Laparoscopic lysis of adhesions

Efficient and safe small-bowel adhesiolysis

Small-intestine adhesiolysis can be very time consuming and may be associated with bowel wall damage. The risk for injuries to the small or large bowel resulting in increased morbidity and costs is considerable. Both efficient and gentle dissection of adhesions is important in order to avoid intraoperative perforation or, worse, postoperative intestinal leaks. We present a technique using drops of body-warm isotonic saline solution to create an edematous swelling of the adhesions. This procedure not only protects the bowel from cooling and drying, but also simplifies the dissection and, thus, lowers the risk of intestinal lesions.

Should adhesive small bowel obstruction be managed laparoscopically? A National Surgical Quality Improvement Program propensity score analysis

BACKGROUND

Celiotomy is the most common approach for refractory small bowel obstruction (SBO). Small reviews suggest that a laparoscopic approach is associated with shorter stay and less morbidity. Given the limitations of previous studies, we sought to evaluate outcomes of laparoscopic (L) compared with open (O) adhesiolysis for SBO, using the National Surgical Quality Improvement Program data set.

METHODS

Patients from the American College of Surgeons' National Surgical Quality Improvement Program 2005 to 2009 database who underwent surgery for SBO were stratified based on surgical approach. A propensity score to undergo L instead of O was calculated based on demographics, comorbidities, physiology, and laboratory values. Logistic regression was then used to determine differences in outcomes between those propensity score-matched patients who actually underwent L compared with O surgery.

RESULTS

There were 6,762 patients who underwent adhesiolysis. The propensity score-matching process created 222 matched patients in L and O groups. Laparoscopy was associated with significantly lower rates of any complication (odds ratio [OR] 0.41; 95% confidence interval [CI], 0.28-0.60), including superficial site infections (OR, 0.15; 95% CI, 0.05-0.49), intraoperative transfusion (OR, 0.22; 95% CI, 0.05-0.90), and shorter hospital stay (4 days vs. 10 days; p < 0.001). There was no significant difference in operative time, rates of reoperation within 30 days, or mortality.

CONCLUSION

Laparoscopic treatment of SBO is associated with lower rates of postoperative morbidity compared with laparotomy as well as shorter hospital stay. Laparoscopic treatment of surgical SBO is not associated with higher rates of early reoperation and seems to be associated with lower resource use.

LEVEL OF EVIDENCE

Therapeutic study, level IV.

Internal hernia caused by epiploic appendices successfully treated by single-incision laparoscopic surgery (SILS)

Internal hernia is a rare and often overlooked cause of small bowel obstruction. We report a case of internal hernia with an orifice composed of epiploic fat, successfully diagnosed and treated by single-incision laparoscopic surgery. This is the second report of this type of internal hernia and the first reported case addressed laparoscopically. Although the use of laparoscopy for the treatment of small bowel obstruction is not firmly established today, it may be beneficial for both its diagnostic value and as a less invasive treatment.

Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2013 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group

Background

In 2013 Guidelines on diagnosis and management of ASBO have been revised and updated by the WSES Working Group on ASBO to develop current evidence-based algorithms and focus indications and safety of conservative treatment, timing of surgery and indications for laparoscopy.

Recommendations

In absence of signs of strangulation and history of persistent vomiting or combined CT-scan signs (free fluid, mesenteric edema, small-bowel feces sign, devascularization) patients with partial ASBO can be managed safely with NOM and tube decompression should be attempted. These patients are good candidates for Water-Soluble-Contrast-Medium (WSCM) with both diagnostic and therapeutic purposes. The radiologic appearance of WSCM in the colon within 24 hours from administration predicts resolution. WSCM maybe administered either orally or via NGT both immediately at admission or after failed conservative treatment for 48 hours. The use of WSCM is safe and reduces need for surgery, time to resolution and hospital stay.

NOM, in absence of signs of strangulation or peritonitis, can be prolonged up to 72 hours. After 72 hours of NOM without resolution, surgery is recommended.

Patients treated non-operatively have shorter hospital stay, but higher recurrence rate and shorter time to re-admission, although the risk of new surgically treated episodes of ASBO is unchanged. Risk factors for recurrences are age <40 years and matted adhesions. WSCM does not decrease recurrence rates or recurrences needing surgery.

Open surgery is often used for strangulating ASBO as well as after failed conservative management. In selected patients and with appropriate skills, laparoscopic approach is advisable using open access technique. Access in left upper quadrant or left flank is the safest and only completely obstructing adhesions should be identified and lysed with cold scissors. Laparoscopic adhesiolysis should be attempted preferably if first episode of SBO and/or anticipated single band. A low threshold for open conversion should be maintained.

Peritoneal adhesions should be prevented. Hyaluronic acid-carboxycellulose membrane and icodextrin decrease incidence of adhesions. Icodextrin may reduce the risk of re-obstruction. HA cannot reduce need of surgery.

Adhesions quantification and scoring maybe useful for achieving standardized assessment of adhesions severity and for further research in diagnosis and treatment of ASBO.

Single-port laparoscopic management of adhesive small bowel obstruction

Laparoscopic adhesiolysis has been the focus of much recent attention; however, the role of single-port laparoscopic surgery for adhesive small bowel obstruction remains unclear. We report our experience of performing single-port laparoscopic surgery for adhesive small bowel obstruction through a retrospective review of 15 consecutive patients who underwent single-port laparoscopic surgery for single adhesive small bowel obstruction between 2010 and 2012. We analyzed data on patient demographics, operating time, conversion, and surgical morbidity. Surgery was completed successfully without conversion to laparotomy or the need for additional intraoperative ports in 14 patients, but the remaining patient had peritoneal dissemination from colon cancer. The median operative time was 49 (25-148) min, and the estimated blood loss was 19 (2-182) ml. There were no major postoperative complications. We conclude that single-port laparoscopic surgery is a technically feasible approach for selected patients with adhesive small bowel obstruction when preoperative imaging identifies a single adhesive obstruction.

Laparotomy for small-bowel obstruction: first choice or last resort for adhesiolysis? A laparoscopic approach for small-bowel obstruction reduces 30-day complications

INTRODUCTION

Small-bowel obstruction (SBO) requiring adhesiolysis is a frequent and costly problem in the United States with limited evidence regarding the most effective and safest surgical management. This study examines whether patients treated with laparoscopy for SBO have better 30-day surgical outcomes than their counterparts undergoing open procedures.

