With the continuous advancement of laparoscopic technology, it is increasingly used in gastrointestinal surgery, and the treatment of adhesive bowel obstruction is one of them. Since there is less chance of adhesions after laparoscopic surgery, the chance of postoperative recurrence is reduced while minimally invasive.
Adhesive intestinal obstruction accounts for approximately 20% to 40% of all types of intestinal obstruction and is the leading cause of small bowel obstruction. Although most of them can be improved by non-surgical treatment, there are few who eventually need surgical treatment. In many patients, the surgical procedure is simply the release of small pieces of adhesions or even the severance of adhesion cords, and for these patients, a major dissection seems to be more than worth the cost, while minimally invasive laparoscopic surgery is obviously more beneficial [1]. In the last decade or so, some scholars have used laparoscopic surgical techniques for the surgical treatment of adhesive bowel obstruction. However, there is no consensus on the suitability of laparoscopic surgery for adhesive bowel obstruction, and compared with conventional laparoscopic surgery, laparoscopic surgery for adhesive bowel obstruction is still more difficult and requires selection of appropriate patients and adherence to certain operating principles to achieve minimally invasive treatment of the disease. This article is a review of this issue. Zhang Xiaoqiao, Department of General Surgery, General Hospital of Jinan Military Region
I. Feasibility and effect of laparoscopic surgery for the treatment of intestinal obstruction
Since the development of laparoscopic surgery, the common view is that this technology is not suitable for patients with a history of abdominal surgery, and a history of abdominal surgery and intestinal obstruction once became a contraindication to laparoscopic surgery. However, with the development of laparoscopic surgery, surgical techniques and instruments have continued to advance, and since 1991, there have been gradual case reports on the use of laparoscopic surgical techniques for intestinal obstruction surgery, which are considered to have the advantages of minimal trauma and smooth postoperative recovery. In recent years, some scholars have summarized laparoscopic surgery for intestinal obstruction to evaluate its safety and effectiveness (Table 1).
Table 1 Results of laparoscopic surgery for intestinal obstruction
Authors (time of publication)
Number of cases
Success rate
Authors’ evaluation of laparoscopic intestinal obstruction surgery
Becmeur F [2], 1998
86
77%
Laparoscopic surgery can be routinely tried
Strickland P[3], 1999
40
28%
Safe and effective for selected patients
El Dahha AA[4], 1999
14
85.7%
It is a better alternative to open surgery
Al-Mulhim AA[5] 2000
19
68%
Laparoscopic surgery is superior to open surgery for most acute intestinal obstructions
Shalaby R[6] 2001
30
66.7%
A safe, effective, and feasible alternative to cesarean surgery for most patients with acute intestinal obstruction
Franklin ME Jr[7] 2004
167
92.2%
Safe and effective, dissection is challenged
Borzellino G[8] 2004
65
80%
Effective in relieving the obstruction, subject to the definition of indications
Tsumura H [9], 2004
25
72%
Safe and effective in patients with selective recurrent attacks
Cavaliere D [10], 2005
44
64%
Safe, effective and suitable for most emergency patients
As shown in Table 1, recent clinical data indicate that the success rate of complete laparoscopic surgery for intestinal obstruction (mainly adhesive intestinal obstruction) is around 80%, and most authors believe that laparoscopic surgery can achieve a definitive diagnosis and release of the obstruction in most cases of intestinal obstruction.Wullstein compared the results of laparoscopic surgery and open surgery for acute intestinal obstruction in a retrospective paired data analysis. The results found that the intraoperative complication rates were comparable between the two procedures, whereas laparoscopic surgery had lower postoperative complications than open surgery and faster recovery of bowel function and shorter hospital stay, and about half of the patients with intestinal obstruction were suitable for laparoscopic surgery [11]. In addition, some studies have found that the formation of adhesions is reduced after laparoscopic surgery compared with open surgery, and its application to adhesive bowel obstruction may help to reduce the recurrence of obstruction [12].Sato et al. performed laparoscopic adhesion release in 17 patients with recurrent adhesive bowel obstruction after abdominal and pelvic surgery and observed its long-term results. The median observation time was 5 years, with only 2 patients recurring [13]. In the study of Leon et al. 21 patients who underwent laparoscopic surgery did not develop preoperative symptoms during a follow-up period of 2 to 56 months [14]. Thus, the long-term results of laparoscopic surgery for adhesive bowel obstruction are satisfactory.
However, at the same time, it should also be noted that there is an intermediate open surgery rate of about 20% in patients who underwent laparoscopic surgery, and the reasons for intermediate open surgery include, on the one hand, intra-abdominal adhesions that are so dense and extensive that they prevent laparoscopic surgery or the disease itself, such as strangulation or necrosis of the obstructed bowel, and also in some patients due to surgical operations, especially the placement of puncture cannulae and release of adhesions that lead to medical factors such as intestinal rupture [2, 14], therefore, the establishment of criteria used to select patients suitable for laparoscopic surgery is a prerequisite for giving full play to the advantages of laparoscopic surgery.
