Minimal Access Surgery 

Updated: Nov 02, 2015
  • Author: Marc A Levitt, MD; Chief Editor: Philip Glick, MD, MBA  more...
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The field of surgery undergoes constant evolution. With the evolution of inhalation anesthetics at Massachusetts General Hospital in 1846, the field of surgery truly expanded. Before then, surgical procedures were avoided and, if performed, were brief. The best surgeon was the fastest surgeon who thereby caused less pain to his restrained and unanesthetized patient. [1]

Since the beginning, larger surgical incisions were an absolute necessity to a successful procedure. Exposure was the key to a safe and successful operation. Exposure is still essential for a safe and successful operation, except that it can now be provided with minimal skin incision and the use of a miniature access approach. The first incisionless operation performed is described in the Old Testament (Genesis 2:21), "And while Adam was sleeping, God took from Adam a rib for Eve and closed the wound with flesh."

Minimal access surgery (MAS) has been in existence since the early 19th century. In 1795, Dr Bozzini developed the Lichtleiter, a crude endoscope, which used a candle as illumination, for exploring intracavitary organs through external orifices. [1] In 1868, Kussmaul performed esophagogastroscopy on a willing sword-swallower using his first open tube in the gullet, illuminated by the reflected light of gasoline lamp. [2] In 1901, Kelling performed the first examination of the abdomen using a cystoscope in a dog. [3] A tremendous breakthrough occurred in 1966 when Hopkins invented the rod lens system. Around the same time, Semm developed an automatic insufflator that monitored intra-abdominal pressure and gas flow. Semm also performed the first incidental laparoscopic appendectomy in 1983.

MAS (ie, laparoscopy) has been used by gynecologists for more than 5 decades. Its application to general surgery began when Muhe performed the first laparoscopic cholecystectomy in 1985. In 1987, Mouret and Dubois helped popularize the laparoscopic cholecystectomy, and laparoscopic cholecystectomy soon became the standard of care. [1] Since that time, MAS has been applied to numerous other procedures with good results.

Advantages of MAS were realized by the adult surgeons long before it was accepted in the pediatric community. Initially, performing MAS in the pediatric population was resisted for the following reasons:

  • A widely held belief was that children did not experience pain.
  • The cost of laparoscopy was believed to be too high.
  • Equipment was not small enough.
  • MAS was believed to be too difficult to perform and too difficult to learn.
  • The cases were thought to take too long to set up and to perform.
  • Many surgeons believed that laparoscopic cases did not really apply to children, and the need for cholecystectomy was relatively uncommon in children.
  • Pediatric surgeons already prided themselves on the ability to work with small incisions.
  • Many believed that MAS was not safe, and its efficacy was not proven.

In 1973, Drs Gans and Berci were the pioneers in pediatric laparoscopy. [4] They performed laparoscopy (ie, peritoneoscopy) on 16 children (aged 1 d to 14 y), mainly for diagnostic purposes and for obtaining biopsies. A long lag period in pediatric MAS had occurred since its evolution.

Poor-quality pediatric laparoscopic instruments and telescopes that were not small enough were perhaps the most hindering in pediatric laparoscopy advancement.

In a comparative 5-year study, the outcomes of 211 children who underwent MAS were compared with age-matched controls with similar diagnoses who experienced open surgery. No significant differences in mortality or morbidity were found. However, the hospital stay was shorter for children who underwent laparoscopic cholecystectomy, appendectomy, nephrectomy, splenectomy, and surgery for intraabdominal testis as compared with open surgery. In addition, all parents favored the cosmetic results of MAS. [5]

Many of the advances made in pediatric laparoscopy have subsequently been used in adults. Adult surgeons sought the smaller telescopes and instruments that were developed for pediatric MAS.


Physiology of Minimal Access Surgery in Pediatrics

Insufflation of the abdomen or chest cavities for minimal access surgery (MAS) procedures has important physiologic effects. Much of this physiology has been studied in adults, but very little work has been conducted on this subject in children.

Pneumoperitoneum is required in most of the cases for successful laparoscopy. Some debate has occurred in terms of which medium is best. Most surgeons prefer carbon dioxide gas because it is easily absorbed, and, thus, the risk of embolism is reduced compared with other gases. In addition, it suppresses combustion. After the peritoneum is accessed, the abdomen is insufflated with carbon dioxide gas. The pressure limit usually does not exceed 15 mm Hg in adults. It varies in infants and children, and care must be taken to start low (eg, 1 L/min and pressures of 8-12 mm Hg) and use only the pressure required to obtain visualization and maintain optimal physiology.

