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HAPTER 1
Current Management of
Small-Bowel Obstruction
Awori J. Hayanga, MD
General Surgery Resident, Johns Hopkins Hospital, Department of
Surgery, Baltimore, Maryland
Kirsten Bass-Wilkins, MD
Attending Surgeon, Associated Colon & Rectal Surgeons, P.A., Edison,
New Jersey
Gregory B. Bulkley, MD
Ravitch Professor of Surgery, Department of Surgery, Johns Hopkins
University School of Medicine, Baltimore, Maryland
PATHOGENESIS
Small-bowel obstruction may be caused by a variety of intrinsic or
extrinsic lesions (Table 1). In technologically advanced countries,
the predominant cause is adhesions from a prior laparotomy, which
account for up to 50% to 80% of the cases in many centers.2,3 In less
Advances in Surgery, vol 39
Copyright 2005, Mosby, Inc. All rights reserved.
TABLE 1.
Etiology of Small-Bowel Obstruction
Etiology
Adhesions
Malignant Tumor
Hernia
Inammatory Bowel Disease
Volvulus
Miscellaneous
Approximate Incidence, %
60
20
10
5
3
2
ing population with chronic diseases, obturator hernias may become more prevalent.
Crohns disease is increasingly being recognized in the surgical
literature as a leading cause of small-bowel obstruction, which is a
concept that has been long entertained in clinical radiology.12 It accounts for approximately 5% of all cases of small-bowel obstruction. This subclass of patients often has a chronic, subacute, or intermittent form of partial obstruction that is usually approached
differently from the more acute forms of small-bowel obstruction.
Miscellaneous causes represent only 2% to 3% of cases of smallbowel obstruction. For example, gallstone ileus is rare in the general
population but more common in the elderly.13 Small-bowel obstruction is also uncommon during pregnancy, but it has been reported
with an incidence of 1 in 16,709 deliveries. Most of these women
have undergone previous surgery, and 50% had had a previous appendectomy. Obstruction most commonly appears during the rst
pregnancy after surgery. The fetal mortality rate is reported to be as
high as 38%.14 In the pediatric population, congenital intestinal
atresia, pyloric stenosis, and intussusception are commonly encountered. Other causes in adult patients include phytobezoar in
patients with a history of previous gastric surgery15 and familial
Mediterranean fever,16 a disease characterized by recurring, selflimiting attacks of febrile inammation of the peritoneum, pleura,
and synovium, of which small-bowel obstruction has been found to
be the most frequent complication.
An important cause of small-bowel obstruction, especially partial obstruction, that is rarely listed in most clinical series is a localized intra-abdominal abscess from any cause but commonly from a
ruptured appendix or diverticulum or an anastomotic leak. At surgery, these patients often do not exhibit actual mechanical occlusion
of the bowel lumen; rather, it appears that their clinical obstruction
is caused by an intense local ileus in the bowel directly adjacent to
the abscess that obstructs functionally.
PATHOPHYSIOLOGY
Mechanical small-bowel obstruction is accompanied rst by the development of mild, proximal intestinal distension that results from
the accumulation of normal gastrointestinal secretions and gas
above the obstructed segment. Initially, this distension physiologically stimulates peristalsis above and below the point of the obstruction. This distal peristalsis accounts for the frequent loose bowel
movements that may accompany partial or even complete smallbowel obstruction in the early hours after onset. This distension also
stimulates the physiologic secretion of uid, electrolytes, and succus entericus into the bowel lumen.17,18 Indeed, this initial response
merely represents the normal physiologic response to feeding. If the
bowel lumen remains occluded distally, increased distension occurs, and a positive feedback relationship evolves between secretion, peristalsis, and distension.
As the distension becomes more severe, the intraluminal hydrostatic pressure increases to the point (only a few centimeters of water) whereby the compression of the intestinal mucosal villus lymphatics, the terminal lacteals, results in obstruction of the normally
substantial level of lymphatic ow and the consequent development of bowel wall lymphedema. The accumulation of uid in the
bowel wall and subsequently within the lumen further increases intraluminal hydrostatic pressure. Consequent compression of the
postcapillary venules eventually results in elevated hydrostatic
pressure at the venous end of the capillary; this increased hydrostatic pressure disrupts the Starling relationship of capillary uid
exchange, and the net ltration of uid, electrolytes, and protein
across the capillary bed into the bowel wall and lumen is increased
massively. This third space loss of extracellular uid from the intravascular space results in dehydration and hypovolemia that can
sometimes be severe. If the obstruction is proximal, the dehydration
may be accompanied by hypochloremic, hypokalemic metabolic alkalosis secondary to the vomiting of gastric juice. Prolonged dehydration may result in oliguria, azotemia, and hemoconcentration.
