Clinical Determinants and Operative Impact of Adhesions in Women Undergoing Laparoscopic Gynaecological Surgery: A Retrospective Analysis

Objective:To find out the prevalence of adhesions, severity, and their relation to the current clinical scenario and to the type of previous surgery.Methods and Materials:A retrospective study of patients who already had different previous abdominopelvic surgery and subsequently underwent gynecological laparoscopic surgery for various indications. The patients’ clinical and operative notes were reviewed and analyzed.Results:There were 654 procedures performed. The most common indication for the laparoscopic surgery was secondary infertility 23.5%, followed by adnexal lesions 22.0% and primary infertility 19.6%. Intraoperative adhesions were found in 45.3%. Adhesions were deemed relevant to the clinical scenario in 21.3%. Patients who had a previous history of open (traditional) surgery were more likely to be found with adhesions in comparison with patients with history of laparoscopic surgery (odds ratio: 2.7, 95% confidence interval: 1.4–5.3, p = 0.0025). The presence of adhesions was found to be strongly associated with previous abdominopelvic surgery than non-abdominopelvic surgery (odds ratio: 4.3, p = 0.0078, 95% confidence interval: 1.5–12.5). The most common location of the adhesions was abdominal (36.1%), mixed abdominal and pelvic (35.1%), and pelvic adhesions (28.1%). Severe adhesions were found in 36.1%; 13.6% of converted laparoscopy to open surgery was due to adhesions. Cesarean sections were significantly associated with adhesions. Patients who had cesarean sections were more likely to have adhesions than those who had not (odds ratio: 5.7, 95% confidence interval: 3.8–8.6, p < 0.0001). Adhesiolysis was done without complications in 19.6% of patients with adhesions.Conclusion:Adhesions were prevalent in gynecological patients with previous abdominopelvic surgery. They were a significant contributor to the gynecological and reproductive issues. To minimize the risk of postoperative adhesions, laparoscopic approach should be encouraged instead of traditional surgery and rates of cesarean section should be reduced. Further high-quality studies are needed to establish conclusion and practical guidance toward the use of adhesion barriers.

The use of robotic-assisted keyhole surgery in gynaecology has expanded in recent years owing to technical advances. These include 3D viewing leading to improved depth perception, limitation of tremor, potential for greater precision and discrimination of tissues, a shorter learning curve and improved comfort for surgeons compared with conventional keyhole and open abdominal surgery. Robotic-assisted keyhole surgery, compared with conventional keyhole surgery, improves surgical performance without increasing operating time, minimises blood loss and intra- or postoperative complications, while reducing the need to revert to abdominal surgery. Moreover, surgeons using a robot experience fewer skeletomuscular problems of their own in the short and long term than those operating without a robot as an additional tool. This Scientific Impact Paper looks at the use of a robot in different fields of gynaecological surgery. A robot could be considered safe and a more effective surgical tool than conventional keyhole surgery for women who have to undergo complex gynaecology surgery or have associated medical issues such as body-mass index (BMI) at 30 kg/m2 or above or lung problems. The introduction of the use of robots in keyhole surgery has resulted in a decrease in the number of traditional open surgeries and the risk of conversion to open surgery after traditional keyhole surgery; both of which should be considered when examining the cost-benefit of using a robot. Limitations of robotic-assisted surgery remain the associated higher costs. In womb cancer surgery there is good evidence that introducing robotics into the service improves outcomes for women and may reduce costs.

