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Hybrid Approach for an Unusual Case of Idiopathic Small Bowel Obstruction in an Infant

A. A. Mahomed¹, M. J. Tipping²

¹Department of Paediatric Surgery, Royal Alexander Children’s Hospital, Brighton, United Kingdom.

²Guys’ King’s & St Thomas’ School of Medicine, London, United Kingdom

 

Correspondence:

Mr AA Mahomed

Department of Paediatric Surgery, Royal Alexandra Children’s Hospital

Eastern Road; Brighton, UK; BN2 5BE

Ph: 01273 696955; Fax: 01273 523120, E mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

Small bowel obstruction is a common paediatric surgical event and when it does occur the aetiology is usually easily recognised. This report highlights an interesting case of primary small bowel obstruction in a 14 month old boy. In this case laparoscopy complemented radiological investigation in establishing a cause and abdominal incision was thus appropriately sized and placed to be less conspicuous. The details of presentation and the advantages of this successful hybrid approach are explored.

Key words: idiopathic small bowel obstruction

  

Introduction

Small bowel obstruction (SBO) in infants usually results from one of several commonly recognised pathologies. Many of these cases can be diagnosed before birth, the remainder mostly presenting in the first few months of life after functional abnormality becomes apparent. Many suspected cases of obstruction are delineated by radiological investigation. Where a definitive cause is elusive, laparoscopy is now being increasingly utilised for investigation. Not only does it provide a clear perspective of pathology but it also gives the option of performing an immediate surgical procedure to correct the problem, reducing risk, time and cost.

Case report

A previously well 14 month old boy with increasing abdominal distension and bilious vomiting over 2 weeks was referred for suspected bowel obstruction. His abdomen was grossly distended with visible peristalsis and borborygmi was evident on auscultation. Past medical history included an admission for suspected pneumonia 5 months previously and family history revealed multiple bowel problems in 1st and 2nd degree relatives. He was otherwise asymptomatic and chest examination was grossly normal.

Plain abdominal X ray showed multiple loops of distended small bowel with air fluid levels(Fig. 1,2). Contrast study excluded malrotation or a specific aetiology. Initial management with fluid replacement and nasogastric decompression of the bowel failed to improve the child’s condition and a decision was taken to proceed to laparoscopy.

hybrid approach 1 hybrid approach 2
Figure 1. Erect abdominal x-ray showing multiple air-fluid levels consistent with distal small bowel obstruction. Figure 2. Supine abdominal x-ray showing distended loops of small bowel with paucity of colonic air.

Surgical technique

A three port approach was used to access the abdomen, one 5 mm umbilical camera port with 5mm suprapubic and left iliac fossa ports. Pneumoperitoneum was induced using Hasson technique and intra-abdominal pressure was maintained at 10mmHg. Laparoscopy revealed stenosis of the small bowel 40cm proximal to the ileocaecal valve with massive proximal distention with distal collapse.(Fig 3) There was no immediate evidence of a specific cause.

Laparoscopy was converted to mini-Pfannensteil muscle splitting incision by extending the suprapubic port site by 2 cm and the stenotic segment externalised. Fifteen cm of the small bowel, inclusive of the stenotic segment, was resected and a primary end to end anastomosis performed. Intravenous fluids were continued until a soft diet was introduced on day 3. He remained in the ward until cystic fibrosis was excluded on DNA analysis.

The histopathology was non specific showing thinning and disruption of the muscularis propria with oedema that extended intramuscularly in the region of the stricture. The mucosa in this region was unremarkable. Follow up at clinic at 12 weeks and subsequently at 4 months confirmed a return to normal bowel function.

hybrid approach 3
Figure 3. Stenosis in distal ileum (arrowed) with proximally dilated bowel loop

Discussion

In the West SBO is common in adults[1-3], especially in females, and its incidence is slowly rising in the paediatric population[4]. Geographically, SBO is common on a worldwide scale although the underlying aetiology differs between regions. In developing countries SBO often results from hernias and in the developed world the leading cause of SBO is adhesions from previous abdominal surgery[3].

The underlying histopathology of SBO is complex and largely depends upon the exact aetiology, however, structural changes which result as a consequence follow very similar patterns [1,4,5,6]. Diagnosis of SBO is essentially performed upon history and examination [1,7,8]. Radiography has proved to be an invaluable tool but has limitations and an exact aetiology, as in this case, is sometimes elusive. In this regard laparoscopy is an ideal diagnostic and therapeutic tool and is gaining rapid acceptance [1,2,4-7]. Indeed, some authors are beginning to question whether conventional open surgical techniques may soon disappear altogether [9].

The simplicity of laparoscopy offers advantages [1,4,7-9] and principle amongst these is the view of the peritoneum and bowel allowing a diagnosis to be established. In this case with a clear stenosis identified as the problem, treatment could have proceeded in one of several ways; firstly, abandoning laparoscopy in favour of a full laparotomy, secondly, continuing laparoscopically by conducting an intracorporeal resection with anastamosis, or lastly, adopting a hybrid approach as was done here, involving initial laparoscopic diagnosis followed by a strategically positioned and appropriately sized incision allowing comprehensive external inspection of bowel, resection and a secure end to end anastamosis. In this patient the suprapubic port site was extended to a limited Pfannensteil muscle splitting incision allowing good exposure and an excellent aesthetic outcome.

Each of the above options have advantages and disadvantages. The first fails to capitalise on the information gained from the laparoscopy and is not advocated. The second option, whilst preferable and an ideal to which to aspire to, would despite current advances in minimally invasive surgery, still be considered a challenge. It runs the potential risk of contamination during initial surgery as well as the possibility of later anastamotic leaks [1,2,3-7]. The hybrid approach which involves extension of an appropriately sited port wound offers the advantage of the facility for comprehensive evaluation of the pathological segment, resection of the involved bowel segment under controlled conditions, and conduct of an anastamosis with security. This approach is safe and certainly within the capability of most paediatric laparoscopic surgeons. Clearly as technique and instrumentation develop, it may be possible for this surgery to be performed exclusively intracorporeally avoiding the need for any laparotomy wounds [1,2,4-7,10,11]. However, at the present time this should not be considered safe enough to be universally advocated.

Original concerns regarding the fragility of distended loops of bowel being prone to damage with laparoscopic handling [11] have proved to be unfounded provided the surgical team is experienced in dealing with both open and laparoscopic techniques [1,2,4,5]. The inability to effectively decompress proximally distended bowel through limited incisions has not been reported to delay recovery of bowel activity in a significant way.

In conclusion, this case aptly demonstrates the diagnostic and therapeutic capability of laparoscopy when used in tandem with minilaparotomy. This hybrid approach is increasingly being utilised by enterprising surgeons and is translating into lower morbidity, shorter hospital stays and a reduced risk of post operative adhesions. The aesthetic advantage of such an approach is an understated benefit.

 

 

 

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