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 ❙ Which operations endometrioma. Now she has come to Why worry? 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

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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 adhesion-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

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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

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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, Baxter BioSurgery). It is FDA-approved for the reduction of adhesion reformation Severe adhesions between the intestines and omentum after laparoscopic adhesiolysis. In a to the uterus. randomized study, the authors found B that instillation of 4% icodextrin solution decreased adhesion formation and reformation after laparoscopic gynecologic surgery.15 Hyaluronic acid. Intergel (Lifecore, John- son & Johnson Gynecare) is a cross- linked HA with ferric ion. It effectively reduces the number, severity, and extent of adhesions after abdominal operation.16 However, the product was withdrawn from the market after several reports of Omental adhesions to the anterior abdominal wall. late-onset postoperative pain requiring FAST TRACK surgery. C A novel technique Sepracoat. This product (HAL-C Bio- resorbable Membrane, Genzyme Corp) is to combine is a modifi cation of Seprafi lm. It coats 2 streams of liquid serosal surfaces and is absorbed from polymer via catheter the peritoneal cavity within 7 days. Its to produce a solid mechanism of action includes the reduction of tissue desiccation. Preliminary polymer over the data show it to be effective in reducing target tissue postoperative adhesions.17 However, it did not receive FDA approval for clinical use, and was withdrawn from the Adhesion between the intestine (lower left hand corner) and the anterior abdominal wall. market in 1997. Hydrogel. A novel technique of substance delivery into the abdominal cavity is by and can potentially serve as a vehicle for combining 2 streams of liquid polymers, localized delivery of drugs. delivered via catheter to target tissue. In a randomized study, Mettler et When combined, the 2 streams produce a al18 evaluated 66 women who underwent solid polymer within minutes. Sprayable myomectomy with or without SprayGel hydrogel (SprayGel, Confl uent Surgical) application. Second-look laparoscopy can be easily applied at laparoscopy. The was performed in 40 women. Seven of solid polymer acts as an adhesion barrier 22 patients (31.8%) in the SprayGel

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group and 2 of 18 patients (11.1%) in nal hysterectomies and 1 case per 1,000 the control group remained free of adhe- vaginal hysterectomies (P<.001).4 We did sions. However, the power of this study is not encounter any small-bowel obstruc- small, and the authors did not break the tion among 303 cases of laparoscopic su- women into subgroups based on whether pracervical hysterectomy. they underwent surgery via laparoscopy Application of an adhesion-reduc- or laparotomy. In the United States, the ing substance to the vaginal vault or pivotal study of SprayGel was stopped cervical stump may prevent small-bowel prior to completion. obstruction. Most adhesions implicated A similar product is a sprayable self- in small-bowel obstruction involve the polymerizing gel called Adhibit (Angio- vaginal vault. Appropriate products in- tech). An unpublished study from Eu- clude Interceed, Preclude, Seprafi lm, or rope showed it to be promising. perhaps Adept. Fibrin sealant. Fibrin glue (Tissucol, Bax- ter) has been used as an adhesion-reduc- Fertility-promoting surgery ing substance, although clinical data on No adhesion-reducing substance has this application are scarce. This product proved to be effective in increasing the is not approved by the FDA. pregnancy rate after a fertility-promoting procedure such as reconstructive tubal surgery or surgery for endometriosis. Which operations are the biggest culprits? CASE Recommendations Myomectomy Myomectomy performed through a B.H., the patient described at the laparotomy incision usually causes ad- beginning of this article, should have hesions, so women who undergo this had her initial surgery performed by an operation are good candidates for adhe- experienced laparoscopist, with minimal sion-reducing substances. The rate of ad- coagulation, meticulous hemostasis, FAST TRACK hesion formation after abdominal myo- “layered” repair of the myomectomy No adhesion- mectomy is more than 90%—and it is incision using nonreactive sutures, and 70% by laparoscopy. liberal irrigation of the abdominal cavity. reducing substance Two helpful preventive strategies: At the conclusion of the operation, the can improve the • Use a laparoscopic approach when incision could have been covered with pregnancy rate after feasible, and Gore-Tex surgical membrane or Sepraﬁ lm fertility-promoting • apply a barrier, such as the Gore-Tex (or Interceed if there was no oozing) at ePTFE membrane, Seprafi lm, or, if least 1 cm beyond the incision. Instillation surgery the myomectomy incision is not ooz- of Adept might have been useful as well. ing, Interceed. Instillation of 1 L of The second operation also should 4% icodextrin may also be useful. have involved a laparoscopic route, which is associated with a lower rate of Hysterectomy adhesions and could have reduced her Most small-bowel obstruction follows risk of further bowel obstruction. ■ abdominal hysterectomy, although a con-

siderable period of time may pass before References the problem occurs. When it does, a gen- 1. Diamond MP. Incidence of postsurgical adhesions. In: eral surgeon usually manages the patient, diZerega G, ed. Peritoneal Surgery. New York: Spring- and the treating gynecologist is unaware er-Verlag; 2000:217–223. 2. Tulandi T, Al-Shahrani A. Adhesion prevention in of this serious complication. gynecologic surgery. Curr Opin Obstet Gynecol. We recently found an incidence of 2005;17:395–398. adhesion-related small-bowel obstruc- 3. Al-Took S, Platt R, Tulandi T. Adhesion-related small bowel obstruction after gynecologic operations. Am J tion of 14 cases per 1,000 total abdomi- Obstet Gynecol. 1999;180:313–315. CONTINUED

