Adhesions in relation to laparoscopic surgery for endometriosis

Adhesions in relation to laparoscopic surgery for endometriosis





Deborah Bush QSM, Dr Ossie Petrucco, and Dr Robert O’Shea

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Deborah Bush, QSM: My name is Deborah Bush. I’m the Chief Executive of the New Zealand Endometriosis Foundation. I’m also on the Advisory Board for EndometriosisZONE. We’re at the 9th Minimal Access Course at the Women’s Hospital at the Hilton Hotel in Auckland, New Zealand.

This afternoon I have with me Dr. Ossie Petrucco. Ossie is a senior lecturer at the University of Adelaide, in the Department of Obstetrics and Gynaecology. He’s the Deputy Head at REPROMED in Adelaide. He’s also the Director of Gynaecology at the Women’s & Children’s Hospital in Adelaide. Welcome Dr. Ossie Petrucco.

And welcome also to Dr. Robert O’Shea, a senior consultant and lecturer at Flanders Medical Centre. He’s head of Flanders Endo-Gynaecology, and Chair of AGES.

Welcome to both gentlemen this afternoon. I’d really like to talk about some of the interesting subjects that were discussed this morning. One of them that came up, of course, was the problem of adhesions in relation to endometriosis surgery. I wonder if you could shed some light on that for us this afternoon?

Dr. Ossie Petrucco: Well, I guess one of the things that attracted us both to laparoscopic surgery, as opposed to traditional surgery that we used to do by laparotomy, was the information that came out from Michael Diamond and other researchers some years ago that seemed to indicate that by utilising the laparoscopic approach, there seemed to be much less adhesion formation, both pre-existing adhesions, but perhaps even more important, de novo adhesion formation in the pelvis. That seemed to be a bit of an incentive at any rate for me to have a look at endoscopic surgery.

I guess you’ve had similar aims and experiences?

Dr. Robert O’Shea: Yes, although there have some conflicting evidence in the literature about this, but I think the general view is that the most appropriate way to treat adhesions would be laparoscopically, just as Ossie is using, less new adhesion formation.

Dr. Ossie Petrucco: And certainly the results that we seem to find in terms of recurrence of the symptoms, of pain, but particularly in relation to fertility, women that want to achieve pregnancies, the success of operations seems to be just as high for operations where women go home the same day, as opposed to laparotomies where they languished in hospital for much longer.

But I guess the other thing about adhesions is that a lot of very important research was done in the last ten, 20 years, and we now know a heck of a lot more about the healing process of the peritoneum. It’s not inappropriate to mention that the peritoneal surface is almost as large as the skin surface in the body, but the two tissues are totally different. Peritoneum heals in a totally different manner. It’s composed of very fragile cells that are able to reduplicate themselves, and the repair process of denuded areas of peritoneum is very rapid, and is very complete. Unlike skin, that has to re-grow very slowly from the edges where injuries have occurred.

The major factor that prevents normal healing happening is trauma to the peritoneal surfaces that may be performed, unfortunately, inappropriately in some areas of surgery.

Dr. Robert O’Shea: Do you have a feel, Ossie, that there’s been some discussion about issues, such as gas temperature, and even about alternative types of insufflation gas?

Dr. Ossie Petrucco: I’m sure it’s very important to try and keep the area in its proper moisture, and at its proper temperature, and not allow desiccation to occur. That’s the type of trauma that we hardly realise was happening at the beginning of endoscopic surgery as Rob says.

It’s also very important to use electrical cautery or laser power judiciously. The more damage, the more death that you produce in tissue, the more difficult it’s going to be for peritoneum to heal itself.

The other two very important features, I believe, and I think Rob will agree, would be taking care of haemostasis, but in such a way where we don’t produce too much associated trauma. In other words use fine and pinpoint haemostasis with electric cautery. And then, use lots and lots of fluid in the pelvis to wash away any necrotic cells, to allow peritoneum to heal itself. We’ve also realised that because of its capacity to virtually heal itself within a few days that it’s totally inappropriate to use sutures and other foreign bodies that will just complicate the whole issue.

So, very careful haemostasis, and plenty of wash out, Robert, I’m sure you agree, is an important feature of the work we do.

Dr. Robert O’Shea: Sometimes one can approach division adhesiolysis as a planned procedure. Very often, one stumbles upon it almost by accident, although so many patients these days have had previous surgery, but there is no doubt that sometimes one will laparoscope somebody for some issue, but then discover they have quite extensive adhesions. And that may be the time to wonder, is this the time to go ahead and perform an extensive adhesiolysis, or should one do it as an interval procedure after carefully counselling the patients about potential complications, making sure the patient is bowel prepped beforehand, and talk about the risk of damage to the bowel and other structures?

Ossie, what are your views about techniques of entry for patients with significant adhesions?

Dr. Ossie Petrucco: I think the patient’s safety is paramount, and it’s very important, I think, that if we feel that there may be any adhesions at the traditional umbilical entry site, that we should simply go higher up in the abdomen. I quite often choose to go below the left subcostal margin (Palmer’s Point), to produce the initial insufflation, and to have a look with a small telescope and see, in fact, what is happening at the umbilicus or further down in the pelvis to make sure that any further insertion of trocars will be done in a safe way.

