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DOI:
10.4103/0189-6725.78671

Exploratory laparotomy for acute intestinal

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conditions in children: A review of 10 years

of experience with 334 cases
Rajendra K. Ghritlaharey, K. S. Budhwani, Dhirendra K. Shrivastava

ABSTRACT Key words: Exploratory laparotomy, ileostomy, ileal

perforations, intestinal obstruction, intussusception
Aim: The aim of this study was to review 10 years of
experience in the management of children with acute
intestinal conditions requiring exploratory laparotomy.
Patients and Methods: This retrospective study INTRODUCTION
included 334 children (244 boys and 90 girls) who
underwent laparotomy for acute intestinal conditions Acute abdomen can be defined as syndrome induced
between Jan 1, 2000 to Dec 31, 2009. Patients
by wide variety of pathological conditions that require
were grouped into two categories: group A (n = 44)
included patients who needed laparotomy with terminal emergent medical or more often surgical management.
ileostomy and group B (n = 290) included patients who Nothing can replace the clinical acumen of the physicians
needed laparotomy without terminal ileostomy. We in the management of acute abdomen in children.[1]
excluded neonates and patients with jejunoileal and Acute abdomen is caused due to gastrointestinal diseases
colonic atresias, anorectal malformations, congenital such as acute appendicitis, intestinal obstructions and
pouch colon, neonatal necrotising enterocolitis,
perforation peritonitis.[2] The causes of obstruction in
Hirschsprungs disease, appendicitis, abdominal
trauma and gastrointestinal tumours. Results: children are anorectal malformations, intussusception,
During the last 10 years, 334 laparotomies were Meckels diverticulum, abdominal Kochs, congenital
performed in children under 12 years: 59.88% for band obstructions, Hirschsprungs disease, ascariasis,
intestinal obstruction and 40.11% for perforation etc.[2-4] Intussusception remains a common cause of
peritonitis. Causes in order of frequency were: ileal bowel obstruction in young children and results in
perforations 34.13%; intussusceptions 26.34%;
significant morbidity and mortality, if not promptly
Meckels obstruction 10.17%; congenital bands and
malrotation 6.88%; postoperative adhesions 5.98%; treated.[2,3,5] Typhoid ileal perforation is still prevalent
miscellaneous peritonitis 5.68%; miscellaneous in many developing countries and associated with very
intestinal obstructions 4.79%; abdominal tuberculosis high morbidity and mortality in children.[6,7] We are
4.19% and roundworm intestinal obstruction 1.79%. reporting our experience of 334 cases of exploratory
Ileostomy closures (n = 39) was tolerated well by all laparotomies done for intestinal obstruction and
except one. The mortalities were 28 (8.38%) in group
perforation peritonitis in children in our department.
B and 6 (1.79%) in group A. Conclusions: The need
for re-exploration not only increases the morbidity but
also increases mortality as well. Diverting temporary PATIENTS AND METHODS
ileostomy adds little cumulative morbidity to the
primary operation and is a safe option for diversion This is a single institution retrospective study in
in selected cases. The best way to further reduce the children aged below 12 years, who underwent
mortality is to create ileostomy at first operation.
exploratory laparotomy for acute intestinal obstruction
and intestinal perforation peritonitis. It was conducted
in the department of paediatric surgery over a period
Department of Paediatric Surgery, Gandhi Medical College & of 10 years (Jan 2000 to Dec 2009). Patients were
Associated Kamla Nehru & Hamidia Hospitals Bhopal, Madhya
Pradesh - 462 001, India grouped into two categories: group A (n = 44) included
patients who needed exploratory laparotomy with
Address for correspondence:
Dr. Rajendra K Ghritlaharey, terminal ileostomy and group B (n = 290) included
Department of Paediatric Surgery, patients needing exploratory laparotomy without
Gandhi Medical College & Associated Kamla Nehru & Hamidia Hospitals,
Bhopal, Madhya Pradesh - 462 001, India terminal ileostomy. We excluded neonates, patients of
E-mail: drrajendrak1@rediffmail.com jejunoileal and colonic atresias and stenosis, anorectal

