Multi-stream saline-jet dissection using a simple irrigation system defines difficult tissue planes

Abstract

Introduction: Single-stream hydro-jet dissection is increasingly used in various laparoscopic procedures, but its use requires special equipment. We describe a simple method for using an irrigation system for saline-jet tissue dissection as a useful adjunct prior to adhesiolysis.

Material and methods: Intraabdominal adhesions prolong laparoscopic procedures, because tissue planes are difficult to identify. We performed multi-jet saline dissection (MSSJ) between 2000 and 2009 in more than 500 patients during laparoscopy involving hernias, gallbladders, appendices, and intestinal obstructions. We use a standard suction irrigation probe, which is attached to a 1-liter saline bag with an inflatable cuff around to create a pressure of 250mm Hg to 300mm Hg. In effect, this is the standard setup generally used for irrigation. After using saline dissection, tissue planes can be better defined and the structures can then be separated.

Result and discussion: Using this method, we have successfully identified tissue planes in spite of dense adhesions, and our conversion rates to open have been reduced dramatically. This method is relatively safer than other modalities of tissue dissection, such as diathermy, ultrasonic, blunt or sharp dissection. The disadvantage is that with tissues saturated with saline it becomes more difficult to use diathermy hemostasis. Care has to be exercised in monitoring the temperature and volume of the fluid used.

Figure 1.

MSSJ bag under pressure and irrigation catheter.

Figure 2.

MSSJ dissection during the dissection of triangle of Calot.

Figure 3.

MSSJ dissection during gallbladder bed dissection.

Figure 4.

MSSJ dissection during subhepatic appendectomy.

Figure 5.

Massive adhesions between intestines and anterior abdominal wall at the site of an incisional hernia (A). MSSJ using a saline bag under pressure and standard laparoscopic irrigation-suction system (B). MSSJ leading to visualization of clear tissue planes (C). MSSJ leading to progression of tissue dissection (D).

Figure 6.

Hydrodissection to free up the bowel from peritoneum in a case of recurrent midline incisional hernia before hydrodissection (A), during hydrodissection (B), after Hydrodissection (C), and after mesh fixation (D).