INCIDENCE AND PREVENTION OF POSTOPERATIVE ADHESIONS
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 . 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® ; 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.
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.
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 . 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.
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.
1. Dcizerega GS. Biochemical events in peritoneal tissue repair. Eur J Surg 1997; 577:10-16.
2. Dizerega GS. The peritoneum: post-surgical repair and adhesions formation. In Rock JA, Murphy AA, Jones HW, eds. Female reproductive surgery. Boston: Williams and Wilkins 1992, 2-18.
3. Coleman MG, McLain AD, Moran BJ. Impact of previous surgery on time taken for incision and division of adhesions during laparotomy. Dis Colon Rectum 2000; 43:1297-99.
4. Rangabashyam N. Peritoneal surgery. Susrutha Surgical Continuing Medical Education Programme, Chennai, 2001.
5. Rangabashyam N. Reopertive Surgery for bowel obstruction following abdominal operation, Methods of intestinal decompression and difficulties in abdominal closure. ASICON, New Delhi, December 2000.
6. Suman.V.Gupta. Post-operative adhesions - Morbidity and Management. Journal of Gastroenterology 1997; 72:28-37.
7. Holmdahl L. The role of Fibrinolysis in Adhesion formation. Eur J Surg 1997; 57;24-31.
8. Ray NF, Denton WG, Thamer M, Henderson SC, Perry S. Abdominal Adhesiolysis: Inpatient care and expenditure in the United States in 1994. J Am Coll Surg 1998; 186(l):l-9.
9. Manzies D, Ellis H. Intestinal obstruction from adhesions: How big is the problem? Ann R Coll Surg, 6, 1993, 9-23.
10. Menzies D, Ellis H. Intestinal obstruction from adhesions: how big is the problem? Ann R Coll Surg Engl 1990; 72:60-3.
11. Nunobe S, Hiki N, Fukunaga T, et al. Previous laparotomy is not a contraindication to laparoscopy-assisted gastrectomy for early gastric cancer. World J Surg 2008; 32:1466-72.
12. De Wilde RL, Trew G, ESGE Expert adhesions working party. Postoperative abdominal adhesions and their prevention in gynaecological surgery. Expert consensus position. Gynecol Surg 2007; 4:161-8.
13. Wiebel MA, Majno G. Peritoneal adhesions and their relation to abdominal surgery. Am J Surg 1973; 126:345-53.
14. Panay N and Lower A.M (1999). New directions in the prevention of adhesions in laparoscopic surgery. Curr Opin Obstet Gynecol 11:379-385.
15. Monk B.J, Berman M.L and Montez F.J (1994). Adhesions after extensive gynaecologic surgery: clinical significance, etiology and prevention. Am J Obstet Gynecol 170:1396-1403.
16. Ray N.F, Larsen J.W, Stillman R.J and Jacobs R.J (1993). Economical effect of hospitalization for lower abdominal adhesiolysis in United States in 1988. Surg Gynecol Obstet 176:271-276.
17. Raftery AT. Regeneration of parietal and visceral peritoneum: an electron microscopical study. J Anat 1973; 115(Pt 3):375-92.
18. Van der Wal JBC, Jeekel J. Biology of the peritoneum in normal homeostasis and after surgical trauma. Colorectal Dis 2007; 9(Suppl. 2):9-13.
19. Bellina JH, Hemmings R, Voros JI, Ross LF. Carbon dioxide laser and electrosurgical wound study with an animal model: a comparison of tissue damage and healing patterns in peritoneal tissue. Am J Obstet Gynecol 1984; 148(3):327-34.
20. Forestier D, Slim K, Joubert-Zakeyh J, Nini E, Dechelotte P, Chipponi J. Do bipolar scissors increase postoperative adhesions? An experimental double-blind randomized trial. Ann Chir 2002; 127(9):680-4.
21. Duron JJ. Postoperative intraperitoneal adhesion pathophysiology. Colorectal Dis 2007; 9(Suppl. 2):14-24.
22. Wilkins BM, Ellis H. Incidence of postoperative adhesion obstruction following neonatal laparotomy. Br J Surg 1986; 73:762-4.
23. Karayiannakis AJ, Polychronidis A, Perente S, et al. Laparoscopic cholecystectomy in patients with previous upper or lower abdominal surgery. Surg Endosc 2004; 18(1):97-101.
24. Hayashi S, Takayama T, Masuda H, et al. Bioresorbable membrane to reduce postoperative small bowel obstruction in patients with gastric cancer. Ann Surg 2008; 247:766-70.
25. Leung TT, Dixon E, Gill M, et al. Bowel obstruction following appendectomy: what is the true incidence? Ann Surg 2009; 250:51-3.
