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Laparoscopic adhesiolysis for small bowel obstruction
The American Journal of Surgery 187 (2004) 464 – 470
Review
Laparoscopic adhesiolysis for small bowel obstruction Alexander Nagle, M.D., Michael Ujiki, M.D., Woody Denham, M.D., Kenric Murayama, M.D.* Department of Surgery, Northwestern University, Feinberg School of Medicine, 201 E. Huron St., Galter 10-105, Chicago, IL 60611, USA Manuscript received March 24, 2003; revised manuscript August 11, 2003
Abstract Background: Historically, laparotomy and open adhesiolysis have been the treatment for patients requiring surgery for small bowel obstruction. Laparoscopic adhesiolysis has not gained wide acceptance. The indications and outcomes of laparoscopic adhesiolysis for small bowel obstruction are not well established. The purpose of this paper is to review the literature on laparoscopic adhesiolysis for small bowel obstruction and to discuss patient selection, surgical technique, and outcomes. Data sources: Medline search from 1980 to 2002. Conclusions: Laparoscopic adhesiolysis has been shown to be safe and feasible in experienced hands. For selected patients, laparoscopic adhesiolysis offers the advantages of decreased length of stay, faster return to full activity, and decreased morbidity. Patient selection and surgical judgment appear to be the most important factors for a successful outcome. © 2004 Excerpta Medica, Inc. All rights reserved. Keywords: Laparoscopy; Intestinal obstruction; Adhesiolysis; Review
Adhesions from prior surgery are the most common cause of small bowel obstruction in the Western world [1]. The incidence of an adhesive small bowel obstruction after open abdominal surgery is between 12% and 17% [2]. The socioeconomic impact of adhesive small bowel obstructions is significant. In 1996, Medicare paid $3.22 billion for adhesionrelated complications [3]. Historically, laparotomy and open adhesiolysis have been the treatment for patients requiring surgery for small bowel obstruction. Unfortunately, this often leads to further formation of intraabdominal adhesions with approximately 10% to 30% of patients requiring another laparotomy for recurrent bowel obstruction [4 – 6]. Laparoscopy has revolutionized the field of general surgery. This was most evident with the introduction of laparoscopic cholecystectomy in the late 1980s. Initially there were many contraindications to laparoscopy, including previous abdominal surgery and bowel obstruction; however, as surgeons gained more experience with laparoscopic techniques and as technical advances in instrumentation were made, minimally invasive techniques have been applied to an increasing number and variety of surgical procedures. Laparoscopic adhesiolysis was first described by gynecologists for the treatment of chronic pelvic pain and infertility.
Laparoscopic adhesiolysis for small bowel obstruction was first reported by Bastug et al [7] in 1991 in 1 patient with a single adhesive band. Since that time, there have been several single case reports and multiple series that attest to the success of laparoscopic adhesiolysis [10 –27]. In addition, laparoscopy has been shown to decrease the incidence, extent, and severity of intraabdominal adhesions when compared with open surgery, thus potentially decreasing the recurrence rate for adhesive small bowel obstruction [8]. However, laparoscopic adhesiolysis has not gained wide acceptance because of concerns regarding iatrogenic injury to the bowel and limited visualization secondary to distended bowel. At this time, there are no prospective randomized trials comparing open and laparoscopic adhesiolysis for small bowel obstruction. Furthermore, the indications and outcomes of laparoscopic adhesiolysis for small bowel obstruction are not well established. The purpose of this paper is to review the literature on laparoscopic adhesiolysis for small bowel obstruction and to discuss patient selection, surgical technique, and outcomes.
* Corresponding author. Tel.: ⫹1-312-695-1414; fax: ⫹312-695-1462. E-mail address: [email protected]
Laparoscopic adhesiolysis for small bowel obstruction has a number of potential advantages: (1) less postoperative
Indications
0002-9610/04/$ – see front matter © 2004 Excerpta Medica, Inc. All rights reserved. doi:10.1016/j.amjsurg.2003.12.036
A. Nagle et al. / The American Journal of Surgery 187 (2004) 464 – 470
pain, (2) quicker return of intestinal function, (3) shorter hospital stay, (4) reduced recovery time, allowing an earlier return to full activity, (5) fewer wound complications, and (6) decreased postoperative adhesion formation. Although laparoscopic adhesiolysis has many potential advantages, the most important aspect to a successful outcome is proper patient selection and surgical judgment. When reviewing the literature, there are no clear guidelines that state which patients are best suited for laparoscopic adhesiolysis; however, there are several factors that have been shown to predict a successful outcome. The first consideration is that the surgeon be trained and capable of performing advanced laparoscopy. With regards to patient selection, patients with an acute small bowel obstruction and peritonitis or free air requiring an emergent operation are best managed with a laparotomy. Chosidow et al [15] reported laparoscopic adhesiolysis on an emergent basis in 39 patients; the conversion rate was 36% compared with 7% in elective cases. Patients without peritonitis who do not resolve with nonoperative management should be considered for laparoscopic adhesiolysis. In these cases, it is important to consider the bowel diameter, degree of abdominal distention, and location of the obstruction (ie, proximal or distal). Bowel diameter can be determined on abdominal plain x-ray films. Suter et al [13] found that a bowel diameter exceeding 4 cm was associated with an increased rate of conversion: 55% versus 32% (P ⫽ 0.02). A computed tomography scan of the abdomen and pelvis can provide additional information about the location of the transition point and delineate a complete from a partial obstruction. Patients with a distal and complete small bowel obstruction have an increased incidence of intraoperative complications and increased risk of conversion. Patients with persistent abdominal distention after nasogastric intubation are also unlikely to be treated successfully with laparoscopy. The influence of dense adhesions and the number of previous operations on the success of laparoscopic adhesiolysis is controversial. Leo´ n et al [19] state that a documented history of severe or extensive dense adhesions is a contraindication to laparoscopy. Navez et al [21] found that patients who had only a previous appendectomy were most likely to be successfully managed with laparoscopy. In contrast, Suter et al [13] found no correlation between the number and or type of previous surgeries and the chance of a successful laparoscopic surgery. Other factors such as an elevated white blood cell count or a fever have not been demonstrated to correlate with an increased conversion rate [13,21]. One group of patients who are suited for laparoscopic adhesiolysis are those with a nonresolving, partial small bowel obstruction or a recurrent, chronic small bowel obstruction demonstrated on contrast study. Pekmezci et al [10] reported the successful management of all 15 patients treated by enteroclysis-guided laparoscopic adhesiolysis with only 1 patient requiring conversion to a laparotomy. Leo´ n et al [19] reported a 100% success rate in 10 patients with nonresolving small bowel obstruction.
