Abstract
Small bowel obstruction in virgin abdomen (SBO-VA) is rarely encountered and there is no standard treatment strategy. Even though nonoperative management is advocated in recent studies, studies evaluating the outcomes and results of laparoscopic surgery in these patients are lacking. This study aimed to compare the results of laparoscopic and open surgeries in SBO-VA patients. Thirty-five patients, ≥18 years old, who were admitted to the Hacettepe University Faculty of Medicine, General Surgery Department between January 2018 and December 2023 with virgin abdomen intestinal bowel obstruction and underwent open surgery and laparoscopic surgeries, were analyzed retrospectively. The demographic and clinical characteristics of patients were analyzed from hospital records. For 19 patients, laparoscopic surgery was conducted; for 16 patients, open surgery was conducted. Adhesions (60%) were the most common underlying etiology followed by Meckel diverticulum (17.4%). Pathological examination revealed malignancy in 4 (11.43%) patients. The diagnostic accuracy of computed tomography performed preoperatively was calculated as 34.3%. In the laparoscopic surgery group, the length of incision, Clavien-Dindo Classification score, pain score 24 hours after surgery, and length of hospital stay were statistically significantly lower compared with open surgery group (P < .001, P = .01, P < .001, P = .001, respectively). Although it was statistically insignificant, median time to oral intake after surgery was shorter in laparoscopic group when compared with the open surgery group (48 hours [48–72] vs 72 hours [48–72], P = .056). Laparoscopic surgery in SBO-VA seems to be more advantageous than open surgery due to its favorable postoperative outcomes as well as diagnostic and therapeutic effectiveness.
Keywords: intestinal obstruction, laparoscopic surgery, laparoscopy, minimally invasive surgery, small bowel obstruction, virgin abdomen
1. Introduction
Small bowel obstruction (SBO) is a clinical syndrome frequently encountered by general surgeons, responsible for 12% to 15% of surgical hospital admissions and over 300,000 operations annually.[1,2] The underlying cause of SBO is mostly adhesions, which accounts for 70% of all SBO etiologies and is usually seen in patients with prior abdominal surgery. Small bowel obstruction is seen in ~5% of patients with previous abdominal surgery. This group of patients consists 80% to 97% of patients with adhesive SBO.[3] Historically, the surgical dogma of “never let the sun set or rise on a small bowel obstruction”[4] has now been replaced by the nonoperative management[5]; due to adhesions being the most common causes of SBO,[3] conservative management has been proved to be successful in majority of patients[6], the frequent use, and enhanced diagnostic utility of computed tomography (CT).[7]
On the other hand, a small subgroup of patients presenting with SBO have not had a previous abdominal surgery who have been referred to as “virgin abdomen (VA).”[6] Although recent retrospective studies have shown that the underlying cause of SBO in VA (SBO-VA) is benign, and mostly related to adhesions despite the absence of prior surgery; obstructive causes, such as internal hernia or most importantly malignancy, cannot be completely ruled out in these patients.[2] Since SBO-VA is rarely seen (reported prevalence of 1.2%–17%), the studies in the literature are mostly limited to case reports, and small case series make it challenging to clarify the underlying etiologies.[6] Therefore, establishing an appropriate and standardized management strategy to SBO-VA is challenging, which results in different management approaches among institutions and individual surgeons.[8] As adhesions were shown to be the most common cause of SBO-VA, some centers prefer nonoperative management over surgery in selected cases in whom the risk of strangulation is low. In some large centers, surgery is still considered necessary in VA patients due to the potential risk of an obstructive lesion as the cause of SBO.[9,10] When surgical intervention is considered for SBO-VA, exploratory laparotomy is usually the approach of choice; however, there is limited evidence about the utility of laparoscopic surgery in SBO-VA.[3]
Determining whether the surgical approach is needed in patients with SBO-VA is still a matter of debate among surgeons as nonoperative management can also successfully resolve the problem, avoiding unnecessary surgery; however, it has been associated with increased risks of recurrence, delay in diagnosis of malignancy, and increased risk of small bowel strangulation. Laparoscopic surgery has been widely used by surgeons in recent years. It is associated with lower morbidity and mortality, less length of hospital stay, less postoperative pain, and faster symptom relief.[11–14]
This study aims to compare the results of laparoscopic and open surgeries for SBO-VA, and present the outcomes of performing surgery for SBO-VA.
