Nº de DOI: 10.34896/RSI.2026.14.94.001
AUTHORS
- Jennifer Alejandra Tacuri Arcentales. General Practitioner. Attached to Private Clinics of Ecuador. Graduate of the Catholic University of Cuenca. (Azogues-Ecuador). https://orcid.org/0000-0002-2719-3776
- Joffre Santiago López Gómez. General Practitioner and Master’s Degree in Occupational Health. Attached to San Luis Hospital in Otavalo. Graduate of the University of the Americas. (Ibarra-Ecuador). https://orcid.org/0000-0002-6303-2240
- Leonardo David Jalca Cantos. General Practitioner. Attached to Private Clinics in Ecuador. Graduate of the Technical University of Manabí. (Portoviejo-Ecuador). https://orcid.org/0000-0003-3625-2819
- Leslie Mandina Acosta Vasquez. General Practitioner. Attached to Private Clinics in Ecuador. Graduate of the Pontifical Catholic University of Ecuador. (Quito-Ecuador). https://orcid.org/0009-0002-8016-6731
- Jeovany Alfredo Caceres Maradiaga. General Practitioner. Attached to the Esmeraldas Rioverde Health District 08D01. Graduate of the Rómulo Gallegos National Experimental University of the Central Plains. (Esmeraldas-Ecuador). https://orcid.org/0009-0000-6190-7819
ABSTRACT
This review summarizes the current evidence with the intention of guiding the surgical intervention in the acute intestinal obstruction patient.
KEY WORDS
Intestinal obstruction, small bowel obstruction, laparoscopy, laparoscopic surgery, laparotomy and open surgery.
RESUMEN
Esta revisión resume la evidencia actual con el objetivo de orientar la intervención quirúrgica en pacientes con obstrucción intestinal aguda.
PALABRAS CLAVE
Obstrucción intestinal, obstrucción del intestino delgado, laparoscopia, cirugía laparoscópica, laparotomía y cirugía abierta.
INTRODUCTION
Intestinal obstruction is still one of the most common indications for a surgical emergency consultation with a preference or traditional approach of an open laparotomy. However, this approach is now on a trajectory towards minimally invasive strategies. The purpose of this systematic review is to assess the comparative clinical outcomes of laparoscopic surgery versus open surgery when managing intestinal obstruction. The authors conducted a systematic review using the PRISMA guidelines to conduct an extensive search through multiple databases to identify studies that compare the two modalities. The primary outcomes of interest included operative time, intraoperative complications, conversion rates, and recovery. The preliminary findings of the study suggest that while laparoscopic surgery often requires longer time periods in the operating room for certain difficult cases, it has advantages with less intraoperative blood loss, recovery of bowel function, and decreased length of hospital stay. The laparoscopic-first option is recommended in stable patients, although patient selection will be important in preventing unintentional enterotomy.
OBJECTIVE
To summarise the current evidence to guide surgical management in patients with acute intestinal obstruction.
METHODOLOGY
The methodology presented in this systematic review was purposely designed to ensure a rigorous and systematic collection of clinical relevant evidence. A systematic search was completed in multiple electronic databases of significance, including PubMed/MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL). The search strategy combined Medical Subject Headings (MeSH) terminology and keywords, combined synonyms, such as «intestinal obstruction,» «small bowel obstruction,» «laparoscopy,» «laparoscopic surgery,» «laparotomy» and «open surgery.»
To search for the most up-to-date evidence, the search was limited to papers published within the last 20 years, as this period marks when the laparoscopic technique for emergency surgery was standardized. Initially there were no language restrictions to included publications; however, in the end, the reference literature only included papers that had English abstracts or full text. The reference lists from the articles and previous meta-analyses were also manually screened for possible citations that were not identified in the electronic search.
To be included studies had to (1) included adult patients (age 18 and older) with mechanical intestinal obstruction; (2) compare laparoscopic with open surgical intervention; (3) include at least one outcome of interest, including operative time, complications, or length of hospital stay. Randomized controlled trials (RCTs) and high quality observational studies (prospective or retrospective cohort studies) were included to provide a broader understanding of surgical practice.
Exclusion criteria were formulated in a tight nature that aimed to keep the review focused. We did not include studies that exclusively contained pediatric populations due to differences in etiology and management between adult and pediatric populations. For the purpose of this review, we did not include case reports, editorials, or review articles that do not contain original data. In addition, international studies of patients with obstruction due to advanced malignancy where the intent was a palliative bypass rather than resection or adhesiolysis were not included to maintain the homogeneity of the population.
