Elective laparoscopy for herald symptoms of mesenteric/internal hernia after laparoscopic Roux-en-Y gastric bypass

BackgroundMesenteric internal hernia (MIH) is the most common cause of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass. Because MIH is a potentially life-threatening complication, we hypothesized that elective repair of MIH before developing acute SBO could decrease morbidity in this population.MethodsThe records of 702 consecutive patients undergoing primary laparoscopic Roux-en-Y gastric bypass from January 2002 and August 2007 were retrospectively reviewed to determine the incidence and etiology of SBO. During the last 9 months of the study, we offered elective laparoscopy to any patient who presented to us with symptoms of intermittent SBO.ResultsOf the 702 patients, 27 (3.8%) developed acute SBO. Of these 27 patients, 15 (55%) had obstruction related to an MIH. Nearly all patients had a typical history of intermittent abdominal pain, nausea, and bloating before developing acute SBO. Elective laparoscopy was offered to 11 patients with symptoms of intermittent SBO. Two patients who refused subsequently underwent operations for acute SBO. MIH was found at elective laparoscopic exploration in all cases. Of the 9 patients undergoing elective surgery, 3 (33%) had small bowel volvulus.ConclusionSBO due to MIH after laparoscopic Roux-en-Y gastric bypass is typically preceded by symptoms of intermittent obstruction. Patients who have these herald symptoms should promptly be offered elective laparoscopic exploration. Elective repair of MIH can be performed safely and expeditiously.     

Small bowel obstruction

Background: This is a retrospective review of our experience using a laparoscopic approach in the treatment of acute and chronic small bowel obstruction (SBO). Materials and methods: Of 136 patients hospitalized in our institutions for acute (94 cases: 69.1%) and chronic (42 cases: 30.8%) SBO, from January 1994 to March 1998, 63 (46.3%) were approached laparoscopically. The etiology was accurately diagnosed in 58 cases (92%), and it was possible to treat it laparoscopically in 82.5% (52 of 63 cases). In the remaining 11 cases (17.4%), a formal laparotomy was needed for bowel resection, due to an ischemic small bowel or for malignant disease. Results: Overall, 82.5% of our cases were successfully treated laparoscopically. Conclusions: We conclude that, in experienced hands, laparoscopy is an excellent diagnostic and, in the majority of cases, a therapeutic surgical approach in selected patients with acute or chronic SBO. Received: 30 June 1998/Accepted: 12 February 1999     

Small Bowel Obstruction After Antecolic Antegastric Laparoscopic Roux-en-Y Gastric Bypass Without Division of Small Bowel Mesentery: A Single-Centre, 7-Year Review

Reported incidence of small bowel obstruction (SBO) after laparoscopic Roux-en-Y gastric bypass varies between 1.5% and 3.5%. It has been suggested that the antecolic antegastric laparoscopic Roux-en-Y gastric bypass (AA-LRYGB) is associated with a low incidence of internal herniation (IH). Therefore we routinely did not close mesenteric defects. The records of 652 consecutive patients undergoing primary AA-LRYGB from January 2003 to December 2009 in a single institution were retrospectively reviewed to determine the incidence, etiology, clinical symptoms, radiologic diagnostic accuracy and operative outcomes of SBO. Of the 652 patients, 63 (9.6%) developed SBO. The majority (6.9%, 45 patients) had a SBO due to IH. In 41 (91%) cases, the IH was at the jejunojejunostomy (JJ), four cases had an IH at Petersen’s space. Adhesions and ventral hernia were found in 14 (2.1%) and four (0.6%) cases, respectively. Twenty-nine out of 63 cases had negative computed tomography (CT) findings and IH was diagnosed on CT in only 33% (14/45) of patients with IH. All patients underwent diagnostic laparoscopy. No bowel resections had to be performed. In contrast to previous reports, a high incidence of SBO with a high rate of IH at the JJ site was found in our series. Accuracy of CT is low and diagnostic laparoscopy is mandatory when SBO is suspected. Since 2010 we have started closing the JJ site, and data on SBO are collected prospectively. We believe that closing of the mesenteric defects is a mandatory step, even in an AA-LRYGB.     

Is laparoscopy safe and effective for treatment of acute small-bowel obstruction?

