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The surgical sequence demonstrated here is based on the example of a patient with complete adhesiolysis following previous midline laparotomy.
Following appropriate prepping and draping, excise the old scar and extend the incision craniad and caudad, if necessary.
Tip: Before excising the scar always check that there is enough skin available. Otherwise, it will be difficult to achieve tension-free skin closure, resulting in ugly scars and impaired wound healing.
Opening the abdomen
Now transect the subcutaneous fatty tissue with the scalpel or electrocautery.
Tip: Often, small incisional hernias are encountered as sequelae of previous operations. After dividing the fatty tissue these hernias grant direct access to the abdomen. Any adherent intestinal segments here can be easily injured.
Expose the fascia and transect it in the median line with the scalpel.
Tip: After previous operations, always open the fascia with a scalpel. Any adherent parts of the intestine would quickly be injured by electrocautery, whereas the intestines are able to “evade” the carefully dissecting scalpel.
Exposing the fascial edges – Inserting an abdominal wall retractor
Now grasp the facial edges with one or more sharp forceps and retract them anteriad/laterad. At the same time pull the intestines posteriad. This will put tension on the adherent intestinal structures. The boundary between the parietal peritoneum and the intestine can always be found this way, and then carefully take down the structures in this region with scissors. The same applies to adherent omental structures.
Note: This surgical step calls for a lot of experience. Traction and countertraction must be precisely controlled to avoid tearing the intestines. Some adhesions may also be divided by blunt dissection with the fingers. If a clear border with the abdominal wall is impossible to identify, the parietal peritoneum may be included in the resection in places.
In this way, proceed laterad and along the longitudinal axis step by step. Once the edges of the fascia have been freed far enough on all sides, insert an abdominal wall retractor.
This starts the actual adhesiolysis. In addition to experience, this also needs patience. Depending on the degree of adhesion, this may take an hour or more.
For practical purposes, start where the intestine is still reasonably mobile. The assistant puts traction on the intestines and/or omentum in all three planes such that the surgeon can see the borders and free them with scissors. If at a certain point further progress is not possible at first, switch to the next segment and dissect until here, too, this no longer possible. This way it is possible to alternate through all four quadrants of the abdomen during adhesiolysis and gradually free the small and large intestines, where necessary.
Tip: The correct layer is always identified by the avascular fibrous tissue between the intestinal loops. Whenever there is heavier bleeding, this usually indicates that the dissection is proceeding in the wrong layer.
Dissection in the wrong layer or excessive traction invariably leads to serosal defects or full-thickness intestinal wall injuries. While this is not a problem, these injuries must be detected and sutured immediately. Always suture these lesions promptly, since otherwise it is easy to lose track of their number and locations during the operation. The most disastrous complication following adhesiolysis is overlooked intestinal leakage!
After completing adhesiolysis, carefully inspect the freed small and large intestines at least twice to identify any defects.