Dr (Colonel) Rakesh Handa
MS, MCh, DNB, FAIS,
Senior Consultant Pediatric and Laparoscopic Surgeon,
Max Healthcare and Bhatia Endosurgery Institute,
Formerly at Army Hospital (Research and Referral),
Delhi Cantt.
Email: drrakeshhanda@gmail.com
Phone: 9810125022
 

Alongwith the runaway success of laparoscopy in adults when it rapidly became the surgical approach of choice, pediatric laparoscopy took tentative steps in the form of laparoscopy by Cortesi et al in 1976, to localize an impalpable testis. The delay, as compared to adult laparocopy was due to the non-availability of smaller laparoscopic instruments suitable for use in children. The trickle of reports in the 80’s, when its use was restricted to localization of the testis, was soon followed by a torrent, when laparoscopy was used for mobilization of the testis and its subsequent scrotal placement.

Laparoscopy in children, having traveled the road of innovation and experience, has come of age. With advances in pediatric anesthesia, it is a safe and routinely performed surgical procedure. It is regularly performed in neonates also where it is of immense value in cases of inguinal hernia to determine a contralateral patent processus vaginalis, to help determine presence of mullerian duct structures in cases of ambiguous genitalia for gender assignment and in cases of suspected volvulus with malrotation. It is now being used for repair of a tracheo-esophageal fistula and duodenal atresia, pyloromyotomy for hypertrophic pyloric stenosis, management of ovarian cysts and diagnosis of biliary atresia. In critically ill neonates with necrotizing enterocolitis, lack of specific indications for surgical intervention is not uncommon and laparoscopy is an excellent tool in the hands of pediatric surgeons (Table 1).

       Table 1: Indications for laparoscopy in neonates

Diagnosis of disease		Repair of anomaly
Presence of contralateral patent processus vaginalis		Herniotomy
Biliary atresia		Tracheo-esophageal fistula
Examination of internal organs in ambiguous genitalia		Duodenal atresia
Necrotising enterocolitis		Pyloromyotomy for hypertrophic pyloric stenosis
		Suspected volvulus with malrotation
		Ovarian cysts

The indications for laparoscopy in the pediatric age group are continuously expanding. The spectrum of conditions in which it is routinely and safely performed are listed in Table 2.

        Table 2: Indications for pediatric laparoscopy

Organ		Disease/Indication		Procedure
Stomach		- Enteral feeding - Idiopathic pyloric   stenosis - Gastro-esophageal   reflux		- Gastrostomy - Ramstedt’s   pyloromyotomy - Fundoplication
Peritoneal cavity		- Adhesive intestinal   obstruction - Recurrent pain   abdomen - Blunt injury abdomen - Intussusception - Peritoneal dialysis - Acute abdomen - Acute appendicitis - GI bleeding of   obscure origin - Necrotising   enterocolitis - CSF pseudocyst   abdomen - Pediatric varicocele		- Adhesiolysis - Diagnostic   laparoscopy - Diagnostic   laparoscopy - Reduction - Placement of PD   catheters - Diagnostic   laparosopy - Appendectomy - Localisation of   bleeding - Diagnostic   laparoscopy - Decompression of   cyst and   placement of shunt   catheter - Laparoscopic   Palomo’s
Solid organs		- Hodgkin's disease - Hepatic and hydatid   cysts - Cholelithiasis - Hematological   disorders and splenic   cysts - Neonatal   hyperbilirubinemia   and biliary atresia		- Liver biopsy &   staging - Excision - Cholecystectomy - Splenectomy - Diagnostic   laparoscopy
Retro- peritoneum		- Neuroblastoma - Dysplastic kidney &   ESRD - Duplicate collecting   system in ectopic   ureterocele - Hydronephrosis - Vesico-ureteric   reflux		- Adrenalectomy - Nephrectomy - Heminephrectomy - Anderson Hynes   pyeloplasty - Extra-vesical Lich   Gregoir
Adnexal organs		- Ovarian cysts and   tumours - Torsion of adnexa - Sexual ambiguity - Chronic pelvic pain - Radiotherapy		- Cystectomy - Detorsion and   proceed - Ablation of gonads - Diagnostic   laparoscopy - Transposition of   ovary
Thoracoscopy		- Patent ductus   arteriosus - Achalasia cardia - Esophageal   duplication cyst - Chylothorax - Empyema		- Ligation - Heller’s myotomy - Excision - Ligation of   thoracic duct - Decortication

In one study in children, because of laparoscopy 52% of patients were spared a laparotomy and in 32% the need for operation was established. Laparoscopy is considered to be a safe, effective, and economical diagnostic and therapeutic procedure that deserves wider application in the pediatric patient.

Undescended Testis
Laparoscopic orchiopexy in the management of impalpable testis is the gold standard today. Laparoscopy allows for easy and accurate localization of an intra-abdominal testis and alongwith permits it to be dealt with appropriately. The testis alongwith the vas deferens and testicular vessels can be mobilized upto the lower pole of the kidney which enables a tension free placement in the scrotum. In case the testis is proximal to the internal ring, a single or two stage Fowler Stephens procedure can be carried out. The biggest advantage of laparoscopy is that in the case of a blind ending vas deferens, no further dissection is required, thereby obviating an extensive groin dissection.

Inguinal hernia in children
Laparoscopic herniotomy offers numerous advantages over open herniotomy, foremost among them being the ability to deal with a contralateral aymptomatic patent processus vaginalis without an extra incision and minimal increase in operation time. It is also the ideal approach to deal with recurrent hernias, femoral hernia, congenital hydrocele and especially irreducible hernias, since after laparoscopic reduction of the hernia contents, the intestine can be easily examined for any vascular compromise.

Spectrum of cases performed at Army Hospital