Dr. Niranjan Chavan well known Obstetrician & Gynaecologist gave a talk on "Recent advances in adhesion prevention post laparoscopic surgery" at 18th AAGL International Congress on "Unravelling Uterine Issues and Beyond."

1. RECENT ADVANCES IN ADHESION
PREVENTION POST LAPAROSCOPIC
SURGERY
Dr Niranjan Chavan
AAGL INDIA MUMBAI
4TH June 2023
Westin Hotel, Mumbai

2. Professor and Unit Chief, L.T.M.M.C & L.T.M.G.H, Sion Hospital
President, MOGS (2022-2023)
Joint Treasurer, FOGSI (2021-2025)
Organising Secretary, AICOG Mumbai 2025
Treasurer, AFG (2023-2024)
Member Oncology Committee, SAFOG (2021-2023)
Dean AGOG & Chief Content Director, HIGHGRAD & FEMAS Courses
Editor-in-Chief, FEMAS, JGOG & TOA Journal
67 publications in International and National Journals with 162 Citations
National Coordinator, FOGSI Medical Disorders in Pregnancy Committee (2019-2022)
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), (2022-2023)
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. PERITONEALADHESIONS
• Peritoneal adhesions are pathological bonds usually between the 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 surfaces.
• 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%.

7. 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

8. 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 adhesiolysis
• Type 2B: Other operative procedures at the site of adhesions besides adhesiolysis

9. WHY DO ADHESIONS FORM?

10. • 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

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

13. 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.

14. 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 is caused by
adhesion.
• Chronic abdominal pain:
Dense adhesions can limit organ mobility,
which may cause visceral pain.

16. ADHESION PREVENTION
TECHNIQUES

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

18. GOOD SURGICAL TECHNIQUE
• Minimal use of dry towels or sponges..
• Use starch and latex-free gloves.
• 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 aerosolized tissue
following cautery.
• Excise tissue—reduce fulguration.
Consensus In Adhesion Reduction management, TOG 2004:6(2),
RCOG Press

19. AVERAGE ADHESION
FORMATION RATE
LAPAROSCOPIC SURGERY AVERAGE ADHESION
FORMATION RATE
Myomectomy 40%
Ovarian Drilling 30-40%
Endometriosis surgery 70-80%
Adhesiolysis 70-80%
Diamond MP (2000): Incidence of Post-surgical adhesions- Peritoneal Surgery, Springer Verlag, New York

20. LAPAROSCOPY AND ADHESIONS
• Minimally invasive surgery offers the advantages of less tissue and
organ handling and trauma.
• Minimally invasive laparoscopic surgery with up to 10-fold
magnification helps to maintain tissue moisture and avoids
contamination with foreign bodies such as surgical gloves 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

21. IMPACT OF POST-OPADHESIONS
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% of adhesions will re-form.
Consensus In Adhesion Reduction management, TOG 2004:6(2),
RCOG PressDiamond MP (2000): Incidence of Post surgical
adhesions- Peritoneal Surgery,Springer Verlag, New York

22. OLD CONCEPT
Laparoscopy= less adhesiolysis
• Less tissue handling.
• Better magnification.
• Precise hemostasis.
• Less drying of the surface.
NEW CONCEPT
• Adhesion formation depends on TYPE of
surgery performed
• High risk: Lap adhesiolysis, endometrioma
drainage.
• Low risk: Lap tubal sterilisation.
• Medium risk: All others.
Surgical & Clinical Adhesion ResearchStudy (SCAR & SCAR-2) , 1999

25. INTERCEED
• Oxidized Regenerated Cellulose absorbable Adhesion Barrier
• It is applied at the end of the procedure.
• Remove all irrigating fluid and installations from the peritoneal cavity.
• Cut to size.
• Apply intercede (if it turns black, then blood is present, remove intercede and achieve
hemostasis).
• No sutures needed.
• Moisten with 5ml of irrigant/ 3*4 inch piece.

26. INTERCEDE ABSORBABLE
ADHESION BARRIER
• Sterile, absorbable, off-white, knitted fabric prepared by the
controlled, off-white, knitted fabric prepared by the controlled
oxidation of regenerated cellulose.
• Mechanism of action: Forms a continuous protective covering over
raw tissue surfaces during the peritoneal healing period.
• Availability: 3x4 inches
5x6 inches

27. 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 and secreted from the body within 28 days.

28. INTERCEED APPLICATION

31. 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”

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

33. 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

34. • 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 prevent post-operative adhesions.
Ahmad G, et al. Cochrane Database Syst Rev. 2020

35. • Postoperative adhesions represent a frequent complication of abdominal surgery. Adhesions can result
from infection, ischemia, and foreign body reaction, but commonly develop after any surgical
procedure.
• The morbidity caused by adhesions affects quality of life and, therefore, it is paramount to continue to
raise awareness and scientific recognition of the burden of adhesions in healthcare and clinical
research.
• This 2021 Global Expert Consensus Group worked together to produce consented statements to
guide future clinical research trials and advise regulatory authorities. It is critical to harmonize the
expectations of research, to both develop and bring to market improved anti-adhesion therapies, with
the ultimate, shared goal of improved patient outcomes.
Rudy Leon De Wilde et al. J Clin Med. 2022

36. • The aim of this review is to appraise critically the literature over the past year with respect to
new developments in adhesion prevention strategies.
• The majority of the work continues to be focused on animal models, and interest continues
in the usage of heterologous barriers, which are increasingly derived from or related to
hyaluronic acid.
• The recent trend has been to develop barriers that are not only effective but also technically
easy to use for the laparoscopic surgeon--hence the development of barrier gels.
• It is only through the development of these user-friendly barriers that many laparoscopic
surgeons will be willing to incorporate these important preventative measures into their busy
daily practice.
• Routine usage of adhesion prevention measures will ultimately reduce patient morbidity and
mortality and relieve the burden on health service provision.
N Panay et al. Curr Opin Obstet Gynecol. 1999 Aug

37. This work reports the use of a dynamically crosslinked polymer‐nanoparticle (PNP) hydrogel
adhesion barrier comprised of hydrophobically modified hydroxypropylmethylcellulose and
biodegradable PEG‐PLA nanoparticles.
The PNP hydrogel significantly reduced peritoneal adhesion severity compared to commercial
control products when assessed by a standardized 5‐point scale (3.18 ± 1.07 versus 1.35 ± 0.63;
p = 0.0014).
These results suggest that the PNP hydrogel adhesion barrier is a simple and effective solution
for the prevention of peritoneal adhesions.