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Anesthesia For Laparoscopy in The Pediatric Patient
Anesthesia For Laparoscopy in The Pediatric Patient
Anesthesia For Laparoscopy in The Pediatric Patient
From the Department of Anesthesiology & Pain Management, University of Texas South-
western Medical School, Dallas, Texas
-
VOLUME 19 NUMBER 1 MARCH 2001 69
70 PENNANT
lier discharge and a more rapid return to normal diet and full
39, 50 There is a perception it is associated with an improved cosmetic
result, reduced postoperative hernias, less wound infections, a lower
incidence of postoperative ileus, and less postoperative pain.
Fewer laparoscopic operations are performed in children, so one
institution does not have extensive experience. There are no published
randomized prospective studies of this type of minimally invasive sur-
gery in this young population. Existing reports are mostly anecdotal in
nature, so that the precise role of this exciting new technique in pediatric
surgery has yet to be defined. More recently, small controlled studies of
laparoscopic appendectomy and fundoplication in children have been
47 These have helped to identify the benefits and drawbacks
of this surgical technique.
Laparoscopy can be a diagnostic procedure in children (e.g., to
evaluate the undescended testis,", 46, 48 as part of the evaluation of in-
tersex, in the diagnosis of the acute abdomen,= and in staging pediatric
cancer). Once the diagnosis is made, laparoscopic techniques can help
to treat the condition (e.g., unwinding adnexal torsion,48appendectomy,
adhesiolysis, resection of Meckel's diverticulum, or even removal of a
pheochromocytoma9).
With the laparoscope, even large, solid intra-abdominal masses such
as the kidney or spleen can be removed after the tissue has been
morcellated. As experience has increased, a variety of more sophisticated
procedures are now possible (e.g., colectomy, "pull-through for Hirsch-
sprung's disease,I7,21, 67 pyeloplasty, and treatments for vesicoureteral
reflux, gut malrotation, and choledochal cysts).
embolism, capnography might not reveal any change in ETco, until late
in the course of the event.
Gasless Laparoscopy
The gasless laparoscopic technique avoids using any gas for insuf-
flation, relying instead on an abdominal wall lift to create an intra-
abdominal space at atmospheric pressure.34This has further advantages
because maintaining a pneumoperitoneum is more difficult in infants
because even the smallest gas leak can cause the small working space to
collapse. Gasless techniques allow the use of valveless ports and instru-
ments of differing calibers without the inconvenience of a variable
pneumoperitoneum, and without the problems attributed to increased
intra-abdominal pressure (IAP).
Intra-abdominal Pressure
Cardiovascular Effects
The critical determinants of cardiovascular function during laparos-
copy are the IAP and patient position.63If the IAP is kept below 15 mm
Hg, venous return actually is augmented as blood is "squeezed" out of
the splanchnic venous bed, producing an increase in cardiac output. At
IAP levels greater than 15 mm Hg, venous return decreases as the
inferior vena cava (IVC) is compressed. This results in a reduction in
cardiac output and arterial blood pressure. In other types of surgery, in
which the N C is cross clamped or ligated, compensatory flow can occur
by collateral vessels and restore blood pressure to acceptable levels, but
in laparoscopy the high levels of IAP also obstruct these collaterals. In
ANESTHESIA FOR LAPAROSCOPY IN THE PEDIATRIC PATIENT 73
this case, the hypotension can be more profound than that following
simple IVC occlusion.
Early work with newborn piglets confirmed the importance of keep-
ing IAP below 15 mm Hg.35Above this level, a progressive decrease in
cardiac index was noticed. For example, at an IAP of 20 mm Hg, the
cardiac index fell to 55% of baseline, but when the IAP was increased to
30 mm Hg, the cardiac index decreased to 38% of its resting level.
