Laparoscopic management of small bowel obstruction – Nguyen Van Tiep

Journal of military pharmaco-medicine no5-2018 206 LAPAROSCOPIC MANAGEMENT OF SMALL BOWEL OBSTRUCTION Nguyen Van Tiep*; Lai Ba Thanh*; Le Thanh Son* Dang Viet Dung*; Nguyen Trong Hoe*; Ho Chi Thanh* SUMMARY Objectives: To evaluate safety, feasibility, and results of laparoscopic management of small bowel obstruction. Subjects and methods: A retrospective study on 124 acute small bowel obstruction cases, who were applied laparoscopy from 6 - 2010 to 8 - 2017. Results: Laparoscopic management were indicated for postoperative obstruction (46.0%), phytobezoar (30.6%) and unknown causes (23.4%), which determined causes of obstruction, suitable surgical method choice: totally laparoscopy (47.6%), laparoscopy-assisted small laparotomy (33.1%), large laparotomy (19.3%). Laparoscopy and assisted laparoscopy were safety, shortened recovery time of patients with oral meal time was 2.8 days, postoperative hospital stay was 5.3 days. Conclusion: Laparoscopic management of selected small bowel obstruction was safety, feasibility and shortened recovery time of patients. * Keywords: Small bowel obstruction; Laparoscopy management. INTRODUCTION Bowel obstruction is a common surgery emergency treatment. Small bowel obstruction (SBO) has a variety of causes such as adhesions, bands following abdominal surgery, phytobezoar or some other rare causes such as hernia, neoplasm, etc. Surgical management of SBO depends on the causes. Some cases are simple with cutting the bands only. While, some cases are complex if intestinal dissection needed. These operations were usually performed through the midline incision. Laparoscopic surgery has recently applied with many advantages in identifying causes and management of the acute SOB in selected patients [1, 3, 4, 6]. Abdominal distension and other complex causes are main disadvantages in selecting indication of laparoscopic management of small bowel obstruction [2, 5]. The effect of this procedure is controversial. In order to clarify clearly the indications, outcomes of the laparoscopic management of small bowel obstruction, we conducted this study with the aim: To describe lesion characteristics, technique and early outcomes of the laparoscopic management of SBO at 103 Military Hospital from 6 - 2010 to 8 - 2017. * ** Corresponding author: Le Van Quan (@gmail.com) Date received: 26/02/2018 Date accepted: 30/05/2018 Journal of military pharmaco-medicine no5-2018 207 SUBJECTS AND METHODS A retrospective study on 124 patients who were definitely diagnosed with SBO based on clinical characteristics, X-ray, and intraoperative lesions. All patients were indicated laparoscopic management based on clinical characteristics and prior conservative results. Collecting clinical characteristics, causes, techniques and postoperative outcomes. Data were analyzed by Microsoft Excel software with statistical tests. * Indication, contraindication and medical procedure: - Indication: Mild abdominal distension, incomplete ileus, prediction of simple etiologies, patients with early operation within 24 hours since the symptoms appeared, less than 3 times of abdominal operations in history. - Contraindication: Severe abdominal distension, diffuse peritonitis due to late operations, hemodynamic instability, shock, severe morbidities of cardiac and respiratory diseases. - Procedure: Locating the trocar site, the first trocar insertion technique has a vital role with the surgeon. Almost of the authors advise inserting the trocar in an open way, clearly observe and stay far away from the previous scars. Later trocars would be carefully inserted under the observation of camera to avoid intestine perforations [3, 4, 5]. The next step, being the most important one, is to approach and determine the location and the cause of ileus. Normally, the obstructed location is the conjunction of distended intestines and collapsed intestines. Like open operations, most authors agree that collapsed intestines should be initially observed and then, look upwards because endoscopic tools are likely to hurt distended intestines easily. If the obstructed location and cause were determined, the mission left is how to solve the lesion, through laparoscopic surgery or switch to open surgery. The laparoscopic surgeries, actually, are able to solve or play a supportive role in the solution of ileus etiologies. The