ADHESIOLYSIS

Reno Rudiman
Bagian Ilmu Bedah FKUP/RSHS
2021
INTRODUCTION

• Abdominal adhesions are fibrous bands that span two

or more intra-abdominal organs and/or the inner
abdominal wall (i.e.peritoneal membrane) which
typically form after abdominal surgery.
INTRODUCTION

• Adhesions may also form secondary to

inflammatory conditions of the abdomen in
the absence of prior abdominal surgery or as
a sequela of abdomino-pelvic radiation.
• Although the majority of patients with intra-
abdominal adhesions remain asymptomatic, a
clinically significant subset of patients will
develop “adhesive disease”, a symptomatic
state ranging from mild and/or vague to highly
distressing and even life-threatening
symptoms
 INTRODUCTION

• Adhesions have no characteristic laboratory features

and are not readily visible by currently available imaging
methods
• Many cases of adhesive disease will go undiagnosed for
prolonged periods of time, causing diagnostic and
therapeutic quandary

D. Menzies, H. Ellis. Intestinal obstruction from adhesions; how big is the problem? Ann. R. Coll. Surg. Engl., 72 (1990), pp. 60-63
ETHIOPATHOGENESIS

• The mechanisms of adhesiogenesis are not well

understood but are believed to involve mesothelial
surface disruption with subsequent fibrinocoagulative
and inflammatory signaling processes

S.M. Kavic, S.M. Kavic. Adhesions and adhesiolysis: the role of laparoscopy. JSLS, 6 (2) (2002 Apr-Jun), pp. 99-109
ETHIOLOGY OF ADHESIOGENESIS
Post-surgical
• Nearly 90% of abdominal adhesions related to
prior abdominal surgery, primarily laparotomy (i.e.
open surgery)

• The incidence of significant adhesions has decreased

considerably in laparoscopic surgery era
ETHIOLOGY OF ADHESIOGENESIS
Post-inflammatory or Infection
• Endometriosis and pelvic inflammatory disease
are the most common etiologies of non-
surgical adhesions in women.
• Other etiologies affecting either sex include
• Diverticular disease (small bowel),
• Crohn's disease,
• Abdominal tuberculosis (in endemic areas)
ETHIOLOGY OF ADHESIOGENESIS
Post-radiation
• Abdominopelvic radiation used for
treatment of a variety of malignancies,
(incl. gynecologic, prostatic, rectal, or
lymphoproliferative diseases), can cause
adhesions as a late sequela
• The severity depends on the anatomic
extent of the area treated, the degree
of dose fractionation, and the total dose
of radiation
ABDOMINAL ADHESIVE DISEASE
Symptoms
• Chronic (persistent or intermittent) bloating
• Abdominal cramping and borborygmi
• Altered bowel habits: constipation or frequent loose stools
• Nausea with or without early satiety.
• Bowel obstruction: transient, partial, or complete
• Female infertility and dyspareunia.
• Rectal bleeding and dyschezia during menses, indicate
colorectal involvement of endometriosis
ABDOMINAL ADHESIVE DISEASE
Differential Diagnosis
• Lactose intolerance
• Medication induced symptoms: PPI, Ca blockers
• Endometriosis: Great masquarader
• Acalculous cholecystitis
• Fatty liver
• Others: Peptic ulcer disease, IBD, diverticulosis
ABDOMINAL ADHESIVE DISEASE
Diagnostic Evaluation
• There are no specific laboratory tests associated with
adhesive disease, but such investigations are needed
to rule out other entities. Examples:
• Increased C-reactive protein
• Profound anemia, or
• Serum liver test abnormalities
• If found: need further evaluation for other etiologies
ABDOMINAL ADHESIVE DISEASE
Diagnostic Evaluation
• Imaging findings are usually non-diagnostic, unless the
adhesions have caused acute obstruction

• If obstruction is seen, adhesions as the cause of

obstruction are generally difficult to discern

• Abdominal imaging is valuable to rule out other

etiologies for a patient's symptoms
ABDOMINAL ADHESIVE DISEASE
Non-invasive Management
• No effective targeted pharmacotherapies for adhesive
disease.
• Empiric and symptomatic treatmet
for dyspepsia (e.g. simethicone, proton pump inhibitors,
nortriptyline) are often given but are of variable efficacy,
• Fiber supplementation to treat “constipation” associated with
adhesive disease will not produce relief and may cause more
discomfort
• For patients with predominantly abdominal cramp-like
symptoms, smooth muscle relaxants such as dicyclomine may
be worth trialing
ABDOMINAL ADHESIVE DISEASE
Surgical Intervention
• Laparoscopic surgery for treatment of acute bowel
obstruction is associated with favorable long-term
success rates, with recurrence rates less than those seen
with open surgery
• If the pathology is identified to be only a few adhesive
bands, laparoscopic surgery may be expedient and highly
successful
• In complex, and/or dense adhesions may necessitate a
more complicated surgery and may produce less
favorable short-and long-term outcomes, since complete
removal of all adhesions is high risk and prone to
recurrent adhesion formation.
SURGICAL MANAGEMENT
Approach Consideration
• The preferred approach should be to operate in a
"known-to-unknown" fashion.
• Enter from virgin teritorry
• Provide the appropriate initial exposure for safely addressing any
problematic adhesions
SURGICAL MANAGEMENT
Open Approach
• Incision starts from virgin area where anatomy is clear,
then move toward the adhesion area

• Fascial dissection guided by finger to detect any

adherent bowel, avoid bowel injury

• One important key: patience

SURGICAL MANAGEMENT
Open Approach
• Gentle traction of the adhesion: helps dealienate the
bowel anatomy

• Signs of obstruction: dilated proximal bowel, collapsed

distal bowel

• Subject of debate: Optimal extent of adhesiolysis; all

bowel involved, or obstructing adhesion only
SURGICAL MANAGEMENT
Laparoscopic Approach
• Advantages of laparoscopic approach in
adhesiolysis:
• Less postoperative pain
• Decreased incidence of ventral hernia
• Reduced recovery time with earlier return of
bowel function
• Shorter hospital stay
SURGICAL MANAGEMENT
Laparoscopic Approach
• Trocar placement:
• First trocar 5-10 cm away from previous scar
• Next 2-4 trocars should provide adequate
visualization and working space, with good
triangulation
SURGICAL MANAGEMENT
Laparoscopic Approach
• Dissection of adhesions:
• Adhesion to abdominal wall take down first
• Blunt and sharp dissections are preferred
• Energy devices: risks of thermal injury. Use with
caution, make sure no hidden bowel when firing
• When a point of obstruction is not clearly defined, the
bowel should be run until all suspicious bands are
removed
SURGICAL MANAGEMENT
Lessons To Learn
• Identification of tissue plane is essential.
• Learn to recognize the interface of two different tissue types,
and cut perpendicular to the bowel wall. If a bowel injury
occurs, repairing a straight laceration is easier.
• Start in an area that is easy. Taking down the adhesions that
are easy to take down may facilitate working in areas that are
harder to handle.
• Try to get a sense of the tissue. Some patients have tissue
that will tear easily, whereas others have tissue that readily
permits blunt dissection.
• An individualized approach to each patient's tissues is
important.