Sebastian-Valverde et al. BMC Surgery (2019) 19:40 https://doi.org/10.1186/s12893-019-0504-x RESEARCH ARTICLE Open Access The role of the laparoscopic approach in the surgical management of acute adhesive small bowel obstruction Enric Sebastian-Valverde1* , Ignasi Poves1,2, Estela Membrilla-Fernández1, María José Pons-Fragero1 and Luís Grande1,2 Abstract Background: Postoperative adhesions represent 75% of all acute small bowel obstructions. Although open surgery is considered the standard approach for adhesiolysis, laparoscopic approach is gaining popularity. Methods: A retrospective study with data from a prospectively maintained data base of all patients undergoing surgical treatment for adhesive small bowel obstruction (ASBO) from January 2007 to May 2016 was conducted. Postoperative outcomes comparing open vs laparoscopic approaches were analysed. An intention to treat analysis was performed. The aim of the study was to evaluate the potential benefits of the laparoscopic approach in the treatment of ASBO. Results: 262 patients undergoing surgery for ASBO were included. 184 (70%) and 78 (30%) patients were operated by open and laparoscopic approach respectively. The conversion rate was 38.5%. Patients in the laparoscopic group were younger (p < 0.001), had fewer previous abdominal operations (p = 0.001), lower ASA grade (p < 0.001), and less complex adhesions were found (p = 0.001). Operative time was longer in the open group (p = 0.004). Laparoscopic adhesiolysis was associated with a lower overall complication rate (43% vs 67.9%, p < 0.001), lower mortality (p = 0.026), earlier oral intake (p < 0.001) and shorter hospital stay (p < 0.001). Specific analysis of patients with single band and/or internal hernia who did not need bowel resection, also demonstrated fewer complications, earlier oral intake and shorter length of stay. In the multivariate analysis, the open approach was an independent risk factor for overall complications compared to the laparoscopic approach (Odds Ratio = 2.89; 95% CI 1.1–7.6; p = 0.033). Conclusions: Laparoscopic management of ASBO is feasible, effective and safe. The laparoscopic approach improves postoperative outcomes and functional recovery, and should be considered in patients in whom simple band adhesions are suspected. Patient selection is the strongest key factor for having success. Keywords: Tissue adhesions, Small intestine, Intestinal obstruction, Laparoscopy, Length of stay Background laparoscopic approach has demonstrated benefits in Postoperative adhesions are the most common cause of other urgent and elective situations, offering lower mor- acute small bowel obstruction, representing 75% of all bidity, less postoperative pain and shorter hospital stay, cases. Around 50% will require surgical treatment, lapar- even in adhesive small bowel obstruction (ASBO) [1, 7]. otomy being the preferred approach [1]. The morbidity Nevertheless, laparotomy continues to be considered the and mortality of adhesiolysis remain significant, with standard surgical approach at most centres [1]. rates around 14–45 and 4% respectively [2–6]. The The main drawbacks related with the laparoscopic ap- proach in ASBO are: risk of intraoperative bowel injury, * Correspondence: esebastian@parcdesalutmar.cat difficulty handling the bowel loops, difficulty obtaining a 1 Department of Surgery, Hospital del Mar, Universitat Autònoma de correct view of the cause of the obstruction and the pre- Barcelona, Passeig Marítim 25-29, 08003 Barcelona, Spain sumably higher cost of the procedure [8]. However, in Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Sebastian-Valverde et al. BMC Surgery (2019) 19:40 Page 2 of 7 the guides of the World Society of Emergency Surgery hepato-bilio-pancreatic laparoscopic procedures and ex- Adhesive Small Bowel Obstruction working group [9, 10], perience in intracorporeal suturing. only factors related to pneumoperitoneum (hemodynamic Any assisted incision or laparotomy was considered to instability or cardiopulmonary impairment) are considered be a conversion regardless of its length. Postoperative absolute exclusion criteria for laparoscopic approach. The complications were recorded during