Objectives
To report the results of laparoscopic treatment of mechanical obstruction of the small intestine and to study the factors of conversion to laparotomy.
For minimally invasive surgery technique, many of them have not received practical training with simulators resembling Laparoscopic Needle Driver .
Methods
Retrospective study, having collected 32 patients between January 2001 and December 2009. The average age was 35 years (20-54). There were 17 men and 15 women. A history of laparotomies was noted in 27 patients. Patients with a hernia or a strangulated eventration were excluded from this study. An analysis was performed to determine the conversion factors for laparotomy Results: Postoperative flanges or adhesions were responsible for 27 of the 32 intestinal obstructions (84%). In 24 cases it was a single flange or localized adhesions treated by simple section with success in 18 patients (56% of cases). A conversion was performed in 14 cases (44%).
The median time to recovery of intestinal transit was shorter after fully laparoscopic surgery than after conversion (1.5 vs 2.5 days; p = 0.004). Similarly, the average length of postoperative stay was smaller in the absence of conversion (2.4 vs. 7; p <0.001). A statistical analysis made it possible to identify 3 factors linked to the conversion which are: the presence of peritoneal signs, the number of bridles> 1, and the need for bowel resection.
Prerequisite
The history of abdominal surgery has long considered a contraindication to laparoscopy. There has been a reluctance to advocate the use of laparoscopy in mechanical obstructions of the small intestine due to technical difficulties related to a distended small intestine and reduced workspace.
Hepatobiliary
The ERAS (enhanced recovery after surgery) concept aims to minimize the metabolic stress and the catabolic state caused by a surgical intervention, with the aim of reducing complications, the length of the postoperative stay and the costs, while improving the well-being of the patient.
It is a multimodal therapeutic concept that is based on four main elements:
1. Simplified preoperative preparation
2. Intraoperative water restriction
3. Thoracic epidural analgesia
4. Early mobilization and refeeding.
The application of these principles to open colorectal surgery has resulted in a significant reduction in the length of hospitalization from 3 to 5 days, without increasing the rate of re-hospitalization, whereas the “traditional” approach is associated with an average hospital stay of 10 days.
For a Fast Track program, it is imperative to follow precise and standardized criteria with regard to the patient's return home.
The latter must:
• Be able to control pain with oral analgesia.
• Eat without any parenteral intake.
• Have regained mobility and independence at least equal to those they enjoyed before entering hospital.
• Fulfill all of the above criteria and wish to return home.
We have recently shown, through a prospective randomized study, a significant reduction in postoperative complications in patients having benefited from FT treatment. Fluid restriction and adequate epidural analgesia have identified as independent predictors of a low complication rate (data pending). Several questions remain open and currently studied, in particular, the benefits of FT in laparoscopic surgery and the type of analgesia required after laparoscopic colorectal surgery.
Clinical Experience
For the practitioner, it is important to know that virtually every patient can benefit from an FT protocol, provided they are capable of a certain degree of discernment and collaboration. Age and associated comorbidities are in no way exclusion criteria. The general principles of preparing the patient for the operation remain valid. For example, malnutrition, predisposing to a major risk of infection and a higher rate of complications, should investigate and treated with an oral dietary supplement. The concepts of FT originally developed for open colorectal surgery. Currently, these principles modified and applied to other abdominal, open and laparoscopic surgeries.
At present, the following conclusions can draw from clinical experience:
The application of FT concepts to open colorectal surgery reduces postoperative complications, hospital stay and costs. FT should therefore become a surgical standard. Key elements include intraoperative fluid restriction, effective epidural analgesia and rapid postoperative mobilization, as well as early re-feeding. Despite the accumulation of evidence in favor of FT, it applied in a minority of cases. Modified FT protocols can now applied to other procedures in visceral, open and laparoscopic surgery.
Conclusion
Laparoscopy is an option for the treatment of mechanical small bowel occlusions 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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