Historia da Medicina History of Medicine

Barvalento Mdico 2008; 1 (vol.1): 34-39

Bridas e aderncias intestinais

Viso histrica de um problema que se mantm actual
Daniel Cartucho
Servio de Cirurgia CHBA

Intra-abdominal adhesions
Historical Vision of a current problem

SUMRIO: Bridas e aderncias intrabdominais so leses j referenciadas nos papiros do antigo Egipto. Bem conhecida nos primrdios da patologia no contexto da tuberculosa ou outra doena inflamatria peritoneal, torna-se comum depois do advento da cirurgia abdominal na segunda metade do sculo XIX, pela obstruo intestinal que estas aderncias ps-operatrias criam. uma patologia que ainda hoje mantm importante morbilidade. O autor rev a evoluo histrica desta doena e apresenta uma imagem dos primrdios do registo grfico desta patologia. PALAVRAS CHAVE: Bridas, aderncias intestinais, histria INTRODUO
1 Ellis H. The clinical significance of 2

ABSTRACT: Knowledge of the existence of intraabdominal adhesions extends back to the ancient Egyptians. Well recognized by early pathologists following tuberculosis and other peritoneal inflammatory diseases, intestinal occlusion created by postoperative adhesions became a common complication after the advent of abdominal bowel surgery in the late 19th century. It still is considered to be the cause of important morbidity today. The author reviews the historical progression of this pathosis and presents a very early graphic image found. KEY WORDS: Intra-abdominal adhesions, history

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INTRODUCTION In the second half of the twentieth century, enormous advances were made in virtually all fields of medicine. However, on entering the twenty-first century, the graveness of the consequences of abdominal fibrosis, with its adherences and fibrotic bands, has remained practically unaltered. We know today that these membranes, or authentic fibrotic laces, bind the intra-abdominal viscera that normally do not have fixed points between each other leading to intestinal occlusion. These membranes are responsible for 60-70% of all small bowel disease and more than 40% of all the cases 1 of intestinal occlusion . Intestinal occlusion can occur in the immediate postoperative period or 34 years 2 after surgery . It is still responsible for abdominal pain, 3 infertility (15 to 20% are caused by adhesions) , ectopic 4 5 6 pregnancy , dispareunia and intestinal ischemia . The knowledge of adhesions retraces equally to ancient Egypt where a case of severe pelvic adhesions in a sick person is registered on papyrus, although there is 7 no suggestion of a treatment . The oldest description of adhesions in relation with functional organ injury, as far back as is known, is a register in the Babylonian 8 Talmud of a case of pleural adhesions . Throughout evolution, with particular reference to the Medieval Age, the debate persisted concerning pleural adhesions as a cause or a consequence of perforation. From Hunter (1728-1793), we established the relationship

4 5

6 7

adhesions: focus on intestinal obstruction. Eur J Surg Suppl, 1997;577: 5-9 Wilson MS, Hawkswell J, McCloy RF. Natural history of adhesional small bowell obstrution: counting the cost. Br J Surg 1998; 85: 1294-1298 Thompson JN, Ellis H, Parker MC et al. Surgical impact of adhesions following surgery in the upper abdomen. Br J Surg 1999; 86: 418-419 Herschlag A, Diamond MP, DeCherney AH. Adhesiolysis. Clin Obstet Gynecol 1991; 34:395-401 Angioli R, Barreau G. Interceed use and adhesion prevention in gynecology. Contemporary OB/GYN Archive 1998 Nov. http://obgyn.pdr.net/obgyn/public. htm?path=content/journals/g/data/1998/ gba/gba096.html 10 Van Der Krabben AA; Dijkstra FR; Nieuwenhuijzen M; Reijnen MM; Schaapveld M; Van Goor H. Morbidity and mortality of inadvertent enterotomy during adhesiotomy. Br J Surg 2000 Apr;87(4):467-71 Wiseman DM. Adhesion prevention: Past the future. In DiZerega GS (Ed.) Peritonea1 Surgery 2000 Springer-Verlag. pp:401-417

