laparoscopic adhesiolysis

Laparoscopic adhesiolysis

Intraabdominal and PostoperativePeritoneal Adhesions

Harold Ellis, CBE, FACS (Hon), FRCS2005 by the American College of Surgeons

• Up to the 1930s, strangulated hernias accounted for the majority of small bowel obstructions.

• In more modern times, as elective repair of hernias becomes standard treatment, and abdominal surgery so common, adhesive obstruction accounts for about three-quarters of all cases of small bowel occlusion.

• Interestingly, in the Third World, where abdominal surgery is fairly uncommon and patients usually do not report their groin hernias until they strangulate, the situation is reversed; strangulated hernias are common, and adhesive obstruction is rare.

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

Laparoscopic compared with conventional treatment of acuteadhesive small bowel obstruction

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

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

Laparoscopic adhesiolysis for chronicabdominal pain is not indicated

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

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

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

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

Tips &Tricks in Laparoscopic Adhesiolysis



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).



• 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.



• 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

• Perforated or gangrenous bowel is best managed with conversion to either a minilaparotomy or a formal laparotomy.



• 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.



• 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.



• 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

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.

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 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.



• 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.



• 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.



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. • 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.

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 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.



• 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.



• 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.

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.

http://80-springerlink.metapress.com.newproxy.downstate.edu/media/4NC6A0BNWQ4JPHD2DR2P/Contributions/Q/2/2/G/Q22GQGEMWJRWLW95_html/fulltext.html#CR7%23CR7










• 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.


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

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

• 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

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.

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

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.

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.

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

• 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.

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.

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

Surg Endosc (2004) 18: 686–690

• 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.

Laparoscopic adhesiolysis for chronicabdominal pain is not indicated

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

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].

laparoscopic adhesiolysis

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