Adhesion reformation after laparoscopic adhesiolysis: where, what type, and in whom they are most likely to recur

Abstract

Study objective: To assess if the severity or extent of adhesions, the organs involved, or presence of endometriosis predict recurrence or de novo adhesion formation.

Design: Comparison of adhesion scores at initial operative laparoscopy and at second-look laparoscopy using the revised American Fertility Society adhesion classification system (Canadian Task Force classification I).

Setting: A university-affiliated reproductive endocrinology and infertility center.

Patients: In all, 38 women with moderate to severe adhesions who underwent laparoscopic adhesiolysis and second-look laparoscopy.

Interventions: Adhesion scores were assessed at 6 sites in the peritoneal cavity before initial laparoscopic adhesiolysis and compared with adhesion scores at second-look laparoscopy. Adhesions were evaluated by extent, severity, organ involvement, and presence or absence of endometriosis to evaluate potential determinants of recurrence and de novo adhesion formation. All adhesions were totally removed at initial laparoscopy, all patients received 1000 mL of Ringer's lactate solution intraperitoneally at the end of procedures, and the same surgeon treated all patients.

Measurements and main results: Adhesion scores decreased in extent [23.3% (p = .005)] and severity [26.3% (p = .001)]. Dense adhesions decreased 31% (p < .000) and filmy adhesions decreased 35% (p = .048). Extent of adhesions assessed at less than one-third, one-third to two-thirds, and more than two-thirds decreased by 33% (p = .002), 42% (p = .000), and 31% (p < .000), respectively. Severity and extent of adhesions of abdominal wall decreased by 45% (p = .003) and 40% (p = .016); of bowel by 33% (p = .002) and 31% (p = .012); and of posterior cul-de-sac by 14% (p = .040) and 9.5% (p = .091), respectively. Severity and extent of adhesions involving both adnexa decreased by 12% to 15%, respectively, which was not statistically significant. Presence of endometriosis did not affect adhesion recurrence. De novo adhesions developed at 48 (21%) of 228 potential sites occurring in 22 of 38 patients, and were most frequent and severe on the adnexa and least on the abdominal wall.

Conclusion: Both extent and severity of adhesions are significantly reduced by laparoscopic adhesiolysis. Initial extent and severity of adhesions did not predict recurrence; however, the involved organ did, being most frequent on the adnexa and least frequent on the abdominal wall and bowel.