How can Adequate Instruments and Adhesion Prevention Support Gynecological Laparoscopic Surgery?
Background: Instruments and apparatuses are the key features that enable a skilled surgeon to perform optimal precise, good and really indicated surgical procedures without the production of inflammation, adhesions and complications.
Thanks to a good application, in our times, of common knowledge in military institutions, aviation, space technology, information technology, engineering, mathematics, biology, genetics, physiology, and medicine, wonderful instruments are available today. Of course, we have to know how to apply them. Concerning adhesions, we performed a selective PubMed/ MEDLINE search using “adhesions”, “laparoscopy”, and “prevention of adhesions” as keywords. Of all known methods, barriers appeared to be the most effective technology. In laparoscopy and hysteroscopy, the use of heated and moist gas definitely causes less adhesion. A continuous suction and irrigation at endoscopic procedures is also advisable.
Methods: Technical developments give us many choices today:
• The OR 1, Alpha Image Track
• Optics like the Endo-Eye, HDT, Endo-Cameleon
• Electronic insufflators with heated and moist gas
• Robi Instruments, articulated instruments, Kymerax
• Bipolar and thermofusion technology for haemostasis, ultrasound instruments, thunderbeat (a combination of US and thermofusion technology)
• Good needle holders, suturing skill, loops, cutting loops for subtotal hysterectomies
• Robotic and single port access
The first generation of barriers consisted of meshes like “Interceed”. Later, viscous solutions such as “Intergel” and “TISSUCOL” were propagated. In recent years, sprayable liquids as polyethylene glycols: PEG’s (SprayShield and Coseal), that polymerize to hydrogels with the addition of colorants and without colour, revealed 65-70% reduced adhesion formation.
Hydroflotation with liters of icodextrin solutions (4%) for rinsing and instillation at the end of surgery gave on the surgical site a significant adhesion reduction. HyaCorp endo gel (BioScience, Germany) is a product on hyaluronate basis that is applied by simple squeezing through an applicator. It has recently gained attraction again and appears to be effective. In second look laparoscopies is 70% reduction of adhesions could be observed (Mettler et al, MITAT, Early Online, 1-6, 2013).
Results: The exchange of knowledge in the different surgical fields as demonstrated in NESA and SLS finally enable us to perform the surgery we would like to achieve (video). As adhesion barriers, for the time being we advise a combination of local coverage of defects with some hydro flotation.
Conclusion: The surgeon and the correct instruments guarantee success. The level of evidence of the currently available products in the market is limited. However, a combination of a site-specific spray or gel together with hydroflotation, and possible assistance by an anti-inflammatory medication seems promising.