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Laparoscopic Adhesiolysis

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  • 1. Laparoscopic adhesiolysis
  • 2. ADHESIONS
  • 3. Adhesions
    • “ Abnormal attachments between tissues and organs”
    • The most common cause of intra-abdominal adhesions is a history of previous abdominal surgery ( Adhesions have been reported after 93% of abdominal operations [12] and after 55% to 100% of pelvic operations [4].)
    • Peritoneal inflammation and trauma that are the important etiologic factors in the formation of these structures (Deaver 1923)
    • Until the introduction of anesthesia and then antiseptic surgery allowed laparotomy to become a comparatively common and comparatively safe procedure in the 1880s, intraabdominal adhesions were an uncommon phenomenon and of little, if any, interest to surgeons.
    • The first fatal case of small bowel obstruction from a band (formed after removal of an ovarian cyst ) was by Thomas Bryant, of Guy’s Hospital, London, in 1872
    • The first account of a laparotomy for adhesive obstruction was reported in the Lancet in 1883 by William Battle, then a surgical registrar at St Thomas’sHospital, London.
  • 4. Adhesions ,Pathophysiology
    • Both adhesion formation and adhesion-free epithelialization are pathways of peritoneal wound healing.
    • The injury of the peritoneum may be inflammatory or surgical and may include exposure to infection or to intestinal contents; ischemia; irritation from foreign materials such as sutures, gauze particles, or glove dusting powder; abrasion; desiccation; overheating by lamps or irrigation fluid; and many others.
    • The healing attempt begins with the formation, through coagulation, of a fibrin gel matrix, which is the ‘‘ground’’ through which mesothelial cells can migrate and accomplish reepithelialization.
    • When two injured peritoneal surfaces covered with this sticky fibrin matrix come into apposition, sticky bands and bridges of fibrin form between them.
    • It is then the role of the fibrinolytic system to dissolve this fibrinous strands within a few days. However, this task cannot be always fulfilled because surgery dramatically reduces fibrinolytic activity, both by increasing the levels of plasminogen activator inhibitors and by decreasing the levels of tissue plasminogen activator (tPA) .
    • If the fibrinous matrix persists, it will be infiltrated by proliferating fibroblasts which subsequently depose collagen. Mesothelial cells also migrate and form an uninterrupted layer on the surface of the already constituted adhesion.
    • As the tissue underlying the adhesion is usually relatively hypoxic, signals initiating angiogenesis will be elaborated, resulting in a vascularized adhesion.
  • 5. Adhesions ,Pathophysiology
    • The most common cause of intra-abdominal adhesions is a history of previous abdominal surgery [1].
    • The formation of intra-abdominal adhesions may result from mechanical peritoneal damage, intra-abdominal tissue ischemia, or the presence of foreign materials [19,20].
    • In the classic pathway of adhesion formation, peritoneal injury from trauma, infection, or ischemia results in an immediate type of inflammatory reaction followed by an increase in vascular permeability and the release of fibrin-rich exudate [15,21].
    • In the absence of the lysis of this fibrin through the plasminogen-plasmin cascade, fibrous adhesions may form through collagen deposition [22]. Lysis of the fibrin depends on the activation of the peritoneal mesothelial plasminogen activator. Normal mesothelial cells possess plasminogen-activating activity [23].
    • This physiologic property of normal mesothelial cells is decreased in the presence of surgical trauma, ischemia, or inflammation [22].
    • Injury results in the rapid release of plasminogen-activator inhibitor-1 and -2 by mesothelial,endothelial, and inflammatory cells. This causes a loss of plasminogen-activating activity [11,24].
    • For many decades, many materials and methods have been used to solve the adhesion problem.
  • 6. Adhesions ,Pathophysiology
    • Adhesions form as the end result of an inflammatory response to injury within the peritoneal cavity.
    • Fibrin clot accumulating at the site of injury is usually lysed by the endogenous fibrinolytic systems.
    • In more severe injury, fibroblasts migrate into the fibrin clot and produce collagen, which forms scars or adhesions.
    • With a greater inflammatory response, there is less fibrinolysis and more fibroblast activity, resulting in more adhesion formation [1].
    • The severity of inflammation is related to the degree of local tissue trauma, ischemia, and the presence of a foreign body [6].
    • Adhesion formation is reduced after laparoscopic surgeryC. L. Garrard,1 R. H. Clements,1 L. Nanney,2,3 J. M. Davidson,4 W. O. Richards1,5 Surg Endosc (1999) 13: 10–13
  • 7. Adhesions ,Pathophysiology
    • We postulate that the tissue trauma of the incision increases the total inflammatory response, thereby inhibiting fibrinolysis and promoting fibroblast migration and collagen formation.
    • The trauma of a midline incision contributes to the formation of intra-abdominal adhesions, even when the incision does not transect the peritoneum.
    • These results strongly suggest that laparoscopic surgical techniques lead to fewer intra-abdominal adhesions by reducing tissue trauma, which in turn reduces circulating inflammatory mediators.
    • Adhesion formation is reduced after laparoscopic surgeryC. L. Garrard,1 R. H. Clements,1 L. Nanney,2,3 J. M. Davidson,4 W. O. Richards1,5 Surg Endosc (1999) 13: 10–13
  • 8. Adhesions ,Pathophysiology
    • Development of acquired adhesions is a biological phenomenon in response to trauma to the peritoneum.
    • Whatever this trauma is—mechanical and ischemic in surgery, inflammatory in endometriosis or septic–in- flammatory in peritonitis—the pathogenesis of adhesion formation follows several steps, the pivotal event being the apposition of the damaged peritoneal surfaces and the insufficient fibrinolysis [16].
  • 9. Adhesions,complications,natural history
    • Abdominal adhesions, which can begin forming within a few hours after an operation, represent one of the most common causes of intestinal obstruction.
    • Complications of adhesions include chronic pelvic pain (20–50% incidence), small bowel obstruction (49–74% incidence), intestinal obstruction in ovarian cancer patients (22% incidence), and infertility due to complications in the fallopian tube, ovary, and uterus (15–20% incidence).
    • Incidence rates for abdominal adhesions have been estimated to be as high as 90% after major gynecologic operations.
    • Abdominal Adhesiolysis: Inpatient Care and Expenditures in the United States in 1994 Nancy Fox Ray, MS,*William G. Denton, RN, MBA,† 1998 by the American College of Surgeons
  • 10. Adhesions,natural history
    • The number of patients with laparoscopically confirmed adhesions without prior laparotomy or laparoscopy was 11 of 101 patients (11%).
