Article

Laparoscopic lysis of adhesions

Bariatric Institute, Section of Minimally Invasive Surgery, Cleveland Clinic Florida, 2950 Cleveland Clinic Blvd., Weston, Florida 33331, USA.
World Journal of Surgery (Impact Factor: 2.35). 05/2006; 30(4):535-40. DOI: 10.1007/s00268-005-7778-0
Source: PubMed

ABSTRACT Intra-abdominal adhesions constitute between 49% and 74% of the causes of small bowel obstruction. Traditionally, laparotomy and open adhesiolysis have been the treatment for patients who have failed conservative measures or when clinical and physiologic derangements suggest toxemia and/or ischemia. With the increased popularity of laparoscopy, recent promising reports indicate the feasibility and potential superiority of the minimally invasive approach to the adhesion-encased abdomen.
The purpose of this study was to assess the outcome of laparoscopic adhesiolysis and to provide technical tips that help in the success of this technique.
The most important predictive factor of adhesion formation is a history of previous abdominal surgery ranging from 67%-93% in the literature. Conversely, 31% of scars from previous surgery have been free of adhesions, whereas up to 10% of patients without any prior surgical scars will have spontaneous adhesions of the bowel or omentum. Most intestinal obstructions follow open lower abdominopelvic surgeries such as colectomy, appendectomy, and hysterectomy. The most common complications associated with adhesions are small bowel obstruction (SBO) and chronic pain syndrome. The treatment of uncomplicated SBO is generally conservative, especially with incomplete obstruction and the absence of systemic toxemia, ischemia, or strangulation. When conservative treatment fails, surgical options include conventional open or minimally invasive approaches; the latter have become increasing more popular for lysis of adhesions and the treatment of SBO. Generally, 63% of the length of a laparotomy incision is involved in adhesion formation to the abdominal wall. Furthermore, the incidence of ventral hernia after a laparotomy ranges between 11% and 20% versus the 0.02%-2.4% incidence of port site herniation. Additional benefits of the minimally invasive approaches include a decreased incidence of wound infection and postoperative pneumonia and a more rapid return of bowel function resulting in a shorter hospital stay. In long-term follow up, the success rate of laparoscopic lysis of adhesions remains between 46% and 87%. Operative times for laparoscopy range from 58 to 108 minutes; conversion rates range from 6.7% to 43%; and the incidence of intraoperative enterotomy ranges from 3% to 17.6%. The length of hospitalization is 4-6 days in most series.
Laparoscopic lysis of adhesions seems to be safe in the hands of well-trained laparoscopic surgeons. This technique should be mastered by the advanced laparoscopic surgeon not only for its usefulness in the pathologies discussed here but also for adhesions commonly encountered during other laparoscopic procedures.

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    ABSTRACT: Background: Intra-abdominal adhesions constitute between 49% and 74% of the causes of small bowel obstruction. Traditionally, laparotomy and open adhesiolysis have been the treatment for patients who have failed conservative measures or when clinical and physiologic derangements suggest toxemia and/or ischemia. With the increased popularity of laparoscopy, recent promising reports indicate the feasibility and potential superiority of the minimally invasive approach to the adhesion-encased abdomen. Methods: The purpose of this study was to assess the outcome of laparoscopic adhesiolysis and to provide technical tips that help in the success of this technique. Results: The most important predictive factor of adhesion formation is a history of previous abdominal surgery ranging from 67%–93% in the literature. Conversely, 31% of scars from pre-vious surgery have been free of adhesions, whereas up to 10% of patients without any prior surgical scars will have spontaneous adhesions of the bowel or omentum. Most intestinal obstructions follow open lower abdominopelvic surgeries such as colectomy, appendectomy, and hysterectomy. The most common complications associated with adhesions are small bowel obstruction (SBO) and chronic pain syndrome. The treatment of uncomplicated SBO is generally conservative, especially with incomplete obstruction and the absence of systemic toxemia, ischemia, or strangulation. When conservative treatment fails, surgical options include conven-tional open or minimally invasive approaches; the latter have become increasing more popular for lysis of adhesions and the treatment of SBO. Generally, 63% of the length of a laparotomy incision is involved in adhesion formation to the abdominal wall. Furthermore, the incidence of ventral hernia after a laparotomy ranges between 11% and 20% versus the 0.02%–2.4% incidence of port site herniation. Additional benefits of the minimally invasive approaches include a decreased incidence of wound infection and postoperative pneumonia and a more rapid return of bowel function resulting in a shorter hospital stay. In long-term follow up, the success rate of laparo-scopic lysis of adhesions remains between 46% and 87%. Operative times for laparoscopy range from 58 to 108 minutes; conversion rates range from 6.7% to 43%; and the incidence of intra-operative enterotomy ranges from 3% to 17.6%. The length of hospitalization is 4–6 days in most series. Conclusions: Laparoscopic lysis of adhesions seems to be safe in the hands of well-trained laparoscopic surgeons. This technique should be mastered by the advanced laparoscopic sur-geon not only for its usefulness in the pathologies discussed here but also for adhesions com-monly encountered during other laparoscopic procedures. I ntra-abdominal adhesions cause small bowel obstruc-tion in 49%–74% of cases. 1–3 The management of intestinal obstruction is initially conservative, provided that the patient is clinically stable and without signs of systemic toxicity. Traditionally, laparotomy and adhesiol-ysis was the treatment of choice for patients who failed conservative measures or when clinical and physiologic derangements suggested toxemia and/or ischemia. 4–6 However, up to one third of patients may require re-lap-arotomy for recurrent small bowel obstruction resulting from the formation of intra-abdominal adhesions. 7–10 Furthermore, laparotomy increases the incidence of ventral hernia, wound infection, postoperative ileus, postoperative pain, and length of hospital stay. 11–13 Since the advent of minimally invasive surgery with the introduction of laparoscopic cholecystectomy in the late 1980s, the laparoscopic method continues to advance the field of general surgery. Initial contraindications to lapa-roscopy such as morbid obesity and previous abdominal surgery have since disappeared with increased experi-ence and technical advances in surgical instrumentation. These advances have also led to the application of min-imally invasive techniques to an increasing number and variety of procedures. Furthermore, recent promising re-ports indicate the feasibility and potential superiority of the minimally invasive approach to the adhesion-encased abdomen. 11,12,14,15 Laparoscopic adhesiolysis was first described in the gynecologic literature for the treatment of chronic pelvic pain and infertility. Since then, this tech-nique has been applied to the treatment of chronic abdominal pain in both adults and children. 16,17 Intra-abdominal adhesions are often well-vascular-ized and innervated, which may explain the relationship to some chronic abdominal pain syndromes. 18 The utility of laparoscopic adhesiolysis has been reported for intrac-table abdominal pain in both the adult and pediatric populations. 16,17,19–21 In these cases, the procedure is not only diagnostic but also curative. Some authors 21 advocate the use of laparoscopy under local anesthesia to reproduce the pain and to identify the specific adhesion causing the pain. Others have concluded that, although laparoscopic adhesiolysis relieves chronic abdominal pain, it is not more beneficial than diagnostic laparoscopy alone and cannot be recommended as a treatment for adhesions in these patients. 22 Bastug et al. 23 reported the first case of laparoscopic adhesiolysis for small bowel obstruction. Subsequently, several case reports and multiple series have reported the success of laparoscopic adhesiolysis. 15,24 Despite these data, laparoscopic adhesiolysis for small bowel obstruction still remains a concern for surgeons, and it has yet to gain widespread acceptance. The purpose of this review was to assess the outcome of laparoscopic adhesiolysis and to provide technical tips for operating with this technique.