Best Practice & Research Clinical Anaesthesiology Vol. 18, No. 2, pp.

343355, 2004
doi:10.1016/j.bpa.2003.10.002 available online at http://www.sciencedirect.com

9 Anaesthetic considerations for laparoscopic surgery in neonates and infants: a practical review
Truchon* Rene
MD, FRCP, CSPQ

Clinical Professor of Anesthesiology, Staff Anesthosiologist of CHUL Anestisiology Department of Laval University, 2705, boul. Laurier, Sainte-Foy, Que., Canada G1V 4G2

Minimally invasive surgery is being applied to an increasing number of neonates and infants undergoing abdominal surgeries. Knowledge of specic implications, patients health status and pathophysiological changes induced by the surgery allow the anaesthesiologist to provide safe anaesthesia to these high-risk patients. This chapter describes the specic pathophysiological effects, peri-operative management, major complications and contraindications related to endoscopic procedures. Key words: laparoscopy; paediatrics; anaesthesia; neonates; infants.

As expertise and technology have improved, the laparoscopic approach to paediatric and neonatal surgery is becoming the modality of choice over open surgical techniques for selected procedures (Table 1). Laparoscopic surgery minimizes tissue trauma and post-operative pain. Patients can return earlier to normal activities and have a shorter hospital stay.1 3 Anaesthetic management is made more complicated due to the major physiological effects of the created pneumoperitoneum, systemic carbon dioxide absorption, patient positioning, extraperitoneal gas insufation, venous gas embolization and surgical trauma to blood vessels or viscera resulting in major haemorrhage. With the advent of laparoscopic surgery in neonates and infants, some specic modications of the anaesthetic technique are necessary.

GENERAL PHYSIOLOGICAL CONSIDERATIONS OF LAPAROSCOPY To achieve a pneumoperitoneum, CO2 is insufated within the abdominal cavity at pressures ranging from 10 to 15 mmHg. This increased abdominal pressure leads to
* Tel.: 1-4186564141x7565; Fax: 1-4186542774. E-mail address: rtruchon@videotron.ca 1521-6896/$ - see front matter Q 2003 Elsevier Ltd. All rights reserved.

344 R. Truchon

Table 1. Indications for laparoscopic procedures in neonates and infants. Laparoscopy for diagnostic purposes Abdominal mass biopsy Chronic abdominal pain Midgut volvulus Meckels diverticulum Impalpable testis Evaluation of ovarian pathology Biliary atresia Staging of tumours and biopsy Laparoscopy for surgery Appendectomy Adhesions lysis Cholecystectomy Fundoplication for gastro-oesophageal reux Hernia repair Hirschsprungs disease (pull-through procedure) Ovarian masses and ovariectomy Nephrectomy Splenectomy Pectus excavatum repair Pyloromyotomy Orchidopexy Malrotation and Ladds procedure

a decrease in total lung compliance and functional residual capacity (FRC) resulting in increased airway pressures, atelectasis and ventilation/perfusion (V/Q) mismatches. In addition, the CO2 insufated causes an increase in CO2 absorption and elimination and this increased CO2 elimination continues for up to 10 minutes after deation of the abdomen.4 These physiological changes associated with CO2 insufation lead to a difference between mean arterial and end-tidal CO2 (ETCO2) tensions ranging from 0.33 to 8.8 mmHg.5 The haemodynamic changes described during laparoscopy consist of an increase in both the systemic vascular resistance and the arterial blood pressure. The changes in cardiac lling pressures can vary according to the degree of intra-abdominal pressure and patient positioning. The cardiac output is maintained in healthy patients but tends to decrease in patients with cardiopulmonary disease. The severity of these haemodynamic changes can be reduced when the pneumoperitoneum is created with the patient in the horizontal position rather than in either the head-up or headdown position.6 Various dysarrhythmias can occur during laparoscopy. Bradyarrhythmias from atrioventricular dissociation to asystole are attributed to vagal stimulation caused by the insertion of a trocar or Veress needle, peritoneal stretch, fallopian stimulation or CO2 embolization.7 Tachyarrhythmias varying from sinus tachycardia to ventricular brillation have been reported and are related to increased concentrations of CO2 and catecholamine secretion.8

INCIDENCE OF SURGICAL TECHNIQUES With the development of new equipments and increased experience, minimally invasive surgery is being applied in more instances to neonates and infants. To reduce the risk of puncturing blood vessels or abdominal viscera, particularly the liver which lies partly below the lower ribs in infants, an open cut down technique is used for gas insufation.9,10

Anaesthesia in laparoscopic surgery in neonates and infants 345

The ideal gas to be used should have specic characteristics, ideally: Limited absorption No physiological effects Incapability of supporting combustion (no ammability) Rapid dissolution should inadvertent intravascular embolization occur.11,12

