Laparoscopic Trocar PlacementLaparoscopic Trocar PlacementLaparoscopic Trocar Placementin Pediatric Urology:

Working in Small Spaces

Laparoscopic Trocar Placementin Pediatric Urology:

Working in Small SpacesWorking in Small SpacesWorking in Small Spaces

Christina Kim MD, FAAPConnecticut Children’s Medical CenterConnecticut Children s Medical Center

Assistant Professor of UrologyHartford, CT

USAUSA

OverviewOverviewOverviewOverview

Todays Goal : Give you mental and physicalTodays Goal : Give you mental and physical maps for trocar placement during pediatric laparoscopic procedures

• Trocars in Pediatric

g p p p p

Laparoscopy• 5 mm most common• 3 mm often3 mm often• 10-12 mm rarely

• Need for a Stapleri.e teenage nephrectomy

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Lecture OverviewLecture OverviewLecture OverviewLecture Overview• Accessing Pediatric Abdomensg• Common Pediatric Urologic procedures

• Testicular• Orchidopexy

• Renal• Nephrectomy & Partial Nephrectomy• Pyeloplasty

• Less Common ProceduresRPLND• RPLND

• Ureteral reconstruction• Reimplant

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• Lap Assisted Augment Procedures

PositioningPositioninggg

• Use of Padding isUse of Padding is unnecessary and risky

• Increases the potential for trocar injuriesj• Lifts critical structures in

harms wayV l• Vessels

• Bowel

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Insufflation & Access - AdultInsufflation & Access - Adult

• Open Hasson TechniqueOpen Hasson Technique

• Veress insufflation with blind percutaneousVeress insufflation with blind percutaneous Access

• Percutaneous under direct vision• Endopath-Xcel (Ethicon)

5 10 11 12• 5,10,11,12 mm • Visiport Plus (US Surgical)

• 12 mm

5Pediatric Abdomen is Too Compliant for this ….!

Extreme Compliance – Mouse ModelExtreme Compliance – Mouse Modelpp

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Children: Abdominal Wall ComplianceChildren: Abdominal Wall Compliancepp

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Be Aware of Epigastric and Iliac Vesselsp g

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Access TipsAccess Tipspp

• Sharp entry into abdomen• Sharp entry into abdomen• Use #15 blade

S id• Snap to guide• #11 blade through peritoneum• Blunt tip trocar

• Trocar with blades primarily on teenagers• Use laparoscopic instruments to counter

anterior abdominal pressure

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p

Video: Working port accessVideo: Working port accessg pg p

10Click here to view video

Insufflation & Access in ChildrenInsufflation & Access in Children

• Open Access in children is• Open Access in children is safest and preferred!

Hasson Techniq e• Hasson Technique

• Bailez Technique

• Radially dilating trocar Step System-US Surgical

• 2/3mm- 12mm•

• Visualize

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• Insufflate with warmed CO2 (Schulam PG et al. Urology 1999)

Insufflation & AccessInsufflation & Access

• Insufflation rate based on age or weight• < 1 yr: 0.3 l/min• > 1 yr: 0 5 l/min> 1 yr: 0.5 l/min• > 5 yr: 1 l/min• >10 yr: 2 l/min

• Be wary rare events• Co2 Embolus2

• Rt Heart Failure• Pneumothorax

• Acute drop in SpO2

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Acute drop in SpO2

(Waterman et al. J Urol 2004)

Trocarless Laparoscopy?Trocarless Laparoscopy?

