Intussusception can be managed by pneumatic reduction, ultrasound-guided hydrostatic reduction, open or laparoscopic surgery, but laparoscopy in such cases remains controversial.

To explore the clinical characteristics, effectiveness, and complications of surgical reduction for intussusception using laparoscopy in children.

This study was a retrospective case series of pediatric patients with intussusception who underwent surgical reduction by laparoscopy from May 2011 to April 2016 at Taizhou Hospital of Zhejiang Province. Clinical characteristics (operation time, intraoperative blood loss, conversion rate of laparotomy, reasons for conversion, postoperative hospital stay, and adverse events) were described.

The 65 patients included 45 boys and 20 girls. The average age was 2.3 years (27.5 ± 24.5 mo). Of the 65 patients, 61 underwent surgical reduction by laparoscopy after a failed enema reduction of intussusception, and four underwent the procedure directly. All patients were treated successfully and 57 (87.7%) patients underwent successful laparoscopic surgery, two of which had a spontaneous reduction. Among the remaining cases, one was converted to open surgery via right upper quadrant incision, and seven required enlarged umbilical incisions. Intestinal resection was performed in 5 patients because of abnormal bowel lesions. There were no complications (intestinal perforations, wound infections, or intestinal adhesions) during the follow-up of 3 years to 8 years. Two patients experienced a recurrence of intussusception; one was resolved with pneumatic reduction, and the other underwent a second laparoscopic surgery.

Laparoscopic approach for pediatric intussusception is feasible and safe. Bowel resection if required can be performed by extending umbilical incision without the conventional laparotomy.

For intussusception, the laparoscopic approach is a feasible alternative when pneumatic reduction or ultrasound-guided hydrostatic reduction failure. Laparoscopic intussusception reduction can be beneficial and without significant complications if well indicated, and an extension of the umbilical incision is used if needed. Laparoscopic assistance can also yield good treatment outcomes in some complicated cases requiring intestinal resection. Next, we can take the results of this study as a starting point for further prospective multicenter cohort studies.

Intussusception can be managed by laparoscopic surgery, but it remains controversial. The results of this study strongly suggest that intussusception reduction using the laparoscopic approach is effective and without complications in patients with complex conditions or those requiring bowel resection.

Laparoscopy has been reported to be effective and without major complications for the management of intussusception[1,2], supporting the present study. In the present study, the success rate of laparoscopy was 88%, which is within the 79%-90% range reported by many case series[1-3]. Nevertheless, the use of laparoscopy remains controversial because laparoscopic intussusception reduction has a high rate of conversion to laparotomy, as high as 70% in some reports[4]. Nevertheless, with the improvement of laparoscopic techniques in recent years, the conversion rate of laparoscopic intussusception reduction to laparotomy has decreased from 14.3% to 5.4%[5,6]. In this study, the overall conversion rate to open laparotomy was 12%, including seven patients with extension of the umbilical incision. Considering that the small transverse umbilical incision is concealed, it is more aesthetically appealing than traditional open surgery. Besides, laparoscopically-assisted surgery can be considered a form of minimally invasive surgery with laparoscopic assistance; thus, there was only one case of true conversion to open surgery, resulting in a rate of conversion to open surgery of only 1.5%.

It has been reported that patients over 3 years of age have a higher probability of intestinal resection[7,8]; for these patients, laparoscopic intussusception reduction surgery is not recommended[9]. In this study, two patients were > 3 years of age, in whom intussusception was diagnosed using preoperative B-mode ultrasound. Considering the patients’ age, there was a possibility of intestinal lesions, and laparoscopic surgery was performed directly. After reduction was completed, erosion was found in the terminal ileum in one patient, and the tissue was frozen and rapidly sent for pathological examination, revealing lymphoma. The umbilical incision was extended to remove the diseased tissue and the ileocecal segment. The patient recovered after chemotherapy, and the incision site maintained a good aesthetic appearance. It was also reported that laparoscopic reduction is not recommended for patients aged < 3 mo[7,8]. In this study, one 1-month-old patient underwent difficult laparoscopic reduction, and the umbilical incision had to be extended. It was found that the terminal ileum had duplication malformations that were managed with intestinal resection and anastomosis. With the improvement of laparoscopic techniques and instrumentation, we believe that laparoscopic surgery will not be contraindicated by age or intestinal resection because minimally invasive surgery through a small umbilical incision can be achieved even for intestinal resection[1-3].

Another major controversy involves the fact that laparoscopic intussusception reduction is associated with a higher recurrence rate than is conventional open surgery. Nevertheless, it was recently reported that the recurrence rate after laparoscopic intussusception was 3.4%[6]. In this study, there were two recurrences (3.1%), nearly the same as traditional open surgery[10]. The ileum's seromuscular layers and the ascending colon were repaired with two sutures, and the terminal ileum and the ascending colon were juxtaposed. If the ileocecal segment was relatively isolated, it was fixed to the lower right abdominal wall with two sutures to prevent relapse. The recurrence rate in our cohort of only 3.1% suggests good effectiveness. One patient experienced recurrence and required re-operation. The original fixation suture was found to be loose and was re-fixed, without subsequent recurrence. In our opinion, intestine fixation to the abdominal wall may be an effective method for intussusception. Although this method of intestine fixation to the abdominal wall has not occurred intestinal torsion in this stuty, but we do not know whether it is a risk factor for intestinal torsion. Therefore, we need longer follow-up time and more cases.

