Abdominal Wall Adhesions Research Articles

Laparoscopic evaluation of infertile patients with chronic pelvic pain

In this study over a 10-year period, 1584 patients complaining of infertility of more than 1 year duration were evaluated for their laparoscopic findings in relation to the presence or not of chronic pelvic pain (CPP). Infertility was the only complaint in 1215 cases (group 1), whereas 369 patients complained of infertility and CPP (group 2). All cases underwent routine infertility investigation and pelvic ultrasonography, followed by diagnostic laparoscopy, with infertility-only cases acting as a control group. At laparoscopy 76.7% of patients with CPP were found with pelvic pathology, compared with only 42.6% of cases without CPP (P ≤ 0.0001). Omental–abdominal wall adhesions, advanced endometriosis, endometriomas with adhesions, pelvic venous congestion, and hydrosalpinges with pelvic adhesions were significantly more frequent in cases with CPP. Dysmenorrhoea was the most frequent type of CPP. Cases with CPP and a negative laparoscopy were further investigated using a multidisciplinary approach. In conclusion, chronic pelvic pain can be the result of several pelvic pathologies. Infertile patients with CPP are much more frequently found with an abnormal pelvis in comparison with cases without CPP. Laparoscopy is an invaluable diagnostic tool especially for symptomatic patients and should be used early in their diagnostic infertility work-up.

156: A Novel Method of 9th Intercostal-Microlaparoscopic Approach for Patients with Previous Laparotomy

To evaluate the availability of a primary laparoscopic approach for a patient with previous laparotomy and to assess postoperative adhesion to the abdominal wall. Retrospective study. University hospital. A total of 172 patients with a history of previous laparotomy who were undergoing laparoscopic surgery in our hospital were evaluated. The primary trocar insertion was performed via the 9th intercostal-microlaparoscopic approach for all patients who had undergone laparotomy previously. This procedure could be performed on all 172 patients and there were no complications. Postoperative abdominal wall adhesion was found in 53 (30.8%) of 172 patients with previous laparotomy, and periumbilicus adhesion was found in 16 patients (9.3%). Among the 172 patients, 150, 19, and 3 patients had undergone laparotomy once, twice, and three times, respectively, prior to this study. Considering the number of previous laparotomies, the frequency of abdominal wall adhesion was 23.3% (35/150 patients), 68.4% (13/19 patients), and 66.7% (2/3 patients), and the frequency of periumbilicus adhesion was 5.3% (8/150 patients), 36.8% (7/19 patients), and 33.3% (1/3 patients) in the patients who had undergone laparotomy once, twice, and thrice, respectively. The type of laparotomy among 150 patients who had undergone laparotomy once was an obstetric-and-gynecologic surgery in 126 patients (126/150) and other surgeries in 24 patients (24/150). There was no significant difference in the frequency of adhesion between types of previous laparotomy. Among the 150 patients who had undergone laparotomy once, surgical incisions were classified as median infra-umbilical incision (94/150 patients), median supra-umbilical incision (3/150 patients), Pfannenstiel incision (33/150 patients), para-rectal incision (15/150 patients), and peri-rectal incision (5/150 patients). A high frequency of adhesion to abdominal wall and periumbilicus was recognized in the all three median supra-umbilical incisions. Ninth intercostal-microlaparoscopic approach is a safe for laparoscopic surgery in patients who have undergone laparotomy previously and this procedure could be prevented the risk of bowel injury.

