Single-incision laparoscopic surgery for idiopathic intussusception in children: Comparison with conventional laparoscopy

Accepted Manuscript Single-incision laparoscopic surgery for idiopathic intussusception in children: comparison with conventional laparoscopy

Paul Chia-Yu Chang, Yih-Cherng Duh, Yu-Wei Fu, Yao-Jen Hsu, Chin-Hung Wei PII: DOI: Reference:

S0022-3468(18)30447-0 doi:10.1016/j.jpedsurg.2018.07.010 YJPSU 58754

To appear in:

Journal of Pediatric Surgery

Received date: Revised date: Accepted date:

11 May 2018 12 July 2018 17 July 2018

Please cite this article as: Paul Chia-Yu Chang, Yih-Cherng Duh, Yu-Wei Fu, Yao-Jen Hsu, Chin-Hung Wei , Single-incision laparoscopic surgery for idiopathic intussusception in children: comparison with conventional laparoscopy. Yjpsu (2018), doi:10.1016/ j.jpedsurg.2018.07.010

This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

ACCEPTED MANUSCRIPT Single-incision laparoscopic surgery for idiopathic intussusception in children: comparison with conventional laparoscopy Paul Chia-Yu Chang1,2 MD, Yih-Cherng Duh3 MD, Yu-Wei Fu4, MD, Yao-Jen Hsu4, MD, Chin-Hung Wei5,6*, MD of Pediatric Surgery, Department of Surgery, Mackay Memorial Hospital, Taipei, Taiwan 2School of Medicine, Mackay Medical College, New Taipei City, Taiwan 3Division of Pediatric Surgery, Department of Surgery, Mackay Memorial Hospital, Hsinchu, Taiwan 4Department of Pediatric Surgery, Changhua Christian Hospital, Changhua, Taiwan 5Division of Pediatric Surgery, Department of Surgery, Shuang Ho Hospital, New Taipei City, Taiwan 6School of Medicine, Taipei Medical University, Taipei, Taiwan

CR

IP

T

1Division

AC

CE

PT

ED

M

AN

US

Corresponding Author: Chin-Hung Wei Tel: + 02-22490088 E-mail: [email protected] Address: No.291, Zhongzheng Rd., Zhonghe Dist., New Taipei City 235, Taiwan

ACCEPTED MANUSCRIPT

US

CR

IP

T

Abstract: Background The aim of this study is to evaluate the feasibility of single-incision laparoscopic surgery (SILS) for idiopathic intussusception in children and compare the outcomes with conventional laparoscopy (CLS). Methods Between January 2011 and December 2012, patients who underwent CLS for idiopathic intussusception were assigned into the group of CLS. Between January 2013 and March 2017, patients who underwent SILS were assigned to the group of SILS. For patients who failed to reduce by SILS, bimanual transabdominal approach was conducted. Results A total of 23 patients were enrolled, including 7 and 16 patients in SILS and CLS, respectively. The mean age was similar in both group (22.4±18.7 vs. 24.6±18.6 months, p=0.80). There is no difference in gender distribution. The main indication was radiological reduction failure in both groups (85.7% vs. 75%, p=0.58). Ileocolic intussusception was found in 6 (85.7%) and 15 (93.8%) patients of SILS and CLS, respectively (p=0.25). The level of intussusception was at ascending colon in 3 (42.9%) and 12 (75.0%) patients, respectively (p=0.11). The operation time was similar in both groups (64.9±53.7 and 70.9±26.1minutes, p=0.79). There were 2 (28.6%) and 1 (6.2%) conversions, respectively (p=0.15). For the two patients in SILS, the intussusception was successfully reduced by bimanual transabdominal approach. There was no significant difference in time to feeding (1.9±1.1 vs. 1.4±0.7 days, p=0.21). The mean length of postoperative hospital stay was 3.9±1.6 and 3.1±1.1 days, respectively (p=0.17).

AN

Conclusions

SILS for pediatric intussusception is technically feasible and has comparable results to CLS.

ED

M

Transabdominal bimanual reduction is applicable in cases of failed laparoscopic reduction.

PT

Keywords: children; idiopathic intussusception; laparoscopy; singleincision; transabdominal bimanual reduction.

