The prevention of postoperative pelvic adhesions: an animal study comparing barrier methods with dextran 70

There are two major approaches to the prophylaxis for adhesions: chemical methods (e.g., dextran) and barrier methods. Theoretically, dextran prevents the formation of adhesions by a surface-coating or hydroflotation effect, whereas the barrier methods either prevent the formation of or mask adhesions by covering and isolating the injured area with an inert substance. This study compared the efficacy of two different concentrations of dextran 70 and various barriers in preventing the formation of adhesions in the female rabbit pelvis. Symmetrical cut and scrape lesions were made on both sides of each rabbit's uterus; for the barrier-treated animals, the lesions on one side were covered with a barrier, and the contralateral side served as a control. The barriers tested were: Gelfilm, Surgicel, Silastic, Gelfoam paste, amnion, peritoneum, and omentum (five rabbits per subgroup). The same cut and scrape lesions were induced in 16 additional rabbits in the chemical group. These rabbits were subsequently treated with 10 ml/kg of intraperitoneal 6% dextran 70 (five rabbits), and 32% dextran 70 (five rabbits), and were compared with six external control rabbits. The severity of the adhesions that formed was graded by a numerical scoring system. The barrier methods tested resulted, generally, in an increased formation of adhesions when a comparison was made with control and with dextran-treated animals. The degree of formation of adhesions in the dextran-treated rabbits did not differ from that in the control animals. The data suggest that the barrier methods actually promote the formation of adhesions whereas the findings with dextran 70 were inconclusive.

[Surgical therapy of enterovaginal fistulae following gynecologic primary procedures (author's transl)]

This is a report on 14 enterovaginal fistulae following gynecologic operations. The fistulae were caused by a hysterectomy in 8 cases. There were 3 other enterovaginal fistulae following exploratory laparotomy for ovarian tumors, which proved to be pseudotumors caused by diverticulitis of the sigmoid colon. Rare causes for fistulae were cesarian section, episiotomy, and incision of an abscess of Bartholins' gland. The time interval between operation and manifestation of the fistula was usually about 10 days. The operative management required a two-or three-step procedure. Only 2 of 14 patients were treated by a colostomy, and a bowel resection was performed in 4 cases. After dissection of the fistula either peritoneum or omentum was interposed in 8 patients. No recurrences were observed.

[Free peritoneal patch grafts in surgery on renal pelvis and ureter (author's transl)]

36 operations of the renal pelvis or ureter were carried out in 35 patients. In all these cases a split stenosis or a tissue defect were covered by free peritoneal patches. Urographic controls of 30 patients showed 29 good or very good results. The following statements can be made: 1. In cases of a secondary scarred stenosis, of renal pelvic or ureteral wall defects, plastic operations of intrarenal pelvis of transsinus operations of staghorn calculi the splitting with splinting and covering by autologous tissue seems to represent a suitable operation. -- 2. As material the renal capsule, the venous wall and the peritoneum are suitable. -- 3. In cases of severe ureteral stenoses, which have to be resected, especially in cases of considerable differences of the ureteral lumen, the semicircular suture with covering should be preferred to the circular suture. -- 4. The covering of the defects by patches of autologous material reduces the time of the postoperative urinary diversion with all its dangers and the period of hospitalization. -- 5. In cases of a short covered stenoses (up to 4 cm) postoperative disturbance of the transport or urine was observed only once. The results of stenoses, longer than 4 cm, cannot yet be evaluated.

Transplantation of a free peritoneal patch in surgery of the renal pelvis and ureter

Operations on the urinary collecting system successfully utilized the free peritoneal patch in a variety of situations, as animal experiments have shown. When used to cover defects the peritoneum works as a multipotent matrix for invasion of urothelium; when used as an envelope it prevents stricture due to perihilar/periureteral scarring. We used a free peritoneal patch in 31 operations on the renal pelvis and ureter between 1975 and 1980. The indications for the patch were; defects of the renal pelvis of ureteropelvic junction due to surgery for recurring stones or carcinoma of the pelvis; and pyelocalicotomy of an intrarenal pelvis if it was impossible to suture the pelvis. We also used the patch to envelop renal pelvis and ureter in extended perihilar inflammation or stenosis of the pyeloureteral junction and proximal ureter due to scarring. The results, as shown by urography, were excellent or good in 25 or the 31 cases. The transplantation of a free peritoneal patch is a simple, reliable technique that can be recommended for covering defects or preventing stricture in surgery of the renal pelvis and ureter.

