ANESTHESIA FOR MINIMALLY INVASIVE SURGERY

LAPAROSCOPY, THORACOSCOPY, HYSTEROSCOPY 0889-8537/01 $15.00 + .OO

ANESTHESIA FOR LAPAROSCOPY

IN THE PEDIATRIC PATIENT
John H. Pennant, MA, MB, BS, FRCA

Although laparoscopy has been available since it was first described

by Kelling in 1923,3l only in the last decade has it found applications in
pediatric surgery. As expertise and equipment have improved, an in-
creasing number of young children now present for laparoscopic inter-
vention. Early pediatric endoscopes, by necessity being smaller than
their adult versions, tended to have a reduced viewing angle and pro-
duced dim images, but modem optical refinements such as the rod lens
telescope, shortened instruments, and video technology allow high-
quality views. As in adults, laparoscopy permits inspection of the ab-
dominal and pelvic organs, and the retroperitoneal space and the lower
portion of the kidneys, without disturbing the anatomic relationships of
these structures. Anesthetic management is complicated by the major
physiologic effects of the pneumoperitoneum and patient positioning.
Modifications in anesthetic technique might be required to allow this
novel operation to be performed safely. As more procedures are per-
formed laparoscopically, knowledge of these physiologic changes has
become fundamental to safe practice, especially when they are applied
to sicker patients.

OVERVIEW OF PEDIATRIC LAPAROSCOPIC SURGERY

As in adults, the laparoscopic approach to pediatric surgery has

been marketed through claims of reducing hospital costs, allowing ear-

From the Department of Anesthesiology & Pain Management, University of Texas South-
western Medical School, Dallas, Texas

ANESTHESIOLOGY CLINICS OF NORTH AMERICA

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VOLUME 19 NUMBER 1 MARCH 2001 69
70 PENNANT

lier discharge and a more rapid return to normal diet and full
39, 50 There is a perception it is associated with an improved cosmetic
result, reduced postoperative hernias, less wound infections, a lower
incidence of postoperative ileus, and less postoperative pain.
Fewer laparoscopic operations are performed in children, so one
institution does not have extensive experience. There are no published
randomized prospective studies of this type of minimally invasive sur-
gery in this young population. Existing reports are mostly anecdotal in
nature, so that the precise role of this exciting new technique in pediatric
surgery has yet to be defined. More recently, small controlled studies of
laparoscopic appendectomy and fundoplication in children have been
47 These have helped to identify the benefits and drawbacks
of this surgical technique.
Laparoscopy can be a diagnostic procedure in children (e.g., to
evaluate the undescended testis,", 46, 48 as part of the evaluation of in-
tersex, in the diagnosis of the acute abdomen,= and in staging pediatric
cancer). Once the diagnosis is made, laparoscopic techniques can help
to treat the condition (e.g., unwinding adnexal torsion,48appendectomy,
adhesiolysis, resection of Meckel's diverticulum, or even removal of a
pheochromocytoma9).
With the laparoscope, even large, solid intra-abdominal masses such
as the kidney or spleen can be removed after the tissue has been
morcellated. As experience has increased, a variety of more sophisticated
procedures are now possible (e.g., colectomy, "pull-through for Hirsch-
sprung's disease,I7,21, 67 pyeloplasty, and treatments for vesicoureteral
reflux, gut malrotation, and choledochal cysts).

PHYSIOLOGIC CHANGES DURING LAPAROSCOPY

Although the perioperative management of children undergoing

laparoscopy is essentially identical to that for other intra-abdominal
procedures, two factors conspire to make anesthesia more challenging,
namely the creation of a pneumoperitoneum (with the associated absorp-
tion of insufflated carbon dioxide [CO,] and elevation of intra-abdominal
pressure), and the extremes of patient positioning that are necessary for
optimal exposure of intra-abdominal structures.

Creation of the Pneumoperitoneum

The creation of a pneumoperitoneum with insufflated gas permits

visualization and manipulation of the abdominal viscera. The volume of
insufflating gas necessary for pneumoperitoneum is obviously much
lower in children; adults require 2.5 L to 5.0 L, whereas a 10-kg patient
needs only about 0.9 L.68
Safety precautions must be taken if one is using the Veress insuffla-
tor needle-namely, aspiration, injection, and the hanging-drop tech-
 ANESTHESIA FOR LAPAROSCOPY IN THE PEDIATRIC PATIENT 71

nique so that the serious consequences of gas embolism can be avoided.24

The risk of injuries to vascular and visceral structures from the Veress
needle is higher in infants.= This has led to its replacement by an open
approach, which is safer. The ideal gas for insufflation would have the
properties listed here:
Minimal peritoneal absorption
Minimal physiologic effects
Rapid excretion of any absorbed gas
Inability to support combustion
Minimal effects from intravascular embolization
High blood solubility

Advantages of CO, for lnsufflation

CO, approaches the ideal insufflating gas, and because other options
(e.g., air, oxygen, nitrous oxide) have undesirable qualities, is almost
universally used. As laparoscopy frequently involves the use of bipolar
diathermy or lasers, the insufflated gas must not support combustion.
This effectively excludes air, nitrous oxide (N,O), and oxygen. Residual
CO, pneumoperitoneum is cleared more rapidly than that created with
other gases, minimizing the duration of postoperative disc0mfort.5~

