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     

Small Bowel Obstruction and Internal Hernias after Laparoscopic Roux-en-Y Gastric Bypass

Background: Small bowel obstruction (SBO) is a recognized complication of open bariatric surgery; however, the incidence after laparoscopic procedures is not clearly established. This paper reviews our experience with small bowel obstruction after laparoscopic Roux-en-Y gastric bypass. Methods: Between 1995 and 2001, 711 (246 antecolic, 465 retrocolic) patients underwent a laparoscopic proximal divided Roux-en-Y gastric bypass via the linear endostapler technique. 13 patients (1.8%) developed SBO requiring surgical intervention.There were 11 females and 2 males, ages 29-60 (mean 38), with mean weight 126 kg (range 105-188), and mean BMI 50 (range 41-59). 7 obstructive patients (55%) had undergone previous open abdominal surgery. Median time to obstruction was 21 days (range 5-1095). Mean follow-up of all patients is 43 months (range 3-79). Results: Etiology of obstruction was internal hernia - 6, adhesive bands - 5 (only 2 were related to prior open surgery), mesocolon window scarring - 1, and incarcerated ventral hernia - 1. The incidence of SBO was 4.5% (11/246) in the retrocolic group, and 0.43% (2/465) in the antecolic group, which was highly significant (P=.006). 1 adhesive patient required an open bowel resection for ischemia. There was 1 death. Conclusion: SBO occurred with an overall incidence of 1.8% in a large series of laparoscopic gastric bypass patients, and was associated with a high morbidity. A significant decrease in occurrence was found after adoption of antecolic placement of the Roux limb.     

Laparoscopic re-exploration in mechanical bowel obstruction after laparoscopic gastric bypass for morbid obesità

AIM: This study reports a series of 7 patients who experienced small-bowel obstruction (SBO) after laparoscopic gastric bypass (LGBP). METHODS: Between July 2001 and June 2004, 211 patients underwent surgery for morbid obesity in 2 different institutions and 7 of them required reoperative laparoscopic surgery or laparotomy for mechanical SBO. RESULTS: Seven patients in the series (3%) developed a postoperative bowel obstruction requiring operative management. Their mean body mass index was 49 (range: 38-65) and the average age was 48 years (range 29-60). Six (86%) had undergone an initial LGBP. One (14%) had been converted to open surgery because of the presence of thick adhesions. One percent of the patients (14%) had undergone abdominal surgery prior to gastric bypass. The most common cause of SBO was internal hernia through a mesenteric defect (57%), followed by adhesions (14%), obstruction at the entero-enterostomy (14%) and Petersen hernia (14%). The obstruction was managed laparoscopically. Small-bowel resection was required in 14% with no death encountered after the second revision of the entero-enterostomy. Recovery time was less than 72 h after laparoscopic approach and more than 92 h following the open procedure. CONCLUSIONS: Laparoscopic surgical correction of SBO following LGBP in morbidly obese patients is feasible. Reoperation of morbidly obese patients after LGBP can be achieved successfully through laparoscopic techniques.     

Does means of access affect the incidence of small bowel obstruction and ventral hernia after bowel resection? Laparoscopy versus laparotomy

BACKGROUND: Laparotomy for bowel resection is causally related to the development of small bowel obstruction (SBO) and ventral hernia, with incidences approaching 12% to 15% each. This report attempts to define the incidence of these access-related complications in a large group of patients undergoing laparoscopic-assisted bowel resection (LABR) and open bowel operation (OPEN). STUDY DESIGN: A retrospective cohort of 716 consecutive patients undergoing either LABR (n = 211) or OPEN (n = 505) procedures between January 1995 and July 2000 was identified and selected from a prospective registry. RESULTS: Index LABR (n = 211) and OPEN (n = 505) cases included segmental colectomy in 146 LABR and 408 OPEN patients; subtotal colectomy with or without stoma in 18 LABR and 6 OPEN patients; ileocolectomy in 37 LABR and 85 OPEN patients; and small bowel resection in 10 LABR and 6 OPEN patients. The mean followup periods in the LABR and OPEN groups were 2.71 years and 2.42 years, respectively.The incidence of wound hernia was significantly higher in OPEN cases (n = 65) compared with LABR (n = 5) (p < 0.05). The incidence of surgical repair of ventral hernia was also significantly higher in the OPEN group (28) compared with LABR (4) (p < 0.05). Postoperative SBO requiring hospitalization with conservative management occurred significantly less frequently in LABR patients (n = 4) compared with OPEN patients (n = 31) (p = 0.016). The need for surgical release of SBO was similar between the OPEN and LABR groups (n = 4 versus n = 11). The overall reoperation rate for these two complications was two times higher in the OPEN group than in the LABR group (7.7% versus 3.8%). CONCLUSIONS: The data demonstrate that laparoscopic access for bowel operation significantly reduces the incidence of ventral hernia and SBO rates compared with laparotomy. This reduces the need for readmission to the hospital and additional surgical procedures, providing a potential source of decreased morbidity. It should be considered as a means of cost savings associated with laparoscopic bowel operations.     