    • Kolmorgen and Schulz reported a rate of 25% of affected patients without prior surgery [4].
    • For Mecke et al., the rate was 30% [9]; for Tavmergen et al., it was 27% [11].
    • Subjective evaluation of the therapeutic value of laparoscopic adhesiolysis A retrospective analysis E. Malik,1 C. Berg,1 A. Meyho¨fer-Malik,1 S. Haider,2 W. G. Rossmanith2 Surg Endosc (2000) 14: 79–81
  • 11. Adhesions,complications,natural history
    • Adhesions from prior surgery are the most common cause of small bowel obstruction in the Western world .
    • The incidence of an adhesive small bowel obstruction after open abdominal surgery is between 12% and 17% .
    • Historically, laparotomy and open adhesiolysis have been the treatment for patients requiring surgery for small bowel obstruction.
    • Unfortunately, this often leads to further formation of intraabdominal adhesions with approximately 10% to 30% of patients requiring another laparotomy for recurrent bowel obstruction .
    • Laparoscopic adhesiolysis for small bowel obstruction Alexander Nagle, M.D., Michael Ujiki, M.D., Woody Denham, M.D., Kenric Murayama, M.D.* The American Journal of Surgery 187 (2004) 464–470
  • 12. Adhesions,complications,natural history
    • A recent survey of 750 German hospitals demonstrated that 2·6 per cent of laparotomies were for adhesional bowel obstruction1
    • A prospective study by Menzies and Ellis3 indicated that approximately 1 per cent of patients will suffer obstruction within a year of abdominal surgery and that over a third of people who develop adhesional obstruction will do so within a year of surgery, with the remainder presenting with an initial episode of obstruction at a steady rate up to 10 years after surgery. This suggests an overall rate of adhesion-related morbidity of 3 per cent.
    • Menzies and Ellis’ prospective study3 indicated that while most adhesional obstruction occurs within 10 years (59 per cent by 5 years and 79 per cent by 10 years) there is no time limit as to when a patient may suffer an episode of obstruction.
    • The mean time to presentation was 8·9 years with 26 per cent presenting within 1 year and 48 per cent presenting within 5·5 years.
    • However, one patient presented with adhesional obstruction 35 years after an appendicectomy.
    • Natural history of adhesional small bowel obstruction: counting the cost British Journal of Surgery 1998, 85 , 1294–1298
  • 13. Adhesions,complications
    • Clinical impact of adhesions
    • The major consequences of adhesions are infertility, pelvic or abdominal chronic pain, and intestinal obstruction In addition to this increased morbidity, adhesions waste surgical time and resources by increasing the difficulty and risk of surgical reentry.
    • Adhesions are responsible for up to 40% of infertilities [29, 45], 80% of chronic postoperative abdominal pain [40], and 60% of intestinal obstructions [7, 10, 21] and they increase the technical difficulty of subsequent intraabdominal surgical procedures [5, 18].
    • Fewer adhesions induced by laparoscopic surgery? C. N. Gutt, T. Oniu, P. Schemmer, A. Mehrabi, M. W. Bu¨ chler Surg Endosc (2004) 18: 898–906
  • 14. Adhesions,complications
    • Infertility
    • In a recent study adhesions were found in 271 (37%) of 733 infertile patients; in 41 (15%) of these 271 cases adhesions were the sole factor for infertility and in the rest of the cases, their presence was associated with tubal occlusion, endometriosis, or other infertility factors [29].
    • Other authors also consider that moderate to severe pelvic adhesions may be responsible for 40% of infertility [45].
    • Fewer adhesions induced by laparoscopic surgery? C. N. Gutt, T. Oniu, P. Schemmer, A. Mehrabi, M. W. Bu¨ chler Surg Endosc (2004) 18: 898–906
  • 15. Adhesions,complications
    • Pelvic and abdominal chronic pain
    • A prospective study revealed that 200 (82%) of 224 patients suffering of chronic abdominal pain had only adhesions and no other disease; they underwent primary laparoscopic adhesiolysis and 3 months after adhesiolysis, 74% of patients were pain-free or had less pain, thus demonstrating that adhesions were the only cause of their suffering [40].
    • Fewer adhesions induced by laparoscopic surgery? C. N. Gutt, T. Oniu, P. Schemmer, A. Mehrabi, M. W. Bu¨ chler Surg Endosc (2004) 18: 898–906
  • 16. Adhesions,complications
    • Intestinal obstruction
    • Worldwide statistics indicate adhesions to be one of the leading causes of intestinal obstruction, accounting for30 to 60% of cases [7, 10, 21, 28, 30, 41, 46].
    • An analysis based on data from the Scottish National Service revealed 280 readmissions (0.67%) necessitating operative treatment for adhesive small-bowel obstruction in a cohort of 41,841 patients who underwent initial abdominal surgery 10 years before [12].
    • A review of 18,912 patients with open surgery found that 2.6% required surgery for adhesive intestinal obstruction within the following 2 years [3].
    • Another study followed 2,708 laparotomies for an average of 14.5 months and counted 26 cases (1%) that developed intestinal obstruction due to postoperative adhesions within 1 year of surgery [28].
    • Although this percent situated between 0.5 and 2.6% may seem low, considering its application to all laparotomies worldwide it results in a considerable number of patients readmitted and re-operated as emergencies.
    • Fewer adhesions induced by laparoscopic surgery? C. N. Gutt, T. Oniu, P. Schemmer, A. Mehrabi, M. W. Bu¨ chler Surg Endosc (2004) 18: 898–906
  • 17. Adhesions,complications
    • Other consequences
    • Adhesions to the abdominal incisions may prolong and complicate reentry into the abdominal cavity at the time of a subsequent medical or surgical procedure.
    • Intraperitoneal therapies, peritoneal dialysis, and chemotherapy are hindered [18].
    • The complications related to laparoscopic access are mainly due to adhesions to the abdominal wall and frequently lead to conversion to open surgery [26].
    • The presence of adhesions from previous surgeries can add at least 15 minutes to the operative time for reoperations, both because of the cautiousness needed when re-entering the abdomen and because of the adhesiolysis required to identify the anatomical structures at the operative site [5].
    • Furthermore, adhesiolysis itself can be dangerous, because of accidental injuries to the bowel which, if not recognized, can lead to life-threatening peritonitis [43].
