Effect of Roux-en-Y Gastric Bypass on Body Weight, Ghrelin and PYY(3-36) in Diet-induced Obese Rats

PURPOSE: Obesity is considered an epidemic worldwide. Nonsurgical treatment such as dietary, physical and pharmacological therapies have limited success and thus, bariatric surgery is the ultimate option. Roux-en-Y gastric bypass (RYGB) is a bariatric procedure, which is a restrictive and malabsorptive procedure simultaneously. The purpose of this study was to develop surgical rat models of bariatric surgery and analyze the effect of gastric bypass on body weight, ghrelin and polypeptide YY(3-36) (PYY(3-36)) changes in rats. METHODS: RYGB, sleeve gastrectomy (SG) and sham operation were performed in diet-induced obese rats and compared to obese control and normal control rats. RESULTS: In RYGB group, 20.7+/-8.56% of weight loss was achieved on postoperative day 18 and maintained thereafter. This outcome was significant compared to SG (8.8+/-1.82%) and sham operated (6.2+/-2.45%) groups. When pre- and postoperative ghrelin levels were compared, there was a significant decrease in RYGB group (P<0.028); nonetheless, there was no difference in SG and sham operated groups. When pre- and postoperative PYY(3-36) levels were compared, there was a significant increase in RYGB (P<0.028), SG (P<0.031) and sham operated (P<0.031) groups. CONCLUSION: We developed surgical rat models of RYGB and SG. Those rats that underwent RYGB lost significant body weight and maintained the weight thereafter. The decrease in ghrelin and increase in PYY(3-36) may be associated with loss of appetite and delay in intestinal transit time with subsequent weight loss maintenance. In the future, this rat model would serve as a tool for further study on endocrine regulation of obesity.

Band Slippage after Laparoscopic Adjustable Gastric Banding (LAGB)

Laparoscopic adjustable gastric banding (LAGB) has proved to be safe and effective, worldwide. The perigastric technique was once the most frequent method of band placement, but posterior prolapse was a problem. The introduction of the pars flaccida technique has considerably reduced the incidence of this complication, and, currently, this technique is the most utilized method and recommended by most bariatric surgeons. However, LAGB with pars flaccida technique has rare complications such as band slippage and gastric pouch dilatation in 2~5% of patients. We have experienced 2 band replacement cases for band slippage and pouch dilatation each happening about 1 and 2 years after LAGB.

Initial Experience with Bariatric Surgery in Korea: 120 Cases (LRYGB and LAGB) / 대한내시경복강경외과학회지

PURPOSE: Obesity has become a global epidemic disease, and bariatric surgery is now being increasingly performed in Korea as well as in western countries. Bariatric surgery has been performed in Korea since 2003. However, there is no data on cases of Korean bariatric surgery regarding the weight loss as well as the factors associated with the surgical outcome. METHODS: 120 total cases of bariatric surgery [LRYGB=48, LAGB=72] were done at St. Mary's Hospital. We retrospectively reviewed the series of bariatric cases and we analyzed the surgical outcome, the complications and the clinical factors associated with the surgical outcomes. RESULTS: There were no significant differences in age, BMI and pre-existing comorbidities for both procedures. The percentage of excess weight loss (%EWL) of the LRYGB at 6, 12 and 24 months was 63.8%, 73.7% and 87.5%, respectively, and the %EWL of the LAGB was 33.4%, 44.7% and 43.8%, respectively. Factors such age and gender were not associated with the surgical outcome. Yet the initial BMI tended to affect the surgical outcome. CONCLUSION: The results of our study indicate that LRYGB and LAGB are technically feasible and safe procedures. Both are quite satisfactory and promising procedures for loosing a significant amount of weight.

