Laparoscopic Enterolysis for Small Bowel Obstruction

Abstract

Indications • Acute small bowel obstruction with moderate bowel dilation and expectation of limited adhesions based on previous surgical history (e.g., appendectomy, tubal ligation, C-section, etc.) • Subacute or recurrent intestinal obstruction with a well-defined transition zone on preop-erative imaging • Suspicion of internal hernia after laparoscopic bariatric surgery (particularly laparoscopic Roux-y-gastric bypass) Essential Steps 1. Position the patient supine with both arms to the side. 2. Enter the abdomen away from the previous incisions using open Hasson technique. 3. Insert all trocars under direct laparoscopic vision away from location of suspected pathology. 4. Manipulate the table position (e.g., Trendelenburg position) to serve exposure. 5. Lyse adhesions to the anterior abdominal with sharp dissection. Minimize use of energy sources. 6. Retract the omentum cephalad along with the transverse colon and mesocolon. 7. Handle the bowel gently, and use intestinal graspers. 8. Run the small intestine from the ligament of Treitz or the ileocecal area. If the bowels are edematous and dilated, it is safer to start distally. 9. Dissect all adhesions sharply. 10. After laparoscopic antecolic gastric bypass procedures , inspect two potential defects for internal hernias, that is, Petersen's defect and the mesenteric defect at the jejunojejunostomy. 11. After laparoscopic retrocolic gastric bypass, inspect the mesocolic window as well. 12. Internal hernia can develop after other laparo-scopic operations such as colonic or small bowel resection and biliopancreatic diversion. Note These Variations • Dense diffuse adhesions with massive bowel distention should prompt the surgeon to convert to open early to avoid intestinal injury. • Small intestinal obstructions in the setting of large incisional hernias are best approached