Prevention of adhesion formation after radical oophorectomy using a sodium hyaluronate-carboxymethylcellulose (HA-CMC) barrier

Objectives. To evaluate the efficacy of a hyaluronate-carboxymethylcellulose (HA-CMC) barrier for prevention of pelvic adhesion formation in women undergoing primary cytoreductive surgery with radical oophorectomy for locally advanced epithelial cancer. Methods. Between 3/1/01 and 3/1/02, all patients undergoing primary surgery for locally advanced FIGO Stage III–IV epithelial ovarian cancer were prospectively offered study enrollment. Radical oophorectomy (en bloc rectosigmoid colectomy) with total pelvic peritonectomy was performed as clinically indicated. Intestinal continuity was reestablished via stapled anastomosis following complete cytoreduction of pelvic disease. The entire pelvic peritoneal defect was covered with subdivided sheets of HA-CMC (6.5 cm × 5.0 cm) using a ‘quilting’ technique. The abdominal wall incision site was not treated with adhesion preventive measures. At second-look surgery, four-quadrant pelvic (treated area) and abdominal wall (untreated internal control) adhesion scores were assigned using a previously validated scoring system. Statistical analysis for differences in mean pelvic and abdominal wall adhesion scores was performed using Student's t test. Results. Fourteen patients satisfied all inclusion criteria. Abdominal wall adhesions were noted in 92.9% of patients. In the pelvis, the dorsal peritoneal surfaces were the most common sites of adhesion formation (42.9%). Overall, the mean pelvic (treated) adhesion score was statistically significantly lower (0.91, SD ± 1.04) than the mean abdominal wall (untreated control) score (5.56, SD ± 4.55, P = 0.02). There were no instances of intestinal anastomotic leak, and no peri-operative complications directly attributable to HA-CMC were observed. Conclusions. Placement of a HA-CMC barrier is associated with a significant reduction in the extent and density of pelvic adhesion formation following radical oophorectomy and pelvic peritonectomy for locally advanced epithelial ovarian cancer.

Clinical and Pathological Outcomes After Endoscopic Transgastric Partial Hysterectomy in a Porcine Model

Introduction: Traditionally per-oral endoscopy has been limited to the intestinal lumen. A transgastric approach may allow less invasive means of performing select surgical procedures. This approach could reduce post-operative abdominal wall pain, wound infection, herniation, and adhesions. Methods: Female Yorkshire pigs were kept NPO for 24 hours. Enrofloxacin and Fentanyl were given at surgery. All instruments were sterilized with glutaraldehyde. Animals were intubated, given Isoflourane, and ventilated as needed. A diagnostic gastroscope was used to place the sterile esophageal overtube. The stomach was lavaged with normal saline and Cefazolin solution was instilled into the stomach for 10 minutes. A needle-knife was used to make a sub-centimeter incision through the anterior gastric wall, and a therapeutic gastroscope was pushed through the incision into the peritoneal cavity. An endoscopic grasping forcep was used to pull the uterus into an Olympus Endoloop which was then secured. The uterine horn and portions of the uterine body, broad ligament, and mesosalpinx were resected with a polypectomy snare. The site was inspected for bleeding and damage to adjacent organs. Using the snare, the resected uterus was removed through the mouth via the gastric incision. The gastric incision was closed with Olympus Hemoclip. Post-operative medications included fentanyl, ranitidine, and enterofloxacin. The animals were, given ad libitum food, and monitored twice daily. After two weeks necropsy was performed. Results: Transgastric partial hysterectomy was successfully performed in five pigs without significant bleeding or organ damage. One animal became lethargic and febrile; and a necropsy was performed on post-operative day four. Necropsy revealed an opened gastric incision, and suppurative peritonitis. No complications were encountered in the other four animals during the two-week survival period. These four animals ate and ambulated within one day of surgery. The four animals exhibited no signs of distress, and gained weight during the survival period. Necropsy revealed well-healed gastric incisions in the four animals; no adhesions, hematomas, abscesses, or lacerations, were seen. Conclusion: We demonstrate that endoscopic transgastric partial hysterectomy is technically feasible and short-term survival without clinical or pathologic complications can be achieved. Secure closure of the stomach incision is essential. Introduction: Traditionally per-oral endoscopy has been limited to the intestinal lumen. A transgastric approach may allow less invasive means of performing select surgical procedures. This approach could reduce post-operative abdominal wall pain, wound infection, herniation, and adhesions. Methods: Female Yorkshire pigs were kept NPO for 24 hours. Enrofloxacin and Fentanyl were given at surgery. All instruments were sterilized with glutaraldehyde. Animals were intubated, given Isoflourane, and ventilated as needed. A diagnostic gastroscope was used to place the sterile esophageal overtube. The stomach was lavaged with normal saline and Cefazolin solution was instilled into the stomach for 10 minutes. A needle-knife was used to make a sub-centimeter incision through the anterior gastric wall, and a therapeutic gastroscope was pushed through the incision into the peritoneal cavity. An endoscopic grasping forcep was used to pull the uterus into an Olympus Endoloop which was then secured. The uterine horn and portions of the uterine body, broad ligament, and mesosalpinx were resected with a polypectomy snare. The site was inspected for bleeding and damage to adjacent organs. Using the snare, the resected uterus was removed through the mouth via the gastric incision. The gastric incision was closed with Olympus Hemoclip. Post-operative medications included fentanyl, ranitidine, and enterofloxacin. The animals were, given ad libitum food, and monitored twice daily. After two weeks necropsy was performed. Results: Transgastric partial hysterectomy was successfully performed in five pigs without significant bleeding or organ damage. One animal became lethargic and febrile; and a necropsy was performed on post-operative day four. Necropsy revealed an opened gastric incision, and suppurative peritonitis. No complications were encountered in the other four animals during the two-week survival period. These four animals ate and ambulated within one day of surgery. The four animals exhibited no signs of distress, and gained weight during the survival period. Necropsy revealed well-healed gastric incisions in the four animals; no adhesions, hematomas, abscesses, or lacerations, were seen. Conclusion: We demonstrate that endoscopic transgastric partial hysterectomy is technically feasible and short-term survival without clinical or pathologic complications can be achieved. Secure closure of the stomach incision is essential.

