by which I base a
“HIGH QUALITY ADHESIOLYSIS”
Because I know this surgeon cares about his patients, and those who
strive to do the highest quality adhesiolysis that can offer the best chances
of improvements for those afflicted with “Adhesion Related Disorder,” can
be respected enough to be mentioned in this web site!
Nothing but the best surgeons found
LAPAROSCOPIC SURGERY FOR ADHESIOLYSIS
Harry Reich, M.D., F.A.C.O.G., FACS1
occur after almost every abdominal surgery and are the leading cause of
intestinal obstruction. In one study, 93% of patients who had undergone
at least one previous abdominal operation had postsurgical adhesions.
This was not considered surprising, given the extreme delicacy of the peritoneum
and the fact that apposition of two injured surfaces nearly always results
in adhesion formation.1
Is an Attending Physician, Wyoming Valley Health Care System, Wilkes-Barre,
Community Medical Center, Scranton, PA, Lenox Hill, NY,NY, St. Vincent’s
Hospital and Medical Center of New York
of intraabdominal adhesions were reported as early as 1872 after removal
of an ovarian tumor resulted in intestinal obstruction.2 Adhesions
are the most common cause of bowel obstruction and most likely result from
gynecologic procedures, appendectomies and other intestinal operations.3
Adhesions have also been proposed to cause infertility and abdominal and
pelvic pain. Although nerve fibers have been confirmed in pelvic
adhesions, their presence is not increased in those patients with pelvic
pain.4 In addition, there does not appear to be an association
between the severity of adhesions and complaint of pain. It is generally
accepted that adhesions may impair organ motility resulting in visceral
pain transmitted by peritoneal innervation.5 Many patients experience
resolution of their symptoms after adhesiolysis.6-9 This may be complicated
by placebo effect as demonstrated by one study that showed no difference
in pain scores between patients who were randomized to adhesiolysis versus
In 1994, adhesiolyis
procedures resulted in 303,836 hospitalizations, 846,415 days of inpatient
care, and $1.3 billion in health care expenditures. Forty-seven percent
of these hospitalizations were for adhesiolysis of the female reproductive
system, the primary site for these procedures. In comparison to similar
data from 1988, the cost of adhesiolysis hospitalizations is down.
One significant influence on this trend is the increased use of minimally
invasive surgical techniques resulting in fewer days of inpatient care.11
This chapter reviews the pathophysiology of adhesion formation, equipment
and technique for adhesiolysis, and methods for adhesion prevention.
PATHOPHYSIOLOGY OF ADHESION FORMATION
Adhesion formation is initiated by peritoneal
trauma. Its morphogenesis was described in detail by diZerega.12
Within hours at the site of injury, polymorphonuclear leukocytes appear
in large numbers meshed in fibrin strands. At 24-36 hours, macrophages
appear in large numbers and are responsible for regulating fibroblast and
mesothelial cell activities. By day 2, the wound surface is covered
by macrophages, islands of primitive mesenchymal cells and mesothelial
cells. By day four the islands of primitive mesenchymal cells have
now come into contact with each other. Fibroblasts and collagen are
now present and increasing. By day five, an organized fibrin interconnection
is now seen composed of collagen, fibroblasts, mast cells, and vascular
channels containing endothelial cells. The adhesion continues to
mature as collagen fibrils organize into bands covered by mesothelium and
containing blood vessels and connective tissue fiber.12
A review of standard equipment such as light sources
and video systems is beyond the scope of this chapter. Equipment
useful for advanced procedures and energy sources is included. However,
the main technique for adhesiolysis with the least possibility for reformation
can simply be described as “cold scissors dissection with bipolar backup.”
Four different laparoscopes should be available for
adhesiolysis: a 10-mm 0° straight viewing laparoscope; a 10-mm operative
laparoscope with 5-mm operating channel; a 5-mm straight viewing laparoscope
for introduction through 5-mm trocar sleeves; and an oblique-angle laparoscope
(30-45°) for upper abdominal and pelvic procedures.
Scissors are the preferred instrument to cut adhesions,
especially avascular and/or congenital adhesions. Using the magnification
afforded by the laparoscope, most anterior abdominal wall, pelvic, and
bowel adhesions can be carefully inspected and divided with minimal bleeding,
rarely requiring microbipolar coagulation. Loose fibrous or areolar
tissue is separated by inserting a closed scissors and withdrawing it in
the open position. Pushing tissue with the partially open blunt scissors
tip is used to develop natural planes.
Reusable 5 mm blunt-tipped sawtooth scissors and
curved scissors cut well without cautery. Blunt or rounded-tip 5mm
scissors with one stable blade and one moveable blade are used to divide
thin and thick bowel adhesions sharply. Sharp dissection is the primary
technique used for adhesiolysis to diminish the potential for adhesion
formation; electrification and laser are usually reserved for hemostatic
dissection of adhesions where anatomic planes are not evident or
vascular adherences are anticipated. Thermal energy sources must be avoided
as much as possible to reduce adhesion recurrence. Blunt-tipped,
sawtooth scissors, with or without a curve, cut well (Richard Wolf Medical
Instruments, Vernon Hills, IL and Karl Storz Endoscopy, Culver City, CA).
Many disposable scissors depend greatly on electrification for cutting.
Hook-scissors are not very useful for adhesiolysis.
Surgeons should select scissors that feel comfortable.
