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.
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.


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