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Minimally invasive surgical approach to small bowel obstruction

Epublication WebSurg.com, Mar 2016;16(03). URL: http://websurg.com/doi/vd01en4692

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  • 2016-03-10
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Due to the lack of laparoscopic experience to work in a small space (small bowel distension), small bowel obstruction seems to be a relative contraindication for a minimally invasive approach. In other hands, many patients have co-morbidities, and consequently it is key to work with a low intra-abdominal pressure to prevent any conversion for pneumoperitoneum intolerance. Small bowel obstruction must be resolved by experts in order to prevent any excessive mobilization and iatrogenic perforation.
Critical comments:
This video presents the laparoscopic management of bowel obstruction. It demonstrates the feasibility of the identification and management of mechanical bowel obstruction. Several parts of the video can be discussed: 1. In their comments, the authors report that the whole bowel has to be explored in order to prevent the presence of a secondary band at the origin of the obstruction. This is absolutely mandatory. Usually, the recommendation is to start the exploration at the level of the caecum and to mobilize the whole non-dilated bowel in order to prevent a risk of bowel injury during this manipulation. Exploration of the dilated bowel is much more risky. The authors did not show this extensive and systematic exploration. 2. The authors reported that they used 5 to 10 liters of warm saline for abdominal lavage. Today, there is no evidence of the benefit of this major abdominal lavage including 5 to 10 liters. Selective lavage can be recommended in case of significant bacterial contamination. 3. The authors consider the potential benefit of irrigation of the ischemic bowel with hot water after band division. This indication can be considered as potentially efficient regarding the recommendations in open surgery. However, laparoscopy has a significant advantage to keep the internal temperature of 37°C at a minimum, and certainly hot lavage, which cannot be over 39°C to 40°C, will probably also have limited impact. Despite these minor remarks, this video has a scientific value in demonstrating a safe approach to a small bowel obstruction related to a single band, which is, in this case, very safely resected. One can also focus on the value of working with a high quality camera, which gives the surgeon the possibility to clearly evaluate the vitality of the small bowel after an ischemic period, which is well demonstrated in this video.