This document discusses techniques for preventing adhesions in gynecological surgeries. It covers the pathophysiology and risk factors for adhesion formation. Good surgical techniques like minimizing tissue trauma and drying can help reduce adhesions. Laparoscopy is associated with fewer adhesions than laparotomy due to less tissue handling and drying. Various barrier agents are described but have limitations. Current research focuses on hydrogels and other absorbable barriers that are easy to apply and prevent reformation of adhesions. Further studies are still needed to determine the best strategies and agents for adhesion prevention.

1. ADHESION PREVENTIVE TECHNIQUES
IN GYNECOLOGICAL SURGERIES
DR NIRANJAN CHAVAN

2. Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H, Sion Hospital
Joint Treasurer, FOGSI (2021-2024)
Vice President, MOGS (2021-2022)
Member Oncology Committee, SAFOG (2020-2021) (2021-2023)
Dean AGOG & Chief Content Director, HIGHGRAD & FEMAS Courses
Editor-in-Chief, FEMAS, JGOG & TOA Journal
54 publications in International and National Journals with 66 citations
National Coordinator, FOGSI Medical Disorders in Pregnancy Committee (2019-2021)
Chair & Convener, FOGSI Cell Violence Against Doctors (2015-16)
Member, Oncology Committee AOFOG (2013-2015)
Coordinator of 11 batches of MUHS recognized Certificate Course of B.I.M.I.E at
L.T.M.G.H (2010-16)
Member, Managing Committee IAGE (2013-17), (2018-20)
Editorial Board, European Journal of Gynaec. Oncology (Italy)
Course Coordinator of 3 batches of Advanced Minimal Access Gynaec Surgery
(AMAS) at LTMGH (2018-19)
DR. NIRANJAN CHAVAN
MD, FCPS, DGO, MICOG, DICOG, FICOG, DFP
,
DIPLOMA IN ENDOSCOPY (USA)

4. INTRODUCTION
• Pelvic adhesions are considered to be post inflammatory scar tissues that are formed
after abdominal surgery, endometriosis and intrabdominal infections.
• Adhesions may also be a severe and sometimes life-threatening complication.
• Although no universal nomenclature exists, they can be described as dense or flimsy,
thick or thin, opaque or translucent and vascular or avascular.

5. PERITONEAL ADHESIONS
• Peritoneal adhesions are pathological bonds usually between omentum, intraoperative
organs and the abdominal wall.
• These bonds may be a thin film of connective tissue, a thick fibrous bridge containing
blood vessels and nerve tissue, or a direct contact between two organ surface.
• Peritoneal adhesions are a consequence of peritoneal irritation by infection or surgical
trauma.
• Their prevalence after major abdominal procedures has been evaluated at 63%-97%.

6. PATHOPHYSIOLOGY
• Abnormal connective tissue attachments between tissues
and organs( Internal scars).
• Congenital or Acquired.
• Trauma to the peritoneum:
Surgical or inflammatory.
Ischemia:
*Desiccation or overheating
*Irritation from foreign materials
*Wound healing

7. TYPES OF POST OPERATIVE
ADHESONS
• Type 1: De novo adhesion formation: adhesions formed at sites that did not have
previous adhesions.
Type 1A : No previous operative procedure at the site of adhesions
Type 1B : Previous operative procedures at the site of adhesions
• Type 2: Adhesion Reformation
Type 2A : No operative procedure at the site of adhesions besides adhesiolys
Type 2B : Other operative procedures at the site of adhesions besides adhesiolysis

8. WHY DO ADHESIONS FORM?

9. On approximately day 3 after surgery, macrophages form the foundation of the advancing
adhesion. Fibrin matrix advancement occurs with the proliferation of fibroblasts and
vascularization. By day 5, the advancing adhesions are increasingly vascular and
organized in structure. No new adhesion formation occurs after day 7.

