Laparoscopic lysis of adhesions

Is laparoscopic colon surgery appropriate in patients who have had previous abdominal surgery?

Laparoscopic techniques in colon surgery reduce postoperative pain, length of hospital stay, and 30-day morbidity when compared with open surgery. The objective of this study was to determine the feasibility of a laparoscopic colectomy in patients who have previously undergone abdominal surgery. We performed a retrospective, single-institution review of laparoscopic colorectal procedures for benign or malignant pathology between October 2002 and September 2008. Our analysis included 55 patients who previously had laparoscopic, open, or a combination of procedures and subsequently underwent laparoscopic colorectal surgery. We observed a 14.5 per cent conversion rate (n = 8). Of the patients who had previous open procedures (n = 48 [87.3%]), the conversion rate was 16.7 per cent. Only one patient (12.5%) who had a history of only laparoscopic surgery required conversion. The highest conversion rate in our study was from patients who underwent a left colectomy (60%, n = 3/5), which was the only statistically significant factor found for conversion. Since the emergence of laparoscopy, use in colon and rectal surgery nationwide has been poor as a result of multiple factors, including a frequent history of abdominal surgery. Our experience shows that laparoscopic colorectal surgery in patients with prior intra-abdominal surgery can be completed with an acceptable conversion rate.

Sleep and fatigue symptoms in women before and 6 weeks after hysterectomy

OBJECTIVE

To compare sleep and fatigue experiences of women before hysterectomy and at 3 and 6 weeks after surgery, to compare symptoms by type of surgical procedure, and to examine the biopsychosocial contextual factors related to symptoms.

DESIGN

A descriptive repeated measures study assessed sleep and fatigue using questionnaires and objective wrist actigraphy monitoring for sleep.

SETTING

Data were collected in women's homes at least 2 days before surgery, and at 3 and 6 weeks postoperatively.

PARTICIPANTS

A convenience sample of 25 women scheduled for hysterectomy.

RESULTS

There was significantly higher self-reported sleep disturbance 3 weeks after surgery compared with baseline. Women who had vaginal hysterectomy continued to experience sleep disturbance and fatigue 6 weeks after surgery, while those who had abdominal hysterectomy reported better sleep and less fatigue at 6 weeks compared with baseline. The number of awakenings recorded with actigraphy increased postoperatively for both groups, and younger women experienced more wake time during the night than older women. Level of education was positively related to preoperative fatigue severity.

CONCLUSIONS

Findings suggested poor sleep and fatigue during the postoperative period should be evaluated in light of women's ages, level of education, and type of surgical procedure.

Is laparoscopic colectomy as cost beneficial as open colectomy?

BACKGROUND

Laparoscopic colectomy has yet to gain widespread acceptance in cost-conscious health-care institutions. The aim of the present study was to define the cost-benefit relationship of laparoscopic versus open colectomy.

METHODS

Thirty-two consecutive patients undergoing elective laparoscopic colectomy (LC) by a single colorectal surgeon between August 2004 and September 2005 were reviewed. Cases were matched with a historical cohort undergoing elective open colectomy (OC) between June 2003 and July 2004. Demography, perioperative data, histopathology and cost were compared.

RESULTS

Both groups had similar demographics. Most resections (90.6%) were for cancer. Operative time was significantly longer for LC compared to OC (180 min vs 110 min, P < 0.001). Four patients (12.5%) in the LC group required conversion. LC patients, however, had lower median pain scores (3, 2 and 1 vs 6, 4 and 2 at 24, 48 and 72 h postoperatively, P < 0.001), faster resolution of ileus (3 vs 4 days, P < 0.001) and earlier discharge (6 vs 9 days, P < 0.001) compared to the OC group. As a result, overall hospital cost for both procedures was not significantly different (US$7943 vs US$7253, P = 0.41).

CONCLUSION

Laparoscopic colectomy is as cost-beneficial in the short term as open colectomy.

