adhesion prevention

18.12.2016

1

Adhesion Prevention

Tevfik Yoldemir MD BBA MMktg

Marmara University, School of Medicine

Dept. of Obstetrics and Gynecology

Div. of Reproductive Endocrinology

and Infertility

[email protected]

Repair and

Adhesion

Formation

after

Surgical Trauma

of the

Peritoneum -1

Fertil Steril 2016;106:998–1010.

Repair and Adhesion Formation after

Surgical Trauma of the Peritoneum -2

Fertil Steril 2016;106:998–1010.



• Repair can be delayed by local factors such as a

decreased decreased fibrinolysisfibrinolysis, presence of, presence of necrotic tissue, necrotic tissue,

tissue ischemia, and oxidative stress secondarytissue ischemia, and oxidative stress secondary to to

vascular damage or sutures, and by infectionvascular damage or sutures, and by infection.

Fertil Steril 2016;106:998–1010.



• CO2 pneumoperitoneum causes superficial

mesothelial hypoxia

• The effect increases with the intraperitoneal

pressure and with duration of exposure

• Desiccation enhances adhesion formation, and the

effect increases with the severity of desiccation.

• Red blood cells and/or fibrin are strongly

adhesiogenic, probably by increasing (acute)

inflammation

Fertil Steril 2016;106:998–1010.

Prevention of Postoperative Adhesion

Formation -1

• Keep opposing lesions separated for five daysseparated for five days.

• Increase bowel motility.

• Decrease the duration and severity of local

inflammation at surgical lesion sites.

• Prevent mesothelial cell trauma and acute

inflammation of the entire peritoneal cavity.

– the addition of 10% of N2O to the CO2

pneumoperitoneum was equally effective as 100% N2O in

reducing pain during laparoscopy under local anesthesia

– In humans, the abdomen can be cooled to 30°C without

side effects and without affecting the core body

temperature Fertil Steril 2016;106:998–1010.

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Formation -2

• Blood and remaining fibrin should be removed from

the peritoneal cavity by means of lavage, because

blood, both red blood cells and plasma are highly

adhesiogenic.

• gentle tissue handling,

• precise hemostasis with minimal manipulation and

grasping,

• and a short duration of surgery

Fertil Steril 2016;106:998–1010.


Formation -3

• Meticulous lavage to remove blood and foreign

material is suggested with the use of a fluid such as

lactatedlactated RingerRinger solutionsolution.

• use of 300-500 ml of Ringers

• Barriers alone decrease postoperative adhesions by

40%–50% in humans.

Fertil Steril 2016;106:998–1010.

Microsurgical principles

1) delicate handlinghandling of tissues and judicious use of

electrical or laser energy;

2) frequent intraoperative irrigationirrigation of exposed tissues

with heparinized lactated Ringer solution at room

temperature (5,000 IU heparin per liter, to which we

also added 100 mg cortisone succinate) to prevent

desiccation of the peritoneum and decrease clotting of

blood in the peritoneal cavity;

3) prevention of foreign body contamination of the

peritoneal cavity: operating gloves thoroughly washed

to remove the talcum before the start of the

procedure Fertil Steril 2016;106:1025–31


the use of lint-free surgical pads which were soaked

in the heparinized Ringer solution before use;

4) Meticulous pinpoint hemostasishemostasis that minimizes

adjacent tissue damage: achieved with the use of a

microelectrode or a very fine bipolar forceps (the

microelectrodes are insulated, have a bare conical tip

of 100 mm, and can also be used for cutting without

touching the tissue);

5) identification and use of proper cleavage planes;

6) complete excision of abnormal tissues;

Fertil Steril 2016;106:1025–31


7) excision and removal of broad adhesions (shallow

adhesions are simply divided mechanically);

8) precise alignmentalignment and approximationand approximation of tissue

planes;

9) performing a thorough lavagelavage with the use of

heparinized Ringer solution at the end of the

procedure to remove any blood clots, foreign body,

or debris that may be present in the peritoneal

cavity;

Fertil Steril 2016;106:1025–31


10) leaving 300–500 mL Ringer solutionRinger solution, to which 500–

1,000 mg hydrocortisone succinate is added, in the

peritoneal cavity before total peritoneal closure

11) use of magnificationmagnification, as necessary: permitting

prompt identification of abnormal morphologic

changes, recognition and avoidance of surgical injury,

and application of the preceding principles with the

use of appropriate fine instruments and suture

materials. The whole procedure is performed with

the use of mechanical instruments assisted by

electrosurgery .Fertil Steril 2016;106:1025–31

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• To reduce inflammation, a 100-mg Voltaren

suppository is inserted before the patient is

anesthetized and after the surgery.

• In addition, the patient is administered one or two

doses of dexamethasone after surgery

• ligamentopexy, ovariopexy, or salpingopexy

Fertil Steril 2016;106:1025–31 Eur J of Obs & Gynecol and Reprod Bio 150 (2010) 111–118

Eur J of Obs & Gynecol and Reprod Bio 150 (2010) 111–118 Eur J of Obs & Gynecol and Reprod Bio 150 (2010) 111–118

Eur J of Obs & Gynecol and Reprod Bio 150 (2010) 111–118

Mechanical Barriers

The American Journal of Surgery (2011) 201, 111–121

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Fertil Steril 2008;89:1247–53 Fertil Steril 2008;89:1247–53

Reproductive BioMedicine Online (2010) 21, 290– 303 Reproductive BioMedicine Online (2010) 21, 290– 303

Reproductive BioMedicine Online (2010) 21, 290– 303

An overview of Cochrane reviews

• No reviews identified any studies that investigated

the effect of solid, gel or pharmacological agents on

pelvic pain, pregnancy rate, live birth rate or QoL,

which were our primary outcomes.

