Medical News from Russia

The method for prevention of postoperative peritoneal adhesions

​Gudiev Chersi Garsoltovich, physician, pediatric surgeon, PhD in Medicine, Associate
Professor of the Department of Public Health and Healthcare Economics of the Pediatric
Faculty of the Pirogov Russian National Research Medical University (RNRMU)
​Peritoneal adhesions (hereinafter referred to as PA) remain a topical issue of abdominal
surgery and, it appears, expectations from scientific search of effective pharmaceutical
preparations for PA treatment are very limited in terms of their applicability.
​The doubts about the possibility of using effective drugs for the PA treatment, if they will
be developed, will be based on works of different authors who determine the process of
adhesion formation as “universal protective reaction of the body” (Chekmazov I.A.
“Adhesive disease”, 2008, and others). Due to this protective reaction, tissues damaged by
surgical intervention (laparotomy wound, anastomoses, sutured organs and vessels, etc.)
healed with adhesion formation. Fusion of layers of peritoneum after surgery occurs in
90-93% of cases (Simonyan K.S., 1966; D. Menries et al., 1990; and others). That is,
adhesive process develops virtually in 100% of patients who underwent abdomial surgery;
this process is the basis not only for the development of PA, but also for the healing of
tissue damage of any origin.
​This means that the adhesive process as a universal protective reaction of the body
targeted on damage healing, in particular, in the abdominal cavity, is unavoidable –
otherwise, we would face failed healing of surgical wound, failure of anastomosis, absence
of scarring of sutured vessels, etc.; all this would lead inevitably to a number of well-
known complications and to a high threat of fatal outcome in each case of surgical
intervention.
​Hence, it appears that the effective prevention of adhesion formation by inhibiting the
biochemical process or lysing of the formed adhesions with drugs appears to be a
futureless and unwanted goal. An effective drug that prevents the adhesion formation or
causes their lysis, will prevent, as mentioned above, the healing of the surgical wound,
anastomosis, sutures blood vessels, etc.; it may be well imagined the consequences of
these events. So, a possible drug that effectively inhibits the adhesion process or lyses
adhesions causes at least a high degree of doubt in term of the safety of its use.
​Many proposed approaches to treatment and prevention of abdominal adhesion help to
obtain an antiadhesive effect only in 20-65% of cases (Chekmazov I.A., 2008; Indar A.A.
et al., 2009, and others). Such a low efficiency can satisfy neither the patient, nor the
physician, nor scientific reason. Besides that, the proposed schemes for the treatment
and/or prevention of PA have often a significant disadvantage – individual differentiated
approach to the treatment in each case.

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​In view of the foregoing, feasibility to prevent (minimize) the fusion of the
layers of peritoneum (by that to prevent PA formation) with physical impact and to save
biochemical process remains more attractive and preferable.
​In connection therewith, it should be mentioned that the drug stimulation of the intestinal
peristalsis and the early activation of the patient in the postoperative period carried out in
many clinics at present aimed to move the intestinal loops, surely, influenced the process
of fusion of the layers of peritoneum. These techniques of physical impact at the time (20-
40 years ago) produced a significant effect and reduced the incidence of PA.
​For this purpose, author proposed the invention “Method of Chersy G. Gudiev for
prevention of postoperative peritoneal adhesions” (hereafter – “Method”) (the patent of
the Russian Federation for invention No. 2477993), which allowed to move the intestinal
loops by physical impact in the early postoperative period, irrespective of patient’s age,
and thus, minimized risk of postoperative PA.
​The proposed invention is a Method of manual action on the abdominal organs in order to
prevent the postoperative peritoneal adhesions.
​The result of the proposed Method is the prevention (impeding) of postoperative adhesion
of the layers of peritoneum and the absence of sideway actions.
​The claimed result is achieved by displacing the abdominal organs relative to each
other and sites of their usual locations manually (and/or by means of a device) in the
early postoperative period until full patient activation.
​
The method presents a procedure including seven exercises that are realized in three
stages. The number of exercises can vary from 2 or more – at the discretion of the
attending physician, depending on disease type, patient’s state, intraoperative features and
other causes. The number of exercises is prescribed by the attending physician, and the
procedure is performed in one step with a one-time anesthesia during 3-5 minutes or more.
Each stage can consist of one or more procedures – at the discretion of the attending
physician.
​The first stage is carried out in the first – second day (until the expiration of 48 hours) after
surgery; 1-3 procedures per day are performed during this stage.
​The second stage is carried out on the second – third day (after 24 – 72 hours) after surgery;
1-2 procedures per day are performed during this stage.
​The third stage is carried out on the third – fourth days (until the expiration of 48-72 hours)
after surgery, once a day, and continues until full patient activation.
​The procedure includes the following seven exercises:

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​The first exercise: the patient is lying on his back; both hands embrace the anterior
abdominal wall, entrapping the largest possible volume of the intestinal loops, lift them and

lower; the exercise is performed two or more times.

