骨盆腔沾黏 Pelvic Adhesion
Definition
Pelvic adhesion are defined as pathologic bonds between surfaces of the peritoneal cavities formed during the scarring of peritoneal scar defects.
Clinical Significance
Four main problems produced by pelvic adhesion
1. small bowel obstruction
2. difficulties on reoperation
3. female subfertility / infertility
4. pelvic pain
Etiology
Post-surgical procedure
Endometriosis
PID (Pelvic inflammatory disease)
Severe form of PID : TOC (Tuboovarian complex) TOA (tuboovarian abscess)
Benign ovarian neoplasm
Malignant disease
Pathogenesis
Crucial events leading to adhesion formation
1. Peritoneal inflammatory response with fibrin formation
2. Loss of fibrinolytic activities in mesothelial cells
Clinical Manifestation
Symptom: noncyclic abdominal pain (esp. increased with intercourse or activity)
Sign : bowel obstruction, infertility
Diagnosis
Previous history of abdomino-pelvic surgery & inflammatory disease of pelvic cavity
Clinical signs suggestive of pelvic adhesion
1. Vaginal exam. : limitation of motion of pelvic organs (uterus & adnexas ) ; fibrosis / nodularity of cul-de-sac
2. Ultrasound : abnormal spatial relationship among pelvic organs
3. Signs related to bowel obstruction : postprandial distension, abdominal distension, constipation, decreased bowel sound, and low quadrant tenderness
Confirmation of diagnosis : Laparotomy/ Laparoscopy
Management
Prevention of Pelvic Adhesion
Improvement in surgical technique
1. Using principles of microsurgery:
(1) Using magnification
(2) Gentle tissue handling
(3) Meticulous hemostasis
(4) Using fine instruments & non-reactive suture material
2. Avoiding tissue dessication
3. Talc-free gloves
4. Avoiding tissue ischemia
5. Liberal use of peritoneal lavage with saline or Ringer's lactate solution
6. Allowing peritoneal defect to heal spontaneously (efficacious in animal study)
Intraperitoneal instillates
1. Ringer's Lactate
(1) around 300-500cc soln could be left in peritoneal cavity;
(2) it decreased adhesion formation in a rat moel; but results in human is unconvinced
(3) there is cocern about the dilutional effect of crystalloid with impaired immune response and subsequent infection or sepsis
2. High molecular weight dextran (dextran-70)
(1) efficacy ??
(2) there is anxiety over pelvic infection after large volume of instillation
3. Carboxymethylcellulose --- similar to dextran
4. Hyaluronic acid ---
(1) a high molecular weight polymer;
(2) it protects and lubricate cell;
(3) it should be used before tissue injury;
(4) combined use with low molecular weight heparin (LMWH) improved the efficacy
5. Chondroitin sulfate --- higher concentration(25%) is superior to carboxymethylcellulose
6. Fibrinolytic agents ---results were promising in animal studies
(1) Streptokinase
(2) Urokinase
(3) tPA
Barrier agents
1. Oxidized cellulose (Interceed®)---absorbable; excellent hemostasis is needed at sites of application; adhesion formation is reduced in human studies; cocerns: it is degraded by inflammatory reaction & may be a procoagulant
2. Polytetrafluoroethylene (Preclude®)---nonabsorbable; it mechanically seperates the traumatic tissues and prevents adhesion formation ; it has to be anchored to the tissue; it has shown fewer postsurgical adhesion than Interceed® in 2 studies.
3. Seprafilm®(hyaluronate + carboxymethylcellulose) ---bioresorbable membrane; adherence to peritoneal surfaces without procoagulant effects; resorption within 7 days and excretion within 28 days; effective in reducing post-myomectomy adhesion
4. Polyethylene gycol hydrogel --- results were comparable to Interceed & Seprafilm
Antiinflammatory agents
(Systemically administered antiinflammatory agents seems to be ineffective in prevention of pelvic adhesion as access of drug to the ischemic/traumatic tissue is poor.)
1. NSAIDs
2. Corticosteroids
3. Histamine antagonists
4. Antioxidants eg.VitE
Second-Look Laparoscopy for Lysis of Adhesion
1. The optimal time to perform second-look lalaproscopy is within 6 weeks after initial surgery.
2. Early second-look laparoscopy and lysis of adhesions are associated with increased pregnancy rate
3. Possible superiority of laparoscopy
(1) Peritoneal surface is less exposed to dehydration during laparoscopy than with laparotomy.
(2) The lack of need to use bowel packs to expose the operative site, which can traumatize peritoneal surface
(3) Magnification of image makes precise incision and coagulation possible.
(4) Reduction in tissue handling