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Surgical Technique

Preventing adhesions after abdominal myomectomy: Tools and techniques

Without preventive strategies, adhesions develop in more than half of women who undergo this procedure. Here, a review of protective adjuvants.

June 2003 · Vol. 15, No. 6
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  • 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.

Principles of microsurgery have been adopted by reproductive surgeons to minimize the likelihood of adhesions after myomectomy and gynecologic surgery in general. The basic techniques reflect respect for tissue integrity:

  • Gentle handling of tissue, with minimal manipulation of all peritoneal surfaces.
  • Meticulous hemostasis. Examine all myomectomy sites to ensure adequate hemostasis prior to closure.
  • Continuous irrigation to prevent tissue desiccation. We favor continuous saline irrigation throughout the procedure. We also use only moistened laparotomy sponges and pads, and avoid applying dry gauze to any tissue surface.
  • Avoidance of foreign-body introduction. We use only talc-free gloves and remove all residual suture fragments and tissue debris before closure. We also perform copious saline suction-irrigation at the end of the procedure to remove as much residue as possible.
  • Use of fine, nonreactive suture. We favor fine, resorbable sutures that incite as little tissue reactivity as possible. For closure of large myomectomy defects, we use braided multifilaments such as Vicryl (polyglactine 910) (Ethicon, Somerville, NJ) or Dexon (polyglycolic acid) (Davis and Geck, Danbury, Conn) for strength and ease of handling. These sutures are absorbed through simple hydrolysis and stimulate less tissue reactivity than do chromic or catgut sutures.

The idea is appealing, but a randomized, blinded comparison of “good” and “bad” microsurgical technique is unlikely, since no one would wish to perform “bad” technique.

With barrier adjuvants, optimal benefit is obtained when the physician can predict potential sites of adhesions.

Wide range of prevention tools has been studied

Many types of agents have been studied in an attempt to reduce postsurgical adhesions after gynecologic surgery. Although most offer little or no benefit (TABLE 2), a few have potential in myomectomy procedures.

Barriers that form mechanical separation (TABLE 3) theoretically physically separate damaged tissues during early peritoneal wound healing, when adhesions form.11 The original adhesion barriers consisted of omental and peritoneal grafts that were placed over surgical sites. However, studies demonstrated that devitalized tissue positioned on damaged peritoneum serves as a potent substrate—not inhibitor—for adhesions.12 More recent trials have examined the adhesion-prevention benefit of other types of absorbable and nonabsorbable barriers.


Pharmacologic agents studied for adhesion prevention in reproductive surgery







Prevent infection or inflammation

Cephalosporins Tetracyclines

Intraperitoneal irrigation with antibiotic fluid Hydrotubation fluid with antibiotic

Theoretical reaction to antibiotic


Clot prevention Fibrin prevention


In conjunction with Interceed

Risk of postoperative bleeding

Anti-inflammatory agents

Decrease permeability and histamine release

Nonsteroidal anti-inflammatory drugs Corticosteroids

Awaiting further investigation

Theoretical reaction to agent

Crystalloid solutions

Hydroflotation effect, decrease surface contact between pelvic organs

Normal saline Ringer’s lactate

Intra-abdominal instillation

Possible volume overload from intravascular absorption

Fibrinolytic agents

Fibrinolysis Plasminogen activation

Streptokinase Trypsin Fibrinolysin

Awaiting further investigation

Theoretical risk of postoperative bleeding


Decrease inflammatory response


Systemic and/or intraperitoneal

Possible suppression of hypothalamic-pituitary axis

Polysaccharide polymer

"Siliconizing" effect to coat raw surfaces

Dextran 70 (Hyskon)

200 mL placed in posterior cul-de-sac or coating surgical site surfaces

Abdominal bloating, anaphylaxis, pleural effusion, liver function abnormalities, wound separation, rare diffuse intravascular coagulation

Other fluid and barrier agents*

Peritoneal surface separation Hydroflotation

Absorbable and nonabsorbable barriers (see Table 3)

See Table 3

See Table 3

*Adjuvants studied in the setting of abdominal myomectomy


Fluid and barrier adjuvants studied for adhesion reduction after myomectomy







Oxidized regenerated cellulose (Interceed)

Protective layer over surgical sites to prevent surface contact

Direct placement onto surface of uterus; no suturing required

Requires hemostasis

Prospective studies and meta-analysis support benefit in reproductive surgery including abdominal myomectomy

