Laparoscopic surgery for intestinal obstruction

Volvulus: small bowel and colon

Volvulus of the intestine is a surgical emergency. Volvulus of the small bowel is more common in children and is most often secondary to malrotation. Small bowel volvulus is an uncommon cause for small bowel obstruction in adults, and is more likely to be secondary to postoperative adhesive bands. Colonic volvulus is a rare cause of large bowel obstruction, but more common than small bowel volvulus. The sigmoid is most frequently involved, with redundant colon as the primary cause. Cecal volvulus most commonly is due to lack of fixation. Colonic volvulus has a specific radiographic appearance; however, small bowel volvulus is difficult to distinguish from other causes of small bowel obstruction by radiographic means. New surgical techniques with minimally invasive surgery are increasingly being applied to this old problem with good results in selected cases.

Feasibility of laparoscopy for small bowel obstruction

BACKGROUND

Adherential pathology is the most common cause of small bowel obstruction. Laparoscopy in small bowel obstruction does not have a clear role yet; surely it doesn't always represent only a therapeutic act, but it is always a diagnostic act, which doesn't interfere with abdominal wall integrity.

METHODS

We performed a review without any language restrictions considering international literature indexed from 1980 to 2007 in Medline, Embase and Cochrane Library. We analyzed the reference lists of the key manuscripts. We also added a review based on international non-indexed sources.

RESULTS

The feasibility of diagnostic laparoscopy is high (60-100%), while that of therapeutic laparoscopy is low (40-88%). The frequency of laparotomic conversions is variable ranging from 0 to 52%, depending on patient selection and surgical skill. The first cause of laparotomic conversion is a difficult exposition and treatment of band adhesions. The incidence of laparotomic conversions is major in patients with anterior peritoneal band adhesions. Other main causes for laparotomic conversion are the presence of bowel necrosis and accidental enterotomies. The predictive factors for successful laparoscopic adhesiolysis are: number of previous laparotomies

CONCLUSION

Laparoscopic adhesiolysis in small bowel obstruction is feasible but can be convenient only if performed by skilled surgeons in selected patients. The laparoscopic adhesiolysis for small bowel obstruction is satisfactorily carried out when early indicated in patients with a low number of laparotomies resulting in a short hospital stay and a lower postoperative morbidity. Although a higher small bowel obstruction recurrence remains the major postoperative risk of the laparoscopic management of these patients.

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Affiliation(s)

Eriberto Farinella Department of General and Emergency Surgery, St Maria Hospital, Terni, University of Perugia, Perugia, Italy
Roberto Cirocchi Department of General and Emergency Surgery, St Maria Hospital, Terni, University of Perugia, Perugia, Italy
Francesco La Mura Department of General and Emergency Surgery, St Maria Hospital, Terni, University of Perugia, Perugia, Italy
Umberto Morelli Department of General and Emergency Surgery, St Maria Hospital, Terni, University of Perugia, Perugia, Italy
Lorenzo Cattorini Department of General and Emergency Surgery, St Maria Hospital, Terni, University of Perugia, Perugia, Italy
Pamela Delmonaco Department of General and Emergency Surgery, St Maria Hospital, Terni, University of Perugia, Perugia, Italy
Carla Migliaccio Department of General and Emergency Surgery, St Maria Hospital, Terni, University of Perugia, Perugia, Italy
Angelo A De Sol Department of General and Emergency Surgery, St Maria Hospital, Terni, University of Perugia, Perugia, Italy
Luca Cozzaglio Department of Surgical Oncology, IRCCS Istituto Clinico Humanitas, Rozzano, Milan, Italy
Francesco Sciannameo Department of General and Emergency Surgery, St Maria Hospital, Terni, University of Perugia, Perugia, Italy

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Laparoscopic approach to postoperative adhesive obstruction

BACKGROUND

Some authors have assessed the feasibility of laparoscopy in the treatment of postoperative adhesive obstruction, but conclusions about its effectiveness are related to different selection criteria used for surgery. This paper reports on our experience in laparoscopic adhesiolysis and analyses the results on the basis of the selection criteria used.

METHODS

From January 1993 to December 2001, 65 patients were submitted to laparoscopic adhesiolysis for small bowel obstruction according to specific selection criteria. Of the 65 patients, 40 were admitted for acute obstruction and 25 for chronic or recurrent transit disturbances. Correlation between historical and clinical data and the results of surgical treatment were statistically analyzed.

RESULTS

The procedure was completed by laparoscopy in 52 patients (conversion rate: 20%). Mean postoperative stay was 4.4 days with a 12.3% morbidity and no mortality. Recurrence rate was 15.4%; a single correlation was found between recurrence and age.

CONCLUSIONS

Laparoscopic adhesiolysis in the treatment of small bowel obstructions seems to be effective; further studies are required to define selection criteria for surgery and confirm real advantages in terms of recurrences.

Laparoscopic diagnosis and treatment of intestinal obstruction

BACKGROUND

Intestinal obstruction is a common reason for general surgical referral. The traditional approach has been conservative management, followed by laparotomy if conservative measures are unsuccessful. However, with the advent of minimally invasive surgery, the need for laparotomy for this common problem is being challenged.

METHODS

From May 1991 to April 2001, 167 patients underwent laparoscopy for diagnosis and/or treatment of intestinal obstruction. Average patient age was 62 years (range, 21-98). The site of obstruction was the stomach in seven patients, small bowel in 116 patients, and colon in 44 patients.

RESULTS

Laparoscopy successfully diagnosed the site of obstruction in all patients. In addition, 154 patients (92.2%) were successfully treated laparoscopically without conversion to laparotomy. Both intraoperative and postoperative complication rates were low (3.5 and 18.6%, respectively) and compared favorably with those of published reports.

CONCLUSIONS

Intestinal obstruction can be approached safely and effectively by laparoscopy with the intent not only to correctly diagnose the patient but also to render treatment.

Laparoscopic management of small bowel obstruction: indications and outcome

Our aim was to evaluate the feasibility of a laparoscopic, minimal access approach for the management of patients with small bowel obstruction. Forty patients underwent laparoscopic treatment of radiologically documented or suspected small bowel obstruction based on history and/or motility study. None had chronic abdominal or pelvic pain. The operation was completed laparoscopically in 14 patients (35%) and with laparoscopic-assisted procedures in 12 (30%); 14 (35%) required conversion to open celiotomy because of dense adhesions (precluding complete inspection or adhesiolysis), small bowel necrosis in the setting of small bowel obstruction, or neoplasia. Three iatrogenic enterotomies occurred while "running" the bowel. There were three (7%) postoperative procedure-related complications (wound infection, intra-abdominal abscess, ileus). The combined group of patients treated laparoscopically or with laparoscopic-assisted procedures had a shorter hospital stay than those converted to open celiotomy (4 +/- 0.6 vs. 7 +/- 0.7 days; P <0.003). At median follow-up of 12 months, 21 of 26 patients managed laparoscopically or with laparoscopic-assisted procedures remain asymptomatic; all 21 patients with an operatively confirmed site of mechanical obstruction managed by a minimal access approach remain asymptomatic. Laparoscopic treatment of small bowel obstruction is effective, leads to a shorter hospital stay, and has good long-term results. A minimal access approach to treatment of small bowel obstruction should be considered in selected patients.