Laparoscopic management of small bowel obstruction

Objectives: To evaluate safety, feasibility, and results of laparoscopic management of small bowel obstruction. Subjects and methods: A retrospective study on 124 acute small bowel obstruction cases, who were applied laparoscopy from 6 - 2010 to 8 - 2017.

LAPAROSCOPIC MANAGEMENT OF SMALL

BOWEL OBSTRUCTION

Nguyen Van Tiep * ; Lai Ba Thanh * ; Le Thanh Son*

Dang Viet Dung * ; Nguyen Trong Hoe * ; Ho Chi Thanh *

SUMMARY

Objectives: To evaluate safety, feasibility, and results of laparoscopic management of small

bowel obstruction Subjects and methods: A retrospective study on 124 acute small bowel

obstruction cases, who were applied laparoscopy from 6 - 2010 to 8 - 2017 Results:

Laparoscopic management were indicated for postoperative obstruction (46.0%), phytobezoar

(30.6%) and unknown causes (23.4%), which determined causes of obstruction, suitable

surgical method choice: totally laparoscopy (47.6%), laparoscopy-assisted small laparotomy

(33.1%), large laparotomy (19.3%) Laparoscopy and assisted laparoscopy were safety,

shortened recovery time of patients with oral meal time was 2.8 days, postoperative hospital

stay was 5.3 days Conclusion: Laparoscopic management of selected small bowel obstruction

was safety, feasibility and shortened recovery time of patients

* Keywords: Small bowel obstruction; Laparoscopy management

INTRODUCTION

Bowel obstruction is a common surgery

emergency treatment Small bowel

obstruction (SBO) has a variety of causes

such as adhesions, bands following

abdominal surgery, phytobezoar or some

other rare causes such as hernia,

neoplasm, etc Surgical management of

SBO depends on the causes Some

cases are simple with cutting the bands

only While, some cases are complex

if intestinal dissection needed These

operations were usually performed through

the midline incision Laparoscopic surgery

has recently applied with many advantages

in identifying causes and management

of the acute SOB in selected patients [1, 3,

4, 6] Abdominal distension and other complex causes are main disadvantages

in selecting indication of laparoscopic management of small bowel obstruction [2, 5]

The effect of this procedure is controversial In order to clarify clearly the indications, outcomes of the laparoscopic management of small bowel obstruction,

we conducted this study with the aim: To

describe lesion characteristics, technique and early outcomes of the laparoscopic management of SBO at 103 Military Hospital from 6 - 2010 to 8 - 2017

*

**

Corresponding author: Le Van Quan (@gmail.com)

Date accepted: 30/05/2018

SUBJECTS AND METHODS

A retrospective study on 124 patients

who were definitely diagnosed with SBO

based on clinical characteristics, X-ray,

and intraoperative lesions All patients

were indicated laparoscopic management

based on clinical characteristics and prior

conservative results

Collecting clinical characteristics, causes,

techniques and postoperative outcomes

Data were analyzed by Microsoft Excel

software with statistical tests

* Indication, contraindication and medical

procedure:

- Indication: Mild abdominal distension,

incomplete ileus, prediction of simple

etiologies, patients with early operation

within 24 hours since the symptoms

appeared, less than 3 times of abdominal

operations in history

- Contraindication: Severe abdominal

distension, diffuse peritonitis due to late

operations, hemodynamic instability, shock,

severe morbidities of cardiac and respiratory

diseases

- Procedure: Locating the trocar site,

the first trocar insertion technique has a

vital role with the surgeon Almost of the

authors advise inserting the trocar in an

open way, clearly observe and stay far

away from the previous scars Later

trocars would be carefully inserted under

the observation of camera to avoid

intestine perforations [3, 4, 5] The next

step, being the most important one, is to

approach and determine the location and

the cause of ileus

Normally, the obstructed location is the conjunction of distended intestines and collapsed intestines Like open operations, most authors agree that collapsed intestines should be initially observed and then, look upwards because endoscopic tools are likely to hurt distended intestines easily