Eventually, hypotension and hypovolemic shock may ensue. Increasing abdominal distension may also lead to increased intraabdominal pressure, which may impair ventilation by diaphragmatic elevation and may further reduce venous return from the
lower extremities by caval compression, thereby potentiating the effects of hypovolemia.
Venous hypertension and ischemia may occasionally progress
directly to arterial occlusion and subsequent frank ischemia at the
microvascular level. However, it is more common for the loop of distended bowel to further twist on itself and its associated mesentery
and result in macrovascular arterial occlusion of the mesenteric vascular branches at the root of the mesentery. Bowel ischemia and necrosis then progress rapidly and, if left untreated, may lead to bowel
perforation, peritonitis, and death from sepsis.
Normally, the mucosa of the gastrointestinal tract acts as a barrier to the systemic circulation of bacteria that normally reside within
the gut lumen. However, the gastrointestinal tract may suffer failure
of this barrier function under a number of conditions.19,20 Normally,
CLINICAL PRESENTATION
The diagnostic and therapeutic approach to small-bowel obstruction should be systematic and lends itself to classication into 4
phases: (1) recognizing mechanical obstruction, (2) distinguishing
partial from complete obstruction, (3) distinguishing simple from
strangulating obstruction, and (4) identifying the underlying cause.
This illustrates that the initial approach to bowel obstruction is generic, and attention to the underlying cause is usually a secondary
consideration.
RECOGNIZING SMALL-BOWEL OBSTRUCTION
In most cases, identication of a patient with small-bowel obstruction is straightforward and based on the characteristic symptoms,
physical signs, and supine and upright plain abdominal radiographs. The patients history is often remarkable for previous, usually pelvic, abdominal surgery. The patient typically has a variable
period of abdominal pain (usually colicky, especially in the early
period), nausea, vomiting, obstipation, or perhaps diarrhea, that
is, the passage of several small loose stools (distally, to the point of
obstruction). The nature of the pain may be helpful because colicky
pain tends to be encountered most frequently in cases of simple obstruction, whereas constant pain has been attributed to late or stran-
gulating obstruction. Diarrhea, if present, is secondary to the increased peristalsis distal to an early, complete obstruction or to most
partial obstructions. Patients who come to the emergency department with crampy abdominal pain, nausea, vomiting, and diarrhea
with hyperactive bowel sounds are often correctly given a diagnosis
of gastroenteritis, but a bowel obstruction may be missed if supine
and upright plain abdominal lms are not obtained.
On physical examination, the patient will usually have abdominal distension, and the degree often varies with the level of obstruction. A duodenal or high proximal small-bowel obstruction may occur with little evident distension. Bowel sounds may be either
hyperactive early or hypoactive if the patient is seen late in the
course of simple obstruction or has a strangulating lesion. Mild abdominal tenderness may be present with or without a palpable mass.
The presence of peritoneal signs may again point toward a late,
strangulating obstruction. The importance of a careful examination
to rule out an obvious incarcerated hernia in the groin, the femoral
triangles, or the obturator foramina (palpable on digital rectal examination) cannot be overemphasized. A rectal examination should
also be performed to screen for intraluminal masses and to check for
the presence of gross or occult blood.
On initial plain-lm examination, the ndings of distended
loops of small bowel with airuid levels (on upright views) and a
paucity of colonic air are characteristic (Fig 1). However, plain lms
may be diagnostic only 45% to 60% of the time.24-27 For example, a
patient may have a gasless abdomen on plain lms in the presence of
complete obstruction. This may be caused by a closed-loop obstruction that precludes the accumulation of gas within the obstructed
loop. Closer evaluation of such a lm may reveal a ground-glass
haziness in the midabdomen or displacement of adjacent bowel by
the invisible, dilated, closed loop (Fig 2).25 In an analysis of plain
lm ndings reported by experienced gastrointestinal radiologists,
a sensitivity of only 66% was found in proven cases of small-bowel
obstruction. Twenty-one percent of patients reported to have normal
results did, in fact, have obstructions. Of those patients whose lm
ndings were interpreted as abnormal but nonspecic, 13% had
low-grade and 9% had high-grade obstruction.28 Despite these limitations, plain lm radiography remains a cornerstone in the diagnosis of small-bowel obstruction, largely because of its widespread
diagnostic capability, availability, accessibility, and low cost. However, when the diagnosis is in doubt, computed topography (CT) will
help clarify the situation.