Laparoscopic Nissen Fundoplication in Korean Patients with Gastroesophageal Reflux Disease

PURPOSE: Although the prevalence of gastroesophageal reflux disease (GERD) is relatively low in Korean population, the number is increasing. The aim of this study is to analyze our experience with laparoscopic Nissen fundoplication. PATIENTS AND METHODS: From Sep. 2003 to Mar. 2008, 31 adult Korean patients diagnosed with GERD underwent laparoscopic Nissen fundoplication. A 360degrees fundoplication was carried out in all patients. RESULTS: There were 19 males and 12 females with an average age of 46.8 +/- 17.0 years. Typical symptoms were present in 15 (48%) of patients, and atypical symptoms in 16 (51.6%). Both typical and atypical symptoms were present in 4 of patients (12.9%). Preoperative studies showed hiatal hernias in 13 patients (41.9%), Barrett's esophagus in 10 (32.3%), and reflux esophagitis in 18 (58.1%). Mean DeMeester score was 17.4 +/- 16.7, mean operative time 206.1 +/- 47.8 min and mean hospital stay 5.2 +/- 2.1 days. Perioperative complications occurred in 5 patients (16.1%), including gastric perforation, subcutaneous emphysema, atelectasis, and prolonged ileus. Gastroesophageal junction stenoses with subsequent endoscopic balloon dilations were required in 5 patients (16.1%). After surgery, symptoms were completely controlled in 17 patients (54.8%), partially improved in 12 patients (38.7%) and not controlled in 2 patients (6.5%). CONCLUSION: In our series, 93.5% of patients had either complete or partial remission of symptom after laparoscopic Nissen fundoplication. Atypical symptoms were more predominant in our Korean patients. Laparoscopic Nissen fundoplication is an efficacious method of controlling symptoms of GERD, even for those who have atypical symptoms.

Laparoscopic Hiatal Hernia Repair during Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) / 대한내시경복강경외과학회지

Obesity is one of the most significant causes of GERD. Nissen fundoplication is a surgical procedure that's performed world widely for treating patients with GERD and a hiatal hernia and who are intractable to medical therapy. However, Nissen fundoplication may have technical difficulties in morbidly obese patients due to the huge perigastric, intraabdominal fat tissue and hepatomegaly. During the laparoscopic Roux-en-Y Gastric Bypass (LRYGB) procedure, the stomach was divided into the gastric pouch and the remnant stomach by vertiacally stapling at the angle of His. The posterior gastric wall and hiatus were easily exposed even when there was huge deposits of perigatric and intraabdominal fat tissue. We report here on a case of concomitant hiatal hernia repair with LRYGB in a morbidly obese patient.

Laparoscopic Surgery

Laparoscopic surgery describes the performance of surgical procedure with the assistance of a video camera and several other instruments. It is now being used in all surgical fields and especially operations for gastrointestinal diseases adopting a laparoscopic procedure in a relatively short period of time. Many benefits of minimally invasive surgery had been proved. With improvement in equipments, instrumentations, and surgical skills, it would be growing and be able to be approached for a more complex procedure. This paper briefly reviews the history, current status, and future of laparoscopic surgery.

Laparoscopic vs. Conventional Appendectomy in Pregnancy

PURPOSE: The purpose of this study was to evaluate the clinical course and pregnancy outcome according to operative management of appendictis in the Department of Surgery. METHODS: We reviewed the charts of pregnant patients who went through a convential appendectomy and a laparoscopic appendectomy at the Department of Surgery, Catholic University of Korea St. Mary's Hospital, from May 1995 to June 2006. RESULTS: The incidence of acute appendicitis during pregnancy was the highest at the 2nd trimester and at ages from 25 to 30 years. The laparoscopic appendectomy was shorter than the open appendectomy in hospital stay and decreased leukocytosis faster in the first postoperative day, except in cases of perforated appendicitis, but the operation times were similar. There was a significant difference in gestational age at delivery between perforated appendicitis and suppurative. We found one fetal anomaly, but it was not related to either the appendicitis or the operation method. CONCLUSIONS: In this study, we found that a laparoscopic appendectomy was better than an open appendectomy for recovery and was safe in pregnant appendicitis patients at any gestational age. However, follow up and investigation in a larger population is needed to get more accurate results.

Minimally Invasive Surgery for Gastroesophageal Reflux Disease / 대한소화기학회지

Gastroesophageal reflux disease (GERD) is a chronic disease deteriorating patient's quality of life. With the advent of proton pump inhibitors, treatment failures have decreased considerably. However, surgical therapy offers the potential for cure in more than 90% of patients with GERD. Specific indications for antireflux surgery are: incomplete response to medical therapy, frequent recurrences despite the medical treatment, laryngopharyngeal, and/or respiratory symptoms, and complications of GERD, such as esophageal stricture, erosive esophagitis, esophageal ulcer, and/or Barrett's esophagus. The introduction of laparoscopic surgery in early ninties had a profound impact on many surgical fields, including the treatment of GERD. In this review, laparoscopic Nissen fundoplication is described and controversial topics, such as total vs. partial fundoplication, and the natural history of Barrett's esophagus after antireflux surgery are addressed.

