Endoscopic Surgery in Children

Endoscopic Ear Surgery in Children
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Guelfand presents the laparoscopic treatment for gastroesophageal reflux. Laparoscopic treatment for gastroesophageal reflux In this key lecture extracted from the IRCAD advanced course "laparoscopy in newborns, infants and children" March , , Dr.

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Guelfand demonstrates the strategy used to perform a total splenectomy in pediatric surgery. Guelfand demonstrates the strategy used to manage choledochal cysts in pediatric surgery. Guelfand demonstrates the operative strategy used to manage congenital diaphragmatic hernia CDH in children. Congenital diaphragmatic hernia In this key lecture extracted from the IRCAD advanced course "laparoscopy in newborns, infants and children" March , , Dr.

Laparoscopic treatment for gastroesophageal reflux GER in infants and children. In this key introductive lecture extracted from the IRCAD advanced course "laparoscopy in newborns, infants and children" March , , Prof. Reinberg describes the laparoscopic treatment for gastroesophageal reflux GER in infants and children. Laparoscopic treatment for gastroesophageal reflux GER in infants and children In this key introductive lecture extracted from the IRCAD advanced course "laparoscopy in newborns, infants and children" March , , Prof.

Reinberg focuses on small bowel volvulus and malrotations in pediatric surgery. Small bowel volvulus and malrotations in children In this key lecture extracted from the IRCAD advanced course "laparoscopy in newborns, infants and children" March , , Prof. Guelfand demonstrates the surgical management of duodenal atresia in children. In this authoritative lecture extracted from the IRCAD advanced course "laparoscopy in newborns, infants and children" March , , Dr. Mattioli outlines feeding surgery. Feeding surgery In this authoritative lecture extracted from the IRCAD advanced course "laparoscopy in newborns, infants and children" March , , Dr.

Becmeur demonstrates the strategy used to perform partial splenectomies in children. Partial splenectomy In this key lecture extracted from the IRCAD advanced course "laparoscopy in newborns, infants and children" March , , Dr. Demarche presents Hirschsprung's disease in children. Podevin outlines the laparoscopic vs. Abdomen: anorectal malformations In this key lecture extracted from the IRCAD advanced course "laparoscopy in newborns, infants and children" March , , Dr.

Patkowski explains how to facilitate endoscopic suturing. Endoscopic suturing is a challenge - How to make it easier In this key introductive lecture extracted from the IRCAD advanced course "laparoscopy in newborns, infants and children" March , , Prof. Patkowski describes how to repair esophageal atresia in pediatric surgery. Thoracoscopic repair of esophageal atresia In this key lecture extracted from the IRCAD advanced course "laparoscopy in newborns, infants and children" March , , Prof. Thoracoscopic repair of long-gap esophageal atresia using internal traction suture.

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Patkowski explains how to manage long-gap esophageal atresia in infants in thoracic surgery. Thoracoscopic repair of long-gap esophageal atresia using internal traction suture In this key lecture extracted from the IRCAD advanced course "laparoscopy in newborns, infants and children" March , , Prof. Laparoscopic approach to intestinal malrotation and midgut volvulus.

Surgical Endoscopy at Children’s National

Laparoscopic surgery in children is not new. Paediatric surgeons were among the pioneers of laparoscopic surgery in the early s,1 but the vast potential of . Our pediatric surgery experts perform advanced, minimally invasive endoscopy procedures.

Philippe describes the laparoscopic approach to intestinal malrotation and midgut volvulus. Laparoscopic approach to intestinal malrotation and midgut volvulus In this key lecture extracted from the IRCAD advanced course "laparoscopy in newborns, infants and children" March , , Dr. Modifications to the Nuss procedure for pectus excavatum PE repair and management of recurrence.

Lopez outlines the modifications to the Nuss procedure in pediatric surgery and how to manage recurrence. Modifications to the Nuss procedure for pectus excavatum PE repair and management of recurrence In this key lecture extracted from the IRCAD advanced course "laparoscopy in newborns, infants and children" March , , Dr. Lopez focuses on thoracoscopic pericardial windows. Thoracoscopic pericardial windows In this key lecture extracted from the IRCAD advanced course "laparoscopy in newborns, infants and children" March , , Dr.

