Adhesiolysis during Hysterectomy

Abstract

Hysterectomy sometimes is not as simple as removing the uterus. The most challenging condition before definitive hysterectomy is mostly an adhesion with various grade of severity and need a careful approach to prevent surrounding organ injury. Adhesions can be a significant source of morbidity in patients and provide a thorough overview of the etiology, pathophysiology, and clinical consequences. The authors provide a step-by-step approach including preoperative preparation, surgical techniques, and postoperative management. This chapter also explains the prevention of adhesions and the use of adhesion barriers. With contributions from leading experts in the field, it seems to be an essential resource for any surgeon seeking to optimize patient outcomes in laparotomy. This comprehensive guide might be used by surgeons to improve their understanding and technical skills in dealing with adhesions during laparotomy.

1. Introduction

Fibrous bands of scar tissue are defined as abdominal adhesion, which spans into two or more intra-abdominal organs, or sometimes that inner abdominal wall arises after abdominal surgery. Adhesions might also form as a result of inflammatory abdominal conditions without prior abdominal surgery or as a sequel to abdomino-pelvic radiation [1, 2]. Postoperative adhesions are a natural consequence of surgical tissue trauma and healing. Although the majority of patients with intra-abdominal adhesions remain asymptomatic, a clinically significant subset of patients will develop “adhesive disease,” a symptomatic state ranging from mild and/or vague to highly distressing and even life-threatening symptoms [2].

2. Etiology

Adhesions are the result of tissue injury, likely to occur by the injury of an incision, electrocoagulation trauma and sutures, infection, or by foreign bodies damaging the parietal and visceral peritoneum, which reacts forming abundant aberrant peritoneal healing and scars [1, 3]. Ischemia has been proposed as the most important injury that leads to adhesion development. Another possible underlying mechanism may be a deficient, suppressed, or overwhelmed natural immune system [1].

The most common location of adhesion is within the abdominal cavity and the pelvis. Abdominal adhesions are a common complication of surgery. The most common is in the small intestinal. Pelvic adhesions may involve any organ, such as the uterus, ovaries, fallopian tubes, or bladder, and usually occur after surgery. Pelvic inflammatory disease (PID) results from an infection that frequently leads to adhesions within the fallopian tubes. Fallopian adhesions can lead to infertility and increased incidence of ectopic pregnancy. Endometriosis may also cause pelvic adhesions.

3. Pathophysiology

Adhesion formation has three steps;: (A) inhibition of extracellular matrix degradation system and fibrinolytic (B) induction of an inflammatory response involving cytokine production and transforming growth factor-β (TGF-β); and (C) induction of tissue hypoxia, leading to increase in expression of vascular endothelial growth factor (VEGF). As adhesions mature their cell population changes from days one to three, cells are mainly polymorphonuclear cells (PMN) leukocytes, whereas between days five and seven fibroblasts predominate [4]. Factors that have been identified include those important for the regulation of inflammatory and immune responses, tissue remodeling, and angiogenesis.

Cellular insult results in an outpouring of fibrin and subsequent fibrinolysis. The insult causes hypoxia and the release of reactive oxygen species (ROS), which lead to inflammation and activation of the coagulation cascade. This increases the production of thrombin, which is a key activator of fibrin [4, 5]. Fibrin production and fibrinolysis are part of the physiologic process; if the balance between fibrin production and fibrinolysis becomes compromised pathological adhesion formation occurs [4].

Deposition of fibrin monomers (red and white blood cells, macrophages, platelets, and tissue exudates) develops a polymeric matrix within which fibroblasts can adhere and produce components of extracellular matrix (ECM), setting the stage for mature adhesion formation [3, 4, 5]. A major determinant of the persistence of the fibrinous mass is the degree of plasminogen activator activity (PAA). PAA, which can be considered to be represented by the ratio of tissue plasminogen activator (tPA) to its inhibitor, plasminogen activator inhibitor 1 (PAI-1), resides in both the mesothelial cells and the underlying fibroblasts [5]. Plasminogen activator inhibitors (PAIs) can prevent PAs from activating plasmin, leading to compromised fibrinolytic activity [6].

