After the first description by Philippe Mouret of Lyon, in 1987, who carried out the first laparoscopic cholecystectomy, videosurgery has gone through a rapid development also in Paediatric Surgery 4-9. This is due, following the success which laparoscopy has had with adults, not only to the technical and instrumental development that there has been over the last years, but also to the growing number of paediatric surgical pathologies which can be treated through this technique. However, as regards indications for operating laparoscopy in the paediatric age, literature does not offer today a wide range of specific cases that may make it possible to critically analyse its employment.
Videosurgical procedures may be classified as follows: a) standardised techniques, which are commonly resorted to for specific indications (Table 1); b) techniques on whose validity further evaluations are required and on whose indications an unanimous opinion does not exist (Table 2); and c) models which are still undergoing an experimental stage (Table 3). GER (Gastro-Esophageal Reflux) refractory to medical therapy, may be deemed as one of the chief indications for surgical laparoscopy in the paediatric age. 11-13 Anti-reflux laparoscopic surgery requires a complete and accurate preoperative investigation, including esophagogram, pH-metry, endoscopy and manometry.
A previous surgical operation or a gastrostomy do not represent a contraindication to laparoscopy4.
Both the fundoplication techniques, the 360° Nissen technique (Fig. 1) and the 270° Toupet technique, prove very successful with children suffering from GER. The choice of the technique depends on the operator’s preferences and on the indications for surgery, but does not depend on the patient’s age. However, in the event of esophageal dismotility or in patients operated at birth for esophageal atresia, a Toupet partial fundoplication appears to be preferable. In neurological patients, who increasingly often require gastrostomy, in addition to fundoplication, the former may be carried out at the same time as the fundoplication, again videosurgically. Laparoscopic correction of GER is more accurate, less traumatic and consequently reduces the risk of complications compared to the traditional technique. All this results in a shorter stay in hospital, as it allows discharge on the third day versus the 10 day stay in hospital following laparotomic fundoplication. Video assisted appendectomy is widely resorted to in the paediatric age for patients affected by appendicopathy 12.
The operation is carried out with only one trocar positioned in the umbilicus area. This technique is possible thanks to 10-mm optical system, equipped with 5-mm operating canal in which a 450-mm long atraumatic forceps is introduced. The appendix is identified and extracted from the abdominal cavity through the umbilicus. Video assisted appendectomy combines the advantages of laparoscopy and those of open surgery. An appendectomy carried out outside the abdominal cavity prevents the possible pollution of the abdominal cavity and allows reversal of the residual appendicular stump, without exteriorising the appendix. In the event of appendicitis complicated by peritonitis, it is advisable to add two more 5-mm trocars and complete the procedure entirely laparoscopically. In cases of non-palpable testis, laparoscopy is regarded as the first-choice diagnostic investigation. The advantage offered by laparoscopy is the possibility of precisely ascertaining the presence and position of the testis, even when it is in an anomalous position, such as for instance behind the bladder or beneath the kidney. (Fig. 3). Once the presence of the gonad as been ascertained, the surgeon is in a position to continue the operation, selecting the most adequate laparoscopic surgical technique. In the event of high testis (that is in a position far away from the inguinal canal), the Fowler-Stephens method appears to be the most frequently adopted orchiopexy technique. This is carried out in two phases and consists of transecting the spermatic vessels, which usually represent the obstacle to the descent of the testis in the scrotum, and in moving the testis to the scrotum. The vitality of the gonad is ensured by the neovascularisation provided by the deferential vessels. In the event of low intraabdominal testis, situated in contact with the internal inguinal ring, video assisted orchiopexy without transecting the spermatic vessels appears to give excellent results-8. In cases of testicular atrophy, orchiectomy can be easily accomplished laparoscopically. Varicocelectomy in the event of varicocele is another routine procedure with children. The operation is extremely simple and consists in the ligation and section of the internal spermatic vein (Ivanisevich technique) that is causing the reflux and consequent symptomatology. A great number of papers reported in international literature, show that the results of laparoscopic varicocelectomy are absolutely comparable to traditional surgical procedures or to embolization 3-4-5.
As regards the surgical technique employed, the ligature of vein and artery is preferable to the ligature of the spermatic vein only, although the Palomo technique displays a non-negligible incidence of post-laparoscopy hydrocele compared to the Ivanisevich technique. Cholecystectomy is another procedure that is regularly practiced, even though cholelithiasis is quite rare during the paediatric age. 6-7 To carry out this operation, 4 5-mm diameter trocars are employed (Fig 4). The operation consists of identifying the cholecyst, sectioning with clips the cystic duct and the cystic artery and removing the cholecyst after having removed it from its hepatic bed. To prevent iatrogenic complications, it is very important to identify with absolute certainty the junction between the cystic duct and the chief bile duct (Fig. 5), which may often be damaged by inexperienced laparoscopic operators with consequent serious damages for the patient. The cholecyst is removed at the end of the operation through the umbilical orifice, after having extracted, in the event of voluminous cholecysts, the calculuses contained thanks to the use of an atraumatic forceps. Ovarian cysts are the most common ovarian masses found in newborn female babies.14. Spontaneous regression of the cysts takes place in 20 to 35% of cases, especially with small-sized cysts. Pre- and post-natal ovarian cyst complications are common, and consist of intracystic bleeding, twisting of the cysts and self-amputation of the cysts. (Fig. 6).
