Salpingo-ovariolysis by laparoscopy in infertility**Presented at the Tenth Annual Meeting of the American Association of Gynecologic Laparoscopists, November 4 to 8, 1981, Phoenix, Arizona

From laparotomy to laparoscopy to in vitro fertilization

Before the modern era of in vitro fertilization, reproductive surgery to deal with pelvic disease was the key intervention in the management of infertility. A series of clinical observations and animal experiments led to the development of microsurgical principles, which were applicable to all forms of gynecologic surgery. The evolution of endoscopy permitted minimally invasive approaches to most pelvic pathology. Assisted reproductive techniques now have primacy in the management of infertility, but women deserve to have fertility-enhancing or fertility-sparing surgery performed by a surgeon with relevant training. Thus, we have an obligation to maintain formal training programs in reproductive surgery.

Pregnancy outcome of laparoscopic tubal reanastomosis: retrospective results from a single clinical centre

Objective Tubal sterilization is a widespread method of contraception. Post-sterilization regret is encountered, despite careful consideration prior to the procedure. Two treatment options are available for women after having had tubal sterilization: microsurgical reversal and IVF treatment. Recent improvements in laparoscopy have allowed tubal reanastomosis to be performed. This study aimed to evaluate the reproductive outcome after laparoscopic tubal reanastomosis and surgical features of the patients. Methods From June 2007 to January 2010, 27 patients with bilateral tubal ligation who underwent laparoscopic tubal reanastomosis were evaluated retrospectively. Tubal sterilization was performed by Pomeroy's technique during caesarean section in all of the patients. Before surgery, all of the patients were evaluated for possible other causes of infertility and the results of the evaluation were normal. Results The mean age of the patients was 31.8 years (range, 27-38 years). The mean interval between sterilization and reversal was 5.1 years (range, 1-14 years). Bilateral reversal was achieved in 24 patients. The operation time ranged from 85 to 140 minutes with a mean time of 105 minutes. All of the patients were discharged on the next day. There were no postoperative complications. Overall pregnancy, intrauterine pregnancy, and ectopic pregnancy rates were 55.5% (15/27), 51.8% (14/27), and 3.7% (1/27), respectively. Of the 14 intrauterine pregnancies, one ended with abortion at 6 weeks' gestation (1/14). The mean interval from surgery to pregnancy was 270 days (range, 147-420 days). Conclusion Laparoscopic tubal reanastomosis has the advantages of fewer complications, less postoperative discomfort, a smaller incisional scar, a shorter recovery time, and earlier resumption of normal activities. This technique has a satisfactory pregnancy rate in selected patients who desire reversal of tubal sterilization.

Randomized Controlled Trial of Hyalobarrier® Versus No Hyalobarrier® on the Ovulatory Status of Women with Periovarian Adhesions: A Pilot Study

Introduction

Periadnexal adhesions are known to contribute to subfertility. The restoration of the tubo-ovarian anatomy is one the key principles in reproductive surgery, and this involves adhesiolysis. However, adhesion formation/reformation is very common after periovarian adhesiolysis. It is not known if the application of Hyalobarrier^®, an anti-adhesion gel, around the adnexal region postsurgery influences ovulatory status. The study is a pilot randomized controlled trial (RCT) randomizing women into the application of Hyalobarrier^® versus no Hyalobarrier^® at the time of laparoscopy, where postsurgical ovulatory status and pregnancy rates were evaluated.

Methods

This was a pilot RCT where women were recruited from the gynecological and subfertility clinic who were deemed to require an operative laparoscopy. If intraoperatively they were found to have periovarian adhesions, they were randomized into having adhesiolysis with and without usage of Hyalobarrier^®. Demographic details and intraoperative details including the severity, extent, and the ease of use of Hyalobarrier^® were recorded. Prior to the surgery and postoperatively, the participants had their serum hormonal status (day 2 FSH, LH and day 21 progesterone) evaluated. Postoperatively, they underwent a follicular tracking cycle at 3 months.

