Laparoscopic Surgery for Adhesiolysis

For the surgeon, laparoscopic lysis of bowel adhesions is fraught with danger to his/her reputation as bad results often are accompanied by poor reimbursement and lawsuits. This surgery is not for every surgeon! But if you take up the challenge, be prepared. Fatal sequelae of intraabdominal adhesions were reported as early as 1872 after removal of an ovarian tumor resulted in intestinal obstruction.2 Adhesions are the most common cause of bowel obstruction and most likely result from gynecologic procedures, trauma, appendectomies and other intestinal operations.3 Adhesions have also been proposed to cause infertility and abdominal and pelvic pain. Although nerve fibers have been confirmed in pelvic adhesions, their presence is not increased in those patients with pelvic pain.4 In addition, there does not appear to be an association between the severity of adhesions and complaint of pain. It is generally accepted that adhesions may impair organ motility resulting in visceral pain transmitted by peritoneal innervation.5 Many patients experience resolution of their symptoms after adhesiolysis.6-9 This may be complicated by placebo effect as demonstrated by one study that showed no difference in pain scores between patients who were randomized to adhesiolysis versus expectant management.10 In 1994, adhesiolysis procedures resulted in 303,836 hospitalizations, 846,415 days of inpatient care, and $1.3 billion in health care expenditures. Forty-seven percent of these hospitalizations were for adhesiolysis of the female reproductive system, the primary site for these procedures. In comparison to similar data from 1988, the cost of adhesiolysis hospitalizations is down. One significant influence on this trend is the increased use of minimally invasive surgical techniques resulting in fewer days of inpatient care.11 This chapter reviews the pathophysiology of adhesion formation, equipment and technique for adhesiolysis, and methods for adhesion prevention.