Page 163 - Postoperative Intra-Abdominal Adhesions- New insights in prevention and consequences

Future Perspectives
Adhesion prevention
Every surgeon will admit that the consequences of postoperative adhesions can be enormous. For example, small bowel obstruction and difficulties at re-operation are two problems caused by adhesions encountered on a daily basis. In addition, although it is out of the scope of the general surgeon, infertility after earlier operations has a major impact for female patients. As described in Chapter 2, a tremendous amount of research has been performed to understand the pathophysiology and consequences of postoperative adhesion formation. However, as with all other diseases, the key to success lies in prevention. This can be approached through two main strategies: accurate surgical technique to minimize surgical trauma and the use of adjuvants, whether pharmacological or as a solid barrier [1, 2]. One of the most efficient ways to minimize surgical trauma is the use of laparoscopy. Although some studies did not demonstrate a difference in the formation of adhesions between open and laparoscopic surgery, in general it has been shown that adhesion formation is less pronounced after laparoscopic surgery [3-6]. This is confirmed by a recent prospective study including 150 second-look procedures [7]. Patients with large T4 or intra-abdominally perforated colon cancer were randomized for systemic and HIPEC therapy versus systemic therapy alone. Routine diagnostic laparoscopy was performed at 18 months in all patients, facilitating a second look after the same time interval in all patients. The results will be published in 2019, demonstrating that the extent (53.5% versus 91.2%, p < 0.001) as well as the severity (Zühlke score; 2.2 versus 2.77, p = 0.011) of adhesion formation is significantly reduced after laparoscopy. Therefore, it can be concluded that minimally invasive surgery is currently the best option to reduce the formation of adhesions and consequently laparoscopy should be promoted worldwide.
When laparoscopy is not possible or during re-do surgery, the use of a physical antiadhesive barrier has great potential, but none of the available ones are commonly used in general surgery. In the experiments as described in Chapters 3–5, a new polyvinyl chloride/carboxymethyl
10
Future perspectives
161