To facilitate direction changes, the scissors should not be too long or
encumbered by an electrical cord. This author prefers to make rapid
instrument exchanges between scissors and microbipolar forceps through
the same portal to control bleeding, instead of applying electrification
When discussing electrosurgery, the term “cautery”
should be abandoned. Cautery, thermocoagulation, or endocoagulation
refer to the passive transfer of heat from a hot instrument heated by electrical
current to tissue. The temperature rises within the tissue until
cell proteins begin to denature and coagulate with resultant cell death.
Electrical current does not pass through the patient’s body!
Monopolar cutting current can be used safely,
as the voltage is too low to arc to organs even 1 mm away. Cutting
current is used to both cut and/or coagulate (desiccate) depending on the
portion of the electrode in contact with the tissue. The tip cuts,
while the wider body tamponades and coagulates.
Monopolar coagulation current which uses voltages
over 10 times that of cutting current can arc 1 to 2mm and is used in close
proximity to tissue, but not in contact, to fulgurate diffuse venous and
arteriolar bleeders. It takes 30% more power to spark or arc
in CO2 pneumoperitoneum than in room air; thus, at the same electrosurgical
power setting, less arcing occurs at laparoscopy than at laparotomy.
Monopolar electrosurgery should be avoided when
working on the bowel unless the surgeon is well versed in this modality.
The expert laparoscopic surgeon can use monopolar electrosurgery safely
to cut or fulgurate tissue, but desiccation (coagulation) on bowel should
be performed with bipolar techniques.13,14
Electrosurgical injury to the bowel can occur
beyond the surgeon’s field of view during laparoscopic procedures from
electrode insulation defects or capacitive coupling. While the surgeon
views the tip of the electrode, electrical discharge may occur from its
body (insulation failure) or from metal trocar cannulas surrounding the
electrode if they are separated from the skin by plastic retention sleeves.
These problems are eliminated by active electrode monitoring using the
Electroshield EM-1 monitor system (Encision, Boulder, CO). This consists
of a sheath surrounding the electrode and a sheath monitor (EM-1) to detect
any insulation faults and shield against capacitive coupling.
Bipolar desiccation using cutting current between
two closely opposed electrodes is safe and efficient for large vessel hemostasis.15,16
Large blood vessels are compressed and bipolar cutting current passed until
complete desiccation is achieved, i.e., the current depletes the tissue
fluid and electrolytes and fuses the vessel wall. Coagulating current
is not used as it may rapidly desiccate the outer layers of the tissue,
producing superficial resistance thereby preventing deeper penetration.
Small vessel hemostasis necessary for adhesiolysis
is best achieved by using microbipolar forceps after precisely identifying
the vessel with electrolyte solution irrigation. Microbipolar forceps
(Richard Wolf Medical Instruments, Vernon Hills, IL) with an irrigation
channel work best for precise tissue desiccation with minimal thermal spread.
The use of Harmonic Scalpel (Ethicon Endosurgery,
Cincinnati, Ohio) for laparoscopic adhesiolysis is gaining popularity.
Although it has its limitations, the benefit of this multifunctional instrument
far outweighs any disadvantage. Many factors can be attributed to
its progressive acceptance. The lack of electrical energy used to
coagulate vessels and the smaller (2mm) lateral energy spread make it more
attractive than conventional electrosurgical instruments by potentially
reducing the percentage of delayed post-operative bowel injuries (caused
by electrical burns.) This is not to say however, that injury cannot
occur. As with standard electrosurgical instruments, the Harmonic
Scalpel, specifically the jaws, can become hot and cause tissue injury
if not used in a prudent manner. Although Harmonic Scalpel has the
ability to grasp, cut, and cauterize simultaneously, making it a useful
instrument for a judicious operator (requiring fewer instrument changes
in and out of port sites), the inability to cut without applying energy
assures the need for a sharp pair of conventional scissors in laparoscopic
Rectal and Vaginal Probes
A sponge on a ring forceps is inserted into the vagina
or the posterior vaginal fornix, and an 81-French probe is placed in the
rectum to define the rectum and posterior vagina for lysis of pelvic adhesions
and/or excision of endometriosis when there is a significant degree of
cul-de-sac obliteration. Whenever rectal location is in doubt, it
is identified by insertion of the rectal probe.
The CO2 laser, with its 0.1 mm depth of penetration
and inability to traverse through water, allows the surgeon some security
when lysing adhesions especially in the pelvis. The Coherent 5000L
laser (Palo Alto, CA), by using a 11.1 um wavelength beam, maintains a
1.5mm spot size at all power settings allowing for more precision than
most standard 10.6 um wavelength CO2 lasers.
Aquadissection is the use of hydraulic energy from
pressurized fluid to aid in the performance of surgical procedures.
The force vector is multidirectional within the volume of expansion of
the uncompressible fluid; the force applied with a blunt probe is unidirectional.
Instillation of fluid under pressure displaces tissue, creating cleavage
planes in the least resistant spaces. Aquadissection into closed
spaces behind peritoneum or adhesions produces edematous, distended tissue
on tension with loss of elasticity, making further division easy and safe
using blunt dissection, scissors dissection, laser, or electrosurgery.
Suction-irrigators with the ability to dissect
using pressurized fluid should have a single channel to maximize suctioning
and irrigating capacity. This allows the surgeon to perform atraumatic
suction-traction-retraction, irrigate directly, and develop surgical planes
(aquadissection). The distal tip should not have side holes as they
impede these actions, spray the surgical field without purpose, and cause
unnecessary tissue trauma when omentum, epiploic appendices, and adhesions
become caught. The shaft should have a dull finish to
prevent CO2 laser beam reflection, allowing it to be used as a backstop.
