|Year : 2019 | Volume
| Issue : 2 | Page : 499-505
The role of laparoscopic adhesiolysis in the treatment of patients with recurrent, adhesive intestinal obstruction Menoufia Medical Journal
Ayman A Albatanony1, Mohammed H El Meligy1, Mohamed A Dorbok2
1 Department of General Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of General Surgery, Damanhour Medical National Institute, Damanhour, El Beheira Governorate, Egypt
|Date of Submission||03-Oct-2017|
|Date of Acceptance||06-Dec-2017|
|Date of Web Publication||25-Jun-2019|
Mohamed A Dorbok
Department of General Surgery, Damanhour Medical National Institute, Damanhour 22516, El Beheira Governorate
Source of Support: None, Conflict of Interest: None
The aim of this study was to assess the role of laparoscopic adhesiolysis in the treatment of patients with recurrent attacks of adhesive intestinal obstruction.
Adhesive intestinal obstruction represents a common clinical problem following abdominal surgery with a high recurrence rate. Once adhesion has formed, its only means of elimination is operative adhesiolysis. Theoretically, adhesiolysis performed through a laparoscope is expected to provide better outcomes than the conventional open procedure.
Patients and methods
This is a prospective study that was done on a consecutive sample of 20 patients who were admitted to Menoufia University Hospital and Damanhour Medical National Institute during the period between April 2016 and February 2017 with recurrent postoperative adhesive intestinal obstruction that improved with conservative management. Exclusion criteria were peritonitis, severe abdominal distension, pregnancy, liver diseases, and previously confirmed or strongly suspected abdominal malignancy. All patients had undergone elective laparoscopic adhesiolysis after obtaining informed consent. Patients were followed up for 6 months. The complications and the outcome of the operation were recorded.
Postoperative adhesions were identified laparoscopically in all patients. In the majority of cases (80%), the location of adhesions was distal to the lower abdomen. Successful complete laparoscopic adhesiolysis was feasible in 18 (90%) patients. Conversion to laparotomy was required for two (10%) patients because of intestinal perforation (n = 1) or a convoluted mass of adherent bowel (n = 1). One recurrence of intestinal obstruction was noted over a follow-up period of 6 months and improved with conservative management.
Laparoscopic adhesiolysis for recurrent postoperative adhesive bowel obstruction is feasible and safe, with a high success rate in experienced hands and results in minimal perioperative morbidity.
Keywords: adhesiolysis, intestinal obstruction, laparoscopy, postoperative adhesions, recurrence
|How to cite this article:|
Albatanony AA, El Meligy MH, Dorbok MA. The role of laparoscopic adhesiolysis in the treatment of patients with recurrent, adhesive intestinal obstruction Menoufia Medical Journal. Menoufia Med J 2019;32:499-505
|How to cite this URL:|
Albatanony AA, El Meligy MH, Dorbok MA. The role of laparoscopic adhesiolysis in the treatment of patients with recurrent, adhesive intestinal obstruction Menoufia Medical Journal. Menoufia Med J [serial online] 2019 [cited 2019 Sep 17];32:499-505. Available from: http://www.mmj.eg.net/text.asp?2019/32/2/499/260911
| Introduction|| |
Abdominal adhesions are abnormal fibroid bands that bind between organ surfaces or the walls in the abdominal cavity. Surgery on the abdomen by laparotomy is the primary cause of adhesions, and the development of adhesions is considered to be the most common physiological reaction following abdominal surgical exposure.
Complications of postoperative adhesions include intestinal obstruction, chronic abdominal pain, infertility in women, and the difficulties experienced during reoperative interventions.
Postoperative adhesions are one of the most common causes of intestinal obstruction. They are responsible for 40% of all cases of intestinal obstruction, but from 65 to 75% of small bowel obstruction (SBO) such as stenoses of the large intestine are produced principally by malignancies and only rarely by adhesions.
A large proportion of the adhesive SBO cases resolve with nonoperative methods such as fasting and ingestion of an oral contrast medium; however, a significant number of patients will need emergency surgery.
The recurrent nature of adhesive SBO represents a major clinical problem. Surgery can induce new adhesions, whereas conservative treatment does not remove the cause of the obstruction.
After Bastug performed the first successful laparoscopic adhesiolysis for SBO in 1991, laparoscopic adhesiolysis has been increasingly accepted by more and more surgeons because of its less intra-abdominal adhesions, low morbidity, shorter hospital stay, and faster recovery.
The aim of this study was to assess the role of laparoscopic adhesiolysis in the treatment of patients with recurrent attacks of adhesive intestinal obstruction.
| Patients and Methods|| |
This prospective study was done on a consecutive sample of 20 patients who were admitted to Menoufia University Hospital and Damanhour Medical National Institute and satisfied the inclusion and exclusion criteria to be enrolled in the study during the period between April 2016 and February 2017. The study was completed in August 2017.
