Tips & Tricks in Laparoscopic Adhesiolysis

Tips &Tricks in Laparoscopic Adhesiolysis

Laparoscopic adhesiolysis for small bowel obstructionAlexander Nagle, M.D., Michael Ujiki, M.D., Woody Denham, M.D.,

Kenric Murayama, M.D.*The American Journal of Surgery 187 (2004) 464–470

• Adhesions from prior surgery are the most common cause of small bowel obstruction in the Western world .

• The incidence of an adhesive small bowel obstruction after open abdominal surgery is between 12% and 17% .

• The socioeconomic impact of adhesive small bowel obstructions is significant. In 1996, Medicare paid $3.22 billion for adhesion related complications .

• Historically, laparotomy and open adhesiolysis have been the treatment for patients requiring surgery for small bowel obstruction.

• Unfortunately, this often leads to further formation of intraabdominal adhesions with approximately 10% to 30% of patients requiring another laparotomy for recurrent bowel obstruction .



• Laparoscopic adhesiolysis was first described by gynecologists for the treatment of chronic pelvic pain and infertility.

• Laparoscopic adhesiolysis for small bowel obstruction was first reported by Bastug et al in 1991 in 1 patient with a single adhesive band.

• In addition, laparoscopy has been shown to decrease the incidence, extent, and severity of intraabdominal adhesions when compared with open surgery, thus potentially decreasing the recurrence rate for adhesive small bowel obstruction [8].



Indications• Laparoscopic adhesiolysis for small bowel obstruction

has a number of potential advantages: (1) Less postoperative pain

(2) Quicker return of intestinal function (3) Shorter hospital stay (4) Reduced recovery time(5) Earlier return to full activity (6) Fewer wound complications(7) Decreased postoperative adhesion formation


Kenric Murayama, M.D.*The American Journal of Surgery 187 (2004) 464–470.*

• The most important aspect to a successful outcome is proper patient selection and surgical judgment.

• There are no clear guidelines that state which patients are best suited for laparoscopic adhesiolysis; however, there are several factors that have been shown to predict a successful outcome.



• Chosidow et al [15] reported laparoscopic adhesiolysis on an emergent basis in 39 patients; the conversion rate was 36% compared with 7% in elective cases.

• Suter et al [13] found that a bowel diameter exceeding 4 cm was associated with an increased rate of conversion: 55% versus 32% (P 0.02).

• Patients with a distal and complete small bowel obstruction have an increased incidence of intraoperative complications and increased risk of conversion.

• Patients with persistent abdominal distention after nasogastric intubation are also unlikely to be treated successfully with laparoscopy.



• The influence of dense adhesions and the number of previous operations on the success of laparoscopic adhesiolysis is controversial.

• Leo´n et al [19] state that a documented history of severe or extensive dense adhesions is a contraindication to laparoscopy.

• Navez et al [21] found that patients who had only a previous appendectomy were most likely to be successfully managed with laparoscopy.

• In contrast, Suter et al [13] found no correlation between the number and or type of previous surgeries and the chance of a successful laparoscopic surgery.



Operative techniquePeritoneal access• Peritoneal access and trocar injury to the distended

bowel are major concerns regarding the feasibility of laparoscopic adhesiolysis.

• The initial trocar should be placed away (alternative site technique) from the scars in an attempt to avoid adhesions (Fig. 1).

• Some investigators have recommended the use of computed tomography scan or ultrasonography to help determine a safe site for the initial trocar insertion.



• Although alternative site entry can be performed with either an open (Hasson) or blind-access (Veress needle) technique, the open approach is more prudent in cases of laparoscopy for small bowel obstruction.

• Sato et al [12] reported using the Veress needle in 16 patients without a single complication. The importance of confirming the position of the needle with the saline drop test and monitoring the pressure during insertion of the Veress needle was emphasized.

• In contrast, Levard et al [11] reported a 3.7% incidence of intestinal perforation using a blind-access technique in cases of bowel obstruction.

• Other studies have confirmed that the blind-access technique (Veress needle) does have a higher rate of bowel injury and vascular complications, even in patients who have not had prior abdominal surgery.



• Most authors advocate the use of the open technique because of concerns about intraabdominal adhesions fixing segments of bowel to the undersurface of the abdominal wall [13,19,21,23].

• The open technique is performed similar to a muscle-sparing incision for an appendectomy.

• Careful dissection is required to avoid injury to the underlying adherent bowel. Blind cutting or spreading must be avoided.

• The open technique allows the identification of adherent bowel and dissection of the bowel away from the abdominal wall.

• Although the open technique does not completely eliminate the risk of bowel injury, it does allow the surgeon to promptly identify and repair any injury that may occur.

• Finally, there have been no reports of vascular injuries with the open technique, as have been described with the blind access technique.

• The disadvantage of the open technique is the increase in operative time, particularly in obese patients.



• Another technique that has gained favor is the use of optical access trocars.

• In experienced hands, optical access trocars are safe and facilitate rapid entry into the peritoneal cavity.

• String et al [9] reported their use in 650 patients, with a mean entry time of 77 seconds and a complication rate of 0.3%.

• With this technique a 0-degree laparoscope is inserted through the transparent cannula as the trocar is advanced through the abdominal wall, thereby visualizing each tissue layer of the abdominal wall.

• The advantage of this technique is that it allows you to identify the bowel wall before inserting the trocar into the bowel.

• Furthermore, if an injury does occur, it is recognized at that time and managed appropriately.



• Once safe access is obtained, the next goal is to provide adequate visualization in order to insert the remaining trocars.

• This often requires some degree of adhesiolysis along the anterior abdominal wall. Numerous techniques are available, including finger dissection through the initial trocar site and using the camera to bluntly dissect the adhesions.

• Sometimes, gentle retraction on the adhesions will separate the tissue planes. • Most often sharp adhesiolysis is required. The best technique is to follow the line of

tissue adherence, if possible, which results in less bleeding and less risk for bowel injury. A traction-countertraction technique as used for open adhesiolysis is effective.

• The use of cautery and ultrasound dissection should be limited in order to avoid thermal tissue damage.

• A particularly difficult situation involves dense adhesions between the bowel and anterior abdominal wall. In this case, the plane between the bowel and the peritoneum is often obliterated, and it is necessary to dissect in the preperitoneal fat.

• In most cases, at least two additional trocars will be needed in order to achieve adequate adhesiolysis.

• If possible, the trocars should be placed to operate along the sights of the camera and not against the camera.

• Surgeons should be flexible about trocar placement, and additional trocars should be placed as needed to accomplish the necessary adhesiolysis.



Technique for adhesiolysis• After trocar placement, the initial goal is to expose the collapsed

distal bowel. • This is facilitated with the use of angled telescopes and maximal

tilting/rotating of the surgical table. It may also be necessary to move the laparoscope to different trocars to improve visualization.

• Manipulation of thin-walled, friable, dilated small bowel should be avoided.

• Even with atraumatic graspers, injury to the bowel wall can occur. • If necessary, the small bowel mesentery (instead of the bowel wall)

should be grasped in order to manipulate the bowel. • Once the collapsed distal bowel is exposed, atraumatic graspers

should be used to run the decompressed small bowel proximally until the site of obstruction (transition point) is found.



• Sharp dissection with the laparoscopic scissors should be used to cut the adhesions. • Cautery should be avoided in order to prevent potential thermal injury to adjacent bowel.• The use of cautery also causes tissue ischemia (a very potent adhesion promoter), which leads

to the formation of more intraabdominal adhesions. • Only pathologic adhesions should be lysed. • Additional adhesiolysis only adds to the operative time and to the risks of surgery without benefit. • If the point of obstruction is not clearly identified, adhesiolysis should continue until all suspicious

adhesion or bands are transected. • If all adhesions cannot be lysed then conversion to an open procedure should be strongly

considered. • Once adequate adhesiolysis is complete, the area lysed should be thoroughly inspected for

possible bleeding and bowel injury.• If found, these complications should be treated appropriately.• Small bleeding points may be controlled with clips, suture, or careful cautery. • Serosal tears and enterotomies can be repaired laparoscopically; however, there should be a low

threshold to convert. • If there is any concern about the integrity of the bowel, we recommend a minilaparotomy in order

to examine the bowel under direct visualization.



Intraoperative findings• There are several intraoperative findings that are

associated with a high risk of conversion. • Perforated or gangrenous bowel is best managed with

conversion to either a minilaparotomy or a formal laparotomy.

• Although laparoscopic small bowel resection and primary anastomosis in the acute setting has been described, we prefer to exteriorize the bowel through an appropriately sized and positioned incision and to perform the bowel resection and anastostomis extracorporally.

• However, in cases of chronic partial small bowel obstruction, the bowel is often thickened and laparoscopic small bowel resection may be feasible.



• Matted small bowel loops and dense adhesions are also best managed with a formal laparotomy.

• Navez et al [21] reported that only 10% of obstructions caused by dense adhesions could be treated successfully with laparoscopy.

• On the other hand, when the cause of obstruction was a single band, laparoscopic adhesiolysis was successful 100% of the time [21].

• Unfortunately, it is difficult to predict the degree of intraabdominal adhesions prior to surgery.



• It is important to be prepared to deal with these other possible etiologies.

• In a number of cases, conversion to a minilaparotomy or a formal laparotomy is required.

• Table 1 shows the percentage of other finding reported in the literature.

• Conversion to a laparotomy should not be considered a failure or complication, but rather a recognition of limitations posed by technology, the surgical expertise, or factors unique to a particular patient or disease process.

• Table 2 shows the most common reasons for conversion.



Outcomes• The results of laparoscopic adhesiolysis as reported in several series are

shown in Table 3.• Most series are retrospective and have only a few patients with short follow-

up. • The largest series is a multicenter study of 308 patients, but the data are

retrospective and the follow-up is only 1.6 months [11]. • Operative times range from 58 to 108 minutes for laparoscopic cases and

up to 208 minutes for cases that are converted to a laparotomy [14,19]. • The conversion rates range from 6.7% to 43% [10,13]. • The reported hospital length of stay in most series is 4 to 6 days for the

laparoscopic group and around 12 days for the converted group. • The incidence of intraoperative enterotomies ranges from 3% to 17.6%, with

most authors reporting an incidence of about 10% [12,15]. • Suter et al [13] reported an intraoperative enterotomy incidence of 15.6%, of

which 62% were repaired laparoscopically.



• One of the most dreaded complications of surgery is missed enterotomy. • Although a missed enterotomy can occur after laparotomy, the incidence is

higher after laparoscopic surgery. • Suter et al [13] reported 4 of 47 cases (8.5%) of missed enterotomies that

required reoperation. • Others have also reported cases that required early reoperation for missed

bowel perforations. • Strickland et al [16] found that the duration of surgery longer than 120

minutes, bowel necrosis, intraoperative perforation, and conversion were significant predictors of postoperative morbidity.

• Levard et al [11] reported the incidence of wound complications to be 1.2% in the laparoscopic group compared with 10% in the converted group (P 0.001).