hospitalization and absence of prospective randomized studies and the lack of up to 30 days after discharge. Mortality was assessed consensus in the indications regarding the most appropri- in-hospital or at 30-day postoperative. Quality outcomes ated approach have meant that laparoscopy remains the were measured using the Poor Quality Outcomes (PQO) second option in the surgical treatment of ASBO. variable. PQO was considered when a patient presented: The aim of our study is to evaluate the impact of the a major complication (Clavien-Dindo IIIb-V), or a minor laparoscopic approach on postoperative outcomes in our complication (II and IIIa) but with a prolonged hospital series of patients consecutively operated for ASBO. We stay beyond 15 days, and/or readmission within 30 days hypothesize that the laparoscopic approach is a feasible of discharge. choice for the ASBO and achieves better outcomes than The surgical approach of choice was decided by indi- the open approach in selected patients. vidual surgeons according to their personal criteria and laparoscopic skills. Hemodynamic instability, suspicion of intestinal ischemia, clearly hostile abdomen and pa- Methods tients with medical contraindications for pneumoperito- After Institutional Review Board approval, a retrospect- neum were considered contraindications for the ive study was conducted using data from a prospectively laparoscopic approach. maintained data base of the patients who underwent lap- aroscopic or open surgery for ASBO (including internal Statistical analysis hernias) at our centre from January 2007 to May 2016. Both the Chi-Square test and the Fisher’s exact test were Only urgent operations were considered for the analysis. used for categorical variables when appropriate, and the Following the protocol of our centre, when an ASBO is Mann-Whitney U test for continuous variables which suspected, a nasogastric tube is placed. If the suspected did not follow a normal distribution. An intention-to- diagnosis of adhesions is supported by clinical and radio- treat analysis was performed in which all the conversions logical data, once the stomach is empty, 100 ml of water were included in the laparoscopic group. The significant soluble oral contrast is administered in those patients variables in the bivariate analysis were included in the with previous abdominal operations. Those in whom multivariate analysis with a logistic regression. Results oral contrast did not reach the colon in 24 h were con- are expressed as n (%), mean values ± standard deviation sidered as a failure of the conservative management and (SD) or as median (interquartile range (IQR)). A p value surgical intervention is indicated. Patients in whom the less than 0.05 was considered significant. The standard cause of the obstruction was not ASBO (primary or program of the Statistical Package for the Social Sciences secondary neoplasm, gallstone ileus, bezoar, post-radio- (IBM® SPSS® Statistics Version 20, Chicago, IL, USA) therapy stenosis), were excluded, as well as obstructions was used for all the statistical analysis. caused by any type of abdominal wall hernia. The variables analysed were: a) preoperative: age, sex, Results American Society of Anesthesiologists (ASA) score, A total of 262 patients underwent surgical operation for number of previous abdominal operations, previous ab- ASBO, 78 (29.8%) by laparoscopy and 184 (70.2%) by dominal mesh; b) intraoperative: surgeon’s experience in open approach. Table 1 shows the patient’s baseline pre- advanced laparoscopy, surgical approach, conversion, operative characteristics of the entire sample and for the operative time, intraoperative findings, intraoperative subgroups. Patients who underwent laparotomy were injury; c) postoperative: morbidity, mortality, onset of significantly older, had more previous abdominal opera- oral intake, reoperation, length of hospital stay, readmis- tions and a higher ASA grade. sions and quality outcomes. The postoperative complica- Table 2 displays the intraoperative and postoperative tions were assessed according to the Clavien-Dindo variables. Although about 50% of all the ASBO were classification [11]. caused by complex adhesions, single bands and/or in- Simple adhesion was defined as a single well-defined ternal hernias predominated in the laparoscopy group band adhesion, clearly causing the bowel obstruction. and complex bands in the open group. 