Pathogenesis, consequences, and control of peritoneal adhesions in gynecologic surgery

Laparoscopic Suturing as a Barrier to Broader Adoption of Laparoscopic Surgery

BACKGROUND

Laparoscopic surgery is increasingly replacing the open procedure because of its many patient-related benefits that are well aligned with policies and programs that seek to optimize health system performance. However, widespread adoption of laparoscopic surgery has been slow, in part, because of the complexity of laparoscopic suturing. The objective of this study was to review the clinical and economic impacts of laparoscopic suturing in key procedures and to assess its role as a barrier to the broader adoption of laparoscopic surgery.

DATABASE

A medical literature search of MEDLINE, EMBASE, and BIOSIS from January 2010 through June 2016 identified 47 relevant articles.

CONCLUSION

Laparoscopic suturing and intracorporeal knot tying may result in extended surgical time, complications, and surgeon errors, while improving patient quality of life through improved cosmesis, diet toleration, and better bowel movements. Despite advancement in surgical techniques and the availability of newer surgical tools, the complexity of laparoscopic suturing continues to be a barrier to greater adoption of MIS. The results of the study underscore the need for development of proficiency in laparoscopic suturing, which may help improve patient outcomes and reduce healthcare costs.

Laparoscopic Management of Adhesions Developed after Peritoneal Nonclosure in Primary Cesarean Section Delivery

OBJECTIVE

The aim of the current study was to laparoscopically investigate the effects of peritoneal nonclosure on the sites, types, and degrees of adhesions developed after primary caesarean section (CS) in women complaining of secondary infertility after first CS delivery.

STUDY DESIGN

This was a cross-sectional study, where 250 women suffering from secondary infertility after their first CS had been recruited. They had been classified into group I (n = 89), where both the visceral and parietal peritoneum had been left opened; group II (n = 75), where only the parietal peritoneum had been closed; and group III (n = 86), where both peritoneal layers had been closed. Laparoscopy had been used to classify those adhesions according to the location, severity, and their adverse impact on the reproductive capacity.

RESULTS

Both adnexal and nonadnexal adhesions had been found significantly higher in group I, while adnexal types of adhesions were significantly higher after nonclosure of the visceral peritoneum in group II. Laparoscopic tubal surgery performed included tubo-ovariolysis, fimbrioplasty, and neosalpingostomy. Pregnancy rate was found correlating with the adnexal adhesion location and score.

CONCLUSION

Nonclosure of the peritoneum in CS is associated with more adhesion formation, which might adversely affect the future women reproduction.

Robotic-assisted laparoscopy in reproductive surgery: a contemporary review

Robotic surgery is a conceptual fusion of the conventional open surgery and the minimally invasive laparoscopic surgery. We reviewed the current role of robotic-assisted laparoscopy in the field of reproductive surgery by a literature search in PubMed database. We analyzed the reported advantages and limitations of the use of robotics in reproductive surgeries like myomectomy, tubal reanastomosis, endometriosis, ovarian tissue cryopreservation, and ovarian transposition. Overall, robotic assistance in reproductive surgery resulted in decreased blood loss, less post-operative pain, shorter hospital stay, and faster convalescence, whereas reproductive outcomes were similar to open/laparoscopic approaches. The main drawbacks of robotic surgery were higher cost and longer operating times. It is as safe and effective as the conventional laparoscopy and represents a reasonable alternate to abdominal approach. Procedures that are technically challenging with the conventional laparoscopy can be performed with robotic assistance. It has advantages of improved visualization and Endowrist™ movements allowing precise suturing. This helps to overcome the limitations of laparoscopy, especially in complicated procedures, and may shorten the steep learning curve in minimal invasive surgery. Randomized controlled trials looking at both short- and long-term outcomes are warranted to strengthen the role of robotic surgery in the field of reproductive surgery.

Lipoic acid decreases peritoneal adhesion formation in a rat uterine scar model

OBJECTIVE

To investigate the effects of lipoic acid in the prevention of postoperative pelvic adhesions by a visual scoring system and immunohistochemistry in a rat uterine horn model with full thickness injury.

MATERIAL AND METHODS

Twenty-eight female Wistar albino rats were randomised into four groups: uterine trauma control, 15 days and 30 days, and uterine trauma + lipoic acid, 15 days and 30 days. A full thickness defect was established by incising a segment of approximately 1.0 cm in length from each uterine horn, leaving the mesometrium intact. Extension and severity of the adhesions in each group were scored by a visual scoring system and evaluated immunohistochemically.

RESULTS

Adhesion scores were 2.00±0.81, 2.14±0.69 0.71±0.75, and 0.85±0.69 for extent and 2.28±0.48, 2.14±0.69, 0.85±0.69, and 1.14±0.69 for severity in Groups 1, 2, 3 and 4, respectively. Adhesion extent and severity were significantly less for groups treated by lipoic acid but no difference was observed between long and short administration. Both Vitronectin and u-PAR staining were significantly increased in treatment groups when compared to the control group.

CONCLUSION

Lipoic acid was found to be effective in reducing postoperative adhesion formation in a rat model.