Introduction

CE

Intussusception is one of common surgical conditions in children. The characteristics includes absence of pathologic lead points, as well as its typical location at the ileocolic area

AC

[1]. Nonsurgical reduction, with barium, saline, or air, has been popularized widely as the first-line management for both diagnostic and therapeutic purposes, and is associated with high successful rate. Surgical intervention is reserved for those patients with failed reduction or recurrence after radiological reductions. With the advent of minimally invasive surgery in children, laparoscopic approach has been gradually recognized as the alternative to laparotomy [2, 3]. However, the organization of port site may be tricky because of the small working spaces in infants or young children. Furthermore, the involved bowel may range from ascending colon on the right to the sigmoid colon on the left. We propose that singleincision laparoscopic surgery (SILS) is an ideal and reasonable evolution for this entity. The

ACCEPTED MANUSCRIPT only site is at the center of the abdominal cavity, which allows the surgeon 360-degree access, and not having to worry about the where to place the other trocars depending on the site of the lesion. This study is to evaluate the feasibility of single-incision laparoscopic surgery for idiopathic intussusception in children and compare the outcomes with conventional

AC

CE

PT

ED

M

AN

US

CR

IP

T

laparoscopic surgery.

ACCEPTED MANUSCRIPT Methods and materials This is a IRB-approved retrospective study. Patient selection was based on the time frame and the surgical technique. Between January 2011 and December 2012, patients who underwent conventional laparoscopic surgery (CLS) for idiopathic intussusception were assigned into the group of CLS. Between January 2013 March 2017, patients who underwent SILS were assigned to the group of SILS. The medical records were retrospectively

T

reviewed. Parameters investigated included age, gender, surgical indications, type of

IP

intussusception, level of intussusceptum, operation time, conversion, complications, time to oral intake, and length of postoperative hospital stay (LOS). The technique of conventional

CR

laparoscopy was performed as the method previously proposed by the authors [3].

US

Single-incision laparoscopic technique

The operation room and patient settings are shown in Fig. 1. The patient was placed in

AN

supine position. A longitudinal transumbilical incision was made into peritoneal cavity by open method (fig. 2). A wound protector (ALEXIS XS, Applied Medical, Taiwan) was placed into the wound. Three 5-mm trocars were inserted into a No. 6 surgical glove and fixed with

M

rubber bands. The glove was attached to the wound protector. A conventional 5-mm telescope

ED

with a 30-degree lens was used to identify the location of intussuceptum. Two 5-mm nontraumatic graspers were utilized. By holding the both ends of the intussusception, the intussuceptum was pulled out of the intussuscipiens. When a great deal of resistance was

PT

encountered, the intussuscipiens was pulled back toward distally. Alternately repeating these

(video 1).

CE

two maneuvers, the intussusception would be loosened step by step and eventually reduced

AC

Transabdominal bimanual reduction When the laparoscopic reduction failed, transabdominal bimanual reduction was

performed. The incision was extended superiorly and inferiorly slightly from the initial umbilical incision, just large enough to allow the surgeon’s index finger of the left hand to go into the abdominal cavity. The index finger was used to locate the intussusceptum intraperitoneally and pushed that segment of bowel against the abdominal wall (fig. 3). The surgeons right hand applied pressure extra-abdominally to reduce the intussusception. Complete reduction was confirmed by exteriorizing the bowel segment through the umbilical incision.

ACCEPTED MANUSCRIPT Statistics Statistical analysis was performed with MedCalc software (ver. 18) with Chi-square

AC

CE

PT

ED

M

AN

US

CR

IP

T

and independent t test. A p value <0.05 represents statistical significance.

ACCEPTED MANUSCRIPT Results A total of 23 patients were enrolled, including 7 and 16 patients in SILS and CLS, respectively. The demographics of SILS were illustrated in detail in table 1. The mean age was similar in both groups (22.4±18.7 vs. 24.6±18.6 months, p=0.80) (table 2). There was no difference in gender distribution. The main indication was radiological reduction failure in both groups (85.7% vs. 75%, p=0.58). Ileocolic intussusception was found in 6 (85.7%) and

T

15 (93.8%) patients of SILS and CLS, respectively (p=0.25). The level of intussusception

IP

was at ascending colon in 3 (42.9%) and 12 (75.0%) patients, respectively (p=0.11). The operation time was similar between both groups (64.9±53.7 and 70.9±26.1 minutes, p=0.79).

CR

There were 2 (28.6%) and 1 (6.2%) conversions, respectively (p=0.15). For the two patients in SILS, the intussusception was successfully reduced by bimanual transabdominal approach.

US

There was no significant difference in time to feeding (1.9±1.1 vs. 1.4±0.7 days, p=0.21). The mean LOS was 3.9±1.6 and 3.1±1.1 days, respectively (p=0.17). The wound cosmesis of

AC

CE

PT

ED

M

AN

SILS was satisfactory (fig. 4).

