The value of ultrasound sliding sign technique in predicting adhesion-related complications: The point of view of the gynecologist and the anesthesiologist.

Sir,

Postoperative adhesion formation is the most common complication of abdominal or pelvic surgery.[1] Adhesion-related complications comprise various clinical entities including small-bowel obstruction, female infertility, difficulties at reoperation, and chronic pelvic pain. Adhesiolysis is associated with a prolonged operative time and an increased risk of intraoperative and postoperative complications.[2]

Recent studies have shown the value of the new real-time dynamic ultrasound technique known as the “sliding sign” in the noninvasive detection of intra-abdominal or pelvic adhesions.[3]

The purpose of this paper is to share the experience of our Department of Gynecology in detecting pelvic adhesions by preoperative transvaginal sonography (TVS) in women with previous history of abdominal or pelvic surgery. Multidisciplinary team, including surgeons and anesthesiologists, discussed the preoperative TVS sliding sign findings and collaboratively decided on the perioperative plan of care.

Surgical Considerations

In our practice, we believe that ultrasound sliding sign technique is a useful screening investigation for women undergoing gynecologic surgery and that it can predict technical difficulties.

All examinations were performed using transvaginal probe (Voluson E8, GE Medical Systems) to assess the uterus, ovaries, vesicouterine pouch, and pouch of Douglas (POD) [Figure 1].

Figure 1

Transvaginal ultrasound to assess the vesicouterine pouch (a), ovaries (b), and pouch of Douglas (c). The ultrasound sliding sign technique may detect the presence or absence of sliding motion between two adjacent structures (arrows). POD: Pouch of Douglas

Adhesions in the vesicouterine pouch were diagnosed if the urinary bladder could not be separated from the anterior aspect of the lower uterine segment, and there was evidence of dense hyperechoic tissue in the vesicouterine pouch [Figure 1a]. Ovarian adhesions were diagnosed when the ovaries could not be mobilized at all by gentle pressure with the vaginal probe and abdominal pressure using the examiner's free hand [Figure 1b]. Adhesions in the POD were diagnosed by the absence of sliding between the uterus and the rectosigmoid colon and by the presence of thick, hyperechoic tissue in the rectovaginal septum [Figure 1c]. Adhesions between the uterus and the anterior abdominal wall were diagnosed if there were no loops of small bowel between the uterus and the anterior abdominal wall.

The preoperative diagnosis of pelvic adhesions offers several important advantages: (1) information of the obstetricians about the presence of extensive adhesions before the operation in women planning further pregnancies, (2) reduction of risk of laparoscopic trocar complications (vascular, bowel, urological, and uterine injuries) by the choice of safe laparoscopic entry technique, and (3) exploring the relationship between adhesions and chronic pelvic pain and the effectiveness of adhesiolysis in pain control.

Anesthetic Considerations

Optimal outcome in gynecologic surgery is dependent on a thorough preoperative patient review and close collaboration between surgeons and anesthesiologists.

The sonographic findings could be a valuable warning sign for taking perioperative precautions in anesthetic management starting with patient stratification and selection, continuing throughout the surgical operation, and finishing with postoperative care (Intensive Care Unit, recommendations for the ward).

The perioperative management of patients with high risk of adhesion-related complications is summarized in Table 1.

Table 1

Anesthetic precautions in patients screened preoperatively with ultrasound sliding sign technique

The preoperative sonographic detection of adhesions by sliding sign technique should alert the anesthesiologist to potentially adhesion/adhesiolysis-related complications. We believe that anesthetic management with proper surgical approaches can play a key role in the outcome.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.