Correspondncia | Correspondence dcartucho@gmail.com

Na segunda metade do sculo XX realizaram-se grandes avanos em praticamente todos os campos da Medicina. No entanto as consequncias da patologia originada pelas bridas e aderncias intra-abdominais, permaneceu praticamente inalterada. Sabemos hoje que estas membranas ou autnticos cordes de tecido fibroso que ligam vrios rgos intra-abdominais que normalmente no tm pontos fixos entre si lideram as causas de obstruo intestinal. So responsveis por mais de 40% de todos os casos de obstruo intestinal 1 e de 60 70% do intestino delgado . Para alm da ocluso intestinal que pode ocorrer no ps-operat2 rio imediato ou 34 anos aps o acto cirrgico , esta patologia responsvel ainda por quadros de dor abdominal, infertilidade 15 a 20% desta causada 3 4 5 pelas aderncias gravidez ectpica , dispareunia ou 6 isqumia intestinal . O conhecimento das adeses remonta igualmente ao antigo Egipto onde h registo de severas adeses plvi7 cas num doente, embora no se sugira um tratamento . A descrio mais antiga de adeses em relao com leso funcional de rgo, tanto quanto se conhece, o registo no Talmud babilnio neste caso para adeses 8 pleurais . Ao longo do tempo, em particular na Idade Mdia, vai persistindo um debate acerca das adeses pleurais como causa ou consequncia de perfurao. A partir de Hunter (1728-1793) temos estabelecida a rela-

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Fig. 1 - Um caso de gestao peritoneal retida. In Thivet M. Maladies du pritoine Grossesse pritonale, morte au bout de dix-huit ans. In Anatomie pathologique du corps humain. Ed. J Cruveilhier, Tome second, Livraison XXXVII, Libraire de lAcademie Royale de Medicine, 1843, Paris. A case of retained peritoneal gestation

Ursachen der peritonealen Adhsionen nach chirurgischen Eingriffen mit RUcksicht auf die Frage des Ileus nach Laparotomien. Langenbecks Arch Chir 37: 745 citado por Treutner KH, Schumpelick V. Adhsionsprophylaxe Wunsch und wirklichleit (Adhesions prevention wish and reality) Chirurg (2000) 71: 510-517 10 Ellis H. Adhesions: the early history. Hospital Medicine, Vol. 65, Iss. 6, 10 Jun 2004, pp 328 - 329 11 Bryant T (1872) Clinical lectures on intestinal obstruction. Med Times Gaz 1: 363 citado por Treutner KH, Schumpelick V. Adhsionsprophylaxe Wunsch und wirklichleit (Adhesions prevention wish and reality) Chirurg (2000) 71: 510-517

9 Von Dembowski T (1889) Ueber die

o entre as adeses, peritonite e infeco . Danbarski em 1889, descreve causas de adesividade peritoneal ps-operatrias, com nfase das localizadas ao leo e concluiu, com base num trabalho experimental no co, que eram induzidas tanto pelos fios de compressas, 9 como pela escarificao do intestino . Estas bridas que podem ser congnitas so normalmente secundrias a um processo intrabdominal como uma cirurgia, uma inflamao ou um trauma. Estas leses referenciadas nos primrdios da patologia no contexto da tuberculosa ou outra doena inflamatria peritoneal, tornam-se comuns depois do advento da cirurgia abdominal na segunda metade do sculo XIX, pela obstruo intestinal que estas aderncias ps-ope10 ratrias criam . Brant em 1897, descreve um caso de adesividade no leo depois de exerse de quisto do ov11 rio . Payr em 1911, descreve a relao entre as adeses a fibrinlise e a importncia das primeiras 48 h para a 12 formao destas aderncias . Posteriormente, utilizou a expresso problemas de adesividade peritoneal chamando a ateno da maior relevncia do problema pelo maior nmero de laparotomias que cirurgies e ginecologistas praticavam. Valoriza a leso da mucosa pelo trauma na laparotomia assptica e a leso do peritoneu pela falta de humidade, leses qumicas e trmicas. Ao longo dos anos vo sendo propostas uma srie de solues para evitar a formao destas aderncias. Wiseman8 em 2000 d-nos uma viso ampla do tema e

