The Mumbai Obstetric & Gynecological Society

The Mumbai Obstetric and Gynaecological Society www.mogsonline.org mogs

Article No. 3

Adhesion Prevention in Laparoscpy

Author   Reviewed by
Dr. Rohan Palshetkar   Dr. Sanket Pisat
Dr. Rohan Palshetkar   Dr. Sanket Pisat
MBBS, MS OBGY
9819732315 • rohanpalshetkar88@gmail.com
   

INTRODUCTION

Adhesions are one of the most common complications post surgery. Pelvic and abdominal adhesions have shown to cause infertility, chronic pelvic pain, bowel obstruction and difficulty with surgical access or complications in future surgeries. Hence it is of significant importance to reduce the adhesions at the time of surgery. It has been estimated that 55% to 100% of women undergoing pelvic surgery develop adhesions. Fortunately, the majority of patients with intra-abdominal adhesions are asymptomatic. As Gynaecologists, it is difficult to predict which patients are predisposed to symptomatic adhesion formation on the basis of the type of surgery performed and the patients’ underlying pathology

ADHESION FORMATION

Fibrin is deposited in the area of surgery. Fibrin is either resorbed or organises into fibrous adhesions. It is unclear why some patients experience resorption, while others have further formation of these adhesions. Two specific risk factors for organisation of fibrin into adhesions are identified: tissue injury and inflammatory response.

When tissue damage is associated with vascular insufficiency, adhesions form to prevent ischemic injury.  Following operations where tissues are crushed, sutured, or ligated, adhesions form in the area of injury to provide new blood supply to the devascularized tissue.

Contamination of the peritoneal cavity by foreign material and bacterial infection is associated with the formation of adhesions due to an inflammatory response. Averting bowel injury, preventing postoperative infections, and precluding the use of foreign materials are advocated to prevent inflammation but cannot always be achieved.

METHODS OF ADHESION PREVENTION

Meticulous surgical technique has been advocated in the prevention of adhesions. Every gynaecologist should avoid tissue trauma by handling tissue gently and prevent thermal injury. One should ensure meticulous homeostasis, avoid infection to prevent adhesions post operatively.

With every surgery, a certain amount of tissue injury inevitably occurs. With increasing number of surgeries there is an increased risk of adhesion formation.

Laparoscopic surgical procedures have been associated with fewer postoperative adhesions than open surgeries. Patients requiring a hysterectomy should be offered a vaginal or laparoscopic approach rather than an abdominal approach when feasible. Gynaecologists should perform surgeries through the least invasive route, taking into account individual characteristics of the patient, pathology and also their own surgical skills.

Adhesions are not always preventable despite meticulous surgical technique. Some conditions may increase the likelihood of forming adhesions, such as endometriosis or chronic pelvic inflammatory disease. Patients undergoing myomectomy are also at increased risk of adhesions, and in those women who are hoping to preserve fertility adhesions add an element of risk of interrupting tubal patency. When patients are at particular risk of postoperative adhesions, the use of adjuvant measures of adhesion prevention could be considered.

Oxidised Regenerated Cellulose (INTERCEED)

Interceed is an absorbable synthetic mechanical barrier made of oxidized regenerated cellulose. When placed over the desired region, a gel forms over the area and prevents adhesion formation. Interceed is cut according to use and can be used in laparotomy & laparoscopic surgeries. It is applied in a single layer between two adjacent tissues. There should be meticulous homeostasis before applying interceed. Interceed mixes with blood and increases fibrin deposition and may increase adhesion formation. Interceed is completely absorbed within two weeks.

There are numerous studies evaluating the use of Interceed versus no treatment. When compared with no treatment, Interceed was showed a reduced incidence of pelvic adhesion following laparotomy. Similar results were noted following laparoscopy, with reduction noted in new formation and in reformation of adhesions. There is no data on incidence of small bowel obstruction, chronic pelvic pain, or pregnancy rates.

Polytetrafluoroethylene (Gore-Tex)

Gore-Tex is a permanent, nonabsorbable membrane that is sutured into place. There may be surgical delays in laparoscopy as it takes longer to stabilise the barrier agent. It requires a second surgery for removal.

There is evidence to suggest that, compared with no treatment, Gore-Tex reduces the formation of new adhesions in patients undergoing a myomectomy. Gore-Tex has been reported to have less adhesion reformation than Interceed in women undergoing adhesiolysis. Results should be interpreted with caution, as it is unclear if the surgeon was unblinded at the time of second look laparoscopy. No evidence exists on the effect of Gore-Tex on chronic pelvic pain and pregnancy. There is no evidence on the incidence of small bowel obstruction.

