Children represent a unique number of patients who're likely to greatly take advantage of non-invasive surgery (Minimal Access Surgery).
The commitment of less postoperative pain, smaller scars, shorter hospital stays, along with a faster go back to school continues to drive development in el born area. The introduction of pediatric-specific techniques and documentation of improved outcomes form a critical gateway to widespread application of pediatric Minimal Access Surgery.
A short perspective on current approaches to Minimal Access Surgery for pediatric congenital and acquired disease is provided in this report. Technical departures from standardized adult Laparoscopic Surgery and also the rationale for their modification are highlighted.
MAS benefits are carried out by surgeons adults long before admission to the pediatric community. Initially, the execution of MAS in the pediatric population was recorded for the following reasons: The widespread belief that children do not know pain.
• The cost of laparoscopy is considered too high.
• Tim was not small enough.
• MAS considered too difficult and too difficult to learn.
• It is believed that cases take too long to implement and execute.
Many surgeons believe that laparoscopic procedures are not really applicable to children, and the need for cholecystectomy was relatively rare in children.
• Pediatric surgeons already had the ability to work with small cuts.
• Many believed that the MAS was not sure, but its effectiveness has not been proven.
In 1973, Gans and Dr. Bercy were pioneers in pediatric laparoscopy. They performed a laparoscopy (ie peritoneoscopy) of 16 children (1-14 years, and D), mainly for diagnostic purposes and to biopsy. The long latency period of pediatric MAS happened of its development. Pediatric laparoscopic instruments of poor quality and telescopes that are not small enough are perhaps the most advance laparoscopic pediatric obstruction. In a comparative study of five years, the results of 211 children who had autism were compared with age-matched with similar diagnoses who underwent open surgery control. We have detected significant differences in mortality or morbidity. However, the hospital stay was smaller for children who undertook laparoscopic cholecystectomy, appendectomy, nephrectomy, splenectomy and intra-abdominal testicular surgery compared to open surgery. In addition, all parents prefer cosmetic results MAS. Many of the advances in pediatric laparoscopy then used in adults. Surgeons adults looked small telescopes and instruments have been developed for pediatric MAS.
Physiology of Minimal Access Surgery in Pediatrics.
Ventilation cavity of the abdomen or chest procedures in minimal access surgery (MAS) has important physiological effects. Great of this physiology has been considered in adults, but very little work has been done on this issue in children. Pneumoperitoneum is necessary in most cases for laparoscopy success. Some discussion was held in the context of this media is the best. Most surgeons prefer to carbon dioxide gas as quickly absorbed, and thus the risk of stroke was reduced compared with other gases. In addition, the combustion is suppressed. After the peritoneum is available abdomen inhaled carbon dioxide gas. The limit pressure generally not exceeding 15 mm Hg in adults. It is different in infants and children, and care should be taken to start small (eg 1 l / min and pressures of 8-12 mm Hg) and use only the pressure required for viewing and maintaining optimal physiology.
After intraabdominal volume exceeds the capacity of the peritoneal cavity to expand, without significant increases in abdominal pressure, a pressure increase causes the physiological adverse effects. This is particularly true when the cavity is low, as in children. The ability of the abdominal cavity to receive pressure rise depends on the applied pressure and the time in which the pressure is maintained. Under normal physiology, intra-abdominal pressure can be as high as 200 mm Hg for the episode of coughing and defecation. During peritoneal dialysis, pressures reach 2.8 mmHg, which did not prove detrimental effect.
Increased intra-abdominal pressure diaphragm plaster vein and arterial blood flow, especially kidneys. You can move the diaphragm into the chest cavity, reducing the total lung capacity and functional residual capacity, adding to the acid-base disorders. Increased intra-abdominal gravity successfully performances as a venous tourniquet. The blood flow in the lower extremities and abdomen, while reducing blood perfusion intact. Cardiac yield drops with increasing rates of ventricular stroke work and heart. The pressure in the abdominal aorta and the pressure increases in the upper body. Among children with pre-existing decreased cardiac output, increased intra-abdominal pressure can lead to acute heart failure.
Ventilation and circulatory changes can be enjoyed within 5 minutes after the start of blowing gas. Pressures greater than 15 mmHg are associated with significant pathophysiological effects or reversible over a period of 2 hours. For infants and children, and no hemodynamic effects are observed under a pressure of 10 mm Hg in less than 15 minutes. Furthermore, the insufflation pressure of 12 mm Hg, the peak airway pressure increases of 40% and reduces the efficiency of 47%, without any change in the dead space. Pediatric anesthesiologists and pediatric surgeons need to work together to breathe properly maintain normal physiological parameters.
Increasing minute ventilation (i.e., increased frequency, airway pressure, and / or volume) may be replaced pulmonary mechanics to limit intra-abdominal pressure below 12 mm Hg. Pulmonary arterial pressure and pulmonary capillary pressure increases with pneumoperitoneum, improving ventilation-perfusion intra-abdominal pressure below 12 mm Hg. This may explain the lack of effect on the pO2 in these conditions. Carbon dioxide is absorbed mainly peritoneal surface, and increase the partial pressure may be offset by an increase in minute ventilation.
Increased carbon dioxide can last for 3 hours after surgery. It is important to recognize, especially in light of post-operative use of narcotics and narcotic effect on ventilation. Continuous monitoring of cardiac, respiratory and kidney function should be performed in the immediate postoperative period.
Increased intra-abdominal pressure can aggravate acid reflux, adding perioperative risk of aspiration. Much more needs to be done in terms of physiological effects of pneumoperitoneum in children. Coronary heart, liver, kidney and mesenteric circulation can affect, and cerebrospinal fluid (CSF) and the pressure lung dynamics.
The advantages of minimal access surgery
• Laparoscopy often offers a better view than open surgery, particularly hiatal better visualization and deep structures in the pool.
• Minimum Access Surgery (MAS) provides significant advantages in terms of quality of life after surgery.
• Postoperative pain is reduced, which reduces postoperative drug and its complications. It also facilitates the inferior pulmonary complications.
• Small wounds are associated with fewer wound complications, less scarring and better cosmetic result.
• MAS results in reducing postoperative adhesions.
• Patients stay in the hospital less and recover faster.
• Patients are able to more quickly (eg food, school, work) to return to normal activities.
• Quick recovery of a child allows parents to return to work faster.
• Videos helps surgical assistants, anesthesiologists and nurses to see what the surgeon and actively participate in the process in their respective roles. Laparoscopy can be performed in infants weighing less than 1.5 kg, without mortality or severe morbidity.
