Laparoscopic Management of Adhesive Small Bowel Obstruction

Abstract

Adhesions from prior surgery are the most common cause of small bowel obstruction (SBO) in the Western world. Although laparoscopic adhesiolysis can be performed safely and effectively, the indications and contraindications to the use of laparoscopic techniques in SBO are not clearly defined. The goal of our study was to determine the outcomes of the laparoscopic approach to SBO and discuss patient considerations for its utilization. We retrospectively surveyed all patients undergoing laparoscopic or attempted laparoscopic adhesiolysis performed by the authors between July 1997 and March 2006. Data obtained included patient demographics, clinical and radiologic presentation, and intraoperative and postoperative course. Thirty-three patients underwent laparoscopic adhesiolysis secondary to a SBO. Mean age was 53.6 years (range, 29–84 years) and 64 per cent (21 of 33) were female. Mean body mass index was 30.0 kg/m2 (range, 22.6–46.1 kg/m2). Thirty-one patients (93.9%) had undergone between one and four abdominal surgeries and seven (21.2%) had a previous episode of SBO. There were no patients with peritonitis. Abdominal CT scan was performed preoperatively in 27 patients (81.8%). Laparoscopy diagnosed the site of obstruction in all patients. Twenty-nine patients (88%) were successfully treated laparoscopically. Conversion to laparotomy was required in four cases as a result of dense adhesions and/or a lack of working space. Mean procedural time was 101 minutes (range, 19–198 minutes). There was one intraoperative complication (enterotomy), which was repaired laparoscopically and did not require conversion. Conversion was associated with significantly increased procedural time (129 versus 93 minutes; P = 0.02), but not blood loss or complications. Average times to passage of flatus and first bowel movement were 2.3 days (range, 0.5–5 days) and 3.2 days (range, 1–6 days), respectively. Seven patients (21.2%) had postoperative complications, including wound infection, urinary tract infection, and acute renal insufficiency, all of which occurred in patients completed laparoscopically. One patient had a recurrent SBO 8 months postoperatively managed by repeat laparoscopic lysis of adhesions. Mean postoperative stay was 6 days (range, 1–19 days). There was no hospital mortality. Laparoscopy is safe and feasible in the management of acute SBO in selected patients. It is an excellent diagnostic tool and is therapeutic in most cases.

Feasibility of laparoscopy for small bowel obstruction

“…In order to reduce the number of conversions some surgeons perform a hand-assisted laparoscopy in some selected cases [ 22 , 23 , 52 ]. The first cause of laparotomic conversion is a difficult exposition and treatment of band adhesions (Table 2 ) [ 15 , 16 , 18 - 22 , 24 - 27 , 29 , 38 , 39 , 41 , 42 ]; this is due to a reduced operating field caused by small bowel dilatation [ 24 , 46 ], multiple band adhesions [ 22 ], and occasionally by the presence of posterior peritoneal band adhesions [ 13 ], which are more difficult to treat laparoscopically.…”

“…The frequency of accidental enterotomies is variable (Table 2 ) [ 15 , 16 , 18 - 22 , 24 - 27 , 29 , 38 , 39 , 41 , 42 ], being more frequent in patients who have a history of previous multiple laparotomies [ 3 , 19 ]. Most of the accidental enterotomies occur while performing adhesiolysis.…”

“…Laparoscopy in small bowel obstruction has not a clear role yet; surely it is a diagnostic act and sometimes also a therapeutic act, which does not interfere with abdominal wall integrity [ 2 , 3 ].…”

Laparoscopy for Small Bowel Obstruction Caused by Single Adhesive Band

“…However, some patients fail to respond to CT and eventually undergo OT, resulting in increased morbidity and mortality rates for SBO, especially in the presence of bowel strangulation. 3 , 4 , 9 , 11 …”

Laparoscopic Management of Adhesive Small Bowel Obstruction

“…Due to objective reasons, laparoscopy has no widespread application at small bowel obstruction yet. If applicable, the diagnostic laparoscopy in smaller adhesions can be transformed in therapeutic one ( 2 ). The first laparoscopic adhesiolysis in small bowel obstruction was performed by Mouret in 1972.…”