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Semin Reprod Med 2011; 29(2): 130-137
DOI: 10.1055/s-0031-1272475
© Thieme Medical Publishers

Management and Prevention of Pelvic Adhesions

Sheikha Al-Jabri1 , Togas Tulandi1
  • 1Department of Obstetrics and Gynecology, McGill University, Montreal, QC, Canada
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Publication History

Publication Date:
24 March 2011 (online)

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ABSTRACT

Postsurgical adhesion formation is an important clinical problem within all surgical specialties. In gynecology, adhesions resulting from gynecologic procedures are a major clinical, social, and economic concern because they may result in pelvic pain, infertility, or bowel obstruction. In addition, it may lead to additional surgery to resolve the adhesion-related complications. This review evaluates the available evidence regarding the effectiveness of various strategies for reducing postsurgical adhesions. Those strategies include surgical techniques and adhesion-reducing substances. Postsurgical adhesions are natural consequences of tissue trauma and healing. Our review indicates that most of the effective adhesion-reducing substances decrease adhesion formation and reformation, but they do not prevent its occurrence. In fact, there is no single modality proven to be unequivocally effective in preventing adhesion formation. Current evidence suggests that the use of ORC (Interceed; Gynecare, Somerville, NJ), e-PTFE (Gore-Tex Surgical Membrane, Preclude; WL Gore, Flagstaff, AZ), HA-CMC (Seprafilm; Genzyme, Cambridge, MA), or 4% icodextrin (Adept; Baxter BioSurgery, Deerfield, IL) is justified. Their use, however, should not replace good surgical techniques. We recommend the use of microsurgical principles, minimally invasive surgery, and the use of adhesion-reducing agents.

