ABSTRACT
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Purpose
Single-port laparoscopy-assisted surgery is being performed for various operations in pediatric patients recently. The aims of this study were to prove the safety and find well-matched indications of small bowel resection using single-site umbilical laparoscopic surgery (SSULS).
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Methods
From 2011 to 2016, 29 pediatric patients underwent SSULS. Medical records were retrospectively reviewed.
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Results
A total of 29 patients were included and 30 SSULS were performed in this study. The mean age at operation was 5.7 years, and the mean weight was 21.9 kg. Meckel's diverticulum was the most common indication for SSULS, followed by small bowel intussusception due to leading point mass, small bowel duplication, and Crohn's disease. In most cases, estimated blood loss was negligible except in Crohn's disease with severe inflammation. While answering post-discharge questions about scars, most parents responded that they were satisfied with the postoperative wound.
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Conclusion
SSULS is a useful operation to try even for surgeons who do not have advanced laparoscopic skills. Complication rates of single-port operations do not differ from those of conventional laparoscopic operations. Most lesions of the small bowel could be indications of SSULS. Careful attention is required when performing SSULS in patients with Crohn's disease.
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Keywords: Laparoscopy; Single port laparoscopy; Small bowel; Small bowel resection; Pediatric
INTRODUCTION
Laparoscopic operation has become another standard approach for many abdominal operations. Laparoscopic operations have a well-known cosmetic superiority with respect to the surgical wound. Single-port laparoscopic operation is the result of the effort to maximize this benefit [
1]. Single-port umbilical laparoscopic surgery can be performed only through the umbilical port site and results in similar outcomes without an obvious scar. Nowadays, single-port laparoscopic operation is adopted for many operations, including appendectomy, cholecystectomy, splenectomy, herniorrhaphy, and colectomy and revealed favorable outcomes [
2].
In pediatric patients, most small bowel resections are being performed via open laparotomy. An open incision or large-caliber trocars are needed for using instruments, such as staplers, removing a specimen, or extracorporeal small bowel anastomosis. Single-site umbilical laparoscopic surgery (SSULS) is a more appropriate procedure than the traditional method in that all procedures can be performed through a small single incision [
3]. Small working space and small sized organs in pediatric patients are known as difficulties associated with laparoscopic operation, but these could be beneficial for SSULS.
The aim of this study is to prove the efficacy and safety of SSULS in children. We will present an appropriate indication for SSULS by reviewing the results of SSULS of our center.
METHODS
1. Material
From 2011 to 2016, 30 SSULSs were performed in 29 pediatric patients in a single center. The demographics, diagnosis, and operative and postoperative outcomes were reviewed retrospectively. All patients were examined until 6 months after SSULS. The scars were evaluated by asking the patients (or their parents) about the scar status and the answers were grouped under 3 categories (satisfaction, fair, and dissatisfaction), at follow-up of 6 months.
2. Operative technique
The patient was placed in a supine position under general anesthesia. A commercially available multichannel single-port, such as OCTO Port (DalimSurgNET, Seoul, Korea) or Lagis (Lagis, Taichung, Taiwan), or homemade glove port was applied. Standard 5-mm laparoscopic equipment, including 30°-angled scope and straight rigid instruments, were used. A 20 to 30 mm vertical incision was made through the umbilicus, and the fascia and peritoneum were opened under direct vision. The pneumoperitoneum was established with an intra-abdominal pressure of 10 to 12 mmHg. Up to three instruments were inserted through the port. Exploration and targeting of the lesion were performed intracorporeally. Though the lesion was fixed or had adhesion, dissection or mobilization was also performed intracorporeally with an electric coagulator and Harmonic scalpel (Ethicon Endo-Surgery Inc., Cincinnati, OH, USA). Then, the lesion was pulled out via the umbilical port site, and resection and anastomosis were performed extracorporeally. The peritoneum and fascia were closed with 3-0 Vicryl interrupted sutures, and the subcutaneous layer was closed with 4-0 or 5-0 Monocryl interrupted sutures. In all cases, no additional working port was needed.
RESULTS
Patients' data are summarized in
Table 1. The male to female ratio was 19 to 10, and a total of 30 SSULSs were performed. The mean age at operation was 5.7±5.6 years old (range, 0.2–16.8 years old), and the mean weight was 21.9±23.2 kg (range, 5.8–95.0 kg).
