{"paper_id":"d1fac006-2084-4d20-8249-954746136daa","body_text":"ORIGINAL ARTICLE\nPelvic adhesion formation at second-look surgery\nafter laparoscopic partial and total peritoneal excision\nfor women with endometriosis\nA. Oboh & A. K. Trehan\nReceived: 13 July 2006 / Accepted: 10 May 2007 / Published online: 11 July 2007\n# Springer-V erlag 2007\nAbstract The purpose of this study was to determine the\nincidence of pelvic adhesion formation at second-look\nsurgery after laparoscopic excision of the pelvic peritoneum\nfor pelvic endometriosis. The setting was a district hospital\nin the UK with a specialised unit for laparoscopic surgical\ntreatment of endometriosis; this was a retrospective study.\nWe used data from the hospital computer database to\nidentify patients who had undergone laparoscopic excision\nof pelvic endometriosis from April 1998 to March 2004.\nAll subsequent admissions for surgery (laparoscopic or\nopen) were reviewed for the presence of pelvic adhesions as\ndocumented in the records and collaborated with photo-\ngraphs from surgery. Forty-eight cases were identified from\na cohort of 236 patients who initially had laparoscopic\nexcision of pelvic peritoneum affected with endometriosis.\nForty-six had laparoscopic surgery and two had open\nsurgery. At second look surgery, 44 patients (91.7%) had\nno de-novo pelvic adhesions in the areas where the initial\nexcision was performed. Four patients (8.3%) had filmy\nadhesions in the pelvis; these patients had other surgical\nprocedures (two had LA VH) or on-going disease (one with\nrecto-vaginal endometriosis nodule and the other with\novarian endometrioma at initial surgery). There were no\ndense or significant pelvic adhesions. Laparoscopic exci-\nsion of the pelvic peritoneum as a treatment for pelvic\nperitoneal endometriosis is not associated with significant\npelvic adhesion formation.\nKeywords Endometriosis . Laparoscopy . Peritoneum .\nExcision . Adhesion\nIntroduction\nThe role of surgery in the treatment for pelvic peritoneal\nendometriosis has been validated by several studies [ 1–7].\nSurgical treatment by laparoscopic excision of pelvic\nperitoneal endometriosis is effective in relieving dysmenor-\nrhoea, dyspareunia, chronic pelvic pain and dyschezia [ 2].\nThe Cochrane systematic review also agreed that surgical\ntreatment has a beneficial effect on pelvic pain and\ninfertility in women with mild to moderate endometriosis\n[3]. However this benefit has to be balanced with the risk of\npelvic adhesion formation after surgery.\nAdhesion formation is common and occurs after almost\nevery abdominal surgery [ 8]. It is difficult to ascertain the\ntrue incidence of peritoneal adhesion formation after sur-\ngery because adhesions may vary from minimal asymp-\ntomatic scarring to dense adhesions and none of the scoring\nsystems for adhesions has been validated [ 9]. The reported\nincidence of postoperative peritoneal adhesion formation\nafter surgery has been reported to be as high as 60% –95%\nin patients at subsequent surgery [ 9, 10]. Recent epidemi-\nological data have demonstrated that one-third of patients\nwho had open surgery were readmitted with adhesion-related\ncomplications within 10 years [ 11]. A subsequent analysis\n(SCAR-2) of women who had gynaecological operation-\nlaparoscopy or laparotomy-also showed an increased risk\nof adhesion-related admission [ 12]. It also confirms that\ncertain open surgical procedures (e.g., ovarian, tubal and\nadhesiolysis) have a higher risk of adhesion formation.\nAlthough the majority of adhesions has no detrimental\neffect on women, a proportion suffers serious short- and\nGynecol Surg (2007) 4:261 –265\nDOI 10.1007/s10397-007-0299-0\nA. Oboh ( *)\nDepartment Obstetrics and Gynaecology,\nPontefract General Infirmary Friarwood lane Pontefract,\nWF8 1PL Pontefract, UK\ne-mail: alexanderoboh@hotmail.com\nA. K. Trehan\nDepartment Obs & Gynae, Dewsbery District General,\nDewsbery, UK\n\nlong-term consequences including fertility-related prob-\nlems, chronic pelvic pain, and bowel obstruction [ 8]. The\nimpact on the quality of life of these women is difficult to\ncalculate. However, one could infer it from the increased\nnumber of claims against gynaecologists by these women.