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Postoperative Adhesions in Gynecologic Surgery: a Committee Opinion

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Postoperative Adhesions in Gynecologic Surgery: a Committee Opinion ASRM PAGES Postoperative adhesions in gynecologic surgery: a committee opinion Practice Committee of the American Society for Reproductive Medicine in collaboration with the Society of Reproductive Surgeons American Society for Reproductive Medicine, Birmingham, Alabama Postoperative adhesions are a natural consequence of surgical tissue trauma and healing and may result in infertility, pain, and bowel obstruction. Adherence to microsurgical principles and minimally invasive surgery may help to decrease postoperative adhesions. Some surgical barriers have been demonstrated to be effective for reducing postoperative adhesions, but there is no substantial evidence that their use improves fertility, decreases pain, or reduces the incidence of postoperative bowel obstruction. This document replaces the document, ‘‘Pathogenesis, consequences, and control of peritoneal adhesions in gynecologic surgery: a committee opinion,’’ last pub- lished in 2013. (Fertil SterilÒ 2019;112:458–63. Ó2019 by American Society for Reproductive Medicine.) Discuss: You can discuss this article with its authors and other readers at https://www.fertstertdialog.com/users/16110-fertility- and-sterility/posts/50136-28463 INTRODUCTION Health Service hospitals and helped to dian women admitted to the hospital fi Postoperative adhesions are a natural de ne the epidemiology and impact of with a diagnosis of small-bowel consequence of surgical tissue trauma postoperative adhesions (1, 2). Overall, obstruction after gynecologic proced- and healing. Peritoneal adhesions may approximately one third of patients ures found that hysterectomy was a sig- fi result in infertility, pain, or bowel who underwent open abdominal or ni cant cause of adhesion-related obstruction and may increase the tech- pelvic surgery were readmitted an small-bowel obstruction and that lapa- nical difficulty of subsequent abdom- average of 2 times over the subsequent roscopic supracervical hysterectomy inal or pelvic surgery. The purpose 10 years for conditions directly or was associated with a lower risk of this document is to review the possibly related to adhesions or for compared with abdominal hysterec- epidemiology, pathogenesis, and clin- further surgery that could be tomy (4). In two studies, the incidence ical consequences of adhesion forma- complicated by adhesions. More than of small-bowel obstruction after tion and to summarize available 20% of all such readmissions occurred abdominal hysterectomy ranged be- fi evidence regarding the effectiveness during the rst year after the initial tween 13.6 and 16.3 per 1,000 proced- of various strategies for reducing post- surgery and 4.5% of readmissions were ures (4, 5). Postoperative adhesions operative adhesion formation. This for small-bowel obstruction (1, 2). increase operating times (6, 7) and the document will not cover intrauterine Among open gynecologic procedures, risk of bowel injury during subsequent adhesions. ovarian surgery had the highest rate surgery (8). Adhesions also have major of readmissions directly related to financial implications. In the United adhesions (7.5/100 initial operations) States, adhesion-related health care EPIDEMIOLOGY AND (2). In the Scottish experience, costs exceed $1 billion annually (9). IMPACT OF POSTOPERATIVE excepting laparoscopic sterilization ADHESIONS procedures, open and laparoscopic Studies conducted by the Surgical and gynecologic surgery was associated PATHOGENESIS Clinical Adhesions Research (SCAR) with comparable risk for adhesion- Adhesions are the consequence of Group have analyzed the records of related hospital readmission (3). tissue trauma that may result from surgical patients in Scottish National Another retrospective study of Cana- sharp, mechanical, or thermal injury; infection; radiation; ischemia; desicca- Received June 14, 2019; accepted June 17, 2019. tion; abrasion; or foreign-body reac- Correspondence: Practice Committee, American Society for Reproductive Medicine, 1209 Montgom- ery Highway, Birmingham, Alabama 35216 (E-mail: [email protected]). tion. Such trauma triggers a cascade of events that begins with the disrup- Fertility and Sterility® Vol. 112, No. 3, September 2019 0015-0282/$36.00 Copyright ©2019 American Society for Reproductive Medicine, Published by Elsevier Inc. tion of stromal mast cells, which re- https://doi.org/10.1016/j.fertnstert.2019.06.027 leases vasoactive substances such as 458 VOL. 112 NO. 3 / SEPTEMBER 2019 Fertility and Sterility® histamine and kinins that increase vascular permeability. direct visualization at surgery can accurately identify and Oxidative stress is the result of tissue hypoxia. Free oxygen quantify postoperative adhesions, though