21% of the pa- Otherwise, adhesions were classified as complex. tients required intestinal resection, which was more fre- Expertise in advanced laparoscopy was considered for quent in open group (p = 0.014). However, the adhesion those surgeons with experience in more than 50 type was not associated with the need of intestinal resec- gastrointestinal, bariatric, colorectal or advanced tion (p = 0.743). 21 of 262 patients required a Sebastian-Valverde et al. BMC Surgery (2019) 19:40 Page 3 of 7 Table 1 Patient’s baseline demographics and summary of preoperative data Total Laparoscopy Open p N = 262 n = 78 n = 184 Age 66.06 ± 18.7 59.36 ± 18.7 68.9 ± 18 < 0.001 Female gender 137 (52.3) 41 (52.6) 96 (52.2) 0.954 Previous abdominal operation 225 (85.9) 62 (79.5) 163 (88.6) 0.053 N°. of previous abdominal operations 1.87 ± 1.6 1.4 ± 1.2 2.07 ± 1.7 0.001 Previous wall mesh placement 69 (26.5) 15 (19.5) 54 (29.5) 0.095 ASA < 0.001 I 22 (8.7) 13 (17.1) 9 (5.1) II 97 (38.2) 41 (53.9) 56 (31.5) III 112 (44.1) 20 (26.3) 92 (51.7) IV 23 (9.1) 2 (2.6) 21 (11.8) Values are n (%) unless otherwise specified as mean (± SD) reoperation. In Table 3, are shown the causes of experts and non-experts in laparoscopic approach (26.1% reoperation and the deaths for both laparoscopic and vs 56.1%; p = 0.007). but this was not associated to fewer open groups. reoperations (8.7% vs 3.1%; p = 0.643) nor fewer complica- Thirty patients (38.5%) were converted due to: technical tions (41.3 vs 46.9%; p = 0.626) respectively. difficulty in 20; need for extensive bowel resection in five; Seventeen (6.5%) patients died. Although no signifi- intestinal intraoperative injury in four; and trocar haemor- cant differences were found, mortality rate was higher in rhage in one. Comparison of outcomes between patients with complex adhesions (9% vs 3,9%; p = 0.091) non-converted and converted patients of the laparoscopic and bowel resection (10.9% vs 5.3%; p = 0.213). The group is shown in Table 4. No differences were found in mean age of the 17 patients who died was 80.5 years, 8 age, ASA or number of previous surgeries. Significant dif- were ASA IV, 12 had complex adhesions and 6 required ferences were found in the conversion rate among the intestinal resection. Table 2 Perioperative data, complications and postoperative variables Total Laparoscopy Open p N = 262 n = 78 n = 184 Advanced laparoscopic skills 70 (26.8) 46 (59) 24 (13.1) < 0.001 Intraoperative findings 0.001 Single band or internal hernia 129 (49.2) 53 (67.9) 76 (41.3) Complex adhesions 133 (50.8) 25 (32.1) 108 (58.7) Operative time 120.75 ± 60.5 103.11 ± 48.2 128.41 ± 63.8 0.004 Intraoperative injury 28 (10.7) 6 (7.7) 22 (12) 0.307 Postoperative complications < 0.001 No 103 (39.3) 44 (56.4) 59 (32.1) Yes 159 (60.7) 34 (43.6) 125 (67.9) Clavien-Dindo I-II-IIIa 113 (43.1) 28 (35.9) 85 (46.2) 0.102 IIIb-IV-V 46 (17.6) 6 (7.7) 40 (21.7) Mortality 17 (6.5) 1 (1.3) 16 (8.7) 0.026 Reoperation 21 (8) 5 (6.4) 16 (8.7) 0.533 Poor Quality Outcomes 86 (33.1) 13 (16.7) 73 (40.1) < 0.001 Onset of oral intake 5.18 ± 5.4 3.83 ± 4.1 5.85 ± 5.8 < 0.001 Length of hospital stay 9 (5–15) 5 (3–10) 11 (7–17) < 0.001 30-day postoperative readmissions 17 (7) 3 (3.9) 14 (8.4) 0.201 Values are n (%) unless otherwise specified as mean ± SD or median (IQR) Sebastian-Valverde et al. BMC Surgery (2019) 19:40 Page 4 of 7 Table 3 Causes of reoperation in laparoscopic and open group approach in this subgroup, laparoscopy presented sig- Causes ITT Laparoscopy Open nificant lower morbidity, less PQO, earlier oral intake n=5 n = 16 and shorter length of hospital stay. In the multivariate Haemorrhage 1 (a)(b) 2 (a) (c) anlaysis (Table 7), the open approach emerged as an in- Evisceration 1 4 (a) dependent factor for the increase in complications. On Anastomotic leak – 3 (a) contrary, among the patients with complex adhesions and/or those patients who required intestinal resection, Missed bowel injury 1 2 we did not find