Laparoscopic access in treatment of reproductive system diseases in women with multiple adhesions

INTRODUCTION

Recent achievements in abdominal surgery and operative gynecology have led to a significant increase in the number of patients with postoperative abdominal adhesions [1]. The development of abdominal adhesions occurs in 67–95% of cases after general abdominal surgery and up to 97% after gynecological surgery with laparotomy access [2][3]. According to research studies, 63% of the laparotomy access length is involved in the formation of anterior abdominal wall adhesion of the omentum and intestinal loops [4][5].

According to the International Adhesion Society experts, postoperative adhesions in the abdominal cavity are the most common complication, posing a serious health problem for patients and significantly reducing their quality of life. The most significant consequences of adhesions involve intestinal obstruction (32–85%), female infertility (15–40%), dyspareunia and chronic abdominal pain syndrome (20–50%) [6]. The need for adhesiolysis during subsequent surgical procedures increases the operation duration by an average of 24–50 min. In addition, the risk of iatrogenic intestinal damage, bleeding, and subsequent fistula formation increases, thus lengthening the recovery time. Moreover, repeated laparotomy and adhesiolysis can only worsen the adhesion formation [2][7–9][10]. At the same time, according to some authors, laparoscopic adhesiolysis decreased the risk of adhesion recurrence and secondary surgical infections (infectious septic complications, wound infection) [11][12].

Currently, the efforts aimed at preventing adhesions involve anti-adhesive barriers made of hyaluronic acid and carboxycellulose, thorough hemostasis during surgery, and delicate tissue handling [2][13–15].

Most publications on the characteristics of adhesions in the abdominal cavity address the features of diagnosis, treatment methods, and analysis of complications of intestinal adhesive obstruction that occur after surgical interventions on abdominal organs [16–18].

Despite the current progress in minimally invasive technologies that have made it possible to minimize the traumatic nature of surgical interventions, the use of modern multimodal postoperative rehabilitation programs and a variety of means and methods aimed at preventing the adhesive process, the results of therapeutic and preventive measures cannot be considered sufficient [6][19]. The issue of pelvic and abdominal adhesions resulting from surgical interventions on the female reproductive system requires research attention due to its decisive importance for selecting treatment tactics and surgical access.

To date, standardized diagnostic criteria and recommendations for selecting surgical access when treating women with reproductive organ pathologies concomitant with a widespread adhesive process are lacking. This dictates the need to study the technological capabilities of minimally invasive surgery for its further improvement and implementation in gynecological practice.

In this study, we set out to investigate the possibility of using laparoscopic access and its outcome in the surgical treatment of women with reproductive system diseases in combination with pronounced abdominal and pelvic adhesions.

MATERIALS AND METHODS

We carried out a retrospective analysis of 265 records of patients operated at the Gynecological Department of the Novorossiysk Clinical Center for Reproductive System Diseases using laparoscopic access.

The general group included 91 women who had undergone surgery for reproductive system diseases in the setting of pronounced abdominal and pelvic adhesions (grade III–IV according to Blinnikov’s scale). The second group (control) consisted of 174 patients who had undergone surgery reproductive system diseases and had no adhesions or those with a slight degree of its severity (I–II degree according to Blinnikov’s scale). The scale is presented in Table 1.

The preoperative examination of the patients and operation planning included ultrasonography and dynamic magnetic resonance imaging (MRI) of the abdominal cavity and lesser pelvis. One of the objectives of this study was to determine the presence, localization, and prevalence of the adhesive process, the involvement of the anterior abdominal wall and intestinal loops with the purpose of selecting the safest access to the abdominal cavity (places of insertion of trocar for optics and trocar for instruments).

Abdominal ultrasonography (US) was performed in all patients. Isolated preoperative ultrasonography in obese patients was associated with technical difficulties, which resulted in an objective diagnostic error. In such cases, 16 (17.6%) patients additionally underwent dynamic MRI of the abdominal cavity and lesser pelvis. This group included women with 3–4 obesity grade.

Laparoscopic surgery was performed using a STORZ high-resolution video system (Germany), a BOWA power plant from (Germany), including high-frequency (HF) electric, laser, and argon plasma energy.

A laparoscopic access using 30° anterolateral vision optics provided more reliable information about the condition of the abdominal organs, as well as the presence, localization, and prevalence of adhesions. The volume of dissected splices was determined individually in each case.

In order to prevent damage to internal organs during the introduction of an optical trocar, taking into account ultrasonography and MRI mapping data, in 18 (19.9%) cases the trocar was installed in an open way along the midline 3–5 cm above the navel; in 9 (9.8%) cases, the optical trocar was not inserted along the classical point of the umbilical region. The Veres needle was not used to create a carboxyperitoneum. To minimize the pathological effect of carboxyperitoneum, abdominal pressure was maintained at a level of 6–8 mmHg.

A combination of various methods and tools was used to dissect the splices: an ultrasonic scalpel (BOWA, Germany), scissors, and mechanical traction. After performing adhesiolysis and gaining access to the pelvic organs, the necessary amount of surgery was performed to solve the set clinical task. To prevent the formation of adhesions in the postoperative period, great importance was given to hemostasis and sanitation of the abdominal cavity. To create an anti-adhesive barrier, an anti-adhesive preparation based on polyethylene oxide and carboxymethylcellulose was injected into the abdominal cavity. Upon the completion of the surgery, the site of the first trocar insertion was examined to ensure the absence of intestinal damage.

A comparative assessment of the results of surgical treatment was carried out by analyzing the duration of surgical treatment, the volume of blood loss, the severity of pain syndrome on the VAS scale, and the duration of hospitalization. In the postoperative period, the classical visual analog pain scale (VAS) was used to assess the pain syndrome [21][22].

