or three feet. The path was winding; the
soil a deep red clay, covered with a thin layer of sand.
Wednesday, 21st.—After passing a great number of towns and
villages, we arrived at a walled town called Bullabulla, where we
encamped outside. As soon as my tent was pitched, I was
surrounded by the inhabitants. They were quite amused with my hat;