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Laparoscopic Adhesiolysis and Adhesion Prevention — 307
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Table 11.3: Advantages of Laparoscopic Procedures for
Preventing Adhesion Formation
Decreased peritoneal injury
Minimized tissue handling
Decreased immune and stress response
Prevention of air pollution in the abdominal cavity
Reduced drying of the peritoneal surface
Intact peritoneal phospholipid layer
Reduced impairment of gut motility
besides being safe and effective, should be noninflammatory and
nonimmunogenic,persistduring the critical remesothelialization
phase, stay in place without suturesorstaples, remain active in the
presence of blood, and be completely biodegradable. In addition,
it should not interfere with healing, promote infection, or cause
adhesions.[26] We still do not have an ideal adhesion-preventing
substance. Following is a summary of the most commonly used
adhesion-reducing substances.
Pharmacologic Interventions
A classical approach to adhesion prevention has been the use
of drugs to inhibit or retard adhesion formation without providing a physical barrier to tissue contact (Table 11.4). These
pharmacologic interventions include the use of anticoagulants
and fibrinolytics (e.g., tissue plasminogen activator,heparin, and
low molecular weight heparins), anti-inflammatory agents (e.g.,
nonsteroidal anti-inflammatory drugs and steroids), growth factor inhibitors and modulators, and various other medications to
attenuate the formation of postsurgical adhesions. Steroids and
antihistamines are used infrequently because of their questionable efficacy and potential adverse effects, such as delayed wound
healing and the risk of wound dehiscence.[44] Unfortunately, a
global examination of the literature suggests there are very little
clinical data supporting the use of any one of these interventions
as the standard of care.[24] Other most commonly known adhesion barriers arelistedin Table 11.5 and evaluated inthefollowing
paragraphs.
Peritoneal Instillates
Crystalloids
Absorption of water and electrolytes fromthe peritoneal cavity is rapid, with up to 500 mL of iso-osmolar sodium chloride
absorbed in less than 24 hours.[45] Because it takes 5 to 8 days
for peritoneal surfaces to remesothelialize, a crystalloid solution
should be absorbed well before the processes of fibrin deposition
and adhesion formation are complete. From a theoretical point
of view, intraperitoneal crystalloid instillates are not expected
to prevent adhesion formation.[26] A substantial body of clinical data is available to assess the benefit of crystalloid instillates,
such as saline and lactated Ringer’s solution, in adhesion prevention. During the early 1980s, many clinical studies were pub-
Table 11.4: Pharmacological Interventions to Prevent
Adhesions
Nonsteroidal anti-inflammatory drugs
Corticosteroids
Antihistamines
Progesterone/estrogen
Anticoagulants
Fibrinolytics
Antibiotics
lished that compared dextran with crystalloid used as instillates.
A combination of these studies showed an adhesion re-formation
rate of approximately 80% in patients who received crystalloid
instillates.[46] To significantly reduce adhesion formation and
re-formation, the device must effectively separate damaged surfaces during the crucial phases of postsurgical repair. The rapid
rate of absorption of crystalloid solution from the peritoneal
cavity (35 to 60 mL/hour) may preclude its residence during
the crucial time of adhesion formation. Meta-analysis of clinical
studies using crystalloid solution conclusively showed no reduction in adhesion with instillation of lactated Ringer’s solution or
saline.[36]
32% Dextran 70 (Hyskon)
Hyskon (Medisan Pharmaceuticals Inc., Parsippany, NJ), a
high molecular weight form ofdextran,isabsorbed from the peritoneal cavity over 7 to 10 days. Its osmotic effect draws fluid into
the peritoneal cavity to float mobile peritoneal organs, reducing
adherence between intraperitoneal structures. Through dilution,
Table 11.5: Barriers to Prevent Adhesions
Peritoneal Instillates
Crystalloids
32% Dextran 70 (Hyskon)
Hyaluronic acid
Hyaluronic acid with ferric ion (Intergel)
Combined hyaluronic acid and carboxymethylcellulose (Sepracoat)
Hydrogel (SprayGel)
Viscous gel
Carboxymethylcellulose and polyethylene glycol (viscoelastic gel)
Auto–cross-linked hyaluronan gel (Hyalobarrier)
Solid Adhesion Barriers
Oxidized regenerated cellulose (Interceed)
Expanded polytetrafluoroethylene (Gore-Tex)
Combined hyaluronic acid and carboxymethylcellulose (Seprafilm)
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dextran also diminisheslocalfibrin concentration, preserves local
plasminogen activators, and interferes with polymorphonuclear
neutrophil expression of adhesion molecules.[47,48] Some studies in animals [49] and humans [49,50] have shown reduced
postoperative adhesions, but inconsistent results suggest limited
efficacy. In addition, there have been reports of allergic reactions
[51,52], infections, and complications of fluid overload.
