Laparoscopic Adhesiolysis in Manegment of Adhesive Intestinal Obstruction

INTRODUCTION

Intra-abdominal adhesions may be congenital or acquired. Acquired adhesions usually occur as a result of abdominal surgery, trauma, or inflammatory insult. Adhesion development may result in intestinal obstruction, prolonged stomach discomfort, or infertility in women. Preventive treatment advancements have not yet achieved the anticipated impact of preventing adhesive formation.¹

The Halstedian concepts of precise hemostasis, gentle tissue handling to reduce trauma, and keeping tissues wet have long been recommended as excellent adhesion prevention measures. Peritoneal damage, abdominal wall trauma, foreign body introduction, trauma to nearby or distant organs, and tissue ischemia are all hypothesised to play a role in adhesion formation aetiology.²

A laparoscopic method should presumably make it easier to avoid these risk factors. Laparoscopy often does not need the use of retractors or bowel packing, resulting in less tissue manipulation. Other benefits of laparoscopic surgery in terms of adhesion prevention include: decreased peritoneal surface dryness and reduced gastrointestinal motility impairments.³

Glucocorticoids and antihistamine preparations, Glucocorticosteroids reduce the vascular permeability by reducing the systemic inflammatory response of the body and increases the separation of cytokines and hemotaxial factors. These medications have yielded few results in the prevention of adhesions. Corticosteroids, such as dexa-methasone, hydrocortisone and prednisolone, were tested and tested separately, along with antihista-mines, such as promethazine. Antihistamines, combined with glucocorticoids, inhibit the proliferation of fibroblasts, which in turn prevents the growth of the adhesions. However, these drugs have side effects, such as immunosuppression or retardation of wound healing, so they are used with caution nowadays.⁴

Operative adhesiolysis is the only way to get rid of adhesion after it has developed. When conservative therapy fails or symptoms signal a clinical or physiological emergency, like toxemia or ischemia, open laparotomy is universally acknowledged as the standard procedure for Adhesive Intestinal Obstruction, but this open method may be followed by many complications such as postoperative pain ,ileus, incresed incidence of wound infections, a more incisional hernia rate, incresed incidence of reccurent attack of adhesive intestinal obstraction, longer postoperative hospital stay, aesthetic Traditional laparotomy has been replaced as an elective therapy for a variety of disorders by laparoscopy. It's linked to a decreased risk of morbidity and a shorter stay in the hospital. Adhesive intestinal obstruction might be a possibility for modification to laparoscopic surgery, as it is becoming a therapeutic option in emergency surgery for acute cholecystitis, acute appendicitis, and peptic ulcer rupture.⁵

Theoretically, adhesiolysis with a laparoscope should result in better results than traditional open surgery.⁶

Due to the higher risk of iatrogenic injuries, the difficulties in controlling dilated intestinal segments, and the inferior operating area, bowel obstruction has traditionally been considered an absolute contraindication for the laparoscopic technique.⁷

Because the above-mentioned challenges have been significantly minimized as a result of growing expertise with this method, this contraindication is now just relative. As a result, patients undergoing this procedure can reap the following benefits: less postoperative pain, less ileus, a lower incidence of wound infections, a lower rate of incisional hernia, a shorter postoperative hospital stay, aesthetic benefits, and a reduction in future adhesions.⁷

This final benefit is likely the most significant, considering that the likelihood of a subsequent episode of bowel obstruction in these patients rises by 30% after the first incident, 40% after the second, and up to 60% after the third.⁷

Patients who show indications of strangulation or peritonitis (fever, tachycardia, leukocytosis, continuos pain, focal tenderness, guarding) and/or radiological findings of bowel ischemia (free peritoneal fluid, mesenteric edema, presence of the small bowel feces sign in CT) need an urgent exploration and a bowel resection in case of ischemia.⁸

 The goal of our research was to see how effective laparoscopic adhesiolysis is in treating individuals with recurring adhesive intestinal obstruction.

PATIENTS AND METHODS

This was a prospective research including 20 participants diagnosed with adhesive intestinal obstruction and underwent diagnostic laparoscopy in in general surgery department at Al-Azhar University Hospitals and Damanhour Medical National Institute.

Inclusion criteria: Patients with adhesive intestinal obstruction not, and resolving with conservative management.

Exclusion criteria: Suspicion of organic intestinal obstruction than adhesions, severe abdominal distension, previously confirmed or strongly suspected abdominal malignancy, abdominal radiation in the past, abdominal surgery in the recent past (within 30 days), and pregnancy, uncontrolled hepatic diseases and cardiopulmonary problems.

According to the ethics committees of both institutions, every patient who participated in the research gave their informed permission.

Preoperatively, all patients underwent to:

History taking including nature of previous surgery and number of previous attacks of intestinal obstruction.

Clinical examination.

Pre-operative Radiological investigations including: Abdominal plan erect x-ray, ultrasonography and CT.

 Laboratory tests performed before to surgery, including: Complete blood count, coagulation profile, serum ALT level, random blood glucose level, serum creatinine level, serum sodium and potassium levels, serum CRP level, and serum LDH level.

Initially, the patients were closely monitored throughout a period of conservative therapy that included fasting, insertion of a nasogastric tube, antibiotic medication, and intravenous fluids and electrolytes. Serial abdominal radiographs, clinical examination, and necessary laboratory testing are all part of the observation process. Patients who did not have their bowel obstruction cleared within 72 hours were operated on.

