Abstract
I
In my work experience, every time I have been called to perform laparoscopic exploration and reoperation of patients with early postoperative complications, I was amazed by the outstanding power of the fibrin exudate. Its bonding efficacy is similar to that of vacuum, and the best way to overcome is by blunt dissection of the adherent surfaces, which I use to achieve by means of a 10-mm laparoscopic palpator. The adhesions resulting from fibrin exudation, deposition, and fibrin-bond formation are extremely resistant to traction, which usually produces injury and tearing of the bowel wall. Also, they are extremely resistant to succussion, so that abdominal massage, hand-shaking of the abdominal wall, and changes in patient's position are quite useless, as I have documented by means of the Laparoscopy-Enhanced HIPEC (LE-HIPEC) technique.a I have never observed fibroid adhesions when performing laparoscopic reoperation in the first three postoperative days. Conversely, I have always observed an intense collagen deposition and fibrosis when reoperation was performed from the fifth postoperative day onward. 1
When developing the LE-HIPEC technique, I was particularly concerned about two issues: avoiding the huge heat dissipation and the severe thermal inefficiency that are peculiar to the open-abdomen Coliseum technique, and finding a way to keep all the peritoneal spaces open, to let the inflow of the heated perfusion fluid.2,3 I put all my observations and considerations mentioned above in the concept of the LE-HIPEC technique.b
Our demonstration of such an extensive formation of intra-abdominal adhesions, in the very early phase after cytoreductive surgery, clearly unfolds one of the reasons (if not the main one) for the uneven distribution of the perfusion fluid that is observed with the conventional closed-abdomen HIPEC technique.
I agree with Dr. Mynbaev et al. that our findings perfectly fit with the classical pathogenesis of postsurgical adhesion formation in the abdominal cavity, according to which the formation of adhesions due to fibrin deposition in the very early period after closure of the abdomen was strongly suspected. Of course, our findings are not a documentation of the mature postoperative adhesions: the aim of our study was to investigate the incidence of early adhesions that could hamper the uniform distribution of the perfusion fluid during closed-abdomen HIPEC. Long-term results are beyond the scope of our article, and we did not address the role of LE-HIPEC in preventing the formation of permanent mature postoperative adhesions. Also, we did not address the role of heat, CO2, and humidification in preventing long-term postoperative adhesions, but we hypothesized that the warm and wet environment, that is created inside the abdominal cavity during the LE-HIPEC, could be protective against any further fibrin deposition during the perfusion period. During laparoscopic surgery, the efficacy of humidification in preventing adhesions is well documented. 4
The onset of very early postoperative adhesions due to the fibrin exudate, which was previously just suspected, is now clearly proven in patients thanks to the LE-HIPEC technique. Our study has shown that this onset is frequent. Moreover, the LE-HIPEC technique has proven to be effective in dividing early intraoperative adhesions, addressing an issue that could affect the circulation of the perfusion fluid during closed-abdomen HIPEC. 5 , c I think that such findings deserve consideration and will hopefully foster the calling into question of the adequacy of the currently available techniques for the administration of HIPEC.