KEYWORDS

Adhesion - postsurgical adhesion - adhesion prevention - adhesion barrier

REFERENCES

  • 1 Baakdah H, Tulandi T. Adhesion in gynecology complication, cost, and prevention: a review.  Surg Technol Int. 2005;  14 185-190
    PubMedGoogle Scholar
  • 2 diZerega G S. Contemporary adhesion prevention.  Fertil Steril. 1994;  61 (2) 219-235
    PubMedGoogle Scholar
  • 3 Tulandi T, Agdi M, Zarei A, Miner L, Sikirica V. Adhesion development and morbidity after repeat cesarean delivery.  Am J Obstet Gynecol. 2009;  201 (1) 56 e1-e6
    PubMedGoogle Scholar
  • 4 Al-Sunaidi M, Tulandi T. Adhesion-related bowel obstruction after hysterectomy for benign conditions.  Obstet Gynecol. 2006;  108 (5) 1162-1166
    CrossrefPubMedGoogle Scholar
  • 5 Lower A M, Hawthorn R J, Ellis H, O'Brien F, Buchan S, Crowe A M. The impact of adhesions on hospital readmissions over ten years after 8849 open gynaecological operations: an assessment from the Surgical and Clinical Adhesions Research Study.  BJOG. 2000;  107 855-862
    CrossrefPubMedGoogle Scholar
  • 6 Menzies D, Ellis H. Obstruction from adhesions: how old is the problem?.  Ann R Coll Surg Engl. 1990;  72 60-63
    PubMedGoogle Scholar
  • 7 Hamilton C J, Evers J LH, Hoogland H J. Ovulatory disorders and inflammatory adnexal damage: a neglected cause of the failure of fertility microsurgery.  Br J Obstet Gynaecol. 1986;  93 (3) 282-284
    PubMedGoogle Scholar
  • 8 Franklin R R. Ovarian Adhesion Study Group . Reduction of ovarian adhesions by the use of Interceed.  Obstet Gynecol. 1995;  86 (3) 335-340
    CrossrefPubMedGoogle Scholar
  • 9 Tulandi T, Collins J A, Burrows E et al. Treatment-dependent and treatment-independent pregnancy among women with periadnexal adhesions.  Am J Obstet Gynecol. 1990;  162 (2) 354-357
    CrossrefPubMedGoogle Scholar
  • 10 Namnoum A B, Murphy A A. Diagnostic and operative laparoscopy. In:, Thompson J D, Rock J A, eds. TeLinde's Operative Gynecology. 7th ed. Philadelphia, PA: JB Lippincott; 1991: 363-371
    Google Scholar
  • 11 Tulandi T. Atlas of Laparoscopy and Hysteroscopy Techniques. New York, NY: Informa HealthCare; 2007
    Google Scholar
  • 12 Serafini P, Batzofin J. Diagnosis of female infertility. A comprehensive approach.  J Reprod Med. 1989;  34 (1) 29-40
    PubMedGoogle Scholar
  • 13 Rock J A, Katayama K P, Martin E J, Woodruff J D, Jones Jr H W. Factors influencing the success of salpingostomy techniques for distal fimbrial obstruction.  Obstet Gynecol. 1978;  52 (5) 591-596
    PubMedGoogle Scholar
  • 14 Benadiva C A, Kligman I, Davis O, Rosenwaks Z. In vitro fertilization versus tubal surgery: is pelvic reconstructive surgery obsolete?.  Fertil Steril. 1995;  64 (6) 1051-1061
    PubMedGoogle Scholar
  • 15 Hulka J F. Adnexal adhesions: a prognostic staging and classification system based on a five-year survey of fertility surgery results at Chapel Hill, North Carolina.  Am J Obstet Gynecol. 1982;  144 (2) 141-148
    PubMedGoogle Scholar
  • 16 Caspi E, Halperin Y. Surgical management of periadnexal adhesions.  Int J Fertil. 1981;  26 (1) 49-52
    PubMedGoogle Scholar
  • 17 Surrey M W, Friedman S. Second-look laparoscopy after reconstructive pelvic surgery for infertility.  J Reprod Med. 1982;  27 (10) 658-660
    PubMedGoogle Scholar
  • 18 Raj S G, Hulka J F. Second-look laparoscopy in infertility surgery: therapeutic and prognostic value.  Fertil Steril. 1982;  38 (3) 325-329
    PubMedGoogle Scholar
  • 19 Asrm V, Asrm J. Practice Committee of the American Society for Reproductive Medicine . Pathogenesis, consequences, and control of peritoneal adhesions in gynecologic surgery.  Fertil Steril. 2007;  88 (1) 21-26
    CrossrefPubMedGoogle Scholar
  • 20 Brokelman W J, Holmdahl L, Bergström M, Falk P, Klinkenbijl J H, Reijnen M M. Peritoneal fibrinolytic response to various aspects of laparoscopic surgery: a randomized trial.  J Surg Res. 2006;  136 (2) 309-313
    CrossrefPubMedGoogle Scholar
