**3.5 Laparoscopic assisted panenteroscopy**


### **3.6 Single incision laparoscopic (SILS) assisted enteroscopy**

• DAE is possible in most of the cases. However, in some cases, DAE may be difficult due to previous laparotomy, or inability to reduce the forming loops during DAE leading to incomplete bowel examination.

**101**

perforation [38].

*Role of Intraoperative Endoscopy in the Management of Small Bowel Diseases*

• In SILS technique, a SILS port is inserted at the umbilicus. A 10-mm laparoscope and two 5-mm non-traumatic graspers are inserted through the SILS port. Laparoscopic adhesiolysis is performed before starting enteroscopy.

• Enteroscopy is performed using conventional flexible endoscope or DBE. Surgical manipulation of the bowel loops is done during enteroscopy if

• The visualized lesions can be excised endoscopically or laparoscopically

• In a recent study of 13 patients who underwent SILS enteroscopy, target

depending upon the location and size of the lesions and the available expertise.

pathology could be reached in all but one patient with PJS, in whom antegrade DBE failed to reach up to the target polyp and a small enterotomy was required

A review of 16 studies involving 468 patients by Voron T, et al. reported that the site of bleeding could be successfully identified in 371 patients (79.3%) [16]. The predominant lesions responsible for obscure GI bleed were vascular lesions (n = 227, 61%), benign ulcers (n = 70, 19%), tumors (n = 36, 10%) and diverticula (n = 15, 4%) [16]. The most common route of IOE was transoral followed by trans-enterotomy. A recent study by Manatsathit W, et al. also reported vascular lesions, ulcers

The reported rates of diagnostic and therapeutic yield of IOE are 79.3% (58–100%) and 75.7% (48–94%), respectively [1–10, 16, 36]. The diagnostic yield for obscure GI bleeding after non-diagnostic abdominal imaging has been reported to be 91–100% and after non-diagnostic VCE/DAE varies from 14.2% to 66.7% [1, 6, 9, 36]. Traditionally, the treatment of the lesions detected during IOE were performed surgically. But, with the advancement in the endoscopic techniques, the lesions are being increasingly tackled endoscopically as far as possible and surgical treatment is performed for the rest

IOE via enterotomy converts clean surgery in to clean-contaminated surgery which increases the risk of infective complications. Another problem of IOE is excessive bowel handling which increases the risk of postoperative ileus. The reported complication rates of IOE vary between 1 and 50% [16, 36, 37]. According to a combined data of 10 studies involving 309 patients, the overall morbidity rate was 16.8% which included surgical and medical morbidities [37]. The complications were mainly related to general anesthesia, laparotomy and bowel surgery required for bowel lesions and not solely related to IOE. Prolonged postoperative ileus was one of the predominant surgical morbidity. Other morbidities included bowel obstruction, wound infection, intrabdominal collections/abscess, intra-abdominal bleeding, chest infection and cardiorespiratory failure [18, 37]. The complications directly related to IOE include mucosal laceration, bowel wall hematoma, mesenteric hematoma or bleeding due to excessive handling during IOE and rarely, bowel

*DOI: http://dx.doi.org/10.5772/intechopen.95851*

to complete IOE and excise the polyp [21].

of the lesions especially in condition like PJS.

and tumors to be the most common lesions detected on IOE [36].

required.

**4. Outcomes**

**5. Complications**

• In such cases, DAE can be performed under laparoscopic guidance. Laparoscopy can be undertaken by conventional 3-ports or SILS technique [21, 27].

*Role of Intraoperative Endoscopy in the Management of Small Bowel Diseases DOI: http://dx.doi.org/10.5772/intechopen.95851*


### **4. Outcomes**

*Endoscopy in Small Bowel Diseases*

**3.4 Insertion of port in bowel**

enteroscopy.

route [24, 26].

laparoscopically.

experienced.

technique [21, 27].

described the use of laparoscopic port.

**3.5 Laparoscopic assisted panenteroscopy**

laparoscopic bowel manipulation [24].

careful manipulation of the small bowel loops.

**3.6 Single incision laparoscopic (SILS) assisted enteroscopy**

during DAE leading to incomplete bowel examination.

passed through it in to the bowel.

