|Year : 2013 | Volume
| Issue : 1 | Page : 25-27
Role of laparoscopy in the management of intussusceptions in children
Vijay C Pujar, Shirin Joshi
Department of Pediatric Surgery, KLE University, Belgaum, Karnataka, India
|Date of Web Publication||28-Mar-2013|
Vijay C Pujar
Department of Pediatric Surgery, J.N. Medical College and K.L.E's Dr Prabhakar Kore Hospital and MRC, Belgaum, Karnataka
Source of Support: None, Conflict of Interest: None
Aim: To evaluate the role and efficacy of laparoscopic reduction of intussusceptions in children with failed initial hydrostatic reductions. Materials and Methods: This is a retrospective study of children who underwent laparoscopy for incomplete reductions following sonoguided hydrostatic reduction.Laparoscopy guided pneumatic reduction or laparoscopic reduction was done. Results: Hydrostatic reduction was successful in 76 (73.5%) of cases. Among 26 children in Laparoscopy group 8 showed completeness of reduction. Features of necrotic bowel were seen in 4 (15%) children requiring laparotomy. Among 14 children with incomplete reduction 3 (21%) children required pneumatic reduction under laparoscopic monitoring. 11 required laparoscopic reduction. None of the incomplete group with viable bowel required conversion to open surgery. No major complications were noted in any groups. The mean hospital stay was 1.8 days in hydrostatic group 4.2 days in laparoscopic group and 6.8 days in laparotomy group. No recurrence of intussusceptions noted. Conclusions: The role of laparoscopy in intussusceptions is evolving as a safe procedure and helps in avoiding laparotomy in large number of children with incomplete reduction. Non operative reduction is the gold standard in management of intussusceptions in children. Excellent results are obtained with either saline or pneumatic reductions. However, in few cases of, incomplete reduction or doubtful complete reduction with non operative technique poses problem for further management and may need laparotomy. Laparoscopy being less invasive has distinct advantage over open laparotomy. Use of Laparoscopy in the management of Intussusceptions is described in literature. We have analyzed our results of laparoscopic management of intussusceptions in children in our center.
Keywords: Children, intussusception, laparoscopy reduction
|How to cite this article:|
Pujar VC, Joshi S. Role of laparoscopy in the management of intussusceptions in children. J Sci Soc 2013;40:25-7
| Introduction|| |
Intussusception refers to the invagination of a part of the intestine into itself. It is the most common abdominal emergency in early childhood, particularly in children younger than two years of age.  Prompt treatment is required to avoid complications like bowel necrosis and perforation. The first successful surgical correction of intussusceptions in an infant was described in 1871 by Hutchinson. Non-operative treatment of intussusceptions by hydrostatic pressure dates back to the days of Hippocrates, who recommended the use of enemas in all forms of ileus. Reduction of intussusceptions by barium enema under fluoroscopy was first reported by Pallin and Olsson in Sweden, Retan in the United States and by Pouliquen in France in 1927. Ravitch popularized and set the guidelines for the use of barium enema reduction in 1948. 
A number of media including air, water-soluble contrast, and saline have been used for reduction of intussusceptions with a reasonably high success rate ranging from 79-90%. ,,,,
There has been tremendous development of laparoscopic surgery in children. Several reports previously described and suggested a role of laparoscopy in the management of childhood intussusceptions. ,
| Materials and Methods|| |
Total 106 children with acute ileocolic intussusceptions were treated in last four years (June 2008 to June 2012). The age group was between six months to fourteen months with sex ratio of 4:3. Children with features of peritonitis on presentation (four) were excluded from this study. One hundred and two children were submitted for hydrostatic reduction under ultrasonic guidance. Reduction was complete in 76 children (73%). In remaining 26 children in whom either the reduction was incomplete or doubtful complete reduction, were taken up for laparoscopy-assisted pneumatic reduction [Figure 1]. Under general anesthesia, five mm port was placed at umbilicus by open Hassan's technique. Laparoscopic findings regarding site of intussusceptions, viability of bowel were noted. Additional ports were placed according to the findings. Pneumatic reduction under laparoscopic monitoring was done [Figure 2] in those with incomplete reduction extending beyond hepatic flexure. Laparoscopic reduction was done with the help of atraumatic forceps. All children underwent ultrasonography after 12 hours and 24 hours after reduction.
| Results|| |
Hydrostatic reduction was successful in 76 (73.5%) of cases. Among 26 children in laparoscopy group, eight showed completeness of reduction. Features of necrotic bowel were seen in four (15%) children requiring laparotomy. Among 14 children with incomplete reduction, three (21%) children required pneumatic reduction under laparoscopic monitoring. Eleven required laparoscopic reduction. None of the incomplete group with viable bowel required conversion to open surgery. No major complications were noted in any groups. The mean hospital stay was 1.8 days in hydrostatic group, 4.2 days in laparoscopic group, and 6.8 days in laparotomy group. No recurrence of intussusceptions noted.
| Discussion|| |
The non-operative reduction of intussusceptions is usually carried out under sono- or fluoroscopic guidance. Pneumatic reduction is an established method for treatment of intussusceptions in children, with a high success rate up to 90%. , In the intussusceptions with a lead point, the non-operative reduction with fluoroscopy is difficult, and recurrence rate is high.  We preferred pneumatic reduction over hydrostatic is due to nonavailability of sonography in the operation theatre. In about 5% of pneumatic reductions, gas can't pass into terminal ileum either because of competent or edematous ileocecal valve. It is also impossible to rule out ileoileal intussusceptions without reflux of gas into the ileum; these problems can be solved by laparoscopy-assisted pneumatic reduction through using higher CO2 pressure and the use of atraumatic grasping forceps; and the reduction can be made complete.
Laparoscopy-assisted hydrostatic in situ reduction of intussusceptions (LAHIRI) is shown to be safe and efficacious treatment modality in the pediatric population. The advantages of laparoscopy-assisted procedures are as they are performed in a controlled environment in the operating room, avoids patient apprehension and discomfort, avoids bowel handling, prevents bowel over distension, and ensures visual assessment of bowel vascularity and completeness of reduction.  One of the main advantages of laparoscopic method is the visualization of the invaginated loop of intestine, and smooth and rapid post-operative recovery. Usage of combined laparoscopy and air enema facilitates the reduction under high pressure and visualization of the entire process. 
The major concern voiced against this procedure is injury to the bowel as it pulled as against retrograde reduction done on open technique. However, as retrograde reduction is combined with this technique, the chances of bowel injury are least. "Chinese fan spread" technique described to avoid bowel injury  has not been tried by us.
Though our study group is small like many other reports, laparoscopic reduction is shown to be safe and effective method in the management intussusceptions in children.
| Conclusion|| |
The role of laparoscopy in intussusceptions is evolving as a safe procedure and helps in avoiding laparotomy in large number of children with incomplete reduction.
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[Figure 1], [Figure 2]