The data extraction process was conducted in an independent fashion by two reviewers using a standardized data collection form. The data being extracted had study characteristics (author, year, country, study design), demographics (age, gender, BMI, ASA score), etiology of obstruction, and the specific surgical technique used. The outcome data was in regards to intraoperative outcomes (operating time, blood loss, conversion rate) and postoperative recovery (time to first flatus, length of stay, morbidity, and mortality).
The methodological quality of the included studies was evaluated using validated tools. The Cochrane Risk of Bias tool was used to assess RCTs to assess domains such as sequence generation, allocation concealment, and blinding. Observational studies used the Newcastle-Ottawa Scale (NOS) to account for the quality of selection, comparability, and outcome reporting. Any disagreements between reviewers during the data extraction process or quality assessment of studies were resolved through discussion or a third senior reviewer reached to assist. This approach allows for the synthesis of the best quality evidence based on the literature.
RESULTS
Intestinal obstruction, especially small bowel obstruction (SBO), has important implications for global healthcare systems and often accounts for a large proportion of emergency general surgical admissions and emergency procedures. Historically, the management of mechanical obstruction had been synonymous with formal laparotomy, allowing for complete visualization and tactile inspection of the bowel length. However, the morbidity associated with large midline incisions, including postoperative pain, prolonged ileus, and the risk of incisional hernia in the future has led to the surgical community looking for alternatives that might produce less morbidity within a minimally invasive framework.
The transition from laparoscopic surgery as a purely diagnostic lift to being a standard treatment option for emergency surgery has not happened rapidly. There were significant fears about working in the abdomen during laparoscopic surgery (i.e., the crowded abdomen) and limited working space when dealing with dilated bowel loops. For many, intestinal obstruction was a «relative contraindication» for laparoscopy and the overall risk was too high for inadvertent enterotomy when entering the abdomen with a trocar of when manipulating the bowel. However, improvements in surgical instrumentation over time (i.e., atraumatic graspers, high-definition optics) and anesthesia have increased the feasibility of the laparoscopic approach.
Current clinical guidelines such as the Cesena guidelines from the World Society of Emergency Surgery (WSES) state that the laparoscopic-first approach should be used in stable general surgery emergencies including intestinal obstruction1. There is a trend towards minimizing surgery to avoid the physiological «second hit» of an operative procedure. Laparoscopy intended to decrease surgical trauma to the abdominal wall and decrease bowel handling, thus potentially reducing the systemic inflammatory response often associated with emergent surgery.
The argument for laparoscopy in place of open surgery involves a biological rationale for decreasing peritoneal trauma. Open surgery will necessarily involve significant exposure of the serosal surfaces to air and mechanical manipulation, which triggers inflammatory mediators. This inflammatory response has been shown to be contributory to postoperative ileus and the formation of new adhesions, which can place a patient into a «vicious cycle» of re-obstruction. A laparoscopic approach takes place in a closed environment to maintain peritoneal homeostasis and theoretically decrease subsequent adhesive disease.
The theoretical benefits of laparoscopy for the surgical treatment of intestinal obstruction may not translate into the real benefit of laparoscopic surgery, given the real-world application of laparoscopic surgery for intestinal obstruction. The surgeon must try to balance the advantages of minimally invasive versus the technical difficulty of manipulation in a distended abdomen. The nature of the obstruction (e.g., single band of adhesion or complex matted adhesions), the degree of ischemia, and, importantly, the surgeon’s experience with advanced laparoscopy factor heavily into the choice of the surgical technique. The decision to convert to open surgery vs. completing the procedure laparoscopically is a dynamic moment that will affect surgical outcomes.
The purpose of this systematic review is to quantitatively compare laparoscopic and open surgical techniques for intestinal obstruction. The goal is to assess intraoperative measures, short-term recovery, and complications, which outlines the role of minimally invasive surgery for a high-risk clinical scenario. The incorporation of evidence from multiple surgical specialties will assist in the integration of evidence and understanding of the present surgical practice2.
Systematic Literature Search Results:
Study Selection Process and PRISMA Flow Analysis:
The initial search of the database yielded 1,245 records. After duplicates were removed, 890 titles and abstracts were screened for relevance. Of the 890 titles and abstracts reviewed, 115 articles were deemed acceptable for a full-text review based on the inclusion and exclusion criteria. Following the full-text review, 28 studies, in total, were included in the systematic review. Reasons from the full-text review for exclusion included lack of a direct comparison group, non-mechanical obstruction, and outcome data.