Hyaluronic Acid
Hyaluronic acid (HA) is a naturally occurring glycosaminoglycan and a major component of the extracellular matrix, including connective tissue, skin, cartilage, and vitreous and synovial
fluids. HA is biocompatible, nonimmunogenic, nontoxic, and
naturally bioabsorbable. Like carboxymethylcellulose, it is negatively charged at physiologic pH and freely soluble.[26] HA coats
serosal surfaces and provides a certain degree of protection from
serosal desiccation and other types of injury. However, its use
after tissue injury is ineffective.
HYALURONIC ACID WITH FERRIC ION (INTERGEL)
Cross-linking HA with ferric ion (FeHA) increases its viscosity and half-life. The first marketed derivative of FeHA is Intergel
(Lifecore, Johnson and Johnson Gynecare Unit, New Brunswick,
NJ). Intergel Adhesion Prevention Solution isa single-use, sterile,
nonpyrogenic 0.5% ferric hyaluronate gel. This amber-colored
aqueous gel of sodium hyaluronatehasbeenionicallycross-linked
with ferric ionsand adjusted to isotonicity with sodium chloride.
It is packaged in a bellows-type container designed to deliver
300 mL of Intergel solution. Intergel solution functions by providing a viscous, lubricated coating on the peritoneal surfaces,
minimizing tissue apposition during the critical period of fibrin formation and mesothelial regeneration. Lymphatic drainage
appears to bethemajor elimination pathway for intraperitoneally
administered Intergel solution. The elimination half-life (t
1/2
)of
Intergelsolutioninhumanshasbeen estimatedfromanimalstudies to be approximately 51 hours. The 300-mL Intergel solution
instillation is expected to clear from the peritoneal cavity in 5 to
7days.
Intergel solution has been shown to be easy to use in a multicenter randomized study and to reducethe number, severity, and
extent of postoperative adhesions after gynecologic surgery.[53]
The product was withdrawn from the market because of several reports of late-onset postoperative pain requiring repeated
surgery. Other reported side effects are foreign body reactions
and tissue adherence.[54]
COMBINED HYALURONIC ACID AND
CARBOXYMETHYLCELLULOSE (SEPRACOAT)
Sepracoat (Genzyme Corp., Cambridge, MA) is composed
of chemically derived sodium hyaluronate and carboxymethylcellulose (HAL-C). Sepracoat is bioresorbable, with an intraabdominal residence time of 24 hours or less and complete
clearance in 5 days or less. It acts by decreasing tissue desiccation. This solution coats tissues with a temporary, protective, viscous barrier.[55] Preclinical studies have shown Sepracoat to be safe and effective in reducing and preventing de
novo adhesion formation in animal models.[56] In animal studies, tissue precoating with Sepracoat significantly reduced de
novo adhesion formation compared with nontreated control
animals.[56,57] Consistent with those observations, in a multi-
center randomized clinicaltrial, Sepracoatsignificantly increased
the percentage of patients who were free of de novo adhesion formation to 13.1%, compared with 4.6% of the control
group.[58] The use of Sepracoat also was associated with significant reductions in the proportion of available sites with
de novo adhesion formation, as well as the severity and extent
of de novo adhesion formation.
