Abdominal and pelvic adhesion formation remains a common phenomenon, affecting up to 90% of those individuals who have undergone previous abdominal surgery. Adhesions have also been documented in those patients with no apparent risk factors. Adhesions occur following peritoneal injury, fibrin production, and dysfunctional repair of a process that would otherwise not result in adhesion formation (see Chapter 22). Risk factors include traumatic or inflammatory exposures that impede normal healing including thermal injury (e.g. electrosurgical applications), infection, foreign body (e.g., suture), tissue ischemia (e.g., exposure to ambient air), blood, and radiation.

The global impact of adhesions is significant, resulting in gastrointestinal obstruction, implicated as a potential contributor to chronic pain syndromes, and complicating subsequent operations. Of most interest to gynecologists and reproductive surgeons is the effect of adhesive disease on fertility. In fact, adhesions may be to blame for approximately 20% of female-specific infertility cases. This chapter focuses not only on the laparoscopic techniques to treat, remove, and minimize the recurrence of periadnexal adhesions, but also on those surgical techniques that may reduce the risk of de novo adhesion formation, in an effort to best preserve tubal function. Finally, the advent of in vitro fertilization (IVF) has significantly changed our approach to reproductive failure secondary to pelvic adhesions; this section will discuss those procedures that are current in light of these developments.

The ability to predict which patient will have preexisting pelvic adhesions is difficult, as the process of formation seems to be variable, depending on the host. Risk factors, such as previous abdominal surgery, should be thoroughly reviewed with patients when being counseled about a planned operation. Perioperative risks, such as visceral injury or need to convert to laparotomy, need to be clearly outlined.

A full understanding of the uterine and tubal anatomy is critical prior to undertaking surgical repair of the adnexa. While transvaginal sonography, with or without sonohysterography, will provide a three-dimensional assessment of the uterus and adnexa, hysterosalpingography (HSG), particularly using water-based contrast, gives the most accurate assessment of internal tubal anatomy, including the intramural portion. It is the opinion of this surgeon that a preoperative HSG is essential prior to undertaking salpingo-ovariolysis.

Consideration to the primary entry point, especially when performing a laparoscopic procedure, is often the first and possibly the most “at-risk” step, whether it be at Palmer’s point (left upper quadrant), or open (Hasson technique), or closed access through the umbilicus. The use of preoperative mechanical bowel preparation in gynecologic surgery to reduce surgical risks in patients with suspected adhesions remains an unanswered debate. However, it seems reasonable to offer a bowel prep to patients who may be at high risk for bowel adhesions, particularly those involving the large intestine to the uterus or adnexa. We feel that
a clear diet the day preceding surgery followed by a single Fleet® enema at night sufficiently empties the distal colon, facilitating access to the deep pelvis. Ultimately, however, it should be the surgeon’s intent to safely complete the procedure, whether adhesiolysis is considered the primary procedure, or whether, adhesions represent an obstacle to the intended procedure.

Restoration of the anatomy and minimization of adhesion reformation with the aim of preserving reproductive function remains the ultimate goal, and so meticulous dissection without the excessive use of electrosurgery is often required.

1. General principles of adhesiolysis: Surgeons should utilize all possible external factors that may facilitate the dissection, such as fairly steep Trendelenburg positioning and an articulating uterine manipulator that reproduces the function of an extra hand. Use of a microsurgical approach such as gentle tissue handling, minimizing desiccation, and limiting foreign body exposure have been well described (see Chapter 22) as a means of reducing subsequent risk of adhesion formation, particularly to prevent the de novo formation of adhesions in patients initially adhesion free.

Adhesiolysis is facilitated using traction—countertraction, placing stretch on the adhesion, and more clearly presenting the intervening tissue planes. The organ to be preserved (e.g., tube) should be grasped with atraumatic graspers, which should hold the organ sufficiently loosely to allow it to escape without injury if excessive traction is applied (Figure 24.1). Alternatively, the adhesion to be removed can and should be grasped firmly, perhaps using a toothed forceps. Often adhesions can be broken apart using blunt dissection. However, thicker more fibrotic adhesions should not be divided bluntly as this may predispose to unintended trauma; sharp dissection with scissors is recommended in this situation.

Adhesions can either be incised or they can be excised, depending on its structure and location. When possible adhesions should be excised at each insertion and the scar tissue removed, rather than simply divided. Hemostasis during dissection should be achieved by expectant management to the extent possible. The vast majority of bleeding during adhesion dissection will be capillary in nature and will stop spontaneously in short order without the need for energy. However, bipolar energy used sparsely is often sufficient to stop more significant bleeding. Monopolar energy should be avoided.

2. Gaining pelvic exposure: The first objective of adhesiolysis is to gain adequate exposure to all reproductive organs, and to do so by destroying as few surgical planes as possible. Hence, dissection should proceed with patience, and it is best performed using traction-countertraction and incising with cold scissors, not electrosurgery. Furthermore, a careful understanding and mental visualization of the underlying anatomy is critical, which requires that the surgeon start his/her dissection high up in the pelvis, where the anatomy may be adhesion free. When adequate exposure has been obtained, the surgeon can then focus on the task of unencapsulating adhesions from the ovaries and tubes.

3. Dissection of adnexa-bowel adhesions: If bowel or bowel appendages are adherent to the adnexa, the approach to the dissection should be to free as much of bowel adherences as is necessary, but not more. While we generally prefer to excise adhesions, when operating on bowel it is best to incise the adhesive bands, erring on the side of leaving some of the adherence on the bowel serosa rather than incising too close to the bowel serosa/muscularis and risking subsequent perforation (Figure 24.2).

In general, when dissecting around bowel it is best to mobilize adhesions beginning in areas that are less risky. For example, a blunt probe can be sweeped along the anterior and posterior surface of the uterus, pressing towards the uterine body,
to identify and stretch adhesions that can then be incised/excised (Figure 24.3

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