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ORIGINAL CONTRIBUTIONS

Received: August 14^th 2014

Accepted: January 26^th 2015

Rethinking the surgical approach to intestinal obstruction surgery in neonates. Experience of a third-level hospital

Ana Carolina Sepúlveda-Vildósola,^a Esmeralda Piedra Buena-Muñoz,^b Irving Partida-Justo,^d Ileana Campos-Lozada^c

^aUnidad de Educación, Investigación y Políticas de Salud, UMAE Hospital de Pediatría, Centro Médico Nacional Siglo XXI

^bDepartamento de Cirugía Pediátrica, Hospital Pediátrico La Villa, Secretaría de Salud del Distrito Federal

^cDepartamento de Cirugía de Alta Especialidad, UMAE Hospital Pediatría, Centro Médico Nacional Siglo XXI

^dDepartamento de Cirugía Pediátrica, HGR 2 Villa Coapa

^a,c,dInstituto Mexicano del Seguro Social

Distrito Federal, México

Communication with: Esmeralda Piedra Buena-Muñoz

Telephone: (55) 5627 6900

Email: nejiux@hotmail.com

Background: Choosing laparotomy incision (transverse or midline) depends on the area that needs to be exposed, the urgency of the procedure, and the surgeon’s preference. In the Hospital de Pediatría of the Centro Médico Nacional Siglo XXI of the IMSS, the traditional approach is performed by midline in these patients. Our objective was to determine if the midline approach is safe for handling neonates undergoing laparotomy for intestinal obstruction.

Methods: A retrospective study included all neonates who underwent laparotomy for intestinal obstruction by midline approach in the period from January 2010 to January 2012.

Results: 34 patients were studied. 88.2 % were urgency procedures; surgery time was more than 120 minutes. Surgical bleeding in all patients was less than 20 milliliters. Complications were found in 44 % of patients, of which the most frequent was infection (29 %) and wound dehiscence (20 %). As for respiratory complications, 32.4 % had atelectasis and 14.7 %, pneumonia. 14.7 % had incisional hernia at one year.

Conclusions: The frequency of immediate and non-immediate post-surgical complications is higher than those reported in the literature with transverse approach. The frequency of post-incisional hernia at one year is similar to that reported with the latter approach.

Keywords: Pediatrics, Newborn infant, Postoperative complications, Hernia.

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Intestinal occlusion is one of the major surgical pathologies in the neonatal stage.¹ Its correct and rapid diagnosis remains a challenge to the capacity of clinicians and surgeons. The overall survival of these patients has increased to nearly 90% thanks to timely management and special care provided after surgery.²

The five leading causes of intestinal obstruction in the newborn are: necrotizing enterocolitis, intestinal atresia (jejunum-ileum), meconium disease (meconium ileus, meconium plug, meconium peritonitis), Hirschsprung's disease, and intestinal malrotation (Ladd bands, volvulus, errors of intestinal fixation and rotation). Such conditions may secondarily cause acute abdomen, which is defined as the syndrome induced by a wide variety of pathological conditions, which requires emergency medical management or on many occasions surgery.³

Choosing a laparotomy incision depends on the area that needs to be exposed, the urgency of the procedure, and the surgeon’s personal preferences.⁴

In studies with adult patients, the results mostly support the approach by transverse incision. Authors like Proske,⁵ Inaba,⁶ Lindgren,⁷ Grantcharov,⁸ and Bichenbach⁹ support the transverse approach to surgery for procedures such as pancreatic, stomach, or colectomy surgeries, reporting better postoperative pulmonary function, reduced risk of pulmonary complications, less pain, less analgesia needed, and decreased possibility of intestinal blockage as a late complication. Waldhausen¹⁰ reported lower rates of dehiscence in children under one year with the transverse incision approach. Other benefits reported with the transverse approach are shorter surgery and better possibilities of extending the incision, so it is recommended in cases of emergency or cases without diagnostic certainty, and in addition it may be cosmetically more acceptable.¹¹ Consensus recommends transverse incision in the right upper quadrant for duodenal injuries, in the right lower quadrant for ileum and colon injuries, or transverse or upper in cases of doubt about the affected site.^12,13 Fassiadis reported lower incidence of post-incisional hernia in transverse laparotomy to repair abdominal aortic aneurysms.¹⁴ Other authors reported complications such as wound dehiscence in 1-3% and wound infection in 3-19%.¹⁵ The rate of post-incisional hernias at one year post-surgery is estimated between 9 to 20%,^16,17 and this is reported as the most common long-term complication derived from laparotomies in general.¹⁸

However, in the pediatric population, particularly in the group of newborns, this recommendation is not so clear, because of anatomical differences in the abdominal major axis, which, in the case of newborns and infants, is greater in the transverse direction than vertically. The neonatal patient in particular is known to have a greater transverse cephalocaudal diameter, and that breathing is thorax-abdominal and requires the abdominal muscles for proper ventilation mechanism, so lung compliance is affected by pain during the postoperative period. In addition, healing takes longer in the transverse line approach, and there is better control of hemostasis in the midline approach because of entering through the middle region of the aponeurosis, an area that is moreover avascular.

