Laparoscopic Treatment Of Small Bowel Obstruction Research Articles

Laparoscopic treatment for adhesive small bowel obstruction: is it the gold standard in children too?

Small bowel obstruction (SBO) due to adhesions is an important cause of surgical admission and postoperative morbidity in the pediatric population [1, 2]. Advanced laparoscopic surgery is now commonly available in the majority of tertiary pediatric centers for the treatment of both urgent and elective cases. In the January edition of Surgical Endoscopy, O’Connor and Winter [3] reviewed the success rate of laparoscopy in the treatment of adult acute SBO. Their review of over 2,000 patients demonstrated clear advantages of laparoscopy (mortality rate 1.5 %, enterotomy rate 6.6 %, and conversion rate 29 %) and concluded that laparoscopic treatment should become the primary surgical technique in the treatment of adult SBO [3]. However, in the pediatric field, data on the laparoscopic treatment of SBO due to adhesions are scarce. We performed a detailed review of the pediatric literature published between 1990 and 2012, and we were able to identify only three retrospective case series on this topic (Table 1). Inclusion criteria for the search were Englishlanguage articles on pediatric SBO and laparoscopy, case series with more than 10 patients, and patients age younger than 18. A meta-analysis of the 150 cases identified showed a mortality rate of 0.7 %, an enterotomy rate of 4.0 %, and a conversion rate of 27.3 % (Table 2). Table 3 lists laparoscopic failure. These results surpass those shown by O’Connor and Winter, suggesting that laparoscopic treatment should also become the gold standard for the treatment of SBO in children. Despite this, a recent report of 20,679 cases of pediatric adhesive bowel obstruction undertaken in the United States from 1997 to 2009 showed that only 17 % were treated with laparoscopy, with laparotomy and open adhesiolysis remaining by far the most common surgical technique used [4]. This study also confirmed the well-known benefits of laparoscopy, such as shorter lengths of stay (6 vs. 8 days), reduced hospital costs ($38,241 vs. $48,552), and reduced complication rates (5.6 vs. 10.4 %) compared to open surgery. Historically, pediatric surgery has shown a delay in embracing minimally invasive surgical techniques. Some could argue that the delay was due to the lack of pediatric instruments at that time, or perhaps due to longer learning curves due to the reduced frequency of some operations (e.g., cholecystectomy), but we also know that the time taken for pediatric surgeons to mentally switch to convert their practice to minimally invasive surgery played a role. On the subject of SBO, a problem common to patients of all ages, pediatric surgeons should be receptive and open to follow adult results, with an aim to better surgical practice and outcomes for children and their families. In conclusion, even if the amount of data is not yet consistent and comparable to that of the adult field, we are confident in supporting the fact that pediatric surgeons with advanced laparoscopic skills are safe and highly efficacious in treating pediatric SBO with minimally invasive techniques and that laparoscopy should become the gold standard for the treatment of this condition in children. Nadja Apelt and Neil Featherstone contributed equally to this work, and both should be considered first author.

Evaluation and management of small-bowel obstruction

Small-bowel obstruction (SBO) represents as many as 16% of surgical admissions and more than 300,000 operations annually in the United States. The optimal strategies for the diagnosis and management of SBO continue to evolve secondary to advances in imaging techniques, critical care, and surgical techniques. This updated systematic literature review was developed by the Eastern Association for the Surgery of Trauma to provide up-to-date evidence-based recommendations for SBO. A search of the National Library of Medicine MEDLINE database was performed using PubMed interface for articles published from 2007 to 2011. The search identified 53 new articles that were then combined with the 131 studies previously reviewed by the 2007 guidelines. The updated guidelines were then presented at the 2012 annual EAST meeting. Level I evidence now exists to recommend the use of computed tomographic scan, especially multidetector computed tomography with multiplanar reconstructions, in the evaluation of patients with SBO because it can provide incremental clinically relevant information over plains films that may lead to changes in management. Patients with evidence of generalized peritonitis, other evidence of clinical deterioration, such as fever, leukocytosis, tachycardia, metabolic acidosis, and continuous pain, or patients with evidence of ischemia on imaging should undergo timely exploration. The remainder of patients can safely undergo initial nonoperative management for both partial and complete SBO. Water-soluble contrast studies should be considered in patients who do not clinically resolve after 48 to 72 hours for both diagnostic and potential therapeutic purposes. Laparoscopic treatment of SBO has been demonstrated to be a viable alternative to laparotomy in selected cases.

Laparoscopy for acute small bowel obstruction: indication or contraindication?

Acute small bowel obstruction (SBO) is a relatively common cause of emergency hospital admission, most frequently due to postoperative adhesions. With increased experience and technical advances in laparoscopic surgery, the laparoscopic management of acute SBO has become feasible and potentially superior to the open approach. This retrospective study presents the authors' experience with laparoscopic treatment of SBO over a 6-year period to assess the feasibility, efficacy, and clinical outcome of this therapeutic method and to present the author's methodology. From April 2003 to January 2009, 32 patients hospitalized in the author's department for acute SBO underwent elective laparoscopic treatment after failure of conservative measures. Standard laparoscopic techniques and instruments were used. Postoperative adhesions were identified in 62.5% of patients (n=20) as well as tumor (n=3), incarcerated ventral hernia (n=4), incarcerated femoral hernia (n=3), internal hernia (n=1), and Crohn's disease (n=1). The conversion rate was 18.7% (n=6), and the postoperative complication rate was 3.25% (n=1). The mean operative time was 78 min. Bowel function returned after a mean of 3.2 days, and the mean hospital stay was 4.6 days. The laparoscopic treatment of acute SBO is an attractive alternative to the open approach. However, it must be kept in mind that surgery longer than 120 min is a significant predictor of postoperative morbidity, that bowel injury may be missed at the time of operation and can be avoided with improved surgical techniques and appropriate instrumentation, that lysis of all intraabdominal adhesions is unnecessary, and that a low threshold for conversion should be maintained, especially in cases of severe, dense, extensive adhesions.

Laparoscopic treatment of small-bowelobstruction following laparoscopic lymphadenectomy

Laparoscopic pelvic lymph node dissection followed by radical perineal prostatectomy has become the treatment of choice for selected patients at our institution with clinically localized adenocarcinoma of the prostate. We describe 2 cases in which bowel obstruction caused by incarceration of a loop of small bowel into a trocar site was managed with laparoscopic techniques.