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Schaefer SD, Alkatout I, Dornhoefer N, Herrmann J, Klapdor R, Meinhold-Heerlein I, Meszaros J, Mustea A, Oppelt P, Wallwiener M, Kraemer B. Prevention of peritoneal adhesions after gynecological surgery: a systematic review. Arch Gynecol Obstet 2024; 310:655-672. [PMID: 38878233 PMCID: PMC11258159 DOI: 10.1007/s00404-024-07584-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 06/03/2024] [Indexed: 07/19/2024]
Abstract
IMPORTANCE The formation of adhesions after gynecological surgery not only has detrimental impacts on those affected, including pain, obstruction, and infertility, but also imposes a high economic burden on healthcare systems worldwide. OBJECTIVE The aim of this review was to evaluate the adhesion prevention potential of all currently available adhesion barriers for gynecological surgery. EVIDENCE ACQUISITION We systematically searched MEDLINE and CENTRAL databases for randomized controlled trials (RCTs) on the use of adhesion barriers as compared with peritoneal irrigation or no treatment in gynecological surgery. Only RCTs with second-look surgery to evaluate adhesions in the pelvic/abdominal (but not intrauterine) cavity were included. RESULTS We included 45 RCTs with a total of 4,120 patients examining a total of 10 unique types of barriers in second-look gynecological surgery. While RCTs on oxidized regenerated cellulose (significant improvement in 6 of 14 trials), polyethylene glycol with/without other agents (4/10), hyaluronic acid and hyaluronate + carboxymethylcellulose (7/10), icodextrin (1/3), dextran (0/3), fibrin-containing agents (1/2), expanded polytetrafluoroethylene (1/1), N,O-carboxymethylchitosan (0/1), and modified starch (1/1) overall showed inconsistent findings, results for expanded polytetrafluoroethylene, hyaluronic acid, and modified starch yielded the greatest improvements regarding adhesion reduction at 75%, 0-67%, and 85%, respectively. CONCLUSIONS AND RELEVANCE Best results for adhesion prevention were reported after applying Gore-Tex Surgical Membrane, hyaluronic acid, and 4DryField®. As Gore-Tex Surgical Membrane is nonabsorbable, it is associated with a greater risk of new adhesion formation due to second-look surgery to remove the product. 4DryField® yielded the greatest improvement in adhesion score compared to all other barrier agents (85%). For better comparability, future studies should use standardized scores and put more emphasis on patient-reported outcome measures, such as pain and infertility.
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Affiliation(s)
- Sebastian D Schaefer
- Department of Gynecology and Obstetrics, Clemenshospital Muenster, Münster, Germany.
| | - Ibrahim Alkatout
- Department of Gynecology and Obstetrics, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Nadja Dornhoefer
- Department of Gynecology, University Hospital Leipzig, Leipzig, Germany
| | - Joerg Herrmann
- Department of Gynecology and Obstetrics, Weimar Hospital, Weimar, Germany
| | - Ruediger Klapdor
- Department of Gynecology and Obstetrics, Albertinen Hospital Hamburg, Hamburg, Germany
| | - Ivo Meinhold-Heerlein
- Department of Gynecology and Obstetrics, University Hospital Giessen, Giessen, Germany
| | - Jozsef Meszaros
- Department of Gynecology, Obstetrics and Reproductive Medicine, University Hospital Magdeburg, Magdeburg, Germany
| | - Alexander Mustea
- Department of Gynecology and Gynecological Oncology, University Hospital Bonn, Bonn, Germany
| | - Peter Oppelt
- Department of Gynecology, Obstetrics and Gynecological Endocrinology, Johannes Kepler University, Kepler University Hospital Linz, Linz, Austria
| | - Markus Wallwiener
- Department of Gynecology and Obstetrics, University Hospital Halle, Halle, Germany
| | - Bernhard Kraemer
- Department of Women's Health, University Hospital Tuebingen, Tübingen, Germany
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Güler O, Hatırnaz Ş, Sparic R, Basbug A, Erol O, Kalkan Ü, Ulubaşoğlu H, Trojano G, Ürkmez SS, Tinelli A. Long-term obstetric, perinatal, and surgical complications in singleton pregnancies following previous cesarean myomectomy: a retrospective multicentric study. Front Surg 2024; 11:1430439. [PMID: 39149134 PMCID: PMC11324572 DOI: 10.3389/fsurg.2024.1430439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 07/16/2024] [Indexed: 08/17/2024] Open
Abstract
Objectives The safety of cesarean myomectomy has been proven by previous studies. Our study aimed to reveal the long-term perinatal, obstetric, and surgical outcomes of cesarean myomectomy (CM) by comparing different CM techniques. Material and methods This retrospective multicentric case-control study involved 7 hospitals and included 226 singleton pregnancies that underwent repeated cesarean section (CS) between 2015 and 2020. Among these pregnancies, 113 of 226 cases had CM (Group A), and 113 had only CS (Group B). Of the 113 cases in which CM was performed, 58 underwent endometrial myomectomy (EM) (Subgroup A1) and 55 underwent serosal myomectomy (SM) (Subgroup A2). The groups were compared in terms of obstetric, perinatal, and surgical outcomes, and fibroid recurrence, myomectomy scar healing rate, and adhesion formation were noted. Results There was no significant difference between the groups in terms of maternal age, body mass index, gravidity, parity, and fibroid diameter in previous CS (p > 0.05). In the perinatal and obstetric evaluation of the groups, there was no significant difference between the groups in terms of neonatal weight, Apgar score, fetal growth restriction, preterm premature rupture of membranes, preterm delivery, hypertension in pregnancy, and diabetes mellitus (p > 0.05). The fibroid recurrence rate was 28.3%, and the myomectomy scar good healing rate was 99.1%. There was no difference between the groups in terms of CS duration, preoperative and postoperative hemoglobin levels, perioperative blood transfusion rates, febrile morbidity, and prolonged hospitalization (p > 0.05). In terms of adhesion formation, although the adhesion rate of the SM group was higher than that of the EM group, no statistically significant difference was detected between the groups. Conclusion This study showed that in pregnancies following CM, obstetrical, perinatal, and surgical outcomes were unaffected. Obstetricians can safely use CM, either the trans-endometrial or serosal technique, as it is a safe and effective method with long-term results.
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Affiliation(s)
- Oğuz Güler
- Department of Obstetrics and Gynecology, Private Asya Hospital, Istanbul, Turkey
| | - Şafak Hatırnaz
- Department of Obstetrics and Gynecology, Mediliv Medical Center, Samsun, Turkey
| | - Radmila Sparic
- Clinic for Obstetrics and Gynecology, University Clinical Center of Serbia, Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Alper Basbug
- Department of Obstetrics and Gynecology, School of Medicine, Duzce University, Duzce, Turkey
| | - Onur Erol
- Department of Obstetrics and Gynecology, Memorial Antalya Hospital, Antalya, Turkey
| | - Üzeyir Kalkan
- Department of Obstetrics and Gynecology, Koç University Hospital, Istanbul, Turkey
| | - Hasan Ulubaşoğlu
- Department of Obstetrics and Gynecology, Ankara Bilkent City Hospital, Ankara, Turkey
| | - Giuseppe Trojano
- Department of Obstetrics and Gynecology, Madonna Delle Grazie Hospital, Matera, Italy
| | - Sebati Sinan Ürkmez
- Department of Medical Biochemistry, Faculty of Medicine, Ondokuz Mayıs University, Samsun, Turkiye
| | - Andrea Tinelli
- Department of Obstetrics and Gynecology, and CERICSAL (CEntro di RIcerca Clinico SALentino), "Veris delli Ponti Hospital", Scorrano, Italy
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Tinelli A, Kosmas I, Medvediev MV, Malvasi A, Morciano A, Sparić R, Mynbaev OA. Myomectomy in adult women of reproductive age: a propensity score-matched study for pregnancy rates. Arch Gynecol Obstet 2023; 308:1351-1360. [PMID: 37450263 DOI: 10.1007/s00404-023-07135-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 06/29/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE To study whether it is better to perform or not a myomectomy, in terms of surgical and reproductive outcomes in patients of advanced reproductive age, by an observational prospective study in university-affiliated and Community Hospitals. MATERIALS AND METHODS 40 years and older patients affected by non-submucous symptomatic uterine fibroids and desiring future fertility were enrolled and treated by laparoscopic intracapsular myomectomy by (LIM) or by open laparotomy (OIM), or by a non-surgical management as control group, while attempting to conceive. The primary outcome measures were fibroid characteristics, pre- and post-surgical parameters, pregnancy achievement; the secondary outcome measures were the spontaneous or ART pregnancy outcomes, eventual week of abortion and type of delivery. Propensity scores have been calculated with logistic regression for binary and continuous variables. RESULTS 202 patients completed the study: 112 operated by LIM, 40 by OIM and 50 patients as control group. Patients undergoing OIM have a worse surgical outcome than LIM. No difference was seen in pregnancy either after myomectomy or control group during follow-up. In the LIM group, there were 44 pregnancies (39.2%), and in the OIM group, there were 9 (22.5%) and 16 in the control group (32%). The weeks of delivery were statistically greater for the control group versus the surgical groups, with no difference in Apgar score between the 3 groups. CONCLUSION Patients aged over 40 years did not show substantial differences in reproductive outcome, whether operated or not. Myomectomy in over 40-year-old patients has no detrimental effect on future pregnancy rates and over when compared to expectant management.
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Affiliation(s)
- Andrea Tinelli
- Department of Obstetrics and Gynecology and CERICSAL (Centro di RIcerca Clinico Salentino), "Veris Delli Ponti Hospital", Scorrano, Via Giuseppina Delli Ponti, 73020, Lecce, Italy.
| | - Ioannis Kosmas
- Department of Obstetrics and Gynecology, Ioannina State General Hospital G. Chatzikosta, Ioannina, Greece
| | - Mykhailo V Medvediev
- Department of Obstetrics and Gynecology, Dnipro State Medical University, Dnipro, 49044, Ukraine
| | - Antonio Malvasi
- Department of Biomedical Sciences and Human Oncology, Unit of Obstetrics and Gynecology, University of Bari, Bari, Italy
| | - Andrea Morciano
- Department of Gynaecology and Obstetrics, Pia Fondazione "Card. G. Panico", Tricase, Lecce, Italy
| | - Radmila Sparić
- Clinic for Gynecology and Obstetrics, University Clinical Centre of Serbia, Belgrade, Serbia
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Ospan A Mynbaev
- Moscow Institute of Physics and Technology, 141701, Dolgoprudny, Russia
- New European Surgical Academy, Berlin, Germany
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Tanos V, Lee SYC, Alexander K, Pavlou A, Balanos I, Sandhu A. Laparoscopic myomectomy complications: META analysis on RCTs and review of large cohort studies. Eur J Obstet Gynecol Reprod Biol 2023; 287:109-118. [PMID: 37302233 DOI: 10.1016/j.ejogrb.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 05/16/2023] [Accepted: 06/05/2023] [Indexed: 06/13/2023]
Abstract
Complications of myomectomy are generally rare and highly dependent on the surgeons' skills and selection of patients. Haemorrhage, direct injury, post-operative pain and fever present as intra and peri-operative complications, while adhesions are considered late complications. 21 RCTs and 15 meta-analyses have been conducted to date, with the last comprehensive meta-analysis being published in 2009. The main disadvantage of the previous meta-analysis included incomplete selection of studies, inclusion of studies with small sample sizes, and major heterogeneity of methods used between studies. The aim of this meta-analysis comparing laparoscopic myomectomy (LMy) to open conservative myomectomy is to provide an updated review of the type, frequency and severity of complications. These results can direct teaching efforts and guidelines and give updated advice to gynaecologists. A literature search was conducted on PubMed and Google scholar for RCTs on this topic. 276 studies were identified and 19 RCTs ultimately met the criteria for inclusion in the meta-analysis and subsequent heterogeneity assessment. The results showed that laparoscopic myomectomy has a more favourable outcome with regards to several complications when compared with laparotomy. Laparoscopic myomectomy is significantly associated with lower Hg drop (WMD = -0.48, 95% CI [-0.89, -0.07], p = 0.02179); lower incidence of post-operative fever (RR = 0.43, 95% CI [0.29, 0.64], p < 0.001); lower levels of pain at 48Hrs post-op (WMD = -0.88, 95% CI [-1.63, -0.014], p = 0.02020) and decreased analgesia requests (RR = 0.49, 95% CI [0.37, 0.64], p < 0.0001). Prophylaxis use was associated with less adhesions (RR = 0.064, 95% CI [0.44, 0.92], p = 0.01), although not enough data was available to draw conclusions regarding specific prophylactic agents. No differences were found between LMy and laparotomy for blood loss (WMD = -13.6494, 95% CI [-44.48, 17.18], p = 0.38553) or pain at 24Hrs post-op (WMD = -0.19, 95% CI [-0.55, 0.18], p = 0.32136). These findings support previously published meta-analyses. Given the right indications of the surgery and training of the surgeon, LMy seems to be most preferable to laparotomy in achieving a better clinical result with fewer complications.
