Diagnostic laparoscopy for neonatal perforated Meckel's diverticulum.

Pneumoperitoneum in a neonate is a serious condition for which bowel perforation is indicated in most cases. Because the transdiaphragmatic air dissection could occur in some ventilated neonates without peritonitis, making the right diagnosis is sometimes difficult, and exploratory laparotomy is often necessary. Here, we report the first case of neonatal pneumoperitoneum caused by a perforated Meckel's diverticulum in which diagnostic laparoscopy was useful in achieving minimal access surgery. Using a multiuse single-site port on the umbilicus could enable the extraction of a certain length of a small intestine with good cosmetic results. This method would decrease the hurdles of early surgical interventions for the suspected perforation of unknown aetiology and shorten the fasting period, which is beneficial for the neurodevelopment of small neonates.

INTRODUCTION

Pneumoperitoneum in a neonate is a serious condition that typically indicates bowel perforation including necrotizing enterocolitis, perforated appendicitis, or spontaneous intestinal perforation. Another cause of pneumoperitoneum is an air dissection from the respiratory tract in the ventilated neonate. On the other hand, some neonatal intestinal perforation does not show the typical features of peritonitis and perforated Meckel's diverticulum (MD) in neonates is sometimes the case which is difficult to diagnose.[1]

CASE REPORT

A male twin baby weighing 1970 g was born at 34 weeks and 2 days’ gestation by caesarean section. The child was transferred to our neonatal intensive care unit. He developed transient respiratory distress and needed mechanical ventilation for a few hours. On the 1st day of life, his vital signs were stable, and the abdomen was palpated soft without tenderness. An abdominal radiograph showed slight pneumoperitoneum [Figure 1]. There was no metabolic acidosis, and the C-reactive protein level was 0.05 mg/dL. On the 2nd day of life, his vital signs were still stable, but abdominal radiographs showed increased free peritoneal gas and ultrasonography showed an increase in ascites. An emergency diagnostic laparoscopy was then performed. Under general anaesthesia, the Alexis Wound Retractor XS® (Applied Medical, Rancho Santa Margarita, CA, USA) was inserted into the abdomen through an omega-shaped circumumbilical incision and a Free Access® (Top Corporation, Tokyo, Japan) was mounted on it. The camera port was inserted through the Free Access® and two 3-mm trocars were placed for working ports besides. After pneumoperitoneum establishment, turbid bilious ascites was detected and wide ranged investigation under laparoscopy showed no evidence of gastric, duodenal, or colonic perforation, which indicated perforation of a small intestine [Figure 2a]. Then, the Free Access® was dismounted, and the small intestine was exteriorised through the Alexis retractor. A perforated MD was detected, and intestinal fluid was leaking from the evaginated tip [Figure 2b] and the MD existing part of the intestine was resected. The remaining small intestine was normal. Two drainage tubes were placed through the trocars. His post-operative recovery was uneventful. Pathological examination of the diverticulum showed no evidence of acute inflammation and no heterotopic mucosa.

Figure 1

Radiograph taken on day 0 after intubation demonstrating slight pneumoperitoneum (arrows)

Figure 2

(a) Laparoscopy showed abdominal cavity covered with ingrained turbid bilious ascites with an excellent view. (b) Perforated tip of the Meckel's diverticulum exteriorised from the umbilical multiuse single-site port

DISCUSSION

Intestinal perforation is a rare condition of MD that reportedly occurs in <10% of symptomatic cases. Symptomatic MD is rare in neonates, accounting for <20% of all paediatric MD cases. In children, the most common presenting symptom is melena, followed by bowel obstruction, diverticulitis, and umbilical discharge. In contrast, the most common presenting symptom in neonates is bowel obstruction.[1] There is only one report of laparoscopic treatment for a neonate MD, which showed intestinal obstruction.[2]

In neonates, gastrointestinal perforation will not demonstrate an intraperitoneal air-fluid level in most cases.[3] Many patients with a perforated MD do not show any features of peritonitis.[4] We believe that the sticky meconium did not diffusely contaminate the abdominal cavity. The perforated tip of the MD is branched away from the main portion of the intestine, so not much of the volume of the meconium drained into the abdominal cavity.

Surgical options for a neonatal pneumoperitoneum range from peritoneal drainage to the major laparotomy with bowel resection or proximal jejunostomy. Most of these options used to require an extensive transverse abdominal incision to thoroughly investigate the whole abdominal cavity.[5] Therefore, a wait and see approach was usually taken, which extended the fasting period and was not beneficial to their future neurodevelopment. On the other hand, diagnostic laparoscopy could reveal ascites as well as bowel perforation with an intra-umbilical incision with inconspicuous scar. Furthermore, the site of bowel perforation could be predicted by the presence of a sentinel collection of pus. Thereupon, a multiuse single-site port on the umbilicus is useful for making the right diagnosis with a minimum incision, and this approach also provides a chance of treating the perforated intestine by exteriorizing the site from the umbilicus.

We believe that a neonate with suspected intestinal perforation of unknown aetiology, especially suspected intestinal perforation with little or no peritonitis symptoms, should be subjected to diagnostic laparoscopy to minimise the fasting period. Although the neonatal abdominal cavity is very narrow, the use of a multiuse single-site port on the umbilicus has good cosmetic results and enables extracorporeal bowel resection from the port site.