- Author: Brian J Daley, MD, MBA, FACS, FCCP, CNSC; Chief Editor: Kurt E Roberts, MD more...
Peritoneal adhesion formation is a common consequence of any operation or intra-abdominal inflammatory process (eg, pelvic inflammatory disease [PID], diverticulitis, spontaneous bacterial peritonitis). It is estimated that intra-abdominal adhesions develop in 90-95% of patients after surgery.[1, 2, 3, 4, 5] The underlying mechanism of adhesion formation involves injury to the peritoneal epithelium resulting in fibrin matrix deposition to the injured intra-abdominal surfaces. Fibrinolysis by plasmin is typically inadequate in the postoperative period, and the nondegraded deposits lead to adhesion formation. Congenital causes of adhesions (eg, Ladd bands) exist but represent only a small minority of cases.
The morbidity from adhesions can range from chronic abdominal pain to female infertility.[1, 6] The most common of these conditions is partial or complete intestinal obstruction, for which the small bowel is the most common location. Postoperative adhesions account for as many as 79% of acute intestinal obstructions.
The spectrum of treatments for a small-bowel obstruction ranges from conservative management with bowel rest to surgical intervention, sometimes requiring bowel resection. The caveat with regard to surgical treatment is that whereas surgery may be required to release symptomatic adhesions, postoperative reformation of these adhesions is common. Debate continues as to whether laparoscopic adhesiolysis yields added benefit in terms of decreasing postoperative adhesion reformation. However, studies have shown promising results using this approach.[7, 8, 9]
Nonsurgical treatments have been used, such as anti-inflammatory agents, synthetic inert solid barriers, and fibrinolytic agents. However, none of these treatments has proven uniformly effective under all circumstances. Therefore, surgical adhesiolysis should be performed promptly for patients for whom surgery is clearly indicated but should be reserved for those patients who do not respond satisfactorily to nonsurgical treatment.
Past surgical dogma dictated that "the sun should never rise or set on a small bowel obstruction," reflecting the view that surgery is the definitive means of preventing progression to bowel necrosis. This school of thought has given way to a more conservative approach that makes use of nasogastric tube decompression, fluid resuscitation and electrolyte correction, bowel rest, serial abdominal examinations, and radiologic contrast studies. All of these methods have improved over time.
Many bowel obstructions can be successfully managed by nonoperative means, but complete or high-grade partial bowel obstructions will require surgical management more often than not. Ultimately, more than half of all patients with small-bowel obstructions who are admitted to the hospital eventually require surgery.
Strangulated or dead bowel, or the fear of such, is an indication for immediate surgical intervention in the context of a small-bowel obstruction. Frank peritoneal signs on abdominal examination findings, demonstrating hemodynamic instability and a lactic acidosis or elevated base deficit, support the clinical diagnosis of strangulated or dead bowel.
Bowel ischemia is more difficult to diagnose immediately; however, increasing abdominal pain, a rising white blood cell (WBC) count, and acidosis that worsens despite adequate resuscitative measures are grounds for concern. In this setting, surgical treatment should not be delayed.
When intestinal ischemia is less likely, the patient may be observed with conservative management. The length of time for which patients can be managed conservatively, if their condition remains stable but does not improve, varies. The period before surgical intervention may be anything from 48 hours to 1 week. However, the decision to operate should be based not on a specific timeframe but on the overall clinical picture and the findings from continuous evaluation.
Imaging studies remain vitally important for therapeutic decision-making (see the images below). For example, water-soluble contrast that reaches the cecum on a plain film within 24 hours of administration predicts resolution of an adhesive small bowel obstruction with a sensitivity and specificity of 96%. Improvements in the capability of computed tomography (CT) have given this modality a sensitivity, specificity, and accuracy of 95% or greater.
Another valid, albeit less definitive, sequela of intra-abdominal adhesions is chronic abdominal pain. Despite the well-known surgical wisdom that "operating purely to cure pain only brings pain," chronic abdominal pain can be a relative indication for adhesiolysis. This diagnosis should be one of exclusion, made after conditions such as gallbladder disease, pancreatitis, mesenteric ischemia, and peptic ulcer disease have been ruled out.
