Perioperative management - Adhesiolysis, open

Around 90% of intraabdominal adhesions result from previous trauma, such as that experienced in every abdominal procedure. Only about 10% of the population have adhesions without prior abdominal manipulation; these may be congenital or can result from intraabdominal inflammation.

Most adhesions are asymptomatic and devoid of pathological significance.  Therefore, adhesiolysis is indicated only for the following symptoms:

• Mechanical ileus
• Symptomatic patients with intestinal obstruction
• Rather tentative indication in patients with chronic abdominal pain arising from adhesions
• In every abdominal repeat procedure
• In some cases of female infertility

Adhesiolysis in patients with chronic complaints is indicated only as a last resort.

If an intraabdominal procedure is indicated and standard criteria evaluate the patient as fit for surgery, there are no further contraindications.

There is no imaging modality able to detect adhesions qualitatively or quantitatively. Only adhesion sonography can roughly evidence the presence of adhesions. Such studies are carried out with the patient in supine position. Then the patient is placed in the lateral recumbent position. Adhesions are likely if the loops of the small intestine displace less than 2 cm.

Abdominal CT studies yield the most information on the possible etiology of mechanical ileus.

Otherwise, the special studies called for in elective operations are undertaken.

There is no special preparation for adhesiolysis; as noted, this depends on the type of operation planned.

As a rule of thumb, elective procedures, e.g. incisional hernia repair, should be carried, out, if at all possible, at least one year after the last operation because empirical data indicate that adhesions will have fully matured by then and are easier to take down.

The following specific risks apply regardless of the procedure planned:

• Abdominal organ injuries, especially to the small and large intestines
• The possible need to resect segments of the bowel.
• The reality that adhesions tend to recur to varying degrees following adhesiolysis.
• Possibility of intestinal stoma
• Peritonitis from missed intestinal leakage
• Postoperative intestinal paralysis
• Persistent adhesion-related complaints
• Postoperative ileus in around 1% within the first year and around 3% later course

Since adhesiolysis requires extensive exploration of the entire abdomen, this mandates general anesthesia, possibly following placement of an epidural catheter.

See also:

General anesthesia

Patient positioning is always determined by the primary procedure planned.

For example, in confirmed small bowel ileus standard supine position is adequate, with the arms tucked to the body or abducted depending on the department protocol.

If colon involvement is suspected, it is best to place the legs in restraints to allow transanal colonoscopy or insertion of a circular stapler.

The operating room setup is also dictated by the planned procedure.

In the examples noted above, the surgeon usually stands to the right of the patient and the assistant to the left. The scrub nurse stands at the foot of the operating table.

A second assistant is often quite helpful.

Adhesiolysis usually only requires a standard abdominal tray, atraumatic intestinal sutures, and possibly bipolar scissors.

Exposure of the surgical field is facilitated by a broad range of fixation systems, e.g., Mercedes retractors, frames with valves, and even self-retaining systems such as Omni-Tract.

A nasogastric tube is mandatory in ileus.

Postoperative care: Fluid and electrolyte balancing, with potassium at a high normal level.

Analgesia: 

Follow this link to PROSPECT (Procedures Specific Postoperative Pain Management).

Follow this link to the International Guideline Library.

The ideal analgesic protocol would include an epidural catheter.

Bowel movement: Bowel stimulation with neostigmine, metoclopramide

Deep venous thrombosis prophylaxis: The individual risk of thromboembolism calls for prophylactic physical measures and conceivably low-molecular-weight heparin, possibly adapted to weight or dispositional risk, until full ambulation reached. Follow this link to the International Guideline Library.

Note: Renal function, HIT II (history, platelet check)

Ambulation: Full ambulation best already on the day of surgery, if necessary, with physiotherapy support.

Diet: Start oral nutrition as early as possible, ideally already on the day of surgery.

Work disability: This depends largely on the individual case and the respective procedure.