Fewer adhesions induced by laparoscopic surgery?

Background Laparoscopic surgery has potential theoretical advantages over open surgery in reducing the rate of adhesion formation, but very few comparative studies are available to prove this.Methods A literature search was performed within Medline and Cochrane databases using the key words: adhesion*, adhesiolysis, laparoscop*, laparotomy, open surgery. Further articles were identified from the reference lists of retrieved literature. Both clinical and experimental studies comparing laparoscopy and laparotomy with regard to adhesion formation were retained. In each article, the rates of adhesion formation were identified or deduced for the operative site, access wound site, and distant sites.Results Fifteen studies from 1987 to 2001 were identified. Most studies assessed the operative site. Thus, three clinical studies and six experimental ones found fewer adhesions following laparoscopy than laparotomy, while other five experimental studies found similar adhesion rates for the two surgical methods. There were fewer adhesions to trocar wounds than to the laparotomy wounds in seven studies and equal rates of adhesion in one study. The problem of distant adhesions is poorly represented in literature; three studies favored laparoscopy as being followed by fewer adhesions. Because of the important differences between studies with regard to the design, end points, and statistical calculations, a metaanalysis could not be achieved. The conclusion is based on the prevalence of evidence.Conclusions All clinical studies and most of the experimental studies found a reduction of adhesion formation after laparoscopic surgery compared to open surgery.     

The Feasibility of Laparoscopic Cholecystectomy in Patients with Previous Abdominal Surgery

A retrospective study was carried in 1500 patients submitted to elective laparoscopic cholecystectomy to ascertain its feasibility in patients with previous abdominal surgery. In 411 patients (27.4%) previous infraumbilical intraperitoneal surgery had been performed, and 106 of them (7.06%) had 2 or more operations. Twenty five patients (1.66%) had previous supraumbilical intraperitoneal operations (colonic resection, hydatid liver cysts, gastrectomies, etc.) One of them had been operated 3 times. In this group of 25 patients the first trocar and pneumoperitoneum were performed by open laparoscopy. In 2 patients a Marlex mesh was present from previous surgery for supraumbilical hernias. Previous infraumbilical intraperitoneal surgery did not interfere with laparoscopic cholecystectomy, even in patients with several operations. There was no morbidity from Verres needle or trocars. In the 25 patients with supraumbilical intraperitoneal operations, laparoscopic cholecystectomy was completed in 22. In 3, adhesions prevented the visualization of the gallbladder and these patients were converted to an open procedure. In the 2 patients Marlex mesh prevented laparoscopic cholecystectomy because of adhesions to abdominal organs. We conclude that in most instances previous abdominal operations are no contraindication to laparoscopic cholecystectomy.     

Laparoscopic cholecystectomy--what is the value of laparoscopic technique in "difficult" cases?]

This prospective study with an external control group of patients investigates the technical aspects of laparoscopic cholecystectomy in patients with difficult intraabdominal situations as well as the postoperative quality of life of these persons. Difficult concomitant circumstances were defined when those patients had multiple adhesions after previous abdominal surgery in the middle and upper quadrants, acute cholecystitis, and severe obesity. 100 patients after classic cholecystectomy represented the external control group. 170 patients were followed after laparoscopic cholecystectomy. Endpoints of investigation were duration of operation, complications, postoperative hospitalization, and postoperative quality of life. Major complications occurred in 1.2%. Although in patients after laparoscopy minor complications were registered at a higher incidence than in classic cholecystectomy, the patients' postoperative quality of life improved significantly faster after laparoscopy in all patients groups. These results show that even patients with severe adhesions, with acute cholecystitis and with prolonged duration of operation still profit from the laparoscopic technique in comparison to laparotomy.     