Nitrous oxide has limited physiological effects when absorbed. Oxygen and air have limited or no physiological effects although these three gases support combustion. Nitrous oxide has more limited effects with inadvertent intravascular embolization. Helium used as the insufating gas causes no physiological changes but its relative insolubility results in severe cardiovascular events if intravascular gas embolization occurs.13 Carbon dioxide is not combustible and is highly soluble; for these reasons, the majority of centres use CO2 for gas insufation during laparoscopy. The main disadvantage of CO2 is related to its physiological effects following its absorption. Other potential surgical complications of CO2 insufation include extraperitoneal insufation leading to subcutaneous emphysema, pneumothorax or pneumomediastinum resulting from the passage of gas through the foramina of Bochdalek and Morgagni or surgical trauma to the diaphragm. These complications can produce major effects on the cardiorespiratory status of the patient and could lead to cardiac arrest. In the immediate post-operative period, residual intraperitoneal CO2 can impair spontaneous ventilation and exacerbate shoulder pain and vomiting. This residual CO2 load is gradually excreted post-operatively and increases the ventilatory needs at a time when the ventilatory drive is often impaired by residual anaesthetic drugs, narcotics or pain. It should also be remembered that in a number of cases, the scheduled surgery cannot be achieved under laparoscopy. The conversion rate to laparotomy ranges from 2.2 to 2.6%. This conversion rate is particularly high during laparoscopy in patients with complicated appendicitis14 or intestinal obstruction.9,15

PATHOPHYSIOLOGICAL EFFECTS OF LAPAROSCOPIC SURGERY IN NEONATES AND INFANTS Pathophysiological changes during laparoscopic surgery are mainly related to the increased intra-abdominal pressure (IAP) associated with CO2 insufation of the abdomen, patients positioning (head-up or head-down tilt) and CO2 absorption. Pneumoperitoneum in infants and neonates has a major impact on cardiac volumes and function. Increased IAP induces a mechanical cephalad displacement of the diaphragm that reduces the pulmonary compliance, total lung volume, vital capacity and FRC. Respiratory effects A signicant amount of CO2 can be absorbed across the extended peritoneal surface resulting in hypercarbia if minute ventilation is not increased. Requirements in ventilatory compensation could be as high as 50 75% to maintain normocarbia.16 A recent prospective study17 investigated CO2 elimination during laparoscopic surgery in infants and children. CO2 elimination increased by 22% after 15 minutes of pneumoperitoneum and did not return to baseline by the end of the operation. ETCO2 reached its peak value at 1 hour (14 21% increased compared to pre-operative values).18 CO2 elimination was age-related. Several studies have suggested that

346 R. Truchon

the younger or smaller the child, the larger the increase in CO2 elimination. Younger children absorb proportionately more CO2 than older individuals. Furthermore, 35% of paediatric patients responded to exsufation by a sharp and transient increase in CO2 elimination that did not appear to be related to the patients age, duration of pneumoperitoneum, abdominal pressure or type of surgery. Hypercarbia produced a sympathetic nervous system stimulation resulting in an increase in heart rate and blood pressure. It also sensitized the myocardium to the arrhythmogenic effects of catecholamines especially with volatile anaesthetic agents. The increase in IAP shifts the diaphragm cephalad and reduces its excursion course, resulting in a decrease in FRC relative to closing volume, an increase in peak airway pressure and a reduction in thoracic compliance. These alterations increase the ventilation-perfusion mismatch that is already increased during general anaesthesia, positive pressure ventilation and by the Trendelenburg position, which causes intrapulmonary shunting and hypoxaemia. Neonates, infants and children who have a low FRC, high closing capacity and oxygen consumption are more prone to develop hypoxaemia following increased IAP. Adverse intra-operative events data has been collected from a retrospective audit of members of the French-Language Society of Paediatric Anaesthetists (ADARPEF). This study, involving neonates, infants and children, revealed a high end-tidal CO2 (PECO2 . 50 mmHg) in 37% of the patients. No hypoxic events were reported, but IAP was maintained at pressures not exceeding 6 mmHg in neonates and infants less than 4 months of age.19 Recent studies evaluating the respiratory function during laparoscopic procedures in paediatric patients demonstrated a 17% decrease in lung compliance induced by the Trendelenburg position which was further decreased by 27% during insufation at an IAP of 12 mmHg. Coincidently the peak airway pressure (PIP) increased by 19% when the patients were placed in the Trendelenburg position and by 32% during insufation. All values returned to baseline after removal of CO2 from the peritoneal cavity.20 In 11 children aged 8 months to 11 years, PIP increased by 26.6%, the respiratory resistance increased by 20.2% whilst the compliance decreased by 38.9% after the creation of the pneumoperitoneum.21 Monitoring of exhaled tidal volume is mandatory to prevent hypoventilation because most paediatric ventilators are pressure cycled. Positive end-expiratory pressure may be used to prevent hypoxaemia related to increased IAP22 and to offset the detrimental effects of increased IAP on FRC and Trendelenburg positioning.23 Cardiovascular effects The cardiovascular physiology of infants is signicantly different from that of adults. Blood pressure and systemic vascular resistance are lower; heart rate, O2 consumption and cardiac output are higher in infants. In addition to the respiratory effects, CO2 insufation, hypercarbia and increased IAP consistently affect the cardiovascular function during laparoscopy. The retrospective audit of ADARPEF19 reported that the usual response to pneumoperitoneum, at an IAP of under 15 mmHg, was an increase in blood pressure without tachycardia. Hypotension was associated with hypovolaemia, head-up position and deep anaesthesia. The authors made the recommendation that IAP should be kept below 6 mmHg in neonates and children under 4 months of age to prevent the development of high pulmonary vascular resistances that could lead to right-to-left cardiac shunting.24 With a moderate increase in IAP (, 15 mmHg), there is an increase

