Introductory Chapter: Nuances of Surgical Technique for the Treatment of Adhesive Small Bowel Obstruction

*Dmitry Garbuzenko*

#### **1. Introduction**

Adhesive small bowel obstruction is one of the most formidable urgent surgical diseases of the abdominal organs [1]. Surgeons that encounter this disease are well aware of how insidious it is and how difficult it is to treat this pathology. Adhesive small bowel obstruction may often be successfully resolved conservatively. However, if conservative treatment is not effective within 72 h, and if there are signs of peritonitis, strangulation, or bowel ischemia, surgery is necessary [2]. Very often, a surgeon on call decides on the necessity of surgery. This surgeon might not have a lot of experience, but has to deal with the disease face-to-face. However, even experienced specialists may run into significant difficulties during such surgical interventions [3]. The only way to disengage from such a situation with honor is to strictly follow tactics and techniques developed by doctors involved in emergency abdominal surgery. In this chapter, I would like to share the nuances of performing surgery in patients with acute adhesive small bowel obstruction, based on more than 35-year experience of night shifts in an urgent surgical clinic.

#### **2. Surgical access**

Despite the achievements of laparoscopic surgery, in most cases of adhesive small bowel obstruction, surgery is performed via a wide incision of the anterior abdominal wall. The optimal surgical approach is midline laparotomy, which, if necessary, is extended up to the umbilicus or down to the pubic symphysis. If the patient has previously undergone midline laparotomy, it is expedient to start surgery with an incision upper or lower the scar. In any case, the scar, encapsulated non-absorbable sutures, and granulation tissue are excised, and the incision is treated with an antiseptic solution.

The parietal peritoneum in the area of the postoperative scar of the anterior abdominal wall always has gross adhesions with aponeurosis forming the *linea alba*. Moreover, as a rule, internal organs are fixed to the *linea alba* by adhesions. Therefore, the peritoneum should be lifted with tweezers and opened very carefully, since the dilated bowel loops may be easily damaged. It is better to keep the surgical site dry for a better view but achieve it without electrocauterization. When a small penetration into the abdominal cavity is achieved, the available area of the peritoneal cavity is carefully examined with a finger. Next, the abdominal wall is lifted with

a Farabeuf retractor or Maikulicz clamp applied to the aponeurosis edge, and the adhered organs are bluntly and sharply dissected; so, the aponeurosis and parietal peritoneum are prepared for the subsequent extension of the incision. When the abdominal cavity is opened, the dilated loops of the small bowel tend to slip out and should be kept with gauze pads moistened in an antiseptic solution. The gauze pads should be fixed, so as not to accidentally leave them in the peritoneal cavity.

#### **3. Examination of the abdominal cavity**

Sometimes the cause of intestinal obstruction is detected immediately, but more often an examination of the abdominal cavity is required. First of all, palpation should be performed. If it yields no result, the intestine should be moved to the left to try to isolate and examine the cecum. Obviously, the cecum is constricted in small bowel obstruction and dilated in large bowel obstruction. When the level of intestinal obstruction is determined, the next step is to search for an obstacle. To identify adhesions that obstructed the small bowel, it is necessary to examine it in the oral direction, starting from the cecum. The site of obstruction is where the constricted small bowel becomes dilated.

Such manipulations are possible only if the bowel is moderately dilated and adhesions are mild. Otherwise, a surgeon has to sort through the intestinal loops sequentially, which is difficult to do without preliminary nasointestinal intubation.

#### **4. Technique of adhesiolysis**

Adhesiolysis is started when the site of obstruction is found. The dissection of "loose" adhesions, which are more common in early adhesive bowel obstruction, is not technically difficult. Such adhesions can be destroyed with a finger, but undue force should not be exerted as it may lead to damage to the serous layer of the intestine. Otherwise, adhesions may be cut with scissors. In the latter case, scissors are used in a reverse manner. The tips of closed scissors are inserted between the adhered organs and then opened to separate them. This helps to find the "layer" between the bowel loops fixed to each other.

The greatest technical difficulties arise when the long portions of bowel loops are intimately fixed to each other and/or to the parietal peritoneum. The resulting single conglomerate is sometimes so dense that it is almost impossible to identify the borderline between the organs. In such cases, the safest way to separate the intestine is to excise it with the adjacent peritoneum.

To eliminate dense planar intestinal adhesions, space is created in the place of their least severity in the direction of the posterior abdominal wall. The index finger of the right hand is introduced into this space and the adhesions are separated along the posterior surface of the intestinal conglomerate by pendulum-like movements and without excessive force. As a rule, their density in this area is not so pronounced, so there is a chance to partially release the intestinal loops located there. After reaching some mobility, the bowel loops are rotated anteriorly, and the dissection of adhesions is completed. If it is not possible to separate the obstructioncausing conglomerate of the bowel loops, then, in the absence of signs of their non-viability, an intestinal anastomosis is performed. Otherwise, a pathologically altered portion of the small bowel is resected.

During adhesiolysis, a surgeon may inadvertently damage the wall of the intestine, especially the dilated proximal portion. In this case, superficial slit-like defects of the serous layer should not be sutured, since after emptying the intestines

**3**

*Introductory Chapter: Nuances of Surgical Technique for the Treatment of Adhesive Small Bowel…*

their edges, as a rule, are converged by themselves. If not only the serous but also the muscle layer is damaged, seromuscular sutures should be applied with absorbable suture material on an atraumatic needle 4/0 or 5/0. If the intestinal lumen is accidentally opened, the perforated area is immediately plugged to prevent the release of contents. Strict adherence to the rules of aseptic technique is extremely important since the microflora located in the proximal dilated loop is always highly virulent. Therefore, in the case of abdominal contamination, there is a high risk of infectious postoperative complications. Before suturing, the damaged portion of the bowel should be separated from the surrounding adhesions and isolated from the abdominal cavity with gauze pads. Then, intestinal clamps are applied above and below the wound and the gauze pads are removed, the remnants of the intestinal contents are aspirated, and the site of perforation and adjacent tissues are treated with an antiseptic solution. The wound is sutured in the transverse direction with a double-row interrupted suture by using an absorbable suture material on an

After eliminating the obstruction, it is necessary to assess the viability of the portion of the small bowel involved in the pathological process. Absolute signs of its necrosis are a change in color to dark purple or black, absence of tone, peristalsis, pulsation of the mesenteric vessels and arteries of the intestinal wall, and specific

In doubtful cases, the altered bowel loop is immersed in the abdominal cavity and after 15–20 min its viability is checked. During this time, a surgeon may perform hemostasis, nasointestinal intubation, and aspirate intestinal contents. A more aggressive way is to warm a doubtful area with gauze pads moistened with hot saline. If these measures are not effective, the bowel is recognized as non-viable, which

Resection of the necrotic small intestine should be performed within healthy tissues to be sure that circulatory disturbances at the point of a cut are minimal. Considering more pronounced microcirculatory changes in the proximal loop, the cut should be 30–40 cm above and 15–20 cm below the site of visible necrosis. From a practical point of view, it should be noted that, due to the significant extensibility of the small bowel, it is impossible to determine the indicated length. Therefore, it is necessary to visually assess the condition of the mucous layer of the remaining bowel loops (color, bleeding, etc.). After resection, a side to side bowel anastomosis is the most appropriate. A two-row interrupted suture is applied with absorbable

The main indications for nasointestinal intubation in acute adhesive bowel obstruction are the dilation of the small bowel lumen for more than 5 cm and the need for its resection. An anesthetist in the operating room usually helps in installing the nasointestinal tube through the nose into the stomach. After this, the surgeon fixes the pylorus with the left hand and moves the tube tip through the stomach into the duodenal bulb with the right hand. Next, the tube is advanced through the duodenum by pushing its portion in the stomach. If the anatomy of the duodenum is normal, this maneuver may be done quite simply and quickly. However, if the duodenum is significantly deformed, the tube tip is slowly moved

*DOI: http://dx.doi.org/10.5772/intechopen.93216*

atraumatic needle 4/0–5/0.

serves as an indication for its resection.

**5. Resection of the gangrenous small bowel**

suture material on an atraumatic needle 4/0 or 5/0.

**6. Nasointestinal intubation**

putrefactive odor.

#### *Introductory Chapter: Nuances of Surgical Technique for the Treatment of Adhesive Small Bowel… DOI: http://dx.doi.org/10.5772/intechopen.93216*

their edges, as a rule, are converged by themselves. If not only the serous but also the muscle layer is damaged, seromuscular sutures should be applied with absorbable suture material on an atraumatic needle 4/0 or 5/0. If the intestinal lumen is accidentally opened, the perforated area is immediately plugged to prevent the release of contents. Strict adherence to the rules of aseptic technique is extremely important since the microflora located in the proximal dilated loop is always highly virulent. Therefore, in the case of abdominal contamination, there is a high risk of infectious postoperative complications. Before suturing, the damaged portion of the bowel should be separated from the surrounding adhesions and isolated from the abdominal cavity with gauze pads. Then, intestinal clamps are applied above and below the wound and the gauze pads are removed, the remnants of the intestinal contents are aspirated, and the site of perforation and adjacent tissues are treated with an antiseptic solution. The wound is sutured in the transverse direction with a double-row interrupted suture by using an absorbable suture material on an atraumatic needle 4/0–5/0.

After eliminating the obstruction, it is necessary to assess the viability of the portion of the small bowel involved in the pathological process. Absolute signs of its necrosis are a change in color to dark purple or black, absence of tone, peristalsis, pulsation of the mesenteric vessels and arteries of the intestinal wall, and specific putrefactive odor.

In doubtful cases, the altered bowel loop is immersed in the abdominal cavity and after 15–20 min its viability is checked. During this time, a surgeon may perform hemostasis, nasointestinal intubation, and aspirate intestinal contents. A more aggressive way is to warm a doubtful area with gauze pads moistened with hot saline. If these measures are not effective, the bowel is recognized as non-viable, which serves as an indication for its resection.

#### **5. Resection of the gangrenous small bowel**

Resection of the necrotic small intestine should be performed within healthy tissues to be sure that circulatory disturbances at the point of a cut are minimal. Considering more pronounced microcirculatory changes in the proximal loop, the cut should be 30–40 cm above and 15–20 cm below the site of visible necrosis. From a practical point of view, it should be noted that, due to the significant extensibility of the small bowel, it is impossible to determine the indicated length. Therefore, it is necessary to visually assess the condition of the mucous layer of the remaining bowel loops (color, bleeding, etc.). After resection, a side to side bowel anastomosis is the most appropriate. A two-row interrupted suture is applied with absorbable suture material on an atraumatic needle 4/0 or 5/0.

#### **6. Nasointestinal intubation**

The main indications for nasointestinal intubation in acute adhesive bowel obstruction are the dilation of the small bowel lumen for more than 5 cm and the need for its resection. An anesthetist in the operating room usually helps in installing the nasointestinal tube through the nose into the stomach. After this, the surgeon fixes the pylorus with the left hand and moves the tube tip through the stomach into the duodenal bulb with the right hand. Next, the tube is advanced through the duodenum by pushing its portion in the stomach. If the anatomy of the duodenum is normal, this maneuver may be done quite simply and quickly. However, if the duodenum is significantly deformed, the tube tip is slowly moved

*Intestinal Obstructions*

a Farabeuf retractor or Maikulicz clamp applied to the aponeurosis edge, and the adhered organs are bluntly and sharply dissected; so, the aponeurosis and parietal peritoneum are prepared for the subsequent extension of the incision. When the abdominal cavity is opened, the dilated loops of the small bowel tend to slip out and should be kept with gauze pads moistened in an antiseptic solution. The gauze pads

Sometimes the cause of intestinal obstruction is detected immediately, but more

often an examination of the abdominal cavity is required. First of all, palpation should be performed. If it yields no result, the intestine should be moved to the left to try to isolate and examine the cecum. Obviously, the cecum is constricted in small bowel obstruction and dilated in large bowel obstruction. When the level of intestinal obstruction is determined, the next step is to search for an obstacle. To identify adhesions that obstructed the small bowel, it is necessary to examine it in the oral direction, starting from the cecum. The site of obstruction is where the

Such manipulations are possible only if the bowel is moderately dilated and adhesions are mild. Otherwise, a surgeon has to sort through the intestinal loops sequentially, which is difficult to do without preliminary nasointestinal intubation.

