What are the clinical implications of postoperative adhesions in gynecologic surgery. How do adhesions form after extensive gynecologic procedures. What strategies can be employed to prevent adhesion formation following gynecologic surgery.

The Prevalence and Impact of Postoperative Adhesions in Gynecologic Surgery

Postoperative adhesions are a common complication following major gynecologic surgery, occurring in 60-90% of patients. These fibrous bands of scar tissue that form between tissues and organs can have significant clinical consequences:

• Intestinal obstruction
• Chronic pelvic pain
• Ureteral obstruction
• Voiding dysfunction
• Reduced efficacy of intraperitoneal cancer treatments

The incidence of adhesion-related intestinal obstruction varies based on the type of gynecologic procedure performed:

• 0.3% for benign conditions without hysterectomy
• 2-3% following hysterectomy
• Up to 5% after radical hysterectomy

These statistics highlight the substantial risk of adhesion formation and its potential to cause serious postoperative complications. Understanding the prevalence and impact of adhesions is crucial for gynecologic surgeons to properly counsel patients and take appropriate preventive measures.

Etiology of Postoperative Adhesions: Unraveling the Underlying Mechanisms

Postoperative adhesions develop as a result of impaired fibrinolysis following peritoneal injury. This process involves the inadequate breakdown of fibrin and cellular exudate that form at the site of tissue damage. But what factors contribute to this impaired fibrinolysis?

Key Factors in Adhesion Formation

• Inadequate blood supply: Normal fibrinolysis requires sufficient blood flow to the affected area.
• Thermal injury: Excessive heat during surgery can damage tissues and promote adhesion formation.
• Infection: Bacterial contamination can trigger an inflammatory response and increase adhesion risk.
• Foreign bodies: The presence of sutures, mesh, or other surgical materials can stimulate adhesion development.
• Radiation-induced endarteritis: Radiation therapy can damage blood vessels, leading to reduced blood flow and increased adhesion risk.

Understanding these contributing factors is essential for developing effective strategies to minimize adhesion formation. By addressing these underlying mechanisms, surgeons can potentially reduce the incidence and severity of postoperative adhesions.

The Role of Animal Models in Advancing Adhesion Research

Recent advancements in adhesion research have been facilitated by the development of appropriate animal models. These models allow researchers to study the process of adhesion formation and test potential prevention strategies in a controlled environment. Why are animal models so crucial in this field?

• Replication of human physiology: Animal models can simulate the conditions under which adhesions form in humans.
• Controlled experiments: Researchers can manipulate variables and test specific interventions.
• Longitudinal studies: The progression of adhesion formation can be observed over time.
• Evaluation of prevention strategies: New techniques and products can be tested for efficacy and safety before human trials.

While animal models have provided valuable insights, it’s important to note that clinical confirmation of findings from these investigations is still necessary before implementing new strategies in human patients. The translation of results from animal studies to clinical practice remains a critical step in advancing adhesion prevention techniques.

Meticulous Surgical Technique: The Cornerstone of Adhesion Prevention

In the absence of definitively proven adhesion prevention strategies, meticulous surgical technique remains the primary method for minimizing postoperative adhesions. How can surgeons optimize their approach to reduce adhesion formation?

Key Principles of Adhesion-Minimizing Surgical Technique

• Gentle tissue handling: Minimize trauma to peritoneal surfaces.
• Precise hemostasis: Control bleeding without excessive cauterization.
• Irrigation: Remove blood and debris from the surgical site.
• Limiting foreign body introduction: Use absorbable sutures when possible and minimize the use of mesh or other permanent materials.
• Preventing tissue desiccation: Keep tissues moist throughout the procedure.
• Reducing operative time: Efficient surgery can minimize tissue exposure and potential damage.

By adhering to these principles, surgeons can significantly reduce the risk of adhesion formation. However, it’s important to recognize that even with optimal technique, some degree of adhesion formation may still occur due to the body’s natural healing response.

Emerging Strategies for Adhesion Prevention: Promising Avenues for Research

While meticulous surgical technique remains the primary method for adhesion prevention, researchers are exploring various innovative approaches to further reduce adhesion formation. What are some of the emerging strategies showing promise in this field?

Potential Adhesion Prevention Strategies Under Investigation

• Barrier agents: Physical barriers placed between tissues to prevent adhesion formation.
• Pharmacological interventions: Medications that modulate the inflammatory response or enhance fibrinolysis.
• Tissue engineering: Development of biocompatible materials that promote healing without adhesion formation.
• Minimally invasive techniques: Laparoscopic and robotic approaches that may reduce tissue trauma.
• Enhanced recovery protocols: Perioperative strategies that optimize healing and reduce inflammation.