Diverticulitis of the Right Colon: Tips for Preoperative Diagnosis and Treatment Strategy

PURPOSE: The planned therapy of right colonic diverticulitis is very difficult because preoperative diagnosis is uncommon and the method of treatment is usually decided at the time of laparotomy. We retrospectively analyzed the clinical characteristics of right colonic diverticulitis, the clinical distinctions between preoperatively and postoperatively diagnosed patients, the recurrence rate, and the hospital stay by treatment modality. METHODS: Among 104 patients who were treated for right colonic diverticulitis from January 1997 to May 2005, we enrolled 90 patients who had been diagnosed by the operation or a barium enema study (BE), and who had not been lost to follow-up. Patients were divided into three groups based on treatment modality: Group 1 (n=28), conservative management with intravenous antibiotics; Group 2 (n=46), aggressive resection; Group 3 (n=16), appendectomy with intravenous antibiotics. RESULTS: Ultrasound and computed tomography (CT) detected 12 (22.6%) and 21 (87.5%) cases of right colonic diverticulitis, respectively. BE was applied to 45 patients, 28 (62.2%) of them with multiple diverticula. Right colonic diverticulitis was the preoperative diagnosis in 39 patients (43.3%). The length of hospital stay was significantly different between the groups (P<0.001): 4.9+/-3.1 days in Group 1, 7.5+/-3.7 days in Group 2, and 3.8+/-0.9 days in Group 3. Two patients (7.1%) in Group 1, 2 patients (4.3%) in Group 2, and 5 patients (31.3%) in Group 3 had recurrent diverticulitis during the follow-up period (P=0.007). The Kaplan-Meier estimated recurrence rates for Groups 1, 2, and 3 were statistically significantly different (P=0.0086). CONCLUSIONS: To differentiate right colonic diverticulitis from appendicitis, focusing on the peculiar feature in contrast to appendicitis and appropriate utilization of CT are important. If diagnosed preoperatively, uncomplicated right colonic diverticulitis can be managed by conservative management with intravenous antibiotics. If diagnosed intraoperatively, aggressive resection is advocated as the most effective method for decreasing the recurrence rate.

A Case of Hepatoid Carcinoma of the Pancreas / 대한소화기학회지

Hepatoid carcinoma is a primary extrahepatic neoplasm exhibiting features of hepatocellular carcinoma (HCC) in terms of morphology, immunohistochemistry, and behavior. In many cases, tumor cytoplasm is positive for alpha- fetoprotein (alpha-FP) with elevated serum alpha-FP level. Because not all hepatoid carcinomas are associated with alpha- FP overproduction, diagnosis should be made essentially by histological features of the tumor. We present a case of hepatoid carcinoma of the pancreas in a 21-year-old male patient. Abdominal computed tomography and magnetic resonance imaging revealed an inhomogeneously enhanced pancreatic head mass. Serum alpha-FP level was markedly elevated. He underwent pylorus-preserving Whipple's operation. The tumor showed hepatoid and neuroendocrine components simultaneously. The histopathological diagnosis was hepatoid carcinoma associated with neuroendocrine tumor of the pancreas. Seven months after the surgery, the patient is healthy without evidence of recurrence. To date, only 7 cases of hepatoid carcinoma of the pancreas have been reported in the literature, and this is the first case report in Korea.

Thrombophlebitis of the Inferior Mesenteric Vein

Isolated thrombophlebitis of the inferior mesenteric vein (IMV) is a rare condition, but delayed diagnosis causes severe problems and serious long-term complications. Therefore, the early diagnosis and adequate management of the underlying disease and thrombus is very important. Here, a case of a 64-year-old man with isolated IMV thrombosis on computed tomography (CT) and CT angiography due to inflammation of an abdominal organ and spell our disseminate intravascular coagulation (DIC) is reported. The patient's condition improved without complication after treatments with an anticoagulant regimen and antimicrobials. In the follow up, there was no thrombus on the CT angiograph and no sign of recurrent disease.