Adhesiolysis is started when the site of obstruction is found. The dissection of "loose" adhesions, which are more common in early adhesive bowel obstruction, is not technically difficult. Such adhesions can be destroyed with a finger, but undue force should not be exerted as it may lead to damage to the serous layer of the intestine. Otherwise, adhesions may be cut with scissors. In the latter case, scissors are used in a reverse manner. The tips of closed scissors are inserted between the adhered organs and then opened to separate them. This helps to find the "layer"

The greatest technical difficulties arise when the long portions of bowel loops are intimately fixed to each other and/or to the parietal peritoneum. The resulting single conglomerate is sometimes so dense that it is almost impossible to identify the borderline between the organs. In such cases, the safest way to separate the intestine

To eliminate dense planar intestinal adhesions, space is created in the place of their least severity in the direction of the posterior abdominal wall. The index finger of the right hand is introduced into this space and the adhesions are separated along the posterior surface of the intestinal conglomerate by pendulum-like movements and without excessive force. As a rule, their density in this area is not so pronounced, so there is a chance to partially release the intestinal loops located there. After reaching some mobility, the bowel loops are rotated anteriorly, and the dissection of adhesions is completed. If it is not possible to separate the obstructioncausing conglomerate of the bowel loops, then, in the absence of signs of their non-viability, an intestinal anastomosis is performed. Otherwise, a pathologically

During adhesiolysis, a surgeon may inadvertently damage the wall of the intestine, especially the dilated proximal portion. In this case, superficial slit-like defects of the serous layer should not be sutured, since after emptying the intestines

should be fixed, so as not to accidentally leave them in the peritoneal cavity.

**3. Examination of the abdominal cavity**

constricted small bowel becomes dilated.

between the bowel loops fixed to each other.

is to excise it with the adjacent peritoneum.

altered portion of the small bowel is resected.

**4. Technique of adhesiolysis**

**2**

from the bulb into the vertical part of the duodenum. Then, the tube is advanced to the lower horizontal part of the duodenum with the right hand placed under the mesentery of the transverse colon. As a rule, from there the tube is easily moved beyond the Treitz ligament into the jejunum. This may not work out due to the deformation of the duodenojejunal transition, which should be eliminated. Forced tube advancement is unacceptable due to the danger of intestinal wall perforation.

When the nasointestinal tube tip passed the Treitz ligament, the tube is advanced through the small intestine, which is the easiest step of intubation. The operating surgeon moves the tube through the proximal part of the bowel, while the assistant straightens the bowel loops and directs the tube tip towards the ileocecal transition. At this step, it is necessary to avoid the formation of excessive tube loops in the stomach, which occur in the absence of synchronous actions of the surgeon and the anesthetist advancing the tube into the stomach. The tube tip should not be inserted into the cecum. The destruction of the ileocecal flap may cause colonic contents reflux and colonization of the small intestine by fecal microflora.

If the small intestine was resected, the tube tip is installed 30–50 cm distal to the intestinal anastomosis.

Intestinal aspiration is performed after intubation is completed. Next, it is necessary to verify the correct location of the nasointestinal tube, since the presence of loops, flexures, and deformations makes decompression ineffective. It is very important to determine the location of the last lateral perforation of the tube, which should be in the middle part of the stomach. Its displacement into the esophagus is strictly unacceptable, because it may lead to aspiration of the gastric contents into the respiratory tract in the postoperative period. A less dangerous mistake is to leave the last lateral perforation in the duodenum. In this case, patients may experience vomiting, as the cavity of the stomach is undrained. The tube may be marked with a narrow strip of adhesive tape near the last lateral perforation to facilitate its search.

At the end of the surgery, a surgeon should check hemostasis and remove the fluid from the abdominal cavity. The drainage tube is installed through a contraperture and placed in the pelvic cavity. The anterior abdominal wall layers are sutured with absorbable suture material.

I do not doubt that each experienced surgeon may offer personal original techniques that he or she uses during surgery for acute adhesive small bowel obstruction. Nevertheless, I would like to hope that the small nuances of the surgical technique described in this modest essay may help to avoid big problems during such surgical interventions.

#### **Author details**

#### Dmitry Garbuzenko

Department of Faculty Surgery, South Ural State Medical University, Chelyabinsk, Russia

\*Address all correspondence to<EMAIL_ADDRESS>
© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

**5**

*Introductory Chapter: Nuances of Surgical Technique for the Treatment of Adhesive Small Bowel…*

*DOI: http://dx.doi.org/10.5772/intechopen.93216*

[1] Garbuzenko DV. Selected Lectures in Emergency Abdominal Surgery. Saarbrücken, Germany: LAP LAMBERT Academic Publishing GmbH & Co.;

[2] Ten Broek RPG, Krielen P, Di Saverio S, et al. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World Journal of Emergency Surgery.

[3] Stich R, Makkas M. Fehler und Gefahren bei Chirurgischen

Deutsch: Verlag: G. Fischer; 1923

Operationen. Mit 146 zum Teil Farbigen Abbildungen im Text und 2 Tafeln. Jena,

**References**

2012

2018;**13**:24

*Introductory Chapter: Nuances of Surgical Technique for the Treatment of Adhesive Small Bowel… DOI: http://dx.doi.org/10.5772/intechopen.93216*

#### **References**

*Intestinal Obstructions*

intestinal anastomosis.

**4**

**Author details**

interventions.

Russia

Dmitry Garbuzenko

with absorbable suture material.

\*Address all correspondence to<EMAIL_ADDRESS>
provided the original work is properly cited.

Department of Faculty Surgery, South Ural State Medical University, Chelyabinsk,

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

I do not doubt that each experienced surgeon may offer personal original techniques that he or she uses during surgery for acute adhesive small bowel obstruction. Nevertheless, I would like to hope that the small nuances of the surgical technique described in this modest essay may help to avoid big problems during such surgical

from the bulb into the vertical part of the duodenum. Then, the tube is advanced to the lower horizontal part of the duodenum with the right hand placed under the mesentery of the transverse colon. As a rule, from there the tube is easily moved beyond the Treitz ligament into the jejunum. This may not work out due to the deformation of the duodenojejunal transition, which should be eliminated. Forced tube advancement is unacceptable due to the danger of intestinal wall perforation. When the nasointestinal tube tip passed the Treitz ligament, the tube is advanced through the small intestine, which is the easiest step of intubation. The operating surgeon moves the tube through the proximal part of the bowel, while the assistant straightens the bowel loops and directs the tube tip towards the ileocecal transition. At this step, it is necessary to avoid the formation of excessive tube loops in the stomach, which occur in the absence of synchronous actions of the surgeon and the anesthetist advancing the tube into the stomach. The tube tip should not be inserted into the cecum. The destruction of the ileocecal flap may cause colonic

contents reflux and colonization of the small intestine by fecal microflora.

If the small intestine was resected, the tube tip is installed 30–50 cm distal to the

Intestinal aspiration is performed after intubation is completed. Next, it is necessary to verify the correct location of the nasointestinal tube, since the presence of loops, flexures, and deformations makes decompression ineffective. It is very important to determine the location of the last lateral perforation of the tube, which should be in the middle part of the stomach. Its displacement into the esophagus is strictly unacceptable, because it may lead to aspiration of the gastric contents into the respiratory tract in the postoperative period. A less dangerous mistake is to leave the last lateral perforation in the duodenum. In this case, patients may experience vomiting, as the cavity of the stomach is undrained. The tube may be marked with a narrow strip of adhesive tape near the last lateral perforation to facilitate its search. At the end of the surgery, a surgeon should check hemostasis and remove the fluid from the abdominal cavity. The drainage tube is installed through a contraperture and placed in the pelvic cavity. The anterior abdominal wall layers are sutured

[1] Garbuzenko DV. Selected Lectures in Emergency Abdominal Surgery. Saarbrücken, Germany: LAP LAMBERT Academic Publishing GmbH & Co.; 2012

[2] Ten Broek RPG, Krielen P, Di Saverio S, et al. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World Journal of Emergency Surgery. 2018;**13**:24

[3] Stich R, Makkas M. Fehler und Gefahren bei Chirurgischen Operationen. Mit 146 zum Teil Farbigen Abbildungen im Text und 2 Tafeln. Jena, Deutsch: Verlag: G. Fischer; 1923

**7**

**Chapter 2**

**Abstract**

minimally invasive era.

**1. Introduction**

Index (PAI) (**Figure 1**) [4, 5].

Adhesive Small Bowel Obstruction

Roughly 60% of all cases of small bowel obstruction are caused by adhesions. Adhesions are a form of internal scar tissue, which develop in over 45–93% of patients who undergo abdominal surgery. With this relatively high incidence, the population at risk for adhesive small bowel obstruction (ASBO) is enormous. Minimally invasive surgery reduces surgical wound surface and thus holds promise to reduce adhesion formation. The use of minimally invasive techniques results in a 50% reduction of adhesion formation as compared to open surgery. However, since ASBO can be caused by just a single adhesive band, it is uncertain whether a reduction in adhesion formation will also lead to a proportional decrease in the incidence of ASBO. Minimally invasive surgery might also improve operative treatment of ASBO, accelerating gastro-intestinal recovery time and lowering the risk of recurrent ASBO associated with adhesion reformation. We will discuss recent evidence on the impact of minimally invasive surgery on the incidence of ASBO and the role of minimally invasive surgery to resolve ASBO. Finally, we will debate additional measures, such as the use of adhesion barriers, to prevent adhesion formation and adhesion-related morbidity in the

**Keywords:** adhesions, adhesive small bowel obstruction, minimally invasive surgery,

As many as 60% of all episodes of small bowel obstruction (SBO) are caused by adhesions [1]. Adhesions are attachments of abdominal structures by internal scar tissue that are the result of healing of the peritoneum after it has been damaged, in most cases by surgery [2]. Adhesions can be filmy or dense and be present as an isolated band or as a 'curtain' or tangle with difficulty recognizing visceral structures. The degree of density and vascularization is traditionally classified using the Zühlke classification (**Table 1**) [3]. A more comprehensive and clinically relevant classification including projected locations of adhesions is the Peritoneal Adhesion

Adhesions develop in 89–93% of patients undergoing open abdominal or pelvic surgery [6, 7]. Incidence rates of adhesion formation are lower after minimally invasive surgery, 45–62% [7, 8]. Adhesions can also develop after other causes of peritoneal trauma, such as inflammatory conditions or radiotherapy [2].

laparoscopy, adhesion barrier, adhesion reduction strategies

in the Minimally Invasive Era

*Pepijn Krielen, Martijn W. J. Stommel,*

*Richard P. G. ten Broek and Harry van Goor*

#### **Chapter 2**

## Adhesive Small Bowel Obstruction in the Minimally Invasive Era

*Pepijn Krielen, Martijn W. J. Stommel, Richard P. G. ten Broek and Harry van Goor*

#### **Abstract**

Roughly 60% of all cases of small bowel obstruction are caused by adhesions. Adhesions are a form of internal scar tissue, which develop in over 45–93% of patients who undergo abdominal surgery. With this relatively high incidence, the population at risk for adhesive small bowel obstruction (ASBO) is enormous. Minimally invasive surgery reduces surgical wound surface and thus holds promise to reduce adhesion formation. The use of minimally invasive techniques results in a 50% reduction of adhesion formation as compared to open surgery. However, since ASBO can be caused by just a single adhesive band, it is uncertain whether a reduction in adhesion formation will also lead to a proportional decrease in the incidence of ASBO. Minimally invasive surgery might also improve operative treatment of ASBO, accelerating gastro-intestinal recovery time and lowering the risk of recurrent ASBO associated with adhesion reformation. We will discuss recent evidence on the impact of minimally invasive surgery on the incidence of ASBO and the role of minimally invasive surgery to resolve ASBO. Finally, we will debate additional measures, such as the use of adhesion barriers, to prevent adhesion formation and adhesion-related morbidity in the minimally invasive era.

**Keywords:** adhesions, adhesive small bowel obstruction, minimally invasive surgery, laparoscopy, adhesion barrier, adhesion reduction strategies

#### **1. Introduction**

As many as 60% of all episodes of small bowel obstruction (SBO) are caused by adhesions [1]. Adhesions are attachments of abdominal structures by internal scar tissue that are the result of healing of the peritoneum after it has been damaged, in most cases by surgery [2]. Adhesions can be filmy or dense and be present as an isolated band or as a 'curtain' or tangle with difficulty recognizing visceral structures. The degree of density and vascularization is traditionally classified using the Zühlke classification (**Table 1**) [3]. A more comprehensive and clinically relevant classification including projected locations of adhesions is the Peritoneal Adhesion Index (PAI) (**Figure 1**) [4, 5].

