Adhesions and Fibroid Embolization
Is it possible to get adhesions after Uterine Fibroid Embolization (UFE)?
There are not many cases in which adhesion formation is cited after UFE. The risk of an adhesion forming after UFE is quite low compared to both Myomectomy and Hysterectomy, mostly due to the less invasive approach of embolization.
Adhesion formation can pose as a threat to fertility; therefore, it is important for patients considering fertility to note this risk when looking into various fibroid treatment options. At any rate, when patients are considering fibroid treatment options and attempting to keep fertility option open, UFE should be taken into consideration. Although none of the fibroid treatment procedures can promise complete preservation of fertility, there are many cases in which embolization patients have been able to conceive after the procedure.
http://www.fibroids.com/news-blog/2011/07/adhesions-and-fibroid-embolization/
Thursday, September 29, 2011
His and Her Hernias: Pelvic Pain Culprit Tough to Diagnose in Women
His and Her Hernias: Pelvic Pain Culprit Tough to Diagnose in Women
Posted: 9/6/11 04:23 PM ET Follow Women's Health , Cedars Sinai , Dr. Glenn Braunstein , Abdominal Pain , Female Health , Hernias , Hiatal Hernia , Inguinal Hernia , Male Health , Pelvic Pain , Women , Los Angeles News .
Women who complain to their doctor of persistent lower abdominal pain could be suffering from any number of ailments: fibroids, endometriosis, ovarian cysts or complications of past pelvic surgeries. With those many possibilities, there often is another that does not even occur to many doctors: hernias.
Hernias often are considered a problem that primarily afflicts men, and in fact, they are far more prevalent in males -- women account for only about 8 percent of diagnosed hernias in the United States. Furthermore, women often do not display the telltale bulge that indicates a hernia, making this an often elusive diagnosis for women who suffer from these excruciating ailments. Women also may complain first to a gynecologist, who is more likely to consider a "female" issue as the cause for the pain, rather than a hernia.
Hernias can appear in various locations. They occur when layers of the abdominal wall weaken, and then tear or bulge. This allows the inner lining of the abdomen to push through the weak spot, forming a sac. A portion of the intestine or other abdominal tissue may slip through, causing pain and other complications. The most common and noticeable symptom is a protrusion in the groin or abdominal area. This symptom may be so slight in women that it goes unnoticed, or it may not be there at all.
Hernias are classified by location. The most common include incisional, occurring in an area weakened by a surgical procedure; femoral, on the outer groin; umbilical, in the belly button; hiatal, in the upper stomach; pelvic floor; and inguinal, in the inner groin. The inguinal type accounts for 80 percent of all hernias, and most occur in men due to a natural weakness in this area. Occult -- or hidden -- inguinal or femoral hernias can cause tough-to-diagnose pelvic pain in women but also are associated with groin pain in men and athletes.
Women's hernias frequently are tiny and internal, which is why they're so often mistaken for other conditions. Because they are unsuspected, they may go unnoticed on an ultrasound or other diagnostic test. The tears themselves may be invisible even on an MRI until fat or other tissue pushes through them.
What Causes Hernias?
A combination of pressure and an opening or weakness of muscle or tissue is the ultimate cause of all hernias. That weakness may be congenital, it may be the result of a surgery, or it may occur later in life. Lifting heavy objects, straining during bowel movements or urination, fluid in the abdomen, obesity, chronic coughing or sneezing, and pregnancy can all contribute to increased risk of hernias. Age and sex also can indicate risk for hernias, with 90 percent of hernias occurring in older men.
Men's vulnerability to hernias can be traced back to the womb. A male fetus' testicles form in the abdomen, then move along the inguinal canal to the scrotum. That canal closes almost completely after birth, leaving just a small space for the spermatic cord to pass through, but not enough room for the testicles to move back into the abdomen. Sometimes, that canal doesn't close properly, creating a weak spot where a hernia will occur. Women have a similar weakness in the femoral canal, where the femoral artery, vein and nerve pass through.
Prevention techniques for hernia are the same as for most other diseases: maintain a healthy weight, eat high-fiber foods to avoid constipation and straining, and stop smoking. If lifting a heavy weight, be sure to do it properly -- bending from the knees, not the waist -- or avoid heavy lifting altogether.
Recognizing Hernias
Women may identify pain as being in their ovaries, and hernia pain may occur around that area. The pain of an occult hernia, however, will not feel like a cramp. It may be described as a sharp, shooting pain in the vagina, around the hip and the back, into the flank and through the thighs. Women also may complain of pain during bowel movements, when their bladder is full, during intercourse, or during their menstrual period. That pain may worsen with exercise, prolonged standing or sitting, lifting, bending, laughing, coughing, climbing stairs -- basically, anything that increases pressure on the abdomen.
All of these additional pains can lead patients to any number of specialists who might diagnose them with -- in the case of women -- any number of gynecological problems. Many women and men are misdiagnosed with lumbar disc, hip, psychosomatic pain, or a host of other ailments.
Finding hidden hernias in women relies on clinical examination. Even with all the sophisticated tools at physicians' disposal -- ultrasound, MRI, herniography -- examination by an MD who knows what to look for is key. If the patient is lying down, this may conceal what little evidence there is of a hernia, so standing sometimes reveals a subtle bulge. More often, occult hernias cannot be seen or felt. Vaginal examination may reveal telltale tension and tenderness in the pelvic muscles, and reproducing a patient's pain by applying pressure on the internal inguinal area is one method that has been considered effective.
Once hernias are diagnosed and identified, pain can be managed with over the counter or prescription medications until they can be surgically repaired. For some, minimally invasive surgery is an option. Laparoscopic procedures in which the hole is patched with mesh have shown to be effective and to significantly alleviate pain.
For men, inguinal hernias not only have been a historic bane -- the afflicted have included Galileo, Michelangelo, Lord Nelson, Sir Winston Churchill and even Sir Astley Cooper, a pioneer in corrective surgical procedures -- they also long led to an industry of gear and protective, or supposedly rehabilitative, wear and devices. With advances in surgery and technology, the once-extensive ads for trusses and the like largely have disappeared, although an online search will still bring up a number of products and suggestions. In fact, while a truss might be recommended as a short-term support, it will not prevent a hernia from worsening or treat the hernia itself.
For women, chronic pelvic pain can be tough to diagnose -- and even tougher to live with. It means they might not be able to bend down to pick up their child. Sex may be too painful to endure. It can impair their ability to work. Lack of awareness of hernias in women can lead women to multiple doctors and multiple treatments, and endless frustration when they don't work. That's why it's important for patients and doctors alike to be aware of the possible causes, and keep looking until an answer is found.
http://www.huffingtonpost.com/glenn-d-braunstein-md/his-and-her-hernias-pelvi_b_950590.html?view=print&comm_ref=false
Posted: 9/6/11 04:23 PM ET Follow Women's Health , Cedars Sinai , Dr. Glenn Braunstein , Abdominal Pain , Female Health , Hernias , Hiatal Hernia , Inguinal Hernia , Male Health , Pelvic Pain , Women , Los Angeles News .
Women who complain to their doctor of persistent lower abdominal pain could be suffering from any number of ailments: fibroids, endometriosis, ovarian cysts or complications of past pelvic surgeries. With those many possibilities, there often is another that does not even occur to many doctors: hernias.
Hernias often are considered a problem that primarily afflicts men, and in fact, they are far more prevalent in males -- women account for only about 8 percent of diagnosed hernias in the United States. Furthermore, women often do not display the telltale bulge that indicates a hernia, making this an often elusive diagnosis for women who suffer from these excruciating ailments. Women also may complain first to a gynecologist, who is more likely to consider a "female" issue as the cause for the pain, rather than a hernia.
Hernias can appear in various locations. They occur when layers of the abdominal wall weaken, and then tear or bulge. This allows the inner lining of the abdomen to push through the weak spot, forming a sac. A portion of the intestine or other abdominal tissue may slip through, causing pain and other complications. The most common and noticeable symptom is a protrusion in the groin or abdominal area. This symptom may be so slight in women that it goes unnoticed, or it may not be there at all.
Hernias are classified by location. The most common include incisional, occurring in an area weakened by a surgical procedure; femoral, on the outer groin; umbilical, in the belly button; hiatal, in the upper stomach; pelvic floor; and inguinal, in the inner groin. The inguinal type accounts for 80 percent of all hernias, and most occur in men due to a natural weakness in this area. Occult -- or hidden -- inguinal or femoral hernias can cause tough-to-diagnose pelvic pain in women but also are associated with groin pain in men and athletes.
Women's hernias frequently are tiny and internal, which is why they're so often mistaken for other conditions. Because they are unsuspected, they may go unnoticed on an ultrasound or other diagnostic test. The tears themselves may be invisible even on an MRI until fat or other tissue pushes through them.
What Causes Hernias?
A combination of pressure and an opening or weakness of muscle or tissue is the ultimate cause of all hernias. That weakness may be congenital, it may be the result of a surgery, or it may occur later in life. Lifting heavy objects, straining during bowel movements or urination, fluid in the abdomen, obesity, chronic coughing or sneezing, and pregnancy can all contribute to increased risk of hernias. Age and sex also can indicate risk for hernias, with 90 percent of hernias occurring in older men.
Men's vulnerability to hernias can be traced back to the womb. A male fetus' testicles form in the abdomen, then move along the inguinal canal to the scrotum. That canal closes almost completely after birth, leaving just a small space for the spermatic cord to pass through, but not enough room for the testicles to move back into the abdomen. Sometimes, that canal doesn't close properly, creating a weak spot where a hernia will occur. Women have a similar weakness in the femoral canal, where the femoral artery, vein and nerve pass through.
Prevention techniques for hernia are the same as for most other diseases: maintain a healthy weight, eat high-fiber foods to avoid constipation and straining, and stop smoking. If lifting a heavy weight, be sure to do it properly -- bending from the knees, not the waist -- or avoid heavy lifting altogether.
Recognizing Hernias
Women may identify pain as being in their ovaries, and hernia pain may occur around that area. The pain of an occult hernia, however, will not feel like a cramp. It may be described as a sharp, shooting pain in the vagina, around the hip and the back, into the flank and through the thighs. Women also may complain of pain during bowel movements, when their bladder is full, during intercourse, or during their menstrual period. That pain may worsen with exercise, prolonged standing or sitting, lifting, bending, laughing, coughing, climbing stairs -- basically, anything that increases pressure on the abdomen.
All of these additional pains can lead patients to any number of specialists who might diagnose them with -- in the case of women -- any number of gynecological problems. Many women and men are misdiagnosed with lumbar disc, hip, psychosomatic pain, or a host of other ailments.
Finding hidden hernias in women relies on clinical examination. Even with all the sophisticated tools at physicians' disposal -- ultrasound, MRI, herniography -- examination by an MD who knows what to look for is key. If the patient is lying down, this may conceal what little evidence there is of a hernia, so standing sometimes reveals a subtle bulge. More often, occult hernias cannot be seen or felt. Vaginal examination may reveal telltale tension and tenderness in the pelvic muscles, and reproducing a patient's pain by applying pressure on the internal inguinal area is one method that has been considered effective.
Once hernias are diagnosed and identified, pain can be managed with over the counter or prescription medications until they can be surgically repaired. For some, minimally invasive surgery is an option. Laparoscopic procedures in which the hole is patched with mesh have shown to be effective and to significantly alleviate pain.
For men, inguinal hernias not only have been a historic bane -- the afflicted have included Galileo, Michelangelo, Lord Nelson, Sir Winston Churchill and even Sir Astley Cooper, a pioneer in corrective surgical procedures -- they also long led to an industry of gear and protective, or supposedly rehabilitative, wear and devices. With advances in surgery and technology, the once-extensive ads for trusses and the like largely have disappeared, although an online search will still bring up a number of products and suggestions. In fact, while a truss might be recommended as a short-term support, it will not prevent a hernia from worsening or treat the hernia itself.
For women, chronic pelvic pain can be tough to diagnose -- and even tougher to live with. It means they might not be able to bend down to pick up their child. Sex may be too painful to endure. It can impair their ability to work. Lack of awareness of hernias in women can lead women to multiple doctors and multiple treatments, and endless frustration when they don't work. That's why it's important for patients and doctors alike to be aware of the possible causes, and keep looking until an answer is found.
http://www.huffingtonpost.com/glenn-d-braunstein-md/his-and-her-hernias-pelvi_b_950590.html?view=print&comm_ref=false
Adhesion-Related Complications Are Common, But Rarely Discussed in Preoperative Consent: A Multicenter Study
Adhesion-Related Complications Are Common, But Rarely Discussed in Preoperative Consent: A Multicenter Study
Taufiek Konrad Rajab, Markus Wallwiener, Sabrina Talukdar and Bernhard Kraemer
Abstract
Background
Peritoneal adhesions are recognized as an important cause for patient morbidity, but complications related to adhesions occur relatively late after the original operation. Therefore preoperative consent may not adequately reflect the proportions of the problem.
Methods
A total of 200 patients admitted for intraperitoneal operations at six hospitals were prospectively reviewed to identify whether adhesion-related complications were documented as possible adverse events in their respective consent forms.
Results
Adhesion-related complications were documented in 8.5% (n = 17) of consent forms (bowel obstruction n = 8, requirement for further operations n = 5, difficult reoperation n = 1, pain n = 3). A direct relationship with adhesions was noted in n = 9 of these consent forms.
Conclusions
Preoperative informed consent does not adequately reflect the magnitude of adhesion-related problems. These findings have immediate implications for clinical practice.
World Journal of Surgery
Volume 33, Number 4, 748-750, DOI: 10.1007/s00268-008-9917-x
http://www.springerlink.com/content/a145283p16236h6k/
Taufiek Konrad Rajab, Markus Wallwiener, Sabrina Talukdar and Bernhard Kraemer
Abstract
Background
Peritoneal adhesions are recognized as an important cause for patient morbidity, but complications related to adhesions occur relatively late after the original operation. Therefore preoperative consent may not adequately reflect the proportions of the problem.
Methods
A total of 200 patients admitted for intraperitoneal operations at six hospitals were prospectively reviewed to identify whether adhesion-related complications were documented as possible adverse events in their respective consent forms.
Results
Adhesion-related complications were documented in 8.5% (n = 17) of consent forms (bowel obstruction n = 8, requirement for further operations n = 5, difficult reoperation n = 1, pain n = 3). A direct relationship with adhesions was noted in n = 9 of these consent forms.
Conclusions
Preoperative informed consent does not adequately reflect the magnitude of adhesion-related problems. These findings have immediate implications for clinical practice.
World Journal of Surgery
Volume 33, Number 4, 748-750, DOI: 10.1007/s00268-008-9917-x
http://www.springerlink.com/content/a145283p16236h6k/
Tuesday, September 27, 2011
Can Adhesions be Prevented?
Although adhesions often form after gynecologic surgery, they are not inevitable. And, even if adhesions do form, they usually don’t cause pain or other problems.
Although there is no way to eliminate the risk of adhesions completely, there are steps your surgeon can take to reduce the likelihood of adhesion formation. The most effective methods of adhesion prevention involve meticulous surgical technique and the use of a physical barrier to separate tissue surfaces while they heal.
Surgeons have developed minimally invasive techniques such as the laparoscopy, that are designed to minimize trauma, blood loss, infection, and the introduction of foreign bodies, all of which can lead to inflammation and adhesion formation. Good surgical technique involves minimizing tissue handling, using delicate instruments, and keeping the tissues moist when they are exposed to the air in open surgeries and using heated and humidified gas.
While good surgical technique is important, but it is often not sufficient to prevent adhesions. There are also other preventive steps that can be taken:
Surgical techniques that can help decrease adhesion formation
Not simply the surgical procedure used, but in combination with these techniques and the lesser of invasive surgery, a laporoscopy, one has the best chance of adhesion reduction when these are used together in a surgery!
Achieve meticulous hemostasis
Maintain vascularity
Moisten tissues
Avoid dry sponges
Minimize tissue handling
Use fine, non-reactive sutures
Avoid peritoneal grafts
Minimize foreign bodies
Even though the most meticulous surgical and microsurgical techniques cannot eliminate the formation of adhesions, the following steps can be taken to reduce adhesion formation:
Achieve meticulous hemostasis: Inadequate hemostasis and the resultant fibrin deposition promote adhesion formation.
Maintain vascularity: Limiting ischemia supports fibrinolysis.
Moisten tissues: Frequent irrigation and the use of moist sponges prevent desiccation of tissue. Ringer's lactate or other irrigating solutions also eliminate any residual talc, lint, or blood clots, which may provide a nidus for a foreign body reaction, inflammation, and adhesion formation.
Avoid dry sponges: Use of gauze and dry sponges should be avoided because they may damage the peritoneal surface and leave a foreign body behind.
Minimize tissue handling: Manipulating tissue increases the possibility of vascular and tissue damage. When direct manipulation of the peritoneum is necessary, use either atraumatic instruments or fingers. In addition, cutting and coagulating should be kept to a minimum to reduce the possibility of trauma and maintain vascularity.
Use fine, nonreactive sutures: To minimize foreign body reactions use the smallest size of suture composed of synthetic material.
Avoid peritoneal grafts: Grafting increases the risk of peritoneal trauma while decreasing vascularity.
Minimize foreign bodies: Foreign bodies may damage the peritoneal surface, lead to inflammation, and ultimately result in adhesion formation.
CONSIDERING SURGERY
If surgery is recommended for you, it's important to know what your options are and what questions to ask your primary-care physician and surgeon. If you learn all you can, you'll be sure that you're making the right decision.
Jason Bodzin, M.D., F.A.C.S., director of the Inflammatory Bowel Disease (IBD) Institute at Sinai Hospital in Detroit, advises you to follow a four-step process:
Examine your options.
Talk to your surgeon.
Talk to patients who have had the operation.
Weigh all the factors in making your decision.
Knowing What to Ask
Before consenting to surgery, the first question you should ask is: "Is this surgery necessary, or are there other medical options that I can try?" For instance, many people with IBD have avoided surgery by combining total parenteral nutrition (intravenous feeding) with medications. 6-MP, an immunomodulator drug, often successfully heals fistulas that once required surgery.
You'll also want to know:
Are there other surgical options?
What risks will I face by having the operation?
How will the operation improve my condition?
How long will my recovery take?
Will I require medications following surgery?
Whom do you recommend as a surgeon? As anesthesiologist?
Choosing a Surgeon
Many sources can help you find a surgeon:
Friends, relatives, neighbors
Your primary-care physician
American Board of Medical Specialties (ABMS): (800) 776-CERT. (The ABMS can tell you whether a surgeon is board-certified.)
American College of Surgeons: (312) 664-4050, Ext. 391
The American Society of Colon and Rectal Surgeons: (708) 290-9184
Your local CCFA chapter
Your health insurance carrier
Your local hospital, or your state or county medical association -- all can provide lists of board-certified surgeons.
Once you've compiled a list of two or three possible surgeons, ask the following questions about each one:
Is he experienced with the particular operation you need? (This is particularly important if you are undergoing a fairly new procedure, such as an ileoanal anastomosis.)
Does she treat many IBD patients?
Is he affliated with the hospital you want to be in?
Is she affiliated with a medical school or is she a member of its clinical faculty?
You'll also want to know:
Where the surgeon trained, what his specialization is, and whether he belongs to any professional organizations or has published any professional articles. (To get this information, ask the surgeon directly or go to the library.)
Whether the hospital frequently performs your kind of surgery and whether the staff is well-versed in IBD.
Getting a Second Opinion:
It is always wise to get a second opinion. In fact, many insurance companies require it. Before seeking a second opinion, you may want to get copies of all your medical records. However, any physician can request these for you.
If you receive conflicting opinions, visit a third surgeon or review the situation with your primary-care physician. Though this process can be frustrating and time-consuming, it will give you peace of mind.
http://www.adhesionrelateddisorder.com/adhesion3.html
Although there is no way to eliminate the risk of adhesions completely, there are steps your surgeon can take to reduce the likelihood of adhesion formation. The most effective methods of adhesion prevention involve meticulous surgical technique and the use of a physical barrier to separate tissue surfaces while they heal.
Surgeons have developed minimally invasive techniques such as the laparoscopy, that are designed to minimize trauma, blood loss, infection, and the introduction of foreign bodies, all of which can lead to inflammation and adhesion formation. Good surgical technique involves minimizing tissue handling, using delicate instruments, and keeping the tissues moist when they are exposed to the air in open surgeries and using heated and humidified gas.
While good surgical technique is important, but it is often not sufficient to prevent adhesions. There are also other preventive steps that can be taken:
Surgical techniques that can help decrease adhesion formation
Not simply the surgical procedure used, but in combination with these techniques and the lesser of invasive surgery, a laporoscopy, one has the best chance of adhesion reduction when these are used together in a surgery!
Achieve meticulous hemostasis
Maintain vascularity
Moisten tissues
Avoid dry sponges
Minimize tissue handling
Use fine, non-reactive sutures
Avoid peritoneal grafts
Minimize foreign bodies
Even though the most meticulous surgical and microsurgical techniques cannot eliminate the formation of adhesions, the following steps can be taken to reduce adhesion formation:
Achieve meticulous hemostasis: Inadequate hemostasis and the resultant fibrin deposition promote adhesion formation.
Maintain vascularity: Limiting ischemia supports fibrinolysis.
Moisten tissues: Frequent irrigation and the use of moist sponges prevent desiccation of tissue. Ringer's lactate or other irrigating solutions also eliminate any residual talc, lint, or blood clots, which may provide a nidus for a foreign body reaction, inflammation, and adhesion formation.
Avoid dry sponges: Use of gauze and dry sponges should be avoided because they may damage the peritoneal surface and leave a foreign body behind.
Minimize tissue handling: Manipulating tissue increases the possibility of vascular and tissue damage. When direct manipulation of the peritoneum is necessary, use either atraumatic instruments or fingers. In addition, cutting and coagulating should be kept to a minimum to reduce the possibility of trauma and maintain vascularity.
Use fine, nonreactive sutures: To minimize foreign body reactions use the smallest size of suture composed of synthetic material.
Avoid peritoneal grafts: Grafting increases the risk of peritoneal trauma while decreasing vascularity.
Minimize foreign bodies: Foreign bodies may damage the peritoneal surface, lead to inflammation, and ultimately result in adhesion formation.
CONSIDERING SURGERY
If surgery is recommended for you, it's important to know what your options are and what questions to ask your primary-care physician and surgeon. If you learn all you can, you'll be sure that you're making the right decision.
Jason Bodzin, M.D., F.A.C.S., director of the Inflammatory Bowel Disease (IBD) Institute at Sinai Hospital in Detroit, advises you to follow a four-step process:
Examine your options.
Talk to your surgeon.
Talk to patients who have had the operation.
Weigh all the factors in making your decision.
Knowing What to Ask
Before consenting to surgery, the first question you should ask is: "Is this surgery necessary, or are there other medical options that I can try?" For instance, many people with IBD have avoided surgery by combining total parenteral nutrition (intravenous feeding) with medications. 6-MP, an immunomodulator drug, often successfully heals fistulas that once required surgery.
You'll also want to know:
Are there other surgical options?
What risks will I face by having the operation?
How will the operation improve my condition?
How long will my recovery take?
Will I require medications following surgery?
Whom do you recommend as a surgeon? As anesthesiologist?
Choosing a Surgeon
Many sources can help you find a surgeon:
Friends, relatives, neighbors
Your primary-care physician
American Board of Medical Specialties (ABMS): (800) 776-CERT. (The ABMS can tell you whether a surgeon is board-certified.)
American College of Surgeons: (312) 664-4050, Ext. 391
The American Society of Colon and Rectal Surgeons: (708) 290-9184
Your local CCFA chapter
Your health insurance carrier
Your local hospital, or your state or county medical association -- all can provide lists of board-certified surgeons.
Once you've compiled a list of two or three possible surgeons, ask the following questions about each one:
Is he experienced with the particular operation you need? (This is particularly important if you are undergoing a fairly new procedure, such as an ileoanal anastomosis.)
Does she treat many IBD patients?
Is he affliated with the hospital you want to be in?
Is she affiliated with a medical school or is she a member of its clinical faculty?
You'll also want to know:
Where the surgeon trained, what his specialization is, and whether he belongs to any professional organizations or has published any professional articles. (To get this information, ask the surgeon directly or go to the library.)
Whether the hospital frequently performs your kind of surgery and whether the staff is well-versed in IBD.
Getting a Second Opinion:
It is always wise to get a second opinion. In fact, many insurance companies require it. Before seeking a second opinion, you may want to get copies of all your medical records. However, any physician can request these for you.
If you receive conflicting opinions, visit a third surgeon or review the situation with your primary-care physician. Though this process can be frustrating and time-consuming, it will give you peace of mind.
http://www.adhesionrelateddisorder.com/adhesion3.html
Abdominal/Pelvic Pain Can Occur After Surgery.
Abdominal/Pelvic pain can occur after surgery. Post surgical pain can present shortly following your surgery, and usually resolves over the following days and weeks as you recover from that surgery. But some pain may linger for months or years following a surgical procedure. The question is, what is the source of this pain?
In some cases, the answer is Adhesions!
Adhesions are bands of scar tissue intra-abdominal and/or pelvic cavity that bind your internal organs together, causing them to stick to each other. The result of these bands of scar tissue can lead to:
Adhesion Related Disorder or ARD.