Then proliferating fibroblasts invade and keep extracellular matrix material including collagen and also have contributed to the formation of adhesion. And next step is after elicitation of angiogenesis factor, for example vascular endothelial growth factor (VEGF). Imbalances in any of these could potentially contribute to adhesion development [1].

It has been shown that fibroblasts derived from tissue adhesions have a different phenotype (myofibroblasts) when compared to normal fibroblasts found in peritoneal tissue. Transformation of the phenotype has been associated with tissue hypoxia, whereas fibroblast adhesions determine increased mRNA expression of fibronectin, collagen I, metalloproteinase-1, Tissue Growth Factor TGF-beta1, Tissue Inhibitors of Metalloproteinases (TIMP-1), Cyclooxygenase-2 (COX-2), and IL-10. All of these proteins support the formation of adhesion action at different times [3, 7].

An enzyme that regulates the inflammatory process of angiogenesis in the formation of postoperative adhesions is COX-2. In the presence of tissue hypoxia and/or fibroblast adhesion, COX-2 expression is increased. While the formation of dense postoperative adhesions, the fibrinolytic system has an important role in converting plasminogen to plasmin. The conversion is determined by the tissue Plasminogen Activator (tPA) and activator-type urokinase (uPA), both are expressed by the complex of the endothelial and mesothelial cells, macrophages, and fibroblasts. The tPA has been shown to be responsible for the plasminogen activation and fibrin degradation, whereas uPA plays a role during tissue remodeling [1, 3].

The process of adhesion formation might be regarded as an ischemic disease. Under hypoxic conditions, metabolic enzymes are regulated via hypoxic responsive elements by the hypoxia-inducible factor 1 (HIF-1) [8]. Molecular pathways involved in fibrinolysis inhibition, inflammation, and tissue hypoxia crosstalk and potentiate the effect of each. The principal molecular aberrations included the reduction of tissue plasminogen activator (tPA) and up-regulation of TGF-β1 and HIF-1α [1].

4. Clinical consequences of adhesion formation

Small bowel obstruction, infertility, and chronic abdominal pain are generally mentioned as the main clinical consequences formation of adhesion [9]. The most important risk of adhesion formation is infertility, abdominal or pelvic pain, obstruction of the bowel, and injury to intra-abdominal structure on another or next surgeries. Imaging tools such as the visceral slide test have been used to determine the presence of periumbilical adhesions before laparoscopy. However, there is no other method for identifying preoperative adhesions and only direct visualization on surgery that accurately identify and measure postoperative adhesion, though periumbilical adhesions could be detected by ultrasonography [10, 11].

The most common cause of postoperative small-bowel obstruction is adhesions [12]. The incidence of small bowel obstruction is 2–3 percent in the first year after surgery in all patients who undergo abdominal or pelvic surgery [13]. The risk of adhesive small bowel obstruction depends on the anatomical location of surgery, the breadth of surgery, and peritoneal injury [13, 14]. And risk varies in abdominal wall surgery from 0.5 percent; 1.2 percent after upper gastrointestinal surgery to 3.2 percent in lower gastrointestinal surgery and 4.2 percent in pediatric surgery [13].

Infertility and adhesions may affect fertility adversely by distorting adnexal anatomy and interfering with gamete and embryo transport. Among infertile women with unexplained infertility diagnosed with adnexal adhesions by laparoscopy, the pregnancy rates were 32 percent at 12 months after subsequent adhesiolysis by laparotomy and 45 percent at 24 months compared with 11 percent at 12 months and 16 percent at 24 months in untreated women [15].

In another study of 198 patients after lower gastrointestinal tract surgery for adhesive small bowel obstruction, 40 percent of patients developed chronic abdominal pain. In four studies following patients with chronic postoperative pain after previous surgery, adhesions were identified as the most likely cause of pain during diagnostic laparoscopy in 57 percent of patients [13]. The relationship between adhesions and pelvic pain is unclear. Between the extent of adhesions and the severity of pain, there is no relationship. In some cases, adhesions may cause visceral pain with impairing organ immobility. A study of patients with chronic pelvic pain randomized to laparotomy with adhesiolysis or laparotomy only, found adhesiolysis was effective for those who had dense adhesions involving the bowel.

