Obviously the experience of the surgeon [46, 49, 58] also influences the outcome of the laparoscopic adhesiolysis. Laparotomic conversion is often related to a higher morbidity rate, for this reason it is necessary to evaluate a primary laparotomic access in those cases without predictive check details factors for successful adhesiolysis. To shorten the operating time and reduce the laparotomic conversion rate, some surgeons suggest performing, when possible, a mini-laparotomy near the occlusion site detected laparoscopically [15, 16, 22, 59]. Tsumura

states that conversion through a mini-laparotomy still allows a mini-invasive access, with a shorter hospital stay (4.5 days in laparoscopically treated patients compared to 6.9 days in patients with a mini-laparotomic access, or 14 days in a patient treated by a classical laparotomic approach) [13, 59]. As well Wexner considers more advantageous the video-assisted approach than laparotomic access. Although these advantages are more evident with the laparoscopic

access rather than with the video-assisted approach: shorter operative time (75 min. laparoscopic treatment vs 98 min laparoscopy-assisted approach), postoperative hospital stay (4 vs 6,5 days), first bowel movement (3 vs 4 days) [29]. It is almost impossible to predict AICAR concentration in the preoperatory phase if the obstruction is caused by a single band adhesion or by multiple adhesions [5]; some surgeons and radiologists state that a CT scan can help to determine the cases in which it is likely to be a large adhesion site blocking the bowel or causing intestinal necrosis [60, 61], and which should be managed laparotomically. The analysis of the convenience of laparoscopic adhesiolysis in small bowel obstructions was evaluated by using the following parameters: surgical operating time, hospital stay, morbidity, mortality and the bowel obstruction recurrence rate (Table 5) [19, 29]. Table 5 Comparison between isothipendyl laparoscopic and laparotomic management

of small bowel obstructions.   Laparoscopic management Laparotomic management   Wullstein [19] Khaikin [29] Wullstein [19] Khaikin [29] Surgical operating time 103 min 78 min 84 min 70 min Hospital stay (postoperative) 11,3 days 5 days 18,1 days 9 days First bowel movement ** 3 days ** 6 days Oral re-intake 5,1 days   6,4 days   Morbidity 19% 16% 40,4% 45% Bowel obstruction recurrence 0–14,2%   0–4,6%   ** Not indicated by the Authors The surgical operating time is CA4P molecular weight greater in patients who underwent laparoscopic surgery compared to patients who underwent a laparotomy [19, 29]. However the duration of laparoscopic procedure is variable ranging from 20 minutes for a simple band adhesion to 2–3 hours for more complex cases [62, 63]. The hospital stay is shorter compared to a laparotomic approach [3, 11, 19, 29, 30], with an early flatus and early realimentation [19, 29].