62 January-April 2011 / Vol 8 / Issue 1 African Journal of Paediatric Surgery

 Ghritlaharey, et al.: Exploratory laparotomy in children

malformations (ARM), congenital pouch colon, neonatal boys and 90 (26.94%) girls with a male to female ratio
necrotising enterocolitis (NEC), Hirschsprungs disease/ of 2.71:1. Ninety-eight (29.34%) patients were infants,
total colonic aganglionosis, appendicitis, abdominal/ 90 (26.94%) were aged 15 years and 146 (43.71%)
intestinal trauma and gastrointestinal tumours. were between 5 and 12 years of age. Other studies also
Diagnostic work up of patients included clinical history showed male predominance but reported more to occur
and examination supported with plain skiagram and in infants as well.[2,8,9] This difference is because of the
ultrasonography (USG) of the abdomen and pelvis. exclusion of ARM, atresias and NEC in our study.
Surgeons who participated in this study are well-
experienced consultant paediatric surgeons (professor, The most common surgical cause of acute abdomen
associate professor and assistant professor of paediatric in children is appendicitis. [2,10] We have excluded
surgery) with clinical experience of 27, 17, and 9 years, appendicitis from our study. Intussusception remains
respectively, in the field of paediatric surgery. a commonest cause of bowel obstruction in infants
and young children and has been reported by many
RESULTS authors.[2,3,5,10] Other causes of intestinal obstruction
in children are Meckels diverticulum, congenital
Three hundred and thirty-four exploratory laparotomies bands, adhesions, ascariasis, etc.[2,11,12] The commonest
were performed at the authors department of paediatric cause of intestinal obstruction in our study was also
surgery for ileal perforation peritonitis and intestinal intussusception 26.34% (n = 88), followed by Meckels
obstructions in children below 12 years of age in the obstruction/patent vitello-intestinal duct (PVID)10.17% (n
last 10 years from Jan 2000 to Dec 2009, and these = 34), congenital bands and malrotation of gut 6.88% (n
children were included in this study. They were 244 = 23), and post operative adhesions 5.98% (n = 20). Ileal
(73.05%) boys and 90 (26.94%) girls with a male to perforation peritonitis, mostly due to typhoid perforation
female ratio of 2.71:1. Ninety-eight (29.34%) exploratory in children, is the leading cause of peritonitis and still
laparotomies were performed in infants, 90 (26.94%) prevalent in many developing countries.[6,7,13] The causes
were operated in the age group of 15 years and 146 of perforation peritonitis in our study include isolated
(43.71%) were between 5 and 12 years of age. Two ileal perforation 34.13% (n = 114) and miscellaneous
hundred (59.88%) laparotomies were done for acute causes of perforation peritonitis (perforations of ileum
intestinal obstructions and 134 (40.11%) done for and jejunum, and colon) 5.68% (n = 19).
intestinal perforation peritonitis [Table 1]. Causes of
acute intestinal conditions that required surgery in the Nothing can replace the clinical acumen of the
order of frequency are shown in Table 2. Re-exploration physicians in the management of acute abdomen
was needed in 9.28% (n = 31) patients: 3 from group in children. Plain radiographs of abdomen in erect
A and 28 from group B for anastomotic leak, burst position are most useful when intestinal obstruction
abdomen, faecal fistula, etc. We observed 34 (10.17%) or perforation of viscus is the concern. In majority
deaths; of these, 28 (8.38%) were from group B and 6 of the cases of acute abdomen in children, USG
(1.79%) from group A. Nine of the 34 deaths were that of abdomen and pelvis can provide specific
of infants. Summary of patients who died from groups diagnosis.[1,10,14] In the modern era of technologies,
A and B are given in Tables 3 and 4, respectively. During computed tomography (CT) scan, magnetic resonance
the study period, 39 ileostomy closures were also done imaging (MRI), and other scanning and laparoscopy are
and were well tolerated by all except one patient who also advocated for the diagnosis of acute abdomen in
died of medical problem in post operative period. children. [10,14,15] In our study, diagnostic work up
of patients included detailed clinical history and
DISCUSSION examination, and supported with plain skiagram and
USG of the abdomen and pelvis.
This study was not an age-, sex-, or disease-matched
study. The objective was to review our 10 years of The surgical objectives at laparotomy for ileal
experience with exploratory laparotomies done in the perforation peritonitis are cleaning of contamination
department of paediatric surgery. We also try to analyse into the peritoneal cavity with either one of the
the importance of temporary terminal ileostomy during following: primary repair of the perforation, wedge
acute abdominal surgery in children and data of these resection and simple closure, segmental resection of
patients were analysed retrospectively. Exclusion diseased bowel and anastomosis, creation of stoma/
criteria are already mentioned in the Section Patients ileostomy, etc. depending upon the condition of
and Methods. This study comprised 244 (73.05%) the involved bowel segment and patient himself /

