Reduction of Adhesions
Case: 30 year old G0 is status post (after) laparotomy for multiple myomectomies (removal of uterine leiomyomata or fibroids) 1 year ago, has a hysterosalpingogram that is abnormal (right sided hydrosalpinx (dilated fallopian tube with distal blockage), probable left peritubal adhesions (spillage from the left fallopian tube is into apparent loculations) and a normal uterine cavity). Tubal disease and pelvic adhesions were not described within the operative report from the laparotomy and myomectomy.
Question: What reasons could account for the development of extensive tubal disease and pelvic adhesions following this surgery?
Answer: The prevention or reduction of postoperative scar (adhesion) formation is a major goal of fertility surgery. Microsurgical techniques are a set of principles by which fertility surgeons generally try to minimize the formation of postoperative scar tissue.
In this case, a multiple myomectomy was performed a year prior to the recognition of probable scar tissue and tubal damage.
Uterine leiomyomata (fibroids) tend to have an abundant blood supply. When fibroids are removed from within the wall of the uterus there often is a significant amount of local bleeding. Meticulous control of bleeding during and following the removal of fibroids should minimize the development of postoperative adhesions. A significant amount of local pelvic irritation and inflammation may result even when a small amount of bleeding is allowed to continue throughout the performance of a uterine myomectomy. Following removal of the fibroids and reconstruction of the uterine wall the surgeon should copiously irrigate and aspirate the pelvis to remove as much remaining blood and blood clots as possible.
During the surgical removal of the uterine fibroids, the surgeon should handle the delicate reproductive organs adjacent to the uterine wall very gently. If the fallopian tubes or ovaries are handled roughly, there is often significant evidence of trauma and trauma generally increases postoperative adhesion formation.
If a laparotomy is required to remove uterine fibroids, then the surgeon should carefully and frequently irrigate the pelvic and abdominal organs with an isotonic fluid (such as Normal Saline Solution or Ringer’s Lactate solution) since the organs can otherwise dry out (due to evaporation of the normal abdominal fluid into the surrounding open air). If the tissue is allowed to become dry then the incidence of postoperative adhesion formation is usually increased significantly.
Immediately following a myomectomy there are usually small pockets of space or blood within the muscular wall of the uterus even after careful reconstruction of the wall. These pockets may provide a “home” for infection. Perioperative antibiotics can reduce the risk of a postoperative pelvic infection. Prophylactic antibiotics are often suggested for surgery that has an increased risk for infection.
The specific reason for this patient’s tubal and pelvic damage a year following the myomectomy is really not clear from the stated history. Should further surgery be required to repair the damage a fertility surgeon with a deep regard for microsurgical techniques would ideally be chosen to perform the case.
Case: 29 year old G0 with a history of bilateral (left and right) tubal disease (1-2 cm diameter hydrosalpinges on hysterosalpingogram) undergoes a laparoscopic fimbrioplasty (surgical opening of the branched fingerlike projections at the distal end of the fallopian tubes) with an experienced fertility surgeon.
Question: Should perioperative antibiotics be administered for this sort of surgery?
Answer:Generally whenever a potentially infected site is opened surgically the benefits of prophylactic antibiotics appear to outweigh the risks of the medication.
A hydrosalpinx is thought to form in response to chronic inflammation or irritation. The reason for the inflammation is often uncertain, but may include infection. Other possible causes for chronic irritation of the fallopian tubes include endometriosis, foreign bodies (such as suture material) from a prior surgery in the vicinity of the tubes, or spillage of the caustic content that is found within some ovarian cysts (such as dermoid cysts).
An infection of the fallopian tubes may be “dormant” or inactive for a long time so that at the time of surgery there may be no real signs of an active infection. Nevertheless, by performing tubal surgery a dormant infection may be “awakened” or reactivated. These sorts of tubal infections often cause a tremendous amount of damage to the fallopian tubes and the surrounding pelvic structures.
Perioperative administration of antibiotics for women undergoing tubal surgery (such as fimbrioplasty) seems to be prudent in order to reduce the possibility of reactivating a local infection.
Case: 42 year old G0 has a paratubal cyst adjacent to the fimbriae at the distal end of her right fallopian tube that is noted during laparoscopic surgery for “unexplained infertility.” This cyst appears to be “tugging” (via gravity) on the distal end of the tube and may interfere with an egg’s ability to enter and be transported through the fallopian tube. A decision is made to remove the cyst.
Question: Is the surgical tool that is used to remove the cyst from this location important in terms of postoperative adhesion formation?
Answer: Postoperative adhesion formation is associated with a number of factors. The surgical interventions that are used to reduce postoperative adhesion formation are known as “microsurgical techniques.” Fertility surgeons are generally aware of these techniques and are careful to employ them whenever potentially useful.
Removal of the paraovarian cyst can be accomplished with many different surgical tools. Each of these tools has specific advantages and disadvantages.
The best tool for fertility work appears to be the CO2 laser when used with superpulse or ultrapulse power settings. The superpulse and ultrapulse power settings deliver many distinct “pulses” of laser energy per second and allow the tissue being vaporized to cool off between the pulses. Therefore, it is possible to vaporize (cut or ablate) tissue using “char free” power settings that also do not cause thermal damage (burn injury) to the surrounding tissue.
Char occurs when tissue is reduced to carbon by burning. Char is strongly associated with adhesion formation.
Irreversible thermal damage (burn injury) can occur whenever living tissue is heated to greater than 57 degrees Celsius (about 135 degrees Fahrenheit). When using a cautery device or a laser on continuous wave power settings there can be significant lateral thermal damage to the tissue that is adjacent to the target (treated) tissue. Burn injuries are also strongly associated with adhesion formation.
The harmonic scalpel is available in many operating rooms. The harmonic scalpel uses an unusual technology in which the scalpel (which may be in the shape of a sharp hook, a ball coagulator, or a spatula) vibrates very rapidly (23,000 to 55,000 times per second) and this action thereby denatures proteins to separate tissues. The harmonic scalpel does not generate much heat so the risk of thermal damage is minimal. Another advantage of the harmonic scalpel is that it is good at controlling bleeding since it coagulates blood efficiently. However, many fertility surgeons do not use the harmonic scalpel since it may cause relatively extensive postoperative adhesions. The mechanism causing these adhesions is not clearly understood. In animal models (pig skin and rat uterus) the use of the harmonic scalpel has been studied and reportedly it causes greater tissue damage, greater adhesion formation, and slower recover times when compared to a sharp knife (steel scalpel).