ENDOSCOPIC PARTIAL HYSTERECTOMY IN A PORCINE MODEL USING A NOVEL PER-ORAL TRANSGASTRIC APPROACH

Purpose: Traditionally per-oral endoscopy has been limited to the intestinal lumen. Previous studies have reported transgastric endoscopy howeverthere are no published reports of organ resection using this method. By avoiding abdominal incisions this approach may reduce post-operative abdominal wall pain, wound infection, herniation, and adhesions. We sought to demonstrate the feasibility of performing a per-oral transgastric partial hysterectomy. Methods: Four-month old female domestic pigs had food withheld for 24 hours and were given antibiotics prior to surgery. After induction of anesthesia, the esophagus was intubated, a sterile overtube placed, and an antibacterial gastric lavage performed. Both written and video logs were kept. A sterile therapeutic endoscope was passed through the overtube into the stomach. Before incising the gastric wall an endoscopic ultrasound was performed to avoid blood vessels and intra-abdominal organs. Using a needle-knife, a 1cm incision was made in the gastric wall and the opening was dilated to 15 mm using a Microvasive CRE balloon. The gastroduodenoscope was pushed through the gastric wall and into the peritoneal cavity. The fallopian tubes, uterus, and ovaries were identified. Forceps were used to pull the uterus and portions of the fallopian tubes through an Olympus Endo-Loop. The loop was then tightly closed and secured. Subsequently, a snare was positioned just distal to the Endo-Loop and cautery was used to resect the uterus and portions of the fallopian tubes. The specimen was removed through the mouth via the gastric incision and was sent for pathology. The gastric incision was closed using endoscopically placed clips. Results: Gastric incisions were performed without significant bleeding. The small intestine, fallopian tubes, uterus, and ovaries were readily identified and could be repositioned with standard endoscopic equipment. We were able to perform the partial hysterectomy without visible bleeding. The animals remained stable throughout the procedure and no immediate postoperative complications were encountered. Necropsy confirmed partial hysterectomy with bilateral partial tubectomy. There was no evidence of intra-abdominal or gastric bleeding, hematoma, infection, or organ damage. Conclusions: This study demonstrates the feasibility of per-oral transgastric organ resection, specifically partial hysterectomy. Although in early development this approach may represent a less invasive alternative to traditional surgery.

