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Surgicaltechniques SURGICALTECHNIQUES Togas Tulandi, MD, MHCM Professor of Obstetrics and Gynecology, Milton Leong Chair in Reproductive Medicine, McGill University, Montreal, Quebec Mohammed Al-Sunaidi, MD Fellow in Reproductive Endocrinology and Infertility, McGill University, Montreal, Quebec The authors report no fi nancial relationships relevant to this article. Adhesions that form between the small bowel and abdominal wall ® Dowden Health Mediacan cause severe constrictions that obstruct the bowel. Bodell Scott Copyright © AvertingFor personal adhesions: use only Surgical techniques and tools IN THIS ARTICLE ❙ Adhesion barriers A laparoscopic approach, microsurgical principles, and instillates, and barriers or instillates can reduce adhesions and how they work Page 88 CASE Could bowel obstruction a given. Nevertheless, there are steps you have been prevented? can take to reduce the incidence of post- ❙ Adhesions through operative adhesions. In this article we de- the laparoscope B.H., 34, undergoes laparotomy for scribe surgical techniques, barriers, and removal of an 8-cm myoma and a left peritoneal instillates that can help. Page 91 ovarian cyst, which is found to be an endometrioma. Now she has come to Why worry? ❙ Which operations the emergency department complaining Intra-abdominal adhesions can cause are the biggest of abdominal distension, pain, vomiting, pain, infertility, and bowel obstruction, culprits? and an inability to defecate. Small-bowel and complicate future surgeries.1–3 Most Page 92 obstruction is diagnosed. Another lapa- studies suggest that more than 50% of rotomy reveals that the obstructed bowel women with adhesion-related small is adhered to the prior surgical incision. bowel obstruction have a history of gy- Could this scenario have been avoided? necologic or obstetric operations. With- in 1 year of laparotomy, adhesions cause Adhesions need no introduction. Every intestinal obstruction in 1% of patients. surgeon is familiar with them; they are After even a single previous abdomi- so ubiquitous they sometimes seem to be nal operation, 93% of patients develop 86 OBG MANAGEMENT • May 2007 For mass reproduction, content licensing and permissions contact Dowden Health Media. adhesions, compared with only 10.4% TABLE 1 of patients who have never undergone 1–3 Surgical principles to reduce laparotomy (FIGURE 1, page 91). adhesion formation We recently found an incidence of ad- hesion-related intestinal obstruction after Take a laparoscopic approach when feasible operation for a benign gynecologic indi- Minimize tissue necrosis cation of 8 cases per 1,000 operations.4 Provide meticulous hemostasis Total abdominal hysterectomy (TAH) was the most common cause of small Liberally irrigate the abdominal cavity bowel obstruction (13.6 cases per 1,000 Use nonreactive suture materials surgeries). When performing laparotomy • Avoid contamination with glove powder, lint, or other foreign bodies Surgical technique • Do not suture the peritoneum Basic strategies Tissue desiccation, necrosis, and the use of reactive suture material can predispose mended that “peritoneal defects and the the patient to adhesion formation. Many pelvic fl oor should be left open, since studies in animal models have demon- they rapidly reperitonealized.” strated an association between adhesions and these parameters. The following Laparoscopy is more protective practices can help: than open surgery • Continuously irrigate the operative Abdominal surgeries injure tissues more fi eld during laparotomy severely than laparoscopy, and are asso- • Use nonreactive suture material such ciated with a greater degree of adhesion as polyglycolic acid (Dexon), poly- formation in up to 94% of patients, al- glactin (Vicryl), or polydioxanone though laparoscopy can also cause adhe- (PDS). Using reactive material, such sions.2 Laparoscopy is more protective as catgut, is discouraged because it involves minimal handling FAST TRACK • Use powder-free gloves and prevent of tissue and little manipulation of the To reduce foreign-body infi ltration (eg, powder, internal organs. Surgery is performed gauze, lint) of the wound. in a closed environment, tissue moist- the likelihood No single parameter is as important ness is maintained, and contamination of adhesions, as good surgical technique, attention to with glove powders or lint does not oc- do not suture microsurgical principles, and precise he- cur. In addition, the tamponade effect the peritoneum mostasis (TABLE 1). of carbon dioxide pneumoperitoneum facilitates hemostasis. Laparoscopy is after abdominal Peritoneal closure is unnecessary also associated with a lower incidence operations Several randomized trials have demon- of infection. strated that closure of the parietal or visceral peritoneum is