Feasibility of laparoscopy for small bowel obstruction

BACKGROUND

Adherential pathology is the most common cause of small bowel obstruction. Laparoscopy in small bowel obstruction does not have a clear role yet; surely it doesn't always represent only a therapeutic act, but it is always a diagnostic act, which doesn't interfere with abdominal wall integrity.

METHODS

We performed a review without any language restrictions considering international literature indexed from 1980 to 2007 in Medline, Embase and Cochrane Library. We analyzed the reference lists of the key manuscripts. We also added a review based on international non-indexed sources.

RESULTS

The feasibility of diagnostic laparoscopy is high (60-100%), while that of therapeutic laparoscopy is low (40-88%). The frequency of laparotomic conversions is variable ranging from 0 to 52%, depending on patient selection and surgical skill. The first cause of laparotomic conversion is a difficult exposition and treatment of band adhesions. The incidence of laparotomic conversions is major in patients with anterior peritoneal band adhesions. Other main causes for laparotomic conversion are the presence of bowel necrosis and accidental enterotomies. The predictive factors for successful laparoscopic adhesiolysis are: number of previous laparotomies

CONCLUSION

Laparoscopic adhesiolysis in small bowel obstruction is feasible but can be convenient only if performed by skilled surgeons in selected patients. The laparoscopic adhesiolysis for small bowel obstruction is satisfactorily carried out when early indicated in patients with a low number of laparotomies resulting in a short hospital stay and a lower postoperative morbidity. Although a higher small bowel obstruction recurrence remains the major postoperative risk of the laparoscopic management of these patients.

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Affiliation(s)

Eriberto Farinella Department of General and Emergency Surgery, St Maria Hospital, Terni, University of Perugia, Perugia, Italy
Roberto Cirocchi Department of General and Emergency Surgery, St Maria Hospital, Terni, University of Perugia, Perugia, Italy
Francesco La Mura Department of General and Emergency Surgery, St Maria Hospital, Terni, University of Perugia, Perugia, Italy
Umberto Morelli Department of General and Emergency Surgery, St Maria Hospital, Terni, University of Perugia, Perugia, Italy
Lorenzo Cattorini Department of General and Emergency Surgery, St Maria Hospital, Terni, University of Perugia, Perugia, Italy
Pamela Delmonaco Department of General and Emergency Surgery, St Maria Hospital, Terni, University of Perugia, Perugia, Italy
Carla Migliaccio Department of General and Emergency Surgery, St Maria Hospital, Terni, University of Perugia, Perugia, Italy
Angelo A De Sol Department of General and Emergency Surgery, St Maria Hospital, Terni, University of Perugia, Perugia, Italy
Luca Cozzaglio Department of Surgical Oncology, IRCCS Istituto Clinico Humanitas, Rozzano, Milan, Italy
Francesco Sciannameo Department of General and Emergency Surgery, St Maria Hospital, Terni, University of Perugia, Perugia, Italy

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Sterile Intra-Abdominal Fluid Collection Associated with Seprafilm Use

Postoperative abdominal adhesions are a significant cause of morbidity and expenditure of healthcare resources. As a result, numerous substances have been studied in an effort to reduce the incidence of adhesive disease. Seprafilm, a hyaluronate-based bioresorbable membrane, has been the subject of considerable research and has been found to be both safe and effective in reducing postoperative adhesions. We report three cases of the development of sterile abdominal fluid collection after the use of Seprafilm in colorectal surgery.

Is Operative Conversion Necessary for Patients Diagnosed With Dense Adhesions During an Elective Laparoscopic Colectomy?

