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Surg Endosc (2012) 26:1217

DOI 10.1007/s00464-011-1885-9

and Other Interventional Techniques

The role of laparoscopy in the management of acute small-bowel


obstruction: a review of over 2,000 cases
Donal B. OConnor Desmond C. Winter

Received: 31 August 2010 / Accepted: 4 August 2011 / Published online: 5 September 2011
Springer Science+Business Media, LLC 2011

Abstract
Background Adhesive small-bowel obstruction (SBO)
contributes significantly to emergency surgical workload.
Laparotomy remains the standard approach. Despite published reports with high success rates and low morbidity,
acute SBO is still considered by many a relative contraindication to laparoscopy. Our aim was to review the available
literature and define important outcomes such as feasibility,
safety, iatrogenic bowel injury, and benefits to patients with
acute SBO who are approached laparoscopically.
Methods A systematic literature search was carried out
using the Medline database and the search terms laparoscopy or laparoscopic approach and bowel obstruction.
Only adult studies published in English between 1990 and
2010 were included. Studies were excluded if data specific
to outcomes for laparoscopic management of acute SBO
could not be extracted.
Results Twenty-nine studies were identified. A laparoscopic approach was attempted in 2,005 patients with acute
SBO. Adhesions were the most common etiology (84.9%).
Laparoscopy was completed in 1,284 cases (64%), 6.7%
were lap-assisted, and 0.3% were converted to hernia
repair. The overall conversion rate to midline laparotomy
was 29% (580/2,005). Dense adhesions, bowel resection,
unidentified pathology, and iatrogenic injury accounted for
the majority of conversions. When the etiology of SBO was
D. B. OConnor  D. C. Winter
Department of Surgery, Institute for Clinical Outcomes Research
and Education, St Vincents University Hospital,
University College Dublin, Dublin, Ireland
D. B. OConnor (&)
Education and Research Centre, St Vincents University
Hospital, Elm Park, Dublin 4, Ireland
e-mail: donaloconor@yahoo.com

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a single-band adhesion, the success rate was 73.4%. Morbidity was 14.8% (283/1,906) and mortality was 1.5% (29/
1,951). The enterotomy rate was 6.6% (110/1,673). The
majority were recognized and converted to laparotomy.
Laparoscopy was associated with reduced morbidity and
length of stay.
Conclusion Laparoscopy is a feasible and effective
treatment for acute SBO with acceptable morbidity. Further
studies are required to determine its impact on recurrent
SBO.
Keywords Bowel  Abdominal  A&E  Complications 
Adhesions  Surgical

Acute small-bowel obstruction (SBO) is a significant cause


of emergency surgical admissions and morbidity. Postoperative adhesions are the most frequent cause. Even after
operative intervention for SBO, recurrences are common.
Laparoscopy is believed to reduce the risk of adhesions
compared to laparotomy. Laparoscopy has revolutionized
the elective management of many surgical conditions and
results in reduced morbidity and shorter hospital stays. In
surgical emergencies such as acute appendicitis and cholecystitis, the laparoscopic approach has replaced open
surgery as standard care. Advances in technology and
increased experience have made laparoscopic treatment of
acute SBO possible. However, laparotomy remains the
standard surgical approach to acute SBO. SBO has been
seen as a relative contraindication for minimal access
surgery. This is due to the belief that in the presence of
distended bowel, which reduces visibility and increases the
risk of bowel injury, the conversion rates and morbidity
would be unacceptable. The feasibility and safety of laparoscopy for SBO has been assessed in several studies but

Surg Endosc (2012) 26:1217

outcomes vary considerably. Using the available published


literature, the aim of this review was to define important
outcomes such as feasibility, safety, risk of iatrogenic
bowel injury, and benefits to patients with acute SBO who
are approached laparoscopically.

Methods
A systematic literature search was undertaken using the
Medline database and the Cochrane Central Register of
Controlled Trials. To identify original peer-reviewed articles that studied outcomes of a laparoscopic approach to
acute SBO, the search terms laparoscopy or laparoscopic approach or minimally invasive surgery and
bowel obstruction were used. Studies on adult patients
published in English between 1990 and December 2010
were included. Studies reporting large-bowel obstruction or
small-bowel obstruction limited to hernia or bariatric surgery were excluded. Studies that included patients with
chronic recurrent or subacute obstruction or who underwent elective surgery were included only if data relevant to
acute cases could be retrieved. Case reports and case series
with 5 or fewer cases were excluded. A manual search of
the bibliographies of retrieved studies was also conducted.
If a patient group was reported twice, the most recent paper
was chosen.
Data retrieved included sample size, mean age, gender
distribution, body mass index, ASA grade, number of cases
completed laparoscopically, etiology of SBO, reasons for
conversion, time to surgery, length of surgery, in-hospital
mortality and morbidity, bowel injury (enterotomy) rate,
early and late SBO recurrences, and length of follow-up.
Additionally, in studies that compared laparoscopy to
laparotomy for acute SBO, data retrieved included time to
return of bowel function, length of stay, and cost.
Data reported in the selected studies varied considerably. Age, gender, BMI, ASA grade, time to surgery, and
operative time were excluded from analysis due to inconsistent reporting. Results for variables are reported as
percentages based on the number of cases that had relevant
data available.

