THE OPERATIVE AETIOLOGY AND TYPES OF ADHESIONS CAUSING SMALL BOWEL OBSTRUCTION

Postoperative adhesions account for 64–79% of admissions with small bowel obstruction (SBO). The aim of this study was to identify the operative procedures and the types of adhesions that cause SBO. A retrospective analysis of all patients with an admission diagnosis of acute adhesive SBO between January 1982 and December 1990 was performed. One hundred and nineteen patients had 144 admissions with an initial diagnosis of acute SBO due to adhesions. The previous operations were: appendicectomy 23.3%; colorectal resection 20.8%; gynaecological surgery 11.7%; upper gastrointestinal (gastric, biliary or splenic) surgery 9.2%; small bowel surgery 8.3%; and more than one previous abdominal operation 23.6%. Sixty-one admissions required surgery to relieve the SBO. Eighteen patients had strangulated small bowel. All but two of these patients had a single band adhesion causing the SBO and associated strangulation. Band adhesions were commonly found following appendicectorny, colorectal resections or gynaecological operations. Seventeen of the 21 patients with previous surgery for a colorectal malignancy had benign adhesions causing the SBO, while four of the six patients with either previous ovarian or previous gastric carcinoma had recurrent malignancy causing the SBO. Five patients had previously undiagnosed carcinomas (three ovarian and two caecal) as the cause of the SBO.     

Laparoscopic diagnosis and treatment of small bowel obstruction caused by postoperative intussusception

Small bowel obstruction is a common problem, especially for patients who have had previous abdominal surgery possibly complicated by postoperative adhesions. In contrast to adhesions, postoperative intussusception is an unusual cause of small bowel obstruction. We report a case of small bowel obstruction that occurred one month after antrectomy for duodenal ulcer with massive bleeding. Laparoscopic surgery was attempted after conservative treatment failed. A segment of jejunojejunal intussusception about 50 cm below the ligament of Treitz was identified and laparoscopic reduction of the intussusception was performed. The patient had an uneventful postoperative course and remained asymptomatic at 10-month follow-up. Although not frequently encountered, postoperative intussusception should be considered a possible etiology in patients with postoperative small bowel obstruction. In experienced hands, the laparoscopic approach offers a feasible option for correct diagnosis and appropriate treatment in this situation.     

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.     

腹部手术后早期炎性肠梗阻的处理

目的腹部手术后早期发生的肠梗阻原因较复杂,处理亦较困难,尤其是炎性肠梗阻,既有麻痹性因素,亦有机械性因素,使外科医师的医疗决策难以取舍,如是否需要手术、手术的时机、以及手术可能造成的并发症等均值得探讨。我科自1987年至1996年12月共收治了重型术后炎性肠梗阻48例,40例(83.3%)经非手术治疗痊愈;7例(14.6%)于症状消退后择期手术治疗并存症后治愈,1例2.1%死亡,临床非手术治疗时间为9～58天,平均27.6±10天,取得较满意的结果,为这种类型的肠梗阻治疗提供了一些经验。     

Laparoscopic management of a primary small bowel volvulus: a case report

Primary small bowel volvulus in adults is a very rare condition, and it is defined as torsion of all or a large segment of the small intestine and its mesentery in the absence of any preexisting etiologic factors. Proper management of the patients suffering from a strangulated obstruction depends on making an early and accurate diagnosis. Timely treatment is crucial to prevent gangrene. A 49-year-old man who had a history of previous abdominal surgery was admitted to our hospital with complaints of acute abdominal pain. Simple abdominal x-ray showed multiple dilated loops of small intestine in the mid-abdomen. Enhanced abdominal computed tomography showed the distended small bowel loops and longitudinal tapering of the collapsed bowel loops. We carried out diagnostic laparoscopy to confirm the cause of suspected mechanical ileus. It revealed strangulation of the small bowel at the terminal ileum due to clockwise torsion of the bowel loop. There were no adhesions or congenital anomalies in the peritoneal cavity. The torsional segment was spontaneously reduced with minimal handling, and the strangulated portion was resected. The patient was discharged from hospital on postoperative day 6. Primary small bowel volvulus in adults is a very rare malady; if the diagnosis is uncertain, then diagnostic laparoscopy is a valuable tool for making the definitive diagnosis and administering prompt treatment.     

