• John Vlot, Lonneke M E Staals, René M H Wijnen, Robert Jan Stolker, and Klaas N M A Bax.
• Department of Pediatric Surgery, Erasmus MC: University Medical Center Rotterdam, the Netherlands. Electronic address: john.vlot@erasmusmc.nl.
• J. Pediatr. Surg. 2015 Mar 1;50(3):465-71.

IntroductionIn our continuing research into the determinants of laparoscopic working space, the influence of small body size was investigated.MethodsIn eight 6-kg pigs, the effects of intraabdominal CO2 pneumoperitoneum pressure (IAP), prestretching of the abdominal wall, and neuromuscular blockade (NMB) on laparoscopic working space volume and distances were studied. Computed tomography was used to measure working space during two stepwise abdominal insufflation-runs up to an IAP of 15mm Hg. Results were compared with data from earlier experiments in 20-kg pigs.ResultsCardiorespiratory parameters were stable up to an IAP of 8-10mm Hg. In 6-kg pigs working-space dimensions were five times smaller than in 20-kg pigs. Working-space volume, anteroposterior (AP) diameter and symphysis-diaphragm distance increased linearly up to an IAP of 8mm Hg. Above 8mm Hg, compliance decreased. Eighty percent of the total volume (618ml) and of AP diameter (3cm) at 15mm Hg had been achieved at an IAP of 10mm Hg. Prestretching by a first insufflation resulted in a statistically significant increase in working space volume and in AP diameter during the second insufflation. This effect was significantly larger than in 20-kg pigs. Neuromuscular blockade did not have a significant effect on working-space.ConclusionsWorking space in growing individuals is very limited. Eighty percent of the working space created by an IAP of 15mm Hg was already achieved at 10mm Hg, while cardiorespiratory side effects at an IAP of 8-10mm Hg seem acceptable. Prestretching of the abdominal wall significantly increased working space, even more so than in 20-kg pigs. As in 20-kg pigs, NMB had no significant effect on laparoscopic working space. Prestretching of the abdominal wall is a promising cheap, safe and easy strategy to increase laparoscopic working space, lessening the need for prolonged high-pressure pneumoperitoneum.Copyright © 2015 Elsevier Inc. All rights reserved.

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