Laparoscopy in young children. Endoscopic surgery in children

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The study in all cases is carried out in the operating room under general anesthesia with mechanical ventilation, since the pneumoperitoneum can significantly limit the movement of the diaphragm, especially in young children.

Before the start of the manipulation, in all cases, a thorough deep palpation of the abdominal cavity under anesthesia is performed, which often allows you to more clearly determine the presence and location of swollen intestinal loops, tumor-like formations, inflammatory infiltrates, intussusception, etc. In addition, during palpation, the sufficiency of gastric emptying and Bladder.

For the initial entry into the abdominal cavity, we widely use a special method of direct puncture with a blunt trocar. A skin incision is made with a length slightly less than the diameter of the trocar, which is supposed to be inserted in this place (usually 5.5 mm, in the presence of peritonitis -11 mm) - more often in the region of the umbilical ring along its upper edge (Figure 7a). Then the surgeon in young children with his left hand raises the anterior abdominal wall. Through this incision, a sharp mosquito-type clamp is inserted, with which the fascia and aponeurosis are stratified without opening the abdominal cavity (Figure 7b). In the same position, but with the help of a blunt clamp (Billroth type), the peritoneum is opened (Figure 7c).

Figure 7. Stages of peritoneal entry into the abdominal cavity by right puncture with a blunt trocar in infants

The moment of penetration into the abdominal cavity is usually clearly felt by the surgeon. In this case, one can almost always note the characteristic sound of "suction" of air into the abdominal cavity. Without changing the position of the left hand, which lifts the anterior abdominal wall, a blunt trocar is inserted through the incision (Figure 7d). In older children, especially with pronounced subcutaneous fat, the surgical assistant also helps to raise the anterior abdominal wall (Figure 8).

Figure 8. Stage of the initial entry into the abdominal cavity in older children

The correct position of the trocar is always controlled using a 5 mm telescope inserted into it with a viewing angle of 30° with a miniature endovideo camera. Careful observance of all the above rules for the first puncture of the abdominal cavity allows you to avoid serious complications - bleeding or injuries to internal organs. After verifying the correct location of the trocar, insufflation of CO 2 is started using an electronic insufflator. The volume of gas used in this case is 1-1.5 liters in young children, up to 3-5 liters in adolescents. The level of intra-abdominal pressure ranges from 5-8 mm Hg. Art. in newborns and infants up to 10-14 mm Hg. Art. at an older age.

The second trocar (3-5.5 mm) is inserted in the left iliac region under the control of the endovideo system. With the help of a video laparoscope and a palpater probe (or atraumatic clamp) inserted through the trocar sleeve in the left iliac region (Figure 9), the abdominal cavity is examined. First of all, the place of entry into the abdominal cavity of the manipulator is examined, which, if necessary, is released from the strands of the omentum. Then a panoramic examination of the entire abdominal cavity is performed, during which the presence of effusion, the condition of the intestinal loops and peritoneum are assessed.

Figure 9. Operational approaches for diagnostic laparoscopy. Places of insertion of trocars:
1 - trocar 5.5 mm (for palpator); 2- trocar 5.5 mm (for laparoscope 5 mm, 30°)

The revision begins with the search for the dome of the caecum. In young children, the dome is usually located higher, in the right lateral canal, sometimes under the right lobe of the liver. There is also increased mobility of the caecum - in these cases, its dome can be found medially, among the loops of the small intestine in the middle floor of the abdominal cavity. Often a long cecum is found with a dome localized in the pelvic area. Thus, if the cecum is absent in the right iliac fossa, and there are difficulties in finding it, it is advisable to start the examination from the transverse colon.

Sequentially moving the laparoscope along the tenia towards the ileocecal angle, using the manipulator and changing the position of the patient's body, determine the localization of the dome of the caecum. Bringing the appendix into the field of view when using the manipulator is not difficult. Some difficulties may arise in the presence of congenital adhesions in the ileocecal region. This is Lane's ligament, which fixes the distal loop of the ileum to the iliopsoas muscle. In this case, the appendix may be located behind the ileum. The examination is also difficult by Jackson's membrane, which is membranous strands that fix the caecum and ascending colon to the parietal peritoneum of the right lateral canal. With the severity of these adhesions in the dome of the caecum, the appendix can be located in a narrow retrocecal pocket.

With difficulties of this kind, it is necessary to turn the patient on his left side, find the base of the process, and, carefully prying it with a manipulator (or grabbing it with a soft clamp), make it light traction. Usually in this position it can be brought into view.

After the discovery of the appendix, it is examined. The normal appendix is movable, easily displaced by the manipulator, its serous membrane is shiny, pale pink in color (Figure 10). The presence or absence of inflammation in it is judged by direct and indirect signs. To indirect signs, we include the presence of a cloudy effusion in the immediate vicinity of the process, the reaction of the peritoneum in the form of hyperemia, the disappearance of its natural luster, the presence of fibrin plaques.

