Laparoscopic adhesiolysis for small bowel obstruction in patients with abdominal surgical history: what makes it technically challenging?

Abstract

Background: Laparoscopic adhesiolysis (LA) has increasingly been adopted as a treatment option for small bowel obstruction (SBO). However, repeated operations and the resulting dense adhesions can make adhesiolysis technically challenging. Although LA generally yields better short-term outcomes than open adhesiolysis (OA), its benefits in patients with prior abdominal surgery, who often present with complex adhesions, remain unclear. Moreover, the pathophysiological characteristics and surgical pitfalls in such patients have not been sufficiently discussed.

Methods: This single-center retrospective study included 373 consecutive patients who underwent surgery for adhesive SBO between 2009 and 2024. Particularly among the 301 patients with a history of prior abdominal surgery, postoperative outcomes between LA and OA were compared, and risk factors for technically difficult cases and complications were analyzed.

Results: The impact of prior abdominal surgery was more pronounced in patients treated with LA than with OA. In the propensity score-matched cohort, LA resulted in faster bowel recovery, fewer complications, and shorter hospitalization compared with OA (p < 0.05). Conversion to OA occurred in 15.8% of LA-attempted cases, mainly due to dense adhesions (68.4%), and was associated with complication rates comparable to those of OA. Higher BMI (odds ratio (OR): 1.15, p = 0.003) and prior malignancy surgery (OR: 2.29, p = 0.014) independently predicted dense adhesions, whereas a 15-min increase in operative time (OR: 1.40, p < 0.001) was a significant risk factor for complications. As the operative time of LA increased, complication rates rose markedly, approaching those of OA.

Conclusions: LA completion demonstrates overall advantages even in patients with prior abdominal surgery; however, in technically demanding cases with prolonged operative times or the need for conversion, complication rates approximate those of OA, warranting prudent case selection.