Anterior Abdominal Wall Adhesions Research Articles

Safety of Laparoscopic Entry Points in Patients With a History of Abdominal Surgery: A Research Article.

This study aimed to assess the safety of laparoscopic entry sites in patients with previous abdominal surgery who subsequently required re-operation. This is a prospective study wherein the data of 118 patients who had undergone previous abdominal surgery and were subsequently re-operated at our center (Bakırköy Doctor Sadi Konuk Research and Study Hospital) were collected from October 2015 to October 2016. Careful attention was paid to gathering information regarding patients' age, parity, body mass index (BMI), type of previous surgery, type of incision made during previous surgery, and medical history. For this study, the abdomen was topographically divided into nine parts. During the operation, all quadrants were examined and evaluated for adhesion and the content of adhesion. Adhesions were found in 44% (55 out of 118) of the patients, while 56% (66 patients) had no adhesions in the abdomen. The majority of cases (74%) had a history of cesarean section, and 87%had a Pfannenstiel incision. Adhesions were reported in 37.5% (33 out of 88) of the patients with a previous history of cesarean section. A significant proportion of subjects with adhesion (83%) had anterior abdominal wall adhesions, including only the omentum, whereas 11.5% (six subjects) had umbilical adhesions. Subjects with a history of umbilical hernia repair had more adhesions. The present study sought to assess the safety of laparoscopic entry points in individuals with prior abdominal surgery. The rise in laparoscopic surgeries, favored for reduced wound infections and quicker recovery times, brings forth concerns about potential complications in those with previous abdominal operations. Historically, postoperative adhesions have been observed in a significant number of patients after gynecological procedures. Our research, however, found a lower adhesion rate, which could be due to the smaller size of our sample and fewer gynecological cases. Existing adhesions can complicate subsequent surgeries, increasing operational times and posing injury risks. Adhesions also elevate healthcare costs and patient morbidity and mortality. Moreover, complications like Trocar-related injuries, including damageto major organs, are pivotal. While certain trocar insertion techniques may have fewer complications, our results align with previous findings suggesting higher adhesion rates after non-gynecological surgeries. Therefore, alternative entry points or methods, such as the palmer site or direct trocar entry, are recommended for those with an abdominal surgery history. Notably, our study's limited sample size may affect its generalizability, urging future studies for broader insights. Comprehensive pre-surgery assessments are crucial to anticipate complications. Our research supports that laparoscopic surgeries are safe for many with prior abdominal surgery, but for certain patients, non-umbilical entry sites are advised to further mitigate risks. The umbilicus is one of the safest entry sites for primary trocar insertion in patients with a history of Pfannenstiel incision. However, the probability of umbilical adhesions is high in patients who have undergone umbilical mesh repair, median incision, or major abdominal surgery. In these patients, surgeons should prefer other laparoscopic entry sites, especially Palmer's point, rather than the umbilicus.

Approach to a Total Laparoscopic Hysterectomy with Anterior Abdominal Wall Adhesions

<h3>Study Objective</h3> The objective of this video presentation is to describe a laparoscopic approach to a hysterectomy where there are anterior abdominal wall adhesions present. <h3>Design</h3> A total laparoscopic hysterectomy where anterior abdominal wall adhesions were noted was recorded in the OR for review. <h3>Setting</h3> This video took place in the OR with the patient in dorsal lithotomy position in Trendelenburg. An umbilical port, suprapubic port, and 2 lateral ports were used for this procedure. A uterine manipulator with a colpotomy cup was in place. <h3>Patients or Participants</h3> This case was selected due to the presence of anterior abdominal wall adhesions found upon entry to the abdomen. <h3>Interventions</h3> A TLH was completed while reviewing multiple approaches in the setting of anterior abdominal wall adhesions Different techniques to complete the hysterectomy depending on the extensiveness of adhesive disease were reviewed including taking down adhesions before placing all ports, potentially taking the uterine artery at its origin, backfilling the bladder, and tunneling through the adhesions. <h3>Measurements and Main Results</h3> The main result of this video presentation was that a review of multiple methods of approaching anterior abdominal wall adhesions while performing a total laparoscopic hysterectomy was done while addressing ways to overcome obstacles that could be encountered. <h3>Conclusion</h3> When approaching a laparoscopic hysterectomy where there are anterior abdominal wall adhesions, there are several different obstacles that can be encountered, and this video presents different approaches to these challenges. One should consider alternate modes of uterine manipulation should a routine manipulator be unsafe to place. Suprapubic ports can be safely placed once adhesions that prevent placement are taken down, but also consider alternative port placement such as a LUQ or subxiphoid port depending on the location of the adhesions. Be prepared for ligation of the uterine artery at its origin. Ensure that there is no bladder involvement by backfilling the bladder to delineate planes.

