7: Physiology of Pediatric Laparoscopy

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Por Devki Shukla, MD , 1  Mariana G. Klinowski, MD , 2  Francisco L. Reed, MD ,   & Mohan S. Gundeti, MD 3, 4
  1. Department of Urology , University of Chicago , Chicago, IL, USA
  2. Pediatric Urology, Hospital Exequiel Gonzalez Cortes, Santiago, Chile
  3. University of Chicago Medical Center, Chicago, IL, USA
  4. Comer Children’s Hospital, Chicago, IL, USA

Background

Over the last two decades, the use of laparoscopic and robotic surgical techniques has been widely adopted into urology and pediatric urology. Advantages of laparoscopic surgical approaches include increased magnification, better cosmesis, decreased post-operative pain scores and overall shorter hospital stays compared to open surgical approaches.1 Since the first adoption of laparoscopy in pediatric urology in 1976 by Crotesti et al for the evaluation of undescended testes, laparoscopic technique has greatly advanced the ability to perform complex surgical procedures.2

The application of robotic surgical systems within pediatric urology was the next breakthrough in advancing minimally invasive technique after laparoscopy. In smaller patients, the limitations of laparoscopy such as limited range of motion and degree of magnification were amplified. Robotic surgery offers greater magnification and visualization of smaller areas, seven degrees range of motion and reduction in hand tremors – ideal when working in small spaces. Since robotic techniques were first implemented within pediatric urology, the role of robotic surgery has expanded to include a variety of procedures including pyeloplasty, heminephrectomy, bladder neck reconstruction, ureteral reimplant, appendicovesicostomy and others.3,4,5

With the growing popularity of laparoscopic and robotic techniques within pediatric urology, understanding the physiology of pediatric laparoscopy is essential for providing safe outcomes for pediatric patients.

Positioning, Access, and Port Placement

The first step to performing a safe and effective laparoscopic/robotic procedure is to gain access to the abdomen or retroperitoneum without injury (see Tips section below). Proper patient positioning can prevent instrument collision and can improve ergonomics. Important aspects of patient positioning include padding all pressure points; securing tubing, electrical cords, and other equipment; and securing the patient to the table.

In addition to providing safety, patient position can play a significant role in patient physiology. Studies have demonstrated that placing a pediatric patient in the Trendelenburg position during laparoscopic/robotic surgery will lead to tachycardia and increased vascular resistance along with decreased mean arterial pressure and overall cardiac output. These effects are reversed in the reverse Trendelenburg position.6 Cardiac and respiratory stress is also increased with flank or left lateral decubitus positioning.

Prior to obtaining access, bowel and bladder distension must be considered. This concept is particularly important in children since they have unique physiologic and anatomic differences compared to adults. Children have faster gastric emptying times which results in increased small bowel and gastric distension. Therefore, it is important to decompress the stomach after intubation but prior to abdominal access for optimal visibility. Similarly, the bladder is in a more abdominal position compared to adults. Foley placement prior to gaining access can help prevent unintentional injury.

The open (Hasson) technique is the preferred method for obtaining access in children and those with previous abdominal surgeries. The Veress technique has been described previously but has been associated with an increased incidence of access related injury in the pediatric patients. In a survey of 153 pediatric urologists in 1995, overall complication rates were significantly higher for the Veress needle technique versus the Hasson technique, 7.8% and 3.9% respectively.7 The open (Hasson) technique involves making an initial incision (5–12mm depending on port size) and dissection down to level of fascia. The port is then inserted under direct vision.

After access has been established, the next step is proper port placement. One aspect to consider is the increased abdominal wall laxity of children. Studies have demonstrated that a child’s abdomen stretches by 17% on average with induction of pneumoperitoneum. As children age, the longitudinal elasticity decreases but the transverse abdominal wall elasticity increases.8 Marking port sites incision, after insufflation can help account for this difference. Trocars also come in a variety of sizes, with or without sheaths, and can be noncutting to allow for radial dilation to help prevent bowel or vascular injury during port placement.