465
Fig. 1. Initial trocar placement: an example of the alternative site technique in the left upper quadrant. Other sites such as the right upper quadrant are also acceptable.
Patient preparation Patients are prepared for laparoscopic adhesiolysis just as they would be for an open operation. Correction of electrolytes, fluid resuscitation, and a Foley catheter are standard practice. Intravenous antibiotics are used in the perioperative period. The nasogastric tube should be checked for proper position and function. Patients and their families are informed of the risk for bowel injury, the possible need for additional trocars, and the risk for conversion.
Operative technique Equipment and room set-up Patients are placed in the supine position with both arms tucked along their sides. The patient is securely strapped to the surgical bed to facilitate maximum tilting and lateral rotation of the operating table. Some authors have advocated the additional use of a beanbag and or a footboard. Two video monitors are used, one on each side of the operating table. The surgeon and the first assistant stand on opposite sides of the table. The surgical team should move around the patient according to the operative findings. Angled telescopes (30- or 45-degree) are helpful to view around structures or adhesions and maximize the field of view. Peritoneal access Peritoneal access and trocar injury to the distended bowel are major concerns regarding the feasibility of laparoscopic adhesiolysis. The initial trocar should be placed away (alternative site technique) from the scars in an attempt to avoid adhesions (Fig. 1). Some investigators have recommended the use of computed tomography scan or
466
A. Nagle et al. / The American Journal of Surgery 187 (2004) 464 – 470
ultrasonography to help determine a safe site for the initial trocar insertion. Although alternative site entry can be performed with either an open (Hasson) or blind-access (Veress needle) technique, the open approach is more prudent in cases of laparoscopy for small bowel obstruction. Sato et al [12] reported using the Veress needle in 16 patients without a single complication. The importance of confirming the position of the needle with the saline drop test and monitoring the pressure during insertion of the Veress needle was emphasized. In contrast, Levard et al [11] reported a 3.7% incidence of intestinal perforation using a blind-access technique in cases of bowel obstruction. Other studies have confirmed that the blind-access technique (Veress needle) does have a higher rate of bowel injury and vascular complications, even in patients who have not had prior abdominal surgery. Most authors advocate the use of the open technique because of concerns about intraabdominal adhesions fixing segments of bowel to the undersurface of the abdominal wall [13,19,21,23]. The open technique is performed similar to a muscle-sparing incision for an appendectomy. Careful dissection is required to avoid injury to the underlying adherent bowel. Blind cutting or spreading must be avoided. The open technique allows the identification of adherent bowel and dissection of the bowel away from the abdominal wall. Although the open technique does not completely eliminate the risk of bowel injury, it does allow the surgeon to promptly identify and repair any injury that may occur. Finally, there have been no reports of vascular injuries with the open technique, as have been described with the blindaccess technique. The disadvantage of the open technique is the increase in operative time, particularly in obese patients. Another technique that has gained favor is the use of optical access trocars. In experienced hands, optical access trocars are safe and facilitate rapid entry into the peritoneal cavity. String et al [9] reported their use in 650 patients, with a mean entry time of 77 seconds and a complication rate of 0.3%. With this technique a 0-degree laparoscope is inserted through the transparent cannula as the trocar is advanced through the abdominal wall, thereby visualizing each tissue layer of the abdominal wall. The advantage of this technique is that it allows you to identify the bowel wall before inserting the trocar into the bowel. Furthermore, if an injury does occur, it is recognized at that time and managed appropriately. Once safe access is obtained, the next goal is to provide adequate visualization in order to insert the remaining trocars. This often requires some degree of adhesiolysis along the anterior abdominal wall. Numerous techniques are available, including finger dissection through the initial trocar site and using the camera to bluntly dissect the adhesions. Sometimes, gentle retraction on the adhesions will separate the tissue planes. Most often sharp adhesiolysis is required. The best technique is to follow the line of tissue adherence, if possible, which results in less bleeding and less risk for bowel injury. A traction-countertraction technique as used for open adhesiolysis is effective. The use of
cautery and ultrasound dissection should be limited in order to avoid thermal tissue damage. A particularly difficult situation involves dense adhesions between the bowel and anterior abdominal wall. In this case, the plane between the bowel and the peritoneum is often obliterated, and it is necessary to dissect in the preperitoneal fat. In most cases, at least two additional trocars will be needed in order to achieve adequate adhesiolysis. If possible, the trocars should be placed to operate along the sights of the camera and not against the camera. Surgeons should be flexible about trocar placement, and additional trocars should be placed as needed to accomplish the necessary adhesiolysis. Technique for adhesiolysis After trocar placement, the initial goal is to expose the collapsed distal bowel. This is facilitated with the use of angled telescopes and maximal tilting/rotating of the surgical table. It may also be necessary to move the laparoscope to different trocars to improve visualization. Manipulation of thin-walled, friable, dilated small bowel should be avoided. Even with atraumatic graspers, injury to the bowel wall can occur. If necessary, the small bowel mesentery (instead of the bowel wall) should be grasped in order to manipulate the bowel. Once the collapsed distal bowel is exposed, atraumatic graspers should be used to run the decompressed small bowel proximally until the site of obstruction (transition point) is found. Sharp dissection with the laparoscopic scissors should be used to cut the adhesions. Cautery should be avoided in order to prevent potential thermal injury to adjacent bowel. The use of cautery also causes tissue ischemia (a very potent adhesion promoter), which leads to the formation of more intraabdominal adhesions. Only pathologic adhesions should be lysed. Additional adhesiolysis only adds to the operative time and to the risks of surgery without benefit. If the point of obstruction is not clearly identified, adhesiolysis should continue until all suspicious adhesion or bands are transected. If all adhesions cannot be lysed then conversion to an open procedure should be strongly considered. Once adequate adhesiolysis is complete, the area lysed should be thoroughly inspected for possible bleeding and bowel injury. If found, these complications should be treated appropriately. Small bleeding points may be controlled with clips, suture, or careful cautery. Serosal tears and enterotomies can be repaired laparoscopically; however, there should be a low threshold to convert. If there is any concern about the integrity of the bowel, we recommend a minilaparotomy in order to examine the bowel under direct visualization.