METHODS

Patients with a diagnosis of adhesive SBO were selected from the ACS National Surgical Quality Improvement Program database from 2005 to 2010. Cases were classified as either laparoscopic or open adhesiolysis groups using Common Procedural Terminology codes. Chi square and Student's t test were used to compare patient and surgical characteristics with 30-day outcomes, including major complications, incisional complications, and mortality. Factors with p < 0.1 were included in the multivariable logistic regression for each outcome. A propensity score analysis for probability of being a laparoscopic case was used to address residual selection bias. A two-sided p value <0.05 was considered significant.

RESULTS

Of the 9,619 SBO included in the analysis, 14.9 % adhesiolysis procedures were performed laparoscopically. Patients undergoing laparoscopic procedures had shorter mean operative times (77.2 vs. 94.2 min, p < 0.0001) and decreased postoperative length of stay (4.7 vs. 9.9 days, p < 0.0001). After controlling for comorbidities and surgical factors, patients having laparoscopic adhesiolysis were less likely to develop major complications [odds ratio (OR) = 0.7, 95 % confidence interval (CI) 0.58-0.85, p < 0.0001] and incisional complications (OR = 0.22, 95 % CI 0.15-0.33, p < 0.0001). The 30-day mortality was 1.3 % in the laparoscopic group versus 4.7 % in the open group (OR = 0.55, 95 % CI 0.33-0.85, p = 0.024).

CONCLUSIONS

Laparoscopic adhesiolysis requires a specific skill set and may not be appropriate in all patients. Notwithstanding this, the laparoscopic approach demonstrates a benefit in 30-day morbidity and mortality even after controlling for preoperative patient characteristics. Given these findings in more than 9,000 patients and consistent rates of SBO requiring surgical intervention in the United States, increasing the use of laparoscopy could be a feasible way of to decrease costs and improving outcomes in this population.

Randomized clinical trial of the benefit of laparoscopy with closure of loop ileostomy

Background

The aim was to compare reversal and laparoscopy with standard reversal of loop ileostomy in terms of hospital stay and morbidity in a randomized study.

Methods

Patients having reversal of a loop ileostomy were randomized to either standard reversal of ileostomy or reversal and laparoscopy. Strict discharge criteria were applied: toleration of two meals without nausea and vomiting, passing a bowel motion, and attaining adequate pain control with oral analgesia. Morbidity and cost were also compared between the two groups.

Results

A total of 74 patients (reversal and laparoscopy 40, standard reversal 34) with a median age of 61 years underwent loop ileostomy reversal; there were 45 men (61 per cent). Ileostomy was most commonly carried out after laparoscopic low anterior resection (36 patients). Median length of stay, based on discharge criteria, was significantly shorter in the reversal and laparoscopy group than in the standard group: 4 (interquartile range 3–4) versus 5 (4–6) days (P = 0·003). The overall morbidity rate was also lower in patients who had ileostomy reversal and laparoscopy: 10 versus 32 per cent (P = 0·023). The median cost per patient was lower in the reversal and laparoscopy group: €3450 (interquartile range 2766–3450) versus €4527 (3843–7263) (P = 0·015). There was no statistically significant difference in American Society of Anesthesiologists fitness grade or time to reversal between the two groups.

Conclusion

Reversal of loop ileostomy with laparoscopy was associated with a shorter hospital stay, lower morbidity and reduced cost compared with the standard technique. Registration number: ISRCTN46101203 (http://www.controlled-trials.com).

Prior abdominal open surgery does not impair outcomes of laparoscopic colorectal surgery: a case-control study in 367 patients

AIM

This prospective case-matched study was conducted to compare the outcome of laparoscopic colorectal surgery in patients with and without prior abdominal open surgery (PAOS).

METHOD

From June 1997 to December 2010, 167 patients with PAOS (including midline, Pfannenstiel, subcostal, right upper quadrant or transverse incision) were manually matched to all identical patients without PAOS from our prospective laparoscopic colorectal surgery database. Matching criteria included age, gender, American Society of Anesthesiology (ASA) score, body mass index, diagnosis and surgical procedure performed. Primary end-points were postoperative 30-day mortality and morbidity. Secondary end-points included operating time, conversion rate and length of stay.

RESULTS

A total of 367 patients (167 with PAOS and 200 without PAOS) were included in this study. PAOS was associated with a significantly increased mean operating time (229±66 min vs 216±71 min, P=0.044). The conversion rate was significantly higher in patients with PAOS, compared with patients without PAOS (22%vs 13%, P=0.017). There was one (0.3%) postoperative death. The overall postoperative morbidity rate was similar in both groups (22%vs 19%, P=0.658), including Grade 3 or Grade 4 morbidity, according to Dindo's classification (5%vs 5%, P=0.694). Mean hospital stay showed no difference between both groups (10±7 days vs 9±5 days, P=0.849).

CONCLUSION

This large case-control study suggests that PAOS does not affect postoperative outcomes. For this reason, a systematic laparoscopic approach in patients with PAOS, even with midline incision, should be considered in colorectal surgery.

Combined laparoscopic and open technique for the repair of large complicated incisional hernias

BACKGROUND

During laparoscopic incisional hernia repair, conversion to open surgery is sometimes needed, especially in cases of large complicated incisional hernias. No guidelines exist for determining when conversions should be considered. This study aimed to investigate the safety of a combined technique as an alternative to conversion in the laparoscopic repair of large complicated incisional hernias and to evaluate the impact of early conversion to the combined technique on patient outcome.

METHODS

Beginning in November 2008, early conversion was initiated for patients with large complicated incisional hernia when dense extensive intraabdominal adhesions were present. Two cohorts of patients with large complicated incisional hernia were retrospectively analyzed: 21 patients before the initiation of early conversion (group 2) and 21 patients after its inception (group 1). The data analyzed included patient demographics, operative parameters, complications, and recurrence.

RESULTS

No significant differences were found between the two groups with respect to age, gender, body mass index, coexisting conditions, number of previous laparotomies, number of previous repairs, or features of the hernia. Groups 1 and 2 differed significantly in terms of mean operative time (110.7 vs 138.8 min), enterotomy rate (0 vs 29 %), and postoperative hospital stay (4.7 vs 6.1 days). In group 1, early conversion to the combined technique was necessary for 16 patients (76 %), and no delayed conversion occurred. In group 2, delayed conversion to the combined technique was necessary for 11 patients (52 %), and no early conversion occurred. During the follow-up period, neither wound/mesh infection nor trocar-site hernia occurred.