II. Indications for laparoscopic surgery for adhesive bowel obstruction
The indications for laparoscopic surgery for adhesive bowel obstruction have not been fully established due to the lack of results from prospective randomized controlled clinical trials.Levard et al. retrospectively analyzed 308 cases of acute intestinal obstruction treated laparoscopically from 35 medical centers, of which 168 (54.6%) were operated on completely laparoscopically [15]. The authors found that the success rate of laparoscopic surgery was significantly higher in patients with a history of 1 or 2 operations than in those who had more than 2 abdominal operations (56% vs 37%; P < 0.05), that patients after appendectomy had a higher success rate than those after other operations (71% vs 33%; P < 0.001), and that obstruction caused by a single adherent cord was easier to succeed than that caused by extensive adhesions (54% vs 31%; P < 0.001); therefore, laparoscopy is used for patients with a In a review of 134 cases of adhesive bowel obstruction, Chosidow et al. compared the timing of surgery and found that gastrointestinal decompression followed by surgery had a higher success rate compared with emergency laparoscopy due to limited intra-abdominal access and brittle bowel wall caused by dilated intestine （Suter performed a univariate analysis and logistic regression analysis of 83 cases of laparoscopic intestinal obstruction and found that intestinal tube diameter greater than 4 cm suggested the possibility of conversion to open surgery (55% vs. 32%, p=0.02), with no other predictors. Leon's analysis of 40 patients with intestinal obstruction indicated that laparoscopic surgery was appropriate for those patients without significant dilatation of the intestine due to highly dilated intestinal collaterals that interfered with safe trocar needle placement, prevented pneumoperitoneum establishment, and limited maneuvering space; in addition, persistent partial intestinal obstruction as well as contrast-confirmed recurrent chronic obstruction were suitable for laparoscopic surgery, whereas intra-abdominal Severe and extensive adhesions, frozen abdomen, and significant intestinal necrosis are contraindications to this procedure [14].
In conclusion, most authors now believe that laparoscopic surgery for adhesive bowel obstruction is indicated for those cases with relatively simple intra-abdominal conditions, mild obstruction, and easy release of the cause of obstruction. During the operation, once the intra-abdominal situation is found to be complicated or complications such as organ perforation occur, the abdomen should be turned decisively so as to give full play to the advantages and avoid the disadvantages of laparoscopic surgery.
III. Surgical techniques for laparoscopic adhesive intestinal obstruction [14, 18]
(A) Patient position
The patient is usually placed in a supine position with both upper limbs fixed to the side of the body, and two monitors are placed at the patient’s left shoulder and right hip, parallel to the mesenteric root of the small intestine, to facilitate the operation.
(ii) Into the abdomen
Because the dilated intestinal collaterals are thin and fragile and easily damaged by the puncture cannula, and because there may be intestinal tubes adhering to the anterior abdominal wall, the open Hasson technique should be used to enter the abdominal cavity to establish the pneumoperitoneum in patients with intestinal obstruction, and generally the first puncture hole can be chosen as a straight incision of about 1.5 cm next to the umbilicus to establish the pneumoperitoneum and place the laparoscope, and then under direct vision in the right upper abdomen, left lower abdomen and other places as needed A trocar is then placed by puncture in the right upper abdomen, left lower abdomen, and elsewhere as needed. If the previous procedure was a median incision, the first trocar may be placed in the left upper abdomen or right upper abdomen.
(iii) Exploration and release of adhesions
The adhesions around the laparoscopic trocar can be separated by fingers or bluntly with a laparoscope, or more commonly by sharp separation under direct vision. To avoid thermal damage to the tissues, scissors should be used for separation and electric or ultrasonic knives should be used as little as possible. The procedure should not begin until the entire small intestine is revealed. The entire jejunum and ileum should be systematically explored, starting from the ileocecal region, with two large non-invasive grasping forceps grasping the opposite mesenteric margin of the intestine, and the two forceps alternately probing the proximal end of the small intestine. During the exploration, extra attention should be paid to the dilated intestinal collaterals, whose intestinal walls are thin, and even the application of non-invasive grasping forceps may lead to the risk of intestinal wall damage or even perforation, so the mesentery can be grasped when necessary to operate without touching the intestinal canal. The two grasping forceps must always be in the field of view during the exploration process, so as not to cause injury or even damage to the intestinal canal that cannot be detected due to improper operation, which may lead to serious complications.
After identifying the site of obstruction, laparoscopic scissors should be used to sharply separate the obstructing adhesions, and an electric knife should not be used at this time to avoid thermal damage to the surrounding intestine and to reduce the possibility of tissue ischemia and the resulting formation of additional adhesions. Only pathological adhesions should be released during laparoscopy to avoid increasing the operative time and risk, but if the exact site of obstruction is not found, all suspected adhesions need to be released. All released adhesions must be checked for bleeding or intestinal injury before the end of the procedure.