    • Fewer adhesions induced by laparoscopic surgery? C. N. Gutt, T. Oniu, P. Schemmer, A. Mehrabi, M. W. Bu¨ chler Surg Endosc (2004) 18: 898–906
  • 18. Adhesions,cost
    • Intra-abdominal adhesions cause a high financial burden for social budgets.Total costs related to adhesions have been estimated to be1.2 billion U.S. dollars per year
    • The socioeconomic impact of adhesive small bowel obstructions is significant. In 1996, Medicare paid $3.22 billion for adhesion related complications .
    • The total cost in 1988 for adhesiolysis hospitalizations (adjusted to 1994 dollars) was $1.44 billion, which is $111.3 million more than the total cost in 1994. The decreased cost of adhesiolysis hospitalizations in 1994 is attributable to a decreased average length of stay.
    • Abdominal Adhesiolysis: Inpatient Care and Expenditures in the United States in 1994 Nancy Fox Ray, MS,*William G. Denton, RN, MBA,† 1998 by the American College of Surgeons
  • 19. Adhesions,cost
    • According to a previous study by Ray and associates,(11) 281,982 hospitalizations and $1.2 billion in hospital and surgeon expenditures were attributed to lower abdominal adhesiolysis in 1988.
    • Since this earlier study was conducted, surgical practice has shifted dramatically from open abdominal procedures, which can lead to recurrent adhesions, to less invasive techniques such as laparoscopy.12–14
    • Minimal-access laparoscopic techniques to identify and lyse adhesions increasingly have become the preferred surgical approach because of the advantages of more precise incision, less bleeding, and minimal damage to the surrounding tissue.3
    • Abdominal Adhesiolysis: Inpatient Care and Expenditures in the United States in 1994 Nancy Fox Ray, MS,*William G. Denton, RN, MBA,† 1998 by the American College of Surgeons
  • 20. Adhesions,prevention
    • Since the beginning of the 20th century, truly enormous attempts have been made to prevent the formation of postoperative adhesions.
    • Attempts to prevent postoperative adhesions can be classified into:
    • A. Prevention of fibrin deposition , using citrate, heparin (both topically and systemically).
    • B. Removal of fibrin exudates between damaged surfaces.
    • Attempts have been made to wash away or dilute the fibrin using saline, hypertonic dextrose, and other solutions, or to digest or remove it with pepsin, trypsin, streptokinase, and tissue plasminogen activator .
    • Intraabdominal and Postoperativ Peritoneal Adhesion Harold Ellis, CBE, FACS (Hon), FRCS 2005 by the American College of Surgeons
  • 21. Adhesions,prevention
    • C. Separation of surfaces .
    • Materials used in the past included saline, Ringer’s solution, dextran, gelatine, olive oil, paraffin, silicones, plasma, lanoline, polyvinyl pyrrolidine, and an amazing variety of membranes—amnion, fish bladder, carp peritoneum, calf peritoneum, oiled silk, silver or gold foil, and free grafts of omentum.
    • Only a membrane composed of hyaluronic acid and carboxymethylcellulose was shown to reduce adhesion formation in a clinical prospective randomized trial.
    • More recently, a solution of icodextrin has reduced adhesion formation after laparoscopic gynecologic operations in a pilot study.
    • D. Inhibition of fibroblastic proliferation .
    • Attempts to prevent the conversion of fibrinous adhesions into established fibrous tissue have included studies of antihistamines and steroids given topically and systemically .
    • Intraabdominal and Postoperativ Peritoneal Adhesion Harold Ellis, CBE, FACS (Hon), FRCS 2005 by the American College of Surgeons
  • 22. Adhesions,prevention
    • Ellis [6] has classified these preventive measures into 5 groups: (1) installation of lubricants or distention with gas, (2) enhancement of peristaltic movements, (3) covering of raw surfaces, (4) enzymatic digestion, and (5) agents to inhibit fibrin deposition.
    • It was reported that anticoagulants, especially heparin, were effective in decreasing the incidence of intra-abdominal adhesions [2,7–10].
    • Hyperbaric oxygen (HBO) treatment has begun to be used with increasing incidence for many occasions and goals in the recent years. Basically, its effect in removing ischemia defines the main indications for its use [14].
    • We concluded that enoxaparine Na decreased abdominal adhesions and HBO therapy had no beneficial effect on the formation of abdominal adhesions. We also showed that enoxaparine Na had no harmful effect on wound healing and HBO therapy increased the process of wound healing.
    • An evaluation of low molecular weight heparin and hyperbaric oxygen treatment in the prevention of intra-abdominal adhesions and wound healing Soykan Arikan, M.D.a,The American Journal of Surgery 189 (2005) 155–160
  • 23. Laparoscopic adhesiolysis
    • Laparoscopic aspects of adhesion formation
    • Type and amplitude of peritoneal trauma seems to play an important role in pathophysiology of adhesion formation.
    • Since laparoscopic procedures are thought to considerably reduce the overall degree of trauma to the abdominal wall, intraabdominal operative site, and distant intraabdominal organs, they potentially have an advantage of reducing the formation of postoperative adhesions.
    • Potential advantages
    • Reduced incision of the parietal peritoneum.
    • The total area of injured peritoneum liable to establish adhesions to underlying omentum or small bowel is much reduced after laparoscopy.
    • Early return of bowel motility.
    • Laparoscopy speeds patients’ recovery from surgery. Earlier return of bowel motility and early ambulation could also diminish postoperative adhesion formation by mechanically separating the coalescent peritoneal surfaces.
    • Reformation of adhesions after adhesiolysis
    • There are only a few reports in the literature dealing with the subject of laparoscopic adhesiolysis, and they all conclude that laparoscopic adhesiolysis leads to significantly reduced adhesion reformation relative to open surgery.
    • Fewer adhesions induced by laparoscopic surgery? C. N. Gutt, T. Oniu, P. Schemmer, A. Mehrabi, M. W. Bu¨ chler Surg Endosc (2004) 18: 898–906
  • 24.
    • 6. Reformation of adhesions
    • Second-look procedures after laparoscopic adhesiolysis showed a permanent reduction of those adhesions connecting organs and the abdominal wall, but not of those between organs themselves [7].
    • However, Mettler [22] found more often an increased adhesion score than a reduced one in patients at second-look laparoscopy.
    • The severity of adhesion formation is influenced by 8.iso prostaglandin F2a, which is increased by elevation of the intra-abdominal pressure induced by carbon dioxide [23].