differences in reoperation (12.9% vs 8.6%; Intraabdominal abscess 1 2 p = 0.495), complications (67.7% vs 72.7%; p = 0.586) and Surgical Wound Infection – 1 PQO (29% vs 44.1%; p = 0.127), between laparoscopic and Early adhesions recurrence 1 2 open group respectively. There were also no differences in ITT intention to treat operative time (p = 0.926), oral intake (p = 0.371) and (a) Death of a patient hospital stay (p = 0.079). (b) Haemorrhage of the epigastric artery due to a paracentesis in a cirrhotic patient (c)One subcutaneous bleeding(a) and one bladder haemorrhage in patient Discussion with a iatrogenic ureter injury The results of our study show that the laparoscopic ap- proach in the management of ASBO is associated with Table 5 shows Odds Ratio (OR) for each variable better postoperative outcomes, lower morbidity, fewer for overall complications in the bivariate and multi- PQO, an earlier onset of oral intake and a shorter length variate analyses. The open approach presented an of hospital stay, especially for selected patients with sim- OR = 2.74 (95% CI 1.59–4.72; p < 0.001) in the bivari- ple adhesions. The number and type of previous opera- ate analysis, however, in the multivariate analysis it tions and peritoneal damage have been considered an did not reach statistical significance (OR = 1.58; 95% important risk factors involved in the pathogenesis of CI 0.78–3.22; p = 0.204), due to an increase in com- adherences [12]. Some studies have also associated the plications in converted patients (OR = 21.66; 95% CI size of the laparotomy with the formation of new adhe- 6.5–72.15; p < 0.001). In the multivariate analysis, sions [13], and have quantified the prevalence of postop- age, the need for intestinal resection and the pres- erative adherences as high as 93% [14]. A study ence of complex adhesions were associated with an comparing two groups of 205 patients undergoing either increase in complications. laparoscopic and open colorectal surgery, did not find On Table 6 are shown the results of the subgroup of differences in admissions for intestinal obstruction (9% patients operated for single bands and/or internal her- vs 13%) but reported a higher indication for surgery in nias without intestinal resection. Compared to open the open approach when present (2% vs 8%; p = 0,006) [15]. Similarly, in a review by Burns et al. of 187,148 pa- Table 4 Comparison of perioperative data, complications and tients who underwent colorectal surgery, 3.5% required postoperative variables between non-converted and converted adhesiolysis within three years of surgery. In that study patients in laparoscopic group the patients who underwent laparoscopic approach, had Non-converted Converted p a lower percentage of readmissions and less need for re- n = 48 n = 30 operation for adhesions (OR = 0.8; p < 0.001) [16]; in Advanced laparoscopic skills 34 (70.8) 12 (40) 0.007 agreement with other studies [17, 18]. Therefore, lapar- Intraoperative findings 0.029 otomy in the management of ASBO is in itself, a factor Single band or internal hernia 37 (77.1) 16 (53.3) for the development of new episodes of ASBO and does Complex adhesions 11 (22.9) 14 (46.7) not seem theoretically the best option. Since Bastug reported the first laparoscopic adhesioly- Intestinal resection 2 (4.2) 7 (23.3) 0.023 sis in 1991 [19], laparoscopic approach has demon- Operative time 78 ± 30.7 143.8 ± 43.6 < 0.001 strated its feasibility and safety. Postoperative morbidity Intraoperative injury 1 (2.1) 5 (16.7) 0.029 varies from 4 to 40% according to the series [20]. In a Postoperative complications 9 (18.8) 25 (83.3) < 0.001 systematic review of 13,728 patients, Wiggins et al. [7], Mortality 0 (0) 1 (3.3) 0.385 found a reduction in overall morbidity after laparoscopy Reoperation 1 (2.1) 4 (13.3) 0.069 (OR = 0.34; p = 0.0001) and other authors have corrobo- rated these results [3, 4, 7, 21, 22]. In our study, we Poor Quality Outcomes 4 (8.3) 9 (30) 0.012 found a reduction in overall morbidity from 67.9 to Onset of oral intake 2.2 ± 2.7 6.3 ± 4.6 < 0.001 43.6% in the laparoscopic group. Although both rates Length of hospital stay 4 (1–7) 10 (1–19) < 0.001 are higher than those