Periumbilical Adhesions Research Articles

Laparoscopy Compared With Laparotomy as a Risk Factor for Intra-abdominal Adhesion Formation [ID 2683454

INTRODUCTION: The objective of this study is to compare the incidence and severity of abdominal and pelvic adhesions after laparoscopy versus laparotomy. METHODS: All patients undergoing laparoscopic surgery with study staff were included in this IRB-approved study. Postoperatively, surgeons filled out data collection forms to capture pertinent details. Patients with a history of only laparoscopy or only laparotomy were included, whereas those with known past inflammatory events, no prior surgeries, or a combination of laparoscopic and open procedures were excluded. RESULTS: Seventy-six laparoscopy-only and 83 laparotomy-only patients were included in this cohort. Adhesions were noted in 31 laparoscopy patients (40.8%) versus 74 laparotomy patients (89.2%; P<.001). Filmy adhesions were noted in 22 laparoscopy patients (28.9%) versus 37 laparotomy patients (44.6%), without statistical significance (P=.06098). Higher-grade adhesions were significantly more prominent in the laparotomy group. Laparotomy group had significantly more dense adhesions (55.4% versus 11.8%; P<.001) and cohesive adhesions with attached surfaces (32.5% versus 10.5%; P=.001614). By location, the laparotomy group had significantly more periumbilical adhesions (34.9% versus 3.9%; P<.001). Adhesiolysis time was shorter in laparoscopy (3 versus 10 minutes; P=.008439). CONCLUSION: Our data demonstrate that not only does laparotomy present a greater risk for adhesion formation than laparoscopy, but they are more likely to be present in the periumbilical area and the quality of those adhesions are significantly more likely to be dense and/or cohesive in nature, subjecting patients to more risk and requiring more surgical time to address.

Ultrasound Visceral Slide Assessment to Detect Adhesions in Patients Undergoing Abdominal Surgery – a Systematic Review and Meta-Analysis

Study Objective To determine the diagnostic accuracy of preoperative visceral slide assessment with ultrasound to detect intra-abdominal adhesions, compared to the gold standard of intraoperative findings. Design Systematic review and meta-analysis, prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO). Setting Abdominal entry at time of laparoscopy is a critical step with risk of injury to underlying viscera due to bowel adhesions. Ultrasound can be used as a preoperative tool to assess slide of viscera underneath the abdominal wall in order to detect adhesion-free areas. Patients or Participants Prospective and cross-sectional studies in English that included patients at risk for adhesions, undergoing ultrasound visceral slide assessment followed by abdominal surgery. Interventions N/A Measurements and Main Results 3737 articles were screened through electronic searches of Cochrane, MEDLINE, EMBASE, and Google Scholar databases. Reference lists of relevant articles were searched for further articles. Two reviewers independently selected articles, extracted data, and assessed bias using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Primary authors were contacted for additional relevant data. Twenty-five articles reported on 1620 patients and 6166 assessed abdominal areas, with considerable heterogeneity of described abdominal areas and degrees of adhesions. Only 5 studies were performed blinded and 21 had high risk of selection bias. The periumbilical area was assessed for bowel adhesions in 869 patients in 11 studies, with 12.2% reported to have adhesions. Ultrasound assessment for periumbilical bowel adhesions had a combined sensitivity of 93.5% (95% confidence interval, 87.0-97.3), specificity of 91.7% (89.6-93.6), positive predictive value of 61.4% (55.5-66.9), and negative predictive value of 99.0% (98.0-99.5). Conclusion Visceral slide assessment with ultrasound has a high negative predictive value for absence of bowel adhesions in patients at risk for adhesions and should be considered as a useful tool to detect adhesion-free areas to assist with safe laparoscopic entry.

Left Lateral Port: Safe Laparoscopic Port Entry in Previous Large Upper Abdomen Laparotomy Scar

The first port entry in patient who underwent previous abdominal surgery. Palmer's point can be used in patients with suspected periumbilical adhesions, a history of an umbilical hernia, or multiple failed attempts of insufflations at the umbilicus. Palmer's point has its limitations in cases of left upper quadrant surgery, splenomegaly, portal hypertension, and improper nasogastric tube placement giving rise to a bloated stomach. In such cases, a new and safe point for laparoscopic entry is needed. In the present case of a patient who underwent previous upper abdominal surgery with the chevron incision obscuring Palmer's point, laparoscopic entry was made through a novel point that was found to be safe in such cases and can be used in similar cases of previously scarred abdomens.

