Overview
Definition:
Laparoscopic adhesiolysis is a minimally invasive surgical procedure to cut or release intra-abdominal adhesions that are causing or contributing to small bowel obstruction
Adhesions are fibrous bands of scar tissue that can form between abdominal organs after surgery, infection, or inflammation, leading to kinking or narrowing of the bowel lumen.
Epidemiology:
Small bowel obstruction (SBO) is a common surgical emergency, with adhesions being the most frequent cause, accounting for approximately 50-70% of cases, particularly in patients with a history of abdominal surgery
Recurrence rates of SBO due to adhesions can be significant, necessitating effective management strategies.
Clinical Significance:
Adhesiolysis, especially when performed laparoscopically, offers a less invasive approach to treating SBO caused by adhesions, potentially reducing postoperative pain, hospital stay, and incisional hernia rates compared to open surgery
It is crucial for surgical residents and DNB/NEET SS aspirants to understand the indications, techniques, and outcomes of this procedure.
Clinical Presentation
Symptoms:
Abdominal pain, typically colicky and diffuse
Nausea and vomiting, which can become feculent in later stages
Abdominal distension
Obstipation (inability to pass stool or gas)
Borborygmi (high-pitched bowel sounds) initially, which may become absent later
Early satiety.
Signs:
Abdominal tenderness, often generalized or localized to areas of distension
Guarding and rebound tenderness may indicate strangulation or perforation
Decreased bowel sounds or absent bowel sounds in severe cases
Tympanic percussion of the abdomen due to trapped gas
Signs of dehydration and hemodynamic instability in advanced cases.
Diagnostic Criteria:
Diagnosis is primarily based on clinical presentation and confirmed by imaging
The presence of characteristic symptoms (pain, vomiting, distension, obstipation) in a patient with a history of abdominal surgery is highly suggestive
Imaging findings such as dilated loops of small bowel with air-fluid levels on plain radiography or computed tomography (CT) are key.
Diagnostic Approach
History Taking:
Detailed history of prior abdominal surgeries, including type and number of procedures
History of intra-abdominal infections (e.g., appendicitis, diverticulitis) or inflammatory conditions (e.g., Crohn's disease, endometriosis)
Onset, character, and progression of symptoms
Previous episodes of bowel obstruction
Red flags: fever, severe localized tenderness, hemodynamic instability suggest complications like strangulation or perforation.
Physical Examination:
Assess general appearance for signs of distress or dehydration
Palpate abdomen systematically, noting tenderness, rigidity, masses, and distension
Auscultate bowel sounds for frequency and character
Perform rectal examination to rule out distal obstruction or impaction.
Investigations:
Plain abdominal radiography (supine and erect) may show dilated loops of small bowel and air-fluid levels
Computed tomography (CT) scan of the abdomen and pelvis is the gold standard, revealing dilated small bowel proximal to the point of obstruction, collapsed bowel distally, transition zone, and can help identify the cause (adhesions vs
hernia vs
tumor) and complications (strangulation, perforation, ischemia)
Laboratory investigations include complete blood count (CBC) to assess for infection/inflammation, electrolytes, renal function tests, and liver function tests to assess for dehydration and organ dysfunction.
Differential Diagnosis:
Other causes of SBO: incarcerated hernia, malignancy (intrinsic or extrinsic compression), strictures (Crohn's disease, radiation, ischemic), intussusception, volvulus
Conditions mimicking SBO: paralytic ileus, functional obstruction, large bowel obstruction.
Management
Initial Management:
Bowel rest (NPO)
Nasogastric (NG) tube insertion for decompression and relief of vomiting/abdominal distension
Intravenous (IV) fluid resuscitation to correct dehydration and electrolyte imbalances
Analgesia for pain control
Broad-spectrum IV antibiotics if there is suspicion of ischemia or perforation.
Surgical Management:
Indications for surgery: clinical deterioration despite conservative management, signs of strangulation or perforation, complete obstruction, recurrent SBO
Laparoscopic adhesiolysis is preferred for uncomplicated SBO due to adhesions when feasible
Procedure involves small abdominal incisions for port placement, insertion of laparoscopic instruments and camera, visualization of adhesions, and careful dissection/division of adhesions using energy devices (e.g., hook diathermy, harmonic scalpel) or scissors
Care must be taken to avoid injury to bowel loops and mesenteric vessels
Open adhesiolysis may be required for extensive adhesions, suspected bowel compromise, or inability to safely perform laparoscopy.
Supportive Care:
Continuous monitoring of vital signs, urine output, and abdominal distension
Regular assessment of NG tube output
Nutritional support may be required if prolonged NPO status is anticipated, often with parenteral nutrition
Postoperative pain management and early ambulation are encouraged.
Preoperative Preparation:
Informed consent, detailed discussion of risks and benefits, including potential conversion to open surgery
Optimization of hydration and electrolyte balance
Prophylactic antibiotics are administered
Adequate bowel preparation is generally not feasible in acute SBO.
Complications
Early Complications:
Bowel injury during dissection (perforation, serosal tear)
Injury to mesenteric vessels leading to ischemia
Bleeding
Anastomotic leak (if bowel resection performed)
Wound infection
Pneumoperitoneum-related complications
Persistent ileus.
Late Complications:
Recurrent SBO due to new adhesion formation
Incisional hernia at port sites
Chronic abdominal pain
Adhesions leading to other issues like infertility or chronic obstruction.
Prevention Strategies:
Minimizing duration of surgery
Gentle tissue handling
Meticulous hemostasis
Judicious use of energy devices
Consideration of barrier membranes (e.g., Seprafilm) in select high-risk patients, although evidence for routine use in adhesiolysis is limited
Avoiding unnecessary laparotomies.
Prognosis
Factors Affecting Prognosis:
Extent and density of adhesions
Presence of strangulation or perforation at diagnosis
Patient's overall health status
Success of initial conservative management
Complications encountered during surgery.
Outcomes:
Successful laparoscopic adhesiolysis typically leads to resolution of obstruction with a shorter hospital stay and faster recovery compared to open surgery
Recurrence rates vary, but recurrence after adhesiolysis is less common than after initial conservative management of SBO
Patients with complete lysis of adhesions have a good prognosis for relief of symptoms.
Follow Up:
Follow-up typically involves monitoring for symptom recurrence
Patients are advised to report any new or worsening abdominal pain, vomiting, or distension promptly
Long-term follow-up is generally not required unless specific complications arise or there is a history of malignancy.
Key Points
Exam Focus:
Adhesions are the most common cause of SBO in the West and India
Laparoscopic adhesiolysis is the treatment of choice for selected cases of SBO due to adhesions
CT scan is crucial for diagnosis and assessing complications like strangulation
Complete bowel rest, NG decompression, and IV fluids are initial management steps.
Clinical Pearls:
Always consider prior surgical history in a patient with SBO
Be vigilant for signs of strangulation (severe localized pain, fever, leukocytosis, peritonitis)
Meticulous dissection is key in laparoscopic adhesiolysis to avoid iatrogenic bowel injury
Transition zone on CT is pathognomonic for SBO
The bowel proximal to obstruction is dilated, distal is collapsed.
Common Mistakes:
Delaying surgery in patients with signs of strangulation or perforation
Inadequate bowel decompression via NG tube
Excessive aggression during adhesiolysis leading to iatrogenic injuries
Failure to consider other causes of SBO
Insufficient fluid resuscitation.