Once the intra-abdominal volume exceeds the ability of the peritoneal cavity to expand without a significant increase in abdominal pressure, increase in pressure leads to detrimental physiologic effects. This is especially true when the cavity is small, as in children.

The ability of the abdominal cavity to accommodate an increase in pressure depends on the pressure applied and the length of time during which the pressure is maintained. Under normal physiology, the intra-abdominal pressure can be as high as 200 mm Hg during a coughing and defecation episode. During peritoneal dialysis, the pressures may rise to 2-8 mm Hg, which has no demonstrable adverse affect.

Increased intra-abdominal pressure interferes with infradiaphragmatic venous and arterial blood flow, especially to the kidneys. It may also displace the diaphragm into the chest cavity, decreasing total lung capacity and functional residual capacity, adding to the acid-base disturbance. An increase in intra-abdominal pressure effectively acts as a venous tourniquet. Blood flow from the lower limbs and abdomen is decreased while the arterial perfusion is intact. Cardiac output is decreased with increase in the ventricular stroke work and the heart rate. Pressure on the abdominal aorta also increases pressure in the upper body. In children with preexisting decreased cardiac output, increased intra-abdominal pressure may lead to acute cardiac failure.

The ventilatory and circulatory changes can be appreciated within 5 minutes of the onset of insufflation of gas. Pressures of more than 15 mm Hg are associated with significant pathophysiologic effects but are reversible over a 2-hour period. In infants and children, no hemodynamic effects are observed at a pressure of 10 mm Hg for less than 15 minutes. On the other hand, at insufflation pressures of 12 mm Hg, peak airway pressure increases by 40%, and compliance decreases by 47% with no change in dead space. Pediatric surgeons and pediatric anesthesiologists must work together to insufflate adequately yet maintain normal physiologic parameters.

Increased minute ventilation (ie, increased rate, airway pressure, and/or tidal volume) can compensate for pulmonary mechanical restriction with intra-abdominal pressures of less than 12 mm Hg. Pulmonary arterial pressure and pulmonary wedge pressure both increase with pneumoperitoneum, improving ventilation-perfusion at intra-abdominal pressures of less than 12 mm Hg. This may help explain the lack of effect on pO2 under these conditions. The carbon dioxide is mostly absorbed across the peritoneal surface, and a rise in its partial pressure can be offset by increasing minute ventilation.

Elevation in carbon dioxide may continue for 3 hours after an operation. This is important to recognize, especially given postoperative narcotic use and the effect of narcotics on ventilation. Continued monitoring of the cardiac, respiratory, and renal systems should be carried out in the immediate postoperative period.

Increase in intra-abdominal pressure can also exacerbate gastroesophageal reflux, adding to perioperative risk of aspiration.

Much work remains regarding the physiologic effects of pneumoperitoneum in children. Coronary, hepatic, mesenteric, and renal flow may be affected, as well as cerebrospinal fluid (CSF) pressure and pulmonary dynamics.


Advantages of Minimal Access Surgery

See the list below:

  • Laparoscopy often offers better visualization than open surgery, particularly better visualization of the hiatus and deep structures in the pelvis.
  • Minimal access surgery (MAS) offers dramatic advantages in terms of the quality of life after the operation.
  • Postoperative pain is reduced, which decreases postoperative narcotic use and its complications. This also aids in lower pulmonary complications.
  • Smaller wounds are associated with fewer wound complications, less scarring, and better cosmesis.
  • MAS results in reduction of postoperative adhesions.
  • Patients stay in the hospital for a shorter period and recover faster.
  • Patients are able to return to their normal activities faster (eg, feeding, school, work).
  • A child's quick recovery allows parents to return to work faster.
  • Video imaging allows surgical assistants, anesthesiologists, and nurses to view what the surgeon is doing and to actively participate in the procedure in their respective roles. [6]
  • Laparoscopy can be performed in infants weighing less than 1.5 kg without significant mortality or morbidity. [7, 8, 9]

Disadvantages of Minimal Access Surgery

See the list below:

  • Initial capital cost is associated with laparoscopy because new equipment and training are necessary.
  • Operating time is longer and the complication rate is higher during the learning curve of the procedure.
  • Loss of tactile sensation occurs, which is perhaps the major disadvantage of minimal access surgery (MAS). Intraoperative ultrasonography is helping to overcome this deficiency.
  • With current technology, the video camera can provide only a 2-dimensional image, although 3-dimensional views are becoming available.
  • Controlling bleeding laparoscopically is difficult.
  • The number of instruments and angles in which they can be applied are limited. Robotic applications using wrist technology is improving this problem.