During trocar placement, another rare complication is air embolism. Air embolism is thought to occur most commonly at the time of initial laparoscopic access with inadvertent injury of a patent umbilical vein. A recent study by Patterson et al revealed a lower relative risk of air embolism in children greater than one year compared to patients less than one-year old.9

Tips for Positioning, Port Placement, and Obtaining Access

  • Trendelenburg positioning has cardiac and cerebral physiological changes
  • Open (Hassan) port placement is a better option than Veress technique
  • Use an orogastric tube to decompress bowels prior to obtaining access
  • Place foley catheter to decompress bladder (bladder is predominantly intraperitoneal in children)
  • Mark port sites and make incision after insufflation
  • Be aware of the increased elasticity of abdominal wall and use force diligently
  • Be aware of Air Embolism in children under age one year

Physiology of Insufflation Agents

Currently, the most common agent for insufflation in laparoscopic and robotic procedures is carbon dioxide. Historically, several other gases were used to induce pneumoperitoneum including helium, argon, and nitrous oxide. The inert gases helium and argon posed the problem of low solubility in blood which subsequently led to higher rates of subcutaneous emphysema and venous gas embolism.10,11 Nitrous oxide gained popularity in the 1970s since it was inexpensive, readily absorbed and rapidly eliminated from the body – like carbon dioxide. However, two case reports of intraperitoneal explosions using nitrous oxide resulted in a rapid decline of its use in laparoscopic surgery.12,13 More recently, several clinical studies have demonstrated the safety and efficacy of nitrous oxide.14,15

Carbon dioxide came to be the most widely used insufflating gas given that it was cost-effective, soluble, rapidly excreted, and noncombustible. However, despite its advantages, carbon dioxide can significantly impact various physiological systems. Insufflation with carbon dioxide has been shown to provoke an inflammatory response created by proinflammatory cytokines.16 In addition, higher insufflation pressure has been shown to affect the integrity of the peritoneal mucosa and cellular infiltration of carbon dioxide – leading to a greater inflammatory response.17 Furthermore, carbon dioxide insufflation has been associated with peritoneal acidosis and oxidative stress.18

Physiology of Pneumoperitoneum

With laparoscopic and robotic surgery, the increased abdominal pressure from pneumoperitoneum can have a profound effect on pediatric patients involving multiple systems (Table 1).

Table 1 Effect of increased abdominal pressure on various body systems during surgery and prevention.

System Effect of Increased Abdominal Pressure Prevention Strategies
CNS Intrabdominal CO2 diffuses into the blood, causing hypercarbia →increased intracranial pressure and reduction in cerebral oxygenation Avoid Trendelenburg positioning, place patient in supine position with head up to minimize rise in intracranial pressure
Monitor cerebral perfusion intraoperatively with near-infrared spectroscopy
Respiratory Increased abdominal pressure can restrict diaphragmatic mobility and compliance →atelectasis and hypercarbia Anesthesiologist may employ PEEP to reduce risk of atelectasis
Use endotracheal tube and increase minute ventilation to maintain end-tidal carbon dioxide
Cardiac Increased intraabdominal pressure → decreased cardiac preload → decreased cardiac output. To compensate, systemic vascular resistance increases Trocar placement can induce vagal response and severe bradycardia
Minimize intraabdominal pressure and administer vagolytic agents
Renal Renal vein compression and direct renal parenchyma compression →decreased blood flow and renal cellular injury and subsequent transient decrease in urine output and creatinine clearance Aggressive volume expansion, especially for patients with pre-existing renal dysfunction
Immune Ischemia-reperfusion injury can lead to local inflammation of the peritoneal wall →development of intraperitoneal adhesions Minimize intraabdominal pressure if able and account for adhesions when obtaining access on patients who have undergone previous laparoscopic surgery
Hepatic Increased intraabdominal pressure → decreased portal venous blood flow and dysfunction of hepatic perfusion autoregulatory system → transient transaminitis Transaminitis generally resolves within 48 hours, but may be clinically significant for patients with pre-existing hepatic dysfunction
Ocular Transient increase in intraocular pressure can be clinically significant for patients with glaucoma or other ocular pathologies Increased central venous pressure →conjunctival congestion (usually self-limited) Avoid high intraabdominal pressure and Trendelenburg positioning if able