previously reported, we stress that Values are n (%) unless otherwise specified as mean ± SD or median (IQR) 82.4% of the complications in laparoscopic group and Sebastian-Valverde et al. BMC Surgery (2019) 19:40 Page 5 of 7 Table 5 Bivariate and logistic regression analysis for overall complications BIVARIATE MULTIVARIATE Laparoscopy vs Open OR (95% CI) p OR (95% CI) p Approach Laparoscopy 1 1 Open 2.74 (1.59–4.72) < 0.001 1.58 (0.78–3.22) 0.204 Totally laparoscopic 1 Open 9.18 (4.17–20.19) < 0.001 Converted 21.66 (6.5–72.15) < 0.001 Age 1.03 (1.02–1.05) < 0.001 1.03 (1–1.04) 0.002 Male gender 0.94 (0.57–1.55) 0.828 0.99 (0.56–1.74) 0.987 N°. of previous abdominal operations 1.32 (1.09–1.61) 0.005 1.13 (0.92–1.38) 0.237 ASA 2.17 (1.52–3.1) < 0.001 1.25 (0.81–1.92) 0.311 Intestinal resection 2.48 (1.26–4.9) 0.009 2.2 (1–4.7) 0.044 Complex adhesions 2.54 (1.52–4.23) < 0.001 2 (1.1–3.6) 0.021 Advanced laparoscopic skills 0.7 (0.4–1.22) 0.212 1.18 (0.58–2.41) 0.647 Table 6 Patient demographics, perioperative and postoperative data for patients with single band or internal hernias without intestinal resection Total Laparoscopy Open p n = 103 n = 47 n = 56 Age 64.6 ± 18.8 60.43 ± 18 68.11 ± 18.8 0.021 Female gender 57 (55.3) 26 (55.3) 31 (55.4) 0.997 Previous abdominal operations 83 (80.6) 36 (76.6) 47 (83.9) 0.349 N°. of previous abdominal operations 1.47 ± 1.17 1.34 ± 1.2 1.57 ± 1.1 0.187 ASA 0.098 I 11 (10.8) 6 (13) 5 (8.9) II 51 (50) 28 (60.9) 23 (41.1) III 35 (34.3) 11 (23.9) 24 (42.9) IV 5 (4.9) 1 (2.2) 4 (7.1) Operative time 90.7 ± 46.3 81.93 ± 38 98.17 ± 51.45 0.188 Intraoperative injury 2 (1.9) 1 (2.1) 1 (1.8) 1 Postoperative complications 0.003 No 58 (56.3) 34 (72.3) 24 (42.9) Yes 45 (43.7) 13 (27.7) 32 (57.1) Clavien-Dindo 0.134 IIIa 33 (32) 12 (25.6) 21 (37.5) IIIb-IV-V 12 (11.7) 1 (2.1) 11 (19.6) Mortality 2 (1.9) 0 (0) 2 (3.6) 0.191 Reoperation 6 (5.8) 1 (2.1) 5 (8.9) 0.216 Poor Quality Outcomes 21 (20.4) 4 (8.5) 17 (30.4) 0.006 Onset of oral intake 3.76 ± 3.2 2.39 ± 1.9 4.89 ± 3.6 < 0.001 Length of hospital stay 6 (4–11.5) 4 (3–8) 9.5 (6–15.25) < 0.001 Values are n (%) unless otherwise specified as mean ± SD or median (IQR) Sebastian-Valverde et al. BMC Surgery (2019) 19:40 Page 6 of 7 Table 7 Multiple regression analysis of single band or internal our study, any incision enlargement was considered a hernia without intestinal resection for overall complications conversion, and so our conversion rate of 38.5%, is MULTIVARIATE within the published limits. Some studies suggest that lap- Laparoscopy vs Open aroscopic success depends on: early treatment (< 24 h after OR (95% CI) p admission in emergency room), diameter of the bowel Approach loops < 4 cm, a maximum of two previous surgeries, no Laparoscopy 1 previous midline laparotomies, single band adhesions, and Open 2.89 (1.1–7.6) 0.033 the surgeon’s experience [9, 23]. The surgeon’s experience in advanced laparoscopy was a decisive factor in conver- Age 1.03 (1–1.1) 0.034 sion in our study. One of our highlights, which has already Male gender 0.9 (0.4–2.2) 0.827 been reported, is the increased morbidity and mortality re- N°. of previous abdominal operations 1.07 (0.7–1.5) 0.734 lated to conversion [5, 20, 24]. In our study, the complica- ASA 1.6 (0.8–3.3) 0.203 tion rate was 83.3% in converted patients, although 80% Advanced laparoscopic skills 1.28 (0.5–3.6) 0.631 were mild complications. This could be explained by a higher rate of complex adhesions and intestinal resection in converted group. Since most conversions are due to technical difficul- 63.2% of those in the open group were minor ties and the inability to identify the cause of the ob- (Clavien-Dindo I-II). Reoperation rates were 6.4 and struction, it is logical to think that patients with single 8.7% for laparoscopic and open approach respectively, adhesions and/or internal hernias without need for re- which were both similar to those reported in other stud- section will be the ideal candidates for laparoscopy. ies [7]. The Clavien-Dindo classification may underesti- The conversion rate for patients with simple adhesions mate or overestimate complications, regardless of the fell to 23.4%. Moreover, in our study, the