The second exercise: the patient is lying on his left side; the abdominal wall and internal
organs hanging down on the left side are thrown with a push movement of the right palm
upwards to the right iliac region so that the organs fall down to the previous position under
their own weight; the exercise is performed 2 or more times.
The third exercise: the patient is lying on his right side; the abdominal wall and internal
organs hanging down on the right side are thrown with a push movement of the hand
upwards to the left iliac region so that the organs fall down to the previous position under
their own weight; the exercise is performed 2 or more times.
The fourth exercise: the patient is lying on his back; pelvis and the lower abdomen are
raised by placing the roller; your fingers of both hands press the abdomen and move
quickly from the upper edge of the pubic bone upwards to the costal arches so that the
intestinal loops would be displaced towards the diaphragm to the extent possible; the
exercise is performed 2 or more times.
The fifth exercise: the patient is lying on his back; palms are placed on low back
abdominal wall and embrace the left and then the right half of the abdomen; and intestinal
loops are displaced relative to each other by pinching them between the palms; the exercise
is performed 2 or more times.
The sixth exercise: the patient is lying on his back; the abdominal organs are kneaded in
both longitudinal and transverse directions; then one palm compressed into a fist is dipped
in the abdomen, and dorsum of one hand kneads the abdominal organs and soft tissues of
the abdominal wall moving and rolling them toward the palm of the other hand; the
exercise is performed 2 or more times.
The seventh exercise: the patient is placed in the prone position so that the entire anterior
abdominal wall hang down without support; abdominal cavity is pressed upward by push-
type, vibrating movements; the exercise is performed 2 or more times. To perform the
seventh exercise, you need a therapy bed with a cut-out in the middle.
Staging of the Method performing, duration of the procedure, the number of exercises and
the technique of the Method can be changed and enhanced at the discretion of the attending
physician depending on disease type and patient’s state. The early start (on the first –
second day after surgery) and duration (until full patient activation) should be
unalterable.
Effectiveness of the Method is determined precisely by the time of its initiation – on
the first – second day after surgery, daily application and duration – until full patient
activation.

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Manual action on the patient (and/or by means of a device) for displacing his
abdominal organs relative to each other and sites of their usual locations, means action
performing by the hands of physician and/or the harmless device if the device’s features are
adoptable for the purposes of the Method, for example, a vibrating massager.
Full activation of the patient means the ability of the patient to perform physical exercises
(therapeutic gymnastics) without assistance, including breathing exercises with maximum
inspiration and expiration with abdominal and diaphragmatic (thoracic) types of breathing;
it can exclude prolonged adjacency of the abdominal organs to each other and and to
normal anatomical structures.
The early application of the Method (on the first – second day after surgery) ensures one of
the main requirements for the invention – its safety. If the Method use starts at the end of
the third or fourth day after surgery, the tear of the formed adhesions can lead to the
deserosing of the intestine, that is, to the microtrauma of the serous membranes, that is one
of the main causes of inflammation and adhesions.
Intensive anti-inflammatory therapy (which eliminates inflammation of the peritoneum as
the cause of adhesions formation) and the Method application in the early postoperative
period until full patient activation will allow overcoming the period of active biochemical
processes of peritoneal adhesion formation and minimize risk of adhesive disease.
Time limits of the Method application (3 to 7 days on the average) should be considered as
relative, since the patient can show sufficient activity much earlier and later.
The number of procedures and exercises in the first and second stages should be
determined by the attending physician (ranging from 1 to 3 procedures per day, 2 or more
exercises during one procedure) as the special featured of the patient’s body can be
considered; primarily it is subject to a predisposition to adhesion formation with suggesting
that the predisposition and rapidity of adhesion formation can and must be different.
As for the rest, since the third – fourth days after surgery the Method can be used once per
day until full patient activation.
Since the abdominal organs are not available for direct contact action, it is necessary to
ensure access for optimal manual action on organs through the abdominal wall by
sufficient anesthesia and, possibly, abdominal wall relaxation (peridural anesthesia).
The Method use has some features that should be considered when performing the
exercises. First of all, it should be remembered that if hollow organ was dissectied at the
surgery, while procedure performing, especially with both hands, high pressure may occur
in the lumen of the hollow organ, in the areas of suturing the wall or anastomosis site; it
can lead to suture insufficiency. Therefore, if the intraoperative dissection of the hollow
organ was done, the procedure should be performed so that no intense pressure of the
hands is applied to the specific site of the abdominal cavity. Moreover, laparotomy wound
should be sutured (with frequent stitches and layer-by-layer) so that that the tissue of the

