Operative management of intussusception is reserved for cases of frank peritonitis, perforation, or failed enema reduction.
Open surgery has traditionally been performed via an infraumbilical transverse right-sided incision. Consideration could also be given to an upper midline incision, which may result in better visualization or ease of delivery of the mass. Upon entering the peritoneal cavity, the intussuscepted mass is delivered through the wound. For an ileocolic intussusception, mobilization of the right colon may be necessary. The maneuver of manual reduction involves gentle squeezing (“taxis”) of the intussusceptum starting at the most distal end (Fig. 45-6). This may be augmented with slow, gentle traction pulling on the proximal ileal edge. Historically, pediatric surgeons were advised not to apply proximal traction due to the risk of tearing the edematous intestine. However, accumulating experience, both open and laparoscopically, demonstrates that gentle proximal traction is safe. Several minutes of continuous pressure to slowly decompress the bowel wall edema is often necessary to manually reduce the mass. Serosal tears may result during this maneuver as both the intussusceptum and intussuscipiens are quite edematous. These should be of no consequence as long as there is no full-thickness injury. It is difficult to ascertain the extent of ischemia until the bowel has been completely reduced. If manual reduction is accomplished, one must be certain that the bowel is viable and adequately perfused and the presence or absence of a pathologic lead point, most frequently a Meckel diverticulum or a polyp, is confirmed.
The most important aspect of the manual reduction of any intussusception is the continuous squeezing of the most distal intussusceptum through the wall of the intussuscipiens. Simultaneously, an assistant gently pulls the intussusceptum out of the proximal end.
If, after several minutes attempting manual reduction, no progress is made, preparation should be undertaken for resection of the irreducible intussusception. For an ileocolic intussusception this will typically involve an ileocecectomy or a right hemicolectomy. This operation will be facilitated by completely mobilizing the right colon to the hepatic flexure. Our preferred approach is to perform primary end-to-end anastomosis if the resection margins are well perfused and only mildly edematous. A temporary stoma can be entertained at the discretion of the operating surgeon, but should be reserved for cases with a high likelihood of poor intestinal healing, such as poor perfusion of the resected margins, hemodynamic instability, or frank perforation with intraabdominal sepsis.
Management of the appendix remains controversial and without consensus. Historically, appendectomy was performed to eliminate confusion concerning the status of the appendix in a patient with a right-sided transverse incision. However, accumulating evidence suggests the potential of a functional immunologic role for the appendix. Additionally, the possibility exists for any patient that the appendix may have other potential uses, such as continent appendicostomy or Mitrofanoff reconstruction. Our approach is generally to leave the appendix in place if it is not included in a resection.
The laparoscopic approach to intussusception is safe, effective, and increasingly accepted as an alternative to traditional open surgery. The ideal candidate for a laparoscopic approach has failed radiologic reduction, has no evidence of peritonitis, and a duration of symptoms <1.5 days. Pathologic lead point and delayed diagnosis are not exclusionary of the laparoscopic approach, but these circumstances increase the likelihood of conversion to open surgical intervention. Due to limitations in manual palpation of the edematous bowel at laparoscopy, the incidence of missed pathologic lead point may be increased with successful laparoscopic reduction.
The technique of laparoscopic approach to intussusception is well established. Our preference is two 5-mm ports (alternately a 3-mm and a 5-mm port) and a 3-mm grasper, placed via a separate “stab” incision. Port placement depends on the location of the intussusception. The abdomen is entered via the open technique through the umbilicus. A 3- or 5-mm port is placed in this umbilical location and pneumoperitoneum is established. For ileocolic intussusception, a 5-mm port is placed in the LUQ and a 3-mm grasper is introduced through the LLQ via the stab technique. These are placed under direct telescopic vision after infiltrating the peritoneum with 0.25% bupivacaine. The goal is to reduce the intussusceptum using the atraumatic graspers. A 3-mm grasper tends to be too traumatic to the edematous bowel, because of the pressure generated over a smaller grasping surface. Some authors recommend a 10-mm grasper as the instrument of choice to assure gentle handling of the edematous bowel. The decision to upsize an existing port can be made intraoperatively. As in the open technique, the key is gentle traction just proximal and constant gentle pressure just distal to the intussusceptum. Again, due to the intestinal wall edema, several minutes of continuous pressure and traction may be required, so one should not too quickly abandon the laparoscopic technique for lack of progress. Other authors have described preoperative placement of a ballooned Foley catheter taped into the rectal vault and attached to a bag of normal saline to provide helpful intracolonic counter pressure during the attempted laparoscopic reduction. Conversion to an open technique is considered for bowel necrosis, discovery of pathologic lead point, or failure of reduction. If a decision for conversion is made, we mobilize the right colon laparoscopically and deliver the intussuscepted mass through an expanded umbilical incision.
Management of the appendix at laparoscopy is not standardized. Our practice is to leave the appendix. If appendectomy is a part of the operative strategy, it can be easily performed via an “open” technique after delivering the appendix into the umbilicus through the 5-mm port site.
Postoperative management depends on the procedure performed. Length of stay (LOS) is shorter for children requiring bowel resection treated laparoscopically (3 vs 4.5 days). If no bowel resection is performed, the patients can eat early and LOS is dictated by traditional parameters of diet and pain control, typically 1 to 2 days in an infant after successful surgical reduction.