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Prevention of Adhesion in Laparoscopic Gynaecological Surgery

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Prevention of Adhesion in Laparoscopic Gynaecological Surgery International Journal of Reproduction, Contraception, Obstetrics and Gynecology Patel S et al. Int J Reprod Contracept Obstet Gynecol. 2016 Dec;5(12):4099-4105 www.ijrcog.org pISSN 2320-1770 | eISSN 2320-1789 DOI: http://dx.doi.org/10.18203/2320-1770.ijrcog20164311 Review Article Prevention of adhesion in laparoscopic gynaecological surgery Shweta Patel*, Amita Yadav Department of Obstetrics and Gynaecology, M.L.N Medical College, Allahabad, Uttar Pradesh, India Received: 20 September 2016 Accepted: 18 October 2016 *Correspondence: Dr. Shweta Patel, E-mail: [email protected] Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. ABSTRACT Adhesions have important consequences for patients, surgeons, and health services. Peritoneal tissue injury can be prevented by using careful surgical techniques. A large number of anti-adhesion products have been used experimentally and clinically to prevent postoperative adhesions. The current author reviewed the surgical literature published about epidemiology, pathogenesis, and various prevention strategies of adhesion formation. Several preventive agents against postoperative peritoneal adhesions have been investigated. Bioresorbable membranes are site-specific anti adhesion products but may be more difficult to use laparoscopically. Liquids and gels have the advantage of more-widespread areas of action and increased ease of use, particularly during laparoscopic operations. Effective pharmacologic agents that can reduce release of pro-inflammatory cytokines or activate peritoneal fibrinolysis are under development. Their results are encouraging but most of them are contradictory. Many modalities are being studied to reduce this risk; despite initial promising results of different measures in postoperative adhesion prevention, none of them have become standard applications. With the current state of knowledge, preclinical or clinical studies are still necessary to evaluate the effectiveness of the several proposed prevention strategies for avoiding postoperative peritoneal adhesions. Keywords: Adnexal adhesions, Adhesion prevention, Laparoscopy, Oxiplex/AP gel, Viscoelastic gel INTRODUCTION both the health care system and the surgeons who are faced daily with the treatment of adhesion-related In abdominal and pelvic surgery, adhesion formation complications. Investigations into the molecular causes of regarded as the most common postsurgical complication adhesion formation have produced new concepts of occurring after 60-90% of procedures.1 In the majority of adhesion prevention. patients, adhesions occur as a result of an injury to the lining membranes of the cavities. Peritoneal injury New anti-adhesion agents have been developed and usually occurs as a result of surgery, peritonitis, or a existing agents have been evaluated randomised combination of the two events. Pelvic and abdominal controlled trials or systematic reviews to validate adhesions have been associated with significant previous data in procedures associated with adhesion morbidity, including infertility, chronic pelvic pain, formation, surgeons should always inform their patients small-bowel obstruction, and difficulty with surgical about the risk of adhesion-related complications. Not access or surgical complications in the future. Adhesions only as a precaution against negligence suits but also first result also in a large surgical workload and cost to health and foremost to provide best possible care to our patients, care systems. we need to be fully aware now of the extent of the problem and adopt anti-adhesion strategies in our daily The Surgical and Clinical Adhesions Research studies routine. (SCAR studies) demonstrated that adhesions are an important issue for the patients and a mounting burden on December 2016 · Volume 5 · Issue 12 Page 4099 Patel S et al. Int J Reprod Contracept Obstet Gynecol. 