26. Parker MC, Wilson MS, Menzies D, et al. The SCAR-3 study: 5- year adhesion related readmission risk following lower abdominal surgical procedures. Colorectal Dis 2005; 7(6):551-8.
27. Ellis H, Moran BJ, Thompson JN, et al. Adhesion-related hospital readmissions after abdominal and pelvic surgery: a retrospective cohort study. Lancet 1999; 353(9163):1476-80.
28. Lower AM, Hawthorn RJ, Ellis H, et al. The impact of adhesions on hospital readmissions over ten years after 8849 open gynaecological operations: an assessment from the surgical and clinical adhesions research study. BJOG 2000; 107(7):855-62.
29. Parker MC, Ellis H, Moran BJ, et al. Postoperative adhesions: ten-year follow-up of 12,584 patients undergoing lower abdominal surgery. Dis Colon Rectum 2001; 44(6):822-9.
30. MacLean AR, Cohen Z, MacRae HM, et al. Risk of small bowel obstruction after the ileal pouch-anal anastomosis. Ann Surg 2002; 235(2):200-6.
31. Fazio VW, Ziv Y, Church JM, et al. Ileal pouch-anal anastomoses complications and function in 1005 patients. Ann Surg 1995; 222(2):120-7.
32. Nieuwenhuijzen M, Reijnen MM, Kuijpers JH, et al. Small bowel obstruction after total or subtotal colectomy: a 10-year retrospective review. Br J Surg 1998; 85(9):1242-5.
33. Andersson RE. Small bowel obstruction after appendicectomy. Br J Surg 2001; 88(10):1387 91.
34. Wong DC, Chung CC, Chan ES, Kwok AS, Tsang WW, Li MK. Laparoscopic abdominoperineal resection revisited: are there any health-related benefits? A comparative study. Tech Coloproctol 2006; 10:37-42.
35. Zhou ZG, Hu M, Li Y, et al. Laparoscopic versus open total mesorectal excision with anal sphincter preservation for low rectal cancer. Surg Endosc 2004; 18:1211-5.
36. Staudacher C, Vignali A, Saverio DP, Elena O, Andrea T. Laparoscopic vs. open total mesorectal excision in unselected patients with rectal cancer: impact on early outcome. Dis Colon Rectum 2007; 50:1324-31.
37. Duron JJ, Hay JM, Msika S, et al. Prevalence and mechanisms of small intestinal obstruction following laparoscopic abdominal surgery: a retrospective multicenter study. French Association for Surgical Research. Arch Surg 2000; 135:208-12.
38. Taylor GW, Jayne DG, Brown SR, et al. Adhesions and incisional hernias following laparoscopic versus open surgery for colorectal cancer in the CLASICC trial. Br J Surg 2010; 97(1):70-8.
39. Miller G, Boman J, Shrier I, Gordon PH. Natural history of patients with adhesive small bowel obstruction. Br J Surg 2000; 87(9):1240-7.
40. Tingstedt B, Isaksson J, Andersson R. Long-term follow up and cost analysis following surgery for small bowel obstruction caused by intra-abdominal adhesions. Br J Surg 2007; 94(6):743-8.
41. Duron JJ, Jourdan Da Silva N, du Montcel ST, et al. Adhesive postoperative small bowel obstruction: incidence and risk factors of recurrence after surgical treatment: a multicenter prospective study. Ann Surg 2006; 244(5):750-7.
42. Wilson MS, Hawkswell J, McCloy RF. Natural history of adhesional small bowel obstruction: counting the cost. Br J Surg 1998; 85(9):1294-8.
43. Levard H, Boudet MJ, Msika S, et al. Laparoscopic treatment of acute small bowel obstruction: a multicentre retrospective study. ANZ J Surg 2001; 71(11):641-6.
44. Choi HK, Chu KW, Law WL. Therapeutic value of gastrografin in adhesive small bowel obstruction after unsuccessful conservative treatment: a prospective randomized trial. Ann Surg 2002; 236(1):1-6.
45. Di Saverio S, Catena F, Ansaloni L, Gavioli M, Valentino M, Pinna AD. Water soluble contrast medium gastrografin) value in adhesive small intestine obstruction (ASIO): a prospective, randomized, controlled, clinical trial. World J Surg 2008; 32(10):2293-304.
46. Fevang BT, Fevang J, Lie SA, et al. Long-term prognosis after operation for adhesive small bowel obstruction. Ann Surg 2004; 240(2):193-201.
47. Margenthaler JA, Longo WE, Virgo KS, et al. Risk factors for adverse outcomes following surgery for small bowel obstruction. Ann Surg 2006; 243(4):456-64.
48. Duron JJ, du Montcel ST, Berger A, et al. Prevalence and risk factors of mortality and morbidity after operation for adhesive postoperative small bowel obstruction. Am J Surg 2008; 195(6):726-34.