Studies using neonatal lambs demonstrated a 35% reduction in renal,
hepatic, and intestinal blood flow at an IAP of 25 mm Hg.38
Sakka et a145used transesophageal echocardiography to study the
hemodynamic changes during laparoscopy in eight healthy supine chil-
dren aged 2 to 6 years. Their results showed that an IAP up to 12 mm
Hg had minimal effects on cardiac index, reducing it approximately
13%.At an IAP of 6 mm Hg, no cardiovascular parameters were affected,
yet surgical conditions were satisfactory. This lower level of IAP is
recommended for patients with serious cardiac disease. Hsing’s= group
also confirmed the absence of hemodynamic compromise in the Trende-
lenburg position in 126 children aged 11 months to 13 years undergoing
laparoscopic inguinal exploration, when pneumoperitoneum was limited
to 10 mm Hg. Others studied 12 healthy supine boys aged 6 to 30
months using a pneumoperitoneum of 10 mm Hg and discovered a 67%
reduction in cardiac performance (aortic blood flow and stroke volume)
and a 162% increase in systemic vascular resi~tance.’~ These changes
were not associated with any deleterious cardiac events. Tobias et a155
studied 53 children aged 1month to 7 years, and looked at cardiorespira-
tory measurements during brief ( 4 5 min) diagnostic inguinal laparos-
copies, in which IAP was kept below 15 mm Hg. Ventilatory settings
were unchanged during the investigation. There were no significant
changes in arterial 0, saturation or other cardiovascular parameters.
These minimal alterations in vital signs were attributed to the brief
surgical times, limiting IAP to 15 mm Hg, and avoiding the Trendelen-
burg position. The authors caution that more dramatic changes could be
seen in longer procedures and when the head-down position is
used.
These cardiovascular changes are complicated by the patient’s posi-
tion during surgery. The head-up position favored for upper abdominal
procedures (e.g., Nissen fundoplication and cholecystectomy) further
reduces venous return and cardiac 0utput.2~This effect is more marked
during fundoplication, in which a greater degree of head-up tilt (25-30
degrees) is required than for laparoscopic cholecystectomy (15-20 de-
grees). In addition, surgical dissection around the esophageal hiatus in
a pig model increased mediastinal and pleural pressures, which also
can produce a significant reduction in cardiac output and explain the
occasional episodes of hypotension and hypoxia seen in this procedure.%
Surprisingly, release of the pneumoperitoneum did not restore cardiac
output, or central venous, pleural, or mediastinal pressures to baseline
levels within an hour, suggesting a prolonged physiologic effect from
gastroesophageal junction dissection. Conversely, when the patient is
74 PENNANT
Respiratory Effects
Elevated IAP reduces diaphragmatic excursion and shifts the dia-
phragm cephalad, resulting in early closure of small airways, an increase
in peak airway pressure, and a reduction in both thoracic compliance
and functional residual capacity (FRC). Upward displacement of the
diaphragm leads to preferential ventilation of nondependent parts of the
lung. This results in ventilation-perfusion mismatch, which is accentu-
ated during positive pressure ventilation and by the Trendelenburg
position. FRC is low in children and quickly falls below closing capacity,
producing small airway collapse, atelectasis, intrapulmonary shunting,
and hypoxemia. This deterioration in respiratory function is reduced
when the patient is in the reverse Trendelenburg position and increased
ANESTHESIA FOR LAPAROSCOPY IN THE PEDIATRIC PATIENT 75
when the patient is placed in a steep head-down tilt, when the weight
of abdominal viscera causes extra diaphragmatic loading.
In Tobias’s study55 of inguinal laparoscopy in 53 children aged 1
month to 7 years, when IAP was limited to 15 mm Hg, peak airway
pressures increased by a mean of 3 cm H20 (maximum, 7 cm H20),and
ETco, increased from a mean of 32 mm Hg to 35 mm Hg (maximum
increase, 11 mm Hg). All values had returned to baseline within 10
minutes of completion of surgery.
One study of ten children revealed a 27% reduction in lung compli-
ance and a 32% increase in peak airway pressure following both 20-
degree head-down tilt and 12 mm Hg pneurn~peritoneum.~~ All values
returned to normal when the abdomen was deflated. These changes are
about one half as extreme as those seen in adults, perhaps because of
the different chest wall configuration and greater thoracic distensibility
in children. H s i n g ’ ~study
~ ~ of 126 children reported that whereas there
were no significant hemodynamic changes when patients were placed
in the Trendelenburg position, as long as IAP was limited to 10 mm
Hg, airway pressures and ETco, both increased by approximately 20%.
Because most pediatric patients are intubated with uncuffed tracheal
tubes and ventilated with pressure-cycled ventilators, this reduction in
pulmonary compliance results in a fall in tidal volume (secondary to an
increased gas leak around the tracheal tube) unless peak airway pressure
and fresh gas flow are raised to keep minute ventilation at adequate
levels. Increasing minute ventilation 20% to 30% is usually adequate to
maintain normocapnia.60The use of positive end-expiratory pressure
(PEEP) can help to alleviate diaphragmatic elevation encroaching on
FRC and may improve arterial oxygen saturation.