Adhesions develop in 89–93% of patients undergoing open abdominal or pelvic surgery [6, 7]. Incidence rates of adhesion formation are lower after minimally invasive surgery, 45–62% [7, 8]. Adhesions can also develop after other causes of peritoneal trauma, such as inflammatory conditions or radiotherapy [2].

**Table 1.** *Zühlke classification.*

**9**

*Adhesive Small Bowel Obstruction in the Minimally Invasive Era*

The occurrence of adhesions does not only cause a lifelong risk of adhesive small bowel obstruction (ASBO). Other clinical consequences of adhesions are difficulties during reoperation, female infertility, and chronic visceral pain; making it the most common cause of long-term complications in peritoneal surgery [1]. The incidence of ASBO is 2–3% in the first years after surgery in all patients who undergo abdominal or pelvic surgery [1]. The risk of ASBO depends on the anatomical location of surgery and the extent of surgery and peritoneal injury [1–10]. ASBO risk varies from 0.5% in abdominal wall surgery, 1.2% after upper gastrointestinal tract surgery to 3.2% in lower gastro-intestinal tract surgery and

Given the high incidence of adhesions and adhesion-related complications, one would assume that every surgeon is aware of the risks of adhesions. However, awareness on the full size of the problem only arose in response to the publication of the Surgical and Clinical Adhesion Research (SCAR) study two decades ago. The SCAR large population based study demonstrated that one of three patients undergoing abdominal surgery is readmitted for a cause possibly related to adhesions [11]. Subsequently adhesion-related complications gained increasing awareness of clinicians, hospitals and vendors, and adhesion reduction strategies were introduced. Laparoscopic surgeons hypothesized that minimally invasive surgical techniques would reduce peritoneal injury and thereby could solve the problem of adhesion formation. Other strategies to reduce adhesion formation were the development of adhesion barriers, the banishment of powdered gloves, and the introduction of new

Over the past decades, minimally invasive surgery has become the standard approach in many surgical disciplines. The rapid introduction of minimally invasive surgery was largely fueled by short-term benefits such as quicker recovery, reduced pain, and better cosmetic outcome [13]. Furthermore, surgeons strongly believed in the effectiveness of minimally invasive surgical techniques to reduce adhesion formation and subsequent morbidity [14]. For this reasons adhesion barriers are only seldomly used in minimally invasive surgery [15], and are believed to be needed only in open surgery. Despite good evidence of effective reduction of adhesion formation and subsequent adhesion-related morbidity, the use of adhesion barriers in open surgery is also limited [16]. Reasons for not using adhesion barriers are the lack of trust in adhesion reduction, the expected limited impact on adhesion-related complications, and the costs of the barriers [15]. The limited use of adhesion barriers has slowed down the research and development of adhesion-prevention strate-

Studies on adhesion formation in minimally invasive surgery report a reduction

of approximately 50% in the extent of postoperative adhesions compared with open surgery [7]. Unfortunately, trials comparing open and minimally invasive surgery have not been designed and powered to compare long-term adhesionrelated outcomes [17]. Therefore, the effect of the broad implementation of minimally invasive surgery on clinically relevant outcome parameters such as ASBO and readmissions is unknown [17]. A reduction in adhesion formation, does not necessarily correlate with a proportionate reduction in the risk of ASBO; a single adhesive band may cause a life-threatening bowel obstruction, whereas extensive dense abdominal adhesions may be asymptomatic [18]. Nevertheless, potential benefits of minimally invasive surgery in preventing adhesion-related morbidity

Minimally invasive surgery may also play a role in the treatment of ASBO. Approximately 25% of patients with ASBO require surgery to resolve the bowel obstruction [1], and recurrence rates are high [19]. The minimally invasive

*DOI: http://dx.doi.org/10.5772/intechopen.91896*

4.2% in pediatric surgery [1].

sealing devices [12].

gies in the past decade.

seem compelling.

**Figure 1.** *Peritoneal adhesion index.*

*Adapted from Ref. [3].*

*Zühlke classification.*

**Table 1.**

**Grade Description**

0 No adhesions or insignificant adhesions

dissection is necessary

I Adhesions that are filmy and easy to separate by blunt dissection

II Adhesions with beginning vascularization that can be dissected blunt but some sharp

III Adhesions with clear vascularization that can only be dissected using sharp dissection IV Adhesions which strongly attached organs, dissection is only possible by sharp dissection, damage of organs is hardly preventable

**8**

**Figure 1.**

*Peritoneal adhesion index.*

The occurrence of adhesions does not only cause a lifelong risk of adhesive small bowel obstruction (ASBO). Other clinical consequences of adhesions are difficulties during reoperation, female infertility, and chronic visceral pain; making it the most common cause of long-term complications in peritoneal surgery [1]. The incidence of ASBO is 2–3% in the first years after surgery in all patients who undergo abdominal or pelvic surgery [1]. The risk of ASBO depends on the anatomical location of surgery and the extent of surgery and peritoneal injury [1–10]. ASBO risk varies from 0.5% in abdominal wall surgery, 1.2% after upper gastrointestinal tract surgery to 3.2% in lower gastro-intestinal tract surgery and 4.2% in pediatric surgery [1].

Given the high incidence of adhesions and adhesion-related complications, one would assume that every surgeon is aware of the risks of adhesions. However, awareness on the full size of the problem only arose in response to the publication of the Surgical and Clinical Adhesion Research (SCAR) study two decades ago. The SCAR large population based study demonstrated that one of three patients undergoing abdominal surgery is readmitted for a cause possibly related to adhesions [11]. Subsequently adhesion-related complications gained increasing awareness of clinicians, hospitals and vendors, and adhesion reduction strategies were introduced. Laparoscopic surgeons hypothesized that minimally invasive surgical techniques would reduce peritoneal injury and thereby could solve the problem of adhesion formation. Other strategies to reduce adhesion formation were the development of adhesion barriers, the banishment of powdered gloves, and the introduction of new sealing devices [12].

Over the past decades, minimally invasive surgery has become the standard approach in many surgical disciplines. The rapid introduction of minimally invasive surgery was largely fueled by short-term benefits such as quicker recovery, reduced pain, and better cosmetic outcome [13]. Furthermore, surgeons strongly believed in the effectiveness of minimally invasive surgical techniques to reduce adhesion formation and subsequent morbidity [14]. For this reasons adhesion barriers are only seldomly used in minimally invasive surgery [15], and are believed to be needed only in open surgery. Despite good evidence of effective reduction of adhesion formation and subsequent adhesion-related morbidity, the use of adhesion barriers in open surgery is also limited [16]. Reasons for not using adhesion barriers are the lack of trust in adhesion reduction, the expected limited impact on adhesion-related complications, and the costs of the barriers [15]. The limited use of adhesion barriers has slowed down the research and development of adhesion-prevention strategies in the past decade.

Studies on adhesion formation in minimally invasive surgery report a reduction of approximately 50% in the extent of postoperative adhesions compared with open surgery [7]. Unfortunately, trials comparing open and minimally invasive surgery have not been designed and powered to compare long-term adhesionrelated outcomes [17]. Therefore, the effect of the broad implementation of minimally invasive surgery on clinically relevant outcome parameters such as ASBO and readmissions is unknown [17]. A reduction in adhesion formation, does not necessarily correlate with a proportionate reduction in the risk of ASBO; a single adhesive band may cause a life-threatening bowel obstruction, whereas extensive dense abdominal adhesions may be asymptomatic [18]. Nevertheless, potential benefits of minimally invasive surgery in preventing adhesion-related morbidity seem compelling.

Minimally invasive surgery may also play a role in the treatment of ASBO. Approximately 25% of patients with ASBO require surgery to resolve the bowel obstruction [1], and recurrence rates are high [19]. The minimally invasive

approach is hypothesized to accelerate recovery, and might also reduce risk of regrowth of adhesions and subsequent recurrence of ASBO. A caveat is the small working space and vulnerability of the bowel caused by the distention of the obstructed bowel that could result in iatrogenic injuries. In this chapter, we discuss recent evidence on the effects of the introduction of minimally invasive surgery on the burden of adhesions and ASBO. We further discuss the role of minimally invasive surgery in the treatment of patients with ASBO. We end with a contemplation on the awareness of adhesion-related complications and the value of adhesion barriers in minimally invasive surgery.

#### **2. The problem of adhesive small bowel obstruction**

The vast majority of adhesions develop after abdominal or pelvic surgery, although adhesions can also form after abdominal and pelvic radiation and peritoneal inflammation [2]. Adhesions are associated with a lifelong risk of ASBO. Incidence and morbidity of ASBO might be somewhat difficult to estimate and compare between studies based on different definitions for ASBO. Most accepted definition of ASBO is an episode of SBO with the presence of adhesions confirmed during reoperation. However, operative confirmation of adhesions is often not possible because many ASBO episodes are managed non-operatively. Therefore a second definition of ASBO is commonly applied: an episode of SBO interpreted as matching ASBO on radiological imaging after excluding other potential causes of bowel obstruction e.g. hernia, tumor, bezoar.

In a systematic review, the incidence of SBO by any cause after surgery is estimated 9% [1]. In 42 etiological studies on SBO, adhesions accounted for 56% of all SBO episodes, either by operative confirmation or by excluding all other potential causes of SBO [1]. The incidence of postoperative ASBO confirmed by surgery is estimated at 2.4%. Depending on the type of initial surgical procedure, the incidence varied between 0.5 and 4.2% [1]. As mentioned, this estimate is conservative because most episodes of ASBO are managed non-operative.

Another way to estimate the burden of ASBO is based on population studies. In the SCAR study more than one in three patients were readmitted for a cause possibly related to adhesions, and more than 1 in 20 patients (6%) who underwent open abdominal or pelvic surgery were readmitted for a directly adhesion-related cause [11]. The most common diagnosis for a directly adhesionrelated readmission was ASBO [11]. More recent population studies in the UK and USA show that ASBO remains a major contributor to the morbidity, mortality and costs related to emergency abdominal surgery. In the UK in 2016, 51% of all emergency laparotomies were for ASBO [20]. Similar results were found in the USA between 2008 and 2011, where SBO needing adhesiolysis belonged to the top 5 of emergency surgical procedures [21]. Given these numbers and the number of patients undergoing abdominal or pelvic surgery, the impact of ASBO on a population level is high.

ASBO causes significant morbidity and a hospital admission for SBO is associated with 2.5% mortality [1]. Initial non-operative management of ASBO includes gastric decompression, fluid resuscitation and nil per os, which is successful in 70–90% [1–23]. In a sizable number of cases ASBO will result in emergency or delayed, after failed initial conservative management, abdominal surgery. Open or minimally invasive adhesiolysis to resolve the obstruction is associated with a incidence of 6–20% enterotomies [24, 25]. In general, complex adhesiolysis is associated with bleeding, sepsis, wound infections and increased mortality,

**11**

*Adhesive Small Bowel Obstruction in the Minimally Invasive Era*

of complications associated with surgical intervention [28].

term clinical efficacy e.g. ASBO could benefit from using CLAS.

