Miss Emergency, Band 2: Diagnose Herzklopfen (German Edition)

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In this review again contraindications to the minimally invasive technique include the following: 1 massive abdominal distension that precludes entry into the peritoneal space and limits adequate working space; 2 the presence of peritonitis with the need for bowel resection and bowel handling in a highly inflamed environment; 3 hemodynamic instability; 4 severe comorbid conditions such as heart and lung diseases that preclude the use of pneumoperitoneum; and 5 finally, but certainly not the least important, the surgeon's comfort level.

Operative time was shortest in the laparoscopy group The author's conclusion confirmed that the parameters associated with successful laparoscopic management of SBO are the presence of isolated bands, lower ASA scorse, younger age, fewer prior operations, and a shorter duration of SBO obstruction before the operation.

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Reasons for primary laparotomy included a state of prolonged ileus with progressive abdominal distension and a higher number or more extensive previous operations. Reasons for converting to open adhesiolysis following initial laparoscopy were inadequate laparoscopic control due to intestinal distension, extensive adhesions, iatrogenic intestinal perforation and the presence of necrotic segments of the small bowel upon initial laparoscopy, requiring secondary open resection.

Zerey et al. Mean procedural time was minutes range, minutes. Only one patient had a recurrent SBO 8 months postoperatively managed by repeat laparoscopic lysis of adhesions. Mean postoperative stay was 6 days. In a series of 17 patients scheduled for elective adhesiolysis [ ], laparoscopic treatment was successful in 14 patients Leon et al. Operative technique has capital role for a successful laparoscopic treatment [ ]. The initial trocar should be placed away alternative site technique from the scars in an attempt to avoid adhesions.

Some investigators have recommended the use of computed tomography scan or ultrasonography to help determine a safe site for the initial trocar insertion. The left upper quadrant is often a safe place to gain access to the abdominal cavity. Alternatively a 10 mm port can be inserted in the left flank with two additional 5 mm ports in the left upper and lower quadrant. Therefore, by triangulating 3 ports aimed at the right lower quadrant, a good exposure and access to the right iliac fossa can be obtained and a technique running the small bowel in a retrograde fashion, starting from the ileocecal valve decompressed intestine proximally towards the transition point between collapsed and dilated loops.

The open Hasson approach under direct vision is the more prudent. Once safe access is obtained, the next goal is to provide adequate visualization in order to insert the remaining trocars. This often requires some degree of adhesiolysis along the anterior abdominal wall. Numerous techniques are available, including finger dissection through the initial trocar site and using the camera to bluntly dissect the adhesions. Sometimes, gentle retraction on the adhesions will separate the tissue planes.


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Most often sharp adhesiolysis is required. The use of cautery and ultrasound dissection should be limited in order to avoid thermal tissue damage and bowel injury. The risk of enterotomy can be reduced if meticulous care is taken in the use of atraumatic graspers only and if the manipulation of friable, distended bowel is minimized by handling the mesentery of the bowel whenever possible. In fact to handle dilated and edematous bowel during adhesiolysis is dangerous and the risk increases with a long lasting obstruction; therefore early operation is advisable as one multicenter study showed that the success rate for early laparoscopic intervention for acute SBO was significantly higher after a shorter duration of symptoms 24 h vs 48 h [ ].

Maintaining a low threshold for conversion to laparotomy in the face of extensive adhesions will further decrease the risk of bowel injury. After trocar placement, the initial goal is to expose the collapsed distal bowel. It may also be necessary to move the laparoscope to different trocars to improve visualization. If necessary, the small bowel mesentery instead of the bowel wall should be grasped in order to manipulate the bowel. Sharp dissection with the laparoscopic scissors should be used to cut the adhesions.

Only pathologic adhesions should be lysed.

Additional adhesiolysis only adds to the operative time and to the risks of surgery without benefit. The area lysed should be thoroughly inspected for possible bleeding and bowel injury. In conclusion, careful selection criteria for laparoscopy [ ] may be: 1 proximal obstruction, 2 partial obstruction, 3 anticipated single band, 4 localized distension on radiography, 5 no sepsis, 6 mild abdominal distension and last but not least 7 the experience and laparoscopic skills of the surgeon.

SBO after appendectomy or hysterectomy. Furthermore the experts highlighted that an open port access should be attempted, and gaining the access in the left upper quadrant should be safe.

