Adding laparoscopy to experimental adhesion study protocols

So why worry about intraabdominal adhesions anyway? If you talk to a general surgeon, there are only three reasons: 1) they might cause a bowel obstruction with or without strangulation; 2) they might result in fistulation, especially when associated with a foreign body; and 3) because they interfere with the performance of elective operations for other indications. The gynecologist will also tell you that infertility and chronic pain can be caused by adhesions. There may be some truth to the latter but many general surgeons maintain a degree of skepticism. The point is that intraabdominal adhesions are responsible for significant morbidity and even mortality. Intraabdominal adhesions are caused by a variety of factors, including mechanical trauma, thermal injury, tissue ischemia and pertinent to this month’s article by Baptista and associates, foreign bodies. Foreign bodies are by far the most common if one includes talc or starch from gloves, sutures, cotton lint, filaments from dressings, products of gastrointestinal tract perforation, and of course, prosthetic materials. The direct clinical relevance of the article by Dr Baptista and associates from the University of Minnesota concerns adhesions as they relate to a polypropylene prosthesis placed intraabdominally in contact with intraabdominal viscera. But all of the causes and clinical presentations relating to adhesions are affected because the ultimate goal of any effort to study adhesions is to prevent them. Although the authors state in their article that the most serious complication of adhesion is “fistulization,” it seems to me that because of its frequency, bowel obstruction secondary to adhesions has to be considered the more clinically relevant. This is important because the difficulty in finding a solution to abdominal adhesion formation is compounded by the fact that it must be “all or none” if the problem of bowel obstruction secondary to them is to be resolved. We know that a solitary adhesion is more likely to result in an internal volvulus or an obstructing band than matted adhesions that keep the bowel fixed. Prophylactic treatments for adhesions that merely decrease them rather than totally eliminate them could drive the incidence of bowel obstruction higher. The high viscosity instillates such as dextran 40 or 70, the mechanical barriers like Interceed oxidized cellulose barrier (Johnson & Johnson Medical, Arlington, TX), bioresorbable films made of various polyethylene glycol and polylactic acid block copolymers, or the latest player on the block sodium hyaluronate carboxymethylcellulose-based bioresorbable membrane (Seprafilm; Genzyme, Cambridge, MA) are limited. Pharmacologic approaches using calcium channel antagonists, heparin, tissue plasma activator, steroids, or nonsteroidal antiinflammatory agents also do not address the all-or-none issue. Not only is the problem of adhesions clinically challenging but it is also a difficult entity to examine in the laboratory. This is because of the significant variation in adhesion formation from species to species and even among members of the same species. To be sure, some general observations can be made. For example, dogs are more tenacious adhesion formers than pigs. But the identical noxious peritoneal insult will not result in a predictable quantity of adhesion within either animal group. As for humans, surgeons have long been fascinated by