Laparoscopic surgery is an important topic in pediatric and adolescent gynecology (PAG) and is becoming the mainstay of operative management for many conditions in this patient population. This chapter aims to outline preoperative, intraoperative, and postoperative considerations for pediatric and adolescent patients undergoing laparoscopic surgery for gynecologic concerns.
Preoperative considerations
Informed consent
Informed consent is imperative for any gynecologic procedure in pediatric and adolescent patients. Most states require a decision maker for those patients under the age of 18. Because most patients presenting to a pediatric and adolescent gynecologist will be under the age of 18, the patient’s decision maker must be present. The decision maker should be the legal guardian of the patient, which can include a parent, appointed legal guardian, or court-appointed legal guardian. Cases of life-threatening surgical emergency, pregnancy, or an emancipated minor may not require a legal guardian for informed consent depending on state laws, so it is recommended that providers become familiar with the laws in the state in which they practice.
Clinicians should also consider involving the patient in the informed consent process when of appropriate age and development in order to allow the patient to participate and provide assent. This allows the patient to demonstrate an understanding of the indications, risks, and benefits of the procedure and allow the patient to actively participate in their own health care decision making. However, this may pose an ethical dilemma in the event the patient opposes the legal guardian and refuses the proposed treatment; thus it is important to understand the laws regarding refusal of lifesaving care in the state they practice.
When possible, and especially with elective gynecologic surgeries, it is recommended that providers schedule a preoperative visit to counsel patients and guardians on the details of the procedure, including the risk and benefits of surgery, alternatives to the procedure, and potential effects on fertility. , , The preoperative visit allows the patient, family members, and/or legal guardians to ask relevant questions before obtaining informed consent.
Anatomic differences in the pediatric and adolescent patient
The subspecialty of PAG continues to grow and expand, resulting in providers who are uniquely trained to understand the anatomic and physiologic differences in the pediatric and adolescent population compared with adults. Pediatric and adolescent anatomy differs based on both the patient’s age and pubertal development.
Newborn females will have effects from estrogen exposure in utero, which manifests as a pronounced clitoris and thickened labia majora and minora. Newborn females may also experience light vaginal discharge and/or spotting in the first several weeks to 18 months of life. Estrogen levels then reach a nadir around the age of 3 to 8 years old, resulting in increasingly atrophic external genitalia with a smaller clitoris and external urethral meatus and smaller and more translucent hymenal ring, compared with the adolescent and adult patient ( Fig. 30.1 ). Additionally, the neonatal uterus is much smaller before pubertal onset, measuring approximately 3.5 cm in length and 1.5 cm in width on average. ,
Prepuberatal females have a distinctly erythematous posterior vestibule because of increased capillary density, which can lead to increased bleeding if disrupted ( Fig. 30.2 ). The cervix in prepubertal females takes up approximately two-thirds of the cervico-uterine length, resulting in a spade-shaped uterus. The fundus grows throughout childhood and results in a tubular-shaped uterus as the fundus and cervix become equivalent in size. Additionally, the ovaries in prepubertal patients are abdominal structures and do not descend down into the pelvis until after pubertal onset. As a result of longer fallopian tubes, a smaller uterus, and higher position of the ovary in the pelvis, there is an increased risk of ovarian and tubal torsion in the pediatric and adolescent population. , The bladder is also higher in the abdomen and extended more cranially than in adults, which can affect positioning of laparoscopic ports.
Pediatric and adolescent gynecologic surgeons should also be aware of differences in hymenal shape, as this may affect surgical planning in the event of the need for uterine manipulation or vaginal surgery. Differences include annular, crescent, redundant, teardrop, microperforated, septated, and imperforate hymenal shapes. Fig. 30.3 includes two specific variations: the septate hymen and annular hymen.
