Our strategy: Lift-Laparoscopc adhesiolysis

May 10, 2011

ADHESIONS : OUR STRATEGY

Since March 2001 we have been using this novel spray substance (spray gel) to prevent adhesions following gynaecological surgical procedures.

In general, adhesions are formed after all surgical measures involving laparotomy.

But even during laparoscopy, which is a form of minimally invasive surgery, wound surfaces can be formed during certain procedures, such as for example endometriosis or myoma operations.

These surfaces can adhere to each other, thus forming adhesions.

These adhesions can later cause problems such as pain, adhesion of the uterine tubes (infertility) or of other organs (intestines / ovaries / uterus).

They thus have the potential to cause chronic problems and pain requiring tedious treatment measures, and possibly even adhesiolysis, a follow-up surgical procedure to remove these adhesions.

The new gel substance (SprayShield™) is sprayed onto the wound surfaces, where it remains in place for some days after surgery.

Since adhesions are formed within 7 days of surgery, the barrier system thus prevents formation of adhesions.

After this period, SprayShield™ is then broken down and simply absorbed by the peritoneum and excreted from the body via the kidneys.

The carbon dioxide customarily used to insufflate the abdomen during laparoscopy converts the entire peritoneum into an acidic environment.

This thus results in oxygen being withdrawn from the tissues and can cause cells to die, with formation of global wound surfaces in the peritoneum and abdominal organs

By using gasless laparoscopy, we avoid insufflation with carbon dioxide, which has been shown by recent studies — for the aforementioned reasons — to be a co-factor adhesion formation.

But since wound surfaces are always formed during surgery because of tissue layers being separated, the formation of adhesions can additionally be prevented on such surfaces by spraying them with SprayShield™.

Hence in the gasless laparoscopy technique and SprayShield™ we have an ideal combination that helps to prevent the occurrence and formation of adhesions.

Dr. Kruschinski has now performed adhesiolysis on around 700 cases using the technique of gasless lift-laparoscopic adhesiolysis with SprayGel™ / SprayShield™ application

Adhesions are known to form as soon as three hours after the completion of a surgical procedure – and will continue to form for up to about seven days.
If any adhesions have formed during this critical time period, they can easily be “swept down” by the surgeon during a second look laparoscopy – and more SprayGel can be applied, if needed.

Dr. Daniel Kruschinski is one of the very few surgeons in the world, who performs a second look laparoscopy (SLL) about seven days after the initial surgical procedure.

In Dr. Kruschinski’s experience the risk of adhesions resulting in the need for a subsequent surgery is greatly reduced. He has mastered the required advanced microsurgical laparoscopic techniques and has logged thousands of hours in performing very difficult, time-consuming, risky surgical procedures.

Repeat surgery for adhesions in these cases is usually less extensive and does not usually involve the same amount of dissection that led to the formation of adhesions in the first place
Here are some of Dr Kruschinski’s results in general

  • About 89,9 % are adhesion free at the 2nd laparoscopy at 7 days postoperative.
  • In those patients who have small adhesion attachments to the surgery sites at the second look laparoscopy 7 days post-operatively, these attachments are removed very easily by simply touching them with an instrument.
  • Only 10% developed pain after surgery and had a third look laparoscopy in which adhesions were seen to be the cause of pain, the scores were reduced when compared to the initial surgery, especially in grade and severity. In other cases there were other reasons fo pain like adnexal tumour etc
  • Thus the success rate of the gasless adhesiolysis with spray gel in patients being adhesion and pain free is about 90%.

For Photos of Our Technique of Gasless Adhesiolysis With Spray Gel Click On The Links Below

And images with SprayGel™ in our Endoscopy Atlas Severe bowel adhaesions & Extremely severe bowel adhesions

WHAT IS SECOND LOOK AND THIRD LOOK LAPAROSCOPY FOR ADHESIONS?

SECOND LOOK LAPAROSCOPY (SLL)

The principle of SSL was first introduced by Swolin to evaluate the result of some surgical procedures.

This principle soon became a routine used by many gynecological surgeons and investigators allowing a chance to perform adhesiolysis for the de novo or recurrent adhesions encountered during SLL.

Dr. Daniel Kruschinski is one of the very few surgeons in the world, who performs a second look laparoscopy (SLL) about seven days after the initial surgical procedure.

In Dr. Kruschinski’s experience the risk of adhesions resulting in the need for a subsequent surgery is greatly reduced.

He has mastered the required advanced microsurgical laparoscopic techniques and has logged thousands of hours in performing very difficult, time-consuming, risky surgical procedures.

Repeat surgery for adhesions in these cases is usually less extensive and does not usually involve the same amount of dissection that led to the formation of adhesions in the first place.

The same was shown by Jansen, who reported that second-look laparoscopy resulted in a significant reduction in adhesions at the time of a “third-look laparoscopy”.

Trimbos-Kemper reported a reduction in the incidence of ectopic pregnancy in women who had undergone SLL, although the intrauterine pregnancy rate was unchanged.

Surry and colleagues reported a 52.1% intrauterine pregnancy in 31 patients who had undergone early SLL after reconstructive pelvic surgery.

Other potential advantages of second-look laparoscopy include the ability of the surgeon to assess the efficacy of surgical techniques or adjuvants, as well as to provide the patient a reasonable assessment of likely prognosis.

If the patient is among the approximately ten percent of subjects in whom adhesions worsen, that patient may benefit from early referral to ART as opposed to protracted lengths of time spent trying to conceive against very long odds.

THIRD LOOK LAPAROSCOPY

Dr Kruschinski offers a third look laparoscopy to patients whom are symptomatic even after 3 months of second look laparoscopy.

Surgeon sees an improvement of the adhesion score as a success, whereas the patient often sees an improvement of symptoms or a complete disappearance of symptoms as a success!

After surgery some adhesions may return, the surgeon might measure the reduction of adhesions as an improvement while the patient says s(h)e has pain and therefore concludes the adhesions are back!

In some cases there may be a huge improvement of adhesions (by 99%), but some small adhesions might have formed somewhere and cause extreme pain.

Hence , a third look laparoscopy will help identify these small adhesions but which cause symptoms and will most importantly treat them.

Trimbos-Kemper and co-workers went to further “third-look laparoscopy” in patients who had undergone an early second-look procedure with adhesiolysis at that time. They reported that more than half of the adhesions that were separated at the second-look laparoscopic procedure did not recur.

Different Examples
 
Left pelvic and abdominal wall adhesions
Left pelvic brim and anterior abdominal wall, omental and bowel adhesions Another view to show the bowel involvement
After first dissection of adhesions, bowel involvement The left pelvic brim and the anterior abdominal wall after dissecting the adhesions
The left pelvic brim and the anterior abdominal after application of SprayGel™ The left pelvic brim and the anterior abdominal at the second-look laparoscopy on day 7 postoperative
 

Related Posts: