Laparoscopic Adhesiolysis

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, 2, 3]}

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. ^[4]  Postoperative adhesions account for 74% of cases of small-bowel obstruction. ^[5]

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. ^{[6, 7, 8]}

Laparoscopic adhesiolysis was first described by a gynecologist for the treatment of chronic pelvic pain and infertility. ^[9]  In the early days of laparoscopy, previous abdominal surgery was a relative contraindication for 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. ^[10]

Since then, many case series have documented this technique. ^{[9, 11]}  Technologic advances in the form of high-definition imaging, smaller cameras, and better instrumentation have allowed an increasing number of adhesiolysis procedures 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 ^{[12, 13]}

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. ^[14]

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

There has been controversy 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.

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

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. ^[5]  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. ^[15]  However, Yao et al studied 156 patients from 2008 to 2015 and concluded that laparoscopic adhesiolysis did not decrease the occurrence of recurrent symptoms. ^[16]

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%). ^[17]

In a nonrandomized follow-up of 68 patients over 15 years, Paajanen et al concluded that adhesiolysis had a long-term positive effect, but although patients experienced pain relief they still had other abdominal symptoms. ^[18]

Molegraff et al studied 100 patients, who were divided into laparoscopic adhesiolysis or a placebo group with laparoscopy alone. After 12 years, both groups reported less pain and improved quality of life, but laparoscopy alone was more beneficial in the long run. Therefore, they concluded that avoiding adhesiolysis, which has increased operative complications, might result in lower morbidity and health care costs. ^[19]

In a international multicenter randomized open-label trial that included 100 patients with adhesive small-bowel obstruction, Sallinen et al compared the results of laparoscopic (n = 51) and open (n = 49) adhesiolysis for adhesive small-bowel obstruction. ^[20] The average postoperative length of hospital stay was 5.5 days (range, 2-19) for the open surgery group and 4.2 days (range, 1-20) for the laparoscopic surgery group. Postoperative complications were noted within 30 days in 21 (43%) patients in the open surgery group and 16 (31%) in the laparoscopy group.

In a randomized controlled trial that evaluated the outcomes of laparoscopic adhesiolysis in patients with postcesarean infertility with regard to restoration of fertility and achievement of pregnancy, Elgergawy et al found that laparoscopic adhesiolysis was the treatment method of choice for patients with mild-to-moderate periadnexal adhesions after cesarean section but that patients with severe periadnexal adhesions were better treated by means of in-vitro fertilization. ^[21]

A comparison (N = 98) of robotic adhesiolysis with standard laparoscopic adhesiolysis found that the former was associated with a significantly lower rate of conversion to open adhesiolysis. ^[22]