Chapter 63 - Lysis of adhesions

Summary

Intra-abdominal adhesions are the most common reason for mechanical small bowel obstruction (SBO) and are implicated in infertility and complex abdominal and pelvic pain. Recent studies suggest that 10% of patients who have undergone colectomy will be re-admitted for SBO within 3 years. The annual cost of managing this condition is well over 1 billion dollars.

Hyaluronate/carboxymethyl cellulose (Seprafilm), oxidized regenerated cellulose (Intercede), and other agents are available to attempt to limit postoperative adhesion formation. These agents have been shown to reduce adhesion formation, but have not been proven to decrease the incidence of SBO. Furthermore, there is a possible link to an increased incidence of anastamotic leak. Thus, utilization of these products varies by institution and surgeon. Other techniques that have been shown to decrease postoperative adhesion include a laparoscopic approach, minimization of foreign material (sutures/mesh), and use of powder-free gloves.

Patients usually present with nausea and emesis if the obstruction is complete. If the obstruction is only partial, patients may have less severe symptoms and may still be passing flatus. Many patients are profoundly dehydrated and hypokalemic and require significant resuscitation and electrolyte repletion. Patients with limited cramping and abdominal distension, and no signs of peritonitis, often benefit from fluid and electrolyte repletion, nasogastric tube decompression and observation. This approach may allow laparotomy to be avoided, but mandates close observation for signs of threatened bowel. Patients with a rising white blood cell count, fever, peritonitis, and persistent or increasing pain (possible closed loop obstruction) will likely need surgical exploration. Obstructed small bowel may become ischemic or necrotic without classical signs and symptoms; when a non-operative approach is taken, serial evaluations and a high index of suspicion are necessary.