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Urologic Robotic Surgery Course

After completing this module, the learner should be able to:

  • Describe the surgical steps involved with the safe performance of pediatric robotic surgery.
  • State the indications and contraindications for the robotic approach to urologic surgical procedures.
  • Identify errors that can occur with the system during robotic surgery conditions.
  • Describe the steps involved with safe operation of the daVinci Surgical System (Intuitive Surgery Inc, Sunnyvale, CA).
  • Describe complications that can occur during urologic robotic surgery and describe methods to avoid and manage the complications.

Authors

Thomas S. Lendvay, MD
Associate Professor
Co-Director of the Robotic Surgical Center
Pediatric Urology
Seattle Children's Hospital
University of Washington
Seattle, WA
Disclosures: Spi Surgical Inc.: Consultant or Advisor

Pasquale Casale, MD
Attending Urologist
Director of Minimally Invasive Surgery
Department of Urology
Children's Hospital of Philadelphia
Philadelphia, PA
Disclosures: Nothing to disclose

Jack S. Elder, MD
Chief of Urology
Henry Ford Health Systems
Detroit, MI
Disclosures: Nothing to disclose

UROLOGIC ROBOTIC SURGERY COURSE

Pediatric Robotic Surgery

Contents:

  1. Abstract
  2. Physiologic Considerations
  3. Patient Selection and Port Placement
  4. Instrumentation
  5. Operative Procedures
  6. Perioperative Management
  7. Tables
  8. References

Abstract

Robotic-assisted laparoscopic procedures in children are primarily reconstructive. Children as young as 3 months have undergone successful robotic-assisted urological procedures. Common procedures include pyeloplasty, ureteroureterostomy, heminephrectomy, extravesical ureteral reimplantation, nephrectomy, and nephroureterectomy. Other procedures include pyelolithotomy, ureterocalicostomy, vascular hitch procedure for ureteropelvic junction(UPJ) obstruction, Mitrofanoff appendicovesicostomy, Malone continent cecostomy, ureteral reimplantation with tapering, intravesical ureteral reimplantation, augumentation enterocystoplasty, and bladder diverticulectomy.

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Physiologic Considerations

Mechanical Effects

Hemodynamic: For low intraabdominal pressures (IAP, < 5-10 mmHg), venous return is increased to the heart, which in turn increases CO2, but for pressures > 10 mmHg the IVC is compressed and venous return from the lower half of the body is decreased. This phenomenon is exacerbated in a dehydrated patient or in reverse Trendelenburg positioning. Because the IAP also applies pressure to the abdominal arterial tree, afterload is increased. In children, if the IAP is maintained between 5-8 mmHg, the cardiac index CI does not change significantly, but if the IAP is >12 mmHg, CI decreases by an average of 13%.1

Pulmonary: The diaphragm tends to shift upwards with insufflation, increasing airway resistance and a decrease in the functional residual capacity. When the insufflation pressure is 12 mmHg (for < 5kg) and 15 mmHg (for > 5kg), the peak inspiratory pressure increases 18% and the tidal volume decreases 33%. When insufflation pressure is kept at 5 mmHg, there is no change in these parameters.2 The elevated diaphragm position increases intrapleural pressure, which is transmitted to the cardiac chambers and results in elevated cardiac filling pressures. If the child is in Trendelenburg position, this effect is accentuated.

Chemical Effects

Neurohumoral: As the IAP rises above 10 mmHg, the increase in afterload secondary to compression of the abdominal arterial vasculature and hypercarbia lead to a neurohumoral response including elevated concentrations of vasopressin, norepinephrine, and renin, causing elevations of the cardiac output (CO) and CI.3 Temporary oliguria is in part a result of these chemical changes. The renin response results in an increase in salt and water reabsorption, while sympathetic stimulation leads to decreased renal plasma flow. Water reabsorption is also enhanced by the release of vasopressin.

Chemical Hypercarbia: Insufflated CO2 is readily absorbed by the peritoneum, which leads to increased total body CO2. During desufflation of the abdomen, retained abdominal CO2 gets rapidly absorbed into the peritoneal capillaries and can lead to a transient rise of end tidal CO2 at the end of an operation.

