소장폐쇄환자에서 복강경 수술의 유용성

Abstract

Purpose: Laparoscopy is being used increasingly for the management of small bowel obstructions (SBOs), but only a few studies have examined the indications and utility of laparoscopic surgery in SBO. This study investigated the feasibility, effectiveness and safety of laparoscopic surgery in SBO, as well as the predictors of the success or failure of laparoscopic surgery.Methods: From June 2006 to March 2010, 73 patients underwent surgery for SBO at the Department of Surgery, Kyung Hee University Medical Center. The patients treated by laparoscopy were compared with those treated by laparotomy in terms of the differences in operative time, postoperative hospital stay and return of bowel function, as evidenced by the toleration of a liquid diet, surgical site infection and recurrence rate. A Chi-square test, student’s t-test and ANOVA test were performed to identify the predictors of success or failure of laparoscopic surgery, particularly the preoperative laboratory findings, vital signs, previous abdominal surgery, duration of illness, bowel diameter on abdomen plain film and location of the transition zone on computerized tomography.Results: Of the 73 cases, 30 cases were in the laparoscopic group (41.1%) and 43 cases were in the laparotomy group (58.9%). The postoperative hospital stay was significantly shorter in the laparoscopic group than in the laparotomy group (8.1±5.8 vs. 15.2±14.9 days, p=0.04), and the period until the return of bowel function was significantly shorter in the laparoscopic group than laparotomy group (4.3±3.1 vs. 6.6±3.6 days, p=0.02). The surgical site infection rate tended to be lower in the laparoscopic group than in the laparotomy group (4.5% vs. 23.3%, p=0.07) and the mean surgery time tended to be shorter in the laparoscopic group than in the laparotomy group (76.3±28.1 vs. 96.3±55.9 minutes, p= 0.06). There were no differences in the incidence of intraoperative bowel injury between the two groups (0/22 (0%) in the laparoscopic group vs. 2/43 (4.7%) in the laparotomy group, p=0.30), recurrence rate (0/22 (0%) vs. 3/43 (7.1%), p=0.34) and mortality rate (1/22 (4.5%) vs 0/43 (0%), p=0.30 respectively). The rate of conversion to open surgery was 26.7% (8/30). The causes of conversion to open surgery were severe bowel distension (2 cases), severe adhesion (2 cases), no visible cause of obstruction (1 case), iatrogenic bowel injury (1 case), bowel ischemia and perforation (1 case) and hemodynamic instability (1 case). There were no significant differences in the preoperative WBC count, CRP, pulse rate, number of past abdominal surgeries, duration of illness, bowel diameter on plain abdominal film and obstruction site between the successful group and conversion group, except for the significant differences in body temperature and marginal differences in the type of previous surgery.Conclusion: The laparoscopic approach has been shown to be safe and feasible in the management of SBO for selected patients. There were no pre-operative predictive factors for successful laparoscopy, except for factors such as afebrility and previous gynecological surgery. Nevertheless, larger, randomized prospective trials will be needed to determine the predictors of success or failure of laparoscopic surgery.