Preventing adhesions after abdominal myomectomy: Tools and techniques
Without preventive strategies, adhesions develop in more than half of women who undergo this procedure. Here, a review of protective adjuvants.
Absorbable barriers
These are largely derivatives of organic materials. Their application to myomectomy may be limited by the requirement for absolute hemostasis at the site of application.
Interceed (Gynecare, a division of Ethicon), which is derived from oxidized regenerated cellulose, is one of the first and most extensively evaluated barriers. A mesh synthetic designed to be placed over injured tissue, it is a derivative of the hemostatic agent Surgicell (Johnson & Johnson, New Brunswick, NJ), with modifications in weave and pore size.
Interceed offers ease of application: It can be cut to the size or shape necessary and requires no suturing. It forms a gelatinous protective layer within 8 hours of placement, and is degraded into monosaccharides and absorbed within 2 weeks.13
The use of Interceed has been shown to reduce adhesions following adhesiolysis and ovarian surgery. In a large, multicenter, prospective, randomized trial, it significantly decreased the incidence of adhesion reformation after adnexal adhesiolysis in infertility patients with bilateral tubal disease.14
In a retrospective series of 38 infertility patients, including 19 patients after myomectomy (13 with the barrier, 6 without), reproductive outcomes were significantly better in the Interceed group, and adhesion development was reduced.15 Pregnancy rates in the 2 years following surgery were 78% in the Interceed group, compared with 47% in controls. In addition, among 23 patients who had second-look procedures, postoperative adhesions were noted in 38% of the Interceed group, compared with 86% in controls.15
Seprafilm (hyaluronic acid-film) (Genzyme Corp, Cambridge, Mass) is a bioresorbable membrane derived from sodium hyaluronate and carboxymethylcellulose. It is absorbed from the peritoneal cavity within 1 week and is completely excreted within 1 month.
Its potential for adhesion prevention after abdominal myomectomy was examined by SLL in a multicenter, prospective, randomized, blinded study11 in which 127 women undergoing abdominal myomectomy at 19 institutions were randomized to either Seprafilm or no barrier. In the Seprafilm group, the barrier was wrapped circumferentially around the uterus, covering all uterine defects, at the time of abdominal closure. Clinical outcomes—including vital signs, adverse events (pain, fever, nausea), and abdominal wound complications—were similar in the control and Seprafilm groups.
In this study, the incidence (mean number of sites), severity, and extent (mean area) of uterine adhesions were significantly lower in the Seprafilm-treated patients. The proportion of patients undergoing anterior hysterotomies who were found to have no anterior uterine adhesions was 39% in the Seprafilm group, compared with 6% in the control group. The percentage of patients with at least 1 adnexa totally free of adhesions to the posterior uterus also was higher in the Seprafilm group—48% versus 31%.11
Nonabsorbable barriers
GoreTex Surgical Membrane (W.L. Gore and Associates, Newark, Del) is an inert expanded polytetrafluoroethylene (PTFE) derivative that must be sutured in place. It is of potential utility in myomectomy because its application does not require absolute hemostasis. However, its usefulness and application are limited by the need for later removal.
In a multicenter, randomized, controlled trial exploring its adhesion-preventive properties after myomectomy, the GoreTex membrane significantly outperformed the barrierfree group.16
In a separate multicenter, randomized clinical trial, the GoreTex membrane was more effective than Interceed in preventing adhesions after pelvic/tubal reconstructive surgery.17
Yet another multicenter, randomized trial—this one involving 27 women undergoing abdominal myomectomy—used SLL to determine the extent of adhesions and to remove the barrier. The percentage of adhesion-free surgical sites was significantly higher in the GoreTex group: 56% compared with 7% in no-barrier controls.16
The adhesion scores, determined by the extent (area of involvement), nature (filmy versus opaque), and tenacity (ease of lysis or dissection) of the adhesions, were significantly lower in the GoreTex group.16
Despite the few prospective, randomized trials, the evidence supports the efficacy of various fluid and barrier adjuvants.
Histologic examination of the removed barriers demonstrated no tissue attachment to the PTFE. Despite these positive findings, however, both fistula formation and graft infection have been reported after placement of a GoreTex barrier.18
The Shelhigh Pericardial No-React Patch (Herzog Surgical, Sacramento, Calif) is a new nonabsorbable adhesion barrier that was first described in gynecologic use by Pelosi and Pelosi in a case series of 20 patients.19 Consisting of a 12-cm-diameter patch of glutaraldehyde-treated bovine/porcine pericardium, this product has an excellent safety record as a permanent pericardial substitute in the cardiovascular literature and has been shown to resist calcification and adhesions.
In the Pelosi series, the patch was placed over the uterine fundus and secured by 4 monofilament sutures at the dome of the uterus and the parietal peritoneum.19 All patients underwent SLL at 6 weeks, and 3 patients also underwent third-look laparoscopy. None of the 20 women had adhesions between the abdominal wall and the bladder, bowel, uterus, or adnexae at SLL. However, minimal adhesions of the ovaries and tubes were found in 7 patients who had undergone posterior hysterotomy. Clinical trials are likely to follow this small pilot study.