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.     

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.     

Small bowel obstruction: a population-based appraisal

BACKGROUND: Small bowel obstruction (SBO) is a common reason for surgical consultation, but little is known about the natural history of SBO. We performed a population-based analysis to evaluate SBO frequency, type of operation, and longterm outcomes. STUDY DESIGN: Using the California Inpatient File, we identified all patients admitted in 1997 with a diagnosis of SBO. Patients were excluded if they had a diagnosis of bowel obstruction in the previous 6 years (1991 to 1996). Of the remaining cohort, the natural history of SBO over the subsequent 5 years (1998 to 2002) was analyzed. Index hospitalization outcomes (eg, surgical versus nonsurgical management, length of stay, in-hospital mortality), and longterm outcomes, including SBO readmissions and 1-year mortality, were evaluated. RESULTS: We identified 32,583 patients with an index admission for SBO in 1997; 24% had surgery during the index admission. The distribution of surgical procedures was: 38% lysis of adhesions, 38% hernia repair, 18% small bowel resection with lysis of adhesions, and 6% small bowel resection with hernia repair. Patients who underwent operations during index admission had longer lengths of stay, lower mortality, fewer SBO readmissions, and longer time to readmission than patients treated nonsurgically. Regardless of treatment during the index admission, 81% of surviving patients had no additional SBO readmissions over the subsequent 5 years. CONCLUSIONS: Most of the 32,583 patients requiring admission for index SBO in 1997 were treated nonsurgically, and few of these patients were readmitted. This is the first longitudinal population-based analysis of SBO evaluating surgical versus nonsurgical management and outcomes, including mortality and readmissions.     

The laparoscopic management of small-bowel obstruction

BACKGROUND: Small-bowel obstruction (SBO) is a common cause of hospital admission. Our objectives were to determine outcomes of laparoscopic adhesiolysis and outline clinical parameters for its utilization. METHODS: We reviewed medical records of patients with SBO undergoing initial laparoscopic treatment by the authors between July 1997 and March 2006. Data obtained included demographics, clinical and radiologic presentation, intraoperative outcomes, and postoperative course. RESULTS: Forty-two patients were included for analysis. The mean age was 54.3 years, whereas the mean body mass index was 29.5 (range 20.2-46.1). Laparoscopy diagnosed the site of obstruction in all patients. Thirty-five patients (83.3%) were successfully treated laparoscopically without conversion to laparotomy. The median procedural time was lower in patients completed laparoscopically (96.3 vs 207.3 minutes, P = .006). The median postoperative stay was 6.5 days (range 1-19) in patients who were completed laparoscopically. CONCLUSIONS: Laparoscopy is safe and feasible in the management of acute SBO in selected patients. It is an excellent diagnostic tool and therapeutic in most cases.     

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     

Treatment of nonadhesive bowel obstruction following gastric bypass

BACKGROUND: Bowel obstruction secondary to internal hernias following laparoscopic and open gastric bypass is well reported. The number of gastric bypasses being performed in the United States continues to increase. As many patients undergo surgery at centers geographically distant from their home, increasing numbers of patients will present to their local emergency rooms with abdominal complaints that will need to be addressed by general surgeons who are not performing bariatric surgery. METHODS: Review of a prospective database of patients operated on in a general surgery practice performing bariatric surgery. RESULTS: Over a 14-month period, 9 patients requiring operative intervention presented to our practice with nonadhesive bowel obstruction following both open and laparoscopic bariatric surgery. Causes of obstructions included cicatrical narrowing in the Roux limb at the transverse mesocolon defect (1 patient) and internal hernias through the transverse mesocolon (5 patients), Petersen's hernia (2 patients), and at the jejunojejunostomy (1 patient). Seven patients were treated laparoscopically and 2 underwent laparotomy. Our diagnostic and operative approach is described. CONCLUSIONS: Surgeons, including those not performing bariatric surgery, will be treating more patients with bowel obstruction following gastric bypass in the future. The etiology and management of bowel obstruction after gastric bypass differs from the conventional management of bowel obstruction. When surgery is required, most of these patients can be treated laparoscopically.     

