腹腔镜小肠切除术的临床应用

目的探讨腹腔镜小肠切除术的治疗价值。方法总结分析1993年3月至2000年12月施行的腹腔镜小肠切除术31例患者的临床资料。结果术式包括:腹腔镜辅助下小肠切除术25例;全腹腔镜下小肠切除术6例。25例腹腔镜辅助下小肠切除术平均手术时间(101.9±32.8)min;术中平均出血(65.3±28.5)ml;平均住院(5.5±1.6)d。6例全腹腔镜下小肠切除术平均手术时间(97.2±28.1)min;术中平均出血(59.6±22.1)ml;平均住院(5.1±1.3)d。两组各指标比较,差异均无显著性意义(P>0.05)。所有患者均在术后48d内恢复胃肠功能,并开始下床活动。仅3例术后使用止痛剂。全组手术无病灶遗漏,也无并发症、中转开腹和手术死亡发生。结论腹腔镜小肠切除术具有良好的治疗效果,器械的更新和经验的积累将使这项技术日臻完善。     

Laparoscopic management as the initial treatment of acute small bowel obstruction.

OBJECTIVES: We prospectively evaluated our experience with laparoscopic management of acute small bowel obstruction (SBO). METHODS: The study group included all patients requiring surgical intervention based on complete mechanical SBO by clinical assessment or who had failed conservative management. Patients with malignant causes were excluded. Experienced laparoscopic surgeons performed all operations. RESULTS: Between January 1998 to January 2003, 61 patients required operative intervention for acute SBO. Causes included adhesions, internal hernia, incarcerated incisional hernia, and inflammatory bowel disease. Laparoscopic techniques (LAP) alone were successfully used to complete 41 cases (67%). Twenty patients (33%) were converted (CONV) to either mini-laparotomy [7 patients (35%)] or standard midline laparotomy [13 patients (65%)]. A single band was identified in 25 patients (41%). Complications occurred in both groups. CONCLUSIONS: We believe all patients requiring surgery in the setting of acute small bowel obstruction should undergo a laparoscopic approach initially. By specifically identifying those patients with a single band as the cause of obstruction, a significant number of patients will be spared a large laparotomy incision. Conversion should not be viewed as failure, but rather, a sometimes necessary step in the optimal management of these patients.     

Laparoscopic approach to acute small bowel obstruction: Review of 1061 cases

Background Acute small bowel obstruction has previously been considered a relative contraindication for laparoscopic management. As experience with laparoscopy grows, more surgeons are attempting laparoscopic management for this indication. The purpose of this study is to define the outcome of laparoscopy for acute small bowel obstruction through an analysis of published cases. Methods A literature search of the Medline database was performed using the key words laparoscopy and bowel obstruction. Further articles were identified from the reference lists of retrieved literature. Only English language studies were reviewed. We excluded studies that included patients with chronic abdominal pain, chronic recurrent small bowel obstruction, or gastric or colonic obstruction, when the data specific to acute small bowel obstruction could not be extracted. Data was analyzed based on an intention to treat. Results Nineteen studies from between 1994 and 2005 were identified. Laparoscopy was attempted in 1061 patients with acute small bowel obstruction. The most common etiologies of obstruction included adhesions (83.2%), abdominal wall hernia (3.1%), malignancy (2.9%), internal hernia (1.9%), and bezoars (0.8%). Laparoscopic treatment was possible in 705 cases with a conversion rate to open surgery of 33.5%. Causes of conversion were dense adhesions (27.7%), the need for bowel resection (23.1%), unidentified etiology (13.0%), iatrogenic injury (10.2%), malignancy (7.4%), inadequate visualization (4.2%), hernia (3.2%), and other causes (11.1%). Morbidity was 15.5% (152/981) and mortality was 1.5% (16/1046). There were 45 reported recognized intraoperative enterotomies (6.5%), but less than half resulted in conversion. There were, however, nine missed perforations, including one trocar injury, often resulting in significant morbidity. Early recurrence (defined as recurrence within 30 days of surgery) occurred in 2.1% (22/1046). Conclusion Laparoscopy is an effective procedure for the treatment of acute small bowel obstruction with acceptable risk of morbidity and early recurrence.     