Intraoperative findings There are several intraoperative findings that are associated with a high risk of conversion. These are important to recognize because early conversion will decrease operative
A. Nagle et al. / The American Journal of Surgery 187 (2004) 464 – 470 Table 1 Operative findings in selected series Isolated band [11,13,16] Dense adhesions [11,13] Internal hernia [13] Stricture [13] Colon cancer [11,13] Other (SB tumor, Meckels, intussusception, etc) [13]
30%–54% 31%–43% 2% 2.4% 1.3%–3.6% 5%
time and potentially decrease patient morbidity. Perforated or gangrenous bowel is best managed with conversion to either a minilaparotomy or a formal laparotomy. Although laparoscopic small bowel resection and primary anastomosis in the acute setting has been described, we prefer to exteriorize the bowel through an appropriately sized and positioned incision and to perform the bowel resection and anastostomis extracorporally. However, in cases of chronic partial small bowel obstruction, the bowel is often thickened and laparoscopic small bowel resection may be feasible. Matted small bowel loops and dense adhesions are also best managed with a formal laparotomy. Navez et al [21] reported that only 10% of obstructions caused by dense adhesions could be treated successfully with laparoscopy. On the other hand, when the cause of obstruction was a single band, laparoscopic adhesiolysis was successful 100% of the time [21]. Unfortunately, it is difficult to predict the degree of intraabdominal adhesions prior to surgery. When operating for suspected adhesive bowel obstruction, other etiologies may be found, such as internal hernia, inguinal hernia, neoplasm, inflammatory bowel disease, intussusception, and gallstone ileus. It is important to be prepared to deal with these other possible etiologies. In a number of cases, conversion to a minilaparotomy or a formal laparotomy is required. Table 1 shows the percentage of other finding reported in the literature. Conversion to a laparotomy should not be considered a failure or complication, but rather a recognition of limitations posed by technology, the surgical expertise, or factors unique to a particular patient or disease process. Table 2 shows the most common reasons for conversion. Outcomes The results of laparoscopic adhesiolysis as reported in several series are shown in Table 3. There are no prospecTable 2 Reasons for conversion in selected series Unable to visualize the site of obstruction [11,13] Bowel necrosis or perforation [11,13] Neoplasm or suspicion of neoplasm [11,13] Iatrogenic perforation [11,13] Dense and numerous adhesions [13,19] Technical difficulties [13] Other [16]
22%–49% 19%–23% 3%–25% 14%–19% 14%–50% 6% 5%
467
tive randomized trials that compare open and laparoscopic adhesiolysis for small bowel obstruction. Most series are retrospective and have only a few patients with short follow-up. The largest series is a multicenter study of 308 patients, but the data are retrospective and the follow-up is only 1.6 months [11]. Operative times range from 58 to 108 minutes for laparoscopic cases and up to 208 minutes for cases that are converted to a laparotomy [14,19]. The conversion rates range from 6.7% to 43% [10,13]. The reported hospital length of stay in most series is 4 to 6 days for the laparoscopic group and around 12 days for the converted group. The incidence of intraoperative enterotomies ranges from 3% to 17.6%, with most authors reporting an incidence of about 10% [12,15]. Suter et al [13] reported an intraoperative enterotomy incidence of 15.6%, of which 62% were repaired laparoscopically. One of the most dreaded complications of surgery is a missed enterotomy. Although a missed enterotomy can occur after laparotomy, the incidence is higher after laparoscopic surgery. Suter et al [13] reported 4 of 47 cases (8.5%) of missed enterotomies that required reoperation. Others have also reported cases that required early reoperation for missed bowel perforations. Strickland et al [16] found that the duration of surgery longer than 120 minutes, bowel necrosis, intraoperative perforation, and conversion were significant predictors of postoperative morbidity. Levard et al [11] reported the incidence of wound complications to be 1.2% in the laparoscopic group compared with 10% in the converted group (P ⬍0.001). Bailey et al [20] reported that in a series of 65 patients operated on for acute bowel obstruction, 7 patients required early reoperation. The reported mortality ranges from 0% to 3%. This rate is lower than the reported mortality after open surgery of adhesiolysis, which most likely represents patient selection. Cost analysis has not been addressed in any of the series in the literature. The long-term results regarding recurrence are limited, with most series reporting a mean follow-up between 12 and 24 months. Navez et al [21] reported that 85% (29 of 34) of the patients treated laparoscopically were asymptomatic with a mean follow-up of 46 months. The series with the longest follow-up (mean 61.7 months) reported 87.5% (14 of 16) of the patients treated laparoscopically were asymptomatic [12]. The question regarding decreased recurrence after laparoscopy compared with laparotomy remains to be answered. Interestingly, Khaitan et al [28] have described a new technique of applying Seprafilm laparoscopically, which could further decrease the recurrence of adhesive bowel obstruction.
Conclusions Laparoscopic adhesiolysis has been shown to be safe and feasible in experienced hands. At this time, laparoscopic surgery for small bowel obstruction is still under evaluation since it has not been directly compared with open surgery.
468
Table 3 Selected reports of laparoscopic adhesiolysis for small bowel obstruction Location
n
Operative time (min)
Laparoscopy assisted (%)
Conversion (%)
Pekmezci et al (2002) [10] Levard et al (2001) [11]
Turkey France
15 308
99 NR
0 NR
6.7 40.9
6.7 8.4
Sato et al (2001) [12]
Japan
17
17.6
17.6
Suter et al (2000) [13]
Switzerland
83
105* 119‡ NR
NR
43
15.6
Al-Mulhim (2000) [14] Chosidow et al (2000) [15]
Saudi Arabia France
19 134
NR 27
32 16
NR 3
Strickland et al (1999) [16]
Pasadena, CA
40
32.5
10
Leon et al (1998) [19]
Rochester, MN
40
Bailey et al (1998) [20]
Australia
65
Navez et al (1998) [21]
Belgium
69
Ibrahm et al (1996) [22] Overall (range)
Englewood, NJ
33
* Laparoscopic group. † Laparoscopic-assisted group. ‡ Converted group. NR ⫽ not reported.
58 71.7* 89.5‡ 68* 106‡ 108* 135† 208‡ 64* 83† 110‡ 77* 120‡ NR 58–208
5.8
7.5 30
35
24.6
21.5
6 12 0–30
40 15 6.7–43
Bowel injury (%)
7.5
NR
9 9.1 3–17.6
Length of stay (days)
Follow-up (months)
4 4 10 10.4* 18‡ 5.9* 15.7‡ 5 5.03* 12.5‡ 3.6* 10.5‡ 2.9* l5.4† 7.4‡ 3
17.2 1.6
6.6* 16.8‡ NR 2.9–18
Success (%)
Mortality rate (%)
0 4.5
100 95
0 2.2
61.7
5.8
88
NR
9
NR
2.4
27 NR
0 NR
100 80
0 0
22
5
97
0
12
17.5
81
0
NR
10.8
NR
1.8
46
2.9
85.3
2.9
NR 80–100
3 0–3
NR 1.6–61.7
Reoperation (%)
3 0–17.5
0
A. Nagle et al. / The American Journal of Surgery 187 (2004) 464 – 470
Reference
A. Nagle et al. / The American Journal of Surgery 187 (2004) 464 – 470
469
Fig. 2. Algorithm for the role of laparoscopic adhesiolysis in management of small bowel obstruction.