Office Visceral Slide Test Compared With Two Perioperative Tests for Predicting Periumbilical Adhesions

Women undergoing laparoscopic gynecologic surgery are at high risk of injury during trocar insertion, with most injuries occurring at the umbilical port site. The authors developed the visceral slide test to create a noninvasive, reliable method for detecting adhesions in women with a history of abdominal surgery. Visceral slide refers to an ultrasound finding of intra-abdominal viscera sliding in relation to the abdominal wall during inspiration and exhalation. When significant adhesions are predicted, surgeons can guide port selection or choose instead to perform laparotomy. Finding this test is accurate in the office could help guide preoperative counseling. The aim of this study was to compare the accuracy of the office visceral slide test for predicting obliterating periumbilical adhesions. Female patients older than 21 years were enrolled who had planned laparoscopic gynecologic surgery for benign disease. All had a history of abdominal or pelvic surgery. Prior to laparoscopic surgery, participants underwent a visceral slide test in the office as well as 2 previously validated tests used in the operating room. When visualized with ultrasonography, the visceral slide was defined as normal (positive test) with movement of the viscera more than 1 cm and as abnormal (negative test) with movement of the viscera less than 1 cm during exaggerated inspiration and exhalation. Each screening test took approximately 2 minutes or less to perform. The accuracy of the tests for predicting periumbilical adhesions was compared with that of diagnostic laparoscopy, the criterion standard. The study group comprised 70 women who had a median of 2 (range, 1–6) previous abdominal surgeries. Among these women, the median number of previous laparotomies was 0 (range, 0–5), and the median number of previous laparoscopies was 1 (range, 0–6). At laparoscopy, the incidence of obliterating periumbilical adhesions was 8.6% (6/70), and the incidence of any adhesions in the abdomen or pelvis was 25.7% (18/70). The office visceral slide test had a sensitivity of 83.3%, specificity of 100%, positive predictive value of 100%, negative predictive value of 98.5%, and diagnostic accuracy of 98.6%. These values were similar to those of the other 2 tests performed in the operating room. These data show that the office-based ultrasound test is an accurate predictor of obliterating periumbilical adhesions and can provide important information to guide incision choice and preoperative counseling.

Office Visceral Slide Test in Predicting Periumbilical Adhesions: A Pilot Study

Half of all laparoscopic complications occur during entry. Thus, reliable detection of obliterating adhesions, defined as thick tissue containing viscera, can assist with preoperative surgical planning. The study objective was to determine if the Office Visceral Slide is an effective diagnostic test for predicting obliterating periumbilical adhesions.

Principles of safe abdominal entry in laparoscopic gynecologic surgery

Laparoscopic gynecologic surgery has been widely used with a range of benefits. However, there are complications that are related to the abdominal entry process. Serious complications are gastrointestinal tract and major blood vessel injuries. This review introduces the recent available literature to prevent and eliminate the laparoscopic entry complications. The open entry technique is associated with a significant reduction of failed entry, compared to the closed entry technique; however there is no difference in the incidence of visceral or vascular injury. Laparoscopic entry by the left upper abdomen (i.e., Palmer's point) or the middle upper abdomen (i.e., the Lee-Huang point) could be considered in patients with suspected periumbilical adhesions or a history of umbilical hernia, or after three failed attempts of insufflation at the umbilicus. The Lee-Huang point has its own benefit for the operative laparoscopy in large pelvic pathologies and gynecology malignancy cases. The angle of Veress needle insertion varies from 45° in nonobese women to 90° in extraordinarily obese women. The high intra-peritoneal pressure entries, which range from 20 mmHg to 25 mmHg, minimize the risk of vascular injury. Therefore, this will not adversely affect the cardiopulmonary function in healthy women. The Veress intraperitoneal pressure (<10 mmHg) is a reliable indicator of correct intraperitoneal placement of the Veress needle. The elevation of anterior abdominal wall for placement of a Veress needle increases the risks of failed entry and shows no advantage in regard to vascular or visceral complications. Surgeons should continue to increase their knowledge of anatomy, their training, and their experience to decrease laparoscopic complications.