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Affiliation(s)
- Vasilios Tanos
- Department of Obstetrics and Gynecology, Aretaeio Hospital, 2024 Nicosia, Cyprus; Department of Basic and Clinical Sciences, University of Nicosia Medical School, Nicosia, Cyprus.
| | - Sum-Yu C Lee
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, Nicosia, Cyprus.
| | - Kyle Alexander
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, Nicosia, Cyprus.
| | - Achilleas Pavlou
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, Nicosia, Cyprus.
| | - Ioannis Balanos
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, Nicosia, Cyprus.
| | - Afreshdeep Sandhu
- Department of Basic and Clinical Sciences, University of Nicosia Medical School, Nicosia, Cyprus.
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Ghobrial S, Ott J, Parry JP. An Overview of Postoperative Intraabdominal Adhesions and Their Role on Female Infertility: A Narrative Review. J Clin Med 2023; 12:jcm12062263. [PMID: 36983263 PMCID: PMC10051311 DOI: 10.3390/jcm12062263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023] Open
Abstract
Postoperative intraabdominal adhesions can occur after more than 90% of gynecologic surgeries. They not only cause chronic pelvic pain and small bowel obstruction, but are also one of the main reasons for infertility. Adhesions are not only a burden for the affected patients, but are also a burden for the healthcare system, since the treatment of adhesion-associated complications costs a considerable amount of money. The gold standard for the diagnosis of adhesions is by laparoscopy, although other methods, such as transvaginal hydro-laparoscopy, are being discussed as better alternatives. Ideally, adhesions are avoided inherently, by operating carefully and by using microsurgical principles. If this is not possible, gel barriers have been shown to be successful in reducing postoperative adhesions.
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Affiliation(s)
- Stefan Ghobrial
- Clinical Division of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Johannes Ott
- Clinical Division of Gynecologic Endocrinology and Reproductive Medicine, Medical University of Vienna, 1090 Vienna, Austria
- Correspondence: ; Tel.: +43-1-40400-28130
| | - John Preston Parry
- Parryscope and Positive Steps Fertility, Madison, Madison, WI 39110, USA
- Department of Obstetrics and Gynecology, University of Mississippi Medical Center, Jackson, MS 39216, USA
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Petrozza JC, Fitz V, Bhagavath B, Carugno J, Kwal J, Mikhail E, Nash M, Barakzai SK, Roque DR, Bregar AJ, Findley J, Neblett M, Flyckt R, Khan Z, Lindheim SR. Surgical approach to 4 different reproductive pathologies by 3 different gynecologic subspecialties: more similarities or differences? Fertil Steril 2023; 119:377-389. [PMID: 36574916 DOI: 10.1016/j.fertnstert.2022.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 12/19/2022] [Indexed: 12/25/2022]
Affiliation(s)
- John C Petrozza
- Division of Reproductive Medicine and IVF, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Victoria Fitz
- Division of Reproductive Medicine and IVF, Department of Obstetrics and Gynecology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Bala Bhagavath
- Department of Obstetrics and Gynecology, University of Wisconsin, Madison, Wisconsin
| | - Jose Carugno
- Obstetrics, Gynecology and Reproductive Sciences Department, Minimally Invasive Gynecology Unit, University of Miami, Miller School of Medicine, Miami, Florida
| | - Jaclyn Kwal
- Obstetrics, Gynecology and Reproductive Sciences Department, Minimally Invasive Gynecology Unit, University of Miami, Miller School of Medicine, Miami, Florida
| | - Emad Mikhail
- Division of Gynecologic Subspecialties, Department of Obstetrics and Gynecology, University of South Florida Health Morsani College of Medicine, Tampa, Florida
| | - Moawad Nash
- Division of Minimally Invasive Gynecologic Surgery, Department of Obstetrics & Gynecology, University of Florida College of Medicine, Gainesville, Florida
| | - Syem K Barakzai
- Division of Gynecologic Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dario R Roque
- Division of Gynecologic Oncology, Feinberg School of Medicine, Northwestern University
| | - Amy J Bregar
- Division of Gynecologic Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joseph Findley
- Department of Obstetrics and Gynecology, University Hospitals of Cleveland, Beachwood, Ohio
| | - Michael Neblett
- Division of Reproductive Endocrinology and Infertility, Mayo Clinic, Rochester, Minnesota
| | - Rebecca Flyckt
- Department of Obstetrics and Gynecology, University Hospitals of Cleveland, Beachwood, Ohio
| | - Zaraq Khan
- Division of Reproductive Endocrinology and Infertility, Mayo Clinic, Rochester, Minnesota
| | - Steven R Lindheim
- Department of Obstetrics and Gynecology, Boonshoft School of Medicine, Wright State University, Dayton, Ohio; Department of Obstetrics and Gynecology, University of Central Florida, Orlando, Florida; Center for Reproductive Medicine Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, People's Republic of China.
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7
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Mercorio A, Della Corte L, Boccia D, Palumbo M, Reppuccia S, Buonfantino C, Cuomo L, Borgo M, Zitiello A, De Angelis MC, Laganà AS, Bifulco G, Giampaolino P. Myomectomy in infertile women: More harm than good? Front Surg 2023; 10:1151901. [PMID: 37139194 PMCID: PMC10150951 DOI: 10.3389/fsurg.2023.1151901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Accepted: 03/22/2023] [Indexed: 05/05/2023] Open
Abstract
Adhesion formation following gynecological surgery remains a challenge. The adoption of minimally invasive surgical approaches, such as conventional or robotic-assisted laparoscopy combined with meticulous microsurgical principles and the application of adhesion-reducing substances, is able to reduce the risk of de novo adhesion formation but do not eliminate it entirely. Myomectomy is the most adhesiogenic surgical procedure and postoperative adhesions can have a significant impact on the ability to conceive. Therefore, when surgery is performed as infertility treatment, attention should be paid to whether the benefits outweigh the risks. Among several factors, the size and the location of fibroids are the most accountable factors in terms of adhesion development and post surgical infertility; therefore, the search for effective strategies against adhesion formation in this setting is of paramount importance. The purpose of this review is to evaluate the incidence and factors of adhesion formation and the best preventive measures current available.
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Affiliation(s)
- Antonio Mercorio
- Department of Public Health, University of Naples Federico II, Naples, Italy
- Correspondence: Antonio Mercorio
| | - Luigi Della Corte
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Dominga Boccia
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Mario Palumbo
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Sabrina Reppuccia
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Cira Buonfantino
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Lara Cuomo
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Maria Borgo
- Department of Public Health, University of Naples Federico II, Naples, Italy
| | - Antonio Zitiello
- Department of Woman Mother Child, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Antonio Simone Laganà
- Unit of Gynecologic Oncology, ARNAS “Civico-Di Cristina-Benfratelli”, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy
| | - Giuseppe Bifulco
- Department of Public Health, University of Naples Federico II, Naples, Italy
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Imaralu J, Ani F, Ayegbusi E, Oguntade F, Nwankpa C, Olaleye B. Peritoneal adhesion findings during laparoscopy: Determinants of occurrence and effect of severity on operative outcomes in a Nigerian Hospital. Ann Afr Med 2023; 22:145-152. [PMID: 37026194 DOI: 10.4103/aam.aam_43_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2023] Open
Abstract
Context Peritoneal adhesions unlike other immediately recognizable complications of the surgery may produce long-term consequences, which include infertility and intestinal obstruction. Aims The study aimed to determine the prevalence, the determinants, and the outcomes of laparoscopic surgery associated with intraperitoneal adhesion findings. Settings and Design This was a retrospective observational study. Materials and Methods The study included all laparoscopic gynecological surgeries done between January 2017 and December 2021. Adhesion severity was graded, using the peritoneal adhesion index (PAI), by Coccolini et al. Statistical Analysis The data were analyzed using the SPSS version 21.0. Binary logistic regression was used to assess the factors associated with adhesion finding during laparoscopy. Results There were 158 laparoscopic surgeries with 26.6% prevalence of peritoneal adhesions. The prevalence of adhesions among women with previous surgery was 72.7%. Previous peritoneal surgery was a significant determinant of occurrence of adhesions (odds ratio = 8.291, 95% confidence interval [CI] = 4.464-15.397, P < 0.001), and such patients had significantly (P = 0.025, 95% CI = 0.408-5.704) more severe adhesions (PAI = 11.16 ± 3.94) than those without prior surgery (PAI = 8.10 ± 3.14). Abdominal myomectomy (PAI = 13.09 ± 2.95) was the most important primary surgical determinant of adhesion formation. There was no significant relationship between adhesion occurrence and conversion to laparotomy (P = 0.121) or mean duration of surgery (P = 0.962). Greater adhesion severity was, however, observed in individuals with operative blood loss <100 ml (PAI = 11.73 ± 3.56, P = 0.003) and those hospitalized for ≤2 days (PAI = 11.12 ± 3.81, P = 0.022). Conclusion The prevalence of postoperative adhesions during laparoscopy in our center is comparable to what has been earlier reported. Abdominal myomectomy is associated with the greatest risk and severity of adhesions. Laparoscopy in patients with more severe adhesions resulted in less blood loss and shorter duration of hospitalization, suggesting an association of better outcomes with a cautious approach to adhesions.
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Waldron MG, Judge C, Farina L, O’Shaughnessy A, O’Halloran M. Barrier materials for prevention of surgical adhesions: systematic review. BJS Open 2022; 6:6602139. [PMID: 35661871 PMCID: PMC9167938 DOI: 10.1093/bjsopen/zrac075] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 04/07/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Postoperative surgical adhesions constitute a major health burden internationally. A wide range of materials have been evaluated, but despite constructive efforts and the obvious necessity, there remains no specific barrier widely utilized to prevent postoperative adhesion formation. The aim of this study was to highlight and characterize materials used for prevention of postoperative surgical adhesions in both animal and human studies. METHODS A systematic review was performed of all original research articles presenting data related to the prevention of postoperative adhesions using a barrier agent. All available observational studies and randomized trials using animal models or human participants were included, with no restrictions related to type of surgery. PubMed and Embase databases were searched using key terms from inception to August 2019. Standardized data collection forms were used to extract details for each study and assess desirable characteristics of each barrier and success in animal and/or human studies. RESULTS A total of 185 articles were identified for inclusion in the review, with a total of 67 unique adhesion barrier agents (37 natural and 30 synthetic materials). Desirable barrier characteristics of an ideal barrier were identified on review of the literature. Ten barriers achieved the primary outcome of reducing the incidence of postoperative adhesions in animal studies followed with positive outputs in human participants. A further 48 materials had successful results from animal studies, but with no human study performed to date. DISCUSSION Multiple barriers showed promise in animal studies, with several progressing to success, and fulfilment of desirable qualities, in human trials. No barrier is currently utilized commonly worldwide, but potential barriers have been identified to reduce the burden of postoperative adhesions and associated sequelae.