\nBetween 1994 and 1999, the UK Medical Defence Union\nreceived 77 adhesion-related claims that resulted in 14 out-\nof-court settlements in 11 years, averaging £50,765 per case\n[8]. Its impact on the healthcare system is also enormous. The\nestimated cost for the UK population, as extrapolated from\nthe SCAR study in 1994, is about 67 million pounds [ 8].\nIn this paper, we set out to look specifically at the inci-\ndence of adhesion formation in patients who had total or par-\ntial laparoscopic excision of the pelvic peritoneum for pelvic\nendometriosis between 1988 and 2004. This paper to our\nknowledge is the first of its kind to look into the incidence of\nadhesion formation after total or partial peritoneal excision.\nMethod\nThis is a retrospective survey. It included all patients who\nhad either a total or partial laparoscopic excision of pelvic\nperitoneum for pelvic endometriosis from April 1988 to\nMarch 2004 under the care of Mr Trehan at the Dewsbury\nDistrict Hospital.\nWe obtained data from the hospital computer database to\nidentify all patients who had laparoscopic excision of pelvic\nperitoneum endometriosis during the study period.\nOperative technique\nAll patients were admitted the day prior to surgery and had\nsystemic bowel preparation. A three-port surgical procedure\nis performed, with a 10-mm port at the umbilicus, and the\nside ports were 12 mm and 5 mm. Scissors dissection of the\npelvic peritoneum and endometriotic implants was per-\nformed. The use of diathermy was usually minimal. Intra-\nabdominal pressure at operation was 12 mmHg with saline\nand heparin irrigation (5,000 in of heparin in 1,000 ml of\nsaline). All patients had intravenous antibiotics (cefuroxime\n750 mg and metronidazole 500 mg) and adhesion preven-\ntion solution instilled (see Table 2) into the pelvic and\nabdominal cavity at the end of operation. The diagnosis was\nconfirmed by histological examination of tissues removed\nat surgery. The majority of patients were discharged home\nthe next day.\nIt is the usual practice in the unit and by the surgeon, Mr\nTrehan, to obtain photographs of the abdominal cavity and\npelvis during laparoscopic operations in addition to written\ndocumentation in the patient ’s case records. See Fig. 1.\nAll subsequent admissions for abdominal surgery were\nreviewed for the presence of pelvic adhesions as docu-\nmented in the case records and collaborated with photo-\nAFTER EXCISION SECOND LOOK LAPAROSCOPY\nCopyright Trehan Copyright Trehan\nFig. 1 Excision of pelvic endo-\nmetriosis does not cause pelvic\nadhesion\nTable 1 Primary surgical procedures in 48 patients having second-\nlook operations\nOperation Number of patients\nLaparoscopic excision of pelvic endometriosis 48\nOther additional operation\nAdhesiolysis 13\nOvarian cystectomy 10\nLUNA 7\nV entrosuspension 7\nSalpingectomy 5\nDye test 5\nLA VH 4\nUnilateral oophorectomy 1\nTable 2 Post-operative use of adhesion prevention fluid (in 48 pa-\ntients having second-look operations)\nAll patients received adhesion prevention solution\nType of fluid Number of patients (%)\nSepracoat® 21 (43.75%)\nIntergel® 18 (37.5%)\nSaline and heparin 9 (18.75%)\n*Heparin dose 5000 iu in 1,000 ml normal saline\n262 Gynecol Surg (2007) 4:261 –265\n\ngraphs from surgery. The presence of adhesion was\ndeducted by comparing the pictures from the first laparo-\nscopic surgery to the pictures at the second operation.\nThe classification of adhesions we used was the oper-\native laparoscopic study group (OLSG) classification [ 13].\nAdhesions were placed as: 0, none; 1, filmy and avascular;\n2, dense and vascular; and 3, binding and cohesive.