Comparative effectiveness of several agents for preventing postoperative adhesions.

Postoperative adhesions (PAs) are usually clinically asymptomatic. Symptomatic cases, however, may present with chronic abdominal and pelvic pain, infertility, and intestinal obstruction; and they may require intensive, costly therapeutic modalities. Various agents have been used to prevent PAs, but the results indicate general suboptimal effectiveness. Our objective was to evaluate the comparative effectiveness of two pharmacologic agents for preventing PA: nadroparine calcium (low-molecular-weight heparin, or LMWH) and aprotinin, as well as a barrier agent, sodium hyaluronate/carboxymethycellulose (SCMC). Our subjects were 40 male Wistar-Albino rats divided into four groups, each consisting of 10 rats, which underwent standard cecal abrasion preceding midline laparotomy. In the control group (group 1) 1 ml of 0.9% NaCl was administered intraperitoneally before abdominal closure. In the three preventive groups, 100 U AXa (anti factor X activity) LMWH, 1800 IU aprotinin, and SCMC were administered intraperitoneally to groups 2, 3, and 4, respectively. Relaparotomy was performed on the 14th postoperative day. Visceral and abdominal wall adhesions were scored in a blinded fashion. The adhesion scores (mean +/- SD) for groups 1, 2, 3, and 4 were 2.00 +/- 0.67, 0.6.00 +/- 0.84, 1.10 +/- 0.74, and 0.20 +/- 0.42, respectively. The differences in the adhesion scores among all three preventive groups (groups 2, 3, 4) were statistically significant when compared with the control group ( p < 0.001, p = 0.017, p < 0.001, respectively). Intraperitoneal SCMC and administration of LMWH were more effective than giving aprotinin.

Use of the PROACT™ System for reduction of postsurgical peritoneal adhesions

Objective To assess the efficacy and safety of a new surgical device designed to prevent adhesions. Design Prospective, controlled two-phase porcine study. Setting Good Laboratory Practice–certified animal facility. Animal(s) Phase I: 10 pigs underwent peritoneal treatment with the PROACT™ System (NTERO Surgical, Inc., Palo Alto, California) at the time of the laparotomy incision, and four had the incision made without treatment. Phase II: 22 animals were randomized to treatment or control groups. Intervention(s) Animals in both groups underwent laparotomy incision and small bowel resection. The treatment group received treatment to the peritoneum before the peritoneal incision was made. Necropsy and adhesion evaluation were conducted by a blinded reviewer 7–13 days after the initial surgery. Main outcome measure(s) Presence or absence of adhesions. Result(s) Phase I: no treated animal developed adhesions to the incision site; three of four control animals developed adhesions to the incision site. Phase II: 4 of 10 control animals and no treated animals developed midline abdominal wall adhesions. Distal adhesions tended to also be reduced in treated animals. No side effects or increased risks were noted. Conclusion(s) The PROACT™ System appears to be safe and efficacious in reducing adhesions to the laparotomy incision line in the porcine model.

Assessment of Risk for Intra-abdominal Adhesions at Laparoscopy for Urological Tumors

Abdominal wall adhesions at laparoscopy may predispose patients to access related injuries and increase the complexity of the procedure. We have observed concern from referring physicians regarding the safety of laparoscopy in patients who previously underwent surgery because of the risk of abdominal adhesions. To assess the risk of adhesions at laparoscopy a retrospective cohort study was performed. All patients who underwent a transperitoneal urological laparoscopic procedure in a 6-year period at our institution were included in this study. A chart review was performed to obtain demographic/surgical data and identify preoperative risk factors for adhesions, such as previous abdominal or pelvic surgery, radiation and/or intra-abdominal inflammatory disease. Operative videotapes were reviewed to determine the presence and location of adhesions. Standard statistical analyses were performed. During the study period 127 patients underwent transperitoneal laparoscopy and videotapes on 82 (65%) were available for review. A total of 44 patients (54%) were identified with preoperative risk factors for adhesions (group 1), while 38 (46%) had no risk factors (group 2). The relative risk of adhesions was 1.34 (95% CI 0.89 to 2.01, p = 0.18) when risk factors were identified. There were no differences in the groups in patient age, operative time, access technique, conversion to open surgery or complications. Estimated blood loss was significantly higher in group 2, likely due to the preponderance of cytoreductive laparoscopic nephrectomy in this group. There was no difference in the risk of intra-abdominal adhesions in patients with and without identifiable preoperative risk factors. Preoperative risk factors for adhesions should not contraindicate the transperitoneal laparoscopic approach for urological oncology procedures.