Long operative cases lead to an elevated CO2 load that is initially buffered in muscles, bone and tissues, but then is exhaled through the lungs post-operatively. In children with poor pulmonary reserve, post-operative cardiopulmonary monitoring is advisable. The CO2 in the abdomen also mixes with existing peritoneal fluid and leads to production of dissolved H+ and HCO3-. This acidification of the peritoneal fluid is thought to be a major source of post-operative pain.3

Intraoperative Considerations

Fluids: Sensible and insensible losses are not as large as with open surgery. Maintenance IV fluids are acceptable if the patient is normovolemic. However, since most children are oligovolemic, an initial 20 mL/kg bolus prior to insufflation may protect against hemodynamic consequences of pneumoperitoneum. Venous access should be obtained in the upper limbs such that in the event rapid drug administration is required, the slow venous return from the legs will not hinder medication flow.

Airway: The elevated diaphragm due to elevated IAP or Trendelenburg position may affect endobronchial tube position. This may be recognized when the child is moved, and should be suspected if the insufflation pressure increases or the end tidal CO2 rise.

Temperature: Children are susceptible to temperature alterations related to CO2 insufflation due to increased proportional peritoneal surface area. The Bair Hugger warming system should minimize the risk of hypothermia.

Pneumoretroperitoneum: Because there is no exposure of the peritoneal fluid to acidifying CO2 nor is there accumulation of subdiaphragmatic CO2, children do not experience shoulder pain postoperatively, and abdominal pain is minimal or nonexistent. There is buffering of CO2 by the local musculature and CO2 can easily track along the retroperitoneum to the retropleural spaces. Peak airway pressures and end tidal CO2 are also usually not changed much from baseline as the diffusabilty of CO2 in the retroperitoneum.3

Ventriculoperitoneal (VP) shunt: Some children with a congenital neurologic abnormality have a VP shunt. Retrospective studies in children with a VP shunt have demonstrated that laparoscopic operations can be performed safely, and that no special precautions are necessary, other than protecting the shunt tubing and administering prophylactic antibiotics.4

Contraindications to Robotic-assisted Surgery in Children

Because hemodynamic parameters may be adversely influenced by pneumoperitoneum, children with congenital heart disease (intracardiac shunting, severe aortic stenosis, severe myocardial dysfunction), and those with a pulmonary disorder may be unable to handle the increase ventilatory requirements to release the excess CO2. In addition, children with decreased cerebral compliance or a history of spontaneous pneumothorax should not undergo a robotic-assisted laparoscopic procedure.

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Patient Selection and Port Placement

Children present a small working environment; the working space in a 1-year-old allows approximately 1 liter, compared with the 5-6 liter working space in an adult. Also, the potential for port site collisions is greater in children. Working pressures of 8-10 mm Hg in children under 2 years and 10-12 mm Hg in older children and adolescents typically are sufficient. In children the abdomen should allow a distance at least 8 cm between the operative ports to prevent robotic port clashing.

In children less than 2 years undergoing a procedure on the upper urinary tract, it is helpful to elevate the child 10 cm on foam pads or blankets. The flank should be flexed slightly. The ipsilateral arm may be secured along the child's side. There are various methods of positioning the child on the operating table. Some place the child on a triangular pad and rotate the operating table, so that port insertion is performed with the child in a supine position. The operating table is rotated back to 45 degree lateral decubitus for the operative procedure. The table may not be rotated after the robot is docked. An alternative method is to secure the child to the edge of the operating table, with 10 degree lateral decubitus.

The child does not need a bowel prep pre-operatively unless they are being treated for constipation. However, some pediatric urologists prescribe clear liquids and a laxative 24 hours pre-operatively. All children should undergo Foley catheter insertion to drain the bladder. For camera insertion, an incision through or adjacent to the umbilicus is made. It is helpful to incise the rectus fascia also. Access to the peritoneum may be made using the Veress needle or Hasson technique; the latter is preferable if the child underwent a previous abdominal operation. During insufflation, 20 mm Hg insufflation pressure may be used for a short time to aid in operating port insertion, as it increases the resistance of the abdominal wall to deformation, easing safe trocar insertion. The operating port sites should not be marked until the abdomen insufflates.

The 30° up scope is used to help insert the working ports. In most procedures the 5 mm instruments may be used. These instruments have a snake-wrist architecture, which requires more working space compared with the 8 mm instruments. The 5 mm cannula may be inserted with either a sharp or blunt obturator. Following insufflation, the working sites are identified and marked. A #15 blade should be inserted straight down toward the peritoneum. It may be helpful to incise the peritoneum to facilitate port insertion. The ports should be inserted under direct vision. Most operative procedures can be performed with 3 ports, although during operative procedures on the upper pole of the right kidney and reconstructive bladder procedures, a 5 mm assistant port is useful to retract the liver or bowel.

