What strategies can be used to prevent adhesions in hysteroscopic myoma resection?

Adhesion Prevention in Hysteroscopic Myoma Resection

For hysteroscopic myomectomy, use oxidized regenerated cellulose (Interceed®) as your primary adhesion barrier, as it reduces intrauterine adhesion formation from 88% to 40% when complete hemostasis is achieved, and prioritize meticulous surgical technique with bipolar or ultrasonic energy devices over monopolar electrocautery.

Surgical Technique Fundamentals

Minimize endometrial trauma during the procedure, as adhesions commonly develop after myomectomy from surgical trauma to the endometrium 1. The procedure should be performed by experienced hysteroscopic surgeons to minimize additional endometrial trauma 1.

Energy Device Selection

• Use bipolar electrocautery or ultrasonic devices instead of monopolar electrocautery to reduce peritoneal and endometrial injury 2
• Ultrasonic devices increase adjacent tissue temperature by only 0.6°C compared to 47°C with monopolar instruments 2
• Bipolar devices increase temperature by only 1.2°C, significantly reducing thermal injury 2

Hemostasis Considerations

• Achieve complete hemostasis before applying any adhesion barrier, as oxidized regenerated cellulose may increase adhesion risk if optimal hemostasis is not achieved 3
• Use techniques such as vasopressin injection and meticulous hemostasis to reduce complications 4

Adhesion Barrier Selection

Primary Recommendation: Oxidized Regenerated Cellulose (Interceed®)

This is the most studied barrier specifically for gynecologic procedures and hysteroscopic myomectomy 3:

• Reduces de-novo adhesion formation after laparoscopic myomectomy from 88% (22/25 patients) to 40% (10/25 patients) in randomized trials 5
• In a larger study of 694 myomectomy patients, reduced adhesion rates to 15.9% with laparoscopy plus barrier versus 22.6% with laparoscopy alone 6
• Changes adhesion character from cohesive (dense) to filmy and organized types, which are less clinically significant 6
• Critical caveat: Only use when complete hemostasis is achieved, as it becomes adhesiogenic in the presence of blood 3, 7

Alternative Barriers for Specific Situations

Hyaluronate carboxymethylcellulose (Seprafilm®) is particularly effective for myomectomies 3:

• Reduces adhesion formation with relative risk 0.49 (95% CI 0.28-0.88) in surgical procedures 8
• More practical for open procedures, though laparoscopic placement has been described 8
• Does not require the same strict hemostasis as oxidized regenerated cellulose 8

Polytetrafluoroethylene (Gore-Tex) is the most effective barrier but requires removal 3:

• Completely prevents adhesion formation regardless of injury type or hemostasis status in experimental models 7
• Must be removed after an appropriate interval (typically 7 days), requiring a second procedure 1
• More effective than oxidized regenerated cellulose but impractical for routine hysteroscopic use 3

Icodextrin (Adept®) is a liquid barrier option 8:

• Easy to apply in hysteroscopic procedures 8
• Good safety record in gynecological surgery 8
• Less evidence specifically for intrauterine adhesion prevention compared to oxidized regenerated cellulose 8

Adjunctive Measures

Postoperative Hormonal Treatment

• Consider estrogen-progestogen treatment postoperatively, though evidence remains insufficient for routine clinical use 9
• Intrauterine devices have been studied as mechanical barriers but lack strong evidence 9

High-Risk Patient Identification

Patients at highest risk for clinically significant adhesions include those with 3:

• Endometriosis
• Pelvic inflammatory disease
• Multiple or large myomas requiring extensive resection
• Previous intrauterine adhesions

Common Pitfalls to Avoid

• Do not apply oxidized regenerated cellulose if hemostasis is incomplete, as it becomes adhesiogenic in the presence of blood and may worsen adhesion formation 3, 7
• Do not rely solely on hysterosalpingography for postoperative adhesion diagnosis, as it has only 66.7-75% sensitivity; use MRI or 3D ultrasound which demonstrate 100% accuracy 1
• Do not use monopolar electrocautery when bipolar or ultrasonic devices are available, as monopolar increases tissue temperature by 47°C versus 0.6°C with ultrasonic devices 2
• Do not underestimate the importance of surgical experience, as the procedure should be performed by appropriately trained surgeons with hysteroscopic expertise 1, 4

Practical Algorithm

1. Preoperatively: Identify high-risk patients (endometriosis, PID, multiple myomas) who warrant aggressive adhesion prevention 3

2. Intraoperatively:

   • Use bipolar or ultrasonic energy devices exclusively 2
   • Minimize endometrial trauma through careful technique 1
   • Achieve complete hemostasis before barrier application 3

3. Barrier application:

   • If perfect hemostasis achieved: Apply oxidized regenerated cellulose (Interceed®) 3, 5
   • If hemostasis uncertain: Use hyaluronate carboxymethylcellulose (Seprafilm®) or icodextrin (Adept®) instead 8, 3

4. Postoperatively: Consider second-look hysteroscopy at 12-14 weeks if fertility is a concern, using MRI or 3D ultrasound rather than HSG for diagnosis 1, 5