• In order to avoid contamination of the operative field, some authors have

• In this technique, a 12-mm or 15-mm bladeless laparoscopic port with or without balloon is inserted from the enterotomy site in to the bowel [31–34].

• The endoscope is passed through the camera sleeve and port in to the bowel for

• In this technique, in order to avoid the laparotomy, the endoscope is passed

• The procedure for IOE via oral or anal route is same as described above except that the adhesiolysis and handling of the small bowel is performed laparoscopically. Additionally, the bowel insufflation has to be minimum to allow space for

• For IOE through enterotomy, a small jejunotomy is made and the endoscope is

• Although the mobility of the scope is restricted compared to conventional IOE through laparotomy, it is possible to visualize the whole small intestine with

• After the withdrawal of the endoscope, the enterotomy wound is sutured

• However, this procedure is technically more demanding and time consuming. Both the laparoscopist and endoscopist need to be highly skilled and

• DAE is possible in most of the cases. However, in some cases, DAE may be difficult due to previous laparotomy, or inability to reduce the forming loops

• In such cases, DAE can be performed under laparoscopic guidance. Laparoscopy can be undertaken by conventional 3-ports or SILS

• IOE can be performed via oral [25, 27, 34], anal [35] or enterotomy

• The laparoscopic camera sleeve is fixed to the port with tape.

• This technique allows to maintain the sterility of the operative field.

through one of the 12- or 15-mm laparoscopic port [24–26].

**100**

A review of 16 studies involving 468 patients by Voron T, et al. reported that the site of bleeding could be successfully identified in 371 patients (79.3%) [16]. The predominant lesions responsible for obscure GI bleed were vascular lesions (n = 227, 61%), benign ulcers (n = 70, 19%), tumors (n = 36, 10%) and diverticula (n = 15, 4%) [16]. The most common route of IOE was transoral followed by trans-enterotomy. A recent study by Manatsathit W, et al. also reported vascular lesions, ulcers and tumors to be the most common lesions detected on IOE [36].

The reported rates of diagnostic and therapeutic yield of IOE are 79.3% (58–100%) and 75.7% (48–94%), respectively [1–10, 16, 36]. The diagnostic yield for obscure GI bleeding after non-diagnostic abdominal imaging has been reported to be 91–100% and after non-diagnostic VCE/DAE varies from 14.2% to 66.7% [1, 6, 9, 36]. Traditionally, the treatment of the lesions detected during IOE were performed surgically. But, with the advancement in the endoscopic techniques, the lesions are being increasingly tackled endoscopically as far as possible and surgical treatment is performed for the rest of the lesions especially in condition like PJS.

### **5. Complications**

IOE via enterotomy converts clean surgery in to clean-contaminated surgery which increases the risk of infective complications. Another problem of IOE is excessive bowel handling which increases the risk of postoperative ileus. The reported complication rates of IOE vary between 1 and 50% [16, 36, 37]. According to a combined data of 10 studies involving 309 patients, the overall morbidity rate was 16.8% which included surgical and medical morbidities [37]. The complications were mainly related to general anesthesia, laparotomy and bowel surgery required for bowel lesions and not solely related to IOE. Prolonged postoperative ileus was one of the predominant surgical morbidity. Other morbidities included bowel obstruction, wound infection, intrabdominal collections/abscess, intra-abdominal bleeding, chest infection and cardiorespiratory failure [18, 37]. The complications directly related to IOE include mucosal laceration, bowel wall hematoma, mesenteric hematoma or bleeding due to excessive handling during IOE and rarely, bowel perforation [38].

The overall mortality rate of IOE from the combined data of 14 studies including 419 patients was 5% [37]. The main causes of death were multiorgan failure, septic shock, diffuse intravascular coagulopathy and hemorrhagic shock [37].

An important issue in patients with obscure GI bleed after any investigation or treatment is the development of recurrent GI bleed. The reported incidence of recurrent GI bleed ranges from 13–52% in different series [9, 36, 37]. It is important to note that differentiation between iatrogenic mucosal trauma from mucosal vascular lesions by IOE is difficult [39]. Secondly, vascular lesions can be evanescent, hence early IOE or at time of bleeding can make the detection of these lesions possible [40]. Other reasons for rebleeding could be appearance of new lesions due to same or different disease, incomplete endoscopic treatment of the existing lesions such as angiodysplasia, etc.
