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Adhesions in relation to laparoscopic surgery for endometriosis
Deborah Bush
QSM, Dr
Ossie Petrucco,
and Dr Robert O’Shea Listen: RealPlayer
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Player Deborah
Bush, QSM: My
name is Deborah Bush. I’m the
Chief Executive of the New Zealand Endometriosis Foundation. I’m also on the
Advisory Board for EndometriosisZONE. We’re at the 9th Minimal
Access Course at the Women’s Hospital at the Hilton Hotel in Auckland, New
Zealand. This afternoon I have with me Dr. Ossie Petrucco. Ossie is
a senior lecturer at the University of Adelaide, in the Department of Obstetrics
and Gynaecology. He’s the Deputy Head at REPROMED in Adelaide. He’s also the
Director of Gynaecology at the Women’s & Children’s Hospital in
Adelaide. Welcome Dr. Ossie Petrucco. And welcome also to Dr. Robert O’Shea, a senior
consultant and lecturer at Flanders Medical Centre. He’s head of Flanders
Endo-Gynaecology, and Chair of AGES. Welcome to both gentlemen this afternoon. I’d really
like to talk about some of the interesting subjects that were discussed this
morning. One of them that came up, of course, was the problem of adhesions in
relation to endometriosis surgery. I wonder if you could shed some light on that
for us this afternoon? Dr.
Ossie Petrucco: Well,
I guess one of the things that attracted us both to laparoscopic surgery, as
opposed to traditional surgery that we used to do by laparotomy, was the
information that came out from Michael Diamond and other researchers some years
ago that seemed to indicate that by utilising the laparoscopic approach, there
seemed to be much less adhesion formation, both pre-existing adhesions, but
perhaps even more important, de novo adhesion formation in the pelvis.
That seemed to be a bit of an incentive at any rate for me to have a look at
endoscopic surgery. I guess you’ve had similar aims and experiences? Dr. Robert O’Shea:
Yes,
although there have some conflicting evidence in the literature about this, but
I think the general view is that the most appropriate way to treat adhesions
would be laparoscopically, just as Ossie is using, less new adhesion formation. Dr.
Ossie Petrucco: And
certainly the results that we seem to find in terms of recurrence of the
symptoms, of pain, but particularly in relation to fertility, women that want to
achieve pregnancies, the success of operations seems to be just as high for
operations where women go home the same day, as opposed to laparotomies where
they languished in hospital for much longer. But I guess the other
thing about adhesions is that a lot of very important research was done in the
last ten, 20 years, and we now know a heck of a lot more about the healing
process of the peritoneum. It’s not inappropriate to mention that the
peritoneal surface is almost as large as the skin surface in the body, but the
two tissues are totally different. Peritoneum heals in a totally different
manner. It’s composed of very fragile cells that are able to reduplicate
themselves, and the repair process of denuded areas of peritoneum is very rapid,
and is very complete. Unlike skin, that has to re-grow very slowly from the
edges where injuries have occurred. The major factor that
prevents normal healing happening is trauma to the peritoneal surfaces that may
be performed, unfortunately, inappropriately in some areas of surgery. Dr. Robert O’Shea:
Do you
have a feel, Ossie, that there’s been some discussion about issues, such as
gas temperature, and even about alternative types of insufflation gas? Dr.
Ossie Petrucco: I’m
sure it’s very important to try and keep the area in its proper moisture, and
at its proper temperature, and not allow desiccation to occur. That’s the type
of trauma that we hardly realise was happening at the beginning of endoscopic
surgery as Rob says. It’s also very important to use electrical cautery or
laser power judiciously. The
more damage, the more death that you produce in tissue, the more difficult
it’s going to be for peritoneum to heal itself. The other two very important features, I believe, and I
think Rob will agree, would be taking care of haemostasis, but in such a way
where we don’t produce too much associated trauma. In other words use fine and
pinpoint haemostasis with electric cautery. And then, use lots and lots of fluid
in the pelvis to wash away any necrotic cells, to allow peritoneum to heal
itself. We’ve also realised that because of its capacity to virtually heal
itself within a few days that it’s totally inappropriate to use sutures and
other foreign bodies that will just complicate the whole issue. So, very careful haemostasis, and plenty of wash out,
Robert, I’m sure you agree, is an important feature of the work we do. Dr. Robert O’Shea:
Sometimes one can approach division
adhesiolysis as a planned procedure. Very often, one stumbles upon it almost by
accident, although so many patients these days have had previous surgery, but
there is no doubt that sometimes one will laparoscope somebody for some issue,
but then discover they have quite extensive adhesions. And that may be the time
to wonder, is this the time to go ahead and perform an extensive adhesiolysis,
or should one do it as an interval procedure after carefully counselling the
patients about potential complications, making sure the patient is bowel prepped
beforehand, and talk about the risk of damage to the bowel and other structures? Ossie, what are your views about techniques of entry for
patients with significant adhesions? Dr.
