Laparoscopic or Laparoscopic-Assisted Pelvic Surgery in Small Infants: Our Experience

Anesthesia techniques

General endotracheal anesthesia was used in all patients. It was maintained by oxygen, sevoflurane, and depolarizing muscle relaxants. Fentanyl was used for analgesia. Intraoperative increase in end tidal carbon dioxide concentration (EtCO₂), if observed, was managed by increasing respiratory rate and minute volume. EtCO₂ came to normal before reversal and extubation. No patient required ventilatory support. Postoperative analgesia was provided using a local anesthetic at port site and oral/rectal paracetamol.

Ports and instruments

Most of the procedures were done using a 5-mm umbilical port, although in selected cases a 10-mm port was used at the umbilicus. Open method of port placement was followed in all. Precaution was taken to insert only a small length inside the abdomen so as to facilitate using the limited space for maximal benefit. Intraabdominal pressures were kept between 8 and 10 mm Hg. Working ports were inserted under vision. Port placement and instrumentation varied from case to case and are described in different indications.

Patient position

In children in whom simultaneous access to abdomen and pelvis was needed (Hirschsprung disease [HD] or anorectal malformations [ARMs]), whole lower body preparation was done. After port placement, pelvis was elevated, and depending upon need, right or left sides were elevated to use gravity to retract the gut. Urinary bladder was catheterized after induction of anesthesia. Bladder retraction was facilitated by hitching it to the abdominal wall through an external suture on a long needle.

Energy source

We used either monopolar or bipolar cautery or harmonic scalpel for dissection and hemostasis. Major vessels such as inferior mesentric vessels were either clipped or ligated. Smaller vessels were cut using harmonic scalpel. Pelvic dissection in HD or ARMs was done with monopolar or bipolar cautery hook.

The salient points about each of major groups of surgery are described below.

Hirschsprung's disease

Port placement for HD is shown in Figure 1a. Four ports were used. Seromuscular biopsy from the expected ganglionic site was taken first and sent to the laboratory for frozen sections. After macroscopic localization of probable site of pull-through, the superior rectal vessels were divided with harmonic scalpel. In patients with high transitional zone, the left colic vessels were also clipped and divided and the splenic flexure of colon was mobilized. The circumferential perirectal dissection was started posteriorly along the presacral space with precise dissection just outside rectal seromuscular layer. Fine strands of blood vessels as they entered the rectal wall were clearly identified and taken down with cautery hook under magnified vision. Anteriorly, to improve visualization, a suture was placed to lift the bladder and open the space between bladder and rectum. Mobilization was done to a level about 2 cm proximal to anal verge. The completeness of dissection was confirmed after passing a gloved finger through rectum. One child had sigmoid fecaloma, which was removed piecemeal after bringing the sigmoid out partially through the umblical port. The fecaloma was removed through an enterotomy (Fig. 1b). After complete mobilization of rectum and availability of frozen section report, the perineal part of transanal pull-through was started. Retracting stitches were put and the mucosa was incised about 0.5 cm proximal to the dentate line. Mucosal sleeve was raised for about 2 cm when the muscle layer started prolapsing (because of laparoscopic mobilization) (Fig. 2a). It was incised to deliver the mobilized colon. Posteriorly, the cuff was incised down to the level of mucosal incision. The anastomosis was performed with 5/0 polydiaxanone (PDS) at the level confirmed as ganglionic by frozen section biopsy (Fig. 2b). Of the 5 patients, 2 had a colostomy, which was released along with adhesiolysis done laparoscopically (Fig. 3a, b). In a female child, the level of normal ganglia was high. The pelvic dissection and left colonic mobilization were performed laparoscopically in this child. For right mobilization and transposition of the mesentery, a small right upper transverse incision was made. Fecal diversion was not needed in any case.

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FIG. 1.

(a) Port placement for transanal pull-through. (b) Fecaloma removal through colotomy from umbilical port.

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FIG. 2.

(a) Transanal submucosal dissection. The muscle starts prolapsing within 2 cm. (b) Long segment of laparoscopically mobilized colon delivered with ease through transanal approach.

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FIG. 3.

(a) Port placement in a child with colostomy for Hirschsprung disease (colostomy mobilized laparoscopically). (b) Postoperative appearance.