• Bailey et al [20] reported that in a series of 65 patients operated on for acute bowel obstruction, 7 patients required early reoperation.

• The reported mortality ranges from 0% to 3%. This rate is lower than the reported mortality after open surgery of adhesiolysis, which most likely represents patient selection.



• The long-term results regarding recurrence are limited, with most series reporting a mean follow-up between 12 and 24 months.

• Navez et al [21] reported that 85% (29 of 34) of the patients treated laparoscopically were asymptomatic with a mean follow-up of 46 months.

• The series with the longest follow-up (mean 61.7 months) reported 87.5% (14 of 16) of the patients treated laparoscopically were asymptomatic [12].

• The question regarding decreased recurrence after laparoscopy compared with laparotomy remains to be answered.

• Interestingly, Khaitan et al [28] have described a new technique of applying Seprafilm laparoscopically, which could further decrease the recurrence of adhesive bowel obstruction.



Conclusions• Laparoscopic adhesiolysis has been shown to be safe

and feasible in experienced hands. • At this time, laparoscopic surgery for small bowel

obstruction is still under evaluation since it has not been directly compared with open surgery.

• In selected patients, laparoscopic adhesiolysis offers the advantages of decreased length of stay, faster return to full activity, and decreased morbidity.

• Patient selection and surgical judgment appear to be the most important factors for a successful outcome.



• Patients who require an emergent operation are not good candidates for laparoscopic adhesiolysis.

• Patients with bowel dilatation less than 4 cm and a partial obstruction can be considered for laparoscopic adhesiolysis.

• Patients who have a chronic or recurrent partial obstruction documented on a contrast study are also good candidates for laparoscopic adhesiolysis.

• Technically, peritoneal access should be achieved with the open (Hasson) technique in order to avoid bowel injury.

• Grasping the dilated, thin-walled bowel and the use of cautery should be avoided. • The most common reasons for conversion include dense adhesions, unable to

visualize the site of obstruction, iatrogenic intestinal perforation, bowel necrosis and colonic cancer.

• There should be a low threshold to convert to a minilaparotomy or to a formal laparotomy.

• Conversion should not be considered a failure, but rather good surgical judgment. • Further studies need to examine the open versus the laparoscopic procedure in a

prospective randomized fashion and evaluate the cost effectiveness of this approach.

Is laparoscopy safe and effective for treatment of acutesmall-bowel obstruction?

P. Strickland, D. J. Lourie, E. A. Suddleson, J. B. Blitz, S. C. Stain

• In these cases, laparoscopy has been contraindicated due to the risk of enteric injury and the possibility of bowel distention, which would prevent the visualization of the point of obstruction.

• As laparoscopic experience has increased and advances have been made in instrumentation, the spectrum of diseases now treated with minimal access techniques has expanded.

• The laparoscopic treatment of acute small bowel obstruction is now possible and undoubtedly will become more common.



Surgical technique• All patients had nasogastric suction and Foley catheter drainage prior to

operation. • The initial trocar placement at the umbilicus and pneumoperitoneum was

established using a blunt-tip Hasson trocar. • Additional ports (usually two) were placed under direct vision. The entire

abdomen was inspected laparoscopically.• If the point of obstruction was readily identified, it was relieved via sharp

dissection or electrocautery. • More recently, the harmonic scalpel has occasionally been utilized (two

cases). • The bowel was then run from the cecum proximally with two atraumatic

graspers. In those cases in which the point of obstruction was clearly identified (with collapsed bowel distally and dilated loops proximally), the obstruction was relieved without further examination of the bowel. In all other cases, inspection was continued to the ligament of Treitz.



• Laparoscopic lysis of adhesions has been performed for decades by gynecologists in the treatment of fertility and chronic pelvic pain [8].

• Several reports have described the use of laparoscopy for the lysis of adhesions in patients with chronic abdominal pain or recurrent bowel obstruction [4, 5, 7].

• These studies found symptomatic improvement in 67– 87% of patients after laparoscopic adhesiolysis and a conversion rate of 5–7%.



Franklin et al. treated 23 patients with acute small bowel obstruction laparoscopically in 1994 [6]. Laparoscopic treatment was possible in 20 of 23 (87%). Their technique utilized a Veress needle, and adhesions were lysed with either scissors or a laser. Three cases were converted to open laparotomy because of severe adhesions, an inability to examine the bowel completely, and a suspected necrotic bowel, respectively.

• In a later series, Ibrahim et al. reviewed 33 consecutive cases of acute small bowel obstruction treated with laparoscopy [9]. Open initial trocar insertion was performed in all cases. Conversion to formal laparotomy was necessary in only five patients—two for small bowel resection, two for malignant adhesions, and one due to intolerance of pneumoperitoneum. Six additional patients underwent minilaparotomy— two for repair of enterotomy, one for gangrenous bowel, one for Meckel’s diverticulum, and one to confirm complete lysis. Overall, 18 patients (55%) underwent successful laparoscopic adhesiolysis, and 22 patients (67%) were spared laparotomy.

• In our series, 40 patients with acute small bowel obstruction were treated with laparoscopy. Open initial trocar insertion was performed in all cases. The point of obstruction was relieved entirely laparoscopically in 24 patients (60%), and only 13 patients required formal laparotomy (32.5%).



• Inability to visualize the point of obstruction solely due to bowel dilatation is unusual. In our series, only one patient was converted to an open procedure for this reason, and no such problems were reported in the studies by Franklin et al. [6] or Ibrahim et al. [9].



• In our series, enterotomies occurred in four of 40 patients (10%) during laparoscopic exploration and adhesiolysis.

• this figure is comparable to the reported incidence after open laparotomy for acute bowel obstruction. An even higher proportion of the patients had enterotomies after conversion (23%).

• The risk of enterotomy can be reduced if meticulous care is taken in the use of atraumatic graspers only and if the manipulation of friable, distended bowel is minimized by handling the mesentery of the bowel whenever possible.

• Maintaining a low threshold for conversion to laparotomy in the face of extensive adhesions will further decrease the risk of bowel injury.

• Using electrocautery rather than scissors or a harmonic scalpel for the lysis of adhesions may also increase the likelihood of injury to adherent bowel.



• We still believe that further experience will show that this procedure shares the advantages that have been reported for other minimal access techniques: decreased morbidity, shorter hospitalization, decreased disability, and fewer complications.

• We found laparoscopic adhesiolysis to be a safe and effective technique in the management of acute small bowel obstruction.

• The increased expertise of surgeons in advanced laparasocpy will allow this methodology to become more widely adopted in the future.

Laparoscopic approach to postoperative adhesive obstructionG. Borzellino, S. Tasselli, G. Zerman, C. Pedrazzani, G. Manzoni

Surg Endosc (2004) 18: 686–690

• No study in literature compared results of adhesiolysis and conservative treatment after resolution of the acute phase of the obstructive episode.

• Retrospective studies reported a high percentage of recurrence in patients treated nonoperatively.

• Landercasper et al. reported a recurrence rate of 53 % after the first obstructive episode and 85% after the second [14],and a 50% recurrence rate within two years was reported by Barkan et al. [3].

• In our study recurrence rate in patients operated on after resolution of the acute phase was 13.5%.


Surg Endosc (2004) 18: 686–690

• A review of literature showed a correlation between selection criteria and conversion rate (range 17–63.4%) [1, 5, 15, 23].

• The highest conversion rates are reported when no selection of patients is adopted [21], while the best results are reached with most severe exclusion criteria [1].

• A significant correlation was found between conversion and presence of peritonism by both Benoist et al.[5] and Suter et al. [23].

• Suter et al. evaluated the diameter of the dilated bowel establishing a limit of 4 cm beyond which the conversion rate increases significantly, while Benoist et al. did not find any correlation between radiological findings and conversion rate.

• Nonetheless, the author reports a conversion rate of 48.4 %, and in 80% of cases the conversion was due to the inability to identify or remove the site of obstruction.


Surg Endosc (2004) 18: 686–690

• The number of previous operations was used as a selection criterion by various authors [1, 5, 23].

• No statistical correlation was found between the number of previous operations and the percentage of recurrence, complication, or need for conversion.

• Some authors included the experience of surgeon in the exclusion criteria [1, 2, 5, 23].

• Literature data reported a rate of intraoperative complications of 0–16.5%; the rate of postoperative complications was 4.5–31% [1, 2, 4, 5, 10, 13, 15, 17, 22, 23].

• The most severe intraoperative complication is small bowel perforation, which may occur at the time of first trocar placement, during manipulation of the bowel, or during lysis of the adhesions.


Surg Endosc (2004) 18: 686–690

• In this study, no intestinal lesion occurred as a result of the insertion of the first trocar.

• This result was obtained with the help of ultrasonographic mapping of abdominal wall adhesions enabling creation of the pneumoperitoneum and insertion of the first trocar in areas free of adhesions in all cases.

• The ultrasonographic examination is systematically performed in our division before a laparoscopic approach in scarred abdomens; the high sensitivity reported in previous studies [6, 7] has also been confirmed in patients with adhesion disturbance.

• In the presence of distended bowels an open laparoscopy could be preferred, but does not seem mandatory, as in our experience the blind approach has been performed safely in all cases.


Surg Endosc (2004) 18: 686–690

• Only two authors reported follow-up data for the assessment of recurrences after laparoscopic adhesiolysis, with an observational period of 22 and 24 months.

• The percentage of recurrences reported by these authors was 5% and 10% [10, 22].

• The follow-up period of this study was longer, with an average length of 48 months. This may explain the higher percentage of symptomatic recurrences found in our study (15.4%), while surgical recurrences (4.6%) were similar to that reported by other authors.

• The laparoscopic approach could be effective also in patients with recurrent transit disturbances without signs of acute obstruction. In these patients adhesiolysis is associated with resolution of symptoms in 88% of cases with conversion and morbidity rates of 12 % and 8%, respectively.


Surg Endosc (2004) 18: 686–690

• The presence of local or generalized peritonitis does not represent an absolute contraindication, but laparoscopy in these cases often fails.

• Preoperative ultrasonographic mapping of abdominal wall adhesions has an important role to play in the selection of patients and for first trocar placement.

• In our experience, this evaluation eliminates the risk of visceral injuries and enables the best location for successive trocars.

• The inclusion of patients with radiologically confirmed massive and diffuse small bowel dilatation should be verified with further randomized studies.

Adhesion formation is reduced after laparoscopic surgeryC. L. Garrard,1 R. H. Clements,1 L. Nanney,2,3 J. M. Davidson,4 W. O. Richards1,5

Surg Endosc (1999) 13: 10–13

• Adhesions form as the end result of an inflammatory response to injury within the peritoneal cavity.

• Fibrin clot accumulating at the site of injury is usually lysed by the endogenous fibrinolytic systems.

• In more severe injury, fibroblasts migrate into the fibrin clot and produce collagen, which forms scars or adhesions.

• With a greater inflammatory response, there is less fibrinolysis and more fibroblast activity, resulting in more adhesion formation [1].

