Risk Of Adhesion Formation Research Articles

Use of the LigaSure for Closing Peritoneal Defects in an Experimental Rat Model

Background: There has not been an absolute consensus over the routine closure of peritoneal defect (PD) during laparoscopic totally extraperitoneal inguinal hernia repair (TEP). Pretied sutures, endoscopic stapling, and suturing are surgical techniques for closing PDs. Moreover, we observed that we could close small PDs during the TEP procedure by sealing with the LigaSure (LS). Objectives: The present study aimed to evaluate the necessity of closure PDs under a polypropylene mesh and the early intraperitoneal inflammatory, fibrotic, and adhesional effects of sealing PDs with the LS in an experimental rat model. Methods: A total of 35 male rats were assigned to five groups. 1- Control group: mesh was not used, and the peritoneum was left open; 2- Mesh group; mesh was placed directly on the PD without repairing, and three peritoneal repairing methods; 3- Stapling group: PD was repaired with metal clips; 4- Suture group: PD was repaired with Vicryl sutures; and 5- LigaSure group: PD was closed with the LS. Rats were sacrificed on the postoperative 14th day. Adhesion scores, fibrosis, and inflammation scores were compared between all groups. Results: All rats completed the 14 days of follow-up without complication. The Mesh group had significantly higher adhesion scores than the other groups (P<0.001). Nonetheless, no significant difference was observed between peritoneal repairing methods (P=0.696). Fibrosis and inflammatory scores were similar in peritoneal repairing methods (P=0.394 and P=0.112, respectively). Conclusion: The direct contact of foreign bodies with the intra-abdominal organs increases the risk of adhesion; therefore, the remaining PDs under the polypropylene mesh should be repaired. Sealing PDFs with LS is a simple method that does not increase the inflammatory response, fibrosis, and the risk of adhesion formation.

Mechanisms and Therapeutic Approaches for Peritoneal Adhesions: A Comprehensive Review.

Peritoneal adhesions are responsible for several and sometimes severe clinical phenotypes remaining a major problem for many patients today. Adhesions are formed within the peritoneal cavity as a result of surgery, inflammation, or injury and can cause a range of clinical symptoms, including abdominal pain, small bowel obstruction, infertility, and other complications. The incidence of peritoneal adhesions remains high as it is estimated that more than 50% of patients who undergo abdominal surgery will develop adhesions. Although advancements in surgical techniques and perioperative management have been developed, the risk of adhesion formation cannot be eliminated, and thus, the development of effective prevention strategies and treatments remains a priority in the field of surgery. In this review, we summarize the cellular and molecular mechanisms involved in the peritoneal adhesions, but also the experimental therapy approaches that have been investigated toward a solution to their possible clinical phenotypes.

Intra‐abdominal adhesion formation: Does surgical approach matter? Questionnaire survey of South Asian surgeons and literature review

The impact of postsurgical intra-abdominal adhesions, which represent a considerable burden for patients and health services, is often underestimated. Various factors influence adhesion formation, including the surgical approach. This study aimed to further understand the condition by investigating surgeons' perceptions of adhesion formation, particularly differences after laparoscopic and open surgery, and by performing a selective literature review. South Asian surgeons attending endoscopy symposia in India and in Germany completed Likert-scale-based questionnaires on awareness of adhesion formation and associated consequences in gynecology. MEDLINE and PubMed were searched for articles published in 2000-2010 comparing laparoscopy and laparotomy in relation to adhesion formation. The results of the questionnaire study were then considered in view of findings from this review. In total, 43.1% (97/225) of questionnaires were completed. Respondents considered that laparoscopy caused fewer adhesions than laparotomy for all gynecological procedures. Although they believed their knowledge of adhesion formation was satisfactory, they widely underestimated the risk, giving estimated rates of 12.5% after laparoscopy and 36.3% after laparotomy. Twenty-eight studies were identified in the review. Most concluded that laparoscopy was less likely to cause adhesions than laparotomy but further statistical analysis was precluded because so many different definitions and classifications of adhesions had been used. The risk of adhesion formation was widely underestimated in the study group. Both the questionnaire study and the review concluded that laparoscopy results in less adhesion than laparotomy but further statistical comparison necessitates the development of standard definitions and classifications of adhesions.

