Prevention of adhesions after gynecologic and obstetric surgery
Adhesions and the formation of adhesions in the abdominal cavity and small pelvis organs is a universal protective adaptive mechanism. It is aimed at the delimitation of the pathological area, the restoration of the anatomical structure of the tissues themselves and their blood supply is impaired by injury or/and inflammation.
Often the formation of adhesions does not cause pathological changes in the abdominal cavity and go unnoticed. At the same time, their formation in inflammatory processes in the appendages often leads to infertility, therefore, for example, prevention of sexually transmitted diseases, or timely and adequate anti-inflammatory therapy is at the same time preventing adhesions in the fallopian tubes and, accordingly, prevention of infertility.
Causes the formation of adhesions after surgery, in gynecology and obstetrics
Traditionally, the adhesion process is considered to be a local violation in the tissues, which occurs mainly as a result of surgical trauma of the peritoneal surfaces and the subsequent inflammatory reactions.
The latter causes the cascade related processes in the form of exudation (effusion) liquid portion of blood, disorders of metabolic processes in tissues, shedding of epithelial peritoneal layer of cells, deposition of fibrin, formation of elastin and collagen fibers, growth of the capillary network at the site of injury and formation of adhesions.
Some authors do not exclude the possibility of participation in the mechanism of the immune system, which manifests itself in sensitization and excessive response of connective tissue in response to external stimulation.
A significant role in this process is played by the desiccation of tissue hypoxia of the mesothelium in the application of pneumoperitoneum using carbon dioxide and surgical manipulation of the tissues.
Most often (in 63-98% of all cases) the formation of pathological intra-abdominal and pelvic adhesions (adhesions) between the surfaces of organs and the internal surface of the abdominal wall into the peritoneal cavity occurs after abdominal surgery, in particular in the pelvic cavity. They are one of the most important and not fully solved problems, celiac surgery, which occupies one of leading places in the structure of postoperative complications.
The presence of adhesions may be asymptomatic. Their clinical symptoms were regarded as commissural disease, manifested:
- acute or chronic adhesive intestinal obstruction;
- violation of functions of organs of abdominal cavity and small pelvis;
- chronic pelvic pain, or abdominal-pelvic pain syndrome;
- disorders of the menstrual cycle and tuboperitoneal infertility (40% of cases) in women of reproductive age.
Prevention of adhesions in the pelvis helps to avoid or significantly reduce the likelihood of adhesive disease. Main causes of adhesions after surgery is damage to the superficial epithelial layer (mesothelium) that covers the internal organs, as a result of:
- mechanical impact, leading to traumatization of the peritoneum at various stages of surgery — dissection of the abdominal cavity, fixation of tissue and hemostasis by capturing clips and other tools for dissecting the individual parts of the peritoneum, wiping and drying a dry gauze and wipes, etc.;
- effects of different physical factors, which include drying of the serous membranes under the influence of air, especially when laparotomies the way, causing burns when using electro — and radio-frequency knife, laser, plasma scalpel, electrocautery and other methods of coagulation of small bleeding vessels, flushing with hot solutions;
- aseptic inflammatory process in the abdominal cavity under the influence of the previous factors, as well as intraperitoneal hematoma and minor hemorrhage, treatment of the peritoneum with alcohol or iodine, the use of the various other concentrated solutions (antiseptics, antibiotics) for lavage of an abdominal cavity;
- the use of absorbable long-time suture material, the presence of abdominal drainage, talc from gloves, gauze or cotton pieces, etc.;
- oxygen deficiency of tissues and disorders of metabolic processes in them, as well as inappropriate temperature regime of gas when using a CO2 pneumoperitoneum for diagnostic or therapeutic laparoscopic surgeries;
- postoperative infection occurs more frequently in laparotomies access than laparoscopy.
All these factors, and often their combination, are the trigger that leads to inflammatory processes that cause excess biological synthesis of connective tissue, formation of adhesions. In operative gynecology to maximize the impact of the first three factors occurs when there is a hysterectomy, in connection with the prevention of adhesions after the removal of the uterus is the most important, compared with other gynecological operations.
In obstetrics the conduct of the cesarean delivery is somewhat less related to mechanical and physical damage of the pelvic organs. However, frequently occurring operating blood loss causes tissue hypoxia, disturbance of their metabolism and the body’s immune response, which also contributes to the development of adhesions and adhesive disease in the immediate or late postoperative period. Therefore, prevention of adhesions after cesarean section should be the same as with other surgical procedures.