2. Patients and methods
2.1. Patient selection
Thirty-five patients, ≥18 years old, who were admitted to our hospital between January 2018 and December 2023 with VA intestinal bowel obstruction and undergone surgery (both open surgery and laparoscopic surgery), were analyzed retrospectively. Whether an open or a laparoscopic surgery would be performed was decided by the surgeon according to the patient’s clinical condition and/or surgeon’s experience. The exclusion criteria were as follows: <18 years old, pregnancy, presence of colonic obstruction, abdominal malignancy, hernia, inflammatory bowel disease, and prior abdominal surgery.
2.2. Demographic, clinical, and laboratory features
Patients’ demographic, clinical, and laboratory characteristics were recorded retrospectively from hospital records. The initial presenting symptoms, signs, physical examination findings, and imaging findings were evaluated. The operative findings and pathological results were examined from the hospital records to determine the etiology of SBO-VA. All patients were followed postoperatively for a minimum of 6 months. The routine follow-up schedule included outpatient visits at postoperative 1 week and, if asymptomatic, at 6 months. Patients diagnosed with malignancy were additionally evaluated at postoperative 3 and 6 months. At each visit, clinical evaluation included a structured physical examination (inspection of surgical wound, abdominal palpation for tenderness or masses, and assessment of bowel sounds), review of gastrointestinal symptoms (abdominal pain, distention, nausea/vomiting, changes in bowel habits), and a symptom assessment checklist. Laboratory investigations and imaging were performed selectively in patients with persistent or recurrent symptoms. All follow-up data were recorded in the electronic hospital system by the operating surgeon. No patients were lost to follow-up during the study period. Successful recovery was defined as complete resolution of symptoms and discharge without complications, while complications were classified according to the Clavien-Dindo classification. Recurrence was defined as readmission with small bowel obstruction during the follow-up period.
2.3. Scores
Charlson Comorbidity Index (CCI), first proposed by Charlson et al in 1987, is an accurate, easy, and readily applicable score to calculate the mortality risk from comorbid diseases widely used in studies.[15] CCI predicts the 1-year mortality by weighting the comorbid diseases from 1 to 6, and the result is given by the total sum of the weights. The higher the CCI is, the higher the risk of mortality and the severity of the comorbidities.[15]
The 100-mm Visual Analog Scale (VAS) for pain is a widely used subjective measure for pain intensity reported by patients twice over the past 24 hours after surgery. The 100-mm VAS ranges from 0 (no pain) to 100 (severe pain).[16]
The American Society of Anesthesiologists score is the physical status classification system developed to predict the operative risk based on 6 classes (I–VI).[17,18]
Clavien-Dindo Classification, first introduced in 1992 and updated in 2004, is a widely used tool to evaluate postoperative complications (morbidity and mortality).[19,20]
2.4. Surgical technique
Insufflation was achieved by entering the abdomen from the Palmer point with the open Hassan technique. Three 10-mm trocars were inserted from the left anterior and mid-axillary line and the palmer point. Anastomoses were made intracorporeally, and the specimen was removed through a Pfannenstiel incision (Figs. 1 and 2).
Figure 1.
Trocar sites. (A) Patient who underwent bowel resection due to Meckel diverticulum. (B) Patient undergoing adhesiolysis.
Figure 2.
Meckel diverticulum excision and intracorporeal anastomosis. (A) Meckel diverticulum. (B) Resection. (C) Anastomosis. (D) Primary closure of stapler sites.
2.5. Statistical analysis
IBM SPSS Statistics for Windows, version 26.0 (SPSS Inc, Chicago), was used to perform the statistical analyses. The variables were investigated using visual (histograms, probability plots) and analytical (Kolmogorov–Smirnov/Shapiro–Wilk test) to determine whether they were normally distributed. Due to the non-normally distribution of the continuous variables, they were presented as median and interquarter range values. The categorical variables were presented as frequency values. Since the non-normal distribution was observed for numerical continuous variables in the intergroup comparisons, the Mann–Whitney U test was used. For categorical variables, chi-squared or Fischer test was used when appropriate. A P-value <.05 was accepted as statistically significant.