Awareness and perception of intra-abdominal adhesions and related consequences: survey of gynaecologists in German hospitals

Objective Intra-abdominal adhesion formation after abdominal surgery is the most common postsurgical complication, and the consequences are a considerable burden for patients, surgeons and health systems. Since a wide variety of factors influence adhesion formation, it is difficult to define clear guidelines on how to reduce adhesion formation in daily practice. Given this dilemma, this study assessed the awareness and perception of adhesion formation among gynaecologists in Germany in order to define a baseline for further research and education. Study design The Clinical Adhesion Research and Evaluation (CARE) group of the University of Giessen designed a questionnaire that was sent to the heads of all gynaecological departments in Germany. The director or one of the surgical consultants was asked to complete the questionnaire and return it for evaluation. Results The completed questionnaire was returned by 279 of 833 gynaecological departments. Interviewed surgeons expected adhesions to form in 15% of cases after laparoscopy and 40% after laparotomy. Before surgery, 83.1% of the respondents told their patients about the risk of prior adhesion formation. More than 60% believed that postsurgical adhesion accounts for major morbidity. Infections within the abdomen, previous surgery and extensive tissue trauma were thought to have the most influence on adhesion formation. Risk of adhesion formation was thought to be highest in endometriosis and adhesiolysis surgery. The respondents agreed on performing adhesiolysis in symptomatic but not in all patients. Only 38.4% used adhesion reduction agents regularly. A total of 65.1% of a repertoire of adhesion prevention agents were familiar to the interviewed surgeons. Only 22.0% of them used anti-adhesion products in clinical practice. In general, the respondents were uncertain whether these products play an important role in adhesion reduction, represented by a range of 1.97 ± 0.98% on a scale from 0 to 4. Conclusions Even though postoperative adhesions are recognized as a major cause for morbidity, and it is widely agreed that infections, extensive tissue trauma and surgery lead to adhesion formation, there is uncertainty about the treatment and prophylactic strategies for dealing with adhesions. This dilemma reflects the awareness and perception of gynaecologists in Germany and is an initial point for further research.

The Gore-Tex biomaterial mesh as temporary divisor in two times surgery for spinal and pelvic tumors

In muscular skeletal spine and pelvic tumor, surgery can be performed by a double anterior and posterior approach to decrease the risk of bleeding and opening the tumor; in first one, neurovascular bundles are divided by the mass; in second one, the tumor is resected by posterior or postero-lateral approach. A Gore-Tex mesh could be used as divisor between neurovascular bundles and the tumor to decrease the adhesion formation risk and facilitate tumor removal during second operation if performed after more days. The cohort was composed by a consecutive series of 11 patients underwent to surgery for spine and pelvic tumor where Gore-Tex mesh spacer was placed. In this study, efficiency and tolerability of Gore-Tex mesh were evaluated. No case of adhesion between Gore-Tex mesh and surrounding structures is reported, no case of migration or complications occurred. Gore-Tex mesh use can be considered a useful and safe procedure to decrease the risk of adhesion formation between tumor and surrounding tissue so that to allow the tumor removal easier.

Intraperitoneal onlay mesh: an experimental study of adhesion formation in a sheep model

Current hernia literature shows that the use of mesh in ventral hernia repair reduces the risk of recurrence significantly. In laparoscopic repair, the mesh is placed intraperitoneally. Accordingly, the close contact between mesh and viscera involves a risk of adhesion formation. In this experimental study, we examined the degree of de novo adhesion formation over time to currently available meshes. Sixteen sheep each received laparoscopic placement of four (10 x 10 cm) meshes on intact peritoneum. Two different mesh materials (coated vs. non-coated) and two different fixation devices (absorbable/non-absorbable) were investigated. (Parietex Composite, DynaMesh IPOM, ProTack and AbsorbaTack). After 3, 6, 12 and 18 months, four animals, respectively, underwent a new laparoscopy to determine the extent of adhesions to the mesh. Parietex Composite significantly reduced the formation of intraabdominal adhesions compared to DynaMesh IPOM. The mean extent of adhesions increases over time without reaching a steady state within the first 12 months after laparoscopic placement. This is the first long-term (18 months) experimental study on adhesion formation in sheep after laparoscopic placement of mesh and may serve as a template for future studies on meshes before marketing.

