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KURNIA PENTA SEPUTRA UROLOGY DEPARTMENT BRAWIJAYA MEDICAL FACULTY SAIFUL ANWAR GENERAL HOSPITAL MALANG INDONESIA 1
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HISTORY 1585 - ARANZI (light source) 1706 - trochartor troise-quarts ( trocar ) 1853 – ANTOINE JEAN DESORMEAUX ( father of endoscopy) 1911 – HC. JACOBAEUS (laparothorakoskopie) 1920 – ZOLLIKFER (CO2 for insufflation) 1938 – JANOS VEREES ( Verees needle) 1953 – HOPKINS (the rigid rod lens system) 1960 – KURT SEMM (automatic insufflation device 2
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HISTORY Pediatric laparoscopy in 1923 by Kelling A laparoscopic approach offers several advantages over an open less analgesia, reduction of postoperative respiratory and wound complications; shortens postoperative convalescence, including an intensive care unit stay; rapid return to normal diet and decreased overall hospital stay. 3
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HISTORY Laparoscopic surgery in the pediatric population is rapidly increasing. Pediatric surgeons were initially slower to adopt laparoscopic techniques than surgeons for adults. 4
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PHYSIOLOGICAL CONSIDERATIONS Physiologic changes during laparoscopic surgery in children is almost similar to adults The volume of insufflating gas necessary for pneumoperitoneum is much lower in children than adults. Adults require 2.5L to 5L where as a 10 kg patient needs about 0.9L The insufflation pressure used in adults is 15 mmHg; in infants and young children, insufflation pressures of 5 to 10 mm Hg typically suffice. 5
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PHYSIOLOGICAL CONSIDERATIONS Gas flow rates are in infants are as low as 2 to 3 L per minute, while up to 40 L per minute is used in larger patients and when leaks of gas need to be overcome to maintain abdominal distention Pediatric laparoscopic procedures are likely to cause an increase in pulmonary and systemic vascular resistance, sudden bradycardia during pneumoperitoneum because of raised intraabdominal pressure(IAP),the chances being much more than adults 6
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TEMPERATURE MAINTENANCE Small children have a high body surface area to mass ratio and little subcutaneous fat or body hair to retain heat A warming mattress, heated humidifier or a convective forced air warmer might be used if available Hypothermia is avoided by warming the insufflating gas and/or maintaining insufflating flows of less than 2 L/min 7
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Cardiovascular effects during Vasovagal reflex response to peritoneal stimulation from trocar or insufflations Myocardial sensitization by halothane Reduced venous return Hypovolemic Hypercapnia venous gas embolism 8 TEMPERATURE MAINTENANCE
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RESPIRATORY SYSTEM Various pulmonary effects include reduced diaphragmatic excursion & cephalic shift; reduced thoracic compliance & functional residual capacity Other problems occurring during laparoscopy include endobronchial intubation, subcutaneous emphysema, pneumothorax, pneumomediastinum, massive CO2 embolism, bronchospasm, bronchial hyper secretion and atelectasis 9
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GASTRO INTESTINAL Increased intraabdominal pressure increases the risk of regurgitation. Trendelenburg NG tube 10
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INSTRUMENTATION Small diameter ports and telescopes - is commonly performed using reusable 3 and 4 mm metal port systems (5 and 10 mm scopes are typical for adult use) "Short" instruments One of the most commonly used infant and toddler telescopes for pediatric is a 4 mm 30° laparoscope. Additionally, 5 mm 30° and 45° Hopkins rod-lens telescopes are commonly used. Zero degree laparoscopes may be used for pelvic region. 11
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COMPLICATIONS Studies of 500 or more procedures have reported a rate of complications of 1 to 2 percent ( peter CA,1996) Vascular, bowel, or bladder injury are the most serious complications of pediatric laparoscopy These occur almost exclusively during initial entry into the abdomen or subsequent placement of trocars Port site hernia (0.2 to 3.2 %) 17
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Fascia closure to prevent hernia In adult laparoscopy, it is common practice to close the fascia of trocar sites that are 10 mm or greater For children who are 5 years of age or younger, we suggest fascia closure for laparoscopic incisions that are 5 mm or larger 18 COMPLICATIONS
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Laparoscopy in children and adolescents bears marked similarities to adult procedures but experience with adult surgery does not sufficiently translate to safe surgery in pediatric patients. Pediatric procedures must be performed with a full understanding of the relevant anatomic and physiologic differences between the pediatric and adult populations. 19 COMPLICATIONS
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PREOPERATIVE EVALUATION AND PREPARATION These include laparoscopic: orchidopexy, laparoscopic total and partial nephrectomy, laparoscopic pyeloplasty, laparoscopic-assisted bladder reconstruction, and laparoscopic urinary antireflux surgery The American Heart Association 2007 guidelines advise that administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure, even for patients with cardiac conditions 20
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LAPAROSCOPIC ORCHIDOPEXY The incidence of undescended testis is 30% in premature infants and 3% in term infants. Twenty percent of undescended testes are nonpalpable Debate continues on the best way to explore a nonpalpable testes, but laparoscopie might be the gold standard for diagnostic and therapeutic purposes 21
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PROCEDURES The camera port is placed through an intraumbilical incision. In a large retrospective series, the complication rate of open access was 1.2% to 3.8%, compared with 2.6% to 7.8% for the Veress needle technique.(Peters CA. J Urol. 1996) When orchidopexy is performed laparoscopically, 3 ports are placed: 1 in the umbilicus and 2 just below the umbilicus along the anterior axillary line 22
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LAPAROSCOPIC NEPHRECTOMY Improved cosmetic, shorter hospital stays, more rapid return to normal activities, and less postoperative pain Some pediatric urologists doubt the relative benefits in younger children Initial procedures were performed through a trans peritoneal approach. This offers a large working space and easily identified anatomic landmarks. 28
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Three ports. The 1 st port is placed at the umbilicus, a 2 nd in the lower quadrant along the midclavicular line between the umbilicus and the pubis, and a 3 rd in the midline or midclavicular line above the umbilicus a fourth port is used for retraction, especially of the liver edge on the right. 29 LAPAROSCOPIC NEPHRECTOMY
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LAPAROSCOPIC PYELOPLASTY Was first described in both population in 1993 Position of the patients is flank position Location of the ports are the same like nephrectomy Trans peritoneal approach has the advantages of greater working space The biggest challenges is the technical difficulty of suturing a small caliber ureter. 30
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LAPAROSCOPIC ANTI-REFLUX SURGERY Open reimplantation has success rates of more than 95% there is interest in finding less invasive method Initial Laparoscopy ureteral reimplantation used an extravesical approach Biggest challenges is intracorporeal and extracorporeal knot tying because of limited working space in small pelvis. 32
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Summary As laparoscopy is applied more widely in pediatric urology, its potential benefits and drawbacks will become apparent. Laparoscopy in pediatric more difficult than adult because of the working space and need special precaution than in adult. 33
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