Pelvic Adhesions: Prevention of Infertility and Surgical Correction of Pelvic Adhesions
Pelvic
adhesions, sometimes referred to as “scar tissue”,
are a common cause of both infertility and pelvic
pain. Pelvic adhesions can occur as a result of a
variety of different conditions including
endometriosis, pelvic infection, and previous
abdominal or pelvic surgery. It is well known that
pelvic adhesions develop over 90% of the time
following major abdominal surgery. The most common
types of surgery that predispose to the development
of pelvic adhesions include the removal of uterine
fibroids (myomectomy), treatment of endometriosis,
removal of ovarian cysts, and the repair of
obstructed fallopian tubes.
Many complications can occur as a result of pelvic adhesions. For
example, it is thought that adhesions may be a significant factor in
as much as 40% of cases of infertility. They are also thought to be
responsible for up to 50% of cases of chronic pelvic pain. In
addition, adhesions are typically responsible for 50-75% of cases of
bowel obstruction. Although more recent data are lacking, the
treatment of pelvic adhesions accounted for 3% of all surgical
procedures performed in the United States in 1998, as well as 1% of
all hospital admissions and 2% of all patients admitted for
surgeries around that time.
How do adhesions occur?
Adhesions typically develop in response to injury, as part of the
normal healing process. Immediately following injury, cells that
cause healing (inflammatory cells) migrate to the site of the
injury. Within seven days following injury, the scaffold for
healing or adhesion formation has already developed. As a result,
it appears that no new adhesions form more than seven days after an
injury. Rather, the character of the adhesion changes, progressing
from thin, filmy adhesions to more dense, vascular adhesions. The
earlier in this process that adhesions can be removed, the less
likely it is that they will recur and cause long-term problems.
Adhesion formation that occurs following surgery can be of two
types; de novo adhesion formation or adhesion reformation. De novo
adhesion formation means the formation of adhesions at a site that
did not have any adhesions affecting it prior to surgery. This
would include the formation of adhesions around the uterus following
the removal of a fibroid tumor or the formation of adhesions around
an ovary following removal of an ovarian cyst. Adhesion reformation
refers to the recurrence of adhesions following a procedure designed
to remove pre-existing pelvic adhesions. This difference is
important, as the techniques described below may be very effective
at preventing de novo adhesion formation, while they appear to be
somewhat less effective at preventing adhesion reformation.
Can adhesions be
prevented?
Many different techniques have been described in order to prevent
the formation of pelvic adhesions following surgical procedures.
The most important of these is the prevention of injury or trauma to
the tissues at the time of surgery. This is important, as studies
suggest that it is much easier to prevent pelvic adhesion formation
in the first place than to treat them once they have formed.
Proper surgical technique is critically important in the prevention
of pelvic adhesions. Such techniques include the minimalization of
tissue manipulation, the use of small non-reactive suture, and the
prevention of infection. The prevention of bleeding is also
critically important, as blood is a primary factor involved in the
formation of pelvic adhesions. Many scientific studies have focused
on the type of surgical approach that should be performed in order
to minimize adhesion formation. There is a suggestion in the
literature that minimally invasive surgery (“belly button surgery”,
or laparoscopy) is associated with significantly less adhesion
formation than is laparotomy (surgery through a large abdominal
incision). Most of the surgical techniques designed to prevent
pelvic adhesions center around the use of adhesion barriers.
Types of adhesion
barriers
Many different adhesion barriers have been developed over the years
in the hope of minimizing the formation of pelvic adhesions. While
some have proven to be effective, others have not been demonstrated
to have any efficacy. The most commonly used adhesion barriers at
this time include Interceed, Seprafilm, and Adept.
Interceed
Interceed is made of oxidized regenerated cellulose. It is packaged
as a 3 x 4 inch fabric and adheres to the tissue without suturing.
It forms a gel within eight hours after application and subsequently
degrades into glucose and glucuronic acid (inert elements) within 3
to 10 days. It is approved by the Federal Food & Drug
Administration (FDA) for use at laparotomy, but is not FDA approved
for use at laparoscopy. Although Interceed works very well, the
major problem associated with its use is that it is ineffective in
the presence of bleeding. In fact, when applied in the presence of
blood, Interceed may actually cause adhesion formation. Multiple
studies have demonstrated the effectiveness of Interceed. A meta
analysis (a scientific technique that combines the results from many
small studies in order to generate a meaningful conclusion),
published in 1999, demonstrated a 24% reduction in adhesions when
Interceed was used.
Seprafilm
Seprafilm is a combination of sodium hyaluronate and carboxymethyl
cellulose. Hyaluronic acid is a commonly occurring chemical found
in cartilage, skin, and most cosmetics. Carboxymethyl cellulose is
added to extend the duration of time that the Seprafilm remains in
place before dissolving. Seprafilm is a clear, almost cellophane
like material that adheres to the tissue without suturing. It turns
into a gel within 24 to 48 hours following application and remains
at the site of the application for up to seven days. It is cleared
from the body in less than 28 days and, unlike Interceed, does not
cause adhesion formation in the presence of blood. The major
difficulty associated with Seprafilm is that it cannot be applied
laparoscopically due to technical factors, as it can splinter or
tear when applied through small incisions. As of the end of 2009,
there were more than 20 published clinical trials of Seprafilm
involving over 5000 patients. These studies have been published in
both the gynecologic and general surgical literature, and
demonstrate significant benefit from using Seprafilm. The most
recent studies also demonstrate the cost effectiveness of Seprafilm,
i.e. using Seprafilm appears to save money for patients and the
healthcare system, as patients who receive Seprafilm have fewer
complications - including less future surgery related to problems
from adhesions.
Adept
Adept is a clear, odorless glucose polymer that can be used either
laparoscopically or at laparotomy. It is very easy to apply, and in
a large pivotal trial, Adept was demonstrated to significantly
reduce the formation of adhesions. Adept is used throughout the
surgical procedure in order to coat the tissues and at the
completion of surgery, a large amount is left in the pelvis. The
major complaint that some patients have following the use of Adept
is that it leaks out of their incisions for up to 2-3 days following
surgery. This is normal, and most patients do not find it to be
more than a minor inconvenience. There is some question as to
whether Adept stays in place long enough to have a significant
benefit, and additional studies to answer this question are ongoing.
Pelvic adhesions are a significant problem following gynecologic and
abdominal surgery. They can cause significant problems, such as
pelvic pain and infertility. While some barriers have been approved
by the FDA for use in surgical procedures, the best way to prevent
complications from pelvic adhesions is to prevent their formation in
the first place. This can be accomplished by having surgery
performed by surgeons who are specifically trained in microsurgical
and advanced laparoscopic techniques – such as the use of adhesion
barriers - designed to prevent their formation.
