Laparoscopic Spleen-Preserving Distal Pancreatectomy

Prevalence and Mechanisms of Small IntestinalObstructionFollowingLaparoscopicAbdominalSurgery

A Retrospective Multicenter Study

Jean-Jacques Duron, MD; Jean Marie Hay, MD; Simon Msika, MD; Denis Gaschard, MD; Jacques Domergue, MD;Alain Gainant, MD; Abe Fingerhut, MD, FACS, FRCS; for the French Association for Surgical Research

Hypothesis: The prevalence and mechanisms of intes-tinal obstruction following laparoscopic abdominal sur-gery have not been studied extensively.

Design: Retrospective review of cases of intestinal ob-struction after laparoscopic surgery.

Setting: Sixteen surgical units performing laparoscopyin France.

Patients: Twenty-four patients with intestinalobstruction.

Main Outcome Measures: Prevalence values and de-scriptive data.

Results: The 3 most frequent primary proceduresresponsible for intestinal obstruction were cholecystec-tomy (10 cases), transperitoneal hernia repair (5 cases),and appendectomy (4 cases). Prevalences of early post-operative intestinal obstruction after these procedureswere 0.11%, 2.5%, and 0.16%, respectively. Intestinalobstruction was due to adhesions or fibrotic bands in

12 cases and to intestinal incarceration in 11 cases.Obstruction was located at the trocar site in 13 cases (9incarcerations and 4 adhesions), mainly at the umbili-cus, and in the operative field in 10 cases (2 incarcera-tions in a wall defect after transperitoneal inguinal her-nia repair, 4 adhesions, and 4 fibrotic bands). The smallintestine was involved in 23 of 24 cases; the other wasdue to cecal volvulus following unrecognized intestinalmalrotation. Intestinal obstruction was treated by lapa-roscopic adhesiolysis in 6 patients and by laparotomy in18 patients, 6 of whom required small intestine resec-tion. Three postoperative complications but no deathsoccurred.

Conclusion: Intestinal obstruction following laparo-scopic abdominal surgery can occur irrespective of thetype of operation; the prevalence is as high as (chole-cystectomy and appendectomy) or even higher than(transperitoneal hernia repair) that seen in openprocedures.

Arch Surg. 2000;135:208-212

A BDOMINAL laparoscopicsurgery began in 1985,1

increased in usage,2,3 andbecame widespread bythe 1990s. Smaller inci-

sions, minute dissection, and experi-mental data4,5 have led one to expectthat laparoscopic abdominal surgerywould be associated with a low or non-existent intestinal obstruction rate.6,7

However, intestinal obstruction compli-cating diagnostic gynecological laparos-copy has been recognized and reportedas early as 1968.8 Short series of 1 to 4cases of small-bowel obstruction aftervarious kinds of laparoscopic abdominalsurgery9-11 have been reported since1992, but do not provide any hard dataon the mechanisms and prevalence ofpostlaparoscopic instestinal obstruction.

The goal of this study was to analyzedata on 24 patients operated on formechanical intestinal obstruction sec-ondary to laparoscopic abdominal sur-gery.

RESULTS

INITIAL SURGICAL PROCEDURES

Compared with 3 series of open sur-gery12-14 (Table 1), in our series there weremore obstructions observed after supra-colonic surgery mainly because there weremore cholecystectomies performed and nocases of gastric surgery were culled. Theinitial infracolonic operations were notsignificantly different except for inguinalhernia, which was more frequent in opensurgery.

ORIGINAL ARTICLE

From the Departments ofSurgery, Groupe HospitalierPitie-Salpetriere, Paris, France(Dr Duron); Hopital LouisMourier, Colombes, France(Drs Hay, Msika, andGaschard); Hopital Saint-Eloi,Montpellier, France(Dr Domergue); HopitalDupuytren, Limoges, France(Dr Gainant); and Hopital LeonTouhladjian, Poissy, France(Dr Fingerhut).For a list of the FrenchAssociation for SurgicalResearch participants in thisstudy, see page 211.

