Pelvic adhesion: A challenge of all gynecologic surgeries

Adhesions, characterized by fibrin deposition leading to fibrous tissue connections (adherence tissues) between various tissue planes or organs, as part of internal healing process and inflammatory reactions passing through the different but overlapping phases (hemostasis/inflammatory phase, proliferative phase, and remodeling phase), are usually the defense mechanisms against the various causes of inflammation (physical, chemical, infections, etc.), resulting in unfavorable consequences, such as chronic pain, obstruction (especially bowel), function impairment, and infertility.1–4 Intra-abdominal and pelvic adhesion are by far the most common of all adhesions, which are mainly caused by various kinds of surgeries and less by previous severe infection or inflammatory reactions.5–7 Sometimes, adhesions-related complications need management, which is often dependent on etiology, location, and the associated symptoms or signs.1 Besides conservative treatment, surgical lysing procedures, called as adhesiolysis sometimes cannot be totally avoided in these subjects with adhesion, since either emergency, such as intestinal obstruction complicated by adhesions or the other indications for further surgery, such as recurrent uterine myomas, adenomyosis, chocolate cysts, or others may occur. Minimally invasive procedures, such as hysteroscopic, laparoscopic, and robotic approaches, are very popular in the management of subjects with various indications for surgeries,5,8,9 and additionally, these approaches are also reported as the preferred options for adhesiolysis.1,10 However, it is believed in long term that history of any of myomectomy, cystectomy, electrofulguration for endometriosis, appendectomy, or bowel surgery is considered as a “contraindication” for laparoscopic surgeries,11 although this hypothesis is worthy of being tested. In the current issue of the Journal of the Chinese Medical Association, we are happy to learn that Dr. Wang and colleagues attempted to clarify the possibility to use a robotic approach to perform total hysterectomy in patients with intra-abdominal adhesions.12 The authors enrolled 410 women with uterine myoma/adenomyosis undergoing robotic total hytserectomy.12 The authors found that surgical difficulty was really present in the subjects with adhesions because more patients with higher severity needed assistant port usage, and a surgeon needed the longer time to perform uterine artery ligation procedure.12 Subgroup analysis, based on the adhesion severity either by scoring system, or adhesion location sites showed that much severe adhesion was positively correlated with much complicated surgery, since these patients with higher percentage needed additional assistance port use, and surgeons needed more time to finish docking and finish certain types of surgeries, such as uterine artery ligation. Although the current study did not add any new information or offer understanding of adhesion, this article is still worthy of our further discussion. First, the current study confirmed the feasibility of minimally invasive surgery in the patients with adhesions. One systematic review enrolling 14 comparative studies on 38 057 patients to evaluate the surgical outcomes in patients with adhesional small bowel obstruction undergoing laparoscopic and exploratory laparotomic adhesiolysis, and the results showed laparoscopic approach took a significant advantage compared to exploratory laparotomic approach, including the reduced risk of hospital stay (standard mean difference [SMS] −0.44, 95% confidence interval [CI] −1.0 to −0.27), mortality (odds ratio [OR] 0.31, 95% CI 0.23–0.42), overall postoperative complications (OR 0.38, 95% CI 0.29–0.48), incidence of bowel resection (OR 0.39, 95% CI 0.20–0.75), incidence of surgical site infection (OR 0.29, 95% CI 0.13–0.65), postoperative respiratory complications (OR 0.22, 95% CI 0.17–0.30), postoperative cardiac complication (OR 0.42, 95% CI 0.26–0.69), as well as postoperative deep vein thrombosis (OR 0.36, 95% 0.24–0.56) and reduced operation time (SMD −2.80, 95% CI −4.69 to −0.91).10 All suggest that adhesion is not a “contraindication” for minimally invasive surgeries, and by contrast, minimally invasive surgery may be a better choice in patients with adhesion. Second, abdominal surgery is a main cause for the development of adhesion, and we still found that near two-thirds (64.1%, 139/217) of patients were not complicated with any adhesion.12 Although the authors did not report the indications of abdominal surgeries for these patients and also did not report whether these patients had been treated with any antiadhesive procedure following the original abdominal surgeries, we believed that many of these patients did have been treated with certain-type of antiadhesive treatment after the careful and meticulous surgical work causing minimal tissue injury,5,6,13,14 since a recent consensus on the prevention of abdominal pelvic adhesions after gynecological tumor surgeries showed that 60% to 90% of patients develop adhesions after abdominopelvic surgeries.13 In term of adhesion, preventing it may be better than managing it,5,6 although it is still relatively difficult to prevent postsurgical adhesion formation partly because adhesions form as a result of a coordinated physiological response to tissue injury and partly because the exact mechanisms driving adhesion formation are not fully understood.15 In Dr. Wang’s study, we highlighted the value of their contribution, since after accessing the abdominal cavity, enough safe place (high-level camera port) should be created for the rest of the ports (use of assistant port) by lysing the easy and close adhesions.1 Their study also confirmed the new directing of using robotic surgery for the treatment of complicated gynecological surgeries, and with far advanced technology and development of new consensus or guidelines, their study may accelerate the path to approval of using minimally invasive surgery for this relatively complicated surgery and fulfills a high unmet need, and both of which are important.14,16 ACKNOWLEDGMENTS This article was supported by grants from the Taiwan Ministry of Science and Technology, Executive Yuan, Taiwan (MOST 109-2314-B-075B-014-MY2 and MOST 110-2314-B-075-016-MY3), and Taipei Veterans General Hospital (V110C-082, and V111C-103). The authors appreciate the support from Female Cancer Foundation, Taipei, Taiwan.