African Journal of Paediatric Surgery January-April 2011 / Vol 8 / Issue 1 63

 Ghritlaharey, et al.: Exploratory laparotomy in children

Table 1: Demographics of exploratory laparotomy (n = 334) done and deaths (n = 34) for acute intestinal conditions in
children (Jan 01, 2000 to Dec 31, 2009)
Year 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Total (%) Deaths (%)
(A + B)
Age group Infants 13 09 07 10 06 13 13 12 08 07 98 (29.34) 09 (2.69)
(1 + 8)
15 years 08 11 10 02 12 06 14 10 09 08 90 (26.94) 11 (3.29)
(2 + 9)
512 years 11 18 19 13 11 16 15 12 15 16 146 (43.71) 14 (4.19)
(3 + 11)
Sex Boys 21 27 27 19 24 27 29 25 22 23 244 (73.05) 24 (7.18)
(5 + 19)
Girls 11 11 09 06 05 08 13 09 10 08 090 (26.94) 10 (2.99)
(1 + 9)
Diagnosis (exp Intestinal 21 21 22 16 19 23 27 21 18 12 200 (59.88) 15 (4.49)
lap done for) obstruction (2 + 13)
Perforation 11 17 14 09 10 12 15 13 14 19 134 (40.11) 19 (5.68)
peritonitis (4 + 15)
Exp lap done Group A 01 01 04 03 02 03 08 07 10 05 44 (13.17) 06 (1.79)
Re-expl 00 00 00 01 01 00 00 00 00 01 03 00
Group B 31 37 32 22 27 32 34 27 22 26 290 (86.82) 28 (8.38)
Re-expl 01 02 03 01 04 05 06 00 01 05 28 09
Total 32 38 36 25 29 35 42 34 32 31 334 34 (10.17)
(6 + 28)
Ileostomy 01 03 01 03 01 03 03 08 12 04 39 01 (2.56)
closure done
Mortality Group A 00 00 01 00 01 00 01 01 01 01 06 (1.79)
(n = 34) Group B 01 04 01 02 05 04 06 02 02 01 28 (8.38)
Infants (A + B) 0 + 0 0+0 0+0 0+1 0+2 0+2 0+1 1+2 0+0 0+0 (1 + 8) 09 (2.69)
Exp lap, exploratory laparotomy; re-expl, re-exploration

(n = 80) were males and 29.82% (n = 34) were females.

Table 2: Causes of acute intestinal conditions in children Seventy-two patients (63.15%) were of 512 years,
(n = 334) and deaths (n = 34) (Jan 01, 2000 to Dec 31, 2009) 27 (23.68%) were of 15 years and only 15 (13.15%)
Causes (in order of Number of cases Deaths (% of patients were infants. More than three fourths (n = 88)
frequency) (%) total exp lap) of the patients had single perforation in ileum and about
(exp lap done) (A + B) one fourth (n = 26) had more than one perforation. The
Ileal perforation peritonitis 114 (34.13) 14 (4.19) surgical treatments done were simple primary closure
(4 + 10)
Intussusceptions 88 (26.34) 13 (3.89)
of perforation after freshening of the margins (n = 62;
(2 + 11) 54.38%), segmental resection and anastomosis (n = 20;
Meckels, PVID obstruction, etc. 34 (10.17) 03 (0.89) 17.54%), ileostomy (n = 19; 16.66%), wedge resection
(0 + 3) and simple closure (n = 8; 7.01%), abdominal drainage
Congenital bands, mal-rotations, 23 (6.88) and other procedures (n = 5; 4.38%).
etc.
Post operative obstructions 20 (5.98)
Miscellaneous peritonitis 19 (5.68) 01 (0.29) Intussusception remains the most common cause of
(0 + 1) bowel obstruction in infants and young children and
Miscellaneous obstructions 16 (4.79) results in significant morbidity and mortality. Treatment
Abdominal TB obstruction 14 (4.19) 02 (0.59) options for the intussusception are hydrostatic/barium
(0 + 2)
enema reduction, exploratory laparotomy (manual
Worm obstruction (ascariasis) 06 (1.79) 01 (0.29)
reduction, segmental bowel resection for gangrene and
(0 + 1)
anastomosis, hemicolectomy, creation of stoma, etc.)
Total 334 (100) 34 (10.17)
(6 + 28)
and laparoscopic procedures.[2,3,5,17-19] Intussusception
Exp lap = exploratory laparotomy comprised about one fourth (26.34%; n = 88) cases of
our study group with 68 (77.27%) boys and 20 (22.72%)
girls. Three fourths (76.13%; n = 67) of the patients
herself.[6,7,13,16] We have operated upon 114 (34.13%) were infants, n = 13 (14.77%) were aged 15 years
cases of ileal perforation peritonitis in children: 70.17% and only n = 8 (9.09%) patients were of 512 years