Anaesthesia in laparoscopic surgery in neonates and infants 347

in venous return and cardiac output resulting from the displacement of blood from the splanchnic venous eld, except in children under 4 months of age. In infants, the maximum IAP should be maintained below 10 mmHg. A prospective study performed in 12 infants of between 6 and 30 months of age investigated the haemodynamic changes occurring during laparoscopy with a noninvasive technique of aortic blood ow measurement using an echo-Doppler oesophageal probe (ABF-echodoppler). At the maximal allowed IAP of 10 mmHg, they observed a signicant decrease in aortic blood ow (ABFI) and stroke volume (SVI), indexed to the body surface area (BSA), of 33 and 32%, respectively. This was associated with a 38% increase P , 0:05 in systemic vascular resistance (SVRI) indexed to BSA without any signicant change in mean arterial pressure (MAP) and PETCO2.25 In a study investigating the haemodynamic effects of two different levels of IAP (6 and 12 mmHg) during laparoscopic surgery in eight children of between 2 and 6 years of age using trans-oesophageal echocardiography (TOE), the authors reported a signicant decrease in cardiac index (CI) of 13% at an IAP of 12 mmHg. Reduction of IAP to 6 mmHg was associated with a return of CI to baseline levels. Left ventricular systolic function was also diminished at an IAP of 12 mmHg and returned to baseline at an IAP of 6 mmHg. There was no signicant change in MAP and SVRI decreased by 24% only at an IAP of 12 mmHg, whilst PETCO2 was kept constant at baseline level.26 Haemodynamic repercussions of pneumoperitoneum seem to be caused by three factors: mechanical compression of the splanchnic vascular bed, a sympathetic reex from the splanchnic region and a release of humoral vasoconstrictive mediators, such as renin or vasopressin.27,28 From these studies, it appears that an IAP of 6 mmHg in neonates and children, is the safe level to avoid haemodynamic alterations while still providing satisfactory conditions for the surgeon. Neurological effects Haemodynamic variations, patient positioning, alterations in PaCO2 and increased intra-abdominal and intrathoracic pressures can modify the cerebral perfusion. Hypercarbia increases the cerebral blood ow and may increase the intracranial pressure (ICP). Elevated IAP could also increase ICP. The Trendelenburg position further increased ICP already increased by the abdominal insufation. Whether or not the ETCO2 was increased, several studies have reported an increase in cerebral blood ow as measured by transcranial Doppler ultrasonography during laparoscopy in adults.29,30 Increased IAP without a concomitant increase in PaCO2 results in an increase in ICP31, an effect that is worsened in patients with a raised ICP, as is commonly seen following closed head injury.32 Furthermore, experimental models have demonstrated that the elevated ICP associated with elevated IAP was unresponsive to hyperventilation and hypocarbia.33 Finally, increased IAP compresses the inferior vena cava and increases intrathoracic pressure. An elevated inferior vena cava pressure results in a rise in lumbar spinal pressure and a decrease in cerebral spinal uid (CSF) absorption that could contribute to increased ICP.34 Thus, laparoscopy may be relatively contraindicated in patients with an altered cerebral compliance. Renal changes Oliguria related to increased IAP is common during CO2 insufation. Pneumoperitoneum produces a reduction in glomerular ltration rate (GFR)35,36 sodium

348 R. Truchon

excretion35, creatinine clearance37 and urinary output35,38 by a decrease in cortical and medullary perfusion. No correlation was demonstrated between the haemodynamic response and the renal arterial blood ow.39 Decreases in renal vein ow and urine output are greater at IAP values exceeding 15 mmHg, but an experimental study in rats has established that a pneumoperitoneum induced with CO2 at an IAP of 10 mmHg could yet induce oliguria at this low IAP.40 Neurohormonal factors also inuence renal perfusion. Plasma rennin activity41, endothelin concentrations35 and antidiuretic hormone (ADH) levels42 rise during pneumoperitoneum. The aetiology of this temporary renal dysfunction during laparoscopy is unclear and multifactorial. Warming the CO2 before insufation improved urine output compared to the use of non-warmed CO2, suggesting that renal vasoconstriction might play a signicant role.43 Aggressive hydration does not prevent oliguria induced by elevated IAP and may increase morbidity for neonates and the children. Further work is needed in these populations. Temperature Laparoscopic procedures are associated with reduced insensible water loss and reduced heat loss compared to open surgery.44 A recent study reported four cases of hypothermia due to insufation of CO2 in a series of 65 laparoscopic procedures in neonates.45 In cases of continuous CO2 insufation, it should probably be mandatory to preheat the CO2 in order to maintain normothermia especially with high-ow insufation and in small babies.

