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Open versus laparoscopic approach for intestinal malrotation in infants and children: a systematic review and
Vincenzo Davide Catania1, Giuseppe Lauriti2, Agostino Pierro1
1Division of General and Thoracic Surgery, Department of Surgery, The Hospital for Sick Children, University of Toronto, 1524C-555 University Ave, Toronto, ON, M5G 1X8, Canada.
Insights
Laparoscopic Ladd's procedure in children offers faster feeding and shorter hospital stays but has a higher risk of post-operative volvulus. Further randomized studies are needed to confirm these findings for intestinal malrotation treatment.
Area of Science:
- Pediatric Surgery
- Minimally Invasive Surgery
- Gastrointestinal Surgery
Background:
- Ladd's procedure is the standard surgical treatment for intestinal malrotation in children.
- The adoption of minimally invasive techniques has raised questions about the comparative benefits of laparoscopic versus open surgery for this condition.
Purpose of the Study:
- To evaluate the impact of surgical approach (open vs. laparoscopic) on patient outcomes following Ladd's procedure for intestinal malrotation in children.
Main Methods:
- A systematic literature search was conducted across major databases (PubMed, Cochrane, Embase, Web of Science).
- Retrospective studies comparing open and laparoscopic Ladd's procedures in pediatric patients were included.
- Key outcomes analyzed included age at operation, time to enteral feeding, hospital stay duration, and post-operative complications. Meta-analysis was performed.
Main Results:
- The meta-analysis included nine studies with 1003 pediatric patients (74% open, 26% laparoscopic).
- Laparoscopic Ladd's procedure was associated with significantly faster time to full enteral feeding (1.5 vs. 4.6 days) and shorter hospital stays (5.9 vs. 11.2 days).
- While laparoscopy showed a lower overall complication rate (8% vs. 21%), it was linked to a higher incidence of post-operative volvulus (3.5% vs. 1.4%).
Conclusions:
- Laparoscopic Ladd's procedure, despite a high conversion rate (25.3%), offers advantages in terms of feeding and hospitalization duration for pediatric intestinal malrotation.
- However, the increased risk of post-operative volvulus with laparoscopy warrants careful consideration.
- Prospective randomized trials are essential to definitively establish the safety and efficacy of the laparoscopic approach.
Purpose:
Although the principles of the Ladd's procedure for intestinal malrotation in children have remained unchanged since its first description, in the era of minimally invasive surgery it is controversial whether laparoscopy is advantageous over open surgery. The aim of our study was to determine whether the surgical approach for the treatment of malrotation had an impact on patient outcome.
Methods:
Using a defined strategy (PubMed, Cochrane, Embase and Web of Science MeSH headings), two investigators independently searched for studies comparing open versus laparoscopic Ladd's procedure in children. Case reports and opinion articles were excluded. Outcome measures included age at operation, time to full enteral feeding, length of hospital stay, and post-operative complications. Maneuvers were compared using Fisher's exact test and meta-analysis was conducted using RevMan 5.3. Data are expressed as mean ± SD.
Results:
Of 308 abstracts screened, 49 full-text articles were analyzed and nine (all retrospective) met our search criteria. Selected articles included 1003 patients, of whom 744 (74 %) underwent open surgery and 259 (26 %) laparoscopy. Patients who had open surgery were younger (0.9 ± 1.2 years) than those who underwent laparoscopy (2.6 ± 3 years; p < 0.0001). Laparoscopy was converted to open Ladd's in 25.3 % patients. Laparoscopy was associated with faster full enteral feeding (1.5 ± 0.3 days) in comparison to open surgery (4.6 ± 0.1 days, p < 0.0001). Length of hospital stay was shorter in the laparoscopic group (5.9 ± 4.3 days) than in the open group (11.2 ± 6.7 days; p < 0.0001). Open surgery was associated with higher overall post-operative complication rate (21 %) than laparoscopy (8 %; p < 0.0001). Although there was no difference in the prevalence of post-operative bowel obstruction (open, n = 10 %; laparoscopy, n = 0 % p = 0.07), post-operative volvulus was more frequent in the laparoscopy group (3.5 %) than in the open group (1.4 %, p = 0.04).
Conclusion:
Comparative but non-randomized studies indicate that laparoscopic Ladd's procedure is not commonly performed in young children. Although one third of laparoscopic procedures is converted to open surgery, laparoscopy is associated with shorter time to full enteral feeds and length of hospital stay. However, laparoscopic Ladd's procedure seems to have higher incidence of post-operative volvulus. Prospective randomized studies with long follow-up are needed to confirm present outcome data and determine the safety and effectiveness of the laparoscopic approach.