The symptoms of ARD include:
Chronic pain
Infertility
Bowel obstruction
Gastro-esophageal reflux disease, (GERD)
Urinary Bladder dysfunction
Pain and difficulty having a bowel movement
Pain on movement such as: Walking, sitting or laying in certain positions.
Loss of Nutrients due to poor eating habits or loss of appetite.
Loss of employment due to lost work days
Loss of family and social life
Emotional Disorders such as: Depression, Thoughts of Suicide, Hopelessness
If you are experiencing pelvic pain, it’s important to see your doctor. Pain in the pelvic or abdominal area can be caused by a variety of conditions, some of which may be serious. Your doctor will be able to perform tests to determine the cause of your pain. Do not assume all pelvic or abdominal is caused by adhesion even if your post adhesiolysis, as adhesions do reform following surgery.
It is important to ask for and allow diagnostic tests to rule out other sources of pathology as being the cause for your symptoms…while some adhesion do cause pain, not all adhesions cause pain and not all pain is caused by adhesions!
If all diagnostic tests result in negative findings, one cause of pain that your doctor might consider is adhesions, particularly if you have had abdominal or pelvic surgery. Adhesions are commonly associated with pelvic pain. In fact, an estimated 38 percent of women suffering from pelvic pain have adhesions.
The better news is that there are things that your doctor can do to reduce the incidence post-operative adhesions – and maybe even prevent them altogether. Educate yourself to “Adhesion Related Disorder” as the informed patient can make informed decisions when you discuss your symptoms and medical care needs with your doctor.
Always request and keep a personal file of all your medical interventions!
Adhesions Can Cause Pain:
Adhesions can cause pain by binding normally separate organs and tissues together - essentially “tying them down.” The stretching and pulling of everyday movements can irritate the nerves involved. Some adhesions can cause pain during intercourse. Ask your medical care provide to order an “ESR = Erythrocyte Sedimentation Rate” ‘ blood test for inflammatory reaction in your body. Inflammation at the adhesion attachment sites become agitated due to the pulling and tugging on the tissues of the attached organs. This inflammation creates pain and must be taken into consideration by the Doctor when treating the ARD sufferer for pain.
While pelvic pain can be an obvious symptom of adhesions, there are other serious complications of which you should be aware. Two of the more common complications of adhesions are infertility and bowel obstruction.
Adhesion can and do cause disabling pain and loss of productivity. You will want recent substantiating information on this issue when you meet with your Doctor.
Be prepared, be your own best Doctor!
http://www.adhesionrelateddisorder.com/adhesion3.html
In some cases, the answer is Adhesions!
Adhesions are bands of scar tissue intra-abdominal and/or pelvic cavity that bind your internal organs together, causing them to stick to each other. The result of these bands of scar tissue can lead to:
Adhesion Related Disorder or ARD.
The symptoms of ARD include:
Chronic pain
Infertility
Bowel obstruction
Gastro-esophageal reflux disease, (GERD)
Urinary Bladder dysfunction
Pain and difficulty having a bowel movement
Pain on movement such as: Walking, sitting or laying in certain positions.
Loss of Nutrients due to poor eating habits or loss of appetite.
Loss of employment due to lost work days
Loss of family and social life
Emotional Disorders such as: Depression, Thoughts of Suicide, Hopelessness
If you are experiencing pelvic pain, it’s important to see your doctor. Pain in the pelvic or abdominal area can be caused by a variety of conditions, some of which may be serious. Your doctor will be able to perform tests to determine the cause of your pain. Do not assume all pelvic or abdominal is caused by adhesion even if your post adhesiolysis, as adhesions do reform following surgery.
It is important to ask for and allow diagnostic tests to rule out other sources of pathology as being the cause for your symptoms…while some adhesion do cause pain, not all adhesions cause pain and not all pain is caused by adhesions!
If all diagnostic tests result in negative findings, one cause of pain that your doctor might consider is adhesions, particularly if you have had abdominal or pelvic surgery. Adhesions are commonly associated with pelvic pain. In fact, an estimated 38 percent of women suffering from pelvic pain have adhesions.
The better news is that there are things that your doctor can do to reduce the incidence post-operative adhesions – and maybe even prevent them altogether. Educate yourself to “Adhesion Related Disorder” as the informed patient can make informed decisions when you discuss your symptoms and medical care needs with your doctor.
Always request and keep a personal file of all your medical interventions!
Adhesions Can Cause Pain:
Adhesions can cause pain by binding normally separate organs and tissues together - essentially “tying them down.” The stretching and pulling of everyday movements can irritate the nerves involved. Some adhesions can cause pain during intercourse. Ask your medical care provide to order an “ESR = Erythrocyte Sedimentation Rate” ‘ blood test for inflammatory reaction in your body. Inflammation at the adhesion attachment sites become agitated due to the pulling and tugging on the tissues of the attached organs. This inflammation creates pain and must be taken into consideration by the Doctor when treating the ARD sufferer for pain.
While pelvic pain can be an obvious symptom of adhesions, there are other serious complications of which you should be aware. Two of the more common complications of adhesions are infertility and bowel obstruction.
Adhesion can and do cause disabling pain and loss of productivity. You will want recent substantiating information on this issue when you meet with your Doctor.
Be prepared, be your own best Doctor!
http://www.adhesionrelateddisorder.com/adhesion3.html
Monday, September 26, 2011
O que é aderências distúrbio relacionado (ARD)?
Blogger note...this is one of many definitions Nota Blogger ... esta é uma das muitas definições
Adhesion related disorder is a complex of symptoms related to adhesions. Desordem adesão relacionados é um complexo de sintomas relacionados à aderências. Patient's primary complaint is usually chronic abdominal pain. Queixa primária do paciente é geralmente a dor abdominal crônica. Their symptoms can be primarily in one area of the abdomen but are often generalized, vague, crampy and difficult to define. Seus sintomas podem ser principalmente em uma região do abdome, mas são muitas vezes generalizada, vaga, cólica e difícil de definir. The symptoms of ARD could include: Os sintomas da ARD podem incluir:
Chronic pain Dor crônica
Infertility Infertilidade
Bowel obstruction Obstrução intestinal
Gastro-esophageal reflux disease, (GERD) Gastro-esofágico doença do refluxo (DRGE)
Urinary Bladder dysfunction Disfunção da bexiga urinária
Pain and difficulty having a bowel movement Dor e dificuldade de ter uma evacuação
Pain on movement such as: Walking, sitting or laying in certain positions. Dor em movimento, tais como: Andar a pé, sentado ou deitado em determinadas posições.
Loss of Nutrients due to poor eating habits or loss of appetite. Perda de nutrientes devido a maus hábitos alimentares ou perda de apetite.
Loss of employment due to lost work days Perda de emprego devido a dias de trabalho perdidos
Loss of family and social life Perda da vida familiar e social
Emotional Disorders such as: Depression, Thoughts of Suicide, Hopelessness Distúrbios emocionais, tais como: depressão, pensamentos de desesperança Suicide,
Other intestinal problems can accompany the pain. Outros problemas intestinais podem acompanhar a dor. Constipation or obstruction is sometimes encountered. Constipação ou obstrução às vezes é encontrado. Alternating constipation with diarrhea from partial obstruction can also be seen. Prisão de ventre alternada com diarréia de obstrução parcial também pode ser visto. Symptoms may also be related to the gynecologic orders in women as this disorder frequently affects women. Sintomas também podem estar relacionados com as ordens ginecológicas em mulheres como este distúrbio freqüentemente afeta as mulheres. Changes in the menstrual cycle, infertility, and pain with sexual intercourse can be encountered. Mudanças no ciclo menstrual, infertilidade, dor e com a relação sexual pode ser encontrado. Other symptoms, not directly related to the adhesions, can also be encountered. Outros sintomas, não diretamente relacionado com as adesões, também podem ser encontradas. Since ARD generally results in chronic problems, anxiety and depression can result. Desde ARD geralmente resulta em problemas crônicos, a ansiedade ea depressão podem resultar. Strained relationships can occur especially when the disorder affects sexual function. Relações tensas pode ocorrer especialmente quando o transtorno afeta a função sexual. Difficulty with conception can result. Dificuldade com a concepção pode ocorrer. This further adds to the anxiety and problems with self esteem experienced by women who suffer with this disorder. Este acrescenta à ansiedade e problemas com a auto-estima vivenciada por mulheres que sofrem com esse transtorno. Difficulty eating can result in poor nutrition, weakening suffers overall medical condition and can also lead to a decrease in immune function leading to many other illnesses. Dificuldade em comer pode resultar em má nutrição, enfraquecendo sofre condição médica geral e também pode levar a uma diminuição da função imune, levando a muitas outras doenças. Since many of the symptoms related to ARD are vague and wide spread and often include emotional factors, they are often difficult to diagnose. Uma vez que muitos dos sintomas relacionados à ARD estão espalhados vaga e ampla e muitas vezes incluem fatores emocionais, são muitas vezes difíceis de diagnosticar. Symptoms of ARD will often be attributed to other abnormalities. Sintomas da ARD, muitas vezes, ser atribuída a outras anormalidades. Patient will often carry multiple diagnoses including chronic fatigue syndrome, endometriosis, irritable bowel syndrome, fibromyalgia, depression, anxiety, along with a whole host of other possible syndromes. Paciente, muitas vezes, realizar diagnósticos múltiplos, incluindo a síndrome da fadiga crônica, endometriose, síndrome do intestino irritável, fibromialgia, depressão, ansiedade, juntamente com toda uma série de outras síndromes possível. While multiple disorders can certainly exist in one patient, the confusion over which abnormality is truly causing the symptoms adds to the frustration of ARD. Enquanto transtornos múltiplos pode certamente existem em um paciente, a confusão sobre o que é verdadeiramente anormalidade causando os sintomas aumenta a frustração de ARD. This, unfortunately, adds to the discomfort experienced by those who suffer with adhesions. Isto, infelizmente, contribui para o desconforto experimentado por aqueles que sofrem com aderências. Undiagnosed chronic pain causes so much physical and emotional pain for victims of adhesion related disorder – and fills their lives with so much indecision. Dor crônica não diagnosticada causa tanta dor física e emocional para as vítimas do distúrbio de adesão relacionados - e preenche suas vidas com tanta indecisão. In time the effects of ARD will begin to affect the lives of their families, their relationships and their jobs. Com o tempo os efeitos da ARD vai começar a afetar as vidas de suas famílias, suas relações e seus empregos. This inordinate control by ARD has the power to erode and change our lives – and not necessarily for the better! Esse controle exagerado pela ARD tem o poder de corroer e mudar as nossas vidas - e não necessariamente para melhor! It is so important to believe in yourself, trust the feelings you have about your pain, and tell it like it is. É tão importante acreditar em si mesmo, a confiança dos sentimentos que você tem sobre a sua dor, e dizer-lhe como ela é. You have the right to be listened to and treated with respect – nothing less!! Você tem o direito de ser ouvido e tratado com respeito - nada menos!
Posted by IHRT at 9/24/2011 08:35:00 AM Postado por IHRT em 2011/09/24 08:35:00 Labels: Adherencias , adhesiolysis , Adhesion Related Disorder , adhesioninfo , adhesions , ARD , capps , hope for adhesion pain , Pain , post-operative adhesion , scar tissue , surgical adhesions , synechiae Marcadores: Adherencias , aderências , Transtorno de Adesão relacionadas , adhesioninfo , aderências , ARD , Capps , esperança para a dor de adesão , Dor , pós-operatório de adesão , tecido cicatricial , aderências cirúrgicas , sinéquias
Adhesion related disorder is a complex of symptoms related to adhesions. Desordem adesão relacionados é um complexo de sintomas relacionados à aderências. Patient's primary complaint is usually chronic abdominal pain. Queixa primária do paciente é geralmente a dor abdominal crônica. Their symptoms can be primarily in one area of the abdomen but are often generalized, vague, crampy and difficult to define. Seus sintomas podem ser principalmente em uma região do abdome, mas são muitas vezes generalizada, vaga, cólica e difícil de definir. The symptoms of ARD could include: Os sintomas da ARD podem incluir:
Chronic pain Dor crônica
Infertility Infertilidade
Bowel obstruction Obstrução intestinal
Gastro-esophageal reflux disease, (GERD) Gastro-esofágico doença do refluxo (DRGE)
Urinary Bladder dysfunction Disfunção da bexiga urinária
Pain and difficulty having a bowel movement Dor e dificuldade de ter uma evacuação
Pain on movement such as: Walking, sitting or laying in certain positions. Dor em movimento, tais como: Andar a pé, sentado ou deitado em determinadas posições.
Loss of Nutrients due to poor eating habits or loss of appetite. Perda de nutrientes devido a maus hábitos alimentares ou perda de apetite.
Loss of employment due to lost work days Perda de emprego devido a dias de trabalho perdidos
Loss of family and social life Perda da vida familiar e social
Emotional Disorders such as: Depression, Thoughts of Suicide, Hopelessness Distúrbios emocionais, tais como: depressão, pensamentos de desesperança Suicide,
Other intestinal problems can accompany the pain. Outros problemas intestinais podem acompanhar a dor. Constipation or obstruction is sometimes encountered. Constipação ou obstrução às vezes é encontrado. Alternating constipation with diarrhea from partial obstruction can also be seen. Prisão de ventre alternada com diarréia de obstrução parcial também pode ser visto. Symptoms may also be related to the gynecologic orders in women as this disorder frequently affects women. Sintomas também podem estar relacionados com as ordens ginecológicas em mulheres como este distúrbio freqüentemente afeta as mulheres. Changes in the menstrual cycle, infertility, and pain with sexual intercourse can be encountered. Mudanças no ciclo menstrual, infertilidade, dor e com a relação sexual pode ser encontrado. Other symptoms, not directly related to the adhesions, can also be encountered. Outros sintomas, não diretamente relacionado com as adesões, também podem ser encontradas. Since ARD generally results in chronic problems, anxiety and depression can result. Desde ARD geralmente resulta em problemas crônicos, a ansiedade ea depressão podem resultar. Strained relationships can occur especially when the disorder affects sexual function. Relações tensas pode ocorrer especialmente quando o transtorno afeta a função sexual. Difficulty with conception can result. Dificuldade com a concepção pode ocorrer. This further adds to the anxiety and problems with self esteem experienced by women who suffer with this disorder. Este acrescenta à ansiedade e problemas com a auto-estima vivenciada por mulheres que sofrem com esse transtorno. Difficulty eating can result in poor nutrition, weakening suffers overall medical condition and can also lead to a decrease in immune function leading to many other illnesses. Dificuldade em comer pode resultar em má nutrição, enfraquecendo sofre condição médica geral e também pode levar a uma diminuição da função imune, levando a muitas outras doenças. Since many of the symptoms related to ARD are vague and wide spread and often include emotional factors, they are often difficult to diagnose. Uma vez que muitos dos sintomas relacionados à ARD estão espalhados vaga e ampla e muitas vezes incluem fatores emocionais, são muitas vezes difíceis de diagnosticar. Symptoms of ARD will often be attributed to other abnormalities. Sintomas da ARD, muitas vezes, ser atribuída a outras anormalidades. Patient will often carry multiple diagnoses including chronic fatigue syndrome, endometriosis, irritable bowel syndrome, fibromyalgia, depression, anxiety, along with a whole host of other possible syndromes. Paciente, muitas vezes, realizar diagnósticos múltiplos, incluindo a síndrome da fadiga crônica, endometriose, síndrome do intestino irritável, fibromialgia, depressão, ansiedade, juntamente com toda uma série de outras síndromes possível. While multiple disorders can certainly exist in one patient, the confusion over which abnormality is truly causing the symptoms adds to the frustration of ARD. Enquanto transtornos múltiplos pode certamente existem em um paciente, a confusão sobre o que é verdadeiramente anormalidade causando os sintomas aumenta a frustração de ARD. This, unfortunately, adds to the discomfort experienced by those who suffer with adhesions. Isto, infelizmente, contribui para o desconforto experimentado por aqueles que sofrem com aderências. Undiagnosed chronic pain causes so much physical and emotional pain for victims of adhesion related disorder – and fills their lives with so much indecision. Dor crônica não diagnosticada causa tanta dor física e emocional para as vítimas do distúrbio de adesão relacionados - e preenche suas vidas com tanta indecisão. In time the effects of ARD will begin to affect the lives of their families, their relationships and their jobs. Com o tempo os efeitos da ARD vai começar a afetar as vidas de suas famílias, suas relações e seus empregos. This inordinate control by ARD has the power to erode and change our lives – and not necessarily for the better! Esse controle exagerado pela ARD tem o poder de corroer e mudar as nossas vidas - e não necessariamente para melhor! It is so important to believe in yourself, trust the feelings you have about your pain, and tell it like it is. É tão importante acreditar em si mesmo, a confiança dos sentimentos que você tem sobre a sua dor, e dizer-lhe como ela é. You have the right to be listened to and treated with respect – nothing less!! Você tem o direito de ser ouvido e tratado com respeito - nada menos!
Posted by IHRT at 9/24/2011 08:35:00 AM Postado por IHRT em 2011/09/24 08:35:00 Labels: Adherencias , adhesiolysis , Adhesion Related Disorder , adhesioninfo , adhesions , ARD , capps , hope for adhesion pain , Pain , post-operative adhesion , scar tissue , surgical adhesions , synechiae Marcadores: Adherencias , aderências , Transtorno de Adesão relacionadas , adhesioninfo , aderências , ARD , Capps , esperança para a dor de adesão , Dor , pós-operatório de adesão , tecido cicatricial , aderências cirúrgicas , sinéquias
Adhesions, Adhesions-Related Disorder or CAPPS – a way to think about the problem from the patient’s perspective.
Dallas TX. June 11 2010. The International Adhesions Society (IAS) is proud to post on its adhesions.org web site the results of groundbreaking and innovative research which will forever change the way the problem of adhesions is viewed.
The paper was published after Dr. Wiseman was invited to submit a manuscript for inclusion in a special volume of “Seminars in Reproductive Medicine” on the subject of adhesions. The paper is entitled: “Disorders of Adhesions or Adhesion-Related Disorder: Monolithic Entities or Part of Something Bigger—CAPPS? “ (click here for .pdf)
Since forming the International Adhesions Society (IAS) in 1996, it became increasingly obvious that the problems of patients suffering from adhesions were not just about adhesions. Accordingly, we were the first to coin the term “Adhesion Related Disorder” (ARD) to include the entire complex of pain, infertility, obstruction, nutrition, psychological and social issues that ARD sufferers and their families experience.
Based on formal patient surveys as well as thousands of emails and phone calls from patients, it became apparent to us that even the term ARD may be inadequate to address the problem. In reality, the ARD patient is part of a much larger group of patients who, in varying degrees, combinations and sequences experience a range of symptoms and conditions including endometriosis, interstitial cystitis (IC), irritable bowel syndrome (IBS), bowel obstruction and chronic abdominal and/or pelvic pain.
Although ‘‘adhesions’’ may start out as a single, stand-alone entity, an adhesions patient may develop a number of related conditions (ARD) which renders those patients practically indistinguishable from patients with multiple symptoms originating from other abdominal or pelvic conditions. (continued)
Click here for a pdf copy of the entire press release.
Click here for a .pdf copy of the CAPPS article
As always, our sincere thanks to the International Adhesion Society.
Visit the IAS at http://www.adhesions.org/
The paper was published after Dr. Wiseman was invited to submit a manuscript for inclusion in a special volume of “Seminars in Reproductive Medicine” on the subject of adhesions. The paper is entitled: “Disorders of Adhesions or Adhesion-Related Disorder: Monolithic Entities or Part of Something Bigger—CAPPS? “ (click here for .pdf)
Since forming the International Adhesions Society (IAS) in 1996, it became increasingly obvious that the problems of patients suffering from adhesions were not just about adhesions. Accordingly, we were the first to coin the term “Adhesion Related Disorder” (ARD) to include the entire complex of pain, infertility, obstruction, nutrition, psychological and social issues that ARD sufferers and their families experience.
Based on formal patient surveys as well as thousands of emails and phone calls from patients, it became apparent to us that even the term ARD may be inadequate to address the problem. In reality, the ARD patient is part of a much larger group of patients who, in varying degrees, combinations and sequences experience a range of symptoms and conditions including endometriosis, interstitial cystitis (IC), irritable bowel syndrome (IBS), bowel obstruction and chronic abdominal and/or pelvic pain.
Although ‘‘adhesions’’ may start out as a single, stand-alone entity, an adhesions patient may develop a number of related conditions (ARD) which renders those patients practically indistinguishable from patients with multiple symptoms originating from other abdominal or pelvic conditions. (continued)
Click here for a pdf copy of the entire press release.
Click here for a .pdf copy of the CAPPS article
As always, our sincere thanks to the International Adhesion Society.
Visit the IAS at http://www.adhesions.org/
Mum died after bowel torn during routine op
By Kevin Doyle
Friday September 23 2011
A WOMAN'S bowel was torn during a routine procedure to remove an ovarian cyst, an inquest has heard.
Elizabeth Dempsey (60), of Bayside Glen, Brittis Road, Wicklow Town, Co Wicklow, suffered septic shock and died after the procedure at St Vincent's Private Hospital, Dublin, on July 26, 2010.
The initial plan was to remove the cyst by keyhole surgery, but that procedure had to be abandoned due to extensive adhesions and the surgeon proceeded to open surgery, Dublin Coroner's Court was told.
Ms Dempsey died at the hospital two days later.
After hearing the evidence, Coroner Dr Brian Farrell said he was satisfied it was the laparoscopy that caused the perforation.
He recorded a verdict of death by medical misadventure.
Speaking outside the court following the inquest, Ms Dempsey's son Colum said he was happy with the verdict.
hnews@herald.ie
- Kevin Doyle
http://www.herald.ie/news/mum-died-after-bowel-torn-during-routine-op-2885925.html
Friday September 23 2011
A WOMAN'S bowel was torn during a routine procedure to remove an ovarian cyst, an inquest has heard.
Elizabeth Dempsey (60), of Bayside Glen, Brittis Road, Wicklow Town, Co Wicklow, suffered septic shock and died after the procedure at St Vincent's Private Hospital, Dublin, on July 26, 2010.
The initial plan was to remove the cyst by keyhole surgery, but that procedure had to be abandoned due to extensive adhesions and the surgeon proceeded to open surgery, Dublin Coroner's Court was told.
Ms Dempsey died at the hospital two days later.
After hearing the evidence, Coroner Dr Brian Farrell said he was satisfied it was the laparoscopy that caused the perforation.
He recorded a verdict of death by medical misadventure.
Speaking outside the court following the inquest, Ms Dempsey's son Colum said he was happy with the verdict.
hnews@herald.ie
- Kevin Doyle
http://www.herald.ie/news/mum-died-after-bowel-torn-during-routine-op-2885925.html
Saturday, September 24, 2011
¿Cuál es el desorden relacionado las adherencias (ARD)?
¿Cuál es el desorden relacionado las adherencias (ARD)?
La nota del Blogger… esto es una de muchas definiciones
El desorden relacionado adherencia es un complejo de los síntomas relacionados con las adherencias. La queja primaria del paciente es generalmente dolor abdominal crónico. Sus síntomas pueden estar sobre todo en una área del abdomen pero son generalizados a menudo, vagos, crampy y difíciles de definir. Los síntomas de ARD podían incluir:
Dolor crónico
Infertilidad
Obstrucción del intestino
Enfermedad del reflujo gastroesofágico, (GERD)
Disfunción de la vejiga urinaria
Dolor y dificultad que tienen un movimiento de intestino
Dolor en el movimiento por ejemplo: El caminar, el sentarse o colocación en ciertas posiciones.
Pérdida de alimentos debido a los hábitos alimentarios pobres o pérdida de apetito.
Pérdida de empleo debido a los días perdidos del trabajo
Pérdida de familia y de vida social
Desordenes emocionales por ejemplo: Depresión, pensamientos del suicidio, desesperación
Otros problemas intestinales pueden acompañar el dolor. El estreñimiento o la obstrucción se encuentra a veces. El estreñimiento de alternancia con diarrea de la obstrucción parcial puede también ser considerado. Los síntomas se pueden también relacionar con las órdenes ginecológicas en mujeres mientras que este desorden afecta con frecuencia a mujeres. Los cambios en el ciclo menstrual, la infertilidad, y el dolor con cópula sexual pueden ser encontrados. Otros síntomas, relacionados no no directamente con las adherencias, pueden también ser encontrados. Desde ARD da lugar generalmente a los problemas crónicos, ansiedad y la depresión puede resultar. Las relaciones filtradas pueden ocurrir especialmente cuando el desorden afecta a la función sexual. La dificultad con el concepto puede resultar. Este más futuro agrega a la ansiedad y a los problemas con el amor propio experimentado por las mujeres que sufren con este desorden. La consumición de la dificultad puede dar lugar a la nutrición pobre, el debilitamiento sufre la dolencia total y puede también llevar a una disminución de la función inmune que lleva a muchas otras enfermedades. Puesto que muchos de los síntomas relacionados con ARD son vagos y separan de par en par e incluyen a menudo factores emocionales, son a menudo difíciles de diagnosticar. Los síntomas de ARD serán atribuidos a menudo a otras anormalidades. El paciente llevará a menudo diagnosis múltiples incluyendo el síndrome crónico de la fatiga, endometriosis, síndrome de intestino irritable, fibromyalgia, depresión, ansiedad, junto con un anfitrión entero de otros síndromes posibles. Mientras que los desordenes múltiples pueden existir ciertamente en un paciente, la confusión sobre quien anormalidad está causando verdad los síntomas agrega a la frustración de ARD. Esto, desafortunadamente, agrega al malestar experimentado por los que sufran con adherencias. El dolor crónico Undiagnosed causa tanto el dolor físico y emocional para las víctimas del desorden relacionado adherencia - y llena sus vidas tanto de la indecisión. A tiempo los efectos de ARD comenzarán a afectar a las vidas de sus familias, de sus relaciones y de sus trabajos. ¡Este control excesivo por ARD tiene la energía de erosionar y de cambiar nuestras vidas - y no no necesariamente para el mejor! Es así que importante creer en se, confiar en las sensaciones que usted tiene sobre su dolor, y decirlo tenga gusto de él es. ¡Usted tiene la derecha de ser escuchado y de ser tratado con el respecto - nada menos!!
