Dr. Bradley "Laparoscopic Approach to Adhesions" Chat
June 16, 1998

Drbradley Welcome all...hope to have lively session tonight.

Drbradley Mary, I really thought your suggestions re: the article were terrific.

Barbaran And what about little old me?

Drbradley We love you too!!

mary_s Thanks.

Drbradley Had a patient come infrom a year ago after an extensive adhesiolysis. I made her laugh when I said I always think about her when I see a blue chart.... that's because they screwed up the video and I had 2 hours of a blue screen. Nothing recorded.!!

mary_s Oh no!!

Barbaran laughs hysterically.

Drbradley The idea of an early second look laparoscopy is not new; the question perhaps is when to, do it.

Barbaran How do you know When to take a look?

Drbradley I have been more and more impressed with the need for early intervention as once the adhesions begin to mature, you are basically starting all over again.

Barbaran What signs and symptoms does a patient have to alert you that they may have the beginnings of adhesions?

Jean-m-s Dr Bradley - why do some people have a lot of problems with adhesions? Is there a predisposition to it?

Drbradley At the moment I favor 7 days as I have delayed 10-12 days and even in that short time frame, they become considerably more dense. Individual variability is part of all biological systems. Last week a patient related that she underwent adhesiolysis, and felt well from about 10 days and then began to feel pain again. I have had patients experience the exact same thing in the same time frame. Delay compounds the problem. The patient I am referring to last week was participating in
Dr.Wiseman's chat.

Jean-m-s I hope it is not a silly question - but can adhesions become a problem long after surgery, or do they normally form shortly after a surgical procedure.

Drbradley Laparoscopy will not solve all partial bowel obstructions, thus the need to be prepared for conventional surgery. I cannot tell you how many times I have seen patients with a long history of severe persistent crampy pain, normal xray work-up, and at laparoscopy, found the have adhesions that were lysed and rendered her pain free. Adhesions start forming almost immediately as it is part of the normal healing process to repair raw tissue. In the process unfortunately some organs/tissues become "stuck" to adjacent tissues and thus cause pain.

Jean-m-s Sounds awful.....having gone through pain with endo, I can relate to what patients must go through.

Drbradley Jean: for unclear reasons adhesions can be silent for years, and then become symptomatic.

Jean-m-s If there were bowel adhesions, for example, what would be the symptoms?

mary_s How long do adhesions keep forming after surgery? They must reach a stopping point somewhere or sometime?

Drbradley The problem is highly suspect given a history of some adhesion forming event such as preceding surgery, then a history of intermittent crampy pain, perhaps with associated episode of coincident bloating, cramps, nausea. If the adhesions are post surgical they begin forming immediately. Once all the raw surfaces are healed probably no new ones occur.

Jean-m-s Well drat! I hate to leave abruptly - hubby is finishing financial statements (corporate year end June 30) and duty calls (yes, he is a bean counter! lol).

Drbradley IMHO, laparoscopic lysis of adhesions makes sense as the fewer the new raw surfaces created the lesser the tendency for adhesions to develop. There have been articles published however that do not agree with this position.

Jean-m-s Nice to see you Dr Bradley, Barbara and Mary. We'll chat again, I know! Take care (don't melt Barbara!).

Drbradley Barb, were you an adhesion sufferer??

Barbaran No...But I had tremendous abdominal swelling post hysterectomy and had dehiscence.

mary_s Dr. B. can you explain what is actually done when you say "lysis"? Are the adhesions completely removed, portions removed or are they just snipped in the middle leaving loose ends?

Drbradley Adhesions can be excised (removed) but most often they are cut and the bound tissues/organs freed.

mary_s Do more adhesions then form on those free ends that were cut? Or do adhesions only form on raw organ tissue?

Drbradley When we attempt laparoscopic adhesiolysis we use a samll 5mm tube that allows access to the abdominal cavity. The TV camera is then attached and several other tubes(trocars) are placed to allow inspection and cutting from many different angles.

Annor What do you think of Interceed to help prevent adhesions?

Drbradley That is the problem!! When ever there is new raw tissue, adhesions can develop. Thus we hope to keep new raw surfaces to a minimum. Barriers can help reduce adhesions, but the evidence is not 100%. I am colleagues with Drs. Mark and Eric Surrey, two very noted reproductive specialists in Beverly Hills (Dr. Mark Surrey was president of the American Asssociation Of Gynecological Laparoscopists in 1997). They are not impressed as to its efficacy.

mary_s Are there certain types of surgery that seem to promote more adhesion growth? It seems like many women who have had surgery for endo have adhesion problems. I have not seen any messages from women with adhesions following a c-section.

Drbradley I think if it possible any barrier can help reduce adhesions, it is certainly worth utilizing.

Annor You agree with them?

Drbradley Any internal injured (including surgical injury) can induce adhesion formation. Endo can be particularly nasty as it can be very widespread, and it is a slow chronic condition.

Annor So, you dont use any barriers, Dr. B?

Drbradley I suppose most surgeons want a "wow" result, and no barrier can give you this. Further improper use may negate the efficacy of a barrier, and I'll bet with Interceed not every case is absolutely blood free as this will adversely effect the barrier.

Annor Ok ..... thanks for your opinion.

Drbradley Because Interceed is the only commercially available barrier for laparoscopic use, I do use it. I have also used Fibrin sealant as a barrier.

mary_s Now what is that? I don't believe we've heard Fiibrin mentioned before. Just Interceed and Seprafilm.

Drbradley My gut reaction is that early second look and lysis in the long run will prove to be very worthwhile. Fibrin is basically a blood clot without the red cells. The data is conflicting.... some studies indicate a reduction in post-surgical adhesion formation, others have suggested it does not make a difference.

mary_s So what is your recommendation to women facing surgery either by laparotomy or laparoscopy? Should they ask their dr to look via laparoscope for adhesions a week after surgery? And will most insurances cover this?

Drbradley A BIG PROBLEM. Unless the indication is for treatment of adhesions, it could be refused. IMHO, if a patient has had several operations for adhesions/pain, I would definitely consider early second look!!

Barbaran How can a patient get the insurance company to pay?

mary_s But for a woman who is having her first pelvic surgery, no need. Instead, wait to see if there are any symptoms later in life?

Drbradley In fact, as miniturization continues, it may be possible to do this in the office although I do not know to what extent one could remove any new adhesions although it usually is a simple sweep of an instrument to take them down.

mary_s That sounds like removing cobwebs ::)

Drbradley I would agree. First time no need as most patients will be okay.

Barbaran Are all gyns able to do this procedure or do they need special training?

Drbradley That is a very close metaphor. Barb, like anything else in life, it varies from person to person. Patients need to ask their docs about their experience with adhesions.

Drbradley Well Kiddies, we have house guests that are sitting in the spa waiting for yours truly. Thanks for your company!!

Barbaran Goodnight

mary_s Nite Dr. B!