Abstract
Abstract
Aim:
To define the role of laparoscopy for treating malrotation in children.
Materials and Methods:
The Ladd procedure (9 laparoscopic [lap-Ladd], 17 open [open-Ladd]; n=26) was performed in children up to and including 30 days of age (neonatal [Group N]) and older (Group C). These groups were compared retrospectively.
Results:
Group N (n=14) comprised 3 lap-Ladd and 11 open-Ladd patients. Group C (n=12) comprised 6 lap-Ladd and 6 open-Ladd patients. No case had ischemic bowel preoperatively. Intestinal volvulus was confirmed in 3 of 3 lap-Ladd and 9 of 11 open-Ladd patients in Group N, compared with 5 of 6 lap-Ladd and 6 of 6 open-Ladd patients in Group C (P=not significant). Mean operating times were significantly longer for lap-Ladd patients (130.7 minutes versus 81.1 minutes in Group N and 119.2 minutes versus 74.2 minutes in Group C). Conversion to an open-Ladd procedure was necessary in 1 of 3 patients in Group N and 1 of 6 patients in Group C (P=not significant). Complications arose in open-Ladd patients, bowel obstruction in Group N (1 of 11), and mesenteric chylorrhea in Group C (1 of 6). There was recurrence in 1 of 3 lap-Ladd patients in Group N. Mean time to recommence feeding was earlier for lap-Ladd patients (P=not significant). Length of hospitalization was similar in Group N but was shorter for lap-Ladd patients in Group C (P=not significant).
Conclusions:
Although lap-Ladd appears to be a safe procedure, it cannot be recommended for the treatment of malrotation in neonates.
Introduction
I
The procedure of choice for the surgical treatment of malrotation and prevention of midgut volvulus is the Ladd procedure, first described in 1936, 2 which was first performed laparoscopically in 1995, 3 and followed by similar reports thereafter.1,4 Reports comparing the conventional open Ladd procedure (open-Ladd) with the laparoscopic Ladd procedure (lap-Ladd) have shown that lap-Ladd is safe and effective in adults, 5 and although several series have demonstrated the safety and efficacy of lap-Ladd in infants and children,6–8 it is still not performed routinely as the procedure of choice for malrotation in infants and children.
We introduced lap-Ladd as an option for the treatment of malrotation in 2007, and since then, the treating surgeon has chosen the technique for surgical intervention for each patient. In this study, we present our experience of treating malrotation with laparoscopy in an attempt to more clearly define its role in children, comparing open and laparoscopy patients with respect to outcome according to age at the time of surgery.
Materials and Methods
We conducted a retrospective analysis of all Ladd procedure operations performed at our institution between 2007 and 2012. Patients with congenital diaphragmatic hernia and gastroschisis were excluded. Patients with malrotation who were asymptomatic were observed. Institutional review board approval was obtained for this study (number 2013-38). In order to compare postoperative outcome, we divided our subjects into two groups according to age at the time of surgery. The neonatal group (Group N) comprised subjects 30 days of age or younger at the time of surgery, and Group C comprised subjects 31 days of age or older at the time of surgery. Diagnosis of malrotation was made most commonly using upper gastrointestinal contrast radiography, with contrast enema or computed tomography performed as required.
Open-Ladd is performed through a circumumbilical incision. Lap-Ladd is performed by accessing the peritoneal cavity initially via the umbilicus with a 5-mm trocar for the scope and then eventually as access for the surgeon's right hand. After insufflation, three other 5-mm working ports are placed: one each on the right and left of the umbilicus and one in the lower abdomen to the right of the umbilicus for the surgeon's left hand, the assistant, and the camera, respectively. After the abdomen is accessed, operative procedures for both open-Ladd and lap-Ladd are the same. In brief, the abdomen is explored to confirm the diagnosis of malrotation. The ligament of Treitz is identified by elevating the transverse colon, and the cecum is identified by gross inspection; if the ligament of Treitz is not properly positioned, a diagnosis of malrotation is made, and a Ladd procedure is performed. Ladd's bands are incised using laparosonic coagulating shears in lap-Ladd; the duodenum is mobilized, straightened, and placed in the right abdomen coursing caudally. The mesentery of the small bowel is examined and released by incising furled portions of the anterior leaflet of the mesentery using hook cautery or laparoscopic colorectal surgery in lap-Ladd. The cecum is identified, the appendix is removed, and the colon is placed in the left abdomen.
