Laparoscopic Adhesiolysis in a Patient with Severe Adherent Syndrome Following Multiple Interventions for Peritonitis

We present a case of a 48 years old patient that presented in our EU with clinical and imaging features of recurrent intestinal obstruction. His past history disease included a perforated appendicitis with peritonitis when he was 12-open apendicectomy with peritoneal washing was then performed, followed by intestinal obstruction with ileal resection when he was 15-complicated with enteral fistula for which was reoperated. During the last 20 years he also has been operated 3 times for intestinal obstruction last intervention was complicated with the injury of the ileum and chronic external fistula that healed several weeks after. During the last 6 months more than 20 obstructive crises were claimed by the patient-his quality of life was poor with severe abdominal colic daily vomiting, casexia, abdominal discomfort and consequent depressive syndrome. In this context our option was to treat this patient conservative at this point. He responded to conservative treatment with the partial restoration of bowel movements within 72 hours. However due to the altered quality of life we decided to perform a prophylactic laparoscopic adhesiolysis. Our first approach was to reach left lower inguinal region using Visiport trocar and two 5 mm additional trocars. We have observed a severe adherence syndrome throughout the entire abdominal cavity extended to all organs. Following this approach we used only scissors to sections these adhesions step by step by freeing the right flank and midline followed by changes in trocars positions that were moved in right inguinal region. At this point dissection continued to right flank and upper abdominal region-at the end both small and large bowels were completely free of adhesions. The intervention lasted 5 hours. Following the intervention, no complication occurred and the patient was discharged in the 6-th postoperative day. The patient has 9 months of follow-up and no signs of recurrence occurred, his quality of life is normal and he was reintegrated into society. Although prophylactic laparoscopic adhesiolysis remains controversial and is not recommended by the vast majority of the authors we believe this procedure is of choice and may represent a solution in patients with multiple open abdominal interventions and intense abdominal adhesions with severe alteration of quality of life due to the obstructive recurrent crises.