Single-port laparoscopic treatment of small bowel obstruction

Background

The aim of this study was to report our initial experience with single-port laparoscopic surgery (SPLS) for small bowel obstruction (SBO).

Methods

Between October 2009 and April 2013, 36 patients underwent SPLS for SBO. SPLS was performed transumbilically. Patient demographics and operative and postoperative outcomes were analyzed.

Results

SPLS for SBO was successful in 35 patients. In 1 patient, a conversion to laparotomy was required. The median incision length, operative time, and postoperative length of stay were 2.3 cm (range, 1.5 to 5.0 cm), 115 min (range, 30 to 250 min), and 8 days (range, 3 to 26 days), respectively. The median time to resume oral intake was 3 days (range, 1 to 16 days). The intra- and postoperative complication rates were 6% and 11%, respectively.

Conclusion

SPLS was a safe and feasible therapeutic approach for SBO and may also be an excellent diagnostic tool when performed by an experienced SPLS surgeon in selected 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     

Internal transomental herniation with a trapped small bowel mimicking acute appendicitis

INTRODUCTIONInternal herniation with subsequent bowel obstruction is uncommon, and making a correct diagnosis prior to surgery is often difficult.PRESENTATION OF CASEIn this case report we present a man, who suffered from sudden extreme right-sided abdominal pain. The diagnostic workup was inconclusive. Emergency surgery was indicated with a suspicion of acute appendicitis. We found a strangulated ileus caused by an internal herniation of the small intestine through a hole in the greater omentum. The patient had no history of surgery or other physical disorders explaining this finding. The obstruction was resolved and the postoperative clinical course was uncomplicated.DISCUSSIONA thorough diagnostic workup including CT scan would most probably have given the correct diagnosis. However, the clinical course and initiation of the correct treatment would have been delayed significantly.CONCLUSIONWe suggest that the diagnostic workup of patients with unclear lower abdominal pain should be limited and that acute clinical symptoms require rapid laparoscopic evaluation and surgical treatment.     

Adhesive small bowel obstruction after appendectomy in children: comparison between the laparoscopic and open approach

Introduction

Adhesive small bowel obstruction (SBO) is a common postoperative complication. Published data in the pediatric literature characterizing SBO are scant. Furthermore, the relationship between the risk of SBO for a given procedure is not well described. To evaluate these parameters, we reviewed the incidence of SBO after laparoscopic appendectomy (LA) and open appendectomy (OA) performed at our institution.

Methods

With institutional review board approval, all patients that developed SBO after appendectomy for appendicitis from January 1998 to June 2005 were investigated. Hospital records were reviewed to identify the details of their postappendectomy SBO. The incidences of SBO after LA and OA were compared with χ² analysis using Yates correction.

Results

During the study period, 1105 appendectomies were performed: 477 OAs (8 converted to OA during laparoscopy) and 628 LAs. After OA, 7 (6 perforated appendicitis) patients later developed SBO of which 6 required adhesiolysis. In contrast, a patient with perforated appendicitis developed SBO after LA requiring adhesiolysis (P = .01). The mean time from appendectomy to the development of intestinal obstruction for the entire group was 46 ± 32 days.

Conclusions

The overall risk of SBO after appendectomy in children is low (0.7%) and is significantly related to perforated appendicitis. Small bowel obstruction after LA appears statistically less common than OA. Laparoscopic appendectomy remains our preferred approach for both perforated and nonperforated appendectomy.     

