Minimally Invasive Surgery in Children with a History of Congenital Abdominal Wall Defects

Introduction

Gastroschisis and omphalocele are distinct congenital abdominal wall defects (AWDs) that occur at between 0.4 to 3 per 10,000 births worldwide. Although there are maternal risk factors associated with different AWDs, the exact etiology is unknown and primarily sporadic.^1,2 It has been widely accepted in the adult literature that prior laparotomy is not a contraindication for attempted laparoscopic approach on subsequent operations. There is less literature available discussing the role of laparoscopy in children after previous open abdominal surgery; however, the available series do demonstrate feasibility.^3,4 There is minimal identifiable literature available regarding the use of laparoscopy in pediatric patients with a history of a congenital AWD. One case report has recently been published describing a laparoscopic Fowler–Stephens orchidopexy in a child with a history of gastroschisis. ⁵ In addition, we have previously published a small study evaluating the management of undescended testes in patients with gastroschisis; in this series we determined that laparoscopic orchidopexy was feasible in this patient population. ⁶ We now aim to broaden this finding and investigate the surgical history and the role of minimally invasive surgery in children with congenital AWDs.

Patients and Methods

This retrospective chart review was completed with institutional review board approval at Children's Healthcare of Atlanta (Atlanta, GA). All neonates admitted to the hospital with a congenital AWD (gastroschisis, omphalocele, or Pentalogy of Cantrell) were included. Study inclusion dates were January 1, 2000 through January 1, 2011.

During the designated study period, there were 139 neonates admitted with a congenital AWD. The charts for each of these children were reviewed with attention to subsequent abdominal operations after their AWD was closed. Data collected on those children who had subsequent operations included age at surgery, indication for surgery, surgical approach (laparoscopic or open), patient weight, estimated blood loss, length of surgery, intraoperative and postoperative complications, and postoperative length of stay. Surgical approach for all children was determined at the discretion of the attending surgeon.

Results

During the 11-year period, there were 139 neonates admitted with AWDs. The vast majority of the patients had a diagnosis of gastroschisis (n=114), with the remaining having omphalocele (n=22) and Pentalogy of Cantrell (n=3). There were 67 girls and 72 boys identified. Additional patient characteristics are shown in Table 1. Of this cohort, 43 children (30%) required at least one abdominal surgery after their defect was closed for a total of 65 abdominal operations. The median time from closure of the abdominal wall to the subsequent operation was 8.62 months (range, 0.77–76 months). Open operations were performed in 74% of the cases (n=48), and laparoscopy was attempted in 26% (n=17). Laparoscopy was converted to open laparotomy in 2 cases secondary to dense adhesive disease (12%). Median age of patients who underwent laparoscopic approach was significantly younger than those who had open surgery (7.1 versus 10.3 months, P=.001).

There were numerous indications for surgery, the most common of which included ventral hernia and gastroesophageal reflux. The complete list of operations and surgical approach is given in Table 2. The length of surgery, estimated blood loss, and postoperative length of stay were all significantly less for those cases performed laparoscopically (P=.018, P=.001, and P=.001, respectively) (Table 3).

There were no documented complications in any of the laparoscopic patients. One patient who underwent an open ventral hernia developed a mesh infection on postoperative Day 68, requiring an additional operation and removal of the mesh. Additionally, 1 of the patients who underwent a laparotomy for necrotizing enterocolitis was found to have necrotizing totalis and died shortly after surgery.

Discussion

This study characterizes the surgical history for patients with AWDs after their defect is closed. Clearly, the need for abdominal surgery after closure of a congenital AWD is not uncommon. In this series, 30% of all children required at least one operation.

Our results demonstrate that laparoscopic surgery is feasible and can be safely performed in children who have a history of an AWD. For the patients selected to have laparoscopic surgery, there were no complications, and the conversion rate to laparotomy was 12%. Both of these cases were attempted laparoscopic Nissen fundoplications, which were converted to laparotomy because of extensive adhesions. The successful completion of the remaining laparoscopic surgeries is likely a direct result of patient selection.

It is notable that surgical approach varied based on the indication for surgery. Laparoscopy was attempted most frequently for patients with cryptorchidism and reflux. Patients with a ventral hernia or bowel obstruction or needing an ostomy reversal were all approached via an open laparotomy. In many cases, this division is secondary to the nature of the individual operations. Recognizing that this is not a matched case-control study, observed differences in length of surgery and length of stay are likely a result of the differences in the type of surgery and surgical indication, rather than a reflection of the techniques used.

Based on our retrospective data, a history of an AWD alone should not be considered a contraindication for minimally invasive surgery. When deciding on the surgical approach for a patient with a history of a congenital AWD, surgeons should consider initiating abdominal surgery laparoscopically with the option to convert to laparotomy if excessive adhesions are encountered.