FIGURE 1.
Supine and upright plain abdominal radiographs in a patient with small-bowel obstruction. A, Supine lm showing characteristic dilated loops of small bowel and a
paucity of colonic air. B, Upright lm revealing air-uid levels and the string of
pearls sign in the right lower quadrant. (Courtesy of Dr Bronwyn Jones, MD, Attending Radiologist, The Johns Hopkins Medical Institutions.)
FIGURE 2.
Supine and upright plain abdominal radiographs in a patient with a closed-loop
small-bowel obstruction. A, Supine lm showing a relatively gasless abdomen
and the ground glass appearance of the midportion of the abdomen. B, Upright
lm showing only a few air-uid levels in the right lower quadrant. (Courtesy of Dr
Bronwyn Jones, MD, Attending Radiologist, The Johns Hopkins Medical Institutions.)
10
but the continuing evolution of multiphasic CT scanning has limited this usefulness considerably.35-37 CT is faster, more available,
less contingent on technical expertise, and capable of providing a
more global evaluation of the abdomen and gastrointestinal tract.1
DISCRIMINATING PARTIAL FROM COMPLETE OBSTRUCTION
Because the management of complete obstruction should usually be
operative and that of partial small-bowel obstruction, at least initially, almost always nonoperative, discrimination between the 2 is
important. The patients history may provide a clue because the continued passage of atus or stool, 6 to 12 hours after the onset of symptoms, is more consistent with a partial obstruction. However, even a
complete small-bowel obstruction can be accompanied early by
loose stools secondary to peristalsis distal to the obstruction. On
plain lms, the persistence of residual colonic gas after 6 to 12 hours
is also suggestive of a partial obstruction. Of importance, rectal examination of supine patients does not introduce signicant rectal
air, whereas exible or rigid sigmoidoscopy may well do so.
Despite the foregoing information, some patients can present a
real diagnostic challenge because early complete obstruction can be
difcult to distinguish from partial, high-grade obstruction on plain
lms. For their discrimination, the use of oral, contrast-enhanced
CT has markedly improved on, and often supplanted, traditional imaging, small-bowel series, and enteroclysis. This may be attributed
to the improvement in speed and resolution of current CT imaging.
CT with IV contrast material is superior to barium studies in showing the bowel wall and extraluminal masses and in revealing inammatory lesions, as well as features of strangulation.1,12
Modern CT may also provide strikingly detailed views of the
mesenteric vasculature. Moreover, images taken at intervals closely
timed to the injection of the IV contrast material can be used to
evaluate mucosal perfusion by estimating the rapidity of the dye
washout. Oral contrast, either Hypaque or, increasingly, just water
alone is particularly useful in evaluating the size, patency, and progression of luminal contents.
CT has proven particularly useful in discriminating a complete
from a partial obstruction by determining the degree of collapse and
the amount of residual air and uid in the collapsed (distal) intestinal segment.12,29 A limitation of CT for the discrimination of a partial obstruction is that a mild partial obstruction may not reveal a
clear transition zone on CT, which could lead to a misdiagnosis of
ileus if there is not a close correlation between the history and physical ndings. In most cases, however, the presence or absence of re-
11
FIGURE 3.
(continued)
13
FIGURE 3. (continued)
Computed tomography in a patient with signs of strangulation. A, Note the massively thickened bowel wall from edema. B and C, Note the areas of pneumatosis
intestinalis, a late sign of ischemic necrosis. Note the bulls eye on the sagittal
view indicative of the massive amounts of air within the bowel wall. (Courtesy of
Dr Elliot Fishman, MD, Attending Radiologist, The Johns Hopkins Medical Institutions)
14
MANAGEMENT
SYSTEMATIC RESUSCITATION
Patients with small-bowel obstructions are usually intravascularly
depleted, often massively, because of a decreased oral intake, vomiting, and the sequestration of uid from the intravascular space
within the bowel wall and lumen. This requires aggressive replacement with an IV saline solution such as Ringers lactate. Routine
laboratory measurements of serum sodium, potassium, chloride, bicarbonate, and creatinine levels should be obtained. Serial measurements of the hematocrit level, white blood cell count, and serum
electrolyte levels are monitored closely to assess the adequacy of
uid repletion and as a possible indication of late tissue necrosis.