If the obstructed location and cause were determined, the mission left is how

to solve the lesion, through laparoscopic surgery or switch to open surgery The laparoscopic surgeries, actually, are able

to solve or play a supportive role in the solution of ileus etiologies The laparoscopic surgery can release adhesions, intestine resection and anastomosis, release the obstructed hernia… Or it can at least guide the sites and abdominal open incision

to continue the procedure

RESULTS AND DISSCUSION

1 Pathological indices

- Mean age was 50.9 ± 21; the youngest was 10 and the eldest was 87; male proportion was 50%

- Mean BMI was 22.36 ± 1.9; min 18; max 26

- Duration of obstruction: Mean time was 3.0 ± 1.8 days, the shortest was 1 day and the longest was 10 days

* Levels of abdominal distension in operating:

In this study, according to a research

of Le Thanh Son [2]: levels of distension were used in our study:

- Mild: Abdominal distension, the highest

abdomen depth does not exceed the chest

depth in supine position

- Moderate: Abdominal distension, the

highest abdomen depth is equal to or

higher than the chest depth in supine

position but the abdomen still cooperates

with the respiratory motion

- Severe: Abdominal distension, the

highest abdomen depth is higher than the

chest depth in supine position but the

abdomen does not cooperate with the

respiratory motion

As above conventional rules, the

distribution of patients according to the

state of the abdominal distension as follows:

- Preoperative abdominal distension: Mild distension: 9 patients (7.2%); moderate distension: 103 patients (83.1%); severe distension: 12 patients (9.7%)

* Preoperative diagnosis:

- Causes and preoperative diagnosis: Post-operative: 66 patients (53.2%); phytobezoar: 32 patients (25.8%); mechanical, unknown causesa: 26 patients (21.0%)

(a : Mechanical small obstruction cases

were definitely diagnosed based on clinical characteristics, plain X-ray, abdominal ultrasound and CT-Scanner, but no definite cause detection, for example post-operation, phytobezoar, abdominal

wall hernia, etc)

Table 1: Causes and postoperative diagnosis

Others

(b : 11 patients without prior abdominal operation, the cause, which was identified

in operating, was band or adhesion In this study, these lesions named primary band

or adhesion)

* The relationship between the preoperative diagnosis and causes of obstruction/postoperative diagnosis:

Table 2: The relationship between the preoperative and postoperative cause identification

Causes

Postoperative Phytobezoar Unknown Causes and

postopera-tive

diagnosis

2 Causes and management

Table 3: Surgical methods

Causes and management

Method

Total Laparoscopy

Laparoscopy-assisted small laparotomy

Large laparotomy

Jejuno-jejunal intussusception

(c : Laparoscopy-assisted small laparotomy is to open the abdomen with a small incision (3 - 7 cm length) with the direction of laparoscopy to manage the lesions)

In this study, 59 patients (47.6%) were

totally managed the lesions by laparoscopy

totally, according to a research of O'Connor

D.B (2,005 patients), laparoscopy was

completed in 1,284 cases (64%) [7] They

were simple lesions, managed by cutting

the band or adhesion dissection 1 case

with inner-hernia, which caused by defecting

large fascia, was reconstructed the fascia

band after releasing the obstructive bowel

2 cases with ileo-ileal intussusception,

which were released the intussusception

and stitched the ileo-ileal permanently

According to Burton E, Kirshtein B and

Ettinger J.E: there were 3 factors related

to the ability of using laparoscopy to

completely manage the bowel obstruction

that we withdrew They are, not very

complex cause, surgeon skills (surgical

skills, disclosure the surgical field, trocar

position, etc) and equipment (300, 450 rigid endoscope, a traumatic tools, etc) [3, 4, 6]

41 cases (33.1%) were managed by laparoscopy-assisted small laparotomy to solve the lesions Most of them (24 cases) with bowel obstruction by phytobezoar and were managed by the right paramedian incision or Mac Burney’s incision to take out phytobezoar or push the phytobezoar into the cecum 4 cases with bowel neoplasm were cut a section of bowel and restored the circulation through a 5 - 7 cm incision In cases of small laparotomy, the laparoscopy helped to identify the lesions and gave the direction for an easy incision 24 cases (19.3%) were managed

by the midline incision opening to solve complex lesions caused by adhesion, band or volvulus and phytobezoar with necrosis within 7 days