Pneumoperitoneal Pressure

The ideal pneumoperitoneal pressure for pediatric patients should result in the least physiologic effects both intraoperatively and postoperatively, while maintaining enough pneumoperitoneum to safely perform laparoscopic surgery. Several studies have investigated the ideal pneumoperitoneal pressure for laparoscopic/robotic pediatric surgery. As expected, older and larger patients can tolerate greater intraabdominal pressures. Studies have demonstrated that intraabdominal pressure levels between 8–12 mm Hg are acceptable for children older than one year.19 Sakka et al used transesophageal echocardiology to study hemodynamic changes in children aged 2–6 years and found that pressures of less than 12 mm Hg had minimal effects on cardiac index while maintaining satisfactory surgical conditions.20 Given the decreased intraabdominal cavity size, studies of pneumoperitoneal pressure on infants have demonstrated the need for decreased intraabdominal pressure. A randomized control trial by Sureka et al found that in infants less than 10 kg undergoing laparoscopic renal surgery, a pneumoperitoneal pressure of 6–8 mm Hg resulted in fewer hemodynamic and respiratory changes and earlier postoperative recovery compared to a pneumoperitoneal pressure of 9–10 mm Hg.21 Given the impact of pneumoperitoneum on the physiologic systems described below, maintaining intraabdominal pressure below 12 mm Hg for children and below 8 mm Hg for infants is imperative to preforming safe and effective laparoscopic/robotic pediatric surgery.

Central Nervous System

The central nervous system is directly impacted by the diffusion of intraabdominal carbon dioxide into the blood. The resulting hypercarbia can contribute to increased intracranial pressure (ICP). This phenomenon is particularly important when considering laparoscopy for patients with ventriculoperitoneal shunts. Case studies have demonstrated that despite maintaining a low intra-abdominal pressure (<10 mm Hg), patients experience a rapid rise in intracranial pressure of greater than 12 mm Hg above baseline and subsequently experience a decrease in cerebral perfusion pressure. The rise in intracranial pressure may be treated by ventricular drainage intraoperatively.22 Furthermore, studies have demonstrated that increased intraabdominal pressure is associated with a reduction in cerebral oxygenation which warrant close monitoring during laparoscopy and the immediate post-operative period.23

Maintaining a low intraabdominal pressure can help prevent this reduction in cerebral oxygenation and increase in ICP. Trendelenberg positioning has also been shown to significantly increase ICP in pediatric patients. Positioning children in a supine position with head up can help prevent the negative consequences of increased ICP. Intraoperatively, anesthesia may employ near-infrared spectroscopy (NIRS) to measure cerebral tissue oxygen saturation and intervene during episodes of suboptimal oxygenation and perfusion to the immature brain.24

Respiratory System

Respiration is also closely tied to changes in pneumoperitoneum and abdominal pressure. Increased intraabdominal pressure leads multiple effects on respiration. One of the most profound effects intraoperatively is the cephalad shift of the diaphragm which results in a decreased functional residual capacity and increased risk of atelectasis. Although atelectasis typically resolves within 24 hours after surgery, post-operative complications such as worsening of bronchitis or development of pneumonia may occur. Aside from lowering intraabdominal pressure, anesthesia may employ positive end expiratory pressure (PEEP) intraoperatively to help prevent atelectasis. In a randomized controlled study of children undergoing laparoscopic inguinal hernia repair, lung ultrasonography demonstrated that the use of PEEP at 5 cm H2O reduced the number of atelectatic regions by half compared to the non-PEEP group.25

Lung compliance, the measure of lung and chest recoil, is also affected by this cephalad shift of the diaphragm. This effect is magnified by Trendelenberg positioning. Studies have shown a 17% decrease in lung compliance upon placing patient into the Trendelenberg position. Upon insufflation, lung compliance decreased by an additional 10%. The reduced lung compliance results in inadequate pulmonary gas exchange which leads to hypercarbia.26 Although most children can tolerate the increased carbon dioxide load, children with underlying lung pathologies may be subject to developing significant acidosis and subsequent neurological damage.