Lysis of Anterior Abdominal Wall Adhesions during Pelvic Laparoscopic Surgery: An Ergonomic Seated Approach

Study Objective To describe a seated position during laparoscopic adhesiolysis of the anterior abdominal wall in pelvic gynecologic surgery that improves the surgeon's ergonomic positioning and lessens discomfort. Design Photos of the surgeon during traditional standing approach and seated approach were taken intraoperatively and posture was compared against standard ergonomic guidelines. Posture was evaluated by measuring angles between anatomic areas such as the angle of flexion at the elbow. Setting Operating room during laparoscopic anterior abdominal wall adhesiolysis. Patients or Participants Primary gynecologic surgeon. Interventions Surgeon assumes a seated position during anterior abdominal wall adhesiolysis. Measurements and Main Results When the table is positioned at the correct height during laparoscopic surgery, accessing the anterior abdominal wall while standing causes extremes in body positioning. This maneuver results in asymmetry of the pelvic girdle, lateral spine bending, misalignment of the neck and back, and excessive wrist radial deviation. This positioning causes the surgeon to potentially have hip, back, neck, and wrist discomfort. In contrast, the seated position gives the surgeon more optimal ergonomic positioning, with return to pelvic symmetry, neutral cervical, thoracic, and lumbar spine position, and neutral wrist position. Conclusion Sitting for anterior abdominal wall adhesiolysis during pelvic surgery improves ergonomics and comfort. Increased awareness of and training in proper ergonomic techniques may decrease musculoskeletal injuries in laparoscopic surgeons.

A Lateral to Anterior Approach to the Scarred Bladder Flap and Anterior Abdominal Wall Adhesions at the Time of Laparoscopic Hysterectomy

The purpose of this video is to present a lateral to anterior approach to the scarred bladder flap and anterior abdominal wall adhesions. The increase in cesarean section rate has made this surgical scenario more prevalent. We will present videos from two separate case. Both patient has 2 previous cesarean sections, suspected adenomyosis, and had failed medical management. We will demonstrate an anatomic based technique where the paravesicle spaces are developed bilaterally. The bladder is then backfilled and the adhesions over the supravaginal septum are transected. The vesicouterine ligaments are then transected at their origin at the pericervical ring. This allows the vesicovaginal space to be developed.

Lysis of Anterior Abdominal Wall Adhesions: A Systematic Approach.

Prior abdominopelvic surgery is the most significant risk factor for the formation of anterior abdominal wall adhesions. These adhesions increase the risk of conversion to laparotomy as well as the risk of inadvertent trocar insertion injury. Adhesive disease may also distort the underlying anatomy during laparoscopy, necessitating modification of port placement or addition of upper abdominal ports. In this video, we show several scenarios of increasing complexity to review key principles and techniques for safe and efficient lysis of abdominal wall adhesions. First, the surgeon must gain visibility above the adhesions and identify the contents for appropriate instrument selection. Next, the surgeon should configure the accessory ports to triangulate to the pathology. Finally, the surgeon must thin the adhesions and create bands of tissue for effective coagulation and identification of underlying structures.

OC16.03: Prevalence of pelvic adhesions on ultrasound examination in women with a history of Caesarean section

To investigate the prevalence and locations of pelvic adhesions following previous Caesarean section (CS), to identify risk factors for their formation and symptoms associated with their presence. This was a prospective observational study of women with history of one or more previous CS who attended for a gynecological ultrasound examination. In all women both transvaginal and transabdominal scans were performed in order to identify the presence of pelvic adhesions. Past medical and surgical history was recorded and a structured questionnaire was used to enquire about any history of pelvic pain and urinary symptoms. A total of 308 women were recruited into the study. On ultrasound examination 139/308 (45.1%, 95% CI 39.7–50.7) women had evidence of adhesions within the pelvis. Adhesions in the vesico-uterine pouch were the most common and they were found in a total of 79/308 (25.6%, 95%CI 20.7–30.5) women. In women with no other surgery other than Caesarean section(s) (n = 220), increasing number of CS (OR 3.4, 95% CI 2.1–5.5) and a post operative wound infection (OR 11.7, 95% CI 3.5–39.5) increased the likelihood of adhesions in the anterior pelvic compartment. There was a significant association between presence of anterior compartment adhesions and chronic pelvic pain. Multivariate logistic regression analysis selected anterior abdominal wall adhesions (OR 2.4, 95% CI 1.6–3.7) and any adhesions on scan (OR 2.6, 95% CI 1.2–5.7) as independently predictive of chronic pelvic pain. Pelvic adhesions are present in more than a third of women with a history of previous CS and they are associated with chronic pelvic pain.