    • Adhesion reformation is a frequent occurrence after laparoscopic surgery, although de novo adhesions appear to occur much less frequently than with open surgery [24].
    • Laparoscopic adhesiolysis for chronic abdominal pain is not indicated D. Swank* International Congress Series 1279 (2005) 85– 89
  • 25. Laparoscopic adhesiolysis
    • There are substantial theoretical reasons to claim fewer postoperative adhesions after laparoscopic surgery compared to conventional surgery:
    • less tissue damage at the abdominal wall incision(s), decreased possibility of blind dissection of adhesions during abdominal exploration, lack of retractor and pack usage, maintenance of a closed abdomen with presumed reduction in peritoneal drying, less likelihood of introduction of foreign bodies, less tissue trauma and hemorrhage at the operative site.
    • The general conclusion based on all materials presented in this article is that laparoscopy is associated with a reduction in the formation and reformation of adhesions.
    • Fewer adhesions induced by laparoscopic surgery? C. N. Gutt, T. Oniu, P. Schemmer, A. Mehrabi, M. W. Bu¨ chler Surg Endosc (2004) 18: 898–906
  • 26. Laparoscopic adhesiolysis
    • Laparoscopic adhesiolysis was first described by gynecologists for the treatment of chronic pelvic pain and infertility.
    • Laparoscopic adhesiolysis for small bowel obstruction was first reported by Bastug et al in 1991 in 1 patient with a single adhesive band.
    • In addition, laparoscopy has been shown to decrease the incidence, extent, and severity of intraabdominal adhesions when compared with open surgery, thus potentially decreasing the recurrence rate for adhesive small bowel obstruction [8].
    • Laparoscopic adhesiolysis for small bowel obstructio Alexander Nagle, M.D., Michael Ujiki, M.D., Woody Denham, M.D. Kenric Murayama, M.D.* The American Journal of Surgery 187 (2004) 464–470
  • 27. Laparoscopic adhesiolysis
    • Laparoscopic adhesiolysis for small bowel obstruction has a number of potential advantages:
    • Less postoperative pain
    • Quicker return of intestinal function
    • Shorter hospital stay
    • Reduced recovery time
    • Earlier return to full activity
    • Fewer wound complications
    • (7) Decreased postoperative adhesion formation
    • Laparoscopic adhesiolysis for small bowel obstructio Alexander Nagle, M.D., Michael Ujiki, M.D., Woody Denham, M.D. Kenric Murayama, M.D.* The American Journal of Surgery 187 (2004) 464–470
  • 28. Laparoscopic adhesiolysis ,small bowel obstuction
    • The most important aspect to a successful outcome is proper patient selection and surgical judgment.
    • There are no clear guidelines that state which patients are best suited for laparoscopic adhesiolysis; however, there are several factors that have been shown to predict a successful outcome.
    • Chosidow et al [15] reported laparoscopic adhesiolysis on an emergent basis in 39 patients; the conversion rate was 36% compared with 7% in elective cases.
    • Suter et al [13] found that a bowel diameter exceeding 4 cm was associated with an increased rate of conversion: 55% versus 32% ( P 0.02).
    • Patients with a distal and complete small bowel obstruction have an increased incidence of intraoperative complications and increased risk of conversion.
    • Leo´n et al [19] state that a documented history of severe or extensive dense adhesions is a contraindication to laparoscopy.
    • In contrast, Suter et al [13] found no correlation between the number and or type of previous surgeries and the chance of a successful laparoscopic surgery.
    • Laparoscopic adhesiolysis for small bowel obstructio Alexander Nagle, M.D., Michael Ujiki, M.D., Woody Denham, M.D. Kenric Murayama, M.D.* The American Journal of Surgery 187 (2004) 464–470
  • 29. Laparoscopic adhesiolysis ,small bowel obstuction
    • The conversion rates range from 6.7% to 43% [10,13].
    • The reported hospital length of stay in most series is 4 to 6 days for the laparoscopic group and around 12 days for the converted group.
    • The incidence of intraoperative enterotomies ranges from 3% to 17.6%, with most authors reporting an incidence of about 10% [12,15].
    • Suter et al [13] reported an intraoperative enterotomy incidence of 15.6%, of which 62% were repaired laparoscopically.
    • Although a missed enterotomy can occur after laparotomy, the incidence is higher after laparoscopic surgery.
    • Suter et al [13] reported 4 of 47 cases (8.5%) of missed enterotomies that required reoperation.
    • The reported mortality ranges from 0% to 3%. This rate is lower than the reported mortality after open surgery of adhesiolysis, which most likely represents patient selection.
    • Laparoscopic adhesiolysis for small bowel obstructio Alexander Nagle, M.D., Michael Ujiki, M.D., Woody Denham, M.D. Kenric Murayama, M.D.* The American Journal of Surgery 187 (2004) 464–470
  • 30. Laparoscopic adhesiolysis ,small bowel obstuction
    • Navez et al [21] reported that 85% (29 of 34) of the patients treated laparoscopically were asymptomatic with a mean follow-up of 46 months.
    • The series with the longest follow-up (mean 61.7 months) reported 87.5% (14 of 16) of the patients treated laparoscopically were asymptomatic [12].
    • The question regarding decreased recurrence after laparoscopy compared with laparotomy remains to be answered.
    • Interestingly, Khaitan et al [28] have described a new technique of applying Seprafilm laparoscopically, which could further decrease the recurrence of adhesive bowel obstruction.
    • Laparoscopic adhesiolysis for small bowel obstructio Alexander Nagle, M.D., Michael Ujiki, M.D., Woody Denham, M.D. Kenric Murayama, M.D.* The American Journal of Surgery 187 (2004) 464–470
  • 31. Laparoscopic adhesiolysis ,small bowel obstuction
    • laparoscopy has been contraindicated due to the risk of enteric injury and the possibility of bowel distention, which would prevent the visualization of the point of obstruction.
    • Conclusions
    • Laparoscopic adhesiolysis has been shown to be safe and feasible in experienced hands.
    • In selected patients, laparoscopic adhesiolysis offers the advantages of decreased length of stay, faster return to full activity, and decreased morbidity.
    • Patient selection and surgical judgment appear to be the most important factors for a successful outcome.