laparoscopic surgery can release adhesions, intestine resection and anastomosis, release the obstructed hernia. Or it can at least guide the sites and abdominal open incision to continue the procedure. RESULTS AND DISSCUSION 1. Pathological indices. - Mean age was 50.9 ± 21; the youngest was 10 and the eldest was 87; male proportion was 50%. - Mean BMI was 22.36 ± 1.9; min 18; max 26. - Duration of obstruction: Mean time was 3.0 ± 1.8 days, the shortest was 1 day and the longest was 10 days. * Levels of abdominal distension in operating: In this study, according to a research of Le Thanh Son [2]: levels of distension were used in our study: Journal of military pharmaco-medicine no5-2018 208 - Mild: Abdominal distension, the highest abdomen depth does not exceed the chest depth in supine position. - Moderate: Abdominal distension, the highest abdomen depth is equal to or higher than the chest depth in supine position but the abdomen still cooperates with the respiratory motion. - Severe: Abdominal distension, the highest abdomen depth is higher than the chest depth in supine position but the abdomen does not cooperate with the respiratory motion. As above conventional rules, the distribution of patients according to the state of the abdominal distension as follows: - Preoperative abdominal distension: Mild distension: 9 patients (7.2%); moderate distension: 103 patients (83.1%); severe distension: 12 patients (9.7%). * Preoperative diagnosis: - Causes and preoperative diagnosis: Post-operative: 66 patients (53.2%); phytobezoar: 32 patients (25.8%); mechanical, unknown causesa: 26 patients (21.0%). (a: Mechanical small obstruction cases were definitely diagnosed based on clinical characteristics, plain X-ray, abdominal ultrasound and CT-Scanner, but no definite cause detection, for example post-operation, phytobezoar, abdominal wall hernia, etc) Table 1: Causes and postoperative diagnosis. Cause No. of patients Percentage Post-operative Adhesion 23 18.6 Band 32 25.8 Volvulus 2 1.6 Total 57 46.0 Phytobezoar 38 30.6 Others Adhesion or primary band b 11 8.8 Volvulus 7 5.6 Inner-hernia 1 0.8 Ileo-ileal intussusception 2 1.6 Jejuno-jejunal intussusception 1 0.8 Uterine cancer metastasis 1 0.8 Small bowel neoplasm 6 4.8 Total 29 23.4 Total 124 100.0 (b: 11 patients without prior abdominal operation, the cause, which was identified in operating, was band or adhesion. In this study, these lesions named primary band or adhesion) Journal of military pharmaco-medicine no5-2018 209 * The relationship between the preoperative diagnosis and causes of obstruction/postoperative diagnosis: Table 2: The relationship between the preoperative and postoperative cause identification. Causes Preoperative diagnosis Total Postoperative Phytobezoar Unknown Causes and postopera-tive diagnosis Postoperative 56 0 1 57 Phytobezoar 7 27 4 38 Primary adhesion or band 0 4 7 7 Volvulus 1 0 6 7 Hernia 0 0 1 1 Ileo-ileal intussusception 0 0 2 2 Jejuno-jejunal intussusception 0 0 1 1 Uterine cancer metastasis 1 0 0 1 Small bowel neoplasm 1 1 4 6 Total 66 32 26 124 2. Causes and management. Table 3: Surgical methods Causes and management Method Total Laparoscopy Laparoscopy- assisted small laparotomy Large laparotomy Postoper-ative Adhesion 15 4 4 23 Band 24 6 2 32 Volvulus 0 0 2 2 Phytobezoar 8 24 6 38 Others Primary adhesion/band 7 2 2 7 Volvulus 1 0 6 3 Hernia 1 0 0 1 Ileo-ileal intussusception 2 0 0 2 Jejuno-jejunal intussusception 0 1 0 1 Uterine cancer metastasis 0 0 1 1 Small bowel neoplasm 1 4 1 6 Total 59 (47.6%) 41 (33.1%) 24 (19.3%) 124 (c: Laparoscopy-assisted small laparotomy is to open the abdomen with a small incision (3 - 7 cm length) with the direction of laparoscopy to manage the lesions) Journal of military pharmaco-medicine no5-2018 210 In this study, 59 patients (47.6%) were totally managed the lesions by laparoscopy totally, according to a research of O'Connor D.B (2,005 patients), laparoscopy was completed in 1,284 cases (64%) [7]. They were simple lesions, managed by cutting the band or adhesion dissection. 1 case with inner-hernia, which caused by defecting large fascia, was reconstructed the fascia band after releasing the obstructive bowel. 