Laparoscopic equipment safety: children and neonates

Laparoscopic equipment, originally designed for use in adult procedures, is now widely used for pediatric and neonatal surgery. As commonly occurs in medical practice, the transition from adult to pediatric use occurs “off-label” and without further investigation into the safety and efficacy of the practice. After a number of reports of catastrophic events associated with neonatal laparoscopy, both published and anecdotal, some suggesting the presence of air in embolized gas, Dr. Susan P. Taylor, Department of Pediatric Anesthesiology, Children’s Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, Wisconsin, and colleagues designed a study to determine the characteristics of laparoscopic gases in both in vitro and clinical samples. Their work is published in this month’s issue of Anesthesia & Analgesia in the article titled “Gas Analysis Using Raman Spectroscopy Demonstrates the Presence of Intraperitoneal Air (Nitrogen and Oxygen) in a Cohort of Children Undergoing Pediatric Laparoscopic Surgery.”

The presence of nitrogen in vitro was predictable algebraically when the volume of the insufflation tubing and the peritoneum was known. Nitrogen was present in all clinical samples regardless of whether or not the surgeon flushed the equipment with carbon dioxide prior to insertion into the peritoneal cavity, and the potential for dangerous levels of insoluble gas increased as the intracavitary volume approached the dead space volume of the delivery system. The authors concluded that changing equipment design by using neonatal and pediatric equipment that minimizes dead space, labeling insufflation tubing so as to warn the user to flush the delivery tubing with at least twice its dead-space volume prior to insertion, and analyzing the delivered gas, which is possible with technology already available in clinical practice, all might improve patient safety.