Strategies to minimize adhesion formation after gynecologic operations

1. 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
tevfik@yoldemir.com
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 and Adhesion Formation after
Surgical Trauma of the Peritoneum -3
• Repair can be delayed by local factors such as a
decreaseddecreased fibrinolysisfibrinolysis, presence of, presence of necrotic tissue,necrotic tissue,
tissue ischemia, and oxidative stress secondarytissue ischemia, and oxidative stress secondary toto
vascular damage or sutures, and by infectionvascular damage or sutures, and by infection.
Fertil Steril 2016;106:998–1010.
Repair and Adhesion Formation after
Surgical Trauma of the Peritoneum -4
• 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.

2. 18.12.2016
2
Prevention of Postoperative Adhesion
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.
Prevention of Postoperative Adhesion
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
Microsurgical principles
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
Microsurgical principles
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
Microsurgical principles
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

3. 18.12.2016
3
Microsurgical principles
• 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

4. 18.12.2016
4
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.

5. 18.12.2016
5
An overview of Cochrane reviews
• 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
Systematic Reviews 2015,
Issue 1. Art. No.: CD011254.
An overview of Cochrane reviews
• 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.
Cochrane Database of
Systematic Reviews 2015,
Issue 1. Art. No.: CD011254.
An overview of Cochrane reviews
• 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).
Cochrane Database of
Systematic Reviews 2015,
Issue 1. Art. No.: CD011254.
An overview of Cochrane reviews
• Gel agents were associated with a reduction
in the incidence of adhesions at SLL when
compared to no treatment (high quality
evidence).
Cochrane Database of
Systematic Reviews 2015,
Issue 1. Art. No.: CD011254.
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)
Cochrane Database of
Systematic Reviews 2015,
Issue 1. Art. No.: CD011254.
Steps to reduce adhesions -1
• Carefully handle tissue with field enhancement
(magnificationmagnification) techniques
• Focus on planned surgeryFocus on planned surgery and, if any secondary
pathology is identified, question the risk/benefit of
surgical treatment before proceeding
• Perform diligentdiligent haemostasishaemostasis but ensure diligent use
of cautery
• ReduceReduce cauterycautery time and frequencytime and frequency and aspirate
aerosolised tissue following cautery
• Excise tissue—reducereduce fulgurationfulguration
Arch Gynecol Obstet (2012) 285:1089–1097

6. 18.12.2016
6
Steps to reduce adhesions -2
• ReduceReduce durationduration of surgery
• Reduce pressureReduce pressure and duration of pneumoperitoneum
in laparoscopic surgery
• Reduce risk of infection
• Reduce drying of tissuesReduce drying of tissues (limit heat and light)
• Use frequent irrigation and aspirationirrigation and aspiration in laparoscopic
and laparotomic surgery
• Limit use of suturesLimit 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) 2007
1. Adhesions need to be recognised as the most frequentmost 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 costshealthcare 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
Expert consens pos Gynecol Surg 2007;4(4):243–253.
Expert Adhesion Working Party of the ESGE
2007
7. Good surgical techniqueGood 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
Expert consens pos Gynecol Surg 2007;4(4):243–253.
Expert Adhesion Working Party of the ESGE
2007
10. Research towards more effective preventative agents should
be encouraged—includingthe use of combinations of agentsuse 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
Expert consens pos Gynecol Surg 2007;4(4):243–253.
Thank you for your attention.
tevfik@yoldemir.com