A case report of small bowel obstruction secondary to congenital peritoneal band in adult

IntroductionSmall bowel obstruction (SBO) is common in adult surgical procedures, mainly due to postoperative adhesions. Acute SBO in adults without history of abdominal surgery, trauma or clinical hernia is less common and has various etiologies. Congenital band is an extremely rare cause.Presentation of caseA 56-year-old man was admitted to our hospital with a two-day history of abdominal pain and bilious vomiting. He had no history of abdominal surgery or any other medical problems. A contrast-enhanced CT of the abdomen showed a distention of small bowel loops with transition point in the right hypochondrium. Distended loops of small bowel were located in the left side of the abdomen, whereas collapsed loops was located in the right side. The normal bowel wall enhancement was preserved. After initial treatment with intravenous fluid and nasogastric suction, he was operated. At laparoscopy a band obstructing the ileum was clearly observed. This anomalous band extending from gallbladder to transverse mesocolon caused a small window leading to internal herniation of the small bowel and obstruction. The band was coagulated and divided. Postoperative outcome was uneventful and the patient was discharged on the second postoperative day. There was no recurrence of symptoms on subsequent follow-up.DiscussionCongenital peritoneal bands are not frequently encountered in surgical practice and these bands are often difficult to classify and define. Diagnosis of acute intestinal obstruction due to CPB must be included in the differential diagnosis in any patient with no history of abdominal surgery, trauma, clinical hernia, inflammatory bowel disease or peritoneal tuberculosis.ConclusionDespite technological advances in radiology preoperative diagnosis remains difficult, however the diagnosis of SBO due to CPB must be considered in any patient with no history of abdominal surgery, Trauma or clinical hernia consulting for occlusive syndrome. The laparoscopic approach should be intended initially for its feasibility and benefits.     

Laparoscopic treatment for small bowel obstruction: Report of a case

An unusual case of small bowel obstruction in a patient with "virgin abdomen" was successfully diagnosed and the localized pathology was elucidated by a computed tomography scan, and the case was successfully treated by laparoscopy.     

A case report of endometriosis presenting as an acute small bowel obstruction

IntroductionEndometriosis is a common and benign condition that causes significant morbidity to women of childbearing age. It uncommonly affects the gastrointestinal tract and rarely manifests as an acute small bowel obstruction.Presentation of caseA 46-year old female presented to the emergency department with signs and symptoms consistent with an acute small bowel obstruction. She had a paucity of background surgical history, having only had a laparoscopic cholecystectomy. Her CT demonstrated small bowel obstruction with a transition point in the distal ileum. Given the site of obstruction was remote from previous surgery, a high index of suspicion was maintained and early laparoscopy performed the same day. Operative findings were consistent with an endometrial stricture of the distal ileum and a formal resection was performed.DiscussionEndometriosis that affects the gastrointestinal tract often presents with non-specific symptoms. This is a rare case of an acute small bowel obstruction as the index symptom of endometriosis in a peri-menopausal patient. This is the first case in the literature to describe same day laparoscopy and small bowel resection of such a case and a prolonged preoperative period and misdiagnoses previously described were avoided due to clinical suspicion.ConclusionEndometriosis as a differential should be considered with a high index of suspicion in pre-menopausal women, particularly in patients with negligible previous surgical history. There should be a low threshold for early laparoscopy and resection of affected bowel in these patients.     

Ischemic necrosis of small bowel following laparoscopic surgery.

