Aust. N.Z. J . Surg. 1993.63.39-41 39

SURGICAL TECHNIQUE

LAPAROSCOPIC MANAGEMENT OF ACUTE SMALL BOWEL OBSTRUCTION

SUSAN ADAMS,* TIM WILSON* AND ALISTAIR R. BROWNt

*Institute for Minimally Invasive Surgery, Sydney Hospital and 'Royal North Shore Hospital, New South Wales, Australia

Acute small bowel obstruction is commonly due to band adhesions.' In the past it has had an overall mortality rate of up to 1 I YO for elderly patients.'

In this paper we report three cases of small bowel obstruction, treated by laparoscopic division of the causative bands. All patients recovered rapidly and were discharged within 5 days of surgery.

Key words: adhesions, laparoscopy, small bowel obstruction.

Introduction 'When called upon to deal with a case of acute intestinal obstruction, the surgeon is confronted with one of the gravest and most disastrous emer- gencies.' Moynihan 1926.*

Much has improved since Moynihan's time, but acute small bowel obstruction (SBO) in the elderly is still a ma'or illness, with a reported mortality of

Although laparoscopic division of adhesions has long been practised by gynaecologists, the standard operative approach in acute SBO has been lapam- tomy. Laparoscopy in such patients has been con- sidered dangerous with the possibility of damage to dilated loops of bowel by the insufflating needle or trocars .

We report three cases of acute SBO due to band adhesions which were successfully managed laparoscopicall y .

upto 11%. I

case 1

A 76 year old woman was admitted to Mona Vale Hospital with a 9 day history of vomiting, abdomi- nal distension, and 6 days of absolute constipation. Previous medical history included hysterectomy with left oophorectomy for benign disease, sympto- matic myocardial ischaemia and a previous cerebro- vascular accident (CVA) with residual left-sided weakness. On examination she was clinically dehy- drated. The abdomen was tensely distended, but non-tender and there was no evidence of masses or

Correspondence: Susan Adams, 64 Hewlett Street, Bmnte. NSW 2024, Australia.

Accepted for publication 5 August 1992.

herniae. Bowel sounds were obstructive. Digital rectal examination was normal. Abdominal X-rays showed multiple dilated loops of small bowel with air fluid levels.

A diagnosis of acute SBO was made. Laparoscopy was undertaken on the fourth day of admission after a period of conservative management during which clinical signs had failed to resolve and the patient had become confused and febrile.

A pneumoperitoneum was induced using a Verres needle inserted at the umbilicus under general anaesthetic. A lOmm video laparoscope was intro- duced via an umbilical port and additional 5mm ports were placed in the left iliac fossa and supra- pubic position. Collapsed small bowel was identi- fied and traced back to a point 30cm from the ileocaecal valve where an engorged but viable 8 cm loop was trapped between two bands passing from the caecum to the terminal ileum mesentery. The bands were divided using diathermy shears and the affected bowel was observed for 5 min to confirm viability.

The patient required one dose of pethidine 75 mg for postoperative analgesia. Flatus and liquid motion were passed on the second postoperative day and a light diet was commenced on day 3. Transient hypo- kalaemia was treated with potassium supplements, the confusion resolved and discharge was effected on the fifth postoperative day.

case 2

A 91 year old female was admitted to Mona Vale Hospital with a 3 day history of periumbilical pain and vomiting. There was no previous history of abdominal surgery.

40 ADAMS ET AL.

On examination, there was dehydration. The abdo- men was distended, there was no evidence of tender- ness, masses or herniae. Digital rectal examination was normal. Abdominal films showed dilated small bowel loops with fluid levels and an absence of gas in the colon.

A diagnosis of acute SBO was made. Laparoscopy was undertaken on the second day of admission following a short period of unsuccessful conserva- tive treatment. A similar technique to that described previously was used. A single obstructing band extending from the umbilicus across to the ileum 90 cm from the ileocaecal valve was divided using diathermy shears.

Postoperatively, the patient suffered minimal dis- comfort and required one dose of pethidine 75 mg. Bowel function was restored on the second post- operative day, a diet was introduced and she was discharged well on day 4.

Case 3

A 49 year old woman was admitted to Royal North Shore Hospital with a 12 h history of pain in the left iliac fossa associated with nausea. Previous surgical history included hysterectomy and bladder repair.

On examination, there was tenderness but no guarding in the left iliac fossa. Bowel sounds were normal. Abdominal X-ray showed faecal loading of the colon. Laparoscopy was performed on the third day after admission after a period of unsuccessful conservative management and increasing accumu- lation of gas in the small bowel indicated by serial X-rays and ultrasound scan.

The needle in this instance was inserted below the left costal margin and a 10 mm video laparoscope was inserted through an umbilical port. Two addi- tional 5 mm ports were placed suprapubically and in the right iliac fossa. The site of the obstruction was readily identified as a band adhesion extending from the right ovary to the caecum including a con- gested loop of distal ileum. The band was divided using diathermy scissors.

Postoperatively the patient was commenced on oral fluids. She was discharged following a bowel action 2 days after the procedure.

Discussion

In treating SBO, the aims of the surgeon are to identify the site and cause, to relieve the obstruc- tion and to confirm the viability of the bowel.-'

The standard surgical approach to acute SBO has been laparotomy. This is often undertaken in an ill patient with fluid and electrolyte imbalance. In elderly patients the picture may be complicated by other medical conditions such as cardiac and pul- monary disease.

To determine the site of obstruction, a large inci- sion may be required, and there may be significant manipulation of the bowel. In the case of a band adhesion the obstruction is relieved speedily with relative ease.

Postoperatively, these patients suffer from the pain of laparotomy and they usually have a signifi- cant ileus complicating existing fluid, electrolyte and nutritional disturbances. There is also a high incidence of cardiorespiratory complications. In addition, there is the risk of more adhesions being caused by the laparotomy designed to release them.

The laparoscopic approach described in these three patients gave significant benefits when com- pared with the open approach. In the past, bowel dilatation and adhesions have been seen as relative exclusion criteria for laparoscopy because of the risk of visceral perforation at insufflation or with the introduction of the first port. The Verres needle was used without complication in the cases presented, but if the abdomen remains tensely distended in spite of effective pre-operative nasogastric suction, the use of the hasson trocar and cannula enables safe insufflation. Some surgeons advocate its use excl~sively.~ When using the Verres needle, the insertion site should be chosen well away from pre- vious incisions. The left subcostal position is an alternative to the standard umbilical position.

In cases reported here, the correct position of the Verres needle was confirmed by allowing saline to flow in under gravity from an attached 20mL syringe. Further confirmation was gained when, on commencing insufflation, the intraperitoneal pres- sure was low. Ultrasound may well be of use to plot adhesions to the abdominal wall but the value of this is yet to be deter~nined.~

The site of the obstruction was identified with the laparoscope, as at laparotomy, by following the collapsed small bowel with atraumatic grasping for- ceps. Bowel viability was accurately assessed, and the obstruction due to a band adhesion was readily relieved by division with diathermy shears.

In these three cases the postoperative course was smooth with rapid resolution of the obstruction and ileus. One patient was confused for 3 days but all three were home within 5 days of surgery.

It has long been claimed that postoperative adhe- sions are fewer following laparoscopic surgery when compared with open. Documentation of this impression should be possible as the numbers of laparoscopically performed operations increase, and the long-term follow-up data become available.

As with laparoscopic cholecystectomy , an early discharge with no increased morbidity or mortality is a significant advantage for patients with acute SBO undergoing laparoscopic division of band adhesions.6

ACUTE SMALL BOWEL OBSTRUCTION

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5.

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