Results

Fifteen women were randomized into use of Hyalobarrier^® (study group) and 15 into the no Hyalobarrier^® group (control group) between December 2011 and January 2014. There was no difference in the patient characteristics in terms of age, BMI, the number of previous pregnancies, or the extent, site, and severity of adhesions between the two groups. There was no significant difference between the study versus control groups in terms of the hormonal profile (day 2 FSH and day 21 progesterone) before or after surgery. The 3-month postoperative day 10–12 follicular tracking findings and endometrial thickness were similar between the study and control groups. Four women were pregnant in the study group (24%) and one in the control group (7%) cumulatively over 2 years.

Conclusion

The use of Hyalobarrier^® post salpingo-ovariolysis did not influence follicular development as inferred from the results of the day 21 progesterone and folliculogram on day 10–12 3-month postsurgery.

Trial Registration

ISRCTN number, ISRCTN1833588.

Funding

Nordic Pharma.

Role of the peritoneal cavity in the prevention of postoperative adhesions, pain, and fatigue

A surgical trauma results within minutes in exudation, platelets, and fibrin deposition. Within hours, the denuded area is covered by tissue repair cells/macrophages, starting a cascade of events. Epithelial repair starts on day 1 and is terminated by day 3. If repair is delayed by decreased fibrinolysis, local inflammation, or factors in peritoneal fluid, fibroblast growth starting on day 3 and angiogenesis starting on day 5 results in adhesion formation. For adhesion formation, quantitatively more important are factors released into the peritoneal fluid after retraction of the fragile mesothelial cells and acute inflammation of the entire peritoneal cavity. This is caused by mechanical trauma, hypoxia (e.g., CO₂ pneumoperitoneum), reactive oxygen species (ROS; e.g., open surgery), desiccation, or presence of blood, and this is more severe at higher temperatures. The inflammation at trauma sites is delayed by necrotic tissue, resorbable sutures, vascularization damage, and oxidative stress. Prevention of adhesion formation therefore consists of the prevention of acute inflammation in the peritoneal cavity by means of gentle tissue handling, the addition of more than 5% N₂O to the CO₂ pneumoperitoneum, cooling the abdomen to 30°C, prevention of desiccation, a short duration of surgery, and, at the end of surgery, meticulous hemostasis, thorough lavage, application of a barrier to injury sites, and administration of dexamethasone. With this combined therapy, nearly adhesion-free surgery can be performed today. Conditioning alone results in some 85% adhesion prevention, barriers alone in 40%-50%.

Use of laparoscopy in unexplained infertility

OBJECTIVE

The use of laparoscopy in unexplained infertility work-up is still a subject of debate, although laparoscopy remains the gold standard for diagnosis and treatment of several pelvic pathologies. The objective of this study was to assess the rates and types of pelvic pathologies observed during diagnostic laparoscopy, and the pregnancy rate in couples with unexplained infertility following laparoscopy.

STUDY DESIGN

Prospective study, from November 2003 to October 2009, including 114 infertile, spontaneously ovulating women with normal clinical examination, ovarian reserve assessment, pelvic ultrasound scan and patent tubes on hysterosalpingography. Semen analyses were normal according to the World Health Organization criteria. After three cycles of ovulation induction with or without intra-uterine insemination and no pregnancy, women were referred for diagnostic laparoscopy.

RESULTS

Laparoscopy revealed pelvic pathology in 95 patients. Endometriosis, pelvic adhesions and tubal disease were observed and treated in 72, 46 and 24 patients, respectively. Following laparoscopy, bilateral and unilateral tubal patencies were observed in 107 and five patients, respectively. Pregnancy was observed in 77 out of 102 patients who tried to conceive after surgery, 35 of whom conceived using their own tubes.

CONCLUSION

Diagnostic laparoscopy should be strongly considered in unexplained infertility work-up, and tubal efficiency should not be underestimated.

