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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_207_библиотеки_им_акад_М_И_Перельмана
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Differential Diagnosis
Postinfective adhesions
Postoperative adhesions
Adhesions due to endometriosis or other pelvic inflammatory processes
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IMAGING AND OTHER DIAGNOSTICS
A hysterosalpingogram (HSG) easily demonstrates distal tubal occlusion, and at times can provide the suggestion of
peritubal or ovarian pelvic adhesions. However, the sensitivity of an HSG to detect more subtle adhesions is low.
1
Standard transvaginal ultrasonography can sometimes detect the presence of adhesions on the basis of limited mobility of
the ovary. Sometimes the presence of normal or pathologic amounts of pelvic fluid can delineate or suggest the presence of
filmy adhesions.
All imaging modalities have limited sensitivity and specificity in the diagnosis of pelvic adhesions without tubal closure or the
presence of a hydrosalpinx.
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PREOPERATIVE PLANNING
Extent of abnormality seen by HSG or ultrasound can help to anticipate surgical findings. More severe findings raise the
odds of requiring more extensive surgical dissection, and therefore could relate to ultimately decreased odds of fertility. The
presence of distal tubal closure necessitates the discussion of performance of a neosalpingostomy, or possible salpingectomy
if the tubes are damaged beyond repair.
Patients should be counseled that even with the most careful techniques of adhesiolysis and adhesion prevention measures,
new adhesions could form postoperatively.
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SURGICAL MANAGEMENT
The treatment of tubal adhesions is primarily performed in an effort to improve fertility. Only rarely may pelvic adhesions
cause pain, most commonly when they involve the patient’s intestines. Treatment of adhesions is often necessary during the
treatment of endometriosis.
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Positioning
The patient should be placed in the normal standard dorsal lithotomy position as for other laparoscopic gynecologic
procedures. An intrauterine manipulator capable of allowing chromotubation is helpful. Devices such as the ClearView
®
(Clinical Innovations, Murray, UT), HUMI
®
(Cooper Surgical, Trumbull, CT), ZUMI™ (Cooper Surgical, Trumbull, CT), or
Kronner Manipujector
®
(Cooper Surgical, Trumbull, CT) allow both manipulation as well as chromotubation. We prefer to
use a very dark chromotubation solution consisting of 10 mL of indigo carmine 0.8% solution (two ampules) mixed in 100
mL of saline.
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Approach
The preferred method of adhesiolysis is by a laparoscopic approach. It is the treatment of choice due the increase in
postoperative adhesions as well as patient morbidity following laparotomy.
The procedure can almost always be approached through the use of 5-mm laparoscopic ports. The number of ports needed
will be proportional to the severity of the disease. It is recommended to start with a lateral lower quadrant and suprapubic
port in addition to an umbilical camera port. An additional contralateral lower quadrant port can be added for additional
assistance.
Instruments for the lysis of adhesions can include monopolar scissors or harmonic scalpel. Monopolar scissors are preferred
as they can be used without cautery for filmy adhesions, or use low power (15 to 20 W) pinpoint cautery for adhesions with
vascularity.
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Procedures and Techniques
Intestinal adhesiol ysi s
Any adhesion involving the sigmoid, rectum, small bowel, or omentum within the pelvis should be lysed to allow retraction of
the intestines out of the pelvis for optimal visualization (Te ch Fig. 4.1.1).
Physiologic adhesions between the descending colon/sigmoid and the left abdominal/pelvic sidewall may be lysed to gain
better access to the left adnexa (Te ch Fig. 4.1.2).
Te ch Fig ure 4.1.1. Lysing any int est inal or omental adhesions.
Te ch Fig ure 4.1.2. Relaxing physiologic connections of sigmoid to left pelvic sidewall for bet ter adnexal exposure.
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Ovarian adhesiolysis
Before addressing the tubes, adhesions around the ovary should be lysed. Grasping the utero-ovarian ligament with an
atraumatic grasper and rotating it medially attempts to lift the ovary out of the pelvis, placing posterior adhesions on traction
for more clear delineation (Te ch Fig. 4.1.3).
Dense adhesions may attach the ovary to the peritoneum overlying the ureter. In these cases retroperitoneal exploration
may be necessary to delineate the ureter location prior to separating the ovary from the sidewall (Te ch Fig. 4.1.4).
Te ch Fig ure 4.1.3. Grasping utero-ovarian ligament and rot at ing medially to place ovary on t raction out of pelvis.
Te ch Fig ure 4.1.4. Dense adhesions under ovary may need retroperitoneal exploration to safeguard ureter.
Adhesions may often form a filmy layer on the surface of the ovary. These adhesions should be removed, as they could act
as a barrier preventing an oocyte from reaching the tube (Tech Fig. 4.1.5).
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Te ch Fig ure 4.1.5. Any filmy adhesions should be fully removed from t he ovarian surface.
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Normalize mobili ty of the body of the fallopian tube
Any adhesions that restrict the movement of the body (isthmic and ampullary portions) of the tube should be relieved. This
could involve adhesions from the tube to the round ligament, lateral sidewall, uterus, or ovary. In some cases these may be
easily resolved, but dense adhesions may not provide a clear plane for separation without significantly affecting the
mesosalpinx. In these cases, normal tubal interaction with the ovary may not be fully achieved (Tech Fig. 4.1.6).
Te ch Fig ure 4.1.6. Mobilizing the body of t he tube to allow maximum ext ent of movement .
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