The market is crowded with many aquadissection devices.
Smoke evacuation during electrosurgery or CO2 laser
laparoscopy is expedited using a Clear View EBS ICM 350 smoke evacuator
(I.C. Medical, Phoenix, AZ).
Gasless laparoscopy (abdominal wall retractors)
Abdominal wall subcutaneous emphysema occurs frequently
during anterior abdominal wall adhesiolysis as peritoneal defects result
in free communication with the rectus sheath. This compromises peritoneal
cavity operating space. A useful technique is to insert an anterior
abdominal wall retractor (AbdaLift, Storz, CA) once the umbilicus has been
cleared of adhesions.
LAPAROSCOPIC PERITONEAL CAVITY ADHESIOLYSIS
Adhesiolysis by laparoscopy and laparotomy can be very time-consuming
and technically difficult and is best performed by an expert surgeon.
However, despite lengthy laparoscopic procedures (two to four hours), most
patients are discharged on the day of the procedure, avoid large abdominal
incisions, experience minimal complications, and return to full activity
within one week of surgery.
In this section, general adhesiolysis, pelvic adhesiolysis, ovariolysis,
salpingo-ovariolysis, and salpingostomy are described. The laparoscopic
treatment of acute adhesions has not been included. However, the
best treatment for sexually transmitted disease adhesive sequelae may be
prevention through early laparoscopic diagnosis and treatment of acute
pelvic infection, including abscesses. Acute adhesiolysis will often
prevent chronic adhesion formation.17-19
Extensive peritoneal cavity adhesion procedures need a classification system
that relates to their degree of severity and the surgical expertise necessary
for adhesiolysis. The single best indicator of the degree of severity
and expertise necessary for adhesiolysis is the number of previous laparotomies.
The frequency of small bowel obstruction symptoms indicates the need for
Peritoneal adhesiolysis is classified into enterolysis including omentolysis
and female reproductive reconstruction (salpingo-ovariolysis and cul-de-sac
dissection with excision of deep fibrotic endometriosis). Bowel adhesions
are divided into upper abdominal, lower abdominal, pelvic, and combinations.
Adhesions surrounding the umbilicus are upper abdominal as they require
an upper abdominal laparoscopic view for division. The extent, thickness,
and vascularity of adhesions vary widely. Intricate adhesive patterns
exist with fusion to parietal peritoneum or various meshes.
Extensive small bowel adhesions are not a frequent finding at laparoscopy
for pelvic pain or infertility. In these cases, the fallopian tube
is adhered to the ovary, the ovary is adhered to the pelvic sidewall, and
the rectosigmoid may cover both. Rarely, the omentum and small bowel
are involved. Adhesions may be the result of an episode of pelvic
inflammatory disease or endometriosis, but most commonly are caused by
previous surgery. Adhesions cause pain by entrapment of the organs
they surround. The surgical management of extensive pelvic adhesions
is one of the most difficult problems facing surgeons today.
Surgical plan for extensive enterolysis
A well-defined strategy is important for small bowel enterolysis.
For simplification, this is divided into three parts:
1. Division of all adhesions to the anterior abdominal wall parietal
peritoneum. Small bowel loops encountered during this process are
separated using their anterior attachment for countertraction instead of
waiting until the last portion of the procedure (running of the bowel).
2. Division of all small bowel and omental adhesions in the pelvis.
Rectosigmoid, cecum, and appendix often require some separation during
this part of the procedure.
3. Running of the bowel Using atraumatic grasping forceps and
usually a suction-irrigator for suction traction, the bowel is run.
Starting at the cecum and terminal ileum, loops and significant kinks are
freed into the high upper abdomen to the ligament of Treitz.
4.(Optional) Finally tubo-ovarian pathology is treated if indicated.
Time frequently dictates that all adhesions cannot be lysed.
From the history, the surgeon should conceptualize the adhesions most likely
to be causing the pain, i.e., upper or lower abdomen, left or right, and
clear these areas of adhesions.
Patients are informed preoperatively of the high risk for bowel injury
during laparoscopic procedures when extensive cul-de-sac involvement with
endometriosis or adhesions is suspected. They are encouraged to hydrate
and eat lightly for 24 hours before admission. A mechanical bowel
preparation (GoLYTELY or Colyte) is administered orally the afternoon before
surgery to induce brisk, self-limiting diarrhea to cleanse the bowel without
disrupting the electrolyte balance.20 The patient is usually admitted
on the day of surgery. Lower abdominal, pubic, and perineal hair
is not shaved. Patients are encouraged to void on call to the OR,
and a Foley catheter is inserted only if the bladder is distended or a
long operation anticipated. A catheter is inserted near the end of
the operation and removed in the recovery room when the patient is aware
of its presence, to prevent bladder distension. Antibiotics (usually
cefoxitin) are administered in all cases lasting over two hours, at the
All laparoscopic surgical procedures are done under general anesthesia
with endotracheal intubation. An orogastric tube is placed routinely
to diminish the possibility of a trocar injury to the stomach and to reduce
small bowel distention. The patient’s arms should be tucked on both
sides so that the surgeon’s position is comfortable and not limited.
The patient’s position is flat (0°) during umbilical trocar sleeve
insertion and anterior abdominal wall adhesiolysis but a steep Trendelenburg
position (30 degrees), reverse Trendelenburg position, and side-to-side
rotation are used when necessary. Lithotomy position, with the hip
extended (thigh parallel to abdomen) is obtained with Allen stirrups (Edgewater
Medical Systems, Mayfield Heights, OH) or knee braces, which are adjusted
individually to each patient before she is anesthetized. Anesthesia
examination is performed prior to prepping the patient.
