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Laparoscopic Adhesiolysis

  • Author: Maria Sophia S Villanueva, MD; Chief Editor: Kurt E Roberts, MD  more...
 
Updated: Sep 14, 2015
 

Overview

Background

Adhesions are bands of scar tissue that form between organs. In the abdomen, they form after an abdominal surgery or after a bout of intra-abdominal infection (ie, pelvic inflammatory disease, diverticulitis). More than 95% of patients who undergo abdominal surgery develop adhesions; these are almost inevitably part of the body’s healing process.[1]

Although most adhesions are asymptomatic, some can cause bowel obstructions, infertility, and chronic pain. In a study that reviewed over 18,912 patients who underwent previous open abdominal surgery, 14.3% presented with a bowel obstruction in 2 years, with 2.6% of these patients requiring adhesiolysis to relieve the bowel obstruction.[2] Postoperative adhesions account for 74% of cases of small-bowel obstruction.[3]

Laparotomy with open adhesiolysis has been the treatment of choice for acute complete bowel obstructions. Patients who have partial obstructions, with some enteric contents traversing the obstruction, may also require surgery if nonoperative measures fail. However, operation often leads to formation of new intra-abdominal adhesions in 10-30% of patients, which may necessitate another laparotomy for recurrent bowel obstruction in the future.[4, 5, 6]

Laparoscopic adhesiolysis was first described by a gynecologist for the treatment of chronic pelvic pain and infertility.[7] In the early days of laparoscopy, previous abdominal surgery was a relative contraindication to performing most laparoscopic procedures. Laparoscopic surgery to relieve bowel obstructions was not routinely performed. However, in 1991, Bastug et al reported the successful use of laparoscopic adhesiolysis for small-bowel obstruction in one patient with a single adhesive band.[8]

Since then, many case series have documented this technique.[7] Advanced technology with high-definition imaging, smaller cameras, and better instrumentation have allowed for an increasing number of adhesiolysis to be performed laparoscopically with good outcomes.

Compared with the open approach to adhesiolysis, the laparoscopic approach offers the following:

  • Less postoperative pain
  • Decreased incidence of ventral hernia
  • Reduced recovery time with earlier return of bowel function
  • Shorter hospital stay

In 2012, a European consensus conference formulated clinical practice guidelines for laparoscopic adhesiolysis, including recommendations for diagnostic assessment, operative timing, patient selection, conversion criteria, equipment, adjunctive agents, and other concerns.[9]

Indications

Patient selection is important in the success of the procedure. Laparoscopic adhesiolysis has a number of potential advantages, but these advantages are realized only if the procedure is performed in patients best suited for it.

Laparoscopic adhesiolysis is indicated in the following patients:

  • Patients with a complete small-bowel obstruction or partial small-bowel obstruction not resolving with nonoperative therapy, but without signs of peritonitis or bowel perforation or ischemia
  • Patients with resolved bowel obstruction but with a history of recurrent, chronic small-bowel obstruction demonstrated by a contrast study

Controversy exists regarding whether patients with chronic pelvic pain benefit from laparoscopic adhesiolysis or whether any seeming benefit is a placebo effect. This controversy notwithstanding, the procedure should be offered to patients with chronic pelvic pain if no other etiology of pain is found in the previous workup.

Contraindications

Laparoscopic adhesiolysis is appropriate only for selected patients. Contraindications include the following:

  • Acute perforation and peritonitis, necessitating bowel resection and handling of severely inflamed organs
  • Massive abdominal distention that precludes insufflation and a sufficient working space during laparoscopy.
  • Hemodynamic instability
  • Patients who are unable to tolerate pneumoperitoneum because of severe comorbid conditions of the heart and lung
  • Surgeons who are not trained to perform this procedure

Outcomes

A meta-analysis comparing laparoscopic versus open adhesiolysis in patients with small-bowel obstruction showed that laparoscopic adhesiolysis was associated with a reduced rate of overall complications, prolonged ileus, and pulmonary complications.[3] There were no significant differences between the two groups with respect to the rate of intraoperative bowel injury, the incidence of wound infection, or mortality.

Laparoscopic surgery also has been shown to decrease the incidence, extent, and severity of intra-abdominal adhesions as compared with open surgery, thereby potentially reducing the rate of recurrent adhesive small bowel obstruction.[10]

In a study comparing laparotomy with laparoscopy in 9619 patients with small-bowel obstruction requiring adhesiolysis, Kelly et al found that at 30 days, the patients in the laparoscopic adhesiolysis group had lower rates of major complications and incisional complications than those in the open group, as well as reduced mortality (1.3% vs 4.7%).[11]

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Periprocedural Care

Preprocedural planning

Preoperative antibiotics are given in case an enterotomy or bowel resection is needed.

