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WJOLS

Adhesion Prevention in Operative Gynecology: How Realistic are our Expectations?
reduced adhesion formation rate is seen in women who The following search terms were used: adhesion
undergo laparoscopic procedures. An epidemiologic study by barriers, oxidized regenerated cellulose, Interceed, icodex­
Lower et al (2004) reported on data from 24,046 patients trin, ADEPT, hyaluronic acid (HA), intergel/hyalobarrier,
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undergoing laparoscopy or laparotomy for gynecological sepracoat, viscoelastic gel, oxiplex.
conditions and partially contrasted with the results from Though there are numerous adhesion barrier agents and
the previous studies. Data from this study have supported devices available in market today (Table 1), we decided to
the concept that laparoscopy is less adhesiogenic than critically evaluate the evidence available about the most
laparotomy but this stands only with respect to laparos­ commonly used ones in the field of operative gynecology.
copic tubal sterilization procedures, which represented a
considerable proportion of laparoscopies (59%), and the dISCUSSION
vast majority of those categorized as having ‘low­risk’ of Oxidized regenerated Cellulose (Interceed)
directly adhesion­related readmission within the first year of
surgery. However, for ‘high­risk’ (laparoscopic adhesiolysis The most relevant data related to this comes from a
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and cyst drainage) and ‘medium­risk’ (other interventions study conducted by Sekiba K (1992). They evaluated
not otherwise categorized) laparoscopies, which constituted Interceed (TC7) in a randomized, multicenter clinical study.
40% of gynecological procedures, the risk of adhesion­ Sixty­three infertility patients had bilateral pelvic sidewall
related readmission has been shown to be considerable adhesions removed at laparotomy. One pelvic sidewall was
(1 in 80 and 1 in 70 respectively) and substantially higher covered by Interceed and the other was left uncovered.
than for the conventional approach (1 in 170) . In the back­ The deperitonealized areas (N = 205) of all sidewalls were
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ground of such controversies related to the occurrence of divided into three groups: less than 100 mm , N = 72; 100­
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more or comparable or lesser incidence of adhesions in 1000 mm , N = 95; and more than 1000 mm , N = 38. The
laparoscopy, this article specifically attempts to look at the effectiveness of interceed was evaluated at laparoscopy
realistic expectations from adhesion barriers in the field of 10 to 98 days after laparotomy. Significantly more adhesions
gynecological laparoscopy. were observed at laparoscopy on the control pelvic sidewalls
(48 of 63, 76%) than on the treated sides (26 of 63, 41%)
Adhesion Barriers (p < 0.0001). The interceed treated sidewalls also had sig­
nificantly less area involved with adhesions at laparoscopy
It was quite a logical thought process of the initial days that (p < 0.05, p < 0.001 and p < 0.001 in the three groups,
mechanical separation of peritoneal surfaces of the pelvic respectively) (Table 2). Twenty­eight women with severe
organs during the early days of the healing postoperatively, endometriosis also had significantly more adhesions on the
is a way to prevent postoperative adhesions. Intra­abdominal control side (23 of 28, 82%) than on the treated side (14 of
instillates and solid barriers were the options available. The 28, 50%) (p < 0.05).
ideal barrier should be noninflammatory, nonimmunogenic,
persist during the remesothelialization, remain in place Icodextrin (AdEPT)
without suture, remain active in the presence of blood and The best of the available evidence regarding this adhesion
be completely biodegradable. barrier comes from a study done in 2011 by Trew et al.
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This randomized, double­blind study comprising of 498
MATERIAlS ANd METHOdS subjects was designed to assess the efficacy and safety of
A literature search was performed using Google, Yahoo, 4% icodextrin solution (ADEPT) in the reduction of de
Springerlink and Highwire Press. novo adhesion compared to lactated Ringer’s solution (LRS)

Table 1: List of commercially available adhesion barriers
Materials Trade name Mechanism
Oxidized regenerated cellulose Interceed Changes into a gelatinous mass covering the injured peritoneum
Icodextrin AdepT Gets metabolized to glucose by a-amylase in the circulation and gets slowly
absorbed from the peritoneal cavity
Hyaluronic acid Intergel/hyalobarrier Transformation into a highly viscous solution coating serosal surfaces
(application before injury)
Solution of HA Sepracoat Transforms into a viscous liquid or gel coating serosal surfaces and minimizing
desiccation (application before injury)
Viscoelastic gel Oxiplex/Ap Transformation into a viscous gel coating surgical sites
Hydrogel Spray Gel Solidification after spraying into a gel strongly adherent to the sites of application
Fibrin sealants Beriplast Rolled fibrin sheets to be placed on surgical wounds
World Journal of Laparoscopic Surgery, May-August 2014;7(2):88-91 89