  • 21 Yesildaglar N, Koninckx P R. Adhesion formation in intubated rabbits increases with high insufflation pressure during endoscopic surgery.  Hum Reprod. 2000;  15 (3) 687-691
    CrossrefPubMedGoogle Scholar
  • 22 Tulandi T, Hum H S, Gelfand M M. Closure of laparotomy incisions with or without peritoneal suturing and second-look laparoscopy.  Am J Obstet Gynecol. 1988;  158 (3 Pt 1) 536-537
    PubMedGoogle Scholar
  • 23 Bamigboye A A, Hofmeyr G J. Non-closure of peritoneal surfaces at caesarean section—a systematic review.  S Afr Med J. 2005;  95 (2) 123-126
    PubMedGoogle Scholar
  • 24 Zareian Z, Zareian P. Non-closure versus closure of peritoneum during cesarean section: a randomized study.  Eur J Obstet Gynecol Reprod Biol. 2006;  128 (1–2) 267-269
    CrossrefPubMedGoogle Scholar
  • 25 Yiyang Z, Qunxi C, Weiling W. Closure vs. nonclosure of the peritoneum at cesarean delivery.  Int J Gynaecol Obstet. 2006;  94 (2) 103-107
    CrossrefPubMedGoogle Scholar
  • 26 Querleu D, Vankeerberghen-Deffense F, Boutteville C. Adjuvant treatment of tubal surgery. Randomized prospective study of systemically administered corticoids and noxythiolin.  [in French] J Gynecol Obstet Biol Reprod (Paris). 1989;  18 (7) 935-940
    PubMedGoogle Scholar
  • 27 Wiseman D M, Trout J R, Diamond M P. The rates of adhesion development and the effects of crystalloid solutions on adhesion development in pelvic surgery.  Fertil Steril. 1998;  70 (4) 702-711
    CrossrefPubMedGoogle Scholar
  • 28 Brown C B, Luciano A A, Martin D, Peers E, Scrimgeour A, diZerega G S. Adept Adhesion Reduction Study Group . Adept (icodextrin 4% solution) reduces adhesions after laparoscopic surgery for adhesiolysis: a double-blind, randomized, controlled study.  Fertil Steril. 2007;  88 (5) 1413-1426
    CrossrefPubMedGoogle Scholar
  • 29 Metwally M, Gorvy D, Watson A, Li T C. Hyaluronic acid fluid agents for the prevention of adhesions after fertility-preserving gynecological surgery: a meta-analysis of randomized controlled trials.  Fertil Steril. 2007;  87 (5) 1139-1146
    CrossrefPubMedGoogle Scholar
  • 30 Johns A. Evidence-based prevention of post-operative adhesions.  Hum Reprod Update. 2001;  7 (6) 577-579
    CrossrefPubMedGoogle Scholar
  • 31 Wiseman D M. Possible Intergel reaction syndrome (pIRS).  Ann Surg. 2006;  244 (4) 630-632
    PubMedGoogle Scholar
  • 32 Tang C L, Jayne D G, Seow-Choen F, Ng Y Y, Eu K W, Mustapha N. A randomized controlled trial of 0.5% ferric hyaluronate gel (Intergel) in the prevention of adhesions following abdominal surgery.  Ann Surg. 2006;  243 (4) 449-455
    CrossrefPubMedGoogle Scholar
  • 33 Burns J W, Skinner K, Colt J et al. Prevention of tissue injury and postsurgical adhesions by precoating tissues with hyaluronic acid solutions.  J Surg Res. 1995;  59 (6) 644-652
    CrossrefPubMedGoogle Scholar
  • 34 Ustün C, Koçak I, Akpolat I. Effects of Seprafilm (sodium hyaluranate-based bioresorbable), Sepracoat (0.4% hyaluronic acid), and Ringer's lactate on the prevention of postsurgical adhesion formation in rat models.  J Obstet Gynaecol. 2000;  20 (1) 78-80
    CrossrefPubMedGoogle Scholar
  • 35 Diamond M P. The Sepracoat Adhesion Study Group . Reduction of de novo postsurgical adhesions by intraoperative precoating with Sepracoat (HAL-C) solution: a prospective, randomized, blinded, placebo-controlled multicenter study.  Fertil Steril. 1998;  69 (6) 1067-1074
    CrossrefPubMedGoogle Scholar
  • 36 Mais V, Bracco G L, Litta P, Gargiulo T, Melis G B. Reduction of postoperative adhesions with an auto-crosslinked hyaluronan gel in gynaecological laparoscopic surgery: a blinded, controlled, randomized, multicentre study.  Hum Reprod. 2006;  21 (5) 1248-1254
    CrossrefPubMedGoogle Scholar
  • 37 Guida M, Acunzo G, Di Spiezio Sardo A et al. Effectiveness of auto-crosslinked hyaluronic acid gel in the prevention of intrauterine adhesions after hysteroscopic surgery: a prospective, randomized, controlled study.  Hum Reprod. 2004;  19 (6) 1461-1464
