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ORIGINAL ARTICLE
Year : 2023 | Volume
: 22
| Issue : 2 | Page : 145-152
Peritoneal adhesion findings during laparoscopy: Determinants of occurrence and effect of severity on operative outcomes in a Nigerian Hospital
John Osaigbovoh Imaralu1, Franklin Inyang Ani1, Ekundayo Oluwole Ayegbusi2, Florence Adebisi Oguntade3, Chimaobi Chukwuemeka Nwankpa1, Bukunmi Deborah Olaleye1
1 Department of Obstetrics and Gynaecology, Babcock University Teaching Hospital, Ilishan-Remo, Nigeria
2 Department of Obstetrics and Gynaecology, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Nigeria
3 Department of Anaesthesia, Babcock University Teaching Hospital, Ilishan-Remo, Nigeria
Correspondence Address:
John Osaigbovoh Imaralu
Department of Obstetrics and Gynaecology, Babcock University, Teaching Hospital, Ilishan-Remo, Ogun State
Nigeria
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/aam.aam_43_22
Abstract
Context: Peritoneal adhesions unlike other immediately recognizable complications of the surgery may produce long-term consequences, which include infertility and intestinal obstruction. Aims: The study aimed to determine the prevalence, the determinants, and the outcomes of laparoscopic surgery associated with intraperitoneal adhesion findings. Settings and Design: This was a retrospective observational study. Materials and Methods: The study included all laparoscopic gynecological surgeries done between January 2017 and December 2021. Adhesion severity was graded, using the peritoneal adhesion index (PAI), by Coccolini et al. Statistical Analysis: The data were analyzed using the SPSS version 21.0. Binary logistic regression was used to assess the factors associated with adhesion finding during laparoscopy. Results: There were 158 laparoscopic surgeries with 26.6% prevalence of peritoneal adhesions. The prevalence of adhesions among women with previous surgery was 72.7%. Previous peritoneal surgery was a significant determinant of occurrence of adhesions (odds ratio = 8.291, 95% confidence interval [CI] = 4.464–15.397, P < 0.001), and such patients had significantly (P = 0.025, 95% CI = 0.408–5.704) more severe adhesions (PAI = 11.16 ± 3.94) than those without prior surgery (PAI = 8.10 ± 3.14). Abdominal myomectomy (PAI = 13.09 ± 2.95) was the most important primary surgical determinant of adhesion formation. There was no significant relationship between adhesion occurrence and conversion to laparotomy (P = 0.121) or mean duration of surgery (P = 0.962). Greater adhesion severity was, however, observed in individuals with operative blood loss <100 ml (PAI = 11.73 ± 3.56, P = 0.003) and those hospitalized for ≤2 days (PAI = 11.12 ± 3.81, P = 0.022). Conclusion: The prevalence of postoperative adhesions during laparoscopy in our center is comparable to what has been earlier reported. Abdominal myomectomy is associated with the greatest risk and severity of adhesions. Laparoscopy in patients with more severe adhesions resulted in less blood loss and shorter duration of hospitalization, suggesting an association of better outcomes with a cautious approach to adhesions.
Abstract in French Résumé
Contexte: Les adhérences péritonéales, contrairement aux autres complications chirurgicales immédiatement reconnaissables, peuvent avoir des conséquences à long terme, notamment la stérilité et l'occlusion intestinale. Objectifs: L'étude visait à déterminer la prévalence, les déterminants et les résultats de la chirurgie laparoscopique associée aux résultats des adhérences intrapéritonéales. Paramètres et conception: Il s'agissait d'une étude d'observation rétrospective. Matériaux et méthodes: L'étude a inclus toutes les chirurgies gynécologiques laparoscopiques réalisées entre janvier 2017 et décembre 2021.La gravité des adhérences a été évaluée, en utilisant l'indice d'adhérence péritonéale (PAI), de Coccolini et al. Analyse statistique: Les données ont été analysées à l'aide de SPSS version 21.0. Une régression logistique binaire a été utilisée pour évaluer les facteurs associés à la recherche d'adhérences pendant la laparoscopie. Résultats: Il y a eu 158 chirurgies laparoscopiques avec une prévalence de 26,6 % d'adhérences péritonéales. La prévalence des adhérences chez les femmes avec une chirurgie antérieure était de 72,7 %. La chirurgie péritonéale antérieure était un déterminant important de l'apparition d'adhérences (rapport de cotes = 8,291, Intervalle de confiance [IC] à 95 % = 4,464-15,397, P < 0, 001), et ces patientes avaient significativement (P = 0,025, IC à 95 % = 0,408-5,704) des adhérences plus sévères (PAI = 11,16 ± 3,94) que celles sans chirurgie préalable (PAI = 8,10 ± 3,14). La myomectomie abdominale (PAI = 13,09 ± 2,95) était le déterminant chirurgical primaire le plus important de la formation de l'adhérence. Il n'y avait pas de relation significative entre l'occurrence de l'adhérence et la conversion en laparotomie (P = 0,121) ou la durée moyenne de la chirurgie (P = 0,962). Cependant, une plus grande sévérité de l'adhérence a été observée chez les personnes ayant une perte de sang opératoire <100 ml (PAI = 11,73 ± 3,56, P = 0,003) et celles hospitalisées pendant ≤2 jours (PAI = 11,12 ± 3,81,P=0,022). Conclusion: La prévalence des adhérences postopératoires lors d'une laparoscopie dans notre centre est comparable à ce qui a été précédemmentRapporté. La myomectomie abdominale est associée au plus grand risque et à la plus grande sévérité des adhérences. La laparoscopie chez les patients souffrant d'adhérences plus sévères a entraîné une perte de sang moins importante et un séjour hospitalier plus court, ce qui suggère une association de meilleurs résultats avec une approche prudente des adhérences.