A nasogastric tube in low continuous suction should be placed before and during the procedure, especially for patients with bowel obstruction to ensure that the bowels are decompressed. This allows the surgeon to have adequate space and visualization while performing the procedure.

Preoperative deep venous thrombosis (DVT) prophylaxis is required. Heparin, low-molecular-weight heparin, or sequential antiembolism stockings should be used.

A Foley catheter should be placed to decrease the bladder size and maximize room to work.

Equipment

At least two video monitors are required. Additionally, the surgeon must be prepared to convert to an open procedure; accordingly, a major abdominal tray should be in the room. The laparoscopic instruments needed include the following:

  • Three to five trocars
  • Angled laparoscopes (30º or 45º)
  • Laparoscopic bowel graspers
  • Laparoscopic shears
  • Laparoscopic energy dissector (of the surgeon's preference)

Patient preparation

Anesthesia

General anesthesia is required for all cases. Paralysis is needed to distend the abdomen. In rare cases, high spinal anesthetics may be used.

Positioning

Patients are placed in supine position with both arms tucked. They should be strapped and secured to the bed so they can be placed in Trendelenburg with the left side down to allow visualization of the cecum and to run the bowel, in steep Trendelenburg to allow evaluation of the pelvis, or reverse Trendelenburg to allow evaluation of the upper abdominal cavity. Care should be taken to ensure that patients are adequately padded in areas where there could be pressure, such as the shoulders and arms.

The surgeon should be on the opposite side of where he or she is working. Monitors should be placed on each side and positioned so that they are directly in the line of view of the surgeon operating.

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Technique

Access to abdominal cavity and insufflation

Because most patients undergoing laparoscopic adhesiolysis have undergone previous abdominal surgery, extra care must be taken in placing the first trocar and establishing pneumoperitoneum. Ideally, the initial trocar should be placed 5-10 cm away from the patient’s previous scar. For example, the left upper quadrant can be a safe place to put the first trocar if patient has had a previous midline incision. The Hasson (open) technique is preferred because it is generally a safer method for accessing the abdominal cavity, especially in dealing with dilated bowel loops and adhesions.

Placement of trocars

Once the first trocar is placed, the goal is to provide adequate visualization and working space to permit insertion of the remaining trocars. At least three and as many as five trocars are used. Depending on the available laparoscopes, one can use three 5-mm trocars or one 11-mm trocar for the camera and two 5-mm trocars for the laparoscopic instruments. Good triangulation should be planned on the basis of the planned site of dissection. Additional trocars should be placed as needed.

Dissection of adhesions

Adhesions to the abdominal wall should be taken down first with laparoscopic scissors. Identifying the white line where the abdominal wall peritoneum meets the adhesions facilitates dissection in a bloodless plane.

If the patient has a ventral hernia, gentle pressure can be placed on the external abdominal wall to allow retraction and visualization of the bowels attached to the hernia sac.

Blunt and sharp dissection is preferred to use of the electrocautery because the heat can be transmitted to adjacent bowel and can cause thermal injury and perforation. Energy devices may be used if adequate room exists and if it is certain that no bowel is hidden in the adhesions.

Adhesiolysis can be safely performed if dissection is done carefully through avascular planes. The laparoscopic approach precludes feeling through these adhesions. Accordingly, a general rule that can be followed in this setting is, If you can see through it, you can cut it.

If the anatomy is still unclear despite meticulous dissection, changing the position or the angle of the camera may yield better visualization of the bowel loops. It cannot be emphasized too strongly that the surgeon should feel free to place additional trocars as needed. The 5-mm port sites do not need fascial closure and do not add much to the length of the procedure or to the risk of hernia. Hence, adding more 5-mm trocars to facilitate the procedure adds less morbidity than converting to an open midline incision would.

When a point of obstruction is not clearly defined, the bowel should be run until all suspicious bands are removed.

Upon completion of the case, it is advisable to run the bowel twice to ensure that there are no missed serosal injuries or enterotomies. Any injuries that are identified should be repaired laparoscopically in a single layer. However, if the surgeon is not comfortable repairing bowel laparoscopically, the injured bowel should be grabbed with a laparoscopic locking bowel grasper so that it can easily be brought out through a midline abdominal incision (typically made by extending one of the port-site incisions) and repaired in an open fashion.

Surgical pearls

Identification of tissue planes is essential. Learn to recognize the interface of two different tissue types, and cut perpendicular to the bowel wall. If a bowel injury occurs, repairing a straight laceration is easier.

Start in an area that is easy. Taking down the adhesions that are easy to take down may facilitate working in areas that are harder to handle.

Try to get a sense of the tissue. Some patients have tissue that will tear easily, whereas others have tissue that readily permits blunt dissection. An individualized approach to each patient's tissues is important.

