Open Adhesiolysis: Background

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com/article/1829778-print
 

 
emedicine.medscape.com

Open Adhesiolysis 
Updated: Dec 03, 2019
Author: Brian J Daley, MD, MBA, FACS, FCCP, CNSC; Chief Editor: Kurt E Roberts, MD 

Overview

Background
Peritoneal adhesion formation is a common consequence of any operation or intra-abdominal inflammatory process
(eg, pelvic inflammatory disease [PID], diverticulitis, spontaneous bacterial peritonitis). It is estimated that intra-abdominal
adhesions develop in 90-95% of patients after surgery.[1, 2, 3, 4, 5, 6, 7]

The underlying mechanism of adhesion formation involves injury to the peritoneal epithelium resulting in fibrin matrix
deposition to the injured intra-abdominal surfaces. Fibrinolysis by plasmin is typically inadequate in the postoperative period,
and the nondegraded deposits lead to adhesion formation.[5]  Congenital causes of adhesions (eg, Ladd bands) exist but
represent only a small minority of cases.

The morbidity from adhesions can range from chronic abdominal pain to female infertility.[1, 8]  The most common of these
conditions is partial or complete intestinal obstruction, for which the small bowel is the most common location. Postoperative
adhesions account for as many as 79% of acute intestinal obstructions.[2]

The spectrum of treatments for a small-bowel obstruction ranges from conservative management with bowel rest to surgical
intervention, sometimes involving bowel resection. The caveat with regard to surgical treatment is that whereas surgery may
be required to release symptomatic adhesions, postoperative reformation of these adhesions is common. Debate continues
as to whether laparoscopic adhesiolysis yields added benefit in terms of decreasing postoperative adhesion reformation;
however, promising results have been obtained with this approach.[9, 10, 11, 12]

Nonsurgical treatments have been used,[13]  such as anti-inflammatory agents, synthetic inert solid barriers, and fibrinolytic
agents. However, none of these treatments has proved uniformly effective under all circumstances.[4] Therefore, surgical
adhesiolysis should be performed promptly for patients for whom surgery is clearly indicated but should be reserved for
those patients who do not respond satisfactorily to nonsurgical treatment.

Indications
Past surgical dogma dictated that "the sun should never rise or set on a small-bowel obstruction," reflecting the view that
surgery is the definitive means of preventing progression to bowel necrosis. This school of thought has given way to a more
conservative approach that makes use of nasogastric tube decompression, fluid resuscitation and electrolyte correction,
bowel rest, serial abdominal examinations, and radiologic contrast studies. All of these methods have improved over time.

Many bowel obstructions can be successfully managed by nonoperative means, but complete or high-grade partial bowel
obstructions will require surgical management more often than not. Ultimately, more than half of all patients with small-bowel
obstructions who are admitted to the hospital eventually require surgery.

Strangulated or dead bowel, or the fear of such, is an indication for immediate surgical intervention in the context of a small-
bowel obstruction. Frank peritoneal signs on abdominal examination findings, demonstrating hemodynamic instability and a
lactic acidosis or elevated base deficit, support the clinical diagnosis of strangulated or dead bowel.

Bowel ischemia is more difficult to diagnose immediately; however, increasing abdominal pain, a rising white blood cell
(WBC) count, and acidosis that worsens despite adequate resuscitative measures are grounds for concern. In this setting,
surgical treatment should not be delayed.

When intestinal ischemia is less likely, the patient may be observed with conservative management. The length of time for
which patients can be managed conservatively, if their condition remains stable but does not improve, varies. The period
before surgical intervention may be anything from 48 hours to 1 week. However, the decision to operate should be based
not on a specific timeframe but on the overall clinical picture and the findings from continuous evaluation.

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Imaging studies remain vitally important for therapeutic decision-making (see the images below). For example, water-
soluble contrast that reaches the cecum on a plain film within 24 hours of administration predicts resolution of an adhesive
small-bowel obstruction with a sensitivity and specificity of 96%.[14]  Improvements in the capability of computed
tomography (CT) have given this modality a sensitivity, specificity, and accuracy of 95% or greater.[9]

Air fluid levels.

Pneumatosis of bowel wall.

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Transition point.

Cecal volvulus.

Another valid, albeit less definitive, sequela of intra-abdominal adhesions is chronic abdominal pain. Despite the well-known
surgical wisdom that "operating purely to cure pain only brings pain," chronic abdominal pain can be a relative indication for
adhesiolysis. This diagnosis should be one of exclusion, made after conditions such as gallbladder disease, pancreatitis,
mesenteric ischemia, and peptic ulcer disease have been ruled out.[9]

Laparoscopy is commonly used for adhesiolysis because of the elective nature of the procedure and because of the shorter
recovery time and lower incidence of pain and infection in comparison with laparotomy.[15, 16, 17, 18, 19]  In addition, the
incidence of postoperative adhesion formation is expected to be lower after laparoscopy.[20]  However, there remains a
need for long-term randomized trials comparing laparoscopic and open adhesiolysis. The major issue in the laparoscopic
approach to treating adhesions is determining which adhesion is the symptomatic one causing pain.