Mots-clés: Fertilité, laparoscopie, myomectomie, adhrérences péritonéales
Keywords: Fertility, laparoscopy, myomectomy, peritoneal adhesions
Introduction 
Adhesions are among the most dreaded complications of surgeries involving the peritoneal cavity in women; over half of abdominal surgeries are reportedly complicated by adhesion formation.[1],[2],[3]
Previous studies have repeatedly implicated previous surgeries involving the peritoneal cavity as the major risk factor for adhesion formation,[4],[5],[6],[7],[8],[9] with an increase in risk for procedure abandonment, conversion to laparotomy,[9] or other adverse outcomes.[4],[5],[7] Conclusions, however, differ on the primary surgical procedures, which portend the greatest risk or are associated with the most severe forms of peritoneal adhesions.[4],[5],[6],[8] Laparoscopic surgery is becoming increasingly popular in Sub-Saharan Africa for the evaluation and treatment of infertility.[10],[11],[12] The laparoscopic grading of adhesions is useful for careful decision-making regarding the extent of repeat operative procedures including adhesion removal.[13],[14] There have been attempts at grading adhesions, but the Coccolini peritoneal adhesion index (PAI) is a quick easy-to-apply gross scoring system, which combines the regional anatomy of the peritoneal cavity and the adhesion grade to obtain the PAI.[13],[14],[15],[16] A total score of 0–30 is can be obtained and increasing PAI score indicates higher severity of the peritoneal adhesions.[13]
This study, therefore, aimed to determine the prevalence, the determinants, and the outcomes of laparoscopic surgery associated with intraperitoneal adhesion findings, using the Coccolini PAI system in a southwestern Nigerian teaching hospital.
Materials and Methods Study design
This was a retrospective observational study.
Study location
The study was conducted at the Department of Obstetrics and Gynaecology of the Babcock University Teaching Hospital (BUTH). The BUTH is located in the Ikenne Local Government Area of Ogun state, southwestern Nigeria. The hospital receives clients and referrals from neighboring towns in Ogun state and frequently from the nearby southwestern states of Lagos, Oyo, and Ondo states.
Sample size and sampling technique
All cases of gynecological laparoscopic surgery done between January 2017 and December 2021 were included in the analysis.
Procedure
The data were extracted by a team of three investigators of senior registrar/consultant level using a pro forma, designed by the authors. The data were obtained from the hospital records, especially the patient case file and the surgeon's operation notes; these records were traced from the operations booking diary, gynecology clinic, gynecological ward, and operating theater records.
Peritoneal entry was with the aid of a Veress needle in all the cases and the umbilical region was used for entry in most cases, while the Palmer's point entry was used in three of the cases. Insufflation was done with carbon dioxide using a preset pressure of 15 mmHg for all diagnostic cases and 18–20 mmHg for all the operative procedures. The reported adhesion locations and grades were scored using the PAI by Coccolini et al., 2013.[13] The Coccolini system considers all the nine regions of the abdominal cavity; bowel-to-bowel adhesions are also considered region. The adhesion grade is scored as follows:
No adhesionsFilmy adhesionsrequiring blunt dissectionStrong adhesions requiring sharp dissectionVery strong vascularized adhesions requiring sharp dissection and in which damage is hardly preventable.An adhesion grade was assigned to each of the nine abdominal regions. Bowel-to-bowel adhesion was also graded. The grades were then summed up to derive the PAI score as described by Coccolini et al. Higher PAI score indicated greater severity of peritoneal adhesions.[13]
Definition of operational terms
Adhesions described as mild, or flimsy, in the operation records were considered filmy and graded I using the Coccolini classification. Adhesions described in the operation notes as moderate, strong, or in which sharp dissection was used were considered strong and classified graded II, while adhesions described as severe or dense or in regions or aspects described as ''frozen'' or in which dissection resulted in injury were graded III.
