Preoperative factors influence technique selection in surgical management of small bowel obstruction: findings from...

Laparoscopic surgery is a standard approach for many elective gastrointestinal procedures but remains underutilized for emergent small bowel obstruction (SBO) resolution. This study evaluates how preoperative factors influence the initial choice of laparoscopic versus open surgery for SBO, and how intra-operative events may modify the initial operative approach and impact outcomes.

Prospective, multicenter, multinational time-bound observational study of SBO patients. Preoperative data and operative details were collected. Primary outcome was initial surgical approach (laparoscopic or open). Secondary outcomes included conversion to open and post-operative complications. Uni- and multivariable analyses identified predictors of approach selection and conversion.

Of 1737 patients, 876 (50.4%) underwent surgery with 172 (19.6%) initially explored using laparoscopy; 60 (34.8%) of those cases converted to open. Laparoscopy was initially pursued in younger patients (mean 60.9 ± 18.2 vs. 66.5 ± 17.5 years, p < 0.001), with fewer comorbidities (66.3% vs. 75.1%, p = 0.018), and less frequent prior abdominal surgery (43.6% vs. 29.8%, p < 0.001) or multiple previous operations (mean 1.5 ± 1 vs. 1.9 ± 1.3, p = 0.03). Presumed etiology influenced approach: laparoscopy was more frequently utilized for adhesive single-band obstructions (60.5% vs. 45.2%), whereas open surgery was more common for hernias (24.4% vs. 38.1%). Both abdominal malignancy (OR = 4.74, p = 0.015) and free intraperitoneal fluid on CT (OR = 6.79, p < 0.001) surfaced as independent predictors of conversion. Laparoscopy was associated with fewer complications (surgical: 13.9% vs. 23.1%, p = 0.009; medical: 9.8% vs. 20.7%, p = 0.001) and lower mortality (0.6% vs. 8.3%, p < 0.001) than open surgery.

Preoperative patient factors and disease etiology are associated with initial operative technique selection, while intraoperative events and findings appear to adjust the probability of conversion to open. Preoperative assessment combined with flexibility in intraoperative decision-making appears to be associated with optimal outcomes in SBO management.