The transverse or midline approach obeys surgical schools and hospital traditions, without an analysis of which is more effective and safe. In our hospital, the approach is traditionally performed through media-, supra- and infra-umbilical incision, as this allows adequate exposure of all the abdominal viscera, and greater control over hemostasis for greater vision and manipulation of abdominal content.¹⁹ An average of 60 neonatal patients are received annually with intestinal occlusive disease requiring surgical management. The aim of this study is to determine if the midline approach is safe for the management of intestinal occlusion in neonates.     

Methods

Retrospective, analytical, longitudinal study, approved by the Local Research Ethics Committee with number R-2013-3603-35. It included all infants with a diagnosis of intestinal occlusion secondary to any pathology, treated by laparotomy via midline incision, who were treated at the IMSS Hospital de Cardiología of the Centro Médico Nacional Siglo XXI between January 2010 and January 2012. Patients were excluded with subsequent laparotomies, with malnutrition, with complex heart disease, or who had sepsis prior to surgery. The following variables were measured: sex, weight, gestational age, intraoperative bleeding, postoperative pain, surgical site infection, surgical wound dehiscence, post-incisional hernia, length of hospital stay, ventilatory support, presence of atelectasis or nosocomial pneumonia, and use of antimicrobial prophylaxis. 

The variables were summarized using percentages. Median percentiles 25 and 75 were determined given the distribution of the variables, and chi-squared was calculated to analyze the association between qualitative variables.

The study is considered safe according to the Ley General de Salud. The confidentiality of the data is assured. The project did not require financial support.

Results

During the study period, 42 neonates underwent surgery for intestinal obstruction, eight were discarded from the study for not having complete files, leaving data from 34 patients for analysis.

Preoperative diagnosis was intestinal atresia for 55.9%, necrotizing enterocolitis for 26.5%, meconium peritonitis for 8.8%, and 2.9% with meconium ileus, jejunal intussusception, and intestinal ischemia, respectively. There was an almost equal ratio of males to females. As for gestational age, 50% were older than 36 weeks, and only 14.7% were less than 31 weeks. 73.5% of children weighed more than 2 kilos.

Most were emergency surgeries. The median operative time was just over two hours and, in general, the bleeding was minimal because all patients were less than 20 cm³. The median number of days needing mechanical ventilation was three, same for analgesia. The analgesic treatment used was buprenorphine and ketorolac, alone or in combination, at doses of 1 to 2 mcg/kg/day in 3 applications on the first day, and 0.5 to 1 mcg/kg/day in 3 applications on the second day. All patients received antimicrobial prophylaxis, three patients received it for only one day, 30 patients for three days, and one patient for 10 days.

Patients stayed in the hospital for a median of 19 days. Median number of complications was one event, ranging from zero to a maximum of four (Table I).

Postoperative complications are listed in Table II. 44.1% had complications from surgery (n = 15). The immediate complications were ten patients with wound infection (29% of all patients) and eight with dehiscence (20% of total). It should be noted that nine of these infections were superficial and were presented after 72 hours in hospital, and one infection was reported as deep, which was identified in the second week in hospital. Regarding dehiscence, all cases occurred after 72 hours, but within the first week. Post-incisional hernia at one-year post-surgery was identified in 14.7% of patients (n = 5).

As for non-surgical complications, eleven patients had atelectasis (32.4% of the total), three occurred in the first five days post-surgery, and the other eight after the fifth day. Five patients (14.7% of the total) developed pneumonia more than 14 days post-surgery.

No variables inherent to the patient or the surgery showed statistical significance when it was attempted to associated them with the development of complications (Table III). However, it is noteworthy that a greater number of complications occurred in emergency procedures than in elective procedures (eight versus two, respectively). The most complications were in cases of jejunoileal atresia, followed by necrotizing enterocolitis. Regarding gestational age, the patients with the most complications were those under 36 weeks of gestation. The two patients with weight under 2000 grams showed more than 2 complications. It can also be seen that the patients with the most complications are those whose surgical time exceeded 120 minutes.

Analyzing the days of mechanical ventilation with the presence of dehiscence, we found that all patients with surgical wound dehiscence continued ventilatory support for more than 24 hours, whereas none of the patients extubated in the first 24 hours presented this complication; although these results did not show statistical significance (p = 0.419), they are clinically relevant, since mechanical ventilation could be increasing intra-abdominal pressure and contributing to the presence of this complication.

Likewise, associating the days of ventilatory support by tracheal cannulation with the presence of respiratory complications, we found that of the 16 patients who developed these complications (atelectasis and/or pneumonia), all remained intubated for more than 24 hours; despite not having statistical significance (p = 0.195), this has great clinical significance.