In selected patients, laparoscopic adhesiolysis offers the advantages of decreased length of stay, faster return to full activity, and decreased morbidity. Patient selection and surgical judgment appear to be the most important factors for a successful outcome. Our algorithm for the role of laparoscopic adhesiolysis in the management of small bowel obstruction is shown in Fig. 2. Patients who require an emergent operation are not good candidates for laparoscopic adhesiolysis. Patients with bowel dilatation less than 4 cm and a partial obstruction can be considered for laparoscopic adhesiolysis. Patients who have a chronic or recurrent par-
tial obstruction documented on a contrast study are also good candidates for laparoscopic adhesiolysis. Technically, peritoneal access should be achieved with the open (Hasson) technique in order to avoid bowel injury. Grasping the dilated, thin-walled bowel and the use of cautery should be avoided. The most common reasons for conversion include dense adhesions, unable to visualize the site of obstruction, iatrogenic intestinal perforation, bowel necrosis and colonic cancer. There should be a low threshold to convert to a minilaparotomy or to a formal laparotomy. Conversion should not be considered a failure, but rather good surgical
470
A. Nagle et al. / The American Journal of Surgery 187 (2004) 464 – 470
judgment. Further studies need to examine the open versus the laparoscopic procedure in a prospective randomized fashion and evaluate the cost effectiveness of this approach.
References [1] Menzies D, Ellis H. Intestinal obstruction from adhesions: how big is the problem? Ann R Coll Engl 1990;223:242– 8. [2] Beck DE, Opelka FG, Bailey HR, et al. Incidence of small bowel obstruction and adhesiolysis after open colorectal and general surgery. Dis Colon Rectum 1999;42:241– 8. [3] Health Care Financing Administration. MEDPAR database, 1990-96. [4] Landercasper J, Cogbill TH, Merry WH, et al. Long-term outcome after hospitalization for small-bowel obstruction. Arch Surg 1993; 128:765–70. [5] Mucha P. Small intestinal obstruction. Surg Clin North Am 1987;67: 597– 620. [6] Barkan H, Webster S, Ozeran S. Factors predicting the recurrence of adhesive small-bowel obstruction. Am J Surg 1995;170:361–5. [7] Bastug DF, Trammell SW, Boland JP, et al. Laparoscopic adhesiolysis for small bowel obstruction. Surg Laparosc Endosc Percutan Tech 1991;1:259 – 62. [8] Tittel A, Treutner KH, Titkova S, et al. Comparison of adhesion reformation after laparoscopic and conventional adhesiolysis in an animal model. Langenbeck’s Arch Surg 2001;386:141–5. [9] String A, Berber E, Foroutani A, et al. Use of the optical access trocar for safe and rapid entry in various laparoscopic procedures. Surg Endosc 2002;15:570 –5. [10] Pekmezci S, Altinli E, Saribeyoglu K, et al. Enteroclysis-guided laparoscopic adhesiolysis in recurrent adhesive small bowel obstructions. Surg Laparosc Endosc Percutan Tech 2001;12:165–70. [11] Levard H, Boudet M, Msika S, et al. Laparoscopic treatment of acute small bowel obstruction: a multicentre retrospective study. Aust NZ J Surg 2001;71:641– 6. [12] Sato Y, Ido K, Kumagai M, et al. Laparoscopic adhesiolysis for recurrent small bowel obstruction: long-term follow-up. Gastrointest Endosc 2001;54:476 –9. [13] Suter M, Zermatten P, Hakic N, et al. Laparoscopic management of mechanical small bowel obstruction: are there predictors of success or failure? Surg Endosc 2000;14:478 – 84.
[14] Al-Mulhim AA. Laparoscopic management of acute small bowel obstruction: experience from a Saudi teaching hospital. Surg Endosc 2000;14:157– 60. [15] Chosidow D, Johanet H, Montario T, et al. Laparoscopy for acute small-bowel obstruction secondary to adhesions. J Laparoendosc Adv Surg Tech 2000;10:155–9. [16] Strickland P, Lourie DJ, Suddleson EA, et al. Is laparoscopy safe and effective for treatment of acute small-bowel obstruction? Surg Endosc 1999;13:695– 8. [17] El Dahha AA, Shawkat AM, Bakr AA. Laparoscopic adhesiolysis in acute small bowel obstruction: a preliminary experience. JSLS 1999; 3:131–5. [18] Kyzer S. Laparoscopic treatment of small bowel obstruction caused by adhesion. Harefuah 1999;139:681–3. [19] Leo´ n EL, Metzger A, Tsiotos GG, et al. Laparoscopic management of small bowel obstruction: indications and outcomes. J Gastrointest Surg 1998;2:132– 40. [20] Bailey IS, Rhodes M, O’Rourke N, et al. Laparoscopic management of acute small bowel obstruction. Br J Surg 1998;85:84 –7. [21] Navez B, Arimont JM, Guit P. Laparoscopic approach in acute small bowel obstruction. A review of 68 patients. Hepatogastroenterology 1998;45:2146 –50. [22] Ibrahim IM, Wolodiger F, Sussman B, et al. Laparoscopic management of acute small bowel obstruction. Surg Endosc 1996;10:1012–5. [23] Benoist S, De Watteville JC, Gayral F. Role of celioscopy in acute obstructions of the small intestine. Gastroenterol Clin Biol 1996;20: 357– 61. [24] Parent S, Bresler L, Marchal F, et al. Laparoscopic surgery for acute adhesions on the small bowel. J Chirug 1995;132:382–5. [25] Federman G, Walenzyk J, Scheider A, et al. Laparoscopic therapy of ileus of the small intestine caused by adhesions or bands—preliminary results. Zentralbl Chirug 1995;120:377– 81. [26] Franklin ME, Dorman JP, Pharand D. Laparoscopic surgery in acute small bowel obstruction. Surg Laparosc Endosc 1994;4:289 –96. [27] Francois Y, Mouret P, Tomaoglu K, et al. Postoperative adhesive peritoneal disease: laparoscopic treatment. Surg Endosc 1994;8:781–3. [28] Khaitan L, Scholz S, Richards W. Laparoscopic adhesiolysis and placement of Seprafilm: a new technique and novel approach to patients with intractable abdominal pain. J Laparosc Surg Tech 2002; 12:241–7.