The economic burden of ASBO is high. Operative management is the single most important determinant of costs. However, based on fewer recurrences of ASBO after surgical treatment, surgery may save costs at the long term [34]. Several studies have been reported regarding the treatment costs of

ASBO. Most have important limitations reporting part of the costs or costs based on reimbursement prices rather than true healthcare costs [35–37]. We modeled in a recent study, costs for ASBO in the Netherlands using a micro-costing method including costs of length of stay, ICU days, operative time, medication, parenteral feeding, imaging studies and laboratory studies [38]. This modeling revealed total healthcare costs of patients operated for ASBO of €16305 (SD €2513) with a mean hospital stay of 16.0 ± 11 days. For non-operatively treated patients costs would be €2277 (SD €265) with a mean hospital stay of 4.0 ± 2.0 days. The majority of the costs were due to ward stay, operative time, ICU stay and (parental) feeding. All surgical procedures for ASBO in this study consisted of open adhesiolysis. Costs estimated in this study were higher compared to previous estimates of treatment costs for ASBO with comparable lengths of stay and, as a result of its design better reflecting reality [35–37]. In the study we adhered to international guidelines for the diagnosis and treatment of ASBO increasing generalizability of outcomes for developed countries.

even in the absence of bowel injury [26]. Mean length of hospital stay for ASBO ranges from 4 to 13 days and generally depends the type of treatment and the

Effort is made to predict the severity of ASBO using peri-operative scores

[29, 30]. However, the scores are not widely adopted for clinical use. The American Association for the Surgery of Trauma (AAST) developed a score based on clinical, imaging, operative and pathologic criteria to grade disease severity of ASBO [31, 32]. The AAST grade uses clinical criteria (flatus, bowel sounds abdominal distention), pathologic criteria (bowel perforation), imaging criteria on CT (intestinal distention, transition point, contrast flow) and operative criteria (intestinal distention, impeding bowel compromise, peritonitis) to define the grade of ASBO on a scale from 1 to 4. A higher AAST score for emergency ASBO is associated with an increase in length of hospital stay, pneumonia, and more severe complications [33]. Recently the Clinical Adhesion Score (CLAS) was developed, measuring the full spectrum of the long-term burden of adhesion formation in post-operative patients. CLAS calculates the overall morbidity based on four domains: ASBO, difficulties during reoperation, female infertility or subfertility, and chronic abdominal pain (data not yet published). Evaluation of current and new adhesion prevention strategies regarding long-

Both operative and conservative management of ASBO are associated with a risk of recurrent ASBO. Operative management includes repeated peritoneal injury with risk of adhesion reformation and re-ASBO. Non-operative management of ASBO does not dissolve abdominal adhesions and harbors the risk of a new episode of ASBO. In a recent study of patients presenting with a first episode of ASBO, operative management was associated with a lower risk of recurrence compared with non-operative management (13% vs. 21%) after a median follow-up of 3.6 years [19]. The study also showed an increased risk of ASBO with every previous episode of ASBO in accordance to findings done 25 years ago [27]. Also the time between episodes of ASBO decreases with an increase in number of episodes [19]. Despite the higher recurrence rate after conservative treatment, current guidelines still recommend a trial of non-operative management of ASBO in order to avoid the risk

*DOI: http://dx.doi.org/10.5772/intechopen.91896*

treatment complications [1].

barriers in minimally invasive surgery.

**2. The problem of adhesive small bowel obstruction**

tial causes of bowel obstruction e.g. hernia, tumor, bezoar.

because most episodes of ASBO are managed non-operative.

approach is hypothesized to accelerate recovery, and might also reduce risk of regrowth of adhesions and subsequent recurrence of ASBO. A caveat is the small working space and vulnerability of the bowel caused by the distention of the obstructed bowel that could result in iatrogenic injuries. In this chapter, we discuss recent evidence on the effects of the introduction of minimally invasive surgery on the burden of adhesions and ASBO. We further discuss the role of minimally invasive surgery in the treatment of patients with ASBO. We end with a contemplation on the awareness of adhesion-related complications and the value of adhesion

The vast majority of adhesions develop after abdominal or pelvic surgery, although adhesions can also form after abdominal and pelvic radiation and peritoneal inflammation [2]. Adhesions are associated with a lifelong risk of ASBO. Incidence and morbidity of ASBO might be somewhat difficult to estimate and compare between studies based on different definitions for ASBO. Most accepted definition of ASBO is an episode of SBO with the presence of adhesions confirmed during reoperation. However, operative confirmation of adhesions is often not possible because many ASBO episodes are managed non-operatively. Therefore a second definition of ASBO is commonly applied: an episode of SBO interpreted as matching ASBO on radiological imaging after excluding other poten-

In a systematic review, the incidence of SBO by any cause after surgery is estimated 9% [1]. In 42 etiological studies on SBO, adhesions accounted for 56% of all SBO episodes, either by operative confirmation or by excluding all other potential causes of SBO [1]. The incidence of postoperative ASBO confirmed by surgery is estimated at 2.4%. Depending on the type of initial surgical procedure, the incidence varied between 0.5 and 4.2% [1]. As mentioned, this estimate is conservative

Another way to estimate the burden of ASBO is based on population studies. In the SCAR study more than one in three patients were readmitted for a cause possibly related to adhesions, and more than 1 in 20 patients (6%) who underwent open abdominal or pelvic surgery were readmitted for a directly adhesion-related cause [11]. The most common diagnosis for a directly adhesionrelated readmission was ASBO [11]. More recent population studies in the UK and USA show that ASBO remains a major contributor to the morbidity, mortality and costs related to emergency abdominal surgery. In the UK in 2016, 51% of all emergency laparotomies were for ASBO [20]. Similar results were found in the USA between 2008 and 2011, where SBO needing adhesiolysis belonged to the top 5 of emergency surgical procedures [21]. Given these numbers and the number of patients undergoing abdominal or pelvic surgery, the impact of ASBO

ASBO causes significant morbidity and a hospital admission for SBO is associated with 2.5% mortality [1]. Initial non-operative management of ASBO includes gastric decompression, fluid resuscitation and nil per os, which is successful in 70–90% [1–23]. In a sizable number of cases ASBO will result in emergency or delayed, after failed initial conservative management, abdominal surgery. Open or minimally invasive adhesiolysis to resolve the obstruction is associated with a incidence of 6–20% enterotomies [24, 25]. In general, complex adhesiolysis is associated with bleeding, sepsis, wound infections and increased mortality,

**10**

on a population level is high.

even in the absence of bowel injury [26]. Mean length of hospital stay for ASBO ranges from 4 to 13 days and generally depends the type of treatment and the treatment complications [1].

Both operative and conservative management of ASBO are associated with a risk of recurrent ASBO. Operative management includes repeated peritoneal injury with risk of adhesion reformation and re-ASBO. Non-operative management of ASBO does not dissolve abdominal adhesions and harbors the risk of a new episode of ASBO. In a recent study of patients presenting with a first episode of ASBO, operative management was associated with a lower risk of recurrence compared with non-operative management (13% vs. 21%) after a median follow-up of 3.6 years [19]. The study also showed an increased risk of ASBO with every previous episode of ASBO in accordance to findings done 25 years ago [27]. Also the time between episodes of ASBO decreases with an increase in number of episodes [19]. Despite the higher recurrence rate after conservative treatment, current guidelines still recommend a trial of non-operative management of ASBO in order to avoid the risk of complications associated with surgical intervention [28].

Effort is made to predict the severity of ASBO using peri-operative scores [29, 30]. However, the scores are not widely adopted for clinical use. The American Association for the Surgery of Trauma (AAST) developed a score based on clinical, imaging, operative and pathologic criteria to grade disease severity of ASBO [31, 32]. The AAST grade uses clinical criteria (flatus, bowel sounds abdominal distention), pathologic criteria (bowel perforation), imaging criteria on CT (intestinal distention, transition point, contrast flow) and operative criteria (intestinal distention, impeding bowel compromise, peritonitis) to define the grade of ASBO on a scale from 1 to 4. A higher AAST score for emergency ASBO is associated with an increase in length of hospital stay, pneumonia, and more severe complications [33]. Recently the Clinical Adhesion Score (CLAS) was developed, measuring the full spectrum of the long-term burden of adhesion formation in post-operative patients. CLAS calculates the overall morbidity based on four domains: ASBO, difficulties during reoperation, female infertility or subfertility, and chronic abdominal pain (data not yet published). Evaluation of current and new adhesion prevention strategies regarding longterm clinical efficacy e.g. ASBO could benefit from using CLAS.

The economic burden of ASBO is high. Operative management is the single most important determinant of costs. However, based on fewer recurrences of ASBO after surgical treatment, surgery may save costs at the long term [34]. Several studies have been reported regarding the treatment costs of ASBO. Most have important limitations reporting part of the costs or costs based on reimbursement prices rather than true healthcare costs [35–37]. We modeled in a recent study, costs for ASBO in the Netherlands using a micro-costing method including costs of length of stay, ICU days, operative time, medication, parenteral feeding, imaging studies and laboratory studies [38]. This modeling revealed total healthcare costs of patients operated for ASBO of €16305 (SD €2513) with a mean hospital stay of 16.0 ± 11 days. For non-operatively treated patients costs would be €2277 (SD €265) with a mean hospital stay of 4.0 ± 2.0 days. The majority of the costs were due to ward stay, operative time, ICU stay and (parental) feeding. All surgical procedures for ASBO in this study consisted of open adhesiolysis. Costs estimated in this study were higher compared to previous estimates of treatment costs for ASBO with comparable lengths of stay and, as a result of its design better reflecting reality [35–37]. In the study we adhered to international guidelines for the diagnosis and treatment of ASBO increasing generalizability of outcomes for developed countries.

Nevertheless costs may vary among countries due to differences in admission and discharge policies, and prices of diagnostics, materials, medication and feeding.

#### **3. Impact of minimally invasive surgery on morbidity of ASBO**

It has been suggested from a few studies that the decreased adhesion formation after minimally invasive surgery associates with a lower incidence of ASBO. This decrease seems limited compared to open surgery as concluded from one systematic review and one trial reported by our group [1–17]. Differences in definitions of ASBO used, types of procedures, outcome parameters and length of follow-up in the studies, preclude a firm conclusion on the beneficial effect of minimally invasive surgery on development of ASBO.

To estimate the impact of minimally invasive surgery at a population level on adhesion-related complications, ASBO in particular, our group recently reported the results of the SCAR update study [39]. Over 72,000 patients, who were operated between June 2009 and June 2011, were followed for a minimum of 5 years. Readmissions were classified, according to the initial SCAR study (1999), as directly-related to adhesions e.g. adhesive small bowel obstruction, possibly related to adhesions, e.g. any small bowel obstruction and reoperations potentially complicated by adhesions e.g. right hemicolectomy years after an appendectomy. Approximately 30% of all index procedures were minimally invasive. Patients who underwent minimally invasive surgery were readmitted less frequently for directly related causes compared with patients after open surgery (1.7% vs. 4.3%). Possibly related readmissions and reoperations potentially complicated by adhesions were also less frequent (16.0% vs. 18.2% and 8.6% vs. 15.0%). Multivariate analysis revealed a 32% reduction in directly adhesion-related readmissions associated with minimally invasive surgery. Readmission rates were similar when comparing patients with open surgery in the SCAR and those in the SCAR update study. The overall small differences found in readmission rates could be explained by the difference in follow-up, 10 years in the SCAR study and 5 years in the SCAR update study. Despite the finding of a small reduction in readmission rates after initial minimally invasive surgery, the overall burden of adhesion-related readmissions on a population level remains high.

To further elaborate differences in adhesion-related readmissions between minimally invasive and open surgery, we analyzed patients with colorectal procedures (data not yet published). This type of surgery is known for its adhesion formation propensity and associated morbidity. Over 15,000 patients underwent colorectal surgery of whom almost one-third with a minimally invasive approach. For open colorectal surgery readmission rates were comparable between the SCAR study and the SCAR update study. Minimally invasive colonic and/or rectal surgery reduced the total number of directly adhesion-related readmissions. However in patients who underwent a (sub)total colectomy readmission rates were over 15% irrespective of an open or minimally invasive approach. Minimally invasive surgery did not reduce adhesion-related complications in rectal procedures. We concluded that an extended colectomy and rectal resection do not benefit from minimally invasive surgery regarding adhesion-related complications. We hypothesized that the large extent of the dissection and injury to the visceral and lateral parietal peritoneum needed in both surgical techniques abolishes the preventive effect of the minimally invasive technique on adhesion formation to the ventral peritoneum, where the injury is relatively limited for both approaches.

**13**

formation.

*Adhesive Small Bowel Obstruction in the Minimally Invasive Era*

**4. Management of adhesive small bowel obstruction**

need to be involved in practice guidelines and protocols.