The PRISMA flow diagram below illustrates the selection process. This process directs focus to the evolution from a broad search to specific high-quality studies to form the foundation and basis for a comparative approach to analysis. The inclusion of randomized and observational data reflects an intention to evaluate both efficacy in controlled clinical conditions, and effectiveness applied in real clinical settings.
Characteristics of Included Studies and Patient Demographics:
The 28 included studies involved a total of 4,560 patients: 2,120 with laparoscopic surgery and 2,440 with open surgery. The geographic distribution of study locations was reported in Europe, North America and East Asia, which provides a global perspective of the management of intestinal obstruction. Most included studies focused on adhesive small bowel obstruction (ASBO), as the most common reason to undergo surgery.
Typically, patient demographics was relatively equal among each group in randomized trials. In observed studies, however, a selection bias was evident, with laparoscopic patients being, on average, younger and with fewer comorbidities (lower ASA scores), than open patients. This suggests surgeons usually reserve laparoscopic surgery for «better» cases, i.e. those with suspected single-bands or earlier presentation. The study mean age ranged from 45-68 years. The etiology was primarily postop adhesions, hernias and volvulus.
Quality and Risks of Bias:
The general quality assessment revealed a mix of higher and moderate quality of evidence. The RCTs in this review generally demonstrated a low-risk of bias for randomization and allocation; blinding the operating surgeon is, by nature, not possible and only a few studies reported blinding of outcomes assessors. Among the observational studies, NOS scores ranged from 6 to 9, which suggests high methodological quality despite the inherent risks of selection biases and non-randomization.
A notable finding that emerged during the quality assessment involved the heterogeneity defining and reporting «conversion.» Some studies classified it as a technical failure, while some regarded it as an important clinical decision to err on the side of safety for the patient (e.g. conversion to open surgery). This finding highlights the need for consistency of reporting habits in surgical trials. Nevertheless, the overall quality of evidence is adequate to reach conclusion on the comparative performance of two forms of surgery3.
Comparative Analysis of Intraoperative Outcomes:
Evaluation of Operative Time and Technical Difficulty:
Operative duration is an important measure of technical difficulty and surgical efficiency. We discovered that the laparoscopic approach tended to have a longer mean operative duration, compared to open surgery, as has been reported in similar studies involving other complex abdominal procedures. The time required for the initial setup in laparoscopic surgery, the challenge of entering the distended abdomen, and the careful dissection required for laparoscopic adhesiolysis have been identified as contributors for increased time spent in the operating room4.
The technical difficulty of laparoscopy in the setting of obstruction cannot be overstated. The surgeon must navigate «no-fly» zones where dilated bowel loops are likely to be injured. With simple adhesive bands, laparoscopy can be surprisingly fast; however, «matted» adhesions or multiple transition points can require exponentially longer time for safe dissection. Interestingly, previous comparative studies in similarly minimally invasive gastric surgery suggest that increased institutional volume, relative to the time required, can narrow more than correct the time disadvantage created by initial learning curves3.
Assessment of Intraoperative Complications and Blood Loss:
There is little argument for the benefit to be gained from laparoscopic approach than a significant reduction in intraoperative blood loss. Our synthesis of the evidence clearly highlighted that laparoscopic patients had less bleeding at the conclusion of surgery than open laparotomy patients. This is most likely due to the better visualization provided by high-definition laparoscopes, which allows for precise hemostasis, and earlier identification of smaller vessels that would have been difficult to identify in open surgery.
The risk of intraoperative complications, specifically inadvertent enterotomy, continues to be debated. While some studies observed similar rates of bowel injury for each group, others reported a slightly higher incidence in the laparoscopic group during earlier phases of the procedure. The loss of haptic feedback in laparoscopy means that the surgeon has to rely completely on ocular feedback with respect to the tension on the bowel wall. The loss of «tactile feedback» has been noted as a major contributor to serosal tears and perforations. In a general sense, when the laparoscopic procedures are performed by experienced surgeons, the overall complication rate is similar to open surgery but with less systemic trauma associated with the surgical intervention4.
Conversion Rates to Open Surgery and Risk Factors:
Laparoscopy to open surgery conversion occurred in approximately 15 to 25% of cases in the studies included in our analysis. It should be emphasized here that conversion should not be seen as a complication, but rather a necessary step to complete the operation when laparoscopic progress was unsafe or had stalled. Some of the common reasons for conversion included dense adhesions that could not be mobilized safely, the requirement for bowel resections in tight working spaces, and the recognition of complex underlying pathology (i.e., internal hernia, malignancy).
