Open Adhesiolysis Technique

Updated: Sep 22, 2017
  • Author: Brian J Daley, MD, MBA, FACS, FCCP, CNSC; Chief Editor: Kurt E Roberts, MD  more...
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Technique

Approach Considerations

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 in 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).

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Open Approach to Abdominal 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, 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. [9]

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.

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Complications

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. [20, 23]  The paradoxic 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. [24]  At present, roughly 2.3 million women suffer from chronic pelvic pain attributed to adhesions. [20]  The economic burden is significant, [25]  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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