Fijado por IHRT en 9/24/2011 08:35: 00
Etiquetas: Adherencias, adhesiolysis, adherencia relacionó el desorden, adhesioninfo, adherencias, ARD, capps, esperanza del dolor de la adherencia, dolor, adherencia postoperatoria, tejido de la cicatriz, adherencias quirúrgicas, synechiae
comentarios 0:
La nota del Blogger… esto es una de muchas definiciones
El desorden relacionado adherencia es un complejo de los síntomas relacionados con las adherencias. La queja primaria del paciente es generalmente dolor abdominal crónico. Sus síntomas pueden estar sobre todo en una área del abdomen pero son generalizados a menudo, vagos, crampy y difíciles de definir. Los síntomas de ARD podían incluir:
Dolor crónico
Infertilidad
Obstrucción del intestino
Enfermedad del reflujo gastroesofágico, (GERD)
Disfunción de la vejiga urinaria
Dolor y dificultad que tienen un movimiento de intestino
Dolor en el movimiento por ejemplo: El caminar, el sentarse o colocación en ciertas posiciones.
Pérdida de alimentos debido a los hábitos alimentarios pobres o pérdida de apetito.
Pérdida de empleo debido a los días perdidos del trabajo
Pérdida de familia y de vida social
Desordenes emocionales por ejemplo: Depresión, pensamientos del suicidio, desesperación
Otros problemas intestinales pueden acompañar el dolor. El estreñimiento o la obstrucción se encuentra a veces. El estreñimiento de alternancia con diarrea de la obstrucción parcial puede también ser considerado. Los síntomas se pueden también relacionar con las órdenes ginecológicas en mujeres mientras que este desorden afecta con frecuencia a mujeres. Los cambios en el ciclo menstrual, la infertilidad, y el dolor con cópula sexual pueden ser encontrados. Otros síntomas, relacionados no no directamente con las adherencias, pueden también ser encontrados. Desde ARD da lugar generalmente a los problemas crónicos, ansiedad y la depresión puede resultar. Las relaciones filtradas pueden ocurrir especialmente cuando el desorden afecta a la función sexual. La dificultad con el concepto puede resultar. Este más futuro agrega a la ansiedad y a los problemas con el amor propio experimentado por las mujeres que sufren con este desorden. La consumición de la dificultad puede dar lugar a la nutrición pobre, el debilitamiento sufre la dolencia total y puede también llevar a una disminución de la función inmune que lleva a muchas otras enfermedades. Puesto que muchos de los síntomas relacionados con ARD son vagos y separan de par en par e incluyen a menudo factores emocionales, son a menudo difíciles de diagnosticar. Los síntomas de ARD serán atribuidos a menudo a otras anormalidades. El paciente llevará a menudo diagnosis múltiples incluyendo el síndrome crónico de la fatiga, endometriosis, síndrome de intestino irritable, fibromyalgia, depresión, ansiedad, junto con un anfitrión entero de otros síndromes posibles. Mientras que los desordenes múltiples pueden existir ciertamente en un paciente, la confusión sobre quien anormalidad está causando verdad los síntomas agrega a la frustración de ARD. Esto, desafortunadamente, agrega al malestar experimentado por los que sufran con adherencias. El dolor crónico Undiagnosed causa tanto el dolor físico y emocional para las víctimas del desorden relacionado adherencia - y llena sus vidas tanto de la indecisión. A tiempo los efectos de ARD comenzarán a afectar a las vidas de sus familias, de sus relaciones y de sus trabajos. ¡Este control excesivo por ARD tiene la energía de erosionar y de cambiar nuestras vidas - y no no necesariamente para el mejor! Es así que importante creer en se, confiar en las sensaciones que usted tiene sobre su dolor, y decirlo tenga gusto de él es. ¡Usted tiene la derecha de ser escuchado y de ser tratado con el respecto - nada menos!!
Fijado por IHRT en 9/24/2011 08:35: 00
Etiquetas: Adherencias, adhesiolysis, adherencia relacionó el desorden, adhesioninfo, adherencias, ARD, capps, esperanza del dolor de la adherencia, dolor, adherencia postoperatoria, tejido de la cicatriz, adherencias quirúrgicas, synechiae
comentarios 0:
What is adhesions related disorder (ARD)?
Blogger note...this is one of many definitions
Adhesion related disorder is a complex of symptoms related to adhesions. Patient’s primary complaint is usually chronic abdominal pain. Their symptoms can be primarily in one area of the abdomen but are often generalized, vague, crampy and difficult to define. The symptoms of ARD could include:
Chronic pain
Infertility
Bowel obstruction
Gastro-esophageal reflux disease, (GERD)
Urinary Bladder dysfunction
Pain and difficulty having a bowel movement
Pain on movement such as: Walking, sitting or laying in certain positions.
Loss of Nutrients due to poor eating habits or loss of appetite.
Loss of employment due to lost work days
Loss of family and social life
Emotional Disorders such as: Depression, Thoughts of Suicide, Hopelessness
Other intestinal problems can accompany the pain. Constipation or obstruction is sometimes encountered. Alternating constipation with diarrhea from partial obstruction can also be seen. Symptoms may also be related to the gynecologic orders in women as this disorder frequently affects women. Changes in the menstrual cycle, infertility, and pain with sexual intercourse can be encountered. Other symptoms, not directly related to the adhesions, can also be encountered. Since ARD generally results in chronic problems, anxiety and depression can result. Strained relationships can occur especially when the disorder affects sexual function. Difficulty with conception can result. This further adds to the anxiety and problems with self esteem experienced by women who suffer with this disorder. Difficulty eating can result in poor nutrition, weakening suffers overall medical condition and can also lead to a decrease in immune function leading to many other illnesses. Since many of the symptoms related to ARD are vague and wide spread and often include emotional factors, they are often difficult to diagnose. Symptoms of ARD will often be attributed to other abnormalities. Patient will often carry multiple diagnoses including chronic fatigue syndrome, endometriosis, irritable bowel syndrome, fibromyalgia, depression, anxiety, along with a whole host of other possible syndromes. While multiple disorders can certainly exist in one patient, the confusion over which abnormality is truly causing the symptoms adds to the frustration of ARD. This, unfortunately, adds to the discomfort experienced by those who suffer with adhesions. Undiagnosed chronic pain causes so much physical and emotional pain for victims of adhesion related disorder – and fills their lives with so much indecision. In time the effects of ARD will begin to affect the lives of their families, their relationships and their jobs. This inordinate control by ARD has the power to erode and change our lives – and not necessarily for the better! It is so important to believe in yourself, trust the feelings you have about your pain, and tell it like it is. You have the right to be listened to and treated with respect – nothing less!!
Adhesion related disorder is a complex of symptoms related to adhesions. Patient’s primary complaint is usually chronic abdominal pain. Their symptoms can be primarily in one area of the abdomen but are often generalized, vague, crampy and difficult to define. The symptoms of ARD could include:
Chronic pain
Infertility
Bowel obstruction
Gastro-esophageal reflux disease, (GERD)
Urinary Bladder dysfunction
Pain and difficulty having a bowel movement
Pain on movement such as: Walking, sitting or laying in certain positions.
Loss of Nutrients due to poor eating habits or loss of appetite.
Loss of employment due to lost work days
Loss of family and social life
Emotional Disorders such as: Depression, Thoughts of Suicide, Hopelessness
Other intestinal problems can accompany the pain. Constipation or obstruction is sometimes encountered. Alternating constipation with diarrhea from partial obstruction can also be seen. Symptoms may also be related to the gynecologic orders in women as this disorder frequently affects women. Changes in the menstrual cycle, infertility, and pain with sexual intercourse can be encountered. Other symptoms, not directly related to the adhesions, can also be encountered. Since ARD generally results in chronic problems, anxiety and depression can result. Strained relationships can occur especially when the disorder affects sexual function. Difficulty with conception can result. This further adds to the anxiety and problems with self esteem experienced by women who suffer with this disorder. Difficulty eating can result in poor nutrition, weakening suffers overall medical condition and can also lead to a decrease in immune function leading to many other illnesses. Since many of the symptoms related to ARD are vague and wide spread and often include emotional factors, they are often difficult to diagnose. Symptoms of ARD will often be attributed to other abnormalities. Patient will often carry multiple diagnoses including chronic fatigue syndrome, endometriosis, irritable bowel syndrome, fibromyalgia, depression, anxiety, along with a whole host of other possible syndromes. While multiple disorders can certainly exist in one patient, the confusion over which abnormality is truly causing the symptoms adds to the frustration of ARD. This, unfortunately, adds to the discomfort experienced by those who suffer with adhesions. Undiagnosed chronic pain causes so much physical and emotional pain for victims of adhesion related disorder – and fills their lives with so much indecision. In time the effects of ARD will begin to affect the lives of their families, their relationships and their jobs. This inordinate control by ARD has the power to erode and change our lives – and not necessarily for the better! It is so important to believe in yourself, trust the feelings you have about your pain, and tell it like it is. You have the right to be listened to and treated with respect – nothing less!!
Friday, September 23, 2011
Is HIPAA Hiding the Wrong Kind of Secrets?
August 16th, 2010 Anyone who has been to a doctor in the last dozen years has seen and signed the HIPAA (Health Insurance Portability & Accountability Act) form given out by their doctor or hospital. The HIPAA Privacy Rule was specifically designed to protect the privacy and integrity of personal health information collected by medical professionals about their patients.
Essentially this means that it is illegal to release the specifics of a patient case you may have either attended or witnessed. Thinking in terms of a laboring woman, what happens in her hospital room stays in her hospital room.
Doulas are not bound to HIPAA, but we do carry a professional code of ethics which makes it unprofessional to openly discuss our clients’ cases. Some of us may gather in small circles to privately work out our thoughts on situations we may have been in, and try to grow our knowledge base by sharing experiences. However, it is considered quite unprofessional to openly discuss any identifying details of a specific mother’s birth experience.
Of course, privacy is essential to trust. A woman cannot trust a provider who would willingly pass the details of her case around the internet for all the world to see. For the most part, it is nobody’s business what happens during her labor.
Well, unless it IS.
Speaking in generalities, because I will not discuss specific cases, I can tell you that some things I’ve witnessed as a doula in a labor room have been nothing short of a crime. Women have the right to informed consent and refusal, and I have seen cases where that right is violated over and over again throughout a labor. According to the American Medical Association,
“Informed consent is more than simply getting a patient to sign a written consent form. It is a process of communication between a patient and physician that results in the patient’s authorization or agreement to undergo a specific medical intervention…
…This communications process, or a variation thereof, is both an ethical obligation and a legal requirement spelled out in statutes and case law in all 50 states.”
So what happens when a woman flatly refuses to give consent, and a physician performs a procedure without her authorization and against her will? Katherine Prown, Ph.D. tells us,
“The legal doctrine of informed consent/refusal developed from the laws on battery. In a medical setting battery is defined as touching or treatment that occurs without obtaining proper informed consent; medical treatments that are substantially different from the ones a patient consented to; treatment that exceeds the scope of consent; or treatment provided by a physician other than the physician who obtained the patient’s consent. As case law on informed consent/refusal evolved, however, the courts increasingly defined lack of proper consent as a matter of negligence. Negligence requires that the lack of proper consent or failure to meet the standard of care resulted in emotional or physical harm worthy of monetary compensation. In certain circumstances in which monetary compensation is not an issue, though, the laws on battery may still apply.”
Given this, I have borne witness to cases where a woman’s rights are so flagrantly violated that it seems like an obscene injustice not to tell the world about what happened to her. But once the labor is over, the dozen or so people in that room simply move on to another labor, and because of privacy laws like HIPAA, nothing that happened is ever shared with the public.
You might be asking “Is it really that bad? Can it really, seriously be that bad?” You tell me. (**Trigger Warning**)
•I have seen a mother flat out refuse a procedure and/or treatment and the doctor say, verbatim, “You can say no, but we’re doing it anyway.” And they did. And nobody in the room could stop them.
•I’ve seen the mother’s parents get into yelling matches with the nurse or doctor because the medical staff constantly coerced or threatened the laboring woman to the point of emotional distress.
•I’ve seen a doctor stand over a woman and force her to “pre-authorize” a major intervention that was neither wanted, needed, or ever actually used during the labor, and refuse to leave the room until her signature was on the paper – giving her no time to contemplate the decision or discuss it with her family.
•I’ve seen a woman scream “No, stop!” while trying to kick a doctor’s hands out of her, as she tries climbing up the back of the bed to escape, while the doctor ignored her pleas and reaches farther into her vagina – blood curdling screams fill the room.
•I’ve had women cry and beg me to help them – to keep the doctor or nurse from doing whatever it is they’re doing to them – and I can’t help at all. Being a bodyguard is outside my professional scope of practice.
•I’ve seen a woman say she does not want an episiotomy, and the doctor say “Sorry” (snip, snip, snip) “I had to make some room.”
On one hand, I’m glad I was there to help those women in whatever way I could. On the other hand, it’s terribly stressful having witnessed crimes against women and know that professional secrecy will prevent everyone in that room from discussing what happened to her.
Of course the mother could take this information to the authorities, but that rarely ever happens. On one hand, as long as the mother came out with a healthy baby, nobody cares how she was treated in the process. She would need to have a damaged baby to have any sort of a legal case that an attorney would see worth his/her time. It’s also quite easy for a laboring woman not to remember or understand the details of what was being done to her. She’s in laborland – not taking minutes in a meeting. Women also have a hard time coming to terms with being violated.
This is the same reason so many women don’t report rape. After the incident is over, they just want it to be over. They don’t want to think about it, or drag it through a court system. They may think that it’s partially their fault, or that going public may put their story under embarassing and unfair scrutiny. When I took my VBAC story to the Chicago Tribune, my obstetrician accused women like me of having a “control issue.” No apology. No admission that his behavior was unethical and potentially illegal. He simply blamed me for not submitting to his violation. There are a million reasons women do not report violations, coupled with a million violators who continue to practice the way they do without anyone holding them accountable.
What can be done? At what point can we, who witness these crimes, open this can of worms and start talking about what is happening to individual women every single day in this system of ours? I know that it’s not my place to file complaint about the way a woman was treated, but if there’s no transparency, where does that leave us? I can tell you that it leaves me angry in my bones and feeling sick to my stomach.
In the mean time, I have to decide whether or not I can handle seeing any more of these hospital births, or if I should send women in to the lion’s den without someone like me there to help them in whatever small way I can. It’s a tough decision, and one that I may grapple with for a long time to come.
_______________________________________________________
If you are a mother who was violated, did you report any of it? Was there a resolution? If you are a birth professional who has witnessed these births, how do you recover emotionally knowing there’s nothing you can do?
http://thefeministbreeder.com/is-hipaa-hiding-the-wrong-kind-of-secrets/
Essentially this means that it is illegal to release the specifics of a patient case you may have either attended or witnessed. Thinking in terms of a laboring woman, what happens in her hospital room stays in her hospital room.
Doulas are not bound to HIPAA, but we do carry a professional code of ethics which makes it unprofessional to openly discuss our clients’ cases. Some of us may gather in small circles to privately work out our thoughts on situations we may have been in, and try to grow our knowledge base by sharing experiences. However, it is considered quite unprofessional to openly discuss any identifying details of a specific mother’s birth experience.
Of course, privacy is essential to trust. A woman cannot trust a provider who would willingly pass the details of her case around the internet for all the world to see. For the most part, it is nobody’s business what happens during her labor.
Well, unless it IS.
Speaking in generalities, because I will not discuss specific cases, I can tell you that some things I’ve witnessed as a doula in a labor room have been nothing short of a crime. Women have the right to informed consent and refusal, and I have seen cases where that right is violated over and over again throughout a labor. According to the American Medical Association,
“Informed consent is more than simply getting a patient to sign a written consent form. It is a process of communication between a patient and physician that results in the patient’s authorization or agreement to undergo a specific medical intervention…
…This communications process, or a variation thereof, is both an ethical obligation and a legal requirement spelled out in statutes and case law in all 50 states.”
So what happens when a woman flatly refuses to give consent, and a physician performs a procedure without her authorization and against her will? Katherine Prown, Ph.D. tells us,
“The legal doctrine of informed consent/refusal developed from the laws on battery. In a medical setting battery is defined as touching or treatment that occurs without obtaining proper informed consent; medical treatments that are substantially different from the ones a patient consented to; treatment that exceeds the scope of consent; or treatment provided by a physician other than the physician who obtained the patient’s consent. As case law on informed consent/refusal evolved, however, the courts increasingly defined lack of proper consent as a matter of negligence. Negligence requires that the lack of proper consent or failure to meet the standard of care resulted in emotional or physical harm worthy of monetary compensation. In certain circumstances in which monetary compensation is not an issue, though, the laws on battery may still apply.”
Given this, I have borne witness to cases where a woman’s rights are so flagrantly violated that it seems like an obscene injustice not to tell the world about what happened to her. But once the labor is over, the dozen or so people in that room simply move on to another labor, and because of privacy laws like HIPAA, nothing that happened is ever shared with the public.
You might be asking “Is it really that bad? Can it really, seriously be that bad?” You tell me. (**Trigger Warning**)
•I have seen a mother flat out refuse a procedure and/or treatment and the doctor say, verbatim, “You can say no, but we’re doing it anyway.” And they did. And nobody in the room could stop them.
•I’ve seen the mother’s parents get into yelling matches with the nurse or doctor because the medical staff constantly coerced or threatened the laboring woman to the point of emotional distress.
•I’ve seen a doctor stand over a woman and force her to “pre-authorize” a major intervention that was neither wanted, needed, or ever actually used during the labor, and refuse to leave the room until her signature was on the paper – giving her no time to contemplate the decision or discuss it with her family.
•I’ve seen a woman scream “No, stop!” while trying to kick a doctor’s hands out of her, as she tries climbing up the back of the bed to escape, while the doctor ignored her pleas and reaches farther into her vagina – blood curdling screams fill the room.
•I’ve had women cry and beg me to help them – to keep the doctor or nurse from doing whatever it is they’re doing to them – and I can’t help at all. Being a bodyguard is outside my professional scope of practice.
•I’ve seen a woman say she does not want an episiotomy, and the doctor say “Sorry” (snip, snip, snip) “I had to make some room.”
On one hand, I’m glad I was there to help those women in whatever way I could. On the other hand, it’s terribly stressful having witnessed crimes against women and know that professional secrecy will prevent everyone in that room from discussing what happened to her.
Of course the mother could take this information to the authorities, but that rarely ever happens. On one hand, as long as the mother came out with a healthy baby, nobody cares how she was treated in the process. She would need to have a damaged baby to have any sort of a legal case that an attorney would see worth his/her time. It’s also quite easy for a laboring woman not to remember or understand the details of what was being done to her. She’s in laborland – not taking minutes in a meeting. Women also have a hard time coming to terms with being violated.
This is the same reason so many women don’t report rape. After the incident is over, they just want it to be over. They don’t want to think about it, or drag it through a court system. They may think that it’s partially their fault, or that going public may put their story under embarassing and unfair scrutiny. When I took my VBAC story to the Chicago Tribune, my obstetrician accused women like me of having a “control issue.” No apology. No admission that his behavior was unethical and potentially illegal. He simply blamed me for not submitting to his violation. There are a million reasons women do not report violations, coupled with a million violators who continue to practice the way they do without anyone holding them accountable.
What can be done? At what point can we, who witness these crimes, open this can of worms and start talking about what is happening to individual women every single day in this system of ours? I know that it’s not my place to file complaint about the way a woman was treated, but if there’s no transparency, where does that leave us? I can tell you that it leaves me angry in my bones and feeling sick to my stomach.
In the mean time, I have to decide whether or not I can handle seeing any more of these hospital births, or if I should send women in to the lion’s den without someone like me there to help them in whatever small way I can. It’s a tough decision, and one that I may grapple with for a long time to come.
_______________________________________________________
If you are a mother who was violated, did you report any of it? Was there a resolution? If you are a birth professional who has witnessed these births, how do you recover emotionally knowing there’s nothing you can do?
http://thefeministbreeder.com/is-hipaa-hiding-the-wrong-kind-of-secrets/
Thursday, September 22, 2011
“September 23rd is ARD AWARENESS Day!”
“September 23rd is ARD AWARENESS Day!”
JOIN NOW
“CEA for ARD!”
"Crusade for Education and Awareness of Adhesion Related Disorder (ARD)"
Start NOW to spread the word! Get into the spirit of a just cause…
WE NEED YOUR HELP NOW!
I want to take a moment to ask everyone who visits any ARD web sites to take the time
to join our cooperative efforts to spread the word about Adhesion Related Disorder!
"Crusade for Education and Awareness of Adhesion Related Disorder (ARD)"
If your afflicted with ARD, or know someone who is, or just have it in your heart to help our cause, as with your voice joining ours, we will conquer this disorder and save others from living this life of hell!
WE NEED YOUR HELP NOW!
And here is how you can do that…
To spread the word on ARD, visit" http://www.adhesionrelateddisorder.com/" and PRINT OUT
the ALL NEW and in FULL COLOR
“ARD Brochure”
Click here; http://www.adhesionrelateddisorder.com/ARD-brochure-printpg1.html
Take your copy to printers, a Kinko’s, Office Max or any other place where you can have
copies made at a reasonable price! Some printer’s will print for free, as long as it is for a medical issue, just ask?
(Please feel free to copy ANY material found in adhesionrelateddisorder.com and use it
as you elect to!)
NO COPYRIGHT on material found with in this website as it is YOUR ARD web site!
USE IT, USE IT and USE IT!
“Circulation of ARD Brochures and Information”
Whether you are afflicted with ARD or not, take them to ALL of appointments, be it the hairdresser or surgeon, take them everywhere and hand them out! Ask permission to leave extra copies on offices and medical facilities, local pharmacies, such as in Wal-Mart, and other stores, BIG or SMALL!
Tack the up in the local Laundromats and restaurants that offer bulletin boards, hand it to the waitress, the store clerks at checkouts, driving through a fast food…hand it to the lady in the service window, leave one for the postal worker!! Libraries, Churches, Museums, Dentists are all great places to spread the word!
Call the local schools and business to see if you can drop some off for the faculties and employees! Go through your telephone book to jog your mind as to where you might drop some off…call ahead and ask!
Every place that you see people visiting, place a brochure or two or three or four, as anyone of those people might be the person who life you save because you took that time to share this information!
“Call Your Local Media”
Call your local newspaper and offer to share your walk with ARD, be it your own or a
loved one! Check with your local radio stations, many have “guest spots” in which
persons from the community are invited to share their stories or interests, etc!
Call your local media and tell them that you’re willing to share your story with them as
“September 23rd is ARD AWARENESS Day!”
“Contact Your Government Officials”
Mail the ARD Brochure and any other ARD material, including your personal ARD story or a loved one’s, story to your local, state and national government representatives!
Include the
“New York, Louisiana, Wisconsin, Massachusetts and Ohio ARD Resolutions”
Ask YOUR STATE ASSEMBLY Representative to create similar documents for
YOUR state!
Do it for yourself, your fellow ARD sufferers in your state and do it from within the
USA!
You can find these resolutions the protocol outlined in the:
International Adhesion Society:
IAS Campaigns & Projects(http://www.adhesions.org/ )
Adhesion Information Site(http://www.adhesionrelateddisorder.com/ )
Or simply ask for step by step instruction in the
ARDvark Forum(http://www.adhesionrelateeddisorder.blogspot.com/ )
or click links below for fast access
New York | Louisiana | Wisconsin | Massachusetts | Ohio |
New Jersey | Pennsylvania | Minnesota
Be sure to tell your government officials that…
“September 23rd is ARD AWARENESS Day!”
The “Governmental Recognition” protocol was written by:
Augusta Sisler “World Adhesion Foundation”(http://www.adhesionsfoundation.com/ )
Beverly J. Doucette “Adhesion Information Site” (http://www.adhesionrelateddisorder.com/ )
Please see
Dawn Rose“ARD Interactive Site”(http://www.adhesionrelateddisorder.blogspot.com/ )
http://www.bombobeach.com/communications/spirit%20of%20awareness%20information/Spirit%20of%20Awareness%20Campaign%202003.doc
And it ALL began with:
Dr. David Wiseman Ph.D., M.R.Pharm.S.
