Year : 2011 | Volume
: 16 | Issue : 1 | Page : 8--10
Laparoscopy-assisted hydrostatic in situ reduction of intussusception: A reasonable alternative?
V. V. S. S. Chandrasekharam, Suhasini Gazula, Rajendra Prasad Gorthi
Department of Paediatric Surgery, Gandhi Medical College and Hospital, Hyderabad, Andhra Pradesh, India
House No. 11-1-907/1/2, Chilkalaguda, Secunderabad - 500 061, Andhra Pradesh
Aim: To evaluate an alternative way of reducing intussusceptions under laparoscopic guidance. Materials and Methods: This is a retrospective observational study of children who underwent laparoscopy-assisted hydrostatic in situ reduction of intussusceptions (LAHIRI). Under general anesthesia with laparoscopic vision, warm saline was infused into the rectum with a 16-18 F Foley catheter and a drip set till the intussusception was reduced. Results: Eleven patients [age 7.8 (±2.8) months] were operated over a period of 1 year. Ten (90.9%) patients had ileocolic intussusception, which got completely reduced, but one (9%) had ileo-ileocolic intusussception, in whom manual reduction by extending the subumbilical incision was required to reduce the ileoileal part. The mean duration of surgery was 38.5 (±6.6) min. No patient had bowel ischemia and there were no intra- or postoperative complications. Conclusions: LAHIRI appears to be an effective and safe technique in children. Specific advantages are that it is performed in a controlled environment in the operating room, avoids patient apprehension and discomfort, avoids bowel handling, provides a safe opportunity to create higher intraluminal pressure, ensures visual assessment of bowel vascularity and completeness of reduction.
|How to cite this article:|
Chandrasekharam V, Gazula S, Gorthi RP. Laparoscopy-assisted hydrostatic in situ reduction of intussusception: A reasonable alternative?.J Indian Assoc Pediatr Surg 2011;16:8-10
|How to cite this URL:|
Chandrasekharam V, Gazula S, Gorthi RP. Laparoscopy-assisted hydrostatic in situ reduction of intussusception: A reasonable alternative?. J Indian Assoc Pediatr Surg [serial online] 2011 [cited 2020 Jan 28 ];16:8-10
Available from: http://www.jiaps.com/text.asp?2011/16/1/8/74513
Intussusception is one of the most common causes of bowel obstruction in the pediatric population. Approximately 85% of these cases are reduced by pneumatic or hydrostatic enema.  Traditionally, unsuccessful radiological reduction has been followed by laparotomy. With the advent of minimally invasive pediatric surgery, laparoscopic reduction has been used as a surgical option.  Available reports claim advantages of laparoscopic over the open approach, such as less postoperative pain, reduced wound complications, minimal scarring, shorter hospital stay and an earlier return to normal activities. ,, We attempted to reduce the intussusception by applying diffusely transmitted intraluminal hydrostatic pressure by means of a saline enema given to the anesthetized child under laparoscopic visual guidance. This study was undertaken to review our experience with laparoscopy-assisted hydrostatic in situ reduction of intussusceptions (LAHIRI), with the aim to analyze its efficacy and safety in children.
Materials and Methods
A retrospective review of all children who underwent LAHIRI between June 2008 and June 2009 was carried out. This review included only those patients in whom laparoscopy was the primary procedure when facilities for fluoroscopic or ultrasonographic reduction were unavailable or were not feasible (logistic reasons, parental anxiety, patient discomfort, etc.). Patients with attempted radiological reduction prior to laparoscopy were excluded from the study.
The patients' medical records were reviewed and data pertaining to age, gender, clinical presentation, duration of symptoms, operative findings, duration of surgery, complications and hospital stay were noted. Under general anesthesia, a 5-mm subumbilical laparoscopic port for the telescope and a 3-mm bowel grasper in the left flank were inserted. Warm normal saline was infused into the rectum with a 16-18 F Foley self-retaining catheter with the bulb inflated and an intravenous drip set maintaining the level of the bottle at 80 cm above the operating table. Under laparoscopic vision, hydrostatic pressure on the intusussceptum was increased by gradually increasing the height of the saline bottle. The bowel grasper was used only to displace the dilated bowel loops for better vision of the intussusception and never to handle the intussuscepted bowel. The height of the saline bottle and hence the hydrostatic pressure on the intussusceptum was not a limiting factor with this technique as bowel distension could be visually assessed and hence overdistension and inadvertent bowel rupture could be prevented. The hydrostatic pressure was transmitted to the intussusceptum and caused reduction of intussusception. Finally, the completeness of reduction, vascularity of reduced bowel and presence of secondary lead points were assessed before withdrawing the telescope.