• The severity of inflammation is related to the degree of local tissue trauma, ischemia, and the presence of a foreign body [6].


Surg Endosc (1999) 13: 10–13

• The analysis of the intraperitoneal mesh area covered with adhesions based on the operation type revealed significantly more adhesions developed when the mesh was placed through a celiotomy (14.11 ± 3.01 cm2) than when the mesh was placed laparoscopically (1.00 ± 0.58 cm2, p 4 0.001).

• Also, a significantly greater area of mesh was covered by adhesions (p 4 0.03) when the mesh was placed laparoscopically followed by the long midline incision that did not incise the peritoneum (9.63 ± 3.50 cm2) than when the procedure was performed with the laparoscope alone (Fig.5).

• There was no significant difference in adhesion formation when the operation was performed through a celiotomy versus laparoscopically followed by a long incision that did not penetrate the peritoneum.


Surg Endosc (1999) 13: 10–13

• It has been generally accepted that the intra-abdominal trauma of celiotomy causes the majority of adhesions.

• This study shows that an incision through skin, subcutaneous tissue, and fascia increases adhesion formation even when the intraabdominal injury is minimal, as is the case with a laparoscopic procedure.

• Thus, it is not only local tissue trauma, but also tissue trauma removed from the site of eventual adhesion formation that increases adhesion formation.

• In either case, this is microscopic evidence of a more significant tissue response to a larger incision removed from the site of eventual adhesion formation.

• We postulate that the tissue trauma of the incision increases the total inflammatory response, thereby inhibiting fibrinolysis and promoting fibroblast migration and collagen formation.

• The trauma of a midline incision contributes to the formation of intra-abdominal adhesions, even when the incision does not transect the peritoneum.

• These results strongly suggest that laparoscopic surgical techniques lead to fewer intra-abdominal adhesions by reducing tissue trauma, which in turn reduces circulating inflammatory mediators.

Laparoscopic adhesiolysis in patients with chronic abdominal pain: a blinded randomised controlled multi-centre trial D J Swank, S C G Swank-Bordewijk, W C J Hop, W F M van Erp, I M C Janssen,

HBonjer, J Jeekel THE LANCET • Vol 361 • April 12, 2003

• In 35–56% of patients with chronic abdominal pain, adhesions will be the only explanation, which suggests that laparoscopy is the best primary intervention in patients with such pain.1,2

• However, although these patients usually do have adhesions, some investigators do not agree that they are the cause of pain.3,4,5

• Unlike adhesiolysis for bowel strangulation or obstruction, which has a mortality rate of 10%,6 laparatomic adhesiolysis for treatment of chronic abdominal pain has never gained acceptance.7

• The reported rates of chronic pain relief after this procedure vary from 38% to 87%.8,9

• However, some suggest that pain relief is attributable to patient reassurance after laparoscopy has excluded serious morbidity, or because of a placebo effect based on a good doctor-patient relationship.10,11



Discussion• We have shown significant relief of chronic pain after laparoscopic adhesiolysis.

However, this reduction in pain did not differ from that in controls with the same symptoms, pain scores, and frequency and severity of

• adhesions who underwent diagnostic laparoscopy only. • This finding suggests that the value of laparoscopic adhesiolysis does not lie in the

adhesiolysis itself.• Some investigators have questioned the benefit of laparoscopic adhesiolysis and

suggested that adhesions do not cause pain unless they are causing an obstruction.5,19

• On the other hand, results from several studies have shown chronic pain relief after laparoscopic adhesiolysis, with improvement rates of 45–84%.8,9,20–22

• However, there is a 10% morbidity rate associated with laparoscopic adhesiolysis. Other investigators have reported bowel injury rates of between 10% and 25% during laparoscopic adhesiolysis for pain.15,23

• diagnostic laparoscopy with the risk of bleeding or viscus perforation; in most cases an incomplete laparoscopy should be accepted.



• Although laparoscopic adhesiolysis is done throughout the world, this procedure is not evidence based.

• In view of our findings, we recommend that clinicians consider abandoning laparoscopic adhesiolysis as a treatment for adhesions in patients with chronic abdominal pain.

Laparoscopic compared with conventional treatment of acuteadhesive small bowel obstruction

C. Wullstein and E. GrossBritish Journal of Surgery 2003; 90: 1147–1151

• Laparoscopy is known to cause fewer intra-abdominal adhesions than open surgery, including adhesiolysis8–11, and results in quicker recovery of postoperative intestinal motility12,13.

• Acute obstruction may be associated with a higher risk of bowel injury and limited exposure due to severe abdominal distension than elective adhesiolysis7.

• Some series have demonstrated the feasibility and safety of laparoscopic treatment for acute SBO7,16–21 and suggested advantages for this procedure.

• The present study was therefore undertaken to compare the results of laparoscopic surgery for acute SBO with those of conventional treatment.

• Variables evaluated were operating time, reason for conversion, intraoperative and postoperative complications, length of hospital stay and bowel movements.



• Insertion of the first trocar in each patient was performed under direct vision using an open technique.

• The incision was made distant to any previous scars. • After creation of pneumoperitoneum additional trocars were placed according to the intra-

abdominal findings. • All patients received standard prophylactic antibiotics, a nasogastric tube and a urinary catheter.• Operation took longer in the LAP group than in the CONV group (103 versus 84 min; P > 0·05)

whereas the operating time in the cLAP group was comparable to that of conventional surgery (83 versus 84 min).

• Major intraoperative complications occurred in 15 patients (28·8 per cent) in the LAP group and eight (15·4 per cent) in the CONV group (P = 0·156) (Table 3).

• Ten complications in the former group occurred during laparoscopy and another five after conversion. In seven patients small bowel perforation required conversion for further treatment.

• Two perforations and a case of haemorrhage were treated laparoscopically. • Serosal defects occurred in four patients in the LAP group and three in the CONV group.• The number of previous laparotomies was identified as a risk factor for intraoperative

complications. • Major intraoperative complications occurred in 11 of 26 patients with two or more previous

laparotomies compared with four of 26 patients with fewer laparotomies (P = 0·066).• The duration of symptoms had no influence on the complication rate.



Postoperative results

• Patients in the LAP group experienced a quicker recovery of bowel movements (P < 0·001), a shorter length of hospital stay (P < 0·001) and had fewer postoperative complications (19·2 versus 40·4 per cent; P = 0·032) than those who had a conventional procedure (Tables 4 and 5).



• The conversion rate of 51·9 per cent in the present study was slightly higher than previously reported values of about 45 per cent21,24,25.

• The main reason for conversion was an obscured view due to intestinal distension in combination with extensive adhesions7,20,26.

• A reduced field of vision together with the vulnerability of the bowel limits the use of laparoscopy and may explain why laparoscopy for acute SBO has the highest rate of conversion in laparoscopic surgery27.

• There is evidence that laparoscopic treatment of acute SBO leads to a higher rate of bowel injury than conventional surgery25.

• The rate of bowel perforation in this series was 26·9 per cent in the LAP group and 13·5 per cent in the CONV group.

• All perforations occurred during adhesiolysis and were not related to trocar insertion, indicating that open insertion of the first trocar can be performed safely.

• The incidence of perforation was higher in this series than reported values of 9–16 per cent7,20,21,25,26 for laparoscopic procedures.



• The number of laparotomies and the complexity of operation are known to increase postoperative adhesion formation 29–31.

• Although postoperative complications have been shown to occur more frequently after converted procedures than after complete laparoscopic treatment of acute SBO7,25, complications after laparoscopic and conventional treatment have not been compared.

• Bailey et al.28 have also shown a shorter hospital stay after laparoscopic compared with open management of acute SBO.

• An advantage with regard to bowel movements has been described previously only for laparoscopically treated patients compared with those whose operations for acute SBO were converted24.

• In the present study laparoscopic treatment of acute SBO led to a shorter period of postoperative ileus than open treatment, even when conversions were included.



• Laparoscopic treatment of acute adhesive SBO was feasible in half of these patients, who benefited from a low postoperative complication rate, a quicker recovery of bowel function and a shorter hospital stay.

• An attempt at laparoscopic management of acute SBO seems justified in patients with fewer than two previous laparotomies but should not be offered to other patients because of the unacceptably high risk of intraoperative bowel perforation.

Results after laparoscopic lysis of adhesions and placement ofSeprafilm for intractable abdominal pain

L. Khaitan, S. Scholz, H. L. Houston, W. O. RichardsSurg Endosc (2003) 17: 247–253

• Adhesion formation after abdominal surgery is a commonly recognized entity.

• Adhesions have been reported after 93% of abdominal operations [12] and after 55% to 100% of pelvic operations [4].

• These abnormal attachments between tissues and organs usually do not lead to any reported problems from patients.

• However, a cohort of patients develop complications from the adhesions including ileus, strangulation of bowel, impaired fertility, bowel obstruction, and chronic abdominal pain.

• Perhaps the most difficult of these complications to manage is chronic abdominal pain.

• A causative association between intraabdominal adhesions and chronic abdominal pain remains debatable among physicians.



• Briefly, a sheet of HA membrane is divided in half and the anterior sheath removed. The HA membrane is rolled within the posterior sheath. This roll is back-loaded into a 10- to 12- mm trocar removed from the abdomen. The entire unit is replaced into the abdominal cavity. The HA membrane is placed and the sheath removed.



• In this study, all the patients had chronic abdominal pain that was localized with identifiable intraabdominal adhesions.

• All the patients underwent laparoscopic adhesiolysis and placement of HA membrane.

• Overall, the outcomes were very good. Of the 19 patients in this study, 14 (74%) are very pleased with their procedure at this writing, and have completely discontinued all analgesics.

• This experience suggests that HA membrane placement may increase the likelihood of a leak from repaired enterotomies when placed directly over the enterotomy repair.

• Our current recommendation is that surgeons should not use Seprafilm next to or on an enterotomy repair.

• There was no correlation between number of previous enterolysis procedures, type of procedure, or extent of adhesiolysis during our procedure, and the absence of symptoms after laparoscopic LOA and placement of HA membrane.



• A causative association between intraabdominal adhesions and pain remains controversial.

• Many surgeons continue to follow the dogma set forth by Ikard [7], who believed that adhesions cannot cause pain unless they are obstructing, and that there is thus no role for adhesiolysis in the treatment of chronic pain without obstruction.

• Since that report, several studies have supported a role for laparoscopic adhesiolysis in the treatment of chronic abdominal pain [2, 9, 11].

• Multiple authors have noted a clear association between adhesions and pain [9, 10, 13].

• Adhesions that cause limitations in the movement or distensibility of organs involving the parietal peritoneum or the bowel are likely to cause pain. Therefore, lysis of adhesions that cause those limitations can relieve the pain.

• Because laparoscopy and placement of HA membrane have been shown to decrease adhesion formation individually, we thought that the combination of the two would be particularly effective for the patient with difficult chronic abdominal pain.



