A Case Control Comparison of Laparoscopic (LX) and Open (OP) Approach for the Surgical Management of Small Bowel Obstruction (SBO)

Background: LX offers enhanced recovery and better cosmesis. Reduction in postoperative adhesions and incisional hernia rates are potential long term benefits. Previous studies have shown that laparoscopic management of SBO is feasible and associated with acceptable morbidity. However, rates of conversion to OP are higher than in other laparoscopic procedures. Data comparing short and long term results of LX and OP in SBO are limited.
Objectives: To identify risk factors for conversion, investigate its consequences, and compare short and long term outcomes of LX and OP.
Methods:
Patients who were operated for a diagnosis of SBO in either an attempted LX or OP were retrospectively identified. Data collected included patients demographics and comorbidities, indication for surgery, operative details, and postoperative recovery. Long term data including recurrent SBO, reoperations, and incisional hernias were obtained using patient charts and a telephone survey.LX and OPpatients were matched (1:1) for age and the extent of previous abdominal operations (no surgery; minor surgery; laparotomy; multiple laparotomies). Short and long term results in both groups were analyzed according to intension to treat. Results: From 1998 to 2007, 202 patients were operated for SBO (90 attempted LX, 112 OP). Most common etiologies for SBO in the LX group included adhesions (85.5%), malignancy (2.2%), and internal hernia (2.2%). 29 (32%) patients in the LX group were converted to an open procedure. Causes of conversion were dense adhesions (31%), need for bowel resection (17%), unidentified etiology (24%), and iatrogenic injury (28%).
Preoperative patient characteristics and the extent of previous surgery were not associated with conversion (previous laparotomy 27% vs. 18%, p=0.3, conversion vs. non-conversion, respectively).
Patients converted from laparoscopy to open surgery had longer operations (92.0±28.7 vs. 48.7±22.0 min, p<0.0001), higher postoperative complication rate (45% vs. 18%, p=0.015), and a tendency for longer postoperative stay compared with non-converted patients (8.8±11.8 vs. 5.1±8.6 days, respectively, p=0.09).
Matched LX (n= 71, age 59.3±20.7, male 39%) and OP (n= 71, age 60.9±20.4, male 34%) patients had similar comorbidity profile and comparable intraoperative findings. Operative time was similar in both groups (62 LX vs. 64 OP, min, p=0.76). LX patients had lower total rate of postoperative complications (32% vs. 51%, p=0.03), and earlier passage of flatus (median postoperative day 2 vs. 3, p<0.01) and stool (2 vs. 4, p<0.01). Postoperative hospital stay was comparable (6.1±8.6 vs. 6.8±2.7 days, p=0.55, LX vs. OP, respectively). 59 (83%) LX and 51 (72%) OP patients were available for long term follow up (median 51 months). During this time 3.4% (LX) and 17.6% (OP) were admitted for SBO (P=0.03). 1 (LX) and 3 (OP) patients required re-operation for SBO (NS). Incisional hernia rates were comparable.
Conclusions:
Successful laparoscopic management of SBO is possible in patients after major abdominal surgery. Laparoscopy may enhance postoperative intestinal recovery, and reduce perioperative morbidity and long term risk for recurrent SBO. Conversion to an open approach might be associated with increased morbidity but is difficult to predict. Further investigation is required for better selection of patients for laparoscopy.


Session: Podium Presentation

Program Number: S089

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