Is laparoscopic cystectomy possible and safe even in severely adhered endometrioma?

Objective: Because possibility of complication due to severe adhesion and anatomic distortion in severely adhered endometrioma in stage IV endometriosis, usually laparotomic cystectomy or adnexectomy is performed. However if laparoscopic skill is sufficient, laparoscopic cystectomy seems to be not impossible even in stage IV endometriosis and sometimes safer than laparotomy because of optic magnification on my experience. Therefore the purpose of this study is to determine the possibility of laparoscopic cystectomy in stage IV endometriosis and to determine the safety by observing the complication rate during and after operation. Design: Prospective study was done to the patients with severely endometrioma of stage IV endometriosis that was diagnosed by diagnostic laparoscopy, but the patients who has entire abdominal wall adhesion due to previous operation on diagnostic laparoscopy were excluded in this study. Materials/Methods: Laparoscopic cystectomies were performed in eighty-eight patients after permission of patients with explanation about possibility of complication and conversion to laparotomy. If the bowel or bladder complication is occurred during the operation, laparoscopic operation was converted to laparotomy immediately. The long-term complications were observed for 1 month after operation. Results: There was no laparotomic conversion and no short-term or long-term complication such as urinary or intestinal perforation or obstruction or uncontrolled hemorrhage during or after operation was found in all 88 patients (0%). Conclusions: Therefore even in severely adhered endometriosis of stage IV endometriosis, I conclude laparosocpic cystectomy is safe procedure and first choice of surgical procedure for the patients with endometrioma. Supported By: No support.

Expression of heat shock protein 70 (HSP70) at the interface of polymer-implants in vivo.

Synthetic polymer meshes are widely applied in the modern surgical approach for repairing abdominal wall defects. The implanted material is often observed leading to post-operative complications such as deficient abdominal wall mobility and adhesion formation with the abdominal cavity and/or abdominal organs. However, the functioning of the implant is primarily affected by the wound healing process guided by inflammatory events occurring at the tissue-material interface. This could presumably be influenced by the physicochemical properties of the polymer. With regard to it, the cellular and molecular processes involved in the successful restoration of the abdominal wall function are poorly understood. The present in vivo study, therefore, exemplary investigated in a rat model, the commercially available polymer-meshes Prolene (polypropylene, PP), Mersilene (polyester, PE) and Vicryl (polyglactin 910), as well as new mesh variants consisting either of PP (EB) or a combination of PP and polyglactin 910 (A plus or Vypro). The implanted material was evaluated by light and electron microscopy, immunohistochemistry as well as morphometry over an implantation period of 90 days. The data show that polymers induce heat shock protein (HSP)70, and its expression at the interface correlates inversely with the activity of the inflammatory reaction in vivo. Further, an ascent in HSP70 expression parallels the increasing implantation period and evolving foreign-body granulomas. Accordingly, a major role for HSP70 in modulating the local acceptance of polymers and as an additional marker for in vivo testing of polymers is suggestive.

Preoperative Ultrasonic Detection of Abdominal Wall Adhesions in the Umbilical Region and the Ninth Costal Approach for Patients with Previous Abdominal Surgery

Preoperative Ultrasonic Detection of Abdominal Wall Adhesions in the Umbilical Region and the Ninth Costal Approach for Patients with Previous Abdominal Surgery

Microlaparoscopic left upper quadrant entry in patients at high risk of periumbilical adhesions.

