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BACKGROUND

The pediatric surgery community was relatively slow to adopt the techniques of minimally invasive surgery (MIS). This reluctance may have stemmed from several factors. Pediatric surgeons typically utilize small incisions during open procedures and therefore the advantage of the MIS approach was not readily apparent. Additionally, adequate instrumentation for MIS in small children required technologic advances above and beyond the standard tools used in adult MIS. Finally, a poor understanding of pain in the pediatric patient tempered enthusiasm for the minimally invasive approach. Despite the aforementioned barriers, pediatric MIS has seen an exponential upsurge in interest in recent years.

INSTRUMENTATION

The equipment used during pediatric MIS is similar to that used in adults but on a smaller scale. Pediatric surgeons commonly use 3- to 5-mm scopes and instruments. These instruments are often shorter than their adult counterparts (Figure 1). When used, trocars are short and may be disposable or reusable. Smaller trocars (3–4 mm) are usually reusable. Because of the thin abdominal wall in neonates and infants, trocars can often become dislodged with instrument changes during the course of an operation. Thus, trocars are often secured to the abdomen by suture or commercially available adhesive products. A standard insufflator may be used for pediatric MIS with the understanding that settings must be adjusted appropriately. Neonates and infants require low pressure (6–8 mm Hg) and flow rates (3–5 L/min). These settings can be increased with age and as tolerated by each patient’s individual physiology.

POSITIONING

Positioning may vary depending on the organ or body cavity of interest. Abdominal procedures are typically performed with the patient in the supine position with the arms tucked. However, a modified decubitus position may be used during a splenectomy or adrenalectomy. In the case of infants, positioning the patient transversely on the table can often facilitate easier access to the patient and instrumentation. Similarly, when performing upper abdominal surgery, such as gastric fundoplication, in patients too small to be placed in stirrups, modified lithotomy or “frog-leg” positions can be used to shorten the distance between surgeon and target area for the operation (Figure 2A). In all cases, in order to maximize the freedom of (anterior-posterior) movement for instruments in lateral port sites, smaller children can be elevated off the table with stacked blankets or towels.

Thoracoscopy is often performed with patients in a lateral decubitus position. Unlike what is typical for adults, prepping the ipsilateral arm into the field may allow for greater flexibility of trocar placement and freedom of instrument movement. As with laparoscopy, neonates and small infants may be positioned transversely on the bed (Figure 2B). This allows both the surgeon ...

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