- 10mm 30 degree scope
- 5mm forward viewing scope
- 5mm ports x 2-3
- 10mm port
- Sharp scissors
- Fenestrated 5mm grasper
- Bipolar diathermy
- 5mm needle holders x 2
- Amielle vaginal dilator (hysterectomised patients)
- Sprakman retractor for patients with uterus and pelvic adhesions
- Sigmoidoscope - Ethicon rectal sounds/luminal size assessors available
- Ureteric stent availability
Whilst laparoscopic lysis of adhesions is a challenging and very difficult procedure, it is safe in the hands of well-trained laparoscopic surgeons. BLA believe that this technique should be mastered, not only for its usefulness in dealing with intestinal obstruction, chronic abdominal pain and endometriosis but also for dealing with adhesions commonly encountered during other procedures.
There are a number of methods of obtaining the pneumoperitoneum. The first is a veres needle inserted in the LUQ, near to the 9th rib in the anterior axillary line. Hold the needle like a dart. An alternate, is Palmers point, located 3cm inferior to the subcostal arch in the left medioclavicular line. Once obtained, insert a 5mm port and using a 5mm scope to inspect the peritoneal cavity. Insert additional ports as necessary, usually lateral to the rectus muscles. Choose the most suitable site for the 10mm port. Alternatively employ a cut down technique as far away from the surgical incision. If you encounter dense adhesions try an alternate site.
Scissors are the preferred method of division, especially avascular and congenital ones. Most can be divided with minimal bleeding and without resort for bipolar diathermy. Provided that you keep them sharp, reusable scissors are fine. Alternatively use disposable ones that you are comfortable and familiar with. Use a combination of sharp and blunt dissection. Move throughout the abdomen. Keep the tips of the scissors in view all the time. Control bleeding with separate bipolar diathermy. Unless you are well versed in its use, avoid monopolar when working on the bowel.
Adhesions are easer divided when working above them than within them. Use gravity. The carbondioxide also helps to disperse them. A suction irrigator can be a useful assistant and clean the scope too.
DO NOT USE the suction irrigator to dissect the small bowel - it will tear the seromuscular layer and an enterotomy will develop within 24hrs. Repair denuded areas of bowel muscularis with a 3/0 vicryl seromuscular stitch.
Start with adhesions to the anterior abdominal wall. Separate bowel from the abdominal wall with countertraction. Follow with omental and pelvic adhesions. Divide small bowel adhesions and run the bowel between forceps. Finally divide tuboovarian adhesions if necessary. All adhesions can not be divided. Be guided by the patients history. If the adhesion is vascular, use a 5mm Haem-o-Loc clip first.
There are three key points to performing adhesiolysis within the pelvis; scissor dissection without cautery, countertraction and blunt dissection. When interfaces are obvious use scissors. When dealing with endometriosis in the pouch of douglas, dissect the anterior rectum until you reach the loose areolar tissue of the rectovaginal space. Using a rectal probe as guide, open the rectal serosa at its junction with the endometrioma lesion. Free up the rectum below the lesion before finally excising the endometriosis. Sometimes it is useful to have a finger in the rectum to cut onto.
Remember the ureter. You may need to open up it covering peritoneum. Use bipolar diathermy for any haemostasis. If you need to resect a segment - do so and repair over a ureteric stent.
Next move on to freeing up the vagina and repair as necessary. You can maintain the pneumoperitoneum with a foley catherer and 30-40 ccs water in the balloon.
BLAs personal experience of dealing with other surgeons complications would caution against the use of the Harmonic Scalpel. Thermal burns and delayed enterotomies are a real issue. Harmonic can be helpful in dealing with organised fibrous adhesions and undertaking any bowel resection (mesentery division). Use endo GIAs for bowel division. If there is an associated incisional hernia use it to remove bowel or carry out an anastomosis.
Use rectal and vaginal probes to identify anatomy and ease dissection within the pouch of douglas.
The most important predictive factor of adhesion formation is previous abdominal surgery. Conversely, 31% of scars from previous surgery are free of adhesions. 10% of patients without any prior surgical scars develop spontaneous adhesions. The treatment of uncomplicated SBO is generally conservative, especially with incomplete obstruction and the absence of systemic toxemia, ischemia, or strangulation.
Approx 2/3 of the length of a laparotomy incision is involved in adhesion formation. The incidence of ventral hernia after a laparotomy ranges between 11% - 20% versus the 0.02%–2.4% incidence of port site herniation. Additional benefits include a decreased incidence of wound infection, pneumonia and a shorter hospital stay.
The published success rate of laparoscopic lysis lies between 46% and 87%. Operative times range is about one hour; conversion rates vary between 7 and 43%. The incidence of intraoperative enterotomy ranges between 3- 18%. The average length of stay is 4–6 days.