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Affiliation(s)
- Michael Gerard Waldron
- Correspondence to: Michael Gerard Waldron, Translational Medical Device Lab, Galway University Hospital, Newcastle Road, Galway, Ireland H91YR71 (e-mail: )
| | - Conor Judge
- Translational Medical Device Laboratory, National University of Ireland Galway, Galway, Ireland
| | - Laura Farina
- Translational Medical Device Laboratory, National University of Ireland Galway, Galway, Ireland
| | - Aoife O’Shaughnessy
- Translational Medical Device Laboratory, National University of Ireland Galway, Galway, Ireland
| | - Martin O’Halloran
- Translational Medical Device Laboratory, National University of Ireland Galway, Galway, Ireland
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Surgicel for Prevention of Postoperative Adhesions in Laparoscopic Myomectomy: A Propensity Score-Matching Analysis. J Gynecol Surg 2022. [DOI: 10.1089/gyn.2021.0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Borghese G, Raffone A, Raimondo D, Saccone G, Travaglino A, Degli Esposti E, Mastronardi M, Salucci P, Zullo F, Seracchioli R. Adhesion barriers in laparoscopic myomectomy: Evidence from randomized clinical trials. Int J Gynaecol Obstet 2021; 152:308-320. [PMID: 33237574 DOI: 10.1002/ijgo.13495] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 10/07/2020] [Accepted: 11/20/2020] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of different adhesion barriers in the prevention of de novo adhesion development after laparoscopic myomectomy. METHODS A systematic review was performed by searching seven electronic databases for all randomized clinical trials (RCTs) comparing the use of any absorbable adhesion barrier (i.e. intervention group) with either no treatment or placebo (i.e. control group) in the prevention of adhesion development after laparoscopic myomectomy. RESULTS Eight RCTs with a total of 748 participants (392 in the intervention group and 356 in the control group) were included. The assessed adhesion barrier methods were: oxidized regenerated cellulose (ORC) in two studies, auto-crosslinked hyaluronic acid (HA) gel in two studies, 4% icodextrin solution in one study, modified HA and carboxy-methylcellulose in one study, polyethylene glycol ester trilysine amine solution plus a borate buffer solution in one study, and polyethylene glycol amine plus dextran aldehyde polymers in another study. CONCLUSION Adhesion barrier methods showing the most promising results were: ORC, auto-crosslinked HA gel, and polyethylene glycol amine plus dextran aldehyde polymers.
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Affiliation(s)
- Giulia Borghese
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), IRCCS S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Antonio Raffone
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Diego Raimondo
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), IRCCS S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Gabriele Saccone
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Antonio Travaglino
- Pathology Unit, Department of Advanced Biomedical Sciences, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Eugenia Degli Esposti
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), IRCCS S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Manuela Mastronardi
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), IRCCS S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Paolo Salucci
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), IRCCS S. Orsola Hospital, University of Bologna, Bologna, Italy
| | - Fulvio Zullo
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Renato Seracchioli
- Gynecology and Human Reproduction Physiopathology, Dipartimento di Scienze Mediche e Chirurgiche (DIMEC), IRCCS S. Orsola Hospital, University of Bologna, Bologna, Italy
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12
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Horii T, Tsujimoto H, Kageyama S, Yoshida T, Kobayashi K, Takamori H, Minato H, Ueda J, Hagiwara A, Ichikawa H, Kawauchi A. The usefulness of re-attachability of anti-adhesive cross-linked gelatin film and the required physical and biological properties. Biomed Mater Eng 2020; 31:351-360. [PMID: 33252061 DOI: 10.3233/bme-206009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND To overcome the unfavorable issues associated with conventional anti-adhesive HA/CMC film, we developed an anti-adhesive thermally cross-linked gelatin film. OBJECTIVE We tried to clarify the re-attachability of the film and the required properties concerning the film thickness, stiffness and anti-adhesion effect. METHODS To determine the optimal thickness, 5 kinds of the thickness of gelatin film and the conventional film were analyzed by the tensile test, shearing test, buckling test and tissue injury test. Finally, using the optimal film thickness, we tried to clarify the anti-adhesion effect of the reattached film. RESULTS The tensile and shearing test showed gelatin films ≥30 μm thick had greater tensile strength and a smaller number of film fractures, than the conventional film. The buckling and tissue injury test showed gelatin films ≥60 μm thick had higher buckling strength and worse injury scores than the conventional film. The anti-adhesive effect of re-attached gelatin film using optimal thickness (30-40 μm) found the anti-adhesion score was significantly better than that of the control. CONCLUSIONS Provided it has an optimal thickness, gelatin film can be reattached with enough physical strength not to tear, safety stiffness not to induce tissue injury, and a sufficient anti-adhesion effect.
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Affiliation(s)
- Tsunehito Horii
- Department of Urology, Shiga University of Medical Science, Otsu, Shiga, Japan.,Division of Medical Life Systems, Department of Life and Medical Science, Doshisha University, Kyotanabe, Kyoto, Japan
| | - Hiroyuki Tsujimoto
- Department of Urology, Shiga University of Medical Science, Otsu, Shiga, Japan.,Division of Medical Life Systems, Department of Life and Medical Science, Doshisha University, Kyotanabe, Kyoto, Japan
| | - Susumu Kageyama
- Department of Urology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Tetsuya Yoshida
- Department of Urology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Kenichi Kobayashi
- Department of Urology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Hideki Takamori
- Division of Medical Life Systems, Department of Life and Medical Science, Doshisha University, Kyotanabe, Kyoto, Japan
| | - Hiroshi Minato
- Department of Surgery, Yawata Central Hospital, Yawatagotanda, Yawata, Kyoto, Japan
| | - Jo Ueda
- Department of Gastroenterology, Ueda Clinic, Kitanakaieshita, Takanosu, Akita, Japan
| | - Akeo Hagiwara
- Department of Urology, Shiga University of Medical Science, Otsu, Shiga, Japan.,Division of Medical Life Systems, Department of Life and Medical Science, Doshisha University, Kyotanabe, Kyoto, Japan
| | - Hiroshi Ichikawa
- Division of Medical Life Systems, Department of Life and Medical Science, Doshisha University, Kyotanabe, Kyoto, Japan
| | - Akihiro Kawauchi
- Department of Urology, Shiga University of Medical Science, Otsu, Shiga, Japan
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Herrmann A, Torres-de la Roche LA, Krentel H, Cezar C, de Wilde MS, Devassy R, De Wilde RL. Adhesions after Laparoscopic Myomectomy: Incidence, Risk Factors, Complications, and Prevention. Gynecol Minim Invasive Ther 2020; 9:190-197. [PMID: 33312861 PMCID: PMC7713662 DOI: 10.4103/gmit.gmit_87_20] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 07/10/2020] [Accepted: 07/10/2020] [Indexed: 12/23/2022] Open
Abstract
Uterine fibroids or uterine myomas are one of the most common benign diseases of the uterus. Symptoms associated with myomas can make surgical removal of myomas necessary. Besides the traditional abdominal route, laparoscopic myomectomy (LM) has gained more acceptances over the last few decades, and it is anticipated that laparoscopy is associated with lower adhesion development. Therefore, we conducted this review to analyze the evidence on adhesions after LM. The PubMed database was searched using the search terms “myomectomy” alone and in combination with “adhesions,” “infertility OR fertility outcome,” and “laparoscopy” among articles published in English and German. Although the well-known advantages of laparoscopy, for example, less pain, less blood loss, or shorter hospital stay, myomectomy belongs to high-risk operations concerning adhesion formation, with at least every fifth patient developing postsurgical adhesions. In laparoscopic surgery, surgeons´ experience as well tissue trauma, due to desiccation and hypoxia, are the underlying mechanisms leading to adhesion formation. Incisions of the posterior uterus may be associated with a higher rate of adhesions compared to anterior or fundal incisions. Adhesions can be associated with severe complications such as small bowel obstruction, chronic pelvic pain, complications in further operations, or impaired fertility. Tissue trauma and the experience of the surgeon in laparoscopic surgery are most of the influencing factors for adhesion formation after myomectomy. Therefore, every surgeon should adopt strategies to reduce adhesion development in daily routine, especially when it conducted to preserve or restore fertility.
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Affiliation(s)
- Anja Herrmann
- University Hospital for Gynecology Pius Hospital, University of Oldenburg, Germany
| | | | - Harald Krentel
- University Hospital for Gynecology Pius Hospital, University of Oldenburg, Germany
| | - Cristina Cezar
- University Hospital for Gynecology Pius Hospital, University of Oldenburg, Germany
| | - Maya Sophie de Wilde
- University Hospital for Gynecology Pius Hospital, University of Oldenburg, Germany
| | - Rajesh Devassy
- University Hospital for Gynecology Pius Hospital, University of Oldenburg, Germany
| | - Rudy Leon De Wilde
- University Hospital for Gynecology Pius Hospital, University of Oldenburg, Germany
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Safety of Use of a Sheet-Type Adhesion Barrier (Interceed ®) During Liver Surgery. World J Surg 2020; 44:4214-4220. [PMID: 32808075 DOI: 10.1007/s00268-020-05743-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Adhesion barriers are increasingly used in hepatobiliary surgery. However, there has been no solid evidence yet in support of their safety. METHODS Incidences of global postoperative morbidities and major abdominal morbidities were compared between 101 consecutive patients who received a sheet-type adhesion barrier (Interceed®) and 134 patients who did not receive any adhesion barriers during hepatectomy. Propensity score (PS) adjustment was used to account for potential bias to receive Interceed. RESULTS In the PS-adjusted population, the incidences of both global postoperative morbidities and major abdominal morbidities showed no significant difference between the Interceed group and the control group (17.9% vs. 17.6%; P = 0.948 and 7.8% vs. 9.1%; P = 0.813, respectively). Multivariate analysis showed that age + 10 years (odds ratio [OR], 1.70; 95% CI, 1.15-2.50; P = 0.007), estimated blood loss + 100 mL (OR, 1.05; 95% CI, 1.01-1.09, P = 0.009), and laparoscopic approach (OR, 0.10; 95% CI, 0.01-0.75; P = 0.026) were independent predictors for global postoperative morbidities and operation time + 1 h (OR, 1.56; 95% CI, 1.23-1.96; P < 0.001) was a risk factor for major abdominal morbidity, while no specific association between the use of Interceed and the risk of postoperative morbidity was observed. CONCLUSIONS Use of Interceed does not increase the risk of postoperative morbidities after hepatectomy.