Chemically modified sodium hyaluronate/ carboxymethylcellulose (Seprafilm)

Seprafilm is an absorbable synthetic membrane made up of two polysaccharides: sodium hyaluronate and carboxymethylcellulose. Seprafilm forms a gel over 24-48 hrs (absorbed within one week). A meta–analysis of 6 RCTs, Kumar et al. reported a significant reduction in the incidence, extent and severity of peritoneal adhesions in nongynaecological abdominal surgery with the use of Seprafilm. However, a comparable reduction in the incidence of intestinal obstruction necessitating surgery was not found.

A Cochrane Review reviewed 8 RCT’s which compared barrier agents vs women who received no intervention. There was no evidence of the effect of barrier agents on pain and fertility. Low quality evidence suggested barrier agents were more effective in preventing adhesions compared to the women with no intervention. No adverse events related to the barrier agents was reported. However it was noted that most of the studies were commercially funded and a possibility of publication bias.

Icodextrin, Adept®

Adept is a high molecular weight isoosmolar, alpha–1, 4–glucose polymer that is slowly absorbed from peritoneal cavity. Studies have revealed conflicting results. diZerega found no significant benefit in an initial small study whereas Brown et al.  revealed a beneficial effect with the use of Icodextrin when compared with Ringer Lactate solution. The use of Icodextrin reported significant reduction in de novo adhesions.

In a double blind RCT Trew et al. compared Icodextrin and Ringer lactate as an adhesion prevention agent following laparoscopic gynaecological surgery. Icodextrin was not associated with a reduction in the incidence of de novo adhesion formation. All three studies used different outcomes relating to adhesions and is impossible to perform a meaningful meta–analysis.

Polyethylene Glycol (PEG) based liquid precursors (SprayGel)

SprayGel applied to the target tissue produces a gel barrier within seconds. It is absorbed from the peritoneal cavity within 30 days. In a meta-analysis of three RCTs (n=113), Broek et al.  demonstrated reduction in adhesion formation with the use of PEG in fertility conserving surgery.

Crystalloids

A meta–analysis of 350 studies, limited by their use of retrospective data and statistical heterogeneity, failed to reveal reduction in adhesion formation with use of crystalloids.

Colloids

Dextran facilitates transudation of fluids into the peritoneal cavity. Four RCTs compared the effect of Dextran to crystalloid in adhesion prevention following pelvic surgery. Meta–analysis revealed no difference in the mean adhesion score or pregnancy rate with the use of Dextran. The large transudate is completely absorbed before healing has occurred. Reported complications include anaphylaxis, pleural effusion, and peritonitis.

CONCLUSION

Adhesions barriers need to be individualised according to each patient. Adhesion barriers are expensive and leads to increased surgical cost and increases the economic burden on the patient. We should consider the least invasive path when operating. Laparoscopic or vaginal approach is much better than abdominal approach for a patient undergoing a hysterectomy. While operating, tissue handling should be minimal and one should achieve meticulous homeostasis to prevent adhesion formation. Adhesion barriers should be used in patients who suffer from Endometriosis, Pelvic Inflammatory Disease and Patients undergoing myomectomy.

There need to be further studies regarding the use of adhesion barrier methods. Current studies show the efficacy against the formation of new adhesions, but newer studies must include pregnancy, pelvic pain and small bowel obstruction into account to give us a better overall picture.

SUGGESTED READING

  1. SOGC Clinical Practice Guideline - Adhesion prevention in Gynaecological Surgeries
  2. RCOG - The use of Adhesion Prevention Agents in Obstetrics & Gynaecology.
  3. Ahmad G, Duffy J, Farquhar C, Vail A, Vandekerckhove P, Watson A, et al. Barrier agents for adhesion  prevention after gynaecological surgery. Cochrane Database Syst Rev 2008;2:1–40.
  4. Ahmad G, O'Flynn H, Hindocha A, Watson A. Barrier agents for adhesion prevention after gynaecological surgery. Cochrane Database Syst Rev. 2015 Apr 30;(4):CD000475. doi: 10.1002/14651858.CD000475.pub3.
  5. Mettler L, Hucke J, Bojahr B, Tinneberg HR, Leyland N, Avelar R. A safety and efficacy study of a resorbable hydrogel for reduction of post–operative adhesions following myomectomy. Hum Reprod 2008;23:1093–100.

Top

Facebook   Twitter   Youtube   LinkedIn   Picasa

The Mumbai Obstetric & Gynecological Society

C-14, 1st Floor, Trade World, D-wing Entrance,
S. B. Marg, Kamala City, Lower Parel (W), Mumbai 400013.

Tel. : 022-24955324 / 24975035 • email: mogs2012@gmail.com

Today Visits
315

Month Visits
13351

Years Visits
144781