Figure 10. Endoscopic picture of the unchanged appendix

Direct signs are detected by direct examination of the appendix. These include the injection of serosa, its hyperemia, the disappearance of the natural luster of serosa, a change in its natural color both in separate areas and in general, infiltration of both the wall of the process and its mesentery, the presence of fibrin deposits. At the same time, it is possible to "palpate" the tension of the process and observe its rigidity (Figure 11). Inflammatory changes are more often expressed in the distal part of the process. In addition, it is often possible to detect the presence of loose adhesions between the process and surrounding tissues. In some cases, in the presence of gangrenous changes in the wall of the process, a perforated hole is detected.

Figure 11. Endoscopic picture of a phlegmonous altered appendix

The greatest difficulties arise in the differential diagnosis of the initial stages of destructive inflammation and superficial inflammation of the appendix. In this case, of all the described signs, it is possible to detect only mild hyperemia of the serosa, injection of its vessels. The only differential diagnostic sign that allows us to distinguish the initial stage of destructive inflammation in the process from the superficial inflammatory reaction is its rigidity.

With the help of this feature, it is possible to detect destructive inflammation in the appendix even in its early stages. This sign is defined as follows: the appendix is lifted by a manipulator brought under it in the middle third. If at the same time the appendix sagged, as if falling from the manipulator, this sign was considered negative (Figure 10) plot, this sign is considered positive (Figure 11).

It should be noted that this symptom is the most reliable of all existing ones and is used by us as a pathognomonic endoscopic symptom.

Significant difficulties arise in the differential diagnosis of pronounced secondary changes in the appendix from truly destructive changes in it. So, with primary pelvioperitonitis, severe mesadenitis or another source of inflammation of the abdominal cavity, secondary changes in the appendix are found.

Swelling of the serous membrane is noted, its vessels are full-blooded, dilated, appearing as a network enveloping the process. Unlike primary inflammation, there is no rigidity (deep layers are not involved in the process), there is also no uniform hyperemia and compaction of the process. Thus, the visible secondary changes in the appendix are serositis and are the result of contact with an inflammatory effusion.

If there is no destructive inflammation in the appendix, a careful gentle revision of the abdominal organs is performed according to the following method.

Since the patient during the examination of the appendix is in the Trendelenburg position with a turn to the left side, it is first of all convenient to examine the ileocecal angle and the mesentery of this section of the intestine (Figure 12). In childhood, acute mesenteric lymphadenitis is a common cause of abdominal pain. In the mesentery of the ileocecal angle, in the mesentery of the small intestine, enlarged, edematous and hyperemic lymph nodes are revealed.

Figure 12. Position of the patient on the operating table when examining the ileocecal angle and appendix

Sometimes enlarged packages of lymph nodes resemble "bunch of grapes". Then the ileum is examined retrogradely at a distance of at least 60-80 cm from the ileocecal angle. At the same time, we use a palpator probe, examining the small intestine loop by loop. This allows you to identify the most diverse pathology: Meckel's diverticulum. angiomatosis. inflammatory diseases, neoplasms, etc.

Increasing the angle of the table in the Trendelenburg position. the organs of the small pelvis are examined, where in girls attention is paid to the uterus with appendages. First, the right appendage is examined, then, having set the lateral tilt of the table, but, maintaining the Trendelenburg position, the left appendage of the uterus is examined.

In the same position, the inner rings of the right and left inguinal canals are examined. Attention is drawn to their consistency, in addition, in boys in these areas, a testicle is sometimes found, indicating the presence of an abdominal form of cryptorchidism. Here, the seminiferous ducts and vessels of the testicles are examined.

Then the patient is given the Fowler position with a turn to the left side, in which the right lobe of the liver, gallbladder, hepatoduodenal ligament, pyloric stomach, duodenal bulb, contours of the lower pole of the right kidney are examined. Having eliminated the lateral turn of the table, but, maintaining the position of Fowler, they examine the left lobe of the liver, the round and falciform ligaments of the liver, the anterior wall of the stomach, the region of the lesser omentum and the gastrocolic ligament.

More difficult is the examination of the spleen, which is located high under the diaphragm and is covered by the omentum, and in young children it is also covered by the left lobe of the liver. The patient must be turned on the right side and raise the head end of the table. By displacing the omentum and intestinal loops with the manipulator, the spleen is brought into view. Its mobility depends on the severity of the ligamentous apparatus, however, it is usually possible to clearly examine the anterior end, the upper edge, the diaphragmatic surface and the region of the gate. Normally, the area of the left kidney is not visible. The revision of the upper and middle floors of the abdominal cavity is completed by examining the loops of the small intestine. Using the manipulator, one can systematically examine the entire intestine, its mesentery, the abdominal part of the aorta, the place of its bifurcation.

