Robert Carachi

Sandeep Agarwala
Tim J. Bradnock Editors

Basic Techniques in
Pediatric Surgery

An Operative Manual

1 23
Basic Techniques in Pediatric Surgery
 

Robert Carachi · Sandeep Agarwala ·

Tim J. Bradnock (Editors)

Salvatore Cascio
Hock Lim Tan
(Associate Editors)

Basic Techniques
in Pediatric Surgery
An Operative Manual

123
Editors
Prof. Dr. Robert Carachi Mr. Tim J. Bradnock
University of Glasgow, The Royal Hospital for Sick Children,
The Royal Hospital for Sick Children, Sciennes Rd 9,
G3 8SJ, Glasgow, UK EH9 1LF, Edinburgh, UK

Dr. Sandeep Agarwala, Additional Professor

Department of Pediatric Surgery, Associate Editors
All India Institute of Medical Sciences, Prof. Hock Lim Tan
New Delhi, India Mr. Salvatore Cascio

ISBN 978-3-642-20640-5    ISBN 978-3-642-20641-2 (eBook)

DOI 10.1007/978-3-642-20641-2

Springer Heidelberg Dordrecht London New York

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Dedication

We would like to dedicate this book to our wives and children. An-
nette Carachi and their sons Peter, Michael Andrew and Philip.
Ranju Agarwala and their son and daughter Rishabh and Shreya.
Rachel Bradnock and their sons Henry and Toby. Mariagrazia Cas-
cio and their daughters Mariateresa and Costanza. Evelyn Tan and
their daughter Melanie and son Alexander.
We would also like to thank Mr. Bachem, Ms. Blasig and Ms.
Schröder from Springer who had an extremely difficult job and
made the book so colourful.
The final dedication is to Mrs Kay Byrne who was a faithful ac-
ademic secretary to the senior author of this book. She was respon-
sible for all the correspondence and collating of the manuscripts
which she has helped edit even after she retired.
 vii
Foreword

The “Basic Techniques in Pediatric Surgery” is not just another book in the field. The manual
has been prepared to meet the basic need of the undergraduate and the postgraduate students
and the general paediatric surgeons with the operative and the postoperative basic details
related to various surgical procedures in children.
The authors of the manual are very senior and experienced paediatric surgeons from the
Royal Children Hospital, University of Glasgow, Glasgow (RC) and All India Institute of Med-
ical Sciences, New Delhi (SA). The scientific information is up-to-date, complete and authen-
tic. Significantly, the chapters have been contributed by the younger trainees in pediatric sur-
gery from the institutions of repute and these have been very well supervised by the senior au-
thors. All the authors are very much familiar with the surgical techniques described in the man-
ual and involved in the day to day actual planning in the preparation of the patients for surgery
or the operative and the postoperative care.
The manual of about 640 pages has covered various paediatric surgical problems with the
emphasis on preoperative, operative and the postoperative aspects. The manual has been di-
vided into various subsections covering the basic surgical techniques, anatomic and fundamen-
tal principles of paediatric surgery.
Being produced by “Springer” a well known name in the field of medical publications around
the world, the manual has maintained highest standard of publication. The language is simple
and easily understood. It is well supported by diagrams and figures.
I wish to compliment the contributors for the thought and the splendid job so well done in
producing a manual which was very much needed in the field. I am sure the manual would fill
the void. It would serve as a good companion to all the under and the postgraduate paediatric
surgical students working in various teaching and non teaching institutions in the developing
and the developed world. I strongly recommend the same to all the users in the specialty and
the institutional libraries around the world.

Professor Devendra K Gupta

MS, M.Ch, FAMS, FRCS (Glas. & Edin.), D.Sc (H.C.)
Prof. of Pediatric Surgery,
Vice Chancellor-CSMMU,
(King George Medical University),
Lucknow. UP. India
President: Federation of Associations of Pediatric Surgeons from SAARC (FAPSS)
President Elect: World Federation of Associations of Pediatric Surgeons (WOFAPS)
Preface

This operative manual is a joint venture between the Department of Surgical Paediatrics at
The Royal Hospital for Sick Children in Glasgow and the Department of Paediatric Sur-
gery, All India Institute of Medical Sciences (AIIMS) in New Delhi. A total of 67 paedi-
atric surgical trainees and consultant mentors have authored chapters for the book, with
additional contributions from leading paediatric surgeons from around the world, who are
well known for their expertise in a particular operation.
The operative manual aims to fill a niche in the surgical literature by providing concise, easy-
to-follow descriptions of 183 paediatric surgical operations and the basic operative techniques
that are required to perform them safely. The manual is intended to be something akin to a sur-
gical ‘cook-book’, in that it describes very clearly, in a step-by-step sequence, the component
parts of each operation. For ease of use, each chapter has been written in the same style, with
a succinct, well-illustrated description of the operative technique, followed by further sections
containing helpful tips and warning the reader about common pitfalls.
The operative manual covers the majority of operations and techniques that a paediatric sur-
gical trainee could expect to be involved with at any level from interested spectator to first as-
sistant and finally, principal operator. We are not suggesting that trainees should perform all the
operations included in this book, but we feel that no matter what their level of experience and
hence involvement in an operation, a trainee should always go into theatre armed with a ba-
sic understanding of the operative steps and sequence involved. We hope that the operative de-
scriptions in the manual will not only help trainees prepare for cases in theatre but also serve
as a useful revision tool for the FRCS (Paed Surg) exam and other Board exams worldwide.
The book starts with a ‘Basic Surgical Techniques’ section. This section takes the trainee
through the preparatory stages of an operation, covering topics such as the ‘WHO Safe Surgery
Checklist’, patient positioning, skin preparation and a ‘field guide’ to commonly employed sur-
gical instruments and their uses. Further chapters describe commonly used skin incisions and
some of the skills and techniques that trainees should develop in theatre. The remainder of the
book describes individual operations by organ system or anatomical region. The final chap-
ter of the book has been included to reflect the changes in the way in which paediatric surgi-
cal training is being delivered in the UK. This chapter provides the reader with an overview of
the new paediatric surgery syllabus, with special reference to the operative competencies that
should be developed by each stage of training. We hope that this will also be of interest to train-
ers in other countries.
It has not been our intention to provide information regarding underlying disease processes
or their management and outcome, as these topics have been well covered elsewhere. We have
excluded complex subspecialty surgery such as liver and bowel transplantation, neurosurgery,
complex reconstructive orthopaedic surgery, and cardiac surgery as these procedures are best
covered in large, specialist operative textbooks. Paediatric surgeons in the UK no longer per-
form some of the operations listed in the contents page. These cases are included for readers in
countries such as India and parts of Europe, where paediatric surgery remains more generalised.
x Preface   

We are cognisant of the fact that in surgery as in life, there are many paths to the same end. We
do not profess that the operative techniques described in this book are the only way of achiev-
ing the intended outcomes of a procedure. The operative descriptions presented in this book are
included because they are safe and effective. Furthermore the descriptions have been enhanced
with tips and modifications, which have been learnt and developed by senior surgeons through
years of personal experience.
It has been a pleasure watching the operative manual evolve. We hope that you enjoy using
it and that it helps you to develop a sound understanding of the operative techniques and pro-
cedures which underpin this most rewarding of specialties.

Robert Carachi Sandeep Agarwala Tim J. Bradnock

Dr. Sandeep Agarwala and Robert Carachi

Tim J. Bradnock and family Prof. Hock Lim Tam Salvatore Cascio
Preface xi

Consultants and trainees of “Department of Surgical Pediatrics, The Royal Hospital for Sick Children, G3 8SJ,
Glasgow, UK”

Contributing authors from the Department of Pediatric Surgery, All India Institute of Medical Sciences,
New Delhi, India
Contents

Part  A Basic Surgical Techniques  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .    1

A1 The World Health Organisation Surgical Safety Checklist  . . . . . . . . . . . . . .    3
A2 Positioning 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .    5
A3 Preparation 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .    8
A4 Surgical Instruments  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .    11
A5 Diathermy 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   21
A6 Local Anaesthesia  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   26
A7 Skin Lines and Wound Healing  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   34
A8 Transverse Supraumbilical Incision  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   37
A9 Midline Laparotomy and Paramedian Incisions  . . . . . . . . . . . . . . . . . . . . . .   40
A10 Subcostal and Rooftop Incisions  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   43
A11 Pfannenstiel Incision  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   47
A12 Gridiron, Lanz and Rutherford Morison Incisions  . . . . . . . . . . . . . . . . . . . .   50
A13 Sutures and Their Uses  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .    53
A14 Knots and Their Uses  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   56
A15 Hand Tying  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   58
A16 Instrument Tying  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   60
A17 Repair of Vessels, Nerves and Tendons  . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   64
A18 Haemostasis 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   67
A19 Debridement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   70
A20 Management of Acute Thermal Injuries in Children  . . . . . . . . . . . . . . . . . . .   72
A21 Venepuncture, Intraosseous Access and Venous Cut-down  . . . . . . . . . . . . .   76
A22 Open Insertion of Tunnelled Central Venous Lines and Portacaths  . . . . . . .   82
A23 Percutaneous Insertion of Central Venous Lines and Portacaths  . . . . . . . . .   85
A24 Principles of Tumour Biopsy   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .    87
A25 Skin and Muscle Biopsies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   90
A26 Excision of Common Skin Lesions  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   92
A27 Compartment Syndrome and Lower-Limb Fasciotomy  . . . . . . . . . . . . . . . .   95
A28 Plastering 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   98
A29 Traction and the Thomas Splint  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  101
xiv Contents  

A30 Tourniquets . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  105

A31 Drains and Drain Fixation Techniques  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  107
A32 Principles of Wound Management  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  110

Part  B Head and Neck  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  119

B1 Layers of the Scalp and Suturing  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  121
B2 External and Internal Angular Dermoid Cyst  . . . . . . . . . . . . . . . . . . . . . . . .  125
B3 Cleft Lip and Palate  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  128
B4 Lacerations to the Face, Lips, Tongue and Ears  . . . . . . . . . . . . . . . . . . . . . .  132
B5 Ear Deformities  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  134
B6 Branchial Remnants  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  137
B7 Parotid Dissection  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  141
B8 Ranula and Tongue-Tie  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  144
B9 Excision of Thyroglossal Cyst and Fistula  . . . . . . . . . . . . . . . . . . . . . . . . . .  147
B10 Lymph Node Biopsy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  149
B11 Principles of Surgery for Lymphatic Malformations  . . . . . . . . . . . . . . . . . . .  151
B12 Tracheostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  153
B13 Torticollis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  155
B14 Burr Holes  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  157
B15 Ventriculoperitoneal Shunting for Hydrocephalus  . . . . . . . . . . . . . . . . . . . .  159
B16 Cervical Oesophagostomy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  163
B17 H-Type Tracheo-oesophageal Fistula  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  166

Part  C Spine and Limbs  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  169

C1 Spina Bifida  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  171
C2 Forearm Manipulation and Molded Cast  . . . . . . . . . . . . . . . . . . . . . . . . . . . .  174
C3 Distal Radius Wiring  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  178
C4 Forearm Diaphyseal Reduction and Fixation (Closed Wiring)  . . . . . . . . . . .  181
C5 Displaced Supracondylar Humeral Fracture  . . . . . . . . . . . . . . . . . . . . . . . . .  184
C6 Femoral Fracture and Spica Cast  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  188
C7 Tibial Diaphysis Fracture – External Fixation . . . . . . . . . . . . . . . . . . . . . . . . .  190
C8 Infection – Washout of the Knee and Hip  . . . . . . . . . . . . . . . . . . . . . . . . . . .  192
C9 Syndactyly 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  195
C10 Polydactyly 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  198
C11 Biopsy of an Extremity Tumour  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  202
C12 Ingrown Toenail  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  204
Contents  xv

Part D Thorax  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  209

D1 Chest Tube Insertion  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  211
D2 Thoracotomy 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  214
D3 Empyema 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  218
D4 Bronchoscopy and Removal of Foreign Body  . . . . . . . . . . . . . . . . . . . . . . . .  222
D5 Oesophageal Atresia and Tracheo-oesophageal Fistula  . . . . . . . . . . . . . . . .  224
D6 Right Pneumonectomy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  228
D7 Right Upper Lobectomy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  231
D8 Right Lower Lobectomy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  234
D9 Wedge Resection  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  237
D10 Cannulation for Extracorporeal Life Support  . . . . . . . . . . . . . . . . . . . . . . . .  239

Part E Abdomen  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  243

E1 Upper Gastrointestinal Endoscopy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  245
E2 Endoscopic Management of Upper Gastrointestinal Bleeding  . . . . . . . . . . .  248
E3 Proctoscopy and Rigid Sigmoidoscopy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  252
E4 Colonoscopy 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  254
E5 Open Pyloromyotomy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  256
E6 Stamm Gastrostomy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  260
E7 Percutaneous Endoscopic Gastrostomy (PEG)  . . . . . . . . . . . . . . . . . . . . . . .  263
E8 Umbilical Hernia Repair  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  266
E9 Epigastric and Supra-umbilical Hernia Repair  . . . . . . . . . . . . . . . . . . . . . . .  268
E10 Open Nissen Fundoplication  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  270
E11 Gastroschisis 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  273
E12 Exomphalos 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  275
E13 Loop Enterostomy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  278
E14 Bowel Resection and Anastomosis  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  280
E15 Right Hemicolectomy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  283
E16 Subtotal Colectomy and Ileostomy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  286
E17 Small Bowel Atresia  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  290
E18 Malrotation and Volvulus  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  293
E19 Open Appendectomy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  296
E20 Meckel’s Diverticulum and other Vitello-intestinal Anomalies  . . . . . . . . . .  300
E21 Intussusception 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  303
E22 Peritoneal Drainage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  306
E23 Trauma Laparotomy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  309
xvi Contents   

E24 Congenital Diaphragmatic Hernia  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  312

E25 Diaphragmatic Eventration  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  314
E26 Long-Gap Oesophageal Atresia – Gastric Pull-Up  . . . . . . . . . . . . . . . . . . . .  317
E27 Duodenal Atresia  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  322
E28 Necrotising Enterocolitis  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  325
E29 Wilms Tumour . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  328
E30 Abdominal Neuroblastoma  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  331
E31 Meconium Ileus  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  334
E32 Rectal Biopsy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  338
E33 Transanal Endorectal Pull-Through for Rectosigmoid Hirschsprung Disease  . 341
E34 Open Endorectal (Soave-Boley) Pull-Through  . . . . . . . . . . . . . . . . . . . . . . .  344
E35 Myomectomy for Ultrashort segmentHirschsprung Disease  . . . . . . . . . . . .  349
E36 Open Swenson Procedure  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  353
E37 Open Duhamel Pull-Through  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  357
E38 Principles of Liver Surgery  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  361
E39 Biliary Atresia  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  364
E40 Choledochal Malformations  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  366
E41 Pancreatic Pseudocyst  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  369
E42 Inflammatory Bowel Disease  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  371

Part  F Groin and Genitalia  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  375

F1 Exposure of the Inguinal Canal and Spermatic Cord Structures . . . . . . . . . .  377
F2 Inguinal Hernia and Ligation of Patent Processus Vaginalis  . . . . . . . . . . . .  380
F3 Incarcerated Inguinal Hernia  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  383
F4 Femoral Hernia  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  386
F5 Acute Scrotal Exploration  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  389
F6 Varicocoele 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  392
F7 Testicular Tumour  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  396
F8 Circumcision and Prepuceplasty  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  398
F9 Urethral Meatotomy and Dorsal Slit of the Foreskin  . . . . . . . . . . . . . . . . . .  402
F10 Open Orchidopexy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  404
F11 Ovarian Surgery  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  407
F12 Labial Adhesions and Imperforate Hymen  . . . . . . . . . . . . . . . . . . . . . . . . . .  410
F13 Principles of Hypospadias Surgery  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  413
F14 Glandular and Coronal Hypospadias Repair  . . . . . . . . . . . . . . . . . . . . . . . . .  423
F15 Two-Stage Hypospadias Repair: Stage One  . . . . . . . . . . . . . . . . . . . . . . . . .  426
F16 Hypospadias Repair: Stage Two  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  429
 Contents xvii

Part G Urology  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  431

G1 Cystourethroscopy 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  433
G2 Urethral and Suprapubic Catheterisation  . . . . . . . . . . . . . . . . . . . . . . . . . . . .  435
G3 Open Surgical Approaches to the Kidney  . . . . . . . . . . . . . . . . . . . . . . . . . . .  439
G4 Open Nephrectomy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  442
G5 Pyeloplasty 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  445
G6 Ureteric Duplication  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  448
G7 Surgery for Renal Calculi  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  450
G8 Nephrostomy 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  453
G9 Vesicostomy 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  459
G10 Ureterostomy 
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  461
G11 Conduit Diversion  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  465
G12 Ileocystoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  468
G13 Continent Catheterisable Conduit  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  471
G14 V-Quadrilateral-Z (VQZ)-plasty for Stoma  . . . . . . . . . . . . . . . . . . . . . . . . . .  473
G15 Endoscopic Treatment of Vesicoureteric Reflux  . . . . . . . . . . . . . . . . . . . . . .  475
G16 Ureteric Reimplantation  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  478
G17 Posterior Urethral Valves  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  482

Part H Perineum  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  485

H1 Perineal Injuries  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  487
H2 Anal Fissures and Skin Tags  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  490
H3 Perianal Abscess and Fistula-in-Ano  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  493
H4 Anterior Ectopic Anus  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  496
H5 Excision of Rectal Polyp  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  499
H6 Sacrococcygeal Teratoma  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  501
H7 Posterior Sagittal Anorectoplasty in Females with Perineal
or Vestibular Fistulae  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  504
H8 Posterior Sagittal Anorectoplasty (PSARP) for Males with Recto-urethral
Bulbar Fistula and Prostatic Fistula  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  508
H9 Posterior Sagittal Anorectoplasty (PSARP) with Laparotomy/Laparoscopy
in Males with Rectal–Bladder Neck Fistulas  . . . . . . . . . . . . . . . . . . . . . . . . .  512
H10 Posterior Sagittal Anorectoplasty (PSARP) with Total Urogenital Mobilization
for Cloacae with a Common Channel Smaller than 3 cm  . . . . . . . . . . . . . . .  515
H11 Colostomy Creation in Anorectal Malformation  . . . . . . . . . . . . . . . . . . . . . .  519
H12 Colostomy Closure in Anorectal Malformation . . . . . . . . . . . . . . . . . . . . . . .  522
xviii   

Part  I Minimally Invasive Surgery  . . . . . . . . . . . . . . . . . . . . . . . . . . . .  525

I1 Ergonomics, Heuristics and Cognitive Skills in Laparoscopic Surgery  . . . .  527
I2 Complications of Laparoscopic Surgery  . . . . . . . . . . . . . . . . . . . . . . . . . . . .  530
I3 Energy Sources in Laparoscopic Surgery  . . . . . . . . . . . . . . . . . . . . . . . . . . .  539
I4 Minimally Invasive Repair of a Pectus Excavatum  . . . . . . . . . . . . . . . . . . . .  542
I5 Thoracoscopic Lung Biopsy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  547
I6 Thoracoscopic Lobectomy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  550
I7 Thoracoscopic Decortication for Empyema  . . . . . . . . . . . . . . . . . . . . . . . . .  556
I8 Thoracoscopic Diaphragmatic Hernia Repair  . . . . . . . . . . . . . . . . . . . . . . . .  558
I9 Laparoscopic Cardiomyotomy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  562
I10 Laparoscopic Fundoplication  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  565
I11 Laparoscopic pyloromyotomy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  569
I12 Laparoscopic Appendectomy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  572
I13 Laparoscopic Button Placement for Antegrade Enema  . . . . . . . . . . . . . . . . .  575
I14 Primary laparoscopic-assisted endorectal pull-through . . . . . . . . . . . . . . . . .  577
I15 Laparoscopic Duhamel Pull-Through Procedure  . . . . . . . . . . . . . . . . . . . . .  580
I16 Laparoscopic Splenectomy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  583
I17 Laparoscopic Cholecystectomy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  586
I18 Diagnostic Laparoscopy for Non palpable Undescended Testis  . . . . . . . . . .  589
I19 Laparoscopic Fowler–Stephens Orchidopexy  . . . . . . . . . . . . . . . . . . . . . . . .  592
I20 Lymphatic-Sparing Laparoscopic Varicocelectomy  . . . . . . . . . . . . . . . . . . .  595
I21 Laparoscopic Inguinal Herniotomy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  598
I22 Retroperitoneoscopic Nephrectomy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  601
I23 Retroperitoneoscopic Partial Nephrectomy  . . . . . . . . . . . . . . . . . . . . . . . . . .  604
I24 Laparoscopic Dismembered Pyeloplasty  . . . . . . . . . . . . . . . . . . . . . . . . . . . .  607
I25 Button Vesicostomy  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  611
I26 Laparoscopic-Assisted Insertion of a Peritoneal Dialysis Catheter  . . . . . . .  614
I27 Laparoscopic Repair of Duodenal Atresia  . . . . . . . . . . . . . . . . . . . . . . . . . . .  618
I28 Laparoscopic excision of Choledochal cyst and Hepatico-duodenostomy  . .  622
I29 Management of Upper Urinary Tract Calculi  . . . . . . . . . . . . . . . . . . . . . . . .  627

Appendix  Training in Paediatric Surgery  . . . . . . . . . . . . . . . . . . . . . .  633

Subject Index  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  639
 PAR T A
Basic Surgical
Techniques
A1  The World Health Organisation Surgical Safety Checklist
A1 The World Health Organisation Surgical
Safety Checklist
I. Yardley
Background
In recent years there has been a growing awareness
of surgical care as an important public health is-
sue. A great deal of mortality and morbidity are
caused by conditions that are amenable to surgi-
cal intervention. For these conditions to be treated
successfully requires safe, efficient surgical facili-
ties and practice.
One estimate puts the number of surgical pro-
cedures performed each year worldwide at 234
million. If conservative estimates for complica-
tion rates of 3 % and mortality rates of 0.4 % are
applied to this figure, then there are 7 million com-
plications and 1 million deaths each year related
to surgical care worldwide. A proportion of these
will be due to unsafe care; they are potentially
preventable.
Development of the Checklist
The World Health Organisation (WHO) Patient
Safety body recognized the importance of unsafe
surgery and the potential to improve surgical
care worldwide and drew up their Safe Surgery
Guidelines in 2007. A key component of the
Guidelines is the recommendation to use a surgical
checklist with every surgical procedure (see figure
below).
The checklist was not intended to introduce
new steps to surgical routines. Instead it applied
techniques from other high-risk activities, notably
the airline industry, to create an evidence-based
collection of simple, mostly cost-neutral, actions
that should be performed for every procedure. If
Iain Yardley (   )
Specialty Registrar in Paediatric Surgery,
Clinical Advisor, World Health Organisation Patient Safety
E-mail: iyardley@doctors.org.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_1, © Springer-Verlag Berlin Heidelberg 2013
3
A1
carried out consistently these steps have the po-
tential to reduce complications and make surgi-
cal care safer. The checklist has been designed to
be applicable in a range of environments, from
the most high tech to the most cost constrained.
The checklist is divided into three sections: the
‘sign in’, performed before the patient is anaesthe-
tised; the ‘time out’ immediately before surgery
starts; and the ‘sign out’ immediately before the
patient leaves the theatre. At each stage the entire
team come together to discuss and agree on the
relevant points before progressing.
An international, multicentre trial of the check-
list demonstrated an improvement in both mor-
bidity and mortality. Use of the checklist has since
spread around the world and is now actively in use
in 1,600 hospitals in more than 50 countries, and a
further 2,000 hospitals have registered an interest
in the checklist. There is growing evidence of its
benefits, both in improving outcome for patients
and for improving communication and teamwork
in the theatre environment.
Implementing the Checklist
The checklist is not intended to be fully compre-
hensive, and individual institutions are encour-
aged to make adaptations and additions in order
to increase the relevance to their respective prac-
tice and environment. For example, an addition
particularly relevant to paediatric surgical practice
is to ensure adequate warming devices are in place.
For further information about the checklist, see
www.safesurg.org and www.who.int/patientsafety.
4 I. Yardley

Further Reading

Haynes et al (2009) A surgical safety checklist to reduce Weiser TG (2008) An estimation of the global volume
morbidity and mortality in a global population. N Eng of surgery: a modelling strategy based on available data.
J Med 360:491–499 Lancet 372:139–144
A2 Positioning
A 2Positioning
P. Sekaran and R. Carachi
The key to an ordered and successful day in the-
atre is good communication among all the staff in-
volved. A briefing involving the surgeons, theatre
staff and anaesthetists should always take place
before starting the theatre list. It is good practice
to discuss each case that will be performed dur-
ing the operating list. Important information that
should be discussed for each patient includes sig-
nificant past medical history (e.g. malignant hy-
pertension), the optimal positioning on the table,
the requirement for specialist equipment (e.g. fluo-
roscopy), the need for a diathermy pad, the site of
the incision and whether antibiotics are required
perioperatively. Any anticipated difficulties should
also be discussed. In conjunction with a briefing
at the start of the list, The World Health Organ-
isation Safe Surgery Checklist has been shown to
reduce surgical morbidity and mortality and its
use for each case should be strongly encouraged
(see Chap. A1).
The position of the patient is as fundamen-
tal as is the initial incision. Good positioning and
draping will allow optimal exposure of the oper-
ative field. For each position, any potential pres-
sure points where the skin overlies a bony prom-
inence should be protected with additional pad-
ding. In this chapter we discuss some of the com-
mon positions used in paediatric surgery.
Prabhu Sekaran ()
Specialty Trainee in Paediatric Surgery
E-mail: Prabhu.sekaran@nhs.net
Robert Carachi
Professor of Surgical Paediatrics
E-mail: Robert.Carachi@glasgow.ac.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_2, © Springer-Verlag Berlin Heidelberg 2013
5
A2
 xtended Neck for Head and Neck
E
Surgery
The patient lies on their back with a roll placed
under the shoulders and the neck extended in the
midline. This position is adopted for operations on
the neck, e.g. thyroid and thyroglossal cyst.
Dorsal Position
The patient lies on their back on the operating ta-
ble (Fig. 1). This is the position most commonly
adopted in paediatric surgery. Arms should be
kept at the side of the patient, with the use of
curved supports.
Trendelenburg Position
The patient is placed on the operating table in
the dorsal position, but the table is tilted with a
head-downwards slope (Fig. 2). The feet are now
at a higher level than the head. This increases
venous return from the body, but increases the
risk of aspiration of gastric contents and may
hinder diaphragmatic excursion. The head-down
position can be used in central venous surgery to
fill the internal and external jugular veins, and in
pelvic surgery to displace the abdominal organs
out of the pelvis. In a laparoscopic appendectomy
the patient is usually positioned head down, with
a left lateral tilt to help mobilise the small bowel
from the pelvis and right iliac fossa, providing
optimal exposure of the caecum and appendix
base.
In the reverse-Trendelenburg position (Fig. 3),
the patient is tilted in the opposite direction, so
that the head and chest lay superior to the lower
limbs. This position may be used to facilitate ex-
posure of the upper abdomen during laparoscopy.
6 P. Sekaran and R. Carachi

Fig. 1

Fig. 2

Fig. 3
A2 Positioning 7

Fig. 4

Fig. 5

Lithotomy Position Lateral Position

The patient lies supine on the operating table.
The thighs and knees are flexed and supported
on stirrups (Fig. 4). Additional padding should
be placed under the posterior compartment mus-
cles of the legs to reduce the risk of pressure ul-
ceration. The legs are secured onto the stirrups
with crepe bandaging. This position is routinely
used for cystoscopy, as it provides good exposure
of the perineum.
The patient is placed on their side with the arm
on the side of the incision, lying forward and over
the face, supported on an armrest (Fig. 6). Care
should be taken to avoid dislodging the endotra-
cheal tube. The patient is secured to the edges of
the table by using strong adhesive tape across the
hips and shoulders to prevent the patient from
rolling during the operation. This position may
be used for posterolateral thoracotomies and open
renal surgery.

Prone Position

The patient is placed flat, face downwards on

the operating table, with their arms at their side
(Fig. 5). The face is supported with a head ring
and the endotracheal tube position is safely se-
cured. This position may be used for closure of
myelomeningocele and excision of sacrococcy-
geal teratoma. Fig. 6
 8 A. Neilson and R. Carachi
A3 A3 Preparation
A. Neilson and R. Carachi

• Position the patient appropriately before you

scrub (see Chap. A2). Pressure areas should be
protected. Ensure that the diathermy plate is
safely attached.
• Select an appropriate antiseptic solution. Povi-
done–iodine may be systemically absorbed in
infancy and can disrupt the thyroid axis.
• Start by painting the site of the incision and
work outwards from there (Fig. 1a). Paint
‘dirty’ areas such as the umbilicus or groin last.
• With the second swab, work outwards again, a b
but finish just within the area covered the first
time. Do not touch unprepared skin with the Fig. 1
second swab (Fig. 1b).
• If you are using sticky drapes, you may need
to dry the outer margin to facilitate good fix-
ation. Be careful not to touch any unprepared
areas with the drying swab.
• Square draping is the most commonly used
technique (Fig. 2). Special techniques are used
for some areas, such as the head, limbs and
perineum (Figs. 3–5).
• For the lithotomy position, move both legs
symmetrically and simultaneously. Triangular
drapes slide easily if the hypotenuse is held to
the ceiling. Fig. 2
• Fixation of the drapes to the patient may be
achieved by using self-adhesive drapes with
sticky edges, securing tapes, towel clips or clear
adherent films that cover the operation site. Al-
ternatively, the drapes may be sutured to the
patient’s skin for the duration of the procedure.

Andrew Neilson ()

Specialty Trainee in Paediatric Surgery
E-mail: agneilson@doctors.org.uk

Robert Carachi
Professor of Surgical Paediatrics
E-mail: Robert.Carachi@glasgow.ac.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_3, © Springer-Verlag Berlin Heidelberg 2013
A3 Preparation 9

Fig. 3 Fig. 4

Fig. 5

Tips

77 Allow time for alcohol-based solutions to evapo-
rate before making your incision.
77 Think where you may need to access in unex-
pected circumstances – for a laparotomy prepare
from nipples to knees.
77 Be careful when removing drapes at the end of
the procedure not to dislodge the endotracheal
tube or intravenous lines.
77 Clean the patient before they wake up; seeing
blood can distress children.

Common Pitfalls

77 When draping, avoid moving the drapes from
dirty to clean. Always place the drapes well
within the prepared area and move them from
clean to dirty if required.
77 Avoid pools of fluid near the diathermy. Be es-
pecially careful with alcoholic preparation solu-
tions, as pools can ignite.
77 Be careful not to catch the patient’s skin in towel
clips.
10 A. Neilson and R. Carachi

W I L L I A M S TEWART HALS TED

(1852 – 1922)
American surgeon and inventor of the surgical gloves

The first Professor of Surgery at John Hopkins, Halstead pioneered many innovations in the
field of surgery: the surgical residency programmes, the careful and meticulous technique of
operating, the green surgical scrubs and the use of gloves in surgery. Halstead’s scrub nurse
was the able Caroline Hampton, for whom he had a soft spot. When he noticed that her
hands were raw and chaffed from the sterilizing liquid mercuric chloride, he acted. He had
the Goodyear Tyre and Rubber Company produce rubber protective gloves for her. Thereaf-
ter both Halstead and his surgical assistant started wearing gloves as well, and this became
the norm. Halstead went on to marry Ms. Hampton, and the surgical gloves have become
an effective tool in the surgical theatre.
A4  Surgical Instruments 11
A 4Surgical Instruments A4
B. Amjad

To enable clear communication with the scrub

nurse, paediatric surgeons of every level of experi-
ence should familiarise themselves with the names
and the uses of the surgical instruments at their
disposal. This chapter aims to provide the reader
with a field guide to the commonly used paediat-
ric surgical instruments and their uses.

Fig. 2  Gallipots and kidney dish

Surgical Instruments

• Rampley sponge-holding forceps

– For the application of antiseptic solution to
the skin prior to draping

Fig. 3  Duff towel clips

Fig. 1  Rampley sponge-holding forceps

• Gallipots and kidney dish Fig. 4  Scalpel handle and disposable blades
– Surgical preparation dispensers
– Kidney dish used for handing instruments
and for collecting samples as well
• Duff towel clips
– Hold together the surgical drapes after they
have been laid out

Basith Amjad ()

Paediatric Surgeon and Senior Research Fellow,
School of Medicine, University of Glasgow
E-mail: basithamjad88@gmail.com Fig. 5  Adson tissue forceps (non-tooth)

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_4, © Springer-Verlag Berlin Heidelberg 2013
12 B. Amjad

• Adson tissue forceps (non-tooth)

– For handling delicate tissues and blood ves-
sels
• Adson tissue forceps (tooth)
– For holding skin, fascia and other tougher
tissues
• Broad non-tooth forceps
– For tissue dissection, holding suture ends,
vascular catheters and ventriculoperitoneal
shunts
Fig. 6  Adson tissue forceps Fig. 7 Broad non-tooth • Charnley–McIndoe forceps
(tooth) forceps – For tissue dissection, holding tough tissues
and skin
• Scalpel handle and disposable blades • DeBakey vascular forceps
– Sizes 10, 11 and 15 – For handling delicate tissues, hernial sacs
– For making incisions, dissecting and excis- and vessels
ing of tissues • Monopolar and bipolar diathermy
– For dissection and haemostasis (see
Chap. A5)
• Quiver and probe
– Quiver for holding diathermy instruments
– Probe for probing tissues and tunnelling
catheters
• Army pattern modified hook retractor and
Kilner–Lane (cat paw) retractors
– For retraction of skin and subcutaneous
Fig. 8  Charnley–McIndoe forceps tissues
– Hook retractors also used for looping ves-
sels
• Langenbeck and Durham retractors
– For retraction of subcutaneous tissues and
deeper retraction during laparotomy
• Malleable copper retractors and Deaver retrac-
tors
– For deeper retraction during laparotomy
and thoracotomy

Fig. 9  DeBakey vascular forceps

Fig. 10  Monopolar (left) and bipolar (right) diathermy

A4  Surgical Instruments 13

Fig. 11  Quiver (left) and probe (right)

Fig. 12  Army pattern modified hook retractor (left) and

Kilner–Lane (cat paw) retractors (right)

Fig. 13  Langenbeck (left) and Durham (right) retractors Fig. 14  Malleable copper retractors (left) and Deaver re-
tractors (right)

Fig. 15 Skin hooks (left) and Brodie hernia director

(right) Fig. 16  Balfour retractor
14
• Skin hooks and Brodie hernia director
– Skin hooks for retracting and holding back
skin
– For retraction and dissection, Brodie hernia
director
• Balfour retractor
– Self-retaining retractor for laparotomies
• Denis Browne retractor
– For retraction during major laparotomies
and urology cases
Fig. 17  Denis Browne retractor
Fig. 18  West self-retaining retractor
Fig. 19  Finochietto self-retaining retractor
B. Amjad
• West self-retaining retractor
– For retracting thin subcutaneous tissues
during relatively minor dissection includ-
ing groin surgery and lymph node biopsy
• Finochietto self-retaining retractor
– For retraction during thoracotomy, e.g. in
open repair of oesophageal atresia and li-
gation of tracheo-oesophageal fistula
• Volkmann and Glasgow slotted spoons
– To debride necrotic tissue and debris from
an abscess cavity, the Volkmann spoon
– During an inguinal herniotomy to keep the
vas and vessels safe during transfixion of the
sac, Glasgow
• Allis forceps
– For retracting and holding fascia
• Babcock forceps
– For holding bowel and mesentery
• Doyen bowel clamps
– Atraumatic clamps for holding, occluding
and controlling the bowel during dissection,
anastomosis and repair
• Protected bulldog clamps
– Used to occlude the bowel during anasto-
mosis, dissection and stoma formation
• Mixter forceps
– For fine dissection around the back of ves-
sels and other delicate tissues
• Straight and curved Kelly (or mosquito) artery
forceps
– Small forceps used for dissection, retraction,
and clamping of vessels or tissues
– Mosquito variant more delicate, with finer
tips
A4  Surgical Instruments 15

Fig. 20 Volkmann (left) and Glasgow slotted (right)

spoons

Fig. 21  Allis forceps

Fig. 22  Babcock forceps Fig. 23  Doyen bowel clamps

• Crile-wood needle holders (8 and 6”) • Metzenbaum scissors

– For mounting needles during suturing
• Strabismus straight and curved scissors
– For sharp dissection and cutting tissues
• Iris scissors
– For fine, sharp dissection and cutting
• Tenotomy scissors
– For delicate, sharp dissection
– For dissection of delicate tissues during lap-
arotomy and thoracotomy
– Available in variable lengths
• Mayo scissors (straight and curved)
– Heavy-duty scissors for suture cutting and
tissue division
16 B. Amjad

Fig. 25  Mixter forceps

Fig. 24  Protected bulldog clamps

Fig. 26  Straight and curved Kelly (or mosquito) artery forceps
A4  Surgical Instruments 17

• Catgut and nursing scissors

– Heavy scissors for cutting sutures and dress-
ings
• Urethral sounds
– For probing or dilating the urethra and ex-
ternal urethral meatus
• Handheld twist drill
– For creating burr holes prior to ventriculo-
peritoneal shunt insertion
• Glasgow pattern rongeur and Luer-Jansen ron-
geur compound action
– Bone nibblers to define and prepare the
edges of a burr hole
• Pennybacker elevator and Cobb spinal eleva-
tor
Fig. 27  Crile–Wood needle holders (8” and 6”) – Used as periosteal and dural elevators
• Watson Cheyne dissectors
– For fine dissection and dural elevation

Fig. 28  Strabismus straight and curved scissors

• Subcutaneous tunnellers
– Available in a variety of forms
– Tunneller on the left in Fig. 39 for passing
ventriculoperitoneal catheters through the
subcutaneous tissues
– Instrument on the right in Fig. 39 for tun-
nelling central venous catheters

Fig. 29  Iris scissors

18 B. Amjad

Fig. 30  Tenotomy scissors Fig. 31  Metzenbaum scissors

Fig. 32  Mayo scissors (straight and curved)

Fig. 33  Catgut scissors and nursing scissors

A4  Surgical Instruments 19

Fig. 35 Handheld twist

drill

Fig. 34  Urethral sounds

Fig. 36  Glasgow pattern rongeur (left) and Luer–Jansen Fig. 37 Pennybacker el-
rongeur compound action (right) evator (left) and Cobb spi-
nal elevator (right)
20 B. Amjad

Fig. 38 Watson Cheyne Fig. 39  Subcutaneous tun-

dissectors nellers

H OWA R D KELLY
(1858 – 1943)
American surgeon and designer of the artery clip

An alumnus of the University of Pennsylvania, where he taught obstetrics. Kelly moved to

Johns Hopkins University when it opened its doors. He is one of The Four Doctors, the fa-
mous painting by John Singer Sargent of the four chiefs at Johns Hopkins University at that
time. The other three Doctors are William Halstead (Surgery), William Welch (Pathology)
and the great William Osler (Medicine).

Over the course of a stellar career he made many advances in the field of obstetrics and gyn-
aecology. A number of surgical procedures and instruments bear his name, including the
most common surgical instrument known: Kelly’s forceps or clamp, also called the mos-
quito or artery clip.
A5 Diathermy
A 5Diathermy
P. Sekaran and R. Carachi
General Principles
Diathermy (dia [through] + therme [heat]) is a tool
used by surgeons to effect coagulation and cutting
of tissues. The passage of high-frequency alter-
nating current through the body causes a local-
ised heating effect, with temperatures in some cir-
cumstances reaching 1,000°C. The safety of dia-
thermy relies on the fact that neuromuscular tis-
sue (such as cardiac tissue) is only stimulated by
low-frequency alternating current. At frequencies
above 50 kHz, the muscle contractions observed
at lower frequencies disappear. Surgical diathermy
employs current frequencies between 400 kHz and
10 MHz, allowing greater amounts of current to
be used safely.
There are two types of diathermy used in sur-
gical practice, monopolar and bipolar.
Monopolar Diathermy
Current is generated by transistors in the dia-
thermy machine and passed to a point or blade
diathermy (Fig. 1), which is held in the surgeon’s
hands. This acts as the small active electrode. Cur-
rent passes through the tip of the blade diathermy,
causing localised heating effects. Residual current
is transmitted through the patient and conducted
away through the diathermy plate, which should
be placed on an area of flat, non–hair-bearing skin
such as the patient’s back or anterolateral thigh.
The diathermy plate should have a large surface
area suitable to the size of the patient (Fig. 2),
Prabhu Sekaran ()
Specialty Trainee in Paediatric Surgery
E-mail: Prabhu.sekaran@nhs.net
Robert Carachi
Professor of Surgical Paediatrics
E-mail: Robert.Carachi@glasgow.ac.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_5, © Springer-Verlag Berlin Heidelberg 2013
21
A5
which ensures that the current density remains
low, and no local heating effect occurs through
the body as the current exits. The diathermy blade
has two buttons, blue for coagulation and yellow
for cutting (Fig. 1). In cutting mode the diathermy
blade generates a continuous output, which re-
sults in current arcing between the active electrode
and adjacent tissue, resulting in instant vaporisa-
tion of water and separation of tissues. In coag-
ulation mode a pulsed output is generated, caus-
ing sealing of blood vessels and minimal tissue
destruction. A ‘blend’ effect can be used in the
cutting mode, to generate both cutting and coag-
ulation waveforms, which increases the degree of
haemostasis. For accurate coagulation, the dia-
thermy blade can be applied to forceps holding
the end of a vessel. It is important to familiarise
yourself with the workings of the different types
Fig. 1
of diathermy machine (Figs. 3 and 4) and the ap-
propriate settings for infants and children of dif-
ferent sizes (Fig. 5).
Bipolar Diathermy
Bipolar diathermy utilises a pair of fine forceps
connected to the diathermy generator and does
not require placement of a diathermy plate (Fig.
6). One limb of the forceps acts as the active elec-
trode and the other limb as the diathermy plate.
Current passes between the limbs facilitating ac-
22
curate and safe coagulation of the tissue held be-
tween the limbs of the forceps. For optimal func-
tioning, the tissue should not be held too tightly,
so that the electrodes of the forceps are not in con-
tact. Bipolar diathermy cannot be used for cut-
ting tissue.
Tips
77 Only the surgeon with the active electrode
should activate the diathermy. It is not a two-per-
son job! Do not ask the assistant to depress the
pedal.
77 You should familiarise yourself with the inner
workings of the diathermy machine – read the
manual.
77 Always check that the diathermy plate is applied
correctly and is of an appropriate size.
Common Pitfalls
77 Thermal injury is the most common risk of dia-
thermy, and it is usually the result of incorrect
placement of the diathermy plate. Always en-
sure proper placement of the diathermy plate
and check that no flammable liquids are present
around the patient. Alcoholic skin preparations
burn with a clear flame, making them almost im-
possible to recognise until significant tissue dam-
age has occurred.
77 Do not site the diathermy plate over a bony
prominence or metal prosthesis and ensure that
it has a good interface with the patient, free from
interposed air or skin preparation. The tissue at
the plate site should have good blood supply to
disperse any heat generated.
77 The operating department practitioner (ODP) is
usually responsible for attaching the diathermy
plate, but it is the surgeon’s responsibility to en-
sure that this has been done safely prior to sur-
gery.
P. Sekaran and R. Carachi
77 Learn to recognise the different diathermy alarm
sounds and their meanings. Never ignore an
alarm.
77 The postoperative checklist should include an in-
spection of the diathermy plate site to ensure
that there is no evidence of tissue injury.
77 Always clean the tip of the active electrode on a
scratch pad or moistened swab to remove any
adherent tissue, which reduces its efficacy.
77 Ensure the patient is not touching ‘earthed’ metal
objects, which offer an alternative return route
for diathermy current with localised heating over
a small surface area.
77 Never use monopolar diathermy on append-
ages with an end-arterial supply, such as the pe-
nis or testes, as the high current density gener-
ated may compromise the arterial inflow, caus-
ing infarction.
77 Monopolar diathermy has the potential to reset
cardiac pacemaker programs or cause current
to travel down the wires, burning the myocar-
dium and raising the pacemaker threshold. Dis-
cuss this with the patient’s cardiologist preopera-
tively. If monopolar diathermy must be used, en-
sure there is a defibrillator in theatre and site the
diathermy plate as near to the active electrode
as possible. Bipolar diathermy is a safer option in
this scenario.
A5 Diathermy 23

In patients with cochlear implants, the current

may be transmitted through the device, perma-
nently damaging the device or the patient’s own
cochlear tissues. Monopolar diathermy must not
be used on the head and neck, and bipolar may
only be used with certain types of implants. If in
doubt, contact the manufacturer. If using mono-
polar diathermy elsewhere on the body, site the
diathermy plate as near to the active electrode as
possible.

Fig. 2

Fig. 3
24 P. Sekaran and R. Carachi

Fig. 4

Fig. 5

Fig. 6
A5 Diathermy 25

H A RV E Y C US HI NG
(1869 – 1939)
American neurosurgeon and inventor of diathermy

A graduate of Harvard Medical School, Cushing trained under William Halstead at the
Johns Hopkins. He is considered the Father of American Neurosurgery and setup his unit at
the Peter Brent Bingham Hospital in Boston. His brilliant approach and hard work consid-
erably improved the outcome of neurosurgical patients. He used x-rays to diagnose brain tu-
mours and electrical stimuli to chart the human sensory cortex. Cushing’s disease and Cush-
ing’s syndrome are named after him.

The electrocautery device or monopolar and bipolar diathermy were developed by Cushing
and an inventor named William Bovie between 1914 and 1927. It was then used in 1927 by
Cushing to remove previously inoperable brain tumours.
Of note, Cushing is also the only physician to have won a Pulitzer Prize in Literature for
his Life of William Osler.
 26
A6 A 6Local Anaesthesia
J. Currie
Local anaesthesia is extremely useful either as the
sole method of anaesthesia for minor surgery or
as an adjunct to general anaesthesia. Well-placed
local anaesthetic solution will allow the child to
wake pain-free and reduce postoperative analgesic
requirements. It is much easier to keep pain away
than to take pain away.
Blocking the pain pathway with local anaes-
thetic solution will also reduce the stress response
to surgery.
There are three commonly used anaesthetic so-
lutions:
Tips
77 A useful technique is to combine lignocaine and
l-bupivacaine. This gives rapid onset of action as
well as long duration of analgesia. One per cent
lignocaine is available combined with 1:200,000
adrenalin. This can be used with the same vol-
ume of l-bupivacaine to reduce bleeding due to
the vasoconstrictive effect of adrenaline. In this
scenario, you should use half the maximum dose
of each drug.
Common Pitfalls
77 Inadvertent intravenous injection of local anaes-
thetic agents can lead to side effects such as fit-
ting and ventricular arrhythmias. These com-
plications are less of a problem with prilocaine,
which is metabolised by plasma enzymes. In the
case of lignocaine, these can usually be treated
symptomatically, but the ventricular arrhythmias
John Currie ()
Consultant in Paediatric Anaesthetisia and Pain Medicine
John.Currie@ggc.scot.nhs.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_6, © Springer-Verlag Berlin Heidelberg 2013
J. Currie
1. Levobupivacaine (l-bupivacaine) has a relatively
slow onset of around 10 min, but is longer act-
ing, giving between 4 and 6 h of analgesia. The
maximum dose is 2 mg/kg (1 mg/kg in an in-
fant <6 months old).
2. Lignocaine is more rapidly acting, having effect
in 2 to 3 min. However, its duration of action
is only about an hour. The maximum dose is 3
mg/kg.
3. Prilocaine has roughly the same rapidity of on-
set and duration of action as lignocaine. The
maximum dose is 5 mg/kilogram. Dose must
be based an optimal weight for height (BMI).
77 Where possible use a 10-ml syringe for your
blocks. This allows consistency in the ease of in-
jection, the feel of the tissues and any loss of re-
sistance. More pressure can be exerted at the
needle tip with a smaller syringe and less with
the greater surface area of the plunger of a
larger-capacity syringe. Consistent ‘feel’ will al-
low for increased confidence and more consis-
tent blocks.
associated with l-bupivacaine can be intractable.
Intravenous intralipid should be administered,
as this binds to the drug, effectively reducing the
blood levels.
77 Toxicity due to overdose or intravenous injection
is usually heralded by side effects such as a tin-
gling sensation or numbness around the mouth
A6  Local Anaesthesia
Fig. 1  Field block technique
Field Block
Indication
This is a simple and very useful technique for an-
algesia for repair of superficial injuries. It is also
very useful when removing skin lesions. In adults
or in older co-operative children, this may be all
that is required.
This technique can also be used in extremis for
operations such as appendicectomy, hernia repair
or caesarean section. In these cases, analgesia is
administered at each layer of the surgical expo-
sure.
Technique
Anaesthetic solution is administered in a double
“V” (Fig. 1) around the wound or incision site,
raising a wheal with the solution. This is a very
simple technique.
Tips
77 It is more comfortable for patient if after rais-
ing the initial wheal further injections are made
through that wheal, as it will be less painful.
Common Pitfalls
77 Innervation is generally from lateral to medial, so
special attention should be given to the lateral
27
Inguinal Block
Indications
This block can be used for analgesia for hernia re-
pair and orchidopexy.
Technique
The aim is to block both the ilioinguinal and il-
iohypogastric nerves. The path of these nerves
from the dorsal horn, takes them through the
three muscular layers of the anterior abdominal
wall (Fig. 2). At the level of the anterior superior
iliac spine, the iliohypogastric nerve lies between
the external and internal oblique muscles. At this
level, the ilioinguinal nerve lies deeper, between
the internal oblique and transversus abdominus.
The traditional way to perform the block is to in-
sert the needle perpendicularly and infiltrate lo-
cal anaesthesia at these two levels. However a bet-
77 The line of anaesthetic solution can be advanced
by injecting successfully through each wheal.
edge of the wound. Midline lesions are inner-
vated bilaterally.
28 J. Currie

1. Aponeurosis of the
external oblique m.
2. External oblique m.
3. Internal oblique m.
4. Anterior superior iliac spine
5. Transversus abdominis m.
6. Iliohypogastric n.
1 7. Inguinal ligament
8. Ilioinguinal n.
9. Genital branch of the
2 genitofemoral n.
3 10. Spermatic cord
11. Pubic tubercle
4 12. Superficial inguinal ring
13. Inguinal hernia
5
6
7
8 13

9
10
11

12

Fig. 2  Inguinal block. The course of the ilioinguinal and iliohypogastric nerves

ter technique is to insert the needle at an angle of
30°, one-finger’s breadth medial to the anterior
superior iliac spine. The needle is advanced par-
allel to the inguinal ligament in a caudal direc-
tion. A sudden loss of resistance or a ‘pop’ will
be felt at the level of Scarpa’s fascia and again at
the external oblique aponeurosis. Below the arcu-
Tips
ate line, the external oblique becomes aponeurotic,
and this denser tissue provides a very good end-
point as the loss of resistance, as the needle ad-
vances beyond it is easily felt. At this level, both
nerves lie in the same plane between external and
internal oblique, and so injection here will give a
reliable block.

77 The analgesic solution will track down into the helping to separate the tissue planes. If l-bupiva-
inguinal canal and hence be visible in the opera- caine is used, the analgesia obtained is usually
tive field during surgery. This confirms the posi- good enough and long enough that only simple
tion of the block and may indeed aid surgery by analgesics are needed thereafter.

Common Pitfalls

77 The inferior and medial aspects of the scro-
tum are innervated by the genitofemoral nerve.
Hence a low incision for testicular fixation during
orchidopexy will be painful, as this nerve will not
be affected by an inguinal block. Local infiltra-
tion of the wound will solve this problem. Spray-
ing local anaesthetic directly onto the wound
has also been shown to be effective. This is not
necessary with a high scrotal incision.
A6  Local Anaesthesia
Bier’s Block
Indication
This is a very useful block for operations on a limb.
Although most commonly used on the leg, it is
also effective for operations on the arm. It is also
effective for setting fractures of the upper limb,
such as Colles’ fracture.
Technique
A tourniquet is placed around the upper part of
the limb and inflated above systolic pressure. Prior
to inflation of the tourniquet, the limb should be
exsanguinated – raising the limb is usually effec-
tive. An Esmarch bandage may be used but is gen-
erally not recommended in fractures. Prilocaine is
injected intravenously into the limb distal to the
tourniquet. The dose is 5 mg/kg by using 1 % so-
lution for the arm and 0.5 % solution for the leg.
After 5 min or so, the limb will be numb.
Tips
77 It is much easier to insert a cannula into the af-
fected limb before inflating the tourniquet. Once
the limb is exsanguinated obtaining venous ac-
cess is nearly impossible. Venous access should
be obtained at another site in case of complica-
tions.
77 A double-cuff tourniquet should be used. The
technique is to inflate the upper cuff and then
inject the local anaesthetic. When the limb be-
Common Pitfalls
77 l-Bupivacaine should not be used, as serious side
effects may be encountered as the drug enters
the general circulation after cuff deflation.
29
Intercostal Block
Indication
This is a useful block for fractured ribs or ante-
rior chest wall trauma. It can also provide anal-
gesia for upper abdominal surgery.
Technique
The patient should be in the sitting position or ly-
ing with the affected side up.
A 22-gauge short-bevelled needle is ideal. The
injection site is at the angle of the rib, which is
found just lateral to the border of the erector
spinae muscle. The needle is inserted to contact
the inferior border of the rib. The needle is then
walked under the inferior border of the rib (Fig.
3). The needle should continue to be inserted, with
pressure applied to the plunger of the syringe un-
til a loss of resistance is felt. This will normally be
between 2 and 5 mm beyond the inferior border of
the rib. A 5-ml injection of numbing agent should
be given at each level. l-Bupivacaine at 0.5 % is the
agent of choice, but keep in mind the maximum
dose for the weight of the patient.
comes numb the lower cuff can be inflated and
the upper cuff deflated. In the conscious patient
this will be much more comfortable, as the cuff
is now over the area of analgesia. If the patient
is anaesthetised then both cuffs can be left in-
flated to give a better tourniquet effect. The limb
will become very mottled and discoloured – this
is normal.
77 The cuff should be let down slowly, pausing ev-
ery 10 mmHg or so. This helps to reduce the ef-
fects of flushing deoxygenated blood and lactic
acid into the general circulation.
30 J. Currie

Tips

77 Remember that the segmental innervation of successful analgesia. l-Bupivacaine at 0.375 % is

the umbilicus is T10, when assessing the level at a good compromise between efficacy and ade-
which to insert the block. You will need to block quate volume to block sufficient segments.
at least one level above and below the lesion for

Common Pitfalls

77 Careful aspiration is essential before injection, as
the artery and vein lie just above the nerve. This
will prevent inadvertent intravascular injection.
The other major complication of pneumothorax
can be avoided by carefully advancing the nee-
dle whilst stabilising the shaft of the needle with
your finger against the patient’s chest wall. Ad-
vancing the needle with a syringe attached fa-
cilitates detection of loss of resistance and pre-
vents entry of air into the pleura if it is acciden-
tally punctured.

Digital Nerve Block

Indication

Surgery of the fingers or toes.

Technique

Insert a small-gauge (23 or 25) needle from the

dorsal aspect of the hand or foot. The needle is
inserted at the base of the proximal phalanx on
either side of the digit (Figs. 4 and 5). The nee-
dle is advanced to lie level with the palmar (plan-
tar) surface of the bone. Local anaesthetic is in-
jected whilst withdrawing the needle to the dorsal
entry point. Thus the local anaesthetic will form
a partial ring around the medial and lateral as-
pects of the digit.

Fig. 3  Intercostal block, anatomical considerations

Fig. 4  Anatomical considerations for digital nerve block-

ade
A6  Local Anaesthesia 31

For operations on the thumb or great toe, a

wheel is raised around the outer (lateral) aspect
of the digit, in a semicircle to block the nerve. The
same technique is employed for the medial aspect
of the smallest finger or toe.

Fig. 5  Technique of digital nerve blockade

Tips

77 An alternative technique is to inject into the

web space of the finger or toe (Figs. 6 and 7). Af-
ter careful cleaning of the skin the needle is ad-
vanced into the midpoint of the web space un-
til the tip lies just proximally to the metacarpal
(metatarsal) joint. The advantage of this tech-
nique is that the local anaesthetic will be depos-
ited in the plane where the nerves lie, giving a
very consistent result. Whichever technique is
used, it is helpful to massage the area to aid the
spread of the solution.

Fig. 6  Anatomy of the web space Fig. 7  Alternative technique for digital nerve blockade
32 J. Currie

Common Pitfalls

77 The digital arteries are end arteries so vasocon- 77 As always, when injecting around a neurovas-
stricting agents should never be used. cular bundle, care must be taken to avoid intra-
77 Care should be taken when injecting, as the vascular injection. Accidental vascular puncture
pressure caused by an excessive volume of lo- may lead to haematoma.
cal anaesthetic in the tissues can lead to vascu-
lar compromise. Use a 10-ml syringe for the cor-
rect feel.

Penile Block

Indication

Operations on the penis, including circumcision.

Technique

Palpate the symphysis pubis. The injection is made
on either side of the midline just below the sym-
physis pubis, slightly medially to the lateral edge
of the base of the penis (Fig. 7). In an infant this
will be approximately 0.5 cm from the midline. A
short-bevelled 23-gauge needle is ideal. The nee-
dle is advanced caudally and slightly medially. Pas-
sage through Scarpa’s fascia will usually be felt
as a ‘give’ but this is membranous fascia, and so
the feel is inconsistent. Buck’s fascia will give a
‘bounce’ (elastic tissue) and a more definite loss
of resistance (Fig. 8).
Inject 0.1 ml/kg into the subpubic space, up to
a maximum of 5 ml each side.

Fig. 8  Anatomical consideration in penile nerve blockade: penile block

A6  Local Anaesthesia 33

Tips

77 The penis is a midline structure and is innervated
bilaterally. It is important to inject both sides of
the root. Anaesthetists often prefer to perform a
caudal block for penile surgery. With experience,
this is more consistently effective and allows
other drugs to be added to the local anaesthetic.
A good example of this is the addition of 1 mcg/
kg clonidine, which considerably extends the
duration of the block. This is the preferred tech-
nique for hypospadias surgery.

Common Pitfalls

77 Careful aspiration is essential to avoid intravascu- 77 Never use a solution containing any vasocon-
lar injection. This is particularly important when strictive agent such as adrenalin.
smaller-gauge needles are used. Advancing the
needle too caudally can result in injection into
the corpus cavernosum or cause a haematoma
from puncture of the dorsal vessels.
 34 L. McIntosh and A. H. B. Fyfe
A7 A7 Skin Lines and Wound Healing
L. McIntosh and A. H. B. Fyfe

Langer’s Lines Wound Healing

• Lines of tension in the skin or cleavage lines
are named after the Austrian anatomist Karl
Langer, who first depicted them. They are re-
markably constant between individuals of sim-
ilar body habitus. In most areas of the body
these correspond with the skin creases (Figs. 1
and 2).
• Skin lines are important when making and
closing wounds. Ideally all wounds should be
made parallel to Langer’s lines to optimize the
cosmetic outcome. Wounds made across the
lines of skin tension promote hypertrophic
scarring.
• When the type of surgery necessitates crossing
Langer’s lines, oblique or S-shaped incisions
may improve cosmesis. Alternatively, Z-plas-
ties may be used.
• Wound healing involves a complex and chang-
ing interplay between haemostatic, inflamma-
tory, epithelial and connective tissue cells.
• Healing may be by primary or secondary inten-
tion. The edges of incised (surgical) wounds re-
main in close apposition and heal by primary
intention. In cases of extensive loss of epithe-
lium or subcutaneous tissue, wound contrac-
tion occurs with abundant formation of scar
tissue to ‘plug’ the defect (secondary intention)
The final outcome in wound healing may be com-
promised by a variety of systemic and local fac-
tors, all of which present the surgeon with an op-
portunity for optimisation (Table 1).

Fig. 1

Lynn McIntosh ()

Specialty Trainee in Paediatric Surgery
Lynneholmes@doctors.org.uk

Alistair A. H. B. Fyfe
Consultant Paediatric Urologist
Fyfe7es@btinternet.com

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_7, © Springer-Verlag Berlin Heidelberg 2013
A7  Skin Lines and Wound Healing 35

Fig. 2
36 L. McIntosh and A. H. B. Fyfe

Table 1  Factors impacting on wound healing and potential methods of amelioration

Systemic factor Intervention

Nutritional status Consider early use of parenteral nutrition after all major
surgery, particularly of the gastrointestinal tract
Systemic immunosuppressants, Consider if the surgery can be deferred until the dose
e.g. steroids of steroid has been reduced or stopped altogether.
Particularly important in surgery for irritable bowel
disease (IBD) – always discuss timing of surgery with
the multidisciplinary team (MDT) (see Chap. E43)

Local factor
Infection Meticulous aseptic technique

Foreign bodies Debridement of necrotic tissue

(including devitalised tissue)
Impaired blood supply and hypoxia
Excess mobility
Meticulous wound lavage
Avoid excessive use of diathermy
Make an assessment of the arterial supply and venous
drainage of the affected region and an overall assess-
ment of the patient’s perfusion and oxygenation
Avoid excess tension on the wound
Pay close attention to postoperative fluid bal-
ance and oxygen saturation
Educate the patient about postoperative wound care
and when they can return to normal activity
A8  Transverse Supraumbilical Incision 37
A8 Transverse Supraumbilical Incision A8
R. Partridge and A. J. Sabharwal

Principles

• The abdomen of a neonate, infant or young

child is more square than rectangular. Accord-
ingly, the transverse supraumbilical incision af-
fords optimal access to all areas of the abdom-
inal cavity.
• As a child grows, the abdomen becomes more
rectangular, and a midline incision becomes the
approach of choice for laparotomy (see Chap.
A9).

Transverse Supraumbilical Approach

Fig. 1 Transverse incision as marked. Monopolar dia-
• This approach provides optimal exposure to thermy to fat. Anterior rectus sheath opened transversely
the abdominal cavity in the children younger
than 5 years of age.
• The supraumbilical skin incision is made ap-
proximately a third of the way up from the um-
bilicus to the xiphisternum.
• Divide the subcutaneous fat with monopolar
diathermy (Fig. 1).
• Watch for and if necessary, control bleeding
from the superficial epigastric vessels – these
may need to be tied.
• The anterior rectus sheath is divided with mo-
nopolar diathermy.
• Curved mosquito artery forceps are used to
part the rectus abdominus muscle to reveal the
posterior rectus sheath.
• The mosquito forceps are then placed trans-
versely under the muscle and opened.

Fig. 2  Mosquito artery forceps placed deep to the rec-

Roland Partridge () tus muscle and monopolar diathermy used to divide the
Specialty Trainee in Paediatric Surgery muscle
rolandpartridge@nhs.net

Atul J. Sabharwal
Consultant Paediatric and Neonatal Surgeon
Atul.Sabharwal@ggc.scot.nhs.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_8, © Springer-Verlag Berlin Heidelberg 2013
38 R. Partridge and A. J. Sabharwal

• Monopolar diathermy is used to divide the Closure

muscle, cutting down to the mosquito forceps
beneath (Fig. 2).
• A combination of coagulation and cutting dia-
thermy is used to divide the rectus abdominus
muscle and to ensure haemostasis in the cut
edges.
• This incision is usually closed in layers, with
continuous 2/0 or 3/0 absorbable sutures to the
posterior rectus sheath, then the anterior rec-
tus sheath (Fig. 4).
• 3/0 Continuous absorbable sutures to the Scar-
pa’s fascia are used, and then a running sub-
cuticular absorbable suture, appropriate to the
size of the patient.
• A mass closure is also an option, taking all fas-
cial layers with a 2/0 absorbable suture and then
closing the skin.

Fig. 3  Posterior rectus sheath and peritoneum are picked-

up and opened between curved mosquito forceps
• The posterior rectus sheath and peritoneum –
which are usually fused at this point – are then
elevated between curved mosquito artery for-
ceps, and a small incision made into the ab-
dominal cavity with scissors or a blade (Fig. 3).
• This incision is then carefully enlarged by us-
ing sharp-scissor dissection, taking care to en-
sure that there are no adhesions to the perito-
neum in the line of the wound.
• Once the incision is sufficiently large, the sur-
geon’s finger may be inserted into the abdomen
and monopolar diathermy used to divide the
remaining posterior sheath down onto this, to
complete the length of the incision.
• On extending the wound medially, the ligamen-
tum teres will be encountered. This should be
formally clipped, divided and tied.

Fig. 4  Closure in layers

A8  Transverse Supraumbilical Incision 39

Tips

77 Always take great care to ensure that all intra-ab- 77 Similarly, on closure, ensure that none of your su-
dominal contents are well clear of your incision tures catches intra-abdominal structures, such as
as you enter the abdomen. omentum.

Common Pitfalls

77 Failure to identify and control the ligamentum 77 In the neonate, the incision should be a little less
teres may result in haemorrhage if its lumen is than a third of the way from umbilicus to xiphi-
still patent. sternum, as the neonatal liver is often large and
extends well down into the abdomen.
 40 R. Partridge and A. J. Sabharwal
A9 A 9M idline Laparotomy
and Paramedian Incisions
R. Partridge and A. J. Sabharwal

Principles • This was based on the thickness of the linea

• In a child over the age of 5 years, the abdomen
begins to elongate and become more rectangu-
lar than square, as with an infant. As a result
of this, a vertical incision may allow optimal
access to all areas of the peritoneal cavity.
• It may be targeted as an upper or lower verti-
cal incision initially, and then safely and read-
ily extended either way as required.
• It is the quickest route into the abdomen, and
thus preferred if time is a critical factor (e.g.
trauma laparotomy – see Chap. E23).
Midline Verses Paramedian
• Traditionally, a midline vertical incision has
been recommended for upper abdominal inci-
sions and a paramedian incision for lower ab-
dominal incisions (Fig. 1).
alba, above and below the umbilicus (Fig. 2).
• Lower midline incisions have been shown to
heal as well as paramedian incisions do, and
this is now the most commonly used approach.
Midline Laparotomy Incision
• A skin incision is made to the required length.
• If the incision extends across the region of the
umbilicus, it is usually routed around rather
than straight through the cicatrix.
• Monopolar diathermy is used to dissect down
to the linea alba. The fascia is cleared of fat for
1 cm or so either side of the midline, to allow
later closure of the linea alba, without fat in-
terposition (Fig. 3).
• The linea alba is picked up with curved mos-
quito forceps and incised in the midline.

Fig. 1  Upper midline and lower paramedian

Roland Partridge ()

Specialty Trainee in Paediatric Surgery
rolandpartridge@nhs.net

Atul J. Sabharwal
Consultant Paediatric and Neonatal Surgeon
Atul.Sabharwal@ggc.scot.nhs.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_9, © Springer-Verlag Berlin Heidelberg 2013
A9  Midline Laparotomy and Paramedian Incisions
Fig. 2  Linea alba is thicker above the umbilicus than below it
• The underlying peritoneum is similarly elevated
between curved mosquito artery forceps and
incised.
• This incision in the linea alba is extended to the
length of the skin incision by using cutting mo-
nopolar diathermy on to the surgeon’s finger to
avoid damage to the intra-abdominal organs.
Closure
• The linea alba is closed with a continuous, slow-
absorbing or non-absorbable suture.
• The knot should be buried to avoid nodule for-
mation.
• A continuous absorbable subcutaneous suture
is placed.
Fig. 3 Midline incision made down to the linea alba,
which is then cleared for ~1 cm each side
41
• The skin is closed with a running subcuticu-
lar absorbable suture with or without adhesive
strips.
Paramedian Incision
• A skin incision is made approximately 2 cm lat-
erally to the midline.
• The anterior rectus sheath is then cleared of fat
and incised vertically.
• The rectus muscle retracted laterally.
• The transversalis fascia and peritoneum (and
posterior rectus sheath if upper incision) are
opened between curved mosquito forceps.
Fig. 4  Linea alba and then peritoneum opened between
clips
42 R. Partridge and A. J. Sabharwal

Fig. 6  Paramedian incision above the umbilicus. Note the

posterior rectus sheath at this level

Fig. 5  Lower paramedian incision with lateral retraction

of the rectus muscle

Tips

77 Near the umbilicus the peritoneum fuses with 77 Care should be taken to ensure that no tissue is
the linea alba, and they will be encountered as a interposed between the adjacent sides of linea
single layer. alba as it is closed.
77 It may be necessary to ligate and divide the lig-
amentum teres, depending on the exposure re-
quired.

Common Pitfalls

77 Always take great care to ensure that all intra-ab- 77 Similarly, on closure, ensure that none of your su-
dominal contents are well clear of your incision tures catches intra-abdominal structures, such as
as you enter the abdomen. omentum.
A10  Subcostal and Rooftop Incisions
A10 Subcostal and Rooftop Incisions
T. J. Bradnock and R. Carachi
A standard subcostal incision can be extended
with a curve across the midline to make a rooftop
(bilateral subcostal) incision (Fig. 1). The Mer-
cedes-Benz modification involves a further exten-
sion to the rooftop incision, with an upper midline
limb extending up to or through the xiphisternum
(Fig. 1, dotted line).
Fig. 1
Tim J. Bradnock ()
Specialty Registrar in Paediatric Surgery
The Department of Paediatric Surgery, Dalnair Street,
Yorkhill Hopsital, Glasgow G3 8SJ, Scotland, UK
Email: tjbradnock@doctors.org.uk
Robert Carachi
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_10, © Springer-Verlag Berlin Heidelberg 2013
43
A10
Subcostal Incision
This is also known as the Kocher incision.
Indications
• Left: access to the diaphragm (diaphragmatic
eventration, congenital diaphragmatic hernia),
oesophagus (Nissen fundoplication) or spleen
(open splenectomy)
• Right: Access to the gallbladder (open chole-
cystectomy) and bile ducts (excision of chole-
dochal malformation and biliary reconstruc-
tion)
Technique
• The skin crease incision is started in the mid-
line, 2–3 cm below the xyphoid process and ex-
tended inferolaterally 2–3 cm below and paral-
lel to the costal margin.
• The surgeon and assistant pick up the subcu-
taneous fat with fine-toothed forceps.
• The fat is divided between forceps by using nee-
dlepoint monopolar diathermy.
• Divide Scarpa’s fascia and the deeper layer of
subcutaneous fat in the same way; this will ex-
pose the anterior rectus sheath at the medial
end of the wound.
• Incise the anterior rectus fascia with the mo-
nopolar diathermy (Fig. 2).
• Insert a pair of curved mosquito forceps trans-
versely under the rectus muscle and use them
to elevate it off the posterior fascia (Fig. 3).
44 T. J. Bradnock and R. Carachi

• Open the jaws of the instrument and divide the

interposed muscle with needlepoint monopolar
diathermy to expose the posterior rectus sheath
(Fig. 4).
• Identify and cauterise any branches of the su-
perior epigastric vessels.
• Pick up the posterior rectus sheath with curved
mosquito forceps 1 cm apart and open with a
blade, taking care to avoid adjacent underlying
viscera.
• Once the peritoneum is opened, the remain-
der of the posterior fascia can be divided safely
with Metzenbaum scissors under direct vision.
• Place the index and middle fingers of your non-
dominant hand into the wound to protect the
bowel and use needlepoint monopolar dia-
thermy to divide the external oblique, internal
oblique and transversalis muscle layers to the
full lateral extent of the wound (Fig. 5).

Closure

Fig. 2 • Typically closure is done in layers with absorb-

able sutures (2/0 to 4/0, depending on the age
of the child).
• Use curved mosquito forceps to grasp perito-
neum, transversalis muscle/fascia and posterior
rectus fascia, at the apices of the wound and
on both sides, halfway along. Close this layer
with a continuous absorbable suture.
• Use a continuous absorbable suture to close
anterior rectus fascia.
• Close the internal and external oblique mus-
cles in separate, continuous layers.
• Use interrupted absorbable sutures to close
Scarpa’s fascia.
• Close the skin with a continuous subcuticular,
absorbable suture and Steri-Strips.

Fig. 3
A10  Subcostal and Rooftop Incisions 45

Rooftop Incision Mercedes-Benz Modification

Indications Indications

Liver surgery and surgery to portal structures are
indications for use of the rooftop incision.
Technique
• The skin incision is extended symmetrically
across the midline to parallel the contralateral
costal margin.
• The incision is deepened to peritoneum, as de-
scribed above.
Closure
Indications include liver surgery including trans-
plantation and access to the diaphragmatic hia-
tuses.
Technique
• If this incision is planned initially, the bilateral
subcostal incisions are usually made lower than
normal.
• The linea alba is opened in the midline with
monopolar diathermy up to or through the xy-
phoid process.

This procedure is as described for the subcostal Closure

incision.
Closure is as described for the bilateral subcos-
tal incision with additional closure of the linea
alba by using a slowly absorbed material such as
polydioxanone or nylon.

Fig. 4 Fig. 5
46
Tips
77 Always use your assistant to best advantage to
apply tension across the tissue being divided.
77 The divided rectus abdominus is held by tendi-
nous intersections superiorly and inferiorly to
the incision and retracts very little. Only the rec-
tus sheath requires closure.
77 The isolated subcostal incision can be extended
up to the xiphisternum to improve access to the
diaphragm or distal oesophagus (‘hockey-stick’
incision).
Common Pitfalls
77 The superior epigastric vessels lie posterior to
the lateral part of rectus abdominus. Be careful
to identify and control the vessels with ligatures
or coagulation.
77 Inevitably the small eighth thoracic nerve is di-
vided in a subcostal incision, but the larger ninth
nerve must be identified and preserved in the
lateral part of the wound, to prevent atrophy of
the rectus abdominus.
T. J. Bradnock and R. Carachi
77 Use a mass closure, in very premature neonates,
where concern about integrity of individual mus-
cle layers exists and when an old incision has
been re-opened.
77 The incisions described in this chapter are effec-
tive because they do not deprive the rectus mus-
cles of their segmental innervation, which run
with slightly downward obliquely from lateral to
medial direction. Avoid making an incision that
is too oblique.
77 Ensure the suture line does not overlie costal
margin, as this will impair healing and cause dis-
comfort.
77 Both the subcostal and rooftop incisions give op-
timal exposure in patients with wide subcostal
angles. In patients with a narrow subcostal angle,
consider an upper midline incision.
77 Avoid making bilateral subcostal incisions too
obliquely, as the acute angle this generates may
result in devitalisation of the apical tissue inferior
to the incisions.
A11  Pfannenstiel Incision 47
A 1Pfannenstiel Incision A11
H. Said and R. Carachi

The Pfannenstiel incision provides access to pel- • Before incising the rectus sheath, the distance
vic organs including the urinary bladder, distal above the pubic symphysis should be checked
ureters, ovary and uterus. It offers good exposure, by palpation, to ensure it remains at least one-
without the need for division of the rectus muscles. finger’s breadth.

Technique

• A semilunar incision is made one-finger’s

breadth above the pubic symphysis. The inci-
sion is extended to the lateral border of both
rectus muscles, with a symmetrical upward
curve (Fig. 1).

Fig. 2

• The rectus sheath is incised with monopolar

diathermy, following the same semilunar arc
as the skin incision, to avoid the inguinal ca-
nals (Fig. 2).
• The incision is continued laterally by using mo-
nopolar diathermy to divide the external, inter-

Fig. 1

• The incision is deepened to anterior rec-

tus sheath, with needlepoint monopolar dia-
thermy.

Hanan Said ()

Consultant Paediatric and Neonatal Surgeon,
King Fahd Armed Forces Hospital, PO Box 9862,
Jeddah 21159, Kingdom of Saudi Arabia
Hanansaid@gmail.com

Robert Carachi
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk Fig. 3

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_11, © Springer-Verlag Berlin Heidelberg 2013
48
nal oblique and transversus abdominus apo-
neuroses and muscles at each extremity.
• The upper edge of the divided rectus sheath is
grasped and elevated with curved mosquito for-
ceps. Its midline attachment should be divided
with monopolar diathermy extending cranially
as far as the umbilicus (Fig. 3).
Fig. 4
• A combination of sharp dissection with mono-
polar diathermy and blunt dissection with pled-
gets or sponge sticks is used to free the rectus
Fig. 5
H. Said and R. Carachi
muscles from the overlying sheath down to the
pubic symphysis (Fig. 4).
• Take care to avoid the perforating branches of
the inferior epigastric vessels or to coagulate
and divide them.
• The lower flap is mobilised caudally in the same
way, as far as the pubic symphysis. Both pyram-
idalis muscles are elevated if well developed;
otherwise they are left attached to the rectus
muscles.
• The rectus and pyramidalis muscles are sep-
arated in the midline by using a combination
of sharp dissection and gentle spreading with
a curved clamp (Fig. 5), until the preperitoneal
and prevesical space is identified.
Fig. 6
• The rectus muscles are retracted laterally with
fingers to expose transversalis fascia (Fig. 6).
• The transversalis fascia and peritoneum are
then elevated in the midline between curved
mosquito forceps, and opened vertically with
dissecting scissors, taking great care to avoid
the bladder inferiorly.
Closure
The incision is closed in layers, starting with peri-
toneum and transversalis fascia, which are closed
as a single layer, using a continuous absorbable
suture. The rectus muscles are loosely approx-
A11  Pfannenstiel Incision 49

imated in the midline, with interrupted absorb-

able sutures. The anterior rectus sheath, internal
and external oblique muscles are closed in sepa-
rate layers with a continuous absorbable suture.

Tips

77 Mark the incision before starting. 77 Leave adequate length of rectus sheath inferi-
77 Preoperatively, place a urinary catheter to empty orly.
the bladder.

Common Pitfalls

77 Inguinal canal injury may occur if the incision ex- 77 Inadvertent injury may occur to the urinary blad-
tends too laterally without curving cranially. der.
77 Injury to the rectus muscle and perforating
branches of the inferior epigastric vessels may
occur.
 50
A12 A 12Gridiron, Lanz
and Rutherford Morison Incisions
T. J. Bradnock and R. Carachi
The gridiron and lanz incisions are muscle-split-
ting incisions which are the incisions of choice for
open appendicectomy. They differ in the orienta-
tion of the skin incision alone. The gridiron inci-
sion can be more readily extended laterally into an
oblique, curvilinear muscle-cutting incision: the
Fig. 1  a Gridiron incision, b Lanz incision, c Rutherford
Morison incision (shown on the left side for clarity)
Rutherford Morison.
Tim J. Bradnock ()
Specialty Registrar in Paediatric Surgery
The Department of Paediatric Surgery, Dalnair Street,
Yorkhill Hopsital, Glasgow G3 8SJ, Scotland, UK
Email: tjbradnock@doctors.org.uk
Robert Carachi
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_12, © Springer-Verlag Berlin Heidelberg 2013
T. J. Bradnock and R. Carachi
Gridiron Incision
The gridiron incision is also known as the classic
McBurney incision (Fig. 1).
• The abdomen is palpated under general anaes-
thetic to exclude an appendix mass. Most com-
monly no mass is palpable, and the incision is
then made perpendicular to McBurney’s point.
If a mass is present, the incision should be cen-
tred over the mass.
• McBurney’s point lies a third of the way along
an imaginary line running from the anterior su-
perior iliac spine (ASIS) to the umbilicus.
• The length of incision depends on the child’s
body habitus and the anticipated severity of
pathology.
• Deepen the incision through Camper’s (super-
ficial) and Scarpa’s (deep) fascia, using curved
dissecting scissors or monopolar diathermy.
• The assistant uses Langenbeck retractors and
a swab to clear the fat off the external oblique
aponeurosis (EOA).
• A scalpel is used to make a 2-mm stab incision
in the EOA, which is extended by inserting par-
tially opened Metzenbaum scissors and push-
ing in the line of the fibres, or with sharp divi-
sion. The split will end at the linea semilunaris
medially.
• Use Metzenbaum scissors or curved mosquito
forceps to split the muscle along the line of its
fibres (Fig. 2).
• Complete the muscle splitting with Langen-
beck retractors. No sharp dissection is re-
quired.
• Split the internal oblique and transversus ab-
dominus- muscles along the line of their fibres
in the same way (Fig. 3). Use Langenbeck re-
A12  Gridiron, Lanz and Rutherford Morison Incisions 51

tractors to further separate the muscle fibres

and expose transversalis fascia (Fig. 4).
• The transversalis fascia is sharply incised to ex-
pose the peritoneum.
• The peritoneum is grasped with curved mos-
quito forceps and the tented portion rolled be-
tween your fingers to exclude interposed bowel,
before opening transversely or vertically with a
scalpel.
• The opening is enlarged with curved dissecting
scissors.

Closure

• Close the wound in layers with a braided, ab-

Fig. 2 sorbable suture after irrigation of each layer.
• The closure is continuous to peritoneum, inter-
rupted to transversus abdominus and internal
oblique in a single layer, continuous to EOA,
interrupted to Scarpa’s fascia and continuous
subcuticular to skin.

Lanz Incision

This incisions is also known as a modified Mc-

Burney, Rocky-Davis or Bikini incision (Fig. 1).
• This is a modification of the gridiron incision
to provide better cosmetic result.
• Instead of making the skin incision at 90° to
the imaginary line between the ASIS and um-
bilicus, the skin incision is made more trans-
versely, parallel to Langer’s lines.
Fig. 3 • It has the added advantage of running paral-
lel to the major cutaneous nerves that traverse
the right iliac fossa and is therefore less likely
to result in transection.
• In the absence of a palpable appendix mass, the
Lanz incision (as with the gridiron incision) is
centred over McBurney’s point. If a mass is pal-
pated, it should be moved to lay over the mass.
• After incision of the skin and subcutaneous tis-
sues, the muscles are split down to transversa-
lis fascia and peritoneum in the same manner
as described for the gridiron incision.

Fig. 4
52 T. J. Bradnock and R. Carachi

Rutherford Morison Incision • If the incision is performed primarily, it should

commence one-finger’s breadth above the pu-
This is also known as the ‘hockey-stick’ incision. bic symphysis and curve upwards to the level
• This is an oblique, curvilinear muscle-cutting of the umbilicus. Vertical extension as far as
incision (Fig. 1). It can be made as a primary in- the costal margin may be necessary.
cision to provide good access to the right or left • The external and internal oblique, transversus
colon, retroperitoneum, major vessels (aorta, abdominus and rectus abdominus muscles are
inferior vena cava and common iliac vessels) all divided with monopolar diathermy.
and bladder for renal transplantation, colonic • Transversalis fascia and peritoneum (if appro-
resection, caecostomy or sigmoid colostomy. priate) are opened as described above.
It can also be made by lateral (with or without
medial) extension of a gridiron incision dur-
ing a difficult appendicectomy, where mobili-
zation of the caecum or right hemicolectomy
is required.
• If a gridiron has been made, the skin incision
is extended cranially in a curvilinear configu-
ration.
• The incision is deepened through subcutane-
ous tissues and then through all three lateral
muscle layers by using monopolar diathermy.
• The peritoneal contents are protected by man-
ually elevating the anterior abdominal wall.

Tips

77 Opening the peritoneum vertically has the the-
oretical advantage of reducing the risk of inad-
vertently opening the rectus sheath and injur-
ing the inferior epigastric vessels medially or cae-
cum laterally.
77 If it is anticipated that the incision is likely to re-
quire extension, it is best to make an oblique in-
cision, which can be easily extended laterally as a
muscle-cutting incision.
77 Maintain a low threshold for extending the orig-
inal incision as described above –‘many big mis-
takes are made through small holes’.

Common Pitfalls

77 Dissect the plane between the internal oblique
and transversus abdominus muscles carefully,
since the supplying the lower rectus abdominus
muscle and the skin of the lower abdominal wall
traverse this plane. Damage results in loss of sen-
sation or atrophy and weakness of the lower rec-
tus muscle.
77 Be careful to avoid inadvertent damage to the
spermatic cord when making a Rutherford Mor-
ison incision. This may be avoided by medial re-
traction of the cord structures.
77 If a Rutherford Morison incision is used for renal
transplantation, take great care to avoid opening
the peritoneum, as this may allow residual dialy-
sis fluid to compromise the operative field.
77 A gridiron incision may result in damage to the
ilioinguinal or iliohypogastric nerves, which in-
creases the risk of subsequent inguinal hernia.
A13  Sutures and Their Uses 53
A13 Sutures and Their Uses A13
R. Kronfli and G. M. Walker

Types of Sutures Monofilament

Sutures can be classified into: • Made of a single strand of material

1. Absorbable or non-absorbable • Resists harbouring microorganisms
2. Monofilament or polyfilament (braided) • Minimal inflammatory reaction
Suture sizes are standardised.
• The more zeros in the number, the smaller the Polyfilament
size of strand.
• The smaller the size of the suture, the less ten- • Multiple strands braided/twisted together
sile strength. • Easy to handle and tie
• Larger, handheld needles are still used by some • Variable knot strength due to braiding/twisting
surgeons.
• In modified vascular sutures the thread fills the Specific Examples of Sutures
hole created by the needle avoiding leaks.
Absorbable Monofilament
Absorbable
• Monocryl
• Absorbed by enzyme degradation or hydroly- • Polydioxanone (PDS)
sis
• Rate of absorption dependent on suture Absorbable Polyfilament
• Used when continued strength not important
• Useful in children, as sutures do not require re- • Vicryl
moval • Vicryl Rapide

Non-absorbable Non-absorbable Monofilament

• Become encapsulated by fibroblasts in vivo and • Ethilon

remain where they are buried • Prolene
• Useful if continued strength is important
Non-absorbable Polyfilament

• Silk
• Ethibond

Rania Kronfli ()

Specialty Trainee in Paediatric Surgery
rkronfli@doctors.org.uk

Gregor M. Walker
Consultant Paediatric and Neonatal Surgeon
Gregor.Walker@ggc.scot.nhs.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_13, © Springer-Verlag Berlin Heidelberg 2013
54 R. Kronfli and G. M. Walker

Fig. 1  Anatomy of a suture needle

Fig. 2  Types of needle point

A13  Sutures and Their Uses 55

Tips

77 Use the finest size of suture possible that will pro- 77 Sutures should be removed at an early stage in
vide adequate strength. cosmetically important areas such as the face
and later over areas of increased skin tension,
such as joints.

Common Pitfalls

77 Give specific advice on suture care and/or re- 77 Consider alternative ways of wound closure, e.g.
moval to avoid confusion. glue, staples, SteriStrips.

Table 1  Suggested sutures

Indication Suggested suture type

Subcuticular skin closure Absorbable monofilament/polyfilament
Interrupted skin closure (tension) Non-absorbable monofilament
Soft tissue approximation/ligation Absorbable monofilament/polyfilament
Securing of lines/drains Non-absorbable monofilament/polyfilament

Table 2  Features of different needle points

Needle point Feature(s)

Blunt (round bodied)
Taper (round bodied)
Taper cut
Conventional cutting
Reverse cutting
Minimizes risk of needle-stick – used in friable tissue or muscle/fascia
Easy penetration of tissues, then minimal trauma
Initial penetration of cutting needle with minimized trauma of round bodied
Cutting edges at inside/front of needle – used in tougher tissues, e.g. skin
Cutting edges on outside/front of needle – increased resistance to bending
 56 R. Kronfli and R. Carachi
A14 A14 Knots and Their Uses
R. Kronfli and R. Carachi

Basic Principles Square Knot

• Knots must be tied firmly to avoid slipping.
• All knots weaken the suture material signifi-
cantly, but applying excessive tension when ty-
ing the knot will cause critical tissue or suture
damage.
• The knot should be as small as possible to avoid
unnecessary tissue reaction.
Simple Knot
• It can be tied two-handed, one-handed or with
instruments.
• The square knot is reliable for tying most su-
ture materials.
• It involves two simple knots tied in opposite di-
rections.
• The addition of a further half-hitch creates a
triple-throw knot, which is the standard knot-
tying method used in surgery.

• This is also called a ‘half-hitch’ or ‘overhand

hitch’.
• It is the (incomplete) basic unit underlying all
knots.

Fig. 2  Square knot

Fig. 1  Simple knot

Rania Kronfli ()

Specialty Trainee in Paediatric Surgery
rkronfli@doctors.org.uk

Robert Carachi
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_14, © Springer-Verlag Berlin Heidelberg 2013
A14  Knots and Their Uses
Surgeon’s Knot
• The surgeon’s knot can be tied two-handed,
one-handed or with instruments.
• It involves a double knot, followed by a simple
knot in the opposite direction.
Fig. 3  Surgeon’s knot
Tips
77 Time should be taken to ensure knots are tied
accurately to ensure maximum strength.
77 Understanding the basic units of knots, how to
tie them and when to use them is an essential
Common Pitfalls
77 Avoid tying a ‘granny’ knot, which may be
formed by incorrectly laying down a square knot
(with two half-hitches in the same direction), as it
has the tendency to slip.
57
Slipknot
• It can be hand tied or instrument tied.
• The slipknot involves simple knots formed
around a straight, taut suture end.
• The knot can be advanced to the wound edge
and then tightened.
• A slipknot can be converted to a square knot
by applying tension to the opposite suture end
to the one that was held taut.
Fig. 4  Slipknot
part of surgical practice. Ensure that you develop
your understanding and mastery at an early
stage in your training.
77 When tying deep in a body cavity, ensure you
do not pull upwards while ‘snugging’ down the
knot, causing damage or avulsion of the tissues.
 58 R. Kronfli and A. J. Sabharwal
A15 A 15Hand Tying
R. Kronfli and A. J. Sabharwal

The hand-tying technique described below is safe
and effective in most situations.
• It is tied by using the left-hand.
• Because it only requires one hand, it can be tied
while holding an instrument in the right hand.
• Two-handed knots are slower to tie but are a
more secure alternative until you have mastered
this technique.
• Mastery of the technique cannot be achieved
through reading alone; a sound theoretical un-
derstanding of the key steps involved will en-
hance your practical skill development and pre-
vent you picking up bad habits at an early stage.
One-Handed Square Knot
1. Hold the top strand in your left hand between
the thumb and middle finger, with a loop over
index finger.
2. Hold the bottom strand in your right hand be-
tween your thumb and index finger.
3. While holding the suture, hook your left index
finger over the taught suture held by your right
hand.
4. Now hook your left index finger around the
distal suture, held between your left thumb and
middle finger.
5. While doing this move your right hand away
from yourself.
6. Pull the left hand strand through the loop to-
wards yourself, while moving your right hand
away (hands cross in the sagittal plane).
7. Apply an even and adequate tension to com-
plete the first part of the knot.
8. Now take the lower suture with your thumb
and index finger and pass it under and over the
ring finger of your left hand.
9. Hold the top strand of suture in your right
hand between thumb and index finger.
10. Hook the middle finger of your left hand un-
der the strand held by your right hand.
11. While keeping hold of the left hand strand,
bend your left middle finger and pass it around
the distal end of left hand strand near to where
it is being held.
12. Pass the suture through the loop.
13. The knot is completed by pulling the right
hand strand towards yourself and moving
your left hand away (hands cross in the sagit-
tal plane again).
14. Apply an even and adequate tension to ensure
the knot is tight.
15. Repeat steps 1–7 for a three-throw knot or
steps 1–14 for a four-throw knot.

Rania Kronfli ()

Specialty Trainee in Paediatric Surgery
rkronfli@doctors.org.uk

Atul J. Sabharwal
Consultant Paediatric and Neonatal Surgeon
Atul.Sabharwal@ggc.scot.nhs.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_15, © Springer-Verlag Berlin Heidelberg 2013
A15  Hand Tying 59

Fig. 1 & 2 Fig. 3 Fig. 4 Fig. 4

Fig. 5 & 6 Fig. 7 Fig. 8 & 9 Fig. 10

Fig. 11 Fig. 12 Fig. 13

Tips

77 Ensure the knot is flat before tightening.
77 To master the art of hand tying, there is no sub-
stitute for endless practice. Get used to the feel
of the suture material and what constitutes the
‘right’ amount of tension to apply.
77 Practice wearing gloves and replicate different
scenarios, e.g. tying in a hole.
77 Basic Surgical Techniques by R. M. Kirk is full of in-
valuable advice to enhance your practice – we
recommend it.

Common Pitfalls

77 Avoid cutting suture too short to enable a com- 77 A two-handed knot is safer for tying sutures in
fortable hand-tied knot to be performed. very delicate tissues, as it is easier to control and
77 Remember that the one-handed knot requires minimise tension on the threads.
two hands to tighten. Failure to use both hands
results in a slipknot and not a square knot (see
Chap. A14).
 60
A16 A 16Instrument Tying
R. Kronfli and A. J. Sabharwal
• Instrument tying is an essential skill for the as-
piring surgeon to master at an early stage in
their professional development. As with any
practical skill, the key to successful mastery is
practice, practice, practice.
• Instrument tying should be used for repetitive
knot tying in routine situations where fine con-
trol of tension is not critical.
• In situations such as vascular ligation, where
fine control of tension is important, it is more
appropriate to use hand tying, as described in
Chap. A15.
Fig. 1
Rania Kronfli ()
Specialty Trainee in Paediatric Surgery
rkronfli@doctors.org.uk
Atul J. Sabharwal
Consultant Paediatric and Neonatal Surgeon
Atul.Sabharwal@ggc.scot.nhs.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_16, © Springer-Verlag Berlin Heidelberg 2013
R. Kronfli and A. J. Sabharwal
Technique
1. The short end of the suture lays free.
2. Hold the long end in your left hand, with the
needle holder in your right hand, as shown in
Fig. 1.
3. Place the needle holder across the long end and
wrap the suture around the tip of the instru-
ment in a counter-clockwise direction (Fig. 2).
4. Keeping the loop on the needle holder, use the
instrument to grasp the short end of the suture.
5. Pull the needle holder towards you (holding the
short end of suture) and use your left hand to
pull the long end of the suture away. Note that
your hands should cross in the sagittal plane
(Fig. 3).
6. Apply even tension to tighten the suture.
7. The short suture now lies on the opposite side
of the knot.
8. Once again, form a loop over the needle holder
in the same way, but this time wrap the suture
around the instrument in a clockwise direction
(Fig. 4).
9. Keeping the loop on the needle holder, use the
instrument to grasp the short end of the suture.
10. Pull the needle holder away from you and use
your left hand to while pull the long end of
the suture back towards you (Fig. 5).
11. Apply even tension horizontally to complete
the knot (Fig. 6).
12. In practice, at least three throws are required
for a secure knot by using braided suture ma-
terial and more if monofilament is used.
13. Repeat steps 1–11 until the desired number of
throws has been reached.
14. The technique of instrument tying described
above is the basis for wound closure by using
interrupted sutures (Fig. 7).
A16  Instrument Tying 61

Fig. 2

Fig. 3

Fig. 4
62 R. Kronfli and A. J. Sabharwal

Fig. 5

Fig. 6

Fig. 7
A16  Instrument Tying
Tips
77 Instrument tying is useful when the ends of the
suture material are short but in this situation, it
is imperative that you do not keep the short end
under tension and tie a slipknot around it.
77 Pull the suture through as much as comfortably
possible before tying the knot in order to avoid
wasting suture material.
Common Pitfalls
77 Be careful when handling sutures with the nee-
dle holder, as repeated grasping may compro-
mise the strength of the suture.
77 Tension is more difficult to gauge when instru-
ment tying, compared with hand tying. Avoid ex-
cessive tightening as the sutures may break.
63
77 Always grasp the distal end of the suture to
avoid entanglement.
77 When tying tissues under tension, use your as-
sistant to keep the tissues in opposition until the
knot is tightened.
77 When using monofilament or tying tissues under
moderate tension, a double throw is required on
the first half-hitch, followed by a single throw on
the second half-hitch. This is called a surgeon’s
knot.
 64
A17 A17 Repair of Vessels, Nerves and Tendons
O. Quaba and A. Hart
Introduction
This chapter provides a basic overview of primary
vessel, nerve and tendon repair. All require ade-
quate exposure using extensile incisions that avoid
risk of flexion contracture (e.g. Bruner incision in
the digits). Tourniquet control, hand table, accu-
rate haemostasis and self-retaining retractors are
of benefit.
• Avoid scars overlying anastomoses and provide
good soft tissue envelope.
• Adequate debridement and prevention of in-
fection is critical.
• Use well-padded dressings and protective
splinting (tendon, 4–6 weeks; nerve, 3 weeks;
vessel 2 weeks).
• Aim for controlled, early active mobilisation.
Vessels
General Principles
• Use magnification (loupes 4.0× are acceptable
for vessels >2 mm in diameter, microscope pre-
ferred) and meticulous tissue handling (no con-
tact on the intima, only grasp adventitia).
• Keep vessels moist with heparinised saline (10
U/ml) and irrigate the wound bed.
• A tension-free anastomosis is critical for pa-
tency – use a reverse vein graft, if a tension-free
repair cannot be achieved – approximate with
a double microvascular clamp (e.g. Ackland)
Omar Quaba ()
Specialist Registrar in Plastic Surgery
omarquaba@hotmail.com
Andrew Hart
Consultant Plastic Surgeon
Andrew.Hart@ggc.scot.nhs.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_17, © Springer-Verlag Berlin Heidelberg 2013
O. Quaba and A. Hart
Technique
• Align stumps to avoid twisting and ensure ves-
sel not so slack as to risk kinking.
• Release constricting/compressing soft tissues.
• Trim to healthy adherent intima, excise further
~5 mm of adventitia.
• Test proximal inflow/distal retrograde flow to
ensure patency and flush with heparinised sa-
line.
• Use vessel dilator forceps to gently counteract
spasm.
• Anastomosis – use 6/0 (brachial artery) to 10/0
(digital artery) nylon/Prolene, depending on
calibre.
• Insert hardest stitch first (back wall), or if ves-
sel can be rotated, triangulate first then fill in
gaps.
• Ensure needle enters vessel at 90°, following
curve of needle, full thickness bite ~3× the
thickness of vessel wall.
• Visualise lumen to ensure back wall not caught,
then pass suture through opposing vessel from
inside to outside.
• Gently knot (externally) avoiding tearing. Next
suture ~2–4 mm away.
• Irrigate lumen before closure.
• Usually complete arterial and venous repairs
before removing clamps and applying topical
vasodilator (e.g. nifedipine)/warm packs.
• Use soft (e.g. Penrose) drains.
• Postoperatively ensure that warming measures
employed, patient is kept well perfused, and use
low-molecular-weight (LMW) heparin.
A17  Repair of Vessels, Nerves and Tendons
Nerves
General Principles
Avoid tension/ischaemia at the repair site (nerve
grafts and transfers beyond the scope of this chap-
ter). Early repair (within 48 h), unless clearly con-
traindicated, is key.
Technique
• Trim stumps (use no. 10 or 11 blade, seek mush-
rooming from fascicles) if unhealthy.
• Nerves can safely be mobilised 1–2 cm to avoid
tension at the repair site.
• Ideally repair with limb/digit in functional po-
sition and rotate stumps to align nerve topog-
raphy.
• Use epineurial blood vessels and morphology
of fascicle to align correctly.
• They should oppose with single 8/0 suture; if
not tension may be excessive for primary repair.
• Epineural repair with 8/0 or 9/0 Ethilon is sim-
plest (similar outcomes to fascicular repair)
(Fig. 1).
• Wraparound devices and fibrin glue have a
place for major nerves.
Tendons
General Principles
• Repair within days of injury – outcomes dimin-
ish significantly within 1 to 2 weeks of injury.
• Atraumatic tendon handling minimises adhe-
sion formation; preserve A2 and A4 pulleys.
Technique
• Trim ends if badly frayed, deliver into wound
and maintain with transfixion needle in pulley.
• Repair lacerations <50 % diameter with a run-
ning epitendinous suture to avoid entrapment.
• A range of sutures can be used depending on
tendon location and size – e.g. 3/0 Prolene core
and 5/0 Prolene epitendinous for flexor ten-
dons. Use only round-bodied needles for epi-
65
tendinous suture to avoid damage to core su-
ture.
• Tendon repair strength is proportional to the
size and number of core sutures placed across
the repair site – two or four strand techniques
are commonly used (Fig. 2).
• Locking loops are essential to grip the longitu-
dinal, parallel collagen fibres of flexor tendons.
• Epitendinous sutures increase repair strength,
minimize bulk and fraying, and aid gliding.
• To aid access in the flexor sheath, insert the
back-wall epitendinous suture before complet-
ing the core suture.
• Extensor tendons in the digits may simply re-
quire running or mattress repairs due to het-
erogeneous collagen orientation.
• Aim to coapt severed ends without bunching
or leaving a gap.
• Test tendon gliding using tenodesis manoeu-
vres to ensure no impingement, or gapping oc-
curs.
• Repair of the musculotendinous junction is dif-
ficult, and best achieved using multiple absorb-
able sutures.
• Restricted mobilisation may be necessary.
Fig. 1  Epineural repair of nerve
Fig. 2  Example of two strand flexor tendon repair
66 O. Quaba and A. Hart

Tips

77 Ensure comfortable setup for microsurgery, with
good access, instruments and assistance.
77 Use wick spears to remove fluid from vessel lu-
mens, or nerves.
77 Obtain skeletal stability and perform tendon re-
pairs before vascular and nerve anastomoses.
77 Bury core suture knot in tendon repair (avoid
over tightening as this causes bunching).
77 Bury epitendinous suture knot by taking first bite
from inside; cut tendon face to outside.
77 Monofilaments are more forgiving when ten-
sioning a core suture, as they glide.

Common Pitfalls

77 Inadequate debridement resulting in infection 77 Using excessive tension, or abnormal positioning

causing vascular thrombosis, failed nerve regen- to permit direct nerve repair, with subsequent
eration or tendon rupture. failed regeneration.
77 Inadequate soft tissue envelope resulting in fi- 77 Failure to reassess compartments after vessel re-
brosis, ischaemia or delayed mobilisation. pair.
77 Failure to explore and repair digital nerves in the
middle phalanx.
A18 Haemostasis 67
A 18Haemostasis A18
R. Partridge and R. Carachi

General Principles of the instrument. The current will flow through

the instrument and be focused between its tips
• A degree of bleeding is inevitable with all dis- where the vessel is held. It is essential that the in-
section. strument and diathermy tip are clean, and that no
• Excessive bleeding should be avoided by care- part of the circuit is in contact with other struc-
ful technique, controlled swiftly if it does oc- tures, such as the skin, as demonstrated in Fig. 1.
cur, and any resultant collection of blood evac- Bipolar diathermy may also be used to coagulate
uated effectively. small vessels either before division or after acci-
• Minor bleeding will stop spontaneously if the dental division.
patient’s clotting mechanisms are uncompro-
mised.
• Heavy bleeding requires a calm and logical ap-
proach to prevent rushed decisions and to avoid
collateral damage to tissues during attempted
control.
• An obsession with preventing all blood loss can
preclude a reasonable rate of progress, and thus
this attitude should be avoided.

Methods of Controlling Bleeding

Pressure

Direct pressure with a gauze swab is usually suf- Fig. 1  Diathermy applied to forceps – always ensure no
ficient to arrest minor bleeding. contact with the skin edge

Diathermy Clip and Tie

Small vessels may be controlled with diathermy
coagulation, either before they are divided or fol-
lowing accidental division. The vessel should be
grasped with non-toothed or curved mosquito
forceps, and current should be applied to any part
Larger vessels should be clipped – usually using
curved mosquito forceps with the concaved tips
facing each other – the vessel divided with curved
dissecting scissors and a ligature placed beneath
the forceps and tied (Figs. 2 and 3).

Roland Partridge ()

Specialty Trainee in Paediatric Surgery
rolandpartridge@nhs.net

Robert Carachi
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_18, © Springer-Verlag Berlin Heidelberg 2013
68 R. Partridge and R. Carachi

Clips

Metallic or plastic clips may be used to clamp

a vessel closed. They are mainly used in laparo-
scopic rather than open surgery.

Under-running

If it is not possible to secure an adequate length

of vessel to diathermy, tie, transfix or clip, then
it may be necessary to ‘under-run’ the vessel us-
ing a ‘figure-8’ suture, as demonstrated in Fig. 4.

Stabilisation of Torrential
Fig. 2  Clipping and cutting a vessel Haemorrhage

In cases of catastrophic haemorrhage, packing the

cavity with large swabs may apply sufficient pres-
sure to arrest the bleeding. The Pringle manoeu-
vre is potentially lifesaving in major liver trauma
(see Chap. E24).

Topical Haemostatic Agents

Topical products containing thrombin or an ad-

mixture of thrombin and fibrinogen, in dry or liq-
uid form, or as a spray or precoated onto sheets,

Fig. 3  Tie placed beneath curved mosquito forceps

Closed–Suction Drain Technique

• This usually comes with a sharp metal intro-

ducer attached to one end of the drain tubing.
• The introducer pushed outwards through wall
from within the cavity.
• A small skin incision may be required.

Transfixion

For added security, a bite through the end of the

vessel may be taken with a suture, which is then
tied around it. This prevents knot slippage. Fig. 4  Under-running a vessel using a ‘figure-8’suture
A18 Haemostasis 69

are available and may serve as a useful adjunct

to direct pressure when packing severe, solid vis-
cous haemorrhage. Products containing throm-
bin and fibrinogen have the capacity to work in-
dependently of the patient’s endogenous clotting
cascade.

Blood Products

In severe haemorrhage blood products such as

platelets concentrate, fresh frozen plasma, fibrin-
ogen, recombinant factor VIIa and recombinant
or donor factor VIII may play a vital role in con-
junction with the surgical techniques described
above. Advice should be obtained from a haema-
tologist, based on the patient’s coagulation profile.

Clot Removal

Use a pool sucker to aspirate large collections of

clot, which may otherwise act as a medium for
infection.

Tips

77 ‘Dab, don’t wipe’ – use dry swabs to dab an area,
but avoid ‘wiping’ across a surface, as this will dis-
lodge small haemostatic clot, and may restart
bleeding.
77 When assisting, become skilled at helping to
control haemostasis – in coordination with the
primary surgeon use non-tooth forceps to pick-
up small bleeding vessels, to which monopolar
diathermy may be applied.

Common Pitfalls

77 Do not panic: apply direct pressure, clear the 77 Always be aware of the skin edges and other
area, identify the bleeding point and apply a suit- structures to which a metal instrument may con-
able technique to control it. duct current.
77 Never diathermy or clip blindly into a pool of
blood or fluid – it will not work, and may cause
damage.
 70
A19 A 19Debridement
R. Partridge and R. Carachi
General Principles
• The French word debridement means to ‘let
loose’, referring to the process of releasing pus
from infected wounds.
• A better term for the process of managing a
dirty wound is wound excision:
– This describes the process of removing all
tissue and matter, which would otherwise
compromise healing.
S
 teps
• The wound should be carefully explored and
extended where necessary.
• Time should be taken to remove all dead and
damaged tissues with a blade, curette or scis-
sors.
• Particular attention should be paid to remov-
ing foreign material such as gravel and small
dirt particles, which may have penetrated deep
into the wound.
• Leaving such small particles may result in com-
promised healing and the formation of un-
sightly scars with ‘tattooing’ of the skin.
• Extensive irrigation is critical to achieving a
clean wound.
• Sterile saline is the irrigation fluid of choice.
• A mild, water-based antiseptic may be used,
but strong agents should be avoided as they
may damage tissue and prevent effective wound
healing.
Roland Partridge ()
Specialty Trainee in Paediatric Surgery
rolandpartridge@nhs.net
Robert Carachi
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_19, © Springer-Verlag Berlin Heidelberg 2013
R. Partridge and R. Carachi
• Many wounds are deeper than immediately ap-
parent, and one should not hesitate to extend
the wound further to exclude damage to under-
lying structures such as vessels, nerves, muscles,
bones, joints and underlying cavities.
Wound Closure
• The decision whether to close a wound or not
is one to be made carefully.
• If the wound is recent, clean and has fresh and
healthy skin edges, consider primary closure.
• The use of interrupted, non-absorbable mono-
filament suture is encouraged.
• Interrupted sutures are used because if a sec-
ondary infection or collection does develop, a
few of these may be removed to allow drainage
of pus, without reopening the entire wound.
• Delayed primary closure after 24–48 h should
be considered for wounds with significant con-
tamination and tissue trauma.
• This allows further tissue necrosis or infection
to be excluded, and any oedema to settle.
Haemorrhage Control
• An important part of wound excision is assess-
ment and control of bleeding.
• Bleeding vessels should be identified and dealt
with (see Chap. A18).
• All old clots must be removed, as this is a rich
culture medium for infection to develop in.
A19 Debridement 71

Reconstruction

• If extensive wound excision is necessary, mus-

cle flaps and skin grafting may be required to
reconstruct the area.
• Figures 1 and 2 show a 9-year-old boy who re-
quired extensive wound excision for necrotizing
fasciitis, but made an excellent recovery with
multiple split-skin grafts.
• Optimal soft tissue reconstruction may require
plastic surgical input.
Fig. 1 Extensive necrotising fasciitis requiring massive
wound excision

Fig. 2  The same child four months later, showing good Fig. 3 A hand which sus- Fig. 4 In theatre the true
result from split skin grafting tained a significant crush extent of the tissue damage
injury necessitated considerable
wound excision

Tips

77 “Irrigate, irrigate, irrigate” – to ensure that all par- 77 Infected or traumatised tissues are more acidic,
ticulate matter had been removed from the preventing the dissociation of local anaesthetics
wound. and limiting their effectiveness
77 In children, general anaesthesia is usually re-
quired for proper wound inspection and exci-
sion.

