Adhesions are bands of scar tissue that form in between organs. In the abdomen, they form after abdominal surgery or after a bout of intra-abdominal infection, such as pelvic inflammatory disease or diverticulitis). More than 95 percent of patients who undergo abdominal surgery develop adhesions; these are almost inevitably part of the body’s healing process.
Although most adhesions are asymptomatic, some can cause bowel obstructions, infertility, and chronic pain. In a study that reviewed over 18,912 patients who underwent previous open abdominal surgery, 14.3 percent presented with a bowel obstruction. Postoperative adhesions account for 74 percent 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 traversing the obstruction, may also require surgery if non-operative measures fail. However, the operation often leads to the formation of new intra-abdominal adhesions in 10-30 percent 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 early days of laparoscopy, previous abdominal surgery was a relative contraindication to performing most laparoscopic procedures. Laparoscopic surgery to relieve bowel obstructions was not routinely performed. However, in 1991, Bastug et al reported the successful use of laparoscopic adhesiolysis for small bowel obstruction in one patient with a single adhesive band.
Since then, many case series have documented this technique. Advanced technology with high-definition imaging, smaller cameras, and better instrumentation have allowed for an increasing number of adhesiolysis to be performed laparoscopically with good outcomes.
Compared with the open approach to adhesiolysis, the laparoscopic approach offers less postoperative pain, decreased incidence of ventral hernia, reduced recovery time with earlier return of bowel function, and a shorter hospital stay.
While laparoscopic adhesiolysis certainly has many advantages, it needs to be done on the right candidates to ensure its success. Patients with a complete small-bowel obstruction or partial small-bowel obstruction that is not resolving with non-operative therapy, but also without signs of peritonitis or bowel perforation or ischemia are best suited for laparoscopic adhesiolysis. Also, patients with resolved bowel obstruction, but with a history of recurrent, chronic small-bowel obstruction that is demonstrated by a contrast study, are also good candidates for the procedure.
Of course, there is controversy surrounding whether or not patients with chronic pelvic pain will reap the benefits of this procedure, or if these benefits are a placebo effect. Regardless of any controversy, patients with chronic pelvic pain should be considered for this procedure, especially if no other etiology of pain can be found in previous workup.
Laparoscopic adhesiolysis should only be considered for selected patients, and there are several contraindications that will keep doctors from suggested this procedure. Acute perforation and peritonitis, necessitating bowel resection and handling of severely inflamed organs, would prevent an otherwise acceptable candidate from receiving laparoscopic adhesiolysis. Similarly, those who suffer from massive abdominal distention that precludes insufflation and a sufficient working space during laparoscopy would be rejected, as well as people with hemodynamic instability and are unable to tolerate pneumoperitoneum because of severe comorbid conditions of the heart and lung would be as well.
Laparoscopic adhesiolysis has been proven to result in a reduced rate of overall complications, prolonged ileus, and pulmonary complications in meta-analyses against open adhesiolysis, making it the more successful procedure. However, there were no significant differences between the two groups with respect to the rate of intraoperative bowel injury, the incidence of wound infection, or mortality.
What’s great about this procedure is that it has proven to cause a decrease in the incidence, extent, and severity of intra-abdominal adhesions as compared with open surgery. As a result, the rate of recurrent adhesive small bowel obstruction is potentially reduced.
A recent study was held comparing 9619 patients that were divided into two groups: laparoscopic patients versus laparotomy patients. In comparing the two groups, both of which with a small-bowel obstruction that required adhesiolysis, it was found that at the 30-day mark, those in the laparoscopic adhesiolysis group had lower rates of major complications and incisional complications than those in the open group, in addition to reduced mortality.
Laparoscopic adhesiolysis is a procedure mastered by Doctors Miklos and Moore. You can rest assured knowing that the doctors understand the pain and frustration that adhesions can cause. If you are suffering and looking for relief, contact Doctor Miklos and Doctor Moore today!