3. Results
During the study period, a total of 349 patients underwent surgery for intestinal obstruction. Among these, 188 patients had small bowel obstruction, and 35 (18.62%) patients had a VA and underwent surgical management. Of 35 patients, 62.9% of whom were male, and the median age was 63 (interquarter range 45–75), were included in this study. All patients with SBO-VA underwent surgery, for which laparoscopic surgery was conducted in 19 patients, and for 16 patients, open surgery was performed. The mean age and sex distribution were similar in both groups (P = .855 and P = .464, respectively). More than half of the patients (54.3%) had no concurrent comorbidities, and the CCI was similar between laparoscopic and open surgery groups (P = 705). The main presenting symptom in both groups was abdominal pain, abdominal distention, nausea/vomiting, and constipation. The main physical examination finding was abdominal tenderness accompanied by a rebound in 6 patients. Additionally, the American Society of Anesthesiologists scores were similar between laparoscopy and open surgery groups (P = .822). The demographic and clinical characteristics of patients are summarized in Table 1.
Table 1.
Demographic and clinical features of patients with small bowel obstruction in virgin abdomen.
| Laparoscopic (n = 19) | Open surgery (n = 16) | P-value | |
|---|---|---|---|
| Age (yr), median (IQR) | 66 (45.0–75.0) | 57 (41.25–75.75) | .855 |
| Sex, male, n (%) | 13 (68.4) | 9 (56.3) | .464 |
| Body mass index (BMI), median (IQR) | 25.43 (24.5–27.3) | 25.34 (24.21–28.86) | .974 |
| ASA score, median (IQR) | 2 (1–3) | 2 (1–3) | .822 |
| Clinical features, n (%) | |||
| Abdominal pain | 18 (94.73) | 16 (100) | 1 |
| Abdominal distention | 14 (73.68) | 12 (75) | 1 |
| Vomiting | 16 (84.21) | 11 (68.75) | .424 |
| Constipation | 6 (31.58) | 2 (12.5) | .244 |
| Comorbidities, n (%) | |||
| None | 13 (68.42) | 6 (37.5) | .067 |
| Diabetes mellitus | 3 (15.79) | 2 (12.5) | 1 |
| Hypertension | 2 (10.53) | 7 (43.75) | .05 |
| Cardiovascular disease | 1 (5.26) | 7 (43.75) | .05 |
| Chronic obstructive pulmonary disease | 2 (10.53) | 2 (12.5) | 1 |
| Chronic kidney disease | 2 (10.53) | 1 (6.25) | 1 |
| Cerebrovascular disorders | 0 | 1 (6.25) | .457 |
| Charlson Comorbidity Index, median (IQR) | 1 (0–4) | 1.5 (0–3) | .705 |
| Physical examination findings, n (%) | |||
| Abdominal tenderness | 17 (89.47) | 10 (62.5) | .105 |
| Defence | 5 (26.31) | 3 (18.75) | .700 |
| Rebound tenderness | 5 (26.31) | 1 (6.25) | .187 |
| Operative features, median (IQR) | |||
| Operation time (min) | 90 (60–120) | 120 (67.5–135) | .341 |
| Length of incision (cm) | 3 (3–7) | 9 (8–9) | <.001 |
| Visual Analog Scale (VAS) for pain | 30 (20–40) | 50 (40–60) | <.001 |
| Clavien-Dindo classification | 1 (1–1) | 1 (1–2) | .01 |
| Begining time to oral intake, hour | 48 (48–72) | 72 (48–72) | .056 |
| Length of hospital stay (d) | 4 (3–5) | 11.5 (6–13.7) | .001 |
| Readmission, n (%) | 0 | 1 (6.25) | .276 |
Bold-faced values indicate statistically significant.
ASA = American Society of Anesthesiologists, IQR = interquartile range.
Table 2 summarizes the underlying etiologies and pathological examination results of SBO-VA. Adhesions were the most common etiology underlying SBO in 60% of patients with VA. Meckel diverticulum was the second most common underlying cause of SBO (n = 6, 17.4%), which was more common in the laparoscopy group. However, internal hernia (n = 4, 11.43%) were only seen in the open surgery group. Pathological specimens were obtained in 17 patients (laparoscopic surgery n = 9; open surgery n = 8) which revealed ulcerated small bowel tissue in 6 patients and ischemic bowel tissue in 2 patients who were diagnosed with adhesions. In addition, pathological examination showed ulcerated small bowel tissue in 4 patients and well-differentiated neuroendocrine neoplasia in 1 patient with Meckel diverticulum to whom laparoscopic surgery was performed. Moreover, low-grade mesenchymal neoplasia and gastrointestinal stromal tumor were described in 2 and 1 patients, respectively, who were diagnosed with intussusception preoperatively. The diagnostic accuracy of CT performed preoperatively was calculated as 34.3% (Table 3).
