15 - Laparoscopic Considerations in Pediatric & Adolescent Gynecology

Dr. Susan Kaufman, PAG physician at Virtua health in New Jersey, and Dr. Olga Kciuk, PAG physician at Stanford University, walk through laparoscopic care for pediatric and adolescent patients from consent and anatomy to entry, pain control and recovery. The focus stays on safety, physiology, and teen-centered decisions that protect fertility and speed return to life.

Reference: NASPAG Essentials of Pediatric and Adolescent Gynecology: Chapter 30

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What is PAG?
Pediatric and Adolescent Gynecology is a subspecialty of OBGYN (2 year fellowship) focusing on reproductive healthcare for children and young adults. It fills the overlap between general gynecologists and pediatricians. It is a multi-disciplinary field involving work with pediatric endocrinology, dermatology, hematology, surgery, ect. Go to NASPAG.org for more PAG educational resources.

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Chapters

• 0:48 Case Setup: Teen Adnexal Mass
• 1:09 Episode Scope & Sources
• 1:25 Host And Guest Intros
• 1:42 Consent And Assent With Teens
• 3:04 Pediatric Anatomy That Changes Surgery
• 4:22 Imaging Strategy And MRI Tricks
• 5:46 Antibiotics And VTE Prophylaxis
• 8:39 Anesthesia And Physiologic Considerations
• 10:01 Exam Under Anesthesia & Manipulators
• 11:56 Prep, Catheters, And Positioning
• 15:19 Entry, Port Placement, Robotics
• 17:31 Insufflation, Electrosurgery, Closure
• 18:45 Pain Control And ERAS For Kids
• 21:04 Recovery, Activity, Timing, Fertility
• 23:06 Key Takeaways And Resources
• 23:46 Closing And How To Reach Us

Transcript

Susan: 0:24

A 13-year-old who presents with an adenexal mask requiring surgical management. What should we think about and what do we need to know before heading to the OR? Welcome to Pag Over Pastry, which is a 20 to 30 minute podcast reviewing very important topics in pediatric and adolescent gynecology. Today we'll be reviewing laparoscopic considerations for the pediatric and adolescent population based on the Essentials of Pediatric and Adolescent Gynecology published by NASPAG and authored by Alexandra Adler and Patricia Hugelett. I'm Susan Kaufman and I'm a Pediatric and Adolescent Gynecology at Virtua Health in South Jersey.

Olga: 1:08

I'm Dr. Olga Kciuk. I'm a pediatric and adolescent gynecologist at Stanford University. Thanks so much for having me.

Susan: 1:14

Well, thank you for joining me on this very important topic. So, what's your favorite pastry?

Olga: 1:21

Ooh, I'm gonna go a little niche. I'm gonna say a cunha man, which is a French pastry. It's buttery, it's caramelized, it's fantastic.

Susan: 1:30

Let's get started. So let's start with some pre-op considerations.

Olga: 1:39

Definitely. So when we are working with our pediatric and adolescent patients, thinking about informed consent needs to come hand in hand with thinking about assent as well. So we obtain informed consent from the legal guardian, but we want to involve the teen. It's empowering for them. It helps to ensure that they understand the procedure, that they feel included. And it's important for us as providers to understand the laws around emergencies, around emancipated minors. These can vary by jurisdiction. So it's really important to know your own local rules.

Susan: 2:17

One of the things I do is I actually have the teens, even as young as 11 and 12, sign the permit, and then the parent signs next to that. So I really feel like I'm involving my patient in the consent to avoid the idea that we're doing something to them versus taking care with them.

Olga: 2:39

Definitely.

Susan: 2:40

And because our patients tend to be smaller, what are some anatomic considerations we have to keep in mind when we're going to perform laparoscopy in a pediatric or teen patient?

