Fig. 33.1.
Operating room setup (a) with standard trocar placement (b). Trocar placement may be altered based on location of the intussusception on air or contrast enema. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2015. All rights reserved.
Bowel preparation is unnecessary as patients are typically obstructed. Appropriate fluid resuscitation should be initiated. Intravenous antibiotics should be given preoperatively. A nasogastric tube should be placed to decompress the stomach. Patients may have swallowed a significant amount of air from crying during enema reduction attempts.
Trocar Position and Instrumentation
A 5-mm, 30-degree laparoscope should be placed in the umbilicus. The intussusception should be identified before placing additional ports. Most commonly, two 3-mm or 5-mm instruments will be placed under direct visualization through stab incisions in the left lower quadrant and suprapubic region to triangulate toward an ileocolic intussusception (Fig. 33.1b).
Instrument size should be chosen such that the instruments can grasp the entire diameter of the bowel to minimize injury from tangential grasps. In larger children, this may prohibit the use of 3-mm instruments. Port placement may be adapted based on the location of the intussusception on imaging, although the intussusception ultimately should reduce to the right lower quadrant. More extensive intussusceptions may require additional ports to improve ergonomics.
Technique
- 1.
Assess the anatomy.
- a.
Identify the intussusception. If no intussusception is present, it may have reduced spontaneously, and the procedure is complete.
- b.
Look for pathologic lead points, such as a Meckel’s diverticulum.
- c.
Determine the feasibility of continuing laparoscopically based on bowel distention or ischemia.
- a.
- 2.
Atraumatic graspers should be used to manipulate the bowel. Reduction may be attempted initially with one instrument by providing traction on the ilium, but this reduction using this method can be challenging. If reduction is not achieved, then an additional instrument may provide countertraction on the cecum (Fig. 33.2a). Pressure should be firm and steady for several minutes. The traditional open technique of applying pressure from distal to proximal in a sequential fashion may be attempted but can be difficult to reproduce laparoscopically (Fig. 33.2b).
Fig. 33.2.
Laparoscopic reduction technique. The standard laparoscopic reduction technique (a) is performed by applying steady traction to ileum with countertraction from the cecum. The traditional open technique (b) may be reproduced laparoscopically by applying pressure from distal to proximal in a sequential fashion. Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2015. All rights reserved.
- 3.
If the intussusception is extensive, an on-table enema under fluoroscopy with simultaneous laparoscopic traction may be performed.
- 4.
If still not reduced, consider conversion to a laparoscopic-assisted procedure through extension of a port site incision or placement of an incision over the lesion large enough to externalize the intussusception and perform open reduction. In cases series, the rate of conversion to an open procedure has been 10–30 % [8–10].
- 5.
If the laparoscopic or laparoscopic-assisted approach is not successful, a formal laparotomy should be done. If open reduction is not possible, resection should be performed with an ileocecectomy or right hemicolectomy.
- 6.
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Once the intussusception is reduced, the bowel should be assessed for viability before closing the incisions. If a segment of bowel is necrotic or remains ischemic, a segmental resection is required. Any serosal tears or mesenteric rents should be repaired primarily (Fig. 33.3).
Fig. 33.3.
Laparoscopic views of ileocecal intussusception before (a), during (b), and after (c) reduction.
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