In the event of large-sized cysts (diameter > 40 mm) the laparoscopic intervention is justified. The most common type of operation is the removal of the cyst, whilst preserving the ovarian parenchyma. This procedure, which is called intraperitoneal cystectomy, is carried out when the residual ovarian parenchyma is in good condition and a cleavage between the cyst and the undamaged ovary can be scheduled; on the other hand, if the ovarian parenchyma is damaged, it is preferable to carry out an ovariectomy.
Adhesion-related intestinal obstructions represent a potential consequence of any laparotomy. Their incidence varies, as a number of authors agree, between 5 and 7%. These adherences are formed by fibrin adhesions anchoring the intestinal loops to the abdominal wall. In many cases, the only symptom is represented by recurring abdominal pain, although occasionally the first clinical evidence is provided by an actual intestinal obstruction requesting immediate resort to surgery. In the event of recurring abdominal pain or in the event of obstruction, laparoscopic section of the adherences is indicated. 4-10.
The lysis of visceroparietal and also viscerovisceral adherences, which consists of coagulating and sectioning the adherences being viewed, represents an easy practice, it results in a rapid restoration of intestinal transit with immediate disappearance of the symptomatology, and prevents the need for a further laparotomy, which would display a fair morbidity rate and is not devoid of further complications. Splenectomy is regarded as another advanced procedure, which may be accomplished laparoscopically.
The technique consists of isolating and sectioning with clips the splenic vessels, in freeing the spleen from posterior adherences, in placing the spleen into a small bag and extracting it, after having “fragmented” it, from the umbilicus, without having to produce a wide laparotomy.
The indication in children is represented by haematological pathologies such as thalassemia or spherocytosis, which cannot be monitored though medical therapy only. However, laparoscopic splenectomy should only be carried out when the size of the spleen does not exceed a weight of 500/600 g, whereas for larger spleens it is advisable to resort to a subcostal mini-laparotomy. Congenital inguinal hernia is the paediatric surgical pathology that is most frequently detected and treated with open surgery. In the treatment of this pathology, laparoscopy does not appear to play a key role, but it may prove useful in the event of monolateral inguinal hernia to carry out the laparoscopic control of the contralateral inguinal canal, to detect the presence of an inguinal hernia on the opposite side, even if clinically silent.
Laparoscopy also has a rightly significant role in the treatment of recurring inguinal hernias. In this case laparoscopy makes it possible to carry out a herniorrhaphy from the inside of the abdomen without reopening the inguinal canal. Irrespective of the pathology that has to be treated, there is no doubt that miniinvasive videosurgery offers a number of advantages. First of all a more limited traumatic effect on the abdominal wall, thanks to the employment of miniaturised tools having a few mm diameter, with a virtually painless post-operative period and rapid discharge from hospital 1-11. Furthermore, in laparoscopy, thanks to the improved vision allowed by the tools employed, it is possible to carry out targeted operations with greater precision, compared to the accuracy which can be obtained with traditional surgery, thus reaching more easily areas which would otherwise prove difficult to access (e.g. the Douglas’ cul-de-sac).
Furthermore, the non opening of the abdominal cavity results, on one side, in a small impact as far as “local” complication are concerned, such as viscerovisceral or visceroparietal adherences, and, on the other side, prevents general complications. Another advantage is undoubtedly represented by the smaller invasivity of the technique, with a more simple postoperative course and, finally, an improved aesthetic result owing to the absence of abdominal scars. 9.
The main criticism which may be expressed about laparoscopy is, on one side, the fact that its use is still restricted to a limited number of paediatrist surgeons and, on the other side, that it still requires a rather long learning period3. By analysing international literature, the “learning curve” of laparoscopy appears to be longer than that of traditional surgery and the success of the procedure greatly depends on the laparoscopic experience of the surgeon who practices it13. For this reason, it is preferable to address patients who are expected to need laparoscopy to centres which have a long experience with this technique, so as to guarantee that these operations have a high success rate with a low complication percentage.
In conclusion, we may state that today, at the beginning of the third millennium, laparoscopy represents a reliable and effective procedure with paediatric patients. As regards indications, over the next few years, more exhaustive case histories will probably be published and this will certainly make it possible to explain in a more accurate way for which pathologies laparoscopy is really preferable, compared to the open approach in paediatric surgery. (trad.Interpres-Giussano)

Alessandro Settimi
Cattedra di Chirurgia Pediatrica,
Università di Napoli “Federico II”,
Napoli, Italia