Operative procedure:

For the laparoscopic approach:

With either an open approach or a Veress needle, the abdomen was penetrated away from scars from prior procedures. When using the Veress needle, a syringe test was done to ensure that the needle's tip was not lodged in a vessel or the intestines, as follows: The Veress needle is used to inject a 5 mL normal saline solution. The saline solution could not be respirated if it got into the peritoneal cavity. Respiration of the saline solution indicated that the Veress needle tip was in a closed cavity or freshly created space.

Carbon dioxide insufflation to a maximum pressure of 14 mmHg had been used to create a pneumoperitoneum. The remaining ports are introduced under direct vision based on the first telescopic inspection of the abdominal cavity and adhesion sites to make it accessible for cutting.

The bowel was manipulated with atraumatic graspers and adhesions are identified and lysed with combination of sharp and blunt dissection.  To reduce the incedince of intestinal injury and recurrence of adhesion formation, diathermy is not used except for haemostasis. The lysed region was meticulously evaluated for any bleeding and intestinal damage once appropriate adhesiolysis was completed.  Ports were removed under vision after insertion of a tubal drain. Fascial defects 10 mm or larger are closed with non-absorbable sutures to prevent port site hernia.

To ensure patient safety, certain criteria for converting to open surgery are established: A minor intestinal perforation that could not be repaired with laparoscopic suturing was confirmed or suspected. There was no mention of a changeover point. The cause of the impediment has yet to be discovered. The presence of peritoneal carcinomatosis is discovered. Diffuse adhesions are prevalent across large areas. Resection of the bowel was required.

The following operative data had been recorded: Number of ports used, site of first port, location of adhesions, duration of operation, and intraoperative complications as visceral injury need for blood transfusion or conversion to laparotomy.

Postoperatively, the patients will be managed as follow:

Patients had been kept nil by mouth on IV fluids till regaining of bowel activity in the form of audible bowel sounds and passing of flatus or motion. After regaining bowel activity, the nasogastric tube is removed and oral fluids are started first followed by soft diet.

Wound infection, postoperative ileus, peritonitis and other general complications eg. DVT and chest infection, if any, are recorded and taken care of. Patients are discharged after per oral nutrition was tolerated and sufficient pain relieve is achieved. Duration of postoperative hospital stay is recorded. Patients were asked to follow up after 1weak, 1, 3, and 6 months for later complications as port site hernia, recurrence of obstruction and need for reoperation. The outcome of the operation will be recorded.

Ethical considerations:

The collected data had been used in research purpose only, the approval of parents of the children were mandatory after informing them about the study's purpose and the procedures their children had been undergo.

Statistical analysis

The data was entered into a computer and statistically evaluated using the SPSS (Statistical Package for Social Science) version 24 application. The Shapiro Walk test was used to determine whether the data had a normal distribution. Frequencies and relative percentages were used to depict qualitative data. The difference between qualitative variables was calculated using the Chi square test (χ2). The median and standard deviation were used to convey quantitative data. For parametric and non-parametric parameters, the Student t test was employed to quantify the variance between quantitative variables in two groups. All statistical comparisons were done using a two-tailed significance level. A P-value of

RESULTS

Table 1: Demographic characteristics of studied patients

Patients aged between 20 to 58 years with mean BMI 29.33 kg/m2. 60% of the patients were males (Table 1).

Table 2: Comorbidities distribution, previous surgeries history and Site of adhesions between the studied patients

Table 2 showed 45% of the patients were smokers, while 25% of the patients were hypertensive and 15% of the patients were diabetics. There was 30% of the patients had no history of previous surgeries due to congenital Adhesions, while 70% had history of previous surgeries, the most common surgery was appendicectomy (30%) and gynecological surgeries (20%) and inguinal hernia (10%). In 80% of patients, adhesions were found in the lower abdomen while 20% of the patients had adhesions in the upper abdomen.

Table 3: Clinical characteristics between the studied patients

Most of the patients had previous two attacks of bowel obstruction (60%), 25% had attacks for three times and 15% had attacks for four times. Laparoscopic access was performed through the umbilicus in 65% of the patients, 20% through the left upper quadrant and 10% through the right upper quadrant while through the right lower quadrant was done in only one patient (5%). 80% of the patients had 3 ports while 20% had 4 ports (Table 3).

Table 4: Operative time and hospital stay of studied patients

This table shows that the average operating duration was 93.42 ± 24.67 min, and average hospital stay was 3.85 ± 4.46 days (Table 4).

Table 5: Success rate among the studied patients

Adhesiolysis was successfully done by laparoscopy in 95% of the patients (Table 5).

Table (6): Postoperative complications among the studied patients

Majority of the patients had no complications (80%). However, the most common complication was prolonged postoperative ileus (10%). One patient was converted to laparotomy (Table 6).

CASES

Fig. 1: Adhesive band during laparoscopic adheiolysis.

Fig. 2: Intestinal obstruction due to Adhesive band on appendicular stamp "during laparoscopic adheiolysis".

Fig. 3: During release of the band by scissors.

Fig. 4: After releasing the band.

Fig. 5: Congenital adhisive band in mal patient presented by intestinal obstruction.

Fig. 6: Adhesive Intestinal obstruction due to Adhesive band post appendectomy with gangrenous part of small bowel "ilium Adhesive Intestinal.

Fig. 7: Obstruction in femal patient due to Adhesive band post appendectomy with dilated part proximal to band and collapsed part distal to the band.

Fig. 8: Adhesive Intestinal obstruction due to multiple Adhesive bands.