Laparoscopic Management of Bowel Obstruction

Abstract

Although some progress in laboratory and imaging studies has been made, the management of intestinal obstruction is still a challenge for the surgeon. Depending on the etiology, intestinal obstruction may be treated conservatively or surgically. As adhesions from previous abdominal surgery are the leading cause of intestinal obstruction, 1 conservative treatment is always attempted first, but any signs or symptoms of bowel ischemia require immediate surgical intervention. In many ways, the wisdom of the adage "never let the sun set on a bowel obstruction" remains the safest guideline whenever any uncertainty exists. Prompt recognition of the need for operative intervention when indicated remains the key to successful management of bowel obstruction.During the past two decades, few major advances have been made in the management of bowel obstruction, and most surgeons continue to rely on clinical criteria as well as laboratory and radiographic findings to determine if and when to operate on these patients. The most common causes for most cases of small bowel obstruction (SBO) eventually requiring operative intervention are adhesions, followed by hernias and neoplasms.2 Combined, these etiologies account for 70% to 80% of all cases. When discussing large bowel obstruction (LBO), one must also consider volvulus of the sigmoid and colonic pseudoobstruction, Ogilvie's syndrome.3 At least 50% of surgical cases are directly related to postoperative adhesions. In these cases, initial nonoperative management is acceptable, with success rates ranging from 50% to 85%. Aggressive, early surgical intervention to avoid ischemic bowel must be balanced against the significant morbidity (30%) and even mortality of such an undertaking. Specifically, previous abdominal surgery and suspected intestinal adhesions along with dilated bowel were initially considered a contraindication to laparoscopy because of the risk of bowel injury and limited visualization. 4 However, both increased surgical experience and improved surgical instrumentation have facilitated a change in opinion to include bowel obstruction as a potential indication for laparoscopic surgery. 5Diagnostic laparoscopy can help avoid laparotomy and allow therapeutic laparoscopy in suitable cases. Laparoscopy in the setting of bowel obstruction does, however, pose certain hazards to the patient. The dilated bowel increases the risk of bowel injury at the entry site, especially at the first entry port. Manipulating friable, edematous bowel may cause bowel injury and perforation. Manipulation of gangrenous bowel without rapid vascular control may lead to endotoxic sepsis. These problems can be limited by using an open-first trocar insertion technique and by handling the bowel loops gently.Another concern related to the laparoscopic technique is the effect of pneumoperitoneum on mesenteric blood flow. Kleinhaus 6 studied the effect of CO 2 insufflation at different intraperitoneal pressures on mesenteric blood flow in dogs. Mesenteric blood flow was reduced to 70% of baseline ...