Preventing pelvic adhesions during surgery
Many different techniques have been described in order to prevent the formation of pelvic adhesions following surgical procedures. The most important of these is the prevention of injury or trauma to the tissues at the time of surgery. This is important, as studies suggest that it is much easier to prevent pelvic adhesion formation in the first place than to treat them once they have formed.
Proper surgical technique is critically important in the prevention of pelvic adhesions. Such techniques include the minimalization of tissue manipulation, the use of small non-reactive suture, and the prevention of infection. The prevention of bleeding is also critically important, as blood is a primary factor involved in the formation of pelvic adhesions. Many scientific studies have focused on the type of surgical approach that should be performed in order to minimize adhesion formation. There is a suggestion in the literature that minimally invasive surgery (“belly button surgery”, or laparoscopy) is associated with significantly less adhesion formation than is laparotomy (surgery through a large abdominal incision). Most of the surgical techniques designed to prevent pelvic adhesions center around the use of adhesion barriers.
Types of pelvic adhesion barriers used during surgery
Many different adhesion barriers have been developed over the years in the hope of minimizing the formation of pelvic adhesions. While some have proven to be effective, others have not been demonstrated to have any efficacy. The most commonly used adhesion barriers at this time include Interceed, Seprafilm, and Adept.
Interceed is made of oxidized regenerated cellulose. It is packaged as a 3 x 4 inch fabric and adheres to the tissue without suturing. It forms a gel within eight hours after application and subsequently degrades into glucose and glucuronic acid (inert elements) within 3 to 10 days. It is approved by the Federal Food & Drug Administration (FDA) for use at laparotomy, but is not FDA approved for use at laparoscopy. Although Interceed works very well, the major problem associated with its use is that it is ineffective in the presence of bleeding. In fact, when applied in the presence of blood, Interceed may actually cause adhesion formation. Multiple studies have demonstrated the effectiveness of Interceed. A meta analysis (a scientific technique that combines the results from many small studies in order to generate a meaningful conclusion), published in 1999, demonstrated a 24% reduction in adhesions when Interceed was used.
Seprafilm is a combination of sodium hyaluronate and carboxymethyl cellulose. Hyaluronic acid is a commonly occurring chemical found in cartilage, skin, and most cosmetics. Carboxymethyl cellulose is added to extend the duration of time that the Seprafilm remains in place before dissolving. Seprafilm is a clear, almost cellophane like material that adheres to the tissue without suturing. It turns into a gel within 24 to 48 hours following application and remains at the site of the application for up to seven days. It is cleared from the body in less than 28 days and, unlike Interceed, does not cause adhesion formation in the presence of blood. The major difficulty associated with Seprafilm is that it cannot be applied laparoscopically due to technical factors, as it can splinter or tear when applied through small incisions. As of the end of 2009, there were more than 20 published clinical trials of Seprafilm involving over 5000 patients. These studies have been published in both the gynecologic and general surgical literature, and demonstrate significant benefit from using Seprafilm. The most recent studies also demonstrate the cost effectiveness of Seprafilm, i.e. using Seprafilm appears to save money for patients and the healthcare system, as patients who receive Seprafilm have fewer complications – including less future surgery related to problems from adhesions.
Adept is a clear, odorless glucose polymer that can be used either laparoscopically or at laparotomy. It is very easy to apply, and in a large pivotal trial, Adept was demonstrated to significantly reduce the formation of adhesions. Adept is used throughout the surgical procedure in order to coat the tissues and at the completion of surgery, a large amount is left in the pelvis. The major complaint that some patients have following the use of Adept is that it leaks out of their incisions for up to 2-3 days following surgery. This is normal, and most patients do not find it to be more than a minor inconvenience. There is some question as to whether Adept stays in place long enough to have a significant benefit, and additional studies to answer this question are ongoing.
Pelvic adhesions are a significant problem following gynecologic and abdominal surgery. They can cause significant problems, such as pelvic pain and infertility. While some barriers have been approved by the FDA for use in surgical procedures, the best way to prevent complications from pelvic adhesions is to prevent their formation in the first place. This can be accomplished by having surgery performed by surgeons who are specifically trained in microsurgical and advanced laparoscopic techniques – such as the use of adhesion barriers – designed to prevent their formation.