These emerging strategies offer exciting possibilities for adhesion prevention, but further research and clinical trials are needed to establish their efficacy and safety in human patients. As the field progresses, a multi-faceted approach combining surgical technique, barrier methods, and pharmacological interventions may prove most effective in minimizing postoperative adhesions.

The Impact of Adhesions on Intraperitoneal Cancer Treatments

Adhesions can have significant implications for patients undergoing intraperitoneal cancer treatments. How do these fibrous bands interfere with cancer therapy, and what are the potential consequences?

Challenges Posed by Adhesions in Cancer Treatment

• Reduced drug distribution: Adhesions can create isolated pockets within the peritoneal cavity, preventing uniform distribution of chemotherapy agents.
• Decreased drug absorption: Scar tissue from adhesions may have reduced vascularity, limiting the uptake of intraperitoneal drugs.
• Complications during subsequent surgeries: Adhesions can make follow-up procedures more challenging and increase the risk of surgical complications.
• Altered tumor biology: The microenvironment created by adhesions may influence tumor growth and metastasis.

Given these potential impacts, adhesion prevention becomes particularly crucial in oncologic gynecologic surgery. Strategies to minimize adhesion formation may not only reduce postoperative complications but also enhance the efficacy of future cancer treatments.

Long-Term Consequences of Adhesions: Beyond Immediate Postoperative Complications

While the immediate postoperative risks of adhesions are well-recognized, it’s important to consider the potential long-term consequences for patients. What are some of the chronic issues that can arise from postoperative adhesions?

Chronic Complications Associated with Adhesions

• Persistent pelvic pain: Adhesions can cause chronic pain by restricting organ movement or compressing nerves.
• Infertility: Adhesions involving the fallopian tubes or ovaries can interfere with conception.
• Recurrent small bowel obstruction: Patients may experience multiple episodes of partial or complete bowel obstruction over time.
• Difficulty with future surgeries: Adhesions can complicate subsequent abdominal or pelvic procedures, increasing operative time and risk.
• Psychological impact: Chronic pain and recurrent hospitalizations can affect patients’ quality of life and mental health.

Recognizing these long-term consequences underscores the importance of adhesion prevention strategies and highlights the need for ongoing patient education and follow-up. Gynecologic surgeons should be prepared to address these potential issues and provide appropriate referrals for multidisciplinary care when necessary.

The Economic Burden of Adhesion-Related Complications

Postoperative adhesions not only impact patient health but also place a significant economic burden on healthcare systems. What are the financial implications of adhesion-related complications?

Costs Associated with Adhesion-Related Issues

• Readmissions: Patients requiring hospitalization for adhesion-related bowel obstruction or pain.
• Reoperations: Surgical procedures to lyse adhesions or address complications.
• Extended hospital stays: Increased length of stay due to adhesion-related complications.
• Lost productivity: Time off work for patients dealing with chronic adhesion-related issues.
• Ongoing medical care: Long-term management of adhesion-related chronic pain or other symptoms.

The substantial economic impact of adhesions further emphasizes the importance of prevention strategies. Investing in adhesion prevention techniques and research may lead to significant cost savings for healthcare systems in the long run, in addition to improving patient outcomes.

As research in this field continues to evolve, it is crucial for gynecologic surgeons to stay informed about the latest developments in adhesion prevention and management. By combining meticulous surgical technique with emerging prevention strategies, the incidence and impact of postoperative adhesions may be significantly reduced, leading to improved outcomes for patients undergoing gynecologic surgery.

Adhesions after extensive gynecologic surgery: clinical significance, etiology, and prevention

Review

. 1994 May;170(5 Pt 1):1396-403.

doi: 10.1016/s0002-9378(94)70170-9.

B J Monk 
¹
, M L Berman, F J Montz

Affiliations

Affiliation

• ¹ Department of Obstetrics and Gynecology, University of California at Irvine, Orange, California.

• PMID:

  8178880

• DOI:

  10.1016/s0002-9378(94)70170-9

Review

B J Monk et al.

Am J Obstet Gynecol.

1994 May.

. 1994 May;170(5 Pt 1):1396-403.

doi: 10.1016/s0002-9378(94)70170-9.

Authors

B J Monk 
¹
, M L Berman, F J Montz

Affiliation

• ¹ Department of Obstetrics and Gynecology, University of California at Irvine, Orange, California.

