Page 4 - World Journal of Laparoscopic Surgery

Laparoscopic vs Open Surgical Management of Adhesive Bowel Obstruction in Children
Center for Pediatric Surgery dealing with all routine and emergency ileus (three cases), appendicectomy (six cases), Meckel’s diverticulum
cases in pediatric surgery from newborn period till 12 years of (three cases), intussusception (four cases), Ladd’s procedure for
age. In this study, charts of all the patients who were admitted malrotation (four cases), congenital diaphragmatic hernia (four
with diagnosis of adhesive bowel obstruction from January 2007 cases), Nissen fundoplication (three cases), and six cases of intra-
to September 2017 were reviewed and analyzed. During first half abdominal benign or malignant masses (ganglioneuroma 1,
of study period (January 2007–August 2012). All the patients who hepatoblastoma 1, Wilms tumor 1, mesenteric cyst 1, ovarian cyst 1,
needed surgical intervention were managed by open laparotomy. and one retroperitoneal cyst). In the open laparotomy group, mean
In the second half of the study period (September 2012–September age in months (51.83 ± 38.92) and weight in kilograms (19.58 ±
2017), laparoscopic management was adopted and laparoscopic 13.24) was not significantly different from laparoscopic group where
adhesiolysis was performed for these cases by the consultant mean age in months and weight in kilograms was 56.19 ± 35.79 and
pediatric surgeon who is well-versed with advanced laparoscopy. 17.50 ± 8.49, respectively. Mean duration since previous surgery
Adhesiolysis was performed by blunt and sharp dissection using in open laparotomy group was 20 months while in laparoscopic
bipolar diathermy in open laparotomy cases while in laparoscopic group it was 28 months. Average operative time was 138 minutes
cases mostly sharp dissection was performed using laparoscopic in laparotomy group and 122 minutes in laparoscopic group.
scissors or laparoscopic energy device for thick bands. Children who Intraoperative findings were similar in both the groups. Transitional
were successfully managed with conservative treatment without zone due to adhesive band or bands between proximal dilated
any surgical intervention were excluded from this study. Also, the and distal collapsed small intestine was observed in all patients
cases where the laparoscopic procedure was converted into an in both open and laparoscopy group. In open laparotomy group,
open laparotomy were excluded from the study. Demographic data three patients (7.1%) had single obstructing band while multiple
of all the patients with diagnosis of adhesive intestinal obstruction obstructing bands between the bowel loops and abdominal scar
were obtained. Details of primary pathology and surgical procedure, were seen in 39 (92.8%). Four patients (16.4%) in the laparoscopic
time between previous surgery and penetration, the duration of group had a single thick obstructing band (Fig. 2) while in 22 (84.6%)
adhesiolysis surgery, intraoperative findings and techniques, of the laparoscopic group patients had multiple adhesive bands
need for total parenteral nutrition, duration of hospital stay, and with scar and bowel loops (Fig. 3). During adhesiolysis in open
complications were recorded for both the open and laparoscopic surgery, serosal tears were reported in 20 patients and two of them
groups. After discharge from the hospital, all the patients were needed intraoperative blood transfusion. None in laparoscopic
followed up for a minimum period of 1 year. Statistical analysis group had this complication. In 35% (15) of laparoscopic cases, it
was carried out comparing open and laparoscopic group and was required to resect a segment of small intestine because it was
significance was devised using paired t-test. p < 0.05 was considered of doubtful viability. No bowel resection and anastomosis was
statistically significant. needed in laparoscopic group. In one case which was managed
by open laparotomy left dome of diaphragm was injured while
results separating dense adhesions with diaphragmatic dome. It was
repaired with interrupted nonabsorbable stiches. One case in each
Seventytwo of 80 children with adhesive bowel obstruction open and laparoscopic group developed postoperative pneumonia,
needed surgical intervention. These children aged between which was managed chest physiotherapy and antibiotics. Wound
2 months and 132 months (mean = 53.88 ± 37.58). There were complications like seroma and infection occurred in six cases in open
43 men and 29 women. All of these 72 children had undergone at least laparotomy group. There were no wound-related complications
one surgical procedure before they had presented with adhesive in laparoscopic group. Thus, overall rate of intraoperative and
bowel obstruction. Previous surgical procedures done on these postoperative complications was significantly higher in open
children are shown in Figure 1. They include colostomy or ileostomy laparotomy group (p = 0.000). Children in laparoscopic group
closure after anorectal malformation (five), Hirschsprung’s disease were fed on postoperative day 2–4 (mean = 2.58) and no total
(three cases), necrotizing enterocolitis (five cases), meconium parenteral nutrition was required for any patient in this group.

Fig. 1: Previous surgeries performed in all 72 patients with adhesive bowel obstruction

90 World Journal of Laparoscopic Surgery, Volume 12 Issue 3 (September–December 2019)