64 January-April 2011 / Vol 8 / Issue 1 African Journal of Paediatric Surgery

 Ghritlaharey, et al.: Exploratory laparotomy in children

Table 3: Summary of patients (n = 6) who died from group A (Jan 01, 2000 to Dec 31, 2009)
Name Age Sex GC Diagnosis Operative Operation done Complications Re-expl Hospital stay Year
findings (days)
A 3 years M Fair Intestinal Intussusception Resection of Septicaemia 18 March 2002
obstruction with gangrene gangrenous ileum
with ileostomy
Sh 5 years M Fair Perforation Multiple ileal Ileal perforations Septicaemia 12 April 2004
peritonitis perforations repair with
ileostomy
S 12 years M Poor Perforation Multiple ileal Ileal perforations Leak, peritonitis, 16 July 2006
peritonitis perforations repair with burst abdomen,
ileostomy septicaemia
Ru 8 months M Fair Intestinal Intussusception Resection of Septicaemia, DIC 08 January 2007
obstruction with gangrene gangrenous ileum
with ileostomy
Ar 10 years F Poor Perforation Multiple ileal Ileal perforations Septicaemia 02 May 2008
peritonitis perforations repair with
ileostomy
Vi 8 years M Poor Perforation Multiple ileal Ileal perforations Leak, peritonitis, 32 March 2009
peritonitis perforations repair with burst abdomen,
ileostomy septicaemia, DIC
GC - General condition on admission; leak - anastomotic leak - re-expl, re-exploration, DIC - disseminated intravascular coagulation

Table 4: Summary of patients (n=28) who died from group B (Jan 01, 2000 to Dec 31, 2009)
Name Age Sex GC Diagnosis Operative findings Operation done Complications Re-expl Hospital Year
stay (days)
J 11 years F Poor Perforation (Abd TB) ileal Repair of ileal Cardiac and 1 May 2000
peritonitis strictures and perforations and respiratory failure
perforations stricturoplasty
Ve 10 years M Fair Perforation Ileal perforation Repair of ileal Pelvic abscess Re-expl + 37 May 2001
peritonitis perforation drainage
B 10 years M Poor Perforation Ileal perforation Repair of ileal Septicaemia 4 June 2001
peritonitis perforation
Vi 4 years F Poor Perforation Multiple jejuno-ileal R/A of jejunum Leak 07 Sept 2001
peritonitis perforations and ileum
Su 6 years M Fair Intestinal Meckels obstruction Meckels Leak R/A of 18 Oct 2001
obstruction diverticulectomy ileum
Mo 2.6 M Poor Intestinal Intussusception R/A of ileum Septicaemia 9 Aug 2002
years obstruction with gangrene
Sa 10 years F Fair Perforation Ileal perforation Repair of ileal Faecal fistula, 50 Aug 2003
peritonitis perforation septicaemia
So 5 F Poor Perforation Intussusception R/A of ileum Respiratory failure 1 Aug 2003
months peritonitis with gangrene
La 10 years M Poor Perforation Ileal perforation Repair of ileal Septicaemia 6 April 2004
peritonitis perforation
Ma 6 years M Poor Perforation Ileal perforation Repair of ileal Septicaemia 16 July 2004
peritonitis perforation
Sau 11 M Poor Intestinal Intussusception Reduction of Septicaemia 11 Aug 2004
months obstruction intussusception and
repair of tear
Di 1.3 M Poor Perforation Intussusception R/A of ileum Leak, faecal fistula R/A of 35 Sept 2004
years peritonitis with gangrene ileum
H 3 M Fair Intestinal Prolapsed ileum Resection of part of Leak, peritonitis, Ileostomy 24 Oct 2004
months obstruction with gangrene ileum + PVID and septicaemia done
through PVID anastomosis
R 4.6 M Poor Intestinal Intussusception Resection of Leak, peritonitis, Ileostomy 7 Mar 2005
years obstruction with gangrene gangrenous ileum septicaemia done
and anastomosis
P 2 F Fair Intestinal Intussusception Resection of Leak, peritonitis Ileostomy 20 May 2005
months obstruction with gangrene gangrenous ileum done
and anastomosis