unnecessary. This practice is associated with slightly lon- Adhesion-reducing ger operating times and greater postop- substances erative pain and may cause more adhe- Many adhesion-reducing products have sions.5 In 1 study, the rate of adhesion been evaluated in human and animal formation after laparotomy with perito- models. A basic assumption behind neal closure was 22.2%, compared with these substances is that surgically in- 16% without closure.6 jured tissues heal without forming ad- Ellis7 noted an increasing number of hesions if the traumatized surfaces in medicolegal claims arising from adhe- apposition are separated to allow each sion-related complications, and recom- to heal independently. CONTINUED www.obgmanagement.com May 2007 • OBG MANAGEMENT 87 SURGICAL TECHNIQUES CONTINUED TABLE 2 ePTFE. Gore-Tex surgical membrane, constructed of ePTFE (Preclude, WL The array of selected adhesion barriers and Gore), is nonabsorbable and produced peritoneal instillates, and how they work in thin sheets (0.1 mm), with an average PRODUCT SPECIAL FEATURES pore size of less than 1 μm. It is sutured to the tissue so that it overlaps the inci- Barriers sion by at least 1 cm. It prevents adhe- Expanded polytetrafl uoroethylene • Very effective sion formation—and reformation—in- (Preclude [Gore-Tex surgical • Nonreactive dependent of the type of injury. It is also membrane]) • Nondegradable effective in the presence of blood. • Requires fi xation to the tissue In a randomized trial, ePTFE de- • Diffi cult to apply by laparoscopy creased postmyomectomy and pelvic • Unpopular sidewall adhesions.8,9 In our experience, Hyaluronic acid and • Blood-insensitive this is the most effective adhesion-reduc- carboxymethylcellulose (Seprafi lm) • Brittle and sticky ing substance available. It is not widely • Diffi cult to use by laparoscopy used, however, because it is nonabsorb- Oxidized regenerated cellulose • The most widely studied material able and has to be fi xed to the tissue. (Interceed [TC7]) • Easy to handle Combined hyaluronic acid (HA) and • Blood-sensitive carboxymethylcellulose (CMC). Known Instillates most widely by its trade name, Sepra- fi lm (Genzyme Corp), this bioresorbable 4% icodextrin (Adept) • Requires high volume (1 L) product is composed of sodium HA and • Decreases adhesion formation and CMC, a combination that produces a reformation after laparoscopic transparent and absorbable membrane gynecologic surgery that lasts for 7 days after application.10,11 Hyaluronic acid and ferric ion • Effective In a study of 259 patients undergo- (InterGel) • Withdrawn from market ing laparotomy for bowel resection or HAL-C bioresorbable membrane • Absorbed within 7 days enterolysis, the incidence of repeat bow- (Sepracoat) • Reduces tissue desiccation el obstruction was similar in the group Hydrogel (SprayGel) • Two polymers must be combined treated with Seprafi lm and the histori- 11 to form membrane • Sprayable cal control group. However, 9 of 12 • Easy to use at laparoscopy bowel obstructions in the treated group • Pivotal study stopped prior to resolved without surgery, compared completion with 5 of 12 in the control group. The enterolysis rate in the treated group was Hydrogel (Adhibit) • Not available in the US 1.5%, compared with 3.9% in the con- Fibrin sealant (Tissucol) • Scarce data trol group. Because of its stickiness, Seprafi lm is not ideal for laparoscopy. However, it The ideal substance is resorbable, can be rolled and passed through the tro- adherent to the traumatized surface, ap- car, with the fi lm separated from its paper plicable through the laparoscope, and in- backing inside the abdominal cavity. expensive, with high biocompatibility. So Oxidized regenerated cellulose. Known far, no substance or material has proved under the brand name Interceed (TC7), to be unequivocally effective. this absorbable adhesion barrier (John- son & Johnson) is the most widely Adhesion barriers are widely studied studied product available today. Sev- The following products are among the eral randomized trials have shown that most widely investigated substances it reduces postoperative formation of (TABLE 2). adhesions on the pelvic sidewalls and Expanded polytetrafl uoroethylene, or near the adnexa.12–14 CONTINUED 88 OBG MANAGEMENT • May 2007 SURGICAL TECHNIQUES CONTINUED The effi cacy of Interceed is reduced FIGURE 1 in the presence of blood. It is the easiest Adhesions adhesion barrier to use at laparoscopy. through the laparoscope Newer agents in development include CMC and polyethylene oxide (PEO) A composite gel (Oxiplex/AP, FrizoMed) and polylactide (PLa): copolymer of 70:30 Poly (l-lactide-co-d,l-lactide) fi lm (SurgiWrap, Mast Biosurgery). Peritoneal instillates The newest peritoneal instillate is 4% icodextrin solution (Adept,
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