--It is helpful to anchor the skin at port sites to the trocar to prevent abdominal wall slippage off the trocar during moments of desufflation.

--"Burping" the port: This is a robotic maneuver whereby the camera port is tented up on the abdominal wall by the bedside assistant. This maneuver provides a more global view in pediatric cases, in which the working space is limited and the abdominal wall is lax.

--When 3 ports are used, if the surgeon needs to suture, an RB-1 needle may be inserted through the 5 mm port by the assistant using a laparoscopic instrument. The assistant must load the tip of the needle in the crotch of the laparoscopic grasper or needle holder without crushing or bending the needle tip.

--ElectroLube (Eagle Surgical Products , Austin, TX) reduces charring and tissue sticking to any cautery instrument.

--At the end of the operative procedures, the fascia should be closed for each port site, even the 5 mm sites.

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Instrumentation

Either a 12 mm cannula or 8.5 mm cannula may be inserted. The 8.5 mm camera in the Si da Vinci system has as much clarity as the 12 mm camera, but the smaller camera has slightly less clarity than the 12 mm camera with the standard and S robotic systems.

5 mm Instruments

8 mm Instruments

Disposable

Disposable

Maryland dissector

Maryland dissector

Monopolar cautery hook

Monopolar cautery hook

Round scissors

Round scissors

Curved scissors

Hot shears

Needle drivers

Needle drivers (standard)

Bowel grasper

Needle drivers (Black Diamond)

5 mm clips

Bipolar grasper

 

ProGrasp

 

Irrigator/aspirator

 

Specimen retrieval bag

 

Hem-o-Lok Clips

Nondisposable (used by assistant)

Laparoscopic grasper
Laparoscopic bowel grasper
Needle driver
Laparoscopic scissors

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Operative Procedures

Pyeloplasty

After the Foley catheter is inserted and the bladder is drained, a clamp is placed on the drainage tube to allow slow filling of the bladder, which is useful during antegrade stent placement.

Transperitoneal: The patient is positioned either flank up or 30° lateral decubitus. Three ports are used: an umbilical port for the camera, and instrument ports midway between the xiphoid and umbilicus and a port in the lower quadrant on the side of the obstruction. In infants, the third port can be placed midway between the umbilicus and pubic symphysis. On the left side, the kidney usually may be approached transmesenteric, whereas on the right side the colon must be mobilized.

Retroperitoneal: With the patient in the flank position and slight flexion with a small gel positioner under the contralateral iliac crest, a 15 mm incision is made just above the iliac crest in the anterior axillary line. The retroperitoneal space is entered and dilated to 100 to 300 ml air with a balloon trocar in older children, and with a homemade dilating balloon catheter (size 8 latex glove finger secured to 12Fr to 14Fr catheter with 3-zero ligature) in infants and younger children. The balloon remains inflated in situ for 5 minutes. Instrument ports are placed under digital guidance. 8 mm ports are used. The lateral 8 mm port is placed just medial to the latissimus dorsi muscle 2 finger breadths above the iliac crest, while the medial 8 mm port is placed just below the costal margin off the anterior axillary line. An additional 5 mm assistant port is inserted in the iliac fossa. A 12 mm balloon tipped trocar is then placed through the primary 15 mm camera port incision, which is tightened by tethering the trocar and ligating 2-zero sutures placed through the fascial and skin edges of the incision.

Since most pediatric urologists perform robotic-assisted pyeloplasty transperitoneal, the remainder of this description will address this operative approach. If the renal pelvis is very large, it is helpful to have the assistant drain it percutaneously under direct vision with a 22 gauge spinal needle. The ureter is identified at the level of the lower pole of the kidney. It is mobilized to the renal pelvis. A hitch stitch can be placed through the renal pelvis; a Keith needle is created by straightening an RB-1 or SH needle with a 4-0 monofilament suture. The needle is inserted percutaneously through the upper quadrant, and the surgeon grasps the needle with Maryland forceps, pulls the suture into the peritoneal cavity, passes it through the superior aspect of the renal pelvis, and back out through the flank near the entry site. A clamp is used to clamp the suture at the appropriate tension. The renal pelvis is mobilized. The surgeon should look for a crossing vessel at the level of the UPJ going to the lower pole of the kidney. The pyeloplasty technique is similar to the adult technique (see IIb in outline). The medial edge of the UPJ may be left attached as a handle during the pyelotomy, ureteral spatulation, and during the first part of the anastomosis. If the renal pelvis is quite large, it should be trimmed and then closed with a running 4-0 or 5-0 absorbable suture. The ureteropyelostomy is performed with interrupted and running 5-0 Monocryl or an absorbable monofilament suture such as 5-0/6-0 PDS. Three to five interrupted sutures are used for the apical stitches. Two needle holders are used or a needle holder and a Maryland grasper. The back wall is then approximated with a running nonlocking stitch.