To investigate the influence of previous abdominopelvic surgery on gynecological laparoscopic operation. A retrospective analysis of 3 283 cases of gynecological diseases by laparoscopic operation patients in Peking University First Hospital from 2007 January to 2012 December, among them, 719 (21.90%) patients with previous abdominopelvic surgery history (study Group), 2 564 (78.10%)patients have no history of abdominopelvic surgery (control group). Study group 719 patients, previous operation times: one time in 525 cases, 194 cases were multiple; previous operation: 185 cases of gynecological surgery, 305 cases of obstetric surgery, 108 cases of general surgery, and 121 complex surgery (include at least two kinds of surgery); previous operative approach: 650 cases laparotomy and 69 cases laparoscopy. Compared two groups of patients with abdominopelvic adhesion and the gynecologic laparoscopic operation situation, analyzed the influence of previous abdominopelvic surgery on abdominopelvic adhesion on and gynecological laparoscopic operation. The incidence of abdominopelvic adhesion in the patients with previous abdominopelvic surgery was 51.2% (368/719), which was significantly higher than that of 8.2% (211/2 564)in patients without previous abdominopelvic surgery (P < 0.01). But the study group score (median 3) and the degree of abdominopelvic adhesion [mild 49.7% (183/368), moderate 36.1% (133/368), severe 14.1% (52 /368)] compared with the control group score (median 2) and degree [mild 55.0% (116/211), moderate 25.6% (54/211), and severe 19.4% (41/211)] were no statistical difference (P = 0.930, P = 0.684). Super-umbilical primary trocar site were chosen more common in patients with previous abdominopelvic surgery (23.1%, 166/719) was significantly higher than that in the control group (3.3% , 85/2 564;P < 0.01). And the rate of conversion to laparotomy was 0.6% (4/719) significantly more than the control groups (0.1%, 2/2 564; P = 0.023). Compared with other groups, patients with gynecological or complex surgery or multiple operation history presented more severe abdominopelvic adhesion both in the score and degree (P < 0.01). The rate of super-umbilical primary trocar site, hospitalization time, operation time and bleeding during operation in patients with multiple operation history were significantly higher than those with single operation history (P < 0.05); the rate of blood transfusion, postoperative complication and conversion to laparotomy showed no statistical difference between the two groups (P > 0.05). The laparoscopic operation could be carried out successfully and safely in patients with a history of various abdominopelvic operations, but the conversion rate increases, for patients with a history of multiple operation because of pelvic adhesion increases the difficulty of the laparoscopic operation.

Background and AimsIntraperitoneal adhesions are a common complication after gynecologic surgery, leading to infertility, chronic pelvic pain, bowel obstruction, and surgical complications. Hyaluronic acid gel functions as a physical barrier, potentially reducing the formation of postoperative adhesions by minimizing tissue contact during the healing process.MethodsA comprehensive search was carried out across PubMed, the Cochrane Library, Scopus, Embase, and http://ClinicalTrials.gov from their inception until July 2023 to locate randomized controlled trials (RCTs) assessing the effectiveness of hyaluronic acid gel in preventing pelvic adhesions following gynecologic surgery. Eligible studies were required to be RCTs with reported clinical outcomes related to adhesion formation and published in English. Two reviewers independently screened the studies, extracted the relevant data, and evaluated methodological quality using the Jadad scoring system. For the statistical analysis, dichotomous variables were analyzed using risk ratios (RR), while continuous outcomes were summarized using standardized mean differences (SMD). Between‐study heterogeneity was examined using the I² statistic, and sources of variability were further explored through meta‐regression techniques. Potential publication bias was assessed through Egger's regression test and visual inspection of funnel plots.ResultsHyaluronic acid gel significantly reduced moderate adhesions (RR: 0.32; 95% CI: 0.20–0.45) and overall adhesion severity (SMD: −1.31; 95% CI: −1.99 to −0.62). The severe adhesion score also decreased (SMD: −0.65; 95% CI: −0.91 to −0.40), but the reduction in severe adhesions was not statistically significant (RR: 0.77; 95% CI: 0.47–1.24).ConclusionHyaluronic acid gel serves as an effective physical barrier to prevent the formation of pelvic adhesions in women undergoing gynecological surgery. While its role in reducing severe adhesions was not statistically significant, it demonstrated a significant reduction in moderate adhesions and overall adhesion severity.Trial RegistrationProtocol registered in PROSPERO (CRD42023429293).

Background Adhesions are the most frequent complication following abdominal and pelvic surgery, developing after more than 90% of interventions concerning the abdominal cavity. Consequences include infertility, chronic pelvic pain and small bowel obstruction. Adhesions increase the complexity of future surgery by increasing the risk of urinary tract and intestinal injury, and by increasing the operative duration and thus the risk of blood loss. Objective To evaluate the efficiency of preoperative transabdominal ultrasonographic features in prediction of intra-abdominal adhesions in pregnant women during third-trimester with history of previous cesarean section surgery scheduled for a planned repeated elective C.S. delivery. Methods After ethical committee approval and informed consent from the patients, this prospective study was performed on total 200 third-trimesteric pregnant women with history of previous cesarean section who admitted for elective caesarian section and willing to participate in the study to investigate the value of the sonographic evaluation in predicting the intra-abdominal adhesions at tertiary care hospital at Ain Shams University Maternity Hospital from January 2023 till October 2023 and performed on total 200 patients who underwent elective caesarean delivery. Results The findings of our study demonstrated a good capability of a simple third-trimester transabdominal sonographic sign, the absence of sliding of the uterus, to predict the presence of intra-abdominal adhesions in women undergoing repeat CS. Conclusion We concluded that the real-time dynamic transabdominal ultrasound sliding sign is a non-invasive, well-tolerated technique. Its preoperative analysis in patients who have had previous abdominopelvic surgery may help to evaluate the risk of bowel or bladder injury and the complexity of the planned intervention, improving the safety of surgery, and may help to inform the anesthesiologist regarding the expected duration of the intervention and any potential complications during the procedure.