ARCH SURG/ VOL 135, FEB 2000 WWW.ARCHSURG.COM208

©2000 American Medical Association. All rights reserved.Downloaded From: http://archsurg.jamanetwork.com/ by a University of Arizona Health Sciences Library User on 12/06/2012

PREVALENCE

Compared with the open surgery series of Stewart et al,14

the prevalence of intestinal obstruction in our series wassignificantly higher in infracolonic procedures, espe-cially in transperitoneal hernia repair (Table 2).

MECHANISMS

As summarized in Table 3, 50% of obstructions weredue to adhesions (33%) or bands (17%) while 46% weredue to intestinal incarceration, accounting for 23 cases,all involving the small intestine. The last patient who ini-tially underwent laparoscopic cholecystectomy was re-operated on 72 hours later for cecal volvulus due to un-recognized intestinal malrotation.

LOCATION

Intestinal obstruction (excepting the case of cecal vol-vulus) occurred at the trocar site in 54% of cases and inthe operative field in 42% of cases (Table 3).

Trocar Sites

Ten (77%) of 13 cases involved 10-mm trocars while 3(23%) of 13 involved 12-mm trocars. Nine trocar portswere at the umbilicus. As regards the 4 lateral trocarsites (three 10-mm trocars and one 12-mm trocar) (allwith incarceration), 1 was in the left iliac fossa and 3were in the right iliac fossa. Of the 13 patients withtrocar site obstruction, 6 had undergone adequate fas-cia closure, 5 in the umbilicus and 1 lateral. Of the 9incarcerations at the trocar site, 3 were closed while 6were not. Slowly resorbable suture material was usedin all cases.

Operative Fields

All 4 obstructions due to bands and half of the adhe-sions originated from the operative field (Table 2). Only2 of 11 incarcerations originated in the operative fieldand these were due to a peritoneal defect following trans-peritoneal mesh inguinal hernia repair.

INTERVAL TO REOPERATION

The median interval to reoperation was significantlyshorter (P,.01) for incarceration (8 days) than for ad-hesions (25 days) or bands (22.5 days). All intestinal ob-

Table 1. Comparison of Causes of Obstruction(Gynecologic Procedures Excluded)*

No. (%) of Patients

PCurrent Series

(N = 24)Open Procedures

in the Literature12-14

Supracolonic 11 (46) 50 (19.8) ,.01Cholecystectomy 10 (42) 20 (8.4) ,.001Reflux disease 1 (4) NA (NA) NAGastric surgery 0 (0) 30 (11.8) ,.001

Infracolonic 11 (46) 140 (55.3) NSAppendectomy 4 (17) 74 (29.2) NSInguinal hernia 5 (21) 13 (5.1) ,.02Colectomy 2 (8) 38 (15.0) NSRectum 0 (0) 15 (5.9) NS

Mixed or not classified 2 (8) 63 (24.9) .10

*NA indicates not available; NS, not significant.

PATIENTS AND METHODS

PATIENTS

From March 1, 1990, to March 1, 1995, 24 patients(15 women and 9 men; mean ± SD age, 56 ± 19 years;age range, 24-82 years) were retrospectively selectedfrom 16 surgical units (8 university hospitals, 7 teach-ing hospitals, and 1 private hospital). The median num-ber of cases per surgical unit was 1 (range, 1-3). Alladult patients previously operated on laparoscopi-cally for gastrointestinal disease or transperitonealhernia repair and then reoperated on for mechanicalintestinal obstruction were eligible.

All patients who had had a previous lapa-rotomy at any time, those undergoing gynecologicallaparoscopic procedures, those who underwent a con-version to an open procedure or who had only a lapa-roscopically assisted procedure, those operated on forintestinal obstruction associated with intraperito-neal infection, and those who improved through non-operative management were not included.

METHODS

The prevalence was calculated only for the 22 pa-tients who underwent reoperations in the same in-stitution. The 2 other patients were initially oper-ated on in another center from which data necessaryto calculate the prevalence were not available. Ini-tial procedures12-14 and the prevalence14 of obstruc-tion in our series were compared with those from pa-tients who had open surgery (Table 1 and Table 2).

