Adhesiolysis – Surgical Removal of Adhesions
Laparoscopic And Minimally Invasive Procedures continued
Chronic pelvic pain is a debilitating disease that affects more than 20% of women today. Much of the pelvic pain is caused by scar tissue known as adhesions. Adhesions are bands of scar tissue that connect normally separated pelvic structures. This connection represents a common problem in gynecologic health care which causes incapacitating pelvic pain, infertility, constipation, and dyspareunia (painful intercourse). Patients are more likely to have adhesive disease after an injury. The injury can be caused by surgery, infection, radiation or trauma to the abdominal area. (See causes below.)
Causes of Pelvic Adhesions
- Previous pelvic or abdominal surgery (most common reason)
- History of infection in the abdominal cavity
- History of cancer or radiation therapy
- Previous intra-abdominal trauma or bleeding (ectopic pregnancy, motor vehicle accidents, appendicitis)
- Surgical glove powder
Adhesions are almost inevitable after a surgical procedure as indicated by the bar graph. It is up to the surgeon to minimize the potential of adhesion formation. Drs. Miklos and Moore are aware of this problem and perform specific adhesion prevention techniques to avoid the formation of new adhesions while trying to eradicate the already existing adhesive disease.
Source: Adapted from Diamond MP.
Surgical aspects of infertility.
Gynecology and Obstetrics, 1998.
Drs. Miklos and Moore minimize adhesion formation by incorporating minimally invasive open laparoscopy (see pictures below) and using barrier membranes and gels. The open laparoscopy technique is a safe and proven technique. Please refer to an article in Obstetrics and Gynecology describing a 29 year experience with open laparoscopy.
The belly button incision is performed with a scalpel instead of a blind stab with a Veress needle. The Veress needle and trocar insertion injuries are unique to conventional laparoscopy. By utilizing the open laparoscopy technique, we can closely monitor the entry into the abdomen to see if there are any adhesions, bowel, or blood vessels in the way. If we encounter an injury, we can recognize and repair it immediately. Because of our experience in advanced laparoscopy, we add an additional edge in the prevention of adhesions over an open laparotomy.
Adhesion Prevention Techniques
- Gentle Tissue Handling
- Use of Barrier Agents (Interceed or Intergel)
- Use of Microsurgical Instruments
- Precise Treatment of the Surgical Area
- Minimal Blood Loss
- Copious Pelvic Irrigation
- No Glove Powder Exposure
Open Laparoscopy Technique
Injecting Incision Site - incision site prior to the incision theoretically reduces the postoperative pain the patient feels
Incision – the incision is made in the inferior border of the belly button
Abdominal Fascia – the abdomen fascia is grasped with two clamps and incised. The fascia is the tissue which holds the abdominal wall together and along with the abdomen muscles gives the abdomen strength
Suture Tags of Fascia - sutures are placed on the edges of the fascia so the surgeon can better identify the fascia at the end of the case. Meticulous closure of the fascia helps to prevent hernia formation.
Hasson trocar placement – the trocar is the tube which allows the surgeon to access the inside of the abdomen. This particular tube will allow the surgeon to place the laparoscope (camera scope) into the belly thus permitting visualizaiton of the procedure and adhesions.
One of the more recent advances in adhesion prevention include barrier agents. These agents function as physical barriers between the adhesiolysis area, which is raw and abraded due to the surgical cutting, and the unaffected areas in the abdominal cavity. This newly dissected area has an increased risk of forming adhesions. An example would be if you were to remove skin from both of your palms of each hand and then bound your hands together for 24 hours, upon removal of the binding your hands would stick together by adhesions. By placing a barrier between your hands, they cannot scar together. We use Interceed and Intergel barrier agents inside of the abdomen to prevent adhesion formation.
Interceed is an absorbable cellulose mesh that prevents adhesion formation at the surgical site as seen below.
Interceed is an absorbable cellulose mesh that prevents
adhesion formation at the surgical site as seen above
The mesh becomes a barrier gel within 8 hours. An Interceed Adhesion Barrier Study Group confirmed its effectiveness.
Intergel (Gynecare) is a hyaluronate gel with consistency of motor oil that forms a coating on the peritoneal surface including areas that have recently been made raw through surgery. Body movement distributes the gel throughout the abdominal cavity covering all areas and reducing the chance that the raw areas will stick and form adhesions. An Intergel Adhesion Prevention Study Group showed a 59% reduction of adhesions with the use of Intergel. Unfortunately, despite its clinical success, it was taken off the market several years ago and therefore is no longer available.