To investigate the role of the transvaginal sonographic (TVS) sliding sign in predicting pelvic adhesions in women with previous abdominopelvic surgery. This was a multicenter, prospective, interventional, double-blind study of patients with a history of abdominopelvic surgery who were undergoing laparoscopy or laparotomy during the 6-month period from March to August 2016 in one of three academic obstetrics and gynecology departments. Prior to surgery, patients were examined by TVS to assess the vesicouterine pouch, uterus, ovaries and pouch of Douglas, using the TVS pelvic sliding sign. Ultrasound findings and medical and surgical data were recorded. We assessed the accuracy of the preoperative TVS sliding sign in the prediction of pelvic adhesions overall and in each compartment separately. During the study period, complete TVS sliding sign and laparoscopic or laparotomic data were available for 107 women. Their mean age was 44.0 (95% CI, 41.6-46.4; range, 20-79) years. Their mean parity was 2.0 (95% CI, 1.7-2.3; range, 0-9) and the mean number of previous abdominal surgical procedures per patient was 1.3 (95% CI, 1.2-1.5; range, 1-4). Adhesions were noted in 27/107 (25.2%) patients. The TVS sliding sign had a sensitivity of 96.3% and specificity of 92.6% in predicting pelvic adhesions. There was a significant relationship between adhesions in each compartment and the TVS sliding sign (P< 0.05). The TVS sliding sign is an effective means to detect preoperatively pelvic adhesions in patients with previous abdominopelvic surgery. Use of such a non-invasive and well-tolerated technique could help in the planning of laparoscopy or laparotomy and counseling of these patients. Copyright © 2017 ISUOG. Published by John Wiley & Sons Ltd.

The background of this investigation is based on a common surgical problem: The access in laparoscopic surgery is more difficult in women with previous abdominopelvic surgery, since adhesions and viscera could be close to the point of trocar insertion. The authors analyzed the safety and the efficacy of a modified direct optical entry (DOE) method versus the Hasson's method by open laparoscopy (OL) in women with previous abdominopelvic surgery in a preliminary prospective case-control study. A total of 168 women underwent laparoscopic surgery in university-affiliated hospitals: 86 were assigned to abdominal DOE (group A) and 82 to OL (group B). The main outcome measures were statistically compared: time required for entry into abdomen, blood loss, and occurrence of vascular and/or bowel injury. All patients had an intraperitoneal view of the primary port site during surgical procedure. Statistical differences, in favor of the DOE group (P < .01), were found in duration of entry and blood loss. The vascular and bowel injuries in OL versus DOE were not statistically different. Obtaining access to the peritoneal cavity in laparoscopic surgery is more difficult in patients with previous abdominopelvic surgery, since it can become a difficult, time-consuming, and occasionally hazardous procedure. The study results suggest that DOE is advantageous when compared with OL in terms of saving time enabling a safe and expeditious visually guided entry for laparoscopy.

Introduction Major abdominal operations result in severe unpredictable scar tissue formation that may contribute to adhesions and then recurrent attacks of acute bowel obstruction, chronic abdominal pain, or both problems. Laparoscopic adhesiolysis provides good relief of symptoms in patients with chronic abdominal pain and/or acute bowel obstruction but without major previous abdominal surgery or severe peritonitis (necrosis or perforation). Early laparoscopic intervention for acute or chronic bowel obstruction has been tried many times worldwide but without complete data about the safety and outcome for both conditions. Patients and methods Between February 2017 and January 2019, a prospective randomized controlled study was done on 32 patients admitted for small bowel obstruction (14 patients with acute bowel obstruction and 18 patients with chronic small bowel obstruction). Patients selected for early laparoscopic adhesiolysis were those who had no preoperative finding of perforation, torsion, strangulation, or any clinical signs or radiological evidences of peritonitis. The outcome of the study was evaluated depending on length of postoperative hospital stay, enteral nutrition, 30-day mortality, positive bowel movement and stool passage, the length of sick leave (return to work), and recurrence of bowel obstruction during the 2-year follow-up. Results A total of 32 patients with a diagnosis of small bowel obstruction were identified and divided into two groups. Group A included 18 patients with chronic bowel obstruction who were treated with laparoscopic adhesiolysis, and group B included 14 patients having acute intestinal obstruction who were treated with laparoscopic adhesiolysis. The follow-up period was ∼24 months. Conclusion Laparoscopic adhesiolysis is a safe and effective management option for patients with prior abdominal surgery with acute or chronic abdominal pain or recurrent bowel obstruction.