Finally, pediatric and adolescent patients have two unique characteristics that affect laparoscopic entry. The first characteristic is the integrity of the abdominal wall and how it varies with age. There are significant laxity and pliability in the abdominal wall in newborns and infants. The fascial wall tension and strength progressively increase throughout childhood and puberty; therefore the entry forces needed for a young child may be significantly lower than that needed for an adolescent. Moreover, the abdominal wall strength of an adolescent may be significantly greater than that of an adult. The second unique characteristic is the short distance from the abdominal wall to the major abdominal vessels, including the aorta, inferior vena cava (IVC), and the left common iliac vein. 
This distance is much shorter compared with the adult population and can result in inadvertent injury to the major pelvic vessels if laparoscopic port placement is not adjusted to account for this difference. , , ,
Preoperative imaging
Preoperative imaging is an important step in surgical planning for many pediatric and adolescent conditions that require laparoscopic surgery. The initial imaging modality of choice for a pelvic mass is a transabdominal ultrasound of the pelvis. Transvaginal ultrasound is unnecessary and should not be performed in pediatric and adolescent patients, particularly if they have not been sexually active. In some settings where transabdominal imaging quality is poor, both transrectal and transperineal approaches have been described to obtain adequate imaging, especially in the setting of patients with distal vaginal agenesis or transverse vaginal septa, where knowledge of the distance between the perineum and thickeness of the obstruction is critical to surgical planning. , , ,
Magnetic resonance imaging (MRI) should be considered in the setting of suspected reproductive tract anomalies or if there is concern for malignancy. MRI in such circumstances allows for full evaluation of the gastrointestinal, genitourinary, and lymphatic systems in addition to the pelvic structures. MRI may also aid in surgical planning for patients with transverse septa or distal vaginal agenesis to help determine septal thickness and distance from introitus to the level of obstruction. , , In these clinical scenarios, placement of a vitamin E or fish oil capsule at the perineum may help delineate the location of the introitus, as the capsule contains fat and appears hyperdense on imaging. ,
Of note, diagnosis of uterine or vaginal anomalies by imaging alone before puberty can be challenging because of the small size of the prepubertal uterus and lack of endometrial stimulation, which would otherwise distend the uterus and vagina in the setting of a reproductive tract obstruction.
Antibiotic prophylaxis
Antibotic prophylaxis at the time of laparoscopic surgery is important in both the pediatric and adolescent and adult populations to reduce the risk of surgical site infections. , , The Centers for Disease Control and Prevention (CDC) recommends preoperative antibiotic prophylaxis for clean-contaminated cases that involve entry into the genitourinary, gastrointestinal, and alimentary tracts. Surgeries involving the adnexal structures alone (fallopian tubes and ovaries) do not require antibiotic prophylaxis.
General guidelines for preoperative antibiotic prophylaxis are provided by the 2013 statement from the American Society of Health-Systems Pharmacists. Recommendations typically include a single dose of antibiotics administered within 60 minutes of surgical incision and redosage based on the half-life of the antibiotic. First- and second-generation cephalosporins are generally recommended as first line for prophylaxis. , , Table 30.1 summarizes specific guidelines, including dosages and redosing intervals, for pediatric and adolescent patients undergoing gynecologic surgery. Of note, it is recommended that surgeons avoid fluoroquinolones in pediatric patients because of concerns regarding the development of arthropathy. However, the data are sparse on use of fluoroquinolones in pediatric patients, including a specific age range in which to avoid this class of drugs.