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15
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Ciebiera M, Łoziński T. The role of magnetic resonance-guided focused ultrasound in fertility-sparing treatment of uterine fibroids-current perspectives. Ecancermedicalscience 2020; 14:1034. [PMID: 32419846 PMCID: PMC7221132 DOI: 10.3332/ecancer.2020.1034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Indexed: 12/16/2022] Open
Abstract
Uterine fibroids (UFs) are the most common benign tumours of the female reproductive system and the most frequent reason for hysterectomy worldwide. UFs are reported in 20%–70% of women of reproductive age depending on a study group. Although most women with UFs are asymptomatic, over 30% of them will present with different symptoms. Abnormal uterine bleeding, pain, pressure and infertility are the most common. Lesions that cause these kinds of symptoms may require medical intervention. Trends in UF treatment change along with patient awareness and the introduction of new methods and techniques. Selecting an appropriate treatment option should be individualised and adjusted to the patient’s expectations as much as possible. This choice will mostly depend on the patient’s age, UF location, the size and number of lesions, severity of symptoms and, most importantly, the patient’s expectations concerning the preservation of fertility. Observations made for the past few years showed an increasing number of pre- and perimenopausal women who wish to preserve their uterus or decline surgery. In line with current trends and demands in medicine, great importance is attached to the development and upgrade of new minimally invasive or noninvasive procedures in UF therapy. Magnetic resonance-guided high-intensity focused ultrasound (MR-HIFU) is not associated with severe destruction of the uterine cavity and walls. For this reason, this method may be considered as a kind of hope in fertility-sparing UF therapy and the data about its use in this indication raises future hope. In this review, we summarise the available data on the use of MR-HIFU as a fertility-sparing method in the treatment of UFs. We also indicate how it could evolve in the future. According to the available data, MR-HIFU is a relatively safe noninvasive method which seems not to deteriorate fertility compared to the pre-treatment status. MR-HIFU may constitute an alternative solution and be chosen in patients who meet the qualification criteria and deny other methods, which also facilitates the use of other treatment options in case the procedure is ineffective. Further randomised studies are necessary to confirm the above information.
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Affiliation(s)
- Michał Ciebiera
- Second Department of Obstetrics and Gynaecology, The Center of Postgraduate Medical Education, Warsaw, Poland.,http://orcid.org/0000-0001-5780-5983
| | - Tomasz Łoziński
- Department of Obstetrics and Gynaecology, Pro-Familia Hospital, Rzeszów, Poland
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16
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Ahmad G, Kim K, Thompson M, Agarwal P, O'Flynn H, Hindocha A, Watson A. Barrier agents for adhesion prevention after gynaecological surgery. Cochrane Database Syst Rev 2020; 3:CD000475. [PMID: 32199406 PMCID: PMC7085418 DOI: 10.1002/14651858.cd000475.pub4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Pelvic adhesions can form secondary to inflammation, endometriosis, or surgical trauma. Strategies to reduce pelvic adhesion formation include placing barrier agents such as oxidised regenerated cellulose, polytetrafluoroethylene, and fibrin or collagen sheets between pelvic structures. OBJECTIVES To evaluate the effects of barrier agents used during pelvic surgery on rates of pain, live birth, and postoperative adhesions in women of reproductive age. SEARCH METHODS We searched the following databases in August 2019: the Cochrane Gynaecology and Fertility (CGF) Specialised Register of Controlled Trials, MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, the Cochrane Central Register of Controlled Trials (CENTRAL), Epistemonikos, and trial registries. We searched reference lists of relevant papers, conference proceedings, and grey literature sources. We contacted pharmaceutical companies for information and handsearched relevant journals and conference abstracts. SELECTION CRITERIA Randomised controlled trials (RCTs) on the use of barrier agents compared with other barrier agents, placebo, or no treatment for prevention of adhesions in women undergoing gynaecological surgery. DATA COLLECTION AND ANALYSIS Three review authors independently assessed trials for eligibility and risk of bias and extracted data. We calculated odds ratios (ORs) or mean differences (MDs) with 95% confidence intervals (CIs) using a fixed-effect model. We assessed the overall quality of the evidence using GRADE (Grades of Recommendation, Assessment, Development and Evaluation) methods. MAIN RESULTS We included 19 RCTs (1316 women). Seven RCTs randomised women; the remainder randomised pelvic organs. Laparoscopy (eight RCTs) and laparotomy (11 RCTs) were the primary surgical techniques. Indications for surgery included myomectomy (seven RCTs), ovarian surgery (five RCTs), pelvic adhesions (five RCTs), endometriosis (one RCT), and mixed gynaecological surgery (one RCT). The sole indication for surgery in three of the RCTs was infertility. Thirteen RCTs reported commercial funding; the rest did not state their source of funding. No studies reported our primary outcomes of pelvic pain and live birth rate. Oxidised regenerated cellulose versus no treatment at laparoscopy or laparotomy (13 RCTs) At second-look laparoscopy, we are uncertain whether oxidised regenerated cellulose at laparoscopy reduced the incidence of de novo adhesions (OR 0.50, 95% CI 0.30 to 0.83, 3 RCTs, 360 participants; I² = 75%; very low-quality evidence) or of re-formed adhesions (OR 0.17, 95% CI 0.07 to 0.41, 3 RCTs, 100 participants; I² = 36%; very low-quality evidence). At second-look laparoscopy, we are uncertain whether oxidised regenerated cellulose affected the incidence of de novo adhesions after laparotomy (OR 0.72, 95% CI 0.42 to 1.25, 1 RCT, 271 participants; very low-quality evidence). However, the incidence of re-formed adhesions may have been reduced in the intervention group (OR 0.38, 95% CI 0.27 to 0.55, 6 RCTs, 554 participants; I² = 41%; low-quality evidence). No studies reported results on pelvic pain, live birth rate, adhesion score, or clinical pregnancy rate. Expanded polytetrafluoroethylene versus oxidised regenerated cellulose at gynaecological surgery (two RCTs) We are uncertain whether expanded polytetrafluoroethylene reduced the incidence of de novo adhesions at second-look laparoscopy (OR 0.93, 95% CI 0.26 to 3.41, 38 participants; very low-quality evidence). We are also uncertain whether expanded polytetrafluoroethylene resulted in a lower adhesion score (out of 11) (MD -3.79, 95% CI -5.12 to -2.46, 62 participants; very low-quality evidence) or a lower risk of re-formed adhesions (OR 0.13, 95% CI 0.02 to 0.80, 23 participants; very low-quality evidence) when compared with oxidised regenerated cellulose. No studies reported results regarding pelvic pain, live birth rate, or clinical pregnancy rate. Collagen membrane with polyethylene glycol and glycerol versus no treatment at gynaecological surgery (one RCT) Evidence suggests that collagen membrane with polyethylene glycol and glycerol may reduce the incidence of adhesions at second-look laparoscopy (OR 0.04, 95% CI 0.00 to 0.77, 47 participants; low-quality evidence). We are uncertain whether collagen membrane with polyethylene glycol and glycerol improved clinical pregnancy rate (OR 5.69, 95% CI 1.38 to 23.48, 39 participants; very low-quality evidence). One study reported adhesion scores but reported them as median scores rather than mean scores (median score 0.8 in the treatment group vs median score 1.2 in the control group) and therefore could not be included in the meta-analysis. The reported P value was 0.230, and no evidence suggests a difference between treatment and control groups. No studies reported results regarding pelvic pain or live birth rate. In total, 15 of the 19 RCTs included in this review reported adverse events. No events directly attributed to adhesion agents were reported. AUTHORS' CONCLUSIONS We found no evidence on the effects of barrier agents used during pelvic surgery on pelvic pain or live birth rate in women of reproductive age because no trial reported these outcomes. It is difficult to draw credible conclusions due to lack of evidence and the low quality of included studies. Given this caveat, low-quality evidence suggests that collagen membrane with polyethylene glycol plus glycerol may be more effective than no treatment in reducing the incidence of adhesion formation following pelvic surgery. Low-quality evidence also shows that oxidised regenerated cellulose may reduce the incidence of re-formation of adhesions when compared with no treatment at laparotomy. It is not possible to draw conclusions on the relative effectiveness of these interventions due to lack of evidence. No adverse events directly attributed to the adhesion agents were reported. The quality of the evidence ranged from very low to moderate. Common limitations were imprecision and poor reporting of study methods. Most studies were commercially funded, and publication bias could not be ruled out.
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Affiliation(s)
- Gaity Ahmad
- Pennine Acute Hospitals NHS TrustDepartment of Obstetrics and GynaecologyManchesterUK
| | - Kyungmin Kim
- Pennine Acute Hospitals NHS TrustManchesterUKM8 5RB
| | | | | | - Helena O'Flynn
- Pennine Acute Hospitals NHS TrustDepartment of Obstetrics and GynaecologyManchesterUK
| | - Akshay Hindocha
- Pennine Acute Hospitals NHS TrustDepartment of Obstetrics and GynaecologyManchesterUK
| | - Andrew Watson
- Tameside & Glossop Acute Services NHS TrustDepartment of Obstetrics and GynaecologyFountain StreetAshton‐Under‐LyneLancashireUKOL6 9RW
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17
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Prapas Y, Zikopoulos A, Petousis S, Xiromeritis P, Tinelli A, Ravanos K, Margioula-Siarkou C, Chalkia-Prapa EM, Prapas N. Single layer suturing in intracapsular myomectomy of intramural myomas is sufficient for a normal wound healing. Eur J Obstet Gynecol Reprod Biol 2020; 248:204-210. [PMID: 32283430 DOI: 10.1016/j.ejogrb.2020.03.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 03/16/2020] [Accepted: 03/17/2020] [Indexed: 10/24/2022]
Abstract
STUDY OBJECTIVE To evaluate surgical outcomes of intracapsular single-layer myomectomy in terms of efficacy and safety as well as examine potential alterations based on kind of surgical approach. METHODS A prospective observational study was performed between January 2010 and December 2018. Women in reproductive age, affected by intramural or subserous myomas (FIGO type 3-6) of 4-14 cm diameter were enrolled. Primary outcomes included initial and final uterine incision length, time to wound healing and uterine rupture in subsequent pregnancies. Furthermore, a sub-analysis was also performed regarding surgical approach, namely laparoscopical or laparoscopically-assisted myomectomy, in order to confirm whether overall observations are similar for both potential surgical approaches. RESULTS There were finally 273 patients included in the present study. Overall mean uterine incision was initially 3.1 cm and was shortened to 2.2 cm at the end of operation, indicating a reduction of 29.1 %. Mean estimated blood loss was 154.2 mL and mean operative time was 82.1 min. No severe intraoperative and postoperative complications were presented. 121 of the studied women had pregnancy 3-36 months after myomectomy, without reporting any uterine rupture. When comparing LIM vs. LAIM, all outcomes were also favorable in the total of patients. CONCLUSION Intracapsular myomectomy either by LIM or LAIM is a safe and attractive alternative to abdominal myomectomy in setting of premenopausal patients with myomas up to 14 cm. A single-layer continuous suturing in intracapsular myomectomies is enough for a successful wound healing.
