Laparoscopic Management of Small Bowel Obstruction in Children

Abstract

The use of laparoscopy in the treatment of acute small bowel obstruction (SBO) faces inherent obstacles, including dilated loops of bowel, a limited working space, and postoperative adhesions. The objective of this study was to outline the efficacy of laparoscopic management of SBO in children. With Institutional Review Board (IRB) approval, children who presented with a diagnosis of SBO and underwent management via a laparoscopic approach at our institution from January 2001 to December 2008 were retrospectively reviewed. Medical records were reviewed for age, weight, etiology of obstruction, radiographic findings, need for conversion, number of operations, length of stay, and postoperative complications. Statistical analyses of data comparison between those patients who were managed utilizing a laparoscopic approach and those in whom the laparoscopic approach was converted to a laparotomy were performed using a Chi-squared or a two-tailed Student's t-test with significance reported for P < 0.05. Thirty-four patients underwent laparoscopic management of SBO. Mean age was 8.1 ± 5.9 years with a mean weight of 32.8 ± 24.6 kg. Sixty-seven percent were male. A preoperative computed tomography scan was obtained in 21 patients (62%). Eleven cases (32%) required conversion to laparotomy. The most common reason for conversion to the open approach was poor working space (45.4%) followed by intestinal volvulus (27.2%), inability to identify source of obstruction (18.2%), and enterotomy (9%). The most common cause of SBO was postoperative adhesions (73.5%), followed by Meckel's diverticulum (8.8%), volvulus (8.8%), and other (8.8%). Postoperative complications occurred in 5 patients (14.7%). One patient died within 30 days of exploration due to intestinal ischemia secondary to midgut volvulus and subsequent septic shock. Five patients (14.7%) had a recurrent SBO with a mean time to recurrence of 2.6 ± 2.1 months. There were no significant differences in demographic or preoperative variables between patients who were successfully managed with laparoscopy alone versus those patients in whom conversion to laparotomy was necessary. In patients who required conversion, the laparoscopic evaluation did aid in identifying the etiology and allowed for a directed surgical approach when appropriate. Laparoscopy for the management of SBO in children is safe and can be therapeutic in the majority of patients. We recommend that consideration for initial exploration in children with SBO be carried out via the laparoscopic approach, with an understanding that conversion to an open approach may be necessary to complete the operation.