    • In these studies, the success rate for laparoscopic adhesiolysis for acute small bowel obstruction has ranged from 46% to 87%.2-4,6
    • Laparoscopic adhesiolysis for small bowel obstructio Alexander Nagle, M.D., Michael Ujiki, M.D., Woody Denham, M.D. Kenric Murayama, M.D.* The American Journal of Surgery 187 (2004) 464–470
  • 32. Laparoscopic adhesiolysis ,small bowel obstuction
    • Franklin et al. treated 23 patients with acute small bowel obstruction laparoscopically in 1994 [6]. Laparoscopic treatment was possible in 20 of 23 (87%).
    • In a later series, Ibrahim et al. reviewed 33 consecutive cases of acute small bowel obstruction treated with laparoscopy [9]. Overall, 18 patients (55%) underwent successful laparoscopic adhesiolysis, and 22 patients (67%) were spared laparotomy.
    • In our series, 40 patients with acute small bowel obstruction were treated with laparoscopy. Open initial trocar insertion was performed in all cases. The point of obstruction was relieved entirely laparoscopically in 24 patients (60%), and only 13 patients required formal laparotomy (32.5%).
    • In our series, enterotomies occurred in four of 40 patients (10%) during laparoscopic exploration and adhesiolysis.
    • this figure is comparable to the reported incidence after open laparotomy for acute bowel obstruction. An even higher proportion of the patients had enterotomies after conversion (23%).
    • Is laparoscopy safe and effective for treatment of acute small-bowel obstruction? P. Strickland, D. J. Lourie, E. A. Suddleson, J. B. Blitz, S. C. Stain
  • 33. Laparoscopic adhesiolysis ,small bowel obstuction
    • A review of literature showed a correlation between selection criteria and conversion rate (range 17–63.4%) [1, 5, 15, 23].
    • The highest conversion rates are reported when no selection of patients is adopted [21], while the best results are reached with most severe exclusion criteria [1].
    • A significant correlation was found between conversion and presence of peritonism by both Benoist et al.[5] and Suter et al. [23].
    • Nonetheless, the author reports a conversion rate of 48.4 %, and in 80% of cases the conversion was due to the inability to identify or remove the site of obstruction.
    • No statistical correlation was found between the number of previous operations and the percentage of recurrence, complication, or need for conversion.
    • Literature data reported a rate of intraoperative complications of 0–16.5%; the rate of postoperative complications was 4.5–31%
    • Laparoscopic approach to postoperative adhesive obstruction G. Borzellino, S. Tasselli, G. Zerman, C. Pedrazzani, G. Manzoni Surg Endosc (2004) 18: 686–690
  • 34. Laparoscopic adhesiolysis ,small bowel obstuction
    • Only two authors reported follow-up data for the assessment of recurrences after laparoscopic adhesiolysis, with an observational period of 22 and 24 months.
    • The percentage of recurrences reported by these authors was 5% and 10% [10, 22].
    • The follow-up period of this study was longer, with an average length of 48 months. This may explain the higher percentage of symptomatic recurrences found in our study (15.4%), while surgical recurrences (4.6%) were similar to that reported by other authors.
    • Laparoscopic approach to postoperative adhesive obstruction G. Borzellino, S. Tasselli, G. Zerman, C. Pedrazzani, G. Manzoni Surg Endosc (2004) 18: 686–690
  • 35. Laparoscopic adhesiolysis ,small bowel obstuction
    • Postoperative results
    • Patients in the LAP group experienced a quicker recovery of bowel movements ( P < 0·001), a shorter length of hospital stay ( P < 0·001) and had fewer postoperative complications (19·2 versus 40·4 per cent; P = 0·032) than those who had a conventional procedure ( Tables 4 and 5) .
    • A reduced field of vision together with the vulnerability of the bowel limits the use of laparoscopy and may explain why laparoscopy for acute SBO has the highest rate of conversion in laparoscopic surgery27.
    • There is evidence that laparoscopic treatment of acute SBO leads to a higher rate of bowel injury than conventional surgery25.
    • The rate of bowel perforation in this series was 26·9 per cent in the LAP group and 13·5 per cent in the CONV group.
    • Laparoscopic compared with conventional treatment of acute adhesive small bowel obstruction C. Wullstein and E. Gross British Journal of Surgery 2003; 90 : 1147–1151
  • 36. Laparoscopic adhesiolysis ,small bowel obstuction
    • Conversion rates as low as 6% to 13% [13, 15] have been reported, sometimes with a significant reoperation rate resulting from incomplete exploration, adhesiolysis, or both [13]. In most studies, however, the conversion rate is higher, between 26% and 54% [1, 3, 5, 18, 21, 22, 23, 29].
    • Reasons for conversion are mainly inability to identify the origin of the obstruction (usually in relation to a reduced working space because of intestinal distension), inability to relieve obstruction completely because of special anatomic features or adhesions that are too extensive, accidental bowel perforation, bowel necrosis, or causes not amenable to laparoscopic treatment (tumor, incarcerated hernia).
    • Neither the number or type of previous operations nor the location of the previous incisions influenced the location and type of adhesions or the need for conversion.
    • Evidence of bowel necrosis obviously could be considered as an indicator for immediate laparotomy.
    • Laparoscopic management of mechanical small bowel obstruction Are there predictors of success or failure? M. Suter, P. Zermatten, N. Halkic, O. Martinet, V. Bettschart Surg Endosc (2000) 14: 478–483
  • 37. Laparoscopic adhesiolysis ,chronic abd pain
    • Several reports have described the use of laparoscopy for the lysis of adhesions in patients with chronic abdominal pain or recurrent bowel obstruction [4, 5, 7].
    • These studies found symptomatic improvement in 67– 87% of patients after laparoscopic adhesiolysis and a conversion rate of 5–7%.
    • Is laparoscopy safe and effective for treatment of acute small-bowel obstruction? P. Strickland, D. J. Lourie, E. A. Suddleson, J. B. Blitz, S. C. Stain
  • 38. Laparoscopic adhesiolysis ,chronic abd pain
    • In 35–56% of patients with chronic abdominal pain, adhesions will be the only explanation, which suggests that laparoscopy is the best primary intervention in patients with such pain.1,2
    • The reported rates of chronic pain relief after this procedure vary from 38% to 87%.8,9
    • Discussion
    • We have shown significant relief of chronic pain after laparoscopic adhesiolysis. However, this reduction in pain did not differ from that in controls with the same symptoms, pain scores, and frequency and severity ofadhesions who underwent diagnostic laparoscopy only.
