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Text based upon : see our publications :
Koninckx PR, Gomel V. Introduction: Quality of pelvic surgery and postoperative adhesions. Fertil Steril. 2016;106:991-993

Koninckx PR, Gomel V, Ussia A, Adamyan L. Role of the peritoneal cavity in the prevention of postoperative adhesions, pain, and fatigue. Fertil Steril. 2016;106:998-1010.


Gomel V, Koninckx PR. Microsurgical principles and postoperative adhesions: lessons from the past. Fertil Steril. 2016;106:1025-1031.


Koninckx PR, Ussia A, Wattiez A, De Wilde RL. Laparoscopic management and prevention of pelvic adhesions and postoperative pain. In: Einarsson JI, Wattiez A, editors. Minimally invasive gynecologic surgery : Evidence based laparoscopic, hysteroscopic and Robotic surgeries. JP Medical limited, victoriastreet 83, London; 2016

Koninckx et al 2010 NEW CONCEPTS IN ADHESION PREVENTION : book chapter

Postoperative adhesions and their prevention in Gynecology

Last International Presentations

gynecology postoperative adhesions
ESHRE , Stockholm July 1th 2011
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Postoperative Adhesions are a major clinical problem

gynecology postoperative adhesions
Postoperative adhesion over adnexa
gynecology postoperative adhesions
Postoperative adhesions over uterus
gynecology postoperative adhesions
Postoperative : Bands

Postoperative adhesions occur in 80% after surgery and cause chronic pain, infertility and bowel obstruction. Thus 30% van alle chronic pain in women, 30% of infertilities 100% of all bowel obstructions are caused by postoperative adhesions

postoperative adhesions
The role of the peritoneal cavity
postoperative adhesions
Clinical importance
postoperative adhesions
The old model of Postoperative adhesions: a local process
Pathophysiology of adhesion formation
postoperative adhesions
the old model of postoperative adhesions : a local process
postoperative adhesions
The new model of postoperative adhesions

The old model of postoperative adhesions  considers adhesion formation as a cascade of local processes between denuded areas. Either repair is rapid within a few days or adhesion formation starts
The new model of postoperative adhesions developed by our group has demonstrated that the acute inflammatory reaction in the peritoneal cavity is 20 times more important than this local process. The sum of all the good and bad factors will determine the degree of acute inflammation of the peritoneal cavity and thus of of postoperative adhesions. These are :

  • Duration of surgery and the degree of manipulation (For this reason a slow or less experienced surgeon will have more adhesions )
  • Desiccation will occur systematically unless specific preventive measurements are taken such as the cooling with a third means.
  • A better gas mixture instead of CO2 that is very irritant

For this we received a series of international rewards

postoperative adhesions
2001 Jerome Hoffman
price of the aagl
1st Prize
BELGIAN SOCIETY OF
REPRODUCTIVE MEDICINE
2001 Molinas et al
1st Prize ESGE
R. Palmer Prize.
2001 Molinas et al
1st Prize ESHRE
PROMISING YOUNG
SCIENTIST AWARD
2002 ESHRE Molinas et al
1st Prize ESGE
Cagliari
2004 Binda et al
2002 : Ospan Mynbaev CO2 resorbtion
postoperative adhesions
the new model
postoperative adhesions
the new model of postoperative adhesions
postoperative adhesions
the old model of postoperative adhesions
Prevention of adhesions

prevention of adhesion formation

During Surgery : updated microsurgical principles or full conditioning

Technique of surgery

Strict antiseptic measures : because of the adhesiogenic effect of inflammation
Reduce duration of surgery : Adhesion formation increases with the duration of surgery. Surgery however should remain safe and should not become a contest.
Gentle tissue handling : reduce as much as reasonable grasping, pulling and pushing, with as little force as possible. A minimal trauma already damages mesothelial cell integrity.
Moisten gauzes or packs for the same reason to decrease mesotheleal cell damage.
Prevent bleeding and prevent fibrin deposition by lavage.
Reduce the amount of de-vascularized or ischaemic tissue as much as possible. Thus avoid excessive coagulation and unnecessarily deep and tight suturing.

Prevent damage to the mesothelial cells in the entire peritoneal cavity

Use a cell friendly solution for irrigation eg Ringers lactate, at RT or at 30°C maximum
During laparoscopy with CO2 pneumoperitoneum

postoperative adhesions
is superficial

Reduce insufflation pressure during laparoscopic surgery as much as practically possible
Add 10% of N2O
Humidify

postoperative adhesions
cooling

Cool the cavity to some 30 ° with a third means

During open surgery : instillate 1 to 2 L of a similar gas deep in the surgical wound and aspirate to avoid OR contamination. This should prevent desiccation and oxidative stress by the 20% of oxygen in air

At the end of surgery

Extensive lavage until the liquid is clear. This can require up to 8L and should comprise also the upper abdomen.
Ovariopexie to keep the ovaries out of the pelvis might is useful but this is unclear. If performed it is unclear for how long.
Dexamethasone 5 mg IM

Flotation agents
Adept : FDA approved
effective ?: unclear
Ringers Lactate : cheap
effective in our mouse model
no clinical evidence
Barriers
maximum 40-50% effective
no demonstrated effect upon
pain, infertility, reintervention
not FDA approved

Apply a barrier to keep opposing lesions separated : Barriers are based upon the old model and are some 40% to 50% effective.All available products have an efficacy of 40 tot 50% at best and this for specific (simple) interventions performed by experts. In addition, the variability of results is high.
Therefore efficacy has not been demonstrated for any product for a clinical endpoint as infertility, or pain or re-intervention. These products are marketed as devices. Only for Adept safety has been extensively demonstrated . This is the only product approved by the FDA today.

After surgery

Do not delay unnecessarily long drinking and re-alimentation in order to resume bowel movements as early as possible. This however is not demonstrated in RCT,

Start prophylactic antibiotics when the risk of infection is increased such as after opening the vagina or the bowel

Conclusions

postoperative adhesions
The future

The near 100% efficacy was demonstrated in RCT’s.

Other advantages of Conditioning of the peritoneal cavity

postoperative adhesions
less tumor metastasis
postoperative adhesions
less CO2 resorbtion
Peritoneal Conditioning
additional advantages
pain
CO2 resorbtione
tumor metastasis

less postoperative pain , estimated at a 60% decrease.
Less CO2 resorption is a major advantage for laparoscopic surgery of longer duration especially in more obese patients
Less tumor metastasis, if confirmed in the human, the importance is obvious in reducing mortality

Important articles of the goup

postoperative adhesions

2009 Schonman et al : surgical manipulation
2006 Binda :cooling
2004 Elkilani : ringers lactate for adhesion prevention
2003 Binda : ROS and adhesions
2001 Molinas : effect of hypoxia

Images of adhesions

postoperative adhesions
Postoperative adhesions : umbilical adhesions
postoperative adhesions
Postoperative adhesions: Velamentous adhesions
postoperative adhesions
Postoperative adhesions: bands
postoperative adhesions
Postoperative adhesions: after Appendectomy
postoperative adhesions
Postoperative adhesions: Frozen pelvis
postoperative adhesions
Postoperative adhesions: severe adhesions
postoperative adhesions
Postoperative adhesions: Vascular adhesions
postoperative adhesions
Postoperative adhesions: Encapsulated ovary

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