(a, b) Abdominal CT scan images and operative findings in a woman with an adhesive closed loop small bowel obstruction after low-anterior resection for rectal cancer. Given the CT findings and peritonitis on exam, the patient was felt to be a poor candidate for laparoscopic exploration and underwent laparotomy and small bowel resection. a shows a coronal image with a class C-shaped closed loop obstruction with thickening and hypoenhancement of the bowel wall as well as edema and lack of perfusion in the associated mesentery. The arrow points to the location of both proximal and distal obstruction. b shows findings on exploratory laparotomy, with internal hernia through a short adhesive band causing closed loop obstruction and ischemia of a loop of small intestine
(a–c) Abdominal CT scan images and operative findings in a woman with adhesive small bowel obstruction of the proximal jejunum after laparoscopic total proctocolectomy and ileal pouch-anal anastomosis for familial adenomatous polyposis. Given the proximal point of obstruction and prior laparoscopic approach, the patient was felt to be a good candidate for laparoscopic exploration and lysis of adhesions, which successfully resolved her obstruction. a shows a coronal image with dilated stomach, duodenum, and proximal jejunum. The arrow points to the point of obstruction from the adhesive band. Note the distal decompressed loops of small intestine in the pelvis. b and c show laparoscopic findings, with a broad adhesive band compressing the proximal jejunum
Predictors for success and contraindications to laparoscopy for small bowel obstruction
Predictors of successful laparoscopic lysis of adhesions | Contraindications to laparoscopic approach for SBO |
|---|---|
Two or fewer prior abdominal operations Previous upper abdominal incision Appendectomy as only prior operation Transition point outside of the pelvis Bowel dilation less than 4 cm Partial bowel obstruction Surgeon training in advanced laparoscopic techniques | Massive abdominal distension that prevents safe entry into the peritoneal space and limits working space Peritonitis with the need for bowel resection Hemodynamic instability Inability to tolerate pneumoperitoneum due to comorbid disease |
Principles and Quality Benchmarks
Principles of surgery for small bowel obstruction include identification of the cause of obstruction, relief of the obstruction, resection of nonviable bowel, and avoidance of inadvertent enterotomy. Laparoscopy can be a valuable tool in accomplishing these goals, but conversion to open surgery should be undertaken without delay if any of these goals cannot be accomplished via laparoscopic approach.
Preoperative Planning, Patient Workup, and Optimization
Initial evaluation of the patient should address early stabilization with nasogastric decompression, fluid resuscitation, and correction of electrolyte abnormalities. Nasogastric decompression should be performed prior to induction of general anesthesia to minimize risk of aspiration.
Early attention to the urgency of surgery is critical in avoiding complications of strangulated bowel. Severe pain, incarcerated hernia, overlying skin changes, significant leukocytosis, free peritoneal fluid or air, or suggestion of compromised perfusion on imaging warrants consideration of emergent surgery. It is important to remember that with a closed loop obstruction, fluid-filled loops are often not seen on abdominal x-ray. If a patient is felt to be stable without impending strangulation, observation with nasogastric decompression is appropriate, but if an obstructed patient does not improve in 24–48 hours, the abdomen should be explored.
The skill level and experience of the surgeon are important in operative planning, both in terms of technical skill and ability to judge if and when it is appropriate to convert to laparotomy. Absolute contraindications for laparoscopy include pulmonary or cardiac status that cannot tolerate abdominal insufflation. Relative contraindications include diffuse abdominal distension, which risks bowel injury both during initial access to the abdomen and in dissection and visualization of the anatomy due to limited exposure. A history of previous abdominal surgery is a relative contraindication to a laparoscopic approach, with prior laparotomy or prior diffuse peritonitis yielding lower probability of success than a prior laparoscopic operation.
Operative Setup and Technique
The patient should be positioned on the operating room table with the entire abdomen exposed and sterilized. The patient’s torso and all extremities should be secured to the operating table such that the table can be tilted in different directions for best visualization. In cases where intraoperative lower endoscopy may be useful (e.g., SBO after ileal pouch-anal anastomosis), a split-leg table or lithotomy position should be considered.