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 Ghritlaharey, et al.: Exploratory laparotomy in children

Table 4: Contd...
Ba 5 M Poor Intestinal Intussusception with Resection Meckels Leak, peritonitis Repair of 20 Sept 2005
months obstruction gangrene gangrenous ileum + leak
congenital band and
anastomosis
K 2 years M Poor Intestinal Intussusception with Resection of Septicaemia 7 Oct 2005
obstruction gangrene gangrenous ileum
and anastomosis
Pri 12 years F Poor Perforation Ileal perforation Repair of ileal Leak, respiratory 17 Feb 2006
peritonitis + TB perforation failure
of lungs
Vai 2 years F Poor Intestinal Round worms with Resection of Leak, septicaemia 27 March 2006
obstruction gangrene gangrenous ileum
and anastomosis
A 10 years M Poor Perforation Ileal perforation Repair of ileal Septicemia 1 April 2006
peritonitis perforation
D 1.6 M Poor Intestinal Intussusception, Resection Meckels Septicaemia 17 May 2006
years obstruction Meckels with + gangrenous ileum
gangrene and anastomosis
Sa 4 years M Fair Perforation Intussusception Resection of Leak, peritonitis Ileostomy 15 Sept 2006
peritonitis with gangrene with gangrenous ileum done
perforation and anastomosis
H 2 M Poor Perforation Ileal perforation Repair of ileal Septicaemia 4 Nov 2006
months peritonitis perforation
Tu 2 M Poor Intestinal Meckels obstruction Resection Meckels Leak, septicaemia 7 March 2007
months obstruction with part of ileum
and anastomosis
S 11 F Poor Intestinal Intussusception with Resection of Septicaemia, cardiac 2 Nov 2007
months obstruction gangrene gangrenous ileum failure
and anastomosis
M 4 years F Poor Perforation Dense adhesion, Adhesiolysis, lavage Septicaemia 3 Feb 2008
peritonitis pyo-peritoneum and drainage
R 6 years M Poor Intestinal Abdominal Adhesiolysis and Septicaemia 7 Aug 2008
obstruction tuberculosis biopsy
Ma 8 years M Poor Perforation Ileal perforation Repair of ileal Leak, faecal fistula, Ileostomy 8 June 2009
peritonitis perforation DIC done
GC - general condition on admission; Abd TB - abdominal tuberculosis; leak - anastomotic leak; re-expl, re-exploration; R/A - resection and anastomosis; DIC - disseminated
intravascular coagulation