Adequate management of ASBO depends on an initially correct diagnosis. Although ASBO is a common diagnosis with clear signs and symptoms, misdiagnosis and delayed diagnosis are a substantial clinical problem. Up to 50% of older patients are initially not adequately diagnosed [42]. Failure to diagnose represents 70% of malpractice claims in ASBO [43, 44]. In this regard it is important to note that patients with ASBO can initially present themselves to a variety of physicians, including general practitioners, surgeons, internal medicine physicians, geriatricians and gastroenterologists. To improve diagnosis of ASBO, multiple specialists

Based on expert opinion the diagnosing of ASBO includes a medical history with an assessment of potential causes of SBO, e.g. previous abdominal surgery, inflammatory bowel disease, important symptoms such as vomiting, absence of stools or flatus, intermittent colicky abdominal pain and abdominal distention. Common pitfalls in diagnosing ASBO are the less prominent pain present in the elderly [42], reporting of watery diarrhea by patients with an incomplete obstruction and normal stool passage in the first days after onset due to stool still present in the colon. The recent update of the international guidelines for diagnosis and management of ASBO gives the current best available evidence for management of ASBO once the diagnosis of bowel obstruction has been established [28]. The first priority in management is to establish the cause of obstruction and to determine if urgent surgical treatment is required. ASBO is the single most common cause for SBO, the differential diagnosis includes strangulated abdominal wall or groin hernia, tumor, paralysis, constipation or bezoars. Laboratory tests should include blood count, CRP, electrolytes, creatinine and lactate. Imaging studies can include water-soluble contrast studies or computer tomography (CT) scans. CT scan is the preferred imaging technique for the diagnosis of ASBO, it can accurately rule out other causes of obstruction and identify patients who might require emergency surgery [28]. Water-soluble contrast enhances the diagnostic accuracy of CT scans. Signs that might suspect ASBO on imaging studies are an abrupt change in bowel diameter and the exclusion of other causes of SBO. The value of plain X-rays is limited [28].

The SCAR update study has demonstrated that minimally invasive surgery is associated with less adhesion-related readmissions. Hence, the overall burden of adhesion-related readmissions on a population level remains high. Adhesion formation therefore continues to be a challenge in abdominal surgery, also in the minimally invasive era. Minimally invasive procedures were only performed in approximately one-third of procedures in 2009–2011, whereas currently in the Netherlands about 75% of colonic resections are performed minimally invasive (by laparoscopy or robot) [40]. On a population base a further decline in adhesionrelated complications can be expected with an increase of minimally invasive abdominal operations. However, we like to warn against unbridled optimism regarding the overall impact of minimally invasive surgery on the burden of adhesions because open surgery is still being preferred when a complicated condition is expected in the abdominal cavity e.g. after multiple previous procedures, with large inflammatory mass or locally advanced cancer [41]. Many of these conditions are complex specifically due to presence of adhesions at baseline surgery and the need to perform adhesiolysis before entering the operative area. It is known that the propensity to reform adhesions after adhesiolysis is higher than de novo adhesion

*DOI: http://dx.doi.org/10.5772/intechopen.91896*

*Adhesive Small Bowel Obstruction in the Minimally Invasive Era DOI: http://dx.doi.org/10.5772/intechopen.91896*

*Intestinal Obstructions*

sive surgery on development of ASBO.

a population level remains high.

injury is relatively limited for both approaches.

feeding.

Nevertheless costs may vary among countries due to differences in admission and discharge policies, and prices of diagnostics, materials, medication and

It has been suggested from a few studies that the decreased adhesion formation after minimally invasive surgery associates with a lower incidence of ASBO. This decrease seems limited compared to open surgery as concluded from one systematic review and one trial reported by our group [1–17]. Differences in definitions of ASBO used, types of procedures, outcome parameters and length of follow-up in the studies, preclude a firm conclusion on the beneficial effect of minimally inva-

To estimate the impact of minimally invasive surgery at a population level on adhesion-related complications, ASBO in particular, our group recently reported the results of the SCAR update study [39]. Over 72,000 patients, who were operated between June 2009 and June 2011, were followed for a minimum of 5 years. Readmissions were classified, according to the initial SCAR study (1999), as directly-related to adhesions e.g. adhesive small bowel obstruction, possibly related to adhesions, e.g. any small bowel obstruction and reoperations potentially complicated by adhesions e.g. right hemicolectomy years after an appendectomy. Approximately 30% of all index procedures were minimally invasive. Patients who underwent minimally invasive surgery were readmitted less frequently for directly related causes compared with patients after open surgery (1.7% vs. 4.3%). Possibly related readmissions and reoperations potentially complicated by adhesions were also less frequent (16.0% vs. 18.2% and 8.6% vs. 15.0%). Multivariate analysis revealed a 32% reduction in directly adhesion-related readmissions associated with minimally invasive surgery. Readmission rates were similar when comparing patients with open surgery in the SCAR and those in the SCAR update study. The overall small differences found in readmission rates could be explained by the difference in follow-up, 10 years in the SCAR study and 5 years in the SCAR update study. Despite the finding of a small reduction in readmission rates after initial minimally invasive surgery, the overall burden of adhesion-related readmissions on

To further elaborate differences in adhesion-related readmissions between minimally invasive and open surgery, we analyzed patients with colorectal procedures (data not yet published). This type of surgery is known for its adhesion formation propensity and associated morbidity. Over 15,000 patients underwent colorectal surgery of whom almost one-third with a minimally invasive approach. For open colorectal surgery readmission rates were comparable between the SCAR study and the SCAR update study. Minimally invasive colonic and/or rectal surgery reduced the total number of directly adhesion-related readmissions. However in patients who underwent a (sub)total colectomy readmission rates were over 15% irrespective of an open or minimally invasive approach. Minimally invasive surgery did not reduce adhesion-related complications in rectal procedures. We concluded that an extended colectomy and rectal resection do not benefit from minimally invasive surgery regarding adhesion-related complications. We hypothesized that the large extent of the dissection and injury to the visceral and lateral parietal peritoneum needed in both surgical techniques abolishes the preventive effect of the minimally invasive technique on adhesion formation to the ventral peritoneum, where the

**3. Impact of minimally invasive surgery on morbidity of ASBO**

**12**

The SCAR update study has demonstrated that minimally invasive surgery is associated with less adhesion-related readmissions. Hence, the overall burden of adhesion-related readmissions on a population level remains high. Adhesion formation therefore continues to be a challenge in abdominal surgery, also in the minimally invasive era. Minimally invasive procedures were only performed in approximately one-third of procedures in 2009–2011, whereas currently in the Netherlands about 75% of colonic resections are performed minimally invasive (by laparoscopy or robot) [40]. On a population base a further decline in adhesionrelated complications can be expected with an increase of minimally invasive abdominal operations. However, we like to warn against unbridled optimism regarding the overall impact of minimally invasive surgery on the burden of adhesions because open surgery is still being preferred when a complicated condition is expected in the abdominal cavity e.g. after multiple previous procedures, with large inflammatory mass or locally advanced cancer [41]. Many of these conditions are complex specifically due to presence of adhesions at baseline surgery and the need to perform adhesiolysis before entering the operative area. It is known that the propensity to reform adhesions after adhesiolysis is higher than de novo adhesion formation.

#### **4. Management of adhesive small bowel obstruction**

Adequate management of ASBO depends on an initially correct diagnosis. Although ASBO is a common diagnosis with clear signs and symptoms, misdiagnosis and delayed diagnosis are a substantial clinical problem. Up to 50% of older patients are initially not adequately diagnosed [42]. Failure to diagnose represents 70% of malpractice claims in ASBO [43, 44]. In this regard it is important to note that patients with ASBO can initially present themselves to a variety of physicians, including general practitioners, surgeons, internal medicine physicians, geriatricians and gastroenterologists. To improve diagnosis of ASBO, multiple specialists need to be involved in practice guidelines and protocols.

Based on expert opinion the diagnosing of ASBO includes a medical history with an assessment of potential causes of SBO, e.g. previous abdominal surgery, inflammatory bowel disease, important symptoms such as vomiting, absence of stools or flatus, intermittent colicky abdominal pain and abdominal distention. Common pitfalls in diagnosing ASBO are the less prominent pain present in the elderly [42], reporting of watery diarrhea by patients with an incomplete obstruction and normal stool passage in the first days after onset due to stool still present in the colon.

The recent update of the international guidelines for diagnosis and management of ASBO gives the current best available evidence for management of ASBO once the diagnosis of bowel obstruction has been established [28]. The first priority in management is to establish the cause of obstruction and to determine if urgent surgical treatment is required. ASBO is the single most common cause for SBO, the differential diagnosis includes strangulated abdominal wall or groin hernia, tumor, paralysis, constipation or bezoars. Laboratory tests should include blood count, CRP, electrolytes, creatinine and lactate. Imaging studies can include water-soluble contrast studies or computer tomography (CT) scans. CT scan is the preferred imaging technique for the diagnosis of ASBO, it can accurately rule out other causes of obstruction and identify patients who might require emergency surgery [28]. Water-soluble contrast enhances the diagnostic accuracy of CT scans. Signs that might suspect ASBO on imaging studies are an abrupt change in bowel diameter and the exclusion of other causes of SBO. The value of plain X-rays is limited [28].

Urgent surgery is required in case of signs of ischemia, perforation or strangulation of the bowel, generalized peritonitis and/or hemodynamic instability. No single test is highly sensitive for ischemia and strangulation. Sensitivity of physical examination for the detection of strangulation is only 48% in experienced hands [45]. Laboratory tests indicating peritonitis or ischemia are a CRP above 75 and a white blood cell count above 10.000/mm3 [45–47]. Again, a CT scan is most accurate in assessing strangulation and perforation and the need for emergency surgery [28]. CT abnormalities indicating strangulation or perforation are free intraperitoneal air or fluid, closed loop obstruction, mesenteric edema or engorgement, mesenteric swirling, pneumatosis intestinalis, decreased or lack of bowel enhancement or thickened bowel wall [48–50].

If bowel obstruction is caused by adhesions, and signs of peritonitis, ischemia, and strangulation are absent, initial conservative treatment is reportedly safe. Conservative treatment is successful in 70–90% of all episodes of ASBO [1–23]. Conservative treatment of ASBO consists of nil per os and decompression of the gastro-intestinal tract using a naso-gastric tube. Further management includes fluid resuscitation, correction of electrolyte disturbances, nutritional support and prevention of aspiration. Optimal duration of a conservative trial is debated; prolonged management for more than 72 h has been associated with adverse outcomes and increased mortality [20, 51–54]. Water-soluble contrast studies seem useful in the follow-up of conservative management of ASBO. If contrast has not reached to colon 24–48 h following administration, continuation of conservative management is likely to fail and surgical management should be considered [28].

An algorithm for the diagnosis and treatment of ASBO is presented in **Figure 2** [28].

#### **4.1 Role of minimally invasive surgery in the management of ASBO**

Operative treatment of ASBO historically comprises an explorative laparotomy with adhesiolysis. The increased use of minimally invasive surgery has raised the question whether minimally invasive surgery is feasible and effective for the treatment of ASBO. Benefits of minimally invasive adhesiolysis are reduction of peritoneal injury possibly resulting in less adhesion reformation, a quick recovery and minimal post-operative pain. Twenty-five years ago the first cases of minimally invasive surgery for treatment of ASBO have been described [55]. Thereafter a few series were reported but adequate comparative trials are scarce [56–60]. Minimally invasive surgery for ASBO is challenging because there is little laparoscopic working space due to the distended bowel. Also visibility can be hampered by multiple adhesions. There are concerns that minimally invasive surgery increases the risk of iatrogenic bowel perforations [57]. Suitability of minimally invasive surgery for ASBO further depends on patient characteristics. In case of hemodynamic instability open surgery is required because patients cannot tolerate the pneumoperitoneum.

One randomized trial comparing minimally invasive and open surgery for ASBO has been performed [56]. Only patients with a high suspicion of a single adhesive band causing the obstruction were included. Patients with confirmed or suspected peritoneal carcinosis, known multiple adhesions, previous open surgery for endometriosis, aorta, iliac vessels or Crohn's disease, previous generalized peritonitis, abdominal malignancy, previous abdominal radiotherapy or recent operations within 30 days were all excluded. Patients started with conservative management of ASBO. If the obstruction did not resolve patients were randomized between open and laparoscopic adhesiolysis. The trial was open label, therefore patients and care providers were not blinded. During 5 years 566 patients were included in the study, 104 patients underwent surgery, 51 were randomly assigned to the open surgery

**15**

**Figure 2.**

*Algorithm for the diagnosis and treatment of ASBO.*

*Adhesive Small Bowel Obstruction in the Minimally Invasive Era*

group, and 53 to the laparoscopic surgery group. Patients in the laparoscopic group had a shorter length of stay (4.2 days) compared with the open group (5.5 days). Mortality and postoperative complications did not differ between the groups. The few matched cohort studies comparing minimally invasive and open surgery for ASBO reported comparable results to those of the trial mentioned above

*DOI: http://dx.doi.org/10.5772/intechopen.91896*

*Adhesive Small Bowel Obstruction in the Minimally Invasive Era DOI: http://dx.doi.org/10.5772/intechopen.91896*

*Intestinal Obstructions*

blood cell count above 10.000/mm3

thickened bowel wall [48–50].

