The Microsurgical or Peritoneal Approach to Conservative Reproductive Surgery
Ricardo Azziz
While surgeons often assume that microsurgical (also called peritoneal) techniques are only to be used when doing microscopic surgery, that is surgery requiring magnification because of the size of the organs being operated upon (e.g., fallopian tube or vas deferens lumens) or size of the sutures being used (i.e., equal to or smaller than 8-0 gauge), these approaches are actually valuable when doing any surgery that involves preserving or restoring normal organs, and in particular reproductive organs. In fact, to a large degree the success of reproductive surgery (i.e., reconstructive/reparative surgery of or around the reproductive organs) principally lies in the ability of the surgeon to clearly understand the nature of the tissues that she/he is operating upon and to maximize efforts to minimize the degree of tissue damage. The general principles of microsurgical surgery are reviewed briefly below.
UNDERSTANDING PERITONEAL ANATOMY, HEALING, AND ADHESION FORMATION
Much of the damage performed during surgery, in particular pelvic surgery, stems from the surgeon’s lack of understanding of peritoneal anatomy and the process of peritoneal healing. Although beyond the purview of this atlas, a few principles are well worth remembering.
First, the peritoneum is not anatomically analogous to the skin (epidermis). The latter is composed of multiple layers of squamous cells, the outermost of which are keratinized embryonically arising from the ectoderm, and which is designed to protect the human body against harm and intrusion by foreign agents. It is relatively tough. Alternatively, the peritoneum is embryonically of mesodermic origin and is designed primarily to allow contiguous organs to slide over each other as the body moves and to help contain infections. It is composed of a single layer of nonkeratinized mesothelial cells overlying a rich network of tiny blood vessels, connective tissue, and inflammatory cells. The mesothelium is composed of a single layer of flattened squamous-like cells with microvilli, peripheral vesicles, and discrete bundles of cytoplasmic microfilaments. The peritoneum is very delicate and easily damaged (Figure 22.1).
As such, rubbing the peritoneum with a laparotomy sponge that is seemingly nonabrasive (although to test the true abrasiveness of these fabrics, try rubbing your nose with one), such as when packing the bowel away from the pelvis, will effectively destroy millions of peritoneal cells, denuding large areas of tissue. Likewise when we allow this tissue to become desiccated as we expose it to ambient air and forget to continuously irrigate, or macerate it as we repeatedly grasp and release it with forceps or hemostat, or leave behind foreign material, irritating fluids (e.g., dermoid or endometrioma contents), or bacteria which result in inflammation and further damage to the peritoneum.
Second, fibrous tissue and adhesive bridges between tissues begin on a scaffold of fibrin. Fibrin is released by blood as it coagulates and by peritoneum as it is damaged, and is quite adherent, covering and bridging damaged areas. In turn, fibrin is broken down into fibrin split products (FSPs) by a process called
fibrinolysis. Blood and peritoneal (mesothelial) cells contain plasminogen, which is converted to the active enzyme, plasmin, through the action of plasminogen inhibitors (PAI1 and PAI2). In turn, plas min breaks down fibrin into the biologically inactive FSPs through the tissue plasminogen activator (tPA) pathway. This process occurs within the first week of surgery (Figure 22.2).
fibrinolysis. Blood and peritoneal (mesothelial) cells contain plasminogen, which is converted to the active enzyme, plasmin, through the action of plasminogen inhibitors (PAI1 and PAI2). In turn, plas min breaks down fibrin into the biologically inactive FSPs through the tissue plasminogen activator (tPA) pathway. This process occurs within the first week of surgery (Figure 22.2).
 FIGURE 22.1 Depiction of the relative anatomies of skin and peritoneum: Note that while skin is a relatively tough multilayered keratinized protective coat designed to protect the human body against harm and intrusion by foreign agents, peritoneum is very delicate and easily damaged, designed primarily to allow contiguous organs to slide over each other as the body moves. Peritoneum is composed of a single layer of flattened nonkeratinized mesothelial cells overlying a rich network of tiny blood vessels, connective tissue, and inflammatory cells. |
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