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Affiliation(s)
- Yannis Prapas
- IAKENTRO, Infertility Treatment Center, Thessaloniki, Greece
| | - Athanasios Zikopoulos
- Department of Obstetrics and Gynaecology, Medical School, University of Ioannina, Greece
| | - Stamatios Petousis
- IAKENTRO, Infertility Treatment Center, Thessaloniki, Greece; 2nd Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Greece.
| | | | - Andrea Tinelli
- Division of Experimental Researches on Endoscopic Surgery, Imaging, Minimally Invasive Technology, Department of Obstetric & Gynecology, Vito Fazzi Hospital, Lecce, Italy
| | | | - Chrysoula Margioula-Siarkou
- IAKENTRO, Infertility Treatment Center, Thessaloniki, Greece; 2nd Department of Obstetrics and Gynaecology, Aristotle University of Thessaloniki, Greece
| | | | - Nikos Prapas
- IAKENTRO, Infertility Treatment Center, Thessaloniki, Greece
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18
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Raimondo D, Raffone A, Saccone G, Travaglino A, Degli Esposti E, Mastronardi M, Borghese G, Zullo F, Seracchioli R. Cellulose absorbable barrier for prevention of de-novo adhesion formation at the time of laparoscopic myomectomy: A systematic review and meta-analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol 2019; 245:107-113. [PMID: 31891893 DOI: 10.1016/j.ejogrb.2019.12.033] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Revised: 12/09/2019] [Accepted: 12/23/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Myomectomy is the standard surgical treatment for symptomatic uterine leiomyomas, especially for patients wishing to preserve their fertility. However, this procedure is associated with adhesion formation. Several strategies have been proposed to reduce them. Cellulose absorbable barrier is widely used. We aimed to assess its effectiveness in the prevention of de-novo adhesion formation after laparoscopic myomectomy. STUDY DESIGN A systematic review and meta-analysis was performed by searching electronic databases (i.e. MEDLINE, Scopus, ClinicalTrials.gov, EMBASE, Sciencedirect, the Cochrane Library at the CENTRAL Register of Controlled Trials, Scielo) from their inception until May 2019. We included all randomized clinical trials (RCT) comparing use of cellulose absorbable barrier (i.e. intervention group) with either placebo or no treatment (i.e. control group) in the prevention of de-novo adhesion formation at the time of laparoscopic myomectomy. Primary and secondary outcomes were defined before data extraction. The primary outcome was the incidence of adhesions at second-look laparoscopy. The secondary outcome was the operative time. RESULTS Three RCT, including 366 participants, were included. All trials evaluated women undergoing laparoscopic myomectomy who were randomized to intervention (either oxidized regenerated cellulose or carboxymethylcellulose powder adhesion barrier) or no treatment (control group). Women who received treatment had significantly lower incidence of adhesions at the second look laparoscopy (RR 0.63, 95 % CI 0.40-0.99). Interventions with use of cellulose absorbable barrier were 4 min longer (MD 4 min, 95 % CI 2.82-5.18). CONCLUSION Use of cellulose absorbable barrier at the time of laparoscopic myomectomy reduces the risk of postoperative adhesions.
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Affiliation(s)
- Diego Raimondo
- Gynaecology and Human Reproduction Physiopathology Unit, Department of Medical and Surgical Sciences (DIMEC), S. Orsola Hospital, University of Bologna, Via Massarenti 13, Bologna, Italy
| | - Antonio Raffone
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy.
| | - Gabriele Saccone
- Gynecology and Obstetrics Unit, Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Antonio Travaglino
- Anatomic Pathology Unit, Department of Advanced Biomedical Sciences, School of Medicine, University of Naples Federico II, Naples, Italy
| | - Eugenia Degli Esposti
- Gynaecology and Human Reproduction Physiopathology Unit, Department of Medical and Surgical Sciences (DIMEC), S. Orsola Hospital, University of Bologna, Via Massarenti 13, Bologna, Italy
| | - Manuela Mastronardi
- Gynaecology and Human Reproduction Physiopathology Unit, Department of Medical and Surgical Sciences (DIMEC), S. Orsola Hospital, University of Bologna, Via Massarenti 13, Bologna, Italy
| | - Giulia Borghese
- Gynaecology and Human Reproduction Physiopathology Unit, Department of Medical and Surgical Sciences (DIMEC), S. Orsola Hospital, University of Bologna, Via Massarenti 13, Bologna, Italy
| | - Fulvio Zullo
- Gynaecology and Human Reproduction Physiopathology Unit, Department of Medical and Surgical Sciences (DIMEC), S. Orsola Hospital, University of Bologna, Via Massarenti 13, Bologna, Italy
| | - Renato Seracchioli
- Gynaecology and Human Reproduction Physiopathology Unit, Department of Medical and Surgical Sciences (DIMEC), S. Orsola Hospital, University of Bologna, Via Massarenti 13, Bologna, Italy
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Penzias A, Bendikson K, Falcone T, Gitlin S, Gracia C, Hansen K, Hill M, Hurd W, Jindal S, Kalra S, Mersereau J, Odem R, Racowsky C, Rebar R, Reindollar R, Rosen M, Sandlow J, Schlegel P, Steiner A, Stovall D, Tanrikut C. Postoperative adhesions in gynecologic surgery: a committee opinion. Fertil Steril 2019; 112:458-463. [DOI: 10.1016/j.fertnstert.2019.06.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 06/17/2019] [Indexed: 10/26/2022]
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20
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A prospective multi-center registry concerning the clinical performance of laparoscopic colorectal surgery using an absorbable adhesion barrier (INTERCEED ®) made of oxidized regenerated cellulose. Surg Today 2019; 49:877-884. [PMID: 31037393 PMCID: PMC6754356 DOI: 10.1007/s00595-019-01816-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 04/15/2019] [Indexed: 01/12/2023]
Abstract
Purpose The aim of this prospective multi-center registry was to evaluate the safety and clinical performance of INTERCEED® in laparoscopic colorectal surgery. Methods This study was a prospective, multi-center, single-arm registry wherein patients who received INTERCEED® in laparoscopic colorectal surgery were registered consecutively (UMIN-CTR 00001872). The primary outcome was the incidence rate of postoperative adhesive small intestinal obstruction within 6 months. The secondary outcomes were reoperation related to postoperative bleeding and anastomotic leak, surgical site infection (SSI) and anastomotic leak. Results Between March 2012 and March 2015, a total of 202 patients were enrolled from six institutions. INTERCEED® was not applied in two patients, so 200 patients were analyzed using the full analysis set population. The incidence rate of postoperative adhesive intestinal obstruction was 1.0% (2/200). The total SSI rate was 3.5% (7/200), the deep incisional SSI rate was 0.0% (0/200), and the organ SSI rate was 0.0% (0/200). The incidence of anastomotic leak was 1.0% (2/200). Reoperation was performed in two cases: one for anastomotic leak and the other as cardiac surgery due to heart disease. Conclusions Using INTERCEED® in laparoscopic colorectal surgery is safe and may be useful for preventing postoperative adhesive small intestinal obstruction.
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Farag S, Padilla PF, Smith KA, Sprague ML, Zimberg SE. Management, Prevention, and Sequelae of Adhesions in Women Undergoing Laparoscopic Gynecologic Surgery: A Systematic Review. J Minim Invasive Gynecol 2018; 25:1194-1216. [DOI: 10.1016/j.jmig.2017.12.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 12/11/2017] [Accepted: 12/17/2017] [Indexed: 01/09/2023]
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Tinelli A, Malvasi A, Favilli A, Gerli S, Stark M. What are the real advantages of trans endometrial myomectomy during cesarean delivery? J Matern Fetal Neonatal Med 2018; 32:3133-3134. [PMID: 29562791 DOI: 10.1080/14767058.2018.1456524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Andrea Tinelli
- a Division of Experimental Endoscopic Surgery, Imaging, Technology and Minimally Invasive Therapy, Department of Obstetrics and Gynecology , Vito Fazzi Hospital , Lecce , Italy.,b Laboratory of Human Physiology, Phystech BioMed School, Faculty of Biological & Medical Physics , Moscow Institute of Physics and Technology (State University) , Dolgoprudny , Moscow Region , Russia
| | - Antonio Malvasi
- b Laboratory of Human Physiology, Phystech BioMed School, Faculty of Biological & Medical Physics , Moscow Institute of Physics and Technology (State University) , Dolgoprudny , Moscow Region , Russia.,c Department of Obstetric and Gynecology , Santa Maria Hospital, GVM Care and Research , Bari , Italy
| | - Alessandro Favilli
- d Department of Obstetrics and Gynecology , University of Perugia , Perugia , Italy
| | - Sandro Gerli
- d Department of Obstetrics and Gynecology , University of Perugia , Perugia , Italy
| | - Michael Stark
- e New European Surgical Academy (NESA) , Berlin , Germany
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Gingold JA, Gueye NA, Falcone T. Minimally Invasive Approaches to Myoma Management. J Minim Invasive Gynecol 2018; 25:237-250. [DOI: 10.1016/j.jmig.2017.07.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Revised: 07/12/2017] [Accepted: 07/13/2017] [Indexed: 10/19/2022]
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Prise en charge des léiomyomes utérins. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 38:S550-S576. [PMID: 28063565 DOI: 10.1016/j.jogc.2016.09.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Surgical treatment: Myomectomy and hysterectomy; Endoscopy: A major advancement. Best Pract Res Clin Obstet Gynaecol 2016; 34:104-21. [DOI: 10.1016/j.bpobgyn.2015.11.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Accepted: 11/26/2015] [Indexed: 12/12/2022]
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Gargiulo AR, Choussein S, Srouji SS, Cedo LE, Escobar PF. Coaxial robot-assisted laparoendoscopic single-site myomectomy. J Robot Surg 2016; 11:27-35. [DOI: 10.1007/s11701-016-0603-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Accepted: 04/26/2016] [Indexed: 12/30/2022]
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Adhesions are the major cause of complications in operative gynecology. Best Pract Res Clin Obstet Gynaecol 2015; 35:71-83. [PMID: 26586540 DOI: 10.1016/j.bpobgyn.2015.10.010] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 10/02/2015] [Indexed: 12/29/2022]
Abstract
Adhesion formation has been found to be highly prevalent in patients with a history of operations or inflammatory peritoneal processes. These patients are at a high risk of serious intraoperative complications during a subsequent operation if adhesiolysis is performed. These complications include bowel perforation, ureteral or bladder injury, and vascular injury. In order to minimize the risk of these complications, adhesiolysis should only be performed by experienced surgeons, and intraoperative strategies must be adopted. The reduction of the overall incidence of adhesions is essential for subsequent surgical treatments. Anti-adhesion strategies must be adopted for preventing the reoccurrence of adhesions after abdominopelvic operations. The strategies employed to reduce the risk and the overall incidence of adhesions have been elucidated in this article.