Antegrade Stent Insertion: A double-J stent can be inserted after the posterior wall of the anastomosis is completed. The stent length is chosen according to the formula age in years + 10.5 The assistant inserts a 14 gauge angiocath through the upper quadrant and is visualized by the surgeon. A 0.025 guidewire or glidewire is then inserted. It can be marked with indelible ink to correspond to the stent length, so that the surgeon knows when the wire has entered the bladder. The surgeon guides the stent through the anastomosis using needle holders. When the wire has reached the bladder, a stent is passed over the guidewire. A 4.5 F stent passes through the 14 gauge angiocath. If a larger stent is used, the angiocath must be removed, and an incision is made through the skin with a #11 blade adjacent to the guidewire. When the proximal end of the stent is visible, the guidewire is pulled out slowly and the tip of the stent is place in the renal pelvis.

The anterior aspect of the anastomosis is then completed with a running stitch. It is unnecessary to leave a drain. On the left side, the peritoneum is approximated over the anastomosis. The stent is removed after 2 to 4 weeks.

The most common complication of pyeloplasty is UPJ stenosis, which occurs in approximately 5%. Common causes include devascularization of the upper ureter, insufficient ureteral spatulation, failure to perform the anastomosis at the dependent aspect of the renal pelvis, and urinary extravasation. These technical complications should diminish with operative experience. Another complication is failure to pass the stent into the bladder. This problem may arise if the distal ureter is traumatized during passage of the guidewire or if the distal ureter is narrow. If the stent cannot be passed, the surgeon may elect to leave a KISS (Cook) stent through the anastomosis and out the flank through the renal pelvis, or perform the pyeloplasty without a stent. If there is a lower pole crossing vessel, then there is a risk of causing thermal or contact injury to the artery, resulting in devascularization of the lower pole. If injury to a lower pole artery is suspected, topical papaverine may be applied to the artery under direct vision through a 22 gauge spinal needle inserted through the flank.

Ureteroureterostomy for Duplication of Urinary Tract

This procedure is performed if there is an ectopic, obstructed, or refluxing moiety of a duplex system. Patient position, approach, and instruments are identical to those for pyeloplasty. It is useful to insert a double-J stent cystoscopically before performing the operative procedure. The stent is inserted through the unaffected moiety. A dangling string may be left through the urethra. The recipient ureter is opened anteriorly by excising a small ellipse and then spatulating with curved scissors. The other ureter is transected at an angle and is spatulated slightly. The anastomosis is performed with two 7" running 5-0 or 6-0 monofilament sutures. The distal ureter is mobilized at least to the external iliac vessels. Without changing the ports, usually it is possible to mobilize the ureter nearly to the bladder. Often there is a common ureteral sheath near the bladder. If there is no reflux, the ureter may be transected, but if the involved ureter refluxes, it must be ligated. An absorbable extracorporeal loop suture (Endoloop; Ethicon) may be placed through the 5 mm port or the ureter may be suture ligated with 4-0 Vicryl. It is unnecessary to leave a drain. The stent is removed 2 to 4 weeks postoperatively.

Heminephrectomy for Duplication of Urinary Tract

This procedure is performed for an obstructed upper pole moiety with poor function (ectopic ureter or ureterocele) or a poorly-functioning lower pole moiety associated with vesicoureteral reflux. It is useful to perform cystoscopy and insert a ureteral catheter into the normal ureter. The approach and instruments are identical to those for pyeloplasty.