CONCLUSION

The combined technique proved to be a safe and minimally invasive alternative to conversion in laparoscopic repair of large complicated incisional hernias. Early conversion to the combined technique was associated with less technical difficulty, deceased operative time, lower enterotomy rate, and shorter postoperative hospital stay.

Stilamin for intestinal obstruction: A systematic review of efficacy

AIM: To assess the efficacy of Stilamin for intestinal obstruction.

METHODS: Cochrane Library, PubMed, Embase, SCI, CNKI, CBM, VIP and WANFANG databases were searched to identify randomized controlled trials and quasi-randomized controlled trials of Stilamin combined with conventional therapy versus conventional therapy for intestinal obstruction. The data were analyzed using the RevMan 5.1 software.

RESULTS: Thirteen studies(852 patients) were enrolled. The results of meta-analysis showed that there is a significant difference between the group of Stilamin combined with conventional therapy and the group of conventional therapy in: (1) time to relief of abdominal pain: MD = -2.96, 95% CI: (-4.08, -1.84); (2) time to relief of abdominal distention: MD = -2.98, 95% CI: (-4.33, -1.63); (3) time required for restoration of anus exhaust: MD = -4.69, 95% CI: (-5.24, -4.13); (4) rate of remission of abdominal pain and abdominal distention: according to the treatment cycle of different subgroups, there is a statistical significance among different subgroups for 48 h after treatment and at the end of treatment: RR = 1.23, 95% CI: (1.08, 1.42); RR = 1.51, 95% CI: (1.29, 1.76); (5) rate of restoration of anus exhaust: according to the treatment cycle of different subgroups, there is a statistical significance for 48 h post-treatment and at the end of the treatment: RR = 1.20, 95% CI: (1.04, 1.37), RR = 1.71, 95% CI: (1.35, 2.17); (6) mean hospitalization stay: MD = -5.09, 95% CI: (-5.95, -4.22); (7) rate of conversion to operation: RR = 0.33, 95% CI: (0.21, 0.52); and (8) amount of gastrointestinal decompression: according to the treatment cycle of different subgroups, there is a statistical significance for 48 h, 72 h post-treatment and at the end of the treatment: MD = -305.43, 95% CI: (-359.84, -251.03); MD = -345.80, 95% CI: (-406.63, -284.97); MD = -507.14, 95% CI: (-549.19, -465.09).

CONCLUSION: Current evidence suggests that Stilamin combined with conventional therapy is superior to the conventional therapy for intestinal obstruction. However, large-scale, high-quality, double-blinded RCTs are required to confirm the efficacy.

The Effects of Repeat Laparoscopic Surgery on the Treatment of Complications Resulting from Laparoscopic Surgery

Laparoscopic surgery is frequently applied in the operative management of appendicitis and symptomatic cholelithiasis because it is a minimally invasive procedure. There are, however, some complications of laparoscopic cholecystectomy (LC) and laparoscopic appendectomy (LA) that result in the need for reoperation. In the current study, we examine the effects of repeat laparoscopic surgery on the treatment of complications arising from LC/LA. From April 2005 to March 2011, we examined a cohort of patients who had received LC or LA and experienced complications that required reoperations. We focused on patients with postoperative hemorrhages, postoperative peritonitis, early postoperative small bowel obstructions (EPSBO), and biliary complications (after LC) who were treated through a repeat laparoscopic approach. The general demographics of the patients, their postoperative complications, procedures for selecting the appropriate reoperation method, and repeat laparoscopic findings are described in detail. During the 6-year period examined, 1608 patients received LC and 1486 patients received LA at the hospitals participating in this study. In patients with complications requiring reoperation, the repeat laparoscopic approach was performed successfully (without the need for further laparotomy) in 50 per cent of the patients with postoperative hemorrhage (2 of 4), 50 per cent of the patients with postoperative peritonitis (2 of 4), 75 per cent of the EPSBO patients (3 of 5), and 50 per cent the of patients with biliary complications (1 of 2). The repeat laparoscopic approach is an appropriate method for the management of complications arising from laparoscopic surgery. In patients with postoperative hemorrhage, laparoscopic hemostasis and hematoma evacuations can be performed while maintaining stable hemodynamics. In addition, laparoscopic approaches are also feasible for selective post-LC ductal injuries, EPSBO, and unconfirmed diagnoses of peritonitis after laparoscopic surgery.

Laparoscopic approach to acute abdomen from the Consensus Development Conference of the Società Italiana di Chirurgia Endoscopica e nuove tecnologie (SICE), Associazione Chirurghi Ospedalieri Italiani (ACOI), Società Italiana di Chirurgia (SIC), Società Italiana di Chirurgia d'Urgenza e del Trauma (SICUT), Società Italiana di Chirurgia nell'Ospedalità Privata (SICOP), and the European Association for Endoscopic Surgery (EAES)

BACKGROUND

In January 2010, the SICE (Italian Society of Endoscopic Surgery), under the auspices of the EAES, decided to revisit the clinical recommendations for the role of laparoscopy in abdominal emergencies in adults, with the primary intent being to update the 2006 EAES indications and supplement the existing guidelines on specific diseases.

METHODS

Other Italian surgical societies were invited into the Consensus to form a panel of 12 expert surgeons. In order to get a multidisciplinary panel, other stakeholders involved in abdominal emergencies were invited along with a patient's association. In November 2010, the panel met in Rome to discuss each chapter according to the Delphi method, producing key statements with a grade of recommendations followed by commentary to explain the rationale and the level of evidence behind the statements. Thereafter, the statements were presented to the Annual Congress of the EAES in June 2011.

RESULTS

A thorough literature review was necessary to assess whether the recommendations issued in 2006 are still current. In many cases new studies allowed us to better clarify some issues (such as for diverticulitis, small bowel obstruction, pancreatitis, hernias, trauma), to confirm the key role of laparoscopy (such as for cholecystitis, gynecological disorders, nonspecific abdominal pain, appendicitis), but occasionally previous strong recommendations have to be challenged after review of recent research (such as for perforated peptic ulcer).