Another factor that can lead to hypercarbia during laparoscopy is absorption of the carbon dioxide gas used for insufflation itself. Pediatric patients are especially susceptible to hypercarbia due to the shorter distance between the capillaries and peritoneum and the rapid absorption and high solubility of carbon dioxide. Furthermore, they have a greater absorptive area in relation to body weight compared to adults. To account for this, anesthesia may increase minute ventilation by up to 60% to maintain end-tidal carbon dioxide levels at baseline.27 To control minute ventilation, endotracheal intubation is often preferred over a supraglottic airway.

Another rare complication of laparoscopic surgery is pneumothorax. A study by Bradley et al investigated the development of pneumothorax in 4 children out of a total 285 laparoscopic pediatric urologic procedures performed. Decreased oxygen saturation, subcutaneous emphysema, increased respiratory effort and asymmetric decreased lung sounds were hallmarks of pneumothorax presentation. Factors that may contribute to pneumothorax development include barotrauma, increased operative time, unrecognized congenital defects and inadvertent diaphragmatic injury during trocar placement.28 Given the quick absorption of carbon dioxide, these events of pneumothorax are often successfully managed conservatively.

Cardiovascular System

The effects of pneumoperitoneum on the cardiovascular system in pediatric patients have been well established. The rise in intraabdominal pressure with pneumoperitoneum causes increased pressure on the inferior vena cava which results in decreased venous return to the heart and overall decreased cardiac output. Studies have demonstrated that an insufflation pressure greater than 5–8 mm Hg results in no significant change in cardiac output, while an intraabdominal pressure of 12 mm Hg decreases cardiac output by 13%.20 To account for the decreased preload, system vascular resistance increases. In a study by Gueugniaud et al, insufflation resulted in a reduction of aortic blood flow by 67%, a decrease in stroke volume—due to decreased preload—by 68% and a compensatory increase in systemic vascular resistance by 162%.29 These effects are magnified by higher intraabdominal pressures. The higher systemic vascular resistance leads to an overall increase in mean arterial pressure with initiation of pneumoperitoneum. In a comparison of children undergoing laparoscopic herniorrhaphy versus open herniorrhaphy, mean arterial pressure was demonstrated to increase by 14.8% with pneumoperitoneum at 10 mm Hg.30

Aside from the effects of increased intraabdominal pressure, the insufflation agent also can significantly impact the cardiovascular system. Hypercarbia from the rapid absorption of carbon dioxide leads to several physiologic changes. With a rise in intracellular acidosis, myocardial contractility is suppressed. This is counter-balanced by the stimulation of the autonomic nervous system by carbon dioxide which leads to an elevation of heart rate, systolic blood pressure and cardiac output.31 A study of patients undergoing laparoscopic varicocelectomy demonstrated a rise in norepinephrine by over two times and epinephrine over 20 times after 10 minutes to insufflation.9

Another important consideration is that children have a higher vagal tone than adults that may occasionally be stimulated by peritoneal stimulation. This may provoke bradycardia or asystole when penetrating the peritoneum with trocars or starting insufflation. This complication is often avoided with administration of a vagolytic agent prior to insufflation.32

Renal System

The primary renal effect of pneumoperitoneum is decreased urine output/oliguria and transient kidney injury. Studies of rat models have demonstrated decreased urine output at 10 mm Hg intraabdominal pressure that was associated with a 92% reduction in caval blood flow and 46% reduction in aortic blood flow.33 In addition to reduction of blood flow with pneumoperitoneum, investigators have hypothesized that the direct renal parenchymal compression can lead to decrease in GFR and oliguria during laparoscopy. Razvi et al used pressure cuffs around canine kidneys at 15 mm Hg which resulted in a decrease in urine output by 63%.34 Indirect effects of pneumoperitoneum have also been investigated in relation to renal function. The direct compression of the kidneys during pneumoperitoneum can stimulate the renin-angiotensin-aldosterone system which results in salt and water retention with oliguria. Additionally, renal damage can occur with pneumoperitoneum-associated ischemia-reperfusion. As mentioned, increased intraabdominal pressure results in decreased renal blood flow. After desufflation, the renal blood flow normalizes which increases oxidative stress and subsequent tissue damage.35