In the absence of suspected periumbilical adhesions, an intraumbilical
vertical incision is made through the skin of the inferior umbilical fossa
extending to and just beyond its lowest point. A Verres needle is
placed through this low point while pulling the umbilicus towards the pubic
symphysis and insufflation with CO2 is continued until an intraabdominal
pressure of 25-30mm Hg is obtained.
The palmed short trocar is positioned at a 90o angle inside the deep
funnel shaped portion of the umbilical fossa where fascia and peritoneum
meet and inserted through this into the peritoneal cavity at a 45o angle
in one continuous thrusting motion, with wrist rotation. This is
performed without lifting the anterior abdominal wall as the high intraabdominal
pressure provides counterpressure against the parietal peritoneum to lift
it above the large vessels below. The result is a parietal peritoneal
puncture directly beneath the umbilicus. Once the trocar is in place
within the abdominal cavity, the intra-abdominal pressure is lowered to
12-15 mm Hg to diminish the development of vena caval compression and subcutaneous
Special alternate entry sites and techniques are used when there is
a high suspicion for periumbilical adhesions in patients who have undergone
multiple laparotomies, have lower abdominal incisions traversing the umbilicus,
or who have extensive adhesions either clinically or from a previous operative
record. Open laparoscopy at the umbilicus carries the same risk for
bowel laceration if the bowel is fused to the umbilical undersurface.
One alternate site is in the left ninth intercostal space, anterior
axillary line. Adhesions are rare in this area, and the peritoneum
is tethered to the undersurface of the ribs, making peritoneal tenting
away from the needle unusual. A 5-mm skin incision is made over the
lowest intercostal space (the 9th) in the anterior axillary line.
The Veress needle is grasped near its tip, like a dart, between thumb and
forefinger, while the other index finger spreads this intercostal space.
The needle tip is inserted at a right angle to the skin (a 45o angle to
the horizontal) between the ninth and tenth ribs. A single pop is
felt on penetration of the peritoneum. Pneumoperitoneum to a pressure of
30 mmHg is obtained. A 5 mm trocar is then inserted through this
same incision that has migrated downward below the left costal margin because
of the pneumoperitoneum.
Another alternate entry site is Palmer’s point21 located 3 cm
inferior to the subcostal arch in the left medioclavicular line.22
Also, if the uterus is present and thought to be free of adhesions, the
surgeon may consider inserting a long Veress needle transvaginally through
When unexpected extensive adhesions are encountered initially surrounding
the umbilical puncture, the surgeon should immediately seek a higher site.
Thereafter, the adhesions can be freed down to and just beneath the umbilicus,
and the surrounding bowel inspected for perforations. The umbilical
portal can then be reestablished safely for further work.
Other laparoscopic puncture sites are placed as needed, usually lateral
to the rectus abdominis muscles and always under direct laparoscopic vision.
When the anterior abdominal wall parietal peritoneum is thickened from
previous surgery or obesity, the position of these muscles is judged by
palpating and depressing the anterior abdominal wall with the back of the
scalpel; the wall will appear thicker where rectus muscle is enclosed,
and the incision site is made lateral to this area near the anterior superior
If an umbilical insertion is possible and extensive adhesions are present
close to but below the umbilicus, the operating laparoscope with scissors
in the operating channel is the first instrument used. If a left
upper quadrant 5 mm incision is necessary, there is usually room for another
puncture site to do initial adhesiolysis with scissors.
Anterior abdominal wall adhesions involve the parietal peritoneum stuck
to the omentum, transverse colon, and small bowel with varying degrees
of fibrosis and vascularity. Adhesions may be filmy and avascular,
filmy and vascular, or dense, fibrous and vascular. All of these
adhesions to the anterior abdominal wall are released. If adhesions
extend from above the level of the laparoscope in the umbilicus, another
trocar is inserted above the level of the highest adhesion and the laparoscope
is inserted there. Adhesions are easier to divide when working above
them, instead of within them, as gravity helps to delineate the plane for
separation after which the CO2 pneumoperitoneum can disperse into the dissection
Adhesiolysis is done using scissors alone if possible. Rarely,
electrosurgery, CO2 laser, and the Harmonic Scalpel are used. In
most cases, the initial adhesiolysis is performed with scissors.
CO2 laser through the laparoscope on adhesions close to the trocar insertion
often results in reflection with loss of precision. Electrosurgery
(cutting current) is used only when there is little chance that small bowel
is involved in the adhesion.
Initially, blunt-tipped scissors in the operating channel of an operating
laparoscope are inserted into the interface between the anterior abdominal
wall parietal peritoneum and the omentum. Rotating the laparoscope
so that the scissors exit at 12 o’clock instead of 3 o’clock facilitates
early adhesiolysis. Blunt dissection is performed by inserting the
scissors at the interface, opening, and withdrawing them. This maneuver
is repeated many times to delineate the thin avascular adhesions from thicker
vascular fibrotic attachments that are individually coagulated and divided.
Frequently, adhesions can be bluntly divided by grasping the adhesion in
the partially closed scissors and gently pushing the tissue. If the
plane of adhesions cannot be reached with the tip of the scissors, the
abdominal wall can be pressed from above with the finger to make it accessible
to the scissors.
After initial adhesiolysis, visualization is improved allowing better
access and exposure for further adhesiolysis. Secondary trocar sites
can now be placed safely. After their insertion, the remainder of
the adhesions can now be lysed using scissors with microbipolar backup
for rare arteriolar bleeders. Small venule bleeders are left alone.