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Robotic single-site myomectomy: initial report and technique. Fertil Steril 2015; 103:1370-7.e1. [DOI: 10.1016/j.fertnstert.2015.02.021] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 02/18/2015] [Accepted: 02/18/2015] [Indexed: 02/08/2023]
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Ahmad G, O'Flynn H, Hindocha A, Watson A. Barrier agents for adhesion prevention after gynaecological surgery. Cochrane Database Syst Rev 2015; 2015:CD000475. [PMID: 25924805 PMCID: PMC7043269 DOI: 10.1002/14651858.cd000475.pub3] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Pelvic adhesions can form as a result of inflammation, endometriosis or surgical trauma. During pelvic surgery, strategies to reduce pelvic adhesion formation include placing barrier agents such as oxidised regenerated cellulose, polytetrafluoroethylene or fibrin sheets between the pelvic structures. OBJECTIVES To evaluate the effects of barrier agents used during pelvic surgery on rates of pain, live birth and postoperative adhesions in women of reproductive age. SEARCH METHODS We searched the following databases in February 2015: the Menstrual Disorders and Subfertility Group (MDSG) Specialised Register of Controlled Trials, MEDLINE, EMBASE, CINAHL, PsycINFO, the Cochrane Central Register of Controlled Trials (CENTRAL) and trial registries. We handsearched relevant journals, conference proceedings and grey literature sources and we contacted pharmaceutical companies for information. SELECTION CRITERIA Randomised controlled trials (RCTs) of the use of barrier agents compared with other barrier agents, placebo or no treatment for the prevention of adhesions in women undergoing gynaecological surgery. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for eligibility and risk of bias and extracted the data. We calculated odds ratios (ORs) or mean differences (MD) with 95% confidence intervals (CIs) using a fixed effect model. The overall quality of the evidence was assessed using GRADE (Grades of Recommendation, Assessment, Development and Evaluation) methods. MAIN RESULTS Eighteen RCTs (1262 women) were included. Six RCTs randomised women; the remainder randomised pelvic organs. Laparoscopy (eight RCTs) and laparotomy (10 RCTs) were the primary surgical techniques. Indications for surgery included myomectomy (six RCTs), ovarian surgery (five RCTs), pelvic adhesions (five RCTs), endometriosis (one RCT) and mixed (one RCT). The sole indication for surgery in three of the RCTs was infertility. Twelve RCTs reported commercial funding; the rest did not state their source of funding.No studies reported either of our primary outcomes of pelvic pain and live birth. Oxidised regenerated cellulose (Interceed) versus no treatment at laparoscopy or laparotomy (13 RCTs)At second-look laparoscopy oxidised regenerated cellulose at laparoscopy was associated with reduced incidence of de novo adhesions (OR 0.50, 95% CI 0.30 to 0.83, three RCTs, 360 participants, I(2) = 75%, very low-quality evidence) and of re-formed adhesions (OR 0.17, 95% CI 0.07 to 0.41, three RCTs, 100 participants, I(2) = 36%, low quality evidence).At second-look laparoscopy no evidence was found of any difference between the groups in the incidence of de novo adhesions after laparotomy (OR 0.72, 95% CI 0.42 to 1.25, one RCT, 271 participants, I(2) = 41%, low-quality evidence). However, the incidence of re-formed adhesions was lower in the intervention group (OR 0.38, 95% CI 0.27 to 0.55, six RCTs, 554 participants, moderate-quality evidence). Expanded polytetrafluoroethylene (Gore-Tex) versus no treatment at gynaecological surgery (one RCT) The evidence suggested that at second-look laparoscopy expanded polytetrafluoroethylene was associated with a reduction in new adhesion formation (OR 0.17, 95% CI 0.03 to 0.94, one RCT, 42 participants, low-quality evidence). Expanded polytetrafluoroethylene (Gore-Tex) versus oxidised regenerated cellulose (Interceed) at gynaecological surgery (two RCTs)One RCT found no difference between the groups at second-look laparoscopy in the incidence of de novo adhesions (OR 0.93, 95% CI 0.26 to 3.41, 38 participants, very low-quality evidence). A second RCT suggested that the expanded polytetrafluoroethylene group had a lower adhesion score (out of 11) (MD -3.79, 95% CI -5.12 to -2.46, 62 participants, very low-quality evidence) and a lower risk of re-formed adhesions (OR 0.13, 95% CI 0.02 to 0.80, 23 participants, very low-quality evidence). This last finding was sensitive to choice of effect estimate and no longer suggested a difference between the groups when a risk ratio was calculated (RR 0.36, 95% CI 0.13 to 1.01). Sodium hyaluronate and carboxymethylcellulose (Seprafilm) versus no treatment at gynaecological surgery (one RCT)Sodium hyaluronate and carboxymethylcellulose was associated with a lower adhesion score (out of 4) at second-look laparoscopy (MD 0.49, 95% CI 0.53 to 0.45, one RCT, 127 participants, moderate-quality evidence). Fibrin sheet versus no treatment at laparoscopic myomectomy (one RCT)There was no evidence of a difference between the groups in the incidence of de novo adhesions at second-look laparoscopy (OR 1.20, 95% CI 0.42 to 3.41, one RCT, 62 participants) or in adhesion score (out of 4) (MD 0.14, 95% CI -0.67 to 0.39, one RCT, 48 participants, low-quality evidence).Fourteen of the 18 RCTs reported adverse events. No events directly attributed to adhesion agents were reported. AUTHORS' CONCLUSIONS We found no evidence on the effects of barrier agents used during pelvic surgery on either pain or fertility outcomes in women of reproductive age.Low quality evidence suggests that oxidised regenerated cellulose (Interceed), expanded polytetrafluoroethylene (Gore-Tex) and sodium hyaluronate with carboxymethylcellulose (Seprafilm) may all be more effective than no treatment in reducing the incidence of adhesion formation following pelvic surgery. There is no conclusive evidence on the relative effectiveness of these interventions. There is no evidence to suggest that fibrin sheet is more effective than no treatment. No adverse events directly attributed to the adhesion agents were reported. The quality of the evidence ranged from very low to moderate. The most common limitations were imprecision and poor reporting of study methods. Most studies were commercially funded, and publication bias could not be ruled out.
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Affiliation(s)
- Gaity Ahmad
- Pennine Acute NHS TrustObstetrics & GynaecologyManchesterUK
| | - Helena O'Flynn
- Pennine Acute Hospitals NHS TrustDepartment of Obstetrics and GynaecologyDelaunays RoadCrumpsallManchesterUKM8 5RB
| | - Akshay Hindocha
- Pennine Acute Hospitals NHS TrustDelaunays RoadCrumpsallManchesterUKM8 5RB
| | - Andrew Watson
- Tameside General HospitalTameside & Glossop Acute Services NHS TrustFountain StreetAshton‐Under‐LyneLancashireUKOL6 9RW
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Moro F, Mavrelos D, Pateman K, Holland T, Hoo WL, Jurkovic D. Prevalence of pelvic adhesions on ultrasound examination in women with a history of Cesarean section. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2015; 45:223-228. [PMID: 25042444 DOI: 10.1002/uog.14628] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 06/11/2014] [Accepted: 07/02/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To investigate the prevalence and location of pelvic adhesions in women with a history of Cesarean section and to identify risk factors for their formation and symptoms associated with their presence. METHODS This was a prospective observational study of women in whom one or more Cesarean sections had been performed > 12 months previously and who attended for a gynecological ultrasound examination. In all women, both transvaginal and transabdominal scans were performed in order to identify the presence of pelvic adhesions. Medical and surgical history was recorded and a structured questionnaire was used to enquire about any history of pelvic pain and urinary symptoms. RESULTS A total of 308 women were recruited into the study. On ultrasound examination, 139 (45.1% (95% CI, 39.7-50.7%)) women showed evidence of adhesions within the pelvis. Adhesions in the vesicouterine pouch were the most common and were found in a total of 79 (25.6% (95% CI, 20.7-30.5%)) women. In women with a history of no surgery other than Cesarean section(s) (n = 220), an increasing number of Cesarean sections (odds ratio (OR) 3.4 (95% CI, 2.1-5.5)) and a postoperative wound infection (OR 11.7 (95% CI, 3.5-39.5)) increased the likelihood of adhesions developing in the anterior pelvic compartment. There was a significant association between the presence of anterior compartment adhesions and chronic pelvic pain. Multivariable logistic regression analysis identified anterior abdominal wall adhesions (OR 2.4 (95% CI, 1.0-5.9)) and any adhesions present on ultrasound scan (OR 2.6 (95% CI, 1.2-5.7)) as independent predictors of chronic pelvic pain. CONCLUSIONS Pelvic adhesions are present in more than a third of women with a history of Cesarean section and they are associated with chronic pelvic pain.
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Affiliation(s)
- F Moro
- Department of Obstetrics and Gynaecology, University College Hospital, London, UK
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Hindocha A, Beere L, Dias S, Watson A, Ahmad G. Adhesion prevention agents for gynaecological surgery: an overview of Cochrane reviews. Cochrane Database Syst Rev 2015; 1:CD011254. [PMID: 25561409 PMCID: PMC6544806 DOI: 10.1002/14651858.cd011254.pub2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Intraperitoneal adhesions are associated with considerable co-morbidity and have large financial and public health repercussions. They have secondary effects that include chronic pelvic pain, dyspareunia, subfertility and bowel obstruction. In women with adhesions, subsequent surgery is more difficult, often takes longer, and is associated with a higher complication rate (Broek 2013). The significant burden of adhesions has led to the development of several anti-adhesion agents, although there is disagreement as to their relative effectiveness. OBJECTIVES To summarise evidence derived from Cochrane systematic reviews on the clinical safety and effectiveness of solid agents, gel agents, liquid agents and pharmacological agents, used as adjuvants to prevent formation of adhesions after gynaecological pelvic surgery. METHODS The Cochrane Database of Systematic Reviews was searched using the keyword 'adhesion' up to August 2014. The Cochrane information management system was also searched for any titles or protocols of reviews in progress. Two review authors independently extracted information from the reviews, with disagreements being resolved by a third review author. The quality of the included reviews was described in a narrative manner, and the AMSTAR tool was used to formally assess each review included in this overview. The quality of evidence provided in the original reviews was described using GRADE methods. MAIN RESULTS We included two reviews, one with 18 studies comparing solid agents (oxidised regenerated cellulose expanded polytetrafluoroethylene, sodium hyaluronate and carboxymethylcellulose, and fibrin sheets) with control or with each other. The other review included 29 studies which compared liquid agents (4% icodextrin, 32% dextran, crystalloids), gel agents (carboxymethylcellulose and polyethylene oxide, polyethylene glycol gels, hyaluronic acid based gel, 0.5% ferric hyaluronate gel, sodium hyaluronate spray) and pharmacological agents (gonadotrophin-releasing hormone agonist, reteplase plasminogen activator, N,O-carboxymethyl chitosan, steroid agents, intraperitoneal noxytioline, intraperitoneal heparin, systemic promethazine) with control or each other. Both reviews met all of the criteria of the AMSTAR assessment.The reviews included as outcomes both the primary outcomes of this overview (pelvic pain, pregnancy, live birth rate and quality of life (QoL)) and our secondary outcomes (adverse effects, presence or absence of adhesions at second-look laparoscopy (SLL) and adhesion score). However, neither of the reviews identified any primary studies of solid, gel or pharmacological agents that reported any of our primary outcomes. The only studies in either review that reported any of our primary outcomes were studies comparing liquid agents versus control (saline or Hartmann's solution), which reported pelvic pain (two studies), live birth (two studies) and pregnancy (three studies).An external source of funding was stated for 25 of the 47 studies across both reviews; in 24 of these studies the funding was commercial. Solid agents (18 studies)None of our primary outcomes were reported. Adverse events were reported as an outcome by only 9 of the 18 studies. These reported no adverse events. Liquid agents (nine studies)There was no evidence of a difference between liquid agents and control (saline or Hartmann's solution) with respect to pelvic pain (odds ratio (OR) 0.65, 95% confidence interval (CI) 0.37 to 1.14, 1 study, n = 286, moderate quality evidence), pregnancy rate (OR 0.64, 95% CI 0.36 to 1.14, 3 studies, n = 310, moderate quality evidence) or live birth rate (OR 0.67, 95% CI 0.29 to 1.58, 2 studies, n = 208, moderate quality evidence). No studies of liquid agents reported QoL. Adverse events were not reported as an outcome by any of the nine studies. Gel agents (seven studies)None of our primary outcomes were reported. Adverse events were not reported as an outcome by any of the seven studies. Pharmacological agents (seven studies)None of our primary outcomes were reported. Adverse events were reported as an outcome by only one of the seven primary studies. This study reported no evidence of difference in ectopic pregnancy rates between intraperitoneal noxytioline and no treatment (OR 4.91, 95% CI 0.45 to 53.27, 1 study, n = 33, low quality evidence). AUTHORS' CONCLUSIONS There is insufficient evidence to allow us to draw any conclusions about the effectiveness and safety of anti-adhesion agents in gynaecological surgery, due to the lack of data on pelvic pain, fertility outcomes, quality of life or safety. A substantial proportion of research in this field has been funded by private companies that manufacture these agents, and further high powered, independent trials will be needed before definitive conclusions can be made.
