Adhesion formation associated with the use of absorbable staples in comparison to other types of peritoneal injury

Effects of peritoneal closure and suture material on adhesion formation in a rabbit model

OBJECTIVE

This study was designed to determine whether postoperative adhesions to the peritoneum beneath the anterior abdominal wall incision could be decreased by peritoneal closure using less reactive suture material.

STUDY DESIGN

Six longitudinal abdominal incisions were made in each of 16 New Zealand white female rabbits. The peritoneum was randomly assigned to nonclosure or closure with chromic gut, braided nylon, braided coated polyglactin 910, polydioxanone monofilament, or poliglecaprone 25 suture. On postoperative day 14, adhesion formation was scored and evaluated microscopically.

RESULTS

Peritoneal closure decreased adhesion scores, compared with nonclosure, regardless of type of suture, and no particular suture was superior. Braided coated polyglactin 910 resulted in the least chronic inflammation and fibrosis.

CONCLUSION

Peritoneal closure of peritoneum immediately below laparotomy incisions results in decreased adhesion scores, compared with nonclosure in our rabbit model. Adhesion formation could not be decreased further using less reactive suture.

Nonclosure of peritoneum: a reappraisal

In our specialty, the practice of closing or not closing the peritoneum is still being debated. Our purpose was to review the literature on the subject, to evaluate the advantages and disadvantages of the procedure, and to provide clinical opinions. Closure of the peritoneum either parietal or visceral peritoneum is unnecessary, it is associated with a slightly longer operating time and more postoperative pain, and there are some suggestions that it might cause more adhesion formation. There are more advantages than disadvantages to not closing the peritoneum. We encourage clinicians not to close both parietal and visceral peritoneum.

Laparoscopic diagnosis of endometriosis

OBJECTIVE

To consider and explain the possibility of difficulties in diagnosis of endometriosis at previous laparoscopy

DESIGN

Retrospective patient record review.

SETTING

The Endometriosis Care Centre of Australia and the private practices of authors.

SAMPLE

Two hundred and fifteen patients with clinical evidence of endometriosis examined laparoscopically between March 1999 and May 2001.

MAIN OUTCOME MEASURES

Confirmation of endometriosis by histological biopsy.

RESULTS

Endometriosis was confirmed in 168 of the 215 women. Of these women 38 had a previous negative laparoscopy within 12 months of the current laparoscopy.

CONCLUSIONS

It is possible that in some of the patients, who previously had a negative laparoscopy, endometriosis was not recognised. Possible reasons for difficulty in diagnosis have been identified and techniques to improve diagnosis suggested. This retrospective study was performed to consider and explain the possibility of difficulties in diagnosis of endometriosis at previous laparoscopy.

Reproductive outcome after treatment of mild endometriosis with laparoscopic excision and electrocoagulation

OBJECTIVE

To compare the pregnancy rates (PRs) of infertile women with mild endometriosis treated laparoscopically by surgical excision and by electrocoagulation. Laparoscopic treatment of minimal and mild endometriosis usually is done by laser or electrocoagulation. Whether surgical excision is associated with similar results is unknown.

DESIGN

Retrospective study with a historical control.

SETTING

University teaching hospitals.

PATIENT(S)

One hundred one infertile women undergoing laparoscopic treatment of mild endometriosis.

INTERVENTION(S)

Forty-eight women were treated with electrosurgery (historical control) and 53 women were treated with excision.

MAIN OUTCOME MEASURE(S)

The PRs of the two groups of women were evaluated using life-table calculations and the Mantel-Cox test.

RESULT(S)

Of the total 24 pregnancies (PR: 57.1%) in the electrosurgery group, there were 3 spontaneous abortions (12.5%) and 1 ectopic pregnancy (4.2%). The total PR in the excision group was 53.5%, the abortion rate was 17.4% (4 of 23), and the ectopic PR was 8.7% (2 of 23). The median interval between surgery and conception was 10.7 months in the electrosurgery group and 13.3 months in the excision group. There was no statistically significant difference in the probability of conception between the two groups of women (Mantel-Cox test: z = 0.24). Using the Cox proportional-hazards model, the effects of age and duration of infertility were evaluated and were found not to be associated with a decreased PR.

CONCLUSION(S)

There is no difference in the PRs of infertile women with mild endometriosis treated laparoscopically by surgical excision and by electrocoagulation. The difference between these two modalities in women with endometriosis-related pelvic pain remains to be determined.

Peritoneal surgery in the treatment of endometriosis--excision or thermal ablation?

Twenty patients with Stage 2 to 4 endometriosis were referred to an Endometriosis Clinic with an average of 3.4 previous medical and surgical treatments. All were treated by peritoneal excision. Follow-up was for 9-36 months and 14 had a further laparoscopy. Seventeen of 20 patients are free of symptoms. In 1 patient recurrence occurred in a separate site and in 2 there were lesions close to the original lesion in the pouch of Douglas and bladder wall. In addition, 1 of the 14 patients having further laparoscopy had mild adhesions. The satisfactory results of the study suggest that a controlled trial comparing peritoneal excision and thermal ablation is worthwhile. There are considerable theoretical advantages in using peritoneal excision rather than peritoneal thermal ablation.

Stapling instrumentation

A number of surgical stapling instruments are on the market. The variety of instruments, stapling cartridges, and their potential veterinary uses are discussed. The basic principles of application and operation of these devices are emphasized.