of age. Fifty-four (61.36%) patients presented with intestinal obstruction, perforation peritonitis and
intestinal obstruction and 34 (38.63%) had features intestinal bleeding. Treatment options for the same
of gangrenous bowel. This study included only those are resection of the diverticulum/diverticulectomy,
patients who needed exploration for the management wedge resection and anastomosis, segmental resection
of intussusception. Operative manual reduction of with Meckels and anastomosis, etc. and can be done
intussusception was possible in n = 30 (34.09%) by open surgery or laparoscopically.[11,20,21] Thirty-
patients (14 had serosal tears/minor bowel tears which four children (29 boys and 5 girls) were treated at the
needed repair only) and 65.90% (n = 58) required authors department for Meckels diverticulum and
bowel resection. Resection of gangrenous ileum and PVID. Majority (n = 28) presented with intestinal
ileo-ileal anastomosis were done in n = 24 patients, obstruction, three had bleeding (diverticulitis) and
segmental resection of gangrenous bowel (ileum and diagnosed on Technetium scan and three were
colon) with ileo-colic (ascending colon) anastomosis incidental findings at laparotomy for others. The
in n = 13 patients, ileo-transverse anastomosis/ findings were Meckels diverticulum with bands (n
hemicolectomy in n = 8 patients and resection of = 9), PVID in n = 9 (n = 3 presented with prolapsed
diseased gangrenous segment with terminal ileostomy intestine), and Meckels diverticulum with gangrene
was done in n = 13 (14.77%) patients. We found that was observed in 16 patients. Twenty patients needed
only six patients had Meckels diverticulum as the lead segmental resection of ileum with Meckels and
point for intussusception. anastomosis, 13 needed diverticulectomy/wedge
resection and 1 patient needed ileostomy after
Meckels diverticulum may present as diverticulitis, resection of gangrenous intestine.

66 January-April 2011 / Vol 8 / Issue 1 African Journal of Paediatric Surgery

 Ghritlaharey, et al.: Exploratory laparotomy in children

Early diagnostic laparoscopy and treatment can be peritonitis (n = 19; 36.53%), intussusception (n = 13;
safely performed in children for acute abdomen. This 25%), anastomotic leaks/faecal fistula (n = 8; 15.38%),
technique not only results in the accurate, prompt and post-operative intestinal obstruction (n = 6; 11.53%),
efficient management of acute abdomen with minimum intestinal tuberculosis (n=3; 5.76%), Meckels with
number of complications but also at the same time bowel gangrene (n = 1; 1.92%), ascariasis with bowel
reduces the rate of unnecessary laparotomy.[19-22] At gangrene (n = 1; 1.92%), and n = 1 (1.92%) for other
present we are not doing any laparoscopic procedure obstruction.
in our department as we do not have the facilities of
doing laparoscopy for these cases. Complications are known to occur with exploratory
laparotomy done in children for perforation peritonitis
Abdominal tuberculosis is treated conservatively with and intestinal obstructions and major complications
anti-tuberculous drugs alone but patients with acute are anastomotic leak, faecal fistula, burst abdomen,
intestinal obstructions and perforation peritonitis septicaemia, post operative intestinal obstructions
may need laparotomy for diagnosis and relief of bowel and multiple organ failure.[6-8,13,25] In our study, we only
obstruction and perforation.[2,23] We included 14 (4.19%) registered the major complications (anastomotic leaks,
(10 boys and 4 girls) cases of abdominal tuberculosis in faecal fistula, burst abdomen and peritoneal abscess)
our study with 7 each presenting as peritonitis and acute and other minor complications were excluded. We
intestinal obstruction. The operative procedures done observed major complications in about 12% (n = 41)
were adhesiolysis and biopsy only (n = 4), adhesiolysis patients and are anastomotic leaks (n = 20), faecal
and stricturoplasty (n = 3), resection of ileum and fistula (n = 7), post operative intestinal obstructions
anastomosis (n = 2), ileo-transverse anastomosis/ (n = 7), burst abdomen (n = 5), peritoneal collections/
bypassing the stricture (n = 2) and n = 3 patients peritoneal abscesses (n = 2).
needed ileostomy. Ascariasis is the infestation by the
largest intestinal (mostly small intestine) nematode of Re-exploration was done in 9.28% (n = 31) patients:
man, a problem in the tropics attributed to poor hygienic 28 (8.38%) from group B and 3 (0.89%) from group A.
and low socioeconomic conditions. Most cases of Surgical procedures done (n = 31) during re-exploration
intestinal obstruction due to Ascaris lumbricoides (round were the following. Thirteen were treated with re-
worms) can be managed conservatively. However, repair/re-anastomosis of anastomotic leaks, 8 needed
emergency surgery (enterotomy, milking of the worm ileostomy, 5 were treated with adhesiolysis and 4 cases
to colon and segmental resection and anastomosis) of burst abdomen were also repaired and 1 peritoneal
is needed in patients with features of gangrene and and pelvis abscess was drained during re-exploration.
perforation.[4,12] We had six cases of ascariasis, three
presented with intestinal obstruction and the other Creation of ileostomy is also prone for the complications
three with peritonitis. Patients of ascariasis treated and most common of these are peristomal skin
conservatively in our department were not included excoriation, redness, bleeding, infections, stoma
in this study. Three patients needed resection of ileum prolapse, retraction, strictures, intestinal obstruction,
for gangrene (n = 2 primary anastomosis and n = 1 fluid and electrolyte imbalances, etc. In this study, three
ileostomy), two needed enterotomy for removal of cases with ileostomy developed major complications
bunch of worms and another one needed milking of in the form of stoma prolapse, para-stomal hernia and
the worms to the colon distally. prolonged frequent loose stool that necessitated early
closure. Peristomal skin excoriation was treated with
Some children required temporary ileostomy in the proper stoma care and local hygiene. Ileostomy closure
course of management for typhoid ileal perforation/ can be achieved using one of the three techniques:
intestinal perforations, intestinal obstructions, etc. for enterotomy suture, resection with either hand sewn
various reasons.[16,24,25] In this study of 334 cases, 52 or stapled anastomosis. [26-28] Laparoscopic assisted
required temporary terminal ileostomy; 44 (13.17%) stoma closure in children has also been reported in
required during first operation (group A) and 8 (2.39%) literature.[29] We preferred to close the ileostomy (n =
cases required ileostomy during second surgery/re- 39) at about 10 weeks or after that, following primary
exploration for anastomotic leak and faecal fistula operation. No special investigations were needed except
(group B). There were 43 male and 9 female children in a few cases wherein distal ileostograms were done.
and this included 16 (30.76%) infants, 13 (25%) between We used manual double layer closure of ileostomy;
1 and 5 years of age and 23 (44.23%) were of 512 inner full thickness with vicryl (interrupted or
years. Indications for ileostomy were ileal perforation continuous) and outer seromuscular with silk or vicryl