Recurrence of hydrosalpinges after cuff neosalpingostomy in a poor prognosis population

PURPOSE

The purpose of this study was to determine the recurrence rate of hydrosalpinges after cuff neosalpingostomy in poor prognosis candidates.

METHODS

Forty consecutive patients with hydrosalpinx treated with cuff neosalpingostomy were included. Main outcome measures were recurrence rate of hydrosalpinx after cuff neosalpingostomy, intrauterine and ectopic pregnancy rates.

RESULTS

Intraoperatively, the mean size of the hydrosalpinx was 1.9+/-0.7 cm, and 77% of patients had evidence of pelvic adhesions. Recurrence of hydrosalpinx, whether unilateral or bilateral was 70% (28/40) per patient. Intrauterine and ectopic pregnancy rates were 5% (2/40) and 2.5% (1/40), with a total pregnancy rate of 7.5% (3/40).

CONCLUSIONS

Most patients experience recurrence of hydrosalpinx after cuff neosalpingostomy, thus requiring additional surgery such as salpingectomy prior to in vitro fertilization (IVF). In a poor prognosis population, salpingectomy should be considered as the primary treatment for hydrosalpinx prior to IVF.

Evidence-based diagnosis and management of tubal factor infertility

PURPOSE OF REVIEW

The investigation for potential tubal disease is an essential step in the work-up of infertility. This review article provides an evidence-based overview of the diagnosis and management of tubal factor infertility.

RECENT FINDINGS

While laparoscopic chromopertubation remains the gold standard in the diagnosis of tubal disease and hysterosalpingography is still widely used, newer modalities offer some advantages. Sonohysterography with the use of contrast medium is superior to hysterosalpingography and comparable to laparoscopic chromotubation in diagnosing tubal blockage. Chlamydia serology is the most cost-effective and least invasive diagnostic test for tubal disease, and it is comparable to, if not better than, hysterosalpingography. Depending on the nature and degree of tubal dysfunction as well as the age and ovarian reserve of the patient, various treatments for tubal infertility are available. For proximal tubal obstruction, transcervical tubal cannulation with tubal flushing is a reasonable first approach. Surgical techniques for tubal repair, such as salpingostomy or fimbrioplasty for distal tubal obstruction, can provide good results. Still, tubal factor remains a major indication for in-vitro fertilization and embryo transfer, which bypasses the tubal problem altogether. In certain situations, such as the presence of hydrosalpinx, prophylactic surgery can be used in conjunction with in-vitro fertilization and embryo transfer.

SUMMARY

As with infertility in general, the diagnosis and management of tubal infertility should be tailored to the individual patient. Future studies should help to further clarify the role of the various diagnostic tests and therapeutic approaches for tubal infertility.

Adhesions: laparoscopic surgery versus laparotomy

This study was undertaken to assess the effectiveness in pregnancy rates of microsurgery and operative laparoscopy in adhesiolysis. Adhesions were found to be the sole infertility factor in 15% of our patients. One hundred and ninety infertile patients with periadnexal adhesions as the only cause of their infertility were treated by microsurgery (86) or operative laparoscopy (104) and were followed up for 24 months. Our results indicate that advanced laparoscopic surgery in general is as effective as microsurgery in healthy infertile patients with adhesions but offers some advantages in comparison to laparotomy. Factors that adversely affect the postoperative success rates are the age of the women, the duration of infertility, and the severity of the adhesions.

Laparoscopic fimbrioplasty and neosalpingostomy. Experience of the Yaoundé General Hospital, Cameroon (report of 194 cases)

OBJECTIVE(S)

To study the fertility results after laparoscopic distal tuboplasty and compare them with the data in the literature.

STUDY DESIGN

194 laparoscopic distal tuboplasties were carried out from May 1992 to May 1994 in the Yaounde General Hospital (Cameroon). The results were analysed according to the age of the patients, the type and duration of infertility, past history of abortion, laparotomy and Chlamydia trachomatis infection, the tube and adhesion scores, surgical procedures and achievement of pregnancy. The fertility rates were calculated according to Cramer's method [11]. The cumulative pregnancy rate curves were drawn up from the life table [12] and compared using the Log-Rank test.

