Columbus, OH - May 2016
Children with Crohn’s disease who must undergo surgical treatment are likely to require other operations in their lifetimes, so limiting abdominal wall trauma and improving the appearance of scars can be important. Single incision laparoscopic surgery (SILS) helps achieve those goals, but the approach isn’t common in the pediatric population.
In a study of the largest series of SILS ileocecectomies in pediatric patients to date – all performed at Nationwide Children’s Hospital – clinician-researchers at Nationwide Children’s have found outcomes are similar to those for children who have open ileocecectomies.
While overall operative times were longer with SILS, they became comparable to open surgery durations as the primary surgeon gained experience with the procedure.
“Single incision is more difficult, without a doubt,” says Benedict Nwomeh, MD, senior author of the study and surgical director of the Center for Pediatric and Adolescent Inflammatory Bowel Disease at Nationwide Children’s. “But this is a discrete population, and I feel the technique has a significant cosmetic advantage for them. It is important from the patient satisfaction perspective.”
The study, published in Pediatric Surgery International, examined the records of 41 patients diagnosed with Crohn’s disease who underwent SILS at Nationwide Children’s, and 19 patients who underwent open surgery. Nearly all patients had ileocecectomy as a primary procedure. Demographics were similar among the cohorts, and stricture/obstruction was the most common indication for surgery in both groups.
There were no statistical differences in postoperative length of stay (median 6.5 days for SILS; 7.4 days for open) or in overall complication rates (24.4% for SILS; 26.3% for open). Conversion from SILS to open occurred once because of a foreshortened mesentery. Approximately one-quarter of the patients in both groups had secondary procedures, including stricturoplasty, fistula takedown, ureteral stent, adhesiolysis and Meckel’s diverticulectomy.
Ileocecectomy is a complex procedure no matter the technique, says Dr. Nwomeh, who is also a professor of Clinical Surgery at The Ohio State University College of Medicine. Single incision can be particularly complicated, because some of the instruments used are designed for standard laparoscopy and its multiple incisions.
“There is a learning curve with single incision,” Dr. Nwomeh explains. “If people are going to try it, I recommend that they have a high enough volume to achieve the learning curve as fast as possible. For surgeons who may do one of these only occasionally, it may be better to use techniques they are more familiar with – open or standard laparoscopy.”
Jennifer Dotson, MD, coauthor of the paper and member of the Division of Gastroenterology, Hepatology and Nutrition at Nationwide Children’s, said medical management remains the primary goal for patients even with the possibility of a minimally invasive procedure.
“From a pediatric gastroenterology perspective, we do our best to aggressively treat Crohn’s disease in an effort to avoid surgical resections for our patients,” says Dr. Dotson, who is also an assistant professor of Clinical Pediatrics at OSU’s College of Medicine. “However, sometimes a surgical approach is required. SILS appears to be an acceptable option in the hands of experienced surgeons.”
Huntington JT, Boomer LA, Pepper VK, Diefenbach KA, Dotson JL, Nwomeh BC. Single-incision laparoscopic surgery (SILS) for children with Crohn's disease. Pediatric Surgery International. 2016 May; 32(5):459-64.