intussusception remains a common cause of bowel obstruction in young children and it is accompanied by a significant morbidity and mortality . however , surgery remains an important part of the treatment , especially in the presence of presumed intestinal ischemia . laparoscopic surgery has progressively been implemented in the general practice in children , including for the management of intussusception . however , laparoscopy , compared to laparotomy , has shown to give less pain , shorter operative time , a better cosmetic result , shorter hospital stay , shorter time to full feeds , lower requirement for intravenous narcotics and a lower long - term risk of adhesive bowel obstruction . in addition , the lead point or ischemic intestinal areas could be identified during the laparoscopic procedure . despite of all its benefits , the laparoscopic approach to treat acute intussusception has been questioned . the surgical technique is demonstrated by the clinical case of 5 months old child with acute occlusion caused by an intestinal intussusception and treated by laparoscopic approach . a retrospective analysis of our database provided a total of 4 patients who underwent laparoscopic reduction of intestinal intussusception between 8/2008 and 4/2013 in our department . a comprehensive review of each case was done including the laparoscopic technique of one of them . three of the children had diarrhea , one of them caused by adenovirus . in all patients , diagnosis was obtained by echography . delay time between initial symptoms and diagnosis and between diagnosis and surgery were 3.5 days ( range : 24 days ) and 6  h ( range : 28  h ) respectively . a 5 month old boy who presented with acute abdominal distention , abdominal pain , nausea and vomiting was admitted to the emergency department . the patient underwent general anesthesia and trocars were placed under direct vision as follows : 10  mm trocar was placed in the lower inferior quadrant , a 5  mm trocar in the left upper quadrant and finally a 5  mm trocar in the suprapubic area ( image a ) . a thorough exploration of the peritoneal cavity was performed and ileocolic intussusception was confirmed ( image b ) . reduction of the ileum was completed by a combination of delicate direct pressure on the transverse colon and gentle pulling on the distal small bowel ( image c ) . the colonic appendix was mobilized and appendectomy was performed ( image d ) . at the conclusion of the appendectomy , a 5 month old boy who presented with acute abdominal distention , abdominal pain , nausea and vomiting was admitted to the emergency department . an ultrasound was performed and showed a typical image of ileocolic intussusception . the patient underwent general anesthesia and trocars were placed under direct vision as follows : 10  mm trocar was placed in the lower inferior quadrant , a 5  mm trocar in the left upper quadrant and finally a 5  mm trocar in the suprapubic area ( image a ) . a thorough exploration of the peritoneal cavity was performed and ileocolic intussusception was confirmed ( image b ) . reduction of the ileum was completed by a combination of delicate direct pressure on the transverse colon and gentle pulling on the distal small bowel ( image c ) . the colonic appendix was mobilized and appendectomy was performed ( image d ) . at the conclusion of the appendectomy , its diagnosis is usually based on clinical features and confirmed by ultrasound and/or computer tomography scan . hydrostatic reduction of intussusception , introduced by ravitch and mccune in 1848 remains the gold standard . although radiological treatment may be effective , its failure rate increases beyond 24  h after the onset of the clinical symptoms . when the clinical situation of the child is poor , including signs of peritonitis , perforation , or hypovolemic shock , radiological treatment is contraindicated . hence , surgical treatment may be required in 1020% of cases . however , laparoscopic reduction of intussusception is still controversial . in the early days of laparoscopy for intussusception management , the presence of a lead point or necrotic bowel was considered an indication for conversion to open surgery . with the improvement of surgeon 's skills and instruments , laparoscopic reduction may be attempted without a significant increase in mortality or morbidity . in adults , laparoscopic reduction of intussusception might be more difficult because of a chronic incarceration of the tissues , necessitating conversion and manual reduction or bowel resection . in the children , the clinical setting is usually within hours allowing even a medical treatment . in a multi - center retrospective study conducted between 1992 and 2005 , including 69 patients [ average age at diagnosis was 2.9 years ( range : 0.314.8 ) ] , the french study group for pediatric laparoscopy ( geci ) showed that after failed hydrostatic enema reduction the best candidates for laparoscopic management were those patients with short lag time between onset of symptoms to diagnosis ( < 1.5 days ) , and in whom there were no signs of peritonitis . the same study group showed that the risk for conversion to an open procedure was higher when a pathologic lead point was present , such as a tumor , a meckel 's diverticulum or even a henoch - schonlein purpura . in our practice we , like other authors , do not contraindicate laparoscopy when dealing with an acute intussusception even in the presence of a lead point . although laparoscopy can be more challenging because of the reduced tactile feedback laparoscopy may offer some benefits in case of recurrent intussusception ( i.e. > 2 ) such as the ability of ruling out the presence of a lead point . for some authors , peritonitis is still considered a major contraindication to the laparoscopic approach because of the theoretical risk of enhanced bacteremia and endotoxemia by the pneumoperitoneum . the use of mini - laparoscopy in children ( usually 2  mm instruments tools ) , described in processes such as acute appendicitis may be useful in the context of intussusception as well . in a recent revisional study , 28 patients requiring operative intervention for reduction of intussusception in 12 years period . in that study , 5 patients underwent laparoscopic reduction of intussusception , and 23 patients underwent open reduction . the rate of overall complications was not statistically different , with 1 of 5 ( 20% ) and 7 of 23 ( 30% ) having complications in the laparoscopic reduction of intussusception and open groups , respectively . the authors found that laparoscopic reduction of intussusception a safe and feasible alternative to the open approach . we consider that performing appendectomy may avoid future confusion as to whether appendectomy actually has been performed or not . more importantly , intussusception and recurrent intussusception have been described in relation to the presence of persisting adenovirus in the appendix ( acting as a reservoir ) . the appendix may thus act as a persisting lead point for intussusception . removing the appendix may help decrease the potential risk of recurrent intussusception . to summarize , intestinal intussusception is a frequent cause of bowel obstruction in children . there is controversy regarding use of the laparoscopic versus the conventional open approach might still remain depending on the team 's experience . this clinical report shows the feasibility and utility of laparoscopy for the management of pediatric intussusception . this approach appears to be safe and reasonable .
highlightsthe success of laparoscopic approach in children has encouraged the application of this technique in young ( < 2 years ) children with non - complicated intussusception.the use of mini - laparoscopy in children ( usually 2  mm instruments tools ) , described in processes such as acute appendicitis may be useful in the context of intussusception as well.laparoscopic reduction of intussusception appears to be a safe procedure , in young children with uncomplicated intussusception .