Hydrogel (SprayGel)
SprayGel Adhesion Barrier (Confluent Surgical, Waltham,
MA) is a synthetic hydrogel that forms when two polyethylene glycol (PEG)-based liquids are sprayed onto target tissue,
where the precursor liquids cross-link within seconds to form
an absorbable, flexible, adherent gel barrier in situ. The delivery system is a 5-mm–diameter, air-assisted sprayer that can be
used in either laparoscopic or open procedures. The gel barrier
remains intact at the site of application for approximately 5 to
7 days, protecting the target tissue during the normal woundhealing period, and then gradually breaks down through hydrolysis into PEGconstituent molecules thatare resorbed andrapidly
cleared by the kidneys. The material has been shown to be highly
biocompatible.[59,60]
Mettler et al. [61] evaluated 66 women who underwent
myomectomy with or without SprayGel application. A secondlook laparoscopy was performed in 40 women. The investigators
reported that seven of 22 patients (31.8%) in the SprayGel group
and two of 18 patients (11.1%) in the control group were free
of adhesions. This product might be well suited for infertility
surgery, endometriosis, pelvic floor repair, and any surgeries carried out for adhesiolysis, but this needs tobe further investigated.
Viscous Gel
The carboxymethylcellulose and PEG formulation is a transparent, viscoelastic gel that is readily administered to the specific
anatomic sites where adhesion formation is a concern. This ease
of use includes single-unit packaging stored at room temperature, which, when opened, delivers the sterile gel and applicator
directly to the operating field. The gel viscosity allows the surgeon to control directly the rate of gel delivery to the surgical site.
When the surgeon stops depressing thesyringe, gel stops flowing.
Gel residingwithin the applicator tubedoes notharden, allowing
for continued application at the convenience of the surgeon. In
a small randomized series, 15 mL of viscoelastic gel was instilled
to the adnexal area in 25 patients. The results were compared
with those of 24 patients who underwent surgery without the use
of the gel.[62] The authors reported that the use of viscoelastic
gel showed a significant reduction in the number of adnexa that
developed adhesions following surgery. In the viscoelastic gel–
treated group, 93% of the adnexa did not have a worse adhesion
category in contrast to 56% of the control adnexa at the time
of second look. These differences were highly significant and
demonstrated the overall benefit of viscoelastic gel when used
with good surgical technique to enhance the likelihood of a good
response to surgical therapy. The gel was safe and no complications or adverse events were observed in the treatment group.
A highly viscous gel of HA derivatives obtained through an
auto–cross-linking processthat does not introduceforeignbridge
molecules, namely auto–cross-linked hyaluronan gel (Hyalobarrier, FAB-Fidia), has recently been developed. The auto–crosslinked polymer is an inter- and intramolecular ester of HA in
Laparoscopic Adhesiolysis and Adhesion Prevention — 309
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which a proportion of the carboxyl groups is esterified with
hydroxyl groups belonging to the same and/or different molecules
of the polysaccharide, thus forming a mixture of lactones and
intermolecular ester bonds. The level of cross-linking can be varied by modulating thereactionconditions.The absence of foreign
bridge molecules ensures the release of native HA only during
degradation, whereas the auto–cross-linking process improves
the viscoelastic properties of the gel compared with unmodified
HA solutions of the same molecular weight.[63]
Preclinical trials in animal models have shown that auto–
cross-linked hyaluronan gel reduces the incidence and severity
of postoperative adhesions.[64,65] Moreover, preliminary clinical studies in hysteroscopic surgery as well as laparotomic and
laparoscopicmyomectomy havesuggestedthatauto–cross-linked
hyaluronan gel may reduce the incidence and severity of postoperative adhesions in pelvic surgery [66,67], with improvement in
the pregnancy rate in infertile patients who were submitted to
laparoscopic myomectomy.[68]
Recently, Mais and et al. [69] investigated the applicability,
safety, and efficacy of an auto–cross-linked hyaluronan gel in
preventing adhesion formation after laparoscopic myomectomy.
