Surgical Techniques Laparoscopic adhesiolysis

Adhesions affect the quality of life of more than half of all women who undergo pelvic surgery and are common sequelae of endometriosis and infectious processes. Laparoscopic resection—done with the proper technique—offers a safe, efficacious treatment option.

By lthough more than 50% of all women infiltrate the fibrin bridges, causing adhe- STEPHEN Awho undergo pelvic or abdominal sur- sions to become more solid. M. COHEN, gery will develop adhesions, the condition Consider the presence of adhesions in MD garners limited attention in the literature and patients who present with pelvic pain or from physicians. And, yet, the problems— infertility, especially if they have had prior infertility, chronic pelvic pain, and bowel pelvic or abdominal surgery. obstruction, to name a few—with which Salpingitis following chlamydia or gonor- patients present to Ob/Gyns every day often rhea is another common etiology of pelvic can be attributed to pelvic adhesions. In short, adhesions. The spread of the infection the quality of life of a significant number of through the fallopian tubes and into the women is affected by this condition, warrant- peritoneal cavity sets the stage for the con- ing a detailed look at the laparoscopic tech- dition, as do ulcerative colitis, appendicitis, nique of adhesiolysis. and diverticulitis. Endometriosis is one of the most common Assessing etiology etiologies because peritoneal lesions activate a Any injury to the peritoneum has the chronic extensive inflammatory process, lead- potential to cause a pelvic adhesion, includ- ing to dense adhesions. In fact, endometriosis- ing endometriosis, pelvic inflammatory dis- related adhesions are so common that the ease (PID), infection with a sexually trans- American Society for Reproductive Medicine mitted disease, bleeding, and prior surgery. (ASRM) assigns more points to adhesions for When the peritoneum is injured, the superfi- the staging of endometriosis than it does to cial mesothelial cells are disrupted allowing the disease itself.1-2 leakage of fibrinogen and cells into the pelvic cavity. Fibrinogen is then converted to Making the diagnosis fibrin, which covers all injured surfaces. After reviewing the patient’s medical histo- When excess fibrin is present, it binds one ry, perform a physical exam. In some patients, organ to another. During normal healing, an area of tenderness may be encountered plasmin (which is formed from plasminogen) when one palpates a prior incision, indicating breaks down these fibrin bridges. But when that a loop of bowel may be adhered to this plasmin production is inhibited, the bridges area. In addition, in women with adhesions, between organs remain intact. Within 7 to 10 the uterus often is fixed either to the posteri- days after the initial injury, mesothelial cells or pelvis or to the anterior abdominal wall, and the adnexa may be thickened and fixed Dr. Cohen is associate clinical professor of obstet- to the uterus or pelvic sidewall. On rectal rics and gynecology and director of the Center for exam, the anterior wall of the rectum may be Women’s Minimal Access Surgery at Columbia adhered to the uterus, or the rectum may be University in New York City. pulled to one side of the pelvis. Radiologic continued on page 31

26 OBG MANAGEMENT • MAY 2002 Figure 1 Figure 2

Carefully inspect the pelvic cavity after placing the Grasp the adhesion from the side contralateral to trocars. In this case, the woman was found to where you plan to make the first cut. Use laparo- have adhesions on the left ovary. scopic scissors to divide and remove the tissue.

Figure 3 Figure 4

After completing adhesiolysis on the left ovary, Begin by excising superficial adhesions. This check the contralateral organ. In this case, adhe- ensures unimpeded access to deeper adhesions sions were found on the distal right tube and ovary. in case bleeding occurs.

Figure 5 Figure 6

After all adhesions have been resected and Just prior to closure, place oxidized regenerated removed, stop all bleeding and lavishly irrigate cellulose (ORC) around both ovaries to help pre-

Images courtesy of Stephen Cohen, Stephen of courtesy Images MD. the pelvis with saline. vent recurrent adhesions.

MAY 2002 • OBG MANAGEMENT 27 Surgical Techniques

Patient selection

Indications. Consider for adhesiolysis any of the pain, adhesiolysis often leads to a patient with chronic pelvic pain for more reduction of symptoms.1-3 than 6 months or infertility for more than 1 Contraindications. An abdominal mass large year, after ruling out other potential etiolo- enough to preclude trocar insertion, bowel ob- gies. Patients who complain of localized struction, or diaphragmatic hernia are absolute pelvic pain are more likely to have adhe- contraindications. One caveat: While previous sions than those with diffuse symptoms. But bowel resection and adhesiolysis are not con- adhesions may be found even in women traindications to laparoscopy, both increase the with diffuse pain. Although this pathology risk of bowel perforation on trocar insertion. cannot always be incriminated as the cause Proceed with caution or consider laparotomy.

