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 umbilicus, 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 laparoscopic 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 laparoscopic 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.

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©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) Ͻ.01 age range, 24-82 years) were retrospectively selected Cholecystectomy 10 (42) 20 (8.4) Ͻ.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) Ͻ.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) Ͻ.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 laparotomy 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 laparoscopically assisted procedure, those operated on for MECHANISMS intestinal obstruction associated with intraperitoneal 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 obstruction 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 obstruction (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- ␹ 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 transperitoneal 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 (PϽ.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-

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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 0.43 4019 41 1.04‡ Mixed or not classified 0 0 0 1824 14 0.76 Total 10 327 22 0.21 8098 56 0.69

*Two patients were not included because the initial procedure was performed in another center. NA indicates not available. †PϽ.001. ‡PϽ.01.

The postoperative course was uneventful in 21 cases. Table 3. Mechanisms of Intestinal Obstruction According to Three patients had complications; 1 had a large mural Initial Procedures, Location, and Interval to Reoperation* intestinal hematoma following reoperation for intestinal incarceration at the umbilical trocar site after lapa- Incarcerations Adhesions Bands Total roscopic cholecystectomy, 1 had acute pancreatitis after Supracolonic 5 5 1 11 reoperation for adhesions at the umbilical site following Cholecystectomy 4 5 0 9 laparoscopic cholecystectomy, and 1 had acute postop- Others 1 0 1 2 erative duodenal ulcer bleeding following reoperation for Location Operative field 0 1 1 2 intestinal incarceration behind the mesh in an inguinal Trocar site 5 4 0 9 hernia repair. None of these patients required another Infracolonic 6 3 3 12 operation and there were no deaths. Appendectomies 0 2 2 4 Hernia 4 1 0 5 Others 2 0 1 3 COMMENT Location Operative field 2 3 3 8 Laparoscopic surgery does not eliminate postoperative Trocar site 4 0 0 4 Median interval to 8 25 22.5 13 obstruction, whether involving the operative field or the reoperation, d incision. The prevalence of obstruction after laparos- Range 3-45 10-650 10-420 3-650 copy might even be greater (transperitoneal inguinal her- Early/late observations 11/0 6/2 3/1 20/3 nia repair) or as high (cholecystectomy and appendectomy) as that seen with open operation. The number of *One patient had cecal volvulus due to malrotation and was operated on at incarcerations was nearly the same as that of adhesions 72 hours. or bands combined (Table 3). Most obstructions occurred at the umbilical trocar site, 10 mm or more, even structions occurred less than 2 years after the initial pro- when the fascia was closed. cedures (Table 3); 21 (88%) in the early postoperative The initial procedures in laparoscopic surgery dif- course and 3 later (180, 420, and 650 days, respec- fer from those in open series (Table 1), simply because tively). All 3 late obstructions were due to adhesions or some operations are performed less often laparoscopi- bands. The early postoperative course of the initial pro- cally than traditionally. Examples are gastric and rectal cedure was uneventful in 14 cases, whereas 10 patients operations, which are often responsible for postopera- underwent reoperation within 8 days. tive mechanical obstruction in open surgery but which are presently not widely performed laparoscopically. TREATMENT AND The relatively high prevalence of small-bowel POSTOPERATIVE COURSE obstruction in laparoscopic transperitoneal hernia repair (Table 2) is explained by the presence of the Intestinal lysis was performed in 6 cases via laparoscopy small intestines near the umbilical and lateral trocar (4 bands, 1 adhesion in the operative field, and 1 adhe- sites, whereas the peritoneal insult in traditional hernia sion at the trocar site). In 17 patients lysis was per- repair is minimal (compared with that necessary for formed through open laparotomy, including 6 small in- insertion of a transperitoneal mesh) and is likely most testine resections—4 for incarcerated loops (2 at the often covered by the nearby colon. For cholecystectomy umbilical trocar site and 2 behind the mesh in a hernia or appendectomy, the lengths of the multiple port inci- repair) and 2 for adhesions at the trocar site. One pa- sions are probably equivalent to one long incision and tient with cecal volvulus required open cecostomy. each port incision in itself is a potential cause of

