After all adhesions have been resected and removed, stop all bleeding and lavishly irrigate the pelvis with saline prior to closure. If extensive adhesions have been resected from the rectal wall, assess this organ’s integrity by filling the pelvis with saline and placing air in the rectum with either a sigmoidoscope or 30-cc Foley catheter.
Tools for excision
Laparoscopic scissors. These are inexpensive, create no peripheral damage, give direct mechanical feedback, and are familiar to all physicians. No smoke or plume is created to obstruct vision. However, because hemostasis cannot be achieved with scissors, they are inappropriate for vascular adhesions. In addition, they cannot be used in areas of the pelvis that can be seen but not reached. Instead, opt for one of the cutting methods described here.
Electrosurgery. The efficiency of electrosurgery depends on the power, shape of the probe tip, and waveform. The higher the power and the finer the tip, the faster the probe will resect the adhesion, thereby minimizing thermal damage. Pure cutting currents also reduce thermal damage but provide less hemostasis than blended or pure coagulation currents.
In general, the thickness, vascularity, and water content of the adhesions will dictate the equipment and settings used. (There are no standard wattage settings, but surgeons typically use 25 to 125 watts.)
Carbon dioxide laser. This instrument allows surgeons to cut with hemostasis without coming into direct contact with the tissue. There are an infinite number of settings, wavelengths, and spot sizes available, making this method of resection extremely precise. However, the laser is costly, cumbersome, and produces a lot of smoke.
Ultrasonic energy. The ultrasonic blade and forceps create hemostasis using vibrational energy to coagulate tissue. Pass the blade through the tissue, slowly separating it while achieving hemostasis. Or, use the forceps to resect vascular adhesions, grasping and coagulating the tissue first and then using the scissors to divide the adhesion.
The advantages: minimal thermal spread, tissue-contact feedback, and essentially no smoke. However, the disadvantages are that direct tissue contact is necessary, traction is vital, the coagulation process is slow, and the disposable equipment is expensive.—Stephen Cohen, MD
Preventing adhesion recurrence
Unfortunately, approximately 85% of patients who undergo surgery for pelvic adhesions will develop recurrent adhesions. Available products that attempt to minimize this effect include oxidized regenerated cellulose (ORC) (Interceed; Ethicon Inc, Somerville, NJ), hyaluronic acid with carboxymethylcellulose (HAL-F) (Seprafilm; Genzyme Biosurgery, Cambridge, Mass), and expanded polytetrafluoroethylene (ePTFE) (Gore-Tex; W.L. Gore & Assocs, Flagstaff, Ariz). However, these products can only be applied to small surface areas, and only ORC can easily be used laparoscopically. As a result, they have achieved limited success.
Some additional progress has been made with the recent FDA approval of hyaluronate gel (Intergel; Gynecare, a division of Ethicon Inc, Somerville, NJ), which coats the entire peritoneal surface and all the intra-abdominal organs.4 Surgeons instill 300 cc of the gel through a trocar into the abdominal cavity just prior to closure, and the body completely absorbs it over time.
The author reports no financial relationship with any companies whose products are mentioned in this article.