Guelfand outlines the surgical strategy used to manage Morgagni-Larrey hernias in children. Minimally invasive surgery for esophagectomy and tubularized gastric pull-up. The accidental ingestion of caustic agents is a common problem in pediatric emergency units.

Single-Incision Surgery | Children's Hospital Colorado

These agents can cause a series of damage to the upper gastrointestinal tract and can lead to an esophageal stricture. We present the case of a 4-year-old girl who was referred to our hospital for vomiting and hematemesis after ingesting a caustic solution. Physical examination revealed tongue edema and denuded buccal mucosa. Wound complications may only occur in a small percentage of ear surgeries but can be unpleasant for the child and are obviously best avoided if possible. Figure 1. Large keloid scar which developed from a post auricular incision after tympanoplasty.

The primary indications for endoscopic ear surgery in children are tympanic membrane perforation, cholesteatoma and ossicular anomalies. The tympanic membrane can be reconstructed with perichondrium or cartilage from the tragus, a relatively hidden donor site. However in young children it may be too small for the size of the tympanic membrane defect, especially if scutum reconstruction is also required.

Porcine submucosal collagen graft is an ideal material to use when the tragus is insufficient — and avoids the small amount of donor site morbidity and time otherwise needed to harvest a graft. It is certainly possible to repair subtotal perforations using an underlay lateral graft technique with this xenograft though adjustment of large grafts through the paediatric meatus can be challenging.

Congenital cholesteatoma confined to the mesotympanum provides a perfect opportunity for TEES, not least because no challenging reconstruction of the tympanic membrane is required Figure 2. Acquired cholesteatoma arises from the pars tensa more commonly in children than the pars flaccida, so commonly extends into retro-tympanic recesses. Figure 2. Congenital cholesteatoma in the antero-superior quadrant of the left middle ear in a 3. This was removed using totally endoscopic surgery through the ear canal right.

Angled endoscopes and instruments allow retro-tympanic dissection under direct vision so are ideally suited, whether used for TEES or through a post auricular incision. Using a front-to-back technique with TEES, cholesteatoma can be followed as far back as the mastoid antrum to the limits of the lateral semicircular canal Figure 3. It is appropriate to reconstruct the canal wall defect to prevent recurrent disease, but in younger children, it is unlikely that the tragus will provide sufficient cartilage, especially if pars tensa reconstruction is also required.

Careful consideration must be given between the merits of TEES in such cases or a conventional canal wall up procedure. Figure 3. Pars flaccida cholesteatoma of the right ear in a year-old left panel which extended into the mastoid antrum.

Pediatric Surgery at Sutter Children's Center Sacramento

Attico-antrostomy was completed totally endoscopically using a bone curette centre. As the pars tensa was normal, adequate tragal cartilage was available for canal wall reconstruction at this age. For congenital or acquired conductive hearing loss, endoscopic tympanotomy provides a good diagnostic and potentially therapeutic option with low morbidity Figure 4.

Endoscopic ossiculoplasty becomes much easier than one might initially expect. Figure 4. Endoscopic tympanotomy for left sided congenital conductive hearing loss, revealing the lenticular process of the incus against the facial nerve and a single columella stapes. It is important to note that although the ear canal is noticeably narrower in young children than in adults, it is also significantly shorter and generally straighter. Greater freedom to manipulate the angle of endoscope and surgical instruments is possible than in a longer ear canal which helps offset the narrower diameter Figure 5.

Gentili et al. Ejection fraction was preserved and blood pressure and heart rate increased. The peak and mean airway pressures also increased. Tobias and colleagues7 found minimal cardiovascular changes in paediatric patients during laparoscopy in their study on the cardiorespiratory changes during brief laparoscopy in children. An increase in blood pressure was seen which probably resulted from an increase in systemic vascular resistance related to the increased IAP and the increased PaCO2.

In a retrospective paediatric study, it was found that arterial pressure increased only when IAP was higher than 6mmHg. The overall cardiovascular changes associated with laparoscopic surgery depend upon the intra-abdominal pressure attained, the amount of CO2 absorbed, the patient's intravascular volume status, the ventilatory technique, surgical conditions, and the anaesthetic agents used. The anaesthesiologist should also be aware of the fact that vagally mediated reflex bradycardia or even asystole can occur during insufflation, especially in infants and small children14, and should be well prepared for any such event.