We performed a prospective study of microlaparoscopic direct entry in the left upper quadrant (LUQ) to determine the efficacy of this technique and the incidence and site of anterior abdominal wall adhesions in high-risk patients. Direct insertion of the MiniPort introducer was successful with 1 attempt in 16 patients and in 2 attempts with 1 patient. Overall, 12 patients (71%) had either bowel or omentum adherent to the anterior abdominal wall. Eight of the 12 patients (75%) with a previous midline abdominal wall incision were found to have subumbilical adhesions. Two patients were noted to have LUQ omental adhesions. Direct insertion of a 2 mm microlaparoscopic primary port in the LUQ appears to be simple, safe and quick to perform. It provides an excellent view of the peritoneal surface of the anterior abdominal wall and umbilical area. This procedure is likely to be the preferred method of peritoneal entry in high-risk patients in the future.

Laparoscopy versus laparotomy: An evaluation of adhesion formation after pelvic and paraaortic lymphadenectomy in a porcine model

Objective: Our purpose was to determine whether there is a difference in adhesion formation after pelvic and paraaortic lymphadenectomy with transperitoneal laparoscopy compared with both extraperitoneal laparotomy and transperitoneal laparotomy in a porcine model. Study Design: Ninety female hogs underwent pelvic and paraaortic lymphadenectomy: 40 with transperitoneal laparoscopy, 40 with extraperitoneal laparotomy, and 10 with transperitoneal laparotomy. Three weeks after the initial surgery, a laparotomy was performed to assess adhesion formation. Results: The transperitoneal laparotomy group had significantly higher adhesion formation, with a 100% (10 of 10) adhesion rate. In the transperitoneal laparoscopy group, 12 of 40 hogs (30%) had adhesions develop versus 8 of 38 (21%) in the extraperitoneal laparotomy group ( p = not significant). Also no differences were found in the transperitoneal laparoscopy and extraperitoneal laparotomy groups when comparing adhesion thickness or the total surface area of adhesions. More anterior abdominal wall adhesions were noted in the extraperitoneal laparotomy group (5 of 38) than in the transperitoneal laparoscopy group (0 of 40, p = 0.02). Conclusions: Pelvic and paraaortic lymphadenectomy performed with transperitoneal laparoscopy does not increase adhesion formation when compared with extraperitoneal laparotomy in a porcine model. The transperitoneal laparoscopy (and extraperitoneal laparotomy) approach also induces significantly fewer adhesions than transperitoneal laparotomy. (Am J Obstet Gynecol 1998;178:499-503.)

Direct laparoscopic cannula insertion at the left upper quadrant

We evaluated the efficacy and safety of direct left upper quadrant (LUQ) cannula insertion for laparoscopic surgery in 23 women with prior pelvic surgery, compared with direct umbilical cannula insertion in a control group of 81 patients. Generally, the laparoscope was retained at the LUQ site throughout the operative procedure. Cannula insertions at the LUQ were successful in the first attempt in 22 patients, compared with a single successful attempt in 78 of 81 umbilical insertions. Nine women had anterior abdominal wall adhesions that extended to the umbilical area. Seven had either a prior midline (1) or Pfannestiel (6) incision; all seven had direct LUQ cannula insertions. Two patients with umbilical adhesions had no prior surgery. Of the three complications, two were related to cannula insertions and both were in the control group. There were no bowel injuries. More experience is required to prove that LUQ cannula insertion accomplishes its intended aim of avoiding bowel or omental injuries due to adhesions in women with prior abdominopelvic surgery, but initial results were favorable.

