Preventing adhesions in laparoscopic surgery

M R C O G PA R T 2 · S O S P O C K E T C A R D · K N O W L E D G E A R E A 3 – C O R E S U R G I C A L S K I L L S

Preventing Adhesions in Laparoscopic Surgery: the Role of Anti- Adhesion Agents Aref-Adib M et al. Preventing adhesions in laparoscopic surgery: the role of anti-adhesion agents. TOG 2019;21:185–192. doi:10.1111/tog.12588

55–100% 13.9% 3–5 days ADHESION RATE AFTER PELVIC SURGERY ADHESION-RELATED READMISSION RATE RE-EPITHELIALISATION WINDOW (SCOTLAND)

DO N' T-M IS S FA C TS

  1. Critical window for adhesion formation and barrier-agent efficacy = 3–5 days (peritoneal re-epithelialisation time)

  2. ORC (Interceed) must only be applied after optimal haemostasis – blood mixed with ORC increases fibrin deposition/adhesion risk

  3. PTFE (Gore-Tex) has no laparoscopic gynaecological evidence – open surgery only, needs suturing + removal

  4. 4% Icodextrin (ADEPT) = only FDA-approved agent for gynae laparoscopy in the USA, but meta-analysis shows no reduction in adhesion formation despite ↓small bowel obstruction (2% vs 11%)

  5. Corticosteroids and heparin are NOT effective anti-adhesive agents

  6. Adhesion barriers used in only 1.9% of cases (Tulandi 2016) – carry small risk of ileus/bowel obstruction

  7. US cost of adhesion complications >$2 billion/year; UK readmission cost £24.2 million in year 1, £95.2 million by year 10

  8. Meticulous surgical technique remains the gold standard – anti-adhesive agents are adjuncts, not substitutes

EVIDENCE TIERS AT A GLANCE

Some benefit: ORC, hyaluronic acid gel, PEG-based barrier (fertility-sparing lap surgery)

Not effective / no laparoscopic evidence: corticosteroids, heparin, PTFE (open only), icodextrin (reoperation outcome)

ABBREVIATION KEY

ORC — oxidised regenerated cellulose (Interceed) RR — relative risk

PTFE — polytetrafluoroethylene (Gore-Tex) CI — confidence interval

PEG — polyethylene glycol FDA — Food and Drug Administration

RCT — randomised controlled trial NHS — National Health Service

OR — odds ratio

Source: The Obstetrician & Gynaecologist (TOG), RCOG journal — doi:10.1111/tog.12588

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