The most successful adhesiolysis procedure we know!
Here is the "Gold Standard" for adhesiolysis which a surgeon should strive to meet.
LAPAROSCOPIC SURGERY FOR ADHESIOLYSIS
Harry Reich, M.D., F.A.C.O.G., FACS
INTRODUCTION
Postoperative adhesions occur after almost every abdominal surgery and are the leading cause of intestinal obstruction. Over 90% of patients undergoing abdominal operations will develop postsurgical adhesions. This was not considered surprising, given the extreme delicacy of the peritoneum and the fact that apposition of two injured surfaces nearly always results in adhesion formation.1
For the surgeon, laparoscopic lysis of bowel adhesions is fraught with danger to his/her reputation as bad results often are accompanied by poor reimbursement and lawsuits. This surgery is not for every surgeon!
But if you take up the challenge, be prepared.
Fatal sequelae of intraabdominal adhesions were reported as early as 1872 after removal of an ovarian tumor resulted in intestinal obstruction.2 Adhesions are the most common cause of bowel obstruction and most likely result from gynecologic procedures, trauma, appendectomies and other intestinal operations.3 Adhesions have also been proposed to cause infertility and abdominal and pelvic pain. Although nerve fibers have been confirmed in pelvic adhesions, their presence is not increased in those patients with pelvic pain.4 In addition, there does not appear to be an association between the severity of adhesions and complaint of pain. It is generally accepted that adhesions may impair organ motility resulting in visceral pain transmitted by peritoneal innervation.5 Many patients experience resolution of their symptoms after adhesiolysis.6-9 This may be complicated by placebo effect as demonstrated by one study that showed no difference in pain scores between patients who were randomized to adhesiolysis versus expectant management.10
In 1994, adhesiolysis procedures resulted in 303,836 hospitalizations, 846,415 days of inpatient care, and $1.3 billion in health care expenditures. Forty-seven percent of these hospitalizations were for adhesiolysis of the female reproductive system, the primary site for these procedures. In comparison to similar data from 1988, the cost of adhesiolysis hospitalizations is down. One significant influence on this trend is the increased use of minimally invasive surgical techniques resulting in fewer days of inpatient care.11
This chapter reviews the pathophysiology of adhesion formation, equipment and technique for adhesiolysis, and methods for adhesion prevention.
PATHOPHYSIOLOGY OF ADHESION FORMATION
Adhesion formation is initiated by peritoneal trauma. Its morphogenesis was described in detail by diZerega.12 Within hours at the site of injury, polymorphonuclear leukocytes appear in large numbers meshed in fibrin strands. At 24-36 hours, macrophages appear in large numbers and are responsible for regulating fibroblast and mesothelial cell activities. By day 2, the wound surface is covered by macrophages, islands of primitive mesenchymal cells and mesothelial cells. By day four the islands of primitive mesenchymal cells have now come into contact with each other. Fibroblasts and collagen are now present and increasing. By day five, an organized fibrin interconnection is now seen composed of collagen, fibroblasts, mast cells, and vascular channels containing endothelial cells. The adhesion continues to mature as collagen fibrils organize into bands covered by mesothelium and containing blood vessels and connective tissue fiber.12
EQUIPMENT
A review of standard equipment such as light sources and video systems is beyond the scope of this chapter. Equipment useful for advanced procedures and energy sources is included. However, the main technique for adhesiolysis with the least possibility for reformation can simply be described as “cold scissors dissection with bipolar backup.”
Laparoscopes
Four different laparoscopes should be available for adhesiolysis: a 10-mm 0° straight viewing laparoscope; a 10-mm operative laparoscope with 5-mm operating channel; a 5-mm straight viewing laparoscope for introduction through 5-mm trocar sleeves; and an oblique-angle laparoscope (30-45°) for upper abdominal and pelvic procedures.
Scissors
Scissors are the preferred instrument to cut adhesions, especially avascular and/or congenital adhesions. Using the magnification afforded by the laparoscope, most anterior abdominal wall, pelvic, and bowel adhesions can be carefully inspected and divided with minimal bleeding, rarely requiring microbipolar coagulation. Loose fibrous or areolar tissue is separated by inserting a closed scissors and withdrawing it in the open position. Pushing tissue with the partially open blunt scissors tip is used to develop natural planes.
Reusable 5 mm blunt-tipped sawtooth scissors and curved scissors cut well without cautery. Blunt or rounded-tip 5mm scissors with one stable blade and one moveable blade are used to divide thin and thick bowel adhesions sharply. Sharp dissection is the primary technique used for adhesiolysis to diminish the potential for adhesion formation; electrification and laser are usually reserved for hemostatic dissection of adhesions where anatomic planes are not evident or vascular adherences are anticipated. Thermal energy sources must be avoided as much as possible to reduce adhesion recurrence. Blunt-tipped, sawtooth scissors, with or without a curve, cut well (Richard Wolf Medical Instruments, Vernon Hills, IL and Karl Storz Endoscopy, Culver City, CA). Many disposable scissors depend greatly on electrification for cutting. Hook-scissors are not very useful for adhesiolysis. I use them only to cut suture.
Surgeons should select scissors that feel comfortable. To facilitate direction changes, the scissors should not be too long or encumbered by an electrical cord. This author prefers to make rapid instrument exchanges between scissors and microbipolar forceps through the same portal to control bleeding, instead of applying electrification via scissors.
Electrosurgery
When discussing electrosurgery, the term “cautery” should be abandoned as it is not electrosurgery. Cautery, thermocoagulation, or endocoagulation refer to the passive transfer of heat from a hot instrument to tissue. The hot instrument is usually heated by electrical current. The temperature rises within the tissue until cell proteins begin to denature and coagulate with resultant cell death. Electrical current does not pass through the patient’s body!
Monopolar cutting current can be used safely, as the voltage is too low to arc to organs even 1 mm away. Cutting current is used to both cut and/or coagulate (desiccate) depending on the portion of the electrode in contact with the tissue. The tip cuts, while the wider body tamponades and coagulates.
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