This Medical Video:
Laparoscopy in acute bowel obstruction following previous surgery is
a difficult procedure and avoided by most of the surgeons due to the
difficulty in obtaining pneumoperitoneum, port placement, lack of
working space, adhesions and risk of bowel injury.
Here is a
patient who had a previous laparotomy for trauma with a midline
incision from xyphysternum to pubis; after unsuccessful conservative
management he underwent a laparoscopy; a prior CT scan showed
adhesions in the left side and a distal-mid small bowel obstruction.
The pneumoperitoneum was obtained with the Visiport placed in the
right lower quadrant; although the abdomen was grossly distended,
under significant tension and distended loops of small bowel were
occupying most the peritoneal cavity, with muscle relaxation there
is usually enough space to perform a thorough inspection of the
abdominal cavity. Port placement has to be done with special care as
there is no room to push and usually a blunt trocar directed away
from the bowel is employed in my practice. The collapsed loops of
small bowel point quickly to the site of obstruction -- it is better
to avoid manipulating the distended bowel as it is heavy, oedematous
and prone to be lacerated with the instruments; once the pathology
is identified, in this case the obstructive band, light packing is
performed in order to expose the working space and protect the bowel
from instruments like scissors or diathermy. In this case the band
adhesion was slightly more difficult to separate from the bowel and
required a combination of sharp and gentle blunt dissection.
the obstruction is release and the transit of contents is confirmed
in the collapsed bowel the procedure is terminated. No abdominal
drainage is usually necessary.