The issue of infertility is another indication for surgical treatment (more often via a laparoscopic approach).[9]  Adhesions
can form that distort the natural tubo-ovarian relationship, precluding normal ovum capture and transport by the fimbriated
end of the fallopian tube and leading to fertility issues.[1]  The success of the operation depends on the underlying cause of
adhesion formation and the severity of the tubal disease.

Contraindications

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In settings where a surgical approach is considered essential, the viability of the bowel is in question and failure to provide
prompt and appropriate treatment can be life-threatening. Given the potentially serious consequences of not performing the
necessary operation, only the most significant contraindications (eg, clear advance directives ruling out surgery, a patient
who refuses treatment, a futile outcome, or the presence of a known "frozen abdomen") should be allowed to alter the
surgical plan.

If the situation is not dire, the surgical alternative can always be deferred and a more conservative approach tried first,
though this option may not prove advantageous in some situations.

Technical Considerations
Complication prevention

Surgical lysis of adhesions may be associated with significant complications; accordingly, care must be taken to minimize
postoperative morbidity and mortality.

Prevention of adhesiolysis-associated enterotomies can have a significant impact on reoperative morbidity and mortality.
This is significant in view of the chronic potential of the condition; patients who have undergone three or more previous
laparotomies have a 10-fold greater risk of enterotomies than patients who have undergone one or two previous
laparotomies.[21]

With the increased rates of unrecognized sharp, blunt, or energy-related bowel injury during laparoscopic adhesiolysis, early
conversion to open adhesiolysis during difficult cases is advantageous. The mortality in this population with an unrecognized
bowel injury is 20-50%.[21, 22]  The rate of conversion from laparoscopic to open adhesiolysis for a small-bowel obstruction
has been reported to be as high as 32%.[9]

Outcomes
A simple obstruction adhesiolysis carries a mortality of 5%, and mortality can be 30% or higher when strangulated or
necrotic bowel is involved.[9] Recurrence rates for adhesive bowel obstruction after conservative or operative treatment
range from 29% to 53% in the literature,[9] illustrating the chronic potential of the problem. In a study of 156 patients, Yao et
al concluded that laparoscopic adhesiolysis led to a higher incidence of recurrence necessitating further surgery.[23]

Periprocedural Care

Preprocedural Planning
A patient with frank peritoneal signs on abdominal examination, hemodynamic instability, lactic acidosis or an elevated base
deficit, and an elevated white blood cell (WBC) count in the context of a small-bowel obstruction is assumed to have a
strangulated or dead bowel until the operation proves otherwise. Such a patient needs immediate surgical intervention.

However, if a patient has mild-to-moderate abdominal tenderness, a stable WBC count, no fever, and a distended abdomen,
and if water-soluble contrast reaches the cecum on a plain film within 24 hours, there is a very high likelihood that an
adhesive small-bowel obstruction will resolve with conservative management.

Equipment
A standard operating room (OR) with the appropriate personnel and staff is required. The equipment in the OR is that
typically needed for any surgical case (eg, a ventilator, other pertinent anesthesia equipment, an operating table, a back-
table instrument setup, and a suction and irrigation system).

A full laparotomy tray should be available. Depending on the surgeon’s preference, an electrocautery, an ultrasonic
dissector, or other energy devices can be used to separate adhesions during the operation. Gastrointestinal (GI) and
vascular staplers may be beneficial, depending on the extent of the operation.

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Patient Preparation
Anesthesia

General anesthesia is essential for the procedure: it ensures a controlled and relaxed patient for the surgeon to work with.
Placement of an arterial catheter is often beneficial for real-time blood pressure monitoring. Placement of a Foley catheter in
the urinary bladder allows intraoperative assessment of volume status and end-organ perfusion; it can also serve as a
landmark for the bladder if the adhesions distort the pelvic anatomy.

Application of a longer-acting local anesthetic (eg, bupivacaine) to the incision site before the incision is beneficial in
controlling postoperative pain. Additional modalities, such as incisional continuous local anesthesia delivery devices and
epidural infusions, are often used but frequently unnecessary.

Positioning

The patient should be placed in the supine position with the arms securely tucked at the sides. A small pillow should be
placed underneath the posterior aspect of the knees, and all of the dependent portions of the body should have
appropriately padded support.

Technique

Approach Considerations
Many adhesiolysis procedures are performed in nonvirgin abdomens, in which the presence of adhesions should be
expected. For any surgeon dealing with a hostile abdomen, the preferred approach should be to operate in a "known-to-
unknown" fashion. For instance, if the patient has an infraumbilical or lower-midline scar from a previous operation, the
abdomen should be entered in the midline superior to the scar, where adhesions presumably are less likely. This will provide
the appropriate initial exposure for safely addressing any problematic adhesions.