African Journal of Paediatric Surgery January-April 2011 / Vol 8 / Issue 1 67

 Ghritlaharey, et al.: Exploratory laparotomy in children

depending upon the surgeons choice. We observed the mortality is to create terminal ileostomy at the first
minor anastomotic leak in two, wound infection in four, operation. Surgical options must be individualised and
postoperative intestinal obstruction in one patient and the patients must be treated on case to case basis. Poor
all were treated conservatively. general condition, delayed presentation, anastomotic
leaks, septicaemia, etc. were also responsible for more
Mortality is reported with exploratory laparotomy morbidity and mortality.
done for ileal perforation peritonitis and intestinal
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intestinal obstruction. Indian Pediatr 2009;46:1102-3.
< 0.01). Re-exploration also increases the number of
10. Zhou H, Chen YC, Zhang JZ. Abdominal pain among children
deaths significantly. We observed 9 (29.03%) deaths re-evaluation of a diagnostic algorithm. World J Gastroenterol
of 31 re-exploration (P < 0.05) cases. Infants account 2002;8:947-51.
for about 30% (n = 98) of total operation in this study 11. Menezes M, Tareen F, Saeed A, Khan N, Puri P. Symptomatic
and we noticed nine deaths. Eight of the nine infantile Meckels diverticulum in children: A 16-year review. Pediatr Surg
Int 2008;24:575-7.
deaths were from group B and three infants required 12. Baba AA, Ahmad SM, Sheikh KA. Intestinal ascariasis: The
re-exploration for anastomotic leaks. There was also one commonest cause of bowel obstruction in children at a tertiary care
(2.56%) death among 39 ileostomy closures. She earlier center in Kashmir. Pediatr Surg Int 2009;25:1099-102.
had exploratory laparotomy with ileostomy for worm 13. Nuhu A, Dahwa S, Hamza A. Operative management of typhoid
ileal perforation in children. Afr J Paediatr Surg 2010;7:9-13.
intestinal obstruction, followed by ileostomy closure. 14. Tseng YC, Lee MS, Chang YJ, Wu HP. Acute abdomen in pediatric
Although she had minor anastomotic leak after stoma patients admitted to the pediatric emergency department. Pediatr
closure, she died suddenly of convulsions at seventh Neonatol 2008;49:126-34.
post operative day. 15. Joshi AV, Sanghvi BV, Shah HS, Parelkar SV. Laparoscopy in
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Surg Tech A 2008;18:763-5.
CONCLUSIONS 16. Onen A, Dokucu AI, Cidem MK, Oztrk H, Otu S, Ycesan
S. Factors effecting morbidity in typhoid intestinal perforation in
Diverting temporary ileostomy adds little cumulative children. Pediatr Surg Int 2002;18:696-700.
17. Blanch AJ, Perel SB, Acworth JP. Paediatric intussusception:
morbidity to the primary operation and is a safe option Epidemiology and outcome. Emerg Med Australas 2007;19:45-50.
for diversion in selected cases in patients with severe 18. Kaiser AD, Applegate KE, Ladd AP. Current success in the treatment
abdominal contamination and whenever a bowel of intussusception in children. Surgery 2007;142:469-77.
condition is in doubt or is unhealthy. The need of re- 19. Bailey KA, Wales PW, Gerstle JT. Laparoscopic versus open
reduction of intussusception in children: A single-institution
exploration significantly increases the mortality. So, comparative experience. J Pediatr Surg 2007;42:845-8.
best possible and safest surgical procedure must be 20. Stepanov EA, Smirnov AN, Dronov AF, Poddubny IV, Chundokova
exercised at first laparotomy. Best way to further reduce MA, Al-Mashat NA, et al. Laparoscopic surgery in children--current

