Peritoneal adhesions: pathogenesis, assessment and effects.

BACKGROUND: As modem surgery has evolved, there has been an increase in iatrogenic peritoneal adhesions. Most surgeons manage adhesions and their related complications on a regular basis. Studies in recent years have improved the understanding of the pathogenesis and impact of adhesions, which are discussed. METHODS: A systematic search of literature was performed to identify publications addressing the etiopathogenesis, clinical spectrum and effects of adhesions, using the following database: Medline (1966 to April 2005), Embase (1974 to April 2005), and the Cochrane controlled trials register. The reference lists of key publications so identified were in addition scrutinized for additional articles of relevance. RESULTS: Adhesions occur in more than three fourths of patients following laparotomy. Perironeal trauma results in a unique inflammatory process in which fibrin formation and fibrinolysis play a central role. The effects of adhesions are unpredictable but are wide ranging, causing a significant health care burden. Intestinal obstruction, infertility, problems at reoperative surgery and cumulative costs of care over many years are the key concerns. While adhesiolysis is beneficial in adhesive intestinal obstruction and infertility, its value in chronic pain is uncertain. CONCLUSION: Every violation of the peritoneum carries a potentially lifelong risk of a range of complications. Data available on the epidemiology and natural history of adhesions call for a wider acknowledgement of the problem in the planning of services and greater attention to preventive strategies.

Management of a pseudo-aneurysm in the hepatic artery after a laparoscopic cholecystectomy.

Introduction Symptomatic hepatic-artery pseudoaneurysm (HAP) after bile-duct injury (BDI) is a rare complication with a varied (but clinically urgent) presentation. Methods A prospectively maintained database of all patients with BDI at laparoscopic cholecystectomy (LC) referred to a tertiary specialist hepatobiliary centre between 1992 and 2011 was searched systematically to identify patients with a symptomatic HAP. Care and outcome of these patients was studied. Results Eight (6 men) of 236 patients with BDI (3.4%) with a median age of 65 (range: 54?6) years presented with symptomatic HAP. Median time of presentation of the HAP from the index LC was 31 (range: 13?16) days. Bleeding was the dominant presentation in 7 patients. One patient presented late (>2 years) with abdominal pain alone. Computed tomography angiography was the most useful investigation. Angioembolisation was successful in 7 patients. One patient died, and another patient developed liver infarction. Three patients (38%) developed biliary strictures after embolisation. Seven patients are alive and well at a median follow-up of 66 months. Conclusions Presentation of HAP is often delayed. A high index of suspicion is necessary for the diagnosis. Computed tomography angiography is the first-line investigation and selective angioembolisation can yield successful outcomes.