Management of catastrophic neonatal midgut volvulus with a silo and second-look laparotomy

Planned Second look laparotomy in neonatal volvulus - A safe approach for bowel salvage

Midgut volvulus can result in gangrene and loss of large segments of intestine. After correction of volvulus the viability of intestine may improve and if given sufficient time a large portion of intestine may be saved. A planned second look laparotomy in babies with volvulus and doubtful gut viability can be helpful in saving large bowel segment. We present a case of a newborn baby admitted with bilious vomiting, abdominal distension and melena. An urgent exploratory laparotomy showed midgut volvulus with near gangrene of about 35 cm of proximal jejunum and bluish discoloration of the rest of the small bowel. After de-rotation and warm packs, the vascularity of ileum & distal jejunum returned to normal, however the proximal jejunum remained dusky and bruised. Ladd’s procedure was done and a decision was made to close the abdomen with a plan for a 2^nd look laparotomy after 24 hours. A relook laparotomy performed after 24 hours showed, a well vascularized small bowel. No bowel resection was required and abdomen was closed. The baby improved and was discharged in stable condition with no long-term ischemic complications. This case indicates that a second look laparotomy may provide time for revascularization of the intestine with doubtful vascularity and avoid unnecessary bowel resection.

Second-look laparoscopy after laparoscopic relief of strangulated small bowel obstruction

Laparoscopy is increasingly used for the treatment of complex small bowel obstructions (SBO). Conventional treatment of strangulated bowel is segmental resection. We have used second-look laparoscopy to preserve bowel in 4 cases of strangulated SBO. Of the 17 patients with bowel obstruction treated laparoscopically 4 had ischemic bowel. The obstructions were relieved and second-look laparoscopy was performed 24 hours later. In 3 cases the bowel had largely regained its normal appearance; 1 case required resection based on persistent ischemia. An average of 20 cm of bowel was preserved per patient, and there were no complications in these 4 patients. In sum, we have shown second-look laparoscopy for strangulated SBO to be feasible, safe, and, in most cases, bowel conserving.