Fifty-two patients were randomly allocated to receive either the
gel or no adhesion prevention. At second look, the incidence and
severity of postoperative adhesions were assessed laparoscopically after 12 to 14 weeks. A nonsignificantly higher proportion
of patients receiving the gel were free from adhesions (13 of 21;
62%) compared with control patients (nine of 22; 41%), with a
statistically significant difference between the severity of uterine
adhesions at baseline and at second look. The authors suggested
that the auto–cross-linked hyaluronan gel might have a favorable safety profile and efficacious antiadhesive action following
laparoscopic myomectomy.
Solid Adhesion Barriers
inated completely. Haney and Doty [74] applied Interceed in the
abdominal cavity of normal mice. They found peritoneal injury
and new adhesions between the abdominal peritoneum and the
intra-abdominal viscera. Pagidas and Tulandi [75] found that
Interceed was not effective in decreasing postoperative adhesions in rats. Fewer adhesions were found in animals treated
with Gore-Tex (W. L. Gore & Associates, Inc., Flagstaff, AZ) and
lactated Ringer’s solution than in control and Interceed-treated
animals.[75] On the other hand, in the rabbit model, Interceed
reduced the incidence and score of postoperative ovarian adhesions and improved the reproductive outcome.[76] Azziz [77]
observed in a prospective,randomized trial involving 134 patients
undergoing adhesiolysis by standard microsurgical techniques at
laparotomy that 90% benefited from the use of Interceed.
Randomized prospective studies showed a significant reduction in the formation of postoperative adhesions after laparoscopic ovarian operations [78,79], myomectomy [80], and surgical treatment of endometriosis.[81] Interceed is supplied as a
sterile unit of 7.6 cm × 10.2 cm and is cut to the appropriate size
to be applied on the desired organ. It is essential that complete
hemostasis be achieved before ORC is placed on the peritoneal
surface, as the presence of intraperitoneal blood negates any beneficial effect. Because hemostasis at the myomectomy incision is
rarely absolute, its use could be precluded.[82] Fixation of Interceed by placing 6-0 Vicryl sutures [83] and the addition of heparin [84]did not enhancethe adhesion-reducing capacity. Rather
than support bacterial growth, ORC exhibits antibacterial properties in vivo. Interceed appears to play an important role and
may provide beneficial effects in preventing and reducing postoperative adhesion development. The efficacy of this absorbable
barrier is limited to situations in which the traumatized area can
be covered completely. Effective application is limited by technical difficulties, including the need for hemostasis and removal of
excess peritoneal fluid.[70]
Oxidized Regenerated Cellulose (Interceed)
Interceed (Gynecare, Johnson & Johnson Medical,
Somerville, NJ) is an absorbable adhesion barrier made of
oxidized regenerated cellulose (ORC). Evidence has shown
that Interceed is safe and effective in reducing the incidence
of postoperative adhesions in patients undergoing various
laparoscopic operations.[70] ORC is the first commercially
marketed adhesion barrier. ORC prevents adhesion formation
by its transformation into a gelatinous mass covering the
damaged peritoneum. When applied to a raw peritoneal surface,
it becomes gel within 8 hours. ORC can be applied easily by
laparoscopy, follows the contour of the organ, and does not need
suturing.
It has been postulated that ORC may compete for the
macrophage scavenger receptorbecause of its polyanionicnature.
