Association between abdominal surgical incision type and midline intraperitoneal adhesion occurrence, findings from laparoscopic evaluation in a low-resource setting; a retrospective cohort of laparoscopic evaluations.

backgroundAbdominal incisions are mostly done in the umbilical or suprapubic regions, typically in the midline, to prevent visceral and vascular injury, by taking advantage of the greater distance between these incision sites and the intraabdominal structures. Unfortunately, adhesions often form at the peritoneal surfaces of these sites, making repeat surgical access, a daunting task. The study aimed to determine the relationship between surgical incision type and the occurrence, location, spread and severity of peritoneal adhesions.

methodsA Retrospective cohort study, involving laparoscopic evaluation of 296 patients. Laparoscopic entry was with the aid of a Veress needle in all cases, while insufflation was done with carbon dioxide using a pre-set pressure of 15mmHg for all diagnostic and 18-20mmHg, for all the operative procedures. The reported adhesions were scored using the Peritoneal Adhesion Index (PAI) score.

resultsThe prevalence of adhesion was 96/296 (32.4%) of laparoscopies, with majority 80/96 (83.3%) in the midline region. Over half of the adhesions were attached to the anterior abdominal wall. Previous peritoneal surgery (p = 0.004, ARR = 40.27, 16.47-64.77), was the main association with adhesion formation. This factor was also the main predictor of adhesion location within the midline regions (p < 0.001, ARR = 10.28, 3.11-34.58) this finding, was irrespective of surgical involvement of uterus or adnexa (p = 0.997). No association was, however, found between the risk of adhesion attachment to the anterior abdominal wall and presence of adhesion in the midline (p = 0.999) or individual midline regions; epigastric (p = 0.778), umbilical (p = 0.345), suprapubic (p = 0.999). Exploratory laparotomy (PAI = 10.80 ± 2.86), myomectomy (PAI = 10.89 ± 3.71) and salpingectomy (PAI = 11.00 ± 5.66) had more severe adhesions, while appendicectomy (PAI = 6.17 ± 3.74) and caesarean section (PAI = 7.47 ± 3.34) the least. Adhesion occurrence (p = 0.883), midline adhesion (p = 0.997) or anterior abdominal wall attachment (p = 0.327) were, however, not significantly associated with incision type.

conclusionPrevious peritoneal surgery, irrespective of uterine or adnexal involvement, was associated with increased risk for adhesion formation. The incision type and the depth of surgery, were, however, not significantly associated with adhesion formation, adhesion location or attachment to the anterior abdominal wall, suggesting an interplay of other operative surgical considerations.