49. Van Goor H. Consequences and complications of peritoneal adhesions. Colorectal Dis 2007; 9(Suppl. 2):25-34.
50. Makoha FW, Fathuddien MA, Felimban HM. Choice of abdominal incision and. risk of trauma to the urinary bladder and bowel in multiple cesarean sections. Eur J Obstet Gynecol Reprod Biol 2006; 125(1):50-3.
51. Van Der Krabben AA, Dijkstra FR, Nieuwenhuijzen M, et al. Morbidity and mortality of inadvertent enterotomy during adhesiotomy. Br J Surg 2000; 87(4):467-71.
52. El-Hakim A, Chiu KY, Sherry B, et al. Peritoneal and systemic inflammatory mediators of laparoscopic bowel injury in a rabbit model. J Urol 2004; 172(4 Pt1):1515-9.
53. LeBlanc KA, Booth WV, Whitaker JM, Bellanger DE. Laparoscopic incisional and ventral herniorrhaphy in 100 patients. Am J Surg 2000; 180(3):193-7.
54. Ben-Haim M, Kuriansky J, Tal R, et al. Pitfalls and complications with laparoscopic intraperitoneal expanded polytetrafluoroethylene patch repair of postoperative ventral hernia. Surg Endosc 2002; 16(5):785-8.
55. Carbajo MA, Martp del Olmo JC, Blanco JI, et al. Laparoscopic approach to incisional hernia. Surg Endosc 2003; 17(1):118-22.
56. Rosen M, Brody F, Ponsky J, et al. Recurrence after laparoscopic ventral hernia repair. Surg Endosc 2003; 17(1):123-8.
57. Bencini L, Sánchez LJ. Learning curve for laparoscopic ventral hernia repair. Am J Surg 2004; 187(3):378-82.
58. Van der Voort M, Heijnsdijk EA, Gouma DJ. Bowel injury as a complication of laparoscopy. Br J Surg 2004; 91(10):1253-8.
59. Gilmore OJA, Reid C. Prevention of peritoneal adhesions by a new povidone-iodine/PVP solution. Jf Surg Res 1978; 25:477-81.
60. Holtz G, Baker ER. Inhibition of peritoneal adhesion formation after lysis with 32% dextran 70. Feruil Steril 1980; 34: 394-5.
61. Adhesion Study Group. Reduction of post-operative pelvic adhesions with intraperitoneal 32% dextran 70:a prospective randomised clinical trial. Fertil Steril 1983; 40:612-19.
62. Johns A. Evidence-based prevention of post-operative adhesions. Human Reproduction Update 2001; 7(6):577-9.
63. Duron JJ. Brides et adherences intraperitoneales postoperatoires: realites actuelles et futures. Ann Chir 2004; 129(9):487-8.
64. Dowson HM, Bong JJ, Lovell DP, Worthington TR, Karanjia ND, Rockall TA. Reduced adhesion formation following laparoscopic versus open colorectal surgery. Br J Surg 2008; 95(7):909-14.
65. Audebert AJ, Gomel V. Role of microlaparoscopy in the diagnosis of peritoneal and visceral adhesions and in the prevention of bowel injury associated with blind trocar insertion. Fertil Steril 2000; 73:631-5.
66. Scholin J, Buunen M, Hop W, et al. Bowel obstruction after laparoscopic and open colon resection for cancer: Results of 5 years of follow-up in a randomized trial. Surg Endosc 2011; 25(12):3755-60.
67. Khaitan L, Scholz S, Richards WO. Laparoscopic adhesiolysis and placement of Seprafilm (trademark): A new technique and novel approach to patients with intractable abdominal pain. J Laparoendosc Adv Surg Tech A 2002; 12(4):241-7.
68. Dunn R, Lyman MD, Edelman PG, et al. Evaluation of the SprayGel adhesion barrier in the rat cecum abrasion and rabbit uterine horn adhesion models. Fertil Steril 2001;75:411– 6.
69. Mettler L, Audebert A, Lehmann-Willenbrock E, et al. A randomized, prospective, controlled, multicenter clinical trial of a sprayable, site-specific adhesion barrier system in patients undergoing myomectomy. Fertil Steril 2004;82:398–404.
70. Johns DA, Ferland R, Dunn R. Initial feasibility study of a sprayable hydrogel adhesion barrier system in patients undergoing laparoscopic ovarian surgery. J Am Assoc Gynecol Laparosc 2003;10:334–8.
71. Tjandra JJ, Chan MK. A sprayable hydrogel adhesion barrier facilitates closure of defunctioning loop ileostomy: a randomized trial. Dis Colon Rectum 2008;51:956–60.
72. Luciano AA. Laparotomy versus laparoscopy. Prog Clin Biol Res 1990;358:35-44.
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