Laparoscopic Approach to Abdominal Adhesions
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.
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, 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]
