The role of laparoscopy in the management of acute small-bowelobstruction: a review of over 2,000 cases

Donal B. OConnor Desmond C. Winter

Received: 31 August 2010 / Accepted: 4 August 2011 / Published online: 5 September 2011

Springer Science+Business Media, LLC 2011

Abstract

Background Adhesive small-bowel obstruction (SBO)

contributes significantly to emergency surgical workload.

Laparotomy remains the standard approach. Despite pub-

lished reports with high success rates and low morbidity,

acute SBO is still considered by many a relative contrain-

dication to laparoscopy. Our aim was to review the available

literature and define important outcomes such as feasibility,

safety, iatrogenic bowel injury, and benefits to patients with

acute SBO who are approached laparoscopically.

Methods A systematic literature search was carried out

using the Medline database and the search terms laparos-

copy or laparoscopic approach and bowel obstruction.

Only adult studies published in English between 1990 and

2010 were included. Studies were excluded if data specific

to outcomes for laparoscopic management of acute SBO

could not be extracted.

Results Twenty-nine studies were identified. A laparo-

scopic approach was attempted in 2,005 patients with acute

SBO. Adhesions were the most common etiology (84.9%).

Laparoscopy was completed in 1,284 cases (64%), 6.7%

were lap-assisted, and 0.3% were converted to hernia

repair. The overall conversion rate to midline laparotomy

was 29% (580/2,005). Dense adhesions, bowel resection,

unidentified pathology, and iatrogenic injury accounted for

the majority of conversions. When the etiology of SBO was

a single-band adhesion, the success rate was 73.4%. Mor-

bidity was 14.8% (283/1,906) and mortality was 1.5% (29/

1,951). The enterotomy rate was 6.6% (110/1,673). The

majority were recognized and converted to laparotomy.

Laparoscopy was associated with reduced morbidity and

length of stay.

Conclusion Laparoscopy is a feasible and effective

treatment for acute SBO with acceptable morbidity. Further

studies are required to determine its impact on recurrent

SBO.

Keywords Bowel Abdominal A&E Complications Adhesions Surgical

Acute small-bowel obstruction (SBO) is a significant cause

of emergency surgical admissions and morbidity. Postop-

erative adhesions are the most frequent cause. Even after

operative intervention for SBO, recurrences are common.

Laparoscopy is believed to reduce the risk of adhesions

compared to laparotomy. Laparoscopy has revolutionized

the elective management of many surgical conditions and

results in reduced morbidity and shorter hospital stays. In

surgical emergencies such as acute appendicitis and cho-

lecystitis, the laparoscopic approach has replaced open

surgery as standard care. Advances in technology and

increased experience have made laparoscopic treatment of

acute SBO possible. However, laparotomy remains the

standard surgical approach to acute SBO. SBO has been

seen as a relative contraindication for minimal access

surgery. This is due to the belief that in the presence of

distended bowel, which reduces visibility and increases the

risk of bowel injury, the conversion rates and morbidity

would be unacceptable. The feasibility and safety of lap-

aroscopy for SBO has been assessed in several studies but

D. B. OConnor D. C. WinterDepartment of Surgery, Institute for Clinical Outcomes Research

and Education, St Vincents University Hospital,

University College Dublin, Dublin, Ireland

D. B. OConnor (&)Education and Research Centre, St Vincents University

Hospital, Elm Park, Dublin 4, Ireland

e-mail: donaloconor@yahoo.com

123

Surg Endosc (2012) 26:1217

DOI 10.1007/s00464-011-1885-9

and Other Interventional Techniques

outcomes vary considerably. Using the available published

literature, the aim of this review was to define important

outcomes such as feasibility, safety, risk of iatrogenic

bowel injury, and benefits to patients with acute SBO who

are approached laparoscopically.