• PMID:

  8178880

• DOI:

  10.1016/s0002-9378(94)70170-9

Abstract

Postoperative adhesions occur in 60% to 90% of patients undergoing major gynecologic surgery and represent one of the most common causes of intestinal obstruction in the industrialized world. The incidence of adhesion-related intestinal obstruction after gynecologic surgery for benign conditions without hysterectomy is approximately 0.3%, increasing to 2% to 3% among patients who undergo hysterectomy, and is as high as 5% if a radical hysterectomy is performed. Other adhesion-related complications include chronic pelvic pain, ureteral obstruction, and voiding dysfunction. Intraperitoneal adhesions also can limit the effectiveness of intraperitoneal therapeutic agents used in cancer treatment. Postoperative adhesions are sequelae of impaired fibrinolysis of the fibrin and cellular exudate after peritoneal injury. Adequate blood supply is essential for normal fibrinolysis. Therefore factors that increase ischemia and potentiate adhesion formation include thermal injury, infection, presence of a foreign body, and radiation-induced endarteritis. Only recently, appropriate animal models have been developed to study the process of adhesion formation and prevention. Until clinical confirmation of findings from these investigations exists, only a meticulous surgical technique can be advocated to minimize these untoward effects of surgery.

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Publication types

MeSH terms

Challenges in total laparoscopic hysterectomy: Severe adhesions

News for Your Practice

By

Author and Disclosure Information

Success is likely if you are 1) proactive and 2) meticulous about abdominal entry, and if you manage adhesions strategically. Two experts offer tips and techniques.

IN THIS ARTICLE

• Palmer’s point, a safer entry
• How to manage adhesiolysis
• Thawing a frozen pelvis

References

1. Liakakos T, Thomakos N, Fine PM, Dervenis C, Young RL. Peritoneal adhesions: etiology, pathophysiology, and clinical significance. Recent advances in prevention and management. Dig Surg. 2001;18:260-273.

2. Ling FW, DeCherney AH, Diamond MP, diZerega GS, Montz FP. The Challenge of Pelvic Adhesions. Crofton, Md: Association of Professors of Gynecology and Obstetrics; 2002.

3. Agarwala N, Liu CY. Safe entry techniques during laparoscopy: left upper quadrant entry using the ninth intercostals space—a review of 918 procedures. J Minim Invasive Gynecol. 2005;12:55-61.

4. Palmer R. Safety in laparoscopy. J Reprod Med. 1974;13(1):1-5.

5. Childers JM, Brzechffa PR, Surwit EA. Laparoscopy using the left upper quadrant as the primary trocar site. Gynecol Oncol. 1993;50:221-225.

6. Shen CC, Wu MP, Lu CH, et al. Small intestine injury in laparoscopic-assisted vaginal hysterectomy. J Am Assoc Gynecol Laparosc. 2003;10:350-355.

7. Diamantis T, Kontos M, Arvelakis A, et al. Comparison of monopolar electrocoagulation, bipolar electrocoagulation, Ultracision, and Ligasure. Surg Today. 2006;36:908-913.

8. Perkins JD, Dent LL. Avoiding and repairing bowel injury in gynecologic surgery. OBG Management. 2004;16(8):15-28.

Dr. Giesler reports that he serves on the speaker’s bureau for Ethicon Endo-Surgery. Dr. Vyas has no financial relationships relevant to this article.

CASE: Probable adhesions. Is laparoscopy practical?

A 54-year-old woman complains of perimenopausal bleeding that has not been controlled by hormone therapy, as well as increasing pelvic pain that has caused her to miss work. She wants you to perform hysterectomy to end these problems once and for all.

Aside from these complaints, her history is unremarkable except for a laparotomy at 13 years for a ruptured appendix. Her Pap smear, endometrial biopsy, and pelvic sonogram are negative.

Is she a candidate for laparoscopic hysterectomy?

A patient such as this one, who has a history of laparotomy, is likely to have extensive intra-abdominal adhesions. This pathology increases the risk of bowel injury during surgery—whether it is performed via laparotomy or laparoscopy.

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The ability to simplify laparoscopic hysterectomy in a woman who has extensive adhesions requires an understanding of the ways in which adhesions form—in order to lyse them skillfully and avoid creating further adhesions. It also requires special techniques to enter the abdomen, identify the site of attachment, separate adhered structures, and conclude the hysterectomy. Attention to the type of energy that is used also is important.

In this article, we describe these techniques and considerations.

In Part 1 of this article, we discussed techniques that facilitate laparoscopic hysterectomy in a woman who has a large uterus.

Don’t overlook preoperative discussion, preparation

The patient needs to understand the risks and benefits of laparoscopic hysterectomy, particularly when extensive adhesions are likely, as well as the fact that it may be necessary to convert the procedure to laparotomy if the laparoscopic approach proves too difficult. She also needs to understand that conversion to laparotomy does not represent a failure of the procedure but an aim for greater safety.