\nResult\nTwo hundred thirty-six patients were identified who had\nlaparoscopic excision of pelvic peritoneum for pelvic en-\ndometriosis from April 1998 to March 2004. Forty-eight pa-\ntients from the initial cohort returned to the unit for a second\nabdominal operation, either diagnostic or therapeutic.\nThe age range of patients was 20 –42 years, with an\naverage age of 32.39 years. Twenty-four patients were\nnulliparous; 7 were para 1; 12 were para 2; 7 were para 3 or\nmore. The primary surgery for the cohort of patients who\nwent on to have a second operation is shown in Table 1.\nAt surgery, 25/48 (52.08%) patients had stage 1, 14/48\n(29.16%) had stage 2, 5/48(10.42%) had stage 3 and 4/48\n(8.33%) had stage 4 endometriosis according to the revised\nAmerican Fertility Society classification (rAFS).\nAll patients had post-operation adhesion prevention\nsolution, albeit different brands (Table2). In the study group,\na majority 23/48 (47.92%) of patients had no post-operative\nmedical treatment; 22/48 (45.83%) of patients had post-\noperative gonadotrophin-releasing hormone analogue treat-\nment for 3 months, and 3/48 (6.25%) had Danazol treatment\nfor 3 months.\nThe surgical procedure at subsequent second-look\nsurgery is shown in Table 3.\nThe time interval between first operation and subsequent\nsurgery is shown in Table 4.\nThe presence and type of pelvic adhesions in the patients\nwho had a subsequent abdominal surgical procedure ac-\ncording to the OLSG classification [ 13] is shown in Table 5.\nDiscussion\nIn our series, 44 patients (91.7%) had no adhesions in the\npelvis. Four patients had class 2 or filmy pelvic adhesions,\nthat is, an incidence of 8.3%. In the four patients with\nTable 3 Surgical procedures at second-look operation (in 48 patients\nhaving second-look operations) some patients had one or more\nprocedures\nSurgical procedure Number of patients\nLaparoscopic excision of endometriosis 16\nLA VH only 13\nOphorectomy 7\nAdhesiolysis 4\nOvarian cystectomy 5\nTAH only 4\nDye test 4\nLUNA 3\nExcision of endometriotic nodule 3\nDiagnostic laparoscopy 2\nTable 5 Incidence of adhesion at 2nd look surgery by operative lapa-\nroscopy study group (OLSG) classification\nOLSG Class Description of adhesion Number of patients (%)\n0 None 44 (91.7%)\n1 (8.3%) filmy/avascular* 4\n2 Dense/vascular 0\n3 Binding/cohesive 0\n*Two patients received sepracoat, one patient intergel and one patient\nsaline mixed with heparin at the end of excision surgery\n0\n2\n4\n6\n8\n10\n12\n14\n<10 10 to\n15\n16 to\n20\n21 to\n25\n26 to\n30\n31 to\n35\n>35\nDuration in months\nNumber of patients\nTable 4 Time interval between\nfirst and second surgical opera-\ntions\nGynecol Surg (2007) 4:261 –265 263\n\nadhesions, one had rAFS* stage IV disease with a recto-\nvaginal endometriotic nodule that was treated at second\noperation, one had rAFS stage III disease with an ovarian\nendometrioma and two had rAFS stage I disease had\nlaparoscopic-assisted vaginal hysterectomy at primary\nsurgery. We would deduce from our result that the presence\nof on-going endometriosis and additional major surgical\nprocedure at the time of peritoneum excision increases the\nrisk of adhesion formation.\nThe reasons for this good outcome, i.e., low incidence of\nadhesion could be due to a combination of the following\nfactors.\n1. Operator experience\n2. Operator technique\n3. Use of adhesion prevention adjuvant.\nOne surgeon, who had been trained in advanced\nlaparoscopic surgery and practiced the same for over a\ndecade, performed all operations. The role of good training\nin endoscopic surgery is not questionable. However there is\ncurrently an unresolved debate on the way forward in\ntraining-an apprenticeship model or modular training [ 14].