Olga: 2:52

Yeah, we know that kids and teens are not just small adults. So pediatric patients have some differences in anatomy that we need to keep in mind and be aware of. So longer fallopian tubes, higher ovaries out of the pelvis sometimes, smaller uterus, and the bladder also is higher in the abdomen. It extends more cranially. So thinking about laparoscopic entry, too, we know that the integrity of the abdominal wall changes with age. So fascial wall tension and strength increasingly progress through childhood. So the entry forces that you need to enter in an adolescent are greater than for a young child. And that abdominal wall strength is greater in an adolescent often than even in adults. We need to be really careful with entry because the other consideration is that the distance from the abdominal wall to the major vessels is shorter than in adults. And so the risk of injury can be increased if port placement and abdominal entry aren't adjusted carefully.

Susan: 3:58

Now, before we even get to the OR, we generally have some pre-op imaging. We generally start with a pelvic ultrasound that's done abdominally. We don't commonly do transvaginal ultrasounds, definitely not on children and generally not on younger teens, maybe some of our older teens who might already be sexually active, but only if it's absolutely necessary. And then depending on what we find and depending on why we're doing the surgery, we may go on to obtain an MRI to help with planning the surgery, especially for anomalies, including uterine anomalies, vaginal septums, vaginal agenesis, and so forth. And a trick that I just learned by reading this chapter is that you can place a vitamin E capsule at the introitus, which I guess will show up on MRI, and it helps the radiologist to measure the distance between the introitus and the obstruction. I used to use vulvar magnets. My radiologist would put a magnet on the vulva, but this is much better to put a little vitamin E capsule.

Olga: 5:10

Yeah, it shows up pretty clearly on the MRI, and it is great as a marker to help exactly delineate that distance between the introitus and the obstruction itself, and that can help a lot with surgical planning.

Susan: 5:22

Now, do we need antibiotic prophylaxis for kids and teens?

Olga: 5:27

It depends, the same way it depends for adults. So antibiotic prophylaxis, we know that it reduces the risk of surgical site infections, and it's recommended for clean contaminated cases that involve entry into the genito-urinary tract. Surgeries that only involve the adnexa, though, like an ovarian cysteomy, like we're talking about for our patient in this case, would not require antibiotic prophylaxis. When we're thinking about antibiotic prophylaxis, a few things to think about for children and teens is that we use weight-based dosing in pediatrics. Generally, if the patient weighs more than about 40 kilograms, then standard adult dosing can be used because that's the point at which they tend to kind of even out. One thing to know is we generally avoid fluoroquinolones in pediatrics, and that's because of concerns about arthropathy.

Susan: 6:18

Right. Although the data on that is sparse, and we could certainly use more data because it's a great antibiotic. And one of the other things we have to think about now is VTE prophylaxis, and that's become a big topic. So we can lower the complication rate of venous thrombosis in our operative patients. I know my institution has a form that we have to fill out, whether it's for outpatient or inpatient surgery, to either support not giving any sort of prophylaxis or what prophylaxis we're going to give. So routine chemoprophylaxis is usually not needed in adolescents under the age of 13, because there's a much lower risk of thrombosis in that population. I tend to think that that applies to older teens as well, unless they have risk factors for a thrombosis. And those risk factors may revolve around obesity if they're currently on an oral contraceptive pill, if they have mobility issues, if they have a known thrombophilia, a malignancy, or congenital heart disease. The reason that children have a lower risk of thrombosis is that there are physiologic differences in their hemostatic system. So they may have lower circulating vitamin K-dependent clotting factors, higher levels of specific thrombin inhibitors, and an overall lower ability to produce thrombin. So all these things help to protect them from developing a blood clot.

Olga: 7:52

Yeah, and if we ever are using chemoprophylaxis, then we would use like a low molecular weight heparin. That would be preferred over heparin. It has a little bit more predictable pharmacokinetics. There's no need for serum monitoring or minimal need for that. And it doesn't tend to have a lot of interactions with other medications. It's also very easy to administer subcutaneously.

Susan: 8:15

Now, what about anesthesia considerations for our patients?