Because bowel injury is a real risk when the patient has extensive adhesions, mechanical bowel preparation is important. Choose the regimen preferred by the colorectal surgeon likely to be consulted if intraoperative injury occurs.

The operating room (OR) and anesthesia staffs also need to be prepared, and the patient should be positioned for optimal access in the OR. These and other preoperative steps are described in Part 1 of this article and remain the same for the patient who has extensive intra-abdominal adhesions.

How adhesions form

When the peritoneum is injured, a fibrinous exudate develops, causing adjacent tissues to stick together. Normal peritoneum immediately initiates a process to break down this exudate, but traumatized peritoneum has limited ability to do so. As a result, a permanent adhesion can form in as few as 5 to 8 days. ^1,2

Pelvic inflammatory disease and intraperitoneal blood associated with distant endometriosis implants are well known causes of abdominal adhesions; others are listed in the TABLE.

TABLE

7 causes of intra-abdominal adhesions

The challenge of safe entry

During laparotomy, adhesions can make it difficult to enter the abdomen. The same is true—but more so—for laparoscopic entry. The distortion caused by adhesions can lead to inadvertent injury to blood vessels, bowel, and bladder even in the best surgical hands. An attempt to lyse adhesions laparoscopically often prolongs the surgical procedure and increases the risk of visceral injury, bleeding, and fistula.¹

In more than 80% of patients experiencing injury during major abdominal surgery, the injury is associated with omental adhesions to the previous abdominal wall incision, and more than 50% have intestine included in the adhesion complex.¹

One study involving 918 patients who underwent laparoscopy found that 54.9% had umbilical adhesions of sufficient size to interfere with umbilical port placement.³ More important, 16% of this study group had only a single midline umbilical incision for laparoscopy before the adhesions were discovered.

The utility of Palmer’s point

Although multiple techniques have been described to minimize entry-related injury, no technique has completely eliminated the risk of inadvertent bowel or major large-vessel injury.³ In 1974, Palmer described an abdominal entry point for the Veress needle and small trocar for women who have a history of abdominal surgery. ⁴ Many surgeons now consider “Palmer’s point,” in the left upper quadrant, as the safest peritoneal entry site.

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Signs of adhesive process of the abdominal cavity.

Causes of development, treatment – clinic “Dobrobut”

Main

Medical Library Dobrobut

Publication date: 2020-03-14

Signs of abdominal adhesions, development, treatment

Adhesions often occur after surgical interventions on the abdominal organs. It can occur without any manifestations, but it can also cause quite pronounced discomfort. In some cases, the adhesive process occurs outside of surgical interventions and not only in the abdominal cavity. The idea of ​​​​this pathology, including what is the adhesive process in the pelvis in women, will help to seek medical help in time.

The dynamics of the development of adhesive disease in the abdominal cavity

All organs of the abdominal cavity are surrounded by peritoneum, which serves as their protection from damage. If some pathological process (often inflammatory) occurs in an organ, fibrin fibers fall out in this place, which form adhesions that limit this location from healthy organs. Such a process starts with a perforated stomach ulcer, destructive appendicitis, and so on. Also, adhesions can occur in the abdominal cavity as a result of surgical intervention as a reaction to the touch of surgical instruments, contact with talcum powder, which is used to treat surgical gloves, and so on.

Adhesions cause the abdominal organs to stick together. The result of such bonding will be a violation of the blood supply to the organ and its functions. So, if adhesions are formed between the intestinal loops, intestinal obstruction is formed – there is a violation of the stool, pain in the abdomen, which are signs of the adhesive process of the abdominal cavity.

In the international classification of diseases, adhesions in the abdominal cavity and small pelvis are considered separately.

Causes of adhesions in the abdominal cavity

The pathological condition under consideration can develop for a variety of reasons. There are three main groups of factors that can provoke the formation of adhesions:

1. Mechanical injuries. These are injuries to the abdomen during a fall from a height, a bullet or knife wound, as a result of surgical intervention.
2. Diseases of the abdominal organs of an inflammatory nature. So, adhesive disease can develop as a result of current or after suffering cholecystitis (inflammation of the gallbladder), enteritis (inflammation of the small intestine), adnexitis (inflammation of the ovaries), and so on.
3. Chemical damage to the abdominal organs. Most often observed with an outpouring of bile or stomach contents (for example, when a perforated stomach ulcer occurs).

Adhesions often occur in the small pelvis. It can develop rapidly, with characteristic symptoms, or be asymptomatic. So, adhesions after caesarean section often do not manifest themselves in any way. They can be diagnosed when a woman sees a doctor about the impossibility of becoming pregnant again, since the adhesive process in the pelvis can provoke female infertility.

