The patients non responders to the long-tube and conservative treatment Ro 61-8048 within 72 hours have a considerable risk of recurrent ASBO (Level of Evidence 2b GoR C). Risk factors for recurrences are age <40 years, matted adhesion
(Level of Evidence Mdivi1 in vitro 1b GoR A) and postoperative surgical complications [43]. Gastrografin use does not affect the recurrences rates or recurrences needing surgery when compared to traditionally conservatively treated patients (Level of Evidence 1b GoR A) [19]. Surgical treatment: open VS laparoscopic approach Open surgery is the preferred method for the surgical treatment of strangulating ASBO and after failed conservative management (LOE 2c GOR C). In highly selected group of patients the laparoscopic can be attempted using an open access technique (LOE 2c GOR C). The access in the left upper quadrant should be safe (LOE 4 GOR C). 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) (LOE 3b GOR C). A low threshold for open conversion should be maintained if extensive adhesions are found (LOE 2c GOR C). Conversion to laparoscopic-assisted adhesiolysis (mini-laparotomy with an incision Tideglusib chemical structure less than 4 cm long) or laparotomy should be considered in those patients presenting with dense or pelvic adhesion (LOE 3b GOR C). The extent of adhesiolysis is a matter still under debate. The approaches Org 27569 to adhesiolysis for bowel obstruction among general surgeons in the United Kingdom were established in 1993 [44]. Half of all surgeons divided all adhesions to prevent recurrence of bowel obstruction, whereas the other half limited adhesiolysis to only the adhesions responsible for the obstruction. The risk of anterior abdominal wall adhesions increases with the number of previous laparotomies although this relationship
is not as evident as the relationship between previous laparotomies and adhesiolysis-induced enterotomy [45, 46]. Higher age and higher number of previous laparotomies appeared to be predictors of the occurrence of inadvertent enterotomy [46]. Patients with three or more previous laparotomies had a 10-fold increase in enterotomy compared with patients with one or two previous laparotomies strongly suggesting more dense adhesion reformation after each reoperation. Historically, laparotomy and open adhesiolysis have been the treatment for patients requiring surgery for small bowel obstruction. Unfortunately, this often leads to further formation of intraabdominal adhesions with approximately 10% to 30% of patients requiring another laparotomy for recurrent bowel obstruction [29]. In animal models laparoscopy has been shown to decrease the incidence, extent, and severity of intraabdominal adhesions when compared with open surgery, thus potentially decreasing the recurrence rate for adhesive small bowel obstruction [47].
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