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Severe Adhesions

Severe Adhesions. Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director Residency in General Surgery University of Cincinnati. Disclosures. Ethicon Endo surgery. Severe Adhesions. Re-operative Surgery

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Severe Adhesions

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  1. Severe Adhesions Bradley R. Davis, MD, FACS, FASCRS Associate Professor of Surgery Director Surgical Education/Surgical Skills Lab Program Director Residency in General Surgery University of Cincinnati

  2. Disclosures • Ethicon Endo surgery

  3. Severe Adhesions • Re-operative Surgery • Small bowel obstruction • Acute • Chronic Recurrent (when to operate?) • Previous abdominal or pelvic surgery

  4. Severe Adhesions • Previous surgery not a contraindication to laparoscopy • Small bowel obstructions – often a single band • PEEK port

  5. Severe Adhesions • Many patients have had previous laparotomy • Kocher • Pfannenstiel • Midline • Chevron • Most deserve a look lap – known prior hostile abdomen exception

  6. Small Bowel Obstructions • 40% of patients with previous laparotomy will develop an SBO • Laparotomy effective but longer LOS and adhesion formation more significant vs. lap • Increasing experience with laparoscopy in the management of SBO

  7. Lap Adhesiolysis for SBO

  8. Lap Adhesiolysis SBO Surg Endosc. 2012 Jan;26(1):12-7

  9. Lap Adhesiolysis for SBO Surg Endosc. 2012 Jan;26(1):12-7

  10. Lap Adhesiolysis for SBO Surg Endosc. 2007 May;21(5)

  11. Lap Adhesiolysis for SBO Surg Endosc. 2007 May;21(5)

  12. Lap Adhesiolysis Am Surg. 2011 Feb;77(2):185-7

  13. Principles • Preoperative abdominal distention may preclude pneumoperitoneum • Generous use of sharp dissection – cautious use of energy • Pelvic adhesions can be the most hostile

  14. Lap Adhesiolysis • MUST identify the transition zone • Consider adhesive barrier • Can be difficult to insert – role seprafilm into ‘cigar’ insert through trocar

  15. PEEK Port • Start difficult procedure through a 6-8cm incision • Assess adhesions after “mini” laparotomy • Proceed with HALS based on assessment • Do not open lap disposables until confirmed

  16. PEEK Port

  17. Re-operative Surgery • Extent of adhesions dictated by the index procedure • This will be discussed in a separate presentation

  18. Thanks

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