laparoscopy number of complications or their effect on length of has not demonstrated to improve the outcomes in pa- hospital stay. For this reason, in the PQO variable we tients with complex and/or with intestinal resection. jointly analysed, the major complications, prolonged For this reason, further specific studies are now needed hospital stay and readmissions in order to assess which to determine the risk factors related to a higher prob- group presented worse outcomes overall. The laparo- ability to identify single adhesions and/or internal her- scopic approach showed better postoperative outcomes, nias; and to analyse risk factors for conversion. Our so it seems that not only the number and grade of com- study has a selection bias already present in other simi- plications matters, but also in case of presenting compli- lar retrospective studies [25], since patients in the lap- cations, these seems to have less clinical impact. aroscopic group are younger, with a lower ASA score One of the drawbacks of the laparoscopic approach is and fewer previous operations. This bias may alter post- the possibility of intraoperative intestinal tearing during operative outcomes compared to the open approach, handling, especially in severe adhesions and multiple and so prospective randomized studies are needed to previous operations [9]. In a review of 19 studies includ- validate the results obtained in this study. At present, ing 1061 cases of ASBO operated by laparoscopy, rates only one randomized prospective trial is underway, of recognized intraoperative enterotomy and missed per- scheduled to finish in 2018 [26]. foration were 6.5 and 0.8% respectively [6]. Dindo et al. Despite these limitations, we think that the results [20] reported an intraoperative lesion rate of 9.5% and obtained are robust enough to confirm the benefits of O’Connor et al. a rate of 6.6% [2]. Unlike most published the laparoscopic approach in ASBO, especially in studies, our study found a lower rate of perforation in selected patients with simple adhesions and when laparoscopy, possibly due to the higher percentage of performed by surgeons skilled in advanced laparo- complex adhesions in open surgery (58.7% vs 32.1%) or scopic surgery. to the low threshold for open conversion recommended by the guidelines [9]. Our results suggest that laparos- copy is a safe technique that does not increase the intra- Conclusions operative risk of enterotomy. The laparoscopic approach for adhesive small bowel ob- A previous review of over 2000 cases reported a struction and/or internal hernias was associated with conversion rate as high as 36, and 6.7% of cases were better postoperative outcomes, earlier oral intake, better considered laparoscopic-assisted [2]. A swiss registry quality outcomes and shorter length of hospital stay also reported a conversion rate of 32.4% in 537 pa- than the open approach, especially in selected patients tients, including elective surgeries [20], and Ming-Zhe with simple band adhesions. Patient selection is the et al. published rates ranging from 26 to 51.9% [4]. In strongest key factor for having success. Sebastian-Valverde et al. BMC Surgery (2019) 19:40 Page 7 of 7 Abbreviations 7. Wiggins T, Markar SR, Harris A. Laparoscopic adhesiolysis for acute small ASA: American Society of Anesthesiologists; ASBO: adhesive small bowel bowel obstruction: systematic review and pooled analysis. Surg Endosc. obstruction; IQR: interquartile range; OR: Odds Ratio; PQO: poor quality 2015;29:3432–42. outcomes 8. Suter M, Zermatten P, Halkic N, Martinet O, Bettschart V. Laparoscopic management of mechanical small bowel obstruction: are there predictors Acknowledgements of success or failure? Surg Endosc. 2000;14:478–83. Not applicable. 9. Di Saverio S, Coccolini F, Galati M, Smerieri N, Biffl WL, Ansaloni L, Tugnoli G, Velmahos GC, Sartelli M, Bendinelli C, Pereira Fraga G, Kelly MD, Moore FA, Funding Mandalà V, Mandalà S, Masetti M, Jovine E, Pinna AD, Peitzman AB, This research did not receive any specific grant from public funding Leppaniemo A, Sugarbaker PH, Van Goor H, Moore EE, Jeekel J, Catena F. agencies, commercial, or non-profit sectors. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2013 update of the evidence-based guidelines from the Availability of data and materials world society of emergency surgery ASBO working group. World J Emerg The datasets used and/or analysed during the current study are not Surg. 2013;8:42. publically available. Permissions to access the data were obtained form the 10. Catena F, Di Saverio S, Kelly MD, Biffl WL, Ansaloni L, Mandalà V, Velmahos Ethical Committee in Clinical Research. Database is available from the GC, Sartelli M, Tugnoli G, Lupo M, Mandalà S, Pinna AD, Sugarbaker PH, Van corresponding author on reasonable request. Goor H, Moore EE, Jeekel J. Bologna guidelines for diagnosis and Management of Adhesive Small Bowel Obstruction (ASBO): 2010 evidence- based guidelines of the world Society of Emergency Surgery. World J Authors’ contributions Emerg Surg. 2011;6:5. ESV and IP performed research and wrote the paper; EMF and MJPF 11. Dindo D, Demartines N, Clavien P-A. Classification of surgical complications: performed research and collecting data; LG contributed to critical revision of a new proposal with evaluation in a cohort of 6336 patients and results of a the manuscript for important intellectual content. All authors have read and survey. Ann Surg. 2004;240:205–13. approved the manuscript. 12. Duepree H-J, Senagore AJ, Delaney CP, Fazio VW. Does means of access affect the incidence of small bowel obstruction and ventral hernia after bowel Ethics approval and consent to participate resection? Laparoscopy versus laparotomy. J Am Coll Surg. 2003;197:177–81. The study was approved by the Ethical Committee in Clinical Research of the 13. Beck DE, Opelka FG, Bailey HR, Rauh SM, Pashos CL. Incidence of small- Parc de Salut Mar (Hospital del Mar, Barcelona). Internal Reference Number: bowel obstruction and adhesiolysis after open colorectal and general 2016/7042/I. surgery. Dis Colon Rectum. 1999;42:241–8. 14. Menzies D, Ellis H. Intestinal obstruction from adhesions--how big is the Consent for publication problem? Ann R Coll Surg Engl. 1990;72:60–3. Not applicable. The Ethical Committee in Clinical Research of the Parc de 15. Reshef A, Hull TL, Kiran RP. Risk of adhesive obstruction after colorectal Salut Mar (Hospital del Mar, Barcelona) approved the study with a consent surgery: the benefits of the minimally invasive approach may extend well waiver due to the characteristics of the study. Internal Reference Number: beyond the perioperative period. Surg Endosc. 2013;27:1717–20. 2016/7042/I. 16. Burns EM, Currie A, Bottle A, Aylin P, Darzi A, Faiz O. Minimal-access colorectal surgery is associated with fewer adhesion-related admissions Competing interests than open surgery. Br J Surg. 2013;100:152–9. The authors declare that they have no competing interests. 17. Aquina CT, Probst CP, Becerra AZ, Iannuzzi JC, Hensley BJ, Noyes K, Monson JR, Fleming FJ. Missed opportunity: laparoscopic colorectal resection is associated with lower incidence of small bowel obstruction compared to Publisher’s Note an open approach. Ann Surg. 2016;264:127–34. Springer Nature remains neutral with regard to jurisdictional claims in 18. Bartels SAL, Vlug MS, Hollmann MW, Dijkgraaf MGW, Ubbink DT, Cense HA, published maps and institutional affiliations. van Wagensveld BA, Engel AF, Gerhards MF, Bemelman WA, Collaborative LAFA study group. Small bowel obstruction, incisional hernia and survival Author details 1 after laparoscopic and open colonic resection (LAFA study). Br J Surg. 2014; Department of Surgery, Hospital del Mar, Universitat Autònoma de 101:1153–9. Barcelona, Passeig Marítim 25-29, 08003 Barcelona, Spain. 2IMIM (Hospital del 19. Bastug DF, Trammell SW, Boland JP, Mantz EP, Tiley EH. Laparoscopic Mar Medical Research Institute), Barcelona, Spain. adhesiolysis for small bowel obstruction. Surg Laparosc Endosc. 1991;1:259–62. 20. Dindo D, Schafer M, Muller MK, Clavien P-A, Hahnloser D. Laparoscopy for Received: 13 November 2017 Accepted: 9 April 2019 small bowel obstruction: the reason for conversion matters. Surg Endosc. 2010;24:792–7. 21. Byrne J, Saleh F, Ambrosini L, Quereshy F, Jackson TD, Okrainec A. 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