International Adhesion Society
http://www.adhesions.org/
JOIN NOW
“CEA for ARD!”
"Crusade for Education and Awareness of Adhesion Related Disorder (ARD)"
Start NOW to spread the word! Get into the spirit of a just cause…
WE NEED YOUR HELP NOW!
I want to take a moment to ask everyone who visits any ARD web sites to take the time
to join our cooperative efforts to spread the word about Adhesion Related Disorder!
"Crusade for Education and Awareness of Adhesion Related Disorder (ARD)"
If your afflicted with ARD, or know someone who is, or just have it in your heart to help our cause, as with your voice joining ours, we will conquer this disorder and save others from living this life of hell!
WE NEED YOUR HELP NOW!
And here is how you can do that…
To spread the word on ARD, visit" http://www.adhesionrelateddisorder.com/" and PRINT OUT
the ALL NEW and in FULL COLOR
“ARD Brochure”
Click here; http://www.adhesionrelateddisorder.com/ARD-brochure-printpg1.html
Take your copy to printers, a Kinko’s, Office Max or any other place where you can have
copies made at a reasonable price! Some printer’s will print for free, as long as it is for a medical issue, just ask?
(Please feel free to copy ANY material found in adhesionrelateddisorder.com and use it
as you elect to!)
NO COPYRIGHT on material found with in this website as it is YOUR ARD web site!
USE IT, USE IT and USE IT!
“Circulation of ARD Brochures and Information”
Whether you are afflicted with ARD or not, take them to ALL of appointments, be it the hairdresser or surgeon, take them everywhere and hand them out! Ask permission to leave extra copies on offices and medical facilities, local pharmacies, such as in Wal-Mart, and other stores, BIG or SMALL!
Tack the up in the local Laundromats and restaurants that offer bulletin boards, hand it to the waitress, the store clerks at checkouts, driving through a fast food…hand it to the lady in the service window, leave one for the postal worker!! Libraries, Churches, Museums, Dentists are all great places to spread the word!
Call the local schools and business to see if you can drop some off for the faculties and employees! Go through your telephone book to jog your mind as to where you might drop some off…call ahead and ask!
Every place that you see people visiting, place a brochure or two or three or four, as anyone of those people might be the person who life you save because you took that time to share this information!
“Call Your Local Media”
Call your local newspaper and offer to share your walk with ARD, be it your own or a
loved one! Check with your local radio stations, many have “guest spots” in which
persons from the community are invited to share their stories or interests, etc!
Call your local media and tell them that you’re willing to share your story with them as
“September 23rd is ARD AWARENESS Day!”
“Contact Your Government Officials”
Mail the ARD Brochure and any other ARD material, including your personal ARD story or a loved one’s, story to your local, state and national government representatives!
Include the
“New York, Louisiana, Wisconsin, Massachusetts and Ohio ARD Resolutions”
Ask YOUR STATE ASSEMBLY Representative to create similar documents for
YOUR state!
Do it for yourself, your fellow ARD sufferers in your state and do it from within the
USA!
You can find these resolutions the protocol outlined in the:
International Adhesion Society:
IAS Campaigns & Projects(http://www.adhesions.org/ )
Adhesion Information Site(http://www.adhesionrelateddisorder.com/ )
Or simply ask for step by step instruction in the
ARDvark Forum(http://www.adhesionrelateeddisorder.blogspot.com/ )
or click links below for fast access
New York | Louisiana | Wisconsin | Massachusetts | Ohio |
New Jersey | Pennsylvania | Minnesota
Be sure to tell your government officials that…
“September 23rd is ARD AWARENESS Day!”
The “Governmental Recognition” protocol was written by:
Augusta Sisler “World Adhesion Foundation”(http://www.adhesionsfoundation.com/ )
Beverly J. Doucette “Adhesion Information Site” (http://www.adhesionrelateddisorder.com/ )
Please see
Dawn Rose“ARD Interactive Site”(http://www.adhesionrelateddisorder.blogspot.com/ )
http://www.bombobeach.com/communications/spirit%20of%20awareness%20information/Spirit%20of%20Awareness%20Campaign%202003.doc
And it ALL began with:
Dr. David Wiseman Ph.D., M.R.Pharm.S.
International Adhesion Society
http://www.adhesions.org/
Wednesday, September 21, 2011
Karen trying to corner the market on ARD
It appears that Karen Steward will do anything to sell her "ARD Product" line to make a buck off the pain and suffering of those who are already used and abused far to often! Karen speaks out of two sides of her mouth when it comes to ARD. One side she gets your sympathy as one who has suffered the worst of ARD, and out of the other side, Karen is hawking, "BUY MY STUFF" and "LOOK AT ME!"
Who does this sound like..."Kruschinski" of course!
So here you will find Karen sending complaint after complaint to other ARD and Endo wed site hosts, and Google as well as any one else will listen to her and then she forces them to spend time and money with her petty little claims in her attempts to corner the market on the Internet! If she were to succeed in her attempt to gain favorable spots in the search engines by knocking a few other ARD web sites off, she will be able to harvest vulnerable, and desperately ill people to her web sites to buy her merchandise; and ultimately to get them to secure surgery with the "Con Doc, Kruschinski," who rise to notoriety comes from "Profiting from Pain!"
BEWARE of any web site associated with Karen Steward of Wetherford, Texas!
Search Results:
Any contains ELM publishing:
3 matching Notices found; showing 50
Articles DMCA (Copyright) Complaint to Google Karen Steward Google, Inc. [Blogger] July 30, 2011 DMCA Notices
Text DMCA (Copyright) Complaint to Google Karen Steward Google, Inc. [Blogger] July 17, 2011 DMCA Notices
Article DMCA (Copyright) Complaint to Google ELM Publishing, Inc. Google, Inc. [Blogger] May 13, 2011 DMCA Notices
Notice UnavailableDMCA (Copyright) Complaint to Google
Sent by: ELM Publishing, IncTo: Google
The cease-and-desist or legal threat you requested is not yet available.
Chilling Effects will post the notice after we process it.
Question: Why does a web host, blogging service provider, or search engine get DMCA takedown notices?
Answer: Many copyright claimants are making complaints under the Digital Millennium Copyright Act, Section 512(c)'s safe-harbor for hosts of "Information Residing on Systems or Networks At Direction of Users" or Section 512(d)'s safe-harbor for providers of "Information Location Tools." These safe harbors give providers immunity from liability for users' possible copyright infringement -- if they "expeditiously" remove material when they get complaints. Whether or not the provider would have been liable for infringement by users' materials it hosts or links to, the provider can avoid the possibility of a lawsuit for money damages by following the DMCA's takedown procedure when it gets a complaint. The person whose information was removed can file a counter-notification if he or she believes the complaint was erroneous.
Question: What does a service provider have to do in order to qualify for safe harbor protection?
Answer: In addition to informing its customers of its policies, a service provider must follow the proper notice and takedown procedures and also meet several other requirements in order to qualify for exemption under the safe harbor provisions.
In order to facilitate the notification process in cases of infringement, ISPs which allow users to store information on their networks, such as a web hosting service, must designate an agent that will receive the notices from copyright owners that its network contains material which infringes their intellectual property rights. The service provider must then notify the Copyright Office of the agent's name and address and make that information publicly available on its web site. [512(c)(2)]
Finally, the service provider must not have knowledge that the material or activity is infringing or of the fact that the infringing material exists on its network. If it does discover such material before being contacted by the copyright owners, it is instructed to remove, or disable access to, the material itself. The service provider must not gain any financial benefit that is attributable to the infringing material.
Question: What are the provisions of 17 U.S.C. Section 512(c)(3) & 512(d)(3)?
Answer: Section 512(c)(3) sets out the elements for notification under the DMCA. Subsection A (17 U.S.C. 512(c)(3)(A)) states that to be effective a notification must include: 1) a physical/electronic signature of a person authorized to act on behalf of the owner of the infringed right; 2) identification of the copyrighted works claimed to have been infringed; 3) identification of the material that is claimed to be infringing or to be the subject of infringing activity and that is to be removed; 4) information reasonably sufficient to permit the service provider to contact the complaining party (e.g., the address, telephone number, or email address); 5) a statement that the complaining party has a good faith belief that use of the material is not authorized by the copyright owner; and 6) a statement that information in the complaint is accurate and that the complaining party is authorized to act on behalf of the copyright owner. Subsection B (17 U.S.C. 512(c)(3)(B)) states that if the complaining party does not substantially comply with these requirements the notice will not serve as actual notice for the purpose of Section 512.
Section 512(d)(3), which applies to "information location tools" such as search engines and directories, incorporates the above requirements; however, instead of the identification of the allegedly infringing material, the notification must identify the reference or link to the material claimed to be infringing.
Question: Does a service provider have to follow the safe harbor procedures?
Answer: No. An ISP may choose not to follow the DMCA takedown process, and do without the safe harbor. If it would not be liable under pre-DMCA copyright law (for example, because it is not contributorily or vicariously liable, or because there is no underlying copyright infringement), it can still raise those same defenses if it is sued.
Question: How do I file a DMCA counter-notice?
Answer: If you believe your material was removed because of mistake or misidentification, you can file a "counter notification" asking the service provider to put it back up. Chilling Effects offers a form to build your own counter-notice.
For more information on the DMCA Safe Harbors, see the FAQs on DMCA Safe Harbor Provisions. For more information on Copyright and defenses to copyright infringement, see Copyright.
Cease and Desist? What is this site?
The Chilling Effects Clearinghouse collects and analyzes legal complaints about online activity, helping Internet users to know their rights and understand the law. Chilling Effects welcomes submission of letters from individuals and from Internet service providers and hosts. These submissions enable us to study the prevalence of legal threats and allow Internet users to see the source of content removals.
Chilling Effects aims to support lawful online activity against the chill of unwarranted legal threats. We are excited about the new opportunities the Internet offers individuals to express their views, parody politicians, celebrate favorite stars, or criticize businesses, but concerned that not everyone feels the same way. Study to date suggests that cease and desist letters often silence Internet users, whether or not their claims have legal merit. The Chilling Effects project seeks to document that "chill" and inform C&D recipients of their legal rights in response.
The Chilling Effects clearinghouse is a database of cease and desist notices (C&Ds) sent to Internet users, legal interpretation of those notices, Frequently Asked Questions about parts of the law that affect online activity, and related news and resources. If you have received a cease and desist, we invite you to add it to our database.
You can use this site in many different ways: choose a topic area and explore its homepage and FAQs; search the database for C&Ds similar to one you've received or sent; submit your own notice for law students at the participating clinics to analyze.
The site's centerpiece is the database of annotated cease-and-desist notices:
Clinical law students review the notices submitted and link their legalese to explanatory FAQs. As the number of notices grows, so will the selection of FAQs, which can be read either alongside the notices or on their own.
Site Organization
The Chilling Effects clearinghouse is organized by topic area. Some topics are related to types of activity, such as fan fiction and reverse engineering, others to areas of law, such as copyright and trademark. Within each topic, you will find the linked notices, FAQs, related news, and resources such as statutes and articles.
We invite you to report your own notice to the database (received or sent), search or browse the database, or read "Weather Reports" on the legal climate for Internet activity -- compiled based on the notices submitted.
Search
The Chilling Effects clearinghouse offers two types of searches:
Quick Search, the box in the left corner of each index page, searches for words or "quoted phrases" among topics, FAQs, news, resources, and the subject lines of C&D notices.
Search the Database, linked from the header bar, offers a more detailed search of our database of cease-and-desist notices.
Maintained by Chilling Effects
http://www.chillingeffects.org/about
Who does this sound like..."Kruschinski" of course!
So here you will find Karen sending complaint after complaint to other ARD and Endo wed site hosts, and Google as well as any one else will listen to her and then she forces them to spend time and money with her petty little claims in her attempts to corner the market on the Internet! If she were to succeed in her attempt to gain favorable spots in the search engines by knocking a few other ARD web sites off, she will be able to harvest vulnerable, and desperately ill people to her web sites to buy her merchandise; and ultimately to get them to secure surgery with the "Con Doc, Kruschinski," who rise to notoriety comes from "Profiting from Pain!"
BEWARE of any web site associated with Karen Steward of Wetherford, Texas!
Search Results:
Any contains ELM publishing:
3 matching Notices found; showing 50
Articles DMCA (Copyright) Complaint to Google Karen Steward Google, Inc. [Blogger] July 30, 2011 DMCA Notices
Text DMCA (Copyright) Complaint to Google Karen Steward Google, Inc. [Blogger] July 17, 2011 DMCA Notices
Article DMCA (Copyright) Complaint to Google ELM Publishing, Inc. Google, Inc. [Blogger] May 13, 2011 DMCA Notices
Notice UnavailableDMCA (Copyright) Complaint to Google
Sent by: ELM Publishing, IncTo: Google
The cease-and-desist or legal threat you requested is not yet available.
Chilling Effects will post the notice after we process it.
Question: Why does a web host, blogging service provider, or search engine get DMCA takedown notices?
Answer: Many copyright claimants are making complaints under the Digital Millennium Copyright Act, Section 512(c)'s safe-harbor for hosts of "Information Residing on Systems or Networks At Direction of Users" or Section 512(d)'s safe-harbor for providers of "Information Location Tools." These safe harbors give providers immunity from liability for users' possible copyright infringement -- if they "expeditiously" remove material when they get complaints. Whether or not the provider would have been liable for infringement by users' materials it hosts or links to, the provider can avoid the possibility of a lawsuit for money damages by following the DMCA's takedown procedure when it gets a complaint. The person whose information was removed can file a counter-notification if he or she believes the complaint was erroneous.
Question: What does a service provider have to do in order to qualify for safe harbor protection?
Answer: In addition to informing its customers of its policies, a service provider must follow the proper notice and takedown procedures and also meet several other requirements in order to qualify for exemption under the safe harbor provisions.
In order to facilitate the notification process in cases of infringement, ISPs which allow users to store information on their networks, such as a web hosting service, must designate an agent that will receive the notices from copyright owners that its network contains material which infringes their intellectual property rights. The service provider must then notify the Copyright Office of the agent's name and address and make that information publicly available on its web site. [512(c)(2)]
Finally, the service provider must not have knowledge that the material or activity is infringing or of the fact that the infringing material exists on its network. If it does discover such material before being contacted by the copyright owners, it is instructed to remove, or disable access to, the material itself. The service provider must not gain any financial benefit that is attributable to the infringing material.
Question: What are the provisions of 17 U.S.C. Section 512(c)(3) & 512(d)(3)?
Answer: Section 512(c)(3) sets out the elements for notification under the DMCA. Subsection A (17 U.S.C. 512(c)(3)(A)) states that to be effective a notification must include: 1) a physical/electronic signature of a person authorized to act on behalf of the owner of the infringed right; 2) identification of the copyrighted works claimed to have been infringed; 3) identification of the material that is claimed to be infringing or to be the subject of infringing activity and that is to be removed; 4) information reasonably sufficient to permit the service provider to contact the complaining party (e.g., the address, telephone number, or email address); 5) a statement that the complaining party has a good faith belief that use of the material is not authorized by the copyright owner; and 6) a statement that information in the complaint is accurate and that the complaining party is authorized to act on behalf of the copyright owner. Subsection B (17 U.S.C. 512(c)(3)(B)) states that if the complaining party does not substantially comply with these requirements the notice will not serve as actual notice for the purpose of Section 512.
Section 512(d)(3), which applies to "information location tools" such as search engines and directories, incorporates the above requirements; however, instead of the identification of the allegedly infringing material, the notification must identify the reference or link to the material claimed to be infringing.
Question: Does a service provider have to follow the safe harbor procedures?
Answer: No. An ISP may choose not to follow the DMCA takedown process, and do without the safe harbor. If it would not be liable under pre-DMCA copyright law (for example, because it is not contributorily or vicariously liable, or because there is no underlying copyright infringement), it can still raise those same defenses if it is sued.
Question: How do I file a DMCA counter-notice?
Answer: If you believe your material was removed because of mistake or misidentification, you can file a "counter notification" asking the service provider to put it back up. Chilling Effects offers a form to build your own counter-notice.
For more information on the DMCA Safe Harbors, see the FAQs on DMCA Safe Harbor Provisions. For more information on Copyright and defenses to copyright infringement, see Copyright.
Cease and Desist? What is this site?
The Chilling Effects Clearinghouse collects and analyzes legal complaints about online activity, helping Internet users to know their rights and understand the law. Chilling Effects welcomes submission of letters from individuals and from Internet service providers and hosts. These submissions enable us to study the prevalence of legal threats and allow Internet users to see the source of content removals.
Chilling Effects aims to support lawful online activity against the chill of unwarranted legal threats. We are excited about the new opportunities the Internet offers individuals to express their views, parody politicians, celebrate favorite stars, or criticize businesses, but concerned that not everyone feels the same way. Study to date suggests that cease and desist letters often silence Internet users, whether or not their claims have legal merit. The Chilling Effects project seeks to document that "chill" and inform C&D recipients of their legal rights in response.
The Chilling Effects clearinghouse is a database of cease and desist notices (C&Ds) sent to Internet users, legal interpretation of those notices, Frequently Asked Questions about parts of the law that affect online activity, and related news and resources. If you have received a cease and desist, we invite you to add it to our database.
You can use this site in many different ways: choose a topic area and explore its homepage and FAQs; search the database for C&Ds similar to one you've received or sent; submit your own notice for law students at the participating clinics to analyze.
The site's centerpiece is the database of annotated cease-and-desist notices:
Clinical law students review the notices submitted and link their legalese to explanatory FAQs. As the number of notices grows, so will the selection of FAQs, which can be read either alongside the notices or on their own.
Site Organization
The Chilling Effects clearinghouse is organized by topic area. Some topics are related to types of activity, such as fan fiction and reverse engineering, others to areas of law, such as copyright and trademark. Within each topic, you will find the linked notices, FAQs, related news, and resources such as statutes and articles.
We invite you to report your own notice to the database (received or sent), search or browse the database, or read "Weather Reports" on the legal climate for Internet activity -- compiled based on the notices submitted.
Search
The Chilling Effects clearinghouse offers two types of searches:
Quick Search, the box in the left corner of each index page, searches for words or "quoted phrases" among topics, FAQs, news, resources, and the subject lines of C&D notices.
Search the Database, linked from the header bar, offers a more detailed search of our database of cease-and-desist notices.
Maintained by Chilling Effects
http://www.chillingeffects.org/about
Karen Steward and her "Business Prospects" on Facebook
Many Facebook Users Willingly Give Out Personal Information
December 8th, 2009
Facebook, Internet Safety, Online Reputation Management, Privacy, Social Networking
Rob Frappier
Karen's quote:
#1 karen on 12.11.09 at 8:39 am
Facebook was presented to me as a way to build my business via networking. Many whom I’ve befriended are also on facebook to build their business connections. With that concept, one would have to add unknown friends. Also, if someone simply googles your name, it is easy to find their address, etc. There’s lots of personal information on the internet about a person that the person did not place there themselves. So, please explain how building a network of friends on facebook is any worse than just being alive and vulnerable to GOOGLE.
http://www.reputation.com/blog/2009/12/08/many-facebook-users-willingly-give-out-personal-information/
December 8th, 2009
Facebook, Internet Safety, Online Reputation Management, Privacy, Social Networking
Rob Frappier
Karen's quote:
#1 karen on 12.11.09 at 8:39 am
Facebook was presented to me as a way to build my business via networking. Many whom I’ve befriended are also on facebook to build their business connections. With that concept, one would have to add unknown friends. Also, if someone simply googles your name, it is easy to find their address, etc. There’s lots of personal information on the internet about a person that the person did not place there themselves. So, please explain how building a network of friends on facebook is any worse than just being alive and vulnerable to GOOGLE.
http://www.reputation.com/blog/2009/12/08/many-facebook-users-willingly-give-out-personal-information/
A safe place for adhesion sufferers on Facebook
There are predators in the world of Adheion Related Disorder we offer this facebook page as a safe and uncensored to meet and talk and find unbiased education about adhesion's.
Remember we are sufferers too and we will never profit from your pain and suffering.
Please visit our new facebook page
http://www.facebook.com/#!/profile.php?id=100002960705092
Remember we are sufferers too and we will never profit from your pain and suffering.
Please visit our new facebook page
http://www.facebook.com/#!/profile.php?id=100002960705092
From Clinical Trails.Gov
Clinical Trails terminated or suspended. Our continuous search for an effective adhesion barrier is still fraught with peril. I will not have one instilled again as it is still a foreign substance introduced into the abdomen.
I have been a Guinea pig one time too many.
I'm no doctor just an adhesion sufferer like you.
In my experience the most effective tool we have is a good surgeon and an adhesiolysis as described below.
~~~~~~~~~~~~~~~~~~~~~~~~
Found 38 studies with search of: adhesions abdomen
http://clinicaltrials.gov/ct2/results?term=adhesions+abdomen
Hide studies that are not seeking new volunteers.
Hide studies with unknown recruitment status. Display Options Rank Status Study
1 Not yet recruiting An Adhesion Reduction Plan in the Management of the Surgical Open Abdomen Condition: Open Abdomen
Intervention: Procedure: Adhesion Reduction Plan
2 Recruiting Comparative Effectiveness Multicenter Trial for Adhesion Characteristics of Ventral Hernia Repair Mesh Conditions: Ventral Hernia; Adhesions
Intervention: Procedure: Clinically-Indicated Abdominal Re-Exploration Surgery
3 Terminated Pregabalin for Abdominal Pain From Adhesions Conditions: Abdominal Pain; Surgical Adhesions
Interventions: Drug: Placebo; Drug: Pregabalin
4 Completed Resorbable Barrier for the Prevention of Abdominal and Peri-hepatic Adhesion Formation Condition: Colorectal Cancer
Interventions: Procedure: - use of resorbable membrane Seprafilm; Procedure: without resorbable barrier (seprafilm)
5 Completed A-Part® Gel as Adhesion Prophylaxis After Major Abdominal Surgery Versus a Non-treated Group Conditions: Adhesions; Abdominal Cavity
Intervention: Device: A-Part® Gel
6 Recruiting Seprafilm™ for the Prevention of Intraperitoneal Adhesions and Improved Delivery of Therapy in Women Undergoing Staging and Intraperitoneal Chemotherapy for Advanced Ovarian Cancer Condition: Epithelial Ovarian Cancer
Intervention: Procedure: Seprafilm™
7 Recruiting Cine-magnetic Resonance Imaging (MRI) Detecting Intra Abdominal Adhesions Condition: Tissue Adhesions
Intervention: Other: CineMRI
8 Completed Evaluation of Bioresorbable Sheet to Prevent Intra-Abdominal Adhesions in Colorectal Surgeries Condition: Adhesions
Intervention: Device: Polylactic Acid Sheet
9 Terminated Evaluation of the Safety and Effectiveness of Sepraspray™ in Reducing Post-surgical Adhesions Condition: Abdominal Adhesions
Intervention: Device: Sepraspray
10 Completed SurgiWrapTM to Reduce Soft Tissue Attachment & Incidence Early Post-Operative Bowel Obstruction in Colorectal Surgery Conditions: Adhesions; Colectomy
Intervention: Other: Polylactic Acid Sheet
11 Terminated SprayShield EU Post Market Study Conditions: Ulcerative Colitis; Familial Polyposis
Interventions: Device: SprayShield Adhesion Barrier System; Procedure: Good Surgical Technique Alone
12 Completed Manageability and Safety Assessment of Sepraspray in Abdominal Surgery. Condition: Adhesion Prevention
Interventions: Device: Sepraspray; Other: No Intervention
13 Active, not recruiting The Effect of Adhesiolysis During Elective Abdominal Surgery on Per- and Postoperative Complication, Quality of Life and Socioeconomic Costs Condition: Tissue Adhesions
Intervention: Procedure: Adhesiolysis
14 Completed NOTES Transgastric Diagnostic Peritoneoscopy With Laparoscopic Assistance Condition: Abdominal Adhesions
Intervention: Device: Transgastric diagnostic peritoneoscopy with laparoscopic assistance
15 Completed Closure of Peritoneum at Cesarean Section and Postoperative Adhesion Conditions: Cesarean Section; Adhesions
Intervention: Procedure: Closure of the peritoneum at cs
16 Unknown † Seprafilm® for Prevention of Adhesions at Repeat Cesarean Condition: Adhesion Formation After Primary Cesarean Delivery
Interventions: Device: Seprafilm®; Other: Control
17 Terminated Evaluation of the Safety of Sepraspray in Open Abdominal Surgery Condition: Adhesion Prevention (Abdominal)
Intervention: Device: Sepraspray
18 Recruiting Early Small Bowel Obstruction Following Laparotomy For Trauma Condition: Small Bowel Obstruction
Intervention:
19 Completed Effects of Extensive Abdominal Lavage on Postoperative Inflammation Following Full Thickness Excision of Deep Endometriosis Condition: Endometriosis
Interventions: Procedure: Extensive abdominal lavage; Procedure: Rinsing of the abdomen
20 Not yet recruiting TIGR vs Polypropylene (Permanent) Mesh: Randomised Trial Condition: Hernia
Intervention: Device: TIGR Mesh
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
The “Standard” by which I base a “HIGH QUALITY ADHESIOLYSIS”
from: http://www.adhesionrelateddisorder.com/high-quality-adhesiolysis.html
Because I know this surgeon cares about his patients, and those who strive to do the highest quality adhesiolysis that can offer the best chances of improvements for those afflicted with “Adhesion Related Disorder,” can be respected enough to be mentioned in this web site!
