Learning Objectives and CME/Disclosure Information

This activity is intended for healthcare providers delivering care to women and their families.

After completing this activity, the participant should be better able to:

1. Discuss the key features of optimal microsurgical technique
2. Describe ASRM’s evidence-based findings regarding reduction of postsurgical adhesions

Estimated time to complete activity: 0.25 hours

Faculty:

Susan J. Gross, MD, FRCSC, FACOG, FACMG
President and CEO, The ObG Project

Disclosure of Conflicts of Interest

Postgraduate Institute for Medicine (PIM) requires instructors, planners, managers and other individuals who are in a position to control the content of this activity to disclose any real or apparent conflict of interest (COI) they may have as related to the content of this activity. All identified COI are thoroughly vetted and resolved according to PIM policy. PIM is committed to providing its learners with high quality CME activities and related materials that promote improvements or quality in healthcare and not a specific proprietary business interest of a commercial interest.

Faculty: Susan J. Gross, MD, receives consulting fees from Sema4, and has financial interest in The ObG Project, Inc.

Planners and Managers: The PIM planners and managers, Trace Hutchison, PharmD, Samantha Mattiucci, PharmD, CHCP, Judi Smelker-Mitchek, MBA, MSN, RN, and Jan Schultz, MSN, RN, CHCP have nothing to disclose.

Method of Participation and Request for Credit

Fees for participating and receiving CME credit for this activity are as posted on The ObG Project website. During the period from 1/15/2020 through 1/15/2021, participants must read the learning objectives and faculty disclosures and study the educational activity.

If you wish to receive acknowledgment for completing this activity, please complete the post-test and evaluation. Upon registering and successfully completing the post-test with a score of 100% and the activity evaluation, your certificate will be made available immediately.

For Pharmacists: Upon successfully completing the post-test with a score of 100% and the activity evaluation form, transcript information will be sent to the NABP CPE Monitor Service within 4 weeks.

Joint Accreditation Statement

In support of improving patient care, this activity has been planned and implemented by the Postgraduate Institute for Medicine and The ObG Project. Postgraduate Institute for Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team.

Physician Continuing Medical Education

Postgraduate Institute for Medicine designates this enduring material for a maximum of 0.25 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Continuing Nursing Education

The maximum number of hours awarded for this Continuing Nursing Education activity is 0.2 contact hours.

Designated for 0.1 contact hours of pharmacotherapy credit for Advance Practice Registered Nurses.

Read Disclaimer & Fine Print

SUMMARY:

Postoperative adhesions are associated with significant adverse outcomes including infertility and bowel obstruction. ASRM, based on evidence review, found that

• Microsurgical technique remains integral for reducing adhesion risk
• No evidence was found for anti-inflammatory agents
• Insufficient evidence for peritoneal instillation of icodextrin
• No evidence for lysis of adhesions to improve pain, treat infertility or reduce bowel obstruction
• “No substantial evidence that the use of FDA approved anti-adhesion barriers improves fertility, decreases pain, or reduces the incidence of postoperative bowel obstruction”

Surgical Technique – Microsurgical Principles

• Benefits of minimally invasive surgery include reduction in
  • Tissue injury | Organ handling/trauma | Exposure to foreign bodies (sponges, surgical gloves) | Infection risk
• Good surgical technique (laparotomy or laparoscopy) includes
  • Gentle tissue handling | Minimizing residual blood and serosanguinous fluid | Length/size of incisions | Removal of necrotic tissue | Nonreactive sutures | Sterile technique

Evidence for Other Adhesion Reducing Options

• Systemic anti-inflammatories
  • Currently, there is no evidence to support the use of anti-inflammatory agents such as steroids for adhesion reduction  
• Peritoneal instillation for hydroflotation  
  • 32% dextran 70 or crystalloid solutions used to detach surgical layers and adjacent structures
    • Currently, no evidence to support the use of this technique, either alone or with additives (e.g., corticosteroids or heparin) for adhesion reduction
  • Icodextrin 4% solution
    • Osmotic agent that draws fluid in to the peritoneum for a few days post-surgery
    • While approved by the FDA, ASRM cites a systematic review that “concluded that there is insufficient evidence for its use as an adhesion preventing agent”  
• Surgical Adhesion Barriers
  • Modifed sodium hyaluronic acid (HA) and carboxymethyl cellulose (CMC) approved by FDA for laparotomy
    • ASRM cites systematic reviews and clinical trials that found “limited evidence for its effectiveness for preventing adhesion formation after myomectomy” and “no overall difference in the incidence of postoperative small-bowel obstruction”
  • Oxidized regenerated cellulose approved by FDA for laparotomy
    • Absorbs within 2 weeks after application
    • ASRM does cite RCTs that demonstrate reduction in new and recurrent adhesions (50 to 60%) for both laparotomy and laparoscopy
    • Limited evidence that this product “improves fertility, decreases pain or bowel obstruction”

KEY POINTS:

• Despite use of good technique, adhesions are “a natural consequence of tissue trauma and healing”
• Some procedures are known to be more closely associated with adhesion formation (e.g., myomectomy), regardless of optimal technique
  • Following laparotomy: 90%
  • Following laparoscopy: 70%
• Closure of parietal peritoneum at time of laparotomy
  • May be of benefit: 22% vs 16% with closure
  • Ovarian cancer: Increased adhesions with closure
  • Cesarean section: Less adhesions
• Adhesiolysis for chronic abdominal and pelvic pain
  • ASRM considers the association between postoperative adhesions and chronic abdominal/pelvic pain to be “unclear”
  • Extent of adhesions and pain are not well correlated
  • Adhesiolysis may be beneficial in the setting of dense adhesions
  • ASRM cites a blinded RCT (Swank et al., Lancet 2003) that demonstrated improvement in chronic abdominal pain following laparoscopy, whether or not  adhesiolysis was performed, with no statistical difference between groups  

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Learn More – Primary Sources:

Postoperative adhesions in gynecologic surgery: a committee opinion

Laparoscopic adhesiolysis in patients with chronic abdominal pain: a blinded randomised controlled multi-centre trial

Related ObG Topics:

Ongoing Pelvic / Lower Abdominal Pain and a Negative Work-Up: What Next?

FDA bans the use of powdered surgical gloves

Infertility Evaluation: Who, When and How