between the adhesions, peritonitis and infection . Danbarski, in 1889, described with basis on experimental 10 work on the dog , postoperative causes of peritoneal adhesions, emphasizing on adhesions located on the ileum, and concluded that adhesions could be induced by the gauze fibres as well as by intestinal scarifica10 tion . Brant, in 1897, described a case of adhesions 11 of the ileum after excision of an ovarian cyst . Payr, in 1911, described the relationship between adhesions, fibrinolysis and the importance of the first 48 hours 12 for the formation of these adhesions . The expression problems of peritoneal adhesiveness was later used by him to call attention to the great relevance of the problem through the large number of laparotomies that surgeons and gynaecologists were practising. He valued traumatic injury of the mucosa and peritoneal injury due to lack of moisture, chemical and thermal injuries in aseptic laparotomy. Congenital bands have been found to exist, but the great majority of all adhesions are secondary to some intra abdominal process such as a surgery, inflammation or intra-abdominal trauma. Adhesions following tuberculosis and other peritoneal inflammatory diseases were well recognized by early pathologists, but it was not until the advent of abdominal surgery in the 19th century that postoperative adhesions, and thus small bowel obstruction complications, became common. Through the years several proposals, for a series of solutions, were made to prevent these formations.

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Fig. 2 - Thivet M. Maladies du pritoine Grossesse pritonale, morte au bout de dix-huit ans. In Anatomie pathologique du corps humain. Ed. J Cruveilhier, Tome second, Livraison XXXVII, Libraire de lAcademie Royale de Medicine, 1843, Paris. A case of peritoneal extrauterine gestation presenting an image of the embryo, restrained for 18 years, in the abdominal cavity.

reporta uma primeira tentativa para a resoluo destas leses motiva uma comunicao com a utilizao de leo de massagem para impedir a sua formao em 1880s. Depois, respectivamente em 1886 e 1889, tanto Muller como Malcolm, descreveram a utilizao de solues salinas para float the intestines. Conceito que como iremos verificar mantm toda a actualidade. Um agente chamado fibrinolysin (tiosinarnine e salicilato de sdio) foi introduzida em 1892, mas no teve eficcia e caiu em desuso. A goma-arbica foi recomendada como lubricant between the viscera em 1902, e em 1905, a Johnson and Johnson lanou no mercado uma preparao de peritoneu cecal bovino (disponvel at 1993). Desde ento, uma grande variedade de substncias, algumas bem exticas, tem sido utilizada numa tentativa de evitar a formao destas adeses ps-operatrias: intestino grosso de touro, peritoneu de tubaro, lanolina, blis, membrana amnitica, bexiga de peixe, retalhos de epiploon e mltiplas pelculas. IMAGEM NOTVEL DE 1839 A Anatomia cincia morfolgica do estudo da arquitectura do corpo baseado na dissecao, legou Histria da Medicina tratados com excepcionais ilustraes. Disciplina muito tempo limitado aos dados de Galeno (129-200), iria ter um novo impulso na Idade Mdia a que se juntou com a dinmica trazida pela impressa de Gutenberg, cerca de 1450. Vrios autores publicam tratados de anatomia com ilustraes. De entre estes Andr Veslio publica em 1543 De humani corporir fabrica, obra notvel de anatomia tanto no plano conceptual com esttico e chegamos ao sculo XIX com um corpo de excepcionais tratados de anatomia. Nessa altura com a litografia era possvel publicar sem demasiados encargos, obras iconogrficas muito volumosas () um favor aos mdicos colocar ao alcance de todos o conjunto dos trabalhos que tiveram 13 a anatomia como objecto . Estamos nos incios dos anos 1880s, a anatomia encontrava-se no seu apogeu e escrevia-se: Sem a anatomia a fisiologia apenas um tecido de fbulas mais ou menos engenhosas, a cirurgia encontra-se sem orientao e a medicina est reduzida 13 a um empirismo cego . patente o primado existente ento da anatomia entre as disciplinas mdicas e na evoluo dos conceitos cientficos. A anatomia patolgica faz igualmente o seu percurso e entre 1828 e 1842 Lon Jean Baptiste Cruveilhier publica em Paris um memorvel tratado Anatomie pathologique du corps humain. A Cruveilhier (17911874) foi conferido o ttulo de doctor de medicina em Paris, em 1816, com uma dissertao com uma nova classificao de rgos de acordo com suas alteraes patalgicas. Em 1830 torna-se director do Hospice de la Maternit, mais tarde Salptrire e Charit, e em 1836 tornou-se o primeiro catedrtico da cadeira de anatomia patalgica, que tinha sido estabelecida pelo 14 seu professor, Dupuytren . Dedicando sempre um

