Evaluation of Role of Laparoscopy in Treatment of Acute Adhesive Intestinal Obstruction

ABSTRACT


INTRODUCTION
Intra-abdominal adhesions are the most common cause of intestinal obstruction. Adhesions are formed early or late post-operative for about 75% of patient submitted to abdominopelvic operation [1] .
In the pathophysiology of adhesion, different cell types, cytokines and coagulation factors are included in restoring integrity of peritoneum. Inhibiting one of them is essential to prevent adhesion [2] .
Transperitoneal incisions, specially surgery in the lower abdomen and pelvis, damage large peritoneal area that lead to sub sequent adhesion [3] . The most common operations in which adhesion is formed include appendicectomy, cholecystectomy, caesarian section. The complications of adhesion are not limited to gastrointestinal tract but also include gynecological issues as secondary infertility chronic pelvic pain [4] .
The method of prevention of adhesion until now is not known, and there is no preventive measure exists either by surgery or drugs. In most cases and meta-analysis, laparoscopic adhesiolysis have more advantages in comparison to open surgery regarding operative time, morbidity and mortality [5] .
The aim of this study is to evaluate the accessibility of using laparoscopy as a safe tool in the management of adhesive intestinal obstruction in New Damietta, Al-Azhar University Hospitals.

PATIENTS AND METHODS
The study was done on 20 patients suffering from adhesive intestinal obstruction. This study was done in General Surgery Department, Damietta Faculty of Medicine, Al-Azhar University from December 2020 to June 2022.

Inclusion criteria
Age group above 20 years, patients with adhesive intestinal obstruction [approved clinically and by investigation].

Exclusion criteria
Query mechanical intestinal obstruction, malignant obstruction, marked abdominal distension, uncontrolled hepatic and cardiopulmonary problems, patients unfit for anesthesia or surgery and patient refusal.
All patients were submitted to the following: Complete history taking, preoperative anesthesia evaluation and post-operative followup. Outpatient clinical data, discharge summary, operative and laboratory data were reviewed, and followed up for a period of 6 months.

Operative procedure
The patient submitted for general anesthesia with insertion of nasogastric tube, Foley's catheter and sterilization of abdomen, then small incision about 1 cm away from the scar enter the abdomen under vision, insufflation of the abdomen was done [14 mmHg], another 2 ports were inserted according to site of adhesion, then adhesion was removed by scissor ligature and meticulous dissection to avoid intestinal perforation. In case of perforation, a trial of repair by laparoscopy if it can be done safely; otherwise, conversion to open surgery was done with repair of bowel and insertion of drain.

Postoperative
We start oral intake after the patient become open bowel, then the patient is discharged and the time of stay in hospital was recorded, together with post-operative complication if occurred. Follow up was done at one week, one month, three months and six months. For recurrent obstruction, also recording other complication as port site hernia if occurred.

DISCUSSION
Adhesive intestinal obstruction is a common disorder duo to intra-abdominal scar and has no definite time to predict its occurrence. The definite pathology is not understood up till now. It affects both males and females [6,7] . A study done by Szomstein et al. [8] noted that the intra-abdominal adhesion was found in about 95% of patient undergone previous laparotomy. Major causes of adhesion were complicated appendicectomy followed by open cholecystectomy, gastrointestinal tumors and gynecological pelvic operation.
In research done by Konstantin [9] , the mean operative time was 57.3 min, with the hospital stay varied from 4-10 days [average 6.3 days].
While in our study, the mean operative time was 73.42 ± 26.50, with the hospital stay [2.25 ± 5.56].
Ville et al. [10] noted that post-operative hospital stay in open surgery for adhesiolysis was on average 5.5 while in laparoscopic surgery 4.2 days with interpretation that the laparoscopic adhesiolysis has rapid recovery in selected patients with acute small bowel obstruction.
In our study, the patient who needed conversion was one patient [5%], with no mortality over a period of the study with no recurrence rate and this may be due to good selection of the cases.
In another study by Yoshiaki Sato et al. [12] , on 17 patients, the laparoscopy was feasible in 14 patients [82%], conversion to open in 17% due to iatrogenic perforation and recurrence rate was 12% [2 cases].
According to these data, we are able to say that; adhesive intestinal obstruction is safely done by laparoscopy and considered first choice for treatment; also, conversion to open is considered when high rate of success is needed.

Conclusion
Adhesive intestinal obstruction is safely done by laparoscopy and may be considered as the first choice for treatment; also, conversion to open is considered when needed.