Laparoscopic colectomy is often complicated by adhesions. Studies examining the morbidity of laparoscopic lysis of adhesions (LOA) combined with colectomy are sparse. Objectives. The goal of this study was to prospectively evaluate the results of using the harmonic scalpel to lyse adhesions in patients undergoing laparoscopic colectomy. Methods. Laparoscopic colectomy was performed in 83 patients between November 2003 and April 2007. A total of 20 patients underwent laparoscopic colectomy with LOA and 53 patients underwent laparoscopic colectomy alone. Patients were prospectively followed to determine operative time (OT), blood loss, operative conversion, length of stay (LOS), and 30-day morbidity. Results. Operative conversion was 2%, mean estimated blood loss (EBL) was 95 ± 84 mL, and mean OT was 220 ± 64 minutes. There were no anastomotic leaks or perioperative mortalities. There were 9 major complications (11%). Patients undergoing laparoscopic colectomy with LOA (n = 20) compared with patients undergoing laparoscopic colectomy alone (n = 63) had similar conversion rates (5% vs 2%), EBL (115 ± 108 vs 88 ± 74 mL), and major complications (15% vs 10%), but prolonged minor complications (25% vs 6%) and LOS (6.0 ± 3.0 vs 4.6 ± 1.5 days). Conclusions. Laparoscopic LOA combined with colectomy leads to similar conversion rates and major morbidity compared to laparoscopic colectomy alone.

Feasibility of laparoscopic partial nephrectomy after previous ipsilateral renal procedures

OBJECTIVES

Previous renal surgery has been considered a relative contraindication to laparoscopic partial nephrectomy (LPN) because of perirenal surgical adhesions. We present our experience with LPN in patients with previous ipsilateral renal surgery.

METHODS

Of 679 patients undergoing LPN for a renal mass from September 1999 to November 2006, 25 (3.7%) had undergone previous ipsilateral open or percutaneous renal procedures. The LPN technique included hilar clamping, cold tumor excision, and sutured renal reconstruction. The perioperative outcomes were retrospectively analyzed from a prospectively maintained database.

RESULTS

Previous renal surgery included open surgery in 12 patients (nephro/pyelolithotomy in 8, pyeloplasty in 2, and partial nephrectomy in 2) and percutaneous surgery in 13 (percutaneous nephrolithotomy in 9 and renal biopsy in 4). The mean interval from previous surgery was 6.6 years (range 0.3-34). LPN (16 transperitoneal and 9 retroperitoneal) was successful in all patients. The mean tumor size was 2.5 cm (range 1-5.6), the warm ischemia time was 35.8 minutes (range 22-57), and the estimated blood loss was 215 mL (range 25-600). The mean operative time was 3 hours (range 1.5-4.5), and the hospital stay was 3.1 days (range 1-7.6). Histopathologic examination confirmed renal cell carcinoma in 19 patients (76%). No open conversions were needed, and no kidneys were lost. No intraoperative complications and 3 postoperative complications (12%) developed, including blood transfusion in 1, nausea and epistaxis in 1, and compartment syndrome requiring fasciotomy in 1 patient.

CONCLUSIONS

The results of our study have shown that, in select patients, LPN is feasible after previous ipsilateral renal surgery. However, it can be technically challenging, and adequate previous experience with LPN is necessary.

Laparoscopic Treatment of Complex Small Bowel Obstruction: Is It Safe?

Laparoscopic treatment of small bowel obstruction has many reported advantages, yet it is infrequently performed. Criticisms include reduced working space, difficult abdominal access, and bowel injury. The experience with laparoscopic treatment of small bowel obstruction to determine its safety has been reviewed. Nineteen patients underwent laparoscopic treatment of small bowel obstruction. A cut-down technique was used for abdominal access and avoided manipulation of dilated bowel. The average number of prior operations was 1.4. The average size of maximally dilated bowel was 3.5 cm, including 6 patients whose diameter was greater than 4 cm. Laparoscopic treatment was successful in 16 patients; 3 patients required laparotomy. There were no complications from abdominal access and no iatrogenic bowel injuries. This series demonstrated that abdominal access and relief of bowel obstruction can be safely performed laparoscopically in patients with complex small bowel obstruction. Neither massively dilated bowel nor multiple previous abdominal operations precluded safe conduct of the operation laparoscopically.

