Avoid the temptation to lyse adhesions using blunt dissection (serosal tears and enterotomies may occur)—except in the case of translucent adhesions. These may be lysed via gentle, blunt dissection by rubbing the index finger and thumb back and forth over tissue. They also may be sharply cut using the tip of the scissors to form a “window” in a portion of the adhesion and cutting the adhesive segments in increments.
A characteristic line of demarcation often appears between adhesions and their peritoneal attachment, denoting a safe dissection plane.
Technique for special challenges: Chronic pelvic disease, prior laparotomies. When operating on these patients, be prepared for a long, meticulous procedure. A hasty approach in such cases is perilous and increases the likelihood of postoperative complications.
First, dissect the anterior abdominal wall from the adherent bowel on either side of the incision. Then extend the dissection laterally on both sides until the ascending and descending colon are identified. Next, dissect the small bowel free and mobilize it out of the pelvis.
It often is helpful to move to another area when dissection becomes too difficult; dissection through easier planes often will clarify the relationship of pelvic structures and adherent bowel loops.
Once the small bowel has been mobilized from the pelvis, lyse adhesions between loops of bowel that are causing kinking or narrowing of the lumen, to reduce the risk of postoperative bowel obstruction. Next, carefully dissect pelvic structures from the sigmoid colon and rectum.
How and when to repair serosal injury
Serosal injury is a breach of integrity of the visceral peritoneum, the outermost covering of the bowel wall. This may occur when the serosa is cut during entry into the abdomen or when it is torn during blunt dissection of dense adhesions.
If the underlying muscular and mucosal layers remain intact, these small areas of “denuded” serosa need not be repaired, since most experts believe that suture placement increases the likelihood of future adhesions. The serosal and muscular layers should be repaired if the mucosa is exposed, however. Otherwise the bowel wall will weaken at the site, making it vulnerable to perforation. The seromuscular layers can be approximated easily using interrupted 4-0 silk on a small tapered needle. Be careful to avoid placing the stitch through the mucosa, which would violate the bowel lumen.
When the defect of the seromuscular layer is large (when a more extensive area is denuded during dissection of densely adherent bowel away from a tumor or endometriotic lesion), repair becomes more involved. This may require resection of the injured area with primary anastomosis.
Intestinal perforations: Early recognition is essential
This critical serious complication can become disastrous if not immediately recognized and repaired. Perforation of the small intestine (enterotomy) or large bowel (colotomy) often occurs upon entry into the peritoneal cavity or during a difficult dissection, particularly when extensive adhesions are present.
Exercise special caution when operating on patients who have undergone prior surgery, who are advanced in age, or both.
Reoperation technique. When entering the abdomen through an old scar, reduce the likelihood of bowel injury by extending the new incision to either side of the old scar. Then enter the peritoneal cavity in a virgin area of the abdominal wall, where adherent loops of bowel are less likely.
Carefully open the fascia and dissect the preperitoneal fat down to the peritoneum. Before entering the abdominal cavity, retract the peritoneum upward with smooth forceps and palpate it between the thumb and index finger to ensure that a bowel loop is not in harm’s way.
If the underlying muscular and mucosal layers remain intact, small areas of “denuded” serosa need not be repaired.
Examine the entire small and large bowel carefully after surgery, to rule out injury. It is not uncommon for more than 1 perforation to occur in a bowel segment during a difficult dissection.
Begin at the ligament of Treitz and continue to the ileocecal junction. This is “running” the bowel—ie, inspecting in hand-over-hand fashion.
In the small bowel, the division between the jejunum and ileum is arbitrary, with no sharply defined line of demarcation. However, the diameter of the lumen decreases as one moves from jejunum to ileum, the number of vascular arcades increases, and the number of windows of Deaver diminishes. Also, the wall of the jejunum is generally thicker than that of the ileum.
In addition, inspect the colon in its entirety, with special emphasis on the sigmoid and rectum. Besides its larger lumen, the large bowel is distinguished by 3 longitudinal muscular bands called taenia coli, out-pouching of the wall (sacculations), and epiploic appendages.