Olga: 8:19

Broadly speaking, it is about collaboration here. So it's really important, as in a lot of aspects of pediatric and adolescent gynecology, to work with our multidisciplinary providers. And in laparoscopy, it's important to work with an anesthesia provider who's experienced in pediatric and adolescent physiology. The CO2 insufflation can impact physiology differently than it does for adults. But generally speaking, patients with cardiac and pulmonary disease histories that we need to be especially careful about. And so that would be a potential contraindication to laparoscopic surgery, as the pneumoparitoneum would increase pressure on the diaphragm. It can cause cephalic displacement of the diaphragm. And that can all compromise venous return as well. So patients with underlying cardiac or pulmonary disease should definitely be medically optimized before any planned procedure.

Susan: 9:16

Yeah. And that's so important since fortunately, so many young people who are born with complicated cardiac anomalies are thriving and living on to their teenage and adult years. So we always have to keep that in mind that these people need additional considerations. So now we've moved our patient into the operating room. We've taken care of their antibiotic prophylaxis if they needed it, BTE prophylaxis if they needed it, collaborated with our anesthesiologist, and let's talk about positioning on the table and examination when they're asleep.

Olga: 9:56

A thorough exam under anesthesia of at least the external genitalia is always recommended. And this can offer the opportunity for identification of variations of normal anatomy, so hymenal variants, for example, that might not otherwise have been picked up. We don't tend to use a speculum, and certainly it's not recommended for pediatric patients. If there is any indication to visualize the vagina and the cervix themselves, then we would use vaginoscopy instead. We would use fluid to distend the vagina, just like in hysteroscopy or cystoscopy to visualize those internal structures. Otherwise, when we think about uterine manipulators, those are rarely needed in pediatrics when necessary. We might use like a sponge stick placed in the vaginal canal, maybe a small Hulka mobilizer. Those can be substituted to allow for just a smaller manipulator if any of that uterine manipulation is necessary, which sometimes for some ednexosystectomies or that kind of procedure can be helpful.

Susan: 10:56

Why do we try to avoid using uterine manipulators on children and younger teens?

Olga: 11:02

We're just trying to minimize the risk of trauma to the tissue. For kids who are prepubertal, we have to keep in mind the hypoestrogenic state too. And that small uterus, there's that risk of uterine perforation. And we have to keep that in mind when we're determining the need for a manipulator. As we get to older teens, though, we have the options of using typical uterine manipulators, similarly to as in adults.

Susan: 11:30

Then the next step is surgical prep. We will generally prep the external genitalia and the abdomen. If we do not need to enter the vagina for any reason or operate on anything on the cervix or the vagina, we don't need to prep that area. If there is a need for a vaginal prep in a pediatric patient, we can actually use a syringe to instill the prep solution. So it's like irrigating the vagina. I have used Q-tips, which I can insert without hymenal trauma and prep the vagina that way, particularly because in pediatric patients, the vagina may only be four or five centimeters long.

Olga: 12:11

A bulb syringe is my favorite trick for that.

Susan: 12:14

Yeah. And we can use betadine if there's no allergy to betadine. And we can also use chlorhexidine. We can use chlorhexidine on the vulva and on the abdomen, and we can use chlorhexidine with lower concentrations of alcohol in the vagina. But I want to just mention that that is an off-label use for chlorhexidine, but it is safe to use in the vagina with lower concentrations of alcohol.

Olga: 12:42

That's right. While we're down there prepping, we can think about our foley catheter as well. So what are some considerations for foley catheter sizing?

Susan: 12:51

Well, we have to keep in mind that these are smaller urethras, so we are absolutely not using an adult-sized catheter. For children ages 5 to 12, we will tend to use a 10 French catheter or maybe even a smaller one. Some people go by the age of the child and then equate that to the size of the catheter. We sometimes need to fill the bladder so that we know exactly where we are anatomically, or use that marker for whether we're doing vaginal surgery or intraabdominal surgery. And I know for my pediatric and adolescent patients, I rarely, if ever, use a catheter. I have them void before we bring them back to the OR.