Anterior abdominal wall adhesions after laparotomy or laparoscopy

To determine the frequency of postoperative adhesions to the anterior abdominal wall peritoneum that could affect safe placement of the initial laparoscopic umbilical cannula at subsequent procedures. Prospective cohort study. Reproductive endocrinology and infertility service of a tertiary care referral hospital. Two hundred fifteen women, 124 with prior abdominal surgery and 91 with no prior surgery. Surgical histories were reviewed, abdominal skin scars noted, and extent of anterior abdominal wall adhesions prospectively recorded. Statistical analysis was performed with the chi2 test. No anterior abdominal wall adhesions were present in 91 patients with no previous surgery or 45 patients with previous laparoscopy (12 had more than 1 laparoscopy; p <0.001 vs laparotomy). Seventeen (59%) of 29 patients with a midline vertical incision had anterior wall adhesions (p <0.05 vs suprapubic transverse incision). Eleven (28%) of 39 with a suprapubic transverse incision had anterior wall adhesions (p <0.001 vs no surgery or laparoscopy). Ninety-six percent of adhesions involved omentum and 29% included bowel. Prior laparotomy, whether through a midline vertical or suprapubic transverse incision, significantly increased the frequency of anterior abdominal wall adhesions, and these adhesions may complicate the placement of the laparoscopic cannula through the umbilicus.

Does the use of pneumoperitoneum and disposable trocars prevent bowel injury at laparoscopy? A randomized experimental study in the rabbit

Objectives The purpose of this experimental study was twofold. The first aim was to compare the incidence of bowel injury after prior insufflation using the Veress needle versus direct trocar insertion, and the second aim was to compare bowel injury with the use of disposable versus reusable trocars, in animals with or without prior abdominal surgery. Design A total of 80 mature New Zealand rabbits (2400–3000 g) were randomly assigned to one of two experimental groups, with (n=40) or without (n=40) prior standardized peritoneal trauma. In each group, four subgroups (n=10 each) were constituted by randomly assigning the animals to initial insufflation using the Veress needle or direct trocar insertion and/or to reusable or disposable trocar insertion. Each animal underwent five trocar insertions. The number of bowel injuries was assessed by laparotomy. Results As expected, the presence of experimentally induced abdominal wall adhesions significantly increased (P=0.0001) the incidence of bowel injury. When abdominal wall adhesions were present, the number of perforations was lower if initial insufflation had been performed compared with those in whom direct trocar insertion was carried out (P=0.03). There was no statistical difference in the rate of injury between disposable and reusable trocars when abdominal wall adhesions were present. However, in those without abdominal wall adhesions, the use of disposable trocars significantly decreased (P=0.04) the risk of bowel injury. Conclusions The presence of abdominal wall adhesions increased the rate of bowel injury at laparoscopy. In the cases with prior abdominal surgery and abdominal wall adhesions, initial insufflation was safer than direct trocar insertion, but the use of disposable trocars did not improve the safety of the procedure. In the absence of prior abdominal surgery, initial insufflation using the Veress needle did not prevent bowel injury; however, in this group the use of disposable trocars proved safer than the use of reusable trocars.

The ultrasonic localization of abdominal wall adhesions.

Laparoscopic candidates with abdominal scars may have adhesions that result in visceral injury during trocar insertion. The purpose of this study was to evaluate the use of preoperative ultrasound mapping of abdominal wall adhesions, to provide safe initial laparoscopic access, and to guide the placement of subsequent trocars, facilitating adhesolysis when necessary. Thirty consecutive patients with previous abdominal surgery who were scheduled for laparoscopy underwent a preoperative ultrasonic examination of the abdominal wall using a 7-MHz linear ultrasound probe. Spontaneous viscera slide was measured during longitudinal scanning (normal = 2-5 cm) and induced viscera slide was evaluated during longitudinal and transverse scanning (normal = 1 cm or more) over the existing abdominal scar, the peri-umbilical region, and the remaining abdominal quadrants. Sixteen (53%) of 30 patients had adhesions under their scar and only four patients (25%) had umbilical adhesions. The 12 patients without umbilical adhesions all had successful closed cannulation while open cannulation at alternate sites was successful in the four individuals with umbilical adhesions. Blind umbilical needle cannulation was successfully done in all of the remaining 14 patients (47%) without visceral injury, including three patients (21%) with upper abdominal scars who were adhesion-free elsewhere. No adhesions were encountered that had not been preoperatively predicted by ultrasound. We conclude that examination of the abdominal wall with spontaneous and induced viscera slide, using ultrasound scanning, can reliably detect intraabdominal adhesions. The examination is best done on a highly selective basis by the operating surgeon to guide the location for initial trocar insertion and determine the type of abdominal wall cannulation in those individuals with previous abdominal scars.