Trocar Site Adhesions After Laparoscopic Surgery in Children

To present our experience of the occurrence of trocar site adhesions in children following laparoscopic procedures. Retrospective case notes review of children who were found to have trocar site adhesions at repeat laparoscopy over a 10-year period between 1998 and 2008. All 26 patients who had 28 episodes of repeat laparoscopic procedures were included in the study. There were 11 different procedures. Patient demographics and time interval between the procedures were noted. Trocar site to omentum or bowel adhesions were observed in 3 (10.7%) of the 28 episodes of laparoscopy. In 1 case (3.6% of the total), there were symptoms of small bowel obstruction that required laparoscopic adhesiolysis. The occurrence of adhesions following laparoscopic procedures was found to increase with the number of trocars used. Our results buttress the claim that the risk of adhesion formation after laparoscopic surgery in children is low. The reduction in the number of trocars used seems to further reduce this risk.

Risk of adhesions formation following microsurgical monopolar laparoscopic ovarian drilling: a comparative study

The objective of the study was to determine the prevalence, extent, and location of adhesion formation following microsurgical monopolar laparoscopic ovarian drilling (LOD) among fertile and infertile women with clomiphene-resistant polycystic ovaries (PCO). The design was a longitudinal cohort follow-up study. The study was performed at the endoscopic unit of a tertiary university center. Three hundred and forty-seven patients with PCO were scheduled for LOD as a treatment option for clomiphene-resistant anovulation. Microsurgical monopolar LOD was performed in all cases. Two hundred and forty-six patients without possible additional predisposing factor for postoperative adhesion formation were followed up. To assess the sole effect of LOD on adhesion formation, only 51 eligible patients were classified into two groups; Group A comprised 22 women who conceived within 6 months following LOD and subjected to cesarean section, while group B included 29 women who failed to conceive over the same period of time and subjected to second-look laparoscopy. The main outcome measure was an evaluation of the prevalence, side, site, and severity of pelvic adhesions following microsurgical monopolar LOD. In total, adhesions were diagnosed in 40 cases (78.4%). Adhesions were diagnosed in 15 cases (68.1%) and 25 cases (86.2%) in groups A and B, respectively, without a statistically significant difference (p = 0.21). Periovarian adhesions were diagnosed in 47/51 (92%) of cases in both groups. In 29 (56.8%) cases in both groups, adhesions were diagnosed on both sides (right and left adnexae) divided as eight (36.3%) and 21 (72.4%) in groups A and B, respectively, with a statistically significant difference (p = 0.01). The documented high prevalence of adhesions among infertile as well as women who conceived following LOD is an added evidence to the established risk of post-LOD adhesion formation. Following microsurgical principles would minimize the risk of these adhesions except periovarian adhesions. There is a bad need for studies on more refinement of LOD to make it as less adhesiogenic procedure as possible.

Biomechanical Comparison of the Simple Running and Cross-Stitch Epitenon Sutures in Achilles Tendon Repairs

Augmenting the strength of Achilles tendon repairs may allow for earlier active rehabilitation with less risk of adhesion formation and re-ruptures, leading to quicker and stronger healing. Building upon previous research that has (1) demonstrated strength gains in Achilles repairs upon addition of simple running epitenon sutures, and (2) shown the cross-stitch epitenon suture to be stronger than the simple running stitch in flexor tendons of the hand, this study compares use of these epitenon sutures in the Achilles tendon. Ruptures were simulated in 7 matched pairs of fresh frozen human Achilles tendons and repaired with the two-tailed Krakow locking loop core technique using No. 2 nonabsorbable, braided, polyester suture. From each pair, one specimen was randomly selected to also receive the epitenon cross-stitch, the other receiving the simple running stitch. All epitenon repairs employed 4-0 nylon suture. Repaired tendons were loaded in tension to the point of failure on a Materials Testing Machine (MTS). Tendon repair augmented with the cross-stitch displayed a significant, 53% greater failure strength than those repaired with the simple running stitch. Increases in initial stiffness and resistance to 2-mm gap formation in the cross-stitch specimens were 3.1% and 3.6%, respectively. Gapping resistance and initial stiffness in Achilles tendon repairs were comparable between the cross-stitch and simple running stitch, but the cross-stitch significantly improved failure strength. Greater failure strength may translate clinically to lower rates of re-rupture and earlier mobilization following Achilles tendon repair.