Risk factors for conversion outlined in the literature are a history of multiple previous abdominal procedures, bowel diameter greater than 4 cm on preoperative CT scan, and signs of bowel ischemia. Early conversion, prior to an injury, is associated with improved outcomes compared to a reactive conversion following an enterotomy. It is important for surgeons maintain a low threshold for conversion to avoid the morbidity of prolonged, unsuccessful laparoscopic attempts.
Postoperative Clinical Outcomes and Recovery:
Recovery of Bowel Function and Length of Hospital Stay:
Recovery of bowel function is one of the most important endpoints in inspection and treatment of intestinal obstruction. The data from our systematic reviews show a consistent trend toward a greater recovery of bowel function in patients undergoing successful laparoscopic intervention. On average, the time to first flatus and time to tolerance of liquid diet decreased in the laparoscopic group by 24 to 48 hours compared to the open group. This improvement in recovery time can primarily be attributed to a reduction in bowel handling and the absence of large abdominal incision, which are attributed to postoperative ileus.
The quicker return of bowel function relates directly to a significantly shorter hospital length of stay (LOS). Patients in the laparoscopic group were discharged 2 to 4 days earlier (on average) than patients receiving open surgical intervention. This finding is consistent across multiple studies, and highlights the economical and system advantages of a minimally invasive surgical approach. Along with decreased LOS, the opportunity for improved bed turnover and hospital resource use is directly advantageous in the context of emergency surgical services. The application of Enhanced Recovery after Surgery (ERAS) may also amplify the benefits of laparoscopic intervention to enhance outcomes5.
5.2 Short-term Postoperative Morbidity and Wound Complications:
Short-term morbidity, particularly with wound complications is significantly decreased in the laparoscopic group. Surgical site infections (SSIs) and wound dehiscence are significant complications associated with large midline laparotomy incisions, especially under emergency conditions and potential contamination. Port-site incisions in laparoscopy have dramatically decreased incidence of wound complications and incisional hernia during the immediate postoperative course. Our analysis has identified that there is a reduction in the incidence of SSIs by greater than 50% in the laparoscopic group.
In addition to wound issues, there was a lower rate of pulmonary complications, including atelectasis and pneumonia, in the laparoscopic cohort. Reduced postoperative pain facilitates earlier mobilization and improves respiratory effort. Although the overall rates of major complications (anastomotic leak, reoperation) did not significantly differ between the two approaches in most high-quality studies, the decrease in «minor,» albeit important, complications, such as SSIs, demonstrate a benefit for the laparoscopic-first approach4.
Mortality and Readmission at 30 days:
Overall, mortality rates for intestinal obstruction surgeries are low and depend on patient age, comorbitidies, and bowel necrosis. In our review, there was no statistically significant difference in 30-day mortality for laparoscopic versus open surgery. This indicates that the laparoscopic approach is safe and does not hinder the basic objectives of surgery (relieving the obstruction and assessing bowel viability).
Examining the 30-day readmission rates is more complicated. Some studies propose that readmission rates are lower due to fewer wound complications; others demonstrate readmission for dehydration or recurrent symptoms if a stoma was required6. In an intestinal obstruction scenario, the primary reason for readmission is recurrent obstructive symptoms or complications related to an enterotomy that may be missed in the initial surgical course. To minimize these risks, it is imperative to examine the bowel thoroughly (even with the laparoscope).
Long-term Outcomes and Recurrence Rates for Bowel Obstruction:
The ultimate goal of operative intervention for adhesive bowel obstruction is to achieve the prevention of future episodes. After all, one of the most significant theoretical benefits of laparoscopy is the decreased risk for the formation of new postoperative adhesions. Although long-term follow-up data available in the literature is less plentiful than short-term metrics (repeat surgeries in <1 year, readmissions, complications), long-term follow-up studies show patients undergoing laparoscopic adhesiolysis had a lower rate of recurrent obstruction compared to those undergoing an open laparotomy. Laparoscopy interrupts the cycle of morbidity associated with adhesions by mitigating the «insult» to the peritoneum.
The long-term risk for incisional hernia in the laparoscopic group is also significantly lower. Midline laparotomy scars are likely to develop hernias over time and may necessitate repair surgically. The use of small trocars reduces the risk of hernia formation and promotes better quality of life over time and reduces lifetime health costs. Longitudinal studies are required to establish the «adhesion-free» interval associated with laparoscopy compared to the open standard.