Disadvantages of CO, for lnsufflation

The chief drawback of CO, is its significant vascular absorption
across the peritoneum. In children, CO, uptake is more efficient owing
to the smaller distance between capillaries and peritoneum, and the
greater absorptive area of peritoneum in relation to bodyweight. In
prolonged procedures (>1 h), hypercapnia can develop. This could
mandate increasing minute ventilation by as much as 60% to restore
end-tidal CO, (ETcq) to baseline levels. Hypercapnia also can provoke
sympathetic nervous system activity, leading to an increase in blood
pressure, heart rate, myocardial contractility, and arrhythmias. Hyper-
capnia also sensitizes the myocardium to catecholamines, particularly
when volatile anesthetic agents are used. The additional CO, load can
lead to hypercapnia in the postoperative period, because large quantities
can be buffered by body tissues. CO, is gradually excreted postopera-
tively, causing an increased ventilatory requirement when the ability
to increase ventilation is impaired by residual anesthetic drugs and
diaphragmatic dysfunction.
Massive intravascular embolization of any gas results in cardiovas-
cular collapse, and CO, is no exception.8 Detection of embolized gas is
difficult unless a precordial Doppler probe or transesophageal echocardi-
ography is in use. The other criteria traditionally used to detect air
embolism, such as an increase in end-tidal nitrogen, will not register any
change when the embolized gas is CO,, N20, or helium. Following CO,
72 PENNANT

embolism, capnography might not reveal any change in ETco, until late
in the course of the event.

Other Gases for Pneumoperitoneum

Studies using helium as the insufflating gas5 show no changes in
arterial pH or Pacq, so that, from this point of view, it would appear to
be a suitable alternative to CO,. Should intravascular gas embolization
occur, however, the relative insolubility of helium compared with CO,
could result in more serious cardiovascular sequelae. Helium is also
expensive, and its widespread adoption into laparoscopic practice could
impact attempts at cost containment in the surgical suite. Nitrous oxide
supports combustion and is therefore contraindicated if cautery is used.
Pollution of the surgical environment is also a concern with this agent.

Gasless Laparoscopy
The gasless laparoscopic technique avoids using any gas for insuf-
flation, relying instead on an abdominal wall lift to create an intra-
abdominal space at atmospheric pressure.34This has further advantages
because maintaining a pneumoperitoneum is more difficult in infants
because even the smallest gas leak can cause the small working space to
collapse. Gasless techniques allow the use of valveless ports and instru-
ments of differing calibers without the inconvenience of a variable
pneumoperitoneum, and without the problems attributed to increased
intra-abdominal pressure (IAP).

Intra-abdominal Pressure

The creation of a pneumoperitoneum necessarily raises IAP,which

can have significant cardiovascular, respiratory, and neurologic effects.

Cardiovascular Effects
The critical determinants of cardiovascular function during laparos-
copy are the IAP and patient position.63If the IAP is kept below 15 mm
Hg, venous return actually is augmented as blood is "squeezed" out of
the splanchnic venous bed, producing an increase in cardiac output. At
IAP levels greater than 15 mm Hg, venous return decreases as the
inferior vena cava (IVC) is compressed. This results in a reduction in
cardiac output and arterial blood pressure. In other types of surgery, in
which the N C is cross clamped or ligated, compensatory flow can occur
by collateral vessels and restore blood pressure to acceptable levels, but
in laparoscopy the high levels of IAP also obstruct these collaterals. In
 ANESTHESIA FOR LAPAROSCOPY IN THE PEDIATRIC PATIENT 73

this case, the hypotension can be more profound than that following
simple IVC occlusion.
Early work with newborn piglets confirmed the importance of keep-
ing IAP below 15 mm Hg.35Above this level, a progressive decrease in
cardiac index was noticed. For example, at an IAP of 20 mm Hg, the
cardiac index fell to 55% of baseline, but when the IAP was increased to
30 mm Hg, the cardiac index decreased to 38% of its resting level.
Studies using neonatal lambs demonstrated a 35% reduction in renal,
hepatic, and intestinal blood flow at an IAP of 25 mm Hg.38
Sakka et a145used transesophageal echocardiography to study the
hemodynamic changes during laparoscopy in eight healthy supine chil-
dren aged 2 to 6 years. Their results showed that an IAP up to 12 mm
Hg had minimal effects on cardiac index, reducing it approximately
13%.At an IAP of 6 mm Hg, no cardiovascular parameters were affected,
yet surgical conditions were satisfactory. This lower level of IAP is
recommended for patients with serious cardiac disease. Hsing’s= group
also confirmed the absence of hemodynamic compromise in the Trende-
lenburg position in 126 children aged 11 months to 13 years undergoing
laparoscopic inguinal exploration, when pneumoperitoneum was limited
to 10 mm Hg. Others studied 12 healthy supine boys aged 6 to 30
months using a pneumoperitoneum of 10 mm Hg and discovered a 67%
reduction in cardiac performance (aortic blood flow and stroke volume)
and a 162% increase in systemic vascular resi~tance.’~ These changes
were not associated with any deleterious cardiac events. Tobias et a155
studied 53 children aged 1month to 7 years, and looked at cardiorespira-
tory measurements during brief ( 4 5 min) diagnostic inguinal laparos-
copies, in which IAP was kept below 15 mm Hg. Ventilatory settings
were unchanged during the investigation. There were no significant
changes in arterial 0, saturation or other cardiovascular parameters.
These minimal alterations in vital signs were attributed to the brief
surgical times, limiting IAP to 15 mm Hg, and avoiding the Trendelen-
burg position. The authors caution that more dramatic changes could be
seen in longer procedures and when the head-down position is
used.
These cardiovascular changes are complicated by the patient’s posi-
tion during surgery. The head-up position favored for upper abdominal
procedures (e.g., Nissen fundoplication and cholecystectomy) further
reduces venous return and cardiac 0utput.2~This effect is more marked
during fundoplication, in which a greater degree of head-up tilt (25-30
degrees) is required than for laparoscopic cholecystectomy (15-20 de-
grees). In addition, surgical dissection around the esophageal hiatus in
a pig model increased mediastinal and pleural pressures, which also
can produce a significant reduction in cardiac output and explain the
occasional episodes of hypotension and hypoxia seen in this procedure.%
Surprisingly, release of the pneumoperitoneum did not restore cardiac
output, or central venous, pleural, or mediastinal pressures to baseline
levels within an hour, suggesting a prolonged physiologic effect from
gastroesophageal junction dissection. Conversely, when the patient is
74 PENNANT

