Open Adhesiolysis

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, 6, 7]}

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. ^[5]  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, 8]}  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. ^[2]

The spectrum of treatments for small-bowel obstruction ranges from conservative management with bowel rest to surgical intervention, sometimes involving bowel resection. Nonsurgical treatments have been used ^[9]  include anti-inflammatory agents, synthetic inert solid barriers, and fibrinolytic agents. However, none of these treatments has proved uniformly effective under all circumstances. ^[4]

The general view has been that 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. Although conservative treatment often suffices, there is evidence to suggest that early surgical treatment (ie, on either the calendar day of admission or the calendar day after admission) during the first episode of adhesive small-bowel obstruction can be highly effective. ^[10]

The traditional caveat with regard to surgical treatment is that whereas surgery may be required to release symptomatic adhesions, postoperative reformation of these adhesions is common. There has been debate as to whether laparoscopic adhesiolysis yields added benefit in terms of decreasing postoperative adhesion reformation; however, good results have been obtained with this approach. ^{[11, 12, 13, 14]}

A systematic review by Srinivasan et al (10 studies; N = 36,178) questioned the view that surgery increases the risk for recurrence of adhesive small-bowel obstruction and suggested that this view is outdated. ^[15]  They found operative management to be associated with a lower risk of recurrence than conservative management, while finding no clear difference in recurrence rates between laparoscopic and open adhesiolysis. 

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%. ^[16]  Improvements in the capability of computed tomography (CT) have given this modality a sensitivity, specificity, and accuracy of 95% or greater. ^[11]

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. ^[11]

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. ^{[17, 18, 19, 20, 21]}  In addition, the incidence of postoperative adhesion formation is expected to be lower after laparoscopy. ^[22]  However, there remains a need for long-term data from randomized trials comparing laparoscopic and open adhesiolysis. The major issue in the laparoscopic 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). ^[11]  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. ^[1]  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, an expected 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.

Complication prevention

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. ^[23]

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 has been in the range of 20-50%. ^{[23, 24]}  The rate of conversion from laparoscopic to open adhesiolysis for a small-bowel obstruction has been reported to be as high as 32%. ^[11]  A study by Milone et al suggested that the conversion rate may be lower with robotic adhesiolysis. ^[25]

A simple obstruction adhesiolysis carries a mortality of 5%, and mortality can be 30% or higher when strangulated or necrotic bowel is involved. ^[11] Recurrence rates for adhesive bowel obstruction after conservative or operative treatment have ranged from 29% to 53% in the literature, ^[11] illustrating the chronic potential of the problem. In a study of 156 patients, Yao et al concluded that laparoscopic adhesiolysis led to a higher incidence of recurrence necessitating further surgery. ^[26]