The procedure followed in the study is in accordance with the ethics committee of Menoufia Faculty of Medicine and Damanhur Medical National Institute and written consents were taken from the patients or their guardians.
Patients with recurrent, postoperative, adhesive intestinal obstruction (experienced at least two attacks of intestinal obstruction) that improved with conservative management.
Those with peritonitis, severe abdominal distension, pregnancy, liver diseases and previously confirmed or strongly suspected abdominal malignancy were excluded.
All patients were subjected preoperatively to a detailed history taking and clinical examination. Their last investigations were revised from their files in the records.
Elective laparoscopy was performed with the patient in the supine position under general anesthesia. All patients received an appropriate single dose of a prophylactic antibiotic (third-generation cephalosporin) at the induction of anesthesia.
Video monitors were placed at the head of the table if the previous operation was in the upper abdomen or at the foot if in the lower abdomen. The surgeon stood on the opposite side of the video monitor.
After inserting a suitable nasogastric tube and a urinary catheter according to age and sex, the abdomen was entered away from the scars of previous operations with either an open approach or through the Veress needle.
When the Veress needle is used, the syringe test was performed to confirm that the tip of the needle was not located in a vessel or intestine as follows: 5 ml of normal saline solution (0.9%) was injected through the Veress needle. If the saline solution entered the peritoneal cavity, it could not be reaspirated. If the saline solution was reaspirated, it signified that the tip of the Veress needle was in a closed cavity or newly formed space.
When operating on a child or a very thin patient, the open Hasson technique was chosen as they are potentially at risk of trocar-related injury, mainly with the primary port, because they have limited abdominal space so the viscera and the major vessels are much closer to the abdominal wall.
Pneumoperitoneum was established by insufflation of carbon dioxide to a maximum pressure of 14 mmHg. Under direct vision, the remaining ports were inserted according to the initial telescopic evaluation of the abdominal cavity and the sites of adhesions to make it accessible for cutting. The bowel was manipulated with atraumatic graspers, and adhesions were identified and lysed with a combination of sharp and blunt dissection. To minimize the risk of intestinal injury and recurrence of adhesion formation, diathermy was not used except for hemostasis.
Once adequate adhesiolysis was complete, the lysed area was thoroughly inspected for possible bleeding and bowel injury. Ports were removed under vision after insertion of a tubal drain. Fascial defects larger than 10 mm were closed with nonabsorbable sutures to prevent port-site hernia.
Postoperatively, the patients were managed as follows:
The patients were kept nil by mouth on intravenous fluids till regaining of bowel activity in the form of audible bowel sounds and passing of flatus or motion. After regaining bowel activity, the nasogastric tube was removed and oral fluids were started first followed by a soft diet.
Wound infection, postoperative ileus, peritonitis, and other general complications – for example, deep venous thrombosis and chest infection, if any, were recorded and taken care of. Patients were discharged after per oral nutrition was tolerated and sufficient pain relief was achieved. The duration of postoperative hospital stay was recorded. Patients were asked to follow up after 1 week, 1, 3, and 6 months for later complications such as port-site hernia, recurrence of obstruction, and need for reoperation.
Data were fed to the computer and analyzed using IBM SPSS software package, version 20.0 for Windows (SPSS Inc., Chicago, Illinois, USA) and MedCalc 13 for Windows (MedCalc Software BVBA, Ostend, Belgium). Qualitative data were described using numbers and percentages. The Kolmogorov–Smirnov test was used to verify the normality of distribution Quantitative data were described using range (minimum and maximum), mean, SD, and median.
| Results|| |
The age of the 20 patients ranged from 10 and 56 years with a median age of 36.0 years. The mean age of the cases was 34.5. Twelve (60%) patients were men, whereas eight (40%) were women. The male to female ratio was 1.5: 1. The highest incidence (35%) was among patients with an age range from 31 to 40 years, whereas the lowest incidence (10%) was in patients with an age of more than 50 years [Table 1].
|Table 1: Distribution of the studied cases according to different parameters|
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The operations accounting for the majority of postoperative, adhesive intestinal obstruction were appendicectomies, followed by gynecological surgeries, then colonic surgeries [Figure 1].
|Figure 1: Distribution of the studied cases according to the previous surgery. PU, peptic ulcer.|
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Out of the 20 cases, 12 (60%) patients had a previous emergency surgery, whereas eight (40%) patients had a previous elective surgery [Table 2].
|Table 2: Distribution of the studied cases according to the cause of previous surgery|
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Most of the patients (12) had previous two attacks of bowel obstruction (60%) whereas only two (10%) had attacks for four times. The rest six (30%) patients had attacks for three times [Table 1].