This technique is appropriate for laparoscopy as well, with port sites being placed in quadrants away from previous scars in
order to avoid injury to adhered or tethered bowel (see Laparoscopic Adhesiolysis).

Open Approach to Abdominal Adhesions


The abdomen is prepared and draped in a sterile fashion. A median (midline) incision is made from the subxiphoid region to
the suprapubic region, with a curvilinear portion to either side of the umbilicus. If necessary, the incision may be extended
inferiorly as far as the symphysis pubis or superiorly as far as the xiphoid. In reoperative surgery, it is advisable to enter the
abdomen in virgin territory (if available) and then work from free space into the adhesions. If an old midline incision exists,
the new incision can retrace it in an effort to minimize scarring.

After dissection through the subcutaneous tissues, the linea alba is identified and exposed over the entirety of the wound.
The fascia is divided carefully and sharply with a scalpel to allow entry into the peritoneal cavity. The fascial defect is probed
with a finger to detect any loops of bowel adhering to the undersurface of the abdominal wall. Any adherent bowel is bluntly
swept away from the midline with the finger. The finger acts as a guide throughout this process to help prevent injury to the
bowel and other intra-abdominal structures.

After the abdominal cavity is opened, the adhesions to the abdominal wall lateral to the facial incision are taken down and
the viscera allowed to fall posteriorly so as to provide working space. The keys here are patience and, again, working from
known to unknown. It is important to start where dissection is easy and the anatomy obvious, then work into the more
difficult and scarred areas.

Often, working with gentle traction on the adhesions to elucidate the anatomy of the bowel loops proves relatively easy. This
may require working proximally and distally to the area of concern before approaching the clear area of obstruction. The
clear area of obstruction will have dilated bowel proximally and decompressed bowel distally.

All quadrants of the abdomen are surveyed for any occult gross pathology or fluid collections. The entire visceral tract, from
stomach to rectum, is examined. The ligament of Treitz is identified, and the small bowel is run up to the terminal ileum. As
the small bowel is mobilized, its viability and integrity are assessed continuously, and any problematic adhesions or
tethering points are separated and taken down even if they do not seem to be responsible for the obstruction.

Other adhesions that mat the bowel together need not be lysed if luminal contents can be manually milked through the
bowel without signs of obstruction. It is helpful to have a nasogastric tube attached to suction during the operation, and the
proximal small bowel can be milked in a distal-to-proximal fashion to decompress the distended bowel loops.
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The optimal extent of adhesiolysis remains subject to debate: some believe that all adhesions should be taken down,
whereas others believe that only the adhesions responsible for the obstruction should be separated.[9]

Any nonviable ischemic bowel is resected, and an end-to-end or end-to-side anastomosis is performed between viable,
healthy portions of the bowel. Under circumstances in which the integrity of an anastomosis may be compromised (eg,
ongoing local or regional infection, diffuse bowel ischemia, or hemodynamic instability), a diverting ostomy is always a
plausible option.

If bowel ischemia is present, a reoperation or second-look operation to confirm viability is a sound practice. In women, the
pelvic anatomy should be examined thoroughly to ensure that adhesions are not distorting the normal anatomic relations of
the ovaries and fallopian tubes.

Complications
Patients can have an extremely complicated course after surgery to lyse adhesions, including sepsis, acute renal failure,
respiratory failure, myocardial infarctions, wound infections, and combinations of these conditions.[24, 25]

Specifically, small-bowel obstruction, chronic abdominal or pelvic pain, inadvertent enterotomy at the time of surgery, and
secondary female infertility are among the most common complications caused by intraperitoneal adhesions.[21, 26] The
paradoxic relation between surgery as a means of treating adhesions and surgery as a factor causing adhesions makes this
condition a difficult one to manage.

The causal association between peritoneal adhesion and chronic abdominal or pelvic pain is widely debated, and research
into this issue is ongoing.[27] At present, roughly 2.3 million women suffer from chronic pelvic pain attributed to adhesions.
[21] The economic burden is significant,[28] given the costs associated with gynecologic medical attention and laboratory
workup, as well as the work hours lost by the patient.

Contributor Information and Disclosures

Author

Brian J Daley, MD, MBA, FACS, FCCP, CNSC Professor and Program Director, Department of Surgery, Chief, Division of
Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian J Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the
Surgery of Trauma, Eastern Association for the Surgery of Trauma, Southern Surgical Association, American College of
Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery,
Association for Surgical Education, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress,
Tennessee Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Chandler Long, MD Resident Physician, Department of Surgery, University of Tennessee Medical Center-Knoxville

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-
in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical
Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of
Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American
Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

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