Serum lactic acid levels are usually obtained; however, a normal lactate level does not rule out early ischemia, and elevated lactate levels can be seen in a number of circumstances. Thus, this test is neither sensitive nor specic but may sometimes be helpful. Because
of their large uid requirements, many patients will need either central venous pressure monitoring or the placement of a pulmonary
artery catheter. Almost all patients will need the placement of a Foley catheter so that hourly urine output may be monitored. Broadspectrum antibiotics are also often given in consideration of the
evidence for bacterial translocation occurring in even simple obstruction, or they are given as prophylaxis for resection or an inadvertent enterotomy at surgery. However, this is a practice that varies
greatly and has not been subject to denitive study.
MANAGEMENT OF OBSTRUCTION
Virtually all patients with small-bowel obstructions benet from the
use of nasoenteric suctioning, whether it be via a nasogastric or long
intestinal tube such as a Baker tube. This provides almost immediate symptomatic relief from the nausea and vomiting and, often to a
signicant degree, the abdominal pain. It allows the administration
of radiographic contrast material to these nauseated patients. It also
helps prevent aspiration at the time of induction of anesthesia. In
some situations, a long tube may provide a postoperative splint to
prevent a recurrent obstruction. Sometimes it provides denitive
treatment in lieu of surgery. However, the decision to use a nasoen-
15
16
in patients who did require surgery after initial nonoperative treatment. Another retrospective series46 reported a 73% rate of resolution of adhesive obstruction without a signicant increase in the
mortality rate or the rate of strangulated bowel when compared with
outcomes in other series. In this series, a trial of tube decompression (ie, nonoperative management) for more than 5 days was ineffective. These authors argue that a trial of nonoperative nasoenteric
decompression of 2 to 3 days duration, even up to 5 days in select
patients, is reasonable in most patients who show no clinical evidence of strangulation. The problem with these and similar studies
is that they include a large, undened population that is usually a
mix of patients with either complete or partial small-bowel obstructions. (Indeed, there is little controversy that partial obstruction
should be managed nonoperatively initially.) The studies fail, therefore, to denitely resolve the controversy over the correct management of complete small-bowel obstruction, but they do indicate that
such an approach is safe in patients with partial obstructions.
If initial nonoperative management fails, several operative approaches are available via conventional laparotomy. Often, the obstruction is caused by the presence of 1 or more constricting adhesive bands, and the obstruction is relieved through simple lysis
of the adhesions and detorsion. An obstructing lesion may also be
present and may require local bowel resection with primary reanastomosis. A side-to-side intestinal bypass or, rarely, the placement of
enterocutaneous stomata may be the appropriate management of
end-stage malignant obstructing lesions or radiation enteritis.