The transperitoneal approach is described. For a left-sided lesion, the colon should be mobilized. For upper pole heminephrectomy, the upper pole ureter, which may be extremely dilated, is identified. The ureter is mobilized using the hook cautery, and separated from the lower pole ureter. The upper ureter is mobilized superiorly to the main renal vascular pedicle. The hook is useful for dissecting out the pedicle. The ureter is transected several cm. inferior to the lower pole of the kidney. It is then passed posterior to the vascular pedicle. The Maryland grasper is then used to place traction on the upper ureter superior to the main vascular pedicle. There is a separate pedicle (artery and vein) to the upper pole that must be identified. It may be occluded with 5 mm Titanium clips or, if the pedicle is substantial, Vicryl ties. The upper pole will then be demarcated as it darkens. Using the hook cautery, the demarcation between the upper and lower poles is incised. It is useful to review a CT scan or renal sonogram to determine the size and configuration of the upper pole moiety. The hook generally controls bleeding along the demarcation. The upper pole moiety is transected. When the moiety is separated, the lower pole moiety is observed. Bleeding vessels are cauterized. If the lower pole collecting system is visualized, it should be closed with a 5-0 Monocryl suture. The anterior and posterior margins of the superior aspect of the lower pole may be approximated with 4-0 or 3-0 Vicryl mattress sutures on an RB-1 needle. Alternatively, it may be unnecessary to place any sutures if there is no bleeding. A third option is to apply Floseal Hemostatic Matrix (Baxter, Freemont, CA). The remaining upper pole ureter should be removed as distally as possible, as described above.

For a lower pole nephrectomy associated with vesicoureteral reflux, the procedure is analogous, with the difference that the ureter does not need to be brought posterior to the renal pedicle. It is useful to perform cystoscopy and ureteral catheter insertion into the upper pole ureter before positioning for the heminephrectomy.

One complication that can occur is urinoma formation at the site of the heminephrectomy. This problem usually is asymptomatic and is apparent on post-operative renal sonography. It tends to remain unchanged and uninfected over time. It probably results from transecting viable tubules in the healthy portion of the kidney. Careful examination of the residual moiety, suture closure, and application of Floseal may reduce the risk of this complication. Another potential complication is devascularization of the healthy moiety. This complication results from traumatic injury to the vascular pedicle, from overvigorous mobilization or placing too much traction on the kidney. If the healthy moiety appears to darken intraoperatively, topical papaverine should be applied to the pedicle and the surgeon should wait 5 minutes before proceeding with the procedure.

Ureteral Reimplantation (Extravesical)

The child is placed in modified lithotomy position with Allen stirrups. One set-up is used. Cystoscopy is performed and the refluxing ureter(s) is cannulated with a 4 F ureteral catheter. A Foley catheter is inserted and the bladder is drained. The Foley and ureteral catheter(s) are kept in the sterile field. The child is placed in Trendelenburg position. The camera port is inserted at the umbilicus and 5 mm ports are placed at the level of the anterior superior iliac spine just lateral to the rectus muscle. A 5 mm assistant port is placed lateral to the 5 mm port, contralateral to the refluxing ureter. Maryland grasping forceps and a hook cautery are used. In girls, the ureter is identified in the pelvis just inferior to the fallopian tube. The ureter is mobilized inferior to the uterine artery to its junction with the bladder. An attempt should be made to identify the pelvic plexus, particularly in children undergoing bilateral extravesical ureteral reimplantation.6 The tissue plane between the medial aspect of the ureter and the internal genitalia is bluntly dissected from the ureter. The ureter is then retracted medially, while the tissue medial and caudal to the ureter is retracted lateral and anterior to expose the nerves from the pelvic plexus. The ureter is then dissected circumferentially from the detrusor, keeping the nerves in sight and away from the dissection.

The bladder is distended with 50-100 cc of saline; some use carbon dioxide to distend the bladder. The detrusor is incised just anterior to the ureterovesical junction. Using the hook, the detrusor muscle is incised around the ureter down to the level of the mucosa. A submucosal tunnel 4-5:1 length:width is then planned. A 3-0 or 4-0 Vicryl "hitch" stitch on an RB-1 needle is placed percutaneously through the abdominal wall. It is placed through the detrusor just above the planned submucosal tunnel. The detrusor is incised along this pathway down to the level of the mucosa. Lifting the muscle fibers and then cauterizing is useful. If the mucosa is incised inadvertently, it is closed with a 6-0 Vicryl on an RB-1 needle. The tunnel should be sufficiently wide to allow the ureter to be placed comfortably against the mucosa. The ureteral catheter is removed. The ureter is lifted and can be fixed to the tip of the submucosal tunnel with a 4-0 Vicryl stitch. Next, the ureter is pushed into the mucosa and the seromuscular layer at the UVJ is fixed to the detrusor with a 4-0 Vicryl stitch. This suture is left long, which the assistant can grasp for traction. The assistant places tension on the external detrusor hitch stitch and the stitch at the ureterovesical junction, which creates a diagonal or horizontal submucosal tunnel to close. The detrusor is closed over the ureter with a running or interrupted 3-0 or 4-0 Vicryl suture. It may be useful to place the distal stitch through the seromuscular layer of the ureter to fix it in place. The bladder is drained.

