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Laparoscopic Procedure >>

Laparoscopic and Minimally Invasive Procedures continued

Adhesiolysis
(Surgical Removal of Adhesions)

Overview

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
	Endometriosis
	History of cancer or radiation therapy
	Previous intra-abdominal trauma or bleeding (ectopic pregnancy, motor vehicle accidents, appendicitis)
	Surgical glove powder

Indications

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.

Adhesiolysis Figure: 1
Source: Adapted from Diamond MP.
Surgical aspects of infertility.
Gynecology and Obstetrics, 1998.

Advantages

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

Adhesiolysis Figure: 2	Adhesiolysis Figure: 3
Adhesiolysis Figure: 4	Adhesiolysis Figure: 5
Adhesiolysis Figure: 6	Adhesiolysis Figure: 7
Facial Anchoring Sutures (Prevents Potential Hernia Formation)	Completed Entry with the Hasson Trocar

Barrier Agents

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.

Adhesiolysis Figure: 8


Adhesiolysis Figure: 9

The mesh becomes a barrier gel within 8 hours. An Interceed Adhesion Barrier Study Group confirmed its effectiveness.

Intergel 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.

Adhesiolysis Figure: 10

An Intergel Adhesion Prevention Study Group showed a 59% reduction of adhesions with the use of Intergel.

Adhesiolysis Figure: 11

Technique

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

Results/Complications
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

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".