Planning, Theater Setup, and Equipment
Introduction
Laparoscopic surgery is open surgery carried out through small incisions with enhanced magnification of the operative field. The advantages of a laparoscopic (or key hole) approach to the abdomen and pelvis have been well documented across the spectrum of surgical disciplines [1]. These include a significant reduction in postoperative pain, length of stay, recovery time, and adhesion formation. In children or adolescents, this will result in a faster return to school and normal activities. Laparoscopic incisions are smaller than a transverse incision and indeed a midline laparotomy. This reduction in wound visibility is especially important in children and adolescents who otherwise may be asked by contemporaries or a new partner about the reasons behind the scar. This will be especially distressing while coming to terms with the psychological impact of the diagnosis of an XY karyotype or an absent uterus.
The enhanced visualization of laparoscopic surgery is due to the greater magnification and ability to see deep into the pelvis, compared to open surgery. This is especially important in cases of Mullerian anomalies or endometriosis when the anatomy is distorted and access to the operative site is difficult to achieve.
The advantages of laparoscopic surgery for both the patient and the surgeon would indicate that this approach should be the technique of choice when operating within the abdomen and pelvis in pediatric and adolescent gynecology.
Who Should Perform These Operations and in Which Location?
The makeup of the team will depend on the age and maturity of the patient and the presenting condition. For example a 16-year-old with an ovarian cyst can be managed in a similar manner to a young adult in terms of anesthetic and operative techniques. Conversely, a 12-year-old with a complex Mullerian anomaly may require a pediatric anesthetist, pediatric urologist, pediatric surgeon, counseling services, and an endocrinologist. In addition, the hospital environment for surgical recovery is important and needs to take into account the age of the patient and the potential need for parental support. A room covered in cartoon characters with lights-off at 7p.m. will put a young child at ease but will leave a teenager distinctly unimpressed. However, in most units adolescents are not treated on adult wards, as this is not an appropriate environment.
A team approach to surgery is paramount to optimize outcome. The requirements for the surgical team are that the correct knowledge and skills are available during the operation. These can be within the same person or more commonly across two specialties. Some of the laparoscopic surgery will be complex, and it is unlikely that an expert pediatric and adolescent gynecology (PAG) consultant who deals with all other aspects of patient management will have a sufficient laparoscopic workload to enable adequate skill acquisition. Likewise an expert laparoscopic surgeon who carries a heavy surgical workload is unlikely to have sufficient knowledge surrounding all the other aspects of care. Thus, a team approach with a PAG specialist (with the correct knowledge) operating with an adult laparoscopic specialist with the skills of dissection of the pouch of Douglas, uterovesical fold, and pelvic sidewall and proficiency in laparoscopic suturing will optimize the surgical outcome. This approach is common in units offering complex surgery to this group of patients in the UK. We would encourage anyone endeavoring to perform complex laparoscopy in the PAG setting to foster this working relationship.
Planning Surgery
The preoperative assessment in making the diagnosis and determining the indications for surgery is dealt with in the relevant chapters in this book. Likewise, consent for surgery in children and adolescents has already been covered in previous chapters. In this section, we address those aspects specifically relevant to the surgery itself.
The suitability for laparoscopic surgery needs to take into account the specifics related to the surgery itself and also general considerations. Cardiovascular reserve to enable the raised intra-abdominal pressure and head down position during surgery is not normally a concern in the younger age group. Previous abdominal surgery and the size of the patient may determine the method for obtaining a pneumoperitoneum. Previous abdominal surgery increases the risks of adhesions and hence organ damage during primary port insertion.
The requirement to use a uterine manipulator should be discussed with the patient and her family during the preoperative period, especially with girls who have never been sexually active. This may have significant social and religious implications, as there is a risk that the hymen may tear. Vaginal examination during the procedure is obviously of less significance during vaginal reconstructive procedures.
In procedures where there is a Mullerian anomaly, preoperative knowledge of the renal tract is essential as it is important to know whether there is an absent kidney or a duplex system. This information will be required during surgical dissection of the pelvic side wall. In patients with XY gonadal dysgenesis, preoperative MRI will in most cases locate the site of the gonads and hence enable preoperative planning of the surgical approach and potential requirements of a pediatric urologist where groin dissection may be required.
