Technique

A minimum of three cannulae are used: 10 mm for the camera and two additional (usually 5-mm) cannulae to obtain good triangulation between the instruments. After inserting the initial 10-mm cannula, the peritoneal cavity is insufflated with CO2 to the level of 8-10 mm Hg of pressure. After the camera is introduced through this cannula, two 5-mm cannulae for manipulation will be inserted into the peritoneal cavity under direct visualization. When there is not enough space to insert another 5-mm cannula, lysis of adhesions to abdominal wall is performed before the additional 5-mm cannula is inserted.

The actual dissection is usually started by adhesiolysis between small intestine or omentum to the parietal abdominal wall (Figure

10.3.3). A proper pressure of pneumoperitoneum, such as 12-14 mm Hg, helps to put the point or line for lysis under tension. The use of scissors without electrosurgery during this procedure has been proven to be advantageous in the dissection of the mostly nonvascularized fields of adhesions. Using a monopolar or bipolar electrode often causes the contraction of adhesional strands, leading to the risk of injuring adherent loops of bowel. Meticulous attention should be given so as not to injure the serosa of bowel. If the distance between bowels and abdominal wall is enough to apply a harmonic scalpel, this instrument is extremely useful because the temperature at the lateral side of the blade is not so high as to cause thermal injury to the intestinal wall (Figure

After all adhesions to parietal abdominal wall are lysed, the small intestine is followed in a retrograde manner with atraumatic bowel graspers, beginning at the terminal ileum when possible. Care is taken to avoid bowel injury by grabbing the mesentery and avoiding direct handling of

Thermal Injury Bowel
Figure 10.3.3. Dissection is usually initiated by lysing adhesions between small bowel loops and the anterior abdominal wall.
Ultrasonic Dissection
Figure 10.3.4. If the length of adhesion between the abdominal wall and intestine is greater than 4-5 mm, use of an ultrasonic dissecting device may be considered.

the dilated intestinal serosa. Placing the patient in the steep Trendelenburg position and tilting the patient with the left side down permits the surgeon to visualize the cecum properly and enhances running of the small bowel. This process should continue until a transition point between dilated and decompressed intestine is found and the responsible adhesion is identified. The point of transition is usually identified between a proximal dilated loop of small intestine and a distal decompressed loop. Gentle manipulation of the bowel loops using the graspers should be performed to identify the obstructing adhesive band.

If the cause of obstruction of small intestine is an adhesive band, it is usually easy to resolve. A grasping instrument is then passed beneath this band, thus isolating it over the mesentery. Again, it is worth emphasizing that using a monopolar or bipolar electrode often causes the contraction of adhesional strands, leading to risk of injuring adherent loops of bowel. Vascularized strands with a sufficient length are dissected after prior ligation using clips, or ligatures administered either by the intra- or extracorporeal knotting technique. It is possible that large hemoclips can be used to clip the band on both sides of the grasper. A hooked electrosurgery tip is then used to divide the band.

When a point of obstruction is not clearly identified, lysis continues until all suspicious adhesions or bands responsible for the symptoms are dissected as with the approach for small bowel obstruction by lapa-rotomy. We also evaluate the entire small intestine even if a convincing obstruction at one point is found.

After small bowel obstruction is resolved by manipulation, the entire bowel is then examined again for signs of intestinal injury during the exploration. If dense adhesions are encountered, laparotomy should be performed. But we try to make the incision as short as possible. Additionally, if nonviable intestine is encountered, the abdomen should be opened through an incision that is long enough to safely manage the problem. Assuming that laparoscopic adhesiolysis to resolve the small bowel obstruction is successful, the abdominal cavity should be irrigated with saline solution, and the omentum placed between the intestine and ventral wall of the abdomen as much as possible.

After final thorough control with complete hemostasis, the inserted ports are retracted under visual control with the camera. In case of extensive adhesiolysis, we position a silicone drain in that area to allow for an early detection of postoperative bleeding and perforation of intestine.

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