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Dr. Gerhart is one of the few surgeons in the world who specializes in adhesion surgery. Most surgeons avoid treating adhesions because surgically separating organs that are connected by extensive scar tissue is difficult, time consuming and potentially dangerous. Some surgeons may perform limited adhesion surgery, but effectively treating adhesions requires an understanding of adhesion disease along with special surgical techniques and use of adhesion preventing liquids and sprays to give the best chance of keeping adhesions from returning. The most important factor is using minimally invasive laparoscopy to avoid open incisions that cause more inflammation and recurrent adhesions. Robotic laparoscopic instrumentation adds improved visualization and precision to the dissection.
ADHESION TREATMENT WITH DR. GERHART
Robotic Laparoscopic Adhesiolysis. Dr. Gerhart uses the latest minimally invasive technology to perform adhesiolyis, cutting of adhesions, to clear the abdomen of adhesions. Even extensive adhesions causing the entire abdominal cavity to be obliterated, called a frozen abdomen, can be managed. Cutting adhesions is done with “cold cutting technique, using scissors without cautery or laser energy, to limit inflammation which limits recurrence of adhesions.
Adhesion Barriers. After clearing the peritoneal cavity of adhesions, the surfaces of structures within the abdomen are covered with substances that create a barrier to the formation of adhesions. Barrier devices keep tissues apart until inflammation subsides, then dissolve leaving the surfaces free of adhesions. Dr. Gerhart uses two different barriers:
Evicel® Fibrin Sealant, a dissolving gel that is used in surgery primarily to stop bleeding. This helps reduce adhesions by reducing the inflammation associated with blood in the abdomen. In addition, when sprayed onto the surface of tissues, Evicel® creates a thin barrier between structures in the abdomen. In two weeks, when the inflammation from surgery has resolved, the Evicel® absorbs leaving empty space without adherence of the tissues.
Adept® Adhesion Reduction Solution, is a liquid adhesion barrier that is instilled into the abdomen following adhesion surgery. This keeps the loops of intestine floating apart from one another, so they will not adhere together. The use of barrier devices significantly reduces the reformation of adhesions in most patients.
WHAT ARE ADHESIONS?
Adhesions are abnormal fibrous connections between internal organs. They form as a result of inflammation that occurs inside the abdomen causing scar tissue to form in the process of healing that joins adjacent surfaces of organs together.
Prior surgery causes adhesions. In fact, it is the most common cause of adhesions. Inflammation is part of the natural healing process that occurs when incisions made in the body by surgeons heal with natural scarring. Adhesions occur when this normal inflammation extends to adjacent tissues causing them to scar together creating abnormal connections that can cause compilations.
Infection is another leading cause of adhesions. Infection in the abdomen also causes inflammation and can also lead to adhesions. Diseases like appendicitis and diverticulitis are common intra-abdominal infections that cause adhesions, especially when perforated and an abscess develops.
Endometriosis is one of the most common causes of adhesions. Endometriosis is endometrial tissue that normally lines the uterus that becomes implanted within the abdomen. It grows into the tissues and can grow from one surface to another causing the two to adhere together, causing adhesions. Other diseases within the abdominal cavity can also cause adhesions.
HOW DO ADHESIONS CAUSE PROBLEMS?
Two structures within the abdomen adhering together inside the abdominal cavity does not, by itself, cause problems. Symptoms occur when the adhesions irritate or disrupt the function of the attached organs.
Pain is a common result from adhesions. The peritoneum, a thin membrane that lines the entire abdominal cavity, is rich in nerves. Scar tissue adhesions grow into the peritoneum and irritate these nerves and cause pain. This pain is very variable. In some people a small amount of adhesions can cause a great deal of pain, while in others a large amount of adhesions can cause little or no pain. Because of this variability it is hard to measure the amount of adhesions or the amount of pain you would expect from adhesions. This has led to some patients and even health providers questioning whether adhesions cause pain, but there is little doubt among surgeons that adhesions cause pain.
Adhesions cause gastrointestinal symptoms when they block the intestines. The blockage can be partial causing chronic nausea and vomiting, poor appetite, abdominal bloating, constipation, gastric reflux and pain. Complete obstruction results in the severe symptoms and requires hospitalization and in some cases emergency surgery. Chronic adhesion sufferers often have repeated hospitalizations to treat their symptoms.
HOW ARE ADHESIONS DIAGNOSED?
