In order to evaluate the effect of training upon postoperative adhesions, standard bipolar and mechanical, nonopposing injuries were performed in the uterine horns and side walls of 52 mature female rabbits using a conventional three-puncture laparoscopy, by an endoscopic surgeon with limited experience. An additional injury, either bipolar or mechanical or both, was performed in the retro-uterine space. With experience, the duration of surgery decreased progressively from 12 +/- 2 to 8 +/- 1 min in the first and last 10 animals respectively. The amount of perioperative bleeding was not affected by experience. With experience the postoperative adhesions decreased in extent (P = 0.0001), tenacity (P = 0.004), type (P = 0.002) and inflammation (P = 0.003) and for total score (P = 0.0002). These changes were correlated with the briefer duration of surgery but not with the amount of perioperative bleeding. The strong correlations of adhesion scores in the pouch of Douglas, and around both uterine horns confirmed the importance of the inter-animal variability in making adhesions. By logistic regression, the adhesions in the pouch of Douglas were explained simultaneously by the adhesions on the uterine horns (P = 0.0004, thus correcting for inter-animal variability) by the amount of bleeding (P = 0.01) and the duration of surgery (P = 0.05). No major differences were found in adhesions following a mechanical or a bipolar injury or following such a lesion in the pouch of Douglas or at the uterine horns. In conclusion, experience, expressed by the duration of surgery and to a lesser extent perioperative bleeding, is a major co-factor in postoperative adhesions, suggesting that duration of surgery should be strictly standardized in endoscopic adhesion studies. The important inter-animal variability can be circumvented by using a standard control lesion, making each animal its own control.

Our aim was to investigate the feasibility of a mouse model to study adhesion formation following endoscopic surgery. Following preliminary studies to establish anaesthesia and pneumoperitoneum pressure, a prospective randomized study was carried out to investigate the effect of CO2 pneumoperitoneum on postoperative adhesions. In group I (control group), the duration of pneumoperitoneum was shorter than 5 min. In groups II, III and IV, pneumoperitoneum was maintained for 60 min without flow, with a continuous low flow (1 ml/min) and a continuous high flow (10 ml/min) through the abdominal cavities of the mice using non-humidified CO2, respectively. Adhesions were scored after 7 days by laparotomy. The total adhesion scores were 0.9 +/- 0.8 (n = 15) in control group, 2.4 +/- 0.8 (n = 15) (P < 0.001 versus control group) in group II with no flow, 2.6 +/- 1.3 (n = 15) (P < 0.001 versus control group) in group III with a continuous low flow and 4.3 +/- 0.9 (n = 15) (P < 0.001 versus control group and P < 0.001 versus group II and III) in group IV with a continuous high flow. In conclusion, the mouse can be used as a model to study adhesion formation following endoscopic surgery. Duration of CO2 pneumoperitoneum is a co-factor in adhesion formation.

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