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Enterotomy Risk in Abdominal Wall Repair: A Prospective Study

ten Broek, Richard P. G. BSc; Schreinemacher, Marc H. F. MD; Jilesen, Anneke P. J. MD; Bouvy, Nicole MD, PhD; Bleichrodt, Robert P. MD, PhD; van Goor, Harry MD, PhD, FRCS

doi: 10.1097/SLA.0b013e31826029a8
Original Articles

Objectives: To establish the incidence and predictive factors of enterotomy made during adhesiolysis in abdominal wall repair and to assess the impact of enterotomies and long-lasting adhesiolysis on postoperative morbidity such as sepsis, wound infection, abdominal complications and pneumonia, and socioeconomic costs.

Background: Adhesions frequently complicate surgical repair of abdominal wall hernia. Enterotomies made during adhesiolysis specifically have a large impact on morbidity of patients, especially surgical site infections. Little is known on the incidence and burden of enterotomies and long-lasting adhesiolysis in abdominal wall repair.

Methods: Between June 2008 and June 2010 demographics, disease characteristics and perioperative data of all patients undergoing elective abdominal wall repair were included in a prospective cohort study that was focused on adhesiolysis-related problems. A trained researcher observed all surgeries and collected data on adhesion location, tenacity, adhesiolysis time, and inadvertent organ damage such as enterotomies. Primary outcome was the incidence of enterotomy, and predictive factors for enterotomy were assessed through univariate and multivariate analyses. In addition, we evaluated the impact of adhesiolysis and enterotomy on morbidity.

Results: A cohort of 133 abdominal wall repairs was analyzed. Adhesiolysis was required in 124 (93.2%), with a mean adhesiolysis time of 35.7 ± 29.8 minutes. Thirty-three enterotomies were made in 17 patients (12.8%). Two patients had a delayed diagnosed bowel perforation. Adhesiolysis time, hernia size greater than 10 cm, and fistula were significant predictive factors in univariate analysis. In multivariate analysis, only adhesiolysis time was a significant and independent predictive factor for enterotomy (P = 0.004). Trends toward an increased risk were seen for patients with mesh in situ and hernia size greater than 10 cm. Patients with enterotomy had significantly more urgent reoperations (P = 0.029), and they more often required parenteral feeding (P = 0.037). Moreover, patients with extensive adhesiolysis (adhesiolysis time, >30 minutes) more often suffered from wound infection (9/63 vs 2/70; P = 0.025), abdominal complications (5/63 vs 0/70; P = 0.022), and sepsis (4/63 vs 0/70; P = 0.048).

Conclusions: One in 8 patients undergoing abdominal wall repair suffer inadvertent enterotomy following adhesiolysis. Adhesiolysis time predicts enterotomy. Morbidity in patients with extensive adhesiolysis and adhesiolysis complicated by enterotomy is high, inducing longer hospital stay and increased health care utilization.

The impact of adhesiolysis during ventral hernia repair was studied in a prospective cohort of 133 hernia repairs. One in 8 patients undergoing abdominal wall repair suffer inadvertent enterotomy following adhesiolysis. Patients with complex adhesiolysis experienced increased morbidity and health care utilization.

*Department of Surgery, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands

Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands.

Reprints: Richard P. G. ten Broek, BSc, Radboud University Nijmegen Medical Centre, Department of Surgery, PO Box 9101, 6500 HB Nijmegen, The Netherlands. E-mail:

R.P.G.B. and M.H.F.S. contributed equally.

Disclosure: No external funding was required for this study, and there are no financial disclosures.

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