Statistical analysis
The data were analyzed using the SPSS version 21.0 (SPSS Inc., Chicago, IL, USA). Numerical data were expressed as mean ± standard deviation. Bivariate analysis was done and the independent t-test used to compare means, while the Chi-square test was used to compare categorical variables. Binary logistic regression was used to assess the factors associated with adhesion finding during laparoscopy. The level of statistical significance was set at P < 0.05.
Ethical consideration
Ethical approval was obtained from the Babcock University Health Research and Ethics Committee. Permission was also obtained from the medical records department of the BUTH for the use of patients'hospital records.
Results There were 158 laparoscopic surgical procedures in the gynecological surgery unit within the study period and all case records were retrieved.
[Figure 1] shows that 42/158 (26.6%) of the patients were observed during laparoscopy to have peritoneal adhesions, giving a prevalence of 26.6%, for adhesion finding during laparoscopy. [Figure 1] also shows that while only 8.8% of patients without a history of previous peritoneal surgery had adhesions, a high prevalence of adhesions of 72.7% was obtained in women with a history of previous surgery involving the peritoneal cavity.
[Table 1] highlights the sociodemographic features of the patients; previous histories of surgery involving the peritoneal cavity (P < 0.001) and abortion (P = 0.001) were significantly associated with adhesion findings during laparoscopy. There was, however, no significant difference in age (P = 0.847), educational status (P = 0.066), marital status (P = 0.406), parity (P = 0.485), or the body mass index (P = 0.204) between patients who had adhesions and those without adhesions. The indication for laparoscopy diagnostic versus therapeutic (P = 0.151), the timing of the procedure (P = 0.062), and the use of laparoscopy for fertility evaluation or treatment (P = 0.410) were also similar between the two groups.
Table 1: Comparing sociodemographic features between patients with peritoneal adhesions and those without peritoneal adhesions during laparoscopy[Table 2] shows that previous peritoneal surgery was a significant determinant of occurrence of peritoneal adhesions (odds ratio [OR] = 8.291, 95% confidence interval [CI] = 4.464–15.397, P < 0.001). The severity of the peritoneal adhesions was also significantly higher among patients with a history of previous surgeries involving the peritoneal cavity as indicated in the higher mean PAI score of 11.16 ± 3.94 compared to 8.10 ± 3.14 observed among those without prior peritoneal surgeries (P = 0.025, 95% CI = 0.408–5.704).
Table 2: Comparing the prevalence and severity of adhesions found at laparoscopy between patients with history of previous peritoneal surgery and those without such history[Table 3] reveals that abdominal myomectomy with the highest PAI score of 13.09 ± 2.95 was the most important risk factor for postoperative adhesion formation. Exploratory laparotomy (PAI = 13.00), ovarian cystectomy (PAI = 12.00), and salpingectomy (PAI = 11.00 ± 5.66) also had high PAI scores. [Table 3] also highlights the PAI scores associated with the various indications for laparoscopy. Higher PAI scores were observed in patients undergoing laparoscopic evaluation for secondary infertility (PAI = 12.33 ± 3.27), secondary amenorrhea (PAI = 14.00), and hydrosalpinx (PAI = 14.00 ± 2.83).
Table 3: The previous peritoneal surgeries, indication for laparoscopy and the associated severity of peritoneal adhesions observed during laparoscopy[Table 4] highlights the relationship between the presence of adhesions and the outcome of laparoscopic surgery. There was no statistically significant relationship between the presence of adhesions and conversion to laparotomy (P = 0.121) or occurrence of operative complications (intraoperative, P = 0.393, and postoperative, P = 0.462).
