Intussusception is impossible to exclude with certainty by history, physical examination, laboratory studies or plain radiographic images either alone or in combination. In fact, if intussusception has been mentioned as a possibility and no other diagnosis can been confirmed, some feel very strongly that it absolutely must be ruled out using either ultrasound or contrast enema. If intussusception is confirmed, the next step is contrast enema, the type of which (air or liquid) should be determined by the radiologist, not the surgeon. Some radiologists insist that a surgeon be present “just in case” of a perforation, even though this is never an indication to perform surgery in the radiology suite or to take a child directly to the OR without first being resuscitated and properly prepared. Perhaps the most important role of the surgeon in these situations is to maintain a calm and commanding presence while patient and parents are being prepared for a trip first back to the ED or ward and then soon thereafter to the OR. Even after a perforation, ileostomy should almost never be necessary, as a primary anastomosis, except in the most extraordinary of circumstances, is almost always able to be done quickly and safely.
I routinely perform surgical reduction laparoscopically and feel that it is enormously preferable to laparotomy. Besides the usual benefits of smaller incisions, quicker recovery, and less conspicuous scarring, perhaps the thing I like most about the approach is that it nicely disproves yet another formerly sacrosanct surgical dictum (“never ever pull the bowel apart”). I still perform an appendectomy, possibly out of habit, but I believe there is little harm done and that it might prevent recurrence or appendiceal colic (due to scarring in the appendix) in the future. Performing a biopsy (or, worse, a resection) when one encounters an edematous or hemorrhagic “mass” in the wall of the cecum or ileum is a common “rookie mistake,” though it should not discourage one to look carefully for a potential lead point.
Children over the age of five with classic ileo-colic intussusception pose a challenge, as do children of any age who develop more than one recurrence. A diligent search for a lead point (US, CT, endoscopy) is reasonable, but I do not believe either is an absolute indication for laparotomy or bowel resection. Obviously, a great deal of clinical experience and good judgment is needed in such cases. On the other hand, small bowel intussusception is always pathologic and should prompt at least a diagnostic laparoscopy to rule out lymphoma, Meckel’s diverticulum, polyp, tumor, or vascular malformation (blue rubber bleb syndrome is an example). A short period of observation (12–24 h, if there are no signs of sepsis or peritonitis) is reasonable when a small bowel intussusception occurs in patients who have recently undergone a retroperitoneal dissection (Wilms tumor) or those with HSP, as it can occasionally resolve spontaneously in these patients.