Using an Optical Trocar for Laparoscopic Access in Overweight and Obese Children

Introduction

Overweight and obese children often undergo elective and emergency surgery. The open Hasson technique ¹ for primary trocar access is generally favored among pediatric surgeons for laparoscopic procedures. This technique is challenging in these children and often leads to delays or conversion to laparotomy. The optical trocar technique for primary port access is widely used in bariatric surgery in adults. In this article, we report our experience with this technique in overweight and obese children undergoing elective and emergency laparoscopic procedures.

Materials and Methods

Body-mass index (BMI) is defined as weight in kilograms divided by height in meters squared. This was calculated for each child, then plotted on a BMI percentile chart. Overweight was defined as a BMI between the 85th and 95th percentiles, and obesity was defined as being above the 95th percentile. ² Children below the 85th percentile were excluded.

A 5- or 10-mm zero-degree telescope can be used. The optical trocars (ENDOPATH^® EXCEL™ Bladeless Trocar; Ethicon Endosurgery, Cincinnati, OH) are hollow, allowing the insertion of the telescope inside the trocar. The trocar tip is bladeless, thereby eliminating trauma to tissues when used appropriately. Depending on the procedure being undertaken, the surgeon selects the optimal site for the primary port. We usually use a skin crease to the left and parallel with the umbilicus. An appropriate skin incision is made with a scalpel. The telescope is mounted in the optical trocar and locked in place. Figure 1 shows the instruments as described. The insufflation tubing is connected to the same port, and insufflation is started. A twisting technique is employed to advance the trocar sequentially through the layers of the abdominal wall until the peritoneum is visualized. Once the tip of the trocar breaches the peritoneum, the insufflation gas creates a pneumoperitoneum. The surgeon removes the telescope and the trocar and then reinserts the telescope through the cannula to examine the peritoneal cavity. Further ports can then be inserted under direct vision as per routine laparoscopy. At the end of the procedure, an absorbable suture is placed in the fascia at the port site.

OPEN IN VIEWER

FIG. 1.

The 5-mm 0-degree telescope is seen in the 5-mm bladeless trocar.

Results

Having used this technique in 22 consecutive adult bariatric patients, we used the optical trocar for primary port access in 11 children between June 2008 and February 2009. Ten patients were overweight or obese and between 7 and 15 years of age. The indications for surgery in these children were: appendicitis (5), cholecystectomy (2), diagnostic laparoscopy (2), fundoplication (1), and colectomy (1). A pneumoperitoneum was successfully and safely created in 8 of the 10 overweight and obese patients. A minor complicaton arose in a 10-year-old cushingoid boy with ulcerative colitis and toxic megacolon undergoing laparoscopic colectomy. A left-upper quadrant trocar was inserted, which penetrated the underlying fatty and brittle omentum. The telescope was removed, leaving the port in situ, and a further optical trocar was inserted in the right-lower quadrant at the site of the proposed ileostomy. A pneumoperitoneum was easily created and the initial port could be seen under the omentum. The omentum was pushed free from the port and was undamaged.

This technique can also be used in overweight and obese children who have undergone previous laparotomies. A 14-year-old girl underwent laparoscopic biopsy of a periportal lymph node to investigate the cause of massive splenomegaly. She had previously undergone a colectomy and ileostomy for ulcerative colitis and, subsequently, had a laparotomy for adhesive obstruction. While the optical trocar allowed easy access through the abdominal wall, a pneumoperitoneum could not be created due to significant adhesions. Laparoscopy was abandoned, and the lymph node was excised through a midline laparotomy.

Discussion

Overweight and obesity affects over one third of school-age children in the United States. ² A recent study in the United Kingdom reports overweight in 19% of boys and 23% of girls, with obesity in 8% of each. ³ Obesity increases the risk of complications in both elective and emergency surgery. Davies and Yanchar ⁴ reported longer operating and recovery times in obese children undergoing appendicectomy. There was also a higher incidence of wound infections. The traditional “open” technique for laparoscopic access in overweight and obese children is difficult because of the depth of the abdominal wall. Placing purse-string sutures in the abdominal wall fascia necessitates bigger skin incisions and often leads to bent needles. Operating times are prolonged, and often, the laparoscopic approach is abandoned. This technique has been well described in adult surgery with acceptable complication rates.^5–7 It has been specifically described as being advantageous in the overweight or obese adult patient, providing quick, safe access. ⁷ The optical trocar technique is quick, safe, and easy to learn. It allows an almost immediate creation of a pneumoperitoneum under direct vision. There is no gas leak during the procedure, because all port tracks are snug on the port.

Conclusion

We recommend the optical trocar technique for safe and efficient primary port insertion for overweight and obese children undergoing laparoscopy.