Common Pitfalls

77 Foreign material may have penetrated deep into 77 The true extent of the tissue injury is usually much
the wound. greater than it at first appears (Figs. 3 and 4).
77 Be careful not to miss damage to deeper struc-
tures such as muscles, bones, joints, nerves and
underlying cavities.
 72
A20 A20 Management of Acute Thermal Injuries
in Children
G. M. Walker and S. Ramsay
The majority of thermal injuries in children are
scalds, typically affecting infants. Outcome is de-
pendant on optimal early management and resus-
citation. Large burns are best managed in burn
centres with appropriate experience and multidis-
ciplinary teams.
History and Documentation
• Nature and time of injury, including action
taken (consider cooling if <2 h from injury)
• Past medical history, including allergy, medi-
cations and immunisations
• Social history, in particular domestic arrange-
ments
Examination
• Examine for other injuries as per Advanced
Trauma Life Support/Advanced Paediatric
Life Support (ATLS/APLS) principles.
• If signs of airway involvement or inhalation in-
jury, involve anaesthesia/critical care early.
• Estimate per cent of total body surface area
(%TBSA) of injury (not erythema) and record
on appropriate chart (e.g. Fig. 1).
• Assess depth of burn:
– Superficial injury – red, painful, no blister-
ing
– Superficial dermal – pink, painful, blister-
ing, brisk capillary refill
Gregor M. Walker ()
Consultant Paediatric and Neonatal Surgeon
Gregor.Walker@ggc.scot.nhs.uk
Sharon Ramsay
Specialist Burns Nurse
Sharon.Ramsay@ggc.scot.nhs.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_20, © Springer-Verlag Berlin Heidelberg 2013
G. M. Walker and S. Ramsay
– Deep dermal – deep red/speckled, altered
sensation, with or without blistering, slow
capillary refill
– Full thickness – white or leathery (black in
flame burns), insensate, dry, no capillary re-
fill
• Obtain accurate weight.
Early Management
• Resuscitation for child with %TBSA >10 %: see
local fluid guidelines for formula.
– Remember to give maintenance fluids in ad-
dition (intravenous [IV] or enteral).
• Analgesia – consider early involvement of pain
team if available.
• Wound care – initial coverage with cling film
until assessed; subsequent antimicrobial dress-
ing recommended.
• Consider need for escharotomy (high index of
suspicion in circumferential injury).
• Microbiology – swab injury at admission and
then weekly with dressing changes or earlier if
signs of infection.
• Nutrition – consider supplementation if
%TBSA >5 % or preexisting under-nutrition.
• Early surgery – early debridement/grafting in-
dicated in full-thickness injuries.
• Observe for signs of toxic shock syndrome (fe-
ver, rash, diarrhoea, vomiting, hypotension).
• Early physiotherapy involvement should be im-
plemented, particularly if joint involvement is
present.
A20  Management of Acute Thermal Injuries in Children 73

Fig. 1  Lund and Browder chart for assessment of TBSA affected in paediatric burns. Note age-related changes in pro-
portion of head and lower limbs to TBSA. Injury is drawn onto chart and proportions of each body part injured are
added together to give a %TBSA. NB: Erythema is not included in calculations

Criteria for Referral/Admission

• Any burn >3 % TBSA • Chemical injury

• Full thickness burns >1 % • Burns with associated significant injury
• Burns to hands, face, feet, perineum or joint in- • Circumferential burns
volvement • Any burn suspected of being non-accidental
• High-voltage electrical injury (refer to local child protection policy)
74 G. M. Walker and S. Ramsay

 riteria for Admission to Paediatric

C
Intensive Care Unit (PICU)

• Burns ≥30 % TBSA

• Possibility of airway burn, airway obstruction
or inhalation injury
• Any major burn complicated by significant
other injury
• High voltage (>1,000 V) electrical burns
• Signs of sepsis (including toxic shock syn-
drome)

Operative technique for Split Skin

Graft

• Check pre-operative bloods and ensure blood

is available, particularly if extensive injury
• Discuss optimal post-operative analgesia with
anaesthetist (e.g wound irrigation, regional
block and/or opiate infusion)
• Prepare/drape site of injury and donor site (see
tips for reduction of blood loss)
• Debride injury with dermabrasion/ knife/ der-
matome/ electrocautery to leave healthy “recip- Fig. 2a  Split-thickness graft
ient” bed
• Harvest split skin graft from donor site (air der-
matome recommended – Fig. 2a)
• Perforated sheet graft recommended in most
cases (Fig. 2b – meshing may be required for
extensive injuries)
• Secure graft with sutures, glue or staples
• Dressings to protect graft and donor site
A20  Management of Acute Thermal Injuries in Children 75

Fig. 2b

Tips

Reduce blood loss during surgery by: 77 Subcutaneous 1:500,000 epinephrine

77 Use of electrocautery 77 Epinephrine-soaked gauze swabs
77 Tourniquet if limb involvement

Common Pitfalls

77 Remember possibility of non-accidental injury. 77 Assessment of depth of scald is very difficult in

Accurate history, careful examination, good doc- first 24 hours. Seemingly superficial injuries can
umentation and high index of suspicion are es- appear deeper on subsequent examination.
sential.
 76 B. Amjad
A21 A21 Venepuncture, Intraosseous Access
and Venous Cut-down
B. Amjad

Venepuncture • Ask your assistant to hold the limb still and

Venepuncture is the insertion of a needle through
the wall of a vein for the purpose of obtaining
blood samples or establishing venous access to
give fluids or medications.
Technique
• In infants and children this procedure requires
an assistant and may be aided by having the
parents present to reassure the patient.
• Use aseptic technique.
• Select a suitable vein and an appropriate gauge
needle or cannula (Fig. 1).
with a firm grip to increase venous pressure
and to fill the vein.
• A skilled assistant should also be able to hold
the skin taught to stabilise the vein.
• Insert the needle, ‘butterfly’ or cannula through
the skin at a 45° angle, just short of the intended
entry point into the vein.
• Level out the needle once the tip is through the
skin and advance slowly until a ‘flashback’ is
obtained (blood entering the hub of the can-
nula of needle).
• If a cannula is to be left in the vein, at this point
pull the needle back by a few millimetres and

Fig. 1

Basith Amjad ()

Paediatric Surgeon and Senior Research Fellow,
School of Medicine, University of Glasgow
E-mail: basithamjad88@gmail.com

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_21, © Springer-Verlag Berlin Heidelberg 2013
A21  Venepuncture, Intraosseous Access and Venous Cut-down
advance the plastic cannula over the needle into
the vein, then remove the needle completely.
• You should occlude the vein with your finger
and ask your assistant to stop gripping the
limb, to prevent bleeding.
• If you are obtaining a blood sample in an older
child, a syringe can be attached to the needle,
‘butterfly’ or cannula and a sample withdrawn.
In neonates and infants, the smaller calibre of
the veins limits the flow rate of blood and usu-
ally means that the sample is best collected by
allowing it to drip directly from the hub of the
needle into the blood bottles or by aspiration
from the hub of the needle using a second nee-
dle and syringe.
• If the cannula is to remain in situ, secure it to
the skin with an adhesive dressing and tape,
confirm the position by flushing with normal
saline and attach the extension set to deliver flu-
ids or medicines. A bandage and splint may fur-
ther reduce the risk of cannula displacement.
 eripherally Inserted Central
P ‘peel-away’ fashion, and the line coiled and se-
Catheters (PICC Lines)
• Compared with peripheral cannulas, PICC
lines have the advantage of increased longev-
ity and can be used for infusion of medications
and solutions (e.g. 15 % dextrose solution in
parenteral nutrition) that normally require for-
mal central venous access.
• Compared with formal central venous access
they have the advantage of being amenable to
insertion without general anaesthetic and of
not compromising a central vein, which may
be required in the future.
• The low gauge of PICC lines (typically 1–3 Fr)
limit the rate of infusion and mean that PICC
lines should not be used for resuscitation in an
emergency setting.
77
Technique
• Aseptic technique is essential.
• Prepare and drape the skin. Sterile gloves with
or without gown.
• Select the vein and measure the approximate
distance from the insertion site to the junc-
tion of the superior vena cava (SVC) or infe-
rior vena cava (IVC) and right atrium (approx-
imately halfway between the tip of the xiphi-
sternum and jugular notch) using a disposable
paper tape measure.
• PICC line sets come with an introducer needle,
through which the line is inserted.
• The introducer needle is inserted as described
above.
• Commonly used veins include the long saphe-
nous, basilic, and cephalic and scalp veins.
• The line is held with plastic forceps and ad-
vanced through the needle. No resistance
should be felt.
• Once the premeasured length of line has been
inserted, the introducer needle is removed in a
cured under a clear adhesive dressing. Some
larger-gauge PICC lines for use in children have
‘wings’ which can be sutured to the skin to pro-
vide good fixation.
• A chest with or without abdominal x-ray is es-
sential to confirm the position of the line tip
before infusing medications or fluids.
Intraosseous Access
• In circulatory failure, the peripheral blood ves-
sels constrict to conserve venous return and
preload, making venipuncture extremely dif-
ficult.
• In contrast, the medullary cavity of long bones
is held open by the bony cortex that surrounds
it.
• For this reason, intraosseous (IO) access (Fig.
2) is the vascular access route of choice in a
clinical emergency when an infant or child ur-
gently requires fluids or medications.
• Advanced paediatric life support (APLS)
guidelines advise that no more than three at-
78
Fig. 2
Fig. 3
tempts at intravenous access lasting not more
than 60 s should be made before recourse to IO
access in a shocked child.
• As a rule, fluids or medications that can be
given centrally can be given by the IO route.
Technique
• Select insertion site – usually this will be the
anteromedial aspect of the tibia, 2–3 cm below
the tibial tuberosity (Fig. 3), or the anterolat-
eral aspect of the femur, 3cm above the lateral
condyle.
• Position the infant accordingly, with the limb
supported by a towel.
• In a conscious child, infiltrate the site with lo-
cal anaesthetic down to the periosteum.
• Always use strict aseptic technique (the risk of
infectious complications is greater than with in-
travenous access) – prepare the skin with an al-
cohol-based solution and allow it to dry.
• Use your non-dominant hand to hold the limb
steady.
B. Amjad
• Hold the IO needle perpendicular to the skin
(needle sizes of 14–18 G).
• Apply pressure to the needle hub and use an
alternating clockwise and anticlockwise screw-
ing motion to advance the IO needle until a loss
of resistance is felt as the tip enters the med-
ullary cavity. Avoid using a rocking motion as
this may splinter the bone. Do not angle the
needle cranially as this may compromise the
growth plate.
• Remove the trocar.
• Confirm the position by allowing the needle to
stand unsupported (should remain upright at
90° to the bone) and by aspirating bone mar-
row. In an emergency (e.g. cardiac arrest) this
may be omitted.
• Attach a three-way tap and flush the cannula
with normal saline.
• Administer fluid and medications as indicated.
• The IO needle can be fixed using a gallipot over
the needle hub or two syringe barrels under the
hub, taped to the skin. Splint the joint.
Venous Cut-Down
• May be used to establish venous access when
attempts at percutaneous venipuncture have
failed. Its use in the resuscitation of critically
Fig. 4
A21  Venepuncture, Intraosseous Access and Venous Cut-down 79

ill children when immediate vascular access is
required has been replaced by IO cannulation.
• Commonly used veins include the long saphe-
nous vein (Fig. 4), the basilic or cephalic veins
at the antecubital fossa or the femoral vein.
• The long saphenous vein is most commonly
used and can be readily accessed at the ankle
because of its superficial location.
Fig. 5
Technique: Long Saphenous Venous Cut-
Down
• Place one throw on the proximal ligature but
leave it untied. Elevating this ligature prevents
back bleeding when the vein is opened.
• If the vein is large, use an 11 blade to create a
short longitudinal or transverse venotomy, tak-
ing care not to transect the vein. Alternatively,
in small veins the needle or catheter can be in-
serted directly into the exposed vein without
the need for a venotomy.
• Relax the proximal ligature to allow the tip of
the catheter to pass (Fig. 9).
• If a PICC line is inserted always confirm cor-
rect placement with fluoroscopy.
• If the position is satisfactory, secure the prox-
imal ligature around the vein and catheter.
• After aspirating and flushing the system with
normal saline, attach the intravenous tubing.
• Close the skin with interrupted absorbable su-
tures and simple dressing (Fig. 10).
• Ensure the catheter is secure with additional
fixation sutures or dressing as required.

• Position the patient supine with the foot exter-

nally rotated.
• Consider the need for a tourniquet around the
proximal leg or mid-thigh.
• Paint the skin with antiseptic solution and
drape.
• Infiltrate around the vein with 0.5 % l-Bupiva-
caine (Fig. 5).
• It may be useful to mark the position of the
vein prior to infiltration with local anaesthetic.
• Make a 3-cm transverse incision overlying the
vein, 2 cm superior and anterior to the medial
malleolus (Fig. 6).
• Use curved mosquito forceps to dissect the sub-
cutaneous tissues parallel to the vein (Fig. 7).
• Expose the vein and dissect it from surround-
ing tissues over a length of 2–3 cm.
• Use curved mosquito forceps to dissect behind
the vein and pass two 4/0 Vicryl ligatures prox-
imally and distally around the vein (Fig. 8).
• Ligate the distal ligature and leave the long
thread to control and manoeuvre the vein.
80 B. Amjad

Fig. 6

Fig. 7

Fig. 8

Fig. 9
A21  Venepuncture, Intraosseous Access and Venous Cut-down
Fig. 10
Tips
77 In neonates, a ‘cold light’ may help delineate
small veins on the dorsum of the hand.
77 Avoid excessive squeezing of the limb or suc-
tion with a syringe when obtaining blood sam-
ples, particularly in neonates and infants, as this
leads to haemolysis of the blood and erroneous
blood results.
77 Whilst awaiting the x-ray to confirm the PICC
line position run an infusion of normal saline at
1 ml/h to prevent the line becoming occluded
with clot, which can happen rapidly.
Common Pitfalls
77 Always dispose of sharps safely.
77 Many cannulas are displaced during an attempt
at flushing with saline or aspirating bloods be-
fore fixation of the cannula to the skin. Apply at
least one piece of tape to secure the cannula be-
fore proceeding.
77 Ensure that there are no air bubbles in the exten-
sion set before flushing, to avoid air embolus.
77 Post insertion the cannula or PICC line site
should be monitored daily for signs of infection
or extravasation.
77 Avoid obtaining IO access through infected skin,
and never in a limb or pelvis at or above the site
of a fracture, as this predisposes to infection and
compartment syndrome, respectively.
81
77 If an IO needle is not available, a bone marrow or
spinal needle can be used as an alternative.
77 Alternative sites for IO access include the distal
tibia proximal to the medial malleolus and the il-
iac crest.
77 Revise the anatomy of the vein and surrounding
tissues prior to attempting venous cut-down.
77 Additionally, siting the IO needle in a fractured
bone allows infused fluid to leak out through the
cortex into the adjacent subcutaneous tissues.
77 Placing your non-dominant hand behind the
limb when obtaining IO access increases the risk
of an inadvertent needle-stick injury.
77 If bone marrow is not aspirated from an IO nee-
dle but the clinical suspicion is that it is well po-
sitioned, it should be used regardless, as it is not
always possible to aspirate marrow through the
narrow lumen needles.
77 Do not allow air to enter larger veins and cause
air emboli during venous cut-down.
A22 A2 Open Insertion of Tunnelled Central
Venous Lines and Portacaths
R. Kronfli and M. E. Flett

Internal Jugular Vein Landmarks

Patient Position (Fig. 1) • Divergence of two heads of sternocleidomas-

toid (SCM)
• Supine • Clavicle and sternal notch
• Roll under scapulae • Nipple
• Neck extended and turned 30° to contralateral
side Incision

The incision should be made 2 cm above clavicle

over divergence of two heads of SCM.

Procedure

Isolation of Vein

• Dissection performed in layers through pla-

tysma, cervical fascia and between two heads
of SCM.
• Retractors used to expose vein.
• Carotid sheath is opened.
• Mixter forceps used to develop plane either side
Fig. 1 of vein.
• Vein controlled with two slings.

Tunnelling of Catheter

• Incision to anterior chest wall is made, lateral

to nipple.
• Small tract made for cuff with artery forceps.
• Catheter attached to blunt tunnelling rod and
tunnelled subcutaneously to lateral edge of
neck wound.
Fig. 2 • Catheter pulled through until cuff about a third
way along tunnel.
Rania Kronfli () • Catheter is cut to size.
Specialty Trainee in Paediatric Surgery • Catheter is flushed with heparinised saline
rkronfli@doctors.org.uk
(1,000 IU/ml) and clamped.
Martyn E. Flett
Consultant Paediatric Urologist
Martyn.Flett@ggc.scot.nhs.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_22, © Springer-Verlag Berlin Heidelberg 2013
22  Open Insertion of Tunnelled Central Venous Lines and Portacaths 83

• Non-absorbable suture made to secure cathe-

ter at exit site.

Other Common Sites

• External jugular vein

• Femoral vein

Types of Catheters

• Broviac/Hickman
• Single/multiple lumen
• Sizes 2.7–12 Fr
If a portacath is being inserted please follow the
additional steps described in Chap. A23.

Fig. 3

Venotomy

• Slings lifted to control and expose vein.

• Vein grasped carefully but firmly.
• Venotomy made with size 11 blade with blade
pointing upwards.
• Catheter passed through venotomy, bevel
pointing down.
• Lower sloop is relaxed while catheter being ad-
vanced.

Confirmation of Position

• Catheter should aspirate and flush freely.

• Position should be confirmed radiologically be-
fore use where possible.

Closure

• SCM tacked together with absorbable suture.

• Neck wound is closed in layers once haemo-
static.
• Absorbable suture is placed snug to wound
around catheter at exit site.
84 R. Kronfli and M. E. Flett

Tips

77 Consider local anaesthetic infiltration when tun-
neller is in situ to avoid inadvertent damage to
catheter or intravenous administration.
77 If catheter does not pass freely through venot-
omy, consider malposition.
77 Venotomy can be closed around catheter with
‘figure-8’ stitch if necessary using a fine vascular
suture – do not use purse-string.
77 If patient has had previous central lines, imag-
ing of veins may be helpful with ultrasound scan
(USS) or a magnetic resonance (MR) venogram.

Common Pitfalls

77 Avoid making your incision too medial or too 77 Avoid cutting the line too short.
low. 77 Avoid piercing the line while closing the neck
77 Beware of the carotid artery and vagus nerve wound.
when dissecting within the carotid sheath.
77 When tunnelling, avoid bringing catheter out
too close to the vein as this can cause kinking of
the line.
A23  Percutaneous Insertion of Central Venous Lines and Portacaths 85
A 23Percutaneous Insertion A23
of Central Venous Lines and Portacaths
R. Kronfli and M. E. Flett

Internal Jugular Vein • Insert guide wire.

• Check position radiologically if possible.
Patient Position

See Fig. 1.
• Supine
• Roll under scapulae
• Neck extended and turned 30° to contralateral
side

Fig. 2  Carotid Artery (CA), Internal Jugular (IJ)

• Leave wire in place.

• Make incision in skin laterally (from wire) ~1
cm.

Tunnelling

• Make incision on anterior chest wall for cath-

Fig. 1 eter exit site.
• Catheter attached to blunt tunnelling rod and
Ultrasound Guidance tunnelled subcutaneously to lateral edge of
neck wound.
Procedure • Catheter should be pulled through until cuff a
third of the way along tunnel.
Accessing Vein • Catheter is then cut to size and discarded and
length recorder and flushed with heparinised
See Fig. 2. saline (1,000 IU/ml) and clamped.
• Seeker needle and 5 ml syringe are needed.
• Puncture vein under ultrasound guidance. Dilatation
• When aspirating easily, remove syringe from
end of needle. • Using dilators, dilate to appropriate size.
• Insert ‘peel-away’ sheath and remove intro-
Rania Kronfli () ducer.
Specialty Trainee in Paediatric Surgery • Insert catheter.
rkronfli@doctors.org.uk
• Check position.
Martyn E. Flett • Peel sheath.
Consultant Paediatric Urologist • Ensure that line is flushing and aspirating eas-
Martyn.Flett@ggc.scot.nhs.uk ily.

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_23, © Springer-Verlag Berlin Heidelberg 2013
86 R. Kronfli and M. E. Flett

Closure Portacath

• Neck wound is closed with absorbable suture.
• Position should be confirmed radiologically be-
fore use if possible.
• Absorbable suture is placed snug to wound
around catheter at the exit site.
• Non-absorbable suture to secure catheter at
exit site are placed.
Other Common Sites
• Accessing vein is done as above described.
• At tunnelling stage, make pocket for port sub-
cutaneously.
• Tunnel, cut and flush the line as above.
• Attach to port.
• Dilatation is done as above described.
• Closure is as above; however port is secured to
fascia with non-absorbable suture.
• Site is closed with absorbable suture.

• External jugular vein

• Femoral vein

Types of Catheters

• Broviac/Hickman
• Single/multiple lumen
• Sizes 2.7–12 Fr

Tips

77 Use non-Luer lock syringe on ‘seeker’ needle to 77
facilitate removal prior to inserting guide wire.
77 Consider local anaesthetic infiltration when tun- 77
neller is in situ to avoid inadvertent damage to
catheter or intravenous administration.
If placing a port, consider patient characteristics
prior to choosing site.
If patient has had previous central lines, imaging
of veins may be helpful.

Common Pitfalls

77 Hold ‘seeker’ needle securely in place when re- 77 Avoid cutting the line too short.
moving syringe to avoid malposition. 77 Avoid piercing the line while closing the neck
77 When tunnelling, avoid bringing catheter out wound.
too close to the vein as this can cause kinking of
the line.
A24  Principles of Tumour Biopsy 87
A24 Principles of Tumour Biopsy A24
P. Hammond and C. A. Hajivassiliou

Principles Practice

A description of the wide range of available tech- Open Biopsy

niques for tumour biopsy is beyond the scope of
this chapter. However, some general principles can
be outlined:
• Incisional biopsy is usually required rather than
excisional biopsy (though some small lesions
may be amenable to primary excision with con-
sideration given to adequate margins).
• Ensure adequate preoperative imaging to guide
biopsy if required.
• Prior discussion with the pathologist is vital
to determine which technique will give an ad-
equate sample to allow accurate diagnosis.
• Consideration may be given to intra-operative
‘frozen’ section to assess adequacy of biopsy.
• Biopsy solid elements – avoid necrotic or cystic
tissue samples if possible. Multiple specimens
reduce the likelihood of false negatives.
• Send fresh samples expeditiously to laboratory.
Fresh specimens are generally required for ge-
netics and electron microscopy in addition to
routine tests.
• Avoid damage to adjacent vital structures.
• Design biopsy site to be excised at subsequent
surgery if possible.
• Observe the patient for bleeding or other com-
plications postoperatively.
An open biopsy is seldom employed routinely.
A good technique to avoid bleeding during
open visceral biopsy is to pre-site deep mattress
sutures to cover a wider area than the planned
tissue sample. The sutures are tightened postbi-
opsy to achieve haemostasis, either with or with-
out a roll of SURGICELL in the biopsy ‘bed’ to
act as a tamponade.
Percutaneous Biopsy (see figures 1–6)
• Ultrasound guidance may be safest.
• Several cores are best.
Laparoscopic Biopsy
The laparoscopic approach allows clear visualiza-
tion of the tumour for direct biopsy and enhances
the accuracy of percutaneous biopsy.
Fine-Needle Aspiration
Usually fine-needle aspiration is inappropriate in
paediatric population (check with pathology).

Philip Hammond ()

Consultant Paediatric and Neonatal Surgeon
Philip.Hammond@ggc.scot.nhs.uk

Constantinos A. Hajivassiliou
Consultant Paediatric and Neonatal Surgeon
ch27z@udcf.gla.ac.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_24, © Springer-Verlag Berlin Heidelberg 2013
88 P. Hammond and C. A. Hajivassiliou

Fig. 1  Spring-loaded core-needle biopsy gun

Fig. 2  ‘cocked’ spring (depth of biopsy may be determined with yellow ratchet)

Fig. 3  Ready to ‘fire’

A24  Principles of Tumour Biopsy
Fig. 4  Suitable core biopsy
Fig. 5  Spring-loaded blade
takes biopsy
Tips
77 Tumour tissue is friable with abnormal vascula-
ture. Bleeding is common. Methods for tampon-
ade should be used as far as possible.
77 If in any doubt opt for biopsy under local vi-
sion, as viscera (especially loops of bowel) could
Common Pitfalls
77 Primary re-excision may be required if an inade-
quate excision biopsy is attempted.
89
Fig. 6  Ultrasound guidance reduces risk of complications
and inadequate biopsy
be adherent to the tumour and when collapsed
may not be demonstrated on routine imaging
modalities. Interposed loops of bowel are at risk
of damage during blind biopsy attempts.
77 Non-diagnostic biopsy is more likely if necrotic
or non-solid elements are biopsied.
 90 P. Hammond and C. A. Hajivassiliou
A25 A25 Skin and Muscle Biopsies
P. Hammond and C. A. Hajivassiliou

• Inform the anaesthetist and clarify transport • A block of muscle 2 × 1 × 1 cm is identified

arrangements for the sample to the lab before
the operating list (depending on the indication
the patient may need to be first on the list).
• Position patient with a roll under the buttock
and slight flexion of the hip and knee to allow
access to a suitable area of the superolateral
thigh (overlying tensor fascia lata).
• A 2- to 3-cm longitudinal elliptical incision
is made with a blade through the skin along
Langer’s lines and continued into the subcuta-
neous fat. (see Fig. 1 and 2)
• The skin is excised (with fat shaved from the
undersurface) and put in transport medium.
• The aponeurosis of tensor fascia lata is exposed
and split with a blade in the line of its fibres.
(see Fig. 3)
and a 4/0 Vicryl stay suture placed at each end.
(see Fig. 4)
• Scissors are used to remove the block of mus-
cle as the biopsy. This should be sent urgently
to the laboratory, following local policies for
specimen care and transportation. (see Fig. 5)
• The 4/0 Vicryl is then used to close the defect
in the aponeurosis in a continuous fashion.
• Local anaesthetic may be infiltrated and dia-
thermy used for haemostasis at this stage.
• The wound is subsequently closed in a stan-
dard fashion.
• An alternative muscle is the rectus femoris, that
can be accessed easily in the anterior compart-
ment of the thigh.

Fig. 1 Fig. 2

Philip Hammond ()

Consultant Paediatric and Neonatal Surgeon
Philip.Hammond@ggc.scot.nhs.uk

Constantinos A. Hajivassiliou
Consultant Paediatric and Neonatal Surgeon
ch27z@udcf.gla.ac.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_25, © Springer-Verlag Berlin Heidelberg 2013
A25  Skin and Muscle Biopsies 91

Fig. 3 Fig. 4

Fig. 5

Tips

77 Avoid monopolar diathermy prior to removal of and/or skeletal deformities. These may necessi-
the sample as this may damage the sample tate the use of alternative muscles for biopsy if
77 Patients undergoing muscle or skin biopsy are access to the anterior thigh is problematic.
often quite ill and have associated neurological

Common Pitfalls

77 Ensure that an adequate mass (especially length) 77 Failure to achieve an adequate biopsy will ne-
of tissue is obtained, as multiple diagnostic tests cessitate a further general anaesthetic in a com-
may be performed on the specimen. plex patient.
 92 J. Andrews and R. Carachi
A26 A26 Excision of Common Skin Lesions
J. Andrews and R. Carachi

• The degree of skin involvement determines the
incision: A, straight; B, elliptical; or C, wide el-
liptical (Fig. 1).
• Mark the position of the intended skin inci-
sion. Try to make it along Langer’s lines (see
Chap. A7).
lesion, as they will retract into fat and be diffi-
cult to control.
• Coagulate and divide the vessels safely using
bipolar diathermy (Fig. 5).
• If a large elliptical incision was used, it can be
helpful to undermine the skin to reduce tension
on the wound (Fig. 6).
• Closure – interrupted absorbable sutures to fat
and Scarpa’s fascia. A continuous subcuticular
absorbable suture to skin should be placed.

Fig. 1
• Use skin hooks or cats paw retractors to gen-
tly retract the edges of the incision (Fig. 2).
• Deepen the incision through subcutaneous fat
using dissecting scissors until the lesion is iden-
tified.
• It may be possible to grasp the capsule with
curved mosquito forceps to provide gentle trac-
tion (Fig. 3).
• Be particularly careful not to rupture the cap-
sule if the lesion is cystic.
• Dissect loose connective tissue off the lesion Fig. 2
using dissecting scissors or bipolar forceps
(Fig. 4).
• Avoid inadvertently tearing the feeding vessels,
which usually run into the deep aspect of the

James Andrews ()

Specialty Trainee in Paediatric Surgery
jandrews@doctors.org.uk

Robert Carachi
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk Fig. 3

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_26, © Springer-Verlag Berlin Heidelberg 2013
A26  Excision of Common Skin Lesions 93

Fig. 4

Fig. 5

Fig. 6
94
Tips
77 Pilomatrixoma is often tethered to skin – an el-
liptical incision should be made in these cases to
reduce the risk of recurrence.
77 Use deep interrupted absorbable sutures to
obliterate the residual cavity after excision of
larger lesions and consider using a pressure
dressing. Failure to do so increases the risk of
haematoma or seroma formation.
Fig. 7
Common Pitfalls
77 Pyogenic granuloma – if feeding vessels are left
behind, it will recur, so make sure you deal with
these.
77 Epidermoid cyst – it is easy to cause the cyst wall
to rupture. If rupture occurs, curved mosquito
forceps can be applied to contain the contents.
If sebum leaks into the wound, perform a thor-
ough washout followed by careful excision of
any residual capsule to prevent recurrence.
J. Andrews and R. Carachi
77 If a cavity is present following excision, inter-
rupted vertical mattress sutures help evert the
skin edges. If there is significant tension on the
wound, interrupted horizontal mattress sutures
reduce the risk of the sutures cutting out (Fig. 7).
77 Lipomas (rare in children) can usually be ‘shelled
out’ though a smaller incision than the lesion it-
self. Avoid making a larger incision than is re-
quired.
77 Viral warts – these are usually self-limiting and
can be treated with topical irritants, cryotherapy,
excision, curettage and bipolar electrocautery.
The optimal method depends on the site and ex-
tent of involvement. Always seek to minimise
scarring in exposed sites.
A27  Compartment Syndrome and Lower-Limb Fasciotomy 95
A 27Compartment Syndrome A27
and Lower-Limb Fasciotomy
J. S. Huntley

Compartment syndrome is a clinical condition – Roughly 2 cm lateral to the lateral subcuta-

in which perfusion of intracompartmental struc-
tures (such as muscle) is compromised because of
a rise in overall compartment pressure.
If emergency decompression is not performed,
ischaemia, necrosis and their attendant complica-
tions ensue. Trauma is the commonest cause of a
compartment syndrome (associated with e.g. hu-
meral supracondylar fracture or tibial diaphysis
fracture).
neous border of the tibia
• For the anterolateral incision, lift the skin on
two rakes at the level of the fascia to allow defi-
nition of the intermuscular septum (visible as a
thickened white line) between the anterior and
lateral compartments.

Indications

The clinical features are (1) pain out of proportion

to the apparent severity of the injury, (2) pain on
passive stretch, (3) paraesthesiae/sensory distur-
bance and (4) paralysis (late). The compartment
is likely to be firm to palpation.
An appropriate emergency investigation is of
direct compartment pressure monitoring – but
this should not delay treatment.
The threshold for compartment release by fas-
ciotomy has not been well defined for children, but
should be performed if the intracompartmental
pressures are raised within 30mm Hg of the mean
arterial pressure.
Fig. 1  Incisions for lower-limb fasciotomies

 perative Technique for Lower–Limb

O • Avoid traumatising the superficial peroneal
Fasciotomy nerve in this region.
• Use a scalpel or scissors under direct vision to
• Full length parallel longitudinal incisions perform complete longitudinal fasciotomies
(Fig. 1): of both anterior and lateral muscle compart-
– Just posterior to the medial subcutaneous ments.
border of the tibia • For the medial incision, minimal posterior flap
elevation on rakes allows access to the super-
ficial posterior compartment for longitudinal
Jim S. Huntley ()
fasciotomy.
Consultant Paediatric Orthopaedic Surgeon • The intercompartmental septum is close to the
Jim.Huntley@ggc.scot.nhs.uk posterior border of the tibia – it can be defined

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_27, © Springer-Verlag Berlin Heidelberg 2013
96 J. S. Huntley

near the tibia by sweeping the soleus fibres pos-

teriorly with a peanut swab (see cross-section
in Fig. 2) before incising the fascial layer – the
deep posterior compartment may be decom-
pressed by incision medially (if the septum is
not too close to the back of the tibia), or of the
intermuscular septum via the superficial com-
partment (if the septum is too close to the tib-
ial border).
• Muscle in all compartments should be assessed
for viability (colour, consistency, contractility
and bleeding), and debrided by sharp excision
if dead.
• Closure should be accomplished by five days
postfasciotomy, whether direct or with split-
skin grafting.

Fig. 2  Lower-limb cross-sectional anatomy with recommended skin and fascial incisions
A27  Compartment Syndrome and Lower-Limb Fasciotomy
Tips
77 In lower-limb decompression, a two-incision
technique gives the best access for four-com-
partment fasciotomies.
77 The above placement of incisions is advised be-
cause they do not compromise the potential lo-
cally available flaps for skin coverage.
Common Pitfalls
77 Delayed diagnosis (and therefore delayed treat-
ment) is the commonest cause of a poor out-
come.
77 Beware the unconscious patient in whom the
cardinal clinical signs will not be evident.
77 The cardinal signs are also masked when nerve
blocks have been used or when there has been
nerve injury.
97
77 Have a high index of suspicion for compartment
syndrome in certain situations, e.g. (1) displaced
(even minimally) proximal tibial physeal fracture,
and (2) completely displaced supracondylar hu-
meral fractures that coexist with ipsilateral ra-
dius/ulna fractures.
77 When soft tissue reconstruction is necessary, de-
finitive closure is subject to the advice and man-
agement of the plastic surgical team.
77 Compartment syndrome does not usually affect
the distal pulses, so do not be reassured by their
presence.
77 Remember the superficial peroneal nerve has a
variable course.
77 If the muscle has already died, then compart-
ment release may cause a reperfusion injury, al-
low access to infection. Compartmentectomy or
amputation may follow.
 98 J. S. Huntley
A28 A 28Plastering
J. S. Huntley

Plaster of Paris is still the standard casting mate-

rial despite the development of alternative 'syn-
thetic'. The process involves the exothermic reac-
tion of calcium sulphate hemihydrate with water
to produce calcium sulphate dihydrate (gypsum):

(CaSO4)2∙H20 + 3H20 → 2CaSO4∙2H20 + heat

Indication

Casting is used for splintage, immobilisation or

maintaining a position.
Fig. 1  Plaster accessories – stockinet, soft-roll, adhesive
backed foam, dipping water, scissors, plaster rolls (tails
ready)
Technique
• The wet plaster is then rolled circumferentially,
• Get all plastering accessories handy before with tucks to allow smooth, economical and
commencing (Fig. 1): even placement along the length to be plastered
– Stockinette – neither too long nor too short (Fig. 4).
– Soft-roll and felt • Smooth circumferentially over the interstices
– Adhesive-backed foam of the plaster bandages as they are applied
– Dipping water (lukewarm temperature only) (Fig. 5).
– Scissors • The cast is molded whilst wet, and should ap-
– Plaster rolls proximate to the limb contours.
• Stockinet (if used) should extend beyond both • The stockinette can be back-folded to make for
ends of where the plaster will end; 'tucks' can a smooth end to the cast (Fig. 6).
be used sparingly but there must be no wrin-
kles.
• Soft-roll should be applied sparingly in the
main (Fig. 2) with extra padding (soft-roll, felt
or foam) appropriate to prominences.
• The plaster is dipped and held under water un-
til the bubbles stop appearing. The plaster roll
is brought out of the water, and excess water
removed with a squeeze (Fig. 3).

Jim S. Huntley ()

Consultant Paediatric Orthopaedic Surgeon
Jim.Huntley@ggc.scot.nhs.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_28, © Springer-Verlag Berlin Heidelberg 2013
A28 Plastering 99

Fig. 2  Soft-roll applied sparingly Fig. 3  Removing excess water

Fig. 4  Plaster of Paris applied to the limb Fig. 5  Circumferential smoothing

100
Fig. 6  Back-folded stockinette
Tips
77 Have enough extra assistants to hold the limb
correctly (one for arm/forearm; two for tibia/
lower limb) before you start.
77 Have the ‘tails’ of the plaster rolls exposed before
you dip them (Fig. 1).
Common Pitfalls
77 Excessive padding can lead to a cast that slips,
fails to maintain position and can cause skin ul-
ceration.
77 If the cast is too long this will restrict movement
at adjacent joints, e.g. with forearm casts, spe-
cial attention should be paid to movement at the
thumb and metacarpophalangeal joints.
77 Foreign bodies under cast can cause ulceration.
‘Plaster instructions’ issued to the patient/par-
ents must emphasise that nothing should be in-
serted down the inside of the cast.
77 Plaster burns can occur if the dipping temper-
ature is too hot, i.e. more than lukewarm – re-
member that the plaster temperature rises
above the dipping temperature because the re-
action is exothermic.
J. S. Huntley
77 Take care not to wind too tightly – the muslin of
a plaster cast is not distensible like an elastic ban-
dage.
77 Other risks for thermal injury are:
– If too many pl of cast are applied, e.g. folding
a posterior slab back on itself over the calf (in-
stead of cutting it) when it is realised to be too
long
– Inappropriate molding (putting focal pressure
onto underlying tissue)
77 If a cast is applied before limb swelling is com-
plete (e.g. if a tourniquet has been used), or if too
forceful a mould is applied then there is the dan-
ger of an extrinsic compartment syndrome. Pres-
sure can be relieved by splitting the cast.
A29  Traction and the Thomas Splint 101
A29 Traction and the Thomas Splint A29
J. S. Huntley

Traction is the application of a tensile force to

part of the body. There is a multitude of indica-
tions, applications and setups, but the two gen-
eral modes of application are (1) via the skin –
skin traction – and (2) via bone – skeletal traction.
A method for skin traction in conjunction with a
Thomas splint for femoral fracture is outlined.

Indication

Splintage and maintenance of reduction of a fem-

oral fracture are indications for traction/splinting.

Operative Technique

Size the Thomas Splint (Fig. 1)

• For length, measure the pelvic attachment of

the adductor longus tendon to the heel and add
25 cm.
• For the ring size, measure the oblique circum-
ference of the groin (around ischial tuberosity
and greater trochanter) of the uninjured side,
and add 5 cm (to account for swelling). This
gives you the desired ring size (internal diame-
ter).

Prepare the Thomas Splint

• Cut a piece of canvas broad enough to support

the length of the thigh and long enough to be
able to be doubled over the widest part of the Fig. 1  Measuring for length and ring size
splint, with a slight concavity (the thigh must
rest within the splint, not on top of it). Pass the

Jim S. Huntley ()

Consultant Paediatric Orthopaedic Surgeon
Jim.Huntley@ggc.scot.nhs.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_29, © Springer-Verlag Berlin Heidelberg 2013
102
Fig. 2  Preparing the Thomas splint
canvas round the shorter bar, and then back on
itself so that both ends pass over the longer side
bar – secure the four-fold of canvas here with
three nappy pins.
• Cut a piece of 7.5-cm stockinette twice the
length from the knees to the toes, and fold it
over itself so that it has a doubled layer. Slide
this over the foot end so that it meets the can-
vas.
Fig. 3  Application of skin traction
Application of Skin Traction
• Femoral nerve block is by the emergency staff
or anaesthetist.
• Clean and dry the skin.
• Apply Tensospray or equivalent to increase the
stickiness of the traction tapes.
• An assistant holds the ankle and applies gen-
tle steady traction.
• The spreader plate of the tapes is positioned
5 cm below the heel, parallel to the transverse
plane of the knee; position the tapes up either
side of the leg with the backing facing inwards.
The malleoli should be padded with foam.
• Start 3 cm above the malleoli, removing the
backing paper as the tape is applied wrinkle
J. S. Huntley
free to the skin. Apply up as far as the level of
the fracture, on both sides of the leg.
• Retention bandages from the level of tape ap-
plication upwards secure the traction tapes but
avoid bandaging the knee.
Application of the Thomas Splint
• With the assistant still applying traction to the
ankle, slide the prepared Thomas splint over
the foot and onto the leg, with the ring snug in
the groin.
• Folded Gamgee pad should be positioned at
the mid-thigh to reconstitute the anterior fem-
oral bow.
• Take the two cords from the bottom of the
spreader plate. Wind the outer cord over the
lateral bar and the inner cord under the medial
Fig. 4  Distal cords attached to the end of the Tomas
splint (outer-over, inner-under)
bar, and attach both cords at the base notch of
the splint (Fig. 4).
• Insert the lollipop stick between the distal
cords. Only tighten if necessary – you should
not have to at this stage.
• Support the distal end of the splint on pillows
to raise the femur clear of the bed until the
splint can be suspended, and the ring brought
out of the groin with a traction weight.
A29  Traction and the Thomas Splint 103

Suspension and Traction of the Splint

• Tie two equal loops of traction cord at each

end of the splint (Fig. 5).
• Pass both loops over the smaller wheels of a
compound pulley (Fig. 6).
• Attach the free cord running from the com-
pound pulley (Fig. 7) with a small weight that
will suspend the splint.
• Tie a length of cord to the distal end of the
splint. Pass this over a pulley at the end of the
bed to a weight carrier with sufficient weight to
bring the ring out of the groin (this must not
exceed 10 lb [4.5kg]) (Fig. 7).

Fig. 5  Two suspending loops to the splint

Fig. 6  Suspending loops over the smaller wheel of a com-

pound double pulley

Tips

77 A bandage roll is a useful spacer for the spreader 77 Elevating the foot of the bed may be necessary
plate of the traction tapes when the tapes are to provide partial counter-traction.
being applied.

Common Pitfalls

77 Skin traction is contraindicated if there are abra- 77 The ring must not be tight in the groin as there is
sions, lacerations or significant skin conditions. a real risk of pressure sore here.
104 J. S. Huntley

Fig. 7  Overall arrangement of suspended Thomas splint, with traction

A30 Tourniquets 105
A 30Tourniquets A30
J. S. Huntley

Indication

Tourniquets are used in limb surgery to provide a

bloodless field and minimise blood loss.

Operative Technique

• Soft-roll padding can be used on both thigh

and upper arm, at the point of maximum cir-
cumference, but should only be a maximum of
two-ply thickness and be wrinkle free (Fig. 1).

Fig. 2  Pneumatic cuff applied

• Exsanguination can be by limb elevation (1

min), Esmarch bandage or Rhys–Davies ex-
sanguinator (Fig. 4).
• Inflation should be rapid to minimise the
amount of time that the tourniquet functions
Fig. 1  Two-ply soft roll to upper arm as a venous tourniquet.

• Apply the pneumatic cuff – this should be

broad (appropriate to the size of the patient),
and the cuff length should exceed the limb cir-
cumference by 7–15 cm (Fig. 2).
• Use a broad 'sleek' to seal the interface between
the bottom of the cuff and the skin – otherwise
the solution used for skin preparation may pool
under the cuff (Fig. 3).
• Set the cuff pressure – usually 50–75 mmHg
is adequate for the upper arm; 70–100mm Hg
above systolic pressure is adequate for the up-
per thigh.

Jim S. Huntley ()

Consultant Paediatric Orthopaedic Surgeon
Jim.Huntley@ggc.scot.nhs.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_30, © Springer-Verlag Berlin Heidelberg 2013
106 J. S. Huntley

Fig. 4  Rhys–Davies exsanguinator

Fig. 3  Sleek tape seals the gap between tourniquet and

skin

Tips

77 It is useful to release the tourniquet before skin 77 Tourniquets should only be used on limbs with a
closure so that bleeding points can be identified normal blood supply.
and haemostasis obtained. 77 The pressure gauge should be checked regularly.
77 Record the tourniquet site, time and pressure as
well as the patient’s index blood pressure.

Common Pitfalls

77 External compression for exsanguination is con-
traindicated in patients with a suspected infec-
tion or malignant lesion.
77 Do not rotate the tourniquet once applied, as
this may cause a shearing injury to the skin.
77 An inadequately inflated tourniquet may func-
tion as a ‘venous tourniquet’, blocking venous
outflow from the limb, though arterial inflow can
still occur. This situation is worse than no tourni-
quet at all.
77 After tourniquet use, the limb swells significantly
– beware of external compression by bandages/
splints/casts.
77 Skin damage or ‘tourniquet burns’ can occur
when solutions have tracked under tourniquets.
77 Two hours is the upper time-limit for tourniquet
use.
A31  Drains and Drain Fixation Techniques
A31 Drains and Drain Fixation Techniques
R. Partridge and A. J. Sabharwal
Principle
• Drains may be placed in a variety of cavities to
channel away fluids.
• They may be used to:
– Prevent a collection
– Herald a collection
– Drain an established collection
– Maintain a tract
• Their role is debated however.
• They are often unreliable, cause discomfort,
and present a route for infection ingress.
• Drains may use gravity, suction or capillary ef-
fect.
• A secure method of keeping them in place is
essential.
Types of Drains
There are four main types of drain:
Fixation Techniques
• Wicks, corrugated and Yate drains may be se-
cured with a simple stitch at the entry site.
• A safety pin may be used on the end of the
drain to prevent it falling into the cavity.
• Tube drains require a more elaborate fixation,
as below.
Roland Partridge ()
Specialty Trainee in Paediatric Surgery
rolandpartridge@nhs.net
Atul J. Sabharwal
Consultant Paediatric and Neonatal Surgeon
Atul.Sabharwal@ggc.scot.nhs.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_31, © Springer-Verlag Berlin Heidelberg 2013
107
A31
Roman Gaiter Fixation Technique
• Tie suture to the skin, leaving both tails long.
• Wind each end around the tube once and tie
again.
• Assistant should hold the tube upwards.
• Threads are wound around tubing, advancing
along its length, ~1 mm with each wrap.
• A single throw is placed each time the threads
cross (i.e. at each turn)
• Each throw should be tight enough to indent
the tubing.
• The tubing should be forced into a slightly tor-
tuous shape; otherwise it is unlikely to have a
firm enough grip and liable to slip.
Locking-Turns Technique
Figures 5–8 demonstrate a slight modification on
the Roman Gaiter technique.
Dressings
• Many dressing techniques have been described
to assist in the safe anchoring of drains.
• Placing a dressing such that there is a ‘mesen-
tery’ of dressing holding the drain off the skin
is thought to be advantageous
• Conclusive evidence of benefit of one tech-
nique over another is lacking.
108 R. Partridge and A. J. Sabharwal

Fig. 1  Wick-ganze/Penrose

Fig. 2  Corrugated

Fig. 3  Yate’s drain

Fig. 4  Tube drain

Fig. 5  Loop in front of tubing, then needle passed behind

tube and through the loop
A31  Drains and Drain Fixation Techniques 109

Fig. 7 Loops drawn tight until the tubing is slightly

Fig. 6  Same process repeated for a second throw waisted

Fig. 8  Live end now tied to the other, previously unused,

tail of the original skin knot to anchor

Tips

77 Suture choice: a non-absorbable suture should 77 Either monofilament or braided are accept-
be used. able, although a braded suture possibly provides
slightly superior grip on the tubing.

Common Pitfalls

77 When tying thread around a compressible drain,

ensure it is not so tight as to compress its lumen.
 110 A. Rodgers, A. Kelly and Y. Bennet
A32 A32 Principles of Wound Management
A. Rodgers, A. Kelly and Y. Bennet

Wound management involves an holistic assess- Ideal Dressing Criteria

ment of the patient including age, diagnosis, nutri-
tional status, medications and clinical condition,
as these are all factors which can affect wound
healing and influence the management plan. The
wound assessment and management plan must be
documented accurately at each dressing change
to ensure continuity of care and provide compa-
rable evidence.
Modern dressings allow moist wound healing
to occur by maintaining a warm, moist and clean
environment. The wear time of dressings will de-
pend on the individual patient and the behaviour
of the wound. The majority of dressings can be
worn for up to 7 days; however in paediatric pa-
tients 3–5 days may be more realistic.
• Create a moist environment
• Control temperature
• Control pH
• Manage exudates
• Impermeable to bacteria
• Do not adhere to wound surface
• Easy to remove
• Reduce pain
• Non toxic/non-allergenic
• Comfortable and conformable
• Cost effective
The optimal management of wounds involves a
multidisciplinary team comprising surgeons, ward
nurses and other specialists such as tissue viabil-
ity nurses. If they are to play an active role in the
decision making of this team, surgical trainees
must develop an ability to recognise the common
types of wound and have knowledge of the avail-
able dressings and their indications (Tables 1–3).

Angela Rodgers ()

Paediatric Tissue Viability Clinical Nurse Specialist
Angela.Rodgers@ggc.scot.nhs.uk

Andrena Kelly
Clinical Nurse Educator
Andrena.Kelly@ggc.scot.nhs.uk

Yvonne Bennett
Clinical Nurse Specialist in Stoma Care
Yvonne.Bennett@ggc.scot.nhs.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_32, © Springer-Verlag Berlin Heidelberg 2013
A32  Principles of Wound Management 111

Table 1  Types of dressings and their applications

Dressing example Description and mode of action Suitable wound type

Post-operative dressings Simple adhesive dressings
with an absorbent pad
Mepore Post operative wounds closed
by primary intention
Primapore
Will only manage very low exudates
Tegaderm plus pad

Wound contact layers

Low-adherent dressings which Granulating
Na ultra promote moist wound healing
Epithelialising
Mepitel Secondary dressing required
Lightly exuding
Urgotul

Film dressings
Transparent, adhesive, va- Epithelialising
Iv 3000 pour permeable but imperme-
able to ingress of bacteria Lightly exuding
Op-site
Primary dressing for central and
Tegaderm peripheral intravenous lines

Secondary dressing over

hydrogel/honey
Hydrogels Typically composed of water (up to
95 %) and cross-linked polymers. Necrotic/dry
Askina gel
Able to absorb or donate mois- Sloughy
Intrasite ture depending on the re-
quirements of the wound Lightly exuding
Intrasite conformable Cavity

Hydrocolloids Typically composed of car- Thin: granulating, epithelialis-

boxymethyl cellulose ing, lightly exuding wounds
Comfeel
Available in thin and thicker prepara- Thick: necrotic, moder-
Duoderm tions which promote moist wound ately exuding wounds
healing in non-infected wounds.
Hydrocoll
112 A. Rodgers, A. Kelly and Y. Bennet

Hydrofiber/aquafiber Absorb wound fluid and convert into

a conformable gel that traps bacteria. Moderate to heavily exuding

Aquacel Available in flat sheet or ribbon Granulating

Activheal Ribbon for cavity wounds/sinuses

Alginates
Derived from seaweed
Kaltostat Fibrous absorbent dressing
Kaltostat also haemostatic in
Sorbsan minor wounds and epistaxis
Available in flat sheet or ribbon
Foam dressings
Polyurethane or silicone foams.
Allevyn range Available in flat sheets or cavity fillers.
Many varieties and thick-
Askina foam nesses available to manage low
to highly exuding wounds
Mepilex range Some offer additional actions
Moderate to heavily exuding
Bleeding (Kaltostat), e.g.
skin graft donor sites
Ribbon for cavity wounds
and nasal packing
Moderate to heavily exuding
Cavity
Thin foams for superficial,
lightly exuding wounds

Tielle range Fillers for cavity wounds

Anti-microbial dressings*
Acticoat A wide range of dressings im- Critically colonised or infected
pregnated or coated with sil- wounds including MRSA and VRE
Activon honey range ver, honey, iodine or PHMB
Burns
Inadine These products either inhibit growth
of or kill bacteria at the wound bed. *Silver and iodine can be absorbed
Iodoflex percutaneously and are not recom-
mended in neonates and infants
Silvercel younger than 6 months of age

Suprasorb x + PHMB

Urgotul ssd

Skin protectants
Provide a protective film over
Cavilon range skin to prevent excoriation.
Must be used sparingly
Lbf no-sting barrier film Available in spray, foam ap-
plicators or cream
Use under adhesives to prevent
skin stripping on removal
Periwound skin to pre-
vent excoriation

Nappy area
A32  Principles of Wound Management
Larvae
Biofoam dressing
Larvae (free-range maggots)
Topical negative pressure
Renasys (Smith and Nephew)
Vacuum-assisted closure (KCI)
Venturi (Talley)
Larvae of the Lucilia sericata avail-
able in pots (larvae) or contained
in a net dressing (biofoam).
Gauze or foam dressings occluded
under a film and attached by tub-
ing to a negative pressure pump.
Pressures of –50 to –75 mmHg are
appropriate for paediatric patients
113
Rapid and selective debride-
ment of devitalised tissue and
eradication of bacteria in a va-
riety of wounds in 3–5 days
Repeated applications may be
required in larger wounds
Cavity wounds
Dehisced surgical wounds
Flaps and grafts
Traumatic wounds
Not suitable for necrotic tissue
or clinically infected wounds
114 A. Rodgers, A. Kelly and Y. Bennet

Table 2  Types of wounds and their management

Colour Example Characteristics Aims Primary Secondary

dressing(s) dressings
Rehydrate • Hydrogel • Low exudate:
Dead tissue necrotic tissue to • Honey film dress-
Black Hard, black facilitate autolytic • Hydrocol- ing or simple
eschar debridement. loid absorbent
Necrotic Brown leathery Debridement only dressing
appearance if holistic assess- *Cau- • High exudate:
ment permits to tion with non-adhesive
prepare wound ischaemic foam + reten-
bed for healing.* injuries tion bandage
Sloughy To remove slough LOW
devitalised from wound bed EXUDATE • Low exudate-
Yellow tissue, yellow as this will hinder • Hydrogel Simple
in appearance healing process • Honey absorbent
Sloughy Can be soft, • Hydrocol- dressing/ thin
moist and loid hydrocolloid
stringy in • High exudate-
consistency HIGH non- adhe-
or more firm EXUDATE sive foam
when dry • Hydro- + retention
fibre bandage or
adhesive foam
Granulat- To protect the LOW • Simple absor-
ing wound wound and main- EXUDATE bent dressing
Red Shiny, moist tain a warm, moist – Non- + tape or reten-
with healthy optimum healing adehrent tion bandage
Granulating red colouration environment contact layer • Thin Hy-
Tissue and a some- through exudate MODER- drocolloid,
times ‘lumpy management ATE/HIGH Non-adhesive
surface appear- EXUDATE or adhesive
ance due to • Hydro- foam+ reten-
new connec- fibre tion bandage
tive tissue and
capillary buds
Epithelialis- Protection and • Non- • Simple ab-
ing wound prevention of adherent sorbent pad
Pink Epithelial cells trauma to fragile contact + retention
migrating new cells layer tape/bandage
Epithelial over healthy
Tissue granulation • Thin Hy-
Shallow with drocolloid
low exudate or Thin
Pink/white adhesive
in colour foam
A32  Principles of Wound Management
Table 3  Management of the contaminated, colonised or infected wound
Bacterial burden Characteristics
CONTAMINATED – the Normal signs
presence of non-multi- of healing
plying micro-organisms Healthy granu-
lation tissue
All open wounds Epithelial tissue
are contaminated may be present
COLONISED – the pres- Higher levels of
ence of multiplying micro- wound exudate
organisms in the wound Exudate may be
with no host reaction brownish in colour
Wound contin-
ues to heal
CRITICAL COLONI- Delayed healing
SATION – numbers Unhealthy/friable
of micro-organisms granulation tissue
in the wound are at a Increased
critical level and without exudate/odour
intervention the wound Dusky/dull
will become infected wound bed
Increased pain
WOUND INFECTION – Erythema To reduce bacterial
the presence of multiply- Increased pain levels at wound bed
ing micro-organisms with Increased swelling and treat infection
a subsequent host reaction Associated pyrexia
Increased exudate
Increased
malodour
The presence
POINTS TO REMEMBER of necrotic or
devitalised tissue
will increase the
bacterial burden
within the wound
115
Aims Suitable pri- Suitable second-
mary dressing ary dressing
To promote the LOW EXUDATE LOW EXUDATE
principles of moist Non-adherent Simple absorbent
wound healing. contact layer dressing + tape or
Protect fragile MODERATE/ retention bandage
new tissue HIGH EXUDATE
Hydrofibre
MODERATE/HIGH
Use of appropriate Thin hydrocolloid,
dressings to absorb Non-adherent contact non-adhesive or
higher levels of layer containing adhesive foam+
exudate and thus silver sulphadiazine retention bandage
reduce bacterial load Honey LOW EXUDATE
Hydrofibre Simple absorbent
dressing + tape or
retention bandage
MODERATE/HIGH
Reduce bacterial Non-adherent contact Non-adhesive or
load at wound layer containing adhesive foam+
bed to allow silver sulphadiazine retention bandage
normal healing Honey LOW EXUDATE
process to return Iodine products* Simple absorbent
Hydrofibre dressing + tape or
retention bandage
MODERATE/HIGH
Honey Non-adhesive or
Iodine products* adhesive foam+
Silver alginate retention bandage
Silver hydrofibre LOW EXUDATE
Simple absorbent
dressing + tape or
retention bandage
MODERATE/HIGH
Remove non-viable Indications for use Non-adhesive or
tissue if appropriate, Wear time adhesive foam+
seek advice if the How to apply and retention bandage
patient is diabetic remove safely Do not use two
or there is any arte- different types of an-
rial insufficiency timicrobials together
*Iodine should not
be used in patients
<6months old
116 A. Rodgers, A. Kelly and Y. Bennet

The perianal skin is vulnerable to excoriation af- complications including pain sepsis and delayed
ter abdominal surgery, and for use of antibiot- discharge from hospital. Table 4 summaries our
ics, in the immunocompromised patient. Meticu- management algorithm.
lous care of the skin in this region is vital to avoid
 Napkin Care Guidelines
Normal Mild Moderate Severe Candidiasis

Erythema (redness). Erythema (redness) Erythema (redness) Bright red rash with satellite
No broken skin + small areas of large areas of lesions/pustules at margins. This
broken skin broken skin rash may extend onto groins and
skin folds. This may occur along
with excoriation

• Cleanse by irrigating with warm water +/- an Emollient and a 20ml syringe.
Passing Frequent Stools YES
• Pat intact skin dry

NO

• Cleanse with water and soft
cotton wipe
• Pat dry
• Apply yellow soft paraffin
• Use a gel core nappy and
change frequently or as soon
as possible after soiling
• Apply Cavilon spray twice
daily
• Apply 1% Ichthammol in zinc
ointment at each nappy
change
• Use a gel core nappy and
change frequently or as soon
as possible after soiling
• Apply Daktacort cream twice daily for 3 days then stop • DO NOT use Cavilon film if
• Apply Cavilon spray twice daily candidiasis present
• Apply Orabase Paste and Yellow Soft Paraffin 50:50 mixture at each • Apply Clotrimazole 1% 3 times
nappy change daily
• Use a gel core nappy and change frequently. If age/condition permits • Apply barrier cream according
nurse exposed on an open nappy to mild/mod/severe guidance
• If no improvement in 72 hours or rapid deterioration in skin contact as appropriate
Tissue Viability Nurse/Dermatology/ Stoma Specialist Nurse • Consider oral Nystan
• Continue Clotrimazole 1% for
3 weeks even if symptoms
have resolved

Special Considerations Ilex Paste

• If the patient has undergone/is preparing for transplant commence
moderate/severe regime to prevent breakdown
• If patient has undergone reversal of ileostomy/
colostomy commence moderate/severe regime
• If the patient has an underlying skin condition refer to Dermatology for
advice
• Cleanse using an emollient and warm water prior to application of Ilex paste, otherwise cleanse gently only to
remove Yellow Soft Paraffin layer
• Apply Ilex paste sparingly 2-4 times daily as required
• Apply a thick layer of Yellow Soft paraffin over Ilex at each nappy change
• Line the nappy with Jelonet to prevent sticking
• Use a gel core nappy and change frequently OR nurse exposed on an open nappy if age/condition permits
MIS, RHSC, Job No. 217863b
 PAR T B
Head and Neck
B1  Layers of the Scalp and Suturing 121
B1 Layers of the Scalp and Suturing B1
D. Datta and S. Agarwala

Layers of Scalp • Pericranium: The pericranium is the periosteum

• Skin: The skin of the scalp is thick and hair
bearing and contains numerous sebaceous
glands. As a result, the scalp is a common site
for sebaceous cysts.
• Connective tissue (superficial fascia): The su-
perficial fascia is a fibrofatty layer that connects
the skin to the underlying aponeurosis and pro-
vides a passageway for nerves and blood ves-
sels. Blood vessels are attached to this fibrous
connective tissue. If the vessels are divided, this
attachment prevents vasospasm, which may
lead to profuse bleeding after injury.
• Epicranial aponeurosis (galea aponeurotica):
The epicranial aponeurosis is a thin tendinous
structure that provides an insertion site for the
occipitofrontalis muscle. Posterolaterally, the
epicranial aponeurosis attachment extends
from the superior nuchal line to the superior
temporal line. Laterally, the epicranial aponeu-
rosis continues as the temporal fascia. Anteri-
orly, the subaponeurotic space extends to the
upper eyelids.
• Loose areolar tissue: Areolar tissue loosely con-
nects the epicranial aponeurosis to the pericra-
nium and allows the superficial three layers of
the scalp to move over the pericranium. Scalp
flaps are elevated along this relatively avascular
plane during neurosurgical procedures. How-
ever, certain emissary veins traverse this layer,
that connect the scalp veins to the diploic veins
and intracranial venous sinuses.
of the skull bones. Along suture lines, the peri-
cranium becomes continuous with the endos-
teum (see Fig. 1).
Technique of Scalp Suturing
• Perform full thickness simple or mattress su-
tures when the wound is superficial to the apo-
neurotic layer.
• Deeper wounds involving the aponeurotic layer
have a tendency to ‘gape’ more. In this situa-
tion, approximate the aponeurotic layer first
with continuous absorbable sutures (Fig. 2).
Then suture the skin and subcutaneous tis-
sues with interrupted non-absorbable sutures
or continuous interlocking sutures for addi-
tional haemostasis.
• If there is loss of skin due to trauma or excision
of a skin lesion, plan a rotational flap along the
loose areolar tissue layer (Figs. 3 and 4).
• Haemostasis can be achieved by applying mos-
quito forceps on the split or incised galea and
flipping it over (Fig. 5).

Dibyarup Datta ()

Senior Resident in Paediatric surgery
dibyarupdatta@gmail.com

Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_33, © Springer-Verlag Berlin Heidelberg 2013
122 D. Datta and S. Agarwala

Fig. 1

Fig. 2
B1  Layers of the Scalp and Suturing 123

Fig. 3

Fig. 4

Fig. 5
124 D. Datta and S. Agarwala

Tips

77 The scalp is highly vascular so pay close atten-
tion to haemostasis. The use of local anaesthetic
agents with adrenaline may help to reduce
bleeding (see Chap. A6).
77 The thickness of the scalp skin allows some ten-
sion across the suture line, but if excessive con-
sider a rotational flap.
77 For neurosurgical procedures make U-shaped
flaps reflected on an inferior pedicle, based on
the vascular anatomy.

Common Pitfalls

77 Inadequate debridement of devitalized tissue
predisposes to infection and poor wound heal-
ing.
77 Failure to approximate the epicranial aponeuro-
sis promotes haematoma formation and distrac-
tion of the healing wound, resulting in a wide
scar.
77 Always palpate the pericranium at the base
of the wound. Failure to do so may result in a
missed underlying depressed skull fracture.
B2  External and Internal Angular Dermoid Cyst
B2 External and Internal
Angular Dermoid Cyst
P. Sekaran and N. Brindley
The soft tissues of the face are formed by the fu-
sion of the frontal, maxillary and mandibular pro-
cesses. Dermoid cysts occur when skin elements
become trapped along lines of embryological clo-
sure. The external angle of the supraorbital ridge
is the most common site of occurrence (Fig. 1).
Fig. 1
External Angular Dermoid Cyst
Setup and Positioning
• General anaesthetic should be used.
• Patient should be positioned supine with the
head stabilised on a head ring.
• The eyes are taped closed to prevent contami-
nation.
• The skin is prepared with aqueous Betadine.
• Consider using a head drape.
Prabhu Sekaran ()
Specialty Trainee in Paediatric Surgery
Prabhu.sekaran@nhs.net
Nicola Brindley
Consultant Paediatric and Neonatal Surgeon
Nicola.Brindley@ggc.scot.nhs.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_34, © Springer-Verlag Berlin Heidelberg 2013
125
B2
Operative Technique
• The incision is made just above or below the
lateral part of the eyebrow, overlying the cyst
(Fig. 2).
• Alternatively, the incision can be hidden in the
superior palpebral fold.
Fig. 2
• Monopolar diathermy is used to deepen the in-
cision down to the cyst wall.
• The assistant retracts the skin edges with skin
hooks, to facilitate exposure (Fig. 3).
• Using blunt dissection with curved Metzen-
baum scissors, expose the cyst circumferen-
tially.
• The cyst lies in a bony hollow through which
small feeding vessels run.
• Use bipolar diathermy to free the cyst from the
underlying bone and coagulate the feeding ves-
sels (Fig. 4).
• Use bipolar diathermy with or without bone
wax for haemostasis.
• Send cyst to pathology for histopathological
confirmation of the diagnosis.
126 P. Sekaran and N. Brindley

 ndoscopic-Assisted Excision of
E
External Angular Dermoid Cysts

• In an attempt to improve cosmesis, some cen-

tres offer an endoscopic approach to external
angular dermoid cysts.
• A 1- to 2-cm incision is made posterior to the
hairline of the forehead, on the affected side.
• A 30° endoscope is used to visualise the subga-
leal compartment.
• An angled needle-tip monopolar diathermy is
used to free the cyst from the periosteum.

Internal Angular Dermoid Cyst

Fig. 3
• The risk of intracranial extension is much
higher for cysts situated at the internal angle
of the supraorbital ridge or midline nasal cysts.
• Patients with cysts in these sites should un-
dergo a preoperative magnetic resonance im-
aging (MRI) scan to exclude intracranial ex-
tension.
• If intracranial extension is confirmed, a crani-
otomy is required and a combined procedure
with neurosurgery with or without ear, nose
and throat (ENT) clinicians should be planned.

Fig. 4

Closure

• Interrupted 4/0 absorbable sutures to muscle

and fat to obliterate the dead space should be
used.
• Subcuticular 5/0 absorbable sutures should be
used for skin (Fig. 5).
• Alternatively, interrupted non-absorbable
monofilament may be used for skin to opti-
mise cosmesis, provided the patient will toler-
ate subsequent removal.

Fig. 5
B2  External and Internal Angular Dermoid Cyst 127

Tips

77 Always obtain preoperative MRI imaging for in- 77 MRI can be used selectively in patients with ex-
ternal angular and midline nasal dermoid cysts. ternal angular dermoid, with imaging reserved
for cases with suspicious features.

Common Pitfalls

77 Skull x-rays do not reliably exclude intracranial 77 Making the incision within the eyebrow dam-
extension. ages hair follicles and may distort the eyebrow,
77 If cyst rupture occurs during excision, irrigate the resulting in a poor cosmetic result.
cavity with normal saline to remove debris and
ensure that the entire cyst wall is excised to re-
duce the risk of recurrence.
 128 P. A. M. Raine
B3 B3 Cleft Lip and Palate
P. A. M. Raine

Cleft Lip Repair Unilateral Repair (Millard Technique)

Indication Essential elements

Repair of a cleft lip confers not only cosmetic
and aesthetic benefits, but also functional ben-
efits. Speech, feeding and dental hygiene are all
improved by normally functioning labial closure.
Approximately 3 months of age is commonly ac-
cepted as the optimal time for lip repair.
Preoperative Preparation
• Preoperative orthodontic care achieves better
alignment of the maxillary segments and nar-
rowing of the cleft gap, which aids surgical clo-
sure.
• Satisfactory weight gain, normal haemoglobin
and control of comorbidities are prerequisites
for surgery. Absence of oral, nasal, dental or
upper respiratory tract infection is also neces-
sary.
Operative Technique
• Medial rotation flap and lateral advancement
flap
• Small columellar lengthening rotation flap
• Detachment of orbicularis oris muscle fibres
from abnormal insertions and careful recon-
struction of sphincter function
• Repositioning of alar cartilages to achieve na-
sal tip symmetry
• Closure with fine absorbable 5/0, 6/0 and 7/0
sutures
Bilateral Repair (Manchester Technique)
This repair is based on the above-stated principles.
• Complicated by the excessive anterior promi-
nence of the premaxilla
• Apposition of orbicularis oris fibres in midline
• Straight line closure of lateral lip segments and
prolabium

• Intra-operatively, close cooperation between

anaesthetist and surgeon is mandatory in en-
suring airway safety.
• Anatomical points and proposed incision lines
are carefully marked with indelible ink.
• A mixture of bupivacaine and 1:200,000 adren-
aline (see Chap. A6) is infiltrated to lessen the
need for general anaesthesia, limit blood loss
and facilitate incision by engorging and stiff-
ening tissues.

Peter A. M. Raine ()

Consultant Paediatric and Neonatal Surgeon
Rainewest@btinternet.com

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_35, © Springer-Verlag Berlin Heidelberg 2013
B3  Cleft Lip and Palate 129

Fig. 2  Completed unilateral cleft lip repair

Fig. 1  Unilateral left cleft lip repair

Fig. 3  Bilateral cleft lip repair Fig. 4  Completed bilateral cleft lip repair
130 P. A. M. Raine

Tips

A good operative outcome depends on: 77 Optical magnification

77 Bright, well-focused lighting 77 Judicious and meticulous use of bipolar dia-
77 A comfortable operating position thermy

Pitfall

77 Avoid closure under excessive tension by ade-

quate mobilisation.

Cleft Palate Repair Operative Technique

Indication • Careful planning and marking of tissue flaps

for mobilisation is important.
Cleft palate repair is usually performed at 6–9 • Infiltrate the skin with bupivacaine and
months of age in order to improve velopharyn- 1:200,000 adrenaline solution.
geal sphincter function with resulting benefit to:
• Feeding and swallowing
• Dental and oral hygiene
• Speech production
• Eustachian tube function and middle ear aer-
ation

Fig. 5  Soft palate cleft incisions Fig. 6  Furlow soft palate repair
B3  Cleft Lip and Palate
Fig. 7  Secondary cleft palate incisions
Furlow Soft Palate Repair (Including
Submucosa Cleft of Soft Palate)
This technique incorporates:
• A double Z-plasty technique on oral and na-
sal surfaces of soft palate
• Reversal of Z-plasty flaps to retropose the le-
vator/tensor muscle complex on each side
• Meticulous apposition of muscle fibre bundles
using 6/0 and 7/0 absorbable sutures
Tips
77 Avoid excessive mobilisation, which leads to in-
terference with jaw growth, disruption of man-
dibular/ maxillary arch relationship and the need
Pitfalls
77 Inadequate haemostasis increases the risk of in-
halation and airway problems in the immediate
postoperative period.
131
Fig. 8  Langenbeck secondary cleft palate repair
Langenbeck Repair for Both Secondary and
Primary Hard Palate Clefts
This repair is based on:
• Mobilisation of mucoperiosteal flaps from pal-
ate shelves, vomer and premaxilla
• Careful preservation of greater palatine artery
pedicle blood supply
• Posterior displacement of levator/tensor mus-
cle complex and reconstruction of velopharyn-
geal sphincter
• Precise closure of flaps using 6/0 and 7/0 ab-
sorbable sutures
for later orthodontic or secondary orthognathic
surgery.
 132 A. Neilson and C. F. Davis
B4 B4 Lacerations to the Face, Lips, Tongue
and Ears
A. Neilson and C. F. Davis

• Be sure that the wound is appropriate for clo-
sure by primary intention and that you are the
right surgeon for the job – does it need a plas-
tic maxillofacial or ear nose and throat (ENT)
surgeon?
• Consider what type of anaesthesia is appro-
priate (local anaesthetic or general anaesthetic
[LA or GA]) – this often requires discussion
with the parents.
• Prepare the area, but be careful with prep near
the eyes and mucous membranes – you may
need to irrigate the eyes with saline at the end.
• Traumatic wounds should be thoroughly
cleaned and any foreign bodies must be re-
moved – with adequate anaesthesia, a scrub-
bing brush can be used initially, then irrigate
with saline before closure (Fig. 1).
• Identify and document the depth of the wound
– can you palpate a step in the skull table or see
a visible fracture?
• It may be appropriate to debride the wound or
freshen ragged edges.
• General surgical principles require that trau-
matic wounds should be closed with inter-
rupted non-absorbable sutures. In paediatrics

Fig. 1a–c

Fig. 2a,b

Andrew Neilson ()

Specialty Trainee in Paediatric Surgery
agneilson@doctors.org.uk

Carl F. Davis
Consultant Paediatric and Neonatal Surgeon
Carl.Davis@ggc.scot.nhs.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_36, © Springer-Verlag Berlin Heidelberg 2013
B4  Lacerations to the Face, Lips, Tongue and Ears 133

some surgeons use rapidly absorbed sutures to

avoid a further procedure for remove of su-
tures, especially in younger children.
• Lacerations through the vermillion border of
the lip should be opposed carefully to minimise
unsigthly scarring (Fig. 2).
• An auricular haematoma requires evacuation
– incise the edge of the haematoma following
the skin crease, apply direct pressure and then
a pressure dressing (Fig. 3).

Fig. 3a, b

• Align landmarks such as the nostril border or

alar rim first when repairing nasal lacerations.
The tongue rarely needs suturing as minor lacera-
tions heal very rapidly with little deformity. How-
ever, if it is split or hanging on a pedicle, it needs
suturing with absorbable material to achieve hae-
mostasis and good apposition.

Tips

77 Use 5-0 or 6-0 sutures on the face. 77 Antibiotics are not generally indicated, but
77 A small dressing (e.g. a Steri-Strip) will keep a should be used for animal and human bites.
toddler’s fingers away from the wound (as will 77 For ear injuries, expedite coverage of exposed
glue). cartilage and minimise haematoma, consider re-
ferral to a specialist.

Common Pitfalls

77 Scalp lacerations in trauma can be multiple and 77 Local anaesthesia can distort the anatomy, par-
are easy to miss due to hair – examine thor- ticularly of the vermilion border or alar rim –
oughly for additional injuries before the proce- mark areas with indelible ink before infiltration,
dure. or infiltrate after closure if using GA.
 134 R. Carachi
B5 B 5Ear Deformities
R. Carachi

There are many types of ear deformities. The one Procedure

that is most often seen by the surgeon is the pro-
truding ear. These may be unilateral or bilateral.
Minor degrees do not need operation but severe
forms need done because they are often the source
of ridicule and bullying.
This chapter will deal only with one type of op-
eration, as there are many plastic surgical proce-
dures that can be performed.
Equipment Needed
• Methylene blue dye as a marker
• Green needles (×3)
• Non absorbable suture (e.g. 3/0 Ethibond)
• Drape with a hole in the centre
• Scalpel blade (15)
• Dissecting scissors
• Bipolar diathermy
• Skin suture for skin closure (00000) undyed on
a cutting needle
• Cotton wool soaked in proflavine, blue swabs
and 10-cm crepe bandage
After preparing and draping position ear with a
fold and transfix with three green needles (Fig. 1)
charged with methylene blue dye. Rotate the nee-
dles to ensure dye marks the sites of puncture.
These will determine where the sutures will be
placed. (Fig. 2) Excise the ellipse of the skin where
the markers have left a blue stain and then dissect
the skin edges off the cartilage.
• Three horizontal mattress sutures are placed
using 3/0 Ethibond. (Fig. 3)
• Then position the ear flat and tie all three su-
tures to maintain the appropriate position.
(Fig. 4)
• The skin is closed with a continuous mattress
suture using 5/0 Vicryl. (Fig. 5)
• The proflavine dressing is then applied behind
each ear and a head dressing is used as indicted
in the Fig. 6.

Robert Carachi ()

Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_37, © Springer-Verlag Berlin Heidelberg 2013
B5  Ear Deformities 135

Fig. 1

Fig. 2
Fig. 3
136 R. Carachi

Fig. 4

Fig. 6

Fig. 5

Tips

77 Avoid implantation as it can cause a dermoid. 77 Tape the head dressing to avoid slippage.
77 Haemostasis is necessary to avoid haematoma. 77 Leave dressing for 1 week before removal.

Common Pitfalls

77 Haematoma 77 Sutures cut out

77 Slippage of bandage 77 Keloid scar
77 Infection
B6  Branchial Remnants 137
B 6Branchial Remnants B6
S. Panda and S. Agarwala

 perative Technique for Excision of

O • Excise cartilage tailored as to the amount of
Accessory Auricle excess tissue present.
• Fill the conchal hollow thus created with spare
• Release the skin from the cartilage of the ac- cartilage. Alternatively, use the excess cartilage
cessory ear component (Fig. 1) to recreate a normal tragus if this is required.

Fig. 1

• Prebond the cartilage sheets with fine non-

absorbable suture material (Fig. 2) or use as
smaller fragments to fill smaller nonconfluent
areas.
• Use extra skin available for closure. Where
there is a potential contour abnormality in a
Fig. 2 grossly abnormal case, skin flaps may be used
to improve the soft tissue contour as the Z-plas-
Shashanka Panda () ties (Fig. 3).
Senior Resident in Pediatric Surgery
drshasank_aiims@yahoo.co.in

Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_38, © Springer-Verlag Berlin Heidelberg 2013
138 S. Panda and S. Agarwala

Tips

77 The distinction of polyotia from a skin tag rests
largely on size and a subjective level of resem-
blance to a normal external ear. None is as large
as the normal auricle, nor is any a complete du-
plication. Some are a mirror image, and others
are based on a different axis.
77 The accessory ear often has a substantial conchal
hollow and in these cases exploration reveals a
cartilage-lined cheek defect. This should be filled
prior to skin closure with spare cartilage, and
may be achieved using excised cartilage from
the accessory ear.

• Dissect the cyst away from the adjacent struc-

tures by blunt and sharp dissection.
• Identify the pedicle of cyst posterior to jugu-
lar vein coursing between carotid artery bifur-
cation.
• Dissect cephalad towards the tonsillar pillar
where it is clamped; transfix fine Vicryl suture
and divide it to remove the cyst (Fig. 6).
• For the second branchial cleft sinus excision,
make an elliptical, transverse skin incision
around the sinus opening.
• Deepen the incision to incise the platysma and
place a couple stay sutures on the skin around
the sinus opening for traction.

Fig. 3

Operative Technique for Branchial

Cysts and Sinus

• Position the patient in supine position with

sandbag beneath shoulders, a roll under the Fig. 4
neck and ring headrest beneath cranium with
the chin is turned away from side of lesion.
• Make a skin incision over cyst along Langer’s
line or in a natural skin crease.
• Deepen the incision through the subcutaneous
tissues and platysma and raise superior and in-
ferior platysma flaps (Fig. 4).
• Divide the deep cervical fascia at the anterior
border of sternocleidomastoid muscle and re-
tract the belly of the muscle away from the cyst.
Incise the fascia and soft tissue overlying the
cyst to expose the superficial aspect of the cyst Fig. 5
( Fig. 5)
B6  Branchial Remnants 139

• Dissect the sinus tract cephalad, keeping on the

tract until the upper cervical region.
• Make another skin crease incision in the upper
cervical region (‘step-ladder’ incision) and re-
trieve the dissected sinus tract through this in-
cision.
• Continue cephalad dissection of the sinus tract
from this superior incision towards the tonsil-
lar fossa, keeping directly on tract to avoid in-
jury to internal jugular vein, bifurcation of ca-
rotid artery and hypoglossal nerve.
• Ask the anaesthetist to place a gloved finger in
tonsillar fossa and exert pressure downwards
towards field of dissection.
• Identify the end of the sinus tract as it reaches
the tonsillar fossa. Transfix the tract with a fine
Vicryl suture and divide.
• Close the wound in layers. Cervical fascia and
platysma are closed with 4/0 continuous ab-
sorbable suture. Skin should be closed with
running 5/0 subcuticular absorbable suture. Fig. 6

Tips

77 During the first branchial cleft cyst dissection
where the tract is leading up to or into external
auditory meatus, injury to adjacent facial nerve is
to be avoided. Nerve stimulator is helpful during
dissection. (Fig. 7)
77 Dissection of sinus tract may be facilitated by
passing a probe or heavy nylon suture through
the tract.

Common Pitfalls

77 Avulsion of the tract midway during dissection 77 Injury to the adjoining nerves and vessels if one
due to undue traction dissects away from the surface of the tract
140 S. Panda and S. Agarwala

 perative Technique for Preauricular

O
Sinus

• Make an inverted L-shaped incision with the

vertical limb running along the groove anterior
to pinna, and the horizontal limb in the hairline
and place stay sutures for retraction. Or make
an elliptical incision in the groove anterior to
the tragus.
• Raise the skin flap avoiding damage to preau-
ricular vessels and nerve by avoiding deep dis-
section anterior to pinna (Fig. 6).
• Deepen the level of dissection progressively and
dissect the sinus and the racemose gland from
the subcutaneous tissue (Fig. 7). Wide excision
should be done with a small portion of carti-
lage included to include all the branching por-
tions of the sinus and the gland.
• The flap is repositioned by subcutaneous inter- Fig. 7
rupted, absorbable sutures. Skin edges approxi-
mated by small interrupted sutures. Then hold-
ing stitch is removed.
• Preauricular depression, crevices of pinna and
postauricular space should be packed with
wool and pressure dressing applied.
• The facial nerve develops at the same time
as the external ear, and abnormalities of the
course and/or size of the facial nerve can be ex-
pected to coexist. This is of concern surgically,
but deep dissection of the cheek is undertaken
rarely.

Common Pitfalls

77 Injury to the facial nerve in attempting to excise 77 Too-tight closure of the skin, leading to wound
the deep portion of the cartilage breakdown and ugly scar formation
B7  Parotid Dissection 141
B 7Parotid Dissection B7
F. B. MacGregor

A parotidectomy may be performed in the man-

agement of benign or malignant tumours, or se-
vere inflammatory or infective disease, e.g. atyp-
ical mycobacterium. Often all or part of the su-
perficial lobe is removed, i.e. superficial parotidec-
tomy, and only in certain circumstances is total
parotidectomy required. A very important and
significant consideration of this operation is the
potential damage to the facial nerve, which may
result in temporary or even permanent damage
to facial movement.

Operative Technique

Set up the nerve monitor and ensure that this is

working prior to preparing the patient for surgery.
It is advisable, particularly in children, to use op-
erating loupes or the operating microscope to ad-
equately visualise the small branches of the fa-
cial nerve.
Use a shoulder roll and head ring. Turn the
head away from the operator. Leave the ipsilat-
eral face including the eye, nose and corner of the
mouth exposed. Protect the exposed eye with, for
example, a corneal shield.
A modified Blair’s incision is popular for this
approach but a modified facelift incision can also
be used with small posterior lesions. In the neck,
take the incision at least 2 cm below the angle of
the mandible to avoid the marginal mandibular
branch (Fig. 1).
Extend the incision through the platysma in
the neck. Take the incision down to the investing
fascia layer around the parotid (white and shiny
appearing). Elevate a flap, dissecting superficial
to the parotid gland. Use fishhooks or a suture
Fiona B. MacGregor ()
Consultant Paediatric Otolaryngologist
Fiona.MacGregor@ggc.scot.nhs.uk
Fig. 1
to secure the flap anteriorly. Release the earlobe
and insert a silk suture to retract posteriorly. Use a
scalpel to release the tail of parotid from the ster-
nocleidomastoid muscle and retract the gland an-
teriorly. Generally, the greater auricular nerve is
divided. Dissect down between the parotid gland
and the tragal cartilage. Remain immediately on
the cartilage and open widely superiorly and in-
feriorly to ease access. Identify the tragal pointer.
Expose the posterior belly of digastric and palpate
the tympanomastoid suture. At this point start us-
ing forceps and open up, dissecting in the direc-
tion of the nerve.
The facial nerve trunk is normally found 1cm
deep and 1cm anterior to the tragal pointer but
it is more superficial in younger children (Fig. 2).
The facial nerve exits through the stylomastoid
foramen approximately 6–8 mm deep to the infe-
rior end of the tympanomastoid suture line. It ex-
its between the styloid process, which can be pal-

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_39, © Springer-Verlag Berlin Heidelberg 2013
142 F. B. MacGregor

pated, and the attachment of the digastric muscle

to the digastric ridge. Once the main nerve trunk is
identified use a fine curved mosquito haemostat,
inserting this immediately above the nerve in the
direction of the nerve. Lift the forceps up slightly
creating a tunnel, open and separate, and then di-
vide the parotid tissue whilst protecting the nerve
(Fig. 3). It is often helpful to use bipolar diathermy
before dividing each section of salivary tissue to
avoid troublesome bleeding but be careful to avoid
using diathermy close to the nerve.
Carefully dissect out the upper and lower divi-
sions of the facial nerve using this technique. De-
Fig. 2 pending on the position of the tumour, it may be
only necessary to dissect out the superior or infe-
rior branches (Fig. 4).
If a deep lobe dissection is required then nerve
branches have to be completely dissected and gen-
tly retracted (use sloops) to gain access and re-
move the deep lobe.
Once the involved portion of the gland is dis-
sected it can be removed. Haemostasis should be
obtained and continuity of the nerve confirmed
with the use of the nerve stimulator. A drain is
recommended in most situations and the wound
is closed with a subcutaneous absorbable suture
and nylon to skin.
Fig. 3

Fig. 4
B7  Parotid Dissection 143

Tips

77 Remind the anaesthetist not to use muscle re- 77 Enhance haemostasis by elevating the head of
laxant. the bed and use adrenaline patties if there is
77 Take a brief rest after nerve trunk has been ex- small ooze around the nerve.
posed. 77 Use regular saline washes.
77 Careful haemostasis is vital so you can see the
fine branches of the nerve.

Common Pitfalls

77 Avoid repeated stimulation of the nerve as this 77 The main trunk is much more superficial than in
may cause temporary weakness. adults and it is at a higher level. The lower divi-
77 Avoid dissecting down a deep hole. sion runs very superficially over the angle of the
77 Open the wound widely to gain good access and mandible.
illumination when identifying the nerve.
77 A parotidectomy is more challenging in children
because the nerve is smaller and there is a lack of
development of the mastoid tip.
 144 L. McIntosh and R. Carachi
B8 B 8R anula and Tongue-Tie
L. McIntosh and R. Carachi

Simple Ranula

A simple ranula is confined to the sublingual space

and occurs due to ductal obstruction (Fig. 1). Sur-
gical options include marsupialisation and exci-
sion.

Fig. 1

Technique for Intra-oral Excision Fig. 2

• General anaesthesia is used with oral or nasal • Make an incision directly over the gland with
endotracheal intubation. monopolar or bipolar diathermy (Fig. 3).
• Avoid muscle relaxation so that tongue move- • Alternatively, making an incision in the lingual
ment can be observed as an indicator of prox- gingival sulcus at the level of the first molar
imity to the motor nerve supply to the tongue. and raising a full-thickness mucoperiosteal flap
• Pack the hypopharynx with a gauze swab. gives good exposure.
• Good exposure can be achieved with a mouth • Well-encapsulated lesions should be removed
gag or small retractors. using dissecting scissors and bipolar diathermy,
• Place a silk stay suture through the tip of the without excising the gland. Loculated or rup-
tongue for retraction.
• Identify the paired submandibular (Wharton’s)
duct orifices, which lie immediately adjacent to
the lingual frenulum (Fig. 2).
• Cannulate the ipsilateral duct orifice with a lac-
rimal probe to avoid inadvertent injury.
• Place four stay sutures around the planned mu-
cosal incision (Fig. 3).

Lynn McIntosh ()

Specialty Trainee in Paediatric Surgery
Lynneholmes@doctors.org.uk

Robert Carachi
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk Fig. 3

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_40, © Springer-Verlag Berlin Heidelberg 2013
B8  Ranula and Tongue-Tie
Fig. 4
tured lesions should be removed with the ipsi-
lateral sublingual gland.
• The incision is closed with interrupted absorb-
able sutures (Fig. 4).
• Alternatively, the cyst can be de-roofed with
dissecting scissors and marsupialised. The
everted cyst wall is sutured back on to the oral
mucosa with interrupted absorbable sutures.
Division of Tongue-Tie
• Ankyloglossia (‘tongue-tie’) is a congenital
anomaly characterised by an abnormally short
lingual frenulum (Fig. 5). In breastfed infants
this may result in difficulties establishing feed-
ing, manifested by sore nipples in the mother
and failure to thrive in the infant.
• Controversy exists regarding the safety and ef-
ficacy of tongue-tie division.
• The National Institute for Health and Clin-
ical Excellence (NICE) (www.nice.org.uk/
Fig. 5 Fig. 6
145
guidance) have issued guidance for doctors in
the UK, applicable to breastfed infants with
tongue-tie.
Technique in the Ward/Outpatient
Department
• During the neonatal/early infancy period, the
tongue-tie can be divided without anaesthetic.
• Swaddle the neonate with a towel to prevent
movement and position across the trolley with
the head on the surgeon’s side.
• The assistant supports the shoulders and uses
their thumbs to gently open the mandible.
• Expose the tongue-tie by placing your non-
dominant index and middle fingers under
the tongue to put the frenulum under tension
(Fig. 6).
• Alternatively, the tongue can be elevated using
forceps or a tongue director.
• Use sterile, sharp, blunt-ended scissors to di-
vide the tongue-tie cleanly, sparing the vessels
(Fig. 7).
• Check haemostasis (Fig. 8). Direct pressure
with a 4 × 4-cm gauze is usually enough.
Technique Under General Anaesthetic
In infants older than a few months the procedure
requires general anaesthetic. In this situation, the
infant is positioned supine and swaddling is not
necessary. Forceps are used to hold the tongue.
The tongue-tie is divided in the same way.
Fig. 7 Fig. 8
146
Tips
77 Most tongue-ties are asymptomatic and do not
require division.
77 The first-line treatment for difficulties establish-
ing breastfeeding should be with breastfeeding
support specialists.
77 Division of a tongue-tie may improve feeding in
bottle-fed neonates although there is currently
little evidence to support this.
Common Pitfalls
77 Use the approaches to a ranula described oppo-
site, to avoid inadvertent injury to the lingual or
hypoglossal nerves.
77 A ‘plunging’ ranula is a pseudocyst which oc-
curs due to mucous extravasation. Typically
they pervade deeply through the fascial planes
of the neck. They may mimic congenital lym-
phatic malformations and usually require a cer-
L. McIntosh and R. Carachi
77 Breastfeeding immediately post–tongue-tie divi-
sion may help achieve haemostasis.
77 Warn parents to expect a white strip of tissue to
persist under the tongue for several days post–
tongue-tie division.
vical approach with excision of the submandibu-
lar gland. Consider a computerized axial tomog-
raphy (CT) and/or magnetic resonance imaging
(MRI) and ear, nose and throat (ENT) referral.
77 Avoid allowing the infant to use a dummy imme-
diately post ranula excision as this may trauma-
tise the incision.
B9  Excision of Thyroglossal Cyst and Fistula 147
B9 Excision of Thyroglossal Cyst and Fistula B9
N. Sugandhi and S. Agarwala

Indications duct, in between the sternohyoid muscle (Fig. 2)

All thyroglossal cysts and fistula should be ex-
cised.
Operative Technique
• Make a transverse incision over the cyst. The
incision is elliptical in cases of a fistula or sinus
(Fig. 1).
Fig. 1
• Deepen the incision to incise the platysma, and
raise superior and inferior flaps in the plane be-
tween the platysma and investing layer of the
deep cervical fascia.
• Identify the thyroglossal duct, from the cyst,
penetrating the deep fascia and dissect on the
cranially to the lower margin of the hyoid bone.
Gentle traction on the cyst assists this dissection.
• Divide the muscle attachments on the inferior
(sternohyoid muscle) and the superior (myelo-
hyoid and geniohyoid muscle) aspects of the
body of the hyoid bone for 5 mm on either side
of the midline (Fig. 3).
• Separate the thyrohyoid membrane from the
posterior aspect of the hyoid bone and remove
1 cm of the body of the hyoid cartilage by us-
ing bone cutters or monopolar diathermy com-
plete with the attached portion of the thyro-
glossal duct.
• Continue dissecting the duct cranially with
about 5 mm cylinder of tissue from the genio-
hyoid and the genioglossus muscle until its ter-
mination on the foramen caecum of the tongue
(Fig. 4). This step can be aided by asking the
anaesthetist to press down the region of the fo-
ramen caecum of the tongue with a finger.
• Transfix the tract with an absorbable suture,
transect it and remove the specimen.
• Approximate the neck muscles and platysma
with interrupted absorbable sutures (Fig. 5)

Fig. 2

Nidhi Sugandhi ()

Senior Resident in Pediatric Surgery
drnidhisugandhi@gmail.com

Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com Fig. 3

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_41, © Springer-Verlag Berlin Heidelberg 2013
148 N. Sugandhi and S. Agarwala

Fig. 4 Fig. 5

and close the skin with an absorbable subcu-

ticular suture.

Tips

77 Avoid excessive traction of the fistulous tract. 77 Dissect carefully posterior to the body of hyoid
to avoid damage to the thyrohyoid membrane.

Common Pitfalls

77 Not removing a cylinder of tissue superior to the 77 Incomplete dissection of the tract to the base of
hyoid bone the tongue
B10  Lymph Node Biopsy
B10 Lymph Node Biopsy
A. Verma and S. Agarwala
Lymphadenopathy in children usually occurs in
response to infection or inflammation, but can
also occur in haematological or metastatic malig-
nancy or as part of a generalised disease process.
Paediatric surgeons may be asked to perform an
excision biopsy for histopathological examination
in cases where the diagnosis is not clear clinically.
Ajay Verma ()
Senior Resident in Pediatric Surgery
talk2ajayverma@gmail.com
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_42, © Springer-Verlag Berlin Heidelberg 2013
149
B10
 perative Technique for Cervical
O
Lymph Node Biopsy
• General anaesthetic should be used.
• Position the patient supine with additional
neck extension (roll under shoulders).
• Prepare the skin with antiseptic.
• Consider using a head drape.
• Deeper nodes may be marked preoperatively
following ultrasound.
• Relevant cross-sectional imaging should be dis-
played in theatre as a ‘roadmap’.
• Make a transverse skin crease incision in the
neck, overlying the node.
• Raise small platysmal flaps and divide the cer-
vical fascia overlying the node.
• Gently dissect around the node using a com-
bination of sharp, scissor dissection and bipo-
lar diathermy.
• Be careful to avoid rupturing the node.
• Ligate the supplying vessel with an absorbable
suture or cauterize it with bipolar diathermy.
• Remove the node intact and send fresh to pa-
thology.
• Check for haemostasis.
• Close the wound in layers with interrupted Vic-
ryl sutures to cervical fascia and subcutaneous
tissues.
• Continuous subcuticular absorbable suture to
skin should be used.
• Routine use of a drain is not necessary.
150
Tips
77 Always revise the relevant regional anatomy
prior to lymph node biopsy and be vigilant to
avoid injuring the associated nerves and major
vessels.
77 Retracting deep-seated nodes with Babcock’s
forceps may be useful but be careful not to dis-
tort the nodal architecture.
Common Pitfalls
77 Selecting a small node that may not be represen-
tative of any pathology present can occur.
77 Not discussing the case with the pathologists
first. The node should always be sent intact and
fresh.
77 The marginal mandibular branch of the facial
nerve passes behind the angle of the mandible
and runs forward less then 2 cm inferior to it be-
fore passing over the body of the mandible to
supply the circumoral musculature. It is vulnera-
ble during jugulodigastric lymph node excision.
Damage results in a distorted smile and impaired
movements of the lower lip.
77 Attempting to access a node deep to the sterno-
cleidomastoid muscle without splitting or divid-
ing the muscle is possible.
77 Performing a biopsy through an inadequate inci-
sion leading to excessive handling and crushing
of the biopsied tissue is also possible. It is impor-
tant to preserve the nodal architecture for histo-
pathological diagnosis.
A. Verma and S. Agarwala
77 Sometimes multiple, large matted lymph nodes
are found, and it may only be possible to per-
form a wedge biopsy. This is best done with a
knife and not diathermy to avoid compromising
the specimen.
77 When approaching the jugulodigastric node,
make your incision at least 2.5 cm inferior to
the mandible to avoid the marginal mandibular
branch of the facial nerve (see below).
77 The upper part of the deep cervical chain of
lymph nodes, drain the tonsils and this is the
most common site of nodal involvement in tu-
berculosis infection. The nodes may be inti-
mately related to the internal jugular vein and
caution should be taken to avoid major vessel in-
jury during excision.
77 Infected lymph nodes underlying the cervical
fascia may rupture to from an abscess, which
then drains out through the fascia into the sub-
cutaneous tissue. This ‘collar-stud’ abscess causes
a characteristic blue–purple discolouration of
the overlying skin and is usually a feature of My-
cobacterium avium, intracellulare and scrofula-
ceum (MAIS) infection. This atypical mycobacte-
rium is found in soil and after entering the child’s
mouth, it drains to the tonsillar or parotid nodes.
Untreated the abscess forms multiple sinuses,
which then drain through the skin. Incision and
drainage alone results in recurrence. Treatment
is complete excision of the infected nodes and
subcutaneous tissue. Always send pus for rou-
tine and mycobacterial culture techniques.
B11  Principles of Surgery for Lymphatic Malformations
B1 Principles of Surgery
for Lymphatic Malformations
F. B. MacGregor
These malformations are usually found in areas
of confluence of major lymphatic channels. The
most common site is the head and neck region. A
typical lesion consists of several dilated lymphatic
channels lined by a single layer of epithelium. Pre-
natal diagnosis is common and the lesion is usu-
ally obvious at birth although rarely, may present
months or even years later. Lesions vary in size
and position within the head and neck and may be
composed of fluid filled microcysts or macrocysts,
often in combination. They tend to invest normal
structures such as arteries, veins and nerves and
can involve muscle and salivary gland. These le-
sions can suddenly increase in size and depending
on their position, may cause airway obstruction,
difficulty swallowing (because of enlarged tongue
and abnormal floor of mouth) and severe defor-
mity in the head and neck region.
Treatment depends on the site of the lesion,
the disability caused and the aesthetic concerns.
Tracheostomy may be required to make an air-
way safe prior to definitive treatment. Occasion-
ally large malformations diagnosed prenatally re-
quire management with an ex-utero intrapartum
treatment (EXIT) procedure to maintain oxy-
genation prior to a tracheostomy. In many situa-
tions treatment consists of a series of staged op-
erative procedures and sclerotherapy may be im-
plemented. In most cases where emergency inter-
vention has not been required, surgery can wait
until the child is 3–6 months old.
Sclerotherapy involves aspiration of larger
cysts (usually under ultrasound control) and then
injecting the empty cyst with an irritative agent
that causes an inflammatory reaction. This sub-
sequently encourages the walls to adhese, causing
Fiona B. MacGregor ()
Consultant Paediatric Otolaryngologist
Fiona.MacGregor@ggc.scot.nhs.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_43, © Springer-Verlag Berlin Heidelberg 2013
151
B11
involution of the cyst. In practice it is not always
successful and can result in a systemic reaction
and severe skin breakdown. The resulting tissues
are subsequently more fibrotic and therefore more
challenging to operate on later. This technique is
most effective in macrocystic lesions, which are
also the lesions that are more amenable to sur-
gery. Popular agents include ethanol and OK432.
Microcystic disease is more challenging to ex-
cise but is also less effectively treated with sclero-
therapy. Conservative treatment may be appropri-
ate. Because of the position of these lesions and
the fact that they are intimately related to nerves
and vessels, these can be at risk. In particular, the
marginal mandibular branch of the facial nerve
and the hypoglossal, vagus, phrenic and accessory
nerves can all be closely related to these lesions
and may be damaged during excision. It is there-
fore important to remember that these are benign
lesions and the desire for complete excision should
not take precedence over preservation of impor-
tant structures.
Excision of a neck lesion is usually performed
through a transverse skin incision at least 2 cm
below the mandible. The platysma is divided and
subplatysmal flaps are elevated to display the mal-
formation. Sharp dissection proceeds carefully
around the lymphatic malformation with dia-
thermy to small bleeding vessels. Knowledge of
the local anatomy is vital to preserve major ves-
sels and nerves. It is often useful to dissect down
to the internal jugular vein and use it as a land-
mark. The lesion may need to be split to dissect
nerves. Identification is usually easier if the cysts
remain intact although large tense cysts may even-
tually require aspiration during surgery to obtain
access to deeper structures. In the lower neck, be
careful to avoid damage to the thoracic duct (left)
and accessory thoracic duct (right). If these are
damaged they should be repaired with 6.0 nylon
to avoid an ongoing chyle leak. Dissection supe-
152 F. B. MacGregor

riorly often requires excision of the submandibu-

lar gland with the specimen.
Involvement of the tongue base and the tongue
itself may require a partial excision to ensure that
the tongue can remain within the mouth and
healthy. This may also aid speech and swallow-
ing development.
There may be redundant skin left at the end of
the procedure. This usually contracts with time
so excision should be conservative, if considered
at all. Suction drainage is mandatory and drains
should be left in situ for a reasonably long period
to prevent lymph tissue and blood expanding any
residual cysts beneath the skin.

Tips

77 Use a nerve monitor when excising lesions 77 Sudden increase in the size of these lesions may
around the parotid and remember to inform the be due to internal haemorrhage – check the in-
anaesthetist. fant’s haemoglobin as it may drop suddenly and
significantly.

Common Pitfalls

77 Do not be tempted to remove the drain too 77 Bulky–tongue base disease may make intuba-
early. The patient will get a collection. tion difficult and result in a challenging postop-
erative airway if the child does not have a trache-
ostomy.
B12 Tracheostomy
B 12Tracheostomy
C. Venkatakarthikeya and P. Sagar
Operative Technique
• Position the patient on the table with extension
of atlanto-axial and cervical joints with head-
rest, neck roll and shoulder pad.
• Mark a horizontal skin incision midway be-
tween the cricoid and suprasternal notch.
• Infiltrate 2 % Xylocaine with adrenaline
(1:200000) along the marked site.
• Make the incision through skin and subcuta-
neous tissues using surgical blade no.15 to ex-
pose superficial layer of deep cervical fascia.
• Identify midline raphe of strap muscles.
• Use blunt artery forceps to dissect straps mus-
cles vertically and retract them laterally (Fig. 1).
Fig. 1
C.Venkatakarthikey ()
Assistant Professor
Department of Otorhinolaryngology
Prem Sagar
Senior Resident, Department of Otorhinolarnygology,
All India Institute of Medical Sciences, New Delhi 110029
sagardrprem@gmail.com
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_44, © Springer-Verlag Berlin Heidelberg 2013
153
B12
• Identify the isthmus of the thyroid and retract
this superiorly (Fig. 2). It may be cauterized
using bipolar cautery, and then divide it in the
midline.
• Incise the pretracheal fascia in the midline and
dissect it laterally over the anterior tracheal
wall.
• Identify the trachea by aspirating air bubbles
in a syringe filled with saline.
• Place two stay sutures (4-0 Prolene) through
the tracheal wall on either side before making
an incision in anterior tracheal wall (Fig. 2).
• Make a vertical/oblique incision in the anterior
tracheal wall between the two stay sutures us-
ing a surgical blade no. 11 (Fig. 3).
154 C. Venkatakarthikeya and P. Sagar

Fig. 2 Fig. 3

• Insert the tracheostomy tube through the open-

ing by retracting the stay sutures laterally.
• Confirm the tracheal position of tracheostomy
tube by asking the anaesthetist to auscultate
both sides of the chest.
• Ensure haemostasis.
• Secure the tracheostomy tube with tracheos-
tomy ties after closing the skin incision.
• Secure the stay suture to chest with adhe-
sive plaster with a warning of ‘DO NOT RE-
MOVE’ written on it with a red marker.
• Place an antiseptic dressing around tracheos-
tomy tube, under the flanges.

Tips

77 Always stay in the midline. 77 Keep the stay sutures until the tracheostomy
77 Always confirm the tubular structure to be tra- tract matures.
chea by aspirating before making any incision. 77 Postoperative chest x-rays help in identifying the
77 Palpate the trachea before each step; remember position of tracheostomy tube and complication
in children trachea is quite soft, unlike adults. like pneumothorax.
77 Remove any nasogastric tube prior to surgery as
it may give a false sense of trachea during pal-
pation.

Common Pitfalls

77 Excessive extension of the neck may expose the
carotids and the pleura during the dissection.
77 In children the trachea is soft and may be con-
fused with the carotids. During palpation, sensi-
tize yourself for any pulsation in nearby area.
77 Do not remove any tracheal tissue. Excision of
tracheal tissue to create an opening for the tra-
cheostomy leads to tracheal stenosis.
77 Always preserve the first cartilaginous ring and
in small infants, the second ring as well.
B13 Torticollis 155
B 13Torticollis B13
A. Verma and S. Agarwala

Operative technique

• Position the patient supine with a roll trans-

versely under the shoulder and moderately ex-
tend the neck. Turn the face to the contra-lat-
eral side.
• Make a transverse skin crease incision at the
level of the junction of the sternal and clavic-
ular heads of the sternocleidomastoid muscle,
one to two finger breadths above the clavicle.
(Fig. 1)
• Divide the platysma and develop sub platys-
mal flaps superiorly and inferiorly to expose
the sternocleidomastoid muscle at the level of
the junction of the sternal and clavicular heads. Fig. 1
• Incise the investing layer of deep cervical fascia
longitudinally at the medial edge of the sterno- • Ask the anesthetist to rotate the head towards
cleidomastoid muscle. the affected side and feel for any residual taut
• Dissect between the sternocleidomastoid mus- fibrotic bands restricting this movement.
cle and its investing layer and the posteriorly • Ensure homeostasis.
placed carotid sheath to develop a plane sep- • Repair the platysma with fine continuous vic-
arating the two at this level. Transect the mus- ryl suture and the skin with fine subcuticular
cle and its investing layer using diathermy, en- monocryl suture.
suring hemostasis. This is best done by grasp-
ing the muscle body with a pair of toothed for-
ceps (this is often fibrous) and dividing it using
cutting diathermy.
• On division, the muscle separates.
• Divide the investing layer of the deep cervical
fascia anteriorly up to the midline and poste-
riorly till the anterior border of the trapezius.

Ajay Verma ()

Senior Resident in Pediatric Surgery
talk2ajayverma@gmail.com

Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_45, © Springer-Verlag Berlin Heidelberg 2013
156 A. Verma and S. Agarwala

Tips

77 Complete division of stermocleidomastoid along 77 Adequate post operative pain relief and early
with deep cervical fascia should always be per- neck physiotherapy should be done.
formed. 77 Ensure good hemostasis.
77 Sometimes few fibers of the anterior edge of the
trapezius may need to be divided. Avoid damage
to the nerve to trapezius in doing this.

Common Pitfalls

77 Inadequate division of the investing layer of 77 Doing the procedure of division of sternocleido-
deep cervical fascia around the muscle will lead mastoid when the cause of torticollis is some-
to persistence of the deformity. thing else, such as a vertebral anomaly.
B14  Burr Holes
B 14Burr Holes
R. Carachi
Our prehistoric ancestors made burr holes in the
skull, and there is archaeological evidence that
these early attempts were successful in saving lives.
Burr holes in the skull can be a life-saving op-
eration in a patient with a head injury when bleed-
ing can cause rapid coning of the brain and death.
Although this is the domain of the neurosur-
geon, every surgeon should be able to carry out
this life-saving procedure while waiting for the
neurosurgeon if necessary.
Operative Technique
The area selected needs to be shaved, prepared
and draped.
• An incision is made in a curved fashion using
a no. 15 blade, often over the temporoparietal
region of the scalp and it is then incised down
to the bone through all the layers of the scalp.
(Fig. 1)
Fig. 1  Mission and proposed site of Buntole.
Robert Carachi ()
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_46, © Springer-Verlag Berlin Heidelberg 2013
157
B14
• Pressure is applied on the edges of the incised
wound and the galea is picked up using mos-
quito forceps and then flipped over the flap to
stop bleeding (the scalp is very vascular). (Fig. 2)
• A periosteal elevator is used to expose the skull
bone; this is often accompanied with some ooz-
ing of blood. This is to allow a burr hole to be
performed. (Fig. 2)
• A no. 10 blade is then rotated through the skull
in a vertical position until the outer table of
bone is breached and the inner table is pene-
trated. At this point the blade is swapped for the
tip of a curved mosquito forceps to open the
hole (Fig. 3a) and allow a bone nibbler to fur-
ther open this area and expose the dura, which
should be glistening. Occasionally blood can be
seen beneath the dura if it is under pressure.
Fig. 2
158 R. Carachi

• Using a dural right-angle hook the dura is

opened in a cruciate incision using a no. 11
blade. (Fig. 3b,c) Blood under pressure will
then emerge to allow the intracranial pressure
to return to normal and allow perfusion of the
brain.

Fig. 3

Tips

77 Any bleeding from the bone can be stopped us- 77 The site of the incision will be determined by the
ing bone wax. nature of the injury and the preoperative imag-
ing.

Common Pitfalls

77 The skull bone may be very thin in infants and 77 Always double-check the side of the injury on
care must be taken not to penetrate the dura the preoperative imaging and mark it preopera-
whilst making the burr hole. tively to ensure that the correct side is chosen for
the operation.
B15  Ventriculoperitoneal Shunting for Hydrocephalus
B 15Ventriculoperitoneal Shunting
for Hydrocephalus
R. Carachi
John Holter – the pioneer who introduced the
shunt for hydrocephalus – developed a valve that
has been effective for many years. There is a vast
array of shunt systems now available on the mar-
ket and their description is beyond the scope of
this chapter.
Ventriculoperitoneal (VP) shunting is carried
out in most centres by paediatric neurosurgeons
and should be in their domain; however, some
paediatric surgical centres still carry out this pro-
cedure. Often the paediatric surgeon has to per-
form this procedure.
The patient is anaesthetised, intubated and po-
sitioned as in Fig. 1. It is essential that the posi-
tioning of the patient establishes a straight hor-
izontal line from the skull to the abdomen. This
is achieved by careful positioning and the use of
rolls under the patient. It is the responsibility of
Fig. 1
Robert Carachi ()
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_47, © Springer-Verlag Berlin Heidelberg 2013
159
B15
the surgeon to ensure that this positioning is cor-
rect before the operation starts.
It is also the responsibility of the surgeon to
select the appropriate shunt device, the ventricu-
lar cannula and peritoneal tubing. This is very of-
ten determined by the personal preference of the
surgeon and the length is determined by the im-
aging available.
The imaging via a computerized axial tomog-
raphy (CT) scan should be on view in the theatre
next to the patient for the surgeon to view when
attempting to insert the ventricular cannula into
the ventricle.
The following rules should be applied to ensure
a reduced risk of perioperative infection, the big-
gest complication of this procedure.
160
• A curvilinear incision is used over the scalp and
its position should not overlie the shunt system.
(Fig. 1)
• Different instruments must be used for the skin
and for the rest of the operation.
• No diathermy, either unipolar or bipolar,
should be used especially in small babies.
• A non-touch technique with minimal tissue
handling should be used at all time.
• Double gloving and removal of the outer gloves
when handling the shunt system is advised.
• The shunt system should be tested and im-
mersed in a antibiotic solution while awaiting
insertion.
• Appropriate cleansing solution (Bethadine)
should be used over the operating field after it
is cleared of any hair that may be present.
The first part of this operation is described under
Chap. B14 entitled ‘Burr Holes’.
Operative Technique
The area selected needs to be shaved, prepared
and draped.
Head
• An incision is made in a curved fashion using
a no. 15 blade, often over the temporoparietal
region of the scalp and it is then incised down
to the bone through all the layers of the scalp.
Fig. 2
R. Carachi
• Pressure is applied to the edges of the incised
wound and the galea is picked up using mos-
quito forceps and flipped over the flap to stop
bleeding (the scalp is very vascular).
• A periosteal elevator is used to expose the skull
bone; this is often accompanied with some ooz-
ing of blood. This is to allow a burr hole to be
performed.
• A no. 10 blade is then rotated through the skull
in a vertical position until the outer table of
bone is breached and then the inner table is
penetrated. At this point the blade is swapped
for the tip of curved mosquito forceps to open
the hole and allow a bone nibbler to further
open this area and expose the dura, which
should be glistening.
• Using a dural right-angle hook the dura is
opened in a cruciate incision using a no. 11
blade.
• The venticular catheder is then inserted in the
direction illustrated in Fig. 2 aiming for the
bridge of the nose to enter the ventricle.
Abdomen
• The next part of the operation involves access
to the peritoneum. An upper transverse ab-
dominal incision is made approximately 2 cm
below the costal margin. The fascia is divided
and then the rectus abdominis is split to reveal
the posterior sheath. This is picked up with two
mosquito forceps and the sheath is opened us-
ing a scalpel. The peritoneum is next picked up
in a similar fashion and opened. (In an infant
this can be very difficult, and it is essential to
ensure that the peritoneum is opened and one
is not dissecting in the extraperitoneal space).
Connection
• Tunnel subcutaneously from the abdominal in-
cision right up to the scalp incision (Fig. 2).
• The peritoneal catheter is threaded through the
cannula and then connected up to the shunt
and the ventricular catheter, as illustrated in
the diagram.
• During this difficult procedure it is essential
that sterility is maintained, and a swab is placed
B15  Ventriculoperitoneal Shunting for Hydrocephalus 161

at the scalp wound and the abdominal wound
to ensure that the catheter is not contaminated.
• The valve is fixed in position with a black silk
stitch (000) in order to prevent it from sliding
out of position. A sample of cerebral spinal
fluid (CSF) should be taken for culture and sen-
sitivity. The entire wound is then irrigated with
antibiotic solution and the wound closed in the
usual fashion.

Fig. 3

Tips

77 Any bleeding from bone can be stopped using

bone wax.