Expression of p14(ARF), p16(INK4a), p53, pRb in Gastric Cancer

PURPOSE: In this study, the level of expression of p14(ARF), p16(INK4a), p53 and pRb was immunohistochemically examined according to the stage of gastric cancer, lymph node metastasis, cell differentiation and Lauren's classification. The effect on survival rate and the associations between the components were examined as well. METHODS: One hundred and fourteen patients who underwent surgery for gastric cancer were studied retrospectively using their paraffin embedded tissue and medical records. Using antibodies of p14(ARF), p16(INK4a), p53 and pRb, immunohistochemical stain was applied and their level of expression examined. RESULTS: The level of p53 expression was high when the stage of gastric cancer was more progressed, the invasiveness higher, lymph node metastasis present and cell differentiation poorer. In contrast, the level of p14ARF expression tended to be lower as the stage was more progressed, but this was not statistically significant. Expression of p16 and pRb did not show any association with stage or other pathologic findings. Expression of p53 and p14(ARF) also had a significant association with survival rate. Survival rate was lower in patients who expressed p53 than in those who did not, but it was higher in who expressed p14ARF than in those who did not. When these two were combined, patients with p14(ARF)(+)/p53(-) had the highest survival rate, whereas those with p14(ARF)(-)/p53(+)had the lowest. This demonstrated that the expressions of p14ART and p53 have value as prognostic indicators. CONCLUSION: From these results, p53 seems closely related to stage and other pathologic findings. Furthermore, p14(ARF) and p53 showed a statistically significant relationship with survival rate, making them valuable as prognostic indicators after surgery. In combination, it would be possible to predict a more accurate prognosis.

The Adequacy of Laparoscopic Appendectomy for Simple and Perforated Appendicitis in Children

Appendectomy is the most common emergency surgical operation in children. The laparoscopic treatment of pediatric appendicitis is controversial, particularly in complicated cases. The purpose of this study is to evaluate laparoscopic appendectomy (LA) and open appendectomy (OA) for simple and perforated appendicitis (SA, PA) in children. A total of 188 patients, operated from January 1992 to September 2003, were reviewed. Ninety-one patients underwent OA (65 SA and 26 PA) and 97 had LA ( 67 SA, 30 PA). There was one conversion of LA to OA in PA. Operative time for LA was longer for OA in PA (55.8 vs. 45.7 min; p=0.0467). Recovery of bowel movement, diet starting time, length of hospital stay for LA were significantly shorter than those for OA. Postoperative complication rate was not different between LA and OA in each group. Laparoscopic appendectomy is a safe and effective method for both simple and perforated appendicitis.

Insulinoma of the Pancreas

PURPOSE: Insulinomas are a rare disease, which can be cured by surgical management if diagnosed early. However, diagnosis and localization are difficult, due to their small size and varied clinical manifestations. We analyzed the clinicopathological features, diagnosis and surgical management of insulinomas. METHODS: We retrospectively analyzed 12 insulinoma patients who had undergone pancreatic surgery, between 1988 and 2001, at the Department of Surgery, College of Medicine, The Catholic University of Korea. RESULTS: The male to female ratio of the insulinoma patients was 1: 1 with a mean age of 37.9 years, ranging from 20 to 65. The clinical manifestations were loss of consciousness, weakness, confusion and dizziness, and all the patients had findings compatible with Whipple's triad. The median duration of symptoms before surgery was 16.8 months, ranging from 1 to 48 months. Hyperinsulinemic hypoglycemia was confirmed, during prolonged fasting, when the concomitant fasting blood sugar level was 42.4mg/dl and insulin level was 25.2 microU/ml (8.1~61.8 microU/ml). The insulinoma can be localized in 11 patients (91.7%) preoperatively. For the preoperative localization, a transhepatic portal vein sample (THPVS), selective angiography and a CT scan were good diagnostic methods. Intraoperative ultrasonography was the most useful localization tool during the operation. For treating the insulinoma, an enucleation, a distal pancreatectomy, and a pylorus preserving pancreaticoduodenectomy were performed in 5, 6 and 1 patients, respectively. An enucleation case was diagnosed as nesidioblastosis after surgery, thus needing a near total pancreatectomy. One patient with a multiple endocrine neoplasia (MEN), subtype I, needed a thyroidectomy and an adrenalectomy. All cases were single, benign tumors within the pancreas. The symptoms of hypoglycemia and the laboratory values were normal in all patients after surgery. CONCLUSION: We experienced 12 insulinoma patients, where preoperative suspicions, proper utilization of diagnostic tools, and prudent intraoperative diagnostic procedures enhanced the diagnostic accuracy of the insulinoma, and led to better treatment strategies.

