Perioperative adhesion prevention in gynaecology.

Overview

The aim of the study:
An analysis of experiences with application of 100% hyaluronic acid for perioperative adhesion prevention during laparotomy and laparoscopic surgeries in reproductive gynaecology.

Material:
The study involved a sample of 39 female patients who underwent surgery between 1.2.2009 and 30.3.2009 at the Clinic of gynaecology and obstetrics, Masaryk University and Teaching Hospital in Brno, and who were administered 100% hyaluronic acid gel to the area of the lesser pelvis. There were 15 (38.5%) laparotomies and 24 (61.5%) laparoscopic surgeries. The surgery was indicated for uterine myomatosis in 13 patients (33.3%), for ovarian cysts in 13 patients (33.3%) and for lesser pelvis adhesions in 7 patients (17.9%). Six patients (15.4%) had another indication for surgery.

Methods:
A total of 10 ml of hyaluronic acid was applied at the end of surgery when the planned procedure was completed and after the bleeding at the surgery site was carefully stopped. The integrity of the gel was preserved in order to ensure that the applied layer of the gel covers the area of the operated focus and that it reaches and covers the surrounding healthy tissue. Following laparotomy surgeries, the gel was applied using thick blunt needle, after laparoscopic surgeries the gel was applied through laparoscopy port using an original application kit.

Results:
In the laparotomy surgery group, hyaluronic acid gel was applied following myomectomy (13 patients, 33.3%), endometrioma cystectomy in one patient (2.6%) and after adnexectomy for chronic post‑inflammatory ad­nexal tumour in one patient (2.6%). Ovarian cyst cystectomy was the main indication for hyaluronic acid application in the laparoscopy surgery patients; of the total of 12 surgeries (30.8%), 10 were for endometrioma (25.6%) and 2 surgeries (5.1%) were to remove dermoid cysts. The gel was applied after laparoscopic adhesiolysis of the lesser pelvis in 7 patients (17.9%), after laparoscopic salpingectomy in 3 patients (7.7%), after unilateral tubal neostomy in one patient (2.6%) and after unilateral adnexectomy in one patient (2.6%).

Discussion:
Clinical efficacy and safety of hyaluronic acid application was confirmed in a multicentre study presented at the World Congress of Gynecologic Endoscopy in Bari in 2008. The study involved 389 patients from 11 Italian centres after endoscopy surgery compared to control group without an anti‑adhesion prevention. The study showed significantly lower incidence of adhesions when hyaluronic acid was used compared to control group and no difference in the incidence of adverse events between the groups. Indications for the use of anti‑adhesion gel include the broad spectrum of pathologies of the lesser pelvis.

Conclusion:
100% hyaluronic acid gel represents a highly effective perioperative adhesion prevention in reproductive gynaecology. Application of the laparotomy and laparoscopic forms of the gel is easy and does not require special instruments. A multicentre study showed significantly lower incidence of post‑operative adhesions after the application of 100% hyaluronic acid and no difference in the incidence of adverse events compared to the control group.

Key words:
adhesions – hyaluronic acid – perioperative adhesion prevention – barriers