Laparoscopic treatment of acute small bowel obstruction: multiple cases of laparoscopic adhesiolysis

The video shows the laparoscopic management of three separate cases of acute small bowel obstruction secondary to adhesions. The difficulties and advantages of such an approach in this emergency scenario are discussed. The author begins by inserting a trocar in the umbilicus. Upon exploration of the abdominal cavity, intestinal obstruction becomes clearly evident from the presence of dilated loops and flattened, collapsed loops. The author follows the collapsed loops until the transition zone is identified. The adhesions appear between the greater omentum and the mesentery. This band is divided. Further exploration leads to the finding of a second adhesion. This area shows no signs of occlusion. The author divides this adhesion. Exploration of the remainder of the small bowel continues to rule out further adhesions.

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Laparoscopic treatment of acute small bowel obstruction: multiple cases of laparoscopic adhesiolysis

Authors

F Costantino, J Marescaux

Abstract

The video shows the laparoscopic management of three separate cases of acute small bowel obstruction secondary to adhesions. The difficulties and advantages of such an approach in this emergency scenario are discussed.
The author begins by inserting a trocar in the umbilicus. Upon exploration of the abdominal cavity, intestinal obstruction becomes clearly evident from the presence of dilated loops and flattened, collapsed loops. The author follows the collapsed loops until the transition zone is identified. The adhesions appear between the greater omentum and the mesentery. This band is divided. Further exploration leads to the finding of a second adhesion. This area shows no signs of occlusion. The author divides this adhesion. Exploration of the remainder of the small bowel continues to rule out further adhesions.

Keywords

acute small bowel obstruction, SBO, adhesions, adhesiolysis, laparoscopy

Media type

Surgical video

Duration

15'00''

Publication

2007-12

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E-publication

WeBSurg.com, Dec 2007;7(12).
URL: http://www.websurg.com/doi-vd01en2226.htm

Laparoscopic treatment of acute small bowel obstruction: multiple cases of laparoscopic adhesiolysis

1. Trocar positioning and overview 00'07''

Adhesions are the most frequent causes of small bowel obstruction and the laparoscopic treatment may be pursued when the bowel dilatation is less than 4cm or where there is partial obstruction, chronic obstruction or recurrent partial obstruction. Specific operative strategies include the use of an open technique, to allow safe placement of the ports for adhesiolysis, a good working space is also essential in order to operate in optimal conditions. The optical trocar is generally placed in the umbilicus and two other trocars are placed suprapubically and in the left and right abdominal wall. The objective is to obtain triangulation to achieve a safe procedure.

2. First case history 00'59''

The first case is a male patient with no previous surgery who has a small bowel obstruction because of inflammatory adhesions who did not resolve with non-operative management. The CT-scan demonstrates the transition area between the collapsed bowel loops and the dilated loops of the small bowel, suggesting a mechanical occlusion.

3. First operative case 01'30''

We begin by installing an optical trocar in the umbilicus. By exploring the abdominal cavity, intestinal obstruction is clearly evident from the presence of dilated loops and flattened, collapsed loops. The collapsed loops will be followed until the transition zone is identified. In this case, we find the adhesions between the greater omentum and the mesentery of the small bowel. This here is the culprit adhesion that is responsible for the bowel occlusion. This band is then divided and we can see here the transition zone a few seconds after the band is divided, the peristaltic movements that have resumed caudally along the bowel. We continue the exploration of the greater omentum and indeed the peritoneal cavity in general and we identify a second adhesion. There were no signs of occlusion however at this area. This adhesion is also divided with monopolar cautery as a safety measure. Exploration of the rest of the small bowel continues to make sure there are no further adhesions nor additional areas of mechanical occlusions left in this patient. You can see that the small bowel is clear.

4. Second case history 03'58''

Our second case is a male patient who has had multiple previous operations for adhesional small bowel obstruction and has again presented with non-resolving symptoms. Here on the CT-scan we can again see a transition line.

5. Second operative case 04'12''

We begin this intervention as before with the introduction of an optical trocar in the umbilicus. You can see several adhesions running to the anterior abdominal wall from previous operations. These are all divided carefully. During the exploration of the peritoneal cavity, we identify signs of bowel obstruction. We then appropriately position three operating trocars after the adhesiolysis is performed. In this case, we place one suprapubically, the second at the level of the left iliac fossa and the third in the right iliac fossa. This will allow us to easily perform the traction and counter-traction necessary for effective adhesiolysis. This adhesiolysis allows us to find the exact cause of the mechanic occlusion: it is a band that has formed again at the level of the greater omentum. This is blocking the bowel and also causing signs of vascular compression. After the adhesiolysis is performed, you can see clearly that the peristaltic movements have resumed and the tone of the bowel has improved. As usual, to complete the operation, we perform full exploration of all the small bowel loops from the ileo-cecal valve up to the duodenojejunal flexure. We could find no further cause of mechanical obstruction in this patient. The obstruction was therefore due to a single band.

6. Third case history 06'17''

The third case is a 40-year-old female patient who presented with partial obstruction of the small bowel again due to adhesions and who again had failed to improve with a conservative approach. The X-ray shows evident signs of small bowel obstruction.

7. Third operative case 06'34''

Again in this patient, we introduced an optical trocar in the umbilicus, and two other trocars to allow triangulation of movement. We can observe here that abdominal exploration has found the site of the mechanic occlusion to be at the level of the left inguinal region. Some adhesions in this area had been cleared when the pneumoperitoneum was established and these had been the likely cause of the patient’s obstruction. The rest of the small bowel is then examined. In doing so, we find a further two adhesions between the greater omentum and the right colon. Although these are not causing obstruction currently, they remain a risk of doing so in the future and are therefore divided. Evident throughout the latter part of this video has been the severely inflamed appearance of the ileum. As no further sites of adhesion or obstruction are found, the procedure finishes with a lavage of the abdominal cavity.