Pelvic adhesion: A challenge of all gynecologic surgeries

摘要

Adhesions, characterized by fibrin deposition leading to fibrous tissue connections (adherence tissues) between various tissue planes or organs, as part of internal healing process and inflammatory reactions passing through the different but overlapping phases (hemostasis/inflammatory phase, proliferative phase, and remodeling phase), are usually the defense mechanisms against the various causes of inflammation (physical, chemical, infections, etc.), resulting in unfavorable consequences, such as chronic pain, obstruction (especially bowel), function impairment, and infertility.1–4 Intra-abdominal and pelvic adhesion are by far the most common of all adhesions, which are mainly caused by various kinds of surgeries and less by previous severe infection or inflammatory reactions.5–7 Sometimes, adhesions-related complications need management, which is often dependent on etiology, location, and the associated symptoms or signs.1 Besides conservative treatment, surgical lysing procedures, called as adhesiolysis sometimes cannot be totally avoided in these subjects with adhesion, since either emergency, such as intestinal obstruction complicated by adhesions or the other indications for further surgery, such as recurrent uterine myomas, adenomyosis, chocolate cysts, or others may occur. Minimally invasive procedures, such as hysteroscopic, laparoscopic, and robotic approaches, are very popular in the management of subjects with various indications for surgeries,5,8,9 and additionally, these approaches are also reported as the preferred options for adhesiolysis.1,10 However, it is believed in long term that history of any of myomectomy, cystectomy, electrofulguration for endometriosis, appendectomy, or bowel surgery is considered as a “contraindication” for laparoscopic surgeries,11 although this hypothesis is worthy of being tested. In the current issue of the Journal of the Chinese Medical Association, we are happy to learn that Dr. Wang and colleagues attempted to clarify the possibility to use a robotic approach to perform total hysterectomy in patients with intra-abdominal adhesions.12 The authors enrolled 410 women with uterine myoma/adenomyosis undergoing robotic total hytserectomy.12 The authors found that surgical difficulty was really present in the subjects with adhesions because more patients with higher severity needed assistant port usage, and a surgeon needed the longer time to perform uterine artery ligation procedure.12 Subgroup analysis, based on the adhesion severity either by scoring system, or adhesion location sites showed that much severe adhesion was positively correlated with much complicated surgery, since these patients with higher percentage needed additional assistance port use, and surgeons needed more time to finish docking and finish certain types of surgeries, such as uterine artery ligation. Although the current study did not add any new information or offer understanding of adhesion, this article is still worthy of our further discussion. First, the current study confirmed the feasibility of minimally invasive surgery in the patients with adhesions. One systematic review enrolling 14 comparative studies on 38 057 patients to evaluate the surgical outcomes in patients with adhesional small bowel obstruction undergoing laparoscopic and exploratory laparotomic adhesiolysis, and the results showed laparoscopic approach took a significant advantage compared to exploratory laparotomic approach, including the reduced risk of hospital stay (standard mean difference [SMS] −0.44, 95% confidence interval [CI] −1.0 to −0.27), mortality (odds ratio [OR] 0.31, 95% CI 0.23–0.42), overall postoperative complications (OR 0.38, 95% CI 0.29–0.48), incidence of bowel resection (OR 0.39, 95% CI 0.20–0.75), incidence of surgical site infection (OR 0.29, 95% CI 0.13–0.65), postoperative respiratory complications (OR 0.22, 95% CI 0.17–0.30), postoperative cardiac complication (OR 0.42, 95% CI 0.26–0.69), as well as postope