LAPAROSCOPIC ADHESIOLYSIS-METHOD OF CHOICE IN SELECTED PATIENTS

and mortality was not registered. Conclusion : Laparoscopic debridement is an excellent and accurate procedure in selected patients with post-operative abdominal adhesions. The last decade has become a method of choice because of its incontrovertible advantages.


INTRODUCTION
Postoperative adhesions following abdominal surgery are more common nowadays, with a range between 12-17 % [1]. They can cause abdominal pain, nausea, vomiting as a result of intestinal obstruction. By increasing the number of laparotomies, as a result, the formation of adhesions increases too. Many patients with postoperative adhesions overcome this condition with conservative treatment, but there are others that require emergency surgury [2,3,4].
Until recent years, laparotomy was the gold standard for emergency surgury, which was chased with the risk of new adhesions, ventral hernia, postoperative pain and ileus [4,5]. In the first steps of laparoscopic surgery, a prior abdominal intervention was considered a contraindication. Afterward, with increased experience, currently, excellent results were performed in selected patients [5,6].
Nowadays, laparoscopy has been shown to be associated with fewer intraperitoneal adhesions. This method includes minimal incision of the parietal peritoneum and, as a result-minimum tissue trauma without lesions to adjacent tissues. Advantages induce laparoscopy as a method of choice for adhesiolysis in selected patients.
The spectrum of potential featuresof laparoscopic adhesiolysiscan be wider. Patients should be carefullysystemized and evaluated for laparoscopic surgery intervention. An important tool is the lysis of minor adhesions,which can lead to new pathological ones.
The goal is an accurate preoperative diagnosis of pathological adhesions. This first stage in performing laparoscopic adhesiolysis [2].
Advanced technology with high-definition imaging, smaller cameras, and better instrumentation have allowed for an increasing number of adhesiolysis to be performed laparoscopically with good outcomes. Compared with the open approach to adhesiolysis, the laparoscopic approach offers shorter hospital stay, less postoperative pain, decreased incidence of ventral hernia, and reduced recovery time with the earlier return of bowel function [2,3].
Surgical examinations are incomplete in determinatingchronic recurrent cases. Verification ofthe diagnosis also includes anenteroclysis-contrast examination of the small bowel loops [6]. It could separate intestinal adhesions from radiation enteritis, Crohn's disease, tumor recurrence. For emergency cases of acute obstruction, a CT scan should be done. Identification of the transition area with dilated and collapsed small bowel loops is the key to laparoscopic exploration [2,3,4].
Most important for laparoscopic adhesiolysisin selected cases requires detailed preoperative examination and careful laparoscopic maneuvers.
According to the EAES (European Association of Endoscopic Surgery) recommendations, in cases of clinical and radiological evidence of small bowel obstruction not reacting to conservative management, laparoscopy could be performed with the open access technique. If adhesions are found at laparoscopy, cautious laparoscopic adhesiolysis can be performed for the release of small bowel obstruction [3,4].
Laparoscopic adhesiolysis in an emergency is not a routine procedure because of the limited visualization of the abdominal cavity due to the distended bowel and because of the risk of iatrogenic intestinal injury.
The high conversion rate in laparoscopic debridement is well known. Optimal cases for the laparoscopic approach are patients with moderate abdominal distension (proximal obstruction), a bowel diameter not exceeding 5 cm, a few adhesions and a limited number of previous scars. Laparoscopy is useful, safe and efficient in all forms of intestinal obstruction, from early, acute and chronic obstruction.
Another feature is as a diagnostic tool in rare cases of intestinal obstruction like internal herniation, mesenteric vein thrombosis. In most of the cases,surgical intervention can be practiced laparoscopically either completely or hand-assisted, which is still minimally invasive, and complications are comparable to conventional procedure. The conversion rate often is high, and it is not a failure if it is in the interest of the patient's health. Laparoscopy for adhesiolysisin selective patients is limited by concern about subsequent scar tissue formation following major laparotomy [5,6].
The present study was designed to estimate the advantages of laparoscopic adhesiolysis in acute or recurrent bowel obstruction, including selected patients.The surgical strategy was to undertake a detailed preoperative diagnosis and careful adhesiolysis.   In this study, the parameters -age, gender, clinical symptoms, treatment, morbidity and mortality were analyzed. Age in this retrospective analysis ranged from 18 to 61 years (average 43.7 years).

MATERIAL AND METHODS
Patients below 18 years of age, as well as those with tumor data, Crohn'sdisease and radiation enteritis, were excluded from the study.
The disease was identified by anamnesis, clinical examinations, and imaging.
Initially, treatment was conservative. If no relief was observed, laparoscopic adhesiolysis was performed. Even if the conservative approach proved to be successful, patients were followed up, and laparoscopic treatment was offered after the normalization of the intestinal passage.