We found no evidence on the effects of barrier agents used during pelvic surgery on pelvic pain or live birth rate in women of reproductive age because no trial reported these outcomes. It is difficult to draw credible conclusions due to lack of evidence and the low quality of included studies. Given this caveat, low-quality evidence suggests that collagen membrane with polyethylene glycol plus glycerol may be more effective than no treatment in reducing the incidence of adhesion formation following pelvic surgery. Low-quality evidence also shows that oxidised regenerated cellulose may reduce the incidence of re-formation of adhesions when compared with no treatment at laparotomy. It is not possible to draw conclusions on the relative effectiveness of these interventions due to lack of evidence. No adverse events directly attributed to the adhesion agents were reported. The quality of the evidence ranged from very low to moderate. Common limitations were imprecision and poor reporting of study methods. Most studies were commercially funded, and publication bias could not be ruled out.

The objective of this study was to investigate the incidence of gastrointestinal injuries during gynaecologic operations, the management of such injuries and associated risk factors. This case-control study (1:4) examined patients who received gynaecologic operations from 2007 to 2016 in Ramathibodi Hospital. The study cases comprised patients who had gastrointestinal injuries, while the control cases comprised patients who had gynaecologic surgeries in the same period with matching the types of procedures. The 10-year incidence was 0.38% (104 cases of gastrointestinal injuries among a total of 27,520 cases). The most common injury site was the small bowel (43.3%). There were 102 cases (98%) of gastrointestinal injuries which were diagnosed intraoperatively and which were immediately repaired with successful outcomes. Logistic regression indicated that a pelvic adhesion, previous pelvic surgery and previous abdominal surgery were predictive risk factors associated with the injuries (odds ratios: 9.45, 3.20 and 11.84, respectively). An immediate consultation with a surgeon and surgical repair of the injury resulted in excellent outcomes.Impact statementWhat is already known about this subject? Gastrointestinal injury is a rare, but fatal complication of gynaecologic operations. The previous small study identified some risk factors such as surgical approach and pelvic surgery associated with the injury.What do the results of this study contribute? Our study identified the associated risk factors for gastrointestinal injury, including previous abdominal injury, pelvic adhesion and previous pelvic surgery. A previous abdominal surgery was the most associated risk factor. Patients with the history of abdominal surgery had an almost 4-fold higher odds ratio than the ones with previous pelvic surgery. Other factors, including endometriosis, ovarian cancer and subsequent oncological procedures, and surgical staging were less related to the gastrointestinal injury.What are the implications of these findings for clinical practice and/or further research? The knowledge is useful for pre-operative evaluation and preparation. Bowel preparation and consultation with surgeon are necessary for patients with these risk factors prior to their surgeries. Moreover, an immediate intra-operative surgical correction of the injury results in excellent outcomes.

We found no evidence on the effects of barrier agents used during pelvic surgery on pelvic pain or live birth rate in women of reproductive age because no trial reported these outcomes. It is difficult to draw credible conclusions due to lack of evidence and the low quality of included studies. Given this caveat, low-quality evidence suggests that collagen membrane with polyethylene glycol plus glycerol may be more effective than no treatment in reducing the incidence of adhesion formation following pelvic surgery. Low-quality evidence also shows that oxidised regenerated cellulose may reduce the incidence of re-formation of adhesions when compared with no treatment at laparotomy. It is not possible to draw conclusions on the relative effectiveness of these interventions due to lack of evidence. No adverse events directly attributed to the adhesion agents were reported. The quality of the evidence ranged from very low to moderate. Common limitations were imprecision and poor reporting of study methods. Most studies were commercially funded, and publication bias could not be ruled out.