Results from in vitro studies suggest that the interaction of
Interceed with macrophages with scavenger receptors results in
decreased secretion of matrix components, inflammatory mediators, and cellular growth factors. Thus, Interceed cellulose may
function asa biologic barrier in preventingadhesions.[71] In two
multicenter clinical studies [72,73], Interceed was placed on only
one pelvic side wall at the conclusion of the operation, although
both areas had been treated for comparable disease. At a secondlook laparoscopy, fewer adhesions re-formed on the side treated
with Interceed, although postoperative adhesions were not elim-
Expanded Polytetrafluoroethylene (Gore-Tex)
Another barrier material is an expanded polytetrafluoroethylene (PTFE) Gore-Tex surgical membrane.This material isa nonabsorbable, nonreactive surgical membrane that has been used
to repair and reconstruct the pericardium and peritoneum.[85]
Expanded PTFE is an antithrombogenic, nontoxic synthetic fabric with small pores that inhibitcellulartransmigration andtissue
adherence. The use of PTFE is strictly reserved for noncontamination operations. This barrier should be sutured to the tissue,
overlapping the incision by more than 1 cm. It prevents adhesion
formation and re-formation regardless of the type of injury or
whether hemostasis is achieved.[82]
Animal studies by Boyers and associates [86] revealed that
the Gore-Tex surgical membrane was effective in reducing primary adhesions after pelvic operations. Gore-Tex membrane was
applied over the raw surface of the peritoneal wall or uterus
after adhesiolysis or myomectomy by laparotomy. At secondlook laparoscopy, when the surgical membrane was removed,
the mean postoperative adhesion score had been reduced from
10.13 ± 0.35 to 0.75 ± 2.12 (P ≤ 0.001).[86] The Gore-Tex surgical membranemayreduce postmyomectomyadhesions.[87] At
laparoscopy, 15 of 27 incisions covered with PTFE (55.6%) and
only two of 27 uncovered sites (7.4%) were completely free of
adhesions. A randomized, prospective crossover studyin nonhuman primates found that the Gore-Tex surgical membrane was
310 — Bulent Berker, Senzan Hsu, Ceana Nezhat, Farr Nezhat, and Camran Nezhat
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Intra-abdominal view
of uterus, ovary, and
Uterus
Fallopian
tube
Ovary
fallopian tube on
T.V. monitor
Laser-laparoscope inside
abdominal cavity
Laser
T.V. camera
attached to
laser-laparoscope
Cable to T.V.
monitor
Figure 11.1. Suprapubic punctures are made to introduce the suction–irrigator probe and grasping forceps.
better than Interceed with respect to the size of the adhesion
area, tenacity, and vascularity, with a significant improvement in
the total adhesion score.[88] These results were confirmed in a
multicenter, nonblinded randomized clinical trial that enrolled
32 women with bilateral pelvic side wall adhesions undergoing
reconstructive pelvic operations and second-look laparoscopy.
Expanded PTFE wasassociatedwith fewer postsurgical adhesions
to the pelvic side wall compared with Interceed.[89]
The Gore-Tex surgical membrane may be used laparoscopically.[89] It is easy to introduce and position over a peritoneal
defect because its handling properties do not diminish with wetting. Fixation is secured with laparoscopic staples.[90] Removal
of the PTFE barrier at early second-look laparoscopy 11 days
after myomectomy was not associated with adhesions.[91] Various studies compared the efficacy of the two adhesion barriers
Suction–irrigator
in women undergoing reconstructive pelvic surgery and found
that PTFE was associated with fewer postsurgical adhesions to
the pelvic sidewall than was ORC.[92,93] However, as a result of
its nonabsorbable nature, most gynecologists are reluctant to use
PTFE.
Combined Hyaluronic Acid and
Carboxymethylcellulose (Seprafilm)
Seprafilm (Genzyme Corp., Cambridge, MA), which is composed of modified HA and carboxymethylcellulose (HA-CMC),
is effective as a surgical adjuvant for the reduction of adhesions.
HA is a normal constituent of the extracellular matrix, connective tissue, synovial fluid, umbilical cord, and vitreous humor.
Carboxymethylcellulose is a commonly used filler found in food,
cosmetics, and pharmaceuticals; it has no known toxic effects
and has been shown in animal studies to be effective in reducing
https://t.me/med1917
postoperative adhesions. The Seprafilm barrier has significantly
reduced the incidence, extent, andseverity of postoperative adhesions in a variety of animal models [94,95] and also in two large
prospective randomized, controlled multicenter clinical studies.
