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Laparoscopic Treatment of Acute Volvulus in Children

C. Zamfir, H. Allal
Montpellier, France

 

Abstract 

Propose: To assess the feasibility of a laparoscopic procedure in the treatment of acute volvulus in children.

Material and methods: From 1992 to 2002 in our institution, 6 children underwent a laparoscopic Ladd’s procedure for acute volvulus of the midgut. The age ranged between 3 days to 1 month. All patients have been hospitalised as an emergency for bilious vomiting or acute occlusive syndrome. Ultrasound study confirmed the diagnosis of midgut volvulus without any delay in all the cases. Laparoscopic procedure was started immediately, using a 5 mm scope (open introduction) and 3 operating trocars of 3 mm each (left and right mid quadrants and the third one in the epigastric area). The pressure of CO2 inflation was 8 mm Hg at a debit of 6l/min. A standard Ladd’s procedure with appendectomy was performed in all cases.

Results: The first 2 from the 6 procedures were converted into open surgery because of inappropriate material and the lack of experience of the surgeon. No intraoperative complications occurred since. However one of the 4 other patients had to be reoperated at day 5, because of persistence of bilious vomiting and difficulties in oral feeding. An open procedure was performed for a probable recurrence of volvulus. In fact there was no volvulus, only a persistent duodenal stricture but not a Ladd one. This case is the only one with a long hospital stay (one month). The other 3 had a smooth post operative course with no recurrence of symptoms. The oral intake was started at day 2 or 3 and they have been discharged between day 5 and 9. The follow up is from 1 to 10 years with a good clinical evolution.

Conclusions: Laparoscopic Ladd’s procedure could be an interesting option for the treatment of acute volvulus of the midgut in children. It must be performed only by experimented surgeons in the neonatal laparoscopic field and with adapted instruments for the size of the baby. The advantages are less postoperative pain, an earlier enteral feeding and less scaring.

Key words: acute midgut volvulus, laparoscopic treatment.

 

Correspondence

Hossein Allal, M.D.
Visceral Pediatric Surgery Department, “Lapeyronie” Hospital
34295 Montpellier Cedex 5 France, e-mail : This email address is being protected from spambots. You need JavaScript enabled to view it.

 

The midgut volvulus was always a challenge for the paediatric surgeons because of the risk of retardation in setting the diagnosis and its important sequels for the babies, in late treated forms. Considering the advantages of evolution in imagistic investigations and the progress in laparoscopy, we want to present our experience about a series of 6 children. In spite of all controversial discussions about this subject, we tried to use the laparoscopic procedure when it was possible.

For this, we considered only the patients who had the diagnosis rapidly settled, with only few hours of evolution. In our series, the babies had the age between 3 days to 1 month, which correspond to the literature.

The midgut volvulus is suspected in young patients after the symptoms (suddenly onset of bilious vomi ting, no intestinal transit and a flat abdomen) and confirmed by imagistic. Even if a contrast upper gastro-intestinal study is indicated for malrotations, we think that in the volvulus makes the evolution and the surgery more complicated. That is why we prefer the ultrasound study done by a very well trained radiological team. It is not invasive and makes very fast the diagnosis. It shows the "whirlpool" pattern of the superior mesenteric artery facilitated by the using of the Doppler-colour exam (fig. 1). In addition, we can appreciate the thickness of the intestinal wall and its degree of ischemia (fig. 2).

acute volvulus in children 1 acute volvulus in children 2
Fig. 1. Superior mesenteric vein turning around the artery Fig 2. Thick-walled bowel loops

Material and methods

Our retrospective study covers 10 years of experience and evolution in laparoscopy field. Between 1992-2002, 6 children had been treated laparoscopically for acute volvulus. We excluded from our series the patients with malrotation who had been operated laparoscopically and the patients with volvulus operated by laparotomy because of the suspicion of ischemic bowel.

Technique  

Under the general anaesthesia with oro-tracheal intubation, the patient is in a supine position at the end of the operating table. The surgeon is placed at baby's feet. The assistant is at the left of the surgeon and the nurse at the right. The laparoscopic tower is placed at the right side of the patient. The material used consisted in at the beginning of a 10 mm and then of 5 mm camera 30o and 3 mm instruments.

The first trocar of 5 mm for the optic is introduced by an "open technique" in the supraumbilical ring. The control of abdominal cavity is done for confirming the diagnosis and appreciates the status of the bowel. If is considered as unsatisfactory, too ischemic or chilous ascites, the conversion is indicated. The operating trocars of 3 mm each are introduced as it follows: one in each right and left abdominal mid-quadrant, on the same line with the camera, and the third one in the epigastric area. The pressure of insufflation is 8 mm Hg at a debit of 6l/min.

The surgeon has a panoramic view of all the bowel and colon (fig 3). Frequently, we discover the cecum and the appendix fixed under the liver (fig 4). If the condition of the intestine permits, sometimes, lifting the liver, it is easier to section the Ladd band, which it is more evident with the volvulated loops. We use the electro coagulating scissors (fig 5, 7). If the colour of the bowel is worrying, we proceed first at the devolvulation (fig. 6) It is very important to establish the sense of the volvulus. Frequently it is twisted in the clock-wise. We try by pulling and grasping the masse of bowel in counter clock-wise to regain a normal position.

 acute volvulus in children 3 acute volvulus in children 4 
 Fig 3. The volvulus of the bowel  Fig 4. The cecum and the appendix situated under the liver
acute volvulus in children 5 acute volvulus in children 6
Fig 5. The Ladd’s band Fig 6: Reducing the volvulus in counter clockwise