Methods

A systematic literature search was undertaken using the

Medline database and the Cochrane Central Register of

Controlled Trials. To identify original peer-reviewed arti-

cles that studied outcomes of a laparoscopic approach to

acute SBO, the search terms laparoscopy or laparo-

scopic approach or minimally invasive surgery and

bowel obstruction were used. Studies on adult patients

published in English between 1990 and December 2010

were included. Studies reporting large-bowel obstruction or

small-bowel obstruction limited to hernia or bariatric sur-

gery were excluded. Studies that included patients with

chronic recurrent or subacute obstruction or who under-

went elective surgery were included only if data relevant to

acute cases could be retrieved. Case reports and case series

with 5 or fewer cases were excluded. A manual search of

the bibliographies of retrieved studies was also conducted.

If a patient group was reported twice, the most recent paper

was chosen.

Data retrieved included sample size, mean age, gender

distribution, body mass index, ASA grade, number of cases

completed laparoscopically, etiology of SBO, reasons for

conversion, time to surgery, length of surgery, in-hospital

mortality and morbidity, bowel injury (enterotomy) rate,

early and late SBO recurrences, and length of follow-up.

Additionally, in studies that compared laparoscopy to

laparotomy for acute SBO, data retrieved included time to

return of bowel function, length of stay, and cost.

Data reported in the selected studies varied consider-

ably. Age, gender, BMI, ASA grade, time to surgery, and

operative time were excluded from analysis due to incon-

sistent reporting. Results for variables are reported as

percentages based on the number of cases that had relevant

data available.

Results

Twenty-nine studies published between 1994 and 2010

were retrieved (Table 1). A laparoscopic approach was

attempted in 2,005 patients with acute SBO. The studies

consisted of 20 single-center retrospective case series [18,

11, 12, 1619, 22, 2427, 29], 2 multicenter retrospective

studies [13, 28], 3 prospective series [9, 10, 20], 2 retro-

spective comparative studies [14, 23], and 2 retrospective

controlled trials [15, 21]. Due to the absence of any ran-

domized controlled trials and the heterogeneous nature of

the available literature, a formal meta-analysis was not

performed.

Postoperative adhesions accounted for the majority of

cases of SBO at 84.9% (1,648/1,940). The etiology inclu-

ded abdominal wall (inguinal, femoral, or incisional) her-

nia in 3.3% (65/1,940) and malignant tumors in 2.5% (49/

1,940). The breakdown of causes is given in Table 2.

Of the 2,005 patients, surgery was completed laparo-

scopically in 1,284 (64%). One hundred thirty-four (6.7%)

required a target incision and were considered as lap-

assisted. Seven of 2,005 (0.34%) were converted to con-

ventional open herniorrhaphy. Five hundred eighty patients

were converted to conventional laparotomy (29%). The

laparoscopic completion rate was 57% (480/840) for

studies between 1994 and 2001 inclusive and increased to

68% (793/1,165) for studies published after 2001. The

reasons for conversion were identified for 301 patients

(Table 3). The most common reasons were the presence of

dense adhesions in 29%, ischemic bowel requiring resec-

tion in 24%, and an inability to identify the pathology in

9%.

In studies with sufficient data, single-band adhesions

were identified as the etiology in 46.6% (368/789). Where

explicitly stated, the rate of laparoscopic completion for

these patients was 73.8% (228/309) (Table 4).

Morbidity was 14.8% (283/1,906) and in-hospital mor-

tality was 1.5% (29/1,951). Data for enterotomies was

available for 1,673 patients. The overall rate was 6.6%

(110/1,673) and 84% (92/110) were recognized intraoper-

atively. Some were repaired laparoscopically but most

were converted to laparotomy. The 16% (18/110) of the

enterotomies that went unrecognized at the original oper-

ation required a subsequent laparotomy. Early SBO

recurrence was defined as recurrence within 30 days of

surgery. It occurred in 2% (39/1,912). There were insuffi-

cient data to calculate a late recurrence rate.