A Comparative Study Using Early Second-Look Laparoscopic Evaluation of Postoperative Adhesion Formation Between Two Surgical Procedures for Polycystic Ovarian Syndrome

The first established treatment for anovulatory women having polycystic ovarian syndrome (PCOS) who failed to respond to medical treatment was laparoscopic ovarian wedge resection. Since then, the risk of adhesion formation has prompted the development of less invasive surgical procedures such as ovarian wedge resection by minilaparotomy. This study compared the risk of adhesion formation in 37 anovulatory infertile women with PCOS who had failed to respond to clomiphene citrate and who had ovarian wedge resection by minilaparotomy (group I), and 39 others who underwent laparoscopic ovarian electrodrilling (group II). All participants had a second-look laparoscopy 1 week after the initial procedure. Adhesion formation was assessed using the American Fertility Society classification. The 2 treatment groups were similar demographically and with respect to serum gonadotropin levels. Three women in group II (7.7%) had periovarian adhesions. In contrast, 81% of group I women had periovarian adhesions, and 54% and 46%, respectively, had intra-abdominal and uterine adhesions. Adhesions at all 3 sites were significantly more frequent in group I women, and AFS adhesion scores differed significantly between the 2 surgical groups. Postoperatively, all the women ovulated spontaneously or with clomiphene therapy. Nearly 60% of women in group I and 87% of group II women conceived a child within a year after surgery. The difference in pregnancy rates was statistically significant. The interval from surgery to pregnancy was significantly shorter in group II women (4.4 vs. 6.5 months). There were no complications in either group, but group II women lost significantly more blood during surgery. The investigators conclude that laparoscopic ovarian electrodrilling should be considered at an early stage for infertile women with PCOS who have not responded to clomiphene citrate.

To Evaluate Feasibility of Laparoscopy Application of a Polylactic Acid (SurgiWrap™ MAST™) Bioabsorbable Sheet

To evaluate feasibility of Laparoscopy application of a polylactic acid (SurgiWrap™ MAST™) bioabsorbable sheet Prospective pilot study Prospective pilot study of 47 patients undergoing various laparoscopic procedure at risk for adhesion formation was performed. A 0.02 mm thickness SurgiWrap was modified to appropriate size to fit the area of dissection and introduced through a 5 mm to 12 mm canula with a grasping forceps. These were placed over the dissection area to cover the raw surface, in a anatomic position which gravity and other tissue would ensure the sheet would not move from its desired position. Otherwise they were secured with suture to achieve this goal. Procedures performed were, 12 myomectomy, 4 laparoscopic supracervical hysterectomy (LSH), 7 total laparoscopic hysterectomy (TLH), 7 ovarian cystectomy, 4 salpingo-oophorectomy, 10 treatments of endometriosis with lysis of adhesions (LOA), 1 bladder resection for endometriosis with LOA, 1 ovarian remnant syndrome with LOA, 1 presacral neurectomy, and 1 vaginal vault suspension with LOA. SurgiWrap was secured to the appropriate site with 0-Vicryl in 12 patients and 4-0 PDS in 7 patients and the rest were placed over the desired spot and secured with the anatomic position of the adjacent organs. All sheets were placed successfully without break down. At least two grasping forceps required to unfold the tissue and secure in the desired site. All patients have been followed between 1 - 5 months and no adverse event related to placement of the SurgiWrap has been noted. SurgiWrap can be applied laparoscopically wherever temporary wound support is required.

