Philippe R. Koninckx

Role of the peritoneal cavity in the prevention of postoperative adhesions, pain, and fatigue.

A surgical trauma results within minutes in exudation, platelets, and fibrin deposition. Within hours, the denuded area is covered by tissue repair cells/macrophages, starting a cascade of events. Epithelial repair starts on day 1 and is terminated by day 3. If repair is delayed by decreased fibrinolysis, local inflammation, or factors in peritoneal fluid, fibroblast growth starting on day 3 and angiogenesis starting on day 5 results in adhesion formation. For adhesion formation, quantitatively more important are factors released into the peritoneal fluid after retraction of the fragile mesothelial cells and acute inflammation of the entire peritoneal cavity. This is caused by mechanical trauma, hypoxia (e.g., CO2 pneumoperitoneum), reactive oxygen species (ROS; e.g., open surgery), desiccation, or presence of blood, and this is more severe at higher temperatures. The inflammation at trauma sites is delayed by necrotic tissue, resorbable sutures, vascularization damage, and oxidative stress. Prevention of adhesion formation therefore consists of the prevention of acute inflammation in the peritoneal cavity by means of gentle tissue handling, the addition of more than 5% N2O to the CO2 pneumoperitoneum, cooling the abdomen to 30°C, prevention of desiccation, a short duration of surgery, and, at the end of surgery, meticulous hemostasis, thorough lavage, application of a barrier to injury sites, and administration of dexamethasone. With this combined therapy, nearly adhesion-free surgery can be performed today. Conditioning alone results in some 85% adhesion prevention, barriers alone in 40%-50%.

Introduction: Quality of pelvic surgery and postoperative adhesions

The health care and the emotional cost of postoperative adhesions that frequently cause chronic pain, infertility, bowel obstruction, and repeat surgery are well known. Our understanding of the pathophysiology of adhesion formation and of its prevention has evolved from good surgical practice based on microsurgical principles, barriers to keep denuded areas separated to the prevention of mesothelial cell damage and of acute inflammation in the entire peritoneal cavity. Oxidative stress, in the surgical lesions and in the peritoneal cavity has an important role in adhesion formation by slowing down repair. This has resulted in virtually adhesion-free surgery, in addition with less CO2 resorption, less postoperative pain, and a faster recovery. The clinical efficacy had been demonstrated by higher pregnancy rates (PRs) using microsurgical tenets.

Evidence-Based Medicine in Endometriosis Surgery: Double-Blind Randomized Controlled Trial Versus the Consensus Opinion of Experts

Medicine used to be an empirical set of methods and nonempirical principles acquired by observation and research to prevent, diagnose, and treat or palliate the disease and help the patient. Medicine is considered an art because the interpretation of complaints and symptoms and the choice of treatment require special skills and individualization. The state of the art progressively evolves and improves by trial and error guided by the available scientific and observational knowledge. This knowledge is shared freely. Research has progressively added knowledge and evidence. We tend to forget that available proven evidence constitutes only a small part of decision-making and of selecting medical treatment or surgery in daily practice. Taking hysterectomy as an example, let us consider all the variables that occur: determining the indication for surgery, selection of the surgical access route and technique, selection of sutures and energy, and the many other parameters that vary within the operating theater environment and with the skill and experience of the surgeon. This plethora of variables and the absence of unanimous agreement on many aspects of this process highlight the problem. Nevertheless, in the absence of concrete evidence, the surgeon must use the available knowledge and make decisions based on experience, the practice of the institution, and the regulations of the jurisdiction in which he or she works. Knowledge of anatomy and understanding the mechanisms involved, as established by research, guides the progressive development of surgery and of the choices involved. Most have become basic surgical principles: preservation of anatomy and function, use of proper dissection planes, and meticulous hemostasis and nerve sparing. The latter was empirically introduced in oncologic surgery; however, it is only over the last decade that we began to understand the anatomy of the pelvic nerves and started to incorporate nerve sparing into reproductive and endometriosis surgery. As surgeons, we almost