Nothing but the best surgeons found here!
LAPAROSCOPIC SURGERY FOR ADHESIOLYSIS
Harry Reich, M.D., F.A.C.O.G., FACS1
Is an Attending Physician, Wyoming Valley Health Care System, Wilkes-Barre, PA,
Community Medical Center, Scranton, PA, Lenox Hill, NY,NY, St. Vincent’s
Hospital and Medical Center of New York
INTRODUCTION
Postoperative adhesions occur after almost every abdominal surgery and are the leading cause of intestinal obstruction. In one study, 93% of patients who had undergone at least one previous abdominal operation had postsurgical adhesions. This was not considered surprising, given the extreme delicacy of the peritoneum and the fact that apposition of two injured surfaces nearly always results in adhesion formation.1
Fatal sequelae of intraabdominal adhesions were reported as early as 1872 after removal of an ovarian tumor resulted in intestinal obstruction.2 Adhesions are the most common cause of bowel obstruction and most likely result from gynecologic procedures, appendectomies and other intestinal operations.3 Adhesions have also been proposed to cause infertility and abdominal and pelvic pain. Although nerve fibers have been confirmed in pelvic adhesions, their presence is not increased in those patients with pelvic pain.4 In addition, there does not appear to be an association between the severity of adhesions and complaint of pain. It is generally accepted that adhesions may impair organ motility resulting in visceral pain transmitted by peritoneal innervation.5 Many patients experience resolution of their symptoms after adhesiolysis.6-9 This may be complicated by placebo effect as demonstrated by one study that showed no difference in pain scores between patients who were randomized to adhesiolysis versus expectant management.10
In 1994, adhesiolyis procedures resulted in 303,836 hospitalizations, 846,415 days of inpatient care, and $1.3 billion in health care expenditures. Forty-seven percent of these hospitalizations were for adhesiolysis of the female reproductive system, the primary site for these procedures. In comparison to similar data from 1988, the cost of adhesiolysis hospitalizations is down. One significant influence on this trend is the increased use of minimally invasive surgical techniques resulting in fewer days of inpatient care.11
This chapter reviews the pathophysiology of adhesion formation, equipment and technique for adhesiolysis, and methods for adhesion prevention.
PATHOPHYSIOLOGY OF ADHESION FORMATION
Adhesion formation is initiated by peritoneal trauma. Its morphogenesis was described in detail by diZerega.12 Within hours at the site of injury, polymorphonuclear leukocytes appear in large numbers meshed in fibrin strands. At 24-36 hours, macrophages appear in large numbers and are responsible for regulating fibroblast and mesothelial cell activities. By day 2, the wound surface is covered by macrophages, islands of primitive mesenchymal cells and mesothelial cells. By day four the islands of primitive mesenchymal cells have now come into contact with each other. Fibroblasts and collagen are now present and increasing. By day five, an organized fibrin interconnection is now seen composed of collagen, fibroblasts, mast cells, and vascular channels containing endothelial cells. The adhesion continues to mature as collagen fibrils organize into bands covered by mesothelium and containing blood vessels and connective tissue fiber.12
EQUIPMENT
A review of standard equipment such as light sources and video systems is beyond the scope of this chapter. Equipment useful for advanced procedures and energy sources is included. However, the main technique for adhesiolysis with the least possibility for reformation can simply be described as “cold scissors dissection with bipolar backup.”
Laparoscopes
Four different laparoscopes should be available for adhesiolysis: a 10-mm 0° straight viewing laparoscope; a 10-mm operative laparoscope with 5-mm operating channel; a 5-mm straight viewing laparoscope for introduction through 5-mm trocar sleeves; and an oblique-angle laparoscope (30-45°) for upper abdominal and pelvic procedures.
Scissors
Scissors are the preferred instrument to cut adhesions, especially avascular and/or congenital adhesions. Using the magnification afforded by the laparoscope, most anterior abdominal wall, pelvic, and bowel adhesions can be carefully inspected and divided with minimal bleeding, rarely requiring microbipolar coagulation. Loose fibrous or areolar tissue is separated by inserting a closed scissors and withdrawing it in the open position. Pushing tissue with the partially open blunt scissors tip is used to develop natural planes.
Reusable 5 mm blunt-tipped sawtooth scissors and curved scissors cut well without cautery. Blunt or rounded-tip 5mm scissors with one stable blade and one moveable blade are used to divide thin and thick bowel adhesions sharply. Sharp dissection is the primary technique used for adhesiolysis to diminish the potential for adhesion formation; electrification and laser are usually reserved for hemostatic dissection of adhesions where anatomic planes are not evident or vascular adherences are anticipated. Thermal energy sources must be avoided as much as possible to reduce adhesion recurrence. Blunt-tipped, sawtooth scissors, with or without a curve, cut well (Richard Wolf Medical Instruments, Vernon Hills, IL and Karl Storz Endoscopy, Culver City, CA). Many disposable scissors depend greatly on electrification for cutting. Hook-scissors are not very useful for adhesiolysis.
Surgeons should select scissors that feel comfortable. To facilitate direction changes, the scissors should not be too long or encumbered by an electrical cord. This author prefers to make rapid instrument exchanges between scissors and microbipolar forceps through the same portal to control bleeding, instead of applying electrification via scissors.
Electrosurgery
When discussing electrosurgery, the term “cautery” should be abandoned. Cautery, thermocoagulation, or endocoagulation refer to the passive transfer of heat from a hot instrument heated by electrical current to tissue. The temperature rises within the tissue until cell proteins begin to denature and coagulate with resultant cell death. Electrical current does not pass through the patient’s body!
Monopolar cutting current can be used safely, as the voltage is too low to arc to organs even 1 mm away. Cutting current is used to both cut and/or coagulate (desiccate) depending on the portion of the electrode in contact with the tissue. The tip cuts, while the wider body tamponades and coagulates.
Monopolar coagulation current which uses voltages over 10 times that of cutting current can arc 1 to 2mm and is used in close proximity to tissue, but not in contact, to fulgurate diffuse venous and arteriolar bleeders. It takes 30% more power to spark or arc in CO2 pneumoperitoneum than in room air; thus, at the same electrosurgical power setting, less arcing occurs at laparoscopy than at laparotomy.
Monopolar electrosurgery should be avoided when working on the bowel unless the surgeon is well versed in this modality. The expert laparoscopic surgeon can use monopolar electrosurgery safely to cut or fulgurate tissue, but desiccation (coagulation) on bowel should be performed with bipolar techniques.13,14
Electrosurgical injury to the bowel can occur beyond the surgeon’s field of view during laparoscopic procedures from electrode insulation defects or capacitive coupling. While the surgeon views the tip of the electrode, electrical discharge may occur from its body (insulation failure) or from metal trocar cannulas surrounding the electrode if they are separated from the skin by plastic retention sleeves. These problems are eliminated by active electrode monitoring using the Electroshield EM-1 monitor system (Encision, Boulder, CO). This consists of a sheath surrounding the electrode and a sheath monitor (EM-1) to detect any insulation faults and shield against capacitive coupling.
Bipolar desiccation using cutting current between two closely opposed electrodes is safe and efficient for large vessel hemostasis.15,16 Large blood vessels are compressed and bipolar cutting current passed until complete desiccation is achieved, i.e., the current depletes the tissue fluid and electrolytes and fuses the vessel wall. Coagulating current is not used as it may rapidly desiccate the outer layers of the tissue, producing superficial resistance thereby preventing deeper penetration.
Small vessel hemostasis necessary for adhesiolysis is best achieved by using microbipolar forceps after precisely identifying the vessel with electrolyte solution irrigation. Microbipolar forceps (Richard Wolf Medical Instruments, Vernon Hills, IL) with an irrigation channel work best for precise tissue desiccation with minimal thermal spread.
Harmonic Scalpel
The use of Harmonic Scalpel (Ethicon Endosurgery, Cincinnati, Ohio) for laparoscopic adhesiolysis is gaining popularity. Although it has its limitations, the benefit of this multifunctional instrument far outweighs any disadvantage. Many factors can be attributed to its progressive acceptance. The lack of electrical energy used to coagulate vessels and the smaller (2mm) lateral energy spread make it more attractive than conventional electrosurgical instruments by potentially reducing the percentage of delayed post-operative bowel injuries (caused by electrical burns.) This is not to say however, that injury cannot occur. As with standard electrosurgical instruments, the Harmonic Scalpel, specifically the jaws, can become hot and cause tissue injury if not used in a prudent manner. Although Harmonic Scalpel has the ability to grasp, cut, and cauterize simultaneously, making it a useful instrument for a judicious operator (requiring fewer instrument changes in and out of port sites), the inability to cut without applying energy assures the need for a sharp pair of conventional scissors in laparoscopic adhesiolysis.
EQUIPMENT (continued)
Rectal and Vaginal Probes
A sponge on a ring forceps is inserted into the vagina or the posterior vaginal fornix, and an 81-French probe is placed in the rectum to define the rectum and posterior vagina for lysis of pelvic adhesions and/or excision of endometriosis when there is a significant degree of cul-de-sac obliteration. Whenever rectal location is in doubt, it is identified by insertion of the rectal probe.
CO2 laser
The CO2 laser, with its 0.1 mm depth of penetration and inability to traverse through water, allows the surgeon some security when lysing adhesions especially in the pelvis. The Coherent 5000L laser (Palo Alto, CA), by using a 11.1 um wavelength beam, maintains a 1.5mm spot size at all power settings allowing for more precision than most standard 10.6 um wavelength CO2 lasers.
Aquadissection
Aquadissection is the use of hydraulic energy from pressurized fluid to aid in the performance of surgical procedures. The force vector is multidirectional within the volume of expansion of the uncompressible fluid; the force applied with a blunt probe is unidirectional. Instillation of fluid under pressure displaces tissue, creating cleavage planes in the least resistant spaces. Aquadissection into closed spaces behind peritoneum or adhesions produces edematous, distended tissue on tension with loss of elasticity, making further division easy and safe using blunt dissection, scissors dissection, laser, or electrosurgery.
Suction-irrigators with the ability to dissect using pressurized fluid should have a single channel to maximize suctioning and irrigating capacity. This allows the surgeon to perform atraumatic suction-traction-retraction, irrigate directly, and develop surgical planes (aquadissection). The distal tip should not have side holes as they impede these actions, spray the surgical field without purpose, and cause unnecessary tissue trauma when omentum, epiploic appendices, and adhesions become caught. The shaft should have a dull finish to prevent CO2 laser beam reflection, allowing it to be used as a backstop. The market is crowded with many aquadissection devices.
Plume Eliminator
Smoke evacuation during electrosurgery or CO2 laser laparoscopy is expedited using a Clear View EBS ICM 350 smoke evacuator (I.C. Medical, Phoenix, AZ).
LAPAROSCOPIC PERITONEAL CAVITY ADHESIOLYSIS
Adhesiolysis by laparoscopy and laparotomy can be very time-consuming and technically difficult and is best performed by an expert surgeon. However, despite lengthy laparoscopic procedures (two to four hours), most patients are discharged on the day of the procedure, avoid large abdominal incisions, experience minimal complications, and return to full activity within one week of surgery.
In this section, general adhesiolysis, pelvic adhesiolysis, ovariolysis, salpingo-ovariolysis, and salpingostomy are described. The laparoscopic treatment of acute adhesions has not been included. However, the best treatment for sexually transmitted disease adhesive sequelae may be prevention through early laparoscopic diagnosis and treatment of acute pelvic infection, including abscesses. Acute adhesiolysis will often prevent chronic adhesion formation.17-19
Classification
Extensive peritoneal cavity adhesion procedures need a classification system that relates to their degree of severity and the surgical expertise necessary for adhesiolysis. The single best indicator of the degree of severity and expertise necessary for adhesiolysis is the number of previous laparotomies. The frequency of small bowel obstruction symptoms indicates the need for surgery.
Peritoneal adhesiolysis is classified into enterolysis including omentolysis and female reproductive reconstruction (salpingo-ovariolysis and cul-de-sac dissection with excision of deep fibrotic endometriosis). Bowel adhesions are divided into upper abdominal, lower abdominal, pelvic, and combinations. Adhesions surrounding the umbilicus are upper abdominal as they require an upper abdominal laparoscopic view for division. The extent, thickness, and vascularity of adhesions vary widely. Intricate adhesive patterns exist with fusion to parietal peritoneum or various meshes.
Extensive small bowel adhesions are not a frequent finding at laparoscopy for pelvic pain or infertility. In these cases, the fallopian tube is adhered to the ovary, the ovary is adhered to the pelvic sidewall, and the rectosigmoid may cover both. Rarely, the omentum and small bowel are involved. Adhesions may be the result of an episode of pelvic inflammatory disease or endometriosis, but most commonly are caused by previous surgery. Adhesions cause pain by entrapment of the organs they surround. The surgical management of extensive pelvic adhesions is one of the most difficult problems facing surgeons today.
Surgical plan for extensive enterolysis
A well-defined strategy is important for small bowel enterolysis. For simplification, this is divided into three parts:
1. Division of all adhesions to the anterior abdominal wall parietal peritoneum. Small bowel loops encountered during this process are separated using their anterior attachment for countertraction instead of waiting until the last portion of the procedure (running of the bowel).
2. Division of all small bowel and omental adhesions in the pelvis. Rectosigmoid, cecum, and appendix often require some separation during this part of the procedure.
3. Running of the bowel Using atraumatic grasping forceps and usually a suction-irrigator for suction traction, the bowel is run. Starting at the cecum and terminal ileum, loops and significant kinks are freed into the high upper abdomen to the ligament of Treitz.
4.(Optional) Finally tubo-ovarian pathology is treated if indicated.
Time frequently dictates that all adhesions cannot be lysed. From the history, the surgeon should conceptualize the adhesions most likely to be causing the pain, i.e., upper or lower abdomen, left or right, and clear these areas of adhesions.
Preoperative preparation
Patients are informed preoperatively of the high risk for bowel injury during laparoscopic procedures when extensive cul-de-sac involvement with endometriosis or adhesions is suspected. They are encouraged to hydrate and eat lightly for 24 hours before admission. A mechanical bowel preparation (GoLYTELY or Colyte) is administered orally the afternoon before surgery to induce brisk, self-limiting diarrhea to cleanse the bowel without disrupting the electrolyte balance.20 The patient is usually admitted on the day of surgery. Lower abdominal, pubic, and perineal hair is not shaved. Patients are encouraged to void on call to the OR, and a Foley catheter is inserted only if the bladder is distended or a long operation anticipated. A catheter is inserted near the end of the operation and removed in the recovery room when the patient is aware of its presence, to prevent bladder distension. Antibiotics (usually cefoxitin) are administered in all cases lasting over two hours, at the two-hour mark.
Patient Positioning
All laparoscopic surgical procedures are done under general anesthesia with endotracheal intubation. An orogastric tube is placed routinely to diminish the possibility of a trocar injury to the stomach and to reduce small bowel distention. The patient’s arms should be tucked on both sides so that the surgeon’s position is comfortable and not limited. The patient’s position is flat (0°) during umbilical trocar sleeve insertion and anterior abdominal wall adhesiolysis but a steep Trendelenburg position (30 degrees), reverse Trendelenburg position, and side-to-side rotation are used when necessary. Lithotomy position, with the hip extended (thigh parallel to abdomen) is obtained with Allen stirrups (Edgewater Medical Systems, Mayfield Heights, OH) or knee braces, which are adjusted individually to each patient before she is anesthetized. Anesthesia examination is performed prior to prepping the patient.
Incisions
In the absence of suspected periumbilical adhesions, an intraumbilical vertical incision is made through the skin of the inferior umbilical fossa extending to and just beyond its lowest point. A Verres needle is placed through this low point while pulling the umbilicus towards the pubic symphysis and insufflation with CO2 is continued until an intraabdominal pressure of 25-30mm Hg is obtained.
The palmed short trocar is positioned at a 90o angle inside the deep funnel shaped portion of the umbilical fossa where fascia and peritoneum meet and inserted through this into the peritoneal cavity at a 45o angle in one continuous thrusting motion, with wrist rotation. This is performed without lifting the anterior abdominal wall as the high intraabdominal pressure provides counterpressure against the parietal peritoneum to lift it above the large vessels below. The result is a parietal peritoneal puncture directly beneath the umbilicus. Once the trocar is in place within the abdominal cavity, the intra-abdominal pressure is lowered to 12-15 mm Hg to diminish the development of vena caval compression and subcutaneous emphysema.
Special alternate entry sites and techniques are used when there is a high suspicion for periumbilical adhesions in patients who have undergone multiple laparotomies, have lower abdominal incisions traversing the umbilicus, or who have extensive adhesions either clinically or from a previous operative record. Open laparoscopy at the umbilicus carries the same risk for bowel laceration if the bowel is fused to the umbilical undersurface.
One alternate site is in the left ninth intercostal space, anterior axillary line. Adhesions are rare in this area, and the peritoneum is tethered to the undersurface of the ribs, making peritoneal tenting away from the needle unusual. A 5-mm skin incision is made over the lowest intercostal space (the 9th) in the anterior axillary line. The Veress needle is grasped near its tip, like a dart, between thumb and forefinger, while the other index finger spreads this intercostal space. The needle tip is inserted at a right angle to the skin (a 45o angle to the horizontal) between the ninth and tenth ribs. A single pop is felt on penetration of the peritoneum. Pneumoperitoneum to a pressure of 30 mmHg is obtained. A 5 mm trocar is then inserted through this same incision that has migrated downward below the left costal margin because of the pneumoperitoneum.
Another alternate entry site is Palmer’s point21 located 3 cm inferior to the subcostal arch in the left medioclavicular line.22 Also, if the uterus is present and thought to be free of adhesions, the surgeon may consider inserting a long Veress needle transvaginally through the uterus.23
When unexpected extensive adhesions are encountered initially surrounding the umbilical puncture, the surgeon should immediately seek a higher site. Thereafter, the adhesions can be freed down to and just beneath the umbilicus, and the surrounding bowel inspected for perforations. The umbilical portal can then be reestablished safely for further work.
Other laparoscopic puncture sites are placed as needed, usually lateral to the rectus abdominis muscles and always under direct laparoscopic vision. When the anterior abdominal wall parietal peritoneum is thickened from previous surgery or obesity, the position of these muscles is judged by palpating and depressing the anterior abdominal wall with the back of the scalpel; the wall will appear thicker where rectus muscle is enclosed, and the incision site is made lateral to this area near the anterior superior iliac spine.
If an umbilical insertion is possible and extensive adhesions are present close to but below the umbilicus, the operating laparoscope with scissors in the operating channel is the first instrument used. If a left upper quadrant 5 mm incision is necessary, there is usually room for another puncture site to do initial adhesiolysis with scissors.
Abdominal Adhesiolysis
Anterior abdominal wall adhesions involve the parietal peritoneum stuck to the omentum, transverse colon, and small bowel with varying degrees of fibrosis and vascularity. Adhesions may be filmy and avascular, filmy and vascular, or dense, fibrous and vascular. All of these adhesions to the anterior abdominal wall are released. If adhesions extend from above the level of the laparoscope in the umbilicus, another trocar is inserted above the level of the highest adhesion and the laparoscope is inserted there. Adhesions are easier to divide when working above them, instead of within them, as gravity helps to delineate the plane for separation after which the CO2 pneumoperitoneum can disperse into the dissection plane.
Adhesiolysis is done using scissors alone if possible. Rarely, electrosurgery, CO2 laser, and the Harmonic Scalpel are used. In most cases, the initial adhesiolysis is performed with scissors. CO2 laser through the laparoscope on adhesions close to the trocar insertion often results in reflection with loss of precision. Electrosurgery (cutting current) is used only when there is little chance that small bowel is involved in the adhesion.
Initially, blunt-tipped scissors in the operating channel of an operating laparoscope are inserted into the interface between the anterior abdominal wall parietal peritoneum and the omentum. Rotating the laparoscope so that the scissors exit at 12 o’clock instead of 3 o’clock facilitates early adhesiolysis. Blunt dissection is performed by inserting the scissors at the interface, opening, and withdrawing them. This maneuver is repeated many times to delineate the thin avascular adhesions from thicker vascular fibrotic attachments that are individually coagulated and divided. Frequently, adhesions can be bluntly divided by grasping the adhesion in the partially closed scissors and gently pushing the tissue. If the plane of adhesions cannot be reached with the tip of the scissors, the abdominal wall can be pressed from above with the finger to make it accessible to the scissors.
After initial adhesiolysis, visualization is improved allowing better access and exposure for further adhesiolysis. Secondary trocar sites can now be placed safely. After their insertion, the remainder of the adhesions can now be lysed using scissors with microbipolar backup for rare arteriolar bleeders. Small venule bleeders are left alone. On occasion, in operations in which symptomatic bowel adhesions are not the main problem, an electrosurgical spoon or knife is used to divide the remaining omental adhesions if bowel is not involved. If bowel is involved, dissection proceeds with scissors, without electrosurgery, through the second puncture site, aided by traction on the bowel from an opposite placed puncture site. Rarely, the CO2 laser may be used through the operating channel of the operating laparoscope. When using the CO2 laser for adhesiolysis, aquadissection is performed to distend the adhesive surface with fluid before vaporizing the individual adhesive layers. The suction-irrigator can also be used for suction traction, instead of a laparoscopic Babcock, and as a backstop to prevent thermal damage to other structures. The suction irrigator is also used to clean the laparoscopic optic which is then wiped on the bowel serosa before continuing. Denuded areas of bowel muscularis are repaired transversely using a 3-0 Vicryl seromuscular stitch. Denuded peritoneum is left alone. Minimal oozing should be observed and not desiccated unless this bleeding hinders the next adhesiolysis step or persists towards the end of the operation. With perseverance, all anterior abdominal wall parietal peritoneum adhesions can be released.
The Harmonic Scalpel is also useful for adhesiolysis. It bears repeating, the Harmonic Scalpel is not a scissor. This instrument works by coagulating tissue in between the blades and allowing it to be “pressed apart” after full coagulation of the tissue between the active blade and the compressing surface. Tissue is first grasped between the blades of the Harmonic Scalpel, steadily compressed, and the blade is activated allowing the tissue to separate once it is fully coagulated. Any tissue between the blades of the Harmonic Scalpel will be heated and then be allowed to fall apart. This includes all blood vessels up to 3mm in diameter incorporated in the tissue between the blades. As stated before, the Harmonic Scalpel can be used to grasp tissue in a general manner when the blades are not active. However, prior to grasping any tissue, the operator must allow the active blade to cool sufficiently so it will not burn any tissue it may come in contact with. The operator must remember that a Harmonic Scalpel does not replace the scissor, especially when dealing with bowel in the same proximity to an adhesion plane. Harmonic Scalpel comes in 5- and 10-mm size instrumentation with active jaws as well as adaptable adjuncts to the instrument such as a spatula type dissector, “ball” type dissector and hook dissector. All of these type instruments can be used in the same location as you would normally use a monopolar electrode; bear in mind once again that the lateral energy spread is just 2mm with the Harmonic Scalpel.
Pelvic Adhesiolysis
The next step is to free all bowel loops in the pelvis. Small bowel attached to the vesicouterine peritoneal fold, uterus or vaginal cuff, and the rectum is liberated. There are three key points when performing bowel adhesiolysis within the pelvis: scissors dissection without electrosurgery, countertraction and blunt dissection. The bowel is gently held with an atraumatic grasper and lifted away from the structure to which it is adhered, exposing the plane of dissection. When adhesive interfaces are obvious, scissors are used. The blunt-tipped scissors are used to sharply dissect the adhesions in small, successive cuts taking care not to damage the bowel serosa. Countertraction will further expose the plane of dissection and ultimately free the attachment. Electrosurgery and laser are generally not used for adhesiolysis involving the bowel due to the risk of recurrent adhesions from thermal damage. However, when adhesive aggregates blend into each other, initial incision is made very superficially with laser, and aquadissection distends the layers of the adhesions, facilitating identification of the involved structures. Division of adhesions continues with laser at 10-20 W in pulsed mode. The aquadissector and injected fluid from it are used as a backstop behind adhesive bands that are divided with the CO2 laser.
The rectosigmoid can be adhered to the left pelvic sidewall obscuring visualization of the left adnexa. Dissection starts well out of the pelvis in the left iliac fossa. Scissors are used to develop the space between the sigmoid colon and the psoas muscle to the iliac vessels, and the rectosigmoid reflected toward the midline. Thereafter, with the rectosigmoid placed on traction, rectosigmoid and rectal adhesions to the left pelvic sidewall are divided starting cephalad and continuing caudad.
Cul-de-sac adhesions can cause partial or complete cul-de-sac obliteration from fibrosis between the anterior rectum, posterior vagina, cervix, and the uterosacral ligaments. The technique of freeing the anterior rectum to the loose areolar tissue of the rectovaginal septum before excising and/or vaporizing visible and palpable deep fibrotic endometriosis is used.24
Attention is first directed to complete dissection of the anterior rectum throughout its area of involvement until the loose areolar tissue of the rectovaginal space is reached. Using the rectal probe as a guide, the rectal serosa is opened at its junction with the cul-de-sac lesion. Careful dissection ensues using aquadissection, suction-traction, laser, and scissors until the rectum is completely freed and identifiable below the lesion. Excision of the fibrotic endometriosis is done only after rectal dissection is completed.
