Open Access

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

It is important to be able to create an adequate air-seal after port placement, however. It is not totally free of complications and caution is needed to avoid bowel injury (6). Several simple maneuvers may be performed to facilitate efficient use of the open access system.

There is no formal Hasson cannula in smaller sizes and most are fairly bulky for pediatric use (7). One can modify a conventional cannula by wrapping it with a cuff of rubber tubing and using this to suture to as well as to press into the skin and fascia to improve an air seal. Vaseline gauze may be used if a leak persists.

The most useful tool has been the placement of a purse string suture in the fascia after the peritoneum (or retroperitoneum) has been entered, but before the cannula is placed (8). The purse string is of 3-0 or 2-0 absorbable suture and the loop side is kept loose. The cannula is placed and if there is a gas-leak, the two ends are pulled taut and held in place with a Rummel tourniquet. If the seal is good, the loop is wrapped twice around the gas input stem and pulled snugly at the point where the cannula is in the appropriate amount. This prevents the cannula from being dislodged. The stitch may be used as the fascial closure stitch at the end of the case.

Port fixation is critical in children as it is very easy to dislodge the cannula. Ports cannot be placed too far in to the abdomen or retroperitoneum as they will interfere with the operative field, but with little inside the body, they are more easily prone to inadvertent removal. The abdominal wall is much thinner and there is less to pass through and less resistance. Any method used to secure the cannula must limit the risk of dislodgement. With the Step system, the cannula is unlikely to be dislodged due to the radially expanding design, but this is not guaranteed and fixation is recommended.

When possible, the fascial purse-string stitch is used to keep the cannulae in the body, and makes later port site closure efficient. A simple fixation stitch to the fascia is just as effective.

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.

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