Laparoscopic management of recurrent adhesive small-bowel obstruction: Long-term follow-up

Purpose  To evaluate the efficiency, safety, and outcome of laparoscopic adhesiolysis for recurrent small-bowel obstruction (SBO), when performed early after failed conservative treatment. Methods  Between 1999 and 2005, elective laparoscopic adhesiolysis was attempted in 46 patients with recurrent SBO after abdominal or pelvic surgery. Laparoscopic adhesiolysis was done during the acute onset of SBO after the patient failed to respond to 24 h of conservative treatment. Results  Fifteen patients (32.6%) presented with recurrent SBO and 31 patients (67.4%) presented with recurrent SBO and chronic abdominal pain. Postoperative adhesions were identified laparoscopically in all patients: as isolated bands in 11 patients, enteroperitoneal angulation in 12 patients, entero-enteral angulation in 17 patients, and extensive dense and matted intra-abdominal adhesions in 6 patients. Successful complete laparoscopic adhesiolysis was achieved in 42 of the 46 patients (91.3%). Conversion to minilaparotomy was required for a convoluted mass of adherent bowel in one patient (2.2%) and laparotomy was required for extensive dense and matted adhesions in three patients (6.5%). The mean follow-up was 46.5 months (range 24–89 months). Forty-three patients (93.5%) were asymptomatic after the operation. Only one patient (2.2%) had a further two episodes of SBO over 38 months of follow-up. Conclusion  Laparoscopic intervention, when done early after the onset of symptoms, is highly feasible, safe, and effective in selected patients with recurrent SBO caused by postoperative adhesion. Q. Wang, Z.Q. Hu, W.J. Wang, and J. Zhang contributed equally to this work.     

Readmission for small-bowel obstruction in the early postoperative period: etiology and outcome.

OBJECTIVES: To determine the frequency of readmission for early postoperative small-bowel obstruction (SBO), to highlight factors that may predispose to this condition, to define the risks of strangulation and to compare the immediate and long-term risks and benefits of operative versus nonoperative treatment. DESIGN: A chart review. SETTING: The Sir Mortimer B. Davis-Jewish General Hospital, a university-affiliated teaching hospital in Montreal. PATIENTS: Out of a total of 1001 cases of SBO in 552 patients, 30 patients were readmitted within 50 days of a previous laparotomy with the diagnosis of SBO. INTERVENTION: Selective nonoperative management and exploratory laparotomy. MAIN OUTCOME MEASURES: The value of nonoperative management and need for operation. RESULTS: Adhesions were the cause of the obstruction in most cases (24); other causes were Crohn's disease (2), hernia (1), malignant neoplasm (1) and a combination of adhesions and malignant disease (2). Thirteen (43%) of the procedures preceding the obstruction were primary small-bowel operations. There was only 1 episode of strangulated bowel. Of the patients readmitted for SBO, 7 (23%) were treated operatively with a long-term recurrence rate of 57% compared with 63% for those treated nonoperatively for the SBO. The median time to recurrence was 0.1 years (range from 0.02-6 yr) for those whose SBO was managed operatively, compared with 0.7 years (range from 0.08-5 yr) for those managed nonoperatively for the SBO. The median length of stay for patients managed operatively for SBO was 12 days (range from 9-17 d) compared with 6 days (range from 2-33 d) for those managed nonoperatively. CONCLUSIONS: Readmission for SBO within 50 days of a previous laparotomy represents a small percentage of all cases of SBO. They frequently follow small-bowel operations. Cases of strangulation are no more common than in general cases of SBO. Patients treated nonoperatively for SBO did not experience less favourable outcomes with respect to resolution of symptoms, length of stay, risk of recurrence and reoperation. Thus, operative intervention is not necessary in an otherwise stable patient.     

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.     

Laparoscopic paracecal hernia repair

The diagnosis and treatment of internal abdominal hernia usually require laparotomy. We report a case of preoperative diagnosis and laparoscopic repair of paracecal hernia. A 90-year-old woman was referred with features of a well-established small bowel obstruction (SBO). Computed tomography and a small bowel contrast examination showed a paracecal hernia. With the patient under general anesthesia, laparoscopic surgery was carried out with the use of pneumoperitoneum, and an easy reduction of the incarcerated intestinal loop was achieved by gentle traction of the intestine. The bowel was assessed for viability and showed no evidence of nonviability. The abnormal orifice in the paracecal region was observed. The orifice was closed with 3-0 PDS II (polydiaxonone) sutures laparoscopically. A laparotomy was avoided, and the patient recovered without significant complications. We conclude that laparoscopy can play a useful role in the treatment of internal hernia causing SBO when an obstructive lesion has been detected and decompression accomplished preoperatively.     

