AGES ASM/ISGE 15 Intraoperative adhesions, your frequent companion in surgery, guide to management (1413)
The problem of adhesion has an incidence and prevalence of 55 % to 95% in open surgery (literature average 85%). The readmission rate in classical surgery lays between 5% and 10% with the exclusive diagnosis of Adhesion Related Disease (ARD). The longer the postoperative follow-up, the more ARD seems the cause of complications. The SCAR (Surgical and Clinical Adhesion Research) study reports that over a period of 10 years 1/3 of the patients is readmitted 2 times up to 4% more frequently (2-5 times). SCAR 2 reports that laparoscopic surgery for the same pathology does not score better than classical surgery. The problem being the trauma, especially to the peritoneum, gendering fibrin deposits. When the fibrin deposits are resorbed completely there is no problem of adhesions. When fibrin remains adhesions are fully formed within 5 days. There are no tests available to distinguish which patient will resorb the deposits completely. Therefore care must be taken by the classical techniques not to traumatise the peritoneum or rather to avoid excessive trauma. In endoscopy a underestimated factor is the blowing of gasses over the peritoneum that will cause trauma even without touching the structures. As adhesions are fully formed within 5 days following the surgery we have to take care to separate the different tissues for that period of time and no to long a period after that time interval. First of all every precaution has to be taken during the surgery, the surgical techniques of minimal invasive surgery including conditioning of the peritoneum by the so called full conditioning, reduction of the pressure, allowing as much oxygenation as possible, reducing the temperature and possibly adding oxygen to the CO2. Additional measures are the barriers. In the talk the historical and current barriers will be discussed in light of evidence based outcomes and costs. It results the most expensive, the hydrogels based on polyethylene glycol are the most effective whilst the hydro-flotation anti adhesion barriers seem to have a good but not excellent effect.
