INCIDENCE AND PREVENTION OF POSTOPERATIVE ADHESIONS

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The barrier phenomenon
It is the preponderant mechanism of action of a variety of products marketed as biocompatible and biodegradable films, such as membrane films of hyaluronic acid on a supporting structure of carboxymethylcellulose (Seprafilm®, Genzyme Corp., USA), oxidized cellulose (Interceed®, Johnson& Johnson, New Brunswick, NJ, USA), and in the form of inert non-resorbable prostheses such as expanded polytetrafluoroethylene patches (PTFE) (Gore-Tex® and Preclude®, Gore & associates, Newark, Delaware, USA). Their principal advantage is to set up a fixed physical barrier between the viscera from the parietal peritoneum, whose reabsorption kinetics can be much better controlled and predictable than is the case for solutions and gels. Their principal disadvantage is that their action is limited only to the site where they are placed. A single leaf of these products covers only a small percentage of the total peritoneal surface; the surgeon must be mindful that it only requires a single adhesion (that may develop at some distance from the operative site) to provoke a severe complication such as bowel obstruction [62]. The surgeon must therefore select the zone for film application where he anticipates the greatest likelihood of adhesion formation; surgeons usually opt for the incision line and the site of surgical dissection. A second disadvantage is that films are technically difficult to apply through laparoscopic access ports. This is particularly the case for Seprafilm® [67]; it is extremely difficult to achieve accurate placement of Seprafilm® at laparoscopy, and yet the effect of the treatment depends essentially on impeccably accurate placement. For placement of nonresorbable patches (expanded PTFE) that require suture fixation, laparoscopic placement is even more difficult. Products in gel form depend of both hydroflotation and the barrier phenomenon for their effect; these include 0.5% ferric hyaluronate gel (Intergel®, Lifecore Biomedical Inc, Chaska, MN, USA) and a hydrogel of polyethylene glycol delivered as a spray (Spraygel®, Confluent Surgical Inc, Waltham, MA, USA), or a derivative with more rapid resorption and neutral coloration (Sprayshield® Covidien,Waltham, MA, USA). The advantages of gel anti-adhesion products are a longer half-life (one to two weeks) than instilled peritoneal liquids, and ease of application compared to film placement, particularly when applied to irregular surfaces such as the limbs of enteric anastomoses.

Bioabsorbable gels
Various agents have been developed and tested, but most have been abandoned or withdrawn because of safety issues or a lack of efficacy. SprayGel (Confluent Surgical, Inc, Waltham, MA) is one of the more extensively tested gels. It is a sprayable hydrogel that adheres to the tissues for a period of 5 to 7 days. After several days it is hydrolyzed into water-soluble molecules and is absorbed. The safety of SprayGel has been shown in a few gynecologic and colorectal studies [68-71].Although early preliminary clinical trials showed its effectiveness, a larger-scale study was stopped owing to a lack of efficacy.

Future advances
In the absence of any clinically proven means of preventing adhesions from forming, the onus lies with the surgeon to try and minimalise their occurrence by improved and assiduous surgical techniques. The advent of laparoscopic surgery may alter the incidence of adhesions and adhesive obstruction after abdominal surgery. The reduced bowel trauma from handling, the absence of large abdominal wounds and the exclusion of foreign material such as lint, gauze and starch from the abdominal cavity must reduce adhesion formation after laparoscopic surgery. One study has already demonstrated that when a stimulus is applied at open laparotomy in an animal it produces more adhesions than when the same stimulus is applied through the laparoscope [72]. No additional adhesions were found at remote areas when the laparoscope had been used. Despite the promise of laparoscopic surgery, adhesions will continue to be a major source of concern for surgeons, not only because of the technical difficulties they present but also because of the volume of work they generate. It is possible that in the future these problems may be reduced by some form of rt-PA peritoneal lavage after surgery or adhesion division that will deter adhesion formation or re-formation and this will go some way in lightening the burden of a pathological process produced by surgery itself.

Conclusion
Postoperative adhesions are a significant health problem with major implications on quality of life and health care expenses. General intraoperative preventative techniques, such as starch-free gloves, avoiding unnecessary peritoneal dissection, avoiding spillage of intestinal contents or gallstones, and reducing remaining surgical material, may reduce the risk of adhesions and should be applied in every patient. Laparoscopic techniques are preferable to open techniques whenever possible. In high-risk procedures the use of bioabsorbable mechanical barriers should be considered.

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