PERI-OPERATIVE MANAGEMENT Pre-operative evaluation and investigations As for open surgery, neonates and infants presenting for laparoscopy should be managed in the same way as for open laparotomy. The scenarios can vary from an elective procedure in a healthy infant to an emergency laparoscopy for an acute abdomen in a premature neonate. A thorough pre-operative history should be taken and a complete physical examination should be performed to identify any underlying medical condition and, specically, heart murmurs. Routine pre-operative laboratory evaluation depends on the clinical status, age and prematurity more than the procedure itself. Major haemorrhage can occur as a complication of the laparoscopic technique and conversion to laparotomy may become necessary. Thus, the procedure should only be performed when cross-matched blood is readily available. Pre-medication and induction The objectives of pre-medication and a pre-anaesthetic visit are to minimize the anxiety of the patient and family and to provide optimal conditions allowing smooth induction of anaesthesia. Pre-medication must be individualized for each patient, based on the post-gestational age, weight, physiological condition and willingness to co-operate in older infants. The administration of an anticholinergic agent 30 45 minutes preoperatively is associated with a lower incidence of cardiovascular and airway complications peri-operatively.46 Anticholinergic pre-medication could prevent

Anaesthesia in laparoscopic surgery in neonates and infants 349

the vasovagal reexes that are occasionally seen when the peritoneum is penetrated or when the abdominal cavity is insufated. The only suitable anaesthetic technique in neonates and infants is general anaesthesia. Usually neonates already have an intravenous access with an infusion running. Obviously, intravenous induction is the rst option in this case. When a venous line is not established, and provided a rapid-sequence induction is not needed, an inhalation induction can be used instead. Sevourane tends to be the induction agent of choice due to its relative lack of haemodynamic depression.47 It should be kept in mind that the minimum alveolar concentration (MAC) value of sevourane in neonates and in infants less than 6 months of age is approximately 3.2%.47 It is recommended that the use of nitrous oxide be avoided since this agent may distend the intestinal loops during long-duration procedures and can cause post-operative nausea and vomiting. Endotracheal intubation and controlled ventilation are recommended for laparoscopic procedures in the paediatric population. One study evaluated the suitability of the laryngeal mask airway (LMA) in 15 paediatric patients.48 In selected patients and for very brief procedures (3 9 min), there were no signicant changes in arterial oxygen saturation.48 However, it would be unsafe to routinely use the LMA during paediatric laparoscopy and certainly even more so in neonates, in patients whose cardiorespiratory status is compromised, in extreme Trendelenburg positioning with high IAP, in long procedures and in patients with acute abdomen or those at risk of regurgitation and aspiration. Monitoring and intraoperative care Routine monitoring should include continuous electrocardiogram, automated noninvasive blood pressure measurement, pulse oximetry, oesophageal stethoscope, inspired oxygen concentration, temperature and ETCO2 measurements. Invasive haemodynamic monitoring of arterial blood pressure and central venous pressure is not routinely used unless indicated by the clinical status of the patient. Ideally, a venous catheter is inserted above the diaphragm (upper extremity) to avoid the consequences of the elevated IAP, which compresses the inferior vena cava and can block the access of drugs and uids to the systemic circulation from access sites in the legs.49 Maintenance volumes of uids are usually required unless there is unanticipated bleeding. Reliance on the use of ETCO2 concentration as an indication of arterial pCO2 may be inaccurate in neonates, small infants and also in children with cyanotic congenital heart disease.50 The PETCO2 often overestimates PaCO2 by up to 8.8 mmHg and, therefore, arterial blood gas analysis should be performed during long procedures to avoid hyperventilation.51 Continuous insufation of large volumes of cold, non-humidied CO2 into the abdominal cavity for long periods of time associated with a high body surface area-tomass ratio and little subcutaneous fat contributes to the development of severe hypothermia in infants and neonates. Different measures can be taken to prevent perioperative hypothermia, e.g. increasing the temperature of the operating room to 25 268C, heating and humidifying the inspired gases, using an active heating blanket, a forced convective air heating system or an infrared radiant heater and warming the solution used for intra-operative irrigation. An oro- or a nasogastric tube should be inserted to permit aspiration of the stomach in order to improve the visualization of the abdominal contents and to reduce the risk of accidental perforation. For the same reasons, the bladder must be emptied. In critical haemodynamic situations, the use of TOE represents an accurate method of monitoring the left ventricular function in children.52