The sparing technique of laparoscopy, taking into account age-related characteristics in children, the use of modern pediatric models of laparoscopes allow a fundamentally new approach to the diagnosis of appendicitis. The use of puncture laparoscopy with questionable results of other research methods allows not only to accurately establish the presence or absence of inflammation in the appendix, but also, with the exclusion of the diagnosis of acute appendicitis, to conduct a sparing revision of the abdominal organs and in more than 1/3 of patients to identify the true cause of abdominal pain syndrome. Most often, nonspecific mesadenitis, gynecological diseases in girls, cryptogenic pelvioperitonitis, diseases of the biliary system and ileocecal angle are found.

Analyzing the obtained data of diagnostic laparoscopy, the following options for further tactics can be distinguished:

1. The study ends at the diagnostic stage, and no pathology is detected.

2. The study ends at the diagnostic stage, and the pathology of the abdominal organs is revealed, requiring conservative treatment.

3. As a result of the diagnostic stage of laparoscopic intervention, diseases of the abdominal organs are detected, the treatment of which can be performed using laparoscopic interventions.

4. At the diagnostic stage of laparoscopic intervention, diseases are detected that cannot be treated laparoscopically. These patients undergo laparotomy.

D.G. Krieger, A.V. Fedorov, P.K. Voskresensky, A.F. Dronov

Our expert is Sergey Bondarenko, surgeon, head of the urological department of the Volgograd Clinical Emergency Hospital.

Until recently, laparoscopic surgeries, which are performed through one or more tiny openings in the body, were fantastic. Something like the work of Filipino healers. Today, the indications for such operations are expanding day by day, and these interventions themselves are used not only in adults, but also in babies.

Small access - big benefit

Once upon a time, doctors used the following phrase: "A big surgeon - a big incision." But for a very long time this statement has lost its relevance. And all thanks to the introduction of the so-called minimally invasive (that is, gentle) surgical methods. After all, such operations (as doctors say, with little access) do not require large incisions, but are carried out through barely noticeable 3-4 punctures, which are made in the patient's anterior abdominal wall. Through these holes, miniature manipulator instruments are inserted, with which the surgeon performs the operation. An optical device with a light source is inserted through another puncture. Modern optics are connected to the monitor screen, which displays a detailed and comprehensive image of the internal organ. It can be viewed in detail, in addition, you can use the zoom function. Naturally, an excellent overview of the surgical field is very convenient for the surgeon, which improves the quality of his work.

The patient also benefits. Blood loss after laparoscopic operations is less, pain syndrome is lower, cosmetic result is better. Healing is faster, the rehabilitation period is easier and shorter. And there are far fewer complications. Of course, at first glance, such operations represent a complete benefit for both the doctor and the patient. But is it really that simple?

Fundamental question

When using laparoscopic techniques, especially when it comes to pediatric surgery, certain important principles must be observed. Chief among them is the principle of safety.

Passing optics and instruments into the patient's abdominal cavity is the most dangerous moment during the operation, since for the surgeon this process is always blind. Doctors have to be especially careful if there are anatomical abnormalities in a small patient - in this case, the risk of accidentally damaging important organs and tissues is higher. And even the data of available studies (ultrasound, MRI) do not always guarantee safety. During laparoscopy in adults, air is forced into the abdominal cavity - this is done in order to raise the abdominal wall and facilitate the introduction of instruments. But for children, this method, alas, cannot be used, since for them the pressure in the abdominal cavity exceeds 7-8 mm Hg. Art., harmful, it can have an extremely negative effect on the heart, respiratory system and brain of the child. Therefore, surgeons use various tricks when inserting instruments. For example, the “open port” technique is used - that is, before introducing the instruments, a small incision (5-6 mm) is made, through which all anatomical details of interest will be clearly visible. The second way to ensure safety is to pass the Veress needle, a device that is a hollow needle with a spring inside and a cannula. After penetration into the cavity (most often the abdominal cavity), the protective part of this instrument extends and covers the tip of the needle, thereby protecting the organs and tissues located there from damage.

Jewelry work

The second important principle that is applied today in pediatric laparoscopic surgery is the principle of low invasiveness. Doctors are sure that a small access must be combined with minimally invasive (that is, sparing) surgery, then this justifies the essence of the method itself and guarantees the absence of postoperative injuries in the patient. Therefore, doctors performing laparoscopic operations in children try to work very carefully and literally with jewelry. This principle also implies the most sparing treatment of neighboring healthy organs and tissues during intervention. With an open operation, this is almost impossible to achieve, since the eyes of the surgeon cannot give such a detailed image as a video camera is capable of showing the organ from all sides. In addition, hand manipulations are always more traumatic than work with fine tools. In this regard, laparoscopic surgery offers great advantages.

Dangerous repeat

Particular attention is required for repeated operations, the difficulty of which lies in the fact that the surgeon, starting to work, is not fully aware of the degree of severity of the cicatricial process that remains in a small patient after the previous intervention. After all, any healing in the body goes through the formation of scar tissue. However, the degree of scarring can vary. Therefore, the most difficult stage of such an operation is the allocation of an organ, since it is rather problematic to excise the surrounding scars, since important tissues are often included in them, for example, vessels that feed organs. Therefore, few surgeons, even in the world, decide on repeated laparoscopic operations, which are difficult not only technically, but also physically and emotionally. However, if we talk about urology, then the risk of losing a kidney with a second open operation is higher than with a second laparoscopic intervention. Therefore, doctors still go for these complex methods. And they often get great results.