Common Pitfalls

77 There are many pitfalls and it is essential to test 77 The skull bone may be very thin in infants and
the shunt at the operation to ensure that it is care must be taken not to penetrate the dura
working properly. CSF must be taken for culture whilst making the burr hole.
and sent to the laboratory.
162 R. Carachi

J. W. H O LT ER
(1916 – 2003)
American scientist

John Holter was a tool maker working for a lock company in Connecticut when his son was
born with spina bifida. The boy went on to develop hydrocephalus and it sparked in his father
an urgent desire to find a cure. He therefore designed the first VP shunts to drain the cerebro-
spinal fluid. The early work was done in John’s garage, but he later built a company which not
only manufactured the VP shunts, but it also led research and trials in various aspects of the
condition and the production of these shunts. Working with Dr. Eugene Spitz he designed the
valved drainage system, that remains the basic principle behind valves to this day. Though he
was unable to help his own son, John Holter has provided help and hope to many thousands.
B16  Cervical Oesophagostomy
B 16Cervical Oesophagostomy
A. Sinha and S. Agarwala
Operative Technique
• Position the patient supine with a roll trans-
versely under the shoulder and moderately ex-
tend the neck. Turn the face to the side op-
posite, where the oesophagostomy is being
planned. Ask the anaesthetist to place a large
bore orogastrically in the oesophagus.
• Make a transverse skin crease incision about
1 cm above and parallel to the medial third of
the clavicle (Fig. 1).
Fig. 1
• Using a diathermy, divide the subcutaneous tis-
sue and platysma in the line of the incision and
develop subplatysmal flaps superiorly and in-
feriorly to expose the medial aspect of sterno-
cleidomastoid muscle (Fig. 2).
• Retract the external jugular vein laterally or di-
vide it between ligatures.
• Incise the investing layer of deep cervical fascia
longitudinally at the medial edge of the sterno-
cleidomastoid muscle and dissect between the
Anand Sinha ()
Senior Research Fellow in Pediatric Surgery
dranandsinha@hotmail.com
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_48, © Springer-Verlag Berlin Heidelberg 2013
163
B16
carotid sheath laterally and the trachea antero-
medially (Fig. 3).
• Delineate the carotid sheath and retract it lat-
erally (Fig. 4). Divide the inferior thyroid vein
between ligatures as close to the carotid sheath
as possible.
• Visualize the trachea (anteromedially) and the
oesophagus (posteriorly) and confirm by pal-
pating the endotracheal tube in the trachea and
nasograstic tube in the oesophagus. Indentify
and preserve the recurrent laryngeal nerve.
Fig. 2
• Mobilize the oesophagus circumferentially,
staying on its wall, and separate it from the
posterior surface of trachea.
• Loop the oesophagus with a sling and continue
dissection inferiorly until the blind pouch is
completely mobilized (Fig. 5).
Fig. 3
164 A. Sinha and S. Agarwala

• Deliver the lower end of the oesophagus

through the incision and retract it outwards.
• Close the fascial sheath on the medial aspect of
sternocleidomastoid muscle, anchoring the oe-
sophageal wall in two or three Vicryl sutures.
• Repair the platysma with fine continuous Vic-
ryl suture and the skin with fine subcuticular
Monocryl suture after placing the oesophagus
in a prime location (Fig. 6).
• Transversely incise the distal most portion of
Fig. 4 the oesophagus (Fig. 7) and anchor it to the
skin in an everting fashion (Fig. 8).
• Cover the oesophagostomy with paraffin gauze
and dress the remaining wound.

Fig. 5

Fig. 6

Fig. 7 Fig. 8
B16  Cervical Oesophagostomy
Tips
77 Maintain hemostasis at all time so that the
planes and structures can be identified.
77 Attempt not to open the carotid sheath.
77 Remove the red rubber catheter before starting
to dissect the oesophagus from the trachea.
Common Pitfalls
77 Injury to the adjoining structures such as:
– Major vessels in the carotid sheath
– Recurrent laryngeal nerve in the tracheo-oe-
sophageal groove
– Posterior surface of trachea while separating it
from the oesophagus
– Thoracic duct on the left side
165
77 A Babcock’s forceps can be handy in circumfer-
entially holding the oesophagus without crush-
ing its walls.
77 The sternal head of the sternocleidomastoid can
be divided for better exposure.
77 Inadequate mobilization results in tension at the
suture line can lead to ischemia, retraction and
stenosis of the oesophagostomy.
77 Sagging oesophagostomy can result in a J-
pouch formation with resultant pooling of saliva
and recurrent aspiration pneumonitis.
 166 A. Sinha and S. Agarwala
B17 B 17H-Type Tracheo-oesophageal Fistula
A. Sinha and S. Agarwala

 perative Technique for H-type

O
Tracheo-oesophageal Fistula (TEF)

• Initial procedure is same as for oesophagos-

tomy (see Figs. 1–4 Chap. B16)

Fig. 2

• Repair the oesophageal end with interrupted

Vicryl sutures and the tracheal end with in-
terrupted non-absorbable sutures like Prolene
(Fig. 2).
Fig. 1 • After placing a soft drain, close the deep cervi-
cal fascia and platysma in two layers with inter-
• Dissect in the plane between the trachea and rupted Vicryl sutures. Close the skin with sub-
oesophagus, and loop the oesophagus. Avoid cuticular Monocryl sutures.
damage to recurrent laryngeal nerve.
• With lateral traction on the oesophagus, con-
tinue dissection distally in the plane between
the trachea and oesophagus until the fistula
is reached. Define the fistula circumferen-
tially. Take stay sutures on both tracheal and
oesophageal ends, both proximal and distal
to the fistula, and divide the fistula between
them (Fig. 1).

Anand Sinha ()

Senior Research Fellow in Pediatric Surgery
dranandsinha@hotmail.com

Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_49, © Springer-Verlag Berlin Heidelberg 2013
B17  H-Type Tracheo-oesophageal Fistula 167

Tips

77 Bronchoscopy and cannulation of the fistula 77 Approach from the right is easier in H-type TEF
with a ureteric stent can be done prior to endo- cases.
tracheal intubation to facilitate identification of 77 The sternal head of the sternocleidomastoid can
the fistula. be divided for better exposure.

Common Pitfalls

77 Injury to the adjoining structures such as:
- Major vessels in the carotid sheath
- Recurrent laryngeal nerve in the tracheo-oe-
sophageal groove
- Posterior surface of trachea while separating it
from the oesophagus
- Thoracic duct on the left side
77 Inability to identify the distal most edge of the
fistula and therefore incomplete repair on both
the sides
 PAR T C
Spine and Limbs
C1  Spina Bifida
C 1Spina Bifida
M. Ragavan and M. Srinivas
Operative Technique
• Position the baby prone with a roll under the
hip and sand bag under the shoulder with the
head turned to one side (Fig. 1).
Fig. 1
• Apply drapes and suture them to the skin with
3/0 black silk.
• Cover the anus with a large transparent, occlu-
sive dressing.
• Make a transverse elliptical incision circum-
scribing the base of the myelomeningocele
(Fig. 2).
• Deepen the incision at the lateral edge to reach
the thoracolumbar fascia. Dissect around the
base of the sac in this layer, just superficial to
M. Ragavan ()
Associate Professor
Department of Pediatric Surgery, Narayana Medical Col-
lege & Superspeciality Hospital, Chinthareddypalem, Nel-
lore, Andhra Pradesh 524002, India
dr_ragavan_2011@rediffmail.com
M. Srinivas
Additional Professor of Pediatric Surgery
srinivasem@hotmail.com
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_50, © Springer-Verlag Berlin Heidelberg 2013
171
C1
Fig. 2
the thoracolumbar fascia. Dissect as close to
the sac as possible without opening it.
• Place two stay sutures on the superior aspect
of the dura and open it in the midline between
stays without damaging the underlying neural
elements (Fig. 3).
• Using a nerve hook, work around the neural
elements, between them and the dura, to sep-
arate them from the dura and then divide the
dura completely (Fig. 4). Place multiple fine
Prolene stay sutures on the edges of the dura.
• De-tether the spinal cord posteriorly and de-
tether the filum terminale between two stay su-
tures, and then release all the arachnoid adhe-
sions.
• Tubularize the neural placode, if open, using
interrupted, fine Prolene sutures (Fig. 5).
• Repair the dura using a continuous fine Prolene
suture (Fig. 6).
• Mobilize the thoracolumbar fascia from one
side and use the erector spinae fascia to rein-
force the dural repair with interrupted Vicryl
sutures (Fig. 7).
• Mobilize the subcutaneous tissue and skin to
achieve a tension-free closure.
• Reconstruct the subcutaneous tissue with in-
terrupted 2/0 Vicryl sutures, and the skin with
a running, subcuticular Monocryl suture.
• A suction drain should be left beneath the sub-
cutaneous layer for 24 h.
172 M. Ragavan and M. Srinivas

Fig. 3

Fig. 4 Fig. 5

Fig. 6 Fig. 7
C1  Spina Bifida 173

Tips

77 A vertical incision should be used if the axis of

the sac is oriented vertically or when a laminec-
tomy is planned.
77 During incision, preserve as much normal skin as
possible.
77 After the dura is opened, use only bipolar cau-
tery.
77 The neural placode is open if the central canal is
open. In such cases the placode should be tubu-
larized.
77 De-tether all arachnoid adhesions. Fig. 8
77 During division of the dura, preserve as much
dura as possible. If the dura cannot be closed
primarily without excessive tension, use a free
patch of thoracolumbar fascia or fascia lata to
bridge the dural defect.
77 In cases where the dura cannot be clearly delin-
eated from the neural elements, it may be ad-
visable to do one or two laminectomies superi-
orly and then open the dura in a normal location,
and then trace the neural elements from there.
This is the procedure to be followed for all cases Fig. 9
of lipomyelomeningocele.
77 For wide skin defects, fashion rotational skin
flaps for tension free closure (Figs. 8 and 9). 77 Use Steri-Strips to reinforce the wound closure
and apply blue-swab pressure for 1 week and
leave undisturbed unless soiled. Cover the dress-
ing with sleek to provide additional waterproof-
ing.

Common Pitfalls 

77 Incomplete de-tethering of the cord structures
and the filum terminale may happen.
77 Attempting to reconstitute the neural tube
should not be attempted if the edges of the
placode do not easily come together, as this risks
strangulation and pressure necrosis of the plac-
ode.
77 Tight dural closure leading to delayed ischaemia
and cerebral spinal fluid (CSF) leak can occur.
77 Contamination of the intradural space with ex-
cess blood is possible.
77 Damage to the cord or the nerve roots due to ex-
cess traction on the sac during dissection is pos-
sible.
77 Skin and subcutaneous closure under tension
can occur, leading to ischaemia and breakdown.
 174 J. S. Huntley
C2 C2 Forearm Manipulation and Molded Cast
J. S. Huntley

Indication

Fractures with unacceptable deformity (transla-

tion/angulation/rotation/shortening) requiring re-
duction, but with reduction being achievable by
closed means are indications for manipulation and
casting. This includes most Salter–Harris II inju-
ries of the distal radius, distal metaphyseal frac-
tures, most both bone forearm fractures (espe-
cially those of the greenstick variety) and plas-
tic deformations.

Operative Technique

Manipulation
Musculoskeletal tissues are visco-elastic, so that
the mechanical response in stretching out of soft
tissues depends not only on the force applied, but
also on the length of time for which it is applied.
Thus longitudinal traction with careful counter-
force, applied over the course of five minutes is
helpful in disimpaction.
All components of deformity (translation, an-
gulation, rotation and shortening) should be re-
duced (check with the image intensifier). Rota-
tional deformity in radial fractures proximal to
pronator teres may be reduced by supination,
whereas in those distal to pronator teres, a pro-
nation manoeuvre is likely to be required.
The manipulative technique varies according
to the fracture configuration:
• Off-ended and shortened fractures (the frag-
ments are termed 'locked') require the frag-
ments to be unlocked by exaggeration of the
deformity. After longitudinal translation of the
Jim S. Huntley ()
Consultant Paediatric Orthopaedic Surgeon
Jim.Huntley@ggc.scot.nhs.uk
Fig. 1 Exaggeration of the deformity unlocks ‘locked’
fractures
distal part, the fragments can then be re-en-
gaged in their proper relative positions as the
deformity is reduced (Fig. 1).
• Greenstick fractures with an intact hinge re-
quire correction by gentle pressure (Fig. 2).
• Plastic bowing requires considerable force ap-
plied in a three-point pattern over an extended
period to unbend (Fig. 3).
Casting
• Usually an above elbow cast with the forearm
in neutral is appropriate (sometimes a prona-
tion or supination position may be required).
• Apply soft-roll sparingly along the arm (one-
ply, just overlapping) with extra to the promi-
nences (Fig. 4).
• Dip the plaster until the bubbles stop appear-
ing. Bring the roll out of the water and remove
the excess.
• Roll the wet plaster circumferentially, with
'tucks' to allow smooth, economical and even

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_51, © Springer-Verlag Berlin Heidelberg 2013
C2  Forearm Manipulation and Molded Cast 175

Fig. 2  Gentle corrective pressure for greenstick fracture

Fig. 3  Correction of plastic bowing

Fig. 4  Soft roll applied sparingly
placement along the length to be plastered –
neither too long nor too short (Fig. 5).
• Mould whilst wet, approximate to the limb
contours, with three-point pressure appropri-
ate to maintain the reduction – the middle site
of pressure is on the opposite side from both
the proximal and distal pressures (Fig. 6).
176 J. S. Huntley

Fig. 5  Plaster of Paris on

Fig. 6  Three-point moulding Fig. 7  Hyndman’s cast ratio

C2  Forearm Manipulation and Molded Cast
Tips
77 Assess for rotational abnormality by match-
ing the medullary and cortical diameters in the
neighbouring fracture fragments.
77 When moulding, keep moving the hands to
avoid sharp peak contact areas in the cast.
Common Pitfalls
77 Too much padding is a recipe for cast slippage,
loss of reduction and complications.
177
77 Hyndman’s cast ratio is a useful predictor of
maintenance of reduction by a forearm cast –
the lateral diameter must be much less than the
anteroposterior diameter (Fig. 7).
77 Fractures must be followed by radiographs in the
clinic so that if they lose reduction it is possible
to intervene before union.
77 Do not accept a poor reduction, especially in the
child of 10 years or older, in whom the remodel-
ling capacity is far less.
 178 J. S. Huntley
C3 C 3Distal Radius Wiring
J. S. Huntley

Indication • Select either a 1.6- or 2.0-mm-diameter K-wire.

Use a Mosquito to dissect to bone. Place the
This procedure is used to stabilise unstable dis- wire against the bone using either a narrow tis-
tal radial fractures after a reduction has been ob- sue protector or an opened Mosquito to pro-
tained by manipulation. tect the soft tissues (Fig. 3).

Operative Technique

• Use the image intensifier to guide your inci-

sions – these should be just distal to the antic-
ipated entry points (catering for the obliquity
of the wires running from distal to proximal).
• Ideally, the entry points should be just proxi-
mal to the physis so that the wires do not cross
it. Fig. 2  Incision over Lister’s tubercle
• A rolled-up drape positioned under the volar
aspect (or under the lateral ulna for the styloid
wire) of the wrist is useful if there is soft tissue
swelling (Fig. 1).
• Make a 1-cm incision over Lister's tubercle
(Fig. 2).

Fig. 3  Dorsal wire insertion

Fig. 1  ‘Roll’ under volar aspect wrist

• Advance the wire minimally to gain an entry
point in the distal fragment (Fig. 4).
• Once this is obtained, check (and adjust) the
line of advancement on both anteroposterior
and lateral views (Fig. 5).
Jim S. Huntley ()
• Advance the wire across the fracture into the
Consultant Paediatric Orthopaedic Surgeon proximal fragment and engage the contralat-
Jim.Huntley@ggc.scot.nhs.uk eral cortex (Fig. 6).

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_52, © Springer-Verlag Berlin Heidelberg 2013
C3  Distal Radius Wiring 179

• Make a 1-cm incision in the mid-lateral line (be

mindful of the superficial radial nerve) (Fig. 7).
• Select either a 1.6- or 2.0-mm-diameter K-wire.
Use a Mosquito to dissect onto bone. Place the
wire against the bone using either a narrow tis-
sue protector or an opened Mosquito to pro-
tect the soft tissues (Fig. 8).
• Advance the wire minimally to gain an entry
point in the distal fragment.
• Once this is obtained, check (and adjust) the
Fig. 4  Wire gaining entry in distal fragment line of advancement on both anteroposterior
and lateral views.
• Advance the wire across the fracture into the
proximal fragment and engage the contralat-
eral cortex (Fig. 9).

Fig. 5  Posterior and anterior (PA) and lateral views to

check alignment
Fig. 8  Wire entry

Fig. 6  Lateral view

Fig. 7  Lateral incision (1 cm) in mid-lateral line (avoid the Fig. 9  Two-wire construct
superficial radial nerve)
180
Tips
77 Watch for the digits (especially thumb) moving,
so that if the edge of a tendon is picked up by
the rotating K-wire, you can stop immediately.
77 At the end, use the ‘tenodesis effect’ to check
that there is no tethering or tendon rupture by
freely flexing and extending the wrist and ob-
serving reciprocal movement at the digits.
Common Pitfalls
77 Avoid the superficial radial nerve below the lat-
eral incision.
J. S. Huntley
77 The wires can be bent and cut, leaving a 1-cm
bent portion proud of the skin – this can be
dressed with a swab or Betadine sponge. The
wires should be removed at 4 weeks (without
anaesthetic).
77 Make sure you advance the wire at the appropri-
ate angle to pick up contralateral cortex in the
proximal fragment.
C4  Forearm Diaphyseal Reduction and Fixation (Closed Wiring)
C4 Forearm Diaphyseal Reduction
and Fixation (Closed Wiring)
J. S. Huntley
Indication
Unstable diaphyseal forearm fractures, in which
the reduction cannot be maintained by casting,
are indications for reduction and fixation.
Operative Technique
• A rolled-up drape positioned under the volar
aspect of the wrist is useful.
• Use the image intensifier to guide your incision
– this should be just distal to the anticipated en-
try point for the radius (catering for the obliq-
uity of the wires running from distal to proxi-
mal). The entry point should be just proximal
to the physis so that the wires do not cross it.
• Place a 2-cm dorsolateral longitudinal incision
over the distal radius (Fig. 1).
Fig. 1  Incision over dorsolateral radius
• Use a combination of sharp (no. 15 scalpel
blade) and blunt (Mosquito and periosteal el-
evator) dissection to clear an area of bone ~0.5-
cm breadth by a 1-cm length, avoiding damage
to the superficial radial nerve and tendons.
• Use a drill or awl to make an extremely oblique
hole in the cortex under direct vision (Fig. 2).
Jim S. Huntley ()
Consultant Paediatric Orthopaedic Surgeon
Jim.Huntley@ggc.scot.nhs.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_53, © Springer-Verlag Berlin Heidelberg 2013
181
C4
Fig. 2  Oblique entry point
• Select the appropriate diameter titanium elas-
tic nail (2-mm diameter usually appropriate).
• Put an additional gentle bend about 1.5 cm
from the tip (the tip itself already has a bend).
• Secure this wire on a chuck handle, and ad-
vance the wire so that it bounces off the con-
tralateral cortex, and runs down the shaft (Fig.
3).
• Manipulate the fracture ends and turn the wire
(under image intensifier control) so that the tip
can be advanced across the fracture and into
the proximal fragment (Fig. 4).
• Advance the wire down the medullary canal
until it gives good fixation.
• Cut the wire close to the bone, leaving enough
length for later removal but not so much that
it tents the skin.
• Make a 1-cm incision over the proximal olecra-
non apophysis (Fig. 5). Use a Mosquito to dis-
sect onto bone. Place a K-wire (usually 2 mm)
against olecranon.
• Check the entry point on anteroposterior and
lateral views before driving the wire straight
down the intramedullary canal as far as the
fracture site (Fig. 6).
• Advance the wire across the fracture into the
intramedullary canal of the distal fragment un-
til a fix is obtained (Fig. 7).
182 J. S. Huntley

Fig. 3  Wire bounces off contralateral cortex

Fig. 4  Wire tip crosses fracture

• At this point, bring the wire back 1.5 cm, and

then bend and cut it close to the skin edge (Fig.
8).
• Take a small circular punch with a concave end
and tap the ulna wire down again, burying it
deep to the triceps insertion so that it does not
tent or irritate the soft tissues (Fig. 9).
• Close the skin incisions with interrupted su-
tures.

Fig. 5  Incision over olecranon

C4  Forearm Diaphyseal Reduction and Fixation (Closed Wiring) 183

Fig. 7  Wire crosses fracture site

Fig. 6  Wire straight down ulna

Fig. 9  Bury the ulna wire

Fig. 8  Wire backed off, bent and cut

Tips

77 Although it is helpful to start the ulna K-wire on wire and advance ‘by feel’, as there is less chance
power, it is then better to use a chuck to grip the of a cortical perforation.

Common Pitfalls

77 Extensor pollicis longus rupture – make sure
you cut the titanium nail short, even off the cut
edges so they are not sharp, and turn the edge
away from the extensor pollicis tendon.
77 Sometimes the described closed nailing is im-
possible because of interposed tissue, and the
fractures have to be opened to allow reduction.
77 Infection – minimise the risk with prophylactic
antibiotics and meticulous technique.
 184
C5 C5 Displaced Supracondylar Humeral
Fracture
J. S. Huntley
Indication
Displaced extension-type supracondylar humeral
fracture.
Operative Technique
• The setup is important (Fig. 1).
– Align the image intensifier parallel to the pa-
tient, coming in from the head end, with the
detector screen uppermost.
– The arm table is slightly raised and set near
the head end of the table to allow the im-
age intensifier to swing through ‘under-the-
table’, for a lateral view.
Fig. 1  Set-up for supracondylar pinning
• Prepare the whole arm.
• Perform maintained gentle, longitudinal trac-
tion (with counter traction in the upper arm)
with the elbow flexed 30° for 5 min (Fig. 2).
Jim S. Huntley ()
Consultant Paediatric Orthopaedic Surgeon
Jim.Huntley@ggc.scot.nhs.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_54, © Springer-Verlag Berlin Heidelberg 2013
J. S. Huntley
• Use the anteroposterior image intensifier view
to correct lateral–medial translation and varus/
valgus alignment (Fig. 3).
• Apply pressure posteriorly to the olecranon,
with counter-pressure anteriorly high in the up-
per arm (not over the spike of bone at the prox-
imal fracture fragment). Then flex the arm (if
the initial displacement was medial, bring the
forearm into pronation; conversely if it was lat-
eral, bring the forearm into supination) up to
lock the distal humeral fragment into place.
Maintain the flexed position (Fig. 4).
• Obtain medial and lateral column views with
minimal tilting movement (Fig. 5).
• Obtain a lateral (under the table) view to check
the reduction.
• Use 2.0-mm-diameter K-wires – the first entry
point is on the distal part of the lateral condyle,
engage the bone and drive the wire at 45° to the
transverse axis and in the coronal plane so that
it passes across the fracture site into the proxi-
mal fragment, engaging the contralateral cor-
tex.
• The second entry point is distal to the first in
the gap between the lateral epicondyle and the
C5  Displaced Supracondylar Humeral Fracture
Fig. 2  Position for traction
olecranon, just posterior to a line connecting
the two.
• The direction of the wire should be parallel or
divergent to the first. Drive the wire across the
fracture site into the proximal fragment, engag-
ing the contralateral cortex (Fig. 6).
• Obtain a lateral (under the table) view to check
the wire position. Adjust the wires if the posi-
tion is not adequate (Fig. 7).
Fig. 3  Initial view
185
• The fracture should now be stable to extension
and rotation – check this gently with real-time
screening.
• If a cross-wire construct is preferred, extended
the elbow to a position of 35°, and make a 3-cm
curvilinear incision between the medial epicon-
dyle and the olecranon. Use a combination of
in-line sharp and blunt dissection to identify
and release the ulna nerve distally (Fig. 8). A
wire can then be inserted into the medial epi-
condyle under direct vision, using a small wire
guide to keep the wire clear from the ulna nerve.
Drive the wire at 45° to the transverse axis and
in the coronal plane so that it passes across the
fracture site into the proximal fragment, engag-
ing the contralateral cortex (Fig. 9).
• Close the skin with interrupted sutures.
• If the position of the fist lateral wire and the
medial wire is good, then the second lateral wire
(which is likely to be intra-articular) can be re-
moved.
• Bend and cut all wires. Apply Betadine sponges
and swabs to the wire sites.
• Apply a back slab in 70° flexion and check the
radial pulse.
Fig. 4  Flexed position maintaining reduction
186 J. S. Huntley

Fig. 5  Medial and lateral column views

Fig. 7  Lateral view

Fig. 6  Lateral wires

C5  Displaced Supracondylar Humeral Fracture
Fig. 8  Exposure of ulnar nerve (running between 2 heads
of flexor carpi ulnaris) allows safe placement of wire
through medial epicondyle under direct vision
Tips
77 Check the setup and make any adjustments [to
allow the image intensifier to swing through for
a lateral view] before scrubbing.
77 The facility to obtain the under-the-table lateral
view is good because otherwise rotating the arm
to obtain the lateral view – with the image inten-
Common Pitfalls
77 Tethering/puckering of the skin is important as
it indicates buttonholing of a proximal fragment
spike through brachialis. This can be released
preoperatively by ‘milking’ the soft tissues down
over the spike.
77 Beware medial column comminution, especially
in the less displaced fractures, that need to be re-
duced at the initial longitudinal traction stage.
Otherwise a cubitus varus (‘gunstock’ deformity)
may result.
77 Higher energy injuries may produce an ipsilat-
eral radial fracture (usually distal) – the ‘floating
187
Fig. 9  Additional medial wire used when laterally sited
ones were not sufficient
sifier in the upright position – runs the danger of
twisting the distal fragment off and losing the re-
duction.
77 Nerve (radial, ulnar, median and anterior interos-
seous) and vascular charting is important both
pre- and postoperatively.
elbow’. Reduce and stabilise the radius (usually
wires) first and then treat the supracondylar frac-
ture as usual.
77 Increasing pain postoperatively may indicate
nerve entrapment and/or compartment syn-
drome.
77 Though rare, beware compartment syndrome
which mandates fasciotomies to prevent mus-
cle necrosis.
 188 J. S. Huntley
C6 C6 Femoral Fracture and Spica Cast
J. S. Huntley

Femoral fractures in children pose particular

problems according to factors designated as pa-
tient (age, co-morbidities, social situation and
habitus), fracture (configuration - stable/unsta-
ble, site, energy, open/closed) and associated (e.g.
polytrauma). There is a variety of modes of treat-
ment with different indications, beyond the scope
of this atlas. Here the application of a spica cast
for femoral fracture is described.

Indication
Fig. 1  Long leg cast
Femoral shaft fractures are indications for spica
casting. placement along the length of the leg, four- to
five-ply.
• Mold laterally and medially in the supracon-
Operative Technique dylar region.
• When this is set, transfer the patient to the spica
• Stabilise the limb by applying traction to the in- table (Fig. 2).
volved extremity with the patient's heel in one • Flex the hip to 50–90° and use the contralat-
hand and calf in the other and the knee flexed eral leg as a guide to rotation.
to 70–90°. • You have good rotational, angular and trac-
• Use two assistants to apply a long leg cast from tional control of the fracture because of the
the supramalleolar region to the level of the long leg cast.
fracture with a supracondylar mold (Fig. 1).
The first assistant should hold the femur in the
supracondylar region below the fracture, mov-
ing his/her hands to avoid indenting the cast.
The second assistant should apply the soft-roll
and cast.
• Dip the plaster until the bubbles stop appear-
ing. Bring the roll out of the water, and remove
the excess.
• Roll the wet plaster circumferentially, with
'tucks' to allow smooth, economical and even

Jim S. Huntley ()

Consultant Paediatric Orthopaedic Surgeon Fig. 2  Transfer the patient to the spica table and apply ab-
Jim.Huntley@ggc.scot.nhs.uk dominal felt over a ‘pudding’ roll

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DOI: 10.1007/978-3-642-20641-2_55, © Springer-Verlag Berlin Heidelberg 2013
C6  Femoral Fracture and Spica Cast 189

• Complete a one-and-a-half-hip spica (for chil-

dren older than 5 years) or a double hip spica
(for children younger than 5 years) in 30° ab-
duction with a valgus and buttock mould on
the cast.
• Apply padding/felt around the abdomen, and
over a 'pudding' (roll of bandage), which will
be removed later but allows for abdominal dis-
tension.
• Apply soft-roll in a 'figure-8' fashion, six- to
eight-ply around the abdomen and groin and
then circumferentially down the legs, leaving
the natal cleft, perineal and genital areas free Fig. 3  Soft roll and cast applied
(Fig. 3).
• Mold whilst wet, approximate to the limb con-
tours with the heels of the hands proximally
over the upper thigh (proximal to the fracture),
and distally on the aspect of the thigh (distal
to the fracture).
• Obtain radiographs once the spica is set.
• Trim the cast in the groin and posteriorly. Ap-
ply a layer of felt to the edge so that this region
is soft.

Tips

77 Do not apply a below-knee cast first and then ex-
tend it, as the ridge is likely to dig into the calf
and may cause a sore or extrinsic compartment
syndrome.
77 In more proximal fractures (e.g. subtrochanteric),
it may be necessary to flex the hip more (e.g. up
to 90°) to cater for the flexion of the proximal
fragment.
77 Shortening of up to 1.5–2.0 cm is acceptable be-
cause of the regional overgrowth that occurs
post-fracture.

Common Pitfalls

77 Compartment syndrome is a recognised compli-

cation of early spica casting.
 190 J. S. Huntley
C7 C7 Tibial Diaphysis Fracture –
External Fixation
J. S. Huntley

Indication • Deepen these onto bone with a Mosquito

Operative stabilisation of unstable tibial diaphy-
sis fracture via the subcutaneous medial face of
the tibia.
Operative Technique
• Make longitudinal 8mm incisions through skin
and fat, at the levels identified for pin placement
[partly dependent on the types of clamp/exter-
nal fixator system being used], along the line of
the centre of the medial ‘face’ (Figure 1).
(Figure 2).
• Apply the trocar with drill sleeve to bone, and
remove the trocar leaving the sleeve (Figure 3).
• Use a hand drill through the sleeve, in a di-
rection from anteromedial to posterolateral
(Figure 4).
• Use appropriately sized pins (e.g. 4 or 5 mm di-
ameter) and screw in via the protective sleeve,
obtaining bicortical fixation (Figure 5).
• When 2 or 3 pins have been sited both prox-
imal and distal to the fracture, assemble the
pin to bar clamps on the pins, and then attach
the bar(s) – reduce the fracture, and tighten all
the articulations so that the construct is stable
(Figure 6).

Fig. 2  Mosquito dissection

Fig. 1  External fixators incisions

Jim S. Huntley ()

Consultant Paediatric Orthopaedic Surgeon
Jim.Huntley@ggc.scot.nhs.uk Fig. 3  Trocar and sleeve

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_56, © Springer-Verlag Berlin Heidelberg 2013
C7  Tibial Diaphysis Fracture – External Fixation 191

Fig. 5.  Pin to both cortices

Fig. 4.  Hand drill

Fig. 6.  Stable construct

Tips

77 The stability of the construct can be increased by
– having more pins either side of the fracture
(e.g. 3 rather than 2),
– increasing the distance between pins on one
side of the fracture, and
– moving the bar (and its articulations) closer to
the skin.
77 As well as the anteromedial pins used above, an-
teroposterior (sagittal) screws are also feasible as
long as care is taken to avoid posterior over-pen-
etration. These may be preferred by plastic sur-
geons wanting access to both sides of the sagit-
tal plane.

Common pitfalls

77 It is not necessary to treat all open tibial fractures

in children with an external fixator - after de-
bridement and wound surgery/irrigation, a cast
may be an appropriate method of stabilisation
(with windowing to allow wound inspection).
 192 J. S. Huntley
C8 C8 Infection – Washout of the Knee and Hip
J. S. Huntley

Most acute musculoskeletal infections can be

treated with intravenous antibiotics. However
the management of septic arthritis and necrotis-
ing infections involves emergency surgery. Oper-
ative procedures described here are for the wash-
out of the two joints most commonly affected by
septic arthritis, the knee and the hip.

Indication

Septic arthritis is an indication for the washout Fig. 1  Lateral incisions for suprapatellar and infrapatellar
procedure. portals

Operative Technique

Knee – Two-Portal Washout

• Make a 1-cm longitudinal incision anterolater-

ally through skin and fat, just proximal to the
superior pole of the patella.
• Use closed dissecting scissors to extend this
track transversely into the suprapatellar pouch,
anterior to the distal femur, then bluntly dissect
to open the track distally (Fig. 1).
• Use large non-toothed forceps to pass a 10 cm
section of wide-bore giving-set tubing into the
suprapatellar pouch (Fig. 2). Fig. 2  Passing the tube
• Aspirate pus/fluid at this stage and send sam- • Take care not to abrade the cartilage.
ples for microbiology. • Use large non-toothed forceps to pass a wide-
• Make a 1-cm transverse incision above the tib- bore giving-set into the knee via the lateral
ial joint line, just lateral to the lateral margin of parapatellar incision (Fig. 3).
the patellar tendon. • Run warmed saline through the lower portal so
• Deepen this by blunt dissection into the knee it can flush through the upper drainage portal.
joint, under the patella. Reverse the direction of flow if desired.
• Continue the washout until the effluent is clear.
Then drain as much fluid as possible from the
Jim S. Huntley ()
knee.
Consultant Paediatric Orthopaedic Surgeon • Remove the two tubes and close the skin with
Jim.Huntley@ggc.scot.nhs.uk a horizontal mattress suture to each site.

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2-57, © Springer-Verlag Berlin Heidelberg 2013
C8  Infection – Washout of the Knee and Hip 193

• Develop the TFL:sartorius interval within the

sheath of TFL by blunt dissection with scissors
and then retraction with two Langenbecks.
• The lateral femoral cutaneous nerve is con-
served as it (usually) runs over sartorius and is
retracted medially.
• Coagulate and divide the ascending branch
of the lateral femoral circumflex artery
here (Fig. 6).

Fig. 3  Two-portal washout

Hip – Anterior Approach and Arthrotomy

• Make a 2- to 4-cm slightly oblique (from trans-

verse) incision, 3–6 cm below the anterior su-
perior iliac spine (ASIS) (Fig. 4). Fig. 6  Coagulate the ascending branch vessel

• Define the interval between the muscles of the

deeper layer: gluteus medius laterally and rec-
tus femoris medially.
• The origin of the direct head of rectus femoris
is the anterior inferior iliac spine (AIIS), which
should also be palpable (Fig. 7).

Fig. 4  Incision for anterior approach

• Use dissecting scissors and a self-retainer to

deepen this to the fascia.
• Identify the interval between the tensor fascia
latae (TFL) and the sartorius. Incise the deep
fascia as it overlies the TFL (Fig. 5).

Fig. 7  Identify and retract direct head of rectus femoris

(runs onto anterior inferior iliac spine)

• Palpate the capsule of the hip joint distal to

AIIS, and confirm this by simultaneously ro-
tating (internal/external) the adducted hip.
• Use Adson’s forceps to lift the capsule and in-
cise it with a number 15 blade, making an L-
Fig. 5  Identify the TFL:sartorious interval shaped capsulotomy (Fig. 8) – fluid/pus will
194 J. S. Huntley

escape at this stage (samples should be sent to

microbiology).
• Use a small sucker to clear the fluid.
• Use non-toothed forceps to pass a feeding tube
round the back of the femoral neck.
• Flush the feeding tube with warm saline from
a 50-ml syringe so that the joint is thoroughly
washed out from deep layers.
• When the fluid runs clear, allow the tissues to
approximate.
• Close the skin with interrupted sutures.

Fig. 8  Make an L-shaped capsulotomy

Tips

77 In the anterior approach to the hip, use the ASIS gluteus medius to be (reassuringly) well lateral to
and the femoral pulse as landmarks. You should the femoral pulse.
find the intervals of TFL to sartorius and rectus to 77 A tag suture to the TFL:sartorius interval can be
useful if a secondary washout is required.

Common Pitfalls

77 For the anterior approach to the hip, avoid mak- 77 Take care not to damage the articular cartilage
ing your incision too high. when making either the parapatellar approach
in the knee, or incising the capsule of the hip.
C9 Syndactyly 195
C 9Syndactyly C9
O. Quaba and J. J. R. Kirkpatrick

Principles

• Separate involved digits

• Provide adequate skin cover (with skin grafts
if required)
• Create a new, properly placed web space with
good quality skin (i.e. requires flap)

Classification

• Complete (to distal phalanx) vs. incomplete

• Simple (soft tissue only) vs. complex (bony
union – usually at distal phalanx)
• Acrosyndactyly (distal fusion)

Operative Technique

Position the patient supine with an arm board and Fig. 1

arm tourniquet.

Web Reconstruction Zigzag Incisions

• Use a proximally based dorsal trapezoidal flap,
extending two thirds of the length of the prox-
imal phalanx (Fig. 1).
• Mark the position of the web space on the pal-
mar side.
• The metacarpophalangeal joint (MCPJ) crease
is often present; if not, the correct web space
position is usually midway between the distal
palmar crease and the proximal interphalan-
geal (PIPJ) crease (Fig. 2).
Omar Quaba ()
Specialist Registrar in Plastic Surgery
omarquaba@hotmail.com
• These are Dorsal and palmar triangular flaps
with matched zigzag incisions.
• The dorsal flaps are designed with the base of
flaps broadly centred over the PIP and distal in-
terphalangeal (DIP) joints of one finger (Fig. 1).
• The palmar flaps are based opposite the dorsal
flaps (mirror images) with bases centred over
the opposite PIP and DIP joints to allow for
interdigitation (Fig. 2).
• The flaps should extend from the midline of
one digit to the midline of the other digit.

James J. R. Kirkpatrick
Consultant Plastic Surgeon
J.Kirkpatrick@nhs.net

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DOI: 10.1007/978-3-642-20641-2_58, © Springer-Verlag Berlin Heidelberg 2013
196
Fig. 2
Separation of Digits
• Raise the dorsal flaps first, identifying interdig-
ital connective tissue.
• Next, raise the palmar flaps, identifying and
preserving the neurovascular bundles (use lon-
gitudinal spreading with scissors).
• Separate the digits from distal to proximal
while protecting the neurovascular bundles.
• Note that the digital artery bifurcation may be
more distal than normal – this may limit the
depth of the web (division of a proper digital
artery may be required – with obvious caveats!).
• Intraneural dissection of the common digital
nerve may be required to overcome a restric-
tion created by distal nerve bifurcation.
Defat the Flaps
• Trimming excess fat from the flaps increases pli-
ability and may reduce potential need for skin
grafts.
• Excise interdigital fat, taking care around the
neurovascular bundles.
O. Quaba and J. J. R. Kirkpatrick
Fig. 3
Nail Folds
• Buck–Gramcko flaps are used to recreate the
lateral nail folds along the contiguous borders
of the digits in complete syndactyly (Fig. 3).
• If complex, cut bony union using an osteo-
tome.
• Raise these flaps before the terminal parts of
the digit are separated.
Full-Thickness Skin Grafts
• Full-thickness skin grafts are usually required,
except in some cases of simple, incomplete syn-
dactyly.
• The best donor site is the groin crease, or lower
abdomen if a large graft is required.
Suture Choice
6/0 Vicryl Rapide is the preferred suture.
C9 Syndactyly 197

Tips

77 Early release is indicated for digits of unequal
length to correct alignment/ allow unimpeded
growth (e.g. first and fourth web).
77 Do not release adjacent webs simultaneously
due to risk of ischaemia.
77 Suture flaps loosely, with small bites.
77 Use an assistant to distract the fingertips with
skin hooks (or use temporary silk sutures
through the pulps).

Common Pitfalls

77 Tight suture of flaps compromising flap viability 77 Skin graft taken from future hair bearing pubic
(use a skin graft if required) area resulting in future hair growth in the web
space
 198 D. Datta and S. Agarwala
C10 C 10Polydactyly
D. Datta and S. Agarwala

 perative Technique for Small

O Technique in Postaxial (Ulnar)
Rudimentary Digit Polydactyly when the Extra Digit
Arises from a Neighbouring
• Transfix the base of a floppy rudimentary digit Metacarpal Bone or Phalanx
with a thin stalk of skin.
• Excise the rudimentary digit with a knife. • Make a zigzag incision and borrow skin from
• Repair the skin with a fine absorbable suture the digit to be excised (Fig. 3).
like Monocryl (Fig. 1). • Ligate vessels and transect the accessory nerve.
• Trim the metacarpal or phalanx to make the
shaft smooth.
• Close skin without tension using fine non-ab-
sorbable sutures.

 echnique for Pre-axial (Radial)

T
Polydactyly for Wassel’s Type 1, 2 or 3
(Where the Two Thumbs Are More or
Less Equal)

• Dissect the nails, keeping the germinal layer in-

tact.
• Expose the distal phalanges up to the interpha-
langeal joints.
• Excise the inner part of both thumbs in a cen-
tral wedge (Fig. 4a) using a saw.
• Align the two halves together with interosseous
wire so that the level of epiphyseal lines (growth
plate) and joint surface of both thumb match
with each other (Fig. 4b).
• Lay the nail on the newly reconstructed thumb
and close skin without tension.

Fig. 1  echnique for Pre-axial (Radial)

T
Polydactyly for Wassel’s Type 5, 6 or 7
Dibyarup Datta ()
Senior Resident in Pediatric Surgery • Make a zigzag incision (Fig. 5a).
dibyarupdatta@gmail.com
• Excise the smaller (usually lateral) thumb.
Sandeep Agarwala • Ligate the vessels and transect the accessory
Additional Professor of Pediatric Surgery nerve.
sandpagr@hotmail.com

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DOI: 10.1007/978-3-642-20641-2_59, © Springer-Verlag Berlin Heidelberg 2013
C10 Polydactyly 199

Fig. 2  Classification of polydactyly (Wassel’s type)

• Trim the metacarpal or phalanx to make the

shaft smooth (Fig. 5b).
• Close skin without tension.

 echnique for Pre-axial (Radial)

T
Polydactyly for Wassel’s Type 4 and
Also for Type 3, 5, 6 or 7 (When a
Deformity is Present in the Thumb to
Be Preserved)

• Make an incision as shown in Fig. 6a, preserv-

ing skin from the thumb to be excised.
• Dissect to expose up to the metacarpal phalan-
geal joint.
• Elevate flaps (Fig. 6b).
• Split the extensor mechanism, and dissect and
detach the ligaments from the thumb to be dis-
carded.
• Form a ligamentoperiosteal flap on the radial
side that is used to reconstruct the retinacular
band.
• Disarticulate the redundant thumb.
• Restore function of flexor pollicis longus.
• Correct longitudinal alignment of the phalan-
ges by corrective-wedge osteotomy (Fig. 6b,c).
• Close the skin with fine non-absorbable su-
tures, interdigitating the various flaps
. Fig. 3
200 D. Datta and S. Agarwala

Fig. 4a,b

Fig. 5a,b

Fig. 6a–c
C10 Polydactyly 201

Tips

77 In the postoperative period, provide support
with a splint, keeping the wrist in extension with
maintenance of the thumb wave.
77 The functional thumb is usually small and de-
formed, so make best use of tissue from both
thumbs to construct a functionally active, cor-
rectly aligned thumb.
77 When the extra finger arises from a metacar-
pal or phalanx, always trim the bone to avoid a
swelling which may over grow later.
77 Discard a little over half the width from both
thumbs; otherwise during alignment an inevita-
ble gap will make the thumb more bulky.

Common Pitfalls

77 Damage to the neurovascular bundle of the

neighbouring finger can happen.
 202 R. Garg and S. Agarwala
C11 C1 Biopsy of an Extremity Tumour
R. Garg and S. Agarwala

Operative Technique • Make a deep elliptical incision over the tumour,

• Make a longitudinal incision over the edge of
the mass on the extremity (Fig. 1).
• Deepen the incision to reach the surface of the
tumour.
• If the tumour arises from the muscular com-
partment, incise the deep fascia.
• Expose the border of the tumour and the
surrounding normal tissue using retractors
(Fig. 2).
including the surrounding normal tissue using
a sharp no. 11 surgical blade (Fig. 2).
• Preserve the sample in appropriate sample
bottles for histological and biological studies
(check local policy with the duty pathologist).
• Achieve haemostasis by a combination of com-
pression, diathermy or interrupted absorbable
sutures.

Fig. 1 Fig. 2

Rajan Garg ()

Senior Resident in Pediatric Surgery
rajangarg1985@gmail.com

Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_60, © Springer-Verlag Berlin Heidelberg 2013
C11  Biopsy of an Extremity Tumour 203

• Repair the fascia with interrupted absorbable

sutures and close the skin with absorbable sub-
cuticular suture.
• Apply a simple dressing.

Tips

77 Avoid raising fascial flaps, so as not increase the 77 Deep sutures may be placed in the tumour, cov-
width of the excision later on. ering an area wider than the intended biopsy,
77 Take the biopsy from a firm or hard part of the before excising a wedge for biopsy. These su-
tissue. tures can then be approximated to close the bi-
77 Never take the biopsy from a soft or fluctuant opsy ‘bed’ and achieve haemostasis.
part of the tumour, as this reflects underlying ne- 77 Avoid using diathermy while taking a wedge of
crotic material. the tumour tissue, as this may render the speci-
men nondiagnostic.

Common Pitfalls

77 Avoid making a transverse incision for two rea- 77 Biopsying from a soft, necrotic area should not
sons: First, the incision should be parallel to the be done.
neurovascular bundles and second, the entire bi-
opsy scar must be easily included in the incision
during definitive surgery.
 204 P. Sekaran and C. F. Davis
C12 C 12Ingrown Toenail
P. Sekaran and C. F. Davis

This condition is caused by sharp edges of the nail Techniques

growing into the surrounding skin folds. Children
usually present once the surrounding skin has be-
come infected and painful.
Successful nail surgery requires a clear under-
standing of the anatomy and physiology of the
nail (Figs. 1 and 2).
Simple Nail Avulsion
• The procedure can be performed on the anaes-
thetic trolley.
• A local anaesthetic ring block (see Chap. A7)
can be used in a cooperative child; otherwise
general anaesthetic should be used.
• The patient is positioned supine.

Fig. 1

Nail Avulsion Fig. 2

For a first presentation, simple avulsion of the
nail may be curative. Nail avulsion involves ex-
cision of the body of the nail plate from its pri-
mary attachments, the nail bed and the proximal
nail fold (PNF).
Prabhu Sekaran ()
Specialty Trainee in Paediatric Surgery
Prabhu.sekaran@nhs.net
Carl F. Davis
Consultant Paediatric and Neonatal Surgeon
Carl.Davis@ggc.scot.nhs.uk
• An assistant holds the leg, elevating the foot off
the bed, whilst the surgeon prepares the entire
skin of the foot paying close attention to the
web spaces and extending superiorly beyond
the ankle.
• A sterile drape is then placed on the trolley un-
der the foot and a further drape folded into a
triangular configuration, wrapped around the
mid-foot and held in place with a towel clip.
• A torniquet can be used but must be visible
(Ring torniquets should be avoided)
• Curved mosquito forceps are gradually in-
serted under the distal central portion of the
nail and used to bluntly dissect the nail plate
from the underlying bed.
• Once the nail is free proximally and distally, it is
grasped with Mosquito forceps and rolled from

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_61, © Springer-Verlag Berlin Heidelberg 2013
C12  Ingrown Toenail
side to side until the nail can be lifted free from
the lateral nail folds (LNFs).
• Any adjacent granulation tissue is sharply ex-
cised with a blade or scissors.
• The avulsed nail should be carefully inspected
to ensure it is completely removed.
• A Mepitel, blue gauze and crepe bandage dress-
ing is applied after removal of the tourniquet,
ensuring that the skin at the end of the
• Postoperatively, the patient should be advised
to avoid narrow shoes and to cut the nail square
(not back at the lateral corners). Despite this,
recurrence rates are high following simple avul-
sion. If the condition recurs, the nail bed (or
part of it) should be ablated surgically or chem-
ically, with phenol.
Wedge excision of the nail and partial
phenolisation of the nail matrix
• The nail matrix is the germinative epithelium
that forms the nail plate (Fig. 2). A wedge ex-
cision removes the diseased (in-growing) por-
tion of the nail plate and the phenol applied
topically to the matrix denatures proteins re-
sulting in chemical matricectomy. The aim of
surgery is to narrow the nail plate preventing
recurrent ingrowth into the LNFs.
Fig. 3
205
• The patient is positioned and prepared as de-
scribed for nail avulsion and a tourniquet ap-
plied.
• Straight iris scissors are used to undermine the
nail plate laterally on the affected side.
• The undermined portion of nail plate is then
divided longitudinally with straight iris scissors
through the full proximal extent of the plate
(Fig. 3).
• The free portion of nail is avulsed with straight
Mosquito forceps by rolling the nail away from
the LNF.
• Local curettage with a Volkmann spoon or
curved Mosquito forceps (Fig. 4) should be
performed to remove granulation tissue from
the LNF and nail bed.
• Apply a small amount of cotton wool to the
nail bed to keep it dry whilst applying soft yel-
low paraffin around the surrounding soft tis-
sues to protect them from the phenol (Fig. 5).
• A supersaturated solution of 88 % phenol on
preprepared cotton-tip applicators (often need
to be reduced in bulk for small children) is ap-
plied to the nail matrix for 2 min (Fig. 6) be-
fore neutralisation with 70 % isopropyl alcohol
(white spirit).
• Remove the tourniquet.
• Apply dressing as before.
Fig. 4
206 P. Sekaran and C. F. Davis

Zadek’s procedure.

• Recurrent ingrowing toenails despite these

measures may warrant complete surgical ex-
cision of the nail matrix (Zadek’s procedure).
Patients and their parents should be counselled
that this procedure will (if performed correctly)
prevent any future nail plate regrowth.
• The patient is positioned and prepared as be-
fore and an exsanguinating tourniquet applied.
• Perform a complete nail avulsion as described
above and use curettage to excise any granula-
tion tissue.
• Make scalpel incisions extending through the
PNF and LNFs.
• Place two 5/0 Vicryl stay sutures on the PNF
Fig. 5 and reflect dorsally to expose the nail matrix.
• The nail matrix is circum-excised using a no. 11
blade, extending down to periosteum and close
attention is paid to the lateral matrix horn ar-
eas. Straight iris scissors may help complete the
dissection.
• The PNF is sutured back to the nail bed us-
ing interrupted absorbable sutures, that help
to provide haemostasis.
• Remove the tourniquet and apply a dressing as
before.

Fig. 6
C12  Ingrown Toenail
Tips
77 Do not fold the Mepitel dressing, as this prevents
exudative fluid release and makes removal of the
dressing difficult.
77 Following Zadek’s procedure, pain can be signif-
icant. A ring block of l-Bupivacaine established
immediately after surgery provides extended
pain relief for 8–12 hours.
Common Pitfalls
77 Always record the tourniquet time on a board in
theatre. It is your responsibility to ensure it has
been removed at the end of the case.
77 Always ensure that the nail bed is dry and blood-
less before applying phenol. Blood deactivates
phenol.
207
77 Postoperatively the patient should be encour-
aged to elevate the foot and limit activity, to en-
courage healing and reduce pain and swelling.
77 A district nurse should visit the patient at home
to change the dressing after 24 h.
77 Follow-up with a podiatrist may help reduce re-
currence.
77 The nail matrix extends laterally into lateral ma-
trix horns – always ensure these areas are fully
excised or covered with phenol to prevent recur-
rent nail spicule formation.
77 Surgical matricectomy should extend onto the
periosteum of the distal phalanx, but take care
to avoid damaging the insertion of the extensor
tendon on the distal portion of this bone.
 PAR T D
Thorax
D1  Chest Tube Insertion
D 1Chest Tube Insertion
D. Datta and S. Agarwala
Operative Technique
The chest tube should be inserted in accordance
with Advanced Paediatric Life Support/Advanced
Trauma Life Support (ATLS/APLS) guidelines.
• Position the patient supine with the affected
side elevated 30 to 40° off the bed, using a towel
as back support.
• Extend the ipsilateral arm over the head to ex-
pose the axillary area.
• Prepare the patient’s skin from the axilla to il-
iac crest and from the midline of chest anteri-
orly to as far posteriorly as possible (Fig. 1).
• The ‘safe triangle’ for chest drain insertion is
bounded anteromedially by the lateral border
of pectoralis major, inferiorly by a horizontal
line at the level of the nipples, and posteriorly
by the anterior border of latissimus dorsi. This
area is ‘safe’ because it avoids damage to the
chest wall muscles and breast.
• Select a chest tube of proper size, according to
the age and need of the patient. Cut the tube
short keeping only one side hole (Fig. 2). Pre-
pare the underwater seal bag and keep ready
to connect to the chest tube.
• Identify the fifth intercostal space in the mid-
axillary line (Fig. 1).
• Widely infiltrate the site of insertion with a lo-
cal anaesthetic through the skin into the sub-
cutaneous tissue, muscle and parietal pleura.
• Make a transverse skin incision in the mid-ax-
illary line, overlying the rib one space below the
proposed site of chest drain insertion (Fig. 3).
Dibyarup Datta ()
Senior Resident in Pediatric Surgery
dibyarubdatta@gmail.com
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
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DOI: 10.1007/978-3-642-20641-2_62, © Springer-Verlag Berlin Heidelberg 2013
211
D1
• Use a curved haemostat to separate the subcu-
taneous tissue to make an oblique tunnel run-
ning up to reach the site of drain insertion in
the fifth intercostal space. Separate the mus-
cles in the intercostal space down to the pari-
etal pleura (Fig. 3).
• Use the curved haemostat to carefully push
through the parietal pleura. A clear ‘give’ will
be felt as the pleura is breached and fluid or air
will emanate from the tract.
• Gently open the haemostat in one direction and
then again at right angles to dilate the tract.
• Grasp the end of the chest tube obliquely with
the tip of a second haemostat and introduce it
into the tract until the pleural space is entered.
• Direct the chest tube towards the apex of the
thorax (mid-clavicle) and anteriorly, ensuring
that the side hole is within the pleural cavity.
• Clamp the chest drain externally to prevent air
being drawn into the pleural space, and connect
the other end of the chest tube to the tubing of
the underwater seal bag.
• Secure the chest drain with a silk suture us-
ing the techniques described in Chap. A32, and
then apply sterile dressing.
• Apply adhesive tape, making flanges on the
chest drain to secure it to the body.
212 D. Datta and S. Agarwala

Fig. 1

Fig. 2 Fig. 3
D1  Chest Tube Insertion
Tips
77 Ensure the correct side of the chest is marked
prior to the procedure.
77 Careful preoperative clinical and radiological
evaluation (chest x-ray with or without ultra-
sound) is important to confirm the nature of the
collection and the optimal site for drainage.
77 Start counting ribs from sternal angle which is
the site of attachment of second rib.
77 After infiltrating local anaesthesia, aspirate the
pleural space at the proposed site of chest drain
insertion to confirm the diagnosis, the nature
(and viscosity) of the fluid and the correct inser-
tion site.
77 During blunt dissection of the intercostal space
with a curved haemostat, hold your index finger
near the tip of the instrument to guard against
sudden entry into the pleural cavity and injury to
lung parenchyma.
77 Always enter the intercostal space adjacent to
the upper border of the rib below, to avoid injury
to the neurovascular bundle which runs beneath
the lower border of rib.
Common Pitfalls
77 Purse-string sutures at the exit site are not neces-
sary to prevent air entrainment during drain re-
moval and do not result in a satisfactory wound.
Older, cooperative children can perform a Val-
salva manoeuvre during removal to prevent air
entrainment, and in younger children the tube is
removed during expiration before immediately
covering the exit site with an occlusive dressing.
77 Ensure the end of the tube connected to the
chest drain remains underwater at all times to
prevent air being drawn into the chest on inspi-
ration.
77 A patent chest tube correctly sited in the pleural
space will be ‘swinging’. In other words, the fluid
in the tubing will move towards the chest on in-
spiration and away from the chest on expiration.
If this is not observed, consider whether the tube
is blocked or the collection is completely drained
and the lung fully expanded.
213
77 An oblique tunnel reduces the risk of pneumo-
thorax on removing the tube.
77 The site of chest drain insertion should be mod-
ified according to whether there is a loculated
pleural effusion, empyema or pneumothorax. In
general, basal chest drains are better for drain-
ing fluid whilst apical chest drains are better for
draining air.
77 Tailor the chest tube size to the pathology. Gen-
erally, larger-diameter tubes (16–24 Fr) are re-
quired for complicated effusions or haemotho-
rax, and smaller tubes (10–16 Fr) for pneumo-
thorax.
77 Post-procedure, obtain an anterior–posterior
(AP) chest x-ray to check correct positioning of
the drain and to exclude any complications.
77 If multiple chest tubes are to be placed, as may
be the case in loculated pleural effusions, empy-
ema or pneumothorax, each chest tube should
be connected to its own underwater seal system.
77 Occasionally, tube displacement will cause a side
hole to come to lie outside the chest. The chest
drain will cease to drain and any pneumothorax
will reaccumulate as air is drawn into the pleu-
ral space.
77 Ongoing bubbling from the chest tube is indica-
tive of an ongoing air leak. Consider the need for
adding suction to the system to encourage lung
re-expansion and never clamp a bubbling tube.
77 Re-expansion pulmonary oedema occurs when
a massive pleural effusion is drained too quickly.
Clamp the chest tube for 1 h after each 10-ml/kg
aliquot of fluid is drained.
 214 R. Partridge and G. Haddock
D2 D 2Thoracotomy
R. Partridge and G. Haddock

Principle Technique

• The infant chest is quite short longitudinally.
• A posterolateral approach through the fifth
intercostal space allows good exposure of
the lung, oesophagus, mediastinum and dia-
phragm.
Positioning
• Place the patient in a lateral position with arm
up over face, on armrest or padding.
• Place a bolster pad under back at nipple level,
as shown below.
• Incision from anterior axillary fold just inferior
to level of nipple, to below scapula tip poste-
riorly, then curving cranially up to erector spi-
nae
• Steps as show in Figs. 2–4
• Carefully place a Finochietto (rib spreader) re-
tractor under the ribs and open slowly.
• Use a pledget mounted on curved mosquito
forceps to depress the parietal pleura and un-
derlying lung, while safely dividing the remain-
ing intercostal muscles using monopolar dia-
thermy.
• For an extrapleural approach (e.g. for an oe-
sophageal atresia repair), a moistened pledget
mounted on curved mosquito forceps should
be used to sweep the parietal pleura anteriorly
and medially to develop the extrapleural plane.
• If a transpleural approach is used, the pleura is
opened whilst the anaesthetist withholds pos-
itive-pressure ventilation. This manoeuvre al-
lows air to enter the pleural space and the lung
to collapse.

Fig. 1
Closure

See to Fig. 5.
• Three to four pericostal heavy, absorbable su-
tures are placed around the ribs and gently ap-
proximated.
• Avoid tying the pericostal sutures too tightly,
as this promotes rib fusion.
• Repair of intercostal muscles is not essential.
Roland Partridge () • Close the other muscles in anatomical layers
Specialty Trainee in Paediatric Surgery using interrupted absorbable sutures, ensuring
rolandpartridge@nhs.net
the muscle edges are aligned.
Graham Haddock
Consultant Paediatric and Neonatal Surgeon
Ghaddock@udcf.gla.ac.uk

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DOI: 10.1007/978-3-642-20641-2_63, © Springer-Verlag Berlin Heidelberg 2013
D2 Thoracotomy 215

Alternative Incisions

Mini (Muscle-Sparing) Thoracotomy

• Multiple incisions have been described.

• It involves retraction, not division of muscles.
• It requires careful placement of the incision to
optimise exposure.

Axillary Thoracotomy

• The skin incision is made vertically or horizon-

tally.
• The serratus anterior is exposed and elevated.
• The latissimus dorsi is retracted posteriorly.
• A rib space is then entered (third to seventh
rib), depending on the intended surgery.
• This procedure can be used for oesophageal
atresia repair.

Fig. 2  Artery forceps are used to elevate each muscle layer

and divide with diathermy. The serratus anterior can usu-
ally be elevated and retracted anteriorly. Diathermy hae-
mostasis is performed on vessels. Count ribs down from
second rib superiorly, and identify the fifth intercostal
space

Fig. 3  Divide the intercostal muscles at the upper border

of the lower rib. Make a short incision into the chest Fig. 4
216 R. Partridge and G. Haddock

Median Sternotomy

• This procedure is generally used for cardiac sur-

gery.
• Can be used for access to the lungs (not the
lower lobes) trachea and anterior mediastinum.

Fig. 5
D2 Thoracotomy 217

Tips

77 Long-acting local anaesthetic should be instilled 77 In older children, it may be preferable to en-
to the intercostal nerve region prior to closure of ter the pleural space through the periosteal bed
the wound. of the fifth rib. Use monopolar diathermy to di-
77 Mark the tip of the scapula before the arm is el- vide the rib. Inadequate exposure may necessi-
evated. tate partial (posterior) or complete rib excision in
this setting.

Common Pitfalls

77 Beware of the long thoracic nerve, that runs near
the anterior border of serratus anterior. Try to
preserve the serratus anterior wherever possible
to avoid inadvertent division of the nerve and
winging of the scapula.
77 Avoid fracturing the ribs when the retractor
placed by mobilising the ribs both anteriorly and
posteriorly.
77 If placing a drain, site it in the mid-axillary line
two rib spaces below the incision to avoid the
patient lying on tube postoperatively (see Chap.
D1).
77 Stabilise with sandbags and tape.
77 Mark the scapula tip.
77 Prep and drape, leaving nipple, lower scapula,
spine and costal margin visible as landmarks.
 218 A. Sinha and S. Agarwala
D3 D 3Empyema
A. Sinha and S. Agarwala

An empyema is an accumulation of purulent ma- Posterolateral thoracotomy with pleural de-

terial in the pleural space. In children, this usu- bridement with or without decortication is usually
ally occurs as a parapneumonic phenomenon. In reserved for advanced cases in which the visceral
simple, parapneumonic effusions without locula- and parietal pleura have fused (stage III empy-
tions (stage I empyema), the initial management ema), for cases with entrapped lung on CT scan or
is tube thoracostomy and intravenous antibiot- persistent pulmonary dysfunction and in centres
ics (see Chap. D1). Progression of the effusion is without access to minimally invasive techniques.
heralded by the development of fibrinous adhe- The technique of open thoracotomy and de-
sions and loculations (stage II empyema). At this cortication is described.
stage, urokinase instillations via a chest tube may
help lyse the adhesions and drain loculations, but
for most patients, early decortication and debride-
ment usually via thoracoscopy (see Chap. I7) or
mini-thoracotomy are generally considered the
management of choice.

Fig. 1

Anand Sinha ()

Senior Research Fellow in Pediatric Surgery
dranandsinha@hotmail.com

Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_64, © Springer-Verlag Berlin Heidelberg 2013
D3 Empyema
Technique of Open Decortication
• Position the patient for posterolateral thora-
cotomy (see Chap. D2).
• Make a posterolateral thoracotomy incision in
the fifth or sixth intercostal space and proceed
down to parietal pleura as described in Chap.
D2 (Fig. 1 and 2 show incision through the rib
bed).
• Open the parietal pleura with a blade between
curved haemostats and use blunt finger dissec-
tion to develop the pleural space.
Fig. 2
Fig. 3
219
• Use a Finochietto rib retractor to spread adja-
cent ribs.
• Begin to separate the thick parietal pleural peel
from the lateral chest wall superiorly and infe-
riorly, and then posteriorly using finger dissec-
tion or curved ring forceps.
• Separate the peel up to the apex, leaving a small
amount of peel over the subclavian vessels. In-
feriorly separate the peel down to the diaphrag-
matic surface.
• Posteriorly separate the peel down to the me-
diastinum, avoiding injury to the oesophagus.
220 A. Sinha and S. Agarwala

Fig. 4

The thick peel over the mediastinal structures

can be left undisturbed.
• Now, incise the thick peel with a diathermy to
enter the empyema cavity. Collect samples for
culture. Suck or mop out the thick purulent
material.
• Make an incision over the thickened visceral
pleura over the lungs with a knife (Fig. 4) and
gently separate the peel from the pulmonary
parenchyma using small pledgets or Kittner
dissector sponges (Fig. 5). Hold the edge of
the peel with small Mosquitoes and continue
to separate the entire visceral peel using gentle
blunt dissection with a moist pledget or Kittner
Fig. 5 sponge.
• Remove the peel intact or piece meal, achieving
haemostasis simultaneously. Look for the ex-
pansion of the lung during the dissection. Mi-
nor air leaks can be left or covered with a fibrin
sealant, but major ones require closure with a
non-absorbable suture material.
• Place one or two wide-bore chest tubes, one at
the base and another posteriorly running up to-
wards the apex, leave on suction and fix as de-
scribed in Chap. A32.
• Place large absorbable pericostal sutures to re-
approximate adjacent ribs. Close the thoracot-
omy as described in Chap. D2.
D3 Empyema
Fig. 6
Tips
77 Place a large-bore nasogastric tube in the oe-
sophagus to identify it during separation of the
peel posteriorly.
77 In critically ill patients with complicated empy-
ema who may not tolerate thoracoscopy or pro-
longed open debridement, rib excision and tube
drainage is sometimes necessary (Fig. 3).
77 For localized empyema, the intercostal space
used for the incision can be tailored according to
the location.
Common Pitfalls
77 Ensure your incision is long enough to allow ade-
quate working space in a chronically contracted
thorax. Occasionally rib resection may be re-
quired.
77 Separation of the peel in the wrong plane may
lead to multiple deep parenchymal tears.
221
Fig. 7
77 At times the visceral pleural peel may be so
densely adherent to the lungs that it may prove
impossible to separate it without causing signif-
icant air leak. In such cases multiple criss-cross
incisions through the peel may ‘release’ its con-
stricting effect and allow the lung to re-expand
(Fig. 7).
77 Postoperative pain relief is extremely impor-
tant to encourage the patient to breathe well.
Epidural analgesia is a good option for such pa-
tients.
77 Proper postoperative chest physiotherapy and
good care of the intercostals drains is the key to
optimising lung re-expansion postoperatively.
77 Injury to mediastinal structures or the subcla-
vian vein in an attempt to separate the peel over
these structures is possible.
 222 D. Datta and S. Agarwala
D4 D4 Bronchoscopy and Removal
of Foreign Body
D. Datta and S. Agarwala

Preoperative Preparation

It is imperative that you personally check that all

the necessary equipment is ready in theatre and
mutually compatible. The telescopes and bron-
choscopes should be prewarmed to prevent fog-
ging during use. A thorough briefing between the
surgeon, anaesthetist and theatre staff should take
place before the child arrives in theatre. Everyone
must know their role in the procedure and the pro-
posed strategy that will be utilised.
Fig. 1

Anaesthetic Care

• Continuous electrocardiogram (ECG) and ox-

ygen saturation monitoring is necessary
• Volatile agent induction, i.e. maintenance of
spontaneous ventilation throughout should be
done.
• Inspired oxygen is administered at 100 % if sig-
nificant obstruction.
• Airway maintenance with facemask and T-
piece anaesthetic circuit is crucial.
 perative Technique for Removal of
O Suction if required.
Foreign Body by Rigid Bronchoscopy
• Position the patient with a folded towel under
the shoulders, a roll under the neck and a ring
under the head.
Dibyarup Datta ()
Senior Resident in Pedriatic Surgery
dibyarupdatta@gmail.com
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
Fig. 2
• The neck is extended so that the oral cavity, la-
ryngopharynx, larynx and trachea all lie in a
straight line.
• Introduce a laryngoscope and lift up the epi-
glottis to visualize the larynx and vocal cords.
• If the foreign body (FB) is apparent in the lar-
ynx it may be retrieved with McGill’s forceps.
If not, introduce the rigid bronchoscope with
your right hand along the right side of laryn-
goscope and advance gently through the vocal
cords into the trachea.
• Connect the anaesthesia ventilator equipment
to the ventilation adapter of the bronchoscope.
• Connect the optical prism to the light source
and look through the bronchoscope to confirm
the position in the trachea.
• Introduce a rigid or flexible suction catheter
and suck the trachea clean.

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_65, © Springer-Verlag Berlin Heidelberg 2013
D4 Bronchoscopy and Removal of Foreign Body 223

• Introduce the telescope into the broncho- • Occasionally, if the FB is small and not too fria-
scope and advance slowly down the trachea, ble, it can be withdrawn with the optical forceps
constantly keeping the lumen in view to avoid through the lumen of the bronchoscope. Usu-
pushing the FB distally. ally, the FB is too large, and the entire bron-
• Position the distal end of bronchoscope 1–2 choscope and optical FB forceps must be re-
cm away from the FB. trieved as a single unit.
• The surgeon maintains the position of the • Following removal of the FB, introduce the
bronchoscope whilst the scrub nurse removes bronchoscope again and use the telescope to
the telescope and attaches the glass eyepiece. perform a thorough examination of the trachea
• Introduce the appropriate optical FB forceps and bronchi, including the uninvolved side.
into the bronchoscope. • This can be performed with a rigid or fibre-op-
• Once the tip of the optical forceps clears the tic bronchoscope and is vital to exclude resid-
end of the bronchoscope, gently open the ual/additional FBs and to aspirate retained se-
forceps and grasp the FB firmly but without cretions.
crushing it. • Additional or residual FBs should be removed
• Align the FB with the vocal cords. as described above.
• Remove the bronchoscope under vision, in-
specting the vocal cords.

Tips

7 The elective retrieval of aspirated FB should not
be initiated without ensuring a full range of sizes
and variety of instrumentation is available. It is
good to check the grasping forceps outside the
patient before commencing the procedure.
7 Straightening of the right or left mainstem bron-
chus can be facilitated by turning the head to
the contralateral side.
7 Avoid applying excessive force to prevent frag-
mentation of FB. Peanuts are particularly suscep-
tible to this and should be handled carefully.
7 Sharp foreign bodies should, if possible, be re-
moved, sheathed within the lumen of broncho-
scope to avoid mucosal injury or perforation.
7 Exuberant granulation tissue in cases of long-
standing foreign bodies (especially common
with peanuts) can lead to haemorrhage dur-
ing attempted retrieval. The granulation tissue
can be touched with a small adrenaline soaked
pledget to decrease vascularity and control
oozing.
7 A large, obstructing FB in the larynx or upper tra-
chea can be brought back to the laryngeal inlet
using a Fogarty embolectomy catheter enabling
retrieval with McGill’s forceps.

Common Pitfalls

7 Avoid mechanical ventilation as this may force
the FB distally creating a ‘ball-valve’ obstruction.
7 The use of an excessively large bronchoscope,
a prolonged procedure and multiple introduc-
tions lead to oedema of the vocal cords and per-
sistence of postoperative stridor and respiratory
distress.
7 Application of undue force when grasping a
long-standing, organic FB may result in fragmen-
tation into multiple pieces.
7 Failure to do a complete examination of the dis-
tal airways may lead to a retained residual FB.
7 If the view is completely obscured by bleeding
from chronic granulation tissue, it may be safer
to stop the procedure, and try a further attempt
at retrieval after 2–3 days.
 224
D5 D 5Oesophageal Atresia
and Tracheo-oesophageal Fistula
P. Goel and S. Agarwala
Operative Technique
• Position an 8- or 10-Fr stiff oral catheter in the
upper pouch.
• Position the child in the left lateral position with
the right arm mildly extended over the head.
• Make a right posterolateral thoracotomy inci-
sion 1 cm inferior to the tip of the scapula, as
described earlier in chapter D2 (Fig. 1).
Fig. 1
• Divide the outer and the inner intercostal mus-
cles, at the upper border of the fifth rib, with
diathermy and then split the innermost inter-
costals muscle with the knee of a small curved
haemostat remaining extrapleural.
• Gently roll dripping gauze under the upper and
the lower ribs to create an extrapleural space.
Sweep the pleura away from the posterolateral
chest wall until the azygos vein and the medi-
astinal structures are visualized (Fig. 2).
Prabudh Goel ()
Assistant Professor of Pediatric Surgery
drprabughgoel@gmail.com
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_66, © Springer-Verlag Berlin Heidelberg 2013
P. Goel and S. Agarwala
• Retract the pleura and lungs anteriorly to ex-
pose the azygos vein (Fig. 3).
• Divide the azygos vein between two silk liga-
tures (Fig. 4).
• The fine endothoracic fascia of the posterior
mediastinum is divided with electrocautery or
with scissors.
Fig. 2
• Sweep the mediastinal pleura away to identify
the lower oesophagus with the vagus nerve
coursing along it. Loop the lower oesophagus
in a vascular sling and sharply dissect proxi-
mally until its junction with the posterior wall
of the trachea (Fig. 4).
• Place a stay suture with 5-0 Prolene on the tra-
cheal side of the fistula. Partially transect the
lower oesophagus, obliquely and place two 6-0
Prolene sutures at the corners, retaining their
needles to be used for the anastomosis. Com-
plete the transection of the lower oesophagus
and place the third stay on it (Fig. 5).
• Repair the tracheal end of the fistula with in-
terrupted 5-0 Prolene/Vicryl sutures (Fig. 5).
D5  Oesophageal Atresia and Tracheo-oesophageal Fistula 225

Confirm its integrity by asking the anaesthe-

tist to maintain positive pressure while a few
millitres of saline is placed in the chest cavity.
• Ask the anaesthetist to push the orally posi-
tioned stiff catheter into the upper pouch to
identify it in the mediastinum.
• Place a 5-0 silk stay suture, in a ’figure-8’ fash-
ion at the fundus of the upper pouch and re-
tract the pouch caudally and laterally (Fig. 5).
• Sharply divide the fascia between the oesoph-
ageal pouch and the tracheal wall to make a
space between the two.
• Meticulously dissect the upper pouch of oe-
sophagus away from the trachea using sharp
and blunt dissection until adequate length is
achieved for a tension-free anastomosis.
Fig. 3 • Check again for tracheal integrity, as described
earlier to exclude an upper pouch fistula.
• Transect the tip of the upper pouch, and use the
anterior and posterior stay suture of the lower
pouch to begin the anastomosis with the up-
per pouch (Fig. 6).
• Complete the posterior layer of the anastomo-
sis with the lower pouch with interrupted 6-0
Prolene/5-0 Vicryl sutures.
• Ask the anaesthetist to remove the stiff catheter
and place a fine nasogastric tube and guide it
through into the lower pouch and to the stom-
ach (Fig. 7). Ask the anaesthetist to anchor the
Fig. 4 catheter to the nostril with an adhesive tape.

Fig. 5 Fig. 6
226 P. Goel and S. Agarwala

• Complete the anastomosis by placing inter-

rupted 6-0 Prolene sutures on the anterior layer
as well (Fig. 8).
• Irrigate the thoracic cavity with some warm sa-
line, and then close in layers as described ear-
lier. A chest drain may be positioned if desired.

Fig. 7

Fig. 8
D5  Oesophageal Atresia and Tracheo-oesophageal Fistula 227

Tips

77 It is important to separate the pleura adequately 77 The lung retraction should be relieved intermit-
from the ribs above and below to prevent it from tently to allow expansion of the lung to prevent
tearing when the chest retractor is applied. atelectasis.
77 The fistula should be divided as close to the
trachea as possible to prevent formation of a
pouch.

Common Pitfalls

77 Misidentification of the right bronchus or the 77 Missing a small tracheal rent caused during the
aorta (in case of a right sided aortic arch) as the upper pouch mobilization
lower oesophageal pouch 77 Improper anastomosis in which the mucosa has
77 Attempting to dissect the upper pouch without been missed
dividing the fascia over it

RO B E RT E. GROS S
(1905­­ – 1988)
American paediatric surgeon

Robert E. Gross was the first William E. Ladd Professor at Harvard Medical School. As a young man
he read Cushing’s biography of William Osler and resolved to be a physician. He was a pioneer in the
field of cardiac surgery of childhood, and was the first to safely ligate a patent ductus arteriosus in a
child. He also developed the classification system for oesophageal Atresia, that now bears his name. In
addition to these achievements, he not only co-wrote “the text book of paediatric surgery” with Ladd
but also established the paediatric surgical residency at Children’s Hospital, and was thus responsible
for the training of a generation of paediatric surgeons who later on became leaders in this field.
 228 N. Sugandhi and S. Agarwala
D6 D 6R ight Pneumonectomy
N. Sugandhi and S. Agarwala

Operative Technique right pulmonary artery (inferior division) into

• Position the patient in left lateral position with
a roll under the chest. Enter the chest through
a standard posterolateral thoracotomy through
the fifth space.
• Assess the disease extent and re-evaluate the
decision for pneumonectomy.
• Retract the lung inferiorly and posteriorly;
make a curved incision over the mediastinal
pleura to reveal the right pulmonary artery.
Incise the perivascular sheath to dissect in the
perivascular plane.
• Continue the dissection distally to expose the
superior division of the right pulmonary artery
to the upper lobe and the continuation of the
the fissure (Fig. 1). Ligate and divide the api-
cal branch of pulmonary vein which may cross
the artery at this point.
• Doubly ligate both these branches and then li-
gate the main right pulmonary artery with a
thick silk suture. Divide the two branches be-
tween the ligatures.
• Divide the two branches between the ligatures
(Fig. 1).
• Retract the lung posteriorly to expose the an-
terior hilar structures. Incise the mediastinal
pleura longitudinally, parallel to the phrenic
nerve; continue to the incision on the superior
surface of the hilum.

Fig. 1

Nidhi Sugandhi ()

Senior Resident in Pediatric Surgery
drnidhisugandhi@gmail.com

Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_67, © Springer-Verlag Berlin Heidelberg 2013
D6  Right Pneumonectomy 229

Fig. 2

• Reflect the pleura laterally to expose the supe- Repair the transected bronchial end with in-
rior pulmonary vein (Fig. 1). Dissect to enter terrupted Prolene sutures applied in a ‘figure-
the perivascular plane. 8’manner.
• Delineate the main trunk and then continue • Alternatively, the bronchus may be secured by
dissection distally to expose the three branches applying and stapling device (Fig. 3).
of the superior pulmonary vein (Fig. 1). • Check for the integrity of the bronchial closure
• Doubly ligate all these three branches and then by dipping the end into a pool of saline and
ligate the trunk of the vein with a thick silk su- asking the anaesthetist to apply positive pres-
ture (Fig. 1). sure.
• Divide the three branches between the ligatures. • Ensure haemostasis, place an appropriately
• Retract the lower lobe of the lung anteriorly sized intercostal drain and close the chest in
and superiorly to identify the inferior pulmo- layers.
nary ligament.
• Divide the inferior pulmonary ligament from
the diaphragm to the lower margin of the in-
ferior pulmonary vein. Many small vessels in
this ligament will need to be cauterized.
• Dissect the inferior pulmonary vein as de-
scribed for superior pulmonary vein. This also
usually has three branches which can be dealt
with as for the superior pulmonary vein (Fig 2).
• Retract the lung anteriorly and elevate it from
the mediastinum to identify the right main
bronchus in the superior portion of the pul-
monary hilum (Fig. 3).
• Secure the two bronchial arteries on it surface
and enter the peribronchial plane.
• Apply a bronchial clamp on the bronchus, tran-
sect it with a knife and remove the specimen. Fig. 3
230
Tips
77 In cases of severe bronchiectasis with the lung
and the thoracic cage severely collapsed, it is
worthwhile opening the chest through the peri-
osteal bed of the resected fifth rib.
77 Pulmonary artery and veins have a very poorly
developed media and hence need careful han-
dling and ligation.
77 The vascular ligatures can be done in many dif-
ferent ways and can also be done with vascu-
lar staplers. During ligation of the veins and the
arteries, all the branches and the main trunk
should be ligated separately and then the
branches should be divided to prevent slipping
of the ligature.
Common Pitfalls
77 Injury to the stump of the superior pulmonary
artery while dissecting the main bronchus as the
artery is just on the anteromedially surface of the
bronchus can occur.
N. Sugandhi and S. Agarwala
77 The trunk of the inferior pulmonary vein is just
anterior to the oesophagus which can be easily
identified by a thick orogastric catheter placed in
the oesophagus by the anaesthetist.
77 The site of bronchial transaction should be as
high as possible to avoid leaving too-long a
bronchial stump which is prone to collection and
repeated infections.
77 The procedure is same for left pneumonectomy.
77 Leaving too-long a bronchial stump will lead to
recurrent infections and may cause stump blow
out and a bronchopleural fistula.
D7  Right Upper Lobectomy
D7 R ight Upper Lobectomy
N. Sugandhi and S. Agarwala
Operative Technique
• Position the patient as described for postero-
lateral thoracotomy.
• Make a posterolateral incision and enter the
chest through the fifth interspace.
• Retract the lung inferiorly to expose the supe-
rior surface of the hilum.
• Incise the pleura on the superior surface of the
hilum, just below the azygos vein, exposing the
right main bronchus (Fig. 1).
• Identify the superior division of the right pul-
monary artery, just anterior to the main bron-
chus.
• Sharply incise the perivascular sheath on the
artery and enter the perivascular plane.
• Dissect distally on the adventia of the artery
to identify the apical and anterior divisions of
the superior division of the pulmonary artery
Fig. 1
Nidhi Sugandhi ()
Senior Resident in Pediatric Surgery
drnidhisugandhi@gmail.com
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_68, © Springer-Verlag Berlin Heidelberg 2013
231
D7
(Fig. 1). Ligate and divide the apical branch of
pulmonary vein which may cross the artery at
this point.
• Doubly ligate both these branches and then li-
gate the superior division of the right pulmo-
nary artery. Divide the two branches between
two ligatures.
• Retract the lung posteriorly to expose the an-
terior hilar structures. Incise the mediastinal
pleura longitudinally, parallel to the phrenic
nerve, and continue to the incision on the su-
perior surface of the hilum (Fig. 1).
• Reflect the pleura laterally to expose the supe-
rior pulmonary vein. Dissect to enter the peri-
vascular plane.
• Delineate the main trunk and then continue
dissection distally to expose the three branches
of the superior pulmonary vein (Fig. 1).
232
• Apply three ligatures to the superior two
branches and divide between the distal two lig-
atures keeping the proximal vein with double
ligatures. The middle lobe tributary (lingular
lobe on the left side) is the inferior most tribu-
tary and this needs to be preserved if the mid-
dle lobe is being preserved (Fig. 1).
• Identify the interlobar fissure by retracting the
lower lobe inferiorly and upper lobe superiorly.
• Begin dissection at the point of convergence of
the horizontal and the oblique fissures.
• Identify the inferior division of the right pul-
monary artery at this point and enter its peri-
vascular plane.
Fig. 2
Fig. 3
N. Sugandhi and S. Agarwala
• Dissect proximally on the artery to identify its
first branch, that is given off posteriorly to the
superior segment of the lower lobe (Fig. 2).
• Also identify the branch to the middle lobe,
that is given off anteriorly (to the lingual on
the left side), just opposite the branch to the
superior segment (Fig. 2).
• Continue dissection proximally in the fissure to
identify the posterior segmental branch to the
posterior segment of the upper lobe (Fig. 2).
Apply three ligatures to this branch and divide
between the distal two ligatures.
• In case the fissure is incomplete, the lung is re-
tracted anteriorly and the pleural incision com-
pleted to complete the division of the fissure.
• Retract the lung anteriorly and elevate it from
the mediastinum to identify the right main
bronchus in the superior portion of the pul-
monary hilum.
• Continue this dissection to identify the right
upper lobe bronchus (Fig. 3).
• Apply a bronchial clamp on the upper lobe
bronchus, transect it with a knife and remove
the specimen.
• Repair the transected bronchial end with in-
terrupted Prolene sutures applied in a figure
of eight manner.
• Alternatively, the bronchus may be secured by
applying and stapling device.
• Check for the integrity of the bronchial closure
by dipping the end into a pool of saline and
asking the anaesthetist to apply positive pres-
sure.
• Ensure expansion and collapse of the remain-
ing pulmonary lobes, especially the middle
lobe.
• Ensure haemostasis and place an appropriate
size intercostal drain and close the chest in lay-
ers.
D7  Right Upper Lobectomy
Tips
77 Often the apical vein overlies the apical branch
of the artery and may need to be divided before
the artery itself can be reached.
77 The posterior wall of the superior pulmonary
vein is in intimate relation to the inferior divi-
sion of the pulmonary artery and damage to this
should be avoided when dissecting the superior
pulmonary vein.
Common Pitfalls
77 Compromise to the main bronchus will lead to
postoperative collapse. Manual lung inflation
should be used to be certain that the main bron-
chus is not compromised before dividing the up-
per lobe bronchus.
233
77 Posterior segmental artery to the posterior seg-
ment of the upper lobe requires separate liga-
tion as it arises separately from the inferior pul-
monary artery. There may be more than three
arteries supplying the upper lobe.
77 The inferior division of the pulmonary artery is
aligned in the direction of the horizontal fissure
and not at right angles to it.
77 During ligation of the superior pulmonary vein
the tributary from the middle lobe must be iden-
tified and preserved.
77 Leaving too-long a bronchial stump will lead to
recurrent infections and may cause stump blow
out and a bronchopleural fistula.
 234 N. Sugandhi and S. Agarwala
D8 D8 R ight Lower Lobectomy
N. Sugandhi and S. Agarwala

Operative Technique

• Position the patient as described for a postero-

lateral thoracotomy.
• Make a posterolateral incision and enter the
chest through the fifth or sixth interspace.
• Identify the interlobar fissure by retracting the
lower lobe inferiorly and upper lobe superiorly.
• Begin dissection at the point of convergence of
the horizontal and the oblique fissures.
• Identify the inferior division of the right pul-
monary artery at this point and enter its peri-
vascular plane.
• Dissect proximally on the artery to identify its
first branch, that is given off posteriorly to the
superior segment of the lower lobe (Fig. 1).
• Apply three ligatures to this branch and divide
between the distal two ligatures (Fig. 1).
• Also identify the branch to the middle lobe,
that is given off anteriorly (to the lingual lobe
on the left side), just opposite the branch to
the superior segment. This branch needs to be
preserved (Fig. 1). Further proximally is the
branch to the posterior segment of the upper
lobe (Fig. 1).
• Continue dissection distally on the inferior di-
vision of the pulmonary artery to delineate the
all the basilar divisions (Fig. 1).
• Doubly ligate all the basilar branches and then
ligate the inferior division of the pulmonary ar-
tery just proximal to the basilar branches. Di-
vide the basilar branches between the ligatures.
Nidhi Sugandhi ()
Senior Resident in Pediatric Surgery
drnidhisugandhi@gmail.com
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
Fig. 1
• Retract the lower lobe of the lung anteriorly
and superiorly to identify the inferior pulmo-
nary ligament.
• Divide the inferior pulmonary ligament from
the diaphragm to the lower margin of the in-
ferior pulmonary vein. Many small vessels in
this ligament will need to be cauterized.
• Dissect the inferior pulmonary vein in the peri-
vascular plane. Delineate the main trunk and
then continue dissection distally to expose the
two or three branches of the inferior pulmo-
nary vein (Fig. 2).
• Doubly ligate all these three branches and then
ligate the trunk of the vein with a thick silk su-
ture. Divide the three branches between the lig-
atures.
• In a case where the fissure is incomplete, the
lung is retracted anteriorly and the pleural in-
cision completed to complete the division of
the fissure.
• Retract the lung anteriorly and elevate it from
the mediastinum to identify the right main
bronchus and its divisions.

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2–69, © Springer-Verlag Berlin Heidelberg 2013
D8  Right Lower Lobectomy 235

Fig. 2

• Identify the bronchial division to the middle

lobe and just opposite of it, the division to the
superior segment of the lower lobe.
• Divide this division to the superior segment of
the lower lobe and repair the stump with inter-
rupted Prolene sutures.
• Identify the basilar bronchus, apply a bronchial
clamp on this, transect it with a knife and re-
move the specimen.
• Repair the transected bronchial end with inter-
rupted Prolene sutures applied in a ‘figure-8’
manner.
• Alternatively, the basilar bronchus may be se-
cured by applying and stapling device.
• Check for the integrity of the bronchial closure
by dipping the end into a pool of saline and
asking the anaesthetist to apply positive pres-
sure.
• Ensure expansion and collapse of the remain-
ing pulmonary lobes, especially the middle
lobe.
• Ensure haemostasis, place an appropriately
sized intercostal drain and close the chest in
layers.
236
Tips
77 The arterial division and the bronchial division to
the superior segment of the lower lobe should
be dealt with separately or else it would lead to
a compromise to the middle lobe arterial supply
and aeration.
77 The posterior wall of the superior pulmonary
vein is in intimate relation to the inferior divi-
sion of the pulmonary artery and damage to this
should be avoided when dissecting the inferior
division of the pulmonary artery in the fissure.
Common Pitfalls
77 Compromise to the middle lobe bronchus will
lead to postoperative collapse. Manual lung in-
flation should be used to be certain that the
main bronchus is not compromised before divid-
ing the bronchus to the superior segment of the
lower lobe.
N. Sugandhi and S. Agarwala
77 The inferior division of the pulmonary artery is
aligned in the direction of the horizontal fissure
and not at right angles to it.
77 The horizontal fissure between the upper and
lower lobes may be complete and this leaves
middle lobe free to undergo torsion on its pedi-
cle. The middle lobe in such a situation should be
secured to the upper lobe either with sutures or
with a stapling device.
77 The middle lobe may become free and prone to
volvulus and hence may need to be fixed with
sutures or staplers to the upper lobe.
77 Leaving too-long a bronchial stump will lead to
recurrent infections and may cause stump blow
out and a bronchopleural fistula.
D9  Wedge Resection 237
D 9Wedge Resection D9
N. Sugandhi and S. Agarwala

Operative Procedure

• Position the patient for a posterolateral, antero-

lateral or anterior thoracotomy as desired.
• After entering the thoracic cavity, identify the
lesion to be resected.
• Remove a wedge of the pulmonary paren-
chyma containing the lesion using a stapling
device (Fig. 1) or by using a non-crushing in-
testinal clamp and continuous sutures (Fig. 2).
• Ensure expansion and collapse of the remain-
ing pulmonary lobes, especially the middle
lobe. Fig. 1
• Ensure haemostasis, place an appropriately
sized intercostal drain and close the chest in
layers.

Fig. 2

Nidhi Sugandhi ()

Senior Resident in Pediatric Surgery
drnidhisugandhi@gmail.com

Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com Fig. 3

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2–70, © Springer-Verlag Berlin Heidelberg 2013
238 N. Sugandhi and S. Agarwala

Fig. 6

Fig. 4

Fig. 7

Fig. 5

Tips

77 For lesions that are peripheral but not near the
fissures, grasp the lesion with a Duval’s lung for-
ceps (Fig. 3) and deflate the lung. Draw out the
lesion and then apply a stapling devise as shown
(Fig. 4).
77 For very small peripherally located lesions: The
lesion may be grasped with Duval’s forceps and
a stapling device (Figs. 5 and 6) or transfixation
suture placed at the base and the lesion excised
(Fig. 7).

Common Pitfalls

77 Too many wedge resections on a lobe may leave

very little functioning pulmonary parenchyma.
In such cases a lobectomy is preferred.
D10  Cannulation for Extracorporeal Life Support 239
D10 Cannulation for Extracorporeal D10
Life Support
G. M. Walker and C. F. Davis

 rinciples of Extracorporeal Life

P rotid artery (RCCA) injury, reduction in risk of
Support
A modified cardiopulmonary bypass circuit is
used to drain blood from the venous side of the
circulation, whilst simultaneously returning it to
the circulation following oxygenation and extrac-
tion of carbon dioxide. In neonates, children and
adults with reversible respiratory (or circulatory)
failure despite optimal conventional management,
extracorporeal life support (ECLS) can provide
temporary support to allow recovery, avoiding the
damaging effects of high-pressure ventilation and
other therapies. ECLS and extracorporeal mem-
brane oxygenation (ECMO) are often used syn-
onymously.
Types of ECLS
In veno-arterial ECLS (VA ECLS) in children,
blood is usually drained from the right atrium
and oxygenated blood returned to the aorta. As
oxygenated blood is returned to the arterial circu-
lation, this method provides both respiratory and
cardiovascular support.
In veno-venous ECLS (VV ECLS), oxygenated
blood is returned, either to the right atrium us-
ing a double lumen cannula or through a separate
cannula placed via a femoral vein. As oxygenated
blood is returned to the venous circulation, only
respiratory support is provided and adequate na-
tive cardiac function is required. Advantages over
VA ECLS include avoidance of right common ca-
Gregor M. Walker ()
Consultant Paediatric and Neonatal Surgeon
Gregor.Walker@ggc.scot.nhs.uk
arterial embolic complication and improvement
in pulmonary hypertension through oxygenated
blood in the pulmonary circulation.
Cannulation Technique
Although direct cannulation of the right atrium
(through the RA appendage) and aorta is possi-
ble through a trans-thoracic route, this chapter
only describes cannulation using neck (or fem-
oral) vessels.
Preparation
Careful coordination between surgeons perform-
ing the procedure and teams looking after the pa-
tient and ECLS circuit is essential. Each individ-
ual must understand their roles and responsibili-
ties. The patient should be paralysed and sedated.
Blood, blood products and resuscitation drugs
should be readily available.
Position
Supine position with shoulder roll to hyperextend
the neck and head turned to left is necessary. Slight
head down is helpful when using percutaneous
technique.
Incision
The incision should be a right cervical transverse
or oblique one centred over the sternomastoid for
cannulation.

Carl F. Davis
Consultant Paediatric and Neonatal Surgeon
Carl.Davis@ggc.scot.nhs.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_71, © Springer-Verlag Berlin Heidelberg 2013
240
Procedure for VA Cannulation
• Split the sternomastoid with blunt dissection,
exposing the carotid sheath.
• Open the carotid sheath and identify the
RCCA.
• Administer IV heparin (50 IU/kg).
• Control the RCCA with 2/0 silk ligatures (Fig.
1) and at least 90 s following heparin injection,
tie the cranially placed ligature and clamp the
RCCA caudally.
RCCA
RIJV
Fig. 1  Right common carotid artery (RCCA) slung with
silk. RIJV right internal jugular vein
• Perform an arteriotomy with a size no. 11 blade
and dilate the opening (e.g. Garrett’s dilators).
• Advance the lubricated, clamped, arterial can-
nula through the arteriotomy after release of
the caudal occlusion clamp (Fig. 2). Aim to po-
Fig. 2 Arterial cannula advanced through arteriotomy
(artery ligated cranially)
G. M. Walker and C. F. Davis
sition the tip of arterial cannula one third of
distance between sternal notch and xyphoid.
• Release clamp until cannula fills with blood
and tie down silk ligatures to secure within the
artery (Fig. 3).
Fig. 3  Arterial cannula secured over silicone. RIJV is now
controlled with silk ties
• Control the right internal jugular vein (RIJV)
in identical fashion and advance a lubricated,
clamped venous cannula though the venotomy,
aiming to position the tip half way between
sternal notch and xyphoid (Fig. 4). Manual
pressure on the liver is often required before
release of the clamp to fill the cannula with
blood and prevent entrainment of air.
Fig. 4  Venous cannula advanced through venotomy
D10  Cannulation for Extracorporeal Life Support
• Secure the cannulae and connect to ECLS cir-
cuit, ensuring a bubbleless technique by irriga-
tion with saline (Fig. 5).
Fig. 5  Both cannulae secured (note clamps in place before
connecting to circuit)
 rocedure for Percutaneous VV
P • Secure cannula(e) and connect to ECLS cir-
Cannulation
In most cases, VV cannulation can be performed
percutaneously using the Seldinger technique.
• Position as above. RIJV can be identified using
anatomical or ultrasound techniques.
• Access the RIJV using a 21-G needle and ad-
vance a 0.018-in (0.045 cm) guide wire into
the vein. Ensure correct placement by echo-
cardiography or radiological identification of
guide wire in RA.
• Advance to larger (0.035 in [0.089 cm]) guide
wire and administer IV heparin (50 IU/kg).
• Advance serial dilators over the guide wire fol-
lowed by an appropriately sized cannula.
• Confirm cannula position with echocardiogra-
phy or image intensifier.
• If two-vessel VV ECLS is required, access the
femoral vein in the same fashion and dilate to
allow cannula insertion – aim to position can-
nula tip in the upper hepatic IVC.
• Secure cannula(e) and connect to ECLS cir-
cuit, ensuring a bubbleless technique by irri-
gation of saline.
241
Procedure for Open VV Cannulation
• Split sternomastoid with blunt dissection, ex-
posing the carotid sheath.
• Open the carotid sheath and identify the RIJV.
• Administer IV heparin (50 IU/kg).
• Control the RIJV with two 2/0 silk ties, and at
least 90 s following the heparin injection, tie the
cranially placed ligature and clamp the RIJV
caudally.
• Perform a venotomy with a size no. 11 blade.
• Advance a lubricated, clamped, venous can-
nula though the venotomy aiming to position
the tip half way between the sternal notch and
xyphoid – put pressure on liver as before to fill
the cannula.
• Repeat for femoral vein if two cannulae tech-
nique required.
cuit, ensuring a bubbleless technique by irri-
gation of saline.
Decannulation from ECLS
• Preparation and positioning techniques are as
for insertion.
• If the vein was percutaneously accessed, the
cannula should be removed during inspiratory
hold, followed by direct pressure over the ve-
notomy. Formal closure is rarely required.
• If an open insertion was used, the vessels
should be isolated and controlled before can-
nula removal. If the ECLS run was short, con-
sider arteriotomy repair.
Complications of ECLS
Complications can be mechanical or patient in or-
igin. Appropriate training and meticulous atten-
tion to detail is required to minimise circuit prob-
lems during ECLS. Simulation training is an im-
portant adjunct to increase experience. Most pa-
tient-related complications are due to increased
bleeding risk from heparinisation.
242 G. M. Walker and C. F. Davis

Tips

77 When securing cannulae into vessels, place a
piece of silicone “sloop” under the silk ligature
before tying knots. This is useful during decan-
nulation (a “Bootie”).
77 Recently introduced double-lumen bicaval can-
nulae should avoid the need for two-vessel VV
ECLS in most children and adults, although the
tip of the cannula needs to be advanced into an
intrahepatic IVC position.
77 A semi-Seldinger technique may be used where
the vein is identified to aid percutaneous punc-
ture.

Common Pitfalls

77 Echocardiography and/or radiology to confirm 77 Remember that the femoral veins angle pos-
accurate cannula position is essential, especially teriorly as they pass into the pelvis – it is not a
for VV ECLS. “straight run” in a supine patient.
 PAR T E
Abdomen
E1  Upper Gastrointestinal Endoscopy
E 1Upper Gastrointestinal Endoscopy
M. Steven and P. McGrogan
Pre-endoscopy Checklist
• Check equipment (see Fig. 1).
• Consider appropriate size of endoscope for in-
dividual patient.
• Check suction, air supply and light source are
all working.
• Ensure biopsy forceps and Campylobacter-like
organism (CLO) test available if needed.
• Ensure the abdomen is fully exposed to iden-
tify and avoid over-insufflation of the stomach
during the procedure.
• Ensure good ergonomics in terms of patient
and screen positioning (see Fig. 2).
Fig. 1  Correct technique for holding the endoscope
Mairi Steven ()
Specialty Trainee in Paediatric Surgery
mairisteven@doctors.org.uk
Paraic McGrogan
Consultant Paediatric Gastroenterologist
Paraic.McGrogan@ggc.scot.nhs.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_72, © Springer-Verlag Berlin Heidelberg 2013
245
E1
• Check with the anaesthetist for a history of
loose teeth and consider using a mouthguard.
• How to hold the endoscope:
– The correct technique for holding the endo-
scope is demonstrated in Fig. 1.
– During the procedure, use your left hand to
hold the control head, with the thumb rest-
ing on the up/down wheel and your forefin-
ger on the air/water buttons.
– The right hand should hold the endoscope
near the tip during insertion into the mouth
and should provide movement through
push, pull and also torque, that is provided
with clockwise or anticlockwise rotation of
the right hand.
– The small cogwheel is rarely used.
Procedure Technique
• Consider radiological assessment with an up-
per gastrointestinal (GI) contrast study prior
to endoscopy if there are obstructive or gas-
tric outlet symptoms.
• Most endoscopies are performed with the child
supine or in the left lateral decubitus position
and under general anaesthetic.
• Apply a little lubricating jelly to the end of the
endoscope avoiding the camera lens.
• Inform the anaesthetist prior to inserting the
endoscope. They may wish to assist by provid-
ing a jaw thrust.
• Insert the endoscope under direct vision into
the oesophagus.
• Insufflate air once a good position is confirmed
on the screen.
• Proceed down the oesophagus, keeping the lu-
men in the centre of the screen at all times.
• Do not advance if you cannot see. If in doubt,
inflate and pull back until you have a full visual
field.
246 M. Steven and P. McGrogan

Fig. 2  Good ergonomics

• Note the appearance of the oesophagus and

the level of oesphageal-gastric (OG) junction.
• Enter the stomach.
• Proceed down the greater curvature of the
stomach with the tip up and slight clockwise
torque with right hand to find the pylorus
(see Fig. 3).
• Enter the pylorus and perform a 360° inspec-
Fig. 3  Normal endoscopic appearance of the pylorus tion of the first part of the duodenum.
• The second part of the duodenum is entered
by advancing towards the superior duodenal
angle and simultaneously bringing the tip up
acutely with the left thumb and rotating the
shaft of the endoscope (by rotating the right
hand) 90° to the right. The tip will paradoxi-
cally advance into the jejunum by slowly with-
drawing the shaft.
• Withdraw from the pylorus and fully retroflex
the endoscope by turning the big wheel back
180° clockwise, rotating the shaft and pulling
Fig. 4  Fully retroflexed providing a retrograde view of the the scope back to inspect the fundus and hia-
fundus and hiatus tus (see Fig. 4).
• Consider biopsies and photographs at all stages
of withdrawal.
E1  Upper Gastrointestinal Endoscopy 247

• Before withdrawal, inform the anaesthetist to

ensure they fix the tracheal tube to avoid dis-
placement.
• Withdraw slowly at all stages.
• The stomach should be deflated fully prior to
withdrawing the endoscope. Confirm by ob-
serving the rugae collapse in and by checking
the patient’s abdomen.
• The endoscope should be appropriately flushed
at the end of the procedure.

Tips

77 When first starting to perform endoscopy prac-
tice different steps before trying to do every-
thing at once, e.g. practice intubation, or keeping
the picture central while an assistant advances
the endoscope.
77 Always perform the pre-endoscopy checklist.
77 In the UK, the Joint Advisory Group on GI Endos-
copy (JAG) sets standards for individual endos-
copists and training, and provides quality assur-
ance for training at individual centres. In addi-
tion, they provide trainees with certification of
endoscopy training. We would recommend ac-
cessing their website for further information at:
http://www.thejag.org.uk.

Common Pitfalls

77 Avoid over-insufflation of air. 77 Avoid removing the endoscope without inform-

77 Avoid oesophageal intubation before the patient ing the anaesthetist, as this may dislodge the tra-
is adequately anaesthetized as this can elicit a cheal tube.
significant vagal response. 77 Be patient when trying to enter the pylorus –
wait for it to open before advancing.
 248 P. McGrogan
E2 E 2Endoscopic Management
of Upper Gastrointestinal Bleeding
P. McGrogan

Pre-endoscopy Check List Injection

• Follow the pre-endoscopy checklist as de- • A 23- to 25-G retractable injection needle is
scribed in Chap. E1. used.
• Ensure that all staff are appropriately trained • Pass the needle down the biopsy port.
and familiar with adjunct therapies. • Inject 0.5-ml aliquots of 1:10,000 adrenaline,
• Use an endoscope with a minimum diameter 0.1 to 0.3mm away from the bleeding site.
of 9.0 mm. • Repeat this in a quadrant fashion around the
• Prepare adjunct therapies: lesion (Figs. 1 and 2).
– Adrenaline diluted to a concentration of
1:10,000 in a 10-ml syringe
– Thermal probe connected and available
– Endoscopic clipping equipment available
– Multiple Bander equipment ready

 on-variceal Bleeding Procedure

N
Technique

• Follow standard endoscopy procedure to iden-

tify the bleeding point.
• Endotherapy should be attempted for active
bleeding lesions, non-bleeding with a visible
vessel lesions and where possible, ulcers with Fig. 1  Retractile 25-gauge needle primed with adrenaline
adherent clots.
• Combination therapy is recommended with
adrenaline injection and either a thermal probe
or mechanical clipping.

Paraic McGrogan ()

Consultant Paediatric Gastroenterologist Fig. 2  Injection sites around bleeding ulcer/vessel
Paraic.McGrogan@ggc.scot.nhs.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_73, © Springer-Verlag Berlin Heidelberg 2013
E2  Endoscopic Management of Upper Gastrointestinal Bleeding
Fig. 3  Endoclip
Thermal Probe
• Use a 10-Fr probe
• The bipolar probe should be applied for 3 to
5 s at 30 W.
• Two types of probe: multipolar uses electrical
current at 15 – 25 watts with a sustained pe-
riod of application (10 – 14 x 2 second pulses)
or a heat probe set to 250 degrees Celsius to de-
liver 3 – 4 x 15 – 30 joule pulses of energy for 8
seconds with extensive irrigation afterwards to
prevent tissue shearing and immediate rebleed-
ing on probe retrieval.
Tips
77 Endoscopic assessment should be carried out
within 24 h of the bleed but only after the pa-
tient has been appropriately resuscitated.
77 All patients with a GI bleed should have an antral
biopsy and CLO test to assess for Helicobacter py-
lori. Eradication therapy should be carried out if
possible.
77 Postoperative supportive medical management
Common Pitfalls
77 Unfamiliarity with equipment
77 Inappropriately trained staff
249
Clipping
• Pass the clipping device down the biopsy port
(Fig. 3).
• Remove the red stopper.
• Pull the yellow cylinder towards the handle to
open the clip.
• To open the clip, slowly pull the slider a short
distance towards the thumb ring, watch action
on the monitor.
• Position towards the target under endoscopic
guidance.
• Press the clip firmly against the target area.
• Release the clip by pulling the slider up to the
thumb ring.
Variceal Bleeding
• Oesophageal banding is preferable to sclero-
therapy.
• Consider treatment for varices that are bleed-
ing, have cherry red spots or associated telan-
giectasia.
• After assessment of the oesophageal varices,
the endoscope is withdrawn and the multiband
ligator is applied.
• Oesophageal variceal therapy is applied to the
distal oesophagus above the gastro-oesopha-
geal junction where bleeding is most likely to
have occurred.
with a proton pump inhibitor intravenously for
72 h is recommended.
77 If active ongoing bleeding, consider using the
endoscope tip around the bleeding point for a
tamponade effect.
77 If you experience difficulty obtaining an ade-
quate view or with the technical aspects of the
procedure, consider rescoping within 24 h.
77 Injection needle not primed with adrenaline so-
lution
250
Application of the Multiband Ligator
• The ligator handle is inserted into the endos-
copy biopsy channel with the handle pulled out
into the two-way position (see Fig. 4 here).
• The valve of the ligator is punctured with a nee-
dle and the loading wire is passed through the
biopsy channel until visible at the end of the
endoscope.
• The proximal end of the cord of the bander
is hooked into the loading wire and gradually
pulled back through the scope (Fig. 5).
• As the cord becomes taut, the bander is pushed
onto the tip of the endoscope.
• Ensure the cord is not nipped.
• The proximal end of the cord is unhooked from
the loading wire and secured into the hole of
the slot of the ligator and the handle (in the
two-way position) and is rotated clockwise to
tighten the wire to obtain minimal tension.
• The ligator handle is changed from the two-
way position into the firing position.
Fig. 4  Saeed® multiband ligator
P. McGrogan
• The scope is re-introduced into the patient.
• The scope is moved directly onto the distal oe-
sophageal varix.
• Constant suction is applied using the endos-
copy suction port.
• The varix is sucked into the sleeve of the
bander, causing a ‘red-out of vision on the
monitor screen.
• The ligator handle is turned clockwise (approx-
imately 180°) until the band release is felt.
• Suction is released and air blown down the
endoscopy channel. The varix with the band
should fall away from the scope (see Figs. 6
and 7)
• Ligation can be repeated to adjacent varices or
if necessary more proximal to the applied band
(Fig. 7).
Fig. 5  Bander and traction cord being applied to the end
of the scope
Fig. 6  Banded oesphageal varices
E2  Endoscopic Management of Upper Gastrointestinal Bleeding 251

Sclerotherapy

• Sclerotherapy may be required in very small

children (<10 kg) where the oesophageal
bander and scope are unable to be successfully
intubated into the oesophagus.
• The sclerosant is injected into the varix either
directly or in the paravariceal area.
• Ensure that the retractable needle has been
completely primed with the sclerosant prior
to the patient being re-endoscoped.
• The sclerosant (ethanolamine oleate, 5 %)
should be injected in 0.5-ml aliquots into the
varix.
• Blanching should be seen as the sclerosant is
introduced.
• Finish injecting before the needle is withdrawn. Fig. 7
• If bleeding ensues after needle withdrawal, pass
the endoscope beyond the varix to provide a
tamponade effect.

Tips

77 Having drawn the varix into the sleeve, ensure
continuous suction with the left hand, using the
right hand to turn the ligator handle clockwise.
77 Multibanders come with four, six or eight shoot-
ers. All bands are black apart from the penulti-
mate band, which is white and allows the endos-
copist to be aware that there is one band left.
77 Having completed the banding or sclerother-
apy, plan a programme of banding to eradicate
the varices.
77 After endoscopic treatment for an acute variceal
haemorrhage, the patient should receive vasoac-
tive treatment such as octreotide for 48 h.
77 Banding can be practised outside the patient to
allow the operator to become familiar with the
process.
77 Sclerotherapy should be considered in children
under the age of 1 year (or 10 kg), in whom intu-
bation of the oesophagus with the bander may
be extremely difficult.
77 If bleeding has occurred following sclerotherapy,
press the tip of the scope against the varix to
provide a tamponade effect.
77 Consider undertaking a chest x-ray postopera-
tively if the patient has respiratory compromise
or chest pain, to look for evidence of oesopha-
geal perforation.

Common Pitfalls

77 Do not use a small-diameter scope, that will be 77 Avoid passing the scope beyond banded varices
too small to allow the bander to be applied to as this may displace the bands.
the tip.
 252
E3 E3 Proctoscopy and Rigid Sigmoidoscopy
M. Steven and P. McGrogan
The main procedure for assessing lower gastroin-
testinal symptoms in children is colonoscopy, and
the clinician should consider the appropriateness
of proctoscopy and rigid sigmoidoscopy as the
sole primary investigation.
Proctoscopy
Proctoscopy is the endoscopic examination of the
anal canal and lower rectum using a proctoscope
(see Figs. 1 and 2).
Rigid Sigmoidoscopy
Rigid sigmoidoscopy is the endoscopic examina-
tion of the rectum to the rectosigmoid junction us-
ing a rigid sigmoidoscope (see Fig. 3). In the ma-
jority of cases, sigmoidoscopy is now performed
using a flexible instrument.
Technique
• Both procedures are performed using direct vi-
sion down the endoscope.
• No bowel preparation is necessary.
• In children, most procedures are performed un-
der general anaesthetic.
• The child can be supine or in the left lateral de-
cubitus position.
• The technique is similar for both except there
are no bellows to insufflate air in proctoscopy,
as this is not necessary.
Mairi Steven ()
Specialty Trainee in Paediatric Surgery
mairisteven@doctors.org.uk
Paraic McGrogan
Consultant Paediatric Gastroenterologist
Paraic.McGrogan@ggc.scot.nhs.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_74, © Springer-Verlag Berlin Heidelberg 2013
M. Steven and P. McGrogan
Fig. 1  The proctoscope
• A thorough inspection of the perineum and
a careful digital rectal examination should al-
ways be performed first to look for diagnostic
stigmata and to ensure that there is no obstruc-
tion to the endoscope being inserted.
• Lubricate the tip of the obturator and endo-
scope and insert gently into the anal canal/
lower rectum.
• Once inserted, remove the obturator and at-
tach the light source.
• Note that the rigid sigmoidoscope has a view-
ing end-seal, comprising a clear window to see
through and an attachment for the light source
and air pump.
• For rigid sigmoidoscopy, use the bellows to
insufflate air and only advance the endoscope
when the lumen of the bowel opens and it is
safe to do so.
• It should be possible to advance to the recto-
sigmoid junction, which lies approximately 15–
17 cm from the anal verge in children.
• Slowly withdraw the scope in a spiral manner,
carefully inspecting all of the mucosa.
• Biopsies can be taken as necessary.
E3  Proctoscopy and Rigid Sigmoidoscopy 253

Fig. 2  The rigid sigmoidoscope

Fig. 4  A sessile polyp

Fig. 3  View at proctoscopy

Tips

77 Perform the pre-endoscopy checklist (see Chap. 77 The rectum lies in the hollow of the sacrum at a
E1). sharp posterior angulation relative to the anal
77 Ensure the lumen is in the centre of your view at canal. Move the external portion of the endo-
all times. scope anteriorly once you enter the rectum to re-
77 Do not advance unless you have a good view. gain a view of the lumen.