CONCLUSIONS

Every surgeon has to develop his or her own approach, taking into account the clinical situation, her/his proficiency (and the experience of the team) with the various techniques, and the specific organizational setting in which she/he is working. This guideline has been developed bearing in mind that every surgeon could use the data reported to support her/his judgment.

Laparoscopic surgery for recurrent ileocolic Crohn's disease is as safe and effective as primary resection

AIM

The safety and short-term outcome of laparoscopic surgery for recurrent ileocolic Crohn's disease was compared with the outcome following primary resection.

METHOD

Between June 2002 and June 2010, 59 consecutive unselected patients (30 of whom had recurrent disease) underwent laparoscopic ileocolic resection. Four primary resections and one revision were performed as a single incision laparoscopic surgery (SILS) procedure.

RESULTS

There was no difference between the two groups in terms of age, body mass index, American Society of Anesthesiology (ASA) grade or the presence or absence of fistulating disease. The median operating time was significantly longer for the revision group (125 min vs 85 min; P < 0.001). The rate of conversion was 8.5%, morbidity was 20% and mortality was 0% (P = not significant between groups). Risk factors for conversion included a complex fistula, fibrosis and the need to carry out multiple stricturoplasty. Patients in whom surgery was converted had a longer hospital stay and a higher morbidity (40%). The median hospital stay was 3 days, the return to theatre rate was 5% and the re-admission rate was 5% (P = not significant between groups).

CONCLUSION

Laparoscopic surgery for recurrent ileocolic Crohn's disease is safe and can lead to significant short-term benefit, including earlier discharge. Conversion increases the length of stay in hospital and the overall morbidity.

Single-incision laparoscopy-assisted surgery for bowel obstruction: report of three cases

We applied single-incision laparoscopy-assisted surgery for several different types of bowel obstruction in selected patients. Before the operation, a long nasal tube was inserted for intestinal decompression and assessment of a stenotic lesion. A specially-designed instrument for single-incision laparoscopic surgery, the SILS Port, was introduced at the umbilicus or proposed ileostomy site. After intracorporeal procedures, extracorporeal resection and reconstruction of the intestine was performed as needed. Three patients with bowel obstruction due to jejunal carcinoma, colonic stenosis, and adhesion underwent single-incision laparoscopy-assisted surgery. The port site was used for subsequent extracorporeal resection and anastomosis of the jejunum in two patients, and for ileostomy in the remaining patient. All of the procedures were completed safely, and there were no postoperative complications. Single-incision laparoscopy can therefore be applied for selected patients with bowel obstruction. In such cases, the preoperative insertion of a long nasal tube for decompression of intestinal contents and assessment of the stenotic lesion is necessary.

Laparoscopic liver resection in patients with a history of upper abdominal surgery

BACKGROUND

The liver is the organ where tumors most frequently metastasize. Hepatic recurrence after resection of hepatocellular carcinoma also occasionally occurs. With the increasing use of laparoscopic surgery for hepatic tumors, there may be a high probability that laparoscopic liver resection can be performed in patients with a surgical history. The purpose of this study was to assess the feasibility and clinical outcomes of laparoscopic liver resection in patients a history of upper abdominal surgery.

METHODS

Of 202 laparoscopic liver resections, 47 patients underwent laparoscopic liver resection after previous upper abdominal surgery between January 2004 and July 2009. Fifty-five previous surgeries were performed in the 47 patients. The previous types of surgical procedures included hepatobiliary and pancreatic (HPB) procedures (n=25) and non-HPB procedures (colorectal malignancies, subtotal gastrectomy, and splenectomy; n=22).

RESULTS

In patients with a history of surgery, the mean operative time for laparoscopic liver resection was 312.3 min and the mean blood loss was 481.0 ml. In 42 patients (89.4%), there were severe adhesions in the hepatoduodenal ligament and hilar areas. Transfusion was required in 7 patients (14.9%). There was one conversion to a laparotomy due to severe adhesions. Complications occurred in 11 patients (23.4%) and the mean hospital stay was 10.6 days. When we compare patients with and without a history of surgery, there were no differences in the above-mentioned perioperative results. However, among patients with a history of surgery, patients who underwent HPB procedures had longer operative times and higher postoperative morbidities than those who had not undergone HPB procedures.

CONCLUSION

Laparoscopic liver resection in patients with a history of upper abdominal surgery is feasible and safe.

Laparoscopy Entry in Patients With Previous Abdominal and Pelvic Surgery

Background: The background of this investigation is based on a common surgical problem: The access in laparoscopic surgery is more difficult in women with previous abdominopelvic surgery, since adhesions and viscera could be close to the point of trocar insertion. Purpose: The authors analyzed the safety and the efficacy of a modified direct optical entry (DOE) method versus the Hasson’s method by open laparoscopy (OL) in women with previous abdominopelvic surgery in a preliminary prospective case–control study. Materials and methods: A total of 168 women underwent laparoscopic surgery in university-affiliated hospitals: 86 were assigned to abdominal DOE (group A) and 82 to OL (group B). The main outcome measures were statistically compared: time required for entry into abdomen, blood loss, and occurrence of vascular and/or bowel injury. All patients had an intraperitoneal view of the primary port site during surgical procedure. Results: Statistical differences, in favor of the DOE group ( P < .01), were found in duration of entry and blood loss. The vascular and bowel injuries in OL versus DOE were not statistically different. Conclusions: Obtaining access to the peritoneal cavity in laparoscopic surgery is more difficult in patients with previous abdominopelvic surgery, since it can become a difficult, time-consuming, and occasionally hazardous procedure. The study results suggest that DOE is advantageous when compared with OL in terms of saving time enabling a safe and expeditious visually guided entry for laparoscopy.

Recurrent adenoid cystic carcinoma in the liver: a repeated laparoscopic surgical approach

Adenoid cystic carcinoma (ACC) is characterized by a particularly aggressive behavior even many years after resection of primary tumor. The evolution of metastasis dramatically affects the final outcome but resection should always be evaluated. Herein is described a case of aggressive ACC of the parotid gland in a 30-year-old female. She developed local recurrence and lung metastases; then, she also developed two liver metastasis 112 and 132 months after the resection of the primitive cancer of the parotid gland. Both lesions were successfully managed by a laparoscopic approach. Intra-abdominal adhesions after the first surgery were mild, allowing an easier access for the second laparoscopic liver resection. At 1 year follow-up, the patient is liver disease free with a stable lung disease. To our knowledge, this is the first report of a double laparoscopic liver resection for parotid gland's ACC metachronous metastases. Patients with resected ACC need a strict and lifelong follow-up after the resection of the primitive cancer. Also for ACC, a laparoscopic approach to liver metastasis should always be considered as a viable alternative to open surgery. In our experience of over 90 cases, laparoscopic surgery causes less adhesions, allowing an easier approach for repeated resections.

