Hilgers, T. W. (2010). Near Adhesion-Free Reconstructive Pelvic Surgery: Three Distinct Phases of Progress Over 23 Years. Journal of gynecologic surgery, 26(1), 31-40. https://doi.org/10.1089/gyn.2009.0031
Hilgers TW. Near Adhesion-Free Reconstructive Pelvic Surgery: Three Distinct Phases of Progress Over 23 Years. Journal of Gynecologic Surgery. 2010;26(1):31-40. doi:10.1089/gyn.2009.0031
Hilgers, Thomas W. "Near Adhesion-Free Reconstructive Pelvic Surgery: Three Distinct Phases of Progress Over 23 Years." Journal of gynecologic surgery, vol. 26, no. 1, 2010, pp. 31-40.
Pelvic adhesion scores fell across three surgical phases in 95 women
Adhesion scores measured at a second look fell across three sequential surgical protocols in a case series of 95 women. All had severe pelvic adhesions from endometriosis or pelvic infection. The third phase, with the most added steps, had the lowest average score, 2.5.
Key Findings
95 women with extensive pelvic adhesions took part: 26 in the first phase (1987–1993), 44 in the second (1994–2005) and 25 in the third (2006–2009).
Total adhesion scores at second-look laparoscopy were 18.1 in the first phase (95% CL 10.7–25.4), 6.0 in the second (4.4–7.6) and 2.5 in the third (1.2–3.7).
Scores before surgery did not differ statistically between phases. Each fall within a phase, from before surgery to second look, was statistically significant (P < 0.001).
Second-look scores were lower in each later phase: first to second, second to third and first to third each differed at P < 0.01.
A second-look score of 5 or less, consistent with minimal adhesions, occurred in 9 of 26 women (34.6%), 23 of 44 (52.3%) and 22 of 25 (88.0%) across the three phases.
Interpretation
This case series followed three surgical phases at one center over 23 years. Each later phase added steps to a standard surgery for pelvic adhesions. Scores were checked at a second-look surgery. The findings support larger studies of this stepwise approach.
RRM Context
The paper places its surgery within NaProTechnology, an approach that looks for the underlying causes of infertility and pelvic pain. Its introduction lists reduced fertility, chronic pelvic pain and difficult repeat surgery among the results of adhesions. The paper describes pelvic surgery as prone to forming new adhesions, which is the risk the score here tracks.
Our editorial summary of this paper, not the article's abstract.
Abstract
Background
A somewhat pessimistic view on the prevention of postsurgical adhesions has developed over the years because rigorous surgical approaches may still result in the formation of postsurgical adhesions. In addition, postsurgical adhesion formation is associated with a significant degree of long-term morbidity. In this article, a surgical technique is presented which allows patients with the most extensive form of pelvic adhesions to undergo reconstructive pelvic surgery with a near–adhesion-free postoperative outcome.
Purpose
This study was undertaken to assess the effectiveness of a comprehensive, well-defined set of surgical techniques, with well-defined additions and subtractions in surgical technique over a period of 23 years and three distinct phases of implementation. This work was a systematic comparison of three case-series evaluated sequentially over time. The three surgical protocols were each completely standardized.
Materials and Methods
This was a systematic comparison of three distinct case series of patients who had extensive pelvic adhesions. Three distinct and standardized surgical protocols were prospectively introduced and adhesion scores before and after surgical treatment were assessed and statistically compared for each of the three case series.
Results
Ninety-five (95) patients with extensive pelvic adhesive disease due to endometriosis or pelvic inflammatory disease participated in this assessment. They were chosen because of the extensive nature of their pelvic and adnexal adhesions. There were 26 patients in phase I (1987–1993), 44 patients in phase II (1994–2005), and 25 patients in phase III (2006–2009). Using the American Fertility Society scoring system for adnexal adhesions, the total adhesion score decreased from 33.8 to 18.1 in phase I, from 33.3 to 6.0 in phase II, and from 33.2 to 2.5 in phase III. Each decrease was statistically significant within each phase (P < 0.001). Further, a statistically significant decrease in subsequent adhesion scores (P < 0.01) was observed at the time of second-look laparoscopy, when comparing phases I to II, II to III, and I to III, with the lowest scores obtained with the phase III surgical techniques.
Conclusions
With the use of a comprehensive, well-defined set of surgical antiadhesion techniques, it is possible to perform adhesion-free or near adhesion-free reconstructive pelvic surgery. (J GYNECOL SURG 26:31)
How fertility-preserving surgery differs by approach: restorative (RRM), specialist, and conventional, across endometriosis, ovarian cysts, PMOS / PCOS, fibroids, tubal disease, Asherman's syndrome, adenomyosis, cesarean scar, pelvic adhesions, and male-factor causes including varicocele and obstruction.
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