10. TRAUMATISED PERITONEUM
Peritoneal trauma Collagen formation
Fibrin band formation Adhesion formation

11. RISK FACTORS
• Intrabdominal Infections:
Inflammatory pelvic disease.
Acute appendicitis.
Perihepatitis.
Others.
• Abdominal Surgery.
• Peritoneal Endometriosis.
• Intraperitoneal tissue ischemia.
• Cauterization, Ligatures.
• Devascularization.
• Dryness of the serosa.

12. DIAGNOSTIC CONSIDERATIONS
• Only a small percentage of patients with chronic pelvic pain have laparoscopically
documented adhesions.
• 27% of patients without any remarkable history of adhesions present on laparoscopy.
• Approximately 50% of patients with 2 or more factors in their history really have
adhesions.
• An abnormal pelvic examination is useful in predicting the presence of adhesions in
74% of the cases.

13. MORBIDITY OF PERITONEAL ADHESIONS
• Intestinal obstruction:
5.7 percent of 21,347 readmissions were
classified as relating directly to adhesions,
and 3.8 percent required operation *
• Infertility:
10% of female infertility caused by
adhesion
• Chronic abdominal pain:
Dense adhesions can limit organ mobility,
which may cause visceral pain.

14. ADHESION PREVENTION TECHNIQUES

15. GOOD SURGICAL TECHNIQUE
• Reduce duration of surgery.
• Meticulous haemostasis.
• Irrigation to prevent drying of surfaces.
• Use of sub-serosal sutures. Limit use of sutures and choose fine non-reactive
sutures.
• Avoid foreign bodies when possible. Avoid non-peritonised implants and meshes.
• Reduce risk of infection.
Consensus In Adhesion Reduction management, TOG 2004;6(2), RCOG Press

16. • Minimal use of dry towels or sponges in laparotomy.
• Use starch and latex-free gloves in laparotomy.
• Reduce pressure and duration of pneumoperitoneum in
laparoscopic surgery.
• Use frequent irrigation and aspiration in laparoscopic and
laparotomic surgery when needed.
• Reduce cautery time and frequency and aspirate aerosolised
tissue following cautery.
• Excise tissue—reduce fulguration
Consensus In Adhesion Reduction management, TOG 2004;6(2), RCOG Press
GOOD SURGICAL TECHNIQUE

17. AVERAGE ADHESION FORMATION RATE
Diamond MP (2000): Incidence of Post surgical adhesions- Peritoneal Surgery, Springer Verlag, New York

18. LAPAROSCOPY AND ADHESIONS
• Minimally invasive surgery offers the advantages of less tissue and organ handling
and trauma.
• Minimally invasive laparoscopic surgery with up to10-fold magnification helps to
maintain tissue moisture, avoids contamination with foreign bodies such as surgical
glove powder.
• Facilitates more precise tissue manipulation.
• Pneumoperitoneum has a tamponade effect that facilitates hemostasis.
• Laparoscopy is associated with a lower incidence of postoperative infection.
• The abdominal incisions are small and thus it reduces the risk for adhesion
formation, especially to the abdominal wall.
Uptodate.com – Nov 2015

19. Adhesion reducing procedures
L
a
1- Microsurgery:
2-Laparoscopic
surgery:
3-Evaluative laparoscopy
(Secondlook laparoscopy)

20. IMPACT OF POST-OP ADHESIONS AFTER
LAPAROSCOPY
• Pelvic Pain
• Intestinal Obstruction: Major cause, 31-40%
• Important cause of hospital readmissions & subsequent repeat
surgery
• Infertility: 15-20% of secondary infertility is solely adhesion-
related*
• Even after adhesiolysis, 85% adhesions will re-form.
Consensus In Adhesion Reduction management, TOG 2004;6(2), RCOG Press
Diamond MP (2000): Incidence of Post surgical adhesions- Peritoneal Surgery,
Springer Verlag, New York

21. WHY DO ADHESIONS FORM?
Laparoscopy = Less Adhesions
• Less tissue handling
• Better magnification
• Precise haemostasis
• Less drying of surfaces
Surgical & Clinical Adhesion Research
Study (SCAR & SCAR-2) , 1999
Adhesion formation depends
upon TYPE of surgery performed
• High Risk: Lap Adhesiolysis,
Endometrioma drainage
• Low Risk: Lap tubal sterilization
• Medium risk: All others

