Update on Adhesions and Gynecologic Surgery
Update on Adhesions and Gynecologic 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: Some surgical barriers have been shown to reduce adhesions, but there are not substantial data to say that they reduce pain, improve fertility, or reduce the incidence of subsequent bowel obstruction.
Source: Practice Committee of American Society of Reproductive Medicine in association with the Society of Reproductive Surgeons. Pathogenesis, consequences, and control of peritoneal adhesions in gynecologic surgery Fertil Steril 2008;90(5 Suppl):S144-S149.
This statement from the practice committee of the American Society for Reproductive Medicine provides an update to what is known about pelvic adhesions and gynecologic surgery. It goes on to say that the use of some barriers, while effective in reducing postoperative adhesions, has not been shown to improve patient outcomes as related to fertility, pain, or bowel obstruction. In a brief yet complete review of the subject, topics such as the epidemiology and impact of postoperative adhesions, pathogenesis, and consequences are examined. Reduction of adhesion formation is also completely explored, covering surgical technique, anti-inflammatory agents, peritoneal instillates, and surgical barriers. The final summary and recommendations include:
- Postoperative adhesions occur as a natural process after surgical trauma and healing;
- Adhesions may result in infertility, pain, and bowel obstruction;
- Reduction in adhesions may be achieved with microsurgical principles, minimally invasive surgery, and some peritoneal instillates;
- There are no data to support the use of anti-inflammatory agents:
- Surgical barriers may reduce adhesions, but that doesn't necessarily translate into better fertility, less pain, or less risk of obstruction.
Commentary
This should be required reading for all practitioners of gynecologic surgery, including all residents in training. It provides a very digestible overview of what is known about adhesions and, more importantly, provides clinicians with what they need to know, i.e., the bottom line. The collaboration between the ASRM Practice Committee and the Society of Reproductive Surgeons is the appropriate group to know the breadth of the literature while culling out what is and isn't relevant to the practice of gynecologic surgery.
The implications for patient care are obvious. For example, the preoperative counseling and surgical approach must bear in mind that approximately one-third of patients who undergo open or pelvic surgery are readmitted on average twice during the 10 years following surgery for problems directly related or potentially related to adhesions. More than 1 of 5 admissions occurs within the first year following surgery. Not surprisingly, ovarian surgery had the highest incidence of readmission. These sobering data will hopefully create an air of caution when a patient is given informed consent about major gynecologic surgery, i.e., the first surgical procedure may well lead to others. Reading this article can also help the surgeon inform the patient in a more complete fashion regarding the benefit, or lack thereof, of surgery when lysis of adhesions is being considered.
Similarly, the surgeon and patient should review the possible surgical approaches since minimally invasive procedures may well provide better long-term outcomes. Of note, it is not the surgical approach that is the key, but the extent of tissue damage at the time of surgery. If the surgeon is rough with tissue at the time of laparoscopy, it may well be that adhesions are as bad or even worse than those resulting from an open procedure if the surgeon handles tissue gently. Intra-operative surgical decision making is a major focus of the findings reported here. Listed under "microsurgical principles" are techniques that we all do or do not adhere to as part of our macroscopic surgery. These include gentle tissue handling, removal of necrotic tissue, strict hemostasis, reduction of ischemia and desiccation, prevention of foreign body reaction, reduction of infection, and use of nonreactive suture material. Hopefully we all think about each of these with every procedure we perform.
The report's recommendations also provide guidance regarding steroids and promethazine (no help), antibiotic solutions (don't help and may hurt), dextran and crystalloid solutions (don't help), Adept Adhesion Reduction Solution (FDA-approved to reduce adhesions in conjunction with good surgical technique), heparin (no help), Seprafilm (reduces midline adhesions, but little effect for myomectomy or bowel resection), and Interceed (helps reduce new and recurrent adhesions after laparoscopy and open procedures, but no effect on fertility). Gore-Tex Surgical Membrane reduces adhesions but requires suturing then reoperation for removal. Sepracoat and Spraygel were not approved by the FDA at the time of publication and Tissel VH is approved for cardiothoracic surgery, splenic surgery, and colostomies.
The teaching point of this Committee Opinion focuses on how we factor adhesions into our practice, both in the office as well as in the operating room. First, let's all recognize that minor surgery and good surgical technique don't totally eliminate the potential formation of adhesions. Second, knowing that adhesions are the natural result of the body healing after trauma, we must be mindful that every step we perform while the patient is under anesthesia may affect how she feels and what the course of her health may be after she leaves the operating room.
Please read the entire document. Hopefully, your response afterwards will be similar to mine. Perhaps you, too, will say to yourself, "Hmmmm, that's both interesting and helpful."
This statement from the practice committee of the American Society for Reproductive Medicine provides an update to what is known about pelvic adhesions and gynecologic surgery.Subscribe Now for Access
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