LAPAROSCOPIC ADHESIOLYSIS FOR RECURRENT SMALL BOWEL OBSTRUCTION WITH THE ULTRASONICALLY ACTIVATED SHEARS

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 SBO 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 SBO. 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 perforation in one patient (4.5%), and 
convoluted masses in 4 patients (17.9%). There 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.