Oral feeding was started within 12 h of surgery and the patients were discharged once full oral feeds were resumed. They were followed-up at least once after discharge in the outpatient clinic. Statistical data were presented as mean ± SD or number (percentage) as appropriate.
Eleven patients (seven males and four females) were operated over a period of 1 year. All our patients except one were infants, with the mean age being 7.8 (±2.8) months. All patients had typical clinical presentation, with sudden-onset excessive crying and an abdominal lump with or without red-currant jelly stools. The mean duration from onset of symptoms to surgery was 27.6 (±8.8) h. The diagnosis was confirmed in all by ultrasonography of the abdomen.
Ten (90.9%) patients had ileocolic intussusception, which got completely reduced with LAHIRI, but one (9%) patient had ileo-ileocolic intussusception, in whom the ileocolic part got reduced with LAHIRI but manual reduction by extending the subumbilical incision was required to reduce the ileoileal part. The mean duration of surgery was 38.5 (±6.6) min. No patient had any signs of bowel ischemia and none had any secondary lead points. There were no intra- or postoperative complications. There was no recurrence of intussusception in any patient. All patients had an uneventful recovery, and the mean duration of hospital stay was 2.1 (±0.3) days.
Nonoperative reduction of intussusceptions is the established first line of therapy, with a high success rate up to 85-90%.  Laparoscopic reduction is feasible, but complications such as serosal tearing and frank bowel perforation have also been described. ,,
All our patients except one were infants, with the mean age being 7.8 (±2.8) months. All patients had typical clinical presentation, with mean duration from onset of symptoms to surgery being 27.6 (±8.8) h. This was as opposed to what was reported by Wiersma et al., with 32% of the patients presenting more than 48 h after the onset of the intussusception. Wiersma et al., Yang et al. and Chatterjee et al. have suggested uncooperative apprehensive patients, delayed presentation and unavailability or lack of expertise in pediatric radiology in developing countries as additional reasons for favoring operative over nonoperative techniques. ,, Despite a relatively early presentation, we opted for laparoscopy as the primary procedure in this group for reasons such as unavailability of fluoroscopy or ultrasonography, parental anxiety and patient discomfort.
The mean duration of LAHIRI was 38.5 (±6.6) min, which is comparable to that reported by Poddoubnyi et al. (32.6 min), who used the additional help of atraumatic graspers along with air enema to reduce intussusceptions.  However, Kia et al. reported longer operating times for both laparoscopic and open approaches (45.00 ± 24.74 vs. 49.56 ± 26.40 min, respectively), which was probably because their study group involved cases with previous failed radiologic reduction. 
Success rate of LAHIRI in our study was 90.9%, which is similar to the success rates reported by Kia et al. (87.5%), Cheung et al. (86.7%) and Bujronrappa et al. (85%). ,, Kia et al. recommended that one must exercise greater caution with the laparoscopic approach because of the potential for injury to bowel in view of the fact that traction is used more extensively with the laparoscopic approach while pulling and squeezing the intussusception with bowel graspers. , Likewise, Chatterjee et al. questioned the subjective "gentleness" of finger pressure applied to the intussusceptum during manual reduction, which varies from surgeon to surgeon and may be responsible for complications and higher rates of resection and anastomosis.  In our study, we had no bowel perforation and no need for bowel resection and anastomosis, which may be attributed to the following reasons: (a) diffusely transmitted hydrostatic pressure delivered in LAHIRI is much less damaging than varying focal pressure on the intussuscipient and the apex of the intussusceptum, (b) with LAHIRI, bowel distension during saline insufflation can be visually assessed and hence overdistension and inadvertent bowel rupture can be prevented, (c) as bowel vascularity can be visually assessed, much lower pressures can be applied or alternative means for reduction can be sought in cases with compromised bowel.