Pain with intestinal adhesions and other signs

There are several signs that may indicate the development of the pathological process in question:

• intermittent vomiting that occurs regardless of food intake;
• pain in the abdomen or chest;
• chronic constipation;
• violation of gas discharge.

These are characteristic signs of the adhesive process. Pain with intestinal adhesions may not depend on food intake and increase over time. Symptoms of diaphragmatic adhesions are manifested by pain on the border between the chest and abdominal cavity, a violation of the excursion (movement) of the diaphragm and difficulty in breathing. Clinical symptoms of adhesions in the pelvis may be absent.

Adhesive disease proceeds for a long time: pain in the abdomen occurs frequently, then becomes constant, its intensity increases.

Treatment of adhesions

Treatment of postoperative adhesions is carried out using conservative and surgical methods. They are not in a hurry to resort to surgical treatment, since repeated introduction into the abdominal cavity can provoke an even greater development of the adhesive process. The operation is mandatory carried out if there are critical changes in the abdominal cavity. The severity of adhesions can only be determined during an operation – for example, performed for intestinal obstruction. The most effective method for removing adhesions that have formed around the fallopian tubes is laparoscopic surgery. The recovery process after such treatment is fast and with minimal risk of complications. The conservative treatment of adhesive disease is based on a diet (restriction of coarse fiber foods) and physiotherapy methods.

How to treat adhesions after appendectomy is up to the doctor – it can be surgery or conservative methods of treatment (diet, physiotherapy). In the early stages of the development of the adhesive process, it can be influenced by conservative methods. Drug treatment of the adhesive process can also be prescribed in gynecology – for adhesions that have arisen in the area of ​​\u200b\u200bthe appendages, vaginal suppositories are used, but such therapy is not very effective.

If adhesions occur after removal of the uterus, treatment is extremely rare, since they do not cause discomfort, and the reproductive function is irretrievably lost in any case. The expediency of treating the adhesive process in this case, the doctor determines based on the complaints of patients.

More detailed information about the pathology, including the causes of adhesions in the chest cavity, can be obtained on our website https://www.dobrobut.com/.

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Prevention of adhesions after surgery in the tubes, in the appendages, in the ovaries

A consensus on the pathogenesis and prevention of adhesions in the pelvic organs has not yet been developed . The difficulty lies in the fact that the formation of adhesions itself is a normal reaction of the body to the spread of the inflammatory process, especially in chronic inflammation or trauma. Adhesions protect surrounding organs from the spread of pathology. This disrupts the natural anatomy. The body, as it were, chooses the lesser of two evils. Therefore, the main direction of prevention should be to prevent diseases that cause adhesions. These diseases include all inflammatory and pathological processes in the pelvic organs: endometriosis, inflammation of the ovaries, fallopian tubes (salpingitis, hydrosalpinx), trauma as a result of miscarriages, abdominal operations. A high percentage of subsequent adhesion formation during non-gynecological operations, for example, after removal of the appendix, laparotomy. The adhesive process in the area of ​​the organs of the reproductive system of a woman leads to infertility, in the area of ​​the intestine – to constipation, pain, the likelihood of intestinal pinching during stress.

For those who have undergone surgery, it is worth highlighting the need to prevent adhesions after laparoscopy and give some recommendations.

Any trauma to the peritoneum (including the inevitable trauma with surgical instruments during surgery) leads to the formation of adhesions. To prevent this process, it is necessary to carry out medical treatment after the operation. Firstly, it is taking antibiotics and anti-inflammatory drugs that stop the spread of infections.

Postoperative adhesions are formed for several reasons: tissue trauma, insufficient blood supply, internal bleeding. Even the installation of the appropriate drainage after surgery cannot completely prevent hemorrhage into the abdominal cavity. At the same time, during the operation, particles of suture material, tampons, talc from gloves may remain at the site of manipulation. By themselves, they are not toxic, but they can cause so-called “crystallization points”, i.e. places of formation of adhesions.

As a prophylaxis after operations, barrier fluids are injected into the abdominal cavity, which prevent organs from sticking to the peritoneum. In addition, a purely mechanical barrier method is used – they wrap the fallopian tubes and ovaries with a polymer film, which spontaneously resolves over time.

fibrinolytic agents are used after surgery to reduce the likelihood of adhesion formation. They prevent the deposition of fibrin, a protein that is the main constituent in the formation of adhesions.

All of the above methods are necessary for the prevention of adhesions. But at the same time, do not forget that the main thing is to eliminate the cause of the original disease.