5. Adhesiolysis technique

5.1 Step-by-step approach

5.1.1 Preoperative evaluation

Preoperative evaluation should be taken from patient’s general medical condition and prior surgical history, especially abdominal surgery. The evaluation could be prepared by understanding patient’s medical history and performing a complete physical examination. Careful attention can substantiate the suspicion of adhesions including medical history, current medications, allergies to medications, food, or environmental agents, previous surgical procedures, family history, and others. Repeated laparotomies, including Cesarean sections (C-sections), maybe a risk factor for intra-abdominal adhesion. Informed consent is taken after preoperative discussion which includes a description of the surgical procedure and its expected outcomes and risks like adhesion. This is the basis for obtaining signed informed consent [16, 17]. Intra-abdominal adhesions are diagnosed intra-operatively. Evidence points of adhesions may be yielded by high-resolution ultrasonography and functional MRI; both could detect limited movement relative. To one another of organs joined by adhesions [17].

5.1.2 Surgical techniques

Adhesiolysis is an inadvertent injury while performing surgery. Injuries when adhesiolysis are made in the bowel most frequently, which classified as bellowing injury [18]:

• Injury of seromuscular, an injury to the visceral peritoneum or serosa layer and smooth muscle layer of the bowel, and usually the bowel lumen or leakage of bowel contents is not visible

• Enterotomy is a full-thickness injury to the bowel

• Delayed diagnosed perforation, and unrecognized bowel injuries that were made during surgery.

Steps in abdominal hysterectomy with enterolysis:

5.1.2.1 Skin incision

The incision is carried down through the subcutaneous tissue and fascia, and so does the peritoneum.

5.1.2.2 Exploration of abdominal

Upper abdomen and pelvis are systematically explored. The liver, stomach, gallbladder, large and small intestines, kidneys, and pelvic and para-aortic lymph nodes should be examined and palpated. We need to give attention to bilateral ovaries uterus, uterus and fallopian tubes, ligaments, bladder, and rectosigmoid colon for any adhesions between these organs which should be evaluated carefully.

5.1.2.3 Retraction of wound

Surgeons should choose an appropriate retractor for each patient. There were a variety of retractors designed for abdominal and pelvic surgery (Figure 1).

Figure 1.

Adhesiolysis abdominal wall and uterus in previous surgical scar.

5.1.2.4 Transection of infundibulo-pelvic ligament, fallopian tube, and utero-ovarian ligament

In the retroperitoneal space, the ureter may be identified. When we need to preserve the ovaries, the utero-ovarian ligament and fallopian tubes are grasped with forceps, cut, and suture ligated. Otherwise, the ovaries tend to be removed, and the window of peritoneal opening is enlarged sufficiently to expose the ovarian vessels inside the infundibulopelvic ligament, uterine artery, and ureter. The infundibulopelvic ligament is grasped with forceps, cut, and suture ligated. The ovarian vessels are ligated. The connective tissue around the cardinal ligament is removed, and the posterior leaf of the broad ligament is divided inferiorly toward the uterosacral ligament to aid in uterine mobilization (Figures 2 and 3).

Figure 2.

Clamping of utero-ovarian ligament (round ligament, fallopian tube, ovarian-proprium ligament).

Figure 3.

Adhesiolysis left adnexa and rectum.

5.1.2.5 Round ligament ligation

Placing clamps on the broad ligament to elevate the uterus, providing traction and securing the field of view. The round ligament was then grasped with forceps at its proximal and distal portions. Transected using suture ligation. Broad ligament is incised to separate the anterior and posterior leaves. These steps are applied on the contralateral side. The anterior leaf of the broad ligament is then incised using an electrical scalpel along the vesicouterine fold, separating the bladder from lower uterine segment (Figures 4–6).

Figure 4.

Clamp and cut left round ligament. The round ligament is grasped with forceps at its proximal and distal portion and transected.

Figure 5.

Opening retroperitoneal space to identify ureter.

Figure 6.

Clamp and cut infundibulo-pelvic ligament after identified ureter.

