Laparoscopic Lysis of Adhesions for Closed Loop Small Bowel Obstruction

CHAPTER 1

Hello, my name is Nicole Cherng. I'm a general surgeon at UMass Memorial Hospital in Worcester, Massachusetts. My specialty is minimally invasive surgery as well as bariatric surgery. Here I'm going to be presenting a case that came in while I was on call. This is a 49-year-old woman who presented with a progressive history, three day history, of abdominal pain, nausea, and vomiting. She presented to our emergency room and was seen by our surgical team as well as the emergency department. There she was found to be hemodynamically stable with a three day history of abdominal pain, nausea, and vomiting. She underwent basic blood work which was fairly unremarkable as well as the CT of the abdomen pelvis. Her surgical history is significant for an open appendectomy when she was younger as well as a previous diagnostic laparoscopy and lysis of adhesion for a prior small bowel obstruction. Her history is also notable for cervical cancer in which she underwent chemoradiation. The CT of the abdomen pelvis did show a dilated stomach as well as multiple loops of dilated small bowel. There is also free fluid within the abdomen. She was also found to have two transition points within the small bowel that was fairly concerning for a closed loop bowel obstruction. There's also some mesenteric edema, so given these findings, a nasogastric tube was placed for decompression. She had some relief from that and she had almost a liter that came out immediately. However, given the CT scan findings, I elected to take her for an emergent diagnostic laparoscopy. She was counseled that there is a possibility that she would have to undergo potentially a laparotomy if she was not able to tolerate general anesthesia or if we could not find the transition point as well as the potential of a bowel resection if there was evidence of any small bowel ischemia or necrosis. Particular things going into the surgery, we wanna make sure that we have a good gastric decompression with the nasogastric tube in order to have a safe induction of general anesthesia. This also allows us to move ahead with laparoscopy if we have more working room inside of the abdomen. Also, given that she may have a longer surgery, she also had a Foley catheter placed to monitor her I's and O's. Particular things for this surgery I would say that are important, are patient positioning. On the CT scan we saw that both transition points were in the right lower quadrant, so we made sure to tent the left arm as we suspected that that's where both surgeon and assistant would be standing. She would also need to be placed in Trendelenburg to identify the area. And then I think the other thing is to be flexible with your part placement. You can always add more ports and as you really wanna try to triangulate to the area of interest, but you don't always necessarily know. You can give your best guess based off the CAT scan, but I do think you need to be flexible when you're in the operating room.

CHAPTER 2

So here you see immediately that there are very dilated distended loops of small bowel. You also see that there's acidic serous fluid within the abdomen. Here we're being very gentle using laparoscopic bowel graspers, being sure to really try to grab the entirety of the small bowel, not taking like little bites because of how distended it is. The patient is now being positioned in Trendelenburg with the left side down with our focus to get to the right lower quadrant. A good starting point is often to find the ileocecal valve and then the ligament of Treves so that we can find distal small bowel and run that proximally. Even with positioning though, you can see dilated loops of small bowel that are kind of flopping in the way. And as we try to mobilize these off of the right lower quadrant into the upper abdomen, you can see that there's some tension. The tension that we feel is more based off of haptic feedback and so we know that as we're trying to pull it, it's not coming easily and it's not something that I or the resident to kind of push through. It usually tells us that there's something that's holding it back. So as we kind of trace the loop of bowel more visually we can see that there is a point of obstruction.

And so we know that there's obstruction. However, we really can't visualize it even with further positioning. So at this point, I elected to place an additional 5-mm trocar to help with retraction such that the active surgeon can then have two working hands, a left and the right hand to really find the point of obstruction. So here we place an additional 5-mm trocar within the upper abdomen under direct visualization.

CHAPTER 3

I set up the assist hand to really hold back this dilated loop of bowel. And now I can see that there's clearly a band that's tethering the loop of bowel that's causing a point of obstruction. It is compressing two loops of bowel, and this is consistent with the CT scan findings that we had two transition points. So this is a very classic traditional closed loop bowel obstruction. There are two transition points and we have dilated loops of bowel both proximal and also the loop of bowel between the two transition points, and decompressed distal loops of small bowel. So another note is that we can tell immediately that we don't have any evidence of bowel ischemia or a necrosis. The ascites that's within the abdomen is very serous and straw colored, very benign looking. There's no bilious or purulent or even feculent fluid.

CHAPTER 4

I elected to use an energy device. I could have used monopolar energy but I felt that just given the proximity to the small bowel, I was worried about a thermal spread or you know, iatrogenic injury. So I used here a laparoscopic Enseal. A Harmonic or a LigaSure would've been fine as well, but some sort of energy device to take down this band and also minimize thermal spread to the small bowel that's so proximal to it. So now that the adhesive band has been lysed, I can now mobilize the loops of small bowel. And here I find one loop that was being compressed by the band. I then can also easily identify the second loop that was being compressed by the band. They're now fairly free and much more easy for me to mobilize.