• In conclusion, laparoscopic lysis of adhesions combined with placement of Seprafilm is a relatively novel approach for patients with chronic abdominal pain secondary to adhesions.

• Patients with this pain syndrome need to be identified early so the cycle can be broken.

• Further studies using objective measures are needed to investigate the treatment of chronic abdominal pain.

• Meanwhile, patients can undergo this procedure with the expectation that their symptoms will improve.

Natural history of adhesional small bowel obstruction: counting the costBritish Journal of Surgery 1998, 85, 1294–1298

• Postoperative adhesions have become a major source of morbidity following laparotomy and are the most common cause of small bowel obstruction in the Western world.

• Similarly, pelvic adhesions are a frequent problem in patients suffering from subfertility.

• A recent survey of 750 German hospitals demonstrated that 2·6 per cent of laparotomies were for adhesional bowel obstruction1

• Ray et al.2 estimated that in 1988 the cost of treatment for lower abdominal– pelvic adhesionolysis in the USA was in excess of $1000 million.

• A prospective study by Menzies and Ellis3 indicated that approximately 1 per cent of patients will suffer obstruction within a year of abdominal surgery and that over a third of people who develop adhesional obstruction will do so within a year of surgery, with the remainder presenting with an initial episode of obstruction at a steady rate up to 10 years after surgery. This suggests an overall rate of adhesion-related morbidity of 3 per cent.

Natural history of adhesional small bowel obstruction: counting the costBritish Journal of Surgery 1998, 85, 1294–1298

• Menzies and Ellis’ prospective study3 indicated that while most adhesional obstruction occurs within 10 years (59 per cent by 5 years and 79 per cent by 10 years) there is no time limit as to when a patient may suffer an episode of obstruction.

• The present study is in agreement with this. • The mean time to presentation was 8·9 years

with 26 per cent presenting within 1 year and 48 per cent presenting within 5·5 years.

• However, one patient presented with adhesional obstruction 35 years after an appendicectomy.

Subjective evaluation of the therapeutic value oflaparoscopic adhesiolysisA retrospective analysis

E. Malik,1 C. Berg,1 A. Meyho¨fer-Malik,1 S. Haider,2 W. G. Rossmanith2Surg Endosc (2000) 14: 79–81

• Our results demonstrate that patients with intermittent pain, such as pain at defecation or micturition, enjoyed marked relief following adhesiolysis if other causes of chronic pain were excluded.

• The majority of patients with dyspareunia were relieved by adhesiolysis.

• Thus, patients who present with dyspareunia should be operated on laparoscopically to establish the existence of adhesions as a possible cause of their discomfort and perform adhesiolysis.

• Chan and Wood emphasized the great benefit of adhesiolysis in eliminating dyspareunia and indicated that amelioration or elimination of the symptoms was achieved in 70% of their patients [1].



• Complete adhesiolysis was only possible in 64 of our 101 patients. • Mecke et al. performed complete adhesiolysis in 73% of their

patients and partial adhesiolysis in 25%.• They reported that 30% of the complaints of the patients improved

[9]. • Herschlein and Lechner performed complete adhesiolysis in 78% of

their patients and partial adhesiolysis in the rest [3]. Amelioration and complete relief of the symptoms was achieved in 20% and 38% of these patients, respectively.

• The number of patients with laparoscopically confirmed adhesions without prior laparotomy or laparoscopy was 11 of 101 patients (11%).

• Kolmorgen and Schulz reported a rate of 25% of affected patients without prior surgery [4].

• For Mecke et al., the rate was 30% [9]; for Tavmergen et al., it was 27% [11].



• Laparoscopic adhesiolysis is a feasible means of ameliorating or completely relieving symptoms related to adhesions.

• Laparoscopical evaluation of the abdomen is appropriate either to exclude other causes of chronic pain or to relieve intermittent pain at defecation or micturition.

• Adhesiolysis is also beneficial in cases of dysmenorrhea or continuous lower abdominal pain.

• Since adhesions can be causally related to chronic pelvic pain, it is mandatory to achieve complete lysis of adhesions.

• Before a complete adhesiolysis is performed in these patients, all complaints must be thoroughly evaluated, and other functional and organic causes of the symptoms must be excluded.

Safe laparoscopic adhesiolysis with optical access trocar and ultrasonic dissectionA prospective study

D. J. Swank,1 H. J. Bonjer,2 J. JeekelSurg Endosc (2002) 16: 1796–1801

• Several safety measures for laparoscopic surgery have been proposed, such as subcostal insertion of the Veress needle [17], use of an optical trocar [10], radially dilating trocars [2], and open introduction of the initial trocar [3, 5, 18].

• The optical trocar (Optiview, Ethicon,Endosurgery, Cincinnati, OH) is a blunt optical trocar, which is guided through the abdominal wall with the camera inside and controlled by the monitor. This device might combine the advantages of a safe and a fast penetration of the abdominal cavity.



• Laparoscopic adhesiolysis with scissors is inconvenient because of bleeding.

• Electrodissection causes charring of tissue and delayed perforations because of its excessive heat production [7, 12, 20, 23].

• Bipolar electrosurgery has the advantage of reducing the electrosurgical complications but still has delayed thermal lesions [23].

• The ultrasonic device for laparoscopic cholecystectomy was introduced by Amaral in 1994 [1]. Several different laparoscopic procedures have been performed successfully with this device [9, 23].

• The ultrasonically activated scalpel causes less heat production compared with electrocautery dissection,thereby theoretically lowering the risk of delayed perforations.



• For pneumoperitoneum a Veress needle was induced preferably caudally to the umbilicus.

• In case of a midline scar, the entry site was chosen left subcostally. In case of a traverse incision in the upper abdomen the Veress needle was introduced in the intercostal space just above the eighth rib in the midclavicular line on the left side.

• Proper placement was controlled with intraabdominal pressure and with percussion of the abdominal wall. A pneumoperitoneum with carbon dioxide was Obtained at a maximum pressure of 12 mmHg.



• Optical trocar• The distal fold of the umbilicus was preferred as introduction site of

the initial trocar (Optiview) in patients without a midline incision.• Otherwise the introduction took place at least 5 cm lateral of the

scar away from the expected location of adhesions. • After a 12-mm skin incision the trocar was introduced bluntly by

slowly rotating the device through all layers of the abdominal wall. • The darkness of the abdominal cavity filled with carbon dioxide was

seen as a big black spot as background of the parietal peritoneum when pressure on the optical trocar was reduced from time to time during penetration.

• If not seen,an adherent organ at the puncture site was likely and the introductionwas attempted elsewhere .

• After checking for possible complications of the Veress needle, the abdominal cavity was examined with two atraumatic clamps (Aesculape) for adhesions and for concomitant pathology.



• A complete adhesiolysis was intended. • Sufficient tension on the organs is necessary to

maximize the effect of ultrasonic adhesiolysis. • If bowel loops were very adherent with the parietal

peritoneum, the latter was released from the abdominal muscles and not lysed from the bowel.

• The lysis of different organs should be done slowly to allow sufficient time to seal small vessels. Small bleedings were dealt with by the UD; if not successful, monopolar electrocautery was used.

• Concomitant pathology was also treated with the UD during the same procedure.



Optical trocar• The traditional approach of the abdominal cavity for laparoscopic surgery is a closed trocar

penetration after the establishment of a pneumoperitoneum with a Veress needle. • Visceral lesions in closed introduction have been reported between 0.06 and 0.4 % [11]. • Half of these visceral lesions are caused by the trocar and consist of damage to the small bowel

ranging from superficial serosal damage to perforation. However, all other intraabdominal organs may also be involved and these have a high mortality rate of 5% up to 15% [16].

• The rate of major vascular injuries with the closed technique varies from 0.02% to 0.24% [11]. • Vascular lesions are mostly caused by the Veress needle and in a minority of cases Caused as a

consequence of trocar introduction [16]. • The eighth intercostal space as the site for the Veress needle has been chosen three times to

avoidad hesions after a previous traverse incision in the upper abdomen. We found an easy introduction due to the short passage and adherent parietal peritoneum. This site is at least 5 cm away from the diaphragm.

• Childers has chosen the left ninth intercostal space after median laparotomies and has recommended this as a safe site in patients with high-risk subumbilical adhesions [6].



• Very large randomized studies might show differences in safety of a specific trocar. • Catarci et al., after evaluation of nearly 13,000 laparoscopic procedures, found the open

approach to be the safest way with minimal risk of visceral and vascular injury (0.09%) versus 0.27% complications with an optical trocar.

• Hashizume emphasizes that with the open Hasson technique only the vascular and visceral risks of the Veress needle and of the initial trocar introduction are diminished and that some visceral lesions are made by the second and following trocars even if introduced under direct vision (0.02%) [11].

• Radially expanding trocars have peritoneal access by dilatation rather than by dissection. • The smaller instrument for introduction has a potential advantage for fewer complications but this

has not been proven [2]. • The cost of an optic trocar is equal to that of the usual disposable trocar. • For adhesiolysis we prefer disposable second and third trocar s because the glide of a

disposable trocar is more convenient for multiple very accurate movements.• Even when a pneumoperitoneum cannot be achieved, the optical trocar access is safe. • String et al. used this trocar without a pneumoperitoneum in 650 different laparoscopic

procedures with two small-bowel and gallbladder perforations (0.3%) [25]. This technique avoids the complication risk of the Veress needle puncture, but misses the black hole as indication of distance between abdominal wall and abdominal organs and one has to rely on the movements of the bowel to differentiate the parietal from the visceral peritoneal layer.

• Lifting the abdominal wall does not change the position of the peritoneum in relation to the intraabdominal organs [4].



• The great advantage of UD is the simultaneous dissection andhemost asis and therefore minimal need for exchange of instruments during the procedure with decreased operating time as a result [8].

• Although coagulation with ultrasonic dissection seems slower than with electrosurgery, its result in hemostasis is equal [14].

• In 98% of our patients a complete or almost complete adhesiolysis could be achieved• This 3.8% (4/105) incidence of perforations is low compared to the literature in which

visceral perforations during laparoscopic adhesiolysis have been reported in up to 25% of patients [22]. In these reports 40% of bowel perforations were not recognizedd uring the operation. These late perforations might have been causedby thermal lesions due to high temperature (570F) of the electrodissection device.

• In this series no late perforations were diagnosed, probably because of the lower temperature of the tip (180F) and the minimal lateral energy spread of the UD.

• Ultrasonic dissection has some concomitant advantages. In patients with a pacemaker the ultrasonic device can be used without additional security measures [24], it produces no smoke, and the lower temperature of the tip of ultrasonic dissection causes less charring and less tissue necrosis.

• A 5-mm UD will have an advantage in separating closely fixed organs and more precise dissection might be expected.



• In conclusion, besides a carefully chosen entry site, the optical trocar identifies all layers of the abdominal wall and adherent organs and contrib utes to safe abdominal access in patients after multiple previous laparotomies.

• Ultrasonic dissection is a very feasible technique for laparoscopic adhesiolysis and might reduce the risk of bowel perforations by preventing the incidence of late (thermal) perforations.

