Laparoscopic adhesiolysis

Indications

• To obtain access during any laparoscopic procedure.

• Adhesiolysis for chronic or recurrent abdominal pain.

• As an emergency to relieve obstruction.

Instruments

• An angled telescope (30/45°) may prove very helpful. A 0° telescope may be adequate.

• Two atraumatic, grasping forceps, preferably insulated.

• Scissors, preferably insulated with double-action curved thin blades.

• Fine hook or needle monopolar diathermy.

• Bipolar diathermy may occasionally help.

• Suction and irrigation (separate or incorporated with diathermy).

• Additional instruments for combined procedures.

Preparation

• Nasogastric intubation, and a urinary catheter may be needed.

• Where to expect adhesions:

(a) Existing abdominal wall scar;

(b) Site of previous surgery and inflammation;

(c) Pre- and per-operative ultrasound studies.

Technique

In adhesioloysis, the number, size and site of cannulae is dependent on the size of the patient, extent of adhesions, and nature of other laparoscopic procedures that need to take place at the same time. Generally, the open technique of laparoscopy is preferred. The primary cannula should be placed well away from the abdominal scars. This will allow a panoramic view of the operative field, and safe access for the secondary cannulae, usually on the same side of the telescope (Fig. 89). A change of telescope from the primary to a secondary cannula may improve exposure and instrument access.

As for open surgery, determine the anatomy first, and then stretch adhesions before division. Avoid stripping if possible. Adhesiolysis is best performed with scissors through the least vascular areas. However, tough adhesions require monopolar needle/fine hook diathermy or the ultrasound activated scalpel or shears. Bleeding

Fig. 89 Position of cannulae for adhesiolysis in the lower abdomen. A, Lower midline scar; B, site for the primary and secondary cannulae.

vessels should be coagulated with diathermy (monopolar or bipolar) or ultrasound scalpel. Suction and irrigation often are needed to clear smoke and clots.

Problems and solutions

• Complications of laparoscopy in general.

• Inappropriately positioned cannulae:

(a) Too close to the scar to see adequately or work instruments.

(b) Working instruments opposite the telescope or obscured by the adhesions.

Here re-siting of the cannula or placing other cannulae may solve the problem.

• Establishing the anatomy may be difficult because of dense or complex adhesions and/or poor imaging from smoke and bleeding. In this situation consider conversion to a laparotomy.

• Bleeding from extensive adhesiolysis may disturb laparoscopic imaging. Meticulous technique and continuous suction/irrigation minimizes this problem.

• Visceral injury from handling and diathermy that might become apparent per- or postoperatively requires immediate attention.

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