Clinical Analysis of the Patients with Choledochal Cyst: A Comparison between Children and Adults / 한국간담췌외과학회지

BACKGROUN/AIMS: We performed this study to review and compare the clinical characteristics of choledochal cyst between children and adults. METHODS: We reviewed medical records of patients with choldochal cyst who underwent surgical treatment between January 1984 and December 1996. We analyzed clinical symptoms, laboratory data and procedures. To compare clinical characteristics, patients under age 15 were grouped as children and the others were as adults. RESULTS: Sixty-eight patients, 21 children and 47 adults, underwent surgical treatment, Female predominance is common in both group. Abdominal pain was the most frequent symptom in both groups. Abdominal mass and jaundice were observed more frquently in children. Fever and chilling is more common in adults. The combined disease were more common in adults. Two adult patients had combined malignant diseases, cholangiocarcinoma and pancreas adenocarcinoma respectively. According to Todani's classsification, the most common type was type I in both group. The most common surgical procedure is cyst excision and hepaticojejunostomy in both groups. CONCLUSION: There was no significant difference in choledochal cysts between child and adults clinically. But combined diseases were common in adults, early detection and early surgry will be needed in this disease.

Expression of Matrix Metalloproteinase-2, Cathepsin D and E-cadherin in Human Gastric Adenocarcinomas

PURPOSE: The prognosis of gastric cancer depends on the depth of invasion, lymph-node metastasis, invasion to adjacent tissues, and distant metastasis. Recently, it is known that tumor-associated proteases and adhesion molecules have been shown to play a relevant role in the process of progression and metastasis. The purpose of our study was to demonstrate the value of MMP-2 (matrix metalloproteinase), cathepsin D and E-cadherin as prognostic factors. MATENRIALS AND METHODS: In this study, formalin-fixed, paraffin-embedded tissue blocks from 69 patients with gastric cancer were immunohistochemically studied using antibodies to MMP-2, cathepsin D, and E-cadherin, and their expressions were analyzed according to the pathologic stage, lymph-node metastasis, histological differentiation, and patient survival. The medical records of these patients were retrospectively reviewed. RESULTS: Increased expression of MMP-2 significantly correlated with advanced pathologic stage (P=0.026). Patients with lymph-node metastasis also had increased expression of MMP-2. Those patients with increased expression of MMP-2 showed a poorer survival; nevertheless, it was not statistically significant. Increased expression of cathepsin D significantly correlated with advanced pathologic stage (p= 0.029). However, no correlation was observed between advanced pathologic stage and either lymph-node status or histological differentiation. Patients with increased expression of cathepsin D had a poorer survival, but that result was not statistically significant. No association was found between reduced expression of E-cadherin and pathologic stage, lymph-node status, or histological differentiation. Also, no correlation was found between the expression of E- cadherin and survival. In addition, when a combination of MMP-2 and cathepsin D expressions was analyzed, if both were negative, the survival seems to be longer, but it was not statistically significant. CONCLUSION: In patients with gastric cancer, expressions of MMP-2 and cathepsin D correlated with tumor stage; therefore, they may be considered as prognostic factors.

A Clinical Analysis of 100 Cases of Gasless Endoscopic Thyroidectomy

PURPOSE: With recent developments in endoscopic surgery for thyroid tumors, several approaches have been applied to endoscopic neck surgery. Gasless endoscopic thyroidectomy has some advantages over gas insufflating surgery. We evaluated the role of gasless endoscopic thyroidectomies on various thyroid tumors including malignant thyroid tumors. METHODS: We performed thyroidectomies for a total of 195 patients who were admitted to Uijongbu St. Mary's Hospital from November 1999 to February 2002. We compared the clinical data of 100 patients who received gasless endoscopic thyroidectomies with the data of 95 patients who underwent conventional thyroidectomies. Furthermore, we subclassified the 100 patients who received a gasless endoscopic thyroidectomy into two groups, before and after the start of 2001. RESULTS: The analysis of the clinical data showed that an endoscopic thyroidectomy gave superior results with respect to the time of postoperative recovery and cosmetic results. Also, the patients in the second half group showed significantly shorter operation times reduced from 153.4 min. to 128.6 min. and length of hospital stay similarly reduced(3.55 days vs. 5.35 days). CONCLUSION: A gasless endoscopic thyroidectomy is a safe and technically feasible alternative to a conventional thyroi-dectomy in benign and early malignant tumors, and provides good cosmetic results.