Laparoscopy in children with acute intestinal obstruction by aberrant congenital bands

Aberrant congenital bands are a rare cause of acute intestinal obstruction and usually present a diagnostic challenge. In 2008, the authors encountered 2 children with acute terminal ileal herniation. In the first case, it was caused by a mesodiverticular band, and numerous freely hanging filmy membranes attached to the antimesenteric side of the small intestine were found concurrently; whereas, an anomalous band from the distal ileum to the cecum was the leading cause in the second case. The vascularity of both herniated intestines was not compromised, and laparoscopy was successfully carried out 84 and 93 hours after the onset of the symptoms, respectively. Instead of cohesive adhesions, both of the causes related to a single vascular band, and laparoscopy was an effective and safe tool in diagnosis and subsequent treatment. The case with a mesodiverticular band and filmy membranes is the first case report with incomplete regression of both the vitelline circulation and the ventral mesentery.

Visceral mobilization can lyse and prevent peritoneal adhesions in a rat model

OBJECTIVE

Peritoneal adhesions are almost ubiquitous following surgery. Peritoneal adhesions can lead to bowel obstruction, digestive problems, infertility, and pain, resulting in many hospital readmissions. Many approaches have been used to prevent or treat adhesions, but none offer reliable results. A method that consistently prevented or treated adhesions would benefit many patients. We hypothesized that an anatomically-based visceral mobilization, designed to promote normal mobility of the abdominal contents, could manually lyse and prevent surgically-induced adhesions.

MATERIAL AND METHODS

Cecal and abdominal wall abrasion was used to induce adhesions in 3 groups of 10 rats (Control, Lysis, and Preventive). All rats were evaluated 7 days following surgery. On postoperative day 7, unsedated rats in the Lysis group were treated using visceral mobilization, consisting of digital palpation, efforts to manually lyse restrictions, and mobilization of their abdominal walls and viscera. This was followed by immediate post-mortem adhesion evaluation. The rats in the Preventive group were treated daily in a similar fashion, starting the day after surgery. Adhesions in the Control rats were evaluated 7 days after surgery without any visceral mobilization.

RESULTS

The therapist could palpate adhesions between the cecum and other viscera or the abdominal wall. Adhesion severity and number of adhesions were significantly lower in the Preventive group compared to other groups. In the Lysis and Preventive groups there were clear signs of disrupted adhesions.

CONCLUSIONS

These initial observations support visceral mobilization may have a role in the prevention and treatment of post-operative adhesions.

Adhesion awareness: a national survey of surgeons

Background

Postoperative adhesions are the most frequent complication of abdominal surgery, leading to high morbidity, mortality, and costs. However, the problem seems to be neglected by surgeons for largely unknown reasons.

Methods

A survey assessing knowledge and personal opinion about the extent and impact of adhesions was sent to all Dutch surgeons and surgical trainees. The informed-consent process and application of antiadhesive agents were questioned in addition.

Results

The response rate was 34.4%. Two thirds of all respondents (67.7%) agreed that adhesions exert a clinically relevant, negative effect. A negative perception of adhesions correlated with a positive attitude regarding adhesion prevention (ρ = 0.182, p < 0.001). However, underestimation of the extent and impact of adhesions resulted in low knowledge scores (mean test score 37.6%). Lower scores correlated with more uncertainty about indications for antiadhesive agents which, in turn, correlated with never having used any of these agents (ρ = 0.140, p = 0.002; ρ = 0.095, p = 0.035; respectively). Four in 10 respondents (40.9%) indicated that they never inform patients on adhesions and only 9.8% informed patients routinely. A majority of surgeons (55.9%) used antiadhesive agents in the past, but only a minority (13.4%) did in the previous year. Of trainees, 82.1% foresaw an increase in the use of antiadhesive agents compared to 64.5% of surgeons (p < 0.001).

Conclusions

The magnitude of the problem of postoperative adhesions is underestimated and informed consent is provided inadequately by Dutch surgeons. Exerting adhesion prevention is related to the perception of and knowledge about adhesions.

Impact of prior abdominal surgery on curative resection of colon cancer via minilaparotomy

PURPOSE

To evaluate the impact of prior abdominal surgery on curative resection of colon cancer via a minilaparotomy approach.

METHODS

Feasibility, safety, and oncological outcomes were evaluated retrospectively in 263 patients scheduled to undergo curative resection of colon cancer via a minilaparotomy approach, defined as a skin incision of ≤ 7 cm, between September 2000 and March 2009.

RESULTS

Abdominal adhesions were found in 59 (77.6%) of 76 patients who had undergone prior abdominal surgery (PAS group) and in 4 (2.1%) of 187 patients who had not (control group). The success rate of the minilaparotomy approach was 92.1% in the PAS group and 97.3% in the control group (P = 0.08). The incidence of extending the minilaparotomy wound for adhesiolysis was significantly higher in the PAS group than in the control group (6.6% vs 0.5%; P < 0.01). The two groups did not differ significantly in terms of the types of surgery, pathological stage, body mass index, operative time, blood loss, incidence of postoperative complications, length of postoperative hospital stay, and disease-free survival.

CONCLUSIONS

These results suggest that prior abdominal surgery might require an extension of the minilaparotomy incision but that it does not seem to contraindicate a minilaparotomy approach for curative colectomy.

Strategies for diagnosis and treatment of small bowel obstruction

Small bowel obstruction, which is caused by a variety of etiological factors and mainly manifests as abdominal pain, vomiting and distension, is one of the most common acute abdomens. A rapid and accurate diagnosis of small bowel obstruction is needed to give reasonable and effective treatment to avoid its rapid deterioration. In this paper we discuss the strategies for diagnosis and treatment of small bowel obstruction through comparing different imaging methods for diagnosis of small bowel obstruction and reviewing the current situation of diagnosis and treatment of the disease in terms of pharmacotherapy, gastrointestinal decompression, and surgical intervention.