2 cases with ileo-ileal intussusception, which were released the intussusception and stitched the ileo-ileal permanently. According to Burton E, Kirshtein B. and Ettinger J.E: there were 3 factors related to the ability of using laparoscopy to completely manage the bowel obstruction that we withdrew. They are, not very complex cause, surgeon skills (surgical skills, disclosure the surgical field, trocar position, etc) and equipment (300, 450 rigid endoscope, a traumatic tools, etc) [3, 4, 6]. 41 cases (33.1%) were managed by laparoscopy-assisted small laparotomy to solve the lesions. Most of them (24 cases) with bowel obstruction by phytobezoar and were managed by the right paramedian incision or Mac Burney’s incision to take out phytobezoar or push the phytobezoar into the cecum. 4 cases with bowel neoplasm were cut a section of bowel and restored the circulation through a 5 - 7 cm incision. In cases of small laparotomy, the laparoscopy helped to identify the lesions and gave the direction for an easy incision. 24 cases (19.3%) were managed by the midline incision opening to solve complex lesions caused by adhesion, band or volvulus and phytobezoar with necrosis within 7 days. Table 4: The relationship between surgical methods and levels of abdominal distension. Levels of abdominal distension Surgical methods Total Laparoscopy Laparoscopy with laparotomy c Large laparotomy Mild 8 1 0 9 (7.2%) Moderate 49 38 16 103 (83.1%) Severe 2 2 8 12 (9.7%) Total 59 41 24 124 According to Farinella E, O'Connor D.B and Duong Trong Hien: Severe level of abdominal distension is associated with the ability of laparoscopy because it limits the surgical field as well as usually combines with complex obstruction [1, 5, 7]. In this study, there were 7 cases with severe distension and managed by wide abdomen opening to solve the lesion (5.6%). In the case of wide abdomen opening, the rate of wide abdomen opening in mild, moderate and severe distension groups was 0%; 15.5% and 66.6%, respectively, the difference was statistically significant (p < 0.05). Journal of military pharmaco-medicine no5-2018 211 3. Early outcomes. * Surgical catastrophe: One patient with intestinal perforation because the trocar insertion was placed in a postoperative adhesion case and severe abdominal distension which performed wide abdomen opening to solve the problem. Two cases with tear of intestinal muscular layer when releasing adhesion and then reconstructing them through laparoscopy. * Postoperative results: 100 cases were performed laparoscopy or laparoscopy-assisted small laparotomy. There were no postoperative early complications. Postoperative recovery time was shown below. Table 5: Postoperative recovery. Meantime to recovery Laparoscopy (59 patients) Laparoscopy-assisted small laparotomy c (41 patients) Total (100 patients) Mean time of flatus (hours) 37.6 ± 16.8 59.0 ± 14.1 45.6 ± 19.2 Time of postoperative liquid feeding (days) 2.2 ± 1.2 3.8 ± 1.1 2.8 ± 1.4 Time of postoperative hospital stay (days) 4.6 ± 1.2 6.4 ± 1.6 5.3 ± 1.6 Ó connor D (2012) reported that laparoscopy for SBO management was safe, feasible, and valuable in minimally invasive surgery that helps patients decrease complications and early postoperative recovery [7]. Median postoperative hospital stay was 5.3 days, according to Yao S, median postoperative hospital stay was 8 days [8]. CONCLUSION The laparoscopy is feasible to manage the SBO in patients with mild to moderate abdominal obstruction with various causes such as postoperative adhesion (46.0%), phytobezoar (30.6%) and unknown mechanical causes prior operation (23.4%). Laparoscopy which helped identify the exact cause, level of injury as a basis to choose the appropriate surgical method: laparoscopy (47.6%), laparoscopy-assisted small laparotomy (33.1%), large laparotomy (19.3%). Laparoscopic surgery and assisted laparoscopy in management of SBO in the study group were safe, helps patients shorten the recovery time with mean time of fart was 45.6 hours, time of postoperative feeding was 2.8 days and time of postoperative inpatient was 5.3 days. REFERENCES 1. Dương Trọng Hiền, Trần Bình Giang, Hà Văn Quyết. Kết quả điều trị tắc ruột sau mổ bằng phẫu thuật nội soi .Phẫu thuật nội soi và nội soi Việt Nam. 2012, 2, tr.70-75. Journal of military pharmaco-medicine no5-2018 212 2. Lê Thanh Sơn. Phẫu thuật nội soi điều trị tắc ruột sau mổ. Tạp chí Y-Dược học quân sự. 2015, 40, tr.193-196. 3. Burton E, McKeating J, Stahlfeld K. Laparoscopic management of a small bowel obstruction of unknown cause. JSLS. 2008, 12, pp.299-302. 4. 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