Results
Twenty-nine studies published between 1994 and 2010
were retrieved (Table 1). A laparoscopic approach was
attempted in 2,005 patients with acute SBO. The studies
consisted of 20 single-center retrospective case series [18,
11, 12, 1619, 22, 2427, 29], 2 multicenter retrospective
studies [13, 28], 3 prospective series [9, 10, 20], 2 retrospective comparative studies [14, 23], and 2 retrospective

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controlled trials [15, 21]. Due to the absence of any randomized controlled trials and the heterogeneous nature of
the available literature, a formal meta-analysis was not
performed.
Postoperative adhesions accounted for the majority of
cases of SBO at 84.9% (1,648/1,940). The etiology included abdominal wall (inguinal, femoral, or incisional) hernia in 3.3% (65/1,940) and malignant tumors in 2.5% (49/
1,940). The breakdown of causes is given in Table 2.
Of the 2,005 patients, surgery was completed laparoscopically in 1,284 (64%). One hundred thirty-four (6.7%)
required a target incision and were considered as lapassisted. Seven of 2,005 (0.34%) were converted to conventional open herniorrhaphy. Five hundred eighty patients
were converted to conventional laparotomy (29%). The
laparoscopic completion rate was 57% (480/840) for
studies between 1994 and 2001 inclusive and increased to
68% (793/1,165) for studies published after 2001. The
reasons for conversion were identified for 301 patients
(Table 3). The most common reasons were the presence of
dense adhesions in 29%, ischemic bowel requiring resection in 24%, and an inability to identify the pathology in
9%.
In studies with sufficient data, single-band adhesions
were identified as the etiology in 46.6% (368/789). Where
explicitly stated, the rate of laparoscopic completion for
these patients was 73.8% (228/309) (Table 4).
Morbidity was 14.8% (283/1,906) and in-hospital mortality was 1.5% (29/1,951). Data for enterotomies was
available for 1,673 patients. The overall rate was 6.6%
(110/1,673) and 84% (92/110) were recognized intraoperatively. Some were repaired laparoscopically but most
were converted to laparotomy. The 16% (18/110) of the
enterotomies that went unrecognized at the original operation required a subsequent laparotomy. Early SBO
recurrence was defined as recurrence within 30 days of
surgery. It occurred in 2% (39/1,912). There were insufficient data to calculate a late recurrence rate.

Discussion
Small-bowel obstruction following abdominal or pelvic
surgery has a significant impact on acute surgical admissions and hospital cost [30]. Adhesions are the most frequent cause and account for 5% of readmissions in surgical
patients and up to 50% of these will require surgical
management [31]. The advantages for patients of minimally invasive surgery, including faster recovery and
reduced morbidity and pain, are well established in elective
surgery. Its safety is accepted in emergencies such as
appendicitis and perforated duodenal ulcer for which it has
become routine [32, 33]. Even in complex disease such as

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Surg Endosc (2012) 26:1217

Table 1 Studies of
laparoscopic management of
acute small-bowel obstruction

Author

Origin

Attempted
laparoscopically

Completed

Franklin (1994) [1]

USA

23

Ibrahim (1996) [2]

USA

33

18 (54.55%)

Bailey (1998) [3]

Australia

65

35 (53.8%)

20 (87%)

Navez (1998) [4]

Belgium

68

31 (45.6%)

El Dahha (1999) [5]

Egypt

14

12 (85.7%)

Strickland (1999) [6]

USA

40

27 (67.5%)

Rosin (2000) [7]

Israel

21

14 (66.6%)

Al-Mulhim (2000) [8]

Saudi Arabia

19

13 (68.4%)

134

77 (57.5%)

Chosidow (2000) [9]

France

Suter (2000) [10]

Switzerland

83

47 (56.6%)

Agresta (2000) [11]


Sato (2001) [12]

Italy
Japan

15
17

4 (26.6%)
14 (82.3%)

Levard (2001) [13]

France/Switzerland

308

168 (54.5%)

Chopra (2003) [14]

USA

34

23 (67.6%)

Wullstein (2003) [15]

Germany

52

25 (48.1%)

Suzuki (2003) [16]

