Adhesiolysis in Patients Undergoing a Repeat Median Laparotomy

Abstract

Background: Adhesiolysis during repeat surgery is associated with a high incidence of iatrogenic enterotomies and an increase in postoperative complications. Identification of risk factors would improve preoperative counseling and operating room strategy.

Objective: The aim of this study was to identify preoperative risk factors for prolonged and difficult adhesiolysis in a repeat median laparotomy.

Design: This is a prospective cohort study. Univariate and multivariate analyses were used to assess the risk factors for prolonged and difficult adhesiolysis.

Settings: This study was conducted at Radboud University Medical Center.

Patients: Patients participating in the LAPAD study (ClinicalTrials.gov Identifier: NCT01236625) undergoing an elective repeat median laparotomy were selected.

Main outcome measures: Detailed data regarding adhesiolysis to gain entry to the abdomen and adhesions underneath the previous incision were gathered by direct observation.

Results: A total of 259 patients underwent a repeat median laparotomy. Adhesiolysis was required for 230 patients (89%); the remaining 29 patients (11%) did not have adhesions underneath the incision. Median adhesiolysis time underneath the midline incision was 10 minutes (interquartile range, 5-25). Seventy-six patients (29%) had grade 1 or grade 2 adhesions; 108 (42%) had grade 3; and 46 (18%) had grade 4. The number of previous laparotomies was the only independent risk factor for prolonged (p ≤ 0.01; 95% CI, 2.5-14.10) and difficult adhesiolysis (p ≤ 0.01; OR, 4.21; 95% CI, 1.74-10.17). History of peritonitis, anatomical location of previous surgery, and the time interval between consecutive median laparotomies did not prolong adhesiolysis.

Limitations: This study involved retrospective data collection of patients' medical histories. No data were collected on the severity of previous peritonitis.

Conclusions: This study demonstrates that 4 or more previous laparotomies and the presence or history of an intraperitoneal synthetic mesh are independently associated with a longer duration of adhesiolysis needed to gain access to the abdomen. A short time interval between median laparotomies or a history of peritonitis did not prolong the duration of adhesiolysis.