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.     

Sigmoid colon strangulation caused by bilateral fallopian tubes: A case report

IntroductionThere are no reports regarding sigmoid colon strangulation caused by bilateral fallopian tubes, which is a rare type of large bowel obstruction. Herein, we report a case of successful laparoscopic treatment of sigmoid colon strangulation.Presentation of caseA 54-year-old woman presented to our hospital with intermittent abdominal pain. Her medical history was significant for endometriosis; however, there was no surgical history. The physical examination revealed tenderness over the lower abdomen. CT scan shows closed loop obstruction of sigmoid colon. Exploratory laparoscopy was performed, and a sigmoid colon strangulated by bilateral fallopian tubes was detected. The adhesions consisting of bilateral fallopian tubes were dissected laparoscopically. The patient's postoperative course was uneventful, with no complications.DiscussionThe most common cause of large bowel obstruction (LBO) is colorectal cancer, including volvulus and diverticulitis. In this case, the adhesion of both the right and left fallopian tubes caused LBO, and it is conceivable that the etiology involved is endometriosis.Few cases have reported bowel obstruction associated with a fallopian tube, and the laparoscopic approach is very rare. In our case, we immediately performed laparoscopic exploration before colon strangulation led to necrosis or perforation. Therefore, we succeeded in releasing the strangulation laparoscopically.ConclusionWe report a case of sigmoid colon strangulation that was treated laparoscopically. This approach can be the treatment of choice for sigmoid colon strangulation.     

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.     

Caustic acid burn of the upper gastrointestinal tract

Acute torsion of the small bowel mesentery is a diagnostically challenging cause of acute abdominal pain, which most commonly afflicts pediatric patients with midgut malrotation. We describe a case of mesenteric torsion in an adult patient that had manifested as acute abdominal pain. The patient had a remote history of prior abdominal surgery, presenting on multiple occasions with undiagnosed acute intermittent abdominal pain. Diagnosis of mesenteric torsion was made by contrast enhanced CT and the ailment was successfully treated with laparoscopic surgery without recurrence.     

Laparoscopic treatment of acute mesenteric torsion

Acute torsion of the small bowel mesentery is a diagnostically challenging cause of acute abdominal pain, which most commonly afflicts pediatric patients with midgut malrotation. We describe a case of mesenteric torsion in an adult patient that had manifested as acute abdominal pain. The patient had a remote history of prior abdominal surgery, presenting on multiple occasions with undiagnosed acute intermittent abdominal pain. Diagnosis of mesenteric torsion was made by contrast enhanced CT and the ailment was successfully treated with laparoscopic surgery without recurrence.     

Laparoscopic adhesiolysis in acute small bowel obstruction

At the beginning of the laparoscopic surgery, intestinal obstruction was considered an absolute contraindication for this approach, because of the high risk of injuring the bowel. Today laparoscopic surgery for small bowel obstruction is still under evaluation. Adhesions are the most common cause of obstruction; although an important proportion of these patients can be nonoperatively treated, some of these require immediate operation. The aim of this review was to evaluate the reliability and immediate results of laparoscopic management of small bowel obstruction by postoperative adhesions. Laparoscopic management of acute small bowel obstruction is feasible, but it is often difficult and may be hazardous. The patients with acute obstruction may be undergo laparoscopy after a careful selection. Morbidity is low if the operation is performed by skilled. The immediate benefit is rapid intestinal motility and shorter hospital stay. The long-term effect is the prevention of small bowel obstruction recurrences by new postoperative adhesions.     

Early intervention in intersigmoid hernia may prevent bowel resection-A case report

INTRODUCTION

Intersigmoid hernia is a rare internal hernia presenting with symptoms of bowel obstruction. Preoperative diagnosis is uncommon but computerised tomography (CT) may show signs to suggest internal hernia.

