Use of Adhesion Prevention Barriers in Pelvic Reconstructive and Gynecologic Surgery

Abstract

Minimization of peritoneal injury forms the basis of modern surgical and microsurgical techniques and is the most important component in the prevention or reduction of postoperative adhesions.1–3 However, despite strict adherence to these principles, serosal trauma inevitably occurs, resulting in adhesion formation. Adhesions after peritoneal surgery are a major cause of postoperative bowel obstruction, infertility, and chronic pelvic pain.4–6 Therefore, a method by which postsurgical adhesion formation could be reduced or prevented would be of great benefit in reducing postoperative morbidity. Studies have indicated that placement of an ab-sorbable barrier of oxidized regenerated cellulose (Interceed® [TC7]) Absorbable Adhesion Barrier; Ethicon, Somerville, NJ, USA), expanded polytetrafluoroethylene (Preclude® Surgical Membrane; W.L. Gore & Associates, Flagstaff, AZ, USA), or hyaluronic acid/carboxymethyl-cellulose (Seprafilm® Bioresorbable Membrane; Gen-zyme, Cambridge, MA, USA; Intergel® Adhesion Prevention Solution; Ethicon) between injured sites or addition of a viscous solution (Hyskon® 32% dextran 70; Pharmacia, Piscataway, NJ, USA; Sepracoat® Hyaluronic Acid Coating Solution; Genzyme) to the peritoneal cavity during or after surgery can reduce postoperative adhesion formation.7–11 In the case of Interceed, Preclude, or Seprafilm, the surgeon must predict potential sites of adhesion formation to determine placement site and optimize barrier benefit. A dilute solution of hyaluronic acid (HA; Sepracoat) has only been shown to be effective at reducing the number of de novo adhesions at sites remote from the surgical trauma,10 while reports indicate that Hyskon is ineffective in several types of pelvic surgery because of gravitational pooling in the cul-de-sac7 In addition, the use of Hyskon in clinical practice has shown some undesirable side effects resulting from the accumulation of intraperitoneal ascites from oncotic properties.12 Intergel, the device most recently released for adhesion prevention, showed promising results in a pilot11 and multicenter study13 as a viscoelastic gel that reduces both de novo and reformed adhesions at both non-surgical as well as surgical sites. This new technology is extensively discussed in Chapter 32 of this volume.