Discussion

Small-bowel obstruction following abdominal or pelvic

surgery has a significant impact on acute surgical admis-

sions and hospital cost [30]. Adhesions are the most fre-

quent cause and account for 5% of readmissions in surgical

patients and up to 50% of these will require surgical

management [31]. The advantages for patients of mini-

mally invasive surgery, including faster recovery and

reduced morbidity and pain, are well established in elective

surgery. Its safety is accepted in emergencies such as

appendicitis and perforated duodenal ulcer for which it has

become routine [32, 33]. Even in complex disease such as

Surg Endosc (2012) 26:1217 13

123

Crohns, laparoscopy provides improved short-term out-

comes [34].

The first laparoscopic adhesiolysis for SBO was reported

in 1991 [35]. Despite the publication of some promising

case series and advances in technology and expertise since,

a laparoscopic approach to patients with acute SBO

remains seldom used. No guidelines exist and there have

been no randomized trials. As recently as 2006, the Euro-

pean Association for Endoscopic Surgery stated, Lapa-

roscopy is of unclear or limited value in adhesive SBO

Table 3 Reasons for conversion to laparotomy

Conversion rate 29% (580/2,005)

Dense adhesions 28.9% (87/301)

Resections for ischemia 23.9% (72/301)

Inability to identify pathology 9.3% (28/301)

Iatrogenic injury 10.3% (31/301)

Inadequate field of view 7.6% (23/301)

Malignancy 5.3% (16/301)

Hernia 3% (9/301)

Other 8.3% (25/301)

Table 1 Studies oflaparoscopic management of

acute small-bowel obstruction

Author Origin Attempted

laparoscopically

Completed

Franklin (1994) [1] USA 23 20 (87%)

Ibrahim (1996) [2] USA 33 18 (54.55%)

Bailey (1998) [3] Australia 65 35 (53.8%)

Navez (1998) [4] Belgium 68 31 (45.6%)

El Dahha (1999) [5] Egypt 14 12 (85.7%)

Strickland (1999) [6] USA 40 27 (67.5%)

Rosin (2000) [7] Israel 21 14 (66.6%)

Al-Mulhim (2000) [8] Saudi Arabia 19 13 (68.4%)

Chosidow (2000) [9] France 134 77 (57.5%)

Suter (2000) [10] Switzerland 83 47 (56.6%)

Agresta (2000) [11] Italy 15 4 (26.6%)

Sato (2001) [12] Japan 17 14 (82.3%)

Levard (2001) [13] France/Switzerland 308 168 (54.5%)

Chopra (2003) [14] USA 34 23 (67.6%)

Wullstein (2003) [15] Germany 52 25 (48.1%)

Suzuki (2003) [16] Japan 21 17 (81%)

Borzellini (2003) [17] Italy 40 30 (75%)

Liauw (2005) [18] Singapore 9 6 (66.6%)

Kirshtein (2005) [19] Israel 65 34 (52.3%)

Lujan (2006) [20] USA 61 41 (67.2%)

Khaikin (2007) [21] USA 31 17 (54.8%)

Zerey (2007) [22] USA 42 35 (83.3%)

Mathieu (2008) [23] Belgium 96 62 (64.6%)

Pearl (2008) [24] USA 19 16 (84.2%)

Agresta (2008) [25] Italy 17 16 (94.1%)

Lee (2009) [26] Korea 19 16 (84.2%)

Grafen (2009) [27] Switzerland 90 66 (73.3%)

Dindo (2009) [28] Switzerland 537 363 (67.6%)

Tierris (2010) [29] Greece 32 26 (81.3%)

Total 2005 1,284 (64%)

Table 2 Etiology of small-bowel obstruction

Adhesions 84.9% (1,648/1,940)

Herniaa 3.3% (65/1,940)

Malignancy 2.5% (49/1,940)

Internal hernia 1.3% (26/1,940)

Bezoar 0.6% (12/1,940)

Meckels diverticulum 0.46% (9/1,940)

Otherb 6.7% (131/1,940)

a Inguinal, femoral, and incisional herniasb Other includes Crohns disease and radiation strictures

14 Surg Endosc (2012) 26:1217

123

[36]. A large study from the Nationwide Inpatient Sample

database in the US revealed only 11.4% of 6,165 randomly

selected operations for adhesive SBO (emergency or

elective) were attempted laparoscopically in 2002 [37].