On occasion, in operations in which symptomatic bowel adhesions are not
the main problem, an electrosurgical spoon or knife is used to divide the
remaining omental adhesions if bowel is not involved. If bowel is
involved, dissection proceeds with scissors, without electrosurgery, through
the second puncture site, aided by traction on the bowel from an opposite
placed puncture site. Rarely, the CO2 laser may be used through the
operating channel of the operating laparoscope. When using the CO2
laser for adhesiolysis, aquadissection is performed to distend the adhesive
surface with fluid before vaporizing the individual adhesive layers.
The suction-irrigator can also be used for suction traction, instead of
a laparoscopic Babcock, and as a backstop to prevent thermal damage to
other structures. The suction irrigator is also used to clean the
laparoscopic optic which is then wiped on the bowel serosa before continuing.
Denuded areas of bowel muscularis are repaired transversely using a 3-0
Vicryl seromuscular stitch. Denuded peritoneum is left alone. Minimal
oozing should be observed and not desiccated unless this bleeding hinders
the next adhesiolysis step or persists towards the end of the operation.
With perseverance, all anterior abdominal wall parietal peritoneum adhesions
can be released.
The Harmonic Scalpel is also useful for adhesiolysis. It bears repeating,
the Harmonic Scalpel is not a scissor. This instrument works by coagulating
tissue in between the blades and allowing it to be “pressed apart” after
full coagulation of the tissue between the active blade and the compressing
surface. Tissue is first grasped between the blades of the Harmonic
Scalpel, steadily compressed, and the blade is activated allowing the tissue
to separate once it is fully coagulated. Any tissue between the blades
of the Harmonic Scalpel will be heated and then be allowed to fall apart.
This includes all blood vessels up to 3mm in diameter incorporated in the
tissue between the blades. As stated before, the Harmonic Scalpel
can be used to grasp tissue in a general manner when the blades are not
active. However, prior to grasping any tissue, the operator must
allow the active blade to cool sufficiently so it will not burn any tissue
it may come in contact with. The operator must remember that a Harmonic
Scalpel does not replace the scissor, especially when dealing with bowel
in the same proximity to an adhesion plane. Harmonic Scalpel comes in 5-
and 10-mm size instrumentation with active jaws as well as adaptable adjuncts
to the instrument such as a spatula type dissector, “ball” type dissector
and hook dissector. All of these type instruments can be used in the same
location as you would normally use a monopolar electrode; bear in mind
once again that the lateral energy spread is just 2mm with the Harmonic
The next step is to free all bowel loops in the pelvis. Small bowel
attached to the vesicouterine peritoneal fold, uterus or vaginal cuff,
and the rectum is liberated. There are three key points when performing
bowel adhesiolysis within the pelvis: scissors dissection without electrosurgery,
countertraction and blunt dissection. The bowel is gently held with
an atraumatic grasper and lifted away from the structure to which it is
adhered, exposing the plane of dissection. When adhesive interfaces are
obvious, scissors are used. The blunt-tipped scissors are used to
sharply dissect the adhesions in small, successive cuts taking care not
to damage the bowel serosa. Countertraction will further expose the plane
of dissection and ultimately free the attachment. Electrosurgery and laser
are generally not used for adhesiolysis involving the bowel due to the
risk of recurrent adhesions from thermal damage. However, when adhesive
aggregates blend into each other, initial incision is made very superficially
with laser, and aquadissection distends the layers of the adhesions, facilitating
identification of the involved structures. Division of adhesions continues
with laser at 10-20 W in pulsed mode. The aquadissector and injected fluid
from it are used as a backstop behind adhesive bands that are divided with
the CO2 laser.
The rectosigmoid can be adhered to the left pelvic sidewall obscuring
visualization of the left adnexa. Dissection starts well out of the pelvis
in the left iliac fossa. Scissors are used to develop the space between
the sigmoid colon and the psoas muscle to the iliac vessels, and the rectosigmoid
reflected toward the midline. Thereafter, with the rectosigmoid placed
on traction, rectosigmoid and rectal adhesions to the left pelvic sidewall
are divided starting cephalad and continuing caudad.
Cul-de-sac adhesions can cause partial or complete cul-de-sac obliteration
from fibrosis between the anterior rectum, posterior vagina, cervix, and
the uterosacral ligaments. The technique of freeing the anterior rectum
to the loose areolar tissue of the rectovaginal septum before excising
and/or vaporizing visible and palpable deep fibrotic endometriosis is used.24
Attention is first directed to complete dissection of the anterior
rectum throughout its area of involvement until the loose areolar tissue
of the rectovaginal space is reached. Using the rectal probe as a guide,
the rectal serosa is opened at its junction with the cul-de-sac lesion.
Careful dissection ensues using aquadissection, suction-traction, laser,
and scissors until the rectum is completely freed and identifiable below
the lesion. Excision of the fibrotic endometriosis is done only after rectal
dissection is completed.
Deep fibrotic, often nodular, endometriotic lesions are excised from
the uterosacral ligaments, the upper posterior vagina, (the location of
which is confirmed by the Valtchev retractor or a sponge in the posterior
fornix), and the posterior cervix. The dissection on the outside of the
vaginal wall proceeds using laser or scissors until soft pliable upper
posterior vaginal wall is uncovered. It is frequently difficult to
distinguish fibrotic endometriosis from cervix at the cervicovaginal junction
and above. Frequent palpation using rectovaginal examinations helps
identify occult lesions. When the lesion infiltrates through the
vaginal wall, an “en bloc” laparoscopic resection from cul-de-sac to posterior
vaginal wall is done, and the vagina is repaired laparoscopically with
the pneumoperitoneum maintained with a 30-cc foley balloon in the vagina.