Japan

21

17 (81%)

Borzellini (2003) [17]

Italy

40

30 (75%)

Liauw (2005) [18]

Singapore

6 (66.6%)

Kirshtein (2005) [19]

Israel

65

34 (52.3%)

Lujan (2006) [20]

USA

61

41 (67.2%)

Khaikin (2007) [21]

USA

31

17 (54.8%)

Zerey (2007) [22]

USA

42

35 (83.3%)

Mathieu (2008) [23]

Belgium

96

62 (64.6%)

Pearl (2008) [24]

USA

19

16 (84.2%)

Agresta (2008) [25]

Italy

17

16 (94.1%)

Lee (2009) [26]


Grafen (2009) [27]

Korea
Switzerland

19
90

16 (84.2%)
66 (73.3%)

Dindo (2009) [28]

Switzerland

537

363 (67.6%)

Tierris (2010) [29]

Greece

32

26 (81.3%)

Total

2005

Table 2 Etiology of small-bowel obstruction


Adhesions

1,284 (64%)

Table 3 Reasons for conversion to laparotomy


84.9% (1,648/1,940)

Conversion rate

Hernia

3.3% (65/1,940)

Dense adhesions

28.9% (87/301)

Malignancy

2.5% (49/1,940)

Resections for ischemia

23.9% (72/301)

Internal hernia

1.3% (26/1,940)

Inability to identify pathology

9.3% (28/301)

Bezoar

0.6% (12/1,940)

Iatrogenic injury

10.3% (31/301)

Meckels diverticulum

0.46% (9/1,940)

Inadequate field of view

7.6% (23/301)

Otherb

6.7% (131/1,940)

Malignancy

5.3% (16/301)
3% (9/301)
8.3% (25/301)

Inguinal, femoral, and incisional hernias

Hernia

Other includes Crohns disease and radiation strictures

Other

Crohns, laparoscopy provides improved short-term outcomes [34].


The first laparoscopic adhesiolysis for SBO was reported
in 1991 [35]. Despite the publication of some promising
case series and advances in technology and expertise since,

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29% (580/2,005)

a laparoscopic approach to patients with acute SBO


remains seldom used. No guidelines exist and there have
been no randomized trials. As recently as 2006, the European Association for Endoscopic Surgery stated, Laparoscopy is of unclear or limited value in adhesive SBO

Surg Endosc (2012) 26:1217

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Table 4 Laparoscopy for single-band adhesions


Author

% single-band

% single-band
completed
laparoscopically

Ibrahim (1996) [2]

33

69.7% (23)

78% (18/23)

Strickland (1999) [6]

40

30% (12)

75% (9/12)

42.4% (35)
54% (166)

68% (24/35)
65% (109/166)

Suter (2000) [10]


Levard (2001) [13]

83
308

Liauw (2005) [18]

66.6% (6)

83.3% (5/6)

Lujan (2006) [20]

61

41% (25)

84% (21/25)

Grafen (2009) [27]


Total

90

46.7% (42)

100% (42/42)

624

49.5% (309)

73.% (228/309)

[36]. A large study from the Nationwide Inpatient Sample


database in the US revealed only 11.4% of 6,165 randomly
selected operations for adhesive SBO (emergency or
elective) were attempted laparoscopically in 2002 [37].
The main reasons for the reluctance to adopt this approach
are the difficulty in identifying the site of obstruction laparoscopically and the risk of enterotomy, both due to the
presence of distended bowel.

small-bowel dilatation greater than 4 cm on preoperative


imaging predicted conversion, although Pearl et al. [24]
reported that this was not a contraindication. The influence
of the patients surgical history is controversial. An
appendectomy was the only previous operation associated
with a higher chance of a successful laparoscopy [4, 13].
The number of previous operations did not correlate with
risk of conversion [10, 17, 21, 23]. However, a documented
history of dense adhesions certainly is associated with a
higher risk of conversion [13, 23], and primary laparotomy
may still be the most appropriate choice for such patients as
well as those with a complex pathology, e.g., malignancy
or inflammatory bowel disease.
Laparoscopy is successful in 73.4% of patients with
acute SBO caused by single-band adhesions. This represents an important group in which laparoscopic adhesiolysis should be attempted. Computed tomography
evaluation on admission may help select these patients
preoperatively [26]. In an increasingly elderly surgical
population, performing a safe and relatively fast laparoscopic adhesiolysis over a laparotomy with its attendant
morbidity represents a true advance in surgery.
Safety