Sfez et a147examined cardiorespiratory function in 25 children aged
1 to 14 years undergoing laparoscopic Nissen fundoplication. All were
intubated and ventilated. Several children had preexisting respiratory
disease, presumably secondary to chronic aspiration. Hypotension or
bradycardia developed in 3 of 4 patients when they were placed in the
reverse Trendelenburg position. This responded promptly to volume
loading and administration of vagolytic drugs. Subsequently, all patients
were operated on in the supine position using LAPS of 6 mm Hg to 10
mm Hg with no significant changes in cardiovascular parameters other
than a slight and gradual increase in blood pressure toward the end of
the procedure. The authors attributed this elevation in blood pressure to
an increased SVR rather than an increase in Paco,. In surgeries that
lasted a mean of 116 minutes, only 2 patients required an increased
minute volume to correct an elevated ETco,; however, 6 children devel-
oped postoperative hypoxemia, defined as an Spoz of less than %YO,
within the first 3 postoperative hours. Two patients were receiving
supplemental Ozby nasal cannulae. This desaturation is not seen after
laparoscopic surgery for inguinal hernia repair, suggesting that it is not
the creation of the pneumoperitoneum per se that causes postoperative
hypoxemia, but rather interference with diaphragmatic function during
fundoplication. The authors suggest that the laparoscopic approach for
76 PENNANT
Neurologic Effects
Another adverse effect of elevated IAP is increased intracranial
pressure (ICP). Hypercapnia, increased SVR, and head-down positioning
combine to elevate An IAP of 25 mm Hg increased ICP from a
mean of 7.6 mm Hg to 21.4 mm Hg and produced a fall in cerebral
perfusion pressure from 82 mm Hg to 62 mm Hg. Because of this
phenomenon, it is inadvisable to perform laparoscopic surgery on pa-
tients with reduced intracranial compliance unless absolutely necessary.
Endocrinologic Effects
When laparoscopy was compared with laparotomy for acute ab-
dominal emergencies (e.g., appendectomy, lysis of adhesions) lasting
about 1 hour, there was a similar increase in blood levels of "stress"
hormones (i.e., insulin, cortisol, prolactin, epinephrine).6 Blood levels of
lactate, glucose, and interleukin-6 were also similar in both groups.
Despite the minimal degree of tissue damage, the neuroendocrine axis
ANESTHESIA FOR LAPAROSCOPY IN THE PEDIATRIC PATIENT 77
PERIOPERATIVE MANAGEMENT
Preoperative Evaluation
Preoperative Investigations
Prernedication
Induction of Anesthesia
Anesthetic techniques available for laparoscopy include local, re-
gional, and general anesthesia. Although local and regional approaches
have been described for brief laparoscopic inspections in healthy adults,
they are generally unsuitable for pediatric patients and are not discussed
further here.
Options available for induction of general anesthesia in children
include inhalational (using sevoflurane or halothane in nitrous oxide
and 0,) or intravenous. The intravenous route is recommended if intra-
venous access has been secured, which can be performed with minimal
discomfort following the use of topical local anesthetic agents, for exam-
ple, Eutectic Mixture of Local Anesthetics (EMLA) cream, amethocaine
gel, or by an iontophoretic technique.
Children requiring emergency exploration of the abdomen should
receive a rapid-sequence intravenous induction with the use of cricoid
pressure until a tracheal tube is securely in place to reduce the risk of
pulmonary aspiration of gastric contents. Although tracheal intubation
is not mandatory for brief laparoscopic procedures in healthy patients
(a f a c e m a ~ kor~LMA5s
~ can be used), good muscle relaxation and intuba-
tion provide optimal surgical conditions and a more secure airway
and allow controlled ventilation in the face of elevated IAP when a
pneumoperitoneum is created.