• Limited Access with S b I i iStab Incisions

(Hanson GR et al. J Urol 2004)

• 53 procedures without• 53 procedures without complications• #11 scalpel stab• 3 mm instruments

• No reported difficulty• Loss of pneumo• Instrument exchange

• Average of $ 277 0013

• Average of $ 277.00 per case

Needlescopic Orchiopexy with 2mm I t t

Needlescopic Orchiopexy with 2mm I t tInstrumentsInstruments

• 10 Patients (8 mo-37 yrs)• 8 Orchiopexy

• 100% success100% success• 2 Orchiectomy• 2 Diagnostic

• Avg time: 110 min

• Excellent Cosmetic Result

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(Gill et al. J Ped Surg 2000)

Laparoscopic OrchiopexyLaparoscopic Orchiopexyp p p yp p p y

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Laparoscopic OrchiopexyLaparoscopic Orchiopexyp p p yp p p y

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Laparoscopic Orchiopexy: ViewLaparoscopic Orchiopexy: Viewp p p yp p p y

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First Stage Fowlers StephensFirst Stage Fowlers Stephensg pg p

• Can attempt with one working port and• Can attempt with one working port and camera port

• Two working ports • Will reuse at the time of 2nd stage

• Place clip as cephalad as possible

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Video: 1st Stage ClipVideo: 1st Stage Clipg pg p

19Click here to view video

NeocanalNeocanal

• Subdartos pouch in scrotum• Subdartos pouch in scrotum• 3 mm instrument from abdomen to scrotum

• Lateral or medial to inferior epigastrics• Identify straight path

• Step trocar back into abdomen• 10 or 12 mm

• 5 mm grasper to pull testis through

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Scrotal Trocar – 10mm or 12mmScrotal Trocar – 10mm or 12mm

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BA

DC

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NeocanalNeocanal

Obliteral umbilicalInferior epigastric

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Video: Neocanal CreationVideo: Neocanal Creation

24Click here to view video

Laparoscopic Renal SurgeryLaparoscopic Renal Surgeryp p g yp p g y

• Place patient close to edge of the bed• Avoid constriction of instruments hitting bedg• Prep to provide flank access if needed

• Triangulate relative to kidney

• Accessory port optional

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Patient PlacementPatient Placement

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Flank incision

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Port PlacementPort Placement

• Camera Port• Camera Port• Infraumbilical

• Working Ports• Between xyphoid and umbilicus• Lateral inferior epigastric

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Basic Renal Port PlacementBasic Renal Port Placement

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(Chen et al. Urol Clin N America 1998)

Lateral inferiorTo epigastrics

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Accessory PortAccessory Portyy

• Place between either working port and umbilicus• Place between either working port and umbilicus

• Careful with instrument passage when patient• Careful with instrument passage when patient rotated

• Multiple uses• Retraction• Retraction• Suction• Fast suture passage

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p g

Accessory port

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Accessory port

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Alternative Port PlacementAlternative Port Placement

• Camera and working ports all in midline• Camera and working ports all in midline• Good for smaller patients

• Keep one working port 5mm• Clip applier• Suction/irrigationg

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Simultaneous R Nephrectomy d L P l l t

Simultaneous R Nephrectomy d L P l l tand L Pyeloplastyand L Pyeloplasty

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Hitch StitchHitch Stitch

P l t• Prolene suture• Place in pelvis a/o

ureterureter• Carter Thomason

device• Direct passage out

abdomen• Fixation to anterior

abdomenCl S I l t M di l Ed P i i MN

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CloseSure, Inlet Medical, Eden Prairie, MN

Video: Hitch StitchVideo: Hitch Stitch

39Click here to view video

Laparoscopic Tx of VURLaparoscopic Tx of VURp pp p

• Transvesical vs ExtravesicalTransvesical vs Extravesical• Transvesical: “Percutaneous”

• Endoscopic trigonoplastyEndoscopic trigonoplastyMedial advancement: Gil-Vernet (1984)

• Trans-trigonal reimplantRoboticPure laparoscopic

• Glenn-AndersonGlenn Anderson

• Extravesical

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Extravesical• Lich-Gregoir

Laparoscopic-Endoscopic TrigonoplastyTh P t

Laparoscopic-Endoscopic TrigonoplastyTh P tThe PastThe Past

• First described as a percutaneous technique• Okamura K et al. J Urol 1996;

156: 198-200156: 198 200 • Cartwright PC et al. J Urol 1996;