350 R. Truchon

Maintenance of anaesthesia may be achieved by inhalation (e.g. using sevourane, isourane or desurane) or by intravenous agents. If there are concerns about a possible myocardial depression by volatile anaesthetics, a totally intravenous technique is an alternative. Nitrous oxide is avoided for the reasons mentioned previously. New non-depolarizing neuromuscular (vecuronium, rocuronium, cis-atracurium, mivacurium) blocking agents are preferred for muscle relaxation. Halothane is avoided because hypercapnia secondary to the pneumoperitoneum will sensitize the myocardium to arrhythmias; furthermore, there are concerns regarding the reduced hepatic blood ow secondary to high IAP, which could predispose to halothane hepatotoxocity. The uid instilled laparoscopically should be warmed, isotonic (e.g. lactated ringer or plasmalyte solutions) and must be calculated in uid maintenance regimens. At the completion of surgery, all of the remaining intra-abdominal CO2 should be evacuated and the neuromuscular blockade reversed. Oxygen supplements can be used for transfer to a post-operative ward. Post-operative course It is generally accepted that pain following laparoscopic surgery is less than that following open procedures, the nociceptive component due to peritoneal irritation by residual CO2 consists of an early transient and vague abdominal and shoulder discomfort. Pain related to trauma at the surgical sites is deep-seated and can be severe, requiring parenteral opioids for adequate relief. Inltration of the port sites with a local anaesthetic with epinephrine at the start of the operation reduces peri-operative bleeding and provides a high degree of post-operative analgesia. In the absence of contraindications, a non-steroidal or Cox II inhibitor anti-inammatory drug will help to reduce the need for post-operative opioids. This regimen is usually required for the rst 24 48 hours after major intra-abdominal surgery. Controversies exist about acetaminophen efcacy in the management of post-operative pain53,54 and limited data are available on the pharmacokinetics of acetaminophen in neonates.55 Few prospective studies have evaluated the pain relief after laparoscopic surgery in neonates and infants.56 Caudal block with a local anaesthetic produces an effective postoperative analgesia in children undergoing laparoscopic inguinal herniorrhaphy and most patients do not require further post-operative analgesia.57 Caudal blocks are reserved for lower abdominal procedures at or below the umbilicus. Post-operative nausea and vomiting are common complications reported after laparoscopy and their incidence is reduced by a prophylactic administration of antiemetic agents.58 The best prophylaxis associates complete aspiration of the pneumoperitoneum at the conclusion of the surgery and various combinations of antiemetic drugs after induction of anaesthesia (Ondansetron 100 mg/kg up to 4 mg, dexamethasone 150 mg/kg, and droperidol 25 mg/kg up to 0.625 mg).

MAJOR COMPLICATIONS OF LAPAROSCOPIC SURGERY In large centres, the complication rate, excluding subcutaneous emphysema and pre-peritoneal insufation, ranges from 1 to 2%, with an overall complication rate of 5.8%.59,60 There are well documented learning curves and skills in paediatric laparoscopic surgery61 63 and the complication rates are inversely correlated with laparoscopic

Anaesthesia in laparoscopic surgery in neonates and infants 351

experience. Most complications are technique-related. Unintentional injuries to major vessel and viscera are decreased by 50% with the use of an open technique for the insertion of the rst trocar instead of using a Veress needle. Other most frequent complications consist of visceral or intestinal injuries with instruments or diathermia, and herniation of the intra-abdominal contents through the port hole.64,65 Conversion to open surgery is described as a complication but should rather be dened as a prevention of complications. Within the 1 2% complication rate are included complications resulting from CO2 insufation, hypercapnia, gas embolism, pneumothorax and pneumomediastinum. The reported incidence of severe gas embolism in adult laparoscopic surgery is 1 in 2000.66 The incidence in children has not been studied. In neonates IAPS exceed 6 mmHg, there is a risk of re-opening a right-to-left shunt via the foramen ovale resulting in hypoxaemia.67

CONTRAINDICATIONS Laparoscopy should be avoided in patients with severe cardiac disease, pulmonary insufciency, bleeding disorders or unstable haemodynamic status. It is more hazardous in patients who have had repeated abdominal surgeries or have abdominal sepsis and remains controversial in malrotation and intussusception.68

CONCLUSION Some paediatric laparoscopic procedures will become routine aspects of paediatric surgery. Infants present a technical challenge due to the small size of the structures and the small workspace available. The gasless laparoscopic technique avoids using any gas insufation and relies on an abdominal wall lift to create an intra-abdominal space. This new technique avoids the problems attributed to increased IAP.69 The use of virtual reality models allows surgeons to perfect their laparoscopic skills and computerization with robot-assisted laparoscopic surgery will allow more sophisticated interventions.70,71 Anaesthesiologists must have a thorough understanding of the physiological changes following pneumoperitoneum with CO2 insufation and positioning and must also be aware of the potential complications of laparoscopic surgery. There are many important factors to be considered; patients and parents preference, the complexity of the procedure, the surgeons experience, medical condition of the patient and duration and cost compared with open surgery. Practice points pneumoperitoneum in infants and neonates has a major impact on cardiac volumes and function neonates, infants and children who have a low functional residual capacity (FRC), high closing capacity and oxygen consumption are more prone to develop hypoxaemia following increased intra-abdominal pressure (IAP)