The role of CT scan in laparoscopic retrieval of a perforated intrauterine device (IUD)

The intrauterine device (IUD) is a common modality of contraception in developing countries; it is inexpensive, effective, can be used for a long period of time and, most importantly, is reversible. An IUD may perforate through the uterine wall into the pelvic abdominal cavity or into adjacent organs. The common and accepted treatment for displaced IUDs is laparoscopic or surgical removal because of the possible risk of adhesion formation or damage to the intestine or urinary bladder. We report four cases of intra-abdominal IUDs that underwent successful extraction by laparoscopic surgery. All of our patients underwent a preoperative CT scan as it was more accurate in locating the device site and its relation to the surrounding organ and bowel. The CT scan gives more information, specifically, whether the device is extending into the bowel or urinary bladder.

A randomized, prospective, controlled, multicenter clinical trial of a sprayable, site-specific adhesion barrier system in patients undergoing myomectomy

Objective To assess the safety and effectiveness of a sprayable, site-specific adhesion barrier system (SprayGel; Confluent Surgical, Waltham, MA) for reduction of adhesion formation. Design Prospective, randomized, controlled phase III trial. Setting University clinic (Kiel, Germany) and private clinic (Bordeaux, France). Patient(s) Sixty-six women aged 34.9 years (range, 23–52 years) undergoing laparoscopic or open uterine myomectomy, enrolled over a 15-month period. Intervention(s) Patients were randomized to receive either optimal surgical treatment plus adhesion barrier or optimal surgical treatment alone, followed by second-look laparoscopy. Main outcome measure(s) Initial and second-look laparoscopy procedures were assessed for incidence, extent, and severity of adhesions; all patients were followed for safety analysis. Result(s) When compared with initial surgery, the mean adhesion tenacity score of adhesions seen at second-look laparoscopy was significantly reduced in treatment patients compared with control patients (0.6 vs. 1.7, a 64.7% reduction). Mean adhesion extent score at second-look laparoscopy compared with initial surgery was 4.5 cm 2 vs. 7.2 cm 2, mean adhesion incidence score was 0.64 vs. 1.22. Of 64 patients, 40 (62.5%) returned for second-look laparoscopy. Conclusion(s) This adhesion barrier was safe, well tolerated, and demonstrated efficacy in a population of patients known to be at risk for adhesion formation. There were no adverse effects attributable to the product and no patients in whom it could not be applied.

Assessment of ovarian reserve. Is there still a role for ovarian biopsy? First do no harm!

Multiple endocrine, ultrasound-based and dynamic tests have been proposed for the assessment of ovarian reserve. Lately, ovarian biopsy has been proposed as a more representative functional test of ovarian reserve, and has been recommended as an early step in the investigation of infertility. Central to this hypothesis is the idea that a random biopsy of the ovarian cortex is reflective of the actual ovarian follicular pool. Recent studies have shown a wide variation in the number and distribution of ovarian follicles even from the same ovary and in the same patient. Coupled with the invasiveness of performing the biopsy and the risk of adhesion formation, we believe that there should not be a role for ovarian biopsy in ovarian reserve testing.

Radical laparoscopic excision of endometriosis: What is the risk of adhesion formation?

Radical laparoscopic excision of endometriosis: What is the risk of adhesion formation?

Incidence of postoperative adhesion formation after transperitoneal genitourinary laparoscopic surgery