92 OBG MANAGEMENT • May 2007 SURGICAL COMMENT & TECHNIQUES CONTINUED CONTROVERSY CONTINUED FROM PAGE 70

4. Al-Sunaidi M, Tulandi T. Adhesion-related bowel ob- rely solely on this mobility to determine struction after hysterectomy for benign conditions. whether or not a trial of forceps or vacu- Obstet Gynecol. 2006;108:1162–1166. um is indicated. Because the basovertical 5. Tulandi T, Al-Jaroudi D. Non-closure of peritoneum: a reappraisal. Am J Obstet Gynecol. 2003;189:609– diameter of the fetal head can be elon- 612. gated, it is possible to palpate the leading 6. Tulandi T, Hum HS, Gelfand MM. Closure of lapa- edge of the skull below the ischial spines rotomy incisions with or without peritoneal suturing and second-look laparoscopy. Am J Obstet Gynecol. and still have an unengaged fetal head. 1988;158:536–537. This is exactly the circumstance in which 7. Ellis H. Medicolegal consequences of postoperative in- a vaginal examination will give false reas- tra-abdominal adhesions. J R Soc Med. 2001;94:331– 332. surance of the chance of success. In this 8. Franklin R, Haney A, Kettel L, et al. An expanded circumstance, although part of the skull polytetrafl uoroethylene barrier (Gore-Tex surgical is below the plane of the ischial spines, membrane) reduces post-myomectomy adhesion the widest diameter of the fetal head formation. Myomectomy Adhesion Multicenter Study Group. Fertil Steril. 1995;63:491–493. (usually the biparietal diameter) is still 9. Haney A, Hesla J, Hurst B, et al. Expanded polytetra- above the plane of the maternal pelvic fl uororethylene (Gore-Tex surgical membrane) is supe- brim, and the fetal head is unengaged. rior to oxidized regenerated cellulose (Interceed TC7) in preventing adhesions. Fertil Steril. 1995;63:1021– I would argue against moving ahead 1026. with a “trial of forceps in the OR” in cases 10. Diamond MP, and the Seprafi lm Adhesion Study with a “tight fi t.” As discussed in the article, Group. Reduction of adhesions after uterine myomectomy by Seprafi lm membrane (HAL-F): a blinded, pro- signifi cant molding implies stretching of spective, randomized, multicenter clinical study. Fertil the underlying soft tissue. In my opinion, Steril. 1996;66:904–910. proceeding with an operative vaginal de- 11. Vrijland WW, Tseng LN, Eijkman HJ, et al. Fewer intra- peritoneal adhesions with use of hyaluronic acid–car- livery in the case of a fetus with 3+ molding boxymethylcellulose membrane: a randomized clinical would be riskier than is justifi ed. Opera- trial. Ann Surg. 2002;235:193–199. tive vaginal delivery should be offered only 12. Sekiba K. The use of Interceed (TC7) absorbable ad- when it is almost certain to succeed. For hesion barrier to reduce postoperative adhesion reformation in infertility and endometriosis surgery. Obstet- that reason, I would also caution against rics and Gynecology Adhesion Prevention Committee. using a trial of forceps in cases where the Obstet Gynecol. 1992;79:518–522. outcome is uncertain. Cesarean section 13. Azziz R, and the Interceed (TC7) Adhesion Barrier Study Group II. Microsurgery alone or with Interceed may be the safest option in such cases. absorbable adhesion barrier for pelvic side wall adhe- I agree completely that liberal use of sion reformation. Surg Gynecol Obstet. 1993;77:135– 139. ultrasound to determine head position and 14. Nordic Adhesion Prevention Study Group. The effi ca- station (if possible) should be encouraged. cy of Interceed (TC7) for prevention of reformation of I recommend that any forceps deliv- postoperative adhesions on ovaries, fallopian tubes, and fi mbriae in microsurgical operations for fertility: a ery that is anything other than an outlet multicenter study. Fertil Steril. 1995;63:709–714. delivery take place in the operating room. 15. DiZerega GS, Verco SJ, Young P, et al. A randomized, In addition, I recommend always having controlled pilot study of the safety and effi cacy of 4% neonatal and anesthesia backup readily icodextrin solution in the reduction of adhesions following laparoscopic gynaecological surgery. Human available with any operative vaginal de- Reprod. 2002;17:1031–1038. livery attempt unless it is an emergency. 16. Hill-West JL, Dunn RC, Hubbell JA. Local release of fi - Finally, I agree that the correct appli- brinolytic agents for adhesion prevention. J Surg Res. 1995;59:759–763. cation of the forceps is essential. In fact, 17. Diamond MP. Reduction of de novo postsurgical ad- the most important part of the forceps hesions by intraoperative precoating with Sepracoat procedure is what happens before the (HAL-C) solution: a prospective, randomized, blinded, placebo-controlled multicenter study. The Sepracoat actual application of traction! If the cor- Adhesion Study Group. Fertil Steril. 1998;69:1067– rect indications have been followed, the 1074. patient has been properly assessed and 18. Mettler L, Audebert A, Lehmann-Willenbrock E, Schive-Peterhansl K, Jacobs VR. A randomized, prepared for the procedure, and if all an- prospective, controlled, multicenter clinical trial of cillary services are available, the traction a sprayable, site-specifi c adhesion barrier system effort is usually the least stressful part of in patients undergoing myomectomy. Fertil Steril. 2004;82;398–404. the delivery, since it is bound to succeed. ■

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