The office visceral slide test for preoperative prediction of periumbilical adhesions

More than half of all laparoscopic complications occur during entry. Thus, reliable detection of obliterating adhesions, defined as thick tissue containing viscera, could assist with preoperative surgical planning. The study objective was to determine if the Office Visceral Slide is an effective diagnostic test for predicting obliterating periumbilical adhesions. A prospective, comparison of the Office Visceral Slide with the previously validated Preoperative Exam with Visceral Slide, Preoperative Periumbilical Ultrasound-Guided Saline Infusion (PUGSI), and laparoscopy. The Office Visceral Slide Test was performed using 7-MHz abdominal ultrasound probe placed at the umbilicus. The patients took an exaggerated inspiration/expiration and the presence or absence of the visceral slide, the longitudinal distance the viscera traveled as visualized on ultrasound, was noted. A normal visceral slide is movement of the viscera greater than 1 cm. Forty-five consecutive patients with prior surgical history and scheduled to undergo laparoscopic surgery were included. Mean age was 44.4 years (SD=12.4), range 21-76. The patients had a median of 2 previous abdominal surgeries (1.4), range 1-6. Median number of prior laparotomies was 0 (1.2), range 0-5. Median number of prior laparoscopies was 2 (1.3), range 0-5. The Office Visceral Slide Test had a sensitivity=80%, specificity=100%, positive predictive value (PPV)=100%, and negative predictive value (NPV)=97.6%. The Preoperative Exam with Visceral Slide had a sensitivity=80%, specificity=95%, PPV=66.7%, and NPV=97.4%. The PUGSI had a sensitivity=60%, specificity=97.5%, PPV=75%, and NPV=95.1%. The Office Visceral Slide Test is a simple and reliable diagnostic for detecting obliterating periumbilical adhesions in an outpatient setting. The accuracy of the test is comparable to the Preoperative Exam with Visceral Slide and PUGSI. This test could be an important tool to assess surgical difficulty before entering the operating room.

A 90th anniversary of AOGS and onwards

A 90^th anniversary of AOGS and onwards

Entry techniques in gynecologic laparoscopy—a review

Laparoscopy is one of the most common surgical procedures in gynecologic medicine. Major complications associated with gynecologic laparoscopy are relatively rare, with up to 50% related to laparoscopic entry. Several entry techniques have been developed, all of which aim to provide a safe and easy entry to the abdominal cavity. In this article, we aim to review the available evidence on laparoscopic entry techniques in gynecologic surgery. We found no evidence that the Hasson (open) technique is superior to the Veress needle entry, the preferred method of most gynecologists all over the world. When entering the abdomen using the Veress needle, an intraperitoneal pressure <10 mmHg is a reliable predictor of correct intraperitoneal placement. Entry at Palmer’s point (left upper quadrant laparoscopy) is recommended for patients with suspected or known periumbilical adhesions, or a history or presence of umbilical hernia, or after three failed insufflation attempts at the umbilicus. Recently published trials suggest that direct trocar entry, especially when using optical trocar systems, might be superior to both the Hasson open technique and the Veress needle entry to avoid extraperitoneal insufflation and failed entry. Moreover, blood loss can be reduced and the mean entry time shortened. Laparoscopic entry techniques are still a controversial topic in gynecologic surgery. Many studies are underpowered in order to assess the risk for rare but life-threatening complications. In conclusion, there is no solid evidence proving the superiority of any method of laparoscopic entry.

Left upper quadrant approach in gynecologic laparoscopic surgery

To review the use of the left upper quadrant approach in benign gynecologic laparoscopic surgery over a nine-year period. Retrospective review. Setting. University-affiliated hospital. Women who underwent laparoscopic gynecologic surgery the upper quadrant approach between January 2002 and December 2010. Medical records were reviewed. Demographic data, past surgical histories, indications for surgery and the use of the left upper quadrant approach, intraoperative findings, diagnosis and any complications. 143 patients were identified, accounting for 4.9% of all gynecologic laparoscopic surgery. The indications for using the left upper quadrant approach were: previous open abdominal surgery (113, 79.0%), surgery in the second trimester of pregnancy (16, 11.1%), presence of large pelvic mass (9, 6.2%), previous transverse rectus abdominis myocutaneous flap for breast reconstruction (3, 2.0%), previous periumbilical hernia repair (1, 0.6%) and previous laparoscopic umbilical wound dehiscence (1, 0.6%). In women with previous abdominal surgery, the overall incidence of adhesions between omentum and/or bowel to the anterior abdominal wall in the umbilical region was 58.4%. Twelve (8.3%) patients required conversion to laparotomy. One patient had subcutaneous surgical emphysema over the left upper quadrant entry site. The left upper quadrant approach is an effective, safe and easy technique for peritoneal cavity access in women undergoing laparoscopic gynecologic surgery and should be considered in women with risk factors of periumbilical adhesions and in the presence of a large pelvic mass.

