Objective
The objective of the study was the laparoscopic evaluation of the incidence of intraabdominal adhesions related to prior abdominal surgery.
Study Design
This was a prospective monocentric study including a continuous series of 1000 gynecologic laparoscopic procedures. Data were collected on history of abdominal surgery. A precise initial description of intraoperative adhesions was performed.
Results
Six hundred thirty-seven of the 1000 procedures (63.7%) were performed in patients with a history of 1 or more than 1 abdominal surgery. Intraoperative adhesions were found in 211 of the 1000 subjects (21.10%). Fifty-nine of the 211 cases (28%) involved bowel loops. The prior indication for surgery did not seem to influence adhesion formation. The rate of intestinal adhesions significantly increased with the number of prior abdominal surgeries. The rate of intestinal adhesions was significantly higher in cases of prior midline incisions in comparison with the other incisions.
Conclusion
Extensive preoperative knowledge of prior surgery is essential to evaluate the risk of adhesion formation.
Adhesion formation appears mostly after intraperitoneal surgery, intraabdominal infection, or inflammation and pelvic endometriosis. The peritoneal response to injury creates a fibrin-rich inflammatory exudate that produces scar tissues and fibrous bands.
It continues to be a central and current problem because of the related complications. Intraabdominal adhesions are responsible for 74% of intestinal obstruction cases and 20–50% cases of chronic pelvic pain. These adhesions are a leading cause for female infertility, causing 15–20% of cases. They pose an increased risk of bowel injuries during subsequent surgery, whatever the route chosen to access the abdominal cavity.
The aim of our study was to evaluate the incidence of intraabdominal adhesions and their relationship to prior abdominal surgery.
Materials and Methods
A prospective monocentric study including a continuous series of 1000 gynecologic laparoscopies was conducted between January 2006–April 2007 in the University Hospital of Clermont-Ferrand, France. Data were collected with a standard questionnaire completed before the surgery by a qualified operator. The presence of intraabdominal adhesions and of any complications related to the installation phase of laparoscopy were noted. The level of evidence was intermediate (II).
Tubal sterilization and diagnostic laparoscopy were classified as minor laparoscopic surgery.
Advanced laparoscopic surgery included the following procedures: hysterectomy, myomectomy, surgical treatment of prolapse, retroperitoneal endometriosis, endometrial and cervical carcinoma, uterine retroversion, vesicovaginal fistula, and pelvic peritonitis.
All other procedures were classified as limited laparoscopic surgery: cystectomy, salpingectomy, ovariectomy, adhesiolysis, ovarian transposition, surgical treatment of superficial endometriosis, and adnexal torsion.
Characteristics of the patient’s surgical history were identified for each procedure by history taking and physical examination: number of previous abdominal surgeries; operative indications (surgery considered at high risk of adhesion formation); access to the abdominal cavity; and type of incision.
Indications representing high risk for intraabdominal adhesion formation included digestive surgery (appendectomy, sigmoidectomy, peritonitis, colectomy, bowel obstruction, splenectomy, and partial hepatectomy) and gynecologic surgery (myomectomy, pelvic inflammatory disease, severe to moderate endometriosis, and neoplasia).
The other types of surgery (including cesarean section) were considered at low risk for adhesion formation.
Seven types of incisions were identified in patients with previous laparotomy: McBurney, Pfannenstiel, midline infraumbilical, midline above and below the umbilicus, midline above the umbilicus, right subcostal, and abdominoplasty.
The initial phase for laparoscopic entry was standardized for all procedures: patients under general anesthesia, endotracheal intubation, and curarization; urinary catheterization; and lithotomy position without Trendelenburg until the scope was in place to inspect the peritoneal cavity.
The technique for laparoscopic entry depended on the surgeon’s preference. The Veress needle was preferentially chosen in our hospital.
A careful inspection of the abdominal cavity was conducted to determine the presence of bowel loops, the severity (dense or filmy), and the mapping (periumbilical or not) of abdominal adhesions.
Statistical tests used were the Pearson χ 2 test and Fisher’s exact test. The threshold for significance was established at P < .05.
Results
One thousand laparoscopic procedures including 975 patients were collected. The average age of the subjects was 43.5 ± 13.4 years.
Among all procedures, 21.6% were minor laparoscopic surgeries, 31.8% were limited laparoscopic surgeries, and 46.6% were advanced laparoscopic surgeries.
Of the 1000 procedures, 637 (63.7%) were performed in patients with a history of ≥1 abdominal surgery and 454 cases (71.27%) were considered at high risk for adhesion formation. The distribution of patients with a history of abdominal surgery according to the type of incision is listed in Table 1 .
| Type of incision in cases of a history of abdominal surgery | n | % |
|---|---|---|
| Laparoscopy | 347 | 54.47 |
| McBurney | 324 | 50.86 |
| Pfannenstiel | 140 | 21.98 |
| Infraumbilical | 50 | 7.85 |
| Above and below the umbilicus | 28 | 4.40 |
| Abdominoplasty | 8 | 1.26 |
| Right subcostal | 6 | 0.94 |
| Above the umbilicus | 6 | 0.94 |
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