Or, more recently, the vaginal lesion is mobilized vaginally, the vagina
closed over the mobilized portion, and the en bloc lesion excision completed
Sometimes the fibrotic cul-de-sac lesion encompassing both uterosacral
ligament insertions and the intervening posterior cervix-vagina and anterior
rectal lesion can be excised as one en bloc specimen.
Endometriotic nodules infiltrating the anterior rectal muscularis are
excised usually with the surgeon’s or his assistant’s finger in the rectum
just beneath the lesion. In some cases, the anterior rectum is reperitonealized
by plicating the uterosacral ligaments and lateral rectal peritoneum across
the midline. Deep rectal muscularis defects are always closed with suture.
Full thickness rectal lesion excisions are suture or staple repaired laparoscopically.
Pelvic Adhesiolysis (continued)
When a ureter is close to the lesion, its course in the deep pelvis
is traced by opening its overlying peritoneum with scissors or laser.
On the left, this often requires scissors reflection of the rectosigmoid,
as previously described, starting at the pelvic brim. Bipolar forceps
are used to control arterial and venous bleeding.
Ovarian adhesions to the pelvic sidewall can be filmy or fused.
Initially, adhesions between the ovary and fallopian tubes and other peritoneal
surfaces are identified. It is imperative that the surgeon knows
the surrounding anatomy prior to cutting any tissue to avoid damage to
vital structures. The plane of dissection is identified and followed
to avoid damage to other structures. The uteroovarian ligament may
be held with an atraumatic grasper to facilitate countertraction and expose
the line of cleavage. During ovariolysis, it is important to preserve
as much peritoneum as possible while freeing the ovary. Dissection
starts either high in the pelvis just beneath the infundibulopelvic ligament
or deep on the pelvic sidewall beneath the ureter in the pararectal space.
In each case, scissors are used both bluntly and sharply to mobilize the
ovary from the sidewall. Alternatively, aquadissection may be used
to facilitate identification of adhesion layers and to provide a safe backstop
for the CO2 laser. Once an adhesion layer is identified, the aquadissector
can also be placed behind this ridge and used as a backstop during CO2
laser adhesiolysis. Adhesiolysis is performed sharply and bluntly in a
methodical manner working caudad until the cul-de-sac is reached.
If fimbrioplasty is to be performed, then hydrodistention is achieved
by transcervical injection of dilute indigo carmine through a uterine manipulator.
This distends the distal portion of the tube which is stabilized, and the
adhesive bands are freed using scissors, laser or micropoint electrosurgery.
If necessary, the fimbriated end can be progressively dilated using 3 mm
alligator-type forceps. The closed forceps are placed through the aperture,
opened, and removed. This is repeated one or more times. If the opening
does not remain everted on its own, the intussusception salpingostomy method
of McComb27 is used to avoid thermal damage to the ciliated tubal epithelium
from CO2 laser or electrosurgery. The tip of the aquadissector is inserted
approximately 2 cm into the newly opened tube, suction applied, and the
tube fimbrial edges pulled around the instrument to turn the tube end inside-out.
The borders of the incision act as a restrictive collar to maintain the
mucosa in this newly everted configuration. In some cases, the ostial margin
is sutured to the ampullary serosa with 6-0
Underwater surgery at the end of each
At the close of each operation, an underwater examination is used to document
complete intraperitoneal hemostasis in stages; this detects bleeding from
vessels and viscera tamponaded during the procedure by the increased intraperitoneal
pressure of the CO2 pneumoperitoneum. The integrity of the rectum
and rectosigmoid is often checked at this time by instillation of dilute
indigo carmine solution or air transanally through a 30 cc Foley catheter.
The CO2 pneumoperitoneum is displaced with 2 to 5 L of Ringer’s lactate
solution, and the peritoneal cavity is vigorously irrigated and suctioned
until the effluent is clear of blood products, usually after 10-20 L.
Underwater inspection of the pelvis is performed to detect any further
bleeding which is controlled using microbipolar irrigating forceps to coagulate
through the electrolyte solution. First hemostasis is established with
the patient in Trendelenburg position, then per underwater examination
with the patient supine and in reverse Trendelenburg, and finally, with
all instruments removed, including the uterine manipulator.
To visualize the pelvis with the patient supine, the 10-mm straight
laparoscope and the actively irrigating aquadissector tip are manipulated
together into the deep cul-de-sac beneath floating bowel and omentum. During
this copious irrigation procedure, clear fluid is deposited into the pelvis
and circulates into the upper abdomen, displacing upper abdominal bloody
fluid which is suctioned after flowing back into the pelvis. An “underwater”
examination is then performed to observe the completely separated tubes
and ovaries and to confirm complete hemostasis.
A final copious lavage with Ringer’s lactate solution is undertaken
and all clots directly aspirated; at least 2 L of lactated Ringer’s solution
are left in the peritoneal cavity to displace CO2 and to prevent fibrin
adherences from forming by separating raw operated-upon surfaces during
the initial stages of reperitonealization. Displacement of the CO2 with
Ringer’s lactate diminishes the frequency and severity of shoulder pain
from CO2 insufflation. No other anti-adhesive agents are employed. No drains,
antibiotic solutions, or heparin are used.
Hand assisted laparoscopy or “handoscopy” has become popular over
the last 5 years, mainly in the field of solid organ surgery and bowel
surgery. The main advantage of handoscopy is that it allows the surgeon
to regain the tactile feel of surrounding tissues previously lost to “laser”
laparoscopists and permits a more purposeful manipulation of larger organs.
Often, it is the use of handoscopy for tissue palpation, that enables a
successful laparoscopic adhesiolysis. At times, during laparoscopic procedures,
visualization can be poor due to dense adhesions and the inability to determine
tissue planes. With the placement of the operator’s hand inside the peritoneal
cavity the surgeon is usually able to palpate surrounding organs and allow
for a better tissue dissection plane that otherwise may not have been possible
through direct visualization only. Not only can the use of a hand
port facilitate an otherwise tedious procedure, it effects a safer operation
for the patient with less chance of bowel injury. If bowel resection should
become necessary, the use of the hand port allows for exteriorization of
the segment that requires resection once again making the procedure easier
and less time consuming. A handoscopy incision is usually only 7-8 cm and
is either placed in the left or right lower portion of the abdomen with
insertion of the operator’s non-dominant hand. The muscle splitting technique
is used in a similar method as in performing an open appendectomy. The
entire peritoneal cavity can be examined through either one of these incisions
with the operator’s hand and it can be used for organ extraction as well.
Several different types of handoscopy ports are available and all provide
equal access to the peritoneal cavity.
When placing a handoscopy port for adhesiolysis, the operator must
first choose a location on the abdominal wall that will allow optimal access
to the point where adhesions are greatest. After the hand port location
is chosen, a marking pen should be used to outline the area of the abdominal
wall where the hand port is to be placed. The area for the incision
should be anesthetized with bupivicaine for post operative pain control
and an incision should then be made into the skin. The size of the incision
should be the same size as the operator’s glove size. After this
is completed, a muscle splitting technique should be used to enter the
peritoneal cavity just as the operator would in performing an open appendectomy.
Once the peritoneal cavity is entered, the hand port can then be placed.
All of the hand port apparatus require that any adhesions on the peritoneal
side of the incision be lysed prior to inserting the handoscopy device.
Additionally, these devices should not be placed over any bony prominences,
i.e., iliac crest, or encompassing any bowel in the peritoneal ring surface
as to injure any bowel in the abdomen. If the handoscopy port is placed
in the upper abdomen, the falciform ligament may require division prior
to inserting the ring.
Once the handoscopy device is in place the lysis of adhesions can precede
in an orderly fashion by identifying the tissue planes by feel with the
operator’s fingers and additionally being able to provide appropriate traction
and countertraction to allow for a safe adhesiolysis. Incidental
enterotomies can be sutured with conventional suture and then tied using
one hand knot tying technique with the intra abdominal hand.
Should any bowel resections be required the hand port can be used as
a mini laparotomy site for extraction of any specimens and for exteriorizing
any bowel that may require resection and/or repair. Additionally all handoscopy
devices that are placed through the abdominal wall act as a wound protector
and may minimize post operative wound infections as well as protect from
any potential tumor seeding if the operation is for malignancy. The opening
of the Ethicon laparodisc device is like a camera shutter that can be circumferentially
reduced to seal the pneumoperitoneum around a 5 mm trocar.
Once the procedure is completed the hand port device is removed, anterior
and posterior rectal sheath muscle fascia are closed with either 0 or 2-0
absorbable suture and the skin is then closed in a subcuticular manner.
Additionally, a variety of “pain buster” catheters are now available for
insertion into the supra fascia layer of the wound which allows for excellent
postoperative analgesia. These help to minimize postoperative narcotic
requirements thereby facilitating an earlier return of bowel function and
more expedient discharge from the hospital. It has been the author’s personal
experience that patients undergoing a handoscopy type of operation parallel
their recovery in the same manner as a conventional laparoscopic case with
a delay of only one day in recovery. If a bowel resection should be required
the patient usually only requires to be NPO overnight and clear liquids
may be started on the first postoperative day. The patient is maintained
on clear liquids until passing flatus and moving bowels. Most patients
are discharged home on the second postoperative day if a bowel resection
has been required.
In the event that a bowel resection is required, stapling instruments
are used routinely for division of the bowel and anastomosis. The
mesentery of the bowel can be divided with the use of surgical ties, Harmonic
Scalpel, or vascular cartridge stapling devices. Bowel resection
is preceded by first identifying the lines of resection, transection of
the bowel, the use of stapling devices proximally and distally, division
of the mesentery, followed by re-anastomosis once again using stapling
devices and closing the enterotomy required by the tines of the stapling
device with an additional stapling device. Any mesentery defect caused
by a small bowel resection are closed with a running 0 or 2-0 absorbable
suture. Mesenteric defects need not be closed after large bowel resections.
In certain situations an open adhesiolysis is best for the patients.
It is usually performed after an attempted laparoscopic approach has been
abandoned. If only a pelvic adhesiolysis is needed, a Pfannenstiel
incision usually is adequate. However if the entire peritoneal cavity
is encased in dense fibrotic adhesions a midline incision is usually required.
Open adhesiolysis should be reserved for the worst possible cases where
laparoscopic adhesiolysis has failed, where there has been several incidental
enterotomies made, or adhesiolysis cannot be performed secondary to encasement
of the bowel. Open adhesiolysis should also be considered in a patient
unable to tolerate CO2 insufflation.