• There was no conclusive evidence of a difference

between liquid agents and control with regard to

pelvic pain (moderate quality evidence), pregnancy

rate (moderate quality evidence) or live birth rate

(moderate quality evidence).

• No reviews identified any studies that investigated

the effect of liquid agents on QoL.Cochrane Database of

Systematic Reviews 2015, Issue 1. Art. No.: CD011254.

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• Oxidised regenerated cellulose during laparoscopy

was associated with a reduction in the incidence of

de novo adhesions and reformation adhesions,

though the evidence ranged from very low to low

quality.

• During laparotomy, oxidised regenerated cellulose

was associated with a reduction in the incidence of

re-formation adhesions compared with control,

though the evidence was low quality.

Cochrane Database of



• There was no conclusive evidence of a difference in

the incidence of adhesions between sodium

hyaluronate and carboxymethylcellulose and

control.

• However, sodium hyaluronate and

carboxymethylcellulose were associated with a

reduction in the mean adhesion score compared to

control on SLL, though the evidence was of moderate

quality.




• Liquid agents were associated with a reduction in

the incidence of adhesions at SLL compared to no

treatment or control (high quality evidence).

• However, there was no evidence of a difference

between liquid agents and control on mean

adhesion scores (high quality evidence) or in

improving adhesion scores as a bimodal outcome

(moderate quality evidence).




• Gel agents were associated with a reduction

in the incidence of adhesions at SLL when

compared to no treatment (high quality

evidence).



An overview of Cochrane reviews• For pharmacological agents, steroids were associated

with a significant improvement in adhesion scores

compared to control (low quality evidence).

• There was no evidence of a difference in adhesion

scores between intraperitoneal noxytioline and

control (moderate quality evidence), intraperitoneal

heparin and control (low quality evidence) or

systemic promethazine (low quality evidence) and

control (moderate quality evidence)



Steps to reduce adhesions -1

• Carefully handle tissue with field enhancement

(magnificationmagnification) techniques

• Focus on planned surgery Focus on planned surgery and, if any secondary

pathology is identified, question the risk/benefit of

surgical treatment before proceeding

• Perform diligent diligent haemostasishaemostasis but ensure diligent use

of cautery

• Reduce Reduce cauterycautery time and frequency time and frequency and aspirate

aerosolised tissue following cautery

• Excise tissue—reducereduce fulgurationfulguration

Arch Gynecol Obstet (2012) 285:1089–1097

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Steps to reduce adhesions -2

• ReduceReduce durationduration of surgery

• Reduce pressure Reduce pressure and duration of pneumoperitoneum

in laparoscopic surgery

• Reduce risk of infection

• Reduce drying of tissues Reduce drying of tissues (limit heat and light)

• Use frequent irrigation and aspirationirrigation and aspiration in laparoscopic

and laparotomic surgery

• Limit use of sutures Limit use of sutures and choose fine nonfine non--reactivereactive

sutures

• Avoid foreign bodies—such as materials with loose

fibres Arch Gynecol Obstet (2012) 285:1089–1097

Expert Adhesion Working Party of the

European Society of Gynaecological

Endoscopy (ESGE) 20071. Adhesions need to be recognised as the most frequent most frequent

complicationcomplication of abdominal surgery

2. Surgeons, other healthcare workers, budget holders and policy

makers need to increase their awareness and understanding

of adhesions and the associated healthcare burden and costs healthcare burden and costs

and take active steps to reduce this

3. Patients need to be informed of the risk of adhesionsrisk of adhesions, given

that adhesions are now the most frequent complication of

abdominal surgery

4. Surgeons who do not advise of the risk of adhesions may put

themselves at risk of claims for medical negligencemedical negligence

Expert consens pos Gynecol Surg 2007;4(4):243–253.

Expert Adhesion Working Party of the ESGE

2007

5. Surgeons have a duty of care to protect patients by providing

the best possible standards of carebest possible standards of care—which should include

taking steps to reduce adhesion formation

6. Surgeons should adopt a routine adhesion reduction strategy,

at least in surgery associated with a high risk of adhesions,

such as:

• Ovarian surgery

• Endometriosis surgery

• Tubal surgery

• Myomectomy

• Adhesiolysis



2007

7. Good surgical technique Good surgical technique is fundamental to any adhesion

reduction strategy

8. Surgeons should consider the use of adhesion-reduction

agents as part of their adhesionadhesion--reduction strategyreduction strategy, giving

special consideration to agents with data to support safety in

routine abdominopelvic surgery and efficacy in reducing

adhesions. The practicality and ease of use of agents, as well

as the cost of any agent, will influence their acceptability in

routine practice

9. Further research to understand the impact that adhesion

reduction agents have on clinical outcomes will be important



2007

10. Research towards more effective preventative agents should

be encouraged—including the use of combinations of agents use of combinations of agents

to prevent the formation of de novo adhesions, as well as

adhesion reformation

11. Surgeons need to act now to reduce adhesions and fulfil their

duty of care to patients


Thank you for your attention.

[email protected]

adhesion prevention

Health & Medicine