One of thesestudiesinvolved gynecologic surgeryusing myomectomy in which patients randomly received Seprafilm wrapped
over the entire uterus or no treatment.[96] The other study
involvedgeneral surgery in which patientsundergoing colectomy
and ileal pouch–anal anastomosis with diverting loop ileostomy
randomly did or did not receive Seprafilm placed under the midline incision before closure of the abdomen.[97] In both trials,
Seprafilm significantly reduced postoperative adhesion development.
Seprafilm is a useful adjuvant in reducing the incidence,
extent, and severity of abdominal and pelvic postoperative adhesions. In the field of gynecology, it is also effective in reducing
the area of postoperative uterine adhesions after myomectomy.
Seprafilm is placed by the surgeon on the traumatized surfaces of
the operated tissues in the abdomen by the end of surgery, before
surgical closure. It is biocompatible, safe, nontoxic, and nonimmunogenic, and itacts as a temporary adhesion barrierthat keeps
tissue surfaces separated during the early days of wound healing,
when adhesions form. Seprafilm hydrates to a gel within 24 to
48 hours following placement and then slowly resorbs from the
abdominal cavity in about 5 to 7 days. It is excreted from the
body within 28 days. Although Seprafilm barrier was shown to
be safe and effective in all human clinical trials, its use did not
eliminate adhesions in all patients. Efficacy of this barrier is limited to surgical situations in which the area in question can be
completely covered. Physician acceptance is constrained by technical difficultiesas well aslimitations in applicationand handling
properties within the surgical field.[98]
LAPAROSCOPIC ADHESIOLYSIS
Before adhesiolysis is attempted, the surgeon should consider
whether (1) lysis of the adhesion would benefit the patient, (2)
whether a sharpor blunt technique should beused, and (3)which
side of the adhesion should be excised to reduce the risk of injury
to vital organs. To do laparoscopic adhesiolysis adequately, three
or four abdominal punctures are required: the infraumbilical
incision for the operative laparoscope and two to three lower,
lateral suprapubic punctures about 4 cm below the level of the
iliac crests (Figure11.1). Through the lateral trocar, on the side of
the assistant, an atraumatic grasping forcepsisinserted toholdthe
adhesion orinvolved organ,stretch it, and identify its boundaries
and avascular planes. The opposite trocar, on the side of the primary surgeon, is used for microscissors or the suction–irrigator
probe. That probe can serve as a manipulator or backstop when
the CO
laser is used (Figure 11.2).
2
Adhesions are cut closetothe affected organ atboth ends and,
if possible, removed from the abdomen. Vascular adhesions are
coagulatedwith lasers or microelectrodes. Whenscissorsareused,
filmy and avascular adhesions are stretched andthen cut (Figures
11.3, 11.4).[103] Thick, vascular adhesions must be coagulated
before being cut (Figures 11.5, 11.6).
Intestinaladhesionsareseveredfirst,followedbyperi-ovarian
adhesions and peritubal adhesions. This approach allows pro-
Laparoscopic Adhesiolysis and Adhesion Prevention — 311
Nezhat-Dorsey hydro-dissection
probe is used for hydrodissection
and a backstop for the CO2 laser
The ovary is pulled up
and put under traction
Ureter
Ovary with endometriosis
and adhesions
Figure 11.2. The left ovary is grasped and put under traction. The
suction–irrigator is used for a backstop, and the adhesions are cut
using the CO
2
laser.
gressive exposure of the pelvic structures. Once the intestines are
freed from adjacent structures, they are pushed gently cephalad.
Adherent ovaries are freed from the pelvic side wall, broad ligament, tubes, and uterus. Grasping forceps are essential for applying traction to the ovary, tube, intestines, or abdominal wall so
that a plane of dissection can be identified.
Bleeding areas are coagulated with the laser or a bipolar electrocoagulator. Whenever possible, either the adhesions or the
ovarian ligaments are grasped instead of the ovarian cortex to
reduce trauma. Once the ovaries are lifted from the cul-de-sac
and mobilized, the peritubal adhesions are removed.
Figure 11.3. Avascular adhesions between the uterusandtheomentum
are put under stretch before dissection with scissors.
