Surgical management
What is the surgical management of adhesions?
No longer can the public ignore the benefits of minimally invasive surgery for adhesions.
While these techniques and procedures are not without risk, patients should not be denied the procedures' inherent advantages.
Patients with symptomatic adhesions usually want minimally invasive therapy.
While the advantages of laparoscopic enterolysis compared with classical laparotomy has not been proven in studies, it is obviously possible with laparoscopy to diminish peritoneal mesothelial cell ischemic damage from trauma, drying, talc, packs and delayed bleeding.
Laparoscopic surgery is distinctly advantageous as the preferred method of access for infertility surgery due to the decreased risk of de novo adhesion formation. Similar surgical outcomes when compared to laparotomy have been demonstrated in the management of endometriosis and extensive adhesions.
The surgical advantages of laparoscopy include panoramic pelvic visualization and magnification, techniques similar to microsurgery, documentation of absolute hemostasis via underwater examination.
Finally, the patient enjoys simultaneous diagnosis and treatment and all the advantages of minimally invasive surgery in terms of cosmetics and rapid recuperation.
Laparascopic Adhesiolysis
Although laparoscopic adhesiolysis can be very time-consuming (2 to 4 hours), and for the surgeon technically difficult, many women are discharged on the same day of the procedure, avoid major abdominal incisions, experience minimal complications and return to full activity within one week of the procedure.
The extent, thickness and vascularity of adhesions varies widely.
Intricate adhesive patterns exist with fusion to parietal peritoneum and/or various meshes.
Peritoneal adhesiolysis is classified into enterolysis, which includes omentolysis and female reproductive reconstruction (salpingo-ovariolysis and cul-de-sac dissection with excision of deep fibrotic endometriosis).
Bowel adhesions are divided into:
* Upper Abdominal
* Lower Abdominal
* Pelvic
* Combinations of the Above
Adhesions surrounding the umbilicus are upper abdominal as they require an upper abdominal laparoscopic view for division.
In cases of pelvic adhesions, either the tube is stuck to the ovary or the ovary is adhered to the pelvic sidewall. The rectosigmoid (the rectum and sigmoid colon) may cover both. Rarely, the omentum (a fold of peritoneum extending from the stomach to adjacent organs in the abdominal cavity) and small bowel are involved.
Pelvic adhesiolysis
One of the indicator of the degree of severity and expertise necessary for adhesiolysis is the number of previous laparotomies.
The frequency of small bowel obstruction symptoms also indicates the need for surgery.
SURGICAL PLAN FOR ADHESIOLYSIS
A well defined strategy is important for adhesiolysis.
In general, cases are divided into three parts:
1.) Division of all adhesions to the anterior abdominal wall parietal peritoneum. Small bowel loops encountered during this process are separated using their anterior attachment for countertraction instead of waiting until the last portion of the procedure (running of the bowel).
2.) Division of all small bowel and omental adhesions in the pelvis. The rectosigmoid, cecum and appendix often require some separation during this part of the procedure.
3.) Running of the bowel. Using atraumatic grasping forceps and (usually) a suction irrigator for suction traction, the bowel is run.
4.) Tubo-ovarian pathology is then treated if indicated.
With minimally invasive surgical approaches, same-day discharge is common, even after long procedures.
Physical motility of the bowel is encouraged by early ambulation and a clear liquid diet for 2 to 4 days.
Patients are instructed to return gradually to their normal activity during the week after surgery.
Partial small-bowel obstruction during the week after surgery is usually due to ileus and is treated by intravenous hydration and a nasogastric tube if vomiting is present.
If peritonitis occurs in the days after the operation, it must be assumed that an injury to the bowel has gone unnoticed and should be aptly treated.
If an abscess forms postoperatively it can be drained percutaneously under sonographic guidance, or possibly by means of a laparoscopy.
Recurrent adhesions may occur even with atraumatic techniques