For suturing, two 5 mm instruments are needed: a Szabo-Berci needle holder (located in the right hand) and an atraumatic grasper (in the left).

The most commonly used are conventional surgical sutures with curved needles (Vicryl, PDS 4 0, 5 0).

Usually the following types of seams are used:

1. Single sutures for suturing small peritoneal defects, suturing and ligation of structures such as the ureter, urachus, etc., cecopexies, etc. The scheme of imposing such a seam is shown in fig. 4 8;

Rice. 4 8. The scheme of applying a single seam.

Features of operational equipment

2. Continuous suture, mainly when closing sufficiently large peritoneal defects after extensive mobilization of the colon (during kidney operations), during laparoscopic orchidopexy, etc. (Fig. 4 9).

4.2. The final stages of the intervention

Revision of the abdominal cavity 1. Careful examination of the abdomen

nay cavity starting from the small pelvis to the upper floor of the abdominal cavity in order to detect previously unnoticed damage to the internal organs.

2. A revision to detect bleeding sites is carried out after a decrease in intra-abdominal pressure to 5 mm Hg. Art., while venous bleeding resumes, which is tamponed at a pressure in the abdominal cavity of about 15 mm Hg. Art.

Sanitation of the abdominal cavity

1. Complete removal of effusion from the abdominal cavity using endoscopic suction.

2. According to the indications - targeted dosed washing of the entire abdominal cavity or its individual sections with saline with the addition of heparin, followed by complete removal of the washing solution.

3. If necessary - dre-

Rice. 4 9. The scheme of imposing a continuous seam.

nirovanie abdominal cavity silicone drainage. handset

aimingly injected into the desired section of the abdominal cavity under the control of a laparoscope. The indication for drainage in our observations is most often the presence of peritonitis. After "clean" elective surgical interventions, drainage of the abdominal cavity is usually not performed.

Laparoscopic surgery. a common part

Trocar removal

1. First of all, 12 and 11 mm trocars are removed necessarily under endoscopic control of their location in order to avoid possible bleeding (when using trocars with a conical stylet shape, this practically does not happen) or entry of the omentum strand into the peritoneal defect (this most often occurs when the trocar removed after complete removal of the pneumoperitoneum and the appearance of tension in the muscles of the anterior abdominal wall after the end of the action of muscle relaxants).

2. Layer-by-layer suturing of a 11 mm wound is also advisable to carry out until the pneumoperitoneum is completely removed and under the control of optics. The wound is closed in layers with obligatory suturing of the fascia (vicryl 4 0) and skin.

3. After removal of the pneumoperitoneum, 5 mm trocars are removed, and the skin wounds in their places of standing are closed with adhesive tapes or one suture is applied.

Literature

1. Emelyanov S., Matveev N.L., Fedenko V.V., Evdoshenko V.V. Manual suture in laparoscopic surgery // Endoscope, hir. - 1995. - No. 2-3. -

pp. 55 62.

2. Box N.M.A., Georgeson K.E., Najmaldin A., Valla J.S.Endoscopic Surgery in Children. Berlin; Heidelberg: Springer Verlag, 1999. P. 14 35.

3. Nathanson L.K., Nethanson P.D., Cuscheri A.Safety of Vessel ligatuon in laparoscopic surgery // Endoscopy. - 2001. - Vol. 23. - P. 206-209.

4. Sabo Z, Hunter J. G., Litwin D. T., Berci G. Training for Advanced Laparoscopic Surgical Skills. - San Francisco: Surgical Universal Medical Press, 1994. - P. 118-

5. Zucker K.A., Bailey R.W., Graham L. et al.Training for laparoscopic surgery // World J. Surg. 1993 Vol. 17. No. 1. P. 3 7.

CHAPTER 5

Laparoscopic surgical techniques place great demands on adequate anesthetic support and on intraoperative monitoring. Despite the accumulation of significant experience in providing adequate patient protection during surgery, during laparoscopic interventions, the anesthetic risk still remains significantly higher than the surgical risk.

In the middle of the 20th century, doctors paid serious attention to changes in the hemodynamic and gas exchange systems caused by the imposition of pneumoperitoneum. Laparoscopy proved to be far from a safe procedure. The performance of these operations is associated with the occurrence of small and large surgical and anesthetic complications, for the prevention and relief of which it is necessary to clearly understand the pathophysiological mechanisms of their development.

5.1. Influence of laparoscopic manipulations on ventilation and gas exchange

Currently, the vast majority of anesthesiologists note the danger of laparoscopic manipulations and operations against the background of spontaneous breathing, since the imposition of pneumoperitoneum limits the mobility of the diaphragm.