The risk of anterior abdominal wall adhesions in patients with previous umbilical hernia repair

The incidence of umbilical hernia may be increased in certain populations during infancy. Many procedures to repair such defects are thus performed during early childhood. Patients may present for adult surgery with minimal or no recollection of these surgeries and with only a small infra-umbilical incision which appears remarkably similar to an incision for laparoscopy. We proposed to evaluate the risk of adhesions to the area of the umbilicus and anterior abdominal wall in patients presenting for laparoscopic surgery. Eight patients with documentable umbilical hernia repair comprise this study. One patient had undergone two procedures. To best evaluate the umbilicus, initial trocar insertion was made in the left upper quadrant, 2 cm below the costal margin in the mid-clavicular line. Findings demonstrated significant bowel and omental adhesions to the area of the umbilicus in all but one patient. Interestingly, one patient had previously undergone an unsuccessful attempt at Veress needle placement and open laparoscopy. This patient had massive bowel adhesions to the entire umbilical region. In all but the one case, trocar or Veress needle insertion would have likely caused significant tissue or visceral injury. No complications occurred in this series. In conclusion, patients with previous umbilical hernia repair may be at higher risk for adhesive disease to this region. Appropriate bowel preparation prior to surgery and site selection for trocar entry may aid in decreasing the risk of visceral injury.

Risk of anterior abdominal wall adhesions increases with number and type of previous laparotomy

Adhesions to the anterior abdominal wall after previous midline vertical laparotomy were found in 68% of patients undergoing laparoscopy (Childers et al: Gynecol Oncol 50:221, 1993). We reviewed the prevalence of anterior wall adhesions in patients with previous laparotomy incisions who underwent laparoscopy (>95% of patients) or laparotomy. The prevalence of omental and/or bowel adhesions to the anterior abdominal wall in proximity to the umbilicus were tallied and analyzed by incision site (midline vertical or suprapubic transverse) and number of previous laparotomies (one or more than one). The following table illustrates the number of patients in each category with anterior abdominal wall adhesions. While the prevalence of adhesions is increased with more than one previous laparotomy this did not reach statistical significance (Chi-square test). A midline vertical laparotomy does significantly increase the risk for anterior wall adhesions compared to a transverse incision (p<0.05). However, it should be noted that 28% of patients with a previous suprapubic transverse incision (Pfannenstiel or Maylard) had omental and/or bowel adhesions. In this series, one patient with two previous transverse incisions had an incidental enterotomy. We currently employ the technique of LUQ trocar placement in patients with previous midline and suprapubic transverse incisions.

Ultrasonic detection of viscera slide as an indicator of abdominal wall adhesions.

Real-time ultrasonography can detect the movement of viscera immediately deep to the abdominal wall. This motion of abdominal contents is called viscera slide, and is produced by the force of respiratory motion (spontaneous viscera slide) or by manual ballottement of the abdomen (induced viscera slide). Viscera slide was observed in 18 "normal" subjects (no history of previous abdominal surgery or peritonitis) and in 24 subjects at "risk" for abdominal wall adhesions because of previous abdominal operations or past history of peritonitis. In 14 of the 24 "risk" group subjects, spontaneous and induced viscera slide was restricted to excursions of less than 1 cm (58.3%). Operations were performed on 18 patients, which confirmed the fact that restriction of ultrasonically detected viscera slide identified abdominal wall adhesions in all cases, but no adhesions were found in patients with normal viscera slide. This ultrasonic finding of restricted viscera slide may be useful in the preoperative discovery and localization of abdominal wall adhesions prior to laparoscopy or laparotomy.