| Antimicrobial | Adult Dosing | Pediatric Dosing | Recommended Redosing Interval From Initial Dose (h) |
|---|---|---|---|
| Ampicillin-sulbactam | 3 g (2 g ampicillin, 1 g sulbactam) | 50 mg/kg of ampicillin component | 2 |
| Ampicillin | 2 g | 50 mg/kg | 2 |
| Aztreonam | 2 g | 30 mg/kg | 2 |
| Cefazolin a | 2 g (3 g if ≥120 kg) | 30 mg/kg | 4 |
| Cefuroxime | 1.5 g | 50 mg/kg | 4 |
| Cefotaxime | 1 g | 50 mg/kg | 3 |
| Cefoxitin | 2 g | 40 mg/kg | 2 |
| Cefotetan a | 2 g | 40 mg/kg | 6 |
| Ceftriaxone | 2 g | 50–75 mg/kg | n/a |
| Ciprofloxacin c | 400 mg | 10 mg/kg | n/a |
| Clindamycin b | 900 mg | 10 mg/kg | 6 |
| Ertapenem | 1 g | 15 mg/kg | n/a |
| Fluconazole | 400 mg | 6 mg/kg | n/a |
| Gentamicin b | 5 mg/kg (based on dosing weight) | 2.5 mg/kg (based on dosing weight) | n/a |
| Levofloxacin c | 500 mg | 10 mg/kg | n/a |
| Metronidazole | 500 mg | 15 mg/kg | n/a |
| Moxifloxacin c | 400 mg | 10 mg/kg | n/a |
| Piperacillin-tazobactam | 3.375 g |
| 2 |
| Vancomycin | 15 mg/kg | 15 mg/kg | n/a |
| Oral antibiotics for colorectal surgery (used for mechanical bowel preparation) | |||
| Erythromycin base | 1 g | 20 mg/kg | n/a |
| Metronidazole | 1 g | 15 mg/kg | n/a |
| Neomycin | 1 g | 15 mg/kg | n/a |
a Recommend as first-line agents.
b Recommend use of gentamicin and clindamycin for patients with β-lactam antibiotic allergies.
c Recommend avoiding use of fluoroquinolones in pediatric patients.
Dosing for the pediatric and adolescent patient is typically weight based. If the patient weighs more than 40 kg, antibiotic dosing calculations on a milligram-per-kilogram basis will generally result in doses that exceed recommended adult thresholds. It is therefore recommended that in pediatric patients weighing more than 40 kg, standard adult dosing should be used.
Venous thromboembolism prophylaxis
The most common cause of venous thrombolism (VTE) in the pediatric population is thrombosis of an indwelling central catheter in hospitalized and postsurgical patients. Other risk factors include sepsis, congenital thrombotic disorders, underlying malignancy, tobacco use, use of oral contraceptive pills (OCPs), pregnancy, and obesity. , ,
Data regarding use of VTE prophylaxis in pediatric and adolescent patients are limited, especially in those less than 13 years old, but it has been shown that the risk of surgery-related VTE is lower in patients under 13 years of age. , Morgan and colleagues found the risk of VTE is negligible in patients under 13 years of age, and routine chemoprophylaxis in this patient population is not recommended. , It has been proposed that the decreased risk of VTE in this patient population is caused by physiologic differences in the hemostatic system. Patients under 13 years old have approximately 50% less circulating vitamin K–dependent clotting factors, twice the amount of specific thrombin inhibitors, and 25% lower ability to produce thrombin. As a result, it is generally recommended to avoid chemical VTE prophylaxis in patients less than 13 years old, as the risk of chemical prophylaxis outweighs the potential benefit.
Some hospital systems and institutions have developed guidelines and scoring systems to determine at-risk patients based on both patient risk factors—including obesity, use of OCPs, immobility, inherited factors, malignancy, or congenital heart disease—and surgical risk factors such as type and length of sugery. We recommend that providers consult their institution-specific guidelines to determine those patients who meet criteria for chemical prophylaxis.
Low-molecular-weight heparins (LMWHs) are the mainstay of chemical prophylaxis in adults and children. LMWHs are preferred to unfractionated heparin (UFH) and warfarin, given the more predictable pharmocokinetics, minimal need for serum monitoring, less alteration in the case of underlying disease, less interaction with concurrent medications, and greater ease of administration, as they are administered subcutaneously instead of intravenously. LMWHs also have less incidence of heparin-induced thrombocytopenia and osteoporosis as compared with UFH. Clinicians should be aware of the patient’s kidney function before administration of LMWHs, as these medications are renally cleared.
Table 30.2 provides dosage recommendations for the most commonly used LMWH, enoxaparin, which was adopted from Morgan and colleagues.
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