\nAdhesion formation starts after localised injury to the\nmesothelial layer of the per itoneum. The interaction\nbetween post-traumatic inflammatory proteins and fibrin\ndeposits at the injury sites finally leads to adhesion\nformation [ 8]. Surgical technique is important to prevent\nadhesion formation after pelvic surgery [ 9]. Laparoscopic\nsurgery is associated with less risk of adhesion formation as\ncompared to laparotomy [ 12, 15–17]. Our surgical tech-\nnique of laparoscopic excision with scissors dissection,\nminimal use of diathermy, gentle tissue handling, meticu-\nlous haemostasis and copious irrigation prevents charring of\ntissues due to thermal injury. This leads to a reduced\nstimulus for an inflammatory cascade reaction following\ntissue trauma and therefore less adhesion formation post\nsurgery.\nIn our unit, all patients undergoing laparoscopic excision\nof endometriosis have intra-operative irrigation with saline\nmixed with heparin in addition to adhesion prevention so-\nlution at the end of surgery. The use of adhesion prevention\nsolution has been extensively studied in the last decade.\nThe general consensus from published data is that an adhe-\nsion prevention solution or barrier significantly reduces the\nincidence of post-operative adhesion formation [ 18–23].\nThe safety profile of the patients treated with adhesion\nprevention solution was comparable to those treated with\nlactated Ringer ’s solution [ 22, 23].\nHowever several reports suggest that the use of\ngonadotrophin-releasing hormone angonist reduces pelvic\nadhesion after surgery [ 24–26]. The use of medical\ntreatment after surgery is not routine in our unit and some\npatients decline to have this treatment after counselling\nbecause of the side effects. The effect on our result is\nlimited because a majority of our patients did not have this\ntreatment.\nOur paper is the first to report on the incidence of\nadhesion formation after laparoscopic excision of the total\nor partial pelvic peritoneum with scissors dissection and\npost-operative use of adjuvant adhesion prevention solu-\ntion. Our study suggests that laparoscopic excision of the\npelvic peritoneum is a safe and effective treatment approach\nfor women with pelvic peritoneum endometriosis. Also, if\nsurgery is carried out in trained hands and with adherence\nto good surgical practice, it does not cause dense adhesion\nin the pelvis.\nWe accept there are limitations to this paper. It is a ret-\nrospective study, with a small sample population. However,\nit offers a snapshot on laparoscopic excision of pelvic peri-\ntoneum and pelvic adhesion formation.\nReferences\n1. Garry R, Clayton R, Hawe J (2000) The effect of endometriosis\nand its radical laparoscopic excision on quality of life indicators.\nBJOG 107(1):44 –54, Jan\n2. Abbott J, Hawe J, Hunter D, Holmes M, Finn P (2004) Garry\nlaparoscopic excision of endometriosis: a randomized, placebo-\ncontrolled trial. Fertil Steril 82(4):878 –884, Oct\n3. Jacobson TZ, Barlow DH, Garry R, Koninckx P (2001)\nLaparoscopic surgery for pelvic pain associated with endometri-\nosis. Cochrane Database Syst Rev 2(4):CD001300\n4. Jacobson TZ, Barlow DH, Koninckx PR, Olive D, Farquhar C\n(2002) Laparoscopic surgery for subfertility associated with\nendometriosis. Cochrane Database Syst Rev 2(4):CD001398\n5. Keye WR Jr, Hansen LW, Astin M, Poulson AM Jr (1987) Argon\nlaser therapy of endometriosis: a review of 92 consecutive\npatients. Fertil Steril 47(2):208 –212, Feb\n6. Sutton CJ, Ewen SP , Whitelaw N, Haines P (1994) Prospective,\nrandomized, double-blind, controlled trial of laser laparoscopy in\nthe treatment of pelvic pain associated with minimal, mild, and\nmoderate endometriosis. Fertil Steril 62(4):696 –700, Oct\n7. Sutton CJ, Pooley AS, Ewen SP , Haines P (1997) Follow-up\nreport on a randomized controlled trial of laser laparoscopy in the\ntreatment of pelvic pain associated with minimal to moderate\nendometriosis. Fertil Steril 68(6):1070 –1074, Dec\n8. Trew G (2004) Consensus in adhesion reduction management.