Averting adhesions: Surgical techniques and tools
A laparoscopic approach, microsurgical principles, and barriers or instillates can reduce adhesions
IN THIS ARTICLE
Myomectomy
Myomectomy performed through a laparotomy incision usually causes adhesions, so women who undergo this operation are good candidates for adhesion-reducing substances. The rate of adhesion formation after abdominal myomectomy is more than 90%—and it is 70% by laparoscopy.
Two helpful preventive strategies:
- Use a laparoscopic approach when feasible, and
- apply a barrier, such as the Gore-Tex ePTFE membrane, Seprafilm, or, if the myomectomy incision is not oozing, Interceed. Instillation of 1 L of 4% icodextrin may also be useful.
Hysterectomy
Most small-bowel obstruction follows abdominal hysterectomy, although a considerable period of time may pass before the problem occurs. When it does, a general surgeon usually manages the patient, and the treating gynecologist is unaware of this serious complication.
We recently found an incidence of adhesion-related small-bowel obstruction of 14 cases per 1,000 total abdominal hysterectomies and 1 case per 1,000 vaginal hysterectomies (P<.001).4 We did not encounter any small-bowel obstruction among 303 cases of laparoscopic supracervical hysterectomy.
Application of an adhesion-reducing substance to the vaginal vault or cervical stump may prevent small-bowel obstruction. Most adhesions implicated in small-bowel obstruction involve the vaginal vault. Appropriate products include Interceed, Preclude, Seprafilm, or perhaps Adept.
Fertility-promoting surgery
No adhesion-reducing substance has proved to be effective in increasing the pregnancy rate after a fertility-promoting procedure such as reconstructive tubal surgery or surgery for endometriosis.
CASE Recommendations
B.H., the patient described at the beginning of this article, should have had her initial surgery performed by an experienced laparoscopist, with minimal coagulation, meticulous hemostasis, “layered” repair of the myomectomy incision using nonreactive sutures, and liberal irrigation of the abdominal cavity. At the conclusion of the operation, the incision could have been covered with Gore-Tex surgical membrane or Seprafilm (or Interceed if there was no oozing) at least 1 cm beyond the incision. Instillation of Adept might have been useful as well.
The second operation also should have involved a laparoscopic route, which is associated with a lower rate of adhesions and could have reduced her risk of further bowel obstruction.
The authors report no financial relationships relevant to this article.
