Fatal small bowel obstruction from a band formed after removal of an ovarian cyst
1883 - Thomas’ Hospital (London)
William Battle (published in the Lancet)
Thomas’s Hospital, London – the first account of a laparotomy for adhesive obstruction. The patient, a 43-year-old woman, had bilateral ovarian tumors removed 4 years earlier. She was admitted with intestinal obstruction. Matted adhesions of terminal ileum in the region of the cecum were found at laparotomy and a terminal ileostomy was performed. Sadly, she died 3 weeks later.
Harold Ellis,CBE,FACS (Hon),FRCS, JACS vol 200, #5 May 2005
Membranes – amnion, fish bladder, carp peritoneum, calf peritoneum, oiled silk, silver or gold foil and free grafts of omentum; hyaluronic acid and carboxymethyl cellulose membrane, more recently, icodextrin.
OR table – full tilt range (extreme positions may be necessary)
Patient’s arms by side to allow the surgical team ample room
Two movable video monitors:
video monitor to the patient’s right positioned inferiorly at the hip and the monitor to the left positioned superiorly at the shoulder (positioning forms a plane parallel to the root of the small bowel mesentery allowing the surgeon to look and work in the same direction as the camera orientation)
Flexible configuration of the operating room arrangement permits modifications during the operation
Patients prepared and draped to allow conversion to an open procedure when necessary
Interventions performed under general endotracheal anesthesia with a nasogastric tube and urinary catheter in place.
Because nitrous oxide as an anesthetic gas has been found to produce bowel
dilatation, its use was specifically avoided in most patients.
Laparoscopic Management of Small Bowel Obstruction: Indications and Outcome Enrique Luque-de Ledn, MD, Altjandro Metzger, MD, Gregory G Tsotos, MD, J GASTROINTEST SURG 1998;2:132-140 5mm trocars in the RUQ and LLQ maximize the distance from the trocars to the iliocecal valve and Ligament of Treitz, respectively. MONITOR 1 MONITOR 2
Laparoscopic approach to postoperative adhesive obstruction G Borzellino, S Tasselli, G Zerman, C Pedrazzani, G Manzoni Surg Endosc (2004) 18: 686–690
Preoperative ultrasonographic mapping of abdominal wall adhesions has an important role to play in the selection of patients and for first trocar placement.
In their experience, this evaluation eliminates the risk of visceral injuries and enables the best location for successive trocars.
Gentle retraction of adhesions may separate the tissue planes – most often sharp adhesiolysis is required. The best technique is to follow the line of tissue adherence, resulting in less bleeding and risk for bowel injury. A traction-countertraction technique as used for open adhesiolysis is effective.
When dense adhesions are present, the plane between bowel and peritoneum is often obliterated. It is then necessary to dissect in the preperitoneal fat.
Usually at least two additional trocars are needed, placed along (not against) the sights of the camera and added as needed.
from collapsed bowel loops to prevent incidental bowel injury.
The need for enterotomy can be reduced only if meticulous care is taken using atraumatic graspers and if the manipulation of friable, distended bowel is minimized by handling the mesentery whenever possible.
Grasping the mesentery in order to manipulate the bowel decreases the likelihood of direct trauma.
Changing the scope port is crucial at times allowing visualization from different angles
Overzealous retraction of thin-walled small bowel fixed intraperitoneally during manipulation may also lead to iatrogenic enterotomies
Safe adhesiolysis requires proper surgical meticulous techniques and skills.
Conversion to a laparotomy should not be considered a failure or complication, but rather a recognition of limitations posed by technology, the surgical expertise, or factors unique to a particular patient or disease process.