positioned head down, as for pelvic laparoscopic examination, venous

return is augmented and blood pressure returns to normal or even
supranormal values. These cardiovascular changes are similar whether
CO, or helium is used for insufflation, suggesting that it is the change
in IAP and position, rather than absorption of gas, that is re~ponsible.~
Gannedahl et all6 used transesophageal echocardiography and pul-
monary artery catheterization to study cardiovascular changes in eight
healthy adults undergoing laparoscopic cholecystectomy. They found
that the creation of a 13 mm Hg pneumoperitoneum was a much more
significant factor than patient position in explaining the increases seen
in left ventricular end-diastolic volume and pulmonary capillary wedge
pressure. This study emphasizes the importance of keeping IAP as low
as possible to minimize adverse cardiovascular developments.
Other cardiovascular phenomena can result simply from insufflating
gas into the peritoneum. Children have a high level of resting vagal
tone, and occasionally peritoneal stimulation by a blast of insufflated
gas or penetration by trocars and laparoscopes can provoke bradycardia
or a~ystole.4~
Patients with normal cardiovascular function tolerate these varia-
tions in preload and afterload well, but those with cardiovascular dis-
ease, anemia, or hypovolemia require meticulous attention to volume
loading, positioning, and insufflation pressures. Causes of cardiovascular
collapse during laparoscopy in patients without cardiac disease are
listed here:
Vasovagal reflex response to peritoneal stimulation from trocars or
insufflation
Myocardial sensitization by halothane
Reduced venous return secondary to reverse Trendelenburg position,
inferior vena cava compression, or high insufflation pressures
Hypovolemia
Hypercapnia (particularly in longer procedures)
Venous gas embolism

Respiratory Effects
Elevated IAP reduces diaphragmatic excursion and shifts the dia-
phragm cephalad, resulting in early closure of small airways, an increase
in peak airway pressure, and a reduction in both thoracic compliance
and functional residual capacity (FRC). Upward displacement of the
diaphragm leads to preferential ventilation of nondependent parts of the
lung. This results in ventilation-perfusion mismatch, which is accentu-
ated during positive pressure ventilation and by the Trendelenburg
position. FRC is low in children and quickly falls below closing capacity,
producing small airway collapse, atelectasis, intrapulmonary shunting,
and hypoxemia. This deterioration in respiratory function is reduced
when the patient is in the reverse Trendelenburg position and increased
 ANESTHESIA FOR LAPAROSCOPY IN THE PEDIATRIC PATIENT 75

when the patient is placed in a steep head-down tilt, when the weight
of abdominal viscera causes extra diaphragmatic loading.
In Tobias’s study55 of inguinal laparoscopy in 53 children aged 1
month to 7 years, when IAP was limited to 15 mm Hg, peak airway
pressures increased by a mean of 3 cm H20 (maximum, 7 cm H20),and
ETco, increased from a mean of 32 mm Hg to 35 mm Hg (maximum
increase, 11 mm Hg). All values had returned to baseline within 10
minutes of completion of surgery.
One study of ten children revealed a 27% reduction in lung compli-
ance and a 32% increase in peak airway pressure following both 20-
degree head-down tilt and 12 mm Hg pneurn~peritoneum.~~ All values
returned to normal when the abdomen was deflated. These changes are
about one half as extreme as those seen in adults, perhaps because of
the different chest wall configuration and greater thoracic distensibility
in children. H s i n g ’ ~study
~ ~ of 126 children reported that whereas there
were no significant hemodynamic changes when patients were placed
in the Trendelenburg position, as long as IAP was limited to 10 mm
Hg, airway pressures and ETco, both increased by approximately 20%.
Because most pediatric patients are intubated with uncuffed tracheal
tubes and ventilated with pressure-cycled ventilators, this reduction in
pulmonary compliance results in a fall in tidal volume (secondary to an
increased gas leak around the tracheal tube) unless peak airway pressure
and fresh gas flow are raised to keep minute ventilation at adequate
levels. Increasing minute ventilation 20% to 30% is usually adequate to
maintain normocapnia.60The use of positive end-expiratory pressure
(PEEP) can help to alleviate diaphragmatic elevation encroaching on
FRC and may improve arterial oxygen saturation.
Sfez et a147examined cardiorespiratory function in 25 children aged
1 to 14 years undergoing laparoscopic Nissen fundoplication. All were
intubated and ventilated. Several children had preexisting respiratory
disease, presumably secondary to chronic aspiration. Hypotension or
bradycardia developed in 3 of 4 patients when they were placed in the
reverse Trendelenburg position. This responded promptly to volume
loading and administration of vagolytic drugs. Subsequently, all patients
were operated on in the supine position using LAPS of 6 mm Hg to 10
mm Hg with no significant changes in cardiovascular parameters other
than a slight and gradual increase in blood pressure toward the end of
the procedure. The authors attributed this elevation in blood pressure to
an increased SVR rather than an increase in Paco,. In surgeries that
lasted a mean of 116 minutes, only 2 patients required an increased
minute volume to correct an elevated ETco,; however, 6 children devel-
oped postoperative hypoxemia, defined as an Spoz of less than %YO,
within the first 3 postoperative hours. Two patients were receiving
supplemental Ozby nasal cannulae. This desaturation is not seen after
laparoscopic surgery for inguinal hernia repair, suggesting that it is not
the creation of the pneumoperitoneum per se that causes postoperative
hypoxemia, but rather interference with diaphragmatic function during
fundoplication. The authors suggest that the laparoscopic approach for
76 PENNANT