Table 1 Patient's summarization
Table 1
|
No. |
Sex |
Age (yr) |
Body weight (kg) |
OP time (min) |
Diet start (day) |
Hospital stay (day) |
Diagnosis |
Location of the leison |
OP |
|
1 |
M |
16.7 |
62.7 |
50 |
3 |
5 |
Meckel's diverticulum |
Ileum |
RA |
|
2 |
M |
13.7 |
52.9 |
120 |
1 |
3 |
Meckel's diverticulum |
Ileum |
RA |
|
3 |
M |
0.7 |
8.0 |
90 |
1 |
6 |
Meckel's diverticulum |
Ileum |
RA |
|
4 |
M |
5.4 |
25.0 |
75 |
2 |
3 |
Meckel's diverticulum |
Ileum |
RA |
|
5 |
F |
1.3 |
10.5 |
75 |
3 |
8 |
Meckel's diverticulum |
Ileum |
RA |
|
6 |
F |
4.4 |
16.9 |
100 |
3 |
6 |
Meckel's diverticulum |
Ileum |
RA+AP |
|
7 |
M |
15.9 |
64.9 |
75 |
1 |
6 |
Meckel's diverticulum |
Ileum |
RA+AP |
|
8 |
M |
12.3 |
53.1 |
120 |
2 |
6 |
Meckel's diverticulum |
Ileum |
RA+AP |
|
9 |
M |
7.8 |
22.8 |
80 |
2 |
5 |
Meckel's diverticulum |
Ileum |
RA+AP |
|
10 |
M |
3.0 |
14.8 |
85 |
2 |
5 |
Meckel's diverticulum |
Ileum |
RA+AP |
|
11 |
M |
11.0 |
49.5 |
95 |
2 |
5 |
Meckel's diverticulum |
Ileum |
RA+AP |
|
12 |
M |
9.4 |
27.7 |
120 |
3 |
9 |
Intussusception d/t lymphoma |
Jejunum |
RA |
|
13 |
M |
13.8 |
95.0 |
155 |
2 |
4 |
Intussusception d/t lymphoma |
Jejunum |
RA |
|
14 |
M |
16.8 |
74.6 |
140 |
3 |
11 |
Intussusception d/t small bowel polyp |
Jejunum |
RA+AP |
|
15 |
M |
5.3 |
15.9 |
80 |
3 |
5 |
Intussusception d/t small bowel polyp |
Ileum |
RA+AP |
|
16 |
M |
9.1 |
29.0 |
120 |
3 |
8 |
Intussusception d/t small bowel polyp |
Ileum |
RA+AP |
|
17 |
M |
1.5 |
12.0 |
60 |
2 |
5 |
Intussusception d/t ectopic pancreas |
Ileum |
RA+AP |
|
18 |
F |
13.6 |
42.5 |
180 |
3 |
6 |
Crohn's disease |
Ileum |
RA |
|
19 |
F |
14.6 |
43.1 |
180 |
2 |
8 |
Crohn's disease |
Ileum |
RA |
|
20 |
F |
0.3 |
6.3 |
105 |
2 |
4 |
Small bowel duplication |
Ileum |
RA |
|
21 |
M |
1.1 |
10.5 |
95 |
4 |
7 |
Small bowel duplication |
Ileum |
RA+AP |
|
22 |
F |
1.5 |
10.4 |
90 |
4 |
11 |
Jejunal web |
Jejunum |
RA |
|
23 |
F |
2.0 |
8.3 |
105 |
10 |
14 |
Jejunal web |
Jejunum |
RA Tapering enteroplasty |
|
24 |
F |
3.6 |
15.5 |
95 |
2 |
4 |
A-V Malformation |
Jejunum |
RA |
|
25 |
M |
5.0 |
21.0 |
80 |
2 |
4 |
Cystic lymphatic malformation |
Jejunum |
RA+AP |
|
26 |
M |
6.0 |
20.8 |
140 |
2 |
7 |
Lymphangioma |
Jejunum |
RA+AP |
|
27 |
F |
7.5 |
23.4 |
150 |
2 |
6 |
Intussusception d/t colonic polyp |
Cecum |
IC |
|
28 |
M |
12.2 |
43.7 |
180 |
2 |
4 |
Intussusception d/t B-cell lymphoma |
Cecum |
IC |
|
29 |
F |
0.3 |
7.0 |
135 |
2 |
5 |
Cecal diverticulum |
Cecum |
IC |
|
30 |
F |
0.2 |
5.8 |
120 |
2 |
5 |
Cecal duplication |
Cecum |
IC |
A total of 26 SSULSs were performed for segmental resection and anastomosis. Meckel's diverticulum (11 cases) and small bowel masses triggering intussusception (6 cases) were common indications. Incidental appendectomy, tapering enteroplasty, and reduction of intussusception were performed when needed. The mean operation time was 95±33.4 minutes (range, 50–180 minutes), including the time for other procedures, and in most cases, the estimated blood loss (EBL) was negligible. The mean days to start diet was 2±1.7 days (range, 1–10 days), and hospital stay was 6.1±2.6 days (range, 3–14 days).