Ossie Petrucco: I
think the patient’s safety is paramount, and it’s very important, I think,
that if we feel that there may be any adhesions at the traditional umbilical
entry site, that we should simply go higher up in the abdomen. I quite often
choose to go below the left subcostal margin (Palmer’s Point), to produce the
initial insufflation, and to have a look with a small telescope and see, in
fact, what is happening at the umbilicus or further down in the pelvis to make
sure that any further insertion of trocars will be done in a safe way. It’s very unusual, even in very bad cases of pelvic and
abdominal adhesions, to find that the left hypochondrium is too encumbered with
adhesions. I believe that’s a reasonable way of approaching any situation that
might be a dangerous one at the umbilicus. Dr. Robert O’Shea:
Yes, I would totally concur with that. The
other problem often arises after one has introduced, sometimes blindly, the
major trocar, at the umbilicus. One is in a mass of bowel adhesions. To really
tackle those adhesions you need to put ports in either the left or right side, I
believe. These are say a 5 mm port through left laterally. Then tackle those
adhesions down the umbilicus, so that one can then move on to the pelvis, or
whatever the designated area of surgery was. Deborah
Bush QSM: Are
either of you using any of the other modes of treatment for preventing adhesions
forming, following surgery, that seem to be gaining some interest in endoscopic
work for endometriosis now? Dr. Robert O’Shea:
Well,
the use of Intercede as an agent has been around for some years, but because of
its nature can be potentially difficult to use laparoscopically. Also, if one
has any bleeding at all, that is if you get any oozing, after say, laying
Intercede on an area of peritoneum for instance, an ovarian fossa, if you get
any slight oozing after that, well that can actually have the opposite effect
from what you wanted, and cause adhesions. So Intercede, I think, has been
technically difficult to use laparoscopically, and hasn’t really achieved its
true potential. The new agent that
Ossie has used is Spraygel; what’s your experience using Spraygel? Dr.
Ossie Petrucco: I
started using Spraygel because it seems a very easy way of applying an adhesion
barrier. As Rob said, Intercede can be a little bit tricky to apply, even if you
just wrap up the ovaries, or to apply on flat surfaces, it’s not always so
easy. But we did do some animal experiments, and so have lots of
other people. And to my satisfaction, in sheep, having created a standard
lesion, we found that we could reduce the incidence of adhesions on the treated
side, as opposed to the untreated side, on the opposite part of the pelvis, in
this experimental animal by at least 50% reduction in adhesion formation.
Similar experiments in rats and other animal models have tended to show the same
thing. The human data - data that I think most people would
accept as being properly conducted research - tended to show the same thing. It
doesn’t by any means reduce adhesions by 100%, but it certainly improves the
outcome as far as patients are concerned. The only thing that I think that has
prevented its very widespread use is, of course, the question of cost. Spraygel, seeing that it is easier, now requires long
term, prospective studies, where people will actually go back and do second look
laparoscopies and document different parts of the pelvis that have been treated
to see whether there’s really been an improvement. Deborah
Bush QSM: Well,
certainly in the look at the surgery that we had this morning, and the
presentations that were made, it was most encouraging to see very little
adhesion formation following good excision of endometriosis on the peritoneal
surfaces anyway. Dr.
Ossie Petrucco: That’s
the point I was going to come back to. I think that if we just rely on crutches
like adhesion prevention barriers, we will ultimately forget the most important
principles of preventing adhesions, and that has to be good surgery. I think Charles Koh demonstrated that even in the worst
cases of endometriosis, with complete obliteration of the cul-de-sac, leaving
large, raw areas, as long as the tissue that remains is healthy the peritoneum
will heal itself. There won’t be a lot of adhesions. Adhering to good surgical
principle, washing away debris, careful haemostasis, not leaving a lot of
foreign bodies or lots of sutures – I think the body heals itself basically.
And particularly if we use the same principles that we used in microsurgery
before, were likely to get the best results. Deborah
Bush QSM: Dr.
Ossie Petrucco I thank you very much for your comments this afternoon. Dr.
Robert O’Shea, would you like to add anything further? Dr. Robert O’Shea:
Well,
just to finish off, Spraygel is not necessarily the panacea in endometriosis as
was discussed. It may well be useful, it may have a place on the pelvic
sidewalls or in the ovarian fossa, but after extensive pelvic pouch Douglas
excision with bowel involvement, currently there are some anxieties about using
Spraygel as it may actually be associated with pelvic abscess or prevent healing
of quiescent bowel injuries. Deborah
Bush QSM: Doctors,
thank you very much for this afternoon’s time and I’m sure we’ll enjoy the
rest of the course both this afternoon and tomorrow. Thank you. Dr. Ossie Petrucco: Thank you, Deborah. See also the EndometriosisZONE.org section on adhesions
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