Survey of opinions on operative management of adhesive small bowel obstruction: laparoscopy versus laparotomy in the state of Connecticut

BACKGROUND

This study sought to know the opinions of general surgeons registered in the state of Connecticut about their use of laparoscopic lysis of adhesions (LLA) to manage adhesive small bowel obstruction (SBO) compared with open lysis of adhesions (OLA) in terms of safety, contraindications, and outcomes.

METHODS

A questionnaire was designed to gather the opinions of general surgeons registered in Connecticut on this topic. The questionnaire was administered electronically and through the mail.

RESULTS

Of the 205 general surgeons to whom the questionnaire was sent, 87 completed it (42% response). The respondents were evenly distributed throughout Connecticut. Of these respondents, 9% were university teaching hospital faculty, 55% were community teaching hospital based, and 36% were community nonteaching hospital based. The answers to the questions were expressed as percentages and differences between groups tested using Fisher's exact test, with the significance level set at a P value less than 0.05. According to their self-reports, 60% of the respondents used LLA in their practice, with 38% of this group using LLA for less than 15% of their adhesive SBO cases. Compared with surgeons out of training less than 15 years, a greater number of surgeons out of training more than 15 years considered LLA to be safer (P = 0.03) and to have better outcomes (P = 0.04) than OLA. More surgeons in academic/teaching settings considered LLA to be safe than did surgeons in nonacademic/nonteaching settings (P = 0.04), and more members of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES)/Society of Laparoendoscopic Surgeons (SLS) considered LLA to be safe than nonmembers (P = 0.001).

CONCLUSIONS

Many surgeons do not perform LLA for reasons that differ from those in the surgical literature, which supports LLA. Surgeons recently trained or with membership in minimally invasive surgery (MIS) societies are more likely to use LLA. These data suggest that recent training and interest or membership in MIS associations influence surgeons' choice for LLA. This survey demonstrated that an opportunity exists to improve patient outcomes with education about the merits of LLA in the state of Connecticut.

Laparoscopic management of intestinal obstruction

Laparoscopic adhesiolysis is a valuable tool for the surgeon performing complex minimally invasive procedures. It can be used for the management of intestinal obstruction and chronic abdominal pain syndromes. It is also an essential skill when performing laparoscopic surgery on patients who had prior abdominal operations. The use of laparoscopy for patients with an intestinal obstruction was once considered an absolute contraindication. With the advancement in optics and increasing experience, more and more surgeons are turning to laparoscopy as a useful diagnostic and therapeutic tool in more complex situations.

Bologna Guidelines for Diagnosis and Management of Adhesive Small Bowel Obstruction (ASBO): 2010 Evidence-Based Guidelines of the World Society of Emergency Surgery

Background

There is no consensus on diagnosis and management of ASBO. Initial conservative management is usually safe, however proper timing for discontinuing non operative treatment is still controversial. Open surgery or laparoscopy are used without standardized indications.

Methods

A panel of 13 international experts with interest and background in ASBO and peritoneal diseases, participated in a consensus conference during the 1^st International Congress of the World Society of Emergency Surgery and 9^th Peritoneum and Surgery Society meeting, in Bologna, July 1-3, 2010, for developing evidence-based recommendations for diagnosis and management of ASBO. Whenever was a lack of high-level evidence, the working group formulated guidelines by obtaining consensus.

Recommendations

In absence of signs of strangulation and history of persistent vomiting or combined CT scan signs (free fluid, mesenteric oedema, small bowel faeces sign, devascularized bowel) patients with partial ASBO can be managed safely with NOM and tube decompression (either with long or NG) should be attempted. These patients are good candidates for Water Soluble Contrast Medium (WSCM) with both diagnostic and therapeutic purposes. The appearance of water-soluble contrast in the colon on X-ray within 24 hours from administration predicts resolution. WSCM may be administered either orally or via NGT (50-150 ml) both immediately at admission or after an initial attempt of conservative treatment of 48 hours. The use of WSCM for ASBO is safe and reduces need for surgery, time to resolution and hospital stay.

NOM, in absence of signs of strangulation or peritonitis, can be prolonged up to 72 hours. After 72 hours of NOM without resolution surgery is recommended.

Patients treated non-operatively have shorter hospital stay, but higher recurrence rate and shorter time to re-admission, although the risk of new surgically treated episodes of ASBO is unchanged. Risk factors for recurrences are age <40 years and matted adhesions. WSCM does not affect recurrence rates or recurrences needing surgery when compared to traditional conservative treatment.

Open surgery is the preferred method for surgical treatment of strangulating ASBO as well as after failed conservative management. In selected patients and with appropriate skills, laparoscopic approach can be attempted using open access technique. Access in the left upper quadrant should be safe. Laparoscopic adhesiolysis should be attempted preferably in case of first episode of SBO and/or anticipated single band. A low threshold for open conversion should be maintained.

Peritoneal adhesions should be prevented. Hyaluronic acid-carboxycellulose membrane and icodextrin can reduce incidence of adhesions. Icodextrin may reduce the risk of re-obstruction. HA cannot reduce need of surgery.

Analysis of the videolaparoscopy potentiality in the surgical treatment of the bowel obstruction

CONTEXT

Laparotomy is the gold standard treatment of patients with intestinal obstruction without response to clinical management. Nowadays, literature has been demonstrating the feasibility of videolaparoscopy in the treatment of intestinal obstruction.

OBJECTIVES

To report the clinical-epidemiological profile of patients with intestinal obstruction submitted to surgery and verify the presence of contraindications for laparoscopy.

METHODS

It was done a observational, descriptive and retrospective study including adults patients with intestinal obstruction submitted to surgery at Hospital de Clínicas de Porto Alegre, RS, Brazil, between January of 2004 and October of 2008.

RESULTS

It was included 135 patients in the study, with a total of 126 patients submitted to open surgery and 9 to laparoscopy. There was similar distribution between gender and the mean age was 59 years (SD +/- 16.9). The most frequent site of obstruction was the small bowel and the most frequent etiology was adhesions. Among the patients submitted to laparotomy, 75.4% presented with abdominal distention, 68.3% previous abdominal surgery, 11.9% body mass index >30 kg/m(2), 4.8% coagulopathy and 3.2% hemodynamic instability. Among the 135 patients, only 5 of them presented with none contraindications for videolaparoscopy.

