Principles of microsurgery have been adopted by reproductive surgeons to minimize the likelihood of adhesions after myomectomy and gynecologic surgery in general. The basic techniques reflect respect for tissue integrity:
- Gentle handling of tissue, with minimal manipulation of all peritoneal surfaces.
- Meticulous hemostasis. Examine all myomectomy sites to ensure adequate hemostasis prior to closure.
- Continuous irrigation to prevent tissue desiccation. We favor continuous saline irrigation throughout the procedure. We also use only moistened laparotomy sponges and pads, and avoid applying dry gauze to any tissue surface.
- Avoidance of foreign-body introduction. We use only talc-free gloves and remove all residual suture fragments and tissue debris before closure. We also perform copious saline suction-irrigation at the end of the procedure to remove as much residue as possible.
- Use of fine, nonreactive suture. We favor fine, resorbable sutures that incite as little tissue reactivity as possible. For closure of large myomectomy defects, we use braided multifilaments such as Vicryl (polyglactine 910) (Ethicon, Somerville, NJ) or Dexon (polyglycolic acid) (Davis and Geck, Danbury, Conn) for strength and ease of handling. These sutures are absorbed through simple hydrolysis and stimulate less tissue reactivity than do chromic or catgut sutures.
The idea is appealing, but a randomized, blinded comparison of “good” and “bad” microsurgical technique is unlikely, since no one would wish to perform “bad” technique.
With barrier adjuvants, optimal benefit is obtained when the physician can predict potential sites of adhesions.
Wide range of prevention tools has been studied
Many types of agents have been studied in an attempt to reduce postsurgical adhesions after gynecologic surgery. Although most offer little or no benefit (TABLE 2), a few have potential in myomectomy procedures.
Barriers that form mechanical separation (TABLE 3) theoretically physically separate damaged tissues during early peritoneal wound healing, when adhesions form.11 The original adhesion barriers consisted of omental and peritoneal grafts that were placed over surgical sites. However, studies demonstrated that devitalized tissue positioned on damaged peritoneum serves as a potent substrate—not inhibitor—for adhesions.12 More recent trials have examined the adhesion-prevention benefit of other types of absorbable and nonabsorbable barriers.
TABLE 2
Pharmacologic agents studied for adhesion prevention in reproductive surgery
| AGENT | THEORETICAL ACTION | EXAMPLES | MODE OF USE/APPLICATION | RISKS/PROBLEMS |
|---|---|---|---|---|
| Antibiotics | Prevent infection or inflammation | Cephalosporins Tetracyclines | Intraperitoneal irrigation with antibiotic fluid Hydrotubation fluid with antibiotic | Theoretical reaction to antibiotic |
| Anticoagulants | Clot prevention Fibrin prevention | Heparin | In conjunction with Interceed | Risk of postoperative bleeding |
| Anti-inflammatory agents | Decrease permeability and histamine release | Nonsteroidal anti-inflammatory drugs Corticosteroids | Awaiting further investigation | Theoretical reaction to agent |
| Crystalloid solutions | Hydroflotation effect, decrease surface contact between pelvic organs | Normal saline Ringer’s lactate | Intra-abdominal instillation | Possible volume overload from intravascular absorption |
| Fibrinolytic agents | Fibrinolysis Plasminogen activation | Streptokinase Trypsin Fibrinolysin | Awaiting further investigation | Theoretical risk of postoperative bleeding |
| Steroids | Decrease inflammatory response | Dexamethasone | Systemic and/or intraperitoneal | Possible suppression of hypothalamic-pituitary axis |
| Polysaccharide polymer | "Siliconizing" effect to coat raw surfaces | Dextran 70 (Hyskon) | 200 mL placed in posterior cul-de-sac or coating surgical site surfaces | Abdominal bloating, anaphylaxis, pleural effusion, liver function abnormalities, wound separation, rare diffuse intravascular coagulation |
