CURRICULUM VITAE• Nama : Brahmana Askandar

• Pekerjaan : Ketua Divisi Onkologi Ginekologi Dept. Obstetri Ginekologi FK Unair SurabayaSekretaris program studi Obsgyn FK Unair Surabaya

• Pendidikan : S1 FK Unair Surabaya (1999))Spesialis Obsgyn FK Unair (2003)Konsultan Onkologi Ginekologi FK UI (2007)S3 FK Unair (2015)

• Fellowship : - St Stephen Hospital – Budapest (2007)- UMC – Utrecht – Netherlands (2011)

• Email : brahmanaaskandar@yahoo.com

D r. B r a h m a n a A s ka n d a r , d r , S p O G ( K )

ADHESION PREVENTION

Divisi Onkologi Ginekologi, Dept. Obstetri GinekologiRSU Dr. Sutomo – FK Unair Surabaya

ADHESION FORMATION

• Adhesion formation begins immediately after surgery. Following tissue trauma, inflammation brings macrophages, fibroblasts, and a fibrin matrix to the surface of the wound

• On approximately day 3 after surgery, macrophages form the foundation of the advancing adhesion. Fibrin matrix advancement occurs with the proliferation of fibroblasts and vascularization.

• By day 5, the advancing adhesions are increasingly vascular and organized in structure.

• No new adhesion formation occurs after day 7 Rev Obstet Gynecol. 2009;2(1):38-45

ADHESION FORMATION• The repair of peritoneal

defects occurs from the underlying mesenchyme. As a result, both large and small peritoneal defects heal relatively quickly

• Fibrinous adhesions form within 3 hours after injury and result from decreased fibrinolytic activity.

• Most fibrinous adhesions are transient and break down within 72 hours, but trauma-induced local suppression of peritoneal fibrinolysis predisposes to adhesion formation Fertility and Sterility Vol. 86, Suppl 4, November 2006 S1

ADHESION FORMATION

• Reduced fibrinolysis activity adhesion

• Surgery diminishes fibrinolytic activity dramatically by increasing levels of plasminogen activator inhibitors and by reducing tissue oxygenation

• Fibrinolysis can be impaired by thermal injury, desiccation, ischemia, foreign bodies, blood, and bacteria.

“ Optimal prevention of adhesion formation requires intervention throughout the critical 7-day period of peritoneal healing “

Rev Obstet Gynecol. 2009;2(1):38-45

MORBIDITY OF ADHESION• Intestinal obstruction

5.7 percent of 21,347 readmissions were classified as relating directly to adhesions, and 3.8 percent required operation *

• Infertility 10% of female infertility caused by adhesion **

• Chronic abdominal pain Dense adhesions can limit organ mobility,

which may cause visceral pain

* Lancet. 1999;353(9163):1476.** Br Med J (Clin Res Ed). 1985;291(6510):1693

COMPLICATIONS FOR THE NEXT SURGERY

• Difficult abdominal access related to loss of tissue planes or distorted anatomy

• Inability to perform laparoscopic surgery, continuous ambulatory dialysis or other intraabdominal drug delivery

• Inadvertent injury to the small bowel, bladder, or ureters

• Increased duration of surgery and prolonged anesthesia

• Increased blood loss

HIGH RISK SURGERIES

• Ovarian surgery • Endometriosis surgery • Tubal surgery • Myomectomy • Adhesiolysis

ADHESION BARRIERS

COCHRANE STUDY• Objective :

To evaluate the role of fluid and pharmacological agents used as adjuvants in preventing formation of adhesions after gynaecological surgery.

• Method- Oxidised regenerated cellulose (Interceed) versus no treatment - Expanded polytetrafluoroethylene (Gore-Tex) versus no

treatment- Expanded polytetrafluoroethylene (Gore-Tex) versus oxidised

regenerated cellulose (Interceed)- Sodium hyaluronate and carboxymethylcellulose (Seprafilm)

versus no treatment

- Fibrin sheet versus no treatment

COCHRANE STUDYConclusion1. 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.2. 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.

3. 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.

4. No adverse events directly attributed to the adhesion agents were reported.

5. 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.

ADHESION BARRIER - UPTODATE

•  Two absorbable membrane sheets are commercially available. One is an oxidized regenerated cellulose sheet, (Interceed) and the second is a sodium hyaluronate-based carboxymethylcellulosesheet (Seprafilm).

• Both appear safe and effective for preventing adhesions between surfaces to which they are applied, but are somewhat difficult to handle and do not prevent adhesion formation at other sites within the abdomen.

IRRIGATION

IRRIGATION SOLUTION

• Crystalloid solutions, • High-molecular-weight dextran • Heparin• Nonsteroidal anti-inflammatory drugs (NSAIDs)

CRYSTALLOID SOLUTION• Results from multiple studies looking at the use of

hydroflotation with crystalloids have been discouraging. • Results of a meta-analysis of 259 reports from 1966

through 1996 concluded that crystalloid does not reduce adhesion formation, and its suggested that its use be discouraged.*

• Crystalloid solutions should not be expected to prevent adhesion formation because of their short intraperitoneal time of residence **

*  Fertil Steril. 1998;70:702–711.** Fertil Steril. 1994 Feb;61(2):219-35.