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anterior abdominal wall can be manipulated close to the stitches without the risk of
sutures insufficience.​   
After the Method use, the patient should be focused on extended active period (we mean
therapeutic exercises) and a lifestyle (up to 6-12 months) in order to prevent adhesion
formation. This is especially important for women, who often suffer from ascendent
inflammatory process in the pelvis.
It should be expected that the adhesive process can be “triggered” if the patient has minor
non-surgical infectious and non-infectious inflammatory processes of the abdominal
cavity. Therefore, the physician and the patient should be aware of the necessity of the long
course of therapeutic exercises after the acute postoperative period.
The advantage of the present invention is its effectiveness, safety, economic availability
and exercise simplicity, which makes it possible to carry them out repeatedly by any
surgeon. It should also be noted that it is recommended that the procedure must be carried
out by the physician, who perform the surgery and who saw the intraoperative picture
directly. The Method has no contraindications and limitations except for the intensity
degree; it must be comparable to the traditional carefulness of a physician performing any
medical procedure.
Proper and timely application of the Method, which is atraumatic to the patient, it is
excluded the possibility of adhesions formation, which can lead to adhesive disease.
Thereby, a number of problems can be solved, such as such as disablement and temporary
disability, and growth of surgical activity in other surgical diseases of the abdominal
organs.

Results of the implementation of the invention in clinics in Russia

143 patients were treated during postoperative period using the author’s Method since 2000
till 2017 in the clinical bases of the SBHI Stavropol Regional Children’s Clinical Hospital,
MBHI Children’s Clinical Hospital # 2 in Grozny, MBHI City Clinical Hospital # 9 in
Grozny, SBHI Republican Children’s Clinical Hospital in Makhachkala, SBHI City
Clinical Hospital № 64 of Moscow City Health Department.
Among these, 116 patients (children of different ages) were operated due to acute intestinal
obstruction of various types. Of these, recurrence of adhesive intestinal obstruction
occured: in 1 patient (0.86%) – early adhesive-paralytic intestinal obstruction, in 1 patient
(0.86%) – late adhesive intestinal obstruction (totally – in 2 patients, 1.72%). One of two
cases of recurrence of acute intestinal obstruction was caused by difficulty in using the
Method due to long-lasting severe state of the patient. The second case was caused by
some factors of procedure performance by clinic physicians in the early period of
technique acquirement; these factors were associated with inadequate anesthesia of the
patient and nonadherence to frequency and volume of the Method use. Analysis of the
treatment performed using the author’s Method showed a significant reduction in the
frequency of recurrences of adhesive intestinal obstruction in children.

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Patients of employable age (27 patients aged from 21 to 57) were routinely operated
(dissection of adhesions) due to various conditions caused by adhesive disease. No
recurrences of peritoneal adhesions in patients operated routinely with the use of the
author’s Method were revealed. Analysis of the treatment performed using the author’s
Method showed the absence of clinically significant recurrences of peritoneal adhesions,
and presented a significant improvement (normalization) in the quality of life of the
patients.
All patients (143 patients) who underwent the treatment using the author’s Method in the
postoperative period were under supervision by clinicians for three years; among them, 136
patients were under supervision for five years after surgery. (3 patients (adults) are under
supervision currently).
Author performed the scientific inquiry and passed Ph.D. dissertation defense on the topic
of “Prevention of the abdominal adhesions in children” at the Department of Pediatric
Surgery of the State Budgetary Educational Institution of Highest Vocational Education
Stavropol State Medical University of Ministry of Healthcare of the Russian Federation.
The dissertation was defended on 30.10.2014 in Rostov-on-Don.
Author’s note
Every physician who took the decision to perform a surgery on the abdominal organs for
diagnostic and/or therapeutic purposes and every patient, irrespective of age, awaiting
such intervention, should understand and remember the high and persistent topicality
of the problem of abdominal adhesive disease.
 

Author and patent owner
                      Chersi G.Gudiev  
​
Contacts:
Phone: +7 (926) 165-34-36
E-mail: chersi05@mail.ru
Website: www.zaokmcdo.com

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