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Severe Adhesions. Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director Residency in General Surgery University of Cincinnati. Disclosures. Ethicon Endo surgery. Severe Adhesions. Re-operative Surgery

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severe adhesions

Severe Adhesions

Bradley R. Davis, MD, FACS, FASCRS

Associate Professor of Surgery

Director Surgical Education/Surgical Skills Lab

Program Director Residency in General Surgery

University of Cincinnati

disclosures
Disclosures
  • Ethicon Endo surgery
severe adhesions1
Severe Adhesions
  • Re-operative Surgery
  • Small bowel obstruction
    • Acute
    • Chronic Recurrent (when to operate?)
  • Previous abdominal or pelvic surgery
severe adhesions2
Severe Adhesions
  • Previous surgery not a contraindication to laparoscopy
  • Small bowel obstructions – often a single band
  • PEEK port
severe adhesions3
Severe Adhesions
  • Many patients have had previous laparotomy
    • Kocher
    • Pfannenstiel
    • Midline
    • Chevron
  • Most deserve a look lap – known prior hostile abdomen exception
small bowel obstructions
Small Bowel Obstructions
  • 40% of patients with previous laparotomy will develop an SBO
  • Laparotomy effective but longer LOS and adhesion formation more significant vs. lap
  • Increasing experience with laparoscopy in the management of SBO
lap adhesiolysis sbo
Lap Adhesiolysis SBO

Surg Endosc. 2012 Jan;26(1):12-7

lap adhesiolysis for sbo1
Lap Adhesiolysis for SBO

Surg Endosc. 2012 Jan;26(1):12-7

lap adhesiolysis for sbo2
Lap Adhesiolysis for SBO

Surg Endosc. 2007 May;21(5)

lap adhesiolysis for sbo3
Lap Adhesiolysis for SBO

Surg Endosc. 2007 May;21(5)

lap adhesiolysis
Lap Adhesiolysis

Am Surg. 2011 Feb;77(2):185-7

principles
Principles
  • Preoperative abdominal distention may preclude pneumoperitoneum
  • Generous use of sharp dissection – cautious use of energy
  • Pelvic adhesions can be the most hostile
lap adhesiolysis1
Lap Adhesiolysis
  • MUST identify the transition zone
  • Consider adhesive barrier
    • Can be difficult to insert – role seprafilm into ‘cigar’ insert through trocar
peek port
PEEK Port
  • Start difficult procedure through a 6-8cm incision
  • Assess adhesions after “mini” laparotomy
  • Proceed with HALS based on assessment
    • Do not open lap disposables until confirmed
re operative surgery
Re-operative Surgery
  • Extent of adhesions dictated by the index procedure
  • This will be discussed in a separate presentation