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GENERAL GYNECOLOGY

Incidence of intraabdominal adhesions in a continuous


series of 1000 laparoscopic procedures
Jean Dubuisson, MD; Revaz Botchorishvili, MD; Sandrine Perrette, PhD; Nicolas Bourdel, MD;
Kris Jardon, MD; Benoît Rabischong, MD; Michel Canis, MD; Gérard Mage, MD

OBJECTIVE: The objective of the study was the laparoscopic evaluation jects (21.10%). Fifty-nine of the 211 cases (28%) involved bowel loops.
of the incidence of intraabdominal adhesions related to prior abdominal The prior indication for surgery did not seem to influence adhesion for-
surgery. mation. The rate of intestinal adhesions significantly increased with the
STUDY DESIGN: This was a prospective monocentric study including a number of prior abdominal surgeries. The rate of intestinal adhesions
continuous series of 1000 gynecologic laparoscopic procedures. Data was significantly higher in cases of prior midline incisions in comparison
were collected on history of abdominal surgery. A precise initial descrip- with the other incisions.
tion of intraoperative adhesions was performed.
CONCLUSION: Extensive preoperative knowledge of prior surgery is es-
RESULTS: Six hundred thirty-seven of the 1000 procedures (63.7%) sential to evaluate the risk of adhesion formation.
were performed in patients with a history of 1 or more than 1 abdominal
surgery. Intraoperative adhesions were found in 211 of the 1000 sub- Key words: adhesion formation, laparoscopy, prior laparotomy

Cite this article as: Dubuisson J, Botchorishvili R, Perrette S, et al. Incidence of intraabdominal adhesions in a continuous series of 1000 laparoscopic procedures.
Am J Obstet Gynecol 2010;203:111.e1-3.

A dhesion formation appears mostly


after intraperitoneal surgery, intra-
abdominal infection, or inflammation
subsequent surgery, whatever the route
chosen to access the abdominal cavity.4
The aim of our study was to evaluate
All other procedures were classified as
limited laparoscopic surgery: cystectomy,
salpingectomy, ovariectomy, adhesiolysis,
and pelvic endometriosis. The peritoneal the incidence of intraabdominal adhe- ovarian transposition, surgical treatment
response to injury creates a fibrin-rich sions and their relationship to prior ab- of superficial endometriosis, and adnexal
inflammatory exudate that produces dominal surgery. torsion.
scar tissues and fibrous bands.1 Characteristics of the patient’s surgical
It continues to be a central and current M ATERIALS AND M ETHODS history were identified for each proce-
problem because of the related compli- A prospective monocentric study in- dure by history taking and physical ex-
cations.2 Intraabdominal adhesions are cluding a continuous series of 1000 gy- amination: number of previous abdom-
responsible for 74% of intestinal ob- necologic laparoscopies was conducted inal surgeries; operative indications
struction cases and 20 –50% cases of between January 2006 –April 2007 in the (surgery considered at high risk of adhe-
chronic pelvic pain. These adhesions are University Hospital of Clermont-Fer- sion formation); access to the abdominal
a leading cause for female infertility, rand, France. Data were collected with a cavity; and type of incision.
causing 15–20% of cases.3 They pose an standard questionnaire completed be- Indications representing high risk for in-
increased risk of bowel injuries during fore the surgery by a qualified operator. traabdominal adhesion formation in-
The presence of intraabdominal adhe- cluded digestive surgery (appendectomy,
sions and of any complications related to
From the Department of Obstetrics and sigmoidectomy, peritonitis, colectomy,
the installation phase of laparoscopy
Gynecology, Polyclinique, University bowel obstruction, splenectomy, and par-
Hospital of Clermont-Ferrand, Clermont-
were noted. The level of evidence was in-
tial hepatectomy) and gynecologic surgery
Ferrand, France. termediate (II).
(myomectomy, pelvic inflammatory dis-
Received Dec. 1, 2009; revised Jan. 29, 2010;
Tubal sterilization and diagnostic
laparoscopy were classified as minor ease, severe to moderate endometriosis,
accepted March 18, 2010.
laparoscopic surgery. and neoplasia).
Reprints: Jean Dubuisson, MD, Department of
Obstetrics and Gynecology, Polyclinique, Advanced laparoscopic surgery in- The other types of surgery (including
University Hospital of Clermont-Ferrand, Bd cluded the following procedures: hysterec- cesarean section) were considered at low
Léon Malfreyt, 63000 Clermont-Ferrand, tomy, myomectomy, surgical treatment of risk for adhesion formation.
France. neajdubuisson@yahoo.fr. Seven types of incisions were identified
prolapse, retroperitoneal endometriosis,
0002-9378/$36.00 in patients with previous laparotomy:
endometrial and cervical carcinoma, uter-
© 2010 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2010.03.031 ine retroversion, vesicovaginal fistula, and McBurney, Pfannenstiel, midline in-
pelvic peritonitis. fraumbilical, midline above and below the

