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 [74]. In fact to handle dilated and edematous bowel during adhesiolysis is dangerous and the risk increases with a long lasting obstruction; this is the reason why early operation is advisable as one multicenter study showed: the success rate for early laparoscopic intervention for acute SBO is significantly higher after a shorter duration

of symptoms (24 h vs 48 h) [75]. After trocar placement, the initial goal is to this website expose the collapsed distal bowel [74]. This is facilitated with the use of angled telescopes and maximal tilting/rotating of the surgical table. It may also be necessary to move the laparoscope to different trocars to improve visualization. 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 AZD5363 solubility dmso for possible bleeding and bowel injury. In AP26113 purchase conclusion, careful selection criteria for laparoscopy [76] may

be: (1) Hemodynamic stability and patient not in shock, (2) absence of peritonitis or severe intra-abdominal sepsis, (3) proximal i.e. SB obstruction, (4) localized distension on radiography, and/or (5) absence of severe abdominal distension, (6) anticipated single band, (7) low or intermediate predicted PAI score in < = 3 abdominal quadrants, and last but not least (8) the experience and laparoscopic skills of the surgeon. A partial obstruction is better first approached with a non-operative challenge with hyperosmolar water soluble contrast medium with both therapeutic and diagnostic purposes. A complete SB obstruction

should no longer be considered an exclusion criteria for laparoscopic approach. The experts panel also agreed, as from the cited studies, that laparoscopic lysis of adhesions should be attempted preferably in case of first episode of SBO and/or anticipated single band adhesion (i.e. SBO after appendectomy or hysterectomy). Previous midline incision is MTMR9 not an absolute exclusion criteria for laparoscopic approach. A multicenter series of 103 patients from the WSES – Iitalian Working Group on peritoneal adhesions and ASBO management, presented at the 2013 Clinical Congress of American College of Surgeons [77], described a safe and effective surgical technique for laparoscopic approach to ASBO and confirmed that laparoscopy should be attempted preferably in case of first episode of SBO and/or anticipated single band adhesion (i.e. SBO after appendectomy or hysterectomy).