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]  

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 ensures that the surgeon has 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.

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)

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 should be supine, 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.

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 bowel attached to the hernia sac.

Blunt and sharp dissection is preferable 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.

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, the spleen, or the ovaries, especially in working next to these organs.

Late complications include port-site hernias and recurrent bowel obstructions. It has been suggested that laparoscopic adhesiolysis may be associated with a lower rate of recurrent obstruction than open adhesiolysis is.[23]