Complications of Minimal Access Surgery

Technique-related complications

See the list below:

  • Complications can be related to placement of the initial trocar or initial creation of pneumoperitoneum. Underlying vessels or viscera can be injured. These injuries can be minimized by the use of open technique for the first trocar placement. [6, 10]
  • Complications can also arise from dissection during the procedure. These include direct injuries to hollow and solid organs, as well as thermal injury. These can also be minimized by careful and precise technique.

Carbon dioxide–related complications

See the list below:

  • Carbon dioxide can be easily absorbed through the peritoneal surface, leading to hypercapnia. Elevation in carbon dioxide can lead to acidosis, which can have further metabolic and hemodynamic consequences.
  • Insufflation of carbon dioxide can also cause cardiovascular compromise because of the previously mentioned venous tourniquet effect.
  • Another serious, but fortunately rare, side complication is gas embolism; this is minimized by carbon dioxide use as opposed to use of other gases.
  • Hypothermia can also ensue because of cold carbon dioxide insufflation, especially in small infants.
  • These complications can be minimized by low pressure and warm humidified gas insufflation, slight hyperventilation, proper fluid resuscitation, and careful monitoring in the operating room.

Minimal Access Surgery Applications

Minimal Access Surgery Applications in the Foregut


  • Operations of the esophagus are associated with significant morbidity directly related to the thoracotomy or laparotomy. Minimal access surgery (MAS) techniques offer a very good alternative to these morbid procedures.
  • Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula has been reported by Rothenberg. [11] Fine suturing of the esophageal anastomosis requires significant technical skills. Robotic surgery may play a role in this procedure in the future.
  • Heller myotomy with Dor anterior fundoplication via a laparoscopic approach is ideal for patients with achalasia. Many surgeons are performing this procedure. When the diagnosis is made, some wait until recurrence occurs after a single pneumatic dilatation. An anterior myotomy is performed 4 cm above the gastroesophageal junction and extending onto the stomach for 2 cm. A Dor fundoplication is performed, suturing anterior fundic patch to both edges of the myotomized extramucosal incision. Simultaneous upper endoscopy is performed to ensure adequate myotomy.
  • Heller myotomy can also be performed using the thoracoscopic technique. See the image below.
    Laparoscopic Heller myotomy. Laparoscopic Heller myotomy.

Gastrostomy tube

  • Enteral access with a gastrostomy feeding tube is necessary in many children. Some are unable to swallow, and others take in inadequate calories because of neurologic impairment. Children with cystic fibrosis, malignancies, neurometabolic diseases, and cardiac malformations may also require exogenous enteral feeding.
  • A MAS technique can be used for this procedure. A minilaparoscope (1.6 mm) with a single 5-mm trocar at the exit site for the gastrostomy button is used, and no special instrumentation or kits are needed. The operative time ranges from 15-30 minutes.
  • MAS-assisted percutaneous endoscopic gastrostomy tube placement assures proper location in the stomach and avoids injury to surrounding structures, particularly the transverse colon.

Nissen fundoplication

  • The indications for and the technique of open surgery are well known to the adult and pediatric surgeons. However, laparoscopic fundoplication offers excellent visualization of the hiatus, and after the initial learning curve, it can be expeditiously performed.
  • The morbidity of the surgical procedure, particularly complications, return of feeds, and hospital stays, is reduced with the laparoscopic approach.
  • Significant respiratory advantages of an MAS approach to this procedure are recognized, particularly in pediatric patients with mental retardation. Likelihood of extubation following the procedure, time spent in the recovery room, time spent in the ICU, and time spent intubated are all reduced with a MAS approach.
  • The laparoscopic technique is similar to the open technique and is typically performed with 5 ports, including the camera port. An angled (30° or 45°) scope is used.
  • This procedure can also be combined with gastrostomy feeding tube if necessary.
  • In children, a previous gastrostomy tube and contractures in patients with cerebral palsy can create additional technical challenges. See the images below.
    Laparoscopic Nissen fundoplication.
    Nissen fundoplication. Nissen fundoplication.
    Nissen fundoplication. Nissen fundoplication.
    Nissen fundoplication. Postoperative view, with ga Nissen fundoplication. Postoperative view, with gastrostomy in place.


