Women's Corner
Women's Corner
A) Proper surgical technique :
- Adequate exposure
- Careful hemostasis using bipolar diathermy (pinpoint electrocautery)
- Gentle handling of tissues :
· moist packs and atraumatic instruments
· Irrigation rather than sponging to prevent tissue drying
· When possible, the use of fine-calibre tapered atraumatic needle
- Avoidance of raw surfaces
- Elimination of foreign bodies
Approximation of tissues without tension
- Suture material : Catgut sutures are the most reactive type and should be avoided when possible .
B) Non-barrier method :
1) Peritoneal lavage :
- Frequent irrigation is usually advocated by many surgeons to prevent tissue drying and to wash fibrinous exudate .
- Ringer’s lactae is usually used to prevent acidosis, swelling and associated tissue serosal damage .
- Intraperitoneal antibiotics as cefazolin and tetracyclin are associated with increased adhesions .
2) Intraperitoneal heparin :
- Inhibition of clotting
- Stimulation of plasminogen activator
- Stimulation of of fibroblast growth factor which is an effective stimulator of wound healing
3) Non-steroidal anti-inflammatory :
- Intravenous use of ibuprofen was associated with reduced adhesions formation .
- Intramuscular use has no effect , because absorption is erratic and blood concentrations are inadeqaute at times during mesothelial healing process
- Intraperitoneal use is associated with highly acidic environment which compound pelvis tissue trauma .
4) Corticosteroids :
- Decrease inflammatory response and vascular permeability
- Has a negative impact on wound healing .
- Comtroversial
5) Others controvesial results : progesterone , calcium channel blockers, plasminogen activator .
C) Barrier methods :
1. Dextran :
- A water-soluble glucose polymer
- 32% dextran 70 200 ml is the most widely used
- The mechanism of action is related to hydrofloatation and formation of a siliconizing effect by coating the serosal surfaces
- Side effects include ascites, pleural effusion, coagulopathy and even anaphylactic shock .
2. Oxidized regenerated cellulose barrier (Interceed [TC-7]) :
- The first and the only adhesion prevention adjuvant approved by the FDA .
- It is an oxidized regenrated cellulose in a knitted weave . It differs from Surgigel in the degree of oxidation, porosity , density and weave .
- Following its placement it is converted to into a gelatinous mass that cover the peritoneal and damaged surfaces within 8 hours . It may also facilitate epithelialization .
- Advantages :
a. A biodegradable barrier easy to apply
b. Remains in place without suturing
c. Molded to the anatomical sites
b. Can be applied during laparoscopy
- Disadvantages : injurious effect on the mesothelium resulting in do novo adhesions (contoversial )
- Results : by second look laparoscopy it was found very effective .
3. Gore-Tex surgical membrane :
- Nonreactive and nondegradable expanded polytetrafluoroethylene .
- Disadvantages :
a. It must be sutured in place
b. Requires surgical removal after re-epithelialization , unless left in-situ
- Results : effective in preventing adhesions
4. Sodium carboxymethylcellulose :
- It is heat-stable ,350 Kda poysaccharide
- Its effect is to produce hydrofloatation or a sliliconizing effect and is conocentration and volume dependent
- Results : more effective than 10% dextran 40 and 32% dextran 70
5. Others : Hydrogel polymerization and Polyxamer 407 .
dr. Hisham Al-Inany Lecturer in Obstetrics and Gynecology Department, Cairo University, Egypt Dr. Amr Hussein Lecturer in Obstetrics and Gynecology Department, Cairo University, Egypt