Four SSULSs were performed for ileocecectomy due to cecal lesions. Cecal masses triggering intussusception were the most common indication. Mobilization of the right colon was performed intracorporeally with a Harmonic scalpel. The mean operation time was 142±25.6 minutes (range, 120–180 minutes), mean days to start diet was 2 days, and hospital stay was 5±0.8 days (range, 4–6 days). EBL was negligible (up to 100 mL).
A patient underwent SSULS twice due to Crohn's disease. A relatively longer operative time (180 minutes, each) was required, and EBL (400 mL, each) was also increased considering SSULS due to other diseases. Median hospital days and dietary start days were 7 and 2.5 days, respectively. Because of the small number of patients, statistical comparison was not performed.
Postoperatively, patients visited at 1 week after discharge and 6 months later. The wound and general status were checked. Almost all patients and their parents were satisfied about the scar, but 3 patients (or their parents) responded fair to the question about the shape of the umbilical scar.
One patient who underwent SSULS for intussusception had mechanical obstruction after 11 months and underwent single segmental resection of the small intestine and adhesiolysis of peritoneal adhesions. There was no surgical site infection. There were no complications of grade III or higher based on the Clavien-Dindo classification [
4].
DISCUSSION
Laparoscopic surgery for pediatric patients has advanced relatively slower than that for adults, and there are many technical and technological challenges that are specific to pediatric laparoscopic surgery. Influences of carbon dioxide insufflation and increased intra-abdominal pressure on cardiovascular, respiratory, and renal functions in children are not certain till now, especially for neonates [
5]. Moreover, the lack of proper instruments for infants and the small working space make a procedure more difficult. A more superior technique is required for intracorporeal sutures too [
6]. In spite of these problems, cosmetic excellence and less invasiveness have led to advances in pediatric laparoscopic operation and an adoption of single-port laparoscopic surgery in children [
16].
In Korea, only a small proportion of bowel resections and anastomosis for pediatric patients were performed entirely laparoscopically; usually, the conventional method is used [
7]. Laparoscopic small bowel resection is gradually becoming popular; however, there are a few studies about SSULS to prove its safety and efficacy in Korean pediatric patients till now.
SSULS is convenient operation to be performed even for surgeons who do not have advanced laparoscopic skills. The fundamental skill for performing SSULS involves 2 principles: to assess the entire length of the small intestine to find an abnormal lesion and to retrieve an involved segment through the umbilicus. In case of Meckel's diverticulum or small bowel masses inducing intussusception, these are not so difficult to find. When a patient has any adhesion, it could be easily resolved because these are only single band or adhesions between the lesion and omentum.
Considering ileocecectomy, mobilizing an involved right colon may be not easy for beginners. However, using energy devices, such as Harmonic scalpel, and endoscopic hook cautery may be helpful [
38]. In the exteriorization of the ileum and cecum through the umbilical single-port, the hepatic flexure must be mobilized. Mobilization of the hepatic flexure in SSULS in children might be easier than that in conventional operation because of the short distance between the working hands and area of dissection [
3].
The other advantage of SSULS is that it does not require any advanced laparoscopic suture skill because the procedure of anastomosis is similar to that of the conventional operation. When there is tension on the mesentery causing a retraction of the intestine into the peritoneal cavity, it is also helpful to apply intestinal clamps at both ends of the extracted intestinal segment. This also helps to prevent contamination by bowel contents after opening the intestine.