Olga: 13:37

Let's talk about patient positioning. As long as you don't need vaginal access, which as we talked about, you most often don't. Younger pediatric patients can be placed in supine position. If you do need access to the vagina, you could consider frog-like position for younger patients. And then as kids get older and for teens, then we use dorsal lithotomy, as we would in adults. But there are pediatric-sized stirrups, which are really helpful because proper sizing and proper support for leg positioning is going to help protect against nerve injury. We should check the arms so that we can optimize surgeon ergonomics and patient safety and trendelingberg positioning. But when it comes to positioning, it's always about protecting against nerve injury. So femoral nerve injury, perineal, ulnar injuries are all possible if positioning isn't super careful. And so we need to focus on proper alignment, padding, positioning similarly to how you would position an adult patient for laparoscopic pelvic surgery.

Susan: 14:39

Absolutely. And then we all know that we must be very careful not to lean on our patients because we can cause injuries by just leaning on a leg, leaning on an arm, leaning on the upper abdomen above our laparoscopic camera. So once we are ready to introduce our instruments, what are the preferred sites and what pressures do we use?

Olga: 15:03

When it comes to entry, we prefer umbolical entry in kids and teens as it uses that confluence of the abdominal wall layers to provide the thinnest entry point. Ferris entry, direct entry, open laparoscopic entry have all been described. And we need to remember, as we touched on earlier, that the integrity of the abdominal wall tissues changes with age. And our abdominal entry is going to be impacted by that. Newborns and infants have a lot of laxity and pliability in their tissues, but the fascia tension and strength increases with age until adolescence, young adulthood, and that can definitely impact our entry technique.

Susan: 15:44

What's your preferred entry method?

Olga: 15:46

I prefer a varus entry.

Susan: 15:47

That's what I've done all my career, too.

Olga: 15:50

It's very important also to remember the distance from the abdominal wall to the large abdominal vessels. That distance is shorter in pediatric and adolescent patients, and so it requires a lot of care.

Susan: 16:03

And then in the if we're going to place accessory ports, we want to avoid neurovascular damage to the vessels and nerves that are traveling down in the rectus sheath. So the guidelines are to place accessory ports superior to the anterior-superior iliac spines greater than six centimeters from the abdominal midline.

Olga: 16:26

And I'll mention here too that we've been talking mostly about straight stick laparoscopy, but there can be a role for using robotic surgery for patients with more complex anatomy as well. It's definitely a developing space in terms of best use cases for pediatric and adolescent populations, thinking about advantages, challenges, and safety.

Susan: 16:48

That'll be an interesting development in pediatric and adolescent kinecologic surgery.

Olga: 16:54

We mentioned insufflation pressures before, and I want to go back to that because we definitely think about lower insuflation pressures, and we can kind of categorize it a little bit based on age group. So typically for infants, we would use distension pressures from about six to eight millimeters of mercury. Then when we think about younger children, we think about that eight to ten millimeters of mercury range. And then for older children and adolescents, we're thinking between 10 and 15 millimeters of mercury. Another adjustment that we may need to make in equipment settings is electrocottery wattage. And so that should also be adjusted for younger patients and kept at the lowest effective power.

Susan: 17:38

What about Trendellenberg?

Olga: 17:40

In my experience, it's been similar to working with an adult patient in that we want to optimize visualization while working closely with our anesthesiologist to make sure that ventilation is still going well. Just thinking about fascial closure. And so, of course, in any age group, anything that's 10 millimeters or larger will definitely be closing the fascia. But we do consider for younger patients closing even smaller, even five millimeter ports because herniations have been reported in that younger age group.

