Prevention of intra-peritoneal adhesions in gynaecological surgery: theory and evidence

Abstract

Post-operative adhesions are a significant complication of all abdominal surgical procedures. The major strategies for adhesion prevention in gynaecological surgery are focused on the optimization of surgical technique and use of anti-adhesive agents, which fall into two main categories: pharmacological agents and barriers. Surgical technique that minimizes peritoneal trauma can reduce, but cannot prevent post-operative adhesion formation. Various local and systemic drugs that can alter the local inflammatory response, inhibit the coagulation cascade and promote fibrinolysis have been evaluated. Limited data support the administration of post-operative corticosteroids in addition to systemic intra-operative corticosteroids for the prevention of adhesions after gynaecological surgery. None of the remaining pharmacological agents have been found effective for the reduction of post-operative adhesions. Barriers are currently considered the most useful adjuncts, which may reduce adhesion formation. They act by separating the traumatized peritoneal surfaces during the healing period. The separation can be achieved by solid barriers or fluids. There is limited evidence from randomized clinical trials that support the beneficial effect of most of these barrier agents in the prevention of intra-peritoneal adhesions after gynaecological surgery. However, the evidence is not adequate for definite conclusions to be drawn and further research in this field is warranted.

Reduction of Postoperative Adhesions after Laparoscopic Surgery for Endometriosis by Using a Novel Anti-Fibrotic Drug Pirfenidone: A Randomized Double Blind Study

“…They include non-steroidal anti-inflammatory drugs, corticosteroids, heparin, fibrinolytic drugs, antibiotics, colchicine, calcium channel blockers, vascular endothelial growth factor inhibitors, platelet-activating factor inhibitors, collagen α1 inhibitors, interleukin-6 inhibitors, melatonin, progestagens, and GnRH analogues. Interference with inflammation and prevention of fibrin formation is the rational for their use [15,[18][19][20].…”

Intra-abdominal adhesions: Anatomy, physiology, pathophysiology, and treatment

“…(127) Other etiologies of acquired adhesions include peritoneal trauma, infection, ischemia, hemorrhage, and exposure of the peritoneum to heat or foreign materials; notably, these causes overlap considerably with surgical intervention in many cases. (80,82,178,193) It is through operative intervention, for example, that the peritoneum would come into contact with a source of heated electrosurgical instrument, such as a Bovie, or with sutures, irrigation fluid, powder from gloves, or packing gauze. Ischemia and tissue trauma are also likeliest in the setting of surgery.…”

Adhérences postopératoires et leur prévention en chirurgie gynécologique : II. Comment les prévenir ?

“…La physiopathologie de la formation des adhé rences fournissant plusieurs possibilité s thé oriques d'inhibition pharmacologique des principales é tapes du processus, un large é ventail d'agents a é té é tudié , incluant antibiotiques, anti-inflammatoires non sté roï-diens, corticoïdes, antihistaminiques, progestatifs, agonistes de la GnRH, hé parine et fibrinolytiques [18,25,26]. Même si certains agents ont obtenu des ré sultats prometteurs chez l'animal, aucune é tude clinique humaine n'a, jusqu'à pré sent, montré de bé né fices dans la ré duction des adhé rences.…”