It might be very difficult to identify a cosmetic advantage of SSULS due to the lack of an objective scale. Thus, in this study, patient satisfaction with the surgical wound was evaluated through subjective points of view. Most patients claimed that the scars were almost invisible. Scars and disfigurement cause severe stress to children and their parents [
9]. Three patients (or parents) said the scars were ‘fair.’ They did not reveal the exact causes of minor dissatisfaction. It might be attributed to the fact that the umbilicus did not appear exactly as it was before. If the patient is obese, hiding the scar is easier, but, when a patient is slender, more attention is required to open and close the umbilicus [
1]. In our experiences, the incision must not exceed the superior and inferior edge of the umbilicus. When the incision is extended beyond any edge, the shape of the umbilicus can change and hiding a scar becomes difficult (
Fig. 1).
Fig. 1 Surgical wounds of an 11-year-old boy who was diagnosed with Meckel's diverticulum and underwent single-site umbilical laparoscopic surgery. (A) Preoperative umbilicus. (B) Exposure of the lesion to the outside of the body. (C) Wound immediately after surgery. (D) Postoperative wound after 6 months.
Generally, a small abdominal cavity and small-sized organ are the known factors that make laparoscopic operation difficult in pediatric patients [
6]. However, in SSULS, there are many benefits to overcome these shortcomings. As distances between the umbilicus and any part of small bowel are relatively closer than in an adult, pulling any part of small bowel toward the umbilicus can be easier. The small size of the small intestine in pediatric patients also helps in performing SSULS easier. The diameter of the opening at the umbilical port being limited to 2 to 3 cm; without extension, smaller-sized organs would be pulled out easily through the umbilical port.
There are only a few reports of single segmental small bowel resection using a single port laparoscopy. Multiport assisted laparoscopic small bowel resection with extracorporeal anastomosis through extension of umbilical incision was performed previously. SSLUS have some advantages compared to conventional multiport operation. Though 3 mm trocars were used in multi-port operation, the cosmetics would be inferior to SSULS. And compared with multiport laparoscopic surgery and single port laparoscopic surgery in Crohn's disease, shortening of operation time and hospital stay were reported [
10]. The reduced number of trocars by SSULS would make reduce the trocar site related complication [
11].
Complication rates of single-port operations did not differ from those of conventional laparoscopic operations. Wound infection and incisional hernia (or umbilical hernia) were of concern, but no significant differences were found [
1213]. SSULS would have a similar complication rate with other single-port operations. Postoperative pain after single-port operation compared to that after multiport laparoscopic operation showed no difference [
13]. Moreover, in this study, no wound infection or incisional hernia were found during the follow-up period.
Based on this study, we propose that most lesions of the small intestine in pediatric patients would be managed with SSULS, especially for Meckel's diverticulum and small bowel masses causing intussusception. Because it is easier to find a lesion and suitable to pull out a lesion through the umbilical opening without extending the umbilical incision; it is a valid option. Cystic duplication and cystic lymphatic malformation of the small intestine would be also good indications. When encountering cystic masses larger than the umbilical opening, the fluid content is first aspirated, reducing the size of the mass enough for it to easily pass through the umbilical opening. In Crohn's disease, SSULS could be feasible in pediatric patients [
13]. Intracorporeal procedures, including mobilization of the right colon, adhesiolysis, and evaluation of stricture sites were not difficult during a single-port laparoscopic operation. Retrieving an involved segment in Crohn's disease could be problematic, but it could be managed by extending a skin incision sufficiently to pass the inflamed segment. Although an advantage of SSULS is a hidden scar, it could be difficult in the case of Crohn's disease. Therefore, when planning to perform SSULS in such conditions, a patient should be selected carefully. For the same reason, careful consideration is also necessary for large solid masses of the small intestine.
In conclusion, SSULS is a feasible procedure to try and does not require superior laparoscopic skills. SSULS is a safe procedure with excellent cosmetic results. It seems to be a feasible procedure for Meckel's diverticulum, small masses causing intussusception, and cystic masses after the fluid content has been removed via aspiration. In Crohn's disease and large solid small bowel masses, the benefits of SSULS could be diminished due to the need for incision extension; thus, careful consideration is necessary before planning it.
Pusan National University Yangsan Hospital
NOTES
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This work was supported by clinical research grant in 2018 from Pusan National University Yangsan Hospital.
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No potential conflict of interest relevant to this article was reported.
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