CONCLUSION

The epidemiological findings of this study are similar to the ones of the worldwide literature. Indications of videolaparoscopy in retrospective analyses have the limitation of subjective evaluation of intestinal obstruction, which was included in this study as a relative contraindication to laparoscopy.

The efficacy of laparoscopy in the diagnosis and management of chronic abdominal pain

BACKGROUND

Chronic abdominal pain is a difficult complaint. It leads to evident suffering and disability, both physically and psychologically. Many diagnostic and therapeutic procedures have been described in literature, but with little proof or evidence of success. Laparoscopy is one of the modalities that could be of benefit in such cases. We aim to evaluate the diagnostic and therapeutic value of laparoscopy in cases with chronic abdominal pain.

MATERIALS AND METHODS

Thirty patients with chronic abdominal pain were included in this prospective descriptive cross-sectional study. The pain in all patients was of unclear etiology despite all the investigative procedures. All patients were subjected to laparoscopic evaluation for their conditions. The findings and outcomes of the laparoscopy were recorded and analyzed.

RESULTS

The most common site of pain was the periumbilical region (30%). A definitive diagnosis was made in 25 patients (83.3%), while five patients (16.7%) had no obvious pathology. Adhesions were the most common laparoscopic findings (63.3%) followed by appendiceal pathology (10%), hernia (3.3%), gall bladder pathology (3.3%), and mesenteric lymphadenopathy (3.3%). Postoperatively, pain relief was achieved in 24 patients (80%) after two months.

CONCLUSION

Laparoscopy is an effective diagnostic and therapeutic modality in the management of patients with chronic abdominal pain.

Predictors of Failure of the Laparoscopic Approach for the Management of Small Bowel Obstruction

Small bowel obstruction (SBO) is a common cause of hospital admission. Our objective is to determine variables that correlate with failure of the laparoscopic approach for SBO. Twenty-three consecutive patients underwent diagnostic laparoscopy with curative intent for treatment of SBO by a single surgeon over a 3-year period. The laparoscopic approach was successful in 18 patients (78%); there were five (22%) conversions to laparotomy. The causes of obstruction included adhesive band in 16 patients; and small bowel lymphoma, metastatic esophageal cancer, small bowel gangrene, Meckel diverticulum, gallstones ileus, and incarcerated incisional hernia in two. Using the Fisher two-sided test, no significant predictor for conversion was identified using gender, American Society of Anesthesiologists class, previous bowel obstruction, history of adhesiolysis, abdominal distention, pelvic surgeries, chemotherapy, radiation, malignancy, chronic obstructive pulmonary disease, asthma, coronary artery disease, hypertension, or hypercholesterolenemia. The Wilcoxon two-sided test did not show significance for age, weight, number of previous abdominal surgeries, or small bowel diameter. The postoperative hospital stay was significantly shorter in the laparoscopic group compared with those who needed conversion (3 vs 9 days) with P = 0.0019. No mortality was noted in any patients. The laparoscopic is safe and feasible for the management of SBO. We believe that the laparoscopic approach should be offered to all patients with SBO unless there is an absolute contraindication to laparoscopic surgery.

A laparoscopic approach to iterative ileocolonic resection for the recurrence of Crohn's disease

BACKGROUND

Laparoscopy is a valuable approach to primary ileocecal resection for ileocolonic Crohn's disease (CD). This study aimed to evaluate the feasibility of using laparoscopy for reoperation in the case of ileocolonic CD recurrence and to determine the risk factors and consequences of conversion for these patients.

METHODS

From 1998 to 2008, 57 patients underwent 62 reoperations for CD recurrence. Of these 62 reoperations, 29 were laparoscopic procedures (laparoscopy group [LG]). Preoperative and intraoperative characteristics and postoperative outcome were compared with those for 33 open procedures (open group [OG]).

RESULTS

The preoperative characteristics were similar in the two groups. The number of intraoperative intestinal injuries was higher in the LG group (n = 5) than in the OG group (n = 0) (p = 0.01). The use of a temporary stoma (7/29 vs. 6/33; nonsignificant difference [NS]) and the mean operating time (215 + or - 70 vs. 226 + or - 107 min, NS) were similar in the two groups. The postoperative mortality was nil in both groups. The overall morbidity rate was 38% (11/29) in LG and 30% (10/33) in OG (NS). Severe complications (DINDO > or = 3) occurred for three of the 29 patients in LG (10%) compared with five of 33 patients in OG (15%) (NS). The median hospital stay was 9 days in both groups. The conversion rate was 31% (9/29). Univariate analysis showed that the risk factors for conversion were fistulizing disease (p = 0.02) and intraoperative intestinal injury (p < 0.001). The morbidity rate was not increased by the need for a conversion (7/20 for the nonconverted vs. 4/9 for the converted patients, NS).

CONCLUSION

Laparoscopy for ileocolonic CD recurrence is challenging and complex. The morbidity rate was similar to that for the open approach, and the risk of small bowel injury associated with laparoscopy could possibly induce postoperative septic complications. However, the authors believe that laparoscopy can be recommended for selected patients with CD recurrence, especially patients with nonfistulizing disease.

Natural orifice transluminal endoscopic surgery versus laparoscopic surgery for inadvertent colon injury repair: feasibility, risk of abdominal adhesions, and peritoneal contamination in a porcine survival model

BACKGROUND

Adhesions are common after conventional surgery; natural orifice transluminal endoscopic surgery (NOTES) avoids peritoneal disruption and may reduce adhesions.

OBJECTIVES

To determine whether adhesions (and peritoneal contamination) are less common with NOTES transgastric colon injury and repair (TGCR) than with laparoscopic colon repair (LCR).

DESIGN/SETTING

Porcine survival study.

INTERVENTIONS

After colon preparation and administration of antibiotics, forty 25-kg male pigs were randomly assigned to either TGCR or LCR. TGCR involved an endoscopic gastrotomy (needle-knife plus balloon dilation), CO(2) pneumoperitoneum, and a 2-cm needle-knife transmural incision of spiral colon. Colotomies were repaired with clips; gastrotomies were closed with clips and a detachable snare.

MAIN OUTCOME MEASUREMENTS

Adhesions were assessed at necropsy at 21 days; biopsy specimens were blindly reviewed. A 9-point adhesion score (density/vascularity, width, and extent) was averaged from 3 reviewers. Peritoneal lavage was sent for cell count and culture.