Feasibility
Most studies were retrospective and open to selection bias.
Some studies covered only adhesive SBO, while many
studies included other etiologies. Successful completion of
a minimally invasive approach was possible in 64%
(range = 2794%). A further 7% required a muscle-splitting incision or open hernia repair thereby avoiding midline
laparotomy in a total of 71%. It is reasonable to believe that
surgeons performing this surgery regularly could achieve
better results. First, in most of the studies, SBO cases were
encountered infrequently. The largest patient samples came
from multicenter reviews where several hospitals dealt
with fewer than 10 patients [13, 28]. In the six studies that
recorded all operative cases of SBO, laparoscopy accounted for only 1049% [1, 3, 4, 6, 22, 23]. Second, the results
have improved considerably since 2001, reflecting
increased expertise and volume. However, it should be
noted that all studies were conducted by surgeons experienced in elective laparoscopic surgery.
The main reasons for conversion to laparotomy in SBO
cases are dense adhesions, ischemic bowel, the inability to
identify the site of obstruction, and iatrogenic bowel injury.
A low threshold for conversion in these cases and where
malignancy is found seems sensible and patients should be
warned preoperatively. Indeed, conversion represents good
surgical judgment and not failure. There are few reliable
preoperative predictive factors to facilitate patient selection
and guide operative choice. Suter et al. [10] found that

The overall mortality and morbidity of laparoscopy for SBO


is 1.5% and 14.8%, respectively. These rates are lower than
those published for open surgery for SBO [38], but as many
studies did not record age or ASA grade, predictors of
mortality and morbidity were not determined. The mortality
rate compares with the rate of 1.7% in a nationwide sample
that included laparoscopic lysis of adhesions for both acute
and chronic bowel obstruction [37]. The early SBO recurrence rate of 2% is again lower than previously reported for
open surgery [39], although open studies included patients
with more complicated disease. Conversion was a significant risk factor for morbidity [6, 15, 19, 28]. Morbidity after
conversion can equal that after primary laparotomy [14, 21].
The reason for conversion may determine the morbidity. In
the largest study, early conversions, e.g., those due to poor
visibility or dense adhesions, have significantly less morbidity than reactive conversions, e.g., those due to iatrogenic bowel injury [28].
Enterotomy is the most feared complication of open or
laparoscopic adhesiolysis. The overall rate was 6.6% in the
studies discussed here. The enterotomies were mostly due
to dissection of dense or matted adhesions, but 12 cases
were due to trocar insertion. Unrecognized enterotomy,
while rare (1%), is an important complication as all cases
reported in this review required reoperation and thus
negated any benefit of an initial laparoscopic approach.
To avoid enterotomy, there should be minimal grasping
of dilated bowel and sparing use of cold electrocautery.

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Open trocar placement under direct vision should be considered routine. Prompt conversion when faced with difficult
adhesions or access may also reduce the risk of enterotomy.

Benefit
Four studies compared laparoscopy to laparotomy for acute
SBO. In two retrospective controlled clinical trials, laparoscopy was associated with significantly lower morbidity
(19 vs. 40% and 16 vs. 45%) and a shorter postoperative
hospital stay [15, 21]. The two unmatched comparative
reviews also showed a reduction in hospital stay and morbidity and a faster return to bowel function [14, 23]. Patients
in the laparotomy groups tended to be older. The benefit of
morbidity reduction was not maintained in patients who
were converted. Taken together, these studies indicate a
possible advantage of laparoscopy over laparotomy. However, they must be viewed in the context of retrospective
studies with their attendant bias and limitations.
Perhaps the most important clinical and economic aspect
of adhesive SBO is recurrence. After laparotomy for SBO
the cumulative recurrence rate is 57% at 1 year and 15%
at 5 years [40, 41]. Given that laparotomy itself is causative of adhesive obstruction and indeed the most important
risk factor in a patients history [42, 43], it may seem
counterintuitive for it to remain as the first line modality
for managing SBO. Animal models have demonstrated a
reduction in adhesion formation with laparoscopy [44, 45].
More importantly, in clinical studies early results from
laparoscopic colorectal surgery also indicate reduced
adhesion formation over open surgery and a reduction in
readmissions for SBO [46, 47]. Therefore, we might expect
that laparoscopy will reduce the risk of recurring obstruction. Unfortunately, few studies to date have reported longterm follow-up and it remains to be seen if the laparoscopic
approach to acute SBO is durable.

Conclusion
When performed by experienced surgeons, laparoscopy is a
feasible alternative to laparotomy for acute SBO, with
acceptable conversion rates and morbidity. It is particularly
effective in patients with relatively simple adhesions or a
single band. In the absence of randomized controlled trials,
which are unlikely to be undertaken, standardized reporting
of institutional experience and longer follow-up is essential
to assess the benefit of laparoscopy with respect to safety
and recurrent SBO.
Disclosure Donal B. OConnor and Desmond C. Winter have no
conflicts of interest or financial ties to disclose.

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