Diagnosis and Management of Internal Hernias after Laparoscopic Gastric Bypass

BACKGROUND: Internal hernia is a known complication of laparoscopic Roux-en-Y gastric bypass (LRYGBP). However, no consensus exists regarding optimal diagnostic modality and management. We reviewed the literature and our own experience, and present an algorithm for the diagnosis and management of internal hernia after LRYGBP. METHODS: A retrospective review of 290 retrocolic LRYGBPs was performed to identify those who developed postoperative small bowel obstruction due to internal hernia. Demographics, clinical symptoms, radiologic characteristics, and operative outcomes were analyzed to determine clinical and radiological diagnostic accuracy. RESULTS: Over a 43-month period, 11 out of 290 (3.79%) post-LRYGBP patients with symptoms suggestive of a small bowel obstruction underwent operative exploration. The most common clinical symptoms included intermittent abdominal pain, and/or nausea/vomiting. All patients were initially explored laparoscopically. Etiology of obstructions included internal hernias--6 [at the transverse mesocolon (n = 1), Petersen's space (n = 2), and at the jejunojejunostomy (n = 3)], adhesions (n = 4) and a negative laparoscopy (n = 1). The mean time for development of internal hernias was 13.7 months. Mean loss of BMI units at time of re-operation was 17 kg/m2. Of the 6 patients with internal hernia, 2 (30%) had normal preoperative radiological work-up. On review of the preoperative films by the surgeon, signs of internal herniation were seen in all the patients. Management included initial laparoscopic exploration, lysis of adhesions, reduction of internal hernia and closure of mesenteric defects in all the patients. There were 2 conversions to laparotomy. CONCLUSION: Small bowel obstruction in the post-LRYGBP patient is difficult to diagnose, especially when due to an internal hernia. Most patients present with intermittent abdominal pain and/or nausea. The most frequently used radiologic study is CT scan, which is most accurate when reviewed by the bariatric surgeon preoperatively.     

Laparoscopic compared with conventional treatment of acute adhesive small bowel obstruction

BACKGROUND: Although laparoscopy may be associated with fewer intra-abdominal adhesions and quicker recovery of bowel function, it remains unclear whether patients with acute small bowel obstruction (SBO) might benefit from laparoscopic techniques. METHOD: The results of patients with acute SBO treated laparoscopically (LAP; n = 52) and conventionally (CONV; n = 52) were compared in a retrospective matched-pair analysis. Conversions were included in the laparoscopic group. RESULTS: Complete laparoscopic treatment was performed in 25 patients (48.1 per cent). Major intraoperative complications occurred in 15 patients in the LAP group and eight in the CONV group (P = 0.156). Intraoperative perforations were more frequent in patients who had undergone more than one previous laparotomy (P = 0.066). Postoperative complications occurred in ten patients (19.2 per cent) in the LAP group and in 21 patients (40.4 per cent) who had conventional surgery (P = 0.032). Bowel movements started 3.5 days after operation in the LAP group and 4.4 days after conventional operation (P = 0.001). The length of hospital stay was 11.3 and 18.1 days respectively (P < 0.001). CONCLUSION: Laparoscopic treatment of acute SBO was feasible in about half of these patients. Postoperative recovery was improved after laparoscopic procedures but the risk of intraoperative complications increased. A laparoscopic approach seems justified in a subset of patients.     

Laparoscopic management of acute small bowel obstruction

Background As minimally invasive surgery gains ground, it is entering realms previously considered to be relative contraindications for laparoscopy. We reviewed our experience with the laparoscopic approach to the management of small bowel obstruction (SBO).Methods From December 1997 to November 2002, 65 patients underwent laparoscopic treatment for SBO. The operating surgeon attempted to identify a transitional point between distended and collapsed bowel and then address the obstruction at that point.Results Postoperative adhesions were the cause of the obstruction in 44 patients. Tumor was identified in five cases, hernia in four, bezoar in three, intussusception in three, acute appendicitis and pseudoobstruction in two cases each, and terminal ileitis in one case. The diagnostic accuracy of laparoscopy was 96.9%. Thirty-four patients (52%) were treated by laparoscopy alone. Thirteen patients (20%) required a small target incision for segmental resection. Eighteen operations were converted to formal laparotomy. The mean laparoscopy time was 40 min (range, 25-160). Patients resumed oral intake in 1-3 days. The complication rate was 6.4%. There were two deaths, but none related to laparoscopy. The mean hospital stay was 4.2 days.Conclusions Laparoscopy is a useful minimally invasive technique for the management of acute SBO. It is an excellent diagnostic tool and, in most cases, a therapeutic surgical approach in patients with SBO. However, a significant number of patients will require conversion.Presented in part at the 10th annual congress of the European Association for Endoscopic Surgery (EAES), Lisbon, Portugal, 2-5 June, 2002     