The imposition of pneumoperitoneum causes the following changes in the work of the child's cardiovascular system:

1. The extensibility of the lung tissue decreases.

2. There are atelectasis of the lungs.

3. The functional residual capacity of the lungs decreases, ventilation-perfusion disorders appear and progress, hypoventilation, hypercapnia and respiratory acidosis develop.

With an increase in the area of pulmonary shunting (i.e., areas of perfumy jnpyeMoft, but not ventilated lung tissue), hypoxemia increases, which is not corrected by an increase in the percentage of oxygen in the inhaled mixture. This is reflected in the decrease in the value of such indicators as partial

arterial oxygen pressure (pa 02 ) and oxygen saturation of hemoglobin (S02 ). As a rule, oxygen deficiency occurs in patients with initial myocardial dysfunction and/or hypovolemia and is associated with a combined effect of reduced pulmonary compliance and reduced cardiac output (CO).

That is why during laparoscopic procedures there is a need for tracheal intubation, mechanical ventilation and total muscle relaxation. However, even against the background of mechanical ventilation in the normoventilation mode with a complete muscle block, alveolar atelectasis occurs, a decrease in lung compliance

Laparoscopic surgery. a common part

tissue, a decrease in FOB, an increase in peak pressure and plateau pressure in the airways (by an average of 40%). These changes are more pronounced during laparoscopic operations, which are performed in the Trendelenburg position and require maintaining high pressure in the abdominal cavity (5-14 mm Hg). Respiratory system disorders are much less significant in laparoscopic cholecystectomy, during which the reverse Trendelenburg position is used and the pressure in the abdominal cavity does not exceed 10-14 mm Hg. Art.

Hypercapnia during laparoscopic manipulations is caused not only by a change in ventilation parameters as a result of an increase in intra-abdominal pressure, but also by the absorption of carbon dioxide (CO2) from the abdominal cavity. CO2 is highly soluble in blood, quickly diffuses through the peritoneum.

Factors determining the intensity of CO2 entry into the blood:

1. Good solubility C0 2 in the blood, rapid diffusion through the peritoneum.

2. pressure level in the abdominal cavity.

3. Duration of surgery.

4. The area of the suction surface (peritoneum).

Since the last parameter per unit of body weight in children is 2 times higher than in adults, in children we can expect a more rapid and massive intake of CO2 into the blood. In adults, hypercapnia and respiratory acidosis usually develop no earlier than 15 minutes after the start of CO2 insufflation into the abdominal cavity, while in children these changes occur immediately after pneumoperitoneum is applied.

The absorption of CO2 into the blood during the application of pneumoperitoneum using CO2 is reflected in an increase in the concentration of CO2 at the end of expiration (ETC02), partial pressure of CO2 in arterial blood (pa CO2), the level of production of CO2 by the lungs (VC02), in the development of acidosis. In some patients, there is an increase in the difference between pa CO2 and ETC02; at the same time, the occurrence of uncontrolled acidosis is also observed. The explanation for this fact is found in the presence of reduced CO and as a consequence of this increased venous shunting in the lungs and reduced splanchnic blood flow.

Some authors note an increased release of CO2 by the lungs even after removal of the pneumoperitoneum. Values of VC02, ETC02, Pa CO2 exceeding the normal level can be observed during the first 30-180 minutes of the postoperative period. This is due to the fact that 20-40% of the absorbed CO2 remains in the patient's body after removal of CO2 from the abdominal cavity.

Possible ways to prevent and correct emerging violations of ventilation and gas exchange:

1. The use of endotracheal anesthesia against the background of total muscle relaxation.

2. IVL in hyperventilation mode (on 30-35% more than normal). In this case, mechanical ventilation can continue after the end of the surgical intervention until the normalization of ETC02 and RA CO2.

3. Using CPAP (Continuous Positive Airway Pressure Expiratory Pressure) modes.

Features of anesthesia during laparoscopic operations

It must be remembered, however, that in cases where the progression of acidosis is partially associated with a decrease in peripheral perfusion, hyperventilation may not give a pronounced compensatory effect, since it itself can cause a decrease in CO. Probably, the most rational variant of mechanical ventilation is high-frequency injection mechanical ventilation, which reduces the negative effect of carboxyperitoneum on central hemodynamics, gas exchange and respiratory function.

