Surgical Techniques

SURGICAL TECHNIQUES ■ BY ALAN H. DECHERNEY, MD; WENDY Y. CHANG, MD; and CATHERINE M. MARIN, MD Preventing adhesions after abdominal myomectomy: Tools and techniques Without preventive strategies, adhesions develop in more than half of women who undergo this procedure. Here, a review of protective adjuvants. bdominal myomectomy is the preferred ticularly when peritubal involvement is pres- treatment in women with large or ent (FIGURES 1–3). Abdominopelvic adhesions A numerous intramural myomas, espe- also contribute to significant chronic pelvic cially in the setting of infertility, recurrent pain, bowel obstruction, and technical diffi- pregnancy loss, and preservation of future fer- culty in subsequent surgical or assisted-repro- tility.1,2 However, postoperative adhesions are duction procedures.5 Unfortunately, most distressingly common following this proce- attempts at adhesiolysis meet with less than dure, resulting in significant potential mor- complete success, since adhesions recur in bidity. Fortunately, a number of products can 55% to 100% of patients (FIGURE 4).6 Thus, reduce their occurrence. Proper surgical tech- preventing adhesions in the first place would niques and a thorough knowledge of these seem to be key to successful outcomes in products are invaluable in helping reduce the abdominal myomectomy. incidence of adhesions. This article reviews the evidence on vari- The association between adhesions and ous approaches and products. While the num- diminished fertility is well-established,3,4 par- ber of studies examining each adjuvant in the setting of abdominal myomectomy is limited, KEY POINTS the overall evidence supports the safety and efficacy of both liquid and barrier adjuvants. ■ To reduce the incidence of postoperative adhesions, follow basic Adhesions present a significant clinical principles of microsurgery: Minimize dilemma after abdominal myomectomy, occur- the number and extent of incisions, ring in 50% to 90% of patients.5,7 In 1 prospec- handle all tissue gently, strive for tive series of women undergoing second-look absolute hemostasis, and use small, nonreactive suture. ■ Dr. DeCherney is professor and Dr. Chang and Dr. Marin are ■ Despite limited data from prospective, clinical fellows, department of obstetrics and gynecology, randomized studies, both fluid and division of reproductive endocrinology and infertility, David barrier adjuvants have proved effective Geffen School of Medicine at the University of California, in reducing the incidence and extent Los Angeles. of adhesions after abdominal myomectomy. 18 OBG MANAGEMENT • June 2003 Preventing adhesions after abdominal myomectomy: Tools and techniques TABLE 1 laparoscopy (SLL) after myomectomy, adnexal Proposed causes adhesions were noted in 94% of patients with of adhesion formation posterior uterine incisions and in 56% of patients with only anterior or fundal incisions; Tissue hypoxia or ischemia Tissue desiccation adhesions between the uterus and omentum or 5 Intra-abdominal infection bowel occurred in 88% of all patients. Introduction of reactive foreign body In another study of early SLL following Presence of intraperitoneal blood abdominal myomectomy, 83% of patients Dissection of adhesions had adhesions between the surgical site and the bowel or omentum, and 65% had adhesions involving the adnexae.2 Removal of FIGURE 1 Peritubal adhesion large, bulky fibroids (with uterine mass exceeding 13 weeks’ gestational size) result- ed in higher adhesion scores than did small myomas. Again, the incidence and severity of adhesions also correlated with location of the uterine incision: Adnexal adhesions were more common after posterior uterine incisions (76%) than after anterior or fundal entries (45%).2 Causes of pelvic adhesions dhesion prevention requires an under- Astanding of risk factors and maneuvers that increase the likelihood of injury (see “Pathophysiology of adhesion formation” on page 27). A number of causes have been pro- Adhesion at distal end of the fallopian tube. Peritubal posed, most of them centering on tissue and involvement often leads to diminished fertility. peritoneal trauma (TABLE 1). Injury can arise from excessive or rough manipulation of tissue and peritoneal sur- FIGURE 2 Adherent structures faces or from common effects such as cut- ting, abrasion, and denudation (FIGURE 5). Tissue desiccation or manual blotting may lead to peritoneal desquamation and fibrin deposition. Exposure of surfaces to intraperitoneal blood in the setting of tissue hypoxia—virtu- ally unavoidable during abdominal myomectomy—disrupts normal fibrinolytic activity, resulting in stimulation of angiogenesis.8 Introduction of reactive foreign bodies such as talc powder, residual suture material, and even lint from laparotomy pads can favor