The increase in IAP also affects the respiratory function. There is a decrease in functional residual capacity FRC relative to the closing volume. This can lead to intrapulmonary shunting and hypoxaemia. Overall ventilator adjustments were made 20 times in this study. They concluded that the magnitude of change correlates directly with intraperitoneal pressure.

Similarly, Bergesio et al. As the cardiorespiratory changes produced by raised IAP are seen at lower values in children, it has been recommended that the IAP produced by pneumoperitoneum should be limited to mmHg in toddlers and infants and to about mmHg in older children. The hypercarbia can lead to further increase in systemic vascular resistance and myocardial depression. The Trendelenburg position along with the raised IAP decreases lung compliance.

FRC is reduced by the Trendelenburg position while the reverse Trendelenburg position may improve respiratory compliance. The venous return is increased by the Trendelenburg position whereas it decreases further by the reverse Trendelenburg position. The physiological changes described above are usually well tolerated in patients with normal cardiovascular function, but may become significant in patients with underlying cardiovascular disorders.

Bozkurt et al. Diffusion of CO2 from the peritoneal cavity into the subcutaneous tissue, or along the fascial planes into the mediastinum can occur occasionally leading to subcutaneous emphysema, pneumothorax or pneumomediastinum. Gas-less laparoscopic procedures have been described21 where devices designed to tent the abdominal wall are used.

This technique may be useful in small children and infants. Management of Anaesthesia for Laparoscopy in Children With the advent of new surgical approaches, there may also be a need for specific modifications in the anaesthetic technique. Although anaesthesia for laparoscopic surgery does not require a major extension of the usual anaesthetic technique for general abdominal surgery, special consideration must be given to the alteration in cardiorespiratory status that occurs due to the raised IAP, absorption of CO2, and the patient positioning during the procedure.

An understanding of the anticipated procedure combined with the knowledge of its effects on cardiorespiratory function will assist in planning the anaesthetic care. A detailed history and physical examination should be undertaken preoperatively to identify any underlying medical conditions that may affect the perioperative management of the patient.

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Preoperative laboratory investigations depend upon the clinical condition of the patient. The haemoglobin and haematocrit levels are usually sufficient for most patients unless the patient has a significant systemic disease.

Blood loss is usually minimal in laparoscopic surgery, but the anaesthesiologist must remember that a laparoscopy may be converted into a laparotomy. Therefore, in cases where the baseline haemoglobin is low or a major procedure is being performed laparoscopically, a sample should be taken for grouping and saving serum for urgent cross matching if required. Atropine or glycopyrrolate may be included in the premedication in order to prevent the reflex bradycardia that can occur on abdominal insufflation, in addition to their effect of decreasing airway secretions.

The choice of the induction agent and technique should be based on the clinical status of the patient.

Minimally Invasive Surgery

Induction of anaesthesia can be performed either by inhalational technique with sevoflurane or halothane in nitrous oxide and oxygen, or with one of the available intravenous induction agents. This is followed by a nondepolarizing neuromuscular blocking agent, such as atracurium or vecuronium, to facilitate endotracheal intubation and provide muscle relaxation for the surgical procedure.

Anaesthesia is maintained with controlled ventilation with an inhalational agent such as isoflurane supplemented with an intermediate acting nondepolarizing neuromuscular blocking agent and intravenous opioids as required. Although general anaesthesia with endotracheal intubation ETT is the usual technique for laparoscopic surgery in children, the laryngeal mask airway LMA has been used safely for short procedures23, and may be considered in patients with severe asthma in whom airway instrumentation needs to be avoided. Halothane should be avoided for maintenance, where possible, because the hypercarbia and the subsequent sympathetic stimulation that occurs due to CO2 absorption from the peritoneal surface can cause arrhythmias when combined with halothane.

Constant intraoperative monitoring of the patient's cardiorespiratory status is essential because of the various physiological alterations that can occur by gas insufflation. Monitoring should include continuous electrocardiogram, pulse oximetry, non-invasive blood pressure measurement, PETCO2 measurement and temperature monitoring.