Pediatric Laparoscopic Techniques in Urology Laparoscopic techniques have been widely used in the field of adult surgery and have been recognized by physicians and patients for their minimally invasive nature and rapid patient recovery. Whether and how laparoscopic techniques can be applied to children is a relatively new topic. Children are not a smaller version of adults. Children are fragile and have a much lower tolerance for general anesthesia, bleeding, electrolyte disturbances, etc. than adults. Specifically, the application of laparoscopy in children has the following difficulties and requirements: Zou Tiejun, Department of Urology, Shaanxi Provincial People’s Hospital, Shaanxi Province, China 1. laparoscopic equipment needs to be specialized. Children’s abdominal and retroperitoneal cavities are smaller than those of adults, and the operating equipment that can be accommodated needs to be as short as possible to avoid accidental injury. And short, fine equipment is also conducive to the operation of physicians. The poke cards and ultrasonic scalpels used for adult laparoscopy need to be further “reduced”, for example, the pediatric laparoscopes from Storz and Rudolf, Germany: 0° and 30° laparoscopes, functional puncture needles and trocar, left bending detachment forceps, and grasping forceps are 3.5 m in diameter, multifunctional puncture needles and trocar are 5 mm in diameter 2. The requirements of anesthesia are higher. Because of the small volume of the pediatric abdominal cavity, the rapid absorption of CO2 by the peritoneum and the poor tolerance to hypoxia, anesthesia for pediatric laparoscopic surgery is difficult to handle. ( 1 ) Preoperative assessment of the child should be done correctly to grasp the indications and the type of surgery should respect the requirements of the child’s parents. Absolute contraindications for pediatric laparoscopy include congenital heart disease, especially pulmonary hypertension, cyanosis, uncorrectable coagulopathy, severe traumatic pneumothorax, brain injury, intestinal obstruction and giant abdomen due to ascites, and prematurity. Relative contraindications include chronic obstructive pulmonary disease, spinal deformities, and large intra-abdominal malignancies. ( 2 ) Fasting is routinely required. The duration of fasting is: 2 h for clear liquids, 4 h for breast milk, 6 h for infant oral fluids and milk, and 8 h for solid foods. For infants and children, preoperative intravenous fluids can be used to supplement energy to relieve crying and irritability caused by hunger and to avoid hypoglycemia. Pre-operative gastric tube, intraoperative continuous gastrointestinal decompression to prevent reflux and aspiration. Actively treat comorbidities, replenish blood volume, and correct electrolyte disorders; postpone surgery if acute respiratory tract infection is present. ( 3 ) The method of induction of anesthesia and the dosage of drugs should be based on the clinical manifestations of the patient, and intravenous anesthesia is commonly used for rapid induction of tracheal intubation for mechanical ventilation, and isoflurane or sevoflurane is commonly used for maintenance of anesthesia. It also reduces the adverse effects of pneumoperitoneum and prohibits the use of nitrous oxide. Fentanyl should be used early in surgery and strictly limited to avoid its delayed respiratory depression side effects. Fentanyl and propofol have a rapid onset of action and are suitable for maintenance of anesthesia. ( 4 ) Use a low pneumoperitoneum pressure, in order to meet the needs of surgical operations, but also to maintain a minimum airway pressure and reasonable ventilation is appropriate. ( 5 ) Ensure CO2 excretion, controlled respiration during anesthesia, and mild hyperventilation to counteract the effects of pneumoperitoneum on respiratory drive and ventilation. ( 6 ) Focus on monitoring PETCO2, SpO2, body temperature and blood gas. ( 7 ) Body temperature should be checked and attention should be paid to keeping warm.3. The requirements of the surgeon are more stringent. As with adult laparoscopic surgery, (1) the pediatric laparoscopic surgeon is also required to have more proficient experience in open surgery and to be strictly trained and qualified in laparoscopic techniques. Due to the physiological characteristics of pediatric patients, it is not possible to extend the operation time indefinitely, and even if there is no accidental organ damage and bleeding, the operation should be intermediate and open in a timely manner if it takes too long to complete. (2) Surgical indications for patients should