Feasibility and convenience of laparoscopic adhesiolysis
Basic technical needs for performing laparoscopic adhesiolysis are good surgical skills, the open laparoscopy approach [
15‐
20] and the possibility to move the operating table in different positions in order to point out the adherences [
4,
21,
47‐
51]. In this review the evaluation of feasibility of laparoscopic adhesiolysis was made considering and analyzing the frequency of two major events, the laparotomic conversions and the relapse of small bowel obstruction.
The frequency of laparotomic conversions is variable ranging from 0 to 52% (Table
1) [
6,
15‐
44], depending on patient selection and surgical skill [
45]. In order to reduce the number of conversions some surgeons perform a hand-assisted laparoscopy in some selected cases [
22,
23,
52]. The first cause of laparotomic conversion is a difficult exposition and treatment of band adhesions (Table
2) [
15,
16,
18‐
22,
24‐
27,
29,
38,
39,
41,
42]; this is due to a reduced operating field caused by small bowel dilatation [
24,
46], multiple band adhesions [
22], and occasionally by the presence of posterior peritoneal band adhesions [
13], which are more difficult to treat laparoscopically.
Table 2
Causes of laparotomic conversions.
| 13 | 69,23% | 15,38% | 23% |
| 11 | 27,2% | 9% | 18,1% |
| 15 | 33,4% | 20% | 0 |
| 27 | 37% | 37% | 25,9% |
| 11 | 72,6% | 9% | 36.3% |
| 17 | 52,9% | 35,3% | 11,8% |
| 11 | 72,7% | 0 | 27,3% |
| 10 | 80% | 10% | 10% |
| 12 | 58,3% | 8,4% | 33,3% |
| 9 | 66,6% | 0 | 33,3% |
| 7 | 85,7% | 0 | 14,3% |
| 10 | 50% | 40% | 0 |
| 4 | 100% | 0 | 0 |
| 14 | 28,57% | 28,57% | 14,28% |
| 6 | 66,7% | 16,7% | 0 |
In some cases it is necessary to use one or two additional 5 mm trocars to manipulate the bowel and point out the band adhesions. If these adhesions are not visible, a laparotomic conversion is necessary. Sometimes, the main band adhesion causing obstruction is not pointed out, and only those band adhesions which are easier to remove get resected. In this case the obstruction persists, and the patient will need a laparotomy for treating the incomplete laparoscopic adhesiolysis [
46]. Tsumura [
13] classified the different location of obstructive band adhesions and estimated their frequency: anterior visceroparietal adhesions (between anterior abdominal wall and small bowel) (40%), anterior visceroparietal adhesions associated to viscerovisceral adhesions (small bowel) (32%), viscerovisceral adhesions (small bowel) (16%), posterior visceroparietal adhesions (between posterior peritoneum and small bowel) (8%), anterior and posterior visceroparietal adhesions associated to viscerovisceral adhesions (4%). The incidence of laparotomic conversions is major in patients with anterior peritoneal band adhesions (anterior visceroparietal adhesions, anterior visceroparietal adhesions associated to viscerovisceral adhesions and viscerovisceral adhesions) compared to patients with posterior band adhesions (posterior visceroparietal adhesions, anterior and posterior visceroparietal adhesions associated to viscerovisceral adhesions) (50% vs 22.7%).
Other main causes for laparotomic conversion are the presence of bowel necrosis, which always needs a resection imperatively performed laparotomically [
46,
53], and accidental enterotomies.
The frequency of accidental enterotomies is variable (Table
2) [
15,
16,
18‐
22,
24‐
27,
29,
38,
39,
41,
42], being more frequent in patients who have a history of previous multiple laparotomies [
3,
19]. Most of the accidental enterotomies occur while performing adhesiolysis. The other less common mechanism of injury is the Verres needle insertion, reported in the Levard's [
25], Parent's [
26] and Chèvre's [
27] series. It is often necessary to perform a laparotomic conversion in order to suture or to perform a resection and anastomosis of the perforated bowel. The suture performed through open access gives more chances of endurance and safety, especially when done on a dilated and fragile obstructed bowel [
54]. When the accidental enterotomy is not pointed out at operating time, it can show up in postoperative course as a peritonitis that increases morbidity and mortality. Unrecognized accidental enterotomies, discovered by the onset of postoperative peritonitis, are an increasingly frequent cause of malpractice claims [
55].
Defensive medicine has delineated many practical strategies in order to avoid accidental enterotomies during laparoscopic adhesiolysis: accurate patient selection excluding patients with history of multiple abdominal surgical procedures and taking early indication for surgical treatment, and particular attention to surgical techniques [
56] always staying close to parietal peritoneum during dissection, not sectioning tenacious band adhesions and always controlling the direction of the instruments. Borzellino routinely performs a preoperatory ultrasonographic mapping of visceroparietal adhesions, in order to avoid lesions resulting from Veress' needle insertion [
24].
In the tables
3 and
4 we report the predictive factors for successful laparoscopic adhesiolysis and the absolute and relative contraindications to laparoscopic adhesiolysis, which allow performing an accurate selection of patients with small bowel occlusion.
Table 3
Predictive factors for successful laparoscopic adhesiolysis.
• Non-median previous laparotomy [ 9, 45, 46] |
• Appendectomy as previous surgical treatment causing adherences [ 11, 17, 28, 46] |
• Unique band adhesion as pathogenetic mechanism of small bowel obstruction [ 8, 46, 57] |
• Early laparoscopic management within 24 hours from the onset of symptoms) [ 8, 11, 28, 46, 57] |
• No signs of peritonitis on physical examination [ 24, 46, 49] |
• Experience of the surgeon [ 46, 49, 58] |
Table 4
Absolute and relative contraindications to laparoscopic adhesiolysis.