Common Pitfalls

77 Never assume that rectal bleeding is secondary 77 Always consider the need for a full colonoscopy
to haemorrhoids. (see Chap. E4).
 254
E4 E4 Colonoscopy
M. Steven and P. McGrogan
Generally colonoscopy is considered a one-per-
son procedure.
It is usually performed with the child supine or
in the left lateral decubitus position under general
anaesthetic. The child may be moved during the
procedure into the supine (or occasionally right
lateral decubitus) position to optimise the visual
field and advancement of the colonoscope.
Perform preprocedural endoscope equipment
and patient check (see Chap. E1).
How to Hold the Colonoscope
• Use your left hand to hold the control the head,
with the thumb resting on the up/down wheel
and forefinger on the air/water buttons.
• The right hand should hold the colonoscope
close to its tip on entering the anus and should
provide movement through push, pull and also
torque (which is done with clockwise or anti-
clockwise rotation of the right hand).
• The small cogwheel is rarely used.
Technique
• Perform a digital rectal examination.
• Apply a little lubricating jelly to the end of the
colonoscope. avoiding the camera lens.
• Insert the colonoscope and keep the lumen
of the bowel in the centre of the picture at all
times. Only advance the scope with direct vi-
sion and with a “1-to-1” movement where push
Mairi Steven ()
Specialty Trainee in Paediatric Surgery
mairisteven@doctors.org.uk
Paraic McGrogan
Consultant Paediatric Gastroenterologist
Paraic.McGrogan@ggc.scot.nhs.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_75, © Springer-Verlag Berlin Heidelberg 2013
M. Steven and P. McGrogan
of the right hand causes an equal observed for-
ward movement at the scope tip.
• When failure of “1-to-1” movement is encoun-
tered, consider de-looping procedures (see
“Tips”).
• Do not push through resistance to movement.
• Movement around bends is achieved by mov-
ing the tip of the scope up/down (left thumb
on large wheel) and clockwise/anticlockwise
torque of the right hand, whilst gently advanc-
ing the scope.
• Stop this series of movements and withdraw
slightly if resistance is encountered.
• The scope should be straightened (to mini-
mise the amount of scope inside the patient)
regularly and in particular after rounding the
splenic flexure and again at the hepatic flexure.
This should be attempted by clockwise torque
with the right hand and a short gentle with-
drawal of the scope shaft.
• The ileocaecal value is approximately 6 cm
distal to the caecum and the scope should be
pulled back from the caecal pole to identify it.
The terminal ileum can be intubated by pass-
ing the scope tip over and proximal to the il-
eocaecal valve, deflating the caecum partially
and pulling back gently with the scope angled
Appendicular orifice
Fig. 2  Colonoscopic view of the caecum with typical tri-
angular or ‘toblerone’ appearance
E4 Colonoscopy 255

downwards. There is a slight red-out before the

terminal ileum is entered.
• Air and water can be used to improve visibil-
ity.
• Biopsies can be taken, using forceps as with-
drawal is undertaken.
• Mucosal inspection and deflation of the bowel
should be undertaken simultaneously.

Fig. 3  Colonoscopic view of the tranverse colon

Tips

77 Perform the pre-endoscopy checklist (see Chap. 77 In the UK, the Joint Advisory Group on GI Endos-
E1). copy (JAG) sets standards for individual endosco-
77 Always hold the colonoscope correctly (see Fig. pists and training and provides quality assurance
1 and text). for training at individual centres. In addition, they
provide trainees with certification of endoscopy
training. We would recommend accessing their
website for further information at http://www.
thejag.org.uk

Fig. 1  The colonoscope

Common Pitfalls

77 Over-insufflation of air 77 Failure to accept the need to abandon the proce-

77 Looping of the colonoscope dure if you are unable to complete it safely- thus
77 Incorrectly identifying the caecum increasing the risk of bleeding or perforation
77 Inadequate bowel preparation
 256 P. Sekaran and G. M. Walker
E5 E 5Open Pyloromyotomy
P. Sekaran and G. M. Walker

Incisions

There are two types of incisions for an open py-

loromyotomy:
1. Supra-umbilical
2. Transverse right upper quadrant

Exposure

• The patient is positioned supine.

• A roll is placed under the mid-thoracic region
to facilitate delivery of the pylorus into the
wound.
• The stomach is emptied with a nasogastric tube

Supra-umbilical Approach

• Make a curvilinear incision around two thirds

of the umbilical circumference in the umbili-
cal fold (Fig. 1).
• Use curved mosquito forceps to spread the sub-
cutaneous fat and expose the linea alba.
• Open posterior rectus fascia and peritoneum
longitudinally along the linea alba using a
blade between the mosquito forceps (dotted
line, Fig. 1).
• Alternatively, divide the rectus abdominis mus-
cle with monopolar diathermy to expose the
posterior fascial layer, that can then be opened
transversely with a blade between curved mos-
quito forceps (dotted line, Fig. 1).
• Identify and ligate the umbilical vein (if neces-
sary).
Fig. 1
Transverse Right Upper Quadrant Approach
• Make a 2- 3-cm incision, 1 cm (or a finger’s
breadth) below the costal margin, starting at
the lateral border of rectus abdominis (Fig. 1).
• Deepen the incision, divide external and inter-
nal oblique, and transversus abdominis in the
line of the wound using monopolar diathermy.
• Open the peritoneum between mosquito for-
ceps.

Prabhu Sekaran () Delivering the Pylorus

Specialty Trainee in Paediatric Surgery
Prabhu.sekaran@nhs.net
• If not immediately apparent, apply gentle
Gregor M. Walker downwards traction on the transverse colon
Consultant Paediatric and Neonatal Surgeon to draw the greater curvature of the stomach
Gregor.Walker@ggc.scot.nhs.uk into view.

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_76, © Springer-Verlag Berlin Heidelberg 2013
E5  Open Pyloromyotomy
• Deliver the greater curvature into the incision
using a moist cotton swab or Babcock forceps.
• Apply gentle traction on the swab in a ‘rock-
ing-to-and-fro’ motion to deliver the antrum
and pylorus.
• If delivery is difficult, extend the incision, as ag-
gressive traction will traumatise the stomach.
• Once the pylorus is delivered, return the body
of the stomach to abdomen.
Pyloromyotomy
• Stabilise pylorus between thumb and index fin-
ger (Fig. 2).
Fig. 2
• Use blade to incise only the anterior gastric se-
rosa from the antrum to the prepyloric vein of
Mayo (dotted line Figs. 2 and 3).
Fig. 3
257
• Use the tip of a closed pair of curved mosquito
artery forceps (hold like a pen) to deepen the
dissection through the hypertrophied muscle.
• Once an adequate depth is reached, turn the
mosquito forceps to lie parallel to the pylorus,
and open the forceps to spread the remaining
muscle and expose the mucosa (Fig. 4).
Fig. 4
• Confirm an adequate pyloromyotomy by en-
suring that bulging gastric mucosa is visible and
by moving both halves of the pyloric muscle in-
dependently (Fig. 5).
Fig. 5
• Ensure there is no leak by direct inspection,
dabbing the pyloromyotomy with a white swab
(looking for bile) or by wetting the pyloromyot-
omy with saline and asking the anaesthetist to
instil ~20 ml of air into the nasogastric (NG)
tube (watch for bubbling).
258 P. Sekaran and G. M. Walker

Management of Mucosal Perforation

• Close by direct suture if possible with or with-

out omental patch.
• Some surgeons advocate closing the pylorus
and redoing the myotomy on the other side.

Closure

• Continuous 3-0 absorbable to fascia (in sep-

arate muscle layers in a transverse RUQ ap-
proach)
• Interrupted 4-0 absorbable subcutaneous
• Continuous 5/0 absorbable subcuticular

Tips

77 Practice feeling the pyloric ‘tumour’ under gen-
eral anaesthesia (GA) for final confirmation and
education.
77 The umbilical wound may be better for cosmesis
but has a higher infection risk- consider antibiot-
ics at induction.
77 The pyloric vein of Mayo marks the distal extent
of the pyloric tumour.
77 Open the linea alba longitudinally as far as re-
quired for easy pyloric delivery.
77 If it is difficult to deliver the pylorus from a su-
pra-umbilical incision, extend the incision into an
Omega (Ω) configuration.

Common Pitfalls

77 Typically perforations occur at the duodenal end
of the pylorus as the pylorus bulges into the du-
odenal lumen – be especially careful here (see
arrow, Fig. 6).
77 Typically an inadequate myotomy occurs at the
gastric end of the pylorus. Avoid inadequate my-
otomy by extending onto the gastric antrum.
77 Do not attempt to obtain haemostasis on the
edges of the pyloromyotomy. This is the result of
venous congestion and will cease on returning
the pylorus to the abdomen.

Fig. 6
E5  Open Pyloromyotomy 259

C O N R A D R AMS TEDT
(1867 – 1962)
German surgeon

Conrad Ramstedt studied medicine in Berlin and Halle, and thereafter joined the Army. He
retired from the Army at the end of the First World War and settled in Munster in North
Rhine-Westphalia, Germany. His name is attached to the condition pyloric stenosis, first
described by Hirschsprung. He operated on a friend’s son who had ‘pylorospasm’ and al-
though he was attempting a pyloroplasty he was unable to approximate the muscles once he
had split them longitudinally. He therefore left the procedure half done and was surprised
that it worked. Even though Styles in Edinburgh had performed the same procedure earlier,
posterity has remembered it as the Ramstedt pyloromyotomy.
 260 N. Sugandhi and S. Agarwala
E6 E 6Stamm Gastrostomy
N. Sugandhi and S. Agarwala

Operative Technique • Make a midline incision extending from 2–3 cm

• Position the patient supine.
• Drape with the umbilicus exposed to help place
the gastrostomy correctly.
• Mark the gastrostomy site on the skin.
• The usual site of placement is at a point two
thirds the way along a line running from the
umbilicus to the midpoint of the left costal
margin, over the mid-portion of the rectus
muscle (Fig. 1).
below the xyphisternum to 2–3 cm above the
umbilicus (Fig. 1). This incision is particularly
useful in a child with a highly placed stomach
(on contrast) or narrow costal-angle. Alterna-
tively, a short left transverse, supra-umbilical
incision may be used (hashed line, Fig. 1).
• Deepen the incision and enter the abdominal
cavity through the linea alba (or posterior rec-
tus fascia), dividing the peritoneum to the left
of the falciform ligament.
• Identify the anterior wall of the stomach and
retract it towards the wound with the help of
two Babcock forceps.
• Choose the site of gastrostomy on the anterior
wall of the body of stomach, mid-way between
the lesser and greater curves.
• Place two concentric seromuscular purse-string
sutures of Vicryl, encompassing an area of gas-
tric wall 0.5–1.0 cm in diameter around the cho-
sen site for the gastrostomy (Fig. 2).

Fig. 1

Nidhi Sugandhi ()

Senior Resident in Pediatric Surgery
drnidhisugandhi@gmail.com
Fig. 2
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_77, © Springer-Verlag Berlin Heidelberg 2013
E6  Stamm Gastrostomy
• Lift the anterior wall of the stomach away from
the posterior wall and make a stab incision in
the centre of the purse-string sutures.
• Use curved mosquito forceps or a stylet to
stiffen and insert a Malecot catheter into the
stomach (Fig. 3).
Fig. 3
• Secure the innermost purse-string suture af-
ter pulling the ‘flower’ of the Malecot cathe-
ter back to be positioned against the stomach
wall (Fig. 3). Then while simultaneously pulling
the two Babcock’s forceps anteriorly and push-
ing the Mallecot posteriorly, the second purse-
string suture is secured, inverting the stomach
wall creating an ‘ink well’.
Fig. 4
261
• Make a 0.5-cm stab incision on the anterior ab-
dominal at the previously marked site for the
gastrostomy. Pass curved mosquito forceps
through the wound to grasp the open end of
the Malecot catheter and deliver it out through
the incision.
• Anchor the anterior wall of the stomach
around the site of the gastrostomy to the peri-
toneal surface with a series of interrupted non-
absorbable sutures, taking good ‘bites’ of trans-
versalis fascia (Fig. 4).
• Anchor the gastrostomy tube at the exit site
with a silk suture (Fig. 4).
• Close the abdomen with continuous Vicryl su-
tures to the linea alba and subcutaneous tissue
in two layers, and subcuticular Monocryl to
skin.
262
Tips
77 The exit of the gastrostomy catheter should not
be too close to the costal margin; with growth of
the child, the gastrostomy tends to migrate near
the costal margin, thus making skin care more
difficult.
Common Pitfalls
77 Gastrostomy made too near the greater curva-
ture can make subsequent creation of a gastric
tube difficult.
77 Gastrostomy made too close to the pyloric end,
that can lead to frequent obstruction of the pylo-
rus with the tip of the catheter.
N. Sugandhi and S. Agarwala
77 A useful technique for opening the stomach is to
pass a curved needle through the anterior gas-
tric wall and to cut onto the needle with monop-
olar diathermy.
77 When siting the gastrostomy, avoid the gastric
pacemaker. Avoid the greater curve, particularly
in neonates with long-gap oesophageal atre-
sia, as that site may be required to fashion a gas-
tric tube for oesophageal replacement; avoid
the fundus in case of future fundoplication; and
avoid the pre-pyloric antrum as a gastrostomy
here may cause gastric outlet obstruction, partic-
ularly if it is subsequently changed to a balloon-
retained device.
E7  Percutaneous Endoscopic Gastrostomy (PEG)
E7 Percutaneous Endoscopic Gastrostomy
(PEG)
B. Adikibi and C. F. Davis
Operative Technique
• An upper gastrointestinal (GI) endoscopy is
performed (see Chap. E1).
• Mark an appropriate site on the upper abdo-
men. This should be well below the costal mar-
gin. The usual site of placement is at a point
two thirds the way along a line running from
the umbilicus to the midpoint of the left cos-
tal margin, over the mid-portion of the rectus
muscle
Fig. 1
Boma Adikibi ()
Specialty Trainee in Paediatric Surgery
boma.adikibi@nhs.net
Carl F. Davis
Consultant Paediatric and Neonatal Surgeon
Carl.Davis@ggc.scot.nhs.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_78, © Springer-Verlag Berlin Heidelberg 2013
263
E7
• Palpate to ensure that the liver and spleen are
not deep to the proposed insertion site (Fig. 1).
• Dim the theatre lights to optimise transillumi-
nation through the abdominal wall. Indenta-
tion should be performed with a clip or finger
under direct endoscopic vision with synchro-
nous gastric distension (Fig. 2). Only proceed
if there is good transillumination and clear in-
dentation, with no suggestion of an interposed
organ. If this is not obtained, abandon the pro-
cedure in favour of an open or laparoscopic-
assisted approach.
Fig. 2
• Incise the skin and fascia (5 mm) and insert the
puncture cannula into the stomach, with sharp
but controlled movements, under direct endo-
scopic vision.
• The optimal entry site is through the anterior
wall of the body of the stomach, approximately
halfway between the greater and lesser curves,
away from the pylorus.
• Remove the stylus of the puncture cannula and
pass the thread or metal wire (depending on the
device) through the lumen into the stomach.
• Pass an endoscopic grasper down the working
channel of the gastroscope and use it to grab
264 B. Adikibi and C. F. Davis

the thread or wire and retrieve it (with the en-

doscope) in a retrograde manner through the
mouth (Fig. 3).

Fig. 4

Fig. 3

• Attach the loop of the percutaneous endo-

scopic gastrostomy (PEG) tube to the loop of
the wire or thread. Fig. 5
• After lubricating the PEG tube, pull the exter-
nal part of the thread or wire back through the
anterior abdominal wall in an antegrade man-
ner until the flange rests snugly up against the
gastric wall.
• Always perform a check endoscopy to confirm
a good position and aspirate insufflated air.
• Fix the gastrostomy device to the anterior ab-
dominal wall, as described in the supplied kit.
E7  Percutaneous Endoscopic Gastrostomy (PEG)
Tips
77 Ensure the site for the PEG tube is not too close
to the costal margin.
77 Good transillumination and indentation are im-
perative. Any uncertainty should prompt an al-
ternative method of insertion, such as the lapa-
roscopic-assisted method.
Common Pitfalls
77 Equipment failure: always check the endoscope
before starting the case.
77 Avoid over-insufflation of the stomach, as air es-
caping through the pylorus will distend the prox-
imal loops of small bowel, causing them to en-
croach on the intended gastrostomy insertion
site.
77 A laparoscopic-assisted or open approach may
be safer in patients with a history of previous ab-
dominal surgery, particularly involving the su-
pracolic compartment, due to the risk of adhe-
sions and distorted anatomy; and in patients
with marked scoliosis or neurological impair-
265
77 Use sharp, confident needle advancement to
puncture the stomach wall. Slow, cautious at-
tempts only serve to push the stomach away, in-
creasing the risk of collateral damage.
77 Be prepared to move to laparoscopy assisted
technique than abandoning the procedure.
ment, in whom it may not be possible to transil-
luminate or indent the stomach below the cos-
tal margin.
77 The transverse colon lies anterior to the lower
margin of the stomach. This may be visible as a
dark line during endoscopic transillumination.
Failure to achieve localised indentation on gen-
tle finger pressure may be indicative of inter-
posed colon. Do not proceed.
77 Poor positioning of the gastrostomy either on
the anterior abdominal wall and/or in the stom-
ach can occur (usually too close to the pylorus,
causing gastric outlet obstruction).
 266 L. McIntosh and R. Carachi
E8 E8Umbilical Hernia Repair
L. McIntosh and R. Carachi

Circumferential infra-umbilical incision. Scal-

pel may be used to make ‘stab’ incision which is
spread along skin lines using artery forcep. (Fig. 1)
Blunt dissection to identify umbilical cicatrix and
anterior rectus sheath (Fig. 2).
Again using clip or scissors, spread tissues on
either side of umbilical stalk (Fig. 3) until clip can
be passed around umbilicus (Fig. 4).
Hernial sac opened along ditted line (Fig. 4)
and stay sutures (2/0 vicryl) placed at edges of
sac. Contents within sac are reduced into perito-
neal cavity. (Fig. 5)
In large hernias, excess tissue is divided it
sheath. Fig. 1
The defect can them be closed using inter-
rupted 2/0 vicryl sutures. (Fig. 6) Sutures are
placed through fascia and peritoneum and clipped
to allow easier placement of remaining sutures.
Umbilicus inverted and undersurface sutured
to the sheath for improved cosmesis.
Skin closure with continuous subcuticular su-
ture. Pressure dressing to wound.
Omphaloplasty – required if large amount of
excess skin. Triangular section of skin is excised.
(Fig. 8) Cut edges then closed in 2 layers. 4/0 vic-
ryl to subcutaneous tissues and 5/0 vicryl to skin. Fig. 2

Lynn McIntosh ()

Specialty Trainee in Paediatric Surgery
Lynneholmes@doctors.org.uk

Robert Carachi
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_79, © Springer-Verlag Berlin Heidelberg 2013
E8  Umbilical Hernia Repair 267

Fig. 3 Fig. 4

Fig. 5 Fig. 6

Fig. 7
Fig. 8

Tips

77 Some hernias with supra-umbilical portion may 77 Large hernias often have significant dead space
be better approached through supraumbilical following closure making haematoma or seroma
incision. formation probable. These should have pressure
dressing placed to reduce occurrence.

Common Pitfalls

77 Button-holing umbilical skin when opening sac

at figure 4.
 268 L. McIntosh and N. Brindley
E9 E9Epigastric and Supra-umbilical Hernia
Repair
L. McIntosh and N. Brindley

Epigastric hernia

• Ensure hernia is marked preoperatively (Fig. 2)

• Incision: Usually a transverse incision over her-
nia but vertical midline incision is alternative.
• The tissues are dissected down to linea alba to
identify the hernia which is usually preperito-
neal fat rather than true hernial sac. (Fig. 3)
• Spread scissors to dissect bluntly and define
edges of defect. (Fig. 4)
• Herniating fat can either be reduced through
defect or ligated and divided. Ensuring haemo-
stasis. (Fig. 5)
• The defect is usually only a few millimetres in
diameter and can be closed with 1-2 interrupted
absorbable sutures. (Fig. 6)
• Skin is closed with continuous subcuticular su-
ture.
Fig. 1

Supraumbilical hernia

• Incision: Supra-umbilical circumferential inci-

sion.
• Repair as above for epigastric hernia
• Some cases may be associated with umbilical
hernia.

Lynn McIntosh ()

Specialty Trainee in Paediatric Surgery
Lynneholmes@doctors.org.uk
Fig. 2
Nicola Brindley
Consultant Paediatric and Neonatal Surgeon
Nicola.Brindley@ggc.scot.nhs.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_80, © Springer-Verlag Berlin Heidelberg 2013
E9 Epigastric and Supra-umbilical Hernia Repair 269

Fig.3

Fig. 4

Fig. 5 Fig. 6

Tips

7 Vertical incision allows dissection above and be-

low incision to identify defect.

Common Pitfalls

7 Failure to mark hernia pre-operatively causing in-

tra-operative difficulty in centering incision over
hernia.
 270 P. Hammond and C. A. Hajivassiliou
E10 E10 Open Nissen Fundoplication
P. Hammond and C. A. Hajivassiliou

Operative Technique • The bowel is packed away inferiorly inside the

• A nasogastric tube should be sited.
• Typically, a midline upper abdominal incision
is used (see Chap. A9) (Fig. 1).
• Alternative incisions include left upper quad-
rant (LUQ) subcostal or rooftop, depending
on the costal margin anatomy and other skel-
etal deformities.
abdomen and gentle retraction/mobilisation of
the left lobe of the liver allows access to the oe-
sophageal hiatus.
• The phreno-oesophageal membrane is divided
whilst maintaining downward traction on the
stomach (the anterior vagus nerve is preserved)
(Fig. 2).

Fig. 2

• The intra-abdominal oesophagus is encircled

using sharp and blunt dissection, and an umbil-
ical tape passed posteriorly around it (Fig. 3).
• The hiatal defect between the diaphragmatic
Fig. 1 crura is repaired, posterior to the oesophagus,
with interrupted mattress 2/0 sutures.
• Mobilization of the gastric fundus to allow a
posterior 360° floppy wrap may require liga-
Philip Hammond () tion and division of the short gastric vessels to
Consultant Paediatric and Neonatal Surgeon avoid traction damage to spleen.
Philip.Hammond@ggc.scot.nhs.uk

Constantinos A. Hajivassiliou
Consultant Paediatric and Neonatal Surgeon
ch27z@udcf.gla.ac.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_81, © Springer-Verlag Berlin Heidelberg 2013
E10  Open Nissen Fundoplication 271

• A suitable part of the fundus is brought pos-

terior to the oesophagus (Fig. 4), wrapped
around it and secured with three 2/0 square-
mattress non-absorbable braided suture – the
superior and inferior sutures should include
some diaphragm and oesophagus, respectively
(Fig. 5).
• An open Stamm gastrostomy (see Chap. E5)
can be performed as required.
• Alternative techniques include:
– Thal-Dor (270° anterior wrap)
– Toupet (270° posterior wrap)
Fig. 3 – Boix-Ochoa (fundus opened-up like an um-
brella, with sutures to the anterior oesoph-
agus and diaphragm to restore the angle of
His as well as crural repair)

Fig. 4

Fig. 5
272
Tips
77 Ensure there is adequate space behind the oe-
sophagus to allow the fundus to slide through
without resistance to avoid wrap ischaemia.
77 A short (1- to 2.5-cm) loose floppy wrap is ideal.
77 The aorta runs posterior to the crura – avoid ex-
cessively large ‘bites’ whilst repairing the defect.
Common Pitfalls
77 Making the wrap too tight exacerbates post-op-
erative dysphagia and regurgitation
77 Avoid repairing the crural defect too tightly (it
should admit just the tip of the finger alongside
the oesophagus)
77 The superior wrap suture should include the di-
aphragm at the anterior oesophageal hiatus to
prevent the wrap migrating into the chest.
P. Hammond and C. A. Hajivassiliou
77 Avoid causing gastric angulation when suturing
the wrap to the diaphragm edge anteriorly.
77 Demonstrate and preserve anterior vagal trunk.
Posterior is usually safe if posterior dissection is
in loose areolar plane (not on oesophageal wall).
77 Meticulous haemostasis is essential as delayed
bleeding may occur, especially around the hia-
tus.
77 Oesophageal or fundal perforation, although
rare, must be identified and repaired at the time.
E11 Gastroschisis 273
E1 G astroschisis E11
M. Steven and R. Carachi

Preoperative Management

• IV access
• Fluid replacement
• “Bowel bag” or cling film wrapped around in-
fant to prevent evaporative losses
• Nasogastric tube

Surgical Technique

• Varies between centres

• We would still advocate when possible
• Primary closure in theatre

Primary Closure
a
• The umbilical cord is tied off with silk. The
assistant then lifts the bowel and the surgeon
preps the skin and bowel and drapes.
• The defect is stretched with two fingers.
• The bowel is inspected for an atresia, oedema,
foreshortening and the presence of peel.
• If the bowel can be reduced into the abdominal
cavity without causing respiratory compromise
or being too tight, then primary repair should
be performed. Intravesical or intragastric pres-
sure monitoring may help in making this deci- b
sion. Fig. 1a,b
• Once the bowel is reduced, the fascia is under-
mined and closure is then performed using in-
terrupted non-absorbable suture

Mairi Steven ()

Specialty Trainee in Paediatric Surgery
mairisteven@doctors.org.uk

Robert Carachi
Professor of Surgical Paediatrics Fig. 2
Robert.Carachi@glasgow.ac.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_82, © Springer-Verlag Berlin Heidelberg 2013
274
Fig. 3
• The subcutaneous tissue and skin is then
closed. It is often possible to fashion a neo-
“umbilicus” by performing a subcuticular
purse-string suture at the medial edge of the
wound.
Silo Application
• When primary closure is not possible then a
silo is applied. This can be done either in the-
Tips
If the bowel looks ischaemic preoperatively, two
manoeuvres can help.
1. With the child supine place two supports (e.g.
a rolled nappy) either side of the baby so the
bowel and mesentery cannot flop to one side.
Common Pitfalls
77 The infant will need plenty of fluid because of
ongoing losses; however, it is important not to
‘chase the base’ [deficit], as most babies with gas-
troschisis will have a degree of metabolic acido-
sis.
M. Steven and R. Carachi
Fig. 4
atre or on the neonatal unit. Most centres now
used preformed silos.
• This involves inserting the ring around the base
of the silo into the defect. The defect may need
to be extended slightly.
• The bowel is then reduced slowly as tolerated
over 5 to 7 days and then a delayed primary
closure is performed.
2. Place the child in the right lateral position. This
means there is less tension on the bowel mesen-
tery.
77 It is important to decompress the bowel prior to
attempt fascial closure this can be done by “milk-
ing” intestinal contents up to the nasogastric
tube and performing a rectal examination.
E12 Exomphalos 275
E 12Exomphalos E12
M. Steven and R. Carachi

Preoperative Management

• IV access
• Fluid replacement
• “Bowel bag” or cling film wrapped around
baby to prevent evaporative losses
• Investigations including CXR, cardiac, renal
and spinal ultrasound.
• Nasogastric tube

Operative Technique

The technique depends on size.

Small to Moderate Exomphalos a

• Primary closure
– Should be undertaken where possible to de-
crease the chance of intra-abdominal sepsis.
– Most surgeons would excise the sac unless
adherent to liver.
– There is a need to control and ligate umbil-
ical vessels.
– Careful examination and reduction of bowel
and viscera especially the liver is important.
• Stretching of the peritoneal cavity
– Undermine the skin to define the fascial lay- b
ers.
– Fascia should be closed with an interrupted Fig. 1a,b
or continuous absorbable suture if tolerated.
• Skin closed and umbilicoplasty performed Moderate to Large Exomphalos

Conservative Treatment

Mairi Steven () • Very large defects may simply be painted with
Specialty Trainee in Paediatric Surgery a disinfectant or Flamazine and observed for
mairisteven@doctors.org.uk
development of eschar.
Robert Carachi • A suitable corset is then fitted.
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_83, © Springer-Verlag Berlin Heidelberg 2013
276 M. Steven and R. Carachi

Fig. 2

Fig. 3 Fig. 4

Application of a Silo Staged Repair

If the sac ruptures it may be possible to repair the This is usually performed at 6–9 months of age
defect in the sac and continue with conservative and involves excising excess skin and repairing the
management. If not a silo may be applied, how- ventral hernia.
ever, this is only a temporary measure. In very
large defects a synthetic patch or skin graft may
be considered.
E12 Exomphalos 277

Tips

77 Intra-abdominal pressure can be measured via 77 Babies with large exomphalos require a pro-
the nasogastric tube and central venous catheter longed hospital stay, and a multidisciplinary ap-
intraoperatively. proach including advice from tissue viability and
orthotics regarding corset application.

Common Pitfalls

77 A primary closure too tight may lead to abdomi- 77 It is often the associated anomalies that cause
nal compartment syndrome morbidity and mortality in these patients and
it is not only important to look for these, but to
also actively manage them, e.g. pulmonary hy-
poplasia often seen with a classic “bell-shaped”
chest.
 278 N. Sugandhi and S. Agarwala
E13 E 13Loop Enterostomy
N. Sugandhi and S. Agarwala

Operative Technique • Anchor the proximal and the distal limbs of

the delivered bowel loop to the abdominal wall
• Make an appropriate laparotomy incision at muscles and the anterior sheath with seromus-
the chosen site of the stoma. cular silk or Vicryl sutures, at both the corners
• Incise the muscles in the line of the incision and (Fig. 2). Similarly anchor the loops superiorly
enter the peritoneal cavity. and inferiorly also. Place the centre suture in a
• Identify the loop of bowel where the stoma has U-shaped fashion, taking both the proximal
to be created and deliver its apex out of the in- and distal loops (Fig. 2).
cision, with the help of a Babcock’s forceps. • Score the antimesenteric wall of the bowel,
• Identify the proximal and distal ends of the de- with diathermy to decrease bleeding and make
livered loop and create a window in the mes-
entery of the bowel, with a small mosquito, as
close to the bowel loop as possible to prevent
injury to the vascular arcade.
• Pass a soft rubber tube through the mesen-
teric window. Retract it upwards and deliver
the bowel loop out of the incision (Fig. 1).
• Place three silk seromuscular sutures between
the two loops of bowel, starting just below the
catheter in the mesenteric window, to create a
spur. Do this similarly on the other side also
(Fig. 1).
Fig. 2

an enterotomy along this, ensuring haemosta-

sis at the edges.
• Anchor the cut edge of the bowel to the skin
in an everting fashion with silk sutures (or any
other non-absorbable suture). To do a proper
eversion take full thickness of the skin, then se-
romuscular on the bowel loop, midway to the
cut edge, and then full thickness through the
cut edge of the bowel (Fig. 3).
Fig. 1 • Close the remainder of the abdominal incision
in layers.
Nidhi Sugandhi ()
Senior Resident in Pediatric Surgery
drnidhisugandhi@gmail.com

Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_84, © Springer-Verlag Berlin Heidelberg 2013
E13  Loop Enterostomy 279

Fig. 3

Tips

77 Mark the appropriate site of placement before
starting the procedure.
77 Deliver adequate length of bowel outside to
fashion a proper pouting and everted stoma.
77 If a divided stoma is to be created, then the loop
of bowel is transected and the two ends an-
chored at the two ends of the abdominal in-
cision, with the intervening muscles and skin
closed in layers.
77 In a non-obstructed child the loop stoma may be
matured 48 h later to prevent the soiling of the
wound.

Common Pitfalls

77 Improper siting, near the costal margin or the il- 77 Improper anchoring to the abdominal wall, es-
iac crest pecially the centre stitch, leading to herniation
77 Mistaken identification of loop such as the sig- at this site
moid instead of the transverse colon 77 Too many anchoring sutures leading to venous
77 Twisting of loop before anchoring causing ob- congestion and ischemia
struction 77 Failure to adequately pout and evert the stoma,
77 Creating a very small incision in the muscle and causing difficulty in application of stoma bags.
fascia again leading to obstruction
 280 S. Gazula and S. Agarwala
E14 E14 B owel Resection and Anastomosis
S. Gazula and S. Agarwala

Operative Technique • Gently ‘milk’ the contents of the bowel away

• Identify the diseased segment of bowel.
• Place sponges soaked in warm saline that
length of bowel to prevent inadvertent intra-
abdominal contamination.
• Select the site for proximal and distal bowel
transection (Fig. 1).
from the margin to be resected and apply bowel
clamps in an oblique manner – atraumatic
clamps on the side to be retained and crush-
ing clamps on the side to be resected (Fig. 3).
• Place a sponge under the transaction area and
transect the bowel proximally and distally us-
ing a tissue scissors or diathermy. Remove the
resected segment of the bowel. Wipe clean the
edges using Povidone iodine–soaked gauze.
Clear the edges for about 2–3 mm from any fat.

Fig. 1

• Lifting the bowel, use transillumination to view

the vascular arcades. Carefully dissect the ves- Fig. 2
sels to be ligated using mosquito forceps. Li-
gate the vessels with silk sutures and divided
between ligatures (Fig. 2). As an alternative,
the vessels may also be coagulated with bipo-
lar forceps and then divided.

Suhasini Gazula ()

Senior Specialist paediatric surgeon
Department of paediatric surgery, Employees‘ State Insur-
ance Corporation (esic) Superspeciality Hospital, Sanath
Nagar, Hyderabad, Andhra Pradesh, India
suhasinigazula@gmail.com

Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com Fig. 3

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_85, © Springer-Verlag Berlin Heidelberg 2013
E14  Bowel Resection and Anastomosis 281

Fig. 5

Fig. 4

• Place the two transected edges next to each

other by approximating the two clamps, and
cover the intestinal clamps with a sponge
(Fig. 4).
• Place full-thickness interrupted silk or Vic-
ryl sutures with the knots outside on both the
corners of the bowel. In case of disparity of Fig. 6
the two lumens make a back cut (the Cheatle
cut) on the antimesenteric side of the narrower
bowel (Fig. 5).
• For a single-layer interrupted anastomosis, with
simple sutures start from the mesenteric end.
Start from the serosal surface of one bowel,
out through the mucosa and then through
the mucosal surface of the other bowel, and
out through the serosa and then tie the knot
(Fig. 6).
• For a two-layered anastomosis, after plac-
ing the two corner stitches, place continuous
through and through Vicryl sutures on the pos-
terior cut edges of the bowel (Fig. 7).
• Interrupt at the corner and then continue Fig. 7
on the anterior edge either in a through and
through manner or by taking continuous self-
inverting sutures (Connell sutures or loop on sal surface of the other bowel, out through the
mucosa). For Connell’s sutures start from the mucosa and then through the mucosal surface
serosal surface of one bowel, out through the of the same bowel, and out through the serosa
mucosa and then through the mucosal surface and continue so on (Fig. 8).
of the same bowel (loop on mucosa), and out • Place a second layer of interrupted seromuscu-
through the serosa and then through the sero- lar sutures with silk (or continuous with Vic-
282 S. Gazula and S. Agarwala

ryl) all around the first layer to invert the first

layer (Fig. 9).
• Approximate the mesenteric defect with inter-
rupted Vicryl sutures (Fig. 9).
• Close the laparotomy incision in layers and the
skin with absorbable subcuticular sutures.

Fig. 8 Fig. 9

Tips

77 Incising the peritoneal layer on the two sides of
the mesentery in a V shape either with electro-
cautery or with Metzenbaum scissors is useful to
visualize the vascular arcades especially in cases
with inflamed, oedematous mesentery or older
children with lot of mesenteric fat.
77 The larger named mesenteric vessels may need
to be secured with transfixion sutures.
77 Bowel may need to be decompressed before
anastamosis is constructed, in cases of massive
dilatation.
77 Always start the anastamosis from the mesen-
teric end so that in cases of disparity the Cheatle
split (making a cut on the antimesenteric border)
may help to enlarge the bowel lumen of the nar-
rower segment.
77 Good vascularity of the transected edges, ab-
sence of tension, noncrushed bowel ends and
accurate apposition are essential for a good
anastamosis.
77 A peritoneal drain may be useful.

Common Pitfalls

77 Using clamps on neonatal bowel or on oedema- 77 Using bowel ends with doubtful vascularity for
tous bowel or bowel with compromised vascu- anastamosis can be risky.
larity may lead to ischemia of the edges.
E15  Right Hemicolectomy 283
E15 R ight Hemicolectomy E15
G. Haddock

Indication should be taken to record the site and limit of

This procedure is most usually undertaken to re-
sect Crohn’s disease affecting the terminal ileum,
for caecal volvulus or for neonatal necrotizing en-
terocolitis (NNEC).
active disease/necrosis.
• Care should also be taken at the end of the pro-
cedure to measure the length of residual small
bowel.

Positioning

The patient’s position should be supine with a dia-

thermy pad placed on thigh or back.

Abdominal Incision

• When the nature and extent of the disease in

an older child is known, a right upper trans-
verse incision just above the umbilicus is usu-
ally best.
• Where the extent of inflammatory disease is not
known in an older child, consideration should
be given to using a midline incision.
• In a neonate an upper transverse incision just
above the umbilicus is usually adequate. Fig. 1

Operative Technique
• A scalpel should be used to lightly incise the
skin.
• Monopolar diathermy should be used to incise
the fascia and muscle.
• A full laparotomy should be undertaken, par-
ticularly in Crohn’s disease and NNEC. Care
Graham Haddock ()
Consultant Paediatric and Neonatal Surgeon
Ghaddock@udcf.gla.ac.uk
Operative Steps
• The peritoneal reflection lateral to the caecum
and ascending colon should be incised and the
right colon mobilized. This should be a rela-
tively bloodless procedure and may best be un-
dertaken standing on the patient’s left side.
• Care should be taken to avoid damage to the
right ureter, the duodenum and the right kid-
ney
• The site of division of the colon should be iden-
tified.
• If dissection along the transverse colon is re-
quired, an attempt should be made to dissect

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_86, © Springer-Verlag Berlin Heidelberg 2013
284 G. Haddock

the omentum off the transverse colon prior to

ligation and division of the mesocolon.
• Attention should now be directed to the termi-
nal ileum.
• The small bowel mesentery should be clipped
with artery forceps, ligated with absorbable ties
and divided.
• The site of small bowel division should be iden-
tified and any residual mesentery ligated and
divided.
• Soft occlusion clamps should be applied to the
small bowel ,proximal to the site of division
and distal to the site of colonic division (a bull-
dog clip covered with a soft catheter works well
Fig. 2 for this purpose).
• Antiseptic-soaked swabs should be placed be-
hind the bowel during division to catch any
leaking intestinal content thus minimizing con-
tamination.
• The small and large bowel can then be divided
with monopolar diathermy (Fig. 4.).
• A primary serosubmucosal end-to-end anasto-
mosis using absorbable suture material should
now be constructed.
• The defect in the mesentery should be closed,
taking care to avoid compromising the blood
vessels supplying the anastomosis.

Closure

• The abdominal wound should be closed either

in layers or as a mass closure in the standard
way, using heavy absorbable sutures.
• No drain should be necessary.

Fig. 3

Fig. 4
E15  Right Hemicolectomy
Tips
77 For larger children, make sure that you have an
adequate self-retaining retractor available to
hold the abdominal wound open.
77 Ensure that a urinary catheter is sited prior to sur-
gery, particularly when the extent of the disease
is not known.
Common Pitfalls
77 Beware of any discrepancy between the diame-
ter of the small bowel and colon at the anasto-
motic site. You may need to angle your incision
when dividing the small bowel to give you more
length to match the colonic diameter.
285
77 Ensure that older children or children above 50
kg in weight receive prophylaxis against venous
thromboembolism (use subcutaneous long-act-
ing heparin and compression stockings).
77 Make sure that your anastomosis and wound
closure are meticulous, particularly if the patient
is on systemic steroids or other immunosuppres-
sive medication.
 286 G. Haddock
E16 E16 Subtotal Colectomy and Ileostomy
G. Haddock

Indication S
 teps

This procedure is undertaken in ulcerative colitis, • The peritoneal reflection lateral to the caecum
colonic Crohn’s disease or for neonatal necrotiz- and ascending colon should be incised and the
ing enterocolitis (NNEC). right colon mobilized. This should be a rela-
tively bloodless procedure and may best be un-
dertaken from the patient’s left side.
Positioning • Care should be taken to avoid damage to the
right ureter, the duodenum and the right kid-
Supine with a diathermy pad placed on thigh or ney.
back. • The terminal ileum should be mobilized and di-
vided using a linear stapling device. This main-
tains a clean operative field.
Abdominal Incision

• Midline lower abdominal incision extending

from the pubis to above the umbilicus in ul-
cerative colitis.
• In a neonate with NNEC where the extent of
the disease is not known, an upper transverse
incision just above the umbilicus is usually ad-
equate, even to access the upper rectum in the
pelvis.

Technique

• A scalpel should be used to lightly incise the

skin.
• Monopolar diathermy should used to incise the
fascia and muscle.
• A full laparotomy should be undertaken par-
ticularly in Crohn’s disease and NNEC. Care
should be taken to record the site and limit of
active disease/necrosis.
• The residual length of small bowel in NNEC
should be measured.

Graham Haddock ()

Consultant Paediatric and Neonatal Surgeon
Ghaddock@udcf.gla.ac.uk Fig. 1  Mobilising the right colon

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_87, © Springer-Verlag Berlin Heidelberg 2013
E16  Subtotal Colectomy and Ileostomy 287

• Mobilisation should continue around the he-

patic flexure. The omentum can be dissected
off the transverse colon, which makes it easier
to ligate and divide the mesocolon vessels.
• Dissection can usually be carried round to the
distal transverse colon. Bipolar diathermy may
be used.
• At this point it is helpful to mobilise the left co-
lon. The lateral peritoneal reflection is incised
and the colon mobilized. The mesocolon is li-
gated and divided. Mobilising transverse colon
and descending colon make it easier to mobi-
lize the splenic flexure by applying gentle trac-
tion to both limbs of the colon.
• Once the splenic flexure is free, mobilize the sig-
moid colon.
• The sigmoid mesocolon is ligated and divided
to the level of the upper rectum. The rectum
should be cleared of tissue at a level above
the pelvic floor. This will facilitate subsequent
pouch ileoanoplasty by leaving a relatively long
rectal stump for easy location later.
• The site of rectal division should be identified.
A stapling device can be used to close off the
rectal stump, the rectum divided and the colon
Fig. 2  Mobilising the hepatic flexure and transverse colon removed. The stump staple line can be oversewn
to prevent leakage and the rectal stump marked
with two long non-absorbable stay sutures.
• A small circular piece of skin is excised from the
right iliac fossa, which should be marked pre-
operatively. The incision is deepened through
the abdominal wall muscles and fascia. The sta-
pled ileum is delivered through the wound and
sutured to the fascia in four places. The staple
line is excised. A spout is then created by evert-
ing the ileum and suturing the ileum to the skin.

Closure

• The abdominal wound should be closed in lay-

ers or a mass closure in the standard way using
suitable absorbable sutures.
Fig. 3a  Mobilising the left colon (a) • No drain should be necessary.
288 G. Haddock

Fig. 3b  and splenic flexure (b)

Fig. 3c  Closure of the rectal stump

Fig. 4a-d  Creating and maturing the end ileostomy

E16  Subtotal Colectomy and Ileostomy 289

Tips

77 For larger children, make sure that you have an
adequate self-retaining retractor available to
hold the abdominal wound open.
77 Ensure that a urinary catheter is sited prior to sur-
gery particularly when the extent of the disease
is not known.
77 Ensure that older children or children above
50 kg in weight receive prophylaxis against ve-
nous thromboembolism (subcutaneous long
acting heparin and compression stockings).

Common Pitfalls

77 Make sure that the splenic flexure dissection is 77 Make sure that you create an adequate spout on
carefully done to avoid damaging the spleen. the ileostomy to accept stoma bags.
77 Make sure that the hole for the ileostomy is not
tight.
 290 A. Sinha and S. Agarwala
E17 E17 Small Bowel Atresia
A. Sinha and S. Agarwala

Operative Technique

• Make a right supra-umbilical transverse lapa-

rotomy.
• Deliver the entire small bowel through the inci-
sion. Rule out any malrotation of small bowel.
• Trace the distended bowel loop to reach the
level of atresia. Examine the mesentry and the
small bowel distal to the atretic segment.
• Examine the rest of the bowel for associated
atresias and other anomalies. Fig. 1
• Resect the tip of the distal small bowel in an
oblique manner (Fig. 1) and introduce a small
feeding tube in it. Instil warm normal saline in
the distal bowel lumen to rule out any distal
atresias (Fig. 2).
• Apply an intestinal clamp to the proximal di-
lated small bowel and make an incision on its
terminal end (Fig. 2). If the distal end of proxi-
mal bowel seems to be hypertrophied and mas-
sively dilated, a small segment of the distal edge
can be resected (Fig. 3).
• Make an appropriate Cheatle cut on the an- Fig. 2
timesenteric side of the distal bowel to spatu-
late the opening (Fig. 4).
• Anastomose the two bowel ends with absorb-
able 5-0 interrupted sutures in a single layer in
an end-to-side manner (Fig. 5a,b).
• Repair the mesenteric defect with 5-0 Vicryl
(Fig. 6).
• Reposit the bowel loops back into the abdo-
men in proper orientation and close the inci-
sion in layers.

Anand Sinha () Fig. 3

Senior Research Fellow in Pediatric Surgery
dranandsinha@hotmail.com

Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_88, © Springer-Verlag Berlin Heidelberg 2013
E17  Small Bowel Atresia 291

Fig. 4

Fig. 5a,b

Fig. 6
292 A. Sinha and S. Agarwala

Tips

77 For type I atresias, make a longitudinal incision,
on the antimesenteric border, on the dilated
proximal bowel. Excise the web, confirm distal
patency and close the enterostomy in a single
layer in a transverse manner (Fig. 7).
77 Tapering of proximal dilated segment should be
considered when a long segment is massively di-
lated or when the atresia is near the duodeno-
jejunal junction and resection of this segment is
not advisable. The tapering can be done either
by hand or with a stapler.
77 In cases of multiple atresias, the entire segment
bearing the atresia can be resected.
77 In some cases the atretic segments involve only
a small length of bowel.
77 In other cases multiple anastamoses can be
made with or without a trans-luminal stent
(‘shish-kabob’ anastamoses) (Fig. 8a, b).

Fig. 7

77 In cases of perforated bowel, give a thorough la-

vage and leave a peritoneal drain before closure.
77 The terminal very dilated and bulbous end of
proximal bowel may be resected to make an
anastamosis in less dilated portion, provided the
length resected is not much (Fig. 3).
77 Due to gross distension of proximal bowel, pro-
longed ileus is a frequent complication and most
of the babies require total parenteral nutrition
for some days.

Fig. 8a,b

Common Pitfalls

77 Failure to rule out distal atresias 77 Kinking of anastamosis while repairing the mes-
77 Retaining the distal massively dilated distal end enteric defect
of proximal bowel that is adynamic
E18  Malrotation and Volvulus 293
E18 Malrotation and Volvulus E18
L. C. Steven and C. A. Hajivassiliou

This approach is used for any child with malrota- • Use small retractors to expose the right upper
tion, with or without volvulus. quadrant (RUQ). Use sharp or bipolar dissec-
tion to divide the Ladd bands close to the ab-
dominal wall. These bands are peritoneal folds
Operative Technique from the caecum and ascending colon, extend-
ing across the duodenum to the RUQ/abdomi-
• Right transverse supra-umbilical incision, 1 nal wall (Fig. 2).
cm above the umbilicus in a neonate (Fig. 1).
Opening the peritoneum may liberate chylous
or haemorrhagic fluid if a volvulus is present.
• Deliver the small bowel carefully. If volvulus is
present, see below. If no volvulus, proceed as
follows.

Fig. 2

• Proceed to separate the adhesions from the cae-

cum to the medial duodenum using sharp dis-
section. Observe the position of the biliary tree
Fig. 1 and ampulla. The caecum should now move
off the duodenum towards the left upper quad-
rant (LUQ), exposing the base of the mesen-
tery (Fig. 3).
Lisa C. Steven () • Broaden along the mesentery by gently lifting
Specialist Registrar in Paediatric Surgery the peritoneum over the mesentery and incising
lisasteven@doctors.org.uk
across it, using scissor dissection, from right to
Constantinos A. Hajivassiliou left in the same plane (Fig. 4).
Consultant Paediatric and Neonatal Surgeon • The duodenum is straightened by dividing lat-
ch27z@udcf.gla.ac.uk eral adhesions and the ligament of Treitz.

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_89, © Springer-Verlag Berlin Heidelberg 2013
294
• An appendectomy can be performed using the
standard or inversion technique.
• Return the viscera to the abdominal cavity in
sequential order from duodenum through to
caecum – this is the final orientation (Fig. 5).
Fig. 3
Fig. 4
L. C. Steven and C. A. Hajivassiliou
Malrotation with Volvulus
If a midgut volvulus is present, devolve (usually)
in an anticlockwise direction. If the bowel looks
viable proceed as above. If the midgut does not
recover despite heating with warm saline-soaked
swabs, the senior surgeon should decide how best
to proceed.
Fig. 5
E18  Malrotation and Volvulus 295

Tips

77 Ensure the incision allows adequate access to the
RUQ. Extend the wound early for safe exposure.
77 Always be cautious and mindful of the (fragile)
neonatal liver.
77 When dissecting the caecum from medial duo-
denum, be aware of the biliary anatomy. It may
have an unexpected configuration. Stay close to
the caecum when dividing the adhesions here.
77 Note the presence and position of the spleen.
Asplenia and polysplenia may be associated.

Common Pitfalls

77 Take care to divide all of the Ladd bands. Failure 77 If a volvulus is present when devolving remem-
to do so will result in difficulties straightening ber the mesenteric base is narrow and will be oe-
the duodenum and mobilising the caecum to- dematous. Correct devolving may be difficult in
wards the LUQ. interpret.
77 When broadening the mesentery it is only the
anterior leaf of the peritoneum which is divided.
Do not incise any deeper into the mesentery.

W I L L I A M E. LADD
(1880 – 1967)
American paediatric surgeon

Considered the father of American Paediatric Surgery. He graduated from Harvard Medical
School and practiced initially as a general surgeon and gynaecologist. On 6 December 1917,
a French cargo ship at Halifax, Nova Scotia, accidentally exploded killing about 2,000 peo-
ple and injuring more than 9,000, many of them children. Ladd, who had arrived with the
US contingent to help was so moved that he dedicated the rest of his professional life to pae-
diatric surgery. His efforts led to the development of paediatric surgery as a separate disci-
pline. He published some of the earliest papers on malrotation, oesophageal atresia, pyloric
stenosis, intussusception, biliary atresia and bladder exstrophy. His classic textbook Abdom-
inal Surgery of Infancy and Childhood, written with Robert Gross, had a major impact on the
international development of paediatric surgery.
 296 T. J. Bradnock and G. Haddock
E19 E19 Open Appendectomy
T. J. Bradnock and G. Haddock

Operation Technique • Suction away any free peritoneal fluid. Send a

• Position the patient supine.
• Make a Lanz incision at McBurney’s point and
down to peritoneum, as described in chapter
A12 and Figs. 1–4.
• Grasp the peritoneum with two curved mos-
quito forceps and use a scalpel to open between
them.
peritoneal swab for culture. Extend the perito-
neal opening with scissors.
• Use finger dissection to gently breakdown any
inflammatory adhesions and to mobilise the
omentum off the appendix.
• Use Babcock forceps to grasp the anterior te-
nia coli and deliver the caecum (Fig. 5).
• Protect the wound with antiseptic swabs.
• Hold the mesoappendix with Babcock forceps.
• Divide the mesoappendix sequentially be-
tween curved mosquito forceps, and ligate with
braided absorbable sutures (Fig. 6).
• Crush the appendix base with straight mos-
quito forceps 5 mm above the caecum, and
then move the forceps a few millimetres dis-
tally (Fig. 7).
• Double ligate the crushed portion with an ab-
sorbable suture (Fig. 8). Use a scalpel to excise
the appendix proximal to the forceps.
• Ensure the caecum and appendix stump are
dry before returning them to the abdomen.
• If free pus is evident, perform a peritoneal la-
vage with normal saline (with or without anti-
biotic).
• In cases of heavy soiling, all of the small bowel
should be delivered into the wound to enable
complete clearance of interloop abscesses.
• Close the wound in layers – as described in
Chap. A12 – after irrigation of each layer.

Fig. 1

Tim J. Bradnock ()

Specialty Registrar in Paediatric Surgery
The Department of Paediatric Surgery, Dalnair Street,
Yorkhill Hopsital, Glasgow G3 8SJ, Scotland, UK
Email: tjbradnock@doctors.org.uk

Graham Haddock
Consultant Paediatric and Neonatal Surgeon
Ghaddock@udcf.gla.ac.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_90, © Springer-Verlag Berlin Heidelberg 2013
E19  Open Appendectomy 297

Fig. 4

Fig. 2

Fig. 3 Fig. 5
298 T. J. Bradnock and G. Haddock

Fig. 6

Fig. 7 Fig. 8
E19  Open Appendectomy 299

Tips

77 Always examine the child’s abdomen under gen-

eral anaesthetic before making your incision. If a
mass is found, the incision should be adjusted to
overlie the mass.
77 It is safer to open the peritoneum medially, as in-
flammation may obscure it laterally.
77 If the caecum cannot be delivered easily into
the wound, the lateral peritoneal attachments
should be divided under direct vision, using mo-
nopolar diathermy.
77 If the appendix base is gangrenous, consider
burying the stump with a simple purse-string su-
ture (Fig. 9).

Fig. 9

Common Pitfalls

77 An appendix mass is usually adherent laterally 77 An inflamed appendix is a source of infection.

and inferiorly. Blind medial dissection should be
avoided.
77 Attempting to perform a difficult dissection
through an inadequate incision is dangerous.
Maintain a low threshold for extending the
wound laterally/medially using muscle-cutting
cautery.
Failure to protect the wound with antiseptic-
soaked swabs after delivering the appendix is
unacceptable. Do not handle the appendix di-
rectly and keep dirty and clean instruments sep-
arate.
77 Always inspect the adjacent organs and walk the
small bowel if the appendix is normal.
 300 L. C. Steven and C. F. Davis
E20 E 20Meckel’s Diverticulum
and other Vitello-intestinal Anomalies
L. C. Steven and C. F. Davis

The operative principles apply whether the vi- • The Meckel’s may be folded onto the mesentery
tello-intestinal anomaly is an expected or inci- by the vitello-intestinal artery remnant. Ligate
dental finding. The most common anomalies are this or divide with bipolar diathermy (Fig. 1).
discussed. • Place stay sutures on the ileum on either side.
Occlude the ileum using silastic ‘sloops’ to pre-
vent soiling. Take hold of the diverticulum and
 eckel’s Diverticulum – Operative
M excise with a wedge of ileum using scissors or
Technique monopolar diathermy (Fig. 2).

• Exposure may be through a right transverse

infra-umbilical incision or by extension of the
peri-umbilical wound if using a laparoscopic
approach.
• Identify the terminal ileum and ‘walk’ the small
bowel proximally. Deliver the Meckel’s into the
wound.

Fig. 2

• Inspect the adjacent ileal mucosa to ensure no

ulceration or abnormality. If any doubt, resect
further on the antemesenteric aspect leaving the
mesenteric mucosa intact if possible. Alterna-
tively, perform a segmental ileal resection.
• Close the ileum transversely using serosubmu-
Fig. 1 cosal or full-thickness (Connell) interrupted
absorbable sutures (Fig. 3).
Lisa C. Steven ()
Specialist Registrar in Paediatric Surgery
lisasteven@doctors.org.uk

Carl F. Davis
Consultant Paediatric and Neonatal Surgeon
Carl.Davis@ggc.scot.nhs.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_91, © Springer-Verlag Berlin Heidelberg 2013
E20  Meckel’s Diverticulum and other Vitello-intestinal Anomalies 301

Persistent Vitello-intestinal Duct

• Perform an infra-umbilical incision with right

lateral extension, if necessary. Open the perito-
neum to isolate the duct and demonstrate its at-
tachment to the abdominal wall. Free the duct
circumferentially from the linea alba and skin,
using sharp or monopolar dissection (Fig. 6).
• The tract is traced down to the ileum and re-
Fig. 3 sected as for a Meckel’s diverticulum. The base
of the duct is often narrow and a less extensive
 itello-intestinal Band with or
V wedge resection is needed than for a Meckel’s.
Without Obstruction • Abdominal closure includes repair of the um-
bilical ring.
• A vitello-intestinal band will extend from the
deep aspect of the umbilicus to the ileum or
into a Meckel’s diverticulum.
• The band should be divided at the umbilical
level and, if associated with a Meckel’s diver-
ticulum, proceed as above (Fig. 4). If there is no
Meckel’s diverticulum, excise the entire length
of the band.

Fig. 5

Fig. 4

• If there is small bowel obstruction, the Meck-

el’s band is often adherent to the base of small
bowel mesentery (Fig. 5). Divide across the fi-
brous segment of the band and excise the as-
sociated diverticulum as above.
302
Fig. 6
Tips
77 As the small bowel is ‘walked’ from distal to prox-
imal, return the small bowel already inspected
to the abdomen. This will prevent excessive oe-
dema of the delivered bowel and allow easier re-
turn of the anastomosis at the end of the proce-
dure.
77 If there is small bowel obstruction associated
with a Meckel’s band, carefully inspect the af-
fected bowel after relief of the obstruction.
Common Pitfalls
77 A Meckel’s diverticulum can be easily missed un-
less both sides of the mesentery are inspected as
it may be adherent to the mesentery on one or
other side rather than truly antemesenteric.
L. C. Steven and C. F. Davis
77 Opening the peritoneum early during dissection
of a patent vitello-intestinal duct prevents inad-
vertent damage to the underlying ileum.
77 Consider using a soft plastic wound protector to
facilitate return of the anastomised bowel into
the abdomen using laparoscopic-assisted tech-
nique.
77 An inadequate size wound compromises return
of the anastomosed intestine and risks damag-
ing the suture line.
77 Failure to perform a generous wedge or segmen-
tal resection of a Meckel’s diverticulum risks leav-
ing residual ulcerated intestinal mucosa in situ.
E21 Intussusception 303
E21 Intussusception E21
R. Kronfli and P. A. M. Raine

Non-operative Management • A control image is taken first.

• Air is carefully introduced, until the first set
Radiological Reduction pressure is reached or the intussusception is
seen to reduce
This should only be done in centres offering pae- • Reduction is confirmed when air flows freely
diatric surgery in case of perforation or failed re- into small bowel.
duction.
Outcome
Preparation
• Success rate is 70–90 %
• IV access • Recurrence rate is 8–10 %
• Ensure full fluid resuscitation prior to enema • Perforation rate is 1–2 %
• Analgesia
• Broad-spectrum antibiotics Contraindications
• Nasogastric tube
Absolute
Position
• Signs of peritonism
• Position the child supine or prone. • Free air
• A soft catheter is inserted into the rectum.
• The buttocks are taped (or squeezed together) Relative
to help retain the catheter.
• The catheter is connected to a device that de- • Long history
livers air at a constant pressure. • Large amount of free fluid
• Water can be used instead of air – pass a tube • Lack of flow on colour Doppler ultrasound
into the anus and attach to an elevated reser- • Presentation outside the usual age range
voir. • Multiple recurrences

Reduction Operative Reduction

• Reduction is done under fluoroscopic or ultra- Indications

sound guidance.
• Perforation is easier to detect on fluoroscopy. • Peritonism or free gas at presentation
• Perforation during air enema reduction
• Failed air enema reduction
Rania Kronfli () • Multiple recurrences or an initial presentation
Specialty Trainee in Paediatric Surgery long after the usual age range. Increased risk of
rkronfli@doctors.org.uk
a pathological lead point over 3 years of age.
Peter A. M. Raine • Radiological reduction not available
Consultant Paediatric and Neonatal Surgeon
Rainewest@btinternet.com

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_92, © Springer-Verlag Berlin Heidelberg 2013
304 R. Kronfli and P. A. M. Raine

Preparation Bowel Resection

Always inform theatre staff of the potential need
for surgery prior to an attempted air enema re-
duction. Otherwise, proceed as for air enema re-
duction.
Setup
• General anaesthetic – muscle relaxation
• Patient supine – prepare entire abdomen
Procedure
See also Chap. E14 for additional information.
• Resection is necessary if:
– Bowel is not viable.
– Lead point is identified.
– Open reduction is not possible.
• Resect bowel to healthy edges
• Standard serosubmucosal anastomosis
• Close the mesenteric defect.
• Washout the abdominal cavity with saline.
• Closure is done in layers.
Recurrence rate is ~1 %.

• Make a transverse supra-umbilical incision.

• Deliver the involved bowel into wound. This
may require mobilisation of the right colon and
caecum by sharp division along the white line
of Toldt.
• Identify the affected segment.
• Return the rest of the bowel to abdomen.
• If bowel is viable, attempt open reduction:
– The forefingers and thumbs are used to ap-
ply pressure to the apex of the intussuscep-
tion (Fig. 1).
• Always palpate the affected bowel after reduc-
tion to exclude a pathological lead point

Fig. 1  Technique for open reduction of intussusception

E21 Intussusception 305

Tips

77 Multiple attempts at air enema reduction can be 77 If perforation occurs during air reduction, de-
made, depending on the clinical condition of the compression may be required (for ventilatory
patient, with incrementally increasing pressures compromise) and can be achieved by placing a
of 80, 100, 120 mmHg. large bore cannula into abdomen prior to lapa-
77 If the intussusception is reduced to the ileocae- rotomy.
cal valve, it may be acceptable, if the child re-
mains stable, to reattempt further reduction af-
ter a few hours, once the oedema settles (if the
child is still stable).

Common Pitfalls

77 Traction on the intestine should be avoided 77 If the intussusception extends into the left colon,
while attempting open reduction, as this risks se- ensure that the bowel is normally rotated.
rosal tearing. 77 If there is uncertainty about the completeness
77 Be aware that an oedematous ileocaecal valve of reduction after air enema, laparoscopy may
can mimic an intraluminal mass. Failure to realise avoid a laparotomy.
this will result in unnecessary resection.
77 Even if complete reduction is not possible, re-
duce the bowel as far as possible to minimise
subsequent loss of bowel length at resection.
 306
E22 E2 Peritoneal Drainage
R. Partridge and A. J. Sabharwal
Peritoneal Drainage
• Peritoneal drains may be placed for a number
of reasons:
– To drain an established intra-abdominal col-
lection –usually done percutaneously under
ultrasound guidance
– As an ‘insurance’ following a difficult or
complicated procedure, e.g. after intestinal
anastomosis in a contaminated abdomen, a
drain will herald an anastomotic leak and al-
low drainage of fluid
– To decompress a distended abdomen in
cases of impaired diaphragmatic excursion
or signs of abdominal compartment syn-
drome
• Drainage systems can be classified as ‘open’ or
‘closed’, ‘suction’ or ‘nonsuction’.
• Suction drains in the abdominal cavity are gen-
erally avoided.
Percutaneous Seldinger Technique
• This allows placement of a drain into a cavity,
which has not been surgically opened.
• Usually it is done under direct ultrasound guid-
ance, or with the site identified by ultrasound
and marked beforehand.
• A fine needle is passed into the peritoneal cav-
ity, the guide wire is passed through the needle,
the needle is removed, and the tract serially di-
lated up to the required size for the drain.
Roland Partridge ()
Specialty Trainee in Paediatric Surgery
rolandpartridge@nhs.net
Atul J. Sabharwal
Consultant Paediatric and Neonatal Surgeon
Atul.Sabharwal@ggc.scot.nhs.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_93, © Springer-Verlag Berlin Heidelberg 2013
R. Partridge and A. J. Sabharwal
• A small skin incision is usually made onto
the wire, to facilitate easy passage of dilators
through the skin.
• A drain may be placed directly over a wire.
• Peel-away introducer kits facilitate placement
of larger calibre drain tubes.
Closed Suction Drain Technique
• Usually come with a sharp metal introducer at-
tached to one end of the drain tubing
• Introducer pushed outwards through wall from
within the cavity
• Small skin incision may be required
Open Technique
• Make a short skin-crease incision using a num-
ber 11 blade, just long enough for the drain tub-
ing to fit snugly through.
• Use curved mosquito artery forceps appropri-
ate to the size of the patient to push through
layers of abdominal wall.
• Use your other hand within the abdominal cav-
ity to protect the internal organs from injury as
the mosquito forceps are pushed through the
peritoneum.
• The tip of the drain tube (Penrose, corrugated
or tube; Fig. 1) is retrieved with the jaws of the
mosquito forceps, from inside the peritoneal
cavity, and pulled out through the skin.
• The drain is fixed to the skin using the tech-
nique described in Chap. A32.
Fig. 1  Penrose and corrugated drains
E22  Peritoneal Drainage 307

Paracentesis

• This involves passage of a needle or catheter

into the abdomen to drain fluid for treatment
or investigation.
• Ultrasound is used to identify the largest pock-
ets of fluid and avoid bladder and bowel. Safe
insertion sites are marked.
• Safe insertion sites are usually found in the Fig. 2  ‘Safe’ catheter insertion
flanks or in the midline just below the umbili- sites
cus (see Fig. 2).
• Figs. 3–6 demonstrate the key steps involved in
paracentesis.

Fig. 4  Catheter advanced over needle

Fig. 3  Small skin incision

Fig. 5  Central portion of catheter is removed Fig. 6  Three-way tap and syringe to drain fluid
308 R. Partridge and A. J. Sabharwal

Tips

77 When cutting the drain tubing, cut at an angle as 77 When tying thread around a compressible drain,
this makes subsequent attachment to a chamber ensure it is not so tight as to compress its lumen.
or vacuum bottle easier. 77 Use a Z-track approach when inserting a needle
in paracentesis, to limit leak from puncture site.

Common Pitfalls

77 Ensure all drain tubing side holes are well within 77 Peritoneal cavity suction drains risk drawing
the target cavity. Failure to do so risks ingress of bowel or other viscera into the tip, with the at-
air or infection and prevents suction working. tendant risk of perforation or bleeding.
77 Remember to send ascitic fluid for microscopy,
culture and sensitivity, protein/albumin, amylase
and electrolytes.
E23  Trauma Laparotomy 309
E23 Trauma Laparotomy E23
R. Partridge and N. Brindley

Principle Transverse Supra-umbilical Approach

• Emergency laparotomy in children is rarely
necessary, but when indicated it must be per-
formed expeditiously.
• There are two options for the approach, trans-
verse supra-umbilical and midline.
See also Chap. A8 for additional information.
• This approach gives better exposure to abdo-
men if the child is 5 years or younger.
• This is because in this age group, the abdomen
has more of a square than rectangular shape.
• An exception to this would be if pelvic organ
injury, such as a ruptured bladder, were sus-
pected, in which case a lower midline incision
may be advantageous.

Fig. 0a

Fig. 0b

Roland Partridge ()

Specialty Trainee in Paediatric Surgery
rolandpartridge@nhs.net

Nicola Brindley
Consultant Paediatric and Neonatal Surgeon
Nicola.Brindley@ggc.scot.nhs.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_94, © Springer-Verlag Berlin Heidelberg 2013
310 R. Partridge and N. Brindley

Midline Laparotomy • Splenic bleeding may be similarly controlled by

See Chap. A9 for further information.
• Can be performed more quickly, thus preferred
if time is crucial.
• This is the incision of choice in older children
with rectangular rather than square abdomens.
Once into the Abdomen
manually compressing the vessels at the splenic
hilum (Fig. 3).
• A stepwise and systematic exploration of each
quadrant, starting from the liver and moving
in a clockwise manner around the abdomen
should be performed (Figs. 3–6).
• Stabilise injuries as they are encountered

• If massive intraperitoneal haemorrhage en-

countered, manual compression of the infra-
diaphragmatic aorta while all four quadrants
of the abdomen are packed may assist.
• Liver bleeding may be controlled using ‘Pring-
le’s manoeuvre’. The dual blood supply of the
liver (hepatic artery and portal vein) is com-
pressed between the surgeon’s index finger
(placed through the foramen of Winslow) and
thumb, as they run through the hepatoduode-
nal ligament anterior to the foramen of Win-
slow (Fig. 2).

Fig. 2  Pinching vessels at the hilum to control splenic

bleeding

Fig. 1  Four-quadrant packing

Fig. 3  Inspection diaphragm and liver with gentle retrac-
tion
E23  Trauma Laparotomy 311

Fig. 5  Kocherisation of the duodenum, if injury identi-

fied here
Fig. 4  Pringle’s manoeuvre: manual compression of the
portal vein and hepatic artery at the foramen of Winslow
to control liver haemorrhage

Fig. 6  Resection of damaged bowel

Tips

77 A retroperitoneal haematoma should be left un-
disturbed unless it is expanding or it overlies the
duodenum or pancreas.
77 A large volume of clear fluid in the abdomen
may herald a ruptured bladder – preoperative
creatinine is likely to be very high and serum so-
dium low in this instance.
77 If massive haemorrhage occurs, unpack the pre-
sumed bleeding quadrant last.

Common Pitfalls

77 Open bowel perforations should be occluded
temporarily with light, noncrushing clamps to
prevent further contamination.
77 If a site of injury is not obvious after a general
search of the abdomen, the lesser sac (which is
opened by dividing the gastrocolic omentum),
subdiaphragmatic spaces and posterior abdomi-
nal wall should all be inspected.
 312 L. Gupta and S. Agarwala
E24 E24 Congenital Diaphragmatic Hernia
L. Gupta and S. Agarwala

Operative Technique

• Make a subcostal laparotomy incision on the

side of the hernia.
• Reduce the herniated visceral contents from the
chest by gentle traction.
• Define the edge of the diaphragmatic defect
and unroll the posterior edge by sharp dissec-
tion (Fig. 1).
• Evaluate if it would be possible to close pri-
marily or if a patch repair would be required.
• Identify a hernia sac is present; if so then ex-
cise the sac.
• Position an intercostal drain through the fifth Fig. 1
intercostal space and anchor this.
• Place interrupted non-absorbable sutures to
double breast the diaphragmatic muscles (Fig.
2). After positioning all the sutures, tie them to
approximate the edges in an overlapping man-
ner. Then apply the second row of sutures to
complete the double breasting (Figs. 3 and 4).
• If the diaphragmatic defect is large and pri-
mary closure is not possible without tension,
then prosthetic mesh can be used to repair the
defect (Fig. 5).
• Close the abdomen layers.

Fig. 2

Lucky Gupta ()

Senior Resident in Paediatric surgery
drgupta_lucky@yahoo.co.in

Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com Fig. 3

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DOI: 10.1007/978-3-642-20641-2_95, © Springer-Verlag Berlin Heidelberg 2013
E24  Congenital Diaphragmatic Hernia
Fig. 4
Tips
77 A right congenital diaphragmatic hernia (CDH)
is more easily repaired with the trans- thoracic
route.
77 Introduction of some air within the hernial sac,
with the help of a catheter, may help in reduc-
tion of its contents.
77 In a case where the posterior rim is absent or hy-
poplastic, the posterior ‘bites’ of the diaphrag-
matic sutures may need to be taken around the
lower ribs.
Common Pitfalls
77 Failure to identify the posterior edge of the dia-
phragmatic defect, that is often curled up, may
make the defect to seem larger than it actually is.
313
Fig. 5
77 For a very small abdominal cavity, stretching of
the wall or creation of ventral hernia may be re-
quired to avoid undue rise in intra-abdominal
pressure.
77 Hernial sac could be opened and retained as a
lining on the patch if a patch closure is done.
77 Failure to properly anchor the patch to the mus-
cles anteriorly and posteriorly will result in re-
currence. Sutures may have to be taken around
the ribs.
 314 M. Clarke and R. Carachi
E25 E25 Diaphragmatic Eventration
M. Clarke and R. Carachi

Diaphragmatic eventration is traditionally man-

aged by plicating the area of the diaphragm which
is either thinned (congenital defects) or weakened
(acquired defects).

Operative Technique

• General anaesthetic with muscle relaxation is

employed
• The patient’s position is supine.
• Isolated left-sided eventration is usually ap-
proached through a subcostal or transverse
upper abdominal incision.
• Right-sided lesions may be approached using
a posterolateral muscle-sparing thoracotomy
through the sixth or seventh intercostal space
to avoid the liver (Fig. 1).
• Bilateral eventration and cases with suspected
or known concomitant abdominal pathology
(i.e. malrotation) should be approached using
an abdominal incision. Fig. 1
• The central area of muscle thinning or weak-
ness is identified (Fig. 2), and the amount of di-
aphragm that must be included in the plication
in order to achieve a taut closure determined.
• The diaphragm should initially aim to be low-
ered to a level of 1–2 intercostal spaces beyond
that which is ultimately desired.
• In some cases the muscle is so thinned that it is
nearly impossible to differentiate the eventra-
tion from a diaphragmatic hernia with a sac.
In this circumstance, it may be necessary to re-

Melanie Clarke ()

Specialty Trainee in Paediatric Surgery
mccclarke@gmail.com
Fig. 2
Robert Carachi
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_96, © Springer-Verlag Berlin Heidelberg 2013
E25  Diaphragmatic Eventration 315

move the attenuated portion of diaphragm or
sac with needle-point monopolar diathermy,
thus creating a defect. This should only be done
to avoid damage to the phrenic nerve.
• Multiple non-absorbable mattress sutures are
then placed in the fashion demonstrated in
Figs. 3 and 4. This has the effect of plicating
the diaphragm and bringing the edges of the
more muscular tissue together.
• If a diaphragmatic defect has been created then
it is closed in a transverse fashion in a similar
manner.
• The result of the repair is that the muscularised
diaphragm edges are brought together with an
intervening portion of ‘gathered’ thin or weak-
ened diaphragm (Fig. 5).

Fig. 3
• Care must be taken to avoid the phrenic
nerve, which divides into anterior and poste-
rior branches in a medial to lateral orientation
(Fig. 4). The phrenic nerve is easier to visual-
ise using a thoracic approach.
• It is important to take bites of tissue that are
adequate enough to avoid the suture cutting
through without being deep enough to cause
damage to any adjacent viscera.

Fig. 4 Fig. 5
316 M. Clarke and R. Carachi

Tips

77 Diaphragmatic eventration can be distinguished 77 If diagnostic doubt persists then dynamic im-
from diaphragmatic herniation by the presence aging using ultrasonography or fluoroscopy to
of a smooth raised diaphragmatic outline on demonstrate paradoxical diaphragmatic move-
chest radiography. ment may be necessary.

Common Pitfalls

77 Care should be taken with suture placement in 77 Fixing the diaphragm to the thoracic wall can be
order to avoid damage both to branches of the at the expense of subsequent mobility.
phrenic nerve and any adjacent viscera.
E26  Long-Gap Oesophageal Atresia – Gastric Pull-Up
E26 Long-Gap Oesophageal Atresia –
Gastric Pull-Up
A. Sinha and S. Agarwala
Technique of Mobilization in the Neck
• Position the patient supine with a roll trans-
versely under the shoulder and neck and ex-
tend the neck. Turn the face to the side oppo-
site to the oesophagostomy (Fig. 1). Ask the
anaesthetist to place a stiff orogastric catheter
in the oesophagus. Prep from the chin to the
lower abdomen.
Fig. 1
• Make an elliptical incision around the oesoph-
agostomy and deepen through the subcutane-
ous tissues and platysma (Fig. 2). Make three-
Anand Sinha ()
Senior Research Fellow in Pediatric Surgery
dranandsinha@hotmail.com
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_97, © Springer-Verlag Berlin Heidelberg 2013
317
E26
or four-stay silk suture on the edge of the oe-
sophagostomy to assist in traction.
• Develop sub platysmal flaps superiorly and in-
feriorly to expose the medial aspect of sterno-
cleidomastoid muscle and the oesophagus. In-
cise the investing layer of deep cervical fascia
longitudinally at the medial edge of the sterno-
cleidomastoid muscle, and dissect between the
carotid sheath laterally and the oesophagus me-
dially.
Fig. 2
• Continue the dissection on the oesophageal
wall to mobilize and separate it from the ster-
nocleidomastoid muscles, carotid sheath and
the trachea (Fig. 3).
• Divide the sternal head of the sternocleidomas-
toid muscle and incise the fascia in the supra-
sternal space of Burns.
• Use blunt and sharp dissection to develop a
plane in the retrosternal space as far distally
possible if a retrosternal route is planned.
• In a case where a mediastinal route for the pull-
up is planned, dissect and develop a plane pos-
318 A. Sinha and S. Agarwala

• Divide the falciform ligament between liga-

tures.
• Dismantle the gastrostomy and repair the
gastric wall in two layers with Vicryl sutures
(Fig. 4).
• Divide the left triangular ligament and fold the
left lobe of the liver medially to expose the gas-
tro-oesophageal (GE) junction, the abdomi-
nal oesophagus and the oesophageal hiatus
(Fig. 4).
• Use diathermy to divide the peritoneum over
the lower oesophagus transversely and dissect
the oesophagus away from the crura. Mobi-
Fig. 3 lize the lower oesophagus circumferentially and
then loop it on a sling.
• With the help of the sling, retract the GE junc-
tion downwards and continue dissection prox-
imally, into the posterior mediastinum, on the
oesophageal wall using blunt and sharp dissec-
tion. The vagal fibres are divided in this dissec-
tion.
• Continue this trans-hiatal dissection proxi-
mally between the pericardium anteriorly and
the prevertebral fascia posteriorly, until the
entire oesophagus is mobilized (Fig. 5). Con-
firm this by placing the index finger of your
left hand into the superior mediastinum from
the neck wound where similar dissection has
already been done during the neck dissection
Fig. 4

terior to the trachea and into the superior me-

diastinum, keeping posterior to the trachea.
• In a case where a previous cervical oesopha-
gostomy has not been fashioned previously,
it is essential to dissect the oesophagus in the
neck and divide it (see Chap. B16, ‘Cervical Oe-
sophagostomy’). The distal portion is excised
with the native oesophagus, and proximal end
is used for the oesophagogastric anastomosis.

 echnique of Mobilization in the

T
Abdomen and Gastric Pull-Up

• Make a supra-umbilical midline incision to ac-

cess the abdomen (Fig. 1).
Fig. 5
E26  Long-Gap Oesophageal Atresia – Gastric Pull-Up
(Fig. 5). If thoracotomy and oesophageal mo-
bilization have been done, this step has already
been carried out.
• Deliver the lower oesophagus into the abdo-
men. Transect the oesophagus at the GE junc-
tion and repair the gastric wall in two layers
with Vicryl sutures (Fig. 6).
Fig. 6
Fig. 7
319
• Mobilize the stomach by dividing the short gas-
tric, left gastric and the left gastro-epiploic ves-
sels. Divide the vessels of the greater omentum
a little distance away from the greater curvature
of the stomach, taking care to preserve the vas-
cular arcade arising from the right gastro-epi-
ploic vessels (Fig. 7).
• Divide the gastrohepatic ligament again pre-
serving the arcade supplying the lesser curva-
ture and the right gastric artery (Fig. 8).
• Perform the Kocher’s manoeuvre to mobilize
the first and second part of duodenum (Fig. 6).
• In cases where a retrosternal route has been
decided on, retract the xyphoid process ante-
riorly and just posterior to it in the midline;
divide the fascia between the anterior attach-
ments of the diaphragm. With your index fin-
ger create a retrosternal space towards the neck
to meet the retrosternal space created from the
neck incision.
• Position a thick catheter from the neck to the
abdomen through the retrosternal space or the
posterior mediastinal space, as the case may be.
• With strong silk sutures anchor the fundus of
the stomach to this catheter (Fig. 9) and gently
pull up the fundus into the neck wound so that
Fig. 8
320 A. Sinha and S. Agarwala

the entire stomach lies in the mediastinum with

the pylorus at the oesophageal hiatus. During
this manoeuvre care should be taken to avoid
rotation of the stomach. Anchor the pylorus
at the hiatus with two Vicryl sutures.
• Anastomose the highest point of the fundus
of stomach to the end of the oesophagus with
interrupted Vicryl sutures, to fashion an wide
oblique anastamosis. Before the anterior layer
is completed ask the anaesthetist to position a
nasogastric tube of appropriate size so that its
tip lies in the stomach which is now in the me-
diastinum (Fig. 10).
• Place a soft drain next to the anastamosis in the Fig. 10
neck (Fig. 11) and close the deep cervical fas-
cia and platysma in two layers with interrupted
Vicryl sutures. Close the skin with subcuticular
Monocryl sutures.
• Place a trans-hiatal mediastinal tube drain and
close the abdomen (Fig. 11).

Fig. 11

Fig. 9
E26  Long-Gap Oesophageal Atresia – Gastric Pull-Up
Tips
77 In cases where dense adhesions are expected in
the mediastinum, as in strictures following cor-
rosive ingestion, excision of oesophagus should
be performed through a lateral thoracotomy.
The oesophageal bed is prepared and a red rub-
ber catheter positioned in the oesophageal bed
from the neck to the abdomen and thoracotomy
closed. This catheter is used in the subsequent
steps for the pull-up.
Common Pitfalls
77 Too much mobilization of the oesophagus in the
neck can result in ischaemia, with resultant anas-
tomotic breakdown and dysmotility later on.
77 Inadequate mobilization in the region of thoracic
inlet can result in constriction at this level.
321
77 It is advisable to fashion a feeding jejunostomy
to institute early enteral feeds. This specially
comes in use in cases where there is an anasto-
motic leak from the oesophagogastric anasta-
mosis.
77 Fashion the oesophagogastric anastamosis pref-
erably in the neck rather than in the posterior
mediastinum, as leaks from this anastamosis are
very common.
77 Some surgeons add a pyloromyotomy or a pylo-
roplasty to aid in gastric emptying.
77 In case the pleura is breached, place an intercos-
tals drain on that side.
77 Choosing gastric pull­-up in cases of scarred
stomach, as cases of acid ingestion, can lead to
graft failure.
 322 N. Sugandhi and S. Agarwala
E27 E27 D uodenal Atresia
N. Sugandhi and S. Agarwala

Operative Technique

• Ask for intravenous antibiotics to be given at

induction of general anaesthesia.
• Leave the nasogastric tube to free drainage to
decompress the stomach.
• Position the patient supine and prepare the ab-
domen from xiphisternum to pubis.
• Make a right transverse supra-umbilical inci-
sion approximately 1–2 cm above the umbili-
cus (see Chap. A8).
• Mobilise the ascending colon and hepatic flex-
ure medially and inferiorly using a combina-
tion of sharp, scissor dissection and bipolar
diathermy, to expose the duodenum.
• Inspect the duodenal abnormality to identify Fig. 1
the dilated proximal blind ending duodenum
and the distal narrow collapsed duodenal seg-
ment. Confirm the type of atresia, and identify
associated anomalies including annular pan-
creas, pre-duodenal portal vein and malrota-
tion.
• Free the duodenum laterally from its retroperi-
toneal attachments with sharp, dissecting scis-
sors and bipolar diathermy dissection (Ko-
cher’s manoeuvre) (Fig. 1). Do not stray me-
dially during this dissection, to avoid iatrogenic
damage to the common bile duct or ampulla
of Vater. Fig. 2
• Place two stay sutures on the distal end of the
dilated proximal segment and make a trans-
verse incision between them (Fig. 2).

Nidhi Sugandhi ()

Senior Resident in Pediatric Surgery
drnidhisugandhi@gmail.com

Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com Fig. 3

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_98, © Springer-Verlag Berlin Heidelberg 2013
E27  Duodenal Atresia 323

• The incision on the proximal dilated part

should be made at least 1 cm away from the
atretic segment to avoid injury to the ampulla
of Vater, hat may open immediately adjacent
to the atresia.
• Make a longitudinal incision of similar length
on the distal collapsed segment to allow ap-
proximation without tension (Fig. 2).
• If the two ends of the duodenum are widely
separated, it may be necessary to divide the lig-
ament of Treitz with additional mobilization
of the distal duodenum posterior to the supe-
rior mesenteric vessels to facilitate a tension-
free anastomosis.
• Construct a diamond-shaped anastomosis
(Kimura’s technique) in a single layer with in-
Fig. 4 terrupted full-thickness 4 or 5/0 Vicryl sutures
(Figs. 3 and 4).
• During the anastomosis it is important to iden-
tify the ampulla of Vater to ensure it is not com-
promised. Squeezing the gallbladder causes bile
to flow from the ampulla, making it easier to
visualize.
• Before completing the anterior layer of the
anastomosis, ask the anaesthetist to advance
a nasal trans-anastomotic tube until it is vis-
ible at the anastomosis. If a gastrostomy is
planned, the trans-anastomotic tube can be
placed through a gastrostomy tract.
• Manipulate the tube until the tip lies beyond
the duodenojejunal flexure before completing
the anterior layer of the anastomosis (Fig. 5).
• Flush the tube with 20–30 ml of normal saline
to exclude a second, synchronous distal atresia.
• Some authors favour leaving a drain next to the
duodenal repair.
• Close the abdomen in layers, as described in
Fig. 5 Chap. A8.
324 N. Sugandhi and S. Agarwala

Tips

77 The presence of bile in a normal distal duode-
num confirms the diagnosis of a pre-ampullary
duodenal atresia.
77 If an atretic segment is not identifiable, a naso-
gastric tube should be advanced into the duo-
denum to exclude a type 1 atresia (a duodenal
membrane or windsock). If doubt persists, ad-
vancing the nasogastric tube may be facilitated
by making a small gastrostomy.
77 If a duodenal web is identified, a 2- to 3-cm du-
odenotomy should be made on the antimesen-
teric bowel wall, overlying the transition from di-
lated to collapsed bowel. Applying traction to
the web puckers the duodenal wall at its point of
attachment. Extreme caution must be exercised
during web excision to avoid damaging the am-
pulla of Vater, which may open anteriorly, poste-
riorly or medially into the web or adjacent to it.
Squeezing the gallbladder (as described above)
may help identify the opening. Do not excise
the web until the ampulla has been clearly iden-
tified. Use a stay suture to apply traction to the
central portion of the web. Dissecting scissors
are used to excise the web, leaving a cuff of tis-
sue on the duodenal wall and sparing the medial
portion of the web where the ampulla of Vater is
usually situated (Fig. 6).

Common Pitfalls

77 Failure to identify a duodenal web can occur.

77 Failure to identify a second, synchronous, distal
atresia in the small bowel is also injurious.
77 Failure to recognize the position of the ampulla
of Vater or making the incision too close to the
atretic segment may result in iatrogenic injury to
the ampulla.
77 If an annular pancreas is identified, it should be
bypassed and never divided.
77 Failure to identify associated anomalies can hap- Fig. 6
pen in 50 % of cases.
77 Air distal to the apparent duodenal obstruction
may occur because of a bifid common bile duct
bypassing the obstruction, but also raises the
possibility of the alternative diagnosis of malro-
tation and volvulus, that must be excluded as a
matter of urgency.
E28  Necrotising Enterocolitis 325
E28 Necrotising Enterocolitis E28
R. Kronfli and C. F. Davis

Surgical Management Options • Primary peritoneal drainage (Fig. 1)

• Primary peritoneal drainage
– With or without subsequent laparotomy
• Laparotomy
– Resection and primary anastomosis
– Resection and formation of stomas
– ‘Clip and drop’ and second look
– ‘Open and close’
– Refer to Chap. E22, ‘Peritoneal Drainage’
– This procedure is best performed in the left
iliac fossa in neonates to avoid liver and
other viscera.
Laparotomy
A standard transverse supra-umbilical incision is
used (Fig. 2).
Refer to chapter entitled ‘Access into the Ab-
domen’ for additional instruction.

Resection and Primary Anastomosis

Refer to Chap. E13, ‘Loop Enterostomy’ for ad-

ditional information.

Fig. 1  Peritoneal drain

Rania Kronfli ()

Specialty Trainee in Paediatric Surgery
rkronfli@doctors.org.uk

Carl F. Davis
Consultant Paediatric and Neonatal Surgeon
Carl.Davis@ggc.scot.nhs.uk
Fig. 2  Laparotomy

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_99, © Springer-Verlag Berlin Heidelberg 2013
326
Resection and Formation of Stomas
Refer to Chap. E14, ‘Enterostomy and Colos-
tomy’ for additional guidance.
‘Clip and Drop’
• All portions of clearly nonviable bowel are re-
sected.
• The ends of the remaining bowel are clipped
and returned to the abdomen.
Fig. 3  ‘Clip and drop’
R. Kronfli and C. F. Davis
• The peritoneal cavity is irrigated.
• A further laparotomy is performed 48–72 h
later.
• At this point either primary anastomosis or
stoma formation is carried out.
‘Open and Close’
• Pan-intestinal necrotising enterocolitis (NEC
totalis)
• Amount of viable bowel not compatible with
life
• Abdomen closed without resection
• Re-orientation of care
E28  Necrotising Enterocolitis 327

Tips

77 Surgery for NEC can be very difficult – if in doubt, 77 Consider using an abdominal patch to increase
ask for help. the abdominal cavity size and optimise intesti-
nal and renal perfusion as well as venous return
to the heart.

Common Pitfalls

77 Be careful of the liver, that is often large and frag- 77 Regardless of surgical management of acute
ile, as haemorrhage can be catastrophic. NEC, remember that patients may develop an in-
testinal stricture, which requires a laparotomy,
resection and anastomosis.
 328
E29 E29 Wilms Tumour
N. Sugandhi and S. Agarwala
Operative Technique
• Place the patient in the supine position.
• Make a long upper abdominal laparatomy.
• Collect any peritoneal fluid if present and send
it for fluid cytology.
• Inspect the abdominal cavity thoroughly for
liver or peritoneal metastasis or contiguous in-
volvement of the adjoining organs.
• Enter the retroperitoneal space by mobilizing
the ascending or the descending colon depend-
ing on the side of the tumour (Fig. 1). Divide
the peritoneal attachments of the colon to the
lateral abdominal wall and mobilize the colon
medially. On the right side, the duodenum also
must to be mobilized medially.
Fig. 1
Nidhi Sugandhi ()
Senior Resident in Paediatric surgery
drnidhisugandhi@gmail.com
Sandeep Agarwala
Associate Professor of Surgical Paediatrics
sandpagr@hotmail.com
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_100, © Springer-Verlag Berlin Heidelberg 2013
N. Sugandhi and S. Agarwala
• Pack with large gauze swabs the rest of the ab-
dominal contents in case of Tumour rupture.
• Start dissecting at the hilum unless the tumour
is huge or crossing the midline. In such cases
start the mobilization laterally and then clear
superiorly and inferiorly before approaching
the hilum.
• Mobilize the renal vein until its entry into the
inferior vena cava (IVC) and suspend it in a
sling. Palpate it and the IVC carefully to rule
out an intra vascular thrombus.
• Identify and mobilize the renal artery, poste-
rior and superior to the renal vein and suspend
it in a sling (Fig. 2).
• Finally identify the ureter and trace it caudally
to the urinary bladder. Transfix the ureter and
divide it (Fig. 2).
• Transfix the renal artery and divide between
ligatures. Transfix the renal vein and di-
vide (Fig. 3).
• Now mobilize the kidney with the tumour
within Gerota’s fascia from the retroperito-
neal surface. Diathermize or ligate any large
vessels from the fascia to the retroperitoneum.
Remove the tumour specimen after mobiliza-
tion.
• Perform lymph node sampling in an orderly
fashion sampling the paracaval and para-aor-
tic supra-hilar and infra-hilar nodes in addition
to the ipsilateral iliac nodes. Biopsy any other
grossly enlarged nodes.
• Inspect the tumour bed for any residual tumour
and ensure adequate heamostasis.
• Close the incision in layers.
E29  Wilms Tumour 329

Fig. 2

Fig. 3
330 N. Sugandhi and S. Agarwala

Tips

77 Occasionally the tumour may be infiltrating the 77 The adrenal is removed with the tumour in up-
diaphragm superiorly. In such cases part of the per polar tumours, but it can be preserved in
diaphragm may need to be removed with the tu- others.
mour specimen. 77 Avoid tumour rupture and spill by gentle han-
dling.

Common Pitfalls

77 Lymph node dissection or sampling, if not done

adequately, is a common cause for under staging
and under management.

C A R L M . W. WI LMS
(1867 – 1918)
German pathologist and surgeon

Max Wilms qualified in medicine from the University of Bonn and then trained in Cologne,
Leipzig and Basel before he was appointed to Chair of Surgery at Heidelberg. During a short
but phenomenal career, he made many innovations in the field of surgery including an ap-
proach for treating pulmonary tuberculosis by a partial rib resection. He is remembered for
his work in the pathological studies of the development of tumour cells; Wilms tumour is an
eponym for nephroblastoma.
E30  Abdominal Neuroblastoma 331
E30 Abdominal Neuroblastoma E30
N. Sugandhi and S. Agarwala

Operative Technique

• Place the patient in the supine position.

• Make a transverse supra-umbilical laparotomy.
• Enter the retroperitoneum by dividing the
peritoneal attachments of the ascending or
descending colon from the lateral abdominal
wall and retracting them medially, depending
on the side of the tumour (Fig. 1).
• Kocherize the duodenum if the tumour is on
the right side. Start the dissection at the caudal
limit of the tumour. Lift the fascia on the ad-
ventitia over the anterior surface of the great
vessel (inferior vena cava on the right and aorta
on the left) and incise it longitudinally (Fig. 2).
• Proceed cranially with the dissection, lifting the Fig. 1
tumour off the vessel in the plane outside the
vessel (Fig. 3).
• Clear the origin of bilateral renal arteries, in-
ferior and superior mesenteric arteries and the
celiac axis from the tumour while proceeding
in the appropriate plane.
• Farther cranially, reflect the right lobe of the
liver by cutting the triangular and coronary lig-
aments to clearly display the upper limit of the
tumour.
• Identify and ligate the blood supply of the tu-
mour. Now mobilize the tumour circumferen-
tially and remove it (Fig. 4).
• Remove any visible gross lymphadenopathy.
• Inspect the displayed vessels for any residual
tumour and ensure adequate haemostasis.
• Close the incision in layers. Fig. 2

Nidhi Sugandhi ()

Senior Resident in Pediatric Surgery
drnidhisugandhi@gmail.com

Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_101, © Springer-Verlag Berlin Heidelberg 2013
332 N. Sugandhi and S. Agarwala

Fig. 3

Fig. 4
E30  Abdominal Neuroblastoma 333

Tips

77 With left-sided tumours, mobilize the spleen, tail
of pancreas and the stomach and retract medi-
ally. The left triangular ligament of the liver also
needs to be divided.
77 Neuroblastomas usually do not invade the tu-
nica of vessels; hence a plane of dissection exists
in a subadventitial position between the vessels
and the tumour. Sharp dissection over the ves-
sels can be done once in the correct plane.

Common Pitfalls

77 Attempting to dissect the tumour from the great
vessels in incorrect plane will lead to haemor-
rhage, tumour rupture and gross residue.
77 Inability to correctly identify the renal vessels can
lead to their transaction and renal loss.
77 Not tackling the grossly enlarged lymph nodes
will leave gross residue.
77 Continuing to dissect in the face of tumour infil-
tration into adjoining organs will unnecessarily
jeopardize the patients safety.

J U DA H F OLKMAN
(1933 – 2008)
American paediatric surgeon and cancer researcher

Judah Folkman is one of the great medical scientists of the last century. During the course
of an illustrious career, he was both Chair of Paediatric Surgery and Chair of Cell Biology at
Harvard Medical School. He was an outstanding surgeon, teacher and mentor at Children’s
Hospital in Boston for many years. He brought about innovative ideas in the management
of hydrocephalus and intraventricular haemorrhages. His research work for which he is bet-
ter known founded the branch of cancer research known as Angiogenesis/Anti-angiogenesis
therapy. Judah Folkman strongly believed that anti-angiogenesis therapy would join other mo-
dalities such as chemotherapy, radiotherapy and immunotherapy in the war against cancer.
 334
E31 E31 Meconium Ileus
M. Steven and G. M. Walker
Complicated Meconium Ileus
A complicated meconium ileus (MI):
• Includes segmental volvulus, bowel perfora-
tion, intestinal atresia or giant cystic meco-
nium peritonitis
• Requires laparotomy after preoperative fluid
resuscitation, nasogastric (NG) tube insertion,
intravenous antibiotics and matching of blood
products
• Requires the approach of a transverse supra-
umbilical incision
• Definitive procedure is dictated by findings at
surgery (see below for surgical options).
• General principles
– Resect atretic/necrotic bowel (see Chap. E17,
‘Small Bowel Atresia’)
– Double-barrelled enterostomy preferable
in (giant cystic) meconium peritonitis (see
Chap. E12, ‘Exomphalos’)
– Primary anastomosis may be considered in
isolated volvulus or atresia (see Chap. E13,
‘Loop Enterostomy’)
Non-complicated MI
• Up to 50 % of cases can be managed non-op-
eratively with therapeutic contrast enema.
• NB – Ensure adequate fluid resuscitation prior
to contrast enema. Contrast solution is hyper-
osmolar and can cause marked fluid shift.
Mairi Steven ()
Specialty Trainee in Paediatric Surgery
mairisteven@doctors.org.uk
Gregor M. Walker
Consultant Paediatric and Neonatal Surgeon
Gregor.Walker@ggc.scot.nhs.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_102, © Springer-Verlag Berlin Heidelberg 2013
M. Steven and G. M. Walker
• If the small bowel is not decompressed and pa-
tient remains stable, consider a repeat enema
after further period of resuscitation.
• Indications for surgery include failure to de-
compress post contrast enema, progressive ab-
dominal distension compromising ventilation
or an iatrogenic perforation at enema.
• The aim of surgery is complete evacuation of
obstructing meconium.
• The approach is a transverse supra-umbilical
incision.
• Findings can include terminal ileum obstruc-
tion with inspissated meconium pellets with
proximal bowel dilatation.
Surgical Options
Enterotomy and Irrigation
• Full laparotomy to delineate anatomy and en-
sure no atresia.
• Simple purse-string suture is sited on antimes-
enteric border of dilated ileum 5–10 cm prox-
imal to narrowed portion of terminal ileum
containing obstructing pellets.
• Pass a 10-Fr Jacques catheter through a small
enterostomy in the centre of purse string.
• Tighten purse string and irrigate proximally
and distally with saline, using a catheter-tip
syringe
• Consider adding N-acetyl cysteine to saline (di-
lute to 4 % concentration).
• Combination of irrigation and manipulation
breaks up thick meconium, that can be re-
moved via the enterostomy or washed out dis-
tally.
• Once pellets are clear of terminal ileum, ex-
clude colonic atresia by distal irrigation.
• Close enterostomy with interrupted absorbable
sutures.
E31  Meconium Ileus
• Alternatively, the appendix can be used as a
conduit (Fig. 1).
• Amputate tip of appendix, pass catheter into
caecum and advance in a retrograde fashion
into ileum.
• Following relief of obstruction, exclude distal
atresia and perform standard appendectomy.
Fig. 1  Appendiceal irrigation
Fig. 2  Bishop–Koop enterostomy
335
T-Tube Ileostomy
This is rarely used now and involves an enteros-
tomy as described above, but a T-tube or Malecot®
catheter is inserted though the abdominal wall
and left in situ to facilitate postoperative wash-
outs. Washouts are commenced on postoperative
day 1 and once full decompression is achieved,
the tube can be removed and the enterostomy will
close spontaneously.
Resection and Primary Anastomosis
Resection of the obstructed ileum and proximal
dilated loop with primary anastomosis (see Chap.
E13) results in loss of bowel length and an un-
vented intraperitoneal anastomosis. As a result,
many surgeons favour irrigations (see above) or
conventional divided stomas (see Chap. E12).
The following surgical options are predomi-
nantly of historical interest, but may (rarely) be
considered in certain circumstances:
Bishop­–Koop Distal Chimney Enterostomy
• Resect the dilated proximal loop.
• Construct an anastomosis between the end of
the proximal bowel and the side of the distal
loop.
• Bring out the end of the distal bowel as an end
ileostomy (Fig. 2).
• Leave a catheter in the distal loop to allow post-
operative antegrade washouts.
• One advantage is that as the obstruction is re-
lieved, intestinal content passes preferentially
into the distal bowel, reducing fluid and elec-
trolyte loss from the stoma. The stoma may
close spontaneously.
• One disadvantage is the potential morbidity of
an intraperitoneal anastomosis.
Santulli–Blanc Enterostomy
• This procedure is essentially a reverse Bishop–
Koop (Fig. 3).
• Resect the dilated proximal loop.
336 M. Steven and G. M. Walker

Fig. 4  Mikulicz enterostomy

Fig. 3  Santulli–Blanc enterostomy

• Construct an anastomosis between the end of

the distal loop and the side of the proximal
loop.
• Bring out the end of the proximal loop as an
end ileostomy.
• An advantage is that the proximal bowel is usu-
ally decompressed effectively at the initial sur-
gery.
• One disadvantage is that persistently high
stoma losses occur if the distal obstruction is
not cleared completely.

Mikulicz Double-Barrelled Enterostomy

• This procedure is rarely used.

• Bring the dilated loop containing inspissated
meconium out of the abdomen.
• Suture afferent and efferent limbs together with
interrupted seromuscular sutures.
• Close the abdomen and resect the exteriorized
dilated loop.
• Use a Mikulicz spur-crushing clamp to create
a common lumen in the stoma (Fig. 4).
• On advantage is that resection occurs outside
the abdomen, reducing the risk of peritoneal
soiling.
• A disadvantage is the loss of bowel length and
the potential for high-output stoma (mid-small
bowel stoma).
E31  Meconium Ileus
Tips
77 Consider widening your enterostomy if pellets
are difficult to retrieve.
77 Always measure and record small bowel length.
77 Construct a clear operation note and consider in-
cluding a diagram to clarify the anatomy.
Common Pitfalls
77 Close monitoring of the child’s posttherapeutic
enema or surgery is vital. Ensure adequate fluid
and electrolyte resuscitation – deaths from hy-
povolaemic shock have been reported after con-
trast enema.
337
77 Primary anastomosis can be performed but a
double-barrelled stoma is the safest option.
77 Cystic fibrosis should be diagnosed promptly to
enable multidisciplinary management to com-
mence.
77 After hyperosmolar contrast enema, 1.5× main-
tenance fluids may be required for 8–12 h.
 338
E32 E 32Rectal Biopsy
T. J. Bradnock and G. M. Walker
Suction Rectal Biopsy
• Administer prophylactic antibiotics.
• Ensure that vitamin K given to neonates.
• Ensure pathologist available; the biopsy must
be sent fresh.
• The procedure can be performed without gen-
eral anaesthetic.
• Neonates should be placed in the lithotomy po-
sition.
• Older children should be placed on the left lat-
eral side, knees bent.
• Anatomy of suction biopsy forceps (Fig. 1)
– Blunt, hollow tube, side hole 1 cm from tip
– Concealed blade within shaft of instrument
– Marks on side of tube show level of biopsy
– Side port for attaching suction tubing
– 5- to 20-ml syringe to apply suction
– Variation
– Disposable capsules and blade (Fig. 2)
– In-line manometer to record suction
Fig. 1
Tim J. Bradnock ()
Specialty Registrar in Paediatric Surgery
The Department of Paediatric Surgery, Dalnair Street,
Yorkhill Hopsital, Glasgow G3 8SJ, Scotland, UK
Email: tjbradnock@doctors.org.uk
Gregor M. Walker
Consultant Paediatric and Neonatal Surgeon
Gregor.Walker@ggc.scot.nhs.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_103, © Springer-Verlag Berlin Heidelberg 2013
T. J. Bradnock and G. M. Walker
Technique
• This procedure requires two people.
• Assemble instrument as per manufacturer’s in-
structions.
• Insert lubricated instrument per rectum.
• Advance so side hole is >2 cm (neonates) or 3
cm (children) above the anal verge.
• Gently press side hole against posterior rectal
wall (Fig. 3).
• The assistant aspirates syringe to apply suction,
drawing superficial bowel wall into side hole.
• Pause 2–3 s and deploy the blade.
• Release suction and remove instrument.
• Unscrew tip or detach and open capsule.
• Remove specimen with needle.
• Check for adequacy of specimen (see ‘Tips’).
• The fresh specimen is sent to pathology in a
sealed container to avoid desiccation.
• Always denote biopsy level on form.
Fig. 2
E32  Rectal Biopsy 339

Open Rectal Biopsy

• Administer prophylactic antibiotics.

• Use general anaesthesia.
• Place patient in the lithotomy position.
• Prepare the operative field using Betadine.
• Perform a rectal examination and evacuate any
stool.
• Insert a Park retractor or nasal speculum into
anal canal to expose the dentate line.
• Place two stay sutures in the midline poste-
rior rectal wall, 2 and 3 cm above dentate line
(Fig. 4).
• Tie the upper suture and leave needle in situ,
as it will be used to close the defect (Fig. 5).
• Use sharp-pointed (Iris) scissors to take a 0.5-
to 1-cm strip of rectal wall including mucosa
and submucosa (dotted line, Fig. 5).
Fig. 3 • The fresh specimen is sent to pathology in a
sealed container.
• Use apical stay stitches to complete a continu-
ous suture opposing the rectal wall, closing the
defect and achieving haemostasis (Fig. 6).

Fig. 4 Fig. 5

• Repeat biopsy at 3 or 4 cm or until sample is

adequate for diagnosis.
• Perform rectal examination to exclude active
bleeding, and observe patient for 4 h.

Fig. 6
340 T. J. Bradnock and G. M. Walker

Tips

77 Suction rectal biopsy 77 Open rectal biopsy

– Good communication with an assistant who
understands the process is essential.
– An adequate specimen for diagnosis should
measure approximately 3 × 1 mm with a whit-
ish layer of submucosa visible.
– Keep scissors flat, parallel to the bowel wall.
– If the bowel wall is not freely mobile when
placing sutures, you are probably still in anal
canal (too low).

Common Pitfalls

77 Suction rectal biopsy
– Do not exceed maximum suction of −20 cm
water.
– Blunt blades reduce the diagnostic yield. En-
sure they are sharpened regularly.
– Always biopsy the posterior rectal wall in the
midline. Anterior biopsies bear the risk of
perforating the rectovesical or rectovaginal
pouch.
– Ensure that a neonate patient has received vi-
tamin K before the biopsy. Significant bleed-
ing is rare but this is vital.
77 Open rectal biopsy
– Do not remove needle from apical stay; bleed-
ing makes closing the wound difficult after-
wards.

H A R A L D H I RS CHS PRUNG
(1830 – 1916)
Danish paediatrician

It is fortunate for us that as a young man, Harald Hirschsprung decided to study medicine
rather than take over his father’s tobacco business. During the course of a career that spanned
over 40 years, he devoted himself to the care of children. He not only practiced conventional
hospital paediatrics, but he also researched and subsequently published his findings on many
conditions including rickets, pyloric stenosis, intussusception as well as a particular form of
constipation, that eventually came to bear his name (Hirschsprung diease).

Even though Hirschsprung was the first to describe Hirschsprung disease, he believed it was
the dilated proximal segment of the bowel, that was diseased rather than the distal agangli-
onic segment, as we now know.
E33  Transanal Endorectal Pull-Through for Rectosigmoid Hirschsprung Disease 341
E3 Transanal Endorectal Pull-Through E33
for Rectosigmoid Hirschsprung Disease
A. T. Hadidi

General Considerations Operative Technique

Endorectal pull-through via an abdominal ap-
proach was first described by Soave in 1964. A
primary laparoscopic-assisted endorectal pull-
through with transanal mucosectomy was de-
scribed by Georgeson in 1995. Three years later,
De la Torre-Mondragon described mucosectomy,
colectomy and pull-through for rectosigmoid
Hirschsprung disease, using an entirely transanal
approach, without the need for laparotomy or lap-
aroscopy (TEPT).
The principle operative steps are illustrated in
Fig. 1.
• Four stay sutures (on a round needle) are
placed around the mucocutaneous junction at
the 12, 3, 6 and 9 o’clock positions.
• Another four stay sutures are taken in between
the first four sutures at the 1, 4, 7 and 11 o’clock
positions to open the anus and facilitate dissec-
tion.
• Another circle of stay sutures are placed 1 cm
proximal to the first eight stay sutures using a
rounded needle, just above the dentate line.
• A circular incision is made in the rectal mucosa
between the two rings of stay sutures (Fig. 1).
• The submucosal dissection is continued proxi-
mally for 5 to 7 cm, using fine-needle diathermy
(Fig. 2), leaving the muscular cuff intact until

Fig. 1

Ahmed T. Hadidi ()

Chairman of Paediatric Department
Emma Klinik GmbH, D63069 Seligenstradt, Germany
Ahmedhadidi@yahoo.de Fig. 2

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_104, © Springer-Verlag Berlin Heidelberg 2013
342 A. T. Hadidi

the peritoneal reflection is reached. Some sur-

geons advocate a shorter muscle cuff of 2–4 cm.
• Once above the peritoneal reflection, the mus-
cular cuff is opened between two stay sutures
and incised around its full circumference.
• The aganglionic bowel is gradually pulled out
through the anus, and the rectal and sigmoid
vessels are divided (Fig. 3). A biopsy is taken
for fresh frozen section analysis to determine
the level of ganglionic bowel.
• The muscle cuff is split down to the internal
sphincter in the posterior midline (Fig. 4).
• Once normal, ganglionic bowel is reached, the
healthy colon is opened anteriorly (Fig. 5) and
sutured to the initial resection site just above
the dentate line.
• The anastomosis is completed with a single
layer of 4-0 interrupted Vicryl sutures, taking
full-thickness ‘bites’ of the pulled-through co-
lon and deep bites of the rectal wall just above
the dentate line (Fig. 6).