  • Laparoscopic pyloromyotomy is typically performed with 3 stab wounds without trocars. [1] The average operating time is approximately 15 minutes.
  • Most (>90%) of the patients are discharged home within 24 hours.
  • The laparoscopic approach is not universally accepted because similar results can be achieved by Ramstedt pyloromyotomy via umbilical incision.
  • The cosmetic results, when compared with the traditional right upper quadrant incisions, are superior. See the images and videos below.
    Laparoscopic pyloromyotomy.
    Laparoscopic pyloromyotomy.
    Pyloromyotomy. Scar in an adult who underwent open Pyloromyotomy. Scar in an adult who underwent open pyloromyotomy as an infant.
    Pyloromyotomy. One month postoperatively after a l Pyloromyotomy. One month postoperatively after a laparoscopic pyloromyotomy.


  • The first pediatric laparoscopic cholecystectomy was reported by Sigman et al in 1991. [12]
  • This is one of the most common laparoscopic procedures performed in adults. However, it is less common in pediatric patients because of lower incidence of gallstones. Many of the pediatric patients who require this procedure have blood dyscrasias and form pigment stones. [13]
  • Similar to its adult counterpart, pediatric laparoscopic cholecystectomy is performed with 4 ports, including the camera port. The size of these ports ranges from 2-10 mm.
  • Laparoscopic cholecystectomy has been shown to be safe, even in an infant (< 19 mo). [14]
  • Biliary dyskinesia, which is less common than symptomatic biliary colic but is certainly encountered by pediatric surgeons, is aided by a laparoscopic cholecystectomy.

Minimal Access Surgery Applications in the Midgut

Small bowel

  • As with the feeding gastrostomy, a jejunostomy tube can be placed laparoscopically.
  • Small bowel can be resected if necessary, with intra- or extra-abdominal anastomosis, using the miniature access technique.
  • Laparoscopy has been used to treat intestinal malrotation, [9, 15] intussusception, [16] adhesiolysis, [9] Meckel diverticulum, [17] and small-bowel atresia. See the image below.
    Laparoscopy in a patient with gastrointestinal ble Laparoscopy in a patient with gastrointestinal bleeding. Laparoscopic view of the Meckel diverticulum.


  • Laparoscopic appendectomy was developed in the early 1980s by the German gynecologists Semm and Schrieber. [18, 19]
  • In 1991, Valla et al reported the first series of pediatric laparoscopic appendectomies. [19]
  • Laparoscopic appendectomy is being performed in increasing numbers throughout the Western world. It offers many of the same advantages as outlined above; however, a few studies show no major differences between open and laparoscopic techniques. [6, 20]
  • Laparoscopic appendectomy is even more useful if diagnosis of appendicitis is in question, especially in girls.
  • The laparoscopic approach allows better visualization of the rest of the abdominal cavity, allows better irrigation of the peritoneal cavity, and offers a lower wound infection rate.
  • Three ports (2-5 mm) are typically used, although single-trocar appendectomy has also been described in the literature. [21]
  • Laparoscopy in children with chronic abdominal pain is valuable and can often cure patients if they are experiencing chronic appendicitis. See the image below.
    Laparoscopic appendectomy.