• Abdominal film showing a remarkable dilatation (> 4 cm) of small bowel [ 3, 10, 11, 24, 28, 49, 58] | • Number of previous laparotomies > 2 [ 3, 11, 18, 27, 46] |
• Signs of peritonitis on physical examination [ 3, 18, 58] | • Multiple adherences [ 3, 18] |
• Severe comorbidities: cardiovascular, respiratory and hemostatic disease [ 3, 18, 58] | |
• Hemodynamic instability [ 58] | |
Since the number of laparotomies is correlated to the grade of adherential syndrome, a number of previous laparotomies ≤ 2 [
8,
9,
46,
57] is considered a predictive successful factor. As well, a non-median previous laparotomy [
9,
45,
46] (McBurney incision), appendectomy as previous surgical treatment causing adherences [
11,
17,
28,
46], and a unique band adhesion as pathogenetic mechanism of small bowel obstruction [
8,
46,
57] are predictive successful factors. On the other hand a number of previous laparotomies > 2 [
3,
11,
18,
27,
46], and the presence of multiple adherences [
3,
18] can be considered relative contraindications. Furthermore since the presence of ischemic or necrotic bowel is an indication to perform a laparotomy, the absence of signs of peritonitis on physical examination [
24,
46,
49] is another predictive successful factor, as it is very uncommon to find out an intestinal ischemia or necrosis without signs on clinical examination. Whereas their presence [
3,
18,
58] is an absolute contraindication to laparoscopy because in case of peritonitis an intestinal resection and anastomosis could be needed and safely performed through open access. Another predictive factor is the early laparoscopic management within 24 hours from the onset of symptoms [
8,
11,
28,
46,
57], before the small bowel dilatation reduces the laparoscopic operating field. For this reason an abdominal film showing a remarkable dilatation (> 4 cm) of small bowel [
3,
10,
11,
24,
28,
49,
58] is an absolute contraindication. Other absolute contraindications are severe comorbidities, as cardiovascular, respiratory and hemostatic disease [
3,
18,
58], and the hemodynamic instability [
58], because they do not allow a safe pneumoperitoneum and need a brief surgical time. Obviously the experience of the surgeon [
46,
49,
58] also influences the outcome of the laparoscopic adhesiolysis.
Laparotomic conversion is often related to a higher morbidity rate, for this reason it is necessary to evaluate a primary laparotomic access in those cases without predictive factors for successful adhesiolysis.
To shorten the operating time and reduce the laparotomic conversion rate, some surgeons suggest performing, when possible, a mini-laparotomy near the occlusion site detected laparoscopically [
15,
16,
22,
59]. Tsumura states that conversion through a mini-laparotomy still allows a mini-invasive access, with a shorter hospital stay (4.5 days in laparoscopically treated patients compared to 6.9 days in patients with a mini-laparotomic access, or 14 days in a patient treated by a classical laparotomic approach) [
13,
59]. As well Wexner considers more advantageous the video-assisted approach than laparotomic access. Although these advantages are more evident with the laparoscopic access rather than with the video-assisted approach: shorter operative time (75 min. laparoscopic treatment vs 98 min laparoscopy-assisted approach), postoperative hospital stay (4 vs 6,5 days), first bowel movement (3 vs 4 days) [
29].
It is almost impossible to predict in the preoperatory phase if the obstruction is caused by a single band adhesion or by multiple adhesions [
5]; some surgeons and radiologists state that a CT scan can help to determine the cases in which it is likely to be a large adhesion site blocking the bowel or causing intestinal necrosis [
60,
61], and which should be managed laparotomically.
The analysis of the convenience of laparoscopic adhesiolysis in small bowel obstructions was evaluated by using the following parameters: surgical operating time, hospital stay, morbidity, mortality and the bowel obstruction recurrence rate (Table
5) [
19,
29].
Table 5
Comparison between laparoscopic and laparotomic management of small bowel obstructions.
Surgical operating time
| 103 min | 78 min | 84 min | 70 min |
Hospital stay (postoperative) | 11,3 days | 5 days | 18,1 days | 9 days |
First bowel movement
| ** | 3 days | ** | 6 days |
Oral re-intake
| 5,1 days | | 6,4 days | |
Morbidity
| 19% | 16% | 40,4% | 45% |
Bowel obstruction recurrence
| 0–14,2% | | 0–4,6% | |
The surgical operating time is greater in patients who underwent laparoscopic surgery compared to patients who underwent a laparotomy [
19,
29]. However the duration of laparoscopic procedure is variable ranging from 20 minutes for a simple band adhesion to 2–3 hours for more complex cases [
62,
63].
The hospital stay is shorter compared to a laparotomic approach [
3,
11,
19,
29,
30], with an early flatus and early realimentation [
19,
29]. This is due to a short period of ileum paralysis following the laparoscopic adhesiolysis compared to the laparotomic procedure.
The postoperative morbidity is lower in patients who underwent laparoscopic adhesiolysis compared to those who underwent the laparotomic approach [
19,
29]. Furthermore a greater rate of morbidity is present in patients who underwent laparotomic conversion [
19,
29]; whereas mortality is comparable in the two groups (0–4%) [
19,
29].
Finally the laparoscopic adhesiolysis can avoid laparotomy, which is itself a cause of new adhesions and bowel obstruction [
5,
8,
25,
45,
46], although some authors noticed a greater incidence of recurrent small bowel obstructions in patients who underwent laparoscopy compared to those in which a laparotomy was performed [
3,
30,
52,
62]. Duron attributes these contrasting results to the selection bias of the populations examined in different studies [
31,
57].