Fig. 4

Fig. 3 Fig. 5
E33  Transanal Endorectal Pull-Through for Rectosigmoid Hirschsprung Disease
Fig. 6
Tips
77 A rigid Nelaton urethral catheter can be intro-
duced per urethra at the start of the procedure
to aid identification and avoid injury to the ure-
thra.
77 Submucosal dissection should start at the 3
o’clock position and be continued anteriorly un-
til the 9 o’clock position is reached to ensure that
the proper plane is identified safely.
Common Pitfalls
77 Avoid opening the muscle cuff before the peri-
toneal reflection is reached as, this increases the
risk of damaging the pelvic splanchnic nerves,
that run close to the rectal wall.
77 Avoid twisting of the bowel during the pull-
through, as this may result in early mechanical
obstruction.
343
77 Submucosal dissection should be carried out for
at least 6 cm above the dentate line to ensure
the peritoneal reflection is reached before the
dissection become full thickness.
77 The muscle cuff should always be split in the
posterior midline to avoid damage to adjacent
structures.
77 Routinely remove all redundant hypertrophied
colon above the funnel (transition zone) to avoid
inertia and faecal stagnation in the redundant
colon.
77 Ensure that a tension-free anastomosis is con-
structed to reduce the risk of anastomotic stric-
ture.
77 Splitting of muscle cuff should stop 2 cm above
the dentate line to avoid any risk of incontinence.
77 Splitting the muscle cuff is essential to prevent
retraction and outlet obstruction. Splitting the
cuff reduces the risk of enterocolitis and im-
proves functional results.
 344 T. J. Bradnock and G. M. Walker
E34 E34 Open Endorectal (Soave-Boley)
Pull-Through
T. J. Bradnock and G. M. Walker

This operation is increasingly being performed us- • Intravenous antibiotics are given at induction
ing laparoscopic-assisted transanal (see Chap. I16, of general anaesthetic.
Laparoscopic Splenectomy’) or purely transanal • The patient is positioned supine with the but-
approaches (see Chap. E33, Transanal Endorec- tocks at the edge of table, elevated on a rolled
tal Pull-Through for Rectosigmoid Hirschsprung towel and the legs padded, draped and sup-
Disease’). In the ‘open’ method, endorectal dissec- ported on ‘plastic skis’ off the end of the table.
tion can be carried out from the abdominal ap- • The entire operative field including the abdo-
proach, or transanally. men, buttocks and perineum is prepared.
• The surgeon stands to the left of the patient.
• Options available for the incision include:
Preoperative Management – Left paramedian, as originally described by
Soave (see Chap. A9, ‘Midline Laparotomy
• Histological confirmation of rectal agangli- and Paramedian Incision’).
onosis on rectal biopsy is done – The Pfannenstiel incision (see Chap. A11,
• Maintenance of colonic decompression: ‘Pfannenstiel Incision’) yields better cosme-
– Rectal washouts if a primary pull-through
is planned.
– Levelling enterostomy if surgical preference
for a staged pull-through, failure to decom-
press with washouts or presentation with se-
vere enterocolitis.
• Evidence of at least regain of birth weight is
important.
• Consider additional rectal washouts with or
without enemas in the days before the pull-
through.

Operative Technique

• Insert urethral catheter.

Tim J. Bradnock ()

Specialty Registrar in Paediatric Surgery
The Department of Paediatric Surgery, Dalnair Street,
Yorkhill Hopsital, Glasgow G3 8SJ, Scotland, UK
Email: tjbradnock@doctors.org.uk

Gregor M. Walker
Consultant Paediatric and Neonatal Surgeon
Gregor.Walker@ggc.scot.nhs.uk Fig. 1

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_105, © Springer-Verlag Berlin Heidelberg 2013
E34  Open Endorectal (Soave-Boley) Pull-Through 345

sis. This procedure is adequate for rectosig- • Once the submucosal layer is reached, develop
moid disease. plane anteriorly (Fig. 2) and continue laterally
– The hockey-stick incision with left pararec- then posteriorly, using blunt dissection with a
tal extension is required for descending co- Kittner dissector or pledgets.
lonic disease and is useful to take down a • The extramucosal dissection is facilitated when
levelling colostomy (Fig. 1). the assistant holds the edges of the developing
• Multiple antimesenteric seromuscular biop- muscle cuff (seromuscular layers) with atrau-
sies are taken as described in Chap. E37, ‘Open matic forceps or stay sutures, to provide coun-
Duhamel Pull-Through’ to identify the level of ter-traction.
the transition zone (TZ) and normal ganglionic • Bipolar haemostasis is used to coagulate larger
bowel. communicating vessels in the bowel wall.
• Divide the mesocolon close to bowel wall us- • Once the mucosal tube is completely free, the
ing serial clip and ligation with 3/0 Vicryl. seromuscular cuff is mobilised distally to a level
• The ganglionic bowel is transected with a linear 1–1.5cm proximal to the anal verge (Fig. 3).
stapling device, approximately 5 cm above the
most distal ganglionic frozen section biopsy.
• Mobilise the distal sigmoid colon and rectum
and transect ~4 cm above peritoneal reflection.
• Send the colonic specimen to pathology fresh
(to ensure adequate length above TZ).
• Two Vicryl stay sutures are placed at the apex
of the transected rectum.
• Incise the seromuscular layer of the rectum
transversely, over the anterior rectal wall, us-
ing sharp dissection or monopolar cautery (can
be facilitated by infiltration between layers with
1:200,000 adrenaline solution).

Fig. 3

Fig. 2 Fig. 4
346
• Adequacy of distal extent of dissection is con-
firmed by bimanual palpation with a finger in
the anus and one outside the mucosal tube.
Wear double gloves and remove the outer pair
afterwards to maintain sterility.
• The descending colon should be mobilised us-
ing Metzenbaum scissors along the white line
of Toldt, as far as the splenic flexure if nec-
essary to ensure tension-free pull-through
(should reach pubis without tension).
 ull-Through and Colo-anal
P
Anastomosis
• The primary surgeon should move to lower end
of the table.
• Elevate and secure the lower limbs to expose
the perineum.
• A Kelly clamp is passed into the rectal stump.
The assistant places the apex of the rectal
stump into the clamp and it is pulled transa-
nally (Fig. 4).
• The everted mucosal tube is left clamped and
placed under traction.
• Incise anterior hemi-circumference of mucosal
tube 0.5–1cm above dentate line (Fig. 5) and
pass a Kelly clamp through the opening into
peritoneal cavity.
Fig. 5
T. J. Bradnock and G. M. Walker
• Grasp the stay sutures on the ganglionic colon
and deliver them through anal opening (Fig. 6).
• The assistant in abdominal field should ensure
the pull through colon is not twisted.
Fig. 6
• The anterior half of the ganglionic colon is in-
cised transversely and anastomosed to the an-
terior half of the mucosal tube at the site of the
previous incision, 0.5–1 cm above the dentate
line with interrupted 4/0 Vicryl sutures (Fig. 7).
• Stay sutures at each quadrant around the mu-
cocutaneous junction facilitate good exposure.
• The rest of the anastomotic circumference is
completed in quadrants between the stays.
• The colon is pulled upwards from inside the
peritoneal cavity to invert the neorectum.
Fig. 7
E34  Open Endorectal (Soave-Boley) Pull-Through 347

• Gloves should be changed before returning to

the peritoneal cavity.
• The risk of early postoperative neorectal pro-
lapse is reduced by suturing the seromuscular
layers of the colon to the muscle cuff, as de-
scribed by Coran.
• The wound is closed in layers as described pre-
viously.

Fig. 8

Tips

77 Performing primary surgery in the first 3 months
of life reduces the duration of rectal washouts
and the risk of chronic proctitis, that makes sub-
sequent endorectal dissection more difficult.
77 If adhesions are dense between the mucosal
sleeve and seromuscular layers, use cautious
sharp dissection with scissors.
77 Current trends are to leave a shorter muscle cuff
and to split the cuff posteriorly to reduce the risk
of cuff stricture and outlet obstruction (Fig. 8).

Common Pitfalls

77 Do not commence endorectal dissection un- 77 Avoid leaving too much aganglionic rectum in
til the level of the TZ has been confirmed, since situ – the colo-anal anastomosis should be no
long-segment or total colonic disease may ne- more than 1–1.5cm above the dentate line, as
cessitate an initial stoma with deferral of defini- this predisposes the patient to outlet obstruc-
tive surgery. tion, stasis and recurrent enterocolitis (Fig. 8).
77 The mucosal tube and muscle cuff are vulnera-
ble to tearing during the endorectal dissection. A
tear in the mucosal tube can be repaired with in-
terrupted 5/0 Vicryl to prevent exacerbation of
the tear.
348 T. J. Bradnock and G. M. Walker

F R A N C O S OAVE
(1917 – 1984)
Italian Paediatric Surgeon

Franco Soave was Surgeon in Chief at the Gaslini Institute Hospital and Professor of Sur-
gery at the University of Genoa. He had a lifelong interest in colon and anorectal surgery
and he is known for his work in the defining operative procedure for Hirschsprung disease.
He was an outstanding teacher and a prolific writer, who toured the world explaining and
demonstrating the Soave procedure for Hirschsprung disease.
E35  Myomectomy for Ultrashort segmentHirschsprung Disease 349
E35 Myomectomy for Ultrashort segment E35
Hirschsprung Disease
R. Carachi

This procedure is limited to children with short

segments of aganglionosis (less than 5 cm). This
myomectomy is a relatively minor operation de-
vised by Bentley and described in 1966.
The minor operation of posterior excisional
anorectal myomectomy not only provides a rep-
resentative biopsy, but it can also be curative for
this disease.
• The patient is placed in the lithotomy–Tren-
delenburg position under general anaesthesia.
• 5-ml 1:125,000 aqueous noradrenaline is infil-
trated into the posterior anorectal wall to as-
sist haemostasis and separate the intramural
layers of the bowel to facilitate dissection.
• A gauze pack is lightly inserted in the upper lu-
men, and a small triangular flap of anal skin is Fig. 1a–e  Posterior excision anorectal myomectomy. a Li-
reflected forward to expose the posterior lower thotomy–Trendelenberg position.
border of the internal anal sphincter.
• A strip of bowel wall about 5-mm wide is cut
with scissors. To avoid damage to the perito-
neum the strip is cut towards the hollow of the
sacrum. Hence a complete longitudinal sec-
tion of the posterior aspect of the anal canal
and distal rectum is excised. The strip is about
5-mm wide and up to 10-cm long.
• A Vicryl 000 suture is used on a 5/8-in (1.6 cm)
circle and a 16- or 25-mm needle. The ends of
the Vicryl are knotted together, and the first
stitch is locked in position by passing the nee-
dle through the loop. This stitch is placed at
the apex of the dissection, and by using trac-
tion on the suture, assists the insertion of fur-
ther stitches as far as the anal verge.

Robert Carachi ()

Professor of Surgical Paediatrics Fig. 1b  Infiltration of anorectal wall with 1:125,000 aque-
Robert.Carachi@glasgow.ac.uk ous noradrenaline.

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_106, © Springer-Verlag Berlin Heidelberg 2013
350 R. Carachi

Fig. 1c  Post-anal triangular

flap of skin, cut after inser-
tion of speculum.

Fig. 1d Traction assists in

cutting the specimen.
E35 Myomectomy for Ultrashort segmentHirschsprung Disease 351

Fig. 2a–c Posterior excision anorectal myomectomy (continued). a Traction on the specimen is main-
tained while the first stitch is locked in position by passing the needle back through the knotted loop.
b The specimen is excised.

Fig. 2c The mucosa and submucosa are ap-

proximated by continuous suture. A small
post-anal area is left open for drainage
352 R. Carachi

Tips

77 A good retractor is essential to view the opera-
tive area. A Parks retractor can be used; alterna-
tively an assistant can retract both sides of the
operative field. Another approach for retraction
could be placing four quadrant sutures (black
silk) to retract this area.
77 Avoid dissecting too deep and perforating the
bowel. (This is why infiltration with fluid helps in
dissection.)
77 Bleeding should be controlled; haemostasis can
be achieved carefully using bipolar cautery.

J O H N F R ANCI S ROGERS BENTLEY

(1920 – 1990)
Consultant paediatric surgeon at the Royal Hospital for Sick Children in Glasgow, and
a graduate of Guys Hospital Medical School in London

Bentley was involved in the early development of infant cardiac surgery in London and then
expanded this service in the West of Scotland. He was the first to perform a neonatal oe-
sophageal replacement using a segment of colon, and he introduced the Spitz–Holter valve
in Scotland. He was always interested in diseases of the colon and described the ultrashort-
segment Hirschsprung disease and its treatment is used to. A rectal myomectomy strip to
diagnose and treat this hitherto unrecognised condition.

Suggested Reading

Bentley JFR (1966) Posterior excisional anorectal

myotomy in management of chronic faecal accu-
mulation. Arch Dis Childhood 41:144–147
E36  Open Swenson Procedure 353
E36 Open Swenson Procedure E36
T. J. Bradnock and C. A. Hajivassiliou

• Insert a urethral catheter.

• Position the patient supine, with legs supported
in stirrups to allow simultaneous exposure of
the perineum and abdomen.
• Employ the Pfannenstiel or left paramedian in-
cision.
• Optimise exposure with a Denis–Browne re-
tractor and stay sutures to lift the bladder out
of the wound.
• Take extramucosal biopsies at intervals along
the antimesenteric border of bowel for frozen
section analysis to determine the transition
zone (TZ).
• Biopsies are taken with Metzenbaum scissors
orientated horizontally and pushed down on Fig. 1
to the bowel wall.
• Preserve the marginal vessels during rectosig-
moid mobilisation.
• The splenic flexure may need to be mobilised
depending on the level of the TZ.
• Transect the bowel 5c m above the most proxi-
mal ganglionic biopsy with a linear cutting sta-
pler (Fig. 1) – bowel clamps are not necessary.
Leave the stay sutures proximally. NB: the pro-
cedure can be performed without dividing the
bowel at this point (see below).
• Divide the peritoneum over its lateral and an-
terior reflection over rectum (Fig. 2).
• If the aganglionic segment is too long, a seg-
ment can be stapled and removed for conve-
nience of pelvic dissection.

Tim J. Bradnock ()

Specialty Registrar in Paediatric Surgery
The Department of Paediatric Surgery, Dalnair Street,
Yorkhill Hopsital, Glasgow G3 8SJ, Scotland, UK Fig. 2
Email: tjbradnock@doctors.org.uk

Constantinos A. Hajivassiliou
Consultant Paediatric and Neonatal Surgeon
ch27z@udcf.gla.ac.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_107, © Springer-Verlag Berlin Heidelberg 2013
354
• Dissection extends distally around the rectum
staying close to the rectal wall to avoid dam-
age to pelvic splanchnic nerves (Fig. 3). Coag-
ulate all vessels under direct vision.
Fig. 3
• Obtain sufficient colonic length and mobil-
ity by dividing the inferior mesenteric pedicle
whilst preserving marginal vessels.
• Continue the dissection to the level of the exter-
nal sphincter laterally and posteriorly but not
anteriorly, where 1.5 cm of intact rectal wall is
left abutting the vagina or urethra.
• Intussuscept the mobilised rectum through the
anus, using Babcock forceps passed transanally
to grasp either the rectal stump or intact recto-
sigmoid (depending on whether the bowel has
been divided) (Fig. 4).
• Gently cleanse the rectal mucosa with chlorhex-
idine.
• If a segment of colon has been excised, incise
the anterior rectal wall 1–2 cm from the den-
tate line, extending around half the rectal wall
circumference.
T. J. Bradnock and C. A. Hajivassiliou
• Pass a curved clamp through this incision and
grasp the stay sutures on the stapled end of the
proximal colon.
Fig. 4
Fig. 5
• If no colon has been excised, divide approxi-
mately half the outer (rectal) wall of the intus-
suscepted bowel, 1–2 cm above the everted den-
tate line, followed by the same length of the in-
ner (colonic) bowel wall. The two walls are then
anastomosed sequentially (Fig. 5).
• The colorectal anastomosis is performed ex-
tracorporeally using interrupted absorbable su-
ture (e.g. 4/0 Vicryl) (Figs. 6 and 7).
• When the anastomosis is complete, the sutures
are cut, allowing the anastomosis to retract into
the anus.
• Antibiotic lavage is performed with normal sa-
line containing 1 mg/ml cefotaxime.
• Close the Pfannenstiel in layers.
E36  Open Swenson Procedure 355

Fig. 6

Fig. 7a,b
356 T. J. Bradnock and C. A. Hajivassiliou

Fig. 8a,b

Tips

77 Use a double-gloved left hand to pass a finger 77 Adequate distal dissection is confirmed when it
into the anus to assess the extent of distal dissec- is possible to evert the anal canal completely by
tion (Fig. 8). traction on the rectum.

Common Pitfalls

77 Devascularisation of the colonic wall can lead to
stricture or dehiscence.
77 Leaving too much aganglionic distal segment
can cause distal functional obstruction (Fig. 7).
77 Damage to the autonomic plexuses in the pelvis
is avoided if dissection remains close to the rec-
tum and the nerve leashes are demonstrated.
77 Misalignment of anastomosed colorectal ends is
possible; ensure alignment is correct when the
proximal segment is intussuscepted distally.
E37  Open Duhamel Pull-Through 357
E37 Open Duhamel Pull-Through E37
T. J. Bradnock and G. M. Walker

This operation was devised to avoid the diffi- Operative Technique

cult peri-rectal dissection of the Swenson proce-
dure, whilst minimising the risk of damaging the
nervi erigenti, that course laterally and anteriorly
over the rectum. Duhamel proposed a retrorec-
tal dissection without resection of the rectum as
a means to achieving this. The rectal reservoir cre-
ated has an anterior aganglionic wall and a poste-
rior ganglionic wall (Fig. 1). Duhamel’s original
operative procedure was later modified with the
use of a linear stapling device to create the rectal
reservoir instead of Kocher clamps, which pre-
viously were left in situ for 5–10 days. The Du-
hamel procedure can also be performed with lap-
aroscopic assistance either as a primary or staged
procedure.
Preoperative Management
As described in Chap. E35, ‘Myectomy for Ultra-
short Hirschsprung Disease’:
• It is imperative that rectal washouts are per-
formed effectively and with adequate frequency
to prevent inspissated faeces accumulating in
the rectum.
• Prior to surgery, a rectal examination should
be performed to ensure the rectum is empty.
• Intravenous antibiotics are given at induction.
• A nasogastric tube is placed after induction of
general anaesthetic.
• The infant is positioned supine, scrubbed and
draped from costal margin to feet. The lower
limbs are padded and the feet placed in stirrups
or skis.
• Insert urethral catheter after sterile field has
been established.
• A muscle-cutting ‘hockey-stick’ incision (in-
corporating the levelling colostomy if applica-
ble) is made and deepened with monopolar dia-
thermy.
• Obtain seromuscular biopsies as described in
Chap. E37, “Open Duhamel Pull-Through’
and submitted for frozen-section analysis be-
fore commencing colonic mobilisation.
• Mobilise the left colon along the white line of
Toldt with sharp/blunt dissection to free splenic
flexure.

Tim J. Bradnock ()

Specialty Registrar in Paediatric Surgery
The Department of Paediatric Surgery, Dalnair Street,
Yorkhill Hopsital, Glasgow G3 8SJ, Scotland, UK
Email: tjbradnock@doctors.org.uk
Fig. 1  The distribution of ganglionic (blue) and agangli-
Gregor M. Walker
onic (red) bowel after Duhamel pull-through
Consultant Paediatric and Neonatal Surgeon
Gregor.Walker@ggc.scot.nhs.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_108, © Springer-Verlag Berlin Heidelberg 2013
358
• Mobilise stoma (if present) and excise limbs
with a linear stapling device (stoma is then sent
to pathology in formalin).
• Commence retrorectal dissection, staying in
midline on bowel wall, using finger dissection
or long clamp/pledgets (Fig. 2).
Fig. 2 The retrorectal dissection is performed with a
clamp and pledget
• Once the pelvic floor is reached, the assistant
should double glove and insert an index finger
into rectum. Adequacy of distal dissection is
confirmed if assistant’s finger is palpable when
inserted no more than 1.5 cm into rectum.
• Transect colon with linear stapling device, ap-
proximately 5 cm above the normal, ganglionic
biopsy.
Fig. 3  An endoanal incision is made 0.5–1.5cm above the
dentate line
T. J. Bradnock and G. M. Walker
• Place stay sutures on distal end of pull through
and proximal end of rectal stump.
• Expose the anus with anal retractors and make
a full-thickness semicircular incision with mo-
nopolar diathermy over posterior rectal wall
0.5–1.5 cm above dentate line (Fig. 3).
Fig. 4  Normal, ganglionic bowel is pulled down through
the retrorectal space
• Three 4/0 Vicryl stay sutures are placed on up-
per and lower border of incision (leave needles
on).
• The surgeon performing the perineal dissection
passes a long clamp through incision into ret-
rorectal space.
• The surgeon working in the abdominal com-
partment passes stay sutures into clamp, checks
the orientation of bowel, and instructs surgeon
at perineal end to gently withdraw the clamp
via the rectum (Figs. 4 and 5).
• Open anterior wall of pulled-through gangli-
onic bowel proximal to staple line (Fig. 6).
• Secure anterior pull-through to anterior part
of rectal wall incision, using the three previ-
ously sited 4/0 Vicryl stays. Complete anterior
part of anastomosis with further interrupted
full-thickness sutures (Fig. 7).
• Excise remainder of staple line and complete
posterior anastomosis with interrupted 4/0
Vicryl.
• Pass linear stapling device via the rectum to di-
vide posterior wall of native rectum and ante-
rior wall of the pulled-through bowel, creating
a side-to-side anastomosis and rectal reservoir
(Fig. 8). The surgeon in abdominal field deter-
E37  Open Duhamel Pull-Through
Fig. 5  Ganglionic bowel is delivered through the endo-
anal incision
Fig. 6  The ganglionic bowel is opened anteriorly to com-
mence the anastomosis
359
Fig. 7  The anterior wall of the anastomosis is completed
with interrupted sutures
mines that staple line has reached most cranial
extent of rectal stump.
• In the long Duhamel procedure (Martin mod-
ification) for total colonic disease, a second fir-
ing of the stapler from above is used to gener-
ate a long side-to-side anastomosis between the
normal ileum and aganglionic rectum, that re-
sults in a more capacious rectal reservoir, with
the aim of improving electrolyte reabsorption.
This necessitates making a short opening on
the staple line of rectal stump and fashioning
Fig. 8  The side-to-side anastomosis between the poste-
rior wall of the rectum and anterior wall of the ganglionic
bowel is made with a linear stapling device
360
a 1-cm enterostomy on the adjacent ganglionic
bowel to accept the two limbs of the stapler.
• Always perform a rectal examination to ex-
clude a residual proximal rectal spur in rectal
reservoir. If present this should be excised or
stapler re-passed from above.
• The proximal aganglionic rectal stump is anas-
tomosed to the enterostomy on the adjacent
bowel.
• The abdominal incision is closed in layers, as
previously described.
Tips
77 The Duhamel pull-though is one of the most
commonly utilised techniques for revisional sur-
gery.
77 Adequacy of colonic length is confirmed if the
mobilised ganglionic colon can be brought
over the infant’s pubic symphysis to reach the
perineum without significant tension
77 If adequate colonic length cannot be obtained,
the inferior mesenteric artery can be ligated
close to its origin. Be certain to preserve the mar-
ginal artery to maintain colonic viability.
Common Pitfalls
77 The left ureter should be carefully visualised dur-
ing the colonic mobilisation and prior to divid-
ing the peritoneal reflection between the rectum
and bladder.
77 During the initial colonic resection, it may be
necessary to back resect a portion of the dilated
ganglionic colon to facilitate an easier anasto-
mosis with the much smaller-calibre rectum. The
degree of back resection required can be min-
imised by good preoperative decompression
with regular, effective rectal washouts.
T. J. Bradnock and G. M. Walker
 uhamel Procedure for Revisional
D
Surgery
• Post–pull-though constipation or recurrent
enterocolitis, failing to respond to conserva-
tive treatment, particularly in the presence of
a transition-zone pull-through, may necessitate
a redo pull-through.
• If the previous pull-through dissection was per-
formed in a perirectal (Swenson) or endorec-
tal (Soave–Boley) plane, redoing with the Du-
hamel pull-through with retrorectal dissection
has the advantage of avoiding the dense adhe-
sions related to previous surgery.
77 Label the mesenteric and antimesenteric bor-
ders of the ganglionic colon with different stay
sutures to enable the surgeon performing the
anastomosis to maintain correct orientation.
77 Although a shared abdominoperineal field is
used, the instruments used in the perineal dis-
section must be kept separate from those in the
abdomen. Similarly, gloves should be changed
before returning to the abdomen.
77 Failure to completely divide any residual prox-
imal spur in the rectal reservoir will result in
faecaloma formation, with an adverse impact on
bowel habit and soiling.
77 The optimal level for the endoanal incision is
contentious and trends have changed with time.
In theory, the endoanal incision should be made
at least 0.5 cm above the dentate line to avoid
performing a complete internal sphincterotomy
with resultant soiling and incontinence. How-
ever, an endoanal incision made more than 2 cm
proximal to the dentate line increases the risk of
faecal impaction in the rectal reservoir.
E38  Principles of Liver Surgery 361
E38 Principles of Liver Surgery E38
M. Davenport

Liver Anatomy Each half of the liver is supplied by right and left
branches of the portal vein and hepatic artery
The segmental nature of the liver is not immedi- (>90 % from celiac axis). Aside from the caudate
ately obvious from the surface; indeed what looks (which is drained by small veins directly into in-
like a large right lobe and smaller left lobe, defined trahepatic cava); venous drainage occurs via three
by the falciform ligament, is somewhat mislead- veins (left, right and middle).
ing. Knowledge of the various divisions is the ba-
sis for liver resection. The key division is between
right and left and the principle plane (of Cantlie)
extends from gallbladder bed to a point slightly to
the left of the hepatic vein confluence.
Table 1 lists the key facts for the segments there-
after.

Fig. 1

Mark Davenport ()

Professor of Hepatobiliary Surgery
King’s College Hospital, Denmark Hill, London,
SE5 9RS, UK
Markdav2@ntlworld.com

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_109, © Springer-Verlag Berlin Heidelberg 2013
362
Table 1  Segmental anatomy of the liver
Segment
I Caudate lobe
LEFT II , III Left lateral
segment
IV Quadrate lobe
RIGHT V, VI Anterior section Right hemihepatectomy
VII, VIII Posterior section
Right Hemihepatectomy
• Incision
– Muscle cutting transverse abdominal, “Mer-
cedes-Benz” (in adolescents)
– Wound/rib cage retraction – using the
Thompson® retractor, for instance
• Liver mobilisation
– Division of falciform, right and left triangu-
lar and coronary ligaments
– Exposes the cava lying at the back Surgical Aspirator [CUSA®]) or to seal the
– Exposure and separation of cava from liver
– divide small veins from caudate
• Cholecystectomy
– Diathermy haemostasis to bed
• Pringle Manoeuvre
– Tape or sling around entire structures in free
edge of lesser omentum. Allows inflow con-
trol to entire liver and can replace individual
vascular ligation step
– If so combine with ischaemic precondi-
tioning. A short-period (5–10 min) tech-
nique of occlusion; reperfuse (15 min)
before definitive parenchymal transec-
tion, under total inflow control
• Exposure of right vascular pedicle at liver hi-
lum
– Ligation/over-sew/transfix right hepatic ar-
tery and portal vein.
– Avoid deliberate ligation of bile duct at this
stage. Bile duct anatomy is very variable and
damage to remaining left duct possible
• Exposure/control of right hepatic vein (can
also be left to end of transection phase)
M. Davenport
Resection
Rarely excised in isolation, but part may be taken
typically with right hemihepatectomy.
Left hemihepatectomy Left lateral Extended left
segmentectomy hepatectomy
Extended right
hepatectomy
–
• Parenchymal transection
– With right inflow ligation, there will be a line
of demarcation on surface.
– Use diathermy to draw limits of resection
– always bear in mind 3D anatomy and the
presence of cava at back.
– There are many devices designed either to
identify network of small vessels within liver
substance and allow diathermy haemostasis
before division (e.g. Cavitational Ultrasonic
network directly (e.g. LigaSure®).
– Similarly use of the Argon beam plasma
coagulator facilitates surface haemostasis.
Last part to be detached should be right
hepatic vein pedicle.
– The right bile duct should have been sep-
arately ligated during transection but once
dry check assiduously for small bile leaks.
Seal with tissue glue (e.g. TISSEEL®, a hu-
man fibrin glue).
• Ensure remnant liver is secured to abdominal
wall to avoid kinking.
– Drain.
– Postoperatively, check coagulation tests es-
pecially the international normalized ratio
(INR). This may necessitate fresh frozen
plasma support if the INR value is >1.5),
platelet count and haemoglobin. Elevation
of liver enzymes is invariable for 2–3 days,
but bilirubin levels should be within normal
limits (Table 2).
E38  Principles of Liver Surgery 363

Fig. 2

Table 2  Complications after liver resection

Time scale Problem Laboratory

0–48 hrs Small remnant ↑­ Lactate
↑­ Coagulopathy
↑­ Acidosis
Bleeding ↓­ Haemoglobin
↓­ PCV
2–14 days Sepsis ↑­ Bilirubin
↑­ CRP
↑­ WBC
5–14 days Bile duct injury ↑­ Bilirubin
↑­ GGT
5–14 days Bile leak ↑­ Bilirubin
→­ GGT
 364
E39 E39 Biliary Atresia
M. Davenport
Biliary atresia (BA) is of essentially unknown
origin, though there are several definable types.
Most are isolated BA, but about 10 % will have
features of biliary atresia splenic malformation
syndrome (e.g. polysplenia, situs inversus, predu-
odenal portal vein, absence of the vena cava, mal-
rotation, etc.). Other variants include cystic BA
(which may contain bile or mucus and are not
simply obstructed choledochal cysts) and Cyto-
megalovirus-associated BA.
It is possible to diagnose BA with a high de-
gree of certainty preoperatively using ultrasound
and percutaneous liver biopsy, but the first essen-
tial operative step is still confirmation of diagno-
sis. Note the characteristics of the gallbladder and
its contents (Fig. 1). The presence of bile implies
that it is not biliary atresia (N.B. the exception be-
ing type 1 BA), and mandates an operative chol-
angiogram.
Fig. 1  Type 3 biliary atresia with atrophic gallbladder
Mark Davenport ()
Professor of Hepatobiliary Surgery
King’s College Hospital, Denmark Hill, London,
SE5 9RS, UK
Markdav2@ntlworld.com
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_110, © Springer-Verlag Berlin Heidelberg 2013
M. Davenport
 xcision of Biliary Remnant and
E
Portoenterostomy (Kasai Operation)
• Incision is a muscle-cutting transverse right up-
per quadrant (usually crosses midline).
• Confirmation of diagnosis may need a cholan-
giogram (but only possible if there is lumen to
the gallbladder). Contrast must show the prox-
imal biliary tract to exclude BA.
• Liver mobilisation:
– Division of the falciform ligament
– Division of left and right (exposes bare area
of liver) triangular ligaments
– Eviscerate liver outside the abdominal cav-
ity to expose the porta hepatis
• Perform retrograde cholecystectomy and divi-
sion of distal common bile duct.
• Identification of hepatic arteries: Follow right
hepatic artery to its bifurcation into anterior
and posterior branches.
• Separate proximal bile duct remnants from ar-
teries and the bifurcation of the portal vein.
On left side, division of liver isthmus from seg-
ments III to IV improves access.
• Portahepatis resection: Identify plane of dis-
section in gallbladder fossa and work towards
left. What remains should be translucent sliver
of connective tissue only. Avoid actual removal
of liver parenchyma. The limit on the right side
is posterior branch of right hepatic artery; on
the left there is often a crossing artery and vein
to segment IV within the Rex fossa.
• Mobilisation of Roux Loop: Measure ~10
cm from the duodenal–jejunal flexure. Divide
bowel with stapler. Measure ~40 cm (length of
Roux limb). Perform sutured (e.g. 5/0 PDS) or
stapled (e.g. EndoGIA®) enteroenterostomy at
this point. Close mesenteric “window” and po-
sition the Roux limb through the mesocolon to
lie adjacent to the duodenum.
E39  Biliary Atresia 365

• Portoenterostomy: Control Roux limb with

soft bowel clamp. Anastomosis should be wide
(~2 cm) and therefore an antimesenteric aspect
of Roux loop is used (Fig. 2). Insert all pos-
terior row of sutures (e.g. 6/0 polydioxanone
[PDS], full-thickness, internal knots) before
parachuting into subhepatic space. Complete
anterior row (external knots) in situ. Check for
obvious leaks. Close mesocolic window.
• A drain often is only needed in the presence of
ascites.

Fig. 2  Portoenterostomy

M O R I O K A S AI
(1922–2008)
Japanese surgeon

Professor Morio Kasai trained in paediatric surgery in Philadelphia, but most of his aca-
demic life in Japan was in general surgery. Despite this, he trained a generation of Japanese
and overseas paediatric surgeons. His work on biliary atresia has been one of the greatest
surgical advances of the last century. The corrective procedure for this condition bears his
name, the Kasai procedure.
 366 M. Davenport
E40 E40Choledochal Malformations
M. Davenport

Choledochal Malformation imal biliary ducts and degree of dilatation to

be appreciated. Lack of contrast in common
Fig. 1 illustrates the current concept in classify- channel may determine need for formal explo-
ing choledochal malformation. Essentially the ration.
three commonest variants are type 1c – the clas- • Exposure of common hepatic duct (CHD).
sical choledochal cyst; type 1f – a fusiform dila- Dissection of Calot triangle, ligation of cys-
tation of the extrahepatic biliary tract; and type tic artery and definition and preservation of
4 – either of the foregoing with significant dilata- right hepatic artery (can be anterior or poste-
tion of the intrahepatic bile ducts. Most of these rior). Aim to sling the CHD prior to formal di-
types also have a definable common pancreato- vision. Recognise potential for variation in in-
biliary channel, that can dilate and become filled sertion of the (usually) right (anterior or pos-
with debris or stones. These children usually pres- terior) bile duct.
ent with pancreatitis. • Division of the CHD now allows choledochus
Anatomical imaging is important in the workup to be freed from bed (N.B. the portal vein lies
and a detailed magnetic resonance cholangiopan- immediately posterior) (Fig. 3).
creatography ([MRCP] is a minimum requirement • Separation of choledochus from duodenum:
ideally showing a common channel and intrahe- This is often a hyper-vascular area, with the
patic ducts) may prevent the need for formal chol- larger cysts displacing duodenum and con-
angiography on-table. tained pancreatic head. Sometimes the hepatic
flexure of colon is also pushed inferiorly. Re-
quires precise bipolar coagulation and ligation
Excision of Choledochal Cyst and of lymphatic trunks, running along right side
Biliary Reconstruction of cyst. Ensure dissection is in the plane of the
wall of the choledochal cyst.
• Incision: muscle cutting right upper quad- • Distal dissection into head of pancreas (Fig.
rant. This may require rib cage retraction (e.g. 4): The type 1c variant should have a marked
Thompson retractor). change in calibre, with the very distal part of
• Liver mobilisation: Divide the falciform liga- the CBD being of “normal” calibre before in-
ment. serting into the common channel. This is less
• A retrograde cholecystectomy is performed obvious in the type 1f variant and requires
with diathermy haemostasis to the bed (Fig. 2). judgement before division. The main pancre-
• An on-table cholangiogram using a small cath- atic duct lies in a fissure on the right side and
eter (e.g. 6 Fr) is inserted into the cystic duct. may insert quite high into the CBD. Recog-
This allows variation in arrangement of prox- nise this before inadvertent damage. A small
catheter with methylene blue inserted into com-
mon channel can be used to confirm integrity
of pancreatic duct system.
Mark Davenport ()
• Choledochoscopy: Insert a small flexible endo-
Professor of Hepatobiliary Surgery
King’s College Hospital, Denmark Hill, London, scope into intrahepatic ducts (sometimes not
SE5 9RS, UK possible if CHD too small). Visualise right and
Markdav2@ntlworld.com left ducts. Recognise areas of stenosis (and di-

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_111, © Springer-Verlag Berlin Heidelberg 2013
E40  Choledochal Malformations
Fig. 1  King’s College Hospital Classification of choledochal malformation
late), lavage debris or stones until satisfied that
all liver segments can drain. Repeat this dis-
tally (if possible) and scope the common chan-
nel, again removing debris. If there is ampul-
lary stenosis in addition to a dilated common
channel – consider transduodenal sphinctero-
plasty (10 % of cases).
• Removal of cyst: Over-sew distal CBD (e.g. 5/0
PDS).
• Mobilisation of Roux Loop: Measure ~10 cm
from duodenal­–jejunal flexure. Divide bowel
with stapler. Measure ~40 cm (length of Roux
limb). Perform sutured (e.g. 5/0 PDS) or sta-
367
pled (e.g. EndoGIA®) enteroenterostomy at
this point. Close mesenteric window and po-
sition the Roux limb through mesocolon to lie
adjacent to duodenum.
• Hepaticojejunostomy: The diameter of the
CHD is usually more than adequate to drain
the proximal biliary tree. There is no need to
incise into the hepatic ducts unless there is de-
monstrable stenosis (<10 % of cases). Triangu-
late stay sutures. Control Roux limb with soft
bowel clamp. Insert all posterior row of sutures
(e.g. 5/0 PDS, full-thickness, internal knots) be-
fore parachuting into subhepatic space. Com-
368 M. Davenport

plete anterior row (external knots) in situ.

Sometimes variation in biliary duct anatomy
requires separate right and left anastomosis
(<5 % of cases). Check for leaks. Anchor Roux
loop to fascia medially and gallbladder bed lat-
erally. Close mesocolic window.
• A drain may or may not be required.

Fig. 2 Schematic of cystic choledochal malformation

(type 1c)

Fig. 3 Mobilisation of gallbladder, division at level of Fig. 4  Mobilisation of duodenum and identification of
common hepatic duct distal CBD within head of pancreas
E41  Pancreatic Pseudocyst 369
E41 Pancreatic Pseudocyst E41
M. Davenport

Acute pancreatitis is uncommon in children, and
its causes can be divided along medical and sur-
gical lines. The commonest causes in the former
category are related to drugs (typically chemother-
apy for leukaemia) and viral infections. Among
the latter group are trauma (typically related to
boys and bicycle handlebars), choledochal mal-
formations because of the common pancreatobi-
liary channel and pancreas divisum.
In the early stages of the disease, amylase-rich
fluid may be exuded from the inflamed pancreas,
but tends not to be confined and is panperitoneal.
In the later stages, beyond 4 weeks or so, these
acute fluid collections evolve into the classic pseu-
docyst. The sites most common for these are the
lesser sac and within the leaves of the mesocolon.
Treatment Options
Acute pancreatitis is managed conservatively for
the most part with parenteral nutrition, analgesia
and strict attention to fluid balance. In the early
stages, prior to formation of a substantial wall,
percutaneous aspiration under ultrasound con-
trol is the only realistic option to control symp-
toms due to intraperitoneal fluid collections. Be-
yond 4–6 weeks, the options include:
• Parenteral nutrition only: Spontaneous resolu-
tion is possible for the smaller ones.
• Aspiration can be utilized, with or without
drain insertion, under ultrasound control.
• Endoscopic cyst gastrostomy is done by us-
ing endoscopic ultrasound; the pseudocyst is
located and punctured. Double –‘J’ stents are
passed into the cavity to keep the connection
open. These are then removed after 4–6 weeks.
• Surgical cyst gastrostomy
Surgical Cyst-Gastrostomy
• Incision: Muscle cutting left upper quadrant.
• The stomach is usually draped, tightly over the
pseudocyst situated in the lesser sac (Fig. 1).
– Stay sutures in the anterior wall of the stom-
ach – open this longitudinally.
– Identify the pseudocyst bulging into the pos-
terior wall. Test that is contains fluid by as-
pirating with a needle and syringe. Using
point diathermy, open into the wall and aim
to create a hole (~1-cm diameter) (Fig. 2).
Over-sew the circumference to achieve hae-
mostasis.
– Close the anterior wall with haemostatic,
full-thickness sutures.
• Alternate sites
Fig. 1  Pseudocyst in the lesser sac, behind stomach

– Some pseudocysts will bulge more into the

Mark Davenport ()
infracolic compartment. Identify the most
Professor of Hepatobiliary Surgery
King’s College Hospital, Denmark Hill, London, dependent portion, and again test that it
SE5 9RS, UK contains fluid.
Markdav2@ntlworld.com

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_112, © Springer-Verlag Berlin Heidelberg 2013
370 M. Davenport

• Roux loop: create an anastomosis (end to side

or end to end) with the wall of the pseudocyst.
– Measure ~10 cm from duodenal–jejunal
flexure. Divide bowel with a stapler.
– Measure ~20 cm (length of Roux limb).
Perform sutured (e.g. 4/0 PDS) or stapled
(e.g. EndoGIA®) enteroenterostomy at this
point. Close the mesenteric window and po-
sition the Roux limb at the most dependent
part of the pseudocyst.
– Create a hole in wall of pseudocyst and
anastomose using full-thickness sutures (e.g. Fig. 2  Posterior wall of stomach is opened via an anterior
4/0 PDS). gastrostomy
E42  Inflammatory Bowel Disease 371
E42 Inflammatory Bowel Disease E42
G. Haddock

Surgery in inflammatory bowel disease (IBD) is
challenging. Failure to control disease by medical
means and the consequences of this, usually ac-
count for the majority of cases coming to surgery.
A much smaller group of patients present acutely,
with complications including intestinal obstruc-
tion, toxic megacolon, acute GI haemorrhage and
fistulating disease.
mine the resection site, bearing in mind that this
may well still be affected by microscopic disease.
2. Small bowel strictureplasty
This operation is useful where there is a short
length of strictured small bowel to avoid resection.

There are a number of operations, which may be Steps

required to treat a child with inflammatory bowel
disease: Figure 1:
1. Small bowel resection • Identify the limits of the stricture
2. Small bowel strictureplasty • Place a stay suture on either side of the stric-
3. Terminal or loop ileostomy ture
4. Right hemicolectomy • Incise the stricture longitudinally along the
5 Subtotal colectomy length of the affected small bowel
6. Colostomy
7. Treatment of fistulating/ulcerating perianal
and perineal Crohn’s disease
8. J-pouch ileoanoplasty

In operating on any patient with IBD, careful

consideration needs to be given to the impact of
drugs (steroids and immunosuppressants) on pa-
tient healing. Thought must also be given to the
need for thromboprophylaxis.

1. Small bowel resection (see Chap. E14) Fig. 1

The technique for small bowel resection is out- Figure 2:

lined in chapter E14. The surgeon should look for • Holding the stay sutures apart, close the enter-
intestine that is normal to the human eye to deter- otomy using interrupted single layer, serosub-
mucosal sutures placed transversely until the
strictureplasty is closed.

Graham Haddock ()

Consultant Paediatric and Neonatal Surgeon
Ghaddock@udcf.gla.ac.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_113, © Springer-Verlag Berlin Heidelberg 2013
372
Fig. 2
Fig. 3
3. Terminal or loop ileostomy (see Chap. E13)
4. Right hemicolectomy (see Chap. E15)
5. Subtotal colectomy (see Chap. E16)
6. End or loop colostomy (see Chap. E13)
G. Haddock
7. Treatment of fistulating or ulcerating
perianal and perineal disease
Fistulating and ulcerating perianal and perineal
Crohn’s disease can be most challenging. The prin-
ciples of surgery are as follows: Identify all cav-
ities and tracks – MRI can sometimes be useful
in this process, but careful examination under an-
aesthetic is essential. All abscess cavities should be
opened out widely and drained. Granulation tis-
sue in the cavity should be curetted out and the
cavity packed. High fistulae may need placement
of a seton suture, although children do not toler-
ate this well. Rarely a defunctioning stoma may
be needed.
8. J-pouch ileoanoplasty and completion
proctectomy
Restorative J-pouch ileoanoplasty and comple-
tion proctectomy is possible in children who have
undergone subtotal colectomy for ulcerative coli-
tis. It should be avoided in Crohn’s disease and in
indeterminate colitis, due to the risk of this be-
coming Crohn’s disease in the future.
Steps
The patient is placed supine with the legs in the
Lloyd–Davis position. Access to the anus is es-
sential. The ileostomy should be circumcised and
fully mobilized. This can be closed using a linear
cutting stapling device. The old midline abdom-
inal wound is reopened and great care taken to
divide all adhesions. Particular care needs to be
taken to free up the root of the small bowel mes-
entery – failure to do this may result in difficulty
getting the J-pouch to reach the anus.
Figure 3:
• The rectum is now mobilized using monopo-
lar diathermy
• The superior rectal vessels if left intact at the
original colectomy, act as a useful marker to
the retro-rectal dissection.
E42  Inflammatory Bowel Disease
• The pelvic nerves and ureters should be iden-
tified and avoided during the dissection. This
is best achieved by keeping the dissection close
to the rectal wall using monopolar diathermy.
• Care should be taken in dissecting the rectum
off of the vagina in girls and the seminal vesi-
cles in boys.
• Dissection should be continued down to within
1 centimetre of the dentate line.
Figure 4:
• A stapling device is then placed across the
rectum and closed. Before firing, the level is
checked by placing a finger in the anal canal.
If satisfactory, the stapling device is fired and
the rectum amputated.
Fig. 4
Figure 5 (1st two diagrams):
• The terminal ileum is now prepared for pouch
formation.
• A 15cm long pouch is usually adequate in chil-
dren.
• A Babcock clamp is placed on the site corre-
sponding to the apex of the pouch.
373
• The distal end of the small bowel is sutured to
the proximal limb taking care to ensure that the
small bowel mesentery is not compromised and
will not be divided when the linear cutting sta-
pler is fired.
• A small hole is created in the distal end of the
j-pouch and two firings of a 75mm linear cut-
ting stapler are made to create the pouch.
Fig. 5
Figure 5 (last diagram):
• An appropriately sized circular stapling device
is identified.
• A purse-string suture of monofilament nylon
in then placed around the circumference of the
open end of the J-pouch.
• The anvil of the stapling device is placed in-
side the open end of the J-pouch and the purse-
string suture is tied in place.
• The stapling device is introduced through the
anus and the spike of the device extended to
pierce the rectal staple line.
• The anvil contained in the pouch is locked onto
the end of the spike and care is taken the check
the orientation of the pouch in relation to its
blood supply.
• The stapling device is then closed and fired.
• The stapling device is removed by a gentle to-
and-fro twisting movement.
• A tube drain may be left alongside the pouch
and brought out through the abdominal wall.
374 G. Haddock

Figure 6:
• A new loop ileostomy is fashioned using a loop
of small bowel just proximal to the pouch.
• The abdominal wound is closed using a mass
closure technique.

Fig. 6
 PAR T F
Groin and Genitalia
F1  Exposure of the Inguinal Canal and Spermatic Cord Structures 377
F1 Exposure of the Inguinal Canal F1
and Spermatic Cord Structures
T. J. Bradnock and P. A. M. Raine

This approach can be used for inguinal herni-
otomies, ligation of a patent processus vagina-
lis (PPV), encysted hydroceles of the cord, orchi-
dectomy for testicular neoplasms and open or-
chidopexies
• Use dissecting scissors to deepen the incision
and cut Scarpa’s fascia (Fig. 2).
• Use small retractors (Cat’s paw or Langenbeck)
to clear the fat off the external oblique aponeu-
rosis (EOA). Striated muscle is seen through the
aponeurosis (Fig. 3).

Operative Technique

• Make a 1- to 2-cm transverse incision 1 cm

above the midpoint of the inguinal canal
(Fig. 1).

Fig. 2

Fig. 1

Tim J. Bradnock ()

Specialty Registrar in Paediatric Surgery
The Department of Paediatric Surgery, Dalnair Street,
Yorkhill Hopsital, Glasgow G3 8SJ, Scotland, UK
Email: tjbradnock@doctors.org.uk Fig. 3

Peter A. M. Raine
Consultant Paediatric and Neonatal Surgeon
Rainewest@btinternet.com

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_114, © Springer-Verlag Berlin Heidelberg 2013
378 T. J. Bradnock and P. A. M. Raine

• Delineate the inguinal ligament by gently open- • Sharply divide the internal spermatic fascia,
ing and closing dissecting scissors perpendic- that loosely invests the cord, for clean expo-
ular to the rolled, inferior edge of EOA. No sure of the cord structures.
sharp dissection is required. • The spermatic cord can be delivered using a
• The inguinal ligament can be followed infero- pair of toothed forceps and a window created
medially to the superficial inguinal ring. posteriorly with artery forceps (Fig. 6). Alter-
• Use a scalpel to make a tiny incision in the EOA natively for an orchidopexy the undescended
1 cm above and lateral to the superficial ingui- testis is usually apparent at the superficial ring
nal ring (Fig. 4). (Fig. 7).
• Dissecting scissors are used to extend the inci-
sion and push the muscle fibres away from the
underside of the fascia, creating a ‘window’ in
the inguinal canal.
• Artery forceps are used to split first the external
oblique and then cremaster along the line of its
fibres, exposing the spermatic cord (Fig. 5).

Fig. 4 Fig. 5

Fig. 6 Fig. 7
F1  Exposure of the Inguinal Canal and Spermatic Cord Structures
Tips
77 It is vital to clearly delineate the inguinal liga-
ment to ensure correct orientation and avoid in-
advertent damage to the femoral vessels.
Common Pitfalls
77 Avoid making your incision too low or too me-
dial. Remember the landmarks.
77 Avoid cutting the superficial epigastric vessels
which cross the medial aspect of wound
379
77 The external oblique forms the anterior wall of
the inguinal canal and can be windowed to gain
excellent access to the deep inguinal ring and
spermatic cord structures.
77 When opening the inguinal canal watch for the
ilioinguinal nerve which runs through the canal
superficial to the cord structures. Transection re-
sults in loss of touch sensation over the scrotum
or labia majora and medial thigh.
 380 T. J. Bradnock and G. Haddock
F2 F2 Inguinal Hernia and Ligation
of Patent Processus Vaginalis
T. J. Bradnock and G. Haddock

• General anaesthesia is used, but consider spi-

nal anaesthesia in ex-preterm infants and pa-
tients with significant cardiorespiratory comor-
bidity.
• Position patient supine on a heating blanket.
• If present, a hernia should be reduced prior to
commencing the operation.
• Palpate the other spermatic cord. If it is thick-
ened or there is a ‘silk-glove’ sign, perform con-
tralateral exploration.
• The spermatic cord and glistening white hernial
sac or patent processus vaginalis (PPV) are de-
livered using the steps described in Chap. F1. Fig. 1
• In neonates and infants the dissection can be • Use fine, non-toothed forceps to first pick up,
performed through the superficial inguinal and then gently tease away, the fine coverings
ring. In older children the increased length of overlying the spermatic vessels and vas defer-
the inguinal canal means that better exposure ens (Figs. 2 and 3).
is obtained by ‘windowing’ the canal. • The vas and vessels are cleared laterally and
• Use fine, non-toothed forceps to gently tease protected by Alice forceps (Fig. 4).
any remaining cremasteric fibres and internal • If in doubt, open the isolated hernial sac be-
spermatic fascia off the spermatic cord. tween clips to exclude a sliding component.
• Lift the spermatic cord and use curved mos- • Transect the sac or PPV distal to curved mos-
quito forceps to create a window posteriorly quito forceps, ensuring the vas and vessels are
(Fig. 1). safe (Fig. 5).
• Use curved mosquito forceps passed medial to
lateral through this window, to elevate the cord
and accompanying sac or PPV.
• Maintain traction by passing your left index
finger posterior to the cord, or alternatively by
elevating the hernial sac anteromedially with
artery forceps.

Tim J. Bradnock ()

Specialty Registrar in Paediatric Surgery
The Department of Paediatric Surgery, Dalnair Street,
Yorkhill Hopsital, Glasgow G3 8SJ, Scotland, UK
Email: tjbradnock@doctors.org.uk Fig. 2

Graham Haddock
Consultant Paediatric and Neonatal Surgeon
Ghaddock@udcf.gla.ac.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_115, © Springer-Verlag Berlin Heidelberg 2013
F2  Inguinal Hernia and Ligation of Patent Processus Vaginalis 381

• Separate the cord structures off the sac or PPV

to the level of the deep ring by gently teasing
away any adhesions with fine, non-toothed for-
ceps, a process that is facilitated by maintain-
ing counter-traction between the vas and ves-
sels and sac or PPV (Fig. 6).
• Adequate proximal dissection is confirmed by
the presence of retroperitoneal fat adjacent to
the neck of the sac or PPV.
• Twist the sac to ensure that all the contents
are fully reduced. Use a slotted spoon placed
around the sac or PPV to protect the cord
structures before transfixion and ligation with
Fig. 3 a braided, absorbable 3/0 or 4/0 suture.
• Excise the redundant sac.
• If the hydrocele does not communicate and
persists, use a scalpel to incise the tunica vagi-
nalis and liberate the fluid under direct vision
before returning the testis to the scrotum. Alter-
natively, aspirate the fluid percutaneously with
a needle.
• Close the wound in layers with continuous, ab-
sorbable 3/0 or 4/0 sutures to external oblique
aponeurosis if a canalicular approach was
used; place interrupted absorbable sutures to
Scarpa’s fascia and continuous absorbable sub-
cuticular sutures to skin.

Fig. 4

Fig. 6
Fig. 5
382 T. J. Bradnock and G. Haddock

Tips

77 In females, the inguinal herniotomy is simplified
by the absence of a vas and testicular vessels. In-
spect and reduce an ovary if present, ligate the
sac and close the superficial ring.
77 During the procedure, traction on the cord may
have drawn the testis out of the scrotum. Always
check it is in the scrotum at the end of the case
and reduce it manually if necessary.
77 Never grasp the vas directly with an instrument,
as this risks causing irreversible damage.
77 If the sac is inadvertently opened, the situation
can be retrieved by sequentially dissecting it
from the vas and vessels with curved strabismus
scissors between curved mosquito forceps.

Common Pitfalls

77 Inadvertent damage to the ilioinguinal nerve
may cause sensory loss/chronic neuralgic pain.
77 Vasal injury during infant inguinal herniotomy is
one of the commonest causes of seminal tract
obstruction in adults.
77 Failure to identify a ‘sliding’ hernia may result in
bladder, bowel or ovarian injury.
77 Seventy-five per cent of patients with complete
androgen insensitivity syndrome present with
an inguinal hernia. Always inspect a gonad in
the sac of a phenotypically normal female to ex-
clude intra-abdominal testis. If in doubt consider
karyotyping.
77 Careful handling of the vessels reduces the risk
of avoidable testicular atrophy.

S I R DE NI S BROWNE
(1892 – 1967)
British paediatric surgeon

Denis Browne qualified in medicine at the University of Sydney and served with the Austra-
lian Army’s Medical Corps before joining the Hospital for Sick Children on Great Ormond
Street in 1928. He was a pioneer in the field of paediatric surgery, who first recognized the
need for special skills in treating children. In addition to his work in the management of in-
guinal hernia, undescended testis, anorectal malformations he also refined the management
of cleft lip and palate. A gifted innovator, he designed many instruments in current use in-
cluding the Denis Browne bowel-holding forceps and the Denis Browne ring used in GI and
urological procedures.
F3  Incarcerated Inguinal Hernia
F3 Incarcerated Inguinal Hernia
B. Adikibi and R. Carachi
Indication
Failed attempt at manual reduction, despite ad-
equate analgesia with or without sedation is a
strong indication for surgery.
Technique
• After induction of anaesthesia, no further at-
tempt at manual reduction should be made.
• A pre-peritoneal approach should be utilised.
• The patient is positioned supine.
• Make a generous skin crease incision at the
level anterior superior iliac spine (Fig. 1).
Fig. 1
Boma Adikibi ()
Specialty Trainee in Paediatric Surgery
boma.adikibi@nhs.net
Robert Carachi
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_116, © Springer-Verlag Berlin Heidelberg 2013
383
F3
• Use a combination of sharp and blunt dissec-
tion to sequentially deepen the incision through
Scarpa’s fascia, external and internal obliques,
and transversalis muscles to the pre-peritoneal
space. The internal ring should now be visi-
ble just lateral to the inferior epigastric vessels
(Fig. 2).
• Dissect the hernial sac free from the surround-
ing tissues.
• Examine the contents. If the bowel is viable at-
tempt reduction with gentle pressure (Fig. 3).
• If the bowel appears ischaemic, opening the
ring may restore vascularity ,and warm saline-
soaked packs should be placed for several min-
utes. The bowel is then reassessed for signs of
Fig. 2
Fig. 3
384 B. Adikibi and R. Carachi

Fig. 4

viability such as return of healthy colour, an-

timesenteric pulsation and peristalsis.
• If the bowel is necrotic, resection and primary
end-to-end anastomosis should be performed
as described in Chap. E14, ‘Bowel Resection
and Anastomosis’ (Fig. 4).
• If the sac contents reduced spontaneously be-
fore inspection, look for blood-tinged or faecu-
lent peritoneal fluid or a foul odour, as these are
indicators of a necrotic bowel. If any of these
findings are present, the bowel must be deliv-
ered into the wound and carefully examined.
This can be performed through the open sac or
with lateral extension of the incision through
the internal ring.
• The internal ring is closed after reduction of
hernia contents with a single purse string su-
ture of 2/0 or 3/0 Ethibond, taking care not to
incorporate the vas or vessels in the suture.
• Closure is in layers with absorbable 3/0 or 4/0
sutures.

Fig. 5
F3  Incarcerated Inguinal Hernia
Tips
77 Once the decision has been made to attempt
operative reduction, do not attempt further re-
duction of the hernia sac contents, as examina-
tion of the incarcerated bowel is an imperative
part of the operation.
77 Always positively identify and preserve the vas
and testicular vessels.
Common Pitfalls
77 Avoid making an inadequate incision, as this
makes dissection under direct vision and care-
ful assessment of the incarcerated bowel more
difficult.
385
77 Dissection should always be performed under
direct vision.
77 Placing the patient in the Trendelenburg posi-
tion may help encourage reduction of viable
bowel.
77 During the consent process for surgery, the par-
ents should be warned that there is risk for testic-
ular atrophy following an episode of hernial in-
carceration, due to compression of the testicular
vessels. Failure to do so will make any retrospec-
tive discussion more difficult. The testicular vol-
umes should be recorded at follow-up.
 386
F4 F4 Femoral Hernia
R. Carachi
A femoral hernia is a (rare) herniation of extraper-
itoneal fat or a viscus (bowel or bladder) through
the femoral canal in children. The femoral vein,
artery and nerve are lateral to the hernia, although
the hernia may sometimes protrude and overly
these structures. Many approaches have been de-
scribed. If there is risk of incarceration or stran-
gulation then a suprainguinal, extraperitoneal ap-
proach is used. (This is described in the Chap. F2,
‘Inguinal Hernia and Ligation of Patent Processus
Vaginalis’). The commonest approach however is
directly over the hernia mass using an infraingui-
nal approach. This approach is now described:
Fig. 1
Robert Carachi ()
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_117, © Springer-Verlag Berlin Heidelberg 2013
R. Carachi
• A transverse skin crease incision over the
mass in the infrainguinal region is performed
(Fig. 1).
• The mass is identified usually covered with fas-
cia around the femoral canal. The vessels, fem-
oral vein and femoral artery should be identi-
fied at this stage to avoid damage.
• The fascia is divided using sharp dissection and
the mass is lifted and dissected to the femoral
canal. Often fatty tissue causes a problem and
this needs to be cleaned with a pledget. Good
views are essential for this dissection to be car-
ried out carefully (Fig. 2).
Fig. 2
F4  Femoral Hernia
Fig. 3
• Traction allows the hernial sac to be identified
and to ascertain whether any contents are pres-
ent.
• The sac is then opened at its apex using mos-
quito forceps to open the sac and allow a good
view inside (Figs. 3 and 4).
• The sac is then twisted on itself and transfixed
at its base with a Vicryl (000) stitch. This region
can be doubly transfixed to avoid recurrence.
• The defect is then closed using a combination
of sutures, usually one or two interrupted ones
Fig. 5
387
Fig. 4
to bring together the pectinate fascia and Coo-
pers ligament.
• Haemostasis is used to control any bleeding
during this procedure.
• The subcutaneous tissues and fascia are closed
using interrupted sutures Vicryl (000).
• A subcuticular stitch is used to close the skin
Vicryl (0000).
388 R. Carachi

Tips

77 Good exposure is essential for this operation 77 If the defect cannot be closed by apposition of
to be carried out safely; if necessary extend the the fascia and the ligament then a prosthetic
wound. patch may need to be used. This is rare.
77 Careful dissection and identification of the femo- 77 The content of the hernia must be visualised to
ral vein is necessary to avoid damage and bleed- avoid damage to bowel or bladder.
ing.

Common Pitfalls

77 On occasion the femoral hernia may be bilateral.

77 The femoral mass may sometimes have an in-
flammatory component if it has been long
standing and may be difficult to dissect from the
vessels.
F5  Acute Scrotal Exploration
F 5Acute Scrotal Exploration
K . Maguire and A. J. Sabharwal
• Holding the testis firmly with the skin held
taught (Fig. 1), make a transverse incision in
the hemiscrotum. Deepen slowly through the
layers (Fig. 2) until the testis, in its tunica albu-
ginea, is free.
• Deliver the testis from the scrotum, everting
the tunica vaginalis, and inspect the testis and
cord structures.
• If a torted hydatid of Morgagni is found
(Fig. 3), grasp it with toothed forceps and use
bipolar diathermy to excise it at the base. En-
sure the testis is not torted and then proceed to
closure.
Fig. 1
Kirsty Maguire ()
Specialty Trainee in Paediatric Surgery
kirstymaguire@doctors.org.uk
Atul J. Sabharwal
Consultant Paediatric and Neonatal Surgeon
Atul.Sabharwal@ggc.scot.nhs.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_118, © Springer-Verlag Berlin Heidelberg 2013
389
F5
• If the testis is torted (Fig. 4), untwist the cord,
wrap the testis in warm, saline-soaked packs
and explore the other side.
• Repeat the incision on the contralateral hemis-
crotum and deliver the healthy testis. Leaving
the tunica vaginalis everted, fix the good testis
to the scrotal wall at three points (Fig. 5) using
fine, non-absorbable sutures. Alternatively, use
the same three-point fixation technique to fix
the testis in a dartos pouch or directly to the
tunica vaginalis.
• Unwrap the previously torted testis and assess
viability. If in doubt, cut the tunica albuginea.
Bleeding implies viability.
• If the testis is viable, fix it in the scrotum as de-
scribed above (Fig. 5).
• If the testis is necrotic, place a large clip or ar-
tery forceps over the cord within the scrotum
and excise the testicle. Tie the cord using strong,
absorbable suture.
• Close the dartos muscle in each hemiscrotum
using absorbable suture.
• Using Alice forceps to lift up the wound edges,
suture the skin of each hemiscrotum using a
fine, absorbable suture in a continuous suture
line (Fig. 6).
– Alternative: A midline raphe incision can be
used, allowing access to both testes from a
single skin incision.
390 K. Maguire and A. J. Sabharwal

Fig. 2

Fig. 4
Fig. 3
F5  Acute Scrotal Exploration 391

Fig. 6

Fig. 5

Tips

77 The testis usually twists towards the midline, i.e. 77 As you incise the tunica vaginalis, a small amount
right twists clockwise, left twists anticlockwise of haemoserous fluid (secondary hydrocele) may
from the examiners perspective. be liberated.
77 There are many thin layers of tissue to incise be-
fore reaching the testis. Have patience and pro-
ceed cautiously.

Common Pitfalls

77 Injudicious use of the knife when deepening the 77 Take care when placing fixation sutures not to
incision may result in inadvertent opening of the suture through the vas, vessels or epididymis.
tunica albuginea.
77 Do not use monopolar diathermy on the scro-
tum or other extremities.
 392 M. Yassin and A. H. B. Fyfe
F6 F6 Varicocoele
M. Yassin and A. H. B. Fyfe

• Varicocoeles affect 10–15 % of children and ad- Open Palomo Procedure

olescents. (Classic and Modified)
• Its impact on fertility is debated, but varico-
coeles are present in 30 % of the male partners Operative Technique
of infertile couples.
• Indications for surgery in the paediatric age • The patient is positioned supine.
group include loss of testicular volume or tes- • A short transverse incision is made just lateral
ticular pain. to the deep inguinal ring (Fig. 1).
• The treatment of asymptomatic lesions re-
mains controversial.
• Treatment options include:
– Embolisation of the testicular vein using
coils or sclerosant via a femoral or internal
jugular vein approach
– Surgical ligation of the testicular vessels:
– Inguinal approach (Ivanissevich)
– High approach (Palomo)
• Palomo described a high ligation of the testicu-
lar artery, veins and lymphatics (classic Palomo
procedure).
• A modified Palomo procedure with sparing of
the testicular artery is commonly used.
• The classic and modified Palomo procedures
can both be performed using an open or lapa-
roscopic approach (see Chap. I15). Fig. 1

• The incision is deepened through subcutane-

ous tissue using monopolar diathermy, and the
wound edges retracted.
• The external oblique aponeurosis is incised with
a blade and the muscle split in the direction of
its fibres with curved dissecting scissors, to re-
veal the underlying internal oblique muscle.
• The internal oblique muscle is separated in the
Musaab Yassin () same way and retractors used to expose the
Core Trainee in Urology transversalis fascia (Fig. 2).
musaab.aldouri@gmail.com
• Transversalis fascia is opened between curved
Alistair H. B. Fyfe mosquito forceps and the retroperitoneal space
Consultant Paediatric Urologist is entered (Fig. 3).
Fyfe7es@btinternet.com

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_119, © Springer-Verlag Berlin Heidelberg 2013
F6 Varicocoele 393

• The peritoneum is pushed medially with the injecting methylene blue into the scrotum pre-
Kittner dissector to expose the spermatic ves- operatively as described in Chap. I15.
sels above the point where they diverge from • Complete division of the testicular vessels and
the vas deferens. Placing the testis under ten- haemostasis should be confirmed.
sion caudally may help locate the vessels. • The external oblique aponeurosis is closed with
• Using a curved clamp or rubber sloupes, interrupted 3/0 vicryl sutures and skin is closed
carefully mobilize the vessels into the wound with a 4/0 continuous absorbable subcuticular
(Fig. 4). suture.
• Under magnification with Loupes, use sharp
and blunt dissection to separate all (usually
three) of the veins from the adjacent artery
and lymphatic vessels. Typically, there are sev-
eral veins next to or adherent to the testicular
artery, with an isolated vein nearby (Fig. 5).
• The dilated veins are identified first (Fig. 5a),
and mobilized carefully using non-toothed for-
ceps and curved mosquito forceps (Fig. 5b),
and a ligature is passed underneath the dilated
vein (Fig. 5c). A short section of vein is excised
between 3/0 non-absorbable ligatures (Fig. 5d).
• The testicular artery is identified and preserved
(modified Palomo) or ligated and divided in the
same way (classic Palomo).
• A further modification of Palomo’s original
operative description is to preserve the lym-
phatics that accompany the testicular vessels.
Identification of these vessels is facilitated by

peritoneal
fold

retroperitoneal
space

Fig. 2 Fig. 3
394 M. Yassin and A. H. B. Fyfe

Fig. 4

Fig. 5
F6 Varicocoele
Tips
77 Always explain to the patient and parents that
there is risk of recurrent varicocoele(s) (4–20 %).
The risk of recurrence may be higher if artery-
sparing surgery is attempted.
77 If the artery is not apparent, bluntly strip the
spermatic fascia off the cord. Dripping Papaver-
ine solution onto the cord will make the artery
dilate and become visibly pulsatile.
Common Pitfalls
77 Postoperative hydrocoeles may occur due to
lymphatic ligation. Consider using a lymphatic-
sparing approach.
77 Although renal tumours are the underlying
cause of less than 1 % of paediatric varicocoeles,
this aetiology should always be considered, par-
ticularly in right-sided varicocoeles (<10 %) or if
the onset of varicocoele is abrupt. Obtain a renal
tract ultrasound if in doubt.
395
77 Placing the patient in the reverse Trendelenburg
position facilitates identification of the veins as
they fill with blood.
77 Very rarely, if identification of all venous collater-
als is in doubt, intra-operative venography may
be a useful adjunct.
77 The overall risk of testicular atrophy is less than
5 %. The risk is increased with techniques that
approach the testicular vessels distal to the deep
ring. In these circumstances, microvascular tech-
niques under magnification, should be used in
conjunction with Papaverine and intra-opera-
tive ultrasound to identify and preserve the tes-
ticular and cremasteric arteries and the artery to
the vas.
 396
F7 F7 Testicular Tumour
K . Maguire and R. Carachi
• The patient should be placed in the supine po-
sition. A caudal block should be used.
• Skin-crease incision is next made, extending lat-
erally from just above the pubic tubercle.
• Expose the external oblique aponeurosis as de-
scribed in Chap. F1, ‘Exposure of the Inguinal
Canal and Spermatic Cord Structures’.
• Make a stab incision in the external oblique
aponeurosis above and lateral to the superfi-
cial ring.
• Split the incision with curved dissecting scis-
sors along the line of the fibres (Fig. 1).
• Identify the ilioinguinal nerve and preserve it
by sweeping it inferiorly off the underside of
the aponeurosis, extending incision into the su-
perficial ring.
Fig. 1
Kirsty Maguire ()
Specialty Trainee in Paediatric Surgery
kirstymaguire@doctors.org.uk
Robert Carachi
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_120, © Springer-Verlag Berlin Heidelberg 2013
K. Maguire and R. Carachi
• Reflect the aponeurosis and split the cremas-
teric fibres using curved dissecting scissors, to
expose the spermatic cord structures (Fig. 2).
• Use curved mosquito forceps to develop the
plane behind the spermatic cord. Pass a rub-
ber sloupe behind the cord.
• Identify the testicular vessels, dissect them
free and ligate as proximally as possible using
a strong suture. Then ligate the rest of the cord
structures, again as high as possible within the
wound.
• Use a combination of blunt dissection and bi-
polar diathermy to mobilise the distal portion
of the cord, then use gentle traction to deliver
the testis up into the wound.
• Gently separate the testicular attachments to
the scrotal wall using blunt dissection until the
gubernacular attachment of the lower testicu-
lar pole to the scrotal wall is reached.
• Divide the gubernacular attachment with mo-
nopolar diathermy, between curved mosquito
clips (Fig. 3).
Fig. 2
F7  Testicular Tumour 397

• Excise the testis and cord and send fresh to the

pathology laboratory. Ensure haemostasis with
bipolar cautery.
• Close the external oblique aponeurosis using a
continuous absorbable suture obliterating the
superficial ring (Fig. 4).
• Use interrupted absorbable sutures to close
Scarpa’s fascia and then subcutaneous tissue.
• Close the skin using a continuous subcuticular
absorbable suture.

Fig. 3 Fig. 4

Tips

77 Always mark the operation side prior to surgery, 77 Always discuss the case with the duty patholo-
after carefully confirming the side of pathology gist prior to surgery. Check their availability to re-
with clinical examination and radiological find- ceive the specimen, and ask how they would like
ings. it to be orientated and received.
77 Ligate the vessels as high as possible within the
inguinal canal to minimise the risk of incomplete
resection.

Common Pitfalls

77 Never approach the tumour through the scro-
tum, as this compromises complete resection.
77 Avoid manipulating the distal cord or tumour
prior to ligating the vessels, as this minimises the
risk of venous embolisation of tumour cells.
77 Retroperitoneal lymph node dissection does not
play a role in the initial surgical management of
testicular tumours in prepubescent children.
 398
F8 F8 Circumcision and Prepuceplasty
R. Stewart and M. E. Flett
Circumcision
• Fully retract the prepuce behind the glans.
• Hold the glans with a small swab and divide
any preputial adhesions using Betadine-soaked
swabs to provide gentle traction (Fig. 1) or a
blunt probe to dissect circumferentially.
• Clean the glans. Remove any smegma.
• If the preputial orifice is too tight to allow re-
traction, it can be dilated with curved mosquito
forceps (Fig. 2).
• Now fully retract the foreskin back over the
glans and elevate it using curved mosquito for-
ceps ventrally and dorsally (Fig. 3).
• Use curved mosquito forceps to mark the skin
at the intended transection point.
• With the skin under tension, place a straight
clamp across the prepuce above the glans, at
the level of the previously made marks (Fig. 4).
• Using a no. 15-blade scalpel, cut across the pre-
puce directly underneath the clamp (Fig. 5).
• Place four clips around the edge of the ex-
posed mucosa. Ask your assistant to hold two
of these (Fig. 6).
• Using curved strabismus scissors, cut circum-
ferentially around the mucosa, leaving a 2- to
3-mm cuff around the corona.
• Alternatively, make a dorsal slit in the mucosal
layer and then transect circumferentially.
• Retract the skin of the penis to expose the de-
nuded penile shaft and any bleeding vessels.
These should be controlled with bipolar dia-
thermy.
Ross Stewart ()
Core Trainee in General Surgery
rossstewart@doctors.org.uk
Martyn E. Flett
Consultant Paediatric Urologist
Martyn.Flett@ggc.scot.nhs.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_121, © Springer-Verlag Berlin Heidelberg 2013
R. Stewart and M. E. Flett
• Use interrupted 5/0 Vicryl sutures on a round
needle, to approximate the shaft skin and mu-
cosa cuff.
• Start by placing a box suture to approximate
the fraenulum. Place a second suture at the
midline dorsally.
• Clip these sutures and use them to manipulate
the penis (Fig. 7).
• Place two to three more interrupted sutures on
each side, approximating skin and mucosal cuff
(Fig. 8).
• Cover the wound with antibiotic ointment.
Prepuceplasty
• Retract the prepuce over the glans. Divide any
residual preputial adhesions, as described op-
posite.
• With the foreskin retracted, the phimotic stric-
ture should be apparent as an area of relative
waisting of the penile shaft (Fig. 1).
• Use a no. 15-blade scalpel to incise the phi-
motic stricture longitudinally over a length of
0.5–1cm (Fig. 2).
• Incise down to Buck’s fascia.
• Use bipolar diathermy for haemostasis.
• Draw the prepuce forward and use interrupted
5/0 Vicryl sutures to close the incision trans-
versely (Fig. 3).
• Cover the wound with antibiotic ointment.
• No dressing is necessary.
• The patient should be encouraged to com-
mence regular retractions as soon as comfort-
able (usually the second post-operative day) to
avoid re-stenosis.
F8  Circumcision and Prepuceplasty 399

Fig. 1 Fig. 2

Fig. 3 Fig. 4
400 R. Stewart and M. E. Flett

Fig. 5
Fig. 6

Fig. 7

Fig. 8
F8  Circumcision and Prepuceplasty 401

Fig. 9

Fig. 10

Fig. 11

Tips

77 The only absolute indication for circumcision is 77 Postoperative bleeding may be arrested using a
balanitis xerotica obliterans (BXO). This is rare in pressure dressing.
children younger than 5 years of age. 77 A common site of bleeding is the fraenular ves-
77 If you are performing a circumcision without as- sels, that may require ligation.
sistance, good exposure can be achieved by re-
flecting the penis over a rolled-up swab, whilst
closing the skin.

Common Pitfalls

77 Never circumcise an infant with hypospadias or a
buried penis, as this may compromise the subse-
quent reconstruction. Refer to Urology.
77 Meatal stenosis occurs in 10 % of boys after cir-
cumcision (usually for BXO). Follow-up BXO cases
to exclude voiding dysfunction which may re-
quire meatoplasty.
77 A urethrocutaneous fistula may arise from injudi-
cious use of bipolar diathermy or from a deep su-
ture placed to control fraenular bleeding.
77 Excising too much skin gives the appearance of a
buried penis; excising too little may cause annu-
lar scarring and phimosis.
 402
F9 F9 Urethral Meatotomy and Dorsal Slit
of the Foreskin
P. Hammond and P. A. M. Raine
Urethral Meatotomy
Indication
Treatment of urethral meatal stenosis (usually
secondary to balanitis xerotica obliterans [BXO])
Operative Technique
• The tip of a straight artery forceps is inserted
at the meatus to define a ‘lip’ of stenotic tissue
dorsally (and/or occasionally ventrally).
• The forceps is then applied across the ‘lip’ in
the dorsal (or ventral) sagittal plane to clamp
and crush the tissue.
• This crushed glans tissue is cut with sharp iris
scissors to achieve minimal bleeding (Fig. 1).
• Interrupted 7/0 Vicryl sutures are placed at the
apex of the cut and either side to appose glan-
ular skin and terminal urethral mucosa.
• An appropriately sized urethral catheter may
be inserted for 24–48 h postoperatively.
Philip Hammond ()
Consultant Paediatric and Neonatal Surgeon
Philip.Hammond@ggc.scot.nhs.uk
Peter A. M. Raine
Consultant Paediatric and Neonatal Surgeon
Rainewest@btinternet.com
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_122, © Springer-Verlag Berlin Heidelberg 2013
P. Hammond and P. A. M. Raine
Dorsal Slit
Indication
An indication for this meatotomy is phimosis
(possibly to prevent recurrent paraphimosis) or
‘buried penis’.
Operative Technique
• The dorsal foreskin is stretched distally using
two curved mosquito forceps applied just to ei-
ther side of the dorsal midline point of the pre-
putial orifice.
• The dorsal midline foreskin in the sagittal plane
is then clamped and crushed for an appropri-
ate distance proximally with straight artery for-
ceps. It should be left clamped for 10 s.
• The crushed foreskin is then divided with scis-
sors to widen the preputial aperture.
• The inner and outer preputial skin is apposed
with interrupted 5/0 Vicryl (Fig. 2).
• This process can be repeated further proximally
until the foreskin aperture is wide enough to
easily permit retraction over the glans.
F9  Urethral Meatotomy and Dorsal Slit of the Foreskin 403

Fig. 1 Fig. 2 Fig. 3 Fig. 4

Tips

77 Local anaesthetic gel should be applied to the 77 The dorsal slit should be performed a centime-
glans during meatotomy. tre at a time until the preputial orifice is deemed
77 Judicious use of bipolar diathermy may be re- wide enough.
quired for haemorrhage during either proce-
dure.

Common Pitfalls

77 An inadequate meatotomy may result in recur- 77 The dorsal slit must be sufficient so that the
rent meatal stenosis. glans is not exposed through a residual tight
foreskin band, as this presents the risk of para-
phimosis.
 404 T. J. Bradnock and G. Haddock
F10 F10 Open Orchidopexy
T. J. Bradnock and G. Haddock

• Perform an examination under anaesthetic
(EUA) of the inguinal region to confirm the
position of the testes
• Expose the inguinal canal as described in
Chap. F1 (Fig. 1).
• In most cases, the undescended testis will be
apparent at the superficial inguinal ring.
• Delivery of a canalicular testis is aided by win-
dowing the canal (see Chap. F1), with exten-
sion into the superficial inguinal ring.
• Use toothed forceps to lift the spermatic cord
from the inguinal canal.
• Hold the testis in your non-dominant hand.
Use artery forceps or finger dissection to cre-
ate a window posterior to cord (Fig. 2).

Fig. 2

• The gubernaculum is divided by gently teas-

Fig. 1
Tim J. Bradnock ()
Specialty Registrar in Paediatric Surgery
The Department of Paediatric Surgery, Dalnair Street,
Yorkhill Hopsital, Glasgow G3 8SJ, Scotland, UK
Email: tjbradnock@doctors.org.uk
Graham Haddock
Consultant Paediatric and Neonatal Surgeon
Ghaddock@udcf.gla.ac.uk
ing the strands away from the testis with fine
non-toothed forceps. Small vessels should be
divided with bipolar diathermy (Fig. 3). Alter-
natively clipping and ligating these vessels (in-
ferior epigastric.)
• Elevate the testis superolateral to the incision
and inspect the posterior surface of the cord
for a hernial sac (Fig. 4).
• Carefully dissect the vas and vessels off the sac
as described in Chap. F02 (Figs. 5–7).
• Use fine non-toothed forceps to tease away any
adherent strands of tissue between the cord and
sac to the level of the deep inguinal ring (Fig. 8).
• Twist the sac, before transfixing and ligating
with 3/0 Vicryl.

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_123, © Springer-Verlag Berlin Heidelberg 2013
F10  Open Orchidopexy 405

• Divide lateral spermatic bands with scissors to
allow the testis to be brought into the scrotum
without tension.
• Create a ‘tunnel’ into the scrotum by gently
passing the index finger of your non-domi-
nant hand from the medial end of the wound
to the scrotum.
• Use a scalpel to incise the scrotal skin over your
finger, and iris scissors to create a dartos pouch
(Figs. 9 and10).
• Pass curved mosquito forceps from the scrotal
to the inguinal wound, guided and protected
by your fingertip.
• Grasp the testis by the tunica albuginea at its
inferior pole and deliver into the dartos pouch,
ensuring no twisting of the cord.
• Use an absorbable 4/0 suture to ‘pex’ (an orchi-
dopexy) the lower septum of the testis to the
median raphe or alternatively, to close the neck
of the dartos pouch around the spermatic cord.
• Close the inguinal wound in layers and the scro-
tum with continuous 4/0 Vicryl.

Fig. 3

Fig. 6

Testis

Fig. 4 Fig. 7

Fig. 5 Fig. 8
406
Fig. 9
Tips
77 On occasion the dissection of the testicular ves-
sels may need to be extended extra-peritoneally
to gain adequate length.
77 If after extensive retroperitoneal dissection the
cord remains too short to reach the scrotum,
consider performing a two-stage procedure (fix
the testis to the pubic tubercle initially).
Common Pitfalls
77 The superficial inferior epigastric vein traverses
the medial end of the incision. Either retract it or
coagulate and divide.
77 When ‘windowing’ the inguinal canal, avoid di-
viding the ilioinguinal nerve. Division results in
loss of sensation over the upper medial thigh
and anterior third of the scrotum.
T. J. Bradnock and G. Haddock
Fig. 10
77 Always ensure the spermatic cord is not twisted
before delivering the testis into the scrotum –
check position of the lateral sulcus.
77 The dartos pouch should be made inferior to in-
cision, so that the testis is not fixed under the
wound.
77 Always inspect the gubernaculum to exclude
a ‘looping vas’, which may be inadvertently di-
vided.
77 Failure to ensure meticulous haemostasis during
dartos pouch creation will result in scrotal hae-
matoma.
F11  Ovarian Surgery 407
F 1O varian Surgery F11
H. Said and R. Carachi

Often findings of antenatal ultrasound or neona-

tal examinations done as part of an evaluation of
congenital anomalies necessitate surgery.
• The majority of findings are simple follicular
cysts associated with high maternal steroid pro-
duction.
• When reasonably small (<7 cm) torsion is un-
likely, regression occurs rapidly, serial ultra-
sound examination to monitor disappearance
is sufficient.
• Intrauterine fetal cyst aspiration has been tried
and yielded good results.
• If larger than 5 cm, the cyst should be removed
to relieve pressure and its consequent pain, to
prevent torsion and to rule out large cystic ter-
atoma.
• An attempt should be made to preserve nor-
mal and functioning ovarian tissue, even if ne-
crotic.
• A laparoscopic approach is the ideal approach
for diagnosis and treatment.
• Percutaneous aspiration should not be tried. Fig. 1

An elliptical incision is made through the thin

Resection of Benign Cyst cortex of the benign cyst (Fig. 2).
• A plane is developed by the use of blunt dissec-
Surgery through Pfannenstiel incision: tion. The end of the knife is then inserted and
• A thin-walled ovarian cyst is shown in Fig. 1. a plane developed over the cyst wall. Fine-nee-
• Careful assessment is necessary before the ini- dle electrocautery or microsurgical can be used
tial incision is made. The incision in the ovar- to separate the cyst wall from the ovarian cor-
ian cortex facilitates symmetric reconstruction. tex (Fig. 3).
• The inner ovarian stroma may be approxi-
mated with a purse-string suture of 5/0 non-
Hanan Said ()
Consultant Paediatric and Neonatal Surgeon, reactive material. Closure of the ovary is done
King Fahd Armed Forces Hospital, PO Box 9862, with a baseball or simple stitch. NB: The re-
Jeddah 21159, Kingdom of Saudi Arabia dundent cortex can be removed and the dead
+966 2 665300 space obliterated with an internal closure, with
Hanansaid@gmail.com
care taken that suture material does not pene-
Robert Carachi trate the ovarian cortex (Fig. 4).
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_124, © Springer-Verlag Berlin Heidelberg 2013
408 H. Said and R. Carachi

Fig. 3

Fig. 2

Fig. 4
F11  Ovarian Surgery 409

Tips

77 Low-power magnification (surgical loupes) of- 77 If the cortex is quite friable, it is necessary to
ten assists the surgeon in identifying the correct place interrupted 6/0–7/0 non-reactive sutures
plane in the cyst wall and ovarian parenchyma. to achieve adequate approximation.

Common Pitfalls

77 Rupture of fragile cyst wall and spillage of the 77 Rough manipulation of the Fallopian tubes
pelvic cavity
77 Excessive redundant thin cortex: can present a
special problem in ovarian reconstruction

Ovarian Transposition Before

Radiotherapy

Surgery through the Pfannenstiel incision:

• This procedure is done, e.g. when there is ovar-
ian transposition in a patient being treated for
malignancy before receiving radiotherapy.
• The ovaries are suspended out of the field of
radiation.
• Bisharah and Tulandi have recommended tran-
section of the ovarian ligament and transposi-
tion of the ovaries without affecting the Fallo-
pian tubes.
• This is associated with positioning of the ova-
ries laterally and anteriorly at the level of the
anterosuperior iliac spines (Fig. 5).
Fig. 5

Tips

77 Gonads are sensitive to radiation. It is estimated the lethal dose required to eliminate 50 % of the
that the sensitivity of the oocytes to radiation is oocytes (LD50) of 2 Gy

Common Pitfalls

77 The consequences of not transecting the ovarian

ligament will affect the Fallopian tubes.
 410 C. Keys and A. H. B. Fyfe
F12 F 12Labial Adhesions
and Imperforate Hymen
C. Keys and A. H. B. Fyfe

Labial Adhesions • Apply soft, yellow paraffin to prevent re-adher-

ence.
Labial adhesions are inflammatory in origin and
usually occur as a result of persistent, low-grade
vulvitis.

Indications for Surgery

• There are no absolute indications for surgery.

• Relative indications are:
– Early urine leakage after voiding, due to ret-
rograde filling of the vagina
– Recurrent urinary tract infection
– Chronic irritation and discomfort
– Failure to respond to a 7- to 10-day course
of topical oestrogen cream

Technique Fig. 1

• Flimsy adhesions may be divided in the clinic Imperforate Hymen

room.
• Adhesions that are more significant require
general anaesthetic.
• Place the patient in the supine or lithotomy po-
sition.
• Safeguard aseptic technique should be under-
taken.
• Gentle manual separation of the labia minora
confirms the diagnosis with midline fusion oc-
cluding part or all of the introitus (Fig. 1).
• Gently run a probe down from the clitoral hood
to the posterior fourchette (Fig. 1).
• The adhesions should separate with no signif-
icant bleeding.
Charlie Keys ()
Specialist Registrar in Paediatric Surgery
charleskeys@doctors.org.uk
The vagina is obstructed but otherwise anatomi-
cally normal. Secretions collect in the obstructed
vagina (hydrocolpos), or vagina and uterus (hy-
drometrocolpos), causing a bulging introital
mass which may be noted by the parents. It may
present later with primary amenorrhoea and
haemato(with or without metro)colpos in post-
pubescent girls. Rarely does it present with uri-
nary retention.
Principles of Surgery
The aims of surgery are to create a patent introi-
tus which permits normal drainage of vaginal se-
cretions/menses and allows normal vaginal inter-
course in later life.

Alistair H. B. Fyfe Technique

Consultant Paediatric Urologist
Fyfe7es@btinternet.com • General anaesthesia is essential in children.

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_125, © Springer-Verlag Berlin Heidelberg 2013
F12  Labial Adhesions and Imperforate Hymen 411

• A pelvic mass (the distended vagina/ uterus)
may be apparent on abdominal examination
at the start of the procedure.
• The lithotomy position should be used for pa-
tient placement.
• Prepare and drape the perineum.
• Insert a urethral catheter to clearly define the
urethral anatomy.
• Gently retract the labia minora to reveal the
bulging hymen (Fig. 2).
• Use tissue forceps to lift each hymenal tag and
excise each in turn at the level of the introitus
to create a concentric opening (Fig. 4).
• Circumferentially over-sew the edges of the
incision with interrupted absorbable sutures
(Fig. 5).
• Remove the urethral catheter.

Fig. 4
Fig. 2

• Incise the hymen vertically and transversely in

a cruciate fashion (Fig. 3).
• Thoroughly irrigate the vagina with warm sa-
line until the effluent runs clear.

Fig. 5

Fig. 3
412 C. Keys and A. H. B. Fyfe

Tips

77 A short course of topical oestrogen cream (7–10 77 Asymptomatic labial adhesions may be man-
days) is usually curative. aged conservatively.
77 In time, all labial adhesions resolve spontane- 77 An elliptical hymenal incision is an alternative to
ously. the cruciate incision.

Common Pitfalls

77 Recurrence of labial adhesions is common after 77 In some circumstances, where the vaginal anat-
surgery. omy is grossly distorted by the hydro/haemato-
77 Beware of the lateral pudendal arteries, which colpos, it may be preferable to simply perform
lie adjacent to the introitus in the 3 and 9 o’clock a vertical hymenotomy to allow irrigation and
positions – trauma causes significant haemor- drainage, with definitive surgery deferred until
rhage. normal anatomy has been restored.
F13  Principles of Hypospadias Surgery
F13 Principles of Hypospadias Surgery
A. T. Hadidi
Surgery for hypospadias is one of the oldest opera-
tions in recorded history. Over 200 operations have
been described to deal with this abnormality. Our
approach was to ask an authority to write a chapter
on the principles of hypospadias surgery, and follow
this with three chapters on our own approach to the
treatment of three types of severities of this condi-
tion. The authors’ views were respected and very lit-
tle editing apart from conformity to the format of
the book took place.
Robert Carachi
Introduction
Hypospadias is the commonest congenital uro-
logical anomaly, occurring in 1–3 per 1,000 live
births. The spectrum of hypospadias anomalies
include an abnormal urethral orifice on the ven-
tral aspect of the penis, chordee (ventral curvature
of the penis), an incomplete prepuce, an abnor-
mal looking globular glans, rotation of the penis,
abnormal raphe, and a disorganised corpus spon-
giosum and penile fascia.
Hypospadias surgery is challenging and tech-
nically demanding. The surgical techniques which
are suitable for a child with a cleft glans and wide,
well-vascularised urethral plate are totally differ-
ent to the techniques suitable for a patient with a
flat glans and fibrotic, nonpliable, narrow urethral
plate. For this reason, hypospadias surgery differs
from the surgery required for most other anoma-
lies of the human body.
Ahmed T. Hadidi ()
Chairman of Paediatric Department
Emma Klinik GmbH, D63069 Seligenstradt, Germany
Ahmedhadidi@yahoo.de
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_126, © Springer-Verlag Berlin Heidelberg 2013
413
F13
Classification
Consistent classification is necessary to stan-
dardise the terminology used to describe hypo-
spadias, to enable improved treatment and com-
parison of results across centres and surgeons.
It has been suggested that forms such as those
illustrated in Fig. 1 are completed during the first
operation.
Principles of Management
• The surgeon should explain the condition to
the parents in detail, emphasizing that it is not
the fault of either parent, and that the familial
incidence is about 7 %.
• Circumcision is contraindicated in the presence
of hypospadias, because the preputial fascia
and skin may be needed to correct hypospa-
dias or its complications.
• The optimum time for hypospadias correction
is between 4 and 18 months of age, provided
experienced paediatric anaesthesia is available.
• Complete degloving of the penis is performed
as a routine first step in the operation by many
surgeons. This is not necessary and may be
harmful as chordee, that when present, involves
the ventral aspect of the penis.
• Fine 6/0 and 7/0 polyglactin absorbable suture
(Vicryl) are the standard sutures used in hypo-
spadias repair. A continuous subcuticular in-
verting technique is suitable for urethroplasty
(Fig. 2a). For glans closure, interrupted trans-
verse mattress sutures using 7/0 Vicryl help to
avoid sutures cutting through the glans due to
postoperative swelling and oedema (Fig. 2b).
For skin closure, continuous transverse mat-
tress sutures using 6/0 or 7/0 Vicryl yields good
results (Fig. 2c).
414 A. T. Hadidi

• Only silastic stents or catheter should be used
and should not be left inside the urethra for
more than a week to avoid irritation of the ure-
thra. Suprapubic catheters are recommended
in the repair of proximal hypospadias.
• More than 150 methods of dressing after hy-
pospadias operations have been described. The
author prefers to apply a simple dressing of
dry gauze and local antibiotic ointment on the
ventral aspect of the penis and to fix the pe-
nis, dressing and catheter against the lower ab-
dominal wall with good adhesive plaster. This
allows adequate compression of the penis as
well as early mobilisation of the child who can
sit and play a few hours after surgery.
• A broad-spectrum antibiotic (e.g. cephalospo-
rin) is recommended in hypospadias surgery, as
long as the catheter is kept inside the urethra.
Objectives of Surgery
The primary goal of hypospadias surgery is to cre-
ate a good functioning penis. This means ensur-
ing that the penis is straight and that the child can
micturate from the tip of the penis in a straight,
adequately wide stream of urine. The second im-
portant goal is for the penis to have a normal or
near-normal appearance with a slit-like meatus at
the tip of the glans.

1. Site of urethral meatus Glanular Distal Penile Proximal

(befor chordee correction) Hypospadias Hypospasias Hypospasias

2. Site of urethral meatus Glanular Distal Penile Proximal

(after chordee correction) Hypospadias Hypospasias Hypospasias

3. Prepuce Complete Incomplete

Cleft Incomplete Flat

4. Glans cleft

No chordee Superficial Deep chordee

5. Chordee chordee

6. Urethral plate width < 1 cm ≥ 1 cm

7. Penile torsion No torsion Present

8. Scrotal transposition No transpsition Present

Fig. 1  Classification of hypospadias. Source: Hadidi AT, Azmy AF (eds) (2004) Hypospadias surgery: an illustrated
guide, 1st edn. Springer, Berlin Heidelberg New York. Reproduced with kind permission
F13  Principles of Hypospadias Surgery 415

An alarming observation in recent literature
is that the cosmetic appearance is taking prior-
ity over the function of the penis. Many patients
with a ‘good-looking’ penis are referred with re-
current fistula and difficulty to pass urine due to
a narrow new urethra.
The steps of hypospadias correction include as-
sessment under anaesthesia, orthoplasty (chordee
correction), urethroplasty, protective intermediate
layer, meatoglanuloplasty and skin cover.

Fig. 2a–c  Different suturing techniques in hypospadias surgery. Source: Hadidi AT, Azmy AF (eds) (2004) Hypospa-
dias surgery: an illustrated guide, 1st edn. Springer, Berlin Heidelberg New York. Reproduced with kind permission

Fig. 3a–c  Different glans configurations. a Cleft glans. b incomplete cleft glans. c Flat glans
416
Glans Configuration
Patients with hypospadias have an abnormal-
looking globular glans. The glans is classified into
cleft glans, incomplete cleft and flat glans based
on the degree of clefting and urethral plate pro-
jection.
Chordee Assessment
The ‘artificial erection test’ (Fig. 4) is used as a
routine by many surgeons to assess the degree of
chordee.
Fig. 4  Artificial erection test. Source: Hadidi AT, Azmy
AF (eds) (2004) Hypospadias surgery: an illustrated
guide, 1st edn. Springer, Berlin Heidelberg New York. Re-
produced with kind permission
Surgical Options
See Fig. 5.
Important factors that determine the surgical
technique suitable for the individual patient in-
clude the glans configuration, the presence and
type of chordee and the quality of tissues to be
used in urethral reconstruction. The double-Y
glanulomeatoplasty (DYG) is suitable for glanu-
lar hypospadias with mobile meatuses (Fig. 6).
The modified Mathieu procedure is suitable for
distal hypospadias with a narrow urethral plate
A. T. Hadidi
and flat glans (Fig. 7). The Thiersch method and
its modification are suitable for patients with wide
urethral plates (Fig. 8). A lateral-based flap is use-
ful in patients with a deep chordee, that necessi-
tates division of the urethral plate (Fig. 9).
Incision of the urethral plate was first described
by Reddy in 1975, Orkiszewski and Rich in 1988,
popularised by Snodgrass in 1994, and is ad-
dressed in Chap. F14.
This method has become popular because of
its simplicity and the good cosmesis that can be
achieved. However, the author does not recom-
mend it, because the long-term complication rate
of the transjugular intrahepatic portosystemic
shunt (TIP) procedure has reached up to 35 % in
distal hypospadias and 66 % in proximal hypo-
spadias.
Glanular Hypospadias with Mobile Meatus
Double-Y Glanuloplasty Technique
The double-Y glanuloplasty (DYG) technique
is suitable for selected patients with glanular hy-
pospadias, mobile meatus and in the absence of
deep chordee. Those patients usually have a small
ridge distal to meatus. This ridge can be pushed
with a mosquito or toothed forceps to the tip of
the glans.
If the distal edge of the urethral meatus is im-
mobile and cannot be pushed to the tip of the
glans, the child is not suitable for the DYG tech-
nique, and another technique suitable for distal
hypospadias is performed (inverted-Y Thiersch in
patients with cleft glans or inverted-Y Mathieu
technique in patients with flat glans).
A 5/0 nylon traction suture is placed on the
glans, dorsal to the tip of the glans. A tourniquet
is placed at the root of the penis and chordee is
excluded using the artificial erection test.
An inverted-Y incision is outlined on the glans.
The centre of the inverted Y is just above the ridge,
distal to the meatus. The longitudinal limb extends
to the tip the glans where the tip of the neomeatus
will be located. Each oblique limb of the inverted
Y is 0.5 cm long and the angle between them is
60° (Fig. 6a and 6b). The incision is deepened and
the flaps are mobilised to allow more mobility of
F13  Principles of Hypospadias Surgery
the meatus (Fig. 6c). A 6/0 Vicryl stitch is approx-
imated, affixing the meatus at the tip of the glans
(Fig. 6d).
If the meatus is narrow or pinpoint; it is in-
cised to make it wide enough to accommodate a
10-Fr catheter or larger, according to the age of
the patient and size of the penis. A transurethral
10-Fr Nelaton catheter or larger is inserted into
the bladder.
A Y-shaped incision is made proximal to the
meatus (Fig. 6e). The longitudinal limb of the Y
incision extends from the meatus to the coronal
sulcus. Extra care should be taken to avoid injury
of the very thin urethra underneath the skin. The
use of sharp scissors and traction helps to avoid
injury of the distal urethra. Traction is applied
on the glanular wings, and the incision is deep-
ened using sharp scissors starting proximally at
the coronal sulcus. The glanular wings are mo-
bilized off the urethra and opened like a book.
This very important step helps to wrap the glanu-
lar wings around the urethra without any tension.
The incision is continued around the meatus to
meet the lateral limbs of the inverted-Y incision.
Local ointment is applied to the wound, nor-
mal gauze is applied and adhesive tape fixes the
gauze, the catheter and the penis against the lower
abdominal wall. This allows mobility of the pa-
tient and secures the catheter and penis against
the lower abdominal wall.
The transurethral catheter is left for 1–2 days,
depending on the degree of mobilization and the
degree of post-operative oedema of the penis. A
caudal block is used as a routine to reduce post-
operative pain.
Fig. 5  Choice of operative technique in different grades of hypospadias
417
Distal Hypospadias
Inverted-Y Modified Mathieu Repair
The Mathieu technique is one of the oldest pro-
cedures, that has withstood the test of time. It has
the drawback, however, of that it results in a cir-
cular meatus which is not at the tip of the glans.
The inverted Y–V modification avoids the draw-
back of the original Mathieu repair and results in
a slit-like meatus at the tip of the glans (Fig. 7).
• A Y-shaped incision is outlined on the glans.
• A 10-Fr catheter or larger is inserted into the
bladder.
• The flap is outlined so that the distance between
the meatus and the proximal end of the flap is
slightly greater than the distance from the me-
atus to the tip of glans.
• A U-shaped incision is made, extending from
the tip of the V in the glans down to the lower
end of the designed flap; this results in two
glanular wings.
• The Mathieu flap is mobilised, preserving its
fascial blood supply.
• Urethroplasty is performed using continuous
subcuticular polyglactin 6-0 sutures.
• A protective intermediate layer is fashioned by
using the flap fascia or dartos fascia.
• Both glanular wings are sutured together
around a neourethra using interrupted mat-
tress sutures.
418 A. T. Hadidi

Fig. 6a–f  Steps of the double-Y glanuloplasty. a Glanular hypospadias with mobile meatus. b Inverted-Y Incision. c
The three flaps are elevated. d The apex of the meatus is sutured to the tip of the glans. e A 10-Fr catheter is introduced
into the urethra and a Y incision is made which surrounds the meatus and extends down to the coronal sulcus. f The
glanular wings are mobilised deep enough to wrap around the urethra and are approximated in the midline. The 6
o’clock stitch is a 3-point stitch which brings the urethra and the two medial edges of the glanular wings together, and
is magnified in the inset. Source: Hadidi AT, Azmy AF (eds) Hypospadias surgery, 2nd edn. Springer, Berlin Heidelberg
New York (in press). Reproduced with kind permission

Proximal Hypospadias Without Deep
Chordee
Inverted-Y Modified Thiercsh Technique
The inverted-Y tubularised plate technique is a
modification of the Thiersch technique. It is suit-
able in hypospadias patients without deep chordee.
Thus, incision of the urethral plate is not needed to
correct deep chordee. The original Thiersch tech-
nique is ideal in patients with cleft glans. How-
ever, it is necessary to modify the technique when
the glans is flat or incompletely clefted, in order
to wrap the glanular wings around the new ure-
thra (Fig. 8).
A traction suture of 4/0 nylon is placed through
the tip of the glans.
• An inverted-Y-shaped incision is outlined on
the glans. The tip of longitudinal limb of the
inverted Y is at the tip of the glans and where
the tip of the neomeatus will be located. The
lower two limbs of the inverted Y are about 0.8
cm long and the angle between them is 90°. The
long vertical limb of the inverted Y is 0.8 cm.
The inverted-Y–shaped incision is deepened to
wrap the glanular wings around the new ure-
thra. This results in a median inverted-V flap
and two lateral wings. The two lateral wings are
elevated and the median flap is mobilised.
• A 10-Fr catheter or larger is inserted into the
bladder.
F13  Principles of Hypospadias Surgery
Fig. 7 Y–V  modified Mathieu technique. Source: Hadidi AT, Azmy AF (eds) (2004) Hypospadias surgery: an illustrated
guide, 1st edn. Springer, Berlin Heidelberg New York. Reproduced with kind permission
• Using two fine surgical forceps, the adequate
diameter of the new urethra is marked around
the catheter.
• A U-shaped skin incision is made using sharp
scissors or scalpel, size no. 15. A transverse in-
cision is made proximal to the meatus, using
sharp scissors.
• If the distal urethra is thin, it is incised until a
healthy vascularised urethra is reached.
• In the glans, the incision is deepened enough
to create mobile lateral glanular wings to wrap
around the new urethra.
• Two or three sutures are tied along the length
of the new urethra to reduce tension and help
orientation.
• The new urethra is constructed using 6/0 Vic-
ryl on a cutting needle in a continuous subcu-
ticular manner.
• A protective intermediate layer is fashioned
from the preputial fascia under the foreskin.
(In proximal hypospadias without deep chor-
dee, the authors prefer scrotal dartos/tunica
vaginalis fascia.)
• Closure of the glans follows, starting at the tip
of the glans to ensure a wide meatus.
419
Proximal Hypospadias with Deep Chordee
Lateral-Based Flap Technique
The lateral-based flap technique may be used in
proximal hypospadias with deep chordee which
necessitates incision of the urethral plate to
straighten the penis. It has a dual blood supply
and allows extensive excision of ventral chordee.
It may offer patients with proximal hypospadias
a single-stage urethral reconstruction with a good
success rate (91 %) and relatively few complica-
tions. The operative steps for the lateral-based flap
technique listed below are illustrated in Fig. 9.
• A deep Y-shaped incision is made on the glans,
that goes all the way down to the coronal sul-
cus. This permits two deep glanular wings and
a wide meatus to be formed.
• The edge of the lateral skin is then sutured at
two points; distally it approximates the lateral
wall to the tip of the glans, and proximally to
the meatus, thus forming ‘a new urethral plate’.
• A 10-Fr catheter (or larger, depending on the
size of the penis and the age of the patient) is
introduced through the meatus.
• A rectangular skin strip is outlined, extending
proximally from the urethral meatus to the tip
of the glans.
• Several interrupted stitches assist in orienta-
tion, and the urethroplasty is carried out from
420 A. T. Hadidi

Fig. 8  Steps of inverted-Y Thiersch technique. Source: Hadidi AT, Azmy AF (eds) Hypospadias surgery, 2nd edn.,
Springer, Berlin Heidelberg New York (in press). Reproduced with permission
proximal to distal in a subcuticular continuous
manner. Urethral Reconstruction Using Buccal
• The adjacent penile skin is elevated (rather Mucosa
than mobilising the flap) to preserve the vas-
cular areolar tissue. In ‘redo’ operations, it is possible to resort to buc-
• The neourethra is covered with a protective in- cal mucosa to form a wide urethral plate as a first
termediate layer (dartos or tunica). stage, and to reconstruct a neourethra in the sec-
• The neomeatus is constructed by suturing the ond stage. Bladder mucosa and one-stage repair
terminal end of the neourethra to the centre of using buccal mucosa are becoming less popular
the glans. in complicated proximal hypospadias, due to the
• The glanular wings are sutured around the neo- high incidence of complications.
urethra using interrupted mattress sutures.
• A percutaneous suprapubic catheter is inserted
into the bladder for 10–14 days.
• A compression dressing is applied for 6–24 h
for haemostasis.
F13  Principles of Hypospadias Surgery 421

Fig. 9a–h  Lateral-based flap (LB flap) technique for proximal hypospadias. a Y-shaped deep incision of the glans. b
Three flaps are elevated and orthoplasty performed. c New urethral plate. d Design of the LB flap. e Urethroplasty. f
Mobilization of dartos/tunica vaginalis fascia. g Protective intermediate layer. h Skin closure. Source: Hadidi AT, Azmy
AF (eds) (2004) Hypospadias surgery: an illustrated guide, 1st edn. Springer, Berlin Heidelberg New York. Reproduced
with kind permission
422
Tips
77 ‘Hypospadias’ comprises a wide spectrum of
anomalies involving all the ventral structures of
the penis and not just the urethra.
77 The ideal time to correct hypospadias is before
18 months of age.
77 The surgeon should use the technique which is
most suitable for the patient, and not make the
patient suitable for the technique that he/she
prefers.
77 Surgeons should be flexible and need to mas-
ter several techniques to suit the wide range of
anomalies encountered.
Common Pitfalls
77 Avoid techniques that have a high incidence of
meatal stenosis and recurrent fistula.
77 Avoid using small catheters when reconstructing
neourethra.
77 Avoid meatal stenosis at the end of the new ure-
thra by wide mobilisation of the glanular wings.
A. T. Hadidi
77 A neourethra should be reconstructed around
size 10-Fr catheters or larger, depending on the
age of the patient.
77 A second protective layer to cover and protect
the new urethra is an essential part of hypospa-
dias surgery.
77 With experience, the success rate in glanular
and distal hypospadias surgery has been greater
than 95 %. In proximal hypospadias, the compli-
cation rate is 10–20 %.
77 Avoid unnecessary degloving of the penis as the
chordee involves the ventral aspect of the penis.
77 Avoid circumcision at the same time as urethral
reconstruction, as the foreskin may be needed to
treat complications and many parents prefer to
have foreskin reconstruction.
F14  Glandular and Coronal Hypospadias Repair 423
F 14Glandular F14
and Coronal Hypospadias Repair
E. Broadis and S. J. O’Toole

Indications

• Glandular or coronal hypospadias necessitate

repair.
• Penis must be straight or have only minimal
chordee (Fig. 1).

Fig. 2 Fig. 3

• Dissection is carried out between the two lay-

ers of dartos. The spongiosum becomes visible
as a ‘V’ shape (Fig. 4).
• The lateral border of each limb of spongiosa
is dissected with bipolar diathermy. As the dis-
Fig. 1 section is continued caudally, the spongiosa ta-
pers off and the glans is seen (Fig. 5).
Operative Technique • The glans is dissected off the spongiosa and
corpora (Fig. 6).
• The foreskin is grasped at the junction of inner
and outer prepuce, and then rolled together to
assess whether a satisfactory tube can be cre-
ated (Fig. 2).
• Ensure there is no ‘cobra-eye’ deformity or ex-
cessive tension.
• Stay sutures are placed at the apex and an in-
cision is made as shown (Fig. 3).

Emily Broadis ()

Specialist Registrar in Paediatric Surgery
Ebroadis@doctors.org.uk

Stuart J. O’Toole
Consultant Paediatric Urologist
Stuart.O’Toole@ggc.scot.nhs.uk Fig. 4 Fig. 5

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_127, © Springer-Verlag Berlin Heidelberg 2013
424 E. Broadis and S. J. O’Toole

Fig. 6 Fig. 7 Fig. 8

Fig. 9

Fig. 10 Fig. 11 Fig. 12

F14  Glandular and Coronal Hypospadias Repair 425

• If the meatus is subcoronal, a urethroplasty

can be performed around an 8-Fr stent using
7/0 Vicryl (Fig. 7).
• A Snodgrass incision on the urethral plate can
be carried out if there is too much tension.
• The spongiosa is brought together with 6/0
Vicryl, that also serves to bring the glandular
wings together. The glans is brought together
with two deep 5/0 or 6/0 Vicryl mattress sutures
(Fig. 8).
• Interrupted 6/0 Vicryl is used to bring the glans
and preputial skin together (Fig. 9).
• The foreskin is then pulled back over the glans
and the inner preputial skin is closed with a 6/0
Vicryl subcuticular suture (Fig. 10).
• Tension on the traction suture helps reveal the
dartos layer which is closed with continuous
6/0 Vicryl (Fig. 11).
• Finally, the skin is closed with a continuous 6/0
Vicryl horizontal mattress suture (Fig. 12).

Tips

77 The initial dissection of the skin over the urethra
must be as superficial as possible to minimize
bleeding and to ensure as much tissue is left
over the urethra as possible.
77 The dissection of the corpora spongiosa is a crit-
ical step; not only does it provide a well vascular-
ized layer to cover your urethroplasty, but it also
leads you into the plane to dissect the glans off
the corpora and at the end of the procedure. It
provides you with a layer of dartos to cover your
repair.
 426 E. Broadis and S. J. O’Toole
F15 F15 Two-Stage Hypospadias Repair:
Stage One
E. Broadis and S. J. O’Toole

Indication

A two-stage repair is done for a hypospadia with

a proximal meatus or severe chordee, when a graft
is required to create a new urethral plate (Fig. 1).

Fig. 2 Fig. 3

• The penis is degloved and dissection continued

inferiorly to allow correction of the bifid scro-
tum (Fig. 4).
Fig. 1 • It is important to dissect the penis down to the
suspensory ligament – tissue often tethers the
Operative Technique penis laterally. The aim of dissection is to get
the tip of the penis as far caudally as possible.
• A stay stitch is placed in the midline of the pos-
terior aspect of the glans (Fig. 2).
• A nasogastric feeding tube is passed into the
urethra, keeping in mind the possibility of a
utriculus or urethral anomaly.
• A degloving incision is made as shown (Fig. 3).
The urethral plate is initially left intact.