Learn more in the article: «Adhesions in the pelvis»
Methods of prevention of adhesive disease
Based on the observations and taking into account the mechanisms of formation of adhesions, prevent the formation of adhesions should be done during the surgery itself. It includes the following main principles:
- Reducing the damage of the peritoneum due to the careful attitude to the tissues, reducing (if possible) time of operations, economical use of coagulation techniques and anorexicly. In addition, the reduced number of seams and overlay clips, careful control of bleeding without compromising circulation in the tissues, removal of all necrotic tissue and accumulations of blood, the suppression of infection low concentration of antibacterial and antiseptic solutions, the hydration of tissues and lavage of an abdominal cavity, the use of suture material that does not cause an immune response, prevention of ingress into the abdominal cavity of glove talc and cotton dust from the gauze napkins and tampons.
- Reduction of inflammatory processes through hormonal and non-hormonal anti-inflammatory drugs.
- Reduction of the primary response to aseptic inflammation.
- The suppression of the cascade enhance clotting blood, decrease the formation of fibrin and activation processes aimed at its dissolution.
- The use of means aimed at reducing the accumulation of elastin and collagen proteins, leading to the subsequent development fibroplastic processes (fibrinolytic enzymes).
- Application of the method of hydrofluoride, which is administered into the abdominal cavity crystalloid solutions (the solution of ringer-lactate) or dextrans (Icodextrin, etc.) along with heparin and a solution of glucocorticoids in order of separation of the contact surfaces, activating the fibrinolytic activity of peritoneal cells and the suppression of the coagulation cascade.
- The use of barrier preparations (gels, biodegradable membranes, hyaluronic acid, polyethylene glycol, and the introduction of surfactant-like funds, etc.), fixed contact surfaces in the abdominal cavity and in the pelvis and leading to their mechanical separation.
Thus, the main important mechanism in the prevention of adhesions is to minimize the morbidity of surgical intervention. Surgical prevention can be supplemented by other means and methods, which in any case can’t replace the first. In this regard, significant advantages of prevention of adhesions by laparoscopy.
The main advantages of the laparoscopic method in operative gynecology as a method of reducing formation of adhesions are:
- the minimum degree of trauma of blood loss due to the lack of large incisions of the anterior abdominal wall in areas of rich blood supply;
- minimal access to help prevent the possibility of penetration into the abdominal cavity of the ambient air and foreign reactive materials, and drying the serous surface with the destruction of the phospholipid layer;
- the use of bipolar electrodes is significantly less tissue damage compared with monopolar and ultrasonic, and prevent the formation of adhesions;
- work on the organs and tissues, increased optical camera, using the tools at a remote distance, thereby greatly reducing the risk of mechanical trauma to the mesothelial layer;
- reducing the manipulation of distant organs and tissues;
- no need to isolate the surgical wipes separate areas and floors of the abdominal cavity, e.g. the intestine;
- more gentle and more rapid recovery of anatomical structures and peristaltic function of the intestine;
- the positive effect of laparoscopy on the activity of the peritoneum in terms of fibrinolysis (fibrin-dissolving).
At the same time, in accordance with statistics, about 30-50% of all cases of pelvic pain occur after laparoscopy ovarian cyst, fallopian tubes and other diagnostic laparoscopic procedures. This is due mainly to the fact that:
- carbon dioxide is introduced into the abdominal cavity to provide laparoscopic access, causing spasm of the capillaries of the superficial peritoneal layers, which leads to hypoxia and impaired metabolic processes in mesothelial layer; adding carbon dioxide to 3 percent by volume of oxygen significantly reduces these effects;
- introduction into the abdominal cavity gas is produced under pressure;
- gas dry.
Thus, laparoscopic gynecology only slightly reduces the incidence and prevalence of adhesive processes in abdominal-pelvic pain syndrome and the frequency of repeated operations associated with peritoneal disease. Laparoscopic methods are not a cause for rejection of the basic principles of preventing the formation of adhesions. Selection of additional protivospaechnyj funds depends on the amount of surgical trauma.
Prevention of adhesive disease in the postoperative period is mainly in:
- the restoration of water and electrolyte balance in the body;
- conduct anti-inflammatory and anticoagulant therapy;
- early activation of the patient;
- the most rapid recovery of bowel function.
Principles of prevention of formation of adhesions is the same in all types of surgical procedures. Their use should be integrated and in accordance with the scope and nature of the injuries.