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Expert Panel: Techniques and tools to prevent pelvic adhesions

Microsurgical techniques, laparotomy versus laparoscopy, use of adjunctive therapy—our panelists relate their views on these issues and discuss which options they would choose in 4 different scenarios.


 

References

PANELISTS
  • Alan DeCherney, MD, moderator, is professor, department of obstetrics and gynecology, and chief, division of reproductive endocrinology and infertility, David Geffen School of Medicine, University of California, Los Angeles.

  • William Hurd, MD, is professor and chair, department of obstetrics and gynecology, Wright State University School of Medicine, Dayton, Ohio.
  • Kelly Pagidas, MD, is reproductive endocrinologist and assistant professor of obstetrics and gynecology, Brown University, Providence, RI, and Tufts University, Boston, Mass.
  • Joseph S. Sanfilippo, MD, MBA, is professor, department of obstetrics, gynecology, and reproductive sciences, University of Pittsburgh, and vice chairman of reproductive sciences, Magee-Womens Hospital, Pittsburgh, Pa. He also serves on the OBG Management Board of Editors.
KEY POINTS
  • Approximately 40% of people who undergo primary surgery develop adhesions and reformation occurs in 80% to 90% of cases.
  • Microsurgical techniques such as gentle handling of tissues, careful hemostasis, and avoidance of heat may help reduce the incidence.
  • Laparoscopy appears to be less likely to produce adhesions than laparotomy.
  • Ob/Gyns should be aware of the potential for adhesion-related bowel obstruction and take steps to prevent it.

Are adhesions a pathologic response to injury or a normal aspect of healing? Can they be avoided, or are preventive efforts part of the problem? How useful are the different barriers in gynecologic surgery? What is the ideal adjuvant?

OBG Management convened a panel of experts to explore these and other questions.

Common problem, high recurrence rate

DECHERNEY: Adhesion formation is serious because it is associated with clinical entities such as infertility, pelvic pain, and bowel obstruction. We all agree that approximately 40% of people who undergo primary surgery develop adhesions and that 80% to 90% of patients who undergo lysis develop recurrent adhesions.

SANFILIPPO: One study several years ago explored adhesion formation.1 Unfortunately, no matter how meticulous the surgeon is, adhesions will form, even with microsurgical techniques and carefully ensured hemostasis.

HURD: The number of patients with significant adhesion formation after some gynecologic procedures has been reported to be greater than 90%.2

DECHERNEY: That higher incidence usually occurs after general surgery—and there’s a reason it is so high: General surgeons don’t use adjunctive therapy. They are critical of it. It is to our credit as gynecologic surgeons that we adopted adjunctive therapies about 15 years ago with the introduction of dextran 70 (Hyskon; Medisan Pharmaceuticals, Parsippany, NJ).

PAGIDAS: If anything, the pelvis seems to have even more of a predilection for adhesion formation than the abdomen, probably because of the close proximity of structures.

How and why adhesions form

DECHERNEY: What is the pathophysiology of adhesion formation? Let’s say you have 2 raw surface areas. What happens?

The process

PAGIDAS: The increase in leukotrienes and prostaglandins and the decrease in plasminogen activity (which actually initiates the inflammation) appear to be significant.

HURD: Vessel permeability also increases, and inflammatory cells leak through the vessels and set up a matrix for adhesion formation.

DECHERNEY: So we have 2 raw surface areas with fibrin leaking out and forming bridges between them.

PAGIDAS: The key is that it takes 2 surfaces to form these bridges. As I mentioned, the greater proximity of pelvic structures—particularly around the tube and ovary—probably contributes to adhesion formation.

DECHERNEY: Macrophage activity also is important. The macrophage “migrates” along these fibrin bridges and lays down collagen over a period of time. Then the collagen becomes organized and, eventually, vascular.

Window of opportunity

SANFILIPPO: Adhesion formation probably occurs and is pretty well established within 5 to 7 days of the precipitating event—usually surgery. Once that process is under way, attempts to halt it yield diminishing returns. Unfortunately, we don’t know how to interfere with it in a positive way.

HURD: Under normal conditions, there seems to be a balance between fibrin deposition and fibrinolysis. In some tissues, however, these functions become imbalanced. This disparity may contribute more to adhesions than the actual laying down of fibrin—especially in tissue that is hypoxic.

DECHERNEY: Would you say that adhesion formation represents normal or abnormal healing?

HURD: It is one of the body’s normal protective mechanisms and an important part of healing. Without it, any abdominal injury would likely result in death.

SANFILIPPO: I don’t think it differs that much from processes that occur externally. For example, if you get cut deeply enough, you develop a scar. Is that scar part of the normal healing process? It is.

PAGIDAS: Right. It is a normal process of tissue remodeling. The question is: What allows it to go astray?

What surgical techniques help prevent adhesions?

DECHERNEY: Let’s review the aspects of surgical technique that are important for adhesion prevention.

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