    • On the other hand, results from several studies have shown chronic pain relief after laparoscopic adhesiolysis, with improvement rates of 45–84%.8,9,20–22
    • However, there is a 10% morbidity rate associated with laparoscopic adhesiolysis. Other investigators have reported bowel injury rates of between 10% and 25% during laparoscopic adhesiolysis for pain.15,23
    • Laparoscopic adhesiolysis in patients with chronic abdominal pain: a blinded randomised controlled multi-centre trial D J Swank, S C G Swank-Bordewijk, W C J Hop, W F M van Erp, I M C Janssen, HBonjer, J Jeekel THE LANCET • Vol 361 • April 12, 2003
  • 39. Laparoscopic adhesiolysis ,chronic abd pain
    • Overall, the outcomes were very good. Of the 19 patients in this study, 14 (74%) are very pleased with their procedure at this writing, and have completely discontinued all analgesics.
    • In conclusion, laparoscopic lysis of adhesions combined with placement of Seprafilm is a relatively novel approach for patients with chronic abdominal pain secondary to adhesions.
    • Meanwhile, patients can undergo this procedure with the expectation that their symptoms will improve.
    • Results after laparoscopic lysis of adhesions and placement of Seprafilm for intractable abdominal pain L. Khaitan, S. Scholz, H. L. Houston, W. O. Richards Surg Endosc (2003) 17: 247–253
  • 40. Laparoscopic adhesiolysis ,chronic abd pain
    • Our results demonstrate that patients with intermittent pain, such as pain at defecation or micturition, enjoyed marked relief following adhesiolysis if other causes of chronic pain were excluded.
    • The majority of patients with dyspareunia were relieved by adhesiolysis.
    • Thus, patients who present with dyspareunia should be operated on laparoscopically to establish the existence of adhesions as a possible cause of their discomfort and perform adhesiolysis.
    • Chan and Wood emphasized the great benefit of adhesiolysis in eliminating dyspareunia and indicated that amelioration or elimination of the symptoms was achieved in 70% of their patients [1].
    • Adhesiolysis is also beneficial in cases of dysmenorrhea or continuous lower abdominal pain.
    • Since adhesions can be causally related to chronic pelvic pain, it is mandatory to achieve complete lysis of adhesions.
    • Subjective evaluation of the therapeutic value of laparoscopic adhesiolysis A retrospective analysis E. Malik,1 C. Berg,1 A. Meyho¨fer-Malik,1 S. Haider,2 W. G. Rossmanith2 Surg Endosc (2000) 14: 79–81
  • 41. Small bowel obstruction Laparoscopic approach F. Agresta,1 A. Piazza, Surg Endosc (2000) 14: 154–156
    • OR table which offers the full range of tilt, as extreme positions may be necessary.
    • Arms must be by their side to allow the surgical team ample room
    • At least two movable video monitors are required to provide a better view of the operative theatre.
    • Patients were prepared and draped in a way that allowed conversion to an open procedure when necessary.
    • General endotracheal anesthesia with a nasogastric tube and urinary catheter in place.
    • Nitrous oxide as an anesthetic gas should be avoided .
  • 42. Laparoscopic Management of Small Bowel Obstruction: Indications and Outcome Enrique Luque-de Ledn, M.D., Altjandro Metzger, M.D., Gregory G. Tsotos, M.D., J GASTROINTEST SURG 1998;2:132-140.)
    • Patients were placed in the supine position with abducted arms and supports mounted to allow safe tilting and lateral rotation of the operating table.
    • Two video monitors were used; the video monitor to the patient’s right was positioned inferiorly at the level of the hip and the monitor to the left positioned superiorly at the level of the shoulder (Fig. 2).
    • This positioning forms a plane parallel to the root of the small bowel mesentery and allows the operating surgeon to look and work in the same direction as the camera orientation.
  • 43. Laparoscopic Management of Small Bowel Obstruction: Indications and Outcome Enrique Luque-de Ledn, M.D., Altjandro Metzger, M.D., Gregory G. Tsotos, M.D., J GASTROINTEST SURG 1998;2:132-140.)
  • 44. Laparoscopic adhesiolysis,Tips & Tricks/ Peritoneal access
    • Peritoneal access and trocar injury to the distended bowel are major concerns regarding the feasibility of laparoscopic adhesiolysis.
    • The initial trocar should be placed away (alternative site technique) from the scars in an attempt to avoid adhesions (Fig. 1).
    • Laparoscopic adhesiolysis for small bowel obstructio Alexander Nagle, M.D., Michael Ujiki, M.D., Woody Denham, M.D., Kenric Murayama, M.D.* The American Journal of Surgery 187 (2004) 464–470
  • 45. Laparoscopic adhesiolysis,Tips & Tricks/ Peritoneal access
  • 46. Laparoscopic approach to postoperative adhesive obstruction G. Borzellino, S. Tasselli, G. Zerman, C. Pedrazzani, G. Manzoni Surg Endosc (2004) 18: 686–690
    • Preoperative ultrasonographic mapping of abdominal wall adhesions has an important role to play in the selection of patients and for first trocar placement.
    • This evaluation eliminates the risk of visceral injuries and enables the best location for successive trocars.
  • 47. Laparoscopic adhesiolysis,Tips & Tricks/ Peritoneal access
    • The traditional approach of the abdominal cavity for laparoscopic surgery is a closed trocar penetration after the establishment of a pneumoperitoneum with a Veress needle.
    • Visceral lesions in closed introduction have been reported between 0.06 and 0.4 % [11].
    • Half of these visceral lesions are caused by the trocar and consist of damage to the small bowel ranging from superficial serosal damage to perforation. However, all other intraabdominal organs may also be involved and these have a high mortality rate of 5% up to 15% [16].
    • The rate of major vascular injuries with the closed technique varies from 0.02% to 0.24% [11].
    • Vascular lesions are mostly caused by the Veress needle and in a minority of cases Caused as a consequence of trocar introduction [16].
    • The eighth intercostal space as the site for the Veress needle has been chosen three times to avoidad hesions after a previous traverse incision in the upper abdomen. We found an easy introduction due to the short passage and adherent parietal peritoneum. This site is at least 5 cm away from the diaphragm.
    • Childers has chosen the left ninth intercostal space after median laparotomies and has recommended this as a safe site in patients with high-risk subumbilical adhesions [6].
