Laparoscopy in the diagnosis and treatment of acute small bowel obstruction

Laparoscopic management of adhesive acute postoperative small bowel obstruction

Laparoscopic management of postoperative acute adhesive small bowel obstruction (SBO) may often have clinical advantages. This prospective study included patients with postoperative acute SBO in whom sufficient intestinal decompression was achieved using a nasoenteric ileus tube preoperatively, but pass disorder was not improved. This study describes our experience with the laparoscopic procedure for patients with adhesive acute SBO. The laparoscopic approach was undertaken in 24 of 51 patients admitted for acute postoperative SBO from July 1994 through June 2000; it was performed successfully in 20 patients (83%), and four cases were converted to open surgery (17%) because of strong adhesions. In four patients with gallstones and inguinal hernia, laparoscopic surgery (cholecystectomy, hernioplasty) was performed simultaneously. There was no mortality and low morbidity (4.1%). The group of patients treated laparoscopically had a shorter hospital stay than the conventional open group (12 versus 21 days; p < 0.05). At the median follow-up of 84 months, 21 of the 22 patients who had received laparoscopic procedure remained asymptomatic. Laparoscopic treatment was effective, involved a shorter hospital stay and has shown good long-term results for most patients with adhesive acute SBO.

Laparoscopic management of acutely incarcerated femoral hernia

Incarcerated femoral hernia is a common surgical emergency condition. Diagnosis is always obvious and straightforward by clinical examination, and open surgical repair is the mainstay of treatment. In the era of minimally invasive surgery, laparoscopic repair of femoral hernia has been shown to be feasible and safe. However, laparoscopic repair of acutely incarcerated femoral hernia has gained little discussion in the past. In this paper, we report the results of 8 consecutive cases of strangulated femoral hernia that was successfully managed by the laparoscopic approach.

A videolaparoscopia no diagnóstico e tratamento da obstrução intestinal

A obstrução intestinal constitui complicação freqüente, de etiologia multifatorial, apresentação clínica variável e alta morbidade. Uma vez esgotados os recursos conservadores em casos específicos, a laparotomia exploradora é empregada para o diagnóstico final e tratamento em grande número de pacientes. Apesar do sucesso da via laparoscópica no manuseio de diversas afecções, a utilização desta via na abordagem inicial da obstrução do intestino delgado tem sido bastante limitada e alvo de numerosas críticas. Entretanto, o acúmulo de experiência com o método nos últimos anos, aliado ao avanço tecnológico e instrumental, têm permitido tratar número cada vez maior de pacientes obstruídos por meio do acesso laparoscópico. Assim, o surgimento de novos instrumentos como grampeadores laparoscópicos, pinças e trocáteres menos traumáticos ajudaram a tornar a videolaparoscopia factível e segura nestes pacientes. Neste artigo, os autores apresentam uma revisão sobre o papel da vídeo-cirurgia em casos selecionados de obstrução intestinal, ressaltando a contribuição dos métodos minimamente invasivos para o arsenal diagnóstico e terapêutico desta importante complicação.

Laparoscopic approach to small-bowel obstruction

BACKGROUND

Small-bowel obstruction poses both a diagnostic and a therapeutic challenge. The laparoscopic approach may assist in determining the cause of the obstruction and in many cases to treat the obstructing lesion.

METHODS

For the last 2 years, we have been approaching patients with small-bowel obstruction laparoscopically.

RESULTS

We have found this technique to be successful as the definitive treatment in more than half of the cases.

CONCLUSION

The laparoscopic approach should be the modality of choice for most, if not all, cases of small-bowel obstruction in which there is an indication for exploration.

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.

Laparoscopic management of acute small bowel obstruction

BACKGROUND

Laparoscopic management of acute small bowel obstruction is hypothetically attractive but little is known of its clinical potential.

METHODS

A retrospective study was undertaken of patients with acute small bowel obstruction requiring surgery, managed by a laparoscopic unit (LU; n = 69) and a general unit (GU; n = 70).

RESULTS

Laparoscopy was performed in 55 patients (80 per cent) in the LU compared with ten (14 per cent) in the GU. Laparoscopic surgery completed treatment in 31 patients (45 per cent) in the LU and assisted in a further 15 (22 per cent). Patients treated laparoscopically were discharged earlier than those treated by laparotomy (median 3 (range 1-15) versus median 8 (range 1-46) days). Patients treated laparoscopically had a higher chance of early unplanned reoperation than those treated by laparotomy (five of 35 versus four of 88) (P < 0.05).

CONCLUSION

Laparoscopy can be performed in a high percentage of patients requiring surgery for acute small bowel obstruction. Hospital stay was reduced but the risk of early unplanned reoperation was increased in patients managed laparoscopically.

