Adhesiolysis

Laparoscopic
 the initial trocar should be placed 5-10 cm away from the patient’s
previous scar.
 For example, the left upper quadrant can be a safe place to put the
first trocar if patient has had a previous midline incision.
 The Hasson (open) technique is preferred because it is generally a
safer method for accessing the abdominal cavity, especially in
dealing with dilated bowel loops and adhesions.

Villanueva, Maria Sophia S. 2019. Laparoscopic Adhesiolysis Technique

https://emedicine.medscape.com/article/1829759-technique
 Once the first trocar is placed, the goal is to provide adequate
visualization and working space to permit insertion of the
remaining trocars.
 At least three and as many as five trocars are used.
 Depending on the available laparoscopes, one can use three 5-mm
trocars or one 11-mm trocar for the camera and two 5-mm trocars
for the laparoscopic instruments.

Villanueva, Maria Sophia S. 2019. Laparoscopic Adhesiolysis Technique

https://emedicine.medscape.com/article/1829759-technique
 Good triangulation should be planned on the basis of the planned
site of dissection. Additional trocars should be placed as needed.
 Adhesions to the abdominal wall should be taken down first with
laparoscopic scissors.
 Identifying the white line where the abdominal wall peritoneum
meets the adhesions facilitates dissection in a bloodless plane.

Villanueva, Maria Sophia S. 2019. Laparoscopic Adhesiolysis Technique

https://emedicine.medscape.com/article/1829759-technique
 If the patient has a ventral hernia, gentle pressure can be placed on
the external abdominal wall to allow retraction and visualization of
the bowels attached to the hernia sac.
 Blunt and sharp dissection is preferable to use of the electrocautery
because the heat can be transmitted to adjacent bowel and can cause
thermal injury and perforation.
 Energy devices may be used if adequate room exists and if it is
certain that no bowel is hidden in the adhesions.
 Adhesiolysis can be safely performed if dissection is done carefully
through avascular planes.

Villanueva, Maria Sophia S. 2019. Laparoscopic Adhesiolysis Technique

https://emedicine.medscape.com/article/1829759-technique
 Accordingly, a general rule that can be followed in this setting is, If
you can see through it, you can cut it.
 If the anatomy is still unclear despite meticulous dissection,
changing the position or the angle of the camera may yield better
visualization of the bowel loops.
 It cannot be emphasized too strongly that the surgeon should feel
free to place additional trocars as needed.
 The 5-mm port sites do not need fascial closure and do not add
much to the length of the procedure or to the risk of hernia.
 Hence, adding more 5-mm trocars to facilitate the procedure adds
less morbidity than converting to an open midline incision would.

Villanueva, Maria Sophia S. 2019. Laparoscopic Adhesiolysis Technique

https://emedicine.medscape.com/article/1829759-technique
 When a point of obstruction is not clearly defined, the bowel should
be run until all suspicious bands are removed.
 Upon completion of the case, it is advisable to run the bowel twice
to ensure that there are no missed serosal injuries or enterotomies.
 Any injuries that are identified should be repaired laparoscopically
in a single layer.

Villanueva, Maria Sophia S. 2019. Laparoscopic Adhesiolysis Technique

https://emedicine.medscape.com/article/1829759-technique
 The injured bowel should be grabbed with a laparoscopic locking
bowel grasper so that it can easily be brought out through a midline
abdominal incision (typically made by extending one of the port-
site incisions) and repaired in an open fashion.
 Closure

Villanueva, Maria Sophia S. 2019. Laparoscopic Adhesiolysis Technique

https://emedicine.medscape.com/article/1829759-technique
  Villanueva, Maria Sophia S. 2019. Laparoscopic
Reference Adhesiolysis Technique.
https://emedicine.medscape.com/article/1829759-technique

Villanueva, Maria Sophia S. 2019. Laparoscopic Adhesiolysis Technique

https://emedicine.medscape.com/article/1829759-technique