Anorectal malformations

All 3 ARM patients had a preexisting divided sigmoid colostomy. There were adhesions, which were released laparoscopically. In the 2 male patients, cystoscopy was done to identify the correct site of fistula, which was found to be rectoprostatic and rectovesical, respectively. After port placement, the rectum was mobilized and fistula was identified. It was ligated as close to the urethra as possible, guided by a urethral catheter. In one case the ligature slipped, but it was not re-applied and the fistula was left open. The anorectum was placed in the center of sphincter complex by making an incision in the perineum at the anal dimple and guiding an instrument in the midline under laparoscopic vision from above. Once the track was created in the center of the muscle complex, it was dilated with Hagar dilators and finger to accommodate the neoanus. No perineal port was used. The mobilized colorectum was then pulled down and anoplasty was performed from the perineal approach. The female ARM was a case of congenital short colon with pouch. Pouch excision had been done in neonatal period and she was on end colostomy at descending colon. The colostomy was taken down, and the colon was mobilized and placed in the center of sphincter complex.

Ovarian mass

One child had an antenatal diagnosis of a subhepatic cyst—probably a duplication cyst. She was followed up for 5 months when an increase in size was noticed. She underwent laparoscopy and was found to have a torted ovarian cyst in subhepatic location. The cyst was aspirated to reveal torted pedicle. The pedicle was taken down with harmonic scalpel and the collapsed cyst was removed through umblical port. The other child presented with an abdominal mass diagnosed as a pelvic cyst. On laparoscopy, the cyst was aspirated to show the true nature. It was a torted ovarian cyst. Vessels were taken down by harmonic scalpel and oophorectomy was done. The children were allowed orally within 6 hours after surgery and discharged on day 2 of surgery.

Undescended testes

The umblical port was the primary port. Two working ports were placed, one in each flank. The level of the three ports was the same in bilateral cases. In the unilateral case, the contralateral port was placed a little lower, that is, in the iliac fossa. The ipsilateral side was elevated for better visualization. Single-stage orchidopexy or first stage of Fowler Stephens (FS) orchidopexy was performed depending on the level of the testis and the length of the vascular pedicle. For orchidopexy, the vessels and vas were mobilized. After mobilization and division of the gubernaculums, the testis was first delivered into the inguinal area through a direct vertical incision medial to the inferior epigastric vessels. Then it was placed in the scrotum much like an open orchidopexy. Four testes underwent stage I FS procedure using Prolene ligature (Fig. 4).

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FIG. 4.

Fowler Stephen stage I. The testicular pedicle is ligated and divided.

Sacrococcygeal teratoma

The child with sacrococcygeal teratoma (SCT) had type III (Altman) variety of SCT. Using a primary umbilical port and two secondary ports, the presacral space was opened and median sacral vessels were ligated. The ureters were also mobilized away from tumor. The child was placed in prone position and complete excision of mass along with coccyx was done.

Hirschsprung's disease

In all 5 cases, the pelvic dissection was done successfully with the laparoscope. The colonic mobilization was completed laparoscopically in 4, but required an additional incision and open dissection in 1 case of long-segment disease. In 1 child who had feculomas in the sigmoid, the feculomas were removed by partially delivering the colon through the umblical site. Transanal anastomosis healed without complications in 4, but in 1 a rectovaginal fistula developed, which healed after a diverting colostomy was done. There was no anastomotic narrowing.

Anorectal malformation

Pull through was successful in all 3. Oral feeds were allowed the same day and the urinary catheter was removed after 5 days. There were no urological complications. The female child with pouch colon had mucosal prolapse, which was excised at 2 months after surgery. Colostomy was closed in 2 male children with ARMs at 6 weeks after surgery and the children are being followed up. There is no anal stenosis and urological complaints. Short-term continence is satisfactory.

Undescended testes

Of the 7 cases with impalpable undescended testes, 3 were bilateral and 4 unilateral. Of total 10 testes, 6 were brought down to the scrotum by laparoscopic mobilization of the vessels and the vas. In four testes, the first stage of Fowler Stephen procedure was done. Two of them have subsequently undergone second-stage completion orchidopexy also. Both these testes were viable at the second stage and could be brought to the scrotum with laparoscopic assistance.

Disorders of sexual differentiation

Of the 3 cases, 2 showed presence of Mullerian structures and intraabdominal gonads. Gonadal biopsy in these children was suggestive of presence of both ovarian and testicular tissue, thus confirming a diagnosis of true hermaphroditism. One child with asymmetric gonads, proximal hypospadias, and 46XY karyotype was found to have a hernia on one side but no Mullerian structures. Hernia was repaired and open orchidopexy performed.