CHAPTER 5

So at this point in the case, with the point of obstruction identified and also resolved, there are two important things that I'm looking at. One is now running the entirety of the small bowel if possible. So here I can easily identify that this is clearly terminal ileum that's entering the cecum. And so now I'm trying to find the distal small bowel, and so I begin to run that proximally. The second thing is now to also look at the bowel viability. And so while on first inspection I didn't see anything obvious, it is important to look at the entirety of the small bowel to make sure that it is all completely viable as well as there's no other points of obstruction either. So here, the terminal ileum and the distal ileum do appear to be a bit tethered down to the right lower quadrant. This isn't surprising given the patient has had an open appendectomy. But none of it looks to be another area of obstruction. And as I continue to run the small bowel proximally, the loops become more mobile and free. And here you can tell that there's a loop that seems to be diving down and it does feel more difficult to bring up. And so you see there, that's where the band was. And this loop is a bit twisted upon itself, but with some retraction we are able to untwist it, and it does become free. So here as we run the small bowel more proximally, it becomes evident that there's another loop that's actually quite difficult for us to bring up. And it should be fairly free. So given how difficult it is, it raises concern that there's another band. And we do see one that is fairly deep. So once again, we use the additional hand to help with retraction or in order for us to find the additional band that needs to be released. So now with that band released, you can tell that that loop is much more mobile. And we can continue to run the small bowel distally to proximally. When the loops of bowel are this distended and fluid-filled, they are quite heavy and so it is critical to use both hands when trying to lift the bowel free. It is critical at this point to use two hands to really lift the small bowel. The weight of the small bowel can make it that it is more prone to iatrogenic injury or serosal tears. So, it's important to do full big bites with laparoscopic graspers and oftentimes acknowledge that it's the weight of the small bowel that's making it difficult and we have to work around that. And so you can see here these loops are quite fluid-filled as we move more proximally. But as we gently kind of brush other loops of small bowel off of it, we can easily visualize it, identify that there is no level of ischemia as well as no further obstruction points, and then continue to run the small bowel safely, proximally. As we continue to walk the small bowel distally to proximally, we also need to be aware of our positioning. As said earlier, we started the patient in Trendelenberg in order to visualize the right lower quadrant, and now as we walk the bowel proximally, we also now also need to move the patient into either supine or reverse Trendelenberg in order to adequately see the small bowel. Here we're going based off of, you know, visualization in order to see the small bowel and clearly see that there isn't any further areas of obstruction. We can also see that it's clearly viable. It's nice and pink, no level of ischemia or necrosis. Now within the patient's left side of the abdomen, we see the loop of very dilated small bowel, which is likely somewhere in the jejunum and it looks a little bit stuck there. And we suspect that it could just be, you know, benign adhesions from either prior surgeries or perhaps she had some other infectious process and then these adhesions were formed. It is important to delineate if these adhesions are causing obstruction or not, and also to determine just how aggressive to get in lysing them. Given that they're compressing the small bowel just slightly and we really can't visualize here in the left upper quadrant - they are fairly flimsy. So we use our energy device, our laparoscopic Enseal to lyse these omental adhesions off of the lateral abdominal wall. And now we can safely visualize and easily mobilize these dilated loops, and they're clearly proximal. And at this point, we've run the majority of the small bowel.

CHAPTER 6

We feel that three transition points were identified and all released by adhesive bands from the patient's prior surgeries. There's no level of ischemia or necrosis, and no bowel section needed to be performed. All the fluid within the abdomen was fairly acidic and straw-colored, so we did not leave a drain. We did leave the nasogastric tube in place for this patient just given the distension of the small bowels, and we felt that this would help continue to decompress her as she opened up clinically.

CHAPTER 7

I think for this surgery it actually went very well. We were able to stay laparoscopic as you can see. She was very fortunate that we had no signs of bowel ischemia or necrosis, so we could not only stay laparoscopic, but I think it shows that time from diagnosis to intervention is really vital for these patients. Once we were able to identify our transition point where we saw a clear adhesive band, in order to adequately visualize this, we did place an additional 5-mm port to have better retraction in order to really lyse this band without injuring the rest of the bowel. The other point to note is also how dilated the loops of the small bowel are. And so, that makes laparoscopy maybe slightly more difficult. But I think the key is just to be very careful with your instruments, being really mindful of where they are in the body as you're coming in and out of your ports. And when you're working the small bowel, not to have too much tension or pulling on it, as they are so fluid-filled and more fragile.