Review
Laparoscopic adhesiolysis for small bowel obstruction Alexander Nagle, M.D., Michael Ujiki, M.D., Woody Denham, M.D., Kenric Murayama, M.D.* Department of Surgery, Northwestern University, Feinberg School of Medicine, 201 E. Huron St., Galter 10-105, Chicago, IL 60611, USA Manuscript received March 24, 2003; revised manuscript August 11, 2003
Abstract Background: Historically, laparotomy and open adhesiolysis have been the treatment for patients requiring surgery for small bowel obstruction. Laparoscopic adhesiolysis has not gained wide acceptance. The indications and outcomes of laparoscopic adhesiolysis for small bowel obstruction are not well established. The purpose of this paper is to review the literature on laparoscopic adhesiolysis for small bowel obstruction and to discuss patient selection, surgical technique, and outcomes. Data sources: Medline search from 1980 to 2002. Conclusions: Laparoscopic adhesiolysis has been shown to be safe and feasible in experienced hands. For selected patients, laparoscopic adhesiolysis offers the advantages of decreased length of stay, faster return to full activity, and decreased morbidity. Patient selection and surgical judgment appear to be the most important factors for a successful outcome. © 2004 Excerpta Medica, Inc. All rights reserved. Keywords: Laparoscopy; Intestinal obstruction; Adhesiolysis; Review
Adhesions from prior surgery are the most common cause of small bowel obstruction in the Western world [1]. The incidence of an adhesive small bowel obstruction after open abdominal surgery is between 12% and 17% [2]. The socioeconomic impact of adhesive small bowel obstructions is significant. In 1996, Medicare paid $3.22 billion for adhesionrelated complications [3]. Historically, laparotomy and open adhesiolysis have been the treatment for patients requiring surgery for small bowel obstruction. Unfortunately, this often leads to further formation of intraabdominal adhesions with approximately 10% to 30% of patients requiring another laparotomy for recurrent bowel obstruction [4 – 6]. Laparoscopy has revolutionized the field of general surgery. This was most evident with the introduction of laparoscopic cholecystectomy in the late 1980s. Initially there were many contraindications to laparoscopy, including previous abdominal surgery and bowel obstruction; however, as surgeons gained more experience with laparoscopic techniques and as technical advances in instrumentation were made, minimally invasive techniques have been applied to an increasing number and variety of surgical procedures. Laparoscopic adhesiolysis was first described by gynecologists for the treatment of chronic pelvic pain and infertility.
Laparoscopic adhesiolysis for small bowel obstruction was first reported by Bastug et al [7] in 1991 in 1 patient with a single adhesive band. Since that time, there have been several single case reports and multiple series that attest to the success of laparoscopic adhesiolysis [10 –27]. In addition, laparoscopy has been shown to decrease the incidence, extent, and severity of intraabdominal adhesions when compared with open surgery, thus potentially decreasing the recurrence rate for adhesive small bowel obstruction [8]. However, laparoscopic adhesiolysis has not gained wide acceptance because of concerns regarding iatrogenic injury to the bowel and limited visualization secondary to distended bowel. At this time, there are no prospective randomized trials comparing open and laparoscopic adhesiolysis for small bowel obstruction. Furthermore, the indications and outcomes of laparoscopic adhesiolysis for small bowel obstruction are not well established. The purpose of this paper is to review the literature on laparoscopic adhesiolysis for small bowel obstruction and to discuss patient selection, surgical technique, and outcomes.
* Corresponding author. Tel.: ⫹1-312-695-1414; fax: ⫹312-695-1462. E-mail address: [email protected]
Laparoscopic adhesiolysis for small bowel obstruction has a number of potential advantages: (1) less postoperative
Indications
0002-9610/04/$ – see front matter © 2004 Excerpta Medica, Inc. All rights reserved. doi:10.1016/j.amjsurg.2003.12.036
A. Nagle et al. / The American Journal of Surgery 187 (2004) 464 – 470
pain, (2) quicker return of intestinal function, (3) shorter hospital stay, (4) reduced recovery time, allowing an earlier return to full activity, (5) fewer wound complications, and (6) decreased postoperative adhesion formation. Although laparoscopic adhesiolysis has many potential advantages, the most important aspect to a successful outcome is proper patient selection and surgical judgment. When reviewing the literature, there are no clear guidelines that state which patients are best suited for laparoscopic adhesiolysis; however, there are several factors that have been shown to predict a successful outcome. The first consideration is that the surgeon be trained and capable of performing advanced laparoscopy. With regards to patient selection, patients with an acute small bowel obstruction and peritonitis or free air requiring an emergent operation are best managed with a laparotomy. Chosidow et al [15] reported laparoscopic adhesiolysis on an emergent basis in 39 patients; the conversion rate was 36% compared with 7% in elective cases. Patients without peritonitis who do not resolve with nonoperative management should be considered for laparoscopic adhesiolysis. In these cases, it is important to consider the bowel diameter, degree of abdominal distention, and location of the obstruction (ie, proximal or distal). Bowel diameter can be determined on abdominal plain x-ray films. Suter et al [13] found that a bowel diameter exceeding 4 cm was associated with an increased rate of conversion: 55% versus 32% (P ⫽ 0.02). A computed tomography scan of the abdomen and pelvis can provide additional information about the location of the transition point and delineate a complete from a partial obstruction. Patients with a distal and complete small bowel obstruction have an increased incidence of intraoperative complications and increased risk of conversion. Patients with persistent abdominal distention after nasogastric intubation are also unlikely to be treated successfully with laparoscopy. The influence of dense adhesions and the number of previous operations on the success of laparoscopic adhesiolysis is controversial. Leo´ n et al [19] state that a documented history of severe or extensive dense adhesions is a contraindication to laparoscopy. Navez et al [21] found that patients who had only a previous appendectomy were most likely to be successfully managed with laparoscopy. In contrast, Suter et al [13] found no correlation between the number and or type of previous surgeries and the chance of a successful laparoscopic surgery. Other factors such as an elevated white blood cell count or a fever have not been demonstrated to correlate with an increased conversion rate [13,21]. One group of patients who are suited for laparoscopic adhesiolysis are those with a nonresolving, partial small bowel obstruction or a recurrent, chronic small bowel obstruction demonstrated on contrast study. Pekmezci et al [10] reported the successful management of all 15 patients treated by enteroclysis-guided laparoscopic adhesiolysis with only 1 patient requiring conversion to a laparotomy. Leo´ n et al [19] reported a 100% success rate in 10 patients with nonresolving small bowel obstruction.