be strictly grasped. Especially for new operations, skilled laparoscopic technicians are needed to give the necessary guidance and to fully estimate and plan for possible intraoperative difficulties. It is more appropriate to start with established procedures, such as resection and simple reconstruction, and to proceed with exploration and complex reconstruction after proficiency. Urological laparoscopic techniques have become more mature, and there are several laparoscopic techniques for pediatric urological diseases as follows: 1. Cryptorchidism. Cryptorchidism is a common disease in pediatric urology. Between 1 0% and 17% of testicular malignancies occur in patients with a history of cryptorchidism. The malignancy rate of cryptorchidism is 3 6 to 4 8 times higher than that of the testis in the scrotum. Cortesi et al. first used laparoscopy in 1976 in patients with cryptorchidism in which the testes were not found, with the main purpose of determining the location of the testes, with an accuracy rate of 88% to 10%. The accuracy rate was 88%-10%. In our group, the rate was 100%. It also helps in the selection of the surgical approach and in determining whether there is a developmental defect in the testis itself, which can be removed if the testis is abnormal. In patients scheduled for second-stage Fowler-Stephens testicular fixation, the spermatic cord vessels are clamped to complete the first stage of surgery. If the testis is absent, surgical exploration of the groin and abdominal cavity can be avoided. Laparoscopy may reveal the following: intraperitoneal testis, spermatic cord entering the inguinal canal via the internal ring, and testicular agenesis. In addition to the location of the testis, it is important to know the length of the spermatic cord and the development of the testis. If the spermatic cord is too short, second-stage testicular fixation and autologous testicular transplantation should be considered, with the first Fowler-Stephens procedure being the preferred method. Testes that are too stunted for testicular fixation should be excised. 2. Stenosis of the ureteropelvic junction (hydronephrosis). The volume of the renal pelvis in children is 1 to 1.5 ml within 1 year of age, increasing by 1 ml/year within 5 years of age, and 5 to 7 ml above 5 years of age, which is close to that of adults. Ureteropelvic junction obstruction (UPJO) is the most common cause of hydronephrosis in pediatric patients and can be seen in all age groups, more in males than females, more on the left than on the right, and can be bilateral. Laparoscopic pyeloureteroplasty has both transabdominal and retroperitoneal routes. The transabdominal route has a large pneumoperitoneal space, clear anatomic landmarks, easily identifiable tissue structures, easy separation and complete exposure of the renal pelvis, easy mastery of cutting the dilated pelvic wall, intraoperative suture incision, placement of double J-tube is more direct than the retroperitoneal route, convenient operation The retroperitoneoscopic technique has a simple and direct access, basically no interference with the abdominal organs, and prevents irritation caused by the inflow of urine into the abdominal cavity, but its operating space is small, the operation is complicated, and the technique However, its small operating space, complex operation and high technical requirements require skilled posterior laparoscopic operation skills. Some scholars have used laparoscopic techniques to free the lesion site, while the pelvic ureteral anastomosis is accomplished under direct vision by traction through the ophthalmoscopic incision, reducing the difficulty of laparoscopic operation and preserving the advantages of laparoscopic surgery, while ensuring the quality of the anastomosis.3. Other surgeries. For example, pediatric hernia repair, hemianephrectomy and double ureteral transplantation with gas bladder have been successful. For renal pelvis and ureterotomy, sutured renal pelvis is used without double J tube, which reduces the postoperative leakage time and reduces the cost and hospitalization. For varicocele and syringomyelia surgery, it is controversial whether laparoscopic surgery should be performed because of the small incision, light trauma, short operation time and low cost of open surgery. In conclusion, the application of laparoscopic techniques in pediatric urology is still a relatively new topic, and further efforts by physicians are needed to preserve the minimally invasive advantages of laparoscopic techniques for the benefit of children. Some of the content is quoted from the internet