Emily Broadis ()

Specialist Registrar in Paediatric Surgery
Ebroadis@doctors.org.uk

Stuart J. O’Toole
Consultant Paediatric Urologist
Stuart.O’Toole@ggc.scot.nhs.uk
Fig. 4 Fig. 5

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_128, © Springer-Verlag Berlin Heidelberg 2013
F15  Two-Stage Hypospadias Repair: Stage One
• The urethral plate is divided and, along with
spongiosa, is mobilised off the corpora (Fig. 5).
• An erection test is performed. If there is resid-
ual chordee, then further dissection is carried
out ventrally.
• If there is still residual chordee, Nesbitt tucks
should be performed.
• The urethral plate is tacked to the corporeal
bodies (Fig. 6). If the corpora are split at the
level of the bulbar urethra (as in a perineal hy-
pospadias), then the urethral plate has to be tu-
bularised to reach the corporeal bodies.
Fig. 6
• Stay sutures are placed either side of the ure-
thral groove on the glans, and the glans is in-
cised and mobilized off the underlying corpora
(Fig. 7). This is facilitated by an erection test
and it is performed using a knife.
• Measure the length of graft required. The
width of the graft is nearly always greater than
1.5 cm to allow future tubularisation.
• The graft is harvested from the inner layer of
preputial skin (Fig. 8). It is best to mark the
Fig. 7
427
area first. Stay sutures are applied to the cor-
ners of the graft and it is dissected using scis-
sors.
• The graft is placed on a silicone block for fur-
ther trimming (Fig. 9). All vessels must be re-
moved, and the graft must be thin enough to
appear transparent.
• Stay sutures are reapplied to the graft to ensure
correct orientation.
• The graft is applied to the penis and bedded
down with 8/0 Vicryl quilting sutures (Fig. 10).
• Scrotal skin is brought together with inter-
rupted 6/0 Vicryl to correct the bifid scrotum.
• The nasogastric feeding tube is wrapped in
Mepitel, and the penis is tied around this to
provide pressure to the graft.
• Three or four sutures are used. They must in-
corporate the graft edge, the body of the cor-
pora and the Mepitel to allow for compression
of the graft (Fig. 11).
• The dressing is removed after 1 week, under
general anaesthetic.
Fig. 8
428 E. Broadis and S. J. O’Toole

Fig. 9

Fig. 10 Fig. 11

Tips

77 Start the initial dissection proximally, locate 77 When completing the skin for the first stage, re-
the spongiosa and use this as a guide to dis- tract the glans of the penis cranially so as much
sect up onto the corporal bodies. This minimises dorsal skin as possible is transposed ventrally.
bleeding.
77 Always incise the glans deeply to create as wide
a graft at this point as possible.
F16  Hypospadias Repair: Stage Two 429
F16 Hypospadias Repair: Stage Two F16
E. Broadis and S. J. O’Toole

Indication

The second stage of a proximal hypospadias re-

pair. Is timed for approximately 6 months after
the first stage.

Operative Technique

• After the first stage, the appearance of the pe-

nis is as shown in Fig. 1.
• A U-shaped incision is made (Fig. 2).
• Often there is some contraction of skin at the
penoscrotal junction. In this situation, a fur- Fig. 1 Fig. 2
ther releasing incision can be made (Fig. 3).
• Dissection is carried out down to the corpora.
• The urethroplasty is performed around an 8-
or 10-Fr nasogastric feeding tube or catheter
(Fig. 4).
• Dissection of the dartos from the skin provides
the first waterproofing layer (Fig. 5).
• A second layer is can be manufactured using
the dartos from the other side.
• The glans is closed in two layers (Fig. 6).
• Try not to be too ambitious with creation of
the glans, as a drive towards perfection may
lead to compromise of the tissues.
• The skin is closed with 6/0 Vicryl (Fig. 7).
• The catheter is removed after 7–10 days. Fig. 3

Emily Broadis ()

Specialist Registrar in Paediatric Surgery
Ebroadis@doctors.org.uk

Stuart J. O’Toole
Consultant Paediatric Urologist
Stuart.O’Toole@ggc.scot.nhs.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_129, © Springer-Verlag Berlin Heidelberg 2013
430 E. Broadis and S. J. O’Toole

Fig. 4 Fig. 5 Fig. 6 Fig. 7

Tips

77 The hardest bit of this operation is drawing the
U-shaped incision at the beginning. Make sure
that the glans and skin can close easily over the
catheter before deciding that your urethral inci-
sion is correct.
77 On occasions the penis is again tethered down
to the scrotum; it is nearly always possible to per-
form releasing incisions at the base of the shaft
of the penis to gain extraventral skin length.
 PAR T G
Urology
G1 Cystourethroscopy 433
G 1Cystourethroscopy G1
C. Keys and S. J. O’Toole

Equipment • Once the external sphincter is identified, the

scope must be dropped down below the hori-
• Cystoscope zontal and advanced upwards into the poste-
• 6- to 8-Fr neonatal scope rior urethra. The verumontanum and bladder
• 9.5-,11- or 14-Fr paediatric scope neck are inspected and the scope may need to
• 5° optics or straight be dropped further to clear a prominent blad-
• Endoscopic camera and stack der neck.
• Light source • Inspect the bladder in a stepwise fashion:
• Irrigation channel – Trigone
• Fluid for irrigation – normally water, but if no – Ureteric orifices
diathermy to be used, then normal saline – Four quadrants of bladder
• On withdrawal inspect the verumontanum and
posterior urethra carefully again. Special atten-
Patient Position and Setup tion should be given to the inferior aspect of
the verumontanum to exclude the presence of
• General anaesthesia posterior urethral valves.
• Lithotomy • Empty the bladder.
• IV antibiotic prophylaxis
Female

Technique • Separate the labia to view the urethra.

• Insert the scope.
Male • The subsequent steps are essentially as those
steps for males (outlined above).
• Hold the penis in vertical position.
• Holding the cystoscope vertically, gently insert
the tip into the urethra.
• Slowly advance the scope with slow irrigation
to keep the lumen in view until the bulbar ure-
thra and external sphincter are identified.
• Remember a syringocoele is difficult to spot
and may be visible in the bulbar urethra.

Charlie Keys ()

Specialist Registrar in Paediatric Surgery
charleskeys@doctors.org.uk

Stuart J. O’Toole
Consultant Paediatric Urologist
Stuart.O’Toole@ggc.scot.nhs.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_130, © Springer-Verlag Berlin Heidelberg 2013
434
Tips
77 Perform the cystoscopy sitting down.
77 Always keep the lumen of the urethra in the mid-
dle of the field of view and remember that all
paediatric scopes (barring resectoscopes) are off-
set 5–10°.
77 Aim to keep the tip of the scope as steady as
possible; the eyepiece is moved in all directions,
but the tip of the scope must stay in the same
position.
Common Pitfalls
77 Over distension of the bladder will distort the
anatomy, making diagnosis difficult and it in-
creases the risk of perforation with a subureteric
transurethral injection (STING) procedure.
77 Driving the scope straight into the urethral wall
at the start of the procedure and getting tissue
on the lens will ruin your view.
C. Keys and S. J. O’Toole
77 When negotiating the external sphincter, the
tip of the scope may actually have to move
slightly outwards as the eyepiece of the scope is
dropped down.
77 The Crede manoeuvre may be useful to assess
for posterior urethral valves. Press on the full
bladder while viewing the verumontanum. Stop
the flow of water and open one of the acces-
sory channels so you can view the urine flow-
ing down the posterior urethra and out of your
scope.
77 Not lowering the scope enough at the point of
negotiating the external sphincter and posterior
urethra can also compromise the procedure.
G2  Urethral and Suprapubic Catheterisation 435
G2 Urethral and Suprapubic Catheterisation G2
C. Keys and S. J. O’Toole

Urethral Catheterisation • If resistance is met at the bladder neck, drop

Male
• Use aseptic technique: skin preparation, drap-
ing and nontouch.
• Retract and clean the prepuce.
• Lift penis to a vertical position (Figs. 1 and 2).
• Gently insert the (lubricated) Foley catheter.
the penis to a horizontal position.
• Insert full length of the catheter.
• Ensure catheter in bladder by aspirating urine.
• Inflate the balloon and pull the catheter back
to the bladder neck.
• Use an adhesive dressing or tape to fix the cath-
eter to the upper thigh or suprapubic area.
• Always return the foreskin over the glans after
the procedure to prevent paraphimosis.

Female

• Clean and separate the labia majora and mi-

nora to identify the urethral orifice (Fig. 3).
• Insert the catheter.
• Inflate the balloon.

Suprapubic Catheterisation

• This form of catheterisation is performed un-

der general anaesthesia.
• Use aseptic technique.
• Palpate the bladder.
• Pierce the incision midline with a scalpel
(Fig. 4).
• Puncture the bladder with large needle (the
‘stab’ cystostomy).
• Insert the catheter (Fig. 5).
• Remove needle and peel away the sheath
(Fig. 6).
• Fix the catheter with non-absorbable suture
Fig. 1 (Fig. 7).

Charlie Keys ()

Specialist Registrar in Paediatric Surgery
charleskeys@doctors.org.uk

Stuart J. O’Toole
Consultant Paediatric Urologist
Stuart.O’Toole@ggc.scot.nhs.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_131, © Springer-Verlag Berlin Heidelberg 2013
436 C. Keys and S. J. O’Toole

Fig. 2

Fig. 3
G2  Urethral and Suprapubic Catheterisation 437

Fig. 4 Fig. 5

Fig. 6 Fig. 7

Tips

77 Check the balloon on the catheter prior to inser- – Large child: 1–14 Fr
tion by inflating and deflating with the appropri- 77 Always document the procedure in the case
ate amount of sterile water. notes including the size of catheter, the volume
77 Urethral catheter sizes: of sterile water in the balloon and the residual
– Neonate: 6–8 Fr urine volume.
– Infant: 8–10 Fr
438 C. Keys and S. J. O’Toole

Suprapubic Catheterisation

• Locate the bladder with a fine-gauge needle

prior to passing the large-bore needle.
• Stay midline.
• Ensure you leave the correct length of catheter
in the bladder.
• The bladder in a young child is intra-abdom-
inal, and it is possible to insert a suprapubic
catheter too low or miss the bladder altogether.

Common Pitfalls

77 Trauma to the male urethra can cause stricture.
Use generous lubrication and a gentle tech-
nique.
77 Inflating the balloon in the urethra; if in doubt,
remove it.
77 Do not inflate the balloon until you see urine fill-
ing the catheter.
77 Aggressive attempts to advance a urethral cath-
eter in the face of resistance may result in false-
passage creation and stricture formation.
77 Do not perform urethral catheterisation if there
is suspicion of perineal/urethral trauma (see
Chap. H1).
77 Urethral catheterisation in the early postoper-
ative period following hypospadias repair may
disrupt the urethroplasty. Consider suprapubic
catheterisation and discuss the case with a urolo-
gist before proceeding.
77 Over-filling the catheter balloon increases the
risk of balloon rupture, with subsequent dis-
placement of the catheter.
G3  Open Surgical Approaches to the Kidney 439
G3 Open Surgical Approaches to the Kidney G3
L. C. Steven and M. E. Flett

There are various open approaches to the kid-

ney. The three most common approaches are de-
scribed below.

Transperitoneal Approach

• Place the patient in the supine position. A mid-

line or left/right transverse supra-umbilical in-
cision may be used to open the peritoneum
safely.
• The peritoneal reflection of the right colon and
hepatic flexure or left colon, splenic flexure and
phrenocolic ligament are mobilised by divid-
ing along the peritoneal ‘white line’ with mo-
nopolar diathermy or sharp dissection (Fig. 1).
Be aware of the ureters and duodenum at this
point. Reflect the mobilised colon towards the
midline.
• The kidney should now be easily visible and
palpable. Open the renal fascia over the paren- Fig. 1
chyma, away from the hilum.

Anterolateral Retroperitoneal
Approach

• Place the patient in supine position with a small

‘roll’ placed under the affected side to elevate
and open the renal angle (Fig. 2). The trans-
verse incision is placed to finish laterally in line
with the lower costal margin.

Lisa C. Steven ()

Specialist Registrar in Paediatric Surgery
lisasteven@doctors.org.uk

Martyn E. Flett
Consultant Paediatric Urologist Fig. 2
Martyn.Flett@ggc.scot.nhs.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_132, © Springer-Verlag Berlin Heidelberg 2013
440
• External oblique, internal oblique and trans-
versalis are split in the lines of their respective
fibres. Divide each layer generously, using the
entire length of the wound. Once transversalis
is split the peritoneum will be visible (Fig. 3).
• Sweep the peritoneum away from the retroper-
itoneal space by using both of your index fin-
gers in the longitudinal plane, moving the peri-
toneum anteriorly and medially. Any breaches
to the peritoneum should be repaired.
• The kidney will now be palpable. Continuing
the same anteromedial mobilisation of the peri-
toneum will allow the parenchyma to be visual-
ised. The renal fascia can be opened safely over
the parenchyma.
Fig. 3
Posterior Approach
• Place the patient in the prone position. The
operating table should be ‘flexed’ to open the
working space between the 12th rib and the il-
iac crest (Fig. 4).
• Surface landmarks should be marked with a
skin-marking pen (Fig. 5).
– Midline
– Eleventh and 12th ribs
– Iliac crest
– Lateral edge of erector spinae
Fig. 4
L. C. Steven and M. E. Flett
• A transverse incision is made from the lateral
edge of erector spinae, 2–3 cm inferior to the
11th rib.
• Fibres of latissimus dorsi will be seen running
posteriorly; these can be divided transversely
using monopolar diathermy.
• Beneath this layer is the tough lumbar fascia.
Splitting of this fascia in the line of the wound
will reveal the pararenal space and fat. Deep
retractors should be used to open and stretch
the fascia. The inferior pole of the kidney will
be palpable, and blunt dissection of this space
will expose the middle and superior poles. Once
this plane is established, the renal fascia should
be safely opened away from the posterior renal
pelvis.
• The muscle layers in this approach are tough
and a strong assistant is essential.
Fig. 5
G3  Open Surgical Approaches to the Kidney 441

Tips

77 If using the transperitoneal approach, always re- 77 If using the anterolateral approach be sure to
flect the colon medially to allow safe access to split the three (separate) muscle layers along the
the renal hilum. same length for each layer. This will maximise ex-
posure through the wound.

Common Pitfalls

77 When using the prone approach, failure to pro- 77 When using the posterior approach, allow gen-
tect potential pressure areas (e.g. anterior bony erous mobilisation of the lumbar fascia; other-
pelvis, arms and ankles) will result in skin necro- wise you will not achieve safe and easy exposure
sis, with or without neuropraxia. to the kidney.
 442
G4 G 4Open Nephrectomy
S. Gazula and S. Agarwala
 perative Technique for an
O • Push the peritoneum away medially by using a
Extraperitoneal Flank Approach
• Palpate the 12th rib. Make a subcostal incision,
beginning at the lateral border of the sacrospi-
nal muscle, about a fingerbreadth below the
lower border of the rib, extending onto the an-
terior abdominal wall.
• Deepen the incision to expose the latissimus
dorsi muscle (Fig. 1). With diathermy divide
the muscle at the posterior part of the wound
to expose the posterior edge of the external
oblique muscle (Fig. 2).
• Using diathermy, divide the external oblique
muscle followed by the internal oblique mus-
cle. Then split the transversus abdominis mus-
cle in the direction of its fibres, using a haemo-
stat to expose the Gerota’s fascia (Fig. 3).
Fig. 1
Suhasini Gazula ()
Senior Specialist Paediatric Surgeon and Head
Department of paediatric surgery, Employees’ State
Insurance Corporation (esic) Superspeciality Hospital,
Sanath Nagar, Hyderabad, Andhra Pradesh, India
suhasinigazula@gmail.com
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_133, © Springer-Verlag Berlin Heidelberg 2013
S. Gazula and S. Agarwala
Sponge-Stick, and incise Gerota’s fascia longi-
tudinally (Fig. 4). Then dissect the perirenal fat
anteriorly to visualize the renal pelvis.
• Retract the kidney is laterally and posteriorly
to identify the renal artery and vein (Fig. 5).
• Identify the renal artery and using a right-an-
gle dissector, carefully dissect it from the renal
vein, that is slightly anterior and inferior to it
(Fig. 6a). Ligate the artery in continuity with
silk sutures. Place a silk transfixation suture lig-
ature at the proximal end, and divide the artery
between the two ligatures (Fig. 6b). If any ad-
ditional arteries are present, address these in a
similar fashion.
• Next, dissect the renal vein, and doubly ligate it
in continuity and divide between the ligatures.
• Deliver the kidney into the wound and identify
the ureter as the lower pole is mobilized. Re-
tract the lower edge of the wound, and dissect
the ureter down to its insertion into the blad-
der, ligate with absorbable suture and divide.
Fig. 2
G4  Open Nephrectomy 443

Fig. 3

The kidney and ureter can now be completely

removed.
• The wound is closed in layers using absorbable
sutures. The skin is closed with subcuticular su-
tures.

Fig. 4

Fig. 5 Fig. 6a,b

444
Tips
77 In cases of renal trauma, a trans-peritoneal ap-
proach is preferred to achieve quick and better
vascular control and to be able to explore the en-
tire abdomen for other injuries.
77 After positioning the patient, make sure that all
areas of pressure are relieved by placement of
pillows/rolls.
77 Care should be taken to avoid injury to the iliohy-
pogastric and ilioinguinal nerves as they emerge
from behind the lateral border of the psoas mus-
cle and pass down over the anterior surface of
the quadratus lumborum in the renal fossa.
Common Pitfalls
77 Avoid injury to the overlying peritoneum by in-
cising Gerota’s fascia on the lateral aspect of the
kidney.
S. Gazula and S. Agarwala
77 There is normally a separate compartment in
Gerota’s fascia for the adrenal gland, that enables
it to be readily separated from the upper pole.
77 On the left side, it may be necessary to divide the
gonadal, adrenal, and reno-lumbar veins before
addressing the renal vein.
77 In excising small, dysplastic kidneys, it may be
easier to first identify the ureter on the psoas
muscle and then trace it proximally to the nub-
bin of dysplastic renal tissue.
77 Whenever possible, secure the vessels individu-
ally away from the hilum, and the artery should
always be ligated first.
G5 Pyeloplasty 445
G 5P yeloplasty G5
A. Neilson and M. E. Flett

• Insert a Foley catheter and administer antibi-
otics preoperatively.
• Arrange the patient in the supine position with
lumbar roll.
• A subcostal muscle-splitting incision provides
good exposure. The incision is sited one finger-
breadth below the lowest rib, lateral to rectus
abdominus (Fig. 1a).
• The external oblique aponeurosis and subse-
quent layers (internal oblique, transversus ab-
dominis) are exposed widely; open each in line
with their respective fibres until the peritoneum
is identified (Fig. 1b).
• The peritoneum is swept medially and Gero-
ta’s fascia identified and entered posterolater-
ally. A Denis Browne ring retractor may help
with exposure (Fig. 1c).
• The ureter is slung, aiding mobilisation of the
pelvis. Stay sutures are places in the ureter,
and caudal and cranial extents of the pelvis
(to maintain orientation) (Fig. 2).

Fig. 1b

Fig. 1a

Andrew Neilson ()

Specialty Trainee in Paediatric Surgery
agneilson@doctors.org.uk
Fig. 1c
Martyn E. Flett
Consultant Paediatric Urologist
Martyn.Flett@ggc.scot.nhs.uk

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_134, © Springer-Verlag Berlin Heidelberg 2013
446 A. Neilson and M. E. Flett

• The pelviureteric junction (PUJ) is excised and

the ureter opened, creating a widely spatulated
end (Fig. 3). Consider passing a catheter to ex-
clude distal narrowing.
• The first three anastomotic sutures are placed
at the caudal end – first at the apex, then anteri-
orly and posteriorly, opening the ureter (Fig. 4).
• First the posterior then the anterior wall of the
anastomosis are completed with a running 6/0
or 5/0 suture, and any remaining defect is closed
pelvis to pelvis (Fig. 5). A stent, when used, can
be placed once the posterior wall is complete.
• Approximate the muscles in layers.
• External stents are blocked at 48 h. If the pa-
tient is afebrile and not in pain, the urethral
catheter can be removed. At 7 days the exter-
nal stent is removed.

Fig. 2 Fig. 4

Fig. 3

Fig. 5
G5 Pyeloplasty 447

Tips

77 Wide dissection of each muscle layer is essential
for good access.
77 Take care when splitting transversus abdominus,
as a peritoneal breech may cause an ileus.
77 Keep knots on the outside of the pelvis, as re-
tained suture material acts as a nidus for stone
formation.
77 Absorbable sutures should be used.
77 Stents are not required in uncomplicated cases.
77 Consider using a stent (internal with or without
external) if ‘floppy’ kidneys or very ‘baggy’ pelvis
is present; in such cases, redo surgery.

Common Pitfalls

77 Avoid excess manipulation of the ureter – dam- 77 When spatulating the ureter, ensure it maintains
age to the adventitial blood supply may cause a correct orientation to avoid torsion or kinking
anastomotic failure or stricture. after anastomosis.
77 Aim to cut the pelvis and ureter with a single,
smooth incision using sharp scissors to avoid
ragged edges.
 448 P. Hammond and A. H. B. Fyfe
G6 G 6Ureteric Duplication
P. Hammond and A. H. B. Fyfe

Incision of Ureterocele

Operative Technique

• A resectoscope (e.g. 9.5 Fr) is passed via the

urethra in the standard fashion (using 2 % gly-
cine irrigation if Bugbee electrode diathermy
is to be used).
• The ureteric orifices are visualized, and a suit-
able site identified on the prominent part of
the ureterocele for incision (Fig. 1). This may
be difficult due to the distortion produced by
a large ureterocele.
• This incision should result in decompression
of the ureterocele, as demonstrated both at the
time of the cystoscopy and by the postopera-
tive ultrasound scan.

Hemi-nephrectomy Fig. 1

Operative Technique

• The kidney is approached as described in Chap.

G3.
• Identify the renal vessels (arteries and veins)
and ureters, isolating each with sloops. Be
aware that the ureters both lie within a single
sheath (Fig. 2).
• Only when it is clear which vessels supply the
moiety to be removed (usually the upper moi-
ety), can they be ligated and divided whilst
carefully preserving the vessels to the remain-
ing kidney.

Philip Hammond ()

Consultant Paediatric and Neonatal Surgeon
Philip.Hammond@ggc.scot.nhs.uk

Alistair H. B. Fyfe
Consultant Paediatric Urologist
Fyfe7es@btinternet.com Fig. 2

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_135, © Springer-Verlag Berlin Heidelberg 2013
G6  Ureteric Duplication
Fig. 3
• The demarcation between upper and lower
moieties is usually identified easily by its ap-
pearance. Diathermy is used to mark this line.
• The parenchyma is divided with care not to en-
tering calyces (Fig. 3).
Tips
77 An Harmonic scalpel or extensive monopolar
diathermy may optimize haemostasis during di-
vision of renal parenchyma in a hemi-nephrec-
tomy.
Common Pitfalls
77 If lower-pole calyces are opened these must
be closed in a watertight manner, and the re-
nal capsule closed over this repair (with or with-
out a corrugated drain left in situ) to reduce the
chance of a urinoma.
449
Fig. 4
• Haemostasis is achieved with diathermy and
large absorbable sutures to the cut renal edge,
taking in the renal capsule (Fig. 4).
• After carefully dissecting the gonadal vessels,
the upper pole ureter is followed to the pelvic
brim, where it is then transfixed.
77 Haemostasis may occasionally require SURGICEL
or fibrin glue.
77 Ensure the remaining moiety is pink and well
perfused after its re-placement in the abdomen.
77 It can be difficult to delineate the precise anat-
omy when dealing with a large ureterocele. En-
sure that you fill the bladder well, as this makes
it easier to identify the anatomy. Occasionally,
it may be useful to distend the ureterocele by
manually compressing the flank containing the
hydro-nephrotic moiety.
 450
G7 G7 Surgery for Renal Calculi
A. Monaghan and A. H. B. Fyfe
Endoscopic Removal
Endoscopic removal can be used for bladder or
ureteric calculi.
• Place patient in the lithotomy position.
• For small- to medium-sized bladder stones,
insert cystoscope into bladder. Stones can be
crushed with a stone crusher or fragmented by
a lithoclast, and the debris removed by irriga-
tion or using a basket.
• For ureteric calculi insert the ureteroscope into
correct ureter. Stones can be disintegrated with
lithoclasty or retrieved with baskets (Fig. 1).
• It is advised to leave a catheter in postproce-
dure in a case of retention.
Fig. 1
Percutaneous Removal
This approach can be used for removal of multi-
ple, large or ‘staghorn’ calculi.
• An approximately 1-cm incision is made at the
appropriate level in the lumbar region.
Ashley Monaghan ()
Core Trainee in Urology
Ashley_paula_monaghan@hotmail.com
Alistair H. B. Fyfe
Consultant Paediatric Urologist
Fyfe7es@btinternet.com
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_136, © Springer-Verlag Berlin Heidelberg 2013
A. Monaghan and A. H. B. Fyfe
• The Seldinger technique, under x-ray guidance,
is used to gain access to the targeted calyx.
• The tract is then dilated to allow passage of the
sheath.
• A nephroscope in a sheath is passed into the
tract (Fig. 2).
• A grasper can be passed to extract the stone
(Fig. 3).
• Staghorn calculi can be disintegrated under di-
rect vision using lithoclast or laser probes.
• Multiple punctures may be required for multi-
ple or complex stones.
• Nephrostomy drainage is required for 24–48 h
postoperatively.
Open Removal
Note: Preoperatively, mark the appropriate side,
having already checked the imaging.
This technique can be used to extract large
stones. It is also used when percutaneous removal
is not possible.
• The patient should be positioned in a full lateral
position, with the lower ribs positioned over the
table break (Fig. 4).
• An incision extending from the tip of the 12th
rib is suitable for younger children. In older
children better access can be obtained from an
11th-interspace approach.
• The incision is deepened using cutting dia-
thermy while being careful to avoid damag-
ing peritoneum at the anterior aspect of the
wound.
• The subcostal nerve should be identified and
preserved.
• Gerota’s fascia is incised longitudinally. Fingers
can be swept over the kidney surface to free it
from surrounding fat.
G7  Surgery for Renal Calculi 451

Fig. 2

Fig. 3

Fig. 4 Fig. 5
452 A. Monaghan and A. H. B. Fyfe

• The ureter should be identified and secured

with a sling to prevent stone fragments from
migrating into it.
• The kidney can now be delivered into the
wound, exposing the posterior surface.
• In a large extrarenal pelvis a vertical incision
may be used. If the pelvis is small, then an
oblique incision extending towards the infun-
dibulum of the upper calyx offers better access
(Fig. 5).
• Apply stay sutures to the margins of the inci-
sion.
• Stones can then be lifted out with stone forceps.
Often the stones fragment during this process.
• Place gauze swabs around the pelvis to catch
debris, and irrigate each calyx with normal sa-
line using a soft catheter.
• A radiograph of the exposed kidney is obtained
to ensure complete clearance.
• The incision in the renal pelvis is closed with
5/0 absorbable suture.
• Position a drain adjacent to renal pelvis, and
close Gerota’s fascia with absorbable suture.

Tips

77 Imaging should be performed to ascertain
whether there is any anatomical or functional
abnormality which is contributing to the forma-
tion of calculi (i.e. pelvi-ureteric obstruction, neu-
rogenic bladder, etc.).
77 Immediately prior to surgery the patient should
have a repeat x-ray to ascertain whether the cal-
culi are still present and in the same position.
G8 Nephrostomy 453
G 8Nephrostomy G8
S. Gazula, M. Jana and S. Agarwala

Technique for Open Nephrostomy mostat guide an appropriately sized Malecot

• Position the patient in the ‘kidney position’, as
depicted in Chap. G4.
• Palpate the 12th rib. A subcostal incision is
made beginning at the lateral border of the sa-
crospinal muscle, about a fingerbreadth below
the lower border of the rib, extending onto the
anterior abdominal wall.
• Deepen the incision to expose the latissimus
dorsi muscle (Fig. 1). With diathermy divide
it in the posterior portion of the wound to ex-
pose the posterior edge of the external oblique
muscle (Fig. 2).
• Using diathermy, divide the external oblique
muscle, followed by the internal oblique mus-
cle. Then split the transversus abdominis mus-
cle in the direction of its fibres using a haemo-
stat to expose Gerota’s fascia (Fig. 3).
• Push the peritoneum away medially by using a
Sponge-Stick and incise Gerota’s fascia longi-
tudinally (Fig. 4). The perirenal fat is then dis-
sected anteriorly to visualize the renal pelvis.
• Between two stay sutures open the renal pelvis.
Insert a fine haemostat into the pelvis, guide it
to the lower calyx and aim at the renal paren-
chyma. Incise the parenchyma on the point-
ing haemostat. Using this haemostat, guide an-
other haemostat through the incision and pa-
renchyma into the renal pelvis. With this hae-
catheter through the calyx into the renal pel-
vis (Fig. 5).
• Pull the catheter through the parenchyma until
the flared portion lies in good position within
the collecting system, usually in the pelvis or
the lower calyx (Figs. 6 and 7).
• Secure the nephrostomy tube to the renal cap-
sule with an absorbable suture. Close the py-
elotomy with fine, interrupted absorbable su-
tures.
• Pass the nephrostomy tube out through the
posterior edge of the same wound or through
another pierce incision, taking care to ensure
proper alignment and prevent kinking of the
tube. Anchor the nephrostomy tube to the skin
using silk suture.
• Place a perinephric corrugated rubber drain
near the pyelotomy site and bring it out through
a separate pierce wound.
• Close the incision by approximating of the cor-
responding muscle and fascial layers using Vic-
ryl sutures after removing the kidney roll from
under the patient’s back.

S. Gazula
Senior Specialist Pediatric Surgeon and Head
suhasinigazula@gmail.com

Manisha Jana ()

Assistant Professor, Radiodiagnosis
manishajana@gmail.com

Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_137, © Springer-Verlag Berlin Heidelberg 2013
454 S. Gazula, M. Jana and S. Agarwala

Fig. 1

Fig. 2

Fig. 3

Fig. 4 Fig. 5
G8 Nephrostomy
Tips
77 The medial end of the incision is curved slightly
downward as it passes the mid-axillary line to
avoid the subcostal nerve, and it may be ex-
tended as far as the lateral border of the rectus
abdominis muscle.
77 Injection of 0.5 % bupivacaine into the fascial
sheath around the intercostal nerves is helpful in
reducing postoperative pain.
Common Pitfalls
77 Avoid injury to the intercostal nerves while incis-
ing the muscle layers; this may cause persistent
postoperative pain or bulging in the flank, due to
paresis of the denervated muscle.
77 It is important to ensure that the nephrostomy
is made near the convex border of the kidney
and not in the anterior or posterior surface; this
 echnique for Percutaneous
T • Make a small nick using a scalpel blade at the
Nephrostomy
Hardware Required
• A 22-G sheathed needle
• Graded fascial dilators (up to 1 Fr higher than
the desired catheter size)
• A 0.035 J-tip metallic guidewire
• Pigtail catheter set (6 Fr for uninfected urine,
8 Fr for suspected pyelonephrosis)
Technique
• Place the patient in a prone/oblique position,
preferably with a bolster under the abdomen
to limit the motion of the lower rib cage and
facilitate proper visualization of the kidneys.
• Scan the patient using ultrasound to localize
the posterior calyces (Fig. 8).
• Prepare and drape the area, maintaining
proper asepsis.
• Infiltrate with local anaesthetic solution to the
depth of the renal capsule.
455
77 Ongoing care of a nephrostomy tube is impor-
tant to prevent dislodgement, infection and to
ensure unobstructed drainage.
77 Periodic tube replacement is recommended at
6- to 8-week intervals. This is usually performed
readily under fluoroscopic guidance once a
chronic track has been established.
allows better positioning of the tube and mini-
mizes the risk of injury to large intrarenal vessels.
77 Care must be taken to avoid entrapment of any
intercostal nerves or branches during closure of
the muscle layers.
selected site of skin puncture, in accordance
with the calyceal puncture.
• Under ultrasound guidance, puncture one
of the lower posterior calyces using a 22-G
sheathed needle (containing outer sheath and
inner needle) (Fig. 9).
• Locate the needle tip under ultrasound
guidance and remove the inner needle, keep-
ing the outer sheath in place, held stable in po-
sition.
• Use a 5-ml syringe to aspirate small amount of
urine to confirm needle position in the calyx.
• Introduce a 0.035-in (0.889 mm) metallic
J-tip guidewire through the sheath, well into the
proximal ureter (Fig. 10). Localize the guide-
wire and remove the sheath (Fig. 11).
• Dilate the tract using graded fascial dilators
(Fig. 12). While dilating under ultrasound
guidance, the reflecting shadow of metallic
guidewire should not visible once the dilators
are mounted over them.
• Sequential dilation should be done to one step
higher than the size of the percutaneous neph-
rostomy (PCN) catheter to be put.
456
• After the last dilator is removed, introduce the
PCN catheter (self-retaining pigtail catheter or
Malecot catheter) over the guidewire until the
catheter is well within the pelvis.
• Confirm the position of the catheter–guidewire
assembly using ultrasound.
• Remove the guidewire, keeping the pigtail cath-
eter stable in place (Fig. 13). Take precaution
to avoid pulling the catheter out along with the
guidewire.
Fig. 6
Fig. 8
S. Gazula, M. Jana and S. Agarwala
• Check the location of the catheter using ultra-
sound or fluoroscopy. A pigtail catheter should
have a well-formed loop in the pelvis, not in the
calyces, and all the holes should be within the
pelvicalyceal system.
• Secure the catheter in place using suture at the
skin entry site, taking care to avoid kinking of
catheter.
• Connect the catheter to a drainage bag.
Fig. 7
Fig. 9
G8 Nephrostomy 457

Fig. 10 Fig. 11

Fig. 12 Fig. 13
458 S. Gazula, M. Jana and S. Agarwala

Tips

77 The procedure should be done under ultrasound 77 Once the needle enters the calyx, a ‘give way’ will
guidance, with or without the use of fluoroscopy, be appreciated.
with the patient under anaesthesia or deeply se- 77 Never press the guidewire hard in a case where
dated. resistance is felt.
77 The prothrombin time should be within normal 77 In cases of planned ureteric stenting, puncture
range. the upper calyces in order to help better manip-
77 Puncture through a posterior calyx traverses the ulation.
relative avascular zone and avoids injuring major
renal vessels.

Common Pitfalls

77 Decompressing the system completely during
insertion of the sheath or checking its position
can make further guidewire visualization diffi-
cult.
77 The guidewire can be malpositioned while with-
drawing the sheath.
77 An inability to advance the catheter over the
guidewire is usually because of a kink in the
catheter or guidewire. Most kinks occur at the
skin or renal cortex. Put enough guidewire in-
side, pull the kink outside the skin and proceed.
G9 Vesicostomy 459
G 9Vesicostomy G9
P. Hammond and A. H. B. Fyfe

Indication

A vesicostomy is used for a temporary lower–uri-

nary tract diversion. Indications include posterior
urethral valves, massive vesico-ureteric reflux or
neuropathic bladder.

Operative Technique (Blocksom

Vesicostomy)

• The patient is positioned supine.

• Make a short, transverse incision, halfway be-
tween the umbilicus and symphysis pubis. (Fig. 1)
• Deepen the incision using monopolar dia-
thermy.
• Identify and divide the urachus, that runs cra-
nially from the dome of the bladder in the mid-
line. (Fig. 2)
• Dissect the peritoneum from the dome of the
bladder, remaining extraperitoneal.
• Choose a site on the bladder dome as far supe-
riorly and posteriorly as possible, and make a Fig. 1
small circular hole in the bladder at this site. This
is important to minimize the risk of prolapse of
the posterior bladder wall through the vesicos-
tomy, resulting in obstruction. (Fig. 3a, b, c)
• Quadrant sutures are placed between the an-
terior rectus sheath of the anterior abdominal
wall and the bladder adjacent to the vesicos-
tomy. (Fig. 4)
• The lateral edges of the rectus sheath are closed
with interrupted absorbable sutures. (Fig. 5)

Philip Hammond ()

Consultant Paediatric and Neonatal Surgeon
Philip.Hammond@ggc.scot.nhs.uk

Alistair H. B. Fyfe
Consultant Paediatric Urologist
Fyfe7es@btinternet.com Fig. 2

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_138, © Springer-Verlag Berlin Heidelberg 2013
460 P. Hammond and A. H. B. Fyfe

• The lateral edges of the skin wound are closed

with interrupted absorbable sutures.
• The vesicostomy is matured with sutures be-
tween the bladder mucosa and skin as a flush
stoma.
• An 18- to 24-Fr Foley catheter is introduced
Fig. 3a into the bladder via the vesicostomy and should
remain in situ for a few days postoperatively
to minimise the risk of prolapse or stenosis.
Thereafter the vesicostomy should be left to
drain freely into the child’s nappy/diaper.

Fig. 3b

Fig. 4
Fig. 3c

Fig. 5

Tips

77 Ensure the vesicostomy is as posterosuperior on 77 Make the size of the hole as wide as an 18- to 24-
the dome as possible to avoid prolapse. Fr Foley catheter to minimize the chance of ste-
nosis, but not any larger as this predisposes to
prolapse.

Common Pitfalls

77 Avoid making the vesicostomy too low on the

anterior bladder wall, as this increases the likeli-
hood of prolapse.
G10 Ureterostomy 461
G 10Ureterostomy G10
N. Sugandhi and S. Agarwala

The number of indications for ureterostomy has
lessened with time. In contemporary practice, a
ureterostomy is used to achieve temporary de-
compression of the upper tracts in carefully se-
lected cases. Many different types of ureterostomy
have been described, including the Sober ureter-
ostomy, reverse Sober ureterostomy, ring ureter-
ostomy, loop ureterostomy and end ureterostomy.
• Deepen the incision to reach Gerota’s fascia.
Identify the lower pole of the kidney and lo-
cate the ureter adjacent to it.
• Mobilize the ureter from its bed cranially as far
as the pelviureteric junction and pass a sling un-
derneath it.
• Deliver the mobilized ureter in a tension-free
manner to the skin at the proposed site of ure-
terostomy (Fig. 2).

Technique for Loop Ureterostomy

• Position the patient in the lateral position with

a roll under the flank between the costal mar-
gin and posterior superior iliac spine (Fig. 1).
• Mark the position of the proposed ureteros-
tomy site in the posterior axillary line.
• Make a small incision as for nephrectomy.
Fashion a shallow anterior or posterior ‘V’ in
the centre of the incision for subsequent for-
mation of a skin bridge (Fig. 1).

Fig. 1 Fig. 2

Nidhi Sugandhi ()

Senior Resident in Pediatric Surgery
drnidhisugandhi@gmail.com

Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com

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DOI: 10.1007/978-3-642-20641-2_139, © Springer-Verlag Berlin Heidelberg 2013
462 N. Sugandhi and S. Agarwala

Fig. 4

Fig. 3

• Anchor the loop of ureter to the muscle and

sheath, at the two edges of the V-shaped inci-
sion. The intervening muscles are sutured be-
neath the loop with interrupted Vicryl sutures
(Fig. 3).
• The V-shaped skin bridge is also approximated
beneath the loop with interrupted Monocryl
sutures (Fig. 4).
• Make a longitudinal ureterotomy on the apex
of the exteriorized loop (Fig. 3). Pass an appro-
priately sized catheter into the proximal loop
to check its smooth and unhindered entry into
the renal pelvis.
• Anchor the full thickness of the edge of ure-
ter to the surrounding with interrupted Vicryl
sutures, taking care to place the knots on the
skin (Fig. 4).
• Close the remaining incision in layers and
the skin with subcuticular Monocryl sutures
(Fig. 4). Fig. 5
G10 Ureterostomy 463

Technique for the Sober Ureterostomy
• Make the initial exposure and mobilization as
described for the loop ureterostomy (above).
• Transect the ureter at the apex of the delivered
ureteric loop.
• Anastomose the distal end of the transected
ureter to the lowest part of the renal pelvis
(Fig. 5).
• Anchor the proximal end of the transected ure-
ter to the muscle, sheath and the skin, as for an
end ureterostomy (Fig. 5).
• Close the abdominal incision in layers.
• Bring out the ureter more dilated as a stoma
at the edge of the Pfannenstiel incision. Take
the contralateral ureter behind the mesentery
of the sigmoid colon (Fig. 8) to anastomose it
to the side of the ureter more dilated (Fig. 9).
• Form an everted stoma from the dilated ure-
ter, making it protrude at least 1 cm from the
skin level (Fig. 10).
• The stoma is everted by passing the suture
through the skin and then through the partial
thickness of the ureteric wall, midway from
the transected edge, and then through the full
thickness of the ureter’s edge before the knot
is tied on the skin’s surface.

Technique for the End Ureterostomy

• Make a high Pfannenstiel incision and dissect

extraperitoneally to gain access to the retro-
peritoneum (Fig. 6).

Fig. 7

Fig. 6

• Identify the ureter as it crosses the iliac vessels.

• Mobilize the pelvic ureter, ligate it close to the
bladder with absorbable sutures, and divide it
(Fig. 7).
• Straighten the proximal ureter by dividing the
adhesions, staying out of the ureteric sheath to
avoid damage to the ureteric vasculature.
• If bilateral end ureterostomies need to be done,
mobilize the contralateral ureter. Fig. 8
464 N. Sugandhi and S. Agarwala

Fig. 9
Fig. 10

Tips

77 Avoid excessive mobilization and subsequent
devascularization of the ureter.
77 Avoid anchoring the ureter too posteriorly, as it
becomes uncomfortable for the patient to lie su-
pine.
77 Bilateral loop ureterostomies may be done in the
prone position with lumbotomy incisions. This
avoids the need to change the position intra-op-
eratively.
77 The proximal tracts may be drained with a Foley
catheter for a short period postoperatively to
keep the wound dry.
77 Double–barrel end ureterostomies can also be
made.
77 Incorporation of a V-shaped skin flap in an end
stoma can reduce the incidence of stenosis.

Common Pitfalls

77 Excessive mobilization and devascularization of
the ureter can occur, causing ischaemic necrosis
and stenosis.
77 Twisting of the ureter while anchoring in end
and loop ureterostomies leads to obstruction.
77 Not bringing out the most proximal part of the
ureter which can reach the skin level leads to
tortuosities and subsequent urinary stagnation
with persistence of urinary infection.
77 Dilated and tortuous ureters may be mistaken
for loops of bowel during dissection.
G11  Conduit Diversion 465
G 1Conduit Diversion G11
M. Yassin and A. H. B. Fyfe

Conduit diversion carries significant compli-

cations, particularly related to urine reflux into
the upper tracts, that limits its use in the paediat-
ric population. Occasionally it is performed in a
child with an advanced pelvic malignancy or neu-
ropathic bladder in which major reconstructive
surgery with a continent diversion is not consid-
ered appropriate.

Ileal Conduit
Fig. 1
• The stoma site is marked preoperatively.
• The patient is positioned supine. • Once clean, the proximal end of the ileal seg-
• A lower midline incision is usually used or the ment is over-sewn with interrupted 4/0 or 5/0
same incision as used for the primary proce- absorbable serosubmucosal sutures.
dure if the conduit is done concurrently. • Ileal continuity is restored with an ileo–ileal se-
• A Denis Browne, or other self-retaining retrac- rosubmucosal anastomosis, constructed using
tor, provides good exposure of the pelvis. interrupted 4/0 or 5/0 absorbable sutures.
• The parietal peritoneum is opened with dissect- • The ileal conduit is passed through the ileal
ing scissors between curved mosquito forceps. mesentery, and any residual mesenteric defect
• An appropriate 6- to 10-cm segment of ileum closed with interrupted absorbable sutures
together with its mesentery is carefully selected (Fig. 2).
for isolation and Doyen bowel clamps applied
as shown (Fig. 1).
• The distal end of the ileal segment is transected
between the clamps, approximately 15–20 cm
from the ileocaecal valve. The proximal end is
transected in the same way.
• The wound is protected with Betadine-soaked
swabs, whilst the mucosa of the ileal segment
is irrigated with normal saline to remove any
faecal debris.

Musaab Yassin ()

Core Trainee in Urology
musaab.aldouri@gmail.com

Alistair H. B. Fyfe
Consultant Paediatric Urologist Fig. 2
Fyfe7es@btinternet.com

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_140, © Springer-Verlag Berlin Heidelberg 2013
466
• The ureters are isolated and transected as close
to the bladder as possible.
• Sharp-scissor dissection is used to create a sub-
mucosal tunnel in the ileal conduit.
• The ureters are spatulated and implanted
through the submucosal tunnel.
• End-to-side uretero-ileal anastomoses are con-
structed over 4- or 6-Fr ureteric stents using in-
terrupted absorbable 6/0 sutures (Fig. 3).
Fig. 3
• A circular disc of skin is excised around the
premarked stoma site, usually in the right iliac
fossa, with a scalpel and monopolar diathermy.
• The anterior rectus fascia is opened with a cru-
ciate incision.
• Curved mosquito forceps are passed through
the incision and spread to widen the aperture so
that the surgeon’s finger can pass easily through
the opening into the peritoneal cavity.
• Babcock forceps are used to grasp the distal end
of the ileal conduit, which is then brought out
through the stoma site, creating a 2- to 3-cm
length outside the abdominal wall for fashion-
ing of the ‘nipple’.
M. Yassin and A. H. B. Fyfe
• The stoma is pexed (urethropexy) to the ante-
rior rectus fascia, using interrupted serosubmu-
cosal absorbable 4/0 sutures.
• The end stoma is matured to create a nipple,
with interrupted 4/0 or 5/0 sutures (Fig. 4) as
described in Chap. E13.
• The ureteric stents should be left protruding
from the stoma.
• The midline incision is closed as described in
Chap. A9.
Fig. 4
Colonic Conduit
Non-refluxing ureterocolonic anastomoses can
be fashioned, using the taenia coli; thus a colonic
conduit may preserve renal function better than
an ileal conduit.
The principles of surgery and technique are
similar to those described for an ileal conduit. Dif-
ferences in technique compared to the ileal con-
duit described above are:
• A short segment of sigmoid or transverse co-
lon is isolated.
• A non-refluxing ureterocolonic anastomosis is
performed (Figs. 5–7).
• The stoma is usually sited in the left iliac fossa.
G11  Conduit Diversion
Fig. 5 Fig. 6
Tips
77 The ideal segment of ileum for a conduit should
contain a rich blood supply, ideally with two ma-
jor vascular arcades.
77 The length of a Kocher clamp approximates the
required length of ileum for a conduit in an ado-
lescent, and it can be used as a measure.
Common Pitfalls
77 Always inspect the conduit. If it appears dusky,
apply warm packs. If the adequacy of the circula-
tion remains in doubt, it is best to excise the con-
duit and start again with a new segment.
77 Avoid compromising the ileal blood supply
when closing the mesenteric defect in the ileal
mesentery.
467
Fig. 7
77 Use stay sutures to manipulate the bowel and tip
of the ureter during suturing.
77 Minimise handling of the ureter with forceps, as
this may compromise the blood supply.
77 Leave a generous cuff of tissue around the distal
ureters to avoid compromising their blood sup-
ply during mobilization.
77 The inferior epigastric vessels may be damaged
during the blind passage of forceps through the
rectus abdominis during stoma formation.
 468 L. C. Steven and S. J. O’Toole
G12 G 12Ileocystoplasty
L. C. Steven and S. J. O’Toole

Catheterise the patient and partially fill the blad-

der. Preoperative antibiotics should be given.
Bowel preparation is not used routinely. Perform
a lower-midline or Pfannenstiel incision with mid-
line rectus split.
• Identify the urachus (can be used for traction)
and mobilise the bladder extraperitoneally us-
ing blunt dissection in the anterior, posterior
and lateral planes, sweeping the peritoneum su-
periorly. Be aware of the vascular pedicle and
ureters at all times (Fig. 1).

Fig. 2  Stay sutures on either side of midline and poste-

Fig. 1  Tie on urachus for traction. Sweep peritoneum su-
periorly
• After the bladder is fully mobilised place stay
sutures on either side of the urachus and ante-
riorly, 2 cm above the bladder neck (Fig. 2).
• Open the bladder in the sagittal plane with mo-
nopolar diathermy, extending the incision pos-
teriorly, and marking the posterior extent with
a further stay suture. Identify the ureteric ori-
fices and always be aware of their position.
• Open the peritoneum superiorly, locate the cae-
cum and deliver the ileum. If a Mitrofanoff
channel is required it should be performed
Lisa C. Steven ()
Specialist Registrar in Paediatric Surgery
lisasteven@doctors.org.uk
Stuart J. O’Toole
Consultant Paediatric Urologist
Stuart.O’Toole@ggc.scot.nhs.uk
riorly. Tie 2 cm proximal to bladder neck in the midline
now and tunnelled into the native bladder
(see Chap. G13).
• A classic ileal segment is 20 cm in length, start-
ing at least 20 cm from the ileocaecal valve. The
ileal segment must have a good arterial arcade
with or more feeding vessels.
• Isolate the ileal segment with division of the
mesentery at 90° to the ileum. Perform a stan-
dard small bowel anastomosis, ensuring that
the segment for augmentation runs underneath
the repaired ileum. Loosely close the mesen-
teric defect.
• Open out the ileal segment by incising along
the antimesenteric border with monopolar dia-
thermy. Clean the mucosa.
• With the ileum opened out, suture point A–A
(Fig. 3). This will form the posterior aspect of
the augment and give the augment a cup shape.

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DOI: 10.1007/978-3-642-20641-2_141, © Springer-Verlag Berlin Heidelberg 2013
G12 Ileocystoplasty 469

These two ileal edges are now brought together

with a continuous full-thickness suture.
• Begin the ileocystoplasty by anchoring poste-
riorly, the midline (point A) of the augment to
the apex of the posterior bladder incision. The
posterior wall is repaired, with a continuous su-
ture, on each side, aligning the coloured edges
as shown (Fig. 4).
• The anterior aspect of the augment can now
be formed by anchoring the midpoint of the
anterior aspect of the augment (point B), to
the apex of the anterior incision on the blad-
der, at the level of the bladder neck stay suture
(Fig. 5).
• Each lateral wall can now be sutured ensuring
equal ‘bites’ of the bladder and augment, that
allows a more waterproof repair. This can be
Fig. 3  Ileal edges to appose tested by filling the bladder and repairing any
large suture-line defects. It is not necessary to
repair all small suture line leaks, as the bladder
will be on free drainage postoperatively.
• The abdomen is closed as appropriate for the
incision used.
We recommend leaving a suprapubic catheter,
through the native bladder, and a urethral cath-
eter for postoperative care. The urethral catheter
can be removed after 7 days. The suprapubic cath-
eter is left on free drainage for 2 weeks until a
‘clamp-and-release’ programme is started to ex-
pand the bladder and clean intermittent cathe-
terisation is restarted.
Fig. 4  Suture point A of the ileal segment to the posterior
aspect of the bladder

Fig. 5  Anchor anterior wall of augment (point B) to the

level of the bladder neck stay suture
470
Tips
77 Once the bladder is open a Denis Browne ring or
Book–Walter retractor are useful in providing ac-
cess and freeing your assistant’s hands.
77 Be sure to mobilise the bladder anteriorly so that
the stay stitch is 2 cm above the bladder neck
and limits any further low dissection.
Common Pitfalls
77 Failure to mobilise the bladder adequately will
hinder the later steps of the procedure. Sweep-
ing the peritoneum superiorly off the bladder
will aid with this dissection.
77 The sagittal incision in the bladder must extend
anteriorly to just above the bladder neck. If not,
the augment will be hourglass-shaped and sub-
optimal.
L. C. Steven and S. J. O’Toole
77 The apex of the bowel segment should easily
reach the level of the bladder neck without ten-
sion. Try it out before dividing the mesentery.
77 To help opening the ileal segment it is useful to
use a large catheter or similar within the lumen
as a guide to where to make your incision.
77 Failure to mobilise the ileal segment high in its
mesentery will mean the segment is under ten-
sion when anastomosed to the bladder.
77 Following augmentation clean intermittent cath-
eterisation, either urethral or via a Mitrofanoff, is
mandatory.
G13  Continent Catheterisable Conduit 471
G13 Continent Catheterisable Conduit G13
E. Broadis and S. J. O’Toole

Indication Operative Technique

• This procedure is used to provide a catheteris-
able conduit between the skin surface and blad-
der.
• It is used in patients who require regular inter-
mittent catheterisation but cannot tolerate or
are unable to perform this by way of the ure-
thra.
Mitrofanoff Principle
The Mitrofanoff principle (also known as an ap-
pendicovesicostomy) is the creation of a passage-
way for fluid which has a valve mechanism to al-
low continence.
• Intravenous cefotaxime and metronidazole are
given on induction of anaesthesia.
• A lower-midline or Pfannenstiel incision can
be used (Fig. 1).
• Appendix is assessed with regard to:
– Length
– Size
– Suitability as a conduit
• Appendix is mobilised with its mesentery
(Fig. 2)
• The tip of the appendix is excised and a naso-
gastric tube passed to confirm its patency and
diameter of the lumen (Fig. 3).

l
lower midline

pfannstiel

Fig. 1 Fig. 2

• The lumen is irrigated with Betadine.

Emily Broadis () • The distal appendix is tunnelled into the blad-
Specialist Registrar in Paediatric Surgery der using a submucosal tunnel of approxi-
Ebroadis@doctors.org.uk
mately 2 cm (Fig. 4).
Stuart J. O’Toole • Interrupted absorbable sutures are used to an-
Consultant Paediatric Urologist chor the appendix to the bladder muscle and
Stuart.O’Toole@ggc.scot.nhs.uk

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DOI: 10.1007/978-3-642-20641-2_142, © Springer-Verlag Berlin Heidelberg 2013
472
the tip of the appendix lumen to the bladder
mucosa.
• The proximal end of the appendix is brought
through the abdominal wall as a stoma (Fig. 5–7
and see Chap. G14).
• An indwelling catheter is left in situ for around
4 weeks before catheterisation is attempted.
Fig. 3
Tips
77 Where should the appendix enter the bladder?
– Towards the bladder base allows good drain-
age but is harder to get to, and catheteriza-
tion can be painful as the catheter impinges
on the trigone.
– The dome of the bladder is easier to reach sur-
gically, decreases the length of conduit within
the abdomen and may be easier to catheter-
ise.
Common Pitfalls
77 Try to avoid over dissection and handling of the
mesoappendix and small bowel mesentery, as
this may lead to damage to the vasculature and
ischaemia of the appendix.
77 Take care not to kink the mesentery of the ap-
pendix as it is brought through the abdominal
wall.

E. Broadis and S. J. O’Toole
Alternatives to Using the Appendix
If the appendix is too short or absent, there are
alternative conduits that may be used:
• Ileovesicostomy (Monti procedure)
• Detrusor tube vesicostomy
Fig. 5
Fig. 4
77 Umbilical versus right iliac fossa skin site
– Umbilical site may confer a cosmetic advan-
tage but tends to have a higher incidence of
leakage.
77 Ways to prevent leakage
– Mucosal tunnel into the bladder
– Appendix tunnelled obliquely through the
abdominal wall muscle
77 Use the straightest and most direct route to
bring the proximal end of the appendix out to
enable easy catheterization.
G14  V-Quadrilateral-Z ( VQZ)-plasty for Stoma 473
G14 V-Quadrilateral-Z (VQZ)-plasty for Stoma G14
E. Broadis and S. J. O’Toole

Indication • The V flap is raised along with a layer of sub-

cutaneous tissue (Fig. 2).
• This procedure is used to create the cutaneous
opening of a continent catheterisable conduit
instead of a flush stoma.
• The mucosa is hidden beneath the skin, result-
ing in a discrete stoma with less contact bleed-
ing and reduced mucus discharge onto cloth-
ing.

Fig. 2
Operative Technique
• The appendix is delivered through the abdomi-
• A V-shaped incision is made, with the base in nal wall and sutured to the fascia. The remain-
the area where the appendix will exit. This will ing fascia is then closed (Fig. 3).
be sutured to the spatulated conduit (Fig. 1).

Fig. 3

• A longitudinal incision is made along the an-

timesenteric border of the appendix and the V
flap is sutured in place, leaving approximately
5 mm free on the inferior border of the V flap
(Fig. 4).
• A Q-tail incision is then made and raised as a
flap. This will form the anterior wall of the en-
Fig. 1 trance to the conduit (Fig. 5).
• The Q flap is turned over to form the anterior
wall of the conduit, suturing the long edge to
Emily Broadis () the anterior wall of the appendix and the short
Specialist Registrar in Paediatric Surgery edge to the free edge of the V flap (Fig. 6).
Ebroadis@doctors.org.uk

Stuart J. O’Toole
Consultant Paediatric Urologist
Stuart.O’Toole@ggc.scot.nhs.uk

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DOI: 10.1007/978-3-642-20641-2_143, © Springer-Verlag Berlin Heidelberg 2013
474 E. Broadis and S. J. O’Toole

• This leaves an area of skin which now requires

closure; there are two options here:
– Firstly, the remaining defect can be closed
without any further incision (VQZ-plasty).
– Alternatively, a Z-plasty can be performed
and the skin rotated to cover the defect
(VQZ-plasty) (Fig. 7).

Fig. 4

Fig. 5

Fig. 7

Fig. 6

Tips

77 Take care not to twist the appendix as it is 77 Do not repair the fascia too tightly around the
brought through the abdominal wall. appendix and its mesentery, as it will compress
the blood supply.
G15  Endoscopic Treatment of Vesicoureteric Reflux
G 15Endoscopic Treatment
of Vesicoureteric Reflux
A. Sinha and S. Agarwala
Numerous implantable materials have been uti-
lized for the endoscopic treatment of vesicoure-
teric reflux (VUR) including Teflon, silicone and
bovine collagen. Since its introduction in 1995, De-
flux, a copolymer of dextranomer microspheres
and non-animal, stabilised hyaluronic acid, has
become the most widely used implant material.
 echnique for Cystoscopic Injection of
T – Introduce the needle through the ureteric
Deflux
• Place the child in the lithotomy position.
• Pass an adequately sized (9.5–14 Fr) operating
urethrocystoscope with a side channel into the
bladder.
• Irrigate the bladder to allow clear visualization
of the trigone and ureteric orifices, but avoid
overdistension.
• Attach the standard, prefilled glass syringe to the
injection needle (e.g. 3.7 Fr × 23 G [tip] × 350 mm).
• Methods of injecting Deflux (Fig. 1):
– Subureteric injection (standard STING
technique)
– Insert the needle through the bladder mu-
cosa into the submucosal plane with the
bevel up, 2–3mm below the ureteric ori-
fice in the 6 o’clock position (Fig. 2).
– Inject Deflux under vision until you
achieve a volcano-like mound, sufficient
to create a crescentic ureteric orifice (usu-
ally 0.3–0.8 ml of Deflux per ureter).
Anand Sinha ()
Senior Research Fellow in Pediatric Surgery
dranandsinha@hotmail.com
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_144, © Springer-Verlag Berlin Heidelberg 2013
475
G15
– Leave the needle in situ for 1 min. With-
draw the needle and repeat the procedure
for the other side (if required).
– HIT and Double HIT (Hydrodistension Im-
plantation Technique)
– The ureteric orifice is distended by di-
recting a pressurized jet of irrigation
fluid from the end of the cystoscope at
the opening.
orifice into the midportion of the ureteric
tunnel, and pass the needle tip into the
submucosal plane at the 6 o’clock posi-
tion (Fig. 3).
– Stop the irrigation of fluid.
– Inject a small amount of Deflux to con-
firm correct placement in the submuco-
sal plane.
– Inject more Deflux until an adequate sub-
mucosal bulge is created to oppose the
walls of the ureteric tunnel.
– Increasingly, two intra-ureteric submuco-
sal injections are being used (double HIT)
with a second injection in the most distal
portion of the ureteric tunnel. This ap-
proach has the effect of closing the ure-
teric tunnel and orifice; it has achieved
high success rates.
– Superior tunnel
– In difficult cases a submucosal injection
can be given over the superior aspect
of the ureteric orifice. This technique is
rarely employed however (Fig. 4).
476 A. Sinha and S. Agarwala

Fig. 1 Fig. 2

Fig. 3 Fig. 4
G15  Endoscopic Treatment of Vesicoureteric Reflux
Tips
77 Always use the needle with the bevel up for ac-
curate injection of Deflux.
77 If the needle crosses the bladder wall the Deflux
injection will not be met with any resistance and
no mound will be created.
77 The needle should be kept in situ for 1 min fol-
lowing injection so that the Deflux is incorpo-
rated into the submucosal space and does not
extrude on withdrawal of the needle.
Common Pitfalls
77 Overdistension of the bladder displaces the ure-
teric orifices laterally and causes tension in the
submucosal layer of the ureter, making implan-
tation of Deflux more difficult and increasing the
likelihood of extravesical placement.
77 The needle can be inserted too deeply, leading
to extravesical injection.
477
77 Following injection of Deflux, using the hydro-
distension technique, the loss of subsequent hy-
drodistension confirms adequate narrowing of
the ureteric orifice.
77 If two intra-ureteric injections fail to adequately
narrow the ureteric orifice, a classical subureteric
injection can be performed.
77 Injecting too little material is possible, as is inject-
ing the wrong area.
77 Multiple passes of the needle through the mu-
cosa should be avoided, as this allows the im-
plant to extrude after injection.
 478
G16 G 16Ureteric Reimplantation
D. Datta and S. Agarwala
Operative Technique
• Make a Pfannenstiel incision.
• Deepen the incision down through subcutane-
ous tissue. Make a transverse incision in the an-
terior rectus sheath. Develop rectal fascial flap
superiorly to the umbilicus and inferiorly to the
pubic symphysis.
• Separate the rectus muscles in the midline. Use
a Denis Browne ring retractor to separate the
rectus muscles.
• Identify the anterior surface of the bladder and
push aside the peritoneum superiorly.
• Take two stay sutures on the anterior surface
of the urinary bladder and incise the bladder
vertically between stay sutures. Extend the inci-
sion inferiorly to visualize the ureteric orifices.
• Reposition the blades of the Dennis Browne
ring retractor to retract the lateral walls of the
incised bladder (Fig. 1).
• Place a small, wet sponge into the bladder
dome and position the remaining two retrac-
tors of ring retractor.
• Identify the ureteric orifices and cannulate
them with infant feeding tubes. Anchor the
feeding tubes with a catgut suture placed me-
dially.
• Make a circumferential incision to the ureteric
orifice with diathermy. Deepen the incision and
divide the muscles of the bladder that anchor
the ureter to the trigone until the ureter is com-
pletely mobilised. Continue mobilisation of the
ureter with blunt and sharp dissection until it
Dibyarup Datta ()
Senior Resident in Pediatric Surgery
dibyarupdatte@gmail.com
Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_145, © Springer-Verlag Berlin Heidelberg 2013
D. Datta and S. Agarwala
is completely free and does not retract back
through the ureteric hiatus (Fig. 2).
• For Cohen’s reimplantation:
– Pick up the medial edge of the circumferen-
tial incision to mobilise the ureter, and make
a small incision with a knife in the submu-
cosal plane.
– Develop a submucosal tunnel by sharp dis-
section with fine scissors to the opposite side
of the trigone, superior or inferior to the op-
posite meatus. The tunnel length should be
3–5 times the diameter of the ureter.
– Do the same thing for the contralateral ure-
ter.
– Pull each ureter with its catheter through the
submucosal tunnel to the contralateral side
using a fine, right-angled forceps (Fig. 3).
– Retract the ureter at the hiatus and place one
or two ‘figure-eight’ Vicryl sutures inferior
to the ureters to narrow the hiatus.
– Suture the tip of ureter to the adjacent blad-
der mucosa with catgut sutures. One of these
sutures should anchor the ureter to the blad-
der muscle as well (Figs. 3 and 4).
• For the Politano–Leadbetter procedure
– After mobilising the ureter, use a right-an-
gle forceps through the ureteric hiatus to in-
dent (from outside) the bladder.
– Make an incision on the mucosa and the
bladder muscle at this point to make a new
hiatus superiorly, and on the same side of
the meatus as shown in Fig. 5.
– Open the right-angle forceps to make the
size of the hiatus satisfactory.
– Now pull the ureter through the new hiatus
using a right-angled forceps.
– Create a submucosal tunnel extending from
the old hiatus to this new one.
– Pull the ureter through the submucosal tun-
nel and anastomose the ureter with the blad-
der mucosa at its original site (Fig. 6).
G16  Ureteric Reimplantation
– Repair the mucosa over the ureter at the site
of the new hiatus.
• Bring the ureteric stents out through bladder
wall and anchor them with catgut.
• Position a Mallecot catheter as a suprapubic
catheter (SPC) at the dome of the bladder and
anchor this as well with catgut.
Fig. 1
479
• Close the bladder in two layers using Vicryl.
• Place the prevesical drain and close the wound
with the SPC in the middle of it and the two
ureteric stents at both the corners.
• Anchor the SPC and the ureteric catheters with
silk sutures.
Fig. 2
480 D. Datta and S. Agarwala

Fig. 3 Fig. 4

Fig. 5 Fig. 6
G16  Ureteric Reimplantation
Tips
77 Tease off the peritoneum superiorly from the
bladder surface before opening of bladder to
avoid inadvertent opening.
77 Start dissection of ureter medially as it traverses
lateral to medial through intramural portion of
bladder.
77 Avoid injury of the peritoneum and the vas dur-
ing mobilisation of ureter.
77 Injection of saline in the submucosal plane may
facilitate creation of submucosal tunnel in diffi-
cult cases.
Common Pitfalls
77 Placing too long a ureteric stent may lead to its
kinking and failure to drain.
77 Mobilisation of the ureters in incorrect plane
may cause excessive difficulty, injury to the ure-
teric blood supply and delayed ischaemia.
77 Making the submucosal tunnel in the wrong
plane, that is actually outside the bladder.
481
77 In case of inflamed, oedematous mucosa, if the
mucosal tunnel is torn, mucosa can be sutured
over ureter to create tunnel.
77 In the Politano–Leadbetter procedure, the site
of the new hiatus should be in fixed portion of
bladder base. Sometimes the submucosal tunnel
may be extended distally towards bladder neck
if necessary to get sufficient length.
77 In females the SPC can be avoided and replaced
with a urethral catheter.
77 Making the hiatus too narrow may constrict the
ureter.
77 Making the new meatus too near the bladder
neck is avoided.
 482 E. Broadis and S. J. O’Toole
G17 G 17Posterior Urethral Valves
E. Broadis and S. J. O’Toole

Operative Technique is used with a 0° lens. The views through this

scope are limited, so a formal cystourethros-
• The valves consist of a leaflet of tissue that copy is often performed using a separate cys-
originates from inferior aspect of the verumon- toscope.
tanum in the posterior urethra (Fig. 1).
• Preoperatively the patient should have an
8-Fr nasogastric tube in situ, on continuous
drainage.

Fig. 2

• Aseptic technique is essential.

Fig. 1
• A voiding cystourethrogram during full mictu-
rition may show a dilated proximal urethra and
thick-walled bladder on a steep oblique projec-
tion (Fig. 2).
• You should know the setup of the cystoscopy
equipment (see Chap. G1). For resection of
posterior urethral valves an 8-Fr urethrotome
Emily Broadis ()
Specialist Registrar in Paediatric Surgery
Ebroadis@doctors.org.uk
Stuart J. O’Toole
Consultant Paediatric Urologist
Stuart.O’Toole@ggc.scot.nhs.uk
• The lubricated scope is inserted with the hook
pointed down, taking care to keep the urethral
lumen in the centre. The cystoscope is lowered
to enable manoeuvre into the posterior urethra.
• The bladder is emptied and the mucosal surface
is inspected for trabeculation or inflammation.
• The urethral orifices can be viewed by mov-
ing the cystoscope to either end of the trigone
(Fig. 3).
• The scope is withdrawn into the posterior ure-
thra and the urethrotome extended from the
cystoscope under direct vision.
• On drawing back the cystoscope with the hook
in the 5 o’clock position, the hook engages the
valve and divides it (Fig. 4).

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_146, © Springer-Verlag Berlin Heidelberg 2013
G17  Posterior Urethral Valves 483

Fig. 4
Fig. 3

• The manoeuvre is repeated in the 7 o’clock po-

sition.
• The cystoscope can be rotated 180° and the ma-
noeuvre can be repeated in the 12 o’clock posi-
tion.
• The cystoscope is removed and urine can be
manually expressed. There should be a good
stream of urine from the meatus.
• Leave a catheter in situ for 24–48 h and cover
with prophylactic antibiotics.

Tips

77 The diagnosis of posterior urethral valves can be 77 A baby with posterior urethral valves can be
difficult. The final diagnosis is often made at cys- managed with a urethral catheter until an expe-
toscopy by an experienced paediatric urologist. rienced paediatric urologist is available.
77 This is a technically difficult procedure where it
is easy to damage other urethral structures and
create lifelong morbidity.
 PAR T H
Perineum
H1  Perineal Injuries 487
H 1Perineal Injuries H1
C. A. Hajivassiliou

Perineal injuries can be blunt or penetrating, and All perineal wounds should be formally explored
can be classified further according to their exact under aseptic conditions for full toilet, with or
anatomical location (Fig. 1). without primary repair as appropriate.
Any child presenting with a perineal injury
should be triaged and assessed according to ad-
vanced paediatric life support (APLS) principles, 
and assessed for any other concomitant trauma/
pathology.
Injury to Perineum

Blunt Penetrating

Urethral / Vaginal - Perineal Body - Anal

Other / Associated Injuries

Fig. 1  Classification of perineal injuries

Principles of Emergency Management Urethral Injury

• Detailed history (time, mode, nature of injury) • Bruising in the perineal body area in males
• Full examination (usually after straddle injury) may signify par-
• IV access tial or complete urethral rupture. The decision
• Routine blood tests including blood cross- to catheterise should only be made by senior
match medical staff.
• Trauma x-ray series • Blood through the urethral meatus suggests ure-
• Abdominal/erect chest x-rays and further im- thral rupture until proven otherwise. Do not at-
aging (ultrasound scan [USS], computer to- tempt catheterisation, and if the patient is in
mography [CT]) as indicated urinary retention, insert an emergency supra-
• Position patient for abdominoperineal ap- pubic catheter (see Chap. G2).
proach (Fig. 2) • Early urethroscopy should be considered by se-
nior medical staff.

Constantinos A. Hajivassiliou ()

Urethral injury in females is very rare after blunt
Consultant Paediatric and Neonatal Surgeon trauma and is usually associated with other seri-
ch27z@udcf.gla.ac.uk ous injuries.

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DOI: 10.1007/978-3-642-20641-2_147, © Springer-Verlag Berlin Heidelberg 2013
488
Perineal Body Injury
• Wounds should be explored and deep exten-
sions defined and managed accordingly.
• Precise repair of the perineal body is necessary
to avoid long-term complications (prolapse, in-
continence).
Vaginal/Labial Injury
• Vaginal injury is exceedingly rare after even
moderate blunt trauma, and its presence sug-
gests possibility of other injuries (bony and vis-
ceral).
• An examination under anaesthesia (EUA) is
necessary to fully delineate labial/hymenal/vag-
inal injury.
• Once deeper injury is excluded, primary repair
of lacerations can be performed using absorb-
able material of appropriate gauge.
Anal Injury
• Any injury to the anal verge can potentially in-
volve the sphincter mechanism and rectum. Do
not perform perirectal (PR) examination unless
you are the person responsible for the manage-
ment/repair of such injuries as it is rarely diag-
nostic, may result in further damage and could
compromise the medicolegal position in case of
non-accidental injury.
• Repair will require specialist expertise and
equipment (electronic muscle stimulator) and
should be performed with a covering defunc-
tioning colostomy (see Chap. E13). A loop co-
lostomy is not appropriate.
Peritoneal Injury
• Peritoneal breach is very common after sharp
trauma to the perineum.
• It is usually secondary to rectal trauma and re-
sults in peritoneal cavity contamination.
C. A. Hajivassiliou
• Full laparotomy is required to assess the site
and degree of injury, effect repair and haemo-
stasis.
• Colonic injuries should be defunctioned prox-
imally.
Other Injuries
• Injuries to the penis or penile urethra are rare
and should be dealt with by experienced urol-
ogy staff.
• Injuries to the scrotum or testes, the common-
est being rupture or haematoma after blunt
trauma, rarely need exploration if closed and
are usually treated conservatively.
• Exceptions include secondary infection and
continuing haemorrhage.
Summary Points
• Assess and manage coexisting injuries.
• Closed injuries can be associated with damage
to deeper structures.
• Wound management
– Clean wounds are explored and closed.
– Contaminated wounds are explored, deep
extension or communication defined, devi-
talised tissue and debris excised, drained or
left open.
• Urethral injury requires specialist management
with suprapubic drainage if patient in reten-
tion.
• Anal or intestinal injury requires specialist
management with early defunctioning colos-
tomy.
• Peritoneal breach, especially after penetrating
injury to the perineum, may result in concom-
itant hollow and solid visceral trauma.
• Consider non-accidental injury/child sexual
abuse.
H1  Perineal Injuries 489

Fig. 2  Patient draped in the lithotomy position to allow access to perineum and abdomen

Pitfalls

77 Do not attempt urethral catheterisation if there is 77 Do not perform PR examination inconsiderately.

blood at the urethral meatus. 77 All colonic/anal repairs should be covered by a
77 Incompletely explored wounds can result in re- defunctioning colostomy.
tained debris and lead to infection. 77 Do not forget the possibility of non-accidental in-
77 Missing associated visceral injury can be life jury.
threatening.
 490 T. J. Bradnock and C. A. Hajivassiliou
H2 H2 Anal Fissures and Skin Tags
T. J. Bradnock and C. A. Hajivassiliou

Anal Fissure

• Most children with anal fissures can be man-

aged medically with dietary measures (increase
fluids and fibre), stool softeners and behaviour
modification (not withholding stool).
• Anal dilatation and lateral anal sphincterot-
omy are effective interventions in expert hands.

Anal Dilatation

• Place an infant in the lithotomy position.

• Put a child in the left lateral position or supine.
• Examine the anus (Fig. 1) and perform a dig-
ital rectal examination. Note the position of
the fissure (Fig. 2). Biopsy if it is suspicious
(see ‘Common Pitfalls’). Fig. 1
• Manually evacuate hard stool and perform
a proctoscopy to inspect the rectal mucosa
(see Chap. E3).
• Perform a gentle two-finger dilatation antero-
posteriorly (Fig. 3), then laterally (Fig. 4), be-
ing careful not to tear the anoderm.

Lateral Anal Sphincterotomy

• The patient should be placed in the lithotomy

position.
Fig. 2

• Examine the anus and perform a digital rectal

Tim J. Bradnock ()
Specialty Registrar in Paediatric Surgery
The Department of Paediatric Surgery, Dalnair Street,
Yorkhill Hopsital, Glasgow G3 8SJ, Scotland, UK
Email: tjbradnock@doctors.org.uk
Constantinos A. Hajivassiliou
Consultant Paediatric and Neonatal Surgeon
ch27z@udcf.gla.ac.uk
exam.
• Insert a lubricated Park’s retractor and open to
reveal the anal canal.
• Infiltrate with Lignocaine and adrenaline
around the dentate line and outside the inter-
nal sphincter.
• Make a 2-cm curvilinear incision just lateral
to the anal verge. Extend the incision up to the

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_148, © Springer-Verlag Berlin Heidelberg 2013
H2  Anal Fissures and Skin Tags 491

dentate line, raising a flap of skin off the inter-

nal sphincter (Fig. 5).
• Repeat this process on other side and divide the
internal sphincter up to the dentate line (Fig. 6).
• Close the skin with interrupted 4/0 absorbable
suture.
• Continue medical management postopera-
tively.

Fig. 3 Fig. 5

Fig. 6

Fig. 4
492 T. J. Bradnock and C. A. Hajivassiliou

Skin Tags

• A sentinel skin tag may occur with chronic fis-

sures, and consists of epithelialised granula-
tion tissue. It may interfere with wiping, pre-
vent good hygiene and cause pruritis.
• To remove, apply traction to the skin tag with
toothed forceps.
• Use short pulses of the bipolar diathermy to
coagulate any feeding vessels (Fig. 7).
• Excise with dissecting scissors.
• Always send the specimen to pathology to ex-
clude the rare presentation of systemic disease,
e.g. Crohn’s disease.
Fig. 7

Tips

77 Avoid using monopolar diathermy to remove 77 Remember that the majority of anal fissures can
skin tags from the external anal sphincter, as this be managed medically. Reserve surgery for re-
practice may result in significant burns to richly fractory and troublesome fissures in which con-
sensate skin or underlying muscle. servative measures have proved ineffective.

Common Pitfalls

77 Most anal fissures occur posteriorly in the mid- 77 Always perform a biopsy if any concern.
line. Atypical, complex, multiple, indolent or
painless fissuring raises the possibility of other
conditions (Crohn’s disease, non-accidental in-
jury).
H3  Perianal Abscess and Fistula-in-Ano 493
H3 Perianal Abscess and Fistula-in-Ano H3
T. J. Bradnock and R. Carachi

• Place the patient in the lithotomy position. • If pus is liberated, send a bacteriology swab for
• Prepare the skin with aqueous Betadine. culture and sensitivity.
• Examine the perianal region for induration, • Use your index finger to manually break down
skin tags or fissures (Figs. 1 and 5). any loculations within the cavity.

Fig. 1 Fig. 2

• Perform a digital rectal examination.
• Perform proctoscopy to exclude an internal fis-
tulous opening (see Chap. E3).
• Palpate the swelling and use a scalpel to make
a cruciate incision over the point of maximal
fluctuance (Fig. 2).
Tim J. Bradnock ()
Specialty Registrar in Paediatric Surgery
The Department of Paediatric Surgery, Dalnair Street,
Yorkhill Hopsital, Glasgow G3 8SJ, Scotland, UK
Email: tjbradnock@doctors.org.uk
• Irrigate the cavity with normal saline using a
20-ml syringe.
• Perform curettage of the cavity with a Volk-
mann spoon to remove all remaining granula-
tion tissue (Fig. 3).
• Irrigate the cavity again with normal saline.
• Pack the cavity with AQUACEL or Kaltostat,
leaving a tail to facilitate change of packing
(Fig. 4).
• Apply GeLonet and blue-gauze dressing.
• Plan for change of packing at 24 h prior to dis-
charge, with subsequent dressing changes per-
formed at home by the district nurse.

Robert Carachi
Professor of Surgical Paediatrics
Robert.Carachi@glasgow.ac.uk

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DOI: 10.1007/978-3-642-20641-2_149, © Springer-Verlag Berlin Heidelberg 2013
494 T. J. Bradnock and R. Carachi

• Cut down onto the probe with a scalpel or mo-

nopolar diathermy (Fig. 7).
• Use a Volkmann spoon to gently curette the
floor of the tract (Fig. 8).
• Trim overhanging skin edges to allow contin-
ued drainage of the fistulous tract.
• Pack the abscess cavity as described above.
• Apply GeLonet and blue-gauze dressing.
• Plan for the first change of packing at 24 h,
prior to discharge, with subsequent dressing
changes at home.

Fig. 3

Fig. 5

Fig. 4

Fistula-in-Ano

• Suspect a fistula-in-ano if the patient experi-

ences recurrent perianal abscesses (Fig. 5).
• Insert a lubricated Park’s retractor into the anal
canal to reveal the internal opening of the fis-
tula.
• Incise and drain any associated abscess, and
wash and debride the cavity as described above.
• Gently pass a silver probe through the base of
the abscess and through the fistulous tract un-
til the tip appears in the anal canal (Fig. 6).
Fig. 6
H3  Perianal Abscess and Fistula-in-Ano
Fig. 7
Tips
77 Ensure the cruciate incision is at least as wide as
the abscess cavity to guarantee drainage contin-
ues after surgery.
77 Unlike in adults, Goodsall’s rule does not usually
apply; typically fistulous tracts are low and run
radially, straight from their mucosal origin in the
anal canal to the abscess.
Common Pitfalls
77 Complex perianal sepsis and recurrent abscesses
raise the possibility of Crohn’s disease. A rectal bi-
opsy should be performed and the abscess roof
sent to pathology.
77 Always perform proctoscopy to exclude a fistu-
lous opening in recurrent abscesses.
495
Fig. 8
77 Do not probe uncomplicated, first-time perianal
abscesses looking for a fistula tract, as this may
lead to iatrogenic fistula formation.
77 Forceful passage of a silver probe through the
abscess cavity may lead to false-passage forma-
tion and failure to adequately lay open the fis-
tula.
77 Although rare, avoid laying open a high fistula
tract, as this may result in faecal incontinence.
 496 M. Ragavan and V. Bhatnagar
H4 H4 Anterior Ectopic Anus
M. Ragavan and V. Bhatnagar

Operative Technique • Place multiple stay sutures at the anocutane-

• Catheterise the patient.
• Position the patient in the lithotomy or prone
jack-knife position.
• Make a racquet-shaped incision around the
anocutaneous junction and extend the inci-
sion posteriorly in the midline from the poste-
rior edge of the anus to the proposed anal site
(Fig. 1).
ous junction for traction.
• Deepen the vertical midline incision, identify
the anterior and posterior edges of the vertical
fibres of the sphincteric muscle complex and
place fine-silk marking sutures at its junction
with the skin (Fig. 2).
• Divide the muscle fibres of the vertical muscle
complex exactly in the sagittal plane (Fig. 3).

Fig. 1
Fig. 2

• Deepen the perianal incision and mobilize the

rectum. The dissection should proceed first
posteriorly, then laterally and finally, anteri-
M. Ragavan ()
Associate Professor orly, using sharp and blunt dissection.
Department of Pediatric Surgery, Narayana Medical • Separate the anterior wall of the anorectum
College & Superspeciality Hospital, Chinthareddypalem, from the posterior vaginal wall in females and
Nellore, Andhra Pradesh 524002, India peri-urethral tissues in males.
dr_ragavan_2001@rediffmail.com
• Mobilise the rectum until loose areolar tissue
V. Bhatnagar
is identified between the rectum and vagina or
Professor of Paediatric surgery
veereshwarb@hotmail.com

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DOI: 10.1007/978-3-642-20641-2_150, © Springer-Verlag Berlin Heidelberg 2013
H4  Anterior Ectopic Anus 497

urethra, confirming their complete separation

(Fig. 3).
• Place the separated rectum in the centre of the
vertical fibres of the sphincteric muscle com-
plex as confirmed visually and by muscle stim-
ulator.
• Reconstruct the perineal body anterior to the
rectum with interrupted Vicryl sutures (Fig. 4).
• Repair the anterior and posterior edges of the
vertical fibres of the sphincteric muscle com-
plex with Vicryl sutures, incorporating the rec-
tal wall in a couple of the sutures to anchor it.
• Suture the edge of the anus to the skin with in-
terrupted Vicryl sutures (Fig. 5).
• Place a gauze pack in the rectum.

Fig. 3

Fig. 4 Fig. 5
498 M. Ragavan and V. Bhatnagar

Tips

77 A muscle stimulator is useful to aid identification 77 Adequately mobilise the rectum and repair the
of the muscle complex. perineal body to prevent dehiscence and ante-
77 Infiltration of saline with adrenaline in the plane rior retraction of rectum.
between rectum and vagina facilitates dissection 77 The procedure can also de done in a prone jack-
between them. knife position as a minimal posterior–sagittal an-
orectoplasty.

Common Pitfalls

77 Inadequate mobilisation results in tension, that 77 Inadequate haemostasis may result in a post-
may lead to retraction of the neo-anus. operative haematoma and breakdown of the
77 Dissection in an incorrect plane will lead to dam- wound.
age of either the rectal or vaginal wall.
H5  Excision of Rectal Polyp 499
H5 Excision of Rectal Polyp H5
P. Hammond and P. A. M. Raine

Presentation and Indications

• Investigation of the passage of blood and mu-

cous per rectum by proctoscopy may identify
a rectal polyp.
• Alternatively a polyp may be seen prolapsing
beyond the anal verge.

Operative Technique

• The patient is placed in the lithotomy position.

• A proctoscope is passed (initially with the ob-
turator and lubricant jelly) to allow visualiza- Fig. 1
tion of the polyp (see also Chap. E3) (Fig. 1).
• The polyp is grasped through the procto-
scope using biopsy forceps and delivered out
of the anus as the proctoscope is withdrawn
(Figs. 2 and 3).
• The stalk base of the polyp can then be trans-
fixed (Fig. 4) and ligated with 3/0 Vicryl, and
the polyp excised with dissecting scissors
(Fig. 5).
• The polyp is sent to pathology for histological
examination.
• Ensure haemostasis has been obtained (Fig. 6).
• Alternatively, if the polyp is too high in the co- Fig. 2
lon to be retrieved per rectum, an electrocau-
tery snare polypectomy may be performed dur-
ing the colonoscopy or sigmoidoscopy.

Philip Hammond ()

Consultant Paediatric and Neonatal Surgeon Fig. 3
Philip.Hammond@ggc.scot.nhs.uk

Peter A. M. Raine
Consultant Paediatric and Neonatal Surgeon
Rainewest@btinternet.com

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DOI: 10.1007/978-3-642-20641-2_151, © Springer-Verlag Berlin Heidelberg 2013
500 P. Hammond and P. A. M. Raine

Fig. 4 Fig. 5 Fig. 6

Tips

77 A Park anal retractor may help with access to al-

low ligation of the stalk following delivery.

Common Pitfalls

77 When applying traction to the polyp, be careful

not avulse it before the stalk is ligated, as this will
result in bleeding.
H6  Sacrococcygeal Teratoma 501
H 6S acrococcygeal Teratoma H6
S. Gazula and S. Agarwala

Operative Technique and divided. Thereafter dissect and ligate col-

• After endotracheal intubation, catheterize the
patient and then position in a prone jack-knife
position, with the shoulders and pelvis being
supported by rolled towels (Fig. 1).
lateral tumour blood supply originating from
the lateral sacral vessels (Fig. 3).
• Using a hook, retract the transected proximal
edge of the sacrococcygeal joint and gently re-
tract the tumour downwards. Using blunt and
sharp dissection dissect around the superior as-
pect of the tumour preserving the pelvic floor
muscles (Fig. 4).
• The rectum is identified and the tumour is care-
fully separated from the rectal wall using dia-
thermy (Fig. 5).

Fig. 1

• Make an inverted V-shaped or chevron inci-

sion, with the apex being lower sacrum or sa-
crococcygeal junction and extending dorso-
laterally on either side of the tumour (Fig. 2).
Deepen the incision to reach the tumour cap-
sule.
• Raise skin flaps to expose the tumour com-
pletely.
• Dissect the tumour from the inferior and me-
dial aspects of the gluteus maximus muscles to
visualize the sacrum and coccyx.
• Transect the coccyx at the sacrococcygeal joint.
Just anterior to the anterior cortex of the bone,
the median sacral vessels are visualized, ligated

Fig. 2
Suhasini Gazula ()
Senior Specialist pediatric surgeon
Department of pediatric surgery, Employees’ State
Insurance Corporation (esic) Superspeciality Hospital,
Sanath Nagar, Hyderabad, Andhra Pradesh, India
suhasinigazula@gmail.com

Sandeep Agarwala
Additional Professor of Pediatric Surgery
sandpagr@hotmail.com

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DOI: 10.1007/978-3-642-20641-2_152, © Springer-Verlag Berlin Heidelberg 2013
502 S. Gazula and S. Agarwala

Fig. 4

Fig. 3

Fig. 5 Fig. 6
H6  Sacrococcygeal Teratoma 503

Fig. 8

Fig. 7
• Dissect the tumour free inferiorly and remove
it in toto (Fig. 6).
• A 6- or 8-Fr suction drain is placed in the peri-
rectal space, and the levator muscles are ap-
proximated to the presacral fascia using Vic-
ryl interrupted sutures (Fig. 7).
• The gluteus maximus muscles are also approx-
imated in the midline with interrupted sutures Fig. 9
(Fig. 8), followed by closure of subcutaneous
tissue.
• Excess skin may have to be trimmed before clo-
sure using continuous Monocryl subcuticular
sutures (Fig. 9).
Tips

77 A rectal saline enema is given on the morning
of surgery to avoid contamination of the opera-
tive field.
77 A rectal examination prior to beginning the pro-
cedure can easily identify any deviation of the
rectum from the midline and help in dissection.
77 Placement of few interrupted sutures to appose
the superior portion of the levator muscles with
the presacral fascia aids in achieving a near nor-
mal configuration of the anal opening.
77 While trimming the excess skin prior to clo-
sure, it is better to remove more from the upper
flap, since this will make the subsequent closure
higher and away from the anus.
77 Additional steps for tumours with extensive in-
tra-abdominal component: In these tumours,
first a laparotomy by Pfannenstiel incision is
done to free the tumour from the pelvic viscera
and to gain control over the median sacral ves-
sels and collateral blood supply. The abdomen is
then closed, the patient turned over and the rest
of the procedure completed as described above.

Common Pitfalls

77 Avoid manipulating the tumour before ligating 77 Failure to excise the coccyx or incomplete coccy-
the median sacral vessels to prevent torrential gectomy increases the risk of tumour recurrence
haemorrhage. by 30–35 % percent.
 504 A. Bischoff, M. A. Levitt and A. Peña
H7 H7 Posterior Sagittal Anorectoplasty
in Females with Perineal or Vestibular
Fistulae
A. Bischoff, M. A. Levitt and A. Peña

• The patient should be placed in the prone po-
sition, with the pelvis elevated.
• Multiple 5-0 silk sutures are placed around the
fistula (mucocutaneous junction) to exert uni-
form traction (Fig. 1).
• A posterior sagittal incision is made through
the skin and subcutaneous tissue.
• The parasagittal fibres and ischiorectal fat are
divided in the midline.
• The muscle complex and levator mechanism
are identified and divided exactly in the mid-
line (Fig. 2).

Fig. 1

Fig. 2

Andrea Bischoff () • The white fascia surrounding the rectum is

Colorectal Center for Children, identified and divided. This creates a plane to
Cincinnati Children’s Hospital, 3333 Burnet Avenue, dissect the rectum.
ML 2023, University of Cincinnati, USA • The lateral walls of the rectum are dissected,
+513 636 3240
following the plane previously established.
Andrea.Bischoff@cchmc.org
• After the posterior and lateral walls of the rec-
Marc A. Levitt tum have been dissected, special attention and
Director, Colorectal Center, care are given to separation of the rectum and
Professor of Surgery, Cincinnati Children’s Hospital, 3333 vagina. The anterior rectal and posterior va-
Burnet Avenue, ML 2023, University of Cincinnati, USA
gina share a common wall. The surgeon’s job
+513 636 3240
Marc.Levitt@cchmc.org is to make two walls from one, without a nat-
ural plane of dissection.
Alberto Peña • While applying uniform traction on the rec-
Founding Director Colorectal Center for Children, tum, a meticulous dissection is performed. In
Cincinnati Children’s Hospital Medical Center Pediat-
the process, the surgeon must frequently check
ric Surgery, 3333 Burnet Avenue, ML 2023 Cincinnati,
Ohio 45229
the thickness of each wall to avoid damage.
Tele 513-636-3240 Fax: 513-636-3248 • The rectum is lifted superiorly, and the com-
Alberto.Pena@cchmc.org mon wall between rectum and vagina is com-

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_153, © Springer-Verlag Berlin Heidelberg 2013
H7  Posterior Sagittal Anorectoplasty in Females with Perineal or Vestibular Fistulae
pletely dissected until the two structures are
separated from each other. A typical areolar
plane is entered once the walls are completely
separated.
• At this point, if there is need to gain additional
rectal length, the dissection can be carried on
as close as possible to the rectal wall, dividing
and cauterizing attachments and vessels until
the rectum reaches the perineum without ten-
sion to allow a comfortable anoplasty to be per-
formed.
• The perineal body is reconstructed, bring-
ing together the anterior limit of the sphinc-
Fig. 3
505
ter mechanism that has been previously deter-
mined with the use of an electrical stimulator
(Fig. 3).
• The rectum is tacked to the posterior edge of
the muscle complex all the way to the level of
the levator proximally and skin distally (Fig. 4).
• Reconstruction of the posterior sagittal inci-
sion consists of the sequential reapproximation
of ischiorectal fat, parasagittal fibres, subcuta-
neous tissue and skin (Fig. 5).
• The anoplasty is performed with 16 interrupted
6-0 Vicryl sutures (Fig. 6).
Fig. 4
506
Fig. 5
Tips
77 Repair of the perineal fistula only requires a short
posterior sagittal incision (the size of the sphinc-
ter). Repair of a vestibular fistula requires a lon-
ger incision which may extend to the coccyx.
77 In perineal fistulas the rectum is intimately re-
lated to the vagina. In vestibular fistulas the rec-
tum shares a common wall with the vagina;
therefore it requires a more careful dissection.
Common Pitfalls
77 Injury to the vaginal and (or) rectal walls is pos-
sible.
77 Failure to separate the rectum and vagina fully
creates tension on the anoplasty.
77 Leaving rectal sutures in front of vaginal sutures
predisposes the patient to fistula formation.
A. Bischoff, M. A. Levitt and A. Peña
Fig. 6
77 Always inspect the vagina under anaesthesia, as
6% of patients with vestibular fistulas have a vag-
inal septum with two hemivaginas and hemi-
uteri.
77 Avoid tension on the anoplasty as this predis-
poses to dehiscence, retraction, and recurrent
fistula.
77 Faecal contamination and infection may occur
due to inadequate bowel preparation in patients
without colostomy or inadequate cleansing of
the distal bowel during colostomy creation.
H7  Posterior Sagittal Anorectoplasty in Females with Perineal or Vestibular Fistulae 507

A L B E RTO PENA
(1938 –  )
Mexican/American paediatric surgeon

Alberto Pena trained in Paediatric surgery first in Mexico City and then in Boston. He then
practiced at the National Institute of Paediatrics in Mexico City and at the Schneider Chil-
dren’s Hospital in New York. He is now the founding Director of the Colorectal Center at
Cincinnati Children’s Hospital. One of the few areas of paediatric surgery where detailed
knowledge was still lacking was anorectal malformations. In 1982, Dr. Pena described how
the posterior sagittal approach, with the help of an electrical stimulator, could be used for the
surgical management of anorectal malformations, named PSARP, an approach and proce-
dure that has placed him with the great names of paediatric surgery.
 508 A. Bischoff, M. A. Levitt and A. Peña
H8 H8 Posterior Sagittal Anorectoplasty
(PSARP) for Males with Recto-urethral
Bulbar Fistula and Prostatic Fistula
A. Bischoff, M. A. Levitt and A. Peña

• A Foley catheter is inserted.

• The patient is placed prone on the operating
table with the pelvis elevated (Fig. 1).
• A posterior sagittal incision is made, staying
precisely in the midline, dividing the skin, sub-
cutaneous tissue, parasagittal fibres, muscle
complex, and levator mechanism (Figs. 2 and 3).
• A white fascia covering the posterior rectal wall
is identified (Fig. 4).
• 5-0 Silk stitches are placed in the posterior rec-
tal wall, that is opened in the midline (Fig. 5).
• More silk stitches are placed in the rectal wall
edges as the opening of the rectum continues
(Fig. 6).
• The fistula is identified in the midline.
• Multiple 6-0 silk stitches are placed in the
hemicircumference above the fistula, and one
6-0 silk stitch is placed in the lower edge of the
fistula (Fig. 7). Fig. 1

Andrea Bischoff ()

Colorectal Center for Children,
Cincinnati Children’s Hospital, 3333 Burnet Avenue,
ML 2023, University of Cincinnati, USA
+513 636 3240
Andrea.Bischoff@cchmc.org

Marc A. Levitt
Director, Colorectal Center,
Professor of Surgery, Cincinnati Children’s Hospital, 3333
Burnet Avenue, ML 2023, University of Cincinnati, USA
+513 636 3240
Marc.Levitt@cchmc.org

Alberto Peña
Founding Director Colorectal Center for Children,
Cincinnati Children’s Hospital Medical Center Pediat-
ric Surgery, 3333 Burnet Avenue, ML 2023 Cincinnati,
Ohio 45229
Tele 513-636-3240 Fax: 513-636-3248 Fig. 2
Alberto.Pena@cchmc.org

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_154, © Springer-Verlag Berlin Heidelberg 2013
H8  PSARP for Males with Recto-urethral Bulbar Fistula and Prostatic Fistula 509

• A submucosal plane of dissection is created be-

tween the anterior rectal wall above the fistula
site and the urinary tract for several millime-
tres, and once the walls are more separated pro-
ceeds full thickness, applying uniform traction
on the multiple silk sutures previously placed
on the edges of the rectal wall and the superior
hemicircumference of the fistula (Fig. 8).
• To facilitate separation of the rectum from
the urinary tract, it is strongly recommended
to proceed cautiously, checking the thickness
of the anterior rectal wall frequently and inter-
mittently dissecting the lateral rectal walls.
• Once the rectum is completely separated from
the urethra, rectal bands and vessels need to
be divided and burned in order to gain enough
rectal length to achieve a perineal anastomosis
without tension.
• The posterior and anterior limits of the sphinc-
Fig. 3 ter are determined with the use of an electrical
stimulator.

Fig. 4

• The fistula site is identified by the one 6-0 silk

stitch previously placed in the lower edge of the
fistula and closed with interrupted long-term
absorbable suture (Fig. 9).
• The perineal body is then reconstructed bring-
ing together the anterior limits of the sphincter.
510 A. Bischoff, M. A. Levitt and A. Peña

Fig. 5
Fig. 7

Fig. 6
Fig. 8
• The levator muscle must be sutured in the mid-
line, behind the rectum.
• The posterior edges of the muscle complex are
sutured together in the midline including, with
each stitch, a bite of the posterior rectal wall,
to anchor the rectum and avoid tension on the
anoplasty and to help avoid prolapse. The is-
chiorectal space is closed with absorbable su-
tures.
• The parasagittal fibres are reapproximated.
• The posterior sagittal incision is closed up to
the skin.
• An anoplasty is performed with 16 long-term,
interrupted absorbable sutures (Fig. 10).
H8  PSARP for Males with Recto-urethral Bulbar Fistula and Prostatic Fistula 511

Fig. 9 Fig. 10

Tips

77 Prior to attempting a posterior sagittal approach,
ensure that a high-pressure distal colostogram
has been performed to define the anatomy.
77 The lower the fistula location is, the longer the
common wall between rectum and urethra.
77 Rectal dissection must be performed, remaining
as close as possible to the rectal wall.
77 In cases of prostatic fistulas, the rectum is located
immediately below the coccyx, the common
wall is short, and the circumferential dissection
to gain length is technically demanding.

Common Pitfalls

77 Inadvertent urethral injury 77 Trying to gain length in a short piece of rectum

77 Approaching posterior sagittally a patient with- after a defective, too distally placed colostomy
out a distal colostogram 77 Searching for the rectum posterior sagittally in
77 Dissecting the rectum in the wrong plane (too the case of recto–bladder neck fistula
far away from the rectal wall)
 512 A. Bischoff, M. A. Levitt and A. Peña
H9 H9 Posterior Sagittal Anorectoplasty (PSARP)
with Laparotomy/Laparoscopy in Males
with Rectal–Bladder Neck Fistulas
A. Bischoff, M. A. Levitt and A. Peña

• A total body preparation from nipples down is
done, allowing for a simultaneous sterile field
in the abdomen and perineum (Fig. 1).
Fig. 1
• A laparoscopy or a lower-midline laparotomy
from umbilicus down to the pubis is performed.
• If a laparotomy is used, a clamp is placed on
the top of the bladder or urachus, and the blad-
Andrea Bischoff ()
Colorectal Center for Children,
Cincinnati Children’s Hospital, 3333 Burnet Avenue,
ML 2023, University of Cincinnati, USA
+513 636 3240
Andrea.Bischoff@cchmc.org
Marc A. Levitt
Director, Colorectal Center,
Professor of Surgery, Cincinnati Children’s Hospital, 3333
Burnet Avenue, ML 2023, University of Cincinnati, USA
+513 636 3240
Marc.Levitt@cchmc.org
Alberto Peña
Founding Director Colorectal Center for Children,
Cincinnati Children’s Hospital Medical Center Pediat-
ric Surgery, 3333 Burnet Avenue, ML 2023 Cincinnati,
Ohio 45229
Tele 513-636-3240 Fax: 513-636-3248
Alberto.Pena@cchmc.org
der is mobilized inferiorly, dividing its lateral
attachments.
• The bowel distal to the mucous fistula is fol-
lowed until it disappears below the peritoneal
reflection.
• The peritoneal reflection between colon and
bladder is identified. The peritoneum is divided
to reach the bowel wall. The bowel is then dis-
sected circumferentially. A silastic vessel loop
is passed around the rectum for traction.
• Applying traction on the vessel loop in a cranial
direction, the rectum is dissected distally, al-
ways remaining in contact with the bowel wall
to ensure that important pelvic structures in-
cluding vas deferens, ureters and nerves vital
for bladder function are preserved.
• At the point where one can identify that there is
a substantial decrease in the calibre of the rec-
tum (close to the bladder neck) four 5-0 Vicryl
sutures are placed in the rectal wall, and the fis-
tula is transected and ligated.
• Multiple 5-0 silk stitches are placed in the distal
rectum to allow for uniform traction (Fig. 2).
• The blood supply of the distal bowel is studied,
and distal vessels of the distal segment of the
rectum are taken in order to gain length, until
adequate for the rectum to reach the perineum
without tension.
• A space is created between the sacrum and uri-
nary tract, dissecting the abdomen as low as
possible.
• Attention is then turned to the perineum. The
patient may remain supine with the legs lifted
(Fig. 3). A posterior sagittal incision is made
from the base of the scrotum towards the coc-
cyx, dividing the sphincters, taking care to stay
exactly midline.
• The abdominal cavity is entered from below,
identifying the space previously created be-
tween sacrum and the urinary tract.
• The bowel is pulled through (Fig. 4).

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_155, © Springer-Verlag Berlin Heidelberg 2013
H9  PSARP with Laparotomy/Laparoscopy in Males with Rectal–Bladder Neck Fistulas 513

Fig. 2

Fig. 3

• The limits of the sphincter are delineated with

an electrostimulator.
• The sphincter mechanism posterior to the rec-
tum is reconstructed ,and the anoplasty per-
formed as described in Chap. H7 (Fig. 5).
• The abdomen is closed by layers.

Fig. 4
514 A. Bischoff, M. A. Levitt and A. Peña

Fig. 5

Tips

77 A point 4 cm below the pubic bone can be used geon to ensure the adequacy of dissection while
to predict whether the rectum will reach the working in the abdomen.
perineum without tension. This allows the sur-

Common Pitfalls

77 Injury to the vas deferens or ureters.

77 Inadvertent bowel devascularization while gain-
ing extra length for the pull-through
H10  PosteriorSagittalAnorectoplasty(PSARP)withTotalUrogenitalMobilizationforCloacaewithaCommonChannelSmallerthan3cm 515
H10 Posterior Sagittal Anorectoplasty (PSARP) H10
with Total Urogenital Mobilization
for Cloacae with a Common Channel
Smaller than 3 cm
A. Bischoff, M. A. Levitt and A. Peña

• A posterior midline–sagittal incision is per-

formed, running from the middle portion of
the sacrum to the single perineal orifice, split-
ting the parasagittal fibres, ischiorectal fat,
muscle complex and levator muscle to the level
of the common channel and or rectal and vag-
inal walls (Fig. 1).
• The white fascia covering the posterior wall of
the rectum is identified (Fig. 2).
• Two 5-0 silk stitches are placed in the posterior
rectal wall, that is opened in the midline.
• The incision is extended, opening the vagina
and the common channel (Fig. 3).
• A Foley catheter is inserted into the urethra.
• Multiple silk stitches are placed to provide uni-
form traction on the rectum. The lateral rectal Fig. 1  Sagittal view of a cloaca with short common chan-
wall is dissected. nel

• The rectal stitches are lifted superiorly and the

common wall between rectum and vagina is
dissected, ensuring that the vaginal and rectal
Andrea Bischoff () walls remain intact (Fig. 4).
Colorectal Center for Children, • The dissection is completed when the vagina
Cincinnati Children’s Hospital, 3333 Burnet Avenue, and the rectum become distinct and separate
ML 2023, University of Cincinnati, USA structures (Fig. 5).
+513 636 3240
• If the rectum requires further mobilization, di-
Andrea.Bischoff@cchmc.org
vide and cauterize bands and vessels until the
Marc A. Levitt rectum comfortably reaches the perineum with-
Director, Colorectal Center, out tension.
Professor of Surgery, Cincinnati Children’s Hospital, 3333 • The rectum is then lifted and retracted superi-
Burnet Avenue, ML 2023, University of Cincinnati, USA
orly out of the field so attention can be directed
+513 636 3240
Marc.Levitt@cchmc.org towards total urogenital mobilization.
• Multiple 5-0 silk traction sutures are placed
Alberto Peña around the edges of the urogenital tract. An-
Founding Director Colorectal Center for Children, other series of stitches are placed horizontally,
Cincinnati Children’s Hospital Medical Center Pediat-
taking the common channel about 5 mm ce-
ric Surgery, 3333 Burnet Avenue, ML 2023 Cincinnati,
Ohio 45229
phalically from the clitoris (Fig. 6).
Tele 513-636-3240 Fax: 513-636-3248 • The common channel is then divided between
Alberto.Pena@cchmc.org the stitches and the clitoris. A plane of dissec-

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_156, © Springer-Verlag Berlin Heidelberg 2013
516 A. Bischoff, M. A. Levitt and A. Peña

Fig. 2

Fig. 3 Fig. 4
H10  PSARP with Total Urogenital Mobilization for Cloacae with a Common Channel Smaller than 3 cm 517

tion is created between the wall of the urogen-

ital sinus (common channel) and the posterior
aspect of the pubis. This manoeuvre is rela-
tively easy due to the fact that there is a natu-
ral space between both structures. The dissec-
tion is carried out up to the upper edge of the
pubis.
• The suspensory ligaments of the urethra and
vagina are identified as a whitish, avascular
membrane fixing the urogenital structures to
the pubis. These ligaments are divided. A con-
spicuous retropubic fat pad is present. Behind
the pubis are important vessels that may bleed
during this manoeuvre. In babies, the bleeding
is easily controlled with cautery. In older pa-
tients it may be necessary to use fine sutures to
Fig. 5 stop them. Dividing the suspensory ligaments
gains between 2 and 3 cm of length, which is
enough to achieve a satisfactory urethral and
vaginal repair in cloacae with a common chan-
nel shorter than 3 cm (which represent over
50% of all cloacae).
• Once enough length is gained, the common
channel is split in the midline.
• Multiple fine 6-0 Vicryl sutures are then uti-
lized to suture the urethra immediately poste-
rior to the clitoris.
• The two flaps created after dividing the com-
mon channel are used to create the new labia.
• The vagina is sutured to the perineum using 6-0
Vicryl sutures.
• The limits of the sphincter are determined with
the use of an electrostimulator.
Fig. 6 • The perineal body is created between the va-
gina and the anterior limit of the sphincter us-
ing 5-0 Vicryl sutures.
• The rectum is placed in front of the levator and
within the limits of the sphincter mechanism,
which is reconstructed as described for other
defects (Fig. 7).

Fig. 7
518 A. Bischoff, M. A. Levitt and A. Peña

Tips

77 The length of the common channel should be
measured with a cystoscope prior to the oper-
ation, since cloacae with a common channel
larger than 3 cm require a more complex recon-
struction.
77 During the dissection between vagina and rec-
tum, continually check the thickness of both
vaginal wall and rectal wall using a thick lacrimal
duct probe.

Common Pitfalls

77 Injury to the vaginal wall during its separation 77 Failure to delineate the correct anatomy and the
from the rectum length of the common channel prior to repair
H11  Colostomy Creation in Anorectal Malformation 519
H 1Colostomy Creation H11
in Anorectal Malformation
A. Bischoff, M. A. Levitt and A. Peña

• An oblique incision is made in the left lower

quadrant of the abdomen. The upper portion
of the incision will accommodate the proximal
stoma, and the distal end will accommodate the
mucous fistula. The distance between both sto-
mas should allow the placement of a stoma bag
only covering the proximal stoma (Fig. 1).
• The sigmoid colon is identified and brought
outside the incision.
• The future colostomy site is selected close to the
fixed portion of the descending colon, where it
attaches to the left retroperitoneum.
• A purse-string suture is placed in the colon, in
the selected location of the future colostomy,
and a 12-Fr Foley catheter is inserted to allow
warm irrigation of the distal bowel until it is
completely clean of meconium (Fig. 2).

Fig. 1  The optimal position of the proximal stoma and

mucous fistula
Andrea Bischoff ()
Colorectal Center for Children,
Cincinnati Children’s Hospital, 3333 Burnet Avenue,
ML 2023, University of Cincinnati, USA
+513 636 3240
Andrea.Bischoff@cchmc.org

Marc A. Levitt
Director, Colorectal Center,
Professor of Surgery, Cincinnati Children’s Hospital, 3333
Burnet Avenue, ML 2023, University of Cincinnati, USA
+513 636 3240
Marc.Levitt@cchmc.org

Alberto Peña
Founding Director Colorectal Center for Children,
Cincinnati Children’s Hospital Medical Center Pediat-
ric Surgery, 3333 Burnet Avenue, ML 2023 Cincinnati,
Ohio 45229
Tele 513-636-3240 Fax: 513-636-3248
Alberto.Pena@cchmc.org Fig. 2  Irrigation of the distal colon

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_157, © Springer-Verlag Berlin Heidelberg 2013
520 A. Bischoff, M. A. Levitt and A. Peña

• Intestinal clamps are placed in the same loca-

tion of the purse string suture, and the colon
is then transected in between them.
• A tapering of the distal segment (mucous fis-
tula) is performed with two layers of 5-0 Vic-
ryl sutures on the antimesenteric side to create
a 5-mm opening (Fig. 3).

Fig. 3  Tapering of the mucous fistula

• The mucous fistula is created in the most infer-

omedial portion of the incision by taking sero-
muscular ‘bites’ to the posterior fascia, allow-
ing a 3- to 4-mm redundancy of mucosa at the
skin level, without maturing the stoma.
• The anterior fascia is closed with interrupted
Vicryl sutures.
• The proximal stoma is then placed in the su-
perior portion of the incision. One centimetre
of bowel must protrude, everted above the skin
level (matured stoma).
• The bowel determined to be the proximal
stoma must be sutured to the peritoneum and
fascia, being sure its lumen is not constricted,
or its blood supply compromised.
• The abdominal wall located between both sto-
mas must be sutured in two layers with inter-
rupted absorbable sutures.
• The subcutaneous tissue is closed with inter-
rupted Vicryl sutures, followed by the skin with
a subcuticular suture.
• The proximal stoma must be matured.
H11  Colostomy Creation in Anorectal Malformation 521

Tips

77 The location of the proximal stoma should be in
the middle of a triangle formed by the last rib,
the umbilicus and the iliac crest in order to leave
enough space to adapt a stoma bag.
77 In patients with cloaca and hydrocolpos, during
colostomy creation the hydrocolpos should be
drained with a pigtail catheter which should
remain in place until the final repair. If there are
two hemivaginas, a window should be created in
the vaginal septum allowing one tube to drain
both hemivaginas. If the hydrocolpos reaches
above the umbilicus, it can be sutured to the skin
as a tubeless vaginostomy.

Common Pitfalls

77 Leaving meconium in the distal bowel leads to

impaction and can contaminate the urinary tract.
77 Take care not to invert the position of the proxi-
mal and distal stomas.
77 Creation of a colostomy too distally results in a
very short piece of bowel distal to the mucous
fistula, that will subsequently interfere with the
pull-through.
77 Placing the proximal stoma in a mobile portion
of the colon will lead to prolapse.
77 Making a large mucous fistula may result in pro-
lapse, since the stoma is created in a mobile por-
tion of colon. Fig. 4  Hydrocolpos in patients with cloacae should
also be drained
 524 A. Bischoff, M. A. Levitt and A. Peña
H12 H 12Colostomy Closure
in Anorectal Malformation
A. Bischoff, M. A. Levitt and A. Peña

• The proximal stoma is packed with Betadine-
soaked packing gauze.
• Multiple 5-0 silk sutures are placed at the mu-
cocutaneous junction around both limbs of the
stoma to allow for uniform traction (Fig. 1).
• An elliptical wedge-type incision is made
around the two stomas and carried down
through skin, subcutaneous tissue, aponeuro-
sis, muscle and peritoneum (Fig. 1).
• Both stomas are completely dissected from the
abdominal wall.
• The packing gauze is removed.
• Baby ALLEN clamps are applied and the sto-
mas are resected (Fig. 2).
• The edges of the bowel are trimmed off.
• A two-layer anastomosis with fine, interrupted
stitches is performed (Figs. 3 and 4).
• The mesenteric defect is then closed with ab-
sorbable suture.
• The abdominal cavity is irrigated with copious
amount of saline solution, as well as each layer
during abdominal wall closure.
• The abdominal wall is closed in layers with in-
terrupted sutures (Fig. 4).
• The skin is closed with a subcuticular running
suture.
• Collodium is placed on the wound.