Warm, humidified carbon dioxide gas insufflation for laparoscopic appendicectomy in children: a double-blinded randomized controlled trial

OBJECTIVE

To investigate clinical benefits of warm, humidified carbon dioxide (CO(2)) insufflation for acute laparoscopic appendicectomy on postoperative pain and recovery in children (age 8-14 years).

BACKGROUND

Conventional CO(2) insufflation leads to desiccation-related peritoneal inflammation and injury, which is preventable with warm, humidified CO2 gas. We hypothesized that reduced peritoneal desiccation would improve patient-centered outcomes in children after laparoscopic appendicectomy.

METHOD

A double-blinded, randomized controlled trial was conducted. Intervention group participants received warm (37°C), humidified (98% relative humidity) CO(2) gas insufflation, whereas control participants received standard room temperature (20°C) gas with 0% relative humidity. Perioperative analgesia and anesthesia were standardized. Postoperative opiate usage was converted to morphine equivalent daily dosages (MEDD) for comparison, and pain intensity at rest and on moving was rated by participants using visual analog scales. Postoperative recovery and return to normal activities was assessed using a questionnaire on day 10.

RESULTS

Between February 2010 and March 2011, a total of 190 participants were randomized. Both intervention and control groups were matched at baseline. Postoperative MEDD and pain scores were also similar. There were no differences in postoperative recovery parameters.

CONCLUSIONS

Warm, humidified CO(2) insufflation for acute laparoscopic appendicectomy has no short-term clinical benefits on postoperative outcomes in pediatric patients (ClinicalTrials.gov trial identifying code: NCT01027455).

Bladder Injury During Cesarean Delivery

Cesarean section is the most common surgery performed in the United States with over 30% of deliveries occurring via this route. This number is likely to increase given decreasing rates of vaginal birth after cesarean section (VBAC) and primary cesarean delivery on maternal request, which carries the inherent risk for intraoperative complications. Urologic injury is the most common injury at the time of either obstetric or gynecologic surgery, with the bladder being the most frequent organ damaged. Risk factors for bladder injury during cesarean section include previous cesarean delivery, adhesions, emergent cesarean delivery, and cesarean section performed at the time of the second stage of labor. Fortunately, most bladder injuries are recognized at the time of surgery, which is important, as quick recognition and repair are associated with a significant reduction in patient mortality. Although cesarean delivery is a cornerstone of obstetrics, there is a paucity of data in the literature either supporting or refuting specific techniques that are performed today. There is evidence to support double-layer closure of the hysterotomy, the routine use of adhesive barriers, and performing a Pfannenstiel skin incision versus a vertical midline subumbilical incision to decrease the risk for bladder injury during cesarean section. There is also no evidence that supports the creation of a bladder flap, although routinely performed during cesarean section, as a method to reduce the risk of bladder injury. Finally, more research is needed to determine if indwelling catheterization, exteriorization of the uterus, and methods to extend hysterotomy incision lead to bladder injury.

Radiation-induced bowel complications: laparoscopic versus open staging of gynecologic malignancy

PURPOSE

To evaluate whether the type of surgical approach used to stage gynecologic malignancies influences the risk of developing nonrectal radiation-induced intestinal injury (NRRIII) in patients who subsequently receive adjuvant radiotherapy.

METHODS

A prospectively entered database was queried for all women with either primary or recurrent gynecologic malignancy who underwent external-beam radiation therapy ± brachytherapy and who had prior abdominopelvic surgery at our institution. Univariate and multivariate analysis of variables potentially affecting the risk of developing significant bowel toxicity (defined as grade 2 or more according to Radiation Therapy Oncology Group scoring) were performed.

RESULTS

One hundred fifty-nine patients were identified. The site of primary tumor was the cervix in 61 (38%) patients and the corpus uteri in the remaining patients (98, 62%). Treatment was delivered with a combination of external-beam and intracavitary irradiation to 50 (31.4%) patients, and 109 (68.6%) patients received only external-beam irradiation. Staging procedures were performed by open surgery in 93 (58.5%) patients, whereas laparoscopy was the surgical approach of choice in 66 (41.5%) women. Fifteen patients (9.4%) developed grade 2 or greater NRRIII, at median latency of 10 months (range 3-64 months); six were diagnosed as grade 3 complications requiring surgery, and three developed grade 4 complication. Multiple regression revealed an independent protective effect of pretreatment laparoscopic staging against the risk of developing both grade ≥2 and grade ≥3 NRRIII.

CONCLUSIONS

Notwithstanding potential limitations of nonrandomized study design, our findings suggest that the benefits of minimal-access surgery used to perform staging procedures may translate into long-term reduction in radiation-induced bowel injury.

Chronic pelvic pain: cause, diagnosis and therapy from a gynaecologist's and an endoscopist's point of view

Chronic pelvic pain is a significant problem in gynaecology, as the causes often cannot be found by a general gynaecologic examination. Subsequently, the women often consult various physicians without a right and precise diagnosis being made. Thus, it is necessary to find a possibility for how to help these women quickly and effectively. As in nearly 1/3 of the cases the reason for the pain is an endometriosis and in another third, adhesions are responsible for the pain, the biggest part can be diagnosed and treated by laparoscopy. If laparoscopically no reason can be found, it is advisable to send the patient to a psychosomatic physician, who then can start a correspondingly differentiated diagnosis and therapy.