Adhesion prophylaxis in gynecological operationsMatthias Korell*, Eduard Elek

International Congress Series 1271 (2004) 278– 280

• Many attempts have been made to solve the problem of postoperative adhesions, but only the barrier methods could reduce its incidence and severity. Currently, we use two products available for adhesion prophylaxis—SprayGel (methylene blue coloured polyethylenglycol) and Adept (4% icodextrin solution) [11].

• SprayGel is as a two-component system with air pump and spray applicator and consists of blue coloured polyethylene glycol (PEG) designed to cover the serosal defects.

• After rapid reaction within seconds, it becomes a gel which sticks to the tissue very well. Rinsing is possible immediately following the application. SprayGel has shown efficacy in both animal and clinical studies [5,6,10,12].

• Adept, which is a 4% icodextrin solution— well-known for years in peritoneal dialysis [7]—has been shown to be effective and safe [2,3,13,16].

Adhesion prophylaxis in gynecological operationsMatthias Korell*, Eduard Elek

International Congress Series 1271 (2004) 278– 280

• The combined use of minimal traumatizing• surgery and the application of adhesion prophylaxis can reduce both incidence and• severity of this problem significantly and allows, beside the preservation of the future• fertility, the prevention of postoperative adhesion related pain even after extensive• surgery. Currently, we are using SprayGel and Adept solution for prophylaxis with• good success. The advantage of SprayGelR is the good coverage of local defects• especially in the middle and upper abdomen. It can also be used in the posterior cul

de• sac and the pelvic sidewalls after extensive endometriosis surgery. It allows the• application of postoperative drainage without any limitations. AdeptR can be used• intraoperatively as a rinsing solution and is very easy to instillate at the end of

surgery.

An evaluation of low molecular weight heparin and hyperbaric oxygentreatment in the prevention of intra-abdominal adhesions and wound healing

Soykan Arikan, M.D.a,*, Gokhan Adas, M.D.a, Gul Barut, M.D.b, Akin Savas Toklu, M.D.c,The American Journal of Surgery 189 (2005) 155–160

• Menzies and Ellis [1] found that 93% of the patients who had undergone 1 or more previous surgeries had intra-abdominal adhesions.

• These are abnormal attachments, and a significant cause of morbidity and mortality.

• Bowel obstruction, female infertility, abdominal pain, and technical difficulties are among the well-known problems caused by abdominal adhesions [1–3].

• It was reported that 5.7% of the hospital readmissions after any kind of previous abdominal or pelvic surgery were directly related to adhesions and 3.8% of these admissions were treated by laparotomy [4].

• Intra-abdominal adhesions cause a high financial burden for social budgets.Total costs related to adhesions have been estimated to be1.2 billion U.S. dollars per year [5].



• Ellis [6] has classified these preventive measures into 5 groups: (1) installation of lubricants or distention with gas, (2) enhancement of peristaltic movements, (3) covering of raw surfaces, (4) enzymatic digestion, and (5) agents to inhibit fibrin deposition.

• It was reported that anticoagulants, especially heparin, were effective in decreasing the incidence of intra-abdominal adhesions [2,7–10].

• Hyperbaric oxygen (HBO) treatment has begun to be used with increasing incidence for many occasions and goals in the recent years. Basically, its effect in removing ischemia defines the main indications for its use [14].

• We concluded that enoxaparine Na decreased abdominal adhesions and HBO therapy had no beneficial effect on the formation of abdominal adhesions. We also showed that enoxaparine Na had no harmful effect on wound healing and HBO therapy increased the process of wound healing.



• The most common cause of intra-abdominal adhesions is a history of previous abdominal surgery [1].

• The formation of intra-abdominal adhesions may result from mechanical peritoneal damage, intra-abdominal tissue ischemia, or the presence of foreign materials [19,20].

• In the classic pathway of adhesion formation, peritoneal injury from trauma, infection, or ischemia results in an immediate type of inflammatory reaction followed by an increase in vascular permeability and the release of fibrin-rich exudate [15,21].

• In the absence of the lysis of this fibrin through the plasminogen-plasmin cascade, fibrous adhesions may form through collagen deposition [22]. Lysis of the fibrin depends on the activation of the peritoneal mesothelial plasminogen activator. Normal mesothelial cells possess plasminogen-activating activity [23].

• This physiologic property of normal mesothelial cells is decreased in the presence of surgical trauma, ischemia, or inflammation [22].

• Injury results in the rapid release of plasminogen-activator inhibitor-1 and -2 by mesothelial,endothelial, and inflammatory cells. This causes a loss of plasminogen-activating activity [11,24].

• For many decades, many materials and methods have been used to solve the adhesion problem.



• Heparin, by forming a complex with• antithrombin III in vivo, prevents the formation of thrombin,• in addition to increasing the degradation of thrombin• [32]. Moreover, this complex also inhibits active serine• proteases other than thrombin, especially factor Xa [33].• Heparin possibly stimulates macrophages to secrete the• plasminogen activator [34], and it also directly stimulates• the plasminogen-activator activity, hence increasing the action• of plasminogen [35]. Thus, the fibrin deposition, which• is the second phase of adhesion formation, is decreased and• this results in a decrease in the adhesion formation.

Small bowel obstructionLaparoscopic approachF. Agresta,1 A. Piazza,

Surg Endosc (2000) 14: 154–156

• Surgical technique and instruments. The patient should be placed on a OR table which offers the full range of tilt, as extreme positions may be necessary. Their arms must be by their side to allow the surgical team ample room, and at least two movable video monitors are also required to provide a better view of the operative theatre.

• We feel that open peritoneoscopy is mandatory, as the patterns and the varieties of intra-abdominal adhesions and findings are unpredictable [1–3, 5, 6, 9]. In our opinion a blind insertion of a Verres needle or trocars is extremely dangerous, especially in the presence of a distended bowel; however, we are aware that this is possible.

• In order to avoid any visceral injury, and to place all trocars in their correct positions, insertions should be made under direct vision.

• To ensure the proper handling of dilated, easily traumatized, distended, or inflamed bowels, we strongly recommend the use of nontraumatic large instruments instead of smaller or sharp dissectors and graspers, as the latter may injure or tear the bowel [1–3, 5, 6, 9].

• We have provided these general rules from our experience with the laparoscopic approach to SBO in 63 of 136 patients. Our overall success with laparoscopic treatments has been 82.5%, with a diagnostic accuracy of 92%. If we take into consideration only the cases of chronic SBO, the diagnostic accuracy is 100% and the treatment capacity reaches 97.2%. Therefore, in patients with partial and intermittent small bowel obstruction, the causes of SBO are mostly simple bands that can be easily lysed, and the possibility of facing a compromized bowel is almost absent.

Small bowel obstructionLaparoscopic approachF. Agresta,1 A. Piazza,

Surg Endosc (2000) 14: 154–156

• Conclusions• We believe that laparoscopic treatment of small bowel obstructions• is feasible and safe in experienced hands and can• be a preferred alternative to open surgery in selected pa-tients.

Increased surgical experience and improvement of• laparoscopic equipment (instrumentation, optics, video• monitoring, etc.) led us to consider laparoscopy in SBO as• a good and effective alternative to the laparotomic one. It• may offer the advantage of localizing the precise problem• and providing a means of both rapid and less extensive• treatment in almost all cases.

Laparoscopic adhesiolysis for chronicabdominal pain is not indicated

D. Swank*International Congress Series 1279 (2005) 85– 89

• Diagnostic laparoscopy can reveal an incidence of adhesions as high as 95% [1–3].

• The presence of adhesions does not mean that these adhesions cause patients pain.

• Many surgeons performed laparoscopic adhesiolysis for chronic abdominal pain, and reported pain relief, but the successes were accompanied with 5% serious complications, and even 1% mortality [2–6].

• Moreover, adhesions reform after laparoscopic adhesiolysis, although to a lesser extent [7], and probably the success of laparoscopic adhesiolysis must be ascribed to placebo surgery [8].

2. Incidence• About 3–5% of all patients with adhesions will suffer from bowel obstruction,

strangulation, acute or chronic pain or infertility [9]. • Readmissions due to adhesion related disorders occurred in 35% of

patients following open gynaecological surgery, with an average of two readmissions per involved patient [10].

• Five percent of patients will be readmitted in the hospital for adhesion-related disorders during the 10 years following surgery [11].



4. Laparoscopic adhesiolysis• In the pre-laparoscopic era, conventional adhesiolysis for chronic pain was rarely

performed, because of its complications and the high recurrence rate of adhesions. After 1990, the laparoscope became a new tool, and many patients were laparoscopically treated for chronic abdominal pain, their indication mainly based on the drive of many surgeons to use their skills in laparoscopic surgery.

4.1. Laparoscopic adhesiolysis pro• A review of 16 studies, published in the last 10 years, most of them retrospective and

none randomised, reported success rates varying from 46% to 87% (Table 1).4.2. Laparoscopic adhesiolysis contra• Swank et al. [8] selected 100 patients with adhesions and chronic abdominopelvic

pain.After diagnostic laparoscopy, the patients were randomly assigned to either diagnostic laparoscopy (control group) or subsequent laparoscopic adhesiolysis (treatment group).

• After 1 year, treated patients experienced improvement of their pain, had a reduced VAS (pain score) and MOS SF-36 (pain part of quality of life score) score, felt an improved quality of life, and used less pain medication. However, the results of the patients in the control group were not different from those who were treated (Figs. 1 and 2).



5. Complications and its prevention• The incidence of serious complications (vascular lesions and visceral perforations) due to laparoscopic

adhesiolysis varies between 5% and 25% [3,8,17,18]. • Patients with greater age and a higher number of previous laparotomies are more prone to complications [18].• Critical in the procedure is the needle insertion, trocar placement and the adhesiolysis itself. • Bonjer et al. [19] reviewed the risks of Veress introduction and noticed 0.05–0.2%risk of visceral perforation. In

patients having had previous laparotomies insertion of the Veress needle in the left ninth intercostal space seems safer than the sub-umbilical route [17,20].

• Tan et al. [21] recommended ultrasonic mapping before trocar insertion in children. • The risk of visceral perforations was halved if an optic trocar (Optiview, Ethicon, Sommerville, NJ, USA) was used

for access, and an ultrasonic device (Ultracision, Ethicon, Cincinatti, OH) was applied for adhesiolysis [17]. • Almost half of all iatrogenous bowel perforations were not recognised, causing general peritonitis and even death

[18].6. Reformation of adhesions• Second-look procedures after laparoscopic adhesiolysis showed a permanent reduction of those adhesions

connecting organs and the abdominal wall, but not of those between organs themselves [7].• However, Mettler [22] found more often an increased adhesion score than a reduced one in patients at second-

look laparoscopy. • The severity of adhesion formation is influenced by 8.iso prostaglandin F2a, which is increased by elevation of the

intra-abdominal pressure induced by carbon dioxide [23]. • Adhesion reformation is a frequent occurrence after laparoscopic surgery, although de novo adhesions appear to

occur much less frequently than with open surgery [24].