Laparoscopic Technique
For laparoscopy, access to the peritoneal cavity was obtained under direct visual control using the Hasson open technique. Most commonly, the chosen point of entry was just above or below the umbilicus. After insufflating the peritoneal cavity with CO2 gas up to 12mmHg, additional trocars were placed under direct visual control as necessary.
As soon as the first trocar is positioned, the aim is to deliver suitable visualization and working space to permit the insertion of the remaining trocars. At least three and as many as five trocars are used. Depending on the available laparoscopes, one can use three 5-mm trocars or one 11-mm trocar for the camera and two 5-mm trocars for the laparoscopic instruments. Good triangulation should be planned on the basis of the planned site of dissection. Further trocars ought to be placed as needed.
If the site and cause of obstruction were not apparent on general inspection, the ileocecal junction was identified, and the small bowel was followed orally until the point and cause of obstruction could be identified. Most commonly, division of adhesions was performed using cold scissors.
The data from thepatient group admittedto the hospital with postoperative abdominal adhesions were analyzed. Patients were followed up for 30 days following discharge.

RESULTS
Age in this retrospective analysis varies from 18 to 61 (average 43,7).
Eleven patients (26.19 %) underwent conversion. The causes were dense fibrous adhesions in six of them, iatrogenic lesions in three, and haemorrhage in two cases. A total of 5 iatrogenic lesions were recorded in 5 patients. Three of them underwent conversion. In two cases, surgery was performed mini-invasive with an intracorporal suture. Suture with conventional surgery was performed in patients with haemorrhage. Conventional debridement was used for cases with dense fibrous adhesions. Hospital stay varied from 4 to 10 days (on average 6.3 days).
The operating interval was registered from 29 to 121 min (average of 57.3 min).
Surgical morbidity (28.57 %), in addition to the five patients with iatrogenic lesions, includes six more-three patients with clinical symptoms of subileus (resolved with conservative management) and other four-with surgical wound suppuration (treated with VAC-dressing). There were no cases of the death-mortality rate of 0%.

DISCUSSION
The results of this research demonstrate that laparoscopic adhesiolysis is a successful and safe procedure for acute and chronic bowel obstruction. Accurate preoperative diagnosis and selection of the patients lead to lower conversion rate. Laparoscopic debridement contributes to good results, in mostcases much better than open surgery [6].
The role of laparoscopy has an important aspect related to the treatment of postoperative adhesions. Ziprinet al. showed that laparoscopic surgery reduces the risk of recidivating adhesions.Tittel et al. noted that the risk of recurrent adhesions after laparoscopic debridement was reduced. Garrard et al. expressed that after mini-invasive surgery,adhesions were lower compared to open surgery. The formation of adhesions after adhesiolysis is the most important key in patients with this disease.There is enough evidence todemonstrate the benefits of mini-invasive surgery and its value as a gold standard for the treatment of postoperative adhesions [7].
Otherworld series have shown promising results for the role of laparoscopic surgery in the treatment of postoperative abdominal adhesions. The mortality rates are from 0 to 3%, and the method is advantageous in 80-100% of cases. In the manner of the other series, a conversionrate of iatrogenic intestinal lesions was 6,7-43% as a result [3,4].
Preoperative identification was diagnosed by a conventional X-ray, abdominal CT andenteroclysis. But it is not possible to perform the acute phase with enteroclysis because patients cannot tolerate oral intake. This diagnosing tool of the small intestine is effective in chronic recurrent abdominal adhesions as it determinatesthe obstruction'slocation, extent, and nature. Preoperative differential diagnosis is made between postoperative adhesions and Crohn's disease, tumors, enterocolitis. An abdominal CT scan is another appropriate tool for imaging the extent and location of the obstruction [8].
The first trocar insertion of laparoscopic adhesiolysis is another matter of debate. The technique of first trocar insertion is important since intra-abdominal adhesions are known to be present inside the abdominal cavity. Bowel injury at this phasewas reported to be 3.7%. Some surgeons suggest left upper quadrant blind cannulation with a Veress needle, and they claim that adhesions are rare in this area. This hypothetical belief is not based on evidence, and adhesions may be present in the left upper quadrant even if the patient had undergone surgery in the pelvis. Therefore, the most considerable decisionis to perform open insertion of the first trocar in an area which is supposed to be adhesion free, according to previous scars and the results of CT and enteroclysis studies [9].
The extent of adhesiolysis is a critical issue, and there is still no consensus about this decision. Some of the studies demonstrated total adhesiolysis of the ligament of Treitz to the ileocecal valve. Large adhesiolysis increases the risk of recidive adhesion. Laparoscopic surgery requires the identification of pathological adhesions. It is manageable in acute obstruction by a determinatetransitional zone between the collapsed intestinal segment and dilated one. But this key tool is not manifested in chronic recurrent conditions. In these cases, diagnosisis performed by enteroclysis.
Postoperative adhesive intestinal obstruction is a complication following laparoscopic as well as open surgeries. Laparoscopy is an effective and useful mode of treatment in these patients. In other cases, even though laparotomy is associated with increased chances of further adhesion formation and recurrent small bowel obstruction, conversion to open surgeries, if needed, must be done and should not be considered a failure.

CONCLUSION
Laparoscopic debridement is an excellent and accurate procedure in selected patients with postoperative abdominal adhesions. The last decade has become a method of choice because of its incontrovertible advantages.