A first attempt for its resolution, in 1880s, motivated a paper on the use of massage oil to hinder the formation of adhesions. In 1886, Muller spoke of the use of a saline solution and in 1889; Malcolm described the use of fluid to float the intestines. This concept, we go on to verify, is pertinent today. In 1892, an agent called fibrinolysin (sodium tiosinarnine and salicylate) was introduced, but it was not effective and fell into disuse. The gum-Arabic was recommended as a lubricant between the viscera in 1902, and in 1905, Johnson and Johnson launched, on the market, a preparation of bovine peritoneal cecum (available up to 1993). Since then, a great variety of substances, some quite exotic, have been used in an attempt to prevent the formation of these postoperative adhesions: large intestine from bulls, shark peritoneum, lanoline, bile, amniotic membrane, fish bladder, strips of epiploon and multiple films. A SINGULAR IMAGE FROM 1839 Anatomy, the morphologic science of the study of the architecture of the body based on dissection, bequeathed to the History of the Medicine compendiums with exceptional illustrations. Long limited to Galens data (129-200), anatomy would go on to have a new impulse in the Medieval age with the Gutenberg prints cerca 1450. Various authors publish illustrated compendiums of anatomy. Among them, Andres Veslio publishes, in 1543, De humani corporir fabrica, a highly notable work on anatomy in its conception as well as aesthetically. We arrive at XIX century with a body of exceptional textbooks on anatomy. At this point, with lithography, it was possible to publish without too much expense, voluminous iconographic compendiums () as a favour to doctors to place, within reach of all, the object of a set of works of anatomy. We are at the beginnings of the 1880s, anatomy was at its epitomy and thus was written: Without anatomy, physiology is just a weaving of more or less ingenious tales, surgery finds itself without orientation 13 and medicine is reduced to blind empirism . The existing primacy of anatomy then is evident amongst the medical disciplines and in the evolution of scientific concepts. Pathological anatomy equally follows suit between 1828 and 1842. Lon Jean Baptiste Cruveilhier publishes, in Paris, a memorable compendium on Anatomie pathologique du corps humain. Cruveilhier (1791-1874) was conferred with the title of Doctor of Medicine, in Paris in 1816, for his dissertation on a new classification of organs according to pathological alterations. In 1830 he became physician-in-chief and director of the Hospice de La Maternit, later Salptrire and the Charit, and in 1836, he became the first Professor to hold the chair of pathological anatomy, which had been established by his Professor, 14 Dupuytren . Always dedicating great interest to

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DISCUSSION The peritoneum with a surface area of 10,000 cm2 in the adult, almost equal to the surface of the skin, reduces the friction between abdominal viscera permitting its free movement. On the surface are highly differentiated mesothelial cells. It is on this level that, a surgical act sets off a cascade of events that flows toward the formation of membranes and adhesions. These can be responsible for a parade of symptoms which can go from abdominal pain to intestinal occlusion. Its diagnosis is, in wide measure, confirmed on surgery since there are no diagnostic procedures available for its identification. Due to the nature of these formations we cannot see them, unless directly due to their effect. In the XX century, most of the types materials in use or under development currently considered for prevention of adhesions: liquids, gels, barriers, fibrinolytic drugs, water soluble polymers and organic polymers. However, after some initial enthusiasm, experience did not consecrate its use. We go back to assume a previous reference on the concept of floating the intestines. In fact if we maintain the intestines and abdominal organs in a solution that keeps them in movement, the injured peritoneal surfaces cannot adhere to form membranes and adhesions. For this purpose, a solution used in dialysis is being proposed