Theatre Setup
Surgery requires an effective team with each member having a specific role. The familiarity of the anesthetic, scrub, and circulating staff with one another, with their equipment, and with the procedures being performed will have a direct effect on the smooth running of each case.
The theater environment has to be fit for purpose. Advanced laparoscopic theatre setups will reduce stress in the operating theater and minimize risks to staff and patients [2,3]. The layout of equipment in the operating room has taken on more relevance as the technology available to the laparoscopic surgeon has increased. When open surgery was the norm, a single diathermy machine and a suction bottle were the only devices that needed to be near the operating table. With laparoscopy that has increased to include newer energy machines such as ultracision and advanced bipolar, insufflator stacks, suction/irrigation setups and multiple high-definition monitors and control screens. The layout needs to facilitate flow of equipment to the operating table without obscuring the surgeons’ view of the monitors, ideally without cables running along the floor, which could represent a trip hazard in the low-light conditions of a laparoscopic theater. Having an integrated system that allows the surgeon to control gas flow, light intensity, and the recording of images rather than requesting circulating staff to do so saves time and improves efficiency.
State of the art theaters result in a quietly flowing environment in which staff feels less stressed, which allows the team to concentrate on the operation itself. This results in a more efficient and relaxed surgical environment, which enables more complex surgery to be carried out in a safer manner.
Laparoscopic Techniques and Equipment
Most laparoscopic pelvic procedures are performed in the Lloyd-Davies position to enable access to the vagina if required. Prior to insufflation, an indwelling catheter normally empties the bladder. At the end of the procedure, this can be removed if the operation was only minor. Consideration should be given to leaving the catheter overnight as trying to catheterize a child who goes into urinary retention postoperatively can be traumatic. If the uterus is present and the operation involves inspection of the pouch of Douglas or uterine manipulation, then the uterus is instrumented.
Three main methods are utilized to obtain a pneumoperitoneum: insertion of a Verres needle at the umbilicus, open entry (Hasson), and subcostal insertion of the Verres needle (Palmer’s entry). Many patients in this age group will be more susceptible to vascular injury from a standard umbilical verres technique due to the short distance from the umbilicus to the major abdominal blood vessels. To minimize the risk of vascular injury, a Hasson entry technique should be considered [4].
Umbilical entry is not suitable, whether via a closed or open technique, where there is an increased risk of adhesions under the umbilicus. An alternative entry site should be used. A Verres needle or a direct optical entry at Palmers point (left upper quadrant 2 cm below the costal margin) provides a relatively safe entry into the abdomen, allowing the inside of the umbilicus to be inspected and a port placed if free of adhesions [5]. Where a subcostal entry point is utilized, there is an increased risk of damaging the stomach if it is distended. An oro-pharyngeal tube should be placed at the start of the operation [6].
Instrumentation would largely reflect the same used in adult surgery. Minimizing the number and size or the ports should be considered to enhance the cosmetic result. However, this should not be at the expense of safe efficient surgery. For most operations we utilize an umbilical 5 or 10 mm port for the laparoscope and 2 lateral ports in line with the umbilicus and very lateral. This enables good triangulation during surgery. For complex cases, we also insert a suprapubic 5 or 10 mm port to enable additional manipulation by the assistant. In cases where further ports to enable retraction would be useful, we insert needles to carry this out without the need for ports [7].
Laparoscopic Management of Benign Ovarian Masses and Endometriosis
General Considerations
The first consideration when deciding on surgical treatment of a presumed benign ovarian mass is preservation of ovarian function. An ovarian cystectomy is always preferred over an oophorectomy as many follicles are left behind after cystectomy and can serve as oocytes for reproduction in the future. The amount of tissue remaining from the ovary after a cystectomy can also alter future fertility.
Among adolescents, the most common benign ovarian masses are functional cysts and benign neoplasms. There is a bimodal distribution of functional cysts, peaking during the fetal/neonatal and perimenarchal ages. As these cysts are usually benign and resolve spontaneously, every effort should be made to manage them expectantly with serial ultrasound prior to considering surgery.