**Figure 2** [28].

Urgent surgery is required in case of signs of ischemia, perforation or strangulation of the bowel, generalized peritonitis and/or hemodynamic instability. No single test is highly sensitive for ischemia and strangulation. Sensitivity of physical examination for the detection of strangulation is only 48% in experienced hands [45]. Laboratory tests indicating peritonitis or ischemia are a CRP above 75 and a white

assessing strangulation and perforation and the need for emergency surgery [28]. CT abnormalities indicating strangulation or perforation are free intraperitoneal air or fluid, closed loop obstruction, mesenteric edema or engorgement, mesenteric swirling, pneumatosis intestinalis, decreased or lack of bowel enhancement or

If bowel obstruction is caused by adhesions, and signs of peritonitis, ischemia, and strangulation are absent, initial conservative treatment is reportedly safe. Conservative treatment is successful in 70–90% of all episodes of ASBO [1–23]. Conservative treatment of ASBO consists of nil per os and decompression of the gastro-intestinal tract using a naso-gastric tube. Further management includes fluid resuscitation, correction of electrolyte disturbances, nutritional support and prevention of aspiration. Optimal duration of a conservative trial is debated; prolonged management for more than 72 h has been associated with adverse outcomes and increased mortality [20, 51–54]. Water-soluble contrast studies seem useful in the follow-up of conservative management of ASBO. If contrast has not reached to colon 24–48 h following administration, continuation of conservative management

is likely to fail and surgical management should be considered [28].

**4.1 Role of minimally invasive surgery in the management of ASBO**

An algorithm for the diagnosis and treatment of ASBO is presented in

with adhesiolysis. The increased use of minimally invasive surgery has raised the question whether minimally invasive surgery is feasible and effective for the treatment of ASBO. Benefits of minimally invasive adhesiolysis are reduction of peritoneal injury possibly resulting in less adhesion reformation, a quick recovery and minimal post-operative pain. Twenty-five years ago the first cases of minimally invasive surgery for treatment of ASBO have been described [55]. Thereafter a few series were reported but adequate comparative trials are scarce [56–60]. Minimally invasive surgery for ASBO is challenging because there is little laparoscopic working space due to the distended bowel. Also visibility can be hampered by multiple adhesions. There are concerns that minimally invasive surgery increases the risk of iatrogenic bowel perforations [57]. Suitability of minimally invasive surgery for ASBO further depends on patient characteristics. In case of hemodynamic instability open

surgery is required because patients cannot tolerate the pneumoperitoneum.

One randomized trial comparing minimally invasive and open surgery for ASBO has been performed [56]. Only patients with a high suspicion of a single adhesive band causing the obstruction were included. Patients with confirmed or suspected peritoneal carcinosis, known multiple adhesions, previous open surgery for endometriosis, aorta, iliac vessels or Crohn's disease, previous generalized peritonitis, abdominal malignancy, previous abdominal radiotherapy or recent operations within 30 days were all excluded. Patients started with conservative management of ASBO. If the obstruction did not resolve patients were randomized between open and laparoscopic adhesiolysis. The trial was open label, therefore patients and care providers were not blinded. During 5 years 566 patients were included in the study, 104 patients underwent surgery, 51 were randomly assigned to the open surgery

Operative treatment of ASBO historically comprises an explorative laparotomy

[45–47]. Again, a CT scan is most accurate in

**14**

#### **Figure 2.**

*Algorithm for the diagnosis and treatment of ASBO.*

group, and 53 to the laparoscopic surgery group. Patients in the laparoscopic group had a shorter length of stay (4.2 days) compared with the open group (5.5 days). Mortality and postoperative complications did not differ between the groups.

The few matched cohort studies comparing minimally invasive and open surgery for ASBO reported comparable results to those of the trial mentioned above [59, 60]. There seems a trend towards a faster recovery in selected patients. Studies showed no major differences in complications or mortality. A few studies specifically addressed the potential drawbacks of the minimally invasive approach and suggested an increased risk of bowel injury [59]. Notably, the non-matched cohorts frequently claim large beneficial effects of the laparoscopic approach [40–58]. However, these studies have a high risk of various types of selection bias, mainly excluding patients who are more sick or are suspected of multiple adhesions.

It seems that minimally invasive adhesiolysis holds promise for patients with signs of a single adhesive band and an uncomplicated disease course. Further studies are needed to identify patients who can benefit from minimally invasive adhesiolysis and patients who can be harmed by minimally invasive treatment for ASBO.

#### **5. Future perspectives**

#### **5.1 Awareness of adhesions formation by minimally invasive surgery**

Morbidity of adhesion formation in minimally invasive surgery is often underestimated. Less than 25% of surgeons and 5–83% of gynecologists routinely inform their patients about adhesions and the life term risk of adhesion-related complications [14–62]. However, recent evidence shows that adhesion-related morbidity remains high in the minimally invasive era [39]. Not informing patients about the risk of adhesions might therefore be considered negligent. Increased awareness of adhesions might create an urge for the development and refinement of adhesion prevention strategies.

Awareness of adhesions may improve by growing awareness for intra-operative complications in general. Impact of adhesions on the operative course of reoperations for ASBO or other indications is often underreported. In a prospective comparison of operative notes and observation by an independent researcher, one in seven iatrogenic bowel injuries was not reported in operative notes, and almost one in three minor injuries [63]. In recent years, there is increasing scientific interest in the consequences of intra-operative events. IAEs are associated with 40% more hospital admissions, a twofold higher readmission rate, and with worse post-operative outcome [64–70]. Recently the Classification of Intraoperative Complications (CLASSIC) has been developed as a new tool for systematic classification for intra-operative complications (iAEs) [71]. CLASSIC defines iAEs as any deviation from the ideal intraoperative course, including technical failures, surgical and anesthesiological difficulties. The score has been update to five grades of severity (https://clinicaltrials.gov/ct2/show/NCT03009929). Lysis of adhesions at reoperations is associated with post-operative increase of sepsis, intra-abdominal complications, wound infections, longer hospital stay, and higher hospital costs [26–72]. As such, adhesiolysis qualifies as an iAE if adhesiolysis is not the intended surgical procedure. We currently investigate the contribution of adhesiolysis and associated intra-operative complications e.g. bleeding, inadvertent enterotomy to the CLASSIC.

Recent published guidelines may also increase awareness of adhesions and treatment of ASBO [28]. An old saying on ASBO is 'you must not let the sun rise on ASBO', all patients presenting with ASBO were operated if conservative management failed to resolve the bowel obstruction within 24 h. Recent insights report that a conservative trial can safely be prolonged to 72 h [51, 52]. The current guideline states that conservative treatment should be instigated in all patients without signs of ischemia, perforation or strangulation of the bowel, generalized peritonitis and/or hemodynamic instability [28]. Contradictory, some studies report lower

**17**

minimally invasive surgery.

*Adhesive Small Bowel Obstruction in the Minimally Invasive Era*

recurrence rates of ASBO after surgical management of ASBO [19–27]. A further disadvantage of prolonged conservative management is the further clinical deterioration of highly comorbid patients who receive starvation treatment for a few days [73]. Minimally invasive surgery could change the paradigm again towards earlier surgical intervention because of faster recovery, reduced length of hospital stay and

Considering the high impact of adhesion-related complications on a population level that is not substantially decreased by minimally invasive surgery, there is a

Until now the most promising approach for reduction of adhesion formation is routinely applying an adhesion barrier. Adhesion barriers are bioresorbable liquids, gels or films that keep injured peritoneal wound surfaces separated. During separation the peritoneal wound can heal with restoration of peritoneal tissue morphology and function without 'scarring' (adhesions). A large systematic review and meta-analysis in 2014 of 28 trials (n = 5191) showed benefits of several adhesion barriers in predominantly open abdominal surgery [16]. However, adhesion barriers are seldomly applied in abdominal or pelvic surgery [14]. Only 1 in 7 surgeons ever uses adhesion barriers [14]. Reluctance of surgeons to use adhesions barriers seems caused by doubts about cost-effectiveness and the need and possibility of adhesion

Cost-effectiveness of adhesion prevention in minimally invasive surgery is an important perquisite for implementation in every day practice. We performed a modeling study on cost-effectiveness of adhesion barriers in minimally invasive procedures with a high risk of adhesion formation [74]. Two strategies were compared: current clinical practice (colorectal surgery without the use of an adhesion barrier) and colorectal surgery with the use of an adhesion barrier (hyaluronate carboxymethylcellulose). Whilst hyaluronate carboxymethylcellulose as such is not applicable in minimally invasive surgery and a gel form has not properly been studied in minimally invasive surgery, probabilities were extrapolated from data of open colorectal surgery. Probability estimates were derived from literature. Costs of treatment of ASBO were derived from our previous report [38]. Cost of hyaluronate carboxymethylcellulose was estimated on \$630, based on the mean number of films used in studies on hyaluronate carboxymethylcellulose [12–75]. We concluded that using an adhesion barrier was more effective than not using a barrier in minimally invasive surgery, but it was more expensive. However, mean expected direct

healthcare costs in the 4 years following index surgery increased with only \$163 per patient. Cost estimates in this modeling study only included direct health care costs. Societal costs (e.g. absence from work) were not modeled in this study. Therefore an increase of \$163 in direct health care may be neglectable considering potential gain in societal costs. Further research is needed on long term savings regarding socioeconomic costs with adhesion barriers also including the new SCAR update data of

An important limitation of most barriers is the inability to properly use these in minimally invasive surgery. Most barriers were developed more than two to three decades ago and were films intended for use in open surgery. This limitation and the disregard needing barriers in minimally invasive surgery have impeded implementation and continued research and development of barriers suitable for minimally invasive surgery (and open surgery). Recently some new barriers have been developed suitable for minimally invasive surgery. Studies on these new barriers are performed mostly in gynecologic populations, and show effectiveness

*DOI: http://dx.doi.org/10.5772/intechopen.91896*

the mentioned lower recurrence rates of ASBO.

pressing need to develop new adhesion reduction strategies.

**5.2 Adhesion reduction strategies**

prevention in minimally invasive surgery.

recurrence rates of ASBO after surgical management of ASBO [19–27]. A further disadvantage of prolonged conservative management is the further clinical deterioration of highly comorbid patients who receive starvation treatment for a few days [73]. Minimally invasive surgery could change the paradigm again towards earlier surgical intervention because of faster recovery, reduced length of hospital stay and the mentioned lower recurrence rates of ASBO.

#### **5.2 Adhesion reduction strategies**

*Intestinal Obstructions*

**5. Future perspectives**

prevention strategies.

[59, 60]. There seems a trend towards a faster recovery in selected patients. Studies showed no major differences in complications or mortality. A few studies specifically addressed the potential drawbacks of the minimally invasive approach and suggested an increased risk of bowel injury [59]. Notably, the non-matched cohorts frequently claim large beneficial effects of the laparoscopic approach [40–58]. However, these studies have a high risk of various types of selection bias, mainly excluding patients who are more sick or are suspected of multiple adhesions. It seems that minimally invasive adhesiolysis holds promise for patients with signs of a single adhesive band and an uncomplicated disease course. Further studies are needed to identify patients who can benefit from minimally invasive adhesiolysis

and patients who can be harmed by minimally invasive treatment for ASBO.