156: 661-4

• Medial Advancement of UO• Medial Advancement of UO• Longitudinal incision intertrigonal

ridge … detrusor intact

• Heineke-Mikulicz closure

• Problem• Poor results: 59% 65%

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• Poor results: 59%-65%• Complication of “Trigonal

Splitting”

Laparoscopic Cohen Cross Trigonal Ureteral Reimplantation Laparoscopic Cohen Cross Trigonal Ureteral Reimplantation

• Gill IS et al. J Urol 2001• 2 Children (10,11) & 1 Adult• OR Time 2.5-4.5 hours• Prolonged JJ stenting and• Prolonged JJ stenting and

bladder cath• 66% Success rate

• 2005: Yeung CK et al. J Endourol 2005• 16 Pats, Avg Age: 4.1 yrs• Avg OR Time: 136 min• 96% success rate

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• 96% success rate

• Kutikov et al J Urol Nov 2006• Kutikov et al. J Urol Nov 2006• N=32, Avg age 5 years (14 mo – 11 years)

• Success rates:• 93% for VUR• 80% for Primary Obstructing Megaureter

• Highest complication rate in younger childrenHighest complication rate in younger children• smaller bladder capacity, < 120cc

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Laparoscopic Reimplantation Trocar Configuration

Laparoscopic Reimplantation Trocar ConfigurationTrocar ConfigurationTrocar Configuration

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Robotic Cohen Cross Trigonal Ureteral Reimplantation for VUR

Robotic Cohen Cross Trigonal Ureteral Reimplantation for VURReimplantation for VURReimplantation for VUR

• Peters CA & Woo R J• Peters CA & Woo R. J Endourol 20056 children (5-15 yrs)( y )• Hospital stay 2-4 days• 83% success rate

• Advantage ?

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Robotic Extravesical ReimplantRobotic Extravesical Reimplantpp

12mm

5mm

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Laparoscopic RPLNDLaparoscopic RPLNDp pp p

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RPLND: Trocar ConfigurationRPLND: Trocar Configurationgg

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RPLND in 10 yr old with 5 mm PortsRPLND in 10 yr old with 5 mm PortsRPLND in 10 yr old with 5 mm PortsRPLND in 10 yr old with 5 mm Ports

• 5 mm Instruments• Monopolar

scissors• Clip applier

• 5mm Flexible Scope HolderScope Holder• Thompson

Surgical Instruments Inc

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Instruments, Inc

Bladder AugmentationBladder Augmentationgg

• Laparoscopic Assisted• Laparoscopic Assisted

• Purely Laparoscopic• 12 mm port umbilicus• 5mm and 12 mm ports in upper quadrants in

midaxillary line

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Laparoscopic Assisted AugmentationLaparoscopic Assisted Augmentationp p gp p g

Video and images to follow, please check back for updates.

51(Hedican et al. J of Urol 1999)

Laparoscopic AugmentationLaparoscopic Augmentationp p gp p g

Video and images to follow, please check back for updates.

52Lorenzo et al. Urology 2007

Augmentation: Nephrectomy with Ureteral Augment, Appendicovesicostomy

Augmentation: Nephrectomy with Ureteral Augment, AppendicovesicostomyAppendicovesicostomyAppendicovesicostomy

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Supplemental LaparoscopicE i t

Supplemental LaparoscopicE i tEquipmentEquipment

• EndostitchL ti• Laparotie

• Size is primary limitation• 10mm port minimum• Large suture material needed

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ConclusionsConclusions

• The Pediatric Abdomen in compliant• The Pediatric Abdomen in compliant• Avoid positioning errors

U• Use open access

• Utilize mental and physical trocar maps• Plan for assistance as needed• Anticipate challenges for the rare cases

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ConclusionsConclusions

• Step Trocar• Step Trocar• Frequently used

E i• Easy to size up• Minimal leakage

• Accessory ports• Can save time and minimize frustration early

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