Laparoscopic Approach to Intestinal Obstruction

Dear Editor,

We have read with great interest the article by Poves et al.¹ about the use of laparoscopy in the treatment of intestinal obstruction due to adherences and internal hernias. We believe it would be useful to complement the information of the authors by reporting our experience.²

We should highlight the importance of adequate patient selection, because the success of this approach depends on it. Also, despite the fact that there are currently no randomized clinical trials, there are certain recommendations that should be considered, in addition to those described by the authors. The suspicion of a single band is the main indication for laparoscopic treatment (fundamentally in patients with embryonic adhesions or after appendectomy). However, it is also indicated in obstructions due to foreign bodies, bezoars or gallstone ileus. Contraindications include patient intolerance of anesthesia, suspicion of obstruction due to peritoneal carcinomatosis, distension of the small bowel of more than 4 cm on imaging tests and suspected dense adhesions. Likewise, the use of laparoscopy in patients with suspected ischemia or peritonitis is controversial and is considered a relative contraindication by certain groups.^3,4

As stated by the authors, the main argument against this procedure has been the increase in iatrogenic injuries that go unnoticed during adhesiolysis. Nonetheless, different groups^4,5 have recently published percentages that are similar to open surgery (3%–17%), which demonstrates the safety of this approach in the hands of expert surgeons. Dissections must be done delicately, while avoiding traction on the intestinal loops and restricting the use of electrocoagulation. It is essential to avoid the placement of trocars over previous incisions. Likewise, during pre-op it is necessary to define the cause of the obstruction. If this were not possible with laparoscopy, conversion to laparotomy is required.^3,5,6

Laparoscopy plays a fundamental role in these cases because it prevents future adhesions, which would cause intestinal obstructions to recur, resulting in additional socioeconomic costs. There have been no national reports on this factor here in Spain; in the United States; however, these costs have been estimated at some 1.3 billion dollars per year.⁶

In short, we agree with the authors about the positive results provided with laparoscopic treatment of intestinal obstruction. However, even when its use is justified, we must remember that laparotomy is still considered the treatment of choice in intestinal obstructions, and laparoscopy should be reserved for selected cases.