BACKGROUND AND OBJECTIVE: Small bowel ischemia following laparoscopy was described recently as a rare fatal complication of the CO2 pneumoperitoneum. Of the 8 cases reported in the surgical literature, 7 were fatal, 1 was not. In this report, we describe the first gynecological case. METHODS: A 34-year-old woman who underwent laparoscopy with extensive adhesiolysis and myolysis was re-admitted with an acute abdomen on postoperative day 4. Immediate laparotomy revealed acute peritonitis, extensive adhesions, and a 3-cm defect in the small bowel. Tissue examination showed ischemic necrosis of edematous, but essentially normal, bowel mucosa. The postoperative course was extremely complicated. She was discharged after a 2-month hospital stay in the intensive care unit for rehabilitation. RESULTS: Data are available on 7 patients (including ours). All procedures were described as uneventful. The intraabdominal pressure was set at 15 mm Hg when specified. Some abdominal pain occurred in all, nausea and vomiting in 4, diarrhea in 2, abdominal distention in 1, fever in none. Quick reintervention laparotomy was performed in 2 and delayed in 5 (up to 4 days). DISCUSSION: The CO2 pneumoperitoneum is a predisposing factor for intestinal ischemia as it reduces cardiac output and splanchnic blood flow. However, critical ischemia relies on underlying vasculopathy or an inciting event. CONCLUSION: Patient selection, maintaining intraabdominal pressure at 15 mm Hg or less, and intermittent decompression of the gas represent the best options for preventing this complication.     

小肠出血的病因及诊断分析

目的为提高小肠出血的诊治水平。方法回顾性分析１９８２年６月至１９９８年６月经手术治疗的小肠出血３２例。结果病变位于十二指肠者８例,空肠者６例,回肠者１７例,空回肠弥漫性病变１例,良、恶性各为５０％。结论小肠出血应首选胃镜或Ｘ线钡餐检查,小肠双重气钡造影和小肠插管灌钡造影为主要诊断手段,及时剖腹探查可协助明确诊断。     

Laparoscopic adhesiolysis in acute small bowel obstruction: a preliminary experience.

OBJECTIVE: The aim of this study is to evaluate laparoscopy as another tool for management of cases of adhesive acute small bowel obstruction. METHODS: Fourteen patients suffering from suspected adhesive small bowel obstruction were explored laparoscopically over a period of 24 months. The Veress needle was inserted either in a virgin part of the abdomen away from previous scars or under direct vision using an open technique. Careful inspection of the entire abdomen was done, and the small bowel was "run" in a retrograde fashion starting at the cecum. The point of obstruction was localized and adhesiolysis was performed, thus resolving the problem. RESULTS: Laparoscopic exploration was able to determine the site and cause of obstruction precisely in all 14 cases, with resolution of the problem laparoscopically in 12 patients (85.7%). Two cases were converted to open surgery (14.3%). There were no mortalities and low morbidity (7.1%). The mean hospital stay was 3.7 days. CONCLUSION: Laparoscopic surgery can be an advantageous alternative to open surgery in acute small bowel obstruction, thus providing a new technique for its diagnosis and treatment with all the advantages of minimally invasive surgery.     

Broad ligament hernia-associated bowel obstruction.

BACKGROUND AND OBJECTIVE: We present the case of a female patient 29 years of age with antecedents of laparoscopic laser ablation for endometriosis, laparoscopic appendectomy, and umbilical hernioplasty. METHODS: The patient was admitted to the hospital's emergency room for abdominal pain in the epigastrium, transfixing, irradiating to both upper quadrants and to the lumbar region, accompanied by nausea and gastrobiliary vomiting. Lipase determination was 170 mg/dL. Other laboratory findings were normal. Plain abdominal films on the patient's admission were normal, and computed tomography (CT) showed data compatible with acute pancreatitis. Without improvement during the patient's hospital stay, pain and vomiting increased in intensity and frequency. RESULTS: New abdominal x-rays revealed dilatation of small bowel loops. Management was begun for intestinal obstruction, with intravenous hydration and placement of a nasogastric tube without a good response. At 48 hours, a diagnostic laparoscopy was performed, revealing a 3-cm internal hernia in the left broad ligament in which a 20-cm segment of terminal ileum was encased. We performed liberation of the ileal segment and closed the hernial orifice by using the laparoscopic approach. CONCLUSION: The patient's evolution was excellent.     

