KEY POINTS
- To reduce the incidence of postoperative adhesions, follow basic principles of microsurgery: Minimize the number and extent of incisions, handle all tissue gently, strive for absolute hemostasis, and use small, nonreactive suture.
- Despite limited data from prospective, randomized studies, both fluid and barrier adjuvants have proved effective in reducing the incidence and extent of adhesions after abdominal myomectomy.
Abdominal myomectomy is the preferred treatment in women with large or numerous intramural myomas, especially in the setting of infertility, recurrent pregnancy loss, and preservation of future fertility.1,2 However, postoperative adhesions are distressingly common following this procedure, resulting in significant potential morbidity. Fortunately, a number of products can reduce their occurrence. Proper surgical techniques and a thorough knowledge of these products are invaluable in helping reduce the incidence of adhesions.
The association between adhesions and diminished fertility is well-established,3,4 particularly when peritubal involvement is present (FIGURES 1-3). Abdominopelvic adhesions also contribute to significant chronic pelvic pain, bowel obstruction, and technical difficulty in subsequent surgical or assisted-reproduction procedures.5 Unfortunately, most attempts at adhesiolysis meet with less than complete success, since adhesions recur in 55% to 100% of patients (FIGURE 4).6 Thus, preventing adhesions in the first place would seem to be key to successful outcomes in abdominal myomectomy.
This article reviews the evidence on various approaches and products. While the number of studies examining each adjuvant in the setting of abdominal myomectomy is limited, the overall evidence supports the safety and efficacy of both liquid and barrier adjuvants.
Adhesions present a significant clinical dilemma after abdominal myomectomy, occurring in 50% to 90% of patients.5,7 In 1 prospective series of women undergoing second-look laparoscopy (SLL) after myomectomy, adnexal adhesions were noted in 94% of patients with posterior uterine incisions and in 56% of patients with only anterior or fundal incisions; adhesions between the uterus and omentum or bowel occurred in 88% of all patients.5
In another study of early SLL following abdominal myomectomy, 83% of patients had adhesions between the surgical site and the bowel or omentum, and 65% had adhesions involving the adnexae.2 Removal of large, bulky fibroids (with uterine mass exceeding 13 weeks’ gestational size) resulted in higher adhesion scores than did small myomas. Again, the incidence and severity of adhesions also correlated with location of the uterine incision: Adnexal adhesions were more common after posterior uterine incisions (76%) than after anterior or fundal entries (45%).2
FIGURE 1 Peritubal adhesion
Adhesion at distal end of the fallopian tube. Peritubal involvement often leads to diminished fertility.
FIGURE 2 Adherent structures
Postoperative adhesion between fallopian tube and the uterus.
FIGURE 3 Cyst dissection
Adhesions can follow common surgeries such as paratubal cyst dissection.
FIGURE 4 Recurrent adhesions
Adhesions may recur following adhesiolysis.
Causes of pelvic adhesions
Adhesion prevention requires an understanding of risk factors and maneuvers that increase the likelihood of injury (see “Pathophysiology of adhesion formation”). A number of causes have been proposed, most of them centering on tissue and peritoneal trauma (TABLE 1).
Injury can arise from excessive or rough manipulation of tissue and peritoneal surfaces or from common effects such as cutting, abrasion, and denudation (FIGURE 5). Tissue desiccation or manual blotting may lead to peritoneal desquamation and fibrin deposition.
Exposure of surfaces to intraperitoneal blood in the setting of tissue hypoxia—virtually unavoidable during abdominal myomectomy—disrupts normal fibrinolytic activity, resulting in stimulation of angiogenesis.8
Introduction of reactive foreign bodies such as talc powder, residual suture material, and even lint from laparotomy pads can favor adhesion formation. These serve as substrates or niduses of fibrin deposition.
FIGURE 5 Conducive conditions
Raw surface area can become a potent substrate for adhesions.TABLE 1
Proposed causes of adhesion formation
| Tissue hypoxia or ischemia |
| Tissue desiccation |
| Intra-abdominal infection |
| Introduction of reactive foreign body |
| Presence of intraperitoneal blood |
| Dissection of adhesions |
Techniques that may help prevent adhesions
Based on findings from studies of second-look procedures, most physicians advocate avoiding posterior uterine incisions, as well as minimizing the number and extent of incisions, to help reduce the likelihood of adhesion formation. Further, many Ob/Gyns favor removing myomas through as few uterine incisions as possible.9 We select anterior hysterotomy sites that enable removal of multiple fibroids, avoiding posterior incisions and the uterotubal junction whenever possible.
Interestingly, reapproximation of peritoneal defects after reproductive surgery (and, probably, myomectomy) does not appear to help prevent adhesions. Tulandi and colleagues10 examined the clinical and SLL outcomes of peritoneal closure in patients undergoing Pfannenstiel incisions with or without peritoneal closure at the end of the procedure. There was no difference in postoperative complications or wound healing in the 2 groups. At the time of SLL, there was no significant difference in the incidence of adhesion formation at the anterior abdominal wall.