Pneumoperitoneum can be established using either Hasson technique or Veress needle depending on surgeon’s preference, but ideally initial access should be gained away from prior surgical sites. Initial use of an optical viewing trocar can facilitate safe peritoneal entry as it allows direct visualization of the layers of the abdominal wall. Insertion of subsequent trocars under direct laparoscopic visualization is critical. Surgeons should not shy away from using several additional 5 mm trocars in order to improve access and exposure. Using a 5 mm rather than 10 mm 30 degree scope allows for frequent change in camera port position during the case. This is particularly helpful in keeping the camera in line with the surgeon’s instruments when running the bowel from distal to proximal. Using a pair of atraumatic laparoscopic forceps, the surgeon follows the loops of bowel, attempting to find a transition point between distended and collapsed bowel. Careful attention to gentle manipulation of the bowel, especially dilated segments, is critical to avoid creating enterotomies. Adhesive bands are lysed with sharp laparoscopic scissors, and blunt dissection of adhesions is minimized in order to avoid tearing of tissue in planes out of direct view. As in reoperative surgery, the use of energy, either monopolar cautery or bipolar energy, should be minimized in order to avoid the risk of inadvertent burn injury and delayed enterotomy. Endo peanuts can be particularly helpful during blunt dissection of soft adhesions. Hemostasis can be achieved with suction and sponges.
Laparoscopy is a very good option to evaluate bowel obstruction in the virgin abdomen, as it allows for diagnosis and, if tumor or other reasons for minilaparotomy are found, helps optimize incision placement.
Pitfalls and Troubleshooting
The decision to convert to open surgery should be made expediently if any of the goals of surgery for SBO cannot be accomplished (identification of the cause of obstruction, relief of the obstruction, resection of nonviable bowel, and avoidance of inadvertent enterotomy). Frequently laparoscopy provides improved visualization over open surgery, but with obstruction, dilated bowel may preclude adequate visualization. Changing camera ports, adding working ports, and tilting the operating table may allow for identification of the transition point. Often after prior open surgery, adhesions to the prior abdominal incision can be divided via lateral laparoscopic ports, and laparoscopic approach is successful.
Ideally, all adhesions should be lysed to allow for running of the entire small bowel. It is necessary, however, to balance the advantage of complete visualization with the risk of bowel injury and causing bleeding by dividing further adhesions. The surgeon should maintain a low threshold for conversion if severely distended bowel or matted adhesions are present, especially in the deep pelvis. If enterotomy with minor contamination occurs and the bowel is minimally distended and otherwise healthy, laparoscopic repair can be considered, but unfortunately these conditions are rarely met, and at least minilaparotomy is typically advisable after iatrogenic bowel injury.
If the cause of obstruction is corrected but question of bowel strangulation exists, the loop of bowel should be observed for at least 5 minutes in the operating room. Return of normal color and peristalsis suggests viability, but with uncertainty the loop of bowel should be resected or at minimum the patient should be closely observed after surgery with a low threshold for second-look laparoscopy. If nonviable bowel is identified, resection should be performed through at least a minilaparotomy to minimize peritoneal contamination.
Laparoscopy can be a safe and effective first-line approach to small bowel obstruction, but maintaining a low threshold to convert to laparotomy is imperative for patient safety.
Outcomes
Logic would suggest that a laparoscopic approach for adhesive small bowel obstruction would confer the same benefits to patients as laparoscopy for other conditions, but the data are not so clear. An important consideration is that the retrospective, nonrandomized nature of nearly all publications on surgery for adhesive SBO heavily biases open surgery toward patients with more comorbidities or worse clinical presentation. As a result, outcomes will tend to favor laparoscopy despite attempts to mediate these confounders with multivariate analysis and case matching. However, it is unlikely that a randomized controlled trial large enough to provide useful results will ever be completed, and so best analysis of the available data is important. Several single institution retrospective reviews, some of which utilize propensity score matching, have been published on the topic. In addition, several authors have pooled analyses of case-matched control or comparative studies, and nationwide databases have been queried on the topic.
Outcomes in laparoscopy for small bowel obstruction
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