The judgement of adhesion formation following laparoscopic and conventional cholecystectomy in an animal model

INTRODUCTION: The development of postoperative adhesions remains an almost inevitable consequence of visceral and gynaecologic surgery, appearing in 50-95% of all patients. Although decreased adhesion formation is one of the accepted advantages of laparoscopic surgery, only a small number of prospective studies have been done to support this claim. AIMS OF THE STUDY: To evaluate the extent of postoperative adhesion formation after laparoscopic and open cholecystectomy. MATERIAL AND METHOD: 60 experimental laparoscopic cholecystectomies (LC) were performed by qualified surgeons in dogs with the aim to acquire the laparoscopic technique. To assess the relation between the complications during the operation (bleeding, injury to the liver substance or gallbladder perforation) and the formation of adhesions, the surviving animals were divided into 4 groups according to the complications occurred. The assessment of the results was made by second--look laparoscopy 4 weeks following LC using the adhesion index. As a control group open cholecystectomy was then performed in 5 dogs without intraoperative complications. RESULTS: No adhesion formation was observed in the groups where no intraoperative complications occurred. In all the cases where bleeding or injury to the liver bed occurred adhesion formation occurred. No adhesion formation was observed in case of gallbladder perforation. In all the animals of the control group adhesion formation was observed. CONCLUSION: It seems that LC has a reduced rate of adhesion formation when compared with the open technique. Complications such as bleeding or injury to the liver substance during LC can enhance adhesion formation. No adhesion formation can be mentioned in relation with gallbladder perforation when the laparoscopic technique is applied.     

有腹部手术史的腹腔镜手术应用分析(附78例报告)

目的 :总结有腹部手术史的患者行腹腔镜手术的经验。方法 :避开原有切口选择第 1戳孔 ,必要时采用开放法置入穿刺鞘 ,注重粘连区的分离技巧。结果 :78例中 77例成功完成手术 ,其中腹腔镜胆囊切除术 (LC) 6 8例 ,LC +胆总管探查取石术 2例 ,阑尾切除术 3例 ,肠粘连松解术 3例 ,十二指肠球部溃疡穿孔修补术 1例 ,因局部粘连严重中转开腹 1例 ,全部病例无手术并发症。结论 :有腹部手术史的腹腔镜手术具有创伤小 ,痛苦轻 ,恢复快 ,不影响切口愈合等优越性     

An unusual case of port site metastasis after laparoscopic cholecystectomy in a renal transplant patient: a case report

Port site metastasis after laparoscopy is a rarely seen intraabdominal malignancy independent of tumor stage. We present an unusual case of port site adenocarcinoma metastasis from unknown origin following laparoscopic cholecystectomy. A 52-year-old woman with a previous renal transplant underwent a laparoscopic cholecystectomy for symptomatic cholelithiasis. Six months later, she was admitted to the hospital with a complaint of a mass at the four trocar sites. A biopsy from the port sites led to the diagnosis of adenocarcinoma metastasis. Port site metastasis after laparoscopic cholecystectomy is seen especially after gallbladder cancer, and less frequently after intraabdominal malignancy independent of tumor stage. Our patient illustrated that port site metastasis probably spread from an undetected cancer site of an early stage intraabdominal tumor. Immunosuppression may have increased the likelihood of tumor seeding at the port sites.     

Accuracy of viscera slide detection of abdominal wall adhesions by ultrasound

Viscera slide is the normal, longitudinal movement of the intraabdominal viscera caused by respiratory excursions of the diaphragm. By detecting areas of restricted viscera slide, ultrasonic imaging was used to identify anterior abdominal wall adhesions prior to laparotomy or laparoscopy. Transcutaneous ultrasound examination was performed on 110 patients. A prediction of adhesions was made for each patient and then compared to the findings during subsequent laparotomy or laparoscopy. Only patients with previous abdominal surgery or history of peritonitis demonstrated adhesions. Sensitivity and specificity of viscera slide ultrasound in predicting adhesions were 90% and 92%. Nine out of 10 false results involved misinterpretation of ultrasound images of the lower one-third of the abdomen. Ultrasonic imaging of viscera slide is highly accurate in detecting abdominal wall adhesions. This technique is most useful in guiding the insertion of trocar in laparoscopic surgery, and as a noninvasive method in studying the formation of adhesions.     