They will notice the changing in colour of the intestine. Then the entire intestine, is inspected from the ligament of Treitz until the sigmoid. All the adhesions and bands are sectioned for liberating the bowel. The mesentery is widened (fig. 8) by incision of the anterior mesenteric sheet, separating the duodenum of cecum, to prevent a new volvulus. The duodenum is dissected after the Kocher manoeuvre (fig. 9). We try to arrange the bowel in the right side of the abdomen and the colon in the left side. An "out" appendectomy it is practiced. The trocars are removed under the vision control to ensure the haemostasis. The meaning operating time is 105 minutes, who ranged from 90 to 120 minutes.

acute volvulus in children 7 acute volvulus in children 8
Fig 7: Ladd’s band section Fig 8: Caecum and appendix in the left side of the abdomen. Base of the mesentery is widened

acute volvulus in children 9 

Fig 9: Duodenal dissection 

Results

For the first 2 from the 6 procedures the first part was an explorative laparoscopy. A 10 mm camera was introduced by an open technique in the supraumbilical ring. The diagnosis was confirmed. No reduction was tried because the enlargement of the image offered by a 10 mm optic make harder the task of the surgeon. Therefore, were converted into open surgery because of inappropriate material and the lack of experience of the surgeon at the beginning of his learning curve.

Case 2 was re-examined 8 months later after the surgery, for the suspicion of volvulus recurrence because of alimentary vomiting but it was only an enterogastritis. Case 3 and 5 were treated laparoscopically without any per-operative incident. Case 4 was hospitalised at 1 month of age for the suspicion of hypertrophyc pyloric stenosis because of alimentary vomiting, after meals, more frequently and failure to thrive. The ultrasound infirmed the diagnosis but noted an inversion of mesenteric vessel and settled the diagnostic of malrotation. Un UGI was done and confirmed it. Until next morning after barium exam the child presented a brutal apparition of a volvulus. Operated laparoscocopically in emergency, we had good results.

Case 6 had to be re-operated at day 5, because of persistence of bilious vomiting and difficulties in oral feeding. An open procedure was performed for a probable recurrence of volvulus. In fact, there was no volvulus, only a persistent duodenal stricture but not a Ladd one. This case is the only one with a long hospital stay (one month). The others have been discharged between day 5 and 9. The follow up is from 1 to 10 years with a good clinical evolution (table 1).

Table 1 

Case Age of Diagnosis Clinical Exam Investigations Surgery Complications Post-operative evolution Follow-up
1 3 days
Full term
2860g
Non contributively X-Ray
Ultrasound
Conversion
10 mm
camera
No Oral feeding at day 4  10 years 
2 3 days
Full term
4200g
Non contributively X-Ray
Ultrasound
Conversion
10 mm
camera
No  Oral feeding at day 4  9 years
3 10 days
Full term
3640g
Non contributively X-Ray
Ultrasound
Laparoscopy No  Oral feeding at day 3  5 years
4 1 month
Full term
Non contributively

X-Ray
Ultrasound

UGI 

Laparoscopy No  Oral feeding at day 2  2 years
5 5 days
Full term
3500g
Non contributively X-Ray
Ultrasound
Laparoscopy No  Oral feeding at day 3  1 years
6 4 days
Full term
3300g
Non contributively X-Ray
Ultrasound
Laparoscopy Open Reintervention  Oral feeding at day 3-stopped  1 years

Discussions 

Laparoscopic treatment of acute volvulus is a very controversial subject. There are some opinions raised against the laparoscopy, arguing that an open procedure could help to form new adherences which contribute at bowel fixation. Other surgeons are warning about the technique difficulties during the intervention. In 1995 Van der Zee and Bax [9] had published a case report of a laparoscopic treatment of a volvulus. In 1998 [13] they present their experience with a series of 9 malrotations, treated also laparoscopically, in which they suggest that it is a good option but only for the surgeons confident and well trained in laparoscopy.

In 1996 Gross and Lobe [10] and in 1998 Bass and Rothenberg [11] approve the laparoscopic treatment for the malrotations as a modern meaning of treatment. They consider this option for a volvulus as dangerous because of the risk of perforation of the ischemic bowel.

We didn't introduced in our article the malrotations treated laparoscopically because they often concerne elderly children and the intervention is a scheduled one. At the beginning of our experience we used lower pressure of insuflation (3-5 mm Hg) that could also be a reason for our initial conversions. Now we use 8 mm Hg that gives us a better exposure of the abdomen, without any effect on blood circulation or ventilation.

In the classic Ladd technique it is recommended to proceed at devolvulation of the bowel and after to section the Ladd's band. K. Bax propose to section the band first with the twisted loops in place, because sometimes it gives you a better exposure, this only if the bowel condition permits. We applied it in 2 cases and we considered it usefully. The recurrence of the volvulus and the eventual complications for the cases treated laparoscopically should be judged at distance, after many studies and years of follow-up. The greatest challenge for the surgeon is the recognition of the anatomical type of malrotation among so many possibilities, who facilitate the volvulus.

From our point of view the advantages of the laparoscopic procedure are:

  1. A better exposure of all the adherences and bands that could be meticulously dissected
  2. Less scarring
  3. Less post-operative pain
  4. Earlier enteral feeding
  5. Shorter hospitalisation

In our series, no other malformations have been associated with the volvulus. We are sure that all the figures could be improved with the learning curve of the surgeon and this diminished the time of surgery, the beginning of oral alimentation and the earlier discharging.

Conclusions

Laparoscopic Ladd's procedure could be an interesting option for the treatment of acute volvulus of the midgut in children, in selected cases. It must be performed only by experimented surgeons in the neonatal laparoscopic field and with adapted instruments for the size of the baby. The advantages are less postoperative pain, an earlier enteral feeding and less scaring.

 

 

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