| Other fluid and barrier agents* | Peritoneal surface separation Hydroflotation | Absorbable and nonabsorbable barriers (see Table 3) | See Table 3 | See Table 3 |
| *Adjuvants studied in the setting of abdominal myomectomy | ||||
TABLE 3
Fluid and barrier adjuvants studied for adhesion reduction after myomectomy
| AGENT | THEORETICAL ACTION | MODE OF USE/APPLICATION | PROBLEMS | EVIDENCE FOR ADHESION REDUCTION |
|---|---|---|---|---|
| ABSORBABLE (BARRIER) | ||||
| Oxidized regenerated cellulose (Interceed) | Protective layer over surgical sites to prevent surface contact | Direct placement onto surface of uterus; no suturing required | Requires hemostasis | Prospective studies and meta-analysis support benefit in reproductive surgery including abdominal myomectomy |
| Hyaluronatecarboxymethycellulose derivative film (Seprafilm) | Protective layer over surgical sites to prevent surface contact | Direct placement around entire uterine surface; no suturing required | Requires hemostasis | Multicenter prospective, randomized study supports benefit in reducing adhesions after abdominal myomectomy |
| NONABSORBABLE (BARRIER) | ||||
| Expanded polytetrafluoroethylene (GoreTex) | Prevent contact between surgical surfaces | Patch sutured onto surface of uterus | Usually must be removed Report of fistula formation when left in situ | Multicenter prospective studies support adhesion-preventive benefit after abdominal myomectomy |
| Pericardial patch (Shelhigh No-React) | Prevent contact between surgical surfaces | Patch sutured onto surface of uterus | Early clinical use in myomectomy Proven safety as pericardial patch in humans | Preliminary study (case series data only) shows potential benefit |
| FLUID | ||||
| Hyaluronic acid-coat (Sepracoat) | Diffuse coating on surgical sites and potential sites of contact | 100-mL to 250-mL aliquots injected into peritoneal cavity | Limited data on efficacy in abdominal myomectomy | Small studies (multicenter, prospective, randomized, controlled trials) demonstrated reduced postoperative adhesions after reproductive surgery via laparotomy, including myomectomy |
| Hyaluronate-carboxymethycellulose derivative gel (Intergel) | Diffuse coating on surgical sites and potential sites of contact | 300-mL aliquot into peritoneal cavity | Withdrawn from market for reports of postoperative pain, complications | Reduced adhesion formation in animal studies and in preliminary human studies |
Pathophysiology of adhesion formation
Adhesions are fibrous or fibrovascular bands that connect tissue surfaces in abnormal locations.1,2 Their development likely results from an imbalance in inflammatory mediators or fibrin degradation during peritoneal wound healing.
Peritoneal injury initiates the release of histamine and vasoactive kinins that mediate increased capillary permeability and outpouring of serosanguineous fluid.3 This proteinaceous exudate coagulates, depositing fibrinous bands between areas of denuded tissue.
Under normal circumstances, the fibrinolytic system is activated to lyse these bands within 72 hours. Peritoneal healing occurs when mesothelial cells migrate from the underlying mesenchyme to reepithelialize the injured site.4 Disequilibrium of the fibrin deposition-fibrinolysis system results in a persistent band that will eventually undergo fibroblast and vascular invasion.
REFERENCES
1. Diamond MP, DeCherney AH. Pathogenesis of adhesion formation/reformation: application to reproductive pelvic surgery. Microsurgery. 1987;8:103-107.
2. Diamond MP, Freeman ML. Clinical implications of postsurgical adhesions. Hum Reprod. 2001;7:567-576.
3. Diamond MP, El-Mowafi DM. Pelvic adhesions. Surg Technol Int. 1998;VII:273-283.
4. Farquhar C, Vandekerckhove P, Watson A, Vail A, Wiseman D. Barrier agents for preventing adhesions after surgery for subfertility. Cochrane Database Systematic Rev. 2002;(4):1-34.