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©2000 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/28/2021 obstruction. Because all patients undergoing the initial Surgeons Participating in the Study procedures were not followed up prospectively, some of these patients could have been operated on for mechanical intestinal obstruction in another institution P. Baillet, MD, Eaubonne; F. Benhamida, MD, Sousse- without the knowledge of the initial center. The preva- Tunisie; P. Cubertafond, MD, A. Gainant, MD, B. Des- cottes, MD, D. Valleix, Limoges; J. Domergue, MD, lence calculated herein was therefore a minimal value. B. Millat, MD, Montpellier; J.-J. Duron, MD, N. Elian, MD, The exact prevalence of intestinal obstruction after H. Levard, MD, Paris; J. M. Hay, MD, Y. Flamant, MD, laparoscopic or open surgery is and will remain difficult G. Zeitoun, MD, Colombes; Y. Laborde, MD, Pau; P. LePi- to evaluate. Most diseases treated by laparoscopic sur- card, MD, Charenton; P. Marre, MD, Marly; J. Mares- gery are common and generally benign conditions: caux, MD, S. Evrard, MD, Strasbourg; S. Msika, MD, Meu- long-term follow-up is therefore difficult to obtain. lan; Y. Soulier, MD, Montmorency; B. Desrousseaux, MD, The most frequently encountered mechanisms in our Lomme, France. series were adhesions (33%) or bands (17%). Although the pathophysiology of these 2 causes is similar,14 bands were encountered in the operative field only whereas adhesions were seen both in the operative field as well as at ture20,24 indicates that adhesions or incarcerations, whether the trocar sites. Adhesions have been reported previously median or lateral, can still occur after fascial closure. On in only 2 cases after abdominal laparoscopic surgery.16 This the other hand, no cases of obstruction due to incisional apparent difference with the literature may be explained hernia at the trocar site (Richter hernia), as described pre- by the fact that the exact mechanism of intestinal obstruc- viously,24 were found in our series. This seems to occur tion was not always mentioned in the literature but was more often in the lateral sites.24 requested specifically in our questionnaire and the fact that The second most frequent location of intestinal ob- the exact mechanism was not always reported back to the struction encountered in our study was the operative field first surgeon when late obstruction occurred. The second (Table 2). Although this has certainly already occurred, mechanism in our series was incarceration (46%) at the to the best of our knowledge, obstruction arising from trocar site or in a peritoneal defect in the operative field the operative field has not yet been described after lapa- after transperitoneal hernia repair. Incarcerations, on the roscopy. Even though laparoscopy is reported to be less other hand, are the most frequently reported mechanism traumatic than open surgery,7 there is no reason to be- in the literature,17-20 undoubtedly because obstruction due lieve that the obstruction rate will decrease in the opera- to incarceration occurs early in the postoperative course. tive field. The prevalence of intestinal obstruction after In our series, the median interval from the initial proce- procedures such as laparoscopic transperitoneal ingui- dure to reoperation was significantly shorter (PϽ.01) when nal hernia repair could actually be higher, as the perito- obstruction was caused by incarceration (8 days) vs ad- neum is violated to a greater extent as compared with the hesions (25 days) (Table 3). In the literature9,10,15,17-20 in- open techniques.25,26 Thus, the extraperitoneal route may carcerations occurred 1 to 9 days after operation, whereas be preferable to the transperitoneal route. Moreover, the the 2 cases of adhesions16 occurred at 3 weeks and at 6 rate of intestinal obstruction could even be higher than months, respectively. Recommendations in the litera- reported here, as operations such as colectomy that use ture21,22 to decrease the prevalence of postlaparoscopic in- more extensive dissection27-29 (2 cases in our series) and carceration include: (1) opening the trocar valve to am- the use of gauze swabs30 or other foreign bodies, which bient air before port removal, as a partial vacuum can be are known to promote adhesions and fibrotic bands, are created when the port is withdrawn, thus drawing omen- performed more often laparoscopically.31 tum or intestines into the fascial defect; (2) shaking the As after laparotomy,12,32 the small intestines were in- abdominal wall, which may help free any temporary vis- volved in the majority of obstructions complicating lapa- ceral incarceration or adhesions; and (3) removing the tro- roscopic abdominal surgery (23 of 24). However, co- car under direct visual control while the pneumoperito- lonic herniation, as well as incarceration or herniation neum is maintained by the surgeon’s finger, temporarily of the greater omentum through trocar ports,11 has been sealing the trocar site. reported after gynecologic laparoscopic procedures.24 In our series, as in the literature,9-11,15,18,20,23 the most In 1 of our patients, a cecal loop volvulated 72 hours common location of intestinal obstruction was the tro- after laparoscopic cholecystectomy. This complication has car site, but the lateral sites were involved less often com- already been reported after laparoscopy,33 and may be due pared with the umbilicus.15,20,21 There are at least 2 ex- to excessive slackness of the malrotated cecum after with- planations for this. First, the lateral wall is composed of drawal of the pneumoperitoneum.34 As complete inspec- 2 fascial planes and muscle, making it theoretically less tion of the abdomen is thought to be less satisfactory un- prone to dehiscence; second, the small intestine is less der laparoscopy,35 the right colon was not seen to be often in contact with the lateral trocar sites. abnormally mobile during the primary operation. All trocars causing intestinal obstruction in our se- Postlaparoscopic obstruction was severe. Six resec- ries were 10 or 12 mm in diameter. Incarcerations, how- tions (26%) were necessary, 4 because of incarcerations ever, can arise even in 5-mm holes when they are not and 2 because of adhesions. This resection rate, how- closed.11,16 Although it has been stated that fascia clo- ever, is comparable to that seen after open procedures sure of trocar holes, which is sometimes difficult,22,23 may (14%-20%).12-14 preclude or decrease the incidence of obstructions,10,11 Techniques for avoiding contact between the intes- our experience (6 cases) as well as that in the litera- tines and the trocar sites include assessment of subxi-

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