Laparoscopic Adhesiolysis

by Ceana H. Nezhat, MD, Daniel S. Seidman, MD Farr R. Nezhat, MD, Camran R. Nezhat MD
SURGICAL ANATOMY AND TECHNIQUES
Laparoscopy is an effective tool for the evaluation of patients with chronic pain. Laparoscopic adhesiolysis is associated with significant relief of chronic abdominal pain in more than 80% of patients. Laparoscopic adhesiolysis was also found to be more effective than microsurgical adhesiolysis for infertility. Although complications due to adhesiolysis are rare, there is understandable concern about blunt, sharp, or thermal injury to the bowel. Adhesions are frequently involved between two organs and most often involve the bowel. The possibility of injury during abdominal entry with a Veress needle or trocar exists in patients with or without a previous history of laparotomy.(Figure 1, Figure 2a, Figure 2b) To adequately perform laparoscopic adhesiolysis, three or four abdominal punctures are required - the infraumbilical incision for the operative laparoscope and two to three lower, lateral punctures for introduction of ancillary instruments. Successful insertion depends on adequate skin incision, the trocar’s working condition, proper orientation, and control over the instrument’s force and depth of insertion. Small diameter (<3 mm in diameter) laparoscopy as an alternative to open laparoscopy can be utilized for initial abdominal entry in patients at risk for adhesions. Through the lateral trocar, on the side of the assistant, an atraumatic grasping forceps is inserted to hold the adhesion or involved organ, stretch it, and identify its boundaries and avascular planes. The opposite trocar, on the side of the surgeon, is used for microscissors or the suction-irrigator probe. Dense adhesions are severed first, followed by thin and filmy adhesions. This approach allows for progressive exposure of the pelvic structures. Once the intestines are freed from the adjacent structures, they can be pushed cephalad. In the pelvis, adherent ovaries are freed from the pelvic sidewall, broad ligament, tubes, and uterus. Once the ovaries are lifted from the cul-de-sac and mobilized, all peritubal adhesions are removed. Any bleeding that cannot be controlled with the laser is desiccated using the bipolar or unipolar electrocoagulator to maintain a clear field.
PREVENTION
Adhesion formation is a serious concern following pelvic surgery. Adhesion formation at the vaginal cuff and pelvic sidewall usually involves bowel and omentum. This may result in pelvic pain, dyspareunia, small bowel obstruction, and residual ovary syndrome when salpingo-oophorectomy is not performed. Adhesions were identified as the primary cause of chronic pelvic pain in 13-26% of females. Painful coitus is frequently reduced after lysis of pelvic adhesions. In many surveys of postoperative bowel obstruction, abdominal surgery is the leading cause of adhesion formation.
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