Minimal Access Surgery Applications in the Hindgut


  • Laparoscopy has been used to treat diseases of the entire colon. [22] Laparoscopy also takes advantage of the excellent collateral blood supply of the colon, which makes mobilizing large segments possible.
  • As mentioned above, laparoscopy offers superb visualization of the pelvic structures, making working in the deep pelvis easier and safer.
  • Once the colon is mobilized, it can be resected with intra- or extra-abdominal anastomosis. The specimen can also be removed via the anus, and anastomosis can be performed transanally from the outside.
  • Laparoscopic pull-through for Hirschsprung disease is as follows:
    • Classically, Hirschsprung disease has been treated by staged procedures involving biopsy, colostomy, pull-through, and colostomy takedown over a period of 6-12 months.
    • However, with the help of MAS, it can be performed as a single-stage procedure in most patients.
    • In 1994, Curran et al performed the first laparoscopic pull-through in a canine. [23] It then was carried out in humans in 1994 by Smith et al. [24]
    • Laparoscopic pull-through has been shown to be safe in infants as young as 1 week and as small as 2.3 kg. [25]
    • The procedure is carried out with 3-4 small (3.5-5 mm) ports in the mid abdomen. Seromuscular biopsies are taken to check for mature ganglion cells in the proximal colon. The blood supply (inferior mesenteric artery [IMA]) of the distal colon is ligated. The colon is then mobilized down to the levator musculature in girls and the prostate in boys.
    • The dissection is then begun transanally, and colon is removed to the level of biopsy-proven ganglionic cells, and if possible, a 2- to 5-cm margin is created. Anastomosis between the anus and neorectum is performed above the dentate line. [6]
    • Average operative time in this series was 147 minutes, and bowel function returned within 24 hours for more than 90% of patients. Patients stayed in the hospital for an average of 2 days postoperatively. [26]

See the video below.

Hirschsprung disease. Laparoscopic mobilization of the rectosigmoid.

Imperforate anus

  • Most surgeons repair a perineal fistula primarily in the newborn period without a colostomy. For all other anorectal defects, most defer to the 3-step approach, consisting of diverting colostomy shortly after birth, the main repair at a later date, and finally, colostomy closure. [27]
  • More recently, a trend to repair congenital malformations earlier in life has developed, and an increasing trend to perform primary procedures without a protective colostomy has developed. [27]
  • The laparoscopic approach is even more attractive because it allows the repair of the defect without laparotomy, without colostomy, and with minimal pain.
  • This procedure has particular application to patients with imperforate anus and recto–bladder neck fistula. The rectum can be mobilized off of the bladder with a laparoscopic approach. Long-term results from this approach are not yet available to determine patient's ability to achieve fecal continence.

Minimal Access Surgery Applications in Hernia and Other Surgeries


  • Conventionally, hernia surgery in children is performed via high ligation of the hernia sac. This requires incision over the inguinal canal and dissection through the abdominal wall, opening of the inguinal canal, dissection of the cord from the hernia sac, high ligation of the hernia sac, and closure in layers. Assessment of the contralateral side can be a diagnostic dilemma with this type of approach. Some authors have used laparoscopy to visualize the contralateral side. Contralateral hernias may not be as prevalent as historical reports in the literature.
  • Laparoscopic repair has been reported via transabdominal approach. The peritoneal cavity is entered at the level of the umbilicus, and a trocar is placed. The peritoneal cavity is insufflated with carbon dioxide. Two 2-mm trocars are then placed under direct vision slightly superior and medial to the anterior superior iliac spine. Both internal rings are inspected, and direct and indirect hernias are visualized easily. These hernias are repaired, and, if a contralateral hernia is visualized, it is also repaired.
  • The repair consists of ligating the sac from the inside at the level of the internal ring. Injury to the gonadal vessels and vas deferens should be avoided during the closure of the hernia defect. This repair does not take care of a distal hydrocele.
  • Laparoscopic hernia repair has a theoretical advantage with recurrent hernia because the surgical planes have not been previously violated. This avoids the risk of operating through scar tissue and injuring the testicular vessels or the vas deferens. It also has a theoretical advantage in girls because ovaries can be visualized adequately, especially if they are incarcerated.
  • With a laparoscopic approach, minimal or no dissection of the cord structure occurs; therefore, the likelihood of injury to the testes is low.
  • In females, the laparoscopic inversion ligation herniorrhaphy (LILH), using peritoneal inversion and high ligation, is a technique that is increasingly used.


  • This procedure is usually performed with 1-3 trocars.
  • In one study, the median operating time was approximately 30 minutes and the median hospital stay was 24 hours. Recurrence with the laparoscopic Palomo technique was low, and the rate of postoperative hydrocele formation was significant (6.6%). [28]

Nonpalpable testes

  • MAS techniques must be used if the cryptorchid testis is not palpable in the inguinal canal after induction of anesthesia.
  • The first report of abdominal testes identified by laparoscopy was in 1976, [29] and since then, laparoscopy has become the criterion standard for nonpalpable testes.
  • Laparoscopy allows localization of intra-abdominal testes, identification of absence of testis and presence of canalicular testis. This localization is easily accomplished by following the course of vas and testicular vessels.
  • Once located, intra-abdominal testes can be treated by MAS-assisted orchidopexy.
  • The nonpalpable testes are usually found between the internal ring and the external iliac vessels. [29]

Ovarian pathology

  • Laparoscopy has been used successfully to manage a wide variety of gynecologic problems, including tubal torsion, adnexal torsion, and oophorectomy.
  • In teenaged girls with abdominal pain, diagnostic laparoscopy is invaluable.
  • It can be performed easily with 2-3 ports and provides excellent operative view.
  • Patients do extremely well and are able to return to their preoperative activity sooner.