68 January-April 2011 / Vol 8 / Issue 1 African Journal of Paediatric Surgery

 Ghritlaharey, et al.: Exploratory laparotomy in children

possibilities and perspectives. Khirurgiia (Mosk) 2003;7:22-8. Colon Rectum 2006;49:1539-45.

21. Sai Prasad TR, Chui CH, Singaporewalla FR, Ong CP, Low Y, Yap TL, 27. Phang PT, Hain JM, Perez-Ramirez JJ, Madoff RD, Gemlo BT.
et al. Meckels diverticular complications in children: Is laparoscopy Techniques and complications of ileostomy takedown. Am J Surg
the order of the day? Pediatr Surg Int 2007;23:141-7. 1999;177:463-6.
22. Bonnard A, Demarche M, Dimitriu C, Podevin G, Varlet F, 28. Leung TT, MacLean AR, Buie WD, Dixon E. Comparison of stapled
Franois M, et al. Indications for laparoscopy in the management versus handsewn loop ileostomy closure: A meta- analysis. J
of intussusception: A multicenter retrospective study conducted by Gastrointest Surg 2008;12:939-44.
the French Study Group for Pediatric Laparoscopy. J Pediatr Surg 29. Miyano G, Okawada M, Yanai T, Okazaki T, Lane GJ, Yamataka A.
2008;43:1249-53. Outcome of stoma closure in children: A comparison of laparoscopy-
23. Talwar BS, Talwar R, Chowdhary B, Prasad P. Abdominal assisted and conventional open techniques. J Laparoendosc Adv
tuberculosis in children: An Indian experience. J Trop Pediatr Surg Tech A 2009;19:559-61.
2000;46:368-70.
24. Pandey A, Kumar V, Gangopadhyay AN, Upadhyaya VD, Srivastava
A, Singh RB. A pilot study on the role of T-tube in typhoid ileal
perforation in children. World J Surg 2008;32:2607-11.
Cite this article as: Ghritlaharey RK, Budhwani KS, Shrivastava DK.
25. Abdur-Rahman LO, Adeniran JO, Taiwo JO, Nasir AA, Odi T. Bowel
Exploratory laparotomy for acute intestinal conditions in children: A review
resection in Nigerian children. Afr J Paediatr Surg 2009;6:85-7.
of 10 years of experience with 334 cases. Afr J Paediatr Surg 2011;8:62-9.
26. Perez RO, Habr-Gama A, Seid VE, Proscurshim I, Sousa AH Jr, Kiss
Source of Support: Nil, Conflict of Interest: None declared.
DR, et al. Loop ileostomy morbidity: Timing of closure matters. Dis

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