title: Adhesiolysis in Patients Undergoing a Repeat Median Laparotomy.
abstract: BACKGROUND
  Adhesiolysis during repeat surgery is associated with a high incidence of iatrogenic enterotomies and an increase in postoperative complications. Identification of risk factors would improve preoperative counseling and operating room strategy.
  
  
  OBJECTIVE
  The aim of this study was to identify preoperative risk factors for prolonged and difficult adhesiolysis in a repeat median laparotomy.
  
  
  METHODS
  This is a prospective cohort study. Univariate and multivariate analyses were used to assess the risk factors for prolonged and difficult adhesiolysis.
  
  
  METHODS
  This study was conducted at Radboud University Medical Center.
  
  
  METHODS
  Patients participating in the LAPAD study (ClinicalTrials.gov Identifier: NCT01236625) undergoing an elective repeat median laparotomy were selected.
  
  
  METHODS
  Detailed data regarding adhesiolysis to gain entry to the abdomen and adhesions underneath the previous incision were gathered by direct observation.
  
  
  RESULTS
  A total of 259 patients underwent a repeat median laparotomy. Adhesiolysis was required for 230 patients (89%); the remaining 29 patients (11%) did not have adhesions underneath the incision. Median adhesiolysis time underneath the midline incision was 10 minutes (interquartile range, 5-25). Seventy-six patients (29%) had grade 1 or grade 2 adhesions; 108 (42%) had grade 3; and 46 (18%) had grade 4. The number of previous laparotomies was the only independent risk factor for prolonged (p ≤ 0.01; 95% CI, 2.5-14.10) and difficult adhesiolysis (p ≤ 0.01; OR, 4.21; 95% CI, 1.74-10.17). History of peritonitis, anatomical location of previous surgery, and the time interval between consecutive median laparotomies did not prolong adhesiolysis.
  
  
  CONCLUSIONS
  This study involved retrospective data collection of patients' medical histories. No data were collected on the severity of previous peritonitis.
  
  
  CONCLUSIONS
  This study demonstrates that 4 or more previous laparotomies and the presence or history of an intraperitoneal synthetic mesh are independently associated with a longer duration of adhesiolysis needed to gain access to the abdomen. A short time interval between median laparotomies or a history of peritonitis did not prolong the duration of adhesiolysis.
authors.affiliation: Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands.
authors.forename: Chema
authors.initials: C
authors.lastname: Strik
authors.forename: Martijn W J
authors.initials: MW
authors.lastname: Stommel
authors.forename: Richard P G
authors.initials: RP
authors.lastname: Ten Broek
authors.forename: Harry
authors.initials: H
authors.lastname: van Goor
mesh_terms: D000328:Adult; D000368:Aged; D015331:Cohort Studies; D005260:Female; D006801:Humans; D010535:Laparoscopy; D007813:Laparotomy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D010532:Peritoneal Diseases / Q000453:epidemiology / Q000601:surgery; D011446:Prospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D013526:Surgical Mesh; D000267:Tissue Adhesions / Q000453:epidemiology / Q000601:surgery*