  • 48. Laparoscopic adhesiolysis,Tips & Tricks/ Peritoneal access
    • For pneumoperitoneum a Veress needle introduced preferably caudally to the umbilicus.
    • In case of a midline scar, the entry site was chosen left subcostally.
    • In case of a traverse incision in the upper abdomen the Veress needle was introduced in the intercostal space just above the eighth rib in the midclavicular line on the left side.
    • Sato et al [12] reported using the Veress needle in 16 patients without a single complication. The importance of confirming the position of the needle with the saline drop test and monitoring the pressure during insertion of the Veress needle was emphasized.
    • In contrast, Levard et al [11] reported a 3.7% incidence of intestinal perforation using a blind-access technique in cases of bowel obstruction.
  • 49. Laparoscopic adhesiolysis,Tips & Tricks/ Peritoneal access
    • Most authors advocate the use of the open technique because of concerns about intraabdominal adhesions fixing segments of bowel to the under surface of the abdominal wall [13,19,21,23].
    • The open technique is performed similar to a muscle-sparing incision for an appendectomy.
    • Careful dissection is required to avoid injury to the underlying adherent bowel.
    • Blind cutting or spreading must be avoided.
    • The open technique allows the identification of adherent bowel and dissection of the bowel away from the abdominal wall.
    • Although the open technique does not completely eliminate the risk of bowel injury, it does allow the surgeon to promptly identify and repair any injury that may occur.
    • Finally, there have been no reports of vascular injuries with the open technique, as have been described with the blind access technique.
    • The disadvantage of the open technique is the increase in operative time, particularly in obese patients.
  • 50. Laparoscopic adhesiolysis,Tips & Tricks/ Peritoneal access
    • Optical access trocars.
    • The distal fold of the umbilicus was preferred as introduction site of the initial trocar (Optiview) in patients without a midline incision.
    • Otherwise the introduction took place at least 5 cm lateral of the scar away from the expected location of adhesions.
    • In experienced hands, optical access trocars are safe and facilitate rapid entry into the peritoneal cavity.
    • String et al [9] reported their use in 650 patients, with a mean entry time of 77 seconds and a complication rate of 0.3%.
    • With this technique a 0-degree laparoscope is inserted through the transparent cannula as the trocar is advanced through the abdominal wall, thereby visualizing each tissue layer of the abdominal wall.
    • The advantage of this technique is that it allows you to identify the bowel wall before inserting the trocar into the bowel.
    • Furthermore, if an injury does occur, it is recognized at that time and managed appropriately.
  • 51. Laparoscopic adhesiolysis,Tips & Tricks/ Peritoneal access
    • Once safe access is obtained, the next goal is to provide adequate visualization in order to insert the remaining trocars.
    • In most cases, at least two additional trocars will be needed in order to achieve adequate adhesiolysis.
    • If possible, the trocars should be placed to operate along the sights of the camera and not against the camera.
    • Surgeons should be flexible about trocar placement, and additional trocars should be placed as needed to accomplish the necessary adhesiolysis.
  • 52. Laparoscopic adhesiolysis,Tips & Tricks/ Peritoneal access
    • This often requires some degree of adhesiolysis along the anterior abdominal wall.
    • Numerous techniques are available, including finger dissection through the initial trocar site and using the camera to bluntly dissect the adhesions.
    • Sometimes, gentle retraction on the adhesions will separate the tissue planes.
    • Most often sharp adhesiolysis is required.
    • The best technique is to follow the line of tissue adherence, if possible, which results in less bleeding and less risk for bowel injury.
    • A traction-countertraction technique as used for open adhesiolysis is effective.
    • The use of cautery and ultrasound dissection should be limited in order to avoid thermal tissue damage.
    • A particularly difficult situation involves dense adhesions between the bowel and anterior abdominal wall. In this case, the plane between the bowel and the peritoneum is often obliterated, and it is necessary to dissect in the preperitoneal fat.
  • 53. Laparoscopic adhesiolysis,Tips & Tricks/ Technique for adhesiolysis
    • After trocar placement, the initial goal is to expose the collapsed distal bowel.
    • This is facilitated with the use of angled telescopes and maximal tilting/rotating of the surgical table. It may also be necessary to move the laparoscope to different trocars to improve visualization.
    • Manipulation of thin-walled, friable, dilated small bowel should be avoided.
    • Even with atraumatic graspers, injury to the bowel wall can occur.
    • If necessary, the small bowel mesentery (instead of the bowel wall) should be grasped in order to manipulate the bowel.
  • 54. Laparoscopic adhesiolysis,Tips & Tricks/ Technique for adhesiolysis
    • Once the collapsed distal bowel is exposed, atraumatic graspers should be used to run the decompressed small bowel proximally until the site of obstruction (transition point) is found.
    • The bowel was then run from the cecum proximally with two atraumatic graspers.
    • In those cases in which the point of obstruction was clearly identified (with collapsed bowel distally and dilated loops proximally), the obstruction was relieved without further examination of the bowel.
    • In all other cases, inspection was continued to the ligament of Treitz.
  • 55. Laparoscopic adhesiolysis,Tips & Tricks/ Technique for adhesiolysis
    • Sharp dissection with the laparoscopic scissors should be used to cut the adhesions.
    • Cautery should be avoided in order to prevent potential thermal injury to adjacent bowel.
    • The use of cautery also causes tissue ischemia (a very potent adhesion promoter), which leads to the formation of more intraabdominal adhesions.
    • Only pathologic adhesions should be lysed.
    • Additional adhesiolysis only adds to the operative time and to the risks of surgery without benefit.
    • If the point of obstruction is not clearly identified, adhesiolysis should continue until all suspicious adhesion or bands are transected.
    • If all adhesions cannot be lysed then conversion to an open procedure should be strongly considered.
  • 56. Laparoscopic adhesiolysis,Tips & Tricks
    • Once adequate adhesiolysis is complete, the area lysed should be thoroughly inspected for possible bleeding and bowel injury.
    • If found, these complications should be treated appropriately.
    • Small bleeding points may be controlled with clips, suture, or careful cautery.
    • Serosal tears and enterotomies can be repaired laparoscopically; however, there should be a low threshold to convert.
    • If there is any concern about the integrity of the bowel, minilaparotomy is recommended in order to examine the bowel under direct visualization.
  • 57. Laparoscopic adhesiolysis,Tips & Tricks
    • Matted small bowel loops and dense adhesions are also best managed with a formal laparotomy.