periumbilical adhe- and nitrogen radicals enhance the inflammatory response sions can be detected by ultrasonography (13, 14). that results in tissue injury (10). Fibrin deposits then form, containing exudates of cells, leukocytes, and macrophages (11). Healing occurs by a combination of fibrosis and meso- Infertility thelial regeneration (12). Unlike skin wounds, which heal Adhesions may affect fertility adversely by distorting adnexal from the edges, the repair of peritoneal defects occurs from anatomy and interfering with gamete and embryo transport. the underlying mesenchyme. As a result, both large and small The only study to assess adhesiolysis and infertility is a small peritoneal defects heal relatively quickly. Fibrinous exudates retrospective review. Among infertile women with otherwise fi form within 3 hours after injury. Most brinous exudates are unexplained infertility diagnosed with adnexal adhesions at fi transient and are broken down by brinolysis within 72 hours. laparoscopy, pregnancy rates after subsequent adhesiolysis fi Trauma-induced local suppression of peritoneal brinolysis by laparotomy were 32% at 12 months and 45% at 24 months fi fi leads to early brinous adhesions (Fig. 1). The invasion of - compared with 11% at 12 months and 16% at 24 months in broblasts and blood vessels soon follows, resulting in perma- women left untreated (15). In women followed for an average nent adhesions which can be vascular (Fig. 1). of 49 months after tubal surgery, term pregnancy rates were inversely correlated with adhesion scores at the time of the CONSEQUENCES OF ADHESION FORMATION surgical procedure, as assigned using the American Society fi The most important potential consequences of adhesion for- for Reproductive Medicine classi cation system for adnexal mation are infertility, bowel obstruction, abdominal/pelvic adhesions (16). pain, and injury to intra-abdominal structures at subsequent surgeries. The use of imaging such as the visceral slide test has been used to determine the presence of periumbilical adhe- Bowel Obstruction sions prior to laparoscopy. However, there is no reliable Adhesions are the most common cause of postoperative method for identifying adhesions preoperatively and only small-bowel obstruction (5). In a series of 552 patients with FIGURE 1 Postoperative adhesion formation. ASRM. Adhesions in gynecologic surgery. Fertil Steril 2019. VOL. 112 NO. 3 / SEPTEMBER 2019 459 ASRM PAGES bowel obstruction, intra-abdominal adhesions were judged may help to reduce risk for postoperative adhesion responsible in 74% of cases (17). formation. The incidence of postoperative infection, another risk factor for adhesion formation, is lower after Abdominal/Pelvic Pain laparoscopy than after laparotomy. Pneumoperitoneum has a tamponade effect that may help to facilitate hemostasis The relationship between adhesions and pelvic pain is un- during laparoscopy. However, as most commonly performed fi fi clear. Although nerve bers have been identi ed in pelvic ad- using standard insufflators, laparoscopy also can desiccate hesions, their prevalence is no greater in patients with pelvic the peritoneum and, thus, may increase the risk for pain than in those without pelvic pain (18). Moreover, there is adhesion formation (29). In animals, adhesion risk increases no relationship between the extent of adhesions and the with both time and insufflation pressure (30, 31). The use of severity of pain. It generally is accepted that adhesions may warmed humidified CO2 has been shown to decrease cause visceral pain by impairing organ mobility (19, 20).A adhesions in a human model (32). study of patients with chronic pelvic pain randomized to Regardless of the surgical approach selected, procedures laparotomy with adhesiolysis or laparotomy alone found such as myomectomy often result in adhesions. The preva- that adhesiolysis was effective only in those having dense lence of adhesions after open abdominal myomectomy is adhesions involving the bowel (21); however, the extent of greater than 90% but is still at least 70% after laparoscopic adhesion reformation after surgery in these individuals myomectomy (33–35). Of note, the size and number of is unknown. It is unclear whether greater reduction in fibroids in these reports were not equivalent, thus limiting adhesions after surgery would reduce pain further. A the ability to compare these results directly. randomized, controlled, multicenter trial observed that Whether parietal peritoneal closure is necessary or advis- laparoscopic lysis of mild abdominal adhesions relieved able remains controversial (36–39). Evidence suggests that abdominal or pelvic pain, but to no greater extent than the incidence of adhesions at the site of closure after sham surgery (22). Clearly, the impact that lysis of bowel or laparotomy is approximately 22% with peritoneal closure adnexal
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