The role of minimal access surgery in the acute abdomen

The improvement in surgical decision-making for patients with abdominal pain but an uncertain diagnosis using DL has now been shown to decrease both negative and nontherapeutic laparotomy rates. Once the diagnosis is established, DL can be taken a step further in many cases, as therapeutic intervention via laparoscopy is possible for a number of these conditions without resorting to a laparotomy. Conditions amenable to therapeutic laparoscopy include appendicitis, perforated peptic ulcer, diverticulitis, small bowel obstruction, acute cholecystitis, diaphragmatic rupture, and splenic or hepatic injuries, to name but a few. However, a number of unanswered questions remain such as: Who should perform emergency laparoscopic procedures? What should the selection criteria be? What are the cost implications? and Is patient outcome actually better with laparoscopy? Only randomized controlled trials can answer these questions. Until such data are available, it is important that common sense prevail. Laparoscopy should be incorporated into the general surgeon's armamentarium for the management of patients with abdominal pain as just another tool to be used selectively when indicated. It is also important that new technologies be carefully evaluated in an unbiased manner under strict protocol so that objective data can be obtained which can be used to devise guidelines for safe and effective use of new devices.

Surgical decisions in the laparoscopic management of small bowel obstruction: report on two cases

Laparoscopic management of bowel obstruction secondary to adhesions presents a difficult challenge for the general surgeon. The surgical management of two such cases is reported here: one patient with recurrent abdominal pain secondary to partial bowel obstruction, the other with acute small bowel obstruction. Surgical decision-making and technical aspects of the procedures are described. With careful patient selection and meticulous technique laparoscopic resolution of bowel obstruction may be feasible and should be attempted.

Finger-assisted laparoscopic surgery

Advances in laparoscopic surgical procedures will facilitate the solution of specific problems, especially in emergency surgery. A simple technique of intracorporeal finger assistance, which permits a fast and safe solution in selected cases involving right and left lower abdominal quadrants, is described. The forefinger, introduced like a cannula, can be used to complete laparoscopic procedures in which there is potential risk for bowel injury or failure in using laparoscopic instruments.

Laparoscopic-assisted colostomy closure after Hartmann's procedure

PURPOSE

The aim of the study was to review our experience with colostomy closure after Hartmann's procedure and the possible impact of laparoscopic colostomy closure.

METHODS

A retrospective review of hospital stay after colostomy closure by laparotomy in the last four years was conducted. A chart review of patients undergoing laparoscopic colostomy closure after Hartmann's procedure since the introduction of operative laparoscopy at our institution was also done.

RESULTS

One hundred twenty patients had colostomy closure carried out by the trauma service at the University of Miami/Jackson Memorial Hospital. In thirty-seven patients, colostomy closure was associated with other surgical procedures such as ventral herniorrhaphy, delayed closure of the open abdomen, ureteroneocytostomy, and so forth, or they underwent loop colostomy closure. These patients were excluded from further review. Sixty-five patients underwent reversal of Hartmann's procedure by laparotomy. They had an average hospital stay of 9.5 days (range, 6 to 34 days). This group of patients had colostomy closure prior to the introduction of operative laparoscopy in our institution. With increased laparoscopy experience, laparoscopically assisted Hartmann's reversal has been attempted in 18 patients and completed in 14 patients. The average hospital stay in the laparoscopically completed group was 6.3 days (range, 4 to 10 days). This group had a 0 percent mortality and a 14.3 percent morbidity. This compares favorably to recently reported series of colostomy closure by laparotomy.

CONCLUSION

Laparoscopically assisted Hartmann's reversal results in comparable morbidity, but may be associated with shorter hospital stay when compared with laparotomy.

Laparoscopic procedures for small bowel disease

Small bowel procedures such as placement of feeding jejunostomy, diagnosis of small bowel ischaemia and obstruction, bowel resection and lysis of adhesions can all be performed laparoscopically. Diagnostic laparoscopy can be performed with low complication rates, and can help avoid unnecessary laparotomy. The open method of trocar placement is preferred in patients with adhesions or distended bowel due to obstruction or ileus. Feeding jejunostomy can be placed by laparoscopically assisted methods, pulling the jejunum out or completely laparoscopically. The latter requires fixation of the jejunum to the abdominal wall by transabdominal sutures or T-fasteners. The T-fastener technique for feeding jejunostomy is simple to perform, safe and effective. Small bowel ischaemia can be difficult to diagnose laparoscopically. Fluorescein and ultrasound Doppler examination of the small bowel may be as useful as in laparotomy, but there is little clinical experience with these techniques. Laparoscopically assisted small bowel resection involves intraperitoneal division of the mesenteric vessels and exteriorization of the small bowel through a small abdominal incision, followed by resection and anastomosis. The causes of small bowel obstruction can be diagnosed laparoscopically, and adhesions can be lysed under laparoscopic guidance. The laparoscopic approach is replacing laparotomy for many small bowel procedures. Improvements in instruments and experience in laparoscopic procedures will continue to make these procedures easier and safer to perform.