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Prevalence and Mechanisms of Small Intestinal Obstruction Following Laparoscopic Abdominal Surgery a Retrospective Multicenter Study

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Prevalence and Mechanisms of Small Intestinal Obstruction Following Laparoscopic Abdominal Surgery a Retrospective Multicenter Study ORIGINAL ARTICLE Prevalence and Mechanisms of Small Intestinal Obstruction Following Laparoscopic Abdominal Surgery A Retrospective Multicenter Study Jean-Jacques Duron, MD; Jean Marie Hay, MD; Simon Msika, MD; Denis Gaschard, MD; Jacques Domergue, MD; Alain Gainant, MD; Abe Fingerhut, MD, FACS, FRCS; for the French Association for Surgical Research Hypothesis: The prevalence and mechanisms of intes- 12 cases and to intestinal incarceration in 11 cases. tinal obstruction following laparoscopic abdominal sur- Obstruction was located at the trocar site in 13 cases (9 gery have not been studied extensively. incarcerations and 4 adhesions), mainly at the umbili- cus, and in the operative field in 10 cases (2 incarcera- Design: Retrospective review of cases of intestinal ob- tions in a wall defect after transperitoneal inguinal her- struction after laparoscopic surgery. nia repair, 4 adhesions, and 4 fibrotic bands). The small intestine was involved in 23 of 24 cases; the other was Setting: Sixteen surgical units performing laparoscopy due to cecal volvulus following unrecognized intestinal in France. malrotation. Intestinal obstruction was treated by lapa- roscopic adhesiolysis in 6 patients and by laparotomy in Patients: Twenty-four patients with intestinal 18 patients, 6 of whom required small intestine resec- obstruction. tion. Three postoperative complications but no deaths occurred. Main Outcome Measures: Prevalence values and de- scriptive data. Conclusion: Intestinal obstruction following laparo- scopic abdominal surgery can occur irrespective of the Results: The 3 most frequent primary procedures type of operation; the prevalence is as high as (chole- responsible for intestinal obstruction were cholecystec- cystectomy and appendectomy) or even higher than tomy (10 cases), transperitoneal hernia repair (5 cases), (transperitoneal hernia repair) that seen in open and appendectomy (4 cases). Prevalences of early post- procedures. operative intestinal obstruction after these procedures were 0.11%, 2.5%, and 0.16%, respectively. Intestinal obstruction was due to adhesions or fibrotic bands in Arch Surg. 2000;135:208-212 BDOMINAL laparoscopic The goal of this study was to analyze surgery began in 1985,1 data on 24 patients operated on for increased in usage,2,3 and mechanical intestinal obstruction sec- became widespread by ondary to laparoscopic abdominal sur- the 1990s. Smaller inci- gery. From the Departments of Surgery, Groupe Hospitalier sions, minute dissection, and experi- A4,5 Pitie´-Salpeˆtrie`re, Paris, France mental data have led one to expect RESULTS (Dr Duron); Hoˆpital Louis that laparoscopic abdominal surgery Mourier, Colombes, France would be associated with a low or non- INITIAL SURGICAL PROCEDURES (Drs Hay, Msika, and existent intestinal obstruction rate.6,7 Gaschard); Hoˆpital Saint-Eloi, However, intestinal obstruction compli- Compared with 3 series of open sur- Montpellier, France cating diagnostic gynecological laparos- gery12-14 (Table 1), in our series there were (Dr Domergue); Hoˆpital copy has been recognized and reported more obstructions observed after supra- Dupuytren, Limoges, France as early as 1968.8 Short series of 1 to 4 colonic surgery mainly because there were (Dr Gainant); and Hoˆpital Le´on cases of small-bowel obstruction after more cholecystectomies performed and no Touhladjian, Poissy, France various kinds of laparoscopic abdominal cases of gastric surgery were culled. The (Dr Fingerhut). 9-11 For a list of the French surgery have been reported since initial infracolonic operations were not Association for Surgical 1992, but do not provide any hard data significantly different except for inguinal Research participants in this on the mechanisms and prevalence of hernia, which was more frequent in open study, see page 211. postlaparoscopic instestinal obstruction. surgery. ARCH SURG/ VOL 135, FEB 2000 WWW.ARCHSURG.COM 208 ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 Table 1. Comparison of Causes of Obstruction PATIENTS AND METHODS (Gynecologic Procedures Excluded)* No. (%) of Patients PATIENTS Current Series Open Procedures 12-14 From March 1, 1990, to March 1, 1995, 24 patients (N = 24) in the Literature P (15 women and 9 men; mean ± SD age, 56 ± 19 years; Supracolonic 11 (46) 50 (19.8) ,.01 age range, 24-82 years) were retrospectively selected Cholecystectomy 10 (42) 20 (8.4) ,.001 from 16 surgical units (8 university hospitals, 7 teach- Reflux disease 1 (4) NA (NA) NA ing hospitals, and 1 private hospital). The median num- Gastric surgery 0 (0) 30 (11.8) ,.001 ber of cases per surgical unit was 1 (range, 1-3). All Infracolonic 11 (46) 140 (55.3) NS adult patients previously operated on laparoscopi- Appendectomy 4 (17) 74 (29.2) NS cally for gastrointestinal disease or transperitoneal Inguinal hernia 5 (21) 13 (5.1) ,.02 hernia repair and then reoperated on for mechanical Colectomy 2 (8) 38 (15.0) NS Rectum 0 (0) 15 (5.9) NS intestinal obstruction were eligible. Mixed or not classified 2 (8) 63 (24.9) .10 All patients who had had a previous lapa- rotomy at any time, those undergoing gynecological *NA indicates not available; NS, not significant. laparoscopic procedures, those who underwent a con- version to an open procedure or who had only a lapa- roscopically assisted procedure, those operated on for MECHANISMS intestinal obstruction associated with intraperito- neal infection, and those who improved through non- As summarized in Table 3, 50% of obstructions were operative management were not included. due to adhesions (33%) or bands (17%) while 46% were due to intestinal incarceration, accounting for 23 cases, METHODS all involving the small intestine. The last patient who ini- The prevalence was calculated only for the 22 pa- tially underwent laparoscopic cholecystectomy was re- tients who underwent reoperations in the same in- operated on 72 hours later for cecal volvulus due to un- stitution. The 2 other patients were initially oper- recognized intestinal malrotation. ated on in another center from which data necessary to calculate the prevalence were not available. Ini- LOCATION tial procedures12-14 and the prevalence14 of obstruc- tion in our series were compared with those from pa- Intestinal obstruction (excepting the case of cecal vol- tients who had open surgery (Table 1 and Table 2). vulus) occurred at the trocar site in 54% of cases and in Other data collected through a preestablished the operative field in 42% of cases (Table 3). questionnaire included (1) mechanism of obstruc- tion (adhesion, band, or incarceration); (2) location of obstruction (at the operative field or at the trocar Trocar Sites site), location of the trocar (umbilical or lateral),15 size of the obstruction,9 and whether the fascia was Ten (77%) of 13 cases involved 10-mm trocars while 3 closed or not11-15; (3) interval time between the ini- (23%) of 13 involved 12-mm trocars. Nine trocar ports tial procedure and the reoperation; and (4) proce- were at the umbilicus. As regards the 4 lateral trocar dure used to deal with obstruction. As regards the sites (three 10-mm trocars and one 12-mm trocar) (all mechanism, incarceration was defined as trapping of with incarceration), 1 was in the left iliac fossa and 3 the intestines in the abdominal wall; adhesions as were in the right iliac fossa. Of the 13 patients with union of intestines to a surface (or conglutination); trocar site obstruction, 6 had undergone adequate fas- bands as fibrotic cordlike processes or anatomical structures that bind the intestines to other parts, cia closure, 5 in the umbilicus and 1 lateral. Of the 9 whether encircling another structure or not; and in- incarcerations at the trocar site, 3 were closed while 6 cisional hernia as protrusion of intestines through a were not. Slowly resorbable suture material was used trocar incision. Early obstruction was defined as ob- in all cases. struction occurring during the first 6 postoperative weeks.14 Operative Fields Statistical comparisons for nonparametric vari- ables were made with the Mann-Whitney test. The 2 All 4 obstructions due to bands and half of the adhe- x test was used to compare proportions. sions originated from the operative field (Table 2). Only 2 of 11 incarcerations originated in the operative field and these were due to a peritoneal defect following trans- peritoneal mesh inguinal hernia repair. PREVALENCE INTERVAL TO REOPERATION Compared with the open surgery series of Stewart et al,14 the prevalence of intestinal obstruction in our series was The median interval to reoperation was significantly significantly higher in infracolonic procedures, espe- shorter (P,.01) for incarceration (8 days) than for ad- cially in transperitoneal hernia repair (Table 2). hesions (25 days) or bands (22.5 days). All intestinal ob- ARCH SURG/ VOL 135, FEB 2000 WWW.ARCHSURG.COM 209 ©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 Table 2. Comparison of Prevalence of Early Mechanical Obstruction* Laparoscopy Procedure in Current Series Open Procedures in Stewart et al14 Series No. of No. of Prevalence, No. of No. of Prevalence, Patients Obstructions % Patients Obstructions % Cholecystectomy 6957 8 0.11 1810 1 0.06 Reflux disease 529 1 0.18 NA NA NA Appendectomy 2295 4 0.16 1054 3 0.35 Inguinal hernia 196 5 2.50 973 1 0.10† Colectomy 183 2 1.10 685 16 2.34 Miscellaneous 589 2 0.33 3576 35 0.95 Supracolonic 7593 10 0.13 2254 1 0.04 Infracolonic 2734 12
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