Pelvic adhesion can form as a result of inflammation, endometriosis or surgical trauma. During pelvic surgery, strategies to reduce pelvic adhesion formation may include placing synthetic barrier agents such as oxidised regenerated cellulose, polytetrafluoroethylene or Fibrin sheets between the pelvic structures. To assess the effect of physical barriers used during pelvic surgery in women of reproductive age on pregnancy rates, pelvic pain, or postoperative adhesion reformation. We searched the Cochrane Menstrual Disorders and Subfertility Group Trials Register (searched September 2007) which is based on regular searches of MEDLINE, EMBASE, CINAHL, PsycINFO and CENTRAL, plus handsearching of 20 relevant journals and conference proceedings, and searches of several key grey literature sources. In addition, companies were contacted for unpublished trials. Any randomised controlled trials (RCTs) comparing the use of physical barriers versus no treatment or other physical barriers in the prevention of adhesions in women undergoing gynaecological surgery. Review authors assessed trial eligibility and quality. Sixteen RCTs were included. Five trials randomised patients while the remainder randomised pelvic organs. Laparoscopy (six trials) and laparotomy (10 trials) were the primary surgical techniques. Indications for surgery included myomectomy (five trials), ovarian surgery (five trials), pelvic adhesions (four trials), endometriosis (one trial), and mixed (one trial). Eleven trials assessed Interceed versus no treatment, two assessed Interceed versus Gore-Tex, one trial assessed Gore-Tex versus no treatment, and one trial assessed Seprafilm versus no treatment. A single trial assessed Fibrin sheet versus no treatment. No studies reported pregnancy or reduction in pain as outcomes. The use of Interceed was associated with reduced incidence of pelvic adhesion formation, both new formation and reformation following laparoscopic surgery or laparotomy. However, this result should be interpreted with caution. Gore-Tex was more effective than no barrier or Interceed in preventing adhesion formation. There was only limited evidence that Seprafilm was effective in preventing adhesion formation following myomectomy and no evidence to support Fibrin sheet. The absorbable adhesion barrier Interceed reduces the incidence of adhesion formation following laparoscopy and laparotomy, but there are insufficient data to support its use to improve pregnancy rates. Gore-Tex may be superior to Interceed in preventing adhesion formation but its usefulness is limited by the need for suturing and later removal. There was no evidence of effectiveness of Seprafilm and Fibrin sheet in preventing adhesion formation.

Background: Infertility is a disease that affects 8%–12% of couples at their reproductive age. Tubal factors account for 20%–30% of infertility cases. Tubal infertility can be caused by infections, endometriosis, and complications from previous abdominopelvic surgery. Objectives: The objective of the study is to determine the impact of pelvic surgery on future fertility by examining the fallopian tubes for any potential damage using a hysterosalpingography (HSG) examination. Materials and Methods: A cross-sectional study was conducted at Nineveh Governorate, Iraq, in two clinics from March 2022 to September 2022 by examining 317 infertile females using HSG. The exam was done as part of an infertility workup. Results: The results revealed that the study included 317 infertile women patients with a mean age of 28.82 ± 6.9 years (range 17–49 years), of these, 184 patients (58.04%) with primary infertility, and 133 patients (41.95%) with secondary infertility. The years of infertility ranged between 1 and 20 years and a median of 4 years. The history of one or more previous pelvic interventions was recorded in 39 cases (12.3%). The prevalence of tubal abnormalities was noted in 23.1% of cases with previous pelvic intervention and 13.3% in other patients, with an odds ratio of 1.95 at a 95% confidence interval. Tubal abnormalities do not differ significantly according to the type of infertility, and the mean age of infertile women with tubal abnormalities is not statistically different from those with normal tubes. Conclusion: This study concludes that pelvic surgeries, particularly cesarean operations increase the risk of developing subsequent fallopian tube abnormalities and pelvic adhesions, which can lead to infertility.

The objective of this study was to evaluate whether a history of previous pelvic surgery is associated with lower urinary tract (LUT) injury at the time of pelvic reconstructive surgery (PRS). A retrospective analysis of patients undergoing pelvic reconstructive surgery from 2006 to 2011 was performed. Patients were divided into two groups: those with previous pelvic surgery and those without previous pelvic surgery. A sample size analysis was performed to determine the number needed to detect at least a 3-fold difference in the rate of LUT injury. Demographic, historical, clinical, intraoperative, and postoperative data were analyzed. Associations between LUT injury and demographics, previous pelvic surgery, or other clinical risk factors were assessed using univariate and multivariate analyses. 685 women were included in the analysis: 514 (74.9%) with and 171 (25.1%) without prior pelvic surgery. The overall rate of LUT injury was 6%. Of the injuries, 3.2% were cystotomies, and 1.9% were ureteral obstructions. Previous pelvic surgery did not significantly affect the rate of LUT injury (OR 0.76, 95%CI 0.38-1.54). A diagnosis of prolapse, concurrent hysterectomy, anterior repair, and apical repair were significantly associated with LUT injury. After controlling for age and race, a diagnosis of prolapse remained significantly associated with LUT injury (OR 3.38, 95% CI 1.11-14.75). Prior pelvic surgery does not affect the rate of LUT injury in pelvic reconstructive surgery. The diagnosis of prolapse is a risk factor for LUT injury in women undergoing pelvic reconstructive surgery.

2735 The Incidence of Abdominal Wall Adhesions at the Time of Laparoscopic Surgery in Women with or without Previous Surgery