Adhesions are a quite common occurrence.
Postinflammatory adhesions were found in 28% of autopsied patients who had not undergone previous surgery. These are caused by intraabdominal inflammation or can be attributed to endometriosis, peritonitis, radiotherapy, or long-term peritoneal dialysis.
High-resolution computed tomography is now considered the imaging modality of choice for abdominal scanning in emergency situations. It is widely available and helps to expedite the diagnostic process.
Perioperative antibiotic prophylaxis (e.g. with cephalosporin and metronidazole) is recommended due to the risk of surgical site contamination with intestinal contents.
As a rule, laparoscopic adhesiolysis (also in obstructive adhesions ) should be preferred whenever possible. Laparoscopy is less aggressive on the adhesion-producing organ (peritoneum), making it less susceptible to develop new adhesions postoperatively.
Unlike conventional techniques laparoscopic adhesiolysis has the benefit of being less aggressive on the underlying structures and thus less conducive to onset of new adhesions (as demonstrated by research in animal studies).
Intraabdominal access should be gained by extending the scar of the old incision into untouched sections of the abdominal wall.
Disadvantages and dangers of closed decompression are serosal tears and intestinal wall bleeding due to manipulation, which may result in perforations or increased adhesion formation.
Open decompression involves the risk of intestinal content leaking into the abdominal cavity.
Carefully inspect the bowel after each adhesiolysis (preferably twice) and suture any deserosations. Some authors recommend suturing only if deserosation has reached the level of the submucosa.
After completing adhesiolysis, return the bowel to the abdominal cavity, while carefully avoiding any torquing. Some publications recommend mesenteric plication (e.g. Noble or Childs-Phillips) to avoid renewed torquing and kinking. Controlled trials have not yet proven the benefit of mesenteric plication in preventing recurrent ileus, hence such procedures are deemed to be outdated.
Practical advice - general strategies for reducing adhesions:
- Tissue-sparing and microinvasive surgical techniques preferred
- Minimize operating time as well as the effects of heat and light
- Avoid peritoneal trauma from unnecessary touch and electrocautery
- Restrict the use of intraabdominal foreign bodies such as patches, meshes and sutures
- Use moist abdominal towels and swabs and occasionally apply saline solution to the mesothelial surfaces to minimize dehydration
- Irrigate the abdominal cavity to remove any residual intraabdominal blood deposits
- Reduce the infection risk through sterile technique and, if necessary, administer perioperative antibiotics
- Preferably use latex and powder-free gloves
- For laparoscopy use humidified gas with an appropriately low insufflation pressure
- In high-risk patients use barrier products or peritoneal instillation after obtaining appropriate informed consent.
Depending on the extent and location of the mesothelial defects, the use of adhesion-reducing adjuvants may be considered in high-risk patients. A list of common adhesion-reducing adjuvants approved in Germany includes: Humidified and warmed laparoscopy insufflation gases, medicinal agents, colloids, and crystalloid solutions as well as peritoneal infusion separators and local mechanical barriers. Attempted drug therapy includes locally and systemically applied anti-inflammatory agents, fibrinolytics and antibiotic solutions. Furthermore, colloids (dextrans) and crystalloid solutions (Ringer lactate or saline) have been used alone or combined with corticosteroids or heparin to separate peritoneal surfaces. None of these substances has been proven to offer demonstrated adhesion-reducing benefits in any clinical trial.
Icodextrin is a 4% glucose polymer for peritoneal instillation to prevent adhesion. In addition to intraoperative wetting of peritoneal surfaces, it is instilled into the abdominal cavity. Due to its osmotic activity, it is thought to retain fluid in the peritoneal cavity for three to four days and thereby help separate organs and injured peritoneal surfaces until renal elimination of the agent. Randomized, double-blind multicenter trials confirmed the postoperative adhesion-reducing properties of icodextrin. Comparison of icodextrin vs. Ringer lactate revealed reduced adhesion formation (52% versus 32%).
Routine drain placement is not recommended.