Laparoscopic access was performed through the umbilicus in 13 (65%) cases. Palmer's point and the corresponding point on the right side were used as the entry site in patients with midline scars of previous operations (30%). Entry through the right lower quadrant was done on one occasion (5%). There were no complications during port placement [Table 1].
In the majority of cases (80%), adhesions were found in the lower abdomen. [Table 1] showed that three ports only were used in 17 (85%) cases. An additional port was needed in the other three (15%) cases.
Adhesiolysis was successfully done by using the laparoscopic approach in 18 (90%) of 20 cases. Conversion to laparotomy was required in two (10%) cases. In one, a minilaparotomy (4 cm length) was performed for an intestinal perforation caused during adhesiolysis. Conventional laparotomy was required in the other patient for extensive dense and matted adhesions that would have been impossible to separate laparoscopically. During laparoscopic adhesiolysis, intestinal serosal injury occurred in two (10%) patients and urinary bladder injury occurred in one (5%) patient. These injuries were successfully repaired by suturing under laparoscopy. There was no need for blood transfusion in any of the cases [Figure 2].
|Figure 2: Distribution of the studied cases according to intraoperative complications.|
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In the cases completed laparoscopically, the mean operative time was 94.11 min, and the mean postoperative hospital stay was 4 days. For the patients in whom laparoscopy was converted to laparotomy, the mean operative time was 146.5 min, and the mean postoperative hospital stay was 9 days [Table 3].
|Table 3: Distribution of the studied cases according to operative time and hospital stay|
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Postoperative complications were present in five (25%) patients. Two patients had prolonged postoperative ileus (>48 h). One of the patients in whom laparoscopy was converted to open surgery had wound infection. Urine leak from the drain occurred in the patient in whom urinary bladder was injured during adhesiolysis and was repaired laparoscopically. It was managed conservatively with inserting a wider Foley catheter and followed up till the leak disappeared after 2 weeks. Chest infection occurred in another one patient. No cases of peritonitis or deep venous thrombosis were recorded [Figure 3].
|Figure 3: Distribution of the studied cases according to postoperative complications.|
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In all, 95% of patients got improved after laparoscopic adhesiolysis. During the 6-month follow-up period, only one (5%) patient had a recurrent attack of obstruction once that improved with conservative management. There were no cases of port-site hernia or need for reoperation. Mortality was nil.
| Discussion|| |
Intra-abdominal adhesions are formed as a result of the inflammatory response to operative injury and infection. These adhesions represent the effect of the imbalance between fibrin deposition and degradation. Although they result in almost all patients after abdominal and pelvic operations, only a minority will develop symptoms and still fewer suffer the morbidity of intestinal obstruction.
Adhesive SBO can be a difficult illness to manage for both patients and surgeons. Peritoneal adhesions are the most common cause of SBO, accounting for 65–75% of cases. The risk to patients following abdominal and pelvic operations is lifelong.
Intraoperative techniques such as meticulous hemostasis, gentle handling of tissues, minimizing peritoneal dissection, avoidance of intestinal or biliary spillage, using starch-free gloves, and removing the remaining suture materials are basic principles that should be applied to all patients in order to reduce the risk of postoperative adhesion formation.
Postoperative peritoneal lavage is an idea developed to minimize postoperative adhesions based on the observation that patients who developed postoperative ascites rarely complain of adhesion-related disorders. It achieved significant reduction in the recurrence rate of adhesive SBO.
In theory, inert materials that prevent contact between the damaged serosal surfaces for the first few critical days allow separate healing of the injured surfaces and may help in the prevention of adhesion formation. Various bioabsorbable films or gels, solid membranes, or fluid barrier agents have been tested experimentally and in clinical trials.
An ideal barrier should be biodegradable, safe, non-inflammatory, and nonimmunogenic, persist during the critical remesothelialization phase, stay in place without sutures or staples, remain active in the presence of blood and are rapidly and easily applied. Also, it should not interfere with healing or promote infection.
The use of hyaluronic acid–carboxymethylcellulose membrane, icodextrin solution, knitted fabric of modified cellulose, or polyvinyl alcohol-based gels have been shown to decrease adhesion burden to some extent. However, their efficacy in the prevention of adhesive SBO has yet to be identified.
Traditionally, adhesiolysis by laparotomy has been the standard surgical management of SBO caused by adhesions, but open surgery is likely to cause further adhesions, with up to 30% of patients requiring another laparotomy for recurrent obstruction.