Susan: 18:14

So now we have operated on our patient and everything has gone great. And now we're going to talk about postoperative pain management. Historically, children and teenagers have been undertreated for their postoperative pain on the assumption that they may not be experiencing as much pain as an adult, or they cannot communicate about the pain that they are experiencing. So there are age-appropriate scales that are used in hospitals, including the CHEOP scale, the FLAC scale, F L A C C, and the FACES scale, F A C E S. It is important to evaluate patients at any age, so don't assume we can't evaluate our nonverbal patients. And it's important to treat their pain, to prevent postoperative pain sensitization, and to help with recovery in terms of their GI motility, their mobility, and so forth. Often pain control is left to the parents once the child is leaving the hospital. So we really have to be cognizant of giving them very sound guidance on pain treatment and also whether to use scheduled pain treatment or symptomatic pain treatment. We use a combination of acetomenophen, NSAIDs, limited narcotics, and blocks when appropriate.

Olga: 19:46

Having a regional anesthesia involved can be really helpful for something like a transverse abdominus plane block or a quadratus limborum block. And depending on the type of surgery, that's definitely something we talk about with our anesthesia teams.

Susan: 20:00

And talk about the development of Aeris for pediatric and adolescent patients.

Olga: 20:05

Aeris protocols have been developed over the years in adult gynecology, pediatric urology, pediatric surgery, and they're now becoming more commonplace in pediatric gynecology as well. So these are guidelines that focus on early feeding, mobilization, and non-narcotic pain management to support an earlier return to school and other activities. As institutions come on board, it is great to see the teamwork that comes with having an ARS guideline to follow that really gets our patients back on their feet and recovering better and sooner.

Susan: 20:40

I have found in throughout my surgical career that teens tend to bounce back really quickly, sometimes too quickly. Like I had a teenager who I told her, you know, not to go to dance class for at least a week. And she comes back for her post-op visit and she went back to dance class two days after her surgery. So we, you know, they do recover quickly, but we have to make sure we're putting proper pain management and other guidelines in place.

Olga: 21:12

I like to tell kids to listen to their body, and that gives them a little bit of agency in the process. But you're right, that adding that counseling around why we're limiting activity, why it's important to take things a little bit easy as you're recovering from surgery can be helpful in involving them and getting their buy-in for this recovery process. I think another thing that's helpful on that note is even considering when we plan an elective surgery. You know, if we have the ability to plan our surgery ahead of time, then it is helpful to schedule it in a way that minimizes disruption to school, to home, social activities for the patient. You know, I've booked surgeries around volleyball season, for example, something where I'm not going to be impacting that important social physical development that's happening in those early years, but also addresses obviously what needs to be done surgically for the patient.

Susan: 22:12

Yeah, absolutely. And another concern that people have when they're having laparoscopic surgery is will there be any impact on their fertility? So it is certainly very important postoperatively that we review thoroughly what we have done and to address whether there may or may not be any impact on fertility, both with the patient and with their parents. Okay, so some takeaway points.

Olga: 22:42

Pediatric analysis and patients are not just small adults. So anatomic and physiologic differences really matter. And careful planning of those pre-operative, intra-operative, postoperative considerations does help to minimize complications and improve recovery. But I think if I can say just one key takeaway and key thought is that it's always to center the patient, include the patient in decision making, use age-appropriate tools, and think about their daily life and their recovery and place the surgery in that context for them.

Susan: 23:15

There are some videos covering positioning, prep, abdominal entry on YouTube for people who want to look them up. So this concludes our podcast on laparoscopic considerations for pediatric and adolescent patients. I want to thank everybody for listening. And Alga, thank you so much for joining me today and sharing your expertise. It's been a real pleasure recording with you. Thank you so much for having me. Our podcast is available on major podcast platforms and the NASBAG website. On the NASBAG website, you'll find a transcription, any additional resources, and all of our previous podcasts. New episodes are released on the last Monday of each month. If you have any questions, our email address is pagoverpastry at gmail.com. All right.

Olga: 24:07

Awesome.