Statistical data processing was carried out using the Statistica 13 and MS Office Excel software. The result was considered statistically significant at p < 0.05.

RESULTS AND DISCUSSION

According to the results obtained, The study found that benign uterine tumor processes prevailed in the general group in 34 (37.4%) cases and in the control group in 86 (49.4%) cases. Benign ovarian neoplasms were registered in 23 (25.3%) patients of the general group and 29 (16.7%) women from the control group. The relevant data is presented in Table 2.

In the general group, 81 (89%) of the patients had previously undergone various surgical procedures on the abdominal and pelvic organs. Only 10 (10.9%) women in this group had no history of any prior surgical procedures. Table 3 shows the types of surgical interventions previously performed in patients of the general group with a pronounced adhesive process. The total number of operations performed was 180, of which 123 (68.3%) were performed for gynecological pathology and 57 (31.7%) operations on abdominal organs. Previous surgical interventions in the vast majority of 149 (82.8%) cases were performed by laparotomy access. Laparoscopic access was performed only in 29 (16.1%) operations, vaginal access — in 2 (1.4%) operations.

To achieve the clinical task, the patients of the general and control groups underwent various amounts of surgery. Table 4 shows the main types of surgical treatment performed. A large proportion were radical operations, such as radical hysterectomy with appendages or fallopian tubes.

The analysis of the medical records of the patients in both groups found that no damage to the internal organs occurred during the introduction of the trocar for optics and instruments. When comparing the features of the course of surgery and the course of the postoperative period in cases of surgical treatment in patients of the general and control groups, no statistically significant differences were found (Table 5).

Thus, the average duration of surgical intervention increased by 25–40 min in the general group due to the time spent on adhesiolysis. The average volume of blood loss and the hospitalization duration did not differ significantly among the groups. In all cases of surgical intervention, the amount of surgical treatment required by the clinical situation was performed, which additionally confirms the possibility of performing the required amount of surgical intervention in the presence of pronounced adhesions in the abdominal cavity. There were no laparotomy conversions in both groups of patients.

Health promotion in both groups was carried out starting from the first day of the postoperative period; sparing nutrition was organized from the second day. In all patients, intestinal motility was restored on days 1–2.

On the first day after surgery, only 6 (6.6%) patients from the general group rated pain on a scale of 7–8 points. Moderate pain at a level of 5–6 points according to VAS was noted in 38 (41.8%), while a mild pain level of 3–4 points was noted by 42 (46.2%) women. There were no complaints of pain at all in 5 (5.4%) patients from the general observation group. By the third day, all patients had reported a pain level of 2–3 points, which made it possible to cancel the use of painkillers. Similar data were obtained in the control group.

The average duration of hospitalization stay in both groups did not differ statistically, the corresponding data are presented in Table 5. The need to perform adhesiolysis during surgery did not lead to an increase in the postoperative bed day. Significant intraoperative and postoperative complications, such as injury to adjacent organs, bleeding from damaged vessels, and purulent-septic complications in the early and late postoperative periods, were not recorded in both groups. In the general group, in one case, sigmoid colon deserosing occurred without opening the lumen. The defect was sutured laparoscopically and did not affect the course of the postoperative period. During the follow-up year, there were no cases of intestinal adhesive obstruction in both groups of patients.

To date, pronounced adhesions remain a contraindication for selecting laparoscopic access during surgical treatment. It is believed that adhesions impair visualization, increase the risk of damage to the internal organs of the abdominal cavity (intestines, large vessels, etc.), and worsen the outcome of surgical treatment in patients with diseases of the female reproductive system. In addition, the range of noninvasive preoperative diagnostic tools of adhesions is limited, not finding application in routine practice [23][24].

The development and implementation of standardized diagnostic criteria and surgical tactics for a safer surgical treatment in patients with reproductive system diseases in combination with pronounced abdominal and pelvic adhesions will make it possible to use laparoscopic technologies in larger groups of patients with reproductive system diseases [24–26].

Preoperative mapping of adhesions using ultrasonography and MRI of the abdominal cavity and lesser pelvis with a high degree of probability facilitates the selection of the safest points of trocar insertion into the abdominal cavity. The refusal to use a Veres needle and the direct introduction of the trocar into the abdominal cavity followed by the creation of a carboxyperitoneum does not increase the risk of abdominal organ damage. The use of 30° anterior-lateral vision optics significantly improves visualization in the presence of adhesions. A combination of modern instruments with various types of energy improves the quality of adhesiolysis, reduces the risk of damage to the abdominal and pelvic organs, injury to surrounding tissues, and bleeding. All of the above increases the safety of surgical intervention performed in the setting of adhesions using the laparoscopic method. The presented conclusions are consistent with the literature data [12][25–27].

The conducted comparative analysis demonstrates the possibility of using laparoscopic access for the treatment of women with reproductive system pathologies concomitant with pronounced abdominal and pelvic adhesions. Laparoscopic access in the setting of pronounced adhesions is a safe choice, which is ensured by preoperative preparation and examination of the patient, the use of necessary modern equipment and tools, the surgical skills and experience of the surgeon.

CONCLUSION

The use of laparoscopic access for performing surgical treatment in patients with reproductive system diseases in combination with pronounced adhesions can be considered as the preferred and safe method of treatment. The use of modern methods of preoperative mapping of adhesions (ultrasonography, MRI) and modern equipment contributes to improving the safety of laparoscopic methods and reducing the risk of intraoperative and postoperative complications.