Use of transabdominal ultrasound to identify intraabdominal adhesions prior to laparoscopy: a prospective blinded study

OVERVIEW: The aim of the current study was to assess the accuracy of transabdominal ultrasound (TAU) in identifying intra-abdominal adhesions (IAA) prior to laparoscopy in patients with previous abdominal surgery. METHODS: Patients with previous open surgical procedures presenting for laparoscopic gastric bypass (LGB) underwent TAU by 1 radiologist. Attempts were made to identify IAA using TAU. The intended trocar sites were categorized as free movement (no adhesions), chaotic movement (omental adhesions), or no movement (frozen bowel). During LGB, adhesions at the 6 trocar sites were graded by 1 blinded surgeon. RESULTS: A significant degree of agreement was found between the radiologist's predictions and the intraoperative findings with regards to identification of trocar sites free of adhesions versus omental adhesions and frozen bowel. CONCLUSIONS: TAU can accurately identify IAA prior to laparoscopy. Widespread application of this technique may decrease trocar-related injuries during laparoscopic procedures in patients with previous abdominal surgery.     

Laparoscopic reintervention in colorectal surgery

Laparoscopic colorectal surgery has developed in the 1990's and beginning of 2000. The favourable results and great progress in the development of laparoscopic techniques have expanded the indications of laparoscopic colorectal surgery. More and more complicated colorectal cases are treated laparoscopically, including those having had previous laparotomies. Surgical reinterventions after colorectal procedures are common. Reinterventions are either intended to treat complications of colorectal surgery or to treat colorectal disease after previous abdominal or pelvic surgery. Laparoscopic reinterventions face surgeons with specific challenges related to morphological changes in the abdomen. Adhesions are primarily responsible for these changes and evoke various complications such as trocar injury, bleeding, enterotomy and conversion to laparotomy. Trocars and Veress needle are responsible for up to half of all bowel injuries in laparoscopic surgery and adhesion formation is the most important risk factor for bowel injury. The risks of adhesions are often underestimated. The first clinical results on laparoscopic reinterventions are promising. Routine use of anti-adhesion agents and diagnostics is advocated to prevent adhesion formation and make reintervention more safe reducing serious complications as inadvertent enterotomy, bleeding and trocar injuries. More research is needed to develop better tools for mapping adhesions, as none of the trocar placing techniques can rule out bowel injury. Improved diagnostic tools for mapping adhesions will also facilitate patient selection for laparoscopic treatment of SBO.     

Prevalence of infraumbilical adhesions in women with previous laparoscopy.

BACKGROUND AND OBJECTIVE: The aim of this study is to evaluate the prevalence of intraabdominal adhesions to the umbilicus following gynecologic laparoscopy through an umbilical incision. METHODS: A retrospective review was performed of all gynecologic laparoscopic procedures in a private practice setting to identify patients with a repeat laparoscopy who had a history of a previous laparoscopy through an umbilical incision. Patients with a history of other surgeries were excluded. All repeat laparoscopies used a left upper quadrant entry technique where the abdominal cavity was surveyed for adhesions. We also reviewed adverse events attributable to the left upper quadrant entry approach. RESULTS: We identified 151 patients who underwent a second laparoscopy and had a previous umbilical scar. Thirty-two of the 151 (21.2%) patients with a history of a laparoscopy had evidence of adhesions to the umbilical undersurface. No adverse events or injuries were attributed to the left upper quadrant entry technique. CONCLUSIONS: Adhesions to the umbilical undersurface occur in 21.2% of patients who have undergone a prior laparoscopy through an umbilical incision. For this reason, we recommend an alternate location for entry in patients with an umbilical scar from a previous laparoscopy.     