Laparoscopy is commonly used for adhesiolysis because of the elective nature of the procedure and because of the shorter recovery time and lower incidence of pain and infection in comparison with laparotomy.[12, 13] In addition, the incidence of postoperative adhesion formation is expected to be lower after laparoscopy. However, laparoscopic and open adhesiolysis have not yet been compared in long-term randomized trials. The major issue in this approach to treating adhesions is determining which adhesion is the symptomatic one causing pain.
The issue of infertility is another indication for surgical treatment (more often via a laparoscopic approach). Adhesions can form that distort the natural tubo-ovarian relationship, precluding normal ovum capture and transport by the fimbriated end of the fallopian tube and leading to fertility issues. The success of the operation depends on the underlying cause of adhesion formation and the severity of the tubal disease.
In settings where a surgical approach is considered essential, the viability of the bowel is in question and failure to provide prompt and appropriate treatment can be life-threatening. Given the potentially serious consequences of not performing the necessary operation, only the most significant contraindications (eg, clear advance directives ruling out surgery, a patient who refuses treatment, a futile outcome, or the presence of a known "frozen abdomen") should be allowed to alter the surgical plan.
If the situation is not dire, the surgical alternative can always be deferred and a more conservative approach tried first, though this option may not prove advantageous in some situations.
Contraindications to laparoscopic adhesiolysis include general considerations common to all laparoscopic procedures (eg, hemodynamic instability with pneumoperitoneum or lack of surgical proficiency), as well as other considerations specific to this procedure (see Laparoscopic Adhesiolysis).
Surgical lysis of adhesions may be associated with significant complications; accordingly, care must be taken to minimize postoperative morbidity and mortality.
Prevention of adhesiolysis-associated enterotomies can have a significant impact on reoperative morbidity and mortality. This is significant in view of the chronic potential of the condition; patients who have undergone three or more previous laparotomies have a 10-fold greater risk of enterotomies than patients who have undergone one or two previous laparotomies.
With the increased rates of unrecognized sharp, blunt, or energy-related bowel injury during laparoscopic adhesiolysis, early conversion to open adhesiolysis during difficult cases is advantageous. The mortality in this population with an unrecognized bowel injury is 20-50%. The rate of conversion from laparoscopic to open adhesiolysis for a small-bowel obstruction has been reported to be as high as 32%.
A simple obstruction adhesiolysis carries a mortality of 5%, and mortality can be 30% or higher when strangulated or necrotic bowel is involved. Recurrence rates for adhesive bowel obstruction after conservative or operative treatment range from 29% to 53% in the literature, illustrating the chronic potential of the problem.
A patient with frank peritoneal signs on abdominal examination, hemodynamic instability, lactic acidosis or an elevated base deficit, and an elevated white blood cell (WBC) count in the context of a small-bowel obstruction is assumed to have a strangulated or dead bowel until the operation proves otherwise. Such a patient needs immediate surgical intervention.
However, if a patient has mild-to-moderate abdominal tenderness, a stable WBC count, no fever, and a distended abdomen, and water-soluble contrast reaches the cecum on a plain film within 24 hours, there is a very high likelihood that an adhesive small-bowel obstruction will resolve with conservative management.
A standard operating room (OR) with the appropriate personnel and staff is required. The equipment in the OR is that typically needed for any surgical case (eg, a ventilator, other pertinent anesthesia equipment, an operating table, a back-table instrument setup, and a suction and irrigation system).
A full laparotomy tray should be available. Depending on the surgeon’s preference, an electrocautery, an ultrasonic dissector, or other energy devices can be used to separate adhesions during the operation. Gastrointestinal (GI) and vascular staplers may be beneficial, depending on the extent of the operation.
Patient preparation includes adequate anesthesia and appropriate positioning.
General anesthesia is essential for the procedure: it ensures a controlled and relaxed patient for the surgeon to work with. Placement of an arterial catheter is often beneficial for real-time blood pressure monitoring. Placement of a Foley catheter in the urinary bladder allows intraoperative assessment of volume status and end-organ perfusion; it can also serve as a landmark for the bladder if the adhesions distort the pelvic anatomy.
Application of a longer-acting local anesthetic (eg, bupivacaine) to the incision site before the incision is beneficial in controlling postoperative pain. Additional modalities, such as incisional continuous local anesthesia delivery devices and epidural infusions, are often used but frequently unnecessary.
The patient should be placed in the supine position with the arms securely tucked at the sides. A small pillow should be placed underneath the posterior aspect of the knees, and all of the dependent portions of the body should have appropriately padded support.