Table 2.
The etiology and postoperative pathological findings of patients with small bowel obstruction in virgin abdomen.
| Laparoscopy (n = 19) | Open (n = 16) | Total (n = 35) | |
|---|---|---|---|
| Etiology, n (%) | |||
| Adhesions | 12 (63.16) | 9 (56.25) | 21 (60) |
| Congenital band | 10 | 4 | 14 |
| Omental adhesions | 1 | 2 | 3 |
| Diffuse congenital adhesions | 1 | 3 | 4 |
| Meckel diverticulum | 5 (26.32) | 1 (6.25) | 6 (17.14) |
| Internal hernia | 0 | 4 (25) | 4 (11.43) |
| Intussusception | 2 (10.53) | 2 (12.5) | 4 (11.43) |
| Pathological findings, n (%) | (n = 9) | (n = 8) | |
| Meckel diverticulum | |||
| Ulcerated small bowel | 4 (44.44) | 1 (12.5) | 5 |
| Well-differentiated neuroendocrine neoplasia | 1 (11.11) | 0 | 1 |
| Intussusception | |||
| Low grade mesenchymal neoplasia | 2 (22.22) | 0 | 2 |
| Gastrointestinal stromal tumor | 0 | 1 (12.5) | 1 |
| Adhesion | |||
| Ulcerated small bowel | 2 (22.22) | 4 (50) | 6 |
| Ischemic small bowel | 0 | 2 (25) | 2 |
Table 3.
Diagnostic accuracy of computed tomography performed preoperatively.
| CT diagnosis | Surgical findings | Accurate CT diagnosis (n = 12, 34.3%) |
Inaccurate CT diagnosis (n = 23, 65.7%) |
|---|---|---|---|
| No underlying cause reported (n = 16) | Adhesions (14) Adhesions and closed-loop obstruction (1) Meckel diverticulum (1) |
0 | 16 |
| Adhesions (n = 4) | Adhesion (2) Internal hernia (1) Meckel diverticulum (1) |
2 | 2 |
| Internal hernia (n = 5) | Internal henia (3) Adhesions (1) Meckel diverticulum (1) |
3 | 2 |
| Small bowel tumor (n = 1) | Meckel diverticulum (1) | 0 | 1 |
| Inflammatory bowel disease (n = 1) | Meckel diverticulum (1) | 0 | 1 |
| Intussusception (n = 4) | Intussusception (4) | 4 | 0 |
| Malrotation (n = 3) | Malrotation and adhesion (2) Adhesions (1) |
2 | 1 |
CT = computed tomography.
The surgical procedures performed for patients with SBO-VA are shown in Table 4, and 17 patients (laparoscopic group n = 9, open surgery n = 8) had to undergo segmental small bowel resection. In 4 patients (11.43%), on the other hand, bowel ischemia was recovered after adhesiolysis. Conversion to open surgery was performed in 5 patients (20.83%). Reasons for conversion to open surgery were as follows: in 2 patients due to massive adhesion, in 1 patient due to long segment small bowel ischemia, in 1 patient because intra-abdominal exposure could not be achieved, and in 1 patient because the intestine was perforated during exploration.
Table 4.
The procedures performed during operation for patients with small bowel obstruction in virgin abdomen.
| Procedures, n (%) | Laparoscopic (n = 19) | Open (n = 16) |
|---|---|---|
| Diagnostic laparotomy + adhesiolysis | 5 (31.25) | |
| Diagnostic laparotomy + internal hernia repair | 3 (18.75) | |
| Diagnostic laparotomy + segmentary small bowel resection | 6 (37.5) | |
| Ischemia secondary to adhesions | 2 | |
| Ischemia secondary to internal hernia | 1 | |
| Intussusception | 2 | |
| Meckel diverticulum | 1 | |
| Diagnostic laparotomy + segmentary small bowel resection + ileostomy | 2 (12.5) | |
| Ischemia secondary to adhesions | 2 | |
| Diagnostic laparoscopy + laparoscopic adhesiolysis | 10 (52.63) | |
| Diagnostic laparoscopy + laparoscopic segmentary small bowel resection | 9 (47.37) | |
| Meckel diverticulum | 5 | |
| Intussusception | 2 | |
| Ischemia secondary to adhesions | 2 |
In the laparoscopic surgery group, the length of incision, Clavien-Dindo Classification score, VAS for pain 24 hours after surgery, and length of hospital stay were statistically significantly lower compared with open surgery group (P < .001, P = .01, P < .001, P = .001, respectively) (Table 1). The length of incision reported in the laparoscopic group refers to the total combined length of trocar sites and, when required, the Pfannenstiel incision for specimen extraction. The operation duration was similar in both groups (P = .341). Although it was statistically insignificant, median time to start oral intake after surgery was shorter in laparoscopic group when compared with the open surgery group (48 hours [48–72] vs 72 hhours [48–72], P = .056). Despite being statistically not significant, 1 patient had to readmit to hospital after open surgery, and none of the patients in the laparoscopy group needed hospital readmission after surgery.