Functional cine MR imaging for the detection and mapping of intraabdominal adhesions: method and surgical correlation

The purpose of this study was to evaluate the presence and localization of intraabdominal adhesions using functional cine magnetic resonance imaging (MRI) and to correlate the MR findings with intraoperative results. In a retrospective study, patients who had undergone previous abdominal surgery with suspected intraabdominal adhesions were examined. A true fast imaging with steady state precession sequence in transverse/sagittal orientation was used for a section-by-section dynamic depiction of visceral slide on a 1.5-Tesla system. After MRI, all patients underwent anew surgery. A nine-segment abdominal map was used to document the location and type of the adhesions. The intraoperative results were taken as standard of reference. Ninety patients were enrolled. During surgery 71 adhesions were detected, MRI depicted 68 intraabdominal adhesions. The most common type of adhesion in MRI was found between the anterior abdominal wall and small bowel loops (n = 22, 32.5%) and between small bowel loops and pelvic organs (n = 14, 20.6%). Comparing MRI with the intraoperative findings, sensitivity varied between 31 and 75% with a varying specificity between 65 and 92% in the different segments leading to an overall MRI accuracy of 89%. Functional cine MRI proved to be a useful examination technique for the identification of intraabdominal adhesions in patients with acute or chronic pain and corresponding clinical findings providing accurate results. However, no differentiation for symptomatic versus asymptomatic adhesions is possible.

Consequences and complications of peritoneal adhesions

Consequences and complications of postsurgical intra-abdominal adhesion formation not including small bowel obstruction and secondary infertility are substantial but are under-exposed in the literature. Inadvertent enterotomy during reopening of the abdomen or subsequent adhesion dissection is a feared complication of surgery after previous laparotomy. The incidence can be as high as 20% in open surgery and between 1% and 100% in laparoscopy depending on the underlying disease. Delayed postoperative detection of enterotomy is a particular feature of laparoscopy associated with significant morbidity and mortality. Adhesions to the ventral abdominal wall are responsible for the majority of trocar injuries. Both trocar injuries and inadvertent enterotomies result in conversion from laparoscopy to laparotomy in almost 100% of cases. There is a paucity of data on other organ injury, such as liver laceration or bladder perforation. Dissecting adhesions before executing the planned operation takes on average 20 min, being one-fifth of the total operating time in patients having had previous open colorectal surgery. There is some evidence that postoperative morbidity and mortality of patients who need adhesiolysis is higher than that of patients with a virgin abdomen. The necessity to dissect adhesions is associated with increased hospital stay. Postsurgical adhesions are considered a main reason for conversion from laparoscopy to laparotomy in many types of procedures including laparoscopic colonic resection. Adhesion formation is part of the innate peritoneal defence mechanism in peritonitis. Abscess formation and bleeding, organ injury and fistula formation at 'on demand' relaparotomies are well-known complications after surgery for intra-abdominal sepsis associated with fibrinous adhesions. The clinical magnitude hereof is poorly researched. Postsurgical adhesions may cause pain as evidenced by pain mapping clinical experiments. Filmy adhesions between movable organs and the peritoneum appear to be worse in terms of generating pain. The high caseload of gynaecological and some colorectal practices suggest an enormous impact of adhesion-related chronic abdominal and pelvic pain on patient's wellbeing and socio-economic costs. The significant risk of inadvertent enterotomy, conversion to laparotomy and trocar injury, and the associated postoperative morbidity and mortality and increased length of hospital stay warrant routine informed consent of adhesiolysis related complications in patients scheduled for abdominal or pelvic reoperation.

Systematic guide to complex cases from adhesive disease

Intestinal adhesions are inevitable after abdominal surgery. The presence of intra-abdominal adhesions can create very complex situations which require careful preoperative planning, meticulous intra-operative technique and detailed postoperative management. This manuscript will review the management of these complex cases of adhesions.