Hyaluronatecarboxymethycellulose derivative film (Seprafilm)

Protective layer over surgical sites to prevent surface contact

Direct placement around entire uterine surface; no suturing required

Requires hemostasis

Multicenter prospective, randomized study supports benefit in reducing adhesions after abdominal myomectomy


Expanded polytetrafluoroethylene (GoreTex)

Prevent contact between surgical surfaces

Patch sutured onto surface of uterus

Usually must be removed Report of fistula formation when left in situ

Multicenter prospective studies support adhesion-preventive benefit after abdominal myomectomy

Pericardial patch (Shelhigh No-React)

Prevent contact between surgical surfaces

Patch sutured onto surface of uterus

Early clinical use in myomectomy Proven safety as pericardial patch in humans

Preliminary study (case series data only) shows potential benefit


Hyaluronic acid-coat (Sepracoat)

Diffuse coating on surgical sites and potential sites of contact

100-mL to 250-mL aliquots injected into peritoneal cavity

Limited data on efficacy in abdominal myomectomy

Small studies (multicenter, prospective, randomized, controlled trials) demonstrated reduced postoperative adhesions after reproductive surgery via laparotomy, including myomectomy

Hyaluronate-carboxymethycellulose derivative gel (Intergel)

Diffuse coating on surgical sites and potential sites of contact

300-mL aliquot into peritoneal cavity

Withdrawn from market for reports of postoperative pain, complications

Reduced adhesion formation in animal studies and in preliminary human studies

Pathophysiology of adhesion formation

Adhesions are fibrous or fibrovascular bands that connect tissue surfaces in abnormal locations.1,2 Their development likely results from an imbalance in inflammatory mediators or fibrin degradation during peritoneal wound healing.

Peritoneal injury initiates the release of histamine and vasoactive kinins that mediate increased capillary permeability and outpouring of serosanguineous fluid.3 This proteinaceous exudate coagulates, depositing fibrinous bands between areas of denuded tissue.

Under normal circumstances, the fibrinolytic system is activated to lyse these bands within 72 hours. Peritoneal healing occurs when mesothelial cells migrate from the underlying mesenchyme to reepithelialize the injured site.4 Disequilibrium of the fibrin deposition-fibrinolysis system results in a persistent band that will eventually undergo fibroblast and vascular invasion.


1. Diamond MP, DeCherney AH. Pathogenesis of adhesion formation/reformation: application to reproductive pelvic surgery. Microsurgery. 1987;8:103-107.

2. Diamond MP, Freeman ML. Clinical implications of postsurgical adhesions. Hum Reprod. 2001;7:567-576.

3. Diamond MP, El-Mowafi DM. Pelvic adhesions. Surg Technol Int. 1998;VII:273-283.

4. Farquhar C, Vandekerckhove P, Watson A, Vail A, Wiseman D. Barrier agents for preventing adhesions after surgery for subfertility. Cochrane Database Systematic Rev. 2002;(4):1-34.

Absorbable barriers

These are largely derivatives of organic materials. Their application to myomectomy may be limited by the requirement for absolute hemostasis at the site of application.

Interceed (Gynecare, a division of Ethicon), which is derived from oxidized regenerated cellulose, is one of the first and most extensively evaluated barriers. A mesh synthetic designed to be placed over injured tissue, it is a derivative of the hemostatic agent Surgicell (Johnson & Johnson, New Brunswick, NJ), with modifications in weave and pore size.

Interceed offers ease of application: It can be cut to the size or shape necessary and requires no suturing. It forms a gelatinous protective layer within 8 hours of placement, and is degraded into monosaccharides and absorbed within 2 weeks.13

The use of Interceed has been shown to reduce adhesions following adhesiolysis and ovarian surgery. In a large, multicenter, prospective, randomized trial, it significantly decreased the incidence of adhesion reformation after adnexal adhesiolysis in infertility patients with bilateral tubal disease.14

In a retrospective series of 38 infertility patients, including 19 patients after myomectomy (13 with the barrier, 6 without), reproductive outcomes were significantly better in the Interceed group, and adhesion development was reduced.15 Pregnancy rates in the 2 years following surgery were 78% in the Interceed group, compared with 47% in controls. In addition, among 23 patients who had second-look procedures, postoperative adhesions were noted in 38% of the Interceed group, compared with 86% in controls.15

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