Peritoneal adhesions after laparoscopic gastrointestinal surgery

Abstract

Although laparoscopy has the potential to reduce peritoneal trauma and post-operative peritoneal adhesion formation, only one randomized controlled trial and a few comparative retrospective clinical studies have addressed this issue. Laparoscopy reduces de novo adhesion formation but has no efficacy in reducing adhesion reformation after adhesiolysis. Moreover, several studies have suggested that the reduction of de novo post-operative adhesions does not seem to have a significant clinical impact. Experimental data in animal models have suggested that CO₂ pneumoperitoneum can cause acute peritoneal inflammation during laparoscopy depending on the insufflation pressure and the surgery duration. Broad peritoneal cavity protection by the insufflation of a low-temperature humidified gas mixture of CO₂, N₂O and O₂ seems to represent the best approach for reducing peritoneal inflammation due to pneumoperitoneum. However, these experimental data have not had a significant impact on the modification of laparoscopic instrumentation. In contrast, surgeons should train themselves to perform laparoscopy quickly, and they should complete their learning curves before testing chemical anti-adhesive agents and anti-adhesion barriers. Chemical anti-adhesive agents have the potential to exert broad peritoneal cavity protection against adhesion formation, but when these agents are used alone, the concentrations needed to prevent adhesions are too high and could cause major post-operative side effects. Anti-adhesion barriers have been used mainly in open surgery, but some clinical data from laparoscopic surgeries are already available. Sprays, gels, and fluid barriers are easier to apply in laparoscopic surgery than solid barriers. Results have been encouraging with solid barriers, spray barriers, and gel barriers, but they have been ambiguous with fluid barriers. Moreover, when barriers have been used alone, the maximum protection against adhesion formation has been no greater than 60%. A recent small, randomized clinical trial suggested that the combination of broad peritoneal cavity protection with local application of a barrier could be almost 100% effective in preventing post-operative adhesion formation. Future studies should confirm the efficacy of this global strategy in preventing adhesion formation after laparoscopy by focusing on clinical end points, such as reduced incidences of bowel obstruction and abdominal pain and increased fertility.

Keywords: Peritoneal adhesions; Laparoscopy; Abdomen; Gastrointestinal surgery; Inflammation; Learning curve; Anti-adhesion; Animal models; Clinical studies; Laparoscopic resection of gastrointestinal

Core tip: Laparoscopy reduces de novo adhesion formation but does not reduce adhesion reformation. Adhesion reduction does not necessarily impact clinical outcomes. CO₂ pneumoperitoneum causes peritoneal inflammation depending on the insufflation pressure and surgery duration. Broad peritoneal cavity protection by insufflating a low-temperature, humidified gas mixture of CO₂, N₂O, and O₂ seems to represent the best approach for reducing peritoneal inflammation due to CO₂ pneumoperitoneum. A global strategy to prevent adhesion formation following laparoscopy should combine broad peritoneal cavity protection with the local application of a barrier.