Hirschsprung's disease

The HD children are a major group in which surgery can be made easier by the PMIS approach. It allows earlier frozen section biopsy, easy mobilization of colon for anastomosis, and less chances of wound infection. It can be done with ease when the transition zone is in the left colon, but when rotation is needed open incision may be done. Although this can be achieved laparoscopically, we have used a small incision to facilitate such dissection by open means. This was exemplified in 1 female child with long-segment HD. In this case, the dissection of left colon and pelvic dissection of the rectum was done laparoscopically. However, to mobilize the right colon and transpose the mesentery, a small incision was made in the right supraumbilical area to do open dissection. The transanal dissection was then carried out. The major advantages in these patients were the magnification, easy access deep into the pelvis, and early frozen section biopsies. Further, the transanal dissection was made much easier as the rectum had been already mobilized from above to a fairly low level—almost within 2 cm of the anal verge. The rectal dissection in smaller children is easier when compared with that in older children probably because of less perirectal fibrosis (less enterocolitis). In our view, laparoscopy is a great boon for HD, as most cases can be managed by a single-stage laparoscopic-assisted transanal pull-through at few weeks of age. Feculomas can also be removed during laparoscopic surgery, as shown in 1 of our cases. In children who have had a colostomy, laparoscopy may still be used to advantage, as shown in 2 of our cases. The port placement needs to be accurate and thoughtful though. Even if the entire procedure cannot be completed laparoscopically, laparoscopic assistance should be used whenever it can give benefit—such as pelvic dissection can be done more accurately through laparoscopic approach. The need for catheterization is much less because the dissection behind the bladder is very accurate and least disturbing to the bladder.

The advantage of PMIS in ARM is again the access and correct placement of neorectum in the center of the muscle complex. Our experience shows that even in small children with colostomy, mobilization of the colon is possible through laparoscopic pelvic dissection. In 1 female ARM with end colostomy and no distal rectum, even in the narrow pelvic confines, laparoscopy gave unprecedented view of the structures and surgery was possible in a single stage. The complication seen in this child was mucosal rectal prolapse, which required trimming later. The functional result of this procedure over classical posterior sagittal anorectoplasty (PSARP), although reported, is doubtful. ¹⁰ Our children are not old enough for a meaningful comment on long-term continence. The advantages in ARM children were access and correct placement of anorectum after ligation of fistula with minimal dissection to sphincter complex.

Laparoscopy has a proven role in the management of impalpable testes. ¹¹ The procedure can also be easily performed in small children. Our experience shows that for single-stage orchidopexy, the vas and vessels can be safely mobilized from the retroperitoneum under a magnified vision, thus enhancing the accuracy and safety. We prefer making a small skin crease incision in the groin to deliver the testis out and then route it to the extradartos scrotal pouch. This step has helped us to minimize traction at odd angles on the slender cord structures. For high intraabdominal testes, the Fowler Stephen procedure is an ideal example of the benefit of laparoscopy. The vision is magnified and even the small vessels around the vas are clearly seen. The case selection is helped by this visualization. In the second stage, the mobilization of vas can be done with clear preservation of all blood vessels in its vicinity because a strip of peritoneum is taken with the testis. Also, the vas can be mobilized deep into the pelvis to gain sufficient length.

The major advantage in SCT was early ligation of sacral vessels. Most SCTs having significant pelvic extension require a laparotomy to control the median sacral pedicle and mobilize the pelvic portion. The operation is then completed by a posterior approach with excision of the tumor along with the coccyx. Laparoscopy has provided a major benefit by avoiding laparotomy. Pelvic mobilization and control of the vascular pedicle was achieved in all our cases. This is a major advantage of laparoscopy. ¹² Even in small children, enough space can be created for mobilization of the tumor and ligation of vessels.

Disorders of sexual differentiation are an area wherein the impacts of laparoscopy are immense. In patients in whom diagnosis after biochemical and genetic workup remains unclear, diagnostic laparoscopy can show macroscopic anatomy, and also biopsy is possible. Earlier, these procedures needed large pelvic incisions. Laparoscopy for these small children is a minimally invasive procedure, associated with low morbidity, shorter postoperative recovery period, and better cosmetic appearance of the cutaneous scar, and enables a better and magnified visualization of the pelvic organs.

Pelvic mass in newborn and young children can be diagnosed with minimal morbidity by laparoscopy. ¹³ The laparoscopic approach is considered to be the gold standard in managing benign adnexal conditions in adults. Its use in neonatal and small children is now more and more being reported from all over the world. ¹⁴