Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 674 - файл

It is very important to evaluate preoperative imaging, inspect the abdomen, and avoid previous surgical incisions. The open access in the abdominal cavity is the gold standard, usually away from previous surgical scars. The use of Veress tech­nique is almost never recommended, but if the surgeon is familiar with this approach, the Veress needle is used in right upper quadrant or left upper quadrant. When the access is done, inspect the anterior abdominal wall with the laparoscopic camera for additional safe entry points. After the positioning of the trocar is important to use sharp dissection of adhesion and where it is possible avoid energy use. It is also mandatory to fully explore the small bowel starting from the cecum and running the small bowel distal to proximal until the transition point is found and the band/transi­tion point identied. After the release of the band, the passage into distal bowel is restored, and the strangulation mark on the bowel wall is visible and should be care­fully inspected. The intestine must never be manipulated directly if it is very dis­tended due to the risk of iatrogenic perforation. If distended bowel must be grasped, ensure large bites that use the entire jaw of the grasper and always prefer the use of laparoscopic forceps with long bite to distribute the tension of the grip over a larger surface and always grasp the intestinal loops in two different places. Approximately 30% of cases that are initiated laparoscopically for SBO are converted to an open procedure. There are several critical moments in which the decision to convert to an open procedure should be considered, to avoid or repair injured bowel. If it is not possible to place trocars in correct positions, the conversion is mandatory. In addi­tion, other causes of conversion are as follows: distal collapse bowel is not identied and grasped, the procedure is not advance for signicant dilatation of the bowel, the intestine is ischemic, and a bowel resection is necessary when a bowel injury has occurred.

Strategies for reduction of adhesions are based on their pathophysiological mecha­nisms of origin. Factors that may limit adhesion formation include preference for tissue-sparing and microinvasive surgical techniques, minimization of operating time and of heat, covering anastomosis and raw peritoneal surfaces and light and avoidance of peritoneal trauma by superuous contact and coagulation. Before clo­sure of the abdominal wall, therefore, it is advisable to perform careful—though not excessive, to avoid necrosis—hemostasis and irrigate repeatedly with saline and Ringer solution. In high-risk patients, the use of adjuvants that reduce adhesions can be applied. The 4% glucose polymer icodextrin is an adhesion-inhibiting peritoneal instillate. By virtue of its osmotic activity, it is thought to retain uid in the perito­neal cavity for 3–4days and keep organs and injured peritoneal surfaces separated from each other until it is eliminated via the kidneys. Comparison of icodextrin and Ringer’s lactate revealed an advantage for the former with regard to the reduction of incidence (52% vs. 32%), extent (52% vs. 47%), and severity (65% vs. 37%) of adhesions. Clinical improvement was observed in 49% of patients following treat­ment with icodextrin, against 38% after Ringer’s lactate. Carboxymethylcellulose (CMC) and polyethylene oxide (PEO) form a gel-like resorbable barrier to adhesions.