22. WHY DO ADHESIONS FORM?
Surgical & Clinical Adhesion Research
Study (SCAR & SCAR-2) , 1999
For high risk
laparoscopic procedures,
the risk of adhesion
formation & re-admission
is almost EQUAL to
Laparotomy! (60 to 90%)

25. CURRENTLY USED ADHESION BARRIERS
Site- Specific Agents Description Drawback
1. Preclude ePTFE membrane Needs to be sutured in place, 2nd surgery to
remove
2. Interceed Oxidised regenerated cellulose 1. Bloodless field required
2. Migrates
3. Seprafilm Carboxymethyl cellulose membrane Difficult to handle laparoscopically
4. SurgiWrap Polylactide film Needs to be sutured in place, but dissolves in 1
year
5. SprayGel/ SprayShield Hydrogel Expensive
Broad Agent Description Drawback
1. Adept Icodextrin solution Studies ongoing

26. INTERCEED
• Oxidized Regenerated Cellulose absorbable Adhesion Barrier
• It is applied at the end of the procedure.
• Remove all irrigating fluid and instillates from peritoneal cavity.
• Cut to size.
• Apply interceed (if it turn’s black, then blood is present, remove interceed and achieve
hemostasis).
• No sutures needed.
• Moisten with 5ml of irrigant/3x4 inch piece.

27. INTERCEED ABSORBABLE ADHESION BARRIER
Product Description:
Sterile, absorbable, off-white, knitted fabric prepared by
the controlled oxidation of regenerated cellulose1
MOA:
Forms a continuous protective covering over raw tissue
surfaces during the peritoneal healing period1
Availability:
3x4 inches
5x6 inches

28. HOW IT WORKS
• Forms continuous gelatinous protective coat over raw tissue surface
• Maintains integrity during peritoneal healing (~5-7 days)
• Removed through hydrolysis
• All is absorbed, secreted from the body by 28 days
Six hours after addition of irrigation solution
Oxidized regenerated cellulose

29. INTERCEED APPLICATION

30. VIDEO OF MYOMECTOMY AND
INTERCEED APPLICATION

31. ADHESION - REDUCTION ADJUVANTS &
PROPOSED MECHANISMS OF ACTION
Class of adjuvant Mechanism of action
Fibrinolytic agents
Fibrinolysin;Streptokinase;Urokinase;Hyal
uronidase;Chymotrypsin;Plasminogen
Activators
Fibrinolysis
Plasminogen Activators
Anticoagulants-
Heparin;Citrates;Oxalates;
Prevention of fibrin & clot formation
Antiinflamatory Agents
Corticosteroids,NSAIDS,Antihistaminics,
calcium channel blockers,Progesterone
Reduce vascular permeability
Reduce histamine release
Stabilises lysosomes
Antibiotics-
Tetracyclines, cephalosporins
Prevent infections

32. ADHESION BARRIERS OF
DOUBTFUL EFFICACY
• Anti- inflammatory agents (e.g. NSAIDS)
• Fibrinolytics (e.g. Streptokinase)
• Anticoagulants (e.g. Heparin)
• Antibiotics (Intra peritoneal instillation)
• Progesterone
• GnRH agonists
• Normal Saline: too rapidly absorbed
“Insufficient usefulness in clinical practice”

33. LIQUID HYDROFLOTATION
• Postoperative Instillates (Hydroflotation)
• Crystalloid solutions
Lactated ringer’s solution
Saline
Dextran 40/70

34. CRYSTALLOID CLINICAL STUDIES
No. of
Author Patients Results
Rosenberg S.M. et al., 1984 21 Non-efficacious
Adhesion Study Group, 1983 47 Non-efficacious
Larsson B. et al., 1985 54 Non-efficacious
Jansen R.P.S., 1985 82 Non-efficacious
Wiseman D. et al., 1998 Meta-analysis of 23 studies

35. CRYSTALLOID SOLUTIONS
0
50
100
150
200
250
300
350
0 1 2 3 4 5 6 7 8 9
Crystalloid
(ml)
• As a post-op instillate, not
effective in preventing
adhesions
• rate of absorption is 35-62
ml/hour.
• 300 ml are absorbed in
about 7 hours.
• The process of peritoneal
healing and adhesion
formation takes place
during the first 5-7 days.

