SANFILIPPO: We need a well-designed prospective study to explore the effects of laparotomy versus laparoscopy. Existing data are not clear. You would assume laparoscopy would be associated with less adhesion formation. But genetic or other factors may explain why patient A is more prone to adhesions than patient B.
Does anybody think carbon dioxide plays a role in adhesion formation?
HURD: In the laboratory, carbon dioxide increases cell growth.8 Without an increased carbon dioxide concentration in the atmosphere, cell cultures don’t grow well. This might suggest that the carbon dioxide used for laparoscopy could actually enhance adhesion growth. Fortunately, this does not appear to be the case clinically.
With myomectomy, the surgeon needs to plan ahead to maximize the number of myomas removed from a single incision.
DECHERNEY: What about second-look laparoscopies? Do any of you perform them after a patient has undergone lysis of adhesions?
SANFILIPPO: Only as part of a research protocol. It amazes me how rapidly adhesions can form and how dense they are 2 or more weeks after the initial laparoscopic surgery.
PAGIDAS: We tend to limit second-look laparoscopy to a research protocol, although it is sometimes valuable after laparoscopic or abdominal myomectomy, which has the highest incidence of adhesions. If the surgeon can perform a second look and lyse adhesions, he or she may potentially alter the reproductive outcome. However, with assisted reproductive techniques becoming integral to every infertility case, that approach has begun to go out of style.
SANFILIPPO: That’s a good point. With myomectomy, the surgeon needs to plan ahead to maximize the number of myomas removed from a single incision. If adhesions do occur, it is best if they occur toward the bladder rather than in the area of the tubes and ovaries.
HURD: For second-look laparoscopy, we must keep in mind the cost and the small but real risks of surgery. Until good controlled studies show a reasonable clinical advantage, this approach probably should remain a research protocol.
SANFILIPPO: The literature suggests it is helpful, but does not help fertility, so second-look laparoscopy is used mainly to evaluate adjunctive therapies. I don’t think anybody uses it as a primary therapy anymore.
Bowel obstruction still a risk, though rarely seen by Ob/Gyns
DECHERNEY: Although bowel obstruction is fairly common, Ob/Gyns do not often encounter it because it occurs relatively distant from the index surgery. Even though a patient may not experience bowel obstruction in the first year, an obstruction related to the index surgery is just as likely to develop 20 years later as 2 years later. These patients usually are treated by general surgeons. Still, we should beware of the potential for bowel obstruction and take steps to prevent it, if at all possible. Do you agree?
PAGIDAS: Yes. We tend to forget about bowel obstruction because we rarely follow patients past pregnancy or the first trimester if they are seeking infertility treatment.
HURD: The primary problem seems to be the abdominal wall incision. Fortunately, cesarean section seems to carry a decreased risk of abdominal wall adhesions, probably because the uterus serves as a splint over the incision.
The Pfannenstiel incision also appears to have some advantage. Both human and animal models suggest little advantage or disadvantage when peritoneal closure is compared to nonclosure.9,10
SANFILIPPO: I’m curious about how the panelists manage loose clips. If you are using an EndoGIA (US Surgical, Norwalk, Conn) or other stapling device and you have free-floating clips, do you make a concerted effort to find them? In some cases, they have been implicated in bowel adhesion and obstruction. I try to retrieve loose clips, whether open or closed.
HURD: The advantage of those devices is minimal tissue damage, and the clips are inert. In general, inert, nonreactive clips have not been implicated as much in adhesion formation. I retrieve them if I see them, but I don’t search them out.
PAGIDAS: I do the same. If the clips are visible, I remove them. But I would not repack the bowel or do anything more heroic than look in locations where they might be.
What drugs may inhibit inflammatory response?
DECHERNEY: What about use of pharmacologic agents to prevent adhesions? Is there reason to think research should focus on inhibiting the inflammatory response? How important is polymorphonuclear cell infiltration?
Cyclooxygenase (COX) 2 agents could be helpful for inhibition of platelet function, since they are low in side effects. Thus, high doses of these drugs might be effective. At one time, aspirin was proposed, but you’d have to give a human so much aspirin that her ears would ring.