Deep fibrotic, often nodular, endometriotic lesions are excised from the uterosacral ligaments, the upper posterior vagina, (the location of which is confirmed by the Valtchev retractor or a sponge in the posterior fornix), and the posterior cervix. The dissection on the outside of the vaginal wall proceeds using laser or scissors until soft pliable upper posterior vaginal wall is uncovered. It is frequently difficult to distinguish fibrotic endometriosis from cervix at the cervicovaginal junction and above. Frequent palpation using rectovaginal examinations helps identify occult lesions. When the lesion infiltrates through the vaginal wall, an “en bloc” laparoscopic resection from cul-de-sac to posterior vaginal wall is done, and the vagina is repaired laparoscopically with the pneumoperitoneum maintained with a 30-cc foley balloon in the vagina. Or, more recently, the vaginal lesion is mobilized vaginally, the vagina closed over the mobilized portion, and the en bloc lesion excision completed laparoscopically.
Sometimes the fibrotic cul-de-sac lesion encompassing both uterosacral ligament insertions and the intervening posterior cervix-vagina and anterior rectal lesion can be excised as one en bloc specimen.
Endometriotic nodules infiltrating the anterior rectal muscularis are excised usually with the surgeon’s or his assistant’s finger in the rectum just beneath the lesion. In some cases, the anterior rectum is reperitonealized by plicating the uterosacral ligaments and lateral rectal peritoneum across the midline. Deep rectal muscularis defects are always closed with suture. Full thickness rectal lesion excisions are suture or staple repaired laparoscopically.
Pelvic Adhesiolysis (continued)
When a ureter is close to the lesion, its course in the deep pelvis is traced by opening its overlying peritoneum with scissors or laser. On the left, this often requires scissors reflection of the rectosigmoid, as previously described, starting at the pelvic brim. Bipolar forceps are used to control arterial and venous bleeding.
Adnexal Adhesiolysis25
SalpingoOvariolysis26
Ovarian adhesions to the pelvic sidewall can be filmy or fused. Initially, adhesions between the ovary and fallopian tubes and other peritoneal surfaces are identified. It is imperative that the surgeon knows the surrounding anatomy prior to cutting any tissue to avoid damage to vital structures. The plane of dissection is identified and followed to avoid damage to other structures. The uteroovarian ligament may be held with an atraumatic grasper to facilitate countertraction and expose the line of cleavage. During ovariolysis, it is important to preserve as much peritoneum as possible while freeing the ovary. Dissection starts either high in the pelvis just beneath the infundibulopelvic ligament or deep on the pelvic sidewall beneath the ureter in the pararectal space. In each case, scissors are used both bluntly and sharply to mobilize the ovary from the sidewall. Alternatively, aquadissection may be used to facilitate identification of adhesion layers and to provide a safe backstop for the CO2 laser. Once an adhesion layer is identified, the aquadissector can also be placed behind this ridge and used as a backstop during CO2 laser adhesiolysis. Adhesiolysis is performed sharply and bluntly in a methodical manner working caudad until the cul-de-sac is reached.
If fimbrioplasty is to be performed, then hydrodistention is achieved by transcervical injection of dilute indigo carmine through a uterine manipulator. This distends the distal portion of the tube which is stabilized, and the adhesive bands are freed using scissors, laser or micropoint electrosurgery. If necessary, the fimbriated end can be progressively dilated using 3 mm alligator-type forceps. The closed forceps are placed through the aperture, opened, and removed. This is repeated one or more times. If the opening does not remain everted on its own, the intussusception salpingostomy method of McComb27 is used to avoid thermal damage to the ciliated tubal epithelium from CO2 laser or electrosurgery. The tip of the aquadissector is inserted approximately 2 cm into the newly opened tube, suction applied, and the tube fimbrial edges pulled around the instrument to turn the tube end inside-out. The borders of the incision act as a restrictive collar to maintain the mucosa in this newly everted configuration. In some cases, the ostial margin is sutured to the ampullary serosa with 6-0
Underwater surgery at the end of each procedure28
At the close of each operation, an underwater examination is used to document complete intraperitoneal hemostasis in stages; this detects bleeding from vessels and viscera tamponaded during the procedure by the increased intraperitoneal pressure of the CO2 pneumoperitoneum. The integrity of the rectum and rectosigmoid is often checked at this time by instillation of dilute indigo carmine solution or air transanally through a 30 cc Foley catheter.
The CO2 pneumoperitoneum is displaced with 2 to 5 L of Ringer’s lactate solution, and the peritoneal cavity is vigorously irrigated and suctioned until the effluent is clear of blood products, usually after 10-20 L. Underwater inspection of the pelvis is performed to detect any further bleeding which is controlled using microbipolar irrigating forceps to coagulate through the electrolyte solution. First hemostasis is established with the patient in Trendelenburg position, then per underwater examination with the patient supine and in reverse Trendelenburg, and finally, with all instruments removed, including the uterine manipulator.
To visualize the pelvis with the patient supine, the 10-mm straight laparoscope and the actively irrigating aquadissector tip are manipulated together into the deep cul-de-sac beneath floating bowel and omentum. During this copious irrigation procedure, clear fluid is deposited into the pelvis and circulates into the upper abdomen, displacing upper abdominal bloody fluid which is suctioned after flowing back into the pelvis. An “underwater” examination is then performed to observe the completely separated tubes and ovaries and to confirm complete hemostasis.
A final copious lavage with Ringer’s lactate solution is undertaken and all clots directly aspirated; at least 2 L of lactated Ringer’s solution are left in the peritoneal cavity to displace CO2 and to prevent fibrin adherences from forming by separating raw operated-upon surfaces during the initial stages of reperitonealization. Displacement of the CO2 with Ringer’s lactate diminishes the frequency and severity of shoulder pain from CO2 insufflation. No other anti-adhesive agents are employed. No drains, antibiotic solutions, or heparin are used.
Handoscopy
Hand assisted laparoscopy or “handoscopy” has become popular over the last 5 years, mainly in the field of solid organ surgery and bowel surgery. The main advantage of handoscopy is that it allows the surgeon to regain the tactile feel of surrounding tissues previously lost to “laser” laparoscopists and permits a more purposeful manipulation of larger organs. Often, it is the use of handoscopy for tissue palpation, that enables a successful laparoscopic adhesiolysis. At times, during laparoscopic procedures, visualization can be poor due to dense adhesions and the inability to determine tissue planes. With the placement of the operator’s hand inside the peritoneal cavity the surgeon is usually able to palpate surrounding organs and allow for a better tissue dissection plane that otherwise may not have been possible through direct visualization only. Not only can the use of a hand port facilitate an otherwise tedious procedure, it effects a safer operation for the patient with less chance of bowel injury. If bowel resection should become necessary, the use of the hand port allows for exteriorization of the segment that requires resection once again making the procedure easier and less time consuming. A handoscopy incision is usually only 7-8 cm and is either placed in the left or right lower portion of the abdomen with insertion of the operator’s non-dominant hand. The muscle splitting technique is used in a similar method as in performing an open appendectomy. The entire peritoneal cavity can be examined through either one of these incisions with the operator’s hand and it can be used for organ extraction as well. Several different types of handoscopy ports are available and all provide equal access to the peritoneal cavity.
When placing a handoscopy port for adhesiolysis, the operator must first choose a location on the abdominal wall that will allow optimal access to the point where adhesions are greatest. After the hand port location is chosen, a marking pen should be used to outline the area of the abdominal wall where the hand port is to be placed. The area for the incision should be anesthetized with bupivicaine for post operative pain control and an incision should then be made into the skin. The size of the incision should be the same size as the operator’s glove size. After this is completed, a muscle splitting technique should be used to enter the peritoneal cavity just as the operator would in performing an open appendectomy. Once the peritoneal cavity is entered, the hand port can then be placed. All of the hand port apparatus require that any adhesions on the peritoneal side of the incision be lysed prior to inserting the handoscopy device. Additionally, these devices should not be placed over any bony prominences, i.e., iliac crest, or encompassing any bowel in the peritoneal ring surface as to injure any bowel in the abdomen. If the handoscopy port is placed in the upper abdomen, the falciform ligament may require division prior to inserting the ring.
Once the handoscopy device is in place the lysis of adhesions can precede in an orderly fashion by identifying the tissue planes by feel with the operator’s fingers and additionally being able to provide appropriate traction and countertraction to allow for a safe adhesiolysis. Incidental enterotomies can be sutured with conventional suture and then tied using one hand knot tying technique with the intra abdominal hand.
Should any bowel resections be required the hand port can be used as a mini laparotomy site for extraction of any specimens and for exteriorizing any bowel that may require resection and/or repair. Additionally all handoscopy devices that are placed through the abdominal wall act as a wound protector and may minimize post operative wound infections as well as protect from any potential tumor seeding if the operation is for malignancy. The opening of the Ethicon laparodisc device is like a camera shutter that can be circumferentially reduced to seal the pneumoperitoneum around a 5 mm trocar.
Once the procedure is completed the hand port device is removed, anterior and posterior rectal sheath muscle fascia are closed with either 0 or 2-0 absorbable suture and the skin is then closed in a subcuticular manner. Additionally, a variety of “pain buster” catheters are now available for insertion into the supra fascia layer of the wound which allows for excellent postoperative analgesia. These help to minimize postoperative narcotic requirements thereby facilitating an earlier return of bowel function and more expedient discharge from the hospital. It has been the author’s personal experience that patients undergoing a handoscopy type of operation parallel their recovery in the same manner as a conventional laparoscopic case with a delay of only one day in recovery. If a bowel resection should be required the patient usually only requires to be NPO overnight and clear liquids may be started on the first postoperative day. The patient is maintained on clear liquids until passing flatus and moving bowels. Most patients are discharged home on the second postoperative day if a bowel resection has been required.
In the event that a bowel resection is required, stapling instruments are used routinely for division of the bowel and anastomosis. The mesentery of the bowel can be divided with the use of surgical ties, Harmonic Scalpel, or vascular cartridge stapling devices. Bowel resection is preceded by first identifying the lines of resection, transection of the bowel, the use of stapling devices proximally and distally, division of the mesentery, followed by re-anastomosis once again using stapling devices and closing the enterotomy required by the tines of the stapling device with an additional stapling device. Any mesentery defect caused by a small bowel resection are closed with a running 0 or 2-0 absorbable suture. Mesenteric defects need not be closed after large bowel resections.
Open Adhesiolysis
In certain situations an open adhesiolysis is best for the patients. It is usually performed after an attempted laparoscopic approach has been abandoned. If only a pelvic adhesiolysis is needed, a Pfannenstiel incision usually is adequate. However if the entire peritoneal cavity is encased in dense fibrotic adhesions a midline incision is usually required. Open adhesiolysis should be reserved for the worst possible cases where laparoscopic adhesiolysis has failed, where there has been several incidental enterotomies made, or adhesiolysis cannot be performed secondary to encasement of the bowel. Open adhesiolysis should also be considered in a patient unable to tolerate CO2 insufflation.
An open adhesiolysis is performed in the exact same way as a laparoscopic adhesiolysis. First, all adhesions are taken down from the abdominal wall usually with the Metzenbaum scissors. Second, all loops of bowel are extracted out of the pelvis. Finally, all interloop adhesions are lysed from the ligament of Treitz to the ileo-cecal valve. Any incidental enterotomies should be repaired at the time of discovery to avoid intra peritoneal contamination and development of an infection. Hemostasis must be meticulous during the entire dissection as in a laparoscopic procedure. An abundant use of warm irrigation fluid is used as well.
It is extremely important to keep the tissues moist to prevent desiccation from atmospheric air as this can stimulate adhesion reformation. It has been a personal experience that the use of adhesion barriers has been ineffective in open procedures on the bowel and is not indicated.
ADHESION PREVENTION
Intraoperatively, the surgeon can minimize adhesion formation through careful tissue handling, complete hemostasis, abundant irrigation, limited thermal injury, infection prophylaxis, and minimizing foreign body reaction.29,30 A recent Cochrane Database Systematic Review investigated whether pharmacological and liquid agents used as adjuvants during pelvic surgery in infertility patients lead to a reduction in the incidence or severity of postoperative adhesion (re-)formation, and/or an improvement in subsequent pregnancy rates. The results of this review are as follows: there is some evidence that intraperitoneal steroid administration decreases the incidence and severity of postoperative adhesion formation; intraperitoneal administration of dextran did not decrease postoperative adhesion formation at second look laparoscopy; there is no evidence that intra-abdominal crystalloid instillation, calcium channel blocking agents, non-steroidal anti inflammatory drugs and proteolytics decrease postoperative adhesion formation.31
Barrier agents for prevention of adhesion formation are commercially available. The Cochrane Menstrual Disorders and Subfertility Group investigated the effects these agents have on postoperative adhesion formation. The 15 randomized controlled trials comprised laparoscopic and laparotomic surgical techniques. Results of the investigation were as follows: oxidized regenerated cellulose (Interceed: Johnson & Johnson Medical, Somerville, NJ) reduces the incidence of adhesion formation and re-formation at laparoscopy and laparotomy in the pelvis; polytetrafluoroethylene (GoreTex: W.L. Gore & Associates, Flagstaff, AZ) appears to be superior to Interceed in preventing adhesion formation in the pelvis but is limited by the need for suturing and later removal; Seprafilm (Genzyme, Cambridge, MA) does not appear to be effective in preventing adhesion formation.32
If Interceed is to be used for prevention of adhesion formation, the intrapelvic fluid should be completely aspirated. A piece of Interceed large enough to cover the at-risk area is placed and moistened with a small volume of irrigant. Complete hemostasis must be achieved prior to placing the material. If hemostasis has not been achieved, the Interceed will turn brown or black and must be replaced as this may actually increase adhesion formation.33 Animal studies and clinical trials of a gel form of modified hyaluronic acid, a naturally occurring glycosaminoglycan, show evidence for reducing de novo adhesion formation.34 Intergel (Gynecare, Johnson & Johnson Inc., Somerville, NJ) is commercially available for open surgery use.
The ideal barrier material should be easy to apply, both in open and laparoscopic surgeries. Additionally, it should be nonreactive, persist during the critical wound reepithelization period, stay in place on the target tissue for several days, and eventually be resorbed following peritoneal healing
A new product, currently undergoing clinical trials, SprayGel (Confluent Surgical, Waltham, MA), meets these criteria. SprayGel is composed of two liquids which are polyethylene glycol (PEG)-based. PEG is widely used in a variety of medical products. When these two liquids are applied while mixing them in situ, they polymerize within seconds to form a visible, adherent, and conforming hydrogel barrier on the target tissues. The gel remains intact for the next 5 to 7 days before breaking down by hydrolysis, and eventual clearance through the kidneys. Preclinical safety studies of SprayGel adhesion barrier demonstrate that it is a remarkably inert, biocompatible material, resulting in no signs of toxicity at multiple time points, even when tested at 25 times the anticipated normal dose. Clinical studies in Europe and the US further support the safety profile of this material as an implant. Preliminary prospective randomized clinical trials have evaluated SprayGel adhesion barrier in open and laparoscopic myomectomy surgery, as well as in laparoscopic ovarian surgery. In the European myomectomy study, a significant improvement was demonstrated in the tenacity of adhesions between the treated and control populations, when comparing the initial procedures and second-look laparoscopies, as evaluated by the surgeon. The product is currently under review in a multicenter pivotal clinical trial in the US.
CONCLUSION
Adhesion formation after gynecologic surgery is common. When compared to laparotomy, laparoscopy has been shown to result in less de novo adhesion formation, but adhesion reformation continues to be a problem.35 Sequelae of intra-abdominal adhesion formation can be fatal, result in infertility, and be a source of chronic pelvic pain. Minimally invasive surgical management of adhesion formation affords the patient all of the known benefits of laparoscopic surgery including less postoperative analgesics, shorter hospital stays, and more rapid convalescence and return to normal activities. Unfortunately, recurrence rates after adhesiolysis for intestinal obstruction are reported to range from 8%36 to 32%37. Thus, for some patients, adhesiolysis may become a repeat surgical procedure.
No longer can the surgeon ignore the benefits of minimally invasive surgery for adhesiolysis. While these techniques and procedures are not without risk, patients should not be denied their inherent advantages. Astute clinicians must work together to discern the most appropriate uses for this therapy
REFERENCES
1. Ellis H: The Clinical Significance of Adhesions: Focus on Intestinal Obstruction. Eur J Surg 1997; Suppl 577:5-9]
2. Bryant T. Clinical lectures on intestinal obstruction. Med Tim Gaz 1872;1:363-5.
3. Welch JP. Adhesions. In: Welch JP, ed. Bowel obstruction. Philadelphia: WB Saunders, 1990:154-65.
4. Kligman I, Drachenberg C, Papdimitriou J, et al. Immunohistochemical demonstration of nerve fibers in pelvic adhesions. Obstet Gynecol 1993;82:566-568.
5. Kresch AJ, Seifer DB, Sachs LB, et al. Laparoscopy in 100 women with chronic pelvic pain. Obstet Gynecol 1984; 64:672-674.
6. Steege JF, Stout AL. Resolution of chronic pelvic pain after laparoscopic lysis of adhesions. Am J Obstet Gynecol 1991;165:278-81.
7. Chan CL, Wood C. Pelvic adhesiolysis: The assessment of symptom relief by 100 patients. Aust NZ Obstet Gynaecol 1985;25:295-298.
8. Daniell JF. Laparoscopic enterolysis for chronic abdominal pain. J Gynecol Surg 1990;5:61-66.
9. Sutton C, MacDonald R. Laser laparoscopic adhesiolysis. J Gynecol Surg 1990;6:155-159.
10. Peters A, Trimbos-Kemper G, Admiraal C et al. A randomized clinical trial on the benefit of adhesiolysis in patient with intraperitoneal adhesions and pelvic pain. Br J Obstet Gynaecol 1992;99:59-62.
11. Fox Ray N, Denton WG, Thamer M, Henderson SC, Perry S. Abdominal Adhesiolysis: Inpatient Care and Expenditures in the United States in 1994. J Am Coll Surg 1998;186(1):1-9.
12. DiZerega GS. Contemporary adhesion prevention. Fertil Steril 1994;61(2):219-235.
13. Odell R. Principles of Electrosurgery. In Sivak M, ed. Gastroenterologic Endoscopy. New
York: W.B. Saunders Company, 1987:128.
14. Reich H, Vancaillie T, Soderstrom R. Electrical Techniques. Operative Laparoscopy. In Martin DC, Holtz GL, Levinson CJ, Soderstrom RM, eds. Manual of Endoscopy. Santa Fe Springs: American Association of Gynecologic Laparoscopists, 1990:105
15. Reich H, McGlynn F. Laparoscopic oophorectomy and salpingo-oophorectomy in the treatment of benign tuboovarian disease. J Reprod Med 1986;31:609.
16. Reich H. Laparoscopic oophorectomy and salpingo-oophorectomy in the treatment of benign tubo-ovarian disease. Int J Fertil 1987;32:233.
17. Reich H, McGlynn F. Laparoscopic treatment of tubo- ovarian and pelvic abscess. J Reprod Med 1987;32:747.
18. Henry-Suchet J, Soler A, Lofferdo V. Laparoscopic treatment of tubo-ovarian abscesses. J Reprod Med 1984;29: 579.
19. Reich H. Endoscopic management of tuboovarian abscess and pelvic inflammatory disease. In Sanfilippo JS and Levine RL, eds. Operative Gynecologic Endoscopy. New York: Springer- Verlag, 1989:118.
20. Reich H. Laparoscopic bowel injury. Surg Laparosc Endosc 1992;2:74.
21. Palmer R. Safety in laparoscopy. J Reprod Med 1974;13:1-5.
22. Fu-Hsing Chang, Hung-Hsueh Chou, Chyi-Long Lee, et al. Extraumbilical Insertion of the Operative Laparoscope in Patients With Extensive Intraabdominal Adhesions. J Amer Assoc Gynecol Laparosc 1995;2(3):335-337.
23. Pasic R, Wolfe WM. Transuterine insertion of Verres needle. N Z Med J 1994;107(987):411.
24. Reich H, McGlynn F, Salvat J. Laparoscopic treatment of cul-de-sac obliteration secondary to retrocervical deep fibrotic endometriosis. J Reprod Med 1991;36:516.
25. Peacock LM and Rock JA. Distal Tubal Reconstructive Surgery. In Sanfilippo J ed. Operative Gynecologic Endoscopy. New York: Springer, 1996:182-191.
26. Reich H. Laparoscopic treatment of extensive pelvic adhesions including hydrosalpinx. J Reprod Med 1987;32:736.
27. McComb PF, Paleologou A. The intussusception salpingostomy technique for the therapy of distal oviductal occlusion at laparoscopy. Obstet Gynecol 1991;78:443.
28. Reich H. New techniques in advanced laparoscopic surgery. In Sutton C, ed. Laparoscopic Surgery. Bailliere’s Clinical Obstetrics and Gynaecology. London: WB Saunders, 1989:6551.
29. Singhal V, Li T, Cooke I. An analysis of the factors influencing the outcome of 232 consecutive tubal microsurgery cases. Br J Obstet Gynaecol 1991;98:628-36.
30. Winston R, Margara R. Microsurgical salpingostomy is not an obsolete procedure. Br J Obstet Gynaecol 1991; 98:637-42.
31. Watson A, Vandekerckhove P, Lilford R. Liquid and fluid agents for preventing adhesions after surgery for subfertility. Cochrane Database of Systematic Reviews. Issue 4, 2000.
32. Farquhar C, Vandekerckhove P, Watson A, Vail A, Wiseman D. Barrier agents for preventing adhesions after surgery for subfertility. Cochrane Database of Systematic Reviews. Issue 4, 2000.
33. Diamond MP, Linsky CB, Cunningham TC, et al. Synergistic effects of Interceed (TC7) and heparin in reducing adhesion formation in the rabbit uterine horn model. Fertil Steril 1991;55:389-94.
34. Burns JW, Skinner K, Yu LP, et al. An injectable biodegradable gel for the prevention of postsurgical adhesions: Evaluation in two animal models. In Proceedings of the 50th Annual Meeting of the American Fertility Society, San Antonio, Texas, November 5-10, 1994.
35. Operative Laparoscopy Study Group. Postoperative adhesion development after operative laparoscopy: evaluation at early second look procedures. Fertil Steril 1991;55:700-4.
36. Close MB, Chistensen NM. Transmesenteric small bowel plication or intraluminal tube stenting. Am J Surg 1979;138:89-91.
37. Brightwell NL, McFee AS, Aust JB. Bowel obstruction and the long tube stent. Arch Surg 1977;112:505-511.
I have been a Guinea pig one time too many.
I'm no doctor just an adhesion sufferer like you.
In my experience the most effective tool we have is a good surgeon and an adhesiolysis as described below.
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Found 38 studies with search of: adhesions abdomen
http://clinicaltrials.gov/ct2/results?term=adhesions+abdomen
Hide studies that are not seeking new volunteers.