Nowadays, symptomatic adhesions such as in recurrent SBO can safely be treated laparoscopically. Thus, patients operated on with this approach can benefit from the widely demonstrated advantages of laparoscopic surgery: less postoperative pain, less ileus, a decreased incidence of wound infections, a lower incisional hernia rate, shorter postoperative hospital stay, esthetic benefits, and a decrease in future adhesions.
In the present study, the highest incidence of adhesive intestinal obstruction (35%) was among patients with an age range from 31 to 40 years.
This is similar to the results obtained by Al-Amiri and Muhi, in a study on 108 patients in 2013. They found that the peak incidence of adhesive intestinal obstruction was 32.4% among the age group of 30–39 years.
In our study, the male to female ratio was 1.5: 1, and this shows a slight increase in the incidence of postoperative adhesive intestinal obstruction in the male sex.
This is similar to the results obtained by Kuremu and Jubi in South Africa in 2006. They found that the male to female ratio was 1.6: 1. In contrast, Sastry et al. reported that women have a greater risk for postoperative adhesive SBO than men, even after exclusion of operations for gynecological indications.
In our study, appendicectomy was the commonest previous operation that caused postoperative adhesive intestinal obstruction.
The high number of obstructions after appendicectomy must reflect the fact that this is a commonly performed operation and not that the appendicectomy is particularly prone to producing obstruction.
Leung et al. reported that the rate of SBO following appendectomy in adults is 2.8%. The risk factors for developing SBO following appendectomy for appendicitis include appendiceal perforation, midline incision, and chronic appendicitis.
There was a higher incidence of postoperative, adhesive intestinal obstruction among those patients with previous emergency surgery as compared with those with previous elective surgery.
This is comparable with the results obtained by Raja et al. in India in 2016 in their study on postoperative adhesions following various abdominal incisions and surgeries. They reported that in 64% of cases, postoperative, adhesive intestinal obstruction occurred after a prior emergency surgery and in 36% after an elective procedure.
Laparoscopic treatment was attempted in all 20 patients. The mean number of hospitalizations for attacks of SBO was 2.5 before entry into the study. All prior episodes resolved with conservative nonsurgical management alone.
Special care was taken in selecting the initial port site. According to the previous operations, the size and position of previous incisions, and the origin of SBO according to preoperative abdominal radiological examinations, the initial port site was determined. The abdomen was entered in a virgin part away from any previous scars and adhesions via an open technique, or through a Veress needle.
In the majority of cases (80%), the location of adhesions was in the lower abdomen. This is similar to the results obtained by Wang et al. in China in their study to evaluate the efficiency, safety and outcome of laparoscopic adhesiolysis for recurrent SBO.
Successful complete laparoscopic adhesiolysis was feasible in 18 (90%) of the 20 patients. Conversion to laparotomy was required in two (10%) cases for intestinal perforation occurred during adhesiolysis or due to the presence of dense, matted adhesions.
In a review study conducted by O'Connor and Winter, the rate of conversion from laparoscopic surgery to open surgery in patients with SBO was 29%.
We feel that the main factor for the low rate of conversion in our study is attributable to the fact that 100% of the cases were performed electively in the absence of acute obstruction.
In the 18 cases completed laparoscopically, intraoperative complications were present in three (15%) occasions. This is comparable with the results of Sato et al., in their study to assess the efficacy and outcome of laparoscopic adhesiolysis in the treatment of patients with recurrent postoperative SBO. They reported that iatrogenic intestinal injuries occurred during laparoscopic adhesiolysis in three cases out of 14 in whom adhesiolysis was completed laparoscopically.
In most of the cases, three ports were used; one for the camera and two working ports. An additional port was inserted when needed during the repair of intestinal serosal tears or urinary bladder injury.
As regards the operative time and the postoperative hospital stay, our results are comparable with those obtained by Sato et al., who reported that the mean operative time of elective laparoscopic adhesiolysis was 105 min and the mean postoperative hospital stay was 10.4 days. In the cases that were converted to laparotomy, the mean operative time was 119 min and the mean postoperative hospital stay was 18.3 days.
In our study, 95% of the patients did not have any recurrence of intestinal obstruction during a follow-up period of 6 months.
The long-term results regarding recurrence are limited, with most series reporting a mean follow-up of between 12 and 24 months. Navez et al. reported that 85% (29 of 34) of the patients treated laparoscopically were asymptomatic with a mean follow-up of 46 months. Sato et al. in the study with the longest follow-up (mean: 61.7 months) reported that 87.5% (14 of 16) of the patients treated laparoscopically were asymptomatic.
| Conclusion|| |
Laparoscopic adhesiolysis for recurrent postoperative adhesive bowel obstruction is feasible and safe, with a high success rate in experienced hands and results in minimal perioperative morbidity. Conversion to laparotomy should be considered when it is difficult or dangerous to separate bowel loops by using laparoscopic techniques.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]