312 — Bulent Berker, Senzan Hsu, Ceana Nezhat, Farr Nezhat, and Camran Nezhat
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Figure 11.4. Avascular adhesions are dissected with scissors.
Figure 11.5. Thick vascularadhesionsarecoagulated beforedissection.
Adhesions can be coagulated effectively and incised with a
laser, superpulse (40 W) laser, ultrapulse (20 to 80 W and
CO
2
25 to 200 millijoules), fiber laser (15 to 25 W), or microelectrode
(15 to 20 W, cutting mode). When there are dense adhesions
among different organs (bowel, uterus, ovaries, pelvic side wall,
Lactated Ringers
Figure 11.6. A coagulated vascular adhesion is cut with scissors.
and anterior abdominal wall), hydrodissection with the suction–
irrigator probe is useful to create tissue planes before dissection.
Because an intestinal injury may occur during enterolysis, patients with a history of previous laparotomies or severe
endometriosis shouldundergo a preoperative bowel preparation.
Inadvertent enterorrhaphy can be repaired with the use of a onelayer closure of 0 polyglactin (Vicryl, Ethicon) or an Endoloop
(Ethicon).
Once the pelvic structures are freed and hemostasis is
achieved, the cul-de-sac is filled with lactated Ringer’s solution
and the adnexa are allowed to float in the clear fluid (Figure
11.7).[99] Filmy adhesions that are difficult to identify on the
surface of the ovary become visible as they float from the ovarian
cortex. These adhesions are grasped with the forceps, cut, and
removed from their attachments, using laparoscopic microscissors. They are filmy and avascular, and so coagulation is not
required.
Agglutinated fimbrial folds are causedby fine avascularadhesions. Asthe fimbrial folds float and disperse in the fluid, the adhesions become visible; they are grasped, stretched, and sharply cut
Microscissors
Adhesions
Fallopian tube
Fimbriae
Figure 11.7. Hydroflotation of the tube and fimbria is used to detect and remove filmy adhesions.
Laparoscopic Adhesiolysis and Adhesion Prevention — 313
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with fine scissors or an ultrapulse laser. The laser beam (other
than ultrapulse) delivered through the laparoscope is at least
1 mm in diameter and is too wide for these narrow bands of
adhesions. Thermal damage may occur with electrosurgery and
the fiber laser (neodymium: yttrium–aluminum–garnet, potassium titanyl phosphate, or argon). For delicate microscopic procedures of fimbriolysis and salpingo-ovariolysis, the microscissors or ultrapulse laser is preferable.
CONCLUSION
Although significantprogresshas been made toward understanding the development of postoperative adhesions and their prevention, the use of adjuvants and microsurgery have not eliminated them. Operative laparoscopy may be more effective than
laparotomy in reducing their formation and should be the first
procedure in their management.
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53. Johns DB, Keyport GM, Hoehler F, diZerega GS; Intergel Adhesion Prevention Study Group. Reduction of postsurgical adhesions with Intergel adhesion prevention solution: a multicenter
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58. Diamond MP; Sepracoat Adhesion Study Group. Reduction of
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60. Ferland R, Mulani D, Campbell PK. Evaluation of a sprayable
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12 LEIOMYOMAS
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Section 12.1. Minimally Invasive Approaches to Myomectomy
Mark H. Glasser
As more articles debatingtheprevalence of hysterectomiesappear
in the lay press and ontheInternet,increasing numbers of women
are demanding alternative procedures. A recent New York Times
article decrying the prevalence of hysterectomies stated that by
the age of 60, one in three women in the United States will have
had her uterus removed.[1] By comparison, in Italy the figure is
one in six, whereas in France, it is onein18women.Ofthe600,000
hysterectomiesperformedannuallyintheUnited States, one third
are done for leiomyomas.[2] This number rises dramatically for
women over the age of 40 and for those in certain ethnic groups.