Hide studies with unknown recruitment status. Display Options Rank Status Study
1 Not yet recruiting An Adhesion Reduction Plan in the Management of the Surgical Open Abdomen Condition: Open Abdomen
Intervention: Procedure: Adhesion Reduction Plan
2 Recruiting Comparative Effectiveness Multicenter Trial for Adhesion Characteristics of Ventral Hernia Repair Mesh Conditions: Ventral Hernia; Adhesions
Intervention: Procedure: Clinically-Indicated Abdominal Re-Exploration Surgery
3 Terminated Pregabalin for Abdominal Pain From Adhesions Conditions: Abdominal Pain; Surgical Adhesions
Interventions: Drug: Placebo; Drug: Pregabalin
4 Completed Resorbable Barrier for the Prevention of Abdominal and Peri-hepatic Adhesion Formation Condition: Colorectal Cancer
Interventions: Procedure: - use of resorbable membrane Seprafilm; Procedure: without resorbable barrier (seprafilm)
5 Completed A-Part® Gel as Adhesion Prophylaxis After Major Abdominal Surgery Versus a Non-treated Group Conditions: Adhesions; Abdominal Cavity
Intervention: Device: A-Part® Gel
6 Recruiting Seprafilm™ for the Prevention of Intraperitoneal Adhesions and Improved Delivery of Therapy in Women Undergoing Staging and Intraperitoneal Chemotherapy for Advanced Ovarian Cancer Condition: Epithelial Ovarian Cancer
Intervention: Procedure: Seprafilm™
7 Recruiting Cine-magnetic Resonance Imaging (MRI) Detecting Intra Abdominal Adhesions Condition: Tissue Adhesions
Intervention: Other: CineMRI
8 Completed Evaluation of Bioresorbable Sheet to Prevent Intra-Abdominal Adhesions in Colorectal Surgeries Condition: Adhesions
Intervention: Device: Polylactic Acid Sheet
9 Terminated Evaluation of the Safety and Effectiveness of Sepraspray™ in Reducing Post-surgical Adhesions Condition: Abdominal Adhesions
Intervention: Device: Sepraspray
10 Completed SurgiWrapTM to Reduce Soft Tissue Attachment & Incidence Early Post-Operative Bowel Obstruction in Colorectal Surgery Conditions: Adhesions; Colectomy
Intervention: Other: Polylactic Acid Sheet
11 Terminated SprayShield EU Post Market Study Conditions: Ulcerative Colitis; Familial Polyposis
Interventions: Device: SprayShield Adhesion Barrier System; Procedure: Good Surgical Technique Alone
12 Completed Manageability and Safety Assessment of Sepraspray in Abdominal Surgery. Condition: Adhesion Prevention
Interventions: Device: Sepraspray; Other: No Intervention
13 Active, not recruiting The Effect of Adhesiolysis During Elective Abdominal Surgery on Per- and Postoperative Complication, Quality of Life and Socioeconomic Costs Condition: Tissue Adhesions
Intervention: Procedure: Adhesiolysis
14 Completed NOTES Transgastric Diagnostic Peritoneoscopy With Laparoscopic Assistance Condition: Abdominal Adhesions
Intervention: Device: Transgastric diagnostic peritoneoscopy with laparoscopic assistance
15 Completed Closure of Peritoneum at Cesarean Section and Postoperative Adhesion Conditions: Cesarean Section; Adhesions
Intervention: Procedure: Closure of the peritoneum at cs
16 Unknown † Seprafilm® for Prevention of Adhesions at Repeat Cesarean Condition: Adhesion Formation After Primary Cesarean Delivery
Interventions: Device: Seprafilm®; Other: Control
17 Terminated Evaluation of the Safety of Sepraspray in Open Abdominal Surgery Condition: Adhesion Prevention (Abdominal)
Intervention: Device: Sepraspray
18 Recruiting Early Small Bowel Obstruction Following Laparotomy For Trauma Condition: Small Bowel Obstruction
Intervention:
19 Completed Effects of Extensive Abdominal Lavage on Postoperative Inflammation Following Full Thickness Excision of Deep Endometriosis Condition: Endometriosis
Interventions: Procedure: Extensive abdominal lavage; Procedure: Rinsing of the abdomen
20 Not yet recruiting TIGR vs Polypropylene (Permanent) Mesh: Randomised Trial Condition: Hernia
Intervention: Device: TIGR Mesh
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The “Standard” by which I base a “HIGH QUALITY ADHESIOLYSIS”
from: http://www.adhesionrelateddisorder.com/high-quality-adhesiolysis.html
Because I know this surgeon cares about his patients, and those who strive to do the highest quality adhesiolysis that can offer the best chances of improvements for those afflicted with “Adhesion Related Disorder,” can be respected enough to be mentioned in this web site!
Nothing but the best surgeons found here!
LAPAROSCOPIC SURGERY FOR ADHESIOLYSIS
Harry Reich, M.D., F.A.C.O.G., FACS1
Is an Attending Physician, Wyoming Valley Health Care System, Wilkes-Barre, PA,
Community Medical Center, Scranton, PA, Lenox Hill, NY,NY, St. Vincent’s
Hospital and Medical Center of New York
INTRODUCTION
Postoperative adhesions occur after almost every abdominal surgery and are the leading cause of intestinal obstruction. In one study, 93% of patients who had undergone at least one previous abdominal operation had postsurgical adhesions. This was not considered surprising, given the extreme delicacy of the peritoneum and the fact that apposition of two injured surfaces nearly always results in adhesion formation.1
Fatal sequelae of intraabdominal adhesions were reported as early as 1872 after removal of an ovarian tumor resulted in intestinal obstruction.2 Adhesions are the most common cause of bowel obstruction and most likely result from gynecologic procedures, appendectomies and other intestinal operations.3 Adhesions have also been proposed to cause infertility and abdominal and pelvic pain. Although nerve fibers have been confirmed in pelvic adhesions, their presence is not increased in those patients with pelvic pain.4 In addition, there does not appear to be an association between the severity of adhesions and complaint of pain. It is generally accepted that adhesions may impair organ motility resulting in visceral pain transmitted by peritoneal innervation.5 Many patients experience resolution of their symptoms after adhesiolysis.6-9 This may be complicated by placebo effect as demonstrated by one study that showed no difference in pain scores between patients who were randomized to adhesiolysis versus expectant management.10
In 1994, adhesiolyis procedures resulted in 303,836 hospitalizations, 846,415 days of inpatient care, and $1.3 billion in health care expenditures. Forty-seven percent of these hospitalizations were for adhesiolysis of the female reproductive system, the primary site for these procedures. In comparison to similar data from 1988, the cost of adhesiolysis hospitalizations is down. One significant influence on this trend is the increased use of minimally invasive surgical techniques resulting in fewer days of inpatient care.11
This chapter reviews the pathophysiology of adhesion formation, equipment and technique for adhesiolysis, and methods for adhesion prevention.
PATHOPHYSIOLOGY OF ADHESION FORMATION
Adhesion formation is initiated by peritoneal trauma. Its morphogenesis was described in detail by diZerega.12 Within hours at the site of injury, polymorphonuclear leukocytes appear in large numbers meshed in fibrin strands. At 24-36 hours, macrophages appear in large numbers and are responsible for regulating fibroblast and mesothelial cell activities. By day 2, the wound surface is covered by macrophages, islands of primitive mesenchymal cells and mesothelial cells. By day four the islands of primitive mesenchymal cells have now come into contact with each other. Fibroblasts and collagen are now present and increasing. By day five, an organized fibrin interconnection is now seen composed of collagen, fibroblasts, mast cells, and vascular channels containing endothelial cells. The adhesion continues to mature as collagen fibrils organize into bands covered by mesothelium and containing blood vessels and connective tissue fiber.12
EQUIPMENT
A review of standard equipment such as light sources and video systems is beyond the scope of this chapter. Equipment useful for advanced procedures and energy sources is included. However, the main technique for adhesiolysis with the least possibility for reformation can simply be described as “cold scissors dissection with bipolar backup.”
Laparoscopes
Four different laparoscopes should be available for adhesiolysis: a 10-mm 0° straight viewing laparoscope; a 10-mm operative laparoscope with 5-mm operating channel; a 5-mm straight viewing laparoscope for introduction through 5-mm trocar sleeves; and an oblique-angle laparoscope (30-45°) for upper abdominal and pelvic procedures.
Scissors
Scissors are the preferred instrument to cut adhesions, especially avascular and/or congenital adhesions. Using the magnification afforded by the laparoscope, most anterior abdominal wall, pelvic, and bowel adhesions can be carefully inspected and divided with minimal bleeding, rarely requiring microbipolar coagulation. Loose fibrous or areolar tissue is separated by inserting a closed scissors and withdrawing it in the open position. Pushing tissue with the partially open blunt scissors tip is used to develop natural planes.
Reusable 5 mm blunt-tipped sawtooth scissors and curved scissors cut well without cautery. Blunt or rounded-tip 5mm scissors with one stable blade and one moveable blade are used to divide thin and thick bowel adhesions sharply. Sharp dissection is the primary technique used for adhesiolysis to diminish the potential for adhesion formation; electrification and laser are usually reserved for hemostatic dissection of adhesions where anatomic planes are not evident or vascular adherences are anticipated. Thermal energy sources must be avoided as much as possible to reduce adhesion recurrence. Blunt-tipped, sawtooth scissors, with or without a curve, cut well (Richard Wolf Medical Instruments, Vernon Hills, IL and Karl Storz Endoscopy, Culver City, CA). Many disposable scissors depend greatly on electrification for cutting. Hook-scissors are not very useful for adhesiolysis.
Surgeons should select scissors that feel comfortable. To facilitate direction changes, the scissors should not be too long or encumbered by an electrical cord. This author prefers to make rapid instrument exchanges between scissors and microbipolar forceps through the same portal to control bleeding, instead of applying electrification via scissors.
Electrosurgery
When discussing electrosurgery, the term “cautery” should be abandoned. Cautery, thermocoagulation, or endocoagulation refer to the passive transfer of heat from a hot instrument heated by electrical current to tissue. The temperature rises within the tissue until cell proteins begin to denature and coagulate with resultant cell death. Electrical current does not pass through the patient’s body!
Monopolar cutting current can be used safely, as the voltage is too low to arc to organs even 1 mm away. Cutting current is used to both cut and/or coagulate (desiccate) depending on the portion of the electrode in contact with the tissue. The tip cuts, while the wider body tamponades and coagulates.
Monopolar coagulation current which uses voltages over 10 times that of cutting current can arc 1 to 2mm and is used in close proximity to tissue, but not in contact, to fulgurate diffuse venous and arteriolar bleeders. It takes 30% more power to spark or arc in CO2 pneumoperitoneum than in room air; thus, at the same electrosurgical power setting, less arcing occurs at laparoscopy than at laparotomy.
Monopolar electrosurgery should be avoided when working on the bowel unless the surgeon is well versed in this modality. The expert laparoscopic surgeon can use monopolar electrosurgery safely to cut or fulgurate tissue, but desiccation (coagulation) on bowel should be performed with bipolar techniques.13,14
Electrosurgical injury to the bowel can occur beyond the surgeon’s field of view during laparoscopic procedures from electrode insulation defects or capacitive coupling. While the surgeon views the tip of the electrode, electrical discharge may occur from its body (insulation failure) or from metal trocar cannulas surrounding the electrode if they are separated from the skin by plastic retention sleeves. These problems are eliminated by active electrode monitoring using the Electroshield EM-1 monitor system (Encision, Boulder, CO). This consists of a sheath surrounding the electrode and a sheath monitor (EM-1) to detect any insulation faults and shield against capacitive coupling.
Bipolar desiccation using cutting current between two closely opposed electrodes is safe and efficient for large vessel hemostasis.15,16 Large blood vessels are compressed and bipolar cutting current passed until complete desiccation is achieved, i.e., the current depletes the tissue fluid and electrolytes and fuses the vessel wall. Coagulating current is not used as it may rapidly desiccate the outer layers of the tissue, producing superficial resistance thereby preventing deeper penetration.
Small vessel hemostasis necessary for adhesiolysis is best achieved by using microbipolar forceps after precisely identifying the vessel with electrolyte solution irrigation. Microbipolar forceps (Richard Wolf Medical Instruments, Vernon Hills, IL) with an irrigation channel work best for precise tissue desiccation with minimal thermal spread.
Harmonic Scalpel
The use of Harmonic Scalpel (Ethicon Endosurgery, Cincinnati, Ohio) for laparoscopic adhesiolysis is gaining popularity. Although it has its limitations, the benefit of this multifunctional instrument far outweighs any disadvantage. Many factors can be attributed to its progressive acceptance. The lack of electrical energy used to coagulate vessels and the smaller (2mm) lateral energy spread make it more attractive than conventional electrosurgical instruments by potentially reducing the percentage of delayed post-operative bowel injuries (caused by electrical burns.) This is not to say however, that injury cannot occur. As with standard electrosurgical instruments, the Harmonic Scalpel, specifically the jaws, can become hot and cause tissue injury if not used in a prudent manner. Although Harmonic Scalpel has the ability to grasp, cut, and cauterize simultaneously, making it a useful instrument for a judicious operator (requiring fewer instrument changes in and out of port sites), the inability to cut without applying energy assures the need for a sharp pair of conventional scissors in laparoscopic adhesiolysis.
EQUIPMENT (continued)
Rectal and Vaginal Probes
A sponge on a ring forceps is inserted into the vagina or the posterior vaginal fornix, and an 81-French probe is placed in the rectum to define the rectum and posterior vagina for lysis of pelvic adhesions and/or excision of endometriosis when there is a significant degree of cul-de-sac obliteration. Whenever rectal location is in doubt, it is identified by insertion of the rectal probe.
CO2 laser
The CO2 laser, with its 0.1 mm depth of penetration and inability to traverse through water, allows the surgeon some security when lysing adhesions especially in the pelvis. The Coherent 5000L laser (Palo Alto, CA), by using a 11.1 um wavelength beam, maintains a 1.5mm spot size at all power settings allowing for more precision than most standard 10.6 um wavelength CO2 lasers.
Aquadissection
Aquadissection is the use of hydraulic energy from pressurized fluid to aid in the performance of surgical procedures. The force vector is multidirectional within the volume of expansion of the uncompressible fluid; the force applied with a blunt probe is unidirectional. Instillation of fluid under pressure displaces tissue, creating cleavage planes in the least resistant spaces. Aquadissection into closed spaces behind peritoneum or adhesions produces edematous, distended tissue on tension with loss of elasticity, making further division easy and safe using blunt dissection, scissors dissection, laser, or electrosurgery.
Suction-irrigators with the ability to dissect using pressurized fluid should have a single channel to maximize suctioning and irrigating capacity. This allows the surgeon to perform atraumatic suction-traction-retraction, irrigate directly, and develop surgical planes (aquadissection). The distal tip should not have side holes as they impede these actions, spray the surgical field without purpose, and cause unnecessary tissue trauma when omentum, epiploic appendices, and adhesions become caught. The shaft should have a dull finish to prevent CO2 laser beam reflection, allowing it to be used as a backstop. The market is crowded with many aquadissection devices.
Plume Eliminator
Smoke evacuation during electrosurgery or CO2 laser laparoscopy is expedited using a Clear View EBS ICM 350 smoke evacuator (I.C. Medical, Phoenix, AZ).
LAPAROSCOPIC PERITONEAL CAVITY ADHESIOLYSIS
Adhesiolysis by laparoscopy and laparotomy can be very time-consuming and technically difficult and is best performed by an expert surgeon. However, despite lengthy laparoscopic procedures (two to four hours), most patients are discharged on the day of the procedure, avoid large abdominal incisions, experience minimal complications, and return to full activity within one week of surgery.
In this section, general adhesiolysis, pelvic adhesiolysis, ovariolysis, salpingo-ovariolysis, and salpingostomy are described. The laparoscopic treatment of acute adhesions has not been included. However, the best treatment for sexually transmitted disease adhesive sequelae may be prevention through early laparoscopic diagnosis and treatment of acute pelvic infection, including abscesses. Acute adhesiolysis will often prevent chronic adhesion formation.17-19
Classification
Extensive peritoneal cavity adhesion procedures need a classification system that relates to their degree of severity and the surgical expertise necessary for adhesiolysis. The single best indicator of the degree of severity and expertise necessary for adhesiolysis is the number of previous laparotomies. The frequency of small bowel obstruction symptoms indicates the need for surgery.
Peritoneal adhesiolysis is classified into enterolysis including omentolysis and female reproductive reconstruction (salpingo-ovariolysis and cul-de-sac dissection with excision of deep fibrotic endometriosis). Bowel adhesions are divided into upper abdominal, lower abdominal, pelvic, and combinations. Adhesions surrounding the umbilicus are upper abdominal as they require an upper abdominal laparoscopic view for division. The extent, thickness, and vascularity of adhesions vary widely. Intricate adhesive patterns exist with fusion to parietal peritoneum or various meshes.
Extensive small bowel adhesions are not a frequent finding at laparoscopy for pelvic pain or infertility. In these cases, the fallopian tube is adhered to the ovary, the ovary is adhered to the pelvic sidewall, and the rectosigmoid may cover both. Rarely, the omentum and small bowel are involved. Adhesions may be the result of an episode of pelvic inflammatory disease or endometriosis, but most commonly are caused by previous surgery. Adhesions cause pain by entrapment of the organs they surround. The surgical management of extensive pelvic adhesions is one of the most difficult problems facing surgeons today.
Surgical plan for extensive enterolysis
A well-defined strategy is important for small bowel enterolysis. For simplification, this is divided into three parts:
1. Division of all adhesions to the anterior abdominal wall parietal peritoneum. Small bowel loops encountered during this process are separated using their anterior attachment for countertraction instead of waiting until the last portion of the procedure (running of the bowel).
2. Division of all small bowel and omental adhesions in the pelvis. Rectosigmoid, cecum, and appendix often require some separation during this part of the procedure.
3. Running of the bowel Using atraumatic grasping forceps and usually a suction-irrigator for suction traction, the bowel is run. Starting at the cecum and terminal ileum, loops and significant kinks are freed into the high upper abdomen to the ligament of Treitz.
4.(Optional) Finally tubo-ovarian pathology is treated if indicated.
Time frequently dictates that all adhesions cannot be lysed. From the history, the surgeon should conceptualize the adhesions most likely to be causing the pain, i.e., upper or lower abdomen, left or right, and clear these areas of adhesions.
Preoperative preparation
Patients are informed preoperatively of the high risk for bowel injury during laparoscopic procedures when extensive cul-de-sac involvement with endometriosis or adhesions is suspected. They are encouraged to hydrate and eat lightly for 24 hours before admission. A mechanical bowel preparation (GoLYTELY or Colyte) is administered orally the afternoon before surgery to induce brisk, self-limiting diarrhea to cleanse the bowel without disrupting the electrolyte balance.20 The patient is usually admitted on the day of surgery. Lower abdominal, pubic, and perineal hair is not shaved. Patients are encouraged to void on call to the OR, and a Foley catheter is inserted only if the bladder is distended or a long operation anticipated. A catheter is inserted near the end of the operation and removed in the recovery room when the patient is aware of its presence, to prevent bladder distension. Antibiotics (usually cefoxitin) are administered in all cases lasting over two hours, at the two-hour mark.
Patient Positioning
All laparoscopic surgical procedures are done under general anesthesia with endotracheal intubation. An orogastric tube is placed routinely to diminish the possibility of a trocar injury to the stomach and to reduce small bowel distention. The patient’s arms should be tucked on both sides so that the surgeon’s position is comfortable and not limited. The patient’s position is flat (0°) during umbilical trocar sleeve insertion and anterior abdominal wall adhesiolysis but a steep Trendelenburg position (30 degrees), reverse Trendelenburg position, and side-to-side rotation are used when necessary. Lithotomy position, with the hip extended (thigh parallel to abdomen) is obtained with Allen stirrups (Edgewater Medical Systems, Mayfield Heights, OH) or knee braces, which are adjusted individually to each patient before she is anesthetized. Anesthesia examination is performed prior to prepping the patient.
Incisions
In the absence of suspected periumbilical adhesions, an intraumbilical vertical incision is made through the skin of the inferior umbilical fossa extending to and just beyond its lowest point. A Verres needle is placed through this low point while pulling the umbilicus towards the pubic symphysis and insufflation with CO2 is continued until an intraabdominal pressure of 25-30mm Hg is obtained.
The palmed short trocar is positioned at a 90o angle inside the deep funnel shaped portion of the umbilical fossa where fascia and peritoneum meet and inserted through this into the peritoneal cavity at a 45o angle in one continuous thrusting motion, with wrist rotation. This is performed without lifting the anterior abdominal wall as the high intraabdominal pressure provides counterpressure against the parietal peritoneum to lift it above the large vessels below. The result is a parietal peritoneal puncture directly beneath the umbilicus. Once the trocar is in place within the abdominal cavity, the intra-abdominal pressure is lowered to 12-15 mm Hg to diminish the development of vena caval compression and subcutaneous emphysema.
Special alternate entry sites and techniques are used when there is a high suspicion for periumbilical adhesions in patients who have undergone multiple laparotomies, have lower abdominal incisions traversing the umbilicus, or who have extensive adhesions either clinically or from a previous operative record. Open laparoscopy at the umbilicus carries the same risk for bowel laceration if the bowel is fused to the umbilical undersurface.
One alternate site is in the left ninth intercostal space, anterior axillary line. Adhesions are rare in this area, and the peritoneum is tethered to the undersurface of the ribs, making peritoneal tenting away from the needle unusual. A 5-mm skin incision is made over the lowest intercostal space (the 9th) in the anterior axillary line. The Veress needle is grasped near its tip, like a dart, between thumb and forefinger, while the other index finger spreads this intercostal space. The needle tip is inserted at a right angle to the skin (a 45o angle to the horizontal) between the ninth and tenth ribs. A single pop is felt on penetration of the peritoneum. Pneumoperitoneum to a pressure of 30 mmHg is obtained. A 5 mm trocar is then inserted through this same incision that has migrated downward below the left costal margin because of the pneumoperitoneum.
Another alternate entry site is Palmer’s point21 located 3 cm inferior to the subcostal arch in the left medioclavicular line.22 Also, if the uterus is present and thought to be free of adhesions, the surgeon may consider inserting a long Veress needle transvaginally through the uterus.23
When unexpected extensive adhesions are encountered initially surrounding the umbilical puncture, the surgeon should immediately seek a higher site. Thereafter, the adhesions can be freed down to and just beneath the umbilicus, and the surrounding bowel inspected for perforations. The umbilical portal can then be reestablished safely for further work.
Other laparoscopic puncture sites are placed as needed, usually lateral to the rectus abdominis muscles and always under direct laparoscopic vision. When the anterior abdominal wall parietal peritoneum is thickened from previous surgery or obesity, the position of these muscles is judged by palpating and depressing the anterior abdominal wall with the back of the scalpel; the wall will appear thicker where rectus muscle is enclosed, and the incision site is made lateral to this area near the anterior superior iliac spine.
If an umbilical insertion is possible and extensive adhesions are present close to but below the umbilicus, the operating laparoscope with scissors in the operating channel is the first instrument used. If a left upper quadrant 5 mm incision is necessary, there is usually room for another puncture site to do initial adhesiolysis with scissors.
Abdominal Adhesiolysis
Anterior abdominal wall adhesions involve the parietal peritoneum stuck to the omentum, transverse colon, and small bowel with varying degrees of fibrosis and vascularity. Adhesions may be filmy and avascular, filmy and vascular, or dense, fibrous and vascular. All of these adhesions to the anterior abdominal wall are released. If adhesions extend from above the level of the laparoscope in the umbilicus, another trocar is inserted above the level of the highest adhesion and the laparoscope is inserted there. Adhesions are easier to divide when working above them, instead of within them, as gravity helps to delineate the plane for separation after which the CO2 pneumoperitoneum can disperse into the dissection plane.
Adhesiolysis is done using scissors alone if possible. Rarely, electrosurgery, CO2 laser, and the Harmonic Scalpel are used. In most cases, the initial adhesiolysis is performed with scissors. CO2 laser through the laparoscope on adhesions close to the trocar insertion often results in reflection with loss of precision. Electrosurgery (cutting current) is used only when there is little chance that small bowel is involved in the adhesion.
Initially, blunt-tipped scissors in the operating channel of an operating laparoscope are inserted into the interface between the anterior abdominal wall parietal peritoneum and the omentum. Rotating the laparoscope so that the scissors exit at 12 o’clock instead of 3 o’clock facilitates early adhesiolysis. Blunt dissection is performed by inserting the scissors at the interface, opening, and withdrawing them. This maneuver is repeated many times to delineate the thin avascular adhesions from thicker vascular fibrotic attachments that are individually coagulated and divided. Frequently, adhesions can be bluntly divided by grasping the adhesion in the partially closed scissors and gently pushing the tissue. If the plane of adhesions cannot be reached with the tip of the scissors, the abdominal wall can be pressed from above with the finger to make it accessible to the scissors.
After initial adhesiolysis, visualization is improved allowing better access and exposure for further adhesiolysis. Secondary trocar sites can now be placed safely. After their insertion, the remainder of the adhesions can now be lysed using scissors with microbipolar backup for rare arteriolar bleeders. Small venule bleeders are left alone. On occasion, in operations in which symptomatic bowel adhesions are not the main problem, an electrosurgical spoon or knife is used to divide the remaining omental adhesions if bowel is not involved. If bowel is involved, dissection proceeds with scissors, without electrosurgery, through the second puncture site, aided by traction on the bowel from an opposite placed puncture site. Rarely, the CO2 laser may be used through the operating channel of the operating laparoscope. When using the CO2 laser for adhesiolysis, aquadissection is performed to distend the adhesive surface with fluid before vaporizing the individual adhesive layers. The suction-irrigator can also be used for suction traction, instead of a laparoscopic Babcock, and as a backstop to prevent thermal damage to other structures. The suction irrigator is also used to clean the laparoscopic optic which is then wiped on the bowel serosa before continuing. Denuded areas of bowel muscularis are repaired transversely using a 3-0 Vicryl seromuscular stitch. Denuded peritoneum is left alone. Minimal oozing should be observed and not desiccated unless this bleeding hinders the next adhesiolysis step or persists towards the end of the operation. With perseverance, all anterior abdominal wall parietal peritoneum adhesions can be released.
The Harmonic Scalpel is also useful for adhesiolysis. It bears repeating, the Harmonic Scalpel is not a scissor. This instrument works by coagulating tissue in between the blades and allowing it to be “pressed apart” after full coagulation of the tissue between the active blade and the compressing surface. Tissue is first grasped between the blades of the Harmonic Scalpel, steadily compressed, and the blade is activated allowing the tissue to separate once it is fully coagulated. Any tissue between the blades of the Harmonic Scalpel will be heated and then be allowed to fall apart. This includes all blood vessels up to 3mm in diameter incorporated in the tissue between the blades. As stated before, the Harmonic Scalpel can be used to grasp tissue in a general manner when the blades are not active. However, prior to grasping any tissue, the operator must allow the active blade to cool sufficiently so it will not burn any tissue it may come in contact with. The operator must remember that a Harmonic Scalpel does not replace the scissor, especially when dealing with bowel in the same proximity to an adhesion plane. Harmonic Scalpel comes in 5- and 10-mm size instrumentation with active jaws as well as adaptable adjuncts to the instrument such as a spatula type dissector, “ball” type dissector and hook dissector. All of these type instruments can be used in the same location as you would normally use a monopolar electrode; bear in mind once again that the lateral energy spread is just 2mm with the Harmonic Scalpel.
