Adhesions are a very common occurrence.
In postmortem examinations of non-previously operated patients, post-inflammatory adhesions were found in 28 percent of cases. These are caused by intra-abdominal inflammations or can be attributed to endometriosis, peritonitides, radiotherapies, or long-term peritoneal dialysis.
High-resolution computed tomography is now considered the examination method of choice in emergency situations of the abdomen. It is now widely available and contributes to accelerating the diagnostic process.
Perioperative antibiotic prophylaxis is advisable in view of the risk of contamination of the site with intestinal contents (e.g., with cephalosporin and metronidazole).
As a rule, the laparoscopic approach for the treatment of adhesive abdomen (including adhesions with obstructive character) should be favored whenever possible. The adhesion-forming organ (peritoneum) is treated less aggressively-irritatively and thus develops fewer new adhesions postoperatively.
The laparoscopic approach in adhesiolysis shows the advantage over the conventional approach that the ground for new adhesions is not or not as pronouncedly prepared (proven by research on animal models).
The intra-abdominal access should be chosen via an incision with extension of the old scar into untouched sections of the abdominal wall.
Disadvantages and dangers of closed decompression are serosal tears and hemorrhages of the intestinal wall due to manipulation, which can secondarily lead to perforations or enhance adhesion formation.
The open decompression carries the risk of intestinal contents leaking into the abdominal cavity.
After every adhesiolysis, the intestine should be carefully inspected (preferably twice) for deserosions, which should be oversewn. Some authors recommend oversewing only if they have reached the level of the submucosa.
After adhesiolysis has been performed, the intestine is repositioned in the abdominal cavity, taking care to ensure that no torsions occur. In the literature, to avoid re-torsions and renewed kinking, the mesenteric plication, such as according to Noble or Childs-Phillips, is occasionally recommended. Its benefit in terms of preventing re-ileus has not yet been proven by controlled studies, so such procedures are considered obsolete.
Practical tips – general strategies for adhesion reduction:
- Preference for tissue-sparing and minimally invasive surgical techniques
- Minimization of operation duration as well as heat and light exposure
- Avoidance of peritoneal traumatization through unnecessary touching and coagulation
- Limited placement of intra-abdominal foreign bodies such as patches, meshes, or suture materials
- Use of moist abdominal cloths and swabs and occasional application of saline solution to minimize drying out of mesothelial surfaces
- Irrigation of the abdominal cavity to remove remaining intra-abdominal blood deposits
- Reduction of infection risk through sterile working and, if necessary, administration of antibiotics in the context of a laparotomy
- Preferred use of latex- and powder-free gloves
- In the context of laparoscopy, use of humidified gases with appropriately low insufflation pressure
- In high-risk collectives, use of barrier methods or peritoneal instillates after appropriate information
In high-risk collectives, depending on the extent and location of the mesothelial defects, the application of adhesion-reducing adjuvants can be considered. A selection of common, commercially available, and approved adjuvants for adhesion reduction in Germany includes, among others: Humidified and warmed insufflation gases for laparoscopy, medicinal agents, colloids and crystalloid solutions, as well as separators consisting of liquids for peritoneal instillation and local mechanical barriers. Medicinal therapeutic attempts include locally and systemically applied anti-inflammatory agents, fibrinolytics, or antibiotic solutions. Furthermore, colloids (dextrans) and crystalloid solutions (Ringer's lactate or saline) alone or with corticosteroid or heparin additives have been used to separate peritoneal surfaces. A clear adhesion-reducing benefit of these substances could not be demonstrated in any clinical study.
The 4-percent glucose polymer Icodextrin is an adhesion-preventive peritoneal instillate. In addition to intraoperative wetting of peritoneal surfaces, it is instilled into the abdominal cavity. Through its osmotic activity, it is intended to retain fluid in the peritoneal cavity for three to four days and effect a separation of organs and injured peritoneal surfaces until renal elimination of the agent. Randomized, double-blind multicenter studies confirmed the adhesion-reducing properties of Icodextrin after surgical interventions. The comparison between Icodextrin and Ringer's lactate yielded a reduction in adhesion formation (52 versus 32 %).
Routine drainage insertion is not recommended.