WHAT IS THE NON-SURGICAL TREATMENT OF ADHESIONS?
Medication can play a crucial role in controlling pain – whether acute or chronic.
For acute pain, medication is often the first treatment choice.
For chronic pain, it may serve as part of a broader treatment package.
This could include exercise, physical therapy and behavior change.
Although they can be helpful, medications aren’t a cure-all and can cause side effects or be ineffective and costly.
The best alternative to surgery is to seek the help of a pain specialist.
Only a pain specialist has the specialized training needed to treat chronic pain.
Their specialized training enables them to offer a variety of pain management techniques that are known to be effective for managing chronic pain.
The specialty of Pain Medicine is concerned with the prevention, evaluation, diagnosis, treatment, and rehabilitation of painful disorders. Such disorders may have pain and associated symptoms arising from a discrete cause, such as postoperative pain or pain associated with a malignancy, or may be syndromes in which pain constitutes the primary problem, such as neuropathic pains or headaches.
The diagnosis of painful syndromes relies on interpretation of historical data; review of previous laboratory, imaging, and electrodiagnostic studies; behavioral, social, occupational and avocational assessment; interview and examination by the pain specialist; and may require specialized diagnostic procedures, including central and peripheral neural blockade or monitored drug infusions.
The special needs of the pediatric and geriatric populations are considered when formulating a comprehensive treatment plan for these patients..
The pain physician serves as a consultant to other physicians but is often the principal treating physician and may provide care at various levels, such as direct treatment, prescribing medication, prescribing rehabilitative services, performing pain relieving procedures, counseling of patients and families, direction of a multidisciplinary team, coordination of care with other healthcare providers and consultative services to public and private agencies pursuant to optimal healthcare delivery to the patient suffering from a painful disorder.
The pain physician may work in a variety of settings and is competent to treat the entire range of painful disorders encountered in delivery of quality health care.
The treatment of chronic pelvic pain is a multidisciplinary specialty.
A team of nurses, psychotherapists, physical therapists, pain specialists, anesthesiologists, urologists, gynecologists and general surgeons working in a coordinated manner can mean maximum benefit for the patient.
Not only is the problem of pelvic pain is receiving the attention is deserves, but the team approach to its management is being recognized as one with merit..
Pain mapping is an emerging technique where, under local anesthetic, the surgeon attempts to locate the focus of pain by prodding different areas within the pelvis.
Sometimes pain is associated with adhesions, and sometimes adhesions (or even loci of endometriosis) do not appear responsible for the pain. If an endometriosis site is discovered and removed, this should be covered with an adhesion barrier.
WHAT IS THE SURGICAL MANAGEMENT OF ADHESIONS?
No longer can the public ignore the benefits of minimally invasive surgery for adhesions.
While these techniques and procedures are not without risk, patients should not be denied the procedures’ inherent advantages.
Patients with symptomatic adhesions usually want minimally invasive therapy.
While the advantages of laparoscopic enterolysis compared with classical laparotomy has not been proven in studies, it is obviously possible with laparoscopy to diminish peritoneal mesothelial cell ischemic damage from trauma, drying, talc, packs and delayed bleeding.
Laparoscopic surgery is distinctly advantageous as the preferred method of access for infertility surgery due to the decreased risk of de novo adhesion formation. Similar surgical outcomes when compared to laparotomy have been demonstrated in the management of endometriosis and extensive adhesions.
The surgical advantages of laparoscopy include panoramic pelvic visualization and magnification, techniques similar to microsurgery, documentation of absolute hemostasis via underwater examination.
Finally, the patient enjoys simultaneous diagnosis and treatment and all the advantages of minimally invasive surgery in terms of cosmetics and rapid recuperation.
Although laparoscopic adhesiolysis can be very time-consuming (2 to 4 hours), and for the surgeon technically difficult, many women are discharged on the same day of the procedure, avoid major abdominal incisions, experience minimal complications and return to full activity within one week of the procedure.
The extent, thickness and vascularity of adhesions varies widely.
Intricate adhesive patterns exist with fusion to parietal peritoneum and/or various meshes.
Peritoneal adhesiolysis is classified into enterolysis, which includes omentolysis and female reproductive reconstruction (salpingo-ovariolysis and cul-de-sac dissection with excision of deep fibrotic endometriosis).
Bowel adhesions are divided into:
* Upper Abdominal
* Lower Abdominal
* Combinations of the Above
Adhesions surrounding the umbilicus are upper abdominal as they require an upper abdominal laparoscopic view for division.
In cases of pelvic adhesions, either the tube is stuck to the ovary or the ovary is adhered to the pelvic sidewall. The rectosigmoid (the rectum and sigmoid colon) may cover both. Rarely, the omentum (a fold of peritoneum extending from the stomach to adjacent organs in the abdominal cavity) and small bowel are involved.
One of the indicator of the degree of severity and expertise necessary for adhesiolysis is the number of previous laparotomies.
The frequency of small bowel obstruction symptoms also indicates the need for surgery.
SURGICAL PLAN FOR ADHESIOLYSIS
A well defined strategy is important for adhesiolysis.
In general, cases are divided into three parts:
1.) Division of all adhesions to the anterior abdominal wall parietal peritoneum. Small bowel loops encountered during this process are separated using their anterior attachment for countertraction instead of waiting until the last portion of the procedure (running of the bowel).
2.)Division of all small bowel and omental adhesions in the pelvis. The rectosigmoid, cecum and appendix often require some separation during this part of the procedure.