It has been reported that the appendix is also a site susceptible to intussusception[4]. The appendix is prone to becoming a lead point for intussusception because of viral or bacterial infection or abnormal anatomical position. Therefore, when intussusception is found in the appendix during operation, the appendix exhibiting congestion and swelling is resected. There were no recurrences after appendicular resection in this study. Besides, there were no complications in our cohort, such as intestinal adhesions, wound infections, and intestinal perforations, as supported by the low rates of complications observed in previous studies[2,4].

The short operative time and hospital stay reflect the advantages of laparoscopic techniques[5,6]. Besides, laparoscopic techniques have obvious advantages for intussusception reduction. First, owing to muscle relaxation after anesthesia, some of the intussuscepted intestines might resolve spontaneously. Second, laparoscopic surgery can more intuitively locate organic lesions such as lymphomas of the terminal ileum and intestinal polyps. With open surgery, only the intussusception at the diverticulum's distal end might have been discovered, and the intussusception of the diverticulum itself might have been missed. Nevertheless, laparoscopy might also have some disadvantages, mainly related to the small abdominal cavity in children and the significant amount of edema in intussusception. First, if the intra-abdominal pressure is too high, the cardiopulmonary function of the patient will be affected. If it is too low, the operating field will be too small. Second, given the abdominal cavity's limited space, a gastric tube could be placed before surgery. Third, intussusception masses are often found in the upper right abdomen because the appendix is sometimes involved. Therefore, searching along the terminal ileum and the appendix is more difficult. Fourth, during reduction, the right-hand grasping forceps pulls the neck of the intussuscepted ileum along the fan-shaped curvature of the mesentery, while the left-hand grasping forceps pulls the neck of the intussuscepted sheath to the opposite direction; in this way, the two forces are maintained in the fan-shaped curvature of the mesentery. If the directions of the two forces are along a straight line, the traction on the mesentery tends to be insufficient. In addition, in the reduced intestine, it is important to change the two forceps' positions at an appropriate time to maintain some tension between the two forces. Finally, if it is found that the intussusception is challenging to reduce by laparoscopy, the umbilical incision should be extended, and the reduction should be performed through the umbilical incision. If necessary, bowel resection should be performed. Although laparoscopic intussusception reduction has many advantages, there are specific contraindications. First, laparoscopic surgery should not be performed in cases with longer times of onset (especially > 48 h), instability of the respiratory or circulatory systems, intestinal perforation, peritonitis, severe abdominal distension, or other manifestations. Second, the intussusceptum ideally should not extend past the middle segment of the transverse colon. Those advantages and disadvantages have been highlighted in previous studies[2,4-6], but this study innovates by indicating that the umbilical excision can be enlarged when laparoscopy is difficult, without the need to convert the surgery to a true open surgery.

This study has limitations. The sample size was relatively small and from a single center. A treatment bias might be observed due to local practices. The retrospective nature of the study prevented the observation of some variables. Prospective multicenter cohort studies should be performed in the future.

Intussusception is an invagination of a proximal segment of the intestine into a distal part of the intestine that may result in bowel obstruction, venous congestion, and bowel wall edema[12-15]. It is a common cause of acute abdominal emergency in infants and children. It is most common in infants and children aged 3 mo to 3 years, with a peak incidence between 5 and 9 mo of age[12,13,16]. The vast majority of cases are ileocolic, but small bowel to small bowel and colocolonic intussusceptions may also occur[12,13]. The incidence is 3-40 cases per 10000 live births in the United States of America, Europe, and Australia[7,14,17,18]. Typical clinical presentation of intussusception includes paroxysmal crying, vomiting, an abdominal sausage-like mass, and jam-like, bloody stool[8,12,13]. It is primarily diagnosed through medical history taking, physical examination, ultrasound, and computed tomography[8,12,13]. Pneumatic reduction and ultrasound-guided hydrostatic reduction are the most widely used methods for treating intussusception in children[12,13,16,19-21]. They have a success rate as high as 95%, but pneumatic reduction and ultrasound-guided hydrostatic reduction still fails in some intussusception cases[7,8], and such children will require surgical treatment.

In the past, conventional open surgery was the mainstream surgical treatment for intussusception[12,13,20,21]. However, conventional surgery is associated with significant trauma in children[12,13]. With the development of laparoscopic techniques, there have been increasingly more reports of successful laparoscopic treatment of intussusception, limiting the surgical trauma and allowing faster recovery[1,21]. Nevertheless, laparoscopic treatment for intussusception remains controversial because the port setting is challenging because of the small working space in infants and small children and because the affected segment may vary among children. Besides, the reported series are small.

Therefore, this retrospective study aimed to explore the clinical characteristics, effectiveness, and complications of surgical reduction for intussusception using laparoscopy in children. The results could provide additional data for the management of this condition.