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Affiliation(s)
- Akshay Hindocha
- Pennine Acute Hospitals NHS TrustDelaunays RoadCrumpsallManchesterUKM8 5RB
| | - Lawrence Beere
- Pennine Acute Hospitals NHS TrustDelaunays RoadCrumpsallManchesterUKM8 5RB
| | - Sofia Dias
- University of BristolSchool of Social and Community MedicineCanynge Hall39 Whatley RoadBristolUKBS8 2PS
| | - Andrew Watson
- Tameside General HospitalTameside & Glossop Acute Services NHS TrustFountain StreetAshton‐Under‐LyneLancashireUKOL6 9RW
| | - Gaity Ahmad
- Pennine Acute NHS TrustObstetrics & GynaecologyManchesterUK
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Canis MJ, Triopon G, Daraï E, Madelenat P, LeVêque J, Panel P, Fernandez H, Audebert A, Descamps P, Castaing N, Roman H, Fauconnier A, Benifla JL. Adhesion prevention after myomectomy by laparotomy: a prospective multicenter comparative randomized single-blind study with second-look laparoscopy to assess the effectiveness of PREVADH™. Eur J Obstet Gynecol Reprod Biol 2014; 178:42-7. [DOI: 10.1016/j.ejogrb.2014.03.020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Revised: 03/19/2014] [Accepted: 03/22/2014] [Indexed: 12/30/2022]
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Mais V. Peritoneal adhesions after laparoscopic gastrointestinal surgery. World J Gastroenterol 2014; 20:4917-4925. [PMID: 24803803 PMCID: PMC4009523 DOI: 10.3748/wjg.v20.i17.4917] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2013] [Revised: 01/11/2014] [Accepted: 02/17/2014] [Indexed: 02/06/2023] Open
Abstract
Although laparoscopy has the potential to reduce peritoneal trauma and post-operative peritoneal adhesion formation, only one randomized controlled trial and a few comparative retrospective clinical studies have addressed this issue. Laparoscopy reduces de novo adhesion formation but has no efficacy in reducing adhesion reformation after adhesiolysis. Moreover, several studies have suggested that the reduction of de novo post-operative adhesions does not seem to have a significant clinical impact. Experimental data in animal models have suggested that CO2 pneumoperitoneum can cause acute peritoneal inflammation during laparoscopy depending on the insufflation pressure and the surgery duration. Broad peritoneal cavity protection by the insufflation of a low-temperature humidified gas mixture of CO2, N2O and O2 seems to represent the best approach for reducing peritoneal inflammation due to pneumoperitoneum. However, these experimental data have not had a significant impact on the modification of laparoscopic instrumentation. In contrast, surgeons should train themselves to perform laparoscopy quickly, and they should complete their learning curves before testing chemical anti-adhesive agents and anti-adhesion barriers. Chemical anti-adhesive agents have the potential to exert broad peritoneal cavity protection against adhesion formation, but when these agents are used alone, the concentrations needed to prevent adhesions are too high and could cause major post-operative side effects. Anti-adhesion barriers have been used mainly in open surgery, but some clinical data from laparoscopic surgeries are already available. Sprays, gels, and fluid barriers are easier to apply in laparoscopic surgery than solid barriers. Results have been encouraging with solid barriers, spray barriers, and gel barriers, but they have been ambiguous with fluid barriers. Moreover, when barriers have been used alone, the maximum protection against adhesion formation has been no greater than 60%. A recent small, randomized clinical trial suggested that the combination of broad peritoneal cavity protection with local application of a barrier could be almost 100% effective in preventing post-operative adhesion formation. Future studies should confirm the efficacy of this global strategy in preventing adhesion formation after laparoscopy by focusing on clinical end points, such as reduced incidences of bowel obstruction and abdominal pain and increased fertility.
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Galen DI, Pemueller RR, Leal JGG, Abbott KR, Falls JL, Macer J. Laparoscopic radiofrequency fibroid ablation: phase II and phase III results. JSLS 2014; 18:182-90. [PMID: 24960480 PMCID: PMC4035627 DOI: 10.4293/108680813x13693422518353] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To review phase II and phase III treatments of symptomatic uterine fibroids (myomas) using laparoscopic radiofrequency volumetric thermal ablation (RFVTA). METHODS We performed a retrospective, multicenter clinical analysis of 206 consecutive cases of ultrasound-guided laparoscopic RFVTA of symptomatic myomas conducted on an outpatient basis under two phase II studies at 2 sites (n = 69) and one phase III study at 11 sites (n = 137). Descriptive and exploratory, general trend, and matched-pair analyses were applied. RESULTS From baseline to 12 months in the phase II study, the mean transformed symptom severity scores improved from 53.9 to 8.8 (P < .001) (n = 57), health-related quality-of-life scores improved from 48.5 to 92.0 (P < .001) (n = 57), and mean uterine volume decreased from 204.4 cm(3) to 151.4 cm(3) (P = .008) (n = 58). Patients missed a median of 4 days of work (range, 2-10 days). The rate of possible device-related adverse events was 1.4% (1 of 69). In the phase III study, approximately 98% of patients were assessed at 12 months, and their transformed symptom severity scores, health-related quality-of-life scores, mean decrease in uterine volume, and mean menstrual bleeding reduction were also significant. Patients in phase III missed a median of 5 days of work (range, 1-29 days). The rate of periprocedural device-related adverse events was 3.5% (5 of 137). Despite the enrollment requirement for patients in both phases to have completed childbearing, 4 pregnancies occurred within the first year after treatment. CONCLUSIONS RFVTA does not require any uterine incisions and provides a uterine-sparing procedure with rapid recovery, significant reduction in uterine size, significant reduction or elimination of myoma symptoms, and significant improvement in quality of life.
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Affiliation(s)
- Donald I Galen
- San Ramon Ob/Gyn, 11030 Bollinger Canyon Rd, Ste 250, San Ramon, CA 94582, USA.
| | - Rodolfo Robles Pemueller
- Department of Obstetrics and Gynecology, Hospital Universitario Esperanza, Guatemala City, Guatemala
| | - José Gerardo Garza Leal
- Department of Gynecology and Obstetrics, Hospital Universitario de Nuevo Leon, Monterrey, Mexico
| | | | - Janice L Falls
- Montefiore Medical Center-Einstein Division, Bronx, NY, USA
| | - James Macer
- Pasadena Premier Women's Health, Pasadena, CA, USA
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Ten Broek RPG, Stommel MWJ, Strik C, van Laarhoven CJHM, Keus F, van Goor H. Benefits and harms of adhesion barriers for abdominal surgery: a systematic review and meta-analysis. Lancet 2014; 383:48-59. [PMID: 24075279 DOI: 10.1016/s0140-6736(13)61687-6] [Citation(s) in RCA: 203] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Formation of adhesions after peritoneal surgery results in high morbidity. Barriers to prevent adhesion are seldom applied, despite their ability to reduce the severity of adhesion formation. We evaluated the benefits and harms of four adhesion barriers that have been approved for clinical use. METHODS In this systematic review and meta-analysis, we searched PubMed, CENTRAL, and Embase for randomised clinical trials assessing use of oxidised regenerated cellulose, hyaluronate carboxymethylcellulose, icodextrin, or polyethylene glycol in abdominal surgery. Two researchers independently identified reports and extracted data. We compared use of a barrier with no barrier for nine predefined outcomes, graded for clinical relevance. The primary outcome was reoperation for adhesive small bowel obstruction. We assessed systematic error, random error, and design error with the error matrix approach. This study is registered with PROSPERO, number CRD42012003321. FINDINGS Our search returned 1840 results, from which 28 trials (5191 patients) were included in our meta-analysis. The risks of systematic and random errors were low. No trials reported data for the effect of oxidised regenerated cellulose or polyethylene glycol on reoperations for adhesive small bowel obstruction. Oxidised regenerated cellulose reduced the incidence of adhesions (relative risk [RR] 0·51, 95% CI 0·31-0·86). Some evidence suggests that hyaluronate carboxymethylcellulose reduces the incidence of reoperations for adhesive small bowel obstruction (RR 0·49, 95% CI 0·28-0·88). For icodextrin, reoperation for adhesive small bowel obstruction did not differ significantly between groups (RR 0·33, 95% CI 0·03-3·11). No barriers were associated with an increase in serious adverse events. INTERPRETATION Oxidised regenerated cellulose and hyaluronate carboxymethylcellulose can safely reduce clinically relevant consequences of adhesions. FUNDING None.
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Affiliation(s)
- Richard P G Ten Broek
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands.
| | - Martijn W J Stommel
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | - Chema Strik
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
| | | | - Frederik Keus
- Department of Critical Care, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | - Harry van Goor
- Department of Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, Netherlands
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Tinelli A, Mettler L, Malvasi A, Hurst B, Catherino W, Mynbaev OA, Guido M, Alkatout I, Schollmeyer T. Impact of surgical approach on blood loss during intracapsular myomectomy. MINIM INVASIV THER 2013; 23:87-95. [DOI: 10.3109/13645706.2013.839951] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Adhesions after abdominal surgery: a systematic review of the incidence, distribution and severity. Surg Today 2013; 44:405-20. [PMID: 23657643 DOI: 10.1007/s00595-013-0591-8] [Citation(s) in RCA: 144] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 02/07/2013] [Indexed: 12/20/2022]
Abstract
Abdominal adhesions are associated with increased postoperative complications, cost and workload. We performed a systematic review with statistical pooling to estimate the formation rate, distribution and severity of postoperative adhesions in patients undergoing abdominal surgery. A literature search was carried out for all articles reporting on the incidence, distribution and severity of adhesions between January 1990 and July 2011. Twenty-five articles fulfilled the inclusion criteria. The weighted mean formation rate of adhesions after abdominal surgery was 54 % (95 % confidence interval [CI] 40-68 %), and was 66 % (95 % CI 38-94 %) after gastrointestinal surgery, 51 % (95 % CI 40-63 %) after obstetric and gynaecological surgery and 22 % (95 % CI 7-38 %) after urological surgery. The mean overall severity score was 1.11 ± 0.98 according to the Operative Laparoscopy Study Group classification. Laparoscopic surgery reduced the adhesion formation rate by 25 % and decreased the adhesion severity score (laparoscopic; 0.36 ± 0.69 vs. open; 2.14 ± 0.84) for gastrointestinal surgery. Our results demonstrate that the incidence and severity of abdominal adhesions varies between surgical specialties and procedures. An increased awareness of adhesions can help in identifying the underlying mechanisms of adhesion formation and novel therapeutic approaches, while also improving the surgical consent process.