Table 4: The relationship between surgical methods and levels of abdominal distension

Levels of

abdominal distension

Laparoscopy Laparoscopy with laparotomyc Large laparotomy

According to Farinella E, O'Connor D.B and Duong Trong Hien: Severe level of abdominal distension is associated with the ability of laparoscopy because it limits the surgical field as well as usually combines with complex obstruction [1, 5, 7] In this study, there were 7 cases with severe distension and managed by wide abdomen opening to solve the lesion (5.6%)

In the case of wide abdomen opening, the rate of wide abdomen opening in mild, moderate and severe distension groups was 0%; 15.5% and 66.6%, respectively, the difference was statistically significant (p < 0.05)

3 Early outcomes

* Surgical catastrophe:

One patient with intestinal perforation because the trocar insertion was placed in a postoperative adhesion case and severe abdominal distension which performed wide abdomen opening to solve the problem Two cases with tear of intestinal muscular layer when releasing adhesion and then reconstructing them through laparoscopy

* Postoperative results:

100 cases were performed laparoscopy or laparoscopy-assisted small laparotomy There were no postoperative early complications Postoperative recovery time was shown below

Table 5: Postoperative recovery

Meantime to recovery

Laparoscopy (59 patients)

Laparoscopy-assisted small laparotomy c (41 patients)

Total (100 patients)

Mean time of flatus (hours) 37.6 ± 16.8 59.0 ± 14.1 45.6 ± 19.2

Time of postoperative liquid feeding

Time of postoperative hospital stay

Ó connor D (2012) reported that laparoscopy for SBO management was safe, feasible, and valuable in minimally invasive surgery that helps patients decrease complications and early postoperative recovery [7] Median postoperative hospital stay was 5.3 days, according to Yao S, median postoperative hospital stay was 8 days [8]

CONCLUSION

The laparoscopy is feasible to manage

the SBO in patients with mild to moderate

abdominal obstruction with various causes

such as postoperative adhesion (46.0%),

phytobezoar (30.6%) and unknown

mechanical causes prior operation (23.4%)

Laparoscopy which helped identify the

exact cause, level of injury as a basis to

choose the appropriate surgical method:

laparoscopy (47.6%), laparoscopy-assisted

small laparotomy (33.1%), large laparotomy

(19.3%)

Laparoscopic surgery and assisted laparoscopy in management of SBO in the study group were safe, helps patients shorten the recovery time with mean time

of fart was 45.6 hours, time of postoperative feeding was 2.8 days and time of postoperative inpatient was 5.3 days

REFERENCES

1 Dương Trọng Hiền, Trần Bình Giang,

Hà Văn Quyết Kết quả điều trị tắc ruột sau

mổ bằng phẫu thuật nội soi Phẫu thuật nội

soi và nội soi Việt Nam 2012, 2, tr.70-75

2 Lê Thanh Sơn Phẫu thuật nội soi điều

trị tắc ruột sau mổ Tạp chí Y-Dược học quân

sự 2015, 40, tr.193-196

3 Burton E, McKeating J, Stahlfeld K

Laparoscopic management of a small bowel

obstruction of unknown cause JSLS 2008,

12, pp.299-302

4 Ettinger J.E, Reis J.M.S et al

Laparoscopic management of intestinal

obstruction due to phytobezoar JSLS 2007,

11, pp.168-171

5 Farinella E, Cirocchi R et al Feasibility

of laparoscopy for small bowel obstruction

World Journal of Emergency Surgery 2009, 3 (4)

6 Kirshtein B, Roy-Shapira A et al

Laparoscopic management of acute small

bowel obstruction Surg Endocs 2005, 19 (4),

pp.464-467

7 O'Connor D.B, Winter D.C "The role of

laparoscopy in the management of acute small-bowel obstruction: a review of over

2,000 cases Surg Endocs 2012, 26 (1),

pp.12-17

8 Yao S, Tanaka E et al Outcomes

of laparoscopic management of acute small owel obstruction: a 7-year experience of 110 consecutive cases with various etiologies Surgery Today 2016, 47 (4), pp.432-439