Abdominal and Pelvic Adhesions After Laparoscopic Ileal Pouch-anal Anastomosis

Ryan W Day, MD, Tonia M Young-Fadok, MD. Mayo Clinic Arizona.

Introduction: Abdominal adhesions are an expected outcome after any open surgical procedure. Patients who undergo open proctocolectomy with ileal pouch-anal anastomosis (IPAA) have up to a 25% chance of developing a future small bowel obstruction secondary to abdominal or pelvic adhesions. Females who undergo open IPAA surgery are at a three-fold risk for infertility. The aim of this study is to evaluate adhesions after laparoscopic IPAA.

Methods and Procedures: A retrospective review was performed of 70 consecutive patients who underwent laparoscopic proctocolectomy, IPAA and diverting loop ileostomy followed by closure of the loop ileostomy and laparoscopic evaluation of their adhesions. Adhesions to the abdominal wall were quantified at the time of the second surgery with the following scale: Grade 0 (no adhesions), Grade 1 (few adhesions, filmy thickness, avascularity), Grade 2 (moderate thickness, limited vascularity), Grade 3 (severe, dense, thickness, vascularity). Adhesions to the adnexae were evaluated using the American Fertility Adhesion Score.

Results: 70 patients underwent a two-stage IPAA procedure with laparoscopic evaluation of their adhesions. Mean age was 39 years (range 18 – 78) with 38 (54%) of subjects being female. 44 patients (63%) had no abdominal wall adhesions (Grade 0), 15 patients (21%) had Grade 1 adhesions, 8 patients (11%) had Grade 2 adhesions, 3 patients (4%) had Grade 3 adhesions. Regarding adnexal adhesions, 25 of the female patients (66%) had no adnexal adhesions, 5 patients (13%) had filmy adhesions to less than one-third of a single adnexa, 1 patient had filmy adhesions encompassing one-third to two-thirds of a single adnexa, 1 patient had dense adhesions to greater than 2/3 of a single adnexa, 4 patients adnexae were unable to be evaluated due to abdominal wall adhesions, and 2 patients had surgically removed adnexae.

Conclusions: Laparoscopic proctocolectomy, IPAA and diverting loop ileostomy has decreased abdominal wall and adnexal adhesions when compared to the previously reported numbers for comparable open surgery either with or without the use of a glycerol/sodium hyaluronate/carboxymethylcellulose bioresorbable adhesion barrier. ¹

Table 1.

1. Cohen Z, Senagore AJ, Dayton MT, Korudo MJ, Beck DE, Wolff BG, Fleshner PR, Thirlby RC, Ludwig KA, Larach SW, Weiss EG, Bauer JJ, Holmdahl L. Prevention of postoperative abdominal adhesions by a novel, glycerol/sodium hyaluronate/carboxymethylcellulose-based bioresorbable membrane: a prospective, randomized, evaluator blinded multicenter study. Dis Colon Rectum. 2005 Jun; 48(6):1130-9.

*A portion of this data was presented at 2008 SAGES. This does represent a more than 50% increase in patient population.