352 R. Truchon

IAP must be maintained at a pressure not exceeding 6 mmHg in neonates and infants under 4 months of age and should be kept below 10 mmHg in other infants agressive hydration does not prevent the oliguria induced by an elevated IAP and may increase the overall morbidity rate of the procedures procedures should only be performed when cross-matched blood is readily available laparoscopy is contraindicated in patients with severe cardiac disease, pulmonary insufciency, bleeding disorders or unstable haemodynamic status

Research agenda the correlation of pathophysiological effects with specic applied intraabdomial pressures is needed in relation to different group of premature and full term neonates, assessed by gestational age and weight an evaluation of the minimal positive end-expiratory pressure required to prevent atelectasis and intrapulmonary shunting without compromising the cardiovascular functions, is needed comparative morbidity between laparoscopic and open surgical techniques should be studied ACKNOWLEDGEMENTS The author thanks Mrs Madeleine Tremblay for her excellent secretarial assistance.

REFERENCES
1. Holcomb III GW, Olsen DO & Sharp KW. Laparoscopic cholecystectomy in the pediatric patient. Journal of Pediatric Surgery 1991; 26: 11861190. 2. Newman KD, Marmon LM, Attorri R et al. Laparoscopic cholecystectomy in pediatric patients. Journal of Pediatric Surgery 1991; 26: 1184 1185. 3. Sigman HH, Laberge JM, Croitoru D et al. Laparoscopic cholecystectomy: a treatment option for gallbladder disease in children. Journal of Pediatric Surgery 1991; 26: 11811183. 4. Puri GD & Singh H. Ventilatory effects of laparoscopy under general anesthesia. British Journal of Anaesthesia 1992; 68: 211213. 5. Brampton WJ & Watson RJ. Arterial to end-tidal carbon dioxide tension difference during laparoscopy. Magnitude and effect of anaesthetic technique. Anaesthesia 1990; 45: 210214. 6. Joshi GP. Abdominal surgery. In Benumof JL & Saidman L (eds) Complication in Anesthesiology. Mosby Year Book, 1999, pp 577. 7. Shifran JL, Adlestein L & Finker NL. Asystolic cardiac arrest: a rare complication of laparoscopy. Obstetrics and Gynecology 1992; 79: 840 841. 8. Cheong MA, Kim YC, Park HK et al. Paroxysmal tachycardia and hypertension with or without ventricular brillation during laparoscopic adrenalectomy: two case reports in patients with non-catecholamine secreting adrenocortical adenomas. Journal of Laparoendoscopic and Advanced Surgical Techniques 1999; 9: 277287. 9. Van der Zee DC & Bax NMA. Laparoscopic approach to intestinal obstruction in children. In Bax NMA, Georgeson KE & Najmaldin A (eds) Endoscopic Surgery in Children. Berlin: Springer, 1999, pp 215219. 10. Peters CA. Complications in pediatric urological laparoscopy: results of a survey. Journal of Urology 1996; 155: 10701073.

