This patient had very extensive abdominal adhesions and challenging surgery, which had not been attempted similarly until then. The patient was 58 years old from Zhangjiakou, Hebei, and had completed a radical surgery for ovarian cancer 18 years ago, which was a longitudinal midline incision in the lower abdomen. In recent years, recurrent intestinal obstruction has recurred, several times a year. The pain experienced made her determined and determined to request surgical treatment. A pneumoperitoneogram predicted that the patient had unusual adhesions. I performed puncture gas injection in the patient’s right lower abdomen, and although the sensation was basically normal and there was not much resistance to gas injection, the patient complained of some slight distension and pain in the right lower abdomen after about 200 ml of gas injection, and it seemed that only a limited bulge in the right lower abdominal wall could be felt with continued gas injection. My confidence was finally shaken, and I confirmed the failure of the pneumoperitoneum operation on that side, so I had to discontinue gas injection and withdraw the needle by pumping back the gas. After giving the patient a few explanations, I decided to continue the puncture attempt in the lower left abdomen. This time the procedure went smoothly, and as the gas injection increased, the abdominal wall gradually expanded, and the pneumoperitoneum became a percussion, not realizing at the time how fortunate I had to be to complete this contrast. After the scan, I hurriedly transferred the raw data to the workstation for post-processing and analysis of the images. What surprised me was the extensive adhesions in the abdominal wall of the patient. In the middle and upper abdomen were large large omental and transverse colon adhesions, in the umbilicus and lower abdomen were wall-like adhesions of the small intestine and the mesentery, and in the right lower abdominal puncture site there were also omental adhesions that had expanded due to the injected gas. It was good that I braked in time and knew what to do and did not just do it brutally. The left lower abdomen was also seen to have intestinal collaterals adhesions. Only the left mid-abdomen and just below the umbilicus had a regional pneumoperitoneal space. The puncture needle in the left lower abdomen was very fortunate to enter the abdominal cavity between the intestinal collaterals and inject gas successfully. Such extensive abdominal wall adhesions would have been almost abandoned for laparoscopic surgery. Not to mention the potential dirty adhesions, the wall adhesions, the operating space to the left and right, how to create a pneumoperitoneum, where to put the laparoscopic viewing hole, and how to arrange the operating hole, all really made me scratch my head. I used virtual laparoscopy to show the patient and family the dynamics of the intra-abdominal adhesions and frankly informed them that this minimally invasive surgery could not be done because the adhesions were too extensive and there was no good space for pneumoperitoneum operation. They were very disappointed to hear what I told them, and after a long hesitation, they plucked up their courage and implored me to try my best, even if it was a failed case, and willingly sacrificed to increase my experience. I was touched by such support and understanding, but after all, completing such an extensive adhesion procedure is not something that can be swayed by enthusiasm and determination. I stumbled over the patient’s request, and there was not a moment when I was relaxed after the notification of the surgery appointment was sent. The pneumoperitoneum had to be pre-built before anesthesia to avoid the embarrassment of not being able to build it on stage. On the right side, there were diffuse abdominal wall adhesions that made it impossible to enter the scope, and on the left side, there were wall-like adhesions, so how to arrange the laparoscopic observation and operation holes in a narrow space so that they would not conflict with each other during the operation. The key is how to get the working surface of the adhesions released smoothly and whether the later work can be carried out smoothly, which can only be known when the specific condition of the patient’s adhesions is known intraoperatively. Although I had given some thought to these issues, I was still apprehensive. The surgery day was a Monday, and the department had a lot of surgeries scheduled, and the intestinal adhesions surgery was an uncertain procedure, so it was always the last one. The main difference between the pneumoperitoneum and the post-anesthesia pneumoperitoneum was that I was able to obtain the patient’s cooperation without the pressure of having to succeed, and I was able to enter and exit freely. In contrast, post-anesthesia pneumoperitoneum is done at the umbilical port, and lifting the patient’s abdominal wall can be accomplished successfully, provided there are no adhesions around the umbilicus. If the initial pneumoperitoneum is done in advance, it is much safer and easier to further refine the pneumoperitoneum after anesthesia. As if by fate, another pneumoperitoneum was successfully completed, but admission to the operating room was still a long way off and had to wait. The patient was lying flat on the bed, unable to go down, and the only way to urinate was to insert a catheter, but it was a good thing that these were clearly explained to the patient’s family in advance, and they cooperated actively without complaint. On the basis of the initial pneumoperitoneum, a 5mm diameter inflatable Trocar was inserted in the subumbilical non-adherent area, and a working pneumoperitoneum was established smoothly, followed by a 10mm diameter Trocar puncture at the left side of the umbilical level as far as possible and introduction of the laparoscope. The safe and successful completion of these tasks without the slightest concern for intra-abdominal organ puncture injuries was attributed to the preoperative virtual laparoscopic examination. The laparoscopy revealed a distribution of adhesions that was unchanged from the preoperative findings. The subumbilical maneuvering hole, although obstructed by the anterior abdominal wall septal-like intestinal collaterals that prevent the laparoscopic view, does not prevent the insertion of instruments from reaching the left lower abdominal region through the gap at the base of the hanging intestinal collaterals, below the septal-like adhesions, for direct visualization. In this way, by creating an operating hole in the left lower abdomen, surgical operations in the left lower abdomen and pelvis can be performed smoothly. It was a lucky arrangement from God that I didn’t have to worry about the space constraint and the inability to interfere with each other’s instruments. When the left lower abdomen and pelvic adhesions were released, a new operating hole could be safely established in the middle region of the lower abdomen above the pubic bone, and in concert with the operating hole in the left lower abdomen, the adhesions of the intestines and omentum of the middle and lower abdominal walls were safely and smoothly completed. With the sequential release of the abdominal wall adhesions, the umbilical region can be safely used as a laparoscopic viewing hole. The subsequent release of adhesions in the upper and middle abdomen was also solved. The patient’s abdominal adhesions were indeed complex, not only extensive abdominal wall adhesions, but also inter-intestinal collateral adhesions and inter-tie adhesions, but fortunately the boundaries of the adhesions were clear. After more than three hours, the operation was finally completed when it crossed the moment of April Fool’s Day. After a short post-operative rehabilitation, the patient’s digestive tract function has been fully restored without any complications, looking forward to a new life, happy every day I do not know how to describe. It turned out that a surgery that was difficult to do in any way, I was happy to overcome the technical difficulties with new ideas and complete it successfully. Figure 1: The patient’s original abdominal incision scar and the puncture port of laparoscopic intestinal adhesion release Figure 2: Distribution of abdominal wall adhesions shown in coronal position on pneumoperitoneography CT scan Figure 3 The status of mid-abdominal adhesions shown by virtual laparoscopy Figure 4: Virtual laparoscopy from the right side showing longitudinal septal wall-like adhesions of the abdominal wall left of the midline Figure 5 Virtual laparoscopy from the left side showing septal wall-like adhesions of the abdominal wall left of the midline Figure 6 The left lower abdominal operating hole and The umbilical operating hole, a match made in heaven, allows for the release of left lower abdominal and pelvic adhesions. Tough scar adhesions formed with the lateral abdominal wall