The influence of intraoperative complications on adhesion formation during laparoscopic and conventional cholecystectomy in an animal model

BACKGROUND: The aim of this study was to evaluate the extent of postoperative adhesion formation after laparoscopic and open cholecystectomy. MATERIALS AND METHODS: Qualified surgeons performed 60 experimental laparoscopic cholecystectomies (LC) in dogs with the aim to acquire the laparoscopic technique. To assess the relation between the complications during the operation (bleeding, laceration of the liver bed, or gallbladder perforation) and the formation of adhesions, surviving animals were divided into four groups according to the type of complication occurred. Assessment of the results was made by second-look laparoscopy 4 weeks after LC using the adhesion index (AI; score range, 0-4). The animals then were killed so the extent of adhesion formation could be measured. As a control, open cholecystectomy was performed in 15 dogs without intraoperative complications. The Mann-Whitney rank-sum test and Dunn's method were used for statistical analysis. RESULTS: No adhesion formation or intraoperative complications were registered in the laparoscopic group I. In all the cases wherein bleeding or laceration of the liver bed occurred and was managed with electrocoagulation, adhesions formed. Adhesion formation in these groups was significantly higher than in "ideal LC" or cases of gallbladder perforation alone (p < 0.01). All the animals in the control group developed significantly more adhesions than those in the experimental group (p < 0.05). CONCLUSIONS: It seems that LC has a lower rate of adhesion formation than the conventional open technique. Complications such as bleeding or laceration of the liver bed during LC can enhance adhesion formation. No adhesion formation can be mentioned in relation to gallbladder perforation during LC.     

The ultrasonic localization of abdominal wall adhesions

Laparoscopic candidates with abdominal scars may have adhesions that result in visceral injury during trocar insertion. The purpose of this study was to evaluate the use of preoperative ultrasound mapping of abdominal wall adhesions, to provide safe initial laparoscopic access, and to guide the placement of subsequent trocars, facilitating adhesolysis when necessary. Thirty consecutive patients with previous abdominal surgery who were scheduled for laparoscopy underwent a preoperative ultrasonic examination of the abdominal wall using a 7-MHz linear ultrasound probe. Spontaneous viscera slide was measured during longitudinal scanning (normal=2–5 cm) and induced viscera slide was evaluated during longitudinal and transverse scanning (normal=1 cm or more) over the existing abdominal scar, the peri-umbilical region, and the remaining abdominal quadrants. Sixteen (53%) of 30 patients had adhesions under their scar and only four patients (25%) had umbilical adhesions. The 12 patients without umbilical adhesions all had successful closed cannulation while open cannulation at alternate sites was successful in the four individuals with umbilical adhesions. Blind umbilical needle cannulation was successfully done in all of the remaining 14 patients (47%) without visceral injury, including three patients (21%) with upper abdominal scars who were adhesion-free elsewhere. No adhesions were encountered that had not been preoperatively predicted by ultrasound. We conclude that examination of the abdominal wall with spontaneous and induced viscera slide, using ultrasound scanning, can reliably detect intraabdominal adhesions. The examination is best done on a highly selective basis by the operating surgeon to guide the location for initial trocar insertion and determine the type of abdominal wall cannulation in those individuals with previous abdominal scars.Presented at the annual meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES), Nashville, TN 18–19 April 1994     

开腹手术后的腹腔镜胆囊切除手术

目的 探讨有腹部手术史的病人行腹腔镜胆囊切除术的某些特点。方法 回顾分析34例有腹部手术史的患行腹腔镜胆囊切除术的临床资料。结果 34例中33例顺利完成腹腔镜胆囊切除术，仅1例中转开腹手术。结论 对有腹部手术史的病人行腹腔镜胆囊切除术是可行的，但穿刺孔选择、气腹、粘连的分离应予以注意。     