Advances in laparoscopic surgery have modied the approach
to many general surgical problems, and laparoscopic management
of acute small-bowel obstruction is an option that is gaining advocacy. Franklin et al47 reported 23 patients with acute obstruction
evaluated initially with laparoscopy (after an initial trial of conservative management had failed). Twenty patients had successful laparoscopic resolution of their obstruction, and 3 required laparotomy. The 3 patients who were converted to laparotomy had severe
adhesions, anatomy that precluded complete examination of the entire length of the bowel, or suspected ischemic necrosis, respectively. The authors47 emphasized the importance of using nontraumatic bowel clamps when manipulating the dilated, friable bowel
during laparoscopy to avoid injury. Similar studies advocate the manipulation of the mesentery rather than the bowel wall whenever
possible, particularly when running the bowel.8 Lerard et al,48 in
a multicenter retrospective study, reported that laparoscopic treatment for small bowel obstruction was, in their series, of greatest
17
18
19
A substantial adjuvant to the management of partial smallbowel obstruction is the enteroclysis study, whereby graded volumes of dilute barium and methyl cellulose are given through a long
tube localized either by peristalsis or direct uoroscopic positioning
in the small bowel just proximal to the site of the obstruction. This
study, in the hands of an experienced radiologist, can often help dene the degree of obstruction, its location, and its progression (ie,
improvement or lack thereof) over time. Enteroclysis can objectively
gauge the severity of the intestinal obstruction, which is an important advantage over other modalities.63 For a low-grade partial
small-bowel obstruction, there is no delay in the arrival of contrast
to the point of the obstruction and there is sufcient ow of contrast
through this point such that fold patterns in the postobstructive
loops are readily dened. A high-grade partial small-bowel obstruction is diagnosed when the presence of retained uid dilutes the
barium, which results in inadequate contrast density above the site
of obstruction and allows only small amounts of contrast material to
pass through the obstruction into the collapsed distal loops. Complete obstruction is diagnosed when there is no passage of contrast
material beyond the point of the obstruction, as seen on delayed radiographs obtained up to 24 hours after the start of the examination.27,64 This may be useful in deciding whether to intervene surgically or to wait longer for resolution. Sometimes, the underlying
cause can be inferred (eg, an adhesion can be discriminated from a
neoplasm).28
To help resolve partial small-bowel obstructions nonoperatively, some have advocated the use of hyperosmolar water-soluble gastrointestinal contrast agents as therapeutic as well as diagnostic modalities. In a prospective randomized trial65 looking at the effect of
Gastrografn in the nonoperative management of partial smallbowel obstructions, among the patients managed successfully nonoperatively, those who received 100 mL of Gastrografn had a signicant reduction in the number of days until the rst stool and in
the length of their overall hospital stay, from approximately 4 to 2
days. However, this trial found no signicant difference in the proportion of patients who eventually required surgical intervention.
Stordahl et al33 have also reported water-soluble contrast agents to
be useful as therapeutic agents. However, there was no control group
treated with nasogastric suction alone. Others66 have reported that
no advantage over conventional nonoperative management of partial small-bowel obstructions was found, although administration of
such hyperosmolar contrast materials was safe in patients with partial small-bowel obstructions. On the other hand, there are 2 signi-
20
21
22
23
24
plete, partial, or intermittent small-bowel obstruction. The obstruction may be secondary to the primary inammatory process itself or
to the gradual development of a brotic stricture as a sequela of repeated episodes of inammation and healing, with or without treatment. These patients, often with partial obstruction, can frequently
be managed initially nonoperatively with tube decompression2 in
combination with pharmacologic treatment of the inammatory process (eg, with high-dose steroids). Parenteral nutrition should be
provided because the period of required bowel rest may be prolonged. On the other hand, if brotic strictures are the primary cause
of the obstruction, primary bowel resection may be necessary to relieve the obstruction. This does not imply that a nonoperative trial
should not be attempted; the obstruction related to the strictures
may prove to be partial as the associated inammation resolves.
Over the past decade, a number of articles81 have reported the success of operative strictureplasty, with or without concomitant bowel
resection in other areas, for multiple, short strictured segments in
patients with Crohns disease.
Intra-Abdominal Abscess
Often, an acute intra-abdominal abscess may produce a clinical picture that is indistinguishable from complete, mechanical, smallbowel obstruction. This is often due not to intraluminal obstruction
or even to external compression of the bowel lumen but to a severe
localized ileus secondary to local inammation and edema. Drainage of the abscess is often sufcient to relieve the obstruction. This
does not necessarily require a laparotomy because the abscess may
be accessible with the use of ultrasound- or CT-guided percutaneous
drainage. However, if the obstruction persists, a laparotomy may be
required.
Radiation Enteritis
Of importance in the current management of malignancies of many
types is the use of radiotherapy. In a retrospective analysis82 of patients at the University of California Los Angeles undergoing radical
hysterectomy, a 5% incidence of subsequent small-bowel obstruction was reported in those undergoing surgery alone, but a 20% incidence was reported in patients receiving adjuvant radiotherapy.
Small-bowel obstruction is a recognized late complication of radiotherapy instituted for the treatment of rectosigmoid and rectal cancer after low anterior resection and abdominoperineal resection. The
rate has been reported to be as high as 30% in patients treated with
daily extended-eld radiotherapy, 21% in those receiving single
25
26
tion. Barium contrast should usually be used, unless there is a danger of perforation or anastomotic leakage.