    • Navez et al [21] reported that only 10% of obstructions caused by dense adhesions could be treated successfully with laparoscopy.
    • The presence of malignant adhesions mandates immediate conversion to laparotomy ( Malignant adhesions are difficult to handle laparoscopically. The transition zone is not clear and the bowel is studded with metastases, dilated and edematous in multiple areas ) .
    • Perforated or gangrenous bowel is best managed with conversion to either a minilaparotomy or a formal laparotomy.
  • 58. Laparoscopic adhesiolysis,Tips & Tricks
    • Patients who require an emergent operation are not good candidates for laparoscopic adhesiolysis.
    • Patients with bowel dilatation less than 4 cm and a partial obstruction can be considered for laparoscopic adhesiolysis.
    • Patients who have a chronic or recurrent partial obstruction documented on a contrast study are also good candidates for laparoscopic adhesiolysis.
  • 59. Safe laparoscopic adhesiolysis with optical access trocar and ultrasonic dissection A prospective study D. J. Swank,1 H. J. Bonjer,2 J. Jeekel Surg Endosc (2002) 16: 1796–1801
    • The great advantage of UD is the simultaneous dissection and hemostasis and therefore minimal need for exchange of instruments during the procedure with decreased operating time as a result [8].
    • Ultrasonic dissection has some concomitant advantages. In patients with a pacemaker the ultrasonic device can be used without additional security measures [24], it produces no smoke, and the lower temperature of the tip of ultrasonic dissection causes less charring and less tissue necrosis.
    • A 5-mm UD will have an advantage in separating closely fixed organs and more precise dissection might be expected.
  • 60. Safe laparoscopic adhesiolysis with optical access trocar and ultrasonic dissection A prospective study D. J. Swank,1 H. J. Bonjer,2 J. Jeekel Surg Endosc (2002) 16: 1796–1801
    • Ultrasonic dissection is a very feasible technique for laparoscopic adhesiolysis and might reduce the risk of bowel perforations by preventing the incidence of late (thermal) perforations.
    • Sufficient tension on the organs is necessary to maximize the effect of ultrasonic adhesiolysis.
    • If bowel loops were very adherent with the parietal peritoneum, the latter was released from the abdominal muscles and not lysed from the bowel.
    • The lysis of different organs should be done slowly to allow sufficient time to seal small vessels. Small bleedings were dealt with by the UD; if not successful, monopolar electrocautery was used.
  • 61. Laparoscopic management of acute small bowel obstruction B. Kirshtein1 , A. Roy-Shapira1, L. Lantsberg1, E. Avinoach1 and S. Mizrahi1 Surgical Endoscopy© Springer-Verlag 2005
    • One of the problems with emergency laparoscopy for SBO is that it is difficult to find the site of the obstruction in the presence of distended bowel loops.
    • Tilting the operating table and changing the scope port enables visualization from different angles, especially in the pelvis or right lower quadrant.
    • We recommend beginning the bowel exploration from the collapsed are loops, as a way of preventing incidental bowel injury.
  • 62. Laparoscopic management of acute small-bowel obstruction I. M. Ibrahim, F. Wolodiger, B. Sussman, M. Kahn, F. Silvestri, A. Sabar Surg Endosc (1996) 10: 1012–1015
    • 2. Bimanual manipulation of the bowel is important. Running the bowel (especially when distended) can be taxing and frustrating. The surgeon must be comfortable.
    • Therefore, the patient’s arms are tucked in to give the surgeon and assistant ample room. Furthermore, two movable video monitors should be used so that the surgeon, the scope, and the monitor are in a straight line for optimal intraabdominal manipulation.
    • In addition the OR table should have the full range of tilt as extreme positions may be necessary.
  • 63. Laparoscopic management of acute small-bowel obstruction I. M. Ibrahim, F. Wolodiger, B. Sussman, M. Kahn, F. Silvestri, A. Sabar Surg Endosc (1996) 10: 1012–1015
    • The site of obstruction may be obscured by dilated loops of small bowel. In addition to tilting the OR table, changing the scope port is crucial at times. This allows visualization from different angles, especially in the pelvis or right lower quadrant.
  • 64. Laparoscopic Management of Small Bowel Obstruction: Indications and Outcome Enrique Luque-de Ledn, M.D., Altjandro Metzger, M.D., Gregory G. Tsotos, M.D., J GASTROINTEST SURG 1998;2:132-140.)
    • Access into the peritoneal cavity to establish the pneumoperitoneum should be obtained by an open, Hasson-type approach.4 We prefer a vertical periumbilical incision because this location is optimal both for intraperitoneal inspection during evaluation of the bowel and for potential laparoscopic-assiste exteriorization of bowel for extracorporeal resection, lysis of difficult adhesions between bowel loops, or stricturoplasty. In addition, if conversion to open celiotomy is necessary, a midline extension of the original periumbilical incision generally provides the best operative exposure. If appropriate access cannot be obtained because of adhesions from a previous midline incision, one can attempt to gain access laterally, but again an open approach with full visualization seems prudent.
  • 65. Laparoscopic Management of Small Bowel Obstruction: Indications and Outcome Enrique Luque-de Ledn, M.D., Altjandro Metzger, M.D., Gregory G. Tsotos, M.D., J GASTROINTEST SURG 1998;2:132-140.)
    • In addition, when “running” the bowel between the two manipulating bowel clamps, both clamps should remain in view at all times. When one clamp leaves the visual field, it is difficult to appreciate the amount of traction being applied; also, if an enterotomy should occur, it may not be appreciated.
  • 66. Safe laparoscopic adhesiolysis with optical access trocar and ultrasonic dissection A prospective study D. J. Swank,1 H. J. Bonjer,2 J. Jeekel Surg Endosc (2002) 16: 1796–1801
    • Laparoscopic adhesiolysis with scissors is inconvenient because of bleeding.
    • Electrodissection causes charring of tissue and delayed perforations because of its excessive heat production [7, 12, 20, 23].
    • Bipolar electrosurgery has the advantage of reducing the electrosurgical complications but still has delayed thermal lesions [23].
    • The ultrasonically activated scalpel causes less heat production compared with electrocautery dissection,thereby theoretically lowering the risk of delayed perforations.
  • 67. Laparoscopic adhesiolysis,Tips & Tricks
    • Conversion to a laparotomy should not be considered a failure or complication, but rather a recognition of limitations posed by technology, the surgical expertise, or factors unique to a particular patient or disease process.

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