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Laparoscopic management of acute small bowel obstruction after laparoscopic gastric bypass

Authors

Abstract

This video demonstrates the laparoscopic approach to a case of acute bowel obstruction that developed in a patient who had previously had a laparoscopic gastric bypass. It involves adhesiolysis and repair of an internal mesenteric hernia.

Keywords

internal mesenteric hernia, repair, adhesiolysis, small bowel obstruction, laparoscopy, gastric bypass

Media type

Duration

09'35''

Publication

2007-12

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E-publication

WeBSurg.com, Dec 2007;7(12).
URL: http://www.websurg.com/doi-vd01en2211.htm

Laparoscopic management of acute small bowel obstruction after laparoscopic gastric bypass

1. Procedure commencement 00'15''

This video presents a case of acute small bowel obstruction in a patient who underwent a laparoscopic gastric bypass procedure 6 months ago. The patient presented with symptoms of nausea, abdominal pain in the form of cramps, and an inflammatory syndrome confirmed by serum biochemistry.

2. Adhesiolysis 00'33''

The procedure starts with the introduction of an optical trocar between the xiphoid cartilage and the umbilicus. Two other trocars of 5mm and 10mm in diameter are introduced at the sites used formerly for the port sites of the previous procedure. The operation begins with panoramic exploration of the abdominal cavity. Adhesions are found between the small bowel and the abdominal wall, most likely related to the port introduction sites of the previous operation. Each of these fibrous bands must be progressively divided by adhesiolysis although this is very difficult in this case since the small bowel loops are very distended.

3. Small bowel exploration 01'27''

Once the adhesions are freed, exploration of the dilated portion of the small bowel is carried out. Here we can observe that there are further adhesions at the level of the anastomosis at the foot of the bypass loop. Here, visible in addition to the adhesions, is the mesenteric hole that was re-approximated and closed at the time of the gastric bypass procedure. We then continue the dissection of all adhesions, which are proximal to the anastomotic site.

4. Identification of mesenteric defect 02'34''

The bowel loop is followed cephalad in order to find the gastrojejunal anastomosis, which itself appears slightly distended.

5. Identification of prior gastrojejunal anastomosis 02'49''

It must again be stressed that the degree of bowel distension makes the exploration of the abdominal cavity fraught since the working space is reduced. Handling of the loops must also be performed with extreme caution. As we approach the anastomosis at the foot of the loop, we find that the small bowel is non-dilated at this level. We therefore explore again the portion of small bowel situated to the right of Petersen’s space. At this point, we identify the presence of fibrous tissue between the biliary limb, the anastomosis and the jejunal limb.

6. Obstructing adhesion 04'05''

This therefore is the site of obstruction. All these adhesions must be successively divided to clear the area in its entirety. We then turn our attention to the defect in the mesentery.

7. Closure of mesenteric defect 07'08''

After examination, it is apparent that it can be closed in a continuity. Closure is achieved using slowly absorbable interrupted sutures to avoid the risk of any further obstruction occurring in the future. We now explore the rest of the abdominal cavity as well as the gastrojejunal anastomosis to make sure that all adhesions have been divided and that there is no other site of small bowel obstruction.

8. Completion of laparoscopy 07'53''

We can see that the rest of the bowel is clear. This patient was able to resume food intake 48 hours after the intervention and has remained well on follow-up since.

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