fundoplication confers perioperative stability and postoperative benefits

such as reduced ileus, reduced postoperative pain, less respiratory dys-
function, and earlier discharge, compared with open surgery. It is gener-
ally believed that the laparoscopic approach is best for older children
without neurologic impairment.
High IAP levels can permit insufflated gas to gain access to tissue
spaces, which explains occasional reports of pneumothorax and pneu-
momediastinum. This appearance of intrathoracic gas is most often seen
following laparoscopic Nissen fundoplication in adults and presumably
occurs because dissection of the esophageal hiatus permits passage of
insufflated gas across the diaphragm. This complication is increased
when a higher IAP is used. A postoperative chest radiograph should be
obtained following laparoscopic Nissen fundoplication to detect this
development, which can remain clinically silent.
Tobias56also studied cardiorespiratory changes in 20 healthy chil-
dren aged 15 to 80 months undergoing brief (mean, 7 min) diagnostic
laparoscopy using a face mask and spontaneous ventilation. Analgesia
was provided by caudal epidural block. Slight but significant elevations
in tidal volume, ETco,, and respiratory rate were noted in a few patients
but were of no clinical significance and had returned to baseline within
10 minutes of completion of the laparoscopy. No significant alterations
in heart rate, blood pressure, or arterial 0, saturation were noted. Spon-
taneous ventilation has the added advantage of lessening ventilation-
perfusion mismatch because the well-perfused dependent areas of the
lung are preferentially ventilated. Avoidance of intubation could have
further advantages in patients with airway disease (e.g., asthmatics).
Laparoscopy using this technique should be restricted to healthy chil-
dren having brief procedures in the supine position, where there is no
risk of aspiration and insufflation pressures are limited to 15 mm Hg.

Neurologic Effects
Another adverse effect of elevated IAP is increased intracranial
pressure (ICP). Hypercapnia, increased SVR, and head-down positioning
combine to elevate An IAP of 25 mm Hg increased ICP from a
mean of 7.6 mm Hg to 21.4 mm Hg and produced a fall in cerebral
perfusion pressure from 82 mm Hg to 62 mm Hg. Because of this
phenomenon, it is inadvisable to perform laparoscopic surgery on pa-
tients with reduced intracranial compliance unless absolutely necessary.

Endocrinologic Effects
When laparoscopy was compared with laparotomy for acute ab-
dominal emergencies (e.g., appendectomy, lysis of adhesions) lasting
about 1 hour, there was a similar increase in blood levels of "stress"
hormones (i.e., insulin, cortisol, prolactin, epinephrine).6 Blood levels of
lactate, glucose, and interleukin-6 were also similar in both groups.
Despite the minimal degree of tissue damage, the neuroendocrine axis
 ANESTHESIA FOR LAPAROSCOPY IN THE PEDIATRIC PATIENT 77

appears to be activated to the same extent as in open procedures. The

significance of this observation is unclear at present.

PERIOPERATIVE MANAGEMENT

Preoperative Evaluation

The child presenting for laparoscopy should be managed in exactly

the same way as any child presenting for surgery. A thorough preopera-
tive history should be taken, and a complete physical examination
should be performed to identify underlying medical conditions that
could influence perioperative care. Laparoscopy can be performed as a
brief elective procedure on a healthy outpatient, or as an emergency
diagnostic procedure in a critically ill patient, so the degree of preopera-
tive evaluation must be tailored to the severity of preexisting disease
and the urgency of the procedure.

Preoperative Investigations

Healthy children presenting for laparoscopy do not require any

preoperative blood tests, a chest radiograph, or an electrocardiogram
unless there is preexisting disease that merits evaluation. Although a
preoperative hemoglobin value is usually not necessary, major hemor-
rhage can occur as a complication of the technique and mandate emer-
gency laparotomy, so this type of surgery should be performed only
where there is immediate access to a blood bank.

Prernedication

The premedication of children is an integral part of pediatric anes-

thetic practice. It is a matter of personal or institutional preference,
although underlying preexisting disease can mandate adjusting premedi-
cants to a more appropriate selection of drugs.
Healthy outpatients can be administered oral midazolam, 0.5 to 0.75
mg/kg 15 to 30 minutes preoperati~e1y.l~This can be dissolved in
acetaminophen or ibuprofen elixir, 10 mg/kg.
Other premedication options include using alternative routes of
administration (e.g., nasal,3O intramuscular, transmucosal), or
other choices of drugs (e.g., antacids, H, antagonists, gastrokinetic agents
[e.g., metoclopramide], opioids, antisialogogues, or ketamineZ0).
Some institutions omit premedication entirely, relying instead on
parental presence at induction to allay the child's apprehensiveness,28
although recent work, suggests parental presence has no additive anxio-
lytic effect in addition to oral m i d a z ~ l a m Children
.~~ younger than 9
months do not suffer separation anxiety and require either no premedi-
78 PENNANT

cation or an anticholinergic (e.g., atropine, 20 kg/kg intramuscularly or

30 to 40 kg/kg orally 30 to 45 minutes preoperatively). The use of
atropine is associated with a lower incidence of cardiovascular and
airway complications peri~peratively.~~ One further advantage of anti-
cholinergic premedication is to prevent vasovagal reflexes that are occa-
sionally seen when the peritoneum is penetrated.