7. Discussion• Ellis [25], the adhesion Godfather, has classified intra-abdominal adhesions as

normal physiology, except for those adhesions causing bowel obstruction. • Many studies published pain relief in patients with chronic pain, but also serious

complications and even death, due to unrecognised bowel perforations. • The risks of iatrogenous bowel perforations can be reduced from 10% to 5% using

blunt optic trocars and ultrasonic dissection, and acceptance of an incomplete adhesiolysis in difficult cases.

• A longer duration of preoperative pain predisposes towards less success.• Adhesions do regrow after lysis, and relapse of chronic pain was described in almost

all studies. • Pain relief is independent of (in)completeness of the adhesiolysis. The only level one

study shows that the outcome of laparoscopic adhesiolysis is not different from control patients who underwent only diagnostic laparoscopy.

• These facts, and noting the morbidity and the mortality, must force a laparoscopic surgeon or gynaecologist to abandon laparoscopic adhesiolysis as a treatment for chronic abdominal pain.

Laparoscopic adhesiolysis for recurrent small bowelobstruction: long-term follow-up

Yoshiaki Sato, MD,Endoscopy 0016-5107/2001/

• Elective laparoscopy was performed with the patient in the supine position under general anesthesia.7-11 The surgeon stood on the left side of the patient. Videomonitors were placed at the head of the table if the previous operation was in the upper abdomen or at the foot if in the lower abdomen.

• The abdomen was punctured away from all scars with a Veres needle, and the syringe test was performed to confirm that the tip of the needle was not located in a vessel or intestines as follows: normal saline solution (5 mL) was injected through the Veres needle. If the saline solution entered the peritoneal cavity, it could not be reaspirated. If the saline solution was reaspirated, it signified that the tip of the Veres needle was in a closed cavity or newly formed space.

• A pneumoperitoneum was established by insufflation of carbon dioxide. The intra-abdominal pressure was monitored. The first trocar was inserted in an area without adhesions as determined by blind exploration with a 23-gauge needle. The remaining trocars were inserted under direct vision in areas devoid of adhesions.

• The pathogenic adhesions were identified and lysed with scissors or forceps. To minimize the risk of intestinal injury, electrosurgical current was not used for dissection.12

• In patients with dense adhesions, especially when there was a convoluted mass of adherent bowel, the operation was converted to a laparotomy.



• Postoperative adhesions are universal after abdominal and pelvic surgery. Menzies and Ellis13 found that in 93% of patients who have undergone a previous laparotomy, intra-abdominal adhesions are found at a subsequent surgery.

• Although adhesions are of little importance in most patients, some may experience clinical consequences such as small bowel obstruction.

• Several investigators have reported that laparoscopic surgery leads to fewer adhesions compared with laparotomy.14,15

• In these studies, the success rate for laparoscopic adhesiolysis for acute small bowel obstruction has ranged from 46% to 87%.2-4,6



• Conversion to laparotomy was performed for intestinal perforation or the presence of dense adhesions, the latter being the most common cause of conversion to laparotomy.2-4

• Adhesions between the small intestines and the abdominal wall were lysed with scissors and forceps close to the abdominal wall.

• Electrosurgical current was used only for hematostatis. • Use of the Veres needle and blind insertion of the first trocar in patients with

an acute small bowel obstruction and bowel distention are associated with an increased risk of bowel injury.2-4

• Although the initial trocar was blindly inserted after the establishment of pneumoperitoneum with a Veres needle, there were no instances of bowel injury. It is our belief that it is safe to use the blind technique if the bowel is adequately decompressed before surgery.

• However, it is important to confirm the position of the needle using the syringe test and to monitor the intra-abdominal pressure during insertion of the first trocar.



• Francois et al.1 reported that 32 of 50 patients (64%) treated by laparoscopic adhesiolysis for small bowel obstruction or chronic abdominal pain were asymptomatic at a mean follow-up of 24 months.

• Strickland et al.3 studied 34 patients who underwent laparoscopic or open laparotomy for acute small bowel obstruction and found one recurrent small bowel obstruction requiring surgery in each group during a mean follow-up of 88 weeks.

• However, there have been no reports of laparoscopic adhesiolysis in which the follow-up period was more than 5 years.

• In the present study, the mean follow-up was 61.7 months. Although 14 patients (87.5%) remained asymptomatic, 2 had recurrent small bowel obstruction develop after laparoscopic adhesiolysis, 1 of whom required surgery.

• Laparoscopic adhesiolysis is safe and effective for the management of recurrent small bowel obstruction.

• This operation is associated with a short hospitalization and a low frequency of recurrence of• obstruction. • Because of the risk of formation of adhesions after conventional laparotomy, it is our belief that

laparoscopic adhesiolysis should be the first choice of operation for recurrent small bowel obstruction.

• However, conversion to laparotomy should be considered when it is difficult or dangerous to separate loops of bowel by using laparoscopic techniques.



1. A, Laparoscopic view of single band adhesion. B,Laparoscopic view of convoluted mass of adherent bowel.

Laparoscopic management of acute small bowel obstructionB. Kirshtein1 , A. Roy-Shapira1, L. Lantsberg1, E. Avinoach1 and S. Mizrahi1

Surgical Endoscopy© Springer-Verlag 2005

• The patient was placed on an electrically controlled table with both arms along the body. One monitor was placed at the caudal end of the table and the second on the patients right side.

• Either the Hasson technique or a Veress needle was used to establish the pneumoperitoneum depending on the individual surgeons preference. In either case, the initial port was placed as far away as possible from previous scars. If a Veress needle was used, it was usually inserted in the left upper quadrant. A periumbilical location was chosen in cases of virgin abdomen.

• Pressures were kept between 10 and 15 mmHg; lower pressures were used with sicker patients. A 45? side-view 10-mm telescope was preferred. After thorough examination of the peritoneal cavity, additional 5- or 10-mm ports were inserted under direct vision. The location of the additional ports depended on the operative findings. As required, the camera was repositioned to enable the viewpoint to be changed for the release of adhesions.

• Using a pair of atraumatic laparoscopic forceps, the surgeon followed the distended loops of bowel, in an attempt to identify the zone of transition from dilated to collapsed loops. This maneuver requires patience and the use of both hands.

• If the zone of transition could not be clearly identified, laparoscopy was aborted and the operation converted to a midline laparotomy.

• Adhesions were usually lysed with scissors; occasionally, bipolar coagulation was used for strands of omentum. We only lysed the band causing the obstruction or adhesions that obstructed the view. No attempt was made to lyse all adhesions present.

• If there were signs of strangulation, we observed the released loop of bowel for 5 min for return of color and peristalsis. When there was doubt about the viability, a second-look laparoscopy was scheduled in 24-36 h.

• Whenever it was necessary to resect a loop of bowel, a small, transverse target incision was made, and the resection and anastomosis were performed outside the abdomen.



• As we have demonstrated in this series, the single band can often be lysed using minimally invasive methods. Multiple dense adhesions, which are difficult to release laparoscopically, are present after pelvic surgery. Due to the reduced posterior view and the small closed pelvic cavity, adhesiolysis by laparoscopy may be difficult and conversion may be necessary.

• A potential problem in operating on patients with adhesions is that the new operation causes even more adhesions. Indeed, every surgeon has encountered patients who have been operated on a number of times for SBO caused by adhesions. Each additional operation is more difficult and more dangerous than the previous one. Laparoscopy is thought to induce fewer postoperative adhesions than laparotomy [7, 16] and therefore appears to be an attractive alternative to laparotomy for the treatment of this type of patient.

• In most cases, the Veress needle was inserted in the left hypochondrium to initiate the pneumoperitoneum. The first trocar was placed as far as possible from the site of the previous operation. Franklin et al. [6] have routinely used this technique without complications. Caprini et al. have used ultrasound mapping of the adhesions as a way of avoiding the complications of Veress needle puncture [4]. Most authors recommend mandatory open insertion of the initial trocar [2, 8, 9, 15] as a means of preventing small bowel injury.

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• One of the problems with emergency laparoscopy for SBO is that it is difficult to find the site of the obstruction in the presence of distended bowel loops. Tilting the operating table and changing the scope port enables visualization from different angles, especially in the pelvis or right lower quadrant. If the transitional point is not found, conversion should be performed for formal bowel exploration.

• Safety has been a primary concern for surgeons performing laparoscopy in cases of acute SBO. Patients with bowel distension associated with obstruction are prone to perforation.

• We recommend beginning the bowel exploration from the collapsed are loops, as described by Bailey et al. [2], as a way of preventing incidental bowel injury.

• The need for enterotomy can be reduced if meticulous care is taken in the use of atraumatic graspers only and if the manipulation of friable, distended bowel is minimized by handling the mesentery whenever possible.

• The ability to work with a different instrument in each hand - a grasper for bowel traction and a pair of scissors for the division of adhesions, or two graspers for bowel exploration - is an important skill for the operating surgeon.

• Maintaining a low threshold for conversion in cases of severe dense, extensive adhesions or when pelvic adhesions are found will further decrease the risk of bowel injury. It is our policy not to persevere in this venture for hours but rather to convert readily to laparotomy.

• In cases of iatrogenic perforation and minor contamination with bowel contents in the presence of minimally dilated loops, laparoscopic closure can be performed.




• We believe that the lysis of all intraabdominal adhesions is unnecessary. • However, it should be done as necessary to create a viable working space and

optimize the view of the operating field. • Release of the stuck band with improvement of the obstruction under direct vision is

sufficient for completion of the operation. • The division of multiple adhesions far from the sites of the obstruction is unnecessary

and dangerous due to the risk of bowel injury and small hemorrhages, which lead to the formation of new bands.

• When pathology other than adhesions is found on laparoscopy, a target incision is needed for the performance of either a bowel resection or an enterotomy.

• We believe that laparoscopic resection for bowel obstruction is feasible, but too expensive. There is a high risk that the peritoneal cavity will be contaminated by bowel content due to the distended loops. Bowel resection via a small target incision is a safe and cheap procedure, however tim-consuming. Specimen removal after laparoscopic resection can be done via the same small incision.

• In sum, we have found laparoscopy to be a safe and effective technique for the management of acute SBO. We strongly recommend its use as the first line of treatment by surgeons with extensive experience in this area.

Laparoscopic management of acute small bowel obstructionExperience from a Saudi teaching hospital

A. A. Al-MulhimSurg Endosc (2000) 14: 157–160

• AbstractBackground: The use of laparoscopy has expanded to include the management

of acute abdomen. This study describes the author’s experience with laparoscopic management of acute small bowel obstruction.

Methods: From February 1994 through March 1998, 19 patients underwent laparoscopic intervention for acute small bowel obstruction. Their clinical data were analyzed to evaluate the outcome.

