Intestinal obstruction definition.
Intestinal obstruction is a clinical picture characterized by colicky abdominal pain, vomiting and lack of feces and gas emission, with signs of abdominal distension, and sometimes increased peristalsis and fluid levels in the abdomen while standing plates.
Laparoscopic treatment of intraperitoneal adhesions is not a new technique as was used for over 60 years by gynecologists for the release of the annexes in the treatment of infertility. Semm performed by surgeons and others, in most cases, was reduced to lysis of adhesions to the parietal peritoneum omentum, not being up in recent years when the advancement of technology and expansion of laparoscopic surgical techniques has allowed treatment of the adhesions in the context of intestinal occlusion.
Flanges and postoperative adhesions, now represent the leading cause of small bowel obstruction, finding the etiology in approximately 70% of cases. Interventions most frequently found, as background, are appendectomy and gynecological surgery Clinically, the existence of such adhesions is, in tabular form of intestinal obstruction or acute chronic intermittent subocclusive lesions.
Most common typologies of intestinal obstruction.
Strangulation occurs most frequently in femoral hernias, and in descending order in the inguinal, umbilical, obsturadora. In large intra-saccular hernia adhesions, strangulation can occur inside the bag. At the end of the involvement of the intestinal loop strangulation, necrosis and perforation occur.
. Occlusion by adhesions.
Etiology is more, frequent bowel obstruction, the figures are 30-40% of all causes and 80% of cases occur in the postoperative period.
Occlusion by Meckel's diverticulum.
The formation of a volvulus or intestinal invaginaron are the two most common causes of intestinal obstruction.
In history, only 40 to 80% of patients have previous episodes of biliary disease. The etiology of ileus, occurs by the passage of a large stone vesicular the duodenum through a fistula caused by local pressure, ulcers and necrosis.
Is the penetration of a segment of intestine in an adjacent, compromising its light, with symptoms of acute intestinal obstruction. The most common is intussusception ileocolic.
Laparoscopic intestinal obstruction.
Placement of the patient and the surgeon.
The patient is installed supine under general anesthesia and nasogastric tube and bladder. With legs abducted on leg, allowing the positional movement of the surgeon.
In some cases, is situated on the left side or between the patient's legs in the first course, is the proper position for lower abdominal adhesiolysis in the parietal area and right colic and the second for the release of adhesions supremesocólico compartment.
A 14 mm Hg, we recommend the use of the art "open" using the Hasson trocar for safety, it is inserted through the camcorder. Supraumbilical be located at or away from this area if we can be obliterated by adhesions, being subsumed in the midline scar.
Placement of the trocars.
The introduction of the other 2 trocars, usually 10 mm, and already under visual control, can be made at predetermined sites or chosen for proper ergonomics to the assessment made by introducing the optics, the seat of adhesions or flanges to release. The first option relates to the need to introduce a third additional trocar often 10 mm trocars facilitate the exchange of laparoscopic instruments and placement of the optics, according to needs and the intervention times and may number one position of another trocar.
Lifting the abdominal wall by the pneumoperitoneum, promotes some degree the display of the cavity, and facilitates the exposure of adhesions, especially those of the parietal peritoneum, which form the laparoscopic vision, laces perpendicular adhesions and "hanging "in the peritoneal cavity.
Release of adhesions.
We consider it in two phases: one initial release webbed, non-pathogenic, we might call approach and exploration of the peritoneal space, and a second time, treatment which is the section of the fibrous adhesions, firmer or responsible for the box flange, which is witnessing the change of size of the handle. For lysis of adhesions is advisable to use scissors and hydrodissection, using coagulation (preferably bipolar) just to make the precise hemostasis. The critique of electrocoagulation is that after a certain period of employment, the smoke accumulates in the cavity making it difficult to sight and poor control of the plane of dissection, this incident is minimal, and keeping open and obvious easily controlled valve allowing the gas outlet with smoke, Laparoflator laparoscopic team is responsible for automatically inject CO2 to keep inflation pressures.
We will have to assess the possible advantages of the harmonic scalpel, which uses ultrasonic energy for precise cutting and controlled coagulation, not burning the tissues, or generating smoke.
Manipulation of the bowel loops.
Will be following a systematic, allowing a satisfactory evaluation of the small intestine along its length will be undertaken with great care (as mentioned above the increased risk of perforation), using more atraumatic clamps, making understanding the mesos, and using the increased weight of the handles filled with liquid and gas in our favor. This may be interesting to change the plane of inclination of the operating table.
The occurrence of a complication perforativa not have to mean a conversion, if you know the techniques of laparoscopic suturing skills or are used with stapler instruments adapted to laparoscopy. What one has to avoid is that a perforation goes unnoticed.
It has been suggested by some authors that there is a particular difficulty in laparoscopy to assess the severity of ischemia of the bowel loops, particularly at the level of the stricture remains in the area where occlusion occurred. In response, in addition to experience in this type of surgery, it is essential to a good white balance, and have a team that provides a quality image. If in doubt the feasibility of a loop is recommended to inspect the existence of pulse in the mesentery, and even wait ten minutes to see if regains normal coloration.
If you continue to doubt the viability of the handle, the wisest, will be assisted by laparoscopy and minilaparotomy but enough conversion to conventional surgery.
Laparoscopic surgery postoperative.
The postoperative laparoscopic adhesiolysis, is fast and gentle, if the technique has been effective, and there has been no iatrogenic bowel injury and the section of the flanges or adhesions was successful, the patient recovers soon and start intestinal peristalsis early fluid intake and ambulation. There is often no septic complications and therefore the patient is afebrile, if fever or delayed recovery of bowel function with maintenance of abdominal distension, suspect complications.