The fate of the dropped gallstones during laparoscopic cholecystectomy

Stones can be spilled from the gallbladder during laparoscopic cholecystectomy. These stones can be left in the peritoneal cavity or trapped at the trocar site. The potential late sequel and associated morbidity are not well documented. We reviewed the records of four patients who underwent laparoscopic cholecystectomy at Mount Sinai Medical Center in New York City who suffered from late complications attributed to gallstones left in the peritoneal cavity or abdominal wall. Four patients presented 1–14 months after laparoscopic cholecystectomy with intraabdominal and abdominal wall abscesses. The spillage of gallstones was noticed during the initial operation only in one of the patients. Three patients required laparotomy and open drainage of intraabdominal abscesses with drainage of pus and gallstones after failed attempts at percutaneous drainage. Two patients underwent local exploration of an abdominal wall abscess containing stones. Stones left in the abdominal cavity or trapped in trocar sites after laparoscopic cholecystectomy can cause serious late complications requiring repeated surgical interventions. Every effort should be made in order to avoid spillage of stones during dissection of the gallbladder and cystic duct and during retrieval of the gallbladder through the abdominal wall. Received: 10 January 1996/Accepted: 2 April 1997     

Prevention of adhesions by bioresorbable tissue barrier following laparoscopic intraabdominal mesh insertion

Intraabdominal adhesions represent a significant problem because of the morbidity associated with adhesive disease, including small bowel obstruction, difficulties in reoperative surgery, and possibly chronic pain. Coating solution of sodium hyaluronate (Sepracoat; Genzyme Production-Surgical Products, Cambridge, MA) was studied in New Zealand white rabbits to determine its potential role for prevention of postoperative adhesions following laparoscopic intraabdominal mesh insertion. A 2-cm polypropylene mesh was inserted laparoscopically to the left iliac fossa and fixed to anterior abdominal wall using a single prolen suture. Group 1 (n = 10) acted as the control group. Mesh was coated using 4% sodium hyaluronate in phosphate buffered saline (Sepracoat) in Group 2 (n = 10). Fourteen days later, all animals underwent diagnostic laparoscopy, and findings were recorded. All animals then were killed, the abdominal cavities were inspected, and adhesions were graded from 0 to 4. All meshes were removed and sent for histologic examination. The degrees of inflammation, fibrosis, and congestion were scored. No adhesions were seen on trocar sites on both groups. Eight of 10 animals in the control group and 5 of 10 animals in the study group had intraabdominal adhesions. The scoring of adhesions revealed that study group had only one (10%) significant adhesion, whereas the control group had eight (80%; < 0.001). Our study suggests that the Sepracoat reduces the incidence and severity of abdominal adhesions following laparoscopic mesh insertion and should be considered as a prophylactic agent, especially in those undergoing laparoscopic transabdominal mesh repair for hernia.     

The direct trocar technique: an alternative approach to abdominal entry for laparoscopy.

OBJECTIVE: The direct trocar technique is an alternative to Veress needle insertion and open laparoscopy for accessing the abdominal cavity for operative laparoscopy. We review our approach to abdominal entry in 1385 laparoscopies performed between September 1993 and June 2000 by our group at Stanford University Hospital, a tertiary Medical Center. METHODS: We performed a retrospective chart review of 1385 patients who underwent operative laparoscopy during the study years. The mode of abdominal entry, patient demographics, and complications were reviewed. RESULTS: The transumbilical direct trocar entry method was used in 1223 patients. In 133 patients, the Veress needle insertion technique was used. Open laparoscopy was used in 22 patients. Three (0.21%) major complicadons occurred: 1 enterotomy, 1 omental herniation, and 1 bowel hemiation. One complication was related to primary access (0.072%) in a patient who had an open laparoscopy. She sustained an enterotomy during placement of the primary trocar. The bowel was repaired laparoscopically. No trocar-related injuries occurred among the 1223 patients in whom the direct trocar entry technique was used. One patient had an omental herniation and required a repeat laparoscopy on postoperative day 2. The second patient had a repeat laparoscopy on the 12th postoperative day to repair a bowel herniation. None of our patients required a laparotomy. No vascular injuries occurred. CONCLUSION: Based on our experience, the direct trocar technique is a safe approach to abdominal entry for laparoscopic surgery.     