RESULTS

53 patients obtained pregnancy (27.3%) of which 45 were inter-uterine (23.2%) and 8 ectopic (4.1%). Of the 45 intra-uterine pregnancies (IUP), 36 were obtained after fimbrioplasty (33.3%) and 9 after neosalpingostomy (10.5%). The monthly fertility rate at one year was 1.4%. The rate of IUP for tube stages I and II is significantly higher than that for stages III and IV (p<0.001). However the rate of ectopic pregnancies (EP) is proportional to damage to the tubes. Infection with Chlamydia trachomatis, and residual inflammation could have an effect on the achievement of pregnancy.

CONCLUSION(S)

Our results are similar to those found in the literature. The tube stage thus remains the decisive factor in terms of fertility (Cox: p<0.001). Operative laparoscopy is the best alternative in our countries compared with laparotomy for distal tubal pathology.

In vitro fertilization versus tubal surgery: is pelvic reconstructive surgery obsolete?

OBJECTIVE

To compare the results of pelvic reconstructive surgery with cumulative success rates of IVF for couples with tubal factor infertility.

DATA RESOURCES

Outcomes of pelvic surgery were obtained from a review of articles from the literature identified by directed Medline searches. Cumulative pregnancy rates of 771 couples with tubal factor infertility treated at the Cornell IVF program between December 1989 and December 1992 were calculated by life-table analysis.

RESULTS

Overall delivery rate per transfer for patients with tubal factor was 28.9% (303 deliveries per 1,048 transfers) and did not appear to be affected significantly by the presence of a secondary diagnosis. A significant decline in pregnancy rates was observed with advancing age: age < 30 years, 48.4%; 30 to 34 years, 44%; 35 to 38 years, 28%; 39 to 40 years, 20%; 41 to 42 years, 9%; and > 42 years, 4.3%. Cumulative pregnancy rates for cycles 1 to 4 were 32%, 59%, 70%, and 77%, respectively, in patients with only tubal factor, and 28%, 55%, 62%, and 75% in patients with tubal combined with other associated infertility factors.

CONCLUSIONS

Our experience suggest that > 70% of women with tubal factor infertility will have a live birth within four cycles of treatment with IVF. These results compare favorably with the best outcomes after tubal reconstructive surgery. In older women, because of the rapid decline of fertility potential with advancing age, efforts should be directed toward the treatment method that provides the highest likelihood of success within the shortest time interval.

Operative laparoscopy: surgical modalities

OBJECTIVE

To review basic physics of different surgical modalities and their clinical applications and outcomes.

DESIGN

The relevant literature and personal experience were used to prepare the manuscript.

RESULTS

Operative laparoscopy is safe and effective whether using sharp dissection, electrosurgical, or laser energy. The newer surgical modalities, including the vibrating ultrasound scalpel and argon beam coagulator, need further evaluation.

CONCLUSIONS

The results of laparoscopic surgery are independent of the surgical modality used. The surgeon's skill and experience, his or her preference of the technique, and proper patient selection play a more important role.

Laparoscopic myomectomy and tubal reconstructive surgery in the infertile patient

This chapter describes the surgical management of uterine fibroids and tubal disease using laparoscopy as a means of access. In both instances the discussion is restricted to attempts to enhance fertility. Myomectomy and tubal reconstructive surgery are totally different procedures and each is discussed separately.

Infertility and endometriosis: comparison of pregnancy outcomes with laparotomy versus laparoscopic techniques

OBJECTIVES

The null hypothesis of this retrospective literature analysis was that the superiority of laparoscopy over laparotomy to correct infertility resulting from tubal injury has not been proved because of the lack of well-designed comparative studies. The same was true for the correction of infertility caused by minimal and mild endometriosis.