REFERENCES 1. Malik E, Berg C, Meyhofer-Malik A, et al. Subjective evaluation of the therapeutic value of laparoscopic adhesiolysis: a retrospective analysis. Surg Endosc. 2000;14(1):79-81. 2. Nezhat FR, Crystal RA, Nezhat CH, et al. Laparoscopic adhesiolysis and relief of chronic pelvic pain. JSLS. 2000;4(4):281-285. 3. Lavonius M, Gullichsen R, Laine S, et al. Laparoscopy for chronic pelvic pain. Surg Laparosc Endosc. 1999;9(10):42-44. studies, with the exception of the hysterosal- place the primary trocar in the left upper quad- pingogram, do not usually aid in the diagnosis rant. The reason: This region usually is spared of pelvic adhesions. from the formation of dense adhesions; there- fore, entry can be performed safely by placing Preparing the patient Stephen M. Cohen, MD the trocar in the midclavicular line After making the diagnosis just below the lowest rib. and determining that surgery From that position, examine is the optimal treatment (see the abdomen for bowel adhe- “Patient selection”), consider sions to the anterior abdominal the approach. With rare wall. If present, excise these exception, the procedure of adhesions prior to placing a tro- choice is laparoscopy and is car at the umbilical site. (It often the method I prefer for adhe- is unnecessary to move the cam- siolysis. Regardless of the route, Coagulate era to the umbilical port, as the prep the bowel either via an view with modern optical equip- extremely thick or enema or an oral solution, as it ment from the left upper quad- decreases distention, making the vascular adhesions rant is more than adequate.) operation safer and easier. In Further, surgery can be eased addition, evacuate the stomach with bipolar forceps by spacing the trocars as widely contents via an oral gastric tube. prior to division. apart as possible and placing them on the same side of the patient. Placing the trocars Entry techniques. An alternative to Correct trocar placement facili- direct trocar placement in high- tates any laparoscopic procedure, especially risk patients is to use the open trocar insertion when dense adhesions are present. First deter- technique. First, make an abdominal incision mine the insertion sites, then select the type of and then insert the trocar through it. While entry technique and the length of the trocars. some believe that this method reduces the risk Insertion sites. In most cases, the primary trocar of bowel perforation, the survey data from the is placed at the umbilicus. However, in a American Association of Gynecologic laparoscopy being performed for adhesions or Laparoscopists (AAGL) have not supported in patients who have had an umbilical hernia this theory.3 operation or a vertical abdominal incision, Trocar length. To determine the proper continued on page 32

MAY 2002 • OBG MANAGEMENT 31 Surgical Techniques

Tools for excision

Laparoscopic scissors. These are inexpensive, typically use 25 to 125 watts.) create no peripheral damage, give direct Carbon dioxide laser. This instrument allows sur- mechanical feedback, and are familiar to all geons to cut with hemostasis without coming physicians. No smoke or plume is created to into direct contact with the tissue. There are obstruct vision. However, because hemosta- an infinite number of settings, wavelengths, sis cannot be achieved with scissors, they and spot sizes available, making this method are inappropriate for vascular adhesions. In of resection extremely precise. However, the addition, they cannot be used in areas of the laser is costly, cumbersome, and produces a pelvis that can be seen but not reached. lot of smoke. Instead, opt for one of the cutting methods Ultrasonic energy. The ultrasonic blade and for- described here. ceps create hemostasis using vibrational ener- Electrosurgery. The efficiency of electro- gy to coagulate tissue. Pass the blade through surgery depends on the power, shape of the the tissue, slowly separating it while achiev- probe tip, and waveform. The higher the ing hemostasis. Or, use the forceps to resect power and the finer the tip, the faster the vascular adhesions, grasping and coagulating probe will resect the adhesion, thereby min- the tissue first and then using the scissors to imizing thermal damage. Pure cutting cur- divide the adhesion. rents also reduce thermal damage but pro- The advantages: minimal thermal spread, vide less hemostasis than blended or pure tissue-contact feedback, and essentially no coagulation currents. smoke. However, the disadvantages are that In general, the thickness, vascularity, and direct tissue contact is necessary, traction is water content of the adhesions will dictate vital, the coagulation process is slow, and the the equipment and settings used. (There are disposable equipment is expensive. no standard wattage settings, but surgeons —Stephen Cohen, MD

