Bowel obstruction is the most frequent surgical complication in abdominal surgery and is one of the main reasons for emergency room visits. It is calculated that approximately 15-35% of the patients operated on will require hospitalization as a result of this complication, and that 2-5% of these patients will require surgical intervention, either for poor progression with conservative treatment or due to complete obstruction with the suspicion of intestinal ischemia.1–3

Traditionally, bowel obstruction has been regarded as an absolute contraindication for the laparoscopic approach due to the increased risk for iatrogenic injuries, the difficulty in managing dilated intestinal segments, and an inferior operating field.4–6

With the increased experience in this approach, this contraindication is now relative, because the abovementioned difficulties have been greatly reduced. Thus, patients operated on with this approach can benefit from the widely demonstrated advantages of laparoscopic surgery: less postoperative pain, less ileus, fewer wound infections, a lower incisional hernia rate, shorter postoperative hospital stay, esthetic benefits, and a decrease in future adhesions.4,5,7–9 This last advantage is perhaps the most important, given that the probability of a new episode of bowel obstruction in these patients increases by 30% after a first episode, by 40% after a second episode, and up to 60% after a third one.8

Despite these advances, the laparotomic approach is still regarded as the surgical treatment of choice for bowel obstruction and the role of laparoscopy in this field continues to be controversial.3,6,10

The aim of the present study was to evaluate the initial results of laparoscopic treatment of bowel obstruction in our center and to confirm whether it was a safe and effective approach in these cases.

A descriptive and retrospective analysis of all patients diagnosed with bowel obstruction and operated on with the laparoscopic approach at the Hospital General de Castellón (Comunidad Valenciana, Spain) within the time frame of January 2008 to June 2012 was carried out. The operations were performed by a total of 10 surgeons (staff specialists and residents in training).

The diagnosis of small bowel obstruction was made in relation to the clinical history, physical examination, and the radiologic findings. According to our center's existing protocol, if the patient had a past history of previous surgeries, and the clinical presentation was consistent with an intestinal sub-obstruction, initial management was conservative with a strict diet, a nasogastric catheter, and serum therapy. If after 24-48h the patient did not improve, then surgical intervention was decided upon. On the other hand, if the clinical presentation was consistent with symptoms of complete bowel obstruction, then the patient was taken directly to surgery (fig. 1).

Figure 1.

Removal, through an auxiliary incision, of the obstruction caused by gallstone ileus.

(0.14MB).

If the patient required surgery, the approach depended on the specific criterion of the surgeon. In general terms, the criteria used for indicating the laparoscopic approach in bowel obstruction were the following:

A total of 26 patients, 18 women (69.2%) and 8 men (30.8%), with a mean age of 64.35 years (range: 21-92 years), were included in the study. As shown in Table 1, bridles were the most frequent indication for the laparoscopic approach in our experience, with 12 cases (46.2%), followed by gallstone ileus with 4 cases (15.4%). The clinical characteristics and patient details are summarized in Table 2. This table shows that 17 patients (65.4%) presented with a past history of prior surgeries and there were up to 2 or more previous surgeries (almost 90% of the open approach cases) in 41.17% of these patients, which adds greater importance to the postoperative results obtained.

In 9 patients (34.6%) the operation could be performed exclusively with a laparoscopic approach. In another 9 patients (34.6%) the laparoscopic process was complemented with an auxiliary incision. This resulted in a total of 18 cases (69.2%) of successful laparoscopy. In 8 patients (30.8%) it was necessary to convert to an open procedure. The causes of conversion are shown in Table 3.

Given that the most frequent etiology of the purely laparoscopic approach was bowel obstruction secondary to bridles, laparoscopy had a success rate of 58.3% (5 conversions) in the management of this pathology.

The group of patients whose procedure was exclusively laparoscopic, in absolute values, presented with shorter anesthesia duration (90min compared with 110min and 107.50min), shorter hospital stay (5 days compared with 7 days and 6 days), relatively fewer postoperative complications (11.1% compared with 33.3% and 37.5%), and an earlier intake of liquids (2.56 days compared with 3.67 days and 4.63 days).

Nevertheless, of all the results, only the lower complication rate reached statistically significant values (p = 0.046).

There were postoperative complications in 9 patients (34.6%), the most important of which were related to surgical wound infection, with 4 cases, one case of septic shock, one case of intestinal fistula, one case of intra-abdominal collection, and one case of respiratory distress. Despite the fact that some of the complications were relatively severe, there were no cases of death (0% mortality). Only one patient had to be reoperated on for an evisceration, precisely one of the patients whose unsuccessful laparoscopy was converted to open surgery, but no diagnosis was reached with either procedure.

Table 4 shows the comparison of results according to the approach employed.