DISCUSSION
Evidence Synthesis and Clinical Relevance:
The evidence synthesis from this systematic review supports a change in practice towards a laparoscopic-first pathway for the treatment of intestinal obstruction in hemodynamically stable individuals. The evidence continues to demonstrate that laparoscopy provides better short-term outcomes, such as lower blood loss, earlier return to bowel function, and reduced length of stay, without increasing significant complications or mortality. These results align well with modern surgical guidelines endorsing minimally invasive techniques in emergency general surgery1.
The clinical significance of these outcomes extends beyond the patient. In an era of growing scrutiny of healthcare resources, ensuring that patients can be safely discharged with reduced LOS and morbidity around
wound complications is a primary concern. On the other hand, «success» with laparoscopy is entirely contingent on patient selection and laparoscopic experience. The benefits of laparoscopy would be most pronounced in cases with simple adhesive bands, while outcomes may be more equivocal for cases that require complex resections or extreme bowel distension.
Impact of the Cause of Obstruction on Surgical Approach:
The cause of the obstruction is an important consideration that significantly influences the laparoscopic approach to efficacy and success. Adhesive small bowel obstruction (ASBO) is still the principal indication where laparoscopy should be favoured, especially with the presence of a single «transition point» characterized on preoperative imaging. In contrast, the more nuanced approach is recommended if the cause of the obstruction is a large abdominal wall hernia or internal hernia, which may even entail a hybrid approach or early conversion to avoid suboptimal closure of a defect7.
If there is evidence of bowel necrosis or perforation, the surgical priority shifts in fundamental ways. While laparoscopy could be used for «source control» for localized perforation or at resection, the threshold for conversion should be less for fecal peritonitis or extensive ischemia. The management of intra-abdominal infections necessitates rapid and effective intervention, so the surgical approach must prioritize safety and stability for the patient, outweighing the potential benefits of a smaller incisional approach2.
Limitations of the Studies Included and Quality of Evidence:
There are multiple considerations that must be recognized when interpreting this review. First, a major limitation is that there is selection bias present in the observational studies that constitutes most of the literature. Surgeons are more likely to attempt laparoscopy in patients who are younger, thinner, and have fewer prior surgeries – and survivor bias likely would lead inferences to suggest greater potential benefits with laparoscopy. Conversely, the RCTs are of higher evidence quality, but are often performed in high volume and specialized centers by expert laparoscopic surgeons; thus, the expertise level likely makes generalizability to community settings unclear.
Second, the variation in definitions of outcomes, especially «conversion» and «postoperative complications,» also limits our ability to compare studies. Some meta-analyses have cautioned that well-reported outcomes when using minimally invasive surgical methods—decreased blood loss and shorter recovery times should be interpreted conservatively with high heterogeneity3. Lastly, the long-term data, especially regarding adhesion recurrence and incisional hernia, continues to develop and requires additional strong follow-up to demonstrate durability of the laparoscopic advantage.
Practical Implications for Surgical Decision-Making and Training:
For the practicing surgeon, conducting minimally invasive surgery for intestinal obstruction should be based on a combination of patient characteristics, imaging characteristics, and the surgeon’s own comfort and expertise. Preoperative CT scan is critical in defining the site of obstruction, the possible cause, and to identify any bowel compromise. A «laparoscopic-first» approach should not mean «laparoscopic-only»; the surgeon must be ready to convert to an open case at any point to ensure the safety of the patient.
These implications extend to surgical training. As laparoscopy continues to be the preferred approach to increasingly more emergency issues, it is imperative that surgical residents and fellows have appropriate training, especially in advanced laparoscopic techniques, bowel handling, and intracorporeal suturing. Simulation alongside proctored experience in elective laparoscopic cases (bariatric surgery or colorectal surgery) can prepare the surgeon to an extent necessary to navigate the technical challenges of an obstructed abdomen8.
CONCLUSION
This systematic review supports that laparoscopic surgery is a safe and effective alternative to open laparotomy for appropriately selected patients with intestinal obstruction. The primary benefits include decreased intraoperative blood loss, faster return of bowel function, and a significant decrease in length of stay and wound complications. The laparoscopic approach may come with longer operating times and conversion may occur, but overall clinical outcomes support laparoscopic surgery as one of the first lines of intervention in a stable patient. Further research is warranted to develop standardized patient selection criteria and to study the long-term effects of laparoscopic surgery on the recurrence of adhesive disease. Finally, the integration of minimally invasive methods into an emergency surgical toolbox represents a significant shift in the quality of care for patients with intestinal obstruction.
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