Other data collected through a preestablishedquestionnaire included (1) mechanism of obstruc-tion (adhesion, band, or incarceration); (2) locationof obstruction (at the operative field or at the trocarsite), location of the trocar (umbilical or lateral),15

size of the obstruction,9 and whether the fascia wasclosed or not11-15; (3) interval time between the ini-tial procedure and the reoperation; and (4) proce-dure used to deal with obstruction. As regards themechanism, incarceration was defined as trapping ofthe intestines in the abdominal wall; adhesions asunion of intestines to a surface (or conglutination);bands as fibrotic cordlike processes or anatomicalstructures that bind the intestines to other parts,whether encircling another structure or not; and in-cisional hernia as protrusion of intestines through atrocar incision. Early obstruction was defined as ob-struction occurring during the first 6 postoperativeweeks.14

Statistical comparisons for nonparametric vari-ables were made with the Mann-Whitney test. Thex2 test was used to compare proportions.



structions occurred less than 2 years after the initial pro-cedures (Table 3); 21 (88%) in the early postoperativecourse and 3 later (180, 420, and 650 days, respec-tively). All 3 late obstructions were due to adhesions orbands. The early postoperative course of the initial pro-cedure was uneventful in 14 cases, whereas 10 patientsunderwent reoperation within 8 days.

TREATMENT ANDPOSTOPERATIVE COURSE

Intestinal lysis was performed in 6 cases via laparoscopy(4 bands, 1 adhesion in the operative field, and 1 adhe-sion at the trocar site). In 17 patients lysis was per-formed through open laparotomy, including 6 small in-testine resections—4 for incarcerated loops (2 at theumbilical trocar site and 2 behind the mesh in a herniarepair) and 2 for adhesions at the trocar site. One pa-tient with cecal volvulus required open cecostomy.

The postoperative course was uneventful in 21 cases.Three patients had complications; 1 had a large muralintestinal hematoma following reoperation for intesti-nal incarceration at the umbilical trocar site after lapa-roscopic cholecystectomy, 1 had acute pancreatitis afterreoperation for adhesions at the umbilical site followinglaparoscopic cholecystectomy, and 1 had acute postop-erative duodenal ulcer bleeding following reoperation forintestinal incarceration behind the mesh in an inguinalhernia repair. None of these patients required anotheroperation and there were no deaths.

COMMENT

Laparoscopic surgery does not eliminate postoperativeobstruction, whether involving the operative field or theincision. The prevalence of obstruction after laparos-copy might even be greater (transperitoneal inguinal her-nia repair) or as high (cholecystectomy and appendec-tomy) as that seen with open operation. The number ofincarcerations was nearly the same as that of adhesionsor bands combined (Table 3). Most obstructions oc-curred at the umbilical trocar site, 10 mm or more, evenwhen the fascia was closed.

The initial procedures in laparoscopic surgery dif-fer from those in open series (Table 1), simply becausesome operations are performed less often laparoscopi-cally than traditionally. Examples are gastric and rectaloperations, which are often responsible for postopera-tive mechanical obstruction in open surgery but whichare presently not widely performed laparoscopically.

The relatively high prevalence of small-bowelobstruction in laparoscopic transperitoneal herniarepair (Table 2) is explained by the presence of thesmall intestines near the umbilical and lateral trocarsites, whereas the peritoneal insult in traditional herniarepair is minimal (compared with that necessary forinsertion of a transperitoneal mesh) and is likely mostoften covered by the nearby colon. For cholecystectomyor appendectomy, the lengths of the multiple port inci-sions are probably equivalent to one long incision andeach port incision in itself is a potential cause of

Table 2. Comparison of Prevalence of Early Mechanical Obstruction*

Laparoscopy Procedure in Current Series Open Procedures in Stewart et al14 Series

