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Laparoscopic Management of Intra-abdominal Adhesions

Peritoneal adhesion is a common cause of bowel obstruction, pelvic pain and infertility. Proper technique of adhesiolysis is important and operating surgeons should have clear concept of mechanism of adhesion formation. Normal fibrinolytic activity prevents fibrinous attachments for 72 to 96 hours after surgery and mesothelial repair occurs within 5 days of trauma. Within these 5 days a single cell layer of new peritoneum covers the injured raw area, replacing fibrinous exudates. However, if fibrinous activity of the peritoneum is suppressed, fibroblast will migrate, proliferate and form fibrous adhesion. Collagen is deposited and neovasular formation starts.

The most important factors which suppress fibrinolytic activity and promote adhesion formation are:

•  Port wound just above the target of dissection
•   Tissue Ischemia
•   Drying of serosal surfaces
•   Excessive suturing Omental Patches
•   Traction of peritoneum
•   Blood clots, stones or dead tissue retained inside
•   Prolonged operation
•   Visceral injury
•   Infection
•   Delayed postoperative mobilization of patient
•   Postoperative pain due to inadequate analgesia.

Contraindications

•  Hemodynamic instability
•  Uncorrected coagulopathy
•  Severe cardiopulmonary disease
•  Abdominal wall infection
•  Multiple previous upper abdominal procedures
•  Late pregnancy

Patient Position

The anaesthetized patient is placed on the operating table with the legs straight or lithotomy position if female. The lithotomy position will allow the gynaecologists and assistant to work simultaneously and uterine manipulation would be possible. The thighs must not be flexed onto the abdominal wall as they would be in the full lithotomy position used for other open surgical gynecological procedures. The operating table is tilted head up or down by approximately 15 degree depending on the main area of examination. Compression bandage may be used on leg during the operation to prevent thromboembolism especially if patient is in lithotomy position.

Position of the Surgical Team

Before starting diagnostic laparoscopy a best guess is made about the quadrant in which adhesion is more likely to be found. The surgeon should stand opposite to this quadrant to allow direct view into this quadrant. If the pathology is more likely in pelvic cavity the surgeon stands on left side of the patient. The first assistant, whose main task is to position the video camera, is also on the patient’s left side. The instrument trolley is placed on the patient’s left, allowing the scrub nurse to assist with placing the appropriate instruments in the operating ports. Television monitors are positioned on either side of the top end of the operating table at a suitable height for surgeon, anesthetists, as well as assistant to see the procedure.