Andrea Bischoff ()

Colorectal Center for Children,
Cincinnati Children’s Hospital, 3333 Burnet Avenue,
ML 2023, University of Cincinnati, USA
+513 636 3240
Andrea.Bischoff@cchmc.org

Marc A. Levitt
Director, Colorectal Center,
Professor of Surgery, Cincinnati Children’s Hospital, 3333
Burnet Avenue, ML 2023, University of Cincinnati, USA
+513 636 3240
Marc.Levitt@cchmc.org

Alberto Peña
Founding Director Colorectal Center for Children,
Cincinnati Children’s Hospital Medical Center Pediat-
ric Surgery, 3333 Burnet Avenue, ML 2023 Cincinnati,
Ohio 45229
Tele 513-636-3240 Fax: 513-636-3248
Alberto.Pena@cchmc.org

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_158, © Springer-Verlag Berlin Heidelberg 2013
H12  Colostomy Closure in Anorectal Malformation 523

Fig. 1.  Application of traction sutures and mobilisation of the stoma

Fig. 2  Trimming and orientation of the stomal ends

Tips

77 Apply uniform traction on the silk sutures to fa- 77 Irrigate all layers during abdominal wall closure.
cilitate the separation of the stomas from the ab- 77 Avoid faecal contamination, excessive burning of
dominal wall. tissues, dead spaces, and hematomas.

Common Pitfalls

77 Contamination of stool in the surgical field

524 A. Bischoff, M. A. Levitt and A. Peña

Fig. 3  Construction of a two-layer anastomosis

Fig. 4  Completion of the anastomosis and closure of the skin

 PAR T I
Minimally Invasive
Surgery
I1  Ergonomics, Heuristics and Cognitive Skills in Laparoscopic Surgery 527
I1 Ergonomics, Heuristics and Cognitive I1
Skills in Laparoscopic Surgery
H. L. Tan

Ergonomics is the study of people at work or in

structured activities. It relates to the design of
equipment and how the equipment affects the
environment and vice versa. Many so-called dif-
ficulties encountered in laparoscopic surgery, such
a mastering hand–eye coordination, reduced free-
dom of movement, and navigating a two-dimen-
sional plane, is due to our failure to understand
how to interact with the equipment used in lap-
aroscopic surgery. Unlike conventional surgery,
every aspect of laparoscopic surgery is different
from conventional surgery.
Laparoscopic surgery can be either very enjoy-
able or tiring, and this first principle to understand
in laparoscopic surgery is to make oneself com-
fortable. Too many surgeons are so focused on
watching the video monitor that they forget to en-
sure maximizing their comfort level and stability.
1. Posture, table height and stability
a. Whether you are standing or sitting, the ta- Fig. 1 
ble height and port positions should be set to
allow the surgeon to operate with the arms tion, as is required for operations such as
by the side without abduction of the shoul- laparoscopic pyeloplasty (Fig. 2).
ders. This is the position of maximum sta- 2. Theatre layout
bility and comfort for laparoscopic surgery. a. The operating theatre layout should be such
As can be seen from the illustration, the sur- that the surgeon, assistant and nurse should
geon can operate for hours in this position in line with video camera, with the endo-
of maximum stability (Fig. 1). scopic camera pointing towards the video
b. Placing instruments access ports too far monitor. Your assistants should all be in line.
apart, or raising the table too high will ei- b. Laparoscopic surgery requires all instru-
ther result in ‘chicken winging’ or other non- ments including the camera, to work around
physiological positions which will leave the a fulcrum, that means that every movement is
surgeon exhausted. It is also not a position paradoxical. This is a first-order paradox. It
of stability that can allow very fine dissec- makes no sense to place your assistant across
the table especially if he or she has to use
a second monitor if the endoscopic camera
Hock Lim Tan () is pointed towards him or her, because this
Visiting Pediatric Surgeon,
creates a second-order paradox in which the
Prince Court Medical Center, 56000 Kuala Lumpur,
Malaysia & Adjunct Professor Faculty of Medicine, horizontal movements are no longer para-
Universitas Indonesia, Jakarta, Indonesia doxical, while the vertical plane remains so.
Email: hockltan@yahoo.com This would make it extremely difficult for the

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_159, © Springer-Verlag Berlin Heidelberg 2013
528
4. Positioning of the video monitor
5. Non stereoscopic navigation
Coping with two-dimensional imaging and
Fig. 2
assistant to help with even simple tasks when
working with second-order paradox.
3. Port positions
a. Your ability to manipulate instruments in-
side the body cavity depends on the vol-
ume of the cone between the point of en-
try and the target organ. Placing instrument
ports too close to the target organ will re-
duce the internal space available to manip-
ulate instruments, and lead to exaggerated
external movements, whereas placing instru-
ment ports too far way while maximizing in-
ternal space can lead to exaggerated inter-
nal movements and make it difficult to per-
form fine dissection, as every movement is
magnified. It is best to aim to have about the
same length of instrument inside the body
cavity as is outside.
Fig. 3
H. L. Tan
a. The video monitor should be placed like a
‘window’ into your operative field. Unfor-
tunately, this is often the afterthought and
the monitor is usually placed at the top of
the ‘stack’, and depending on the amount of
equipment on the stack. can be at a height of
2 m. It is ergonomically far superior for the
video monitor to be either pendant mounted
or mounted on a separate arm for the most
ergonomic position (Fig. 3).
learning navigational skills are the most chal-
lenging aspects of laparoscopic surgery, and
there are several useful methods to cope with
this.
a. Your navigational skills can be improved by
developing Gestald or your own mental spa-
tial memory, especially during instrument
interchange. Remaining motionless, it is al-
ways possible to introduce instruments to
the exact spatial location if you make it a
habit to remember the spatial location of
the instrument you are extracting.
b. Depth recognition especially is greatly en-
hanced by working at close quarters in your
operating field. The surface texture and size
of organs and instruments are greatly en-
hanced when you are working close up and
use the largest video monitor possible. Ac-
cording to Fitt’s law, the closer the target is
and the larger the target is, the easier it is to
reach.
I1  Ergonomics, Heuristics and Cognitive Skills in Laparoscopic Surgery 529

6. Heuristics are ‘rules of thumb’ used everyday

in surgery and form a very important basis of
our surgical skills. However the rules of thumbs
that apply to open surgery may not necessarily
apply to laparoscopic surgery. For example, it is
completely unnecessary to ‘break the table’ for
renal surgery and in fact may be counter pro-
ductive.
7. Laparoscopic suturing is probably the most in-
timidating skill to develop and there is no bet-
ter substitute than practicing on a dry Endo-
Trainer. However there are some basic rules
which are helpful including working at close Fig. 4
quarters, e.g. keeping the suture as short a pos-
sible. The alignment of the port is critical, as
it has to be in the line of your suturing anas-
tomosis. Because of the restriction of freedom
of movement, it would be extremely difficult to
place accurate sutures if your suturing port is
not in line with the suture line.

There are many aspects of laparoscopic surgery

which differ from conventional open surgery. An
appreciation of the fundamental differences, and
especially of the ergonomics, will greatly enhance
your laparoscopic skills and make your laparo-
scopic experience thoroughly enjoyable.
 530
I2 I2 Complications of Laparoscopic Surgery
H. L. Tan
The true incidence of complications in paediat-
ric laparoscopy is only now becoming apparent.
Gans in 1973 reported 300 cases of laparoscopy
without complications in children. While the ad-
vantages of Minimally Invasive Surgery such as
less physical trauma, reduction in debility, quicker
recovery and other advantages have been extolled
by enthusiasts, it should be noted that paediatric
Minimal Invasive Surgery is not without its com-
plications.
A multicentre assessment of the safety of neo-
natal laparoscopic surgery in 218 in seven Euro-
pean Hospitals reported a 7% incidence of surgi-
cal events and 12% incidence of anaesthetic in-
cidents. Similarly, an audit of complications of
laparoscopic Splenectomy in 10 institutions in-
dicated an intra-operative surgical complication
rate of 19%, with bleeding being the most com-
mon complication.
In this chapter the potential complications of
laparoscopic surgery and their management are
discussed. The best management of complications
is prevention, and this chapter focuses on this.
Incidence
The strongest predictor of overall laparoscopic
complication rate is the experience of the practi-
tioner. Most major complications occur during the
learning curve, either in the form of inability to
complete the operation or visceral injuries. There
is no substitute for experience.
Hock Lim Tan ()
Visiting Pediatric Surgeon,
Prince Court Medical Center, 56000 Kuala Lumpur,
Malaysia & Adjunct Professor Faculty of Medicine,
Universitas Indonesia, Jakarta, Indonesia
Email: hockltan@yahoo.com
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_160, © Springer-Verlag Berlin Heidelberg 2013
H. L. Tan
Complications of Pneumoperitoneum
Hypercarbia
Insufflation of carbon dioxide (CO2) into the peri-
toneal cavity causes hypercarbia. This occurs for
two reasons, direct CO2 absorption and reduced
CO2 excretion – the latter due to diaphragmatic
splinting with a fall in tidal volume. It is essential
that all patients be closely monitored, not only for
the normal cardiorespiratory parameters, but also
for end-tidal CO2. The fact that young children
rely on diaphragmatic breathing more than inter-
costal breathing increases their predisposition to
hypercarbia. Increasing the insufflation pressure
to 10 mmHg in the neonate compromises the tidal
volume by 30 %. An immediate rise in end-tidal
CO2 by 10 mmHg occurs at the start of laparos-
copy due to diaphragmatic splinting, followed by
a second rise after 20 min, presumably due to ab-
sorption of CO2 across the peritoneum.
Recent reports of neonates arresting on com-
mencement of abdominal insufflation, with one
fatality, strongly suggests that this is due to gas
embolism via the umbilical vein (or falciform lig-
ament) which is patent at this age. In one case, gas
was actually visualised in the brain on MRI. It is
therefore extremely important that the falciform
ligament is not breached during the insertion of
the umbilical trocar.
Cardiac Arrhythmias
Arrhythmias including sinus bradycardia, atrio-
ventricular (AV) dissociation and nodal rhythms
have been attributed to a vagal response second-
ary to abdominal distention and peritoneal irri-
tation. When arrhythmias occur, the abdomen
should be desufflated and the patient hyperven-
tilated. Drug therapy should be administered as
indicated.
I2  Complications of Laparoscopic Surgery
Note that most high-flow insufflators have a de-
fault setting of 1 l/min. This default setting is ex-
cessive in infants. It is important that you choose
an insufflator with a low default setting of 100 ml/
min. If you are meticulous in laparoscopy and mi-
nimise gas leak from your trocars and instruments,
you should not need high-flow insufflation, that
carries the attendant risk of hypothermia due to
a high flow of cold CO2.
Reduction in Tidal Volume
Mask anaesthesia is completely inappropriate for
paediatric applications. Several deaths have been
attributed to using mask anaesthesia. Endotra-
cheal anaesthesia with paralysis and positive-pres-
sure ventilation should be used in paediatric lapa-
roscopy. For short procedures, the laryngeal mask
can be used.
Avoid nitrous oxide anaesthesia in infants, as
this leads to gaseous distention of the bowel and
can compromise an already small abdominal cav-
ity, making laparoscopy impossible. Advise your
anaesthetist to avoid prolonged bagging, as this
will very quickly lead to gaseous distention of the
bowel and may compromise your internal work-
ing space. It is advisable to insert an orogastric
tube and leave the drainage open at induction to
avoid gaseous distention.
Increasing intra-abdominal pressure beyond 10
mm in an infant will increase splinting of the di-
aphragm and restrict ventilation. To avoid com-
plications the insufflator should be checked be-
fore each operation; the intra-abdominal pressure
should be set at 10 mmHg in an infant under 10
kg, and 12 mmHg in larger children. With the ex-
ception of patients weighing less than 1 kg, it is
not necessary to set a lower abdominal pressure
limit, as there will usually be enough resilience
in the abdominal wall to safely introduce trocars.
Anaesthetic Complications
Anaesthetic-related complications have been a
major cause of mortality in gynaecological lap-
aroscopic surgery. A study from the Centers for
Disease Control and Prevention suggests that an-
531
aesthetic complications may account for approx-
imately a third of the few deaths associated with
laparoscopic tubal ligation. It is important for the
anaesthetist to continuously monitor the patient
in order to quickly recognise and treat problems
as they arise. Careful positioning of the patient
and padding is required to avoid potential ortho-
paedic injuries or nerve palsies.
Potential anaesthetic complications reported in
laparoscopic surgery include hypothermia, hypo-
tension, oesophageal intubation, gastro-oesopha-
geal reflux, bronchospasm and narcotic overdose.
There are several significant anaesthetic con-
cerns pertaining to laparoscopy, that are discussed
further.
Hypothermia
Because of their relatively small body mass, pae-
diatric patients are particularly at risk of hypo-
thermia from high-flow CO2 insufflation. High-
flow insufflation dissipates body heat rapidly, as
the temperature of CO2 leaving the insufflator is
20°C or less. Keep gas flow rates low by minimis-
ing gas leaks from your instrument ports and port
sites. The commonest cause of excessive gas leaks
are worn washers or opened taps. Regular main-
tenance checks on all equipment, especially taps
and washers, will minimise gas leaks.
Wrap the extremities of infants with cotton
wool to minimise heat loss, use a warmer, avoid
high flow and keep the patient dry.
Positioning the Patient
The position of the patient can impair ventilation
and increase the risk of aspiration. For example,
positioning the patient in a steep Trendelenburg
position increases the risk of aspiration, and it
may be necessary to insert a naso gastric tube to
prevent this.
If you need to use image intensifier (II) intra-
operatively, check that the ‘C’ arm of your II can be
positioned under the area you wish to image, and
that the warmer does not interfere with your imag-
ing. It may be necessary to run a spot check with
the II before accepting the final patient position.
532
Veress Needle
The Veress needle is a potential cause of serious
complications in children. The water drop test used
to confirm correct Veress needle placement is not
necessarily reliable because of the laxity of the
peritoneal attachment to the overlying abdomi-
nal musculature. In the same way, pressure mon-
itoring during insufflation is not a reliable indi-
cator that you are in the abdomen, because ex-
traperitoneal insufflation will easily strip the peri-
toneum from its abdominal wall attachment in
young infants.
Open laparoscopy was introduced by Hasson
in 1971 and involves placing the primary cannula
through a ‘mini-laparotomy’ incision. A blunt-
tipped trocar and cannula is inserted under direct
vision to avoid inadvertent visceral or vascular in-
jury. This is our recommended technique for lapa-
roscopic access to the peritoneal cavity in children.
The Hasson open-laparoscopy method is not
without its complications, the most serious com-
plication being inadvertent bowel perforation
from adherent underlying bowel due to previous
surgery. While it is the usual practice to use the
umbilicus as the portal of entry, remember that
this is not the only port. The Hasson cannula can
be introduced anywhere on the anterior abdom-
inal wall, especially in a small child in whom the
abdominal wall is thin.
Surgical Emphysema
Surgical emphysema is mostly due to incorrect
(extraperitoneal) placement of cannulae into the
abdominal wall, allowing CO2 to pervade the tis-
sue layer planes. It is readily detected as crepitus
over the abdominal wall. It can be very alarming
to the staff especially when it is discovered in re-
covery. No specific intervention is required, as it
will resolve spontaneously, but may take about
48 h.
Localised emphysema is harmless. However,
it is important to recognise that extensive subcu-
taneous emphysema may lead to pneumothorax,
pneumomediastinum and hypercarbia. Exclude
pneumomediastinum as the cause if surgical em-
H. L. Tan
physema is detected in the neck following a lapa-
roscopic procedure.
Tension Pneumothorax
A tension pneumothorax may arise in a number
of ways. The parietal pleura is particularly at risk
while dissecting the hiatus during laparoscopic
fundoplication. If the parietal pleura is breached,
tension pneumothorax will rapidly ensue.
Transabdominal mediastinal surgery may
cause peribronchial tracking of CO2 and pneu-
mopericardium. It is best to reduce insufflation
pressures when dissecting the mediastinum via the
abdominal route.
Undetected small diaphragmatic defects or
weakness can lead to a tension pneumothorax.
Increased intra-abdominal pressure can also re-
sult in direct passage of gas along the great ves-
sels hiatus into the mediastinum.
Insufflator malfunction, or prolonged high in-
tra-abdominal pressure, may also lead to tension
pneumothorax. This causes decreased venous re-
turn due to caval compression and results in a fall
in cardiac output.
The procedure should be discontinued if crep-
itus is detected extending up the chest wall into
the neck. Subcutaneous emphysema of the neck,
face and chest wall, should also raise immediate
concern that there may be a pneumothorax or
pneumomediastinum, and a chest x-ray should
be obtained immediately, as it can be life threat-
ening. Similarly, if the anaesthetist expresses con-
cern about increasing difficulties with ventilation,
a pneumothorax should be suspected.
If a tension pneumothorax develops, the pro-
cedure should be stopped and the abdomen desuf-
flated. Insert a chest tube and if the patient is sta-
ble, then you can complete the procedure.
The chest tube can be removed if there has
not been any lung damage, but only after com-
plete desufflation of the abdomen, otherwise CO2
will continue to find its way through the pleural
breach.
I2  Complications of Laparoscopic Surgery
Gas Embolism
A gas embolism is an infrequent but disastrous
complication of laparoscopic surgery. Many of
the early reported fatalities occurred with air. The
ease of solubility of CO2 has made it the insuffla-
tion agent of choice today. Nevertheless, a CO2
embolism can occur. Recent reports of neoborns
collapsing on insufflation etc.
Fatal gas emboli have been confirmed by radio-
logic and pathologic examination in a number of
reports, and have been suspected as the cause of
fatality in a large number of cases. The reported
incidence in the gynaecological literature is small,
but 1.7 % of laparoscopic surgeons in a large sur-
vey have reported first-hand experience.
The most likely cause is unrecognised place-
ment of the Veress needle into a major vessel, al-
though inadvertent small perforations in veins
have also been reported as a cause of gas embo-
lism, especially when high insufflation pressures
are used.
The diagnosis of a gas embolism may be dif-
ficult, as there is often no warning prior to sud-
den cardiovascular collapse. A ‘millwheel’ mur-
mur over the pericardium has been classically de-
scribed. Deep cyanosis of the hand and neck, con-
sistent with inflow obstruction to the right heart,
supports the diagnosis of a gas embolus. Intra-op-
erative end-tidal CO2 monitoring will detect early
embolism, as an abrupt decrease in measured CO2
may be indicative of a gas embolus.
If a gas embolism is suspected, insufflation
should be discontinued and the abdomen deflated
immediately. The patient should be placed in the
left lateral decubitus position with the head down,
to allow the gas to rise to the apex of the right ven-
tricle and retard entry into the pulmonary artery.
Cardiopulmonary resuscitation should be insti-
tuted and a central venous line placed to attempt
aspiration of gas. Other successful treatments for
gas embolism include hyperbaric oxygen, direct
cardiac aspiration of the gas through a percuta-
neously inserted aspiration needle, and cardiopul-
monary bypass (ECMO).
The overall incidence of penetrating injury
(Veress needle and trocar) is reported as 2.7 per
1,000 patients, but a recent survey found that
533
nearly a quarter of gynaecologists had experi-
enced at least one case of Veress needle or trocar
injury, with half of these requiring laparotomy.
Of 104 laparoscopic-related complications re-
ported in adults in 1 year in an Australian state-
wide survey, it is noteworthy that approximately
70 % of visceral injuries were caused by blind Ver-
ess needle insertion alone. Blind Veress needle and
blind trocar insertion combined are responsible
for about 90 % of visceral trauma.
Avoiding Trocar Complications
Several steps should be taken to assure compli-
cation-free trocar insertion, the most important
of which is to always observe the trocars from the
inside whenever you have to insert a new trocar.
Even so, it is still possible to damage viscera with
the sudden loss of resistance, the ‘oops! factor’.
An added precaution to prevent this injury is to
place the index finger on the shaft of the cannula
as a guard to prevent over-penetration when the
abdominal wall suddenly gives way.
Some paediatric laparoscopists advocate even
lower insufflation pressures than our current rec-
ommendation, but this may create difficulties with
trocar insertion because of the lack of inherent
abdominal wall resistance to an advancing trocar,
leading to tenting. Sharp trocars will reduce the
force necessary to penetrate the abdominal wall
and are generally safer to use, except in neonates,
due to the proximity of viscera to the anterior ab-
dominal wall in this group.
Bleeding
Bleeding has potentially serious consequences
in paediatric laparoscopic surgery, and because of
the smaller blood volume in children, any bleeding
must be controlled quickly. Blood is also a very
effective absorber of light in the peritoneal cav-
ity. Much of the illumination in body cavities de-
pends on reflected light from the surrounding vis-
cera, and bleeding will very quickly result in loss
of illumination from absorption of reflected light.
534
Injury to the inferior epigastric vessels is the most
common injury reported with trocar punctures in
the lower abdomen. The absence of a posterior
rectus sheath in the lower abdomen does not al-
low any tamponade to occur, and bleeding will
continue unless physically controlled. The infe-
rior epigastric vessels are very easily identifiable
as they run along the peritoneum. They are best
identified just medial to the internal inguinal ring.
When introducing trocars through the iliac fos-
sae, always indent the overlying skin with a pair
of mosquito forceps before inserting a trocar, to
avoid injury to this vessel.
One should also make a habit of transillumi-
nating the abdomen before puncturing the cho-
sen site to ensure that there are no large subcuta-
neous vessels. Simple measures like this will min-
imise the risk of bleeding.
Control of Abdominal Wall Bleeding
Should abdominal wall bleeding occur, the follow
measures would control it.
Tamponade
Minor bleeding can be controlled by inserting a
larger cannula. Unless it is a major vessel bleed,
this will stop the bleeding, allowing you to con-
tinue with the operation. If this fails, insert a large
Foley catheter through the trocar site, inflate the
balloon, apply firm traction and clamp the cathe-
ter against the abdominal wall with an artery for-
ceps, that will maintain the traction and tampon-
ade the bleeding. The catheter can be left in for
several hours.
Full-Thickness Abdominal Wall Suture
Bleeding can also be controlled by passing a suture
on a long straight needle through the full thickness
of the abdominal wall to one side of the bleeding
vessel, passing it out on the other side, and ligat-
ing the vessel. You can form a figure 8 using this
technique.
If these fail, it will be necessary to perform an
‘open’ operation to control bleeding. However, if
the necessary preventative measures are taken as
H. L. Tan
suggested in this section, then the risk of bleeding
from the puncture site should be low.
Major Vessel Injury
In the unfortunate circumstance of a major pen-
etrating injury to the aorta, common iliac artery
or inferior vena cava, do not remove the trocar. Re-
moving the trocar will only result in catastrophic
bleeding due to loss of tamponade, and you will
not be able to identify the puncture site. It is best
to leave the trocar in situ and proceed to imme-
diate laparotomy. You should then be able to fol-
low the trocar to the site of injury, hopefully con-
trol the bleeding and repair the damage. Do not
forget to check the opposite side of the vessel, as it
is likely that the trocar will have gone through the
far side of the damaged vessel.
Always be suspicious of major vessel injury if
the retroperitoneum is breached and inspect the
area from time to time for evidence of an expand-
ing haematoma. Surgical exploration is manda-
tory if one identifies an expanding haematoma.
Again, it must be stressed that most major vas-
cular injuries are caused through blind Veress nee-
dle or trocar punctures, and are avoidable with the
Hasson technique and by inserting all subsequent
trocars under direct vision.
Visceral Bleeding
This can be difficult to control, and like most com-
plications of laparoscopic surgery, is avoidable.
Electrocoagulation will work with small bleeding
vessels. Alternatively, one can use an endoclip to
control active bleeding.
However, one must always be aware of the sur-
rounding anatomy. Diathermy control of bleeding
may lead to unrecognised injury to the ureter or
bowel, and the use of clips to control bleeding is
a common way for common bile duct or hepatic
artery injury to occur in cholecystectomy.
One can also place an ‘extracorporeal’ loop
around the vessel, but be careful that the vessel is
not avulsed in the process by pulling too hard on
the loop during tightening.
I2  Complications of Laparoscopic Surgery
Electrosurgical Complications
Monopolar electrocoagulation is used extensively
in modern laparoscopic surgery, even though early
laparoscopic literature does not advocate this. It is
a highly efficient tool and it will continue to have
widespread laparoscopic applications in spite of
its inherent dangers. An understanding of how
electrocoagulation works and how it can cause
unrecognised damage is important, as there are
now increasing numbers of potentially fatal com-
plications of electrocoagulation being reported in
the literature.
All modern diathermy machines have better
control of the power output and have built-in fea-
tures to avoid return electrode faults, that makes
them safer. However, it is still possible to produce
complications, sometimes through obscure mech-
anisms, and it is important to be aware of the com-
plications which can arise from its use.
Electrosurgical complications (i.e. burns) oc-
cur at three sites: the active site (the active elec-
trode), alternative sites such as electrocardiogram
(ECG) leads or stirrups or at the return plate.
Most modern electrosurgical units employing re-
turn electrode monitoring (REM) circuits have
all but eliminated the risks of accidental burns
at alternative sites with the exception of one sit-
uation, and this is if a towel clip is clipped in-
advertently through the active electrode and at-
tached to skin.
Electrosurgical complications in laparoscopic
surgery are most likely to occur with monopolar
diathermy, and burns may occur in areas outside
of the viewing field, by mechanisms not fully un-
derstood by many laparoscopists. These will be
discussed in some detail later.
Active Electrode Burns
Direct inadvertent burns can occur in one of sev-
eral ways: leaving the electrode in the body cavity
while performing other tasks, or the electrode slip-
ping during electrocoagulation and burning some
adjacent viscera while the current is still flowing.
It is therefore very important to always remove
the electrode from the body cavity immediately af-
ter use and to replace it in the insulating sheath in
535
case someone accidentally steps on the diathermy
control.
Monopolar Hook
This is a very good instrument for developing tis-
sue planes, and the typical action is to hook tis-
sue towards the surgeon while coagulating. This
allows practically bloodless division of the inter-
vening tissue. If however the hook suddenly gives
through loss of resistance (as it usually does when
it has divided the intervening tissue), it is very easy
for it to come in contact with neighbouring vis-
cera such as bladder or bowel and burn the ad-
jacent organ.
The monopolar hook should always be used
carefully and judiciously and never towards a ma-
jor vessel. Always be aware of surrounding anat-
omy, such as the vas, ureter and gonadal vessels
in the paracolic gutter. A cardinal rule is that the
diathermy tip should always be in full view when
in use, well exposed and away from any metal can-
nula.
Remember that a monopolar diathermy cur-
rent has to find a return path to the return plate.
This means that it is potentially dangerous to use
monopolar diathermy on the appendix and other
similar structures, as the return path current may
result in a burn at the base where it joins the cae-
cum. This complication has previously been re-
ported.
Vessels embedded in fatty tissue, such as mesen-
tery, will retract into the fat and be difficult to lo-
calise, if they are cut before they have been coag-
ulated. Monopolar diathermy dissection requires
one to place sufficient counter traction between
the tissues being diathermied; otherwise the ad-
jacent tissue will tend to contract towards the dia-
thermy tip. As in open surgery, counter traction is
the key to developing tissue planes.
Remote burns can also occur by less obvious
mechanisms and these can be classified into three
types: insulation failure, direct coupling and ca-
pacitive coupling.
536
Insulation Failure
The insulation may be damaged for a variety of
reasons. If the insulation defect is small, it may be
unnoticed, and even a minute defect can lead to
burns. A typical situation where burns may go un-
noticed is if the defect is within a metal cannula,
allowing current to leak from the defect to virtu-
ally any tissue, or the abdominal wall, and cause
an unrecognised burn.
Direct Coupling
Another method of producing accidental burns
is if the active electrode touches another un-insu-
lated metal instrument including the endoscope.
Burns occurring via this route will occur outside
the view of the surgeon, but if the cannula is en-
tirely made of metal, the burn will be dissipated
to the abdominal wall at the puncture site.
It is also possible for burns to occur by ‘direct
coupling’ if a metal cannula is not withdrawn suf-
ficiently to expose the tip and the insulation, as
the high-voltage current has the capacity to jump
across to the metal cannula to cause burns.
Capacitive Coupling
Any radio frequency current flowing through a
conductor will induce stray currents in nearby
conductors, and this effect is termed ‘capacitive
coupling’. A capacitor is two conductors sepa-
rated by an insulator. This is a condition which
is commonly reproduced in laparoscopic surgery
and is poorly understood by many laparoscopists.
In laparoscopic surgery, it is easy to reproduce
a capacitor. The active electrode at the monopolar
hook acts as one conductor, while its metal can-
nula or a nearby grasper acts as the second elec-
trode. If the active electrode is not touching tissue
when it is activated, an equal and opposite charge
is induced across the insulator to the second con-
ductor, which in this case would be the metal tro-
car or a nearby metal instrument. This phenom-
enon occurs frequently in electrosurgical cautery.
Under certain conditions, these stray currents can
cause serious burns, typically outside of the view-
ing area of the endoscopist.
H. L. Tan
Remember that these stray currents are maxi-
mal if the active electrode is energized on an open
circuit, i.e. when the tip is not in contact with tis-
sue. Full power may be delivered through the sec-
ond unintentional electrode even though it is not
in direct contact with the active electrode. When
the active electrode is in contact with tissue how-
ever, the induced stray current is markedly reduced
but not completely eliminated. Hence it is not safe
to activate the active electrode unless it is in direct
contact with tissue.
Bipolar Diathermy
Bipolar diathermy is safer, as there is no risk of
capacitive coupling nor are there issues with the
return path. There are now bipolar laparoscopic
scissors which are excellent for bloodless dissec-
tion, and the new vessel sealant technologies avail-
able all use the principle of bipolar electrocoag-
ulation.
Ultrasonic Shears
These are highly effective to coagulate small ves-
sels but one should be aware that the tips of the
shears can burn for up to 7 s, and one must there-
fore avoid using them to dissect tissues immedi-
ately after coagulating a vessel.
Telescope Burns
The telescope must not touch viscera, as the tip
is very hot and can produce an inadvertent burn.
Visceral Injuries
Other visceral injuries such as bowel perforation,
injury to the urinary tract or damage to the vas
have all been reported. Most of these injuries are
preventable.
Bowel Injury
Bowel injuries occur most commonly with blind
punctures, but they have also been reported from
diathermy burns and the use of laser. The risk is
I2  Complications of Laparoscopic Surgery
increased in patients with previous open surgery,
where bowel may be adherent to the under sur-
face of previous abdominal incisions. Many pae-
diatric exploratory laparotomy incisions are trans-
verse supra-umbilical incisions, so special care has
to be taken with the Hasson technique of intro-
ducing trocars.
It may sometimes be necessary to enlarge the
Hasson incision sufficiently to insert a finger and
sweep adhesions aside, or alternatively to make
a mini-incision well away from the site of previ-
ous surgery.
Diathermy burns may be more extensive than
their superficial appearances. Minor burns or lac-
erations may be managed conservatively. Small
perforations may be over-sewn, but larger ones
probably require open surgery, although with end-
ostapling techniques it is technically feasible to
resect and re-anastomose bowel entirely laparo-
scopically.
Wheeless reported on bowel injury in 33 pa-
tients. In the first 6 cases in which a burn was seen
endoscopically, a perforation was identified in
only 2 patients at open laparotomies. The next 27
were all managed completely conservatively and
none required laparotomy subsequently.
Bowel injuries are often unrecognised at the
time. The appearance of succus entericus or a fa-
eculent odour should alert one to this possibility,
if it occurs during laparoscopy.
Unrecognised bowel perforations present 3–7
days postoperatively with abdominal pain, py-
rexia and ileus. However, it can be difficult to elim-
inate the possibility of bowel injury in patients
recovering from severe appendicitis after laparo-
scopic appendicectomy, but failure to respond to
antibiotics or deterioration in clinical signs would
suggest an underlying problem.
Urinary Tract Injury
Bladder and ureteral injuries have been reported,
mostly with pelvic surgery. However, there is a
greater risk of bladder injury in children because
the bladder is an intra-abdominal organ in this
age group. Emptying the bladder before laparos-
copy will reduce this risk. Be aware that the ura-
537
chus is prominent in infants, and its extension to
the umbilical cicatrix could still be patent. Infra-
umbilical cannula placement, even with the blad-
der emptied, therefore could still lead to bladder
injury. The best way of avoiding this is to watch
the tip of the trocar during insertion into supra-
pubic sites.
Small bladder perforations from Veress needle
punctures may be managed conservatively with
urinary catheter drainage, but large injuries should
be over-sewn laparoscopically. A urinary cathe-
ter should be inserted for postoperative drainage.
Ureteral Injuries
These are often unrecognised and may present as
an acute abdomen or urinary ascites. If the injury
is identified intraoperatively, it can be repaired.
Small defects can be managed with stenting.
Unrecognised ureteral injury presenting in the
postoperative period require intravenous urogra-
phy to confirm the diagnosis. These can be man-
aged with a double-pigtail catheter, but if this is
difficult, a percutaneous nephrostomy should be
performed to allow the situation to resolve. A
nephrostogram can then be performed at a later
stage to assess the full extent of ureteral injury,
and an antegrade double-pigtail catheter can still
be inserted to stent the ureter. Often, proximal
drainage is all that is required.
Ventral Hernia
Ventral hernias have been reported, particularly
with the use of a large trocar and cannula. We ad-
vise closing the fascia on all trocar sites except for
3-mm trocars in older children.
Postoperative umbilical hernias have been re-
ported, especially in premature infants if the can-
nula is inserted through the umbilical cicatrix. It is
for this reason that we recommend that the Has-
son is inserted through the linea alba.
Other Areas of Hidden Danger
There is a considerable amount of new technol-
ogy appearing on the laparoscopic scene, and one
538
must approach the introduction of some of these
technologies with caution.
Lasers
While lasers may be useful in laparoscopic surgery,
several deaths have been reported recently from
the use of laser, and most of these have been due
to user error. It is important to realize that some
lasers require a backstop, while some require a
large volume of a cooling gas such as nitrogen,
which in itself can cause problems when insuf-
flated into a small abdominal cavity.
Argon-Beam Coagulator
The argon-beam coagulator (ABC) likewise also
suffers from the need to pump a large volume of
argon into the abdomen for it to be effective. This
can cause a marked increase in the intra-abdom-
inal pressure and is therefore largely unsuitable
for use in children.
Tips
77 Check all instrumentation, video equipment, gas
supply and diathermy before starting the oper-
ation.
77 Start with simple procedures.
77 Convert to an open procedure if unsure. It is no
shame to convert.
77 Keep the patient warm.
77 Use the Hasson technique.
77 Always watch trocars from the inside when they
are being introduced.
77 Avoid insufflators with high default settings.
Start with low flow.
77 Do not open the jaws of an instrument blindly
within any body cavity unless you can fully visu-
alize the tip.
H. L. Tan
Conclusion
It is clear that most laparoscopic complications
are preventable by a better understanding of the
capabilities and limitations of your equipment,
and of the capabilities and limitations of yourself.
Vascular and visceral injuries are largely pre-
ventable by using the Hasson technique for intro-
ducing the primary trocar and cannula, and by
directly viewing the introduction of all second-
ary trocars.
Most major complications occur during an indi-
vidual’s learning curve. Remember that most pae-
diatric open operations have such low morbidity
that it is difficult to justify the introduction of an
alternative technique which might be seen to be
unsafe, or one that causes too many complications
during its introduction. It is best to begin with sim-
ple diagnostic procedures until you are completely
familiar with the technique and equipment before
performing complex procedures.
77 Avoid monopolar diathermy unless you are well
aware of the risks of capacitive coupling and
have taken measures to avoid them. Avoid mo-
nopolar when the return path may result in
burns at the base (e.g. the appendix and ureters).
77 Only use lasers with appropriate backstops if re-
quired. Do not use lasers which utilise gas to cool
the tip. This can result in dangerously high insuf-
flation pressures.
77 Use the ABC with extreme care.
77 The tip of the ultrasonic scalpel (harmonic scal-
pel) can remain very hot for up to 8 s. This can re-
sult in contact burns.
I3  Energy Sources in Laparoscopic Surgery
I3 Energy Sources in Laparoscopic Surgery
M. McHoney
Energy Sources
Energy sources in laparoscopic surgery fall
broadly into three categories. The first and most
commonly used is electrocautery, i.e., when an al-
ternating current is passed between tissues and
the heat produced used to create the desired ef-
fect of cutting and or coagulation. The second
is ultrasonic sources; this causes the heat created
by the vibrating limbs of the instrument to pro-
duce effect. No electricity passes through the pa-
tient. The third, and least used, is laser. Laser en-
ergy sources are more commonly used in endo-
scopic (e.g. gastrointestinal [GI] endoscopy, lith-
otripsy) surgery and rarely during laparoscopic
surgery. The use of laser energy is not discussed
in detail in this chapter.
Electrocautery
Electrocautery produces its effect from the heat
created by passing an alternating current through
active electrodes. The exact effect depends on the
temperature achieved. At temperatures between
70 and 100° C coagulation occurs; above 100° C
desiccation occurs. The effect on the tissues can
be further modified by altering the waveform of
the alternating current.
For cutting effect a low-voltage current creates
faster heat generation and vaporisation. For co-
agulating, bursts of higher voltage currents are
used. The tissue does not vaporise, but cools be-
tween bursts. A ‘blend’ contains a mix of cutting
and coagulating currents.
Merrill McHoney ()
Consultant Paediatric Surgeon,
Royal Hospital for Sick Children, 9 Sciennes Road,
Edinburgh EH9 1LF, Scotland, UK
+44 131 536 0668?0769,
merrillmchoney@nhs.net
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_161, © Springer-Verlag Berlin Heidelberg 2013
539
I3
Monopolar
Monopolar diathermy encompasses an active
hand electrode, with a patient plate as the return
electrode. Monopolar diathermy is probably the
most commonly used energy source in paediatric
laparoscopy. Monopolar electrocautery is most
often delivered via a hook diathermy, but can also
be applied to a variety of instruments equipped
for electrode attachment. This includes Maryland
forceps, that can be used to grasp bleeding points
and apply diathermy for coagulation.
Bipolar
Bipolar diathermy utilises two active electrodes
within the instrument (e.g. forceps), between
which the high-frequency current flows between
their jaws. Bipolar diathermy is inherently safer
than monopolar, as the current does not flow
through the patient.
There are some bipolar diathermy instruments
available for paediatric laparoscopy; available in
both 3- and 5-mm varieties. Figure 1 shows a va-
riety of bipolar instruments available from Storz®.
Initial problems with retractability of the active
electrode during deployment has been addressed
in new instruments, but it should be taken into ac-
count when using.
Bipolar instruments are also available in grasp-
ing forceps. This allows for capture of fine bleed-
ing points and subsequent coagulation, or for the
use of fine bipolar dissection (e.g. the mesentery
of the appendix).
Gyrus Plasma Kinetic
Plasma kinetic (PK) technology encompasses bi-
polar electrocautery, with some advance features.
It delivers pulsed output, and the generator ad-
justs current delivery based on tissue resistance.
The manufacture assures minimal thermal spread,
540
Fig. 1  Bipolar instruments in 5 mm
with less charring and sticking of tissue to the in-
struments. There are several forceps available for
use, allowing for fine dissection in small spaces.
Ligasure® is a high-burst-strength, feedback-
controlled bipolar vessel sealing system. It uses a
high-current/low-voltage output which the manu-
facturer recommends can seal vessels up to 7 mm.
It encompasses a feedback-controlled response
system which adjusts the pulsed output to tissue
type and quantity. A sound/tone alerts the user
when seal is complete, and the current stops. It
can be used with a cutting device deployed be-
tween two limbs of sealed tissue. There is a the-
oretical risk of tissue sticking to the instrument,
but this risk has been reduced with newer versions.
The manufacturer suggests that there is min-
imal thermal spread (2 mm) with most versions.
Average thermal spread is less than 1 mm when
using the LigaSure Precise™ instrument, and ap-
proximately 1.5 mm when using the LigaSure™
V instrument. The user is still advised to be wary
when using close to vital structures.
Instruments are available in 5-mm versions
suitable for paediatric laparoscopy (Fig. 2).
Ultrasonic Energy
Ultrasonic energy uses the heat produce by vibra-
tions (at around 55,500 Hz) between blades of
the instrument to produce its effect. Therefore no
electricity flows to or through the patient, and is
therefore safer than electrocautery in that respect.
It produces lower temperatures and less smoke
than electrocautery. The heat denatures protein
M. McHoney
Fig. 2  PK laparoscopic forceps
to form sticky coagula. It can be used to achieve
haemostatic cutting and/or coagulation of tissue.
The systems include an ultrasonic generator,
a foot switch and a hand piece. Manufacturers
suggest its use for incising tissue when haemosta-
sis and minimal thermal injury are desired. Sys-
tems using ultrasonic energy include the Olym-
pus SonoSurg® and the Ethicon Ultracision® Har-
monic scalpel.
Although there is less risk of thermal spread
with ultrasonic scalpels, the user should remain
aware that the electrodes are hot and can cause in-
jury to adjacent structures with which they come
into contact, and is reported.
Ultrasonic dissectors are available in 5-mm ver-
sions, suitable for precise paediatric use (Fig. 3).
With these different energy sources available,
the laparoscopist has a varied choice. Safety for
the patient should be paramount; the surgeon
should be familiar with whichever source they use.
Studies show that Ligasure® and the ultrasonic
scalpel are both useful instruments for laparo-
scopic colorectal surgery, with no significant dif-
ference in terms of intraoperative/postoperative
morbidity and operative time. Choice of which
energy source and instrument to use should be
based on the type of surgery and the surgeon’s
preference, experience and familiarity. The user
should be aware of the possible complications
and steps to reduce the chances of causing ad-
verse results.
I3  Energy Sources in Laparoscopic Surgery 541

Fig. 3  LigasureTM 5-mm instrument

Electrocautery Complications

The complications of electrocautery in laparos-

copy are discussed in detail in another chapter
(see Chap. I2). It is important just to highlight a
few points in this chapter.
Complications are most likely to occur with
monopolar diathermy, and burns may occur in ar-
eas outside of the viewing field. Bipolar is inher-
ently safer, although less popular in everyday use.
Capacitive coupling (see Chap. I2) can cause in-
jury at sites outside the operative field. The risks
can be reduced by only using the diathermy judi-
ciously and ensuring no hybrid ports (containing
both metallic and plastic components) are used.
Complications are less likely if electrodes are
active for as little time as possible, and should al-
ways be done with the entire active electrode in
vision.
Although thermal spread is said to be mini-
mally with ultrasonic energy (and to some extent
Ligasure®), the jaws of the instruments remain hot
and can cause collateral contact damage.
 542 F. W. Frantz and D. Nuss
I4 I4 M inimally Invasive Repair
of a Pectus Excavatum
F. W. Frantz and D. Nuss

• Minimally invasive repair of pectus excavatum
is indicated for patients with a severe pectus ex-
cavatum deformity and associated physiologic
impairment. Specific inclusion criteria include
two or more of the following:
– Computed tomography (CT) index greater
than 3.25, with associated cardiac or pulmo-
nary compression
– Pulmonary function tests (PFTs) demon-
strating restrictive and/or obstructive im-
pairment
– Cardiology evaluation demonstrating car-
diac compression, displacement, mitral
valve prolapse, murmurs or conduction ab-
normalities
– Documentation of progression of the de-
formity with advancing age, in association
with development or worsening of physi-
ologic symptoms (i.e. shortness of breath,
lack of endurance, exercise intolerance, pal-
pitations or chest pain)
Pre-operative
• All patients who present with clinical evidence
of a severe pectus excavatum deformity should
undergo workup with a noncontrast chest CT
scan, pulmonary function testing (PFTs) and
cardiac evaluation to allow assessment based
on these criteria.
Patient Positioning
• The patient is placed supine with the arms ab-
ducted to expose the lateral chest walls.
Operative Technique
• Landmarks identified on the anterior chest wall
include the deepest point of sternal depression
and the lateral ridges of the pectus deformity
on each side. The goal is to place the pectus bar
in a horizontal plane encompassing these land-
marks.
• Using low-pressure CO2 insufflation, a 30° tho-
racoscope is inserted to confirm the internal
anatomy in preparation for substernal dissec-
tion (Fig. 1). Bilateral transverse thoracic in-
cisions from mid- to anterior axillary lines are
made in the plane of anticipated bar place-
ment. Dissection is advanced medially to the

Frazier W. Frantz ()

Assistant Professor, Departments of Surgery and Pediatrics
Children’s Hospital of The King’s Daughters, 601 Children’s
Lane, Norfolk VA 23507, USA
Frazier.Frantz@chkd.org

Donald Nuss
Professor of Surgery and Pediatrics, Emeritus.
1429 W. Princess Anne Road, Norfolk,Virginia 23507,USA.
Donald.Nuss@chkd.org Fig. 1

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_162, © Springer-Verlag Berlin Heidelberg 2013
I4  Minimally Invasive Repair of a Pectus Excavatum
pectus ridge on each side in a subcutaneous
or submuscular plane, depending on the pres-
ence of pectoralis muscle at the level of dissec-
tion. Under thoracoscopic visualization, a ton-
Fig. 2
sil clamp is inserted into the right pleural space
to create a soft tissue defect in the intercostal
muscles (thoracostomy), just medial to the pec-
tus ridge.
• The pectus introducer is inserted into the sub-
cutaneous/submuscular tunnel and through
the intercostal muscle defect under direct vi-
sualization (Fig. 2).
• Upward pressure is applied by the introducer
to elevate the sternum, and the blunt tip facili-
tates dissection of the pericardium and pleura
off the sternum to create a substernal tunnel
(Fig. 3). The tip of the introducer should be
Fig. 3
543
kept in view during the entire substernal dis-
section to avoid injury to the heart. Attention
is focused on the electrocardiogram (ECG)
monitor during this process to detect evidence
of arrhythmia or injury pattern. If adequate
visualization of the introducer tip cannot be
achieved due to the severity of the pectus de-
formity, additional measures to optimize visu-
alization may be necessary, as explained in the
‘Tips’ section below.
• To complete the transthoracic tunnel, the intro-
ducer is advanced through the intercostal mus-
cles of the left chest medial to the pectus ridge
and into the subcutaneous/submuscular tunnel
on that side (Fig. 4). Upward traction applied
to the ends of the introducer facilitates flatten-
ing of the sternum and stretching of the inter-
costal muscles. Complete correction of the pec-
tus deformity should be demonstrated at this
time.
• A pectus bar of appropriate length is bent to
match the patient’s desired chest wall contour.
This length is typically determined by measur-
ing the anterior chest wall circumference from
the thoracic incisions and subtracting 1–1.5 in
(2.5–3.8 cm).
• Umbilical tape is secured through the eyelet
at the tip of the introducer and deposited in
the transthoracic tunnel by withdrawing the
introducer under thoracoscopic visualization
(Fig. 5).
544 F. W. Frantz and D. Nuss

Fig. 4

Fig. 5

Fig. 6 Fig. 7
I4  Minimally Invasive Repair of a Pectus Excavatum 545

Fig. 8

• The umbilical tape is secured to the pectus bar. • Insufflated CO2 is evacuated from the right
The bar is pulled into the right pleural space pleural space by cutting the insufflation tub-
and through the tunnel in a posterior convex ing and placing the end of the tube under a wa-
orientation via gentle traction applied to the ter seal. This evacuation is facilitated by placing
umbilical tape (Fig. 6). the patient in the Trendelenburg position, with
• The umbilical tape is removed, and the bar is the right side elevated and the administration
rotated 180° using bar flippers applied on each of a series of large positive-pressure breaths.
end of the bar (Fig. 7). Complete correction of As the soft tissue and skin incisions are closed
the pectus deformity should be noted at this in layers with absorbable sutures, progressive
point. After placement, the sides of the pectus decrease and eventual cessation of bubbling
bar should rest comfortably against the lateral through the tubing should be observed. A chest
ribs and chest wall musculature. x-ray is obtained to exclude a residual pneumo-
• Pectus bar stabilization and fixation is neces- thorax. If bubbling persists, a chest tube should
sary to minimize the risk of bar displacement be inserted and secured in place.
(Fig. 8). Stabilization entails attaching a steel
rectangular stabilizer to the bar, usually on the
left side. Three-point fixation entails both lat-
eral and medial attachment of the bar to un-
derlying chest wall tissues. Lateral fixation is
achieved by placing multiple absorbable su-
tures through the holes on the end of the bar
and stabilizer, and underlying fascia/muscle on
both sides. Medial fixation involves attachment
of the bar to underlying ribs using polydioxa-
none suture (PDS) pericostal sutures of 0 or 1,
placed with the Endo Close needle under tho-
racoscopic guidance.
546
Tips
77 The optimal age for minimally invasive repair is
between 10 and 14 years of age, while the chest
wall is still malleable.
77 Any patient with a history of eczema or atopy is
at higher risk of allergic reaction and should be
tested for a metal allergy. Those patients with
positive skin tests or history of nickel allergy
should have titanium bars used in the procedure.
77 In female patients, inframammary incisions may
be preferred over transverse thoracic incisions to
enhance cosmesis.
77 During substernal dissection, if the sternal de-
pression is too deep or the chest wall is too stiff
to allow visualization of the introducer tip, ex-
ternal elevation of the sternum can be achieved
by using the vacuum chest wall elevator or with
Common Pitfalls
77 During creation of the transthoracic tunnel,
avoid thoracic entry and exit sites that are too
lateral, as this can predispose to intercostal mus-
cle stripping and subsequent bar instability. Ap-
propriate entry and exit sites are medial to the
greatest apex of the deformity (pectus ridge) on
each side. This is especially pertinent in postpu-
bertal patients and those with stiff chest walls.
77 Ensure proper configuration of the pectus bar
after bending. The bar should have a semicir-
cular shape with a flat central apex (to support
the sternum) flanked with gentle, convex curves
on each side that matches the patient’s desired
chest wall contour. Bars bent on the ends only
with a rectangular configuration will result in un-
dercorrection. Bars that are too tight on the sides
are associated with prolonged pain due to bone
and muscle erosion.
F. W. Frantz and D. Nuss
mechanical retraction introduced via a sub-
xiphoid incision. If multiple-bar placement is
planned in this setting, the more cephalad trans-
thoracic tunnel, which is usually less depressed,
can be created first. The introducer is then left in
place at this site while dissection for the lower
tunnel is undertaken.
77 Multiple-bar placement should be considered
in older patients and those with stiff chest walls
and/or significant sternal torsion, as this config-
uration appears to provide better pressure distri-
bution and bar stability.
77 The pectus bar should remain in place for 2–4
years after repair to ensure permanent remodel-
ling of the chest wall.
77 Avoid single-bar placement inferior to the body
of the sternum. Even if this is the deepest point
of depression and results in immediate correc-
tion of the deformity after bar placement, this lo-
cation is unstable and carries a higher risk of bar
displacement. A bar placed inferior to the ster-
nal body (i.e. subxiphoid) in combination with a
second bar placed under the bony sternum is a
much more stable configuration.
77 Avoid undercorrection of the pectus deformity.
Slight overcorrection of the deformity is actually
felt to be most desirable. Adequate repair is con-
firmed by complete resolution of the preopera-
tive excavatum deformity and complete straight-
ening of the sternum when viewed thoracoscop-
ically. If these criteria are not met, a second pec-
tus bar should be inserted.
I5  Thoracoscopic Lung Biopsy 547
I5 Thoracoscopic Lung Biopsy I5
S. S. Rothenberg

Lung biopsies are helpful in cases of interstitial
lung disease, infiltrates of unknown origin (espe-
cially in immunosuppressed patients), and possi-
ble metastatic disease.
Operative Technique
• The room should be set up to maximize expo-
sure and ergonomics for the surgeon. If the site
of biopsy is in the anterior portion of the lung,
then the monitor is placed across the front of
the patient, and the surgeon and assistant stand
at the patient’s back (Fig. 1). The reverse is done
if the site to be biopsied is posterior. If multi-
ple sites are to be biopsied, monitors may be
necessary on both sides to facilitate the proce-
dure.
• The patient is placed in a lateral decubitus po-
sition, with the side to be biopsied placed up.
If a specific lesion is the target the patient may
be placed in a more supine or prone position
to give greater exposure to that area.
• The patient is prepared and draped, and then a
Veress needle is inserted in the mid-axillary line
in the fifth or sixth interspace, and the pleural
cavity is insufflated with a low flow (1-2 l/min)
low pressure (4–8 mmHg) of CO2 to collapse
the lung.
• A 3- or 5-mm trocar is then inserted, and a 30°
lens is used to survey the chest.
• The second and third ports are placed to op-
timize the approach for the biopsy. If an ante-
rior site is being biopsied the larger port (5 or
12 mm) is placed more posteriorly to allow for
adequate room for the endoloops or stapler. It
is placed in the lowest interspace which gives
an acceptable approach to the biopsy site.
• The third trocar is placed more anteriorly,
closer to the biopsy site. A grasper is used
through this site to grasp the biopsy site and
facilitate a wedge resection (Fig. 2).
• In smaller patients a series of two endoloops
(0 Ethibond or a similar braided suture) are
passed around the tongue of tissue to be biop-
sied and snared at the base (Fig. 3). The spec-
imen is then resected distally to the loops. In
larger patients the endoscopic stapler is used
to cut out the wedge of tissue (Fig. 4).
• After the lung is biopsied the lung is re-in-
flated and a drain is inserted through one of
the smaller trocars sites and is placed to water
seal. Prior to extubation in the operating room
(OR), if there is no evidence of an air leak, the
chest drain is removed and an occlusive dress-
ing is applied. This can eliminate a good deal
of the postoperative pain.

Steven S. Rothenberg ()

Chief of Paediatric Surgery,
the Rocky Mountain Hospital for Children,
Denver, CO 80205, USA
Dr.rothenberg@pediatricsurgeon.com

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_163, © Springer-Verlag Berlin Heidelberg 2013
548 S. S. Rothenberg

Fig. 2.  Trocar placement for lung biopsy

Fig. 1.  Room setup for thoracoscopic lung biopsy. The

surgeon and assistant are in line with the camera, looking
at the lesion and the monitor.

Fig. 3a–c  Lung biopsy using endoloops to snare the lung in children weighing <15 kg
I5  Thoracoscopic Lung Biopsy
Fig. 4  Lung biopsy using endoscopic stapler in patient weighing >15 kg
Tips
77 In general CO2 insufflation is adequate to get
enough lung collapse for biopsy; however if
there are multiple sites, single–lung ventilation
may be helpful.
77 If lesions are not on the pleural surface or are
smaller then 0.5 mm, it may be helpful to do pre-
operative computer tomography (CT) localiza-
tion either by marking the pleura with a blood
patch or by placing a localizing wire.
Common Pitfalls
77 Inability to locate the lesion: As recommended
above, use preoperative CT localization to avoid
this issue. In addition discuss a plan with the pa-
tient and family as to whether you will convert
to an open thoracotomy if the lesion cannot be
found.
549
77 Small lesions can often be ‘cherry picked’ (enucle-
ated) using cautery or an energy-sealing device,
but in this case it is important to leave a chest
drain in, as the risk of postoperatively air leak is
much higher.
77 The lesion is not located near the edge of the
lung, making wedge resection difficult. Do not
force the stapler to take a biopsy in an area were
you can adequately get across the tissue. If nec-
essary, ‘core out’ the lesion and over-sew or tissue
seal the biopsy site.
77 There is no room to open the stapler: In general
endoloops rather than a staple should be used
in patients lighter than 10 kg because of the lim-
ited space.
 550
I6 I 6Thoracoscopic Lobectomy
S. S. Rothenberg
Lobectomy is indicated in cases of congenital lung
malformations such as congenital cystic adeno-
matoid malformations (CPAM) intralobar se-
questrations and congenital lobar emphysema.
Lobectomy in children is also necessary in some
cases of severe chronic or recurring infections re-
sulting in bronchiectasis, or in acute cases of se-
vere necrotizing pneumonia.
Operative Technique
Lower Lobectomy
A lower lobectomy procedure is performed with
the patient in a lateral decubitus position. In all
cases single-lung ventilation is desirable if at all
possible, but a successful lobectomy can be per-
formed using just CO2 insufflation to collapse the
lung.
The room setup is shown in Fig. 1. The sur-
geon and assistant are at the patient’s front, with
the monitor at the patients back. The chest is ini-
tially insufflated through Veress needle placed be-
tween the anterior and the mid-axillary line at the
fifth or sixth interspace. This is the scope port, and
it should focused over the major fissure.
The working ports (3 or 5 mm) are then placed
in the anterior axillary line between the fifth and
eighth or ninth interspace. If a staple is used a 12-
mm port is placed in the lower innerspace (Fig. 2).
The first step is mobilization of the inferior pul-
monary ligament. During this manoeuvre care is
taken to look for the systemic vessel branching
from the aorta in cases of sequestration. If one
Steven S. Rothenberg ()
Chief of Paediatric Surgery,
the Rocky Mountain Hospital for Children,
Denver, CO 80205, USA
Dr.rothenberg@pediatricsurgeon.com
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_164, © Springer-Verlag Berlin Heidelberg 2013
S. S. Rothenberg
is found the vessel is mobilized and ligated using
clips, sutures or a vessel sealing devise (Fig. 3).
Dissection is continued until the inferior pul-
monary vein is visualized.
The fissure is then approached anteriorly to
posteriorly, exposing the pulmonary vein as it
passes through the fissure. Gradually the pulmo-
nary artery to the lower lobe is isolated. Often
it is necessary to dissect into the parenchyma of
the lower lobe to gain extra exposure and length
(Fig. 4). The vessel is then ligated and divided. In
smaller vessels a vessel sealer can be used. In larger
patients an endoscopic stapler may be employed.
This exposes the bronchus to the lower lobe,
that lies directly behind the artery, and it can of-
ten be palpated before it is seen.
The pulmonary vein is then dissected while re-
tracting the lung up and back. It is ligated in a
fashion similar to the that for the artery (Fig. 5).
The bronchus is divided with the EndoGIA in
larger children or cut sharply and closed with 3-0
polydioxanone sutures (PDS) in smaller patients
(Fig. 6). In infants and children weighing less than
5 kg, it is possible to seal the bronchus with en-
doclips (Fig. 7).
Middle Lobectomy
The initial approach for a middle lobectomy is
the same as for the lower lobe; however the work-
ing ports are shifted slightly cranially to allow for
good access to the minor fissure. The middle lobe
arteries are encountered near the confluence of the
minor and major fissure, and should be isolated
and ligated here. The lobe is the retracted poste-
riorly to expose the middle pulmonary vein, that
comes off the superior pulmonary vein. Once the
artery and vein are divided, the bronchus to the
middle lobe is easily identified and enters the lobe
near its apex, and can safely be divided here.
I6  Thoracoscopic Lobectomy 551

Fig. 1  Room setup for a thoracoscopic lobectomy

Fig. 2  Trocar placement. The camera port is placed to look down on the major fissure, where most of the difficult dis-
section is performed
552 S. S. Rothenberg

Fig. 3  Identification and ligation of the systemic vessel in an intralobar sequestration

Fig. 4  Completing the major fissure to expose the pulmonary artery for ligation
I6  Thoracoscopic Lobectomy 553

Fig. 5  Dissecting out inferior pulmonary vein for ligation

Fig. 6  Division of the bronchus to the lower lobe bronchus

554 S. S. Rothenberg

Fig. 7  Using a endoscopic clip to seal the bronchus in an infant

Fig. 8  Exposing the superior pulmonary artery by retracting the lung posteriorly and inferiorly
I6  Thoracoscopic Lobectomy
Upper Lobectomy
The upper lobe is technically the most demanding
to resect, because it is necessary to ‘peel’ the lobe
from the main pulmonary artery. The port place-
ment varies slightly, in that the ports are moved
one or two interspaces superiorly, and are placed
more anteriorly. The lung is retracted back and
down to expose the main pulmonary artery trunk
to the upper segments, and they are dissected and
ligated (Fig. 8).
Tips
77 Understanding the spatial relationships in the
chest is key to successful lung resection. It is best
to work anteriorly to posteriorly in most cases,
rather then flipping from one side to another.
This only results in added time, repeated loss of
exposure and unnecessary manipulation of what
may be inflamed and friable tissue.
77 Allow gravity to do the majority of the retracting.
Rotate the bed aggressively to improve expo-
sure. This will save the need for adding another
port site for an additional instrument. However if
adequate exposure cannot be obtained, do not
hesitate to add more ports.
Common Pitfalls
77 Failure to identify all segmental vessels. This can
result in an avulsion with uncontrolled bleeding,
requiring conversion to an open thoracotomy.
The most likely suspects are the apical branch to
the lower lobes and the lingular branch to the
left upper lobe.
555
The lung is then retracted posteriorly to expose
the superior pulmonary vein. Once the vein is li-
gated the major fissure is completed.
The lingular artery lies in the anterior portion
of the major fissure, and it should be divided here.
The last manoeuvre is to take the bronchus to
the upper lobe, that lies behind the lingular seg-
mental artery.
Once the lobe is free it is brought out piecemeal
through the lower trocar site, that is slightly en-
larged to facilitate removal.
A chest drain is left in for all cases of lobectomy.
77 Maintain as dry a field as possible; even a small
amount of blood/fluid can greatly obscure the
field.
77 Whenever possible divide the arterial branches
first. This will decrease shunting within the lung,
aiding the anaesthetist, and will diminish con-
gestion within the lobe, that can make it more
difficult to manipulate.
77 Mass ligations/divisions. Avoid the temptation
to place a stapler across the major fissure with-
out fully identifying all structures. You might get
lucky, but you are just as likely compromise ar-
terial branches or bronchi to lung tissue you are
not resecting.
77 Over-manipulation of the lung tissue will result
in slow bleeding, obscuring the visual field. Use
an atraumatic clamp on the lung and try to avoid
repeated grabs and excessive tension.
 556 F. Becmeur, C. G. Ferreira

I7 I 7Thoracoscopic Decortication
for Empyema
F. Becmeur, C. G. Ferreira

The indication for a video-assisted thoracoscopic

debridement is discussed with clinical and ultra-
sonographic data. A persistent fever despite an-
tibiotic treatment is a sign of a probable septated
effusion. Respiratory distresses with a need for
oxygenotherapy and/or a mediastinal shift are
signs of an important empyema. Primary thora-
coscopic surgery may be discussed as soon as a
chest tube placement is required and/or fibrinoly-
sis. A thick pleura with a septated parapneumonic
effusion, as well as multiple collections or evidence
for broncho pleural fistula are good indications.

Equipment

• One 5 mm trocar (transparent if possible)

• 5 mm 0° degrees telescope
• Suction and Irrigation
• Paenut gauze
• Atraumatic forceps (can be introduced percu-
taneously and not through a port, as pleural
peel are often very large and fragile)
Fig. 1

Patient Positioning sary to move during the thoracoscopic approach.

Patient is lying in a lateral decubitus position
(Fig. 1). Commonly, collections are on the back of
the pleural cavity; thus the surgeon is positioned in
front of child and the monitor on the back. As the
collections mostly are scattered, it may be neces-
It should be possible to change the position of the
monitor, either at the level of the patient shoul-
der or at the base of the thorax. A second moni-
tor may be useful to complete the debridement on
the anterior part of the pleural cavity.

Ports Position and Placement

Francois Becmeur ()
Professor of Paediatric Surgery,
University of Strasbourg, Strasbourg Cedex 67098, France
Francios.Becmeur@chru-strasbourg.fr
C. Gomes Ferreira
Paediatric Surgery,
University of Strasbourg, Strasbourg Cedex 67098, France
The introduction of the optical device is per-
formed through a 5 mm incision between two ribs,
the muscle are divided with scissors. Guided by
ultrasonography or CT scan, the telescope may
go directly into the collection (large) ore outside
and anteriorly (small). In any case, the aim is to

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_165, © Springer-Verlag Berlin Heidelberg 2013
I7  Thoracoscopic Decortication for Empyema 557

avoid any injury of the lung. The optical trocar is

placed on the tip of the scapula or anterior to it
and should never cross the anterior axillary line.

Operative Technique

With a gentle mobilization of the tip of the tele-

scope inside the chest, the lung is progressively de-
tached from the parietal wall and a working space
is created. The working space is maintained with
insufflation of CO2 at low pressure (4mmHg) and
a low flow (1.5L/min).
At this point the anatomy should be clearer
and a second port should be placed under direct
vision between the anterior and posterior axillary
line, lower than the optical port.
Alternatively, pleural peels are scrubbed with
low flow irrigation and then removed. The pur-
pose is to collapse the collections and to free the
entire pleural cavity.
In case of bubbling after irrigation, a suture
should be placed at the broncho-pleural fistula
with intracorporeal knots.
In rare circumstancees necrotectomy may be
necessary and padding of the normal remaining
parenchyma is indicated for significant air leakage.
At the end of the procedure, when the lung and
its pleura are freed, a double drainage is placed un-
der videoscopic control.

Tips

77 The optical port and the instrument may be in- this approach, two ports are enough for a good
terchangeable: it offers a good overview of the and efficient debridement of the pleural cavity.
pleural cavity and new possibilities to remove But in some cases, a third port hole is required.
pleural peels and/or clean the pleura. Through

Common Pitfalls

77 Avoid blind introduction of any instrument, 77
which can be responsible for a severe lung injury
77 Avoid making any incision anteriorly to the ante- 77
rior axillary line. They have to be far enough from
the nipple, especially in girls, to avoid damage to
the developing breast.
Avoid tearing the pleura which causes important
bleeding.
This surgery is a long procedure which takes
time (generally more than one hour). Don’t be in
a hurry.
 558
I8 I 8Thoracoscopic Diaphragmatic
Hernia Repair
M. McHoney
Thoracoscopic repair of congenital diaphrag-
matic hernia is possible in stable neonates and
late-presenting cases. However, surgery is usually
contemplated only in those who stabilise and im-
prove with medical management. The potential
advantages of the thoracoscopic approach are im-
proved cosmesis, less deformity and less intra-ab-
dominal adhesions. Attention to technical details
are however necessary to avoid recurrences. Ex-
perienced anaesthetic management is required to
handle the increased ventilation required for the
CO2 load, and achieve good oxygenation in the
face of the pneumothorax.
Equipment
• 5-mm Hasson trocar and accessory ports (×2)
• 4-mm 30° telescope
• 3-mm short Kelly’s dissector
• 3-mm short scissors
• 3-mm needle holder
• 3-mm Johan forceps (×2)
• Non-absorbable suture on a small curved nee-
dle
• Patch of surgeons preference (e.g. Dacron®,
Surgisis®, Gore-Tex® or Permacol®) if needed
Patient Positioning
Small infants can be placed across the end of the
table in the lateral position with the affected side
up. Larger infants can be placed along the ta-
Merrill McHoney ()
Consultant Paediatric Surgeon,
Royal Hospital for Sick Children, 9 Sciennes Road,
Edinburgh EH9 1LF, Scotland, UK
+44 131 536 0668?0769,
merrillmchoney@nhs.net
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_166, © Springer-Verlag Berlin Heidelberg 2013
M. McHoney
ble again with affected side up. The monitor(s)
is placed at the foot of the patient. The surgeon
and assistant should stand on the cephalic end
of the patient. During the operation, the patient
can be put into an approximately 5–15° reverse
Trendelenburg position; this allows gravity to fa-
cilitate reduction of the herniated viscera into the
abdomen.
Port Positioning and Placement
The 5-mm Hasson port is inserted by an open
technique below the tip of the scapula in the mid-
axillary line. A small incision is made and deep-
ened through the intercostal space. The last dis-
section can be done bluntly with an artery for-
ceps to avoid injury to intestine/viscera on entering
the pleural space. The port is then inserted either
without a trocar or with a blunt one if deemed
necessary.
A pneumothorax is created with 5 mmHg CO2
pressure. Two further 3- or 5-mm ports are placed
in the anterior and posterior axillary lines under
visualisation.
Operative Technique
The intestinal organs and viscera are identified in
the hemithorax (Fig. 1).
If there is an intact sac, this is visualized first
with the abdominal contents visible beneath. The
sac should not be incised and the contents are re-
duced partially under the influence of the pneu-
mothorax and partially by gentle manipulation.
Care should be taken in reducing the contents,
especially the spleen (which can be traumatised),
and is usually the last to be reduced. Even a min-
ute amount of blood resulting from this can im-
pair visualisation.
I8  Thoracoscopic Diaphragmatic Hernia Repair 559

Fig. 1

Fig. 2
560 M. McHoney

Fig. 3

Fig. 4
I8  Thoracoscopic Diaphragmatic Hernia Repair
After reducing the viscera the diaphragmatic
defect will become visible (Fig. 2). Occasionally
the lips of the diaphragmatic defect need defin-
ing by dissecting from the thoracic wall or medi-
astinum. This allows maximising the amount of
muscle available for closure to reduce tension and
the need for a patch repair.
A 6-cm length of non-absorbable suture on
half-circle needle is introduced directly into the
chest through a suitable intercostal space with a
needle holder.
The muscular defect is repaired with inter-
rupted sutures passed through the diaphragm to
close the defect (Fig. 3, in this picture an excised
hernial sac is seen in the field). Care is taken to
avoid injury to the viscera beneath the diaphragm
when passing the sutures through the diaphragm.
The posterolateral defect is often the most defi-
cient and difficult to close. To achieve closure of
a slightly tight defect, the posterolateral stitches
may be tied extracorporeally (subcutaneously) us-
ing small skin incisions, after passing the suture
around a rib if necessary. This is one of the more
Tips
77 The use of a sliding knot may be of benefit in
closing the defect if there is tension.
561
technically important steps in preventing recur-
rence.
If necessary, a patch can be used to close large
defects which would otherwise be impossible or
result in undue tension. A suitable patch of the
surgeon’s choice should be trimmed to size ex-
tracorporeally, and inserted through a small stab
incision in the chest wall or one of the port site
wounds. The size of the patch can be refined if
necessary. It is then sutured to the edge of the de-
fect with interrupted sutures (Fig. 4).
The lung is re-expanded under visualisation,
displacing the CO2 in the chest. The wounds are
closed with absorbable suture to muscle and sub-
cuticular stitch or glue to skin. The use of a chest
tube postoperatively is not mandatory, but it
should be used if air leakage is suspected on re-
expanding the lung.
 562 H. L. Tan
I9 I 9Laparoscopic Cardiomyotomy
H. L. Tan

Achalasia is uncommon in child and the diagno-

sis is often delayed, with the child being treated
for gastro-esophageal reflux. The diagnosis is es-
tablished by the classical apperance of a “rat’s
tail” on contrast study, and failure of relaxation
of the lower esophageal sphincter on esopha-
geal manometry, disordered peristalsis, and high
lower esphageal sphincter pressure. The princi-
ple is to perform a myotomy (5 cm) at the lower
end of the oesophagus, preserving the integrity of
the mucosa. The Heller cardiomyotomy may be
performed via either a thoracoscopic or a lapar- Fig. 1
ascopic approach. The transabdominal laparo-
scopic approach is now widely accepted as the Patient positioning
method of choise. and Ports Positioning and Placement

The patient is positioned as for Laparoscopic Fun-

Equipment doplication and the port positions are identical
(Chapter I10 Laparoscopic Fundoplication)
• 5 mm 30 degree telescope
• 7 mm Hasson Trocar
• 3 mm Koh needle holder Operative Technique
• 2 pairs of 3 mm Kellys forceps
• Two pairs of 3 mm “Reddick Olsen” forceps Liver Retraction
• Nathanson retractor or 3 mm Manhes toothed
grasper on ratched handle The left lobe of the liver can be easily retracted
• 5 mm Tan Bipolar forceps. with a single-toothed ratcheted grasper. The instru-
ment is curled around the falciform ligament just
at the point where it attaches to the anterior edge
Pre-operative of the liver. This manoeuvre will lift the falciform
ligament and the liver off the underlying viscera.
A 10 Fr nasogastric tube is inserted to ensure that The grasper is fixed to the muscular diaphragm
the stomach is empty for the duration of the op- by grasping it just above the hiatus. It can then be
ertion. left in situ, without any further attention paid to
it during the duration of the operation (Fig. 1).

Hock Lim Tan () Exposure of the Intra-abdominal

Visiting Pediatric Surgeon,
Oesophagus
Prince Court Medical Center, 56000 Kuala Lumpur,
Malaysia & Adjunct Professor Faculty of Medicine,
Universitas Indonesia, Jakarta, Indonesia The phreno-oesophageal membrane should be left
Email: hockltan@yahoo.com undisturbed and intact. The parietal peritoneum

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_167, © Springer-Verlag Berlin Heidelberg 2013
I9  Laparoscopic Cardiomyotomy
Fig. 2
Fig. 4
overlying the ‘white line’ should be incised from the
10 to the 2 o’clock position to expose the underly-
ing oesophagus (Fig. 2). The anterior wall of the
esophagus should be exposed from the diaphrag-
matic crura down to the esophagogastric junction.
The myotomy is performed in situ without mo-
bilising the abdominal oesophagus.
The crura are lifted away from the oesopha-
gus to gain entry into the mediastinal oesopha-
gus. An easy plane can be developed between the
overarching crus and the oesophagus, allowing the
oesophagus to be exposed in the mediastinum for
about 5 cm (Fig. 3).
Lifting the crura off the oesophagus will usu-
ally provide sufficient exposure.
Oesophageal Myotomy
An oesophageal myotomy is best started on the
anterior wall of the oesophagus, with needle-point
563
Fig. 3
Fig. 5
bipolar forceps about 1 cm proximal to the esoph-
agogastric junction (Fig. 4).
The myotomy can be extended with either bi-
polar scissors or the needlepoint bipolar forceps.
The myotomy can be extended proximally by
grasping the edges and gently tearing the muscle
apart. The mucosa should be easily seen to bulge
through the muscle defect (Fig. 5).
The muscle should be spread further apart us-
ing blunt laparoscopic spreaders to allow the un-
derlying mucosa to pout out as much as possible.
The myotomy is extended only to the gastric junc-
tion, which can be identified when one seas the
edge of circular gastric muscle fibres.
Any mucosal leak can be repaired with a mu-
cosal suture.
The patient can commence fluids immediately
and should experience an immediate relief of
symptoms. in the event of an inadvertent perfo-
564
ration requiring a simple mucosal repair, the pa-
tient should be fasted for 48 hours.
In our experience, it has not been necessary to per-
form an anterior fundoplication, if the cardiomy-
otomy is performed in situ as the attachments of
the esophagus is left largely intact.
Common Pitfalls
77 Breaching the left pleural cavity during dis-
section of the anterior wall of the mediastinal
H. L. Tan
We do not extend the myotomy onto the fundus
of the stomach but identify the precise anatomi-
cal margin of the fundus, by the circular muscu-
lar fibres as opposed to the longitudinal fibres of
the distal esophagus.
esophagus, and a tension pheumothorax may
ensue.
I10  Laparoscopic Fundoplication
I 10Laparoscopic Fundoplication
H. L. Tan and S. Cascio
Laparoscopic fundoplication is one of the most
common elective laparoscopic procedures in
childhood. The indications for laparoscopic fun-
doplication are similar to those for the openproce-
dure and include failure of medical therapy in
children with symptomatic gastroesophageal re-
flux disease (GERD). Childrens with GERD can
present with digestive (recurrent vomiting, fail-
ure to thrive, oesophagitis, peptic stricture) or re-
spiratory symptoms (apnea, aspiration pneumo-
nia, apparent life threatening events – ALTE). In
addition GERD often required surgical correc-
tion in neurologically impaired children or in chil-
dren previously operated for oesophageal atre-
sia, congenital diaphragmatic hernia or abdom-
inal wall defects.
Equipment
• 5-mm 30° telescope
• 7-mm Hasson Trocar
• 3-mm KOH needle holder
• Two pairs of 3-mm Kelly forceps
• Two pairs of 3-mm Reddick–Olsen forceps
• Nathanson retractor or 3-mm Manhes toothed
grasper on ratcheted handle
• 5-mm bipolar scissors or other energy sources,
such as an Harmonic scalpel., etc.
Hock Lim Tan ()
Visiting Pediatric Surgeon,
Prince Court Medical Center, 56000 Kuala Lumpur,
Malaysia & Adjunct Professor Faculty of Medicine,
Universitas Indonesia, Jakarta, Indonesia
Email: hockltan@yahoo.com
Salvatore Cascio
Consultant Paediatric Surgeon and Urologist
The Royal Hospital for Sick Children, Dalnair Street,
Yorkhill, Glasgow G3 8SJ, Scotland, UK
Email: salvatore.cascio@ggc.scot.nhs.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_168, © Springer-Verlag Berlin Heidelberg 2013
565
I10
Pre-operative
A large nasogastric tube (10-12 Fr) must be in-
serted preoperatively. In neurologically impaired
children it is important to ensure that they are not
constipated, because a large distended transverse
colon will make the operation considerably more
challenging. It may be necessary to administer a
bowl wash out in these patients preoperatively.
Patient Positioning
The patient is positioned at the foot of the oper-
ating table, with the surgeon at the end of the ta-
ble and the assistant surgeon on the right of the
surgeon.
In older children the patients, legs should
parted as per French position, supine with legs
apart, (Fig. 1) for laparoscopic fundoplication.
If the video monitor is pendant mounted, it
should be placed directly in front of the patient
for the best hand-to-eye coordination; otherwise it
is better on the patient’s right. The patient should
be tilted 30°, head up, which allows the transverse
colon to fall away from the stomach.
Ports Position and Placement
• The Hasson cannula should be inserted in the
umbilicus using the open laparoscopy method
previously described.
• An additional three instrument ports are re-
quired, one for liver retraction, and one each
from each hand instrument. In older children
hand instruments can be sited higher in the up-
per quadrant, about 10 cm to each side of the
midline. If the patient requires a gastrostomy,
then site the left upper quadrant (LUQ) port at
566 H. L. Tan and S. Cascio

the position which suits the gastrostomy place- Operative Technique

ment best (Fig. 2).
Liver Retraction

It is necessary to retract the left lobe of the liver

off the hiatus to gain exposure to the hiatus, and
this can be done either by attaching a toothed
grasping forceps on the muscular diaphragm

Fig. 1 

Fig. 2
I10  Laparoscopic Fundoplication
1–2 cm above the hiatus or by inserting a Na-
thanson retractor.
Hiatal Exposure
The hiatus is easily identified but the right crus
will not be easily seen, as it will be deep to the
phreno-oesophageal membrane covering the cau-
date lobe and the crus. This membrane has to be
divided (Fig. 3).
The right crus can then be identified sitting
snugly on the oesophagus, and can be separated
from the loose adventitial attachments with ease.
The peritoneum over the “white line” should be
completely divided to expose the underlying oe-
sophagus, this incision is followed over the crus
(Fig. 4), the left crus is seperated from the oeso­
phagus by incising the overlying peritoneum un-
til it meets the R crus as a V.
Fig. 3  Fig. 4
Fig. 5  Fig. 6
567
At this point you will be able to see the gastro-
phrenic ligament which attaches the fundus of the
stomach (between the spleen and left crus); that
must be divided (Fig. 5). These ligaments will pre-
vent the fundus from being pulled through the
posterior oesophageal window. Completely free-
ing this ligament will allow the fundus to be pulled
without tension.
Once the gastrophrenic ligament is mobilised,
a small posterior window is created behind the oe-
sophagus in the peritoneum between the oesoph-
agus, left gastric artery and the posterior vagus
nerve, that should be easily identifiable (Fig. 6).
The posterior wall of the fundus should then be
visible and can be pulled through this hiatus af-
ter enlarging the window with blunt instruments.
You should now see if the stomach is easily pulled
through this window.
 
 
568 H. L. Tan and S. Cascio

Fig. 7 
Fig. 8 

Fig. 9 

The next step is to repair the crus to prevent

the wrap from migrating into the chest; a single
suture to approximate the crus is all that is usu-
ally required (Fig. 7).
The fundus is then pulled through again, and a
loose, floppy wrap performed with a non-absorb-
able suture which should not be anchored to the
underlying oesophagus (Fig. 8). This allows you
to manoeuvre the wrap along the oesophagus to
determine the optimum site for the second and
third suture which are transfixed to the anterior
oesophagus (Fig. 9).
The liver retractor can then be removed, the
fascia of the instrument ports sites is closed with
a single absorbable suture and topical skin adhe-
sive for skin (2 Octyl-Cyanoacrylate). The naso-
gastric tube is left on free drainage, removed the
next day and feeding commenced.
I11  Laparoscopic pyloromyotomy
I 1Laparoscopic pyloromyotomy
S. Cascio and H. L. Tan
Laparoscopic pyloromyotomy is an uncompli-
cated operation but it requires meticulous atten-
tion to detail. Only 3 hand instruments are re-
quired for this operation.
Equipment
• 4 mm short 0 degree telescope
• 4.5 mm Hasson trocar
• 3 mm short atraumatic bowel holding forceps
• Tan endotome
• Tan pyloric spreader
Pre-operative
The stomach must be emptied with an oro-gas-
tric tube.
Patient positioning
The patient is positioned at the foot of the oper-
ating table, with the surgeon standing at the end
of the table and the assistant surgeon to the right
of the surgeon. If the video monitor is pendant
mounted, it should be placed directly in front of
the patient for the best hand-eye co-ordination,
Salvatore Cascio ()
Consultant Paediatric Suregeon and Urologist
The Royal Hospital for Sick Children, Dalnair Street,
Yorkhill, Glasgow G3 8SJ, Scotland, UK
Email: salvatore.cascio@ggc.scot.nhs.uk
Hock Lim Tan
Visiting Paediatric Surgeon
Prince Court Medical Centre, Kuala Lumpur Malaysia &
Adjunct Professor Faculty of Medicine,
Universitas Indonesia, Jakarta, Indonesia
Email: hockltan@yahoo.com
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_169, © Springer-Verlag Berlin Heidelberg 2013
569
I11
otherwise it is better on the patient’s right. The
patient should be tilted 15 degrees head up to al-
low the transverse colon to fall away from the py-
lorus under gravity (Figure 1).
Ports position and placement
A 2mm stab incision is made in the supra-um-
bilical skin fold with an 11 blade knife. The in-
cision is spread along Langer’s lines using sharp
pointed scissors. The linea alba is identified about
1cm above the umbilical cicatrix, grasped with
two pairs of mosquito forceps and lifted into
the wound by everting the haemostats. A trans-
verse incision is made in the linea alba between
the two mosquito forceps. The underlying trans-
lucent parietal peritoneum is grasped with mos-
quito haemostats and opened adjacent to the um-
bilical vein.
A purse string is placed in the linea alba be-
fore inserting the 4 mm Hasson trocar. This purse
string is tightened around the trocar with a single
throw to stabilize the trocar and prevent air leak-
age. The same suture is used at the end of the pro-
cedure to close the defect by tightening the purse
string.
A 4 mm Telescope is inserted through the su-
pra-umbilical 4.5 mm Hasson cannula.
There is no need to insert ports. Instead, full
thickness stab incisions are made with an 11 blade,
in the nipple line one finger’s breath below the cos-
tal margin. The incision is dilated with a straight
mosquito haemostat just wide enough to accom-
modate the 3mm hand instruments (Figure 2).
Operative Technique
The hand instruments are introduced directly into
the abdominal cavity under direct visual guidance.
570 S. Cascio and H. L. Tan

Fig. 1 

Fig. 3 

Note that the duodenal grasper is inserted below

the sub-costal margin above the liver. This is coun-
ter intuitive as one would think that the liver will
obstruct the duodenum, but this instrument is
then used to retract the liver at the same time as
grasping the duodenum (Figure 3).
The endotome is inserted in the same position
Fig. 2  in the left upper quadrant. The endotome is then
used to lift the falciform ligament to expose the
underlying duodenum (Figures 4 and 5).
The duodenum is gently grasped just distal to
the vein of Mayo and retracted inferiorly down-
wards and towards the right hip (laterally) while
I11  Laparoscopic pyloromyotomy 571

maintaining the falciform lift with the endotome.

Do not lift the duodenum upwards. Instead, in-
fero-lateral traction on the 1st part of the duode-
num will stabilise the pylorus because the duode-
num is now fixed by counter-traction on the free
edge of the lesser omentum.
A deep sero-muscolar incision is made starting
at the distal third of the olive extending onto the
antrum (Fig. 6). We use the Tan endotome with
the retractable blade and if the incision is deep
enough the seromuscular incision should open up.
The endotome is exchanged for the Tan py-
loric spreader under direct visual guidance. The
Fig. 4  spreader should thrust confidently through the
middle of the olive until slight resistance is felt
(Figure 7).
The ‘tumour’ is spread widely by opening
the jaws of the pyloric spreader. The spreader is
moved distally to complete the spread, avoiding
spreading the last millimetre at the duodenal end
of the olive. This is where perforations occur. It
is important to extend the pyloromyotomy onto
the pyloric antrum, although this is the most dif-
ficult part of the operation.
The mucosa is inspected by asking the anaes-
thetist to insufflate 30-50ml of air into the stom-
ach. The mucosa will bulge excluding an inadver-
tent perforation.
The abdomen is deflated and the instruments/
Fig. 5  port removed under direct vision. The purse string
at the Hasson port is tightened and skin closed
with topical skin adhesive.

Fig. 6  Fig. 7 
 572 H. L. Tan and S. Cascio
I12 I 12Laparoscopic Appendectomy
H. L. Tan and S. Cascio

We describe the conventional laparoscopic appen- Patient Positioning

dectomy which, in our hands, has proven to be
suitable for appendicitis of all grades of severity,
regardless of whether the appendix is high retro-
caecal in position.
Equipment
• 10-mm blunt-tip Hasson trocar
• 5-mm 0° telescope
• Two 5-mm sharp trocars
• 5-mm bipolar scissors
• Two pairs of Kelly forceps
• Two endoloops
• One ratcheted grasper
Most straightforward cases of laparoscopic ap-
pendectomy will not require suction irrigation, but
it is handy to have a 5-mm suction irrigator avail-
able in the operating room in case of need. It is
also better to use normal saline in plastic bags, as
this enables to wrap a pneumatic pump around
the bag so that the irrigation fluid has a sufficient
head of pressure.
The patient is positioned supine, with the head
down and right side rolled towards the surgeon.
The surgeon, assistant and scrub nurse should be
on the patient’s left with the video monitor posi-
tioned at eye level on the patient’s right. This is the
most ergonomic position, as it allows all three to
work in first-order paradox (Fig. 1).
Ports Positioning and Placement
The port sites are as indicated (Fig. 2). A full-
thickness supraumbilical incision is made in the
skin fold down to the level of the linea alba. The
plane between the subcutaneous tissue and the
linea alba should be developed to allow two pairs
of haemostats to be placed on the linea alba. A
transverse incision is made in the linea alba be-
tween the two instruments; the translucent pa-
rietal peritoneum will drop away from the linea

Hock Lim Tan ()

Visiting Pediatric Surgeon,
Prince Court Medical Center, 56000 Kuala Lumpur,
Malaysia & Adjunct Professor Faculty of Medicine,
Universitas Indonesia, Jakarta, Indonesia
Email: hockltan@yahoo.com

Salvatore Cascio
Consultant Paediatric Surgeon and Urologist
The Royal Hospital for Sick Children, Dalnair Street,
Yorkhill, Glasgow G3 8SJ, Scotland, UK
Email: salvatore.cascio@ggc.scot.nhs.uk Fig. 1  Standard laparoscopic tray for appendectomy

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_170, © Springer-Verlag Berlin Heidelberg 2013
I12  Laparoscopic Appendectomy
alba. The peritoneum is grasped with two mos-
quito haemostats, and a small incision is made
with scissors to enter the abdominal cavity. A
purse string is placed in the linea alba before in-
serting the primary 10-mm Hasson trocar. Two
additional ports are inserted, a 5-mm port in the
left iliac fossa, avoiding the inferior epigastric ves-
sels for the left-handed instrument, and a second
5-mm port in the right paracolic gutter in the nip-
ple line for your right-handed instruments. How-
ever if a high caecum is encountered, it may be
preferable to insert this port even higher to give
you more internal space to manipulate the instru-
ments.
Operative Technique
The appendix is mobilised and the mesoappendix
at the tip of the appendix is grasped. The main ap-
pendicular artery that runs along the free edge of
the mesoappendix is then divided using bipolar
scissors (Fig. 3). This will allow to skeletonise the
appendix down to the base using bipolar scissors,
as the vessels supplying the rest of the appendix
are less than 1 mm and easily handled.
Fig. 2  Port position and placement
573
Endosurgical Loop Application
Many pretied endosurgical loops come with a
5-mm reducer which allows the loop to be intro-
duced into the abdominal cavity without disrupt-
ing the preformed loop. However the loop is usu-
ally far too big to allow for easy manipulation,
and it is necessary to reduce the diameter of the
loop before use.
This is done by breaking the end of the straw
and drawing on the suture to reduce the loop to a
suitable diameter, and withdrawing the loop into
the straw in its entirety (Fig. 4).
The base of the appendix is ligated with the
loops, and the appendix is then divided using the
bipolar scissors (Fig. 5). The loop can be manip-
ulated to its correct position using some counter
traction between the appendix and the straw of
the endo surgical loop.
The telescope is transferred to the left iliac fossa
(LIF) port, and the grasper is placed in the 10-
mm umbilical port to grasp the tip of the appen-
dix, delivered under visualisation, through the 10-
mm Hasson port.
If the appendix is gangrenous, perforated or
associated with an appendicular abscess, the peri-
toneal cavity is thoroughly irrigated with normal
saline until clear fluid is aspirated from the ab-
dominal cavity.
The abdomen is deflated, the purse string at the
Hasson port is tightened, subcutaneous approx-
imated with absorbable sutures and skin closed
with topical skin adhesive.
Fig. 3 
574 H. L. Tan and S. Cascio

Fig. 4  Fig. 5 
I13  Laparoscopic Button Placement for Antegrade Enema 575
I13 Laparoscopic Button Placement I13
for Antegrade Enema
F. Becmeur

• A colonic antegrade enema is proposed in cases
of intractable faecal incontinence or major
constipation with encopresis.
• This procedure allows for caecostomy button
placement and a sigmoidostomy.
the left lower quadrant in the case of a caecos-
tomy, and in the right lower quadrant for a sig-
moidostomy.
• Laparoscopy allows selecting the site for cae-
costomy or sigmoidostomy by looking at the

Equipment

• 5-mm 0° telescope
• Atraumatic 3- or 5-mm forceps
• Simple needle holder for open surgery

Pre-operative

• One or two enemas with serum saline are re-

quired the day before surgery.
• A single dose of intravenous metronidazole is
administered at the beginning of the procedure.
Patient Positioning
The patient is positioned in a supine decubius. For
a caecostomy, the surgeon is on the left of the pa-
tient and the monitor in front of the surgeon on
the right side of the patient. Conversely, for a sig-
moidostomy, the surgeon is on the right side and
the monitor on the left.
Fig. 1
place where the cecum or the sigmoid colon can
be hung to the anterior parietal wall. Some ad-
hesions can be removed beforehand.
• Two U stitches are used to secure the bowel
where the caeco- or sigmoidostomy will be in
relation to the anterior abdominal wall (Fig. 1).
• A tiny incision (5 mm) is made at the future
caeco- or sigmoidostomy site, on the anterior
abdominal wall.

Operative Technique

• An open laparoscopy is performed through the

umbilicus, and an operative trocar is placed in

Francois Becmeur ()

Professor of Paediatric Surgery,
University of Strasbourg, Strasbourg Cedex 67098, France
Francios.Becmeur@chru-strasbourg.fr Fig. 2

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_171, © Springer-Verlag Berlin Heidelberg 2013
576 F. Becmeur

Fig. 3 Fig. 4

• The next device will be easily introduced into

the colon, e.g. a Chait TrapDoor® button or a
gastrostomy button with a balloon. These de-
vices have their own specific material for intro-
duction. In case of the TrapDoor® button, it is
a long needle (Figs. 2 and 3). In the case of a
gastrostomy button (Fig. 4), it is a guide wire
with a needle and two or three bougies.
• The U stitches are tied on a pledget to avoid
damaging the skin. They must be removed 5–8
days later.
• The first enemas must explained to the pa-
tient and parents in the institution before be-
ing done. Enemas can be done 2–3 weeks af-
ter button placement.

Tips

77 It is essential to operate on with an empty colon. 77 The needle must slip easily in the Chait button
77 Surgery can be easier with an attendant colonos- TrapDoor®. Use oil to lubricate the lumen of the
copy, that allows checking the placement of the button.
device into the lumen of the colon. However, is
it not necessary except in case of numerous ad-
hesions.

Common Pitfalls

77 Avoid running the colon through with the nee-
dle or piercing another bowel loop. Laparoscopic
control is mandatory to avoid this accident.
77 Performing a parietal incision too narrow may
damage the button.
77 Performing antegrade enemas too early after the
button placement can lead to peritoneal leakage
and peritonitis or local abscess.
I14  Primary laparoscopic-assisted endorectal pull-through
I 14Primary laparoscopic-assisted
endorectal pull-through
T. J. Bradnock and G. M. Walker
Single stage pull-through for Hirschsprung’s Dis-
ease has gained in popularity since its introduction
in 1980 and is suitable for left-sided disease where
colonic decompression can be achieved with rec-
tal washouts. A defunctioning stoma may be re-
quired if adequate decompression is not achieved,
in cases of severe enterocolitis, perforation or
long-segment aganglionosis.
Laparoscopy offers the advantage of intra-op-
erative biopsies to determine the level of agangi-
olosis prior to any dissection, and provides excel-
lent visualisation for colonic mobilisation to en-
sure a properly rotated, tension-free pull-through.
Equipment
• Standard laparoscopic set-up.
• 3mm instruments are useful for neonates, oth-
erwise 5mm instruments are used.
• Hook electrocautery adequate for dissection in
neonate, ultrasonic scalpel may be preferable in
the older child.
Pre-operative
• Thorough rectal washout in advance of proce-
dure for bowel preparation.
• Broad spectrum antiobiotics at induction (e.g.
Cefotaxime and Metronidazole).
Tim J. Bradnock ()
Specialty Registrar in Paediatric Surgery
The Department of Paediatric Surgery, Dalnair Street,
Yorkhill Hopsital, Glasgow G3 8SJ, Scotland, UK,
Email: tjbradnock@doctors.org.uk
Gregor M. Walker
Consultant Paediatric and Neonatal Surgeon
Gregor.Walker@ggc.scot.nhs.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_172, © Springer-Verlag Berlin Heidelberg 2013
577
I14
• 1% xylocaine and 1:200,000 adrenaline for
port-sites.
• Insert the urethral catheter after draping.
Patient Positioning
• Position the patient supine and slightly head
down, across the table for neonates or in a stan-
dard position for the older child.
• Place two gauze swabs or a roll under sacrum
to elevate the perineum.
• Prepare the abdomen, perineum, buttocks and
lower limbs
• Wrap feet in crepe and then place on sterile
drape
Ports Position and Placement
• Establish a 5mm optical port by open Hasson
technique in the epigastrium or RUQ in neo-
nate or supraumbilical in older infant. Further
3 or 5mm ports in left and right flank (Fig. 1).
• CO2 pneumoperitoneum is set at 6mmHg, with
a flow of 1L/min in most cases.
Operative Technique
Laparoscopic sero-muscular colonic biopsies
• The procedure starts with confirmation of the
transition zone (TZ) by frozen-section of sero-
muscular colonic biopsies.
• ‘Walk’ the colon and attempt to visualise the
TZ from collapsed, aganglionic bowel to di-
lated, ganglionic bowel.
• Select biopsy sites. Usually commencing just
distal to the perceived TZ and with 1-2 further
proximal biopsies at 3–5 cm intervals.
578 T. J. Bradnock and G. M. Walker

• Use fine curved forceps (e.g. Maryland) to

grasp and elevate a small portion of the anti-
mesenteric bowel wall.
• Make a small incision through the seromuscu-
lar layers using the tip of laparoscopic Metzen-
baum scissors (the apex should lift away from
mucosal layer).
• Grasp the apex of the biopsy specimen and
develop the extramucosal plane by sliding one
blade of the scissors into the incision and cut-
ting along each side of biopsy.
• The mucosal layer can be gently pushed away
from the muscle layers using the closed tips of
the scissors.
• Transect the specimen and retrieve it through
the port under direct vision.
• This technique is repeated at each biopsy site.
• Mark the most proximal biopsy with a suture
(for identification at pull-through).
• The specimens should be labelled and sent im-
mediately to the pathology laboratory.
• Inadvertent full thickness biopsies should be
closed intra-corporeally using a single 5/0 vic- Fig. 1
ryl suture.

• The peritoneum over the anterior rectal wall is

Laparoscopic Colonic Mobilisation
• Commence mobilisation of the sigmoid colon
mesentery just proximal to the most proximal
normal biopsy.
• Grasp and elevate the colon with non-trau-
matic forceps, creating a mesenteric window
with hook monopolar diathermy.
• The mesentery is then divided close to the
bowel wall, taking care to preserve the supe-
rior rectal vessels.
• Progress distally, moving the non-traumatic
forceps to the most distal end of the mesen-
teric window to keep the mesentery under mild
tension.
• At the level of the proximal mesorectum, the
mesentery widens and each side can be taken
separately.
• Dissect down to the peritoneal reflection, en-
suring the ureters, vas and testicular vessels are
not in close proximity to the diathermy.
often quite adherent and complete division is
not necessary.
• Once the colon is fully mobilised, deflate the
pneumoperitoneum but leave the ports in place.
• Ensure the skin under the ports is protected
with swabs.
Endorectal dissection
See Chapter E34 Open Endorectal (Soave-Boley)
Pull Through for diagrams of endo rectal pull
through technique.
• Elevate the legs to expose the anus (see tips).
• 8 x 4/0 silk everting sutures are sited around the
anoderm and sutured to the flange of a stoma
bag, to expose the dentate line.
• Circumferentially mark the intended start
point for endorectal dissection using needle-
point monopolar diathermy (approximately
0.5cm above dentate line). (see tips)
I14  Primary laparoscopic-assisted endorectal pull-through
• Deepen the incision with needlepoint cutting
monopolar diathermy.
• Multiple 5/0 vicryl stay sutures are used to close
the mucosal tube and provide traction.
• Commence with the posterior hemicircumfer-
ence, and move anteriorly.
• Develop the submucosal plane with a combi-
nation of sharp (monopolar diathermy) and
blunt (pledget) dissection.
• Progress cranially in the sub-mucosal plane,
keeping the mucosal sleeve under moderate
tension as this helps delineate areas of resid-
ual muscle tethering.
• Once the mucosal sleeve and rectum start to
evert, divide any remaining muscular fibres and
use a pledget to push the muscle cuff away from
the mucosal sleeve.
• Once the mucosal sleeve has prolapsed, grasp
the muscle cuff and divide circumferentially
with monopolary diathermy.
• This allows the full thickness rectum to pro-
lapse out of the anus.
• Divide the muscle cuff posteriorly with mono-
polar diathermy and excise the redundant cuff.
Tips
77 Await results of frozen section analysis BEFORE
commencing colonic dissection. If the TZ is sub-
sequently found to lie proximal to mid-TC, a lev-
elling stoma may be more appropriate with de-
ferral of definitive surgery.
Common pitfalls
77 Avoid straying too deep during endorectal dis-
section by ensuring muscle fibres are perpendic-
ular to bowel wall, rather than oblique.
579
Coloanal anastomosis
• Identify the most proximal (ganglionic) biopsy.
• Some further posterior mobilisation may be re-
quired with bipolar diathermy.
• Open the pulled-through colon anteriorly,
5–10 cm above the most proximal ganglionic
biopsy.
• Secure the colon to the anorectal mucosa at the
12 o’clock position.
• Continue full thickness circumferential incision
of the pull-through, securing with dyed 4/0 vic-
ryl at the 3, 6 and 9 o’ clock positions.
• 4 more dyed 4/0 vicryl sutures are placed half
way between each quadrant suture.
• All sutures should include the full thickness of
the pull-through bowel wall and the muscularis
layer of the distal rectum to approximate the
mucosal edges.
• 3 x 5/0 vicryl sutures are placed between each
dyed vicryl suture to complete a 32-suture anas-
tomosis.
• Re-establish the pneumoperitoneum and insert
the laparoscope to ensure the pull-through co-
lon is not under tension or twisted.
• Remove the silk stay sutures from the anoderm,
allowing the anastomosis to retract cranially.
• Close the port-sites.
77 For the endorectal dissection, the feet can be
held over head by securing the crepe bandage
to a metal bar.
77 Elevate the rectal mucosa with 1:200,000 epi-
nephrine in saline before commencing the en-
dorectal dissection.
 580 D. C. Van Der Zee
I15 I15 Laparoscopic Duhamel Pull-Through
Procedure
D. C. Van Der Zee

Indication Patient positioning

All types of Hirschsprung disease can necessitate
this procedure.
Equipment
For the laparoscopic Duhamel procedure 3mm
short re-usable instruments are used in the
younger child and 3- or 5mm instruments for
older children.
For the side-to-side anastomosis a 45-mm en-
doscopic stapling devise is used.
Pre-operative Management
The day prior to surgery the children receive an
antegrade bowel washout with 50ml/kg Klean-
Prep over 4 hr through a nasogastric tube with a
rectal cannula in place.
After induction of general anesthesia on the
day of surgery, the rectum is washed out again
with physiological saline to clear all residual fae-
ces.
Perioperatively the child receives antibiotics ac-
cording to protocol for 24h. An epidural catheter
is positioned for analgesia. A urinary catheter is
introduced under sterile conditions after the pa-
tient has been draped. The legs are draped sepa-
rately to facilitate both the abdominal and peri-
neal approach.
Neonates and small children can be positioned
transversely at the lower end of the operating table
to allow easy access to the small pelvis and to fa-
cilitate the anal part of the procedure. If necessary
an armrest can be used to elongate the width of
the table in somewhat older toddlers. Older chil-
dren are placed at the lower end of the table in the
lithotomy position.
Operative Technique
• An open infra-umbilical incision is used for first
trocar.
• Under direct vision two to three additional tro-
cars are placed, one in the left and the right
lower quadrant and another in the right up-
per quadrant.
• Two to three subserosal biopsies are taken
to determine the correct level of transaction
(Fig. 1).
• The dissection of the mesocolon is carried out
close to the intestinal wall down to the pelvic
floor and up to the level of the normal biopsy
site.

David C. Van Der Zee ()

Professor of Paediatric Surgery,
Wilhelmina Children’s Hospital, P.O. Box 85090, Utrecht,
3508, The Netherlands
+31 88 7554004
d.c.vanderzee@umcutrecht.nl Fig. 1

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_173, © Springer-Verlag Berlin Heidelberg 2013
I15  Laparoscopic Duhamel Pull-Through Procedure
Fig. 2
Fig. 3
• The rectum is tied off with a vicryl 2 × 0, 2 cm
above the peritoneal reflection and it is trans-
acted distal to this ligature (Fig. 2).
Anal Part
• An incision is made on the posterior rectal wall
0.5 cms above the dentate line. This incision is
extended both to the left and the right of the
mid line.
• Two sutures are positioned outside in through
the anterior side of the incision and two
more sutures are placed at the ends of the in-
cision.
• An artery clamp is guided with the help of an
endoscopic instrument through the incision.
• Under endoscopic guidance, the transected
rectum is grasped and the dissected colon is
581
Fig. 4
Fig. 5
pulled through the anal incision under endo-
scopic control.
• This prevents twisting of the bowel until the
ganglionated biopsy site becomes visible.
• Incision in the anterior wall of the transected
colon and the proximal part of the colon is su-
tured to the anterior wall of the incision with
the two anteriorly placed sutures.
• The incision is extended sideways and two lat-
eral sutures are also placed.
• Complete resection of the pull through colon
and placement of the posterior suture against
the upper limit of the dentate line.
• Additional sutures are placed in between the
stay sutures to complete the side to side anas-
tomosis.
• Introduction of 45 mm endoscopic stapling de-
vice between the two anteriorly placed stay su-
tures, with the upper leg in the remnant rectum
582 D. C. Van Der Zee

and the lower leg in the pulled-through colon,

and closed with one “click” (Fig. 3).
• Check endoscopically that the stapling device
is in the middle of the rectal stump and pull
through colon. If necessary re-open the sta-
pling device and reposition.
• After closing, fire the stapling device and re-
move after re-opening the device. Usually two
fillings are necessary, whereby the second fill-
ing should just reach the end of the posterior
wall of the rectal stump (Fig. 4).
• The rectum stump can be closed with a run-
ning vicryl 4 × 0 suture (Fig. 5).

Tips

77 Rectal washouts prior to the procedure can pre-
vent the necessity to construct a colostomy at
the end of the procedure, and colostomies that
are in place can usually be closed in the same
procedure.
77 The patient is placed transversely at the lower
end of the table to allow a comfortable position
for the surgeon.
77 A trans-anastomotic tube is placed for the first
2–3 days postoperatively for decompression.

Pitfalls

77 Contamination in the case of mucosal perfo- poned until diagnosis of extension is ascer-
ration can be reduced by suturing the biopsy tained.
place. 77 Take care not to twist the pulled-through bowel.
77 In a case of inconclusive results from frozen sec- 77 Avoid leaving a “blind” rectal stump.
tion biopsies, the procedure should be post-
I16  Laparoscopic Splenectomy
I 16Laparoscopic Splenectomy
A. J. Sabharwal
The principle indications for laparoscopic sple-
nectomy in childhood are hypersplenism and
concomitant splenomegaly secondary to haema-
tological disorders such as hereditary spherocy-
tosis, thalassaemia major, sickle cell disease and
idiopathic thrombocytopenic purpura. Less com-
mon indications include neoplastic disease, large
cysts and abscesses. Trauma is now rarely an in-
dication for splenectomy in childhood.
Equipment
• 5- to 15 mm trocar to accommodate laparo-
scope and subsequently retrieval bag
• 5- or preferably 10 mm 30 ° laparoscope
• 3 × 5 mm trocars
• Grasping forceps
• Endopledgets
• Hook monopolar diathermy
• Vessel sealant devices, e.g. harmonic scalpel,
Ligasure
• Retrieval bag
• Suction/irrigation
Pre-operative
In an elective setting the patient should receive pro-
phylaxis against postsplenectomy sepsis. A pneu-
mococcal vaccine should ideally be administered 6
weeks prior to surgery. Children younger than 10
years old and all patients with immunosuppression
or an associated immunodeficiency should be vac-
cinated against Pneumococcus, Haemophilus influ-
enza, Meningococcus and Hepatitis B.
Atul J. Sabharwal ()
Consultant Paediatric and Neonatal Surgeon
Atul.Sabharwal@ggc.scot.nhs.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_174, © Springer-Verlag Berlin Heidelberg 2013
583
I16
Patient Positioning
Some form of support should be placed under
the patient’s left flank to elevate the left side (see
Figs. 1, 2).
The operating table can then be tilted to the
right to further increase the angle of tilt from the
horizontal to about 60° during surgery. Not only
does this facilitate splenic movement in to a bet-
ter position, but it also helps bowel loops gravi-
tate from the operative field. The patient should
be secured to the table (see Fig. 2).
Fig. 1
Ports Position and Placement
The visualisation port (5–15 mm) is sited in an in-
fra-umbilical position by an open technique and
pneumoperitoneum established. Three 5-mm
ports are then sited as shown below (see Fig. 3).
These comprise an epigastric port and one to the
left of the umbilicus in the mid-clavicular line,
which serve as working ports. An additional left
lateral port is used to retract the spleen with an
endopledget.
The surgeon and videographer stand on the
patient’s right side, with the surgeon on the right
of the videographer. An assistant stands on the
584
Fig. 2
patient’s left side and retracts the spleen super-
olaterally with an endopledget. The scrub nurse
stands either to the right of the surgeon or on the
patient’s left if an additional monitor is available.
The active monitor utilised by the operators is sit-
uated on the left side of the patient (see Fig. 4).
Fig. 3
A. J. Sabharwal
Using the grasping forceps inserted into the
epigastric port and the Harmonic scalpel in the
second working port, the gastrosplenic ligament
is divided. An endopledget inserted through the
left lateral port is used to counter-tract the spleen
laterally and aid dissection. Dissection is com-
menced by taking down the splenocolic attach-
ments using either the harmonic scalpel or mo-
nopolar hook diathermy. The tail of the pancreas
is visualised and care taken to avoid injury to the
gland. The cranial gastrosplenic attachments are
then divided, and the fundal short gastric vessels
dealt with using either the harmonic scalpel or
monopolar hook diathermy.
The splenic artery and vein will often branch
some distance from the hilum of the spleen, and
ligation of these vessels should be attempted be-
fore the artery has divided and the venous tribu-
taries have united. This may not be possible in all
cases, especially very large spleens, and in these
cases the individual vessels can be dealt with us-
ing the harmonic scalpel. Characteristically the
main vessels run superiorly to but closely abut-
ting the pancreas, with the vein lying posterior to
the artery. Taking the artery first interrupts most
of the splenic blood supply, reduces the risk of
major haemorrhage and reduces splenic size by
venous drainage. Care should be taken to avoid
tearing venae comitantes and small arteries run-
I16  Laparoscopic Splenectomy
Fig. 4
ning to the spleen. A Mixter dissecting instrument
is a useful aid to circumnavigate the main vessels.
A Ligasure can then be used to coagulate and di-
vide the main vessels.
The remainder of the splenic peritoneal attach-
ments can then be divided near their attachment
to the gastric fundus and diaphragm superomedi-
ally. Attention is then turned to the lateral attach-
ments to the abdominal wall. Prior to retrieval it
is important to ensure the spleen is free of all at-
tachments by rotating it carefully in its bed. An
inspection of the omentum and upper abdomen
is made to exclude the presence of splenunculi.
585
The laparoscope is moved to one of the work-
ing ports, and a retrieval bag inserted in to the um-
bilical port. The spleen is manipulated in to the
bag, care being taken not to damage the splenic
capsule. The spleen is then retrieved piecemeal
with Rampleys forceps and suction utilised to re-
move blood within the splenic body.
If the spleen is too large to fit in to the retrieval
bag, a Pfannenstiel incision can be used for re-
trieval.
A final inspection to ensure haemostasis is car-
ried out, the ports removed under vision and the
sites closed with absorbable suture.
 586 H. L. Tan, B. Tecson and S. Cascio
I17 I 17Laparoscopic Cholecystectomy
H. L. Tan, B. Tecson and S. Cascio

Gallstones are relatively uncommon in children Equipment

and their prevalence vary between countries. The
large majority of gallstones are discovered in • 0° 5 mm telescope
asymptomatic children while assessing for other • 11-mm Hasson trocar and cannula
abdominal pathology or following episodes of • Three 6-mm instruments ports
non specific abdominal pain and irritability, typ- • Liver retractor
ically seen in patients <5 years of age and in hae- • Tissue graspers
molytic disease. Rarely gallstones can present • Monopolar hook diathermy
acutely with a biliary colic/cholecystitis or cholan- • Bipolar scissors
gitis/pancreatitis. Many conditions predispose to • Bipolar diathermy forceps
cholelithiasis including haemolytic disease (sickle • Endoscopic clip applicators
cell disease, thalassemia, hereditary spherocyto-
sis), prematurity, long term parenteral nutrition,
cystic fibrosis, obesity, bowel resections, cardiac Pre-operative
surgery etc. Like adults studies in children have
shown significant benefits of the laparoscopic ap- A 10-Fr nasogastric tube is inserted to decom-
proach and laparoscopic cholecystectomy has be- press the stomach and ensure that it is kept empty.
come the preferred technique.