Many adhesiolysis procedures are performed in nonvirgin abdomens, in which the presence of adhesions should be expected. For any surgeon dealing with a hostile abdomen, the preferred approach should be to operate in a "known-to-unknown" fashion. For instance, if the patient has an infraumbilical or lower midline scar from a previous operation, the abdomen should be entered on the midline superior to the scar, where adhesions presumably are less likely. This will provide the appropriate initial exposure for safely addressing any problematic adhesions.
This technique is appropriate for laparoscopy as well, with port sites being placed in quadrants away from previous scars in order to avoid injury to adhered or tethered bowel (see Laparoscopic Adhesiolysis).
Open surgical lysis of adhesions
The abdomen is prepared and draped in a sterile fashion. A median (midline) incision is made from the subxiphoid region to the suprapubic region, with a curvilinear portion to either side of the umbilicus. If necessary, the incision may be extended inferiorly as far as the symphysis pubis or superiorly as far as the xiphoid. In reoperative surgery, it is advisable to enter the abdomen in virgin territory (if available) and then work from free space into the adhesions. If an old midline incision exists, the new incision can retrace it in an effort to minimize scarring.
After dissection through the subcutaneous tissues, the linea alba is identified and exposed over the entirety of the wound. The fascia is divided carefully and sharply with a scalpel to allow entry into the peritoneal cavity. The fascial defect is probed with a finger to detect any loops of bowel adhering to the undersurface of the abdominal wall. Any adherent bowel is bluntly swept away from the midline with the finger. The finger acts as a guide throughout this process to help prevent injury to the bowel and other intra-abdominal structures.
After the abdominal cavity is opened, the adhesions to the abdominal wall lateral to the facial incision are taken down and the viscera allowed to fall posteriorly so as to provide working space. The keys here are patience and, again, working from known to unknown. It is important to start where dissection is easy and the anatomy obvious, and then work into the more difficult and scarred areas.
Often, working with gentle traction on the adhesions to elucidate the anatomy of the bowel loops proves relatively easy. This may require working proximally and distally to the area of concern before approaching the clear area of obstruction. The clear area of obstruction will have dilated bowel proximally and decompressed bowel distally.
All quadrants of the abdomen are surveyed for any occult gross pathology or fluid collections. The entire visceral tract, from stomach to rectum, is examined. The ligament of Treitz is identified, and the small bowel is run up to the terminal ileum. As the small bowel is mobilized, its viability and integrity are assessed continuously, and any problematic adhesions or tethering points are separated and taken down even if they do not seem to be responsible for the obstruction.
Other adhesions that mat the bowel together need not be lysed if luminal contents can be manually milked through the bowel without signs of obstruction. It is helpful to have a nasogastric tube attached to suction during the operation, and the proximal small bowel can be milked in a distal-to-proximal fashion to decompress the distended bowel loops.
The optimal extent of adhesiolysis remains subject to debate: some believe that all adhesions should be taken down, whereas others believe that only the adhesions responsible for the obstruction should be separated.
Any nonviable ischemic bowel is resected, and an end-to-end or end-to-side anastomosis is performed between viable, healthy portions of the bowel. Under circumstances in which the integrity of an anastomosis may be compromised (eg, ongoing local or regional infection, diffuse bowel ischemia, or hemodynamic instability), a diverting ostomy is always a plausible option.
If bowel ischemia is present, a reoperation or second-look operation to confirm viability is a sound practice. In women, the pelvic anatomy should be examined thoroughly to ensure that adhesions are not distorting the normal anatomic relations of the ovaries and fallopian tubes.
Patients can have an extremely complicated course after surgery to lyse adhesions, including sepsis, acute renal failure, respiratory failure, myocardial infarctions, wound infections, and combinations of these conditions.
Specifically, small bowel obstruction, chronic abdominal or pelvic pain, inadvertent enterotomy at the time of surgery, and secondary female infertility are among the most common complications caused by intraperitoneal adhesions.[15, 16] The paradoxical relation between surgery as a means of treating adhesions and surgery as a factor causing adhesions makes this condition a difficult one to manage.
The causal association between peritoneal adhesion and chronic abdominal or pelvic pain is widely debated, and research into this issue is ongoing. At present, roughly 2.3 million women suffer from chronic pelvic pain attributed to adhesions. The economic burden is significant, given the costs associated with gynecologic medical attention and laboratory workup, as well as the work hours lost by the patient.
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