Paratubal and paraovarian cysts may mimic simple ovarian cysts in both presentation and imaging. Surgical management is usually suggested for any adnexal cyst greater than 4 cm that fails to regress. Surgical intervention will prevent potential torsion as well as provide a pathologic diagnosis. Fortunately, the majority of ovarian cysts can be managed by laparoscopy.
Neoplastic ovarian masses in the pediatric and adolescent population include tumors of germ cell, epithelial, sex cord stromal, and metastatic of other origins. Germ cell tumors are the most common histological subtype in adolescents. Because non-epithelial masses predominate in the adolescent, the following discussion focuses on the most common benign germ cell tumor, the mature cystic teratoma.
Dermoid Cysts
Mature cystic teratomas, or dermoid cysts, arise from ectodermal, mesodermal, and endodermal tissue and are the most common benign ovarian tumor found in children and adolescents. The majority of surgeons agree that symptomatic, large, and atypical dermoids require surgical removal. In asymptomatic patients, the age of the patient, future fertility, and cyst size are considered when deciding if surgery is indicated.
Traditionally, dermoid ovarian cysts have been removed by laparotomy. More recently, surgeons prefer a laparoscopic approach for treating ovarian cysts, as it is associated with less blood loss, shorter hospital stay, and fewer intraoperative and postoperative complications.
Normally, a three-port technique will suffice. The increased risk of intraoperative cyst rupture remains the main disadvantage for considering a laparoscopic approach. Intraoperative rupture may result in a theoretical risk of chemical peritonitis, spillage of malignant cells into the peritoneal cavity, and/or adhesion formation. Fortunately, many studies have failed to demonstrate any complications of chemical peritonitis following spillage of dermoid contents, supporting a minimally invasive approach [8]. Laparoscopic cystectomy is the preferred method of treating dermoid cysts, with the aim of preserving as much ovarian tissue as possible. Bilateral dermoids occur in 10 percent to 15 percent of cases; therefore, the contralateral ovary should always be visualized at the time of surgery. As the recurrence/persistence rate of dermoids following surgery is approximately 3 percent to 15 percent, follow-up with ultrasound 6–12 months postoperatively is recommended.
Adnexal Torsion
If torsion is suspected, prompt diagnosis and intervention are necessary to avoid long-term damage to the ovary and prevent oophorectomy. In cases of suspected ovarian torsion, detorsion with or without cystectomy has become the recommended surgical practice, even with a necrotic appearance of the ovary. Despite this recommendation, oophorectomy is still performed frequently at the time of ovarian torsion (30 percent to 86 percent).
Historically, it was recommended to remove the adnexa due to a theoretical risk that untwisting the ovarian pedicle would result in a thromboembolic event. Large retrospective series of detorsion have failed to demonstrate any patients with a thromboembolic event, further supporting a conservative surgical approach.
A laparoscopic approach is the preferred method of managing a presumed ovarian torsion. Usually, a three-port technique will suffice. The presence of a large ovarian mass (>8 cm) or suspected malignancy may preclude a laparoscopic approach but, fortunately, malignant lesions are particularly uncommon (<3 percent) in both the pediatric and adult populations.
Multiple studies have reported ovarian salvage following detorsion of the blue black ovary. Ovarian function has been documented at the time of follow-up ultrasound, following additional surgery, or following successful IVF [9].
Recurrence of torsion can result in an agonadal patient; therefore, prophylactic oophoropexy should be discussed at the time of surgery. The long-term effects of oophoropexy on fertility remain uncertain. Most surgeons consider performing this procedure when the ovarian ligament is congenitally long, in cases of repeat torsion, or when no obvious cause for the torsion is found. If an oophoropexy is carried out, the ovary is usually pexed to the pelvic side wall, back of the uterus, or the ipsilateral uterosacral ligament with either absorbable with nonabsorbable suture. Alternatively, the utero-ovarian ligament can be shortened [10] (Figure 11.1).