**5.1 Awareness of adhesions formation by minimally invasive surgery**

Morbidity of adhesion formation in minimally invasive surgery is often underestimated. Less than 25% of surgeons and 5–83% of gynecologists routinely inform their patients about adhesions and the life term risk of adhesion-related complications [14–62]. However, recent evidence shows that adhesion-related morbidity remains high in the minimally invasive era [39]. Not informing patients about the risk of adhesions might therefore be considered negligent. Increased awareness of adhesions might create an urge for the development and refinement of adhesion

Awareness of adhesions may improve by growing awareness for intra-operative

complications in general. Impact of adhesions on the operative course of reoperations for ASBO or other indications is often underreported. In a prospective comparison of operative notes and observation by an independent researcher, one in seven iatrogenic bowel injuries was not reported in operative notes, and almost one in three minor injuries [63]. In recent years, there is increasing scientific interest in the consequences of intra-operative events. IAEs are associated with 40% more hospital admissions, a twofold higher readmission rate, and with worse post-operative outcome [64–70]. Recently the Classification of Intraoperative Complications (CLASSIC) has been developed as a new tool for systematic classification for intra-operative complications (iAEs) [71]. CLASSIC defines iAEs as any deviation from the ideal intraoperative course, including technical failures, surgical and anesthesiological difficulties. The score has been update to five grades of severity (https://clinicaltrials.gov/ct2/show/NCT03009929). Lysis of adhesions at reoperations is associated with post-operative increase of sepsis, intra-abdominal complications, wound infections, longer hospital stay, and higher hospital costs [26–72]. As such, adhesiolysis qualifies as an iAE if adhesiolysis is not the intended surgical procedure. We currently investigate the contribution of adhesiolysis and associated intra-operative complications e.g. bleeding, inadvertent enterotomy to

Recent published guidelines may also increase awareness of adhesions and treatment of ASBO [28]. An old saying on ASBO is 'you must not let the sun rise on ASBO', all patients presenting with ASBO were operated if conservative management failed to resolve the bowel obstruction within 24 h. Recent insights report that a conservative trial can safely be prolonged to 72 h [51, 52]. The current guideline states that conservative treatment should be instigated in all patients without signs of ischemia, perforation or strangulation of the bowel, generalized peritonitis and/or hemodynamic instability [28]. Contradictory, some studies report lower

**16**

the CLASSIC.

Considering the high impact of adhesion-related complications on a population level that is not substantially decreased by minimally invasive surgery, there is a pressing need to develop new adhesion reduction strategies.

Until now the most promising approach for reduction of adhesion formation is routinely applying an adhesion barrier. Adhesion barriers are bioresorbable liquids, gels or films that keep injured peritoneal wound surfaces separated. During separation the peritoneal wound can heal with restoration of peritoneal tissue morphology and function without 'scarring' (adhesions). A large systematic review and meta-analysis in 2014 of 28 trials (n = 5191) showed benefits of several adhesion barriers in predominantly open abdominal surgery [16]. However, adhesion barriers are seldomly applied in abdominal or pelvic surgery [14]. Only 1 in 7 surgeons ever uses adhesion barriers [14]. Reluctance of surgeons to use adhesions barriers seems caused by doubts about cost-effectiveness and the need and possibility of adhesion prevention in minimally invasive surgery.

Cost-effectiveness of adhesion prevention in minimally invasive surgery is an important perquisite for implementation in every day practice. We performed a modeling study on cost-effectiveness of adhesion barriers in minimally invasive procedures with a high risk of adhesion formation [74]. Two strategies were compared: current clinical practice (colorectal surgery without the use of an adhesion barrier) and colorectal surgery with the use of an adhesion barrier (hyaluronate carboxymethylcellulose). Whilst hyaluronate carboxymethylcellulose as such is not applicable in minimally invasive surgery and a gel form has not properly been studied in minimally invasive surgery, probabilities were extrapolated from data of open colorectal surgery. Probability estimates were derived from literature. Costs of treatment of ASBO were derived from our previous report [38]. Cost of hyaluronate carboxymethylcellulose was estimated on \$630, based on the mean number of films used in studies on hyaluronate carboxymethylcellulose [12–75]. We concluded that using an adhesion barrier was more effective than not using a barrier in minimally invasive surgery, but it was more expensive. However, mean expected direct healthcare costs in the 4 years following index surgery increased with only \$163 per patient. Cost estimates in this modeling study only included direct health care costs. Societal costs (e.g. absence from work) were not modeled in this study. Therefore an increase of \$163 in direct health care may be neglectable considering potential gain in societal costs. Further research is needed on long term savings regarding socioeconomic costs with adhesion barriers also including the new SCAR update data of minimally invasive surgery.

An important limitation of most barriers is the inability to properly use these in minimally invasive surgery. Most barriers were developed more than two to three decades ago and were films intended for use in open surgery. This limitation and the disregard needing barriers in minimally invasive surgery have impeded implementation and continued research and development of barriers suitable for minimally invasive surgery (and open surgery). Recently some new barriers have been developed suitable for minimally invasive surgery. Studies on these new barriers are performed mostly in gynecologic populations, and show effectiveness reducing adhesions [76, 77]. The important next step in adhesion prevention is the development of a new generation of barriers suitable for minimally invasive use in general surgery [78, 79]. Using increased knowledge of the pathophysiology of adhesions, new barriers consist of bioactive and targeted technology e.g. modulation of inflammation [2]. Pilpel and colleagues developed a liquid solution modulating the fibrin matrix which is generated by the hemostatic system after peritoneal injury [80]. This novel therapy is currently tested in animal models. Roberston and colleagues are testing a drug (L-Alanyl-L-Glutamine) to regulate the formation of adhesions due to hypoxia and oxidative stress caused by surgical injury of the vascular supply to the tissue caused by surgical intervention [81]. The first results of this drug in a double-blinded placebo controlled study show that L-Alanyl-L-Glutamine is safe to use and is effective at reducing adhesion formation after laparoscopic myomectomies [82]. Definitive results from this study are expected in due time. When proven safe, effective and affordable in patients, these new bioactive and targeted technology agents should be administered during index minimally invasive surgery to break the sequence of intra- and postoperative adhesion-(re) formation related complications.

#### **6. Conclusions**

Adhesion-related morbidity remains a clinically relevant problem in the minimally invasive era. Minimally invasive surgery is associated with only a modest reduction in adhesion-related readmissions and incidence of ASBO. The growing body of scientific evidence provides the clinician with a firm guideline for the diagnosis and treatment of ASBO. Minimally invasive surgery in the management of ASBO appears to be safe and effective alternative to open adhesiolysis, however in a very selected patient group. To allow as many patients as possible to benefit from a minimally invasive approach future research should focus on the selection criteria for minimally invasive surgery in ASBO. Adhesion-related morbidity is often underestimated and complications of adhesiolysis underreported. Raising awareness of adhesions therefore remains important. Using newly proposed scores for intraoperative complications, may increase awareness for the intra-operative events caused by adhesions. Adhesion barriers can safely reduce adhesion formation, are cost-effective in open colorectal surgery and effective with slightly higher costs in minimally invasive surgery. Future research should focus on new bioactive barriers that are easily applicable in minimally invasive abdominal surgery and safe to use. Preventing adhesions during first minimally invasive surgery is key to break the sequence of intra- and postoperative adhesion (re)formation related complications.

**19**

**Author details**

The Netherlands

Pepijn Krielen\*, Martijn W. J. Stommel, Richard P. G. ten Broek and Harry van Goor

© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

Department of Surgery, Radboud University Medical Center, Nijmegen,

\*Address all correspondence to<EMAIL_ADDRESS>
provided the original work is properly cited.

*Adhesive Small Bowel Obstruction in the Minimally Invasive Era*

*DOI: http://dx.doi.org/10.5772/intechopen.91896*

#### **Conflict of interest**

The authors declare no conflict of interest.

*Adhesive Small Bowel Obstruction in the Minimally Invasive Era DOI: http://dx.doi.org/10.5772/intechopen.91896*

*Intestinal Obstructions*

formation related complications.

**6. Conclusions**

**Conflict of interest**

The authors declare no conflict of interest.

reducing adhesions [76, 77]. The important next step in adhesion prevention is the development of a new generation of barriers suitable for minimally invasive use in general surgery [78, 79]. Using increased knowledge of the pathophysiology of adhesions, new barriers consist of bioactive and targeted technology e.g. modulation of inflammation [2]. Pilpel and colleagues developed a liquid solution modulating the fibrin matrix which is generated by the hemostatic system after peritoneal injury [80]. This novel therapy is currently tested in animal models. Roberston and colleagues are testing a drug (L-Alanyl-L-Glutamine) to regulate the formation of adhesions due to hypoxia and oxidative stress caused by surgical injury of the vascular supply to the tissue caused by surgical intervention [81]. The first results of this drug in a double-blinded placebo controlled study show that L-Alanyl-L-Glutamine is safe to use and is effective at reducing adhesion formation after laparoscopic myomectomies [82]. Definitive results from this study are expected in due time. When proven safe, effective and affordable in patients, these new bioactive and targeted technology agents should be administered during index minimally invasive surgery to break the sequence of intra- and postoperative adhesion-(re)

Adhesion-related morbidity remains a clinically relevant problem in the minimally invasive era. Minimally invasive surgery is associated with only a modest reduction in adhesion-related readmissions and incidence of ASBO. The growing body of scientific evidence provides the clinician with a firm guideline for the diagnosis and treatment of ASBO. Minimally invasive surgery in the management of ASBO appears to be safe and effective alternative to open adhesiolysis, however in a very selected patient group. To allow as many patients as possible to benefit from a minimally invasive approach future research should focus on the selection criteria for minimally invasive surgery in ASBO. Adhesion-related morbidity is often underestimated and complications of adhesiolysis underreported. Raising awareness of adhesions therefore remains important. Using newly proposed scores for intraoperative complications, may increase awareness for the intra-operative events caused by adhesions. Adhesion barriers can safely reduce adhesion formation, are cost-effective in open colorectal surgery and effective with slightly higher costs in minimally invasive surgery. Future research should focus on new bioactive barriers that are easily applicable in minimally invasive abdominal surgery and safe to use. Preventing adhesions during first minimally invasive surgery is key to break the sequence of intra- and postoperative adhesion (re)formation related complications.

**18**

#### **Author details**

Pepijn Krielen\*, Martijn W. J. Stommel, Richard P. G. ten Broek and Harry van Goor Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands

\*Address all correspondence to<EMAIL_ADDRESS>
© 2020 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

#### **References**

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[2] Stommel MW, Strik C, van Goor H. Response to pathological processes in the peritoneal cavity—Sepsis, tumours, adhesions, and ascites. Seminars in Pediatric Surgery. 2014;**23**(6):331-335

[3] Zuhlke HV et al. Pathophysiology and classification of adhesions. Langenbecks Archiv für Chirurgie. Supplement II, Verhandlungen der Deutschen Gesellschaft für Chirurgie. Deutsche Gesellschaft für Chirurgie. 1990:1009-1016. Available from: https://www.ncbi.nlm.nih.gov/ pubmed/?term=1983476

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[5] Fugazzola P et al. Validation of peritoneal adhesion index as a standardized classification to universalize peritoneal adhesions definition. Journal of Peritoneum (and Other Serosal Surfaces). 2017;**2**:61-69

[6] Menzies D, Ellis H. Intestinal obstruction from adhesions—How big is the problem? Annals of the Royal College of Surgeons of England. 1990;**72**(1):60-63

[7] Stommel MWJ et al. Multicenter observational study of adhesion formation after open- and laparoscopic surgery for colorectal cancer. Annals of Surgery. 2018;**267**(4):743-748

[8] Polymeneas G et al. A comparative study of postoperative adhesion formation after laparoscopic vs open cholecystectomy. Surgical Endoscopy. 2001;**15**(1):41-43

[9] Parker MC et al. Colorectal surgery: The risk and burden of adhesion-related complications. Colorectal Disease. 2004;**6**(6):506-511

[10] Barmparas G et al. The incidence and risk factors of post-laparotomy adhesive small bowel obstruction. Journal of Gastrointestinal Surgery. 2010;**14**(10):1619-1628

[11] Ellis H et al. Adhesion-related hospital readmissions after abdominal and pelvic surgery: A retrospective cohort study. Lancet. 1999;**353**(9163):1476-1480

[12] Ten Broek RP et al. Different surgical techniques to reduce postoperative adhesion formation: A systematic review and meta-analysis. Human Reproduction Update. 2013;**19**(1):12-25

[13] Kuhry E et al. Long-term results of laparoscopic colorectal cancer resection. Cochrane Database of Systematic Reviews. 2008;**2**:CD003432

[14] van Steensel S et al. Adhesion awareness in 2016: An update of the national survey of surgeons. PLoS One. 2018;**13**(8):e0202418

[15] Schreinemacher MH et al. Adhesion awareness: A national survey of surgeons. World Journal of Surgery. 2010;**34**(12):2805-2812

[16] Ten Broek RPG et al. Benefits and harms of adhesion barriers for abdominal surgery: A systematic review and meta-analysis. Lancet. 2014;**383**(9911):48-59

[17] Yamada T et al. Meta-analysis of the risk of small bowel obstruction following open or laparoscopic colorectal surgery. The British Journal of Surgery. 2016;**103**(5):493-503

**21**

*Adhesive Small Bowel Obstruction in the Minimally Invasive Era*

[27] Barkan H, Webster S, Ozeran S. Factors predicting the recurrence of adhesive small-bowel obstruction. American Journal of Surgery.

