PAGIDAS: Pharmacologic agents have a role, especially for dampening the inflammatory immune response. But you don’t want to dampen it completely because, as we observed, it is an important part of healing. The difficulty is finding a balance between allowing the tissue to heal and preventing adhesions.
HURD: We studied the ability of a water-soluble prostaglandin inhibitor to prevent postoperative adhesion formation. Like many other agents, we found only a partial response.11
DECHERNEY: With current options, the best you can aim for is a 50% reduction.
Adjunctive therapy likely to limit adhesion rate Hydroflotation
DECHERNEY: The original adjunctive therapy was 20 mg dexamethasone and 25 mg femergin in 200 cc of Ringer’s lactate, with an equivalent amount of dexamethasone and femergin every 4 hours for a total of 6 doses. I prescribed that regimen because I was trained to do so. I stopped after it became clear that hydroflotation from the fluid—not the medication itself—was responsible for the improvement.
I must admit I gave it up reluctantly; patients felt fabulous with those higher load doses of glucocorticoids after surgery.
Do any of you use crystalloids as adjunctive therapy?
SANFILIPPO: In the animal model, they are so rapidly absorbed that they aren’t effective. I was a strong advocate, but now I don’t use them at all.
HURD: A lot depends on the kind of case. For instance, at the end of an open myomectomy, the patient often is oozing, so you want to use a barrier that blood won’t affect.
For ovarian surgery, you might want to specifically target the ovaries with some kind of coverage. But when you are doing a broad lysis of adhesions, you have few choices to cover the pelvis. In those cases I use hydroflotation with Ringer’s lactate. Both human and animal studies have shown some benefit in preventing adhesions, and it appears to have little risk.12,13
It’s better than nothing, in my opinion.
DECHERNEY: Do you use dextran 70 or crystalloids?
HURD: I use Ringer’s lactate solution. I was trained in the dextran 70 era, and there were certain problems with that approach. Since studies have failed to show a consistent effect of dextran 70, I no longer use this solution.14,15
DECHERNEY: Another problem with crystalloids is that they leak, which is disconcerting to the patient.
HURD: They also can mask an injury to the bladder in difficult cases.
DECHERNEY: I agree that dextran 70 is only appropriate in certain cases, but it is a good hydroflotation agent. Every cubic centimeter of dextran 70 brings in 1.2 cc of transudate, so it hangs around for at least 4 days.
It is appropriate only for certain surface areas—mainly the cul-de-sac. It is harmful on raw surface areas on the lateral pelvic sidewall because it tends to push the ovary and tube to those areas. Unless you are doing a lot of work in the deep pelvis, I would avoid dextran 70.
CASE 3 Managing devascularized tissue at hysterectomy
A 45-year-old woman undergoes an abdominal hysterectomy. The cuff is closed and the ovaries are intact.
PAGIDAS: I would do nothing other than ensure adequate hemostasis, check that I have left no round surfaces and, probably, use hydroflotation. I see no advantage to barriers.
HURD: One of the main causes of adhesions is devascularized tissue, and the perfect devascularized tissue might be the vaginal cuff. Re-“peritonealizing” the cuff might be advantageous. Thus, I would use minimal sutures—probably a slowly absorbable, light polydioxanone suture to place the peritoneum over the cuff so there are no pedicles.
DECHERNEY: All the pedicles are exteriorized.
HURD: Yes, that could be. We don’t bring all of it down like we used to years ago, but we do cover the cuff.
PAGIDAS: I agree that closing the cuff and reperitonealizing may actually minimize formation of hematomas—clearly an advantage.
SANFILIPPO: I agree. I guess I’m old fashioned. If it looks good, then hopefully it will stimulate less adhesion formation, so peritonealization is important.
As far as the abdominal incision is concerned, I would not close that peritoneum. I’m convinced now that there is no advantage.
DECHERNEY: Reperitonealizing the cuff is controversial. Most gynecologic surgeons do not do it, the theory being that the peritoneum is being stretched, attenuating the vessels that go through it and thereby creating an ischemic barrier that contributes to adhesions. Personally, I like to do it because it looks better—and that is certainly an important aspect of a surgery. No evidence shows that it is bad or good, either way.
In addition, there have been allergic reactions, most of which seem to occur in patients with fluid overload; a lot of the dextran 70 is absorbed.