Table 4: Comparing the outcomes of laparoscopic surgery, with presence and severity of adhesionsAlthough the mean estimated blood loss (EBL) (P = 0.714) and the mean duration of hospitalization were similar between those with adhesions and those who had no adhesions, the second part of [Table 4] reveals clearly that adhesions were more severe in patients with EBL <100 ml (PAI = 11.73 ± 3.56, P = 0.003) and also in patients with duration of hospitalization ≤2 days (PAI = 11.12 ± 3.81, P = 0.022). The mean duration of surgery was also shorter in patients with adhesions 84.7 ± 37.6 min compared to the 92.6 ± 54.9 min observed among the patients who had no adhesions, although this was not statistically significant (P = 0.962).
Discussion The prevalence of adhesions observed among individuals undergoing laparoscopic evaluation for gynecological indications in our center was 26.6%, while it was 8.8% for patients who had never undergone any previous surgery involving the peritoneal cavity, buttressing the role of other causes of peritoneal adhesions apart from surgery, such as pelvic inflammatory disease, endometriosis, and appendicitis. For comparison purposes, however, the prevalence of adhesion findings of 72.7% among women who have previously undergone surgery involving the peritoneal cavity would be compared with findings from similar studies which focused mainly on the prevalence of adhesions following previous surgeries. This prevalence falls within the overall reported range of 63%–97% for adhesion complications of all previous peritoneal surgeries, the 60%–90% prevalence reported for gynecological operative procedures, and the 85%–100% adhesion prevalence reported for gynecological laparoscopic surgery from some developed countries.[14],[15],[16],[17] Postmortem findings of adhesions in patients who had abdominal or pelvic surgeries had been recognized for over five decades, a study reported a prevalence rate of 67%.[18]
The prevalence of postsurgical adhesion in our study is also in agreement with the 65% rate observed by Nzau-Ngoma et al., from a study involving repeat laparotomy or laparoscopy for patients with previous abdominal surgery in the Democratic Republic of Congo.[4] It is comparable with the findings from a southeastern Nigerian hospital, where a relatively high prevalence of 80.2% was observed in a prospective study on patients who had undergone prior appendicectomy. It is, however, higher than the reported 40.6% among women with a history of previous myomectomy that were undergoing diagnostic laparoscopy for fertility evaluation in the same hospital in the southeastern Nigeria.[5],[19] Our finding also contrasts an observation from Ghana, in a study involving repeat cesarean section, which reported a prevalence of 38% adhesion formation rate among women who had undergone prior cesarean section.[7] A similar study from Jordan reports a prevalence of 45.3%,[9] which is lower than observed in our center. A much lower rate of 21.1% was observed by Dubuisson et al. in 2010 among women with a prior history of gynecological surgeries involving the peritoneal cavity.[20]
There was no difference in sociodemographic characteristics between patients who had adhesions and those who did not. Previous surgery involving the peritoneal cavity (P < 0.001) and previous abortion (P = 0.001) was, however, the most important determinants of occurrence of adhesions. It is not surprising that secondary infertility was the most common indication for laparoscopy in our centre, as high adhesion rates were also observed among the patients with secondary infertility. Most of these women have had prior abortions which is a recognized risk factor for secondary infertility due to tubal, endometrial or peritoneal disease.[5],[9],[19],[20] Unsafe abortion is a recognized risk factor for pelvic infection, including adhesion formation and infertility.[21]
Previous peritoneal surgery was, however, the most important determinant of peritoneal adhesion findings at laparoscopy as it was associated with an eight-fold risk. The odds of adhesion formation were 3 times for patients with a history of previous abdominal surgeries compared to those without such history, in a report from a similar study in DRC, Central Africa.[4] Previous peritoneal surgery was also reported as having more than two-fold risk of adhesion formation from an earlier study in Jordan.[9] The severity of the adhesions as evidenced by the higher PAI scores was also significantly higher than in those patients who never had surgery involving the peritoneal cavity (P = 0.025). The presence of adhesions has been reported as being strongly associated with previous peritoneal surgeries. More severe adhesions have also been linked to a history of previous surgery involving the peritoneal cavity in many studies.[4],[5],[6],[9],[19],[20]