2016 Dec;5(12):4099-4105 Cofactors contributing to adhesion formation with an antioxidant system known as ROS scavengers. Recent data also point to a role for ROS in adhesion Ischemia formation, because the administration of ROS scavengers has decreased adhesion formation in several animal Ischemia has been proposed as the most important insult models. ROS activity increases during both laparotomy that leads to adhesion development. It has been and laparoscopy. demonstrated that fibroblasts in adhesion tissues have a different phenotype (myofibroblasts) than do the normal Tissue drying during surgery peritoneal tissue fibroblasts. More importantly, it has been shown that conversion of these cells from the This increases adhesions formation; intentional drying of normal phenotype to the adhesion phenotype can be the tissues, is an otherwise desirable procedure to aid the induced by hypoxia.2 Compared with peritoneal surgeon’s view of the area but increases the risk of fibroblasts, adhesion fibroblasts have a significant adhesion formation. Laparotomy is more likely to increase in basal mRNA levels of collagen I, fibronectin, produce adhesions than laparoscopy.9,10 matrix metalloproteinase- 1 (MMP-1), tissue inhibitor of metalloproteinase-1 (TIMP-1), transforming growth Types of intra peritoneal adhesions factor (TGF)-b1, cyclooxygenase- 2 (COX-2), and interleukin (IL)-10.2 Tissue plasminogen activator (tPA) Two types of adhesion formation are recognized and have and PAI-1 are intracellular enzymes found in the been classified are de novo adhesions (type 1) and peritoneal mesenchymal cells. These are involved in the reformed adhesions (type 2). intrinsic protective fibrinolytic activity of fibroblasts. The tPA/PAI-1 ratio has been shown to be 80% higher in METHODS normal peritoneal fibroblasts than in adhesion fibroblasts. Under hypoxic conditions, this ratio significantly A literature search was performed using Google, yahoo. decreases in normal and adhesion fibroblasts.13 MMPs Highwire press. The following search term was used: and TIMPs are crucial proteolytic enzymes in the Laparoscopy, viscoelastic gel, adnexal adhesions, extracellular matrix remodeling process of healing. adhesion prevention, Oxiplex/AP Gel. Articles were Hypoxia has been shown to inhibit MMP-1 and MMP-9 included in the review if the title indicated any relevance and augment TIMP-1 expression. This decrease in the to the topic. Statements in the articles were scrutinised by MMP/TIMP-1 ratio during hypoxia may favour an searching the corresponding articles listed in the increase in extracellular matrix production, and a references sections. The reference lists were also decrease in turnover and degradation that may lead to searched for relevant literature. tissue fibrosis and adhesion development. COX-2 has been shown to have an important role in the regulation of DISCUSSION inflammation and angiogenesis. In adhesion fibroblasts, the expression of COX-2 is significantly increased, Adhesion formation is a complex process influenced by compared with that of normal fibroblasts. COX-2 various factors and resulting in an abnormal deposition of inhibitors, such as celecoxib, tenoxicam, have been fibrin. After trauma to the peritoneum, fibrin deposition reported to reduce postoperative adhesions through their occurs immediately, which is a normal process in antiangiogenic, antiinflammatory, and antioxidant effects 3,4 peritoneal healing. Usually, there is a balance between in animal studies. fibrin deposition and fibrinolysis so that fibrin is degraded within a few days. However, if this process is Pneumoperitoneum impaired in favour of fibrin deposition, fibrin strands occur and stable adhesions are subsequently formed. This is a cofactor in adhesion formation, because There are numerous cytokines which influence adhesion adhesions have been shown in animal models to increase formation both directly via the fibrinolytic system and by with the duration of the pneumoperitoneum and with changing the peritoneal fluid and, hence, the peritoneal 5,6 11 insufflation pressure. CO2 pneumoperitoneum induces healing environment. Further studies into the molecular adverse effects, such as hypercarbia, acidosis, mechanisms of adhesion formation are essential to the hypothermia, and desiccation and alters peritoneal fluid development of future pharmacological anti-adhesion 7,8 and the morphology of the mesothelial cells. agents. To date, a number of studies have demonstrated the efficacy of various pharmacological approaches to Pelvic inflammatory disease and endometriosis adhesion prevention in animals.12 In humans, however, none of the promising molecular approaches have led to It is recognized that pelvic inflammatory disease and an effective pharmacological anti-adhesion agent.13,14 endometriosis are additional potential causes of Further research into new uses of such pharmacological adhesions. Reactive oxygen species. Reactive oxygen agents in humans is awaited. In addition to this purely species (ROS) are produced in a hyperoxic environment pharmacological approach, other recent studies have and during the ischemia/reperfusion process. ROS revealed important co-factors which play a role in activity is injurious to cells, which protect themselves adhesion formation and could theoretically be targeted in International Journal of Reproduction, Contraception, Obstetrics and Gynecology Volume
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