length, consider the thickness of the manipulation, including the Duval and patient’s abdominal wall and the distance Pennington forceps. Avoiding injury to the from the trocar to the adhesion. Trocars that bowel is paramount to the procedure, as are too long prevent the grasper jaws and trauma will cause more adhesions, worsen- scissors from opening, while those that are ing the patient’s condition. too short keep slipping back into the After grasping the adhesion, select a retroperitoneal space. method by which to divide and remove it. After all the trocars have been placed, care- This selection is based on the surgeon’s fully inspect the pelvic cavity because the experience, the location of the adhesions, peritoneum becomes more opaque as surgery and the organs involved. In most cases, progresses, obscuring anatomical definition. laparoscopic scissors are the instrument of choice. However, opt for electrosurgery Divide and conquer (unipolar and bipolar), carbon dioxide laser, To excise the adhesion, grasp it from the or ultrasonic energy (see “Tools for exci- side contralateral to where you plan to make sion”) when energy is needed as a secondary the first cut. Traction on both the organ and source of hemostasis. the adhesion is essential to establish the cor- Begin by excising superficial adhesions. rect tissue planes, which in turn ensures ade- This ensures unimpeded access to deeper quate and safe excision of the adhesion. adhesions in case bleeding occurs. In electro- Because the bowel is the organ commonly surgery, slowly pass the probe near the adhe- involved in the adhesive process, there are sion, allowing the electrons to arc from the many graspers available for atraumatic instrument tip to the tissue. Proceed with continued on page 37

32 OBG MANAGEMENT • MAY 2002 Surgical Techniques extreme care when using unipolar energy Key points near vital structures because electrons travel the path of least resistance. For example, if ■ Inspect the pelvic cavity prior to beginning there is an adhesion between a loop of bowel adhesiolysis because the peritoneum becomes and the uterus, always resect the adhesion more opaque as the surgery progresses, from the bowel first. The reason: If you obscuring anatomical definition. remove the adhesion from the uterus first, ■ Grasp adhesions from the side contralateral to electrons would flow toward the bowel while where you plan to make the first cut. you excise the adhesion from this organ. This is because it is the only path remaining for the ■ Divide superficial adhesions first to ensure electrons to egress, as you already have sev- unimpeded access to deeper ones in case ered the adhesion from the uterus. The end bleeding occurs. result: thermal damage to the bowel. ■ Coagulate thick or vascular adhesions with When extremely thick or vascular adhe- bipolar coagulation prior to division. sions are encountered, coagulate them prior ■ Cut adhesions at both ends and remove the to division as follows: First, achieve hemo- tissue rather than just dividing it. stasis using bipolar forceps. This instrument allows the precise application of energy to Available products that attempt to minimize the tissue because electrons flow from one this effect include oxidized regenerated cel- side of the forceps to the other, rather than lulose (ORC) (Interceed; Ethicon Inc, through the body as with unipolar electro- Somerville, NJ), hyaluronic acid with car- surgery. Apply the energy until the tissue is boxymethylcellulose (HAL-F) (Seprafilm; desiccated and the high resistance stops elec- Genzyme Biosurgery, Cambridge, Mass), and tron flow. Second, divide the tissue using expanded polytetrafluoroethylene (ePTFE) laparoscopic scissors. Bipolar electrosurgery (Gore-Tex; W.L. Gore & Assocs, Flagstaff, also should be used when coagulation is Ariz). However, these products can only be needed near vital structures such as great applied to small surface areas, and only ORC vessels, the bowel, bladder, and ureters. can easily be used laparoscopically. As a A new type of electrosurgical generator result, they have achieved limited success. seals vessel walls rather than coagulating Some additional progress has been made them (LigaSure; Valleylab, Boulder, Colo). with the recent FDA approval of hyaluronate This results in a much higher vessel burst gel (Intergel; Gynecare, a division of Ethicon strength than either unipolar or bipolar elec- Inc, Somerville, NJ), which coats the entire trosurgery, allowing the surgeon to close ves- peritoneal surface and all the intra-abdominal sels up to 7 mm in diameter prior to division organs.4 Surgeons instill 300 cc of the gel of the vascular adhesion. through a trocar into the abdominal cavity After all adhesions have been resected and just prior to closure, and the body complete- removed, stop all bleeding and lavishly irri- ly absorbs it over time. ■ gate the pelvis with saline prior to closure. If extensive adhesions have been resected from REFERENCES 1.Porpora MG, et al. Correlation between endometriosis and pelvic pain. J the rectal wall, assess this organ’s integrity by Am Assoc Gynecol Laparosc. 1999;6(4):429-434. 2.Buttram VC, et al. Pelvic Adhesions American Fertility Society. Fertil Steril. filling the pelvis with saline and placing air in 1998;49:6. the rectum with either a sigmoidoscope or 3. Levy BS, Hulka JF, Peterson HB, Phillips JM. Operative laparoscopy: American Association of Gynecologic Laparoscopists. 1993 30-cc Foley catheter. Membership Survey. J Am Assoc Gynecol Laparosc. 1994;1:301. 4. Johns DB, Keyport GM, Hoehler F, et al. Reduction of postsurgical adhe- sions with Intergel adhesion prevention solution: a multicenter study Preventing adhesion recurrence of safety and efficacy after conservative gynecologic surgery. Fertil Steril. 2001;76(3):595-604. Unfortunately, approximately 85% of patients who undergo surgery for pelvic The author reports no financial relationship with any adhesions will develop recurrent adhesions. companies whose products are mentioned in this article.

MAY 2002 • OBG MANAGEMENT 37