RÉSUMÉ
Postoperative adhesions are the most common cause of recurrent small bowel obstruction [SBO]. Laparotomy has classically been used in its treatment. The aim of this prospective study was to assess the feasibility, safety and clinical outcome of laparoscopic adhesiolysis in patients with recurrent 530 with the use of the ultrasonically activated shears. Between January 1998 and January 2001, elective laparoscopic adhesiolysis was attempted in 23 patients [13 men and 10 women, mean age 49.6 +/- 6.3 years, range 16-63 years] with post operative recurrent 530. All patients were subjected for complete clinical assessment, laboratory investigations, serial abdominal radiographs, abdominal ultrasound and CT. Patients in whom the bowel obstruction resolved within one day and who fulfilled the following criteria were treated laparoscopically: at least 2 prior episodes of small obstruction, confirmed improvement in physical signs of peritoneal inflammation, a decrease in white blood cell count to normal level and disappearance of air and fluid levels on plain abdominal radiographs . The technique of open laparoscopy was used for initial access to the peritoneum. The adhesions were lysed with the ultrasonically activated shears [Harmonic Scalpel]. Follow up evaluation was performed by clinical examination every 6 months for 3 years [range 1-4]. Laparoscopic adhesiolysis was successful in 18 patients [78.26%]. Conversion to laparotomy was required in 5 cases [21.74], because of intestinal peforation in one patient [4.5%], and convoluted masses in 4 patients [17.9%]. T here was no mortality and low morbidity in the form of serosal injuries in 4 patients [17.9%] and intestinal perforation in one patient [4.5%]. The mean time of operation, return of intestinal motility, and postoperative hospital stay were significantly shorter in the laparoscopically successful adhesiolysis group versus the group of patients who were converted to laparotomy. [[115 +/- 9.1 vs 130 +/- 6.7] P<0.001, [1.9 +/- 0.3 vs 3.8 +/- 1.2] P<0.01, [5.5 +/- 2.2 vs 8.3 +/- 3.4] P<0.001, respectively]. Recurrent SBO developed in 2 patients [12.5%] over a mean period of follow up [3 years]
Conclusion: Laparoscopic adhesiolysis is a feasible procedure for recurrent SBO with the use of the ultrasonically activated shears. It is safe [low morbidity and no mortality] and effective [low rate of recurrence of intestinal obstruction]. Conversion to laparotomy should be considered only in patients with intestinal perforation or convoluted masses