Pelvic Adhesiolysis
The next step is to free all bowel loops in the pelvis. Small bowel attached to the vesicouterine peritoneal fold, uterus or vaginal cuff, and the rectum is liberated. There are three key points when performing bowel adhesiolysis within the pelvis: scissors dissection without electrosurgery, countertraction and blunt dissection. The bowel is gently held with an atraumatic grasper and lifted away from the structure to which it is adhered, exposing the plane of dissection. When adhesive interfaces are obvious, scissors are used. The blunt-tipped scissors are used to sharply dissect the adhesions in small, successive cuts taking care not to damage the bowel serosa. Countertraction will further expose the plane of dissection and ultimately free the attachment. Electrosurgery and laser are generally not used for adhesiolysis involving the bowel due to the risk of recurrent adhesions from thermal damage. However, when adhesive aggregates blend into each other, initial incision is made very superficially with laser, and aquadissection distends the layers of the adhesions, facilitating identification of the involved structures. Division of adhesions continues with laser at 10-20 W in pulsed mode. The aquadissector and injected fluid from it are used as a backstop behind adhesive bands that are divided with the CO2 laser.
The rectosigmoid can be adhered to the left pelvic sidewall obscuring visualization of the left adnexa. Dissection starts well out of the pelvis in the left iliac fossa. Scissors are used to develop the space between the sigmoid colon and the psoas muscle to the iliac vessels, and the rectosigmoid reflected toward the midline. Thereafter, with the rectosigmoid placed on traction, rectosigmoid and rectal adhesions to the left pelvic sidewall are divided starting cephalad and continuing caudad.
Cul-de-sac adhesions can cause partial or complete cul-de-sac obliteration from fibrosis between the anterior rectum, posterior vagina, cervix, and the uterosacral ligaments. The technique of freeing the anterior rectum to the loose areolar tissue of the rectovaginal septum before excising and/or vaporizing visible and palpable deep fibrotic endometriosis is used.24
Attention is first directed to complete dissection of the anterior rectum throughout its area of involvement until the loose areolar tissue of the rectovaginal space is reached. Using the rectal probe as a guide, the rectal serosa is opened at its junction with the cul-de-sac lesion. Careful dissection ensues using aquadissection, suction-traction, laser, and scissors until the rectum is completely freed and identifiable below the lesion. Excision of the fibrotic endometriosis is done only after rectal dissection is completed.
Deep fibrotic, often nodular, endometriotic lesions are excised from the uterosacral ligaments, the upper posterior vagina, (the location of which is confirmed by the Valtchev retractor or a sponge in the posterior fornix), and the posterior cervix. The dissection on the outside of the vaginal wall proceeds using laser or scissors until soft pliable upper posterior vaginal wall is uncovered. It is frequently difficult to distinguish fibrotic endometriosis from cervix at the cervicovaginal junction and above. Frequent palpation using rectovaginal examinations helps identify occult lesions. When the lesion infiltrates through the vaginal wall, an “en bloc” laparoscopic resection from cul-de-sac to posterior vaginal wall is done, and the vagina is repaired laparoscopically with the pneumoperitoneum maintained with a 30-cc foley balloon in the vagina. Or, more recently, the vaginal lesion is mobilized vaginally, the vagina closed over the mobilized portion, and the en bloc lesion excision completed laparoscopically.
Sometimes the fibrotic cul-de-sac lesion encompassing both uterosacral ligament insertions and the intervening posterior cervix-vagina and anterior rectal lesion can be excised as one en bloc specimen.
Endometriotic nodules infiltrating the anterior rectal muscularis are excised usually with the surgeon’s or his assistant’s finger in the rectum just beneath the lesion. In some cases, the anterior rectum is reperitonealized by plicating the uterosacral ligaments and lateral rectal peritoneum across the midline. Deep rectal muscularis defects are always closed with suture. Full thickness rectal lesion excisions are suture or staple repaired laparoscopically.
Pelvic Adhesiolysis (continued)
When a ureter is close to the lesion, its course in the deep pelvis is traced by opening its overlying peritoneum with scissors or laser. On the left, this often requires scissors reflection of the rectosigmoid, as previously described, starting at the pelvic brim. Bipolar forceps are used to control arterial and venous bleeding.
Adnexal Adhesiolysis25
SalpingoOvariolysis26
Ovarian adhesions to the pelvic sidewall can be filmy or fused. Initially, adhesions between the ovary and fallopian tubes and other peritoneal surfaces are identified. It is imperative that the surgeon knows the surrounding anatomy prior to cutting any tissue to avoid damage to vital structures. The plane of dissection is identified and followed to avoid damage to other structures. The uteroovarian ligament may be held with an atraumatic grasper to facilitate countertraction and expose the line of cleavage. During ovariolysis, it is important to preserve as much peritoneum as possible while freeing the ovary. Dissection starts either high in the pelvis just beneath the infundibulopelvic ligament or deep on the pelvic sidewall beneath the ureter in the pararectal space. In each case, scissors are used both bluntly and sharply to mobilize the ovary from the sidewall. Alternatively, aquadissection may be used to facilitate identification of adhesion layers and to provide a safe backstop for the CO2 laser. Once an adhesion layer is identified, the aquadissector can also be placed behind this ridge and used as a backstop during CO2 laser adhesiolysis. Adhesiolysis is performed sharply and bluntly in a methodical manner working caudad until the cul-de-sac is reached.
If fimbrioplasty is to be performed, then hydrodistention is achieved by transcervical injection of dilute indigo carmine through a uterine manipulator. This distends the distal portion of the tube which is stabilized, and the adhesive bands are freed using scissors, laser or micropoint electrosurgery. If necessary, the fimbriated end can be progressively dilated using 3 mm alligator-type forceps. The closed forceps are placed through the aperture, opened, and removed. This is repeated one or more times. If the opening does not remain everted on its own, the intussusception salpingostomy method of McComb27 is used to avoid thermal damage to the ciliated tubal epithelium from CO2 laser or electrosurgery. The tip of the aquadissector is inserted approximately 2 cm into the newly opened tube, suction applied, and the tube fimbrial edges pulled around the instrument to turn the tube end inside-out. The borders of the incision act as a restrictive collar to maintain the mucosa in this newly everted configuration. In some cases, the ostial margin is sutured to the ampullary serosa with 6-0
Underwater surgery at the end of each procedure28
At the close of each operation, an underwater examination is used to document complete intraperitoneal hemostasis in stages; this detects bleeding from vessels and viscera tamponaded during the procedure by the increased intraperitoneal pressure of the CO2 pneumoperitoneum. The integrity of the rectum and rectosigmoid is often checked at this time by instillation of dilute indigo carmine solution or air transanally through a 30 cc Foley catheter.
The CO2 pneumoperitoneum is displaced with 2 to 5 L of Ringer’s lactate solution, and the peritoneal cavity is vigorously irrigated and suctioned until the effluent is clear of blood products, usually after 10-20 L. Underwater inspection of the pelvis is performed to detect any further bleeding which is controlled using microbipolar irrigating forceps to coagulate through the electrolyte solution. First hemostasis is established with the patient in Trendelenburg position, then per underwater examination with the patient supine and in reverse Trendelenburg, and finally, with all instruments removed, including the uterine manipulator.
To visualize the pelvis with the patient supine, the 10-mm straight laparoscope and the actively irrigating aquadissector tip are manipulated together into the deep cul-de-sac beneath floating bowel and omentum. During this copious irrigation procedure, clear fluid is deposited into the pelvis and circulates into the upper abdomen, displacing upper abdominal bloody fluid which is suctioned after flowing back into the pelvis. An “underwater” examination is then performed to observe the completely separated tubes and ovaries and to confirm complete hemostasis.
A final copious lavage with Ringer’s lactate solution is undertaken and all clots directly aspirated; at least 2 L of lactated Ringer’s solution are left in the peritoneal cavity to displace CO2 and to prevent fibrin adherences from forming by separating raw operated-upon surfaces during the initial stages of reperitonealization. Displacement of the CO2 with Ringer’s lactate diminishes the frequency and severity of shoulder pain from CO2 insufflation. No other anti-adhesive agents are employed. No drains, antibiotic solutions, or heparin are used.
Handoscopy
Hand assisted laparoscopy or “handoscopy” has become popular over the last 5 years, mainly in the field of solid organ surgery and bowel surgery. The main advantage of handoscopy is that it allows the surgeon to regain the tactile feel of surrounding tissues previously lost to “laser” laparoscopists and permits a more purposeful manipulation of larger organs. Often, it is the use of handoscopy for tissue palpation, that enables a successful laparoscopic adhesiolysis. At times, during laparoscopic procedures, visualization can be poor due to dense adhesions and the inability to determine tissue planes. With the placement of the operator’s hand inside the peritoneal cavity the surgeon is usually able to palpate surrounding organs and allow for a better tissue dissection plane that otherwise may not have been possible through direct visualization only. Not only can the use of a hand port facilitate an otherwise tedious procedure, it effects a safer operation for the patient with less chance of bowel injury. If bowel resection should become necessary, the use of the hand port allows for exteriorization of the segment that requires resection once again making the procedure easier and less time consuming. A handoscopy incision is usually only 7-8 cm and is either placed in the left or right lower portion of the abdomen with insertion of the operator’s non-dominant hand. The muscle splitting technique is used in a similar method as in performing an open appendectomy. The entire peritoneal cavity can be examined through either one of these incisions with the operator’s hand and it can be used for organ extraction as well. Several different types of handoscopy ports are available and all provide equal access to the peritoneal cavity.
When placing a handoscopy port for adhesiolysis, the operator must first choose a location on the abdominal wall that will allow optimal access to the point where adhesions are greatest. After the hand port location is chosen, a marking pen should be used to outline the area of the abdominal wall where the hand port is to be placed. The area for the incision should be anesthetized with bupivicaine for post operative pain control and an incision should then be made into the skin. The size of the incision should be the same size as the operator’s glove size. After this is completed, a muscle splitting technique should be used to enter the peritoneal cavity just as the operator would in performing an open appendectomy. Once the peritoneal cavity is entered, the hand port can then be placed. All of the hand port apparatus require that any adhesions on the peritoneal side of the incision be lysed prior to inserting the handoscopy device. Additionally, these devices should not be placed over any bony prominences, i.e., iliac crest, or encompassing any bowel in the peritoneal ring surface as to injure any bowel in the abdomen. If the handoscopy port is placed in the upper abdomen, the falciform ligament may require division prior to inserting the ring.
Once the handoscopy device is in place the lysis of adhesions can precede in an orderly fashion by identifying the tissue planes by feel with the operator’s fingers and additionally being able to provide appropriate traction and countertraction to allow for a safe adhesiolysis. Incidental enterotomies can be sutured with conventional suture and then tied using one hand knot tying technique with the intra abdominal hand.
Should any bowel resections be required the hand port can be used as a mini laparotomy site for extraction of any specimens and for exteriorizing any bowel that may require resection and/or repair. Additionally all handoscopy devices that are placed through the abdominal wall act as a wound protector and may minimize post operative wound infections as well as protect from any potential tumor seeding if the operation is for malignancy. The opening of the Ethicon laparodisc device is like a camera shutter that can be circumferentially reduced to seal the pneumoperitoneum around a 5 mm trocar.
Once the procedure is completed the hand port device is removed, anterior and posterior rectal sheath muscle fascia are closed with either 0 or 2-0 absorbable suture and the skin is then closed in a subcuticular manner. Additionally, a variety of “pain buster” catheters are now available for insertion into the supra fascia layer of the wound which allows for excellent postoperative analgesia. These help to minimize postoperative narcotic requirements thereby facilitating an earlier return of bowel function and more expedient discharge from the hospital. It has been the author’s personal experience that patients undergoing a handoscopy type of operation parallel their recovery in the same manner as a conventional laparoscopic case with a delay of only one day in recovery. If a bowel resection should be required the patient usually only requires to be NPO overnight and clear liquids may be started on the first postoperative day. The patient is maintained on clear liquids until passing flatus and moving bowels. Most patients are discharged home on the second postoperative day if a bowel resection has been required.
In the event that a bowel resection is required, stapling instruments are used routinely for division of the bowel and anastomosis. The mesentery of the bowel can be divided with the use of surgical ties, Harmonic Scalpel, or vascular cartridge stapling devices. Bowel resection is preceded by first identifying the lines of resection, transection of the bowel, the use of stapling devices proximally and distally, division of the mesentery, followed by re-anastomosis once again using stapling devices and closing the enterotomy required by the tines of the stapling device with an additional stapling device. Any mesentery defect caused by a small bowel resection are closed with a running 0 or 2-0 absorbable suture. Mesenteric defects need not be closed after large bowel resections.
Open Adhesiolysis
In certain situations an open adhesiolysis is best for the patients. It is usually performed after an attempted laparoscopic approach has been abandoned. If only a pelvic adhesiolysis is needed, a Pfannenstiel incision usually is adequate. However if the entire peritoneal cavity is encased in dense fibrotic adhesions a midline incision is usually required. Open adhesiolysis should be reserved for the worst possible cases where laparoscopic adhesiolysis has failed, where there has been several incidental enterotomies made, or adhesiolysis cannot be performed secondary to encasement of the bowel. Open adhesiolysis should also be considered in a patient unable to tolerate CO2 insufflation.
An open adhesiolysis is performed in the exact same way as a laparoscopic adhesiolysis. First, all adhesions are taken down from the abdominal wall usually with the Metzenbaum scissors. Second, all loops of bowel are extracted out of the pelvis. Finally, all interloop adhesions are lysed from the ligament of Treitz to the ileo-cecal valve. Any incidental enterotomies should be repaired at the time of discovery to avoid intra peritoneal contamination and development of an infection. Hemostasis must be meticulous during the entire dissection as in a laparoscopic procedure. An abundant use of warm irrigation fluid is used as well.
It is extremely important to keep the tissues moist to prevent desiccation from atmospheric air as this can stimulate adhesion reformation. It has been a personal experience that the use of adhesion barriers has been ineffective in open procedures on the bowel and is not indicated.
ADHESION PREVENTION
Intraoperatively, the surgeon can minimize adhesion formation through careful tissue handling, complete hemostasis, abundant irrigation, limited thermal injury, infection prophylaxis, and minimizing foreign body reaction.29,30 A recent Cochrane Database Systematic Review investigated whether pharmacological and liquid agents used as adjuvants during pelvic surgery in infertility patients lead to a reduction in the incidence or severity of postoperative adhesion (re-)formation, and/or an improvement in subsequent pregnancy rates. The results of this review are as follows: there is some evidence that intraperitoneal steroid administration decreases the incidence and severity of postoperative adhesion formation; intraperitoneal administration of dextran did not decrease postoperative adhesion formation at second look laparoscopy; there is no evidence that intra-abdominal crystalloid instillation, calcium channel blocking agents, non-steroidal anti inflammatory drugs and proteolytics decrease postoperative adhesion formation.31
Barrier agents for prevention of adhesion formation are commercially available. The Cochrane Menstrual Disorders and Subfertility Group investigated the effects these agents have on postoperative adhesion formation. The 15 randomized controlled trials comprised laparoscopic and laparotomic surgical techniques. Results of the investigation were as follows: oxidized regenerated cellulose (Interceed: Johnson & Johnson Medical, Somerville, NJ) reduces the incidence of adhesion formation and re-formation at laparoscopy and laparotomy in the pelvis; polytetrafluoroethylene (GoreTex: W.L. Gore & Associates, Flagstaff, AZ) appears to be superior to Interceed in preventing adhesion formation in the pelvis but is limited by the need for suturing and later removal; Seprafilm (Genzyme, Cambridge, MA) does not appear to be effective in preventing adhesion formation.32
If Interceed is to be used for prevention of adhesion formation, the intrapelvic fluid should be completely aspirated. A piece of Interceed large enough to cover the at-risk area is placed and moistened with a small volume of irrigant. Complete hemostasis must be achieved prior to placing the material. If hemostasis has not been achieved, the Interceed will turn brown or black and must be replaced as this may actually increase adhesion formation.33 Animal studies and clinical trials of a gel form of modified hyaluronic acid, a naturally occurring glycosaminoglycan, show evidence for reducing de novo adhesion formation.34 Intergel (Gynecare, Johnson & Johnson Inc., Somerville, NJ) is commercially available for open surgery use.
The ideal barrier material should be easy to apply, both in open and laparoscopic surgeries. Additionally, it should be nonreactive, persist during the critical wound reepithelization period, stay in place on the target tissue for several days, and eventually be resorbed following peritoneal healing
A new product, currently undergoing clinical trials, SprayGel (Confluent Surgical, Waltham, MA), meets these criteria. SprayGel is composed of two liquids which are polyethylene glycol (PEG)-based. PEG is widely used in a variety of medical products. When these two liquids are applied while mixing them in situ, they polymerize within seconds to form a visible, adherent, and conforming hydrogel barrier on the target tissues. The gel remains intact for the next 5 to 7 days before breaking down by hydrolysis, and eventual clearance through the kidneys. Preclinical safety studies of SprayGel adhesion barrier demonstrate that it is a remarkably inert, biocompatible material, resulting in no signs of toxicity at multiple time points, even when tested at 25 times the anticipated normal dose. Clinical studies in Europe and the US further support the safety profile of this material as an implant. Preliminary prospective randomized clinical trials have evaluated SprayGel adhesion barrier in open and laparoscopic myomectomy surgery, as well as in laparoscopic ovarian surgery. In the European myomectomy study, a significant improvement was demonstrated in the tenacity of adhesions between the treated and control populations, when comparing the initial procedures and second-look laparoscopies, as evaluated by the surgeon. The product is currently under review in a multicenter pivotal clinical trial in the US.
CONCLUSION
Adhesion formation after gynecologic surgery is common. When compared to laparotomy, laparoscopy has been shown to result in less de novo adhesion formation, but adhesion reformation continues to be a problem.35 Sequelae of intra-abdominal adhesion formation can be fatal, result in infertility, and be a source of chronic pelvic pain. Minimally invasive surgical management of adhesion formation affords the patient all of the known benefits of laparoscopic surgery including less postoperative analgesics, shorter hospital stays, and more rapid convalescence and return to normal activities. Unfortunately, recurrence rates after adhesiolysis for intestinal obstruction are reported to range from 8%36 to 32%37. Thus, for some patients, adhesiolysis may become a repeat surgical procedure.
No longer can the surgeon ignore the benefits of minimally invasive surgery for adhesiolysis. While these techniques and procedures are not without risk, patients should not be denied their inherent advantages. Astute clinicians must work together to discern the most appropriate uses for this therapy
REFERENCES
1. Ellis H: The Clinical Significance of Adhesions: Focus on Intestinal Obstruction. Eur J Surg 1997; Suppl 577:5-9]
2. Bryant T. Clinical lectures on intestinal obstruction. Med Tim Gaz 1872;1:363-5.
3. Welch JP. Adhesions. In: Welch JP, ed. Bowel obstruction. Philadelphia: WB Saunders, 1990:154-65.
4. Kligman I, Drachenberg C, Papdimitriou J, et al. Immunohistochemical demonstration of nerve fibers in pelvic adhesions. Obstet Gynecol 1993;82:566-568.
5. Kresch AJ, Seifer DB, Sachs LB, et al. Laparoscopy in 100 women with chronic pelvic pain. Obstet Gynecol 1984; 64:672-674.
6. Steege JF, Stout AL. Resolution of chronic pelvic pain after laparoscopic lysis of adhesions. Am J Obstet Gynecol 1991;165:278-81.
7. Chan CL, Wood C. Pelvic adhesiolysis: The assessment of symptom relief by 100 patients. Aust NZ Obstet Gynaecol 1985;25:295-298.
8. Daniell JF. Laparoscopic enterolysis for chronic abdominal pain. J Gynecol Surg 1990;5:61-66.
9. Sutton C, MacDonald R. Laser laparoscopic adhesiolysis. J Gynecol Surg 1990;6:155-159.
10. Peters A, Trimbos-Kemper G, Admiraal C et al. A randomized clinical trial on the benefit of adhesiolysis in patient with intraperitoneal adhesions and pelvic pain. Br J Obstet Gynaecol 1992;99:59-62.
11. Fox Ray N, Denton WG, Thamer M, Henderson SC, Perry S. Abdominal Adhesiolysis: Inpatient Care and Expenditures in the United States in 1994. J Am Coll Surg 1998;186(1):1-9.
12. DiZerega GS. Contemporary adhesion prevention. Fertil Steril 1994;61(2):219-235.
13. Odell R. Principles of Electrosurgery. In Sivak M, ed. Gastroenterologic Endoscopy. New
York: W.B. Saunders Company, 1987:128.
14. Reich H, Vancaillie T, Soderstrom R. Electrical Techniques. Operative Laparoscopy. In Martin DC, Holtz GL, Levinson CJ, Soderstrom RM, eds. Manual of Endoscopy. Santa Fe Springs: American Association of Gynecologic Laparoscopists, 1990:105
15. Reich H, McGlynn F. Laparoscopic oophorectomy and salpingo-oophorectomy in the treatment of benign tuboovarian disease. J Reprod Med 1986;31:609.
16. Reich H. Laparoscopic oophorectomy and salpingo-oophorectomy in the treatment of benign tubo-ovarian disease. Int J Fertil 1987;32:233.
17. Reich H, McGlynn F. Laparoscopic treatment of tubo- ovarian and pelvic abscess. J Reprod Med 1987;32:747.
18. Henry-Suchet J, Soler A, Lofferdo V. Laparoscopic treatment of tubo-ovarian abscesses. J Reprod Med 1984;29: 579.
19. Reich H. Endoscopic management of tuboovarian abscess and pelvic inflammatory disease. In Sanfilippo JS and Levine RL, eds. Operative Gynecologic Endoscopy. New York: Springer- Verlag, 1989:118.
20. Reich H. Laparoscopic bowel injury. Surg Laparosc Endosc 1992;2:74.
21. Palmer R. Safety in laparoscopy. J Reprod Med 1974;13:1-5.
22. Fu-Hsing Chang, Hung-Hsueh Chou, Chyi-Long Lee, et al. Extraumbilical Insertion of the Operative Laparoscope in Patients With Extensive Intraabdominal Adhesions. J Amer Assoc Gynecol Laparosc 1995;2(3):335-337.
23. Pasic R, Wolfe WM. Transuterine insertion of Verres needle. N Z Med J 1994;107(987):411.
24. Reich H, McGlynn F, Salvat J. Laparoscopic treatment of cul-de-sac obliteration secondary to retrocervical deep fibrotic endometriosis. J Reprod Med 1991;36:516.
25. Peacock LM and Rock JA. Distal Tubal Reconstructive Surgery. In Sanfilippo J ed. Operative Gynecologic Endoscopy. New York: Springer, 1996:182-191.
26. Reich H. Laparoscopic treatment of extensive pelvic adhesions including hydrosalpinx. J Reprod Med 1987;32:736.
27. McComb PF, Paleologou A. The intussusception salpingostomy technique for the therapy of distal oviductal occlusion at laparoscopy. Obstet Gynecol 1991;78:443.
28. Reich H. New techniques in advanced laparoscopic surgery. In Sutton C, ed. Laparoscopic Surgery. Bailliere’s Clinical Obstetrics and Gynaecology. London: WB Saunders, 1989:6551.
29. Singhal V, Li T, Cooke I. An analysis of the factors influencing the outcome of 232 consecutive tubal microsurgery cases. Br J Obstet Gynaecol 1991;98:628-36.
30. Winston R, Margara R. Microsurgical salpingostomy is not an obsolete procedure. Br J Obstet Gynaecol 1991; 98:637-42.
31. Watson A, Vandekerckhove P, Lilford R. Liquid and fluid agents for preventing adhesions after surgery for subfertility. Cochrane Database of Systematic Reviews. Issue 4, 2000.
32. Farquhar C, Vandekerckhove P, Watson A, Vail A, Wiseman D. Barrier agents for preventing adhesions after surgery for subfertility. Cochrane Database of Systematic Reviews. Issue 4, 2000.
33. Diamond MP, Linsky CB, Cunningham TC, et al. Synergistic effects of Interceed (TC7) and heparin in reducing adhesion formation in the rabbit uterine horn model. Fertil Steril 1991;55:389-94.
34. Burns JW, Skinner K, Yu LP, et al. An injectable biodegradable gel for the prevention of postsurgical adhesions: Evaluation in two animal models. In Proceedings of the 50th Annual Meeting of the American Fertility Society, San Antonio, Texas, November 5-10, 1994.
35. Operative Laparoscopy Study Group. Postoperative adhesion development after operative laparoscopy: evaluation at early second look procedures. Fertil Steril 1991;55:700-4.
36. Close MB, Chistensen NM. Transmesenteric small bowel plication or intraluminal tube stenting. Am J Surg 1979;138:89-91.
37. Brightwell NL, McFee AS, Aust JB. Bowel obstruction and the long tube stent. Arch Surg 1977;112:505-511.
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