Postoperative adhesion between fallopian tube and adhesion formation. These serve as substrates the uterus. or niduses of fibrin deposition. CONTINUED 20 OBG MANAGEMENT • June 2003 TABLE 2 Pharmacologic agents studied for adhesion prevention in reproductive surgery AGENT THEORETICAL EXAMPLES MODE OF USE/ RISKS/PROBLEMS ACTION APPLICATION Antibiotics Prevent infection or Cephalosporins Intraperitoneal Theoretical reaction to inflammation Tetracyclines irrigation with antibiotic antibiotic fluid Hydrotubation fluid with antibiotic Anticoagulants Clot prevention Heparin In conjunction with Risk of postoperative Fibrin prevention Interceed bleeding Anti-inflammatory Decrease Nonsteroidal anti- Awaiting further Theoretical reaction agents permeability and inflammatory drugs investigation to agent histamine release Corticosteroids Crystalloid Hydroflotation Normal saline Intra-abdominal Possible volume solutions effect, decrease Ringer’s lactate instillation overload from surface contact intravascular absorption between pelvic organs Fibrinolytic Fibrinolysis Streptokinase Awaiting further Theoretical risk of agents Plasminogen Trypsin investigation postoperative bleeding activation Fibrinolysin Steroids Decrease Dexamethasone Systemic and/ or Possible suppression of inflammatory intraperitoneal hypothalamic- response pituitary axis Polysaccharide "Siliconizing" effect Dextran 70 (Hyskon) 200 mL placed in Abdominal bloating, polymer to coat raw surfaces posterior cul-de-sac or anaphylaxis, pleural coating surgical site effusion, liver function surfaces abnormalities, wound separation, rare diffuse intravascular coagulation Other fluid and Peritoneal surface Absorbable and See Table 3 See Table 3 barrier agents* separation nonabsorbable Hydroflotation barriers (see Table 3) *Adjuvants studied in the setting of abdominal myomectomy Techniques that may terior incisions and the uterotubal junction help prevent adhesions whenever possible. ased on findings from studies of second- Interestingly, reapproximation of peri- Blook procedures, most physicians advo- toneal defects after reproductive surgery (and, cate avoiding posterior uterine incisions, as probably, myomectomy) does not appear to well as minimizing the number and extent help prevent adhesions. Tulandi and col- of incisions, to help reduce the likelihood of leagues10 examined the clinical and SLL adhesion formation. Further, many outcomes of peritoneal closure in patients Ob/Gyns favor removing myomas through undergoing Pfannenstiel incisions with or as few uterine incisions as possible.9 We without peritoneal closure at the end of select anterior hysterotomy sites that enable the procedure. There was no difference in removal of multiple fibroids, avoiding pos- postoperative complications or wound heal- 26 OBG MANAGEMENT • June 2003 Preventing adhesions after abdominal myomectomy: Tools and techniques Meticulous hemostasis. Examine all myomectomy sites to ensure adequate hemostasis prior to closure. EVIDENCE FOR ADHESION Continuous irrigation to prevent tissue REDUCTION desiccation. We favor continuous saline irri- Some evidence that gation throughout the procedure. We also use hydrotubation with only moistened laparotomy sponges and antibiotic solution may be of benefit after tubal surgery pads, and avoid applying dry gauze to any tissue surface. Controversial/ unproven Avoidance of foreign-body introduction. We use only talc-free gloves and remove all Unproven residual suture fragments and tissue debris before closure. We also perform copious saline Unproven suction-irrigation at the end of the procedure Animal studies suggest to remove as much residue as possible. increased adhesion formation Use of fine, nonreactive suture. Rapid absorption (24-48 h) makes We favor adhesion benefit unlikely fine, resorbable sutures that incite as little tis- Unproven sue reactivity as possible. For closure of large myomectomy defects, we use braided multi- filaments such as Vicryl (polyglactine 910) Unproven (Ethicon, Somerville, NJ) or Dexon (polygly- colic acid) (Davis and Geck, Danbury, Conn) for strength and ease of handling. These Controversial sutures are absorbed through simple hydroly- Studies with conflicting results after reproductive sis and stimulate less tissue reactivity than do surgery; unlikely to be of chromic or catgut sutures. significant benefit Lacks FDA approval for The idea is appealing, but a randomized, adhesion prevention; blinded comparison of “good” and “bad” now rarely used microsurgical technique is unlikely, since no See Table 3 one would wish to perform “bad” technique. With barrier adjuvants, optimal benefit is obtained when the physician can predict ing in the 2 groups. At the time of SLL, there potential sites of adhesions.

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