STUDY DESIGN

A retrospective review of the English-language literature since 1975 was made to ascertain whether laparoscopic surgical correction of infertility caused by tubal injury and endometriosis resulted in an increased pregnancy rate compared with laparotomy techniques. Complication rates associated with laparoscopy versus laparotomy were also compared.

RESULTS

There were almost no adequate studies designed and executed to answer these questions based on criteria established by the United States Preventive Services Task Force. Furthermore, there was no evidence in the reported series that laparoscopic surgical procedures were superior to laparotomy in correcting infertility. The complication rates were similar. There was suggestive, but not yet proven, evidence that laparoscopic surgery with laser techniques may be superior to laparotomy in the management of infertility resulting from moderate and severe endometriosis.

CONCLUSION

Although results and complications were similar, the cost in savings with respect to decreased hospital expenses and loss of work time favor the use of laparoscopy over laparotomy when results are similar and not associated with increased risk. What has not been established are costs and work-time losses for minilaparotomy compared with laparoscopy.

Laparoscopic distal tuboplasty: report of 87 cases and a 4-year experience

OBJECTIVE

To evaluate fertility results after laparoscopic distal tuboplasty and to compare these results with those obtained previously with microsurgery.

DESIGN

Retrospective, nonrandomized.

SETTING

Department of Obstetrics and Gynecology at the University Hospital of Clermont-Ferrand, France.

PATIENTS

All the distal tuboplasties performed between October 1985 and June 1989 were included. Adnexal damage was assessed using tubal and adhesions scoring systems described previously. Tuboplasty was carried out bilaterally except when one tube was absent or severely damaged (tubal stage III or IV and/or with severe adhesions). Patients with bilateral severe adnexal damages were treated only if they refused to undergo in vitro fertilization. Laparoscopic tuboplasty was performed either with the CO2 laser or with conventional instruments.

MAIN OUTCOME MEASURE

Fertility after laparoscopic treatment was evaluated using simple and cumulative pregnancy rates (PRs) according to the adnexal damage and compared with the microsurgical results using PRs according to the adnexal damage.

RESULTS

The overall intrauterine and extrauterine PRs were 33.3% and 6.9%, respectively. Twenty-six of the 29 intrauterine pregnancies were obtained within the 1st postoperative year. According to tubal and adhesion stages, the results of laparoscopic distal tuboplasty are similar to those obtained using microsurgery.

CONCLUSION

We conclude that laparoscopic distal tuboplasty, when performed by experienced surgical laparoscopists, represents an effective alternative to microsurgery.

Present day endoscopic surgery in gynecology

The last ten years have been characterized by a tremendous change in laparoscopy. Initially used exclusively for diagnosis, laparoscopy is now a surgical method in its own right and plays a strategic role. Long-term evaluation of results for various pathologies (such as ectopic pregnancy and tubo-peritoneal sterility) means that just one laparoscopic procedure can be used for diagnosis, selection of the best therapeutic approach and also for treatment in those cases where laparoscopy is the optimum choice. Other more recent indications (including hysterectomy, lymphadenectomy etc.) which are now possible thanks to recent technological developments (such as clips and mechanical sutures) need long-term analysis of their results.

Operative laparoscopy with the Nd:YAG laser in the treatment of endometriosis and pelvic adhesions

A multicenter, prospective trial was initiated to test the effectiveness and safety of the Nd:YAG laser equipped with artificial sapphire contact tips for the laparoscopic treatment of pelvic pain. Ninety-three women were enrolled in the study, 37 with endometriosis alone, 47 with endometriosis complicated by pelvic adhesions, and 9 women with adhesions alone. In over 90% of adhesions and 96% of endometriotic implants the Nd:YAG laser could be delivered to the site and be used to restore normal anatomy. The exception was deep bowel involvement with endometriosis, which was not treated. The majority of women had marked reduction or resolution of their symptoms for up to 12 months postoperatively. We conclude that the use of the Nd:YAG laser is an appropriate method to laparoscopically treat pelvic pain resulting from endometriosis or pelvic adhesions.

