Postoperative Peritoneal Adhesion Syndrome-a Challenging Issue in Laparoscopic Surgery

1 Department of General Surgery, „Sfantul Pantelimon” Emergency Hospital, „Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania 2 Department of General Surgery, „Sfantul Pantelimon” Emergency Hospital, Bucharest, Romania Corresponding author: Simona Bobic, Department of General Surgery, „Sfantul Pantelimon” Emergency Hospital, fi rst floor, 340-342 Pantelimon Avenue, 2nd District, Bucharest, Romania. E-mail: simona.bobic@umfcd.ro/ simona.bobic@yahoo.ca Abstract

Using the variables resulted from the analysis of the database, the risk of intra-and postoperative complications was estimated.Th e long-term evolution of the patients has been evaluated by strict monitoring of the continuous or day hospitalizations in the General Surgery Department and the reasons for these readmissions, between January 2014 and October 2018.
Th e principle of individual patient confi dentiality has been respected.Th e informed consent of each patient, for any diagnostic maneuver or therapeutic procedure, has been obtained.Th e study protocol respects the ethical guidelines of the Declaration of Ethics adopted by the 18 th WMA General Assembly, Helsinki, Finland, June 1964, and amended by WMA General Council of Fortaleza, Brazil, 2013 at the 64 th edition (64 th WMA General Assembly, Fortaleza, Brazil, October 2013).
Data on demographics, diagnosis, duration of hospitalization, complications and mortality rate were analyzed, the statistical processing being created using Microsoft Offi ce Excel Software 2013.

RESULTS
Between January 2014 and October 2018, there were 1407 patients undergoing laparoscopic cholecystectomy, admitted in the General Surgery Department of the "Sfântul Pantelimon" Emergency Clinical Hospital from Bucharest.For 537 patients with known surgical history, out of a total of 1407, peritoneal adhesions were identifi ed during laparoscopic cholecystectomy (Figure 1), the remaining 870 cases having no peritoneal adhesions.
Th e demographic characteristics of the population (mean age, mean body mass index (BMI), female: male ratio (F: M), surgical history, and mean ASA score (American Society of Anesthesiology) presented no statistically signifi cant diff erences between the case and the control group (Table 1).
Th e presence of the peritoneal adhesions determines an increased operative time and a higher risk of converting the laparoscopic cholecystectomy to open surgery (Table 2).Intraoperative complications that required the conversion of the laparoscopic intervention were represented by: accidental intra-operative enterotomy, iatrogenic lesions of the main bile ducts, diffi cult adhe-

INTRODUCTION
It is diffi cult to evaluate the intra-and postoperative complications secondary to peritoneal adhesions identifi ed during laparoscopic cholecystectomy.Th e Web of Science database was used in order to search for articles about laparoscopic cholecystectomy in patients with a personal history of abdominal or pelvic surgery, published over the past 10 years.Th e results of the search identifi ed 9 articles published in English, highlighting the paucity of studies on this subject.
Th e postoperative peritoneal adhesions represent, for the majority of cases, an incidental fi nding during diff erent surgical interventions, 90% being the reported incidence after abdominal and pelvic surgery 1 .Recent studies have shown a frequency rate of the intestinal obstruction secondary to peritoneal adhesions between 14% and 40% 2,3 .
Th e incidence of the intestinal obstruction caused by peritoneal adhesions secondary to laparoscopic cholecystectomy has been estimated at 0.4% 4 .
Th e presence of the peritoneal adhesions can determine multiple intra-or postoperative complications, the adhesiolysis prolonging the operative time and the hospital stay, increasing the risk of conversion 5,6 .
Th e aim of the present study is to evaluate the impact of the peritoneal adhesions, identifi ed during laparoscopic cholecystectomy, on the postoperative evolution of the patients.