The patient in the open surgery group was readmitted on postoperative day 61 due to abdominal pain and vomiting. The patient, who did not exhibit signs of acute abdomen, was diagnosed with intestinal obstruction. Nonoperative management was initiated, including nasogastric tube decompression. Three days after readmission, the patient’s symptoms resolved, and passage of flatus and stool occurred. The patient tolerated oral intake and was discharged on the fifth day of hospitalization, with no further readmissions required.
4. Discussion
Management of small bowel obstruction in patients without previous abdominal surgery, namely VA, is still a topic of debate among surgeons due to its rarity and adhesions being unlikely to be the underlying cause. In this study, 35 patients with VA underwent surgery, with 54.3% of those laparoscopic surgery performed. The current study showed that although adhesions were the most common underlying cause in SBO-VA, 17 patients (48.6%) needed segmental small bowel resection; in 4 patients, surgery helped solve the bowel ischemia; and in 4 patients, neoplasia was detected in pathological specimen. Based on our findings, we therefore think that surgery may be preferred over conservative treatment in patients with SBO-VA. Therewithal, due to the shorter incision length, lower postoperative complication rate, diminished pain scores 24 hours after surgery, and shorter length of hospital stay, laparoscopic surgery is more advantageous and preferable than open laparotomy in SBO-VA. To the best of our knowledge, there has been no study in the literature comparing the outcomes of laparoscopic surgery versus open surgery in patients with VA. This study demonstrated the efficacy and the utility of laparoscopic surgery in patients with SBO-VA.
Contrary to expectations, recent studies have shown that adhesions were the most common cause of SBO in VA. In the study of Beardsley et al, 62 (9%) patients out of 689 patients with SBO were classified as VA, and of these 62 patients, only 49 had no previously diagnosed disease as a cause of SBO.[5] Laparotomy was performed in 34 patients of the 49 patients with SBO-VA (69.4%); adhesions (75.5%) were the most common etiology, followed by malignancy as the second most common cause for SBO (10.2%).[5] Comparably, in a different study comprising 72 VA patients, 43 patients (61%) needed surgery, and 5 of them had laparoscopic surgery.[7] This study also demonstrated adhesions being the most common cause (62%) for which laparotomy was needed to establish the diagnosis in 23 patients.[7] Likewise, our study also showed that 60% of our patients had adhesions, followed by Meckel diverticulum (17.1%), internal hernia (11.4%), and intussusception (11.4%) as the underlying etiology. All patients in our cohort underwent preoperative CT, with a diagnostic accuracy of 34.3%, which is lower than the 45 to 75% range reported in earlier series.[21] Nonetheless, recent prospective real-world studies have demonstrated that the diagnostic accuracy of CT may in fact be substantially lower than traditionally reported, ranging between 23% and 40% for critical findings such as closed-loop obstruction and bowel ischemia.[22] This discrepancy underscores the gap between controlled research conditions and daily clinical practice. In VA cases, radiological findings are often more subtle than in adhesive SBO following prior surgery. Features such as indistinct transition points or early ischemic changes can be easily overlooked. Furthermore, as our study was retrospective, CT reports were extracted from hospital records and had been interpreted by different on-call radiologists, often with varying levels of experience, under emergency conditions. These factors likely contributed to the relatively low diagnostic accuracy observed in our cohort. Taken together, these findings highlight the need for future prospective, large-scale studies focusing specifically on VA populations to validate diagnostic strategies and to establish standardized imaging protocols that may improve diagnostic yield in this unique patient group.