Impact of previous abdominal surgery on the outcome of laparoscopic colectomy: a case-matched control study

BACKGROUND

Adhesions are a major risk for visceral injury and can increase the difficulty of both laparoscopic and open colectomy. The aim of the present study was to evaluate the impact of previous abdominal surgery on laparoscopic colectomy in terms of early outcome.

METHODS

We performed a case-control study of patients who underwent laparoscopic colectomy for colorectal disease. The case group comprised 91 patients with a history of prior abdominal surgery, while the 91 controls had no such history. Case and controls were matched for age, gender, site of primary disease, comorbidity on admission and body mass index.

RESULTS

The two groups were homogeneous for demographic and clinical characteristics. Conversion rate was 16.5% in the case group and 8.8% in the control group (p=0.18). Of the 7 patients who underwent conversion because of adhesions, six had prior surgery (cases) and one did not (p=0.001). Operative time was 26 minutes longer in the case group than in the control group (p=0.001). Morbidity rate was 25.3% among cases and 23.1% for controls. Patients in the two groups experienced a similar time to recovery of bowel function, length of postoperative stay, and 30-day readmission rate.

CONCLUSIONS

Laparoscopic colectomy in previously operated patients is a time-consuming operation, but it does not appear to affect the short-term postoperative outcome.

Laparoscopic-assisted vaginal hysterectomy for patients with extensive pelvic adhesions: A strategy to minimise conversion to laparotomy

AIM

To evaluate a strategy for successful laparoscopic-assisted vaginal hysterectomy (LAVH) in patients with extensive pelvic adhesion.

METHODS

Two hundred and thirty-six patients who underwent LAVH at National Taiwan University Hospital were retrospectively enrolled. Twenty-three patients (9.7%) had unexpected extensive pelvic adhesions. A special procedure of uterine artery preligation through retroperitoneal downstream ureter tracking was applied to overcome this problem. The clinical characteristics of the study group were analysed. The operative parameters and the outcome were compared between those with and without extensive pelvic adhesions.

RESULTS

Having extensive adhesions, 17 patients were associated with endometriosis and the other six were secondary to previous Caesarean delivery or pelvic inflammation. The cul-de-sac was partially and totally obliterated in 10 and 13 patients, respectively. These 23 patients had longer operation time (184 vs 146 min, P < 0.05), more blood loss (146 vs 89 mL, P < 0.05), but smaller extirpated uteri (278 vs 372 g, P = 0.063), compared with the other 213 patients. The average hospital stay was comparable (3.2 vs 3.4 days) and there were no ureteral injuries or excessive bleeding. Most importantly, not a single case was converted to laparotomy.

CONCLUSION

Pelvic adhesions of various underlying diseases are associated with increased complication and conversion rates during LAVH. Although this technique is not new, we believe that the special procedure of uterine artery preligation through retroperitoneal downstream ureter tracking may provide a safe approach for general gynecologists to complete successful LAVH in patients with unexpected extensive pelvic adhesions.

Minimally invasive surgery in the diagnosis and treatment of abdominal pain in children

PURPOSE OF REVIEW

Children with abdominal pain sometimes require surgical intervention, and laparoscopy is increasingly the preferred approach for the diagnosis and treatment of both acute and chronic abdominal pain in children. This review describes the current state of the art and recent developments in the application of minimally invasive surgical techniques for the treatment of children with various abdominal pain syndromes.

RECENT FINDINGS

Laparoscopy provides distinct advantages over traditional open surgery, including less pain, shorter recovery and improved cosmesis. Cumulative experience and ongoing outcomes research continue to substantiate the safety and efficacy of the approach when applied thoughtfully and by experienced practitioners. In fact, as minimally invasive surgery is being applied to treat more wide-ranging disorders, it is becoming apparent that for many conditions laparoscopy should be adopted as the standard of care.

SUMMARY

Recent advances in minimally invasive surgery have clearly benefited children with abdominal pain who need surgery, and as techniques improve and instruments get smaller we can expect this trend to continue into the future.