One patient risk factor for post-operative kidney injury is age younger than one year. A prospective study by Gomez et al demonstrated that children less than one year of age are significantly more susceptible to more severe temporary renal injury resulting in anuria than children above one-year old, 88% versus 14%. In all cases, anuria was transient and urine output returned to baseline before discharge.36 Wingert et al investigated almost 9,000 cases of children undergoing noncardiac surgery and found several factors associated with postoperative acute kidney injury (AKI) which occurred in 3.2% of cases. Patients with a higher ASA status were at significantly greater risk of developing AKI postoperatively. Post-operative AKI was also associated with significantly worse outcomes, including a 3-fold higher estimated mortality rate and 1.5 times higher readmission rate.37

To minimize the risk of developing post-operative AKI, aggressive intra-operative volume expansion has been shown to be effective.38 Furthermore, maintaining intraabdominal pressure as low as possible can minimize the direct compression-related effects on renal parenchyma.

Immune System

Another effect of pneumoperitoneum is on the inflammatory system. The compromised intraabdominal perfusion with increased intraabdominal pressure can lead to ischemia-reperfusion injury with the formation of reactive oxygen species (ROS) and other inflammatory cytokines. Once the peritoneum is injured, the healing process consists of repairing the damaged tissue with a fibrin plug with subsequent mesothelial regeneration. However, in the presence of inflammation, fibroblasts can proliferate and lead to the development of peritoneal adhesions which can significantly impact clinical outcomes and complications.39

Although local ischemia-reperfusion injury from carbon dioxide pneumoperitoneum can lead to an increase in inflammatory cytokines, carbon dioxide insufflation has been shown to decrease hepatic expression of acute phase reactants into systemic circulation. Investigations on rat models have shown that insufflation with carbon dioxide decreased the expression of hepatic expression of alpha-2 macroglobulin after endotoxin insult.40

Hepatic System

The hepatic system is also affected by increased intraabdominal pressure. In both human and animal studies, increased intraabdominal pressure of 15 mm Hg has been shown to reduce portal venous blood flow. Normally, a reduction in portal venous flow leads to reduced flow resistance through the hepatic artery—therefore maintaining blood flow to the liver. This autoregulatory system is known as the hepatic arterial buffer response. However, studies have shown that with increased intraabdominal pressure (12–15 mm Hg) control by this autoregulatory system is lost.41 In a clinical study, Jakimowicz et al reported a 53% reduction in portal blood flow with pneumoperitoneum of 14 mm Hg. Hepatic hypoperfusion can result in acute hepatocyte injury and transient elevation of liver enzymes. Transaminitis has been shown to resolve within 48 hours after surgery, however, can be clinically significant in patients with pre-existing hepatic dysfunction.42

Ocular System

Increased intraabdominal pressure also impacts the ocular system. Like the increase in intracranial pressure with pneumoperitoneum, intraocular pressure has also been shown to rise with an increase in intraabdominal pressure. Studies have shown that a combination of pneumoperitoneum pressure of 15 mm Hg and Trendelenburg positioning almost doubled intraocular pressure. After pneumoperitoneum evacuation and return to supine positioning, intraocular pressure returned to baseline.43 Other studies have demonstrated that during longer cases in Trendelenburg position, a 5-minute supine rest intervention can greatly reduce the intraocular pressure to safe levels. Although most children with healthy eyes can tolerate the increased intraocular pressure during pneumoperitoneum, extra care must be taken in children with congenital glaucoma who are particularly susceptible to intraocular pressure changes.