Hasson's cut-down technique through Palmer's point

Response Letter to Article: Direct optical entry through Palmer's point: A new technique for those at risk of entry-related trauma at laparoscopy Aust TR, Kayani SI, Rowlands DJ Gynecol Surg 2010; 7:315–317 We read with interest the recent report of an alternative laparoscopic entry method proposed by Aust et al. for those gynaecological patients who are at risk of bowel injury as a result of periumbilical adhesions, as well as very thin or morbidly obese patients who require an alternative entry site [1]. The authors have described a new technique which uses a direct optical entry method at Palmer's point (3 cm below the left costal margin in the midclavicular line) [2]. By doing this, one is allowed a visual inspection of the umbilicus and ensuing adhesiolysis to allow subsequent insertion of an umbilical port under direct vision. The authors have performed this technique on 15 patients and reported no entry-related complications. Periumbilical adhesions were seen in 12 of the 15 patients.

Direct optical entry through Palmer’s point: a new technique for those at risk of entry-related trauma at laparoscopy

We present a technique of direct optical entry through Palmer's point (3 cm below the left costal margin in the mid-clavicular line) as an alternative laparoscopic entry method for those gynaecological patients at risk of periumbilical adhesions. This method has been used in 15 patients and allowed the adhesions to be cleared where necessary. We feel that this technique can provide a safe approach to the abdominal cavity and should be considered as another method alongside closed and open umbilical techniques in the laparoscopic gynaecologist's repertoire.

The Minilaparoscope as a Tool for Localization and Preparation for Cannula Insertion in Patients with Multiple Previous Abdominal Incisions or Umbilical Hernia

Study Objective To access a method that attempts to reduce the risk of bowel and blood vessel trauma in entry-risk patients during laparoscopy. Design Three-year observational study (Canadian Task Force classification II-2). Setting Tertiary university hospital. Patients Thirty-one women defined as entry-risk due to previous multiple abdominal surgeries or repair of umbilical hernia. Intervention Laparoscopy performed with a 2 mm minilaparoscope inserted at Palmer's point, a midclavicular position under the lower left rib. Measurements and Results In most cases the minilaparoscope was used to inspect the anterior abdominal wall for adhesions. When a location free from adhesions was seen or created by adhesiolysis, the 5- or 10-mm cannula was inserted, followed by the laparoscope. Periumbilical adhesions were more common after previous longitudinal incisions. There were no complications. Conclusion Minilaparoscopy is safe and effective for identifying and preparing a proper cannula insertion point. This may be useful for avoiding bowel or other cannula-related trauma in women at high risk for such a complication.

A survey of entry techniques and complications of members of the Australian Gynaecological Endoscopy Society.

To identify various aspects of laparoscopic entry technique and visceral injury experienced by members of the Australian Gynaecological Endoscopy Society (AGES). A retrospective mailed survey. All members of the Australian Gynaecological Endoscopy Society (AGES). Numbers of bowel and major retroperitoneal vascular injuries experienced, entry techniques utilised, alternative entry sites. Of the respondents, 73% use a Veress needle entry. In subjects with an increased risk of peri-umbilical adhesions 83% of respondents use an alternate site of entry, 66% of which use Palmer's point. Sixty-four per cent of respondents had experienced one or more bowel injuries, 21% had experienced major retroperitoneal vascular injury, 33% of respondents had no plan in place for the management of vascular injury and 51% of respondents would alter their clinical practice if accepted entry technique guidelines were available. The majority of respondents use the Veress needle method of entry, have had at least one entry-related bowel injury and use Palmer's point as an alternative entry site in high-risk subjects. The majority of subjects would alter their clincal practice if accepted entry technique guidelines were available.

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.

A new technique of primary trocar insertion for laparoscopy

A new method of primary trocar insertion exploits the anatomy of the anterior abdominal wall at the umbilicus. The point of fusion between the skin, fascia, and peritoneum is identified, and a tiny incision is made precisely over this point, enabling a small clamp to be introduced directly into the peritoneal cavity. After stretching the opening this clamp, a 5-mm trocar is introduced into the peritoneal cavity over a blunt probe, and the abdomen is insufflated. The opening is stretched further with a Kelly clamp, and a 10-mm trocar is introduced over a blunt probe. The technique was used in 54 consecutive patients, 20 of whom had prior low vertical incisions. Ten women had very dense periumbilical adhesions, placing at least four at extremely high risk of bowel injury from blind entry. There were no injuries, and the technique is so quick and effective that it is now the author's routine method of trocar insertion for laparoscopy.

