The Laparoscopic Versus Open Approach for Reduction of Intussusception in Infants and Children: An Updated Institutional Experience

Introduction

Idiopathic intussusception remains the most common cause of bowel obstruction in children, the highest incidence occurring between 5 and 9 months of age. ¹ The first line treatment option is reduction by air contrast enema. ² The success rate approaches 80%²; those who fail require an operation.

The surgical management for children with intussusception who have failed radiographic reduction has evolved from the traditional laparotomy to a more minimally invasive approach. ³ We have previously reported our initial institutional experience utilizing laparoscopy for operative management of intussusception that showed that 91% of children were managed entirely laparoscopically or through extension of the umbilical incision even in the event of a potential bowel resection. ⁴ The purpose of this study is to provide an update to our previous institutional experience with laparoscopic management of intussusception as well as to compare outcomes in patients treated with the open approach with those in patients managed laparoscopically.

Materials and Methods

After institutional review board approval was obtained (Children's Mercy Hospital Institutional Review Board # 17070454), a retrospective chart review was conducted. All children <18 years old undergoing operative management for intussusception between January 2008 and May 2017 were included. Patients with radiographic evidence of intussusception who failed radiographic reduction were classified according to whether operative reduction was done by either the open or laparoscopic approach. For the purpose of our study, extension of our umbilical incision during initial laparoscopic reduction was classified as laparoscopic.

Patients undergoing an operative reduction of intussusception received a preoperative dose of ceftriaxone and metronidazole. A standard right lower quadrant incision was utilized during open reduction. For laparoscopic reduction, port placement included a 5–10 mm port placed directly through the umbilicus, one in the left lower quadrant and another in the suprapubic region just to the left of the midline. These additional sites are either 3- or 5-mm stab incisions with or without port placement. When laparoscopic reduction is not feasible, the umbilical incision is extended in the midline. The operative trend among our 9 pediatric surgeons is to initially attempt laparoscopic reduction in physiologically stable patients.

Demographic data, duration of symptoms, primary diagnostic modality, location of bowel obstruction, postoperative length of stay, return to the operating room, and hospital readmission rates were abstracted from patient medical records. Comparative analysis was performed in STATA (StataCorp 2017, Stata Statistical Software: Release 15. College, Station, TX: StataCorp LLC) using chi square or Fisher exact test for categorical variables and t-test or the Wilcoxon rank sum test for continuous variables. Statistical significance was determined with a P value ≤.05.

Results

From March 2008 to May 2017, 81 children required operative reduction for intussusception. Sixty-three patients (78%) underwent a laparoscopic reduction, whereas 18 patients (22%) underwent an open operation. There were no statistically significant differences with regard to demographics between the two groups (Table 1). Median days of clinical symptoms in the laparoscopic group were 2 days (interquartile range [IQR]: 1–4 days), which was similar to that of the patients who underwent an open reduction (2 days, IQR: 2–4 days, P = .504, Table 2).

A pathological lead point was present in 13 patients (21%) who underwent a laparoscopic reduction compared with 4 patients (22%) who had an open operation (P = .884, Table 2). The need for a bowel resection occurred in 27 patients (43%) in the laparoscopic group compared with 9 patients (50%) in the open group (P = .591, Table 2), with the ileum and cecum being the two most common locations for bowel resection. Furthermore, the median length of operation was 57 minutes in the laparoscopic group (IQR: 32–92 minutes) compared with 81 minutes in the open group (IQR: 56–106 minutes, P = .068, Table 2).

Children undergoing laparoscopic reduction carried similar complication rates (11%) when compared to children undergoing an open reduction (11%, P = 1.00, Table 3). Complications in the laparoscopic group included two enterotomies, two wound infections, one recurrence, a pelvic abscess drained by interventional radiology, and a wound dehiscence occurring at the umbilical incision. Complications in the open group included one enterotomy and 1 patient who developed abdominal compartment syndrome postoperatively requiring a bedside exploratory laparotomy.

Both hospital readmission rates and reoperations were similar between the two groups (P = .345 and P = .672, respectively, Table 3). The median postoperative length of stay was shorter for patients undergoing a laparoscopic reduction (4 days, IQR: 2–5 days) than for patients undergoing an open reduction (5 days, IQR: 4–6 days, P = .001, Table 3).

