1. 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

2. Severe Adhesions Small bowel obstruction Previous surgery Re-operative Surgery

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

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

5. 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

6. Lap Adhesiolysis SBO Surg Endosc. 2012 Jan;26(1):12-7

7. Lap Adhesiolysis for SBO

8. Surg Endosc. 2012 Jan;26(1):12-7

9. Lap Adhesiolysis for SBO Surg Endosc. 2007 May;21(5)

10. Lap Adhesiolysis for SBO Surg Endosc. 2007 May;21(5)

11. 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. 2011 Feb;77(2):185-7

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

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

14. 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

15. PEEK Port

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

17. Movies Assessing adhesions Adhesive SBO following APR