ACCEPTED MANUSCRIPT Discussion In the era of laparoscopy, it is evident that CLS is as efficient and effective as the traditional open surgery for pediatric intussusception [4, 5]. When it has been gradually advanced to SILS for a diversity of pediatric surgical entities, SILS is scarcely noted for intussusception in the literature [6-8]. Ponsky et al. was the first one who proposed the singlesite technique for intussusception in series of various surgical indications [7]. Panya et al.

T

demonstrated a case report by visualizing the procedure [8]. The series from Ming et al.

IP

revealed comparable outcomes between CLS and SILS [6], which is consistent with the result of the current study. Nevertheless, those studies did not provide the variables of surgical

CR

indication, the type of intussusception, and the level of intussusceptum. These are important parameters that affect surgical outcomes. The detail of the procedure was also not clearly

US

described, particularly for long intussusception, so it is suboptimally educational for other surgeons to learn this technique.

AN

In laparoscopy for intussusception, how to place the patient position and port locations can be a difficult decision. There have been several different ways to organize the port location in the literature [3, 9-11]. Firstly, the level of intussusception is uncertain although

M

the preoperative enema images provide the tentative location. As demonstrated in the video

ED

of patient No. 7, the filling defect was at proximal ascending colon, which was not consistent to the operative finding. Secondly, the operation field may involve a wide range of peritoneal cavity, from the left side abdomen to the right lower quadrant. It is not rare to have

PT

instrument collisions due to the inappropriate port arrangement. More accurately speaking, there might not be a three-port setting that is able to approach three quadrants of the

CE

peritoneal cavity at the same time. SILS has the benefit of exploring the entire peritoneal cavity without being hampered by the location of ports. Centered with the umbilical,

AC

surgeons are able to have proper operation field comfortably. Intussuceptum is located at ascending colon in above 70% of patients [3]. The conversion rate is low by using CLS for this group of patients [3]. They were also the ideal candidates to start with SILS and build up skills. Our experience suggests that SILS reduction could be simply done by pulling the intussusceptum out of the intussuscipiens. Nevertheless, it is obviously more difficult for long intussusception to transverse or descending colon. Forcefully retrieval may lead to bowel injury or perforation. The trick for this situation is to pull the intussuscipiens distally when the reduction is stuck. Alternately pulling proximal and distal part of intussusception will stepwise loosen and eventually reduce it. Five-mm rather than 3-mm nontraumatic instruments are favored because they provide stronger and steadier

ACCEPTED MANUSCRIPT tissue handling that decreases bowel wall injuries during manipulations. Serosal tearing is nearly inevitable when dealing with long intussusceptum. It is not necessary to repair serosal injuries. There was no delayed perforation noted in our series. Laparoscopic reduction was not accomplished in the first two attempts of SILS. Long and tight intussusception has been identified as a risk factor for conversion [2, 3]. Another reason is our insufficient experiences during the early period. The conversion could be

T

conducted through laparotomy [11] or an extended umbilical incision [3, 9]. It was advised in

IP

the literature to bring the involved segment out of the abdominal wall and perform manual reduction [2, 3, 9, 11]. Instead, we utilized transabdominal bimanual reduction in this study.

CR

This technique takes advantage of the thin abdominal wall. After laparoscopic localization of the intussusception, the surgeon will be able to feel the intussusception both intraperitoneally

US

and extra-abdominally, and perform traditional milking maneuver. The ileocecal segment is generally redundant. It can be exteriorized through the umbilical wound to confirm complete

AN

reduction.

As any other retrospective studies, this study presents with several biases. The major one is the small case number. Due to the high successful rate of radiologic reduction for

M

intussusception, the number of patients who need operations has been abruptly declining.

ED

However, patients with long intussusception account for relatively larger portion of SILS group. We accumulated experiences from these difficult conditions and developed speculate

AC

CE

PT

skill to solve them.

ACCEPTED MANUSCRIPT Conclusion SILS for pediatric idiopathic intussusception is as technically feasible and effective as CLS. Transabdominal bimanual reduction is also applicable in cases that fails to complete

AC

CE

PT

ED

M

AN

US

CR

IP

T

laparoscopic reduction.

ACCEPTED MANUSCRIPT Acknowledgement Drs. Paul Chia-Yu Chang, Yih-Cherng Duh, Yu-Wei Fu, Yao-Jen Hsu, and Chin-Hung

AC

CE

PT

ED

M

AN

US

CR

IP

T

Wei declare no conflict of interest.