Terminal tuboplasties by laparoscopy: 65 consecutive cases

A series of 65 consecutive laparoscopic distal tuboplasties, performed from May 1986 to May 1988 is reported. Thirty-one were fimbrioplasties and 34 were neosalpingostomies. Outcome was evaluated at 18 months postoperatively. Twenty-two patients obtained pregnancies (33.8%), of which 18 were intrauterine (27.7%). The intrauterine pregnancy rate was 25.8% after fimbrioplasty and 29.4% after neosalpingostomy. These results are comparable with those obtained after microsurgery. Progress in operative laparoscopy may be attributed to the development of an appropriate atraumatic instrumentation and the CO2 laser. The major advantage of laparoscopic techniques is their availability at the time of diagnostic laparoscopy. Immediate opening of hydrosalpinges allows for precise evaluation of the tubal mucosa, thereby establishing prognosis. In cases with a severely altered mucosa, in vitro fertilization may be considered immediately. When the mucosa is satisfactory, laparoscopic fimbrioplasty or neosalpingostomy may be performed. Within 1 year after one of these procedures, a pregnancy is generally achieved in 1 of 3 patients.

Videolaseroscopy for the treatment of endometriosis associated with infertility

Recent advances in laparoscopic surgery have enabled the gynecologic surgeon to treat an increased number of diseases of the reproductive organs by using the laser through the laparoscope. This article reviews the results of 243 patients with infertility associated with endometriosis ranging in severity from mild to extensive who were treated by the same surgeon using CO2 laser laparoscopically with videocamera augmentation and control. Of the 243 infertility patients, 168 (69.1%) achieved pregnancy. The pregnancy rates were 71.8% in 39 patients with stage I disease, 69.8% in 86 patients with stage II disease, 67.2% of 67 patients with stage III disease, and 68.6% in 51 patients with stage IV disease. The life table and two-parameter exponential model were used to calculate monthly fecundity, "cure," and "probability of pregnancy" rates. The results indicate that videolaseroscopic treatment of endometriosis associated with infertility, in surgically experienced hands, is at least as efficacious as other forms of therapy for mild and moderate cases of disease, but appears to be more successful than laparotomy for the more severe and extensive stages of disease.

The effect of periovarian adhesions on follicular development in patients undergoing ovarian stimulation for in vitro fertilization-embryo transfer

It has been suggested that the presence of periovarian adhesions might impair the ovarian response to gonadotropins. Periovarian adhesions were recorded in 49 women, and the total percentage of accessible ovarian cortex was described at the initiation of the operative procedure. Adhesiolysis was performed as needed for oocyte recovery. Ovarian access did not correlate with serum estradiol level on either the day of human chorionic gonadotropin (hCG) administration or the day after hCG administration. Similarly, neither the total number of follicles on the day of hCG or on the day after hCG, nor the number of follicles 1.0 to 1.4 cm or greater than or equal to 1.5 cm correlated with ovarian access. We conclude that periovarian adhesions are not a major determinant of the ovarian response to gonadotropin stimulation.

Operative laparoscopy versus open abdominal surgery: a comparative study on postoperative adhesion formation in the rat model

The aim of this study was to compare the occurrence of adhesions after a standard uterine injury inflicted by laparoscopy or by laparotomy during which microsurgical principles were observed. The cross-sectional areas of adhesions involving the uterus were assessed and the 31 rats operated upon laparoscopically were compared with the 30 rats subjected to a laparotomy. The mean area of uterine adhesions formed in the laparotomy group was 4.29 mm2 and 8.88 mm2 in the laparoscopy group. The difference was not statistically significant. The results imply that a standard tissue injury to uterine tissue, whether conducted by laparoscopy or via laparotomy, carries the same potential to induce postoperative adhesions.

