The trusted source for
healthcare information and
In Search of Adhesion-free Pelvic Surgery
Abstract & Commentary
By Frank W. Ling, MD, Clinical Professor, Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, is Associate Editor for OB/GYN Clinical Alert.
Dr. Ling reports no financial relationship to this field of study.
Synopsis: Prospective protocols were successfully used in 95 patients at one institution to prevent recurrent adhesions in patients who had significant adhesions at the time of surgery.
Source: Hilgers TW. Near adhesion-free reconstructive pelvic surgery: Three distinct phases of progress over 23 years. J Gynecol Surg 2010;26:31.
The author summarizes the protocols used at his institution to prevent adhesions in patients who were undergoing evaluation and treatment for significant pelvic pathology. Over the duration of the report, three distinct protocols were applied sequentially. The intent was to reduce as much as possible the adhesions that occurred in the pelvis following extensive reconstructive surgery. The 95 patients had adhesions due to endometriosis or pelvic inflammatory disease. All patients underwent laparoscopy with scoring of adhesions utilizing the American Fertility Society system. The patients then underwent the laparotomy to normalize anatomy using the techniques included in the protocol at that time. A repeat laparoscopy at 8-10 days post-laparotomy was performed to treat any recurrent adhesions and to score the adhesions seen.
The difference in scores within each protocol was statistically significant when comparing the first and the second laparoscopy. Similarly, there was significant improvement between the phases (i.e., I vs II, I vs III, and II vs III). In Phase I, the adhesion score went from 33.8 to 18.1. In Phase II, the scores were 33.3 and 6.0, respectively, while in Phase III, the score went from 33.2 to 2.5. Innovative approaches included the use of fluid-filled gloves instead of lap packs to hold bowel out of the surgical field, use of Preclude® peritoneal membrane, and CoSeal® surgical sealant. The key aspects of the protocols include:
Phase I (1987-1993)
Phase II (1994-2005)
Phase III (2006-2009)
This is pretty wild stuff ... not because it's bad medicine or crazy decision-making or misuse of technology, but because it addresses a unique group of patients in an unusual clinical circumstance. The benefit to us is that there are principles that each of us can adapt for our own practice.
It should be noted right up front that the institution that the author represents is the Department of Obstetrics and Gynecology at the Pope Paul VI Institute in Omaha, NE. Patients included in these protocols had extensive disease, but, as I infer from the article, were not able to participate in the use of contemporary assisted reproductive technologies (ARTs). As a result, tough endometriosis or pelvic infection cases, which might in other practice settings lead to use of ART, had to be dealt with using aggressive and extensive pelvic reconstruction.
The author describes several techniques that we were taught even way back when I was a resident. They held true then, as they do now. As a side note, some of us in Memphis also did some early animal work using instillation of sodium carboxymethylcellulose (SCMC) which did prove to work, but did not progress to human application. One reason was that SCMC was in Rely® tampons (the ones that were tied to toxic shock syndrome).
The ePTFE membrane (Gore-Tex®) reduces adhesions in myomectomy and adhesion cases and is not compromised by residual blood as is the case with other barriers. Some view its primary limitation to be the need to suture it in place initially, then to remove it at the time of laparoscopy.
CoSeal is a sprayable polymeric matrix, which was developed as a vascular sealant in vascular surgery. It has been shown to be useful to prevent pericardial adhesions and has been successfully applied to use in myomectomy cases.
The use of Hyskon is now limited by the lack of availability. The recent FDA approval of Adept® by Baxter, which is approved only for laparoscopy, may well provide a replacement.
The obvious question that should be addressed is whether these patients got pregnant or not. Since the paper only reported the adhesion scores as the endpoint, I can't give you the answer to the pregnancy outcome question. Nor can I provide information on pain scores or long-term follow-up for these patients. The paper certainly has limitations for all these reasons, but it remains an interesting read. Admittedly, it would have been even more interesting if the author gave us an incredible pregnancy rate outcome and/or report that the patients didn't have pain or any occurrences of small bowel obstruction. Unfortunately, none of that was reported.
Even though many patients in our practices with the extensive adhesions seen in this series might opt for ART, some might choose fertility-sparing surgery instead. This could be for insurance reasons, moral/ethical issues, or financial considerations. The principles of the protocols provide us with options to help these patients, but they also guide us in our day-to-day surgical procedures that we perform on other patients. We know that adhesions can cause pain, infertility, and small bowel obstruction in any patient, regardless of what we're doing surgically. We can certainly do our part in every case to minimize risks of adhesions.