[The surgical treatment of tubal sterility. Value of free peritoneal graft and of early coelloscopy in the prevention of adhesions (author's transl)]

We have greatly improved in prevention of adhesions after tuboplasty, using two different and new technics: --peritoneal grafts on crude surfaces (21 cases) --laparoscopy 8 days after tuboplasty (54 cases), and sweeping off fresh adhesions with a rod. First results seem to confirm the interest of these methods.

[Phallus phantom - a superfluos remnant in surgical correction of vaginal aplasia (author's transl)]

Reported are 32 cases of surgical correction of congenital atrophy of the vagina in concomitance with Mayer-Rokitansky-Küster syndrome. The authors gained experience from using a surgical technique modified by themselves after Kurbanova's approach. Described in greater detail is their approach exclusively on the vaginal route. The outcome, some time after surgery, was analysed, and all results were found to be good. Phantom insertion proved to be superfluos in follow-up treatment of the peritoneal vagina. Vaginoplasty, using pelveoperitoneum, is considered to be the most successful method, at present, against the background of all results so far available from follow-up checks.

[Fixation of a pathologically mobile kidney using a fascial pocket reinforced with a strip of heterogenous peritoneum]

The method of fixation of a pathologically movable kidney with a graft from the retrorenal fascia, modelled as a poach and strengthened with a heterogenic abdominal stripe, is described. The operation was carried out upon 76 patients. There were no complications. 63 patients were followed up for 6 month to 2.5 years. There were no cases of the recurrence of nephroptosis. The results of the operation are considered as favourable ones.

[Healing of peritonized and nonperitonized peritoneal defects in growing organisms]

Clinical data (110 observations over 106 cases) and experiments on animals proved the inexpediency of the peritonization of non-pertonized surfaces in children both in "pure" peritoneum and under the condition of a pronounced inflammation. Renouncement of peritonization of peritoneal defects has favoured the decrease of the incidence rate of the recurrence of ileum and the improvement of late results of the treatment. The authors believed that the peritonization is needed only when defects of the intestinal wall reach the submucous level and as this takes place a pronounced bleeding, which cannot be controlled without suturing, is noted. Intestinal perforation localized in the non-peritonized sites was never observed, even when the muscular layer of the intestinal wall was damaged.

The free peritoneal transplant as substitute for the urinary bladder wall

In 13 rabbits the fundus of the bladder was resected and the defect repaired by a free peritoneal transplant from the lateral abdominal wall. One animal died postoperatively of purulent peritonitis. In the remaining animals the transplant healed with no signs of irritation. The mean reduction of bladder capacity per body weight between the 5th and 18th postoperative week was only 13 per cent. Histologic tests after 5 weeks showed a germinating epithelium on the transplant which was replaced by a fibromuscular lamina after 10 weeks. The successful results of these animal experiments seem to justify the clinical use of free peritoneal transplants. The good healing tendency and matrix function of this tissue permit transplantation of the peritoneum wherever intraoperative defects occur or suture dehiscence may be expected.

Management of the pelvic floor after pelvic exenteration

At the Mayo Clinic, 198 exenterative operations were performed from 1950 through 1971. Although the 5-year survival rate of all patients was 33%, bowel obstruction occurred in 11.6% of patients and intestinal fistula formation in 12.6%. The majority of patients with these complications had had previous pelvic irradiation. The difficulty in dealing with the large raw area in the pelvis is discussed with a review of the various methods that have been tried to date to reperitonealize the pelvis and thereby, it is hoped, prevent adhesions or fistula formation.