Anaesthesia in laparoscopic surgery in neonates and infants 353 11. Greilich PE, Grelich N & Froelich EG. Intra-abdominal re during laparoscopic cholecystectomy. Anesthesiology 1995; 83: 981984. 12. Neuman GG, Sidebotham G, Negoianu E et al. Laparoscopic explosion hazards with nitrous-oxide. Anesthesiology 1993; 78: 875879. 13. Bongard FS, Pianim NA, Leighton TA et al. Helium insufation for laparoscopic operation. Surgery, Gynecology and Obstetrics 1993; 177: 140 146. 14. Ure BM, Spangenberger W, Hebebrand D et al. Laparoscopic surgery in children and adolescents with suspected appendicitis: results of medical technology assessment. European Journal of Pediatric Surgery 1992; 2: 336340. 15. Duckett JW. Pediatric laparoscopy: prudence please. Journal of Urology 1994; 151: 742743. 16. Liu SY, Leighton T, David I et al. Prospective analysis of cardiopulmonary responses to laparoscopic cholecystectomy. Journal Laparoendoscopic Surgery 1991; 1: 241245. 17. McHoney M, Pierro A, Corizia L et al. Carbon dioxide elimination during laparoscopy in children is age dependant. Journal of Pediatric Surgery 2003; 38: 105110. 18. Reinoso-Barbero F, Diez A, Paz JA et al. Physiopathologic implications of the anesthesiologic management of pediatric laparoscopic surgery. Revista Espanola de Anesthesiologia y Reanimacion 1995; 42: 277 282. diatrie: le point de vue de lanesthe siste. Cahiers dAnesthe siologie 1993; 41: 19. Sfez M. Coeliachirurgie en pe 237244. 20. Manner T, Aantaa R & Alanen M. Lung compliance during laparoscopic surgery in paediatric patients. Paediatric Anaesthesia 1998; 8: 2531. * 21. Bergesio R, Habre W, Lanteri C & Sly P. Changes in respiratory mechanics during abdominal laparoscopic surgery in children. Anaesthesia and Intensive Care 1999; 27: 245248. * 22. Tobias JD. Anesthetic considerations for laparoscopy in children. Seminars in Laparoscopic Surgery 1998; 5: 60 66. * 23. Ekman LG, Abrahamsson J, Biber B et al. Hemodynamic changes during laparoscopy with positive and expiratory pressure ventilation. Acta Anesthesioloica Scandinavica 1988; 32: 447 453. 24. Alain JL, Grousseau D & Terrier G. Extramucosal pyloromyotomy by laparoscopy. Journal of Pediatric Surgery 1991; 26: 11911192. 25. Gueugniaud PY, Abisseror M, Moussa M et al. The hemodynamic effects of pneumoperitoneum during laparoscopic surgery in healthy infants. Anesthesia and Analgesia 1998; 86: 290293. * 26. Sakka SG, Huettemann E, Petrat G et al. Transoesophageal echocardiographic assessment of haemodynamic changes during laparoscopic herniorraphy in small children. British Journal of Anaesthesia 2000; 84: 330334. 27. Gentili A, Iannettone CM, Pigna A et al. Cardiocirculatory changes during videolaparoscopy in children: an echocardiographic study. Paediatric Anaesthesia 2000; 10: 399406. 28. Walder AD & Aitkenhead AR. Role of vasopressin in the haemodynamic response to laparoscopic cholecystectomy. British Journal of Anaesthesia 1997; 78: 264 266. 29. DeCosmo G, Iannace E, Primieri P et al. Changes in cerebral hemodynamics during laparoscopic cholecystectomy. Neurological Research 1999; 21: 658 660. 30. Fujii Y, Tanaka H, Tsuruoka S et al. Middle cerebral arterial blood ow velocity increases during laparoscopic cholecystectomy. Anesthesia and Analgesia 1994; 78: 80 83. 31. Emeljanov SI, Fedenko VV, Levite EM et al. Pneumoperitoneum risk prognosis and correction of venous circulation disturbances in laparoscopic surgery. Surgical Endoscopy 1998; 12: 12241227. 32. Johannsen G, Anderson M & Juhl B. The effects of general anaesthesia on the haemodynamic event during laparoscopy with CO2 insufation. Acta Anaesthesiologica Scandinavica 1989; 331: 132 135. 33. Rosenthal RJ, Friedman RL, Chidambaram A et al. Effects of hyperventilation and hypoventilation on PaCO2 and intracranial pressure during acute elevations of intraabdominal pressure with CO2 pneumoperitoneum. Journal of the American College of Surgeons 1998; 1871: 3236. 34. Halverson AL, Barrett WL, Iglesias AR et al. Decreased cerebrospinal uid absorption during abdominal insufation. Surgical Endoscopy 1999; 13: 797 799. 35. Hamilton BD, Chow GK, Inman SR et al. Increased intra-abdominal pressure during pneumoperitoneum stimulates endothelin release in a canine model. Journal of Endourology 1998; 12: 193 195. 36. Dolgor B, Kitano S, Yoshida T et al. Vasopressin antagonist improves renal function in a rat model of pneumoperitoneum. Journal of Surgical Research 1998; 79: 109 111. 37. McDougall EM, Monk TG, Wolf JS et al. The effect of prolonged pneumoperitoneum on renal function in an animal model. Journal of the American College of Surgeons 1996; 182: 317320. * 38. Koivusalo AM, Kellokumpu I, Riskari S et al. Splanchnic and renal deterioration during and after laparoscopic cholecystectomy: a comparison of the carbon dioxide pneumoperitoneum and the abdominal wall lift method. Anesthesia and Analgesia 1997; 85: 886890. 39. Junghans T, Bohm B, Graudel K et al. Does pneumoperitoneum with different gases, body positions and intraperitoneal pressures inuence renal and hepatic blood ow? Surgery 1997; 121: 206 208.

