Access Veress Access

Access using the Veress method is applicable to children as long as the operator recognizes several issues.

FIGURE2 ■ Diagram of surgical setup with the surgeon at the patient's feet for an upper abdominal procedure in a small child. The surgeon is orientated in a straight line with the operative area. Abbreviations: S, surgeon; SN, scrub nurse; SA, surgical assistant; A, anesthesiologist; M, monitor.

FIGURE3 ■ Diagram showing the surgical setup in a larger child for a renal procedure with the surgeon at the side of the patient, similar to that for adult patients. Abbreviations: S, surgeon; SN, scrub nurse; SA, surgical assistant; A, anesthesiologist; M, monitor.

FIGURE4 ■ Diagram showing the surgical setup for a pelvic procedure such as an antireflux operation with the surgeon at the patient's head to permit alignment with the operative filed. Abbreviations: S, surgeon; SN,scrub nurse; SA, surgical assistant; A, anesthesiologist; M, monitor.

FIGURE2 ■ Diagram of surgical setup with the surgeon at the patient's feet for an upper abdominal procedure in a small child. The surgeon is orientated in a straight line with the operative area. Abbreviations: S, surgeon; SN, scrub nurse; SA, surgical assistant; A, anesthesiologist; M, monitor.

FIGURE3 ■ Diagram showing the surgical setup in a larger child for a renal procedure with the surgeon at the side of the patient, similar to that for adult patients. Abbreviations: S, surgeon; SN, scrub nurse; SA, surgical assistant; A, anesthesiologist; M, monitor.

FIGURE4 ■ Diagram showing the surgical setup for a pelvic procedure such as an antireflux operation with the surgeon at the patient's head to permit alignment with the operative filed. Abbreviations: S, surgeon; SN,scrub nurse; SA, surgical assistant; A, anesthesiologist; M, monitor.

In the child it is very easy to tent the peritoneum upward at the umbilical attachments and slide the Veress needle along the preperitoneal space.

The author prefers to close all ports of 3 mm and larger.

Skin stitches in children may not be as useful as the skin can pull away from the abdominal wall much more easily. Fixation sutures should include some external fascia as well for security.

Port fixation is critical in children as it is very easy to dislodge the cannula.

In general the open access approach is used in our routine pediatric laparoscopic cases. It is likely the lowest risk and most efficient system.

In the child tissue resistance may not be great and the shield can snap back blunting the needle before the peritoneum is pierced. It is also important to recognize the danger of past-pointing when passing the needle or subsequent trocars in children. It is much closer to the back wall of the body and associated vascular structures.

In the child it is very easy to tent the peritoneum upward at the umbilical attachments and slide the Veress needle along the preperitoneal space.

This space is insufflated, which may make subsequent laparoscopy difficult. There is a tendency of the pediatric peritoneum to pull away from the abdominal wall more readily than in adults, so this problem is more of an issue. Similarly, as the Veress needle advances, the safety shield is pushed back by the resistance of the tissues.

In the child this resistance may not be great and the shield can snap back blunting the needle before the peritoneum is pierced. It is also important to recognize the danger of past-pointing when passing the needle or subsequent trocars in children. It is much closer to the back wall of the body and associated vascular structures.

When using the Veress system it is preferable to utilize a single-pass system that allows positioning of the endoscope through the Veress needle (using a miniature 2 mm endoscope), or to use the sheath placed with the Veress needle to permit placement of the larger cannula, as in the Step® systema. This eliminates the need for a second part placement after the insufflation and reduces the risk of inadvertent injury. The Visiport® system has not been of much use in pediatric applications due to its size.

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