Induction of Anesthesia
Anesthetic techniques available for laparoscopy include local, re-
gional, and general anesthesia. Although local and regional approaches
have been described for brief laparoscopic inspections in healthy adults,
they are generally unsuitable for pediatric patients and are not discussed
further here.
Options available for induction of general anesthesia in children
include inhalational (using sevoflurane or halothane in nitrous oxide
and 0,) or intravenous. The intravenous route is recommended if intra-
venous access has been secured, which can be performed with minimal
discomfort following the use of topical local anesthetic agents, for exam-
ple, Eutectic Mixture of Local Anesthetics (EMLA) cream, amethocaine
gel, or by an iontophoretic technique.
Children requiring emergency exploration of the abdomen should
receive a rapid-sequence intravenous induction with the use of cricoid
pressure until a tracheal tube is securely in place to reduce the risk of
pulmonary aspiration of gastric contents. Although tracheal intubation
is not mandatory for brief laparoscopic procedures in healthy patients
(a f a c e m a ~ kor~LMA5s
~ can be used), good muscle relaxation and intuba-
tion provide optimal surgical conditions and a more secure airway
and allow controlled ventilation in the face of elevated IAP when a
pneumoperitoneum is created.
Peripheral intravenous access should be obtained in all patients to
allow continued hydration and drug administration, especially in case
of accidental vascular injury from endoscopic instruments. Because
laparoscopic nephrectomy or splenectomy can result in major hemor-
rhage, intravenous access must be adequate to permit rapid fluid resusci-
tation. A venous catheter is preferably inserted above the diaphragm in
case the elevated IAP compresses the IVC and impairs access of drugs
and fluid to the circulation from venous access sites in the legs.61 A
central venous catheter is necessary only if peripheral access is unobtain-
able or if preexisting medical conditions dictate. Once venous access is
obtained, some authors routinely administer a 20-mL/kg fluid bolus to
offset the hemodynamic effects when the pneumoperitoneum is cre-
ated.68

Monitoring
Monitoring the child’s clinical status should follow the American
Society of Anesthesiologists’ (ASA) recommendations. These include
 ANESTHESIA FOR LAPAROSCOPY IN THE PEDIATRIC PATIENT 79

continuous electrocardiography, automated noninvasive blood pressure,

pulse oximetry, temperature, and capnography. In some instances, ETco,
values do not accurately reflect Paco2, especially when higher IAPs are
in use.33Exhaled tidal volume should be measured in case the decrease
in pulmonary compliance that follows insufflation leads to underventila-
tion secondary to increased leak around the tracheal tube.61A peripheral
nerve stimulator should be used to monitor the degree of neuromuscular
blockade and to assess the adequacy of reversal of paralysis at the
completion of surgery.
Small children have a high body surface area-to-mass ratio and little
subcutaneous fat or body hair to retain heat. This, plus surgical exposure
of the entire abdomen, tends to provoke rapid heat loss. Continuous
insufflation of large volumes of cold, nonhumidified CO, directly into
the abdominal cavity also contributes to a major risk of hypothermia.
For all but the shortest procedures, core temperature should be measured
in the distal one third of the esophagus. An infrared radiant heater, a
warming mattress, a heated humidifier for inspired anesthetic gases, and
a convective forced air warmer should be used if available.
Use of a precordial or esophageal stethoscope allows continuous
auscultation of breath and heart sounds and is especially helpful should
endobronchial intubation occur. This is a well-recognized complication
when the diaphragm and mediastinum are moved cephalad by the
pneumoperitoneum, particularly in the Trendelenburg po~ition.'~
Multiorifice central venous catheters are the most effective devices
for aspiration of embolized gas, but their routine use is not necessary
during laparoscopy because the risk of this complication is so low.62
An oro- or nasogastric tube should be inserted after induction to
permit deflation of the stomach. This not only improves visualization of
abdominal contents but also reduces the risk of the Veress needle's
accidentally perforating the inflated viscus.
If continuous cardiovascular monitoring is required, use of trans-
esophageal echocardiography is a satisfactory technique, particularly
when extremes of tilt are used. Repositioning of the esophageal probe
may be necessary to maintain optimal signal quality throughout all
phases of the procedure.12