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Pitter MC, Gargiulo AR, Bonaventura LM, Lehman JS, Srouji SS. Pregnancy outcomes following robot-assisted myomectomy. Hum Reprod 2012; 28:99-108. [PMID: 23081871 DOI: 10.1093/humrep/des365] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
STUDY QUESTION What are the characteristics of the pregnancy outcomes in women undergoing robot-assisted laparoscopic myomectomy (RALM) for symptomatic leiomyomata uteri? SUMMARY ANSWER Despite a high prevalence of women with advanced maternal age, obesity and multiple pregnancy in our cohort, the outcomes are comparable with those reported in the literature for laparoscopic myomectomy. WHAT IS KNOWN ALREADY Reproductive outcomes after traditional laparoscopic myomectomy are well documented. However, reproductive outcomes following robotic myomectomy are not well studied. This paper describes the pregnancy outcomes for a large cohort of women after robotic myomectomy. STUDY DESIGN, SIZE, DURATION This is a retrospective cohort of women who became pregnant after robot-assisted myomectomy at three centers. Of the 872 women who underwent robotic myomectomy during the period October 2005-November 2010, 107 subsequently conceived resulting in 127 pregnancies and 92 deliveries through 2011. PARTICIPANTS/MATERIAL, SETTING, METHODS Women of reproductive age with fibroids who wanted a minimally invasive treatment option and desired uterine preservation were recruited. We conducted a multicentre study with three centers, two in a private practice and one in an academic setting. Pregnancy outcomes and their relationship to myoma characteristics were analyzed. MAIN RESULTS AND ROLE OF CHANCE Mean ± SD age at myomectomy was 34.8 ± 4.5 years and 57.4% [95% confidence interval (CI) 48.0, 66.3] of women were overweight or obese. The mean number of myomas removed was 3.9 ± 3.2 with a mean size of 7.5 ± 3.0 cm and mean weight of 191.7 ± 144.8 g. Entry of the myoma into the endometrial cavity occurred in 20.6% (95% CI 15.0, 27.7) of patients. The mean time to conception was 12.9 ± 11.5 months. Assisted reproduction techniques were employed in 39.4% (95% CI 32.6, 46.7) of these women. Seven twin pregnancies and two triplet pregnancies occurred, for a multiple pregnancy birth rate of 9.8% (95% CI 5.0, 17.8). Spontaneous abortions occurred in 18.9% (95% CI 13.0, 26.6). Preterm delivery prior to 35 weeks of gestational age occurred in 17.4% (95% CI 10.9, 26.5). One uterine rupture (1.1%; 95% CI 0.3, 4.7) was documented. Pelvic adhesions were discovered in 11.4% (95% CI 7.0, 18.0) of patients delivered by Cesarean section. Higher preterm delivery rates were significantly associated with a greater number of myomas removed and anterior location of the largest incision (compared with all other sites) in logistic regression analyses (P = 0.01). None of the myoma characteristics were related to spontaneous abortion. BIAS, CONFOUNDING AND OTHER REASONS FOR CAUTION Given the retrospective nature of the data collection, some pregnancies may not have been captured. In addition, owing to the high prevalence of infertility patients in this cohort, the data cannot be used to counsel women who are undergoing RALM about fertility rates after surgery. GENERALIZABILITY TO OTHER POPULATIONS Prospective studies are needed to determine if the results shown in our cohort are generalizable to all women seeking a minimally invasive option for the conservative treatment of symptomatic fibroids with pregnancy as a desired outcome. STUDY FUNDING/COMPETING INTEREST(S) There was no funding source for this study.
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Tinelli A, Hurst BS, Mettler L, Tsin DA, Pellegrino M, Nicolardi G, Dell'Edera D, Malvasi A. Ultrasound evaluation of uterine healing after laparoscopic intracapsular myomectomy: an observational study. Hum Reprod 2012; 27:2664-2670. [DOI: 10.1093/humrep/des212] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Hirschelmann A, Wallwiener CW, Wallwiener M, Weyhe D, Tchartchian G, Hackethal A, De Wilde RL. Is Patient Education About Adhesions a Requirement in Abdominopelvic Surgery? Geburtshilfe Frauenheilkd 2012; 72:299-304. [PMID: 25284835 DOI: 10.1055/s-0031-1298425] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2012] [Revised: 02/17/2012] [Accepted: 02/28/2012] [Indexed: 12/14/2022] Open
Abstract
Background: Over the past decades, our knowledge and understanding of adhesions and adhesion-related complications has increasingly grown and it has become evident that adhesions have significant implications for patients, physicians and the healthcare system. The question arises whether this has resulted in greater awareness of adhesion-related problems among practicing physicians and appropriate patient education on this topic in daily practice. The following article provides a brief overview of the important subject of adhesions, discusses current awareness of adhesions among patients and doctors and addresses the consequences of failure to provide patient education and consent from a medical perspective. Methods: Selective literature searches were conducted in PubMed and the Cochrane Library. A patient information and consent form was developed based on several years' experience and expertise in the field of adhesions. Results: Adhesions are the most common type of complication in abdominopelvic surgery today, with devastating consequences for some patients. Surveys investigating the awareness of adhesions among physicians and patients clearly showed that even well-informed physicians fail to educate their patients adequately. Such failure could potentially lead to successful medical malpractice lawsuits against doctors. Conclusion: Considering their clear clinical impact, adhesions and related consequences should always be discussed with patients preoperatively. A newly developed consent form that specifically addresses adhesion formation may serve to thoroughly educate patients preoperatively and to adequately document the process of doing so.
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Affiliation(s)
- A Hirschelmann
- Department of Gynaecology, Obstetrics and Gynaecological Oncology, Pius-Hospital, Oldenburg
| | - C W Wallwiener
- Division of Gynaecological Surgery, Department of Obstetrics and Gynaecology, University of Tübingen, Tübingen
| | - M Wallwiener
- Department of Obstetrics and Gynaecology, University of Heidelberg, Heidelberg
| | - D Weyhe
- Department of General and Visceral Surgery, Pius-Hospital, Oldenburg
| | - G Tchartchian
- Clinic for Minimal Invasive Surgery, Berlin-Zehlendorf
| | - A Hackethal
- Queensland Centre for Gynaecological Cancer, Royal Brisbane and Women's Hospital, Herston, Queensland, Austria
| | - R L De Wilde
- Department of Gynaecology, Obstetrics and Gynaecological Oncology, Pius-Hospital, Oldenburg
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Malvasi A, Cavallotti C, Morroni M, Lorenzi T, Dell'Edera D, Nicolardi G, Tinelli A. Uterine fibroid pseudocapsule studied by transmission electron microscopy. Eur J Obstet Gynecol Reprod Biol 2012; 162:187-91. [PMID: 22445207 DOI: 10.1016/j.ejogrb.2012.02.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2011] [Revised: 12/05/2011] [Accepted: 02/17/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The fibroid pseudocapsule is a structure which surrounds the uterine fibroid, separates it from the uterine tissue and contains a vascular network rich in neurotransmitters like a neurovascular bundle. The authors examined the composition of the fibroid pseudocapsule using electron microscopy. STUDY DESIGN Twenty non-pregnant patients were submitted to laparoscopic myomectomy by the intracapsular method and samples of the removed pseudocapsules were analyzed using transmission electron microscopy. RESULTS At the ultrastructural level the pseudocapsule cells have the features of smooth muscle cells similar to the myometrium. So, the pseudocapsules are part of the myometrium which compresses the leiomyoma. CONCLUSION This ultrastructural feature suggests that when removing fibroids their pseudocapsules should be preserved. This study confirms preliminary evidence that pseudocapsules contain neuropeptides together with their related fibers, as a neurovascular bundle. The surgeon's behavior should be directed to carefully control and spare this muscular surrounding tissue during fibroid excision, in order to preserve the myometrium as much as possible.
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Affiliation(s)
- Antonio Malvasi
- Department of Obstetrics and Gynaecology, Santa Maria Hospital, Bari, Italy.
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KUMAKIRI JUN, KIKUCHI IWAHO, KITADE MARI, MATSUOKA SHOZO, KONO AYAKO, OZAKI RIE, TAKEDA SATORU. Association between uterine repair at laparoscopic myomectomy and postoperative adhesions. Acta Obstet Gynecol Scand 2012; 91:331-7. [DOI: 10.1111/j.1600-0412.2011.01339.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Tinelli A, Hurst BS, Hudelist G, Tsin DA, Stark M, Mettler L, Guido M, Malvasi A. Laparoscopic myomectomy focusing on the myoma pseudocapsule: technical and outcome reports. Hum Reprod 2012; 27:427-435. [DOI: 10.1093/humrep/der369] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Hirschelmann A, De Wilde RL. Plastic and reconstructive uterus operations by minimally invasive surgery? A review on myomectomy. GMS INTERDISCIPLINARY PLASTIC AND RECONSTRUCTIVE SURGERY DGPW 2012; 1:Doc09. [PMID: 26504693 PMCID: PMC4582479 DOI: 10.3205/iprs000009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Plastic and reconstructive uterus operations are performed in congenital uterine anomalies or benign uterine conditions. Congenital uterine anomalies are relatively rare diseases with various approaches for surgical treatment. Therefore, to address the question of the usefulness of a minimally invasive approach in plastic uterus operations, the most common uterine condition which requires reconstructive surgery, namely myomectomy, is discussed. METHOD Searches were conducted in PubMed and The Cochrane Library to identify relevant literature. FINDINGS Compared with myomectomy by laparotomy and minilaparotomy, laparoscopic myomectomy is associated with improved short-term outcomes. Laparoscopy is further associated with less adhesion formation. Pregnancy rates after myomectomy in symptomatic patients might be higher after laparoscopy than after laparotomy. Although uterine ruptures following laparoscopic myomectomy are described in the literature, it seems to be a rare event. Concerning the recurrence, there is evidence that rates are similar after laparoscopy and laparotomy. CONCLUSION Myomectomy by laparoscopy has several advantages over abdominal myomectomy (by conventional laparotomy and minilaparotomy) and should be the standard procedure. Despite the advantages of laparoscopy, abdominal myomectomy is still a frequently performed procedure. Lack of training in advanced laparoscopic procedures hampers the wide-spread use of laparoscopic myomectomy. Due to the advantages of laparoscopic surgery, efforts should be made to implement this procedure into daily practice. To provide the best care, physicians should offer patients the opportunity of a laparoscopic treatment of myomas.
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Affiliation(s)
- Anja Hirschelmann
- Pius-Hospital Oldenburg, Klinik für Frauenheilkunde, Geburtshilfe und Gynäkologische Onkologie, Oldenburg, Germany
| | - Rudy Leon De Wilde
- Pius-Hospital Oldenburg, Klinik für Frauenheilkunde, Geburtshilfe und Gynäkologische Onkologie, Oldenburg, Germany
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Tinelli A, Malvasi A, Hurst BS, Tsin DA, Davila F, Dominguez G, Dell'edera D, Cavallotti C, Negro R, Gustapane S, Teigland CM, Mettler L. Surgical management of neurovascular bundle in uterine fibroid pseudocapsule. JSLS 2012; 16:119-29. [PMID: 22906340 PMCID: PMC3407432 DOI: 10.4293/108680812x13291597716302] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
The uterine fibroid pseudocapsule is a fibro-neurovascular structure surrounding a leiomyoma, separating it from normal peripheral myometrium. The fibroid pseudocapsule is composed of a neurovascular network rich in neurofibers similar to the neurovascular bundle surrounding a prostate. The nerve-sparing radical prostatectomy has several intriguing parallels to myomectomy. It may serve either as a useful model in modern fibroid surgical removal, or it may accelerate our understanding of the role of the fibrovascular bundle and neurotransmitters in the healing and restoration of reproductive potential after intracapsular myomectomy. Surgical innovations, such as laparoscopic or robotic myomectomy applied to the intracapsular technique with magnification of the fibroid pseudocapsule surrounding a leiomyoma, originated from the radical prostatectomy method that highlighted a careful dissection of the neurovascular bundle to preserve sexual functioning after prostatectomy. Gentle uterine leiomyoma detachment from the pseudocapsule neurovascular bundle has allowed a reduction in uterine bleeding and uterine musculature trauma with sparing of the pseudocapsule neuropeptide fibers. This technique has had a favorable impact on functionality in reproduction and has improved fertility outcomes. Further research should determine the role of the myoma pseudocapsule neurovascular bundle in the formation, growth, and pathophysiological consequences of fibroids, including pain, infertility, and reproductive outcomes.
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Affiliation(s)
- Andrea Tinelli
- Department of Obstetrics and Gynaecology, Vito Fazzi Hospital, Lecce, Italy.
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