Perioperative management - Adhesiolysis, open

Around 90% of intraabdominal adhesions result from previous trauma, such as that experienced in every abdominal procedure. Only about 10% of the population have adhesions without prior abdominal manipulation; these may be congenital or can result from intraabdominal inflammation.

Most adhesions are asymptomatic and devoid of pathological significance.  Therefore, adhesiolysis is indicated only for the following symptoms:

• Mechanical ileus
• Symptomatic patients with intestinal obstruction
• Rather tentative indication in patients with chronic abdominal pain arising from adhesions
• In every abdominal repeat procedure
• In some cases of female infertility

Adhesiolysis in patients with chronic complaints is indicated only as a last resort.

If an intraabdominal procedure is indicated and standard criteria evaluate the patient as fit for surgery, there are no further contraindications.

There is no imaging modality able to detect adhesions qualitatively or quantitatively. Only adhesion sonography can roughly evidence the presence of adhesions. Such studies are carried out with the patient in supine position. Then the patient is placed in the lateral recumbent position. Adhesions are likely if the loops of the small intestine displace less than 2 cm.

Abdominal CT studies yield the most information on the possible etiology of mechanical ileus.

Otherwise, the special studies called for in elective operations are undertaken.

There is no special preparation for adhesiolysis; as noted, this depends on the type of operation planned.

As a rule of thumb, elective procedures, e.g. incisional hernia repair, should be carried, out, if at all possible, at least one year after the last operation because empirical data indicate that adhesions will have fully matured by then and are easier to take down.

The following specific risks apply regardless of the procedure planned:

• Abdominal organ injuries, especially to the small and large intestines
• The possible need to resect segments of the bowel.
• The reality that adhesions tend to recur to varying degrees following adhesiolysis.
• Possibility of intestinal stoma
• Peritonitis from missed intestinal leakage
• Postoperative intestinal paralysis
• Persistent adhesion-related complaints
• Postoperative ileus in around 1% within the first year and around 3% later course