SEPRAFILM Adhesion Barrier (Genzyme Corp) is a temporary, bioresorbable adhesion barrier proven to reduce the incidence, extent, and severity of adhesions in patients undergoing abdominal or pelvic laparotomy. It physically separates traumatized, adhesiogenic tissues and organs while normal tissue repair takes place.
Upon hydration, SEPRAFILM becomes a gel within 24 to 48 hours. This gel remains in place during the critical seven-day healing period — the time during which new adhesions typically form.1 It slowly resorbs and is excreted from the body in less than 28 days.
SEPRAFILM is composed of two chemically modified polysaccharides: hyaluronic acid and carboxymethylcellulose. Hyaluronic acid (HA) is a naturally occurring polysaccharide expressed throughout the human body. Carboxymethylcellulose (CMC), also a polysaccharide, is a derivative of cellulose. Both are common components in pharmaceuticals, foods, and cosmetics. These components’ properties render SEPRAFILM hydrophilic so it doesn’t require suturing and stays where it is applied until reabsorbed. Clinical studies have shown that its use reduces the formation of adhesions.
51% of SEPRAFILM patients in the study were free of adhesions at the site of application, compared to 6% of control patients (Figure 1). Application of SEPRAFILM reduced the extent of adhesions (percentage of the incision length involved) by 48% relative to control.
Becker JM, Dayton MT, Fazio VW, et al. Prevention of postoperative abdominal adhesions by a sodium hyaluronate-based bioresorbable membrane: a prospective, randomized, double-blind multicenter study. J Am Coll Surg. 1996;183:297-306.
To view an animated video on how Seprafilm works, click here.
An adhesion-prevention solution made from 4% icodextrin has also been shown to significantly reducedthe incidence of adhesions after gynecologic laparoscopic adhesiolysis, compared with Ringer's lactate solution, in a multicenter, double-blind clinical trial that Dr Miklos and Moore were involved in and had patients enrolled in the trial and were key US investigators in the study.
The product, called Adept, is made by ML Laboratories PLC of Leicestershire, England. It has been licensed for use in Europe since 1999; in the United States, it received FDA approval for adhesion prevention in 2006 and is carried by Baxter Labs.
The study of postsurgical adhesions after gynecological laparoscopic adhesiolysis--known as the PAMELA study that Dr Miklos and Moore were investigators in--formed the basis of the company's submission for Food and Drug Administration approval.
Data from the PAMELA study were presented at the annual congress of the International Society for Gynecologic Endoscopy. The study randomized 449 laparoscopic adhesiolysis patients to intraoperative irrigation and instillation of Adept or Ringer's lactate solution (RLS) during a first surgical procedure. The fluids were irrigated at 100 mL/30 min in-traoperatively, and a postoperative instillate of 1 L was left in the pelvic cavity.
Because of its high molecular weight, Adept is absorbed slowly via the lymphatic system and remains in the pelvic cavity, providing hydroflotation for 3-5 days post surgery, the critical time for adhesion formation. Secondary to this, the bowel, omentum and other pelvic organs float in the abdominal cavity and should not form adhesions to each other, nor the abdominal wall (where many adhesions are formed). A summary of the trial can be seen below.
Patients with reduction in asf score
In patients whose primary diagnosis was infertility, significantly more (52.9% versus 30.4% p=0.001) had a reduction in American Fertility Society (AFS) score with ADEPT than with lactated Ringers solution (LRS).1 This indicates a decrease in adhesion formation.
Significantly more Adept patients achieved clinical success than did LRS (control grop that just had Lactated Ringers placed in abdomen) patients (49% vs. 38%). In infertility patients, Adept demonstrated particular clinical success compared with LRS (55% vs. 14%). Safety was comparable in both groups. Most events were related to the surgery, with an increase in transient labial edema in the Adept group. Brown, C., Luciano, A., Martin, D., Peers, E., et al. ‘Adept (icodextrin 4% solution) reduces adhesions after laparoscopic surgery for adhesiolysis: a double-blind, randomized, controlled study.’ Fertility and Sterility, 2007, vol. 88 (5), pp. 1413-1426.
ADEPT mode of action and clinical effects
ADEPT keeps peritoneal surfaces apart, minimising tissue apposition, during the critical post-surgery period of fibrin formation and mesothelial regeneration, when patients are at the greatest risk of adhesion formation.
