Page 164 - Postoperative Intra-Abdominal Adhesions- New insights in prevention and consequences
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                                Chapter 10
cellulose (PVC/CMC) gel was tested in different circumstances. This resulted in a prospective, controlled, randomized, monocentre phase I–II study [8]. Sixty-two patients either received the PVC/CMC gel or were untreated after elective midline laparotomy. In addition to the assessment of the safety of the gel, peritoneal adhesions along the scar were examined using an ultrasound technique [9]. Although this study showed that the PVC/CMC gel is safe for application, the data did not indicate an adhesion prevention effect. The authors suggested that this might be due to the limitations of the sample size as well as application gaps of the gel coverage along the abdominal wall incisions. The latter refers to some of the characteristics a barrier should have as described in Chapter 2 on page 21: it should effectively and reliably cover the entire damaged peritoneum during the period of wound healing. In gynaecology, some barriers are used and have been proven to be effective, but compared to the gastrointestinal surgeon, the gynaecologist has the advantage that the location of adhesion prevention is limited to the pelvis and in general no bowel anastomoses are made [10, 11]. Especially concerning adhesive small bowel obstruction, it is impossible to predict the possible location of the obstructive adhesion. Consequently, peritoneal lavage with a fluid barrier seems to be the most logical option. However, the only available fluid on the market (Adept) failed to reduce de novo adhesion in a randomized controlled trial [12]. Further research should ideally lead to a fluid barrier that can safely be used in the presence of infection or a bowel anastomosis.
Mesh and adhesions
As mentioned earlier, the best treatment of postoperative adhesions is prevention. For this reason, intraperitoneal positioning of a mesh should be avoided if possible. During laparoscopic hernia repair in most cases this is inevitable, emphasizing the importance of a critical view on the indications for this specific technique. In a recent study, five hernia experts answered questions about real-life clinical abdominal hernia cases [13]. Agreement in technique (open versus laparoscopic) and in mesh position (onlay, sublay, or intraperitoneal) was found in only 40% of cases. This indicates that in most cases there is more than one defendable option depending on which arguments are prioritized.
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