For African American women, 61.3% of hysterectomies are done
for leiomyomas, and for women in the 45-to-54–year age group,
53% of all hysterectomies, regardless of race, are done for this
indication. Itis estimated that more than25% of women over the
age of 36 have one or more leiomyomas, with 50% of these being
symptomatic.[3]
Uterine leiomyomas (myomas) are benign smooth muscle
tumors arising from the myometrium. Despite the fact that
myomas are quite common, very little is known about their etiology. They are monoclonal – arising from a single myometrial
cell. Different karyotypes of multiple myomas have been found
in the same patient. What causes abnormal myometrial cells to
transform into clinically detectable myomas is also unknown.
There are, however, more estrogen receptors in myomas than in
the surrounding myometrium and less estradiol conversion, so
hormonal factorscertainly play a role. There has also been speculation thatchromosome rearrangement maycontribute to tumor
initiation and growth as well as stimulation by growth hormone
and other insulin-likegrowthfactors.Myomasareheterogeneous;
some women have solitary myomas, whereas others have multiple myomas. Myomas may be subserous, intramural, pedunculated, or submucous. There are even different classifications of
submucous myomas according to the percentage of the myoma
that iswithin the endometrial cavity versus thepercentage within
the myometrium. Treatment options depend greatly on careful
classification of the myoma or myomas present in an individual
patient and on what symptoms are most bothersome to her and
require treatment.
Most myomas do not cause any symptoms, and the first lesson physicians must learn is that if the patient is asymptomatic,
no treatment is necessary. The presence of an abdominal mass
is not an indication for a hysterectomy or myomectomy unless
it is of significant concern to the patient. Also, the old teaching
that a hysterectomy is necessary in uteri larger than 12 gestational weeks because the adnexa cannot be adequately examined is no longer true in the age of modern imaging technology
such as ultrasound, computed tomography (CT), and magnetic
resonance imaging (MRI). Patients with myomas may present
with a wide variety of symptoms, including menometrorrhagia,
dyspareunia, pelvic pressure or discomfort, urinary frequency,
bowel or back discomfort, infertility or repeated pregnancy loss,
and the presence of a large pelvic mass.[4] Symptoms very often
are related to the size, type, and location of the myoma as
well as the lifestyle of the individual patient. The criteria for
intervention as outlined by the American College of Obstetrics
and Gynecology in their published Quality Assurance criteria
sets are:
r
Clinically apparent myomas that are a significant concern to
the patient, even if otherwise asymptomatic
r
Myomas causing excessive bleeding and/or anemia
r
Myomas causing acute or chronic pain
r
Myomas causing significant urinary problems not due to
other abnormalities
Various modalities besides the bimanual pelvic and rectal
examination have been used to diagnose and classify myomas,
the mainstay being transabdominal and transvaginal ultrasound.
MRI has been used for more accurate myoma “mapping” as
well as differentiation of pedunculated myomas from adnexal
masses. To evaluate whether or not an intracavitary component
is present, saline infusion sonography as well as hysteroscopy
are valuable tools. Hysterosalpingography is useful in the evaluation of infertile patients with myomas because tubal patency,
as well as the size and shape of the uterine cavity, can be
assessed.
The treatment of symptomatic leiomyomas for women who
have completed childbearing has been, in the vast majority of
cases, hysterectomy. Perimenopausal women are often given no
choice other than hysterectomy, with myomectomy offered in
only a small number of cases. Recent advances in the nonsurgical management of leiomyomas, including medical management with gonadotropin-releasing hormone (GnRH) analogues
or antagonists, mifepristone, raloxifene, and progesterone receptor modifiers as well as uterine artery embolization, have been
promising for these patients but may be inappropriate for those
who want topreserve childbearing, becausenone has beenshown
to enhance fertility.[5] Certainly, for women in the reproductiveage group wanting to maintain fertility, a myomectomy remains
the “gold standard.” Abdominal myomectomy, however, is associated with significant morbidity, including excessive blood loss,
a high rate of blood transfusion, infection, and postoperative
adhesions.[6] Recurrence rates have been reported to be between
5% and 30%, with 20%to 25% ofpatients requiring asubsequent
hysterectomy.[7]
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