354 R. Truchon 40. Kirsch AJ, Hensle TW, Chang DT et al. The renal effects of CO2 insufation: oliguria and acute renal dysfunction in a rat pneumoperitoneum model. Urology 1994; 43: 453 459. 41. Koivusalo A, Kellokumpu I, Scheinin M et al. A comparison of gasless mechanical and conventional carbon dioxide pneumoperitoneum methods for laparoscopic cholecystectomy. Anesthesia and Analgesia 1998; 86: 153158. 42. Walder AD & Aitkenhead AR. Role of vasopressin in the haemodynamic response to laparoscopic cholecystectomy. British Journal of Anaesthesia 1997; 78: 264266. 43. Backlund M, Kellolumpu I, Scheinin T et al. Effect of temperature of insufated CO2 during and after prolonged laparoscopic surgery. Surgical Endoscopy 1998; 12: 11261130. 44. Biognar AR, Anderson D, Olson RL et al. Quantication of insensible water loss associated with insufation of nonhumidied CO2 in patients undergoing laparoscopic surgery. Journal of Laparoendoscopic and Advanced Surgical Techniques 1999; 9: 325 329. * 45. Fujimoto T, Segawa O, Lane GJ et al. Laparoscopic surgery in newborn infants. Surgical Endoscopy 1999; 13: 773 777. 46. Shaw CA, Kelleher AA, Gill CP et al. Comparison of the incidence of complications at induction and emergence in infants receiving oral atropine vs no premedication. British Journal of Anaesthesia 2000; 84: 174178. 47. Lerman J, Sikich N, Kleinman S & Yentis S. The pharmacology of sevourane in infants and children. Anesthesiology 1994; 80: 814824. * 48. Tobios JD, Holcomb III GW, Rasmussen E, Lowe S & Morgan III WM. General anesthesia using the laryngeal mask airway during brief, laparoscopic inspection of peritoneum in children. Journal of Laparoendoscopic Surgery 1996; 6: 175 180. 49. Tobias JD. A review of anesthetic management during laparoscopic procedures, emphasizing concerns in pediatric population. American Journal of Anesthesiology 1998; 25: 165. 50. Wulkan ML & Vasudevan SA. Is end-tidal CO2 an accurate measure of arterial CO2 during laparoscopic procedures in children and neonates with cyanotic congenital heart disease? Journal of Pediatric Surgery 2001; 36: 1234 1236. 51. Resinoso-Barbero F & Diez-A-Paz JA. Physiopathologic implications of the anesthesiologic management of pediatric laparoscopic surgery. Revista Espanola de Anesthesiologica Reanimacion 1995; 42: 277 282. 52. Gueugniaud PY, Muchada R, Moussa M et al. Non-invasive hemodynamic monitoring during general anaesthesia in infants: interest of a continuous aortic blood ow echo-doppler measurement. Anesthesiology 1995; 83: A1160. 53. Shah V, Taddio A & Ohlsson A. Randomized controlled trial of paracetamol for heel prick pain in neonates. Archives of Disease in Childhood. Fetal and Neonatal Edition 1998; 79: F209F211. 54. Howard CR, Howard FM, Weitzman ML et al. Acetaminophen analgesia in neonatal circumcision: the effect on pain. Pediatrics 1994; 93: 641646. 55. Van Lingen RA, Deinum JT, Quak JM et al. Pharmacokinetics and metabolism of rectally administered paracetamol in preterm neonates. Archives of Disease in Childhood. Fetal and Neonatal Edition 1999; 80: F59F63. 56. Tobias JD, Holcomb GW, Lowe S et al. Caudal epidural block for analgesia following herniorraphy with laparoscopy in children. Journal of Laparoendoscopic Surgery 1994; 4: 117 120. 57. Tobias JD, Holcomb GW, Brock JW et al. Analgesia after inguinal herniorrhaphy with laparoscopic inspection of the peritoneum in children: caudal block versus ilioinguinal/iliohypogastric block. American Journal of Anesthesiology 1995; 22: 193 197. 58. Conte ATH. Antiemetic therapy for the pediatric ambulatory surgery patient. American Journal of Anesthesiology 1996; 23: 130. 59. Peters CA. Complications of pediatric urologic laparoscopy: results of a survey. Journal of Urology 1996; 155: 10701073. 60. Rothenberg SS, Chang JHT & Bealer JF. Experience with minimally invasive surgery in infants. American Journal of Surgery 1998; 176: 654658. 61. Firilas AM, Jackson RJ & Smith SD. Minimally invasive surgery: the pediatric surgery experience. Journal of the American College of Surgeons 1998; 186: 542544. 62. Meehan JJ & Georgeson KE. The learning curve associated with laparoscopic antireux surgery in infants and children. Journal of Pediatric Surgery 1997; 32: 426427. 63. Ford WDA, Crameri JA, Holland AJA et al. The learning curve for laparoscopic pyloromyotomy. Journal of Pediatric Surgery 1997; 32: 552. 64. Voyles CR & Tucker RD. Education and engineering solutions for potential problems with laparoscopic mono electrosurgery. American Journal of Surgery 1992; 164: 5762. 65. Bloom DA & Ehrlich RM. Omental evisceration through small laparoscopy port sites. Journal of Endourology 1993; 7: 3133.

Anaesthesia in laparoscopic surgery in neonates and infants 355 cystectomie coelioscopique chez 2006 66. Dubois F, Levard H & Berthelot G. Complications de la chole malades. Annales de Chirurgie 1994; 48: 899 904. * 67. Sfez M. Anesthesia for laparoscopic surgery in pediatrics. Annales Franc aises f Anestheie et Reanimation 1994; 13: 221 232. 68. Poddoubnyi IV, Dronov AF, Blinnikov OI et al. Laparoscopy in the treatment of intussusception in children. Journal of Pediatric Surgery 1998; 33: 11941197. 69. Luks FI, Peers KHE, Deprest JA et al. Gasless laparoscopy in infants: the rabbit model. Journal of Pediatric Surgery 1995; 30: 12061208. * 70. Hollands CM & Dixey LN. Applications of robotic surgery in pediatric patients. Surgical Laparoscopy, Endoscopy and Percutaneous Techniques 2002; 12: 71 76. 71. Parr KG & Talamini MA. Anesthetic implications of the addition of an operative robot for endoscopic surgery: a case report. Journal of Clinical Anesthesia 2002; 14: 228233.