DISCUSSO O peritoneu com uma superfcie de 10,000 cm2 no adulto, quase igual superfcie da pele, diminui a frico entre as vsceras abdominais permitindo o seu movimento livre. Apresenta superfcie clulas mesoteliais altamente diferenciadas e a este nvel que, aps um factor desencadeante, por exemplo um acto cirrgico, ocorre aquela cascata de eventos que pode confluir para a formao de bridas e aderncias. Estas podem ser responsveis por um cortejo de sintomatologia que pode ir da dor abdominal ocluso intestinal. O seu diagnstico em larga medida confirmado intra-operatoriamente, j que no dispomos de exames complementares de diagnstico para a sua identificao. Pela sua natureza no visualizamos estas leses, s identificamos o seu rebate. No sculo XX a maior parte de tipos de materiais actualmente em utilizao ou em desenvolvimento foram propostos para preveno das aderncias: lquidos, geles, barreiras, drogas fibrinolticos, polmeros hidrossoluveis e polmeros orgnicos. No entanto aps um perodo inicial de algum entusiasmo a prtica no consagrou a sua utilizao. E voltamos mesmo assumir uma referncia prvia com o conceito flot the intesti-

12 Payr E (1924) Biologisches zur Ents-

13 14 15 16

tehung, Rtickbildung und Vorbeugung von Bauchfel lverwachsungen. Zentralbl Gyniikol 14: 718 citado por Treutner KH, Schumpelick V. Adhsionsprophylaxe Wunsch und wirklichleit (Adhesions prevention wish and reality) Chirurg (2000) 71: 510-517 Bourgery JM, Jacob NH. Trait complet de lanatomie de lhomme. Na Edio Taschen Gmbh 2006 http://www.whonamedit.com/doctor. cfm/892.html http://www.cosmovisions.com/Cruveilhier.htm Thivet M. Maladies du pritoine Grossesse pritonale, morte au bout de dix-huit ans. in Anatomie pathologique du corps humain. Ed. J Cruveilhier, Tome second, Livraison XXXVII, Libraire de lAcademie Royale de Medicine, 1843, Paris.

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grande interesse Anatomia passava os seus dias nos pavilhes da Escola prtica, recolhendo os materiais para as obras Anatomie Pathologique du Corps Humain (1828-1842) e o Trait DAnatomie Pathologique Gnrale (1849-1864), Cruveilhier assenta a sua fama nas suas illustraes, notveis ainda hoje, bem como o estabelecimento do que constitu a primeira e magnifica tentativa de vulgarizao da cincia anatomo-patolo15 gica pela acessibilidade da imagem fiel das leses . De entre as diversas alteraes mrbidas susceptveis de ocorrer no corpo humano, apresenta-nos em 1839, no segundo tomo da obra, um captulo por Thivet M. com o ttulo: Maladies du pritoine Grossesse pri16 tonale, morte au bout de dix-huit ans . Neste texto o autor descrevendo um caso de gestao peritoneal, apresenta uma imagem verdadeiramente notvel do feto retido, durante 18 anos, na cavidade abdominal por gestao extra-uterina. Exibem-se vrias aderncias nesta estampa de grande rigor destas leses. on voit quil est encore recouvert de ses envelopes primitives, qui, aprs stre appliques etroitement sur lui, se porolongent sous forme de brides, et vont se fixer aux colons ascendant et transverse, en se continuant insensiblement avec le pritoine () La partie mdiane et occipitale de la tte donne insertion un grand nombre de cs brides () et qui vont sinsrer dautre au clon ascendent; elles mont paru organises, car jai pu y constater la presnce de vaisseaux et de petits paquets graisseux de la grosseur dune noisette () Tous ces prolongemens que nous retrouverons encore aux pieds AF, servaient de moyens de suspension lenfant dans la cavit abdominale.

Anatomy, his days were spent within the school pavilion laboratories, gathering material for the works on Anatomie Pathologique du Corps Humain (1828-1842) and the Trait DAnatomie Pathologique Gnrale (1849-1864). Cruveilhier s claims fame for his remarkable illustrations, even today, and establishes a first and magnificent attempt to popularize anatomo-pathological science through its accessibility of loyal images of 15 the lesions . This chapter shows a truly notable image 1. The author describes a case of peritoneal extrauterine gestation presenting an image of the embryo, restrained 16 for 18 years, in the abdominal cavity . Shown are 3 adhesions, using the expressions adhesions and tacks. It describes the neovascularization observed in the membranes presents an image of the great severity of these injuries. on voit quil est encore recouvert de ses envelopes primitives, qui, aprs stre appliques etroitement sur lui, se porolongent sous forme de brides, et vont se fixer aux colons ascendant et transverse, en se continuant insensiblement avec le pritoine () La partie mdiane et occipitale de la tte donne insertion un grand nombre de cs brides () et qui vont sinsrer dautre au clon ascendent; elles mont paru organises, car jai pu y constater la presnce de vaisseaux et de petits paquets graisseux de la grosseur dune noisette () Tous ces prolongemens que nous retrouverons encore aux pieds AF, servaient de moyens de suspension lenfant dans la cavit abdominale.