Background: Acute small bowel obstruction (SBO) has been a relative contraindication for laparoscopic treatment due to the potential for bowel distention and the risk of enteric injury. However, as laparoscopic experience has increased, surgeons have begun to apply minimal access techniques to the management of acute SBO. Methods: A retrospective review was performed of all patients with acute SBO in whom laparoscopic treatment was attempted. Patients with chronic symptoms and elective admission were excluded. Patients treated by laparoscopy were compared to those converted to laparotomy for differences in morbidity, postoperative length of stay, and return of bowel function as evidenced by toleration of a liquid diet. Results: Laparoscopy was performed in 40 patients for acute SBO. The etiologies of obstruction included adhesions (35 cases), Meckel's diverticulum (two cases), femoral hernia (one case), periappendiceal abscess (one case), and regional enteritis (one case). Laparoscopic treatment was possible in 24 patients (60%), but 13 patients required conversion to laparotomy for inadequate laparoscopic visualization (two cases), infarcted bowel (two cases), enterotomy (four cases), and inability to relieve the obstruction laparoscopically (five cases). There were ten complications—one in the laparoscopic group (pneumonia) and nine in the converted group (prolonged ileus, four cases; wound infection, two cases; pneumonia, two cases; and perioperative myocardial infarction, one case). Respectively, the laparoscopic and converted groups had mean operative times of 68 and 106 min a mean return of bowel function of 1.8 and 6.2 days, and a mean postoperative stay of 3.6 and 10.5 days. Long-term follow-up was available in 34 patients. One recurrence of SBO requiring operation occurred in each group during a mean follow-up of 88 weeks. Conclusions: Laparoscopy is a safe and effective procedure for the treatment of acute SBO in selected patients. This approach requires surgeons to have a low threshold for conversion to laparotomy. Laparoscopic treatment appears to result in an earlier return of bowel function and a shorter postoperative length of stay, and it will likely have lower costs. Received: 31 March 1998/Accepted: 25 August 1998     

Laparoscopic Lysis of Adhesions

Background Intra-abdominal adhesions constitute between 49% and 74% of the causes of small bowel obstruction. Traditionally, laparotomy and open adhesiolysis have been the treatment for patients who have failed conservative measures or when clinical and physiologic derangements suggest toxemia and/or ischemia. With the increased popularity of laparoscopy, recent promising reports indicate the feasibility and potential superiority of the minimally invasive approach to the adhesion-encased abdomen. Methods The purpose of this study was to assess the outcome of laparoscopic adhesiolysis and to provide technical tips that help in the success of this technique. Results The most important predictive factor of adhesion formation is a history of previous abdominal surgery ranging from 67%–93% in the literature. Conversely, 31% of scars from previous surgery have been free of adhesions, whereas up to 10% of patients without any prior surgical scars will have spontaneous adhesions of the bowel or omentum. Most intestinal obstructions follow open lower abdominopelvic surgeries such as colectomy, appendectomy, and hysterectomy. The most common complications associated with adhesions are small bowel obstruction (SBO) and chronic pain syndrome. The treatment of uncomplicated SBO is generally conservative, especially with incomplete obstruction and the absence of systemic toxemia, ischemia, or strangulation. When conservative treatment fails, surgical options include conventional open or minimally invasive approaches; the latter have become increasing more popular for lysis of adhesions and the treatment of SBO. Generally, 63% of the length of a laparotomy incision is involved in adhesion formation to the abdominal wall. Furthermore, the incidence of ventral hernia after a laparotomy ranges between 11% and 20% versus the 0.02%–2.4% incidence of port site herniation. Additional benefits of the minimally invasive approaches include a decreased incidence of wound infection and postoperative pneumonia and a more rapid return of bowel function resulting in a shorter hospital stay. In long-term follow up, the success rate of laparoscopic lysis of adhesions remains between 46% and 87%. Operative times for laparoscopy range from 58 to 108 minutes; conversion rates range from 6.7% to 43%; and the incidence of intraoperative enterotomy ranges from 3% to 17.6%. The length of hospitalization is 4–6 days in most series. Conclusions Laparoscopic lysis of adhesions seems to be safe in the hands of well-trained laparoscopic surgeons. This technique should be mastered by the advanced laparoscopic surgeon not only for its usefulness in the pathologies discussed here but also for adhesions commonly encountered during other laparoscopic procedures.     