Results: A total of 19 patients underwent 20 exploratory laparoscopies. The cause of obstruction was diagnosed correctly in 17 of the patients (90%). Fifteen patients (79%) had adhesions, nine of which were postoperative. Of the 19 patients, 13 (68%) had successful laparoscopic treatment. Laparotomy was required in six patients (32%) for various lesions including ileocecal tuberculosis. The average time for laparoscopy was 58 min. The mean postoperative hospital stay was 5 days. There was no morbidity or mortality in this series.

Conclusions: Laparoscopy is a feasible and safe alternative to laparotomy for most patients with acute small bowel obstruction.



• Opinion regarding the blind insertion of the Veress needle and the first trocar in an already distended abdomen remains divided: Franklin et al. [9] have routinely used this technique without complications, whereas Ibrahim et al. [11] had to contend with an iatrogenic perforation even after employing the open peritoneoscopy.

• As yet, there are no clinical or radiologic criteria for deciding on the use of a particular technique because the overall experience in this field is limited.

• One difficulty of emergency laparoscopy for acute SBO is the problem of finding the site of obstruction in the presence of distended bowel.



• What then are the possible safeguards? • We believe that positioning the patient on an electrically

controlled table with arms on the side is crucial because this spares extra space for the surgeon and assistants.

• In case of previous abdominal surgery, the choice of left hypochondrium for Veress needle insertion is preferable because adhesions usually are distant from this area, although alternative sites may be used as indicated.

• The use of 10-mm rather than the 5-mm instruments makes handling the distended bowel safer, and the use of active electrode monitoring to avert thermal injury to the bowel from monopolar electrosurgery may eliminate the risk of perforation [19].

Laparoscopic management of acute small-bowel obstructionI. M. Ibrahim, F. Wolodiger, B. Sussman, M. Kahn, F. Silvestri, A. Sabar

Surg Endosc (1996) 10: 1012–1015

• AbstractBackground:• A retrospective review is given of the authors’ experience with a consecutive series

of acute small-bowel obstruction unresponsive to medical management.Methods: • There were 33 exploratory laparoscopies. The etiology was accurately diagnosed in

100% of the cases. Twenty-five (76%) were secondary to postoperative adhesions, of which 18 (72%) were successfully treated by laparoscopic lysis of adhesions. Minilaparotomy was needed to treat iatrogenic perforation (two), gangrenous bowel (one), and Meckel’s diverticulectomy (one). Formal laparotomy was utilized for small-bowel resection (two), malignant adhesions (two), and intolerance of pneumoperitoneum (one). Four cases of incarcerated hernias were treated by conventional herniorrhaphy.

Results: • Overall, 67% of our cases were spared formal laparotomy.Conclusion:• We conclude that laparoscopy is an excellent diagnostic modality in acute small-

bowel obstruction, the majority of which can be simultaneously managed laparoscopically. Laparotomy should be reserved for malignant adhesions, surgical misadventure, or when the pathology dictates.


Surg Endosc (1996) 10: 1012–1015

• The patient was placed on an electrically controlled operating table, both arms placed by his side, enabling the surgeon to work easily in the upper and lower abdomen.

• A monitor on each side of the table facilitates proper orientation as the procedure shifts from quadrant to quadrant.

• Open peritoneoscopy [12] (open initial trocar insertion) was performed in all cases.• An area on the abdomen free of scars was chosen and the peritoneal cavity was

entered. • Operating trocars were placed under direct vision after the abdomen was insufflated

to 14 mmHg to permit bimanual laparoscopic manipulation of the bowel. • Tilting the operating table in various positions enables the heavy distended bowel to

fall away from the laparoscopic line of vision.• In cases of obstruction secondary to adhesions only the culprit adhesive bands were

lysed. Complete adhesiolysis was felt to be unnecessary.• After the viability of the bowel was assured the procedure was terminated.• All trocar sites greater than 5 mm in size (including the peritoneal layer) were closed

with absorbable sutures.


Surg Endosc (1996) 10: 1012–1015

• Levard et al. [7] reported less than 50% success with laparoscopic techniques.

• Federman et al. [2] treated 26 patients by initial laparoscopy and achieved 62% success in resolving smallbowel ileus secondary to obstruction.

• Franklin et al. [3] reported successful laparoscopic management in 20 of 23 patients with small-bowel obstruction.

• Keating et al. [5] reported five cases treated successfully in the same fashion with early discharge from the hospital.

• Other single-case reports [1, 6, 9, 10] attest to the utility of laparoscopy in management of small-bowel obstruction.


Surg Endosc (1996) 10: 1012–1015

1. Although Franklin et al. [3] used a Veress needle successfully to initiate pneumoperitoneum, we feel that open peritoneoscopy (initial trocar insertion) is mandatory.

• The pattern of intraabdominal adhesions is unpredictable. Blind insertion of a Veress needle or trocar into the abdomen is in our opinion dangerous, especially in the presence of distended bowel.

• Identifying the peritoneum before inserting a trocar is crucial to avoid smallbowel injury. All subsequent trocars should be inserted under direct vision. Obstructed bowel is distended, rigid, and easily traumatized.

2. Bimanual manipulation of the bowel is important. Running the bowel (especially when distended) can be taxing and frustrating. The surgeon must be comfortable.

• Therefore, the patient’s arms are tucked in to give the surgeon and assistant ample room. Furthermore, two movable video monitors should be used so that the surgeon, the scope, and the monitor are in a straight line for optimal intraabdominal manipulation.

• In addition the OR table should have the full range of tilt as extreme positions may be necessary.


Surg Endosc (1996) 10: 1012–1015

3. Edematous and dilated bowel is prone to perforation from small blunt instruments. It should not be grasped by small instruments. Larger 10-mm instruments are preferable.

• Grasping the mesentery in order to manipulate the bowel decreases the likelihood of direct trauma.

4. The site of obstruction may be obscured by dilated loops of small bowel. In addition to tilting the OR table, changing the scope port is crucial at times. This allows visualization from different angles, especially in the pelvis or right lower quadrant.

5. In the virgin abdomen it is not enough to lyse bands, adhesive or otherwise. The cause of adhesions should be sought.

• In one of our cases, not satisfied with simple lysis, we followed the band to its insertion into the small bowel and a Meckel’s diverticulum was discovered.

6. Malignant adhesions are difficult to handle laparoscopically. The transition zone is not clear and the bowel is studded with metastases, dilated and edematous in multiple areas. Therefore, our recommendation is that the presence of malignant adhesions mandates immediate conversion to laparotomy.


Surg Endosc (1996) 10: 1012–1015

• In conclusion, we believe that laparoscopic management of small-bowel obstruction is feasible and safe in experienced hands.

• The open peritoneoscopy technique is, in our opinion, mandatory.

• About two-thirds of postoperative adhesive bands can be successfully lysed.

• Furthermore, incarcerated hernias can be diagnosed with great accuracy.

• One should not hesitate to resort to mini- or formal laparotomy in cases of malignant adhesions, surgical mishap, or whenever the pathology dictates.

Laparoscopic management of mechanical small bowel obstructionAre there predictors of success or failure?

M. Suter, P. Zermatten, N. Halkic, O. Martinet, V. BettschartSurg Endosc (2000) 14: 478–483

• In any case, the first trocar or the Veress needle always was placed in an area without former surgical incision, and very often in the left upper quadrant.

• Additional trocars (5 or 10 mm) then were placed according to intra-abdominal status and location of adhesions, to provide for a good triangulation between the instruments and to allow for an optimal placement of the optic.

• The small bowel was followed proximally starting from the ileocecal junction whenever possible. • Care was taken to manipulate the bowel gently and to avoid holding the bowel itself, but rather to grasp the

mesentery. • If a band was found that clearly was responsible for the obstruction, it was cut with scissors, sometimes after

bipolar coagulation. We did not systematically look for a second band, especially if relief of the obstacle and progression of bowel content could be demonstrated clearly.

• When multiple adhesions were found, they were freed as completely as possible. The small bowel then was examined on its entire length until the operating surgeon was convinced that the obstruction was relieved.

• If the cause of the obstruction could not be demonstrated clearly, or if division of adhesions was deemed too risky, especially when the bowel was very distended, the procedure was converted to laparotomy.

• Conversion was the rule also if accidental bowel perforation occurred with gross peritoneal contamination, in case of bowel necrosis, or if a tumor was found.

• However, small perforations with only minor leakage of intestinal content or seromuscular tears were sutured laparoscopically. The nasogastric tube was left in place at the end of the procedure, and removed according to clinical evolution.

• When the Veress needle was used, the site planned for trocar placement always was checked with needle punctures before the trocar was inserted.

• In these cases, the first trocar always was a so-called “security-trocar” (Surgiport®, USSC), which somehow prevents accidental puncture of intra-abdominal organs once the peritoneum is entered, but does not completely rule out iatrogenic perforation.



• In this study, laparoscopy established the cause of obstruction in 78% of the patients, and treatment was completed

• endoscopically in 57% of the cases. • Of concern in the latter group are four patients in whom signs of peritonitis developed during the

early postoperative period, requiring reoperation (laparotomy) for closure of a small bowel perforati probably of iatrogenic origin.

• Laparoscopy therefore was totally successful, avoiding laparotomy in 43 patients (52%). The patients successfully treated with laparoscopy had a very smooth postoperative recovery as compared with those in whom conversion was necessary, or compared with a group of 59 patients for whom laparotomy was the initial option [28].

• Other groups have shown that laparoscopy can be successful in a significant proportion of patients with SBO.

• Conversion rates as low as 6% to 13% [13, 15] have been reported, sometimes with a significant reoperation rate resulting from incomplete exploration, adhesiolysis, or both [13]. In most studies, however, the conversion rate is higher, between 26% and 54% [1, 3, 5, 18, 21, 22, 23, 29].

• Reasons for conversion are mainly inability to identify the origin of the obstruction (usually in relation to a reduced working space because of intestinal distension), inability to relieve obstruction completely because of special anatomic features or adhesions that are too extensive, accidental bowel perforation, bowel necrosis, or causes not amenable to laparoscopic treatment (tumor, incarcerated hernia).



• For the laparoscopic approach of SBO, proper installation of the patient and the equipment are important. Both arms must be placed along the patient and, ideally, two monitors should be available. In this way, the surgical team can move around the patient according to the operative findings. Tilting of the operating table can be useful for adequate exposure.

• An open technique must be used to create the pneumoperitoneum. The trocars must be placed in relation to previous incisions, and according to the position of the adhesions to be divided.

• Manipulation of the distended bowel with atraumatic forceps must be very cautious and limited.• A small bowel diameter exceeding 4 cm, as seen on the preoperative plain abdominal film,

predicted an increased risk of conversion in this study. This is not surprising, because the working space in the abdominal cavity is considerably reduced as dilation of the intestinal loops increases.

• Additionally, intestinal fragility increases with distension and makes accidental perforation more likely.

• Others consider only patients with moderate intestinal distension as candidates for laparoscopy [6, 8, 12, 20].

• In the current study, 24 patients with a small bowel diameter exceeding 4 cm, including 11 with a diameter exceeding 5 cm, have been successfully treated without conversion.

