Laparoscopic Surgery in Pediatric Urology

Traditionally, Surgery involves cutting the body wall to reach for an organ inside the tummy to perform surgery on that organ.

With laparoscopy, the same surgery is done through small key holes in the belly wall to reach to the organ by using special telescopes and instruments.

Initially, a small hole is made in the belly button to put a telescope and to infuse gas (generally carbon dioxide) into the belly. This inflates the belly and gives working space to the surgeon. Then through small holes, instruments are put to perform the procedure. A camera is attached to the telescope and is used to watch the procedure on a monitor in a magnified and more precise way. At the end of the surgery, the instruments are removed from the belly and one or two stitches are put within the skin to finish the procedure. These stitches need not be removed. It is amazing how extensive procedures can be performed with 3-4 key hole punctures.

With laparoscopic surgery, the ACCESS trauma, i.e. trauma caused to body while getting to the organ is avoided and this seems to be the logical approach.

 
  • Is Laparoscopic surgery possible in children?
  • Is Laparoscopic Surgery safe in kids?
  • What are the common urological surgeries done laparoscopically in children?
  • What are the advantages of laparoscopic surgery in children?
  • What are the disadvantages of laparoscopic surgery in children?
  • What is the usual post-operative course after a laparoscopic Surgery?
  • Cases Case 2 , Case 7, Case 21
  • Is Laparoscopic surgery possible in children?

Yes, Pediatric Laparoscopy or laparoscopic surgery in children is a new and upcoming specialty and it has been possible due to availability of miniaturized equipment, small telescopes and above all well trained doctors.

  • Is Laparoscopic Surgery safe in kids?

Yes, with good anesthesia, pediatric laparoscopic equipment and trained surgeon - Laparoscopic surgery is safe in children.

  • What are the common urological surgeries done laparoscopically in children?
  • Undescended testis: Laparoscopy is advisable for only those undescended testis which can’t be felt outside the belly. Also useful for confirming the diagnosis of absent testis- the gold standard of care for such patients. If the testis is present inside the belly, laparoscopic Orchiopexy can be done at the same time.
  • Hernia: As in itself conventional hernia surgery in kids is a minor surgery, so laparoscopic hernia surgery should be done only if hernia is on both sides or the previous surgery has failed or in a girl child with suspected internal reproductive system problems.
  • Ovarian cysts: Some newborns have cysts in their ovaries- very useful in such cases to avoid major abdominal incision. Cysts can be decompressed laparoscopically.
  • Pyeloplasty for PUJ obstruction: Laparoscopic pyeloplasty is one of the most challenging reconstructive surgeries in laparoscopy. It involves dissection of the pelvi-ureteric junction, excision of junction and excess pelvis and then re-stitching the junction back properly. It takes 3-4 hours as each suture is critical and takes a lot of time. But all this is compensated by a fast recovery and less pain post-operatively. There are hardly any stitch marks on the belly. Laparoscopic pyeloplasty is possible only in children more than one year of age due to the limitation of the current equipment.
  • Nephrectomy: Non-functioning kidneys if required to be removed are ideally suited for removal by Laparoscopic surgery if indicated
  • Hemi-nephrectomy- Children born with duplex system and having problems due to a non-functioning upper pole can be managed laparoscopically by laparoscopic hemi-nephrectomy.
  • Ureterolithotomy: A stone impacted in the lower ureter can be managed laparoscopically if endourological procedures are not feasible or they fail.
  • Adrenal surgery: Tumors in adrenal glands can be removed laparoscopically.
      • It is said that “the scope of laparoscopic surgery is limited only by surgeon’s own mind”.
      • In near future, more and more surgeries would be done laparoscopically in children.
  • What are the advantages of laparoscopic surgery in children?
    1. Shorter hospitalisation
    2. Magnified and clear view making the surgery more precise
    3. Smaller cuts- smaller scars- may be practically sutureless
    4. Faster recovery
    5. Less Pain, Less blood loss
    6. Less chances of infection & other post-operative complications.
  • What are the disadvantages of laparoscopic surgery in children?
    1. Not all surgeries are possible laparoscopically but with increasing skills everyday new ones are added to the list
    2. Expensive due to equipment cost (but eventually shorter hospitalization offsets some of these expenses)
    3. Learning curve for surgeons initially as feel of tissues is lost, it takes some time to get used to that.
    4. May take more time in certain cases.
    5. Anesthesia required may be more for surgeries like hernia repair
  • What is the usual post-operative course after a laparoscopic Surgery?
    1. The child may have some pain post-operatively and also some bloating of the belly. This occurs as during laparoscopic surgery we put in carbon Dioxide gas to inflate the belly for creating a working space.
    2. Generally after most of the surgeries we allow feed in the evening after surgery.
    3. Most of the times the babies are discharged the day after surgery.
Given a choice, “No surgery” would obviously be the first option, but if surgery is really indicated then parents would prefer a procedure for their kids which is less painful and provides for a faster recovery. Initially, it was said that the concept of shorter hospitalization is more important in adults as being the earning members they can return to work faster. But in the current era, a lot of parents live in nuclear families and some of the mothers are also working mothers. Infact, with a child in the hospital, two people are off work and making the hospitalization shorter has a bigger economic and social effect on the family.
With the advent of laparoscopic surgery, there should not be any reason to subject these children to extensive open surgery if the same can be done laparoscopically. After all, we would all like to see only happy faces of kids.

 

Cases Case 2 , Case 7, Case 21
 
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