Background
The inability to adequately evaluate compromised bowel segments has been cited as one of the main limitations to the application of laparoscopy for the management of acute small bowel obstruction (SBO) and a major reason for conversion to laparotomy.1–3 This is essentially attributable to a reduced field of vision due to intestinal distension, the lack of haptic feedback and an incomplete, bi-dimensional view.2,4 In the presence of concerns for vascular impairment, the application of fluorescence angiography permits direct assessment of bowel viability.
Technique
After the cause of obstruction is identified, repeatable boluses of indocyanine green (ICG) are given intravenously and as required to evaluate intestinal microcirculation extemporaneously. The presence and pattern of arterial supply are tested before and after the obstructing mechanism is resolved (Figures 1 and 2). An adequate clearance of ICG is used to demonstrate proper venous drainage. In the case of ascertained, irreversible vascular insufficiency (Fig 3), exteriorisation of the involved segment is made via a minimal, protected incision, and a bowel resection and anastomosis are performed. Following resection, further assessment of fluorescence distribution is performed to confirm adequate perfusion of the anastomosis.
Figure 1.
Patient with acute SBO before (top left) and after (top right) the release of the underlying adhesive band, viewed under standard (top row) and fluorescent (bottom row) light. Note the progressive and complete recovery from ischemic to regular vascular supply of the involved bowel.
Figure 2.
Patient with acute SBO due to an incarcerated right inguinal hernia (a) with initial signs of ischemia (b). A cyanosed bowel segment is reduced intra-abdominally (c and d). A regular vascularity is observed after generous irrigation with warm saline (d and e).
Figure 3.
Patient with adhesive SBO and acute volvulus. Following the resolution of the strangulating mechanism, the involved bowel revealed an irregular, patchy fluorescence pattern, despite the presence of lively peristalsis. A bowel resection was carried out.
Discussion
Laparoscopic ICG angiography enables the need for intestinal resection and its precise extent to be objectively determined. This may limit the percentage of unnecessary bowel resections and widen the proportion of patients benefiting from a minimally invasive intervention.1–4 At the same time, it may support the decision-making process of any emergency surgeon, regardless of his or her personal expertise, with possible implications on several medicolegal aspects.5
References
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