    CrossrefPubMedGoogle Scholar
  • 38 Ahmad G, Duffy J M, Farquhar C et al. Barrier agents for adhesion prevention after gynaecological surgery.  Cochrane Database Syst Rev. 2008;  (2) CD000475
    PubMedGoogle Scholar
  • 39 Ates U, Ata B, Ortakuz S, Seyhan A, Urman B. Prevention of adhesion formation following ovarian surgery in a standardized animal model: comparative study of Interceed and double layer Surgicell.  J Obstet Gynaecol Res. 2008;  34 (1) 12-17
    PubMedGoogle Scholar
  • 40 Chuang Y C, Fan C N, Cho F N, Kan Y Y, Chang Y H, Kang H Y. A novel technique to apply a Seprafilm (hyaluronate-carboxymethylcellulose) barrier following laparoscopic surgeries.  Fertil Steril. 2008;  90 (5) 1959-1963
    CrossrefPubMedGoogle Scholar
  • 41 Vrijland W W, Tseng L N, Eijkman H J et al. Fewer intraperitoneal adhesions with use of hyaluronic acid-carboxymethylcellulose membrane: a randomized clinical trial.  Ann Surg. 2002;  235 (2) 193-199
    CrossrefPubMedGoogle Scholar
  • 42 Bristow R E, Montz F J. Prevention of adhesion formation after radical oophorectomy using a sodium hyaluronate-carboxymethylcellulose (HA-CMC) barrier.  Gynecol Oncol. 2005;  99 (2) 301-308
    CrossrefPubMedGoogle Scholar
  • 43 Tsuji S, Takahashi K, Yomo H et al. Effectiveness of antiadhesion barriers in preventing adhesion after myomectomy in patients with uterine leiomyoma.  Eur J Obstet Gynecol Reprod Biol. 2005;  123 (2) 244-248
    CrossrefPubMedGoogle Scholar
  • 44 Beck D E, Cohen Z, Fleshman J W, Kaufman H S, van Goor H, Wolff B G. Adhesion Study Group Steering Committee . A prospective, randomized, multicenter, controlled study of the safety of Seprafilm adhesion barrier in abdominopelvic surgery of the intestine.  Dis Colon Rectum. 2003;  46 (10) 1310-1319
    CrossrefPubMedGoogle Scholar
  • 45 Fazio V W, Cohen Z, Fleshman J W et al. Reduction in adhesive small-bowel obstruction by Seprafilm adhesion barrier after intestinal resection.  Dis Colon Rectum. 2006;  49 (1) 1-11
    CrossrefPubMedGoogle Scholar
  • 46 Mohri Y, Uchida K, Araki T et al. Hyaluronic acid-carboxycellulose membrane (Seprafilm) reduces early postoperative small bowel obstruction in gastrointestinal surgery.  Am Surg. 2005;  71 (10) 861-863
    PubMedGoogle Scholar
  • 47 Rodgers K E, Robertson J T, Espinoza T et al. Reduction of epidural fibrosis in lumbar surgery with Oxiplex adhesion barriers of carboxymethylcellulose and polyethylene oxide.  Spine J. 2003;  3 (4) 277-283; discussion 284
    CrossrefPubMedGoogle Scholar
  • 48 Kim K D, Wang J C, Robertson D P et al. Reduction of leg pain and lower-extremity weakness for 1 year with Oxiplex/SP gel following laminectomy, laminotomy, and discectomy.  Neurosurg Focus. 2004;  17 (1) ECP1
    PubMedGoogle Scholar
  • 49 The Myomectomy Adhesion Multicenter Study Group . An expanded polytetrafluoroethylene barrier (Gore-Tex Surgical Membrane) reduces post-myomectomy adhesion formation.  Fertil Steril. 1995;  63 (3) 491-493
    PubMedGoogle Scholar
  • 50 Haney A F, Hesla J, Hurst B S et al. Expanded polytetrafluoroethylene (Gore-Tex Surgical Membrane) is superior to oxidized regenerated cellulose (Interceed TC7 + ) in preventing adhesions.  Fertil Steril. 1995;  63 (5) 1021-1026
    PubMedGoogle Scholar
  • 51 Young P, Johns A, Templeman C et al. Reduction of postoperative adhesions after laparoscopic gynecological surgery with Oxiplex/AP Gel: a pilot study.  Fertil Steril. 2005;  84 (5) 1450-1456
    CrossrefPubMedGoogle Scholar
  • 52 Lundorff P, Donnez J, Korell M, Audebert A J, Block K, diZerega G S. Clinical evaluation of a viscoelastic gel for reduction of adhesions following gynaecological surgery by laparoscopy in Europe.  Hum Reprod. 2005;  20 (2) 514-520
    PubMedGoogle Scholar
  • 53 Takeuchi H, Kitade M, Kikuchi I, Shimanuki H, Kumakiri J, Kinoshita K. Adhesion-prevention effects of fibrin sealants after laparoscopic myomectomy as determined by second-look laparoscopy: a prospective, randomized, controlled study.  J Reprod Med. 2005;  50 (8) 571-577