An open adhesiolysis is performed in the exact same way as a laparoscopic
adhesiolysis. First, all adhesions are taken down from the abdominal
wall usually with the Metzenbaum scissors. Second, all loops of bowel
are extracted out of the pelvis. Finally, all interloop adhesions are lysed
from the ligament of Treitz to the ileo-cecal valve. Any incidental
enterotomies should be repaired at the time of discovery to avoid intra
peritoneal contamination and development of an infection. Hemostasis
must be meticulous during the entire dissection as in a laparoscopic procedure.
An abundant use of warm irrigation fluid is used as well.
It is extremely important to keep the tissues moist to prevent
desiccation from atmospheric air as this can stimulate adhesion reformation.
It has been a personal experience that the use of adhesion barriers has
been ineffective in open procedures on the bowel and is not indicated.
Intraoperatively, the surgeon can minimize adhesion formation through careful
tissue handling, complete hemostasis, abundant irrigation, limited thermal
injury, infection prophylaxis, and minimizing foreign body reaction.29,30
A recent Cochrane Database Systematic Review investigated whether pharmacological
and liquid agents used as adjuvants during pelvic surgery in infertility
patients lead to a reduction in the incidence or severity of postoperative
adhesion (re-)formation, and/or an improvement in subsequent pregnancy
rates. The results of this review are as follows: there is some evidence
that intraperitoneal steroid administration decreases the incidence and
severity of postoperative adhesion formation; intraperitoneal administration
of dextran did not decrease postoperative adhesion formation at second
look laparoscopy; there is no evidence that intra-abdominal crystalloid
instillation, calcium channel blocking agents, non-steroidal anti inflammatory
drugs and proteolytics decrease postoperative adhesion formation.31
Barrier agents for prevention of adhesion formation are commercially
available. The Cochrane Menstrual Disorders and Subfertility Group investigated
the effects these agents have on postoperative adhesion formation. The
15 randomized controlled trials comprised laparoscopic and laparotomic
surgical techniques. Results of the investigation were as follows: oxidized
regenerated cellulose (Interceed: Johnson & Johnson Medical, Somerville,
NJ) reduces the incidence of adhesion formation and re-formation at laparoscopy
and laparotomy in the pelvis; polytetrafluoroethylene (GoreTex: W.L. Gore
& Associates, Flagstaff, AZ) appears to be superior to Interceed in
preventing adhesion formation in the pelvis but is limited by the need
for suturing and later removal; Seprafilm (Genzyme, Cambridge, MA) does
not appear to be effective in preventing adhesion formation.32
If Interceed is to be used for prevention of adhesion formation, the
intrapelvic fluid should be completely aspirated. A piece of Interceed
large enough to cover the at-risk area is placed and moistened with a small
volume of irrigant. Complete hemostasis must be achieved prior to
placing the material. If hemostasis has not been achieved, the Interceed
will turn brown or black and must be replaced as this may actually increase
adhesion formation.33 Animal studies and clinical trials of a gel
form of modified hyaluronic acid, a naturally occurring glycosaminoglycan,
show evidence for reducing de novo adhesion formation.34 Intergel
(Gynecare, Johnson & Johnson Inc., Somerville, NJ) is commercially
available for open surgery use.
The ideal barrier material should be easy to apply, both in open and
laparoscopic surgeries. Additionally, it should be nonreactive, persist
during the critical wound reepithelization period, stay in place on the
target tissue for several days, and eventually be resorbed following peritoneal
A new product, currently undergoing clinical trials, SprayGel (Confluent
Surgical, Waltham, MA), meets these criteria. SprayGel is composed
of two liquids which are polyethylene glycol (PEG)-based. PEG is
widely used in a variety of medical products. When these two liquids are
applied while mixing them in situ, they polymerize within seconds to form
a visible, adherent, and conforming hydrogel barrier on the target tissues.
The gel remains intact for the next 5 to 7 days before breaking down by
hydrolysis, and eventual clearance through the kidneys. Preclinical safety
studies of SprayGel adhesion barrier demonstrate that it is a remarkably
inert, biocompatible material, resulting in no signs of toxicity at multiple
time points, even when tested at 25 times the anticipated normal dose.
Clinical studies in Europe and the US further support the safety profile
of this material as an implant. Preliminary prospective randomized
clinical trials have evaluated SprayGel adhesion barrier in open and laparoscopic
myomectomy surgery, as well as in laparoscopic ovarian surgery. In the
European myomectomy study, a significant improvement was demonstrated in
the tenacity of adhesions between the treated and control populations,
when comparing the initial procedures and second-look laparoscopies, as
evaluated by the surgeon. The product is currently under review in a multicenter
pivotal clinical trial in the US.
Adhesion formation after gynecologic surgery is common. When
compared to laparotomy, laparoscopy has been shown to result in less de
novo adhesion formation, but adhesion reformation continues to be a problem.35
Sequelae of intra-abdominal adhesion formation can be fatal, result in
infertility, and be a source of chronic pelvic pain. Minimally invasive
surgical management of adhesion formation affords the patient all of the
known benefits of laparoscopic surgery including less postoperative analgesics,
shorter hospital stays, and more rapid convalescence and return to normal
activities. Unfortunately, recurrence rates after adhesiolysis for
intestinal obstruction are reported to range from 8%36 to 32%37.
Thus, for some patients, adhesiolysis may become a repeat surgical procedure.
No longer can the surgeon ignore the benefits of minimally invasive
surgery for adhesiolysis. While these techniques and procedures are
not without risk, patients should not be denied their inherent advantages.
Astute clinicians must work together to discern the most appropriate uses
for this therapy
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