Pediatric Surgery
Keyhole surgery lets surgeons operate inside a child's abdomen through cuts a few millimeters long. For many operations it means less pain and a faster recovery, and for a few the randomized trials found no advantage.
A small camera and fine instruments pass through tiny openings. Gas gently lifts the abdominal wall to give the surgeon room. In children it is used for appendicitis, hernias, undescended testes, pyloric stenosis in babies, gallbladder and spleen removal, reflux surgery and many other operations. A double-blind trial in 180 babies with pyloric stenosis found that babies treated by keyhole surgery reached full feeds and went home sooner. A Norwegian trial of reflux surgery found the opposite of what surgeons expected, with more recurrences after the keyhole operation. Good pediatric surgeons choose the approach operation by operation. Send us your child's reports, and a pediatric surgeon will tell you whether keyhole surgery is the right choice and how long to plan.
18.5 vs 23.9 h
Time to full feeds after keyhole against open pyloromyotomy
3 to 5 mm
Typical size of each keyhole incision in a child
2 to 5 days
In Istanbul for most keyhole operations
Free
Pediatric surgeon's review of your child's file
Free consultation
Both open and laparoscopic pyloromyotomy are safe procedures for the management of pyloric stenosis.
Double-blind trial of 180 infants, The Lancet, 2009
Smaller scars that fade to faint marks, less pain in the first days, earlier eating and walking, and a shorter stay are the benefits families see most. The camera also gives the surgeon a magnified view of the whole abdomen through the same openings, which helps when the diagnosis is uncertain or both sides need checking, and lets the surgeon look at organs far from the incision, the appendix, the ovaries or the bowel, without making a long cut to reach them.
Where does keyhole surgery help most?
The answer varies by operation.
Smaller cuts sound better. Randomized trials, in which children are assigned to keyhole or open surgery by chance, are the only fair test, and only a few have been done in children. Their results are clear for some operations and surprising for others. They explain why an experienced pediatric surgeon offers keyhole surgery selectively.
Pyloric stenosis in babies
In pyloric stenosis, the muscle at the outlet of the stomach thickens in the first weeks of life, and the baby vomits forcefully after feeds. The operation splits the muscle. A double-blind trial at six centers randomized 180 babies to open or keyhole pyloromyotomy, without telling parents or nurses which they had.
Babies treated by keyhole surgery reached full feeds in 18.5 hours against 23.9, and went home after 33.6 hours against 43.8. Vomiting and complications were the same. The trial was stopped early because the benefit was clear, and the authors recommended keyhole surgery in centers with suitable experience.
1
Before surgery
Fluids through a vein for a day or so to correct the salts lost through vomiting. Surgery waits until the blood tests are normal.
2
The operation
Three tiny cuts, 20 to 30 minutes, under general anesthesia.
3
Feeding and home
Feeds restart within hours and build up over a day. Most babies go home the next day.
Inguinal hernia
Hernias are among the commonest operations in children. Keyhole repair closes the opening from inside and lets the surgeon see the other side, where the surgeon repairs a hidden hernia at the same time. Techniques differ. An Egyptian randomized study of 132 young children compared two keyhole methods and found fewer recurrences when the hernia sac was disconnected and the opening closed than when it was simply tied with a purse-string stitch.
- Look inside both groins through the navel.
- Close the hernia opening with a stitch from inside.
- Repair any hidden hernia on the other side in the same operation.
Reflux surgery, a surprise
Children operated with LF have a higher recurrence rate of GERD than those operated with OF.
Norwegian randomized trial of 87 children, Annals of Surgery, 2015
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Open against keyhole Nissen fundoplication in children, Norway
| Outcome |
Keyhole |
Open |
| Operating time |
150 minutes |
89 minutes |
| Median hospital stay |
7.0 days |
7.5 days |
| Complications in the first month |
24 children |
24 children |
| Reflux recurrence after a median of 4 years |
37 percent |
7 percent |
Questions to ask about any keyhole operation
- Is there trial evidence that keyhole surgery is better for this operation, or only for others?
- How many of these operations does the team perform each year by keyhole?
- What is the chance of converting to an open operation, and why might that happen?
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Open against keyhole pyloromyotomy, 180 babies
| Outcome |
Keyhole |
Open |
| Time to full feeds |
18.5 hours |
23.9 hours |
| Hospital stay after surgery |
33.6 hours |
43.8 hours |
| Complications |
Similar |
Similar |
Apart from surgery duration, the results were surprisingly similar.
