腹腔镜手术和术后粘连形成

Laparoscopy and Postoperative adhesion formation

Prof. Dr. R. K. Mishra.

                               
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Introduction:

Adhesions begin with a fibrin matrix that occurs during coagulation. The factor responsible is which involved in clotting like: inflammatory cells, cytokines and growth factors. Histamine release from these injured sites further increases in exudation of pertinacious material. Over the next few days various cellular elements become encased in this fibrin matrix, which gradually replaced by vascular granulation tissue containing macrophages, fibroblasts and giant cells.  By four days post-operative, most of the fibrin disappears and more fibroblasts and collagen are present. From day 5 to 8th, fibroblasts align within the adhesion. At day 15th, the relatively few cells present are predominantly fibroblasts. At 30th to 60th day, the collagen fibrils organize into discrete bundles. The mature adhesion develops as a fibrous band. The adhesion not only develops where there is direct tissue insult, it is also quite common in the case of slight tissue trauma. It is well known that hypoxia of tissues, or extensive electro-cautery would increase the chance of postoperative adhesions.

Studies have shown that it is not necessary to suture the peritoneum to prevent adhesion formation. It is better to leave the peritoneum unsutured after surgery. It will heal satisfactorily on its own.

The development of postoperative adhesions occurs within the first 3-5 days following the surgical procedure. Thus, modulation of the healing process during this time period is critical to minimize the adhesion formation. One day can prevent post-operative adhesion formation.

Factors which increases the chance of postoperative adhesion formation is:

• ·         Extensive tissue incision
• ·         Prior surgeries
• ·         Poor surgical techniques (Raw areas)
• ·         Excessive handling of viscera
• ·         Desiccation of tissue at the time of open surgery.
• ·         Ischemia of tissue.
• ·         Increased Inflammatory response
• ·         Wound Infection
• ·         Endometriosis
• ·         Delayed post operative mobilisation of patient.
• ·         Inadequate fluid and electrolyte balance during post-operative recovery.
• ·         Poor nutrition.
• .         Chemotherapy.
• .         Peri-operative radiotherapy
• .         Cancer.
  
  

It is estimated that 55 - 94% of patients having abdominal or pelvic open surgery has chance to develop post-operative surgical adhesions. The surgical procedures which have a higher incidence of adhesion formation are following:

• ·         Cholecystectomy
• ·         Appendectomy
• ·         Colonic surgery (large colon and small bowel)
• ·         Pelvic surgery (surgery on uterus, fallopian tubes, ovaries)
• .         Total abdominal hysterectomy
• .         Salpingostomy,
• .         Fimbrioplasty, excision of endometriosis, excision of eptopic pregnancy,
• .         Caesarean section, and   
• .         Adhesiolysis.
  
  

Possible consequences of postoperative adhesion:

For most patients, Adhesions formation has little long term effect. However for some patients, Adhesions can cause severe clinical

consequences. Chronic abdominal pain pain, Intestinal obstruction and infarction These condition some times necessitate

re-operation. There is a great need of awareness among doctors, healthcare providers, government, and the public as a whole, to

prompt a more comprehensive and integrated care system for adhesion related disorder sufferers.

Adhesion formation and Laparoscopic surgery.

It is well accepted fact that postoperative recovery after laparoscopic procedure is fast than conventional approach. It is now proved that delayed tissue healing, Increased tissue trauma, Restricted mobility and enhanced inflammatory response are the key factors, which is responsible for postoperative adhesion formation. On to basis of these benefit of laparoscopic surgery many literatures claims that laparoscopy reduces surgical adhesions. The chance of development of adhesion formation after laparoscopic surgery is also less because, there is less tissue handling and no chance of tissue desiccation. After laparoscopic surgery the postoperative recovery of the patient is very fast and so the post-operative mobilization. The early postoperative mobilization is also an important factor for reducing post-operative adhesion formation. Laparoscopic procedures cause less post-operative pain than their conventional counterparts and so less tissue inflammatory response.  In the present review, none of the published series reported more pain after laparoscopic procedure.  The post-operative narcotic use is less after laparoscopic appendicectomy.  In one study done by Ortega et al; linear analogue pain scores were recorded in 135 patients blinded to the procedure of operation by special dressing.  Pain scores were substantially less in laparoscopic group compared to open one.  

The chance of adhesion formation after laparoscopic surgery is less also patient have a better sense of wellbeing and earlier postoperative food intake, ambulation and return to work and sport.

Conclusion:

Adhesion formation is now one of the most common causes of intestinal obstruction.  The role of adhesion in the development of chronic abdominal pain, although less certain, cannot be ignored.  Reduced adhesion formation is a substantive long term advantage of laparoscopic appendicectomy.

References:

[1] Cuschieri. A. Appendectomy—laparoscopic or open? Surg Endosc (1997) 11: 319–320.

[2] C.L.Garrard, R.H.Clements, L.Nanney, J.M.Daviddson, W.O.Richards.Surg Endosc 1999; 13: 10-13.  Adhesion formation is reduced after laparoscopic surgery.

Prof. Dr. R. K. Mishra.