Once the diagnosis of obstruction has been established, it should
be managed like an obstruction that occurs otherwise in the postoperative period. Specically, partial obstruction may be afforded a
trial of tube decompression. In fact, in this situation, the opportunity to temporarily stabilize the patient and delay surgery a while
longer into the postoperative period may be an advantage. Complete
obstruction is a relatively clear indication for early exploration.
However, in the postoperative setting, it is not uncommon for the
surgeon to prefer an initial trial of nonoperative management. Caution must be taken, however, because several series25 have reported
an especially high rate of missed strangulation in patients with early
postoperative obstruction. Moreover, an initial delay can move the
timing of surgery to 10 to 14 days postoperatively, which is a time at
which new, vascularized, dense adhesion formation can make the
operative dissection difcult and dangerous.
Recurrent Obstruction
Patients with multiple recurrent adhesive obstructions represent a
difcult management problem. (Various studies3-5 report recurrence
rates of approximately 10% to 30%.) Recurrent obstruction seems to
be a particular problem for patients with extensive, dense intraperitoneal adhesions. An initial nonoperative trial is usually desirable
and is often safe. However, a retrospective study86 found that a recurrence happened sooner and more frequently in patients managed
conservatively than in patients managed operatively after their second episode of a recurrence. This does not mean that every patient
with recurrent obstruction should be managed operatively. Patients
must be evaluated as individuals, and their previous responses to
particular interventions must be taken into account when their management plan is formulated.
Bowel xation procedures have been used at surgery in an attempt to splint the bowel in a nonobstructive conguration while
the inevitable adhesions form. There are 2 categories of bowel xation, external and internal. External plication procedures include
the Noble87 and the Childs-Phillips88 procedures and other variations of these techniques, whereby the small intestine or its mesentery is sutured in large, gently curving loops. Variable success in preventing recurrent obstruction has been reported87-90 when these
techniques are used. Common complications are the development
of enteroenteric, enterocolic, and enterocutaneous stulas, gross
leakage, peritonitis, and death.87-90 For this reason and because of
27
the low overall success rate, these procedures have largely been
abandoned.
Internal xation or stenting procedures use a long intestinal tube
inserted via the nose, a gastrostomy, or even a jejunostomy to splint
the bowel in gentle, unobstructing curves. The intestinal tube is then
left in place for at least 1 week postoperatively, even after nasoenteric suctioning has been discontinued. The hope is that adhesions
will form in such a manner that future torsion of loops about band
adhesions is less likely. Several series91-94 have reported moderate
success with the use of this approach. Complications associated
with the use of internal stenting tubes include intussusception of
the bowel, either over the tube while it is in place or after tube removal, and difcult removal of the tube, which may require surgical
re-exploration.91-95 Close and Christensen96 have looked at the rate
of recurrent obstruction in patients undergoing Childs-Phillips plication or Baker tube stenting versus enterolysis alone in a retrospective series. They found that the rate of recurrent obstruction was
relatively low after all 3 interventions; the highest recurrence occurred after enterolysis alone (6.5%). These authors recommend
that enterolysis alone is adequate for single-band adhesions or for
few adhesions. In cases of severe, multiple adhesions, they advocate
the use of either Childs-Phillips plication or Baker tube stenting.
They further suggest that the Baker tube should be used in cases of
massive bowel distension because of its capability to decompress
the bowel as well as provide a means of plication. They also prefer
Baker tube stenting over external plication in cases of peritonitis because the transmesenteric sutures may provide a nidus of infection.
In the absence of studies controlled by comparable groups, however,
it is problematic to advocate dogmatically; few modern surgeons use
any method of stenting, and most of those that do use internal tube
xation.
SUMMARY
The most signicant advances in the management of small-bowel
obstruction are developments in imaging modalities available to assist in the diagnosis itself, as well as to possibly assist in the early
identication of those cases requiring urgent operative decompression. The most marked of these have been in the use and interpretation of contrast-enhanced CT. This has decreased the use of barium
studies and has largely supplanted ultrasound and magnetic resonance imaging in the management of these patients.
Diagnostic and therapeutic laparoscopic techniques are also
growing in both capability and popularity. Laparoscopic adhesioly-
28
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93.
94.
95.
96.
33