The main reasons for the reluctance to adopt this approach

are the difficulty in identifying the site of obstruction lap-

aroscopically and the risk of enterotomy, both due to the

presence of distended bowel.

Feasibility

Most studies were retrospective and open to selection bias.

Some studies covered only adhesive SBO, while many

studies included other etiologies. Successful completion of

a minimally invasive approach was possible in 64%

(range = 2794%). A further 7% required a muscle-split-

ting incision or open hernia repair thereby avoiding midline

laparotomy in a total of 71%. It is reasonable to believe that

surgeons performing this surgery regularly could achieve

better results. First, in most of the studies, SBO cases were

encountered infrequently. The largest patient samples came

from multicenter reviews where several hospitals dealt

with fewer than 10 patients [13, 28]. In the six studies that

recorded all operative cases of SBO, laparoscopy accoun-

ted for only 1049% [1, 3, 4, 6, 22, 23]. Second, the results

have improved considerably since 2001, reflecting

increased expertise and volume. However, it should be

noted that all studies were conducted by surgeons experi-

enced in elective laparoscopic surgery.

The main reasons for conversion to laparotomy in SBO

cases are dense adhesions, ischemic bowel, the inability to

identify the site of obstruction, and iatrogenic bowel injury.

A low threshold for conversion in these cases and where

malignancy is found seems sensible and patients should be

warned preoperatively. Indeed, conversion represents good

surgical judgment and not failure. There are few reliable

preoperative predictive factors to facilitate patient selection

and guide operative choice. Suter et al. [10] found that

small-bowel dilatation greater than 4 cm on preoperative

imaging predicted conversion, although Pearl et al. [24]

reported that this was not a contraindication. The influence

of the patients surgical history is controversial. An

appendectomy was the only previous operation associated

with a higher chance of a successful laparoscopy [4, 13].

The number of previous operations did not correlate with

risk of conversion [10, 17, 21, 23]. However, a documented

history of dense adhesions certainly is associated with a

higher risk of conversion [13, 23], and primary laparotomy

may still be the most appropriate choice for such patients as

well as those with a complex pathology, e.g., malignancy

or inflammatory bowel disease.

Laparoscopy is successful in 73.4% of patients with

acute SBO caused by single-band adhesions. This repre-

sents an important group in which laparoscopic adhesiol-

ysis should be attempted. Computed tomography

evaluation on admission may help select these patients

preoperatively [26]. In an increasingly elderly surgical

population, performing a safe and relatively fast laparo-

scopic adhesiolysis over a laparotomy with its attendant

morbidity represents a true advance in surgery.

Safety

The overall mortality and morbidity of laparoscopy for SBO

is 1.5% and 14.8%, respectively. These rates are lower than

those published for open surgery for SBO [38], but as many

studies did not record age or ASA grade, predictors of

mortality and morbidity were not determined. The mortality

rate compares with the rate of 1.7% in a nationwide sample

that included laparoscopic lysis of adhesions for both acute

and chronic bowel obstruction [37]. The early SBO recur-

rence rate of 2% is again lower than previously reported for

open surgery [39], although open studies included patients

with more complicated disease. Conversion was a signifi-

cant risk factor for morbidity [6, 15, 19, 28]. Morbidity after

conversion can equal that after primary laparotomy [14, 21].

The reason for conversion may determine the morbidity. In

the largest study, early conversions, e.g., those due to poor

visibility or dense adhesions, have significantly less mor-

bidity than reactive conversions, e.g., those due to iatro-

genic bowel injury [28].