3.)Running of the bowel. Using atraumatic grasping forceps and (usually) a suction irrigator for suction traction, the bowel is run.
4.). Tubo-ovarian pathology is then treated if indicated.
With minimally invasive surgical approaches, same-day discharge is common, even after long procedures.
Physical motility of the bowel is encouraged by early ambulation and a clear liquid diet for 2 to 4 days.
Patients are instructed to return gradually to their normal activity during the week after surgery.
Partial small-bowel obstruction during the week after surgery is usually due to ileus and is treated by intravenous hydration and a nasogastric tube if vomiting is present.
If peritonitis occurs in the days after the operation, it must be assumed that an injury to the bowel has gone unnoticed and should be aptly treated.
If an abscess forms postoperatively it can be drained percutaneously under sonographic guidance, or possibly by means of a laparoscopy.
Recurrent adhesions may occur even with atraumatic techniques
WHAT CAN BE DONE TO PREVENT ADHESIONS?
Although there is no way to eliminate the risk of adhesions completely, there are steps your surgeon can take to reduce the likelihood of adhesion formation.
The most effective methods of adhesion prevention involve meticulous surgical technique and the use of a physical barrier to separate tissue surfaces while they heal.
Surgeons have developed microsurgical techniques that minimize trauma, ischemia, foreign bodies, hemorrhage, raw surfaces and infection to reduce adhesion formation.
Minimally invasive techniques such as the laparoscopy, that are designed to minimize trauma, blood loss, infection, and the introduction of foreign bodies, all of which can lead to inflammation and adhesion formation.
Good surgical technique involves minimizing tissue handling, using delicate instruments, and keeping the tissues moist when they are exposed to the air.
Surgical techniques that can help decrease adhesion formation
- Achieve meticulous hemostasis
- Maintain vascularity
- Moisten tissues
- Avoid dry sponges
- Minimize tissue handling
- Use fine, non-reactive sutures
- Avoid peritoneal grafts
- Minimize foreign bodies
Not simply the surgical procedure used, but in combination with these techniques and the minimal invasive surgery, i.e. laparoscopy, one has the best chance of adhesion reduction when used in combination.
While good surgical technique is important, but it is often not sufficient to prevent adhesions.
Even though the most meticulous surgical and microsurgical techniques cannot eliminate the formation of adhesions, the other steps can be taken to reduce adhesion formation further are:
- Achieve meticulous hemostasis: Inadequate hemostasis and the resultant fibrin deposition promote adhesion formation.
- Maintain vascularity: Limiting ischemia supports fibrinolysis.
- Moisten tissues:Frequent irrigation and the use of moist sponges prevent desiccation of tissue.
Ringer’s lactate or other irrigating solutions also eliminate any residual talc, lint, or blood clots, which may provide a nidus for a foreign body reaction, inflammation, and adhesion formation.
- Avoid dry sponges: Use of gauze and dry sponges should be avoided because they may damage the peritoneal surface and leave a foreign body behind.
- Minimize tissue handling:Manipulating tissue increases the possibility of vascular and tissue damage.When direct manipulation of the peritoneum is necessary, use either atraumatic instruments or fingers.In addition, cutting and coagulating should be kept to a minimum to reduce the possibility of trauma and maintain vascularity.
- Use fine, nonreactive sutures:To minimize foreign body reactions use the smallest size of suture composed of synthetic material.
- Avoid peritoneal grafts:Grafting increases the risk of peritoneal trauma while decreasing vascularity.
- Minimize foreign bodies: Foreign bodies may damage the peritoneal surface, lead to inflammation, and ultimately result in adhesion formation.
Various drugs have been evaluated in an effort to reduce the post-operative incidence of adhesions.
To date, no well-controlled study has documented the efficacy of these drugs.
The use of a barrier between raw tissue surfaces appears to be one of the most promising methods of adhesion prevention.
Barriers mechanically separate the surgical surfaces and keep those surfaces apart.
WHAT ARE THE DIFFERENT TYPES OF ADJUVANTS USED TO PREVENT ADHESIONS?
Adhesion formation and reformation are still an unavoidable event in reproductive pelvic surgery in spite of the variable skills in microsurgery and endoscopic surgery.
This fact necessitates the search for barrier that can be used in the perioperative period.
There have various barriers or adjuvants that have been used but none have conclusively proven to be effective in various studies.
CLASSES OF ADHESION-REDUCTION ADJUVANTS AND THEIR PROPOSED MECHANISM OF ACTION
I. Fibrinolytic agents (fibrinolysis, stimulation of plasminogen activators)
II. Anticoagulants (prevention of clot and fibrin formation)
III. Anti-inflammatory Agents (reduce vascular permeability, reduce histamine release and, stabilize lysozomes)
Nonsteroidal anti-inflammatory agents
Calcium channel blockers
VI. Antibiotics (prevent infection)
V. Mechanical Separation (surface separation, hydroflotation)
A. Intra-abdominal Instillates:
Chelated hyaluronic acid
Oxidized regenerated cellulose
Modified from Diamond MP, DeCherney AH: Pathogenesis of adhesion formation/reformation: Application to reproductive pelvic surgery. Microsurgery 1987: 8: 103 and Diamond MP, Hershlag A: Adhesion formation/reformation: in Treatment of postsurgical Adhesions, Wiley-Liss, Inc. 1990: 23-33.