• On the basis of these results, we still consider laparoscopy in patients with important dilation, but set a lower threshold for conversion.



• Neither the number or type of previous operations nor the location of the previous incisions influenced the location and type of adhesions or the need for conversion.

• Evidence of bowel necrosis obviously could be considered as an indicator for immediate laparotomy.

• The only preoperative predictor of bowel necrosis was a WBC count exceeding 11 × 109 per liter, as was shown by Benoist et al. [6]. In this study, however, 25 patients with an WBC count higher than 11 × 109 per liter were successfully managed through the laparoscope. We therefore do not consider an elevated WBC count as a contraindication to laparoscopy.

• Furthermore, if bowel necrosis is found at laparoscopy, a minilaparotomy incision can be placed properly according to the operative findings.

• Contrarily to the belief of many, neither the number and type of previous operations nor the location of previous abdominal incisions influenced the outcome in this study.

• Iatrogenic perforation represents a significant risk factor for postoperative complications, however, only if it is not recognized, or if conversion is required because of gross abdominal contamination with intestinal content.



• During laparoscopy, intestinal trauma can result from two steps: establishment of the pneumoperitoneum and intraoperative handling of the small bowel.

• In this study, the Veress needle was used in more than half the patients. It was thought to be responsible for an unrecognized perforation in one case. Although some other authors have used the Veress needle without any problem [13, 14, 17], we strongly recommend the open technique for inserting the first trocar and establishing the pneumoperitoneum, as do most authors [3, 18, 20, 22, 23].

• Manipulation of the small bowel, also very dangerous, should be kept to a minimum. Ideally, the first step is to identify the ileocecal junction, and thereafter to run the intestine proximally until the cause of obstruction is found.

• In this way, the nondistended bowel is grasped using atraumatic forceps. Fenestrated forceps or large intestinal Glassman graspers, as advocated by Franklin [14], are the best suited instruments.

• In areas of bowel distension, the mesentery should be grasped rather than the intestinal wall itself. • Single bands or adhesions can be divided using scissors or an ultrasonically activated scalpel. Bipolar

coagulation can be used, but monopolar current should be avoided because of its associated risk of electrical tissue damage, which often is not recognized at the time the lesion occurs.

• If accidental perforation occurs despite all of the preceding precautions, it can be sutured laparoscopically or after conversion [8]. We recommend laparoscopic closure only if contamination with bowel content is minimal, as is the case with small perforations of a not too dilated intestinal loop.

• Any serosal tear should be oversewn.• In the other cases, conversion is probably safer to ensure a tight closure and to allow for complete clearance of

the spilled intestinal fluid.• In any case, if intraoperative manipulation of the small bowel is deemed dangerous because of massive dilation

or reduced space, conversion is indicated to avoid accidental perforation.



• In conclusion, we found that laparoscopy can be successful in managing mechanical SBO in 57% of the patients selected for this approach.

• A preoperative WBC count higher than 11 × 109 per liter predicts intestinal necrosis, and a maximal intestinal diameter exceeding 4 cm on the plain abdominal film is associated with an increased risk of conversion. We do not, however, consider these findings as a contraindication to laparoscopy.

• Accidental bowel perforation during surgery, especially if leading to conversion or not recognized, and conversion by itself are significant risk factors for postoperative morbidity.

• Patients with successful laparoscopic treatment have a lower postoperative morbidity, resume intestinal function and a normal diet earlier, and have a shorter hospital stay than those in whom conversion advanced laparoscopic surgery, laparoscopy is a valuable alternative to conventional surgery in the management of mechanical SBO [3].

• Laparotomy can be avoided in a significant number of cases; duration of hospital stay can be shortened; and costs, although not analyzed in the current study, are probably lowered.

• Conversion is not to be regarded as a failure, but as a useful adjunct for avoiding complications in selected cases.

Laparoscopic Management of Small BowelObstruction: Indications and Outcome

Enrique Luque-de Ledn, M.D., Altjandro Metzger, M.D., Gregory G. Tsotos, M.D.,J GASTROINTEST SURG 1998;2:132-140.)

• Patients were placed in the supine position with abducted arms and supports mounted to allow safe tilting and lateral rotation of the operating table.

• Two video monitors were used; the video monitor to the patient’s right was positioned inferiorly at the level of the hip and the monitor to the left positioned superiorly at the level of the shoulder (Fig. 2).

• This positioning forms a plane parallel to the root of the small bowel mesentery and allows the operating surgeon to look and work in the same direction as the camera orientation.

• The configuration of the operating room arrangement was flexible to permit modifications during the operation.

• Patients were prepared and draped in a way that allowed conversion to an open procedure when necessary.

• All interventions were performed under general endotracheal anesthesia with a nasogastric tube and urinary catheter in place.

• Because nitrous oxide as an anesthetic gas has been found to produce bowel dilatation, its use was specifically avoided in most patients.



• A pneumoperitoneum (15 cm HzO) was established using an open technique with a modified Hasson-type4 balloon cannula (Origin Medsystems Inc., Menlo Park, Calif.) inserted via a 1.5 cm periumbilical vertical incision. A 30-degree angled-view laparoscope was used, and twoadditional 5 mm trocars, introduced under direct vision, were usually placed in the right upper and left lower quadrants (see Fig. 2). A fourth or rarely a fifth trocar was required to allow better retraction, improve visualization, or facilitate intraperitoneal adhesiolysis

• in a few cases. Adhesions to the anterior abdominal wall were dissected using scissors, electrocautery hook, or blunt avulsion and the operation proceeded until complete visualization of the small bowel could be obtained.

• Evaluation of the entire jejunoileum was attempted in a systematic fashion starting at the ileocecal junction, looking at the right (lower) monitor, with the patient in a Trendelenburg position. The bowel was carefully inspected and systematically “run” in a retrograde fashion with a “hand-to-hand” technique, which involved grasping the bowel by its antimesenteric border alternately between two large, atraumatic graspers. Extreme care was necessary while “running” the acutely obstructed bowel because traumatic iatrogenie enterotomies can occur (see below).

• Inspection was facilitated by tilting and rotating the operating table. As the proximal jejunum was approached, the patient was placed in a reverse Trendelenburg position, and visualization shifted to the left-sided (upper) monitor.

• We considered this systematic exploration of the entire jejtmoileum an essential part of the procedure such that when complete inspection of the small bowel was not feasible, conversion to an open procedure was strongly considered.

• Use of a 5 mm laparoscope placed through one of the lateral 5 mm trocars was often necessary to obtain a better view of certain regions.

• When adhesions or obstructing bands were encountered, they were usually lysed with scissors, thereby avoiding potential thermal injury to adjacent bowel.



• As with the open operative approach for SBO, when a point of obstruction was not clearly identified, lysis continued until all suspicious adhesions or bands responsible for the symptomatology were dissected.

• Similarly, we evaluated the entire jejunoileum, even if a convincing obstruction was found in the ileum.

• Abnormalities requiring bowel resection or stricturoplasty prompted performance of laparoscopicassisted procedures. These were carried out by removing the 10 mm laparoscope and placing a 5 mm laparoscope in another port. The abnormal bowel was then grabbed with a Babcock clamp placed through the 10 mm periumbilical port and pulled through the umbilical incision; the incision was enlarged just enough (usually 2 to 3 cm) to allow exteriorization and extracorporeal repair of the bowel (Fig. 3).

• The bowel was then returned to the abdominal cavity, the fascial defect closed or occluded with the balloon trocar, and the pneumoperitoneum reestablished so that a final inspection could be performed. In patients in whom conversion to laparotomy was deemed necessary, a midline incision was usually performed.



• Because of dilated and fragile thin-walled bowel, the risk of traumatic iatrogenic enterotomies is increased during both trocar insertion and bowel manipulation.

• For these reasons and because of fear of intraperitoneal adhesions fixing segments of bowel to the undersurface of the abdominal wall, we strongly believe that access into the peritoneal cavity to establish the pneumoperitoneum should be obtained by an open, Hasson-type approach.4 We prefer a vertical periumbilical incision because this location is optimal both for intraperitoneal inspection during evaluation of the bowel and for potential laparoscopic-assiste exteriorization of bowel for extracorporeal resection, lysis of difficult adhesions between bowel loops, or stricturoplasty. In addition, if conversion to open celiotomy is necessary, a midline extension of the original periumbilical incision generally provides the best operative exposure. If appropriate access cannot be obtained because of adhesions from a previous midline incision, one can attempt to gain access laterally, but again an open approach with full visualization seems prudent.



• Overzealous retraction of thin-walled small bowel fixed intraperitoneally during manipulation may also lead to iatrogenic enterotomies as occurred in three of our patients. The incidence of iatrogenic enterotomies in other reported series has ranged from 3 % to 2 1% .10J2J5,17,18,20

• Nontraumatic bowel clamps rather than the “dissecting” graspers commonly used during laparoscopic cholecystectomy are suggested.

• In addition, when “running” the bowel between the two manipulating bowel clamps, both clamps should remain in view at all times. When one clamp leaves the visual field, it is difficult to appreciate the amount of traction being applied; also, if an enterotomy should occur, it may not be appreciated. One of our patients was readmitted several weeks postoperatively with an intraperitoneal abscess. He had undergone an extensive laparoscopic adhesiolysis, and presumably a small enterotomy was made that we did not recognize.

• Repair of an iatrogenic enterotomy does not necessarily require conversion to open celiotomy and can be accomplished either by intracorporeal suturing’* or by extracorporeal repair by exteriorizing the involved bowel.



• Indications for a Minimal Access Approach• Our experience suggests that an attempt at laparoscopic management seems appropriate in

patients with acute SBO provided they are not markedly distended, which would compromise safe insertion of trocars, jeopardize establishment of a pneumoperitoneum, and limit work space. Other even more ideal candidates include patients with a nonresolving, partial SBO or a recurrent, chronic SBO demonstrated on contrast study. In addition, patients with a history strongly suggestive of recurrent, intermittent SBO or those in whom functional “pseudo-obstruction” is suspected but in whom a mechanical obstruction cannot be excluded also appear to be appropriate candidates, and a minimal access approach may obviate the need for a formal celiotomy with manual evaluation and exploration. Contraindications to this approach include a documented history of severe or extensive dense adhesions, a frozen abdomen, or obviously necrotic, obstructed bowel.

• CONCLUSION• A minimal access approach certainly appears to be appropriate for selected patients with

radiologically documented or suspected SBO and may prevent the need for a formal open celiotomy in up to 65 % of patients

• in our experience. Management of the site of obstruction may be amenable to a fully laparoscopic adhesiolysis or to a laparoscopic-assisted bowel resection, stricturoplasty, or adhesiolysis depending on the bowel abnormality and laparoscopic expertise of the surgeon in performing complex intracorporeal suturing.

• This minimal access approach appears to minimize the length of the incision (and thus postoperative pain and disability), shorten the hospital stay, and speed convalescence. Long-term relief of SBO has been excellent.

Tips & Tricks in Laparoscopic Adhesiolysis

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