PRESENTATION OF CASE

A 63-year-old female presented with abdominal pain, vomiting and absolute constipation. Examination revealed a tense distended abdomen. A plain abdominal radiograph showed features of small bowel obstruction. Conservative management was initiated without success and a CT scan was performed which showed a dilated distal oesophagus, stomach and small bowel with a non-dilated length of distal ileum and large bowel. Internal hernia was suggested as a possible cause and the patient underwent a laparotomy where a loop of small bowel was found to be strangulated and gangrenous within the intersigmoid fossa. The gangrenous bowel was resected, an end-to-end anastamosis was performed and the fossa was closed. The patient made an uneventful recovery.

DISCUSSION

Hernias of the sigmoid mesocolon account for 6% of internal hernias with internal hernias themselves causing between 0.2 and 4.1% of intestinal obstruction. This report presents a case of intersigmoid hernia, a rare internal hernia which should be suspected in patients presenting with acute obstruction, no past surgical history and no external hernia. Patients with these symptoms should receive an urgent CT scan to facilitate early surgery and minimise strangulation and prevent bowel resection.

conclusion

Intersigmoid hernia presents with acute obstruction, no past surgical history and no external hernia. Urgent CT scanning and early surgery may minimise strangulation, conserve bowel and reduce patient morbidity and mortality.     

Small bowel obstruction by a congenital band in 16 adults

During embryogenesis, abnormal adhesion of the peritoneal folds induces a congenital band which can cause small bowel obstruction. PATIENTS AND METHODS: From 1987 to 2001, 16 adult patients underwent surgery for small bowel obstruction due to a congenital band. There were 8 men and 8 women with a mean age of 59 years (range 23-90). None presented previous abdominal surgery. RESULTS: Six patients presented acute abdominal pain the month before hospitalization. Among the 16 patients, 9 were operated at admission, and 7 after initial surveillance. Suspected diagnosis before operation was small bowel obstruction in 8 cases (with a diagnosis of congenital band in 3); perforated duodenal ulcer (n = 2); appendicitis (n = 2); mesenteric infarction (n = 1); diverticultis (n = 1); cholecystitis (n = 1); and strangulated hernia (n = 1). During operation performed through laparotomy or laparoscopy, a congenital band was noted in 100% of the cases, associated with intestinal necrosis in 5. One patient died postoperatively. CONCLUSION: Because small bowel obstruction by congenital band is a rare condition, it represents a frequent problem of diagnosis. In this situation, the possibility of intestinal necrosis expose the patient to a possible fatal outcome.     

Adhesive small bowel adhesions obstruction: Evolutions in diagnosis,management and prevention

Intra-abdominal adhesions following abdominal surgery represent a major unsolved problem. They are the first cause of small bowel obstruction. Diagnosis is based on clinical evaluation, water-soluble contrast followthrough and computed tomography scan. For patients presenting no signs of strangulation, peritonitis or severe intestinal impairment there is good evidence to support non-operative management. Open surgery is the preferred method for the surgical treatment of adhesive small bowel obstruction, in case of suspected strangulation or after failed conservative management, but laparoscopy is gaining widespread acceptance especially in selected group of patients. "Good" surgical technique and anti-adhesive barriers are the main current concepts of adhesion prevention. We discuss current knowledge in modern diagnosis and evolving strategies for management and prevention that are leading to stratified care for patients.     

Small Bowel Obstruction Creates a Closed Loop in Patients with a Laparoscopic Adjustable Gastric Band

We report on two cases of small bowel obstruction in the setting of a previous laparoscopic adjustable gastric band insertion. In both cases, a closed loop obstruction was created by the band and delayed diagnosis resulted in significant morbidity. Early recognition with deflation of the adjustable gastric band and nasogastric tube insertion is paramount to managing these patients.     

Celioscopic treatment of small intestine obstructions

We evaluated the reliability and immediate results of celioscopic management of acute small bowel obstruction. From January 1995 to April 1998, 39 patients underwent a primary celioscopic procedure for small bowel obstruction. The most common etiology was post operative adhesions (34 patients). The whole operation could be carried out exclusively by celioscopy in 22 patients (56%). A laparotomy had to be performed in 17 patients due to: impossibility to identify or treat the cause of obstruction, bowel necrosis or intraoperative complication (3 bowel wounds). Post operative complications were: 1 death (not directly related to the surgical procedure), 2 early recurrences of obstruction after exclusive celioscopy, 1 evisceration after laparotomy and 1 small bowel fistula after conversion to laparotomy. Mean hospital stay was 5 days after exclusive celioscopy and 9.5 days after conversion to laparotomy. Celioscopic management of small bowel obstruction is feasible, but it is often difficult and may be hazardous; a careful selection of patients must be made, based on the importance of obstruction and the type of previous abdominal surgery.     

