The Role of Laparoscopy in Newborns Affected by NEC

Introduction

For many years, laparoscopic procedures have been reported in the literature in pediatrics also. Only in the last few years has the use of laparoscopy been described also in newborns, including small for gestational age (SGA) neonates. This technique is preserved for high-experienced centers, where laparoscopy can be safely managed by the operators. Few articles report the use of laparoscopy in newborns, especially as treatment for necrotizing enterocolitis (NEC), and its role is becoming a new aspect in pediatric surgery.^1–5

Materials and Methods

From January 2007 to May 2008, 8 patients affected by stage 1–2 NEC were treated at the Department of Pediatric Surgery, Fondazione Policlinico Milano (Milan, Italy). Of those, 3 patients presented with a birth weight below 1.5 kg, with the others between 1.9 and 2.8 kg. All patients presented bile-standing vomits associated with abdominal distension; in 3 of 8 patients, enteral nutrition was at regime. Radiologic findings showed the presence of pneumatosis, without evidences of free air. Biochemical status presented an increase of C-reactive protein and white cells, and at clinical examination, all the patients presented with a distended abdomen, without erithema or edema of the abdominal wall. After a period of 24 hours of intravenous antibiotic therapy (ampicillin, metronidazole, and gentamicine), a deterioration of clinical status of the patients was reported, associated with an increase of abdominal distension, deterioration of biochemical status (including decreasing of platelets), and deterioration at X-ray, where signs of diffuse pneumatosis was detected (Fig. 1). Due to this scenario, a surgical approach was decided.

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FIG. 1.

Evidence of abdominal distension and deterioration at X-ray.

Results

All patients were submitted to gasless laparoscopy (Figs. 2 and 3). Through a minimal incision in the umbilicus, a 3-mm camera was inserted and the abdominal cavity explored. ³ In 1 case, we utilized a cystoscope (0-degree camera). In 6 of 8 patients, a covered perforation was detected; in 5 cases, the perforation was on the posterior wall of the ascending colon, and in 1, a perforation of the transverse colon was detected. In all the patients, it was possible to detect a collection in the area where the perforation was, at laparotomy, found. In all patients, the procedure was converted to a formal laparotomy, which confirmed the presence of the perforation of the colon, with a covered collection. A colonic resection and primary anastomosis was then performed.

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FIG. 2.

Gasless approach.

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FIG. 3.

Camera (3 mm).

In 2 of 8 patients, a diffuse necrotizing enteritis of the small bowel was reported, without evidence of perforation; all abdominal cavities were inspected, despite the distension of the intestinal loops. Once we had the proof there were any perforations or parts of the bowel affected by gangrene or preperforate status, two drains were placed and continued abdominal washout with antibiotic solution was maintained for 48 hours, associated with systemic therapy. All patients were maintained on systemic antibiotic therapy for 7 days with the regression of sepsis; all patients survived and were discharged in good general conditions. At the follow-up of 3 months, none of the patients presented with complications.

Discussion

It has been well defined in the last few years that operative laparoscopy in neonatal surgery is a big challenge for surgeons^2,4–6; this is increasingly important when an SGA baby with an acute septic status would be taken for a laparoscopic procedure.

In the series presented at the BAPES 2009 meeting in Nottingham, we believe that the decision to perform a laparoscopy, despite the very low weight of the patient, was crucial in the management of nondetected perforations at X-ray. Retrospectively, laparoscopy would be the best option to define the presence of NEC without perforation, which may only require washout of the cavity, which can be also managed with this technique. Due to the instability of the patients, the decision to utilize gaslesslaparoscopy gave important advantages in the management of these patients. Especially for anesthetic aspects, the decision we made to perform a gasless approach presented more advantages. This did not result in more difficulty, compared to the formal laparoscopic approach.

Conclusions

We believe that laparoscopy can be easily managed also in newborns and SGA neonates, reducing the morbidity of laparotomy for suspicion of perforation in patients affected by NEC who do not respond to medical treatment. Especially in those patients where no evidences of perforation are present at formal imaging, we believe that laparoscopy reduces the morbidity and mortality of a nondetected bowel perforation in a newborn. Due to the instability of the patients, the role of gaslesslaparoscopy is also fundamental in obtaining a good prognosis of these babies. Moreover, the gasless-laparoscopic approach can represent the first approach to a newborn where suspicion of perforation is one of the diagnostic options.