The most common complications of extravesical ureteroneocystostomy are persistent reflux and ureteral obstruction. Persistent reflux results if the submucosal tunnel is too short or if the ureter is not laid against the bladder musosa. Ureteral obstruction may result if the ureter sustains a thermal injury during mobilization, if the submucosal tunnel is not straight, or if there is undiagnosed distal ureteral narrowing. An atonic or hypotonic bladder may occur following bilateral extravesical ureteroneocystostomy if the ureters are overmobilized near the pelvic plexus.6 In these children, a urethral catheter should be left for 4 to 7 days.

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Perioperative Management

Most children undergoing the operative procedures described in this section can be discharged in one or two days. Near the end of the operative procedure, intravenous ketoralac 0.5 mg/kg (maximum dose 30 mg) is administered, unless renal function is abnormal, the child has asthma, or there is a significant risk of post-operative bleeding. In addition, bupivacaine 0.25% is infiltrated into the incisions at the end of the operation. Intravenous fluids are administered at 1 to 1½ maintenance over the first night. A regular diet is encouraged. The urethral catheter is left in place overnight and removed the next morning. Ambulation is encouraged at that time. Pain control is managed with intravenous ketoralac 0.25 mg/kg (maximum 15 mg) every 6 hours with a maximum of 7 doses. Supplemental morphine sulfate (0.05-0.1 mg/kg every 3 hours), acetaminophen, or acetaminophen with codeine are administered as needed.

Results

Results of common robotic pediatric urological procedures are shown in Table 1.

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Tables

Table 1. Summary of Robotic Reconstructive Procedures in Children

Reference

Procedure

Number

Time

Results

Complications

Sorensen et al, J Urol
2011; 185: 2517-2522

Pyeloplasty

33

245 min

32/33 (97%)

5/33 (15%)

Minnillo et al, J Urol
2011; 185: 1455-1460

Pyeloplasty

155

198.5 min

149/155 (96%)

17/155 (11%)

Olsen et al, J Urol
2007; 178: 2137-2141

Pyeloplasty
Retroperitoneal

67

143 min

63/67 (94%)

12/67 (18%)

Lee et al, J Urol 2009;
181: 823-828

Partial nephrectomy
Duplex system

9

275 min

9/9 (100%)

1/9 (urinoma)

Smith et al, J Urol
2011; 185: 1876-1881

Ureteral
reimplantation

25

185 min

22/23 (97%)

3/25 (12%)

Marchini et al, J Urol
2011; 185: 1870-1875

Ureteral
reimplantation
(extravesical)

20

233.5 min

20/20 (100%)

4/20 (20%)

 

Ureteral
reimplantation
(intravesical)

19

232.6 min

33/36 (92%)

8/19 (42%)

Casale et al, J Urol
2008; 179: 1987-1989

Bilateral ureteral
reimplantation
(extravesical)

41

140 min

40/41 (98%)

0/41 (0%)


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References

  1. Huettman E, Sakka SG, Petrat G et al. Left ventricular regional wall abnormalities during pneumoperitoneum in children. Br J Anaesth 2003; 90:733-736.
  2. Bannister CF, Brosius KK, Wulkan M. The effect of insufflation pressure on pulmonary mechanics in infants during laparoscopic surgical procedures. Paediatr Anaesth 2003; 13:785-789.
  3. Veyckemans F. Celioscopic surgery in infants and children: the anesthesiologist's point of view. Pediatric Anesthesia 2004; 14:424-432.
  4. Fraser JD, Aguayo P, Sharp SW, et al: The safety of laparoscopy in pediatric patients with ventriculoperitoneal shunts. J Laparoendosc Adv Surg Tech A 2009; 19: 675-678.
  5. Palmer JS, Palmer LS: Determining the proper stent length to use in children: age plus 10. J Urol 2007; 178: 1586-1589.
  6. Casale P, Patel RP, Kolon TF: Nerve sparing robotic extravesical ureteral reimplantation. J Urol 2008; 179: 1987-1990.

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Status
Module 8 Pediatric Surgery Posttest Available 1.50 credits/hours

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