(iv) Interventional laparotomy
If the intra-abdominal condition is complex and it is difficult to perform laparoscopic surgery, the abdomen should be promptly converted to open or to add a small incision for dissection (minilaparotomy), depending on the situation. Common reasons for this are: dense and extensive intra-abdominal adhesions that make it difficult to enter the abdomen and to define the site of the lesion or to loosen it; serious medical injuries such as intestinal perforation during the exploration; necrosis, rupture, or stenosis of the obstructed intestinal collaterals that require open surgical management; and intestinal obstruction caused by tumors and other causes that require open surgery [2, 14, 18]. Although some injuries that can be treated laparoscopically, such as tears of the plasma surface, do not need to be the cause of conversion to open surgery, in general, with further development of laparoscopic surgery, it is prudent to set lower standards and to convert to open surgery as soon as necessary, which is a prudent approach for both doctors and patients, weighing the subjective and objective conditions such as instrumentation, lesions, and surgical skills, and should not be It should not be considered as a failure of surgery.
In conclusion, laparoscopic surgery for adhesive intestinal obstruction has the advantages of less trauma, faster postoperative recovery, and better long-term results, and is a useful supplement and good alternative to traditional dissection under the premise of selecting appropriate patients, standardizing the operation, and grasping the indications for intermediate laparotomy.
References
1 van der Zee DC, Bax NM. Management of adhesive bowel obstruction in children is changed by laparoscopy [J]. Surg Endosc, 1999, 13(9): 925-927.
2 Becmeur F, Besson R. Treatment of small-bowel obstruction by laparoscopy in children multicentric study. GECI. Groupe d”Etude en Coeliochirurgie Infantile [J]. Eur J Pediatr Surg, 1998, 8(6): 343-346.
3 Strickland P, Lourie DJ, Suddleson EA, et al. Is laparoscopy safe and effective for treatment of acute small-bowel obstruction[J]? Surg Endosc, 1999, 13(7): 695-698.
4 El Dahha AA, Shawkat AM, Bakr AA. Laparoscopic adhesiolysis in acute small bowel obstruction: a preliminary experience[J]. JSLS, 1999, 3(2): 131-135.
5 Al-Mulhim AA. Laparoscopic management of acute small bowel obstruction. experience from a Saudi teaching hospital[J]. Surg Endosc, 2000, 14(2): 157-160.
6 Shalaby R, Desoky A. Laparoscopic approach to small intestinal obstruction in children: a preliminary experience[J]. Surg Laparosc Endosc Percutan Tech, 2001, 11(5): 301-305.
7 Franklin ME Jr, Gonzalez JJ Jr, Miter DB, et al. Laparoscopic diagnosis and treatment of intestinal obstruction[J]. Surg Endosc, 2004, 18(1): 26-30.
8 Borzellino G, Tasselli S, Zerman G, et al. Laparoscopic approach to postoperative adhesive obstruction[J]. Surg Endosc, 2004, 18(4): 686-690.
9 Tsumura H, Ichikawa T, Murakami Y, et al. Laparoscopic adhesiolysis for recurrent postoperative small bowel obstruction[J]. Hepatogastroenterology, 2004, 51(58): 1058- 1061.
10 Cavaliere D, Schirru A, Caristo I, et al. Laparoscopic management of small-bowel obstruction[J]. Chir Ital, 2005, 57(2): 215-220.
11 Wullstein C, Gross E. Laparoscopic compared with conventional treatment of acute adhesive small bowel obstruction[J]. Br J Surg, 2003, 90(9): 1147-1151.
12 Gutt CN, Oniu T, Schemmer P, et al. Fewer adhesions induced by laparoscopic surgery[J]? Surg Endosc, 2004, 18(6): 898-906.
13 Sato Y, Ido K, Kumagai M, et al. Laparoscopic adhesiolysis for recurrent small bowel obstruction: long-term follow-up[J]. Gastrointest Endosc, 2001, 54(4): 476-479.
14 Leon EL, Metzger A, Tsiotos GG, et al. Laparoscopic management of small bowel obstruction: indications and outcome[J]. J Gastrointest Surg, 1998, 2(2): 132-140.
15 Levard H, Boudet MJ, Msika S, et al. Laparoscopic treatment of acute small bowel obstruction: a multicentre retrospective study[J]. ANZ J Surg, 2001, 71(11): 641-646.
16 Chosidow D, Johanet H, Montariol T, et al. Laparoscopy for acute small-bowel obstruction secondary to adhesions[J]. J Laparoendosc Adv Surg Tech A, 2000, 10(3): 155-159.
17 Suter M, Zermatten P, Halkic N, et al. Laparoscopic management of mechanical small bowel obstruction: are there predictors of success or failure[J]? Surg Endosc, 2000, 14(5): 478-483.
18 Nagle A, Ujiki M, Denham W, et al. Laparoscopic adhesiolysis for small bowel obstruction[J]. Am J Surg, 2004, 187(4): 464-470.
[This article was published in the Journal of Practical Clinical Medicine 2005].