Minimal Access Surgery Applications in Solid Organs


  • The first MAS approach to splenectomy was successfully performed in 1990 in animals. [30] Since then, many accounts of laparoscopic splenectomy in humans have been reported in the literature. The first laparoscopic splenectomy was performed in Buffalo, New York. It has now become the criterion standard for removal of the spleen.
  • Indications for laparoscopic splenectomy are the same as they are for open procedure unless malignancy is suspected.
  • Patients are usually placed in a supine position or in a 45° right lateral decubitus position. Typically, 4-5 trocars of varying sizes (5-12 mm) are used.
  • Laparoscopic approach offers a much-improved view without an extensive incision. Most of the dissection has been facilitated by development of better energy modalities and improved stapling devices.
  • The spleen is placed in a bag, which is exteriorized and removed after breaking it with a finger or sponge stick.
  • Patients do extremely well postoperatively, and most are able to return home within 48 hours.
  • Splenopexy has been performed for a wandering spleen in a 2-year-old girl. [31]
  • Partial splenectomy, splenopexy for wandering spleen, and splenic cyst excision all have been reported. See the image below.
    Splenic cyst.


  • Laparoscopic nephrectomy was first described in 1991 in adults. [32]
  • Transperitoneal or retroperitoneal approaches have been used.
  • Ehrlich et al reported the first series of laparoscopic renal surgery in children. [33]
    • He performed a total of 17 procedures, consisting of 10 nephrectomies, 4 nephroureterectomies, 2 partial nephrectomies, and 1 giant renal cyst excision.
    • A transperitoneal approach was used in 17 children (age 4 mo to 11 y) with good results.
    • Ehrlich et al also reported the first laparoscopic partial nephrectomy in 1993.
  • The retroperitoneal approach completely avoids the peritoneum, thereby decreasing the related complications. The incidence of postoperative ileus and postoperative adhesions are also avoided. It is also ideal in patients who have had previous abdominal surgeries.
  • In 1992, Gaur performed the first successful retroperitoneal approach for renal surgery in India. [34]
  • This approach can be used for renal biopsy, nephrectomy, heminephrectomy, nephroureterectomies, nephropexy, adrenalectomy, and pyeloplasty. [35]
  • The retroperitoneum is dissected using balloon, saline, finger, or direct vision. Angled scopes provide a much better view because of the limited operational space. This approach is limited in small children.
  • Laparoscopic donor nephrectomy has improved the operation for the donor and has increased the use of the living related renal transplantation.
    Laparoscopic donor nephrectomy.
  • Other urologic procedures have also been performed laparoscopically, including pyeloplasty, bladder reconstruction, and ureteral reimplantation. See the images below. [36, 37]
    Laparoscopic donor nephrectomy.
    Nephrectomy for multicystic kidney.


  • The MAS approach can be applied to adrenal tumors, such as pheochromocytoma, and incidentally found adrenal masses.
  • The MAS approach can be transperitoneal or retroperitoneal. MAS offers an excellent view of the surgical anatomy and the vasculature.
  • This approach is similar to the laparoscopic nephrectomy.

Minimal Access Surgery Applications in the Thorax


  • In 1910, Jacobeus first introduced thoracoscopy for dissection of tuberculosis (TB) adhesions. [7]
  • Thoracoscopy is safe and effective, even in infants weighing less than 1.5 kg, without significant morbidity or mortality. [7, 8]
  • Patients are placed in a lateral position with the operative side up, as in the open technique. Three trocars are used in most cases.
  • Thoracoscopy is useful for the following [38] :
    • Assessment or resection of mediastinal or lung masses [8]
    • Closure of patent ductus arteriosus [39]
    • Vascular rings [40]
    • Diaphragm plication [24]
    • Resection of subpleural blebs
    • Pleurodesis
    • Pericardial drainage
    • Lung biopsies
    • Drainage of empyema
    • Tumor biopsies