Adhesions are bands of scar tissue which are formed between different organs. In the abdomen, they form after an abdominal surgery or after a stint of intra-abdominal infection (i.e. pelvic inflammatory disease, diverticulitis). More than 95% of patients who undergo abdominal surgery develop adhesions these are almost inevitably part of the body's healing process.
Although most adhesions are not associated, some can cause bowel obstructions, infertility and chronic pain. In a study that reviewed over 20,000 patients who underwent previous open abdominal surgery, 15% presented with a bowel obstruction in 2 years, with 5% of these patients requiring adhesiolysis to relieve the bowel obstruction. Postoperative adhesions account for 75% of cases of small-bowel obstruction.
Laparotomy with open adhesiolysis has been the treatment of choice for acute complete bowel obstructions. Patients, who have partial obstructions, with some enteric contents negotiating the obstruction, may also require surgery if non-operative measures fail. However, operation may lead to the formation of new intra-abdominal adhesions in 10-30% of patients, which may necessitate another laparotomy for recurrent bowel obstruction in the future.
Laparoscopic adhesiolysis was first described by a gynecologist for the treatment of chronic pelvic pain and infertility. In the initial days of laparoscopy, the abdominal surgery which was performed earlier is in a relative contraindication with performing most laparoscopic procedures. Laparoscopic surgery to provide relief from bowel obstructions was not routinely performed.
Since then, many case series have documented this technique. The number of adhesiolysis to be performed laparoscopically with good results is due to the available advanced technologies with high-definition imaging, smaller cameras, and better instrumentation.
Compared with the open approach to adhesiolysis, the laparoscopic approach offers the following:
- Less post-operative pain
- Decreased incidence of ventral hernia
- Reduced recovery time with earlier return of bowel function
- Shorter hospital stay
In 2012, a European agreement seminar made a medical guideline for laparoscopic adhesiolysis, which includes advice for diagnostic assessment, operative timing, patient selection, conversion criteria, equipment, adjunctive agents and other concerns.
Patient selection is important in the success of the procedure. Laparoscopic adhesiolysis has tremendous potential advantages, but these advantages are realized only if the procedure is performed in patients best suited for it.
Laparoscopic adhesiolysis is indicated in the following patients:
- Patients with a complete small-bowel obstruction or partial small-bowel obstruction not resolving with non-operative therapy, but without signs of peritonitis or bowel perforation or ischemia
- Patients with resolved bowel obstruction but with a history of recurrent, chronic small-bowel obstruction demonstrated by a contrast study
Controversy exists regarding whether patients with chronic pelvic pain benefit from laparoscopic adhesiolysis or whether any seeming benefit is an effect.
Laparoscopic adhesiolysis is appropriate only for selected patients. Contraindications include the following:
- Acute perforation and peritonitis, necessitating bowel resection and handling of severely inflamed organs
- Massive abdominal distention that precludes insufflation and a sufficient working space during laparoscopy.
- Hemodynamic instability
- Patients who are unable to tolerate pneumoperitoneum because of severe co-morbid conditions of the heart and lung
- Surgeons who are not trained to perform this procedure
An analysis comparing laparoscopic adhesiolysis versus open adhesiolysis in patients with small-bowel obstruction showed that laparoscopic adhesiolysis was associated with a reduced rate of overall complications. There were no significant differences between the two groups with respect to the rate of intra-operative bowel injury, the incidence of wound infection, or mortality.
Laparoscopic surgery also has been shown to decrease the incidence, extent, and severity of intra-abdominal adhesions as compared with open surgery, thereby potentially reducing the rate of recurrent adhesive small bowel obstruction.
In a study comparing, laparotomy with laparoscopy in 9600 patients with small-bowel obstruction requiring adhesiolysis, it was found that the patients in the laparoscopic adhesiolysis group had lower rates of major complications and incisional complications than those in the open group, as well as reduced mortality (1.3% Vs 4.7%).
In a non randomized follow-up of 70 patients over 15 years, it was concluded that adhesiolysis had a long-term positive effect, but although patients experienced pain relief they still had other abdominal symptoms.