Further delineation of the patients undergoing laparoscopic reduction identified 37 children (46%) undergoing midline extension of their umbilical incision. When compared with children undergoing open reduction, there was no significant difference in median length of operation (89 minutes, IQR: 71–96 minutes versus 81 minutes, IQR: 56–106 minutes, P = .456). However, postoperative length of stay was still shorter than that for patients undergoing open reduction (4 days, IQR: 3–5 days versus 5 days, IQR: 4–6 days, P = .037). Furthermore, when children who had a bowel resection were removed from this group, the median postoperative length of stay was 2 days (IQR: 1–3 days) for patients treated laparoscopically versus 5 days (IQR: 4–6 days, P = .001) for patients who had an open operation. Furthermore, 4 patients (5%) with pneumoperitonuem after attempted radiographic reduction were approached laparoscopically. All 4 ultimately had an extension of the umbilical incision with bowel resection.

Discussion

The operative management of intussusception at our free standing children's hospital continues to favor the laparoscopic approach, occurring in 78% of children. This is consistent with reported trends in the literature,^5,6 yet controversy remains among pediatric surgeons regarding the optimal operative approach. A recent meta-analysis that retrospectively analyzed all children with intussusception who required operative reduction found that laparoscopic reduction is both a safe and feasible alternative to the open approach. ⁶ Our current findings confirm these results and show that laparoscopic reduction of pediatric intussusception had no significant differences in postoperative complications or unplanned return visits to the operating room when compared with children treated with an open approach.

Although our study did not show significant differences in complication rates between our two groups, they do suggest that the laparoscopic technique has a number of advantages over the open approach. These advantages include similar postoperative complication rates, shorter operative times, and shorter postoperative length of stay—making it the more desirable technique in children. A second systematic review of all publications on the laparoscopic treatment of intussusception showed children had a shorter mean length of stay as well as low postoperative complication rates and recurrence rates after laparoscopic reduction. ³ Our study again confirms this review in that our patients had a shorter length of stay in the laparoscopic reduction group, including those patients who required midline extension of their umbilical incision.

Despite an increased risk of converting to an open procedure when a pathological lead point is found, ⁷ laparoscopic reduction should still be attempted. By slightly extending the underlying fascia and skin at the umbilical incision and exteriorizing the unreducible bowel, laparoscopic-assisted reduction can be performed with minimal morbidity and mortality.^8,9 We report similar complication rates and decreased postoperative length of stay with no increased time spent in the operating room when the umbilical incision is extended in the midline when compared with open reduction. In addition, any evidence of bowel ischemia or necrosis can be resected once the area of concern is exteriorized. From both a pain and cosmetic perspective, extending the umbilical incision to perform a bowel resection is preferred to a standard right lower quadrant incision. ⁷

There were a number of limitations in our study. One limitation relates to its retrospective format and our inability to standardize the operative approach for children needing surgery for intussusception. With 9 different pediatric surgeons at our free standing children's hospital, all with different levels of clinical and operative experience, a standard approach to achieve reduction of pediatric intussusception was difficult to achieve.

A second limitation relates to the potential for selection bias where a patient's presenting symptoms and clinical examination can affect his or her operative intervention. Despite these possibilities, the recent operative trend among pediatric surgeons at our hospital is to initially attempt laparoscopic reduction in children who are physiologically stable even in the presence of peritonitis or pneumoperitoneum. Extension of the umbilical incision occurs only in instances wherein the intussusception cannot be reduced laparoscopically or in the event a bowel resection is needed.

To the best of our knowledge, we report one of the largest single institution series of patients comparing laparoscopic and open reduction for children with intussusception. We demonstrate that laparoscopic reduction is a reasonable initial approach, even in the event of a presumed pathological lead point or bowel ischemia requiring a resection. When necessary, simple extension of the umbilical incision to further reduce or resect the affected bowel allows more invasive treatment without the morbidity of a laparotomy. This study highlights the safety and efficiency for laparoscopic reduction of intussusception in children who fail radiographic air contrast enema reduction.