Enterotomy is the most feared complication of open or

laparoscopic adhesiolysis. The overall rate was 6.6% in the

studies discussed here. The enterotomies were mostly due

to dissection of dense or matted adhesions, but 12 cases

were due to trocar insertion. Unrecognized enterotomy,

while rare (1%), is an important complication as all cases

reported in this review required reoperation and thus

negated any benefit of an initial laparoscopic approach.

To avoid enterotomy, there should be minimal grasping

of dilated bowel and sparing use of cold electrocautery.

Table 4 Laparoscopy for single-band adhesions

Author n % single-band % single-bandcompleted

laparoscopically

Ibrahim (1996) [2] 33 69.7% (23) 78% (18/23)

Strickland (1999) [6] 40 30% (12) 75% (9/12)

Suter (2000) [10] 83 42.4% (35) 68% (24/35)

Levard (2001) [13] 308 54% (166) 65% (109/166)

Liauw (2005) [18] 9 66.6% (6) 83.3% (5/6)

Lujan (2006) [20] 61 41% (25) 84% (21/25)

Grafen (2009) [27] 90 46.7% (42) 100% (42/42)

Total 624 49.5% (309) 73.% (228/309)

Surg Endosc (2012) 26:1217 15

123

Open trocar placement under direct vision should be con-

sidered routine. Prompt conversion when faced with difficult

adhesions or access may also reduce the risk of enterotomy.

Benefit

Four studies compared laparoscopy to laparotomy for acute

SBO. In two retrospective controlled clinical trials, lapa-

roscopy was associated with significantly lower morbidity

(19 vs. 40% and 16 vs. 45%) and a shorter postoperative

hospital stay [15, 21]. The two unmatched comparative

reviews also showed a reduction in hospital stay and mor-

bidity and a faster return to bowel function [14, 23]. Patients

in the laparotomy groups tended to be older. The benefit of

morbidity reduction was not maintained in patients who

were converted. Taken together, these studies indicate a

possible advantage of laparoscopy over laparotomy. How-

ever, they must be viewed in the context of retrospective

studies with their attendant bias and limitations.

Perhaps the most important clinical and economic aspect

of adhesive SBO is recurrence. After laparotomy for SBO

the cumulative recurrence rate is 57% at 1 year and 15%

at 5 years [40, 41]. Given that laparotomy itself is causa-

tive of adhesive obstruction and indeed the most important

risk factor in a patients history [42, 43], it may seem

counterintuitive for it to remain as the first line modality

for managing SBO. Animal models have demonstrated a

reduction in adhesion formation with laparoscopy [44, 45].

More importantly, in clinical studies early results from

laparoscopic colorectal surgery also indicate reduced

adhesion formation over open surgery and a reduction in

readmissions for SBO [46, 47]. Therefore, we might expect

that laparoscopy will reduce the risk of recurring obstruc-

tion. Unfortunately, few studies to date have reported long-

term follow-up and it remains to be seen if the laparoscopic

approach to acute SBO is durable.

Conclusion

When performed by experienced surgeons, laparoscopy is a

feasible alternative to laparotomy for acute SBO, with

acceptable conversion rates and morbidity. It is particularly

effective in patients with relatively simple adhesions or a

single band. In the absence of randomized controlled trials,

which are unlikely to be undertaken, standardized reporting

of institutional experience and longer follow-up is essential

to assess the benefit of laparoscopy with respect to safety

and recurrent SBO.

Disclosure Donal B. OConnor and Desmond C. Winter have noconflicts of interest or financial ties to disclose.

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The role of laparoscopy in the management of acute small-bowel obstruction: a review of over 2,000 casesAbstractBackgroundMethodsResultsConclusion

MethodsResultsDiscussionFeasibilitySafetyBenefit

ConclusionDisclosureReferences