Laparoskopie bei Dünndarmileus

Today laparoscopic procedures are routinely performed in patients with intestinal adhesions from previous abdominal surgery. Does laparoscopy have a potential benefit in acute small-bowel obstruction? Theoretically, a lower rate of wound complications and incisional hernias, as well as less subsequent adhesions with a lower incidence of recurrent intestinal obstruction, can be expected. However, laparoscopy is successful in only 50-70% of selected patients, thereby representing the highest rate of conversion in minimally invasive surgery. Laparoscopic management of severe abdominal distension with massively dilated and fragile small-bowel or dense adhesions is extremely difficult even when performed by experienced surgeons. Significantly prolonged operating time, the high risk of bowel injury (> 6-10%) and an increased frequency of early reoperations jeopardize the patient's safe outcome. However, in strictly selected patients the laparoscopic approach may be promising. In acute intestinal obstruction without a history of previous abdominal surgery, laparoscopy is--in the absence of adhesions--an excellent diagnostic tool and may also be a successful therapeutic modality in a variety of bowel-obstruction etiologies. Furthermore, the laparoscopic option should be considered in patients who previously had undergone small laparotomies (e.g., appendectomy) or laparoscopic surgery. We recommend "postlaparoscopic" intestinal obstruction as the ideal case for laparoscopic reexploration. Incarcerated hernias at the site of trocar insertion or adhesions due to peritoneal tears are easily identified as the cause of obstruction and successfully cured with the laparoscope. In conclusion, we advocate the laparoscopic approach in acute small-bowel obstruction exclusively for selected patients. Clinical studies are required to define appropriate surgical indications objectively.     

Internal hernia through an iatrogenic defect in the falciform ligament: a case report

The incidence of internal hernia through a defect in the falciform ligament, mostly congenital, is very rare. In this era of minimally invasive laparoscopic surgeries, a few cases of internal hernia through an iatrogenic defect in the falciform ligament have also been reported. Here, we present a case of a 65-year-old patient who presented with acute small-bowel obstruction. The patient had undergone a laparoscopic fundoplication 4 years ago. On diagnostic laparoscopy, it was found that the cause of the intestinal obstruction was herniation of the small bowel through a window in the falciform ligament (which was probably created due to port insertion during the previous surgery of laparoscopic fundoplication). The obstruction was relieved by the division of the falciform ligament.     

Laparoscopic approach to small bowel obstruction

Historically, laparotomy and open adhesiolysis have been the treatment of choice for patients requiring surgery with small bowel obstruction (SBO), although laparotomy itself is an independent risk factor for bowel obstruction. Laparoscopy is known to create fewer intra-abdominal adhesions than open laparotomy. The observation that many patients with SBO have isolated adhesive bands has led to the use of laparoscopy as primary treatment of SBO by some authors. Although the laparoscopic approach to SBO has been described, the outcomes and indications are not well established. We will review the available literature regarding the laparoscopic approach to SBO. Additionally, we will describe the technique and make recommendations regarding which patients may be best suited for a trial of laparoscopy for adhesiolysis.     

Laparoscopic management of adhesive small bowel obstruction

Adhesions from prior surgery are the most common cause of small bowel obstruction (SBO) in the Western world. Although laparoscopic adhesiolysis can be performed safely and effectively, the indications and contraindications to the use of laparoscopic techniques in SBO are not clearly defined. The goal of our study was to determine the outcomes of the laparoscopic approach to SBO and discuss patient considerations for its utilization. We retrospectively surveyed all patients undergoing laparoscopic or attempted laparoscopic adhesiolysis performed by the authors between July 1997 and March 2006. Data obtained included patient demographics, clinical and radiologic presentation, and intraoperative and postoperative course. Thirty-three patients underwent laparoscopic adhesiolysis secondary to a SBO. Mean age was 53.6 years (range, 29-84 years) and 64 per cent (21 of 33) were female. Mean body mass index was 30.0 kg/m2 (range, 22.6-46.1 kg/m2). Thirty-one patients (93.9%) had undergone between one and four abdominal surgeries and seven (21.2%) had a previous episode of SBO. There were no patients with peritonitis. Abdominal CT scan was performed preoperatively in 27 patients (81.8%). Laparoscopy diagnosed the site of obstruction in all patients. Twenty-nine patients (88%) were successfully treated laparoscopically. Conversion to laparotomy was required in four cases as a result of dense adhesions and/or a lack of working space. Mean procedural time was 101 minutes (range, 19-198 minutes). There was one intraoperative complication (enterotomy), which was repaired laparoscopically and did not require conversion. Conversion was associated with significantly increased procedural time (129 versus 93 minutes; P = 0.02), but not blood loss or complications. Average times to passage of flatus and first bowel movement were 2.3 days (range, 0.5-5 days) and 3.2 days (range, 1-6 days), respectively. Seven patients (21.2%) had postoperative complications, including wound infection, urinary tract infection, and acute renal insufficiency, all of which occurred in patients completed laparoscopically. One patient had a recurrent SBO 8 months postoperatively managed by repeat laparoscopic lysis of adhesions. Mean postoperative stay was 6 days (range, 1-19 days). There was no hospital mortality. Laparoscopy is safe and feasible in the management of acute SBO in selected patients. It is an excellent diagnostic tool and is therapeutic in most cases.