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Fig. 1. Initial trocar placement: an example of the alternative site technique in the left upper quadrant. Other sites such as the right upper quadrant are also acceptable.
Patient preparation Patients are prepared for laparoscopic adhesiolysis just as they would be for an open operation. Correction of electrolytes, fluid resuscitation, and a Foley catheter are standard practice. Intravenous antibiotics are used in the perioperative period. The nasogastric tube should be checked for proper position and function. Patients and their families are informed of the risk for bowel injury, the possible need for additional trocars, and the risk for conversion.
Operative technique Equipment and room set-up Patients are placed in the supine position with both arms tucked along their sides. The patient is securely strapped to the surgical bed to facilitate maximum tilting and lateral rotation of the operating table. Some authors have advocated the additional use of a beanbag and or a footboard. Two video monitors are used, one on each side of the operating table. The surgeon and the first assistant stand on opposite sides of the table. The surgical team should move around the patient according to the operative findings. Angled telescopes (30- or 45-degree) are helpful to view around structures or adhesions and maximize the field of view. Peritoneal access Peritoneal access and trocar injury to the distended bowel are major concerns regarding the feasibility of laparoscopic adhesiolysis. The initial trocar should be placed away (alternative site technique) from the scars in an attempt to avoid adhesions (Fig. 1). Some investigators have recommended the use of computed tomography scan or
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ultrasonography to help determine a safe site for the initial trocar insertion. Although alternative site entry can be performed with either an open (Hasson) or blind-access (Veress needle) technique, the open approach is more prudent in cases of laparoscopy for small bowel obstruction. Sato et al [12] reported using the Veress needle in 16 patients without a single complication. The importance of confirming the position of the needle with the saline drop test and monitoring the pressure during insertion of the Veress needle was emphasized. In contrast, Levard et al [11] reported a 3.7% incidence of intestinal perforation using a blind-access technique in cases of bowel obstruction. Other studies have confirmed that the blind-access technique (Veress needle) does have a higher rate of bowel injury and vascular complications, even in patients who have not had prior abdominal surgery. Most authors advocate the use of the open technique because of concerns about intraabdominal adhesions fixing segments of bowel to the undersurface of the abdominal wall [13,19,21,23]. The open technique is performed similar to a muscle-sparing incision for an appendectomy. Careful dissection is required to avoid injury to the underlying adherent bowel. Blind cutting or spreading must be avoided. The open technique allows the identification of adherent bowel and dissection of the bowel away from the abdominal wall. Although the open technique does not completely eliminate the risk of bowel injury, it does allow the surgeon to promptly identify and repair any injury that may occur. Finally, there have been no reports of vascular injuries with the open technique, as have been described with the blindaccess technique. The disadvantage of the open technique is the increase in operative time, particularly in obese patients. Another technique that has gained favor is the use of optical access trocars. In experienced hands, optical access trocars are safe and facilitate rapid entry into the peritoneal cavity. String et al [9] reported their use in 650 patients, with a mean entry time of 77 seconds and a complication rate of 0.3%. With this technique a 0-degree laparoscope is inserted through the transparent cannula as the trocar is advanced through the abdominal wall, thereby visualizing each tissue layer of the abdominal wall. The advantage of this technique is that it allows you to identify the bowel wall before inserting the trocar into the bowel. Furthermore, if an injury does occur, it is recognized at that time and managed appropriately. Once safe access is obtained, the next goal is to provide adequate visualization in order to insert the remaining trocars. This often requires some degree of adhesiolysis along the anterior abdominal wall. Numerous techniques are available, including finger dissection through the initial trocar site and using the camera to bluntly dissect the adhesions. Sometimes, gentle retraction on the adhesions will separate the tissue planes. Most often sharp adhesiolysis is required. The best technique is to follow the line of tissue adherence, if possible, which results in less bleeding and less risk for bowel injury. A traction-countertraction technique as used for open adhesiolysis is effective. The use of
cautery and ultrasound dissection should be limited in order to avoid thermal tissue damage. A particularly difficult situation involves dense adhesions between the bowel and anterior abdominal wall. In this case, the plane between the bowel and the peritoneum is often obliterated, and it is necessary to dissect in the preperitoneal fat. In most cases, at least two additional trocars will be needed in order to achieve adequate adhesiolysis. If possible, the trocars should be placed to operate along the sights of the camera and not against the camera. Surgeons should be flexible about trocar placement, and additional trocars should be placed as needed to accomplish the necessary adhesiolysis. Technique for adhesiolysis After trocar placement, the initial goal is to expose the collapsed distal bowel. This is facilitated with the use of angled telescopes and maximal tilting/rotating of the surgical table. It may also be necessary to move the laparoscope to different trocars to improve visualization. Manipulation of thin-walled, friable, dilated small bowel should be avoided. Even with atraumatic graspers, injury to the bowel wall can occur. If necessary, the small bowel mesentery (instead of the bowel wall) should be grasped in order to manipulate the bowel. Once the collapsed distal bowel is exposed, atraumatic graspers should be used to run the decompressed small bowel proximally until the site of obstruction (transition point) is found. Sharp dissection with the laparoscopic scissors should be used to cut the adhesions. Cautery should be avoided in order to prevent potential thermal injury to adjacent bowel. The use of cautery also causes tissue ischemia (a very potent adhesion promoter), which leads to the formation of more intraabdominal adhesions. Only pathologic adhesions should be lysed. Additional adhesiolysis only adds to the operative time and to the risks of surgery without benefit. If the point of obstruction is not clearly identified, adhesiolysis should continue until all suspicious adhesion or bands are transected. If all adhesions cannot be lysed then conversion to an open procedure should be strongly considered. Once adequate adhesiolysis is complete, the area lysed should be thoroughly inspected for possible bleeding and bowel injury. If found, these complications should be treated appropriately. Small bleeding points may be controlled with clips, suture, or careful cautery. Serosal tears and enterotomies can be repaired laparoscopically; however, there should be a low threshold to convert. If there is any concern about the integrity of the bowel, we recommend a minilaparotomy in order to examine the bowel under direct visualization.