RESULTS

Two of 20 TGCR pigs died immediately (unrecognized preoperative autopsy-proven pneumonia). The median procedure times were 70.5 and 19.0 minutes for TGCR and LCR, respectively; weight gains were 7.1 and 8.2 kg, respectively. The median adhesion scores were 4.3 and 3.7, respectively (P = .26); subscores were similar (1.9, 1.5, 1.3 vs 1.7, 1.1, 1.0, respectively (P = .3-.6)). Peritoneal lavage bacterial growth was nonsignificantly lower after TGCR than after LCR (38.9% vs 60.0%, respectively; P = .30); administration of intragastric antibiotics did not decrease contamination. Three TGCR (vs no LCR) pigs had histologic peritonitis.

LIMITATIONS

Animal model, colon prepped, injury immediately recognized.

CONCLUSION

NOTES colon repair is feasible after transmural injury. Adhesions, histologic peritonitis, and contamination were similar to those with laparoscopy and were not helped by intragastric antibiotics.

Open adhesiolysis is more effective in reducing adhesion reformation than laparoscopic adhesiolysis in an experimental model

BACKGROUND

This study compared adhesion reformation after open and laparoscopic adhesiolysis in a rat model.

METHODS

Adhesions were induced by surgically creating ischaemic buttons on the peritoneal side wall. After 7 days the animals underwent laparoscopy with carbon dioxide insufflation or laparotomy to score and lyse adhesions. Peritoneal tissue and fluid were collected after 24 h in a subset of animals, and adhesion reformation was scored 7 days after lysis in the remainder. Tissue plasminogen activator (tPA), plasminogen activator inhibitor (PAI) 1, transforming growth factor (TGF) beta1 and tumour necrosis factor (TNF) alpha mRNA, and total fibrinolytic activity were assessed. The abdomen of non-operated animals was insufflated for 7, 15 or 30 min with carbon dioxide, after which tPA and PAI-1 mRNA and total fibrinolytic activity were measured.

RESULTS

Animals that underwent open adhesiolysis had 60 per cent fewer reformed adhesions than the laparoscopic adhesiolysis group (P < 0.001). There were no differences in tPA activity or tPA, PAI-1 and TNF-alpha mRNA between groups, but TGF-beta1 mRNA levels were significantly increased in the open group. Carbon dioxide insufflation did not affect peritoneal tPA activity.

CONCLUSION

Open adhesiolysis may be more beneficial in minimizing adhesion reformation in the management of adhesion-related complications.

Laparoscopic versus open surgery in small bowel obstruction

BACKGROUND

Acute intestinal obstruction is one of the most common surgical emergencies. The small bowel obstruction (SBO) is the site of obstruction in most patients (76%) and adhesions are the most common etiology (65%). Laparoscopy in SBO has no clear role yet as it may have a therapeutic and diagnostic function. In some settings laparoscopic or laparoscopy-assisted surgery is considered feasible and convenient more than conventional surgery for SBO; however little is known if laparoscopic or laparoscopy-assisted surgery is more suitable with respect to open surgery for patients with SBO.

OBJECTIVES

The aim of this systematic review is to assess whether laparoscopic or laparoscopy-assisted surgery is feasible and safe for acute SBO, and whether laparoscopic and laparoscopy-assisted surgery present advantages compared to open surgery in terms of short-term and long-term outcomes.

SEARCH STRATEGY

We searched for published randomised and prospective controlled clinical trials without language restrictions using the following electronic databases: Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1950 onwards) and EMBASE (1980 onwards).

SELECTION CRITERIA

Randomised controlled trials and non randomised controlled prospective trials evaluating laparoscopic and laparoscopy-assisted surgery versus traditional open surgery for acute SBO were considered.

DATA COLLECTION AND ANALYSIS

We conducted the review according to the recommendations of The Cochrane Collaboration and the Cochrane Colorectal Group as well, using Review Manager 5 to conduct the review.

MAIN RESULTS

No published or unpublished randomised controlled trials or prospective controlled clinical trials comparing laparoscopy with open surgery for patients with SBO were identified.

AUTHORS' CONCLUSIONS

Although data from retrospective clinical controlled trials suggest that laparoscopy seems feasible and better in terms of hospital stay and mortality reduction, high quality randomised controlled trials assessing all clinically relevant outcomes including overall mortality, morbidity, hospital stay and conversion are needed.

[Are there still contra-indications to laparoscopic treatment of endometrial carcinoma?]

Laparoscopic treatment is becoming a standard of care for early endometrial carcinoma. However, not all patients are suitable for this approach. A review of the current literature provides some arguments to differentiate absolute contra-indications from relative ones, for which, whenever possible, some options are suggested.

Laparoscopic versus open colectomy for patients with American Society of Anesthesiology (ASA) classifications 3 and 4: the minimally invasive approach is associated with significantly quicker recovery and reduced costs

BACKGROUND

Conceivably, the benefits of earlier recovery associated with a minimally invasive technique used in laparoscopic colectomy (LC) may be amplified for patients with comorbid disease. The dearth of evidence supporting the safety of laparoscopy for these patients led to a comparison of outcomes between LC and open colectomy (OC) for patients with American Society of Anesthesiology (ASA) classifications 3 and 4.

METHODS

Data for all ASA 3 and 4 patients who underwent elective LC were reviewed from a prospectively maintained laparoscopic database. The patients who underwent LC were matched with OC patients by age, gender, diagnosis, year, and type of surgery. Estimated blood loss, operation time, time to return of bowel function, length of hospital stay, readmission rate, and 30-day complication and mortality rates were compared using chi-square, Fisher's exact, and Wilcoxon tests as appropriate. A p value <0.05 was considered statistically significant.

RESULTS

In this study, 231 LCs were matched with 231 OCs. The median age of the patients was 68 years, and 234 (51%) of the patients were male. There were 44 (19%) conversions from LC to OC. More patients in the OC group had undergone previous major laparotomy (5 vs. 15%; p < 0.001). Estimated blood loss, return of bowel function, length of hospital stay, and total direct costs were decreased in the LC group. Wound infection was significantly greater with OC (p = 0.02). When patients with previous major laparotomy were excluded, the two groups had similar overall morbidity. The other benefits of LC, however, persisted.

CONCLUSION

The findings show that LC is a safe option for patients with a high ASA classification. The LC approach is associated with faster postoperative recovery, lower morbidity rates, and lower hospital costs than the OC approach.