PerioperativeCare

A balanced anesthetic technique with controlled ventilation using

inhalational agents (e.g., sevoflurane, isoflurane, or desflurane), intrave-
nous opioids, nondepolarizing neuromuscular blocking agents (e.g., ve-
curonium, rocuronium, cis-atracurium, mivacurium, or rapacuronium) is
generally preferred.63A total intravenous technique is also an option,13
particularly if there are concern over myocardial depression by volatile
anesthetics.26,47 Some anesthesiologists avoid nitrous oxide because of
the small risk of venous gas embolism and because its diffusion into the
intestinal lumen could distend the bowel and impair the surgeon's visual
80 PENNANT

field. Nitrous oxide also can increase the incidence of postoperative

nausea and vomiting (POW).
Although halothane can be used for inhalational induction, it should
be discontinued once the trachea is intubated because hypercapnia sec-
ondary to the pneumoperitoneum will sensitize the myocardium to this
agent. There are also concerns regarding the reduced hepatic blood
flow secondary to the pneumoperitoneum,38which could predispose to
halothane hepatotoxicity.
The chief difference in anesthetic management between laparoscopy
and other abdominal procedures in children relates to the cardiorespira-
tory changes resulting from pneumoperitoneum and positioning. Venti-
lation should be controlled, because this facilitates removal of exogenous
CO, and minimizes the reduction in FRC caused by a combination of
increased IAP, the Trendelenburg position, and the use of volatile anes-
thetic agents. Minute ventilation might need to be increased by 20% or
more to maintain normocapnia.
Occasionally, fluid is instilled laparoscopically to improve surgical
exposure. This fluid should be isotonic (e.g., lactated Ringer’s solution
or Plasmalyte), and allowance must be made for systemic absorption
when calculating fluid maintenance regimes.
At the completion of surgery, the peritoneum should be deflated
completely. Otherwise, any remaining intra-abdominal CO, is absorbed
into the circulation during the postoperative phase. Furthermore, any
trapped gas will irritate the undersurface of the diaphragm, which
presents as referred pain in the shoulder and increases the incidence
of POW.
Volatile anesthetic agents then should be discontinued, neuromuscu-
lar blockade reversed, and the trachea extubated when the patient satis-
fies accepted criteria.

Use of the Laryngeal Mask Airway

The laryngeal mask airway (LMA) has proved a remarkably useful

adjunct to anesthesia for patients having minor procedures. It has been
used extensively in pediatric practice, although there are concerns about
aspiration, gastric distention, and hypercapnia when spontaneous respi-
ration is permitted. It might be expected that laparoscopy would increase
the risk of regurgitation and aspiration because of the use of the Trende-
lenburg position, increased IAP,the surgeon’s pressing on the abdominal
wall, and peritoneal stimulation. Furthermore, inflation of the LMA cuff
in the hypopharynx has been shown to lower the lower esophageal
sphincter pressure by way of a reflex action, predisposing the patient to
reg~rgitation.~~A few studies have addressed this issue in small groups
of patients having brief laparoscopic operations.
Pelvic laparoscopy has been performed safely in women using the
LMA with spontaneous respiration.18,53 No cardiorespiratory complica-
tions were noted by the authors, who recommend that procedures be
 ANESTHESIA FOR LAPAROSCOPY IN THE PEDIATRIC PATIENT 81

kept as brief (<30 min) and LAP kept as low as possible. Although the
LMA does not reliably protect the airway and concerns remain regarding
aspiration of gastric contents, it appears that the lower esophageal
sphincter pressure is increased by the presence of a pneumoperitoneum.
Although the incidence of aspiration with the LMA is very low when it
is used as recommended, there has not been any reported increase in
this complication when it has been used for laparoscopy, even when
positive-pressure ventilation was used.3,66
Only one report exists on the use of the LMA in pediatric patients
having laparoscopic inspection of the pelvic Fifteen patients
breathed spontaneously during these brief operations, which only lasted
3 to 9 minutes. In 4 of these 15 children, ETco, exceeded 60 mm Hg but
returned to baseline within a few minutes of the end of surgery. The
ETco, increased to a lesser degree in the remaining patients. There were
no significant changes in arterial oxygen saturation in any child.
Although these preliminary studies suggest the LMA can be safely
used in pediatric laparoscopy, it is not recommended for use in longer
procedures, or in patients with limited cardiorespiratory It
appears to be a safe technique in healthy patients having brief proce-
dures, in whom extremes of head-down tilt and IAP are avoided, and
in whom there are genuine concerns about instrumenting the airway
(e.g., history of severe asthma). As in all areas of pediatric anesthesia,
there is less margin for error than in adults, and slight displacement of
the device could lead to underventilation or gastric distention. The
anesthesiologist must be vigilant for this complication by regularly aus-
cultating over the stomach to detect gas insufflation.
Anesthetic recommendations for laparoscopy in children with se-
vere myocardial disease follow from Tobias and Holcomb’s report on
two sick patients undergoing cholecystectomy.60* 61 These include the
following:
1. Avoid anesthetic agents that directly depress or sensitize the
myocardium, such as halothane. Sevoflurane is a safer alterna-
tive. If intravenous induction is considered, etomidate is a better
choice than propofol or barbiturates.
2. Preoperative atropine prevents the bradycardia that is occasion-
ally seen as a vagal response to peritoneal insufflation. Patients
with noncompliant ventricles have a fixed stroke volume and
rely on heart rate to maintain cardiac output, so bradycardia is
poorly tolerated.
3. Avoid muscle relaxants and opioids that release histamine (e.g.,
mivacurium, rapacuronium, morphine).
4. Avoid caudal epidural block for postoperative analgesia because
the reduction in preload can lead to a fall in cardiac output.
5. Use local anesthetic infiltration at trocar sites to minimize s p -
pathetic stimulation.
6. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be used
for postoperative analgesia.
7.Consider using transesophageal echocardiography in preference
82 PENNANT

to central venous pressure monitoring, because it more accu-

rately demonstrates preload and myocardial contractility.
8. Consider pulmonary artery catheters for children weighing
> 15 kg.
9. Insufflate the abdomen slowly, and keep IAP as low as is com-
patible with good visualization of abdominal contents. Do not
permit IAP to exceed 15 mm Hg.
10. Consider replacing gas insufflation with an abdominal wall lift
(gasless laparoscopy),34which eliminates problems related to
IAP and CO,.
11. Use an arterial catheter to allow blood gas monitoring of Paco,,
rather than relying on ETco, values, which might not accurately
reflect the true arterial level.
12. Perform surgery in the supine position if possible to minimize
changes in venous return and SVR.
13. Quickly convert to an open procedure if severe cardiovascular
compromise occurs.