However a large consensus has been reached in recommending a low threshold for open conversion if extensive adhesions are found. A systematic review including a total of , abdominal operations found an overall incidence of SBO of 4. The risk of SBO was highly influenced by the type of procedure, with ileal pouch-anal anastomosis being associated with the highest incidence of SBO Gynecological procedures were associated with an overall incidence of Another multicer prospective study [ ] showed that the cumulative incidence of overall recurrence of ASBO was Therefore, in view of the incidence of adhesions and recurrence rates of ASBO as well as of the magnitude of the medical problems and financial burden related to adhesions, prevention or reduction of postoperative adhesions in an important priority.

Even though awareness of this problem is widely agreed among surgeons and gynaecologists, uncertainty still exists about the treatment and prophylactic strategies for dealing with adhesions [ ].

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A recent national survey among Dutch surgeons and surgical trainees [ ] showed that underestimation of the extent and impact of adhesions resulted in low knowledge scores and Lower scores correlated with more uncertainty about indications for antiadhesive agents which, in turn, correlated with never having used any of these agents.

Several articles on adhesion barriers have been published but several controversies such as the effectiveness of available agents and their indication in general surgical patients still exist. Most of the available literature is based on gynecologic patients. For general surgical patients no recommendations or guidelines exist. Any prevention strategy should be safe, effective, practical, and cost effective. A combination of prevention strategies might be more effective [ ].

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The prevention strategies can be grouped into 4 categories: general principles, surgical techniques, mechanical barriers, and chemical agents. Intraoperative techniques such as avoiding unnecessary peritoneal dissection, avoiding spillage of intestinal contents or gallstones [ ], and the use of starch-free gloves [ , ] are basic principles that should be applied to all patients. In a large systematic review [ ], the closure of the peritoneum, spillage and retention of gallstones during cholecystectomy, and the use of starched gloves all seems to increase the risk for adhesion formation.

The surgical approach open vs laparoscopic surgery plays an important role in the development of adhesive SBO. In the long term follow up study from Fevang et al. The technique of the procedure open vs.

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The incidence was 7. There was no difference in SBO following laparoscopic or open appendectomies 1. In most abdominal procedures the laparoscopic approach is associated with a significantly lower incidence of adhesive SBO or adhesion-related re-admission. In a collective review of the literature the incidence of adhesion-related re-admissions was 7.

Only in appendectomies there was no difference between the two techniques [ ]. There is some class I evidence in obstetrics supporting the theory that suturing the peritoneum increases the risk of adhesions [ ]. It is therefore prudent to avoid peritoneal closure during laparotomies. In theory, inert materials that prevent contact between the damaged serosal surfaces for the first few critical days allow separate healing of the injured surfaces and may help in the prevention of adhesion formation.

Various bioabsorbable films or gels, solid membranes, or fluid barrier agents have been tested experimentally and in clinical trials. Its safety with regard to systemic or specific complications has been established in many studies, including a safety study of 1, patients with abdominal or pelvic surgery, however there are concerns about a higher incidence of anastomotic leaks in cases in which the film is placed directly around the anastomosis [ ].

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Several prospective randomized controlled trials showed efficacy in reducing the incidence and extent of postoperative adhesions. In a prospective, randomized, multicenter, double-blind study of evaluable patients with colectomy and ileoanal pouch procedure, compared Seprafilm with controls, The Seprafilm group had significantly fewer and less severe adhesions and well as of reduced extent [ ]. A further prospective multicenter study, randomized 71 patients undergoing Hartmann's resection into a Seprafilm and a control group: although the incidence of adhesions did not differ significantly between the study groups, the Seprafilm group showed a significant reduction of the severity of adhesions [ ].

Cohen et al, in a prospective multicenter trial, randomized patients with colectomy and ileal pouch surgeries into a Seprafilm and a control group [ ]. The outcomes included incidence and severity of adhesions and were assessed laparoscopically by a blinded observer at a second surgery 8 to 12 weeks later for ileostomy closure.

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Treatment with Seprafilm significantly reduced the incidence and severity of adhesions. Kumar et al in a recent Cochrane collective review of 6 randomized trials with nongynecologic surgical patients found that Seprafilm significantly reduced the incidence of adhesions OR,.

Although there is satisfactory class I evidence that Seprafilm significantly reduces the incidence and severity of postoperative adhesions, there is fairly limited work on the effect of this adhesion reduction on the incidence of SBO. Fazio et al in a prospective, randomized, multicenter, single-blind study of 1, patients with intestinal resection compared Seprafilm with no treatment intervention.

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