MATERIAL AND METHOD
Th e present study used anonymous data taken from the InfoWord Data Base of the General Surgery Department of the "Sfântul Pantelimon" Emergency Hospital from Bucharest, Romania.
Th e results were used in order to identify the patients undergoing laparoscopic cholecystectomy between January 2014 and October 2018, their evolution being followed-up for approximately 16 months.
Th e study group was conducted after searching the patients' data in the InfoWord database using the ICD-10 diagnostic codes (International Code of Disease -10 th Edition: K81.0-Acute Cholecystitis, K66.0-Peritoneal Adhesions) and the ROv1DRG Surgical Codes ( J10102 -laparoscopic cholecystectomy, J12202 -laparoscopic adhesiolysis, J10103 -open cholecystectomy after laparoscopic attempt), thus providing information on the aetiology and the surgical intervention.Taking into consideration the data resulted, the patients were divided into two groups: the case group, represented siolysis, poor control of the bleeding, iatrogenic lesions during the positioning of the trocars and technical errors.
Th e rate of conversion to laparotomy is 9.31% in the case group and 0.8% in the control group (Figure 2), a   Table 3 shows that there is no statistically signifi cant impact of the peritoneal adhesions on the risk of postoperative complications.
Th e data presented in Table 4 shows the prolonging eff ect of the peritoneal adhesions upon hospitalization, adding an average of two days to the mean hospitalization of the patients who have no peritoneal adhesions.Higher rates of readmission and reintervention in the fi rst 30 postoperative days have been demonstrated in the case group.Th e peritoneal adhesions identifi ed during laparoscopic cholecystectomy do not infl uence the in-hospital mortality rate, according to the results of the present study.
By summarizing the data obtained, an increased operative time, a higher risk of conversion, a prolonged hospitalization and a higher risk of readmission or reintervention in the fi rst 30 days have been observed in patients with postoperative peritoneal adhesions iden-higher frequency of intraoperative complications in the fi rst group compared to the second group being observed, which suggests a correlation between the presence of the peritoneal adhesions and the risk of intraoperative incidents and accidents.
A prolonged operative time has been observed for patients with peritoneal adhesions (case group -Figure 3).
Th e rate of the postoperative complications is higher in the case group, in comparison with the control group (Table 3).Th e limits of this study are represented by its retrospective design and the high potential of reporting errors, the data being collected through operative protocols and discharge papers, the high degree of subjectivity involved in the process of identifying and describing the peritoneal adhesions being already known.In order to overcome the limits of the study, it is necessary to develop a prospective study on a large group of patients, based on a standardized method of classifi cation of the peritoneal adhesions.
Taking into account the study population, that included a signifi cant number of patients (1407), valid conclusions can be elaborated following the statistical analysis of the data.Th us, a minimal impact of the preexisting peritoneal adhesions on the risk of early postoperative complications has been proven.According to the results of the present study, the preexisting postoperative peritoneal adhesions can increase the operative time, the conversion rate, the duration of the hospitalization and the risk of readmission or surgical reintervention.

CONCLUSIONS
 Pre-existing postoperative peritoneal adhesions discovered during laparoscopic cholecystectomy do not infl uence the risk of early postoperative complications. Pre-existing postoperative peritoneal adhesions increase the operative time and the hospital stay, due to delayed return of the bowel function that tifi ed at the time of the laparoscopic cholecystectomy (Figure 4).

DISCUSSION
Th e clinical consequences and the possible complications of the postoperative peritoneal adhesions represent highly studied topics in the medical fi eld.Th e data from the literature regarding the impact of the postoperative peritoneal adhesions on the evolution of the patients with personal surgical history, who will be subjected to laparoscopic cholecystectomy, is, however, limited.Th e purpose of the study is to evaluate the impact of the peritoneal adhesions on the perioperative evolution of the patients undergoing laparoscopic cholecystectomy.Th e comparative analysis of the intra-and postoperative data has shown that adhesiolysis leads to a prolonged operative time, to an increased risk of conversion to the classical method, to a longer hospital stay and a higher risk of readmission or reintervention.
Th e association between the presence of the peritoneal adhesions at the time of the surgical intervention and the prolonged operative time is sustained by multiple recent studies 7,8 .
Schwartz et al. demonstrated an increased risk of conversion in the presence of peritoneal adhesions 9 .
Th e longer hospital stay with no increase of the incidence of postoperative complications suggests a delay in the postoperative recovery of the patients with adhesions, secondary to adhesiolysis, similar results being recently published 10,11 .

Figure 1 .
Figure 1.Postoperative peritoneal adhesion bands between right the parietal peritoneum and the right colic wall identifi ed during laparoscopic cholecys tec tomy (patient with personal history of appe n dec tomy) (personal collection).

Figure 2 .
Figure 2. The rate of conversion of the laparoscopic cholecystectomy to laparotomy in the case and control groups.

Figure 3 .
Figure 3.An increased operative time for patients diagnosed with peritoneal adehsion syndrome at the time of the laparoscopic cholecystectomy.

Figure 4 .
Figure 4. Readmission and reintervention risks in the fi rst postoperative days.

Table 1 .
The demographic characteristics of the study population

Table 2 .
The intraoperative characteristics of the study population

Table 4 .
Average hospitalization, in-hospital mortality rate, and readmission or reintervention rate in the fi rst 30 days, in case and control groups

Table 3 .
The postoperative complications in the study groups