Immediate Postoperative Care

Monitoring of vital signs should continue in the postanesthesia care

unit (PACU), because an excess of CO, must be cleared from the body.
Patients with respiratory disease can have problems excreting this CO,
load, resulting in hypercapnia and respiratory failure. A postoperative
chest radiograph should be obtained following laparoscopic fundoplica-
tion or other upper abdominal laparoscopy to detect pockets of gas
that have traversed the diaphragm and produced a pneumothorax or
pne~momediastinum.4~

POSTOPERATIVE PAIN MANAGEMENT

Pain following laparoscopy results from a variety of maneuvers,

including rapid distention of the peritoneum when the pneumoperito-
neum is created. Its severity is related to the degree of distention, and
the volume of residual gas after desufflation. Excitation of the phrenic
nerve by instrumentation or CO,, and the unusual positions required for
some procedures, can stretch nerves and present as postoperative pain.
As much gas as possible must be removed from the abdomen at the
completion of surgery.
Pain can present anywhere in the abdomen but is sometimes re-
ported in the back and in 35% to 63% of adult patients is referred to
the shoulders., Shoulder pain is less common in pediatric patients.
Postoperative pain is usually mild and transient, requiring little more
than NSAIDs for 24 hours. In Sfez’s study of 25 children undergoing
laparoscopic Nissen f~ndoplication,4~ no analgesics were needed after
the first postoperative day, and even acute postoperative pain was satis-
 ANESTHESIA FOR LAPAROSCOPY IN THE PEDIATRIC PATIENT 83

factorily controlled by nonopioid analgesics. Occasionally, pain persists

for more than 3 days, by which time the patient is probably home and
trying to return to normal activity.
Pain is best controlled using a multimodal approach of local anes-
thetics, NSAIDs (e.g., ketorolac, 0.5 mg/kg IV),and opioids. Local anes-
thetic can be injected at all trocar and endoscope puncture sites or
instilled into the peritoneum. The application of topical bupivacaine to
the gallbladder bed and subphrenic area after laparoscopic cholecystec-
tomy in adults remains controversial and might not reduce postoperative
pain"; it is possible that the number of hypoxic events could increase in
the postoperative period, presumably secondary to partial phrenic nerve
block. There is evidence that intraperitoneal local anesthetic, especially
if given preemptively, reduces postoperative pain from laparoscopic
cholecystectomy, however.4°There are no data on this aspect of postoper-
ative pain in children, and further studies are warranted in this popula-
tion. NSAIDs reduce pain, reduce opioid requirement, and appear to be
an excellent choice for control of "late" postoperative pain. They may
be given by oral, rectal, intramuscular, or intravenous routes. Oral ibu-
profen has been shown to be better at controlling postoperative pain
than perioperative fentan~1.4~
Bilateral rectus sheath block gives good pain relief after lower ab-
dominal laparo~copy.~~ Spinal, epidural, and caudal epidural57blocks
are also effective. Tobias59compared caudal epidural block with local
infiltration and iliohypogastric/ilioinguinalblock in children undergoing
laparoscopic inguinal herniorrhaphy. Those receiving caudal blocks were
more comfortable; some did not require any further postoperative anal-
gesia. Caudal blocks are best reserved for lower abdominal procedures
or when all puncture sites are at or below the umbilicus.
It would appear that there are no benefits from a postoperative
pain viewpoint when laparoscopy is advocated for a procedure that is
normally performed through a minimal incision (e.g., pyloromyotomy
or appendectomy). L e j ~ compared
s~~ laparoscopic and open appendec-
tomy in 63 children and found a 35% incidence of postoperative shoulder
pain in the laparoscopic group versus 10% in the open group. There
were no obvious advantages to recommend the laparoscopic approach,
which also took longer to perform. In larger children, in whom the
incision for open appendectomy tends to be larger and therefore is
more likely to produce muscle damage, there can be advantages to the
laparoscopic approach.

POSTOPERATIVE NAUSEA AND VOMITING

P O W is a common complication following laparoscopy, delaying

discharge from the PACU. The incidence can be reduced significantly
by prophylactically administering a variety of antiemetic agents.10 f i e
author's practice is to use combinations of drugs including a 5-HT3-
antagonist (e.g., ondansetron, 100 &kg, to a maximal dose of 4 mg,
84 PENNANT

dexamethasone, 150 kg/kg, and droperidol, 25 pg/kg, to a maximal

dose of 0.625 mg). Other important maneuvers include complete aspira-
tion of the pneumoperitoneum at the conclusion of the procedure.