No. ofPatients

No. ofObstructions

Prevalence,%

No. ofPatients

No. ofObstructions

Prevalence,%

Cholecystectomy 6957 8 0.11 1810 1 0.06Reflux disease 529 1 0.18 NA NA NAAppendectomy 2295 4 0.16 1054 3 0.35Inguinal hernia 196 5 2.50 973 1 0.10†Colectomy 183 2 1.10 685 16 2.34Miscellaneous 589 2 0.33 3576 35 0.95Supracolonic 7593 10 0.13 2254 1 0.04Infracolonic 2734 12 0.43 4019 41 1.04‡Mixed or not classified 0 0 0 1824 14 0.76Total 10 327 22 0.21 8098 56 0.69

*Two patients were not included because the initial procedure was performed in another center. NA indicates not available.†P,.001.‡P,.01.

Table 3. Mechanisms of Intestinal Obstruction According toInitial Procedures, Location, and Interval to Reoperation*

Incarcerations Adhesions Bands Total

Supracolonic 5 5 1 11Cholecystectomy 4 5 0 9Others 1 0 1 2

LocationOperative field 0 1 1 2Trocar site 5 4 0 9

Infracolonic 6 3 3 12Appendectomies 0 2 2 4Hernia 4 1 0 5Others 2 0 1 3

LocationOperative field 2 3 3 8Trocar site 4 0 0 4

Median interval toreoperation, d

8 25 22.5 13

Range 3-45 10-650 10-420 3-650Early/late observations 11/0 6/2 3/1 20/3

*One patient had cecal volvulus due to malrotation and was operated on at72 hours.



obstruction. Because all patients undergoing the initialprocedures were not followed up prospectively, someof these patients could have been operated on formechanical intestinal obstruction in another institutionwithout the knowledge of the initial center. The preva-lence calculated herein was therefore a minimal value.The exact prevalence of intestinal obstruction afterlaparoscopic or open surgery is and will remain difficultto evaluate. Most diseases treated by laparoscopic sur-gery are common and generally benign conditions:long-term follow-up is therefore difficult to obtain.

The most frequently encountered mechanisms in ourseries were adhesions (33%) or bands (17%). Althoughthe pathophysiology of these 2 causes is similar,14 bandswere encountered in the operative field only whereas ad-hesions were seen both in the operative field as well as atthe trocar sites. Adhesions have been reported previouslyin only 2 cases after abdominal laparoscopic surgery.16 Thisapparent difference with the literature may be explainedby the fact that the exact mechanism of intestinal obstruc-tion was not always mentioned in the literature but wasrequested specifically in our questionnaire and the fact thatthe exact mechanism was not always reported back to thefirst surgeon when late obstruction occurred. The secondmechanism in our series was incarceration (46%) at thetrocar site or in a peritoneal defect in the operative fieldafter transperitoneal hernia repair. Incarcerations, on theother hand, are the most frequently reported mechanismin the literature,17-20 undoubtedly because obstruction dueto incarceration occurs early in the postoperative course.In our series, the median interval from the initial proce-dure to reoperation was significantly shorter (P,.01) whenobstruction was caused by incarceration (8 days) vs ad-hesions (25 days) (Table 3). In the literature9,10,15,17-20 in-carcerations occurred 1 to 9 days after operation, whereasthe 2 cases of adhesions16 occurred at 3 weeks and at 6months, respectively. Recommendations in the litera-ture21,22 to decrease the prevalence of postlaparoscopic in-carceration include: (1) opening the trocar valve to am-bient air before port removal, as a partial vacuum can becreated when the port is withdrawn, thus drawing omen-tum or intestines into the fascial defect; (2) shaking theabdominal wall, which may help free any temporary vis-ceral incarceration or adhesions; and (3) removing the tro-car under direct visual control while the pneumoperito-neum is maintained by the surgeon’s finger, temporarilysealing the trocar site.

In our series, as in the literature,9-11,15,18,20,23 the mostcommon location of intestinal obstruction was the tro-car site, but the lateral sites were involved less often com-pared with the umbilicus.15,20,21 There are at least 2 ex-planations for this. First, the lateral wall is composed of2 fascial planes and muscle, making it theoretically lessprone to dehiscence; second, the small intestine is lessoften in contact with the lateral trocar sites.