Medical records were reviewed for patient demographics, operative findings, postoperative data, and complications. All procedures were performed by senior pediatric surgery residents assisted by board-certified pediatric surgeons. Cases requiring reoperation were excluded when assessing time taken to start feeding and length of hospitalization. Deaths from causes unrelated to the original malrotation (n=1) and infants born prematurely who required prolonged hospitalization to gain weight postoperatively (n=1) were also excluded when assessing length of hospitalization. Data were analyzed using standard statistical methods. Demographic data were compared using Student's t test. The chi-squared test or Fisher's exact test was used for analyzing the incidence of complications. For all statistics, P<.05 was used to determine significance.
Results
There were 26 consecutive Ladd's procedures performed during the study period. Of these, 9 were lap-Ladd, and 17 were open-Ladd. Patient demographics are given in Table 1. When categorized according to age at surgery, there were 14 cases in Group N (3 lap-Ladd [mean, 10 days of age and weighing 2.9 kg] and 11 open-Ladd [6.9 days and 2.6 kg, respectively]) and 12 cases in Group C (6 lap-Ladd [7.5 years and 25.1 kg, respectively] and 6 open-Ladd [3 years and 13 kg, respectively]). Mean age and mean body weight at surgery were higher in lap-Ladd than open-Ladd, but the difference was not significant. Mean duration of follow-up was 39.9±25.5 months (range, 10–70 months for Group N cases and 6–78 months for Group C cases) in lap-Ladd and 40.6±24.6 months (range, 13–74 months for Group N cases and 6–78 months for Group C cases) in open-Ladd. None of the cases in this series was suspected of having ischemic or necrotic bowel preoperatively. Intestinal volvulus was confirmed at surgery in 3 lap-Ladd cases in Group N (100%), 9 open-Ladd cases in Group N (82%), 5 lap-Ladd cases in Group C (83%), and 6 open-Ladd cases in Group C (100%), respectively (P=not significant).
Group C, patients 31 days of age or more at the time of surgery; Group N, patients 30 days of age or less at the time of surgery; lap-Ladd, laparoscopic Ladd procedure; NS, not significant; open-Ladd, conventional open Ladd procedure.
No cases required bowel resection in our series. Mean operating time was significantly longer in lap-Ladd (130.7 minutes) versus open-Ladd (81.1 minutes) in Group N, as well as in lap-Ladd (119.2 minutes) versus open-Ladd (74.2 minutes) in Group C. The rate of conversion to open-Ladd from lap-Ladd was 33.3% (1 of 3) in Group N and 16.7% (1 of 6) in Group C; all cases were converted because of inadequate visualization of key structures.
Postoperative data showed several differences between lap-Ladd and open-Ladd (Table 2). There was one death in the open-Ladd subgroup in Group N due to an incidental anomaly unrelated to malrotation and Ladd's procedure. There was 1 case of bowel obstruction in the open-Ladd subgroup in Group N (9.1%) and 1 case of chylorrhea (16.7%) in the open-Ladd subgroup in Group C, both necessitating laparotomy, and 1 case of recurrence in the lap-Ladd subgroup in Group N (33.3%). These 3 cases were excluded when time taken to start feeding and length of hospitalization were assessed. The death due to an incidental anomaly in the open-Ladd subgroup in Group N and a premature baby were also excluded when length of hospitalization was assessed. The mean time taken to start feeding in Group N was shorter for lap-Ladd (3.7 days) versus open-Ladd (4.1 days), as it was in Group C also (lap-Ladd [2.6 days] versus open-Ladd [3.0 days]), but these differences were not significant (P=.73 for Group N; P=.64 for Group C). Length of hospitalization was similar in Group N cases (lap-Ladd, 13.7 days; open-Ladd, 13.9 days), but in Group C it was shorter for lap-Ladd (6.6 days) compared with open-Ladd (8.2 days), which was not statistically significant (P=.94 for Group N; P=.28 for Group C).
