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Challenges in total laparoscopic hysterectomy: Severe adhesions

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Success is likely if you are 1) proactive and 2) meticulous about abdominal entry, and if you manage adhesions strategically. Two experts offer tips and techniques.


 

References

Dr. Giesler reports that he serves on the speaker’s bureau for Ethicon Endo-Surgery. Dr. Vyas has no financial relationships relevant to this article.

CASE: Probable adhesions. Is laparoscopy practical?

A 54-year-old woman complains of perimenopausal bleeding that has not been controlled by hormone therapy, as well as increasing pelvic pain that has caused her to miss work. She wants you to perform hysterectomy to end these problems once and for all.

Aside from these complaints, her history is unremarkable except for a laparotomy at 13 years for a ruptured appendix. Her Pap smear, endometrial biopsy, and pelvic sonogram are negative.

Is she a candidate for laparoscopic hysterectomy?

A patient such as this one, who has a history of laparotomy, is likely to have extensive intra-abdominal adhesions. This pathology increases the risk of bowel injury during surgery—whether it is performed via laparotomy or laparoscopy.

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The ability to simplify laparoscopic hysterectomy in a woman who has extensive adhesions requires an understanding of the ways in which adhesions form—in order to lyse them skillfully and avoid creating further adhesions. It also requires special techniques to enter the abdomen, identify the site of attachment, separate adhered structures, and conclude the hysterectomy. Attention to the type of energy that is used also is important.

In this article, we describe these techniques and considerations.

In Part 1 of this article, we discussed techniques that facilitate laparoscopic hysterectomy in a woman who has a large uterus.

Don’t overlook preoperative discussion, preparation

The patient needs to understand the risks and benefits of laparoscopic hysterectomy, particularly when extensive adhesions are likely, as well as the fact that it may be necessary to convert the procedure to laparotomy if the laparoscopic approach proves too difficult. She also needs to understand that conversion to laparotomy does not represent a failure of the procedure but an aim for greater safety.

Because bowel injury is a real risk when the patient has extensive adhesions, mechanical bowel preparation is important. Choose the regimen preferred by the colorectal surgeon likely to be consulted if intraoperative injury occurs.

The operating room (OR) and anesthesia staffs also need to be prepared, and the patient should be positioned for optimal access in the OR. These and other preoperative steps are described in Part 1 of this article and remain the same for the patient who has extensive intra-abdominal adhesions.

How adhesions form

When the peritoneum is injured, a fibrinous exudate develops, causing adjacent tissues to stick together. Normal peritoneum immediately initiates a process to break down this exudate, but traumatized peritoneum has limited ability to do so. As a result, a permanent adhesion can form in as few as 5 to 8 days.1,2

Pelvic inflammatory disease and intraperitoneal blood associated with distant endometriosis implants are well known causes of abdominal adhesions; others are listed in the TABLE.

TABLE

7 causes of intra-abdominal adhesions

Instrument-traumatized tissue
Poor hemostasis
Devitalized tissue
Intraperitoneal infection
Ischemic tissue due to sutures
Foreign body reaction (carbon particles, suture)
Electrical tissue injury
Source: Ling FW, et al2

The challenge of safe entry

During laparotomy, adhesions can make it difficult to enter the abdomen. The same is true—but more so—for laparoscopic entry. The distortion caused by adhesions can lead to inadvertent injury to blood vessels, bowel, and bladder even in the best surgical hands. An attempt to lyse adhesions laparoscopically often prolongs the surgical procedure and increases the risk of visceral injury, bleeding, and fistula.1

In more than 80% of patients experiencing injury during major abdominal surgery, the injury is associated with omental adhesions to the previous abdominal wall incision, and more than 50% have intestine included in the adhesion complex.1

One study involving 918 patients who underwent laparoscopy found that 54.9% had umbilical adhesions of sufficient size to interfere with umbilical port placement.3 More important, 16% of this study group had only a single midline umbilical incision for laparoscopy before the adhesions were discovered.

The utility of Palmer’s point

Although multiple techniques have been described to minimize entry-related injury, no technique has completely eliminated the risk of inadvertent bowel or major large-vessel injury.3 In 1974, Palmer described an abdominal entry point for the Veress needle and small trocar for women who have a history of abdominal surgery.4 Many surgeons now consider “Palmer’s point,” in the left upper quadrant, as the safest peritoneal entry site.

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