Ectopic pregnancy: its relationship to tubal reconstructive surgery

Ectopic pregnancy is the shady companion of tubal surgery. Among patients with ectopic pregnancy, relatively few have a history of tubal surgery as their underlying etiologic factor when compared with other etiologies such as PID. Nevertheless, a history of tubal surgery should place the patient at a higher-risk group for ectopic pregnancy; 3% to 20% of these patients will encounter an ectopic pregnancy after the corrective surgery. The incidence of ectopic pregnancy after tubal surgery is extremely variable and is closely linked to the degree of restoration of normal functional and anatomic integrity after the surgical procedure. This depends, to a large extent, on the amount of previous damage to the tube and its potential reversibility. Major improvements in surgical technique can, therefore, have reduced, but not eliminated, the occurrence of tubal pregnancy. The incidence of ectopic pregnancy associated with any given tubal surgical procedure should be taken into consideration when surgery is contemplated. When the risk of ectopic pregnancy is unacceptably high, or when the patient is reluctant to be exposed to a high risk of ectopic pregnancy, IVF-ET could be offered as an alternative. Table 11 represents the incidence of ectopic pregnancy associated with the various surgical procedures. The figures demonstrate the wide variation in outcome for the same procedure.

Laparoscopic salpingectomy for tubal pregnancy

This study presents 100 consecutive cases of total salpingectomy by laparoscopy for the treatment of ampullar ectopic pregnancy. A three-puncture technique was used, and the salpingectomy was done by thermocoagulation and transection of the isthmus, mesosalpinx, and tubo-ovarian ligament. Tubal extraction was accomplished by one of the suprapubic punctures with the use of a polyp forceps. No complications have been encountered during the operation. However, because of severe pelvic adhesions or a voluminous hematocele, laparotomy was used in two cases (2%). The only postoperative complication was a deep vein thrombosis in one of the patients. A second-look operation was performed in 36 cases, and good healing with no adhesion formation at or near the site of salpingectomy was found. This technique therefore appears to be simple, fast, and almost complication-free.

A model for sidewall adhesions in the rabbit: reduction by an absorbable barrier

Despite use of surgical adjuvants, pelvic adhesions frequently develop following infertility surgery. Recently a resorbable biocompatible material, TC 7, has been designed to be used as a barrier to reduce adhesion formation. Reproducibly severe sidewall adhesions were only able to be created in one of six models tested. The model consisted of the following steps: excision of a full thickness 2 x 2-cm musculoperitoneal tissue mass, scraping of an adjacent 2-cm length of uterine horn, tamponading of all bleeding, and suturing (6-0 Vicryl) of normal tube and sidewall so as to directly approximate the traumatized tissues. Studies were conducted in 13 rabbits after creation of the bilateral sidewall and horn lesions, each serving as its own control. Choice of control and TC 7 sides was determined randomly. Adhesion formation was examined 2 weeks postoperatively. No residual material was noted at that time. Adhesion scores were the composite total of extent (0-4), type (0-4), and tenacity (0-3) of sidewall adhesions, and were significantly reduced on the TC 7 side as compared with the control side (mean 6.8 +/- 0.4 vs 9.0 +/- 0.3, median 6 vs 9, sign test P = 0.0032). No complications of use of the barrier were noted. It is concluded that use of TC 7, a resorbable biocompatible barrier, was able to significantly reduce postoperative adhesion formation on the rabbit sidewall.

Pathogenesis of adhesion formation/reformation: application to reproductive pelvic surgery

Pelvic adhesions are a major contributing factor to infertility in women with tubal peritoneal disease. Surgical treatment of such adhesions often does not resolve their presence. Such postoperative adhesion formation occurs despite the use of microsurgical techniques in a wide variety of surgical adjuvants. The process of adhesion formation represents a variation of the normal healing process of the peritoneum. However, rather than normal mesothelial healing, the fibrinous mass resulting from the peritoneal defect is infiltrated by fibroblasts with subsequent adhesion formation. A description of the pathophysiology of this process is described. The current understanding of the pathologic/pathophysiologic interaction of the surgical adjuvants with this process is described.