Some surgeons regard major laparotomy as a contraindication to subsequent laparoscopic surgery. This appears to stem from anticipated loss of laparoscopic field or peritoneal domain and perceived lack of cosmetic benefit due to existing laparotomy scar. We report two cases that illustrate the feasibility of laparoscopic surgery following major laparotomy.
Review of recent experience where laparoscopic procedures had been undertaken following major laparotomy.
Case one: an ex-32-week neonate who developed advanced necrotising enterocolitis in the first two weeks of life. He required a laparotomy (supraumbilical transverse), bowel resection, ‘clip and drop’ and laparostomy formation followed by a second-look laparotomy 72 hours later with resection and anastomosis. At 42 weeks corrected gestational age he was diagnosed with pyloric stenosis and underwent laparoscopy via a 5 mm supraumbilical port. Extensive adhesions between the small bowel and laparotomy incision as well as to the liver were encountered. There was only room for a single 3 mm working instrument in the left flank. The pylorus was fixed in place permitting a ‘single instrument’ pyloromyotomy. An open approach would have necessitated full laparotomy, extensive adhesiolysis and endangered bowel and liver.
Case two: a 2 year-old boy who initially underwent a right Wilm’s tumour nephrectomy. At 72 hours post-operatively he developed intussusception, proven on ultrasound. After failed pneumatic reduction he underwent laparoscopic reduction of an ileo-ileo-colic intussusception. 5 mm ports were placed at the umbilicus and in the right upper and left lower quadrants. This minimally invasive approach obviated the need to re-open his laparotomy wound and enabled discharge within 48 hours.
Laparoscopic surgery following major laparotomy is feasible and should be considered in appropriate cases. This approach allows the other benefits of minimally invasive surgery such as reduced post-operative pain and shorter post-operative recovery to be realised.