Exploratory laparoscopy is the only reliable test for adhesions. Unfortunately, there is no non-invasive test that reliably shows adhesions. The problem is that an adhesion is simply when two structures within the abdomen adhere to one another. So, even highly accurate CT scans of the abdomen will only show organs next to one another with no way to know if they are connected by scar or not.
Testing before adhesion surgery evaluates other causes of symptoms. Since adhesion symptoms can be mimicked by other gastrointestinal problems, a panel of tests is done before adhesion surgery to identify other possible sources of pain.
HAVING ADHESION TREATMENT WITH DR. GERHART
We will gather all necessary information and then I will review it and speak with by phone to discuss whether surgery may be right for you. Then we will help you arrange travel to Wilkes-Barre for robotic laparoscopic adhesiolysis.
Evaluation begins with a review of your medical and surgical history. Fill out our medical history form or by emailing pictures of the form to Susan Cerreta at email at SCerreta@commonwealthhealth.net
Next you must send copies of all your previous operative reports. These are the most important part of your history for this treatment. Send reports to Susan Cerreta, above.
Pre-operative testing before adhesion surgery. We will have all pre-operative testing done near your home for your convenience. You must complete the following tests:
- Upper and lower endoscopies.
- CT scan of abdomen and pelvis with oral and intravenous contrast.
- Ultrasound of gallbladder (if gallbladder has not been removed)
- Nuclear hepatobiliary scan (If no gallstones are seen in gallbladder on ultrasound)
- Labs: comprehensive metabolic profile, complete blood count, prothrombin time, partial thromboplastin time, amylase, lipase
- Chest x-ray
If any of these have been done recently, while experiencing your current symptoms, you only need to send reports of prior tests.
If you had any tests other than those above, please send those results also.
To arrange testing and to send results, contact Sue Cerrata at my office at 570-821-1100.
Scheduling adhesion surgery. After I speak with you by phone our schedulers will call you to arrange a date for surgery. Travel to Wilkes-Barre by car or via Scranton-Wilkes-Barre International Airport (AVP) which is about 15 minutes from my office. My office can recommend nearby hotels. The day before surgery you will be seen in my office and we will review your history again and carry out a physical exam.
After surgery. Total stay in the Wilkes-Barre area will be one week. Patients will generally stay in the hospital one to three days depending on their procedure. Patients will then stay and additional 3-4 days in the local hotel where they will have to be active and eating, simulating life at home. I will then see you in the office and you will return home.
READ A TESTIMONIAL FROM AN ADHESION PATIENT
My name is Jeff Walsh. I have had Crohn’s disease since age 11. I am now 46. My name is Jeff Walsh. I have had Crohn’s disease since age 11. I am now 46.
My first bowel resection was performed when I was 17. Since then I have had too many surgeries to recall (20+). My surgeries have included: Bowel resections, ostomies, adhesion surgeries, granuloma surgeries to name just a few.
Unfortunately, due to the nature of my illness and the exorbitant number of surgeries I have endured; postoperative complications, infections, etc. have been status quo. Until now, those surgeries have required midline incisions, which have been most painful and difficult to recover from.
I was introduced to Dr. Gerhart in 2005. I knew nothing of him, except that he was specializing in less invasive surgeries pertaining to my GI problems. I have had both midline (when necessary) and also laparoscopic procedures performed. I can say from 30 years of experience, that the less invasive approach used on me on a number occasions is not only welcome, but is the answer to my prayers.
Moreover, pertaining to my latest adhesion removal surgery, which was my first introduction to the de Vinci Robotic System, was a great success. My surgery was performed on Wednesday and I was home on Friday; which was amazing to me. The same surgery when necessary done using a midline incision had in the past resulted in much pain, with longer duration, longer recovery time and as I mentioned due to my history, other long lasting complications. The same adhesion surgery performed midline would have had me in the hospital a week or longer.
I am thankful for the latest technology and it brings me great solace to know that when my next surgery is required I have this great tool at my disposal.
In closing, I would like to thank Dr. Gerhart for his persistency, patience, and compassion concerning my care over the years. Let us remember that the greatest technological tools in the world are only as good as the individuals operating them and I can say from a lifetime of experience that Dr. Clark Gerhart is as skilled and proficient as a surgeon I have ever encountered.
All my appreciation and thanks,
Jeffrey J. Walsh