In the event of progressive hypercapnia, acidosis, hypoxemia against the background of hyperventilation, the following measures are taken sequentially until the desired effect is achieved:

1. Ventilation 100% Og

2. Maintenance of CO and peripheral perfusion by various methods.

3. Return the patient to a horizontal position.

4. Removal of CO 2 from the abdominal cavity.

5. Transition from laparoscopy to laparotomy.

5.2. Influence of laparoscopic manipulations on hemodynamics

An increase in pressure in the abdominal cavity during the application of pneumoperitoneum can affect the CO value in two ways: on the one hand, it contributes to the “squeezing out” of blood from the abdominal organs and the inferior vena cava to the heart, on the other hand, to the accumulation of blood in the lower extremities, followed by a regular decrease in venous return. The prevalence of this or that effect depends on many factors, in particular on the magnitude of intra-abdominal pressure. It has been noted that the position opposite to the Trendelenburg position contributes to the development of more serious hemodynamic changes, since in this case, the influence of high intra-abdominal pressure is accompanied by a gravitational effect on the return of blood to the heart with the regular development of venous congestion in the periphery and a pronounced decrease in preload for the left ventricle , and SV. The Trendelenburg position, on the contrary, is favorable for maintaining proper CO values, as it contributes to the normalization of venous return and, thereby, an increase in the central blood volume under conditions of pneumoperitocheum.

The imposition of pneumoperitoneum contributes to an increase in peripheral vascular resistance due to compression from the outside of the arterioles, in particular the splanchnic basin. Increased to a certain level pressure in the abdominal cavity can cause compression of the aorta. The renal blood flow also suffers to a large extent.

Along with the above factors, hypoxemia, hypercapnia and respiratory acidosis have a certain effect on hemodynamics. On the one hand, CO2, acting directly on the vascular wall, causes vasodilation, which compensates for the increase in peripheral vascular resistance. On the other hand, both hypoxemia and a decrease in blood pH stimulate the sympathetic-adrenal system, thereby

Laparoscopic surgery. a common part

strong release of catecholamines. All this can lead to an increase in CO, peripheral vascular resistance, blood pressure, the development of tachycardia, cardiac arrhythmias, and even cardiac arrest.

In the event of severe disorders in the circulatory system, all experts recommend the removal of pneumoperitoneum and the transition to laparotomy.

An increase in intra-abdominal pressure during laparoscopic operations creates the prerequisites for the occurrence of gastroesophageal regurgitation followed by aspiration of acidic gastric contents. The risk of developing this complication is especially high in patients with gastroparesis, hiatal hernia, obesity, gastric pyloric obstruction, outpatients and children (due to the lower pH of gastric contents and a higher ratio of the latter to body weight). Possibly, the high probability of occurrence of gastroesophageal reflux followed by aspiration limits the use of the laryngeal mask, which is currently widely used in laparoscopic surgery.

The following preventive measures for regurgitation are suggested:

1. Preoperative use of metoclopramide (10 mg orally or intravenously)

rivenno), which increases the tone of the cardiac sphincter of the stomach, and H2 torus block, which reduces the acidity of gastric contents.

2. Preoperative gastric lavage followed by the installation of a gastric tube (after tracheal intubation); the presence of a probe in the stomach, in addition, prevents injury to the stomach when applying pneumoperitoneum and improves the visualization of the surgical field for surgeons.

3. Tracheal intubation is mandatory, and it is desirable that the endotracheal tube be cuffed.

One of the most dangerous, fatal complications of paw-

roscopic surgery is gas embolism. CO2 is rapidly absorbed through the peritoneum and absorbed into the splanchnic vessels. Since it is highly soluble in the blood, the entry of a small amount of it into the blood

current passes without visible complications. Massive absorption of CO2 leads to gas embolism.

Prerequisites for the development of CO2 embolism:

1. Reduced splanchnic blood flow, which is observed with high intra-abdominal pressure.

2. The presence of gaping venous vessels as a result of surgical trauma. Clinical signs of gas embolism are a significant decrease in blood pressure, cardiac dysrhythmias, the appearance of new heart murmurs, cyanosis,

pulmonary edema, increased ETC02 level, i.e. there is a picture of the development of right ventricular heart failure against the background of pulmonary hypertension and hypoxemia. Early diagnosis of this complication requires careful monitoring of ECG, BP, heart sounds, and ETC02.

When diagnosing a gas embolism, it must be remembered that collapse can also be observed with bleeding, pulmonary embolism, myocardial infarction, pneumothorax, pneumomediastinum, high intra-abdominal pressure, pronounced vagal reflexes.

Features of anesthesia during laparoscopic operations

5.3. Choice of anesthetic aid

Anesthesiologists working with children point out the need for careful history taking in patients who are planned for laparoscopic intervention. An absolute contraindication to such operations is fibrous dysplasia of the lungs.

Contraindications for emergency laparoscopy in children:

1. Coma.

2. Decompensated heart failure.

3. Decompensated respiratory failure.

4. Severe bleeding disorders (Quick test value below 30%, a significant increase in bleeding time).

5. Borderline conditions in which laparoscopy can cause the above complications.

The use of various local anesthesia techniques with preserved spontaneous breathing in adults is still under discussion. In pediatric practice, this method is unacceptable, since it is impossible and inappropriate to perform epidural anesthesia or bilateral intercostal block in a child who is conscious. The use of epidural anesthesia as part of combined anesthesia, despite some advantages, is often accompanied by hemodynamic disorders, does not prevent irritation of the phrenic nerve (C1N-Cv), nausea and vomiting in the postoperative period.