PTH-243 Intra-abdominal adhesions: identifying the “sticking point(s)” using novel cine-magnetic resonance image analysis. pilot results

<h3>Introduction</h3> Peritoneal adhesion formation is a common complication of abdominal surgery and is associated with chronic abdominal pain, bowel obstruction, female infertility and reoperation complications. Non-invasive diagnosis has the potential to improve patient management by determining the cause of symptoms. Cine-MR (cMR) has been used for this purpose¹but in our experience has proven labour intensive and with high inter-operator variability. We previously presented a mathematical interpretation of abdominal movement in cMR to infer gross abnormalities.²We have since refined our approach to detect more subtle changes. Here we present the preliminary results of our new technique. <h3>Method</h3> Sagittal cMR images were obtained using a previously defined scanning protocol.²Images from 3 patients were analysed, 2 with abdominal wall adhesions and 1 without. The principle driving the methodology is the expectation that an adhesion’s resistance to visceral slide produces a quantifiable reduction in shear at that location. The method entails image processing of cMR images in which visceral slide is captured over several breathing cycles. Specifically this involves: Defining a line of demarcation between the sliding regions, typically the abdominal contents and the abdominal wall. Independent interrogation of the respective modes of motion in these separate regions using image registration software. Deduction of the relative motion at the boundary between the two regions Extraction of the magnitude of shear and its presentation in a ‘sheargram’. <h3>Results</h3> The images display the accumulated shear over approximately 3 respiratory cycles in patients with and without abdominal wall adhesions. The left image (with adhesions) shows a marked reduction in shear in the lower fifth of the abdominal wall correlating to a surgically verified adhesion. The reliability of these preliminary results is also supported by the more even distribution of shear observed in a patient without anterior abdominal wall adhesions (right image). <h3>Conclusion</h3> Our pilot results demonstrate the potential of this newly developed image analysis technique. In combination with other relevant diagnostic information it facilitates the efficient localisation of adhesions to the abdominal wall. A larger study is in progress to confirm these results. <h3>Disclosure of interest</h3> None Declared. <h3>References</h3> Lienemann, <i>et al</i>. <i>Radiology</i>2000;<b>217</b>(2):421–5 Fenner, <i>et al</i>. <i>Phys Medica</i>2014;<b>30</b>(4):437–447

Mo2016 Intra-Abdominal Adhesions: Identifying the “Sticking Point(s)” Using Novel Cine-Magnetic Resonance Image Analysis. Pilot Results

Introduction Peritoneal adhesion formation is a common complication of abdominal surgery and is associated with chronic abdominal pain, bowel obstruction, female infertility and reoperation complications. Non-invasive diagnosis has the potential to improve patient management by determining the cause of symptoms. Cine-MR (cMR) has been used for this purpose1but in our experience has proven labour intensive and with high inter-operator variability. We previously presented a mathematical interpretation of abdominal movement in cMR to infer gross abnormalities.2We have since refined our approach to detect more subtle changes. Here we present the preliminary results of our new technique. Method Sagittal cMR images were obtained using a previously defined scanning protocol.2Images from 3 patients were analysed, 2 with abdominal wall adhesions and 1 without. The principle driving the methodology is the expectation that an adhesion’s resistance to visceral slide produces a quantifiable reduction in shear at that location. The method entails image processing of cMR images in which visceral slide is captured over several breathing cycles. Specifically this involves: 1. Defining a line of demarcation between the sliding regions, typically the abdominal contents and the abdominal wall. 2. Independent interrogation of the respective modes of motion in these separate regions using image registration software. 3. Deduction of the relative motion at the boundary between the two regions 4. Extraction of the magnitude of shear and its presentation in a ‘sheargram’. Results The images display the accumulated shear over approximately 3 respiratory cycles in patients with and without abdominal wall adhesions. The left image (with adhesions) shows a marked reduction in shear in the lower fifth of the abdominal wall correlating to a surgically verified adhesion. The reliability of these preliminary results is also supported by the more even distribution of shear observed in a patient without anterior abdominal wall adhesions (right image). Conclusion Our pilot results demonstrate the potential of this newly developed image analysis technique. In combination with other relevant diagnostic information it facilitates the efficient localisation of adhesions to the abdominal wall. A larger study is in progress to confirm these results. Disclosure of interest None Declared. ![Abstract PTH-243 Figure 1][1] Abstract PTH-243 Figure 1

Prevalence of pelvic adhesions on ultrasound examination in women with a history of Cesarean section.

