With infertility patients, even if you lyse dense adhesions, you do not render the ovarian surface normal.
SANFILIPPO: Dextran 70 is not recommended for patients with sugar beet allergy, either.
We completed a study in a rabbit model, in which the peritoneal cavity was lavaged with either chlorhexidine or iodine.16 At the time of second-look surgery, the rate of adhesion formation was decreased, especially with the iodine preparation. I would hope that this has potential in humans.
DECHERNEY: In your lavage procedures to prevent adhesions, do any of you use heparin?
HURD: No.
PAGIDAS: I don’t think any evidence suggests that local administration changes the outcome.
DECHERNEY: I agree. When heparin has been used, the doses have been so low that it was not terribly helpful. And when you consider that hemorrhage can be a problem, heparin is probably deleterious rather than helpful.
Barriers
DECHERNEY: What about barriers? The first to become available, Interceed (Gynecare, a division of Ethicon, Somerville, NJ), is oxidized cellulose, similar to Surgicell (Johnson & Johnson, New Brunswick, NJ). Since it gelates quickly, there is no fenestration, so the fibrin is unable to penetrate. However, if the patient has bleeding by capillary action, the raw surface just moves from one side of the Interceed barrier to the other.
What has been your experience? Do you use it?
PAGIDAS: I do not use Interceed, although prospective randomized trials and a meta-analysis confirmed its benefits in de novo formation and reformation.17-19 I don’t use it because it requires complete hemostasis. Also, with the surfaces we work on—notably, the ovary and tube—it is difficult to apply to just 1 surface area. From a clinical perspective, I appreciate the data, but it is hard to ensure a good application to optimize its effectiveness.
CASE 4 No ideal adjuvant for repeat cesareans
A 29-year-old woman is undergoing her third cesarean section, although adhesions cause difficulty getting through anteriorly.
DECHERNEY: In this case, will you use barriers or re-peritonealize the surface? Will you do a 1- or a 2-layered closure?
HURD: In these cases, I have not been doing anything, since there is no peritoneum to reperitonealize—just old scar tissue. I assume that the uterus will immediately readhere to the anterior peritoneum where it was before.
DECHERNEY: You would use a barrier?
HURD: No. I would not.
PAGIDAS: I would take the same approach, although I have not performed cesarean sections in about 4 years. I don’t think any intervention would change the outcome. And, as Dr. Hurd mentioned, that is pretty much old scar tissue anyway.
SANFILIPPO: I use Interceed, but I agree with you about its limitations. Meticulous hemostasis is a prerequisite.
HURD: With infertility patients, even if you lyse dense adhesions, you do not render the ovarian surface normal. If those patients have dense adhesions of the ovary or the sidewall, I generally leave them alone, and I try to avoid putting Interceed around the ovaries. No study has shown that using Interceed improves pregnancy.
In contrast, when a chronic pain patient’s ovaries are densely adherent to the cul-de-sac, which appears to be highly associated with dyspareunia, I lyse the adhesions, achieve meticulous hemostasis, and then use Interceed. It is hard to demonstrate in a study that this approach decreases the chance of pain. Even so, it certainly does decrease the chance of the ovaries being adherent.
DECHERNEY: One issue with Interceed is that we don’t know what happens to it once the abdomen is closed. It may migrate significantly.
Psychological issues may also be involved. For example, patients with multiple somatic complaints may be less likely to benefit from lysis of adhesions.
PAGIDAS: Right. Interestingly, a meta-analysis of all the randomized trials involving mechanical barriers found no correlation to pregnancy outcome or pelvic pain.18 If we were to consider new trials, the psychological aspect would be worth looking into.
Seprafilm
DECHERNEY: Let’s move on to Seprafilm (Genzyme, Cambridge, Mass). What is it and how useful is it?
HURD: Seprafilm is modified hyaluronic acid, which forms a brittle, thin plastic layer. It is somewhat difficult to work with but, once it is in place, seems to adhere well. The presence of blood does not appear to be a problem, since the Seprafilm forms an impermeable barrier—unless it breaks. I have found it especially useful in myomectomies, which produce postoperative oozing through the incisions no matter how hard you try to prevent it.
In addition, in open cases, surfaces can easily be covered with this material. Unfortunately, it can’t be used laparoscopically because it is so brittle.