Subkostaler Einstich in der Medioklavikularlinie zur primären Insufflation und Inspektion im Rahmen der gynäkologischen Laparoskopie

Laparoscopy using subcostal insertion is particularly mentioned in the literature in connection with cholecystectomies and nephrectomies. Subcostal access was chosen for placement of the Veress needle and the primary trocar in 72 patients. The following indications have been considered: prior midline vertical abdominal incisions, previous described periumbilical adhesions, prior peritonitis, umbilical hernias, obesity. The location of the incision was subcostal of the 9th rib in the midclavicular line. 28 patients (43.1%) had periumbilical, 23 (32.0%) had subumbilical omental adhesions. Periumbilical bowl adhesions have been described for 12 patients (16.7%) and 20 (27.8) had subumbilical bowl adhesions. One patient required laparotomy. There have been no complications during the operation or postoperative in the remaining 71 patients. The subcostal insertion is a safe location for primary trocar placement and can possibly help to prevent serious omental or bowl lesions.

Die Bedeutung der Sonographie vor laparoskopischer Cholezystektomie

The increasing use of minimally invasive techniques for the treatment of symptomatic cholecystitis requires exact preoperative diagnosis. The significant sonographic findings are stones in the biliary system or indirect evidence of stones, consisting in dilatation of the bile duct to more than 10 mm, as well as free mobility of the abdominal wall to exclude peri-umbilical adhesions. Amongst 100 patients who had laparoscopic cholecystectomies there were 7 with bile ducts wider than 10 mm. In two of these cases calculi could also be demonstrated. ERCP was performed on the remaining five and in 3 of these stones were seen. Peri-umbilical adhesions were seen in 6 Patients, resulting in alternative placing of the incision. The sonographic findings which are of relevance to the surgeon were analysed in these 100 cases. A standardised examination protocol is an important feature for proper patient selection.

Use of Palmer's point for insertion of the operative laparoscope in patients with severe pelvic adhesions: Experience of seventeen cases

Seventeen patients who had known or suspected intra-abdominal adhesions underwent laparoscopic surgery with the use of Palmer's Point for insertion of the operative laparoscope. Five of them were found to have extensive periumbilical adhesions. Intestinal or omental injury can occur if the trocar is inserted directly through the umbilical fossa. Though the incidence of direct trauma is reportedly low, there were still mild to moderate omental adhesions to the anterior abdominal wall, as we expected, in the remaining 12 patients. Possible inadequate aspiration and irrigation during laparoscopic removal of a dermoid cyst in one woman had resulted in severe postsurgical intraabdominal adhesions. More than two 10 mm incisions were used in our patients for insertion of the laparoscope interchangeablely to facilitate the procedure of laparoscopic adhesiolysis. The operative field can be expanded greatly. Fourteen patients completed the laparoscopic surgery, and the other 3 had alternative procedures eventually. No complications occurred during the laparoscopic procedure. The postoperative courses were uneventful in all 17 patients. Our experience suggests that Palmer's Point is a good alternative for insertion of the Veress needle and laparoscope in patients with previous laparotomies and suspected severe pelvic adhesions.

An angiosarcoma associated with an Œdematous limb: A case report

Laparoscopic gynecologic surgery has been widely used with a range of benefits. However, there are complications that are related to the abdominal entry process. Serious complications are gastrointestinal tract and major blood vessel injuries. This review introduces the recent available literature to prevent and eliminate the laparoscopic entry complications. The open entry technique is associated with a significant reduction of failed entry, compared to the closed entry technique; however there is no difference in the incidence of visceral or vascular injury. Laparoscopic entry by the left upper abdomen (i.e., Palmer's point) or the middle upper abdomen (i.e., the Lee-Huang point) could be considered in patients with suspected periumbilical adhesions or a history of umbilical hernia, or after three failed attempts of insufflation at the umbilicus. The Lee-Huang point has its own benefit for the operative laparoscopy in large pelvic pathologies and gynecology malignancy cases. The angle of Veress needle insertion varies from 45° in nonobese women to 90° in extraordinarily obese women. The high intra-peritoneal pressure entries, which range from 20 mmHg to 25 mmHg, minimize the risk of vascular injury. Therefore, this will not adversely affect the cardiopulmonary function in healthy women. The Veress intraperitoneal pressure (<10 mmHg) is a reliable indicator of correct intraperitoneal placement of the Veress needle. The elevation of anterior abdominal wall for placement of a Veress needle increases the risks of failed entry and shows no advantage in regard to vascular or visceral complications. Surgeons should continue to increase their knowledge of anatomy, their training, and their experience to decrease laparoscopic complications.