Principles of surgical tactics in laparoscopic procedures under conditions of adhesive process and multiple previous laparotomies

Introduction. Adhesive process is a multifactorial pathological condition characterized by the formation of peritoneal adhesions in the abdominal cavity due to an imbalance between fibrin formation and fibrinolysis. To date, the leading etiological factor in adhesion formation is considered to be a history of surgery. Globally, a pronounced adhesive process is observed after the initial surgical intervention in 55–90 % of people. However, it is worth noting that the frequency of adhesion development in the abdominal cavity directly correlates with the type of previously performed surgical access. According to several authors, in abdominal surgery, the incidence of adhesions after laparotomy procedures is 70–90 %, and after laparoscopic procedures – 35–40 %.
The purpose of this study is to develop principles of surgical management for adhesive processes in the abdominal cavity and pelvis.
Materials and methods. The study is based on data obtained from 635 patients who underwent inpatient treatment at the State Budgetary Healthcare Institution “I.V. Davydovsky City Clinical Hospital of the Moscow Department of Health,” the Federal State Budgetary Institution “A.I. Burnazyan Federal Medical-Biological Center of FMBA of Russia,” the University Clinic of the Moscow State University named after M. V. Lomonosov, the Federal State Budgetary Institution “Federal Clinical Center for High-Tech Medicine of FMBA of Russia,” the Federal State Budgetary Institution “Federal Scientific and Clinical Center of Russia,” and Clinical Hospital no 1 “Medsi” in Otradnoye, between June 2021 and July 2026. The main criteria for inclusion of patients in the study were the presence of an adhesive process in the abdominal cavity or pelvis associated with a previously performed surgical intervention. Based on the nature of the previously performed access, the patients were divided into 2 clinical groups: group 1 (n=334) consisted of patients who had a history of laparoscopic interventions; group 2 (n=301) consisted of patients with a history of laparotomies.
Research results and discussion. In group 1, 334 patients (100 %) underwent laparoscopic surgery; no conversions were performed. In group 2, 296 patients (98,3 %) were operated on using a minimally invasive approach; 5 patients (1,7 %) were treated via an open approach. The Veress needle was used in 10 patients (3 %) of the 1st group and in 3 patients (1 %) of the 2nd group, the Hasson access was used in 28 patients (8,4 %) of the 1st group and in 26 patients (8,7 %) of the 2nd group, the "direct trocar" technique – in 85 patients (25,5 %) of the 1st group and in 48 patients (16 %) of the 2^nd group, optical trocar – in 221 patients (63,2 %) of the 1st group and in 219 patients (72,8 %) of the 2nd group. The “stepping” trocar technique was used in 41 patients (12,3 %) in group 1 and in 91 patients (30,2 %) in group 2. The average duration of the surgical intervention in patients in group 1 was 114±13,5 minutes, and in group 2 – 139±24,6 minutes. The average blood loss during the operation in the 1st and 2nd groups was 101±33 ml and 151±25 ml, respectively. In the patient
Conclusion. We have developed principles of personalized surgical tactics that take into account the nature and extent of previous surgical interventions, their number, the extent of the adhesive process, and the localization of the adhesion. These principles include: a variable approach to the type of surgical access, performing multi-position ultrasound to determine the “acoustic window” for inserting the first trocar, the staged nature of the surgical intervention, and a variable design for the placement of ports.

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