    PubMedGoogle Scholar
  • 54 Mettler L, Audebert A, Lehmann-Willenbrock E, Schive K, Jacobs V R. Prospective clinical trial of SprayGel as a barrier to adhesion formation: an interim analysis.  J Am Assoc Gynecol Laparosc. 2003;  10 (3) 339-344
    CrossrefPubMedGoogle Scholar
  • 55 Johns D A, Ferland R, Dunn R. Initial feasibility study of a sprayable hydrogel adhesion barrier system in patients undergoing laparoscopic ovarian surgery.  J Am Assoc Gynecol Laparosc. 2003;  10 (3) 334-338
    CrossrefPubMedGoogle Scholar
  • 56 Montanino-Oliva M, Metzger D A, Luciano A A. Use of medroxyprogesterone acetate in the prevention of postoperative adhesions.  Fertil Steril. 1996;  65 (3) 650-654
    PubMedGoogle Scholar
  • 57 Wiczyk H P, Grow D R, Adams L A, O'Shea D L, Reece M T. Pelvic adhesions contain sex steroid receptors and produce angiogenesis growth factors.  Fertil Steril. 1998;  69 (3) 511-516
    CrossrefPubMedGoogle Scholar
  • 58 Frazier-Jessen M R, Mott F J, Witte P L, Kovacs E J. Estrogen suppression of connective tissue deposition in a murine model of peritoneal adhesion formation.  J Immunol. 1996;  156 (8) 3036-3042
    PubMedGoogle Scholar
  • 59 Grow D R, Coddington C C, Hsiu J G, Mikich Y, Hodgen G D. Role of hypoestrogenism or sex steroid antagonism in adhesion formation after myometrial surgery in primates.  Fertil Steril. 1996;  66 (1) 140-147
    PubMedGoogle Scholar
  • 60 Ergeneli M H, Kuscu E, Zeyneloglu H B, Haberal A, Erdogan M. GnRHa for adhesion formation after uterine serosal injury in an euestrogenic milieu.  J Reprod Med. 2000;  45 (1) 35-38
    PubMedGoogle Scholar
  • 61 Imai A, Sugiyama M, Furui T, Takahashi S, Tamaya T. Gonadotrophin-releasing hormones agonist therapy increases peritoneal fibrinolytic activity and prevents adhesion formation after myomectomy.  J Obstet Gynaecol. 2003;  23 (6) 660-663
    CrossrefPubMedGoogle Scholar
  • 62 Wright J A, Sharpe-Timms K L. Gonadotropin-releasing hormone agonist therapy reduces postoperative adhesion formation and reformation after adhesiolysis in rat models for adhesion formation and endometriosis.  Fertil Steril. 1995;  63 (5) 1094-1100
    PubMedGoogle Scholar
  • 63 Canbaz M A, Ustün C, Koçak I, Yanik F F. The comparison of gonadotropin-releasing hormone agonist therapy and intraperitoneal Ringer's lactate solution in prevention of postoperative adhesion formation in rat models.  Eur J Obstet Gynecol Reprod Biol. 1999;  82 (2) 219-222
    CrossrefPubMedGoogle Scholar
  • 64 Hellebrekers B W, Trimbos-Kemper T C, Trimbos J B, Emeis J J, Kooistra T. Use of fibrinolytic agents in the prevention of postoperative adhesion formation.  Fertil Steril. 2000;  74 (2) 203-212
    CrossrefPubMedGoogle Scholar
  • 65 Hellebrekers B, Emeis J, Kooistra T et al. A role for the fibrinolytic system in postsurgical adhesion formation.  Fertil Steril. 2005;  83 122-129
    CrossrefPubMedGoogle Scholar
  • 66 Diamond M P, Linsky C B, Cunningham T et al. Synergistic effects of INTERCEED(TC7) and heparin in reducing adhesion formation in the rabbit uterine horn model.  Fertil Steril. 1991;  55 (2) 389-394
    PubMedGoogle Scholar
  • 67 Jansen R P. Failure of peritoneal irrigation with heparin during pelvic operations upon young women to reduce adhesions.  Surg Gynecol Obstet. 1988;  166 (2) 154-160
    PubMedGoogle Scholar
  • 68 Gutmann J, Diamond M. Principles of Laparoscopic Microsurgery and Adhesion Prevention. New York, NY: Springer Verlag; 1997
    Google Scholar
  • 69 Gutmann J, Penzias A, Diamond M. Adhesions in reproductive surgery. In:, Wallach E E, Zacur H A, eds. Reproductive Medicine and Surgery. St. Louis, MO: Mosby; 1995: 681-693
    Google Scholar

Togas TulandiM.D. M.H.C.M. 

Department of Obstetrics and Gynecology

McGill University, 687 Pine Ave. West, Montreal, QC, Canada H3A 1A1

Email: togas.tulandi@mcgill.ca

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