CLINICAL EXPERIENCE IN PEDIATRIC LAPAROSCOPY

Alain et all described laparoscopic pyloromyotomy for idiopathic

hypertrophic pyloric stenosis in ten infants weighing 2.6 to 5.4 kg. They
recommend continuous monitoring of inspired and expired C02, and
keeping IAP below 8 cm H20. All procedures were unevenful, with
operating times shorter than 30 minutes. It is important not to use access
points in the periumbilical area in this age group because the umbilical
vessels have not involuted and are at risk of puncture. Many pediatric
surgeons believe a laparoscopic approach that requires at least three
puncture sites in the abdominal wall has little or no advantage over the
traditional 10-minute procedure, which is safe, has few complications,
and requires only a 3-cm to 4-cm incision that can easily be infiltrated
with local anesthetic. To date, studies comparing these two operations
for pyloric stenosis have failed to show any dramatic advantages of
laparoscopy.
One surgical investigation compared laparoscopic versus open ap-
pendectomy in a cohort of 63 children3*The laparoscopic approach did
not confer any improvement in postoperative pain or recovery but
increased hospital costs because the procedure took longer to perform.
Many surgeons believe that laparoscopic appendectomy offers little ad-
vantage to the child, except when the patient is young, muscular, ath-
letic, or obese. A large retrospective analysis of 1379 laparoscopic appen-
dectomies in children aged 2 to 16 years found that this technique
allowed rapid localization of the appendix and the ability to explore and
lavage the entire peritoneal cavity,I3 resulting in a lower incidence of
postoperative abscesses and adhesions. Hospital stay was shorter, and
there was a quicker return to normal activities than with traditional
surgery. Varlet65retrospectively compared open and laparoscopic appen-
dectomy in 403 children. Patients who underwent laparoscopy had a
1.5% incidence of complications, whereas the open group had a 10.8%
complication rate. Complications included wound abscesses, infections,
and bowel obstructions. These two studies suggest that laparoscopic
appendectomy can offer significant advantages.
Until recently, inguinal hernia repair was routinely performed bilat-
erally even when a hernia was clinically apparent on only one side,
because physical examination often failed to demonstrate contralateral
disease. The laparoscope allows inspection of the contralateral side23 to
see if bilateral surgery is truly warranted. Children undergoing unilateral
inguinal hemiorrhaphy with peritoneal inspection of the contralateral
side were more comfortable, required less postoperative analgesia, and
were discharged sooner than those having bilateral herni~mhaphy.~~
 ANESTHESIA FOR LAPAROSCOPY IN THE PEDIATRIC PATIENT 85

COMPLICATIONS

The cardiorespiratory and neurologic problems resulting from hy-

percapnia and reduced venous return secondary to pneumoperitoneum
and extremes of positioning were discussed previously. Elevation of
the diaphragm can produce atelectasis and shunting. This cephalad
diaphragmatic movement also moves the carina in the same direction
and can lead to endobronchial intubation because the tracheal tube is
fixed proximally to the lip. In addition, peritoneal stimulation from
endoscopic instruments can provoke vagal reflexes and cause bradycar-
dia. Surgical trauma to blood vessels or viscera can result in major
hemorrhage, necessitating urgent laparotomy. Insufflated gas can track
subcutaneously, or produce a pneumothorax or pneumomediastinum,
particularly following fundoplication or surgery for esophageal acha-
lasia. Insufflation of large volumes of cold gas in prolonged procedures
has caused hypothermia in small children. Intravascular placement of
the Veress needle can result in massive venous gas embolism.
Chen et a17 reviewed the records of 574 children who underwent a
laparoscopic procedure over a 5-year period and reported a complication
rate of 2%. These included hemorrhage (four cases), esophagotomy
during fundoplication (one case), hernia at trocar site (two cases), and
cellulitis (three patients). Trocar site hernias are more common in pediat-
ric patients because of the thinner abdominal wall. The authors noted a
reduction in complication rate as experience increased.

FETAL ENDOSCOPY

The technique of fetal endoscopy has been applied in the diagnosis

and treatment of fetal disease.*l Fetal endoscopy differs from laparos-
copy in that no gas is insufflated to aid visualization and manipulation
of fetal tissues. It is possible to view the fetal trachea, esophagus, and
bladder. One major advantage is the ability to perform fetal surgery
without a hysterotomy and thus avoid risking premature labor. Tracheal
plugging to encourage lung development in congenital diaphragmatic
hernia can be performed in some centers using video fetoscopic technol-
ogy. In the future, this development inevitably will find more indications.

SUMMARY

Pediatric laparoscopy is a novelty that has yet to be critically as-

sessed in large, randomized controlled trials. Just because an operation
can be performed laparoscopically does not mean it must be done
that wayu Many procedures can now be performed more quickly and
cheaply36through small incisions without the added cardiorespiratory
risks seen in laparoscopy. Reports of serious complications are beginning
to appear in publicatiom.@It will become important to compare laparo-
86 PENNANT

scopic techniques with both open surgery and the minimally invasive
approach for the same procedure. Many published studies suggest lapa-
roscopy offers significant advantages for some operations and for sicker
patients. Practitioners must have a thorough understanding of the physi-
ologic changes that follow pneumoperitoneum and extremes of position-
ing.
As enthusiasm builds, it is essential to maintain safety standards.
Endoscopists must be appropriately trained and peer reviewed. The use
of virtual reality models now allows surgeons to develop and perfect
their laparoscopic skills. When the laparoscopic approach is difficult,
surgeons must be willing to convert to open surgery rather than perse-
vere and risk iatrogenic damage. The role of pediatric laparoscopy has
yet to be defined, although current trends suggest that it will assume an
important position in pediatric surgery.

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Address reprint requests to
John H. Pennant, MA, MB, BS, FRCA
Department of Anesthesiology & Pain Management
University of Texas southwestern Medical School
5323 Harry Hines Blvd
Dallas, TX 75390-9068