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nes. De facto se mantivermos os intestinos e rgos intra-abdominais com uma soluo que os mantenha com movimento no permitimos a juno de duas superfcies peritoneais lesadas que possam levar formao de bridas. Para este fim vem sendo proposto o uso de soluo utilizada na dilise que se mantm no abdmen por um perodo de cerca de 5 dias, antes da sua reabsoro. No texto que descrevia o caso da gestao intraperitoneal retida verificamos que h cerca de 180 anos atrs se utilizava uma nomenclatura, bridas e aderncias, que se mantm actual. Por outro lado a noo de maturidade das bridas, j est igualmente presente nesse texto. Sabemos hoje que a maturidade pode condicionar a sua classificao Histolgica e Macroscpica. A neovascularizao que o autor to bem assinala factor de verificao na classificao Histolgica das bridas de 17 Zuhlke . De acordo com a sua classificao Macroscpica que se refere facilidade com que se liberta as aderncias, desde uma pelcula que se separa com facilidade por disseco romba (grau I) ou onde a sua lise s possvel por disseco com tesoura ou bisturi e onde a libertao do rgo previsivelmente acarreta a sua leso (grau IV) a maturidade proporcionada pelo tempo que j levam desde a sua formao, deixa antever uma consistncia que est de acordo com a sua observao:serviam de meios de suspenso da criana na cavidade abdominal. So leses que tal como ento ainda hoje nos confrontamos quotidianamente. Na imagem 3 verificamos a ansa do delgado atingida, depois da lise de brida unica, numa operao de Janeiro de 2007. Este um campo que vem merecendo a ateno de muitos investigadores. Utilizando duas citaes poderemos dizer, em concluso, que nesta patologia oscilamos hoje entre uma constatao e um desejo. Por um lado as aderncias desde sempre fizeram parte da vida de um doente cirrgico bem como do cirurgio. O cirurgio aceita a formao destas aderncias como uma leso inevitvel, assim como algo que pode ser controlado to facilmente como o tempo que far 18 amanh . Por outro as feridas convivem com a humanidade desde o seu incio. A evoluo na cura no pode ser deixada em paz com a moderna tecnologia. O grau de inflamao e fibrose necessria em tempos 19 pr-histricos pode ser excessiva hoje .

