SOBRACIL

Newsletter Sobracil-SP vol 1; 2007

Audebert AJ & Gomel V
Role of microlaparoscopy in the diagnosis of peritoneal and visceral adhesions and in the prevention of bowel injury associated with blind trocar insertion.

Fertil Steril. 2000;73(3):631-5. Institut Greenblatt France, Bordeaux, France. audebert@alienor.fr

OBJECTIVE: To determine the frequency of peritoneal and visceral adhesions to the umbilical region according to past surgical history and to estimate the risk of bowel injury with blind insertion of the principal trocar-cannula. DESIGN: Prospective, unicentric study by a single operator. SETTING: Clinique Saint-Sernin and Polyclinique de Bordeaux, Bordeaux, France. PATIENT(s): Eight hundred fourteen patients undergoing diagnostic or operative laparoscopy were classified into four groups based on their history of abdominal surgery: group I (n = 469), no previous abdominal surgery; group II (n = 125), prior laparoscopic surgery; group III (n = 131), previous laparotomy with a horizontal supra-pubic incision; group IV (n = 89), previous laparotomy with a midline incision. INTERVENTION(s): Initial microlaparoscopy performed through the left upper quadrant of the abdomen, inspection of the anterior abdominal wall and particularly the umbilical area for the presence of adhesions. Patients who had adhesions were assessed as to whether or not they were at significant risk of injury from blind insertion of the principal trocar. MAIN OUTCOME MEASURE(s): Incidence of umbilical adhesions and the potential risk of bowel injury with blind insertion of the umbilical (principal) trocar. RESULT(s): Umbilical adhesions were found in 9.82% of the 814 cases. The rates of umbilical adhesions were as follows: group I, 0.68%; group II, 1.6%; group III, 19.8%; and group IV, 51.7%. Severe adhesions with potential risk of bowel injury with blind insertion of the umbilical trocar in the four groups were 0.42%, 0.80%, 6.87%, and 31.46%, respectively. CONCLUSION(s): Women with previous laparotomy have a higher incidence of umbilical adhesions, especially in case of midline incision. Preliminary inspection of the umbilical area with a microlaparoscope and insertion of the umbilical trocar under direct vision are recommended for patients at risk for adhesions to reduce complications associated with insertion of the principal (umbilical) trocar.

Comentários: o presente trabalho fornece informações importantes sobre os riscos de lesão de vísceras durante a realização de pneumoperitônio. Conforme demonstrado, aderências peri-umbilicais foram registradas em cerca de 10% dos casos, que é uma porcentagem não desprezível. Levando-se em conta o tipo de incisão prévia, o risco potencial de lesão intestinal é importante em pacientes com laparotomias por incisão horizontal supra-púbica (7%) e vertical mediana (30%). Esses dados devem, portanto, ser considerados em pacientes com incisões prévias, ficando a cargo do cirurgião escolher a forma mais apropriada de instituir o pneumoperitônio.

Fábio Guilherme Campos (fgmcampos@terra.com.br)