5.1.2.6 Release adhesion to surrounding organs

Lysis of adhesions can be performed as a part of the various procedures in abdominal cavity. Adhesiolysis is releasing adhesions either by blunt or sharp dissection during surgery. The standard method of removing adhesions using “blunt dissection” is to pull adhesions apart with gentle traction during surgery. The main principles of adhesion prevention and complications are minimizing surgical trauma and could use adjuvants to reduce adhesion formation. Adhesiolysis can be done during laparoscopy or open laparotomy. In case of severe and extensive adhesion would be safer with open laparotomy. Severe adhesion between uterus and bowel during open laparotomy (Figures 7–9).

Figure 7.

(a) Fibrin adhesiolysis in laparoscopy. (b) Adhesiolysis in open laparotomy.

Figure 8.

Adhesiolysis posterior part of uterus and anterior part of rectum.

Figure 9.

Clamp and cut uterine artery and vein.

5.1.2.7 Cardinal ligament ligation

Two curved forceps at the level of the internal os of the cervix are dissected and clamp the uterine artery and vein. The vessels are cut and suture ligated. Then the remaining cardinal ligament is clamped, cut, and suture ligated. These steps are repeated two or three times until reach the level of the cervicovaginal junction. The bladder and rectum are inspected to be sure they are clear of the surgical specimen. At this point, the anterior and posterior vaginal walls are exposed (Figure 10).

Figure 10.

Clamp and cut cardinal and uterosacral ligament.

5.1.2.8 Uterus removal

The uterus is placed on the traction of cephalad direction and vaginalis portion of the cervix is palpated. Incision is made in the vaginal wall, beneath the cervicovaginal junction, using an electrical scalpel. Then the uterus is removed (Figure 11).

Figure 11.

Cutting uterus at the level of fornix.

5.1.2.9 Closure of the vaginal cuff

Make sure the bladder and rectum should be clearly seen in the operative field, and the vaginal cuff is cross-clamped using forceps to achieve hemostasis and provide traction. The vaginal cuff is typically closed by suturing (Figure 12).

Figure 12.

Vaginal stump closure with no. 1 PGA.

5.1.2.10 Irrigation and hemostasis

The pelvis is irrigated with warm saline. We should ensure carefully the vascular pedicles for complete hemostasis. Suture ligation or electrocautery is used to control bleeding in small areas. The bladder, ureter, and rectosigmoid colon should be checked to confirm that they are intact. Adhesion formation could be prevented by anti-adhesive material.

5.1.2.11 Fascia and skin closure

Interrupted or continuous suturing could be used for closing the fascia. For hemostasis, subcutaneous tissue should be irrigated and inspected carefully. The wound disruption risk seems to be decreased with subcutaneous fat layer closure or with continuous low-pressure suction for draining subcutaneous hemorrhage or exudate in obese women. Skin closure is performed using either staples or subcuticular sutures with adhesive tape.

5.1.3 Postoperative management

Postoperative care is important for general management and wound management. Prophylactic antibiotics and suction drainage are the key points for wound healing. Wound dehiscence and infection should be managed by good wound bed preparation.

6. The prevention of adhesions and the use of adhesion barriers

Adhesion barriers are adjuvants for peritoneal administration that can reduce adhesion formation [18]. Anti-adhesive material used to prevent adhesion formation, especially in patients who already have intraperitoneal adhesions from previous surgery, pelvic inflammatory disease, or endometriosis [16]. There are several forms of adhesion barriers: solid membranes, gels, and liquids. Adhesion barrier act as a spacer that separates injured surfaces of the peritoneum, allowing these surfaces to heal without forming fibrinous attachment, which eventually leads to adhesions. Barriers should be inert to the human immune system and be slowly degradable. Adhesion barriers might also be used to prevent recurrence after surgical treatment. The most common applied adhesion barriers and their impact on adhesion formation are described below [8]:

1. Hyaluronate carboxymethylcellulose adhesion barrier can reduce the incidence of reoperations for adhesive small bowel obstruction.

2. Oxidized regenerated cellulose, a solid barrier most suitable for open surgery and reduces incidence of adhesion formation.

3. Icodextrin, a liquid barrier which easy to apply in both open and laparoscopic surgery.

4. Polyethylene glycol, a gel barrier which easy to apply in both open and laparoscopic surgery.