AUGUST 2010 American Journal of Obstetrics & Gynecology 111.e1


Research General Gynecology www.AJOG.org

TABLE 1 TABLE 3
Distribution of patients with a Incidence of adhesion formation according to the type of incision
history of abdominal surgery in cases of only 1 previous abdominal surgery (n ⴝ 350)
according to the type Intraabdominal Intestinal
of incision (n ⴝ 637) Type of incision n adhesions, n (%) adhesions, n (%) P value
Type of incision in Laparoscopy 129 10.16 (13) 1.56 (2) ⬍ .001a
..............................................................................................................................................................................................................................................
cases of a history
McBurney 160 23.75 (38) 6.25 (10)
of abdominal ..............................................................................................................................................................................................................................................
surgery n % Pfannenstiel 36 36.11 (13) 13.89 (5)
..............................................................................................................................................................................................................................................
Laparoscopy 347 54.47 Infraumbilical 16 68.75 (11) 6.25 (1)
........................................................................................................... ..............................................................................................................................................................................................................................................
McBurney 324 50.86 Above and below the 6 66.67 (4) 50.00 (3)
...........................................................................................................
Pfannenstiel 140 21.98 umbilicus
..............................................................................................................................................................................................................................................
...........................................................................................................
Infraumbilical 50 7.85 Above the umbilicus 3 100.00 (3) 33.33 (1)
..............................................................................................................................................................................................................................................
........................................................................................................... a
Significant (Fisher’s exact test).
Above and below 28 4.40
Dubuisson. Intraabdominal adhesions in laparoscopic procedures. Am J Obstet Gynecol 2010.
the umbilicus
...........................................................................................................
Abdominoplasty 8 1.26
...........................................................................................................
Right subcostal 6 0.94 A careful inspection of the abdominal hesions, only 6.64% were periumbilical
...........................................................................................................
Above the umbilicus 6 0.94 cavity was conducted to determine the and involved the bowel.
...........................................................................................................
presence of bowel loops, the severity Extensive adhesiolysis was necessary
Dubuisson. Intraabdominal adhesions in (dense or filmy), and the mapping (peri- for 32 of the 1000 procedures (3.20%).
laparoscopic procedures. Am J Obstet Gynecol 2010.
umbilical or not) of abdominal adhesions. In 1 case a laparotomy was directly
Statistical tests used were the Pearson caused by the inability of the surgeon to
umbilicus, midline above the umbilicus, ␹2 test and Fisher’s exact test. The access the abdominal cavity because of
right subcostal, and abdominoplasty. threshold for significance was estab- extensive adhesions.
The initial phase for laparoscopic en- lished at P ⬍ .05. Seven procedures in women without a
try was standardized for all procedures: history of abdominal surgery found ad-
patients under general anesthesia, endo- R ESULTS hesions. One procedure found intestinal
tracheal intubation, and curarization; One thousand laparoscopic procedures adhesions in the region of the appendix.
urinary catheterization; and lithotomy including 975 patients were collected. Six procedures found filmy and never
position without Trendelenburg until The average age of the subjects was 43.5 periumbilical adhesions. Two of these
the scope was in place to inspect the peri- ⫾ 13.4 years. patients had a history of pelvic inflam-
toneal cavity. Among all procedures, 21.6% were matory disease not treated surgically.
The technique for laparoscopic entry minor laparoscopic surgeries, 31.8% Intestinal adhesions occurred in 45 of
depended on the surgeon’s preference. were limited laparoscopic surgeries, and the 454 cases (9.91%) in patients with a
The Veress needle was preferentially 46.6% were advanced laparoscopic history of abdominal surgery that was
chosen in our hospital. surgeries. considered to be at high risk for adhesion
Of the 1000 procedures, 637 (63.7%) formation. Of the 183 procedures per-
TABLE 2 were performed in patients with a his- formed in patients with a history of ab-
Number of previous surgeries tory of ⱖ1 abdominal surgery and 454 dominal surgery that was considered at
for each procedure (n ⴝ 1000) cases (71.27%) were considered at high low risk for adhesion formation, 14 pa-
risk for adhesion formation. The distri- tients (7.65%) had intestinal adhesions.
Number of previous
surgeries n % bution of patients with a history of ab- The difference between the 2 groups was
dominal surgery according to the type of not significant (P ⫽ .46).
0 363 36.30
........................................................................................................... incision is listed in Table 1. The rate of intestinal adhesions signif-
1 350 35.00 Two hundred fourteen patients icantly increased with the number of
...........................................................................................................
2 181 18.10 (21.40%) had a history of surgery by lap- prior abdominal surgeries (P ⬍ .001):
...........................................................................................................
3 65 6.50 arotomy. The number of previous sur- 0.28% (n ⫽ 1) without prior surgery,
...........................................................................................................
geries for each patient varied from 1– 6 as 6.29% (n ⫽ 22) with 1 prior surgery,
4 37 3.70
........................................................................................................... shown in Table 2. 8.29% (n ⫽ 15) with 2 prior surgeries,
5 2 0.20
........................................................................................................... Intraoperative adhesions were found 16.90% (n ⫽ 11) with 3 prior surgeries,
6 2 0.20 in 211 of the 1000 cases (21.10%). Of and 74% (n ⫽ 10) with more than 3 prior
........................................................................................................... these, 59 (28%) involved bowel loops surgeries.
Dubuisson. Intraabdominal adhesions in
laparoscopic procedures. Am J Obstet Gynecol 2010.
and 14 (23.73%) of these were perium- In patients with only 1 prior surgery, the
bilical. Thus, among intraoperative ad- rate of intestinal adhesions varied with the

111.e2 American Journal of Obstetrics & Gynecology AUGUST 2010


www.AJOG.org General Gynecology Research

The prior indication for surgery does


TABLE 4 not seem to influence adhesion formation.
Incidence of adhesion formation for midline incision in cases Extensive preoperative knowledge of
of only 1 previous abdominal surgery (n ⴝ 350) prior surgery is essential to evaluate the
Type of Intraabdominal Intestinal risk of adhesion formation. Patients at
incision n adhesions, n (%) adhesions, n (%) P value high risk for bowel injury during the
Midline 25 72.00 (18) 20.00 (5) .012a laparoscopic phase of entry can be better
..............................................................................................................................................................................................................................................
Other 325 19.69 (64) 5.23 (1710) identified with knowledge of her history
(laparoscopy, of abdominal surgery. f
McBurney,
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AUGUST 2010 American Journal of Obstetrics & Gynecology 111.e3