laparoscopic adhesiolysis

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  • 1.Laparoscopic adhesiolysis

2. ADHESIONS 3. Adhesions

  • Abnormal attachments between tissues and organs
  • The most common cause of intra-abdominal adhesions is a history of previous abdominal surgery ( Adhesions have been reported after 93% of abdominal operations [12] and after 55% to 100% of pelvic operations [4].)
  • Peritoneal inflammation and trauma that are the important etiologic factors in the formation of these structures (Deaver 1923)
  • Until the introduction of anesthesia and then antiseptic surgery allowed laparotomy to become a comparatively common and comparatively safe procedure in the 1880s, intraabdominal adhesions were an uncommon phenomenon and of little, if any, interest to surgeons.
  • The first fatal case of small bowel obstruction from a band (formed after removal of an ovarian cyst ) was by Thomas Bryant, of Guys Hospital, London, in 1872
  • The first account of a laparotomy for adhesive obstruction was reported in theLancetin 1883 by William Battle, then a surgical registrar at St ThomassHospital, London.

4. Adhesions ,Pathophysiology

  • Both adhesion formation and adhesion-free epithelialization are pathways of peritoneal wound healing.
  • The injury of the peritoneum may be inflammatory or surgical and may include exposure to infection or to intestinal contents; ischemia; irritation from foreign materials such as sutures, gauze particles, or glove dusting powder; abrasion; desiccation; overheating by lamps or irrigation fluid; and many others.
  • The healing attempt begins with the formation, through coagulation, of a fibrin gel matrix, which is the ground through which mesothelial cells can migrate and accomplish reepithelialization.
  • When two injured peritoneal surfaces covered with this sticky fibrin matrix come into apposition,sticky bands and bridges of fibrin form between them.
  • It is then the role of the fibrinolytic system to dissolve this fibrinous strands within a few days. However, this task cannot be always fulfilled because surgery dramatically reduces fibrinolytic activity, both by increasing the levels of plasminogen activator inhibitorsand by decreasing the levels of tissue plasminogen activator (tPA) .
  • If the fibrinous matrix persists, it will be infiltrated by proliferating fibroblasts which subsequently depose collagen. Mesothelial cells also migrate and form an uninterrupted layer on the surface of the already constituted adhesion.
  • As the tissue underlying the adhesion is usually relatively hypoxic, signals initiating angiogenesis will be elaborated, resulting in a vascularized adhesion.

5. Adhesions ,Pathophysiology

  • The most common cause of intra-abdominal adhesions is a history of previous abdominal surgery [1].
  • The formation of intra-abdominal adhesions may result from mechanical peritoneal damage, intra-abdominal tissue ischemia, or the presence of foreign materials [19,20].
  • In the classic pathway of adhesion formation, peritoneal injury from trauma, infection, or ischemia results in an immediate type of inflammatory reaction followed by an increase in vascular permeability and the release of fibrin-rich exudate [15,21].
  • In the absence of the lysis of this fibrin through the plasminogen-plasmin cascade, fibrous adhesions may form through collagen deposition [22]. Lysis of the fibrin depends on the activation of the peritoneal mesothelial plasminogen activator. Normal mesothelial cells possess plasminogen-activating activity [23].
  • This physiologic property of normal mesothelial cells is decreased in the presence of surgical trauma, ischemia, or inflammation [22].
  • Injury results in the rapid release of plasminogen-activator inhibitor-1 and -2 by mesothelial,endothelial, and inflammatory cells. This causes a loss of plasminogen-activating activity [11,24].
  • For many decades, many materials and methods have been used to solve the adhesion problem.

6. Adhesions ,Pathophysiology

  • Adhesions form as the end result of an inflammatory response to injury within the peritoneal cavity.
  • Fibrin clot accumulating at the site of injury is usually lysed by the endogenous fibrinolytic systems.
  • In more severe injury, fibroblasts migrate into the fibrin clot and produce collagen, which forms scars or adhesions.
  • With a greater inflammatory response, there is less fibrinolysis and more fibroblast activity, resulting in more adhesion formation [1].
  • The severity of inflammation is related to the degree of local tissue trauma, ischemia, and the presence of a foreign body [6].
  • Adhesion formation is reduced after laparoscopic surgeryC. L. Garrard,1 R. H. Clements,1 L. Nanney,2,3 J. M. Davidson,4 W. O. Richards1,5Surg Endosc (1999) 13: 1013