Intraoperative findings There are several intraoperative findings that are associated with a high risk of conversion. These are important to recognize because early conversion will decrease operative
A. Nagle et al. / The American Journal of Surgery 187 (2004) 464 – 470 Table 1 Operative findings in selected series Isolated band [11,13,16] Dense adhesions [11,13] Internal hernia [13] Stricture [13] Colon cancer [11,13] Other (SB tumor, Meckels, intussusception, etc) [13]
30%–54% 31%–43% 2% 2.4% 1.3%–3.6% 5%
time and potentially decrease patient morbidity. Perforated or gangrenous bowel is best managed with conversion to either a minilaparotomy or a formal laparotomy. Although laparoscopic small bowel resection and primary anastomosis in the acute setting has been described, we prefer to exteriorize the bowel through an appropriately sized and positioned incision and to perform the bowel resection and anastostomis extracorporally. However, in cases of chronic partial small bowel obstruction, the bowel is often thickened and laparoscopic small bowel resection may be feasible. Matted small bowel loops and dense adhesions are also best managed with a formal laparotomy. Navez et al [21] reported that only 10% of obstructions caused by dense adhesions could be treated successfully with laparoscopy. On the other hand, when the cause of obstruction was a single band, laparoscopic adhesiolysis was successful 100% of the time [21]. Unfortunately, it is difficult to predict the degree of intraabdominal adhesions prior to surgery. When operating for suspected adhesive bowel obstruction, other etiologies may be found, such as internal hernia, inguinal hernia, neoplasm, inflammatory bowel disease, intussusception, and gallstone ileus. It is important to be prepared to deal with these other possible etiologies. In a number of cases, conversion to a minilaparotomy or a formal laparotomy is required. Table 1 shows the percentage of other finding reported in the literature. Conversion to a laparotomy should not be considered a failure or complication, but rather a recognition of limitations posed by technology, the surgical expertise, or factors unique to a particular patient or disease process. Table 2 shows the most common reasons for conversion. Outcomes The results of laparoscopic adhesiolysis as reported in several series are shown in Table 3. There are no prospecTable 2 Reasons for conversion in selected series Unable to visualize the site of obstruction [11,13] Bowel necrosis or perforation [11,13] Neoplasm or suspicion of neoplasm [11,13] Iatrogenic perforation [11,13] Dense and numerous adhesions [13,19] Technical difficulties [13] Other [16]
22%–49% 19%–23% 3%–25% 14%–19% 14%–50% 6% 5%
467
tive randomized trials that compare open and laparoscopic adhesiolysis for small bowel obstruction. Most series are retrospective and have only a few patients with short follow-up. The largest series is a multicenter study of 308 patients, but the data are retrospective and the follow-up is only 1.6 months [11]. Operative times range from 58 to 108 minutes for laparoscopic cases and up to 208 minutes for cases that are converted to a laparotomy [14,19]. The conversion rates range from 6.7% to 43% [10,13]. The reported hospital length of stay in most series is 4 to 6 days for the laparoscopic group and around 12 days for the converted group. The incidence of intraoperative enterotomies ranges from 3% to 17.6%, with most authors reporting an incidence of about 10% [12,15]. Suter et al [13] reported an intraoperative enterotomy incidence of 15.6%, of which 62% were repaired laparoscopically. One of the most dreaded complications of surgery is a missed enterotomy. Although a missed enterotomy can occur after laparotomy, the incidence is higher after laparoscopic surgery. Suter et al [13] reported 4 of 47 cases (8.5%) of missed enterotomies that required reoperation. Others have also reported cases that required early reoperation for missed bowel perforations. Strickland et al [16] found that the duration of surgery longer than 120 minutes, bowel necrosis, intraoperative perforation, and conversion were significant predictors of postoperative morbidity. Levard et al [11] reported the incidence of wound complications to be 1.2% in the laparoscopic group compared with 10% in the converted group (P ⬍0.001). Bailey et al [20] reported that in a series of 65 patients operated on for acute bowel obstruction, 7 patients required early reoperation. The reported mortality ranges from 0% to 3%. This rate is lower than the reported mortality after open surgery of adhesiolysis, which most likely represents patient selection. Cost analysis has not been addressed in any of the series in the literature. The long-term results regarding recurrence are limited, with most series reporting a mean follow-up between 12 and 24 months. Navez et al [21] reported that 85% (29 of 34) of the patients treated laparoscopically were asymptomatic with a mean follow-up of 46 months. The series with the longest follow-up (mean 61.7 months) reported 87.5% (14 of 16) of the patients treated laparoscopically were asymptomatic [12]. The question regarding decreased recurrence after laparoscopy compared with laparotomy remains to be answered. Interestingly, Khaitan et al [28] have described a new technique of applying Seprafilm laparoscopically, which could further decrease the recurrence of adhesive bowel obstruction.
Conclusions Laparoscopic adhesiolysis has been shown to be safe and feasible in experienced hands. At this time, laparoscopic surgery for small bowel obstruction is still under evaluation since it has not been directly compared with open surgery.
468
Table 3 Selected reports of laparoscopic adhesiolysis for small bowel obstruction Location
n
Operative time (min)
Laparoscopy assisted (%)
Conversion (%)
Pekmezci et al (2002) [10] Levard et al (2001) [11]
Turkey France
15 308
99 NR
0 NR
6.7 40.9
6.7 8.4
Sato et al (2001) [12]
Japan
17
17.6
17.6
Suter et al (2000) [13]
Switzerland
83
105* 119‡ NR
NR
43
15.6
Al-Mulhim (2000) [14] Chosidow et al (2000) [15]
Saudi Arabia France
19 134
NR 27
32 16
NR 3
Strickland et al (1999) [16]
Pasadena, CA
40
32.5
10
Leon et al (1998) [19]
Rochester, MN
40
Bailey et al (1998) [20]
Australia
65
Navez et al (1998) [21]
Belgium
69
Ibrahm et al (1996) [22] Overall (range)
Englewood, NJ
33
* Laparoscopic group. † Laparoscopic-assisted group. ‡ Converted group. NR ⫽ not reported.
58 71.7* 89.5‡ 68* 106‡ 108* 135† 208‡ 64* 83† 110‡ 77* 120‡ NR 58–208
5.8
7.5 30
35
24.6
21.5
6 12 0–30
40 15 6.7–43
Bowel injury (%)
7.5
NR
9 9.1 3–17.6
Length of stay (days)
Follow-up (months)
4 4 10 10.4* 18‡ 5.9* 15.7‡ 5 5.03* 12.5‡ 3.6* 10.5‡ 2.9* l5.4† 7.4‡ 3
17.2 1.6
6.6* 16.8‡ NR 2.9–18
Success (%)
Mortality rate (%)
0 4.5
100 95
0 2.2
61.7
5.8
88
NR
9
NR
2.4
27 NR
0 NR
100 80
0 0
22
5
97
0
12
17.5
81
0
NR
10.8
NR
1.8
46
2.9
85.3
2.9
NR 80–100
3 0–3
NR 1.6–61.7
Reoperation (%)
3 0–17.5
0
A. Nagle et al. / The American Journal of Surgery 187 (2004) 464 – 470
Reference
A. Nagle et al. / The American Journal of Surgery 187 (2004) 464 – 470
469
Fig. 2. Algorithm for the role of laparoscopic adhesiolysis in management of small bowel obstruction.
