Severe Adhesions Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director Residency in General Surgery University of Cincinnati

Severe Adhesions Small bowel obstruction Previous surgery Re-operative Surgery

Severe Adhesions Previous surgery not a contraindication to laparoscopy Small bowel obstructions – often a single band PEEK port

Severe Adhesions Many patients have had previous laparotomy –Kocher –Pfannenstiel –Midline –Chevron Most deserve a look lap – known prior hostile abdomen exception

Small Bowel Obstructions 60% of patients with previous laparotomy will develop an SBO Laparotomy effective but longer LOS and adhesion formation more significant vs. lap Increasing experience with laparoscopy in the management of SBO

Lap Adhesiolysis SBO Surg Endosc Jan;26(1):12-7

Lap Adhesiolysis for SBO

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

Lap Adhesiolysis for SBO Surg Endosc May;21(5)

Lap Adhesiolysis for SBO Surg Endosc May;21(5)

Lap Adhesiolysis Successful LapConverted Open TZ in the abdomen 92 TZ in the pelvis Upper and lower abdominal incision 015 LOS (days) 3 +/- 17 =/- 4 Am Surg Feb;77(2):185-7

Principles Preoperative abdominal distention may preclude pneumoperitoneum Generous use of sharp dissection – cautious use of energy Pelvic adhesions can be the most hostile

Lap Adhesiolysis MUST identify the transition zone Consider adhesive barrier in case of “elective” adhesiolysis for multiple recurrent PSBO

PEEK Port Start difficult procedure through a 6-8cm incision Assess adhesions after “mini” laparotomy Proceed based on this assessment –Do not open lap disposables until confirmed

PEEK Port

Re-operative Surgery Extent of adhesions dictated by the index procedure This will be discussed in a separate presentation

Movies Assessing adhesions Adhesive SBO following APR