ACCEPTED MANUSCRIPT

AC

CE

PT

ED

M

AN

US

CR

IP

T

Reference [1] Coran AG, Caldamone A, Adzick NS, Krummel TM, Laberge J-M, Shamberger R. Pediatric Surgery E-Book. Elsevier Health Sciences; 2012. [2] Houben CH, Feng XN, Tang SH, Chan EKW, Lee KH. What is the role of laparoscopic surgery in intussusception? ANZ journal of surgery 2016;86(6):504-8. [3] Wei CH, Fu YW, Wang NL, Du YC, Sheu JC. Laparoscopy versus open surgery for idiopathic intussusception in children. Surgical endoscopy 2015;29(3):668-72. [4] Sklar CM, Chan E, Nasr A. Laparoscopic versus open reduction of intussusception in children: a retrospective review and meta-analysis. Journal of laparoendoscopic & advanced surgical techniques Part A 2014;24(7):518-22. [5] Apelt N, Featherstone N, Giuliani S. Laparoscopic treatment of intussusception in children: a systematic review. J Pediatr Surg 2013;48(8):1789-93. [6] Ming YC, Yang W, Chen JC, Chang PY, Lai JY. Experience of single-incision laparoscopy in children. Journal of minimal access surgery 2016;12(3):245. [7] Ponsky TA, Diluciano J, Chwals W, Parry R, Boulanger S. Early experience with single-port laparoscopic surgery in children. Journal of Laparoendoscopic & Advanced Surgical Techniques 2009;19(4):551-3. [8] Pandya SR, Wulkan ML. Single-Site Laparoscopic Reduction of Intussusception. 2011. [9] Fraser JD, Aguayo P, Ho B, Sharp SW, Ostlie DJ, Holcomb GW, 3rd, et al. Laparoscopic management of intussusception in pediatric patients. Journal of laparoendoscopic & advanced surgical techniques Part A 2009;19(4):563-5. [10] Vilallonga R, Himpens J, Vandercruysse F. Laparoscopic treatment of intussusception. International journal of surgery case reports 2015;7C:32-4. [11] Bonnard A, Demarche M, Dimitriu C, Podevin G, Varlet F, Francois 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(7):1249-53.

ACCEPTED MANUSCRIPT Figure legends Figure 1. The patient position and operation room settings. The dotted-line arrows indicate that SILS is able to approach the majority of peritoneal cavity.

Figure 2. Steps of preparation for an in-house port

inserted and secured with elastic bands.

IP

B) A wound protector was required (size XS, Alexis, Taipei, Taiwan)

T

A) A No. 6 glove with tips of 3 finger tips cut off, and 3 trocars of different size were

CR

C) Traction sutures were used for a 2-cm vertical umbilical skin incision D) The wound protector was inserted into the peritoneal cavity

US

E) and held straight upwards

F) The glove prepared in step A was placed over the top of the wound protector by the surgeon and the assistant.

H) until it lies over the abdominal wall

AN

G) The connected piece was rolled downwards by 2 people with both hands simultaneously

M

I) insufflation might begin and proceed with surgery

ED

Figure 3. Transabdominal bimanual reduction.

AC

CE

PT

Figure 4. Wound cosmesis. A. immediately after operation. B. postoperative 1 week.

ACCEPTED MANUSCRIPT Table 1 Demographics for SILS Sex

Age (month)

Type

Indication

1

M

10

ileocolic

Descending colon

181

Reduction failure

+

2

M

6

ileocolic

Descending colon

78

Reduction failure

+

3

M

43

ileocolic

Ascending colon

28

Recurrence

4

F

5

ileocolic

Transverse colon

43

Reduction failure

5

M

36

ileocolic

Ascending colon

49

Reduction failure

6

M

47

ileocolic

Ascending colon

34

Reduction failure

7

M

10

ileoileocolic

Transverse colon

41

Reduction failure

CE

PT

ED

M

AN

US

Patient No. 3, 4, 7 were demonstrated in video 1.

AC

Convert

IP

OP time (min)

CR

Level of intussusceptum

T

Case

ACCEPTED MANUSCRIPT Table 2 Comparison of SILS and CL

Age (m)

SILS

CL

(n=7)

(n=16)

p

22.4±18.7

24.6±18.6

0.80

1:6

2:14

0.91

Sex (female: male)

0.58 1

4

failed reduction

6

12

Type

IP

radiological recurrence

T

Indication

0.25

6

15

ileoileocolic

1

0

ileoileal

0

CR

ileocolic

US

1

0

ascending colon

3

transverse colon

2

descending colon

Conversion Time to feeding (d)

CE AC

3 0

64.9±53.7

70.9±26.1

0.79

2 (28.6%)

1 (6.2%)

0.15

1.9±1.1

1.4±0.7

0.21

3.9±1.6

3.1±1.1

0.17

PT

LOS (d)

12

2

ED

Operation time

0.11

1

AN

ileum

M

Level of intussusceptum

Figure 1

Figure 2

Figure 3

Figure 4