Objectives. To evaluate adhesion formation after urologic laparoscopy, a multi-institutional review was conducted among adult patients who underwent a second procedure after an initial transperitoneal laparoscopic procedure. Adhesion formation after abdominal surgery remains a major cause of postoperative morbidity. Peritoneal adhesions result in hospitalizations and interventions that result in healthcare costs of more than 1 billion dollars annually. The risk of adhesion formation from transperitoneal genitourinary laparoscopy in adults has not been previously studied. Methods. Twenty-seven patients (mean age 45.5 years, range 24 to 71) were identified who underwent a second laparoscopic procedure after their initial urologic laparoscopic procedure was performed. The mean time between the procedures was 11.4 months (range 8 days to 38 months). At the time of the repeated laparoscopy or open surgery, the peritoneal cavity was examined and mapped for type (grade), extent (length), and location of any adhesions at the operative and trocar sites. The adhesions were graded as 0, no adhesions; 1, flimsy; 2, dense; and 3, cohesive. The extent was graded as 0, no adhesions; 1, less than 2 cm; 2, 2.1 to 10 cm; 3, greater than 10.1 cm. Results. Overall, adhesions occurred in 6 (22.2%) of 27 patients. Operative site adhesions occurred in only 3 (8.2%) of 34 possible operative sites (gastric augmentation cystoplasty, renal cyst ablation, nephropexy). Trocar site adhesions occurred in 4 (3.5%) of 114 possible sites (two nephrectomies, one cyst decortication, and one orchiectomy). All adhesions were classified as grade 1 and extent 1, except for a single grade 2, extent 2 adhesion. In most patients, retroperitonealization occurred with minimal or no scarring noted. None of the patients developed symptoms as a result of the adhesion formation. Conclusions. Although intraperitoneal adhesions do occur with adult urologic laparoscopy, the incidence is low. Also, in the few patients who do form adhesions, they are flimsy and short. This evidence, when contrasted with the available data on adhesion formation after open surgery, suggests that transperitoneal laparoscopic approaches to genitourinary surgery may have advantages over traditional open transperitoneal approaches by lowering the incidence and severity of adhesion formation.

Myomectomy: Comparison of open and laparoscopic techniques

It appears that both laparoscopic and laparotomy approaches to myomectomy are viable surgical procedures. Both surgeries can be performed with minimal risk. Pregnancy rates after either procedure are high. The advantage of laparotomy over laparoscopy is that it is technically easier. On the other hand, laparoscopy enables quicker and easier recovery. Moreover, the risk of adhesion formation is reduced. If the surgeon can rise to the technical challenge, a laparoscopic approach to myomectomy should be the intended surgery.

Bilateral or Unilateral KTP Laser Ovarian Drilling in Polycystic Ovarian Disease

Bilateral or Unilateral KTP Laser Ovarian Drilling in Polycystic Ovarian Disease

Evidence of genetic susceptibility to Chlamydia trachomatis-induced pelvic inflammatory disease in the pig-tailed macaque.

The macaque model of chlamydial pelvic inflammatory disease (PID) demonstrates individual variability in the time of onset of intrapelvic adhesions. Some animals develop adhesions rapidly, within 2 weeks after a single tubal inoculation with Chlamydia trachomatis, while in others, adhesions are not observed until 2 weeks after a second tubal inoculation. To test whether this variability correlates with major histocompatibility complex (MHC) class I haplotype, we used macaque alloantisera and mouse anti-HLA monoclonal antibodies to determine the MHC class I haplotypes of 44 C. trachomatis-infected macaques (Macaca nemestrina). Macaques developing gross tubal adhesions after the first chlamydial inoculation were classified as susceptible (n = 29), while those not developing adhesions until after the second chlamydial inoculation were classified as relatively resistant (n = 15), to adhesion formation. Three antibody specificities correlated with susceptibility (odds ratio [OR] 5.2, P < 0.01; OR 6.1 and 4.3, P < 0.05), and two correlated with relative resistance to adhesions (OR 0.1, P < 0.05; OR 0.2, P < 0.01). Because several of these antibodies are cross-reactive, as many as five different MHC class I alleles (three increasing and two decreasing ORs) or as few as two different MHC class I alleles (one increasing and one decreasing OR) could be correlated with risk of adhesion formation. We conclude that in macaques, susceptibility or relative resistance to rapid formation of tubal adhesions is correlated with expression of MHC class I alleles, consistent with reports of MHC class I restriction of chlamydial immunopathology in humans.

THE ROLE OF WEDGE RESECTION OF THE OVARY AS A CAUSE FOR MECHANICAL STERILITY

The role of wedge resection of the ovary in inducing secondary sterility of a mechanical nature has been evaluated. Two groups of patients were studied. Fifty-seven patients underwent wedge resection of ovary because of symptoms of the Stein-Leventhal syndrome. Of these, eight were found to have extensive peritubal and periovarian adhesions after operation. In the second group, a retrospective study was made. One hundred and ninety-eight women were known to have mechanical sterility. Of these, 28 gave a history of bilateral wedge resection of ovaries because of the Stein-Leventhal syndrome. All pelvic operations for correction of sterility carry a considerable risk of adhesion formation.