Looking for association between surgical time and the presence of infection, it was found that 70% of patients with infection had operating time greater than 120 minutes, compared to only 30% of patients with infection with operating time less than 2 hours (p = 0.285). Notably, the patient who presented deep wound infection had operating time over 120 minutes.

Discussion

Historically, our hospital has used the midline approach for the management of infants with intestinal surgical pathology, without a clear scientific basis to back it up. This practice has been promoted by individual preferences, reporting increased exposure of the abdominal organs and less bleeding.¹⁹ Other studies show intraoperative advantage with this approach because of greater possibility of extending the incision.⁸

However, recent studies have shown lower complication rates, and less need for analgesia and ventilatory support with the transverse approach. The technical explanation is that in the midline approach, the incision includes skin, cell tissue, and the linea alba, which is the union of the aponeurosis of the rectus femoris and transverse muscles, with a line of low resistance from being a single plane of suture. It follows that infections of the skin and cellular tissue could more easily compromise its integrity, promoting dehiscence and evisceration that could even endanger the patient's life. 

In contrast, the transverse approach affects skin, cell tissue, rectus femoris, obliques, transverse, and linea alba, with increased risk of bleeding, but with greater resistance due to suturing of the 3 muscle planes. That is why we wanted to analyze our experience and compare it with that reported in the literature.

Our findings show that the number of complications in general is higher than that reported by the authors who recommend transverse incision. Proske⁵ reports a general complication rate of 20% and mortality of 4%. It is noteworthy that none of our patients died.

Our frequency of surgical wound dehiscence was 23.5%, much higher than that reported by Brown,¹¹ who reports 1-3% of this complication, and Waldhausen¹⁰ (0.24% for the transverse approach and 1.74% for the midline approach [p < 0.001]). One factor that could explain these findings is the surgeon's experience, in our case, we included doctors in various stages of training as well as physicians with more years of practice. However, this variable was not analyzed in our study.

Regarding post-incisional hernia, our rate was 14.7%, similar to that reported by Brown¹¹ with 20%. However, two systematic reviews conducted by Grantcharov⁸ and Bickenbach⁹ demonstrate increased risk of dehiscence with the midline approach compared with the transverse (OR of 1.68 (95% CI 1.10-2.57; p = 0.02 and RR = 1.77 [95% CI 1.09 to 2.8], respectively).

Regarding the use of analgesics, our patients generally required less than 72 hours of support with analgesics (buprenorphine and ketorolac). However, it is not possible to compare these analgesia needs with other approaches, since the design of our study does not allow it, and it is worth noting that pain measurement in a newborn is much more complex than in an adult patient. In general, several authors have demonstrated less postoperative pain with transverse incision and less analgesic need when comparing the two incisions. For example, Lindgren⁷ reported lower analgesic need with transverse incision (50 ± 7.9 mg), than midline (85 ± 9.8 mg) (p < 0.05). Bickenbach⁹ also reports a lower need for doses of postoperative analgesic (morphine) in patients with transverse incision. Finally, Inaba⁶ documents decreased postoperative pain and fewer dosages needed in patients with transverse incision versus midline (3.3 ± 0.2 vs. 2.9 ± 0.2).

Our results show a frequency of infection much higher than that reported by other authors, even for midline incision. Inaba⁶ reports a frequency of surgical wound infection very similar in both approaches (5% midline versus 5.1% for transverse). These results are similar to those reported by Proske,⁵ who reports an incidence of wound infection of 4% for midline in contrast to 2% for transverse (p < 0.05). It is therefore necessary to do a thorough review of this problem in our hospital. First, there seems to be a lack of unified criteria regarding the use of antimicrobial prophylaxis and its duration, which is coupled with the participation of diverse staff involved in the handling of surgical wounds. We therefore recommend antimicrobial coverage with beta-lactam-aminoglycoside (or even carbapenem monotherapy), especially in contaminated surgeries (as are most emergency laparotomies), and consider it necessary to continue such support for up to ten days, as recommended by the Guidelines for the selection of antimicrobial therapy in children from the Pediatric Clinics of North America,²⁰ to which the various specialists involved in the management of these patients must adhere.

Respiratory complications in our study were higher compared to those reported in the literature. Our findings report a frequency of pneumonia of 14.7%, much higher than that reported by Inaba⁶ (6.5% for midline compared with 1.5% for transverse) (p < 0.05). It is notable that, at present, ventilator-associated pneumonia is the third leading cause of nosocomial infection, which is a problem for patient care, so therefore it is important to promote early extubation of patients.

Because of our study design it was not possible to analyze the ventilatory variables with which patients were managed, as these were unfortunately not always reported in the notes of patient records. However, Bickenbach9 and Proske⁵ show less impact on postoperative lung function and decreased FEV1 with the transverse approach.

Although the sample of patients is small and the comparisons are not significant, the significant number of complications should make us reconsider our preference for surgical midline approach for these patients. To obtain more conclusive results, we suggest a randomized pilot study to determine the safety of either approach in our context.

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