7. Adhesions ,Pathophysiology

  • We postulate that the tissue trauma of the incision increases the total inflammatory response, thereby inhibiting fibrinolysis and promoting fibroblast migration and collagen formation.
  • The trauma of a midline incision contributes to the formation of intra-abdominal adhesions, even when the incision does not transect the peritoneum.
  • These results strongly suggest that laparoscopic surgical techniques lead to fewer intra-abdominal adhesions by reducing tissue trauma, which in turn reduces circulating inflammatory mediators.
  • Adhesion formation is reduced after laparoscopic surgeryC. L. Garrard,1 R. H. Clements,1 L. Nanney,2,3 J. M. Davidson,4 W. O. Richards1,5Surg Endosc (1999) 13: 1013

8. Adhesions ,Pathophysiology

  • Development of acquired adhesions is a biological phenomenon in response to trauma to the peritoneum.
  • Whatever this trauma ismechanical and ischemic in surgery, inflammatory in endometriosis or septicin- flammatory in peritonitisthe pathogenesis of adhesion formation follows several steps, the pivotal event being the apposition of the damaged peritoneal surfaces and the insufficient fibrinolysis [16].

9. Adhesions,complications,natural history

  • Abdominal adhesions, which can begin forming within a few hours after an operation, represent one of the most common causes of intestinal obstruction.
  • Complications of adhesions include chronic pelvic pain (2050% incidence), small bowel obstruction (4974% incidence), intestinal obstruction in ovarian cancer patients (22% incidence), and infertility due to complications in the fallopian tube, ovary, and uterus (1520% incidence).
  • Incidence rates for abdominal adhesions have been estimated to be as high as 90% after major gynecologic operations.
  • Abdominal Adhesiolysis: Inpatient Care and Expenditures in the United States in 1994Nancy Fox Ray, MS,*William G. Denton, RN, MBA, 1998 by the American College of Surgeons

10. Adhesions,natural history

  • The number of patients with laparoscopically confirmed adhesions without prior laparotomy or laparoscopy was 11 of 101 patients (11%).
  • Kolmorgen and Schulz reported a rate of 25% of affected patients without prior surgery [4].
  • For Mecke et al., the rate was 30% [9]; for Tavmergen et al., it was 27% [11].
  • Subjective evaluation of the therapeutic value of laparoscopic adhesiolysis A retrospective analysis E. Malik,1 C. Berg,1 A. Meyhofer-Malik,1 S. Haider,2 W. G. Rossmanith2Surg Endosc (2000) 14: 7981

11. Adhesions,complications,natural history

  • Adhesions from prior surgery are the most common cause of small bowel obstruction in the Western world .
  • The incidence of an adhesive small bowel obstruction after open abdominal surgery is between 12% and 17% .
  • Historically, laparotomy and open adhesiolysis have been the treatment for patients requiring surgery for small bowel obstruction.
  • Unfortunately, this often leads to further formation of intraabdominal adhesions with approximately 10% to 30% of patients requiring another laparotomy for recurrent bowel obstruction .
  • Laparoscopic adhesiolysis for small bowel obstruction Alexander Nagle, M.D., Michael Ujiki, M.D., Woody Denham, M.D., Kenric Murayama, M.D.* The American Journal of Surgery 187 (2004) 464470

12. Adhesions,complications,natural history

  • A recent survey of 750 German hospitals demonstrated that 26 per cent of laparotomies were for adhesional bowel obstruction1
  • A prospective study by Menzies and Ellis3 indicated that approximately 1 per cent of patients will suffer obstruction within a year of abdominal surgery and that over a third of people who develop adhesional obstruction will do so within a year of surgery, with the remainder presenting with an initial episode of obstruction at a steady rate up to 10 years after surgery. This suggests an overall rate of adhesion-related morbidity of 3 per cent.
  • Menzies and Ellis prospective study3 indicated that while most adhesional obstruction occurs within 10 years (59 per cent by 5 years and 79 per cent by 10 years) there is no time limit as to when a patient may suffer an episode of obstruction.
  • The mean time to presentation was 89 years with 26 per cent presenting within 1 year and 48 per cent presenting within 55 years.
  • However, one patient presented with adhesional obstruction 35 years after an appendicectomy.