which remains in the cavity for a period of five days before being absorbed. In the text which described the case of the retained intra peritoneal gestation, 180 years ago, we verified the use of the nomenclature, adhesions and membranes, still used today. On the other hand, the notion of the maturity of membranes is equally present in that text. We understand today that maturity can condition its histological and macroscopic classification. In the second half of the twentieth century enormous advances were made in virtually all fields of medicine. Nevertheless, we have entered the twenty-first century and the situation concerning the gravity of the consequences of abdominal fibrosis, with its adherences and fibrotic bands, has remained practically unaltered. Neovascularization, which the author so well remarks, is a factor which is verified in the Zuhlke histological classification of membranes. In agreement with his macroscopic classification which refers to the ease with which the membranes are freed, from the membrane which is separated with ease through rhombus dissection (grade I), or its lysis only possible through dissection with scissors or scalpel blade where the freeing of the organ will provoke its lesion (grade IV). The maturity proportioned by time evolved from its formation allows the foresee all of a consistency in accordance with its observation: the use of the means of suspension of the child in the abdominal cavity Lesions, which just as before, still confront us today. In image 3, we verify that the small intestine segment affected, after lysis of the only membrane, in an operation in January of 2007. This is an area which has received the attention of several investigators. Citing two quotes, we could say that, in conclusion, in this pathology we swing today between acknowledgement and desire. On the one hand adhesions have always been part of the life of the surgical patient and of the surgeon. The surgeon accepts the formation of these adhesions as inevitable, something so easily controlled as the weather 18 tomorrow . On the other hand wounds are familiar to humanity since the beginning. The evolution of healing has not kept up with modern technology. The degree of inflammation and fibrosis necessary in pre 19 historic times can be excessive today .
Fig. 3 - Imagem II. Ansa do intestino delgado atingida, depois da lise de brida nica.
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Referncias | References 1.Ellis H. The clinical significance of adhesions: focus on intestinal obstruction. Eur J Surg Suppl, 1997;577: 5-9 2. Wilson MS, Hawkswell J, McCloy RF. Natural history of adhesional small bowell obstrution: counting the cost. Br J Surg 1998; 85: 1294-1298 3. Thompson JN, Ellis H, Parker MC et al. Surgical impact of adhesions following surgery in the upper abdomen. Br J Surg 1999; 86: 418-419 4. Herschlag A, Diamond MP, DeCherney AH. Adhesiolysis. Clin Obstet Gynecol 1991; 34:395-401 5. Angioli R, Barreau G. Interceed use and adhesion prevention in gynecology. Contemporary OB/GYN Archive 1998 Nov. http://obgyn.pdr.net/obgyn/public.htm?path=content/journals/g/ data/1998/gba/gba096.html 6. 10 7. Van Der Krabben AA; Dijkstra FR; Nieuwenhuijzen M; Reijnen MM; Schaapveld M; Van Goor H. Morbidity and mortality of inadvertent enterotomy during adhesiotomy. Br J Surg 2000 Apr;87(4):467-71 8. Wiseman DM. Adhesion prevention: Past the future. In DiZerega GS (Ed.) Peritonea1 Surgery 2000 Springer-Verlag. pp:401-417 9. Von Dembowski T (1889) Ueber die Ursachen der peritonealen Adhsionen nach chirurgischen Eingriffen mit RUcksicht auf die Frage des Ileus nach Laparotomien. Langenbecks Arch Chir 37: 745 citado por Treutner KH, Schumpelick V. Adhsionsprophylaxe Wunsch und wirklichleit (Adhesions prevention wish and reality) Chirurg (2000) 71: 510-517 10. Ellis H. Adhesions: the early history. Hospital Medicine, Vol. 65, Iss. 6, 10 Jun 2004, pp 328 - 329 11. Bryant T (1872) Clinical lectures on intestinal obstruction. Med Times Gaz 1: 363 citado por Treutner KH, Schumpelick V. Adhsionsprophylaxe Wunsch und wirklichleit (Adhesions prevention wish and reality) Chirurg (2000) 71: 510-517 12. Payr E (1924) Biologisches zur Entstehung, Rtickbildung und Vorbeugung von Bauchfel lverwachsungen. Zentralbl Gyniikol 14: 718 citado por Treutner KH, Schumpelick V. Adhsionsprophylaxe Wunsch und wirklichleit (Adhesions prevention wish and reality) Chirurg (2000) 71: 510-517 13. Bourgery JM, Jacob NH. Trait complet de lanatomie de lhomme. Na Edio Taschen Gmbh 2006 14. http://www.whonamedit.com/doctor.cfm/892.html 15. http://www.cosmovisions.com/Cruveilhier.htm 16. Thivet M. Maladies du pritoine Grossesse pritonale, morte au bout de dix-huit ans. in Anatomie pathologique du corps humain. Ed. J Cruveilhier, Tome second, Livraison XXXVII, Libraire de lAcademie Royale de Medicine, 1843, Paris. 17. Zuhlke HV, Lorenz EMP, Straub EM, Savvas V. Pathophysiologie und klassifikation von adhasionen. Langenbecks Arch Chir Suppl II (Kongressbericht 1990): 1009-1016. citado por Luijendijk RW, Foreign material in postoperativa adhesions. Ann Surg 1996; 223: 242-248 18. Wolff B G. Invited Commentary to Parker MC, Ellis H, Moran BJ, et al. Postoperative Adhesions: Ten-Year Follow-Up of 12,584 Patients Undergoing Lower Abdominal Surgery. Dis Colon Rectum 2001 Jun; 44(6):822-830 19. Robson MC, Steed DL, Franz MG. Wound healing: Biologic features and approaches to maximize healing trajectories. Current Problems in Surgery February 2001; Vol.38. Number 2

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