As discussed earlier, the approach to patients with VA differs among centers and even among surgeons in the same institution. In our tertiary center, surgery is preferred over nonoperative management for SBO-VA, along with the increasing experience, success in the laparoscopic surgery, and its favorable outcomes, so that laparoscopic surgery has been gradually becoming the preferred surgery method. The few retrospective case series in the literature demonstrated that more than half of the patients with SBO-VA needed surgery.[2,5,7,23] In a systemic review published in 2021, of the total 442 patients analyzed, 50% of them needed urgent surgery, while 1.5% needed delayed surgery. Of the 211 procedures that were carried out, 188 (89.1%) of them were open laparotomies; however, laparoscopic surgery was performed only in 23 (10.9%) patients.[24] In another review, of 416 patients with SBO-VA, 211 of them needed surgery (50.7%). The main reasons for surgery in the previous studies were the failure of conservative management, radiological findings of closed-loop obstruction, obstructing tumor, incarcerated hernia, and hemodynamic instability.[6] In addition, although adhesions were the most common cause in our case series, in 48.6% of patients, segmental small bowel resection was needed due to the bowel ischemia, and in 11.4% of patients, the ischemia was resolved intraoperatively without the need of resection. Thus, surgery does not only provide a diagnosis but also yield therapeutic relief. Conservative management of these patients could not be possible and would result in hospital readmissions, which in return would cause more absence from work, social life, and higher cost. Furthermore, the major argument against nonoperative management in SBO-VA is the risk of misdiagnosis of malignancy, which cannot be determined before by imaging techniques. In the study of 60 patients with SBO-VA from Mayo Clinic, 50 patients were undergone laparotomy in whom 18 (35%) were completed laparoscopically. In this study, the laparotomy was therapeutic in 58% of the patients, diagnostic but nontherapeutic in 2%, and negative abdominal exploration was seen in 40% of patients.[3] However, in 15% of patients with prior negative exploration, recurrence of SBO was reported during the follow-up period. In patients who were managed non-operatively (n = 10), during the follow-up period, 5 patients had other underlying causes, and 3 of them needed resection due to cancer, endometriosis, and stricture with an overall malignancy rate of 13%.[3] In the cohort of 49 patients with SBO-VA, 5 patients (10.2%) were newly diagnosed with malignancy.[5] In a meta-analysis performed by Choi et al, the pooled prevalence of malignancy was reported as 13.4% (95% confidence interval: 7.6%–20.3%), and most of these malignant etiologies were not suspected before surgery.[21] In our study, 4 out of 35 patients (11.4%) were diagnosed with cancer, which was comparable with the previous studies.
On the other hand, the main concerns about surgery being the first-line treatment approach for SBO-VA are the high negative exploration rate, and increased risk of mortality and morbidity of surgery. However, our study showed that in 19 patients who underwent laparoscopic operation, there was no negative operation; therefore, none of the patients had unnecessary surgery. Similarly, the studies conducted by Fukami et al and Ng et al also reported no negative laparotomies.[7,25] In the systemic review conducted with 416 patients, 211 underwent surgery, and the negative laparotomy rate was calculated as 11.4%.[6] Also, the risk of postoperative complication calculated by Clavien-Dindo Classification was low in our study and was significantly lower in the laparoscopy group compared with open laparotomy group (P = .01). Laparoscopic surgery was also shown to have better outcomes regarding length of hospital stay, postoperative pain intensity, and incision length (P = .001, <.001, <.001, respectively). Similarly, in the study of Ng et al, 43 patients out of 72 underwent surgery and in 5 of them laparoscopic surgery was performed successfully.[7] Therefore, adhesions in patients with VA are suitable for laparoscopic surgical intervention that would achieve not only treatment but also diagnosis which is related with lower morbidity and accelerated recovery period.[7]
In the presence of intestinal obstruction, the intestines become dilated, edematous, and fragile. Moreover, due to bowel dilatation, difficulties may arise in obtaining sufficient abdominal space for safe exposure. As a result, the risk of organ injury during insertion of the first trocar is higher compared with other elective surgeries. Therefore, we recommend that laparoscopic exploration in patients with SBO-VA be performed by surgeons experienced in minimally invasive surgery and that the first trocar be placed using the open (Hasson) technique. In our study, no complications related to trocar insertion were observed. However, 1 patient experienced an iatrogenic bowel perforation during exploration, and in another case, adequate exposure could not be achieved due to limited operative space, necessitating conversion to an open approach.