Previous abdominal myomectomy was the most common risk factor for postoperative adhesions from our findings, accounting for 14/32 (43.8%) of patients with adhesions. This surgery was also responsible for the most severe forms of adhesions in our study, as it had the highest PAI score of 13.09 ± 2.95. This finding largely agrees with the high severity of postmyomectomy adhesions reported from a study by Coddington et al., where every additional centimeter of uterine incision was associated with 0.55 cm2 surface area of uterine serosal adhesions.[22] Ikechebelu et al. in their study also observed a high rate of cohesive adhesions in individuals with a history of prior myomectomy. They observed that myomectomy had great potential for fertility alteration as the Fallopian tube was the most common organ involved in postmyomectomy adhesions in their study.[19] Bilateral tubal occlusion was significantly more common among patients with previous myomectomy in that study. Other affected organs in order of prevalence were the uterus and the ovaries which have serious implications for future fertility.[19] Laparoscopic myomectomy has been shown to have less risk and severity of postoperative adhesions.[6],[13],[19],[20] Cesarean appears to have a lower risk for peritoneal adhesions as evidenced by the findings of a lower prevalence and severity of adhesions (21.9% and PAI score of 8.57±3.21) than myomectomy (43.8%, PAI score of 13.29±2.95). All the patients in our series, however, had lower segment cesarean section and only one of them had two previous cesarean sections. One similar study reported more than five-fold risk of adhesions following cesarean section,[9] while a similar study which assessed the prevalence of adhesions following cesarean section in Ghana, another African country, reported a high prevalence of 38% and significant effect on prolonging the duration of repeat cesarean section time and increasing the operative blood loss.[7]
The lower severity of adhesions observed in our study among women with previous cesarean section is in agreement with findings from some earlier studies, where it was also additionally found that adhesion complications such as infertility, chronic pelvic pain, and intestinal obstruction, after cesarean section, were significantly less than in gynecological surgery, despite the fact that pregnancy is associated with diminished fibrinolytic activity.[23],[24],[25],[26]
Concerning the indications for surgery and the surgical planning logistics, the more severe forms of adhesions were observed in patients undergoing laparoscopic evaluation and treatment for secondary infertility, secondary amenorrhea, and hydrosalpinx, which have high PAI scores. This buttresses the need for high index of suspicion for adhesions in patients being evaluated for infertility, especially in patients with a history of prior surgery, to prevent inadvertent injury to bowel and other viscera, especially during entry either at laparotomy or at laparoscopy. Adhesions significantly increase the risk of entry injuries at repeat laparoscopies.[27]
Adhesion finding at laparoscopy in our study was not significantly associated with longer duration of surgery, which contrasts reports from earlier studies.[7],[8],[28],[29] It was however responsible for 8.3% of conversions to laparotomy, which is less than the 13.6% reported from a study done in Jordan, the reason for conversion was adhesions in 9 patients, that series compared to 1 in our study, although their study involved a larger number of laparoscopic surgeries and conversions.[9]
The finding of higher PAI scores among patients with lower EBL (statistically significant) largely contrasts findings of higher mean EBL from Ghana in a prospective study on postcesarean section adhesions.[7] The above finding, together with the observation of shorter duration of surgery among patients with more severe adhesions (higher PAI), suggests a cautious approach to adhesions by the surgeons with tendency toward less aggressive approach toward the observed adhesions. The finding that most of the therapeutic procedures were done in patients without adhesions supports the earlier explanation. Another finding that significantly higher PAI scores were found in patients who spent ≤2 days in the hospital postoperatively also corroborates the above findings and supports the suggestion that most of the major therapeutic surgeries were done in patients with less severe adhesions. Adhesiolysis is one such therapeutic procedure in patients that has also been shown to be a risk factor for further adhesion formation. Contrasting findings on the role and benefits of laparoscopic adhesiolysis have been reported.[6],[30],[31]
The results give an impression of attempts to avoid undue meddlesomeness, probably a caution to prevent iatrogenic injury to bowel and other surrounding viscera. Other factors that may be responsible for the above findings include the location of the adhesions, ease of separation, the risk of injury to contiguous structures, the indication for the surgery, laparoscopic access to target organ, surgeon competence, and appropriate equipment. It has been advocated that the risk–benefit analysis for surgery planned solely for the treatment of postoperative adhesions should be carefully considered.
Conclusion The prevalence of postoperative adhesions during laparoscopy in our center is comparable to what has been earlier reported. Previous peritoneal surgery is the most important risk factor for adhesion formation. Gynecological surgeries performed by the abdominal route are the most common risk factors, with myomectomy being associated with relatively higher severity of adhesions. Although conversion to laparotomy, duration of surgery, and occurrence of operative complications were comparable, patients with greater severity of adhesions had significantly lower EBL and shorter duration of hospitalization, suggesting a cautious approach to adhesions. A risk–benefit analysis for adhesiolysis may be beneficial when adhesions are encountered during laparoscopy.
Acknowledgments
The authors express sincere gratitude to the staff of the departments of anaesthesia, nursing and medical records, for their assistance in retrieving patient records used for the study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References 
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