To investigate the prevalence and location of pelvic adhesions in women with a history of Cesarean section and to identify risk factors for their formation and symptoms associated with their presence. This was a prospective observational study of women in whom one or more Cesarean sections had been performed > 12 months previously and who attended for a gynecological ultrasound examination. In all women, both transvaginal and transabdominal scans were performed in order to identify the presence of pelvic adhesions. Medical and surgical history was recorded and a structured questionnaire was used to enquire about any history of pelvic pain and urinary symptoms. A total of 308 women were recruited into the study. On ultrasound examination, 139 (45.1% (95% CI, 39.7-50.7%)) women showed evidence of adhesions within the pelvis. Adhesions in the vesicouterine pouch were the most common and were found in a total of 79 (25.6% (95% CI, 20.7-30.5%)) women. In women with a history of no surgery other than Cesarean section(s) (n = 220), an increasing number of Cesarean sections (odds ratio (OR) 3.4 (95% CI, 2.1-5.5)) and a postoperative wound infection (OR 11.7 (95% CI, 3.5-39.5)) increased the likelihood of adhesions developing in the anterior pelvic compartment. There was a significant association between the presence of anterior compartment adhesions and chronic pelvic pain. Multivariable logistic regression analysis identified anterior abdominal wall adhesions (OR 2.4 (95% CI, 1.0-5.9)) and any adhesions present on ultrasound scan (OR 2.6 (95% CI, 1.2-5.7)) as independent predictors of chronic pelvic pain. Pelvic adhesions are present in more than a third of women with a history of Cesarean section and they are associated with chronic pelvic pain.

Laparoscopic ileal pouch–anal anastomosis reduces abdominal and pelvic adhesions

Postoperative adhesions are an expected outcome for the majority of open abdominal operations, occurring in more than 90% of cases. Adhesions are responsible for more than 75% of small bowel obstruction cases. This study aimed to evaluate adhesions to the anterior abdominal wall and adnexal organs after laparoscopic ileal-pouch anal anastomosis (IPAA). Patients who underwent laparoscopic IPAA for ulcerative colitis had laparoscopic evaluation of adhesions at loop ileostomy closure for assessment of adhesions to the anterior abdominal wall and for adhesions to the adnexae in the case of women. Adhesions to the adnexae were quantified using the American Fertility Society adhesion score. Data were maintained prospectively. In this study, 34 patients (21 women) ranging in age from 19 to 78 years (median, 36 years) underwent laparoscopic IPAA. With regard to anterior abdominal wall adhesions, 23 patients (68%) had no adhesions to the anterior abdominal wall, and the remaining 11 patients had few adhesions (filmy, avascular). No patients had dense adhesions to the abdominal wall. Of the 21 women, 15 (71%) had no adnexal adhesions, 5 had filmy adhesions enclosing less than one-third one adnexa, and 1 had filmy adhesions enclosing one-third to two-thirds of one adnexa. No patient had adhesions affecting both adnexae. Laparoscopic IPAA results in few adhesions to the anterior abdominal wall or to gynecologic organs. These adhesions were significantly fewer than previously reported for open operations with or without the use of a glycerol hyaluronate/carboxymethylcellulose bioresorbable (GHA/CMC) adhesion barrier.

Feasibility of the Maylard transverse incision for ovarian cancer cytoreductive surgery

The vast majority of abdominal incisions used in gynecologic surgery are either transverse or vertical midline. The advantages of a vertical midline incision are considered to be rapid abdominal entry and increased exposure to the abdomen and pelvis. The advantages of transverse incisions are purported to be cosmesis, decreased postoperative pain, decreased hernia rate, decreased abdominal adhesions, and fewer postoperative pulmonary complications. The Maylard incision is a transverse incision that combines the advantages of a transverse incision with improved pelvic and abdominal exposure. We wanted to evaluate the feasibility of the Maylard incision to provide adequate abdominal and pelvic exposure in women with advanced ovarian cancer undergoing cytoreductive surgery and to evaluate the extent of anterior abdominal wall adhesions at secondary cytoreductive surgery. In our experience, it appears that the Maylard incision provides adequate exposure to perform ovarian cytoreductive surgery. It appears that there are minimal anterior abdominal adhesions after cytoreductive surgery through a Maylard incision.

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.

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.

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.