Our study has some limitations as the low number of patients included as SBO-VA is a rare entity and the retrospective nature of the study. In addition, the follow-up period of the patients recruited for this study was short; however, as all the patients had undergone surgery, there were no patients who were initially underdiagnosed for malignancy or inflammatory bowel disease as the cause of small bowel obstruction. We did not observe any recurrence during the follow-up period.
In conclusion, although there is a trend toward conservative management for SBO-VA, retrospective case studies showed that more than half of these patients underwent either urgent or delayed surgery (due to recurrence and/or malignancy). Therefore, surgery seems more advantageous when encountered with SBO-VA patients, and with its better postoperative outcomes (e.g., lower recurrence rate, lower hospital stay, lower postoperative complication rate, and lower postoperative pain), also aiding a therapeutic approach, laparoscopy may be preferred over laparotomy as the choice of surgery. Larger, multicenter, and prospective studies should be further performed to evaluate the utility of laparoscopic surgery for SBO-VA.
Author contributions
Conceptualization: Hilmi Anil Dincer, Nezih Akkapulu.
Data curation: Hilmi Anil Dincer, İbrahim Alkan, Omer Cennet.
Formal analysis: Hilmi Anil Dincer, İbrahim Alkan.
Investigation: Hilmi Anil Dincer, İbrahim Alkan, Omer Cennet, Sahin Kaymak, Timucin Erol, Ahmet Bulent Dogrul, Nezih Akkapulu.
Methodology: Hilmi Anil Dincer, Omer Cennet, Sahin Kaymak, Timucin Erol, Ahmet Bulent Dogrul.
Project administration: Hilmi Anil Dincer.
Supervision: Ahmet Bulent Dogrul, Nezih Akkapulu.
Visualization: Sahin Kaymak, Nezih Akkapulu, Timucin Erol.
Writing – original draft: Hilmi Anil Dincer, Nezih Akkapulu.
Abbreviations:
- CCI
- Charlson Comorbidity Index
- CT
- computed tomography
- SBO
- small bowel obstruction
- SBO-VA
- small bowel obstruction in virgin abdomen
- VA
- virgin abdomen
- VAS
- Visual Analog Scale
The Institutional Review Board of Medicine, Hacettepe University, ethically approved this study (GO 23/502; 2023/10-27).
The authors have no funding and conflicts of interest to disclose.
The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.
How to cite this article: Dincer HA, Alkan İ, Cennet O, Kaymak S, Erol T, Dogrul AB, Akkapulu N. Evaluating surgical strategies for small bowel obstruction in virgin abdomen: A comparative analysis of laparoscopic and open approaches. Medicine 2025;104:40(e44998).
Contributor Information
İbrahim Alkan, Email: ibrahim_ialkan@hotmail.com.
Omer Cennet, Email: ocennet@hotmail.com.
Sahin Kaymak, Email: sahinkaymak@hotmail.com.
Timucin Erol, Email: timucinerol@yahoo.com.
Ahmet Bulent Dogrul, Email: adogrul@hacettepe.edu.tr.
Nezih Akkapulu, Email: akkapulu@hacettepe.edu.tr.
References
- [1].Maung AA, Johnson DC, Piper GL, et al. Evaluation and management of small-bowel obstruction: an Eastern Association for the Surgery of Trauma practice management guideline. J Trauma Acute Care Surg. 2012;73:S362–9. [DOI] [PubMed] [Google Scholar]
- [2].Ghabisha S, Ahmed F, Altam A, Hassan F, Badheeb M. Small bowel obstruction in virgin abdomen: predictors of surgical intervention need in resource-limited setting. J Multidisciplinary Healthcare. 2023;16:4003–14. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [3].Strajina V, Kim BD, Zielinski MD. Small bowel obstruction in a virgin abdomen. Am J Surg. 2019;218:521–6. [DOI] [PubMed] [Google Scholar]
- [4].Mucha P, Jr. Small intestinal obstruction. Surg Clin North Am. 1987;67:597–620. [DOI] [PubMed] [Google Scholar]
- [5].Beardsley C, Furtado R, Mosse C, et al. Small bowel obstruction in the virgin abdomen: the need for a mandatory laparotomy explored. Am J Surg. 2014;208:243–8. [DOI] [PubMed] [Google Scholar]
- [6].Yang TWW, Prabhakaran S, Bell S, et al. Non‐operative management for small bowel obstruction in a virgin abdomen: a systematic review. ANZ J Surg. 2021;91:802–9. [DOI] [PubMed] [Google Scholar]