Impact of bowel rotation and fixation on obstructive complications in congenital diaphragmatic hernia

Aim of the studySmall bowel obstruction (SBO) is a known complication after congenital diaphragmatic hernia (CDH) repair, which can require surgery and even extensive bowel resection causing short bowel syndrome (SBS). We investigate whether specific bowel rotation and fixation can be used as a predictor for SBO including volvulus.MethodsA retrospective review of 256 CDH survivors following repair from 2003 to 2020 was performed. Operative notes and upper gastrointestinal series (UGI) were screened to determine the rotation and fixation of the bowel. Primary outcomes included SBO occurrence, SBO treated surgically, and volvulus. For statistical analysis Fisher's exact test was utilized.ResultsTwenty-two (9%) patients presented with SBO and majority, 19 (86%), required surgery. Adhesion were observed in 10 (45%), recurrence in 5 (23%), and extensive volvulus leading to SBS in 3 (14%). Both rotation and fixation were recorded in 117 (46%). Presence of left CDH with malrotation and nonfixation was a significant predictor for SBO requiring surgery (P<0.05 vs all other groups). All 3 patients with extensive volvulus had left CDH with nonfixed bowel (100%), however only 1 had malrotation (33%).ConclusionsMalrotation and nonfixation are associated with increased SBO in CDH. Normal rotation is not protective and patients are still at risk for volvulus resulting in SBS. SBO requiring surgical intervention is common in CDH. Bowel rotation and fixation are important determinants that, should be routinely documented and education about the risk of SBO should be included in family counseling.Level of EvidenceLevel IV – Case Series     

Laparoscopic management of acute small bowel obstruction

BACKGROUND: The use of laparoscopy has expanded to include the management of acute abdomen. This study describes the author's experience with laparoscopic management of acute small bowel obstruction. METHODS: From February 1994 through March 1998, 19 patients underwent laparoscopic intervention for acute small bowel obstruction. Their clinical data were analyzed to evaluate the outcome. RESULTS: A total of 19 patients underwent 20 exploratory laparoscopies. The cause of obstruction was diagnosed correctly in 17 of the patients (90%). Fifteen patients (79%) had adhesions, nine of which were postoperative. Of the 19 patients, 13 (68%) had successful laparoscopic treatment. Laparotomy was required in six patients (32%) for various lesions including ileocecal tuberculosis. The average time for laparoscopy was 58 min. The mean postoperative hospital stay was 5 days. There was no morbidity or mortality in this series. CONCLUSIONS: Laparoscopy is a feasible and safe alternative to laparotomy for most patients with acute small bowel obstruction.     

Diagnosis and management of partial small bowel obstruction after laparoscopic antecolic antegastric Roux-en-Y gastric bypass for morbid obesity

BACKGROUND: The resultant derangement of the normal gastrointestinal anatomy after a gastric bypass procedure increases the incidence of, and level of difficulty diagnosing, partial small bowel obstruction (SBO) in morbidly obese patients. We evaluated the diagnostic methods for partial SBO and the clinical characteristics according to the time after initial operation. STUDY DESIGN: Data of 1,400 consecutive patients who underwent antecolic antegastric laparoscopic Roux-en-Y gastric bypass between 2001 and 2004 were retrospectively analyzed. RESULTS: Partial SBO developed in 21 (1.5%) patients after laparoscopic Roux-en-Y gastric bypass. Five of 15 patients were preoperatively diagnosed with SBO by a gastrograffin study and CT scan diagnosed 17 of 19 patients (p = 0.002). Causes of SBO included jejunojejunostomy stenosis (n = 6), adhesions (n = 5), incarcerated ventral hernia (n = 5), internal hernia (n = 3), and other (n = 2). The majority of patients (n = 19) underwent surgical treatment. CONCLUSIONS: The most frequent cause of early SBO is jejunojejunal anastomotic stenosis. CT scan is a more accurate diagnostic tool for detecting partial SBO, compared with use of a gastrograffin study. Operation remains the most appropriate and definitive treatment for this complication and the laparoscopic approach is a feasible and safe surgical treatment option.