Technical Basics: Insufflation, Trocar Insertion, Instruments, Needle Insertion, Suturing, Ligating
The physical dimensions are smaller in children. The small spaces are quickly filled with gas. The space within the CO2 tubing may suffice to fill the child’s abdomen; it will be room air if the tubes are not flushed with CO2 prior to starting the insuffl
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Technical Basics: Insufflation, Trocar Insertion, Instruments, Needle Insertion, Suturing, Ligating
The physical dimensions are smaller in children. The small spaces are quickly filled with gas. The space within the CO2 tubing may suffice to fill the child’s abdomen; it will be room air if the tubes are not flushed with CO2 prior to starting the insufflation – with the incorrect assumption that CO2 is insufflated. The distance from skin to aorta is short. We never start insufflation without prior having checked with the laparoscope where the Veres needle tip is located. Insufflation rates are smaller than in adult patients, although a number of pediatric laparoscopists insufflate at rates of 1 l/min. In animal experiments, however, such high insufflation rates have led to cardiovascular problems (and more so did rapid desufflation). It is an incorrect prejudice that 2-mm instruments bend and break easily. They are sturdy enough, and 3-mm instruments are even sturdier. Two- and threemillimeter instruments come in all varieties, just like 5- or 10-mm instruments. Needle insertion is in small children mostly directly through the abdominal wall. If a needle has to be removed at the end, it is removed together with the trocar – and the trocar reinserted if needed. Suturing and ligating are just as in “instrument knotting” in “open” surgery.
F. Schier, S. Turial, Laparoscopy in Children, DOI 10.1007/978-3-642-37638-2_2, © Springer-Verlag Berlin Heidelberg 2013
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2.1 2.1.1
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Technical Basics
Insufflation (1) When Starting Insufflation with a 5-mm Trocar
A 4-mm transverse incision below the lower rim of the umbilicus is made so that the incision is later hidden inside the umbilicus. This also may save a skin suture later when withdrawing the trocar (Fig. 2.1). The tissue is spread with small scissors down to the fascia (Fig. 2.2). The Veres needle is inserted while lifting up the abdominal wall on both sides (Fig. 2.3). There are two distinct snaps – both of them visible, audible and palpable – when inserting the Veres needle. The second structure, the peritoneum, is the tougher one. It is preferable to stay inside the umbilicus, because there are fewer structures to be crossed, and to go almost vertically down, not too obliquely because one may end still within the abdominal wall layers. Do not aim toward the bladder. The penetration depth of the Veres needle may be estimated by tilting it and palpating for the tip (Fig. 2.4).
2.1
Insufflation (1)
Fig. 2.1 Scalpel incision at the lower aspect of the umbilicus for insertion of a 5-mm trocar
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Fig. 2.2 Spreading with scissors down to the fascia
Fig. 2.3 Lifting the abdominal while inserting Fig. 2.4 Estimating the intraabdominal length of the Veres needle the Veres needle
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2.2
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Technical Basics
Insufflation (2)
First, physiologic saline is injected in order to rule out high resistance as one would expect in intramuscular injection (Fig. 2.5). Intravascular placement is ruled out by aspiration. When using a 2-mm trocar and a 2-mm laparoscope f
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