PAGIDAS: I emphasize the value of microsurgical techniques, which help to minimize severe tissue handling. It also is important to keep surfaces moistened so they don’t desiccate.
SANFILIPPO: I agree with Dr. Pagidas about microsurgical techniques such as gentle tissue handling, careful hemostasis, and keeping tissues moist. If we follow these principles, we create an environment that minimizes the potential for adhesion formation.
HURD: The findings of many well-controlled animal studies have been surprising. For example, it is difficult to demonstrate that drying of tissue increases adhesions.3 Probably the greatest contributor to adhesions in these models was abrasion.4 One way that laparoscopic surgery decreases adhesions is by avoiding abrasion of the bowel mucosa, which occurs specifically with packing.
A 38-year-old mother of 2 undergoes myomectomy for menorrhagia.
SANFILIPPO: The initial question is: Can this case be managed laparoscopically? I do myomectomies laparoscopically whenever possible, although I do close the uterus with a minilaparotomy incision. The reason is my strong concern about reapproximating the myometrium, since wound dehiscence sometimes occurs at the site of myoma removal.
In this case, depending on the size of the myomas, I would do as much as possible laparoscopically and then reapproximate the myometrium. I would plan my incisions carefully, to maximize the number of myomas that can be removed. I would end with meticulous hemostasis and, assuming it is successful, use a barrier over the incision—in this case, Interceed.
HURD: Does the patient desire future childbearing? If so, I would avoid the laparoscopic approach because of the possibly increased risk of uterine rupture during pregnancy. If she isn’t planning pregnancy, there are more options.
The next question is: How many myomas are there, and where are they located? If they are intrauterine, a hysteroscopic approach would avoid extrauterine adhesions. If they are multiple and large, I am pretty much limited to laparotomy. If there is 1 or only a few myomas, a laparoscopic approach would be best.
I have not used Interceed. In laparoscopic cases, I worry that it would create more problems because, as you allow the carbon dioxide to decrease at the end of a case, oozing begins. Instead of a barrier, I would use limited hydroflotation.
SANFILIPPO: That’s a good point. At the end of the myomectomy, with the laparoscope in place, I decrease the insufflation, eliminating the tamponade effect. Then, assuming good hemostasis, I apply Interceed.
HURD: With open cases, I use Seprafilm, which takes practice because, as it gets wet, it sticks to anything, including gloves and instruments. But if you can put it down dry on the uterus, it sticks and stays in place. If oozing occurs, it seems to block or stop it.
PAGIDAS: I want to reiterate the importance of determining whether childbearing is an issue. In this case, the biggest concern is the risk of adhesions developing on our incision, so I would use a barrier. My preference would be Seprafilm or GoreTex. If we can limit adhesions at the incision site, then hopefully we can minimize bowel and tuboovarian adhesions, too.
In open cases, one thing we can do to minimize the risk of adhesions is to pack gently when needed. Also, we should avoid using packing to reposition the bowel.
Another factor frequently overlooked is the application of heat, which appears to be a very effective way to create adhesions. This probably isn’t an issue for laparoscopic cases, but when you use irrigation fluid in an open case, watch the temperature. If it feels hot to you, you need to worry about potential injury to the bowel surfaces.
PAGIDAS: That is critical. In abdominal cases you want to make sure irrigation fluid is warm, but not too warm, because heat increases the vascular permeability of vessels and leads to more macrophages, more prostaglandins, and more leukotrienes.
HURD: Another important element is the type of suture material used.
DECHERNEY: Overall, we need to minimize the use of sutures. For example, when I am operating laparoscopically on an ovarian cyst, I try to apply bipolar energy to the edges so that they will coapt without a stitch.
HURD: When it first became clear that suturing ovaries increased adhesion formation, we conducted a controlled trial of different kinds of sutures in animals. Not surprisingly, we found that the less reactive the suture, the fewer adhesions.5 Sutures that are absorbed more slowly, such as polydioxanone, seem to be less reactive.
Obviously, inert sutures like nylon are the least reactive, but they are permanent. It is assumed that animal-protein sutures such as chromic and plain gut are the most reactive, although I am not sure there are sufficient data to support that conclusion.