Currently there are no randomized clinical trials in the scientific literature that compare the open and laparoscopic approaches for treating bowel obstruction.5 For this reason, and due to the lack of clear criteria for patient selection, the use of the laparoscopic approach has not been as extensive in bowel obstruction as it has been in many other digestive pathologies.

Different studies that support the safety of this approach in the hands of experienced surgeons have recently appeared.7,9,11–13 Despite the fact that there can be high conversion rates, they have been considerably reduced through increased experience and better patient selection. For example, in 1995 the Swiss Surgical Society designed a multicenter prospective study7 with 537 patients and obtained a 32.4% conversion rate. In 2001, Levar et al.11 conducted a retrospective multicenter study on 308 patients that produced a conversion rate of 54.6%. A recent meta-analysis by O¿Connor et al.12 that included 2,005 patients showed a lower conversion rate of 29%, that was reduced to 17% in the group of Mancini et al.13 In our experience the conversion rate was 30.8%, which is close to the figures published in the literature.

As mentioned above, good patient selection is essential for reducing this figure. The suspicion of a single bridle is the main indication for the laparoscopic approach (principally in patients with embryogenic adhesions or after appendectomy), together with obstruction due to foreign bodies, bezoars, or gallstone ileus. In this sense, we believe that a CAT scan prior to surgery is extremely useful in deciding upon both the indication for surgery and the approach.3,4

On the other hand, according to the bibliography reviewed and our own experience, the anesthetics used in relation to the patient's status, the suspicion of obstruction due to peritoneal carcinomatosis, intestinal distension greater than 4cm in imaging studies, and the suspicion of dense adhesions, can all be considered relative contraindications.3,5,14 Likewise, the use of the laparoscopic approach in patients suspected of presenting with ischemia or peritonitis is controversial and regarded by certain groups as relatively contraindicated. However, even if laparoscopy is technically feasible, the majority of authors, ourselves included,4,5 recommend an auxiliary incision for performing the resection and anastomosis, if they are necessary. Nevertheless, to reduce this conversion rate, more specific criteria need to be defined for case selection since surgeon preference continues to be the determining factor in the choice of approach.

Traditionally, another of the arguments against the laparoscopic approach for the surgical treatment of bowel obstruction has been the increase in unnoticed iatrogenic injuries during adhesiolysis. Wullstein et al.6 described figures close to 27% for the laparoscopic approach and 13% for the open approach. Different groups3,10 have recently published clearly lower figures (3-17%) that support the safety of this approach in the hands of expert surgeons. In our series, only one accidental enterotomy occurred; it was detected during surgery and promptly repaired. As we stated before, dissection must be performed with care, avoiding traction on the intestinal segments and taking great precautions when using electrocoagulation.4 By following these principles, the complication rate can be lowered. Likewise, another recommended surgical maneuver is pneumoperitoneum creation through an open technique to avoid intestinal injury due to patient adhesion syndrome. However, the rest of the techniques for creating the pneumoperitoneum are not contraindicated, and even though the open technique is the most frequently employed, the approach through the Veress needle is also used, as was the case with the patients in our study. In addition, it is essential to avoid placing the trocars at previous incision sites; they should be placed as far as possible from them. Likewise, the etiology of the obstruction should be identified during the operation. If that is not possible through laparoscopy, then the conversion to laparotomy is obligatory.4,5,8,10

Basically, the role of the laparoscopic approach in this field is to prevent future adhesions that would cause bowel obstruction recurrence, with the consequent socio-economic costs this implies. To the best of our knowledge, no report in relation to this aspect has been carried out for Spain, but in the United States such a cost is an estimated 1.3 billion dollars per year.4 The higher perioperative costs of laparoscopy could be compensated for by such annual expense.

The appearance of adhesions is clearly related to the use of laparotomy, with a possible presentation in 70-90% of the cases.4 This figure would be drastically reduced if the procedures were performed laparoscopically.

Our study had certain basic limitations in the selection of patients; this was carried out according to surgeon indication and so the surgeons with more experience in the laparoscopic approach operated on a greater number of patients. Furthermore, the results of the different approaches were compared and there may have been selection bias because those patients that underwent conversion to open surgery were the cases of greater technical difficulty, and so logically they would have a longer hospital stay and more complications. In our opinion, randomized prospective studies comparing the two approaches are necessary. Nevertheless, the laparoscopic approach to bowel occlusion is safe and reproducible, a fact that was supported by our series and that coincides with the international literature.4,5,7–9

In conclusion, good results in the treatment of bowel obstruction can be obtained with the laparoscopic approach, as long as the human and technical resources for performing it are available. Nevertheless, despite the increased experience with this approach, there is still a high conversion rate. Therefore, good patient selection is essential for reducing this figure. The experience of the surgical team is fundamental in these cases.

No financial support was received in relation to this article.

The authors declare that there is no conflict of interest.