36. METHODS OF ADHESION PREVENTION
IN LAPAROSCOPIC SURGERY
• Preventing Gas-Induced drying
of peritoneal surfaces by using
pre-warmed, humidified CO2
(Thermoflator, Karl Storz)
• Adhesion barrier substances

37. • Evidence suggests that the incidence of adhesions at the site of closure after
laparotomy is approximately 22% with peritoneal closure and 16% without
peritoneal closure.
• In women with ovarian cancer, closure of pelvic and periaortic peritoneum appears to
result in greater adhesion formation than is observed when the dissected areas are left
open.
• However, parietal peritoneal closure at primary cesarean delivery has been observed
to yield significantly fewer dense and filmy adhesions.

38. A retrospective study of 654 patients who already had different previous abdominopelvic
surgery and subsequently underwent gynecological laparoscopic surgery for various
indications.
Adhesions were prevalent in gynecological patients with previous abdominopelvic surgery.
They were a significant contributor to the gynecological and reproductive issues.
To minimize the risk of postoperative adhesions, laparoscopic approach should be encouraged
instead of traditional surgery and rates of cesarean section should be reduced.

39. A search was conducted using PubMed, EMBASE and CENTRAL, without restrictions pertaining to
date, publication status or language. Randomized trials and cohort studies from all surgical
interventions for chronic post-operative pain were considered eligible.
Laparoscopic adhesiolysis reduces pain from adhesions in ~70% of patients in the initial phase after
treatment.
Drawbacks of laparoscopic adhesiolysis are the high rate of negative laparoscopies and the risk of
bowel injury. At present, there is little evidence to support routine use of adhesiolysis in treatment for
chronic pain.

40. The PNP hydrogel adhesion barrier reported here resulted in a significant reduction in the severity and
incidence of peritoneal adhesions. This treatment approach has the potential to positively impact patients
and prevent adhesion formation as a result of surgery of any kind in any part of the body. Overall, this
work establishes a proof of concept translation across surgery indications and demonstrates an adhesion
barrier system that is simple to deploy, stable over extended timeframes, and successfully prevents post-
operative adhesions.

41. Randomised controlled trials (RCTs) on the use of barrier agents were compared with other barrier
agents, placebo, or no treatment for prevention of adhesions in women undergoing gynecological
surgery. They included 19 RCTs (1316 women). Low quality evidence suggests that collagen membrane
with polyethylene glycol plus glycerol may be more effective than no treatment in reducing the
incidence of adhesion formation following pelvic surgery and oxidized regenerated cellulose may
reduce the incidence of re-formation of adhesions when compared with no treatment at laparotomy. It
We found no evidence on the effects of barrier agents used during pelvic surgery on pelvic pain or live
birth rate in women of reproductive age because no trial reported these outcomes.

42. The Jessop Wing, Sheffield University and Teaching Hospitals, Sheffield, South Yorkshire and b
Princess Anne Hospital, University of Southampton, Southampton, Hampshire, UK.
Purpose of review To explore recent developments in the techniques used for the prevention of
adhesion formation after gynaecological surgery as well as the current evidence for existing agents
and techniques.
There is preliminary evidence to support the use of hyaluronic acid, although the best preparation is
yet to be determined. The use of icodextrin, Interceed (Ethicon Inc, Somerville, New Jersey, USA)
and Oxiplex seem to be justified by the currently available data.
The results of interesting new technologies such as the use of hybrid systems and new forms of
biomaterials are awaited.

45. THANK YOU