Benefits of general endotracheal anesthesia:

1. Improving the working conditions of surgeons with total muscle relaxation and the presence of a gastric tube. Deep sedation of the patient makes it easy to give him the desired position.

2. Tracheal intubation ensures free airway patency and prevents aspiration (when the cuff of the endotracheal tube is inflated).

3. Cardiopulmonary changes caused by CO injection 2 into the abdominal cavity can be eliminated by maintaining minute ventilation, oxygenation and circulating blood volume (CBV) at the proper level.

For general endotracheal anesthesia, different specialists offer a wide variety of schemes, as a rule, not much different from the methods of general anesthesia in conventional surgical interventions. The accumulated experience and studies of the features of pain relief in laparoscopic operations in children allow us to formulate the following practical recommendations for the implementation of anesthesia in a pediatric clinic.

Premedication. For the purpose of premedication, children are injected intramuscularly with 0.1% atropine at the rate of 0.01 mg / kg, 0.5% Relanium 0.35 mg / kg for children aged 1-3 years, 0.3 mg / kg for children aged 4- 8 years and 0.2-0.3 mg/kg for older patients. Differentiation is due to the weaker sensitivity of patients of the younger age group to ataractics. If there is a history of indications of allergies, premedication includes diphenhydramine or suprastin at a dose of 0.3-0.5 mg / kg.

Laparoscopic surgery. a common part

The choice of anesthetic remains with the anesthesiologist. Traditionally, inhalation anesthesia with the use of halothane (halothane, narcotan) is widely used in children's clinics. This halogenated anesthetic is so popular due to the rapid induction into general anesthesia and rapid awakening, providing sufficient depth and control of anesthesia. Fluorotan is used according to the traditional scheme, adhering to the minimum sufficient concentrations of anesthetic in the inhaled mixture. The use of a combination with nitrous oxide (N02) is permissible only at the stage of induction of anesthesia. In the future, taking into account the ability of N2 0 to actively accumulate in the physiological and pathological cavities of the body and its potentially hypoxic effect, ventilation should be carried out at 100% Og.

The pronounced cardiodepressive effect of halothane is manifested by a decrease in CO, a slowdown in atrioventricular conduction, and a decrease in blood pressure. Diprivan and midazolam were selected from modern and available drugs for anesthesia as alternative drugs to halothane, which do not give such pronounced side effects.

Midazolam, synthesized in 1976, is one of the numerous representatives of the benzodiazepine group. It has the ability to quickly bind to GABAergic and benzodiazepine receptors. As a result, a few (5-10) minutes after intramuscular injection, a rapid psychomotor inhibition of the patient develops, and at the end of the injection, he quickly returns to normal activity. It should be noted pronounced anxiolytic, sedative and anticonvulsant effects and low allergenicity inherent in midazolam,

a also the fact that when using it, there is a significant antero

and retrograde amnesia. This drug compares favorably with ftorotane with minimal effect on the cardiovascular and respiratory systems. Induction anesthesia is carried out by intravenous administration of midazolam.(0.3-0.4 mg/kg for children 1-3 years old, 0.2-0.25 mg/kg for children 4-8 years old, 0.1-0.15 mg/kg for children 9-14 years old) combinations with intravenous fractional administration of fentanyl and muscle relaxants. The maintenance period is a constant infusion of midazolam 0.3-0.4 mg / kg per hour in combination with intravenous fractional administration of fentanyl and muscle relaxants. The introduction of midazolam is stopped 8-12 minutes before the end of anesthesia.

Diprivan (propofol) is similar in mechanism of action to benzodiazepine drugs. Its advantages include:

1. Rapid onset of hypnotic effect.

2. High metabolic rate.

3. Soft recovery period.

These properties ensure that Dipriva is increasingly used in clinical practice. Like most anesthetics, Diprivan affects the respiratory function, causing spontaneous respiratory depression at the stage of induction of anesthesia. The drug can cause hypotension due to a decrease in total peripheral resistance. The introduction of diprivan in a clinically effective dose is usually accompanied by a decrease in heart rate, which is explained by the vagotonic effect of the drug and

Features of anesthesia during laparoscopic operations

feasted by the preemptive administration of atropine or metacin. Induction anesthesia is carried out by intravenous administration of 2.5 mg/kg Diprivan. The maintenance period is a constant infusion of diprivan 8-12 mg / kg per hour in combination with the fractional administration of fentanyl and muscle relaxants. The introduction of Diprivan stops 6-10 minutes before the end of anesthesia.

5.4. Artificial lung ventilation, infusion therapy

and monitoring

IVL. Ensuring adequate gas exchange is possible only when using mechanical ventilation in hyperventilation mode. In the ventilation mode with intermittent positive pressure, the tidal volume is calculated from the Radford nomogram. The respiratory rate corresponds to the age norm. Inspiratory pressure is set for each patient depending on age and individual characteristics in the range of 14-22 mbar. Expiratory pressure 0. After the imposition of pneumoperitoneum, the minute volume of ventilation increases by 30-35%, and due to an increase in both tidal volume and respiratory rate.

