Dvorakevych, Pereyaslov, and Tkachyshyn: Laparoscopy in Management of Children with Small Bowel Obstruction



Problem statement and analysis of the recent research

In children, small bowel obstruction (SBO) is one of the most common factors of hospital admission, and the adhesive process in the abdominal cavity is the main cause of its development [12].Laparotomy, which remains the main method of treatment of this pathology, is associated with the disruption of the visceral peritoneum that predisposes to more adhesion formation in 10-30% of patients and, as the result, the disease recurrence and re-surgery [1, 3]. Until recently, the presence of symptoms of small bowel obstruction was the contraindication for laparoscopy, as significantly distended loops of small bowel limit the visualization and increase the risk of bowel injury [8].Rapid development of minimally-invasive surgery determined the implementation of these methods in the management of patients with SBO, since they are accompanied by less risk of adhesion formation after surgery, shorter length of hospital stay and faster recovery [9].

Traditionally, pediatric surgeons are adopting the methods of minimally-invasive surgery later than general surgeons due to longer learning curve, in some cases the lack of pediatric instruments; however, we also know that the time needed by pediatric surgeons to shift his/her consciousness from the implementation of traditional interventions to conducting laparoscopic surgeries plays a significant role.

The objective of the research was to summarize our own experience of laparoscopic treatment of children with SBO.

Materials and methods

The study is based on the results of laparoscopic management of 86 children being operated on at the surgical department I of Lviv Regional Children’s Clinical Hospital “Okhmatdyt” during 2007-2015. The age of the patients ranged from 1.5 to 18 years. Laparoscopy was used in 78 (90.7%) patients and laparoscopically assisted procedure were performed in 8 (9.3%) of cases.

Previously, 61 (70.9%) children underwent laparotomy and 14 (16.3%) children had laparoscopic interventions. Patients, in which acute SBO was caused by destructive appendicitis, incarcerated hernia or atresia/stenosis of the small bowel, were excluded from this study.

Pneumoperitoneum was created by the open Hasson technique with a working pressure of 5-7 mm Hg. Surgical inspection using smooth tissue forceps started from the ileocecal valve to the ligament of Treitz. Adhesiolysis was performed “sharply” or “bluntly” using monopolar or bipolar coagulator, and in some cases a bipolar clamping device LigaSure® or ultrasonic scalpel.

To prevent the recurrence of the disease, the gel Intercoat (Ethicon, USA) was applied in 16 (18.6%) children; an oxidized regenerated cellulose (Interceed, Ethicon, USA) was used in 8 (9.3%) children; and 7 (8.1%) children received a poly-functional anti-adhesion fluid DEFENSAL® (Ukraine).

Results and Discussion

The management of children with acute and chronic SBO requiring adhesiolysis is a rather common problem for pediatric surgeons. According to the data of Scott FI et al. (2012) [13], in the USA, every 120th patient out of 100,000 hospitalized patients had problems due to the adhesive processes and annual medical expenses in 2005 amounted to $ 2.3 billion, and these costs tend to constant increase.

According to the results of our study, acute SBO were caused by intra-abdominal adhesions in 75 (87.2%) patients, and in 13 (12.8%) patients twisting of a loop of small bowel around the Meckel’s diverticulum was the main cause of acute SBO. According to literature data adhesions cause the development of SBO in 52-85% of patients [9, 12]. Such difference between literature data and our own results is caused by exclusion of patients with SBO caused by destructive appendicitis, inflammation of the large intestine, incarcerated hernia, etc. from the study. Adhesive small bowel obstruction occurred more often after laparotomy (70.9%), while after laparoscopy it was detected in 16.3% of patients only that conformed to literature [1, 3, 7, 10].

The indications for laparoscopic adhesiolysis were the signs of acute adhesive bowel obstruction (the first 24-48 hours after symptoms of obstruction) and the absence of signs of decompensation of obstruction and shock. The absolute contraindication for laparoscopy in children with SBO included hemodynamic instability and respiratory failure, as the application of pneumoperitoneum could aggravate these disorders - that corresponds with the international guidelines [6].

The application of pneumoperitoneum using the Veress needle is one of the dangerous moments of laparoscopy in children with SBO that determines the risk of bowel injury. The usage of the open Hasson technique in combination with preoperative ultrasonography prevents such injury that is confirmed by literature data [5].

During surgical revision of the abdominal cavity, single obstructive bands often in the area of the ileocecal valve were found in 55.8% patients; diffuse dense bands were observed in 31.4% of children; in 12.8% of children twisting of a loop of small bowel around the Meckel’s diverticulum was noted. In contrast to other researchers [2, 5, 6] who consider the presence of diffuse dense adhesions as a criterion for the conversion, we performed laparoscopic adhesiolysis in all children with diffuse adhesions being included in our study that allowed us to avoid re-surgery in 25 (92.6%) patients.

To prevent the recurrence of the disease, the gel Intercoat (Ethicon, USA) was usedin 16 children with multiple diffuse bands and a poly-functional anti-adhesion fluid DEFENSAL® (Ukraine) injected through the trocar was applied in 5 cases. The usage of anti-adhesive barriers is one of the possible ways to decrease the incidence of SBO after surgery [4]. In 8 (9.3%) children with the localization of adhesive bands in the pelvis, the oxidized regenerated cellulose (Interceed, Ethicon, USA) the only disadvantage of which is the difficulty when injecting through the trocar [2, 14], was used to prevent adhesion recurrence.

Necrotic loop resection is considered to be the main (up to 30%) cause of the conversion [9, 11]. Last year, in children requiring bowel resection, laparoscopically assisted procedures were performed. In such cases, the diagnosis, adhesiolysis, and bowel mobilization were performed laparoscopically; necrotic bowel resection and anastomosis were carried out intraperitoneally through the small incision in the projection of damaged intestinal segment.

Conclusions

In the presence of appropriate skills, laparoscopic adhesiolysis can be a real alternative to conventional laparotomy in treating children with small bowel obstruction. The usage of remedies with anti-adhesive properties improves the results of treating children with bowel obstruction.

Prospects for further research

Laparoscopic adhesiolysis in children with small bowel obstruction is not widely used in clinics of pediatric surgery that determines the necessity of randomized study with the determination of clear indications and contraindications for applying laparoscopic adhesiolysis. Further investigations regarding using anti-adhesive barriers in pediatric surgery are also required.

References

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Copyright (c) 2017 A O Dvorakevych, A A Pereyaslov, Yu I Tkachyshyn

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