Preoperative risk factors for intraabdominal adhesions should not contraindicate surgical laparoscopy for infertility

OBJECTIVE: Abdominal wall adhesions at laparoscopy may predispose infertile patients to access-related injuries and increase the complexity of the procedure. We have observed concern from referring physicians regarding the safety of surgical laparoscopy in infertile patients who previously underwent surgery because of the risk of abdominal adhesions. To assess the risk of intraabdominal adhesions at laparoscopy, a retrospective cohort study was performed. METHODS: All infertile patients who underwent a reproductive laparoscopic procedure in a 6-year period at our institution were included in this study. A chart review was performed to obtain demographic/surgical data and identify preoperative risk factors for intraabdominal adhesions. Operative videotapes were reviewed to determine the presence and location of adhesions. Standard statistical analyses were performed. RESULTS: During the study period, 254 infertile patients underwent reproductive surgical laparoscopy, and videotapes on 164 (65%) were available for review. A total of 88 patients (54%) were identified with preoperative risk factors for intraabdominal adhesions (group 1), while 76 (46%) had no risk factors (group 2). The relative risk of adhesions was 1.34 (95% CI, range 0.89 to 2.01, P=0.18) when risk factors were identified. There were no differences in the groups regarding patient age, operative time, access technique, conversion to open surgery, or complications. Estimated blood loss was significantly higher in group 2, likely due to the predominance of laparoscopic surgery for ovarian endometriomata and complexity of the cases rather than the presence or absence of intraabdominal adhesion risk factors. CONCLUSIONS: No difference existed in the risk of intraabdominal adhesions in infertile patients with and without identifiable preoperative risk factors. Preoperative risk factors for intraabdominal adhesions should not contraindicate the surgical laparoscopic approach for reproductive procedures.     

LAPAROSCOPIC CHOLECYSTECTOMY AND PREVIOUS ABDOMINAL SURGERY: A SAFE TECHNIQUE

Previous abdominal surgery has been cited as a contraindication to the performance of laparoscopic cholecystectomy. The present paper describes a technique whereby a Hasson cannula was introduced into the right iliac fossa by the open technique, using a method similar to an appendicectomy. The laparoscope was then introduced through this port and the safe introduction of other ports was achieved. Any adhesions were divided at this stage. The laparoscope was then moved to the umbilical port and a conventional laparoscopic cholecystectomy performed. In the series of six patients with upper or upper and lower abdominal scars, no patient suffered a complication or required a conversion to laparotomy. However, the operating time was increased from 75 to 105 min. This method involves open introduction of the primary trocar in an area devoid of adhesions. It was shown to be safe and with this method previous abdominal surgery should not be regarded as a contraindication.     

Incisional hernias after laparoscopic vs open cholecystectomy

Background: The aim of this study was retrospectively to compare the incidence of incisional hernia formation at trocar sites in laparoscopic cholecystectomy with that after conventional open cholecystectomy. Methods: In all, 271 patients with cholelithiasis underwent either laparoscopic cholecystectomy (LC group, n= 142) or open cholecystectomy (OC group, n= 129). In the OC group, the surgical approach was to use a right subcostal incision in 20.2%, right transrectal laparotomy in 73.6%, and midlaparotomy in 6.2%. Laparotomy closure was performed by continuous absorbable suture for the peritoneum and discontinuous absorbable stitches for muscle and fascia. Laparoscopic access was achieved by use of four trocars (two 10 mm and two 5 mm). Umbilical port closure was performed by suture of fascia using discontinuous stitches. Closure of the remaining ports was performed by suture of the skin. Results: Both patient groups were statistically similar with respect to general risk factors. Follow-up was performed in 84 (65.1%) OC and 123 (86.6%) LC patients and ranged from 2 to 10 years (mean, 8 years) and 1 to 5 years (mean, 3 years) respectively. Five (5.9%) OC and two (1.6%) LC patients developed incisional hernias, although the difference between groups was not significant. All hernias in OC patients appeared after transrectal laparotomy. The LC hernias appeared at the umbilical port, and one of the patients developed an additional xiphoides port-associated hernia. Conclusions: The laparoscopic technique showed a lower (although not significantly) incidence of incisional hernias than the open procedure. Received: 16 July 1998/Accepted: 27 November 1998