Surgical examples of 1st and 2nd look laparascopy1
Intraoperative photos from an ADEPT treatment group
Pre-adhesiolysis of right tubo-ovarian adhesions
Status post right tubo-ovarian adhesiolysis
Arista Hemostatic Agent
Dr Miklos and Moore also utilize Arista powder in laparoscopic surgery as a hemostatic agent when necessary. Post operative bleeding is thought to cause adhesions and in many instances there may be some slight oozing from raw surfaces following laparoscopoic takedown of adhesions. A recent study has suggested (stacey, I have this study on my desk in office, need to just get a link for it and place here) that the use of Arista to prevent post-operative bleeding also reduces adhesion formation. Dr Miklos and Moore also believe in this theory and utilize this FDA approved agent when they feel is necessary.
Arista™AH is a natural composition synthesized from a purified plant polymer and free of all biological components. As such, it is non toxic, non irritating, non hemolytic and non mutagenic. Arista™AH reaches its maximum volume immediately upon contact with blood or other fluids. In clinical studies, Arista™AH has produced no adverse reactions. It is non immunogenic, fully biocompatible and readily absorbed in tissue in 24 to 48 hours.
Unlike other surgical hemostats, Arista™AH:
- is fully and safely ABSORBABLE – within 24 to 48 hours (min. absorption time for other surgical hemostats is typically 3-8 weeks)
- contains NO HUMAN OR ANIMAL components
- DOES NOT SERVE AS A NIDUS FOR INFECTION OR GRANULOMA FORMATION
- is ready INSTANTLY, requiring NO PREPARATION TIME
- is CELL SAVER COMPATIBLE
The goal of adhesiolysis is to eliminate pain caused by the adhesion or scar tissue. Many surgeons use laser, electroenergy or electrocoagulation to perform this procedure. Drs. Miklos and Moore perform laparoscopic adhesiolysis using scissors, just as they would do if they did the surgery through a large open incision. They utilize precise surgical technique with minimal bleeding during the adhesiolysis thus preventing further damage and potentially more adhesions. They believe that laparoscopy is only a mode of access into the abdominal cavity and should not change the way one performs the operation. To prevent future adhesions, Drs. Miklos and Moore utilize anti-adhesive barriers. They agree with a recent study in the Journal of Laparoscopic Surgeons that advocates the combination of laparoscopy and adhesion barriers.
Drs. Miklos and Moore are also involved in ongoing multi-center research trials involving new adhesion barriers. Because of the laparoscopic approach, most patients undergoing adhesiolysis usually remain in the hospital for less than 23 hours.
Adhesiolysis Figure 12
Adhesiolysis Figure 13
Abdominal Adhesions - Patients with adhesions inside the abdominal cavity. Adhesions can come in various sizes, length and structure. No matter what the size they can cause abdominal pain, discomfort, bloating, and difficulty with bowel movements.
We achieve great results from our laparoscopic adhesiolysis cases. Patients feel a significant relief from our surgical intervention. Since the main cause of adhesions is previous surgery, adhesiolysis can be an intricate procedure. We have success in many patients who were advised not to have another laparoscopic procedure. Our open laparoscopy technique allows us to safely perform adhesiolysis surgery on a patient with an extensive surgical history in 99% of the cases.
Scar tissue causes difficult re-entry into the abdominal cavity. By incorporating the safe open laparoscopic technique, Drs. Miklos and Moore can minimize further trauma. We have never had a major vascular injury (rate < 0.01%) during our surgical procedures despite performing 400 operations per years. This extremely low vascular complication rate is due to our expert training and utilization of the open laparoscopic technique. We also have < 0.1 % chance of ureteral or intestinal injury.
We had a patient from Florida who had a history of 6 laparoscopies that were converted to open laparotomies (large abdominal incisions). The last surgeon told the patient to avoid any future laparoscopy because of the thickened adhesions. Drs. Miklos and Moore performed the laparoscopic adhesiolysis (via the open laparoscopic technique) without complications and avoided a large incision.
Atlanta Urogynecology Associates Experience
Drs. Miklos and Moore have performed laparoscopic adhesiolysis procedure over the past 15 years with great success. We believe that the minimally invasive adhesiolysis with the use of barrier agents is a safe and effective way help patients with chronic pelvic pain. We understand this pain affects your lifestyle and we strive to use our adhesion prevention techniques to help you live an active and pain-free lifestyle.
Adhesiolysis or Lysis of Adhesions - Adhesiolysis is the process of cutting the adhesions between two abdominal structures. Here, Dr. Miklos uses scissors to cut or release the adhesive disease between the abdominal wall and the bowels' protective fatty covering called the "great omentum".