Another rare ocular occurrence post-laparoscopy is conjunctival congestion. Increased pressure in the abdominal cavity can lead to increased central venous pressure which can cause increased capillary pressure. Children have more fragile ocular capillaries in than adults, and thus the increased venous congestion can result in postoperative conjunctival congestion. This is often self-limited. However, measures that may prevent this complication include reducing intraabdominal pressure and avoiding Trendelenburg positioning if possible.44

Metabolic System

As in other surgical procedures, several hormones (e.g., β-endorphin, cortisol, prolactin, epinephrine, norepinephrine, dopamine) have been noted to increase during laparoscopic surgery as a response to tissue manipulation, intraoperative trauma, and postoperative pain.45,46,47 The clinical significance of increased serum arginine vasopressin levels seen in open surgery and in response to intraperitoneal insufflation during laparoscopy remains unexplained.48,49,50

Blood glucose concentration, used as a marker of stress associated with the procedures, was found not to be significantly different between laparoscopic or open procedures.51 In contrast, Devitt et. al. studies found significantly increased blood glucose levels at 2, 4, and 6 hours postoperatively in the open surgery group but not the laparoscopic-assisted group. It is possible that more frequent glucose monitoring may have elicited some differences in glucose levels.

As described by Devitt, blood cortisol was significantly higher in open procedures at 1 and 2 hours postoperatively, but returned to normal by 6 hours postoperatively, but not increased in those operated via laparoscopic-assisted.52

Several adverse metabolic changes observed during open cholecystectomy are less pronounced with laparoscopic cholecystectomy:1 reduced postoperative plasma glucose elevation,2 less decrease in insulin sensitivity, and3 reduced hepatic stress response.53,54,55 In addition, conventional open surgery results in several other, potentially adverse, reactions: muscle proteolysis, increased intestinal mucosal protein synthesis, and increased hepatic protein synthesis.

The conversion of amino acids to urea by the liver is much higher after open incisional cholecystectomy than it is after laparoscopic cholecystectomy; hence, the catabolic reaction of the body is decreased with a laparoscopic versus an open, incisional approach.56 Indeed, in the laparoscopic patient, the reduced postoperative hepatic catabolic stress associated with reduced tissue loss of amino nitrogen may, in some way, be responsible for the more rapid convalescence that is the hallmark of laparoscopy in general.

Role of Anesthesia

Many of the physiologic effects of increased abdominal pressure from pneumoperitoneum can be controlled by the anesthesia team. Intraoperatively, anesthesiologists can closely monitor critical values such as intracranial pressure, end-tidal carbon dioxide, oxygen saturation, heart rate and blood pressure, among many others. As described previously, alterations to ventilation settings and intravascular volume are critical during laparoscopic surgery, especially in the pediatric population. Hence why close communication between surgeons and anesthesiologists is so critical to overall patient outcomes.

Conclusions

As laparoscopic and robotic technology continues to evolve, the impact of laparoscopic surgery on pediatric patients’ physiology will continue to change. Pediatric surgeons must be conscious of the physiologic effects of laparoscopy to safely perform procedures and be able to adjust intraoperatively to avoid complications. Careful consideration of all steps during laparoscopy – including patient positioning, pneumoperitoneum pressure, trocar placement and volume status can be crucial for minimizing the physiologic effects of pneumoperitoneum. Therefore, as a specialty, pediatric urology must continue to consider the physiologic impact of laparoscopy on their patients and work as a multidisciplinary team to provide safe and effective care.

Key Points

  • Be aware of unique features of pediatric anatomy when gaining access: increased abdominal elasticity, more intraperitoneal bladder, increased small bowel and gastric distension.
  • To minimize the physiologic effects of pneumoperitoneum, avoid Trendelenburg positioning if possible and maintain the lowest intraabdominal pressure possible (6-8 mmHg for children <1 year, 8-12 mmHg for children >1 year).
  • Anesthesia can monitor for effects of increased intraabdominal intraoperatively with near-infrared spectroscopy for cerebral perfusion, end-tidal CO2, heart rate and blood pressure.
  • Strategies to minimize impact of pneumoperitoneum include: using PEEP to prevent atelectasis, increasing minute ventilation to prevent hypercarbia, administering vagolytic agents to prevent vagal response and volume expansion to prevent renal injury

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