Excluding a death and a premature baby.
Due to small bowel obstruction.
Excluding the case with chylorrhea.
Due to mesenteric chylorrhea.
Group C, patients 31 days of age or more at the time of surgery; Group N, patients 30 days of age or less at the time of surgery; lap-Ladd, laparoscopic Ladd procedure; NS, not significant; open-Ladd, conventional open Ladd procedure.
Discussion
Although it is widely accepted that once a diagnosis of malrotation is made, surgical intervention (Ladd's procedure) is mandatory, the optimal method remains the subject of debate. Recently, three separate large retrospective studies each involving more than 35 children reported that lap-Ladd was a successful procedure.9–11 However, only one 10 of these three studies reported successful postoperative outcome of lap-Ladd in children of all ages. In the other two studies,9,11 subjects came from all age groups, from neonates to adolescents. In our series, we chose 30 days as the cutoff age because we hypothesized that outcome of lap-Ladd would be most affected by differences in physiology, etc., evident by this time. We found there was a risk for recurrence and higher conversion rate in Group N compared with Group C. One study reported that laparoscopy is feasible for correction of malrotation in both the neonatal and infant populations with acceptable rates of conversion that do not differ significantly with respect to age group. 10 Another also reported that laparoscopy is feasible even in neonates and infants with volvulus. 12 However, a larger series of 43 children reported that although laparoscopy is associated with shortened time to full feeds and a shorter hospital stay, a significant number of patients required conversion, reoperation, or both owing to postoperative volvulus. 9 Although our series is limited by its small sample size, we believe there is enough of a trend to recurrence and conversion in lap-Ladd cases in Group N that after the completion of this study in late 2012, we decided to no longer perform lap-Ladd in neonates. Instead, we use open-Ladd, accessing the abdomen through a circumumbilical incision in neonates.
Clinically, older children and adolescents are likely to present with recurrent abdominal pain, intermittent obstructive symptoms,13,14 as intermittent volvulus or partially obstructing bands usually cause vague gastrointestinal symptoms. Thus, in contrast to the most common form of clinical presentation in neonates, which is incomplete rotation predisposing to acute midgut volvulus; older children present more commonly with chronic volvulus. In addition, despite being one of the most standard diagnostic radiographic modalities for diagnosing abdominal pathology, upper gastrointestinal studies tend to give false-positive results, which can result in unnecessary laparotomy.15,16 Considering the difficulty associated with diagnosing malrotation in older children, as well as somewhat unreliable diagnostic imaging results, laparoscopic exploration should be regarded as the procedure of choice when malrotation is suspected in older children because the presence of malrotation can be confirmed accurately and can be treated by lap-Ladd at the same time. However, in the neonatal age group, limited intraperitoneal working space hinders visualization of abdominal organs, and the orientation of anatomic landmarks can be complicated. In other words, the anatomy of the abdomen in neonates may prevent accurate assessment with laparoscopy and be the cause of conversion to open surgery or recurrence. Although the sample size of our series is small, there was a tendency for the recurrence rate to be higher in Group N in lap-Ladd than in open-Ladd, and the rate of conversion from lap-Ladd to open-Ladd was higher in Group N than Group C.
Our data confirm that lap-Ladd is a safe procedure, limited by factors that affect how effectively laparoscopy can be performed safely, such as patient size and weight. Thus, lap-Ladd may not be indicated for the treatment of all cases of malrotation, and its role in the treatment of malrotation in neonates needs further assessment.
Footnotes
Acknowledgments
We would like to express our sincere appreciation to Dr. Geoffrey J. Lane for reviewing this manuscript as a native English speaker.
Disclosure Statement
No competing financial interests exist.