In selected patients, laparoscopic adhesiolysis offers the advantages of decreased length of stay, faster return to full activity, and decreased morbidity. Patient selection and surgical judgment appear to be the most important factors for a successful outcome. Our algorithm for the role of laparoscopic adhesiolysis in the management of small bowel obstruction is shown in Fig. 2. Patients who require an emergent operation are not good candidates for laparoscopic adhesiolysis. Patients with bowel dilatation less than 4 cm and a partial obstruction can be considered for laparoscopic adhesiolysis. Patients who have a chronic or recurrent par-
tial obstruction documented on a contrast study are also good candidates for laparoscopic adhesiolysis. Technically, peritoneal access should be achieved with the open (Hasson) technique in order to avoid bowel injury. Grasping the dilated, thin-walled bowel and the use of cautery should be avoided. The most common reasons for conversion include dense adhesions, unable to visualize the site of obstruction, iatrogenic intestinal perforation, bowel necrosis and colonic cancer. There should be a low threshold to convert to a minilaparotomy or to a formal laparotomy. Conversion should not be considered a failure, but rather good surgical
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judgment. Further studies need to examine the open versus the laparoscopic procedure in a prospective randomized fashion and evaluate the cost effectiveness of this approach.
References [1] Menzies D, Ellis H. Intestinal obstruction from adhesions: how big is the problem? Ann R Coll Engl 1990;223:242– 8. [2] Beck DE, Opelka FG, Bailey HR, et al. Incidence of small bowel obstruction and adhesiolysis after open colorectal and general surgery. Dis Colon Rectum 1999;42:241– 8. [3] Health Care Financing Administration. MEDPAR database, 1990-96. [4] Landercasper J, Cogbill TH, Merry WH, et al. Long-term outcome after hospitalization for small-bowel obstruction. Arch Surg 1993; 128:765–70. [5] Mucha P. Small intestinal obstruction. Surg Clin North Am 1987;67: 597– 620. [6] Barkan H, Webster S, Ozeran S. Factors predicting the recurrence of adhesive small-bowel obstruction. Am J Surg 1995;170:361–5. [7] Bastug DF, Trammell SW, Boland JP, et al. Laparoscopic adhesiolysis for small bowel obstruction. Surg Laparosc Endosc Percutan Tech 1991;1:259 – 62. [8] Tittel A, Treutner KH, Titkova S, et al. Comparison of adhesion reformation after laparoscopic and conventional adhesiolysis in an animal model. Langenbeck’s Arch Surg 2001;386:141–5. [9] String A, Berber E, Foroutani A, et al. Use of the optical access trocar for safe and rapid entry in various laparoscopic procedures. Surg Endosc 2002;15:570 –5. [10] Pekmezci S, Altinli E, Saribeyoglu K, et al. Enteroclysis-guided laparoscopic adhesiolysis in recurrent adhesive small bowel obstructions. Surg Laparosc Endosc Percutan Tech 2001;12:165–70. [11] Levard H, Boudet M, Msika S, et al. Laparoscopic treatment of acute small bowel obstruction: a multicentre retrospective study. Aust NZ J Surg 2001;71:641– 6. [12] Sato Y, Ido K, Kumagai M, et al. Laparoscopic adhesiolysis for recurrent small bowel obstruction: long-term follow-up. Gastrointest Endosc 2001;54:476 –9. [13] Suter M, Zermatten P, Hakic N, et al. Laparoscopic management of mechanical small bowel obstruction: are there predictors of success or failure? Surg Endosc 2000;14:478 – 84.
[14] Al-Mulhim AA. Laparoscopic management of acute small bowel obstruction: experience from a Saudi teaching hospital. Surg Endosc 2000;14:157– 60. [15] Chosidow D, Johanet H, Montario T, et al. Laparoscopy for acute small-bowel obstruction secondary to adhesions. J Laparoendosc Adv Surg Tech 2000;10:155–9. [16] Strickland P, Lourie DJ, Suddleson EA, et al. Is laparoscopy safe and effective for treatment of acute small-bowel obstruction? Surg Endosc 1999;13:695– 8. [17] El Dahha AA, Shawkat AM, Bakr AA. Laparoscopic adhesiolysis in acute small bowel obstruction: a preliminary experience. JSLS 1999; 3:131–5. [18] Kyzer S. Laparoscopic treatment of small bowel obstruction caused by adhesion. Harefuah 1999;139:681–3. [19] Leo´ n EL, Metzger A, Tsiotos GG, et al. Laparoscopic management of small bowel obstruction: indications and outcomes. J Gastrointest Surg 1998;2:132– 40. [20] Bailey IS, Rhodes M, O’Rourke N, et al. Laparoscopic management of acute small bowel obstruction. Br J Surg 1998;85:84 –7. [21] Navez B, Arimont JM, Guit P. Laparoscopic approach in acute small bowel obstruction. A review of 68 patients. Hepatogastroenterology 1998;45:2146 –50. [22] Ibrahim IM, Wolodiger F, Sussman B, et al. Laparoscopic management of acute small bowel obstruction. Surg Endosc 1996;10:1012–5. [23] Benoist S, De Watteville JC, Gayral F. Role of celioscopy in acute obstructions of the small intestine. Gastroenterol Clin Biol 1996;20: 357– 61. [24] Parent S, Bresler L, Marchal F, et al. Laparoscopic surgery for acute adhesions on the small bowel. J Chirug 1995;132:382–5. [25] Federman G, Walenzyk J, Scheider A, et al. Laparoscopic therapy of ileus of the small intestine caused by adhesions or bands—preliminary results. Zentralbl Chirug 1995;120:377– 81. [26] Franklin ME, Dorman JP, Pharand D. Laparoscopic surgery in acute small bowel obstruction. Surg Laparosc Endosc 1994;4:289 –96. [27] Francois Y, Mouret P, Tomaoglu K, et al. Postoperative adhesive peritoneal disease: laparoscopic treatment. Surg Endosc 1994;8:781–3. [28] Khaitan L, Scholz S, Richards W. Laparoscopic adhesiolysis and placement of Seprafilm: a new technique and novel approach to patients with intractable abdominal pain. J Laparosc Surg Tech 2002; 12:241–7.