It’s very unusual, even in very bad cases of pelvic and abdominal adhesions, to find that the left hypochondrium is too encumbered with adhesions. I believe that’s a reasonable way of approaching any situation that might be a dangerous one at the umbilicus.

Dr. Robert O’Shea: Yes, I would totally concur with that. The other problem often arises after one has introduced, sometimes blindly, the major trocar, at the umbilicus. One is in a mass of bowel adhesions. To really tackle those adhesions you need to put ports in either the left or right side, I believe. These are say a 5 mm port through left laterally. Then tackle those adhesions down the umbilicus, so that one can then move on to the pelvis, or whatever the designated area of surgery was.

Deborah Bush QSM: Are either of you using any of the other modes of treatment for preventing adhesions forming, following surgery, that seem to be gaining some interest in endoscopic work for endometriosis now?

Dr. Robert O’Shea: Well, the use of Intercede as an agent has been around for some years, but because of its nature can be potentially difficult to use laparoscopically. Also, if one has any bleeding at all, that is if you get any oozing, after say, laying Intercede on an area of peritoneum for instance, an ovarian fossa, if you get any slight oozing after that, well that can actually have the opposite effect from what you wanted, and cause adhesions. So Intercede, I think, has been technically difficult to use laparoscopically, and hasn’t really achieved its true potential.

The new agent that Ossie has used is Spraygel; what’s your experience using Spraygel?

Dr. Ossie Petrucco: I started using Spraygel because it seems a very easy way of applying an adhesion barrier. As Rob said, Intercede can be a little bit tricky to apply, even if you just wrap up the ovaries, or to apply on flat surfaces, it’s not always so easy.

But we did do some animal experiments, and so have lots of other people. And to my satisfaction, in sheep, having created a standard lesion, we found that we could reduce the incidence of adhesions on the treated side, as opposed to the untreated side, on the opposite part of the pelvis, in this experimental animal by at least 50% reduction in adhesion formation. Similar experiments in rats and other animal models have tended to show the same thing.

The human data - data that I think most people would accept as being properly conducted research - tended to show the same thing. It doesn’t by any means reduce adhesions by 100%, but it certainly improves the outcome as far as patients are concerned. The only thing that I think that has prevented its very widespread use is, of course, the question of cost.

Spraygel, seeing that it is easier, now requires long term, prospective studies, where people will actually go back and do second look laparoscopies and document different parts of the pelvis that have been treated to see whether there’s really been an improvement.

Deborah Bush QSM: Well, certainly in the look at the surgery that we had this morning, and the presentations that were made, it was most encouraging to see very little adhesion formation following good excision of endometriosis on the peritoneal surfaces anyway.

Dr. Ossie Petrucco: That’s the point I was going to come back to. I think that if we just rely on crutches like adhesion prevention barriers, we will ultimately forget the most important principles of preventing adhesions, and that has to be good surgery.

I think Charles Koh demonstrated that even in the worst cases of endometriosis, with complete obliteration of the cul-de-sac, leaving large, raw areas, as long as the tissue that remains is healthy the peritoneum will heal itself. There won’t be a lot of adhesions. Adhering to good surgical principle, washing away debris, careful haemostasis, not leaving a lot of foreign bodies or lots of sutures – I think the body heals itself basically. And particularly if we use the same principles that we used in microsurgery before, were likely to get the best results.

Deborah Bush QSM: Dr. Ossie Petrucco I thank you very much for your comments this afternoon. Dr. Robert O’Shea, would you like to add anything further?

Dr. Robert O’Shea: Well, just to finish off, Spraygel is not necessarily the panacea in endometriosis as was discussed. It may well be useful, it may have a place on the pelvic sidewalls or in the ovarian fossa, but after extensive pelvic pouch Douglas excision with bowel involvement, currently there are some anxieties about using Spraygel as it may actually be associated with pelvic abscess or prevent healing of quiescent bowel injuries.

Deborah Bush QSM: Doctors, thank you very much for this afternoon’s time and I’m sure we’ll enjoy the rest of the course both this afternoon and tomorrow. Thank you.

Dr. Ossie Petrucco: Thank you, Deborah.

See also the EndometriosisZONE.org section on adhesions


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Feedback/Questions:

Question:
30 May 2004: I read with interest the discussion on 'prevention of adhesions' between Deborah Bush QSM, Dr Ossie Petrucco, and Dr Robert O’Shea. I wish to get a clarification on role of extensive washing of peritoneal cavity!!

My impression is that with irrigation of cavity with saline or RL we also was out the natural antibodies etc. and thereby increase the chances of adesions!! The body homeostasis requires a few hours to regain the pre-surgery status and these few hours may be critical in tissue healing and adhesion formation, and extensive washing and suction may harm rather than benefit the patient!!

I welcome some discussion on this.

Dr Parul Kotdawala

Answer:
1 June 2004: There is no evidence in the literature that irrigation is detrimental ie. adhesion provoking. It is used during haemostasis to secure bleeding points and then wash out blood and other irritant products eg. carbon
deposits, which may interfere with natural healing. Irrigation is not used to prevent adhesions!

Dr OM Petrucco
Director of Gynaecology
Women's & Children's Hospital


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