[28] Ten Broek RPG et al. Bologna guidelines for diagnosis and

Emergency Surgery. 2018;**13**:24

[29] Zielinski MD et al. Small bowel obstruction—Who needs an operation? A multivariate prediction model. World Journal of Surgery.

[30] Jancelewicz T et al. Predicting strangulated small bowel obstruction: An old problem revisited. Journal of Gastrointestinal Surgery.

[31] Shafi S et al. Measuring anatomic severity of disease in emergency general surgery. Journal of Trauma and Acute Care Surgery. 2014;**76**(3):884-887

[33] Hernandez MC et al. Application of the AAST EGS grade for adhesive small bowel obstruction to a multi-national patient population. World Journal of Surgery. 2018;**42**(11):3581-3588

[34] Colonna AL et al. Nonoperative management of adhesive small bowel obstruction: What is the break point? American Journal of Surgery.

[32] Utter GH et al. ICD-9-CM and ICD-10-CM mapping of the AAST emergency general surgery disease severity grading systems: Conceptual approach, limitations, and recommendations for the future. Journal of Trauma and Acute Care Surgery.

2015;**78**(5):1059-1065

2016;**212**(6):1214-1221

2010;**34**(5):910-919

2009;**13**(1):93-99

management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World Journal of

1995;**170**(4):361-365

*DOI: http://dx.doi.org/10.5772/intechopen.91896*

[18] Diamond MP et al. Adhesion prevention and reduction: Current status and future recommendations of a multinational interdisciplinary consensus conference. Surgical Innovation. 2010;**17**(3):183-188

[19] Behman R et al. Association of surgical intervention for adhesive small-bowel obstruction with the risk of recurrence. JAMA Surgery.

[20] NELA Project Team. The Third Patient Report of the National Emergency Laparotomy Audit

[21] Scott JW et al. Use of national burden to define operative emergency general surgery. JAMA Surgery.

(NELA). London: The Royal College of

[22] Fazel MZ, Jamieson RW, Watson CJ. Long-term follow-up of the use of the Jones' intestinal tube in adhesive small bowel obstruction. Annals of the Royal College of Surgeons of England.

[24] Wullstein C, Gross E. Laparoscopic compared with conventional treatment

2019;**154**(5):413-420

Anaesthetists; 2017

2016;**151**(6):e160480

2009;**91**(1):50-54

[23] Schraufnagel D, Rajaee S, Millham FH. How many sunsets? Timing of surgery in adhesive small bowel obstruction: A study of the nationwide inpatient sample. Journal of Trauma and Acute Care Surgery. 2013;**74**(1):181-187. discussion 187-9

of acute adhesive small bowel obstruction. The British Journal of Surgery. 2003;**90**(9):1147-1151

[25] Fevang BT et al. Long-term prognosis after operation for adhesive small bowel obstruction. Annals of Surgery. 2004;**240**(2):193-201

[26] ten Broek RP et al. Adhesiolysisrelated morbidity in abdominal surgery. Annals of Surgery. 2013;**258**(1):98-106

*Adhesive Small Bowel Obstruction in the Minimally Invasive Era DOI: http://dx.doi.org/10.5772/intechopen.91896*

[18] Diamond MP et al. Adhesion prevention and reduction: Current status and future recommendations of a multinational interdisciplinary consensus conference. Surgical Innovation. 2010;**17**(3):183-188

[19] Behman R et al. Association of surgical intervention for adhesive small-bowel obstruction with the risk of recurrence. JAMA Surgery. 2019;**154**(5):413-420

[20] NELA Project Team. The Third Patient Report of the National Emergency Laparotomy Audit (NELA). London: The Royal College of Anaesthetists; 2017

[21] Scott JW et al. Use of national burden to define operative emergency general surgery. JAMA Surgery. 2016;**151**(6):e160480

[22] Fazel MZ, Jamieson RW, Watson CJ. Long-term follow-up of the use of the Jones' intestinal tube in adhesive small bowel obstruction. Annals of the Royal College of Surgeons of England. 2009;**91**(1):50-54

[23] Schraufnagel D, Rajaee S, Millham FH. How many sunsets? Timing of surgery in adhesive small bowel obstruction: A study of the nationwide inpatient sample. Journal of Trauma and Acute Care Surgery. 2013;**74**(1):181-187. discussion 187-9

[24] Wullstein C, Gross E. Laparoscopic compared with conventional treatment of acute adhesive small bowel obstruction. The British Journal of Surgery. 2003;**90**(9):1147-1151

[25] Fevang BT et al. Long-term prognosis after operation for adhesive small bowel obstruction. Annals of Surgery. 2004;**240**(2):193-201

[26] ten Broek RP et al. Adhesiolysisrelated morbidity in abdominal surgery. Annals of Surgery. 2013;**258**(1):98-106

[27] Barkan H, Webster S, Ozeran S. Factors predicting the recurrence of adhesive small-bowel obstruction. American Journal of Surgery. 1995;**170**(4):361-365

[28] Ten Broek RPG et al. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2017 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World Journal of Emergency Surgery. 2018;**13**:24

[29] Zielinski MD et al. Small bowel obstruction—Who needs an operation? A multivariate prediction model. World Journal of Surgery. 2010;**34**(5):910-919

[30] Jancelewicz T et al. Predicting strangulated small bowel obstruction: An old problem revisited. Journal of Gastrointestinal Surgery. 2009;**13**(1):93-99

[31] Shafi S et al. Measuring anatomic severity of disease in emergency general surgery. Journal of Trauma and Acute Care Surgery. 2014;**76**(3):884-887

[32] Utter GH et al. ICD-9-CM and ICD-10-CM mapping of the AAST emergency general surgery disease severity grading systems: Conceptual approach, limitations, and recommendations for the future. Journal of Trauma and Acute Care Surgery. 2015;**78**(5):1059-1065

[33] Hernandez MC et al. Application of the AAST EGS grade for adhesive small bowel obstruction to a multi-national patient population. World Journal of Surgery. 2018;**42**(11):3581-3588

[34] Colonna AL et al. Nonoperative management of adhesive small bowel obstruction: What is the break point? American Journal of Surgery. 2016;**212**(6):1214-1221

**20**

*Intestinal Obstructions*

**References**

[1] ten Broek RP et al. Burden of adhesions in abdominal and pelvic surgery: Systematic review and metanalysis. BMJ. 2013;**347**:f5588

[2] Stommel MW, Strik C, van Goor H. Response to pathological processes in the peritoneal cavity—Sepsis, tumours, adhesions, and ascites. Seminars in Pediatric Surgery. 2014;**23**(6):331-335

[9] Parker MC et al. Colorectal surgery: The risk and burden of adhesion-related complications. Colorectal Disease.

[10] Barmparas G et al. The incidence and risk factors of post-laparotomy adhesive small bowel obstruction. Journal of Gastrointestinal Surgery.

[11] Ellis H et al. Adhesion-related hospital readmissions after abdominal and pelvic surgery: A retrospective cohort study. Lancet.

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[13] Kuhry E et al. Long-term results of laparoscopic colorectal cancer resection. Cochrane Database of Systematic Reviews. 2008;**2**:CD003432

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[47] Shih SC et al. Adhesive small bowel obstruction: How long can patients tolerate conservative treatment? World Journal of Gastroenterology.

[48] Zielinski MD et al. Prospective, observational validation of a

multivariate small-bowel obstruction

model to predict the need for operative intervention. Journal of the American College of Surgeons.

[49] Millet I et al. Assessment of strangulation in adhesive small bowel obstruction on the basis of combined CT findings: Implications for clinical care. Radiology. 2017;**285**(3):798-808

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2011;**212**(6):1068-1076

2015;**25**(6):1823-1835

2007;**54**(75):787-790

[52] Keenan JE et al. Trials of

Surgery. 2015;**209**(2):347-351

1983;**145**(1):176-182

2003;**9**(3):603-605

[36] ten Broek RP et al. Epidemiology and prevention of postsurgical

adhesions revisited. Annals of Surgery.

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[40] Behman R et al. Laparoscopic surgery for adhesive small bowel obstruction is associated with a higher risk of bowel injury: A population-based analysis of 8584 patients. Annals of Surgery. 2017;**266**(3):489-498

[41] Licciardello A et al. Preoperative risk factors for conversion from laparoscopic to open cholecystectomy. European Review for Medical and Pharmacological Sciences. 2014;**18**

[42] Ozturk E et al. Small bowel obstruction in the elderly: A plea for comprehensive acute geriatric care. World Journal of Emergency Surgery.

[43] Ellis H, Crowe A. Medico-legal consequences of post-operative intraabdominal adhesions. International Journal of Surgery. 2009;**7**(3):187-191

[44] Choudhry AJ et al. Medical

malpractice in the management of small

2020;**395**(10217):33-41

(2 Suppl):60-68

2018;**13**:48

**22**

[53] Fevang BT et al. Early operation or conservative management of patients with small bowel obstruction? The European Journal of Surgery. 2002;**168**(8-9):475-481

[54] Foster NM et al. Small bowel obstruction: A populationbased appraisal. Journal of the American College of Surgeons. 2006;**203**(2):170-176

[55] Mouret P. L'adesiolisi coelioscopia. In: Testas P, Delaitre B, editors. Chirurgia digestiva per via coelioscopica. Edizioni Vigot, Friburgo; 1994. pp. 53-69

[56] Sallinen V et al. Laparoscopic versus open adhesiolysis for adhesive small bowel obstruction (LASSO): An international, multicentre, randomised, open-label trial. The Lancet Gastroenterology & Hepatology. 2019;**4**(4):278-286

[57] Di Saverio S et al. Laparoscopic adhesiolysis: Not for all patients, not for all surgeons, not in all centres. Updates in Surgery. 2018;**70**(4):557-561

[58] Kelly KN et al. Laparotomy for small-bowel obstruction: First choice or last resort for adhesiolysis? A laparoscopic approach for smallbowel obstruction reduces 30-day complications. Surgical Endoscopy. 2014;**28**(1):65-73

[59] Hackenberg T et al. Laparoscopic versus open surgery for acute adhesive small-bowel obstruction: A propensity score-matched analysis. Scandinavian Journal of Surgery. 2017;**106**(1):28-33

[60] Yao S et al. Does laparoscopic adhesiolysis decrease the risk of recurrent symptoms in small bowel obstruction? A propensity

score-matched analysis. Surgical Endoscopy. 2017;**31**(12):5348-5355

[61] Meuleman T et al. Adhesion awareness: A nationwide survey of gynaecologists. European Journal of Obstetrics, Gynecology, and Reproductive Biology. 2013;**169**(2):353-359

[62] Hackethal A et al. Awareness and perception of intra-abdominal adhesions and related consequences: Survey of gynaecologists in German hospitals. European Journal of Obstetrics, Gynecology, and Reproductive Biology. 2010;**150**(2):180-189

[63] ten Broek RP, van den Beukel BA, van Goor H. Comparison of operative notes with real-time observation of adhesiolysis-related complications during surgery. The British Journal of Surgery. 2013;**100**(3):426-432

[64] Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine (US) Committee on Quality of Health Care in America; 2000. Available from: https://www.ncbi.nlm.nih.gov/ pubmed/25077248

[65] Vonlanthen R et al. The impact of complications on costs of major surgical procedures: A cost analysis of 1200 patients. Annals of Surgery. 2011;**254**(6):907-913

[66] Ramly EP et al. The financial impact of intraoperative adverse events in abdominal surgery. Surgery. 2015;**158**(5):1382-1388

[67] Nandan AR et al. The impact of major intraoperative adverse events on hospital readmissions. American Journal of Surgery. 2017;**213**(1):10-17

[68] Vibert E et al. Arterial lactate concentration at the end of an elective hepatectomy is an early predictor of the postoperative course and a potential surrogate of intraoperative events. Annals of Surgery. 2015;**262**(5):787-792. discussion 792-3

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