Peripheral intravenous access should be obtained in all patients to
allow continued hydration and drug administration, especially in case
of accidental vascular injury from endoscopic instruments. Because
laparoscopic nephrectomy or splenectomy can result in major hemor-
rhage, intravenous access must be adequate to permit rapid fluid resusci-
tation. A venous catheter is preferably inserted above the diaphragm in
case the elevated IAP compresses the IVC and impairs access of drugs
and fluid to the circulation from venous access sites in the legs.61 A
central venous catheter is necessary only if peripheral access is unobtain-
able or if preexisting medical conditions dictate. Once venous access is
obtained, some authors routinely administer a 20-mL/kg fluid bolus to
offset the hemodynamic effects when the pneumoperitoneum is cre-
ated.68
Monitoring
Monitoring the child’s clinical status should follow the American
Society of Anesthesiologists’ (ASA) recommendations. These include
ANESTHESIA FOR LAPAROSCOPY IN THE PEDIATRIC PATIENT 79
PerioperativeCare
kept as brief (<30 min) and LAP kept as low as possible. Although the
LMA does not reliably protect the airway and concerns remain regarding
aspiration of gastric contents, it appears that the lower esophageal
sphincter pressure is increased by the presence of a pneumoperitoneum.
Although the incidence of aspiration with the LMA is very low when it
is used as recommended, there has not been any reported increase in
this complication when it has been used for laparoscopy, even when
positive-pressure ventilation was used.3,66
Only one report exists on the use of the LMA in pediatric patients
having laparoscopic inspection of the pelvic Fifteen patients
breathed spontaneously during these brief operations, which only lasted
3 to 9 minutes. In 4 of these 15 children, ETco, exceeded 60 mm Hg but
returned to baseline within a few minutes of the end of surgery. The
ETco, increased to a lesser degree in the remaining patients. There were
no significant changes in arterial oxygen saturation in any child.
Although these preliminary studies suggest the LMA can be safely
used in pediatric laparoscopy, it is not recommended for use in longer
procedures, or in patients with limited cardiorespiratory It
appears to be a safe technique in healthy patients having brief proce-
dures, in whom extremes of head-down tilt and IAP are avoided, and
in whom there are genuine concerns about instrumenting the airway
(e.g., history of severe asthma). As in all areas of pediatric anesthesia,
there is less margin for error than in adults, and slight displacement of
the device could lead to underventilation or gastric distention. The
anesthesiologist must be vigilant for this complication by regularly aus-
cultating over the stomach to detect gas insufflation.
Anesthetic recommendations for laparoscopy in children with se-
vere myocardial disease follow from Tobias and Holcomb’s report on
two sick patients undergoing cholecystectomy.60* 61 These include the
following:
1. Avoid anesthetic agents that directly depress or sensitize the
myocardium, such as halothane. Sevoflurane is a safer alterna-
tive. If intravenous induction is considered, etomidate is a better
choice than propofol or barbiturates.
2. Preoperative atropine prevents the bradycardia that is occasion-
ally seen as a vagal response to peritoneal insufflation. Patients
with noncompliant ventricles have a fixed stroke volume and
rely on heart rate to maintain cardiac output, so bradycardia is
poorly tolerated.
3. Avoid muscle relaxants and opioids that release histamine (e.g.,
mivacurium, rapacuronium, morphine).
4. Avoid caudal epidural block for postoperative analgesia because
the reduction in preload can lead to a fall in cardiac output.
5. Use local anesthetic infiltration at trocar sites to minimize s p -
pathetic stimulation.
6. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be used
for postoperative analgesia.
7.Consider using transesophageal echocardiography in preference
82 PENNANT
COMPLICATIONS
FETAL ENDOSCOPY
SUMMARY
scopic techniques with both open surgery and the minimally invasive
approach for the same procedure. Many published studies suggest lapa-
roscopy offers significant advantages for some operations and for sicker
patients. Practitioners must have a thorough understanding of the physi-
ologic changes that follow pneumoperitoneum and extremes of position-
ing.
As enthusiasm builds, it is essential to maintain safety standards.
Endoscopists must be appropriately trained and peer reviewed. The use
of virtual reality models now allows surgeons to develop and perfect
their laparoscopic skills. When the laparoscopic approach is difficult,
surgeons must be willing to convert to open surgery rather than perse-
vere and risk iatrogenic damage. The role of pediatric laparoscopy has
yet to be defined, although current trends suggest that it will assume an
important position in pediatric surgery.
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Address reprint requests to
John H. Pennant, MA, MB, BS, FRCA
Department of Anesthesiology & Pain Management
University of Texas southwestern Medical School
5323 Harry Hines Blvd
Dallas, TX 75390-9068