- [7].Ng YYR, Ngu JCY, Wong ASY. Small bowel obstruction in the virgin abdomen: time to challenge surgical dogma with evidence. ANZ J Surg. 2018;88:91–4. [DOI] [PubMed] [Google Scholar]
- [8].Tavangari FR, Batech M, Collins JC, Tejirian T. Small bowel obstructions in a virgin abdomen: is an operation mandatory? Am Surg. 2016;82:1038–42. [PubMed] [Google Scholar]
- [9].Zielinski MD, Bannon MP. Current management of small bowel obstruction. Adv Surg. 2011;45:1–29. [DOI] [PubMed] [Google Scholar]
- [10].McCloy C, Brown TC, Bolton JS, Bowen JC, Fuhrman GM. The etiology of intestinal obstruction in patients without prior laparotomy or hernia. Am Surg. 1998;64:19–23. [PubMed] [Google Scholar]
- [11].Cucchetti A, Bocchino A, Crippa S, et al. Advantages of laparoscopic distal pancreatectomy: systematic review and meta-analysis of randomized and matched studies. Surgery. 2023;173:1023–9. [DOI] [PubMed] [Google Scholar]
- [12].Gan L, Meng C, Li K, Li J, Wu J, Li Y. Safety and effectiveness of minimally invasive adrenalectomy versus open adrenalectomy in patients with large adrenal tumors (≥5 cm): a meta-analysis and systematic review. Int J Surg. 2022;104:106779. [DOI] [PubMed] [Google Scholar]
- [13].Zhang G, Wu B. Meta-analysis of the clinical efficacy of laparoscopic appendectomy in the treatment of acute appendicitis. World J Emerg Surg. 2022;17:26. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [14].Anania G, Arezzo A, Davies RJ, et al. A global systematic review and meta-analysis on laparoscopic vs open right hemicolectomy with complete mesocolic excision. Int J Colorectal Dis. 2021;36:1609–20. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [15].Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40:373–83. [DOI] [PubMed] [Google Scholar]
- [16].Myles P, Myles D, Galagher W, et al. Measuring acute postoperative pain using the visual analog scale: the minimal clinically important difference and patient acceptable symptom state. Br J Anaesth. 2017;118:424–9. [DOI] [PubMed] [Google Scholar]
- [17].Saklad M. Grading of patients for surgical procedures. Am Soc Anesthesiol. 1941;2:281–4. [Google Scholar]
- [18].Hendrix JM, Garmon EH. American Society of Anesthesiologists Physical Status Classification System. [Updated February 11, 2025]. In: StatPearls. StatPearls Publishing; 2025. [PubMed] [Google Scholar]
- [19].Clavien P-A, Sanabria JR, Strasberg SM. Proposed classification of complications of surgery with examples of utility in cholecystectomy. Surgery. 1992;111:518–26. [PubMed] [Google Scholar]
- [20].Dindo D, Demartines N, Clavien P-A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–13. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [21].Choi J, Fisher AT, Mulaney B, et al. Safety of foregoing operation for small bowel obstruction in the virgin abdomen: systematic review and meta-analysis. J Am Coll Surg. 2020;231:368–75.e1. [DOI] [PubMed] [Google Scholar]
- [22].Nielsen LBJ, Ærenlund MP, Alouda M, et al. Real-world accuracy of computed tomography in patients admitted with small bowel obstruction: a multicentre prospective cohort study. Langenbecks Arch Surg. 2023;408:341. [DOI] [PMC free article] [PubMed] [Google Scholar]
- [23].Motto GB, Fabrice T, Boukar YME, Emmanuella E-AMK, Ngoumfe JCC, Essomba A. Etiologies, clinical presentation and outcome of adult patients presenting with bowel obstruction on a virgin abdomen. Surg Sci. 2023;14:252–69. [Google Scholar]
- [24].Hew N, Ng ZQ, Wijesuriya R. Non-operative management of small bowel obstruction in virgin abdomen: a systematic review. Surg Today. 2021;51:1558–67. [DOI] [PubMed] [Google Scholar]
- [25].Fukami Y, Kaneoka Y, Maeda A, Takayama Y, Takahashi T, Uji M. Clinical effect of water-soluble contrast agents for small bowel obstruction in the virgin abdomen. World J Surg. 2018;42:88–92. [DOI] [PubMed] [Google Scholar]