Thirty-day results of the Norwegian fundoplication trial, Journal of Pediatric Surgery, 2012
Keyhole is a tool
The goal is the best operation for the child. For pyloric stenosis, hernias and appendicitis the evidence favors keyhole surgery in experienced hands. For reflux surgery in one well-run trial the open operation gave fewer recurrences. A pediatric surgeon who does both can choose honestly.
We did not find that laparoscopy induced a substantially less inflammatory response than laparotomy in children undergoing fundoplication.
Randomized study of 29 children, Pediatric Surgery International, 2014
Hernia technique
It has a lower recurrence rate than the purse string suturing leaving the sac intact.
Randomized study of 132 children, Journal of Pediatric Surgery, 2017
When open surgery is better
Very large tumors, extensive adhesions from earlier operations, some emergencies in unstable children and some reflux operations are done open. A planned keyhole operation is sometimes converted to open when the view is poor or bleeding needs control, and that choice keeps the child safe.
Is keyhole surgery safe for babies and small children?
Yes, with the right team.
Signs to watch for after keyhole surgery
Fever, increasing abdominal pain, repeated vomiting, a swollen abdomen, or redness and discharge from a cut need a doctor. Shoulder-tip pain in the first day or two comes from the gas and fades on its own.
Anesthesia and gas
Babies and small children tolerate keyhole surgery well when the anesthetist and surgeon adjust the gas pressure and breathing to the child's size. Pediatric anesthetists monitor carbon dioxide levels throughout, and most operations take less than an hour.
How long is the stay, and what decides the cost?
Most keyhole operations in children need only a short hospital stay, and many families are back at their hotel the same evening or the next morning.
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Typical length of stay in hospital
| Operation |
Hospital stay |
| Hernia repair |
Same day |
| Appendix, uncomplicated |
One to two days |
| Pyloromyotomy |
One to two days |
| Gallbladder or spleen removal |
One to three days |
Plan two to five days in Istanbul for most keyhole operations, including a wound check before the flight, and a week for the larger ones. Children fly comfortably once they eat and walk and the surgeon has checked the cuts.
Cost depends on the operation, the anesthesia and the hospital stay. Your own figure follows the free review of your child's file.
One coordinator plans the visit with the family, from the visa invitation letter sent ten days ahead to the transfer and a family hotel near the hospital. Both parents can stay until the child is asleep, one parent stays throughout, and the team works in seven languages with halal meals and a prayer room available. Back home, photographs of the wounds sent at one and two weeks let the surgeon confirm healing, and the coordinator stays reachable on the same WhatsApp number for any question on pain, bathing, school or sport, which after most keyhole operations can resume within a week or two.
Keyhole surgery in children FAQ
Is keyhole surgery better than open surgery for children?
For many operations, such as pyloromyotomy, hernia repair and appendix removal, it means faster recovery. For reflux surgery, a Norwegian trial found more recurrences after keyhole surgery, so the choice depends on the operation.
How big are the scars?
Each cut is 3 to 5 millimeters, one usually hidden in the navel, and they fade to faint marks.
Is keyhole surgery safe for newborns?
Yes, in experienced hands, with gas pressure and breathing adjusted to the baby's size.
Why might a keyhole operation be converted to open?
When the view is poor or bleeding needs control, the surgeon converts to an open operation, a safe decision taken for the child's benefit that happens in a small minority of planned keyhole operations.
How long will we stay in Istanbul?
Two to five days for most keyhole operations, including a wound check before the flight.
Can a parent stay with the child?
Yes. One parent stays with the child throughout the hospital stay.
References
- Hall NJ, Pacilli M, Eaton S, et al. Recovery after open versus laparoscopic pyloromyotomy for pyloric stenosis: a double-blind multicentre randomised controlled trial. Lancet. 2009;373(9661):390-398.
- Fyhn TJ, Knatten CK, Edwin B, et al. Randomized Controlled Trial of Laparoscopic and Open Nissen Fundoplication in Children. Annals of Surgery. 2015;261(6):1061-1067.
- Knatten CK, Fyhn TJ, Edwin B, et al. Thirty-day outcome in children randomized to open and laparoscopic Nissen fundoplication. Journal of Pediatric Surgery. 2012;47(11):1990-1996.
- Knatten CK, Hviid CH, Pripp AH, Emblem R, Bjørnland K. Inflammatory response after open and laparoscopic Nissen fundoplication in children: a randomized study. Pediatric Surgery International. 2014;30(1):11-17.
- Abd-Alrazek M, Alsherbiny H, Mahfouz M, et al. Laparoscopic pediatric inguinal hernia repair: a controlled randomized study. Journal of Pediatric Surgery. 2017;52(10):1539-1544.
