Intestinal malrotation is a common cause of duodenal obstruction in neonates and infants. Malrotation is abnormal twisting and fixation of the intestine [1] which may cause torsion necrosis of the bowel, abdominal pain, and chyloascites [2]. Although laparoscopic Ladd’s procedure is controversial for newborns [3], the advantages of laparoscopic surgery are minimally invasive, aesthetic incision and less postoperative pain [4,5,6]. Torsion of the bowel will prolong the operative time and postoperative recovery [7]. Different ages may also recover differently. Therefore, we matched the PSM according to the sex, age, and degree of intraoperative torsion of the child to reduce the influence of these selection biases. A propensity matching study found that laparoscopy has an advantage in shortening the postoperative hospital stay, but the children in this study are older and the proportion of newborns in the study is small. In our study, most patients are newborns and all patients are below 1 year old.
This study confirmed that laparoscopy can decrease hospital stay and the chance of incision infection. However, we did not find a gap in the first bowel movement and adequate feeding after laparoscopy. Laparoscopic surgery will prolong the operation time, the transfer rate is low, and postoperative complications are similar to laparoscopic procedure except for incision infection.
In this study, children who underwent laparoscopic surgery had less time to stay and a lower rate of incision infection. Since appendectomy during surgery is a common practice in our center, incision infections also occur occasionally. The incision infection rate of the children in our study is similar to previous studies [3]. Incision infection requires long-term incision dressing and long-term hospitalization. The length of stay in our study is similar to previous studies [8]. The standards for discharge are usually different in different centers, resulting in different hospital stays. Our discharge standard is usually to be able to achieve adequate feeding and exclude other complications. Since laparoscopic surgery rarely causes infection of the incision, surgeons may be more inclined to discharge the child after adequate feeding.
The big series described conversion rates between 8 and 45% [9,10,11]. Although our center has more neonates with volvulus, our transit rate is 8.1% (5/62). Our research also confirmed that the laparoscopy method is also suitable for newborns and infants. During our procedure, we placed a laparoscopic trocar in the umbilical cord for observation, and 2 trocars are put in the right abdomen and right lower abdomen. This allows the surgeon to perform the operation comfortably. The procedure was similar to Pham reported [9]. Although Agrawal reported a “steering wheel” method to reset the twisting midgut [12], we found that for the most part the twisted intestine was not what they suggested [10]. We not only reset the bowel, but also probe the bowel from caecum to jejunum to ensure sufficient torsion reduction. We discovered that after the reduction of the torsion of the mesenteric root, some children had the folded part of the mesenteric torsion. So this exploration is very important, which may be the reason why our reversion rate is not high as reported. At the same time, in addition to the release of Ladd’s band, we also need to release the greater omentum from the transverse colon. Because of our two reversion cases, we found that both of the greater omentums were involved in the reversion of the bowel. Only sufficient release of the greater omentum can fully expand the mesenteric membrane. It has been reported that part of the intestine may retract after laparoscopic surgery, possibly due to inadequate release of the greater omentum. However, the majority of our patients with midgut volvulus underwent laparoscopic Ladd’s procedure successfully, and only two relapsed. This is different from what has been reported before. Even in the case of torsion, we attempted a laparoscopic reoperation without a recurrence. Although follow-up time was limited and the risk of reversal was lifelong, all of our cases recurred within 2 months after surgery.
Although a rapid postoperative recovery of peristalsis after laparoscopic surgery has been reported in many studies [8, 11, 13], we did not find that the laparoscopic group had a significant advantage in postoperative intestinal function recovery in our study as the other reports [14, 15]. Our method of judging the recovery of bowel function is by the time of the first defecation after surgery. The method of judging bowel function is not consistent, and it must be subjective, which may be the reason for the difference in results. Another reason for the difference in recovery may be the higher proportion of midgut volvulus in our study.
At the same time, we found that the operation time of laparoscopic surgery was longer than that of open surgery group. Many studies have the same opinion [13, 16, 17]. Our operation time is similar to the previous study [10]. This may be due to the high number of children with volvulus in our study.
As many reports have said, laparoscopic Ladd’s procedure has significantly higher difficulty in torsion and redo than open surgery. However, extended follow-up is necessary to determine the long-term efficacy of laparoscopic surgery. The incidence of postoperative adhesive obstruction after open Ladd’s surgery has been declared to be as high as 13%; Our incidence of postoperative adhesive intestinal obstruction is similar to about 10.5%. The unavoidable and extensive Ladd’s band separation during surgery may be the cause of postoperative intestinal adhesion obstruction. The treatment of asymptomatic dyspraxia remains controversial [3, 18].
Although the rate of reoperation was 8.1%, which is similar to of laparotomy as in the past literature [7, 19]. In the laparoscopic group, there were two cases of reversion, this may be due to the stenosis of the mesentery. At the same time, we found that the greater omentum enveloped the duodenum during the reoperation, so in addition to cutting the Ladd band, attention should be paid to the over-hyperplasia of the greater omentum. Although malrotation of the intestine with other intestine malformations is rare [20], it is difficult to detect it during surgery. Although there are many studies on necrotizing enterocolitis [21], the cause of necrotizing enterocolitis in our case is still unclear, intensive high frequency coagulation may be a reason [22]. It suggests that we need to pay attention to the abdominal signs during feeding. Complications seem to be unavoidable in both open and laparoscopic Ladd’s procedure with a certain chance of reoperation [19, 23], so it is important to inform the family members after discharge to avoid irreversible volvulus necrosis.
In summary, by a propensity score matching analysis, laparoscopic Ladd’s procedure is a safe approach even in infants and neonates. It can reduce the length of hospital stay and incision infection, but the operation time was extended, other complications are similar compared with open procedure for intestinal malrotation in neonates and infants. Therefore, it is recommended to be performed at the center skilled in laparoscopic technology.