The mean duration of hospital stay in our group was 2.1 (±0.3) days. Also, after successful laparoscopic reduction, resumption of full diet was much earlier than the open group in all the studies. Like all other laparoscopic procedures, LAHIRI also has benefits such as less postoperative pain, reduced wound complications, shorter hospital stay and an earlier return to normal activities. ,
In addition, we also noted that LAHIRI has certain specific benefits: (a) like Wiersma et al., we perceive a distinct advantage to attempting reduction in a controlled environment in the operating theater on an anesthetised child who is fully resuscitated. The child is totally relaxed and pain-free, which thereby abolishes the unhelpful effects of a straining abdomen, allowing the intraluminal forces to act unopposed, giving this method a greater chance of success.  (b) The height of the saline bottle and hence the hydrostatic pressure on the intussusceptum is not a limiting factor with LAHIRI as visual control of bowel condition gives the safe opportunity to create higher intraluminal pressure.  (c) The completeness of reduction, vascularity of reduced bowel and presence of secondary lead points can be visually assessed.
There may however be certain shortcomings of LAHIRI - hemodynamic instability and excessive bowel distension may compromise the surgeon's ability to achieve adequate pneumoperitoneum; absence of tactile sensation may result in secondary intraluminal lead points being missed. 
To conclude, LAHIRI appears to be a safe and efficacious treatment modality in the pediatric population. Its specific advantages are that it is performed in a controlled environment in the operating room, avoids patient apprehension and discomfort, avoids bowel handling, prevents bowel overdistension and ensures visual assessment of bowel vascularity and completeness of reduction. Nevertheless, our study was not without its limitations, such as relatively small number of cases. All cases were fairly early presenting and uncomplicated (which may have contributed to the high success rate) and absence of simultaneous cohorts undergoing radiological reduction and laparotomy for comparison. Hence, there is a need for a randomized controlled prospective trial to compare LAHIRI with other well-established approaches and to look into the possible selection criteria for this technique.
|1||Bonnard A, Demarche M, Dimitriu C, Podevin G, Varlet F, Franηois M, et al. Indications for laparoscopy in the management of intussusception: A multicenter retrospective study conducted by the French Study Group for Pediatric Laparoscopy (GECI). J Pediatr Surg 2008;43:1249-53.|
|2||Burjonrappa SC. Laparoscopic reduction of intussusception: an evolving therapeutic option. JSLS 2007;11:235-7.|
|3||Kia KF, Mony VK, Drongowski RA, Golladay ES, Geiger JD, Hirschl RB, et al. Laparoscopic vs open surgical approach for intussusception requiring operative intervention. J Pediatr Surg 2005;40:281-4.|
|4||Tam PK. Laparoscopic surgery in children. Arch Dis Child 2000;82:240-3.|
|5||Chatterjee US, Ghosh A, Basu AK, Mukhopadhyay PP. Intraoperative hydrostatic reduction of intussusception. J Indian Assoc Pediatr Surg 2008;13:107-8.|
|6||Navarro OM, Daneman A, Chae A. Intussusception: the use of delayed, repeated reduction attempts and the management of intussusceptions due to pathologic lead points in pediatric patients. AJR Am J Roentgenol 2004;182:1169-76.|
|7||Cheung ST, Lee KH, Yeung TH, Tse CY, Tam YH, Chan KW, et al. Minimally invasive approach in the management of childhood intussusception. A N Z J Surg 2007;77:778-81.|
|8||Fraser JD, Aguayo P, Ho B, Sharp SW, Ostlie DJ, Holcomb GW 3 rd , et al. Laparoscopic management of intussusception in pediatric patients. J Laparoendosc Adv Surg Tech A 2009;19:563-5.|
|9||Wiersma R, Hadley GP. Minimizing surgery in complicated intussusceptions in the Third World. Pediatr Surg Int 2004;20:215-7.|
|10||Yang CM, Hsu HY, Tsao PN, Chang MH, Lin FY. Recurrence of intussusception in childhood. Acta Paediatr Taiwan 2001;42:158-61.|
|11||Poddoubnyi IV, Dronov AF, Blinnikov OI, Smirnov AN, Darenkov IA, Dedov KA. Laparoscopy in the treatment of intussusception in children. J Pediatr Surg 1998;33:1194-7.|
|12||Schier F. Experience with laparoscopy in the treatment of intussusception. J Pediatr Surg 1997;32:1713-4.|