All patients after tracheal intubation are recommended to install the probe into the stomach and catheterize the bladder. This not only prevents dangerous complications (aspiration of gastric contents, perforation of hollow organs with a trocar), but also improves the visualization of the surgical field by surgeons.

infusion therapy. The use of the forced infusion load regimen makes it possible to prevent the development of hemodynamic disorders caused by the state of relative hypovolemia provoked by pneumoperitoneum. Intravenous infusion therapy can be carried out with crystalloid solutions (eg Inosteril from Frisenius). If it is necessary to correct intraoperative blood loss, infusion transfusion therapy is performed. In these cases, one-group fresh frozen plasma, plasma protectors (reopoliglyukin, polyglucin), polyionic crystalloid solutions, 5-10% glucose solutions are used. If the Hb value is less than 100 g/l and SH is less than 30%, transfusion of a single-group erythrocyte mass is recommended.

Studies have shown that, regardless of the chosen anesthetic, standard infusion therapy (8-10 ml/kg per hour for elective operations and 12-14 ml/kg per hour for emergency ones) does not prevent the development of a state of relative hypovolemia caused by the redistribution of blood to the periphery with a decrease in venous return, a fall in CO and stroke volume after the imposition of pneumoperitoneum. To correct this condition, the following scheme of infusion therapy is used. From the moment of catheterization of a peripheral vein in the operating room until the moment of imposition of pneumoperitoneum, the infusion rate should be 10-15 ml / kg per hour for elective operations and 15-28 ml / kg per hour for emergency ones. After insufflation of gas into the abdominal cavity, it is advisable to reduce the infusion rate to 10-12 ml/kg per hour.

Clinic of pediatric surgery "MedicaMente" in Korolev (Moscow region) performs surgical treatment of inguinal hernia in children by laparoscopy (through punctures).

Laparoscopy of an inguinal hernia: how is the operation performed?

Today, pediatric surgery increasingly uses endoscopic methods using a miniature video camera and microsurgical instruments. Parents are interested in how such operations are carried out, since in the professional hands of a surgeon, the technique allows you to achieve an effective treatment result with a good cosmetic effect.

Laparoscopy of an inguinal hernia in children is performed exclusively under general anesthesia. The duration of the operation is on average 40-50 minutes. With the help of a special laparoscope device, through minor punctures of the abdominal wall, the surgeon performs a full examination of the abdominal cavity, reveals the pathological process and takes the necessary measures to eliminate it.

Pediatric surgeons at MedicaMente have accumulated significant practical experience in the use of laparoscopic techniques, including in the treatment of inguinal hernia in children. The operating unit of our clinic is equipped with all the necessary medical equipment for laparoscopic operations, including the latest endoscopic equipment designed specifically for children.

The photo below shows the results of the treatment of an inguinal hernia in a girl by laparoscopy.

Inguinal hernia in a girl. Laparoscopy

In the photo: an inguinal hernia in a girl on the left. Laparoscopic surgery. Sutures after laparoscopy of an inguinal hernia in a child (instrument width 11 mm)

Open surgery or laparoscopy for inguinal hernia in a child?

Open treatment:

FOR: fast 30-40 minutes, apparatus-mask anesthesia,no pain in the abdomen.
CONS: scar up to 2-5 cm (depending on the surgeon). A pediatric surgeon at the MedicaMente clinic in Korolyov applies an intradermal suture that does not need to be removed. The child no longer experiences unpleasant procedures. After the operation, an inconspicuous scar is only 2 cm long.

Laparoscopy:

FOR: time about 45 minutes, no sutures with 3 mm instruments (there are 6 mm more), scar: from three punctures of 3 mm each. Possibility of carrying out hernia repair from two sides at once.
CONS: the child is under endotracheal anesthesia, periodically there is pain in the abdomen, most often the high cost of surgical treatment (even in state structures under the CHI policy).

The decision on the choice of the method of the operation is made by a pediatric surgeon after a thorough examination of the patient, an assessment of his concomitant diseases and a conversation with his parents.

Laparoscopy of an inguinal hernia: the price of the operation

Below are the prices for laparoscopic treatment of inguinal hernia in children. You can get acquainted with the prices for inguinal hernia surgery in adults.

* Price includes:

inpatient accommodation 1 day (double room with toilet, TV, cartoon channel)
anesthetic aid: anesthetic Sevoran, execution of local blockade - Naropin
surgery, all necessary operating consumables
the imposition of an intradermal cosmetic suture - the suture does not need to be removed
constant telephone communication with the attending physician
examination on any day in the clinic within 30 days after the operation

The cost of the operation does not include:preoperative examination (tests can be taken at the polyclinic at the place of residence, in our medical center - the “For Operation” panel or in any commercial laboratory)

** Not a public offer agreement. Specify the cost of services on the day of treatment.