Precautions When Performing a Laparotomy Through a Previous Laparotomy Scar

1. Pre-operative Assessment

• Know exactly what was done before, what incision was used, what organs were handled/resected, and whether any mesh, drains, or foreign material was left behind.
• History of peritonitis, multiple previous surgeries, inflammatory bowel disease (Crohn's), radiation, or bowel resections predicts dense adhesions.

• Obtain CT abdomen/pelvis with contrast to map adhesion burden (thickened loops, tethered bowel), identify organ proximity to the scar, and plan your approach.

• Consider mechanical bowel prep if bowel injury is anticipated - it does not prevent injury but limits contamination if it occurs.

• Specifically warn the patient about higher risk of inadvertent enterotomy, prolonged surgery, stoma formation, and potential conversion (if laparoscopic approach planned).

2. Incision Planning

• Do not simply re-enter through the middle of the old scar. Extend the incision superiorly and/or inferiorly into virgin tissue first, where adhesions are less dense and the peritoneum can be safely opened.

• (Sabiston Textbook of Surgery - Intraoperative Procedures)

3. Entering the Peritoneum - The Most Dangerous Step

• Use a scalpel (not scissors or cautery) to incise the old scar and underlying fascia in a controlled layer-by-layer fashion.
• Never blindly push scissors or a finger through the peritoneum at the old scar - bowel is frequently adherent here.

• Open peritoneum at an area away from the densest adhesions (usually above or below the most fibrotic zone).
• Enter the peritoneal cavity where you can clearly see and feel normal tissue planes before proceeding centrally.

4. Adhesiolysis - Taking Down Adhesions

• (Bailey and Love's Short Practice of Surgery, 28th Ed - Adhesions)

• Always use sharp dissection (scissors, not blunt finger dissection) for dense adhesions - blunt traction tears bowel serosa/mucosa.
• Stay on the adhesion band, not on the bowel wall. Dissect close to the parietal peritoneum or the adhesion itself, not directly on the viscus.
• Divide, don't tear - every centimetre of safe sharp dissection is better than tearing.
• Release bands under direct vision. Band adhesions causing a closed-loop obstruction (Figure 78.4, Bailey & Love) can cause immediate bowel infarction if strangulated - handle carefully.

5. Intraoperative Hazards to Watch For

6. Specific Entry Considerations for Laparoscopic Approach (if planned instead of open)

• Avoid inserting Veress needle or primary trocar at the site of the old scar - 71% of adhesions involve the laparotomy scar directly. (SLRS guidelines)
• Use an alternate access site: Palmer's point (left subcostal, 3 cm below costal margin in mid-clavicular line) is preferred in cases with prior midline scars.
• Use the Hasson (open) technique for initial port insertion rather than closed Veress needle technique - this allows direct visualisation and is strongly preferred in previously operated abdomens. (Sabiston Textbook of Surgery)
• Consider optical access trocars (e.g., Optiview) for better visualisation during entry.

7. Intra-operative General Measures

• Minimise unnecessary tissue handling - extra peritoneal trauma means more adhesions at the next operation.
• Keep bowel moist - use warmed saline-soaked packs; avoid prolonged air exposure of bowel.
• Use latex-free, powder-free gloves - powder is a potent adhesion promoter.
• Limit gauze contact with viscera - use moist swabs; dry gauze abrades serosa.
• Thorough peritoneal irrigation at the end - wash out blood, fibrin clots, and debris to reduce post-operative adhesion formation. (Bailey & Love's Short Practice of Surgery)
• Avoid unnecessary reperitonealisation - suturing raw peritoneum promotes ischaemia and paradoxically increases adhesions.
• Limit foreign material - minimise mesh, staples, and suture material left inside where not essential.

8. Damage Control Consideration

• Planned staged procedure (damage control laparotomy - pack and close temporarily).
• Accepting a limited procedure (e.g., proximal diversion without full adhesiolysis).
• Conversion to open if laparoscopic.

9. Closure

• Use mass closure technique (loop PDS/nylon) if the fascia quality is poor from previous scar.
• Consider mesh-augmented closure if at high risk of incisional hernia.
• Leave the skin open or use delayed primary closure if there is significant contamination.

10. Adhesion Prevention at Closure

• Consider applying an adhesion barrier (e.g., Seprafilm - sodium hyaluronate/carboxymethylcellulose) over raw areas before closure - evidence supports reduction of adhesion severity, with most benefit when applied onto dense adhesion sites at redo surgery. (PMC8301806)
• Achieve meticulous haemostasis - blood in the peritoneum is a potent adhesion former.

• Bailey and Love's Short Practice of Surgery, 28th Ed - Adhesions (intestinal obstruction chapter)
• Sabiston Textbook of Surgery - Intraoperative Procedures (laparoscopic access in prior surgery)
• Fischer's Mastery of Surgery - Damage Control Laparotomy
• Schwartz's Principles of Surgery - Excess Healing / Adhesions