If you feel you are not making progress, pick a time at which you will convert to an open procedure if you are still struggling; this allows peace of mind as you continue to work laparoscopically. If you are making progress when the chosen time is reached, continue with the laparoscopic approach; if not, convert.

Never be afraid to convert to an open procedure. Patient safety is the most important metric.

Complications

The most common intraoperative complication is injury to the bowel. With dense adhesions, this risk increases. Always inspect all sides of the bowel prior to closure. Other intraoperative complications may include bleeding and injury to adjacent organs such as the gallbladder, spleen, ovaries, especially in working next to these organs. Late complications include port-site hernias and recurrent bowel obstructions.

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Contributor Information and Disclosures
Author

Maria Sophia S Villanueva, MD Fellow in Colon and Rectal Surgery, Department of Surgery, Washington Hospital Center

Maria Sophia S Villanueva, MD is a member of the following medical societies: American College of Surgeons, American Society of Colon and Rectal Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Association of Women Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

David E Stein, MD Chief, Division of Colorectal Surgery, Associate Professor, Department of Surgery, Director, Mini-Medical School Program, Drexel University College of Medicine; Chief, Division of Colorectal Surgery, Department of Surgery, Hahneman University Hospital; Consultant, Merck; Consultant, Ethicon Endo-Surgery; Consultant, Health Partners; Consultant, Cook Surgical

David E Stein, MD is a member of the following medical societies: American College of Surgeons, American Society of Colon and Rectal Surgeons, Association for Surgical Education, Pennsylvania Medical Society, Society for Surgery of the Alimentary Tract, Crohn's and Colitis Foundation of America

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Merck<br/>Serve(d) as a speaker or a member of a speakers bureau for: Merck.

Chief Editor

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

References
  1. Ellis H, Moran BJ, Thompson JN, et al. Adhesion-related hospital readmissions after abdominal and pelvic surgery: a retrospective cohort study. Lancet. 1999 May 1. 353(9163):1476-80. [Medline].

  2. Beck DE, Opelka FG, Bailey HR, Rauh SM, Pashos CL. Incidence of small-bowel obstruction and adhesiolysis after open colorectal and general surgery. Dis Colon Rectum. 1999 Feb. 42(2):241-8. [Medline].

  3. Li MZ, Lian L, Xiao LB, Wu WH, He YL, Song XM. Laparoscopic versus open adhesiolysis in patients with adhesive small bowel obstruction: a systematic review and meta-analysis. Am J Surg. 2012 Nov. 204(5):779-86. [Medline].

  4. Landercasper J, Cogbill TH, Merry WH, Stolee RT, Strutt PJ. Long-term outcome after hospitalization for small-bowel obstruction. Arch Surg. 1993 Jul. 128(7):765-70; discussion 770-1. [Medline].

  5. Mucha P Jr. Small intestinal obstruction. Surg Clin North Am. 1987 Jun. 67(3):597-620. [Medline].

  6. Barkan H, Webster S, Ozeran S. Factors predicting the recurrence of adhesive small-bowel obstruction. Am J Surg. 1995 Oct. 170(4):361-5. [Medline].

  7. Nagle A, Ujiki M, Denham W, Murayama K. Laparoscopic adhesiolysis for small bowel obstruction. Am J Surg. 2004 Apr. 187(4):464-70. [Medline].

  8. Bastug DF, Trammell SW, Boland JP, Mantz EP, Tiley EH 3rd. Laparoscopic adhesiolysis for small bowel obstruction. Surg Laparosc Endosc. 1991 Dec. 1(4):259-62. [Medline].

  9. [Guideline] Vettoretto N, Carrara A, Corradi A, et al, Italian Association of Hospital Surgeons (Associazione dei Chirurghi Ospedalieri Italiani-ACOI). Laparoscopic adhesiolysis: consensus conference guidelines. Colorectal Dis. 2012 May. 14 (5):e208-15. [Medline].

  10. Tittel A, Treutner KH, Titkova S, Ottinger A, Schumpelick V. Comparison of adhesion reformation after laparoscopic and conventional adhesiolysis in an animal model. Langenbecks Arch Surg. 2001 Mar. 386(2):141-5. [Medline].

  11. Kelly KN, Iannuzzi JC, Rickles AS, Garimella V, Monson JR, Fleming FJ. Laparotomy for small-bowel obstruction: first choice or last resort for adhesiolysis? A laparoscopic approach for small-bowel obstruction reduces 30-day complications. Surg Endosc. 2014 Jan. 28 (1):65-73. [Medline].

  12. Soper NJ, Swnastrom L.l, Eudans W. Mastery of Endoscopic and Laparoscopic Surgery. Lippincott and Williams; 2009.

  13. Milson JW, Bohm B. Laparoscopic Colorectal Surgery. 2nd. New York: Springer; 2006.

 
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