HEPARIN

• The rationale behind the use of heparin includes the prevention of blood clotting and fibrin deposition, which are involved in adhesion formation. Unfortunately

• The largest randomized, placebo-controlled clinical trial addressing this approach showed no benefit in terms of adhesion formation between the study and control groups*

 Surg Gynecol Obstet. 1988 Feb; 166(2):154-60.

DEXTRAN

• High-molecular-weight dextran has also been used for hydroflotation. Due to its high viscosity and long half-life in the peritoneal cavity, concerns have arisen about excessive fluid shifts leading to cardiovascular compromise• Results of prospective randomized trials

evaluating the efficacy of high-molecular-weight dextran are conflicting.

  Acta Obstet Gynecol Scand. 1985; 64(5):437-41.

NSAID

• NSAIDs have also been recommended to prevent postoperative pelvic adhesions by blocking the production of thromboxanes, which are known to be involved in the biochemical pathways leading to adhesion formation.

• However, lack of adequate studies evaluating their safety and efficacy has limited their clinical application

CONCLUSION OF INTRAOPERATIVE IRRIGATION

• A systematic review found no significant benefit from the use of intraoperative irrigation or infusion of various drugs and liquids, including intraperitoneal steroids (one trial, 61 subjects), dextran (two trials, 210 subjects), or heparin (one trial, 63 subjects) 

Cochrane Database Syst Rev. 2006

LAPAROSCOPY

LAPAROSCOPY AND ADHESION• Minimally invasive surgery offers the advantages of less tissue

and organ handling and trauma.

• Minimally invasive laparoscopic surgery with up to10-fold magnification helps to maintain tissue moisture, avoids contamination with foreign bodies such as surgical glove powder

• Facilitates more precise tissue manipulation. • Pneumoperitoneum has a tamponade effect that facilitates

hemostasis

• Laparoscopy is associated with a lower incidence of postoperative infection.

LAPAROSCOPY AND ADHESION• The abdominal incisions are small and thus to reduce the

risk for adhesion formation, especially to the abdominal wall *

• Laparoscopic surgery certainly does not guarantee the prevention of adhesions*

• Longer durations of surgery and high insufflation pressures can even increase the risk for adhesion formation*

• With the exception of laparoscopic sterilizations, open and laparoscopic gynaecological surgery are associated with comparable risks of adhesion-related readmissions **

  * Uptodate.com – Nov 2015** Hum Reprod. 2004;19(8):1877.

ADHESIOLYSIS

THE INDICATIONS FOR SURGICAL LYSIS OF ADHESIONS

• For patients with signs and symptoms of bowel obstruction and  for those with partial obstruction who do not respond to conservative management

• For treatment of infertility

• Performing adhesiolysis for pain relief can be effective in certain subsets of patients Unfortunately, even after lysis, adhesions often re-form

Peritoneal Closure

PERITONEAL CLOSURE

• Surgical closure of the peritoneum does not impact incision strength or healing• The peritoneum reepithelializes within 48 to 72

hour*• Peritoneal closure results in more advanced

adhesion formation at the time of a subsequent procedure• The incidence of adhesions at the site of closure

after laparotomy is approximately 22% with peritoneal closure and 16% without peritoneal closure *

  * Am J Obstet Gynecol, 158 (1988), pp. 536–537**Eur J Obstet Gynecol Reprod Biol, 108 (2003), pp. 40–44.

SURGICAL TECHNIQUE

SURGICAL TECHNIQUES• Good surgical technique was the main way to prevent

postoperative adhesions

• Careful surgical technique including - gentle tissue handling- meticulous hemostasis- excision of necrotic tissue- minimizing ischemia and desiccation- the use of fine, nonreactive suture materials- prevention of foreign-body reaction and infection

GOOD SURGICAL TECHNIQUES• Carefully handle tissue with field enhancement

(magnification) techniques

• Perform diligent haemostasis and ensure diligent use of cautery

• Reduce cautery time and frequency and aspirate aerosolised tissue following cautery

• Excise tissue—reduce fulguration

GOOD SURGICAL TECHNIQUES• Reduce duration of surgery

• Reduce pressure and duration of pneumoperitoneum in laparoscopic surgery

• Reduce risk of infection

• Reduce drying of tissues`• Use frequent irrigation and aspiration in

laparoscopic and laparotomic surgery when needed

GOOD SURGICAL TECHNIQUES• Limit use of sutures and choose fine non-reactive

sutures

• Avoid foreign bodies when possible

• Avoid non-peritonised implants and meshes

• Minimal use of dry towels or sponges in laparotomy

• Use starch and latex-free gloves in laparotomy

ADHESION PREVENTION

• Technical measures (surgical techniques), • Physical barriers, which may be solid or liquid• Pharmacologic therapies

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