Hock Lim Tan ()

Visiting Pediatric Surgeon,
Prince Court Medical Center, 56000 Kuala Lumpur,
Malaysia & Adjunct Professor Faculty of Medicine,
Universitas Indonesia, Jakarta, Indonesia
Email: hockltan@yahoo.com

B. Tecson
Associate Professor of Surgery,
School of Medicine, Saint Louis University, Baguio City.
Chairman,
Department of Surgery, Notre Dame De Chartres Hospital,
Baguio City, Phlippines

Salvatore Cascio
Consultant Paediatric Surgeon and Urologist
The Royal Hospital for Sick Children, Dalnair Street,
Yorkhill, Glasgow G3 8SJ, Scotland, UK
Email: salvatore.cascio@ggc.scot.nhs.uk Fig. 1

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_175, © Springer-Verlag Berlin Heidelberg 2013
I17  Laparoscopic Cholecystectomy 587

Patient Positioning

The patient is positioned at the end of the oper-

ating table as per fundoplication procedures, the
video monitor is placed at the head of the table.
The patient should be tilted 20° head up (Fig. 1).

Ports Position and Placement

An open laparoscopy is performed to insert a Has-

son cannula in the umbilicus. Two further instru-
ment ports are inserted under direct endoscopic
visualisation, a further port is placed in the epi-
gastrium (Fig. 2). In small children it may be pref-
erable to place the instrument ports lower, par-
allel to the umbilical port. The liver is often big-
ger and overhangs the costal margin, so placing
instrument ports in the conventional position in
the upper quadrant will severely limit the ability
to manipulate the instruments within the abdom-
inal cavity. Fig. 2

Operative Technique

• Hartmann’s pouch should be grasped with a

toothed, ratcheted grasper and retracted to-
wards the right hip. A retractor is then placed
in the epigastric port to retract the liver from
Hartmann’s pouch to display Calot’s triangle
(Fig. 3).
• Peritoneum overlying the cystic duct should be
opened with monopolar hook diathermy, with
care taken not to damage the duodenum or
common bile duct (Fig. 4). Peritoneum cover-
ing the free edge of the cystic duct should be
opened, as should the peritoneum covering the
posterior part of Calot’s triangle.
• The cystic duct and cystic artery should be ex-
posed by dividing the respective overlying peri-
toneal lining. Hook diathermy can be used to
incise the peritoneum, the cystic artery is care-
fully separated from the cystic duct. Only 1cm
of the cystic duct needs to be exposed close to
the Hartmann’s pouch. Do not chase the cys-
tic duct medially as there is significant risk of
common bile duct injury. Three clips need to be
applied on the exposed cystic artery and cystic
Fig. 3
duct (Fig. 5), two on the “stump” and one the
gallbladder side. The cystic artery should be
divided before dividing the cystic duct as this
minimizes the risk of accidental avulsion of the
cystic artery, if the cystic duct is divided first.
The gallbladder can be dissected from its fossa
using monopolar hook diathermy (Fig. 6).
Check the gallbladder fossa for bleeding and
also the divided end of the cystic duct. It is not
necessary to insert a wound drain unless there
is ooze. The gallbladder is retrieved by insert-
ing into an endobag and removing it through
the umbilical port. A purse string suture is used
588 H. L. Tan, B. Tecson and S. Cascio

to close the Hasson port site. The fascia of the

instrument ports should be closed with a sin-
gle suture to prevent omental herniation and
the port sites can be closed with topical skin
adhesive (2 Octyl-cyanoacrylate).

Fig. 4

Fig. 5

Fig. 6
I18  Diagnostic Laparoscopy for Non palpable Undescended Testis
I18 Diagnostic Laparoscopy for Non
palpable Undescended Testis
S. Cascio and H. L. Tan
Approximately 1% of boys at age one year have
an undescended testis, 20% of which are nonpal-
pable. Laparoscopy has replaced ultrasonogra-
phy, magnetic resonance imaging and computer-
ized tomography as the modality of choice for the
localization of the nonpalpable testis; in some of
these patients can eliminate the need for further
exploration. Laparoscopy can also be used for pri-
mary orchidopexy, for the two-staged Fowler–Ste-
phens orchidopexy and for removal of the dys-
plastic/atrophic gonad in older children or in pa-
tients with disorders of sex development.
Equipment
• 5-mm Hasson Trocar
• 5-mm 30° telescope
Pre-operative
A neonate with bilateral impalpable testis espe-
cially if associated with hypospadias or a micro-
penis should raise immediate suspicion that the
baby has a Disorder of Sex Development (DSD).
Appropriate and urgent investigations including a
karyotype, serum and urinary steroid profile, se-
Salvatore Cascio ()
Consultant Paediatric Surgeon and Urologist
The Royal Hospital for Sick Children, Dalnair Street,
Yorkhill, Glasgow G3 8SJ, Scotland, UK
Email: salvatore.cascio@ggc.scot.nhs.uk
Hock Lim Tan
Visiting Pediatric Surgeon,
Prince Court Medical Center, 56000 Kuala Lumpur,
Malaysia & Adjunct Professor Faculty of Medicine,
Universitas Indonesia, Jakarta, Indonesia
Email: hockltan@yahoo.com
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_176, © Springer-Verlag Berlin Heidelberg 2013
589
I18
rum electrolytes and a pelvic ultrasound are re-
quired. Having excluded Congenital Adrenal Hy-
perplasia any further test such as basal gonatro-
phins, a human chorionc gonadotropin (hCG)
stimulation test with measurement of androgen
production and Mullerian Inhibitory Hormone
(MIH) can be deferred to a later stage to assess
testicular function.
In the anaesthetic room under general anaes-
thesia, a physical examination of the groin is man-
datory before proceeding to laparoscopy. Approx-
imately 18% of boys with a previously nonpalpa-
ble testis will have a palpable testis when examined
under general anaesthesia. The bladder should be
emptied by manual suprapubic compression.
Patient Positioning
The patient is positioned close to the end of the
table, with the video monitor in the midline at the
end of the table. In unilateral cases the operating
surgeon and the scrub nurse should stand on the
contralateral side to the testis being explored. The
patient should be tilted into a 30 Trendelenburg
position. The testicles should be included in the
operating field.
Port Position and Placement
An open Hasson technique is used the enter the
abdominal cavity as described in chapter I 11 Lap-
aroscopic Pyloromytomy. The abdominal cavity
is insufflated with carbon dioxide to a pressure
of 10 mm Hg.
The telescope is inserted in the peritoneal cav-
ity, and in unilateral cases the normal internal ring
is inspected first. The vas deferens medially and
the testicular vessels laterally converge into the
ring in the shape of an inverted V. It is important
590
to assess the diameter of the testicular vessels in
the normal side (Fig. 1) and to compare with the
testicular vessels on the affected side.
Possible Intraoperative Findings
• Normal vas and testicular vessels entering an
open internal ring. Exploration of the groin is
mandatory, as the testis could be present in 75–
97% of cases (Fig. 2).
• Vas and either normal or hypoplastic testicular
vessels entering a closed internal ring. Inguinal
exploration is indicated (Fig. 3). Either a tes-
ticular remnant or a small viable testis (3–25%)
can be found in the inguinal canal. Excision
of the testicular remnant is recommended be-
cause of the small risk (0–7%) of detecting vi-
able germ cell elements in the testicular rem-
nant that theoretically could undergo malig-
nant change.
• Vas and atrophic testicular vessels ends blindly
before entering the internal ring – ‘vanishing tes-
tis’. Inguinal exploration is not indicated.
• The testis is visualized at the internal ring: peep-
ing testis (Fig. 4,5). It is of importance to as-
sess the length of the spermatic cord to decide
whether a direct open or laparoscopic orchido-
pexy or a staged Fowler Stephens orchidopexy
with division of the spermatic vessels should
be performed. As part of the decision-making
process, it is essential to evaluate intraopera-
tively the testis, the epididymis, the extent of the
vasal descent into the inguinal canal, the guber-
Fig. 1
S. Cascio and H. L. Tan
nacular attachments and finally the measure-
ment of the distance between the testis and the
internal ring. Peeping testis or those located in
proximity to the internal ring (<2 cm from or
below the external iliac vessels) can usually be
mobilized into the scrotum in a single stage or-
chidopexy, either with an open or laparoscopic
approach without dividing the testicular ves-
sels.
• High Intra-abdominal testis with short vessels.
A high intra-abdominal testis is commonly de-
fined as when the testis lies inside the abdo-
men above the external iliac vessels or is more
than 2 cm away from the internal ring. In these
circumstances a staged Fowler–Stephens ap-
proach is recommended.
• Normal vas deferens but no vessels and no ob-
vious testis near the vas. The abdomen is in-
spected along the normal line of descent of the
testis, along the colonic gutter until the lower
pole of the kidney, and in ectopic sites in the
pelvis, beside the bladder, rectum or on the op-
posite site (crossed ectopia).
• Normal vessels with an absent vas deferens. The
vessels may lead to an intra-abdominal testis or
may enter the internal ring, necessitating an in-
guinal exploration. The contralateral internal
ring should be inspected, as bilateral absence
of vas deferens is considered an invariable find-
ing in cystic fibrosis. Also, patients with uni-
lateral absence of the vas deferens may have
cystic fibrosis mutations. The presence of an
ipsilateral kidney should be confirmed post-
operatively with a renal ultrasonography. The
Fig. 2
I18  Diagnostic Laparoscopy for Non palpable Undescended Testis 591

association of the absence of the vas deferens

with ipsilateral renal agenesis emphasizes the
close relationships between mesonephric duct
development and nephrogenesis itself.
• Abnormal dysplastic testis or Müllerian struc-
tures are found intra-abdominally. A laparo-
scopic biopsy or laparoscopic orchidectomy is
indicated (Fig. 6).

Fig. 3 Fig. 4

Fig. 5 Fig. 6
 592 S. Cascio and H. L. Tan
I19 I 19Laparoscopic Fowler–Stephens
Orchidopexy
S. Cascio and H. L. Tan

Fowler and Stephens in 1959 describing the vascu-
lar supply of the testis proposed in children with
intra abdominal testis the ligation of the testicu-
lar vessels with the hope of preserving function
through collateral circulation through the defer-
ential artery, a branch of the inferior vesical ar-
tery and the cremasteric artery, a branch of the
inferior epigastric. In their experience, orchido-
pexy was performed under the same anaesthetic.
Ransley introduced the practice of ligating the
testicular vessels and waiting 6 to 12 months be-
fore doing an orchidopexy to allow the deferen-
tial artery to increase its flow. Bloom was the first
to describe a laparoscopic approach for the first
stage and since then a laparoscopic “Fowler Ste-
phens” procedure, performing both stages lapa-
roscopically has gained a wide acceptance. Stag-
ing the procedure will enable delivery of the testis
into the scrotum without tension and a decreased
risk of atrophy.
• Two pairs of Kellys forceps (one 3mm and one
5mm)
• 1 Roberts forceps
• Disposable laparoscopic Ligaclip and bipolar
scissors
Pre-operative
The bladder is emptied in the anaesthetic room
either with the insertion of a urinary catheter or
with the Crede maneuver.
Patient Positioning
The patient is positioned supine with the video
monitor at the end of the table in the midline.
The operating surgeon and the scrub nurse should

Equipment

• 5 mm Hasson Trocar
• 5 mm 30 degrees telescope
• One 5 mm Trocar

Salvatore Cascio ()

Consultant Paediatric Surgeon and Urologist
The Royal Hospital for Sick Children, Dalnair Street,
Yorkhill, Glasgow G3 8SJ, Scotland, UK
Email: salvatore.cascio@ggc.scot.nhs.uk

Hock Lim Tan

Visiting Pediatric Surgeon,
Prince Court Medical Center, 56000 Kuala Lumpur,
Malaysia & Adjunct Professor Faculty of Medicine,
Universitas Indonesia, Jakarta, Indonesia
Email: hockltan@yahoo.com Fig. 1 

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_177, © Springer-Verlag Berlin Heidelberg 2013
I19  Laparoscopic Fowler–Stephens Orchidopexy 593

stand on the contralateral side to the unpalpable

undescended testis. The patient should be tilted
into a 30 head down position.

Ports Position an Placement

The open Hasson technique is used to place the

primary cannula through a supra-umbilical inci-
sion as described in chapter I 18. For left sided or-
chidopexy one 5 mm ports is inserted in the right
iliac fossa in the midclavicular line and a 3mm in-
struments without port lateral to the rectus and Fig. 2 
to the left of the umbilicus. On the opposite for
right sided orchidopexy (Fig. 1).

Operative Technique: First Stage

The peritoneal reflection lateral to the testicular

vessels is divided with bipolar scissors at least 2
cm away from the testis, a window is created pos-
teriorly to the testicular vessels with Kellys for-
ceps (Fig. 2)
The testicular vessels are double clipped proxi-
mally and a single clip is placed distally (Fig. 3, 4).
Alternatively the vessels can be tied or coagulated
with Ligasure.
The testicular vessels are divided between clips Fig. 3 
(Fig. 5, 6)

Operative Technique: Second Stage

A laparoscopic second stage Fowler Stephens will

be performed approximately three to six months
later when collateral circulation from the deferen-
tial artery has matured.
For the second stage Fowler Stephens orchi-
dopexy the two ports and the 3mm instrument
are placed as for the first stage. At the beginning
of the procedure confirmation of adequate neo-
vascularisation of the testis through the deferen-
tial artery is required. The dissection with bipo-
lar scissors starts in the peritoneum lateral to the Fig. 4
testicular vessels, proximal to the clips placed for
the first stage, towards the internal ring. The gu-
bernaculum is grasped and divided with bipolar
594 S. Cascio and H. L. Tan

scissors as far distally as possible. The incision in

the peritoneum is extended medially towards the
medial umbilical ligament 1 cm lateral and supe-
rior to the vas. Care must be taken not to activate
cautery in proximity of the vas and of the deferen-
tial artery avoiding to damage the inferior epigas-
tric vessels or the bladder. We intentionally leave
the peritoneal triangle between the testicular ves-
sels and the vas undisturbed. The testis is held at
the level of the gubernaculum and moved to the
opposite internal inguinal ring to determine ade-
quacy of mobilization. Once the testis can reach
the contralateral internal inguinal ring it usually Fig. 5 
means that the length is sufficient to allow the
placement of the testis into the hemiscrotum. A
1.5 cm incision is made in the scrotum and a subd-
aortos pouch is created in a standard fashion. The
laparoscopic 3mm grasper ipsilateral to the unde-
scended testis is placed over the anterior pubic ra-
mus, between the medial umbilical ligament (oblit-
erated umbilical artery) and the inferior epigastric
vessels (lateral umbilical ligament) directed from
the peritoneal cavity towards the scrotal incision.
This creates a new internal ring with a short di-
rect course to the scrotum. A long curved Roberts
is introduced through the scrotum into the abdo-
men over the 3 mm grasper. The tips of the Rob- Fig. 6 
erts forceps are opened up widening the new in-
ternal ring, the testis is grasped at the gubernacu-
lum and delivered into the hemiscrotum. The tes-
tis is secured in the subdaortos pouch with a single
stitch to the midline septum. The scrotal wound
is closed with Vicryl rapid, the subcutaneous ap-
proximated with a single suture and topical skin
adhesive for skin closure.
I20  Lymphatic-Sparing Laparoscopic Varicocelectomy
I 20Lymphatic-Sparing Laparoscopic
Varicocelectomy
S. Cascio and H. L. Tan
Hydrocele following varicocelectomy is very com-
mon and occurs in up to 25% of cases. The cause
is the disruption of the lymphatic drainage of the
tunica vaginalis of the testis. We here describe high
ligation of the internal spermatic vessels via a lap-
aroscopic transperitoneal approach (Palomo pro-
cedure), with sparing of the lymphatic vessels.
Equipment
• 5-mm Hasson trocar
• 5-mm 30° telescope
• Two 5-mm sharp trocars
• Two pairs of Kelly forceps
• 5-mm laparoscopic scissors
• Disposable laparoscopic LIGACLIP
Patient Positioning
The patient is positioned supine, with the testes
included in the operative field. For a left-sided
varicocele the surgeon, assistant and scrub nurse
should stand on the right side of the patient, with
the video monitor placed in front of them, on the
patient’s left side, so that it is in the same visual line
to facilitate hand-to-eye coordination. The patient
should be tilted into a 30° head-down position, to
Salvatore Cascio ()
Consultant Paediatric Surgeon and Urologist
The Royal Hospital for Sick Children, Dalnair Street,
Yorkhill, Glasgow G3 8SJ, Scotland, UK
Email: salvatore.cascio@ggc.scot.nhs.uk
Hock Lim Tan
Visiting Pediatric Surgeon,
Prince Court Medical Center, 56000 Kuala Lumpur,
Malaysia & Adjunct Professor Faculty of Medicine,
Universitas Indonesia, Jakarta, Indonesia
Email: hockltan@yahoo.com
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_178, © Springer-Verlag Berlin Heidelberg 2013
595
I20
allow the sigmoid colon to fall away in a depen-
dent position.
Pre-operative
 apping of the testicular lymphatics can be
M
achieved with an intravaginal injection of two
millilitres of methylene blue between the two lay-
ers of the tunica vaginalis 10 minutes before the
beginning of the operation.
Ports Position and Placement
A two mm stab incision is made in the supra-um-
bilical skin crease with a no.11 blade and the pri-
mary Hasson cannula is placed using the open lap-
aroscopy method described in chapter I12 lapa-
roscopic appendectomy. A second 5-mm incision
is made in the right iliac fossa, lateral to the rec-
tus muscle; the incision is widened by spreading
a pair of straight mosquito forceps, and a 5-mm
trocar is placed under vision. A third 5-mm tro-
car is placed on the left of the umbilicus lateral to
the rectus (Fig. 1).
Operative Technique
The internal spermatic vessels are identified as
they enter the internal ring (Fig. 2).
With curved dissecting scissors, the peritoneum
is incised on each side of the vessels, and a win-
dow is created posteriorly (Fig. 3).
The lymphatics (stained blue) are easily identi-
fied and preserved during the dissection (Fig. 4).
The internal spermatic vessels are lifted from
the lateral abdominal wall with Kelly forceps and
clipped (two proximal clips and one distal clip)
(Fig. 5).
596 S. Cascio and H. L. Tan

The spermatic vessels are divided with scissors

between the proximal and distal clips. The vas and
lymphatics are carefully preserved (Fig. 6).
The ports are removed under direct vision and
the pneumoperitoneum is evacuated. The purse
string is tightened at the umbilicus, and a single
suture is placed to approximate the subcutaneous
tissue. Topical skin adhesive (2-octyl-cyanoacry-
late) is used for skin closure.

Fig. 1 

Fig. 2

Fig. 3
I20  Lymphatic-Sparing Laparoscopic Varicocelectomy 597

Fig. 4

Fig. 5

Fig. 6
 598
I21 I21 Laparoscopic Inguinal Herniotomy
H. L. Tan and S. Cascio
Indirect inguinal hernias are some of the com-
monest surgical conditions in infancy, and while
there is debate as to whether conventional or
open inguinal hernia repair is the preferred op-
tion, there is now an established role for laparo-
scopic inspection of the contralateral internal ring
to exclude an open internal inguinal ring. In ne-
onates with an undescended testis and a hernia,
laparoscopic closure of the internal ring is an in-
dication par excellence, as it leaves the contents
of the inguinal canal – including the testis – com-
pletely untouched, making subsequent orchido-
pexy much easier.
Equipment
• 5-mm Hasson Trocar
• 4-mm 0° telescope
• 3-mm short Kellys dissector
• 3-mm short Metzenbaum scissors
• 3-mm KOH needle holder
Patient Positioning
The patient should be placed at the foot of the ta-
ble and in an approximately 15–20° degree Tren-
delenburg position to allow the small bowel to fall
Hock Lim Tan ()
Visiting Pediatric Surgeon,
Prince Court Medical Center, 56000 Kuala Lumpur,
Malaysia & Adjunct Professor Faculty of Medicine,
Universitas Indonesia, Jakarta, Indonesia
Email: hockltan@yahoo.com
Salvatore Cascio
Consultant Paediatric Surgeon and Urologist
The Royal Hospital for Sick Children, Dalnair Street,
Yorkhill, Glasgow G3 8SJ, Scotland, UK
Email: salvatore.cascio@ggc.scot.nhs.uk
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_179, © Springer-Verlag Berlin Heidelberg 2013
H. L. Tan and S. Cascio
away from the internal rings. The monitor is po-
sitioned at the bottom of the table. The surgeon
should stand on the side opposite of the hernia
and the assistant opposite the surgeon. This al-
lows both the surgeon and assistant to work in
line, avoiding second-order paradox.
The abdomen should be draped to include the
testes, to enable the surgeon to reduce by taxis
any contents within the hernial sac should this
be necessary.
Ports Positioning and Placement
The 5-mm Hasson cannula is inserted by open
laparoscopy in the supra-umbilical position and
secured with a purse-string suture as described in
Chap. I11 (‘Laparoscopic Pyloromyotomy’). In-
strument ports are unnecessary for hand instru-
ments, that are introduced directly through the ab-
dominal wall lateral to the recti, with a stab inci-
sion (no. 11 blade) and dilating the incision with a
pair of straight haemostats (Figs. 1 and 2).
Operative Technique
The right (Fig. 3) and left (Fig. 4) internal rings
should be inspected first to determine if they are
patent.
In a female patient, it is important to confirm
that both Fallopian tubes and ovaries are present.
Absence of one or both of these structures should
raise immediate suspicion that they are within the
sac or they form the wall of a slider.
A 6-cm length of non-absorbable suture on
a half-circle 11-mm needle is introduced directly
into the abdominal cavity by grasping the suture
(not the needle) on the 3-mm needle holder. The
curved needle can be negotiated through a thin ab-
dominal wall alongside the needle holder.
I21  Laparoscopic Inguinal Herniotomy 599

Fig. 2

Fig. 1

Fig. 3 Fig. 4

Fig. 5 Fig. 6
600
The needle is then mounted 30° from horizon-
tal. The success of herniotomy and ease of closure
depends on correct needle placement, as it would
be difficult to purse string the peritoneum around
the internal ring (Fig. 5), if the needle were incor-
rectly mounted.
Transperitoneal closure of an indirect inguinal
hernia is akin to the open extraperitoneal closure.
The pre-peritoneal fascia is a definite tissue plane
formed by loose connective tissue, that separates
the peritoneum from the surrounding structures
such as the vessels and vas, and allows the perito-
neum to be picked up and lifted away from these
H. L. Tan and S. Cascio
structures. The essence of laparoscopic closure
thus is to lift the peritoneum away from the vas,
internal spermatic vessels and the internal epigas-
tric artery, that are easily visualised. The common-
est site for ‘recurrence’ or incomplete closure is at
the inferior epigastric artery, but lifting the perito-
neum off the artery will minimise injury.
The purse string is then tightened securely and
the needle removed (Fig. 6).
The purse string securing the Hasson cannula is
then loosened to remove the Hasson, and simply
retightened to close the umbilical port site. If an
umbilical hernia is present, it is easiest to use the
umbilical defect to insert the Hasson and the um-
bilical hernia formally repaired after herniotomy.
The 3-mm instrument port sites can be closed by
topical skin adhesive.
I22  Retroperitoneoscopic Nephrectomy 601
I 2Retroperitoneoscopic Nephrectomy I22
S. Cascio, S. J. O’Toole and H. L. Tan

There are fewer indications for nephrectomy in

children than in adults. These include non or min-
imally functioning kidneys due to congenital renal
dysplasia/hypoplasia, end stage reflux nephropa-
thy, pelvic ureteric junction obstruction and non
involuting multicystic dysplastic kidney.

Equipment

• 5-mm 30° telescope

• 12-mm blunt-tip trocar
• 5-mm short mini-step trocar Fig. 1
• 5-mm sharp trocar
• Disposable lap Ligaclip or Ligasure or Har- Patient Positioning
monic Scalpel
• Laparoscopic tray Position the patient fully prone, with a cushion
• Pillows, gamgees and gelpads below the ribcage and a gel pad under the hips to
allow the abdominal content to fall away in a de-
pendent position (Fig. 1). Surgeon, assistant and
Pre-operative scrub nurse stand on the same side of the nephrec-
tomy, with the video monitor in front of them and
The affected side is marked. A urethral catheter is the camera pointing towards the monitor (Fig. 2).
placed in the anaesthetic room.

Salvatore Cascio ()

Consultant Paediatric Surgeon and Urologist
The Royal Hospital for Sick Children, Dalnair Street,
Yorkhill, Glasgow G3 8SJ, Scotland, UK
Email: salvatore.cascio@ggc.scot.nhs.uk

Stuart J. O’Toole
Consultant Paediatric Urologist
Stuart.O’Toole@ggc.scot.nhs.uk

Hock Lim Tan Fig. 2

Visiting Paediatric Surgeon,
Prince Court Medical Centre, Kuala Lumpur Malaysia
& Adjunct Professor Faculty of Medicine, Universitas
Indonesia, Jakarta, Indonesia

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_180, © Springer-Verlag Berlin Heidelberg 2013
602
Ports Position and Placement
A transverse 12-mm incision is made lateral to the
sacrospinalis muscle, midway between the twelve
rib and the iliac crest (Fig. 3). The subcutaneous
tissue is divided with diathermy. Access to the ret-
roperitoneum is created by spreading the posterior
and anterior lamella of the thoracodorsal fascia
with a pair of haemostat (Fig. 4). A balloon (as
described by Gaur in 1992) made by the finger of
a glove, double tied to a size 3 endotracheal tube
and connected to a three-way tap to a 50 ml sy-
ringe (Fig. 5), is introduced into the retroperito-
neal space and is inflated with 150-200 mls of air.
A 12-mm Hasson trocar is placed through the
incision, and the retroperitoneal space is insuf-
flated with carbon dioxide to a pressure of 10 or
12 mmHg, according to the age of the child. Lo-
cal anaesthetic is infiltrated, and a 5-mm incision
is made on the lateral aspect of the retroperito-
neal space, the incision is widened by spreading a
pair of straight mosquito forceps along the tract
and a second 5-mm sharp trocar is placed under
direct visualisation.
Fig. 3
S. Cascio, S. J. O’Toole and H. L. Tan
Operative Technique
Gerota’s fascia is incised with bipolar scissors
close to the posterior abdominal wall and the peri-
nephric fat is visualized.
A third 5-mm incision is made on the outer
border of the sacrospinalis muscle and a step tro-
car is introduced.
The ureter is visualized and traced down to the
brim of the bony pelvis, divided with diathermy
scissors and tied with an endoloop in refluxing
ureters, while dilated obstructed ureters are left
open. The ureter is followed to the hilum of the
kidney and used as countertraction to expose the
hilum (Fig. 6). The posterior branch of the renal
artery is visualized and two clips are applied prox-
imally and one distally before is divided. The re-
nal vein and the anterior branch of the renal ar-
tery are clipped and divided. Alternatively the ves-
sels can be divided either with the Harmonic scal-
pel or with the Ligasure if they are less than 5 mm
in diameter. The remaining attachments of the
kidney laterally to the perinephric fat and to the
transversalis fascia, medially and anteriorly to the
peritoneum and superiorly to the under aspect of
the diaphragm are divided with hook diathermy.
Small dysplastic kidneys are removed through the
12 mm Hasson port, larger kidneys with the use
of an EndoPouch retrieval system. The fascia and
subcutaneous are closed in layers with absorbable
suture and topical skin adhesive for skin closure.
I22  Retroperitoneoscopic Nephrectomy 603

Fig. 4

Fig. 6

Fig. 5
 604
I23 I 23Retroperitoneoscopic Partial
Nephrectomy
S. Cascio, S. J. O’Toole and H. L. Tan
Indications for partial nephrectomy in children
include a dysplastic nonfunctioning upper moi-
ety associated with a ureterocele or an ectopic
ureter, or a high grade vesico-ureteric reflux in a
poorly functioning lower moiety. For partial neph­
rectomy our preference is the prone retroperito-
neal approach (PR), as it avoids entering the peri-
toneal cavity and provides excellent access to the
renal vessels. We also describe the lateral retroper-
itoneoscopic approach (LR), that compared to
PR creates more space inferomedially and gives
better access to the lower pole or to an ectopic
pelvic kidney and allows for a complete ureterec-
tomy in all cases.
Equipment
• 5-mm 30° telescope
• 12-mm blunt tip trocar
• 5-mm short mini-step trocar
• 5-mm sharp trocar
• Harmonic scalpel
• Laparoscopic tray
• Pillows, gelpads and gamgees
Salvatore Cascio ()
Consultant Paediatric Surgeon and Urologist
The Royal Hospital for Sick Children, Dalnair Street,
Yorkhill, Glasgow G3 8SJ, Scotland, UK
Email: salvatore.cascio@ggc.scot.nhs.uk
Stuart J. O’Toole
Consultant Paediatric Urologist
Stuart.O’Toole@ggc.scot.nhs.uk
Hock Lim Tan
Visiting Paediatric Surgeon,
Prince Court Medical Centre, Kuala Lumpur Malaysia
& Adjunct Professor Faculty of Medicine, Universitas
Indonesia, Jakarta, Indonesia
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_181, © Springer-Verlag Berlin Heidelberg 2013
S. Cascio, S. J. O’Toole and H. L. Tan
Pre-operative
The affected side is marked. A urethral catheter
is placed in the bladder in the anaesthetic room.
For partial nephrectomy we recommend a ure-
throcystoscopy with insertion of a size 3 ureteric
catheter into the ureteric orifice of the function-
ing moiety. The ureteric catheter is secured with
tape to the patient and connected to a methylene
blue syringe to inject at the moment of transec-
tion. If there is a leak of blue, the tear can be eas-
ily identified and sutured.
 rone Retroperitoneoscopic Approach
P
for Upper-Pole Partial Nephrectomy
Patient Positioning and Ports Position and Place-
ment are identical to the Retroperitoneoscopic
Nephrectomy and have been described in chap-
ter I22.
Operative Technique
The renal fascia is incised (Fig. 1) with laparo-
scopic bipolar scissors and the perinephric fat
(Fig. 2) is visualized. The upper pole ureter is iden-
tified and followed to the upper pole and down to
the bony pelvis. The ureter is tied with an absorb-
able suture before cutting it, so that the proximal
ureter remains dilated facilitating the dissection
of the upper pole. The transected upper-pole ure-
ter is grasped with ratcheted forceps and used as
counter-traction to expose the vessels.
The upper-pole vessels are identified as run-
ning from the aorta or from the renal vessels to
the upper-pole parenchyma. The vessels are skel-
etonised with Kelly forceps and divided with Har-
monic scalpel.
I23  Retroperitoneoscopic Partial Nephrectomy 605

Fig. 1 Fig. 2

After vessels ligation a clear line of demarca-

tion with colour changes will separate the normal
lower pole and the dysplastic upper pole. Tran-
section of the renal parenchyma is made with the
Harmonic scalpel as it provides a better cut be-
tween the upper and lower moiety. The excised up-
per moiety is removed through the 12-mm Hasson
trocar. Ports are removed under direct visualisa-
tion and the wounds are closed in layers.

Lateral Retroperitoneoscopic
Approach for Lower-Pole Partial
Nephrectomy

Patient Positioning

The patient is positioned in the lateral position,

with the affected side up and a gel pad under the
patient to extend the space between the 12th rib
and the iliac crest (Fig. 3). The break in the operat-
ing table can be utilised to increase this space. The
surgeon, assistant and scrub nurse stand behind
the patient, with the video monitor in front of
them and the camera directed towards the moni- Fig. 3
tor. The child is secured to the operating table with
two long strips of elastoplast, one at the level of
the chest and one at the hip.
606 S. Cascio, S. J. O’Toole and H. L. Tan

Ports Position and Placement

A 12-mm transverse incision is made 1 cm below

the lower border of the 12th rib on the posterior
axillary line (Fig. 4). Subcutaneous tissue is di-
vided with monopolar diathermy. External and
internal obliques are split in the line of their fi-
bres with scissors. Two 3/0 Vicryl stay sutures are
placed in the muscles. The white transversalis fas-
cia is grasped with curved mosquito forceps and
pierced with scissors. A small gauze swab is intro-
duced through the wound into the retroperitoneal
space, starting posteriorly and gently pushed the
peritoneum anteriorly. The primary 12-mm Has-
son trocar is placed and secured to the stay su- Fig. 4
tures. Carbon dioxide insufflation is commenced
and the telescope inserted. The working space is into the normal pelvis of the upper moiety. The
enlarged by moving the tip of the telescope to free transection of the lower moiety from the upper is
retroperitoneal fibrous tissues, thus exposing the completed with the Harmonic scalpel. If a leak of
anatomical landmarks: the quadratus lumborum, methylene blue is seen during the transection, the
psoas muscle and posterior part of the kidney. calyceal tear can be easily identified and repaired
A second port is positioned posteriorly under with an intracorporeal suture. The attachments
direct visualisation in the costovertebral angle, at of the transected lower pole to the perinephric
the junction of the lateral border of the erector fat and to the peritoneum are divided with hook
spinae muscle and the undersurface of the 12th diathermy. The remaining upper moiety should be
rib. An Endo Peanut is inserted in the second port left attached to its surrounding structures to pre-
to sweep the lateral peritoneal reflection medially vent twisting of the main renal pedicle and loss of
in the lower part of the field, so that the last trocar function of the remaining moiety. The lower pole
can be introduced safely. The third inferior port is removed from the Hasson port and the wound
is inserted in the anterior axillary line, one finger is closed in layers.
breath above the iliac crest. It is essential that the
third port is not placed too close to the iliac crest,
because it can reduce instrument mobility.
Gerota’s fascia is incised with bipolar scissors
and the perirenal fat is then visualized. The lower-
pole ureter is identified, mobilized and followed to
the lower pole of the pelvis and down to the pelvic
brim. The ureter is tied with an absorbable suture
as close as possible to the bladder to avoid postop-
erative reflux into the ureteral stump. The lower-
pole vessels are identified running from the renal
vessels to the lower-pole parenchyma. The feeding
vessels to the lower moiety are skeletonised with
Kelly forceps and divided with Harmonic scal-
pel. The line of transection is visualized, the Har-
monic scalpel is placed parallel to the demarcation
line, an unscrubbed assistant in the operating the-
atre will start injecting few mls of methylene blue
I24  Laparoscopic Dismembered Pyeloplasty 607
I24 Laparoscopic Dismembered Pyeloplasty I24
S. Cascio and H. L. Tan

Laparoscopic ‘Anderson–Hynes’ dismembered Suture Requirements

pyeloplasty was first described in the 1990s and
remains one of the most challenging laparoscopic
procedures. While some surgeons are proponents
of the retroperitoneal route, we prefer the trans-
peritoneal route, as this offers maximum internal
working space and the best ergonomics to per-
form fine delicate suturing, an essential prereq-
uisite to perform this procedure well. In spite of
the technical challenge it is gaining acceptance
among paediatric surgeons as they become more
adept at performing advanced laparoscopic sur-
gery and fine suturing. It has also been shown that
laparoscopic pyeloplasty is safe and feasible in the
younger age group, with results equal to conven-
tional open pyeloplasty.
• 5/8 Trocar-cut 26-mm needle
• Straight, short 4/0 monofilament suture for the
hitch stitch
• Several 5/0 or 6/0 monofilament absorbable,
round body, 13 mm, half-circle (for anastomo-
sis)
Pre-operative
It is helpful to administer an enema to patients un-
dergoing a left pyeloplasty prior to the operation
to maximise the internal working space. A urinary
catheter is inserted after anaesthetic induction.

Equipment Patient Positioning

• 7-mm Hasson trocar The patient is positioned laterally with the affected
• 5-mm 30° telescope side up, placed near the edge of the operating table
• Two Kelly dissectors
• Two KOH needle holders
• KOH assistant needle driver
• Laparoscopic pyeloplasty scissors

Salvatore Cascio ()

Consultant Paediatric Surgeon and Urologist
The Royal Hospital for Sick Children, Dalnair Street,
Yorkhill, Glasgow G3 8SJ, Scotland, UK
Email: salvatore.cascio@ggc.scot.nhs.uk

Hock Lim Tan

Visiting Paediatric Surgeon,
Prince Court Medical Centre, Kuala Lumpur Malaysia
& Adjunct Professor Faculty of Medicine, Universitas
Indonesia, Jakarta, Indonesia Fig. 1

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_182, © Springer-Verlag Berlin Heidelberg 2013
608 S. Cascio and H. L. Tan

in an approximately 70° lateral decubitus (Fig. 1).

A sandbag or beanbag placed behind the patient is
helpful to stabilise the patient, and a 3-inch Elas-
toplast is used to strap the patient to the operat-
ing table. Ensure that the patient’s hips are not
flexed, as this will severely restrict your ability to
manipulate the laparoscopic instruments. There
is no need to ‘break the table’.
The surgeon, the assistant and the scrub nurse
stand all on the same side in front of the patient,
with the video monitor directly in front of them
to facilitate hand–eye coordination (Fig. 2).

Ports Position and Placement

The Hasson trocar for the telescope is inserted

through a small, transverse 5-mm incision in the
linea alba through a supraumbilical skin crease
incision. The subcutaneous tissue is divided with
scissors. The linea alba is lifted between a pair of
artery forceps and opened transversely with scis-
sors. The peritoneum is picked up with a pair of
small haemostats and opened with care, as not
to injure viscera which will be in close proximity
when the patient is lying in the lateral position.
The linea alba defect is purse stringed and the
Hasson cannula inserted. The purse string is then
tightened around the Hasson with a secure sin-
gle throw, effectively securing the Hasson and an
airtight seal.
In younger children weighing less than about
7 kg, the additional 3-mm hand instruments can
be inserted directly through the abdominal wall
without any trocars. This allows the surgeon to
carry a curved needle alongside the hand instru-
ment (Fig. 3). The abdominal wall in young in-
fants is thin, that makes introduction of instru-
ments through puncture holes easy with minimal
loss of gas. In older children this operation can be
performed using one 3-mm port and a 5-mm port
to enable the sutures to be passed into the abdo-
men. The instrument ports, particularly the sutur-
ing port, should be inserted in a position close to
the midline, as it has to be in line with the uretero
pelvic anastomosis to facilitate the fine suturing.
Fig. 2
Operative Technique
The kidney is exposed by detaching the colon
along the white line of Toldt. This approach al-
lows the colon to fall medially under gravity, ex-
posing the kidney (Fig. 4).
Gerota’s fascia is visualized and opened with
a monopolar hook. The kidney is traced towards
the sinus where the dilated pelvis will be encoun-
tered, and the ureter is identified by following the
renal pelvis more medially. Once the ureteropel-
vic junction is visualized, the pelvis is stabilized
with a hitch stitch, by passing a 4/0 monofilament
on a straight needle through the abdominal wall,
transfixing the renal pelvis, and passing again the
needle and suture through the abdominal wall at
its entry point. The hitch stitch is held by a hae-
mostat. Ideally the hitch stitch should be placed 1
cm from the apex of the anastomosis. The trans-
abdominal hitch stitch remains an important and
integral part of the operation, since it completely
I24  Laparoscopic Dismembered Pyeloplasty
Fig. 3
stabilises the pelvis, making precision suturing
possible (Fig. 5).
At this stage only the anterior wall of the pelvi-
ureteric junction is dismembered, preserving the
posterior wall. This approach makes easier to ori-
entate and spatulate the proximal ureter (Fig. 6).
The angle of the ureter is then re-anastomosed
to the most dependent part of the renal pelvis,
with an accurate apical suture (Fig. 7), before the
posterior wall is completely dismembered (Fig. 8).
The posterior anastomosis is completed with
a continuous suture of 6/0 or 5/0 polydioxanone.
Stenting
A transanastomotic stent is inserted transabdomi-
nally before trimming the redundant pelvis. A Tef-
lon needle is passed through the abdominal wall
into the proximal ureter, and a guidewire is in-
Fig. 5
609
Fig. 4
serted all the way into the bladder. The Teflon nee-
dle is withdrawn and a multilength pigtail catheter
is inserted over the guidewire into the bladder. The
proximal end of the pigtail is positioned into the
renal pelvis. The redundant pelvis allows main-
taining counter-traction, avoiding any trauma to
the urothelium. The placement of a stent will pro-
tect the anastomosis and prevent urinary leak.
It is only after the insertion of the double-J
stent that the redundant pelvis is trimmed, and
the anterior anastomosis completed with a sec-
ond continuous 6/0 or 5/0 polydioxanone suture
(Fig. 9).
On completion of the anastomosis the hitch
stitch is removed, and the kidney returned to its
bed and visually inspected to check that there
are no extrinsic kinks. The Hasson cannula is re-
moved, the abdomen is deflated and the purse
string retightened to close the umbilical port site.
Fig. 6
610 S. Cascio and H. L. Tan

Subcutaneous tissue is closed with a single inter-

rupted suture, and the skin is closed with topical
skin adhesive.
An abdominal x-ray is organised postopera-
tively to check the position of the stent and the
urinary catheter left for 48 h.
The stent is removed at 6 weeks.

Fig. 7 Fig. 8

Fig. 9
I25  Button Vesicostomy 611
I 25Button Vesicostomy I25
S. Cascio and M. S. Yassin

The button vesicostomy (BV) is a well-described Equipment

technique which allows short- and medium-term
bladder drainage. Originally described to assess • Cystoscope
bladder function prior to closing a long-standing • Insertion kit, PD introducer with 16-Fr peel-
vesicostomy, its use in recent years has been ex- away sheath and dilator (Fig. 1)
tended to children with poor bladder emptying,
children with bilateral high-grade vesicoureteric Option 1
reflux and children unsuitable for the formation
of an appendicovesicostomy. • Mic-Key over-the-wire-stoma-measuring de-
vice
• Dilators: 8, 10, 12, or 14
• Mic-Key or Mini gastrostomy button (size 14
Fr)

16F

Fig. 1

Salvatore Cascio ()

Consultant Paediatric Surgeon and Urologist
The Royal Hospital for Sick Children, Dalnair Street,
Yorkhill, Glasgow G3 8SJ, Scotland, UK
Email: salvatore.cascio@ggc.scot.nhs.uk

Musaab S. Yassin
Core Trainee in Urology
musaab.aldouri@gmail.com

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_183, © Springer-Verlag Berlin Heidelberg 2013
612 S. Cascio and M. S. Yassin

Option 2 has centimetre markings on the outside, that al-

Expanded CORFLO gastrostomy tube or AMT
G-Tube Balloon kit, size 14 Fr
Pre-operative
lows the accurate measurement of the distance of
the bladder from the skin surface. It has also a re-
tention bolster which can be stitched to the skin,
and it helps to keep the bladder secured to the ab-
dominal wall. The tube can be changed to the ap-
propriate button after 6 – 8 weeks.

The site of BV is marked preoperatively by the

stoma nurse.

Patient Positioning

The patient is placed in the lithotomy position.

A single daily dose of intravenous gentamicin is
given at induction of anaesthesia. The operating
surgeon should be on the left side of the patient
and the assisting surgeon at the bottom of the ta-
ble ready to perform the cystoscopy. Two video
monitors should be present, one in front of the Fig. 2
operating surgeon and one in front of the assis-
tant surgeon.

Operative Technique

The bladder is filled with normal saline and a 1

cm incision is made with a no 11 blade. The blad-
der is punctured percutaneously with a needle un-
der cystoscopic view (Fig. 2).
A guidewire is introduced over the needle
(Fig. 3); the needle is removed and replaced by a
serial dilator, size 8, 10, 12, or 14.
A Mic-Key over-the-wire stoma-measuring de- Fig. 3
vice is introduced in the bladder, and an accurate
measurement of the depth of the button is made.
The stoma-measuring device is removed and re-
placed by a size 16-Fr peel-away sheath (Fig. 4).
The guidewire is removed.
The obturator is removed, the outer sheath
peeled away and the appropriately sized Mic-Key
or mini gastrostomy button inserted into the blad-
der (Fig. 5). The balloon is inflated with the rec-
ommended amount of water (3–6 ml).
A possible alternative to the gastrostomy but-
ton is the gastrostomy tube. The tube can be in-
serted directly over the peel-away sheath. The tube
I25  Button Vesicostomy 613

Fig. 4

Fig. 5
 614 S. Cascio, T. J. Bradnock and H. L. Tan
I26 I 26Laparoscopic-Assisted Insertion
of a Peritoneal Dialysis Catheter
S. Cascio, T. J. Bradnock and H. L. Tan

Peritoneal dialysis is an alternative to haemodial- Patient Positioning

ysis and is used to treat patients with end-stage re-
nal disease. Different techniques have been devel- • Patient supine
oped for catheter placement. We describe a single- • Operating surgeon on the left-hand side of the
port laparoscopic technique which allows good vi- patient
sualization of the pelvis and accurate positioning • Assistant and scrub nurse on the right-hand
of the peritoneal catheter, with a low complication side
rate and excellent cosmetic result. • Video monitor at the end of the operating ta-
ble, in the midline

Equipment
Port Position and Placement
• 5-mm 30° telescope
• Insertion kit, PD introducer with 16-Fr peel- • A supra-umbilical inverted-J incision is made,
away sheath and dilator (Fig. 1) extending to the left of the umbilicus (Fig. 2).

Pre-operative Operative Technique

• The exit site is marked, taking into consider-
ation the belt line with the patient standing.
• A urethral catheter is inserted and a single dose
of antibiotic is given.
Salvatore Cascio ()
Consultant Paediatric Surgeon and Urologist
The Royal Hospital for Sick Children, Dalnair Street,
Yorkhill, Glasgow G3 8SJ, Scotland, UK
Email: salvatore.cascio@ggc.scot.nhs.uk
A supraumbilcal “inverted J” incision is made on
the left side of the umbilicus (Fig. 2). Monopolar
diathermy is used to divide the subcutaneous tis-
sue and to expose the anterior rectus sheath below
the umbilicus and with the index finger, by blunt
dissection, a space for the cuff is created between
the anterior rectus sheath and the subcutaneous
tissue. The peritoneal cavity is entered with a stan-
dard Hasson technique above the umbilicus. It is
essential to remove as much omentum as possi-
ble to minimize catheter blockage. The omentum

Tim J. Bradnock
Specialty Registrar in Paediatric Surgery
The Department of Paediatric Surgery, Dalnair Street,
Yorkhill Hopsital, Glasgow G3 8SJ, Scotland, UK
Email: tjbradnock@doctors.org.uk

Hock Lim Tan

Visiting Paediatric Surgeon,
Prince Court Medical Centre, Kuala Lumpur Malaysia
& Adjunct Professor Faculty of Medicine, Universitas
Indonesia, Jakarta, Indonesia Fig. 1

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_184, © Springer-Verlag Berlin Heidelberg 2013
I26  Laparoscopic-Assisted Insertion of a Peritoneal Dialysis Catheter
is grasped with forceps and delivered outside the
abdominal cavity, is tied with ligature and excised.
The abdomen is insufflated with carbon dioxide
to a pressure of 10-15 according to the age of the
child. A long oblique tract in the abdominal wall
extending from the infraumbilical space towards
the pelvis is created with a large needle under lapa-
Fig. 2
Fig. 3
615
roscopic vision (the needle at 30 degree angle with
the abdominal wall) (Fig. 3). This allow the cathe-
ter to be sited in the pelvis and the obliquity of the
track to prevent leakage. The double ended guide-
wire is advanced through the needle into the pelvis
(Fig. 4). The needle is removed and a 16 Fr peel
away sheath and dilator are inserted over the wire
(Fig. 5). The dilator is removed and the peritoneal
dyalisis catheter is fed through the sheath toward
the pelvis, behind the bladder (Fig. 6). Once the
catheter is inside the pelvis, the sheath is peeled
away leaving the peritoneal dyalisis catheter in the
pelvis. A 1cm stab incision is made lateral to the
rectus muscle on the left (Fig. 2). A long curved
mosquito forceps is introduced into the 1 cm inci-
sion to create a subcutaneous tunnel towards the
umbilicus. At the umbilicus the catheter is grasped
with the curved mosquito forceps and pulled to-
wards the exit site. It is important that the cuff is
at least 2 cm away from the exit site. The abdomen
is deflated, the Hasson port is closed, subcutane-
ous approximated with an absorbable suture and
skin closed with topical skin adhesive.
616 S. Cascio, T. J. Bradnock and H. L. Tan

Fig. 4

Fig. 5
I26  Laparoscopic-Assisted Insertion of a Peritoneal Dialysis Catheter 617

Fig. 6

Tips

77 The optimally sited catheter has:
– Long, oblique course through rectus sheath
to minimise the risk of leak and help maintain
its position in the pelvis
– Long, curved subcutaneous tunnel to reduce
the risk of displacement and infection
77 Ensure the catheter exit site does not lie over the
belt line; it should be above the nappy/diaper
line in infants.
77 The exit site should be located as far as possible
from other exit sites (gastrostomies, colostomies,
urostomies).
77 The exit site should be located on the left side of
the abdomen, as the majority will require future
renal transplantation on the right
77 The catheter should be irrigated in theatre for
patency using 10–20 ml/kg of normal saline,
flushed with 5 ml heparinised saline (500 U/l)
and then capped off.

Common Pitfalls

77 Failure to excise the omentum can be the cause

of catheter blockage.
 618 H. L. Tan
I27 I27 Laparoscopic Repair of Duodenal Atresia
H. L. Tan

The laparoscopic repair of Duodenal atresia was Equipment

first reported by Ure and Bax in 2001, followed by
reports from Rothenberg and Holcomb, who de-
scribed the use of “U” clips instead of using con-
ventional suturing. Since then there has been spo-
radic reports of this operation. It is a technically
challenging operation and requires considerable
dexterity in being able to operate within a con-
fined space requiring the surgeon to understand
the ergonomics and be very adept at performing
5/0 intracorporeal anastomosis.
Most cases of duodenal atresia including du-
odenal membrane are amenable to laparoscopic
repair, the only limiting factor is very low birth
weight infants. The only relative contra-indication
is when the proximal blind duodenum is very dis-
tended as this will obscure the operation site. Very
low birth weight infants can have TPN until they
reach about 2.0Kg.
Only few instruments are required:
• 0 degree and 30 degree 4mm telescope
• 5mm Hasson cannula
• 20cm 3mm Koh needle holder
• 20cm 3mm curved “Kelly” forceps X 2
• Monopolar diathermy hook
Patient positioning
The patient is positioned at the foot of the table
with the video monitor directly above the patient’s
head. The surgeon should be sitting down and the
assistant surgeon on his right. The nurse should
be on the surgeons left. It is not necessary to use
two monitors (Fig. 1).

Fig. 1

Hock Lim Tan ()

Visiting Paediatric Surgeon,
Prince Court Medical Centre, Kuala Lumpur Malaysia
& Adjunct Professor Faculty of Medicine, Universitas
Indonesia, Jakarta, Indonesia

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2_185, © Springer-Verlag Berlin Heidelberg 2013
I27  Laparoscopic Repair of Duodenal Atresia
The patient is intubated and paralysed, and an
8Fr naso gastric tube inserted prior to commence-
ment of surgery. The operation is commenced
with the patient supine but it will be necessary to
tilt the patient into reverse Trendelenberg but only
after insertion of the hand instruments.
Port Position and Placement
The first port for the telescope is inserted in the
umbilicus by open laparoscopy. While our prac-
tice is to insert this in the supra-umbilical skin
crease, in the case of Duodenal Atresia repair, our
preference is to place the port in the infra-umbili-
cal skin crease as it allows for easier visualization
of the falciform ligament to hitch it up to the an-
terior abdominal wall.
The laparoscopic hand instruments are in-
serted directly through the abdominal wall after
making a full thickness stab incision. There is no
need to use a port. The position of these ports is
critical if you are to maximize the working vol-
ume inside a small abdomen. The left handed in-
strument is placed in the Right Iliac Fossa, tak-
ing care to avoid the inferior epigastric vessels. It
is best to insert this instrument first, before tilting
the patient into reverse Trendelenberg. The right
handed instrument should be in the left paracolic
gutter, approximately parallel to the intended line
of anastomosis (Fig. 2).
Fig. 2
619
Operative Technique
The first step of this operation is to hitch the fal-
ciform ligament to the anterior abdominal wall.
This is best performed by passing a ½ circle needle
through the full thickness of the anterior abdomi-
nal wall to the right of the falciform ligament, and
winding it twice around the falciform at its liver
attachment, and then passing it through the ab-
dominal wall at approximately the same position.
Traction on this “hitch stitch” will lift the falciform
ligament and the accompanying liver onto the an-
terior abdominal wall, creating the much needed
room to manipulate your instruments. Fig. 3
Fig. 3
Next you should identify the proximal dilated
duodenum. The stomach is often still distended
with gas and it is best to ensure that the stomach
is completely empty. Follow the stomach to the an-
trum where you will find the vein of Mayo which
demarcates the first part of the Duodenum from
the Stomach. The hepatic flexture should be de-
tached at this point and if the patient is in reverse
Trendelenberg, it should fall away from the oper-
ative site, to expose the lesser sac. Fig. 4
The duodenum is followed distally to its blind
distal end. Avoid injuring the head of the pancreas
which lies in close anatomical relation to the me-
dial wall of the dilated duodenum. The dilated
proximal duodenum can be lifted out of the lesser
sac with one instrument and blunt gentle dissec-
tion used to identify the blind distal duodenum
by following the pancreatic head. This is an im-
portant landmark as it is not possible to perform
620 H. L. Tan

this operation without confidently identifying the

blind distal atretic end (Fig. 5). In the case of du-
odenal webs or incomplete atresia, you will no-
tice an abrupt narrowing of the distal duodenum
at the position of the web.
Once the distal duodenum is confidently iden-
tified, the duodenum and pancreas can be lifted
en bloc out of the lesser sac but using a transab-
dominal transfixion suture (Fig. 6).
The lateral most part of the proximal blind du-
odenum is then identified and sutured to the end
of the distal atretic duodenum. The medial wall
of the proximal blind duodenum is then sutured Fig. 4
to the side of the distal duodenum about 15mm
medial to the first stay, in preparation for a end to
side duodenoduodenostomy (Fig. 7). It is not nec-
essary to perform a diamond or kite anastomosis.
With both the proximal duodenum and distal
atretic duodenum properly aligned in close prox-
imity, the proximal and distal atretic duodenum
are opened between the stay sutures with monop-
olar hook diathermy, creating an end to side anas-
tomosis of about 15mm (Fig. 8).
The posterior walls of the duodenum are then
anastomosed together using a continuous 5/0 PDS
starting from the lateral angle and towards the me-
dial stay. The integrity of the posterior anastomo- Fig. 5
sis is now inspected to ensure that it is not neces-
sary to place reinforcing sutures (Fig. 9).
The anterior anastomosis is then completed us-
ing continuous 5/0 PDS starting from the lateral-
most angle. The completed anastomosis is then in-
spected (Fig. 10) to see if it may be necessary to in-
sert a few interrupted sutures in the anterior layer.
The falciform hitch stitch is then removed and the
duodenum is returned to its bed.
The abdomen is deflated, the purse string at the
Hasson port is tightened and skin closed with top-
ical skin adhesive.

Fig. 6
I27  Laparoscopic Repair of Duodenal Atresia 621

Fig. 7 Fig. 8

Fig. 9 Fig. 10
 622
I28 I28 Laparoscopic excision of Choledochal
cyst and Hepatico-duodenostomy
H. L. Tan
Choledochal cysts are uncommon in the western
population but are commoner in Asian children.
Most present in the first year of life, and rarely
present with the classical triad of abdominal pain,
jaundice and a palpable mass in the right upper
quadrant of the abdomen.
The diagnosis is most commonly made today
on an abdominal ultrasound during the course
of investigations for recurrent abdominal pain,
obstructive jaundice or acute pancreatitis. Spon-
taneous perforation of the choledochal cyst can
also occur. With the advent of antenatal diagno-
sis, many cases are being diagnosed in the ante-
natal period.
Todani classified choledochal cysts into several
types, the classical and commonest type being the
fusiform or saccular dilatation of the common bile
duct (type 1). Other forms are far less common.
The etiology of choledochal cyst is a subject of
debate, although the so called “common channel”
where the pancreatic duct and distal common bile
duct are joined together some distance from the
ampulla, has been implicated.
The principle of treatment of choledochal cyst
is to remove the cyst in its entirety and to perform
a hepatico- enterostomy, either a roux-en-Y which
is still the commonest operative procedure, or al-
ternatively, a cyst excision and hepatico-duode-
nostomy.
There is increasing support in recent literature
for a hepatico-duodenostomy, and this is the pre-
ferred option of the author and will be described.
Hock Lim Tan ()
Visiting Paediatric Surgeon,
Prince Court Medical Centre, Kuala Lumpur
Malaysia & Adjunct Professor Faculty of Medicine,
Universitas Indonesia, Jakarta, Indonesia
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_186, © Springer-Verlag Berlin Heidelberg 2013
H. L. Tan
Equipment
The operation should be performed with high def-
inition camera preferably using as large a video
monitor as possible.
• 5 mm 30 and 0 degree telescope
• 3 mm curved Kelly’s forceps X2
• 3 mm Reddick Olsen forceps X1
• 3 mm Manhes toothed grasper
• 3 mm Koh Needle Driver
• 3 mm Koh assistant driver
• 3 mm Metzembaum scissors
• Monopolar hook
• Tan Bipolar forceps
• 5 mm Haemalok
• Minivac drain
Trocar
• 7 mm Hasson trocar and cannula.
• 6 mm instrument trocar (X1)
• 3.5 mm instrument trocar (X2)
Pre-operative
A detailed ultrasound examination of the chole-
dochal cyst should be performed, paying attention
to the anatomy, and the presence or otherwise of
intra-hepatic biliary dilatation. A magnetic res-
onance cholangio-pancreatogram or MRCP if
available is useful to delineate the pancreatic duct.
CT scan can also be performed although the au-
thors preference is for a MRCP, due to the rela-
tively high radiation exposure required for a CT
scan. Other essential investigations includes liver
function tests and serum lipase or amylase to ex-
clude pancreatitis.
I28  Laparoscopic excision of Choledochal cyst and Hepatico-duodenostomy
Patient positioning
The patient is placed at the foot of the table and
the surgeon operates from the patient’s left side of
at the foot of the table (Fig. 1).
Fig. 1
A single video monitor is all that is required,
and it is preferable if the surgeon can be seated
and comfortable as this operation requires very
delicate manipulation and a great deal of finesse.
Port Position and Placement
The operation is performed with three instrument
ports.
A 7 mm Hasson cannula is inserted in the um-
bilicus as per our previous description and se-
cured with a purse string suture which not only
seals the opening to minimise gas leak, but also
secures the Hasson cannula to prevent acciden-
tal dislodgement.
In infants smaller than 5 kg, the entire opera-
tion can be performed by direct insertion of the
hand instruments through the abdominal wall
without the use of ports, although some gas leak-
age will inevitably occur.
The first instrument port should be inserted
in the right iliac fossa, about 5 cm inferior to the
623
liver edge taking care to avoid the inferior epi-
gastric vessels. This will allow sufficient space in-
side the abdomen to manipulate your hand in-
struments. This port is inserted with the patient
lying flat (Fig 2).
Fig. 2
A second instrument port can then inserted in
the left upper quadrant of the abdomen, so that
it is reasonably in line with the intended line of
the hepatico-duodenostomy. This can be placed
in the nipple line, or more laterally if the cyst is
very large.
Operative Technique
The patient is then tilted into approximately 20-20
degrees reverse Trendelenberg (head up) which al-
lows the colon to gravitate away from the opera-
tive field.
A transcutaneous suture is passed through the
abdominal wall, and wrapped around the falci-
form ligament where it is attached to the liver and
passed through the abdominal wall again (Fig. 3).
624
Fig. 3
External traction on this hitch stitch will lift the
liver to the anterior abdominal wall, and both
ends of the suture secured with a single artery
forceps for the entire duration of the operation.
It is usually necessary to “take down” the gas-
tro-colic omentum for adequate surgical exposure
to choledochal cyst and its deeper extension be-
hind the duodenum into the head of the pancreas.
Retrograde Cholecystectomy
A retrograde Cholecystectomy is performed, de-
taching the gall bladder off its fossa, but leaving
it attached to the cystic duct. The attached gall
bladder serves as a very useful “handle” to ma-
nipulate the choledochal cyst when you are dis-
secting it off the common hepatic artery and por-
tal vein (Fig. 4).
Fig. 5
H. L. Tan
Fig. 4
Mobilising the cyst
The common hepatic artery is usually medial to
the choledochal cyst although the right hepatic ar-
tery can cross anterior to the choledochal cyst, and
extreme care must be taken dissecting the proxi-
mal port of the choledochal cyst at its common
hepatic duct end.
The portal vein is usually posterior and is usu-
ally very closely related to the posterior wall of
the choledochal cyst.
Dissection is commenced at the lateral margin
of the cyst, where the gall bladder, and the correct
tissue plane developed. While this initial dissec-
tion can be commenced with monopolar hook,
the development of the tissue plane and identifi-
cation of the common hepatic artery is best done
using a needle point laparoscopic bipolar forceps
(Tan bipolar) to mininise lateral damage and to
I28  Laparoscopic excision of Choledochal cyst and Hepatico-duodenostomy 625

avoid inadvertent injury to the common hepatic

artery.
Once the common hepatic artery is separated
from the choledochal cyst, the posterior wall of
the choledochal cyst is separated from the under-
lying portal vein (Fig. 5). This may challenging
particularly in patients with previous cholangitis
in which case, the cyst is opened and the dissection
of the posterior wall away from the portal vein is
performed from within the cyst.
The junction of the cyst to the common hepatic
duct is identified and divided. If the common he-
patic duct is narrow, it is preferable to leave a small
cuff of choledochal cyst attached to the common Fig. 6
hepatic duct to make for an easier anastomosis.

The lower end

The choledochal cyst now detached from the prox-

imal common hepatic duct, should be grasped
with the toothed Manhes grasper inserted directly
through the abdominal wall without a trocar, and
the entire cyst complex lifted upwards towards the
anterior abdominal wall. This countertraction will
allow you to mobilize the choledochal cyst from
Pancreas and to carefully seperate it from the pan-
creatic head. The dissection plane should be on the
cyst itself, to avoid injury to the pancreatic duct. Fig. 7
The distal normal bile duct should be clipped
with two “Hemalocks” and divided (Fig. 6).
The choledochal cyst should then be “parked”
between the liver and the diaphragm and atten-
tion turned to the common hepatic duct to con-
firm that both the right and left hepatic ducts are
not divided (Fig. 7).

Hepatico-Duodenostomy

Minimal mobilization of the Duodenum is re-

quired. Because this operation is performed in
situ, the 2nd part od Duodenum abuts the com- Fig. 8
mon hepatic duct. An appropriate site on the 2nd
part on the Doudenum 2 cm distal to the vein of
Mayo is identified and a longitudinal full thickness
incision made in the Duodenum corresponding to
the width of the common hepatic duct.
626 H. L. Tan

The duodenum is then anastomosed to the

common hepatic duct with continuous 5/0 Poly­
diaxanon (PDS) to the posterior layer. The an-
terior anastomosis is also completed in a similar
fashion (Fig. 8).
The anastomosis is observed for a few minutes
to eliminate a significant bile leak. It may be nec-
essary to place a few reinforcing sutures to the an-
terior anastomosis.
The Right Iliac Fossa instrument is then re-
moved and the minivac drain inserted through
this and placed in the vicinity of the anastomosis.
The choledochal cyst complex is then re-
moved through the umbilicus port and the inci-
sions closed. The mini ports are usually closed
with Octyl Cyanoacrylate.
A nasogastric tube is left on free drainage and
removed usually within 24 hours and fluids com-
menced. The minivac drain should be removed
once you are assured that there is no bile leak.
I29  Management of Upper Urinary Tract Calculi
I29 Management of Upper Urinary Tract
Calculi
H. L. Tan
Renal calculi are rare in children and accounts for
about 1–3 percent of all patients presenting with
urinary calculi. Unlike in adults where the great
majority of stones are idiopathic, it is not uncom-
mon to find an infective, or metabolic cause. An
underlying anatomical abnormality may also pre-
dispose to the formation of calculi, particularly
if the patient has had a proteus urinary tract in-
fection. Bladder stones are particularly prevalent
in children following bladder augmentation. In-
fective calculi are usually soft, containing organic
matrix, and may be poorly opacified.
Hypercalciuria is the most common meta-
bolic abnormality, followed by cystinuria, hyp-
eroxaluria, hyperuricosuria, and unclassified hy-
percalcemia. Aboriginal children in the outback
of Australia are particularly susceptible to uric
acid stones.
Preoperative Evaluation
Radiology
The main imaging modality for upper urinary
tract stones is ultrasound. Ureter may be difficult
to visualize in children, although indirect evidence
of mild ureteric dilatation may indicate the pres-
ence of a stone.
A plain abdominal x-ray of the whole urinary
tract may be useful in children, and a limited in-
travenous urogram may be required to detect ra-
dioluscent stones in the distal ureter.
A dimercaptosuccinyl acid (DMSA) scan or
mercaptoacetyl-triglycine (Mag3) may provide
functional information of the kidneys except in
Hock Lim Tan ()
Visiting Paediatric Surgeon,
Prince Court Medical Centre, Kuala Lumpur
Malaysia & Adjunct Professor Faculty of Medicine,
Universitas Indonesia, Jakarta, Indonesia
R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery
DOI: 10.1007/978-3-642-20641-2_187, © Springer-Verlag Berlin Heidelberg 2013
627
I29
the presence of upper tract infection when there
may be poor uptake of DMSA by the renal cortex.
A MAG3 scan is better if obstruction is suspected.
Urinalysis
Routine microscopy and urine culture should be
performed. Other investigations of use is urinary
calcium, urate, oxalate, cystine, and creatinine.
Any stone should be sent for chemical compo-
sition analysis.
Plasma
Blood investigations should include creatinine,
urea, electrolyte profile, magnesium, calcium,
phosphate, alkaline phosphatase, albumin, and
urate. Reecurrent calculi strongly suggests a met-
abolic cause.
Management Options
Extracorporeal shock-wave lithotripsy (ESWL),
Percutaneous nephrolithotomy (PCNL), and ure-
terorenoscopy (URS) have almost replaced open
surgery for renal calculi in children.
The aim of treatment is to clear the stone bulk
with minimal damage to the functioning of re-
nal tissue. An infected and obstructed collecting
system must be drained urgently by percutane-
ous nephrostomy.
Any patient undergoing any form of interven-
tion or stone manipulation should be adminis-
tered intravenous antibiotics perioperatively on
the presumption that the stone is infective in or-
igin.
The treatment modality/modalities chosen will
depends on the age of the patient, the stone bur-
den etiology, pelvicalyceal anatomy, including any
co-morbidities.
628
Extracorporeal shock-wave lithotripsy
First performed in 1980, the principle of shock-
wave lithotripsy is to shatter a stone into smaller
fragments, to enable the stone fragments to pass
spontaneously. High energy shock waves gener-
ated outside the body are reflected via an exter-
nal parabolic dish to a distant focal point. The pa-
tient is positioned using ultrasound or image in-
tensifier so that the calculus is at this focal point.
While the latest lithotripsy machines employs
a water filled cushion instead of a water bath to
couple the shock waves, allowing adults to be
treated under sedation, in practice, it is difficult to
maintain the child in the same position (typically
30-45 minutes), and general anesthesia should be
utilized in children.
Modifications to the gantry is necessary when
performing ESWL in young children to prevent
the child from falling through the table, and it will
be necessary to place an additional water cuopler,
usually a large saline bag, to focus the beam onto
the stone, as the stones are usually much shallower
than those in adults. It is important to shield the
thorax with polystyrene foam to prevent the shock
waves from injuring the lung in infants. Haemop-
tysis and lung damage has been reported in young
children undergoing ESWL.
In practice, ESWL is best for children with id-
iopathic stones. Infective matrix stones are usually
soft with a consistency of mud and can be diffi-
cult to fragment. Likewise, metabolic stones, es-
pecially cysteine stones are too hard for ESWL to
be effective, and these usually occur in small in-
fants. The long-term effects of ESWL on the de-
veloping kidney is unknown.
Percutaneous nephrolithotomy
Percutaneous nephrolithotomy involves creating a
nephrocutaneous tract which allows the urologist
to manipulate, fragment and remove the stones
under direct visualization. Teamwork is essential
and the urologist has to work in close association
with the interventional radiologist in planning the
optimal puncture site.
H. L. Tan
The aim of the interventional radiologist is to
establish percutaneous access to the collecting sys-
tem to enable the surgeon to create an operating
channel.
There are special challenges in performing
PCNL in young children. Unlike adults, the kid-
ney is very mobile and can move away from the di-
lators during dilatation, resulting in loss of tract.
Children with unobstructed upper tract stones
also have a much smaller collecting systems than
in adults, compounding this problem. While it is
routine in adults to perform a “supra 12” punc-
ture (accessing the collecting system above the 12th
rib), this may result in pneumothorax because of
the proximity of the lung to the kidney.
We have developed a technique to safely per-
form PCNL even in very young infants which mi-
nimises the risk of losing the tract.
Patient preparation
The parents should be aware of the risks of bleed-
ing, hypothermia, water overload and post oper-
ative urosepsis. Young children are still prone to
develop serious urosepsis particularly when treat-
ing infective stones even if peri-operative antibi-
otics are administered.
Equipment for PCNL in children
1. 14 Fr Paediatric cystoscope with offset lens
This telescope has a straight 5Fr operating
channel which allows the surgeon to manipu-
late stones and to fragment the stone with the
laser fibre through
2. 18Fr dilator with peel away sheath
3. Holmium laser
4. 200 or 400 micron laser fibres
5. An assortment of graspers and stone baskets
6. Minor operating set
Although it is possible to use the “lithoclast”, in
practice it is too long to be used for PCNL in chil-
dren and our preference is to use the Holmium
laser.
I29  Management of Upper Urinary Tract Calculi 629

Operation technique

“Single Pass Common Rail Percutaneous

Access”

This procedure is performed with an interven-

tional radiologist and a paediatric urologist work-
ing hand in hand.
A percutaneous renal puncture is performed by
the interventional radiologist in the most appro-
priate calix which is usually the lower pole medial
calix, identified during a planning exercise with
the surgeon. After puncturing the kidney with
a nephrostomy needle (Fig. 1a), the radiologist
passes a guidewire into the bladder and if possi- Fig. 1
ble, out through the urethra to be retrieved by the
attending surgeon.
The alternative is to leave several coils of guide
wire in the bladder in which case an extra long 5fr
“Cope” nephrostomy tube is passed over the guide
into the bladder, if the guide wire is coiled within
the bladder. (Fig. 1b)
A cystoscopy is then performed to retrieve the
guide wire, creating a “common rail”. (Fig. 2) A
5fr retrograde angiographic catheter in inserted
under image intensifier to sit just at the UPJ. A
Foley’s catheter is then inserted and the angio-
graphic catheter and the common rail guide wire
fixed to the foley to prevent accidental dislodge-
ment. We use a 10 cm length of 1" sleek which is Fig. 2
first attached to the foley catheter, and the angio-
graphic catheter and guide sandwiched between
an omentum of sleek.
The patient is then positioned prone on the op-
erating table to ensure that there is adequate room
for the C arm to be positioned without obstuction
during the procedure. This is an important check.
A small radioluscent foam cushion is placed be-
tween the kidney and the operating table as a soft
buttress to stabilise and prevent the kidney from
pushing away during renal puncture. The angi-
ographic catheter and the guide wire previously
retrieved is then passed between the patients legs
and positioned within the operating field so that
the surgeon has access to the angiographic cathe-
ter and both ends of the previously inserted guide. Fig. 3
(Fig. 3)
630
The patient is then draped with a large dispos-
able neuroincise drape which keeps the patient
completely dry during the procedure, to allow
fluids to run off during PCNL will into the bag.
Before commencing the procedure, the “C” arm
should be positioned and a still image obtained
to ensure that there is no radio-opaque heater el-
ements, ECG leads etc which may interfere with
the imaging.
A small full thickness skin incision is made at
the nephrostomy puncture site and a straight hae-
mostat used to dilate the underlying fascia and
lumbar musculature. (Fig. 4)
An 18 Fr dilator is then passed over the “com-
mon rail”, (with its peel away sheath), and passed
into the renal pelvis under direct radiological guid-
ance Fig. 5a, 5b. It is usually necessary to image
the collecting system by performing a limited ret-
rograde pyelogram using the previously inserted
angiographic catheter.
Once the tip of the dilator is correctly posi-
tioned in the renal pelvis, evident on the imaging
(Fig. 5b), the peel away sheath is then advanced
over the dilator into the collecting system. The
Fig. 5
H. L. Tan
peel away sheath serves as an “Amplatz” sheath
and can be peeled down to the appropriate length
to accommodate the infant operating cystoscope.
This is a very secure method of dilating the
tract. As it is “railroaded” over the guide wire with
very little chance of dislodgement or loss of tract.
It is not necessary to perform serial dilatations. In
earlier studies, we demonstrated that most of the
bleeding occurs during the interchange of dila-
tors. We have also found that performing a single
pass using an 18fr dilator does not split the kidney.
Nephroscopy can then be performed in a vir-
tually bloodless field and the stones fragmented.
Smaller pieces of stone will be flushed out with the
irrigant, but larger pieces can be removed with the
assortment of graspers.
Following stone clearance, a 8Fr “cope” neph-
rostomy catheter is passed over the guide wire into
the ureter and then retracted slowly while tugging
on the “string” gently, to place the loop accurately
within the renal pelvis.
Fig. 4
I29  Management of Upper Urinary Tract Calculi 631

Points of technique:

1. Your assistant must hold onto the peel away

sheath at all times or it will dislodge.
2. Use 2 liter saline bags which should not be
more than 30cm above the patient ie this pro-
cedure has to be performed under low hydro-
static pressure.
3. Ensure that the irrigation fluid freely drains out
the peel away sheath, does not pool on the pa-
tient and runs off into the neuro-incise drain-
age bag.
4. The Holmium laser fibre should be positioned
in very close proximity to, but not touching the
stone as you may end up drilling a hole in the
stone which entraps the laser fibre.
5. Do not activate the holmium laser unless the
fibre tip is clearly visible. Activating the laser
inside the telescope may result is fracturing of
the lens system due to the shock wave gener-
ated.
6. A strong odour of sulpur is almost certainly
due to a cysteine stone.
7. Remove stents and or nephrostomy tubes very
early in children with cysteine stones. They have
a propensity to very quickly form stones over
any stent.
 APPENDIX
Training in
Paediatric Surgery

App. 1 Syllabus for training in paediatric G. Haddock

surgery in the United Kingdom

App. 2 The European syllabus for training R. Carachi

in paediatric surgery
For information refer to the EUPSA web-
site or www.paediatricsurgeryexam.org

R. Carachi, S. Agarwala, T. J. Bradnock (Eds), Basic Techniques in Pediatric Surgery

DOI: 10.1007/978-3-642-20641-2, © Springer-Verlag Berlin Heidelberg 2013
  Training in Paediatric Surgery
Training in Paediatric Surgery
G. Haddock
Training in Paediatric Surgery in the UK is di-
vided into two parts:
• Core Surgical Training 2–3 years
• Higher Surgical Training 6 years
Details of the syllabus of both Core and Higher
Surgical training can be found on the Intercol-
legiate Surgical Curriculum Programme (www.
iscp.ac.uk).
The level of skill and knowledge expected at
each stage of training is noted in the syllabus as
follows:
Level of knowledge
• Level 1 knows of
• Level 2 knows basic concepts
• Level 3 knows generally
• Level 4 knows specifically & broadly
Clinical & technical skills
• Level 1 has observed
• Level 2 can do with assistance
• Level 3 can do whole but may need assistance
• Level 4 competent to do without assistance
– trainee is at Certificate of Comple-
tion of Training (CCT) level
Trainees in the early years of training will be ex-
pected to have reached levels 1-3 in both knowl-
edge and skills. Trainees nearing completion of
training will be expected to be at level 4 in most
topics and procedures.
Core Surgical Training (CST)
CST can be generic or themed. Generic training
rotations will expose the trainee to a wide range of
surgical specialties without focussing on any par-
ticular specialty. Themed core training will have
as its focus one of the surgical specialties that the
trainee wishes to continue as their higher surgi-
cal training.
635
There are 10 modules in CST that every trainee
must cover. These are:
• Module 1: Basic science knowledge relevant
to surgical practice
• Module 2: Common surgical conditions
• Module 3 Basic surgical skills
• Module 4: The principles of assessment and
management of the surgical pa-
tient
• Module 5: Peri-operative care of the surgical
patient 
• Module 6: Assessment and early treatment of
the patient with trauma
• Module
�����������������������������������������������
7: Surgical care of the paediatric pa-
tient
• Module 8: Management of the dying patient
• Module 9: Organ and tissue transplantation
• Module 10: Professional behaviour
In addition, any trainee wishing to progress to
higher training in Paediatric Surgery must have
undertaken a six month post in Paediatric Sur-
gery and have covered the following topics in their
learning plan:
• Basic science 
• Child with abdominal pain
• The vomiting child
• Trauma in children
• Child with groin conditions
• Abdominal wall pathology
• Paediatric urology
• Child with constipation
• Head or neck swelling 
• Emergency paediatric surgery
Higher Surgical Training (HST)
HST in Paediatric Surgery is divided into two parts:
• Intermediate – years 1 and 2 after CST (also
known as ST3 and 4)
• Final – years 3–6 after CST (also known as ST5-8)
636
Topics in Higher Training in Paediatric Surgery
fall into different subsections:
• General Surgery of Childhood
• Gastrointestinal Surgery
• Neonatal Surgery
• Oncological Surgery
• Endocrine Surgery
• Thoracic Surgery
• Paediatric Urology
• Other surgical disciplines
• Operative skills
Assessment of Higher Surgical
Training
Paediatric Surgery trainees are continually as-
sessed throughout their training. At the beginning
of each attachment a learning agreement (LA) is
negotiated with the trainee’s assigned educational
supervisor. The LA outlines what is expected of
the trainee and what the trainer and the depart-
ment should expect to offer the trainee in terms
of support and learning opportunities.
During training, trainees complete a series of
workplace-based assessments, these include:
• Procedure based assessments (PBAs)
– PBAs assess trainees’ technical, operative
and professional skills in a range of spe-
cialty-specific procedures or parts of pro-
cedures during routine surgical practice up
to the level of CCT.
• Mini clinical evaluation exercise (mini-CEX)
– The assessment involves observing the
trainee interact with a patient in a clinical
encounter. The areas of competence cov-
ered include: history taking, physical ex-
amination, professionalism, clinical judge-
ment, communication skills, organisation/
efficiency and overall clinical care.
• Direct Observation of Procedural Skills in Sur-
gery (SDOPS)
– Surgical DOPS is used to assess the trainees’
technical, operative and professional skills
in a range of basic diagnostic and interven-
tional procedures, or parts of procedures,
during routine surgical practice and facili-
tate developmental feedback.
G. Haddock
• Case-based discussions (CBDs)
– These are structured, in-depth discussions
between the trainee and assigned educa-
tional supervisor about how a clinical case
was managed by the trainee.
• Multisource feedback (MSF)
– The MSF is a method of assessing profes-
sional competence within a team-working
environment and providing developmental
feedback to the trainee.
All of these workplace based assessments are meant
to be formative. This means that they are assess-
ments to inform training and not assessments of
training. In other words, they are meant to identify
for the trainee areas where improvement is needed,
to allow the trainee to address deficiencies.
The minimum number and type of WBA’s in
Paediatric Surgery to be completed by trainees in
Paediatric Surgery each year are outlined below:
ST3 to ST8 – for each 12 month period in Pae-
diatric Surgery at that level
CBD Mini-CEX SDOPS PBA MSF
ST3-4 4 4 2 12 1 (year 3)
ST5-6 6 4 0 12 1 (year 5)
ST7-8 6 4 0 12 1 (year 7)
For years ST3 to ST8 it is recommended that each
PBA undertaken should be done at least twice in
each two year block (and preferably, if at all pos-
sible, in one year). This will allow trainees and
trainers to determine whether progress in opera-
tive skill has been achieved. Table 1 shows an in-
dicative list of procedures for each of the three two
year blocks of training from ST3 to ST8.
Trainees are also required to keep a logbook of
operative procedures and to develop their curricu-
lum vitae in terms of audit’s completed, research
work carried out, presentations made at scientific
meetings and papers published.
The WBAs, logbook, and curriculum vitae are
assessed against the learning agreement at the end
of each training year at the Annual Review of
Competence progression (ARCP).
More details about the curriculum for Paedi-
atric Surgery and Core Surgical Training can be
found on the ISCP website (see above).
  Training in Paediatric Surgery 637

Table 1
Category Years 3-4 (Intermediate) Years 5-6 (Final 1) Years 7-8 (Final 2)
Neonatal Pyloromyotomy Operative closure of gas- Operative closure of gas-
Surgery Operative closure of gas- troschisis/exomphalos troschisis/exomphalos
troschisis/exomphalos Repair congenital dia- Repair oesophageal atresia
Laparotomy for intestinal atresia phragmatic hernia Repair congenital dia-
Colostomy Correction of malrotation phragmatic hernia
Laparotomy for NNEC Correction of malrotation
Laparotomy for simple Laparotomy for NNEC
meconium ileus Laparotomy for simple/
Duodenoduodenostomy complex meconium ileus
Neonatal inguinal herniotomy Duodenoduodenostomy
Gastro- Flexible upper/lower Subtotal colectomy Subtotal colectomy
intestinal GI endoscopy and ileostomy and ileostomy
Surgery Change or removal of PEG tube Right hemicolectomy Right hemicolectomy
Insertion of PEG tube Small bowel resection Small bowel resection
for Crohn’s disease for Crohn’s disease
Pull-through for
Hirschsprung’s disease
PSARP
Uro- Cysto-urethroscopy Distal hypospadias repair Proximal hypospadias repair
logical Circumcision Open nephrectomy Reimplantation of ureter
Surgery Exploration of acute scrotum Open heminephrectomy Open nephrectomy
Insertion of perito- Closure of vesicos- Open heminephrectomy
neal dialysis catheter tomy or urostomy Bladder augmentation
Pyeloplasty Pyeloplasty
Laparo- Laparoscopic appendicectomy Laparoscopic fundoplication Laparoscopic fundoplication
scopic Laparoscopy for im- Laparoscopic cholecystectomy Laparoscopic nephrectomy
Surgery palpable testis Laparoscopic assisted inser- Laparoscopic cholecystectomy
Laparoscopic Fowler Ste- tion of gastrostomy tube
phen’s procedure Laparoscopic pyloromyotomy
Laparoscopic liga-
tion of varicocele
Oncologi- Cervical lymph node biopsy Tumour nephrectomy Resection of neuroblastoma
cal Sur- Insertion of portacath
gery Open insertion of CVL
Percutaneous insertion of CVL
Thoracic Thoracotomy Thoracotomy and lo- Thoracotomy and lo-
Surgery bectomy for CCAM bectomy for CCAM
Thoracoscopic decortica- Thoracoscopic decortica-
tion for empyema tion for empyema
Thoracoscopic resection Thoracoscopic resection
of mediastinal mass of mediastinal mass
General Open appendicectomy Laparotomy for trauma Laparotomy for trauma
Surgery Open reduction of in- Laparotomy and divi- Laparotomy and divi-
tussusception sion of adhesions sion of adhesions
Epigastric hernia repair
Ligation of PPV
Umbilical hernia repair
Orchidopexy
Inguinal herniotomy
– non-neonatal
Subject Index
A –– suction rectal  338
abscess 150
–– collar-stud 150
access 76
–– central venous  82
–– intraosseous 76–78
–– peripherally inserted
central catheter  77
–– venous 76
–– venous cut-down  78–80
anal fissure  490
–– dilatation 490
–– lateral anal sphincteroto-
my 490
ankyloglossia 145
anterior ectopic anus  496,
497
appendectomy 294
–– complications 299
–– inversion 294
appendectomy, open  296
approach, extrapleural  214
arthritis, septic  192
arthrotomy, hip  193
atresia 290
–– back-resection 292
–– jejunoileal (small bo-
wel) 290
–– type I  292
auricle 137
–– accessory 137
B –– peripherally inserted
bandage  29, 105
–– Esmarch  29, 105
Bentley, John Francis Ro-
gers 352
biliary atresia  364
–– Kasai procedure  364
biopsy  87, 90, 149, 202
–– core 89
–– extremity tumour  202
–– fine-needle aspira­
tion 87
–– laparoscopic 87
–– lymph node  149
–– muscle  90, 91
–– open 87
–– open rectal  339
–– percutaneous 87
–– seromuscular colo-
nic 345
–– skin 90
Subject Index
–– tumour 87
–– ultrasound-guided 89
bone  148, 158
–– hyoid 148
–– skull 158
bowel
–– anastomosis 298
–– resection 298
bronchoscopy  167, 222
–– rigid 222
Browne, Sir Denis 382
burr hole  157
button vesicostomy  611
–– equipment 611
–– evolving indica-
tions 611
–– operative tech-
nique 611
–– patient positioning  611
–– pre-operative prepara­
tion 611
C –– complica­tions in
cannula 76
casting  176, 188
–– Hyndman’s cast ra-
tio 176
–– spica 188
catheter  77, 82, 85
–– central venous  82, 95
–– Malecot 261
central 77
–– portacaths  82, 85
chart, Lund and Brow-
der 73
Cheatle’s cut  281, 291
chest tube  211
–– complications 213
–– insertion  211, 212
–– safe triangle  211
choledochal malforma­
tion 366
–– biliary reconstruc­
tion 366
–– excision 366
–– forme fruste  367
–– King’s College Hospital
Classifica­tion  367
circumcision 398–400
–– complica­tions  401
–– urethral meatoto-
my 403
clamp
–– Doyen bowel  14, 15
–– protected bulldog  14,
16
–– cleft lip  128
–– bilateral repair  128, 129
–– unilateral repair  128,
129
cleft palate  128, 131
–– Furlow repair  131
–– Langenbeck repair  131
clips 11
–– Duff towel  11
closure, mass  46
colectomy 286
–– complica­tions  289
–– subtotal 286
–– technique 287
colostomy
–– closure 522
–– complica­tions  523
–– in anorectal malforma­
tion 522–524
–– crea­tion  519
anorectal malforma­
tion 521
–– for anorectal mal­
forma­tion  519, 520
compartment syndro-
me 95
–– clinical features  95
conduit diversion  465
–– colonic conduit  466
–– complications 467
–– ileal conduit  465
–– indications 465
congenital diaphragmatic
hernia 312
–– patch 313
–– subcostal laparoto-
my 312
continent catheterisable
conduit 471
–– alternatives to the appen-
dix 472
–– complications 472
–– indication 471
–– Mitrofanoff princip-
le 471
contracture, flexion  64
Cushing, Harvey  25
cut, Cheatle’s  281, 291
cyst 125
–– external angular dermo-
id 125
639
–– internal angular dermo-
id 125
–– branchial 138
–– thyroglossal 147
cystourethroscopy 433
–– complications 434
D
diagnostic laparoscopy (non-
palpable undescended
testis) 589
–– equipment 589
–– intraoperative fin-
dings 589
–– patient positioning  589
–– port positioning and
placement 589
–– pre-operative work-
up 589
diaphragmatic eventra­
tion 314
–– operative tech-
nique 314
diathermy  21, 23, 24
–– bipolar  12, 21, 22
–– mode of action  21
–– monopolar  12, 21, 22
–– safety 22
dish 11
–– Gallipots 11
–– kidney 11
dissector, Watson Chey-
ne  17, 20
dorsal slit of the fores-
kin 402
–– complications 403
drain  107, 226
–– chest 226
–– corrugated 108
–– dressings 107
–– fixation 107
–– tube 108
–– types 107
–– Wick’s 108
–– Yate’s 108
draping 8
–– square 8
–– triangular 8
drill, handheld twist  17, 19
duct  144, 151, 165
–– accessory thoracic  151
–– submandibular 144
–– thoracic  151, 165, 166
duodenal atresia  322
640
–– diamond-shaped anasto-
mosis (Kimura)  323
–– duodenal membrane/
windsock 324
–– repair 322
dura 171
E –– lower-limb 95
ear deformity  134
elevator 17
–– Cobb spinal  17, 19
–– Pennybacker  17, 19
empyema 218
–– complications 221
–– definition 218
–– management 218
–– open decortica-
tion 218–220
encysted hydrocele of the
cord  377, 378
endoscopy 245
–– colonoscopy 254
–– complications 245
–– pre-operative check-
list 245
–– proctoscopy 252
–– rigid sigmoidosco-
py 252
–– upper gastrointesti-
nal 245
enterostomy 278
–– complications 278
–– loop 278
–– Bishop–Koop distal chim-
ney 335
–– Mikulicz double-bar-
relled 336
–– Santulli–Blanc 335
epigastric hernia  268
–– repair 268
ex-utero intrapartum treat-
ment (EXIT)  151
exomphalos 275
–– conservative treat-
ment 275
–– primary closure  275
–– silo application  276
–– staged repair  276
extracorporeal life sup-
port 239
–– cannulation 239
–– technique 240
–– complications 241
–– decannulation 241
–– principles 239
–– veno-arterial 239
–– veno-venous 239
F –– greenstick  174, 175
fascia 171
–– erector spinae  171
–– thoracolumbar 171
fasciotomy 95
–– compartment syndro-
me 95
femoral hernia  386
–– repair 386
filum terminale  171
fistula  147, 224, 233
–– bronchopleural 233,
236
–– H-type tracheo-oesopha-
geal 166
–– thyroglossal 147
–– tracheo-oesophage-
al 224
fistula-in-ano 493
–– opening 494
fixation, external  190
flap, Buck–Gramcko 196
Folkman, Judah 333
forceps 11
–– Adson tissue (non-
tooth)  11, 12
–– Adson tissue (tooth)  12
–– Allis  14, 15
–– Babcock  14, 15
–– bipolar diathermy  21
–– broad non-tooth  12
–– Charnley–McIndoe 12
–– curved Kelly (mosquito)
artery  14, 16
–– DeBakey vascular  12
–– McGill’s 222
–– Mixter 14
–– Rampley sponge-hol-
ding 11
–– straight artery  14, 16
–– forearm 174
–– Hyndman’s cast ra-
tio 176
–– manipulation 174
–– plaster of Paris  176
–– diaphyseal reduc-
tion 181
–– unstable diaphyseal
fractures 181
foreign body, bronchoscopic
removal 222
fracture  29, 184
–– Colles’ 29
–– displaced supracondylar
humeral 184
–– femoral  101, 188
–– forearm manupulation 
–– molded cast  174
–– plastic deforma­
tion 174
–– Salter-Harris 174
–– tibial diaphysis  190
–– external fixation  190
fundoplication 270
–– complications 272
–– open Nissen  270
G pair 423–425
gastric pull-up  317
–– complications 321
–– mobilization 318
–– in the abdomen  318
–– of oesophagosto-
my 317
–– oesophago-gastric anas-
tomosis 320
gastroschisis 273
–– primary closure  273
–– silo application  274
gastrostomy 260
–– complications  262, 265
–– correct positioning  262
–– percutaneous endosco-
pic 263
–– Stamm  260, 271
gland 151
–– salivary 151
–– thyroid 153
Gross, Robert E. 227
H
haematoma 94
haemorrhage  68, 70
–– control 70
–– stabilisation 68
haemostasis 67
–– methods  67, 68
–– principles 67
Halstead, William Ste-
wart 10
hemicolectomy, right  283
Hirschsprung disease  341,
344, 353
–– myomectomy 349–351
–– rectosigmoid 341
–– ultrashort segment  349
Hirschsprung, Harald 340
Holter, John  159, 162
hydrocele 380
hydrocephalus 159
hypospadias surgery  413
Subject Index
–– artificial erection
test 416
–– chordee assess-
ment 416
–– classification of hypospa-
dias  413, 414
–– complications 422
–– double-Y glanuloplasty
technique 416
–– general principles  413
–– glandular and coro-
nal hypospadias re-
–– glans configuration  415
–– inverted-Y modified
Mathieu repair  417
–– inverted-Y modified
Thiersch technique  418
–– lateral-based flap tech-
nique 419
–– management princip-
les 413
–– objectives of surge-
ry 414
–– suturing tech-
niques 415
–– two-stage hypospadias
repair (1st stage)  426–
428
–– two-stage hypospadias
repair (2nd stage)  429,
430
–– urethral reconstruction
using buccal muco-
sa 420
I
ileocystoplasty  468, 469
–– complications 470
ileostomy 286
–– complications 289
–– technique 288
imperforate hymen  410
–– complications 412
incision 37
–– Bikini 51
–– classic McBurney  50
–– Gridiron 50
–– hockey-stick  46, 52
–– Kocher 43
–– Lanz  50, 51
–– Mercedes-Benz  43, 45
–– midline 40
–– modified Mc-Burney  51
–– muscle-splitting 50
–– paramedian 40
–– Pfannenstiel 47
Subject Index 641

–– Rocky-Davis 51 –– half-hitch 56 –– port positioning and laparoscopic inguinal hernio-

–– rooftop  43, 45
–– Rutherford Morison  50,
52
–– subcostal 43
–– transverse supraumbili-
cal 37
–– zigzag  195, 198
infection  192, 195
–– musculoskeletal 192
–– washout 192
–– of the hip  192
–– of the knee  192
inflammatory bowel di-
sease 371
–– completion proctecto-
my 372
–– J-pouch ileoano-
plasty 372
–– perianal disease  372
–– small bowel resec­
tion 371
–– small bowel stricture-
plasty 371
inguinal canal, exposu-
re 377
inguinal hernia  380, 381
–– incarcerated 383
–– sliding 380
inguinal herniotomy  377,
378, 380
–– complications 382
–– pre-peritoneal ap-
proach 383
–– testicular atrophy  385
intussusception 303
–– air-enema reduc­
tion  303, 305
–– complications 305
–– non-operative manage-
ment 303
–– operative reduction  303
–– outcome 303
–– pathological lead
point 303
K –– operative tech-
Kasai, Morio 365
Kelly, Howard 20
kidney surgery  439
–– approaches 439
–– anterolateral retrope-
ritoneal 439
–– posterior 440
–– transperitoneal 439
knots 56
–– basic principles  56
–– simple 56
–– slip 57
–– square 56
–– surgeon’s 57
–– triple-throw 56
L nique 607
labial adhesion  410
–– separation 410
laceration  121, 132
–– ear 132
–– facial 123
–– lip 132
–– tongue 132
Ladd bands  293
Ladd, William E. 295
Langer, Karl 34
Langer’s lines  34, 35
laparoscopic appendecto-
my 572
–– equipment 572
–– operative tech-
nique 573
–– patient positioning  572
–– port positioning and
placement 572
laparoscopic button place-
ment for antegrade colo-
nic enema (ACE)  575
–– Chait TrapDoor but-
ton 576
–– complications 576
–– indications 575
–– operative tech-
nique 575
laparoscopic cardiomyoto-
my 562
–– equipment 562
–– exposure of the intra-
abdominal oesopha-
gus 562
–– liver retraction  562
–– oesophageal myoto-
my 563
nique 562
–– pre-operative prepara­
tion 562
laparoscopic cholecystecto-
my 586
–– equipment 586
–– gallstone presenta­
tion 586
–– operative tech-
nique 587
–– patient positioning  586
placement 587
–– pre-operative prepara­
tion 586
laparoscopic dismembered
pyeloplasty 607
–– equipment 607
–– operative tech-
–– patient positioning  607
–– port positioning and
placement 607
–– pre-operative prepara­
tion 607
–– stenting 609
–– suture require-
ments 607
–– laparoscopic Duhamel
pull-through 580
–– complications 582
–– equipment 580
–– indications 580
–– operative tech-
nique 580
–– patient positioning  580
–– pre-operative manage-
ment 580
laparoscopic excision of cho-
ledochal cyst  622
–– equipment 622
–– operative tech-
nique 623–625
–– patient positioning  623
–– port positioning and
placement 623
–– pre-operative prepara­
tion 622
laparoscopic Fowler–Ste-
phens orchidopexy  592
–– equipment 592
–– operative technique (1st
and 2nd stages)  593
–– patient positioning  592
–– port positioning and
placement 593
–– pre-operative prepara­
tion 592
laparoscopic fundoplica-
tion 565
–– equipment 565
–– hiatal exposure  567
–– liver retraction  565
–– operative tech-
nique 565
–– patient positioning  565
–– port positioning and
placement 565
–– pre-operative prepara­
tion 565
tomy 598
–– equipment 598
–– operative tech-
nique 598
–– patient positioning  598
–– port positioning and
placement 598
laparoscopic pyloromyoto-
my 569
–– equipment 569
–– operative tech-
nique 569–571
–– patient positioning  569
–– port positioning and
placement 569
–– pre-operative prepara­
tion 569
laparoscopic repair of duode-
nal atresia  618
–– equipment 618
–– operative tech-
nique 619
–– patient positioning  618
–– port positioning and
placement 619
laparoscopic splenecto-
my 583
–– equipment 583
–– indications 583
–– operative tech-
nique 584
–– patient positioning  583
–– port positioning and
placement 583
–– pre-operative prepara­
tion 583
laparoscopic surgery  527
–– cognitive skills  527
–– complications 530
–– anaesthetic complica-
tions 531
–– argon-beam coagula-
tor 538
–– bleeding 533
–– capacitive coup-
ling 536
–– direct coupling  536
–– electrocautery com-
plications 541
–– electrosurgical com-
plications 535
–– gas embolism  533
–– haemorrhage 534
–– incidence 530
–– lasers 538
–– of pneumoperito-
neum 530
642 Subject Index

–– patient posi­
tioning 531
–– equipment 614
–– operative tech-
–– Santulli–Blanc enterosto-
my 335
O
–– surgical emphyse- nique 614 –– T-tube ileostomy  335 oesophageal atresia  224
ma 532 –– patient positioning  614 midgut volvulus  293 –– repair  224, 225
–– tension pneumotho- –– port positioning and molded cast  174 –– long-gap 317
rax 532 placement 614 mycobacterium, atypi- oesophagostomy  163, 317
–– trocar complica- –– pre-operative prepara­ cal 150 –– cervical  163, 164
tions 533 tion 614 omphaloplasty 266
–– urinary tract inju- ligation of patent processus orchidectomy  377, 378
ry 537
–– ventral hernia  537
vaginalis  377, 378, 380,
381
N orchidopexy (open)  377,
378, 404
–– Veress needle  532 –– complications 382 necrotising enterocoli- –– complications 406
–– visceral injury  536 linea alba  41 tis 325 ovarian surgery  407
–– energy sources  539 liver –– clip and drop  325 –– ovarian transposition be-
–– electrocautery 539 –– principles of surge- –– open and close laparoto- fore radiotherapy  409
–– gyrus plasma kine- ry 361 my 325 –– resection of benign
tic 539 –– resection 362 –– primary peritoneal cyst  407, 408
–– Ligasure 540 –– segmental anato- drain 325
–– ultrasonic ener- my  361, 362 –– resection and primary
gy 540
–– ergonomics 527
local anaesthesia  26–31
–– Bier’s block  29
anastomosis 325
–– resection and stoma
P
–– heuristics 527 –– digital nerve block  30, formation 325 pancreatic pseudocyst  369
–– laparoscopic sutu- 31 –– second look laparoto- –– surgical cyst-gastrosto-
ring 529 –– field block  27 my 325 my 369
–– non-stereoscopic naviga- –– inguinal block  27, 28 needle holder  15 –– treatment options  369
tion 528 –– intercostal block  29, 30 –– Crile-Wood  15, 17 parotidectomy 141
–– port positions  528 –– penile block  32 nephrectomy (open)  442, pectus excavatum, minimally
–– positioning of the video –– safety  26, 32, 33 443 invasive repair of  542
monitor 528 –– types 26 –– complications 444 –– complications 546
–– theatre layout  527 lung resection  228, 231 nephrostomy 453 –– indications 542
laparoscopic varicocelec- –– complications  230, 233, –– complications 458 –– operative tech-
tomy (lymphatic-spa- 236, 238 –– open  453, 456 nique  542, 544
ring) 595 –– right lower lobecto- –– percutaneous 455 –– patient positioning  542
–– equipment 595 my 234 nerve –– pectus bar  543
–– operative tech- –– right pneumonecto- –– accessory 151 –– fixation 545
nique 595 my 228 –– digital 30 –– flippers 544
–– patient positioning  595 –– right upper lobecto- –– facial  140, 141, 150 –– stabilization 545
–– port positioning and my 231 –– genitofemoral 28 –– pectus introducer  543
placement 595 –– wedge resection  237 –– hook 171 –– pre-operative assess-
–– pre-operative prepara­ –– hypoglossal 151 ment 542
tion 595 –– iliohypogastric 27, Pena, Alberto 507
laparoscopic-assisted endo-
rectal pull-through  577
M 28, 52
–– ilioinguinal  27, 28, 52,
perianal abscess  493
perineal injuries  487
–– colonic mobilisa­ malformation, lympha- 379, 382 –– anal injury  488
tion 578 tic 151 –– intercostal 30 –– classification 487
–– complications 579 malrotation 293 –– long thoracic  217 –– perineal body inju-
–– endorectal dissec- manoeuvre 319 –– monitor 152 ry 488
tion 578 –– Kocher’s  319, 322 –– phrenic 151 –– peritoneal injury  488
–– equipment 577 –– Pringle 362 –– recurrent laryngeal  165 –– principles of emergency
–– operative tech- meconium ileus  334 –– marginal mandibular management 487
nique 577 –– Bishop–Koop distal chim- branch  150, 151 –– urethral injury  487
–– patient positioning  577 ney enterostomy  335 –– subcostal 450 –– vaginal/labial injury  488
–– port positioning and –– complicated 334 –– superficial peroneal  95 peritoneal drainage  306
placement 577 –– enterotomy and irriga­ –– ulnar 187 –– closed suction  306
–– pre-operative prepara­ tion 334 –– vagus 151 –– complications 308
tion 577 –– Mikulicz double-barrelled neuroblastoma 331–333 –– indications 306
laparoscopic-assisted peri- enterostomy 336 –– abdominal 331 –– open 306
toneal dialysis catheter –– non-complicated 334 –– reduction 331 –– paracentesis 307
insertion 614 –– resection and primary –– percutaneous Seldin-
–– complications 614 anastomosis 335 ger 306
Subject Index
plastering 98
–– complications 100
–– indication 98
–– technique  98, 99
polydactyly 198
–– classification  198, 199
–– postaxial 198
–– pre-axial  198, 199
–– Wassel’s type  199
positioning 5
–– dorsal 5
–– extended neck  5
–– lateral 7
–– lithotomy 7
–– prone 7
–– reverse-Trendelen-
burg 5
–– Trendelenburg 5
posterior sagittal anorec-
toplasty (PSARP)  504,
512, 515
–– complications  506, 511,
514, 518
–– females with perineal or
vestibular fistulae  505
–– males with recto-urethral
bulbar fistula and prosta-
tic fistula  509, 510
–– with laparotomy/lapa-
roscopy in males with
rectal–bladder neck
fistulas 512–514
–– with total urogenital mo-
bilization for cloacae with
a common channel less
than 3 cm  515–517
posterior urethral
valves 482
–– complications of surge-
ry 483
–– resection 482
–– voiding cystourethro-
gram appearance  482
preparation 8
prepuceplasty  398, 401
probe  12, 13
pull-through  341, 344
–– long Duhamel (Martin
modification) 359
–– open Duhamel  357–359
–– open endorectal (Soave-
Boley)  344, 346
–– open Swenson  353–356
–– transanal endorec-
tal 341
–– transition zone  347
pyeloplasty 445
–– Anderson-Hynes dis-
membered 446
–– complications 447
pyloromyotomy 256
–– complications 256
–– open 256
Q lower pole  605
quiver  12, 13
R –– prone approach to the
Ramstedt, Conrad 259
ranula 144
–– plunging 146
rectal polyp  499
–– excision 499
–– snare polypectomy  499
reduction 101
–– diaphyseal forearm  181
–– femoral fracture  101
remnant, branchial  137
renal calculi  450
–– endoscopic remo-
val 450
–– open removal  450
–– percutaneous remo-
val 450
–– staghorn calculi  450
repair 64
–– nerve 65
–– tendon 65
–– vessel 64
retractor 12
–– army pattern modified
hook  12, 13
–– Balfour  13, 14
–– Brodie hernia direc-
tor  13, 14
–– Deaver  12, 13
–– Denis Browne  14
–– Durham  12, 13
–– Finochietto self-retai-
ning 14
–– Kilner–Lane (cat
paw)  12, 13
–– Langenbeck  12, 13
–– malleable copper  12, 13
–– skin hooks  13, 14
–– West self-retaining  14
retroperitoneoscopic ne-
phrectomy 601
–– equipment 601
–– operative tech-
nique 602
–– patient positioning  601
–– port positioning and
placement 602
–– pre-operative prepara­
tion 601
retroperitoneoscopic partial
nephrectomy 604
–– equipment 604
–– indications 604
–– lateral approach to the
–– operative tech-
nique 604
–– pre-operative prepara­
tion 604
upper pole  604
rongeur 17
–– Glasgow pattern  17, 19
–– Luer-Jansen  17, 19
S –– urethral  17, 19
sac, dural  172
sacrococcygeal terato-
ma 501
–– complications of surge-
ry 503
–– excision 501
–– incisions 501
scalp 121
–– laceration 121
–– layers 121
–– suturing  121, 123
–– layers 122
scalpel 11
–– disposable blades  11
–– handle 11
scissors 15
–– catgut  17, 18
–– iris  15, 17
–– Mayo  15, 18
–– Metzenbaum  15, 18
–– nursing  17, 18
–– strabismus curved  15,
17
–– strabismus straight  15,
17
–– tenotomy  15, 18
sclerotherapy 151
–– ethanol 151
–– OK432 151
scrotal exploration  389
–– complications 391
–– midline raphe inci­
sion 389
–– testicular torsion  389
–– torted hydatid of Morga-
gni 389
–– transverse incision  389
septic arthritis  192
seroma 94
shunt, ventriculoperitone-
al 159
643
sign, silk-glove  380
sinus 138
–– branchial 138
–– preauricular 140
skin graft, full-thick-
ness 196
skin lesion  92, 93
–– epidermoid cyst  94
–– lipoma 94
–– pilomatrixoma 94
–– pyogenic granuloma  94
–– viral warts  94
skin tag  490
skin traction  101
–– application 102
Soave, Franco 348
sounds 17
spermatic cord  377
spica cast  188
spina bifida  171
spinal cord  172
splint 101
–– suspension 103
–– Thomas 101
–– application 102
–– traction 103
spoon 14
–– Glasgow slotted  14, 15
–– Volkmann  14, 15
supra-umbilical hernia re-
pair 268
suprapubic catheterisa­
tion  435, 437
suture 53
–– absorbable 53
–– braided 53
–– monofilament 53
–– needle 54
–– needle point  54, 55
–– non-absorbable 53
–– polyfilament 53
–– removal 55
–– types 53
–– uses 55
syndactyly 195
–– classification 195
–– separation of digits  196
–– web reconstruction  195
T
testicular tumour  396
–– complications of surge-
ry 397
–– high ligation of the sper-
matic cord  396
–– ilioinguinal nerve  396
–– orchidectomy 397
644 Subject Index

–– retroperitoneal lymph
node dissection  397
thermal injury  72
–– assessment of depth  72
–– burn 72
–– criteria
–– for admission  73
–– for PICU admis­
sion 74
–– for referral  73
–– deep dermal  72
–– documentation 72
–– early management  72
–– examination 72
–– full thickness  72
–– history 72
–– resuscitation 72
–– scald 72
–– split skin graft  74
–– superficial 72
–– superficial dermal  72
Thomas splint  101
thoracoscopic decortication
for empyema  556
–– complications 557
–– indications 556
–– operative tech-
nique 556
thoracoscopic diaphragmatic
hernia repair  558
–– equipment 558
–– operative tech-
nique 558
–– patient positioning  558
–– port positioning and
placement 558
thoracoscopic lobecto-
my 550
–– complications 555
–– indications 550
–– lower lobectomy  550
–– middle lobectomy  550
–– room setup  551
–– trocar placement  551
–– upper lobectomy  555
thoracoscopic lung bio-
psy 547
–– complications 549
–– indications 547
–– operative tech-
nique 547
–– room setup  548
–– trocar placement  548
–– using endoloops  549
–– using endoscopic stap-
ler 549
thoracotomy 214
–– axillary 215
–– complications 217
–– mini (muscle-spa-
ring) 215
–– positioning 214
–– technique  214, 215
tissue, musculoskeletal  174
toenail 204
–– ingrown 204
–– phenolisation 205
–– simple avulsion  204
–– wedge excision  205
–– Zadek’s procedure  207
tongue-tie 144
torticollis 155
tourniquet  105, 204
–– complications 106
tracheostomy  151, 153
trauma laparotomy  309
–– four-quadrant pa-
cking 310
–– Pringle’s manoeuv-
re 311
T-tube 335
–– ileostomy 335
tube, trans-anasto-
motic 323
tumour, Wilms  328–330
tunneller  17, 20
tying 58
–– hand  58, 59
–– instrument 60–63
U vesicostomy 459
umbilical hernia repair  266
upper gastrointestinal blee-
ding 248
–– banding (varices)  250
–– endoscopic manage-
ment 248–250
–– non-variceal 248
–– pre-endoscopy check
list 248
–– sclerotherapy 251
–– variceal 249
upper urinary tract calcu-
li 627
–– extracorporeal shock-
wave lithotripsy  628
–– management op-
tions 627
–– percutaneous nephroli-
thotomy 628–630
–– pre-operative evalua­
tion 627
ureteric duplication anoma­
lies 448
–– complications of surge-
ry 449
–– hemi-nephrectomy
(open) 448
–– incision of ureteroce-
le 448
ureteric reimplantation  478
–– Cohen technique  478
–– complications 481
–– Politano–Leadbetter
technique 478
ureterostomy 461
–– complications 464
–– end 463
–– loop 461
–– sober 463
urethral catheterisa­
tion  435, 436
–– complications 438
urethral meatotomy  402
V –– contaminated 116
varicocoele 392
–– complications 395
–– management 392
–– open Palomo procedu-
re 392
venepuncture 76
venogram 84
–– magnetic resonance  84
venotomy 83
–– blocksom 459
–– complications 460
–– indication 459
vesicoureteric reflux  475
–– complications of endo-
scopic surgery  477
–– endoscopic treat-
ment 475
–– hydrodistension im-
plantation technique
(HIT) 475
Vitello-intestinal anoma­
lies 300
–– Meckel’s diverticu-
lum 300
–– persistent Vitello-intesti-
nal duct  301
–– Vitello-intestinal
band 301
V-quadrilateral-Z (VQZ)-
plasty for stoma  473
–– indication 473
W
washout 192
–– hip 192
–– knee 192
Wilms tumour  328–330
Wilms, Carl M.W. 330
wiring 178
–– closed 181
–– distal radius  178
–– entry 179
World Health Organisation
(WHO) 3
–– Safe Surgery Guideli-
nes 3
–– Surgical Safety Check-
list 3–5
wound  70, 71, 110
–– closure 70
–– delayed primary  70
–– primary 70
–– colonised 116
–– debridement 70
–– dressings 110–112
–– infected 116
–– irrigation 71
–– management  110, 114,
115
–– Napkin Care Guideli-
nes 117
–– reconstruction 71
–– types 114
wound healing  34
–– local factor  36
–– primary intention  34
–– secondary intention  34
–– systemic factor  36