The role of laparoscopy in small bowel obstruction after previous laparotomy for trauma: an initial report

Presently, there are no guidelines to help predict which patients are more likely to have successful laparoscopic adhesiolysis. We attempt to define which preoperative characteristics of trauma patients who later develop small bowel obstruction are most amenable to a laparoscopic operation. We did a retrospective review of all patients with small bowel obstruction after previous laparotomy for trauma. For the patients that received an operation to relieve the obstruction, the location of transition zone via CT scan and location of the previous abdominal scar were recorded. A previous upper abdominal surgical incision and a transition zone outside of the pelvis on CT scan were preoperative predictors of a successful laparoscopic adhesiolysis. The laparoscopic group had a shorter length of stay. Laparoscopic surgery as the initial operative approach in the management of SBO after previous laparotomy for trauma is safe and effective. Characteristics that make the laparoscopic approach most favorable are CT transition point above the pelvis and previous midline incision above umbilicus.     

Internal hernia through the mesenteric opening after laparoscopy-assisted transverse colectomy

We report a case of a rare complication in laparoscopic colectomy. A 55-year-old woman underwent a laparoscopy-assisted transverse colectomy for transverse colon cancer. On the 5th postoperative day, she developed bowel obstruction. Decompression by a long intestinal tube failed to resolve the bowel obstruction. She underwent operative intervention. Abdominal exploration showed jejunal loop caused by a strangulation forming on an internal hernia through the mesenteric opening at the anastomotic colonic stumps, which had not been sutured during the previous operation. Our experience might indicate the need for closure of small mesenteric opening after laparoscopic colectomy.     

Small intestinal obstruction

Small intestinal obstruction remains a frequently encountered problem in abdominal surgery. Although modern day surgical management continues to focus appropriately on avoiding operative delay whenever surgery is indicated, not every patient is always best served by immediate operation. Certain entities, such as SBO secondary to incarcerated abdominal wall hernia, and patients with clinical signs and symptoms suggestive of strangulation do require prompt operative intervention. Other conditions, however, such as postoperative adhesions and neoplastic-associated SBO, particularly in patients with numerous previous abdominal procedures, concomitant medical problems, or incomplete or partial obstruction, often justifiably benefit by a trial of nonoperative management. The risk of strangulation with adhesive and neoplastic SBO is relatively low as compared with incarcerated hernia and small bowel volvulus. Close and careful clinical evaluation, in conjunction with laboratory and radiologic studies, will usually dictate the proper course of management in any given case. If any uncertainty exists, prompt operative intervention is indicated. Because over 50 per cent of all cases of SBO are the direct result of postoperative adhesions, it is probably just as important as the actual management of SBO for all practicing abdominal surgeon to familiarize themselves with the widely accepted "ischemic theory" of adhesion formation. A number of intraoperative measures, many of which go against established surgical principles, are now encouraged during routine elective abdominal surgery to reduce the incidence of detrimental adhesions that might subsequently produce SBO. At the same time, surgeons should continue their aggressive attitude towards elective repair of any and all abdominal hernias, which continue to account for close to 15 per cent of all cases of small intestinal obstruction and still remain the most common cause of strangulation.     

Left paraduodenal hernia causing small bowel obstruction in an adolescent patient

Internal hernias are an uncommon cause of bowel obstruction, accounting for less than 1% of cases. Paraduodenal hernias, the most common type of internal hernias, are believed to be congenital in origin. They can be asymptomatic, cause chronic abdominal pain, or present with acute intestinal obstruction with strangulation and ischemia. We describe a case of left paraduodenal hernia found in a patient who presented with acute intestinal obstruction.