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[Anesthesia for laparoscopic surgery in pediatrics]
1Clinique Chirurgicale, Boulogne-Billancourt.
Insights
Laparoscopic surgery in children presents unique physiological challenges. Careful management of intra-abdominal pressure and patient positioning is crucial, especially in infants, to prevent cardiorespiratory complications.
Area of Science:
- Pediatric Surgery
- Anesthesiology
- Physiology
Context:
- Laparoscopic surgery is increasingly used in pediatric cases, expanding its applications.
- This technique introduces novel physiological challenges due to pneumoperitoneum and patient positioning.
- Understanding these modifications is key for safe surgical practice.
Purpose:
- To review the physiological modifications and potential complications associated with laparoscopic surgery in children.
- To highlight age-specific risks and recommended management strategies.
- To provide guidance on anesthetic considerations and contraindications.
Summary:
- Physiological changes in pediatric laparoscopic surgery, including respiratory and cardiovascular effects, are influenced by intra-abdominal pressure and patient posture.
- Infants under 6 months are at higher risk, necessitating lower intra-abdominal pressures (≤6 mmHg) to avoid complications like low cardiac output and gas embolism.
- Contraindications include hypovolemia, heart disease, and increased intracranial pressure, with special care required for high-risk newborns.
Impact:
- Informs pediatric surgeons and anesthesiologists about the risks and management of laparoscopic procedures in children.
- Emphasizes the importance of tailored anesthetic approaches and careful monitoring.
- Aims to improve patient safety and outcomes in pediatric minimally invasive surgery.
Abstract:
The increasing use of laparoscopic surgery in children is associated with the enlargement of the spectrum of indications to appendicectomy, extramucosal pylorotomy and cure of oesophageal reflux. It is also linked with new problems, mainly due to physiologic modifications elicited by pneumoperitoneum and patient's posture. Although sufficient data are not yet available, the respiratory and cardiovascular modifications are probably similar to those occurring in adults, at least in children more than 4-month-old, as long as the intra-abdominal pressure remains under 15 mmHg. The use of higher intra-abdominal pressures has not been reported in children. In this case, the cardiovascular changes consist mainly in an increase in arterial pressure. In some children, non specific decreases in heart rate and in blood pressure can be observed. The latter can be elicited by a surgical complication, hypovolaemia, head-elevated position or deep anaesthesia. In the newborn and infant under 6 months, intra-abdominal pressures of 15 mmHg or more carry a risk of low cardiac output due to a decrease in contractility and compliance of the left ventricle. In this group of age it is therefore recommended to establish a pressure not higher than 6 mmHg. Moreover, in these very young children, the risk for reopening of the right-left shunts can result in heart insufficiency and systemic gas embolism. Peroperative respiratory changes include an increase in PetCO2 and more rarely a decrease in SaO2. The interpretation of the former depends on the site of gas sampling in the anaesthetic system. It is easily controlled by an increased minute ventilation. Various causes, such as bronchial intubation, inhalation of gastric contents or gas embolism, can decrease SaO2. Contra-indications for laparoscopic surgery include hypovolaemia, heart diseases, increased intracranial pressure and alveolar distension. Therefore newborns are patients at high risk in so far as their foramen ovale or their ductus arteriosus is patent, the pulmonary arterial resistances remain increased and a bronchodysplasia is existing. In some cases a special disease is often associated. As an example recurrent bronchitis or asthma is associated with an oesophageal reflux and a sickle-cell disease in patients with cholelithiasis. These patients require special pre-, per- and postoperative care for prevention of complications. Anaesthesia for laparoscopic surgery does not require a major extension of the usual security regulations. Special attention must be paid to arterial pressure. Therefore end-expiratory concentration of the halogenated anaesthetic agent should not be kept higher than 1.5 times the MAC related to the age during maintenance of anaesthesia.(ABSTRACT TRUNCATED AT 400 WORDS)