Adhesiolysis
Adhesions create anatomic difficulties because they blur normal tissue planes and boundaries. Adhesions may range from thin and filmy to thick and fleshy. Fibrosis may simply agglutinate one structure to another. The key points in separating adhesions are to utilize sharp dissection whenever possible and to avoid blunt dissection, because the latter frequently results in the tearing of one or both adhesed structures during dissection (e.g., when separating adhesed intestine from the uterus, it is better to err in the direction of leaving extra tissue attached to the bowel and to dissect closer to the uterus) (Fig. 24–1A–E). The author avoids energy sources when the adhesions are proximate to bowel, bladder, ureter, or larger blood vessels. The initial cut should attempt to reverse the original attachment sequence rather than create new tissue planes.
Careful and detailed inspection of visceral structures closely involved in adhesiolysis surgery is vitally important to avoid missing an iatrogenic bowel or bladder, or ureteral injury. Tubo-ovarian adhesiolysis may require magnification to avert heavy, obscuring hemorrhage. In this location, carbon dioxide (CO2) laser and bipolar electrosurgery are vital tools to prevent or reduce bleeding (Fig. 24–2A–C).
Adhesions covering or enveloping the ovary are better treated by careful laser vaporization rather than by sharp dissection (Fig. 24–3A–C). Omental adhesions may require the omentum to be doubly clamped, cut, and suture-ligated to facilitate takedown. Sidewall adhesions deserve some special considerations. Ovary and tube may be “plastered” to the pelvic peritoneum (Fig. 24–4A, B). The surgeon must identify the anatomy behind the adhesions. In this instance, entry into the retroperitoneal space facilitates identification. The external iliac vein, hypogastric artery and vein, ureter, and ovarian vessels must be identified and secured from injury during adhesiolysis. Injection of sterile water with a fine needle may facilitate the development of a safe dissection plane between adhesions involving the bladder, bowel, and sidewall structure (Fig. 24–5A–D).
Adhesiolysis cannot be optimally accomplished without the use of traction and countertraction (see Fig. 24–5). The latter technique helps the clinician to identify the plane of attachment of the adhesion to a visceral structure and in turn permits the least bloody and least traumatic separation. Adhesions are obviously always best dissected from superficial (first cut) to deep (last cut). Similarly, the tip of the scissors must always be in view. If an energy device (e.g., a CO2 laser) is to be used, a backstop should be placed behind the adhesion. Similarly, in this circumstance, water can serve as a backstop because it will absorb laser light (Fig. 24–6A–J).
