Introduction
The aim of this study was to report the results of laparoscopy in the treatment of, and to study the conversion factors in laparotomy in order to better specify the indications for this technique.
For minimally invasive surgery technique, many of them have not received practical training with simulators similar to Laparoscopic Needle Driver
Mechanical small bowel occlusions require surgical treatment in nearly 30% of cases. The formation of bridles and adhesions is the major cause, but other etiologies can implicate. Until recently, a history of abdominal surgery considered a contraindication to laparoscopy. There has been a reluctance to advocate the use of laparoscopy in acute due to technical difficulties related to a distended small intestine and reduced workspace.
The comparisons of two means on independent series carried out by means of Student's t test for independent series. Comparisons of two medians on independent series performed by the median test. Comparisons of percentages on independent series performed by Fisher's two-tailed exact test. In order to identify the risk factors independently related to the event, we tried to conduct a multivariate logistic regression analysis. The latter could not completed due to the presence of strong collinearity between the variables. In entire statistical trials, the significance level was set at 0.05.
Effects
Postoperative bands or adhesions were responsible for 27 of 32 intestinal obstructions, or 84% of cases. Among them, 24 patients had a single flange or localized adhesions. Three patients had stenosis of the last ileal loop related to occlusive Crohn's disease. One patient had a tumor of the small intestine (lymphoma). In another patient, it was an omental flange adhering to a Meckel's diverticulum. The bands treated by single section with success in 18 patients, for a fully laparoscopic treatment rate of 56%. Fourteen patients had a conversion, ie a rate of 44%.
The conversion performed by a lateral incision in the right flank in four patients. It involved a Meckel's diverticulum, a tumor of the small intestine, and two ileal stenoses in Crohn's disease. Intestinal resection followed by immediate anastomosis performed in all these patients. Ten patients had a conversion to midline laparotomy, they were tight adhesions difficult to dissect laparoscopically (n = 3), a significant dilation of the small intestine hampering exploration (n = 2), to check intestinal viability (n = 2), for intestinal resection of a painful loop (n = 2), and for resection of an ileal stenosis in Crohn's disease (n = 1).
The median duration of the fully laparoscopic intervention was 52 min, and 100 min after conversion (p <0.001). The median length of postoperative stay was shorter in the absence of conversion (2.4 vs. 7 days; p <0.001). No deaths occurred in this series. Four patients presented postoperative complications, ie a rate of 12.5%.
Duration of the Procedure
Duration of the operation, delays in reestablishing transit and length of postoperative stay depending on the route of entry. Discussion Laparoscopic treatment of OMGs is an alternative to laparotomy in selected patients. Its best indication may be the occlusion on a single flange. This alternative to laparotomy could reduce the formation of adhesions, and decrease the next occlusive episodes. After conventional surgery, recurrence of the obstruction leads to iterative laparotomy in 15% of cases.
Over 50% of patients have associated with a single bridle. On the other hand, experimental studies have suggested the value of laparoscopy in preventing the formation of postoperative bands and adhesions.
The efficacy of laparoscopic surgery for the treatment of OMG can be defined by the detection and removal of the intestinal obstruction (pure laparoscopic intervention) or by the fact that laparoscopy has made it possible to treat the cause of the intestinal obstruction. Occlusion without resorting to a midline laparotomy, and this thanks to a mini-incision opposite the lesion (coelio-assisted intervention). All the patients in our study, treated exclusively by laparoscopy, had a single clamp and / or localized adhesions that easily released.
Postoperative Adhesions
Analysis shows that the laparoscopic route made it possible to treat the occlusion and avoid a median laparotomy in 36% to 76% of cases. The difficulty in locating the seat of the occlusion or in releasing the small intestine due to multiple adhesions represents half of the causes of the failures, as well as the existence of another pathology (than the flanges and adhesions) at the origin of the occlusion. The conversion rate varies according to the studies from 13 to 52% (10, 17), it was 44% in our series. This conversion carried out by a lateral approach in 40% of cases. A midline laparotomy thus avoided in 26 patients (81%). Several authors (22-25) have attempted to identify predictive factors for conversion to laparotomy, namely a long duration of the operation, or significant distension of the small intestine.
Risk Factors for Conversion to Laparotomy
The suspicion of intestinal ischemia preoperatively based on clinical and biological arguments could consider as a contraindication to laparoscopy. In addition, a mini laparotomy can be adapted according to the operative findings, in order to ensure the viability of a strangled loop.
In our series, the median time to recovery of intestinal transit was shorter after fully laparoscopic surgery compared to patients who underwent conversion (1.5 vs 2.5 days; p = 0.004), which can be explained by absence of retrograde emptying of the hail. Likewise, the median length of postoperative stay was shorter in the absence of conversion (2.4 vs. 7; p <0.001).
Several authors have compared the postoperative consequences of completed laparoscopy with those of converted procedures (10, 20). Agresta et al (6), reported an average length of stay of 3.6 days for the laparoscopy group against 10.5 days for the conversion to laparotomy group, these results being similar to ours. No intraoperative incident observe in our study, and the mortality rate was zero. This is because the patients were young, and the criteria for conversion were broad.
Conclusion
They were a myocardial infarction, a pneumonia and two parietal infections. The univariate analysis (Table 1) made it possible to identify 3 factors linked to the conversion, which are: the presence of peritoneal signs, the number of flanges> 1 and the need for intestinal resection.
In conclusion, laparoscopy is an option for the treatment when performed in selected patients. Its best indication may be the occlusion on a single flange. This alternative to laparotomy could reduce adhesion formation and potentially decrease subsequent occlusive episodes.
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