Peritoneal closure and adhesions

Postoperative adhesion development following cesarean and open intra-abdominal gynecological operations: a review

In this review, we discuss the pathophysiology of adhesion development, the impact of physiological changes associated with pregnancy on markers of adhesion development, and the clinical implications of adhesion development following cesarean delivery (CD). Although peritoneal adhesions develop after the overwhelming majority of intra-abdominal and pelvic surgery, there is evidence in the literature that suggests that patients having CD may develop adhesions less frequently. However, adhesions continue to be a concern after CD, and are likely significant, albeit on average less than after gynecological operations, but with potential to cause significant delay in the delivery of the baby with serious, lifelong consequences. Appreciation of the pathophysiology of adhesion development described herein should allow a more informed approach to the rapidly evolving field of intra-abdominal adhesions and should serve as a reference for an evidence-based approach to consideration for the prevention and treatment of adhesions.

Adhesion-Related Bowel Obstruction After Hysterectomy for Benign Conditions

OBJECTIVE

To evaluate the occurrence of small bowel obstruction after hysterectomy.

METHODS

Analysis of 326 cases of women who were admitted with a diagnosis of small bowel obstruction during the period 1998-2005. Among cases with small bowel obstruction after hysterectomy for benign conditions, we evaluated the type and technique of hysterectomy and whether the parietal peritoneum was sutured at the completion of the procedure.

RESULTS

The main causes of bowel obstruction were intra-abdominal adhesions (41.9%) and abdominal malignancy (40.1%). After excluding oncologic cases, we found that, of 135 cases of adhesion-related small bowel obstruction, gynecologic operations played the largest role in the occurrence of bowel obstruction (n=68, 50.4%). Among all gynecologic operations for benign conditions, total abdominal hysterectomy (TAH) was the most common cause of small bowel obstruction (13.6 per 1,000 TAHs). We did not encounter small bowel obstruction after laparoscopic supracervical hysterectomy. The reduction in absolute risk of small bowel obstruction from TAH to laparoscopic supracervical hysterectomy is 13.6 per 1,000 cases; 73 patients would undergo laparoscopic supracervical hysterectomy to prevent one small bowel obstruction. The median interval between TAH and small bowel obstruction was 4 years. The adhesions were adherent to the previous laparotomy incision in 27 cases (75%) and to the vaginal vault in nine cases (25%). Peritoneal closure was not associated with small bowel obstruction.

CONCLUSION

Hysterectomy plays a major role in the occurrence of adhesion-related small bowel obstruction. Closure of the parietal peritoneum does not contribute to the occurrence of adhesion-related small bowel obstruction, and small bowel obstruction rarely occurs after laparoscopic supracervical hysterectomy.

LEVEL OF EVIDENCE

II-3.

Prospective study of non-closure or closure of the peritoneum at cesarean delivery in 124 women: Impact of prior peritoneal closure at primary cesarean on the interval time between first cesarean section and the next pregnancy and significant adhesion at second cesarean

AIM

The aim of this study was to evaluate the effect of non-closure of the peritoneum at cesarean delivery on postoperative complications and the interval time to the next pregnancy, and to investigate the incidence of adhesion following cesarean and the association between adhesion formation and peritoneal closure.

METHODS

One hundred and twenty four women scheduled for cesarean section were randomized to either closure of both the visceral and parietal peritoneum (C-group, n = 70) or non-closure (NC-group, n = 54). At repeated cesarean, the levels and extent of adhesion, operating time, and any complications were examined.

RESULTS

There was no difference in the incidence of postoperative complications at the first cesarean section. The operating time of the C-group was significantly longer than that of the NC-group. The frequency of analgesic use was significantly higher in the C-group. The time interval from cesarean section to the next pregnancy in the NC-group was significantly shorter than that in the C-group. There are no significant differences between the rates of complications in the C-group and the NC-group at repeated cesarean. The incidence of adhesion in the C-group was significantly higher than that in the NC-group (P < 0.05). The mean total operating time and the mean interval time for skin incision to delivery in the C-group were significantly longer than those in the NC-group (P < 0.05 and P < 0.001, respectively) at repeated cesarean section.

CONCLUSIONS

Non-closure of the peritoneum at cesarean delivery appears to have no adverse effect on postoperative recovery, it also decreases the number of analgesic doses and shortens the operating time and may be more desirable in achieving a next pregnancy. The present study demonstrated that surgical peritoneal closure resulted in more advanced adhesion formation. The practice of non-closure of the peritoneum should be performed at cesarean.

Peritoneal closure vs. non-closure: estimation of pelvic fluid by transvaginal ultrasonography after abdominal hysterectomy

OBJECTIVE

To determine the volume of pelvic fluid and febrile morbidity after hysterectomy in which the peritoneum was or was not closed.

DESIGN

Prospective single-center study.

PARTICIPANTS

Fifty-four women undergoing abdominal hysterectomy were enrolled in the study. Patients were randomized into two groups according to peritoneal closure: group I (n = 28) in which the peritoneum was closed, and group II (n = 26) in which the peritoneum was left open. All participants had early postoperative transvaginal ultrasound.

OUTCOME MEASURES

Volume of pelvic fluid accumulated after hysterectomy, total leukocytic count before and after hysterectomy, body temperature over the first 24 h, and wound healing.

RESULTS

There was a statistically significant difference between both groups regarding the volume of pelvic fluid collection, the duration of the operation and number of ampoules needed (p < 0.05). There was no statistically significant difference regarding body temperature, TLC, and wound complications.

CONCLUSION

Peritoneal non-closure does not increase short-term morbidity, however it does cause an increase in peritoneal pelvic fluid. The impact of this on long-term sequelae as adhesions should be investigated.

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.