All trocars causing intestinal obstruction in our se-ries were 10 or 12 mm in diameter. Incarcerations, how-ever, can arise even in 5-mm holes when they are notclosed.11,16 Although it has been stated that fascia clo-sure of trocar holes, which is sometimes difficult,22,23 maypreclude or decrease the incidence of obstructions,10,11

our experience (6 cases) as well as that in the litera-

ture20,24 indicates that adhesions or incarcerations, whethermedian or lateral, can still occur after fascial closure. Onthe other hand, no cases of obstruction due to incisionalhernia at the trocar site (Richter hernia), as described pre-viously,24 were found in our series. This seems to occurmore often in the lateral sites.24

The second most frequent location of intestinal ob-struction encountered in our study was the operative field(Table 2). Although this has certainly already occurred,to the best of our knowledge, obstruction arising fromthe operative field has not yet been described after lapa-roscopy. Even though laparoscopy is reported to be lesstraumatic than open surgery,7 there is no reason to be-lieve that the obstruction rate will decrease in the opera-tive field. The prevalence of intestinal obstruction afterprocedures such as laparoscopic transperitoneal ingui-nal hernia repair could actually be higher, as the perito-neum is violated to a greater extent as compared with theopen techniques.25,26 Thus, the extraperitoneal route maybe preferable to the transperitoneal route. Moreover, therate of intestinal obstruction could even be higher thanreported here, as operations such as colectomy that usemore extensive dissection27-29 (2 cases in our series) andthe use of gauze swabs30 or other foreign bodies, whichare known to promote adhesions and fibrotic bands, areperformed more often laparoscopically.31

As after laparotomy,12,32 the small intestines were in-volved in the majority of obstructions complicating lapa-roscopic abdominal surgery (23 of 24). However, co-lonic herniation, as well as incarceration or herniationof the greater omentum through trocar ports,11 has beenreported after gynecologic laparoscopic procedures.24

In 1 of our patients, a cecal loop volvulated 72 hoursafter laparoscopic cholecystectomy. This complication hasalready been reported after laparoscopy,33 and may be dueto excessive slackness of the malrotated cecum after with-drawal of the pneumoperitoneum.34 As complete inspec-tion of the abdomen is thought to be less satisfactory un-der laparoscopy,35 the right colon was not seen to beabnormally mobile during the primary operation.

Postlaparoscopic obstruction was severe. Six resec-tions (26%) were necessary, 4 because of incarcerationsand 2 because of adhesions. This resection rate, how-ever, is comparable to that seen after open procedures(14%-20%).12-14

Techniques for avoiding contact between the intes-tines and the trocar sites include assessment of subxi-

Surgeons Participating in the Study

P. Baillet, MD, Eaubonne; F. Benhamida, MD, Sousse-Tunisie; P. Cubertafond, MD, A. Gainant, MD, B. Des-cottes, MD, D. Valleix, Limoges; J. Domergue, MD,B. Millat, MD, Montpellier; J.-J. Duron, MD, N. Elian, MD,H. Levard, MD, Paris; J. M. Hay, MD, Y. Flamant, MD,G. Zeitoun, MD, Colombes; Y. Laborde, MD, Pau; P. LePi-card, MD, Charenton; P. Marre, MD, Marly; J. Mares-caux, MD, S. Evrard, MD, Strasbourg; S. Msika, MD, Meu-lan; Y. Soulier, MD, Montmorency; B. Desrousseaux, MD,Lomme, France.



phoid microceliotomy36 for cholecystectomy, the extra-peritoneal approach16 for inguinal herniorrhaphy, andlaparoscopic surgery with low pressure37 or gaslesslaparoscopy.38

Corresponding author: Jean-Jacques Duron, MD, Service deChirugie Digestive, Groupe Hospitalier Pitie-Salpetriere, 83boulevard de l’Hopital, 75013 Paris, France.

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Laparoscopic Spleen-Preserving Distal Pancreatectomy