Zoom endoscopic monitoring of small bowel allograft rejection

Background The small bowel has been successfully transplanted in patients with irreversible intestinal failure. This report aims to describe endoscopic monitoring of small bowel rejection. Methods A magnification endoscope (zoom endoscope) was used in this study. In the first part of the study (October 1998 to March 2000, 271 endoscopy sessions), the specific endoscopic findings that correlated with rejection were determined. An analysis then was performed on data from the second period (March 2001 to November 2002, 499 sessions) to evaluate the zoom endoscope’s accuracy in monitoring rejection. Results Specific endoscopic findings of rejection found in the first period included background erythema, villous congestion, blunted villous tip, and shortened villous height. When the rejection was successfully treated, endoscopic appearance returned to normal. On the basis of these findings, five endoscopic criteria (villous shortening, villous blunting, background erythema, villous congestion, and mucosal friability) were used to score endoscopic sessions in the second period. Endoscopic diagnosis of rejection was compared with histology. Adult patients showed a sensitivity of 45%, a specificity of 98%, a positive predictive value of 82%, and a negative predictive value of 88%. In pediatric patients, these values were, respectively, 61%, 84%, 57%, and 86%. On 59 distinct occasions (30 in period 1 and 29 in period 2) in which the results were endoscopy negative yet biopsy positive (mild) for rejection, we elected not to treat these rejections on the basis of clinical evaluation, and 58 (98%) resolved without further therapy. Conclusions With the use of magnification, endoscopy is a useful tool for monitoring acute rejection in the small bowel allograft. Part of this work was presented during the annual meeting of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), 29 March to 1 April 2000, Atlanta, GA.     

Surgical treatment of small bowel cancer: A 20-year single institution experience

Small bowel malignancies are rare. The aims of this study were to evaluate the outcomes associated with surgical therapy for small bowel cancers and to define prognostic factors. The medical records of 96 consecutive patients with primary small bowel cancer (excluding lymphoma) treated at our institution over a 20 year period were reviewed. Survival was analyzed using the Kaplan-Meier method (mean follow-up period 57 months). Mean patient age was 56 years, and 58% of patients were male. Sixty percent of patients had an adenocarcinoma, 21% had a sarcoma, and 19% had a carcinoid tumor. The percentages of patients who underwent complete (curative) resection were 51%, 90%, and 50% for those with adenocarcinoma, sarcoma, and carcinoid tumor, respectively. For patients with adenocarcinoma who underwent curative resection, tumor (T) and node (N) stages were significant prognostic factors predicting overall survival. For patients with sarcomas who underwent curative resection, tumor grade was a significant prognostic factor predicting overall survival. The prognosis for patients with small intestinal carcinoid tumors is uniformly favorable. The prognosis for patients with sarcomas and adenocarcinomas is generally poor, although long-term survival is achieved by patients with favorable prognostic factors. Presented at the Society of Surgical Oncology Fifty-Sixth Annual Cancer Symposium, Los Angels, California, March 5–9, 2003.     

Incarcerated internal hernia of the small intestine through a breach of the broad ligament: two cases and a literature review.

Two cases of internal herniation through a defect in the broad ligament of the uterus are described. Both were successfully treated laparoscopically. This rare condition should be borne in mind when a middle-aged woman presents with colicky lower abdominal pain. The cause is unknown, but both congenital and acquired origins have been proposed. As far as emergency situations are concerned, laparoscopy has proven to be both a diagnostic and a therapeutic tool.     

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目的 研究提高成人小肠扭转早期诊断率的方法。方法 回顾分析过去１０年经手术证实的成人小肠扭转８３例。结果 首要病因是 腹腔粘连,占５！％,发病年龄６０岁以上者占５７％,９５％的病例有绞窄性肠阻的临床表现;腹部平片诊断率低（１４．５％）。结论提高早期诊断率首先要注重临床症状与体征;不能盲目依赖腹部平片,应特别重视术后粘连引起小肠扭转的诊断。