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A short midline laparotomy was performed. The entire bowel was run and sites of intussusception identified, as seen in the accompanying Video S1. The intussusceptions were reduced by gently milking the intussusceptum out of the distal segment (Fig. 2). The bowel was palpated along its length to locate sizeable intra-luminal polyps (Fig. 3). Variably sized polyps were present from the duodeno-jejunal flexure to the ilio-caecal (IC) junction. An enterotomy was created mid-way between the DJ flexure and the IC junction with a purse string suture around it (Fig. 4). A 10 mm laparoscopic trocar was introduced through this enterotomy while tightening the purse-string around it. Atraumatic bowel clamps were applied near the DJ flexure and distal to the port. Carbon dioxide was insufflated at a pressure of 2 mmHg in the small bowel segment at a flow rate of 4 l/min (Fig. 5). Two 5 mm working ports were introduced via small enterotomies on either side of the camera port (Fig. 6). The entire bowel length is scanned endoscopically from the site of port insertion up to the DJ flexure (Fig. 7). Advancement is facilitated by telescoping the bowel like a sleeve onto the rigid laparoscope (Fig. 8). Polyps, when encountered, were excised using ultrasonic shears (Fig. 9). The monopolar snares commonly used for endoscopic polypectomy carry the disadvantage of possible direct coupling, thereby risking damage to the adjacent bowel wall (Fig. 10). The usage of ultrasonic shears helps prevent this while also limiting lateral thermal spread [5]. Once the DJ flexure was reached, the bowel was unsleeved over the scope and the scope redirected towards the IC junction. The bowel clamps were now applied proximal to the ports and at the IC junction. The remainder of the procedure was repeated as earlier. The ports were then pulled and the disconnected polyps were milked towards the 10 mm enterotomy and retrieved through it (Fig. 11, Fig. 12). At the end of the procedure, enterotomies were closed with polydiaxonone sutures. The highest polyp yield within our small group was 41 from a single patient. This study is registered with a research registry. UIN - researchregistry6816. (See Table 1.)

Milking the intussusceptum out.

At laparotomy of a case of Peutz-Jeghers Syndrome with acute small bowel obstruction, polyps are confirmed to be the lead point of intussusception.

The 10 mm enterotomy for the camera port is created mid-way between the duodeno-jejunal flexure and the ileo-colic junction, secured with a purse string suture around it.

Carbon dioxide insufflation in the bowel loop, till the DJ flexure.

Final position of the three ports.

Intra-luminal view of the bowel as seen through the scope.

Sleeving the small bowel over the rigid laparoscope.

Division of polyp base using ultrasonic shears.

The use of monopolar energy in snares for polypectomy can produce inadvertent damage to adjacent healthy bowel wall as a result of direct coupling. This is particularly challenging in larger polyps.

Retrieval of polyps through the 10 mm camera-port enterotomy.

A photograph of retrieved polyps extracted from the enterotomy for the 10 mm camera-port.

Outcomes of enteroscopic polypectomy with rigid instruments at our institute.

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