Early Gastric Cancer Accompanied with a Giant Metastatic Abdominal Lymph Node

Lymph node metastasis is found in 10-15% of patients with early gastric cancer; however, metastatic nodes forming giant abdominal masses or distant metastases are extremely rare. A 51-year-old male, HBs Ag-positive patient presented with an incidentally found huge upper abdominal mass. Imaging studies showed a 7 cm-sized epigastric mass consistent with hepatocellular carcinoma. His serum -fetoprotein level was also significantly elevated (330.6 ng/ml). Endoscopic studies revealed a suspicious early gastric carcinoma located on the lesser curvature and the anterior wall of the antrum. He was operated on with a preoperative diagnosis of hepatocellular carcinoma coexisting with an early gastric carcinoma. However, the actual abdominal tumor was a metastatic lymph node resulting from a gastric carcinoma which was located around the hepatic artery. Accordingly, he underwent a subtotal gastrectomy with the D2 lymph node dissection and the removal of the metastatic node. Postoperatively, he did well without any complications. His serum -fetoprotein level decreased to 49.3 ng/ml one week after the surgery and was completely normalized 3 months later. To date, one year and 4 months after the operation, he is in good conditions without evidence of recurrence on endoscopic and imaging studies.

Laparoscopic Appendectomy is Feasible for All Forms of Appendicitis

PURPOSE: Acute gangrenous and perforated appendicitis are associated with an increased risk for intraoperative conversion, postoperative complications and have been considered a relative contraindication for laparoscopic appendectomy. The objective of this study was to analyze the feasibility of the laparoscopic approach in all forms of appendicitis. METHODS: A retrospective review of 101 patients who underwent laparoscopic appendectomy for uncomplicated and complicated appendicitis (perforated appendicitis and periappendiceal abscess) between June 2000 and May 2001 was performed. RESULTS: There were 84 patients with uncomplicated appendicitis (group A), 11 patients with perforated appendicitis (group B) and 16 patients with periappendiceal abscess (group C). The mean age of the patients was 42 (12~79) years and there were 47 men and 54 women. The mean operation time was 43, 67 and 105 minutes in groups A, B and C, respectively. Oral intake commenced at 1.4, 2.2 and 2.9 days and the hospital stay was 2.5, 2.9 and 5.2 days in groups A, B and C, respectively. There was no conversion to open surgery in groups A and B; however 4 patients in group C were converted. Complications were noted in 3 patients, one for each group. The overall complication rate was 2.9% and conversion rate, 0.9%. CONCLUSION: Although our experience is limited, the laparoscopic appendectomy seems to be a feasible and safe procedure for all forms of apppendicitis, including periappendiceal abscess.

Clinical Analysis of Laparoscopic Adhesiolysis

PURPOSE: Laparoscopic management of intestinal obstruction is hypothetically attractive, However little is known about this procedure in our country. With new advances in diagnostic and therapeutic tools such as laparoscopic procedures, the management of intestinal obstruction has become feasible. METHODS: In order to analyze the clinical results of laparoscopic adhesiolysis, a retrospective review of a consecutive series of 20 cases of intestinal obstruction unresponsive to medical management was done between 1997 and 2000. RESULTS: The mean surgical time for the laparoscopic procedure was 75 min and two cases were converted to open surgery due to dense adhesion and intestinal strangulation. The characterization of adhesion type included 10 cases with simple fibrotic band, 4 cases with multiple fibrotic band and 5 cases with dense adhesion. Additionally, the most common site for adhesion was the small intestine and colon (12 cases). The mean diet start time was 2.3 days, mean hospital stay was 4.7 days and totally mean analgesic use was 1.6 times. CONCLUSION: Laparoscopic management of adhesive bowel obstruction is feasible and safe in experienced hands. The laparoscopic procedure also is an excellent diagnostic modality in case of obstruction, and the majority of these cases can be simultaneously managed laparoscopically. A laparoscopic approach is recommend as a first choice of treatment for selective cases of intestinal adhesion.