\nObstetr Gynaecol Suppl 6(2):1\n9. Monk BJ, Berman ML, Mont z FJ (1994) Adhesions after\nextensive gynecologic surgery: clinical significance, etiology,\nand prevention. Am J Obstet Gynecol 170(5 Pt 1):1396 –1403,\nMay\n10. Menzies D, Ellis H (1990) Intestinal obstruction from adhesions-\nhow big is the problem? Ann R Coll Surg Engl 72(1):60 –63, Jan\n11. Ellis H, Moran BJ, Thompson JN, Parker MC, Wilson MS,\nMenzies D, McGuire A, Lower AM, Hawthorn RJ, O ’Brien F,\nBuchan S, Crowe AM (1999) Adhesion-related hospital readmis-\nsions after abdominal and pelvic surgery: a retrospective cohort\nstudy. Lancet 353(9163):1476 –1480, May 1\n12. Lower AM, Hawthorn RJ, Clark D, Boyd JH, Finlayson AR,\nKnight AD, Crowe AM, Surgical and Clinical Research (SCAR)\n264 Gynecol Surg (2007) 4:261 –265\n\nGroup (2004) Adhesion-related readmissions following gynaecol-\nogical laparoscopy or laparotomy in Scotland: an epidemiological\nstudy of 24,046 patients. Hum Reprod 19(8):1877 –1885, Aug.\nEpub (2004), Jun 3\n13. Chapron C, Guibert J, Fauconnier A, Viera M, Dubuisson JB\n(2001) Adhesion formation aft er laparoscopic resection of\nuterosacral ligaments in women with endometriosis. J Am Assoc\nGynecol Laparosc 8(3):368 –373, August\n14. Wright J (2005) Training in minimal access gynaecological\nsurgery. Gynecol Surg 2:1 –2\n15. Lundorff P , Hahlin M, Kallfelt B, Thorburn J, Lindblom B (1991)\nAdhesion formation after laparoscopic surgery in tubal pregnancy: a\nrandomized trial versus laparotomy. Fertil Steril 55(5):911 –915,\nMay\n16. Takeuchi H, Kinoshita K (2002) Evaluation of adhesion formation\nafter laparoscopic myomectomy by systematic second-look micro-\nlaparoscopy. Am Assoc Gynecol Laparosc 9(4):442 –446, Nov\n17. Gutt CN, Oniu T, Schemmer P , Mehrabi A, Buchler MW (2004)\nFewer adhesions induced by laparoscopic surgery? Surg Endosc\n18(6):898–906, Jun, Epub (2004), Apr 27\n18. Farquhar C, V andekerckhove P , Watson A, V ail A, Wiseman D\n(2000) Barrier agents for preventing adhesions after surgery for\nsubfertility. Cochrane Database Syst Rev (2):CD000475\n19. Azziz R (1993) Microsurgery alone or with INTERCEED\nAbsorbable Adhesion Barrier for pelvic sidewall adhesion re-\nformation. The INTERCEED (TC7) Adhesion Barrier Study\nGroup II. Surg Gynecol Obstet 177(2):135 –139, Aug\n20. diZerega GS (1996) Use of adhesion prevention barriers in\novarian surgery, tubalplasty, ectopic pregnancy, endometriosis,\nadhesiolysis, and myomectomy. Curr Opin Obstet Gynecol 8\n(3):230–237, Jun\n21. Diamond MP (1998) Reduction of de novo postsurgical adhesions\nby intraoperative precoating with Sepracoat (HAL-C) solution: a\nprospective, randomized, blinded, placebo-controlled multicenter\nstudy. The Sepracoat Adhesion Study Group. Fertil Steril 69\n(6):1067–1074, Jun\n22. Johns DB, Keyport GM, Hoehler F, diZerega GS, Intergel\nAdhesion Prevention Study Group (2001) Reduction of postsur-\ngical adhesions with Intergel adhesion prevention solution: a\nmulticenter study of safety and efficacy after conservative\ngynecologic surgery. Fertil Steril 76(3):595 –604, Sep\n23. diZerega GS, V erco SJ, Y oung P , Kettel M, Kobak W, Martin D,\nSanfilippo J, Peers EM, Scrimgeour A, Brown CB (2002) A\nrandomized, controlled pilot study of the safety and efficacy of\n4% icodextrin solution in the reduction of adhesions following\nlaparoscopic gynaecological surgery. Hum Reprod 17(4):1031 –\n1038, Apr\n24. Schindler AE (2004) Gonadotropin-releasing hormone agonists\nfor prevention of postoperative adhesions: an overview. Gynecol\nEndocrinol 19(1):51 –55, Jul\n25. Wright JA, Sharpe-Timms KL (1995) Gonadotropin-releasing\nhormone agonist therapy reduces postoperative adhesion forma-\ntion and reformati on after adhesiolysis in rat models for\nadhesion formation and endometriosis. Fertil Steril 63(5):1094 –\n1100, May\n26. Sharpe-Timms KL, Zimmer RL, Jolliff WJ, Wright JA, Nothnick\nWB, Curry TE (1998) Gonadotropin-releasing hormone agonist\n(GnRH-a) therapy alters activity of plasminogen activators, ma-\ntrix metalloproteinases, and their inhibitors in rat models for ad-\nhesion formation and endometriosis: potential GnRH-a-regulated\nmechanisms reducing adhesion formation. Fertil Steril 69(5):\n916–923, May\nGynecol Surg (2007) 4:261 –265 265","source_license":"CC0","license_restricted":false}