Retograde migration of starch particles in the female genital tract

Abstract

Tubal and pelvic adhesions are a major cause of female infertility in humans. The majority of postoperative intra-abdominal adhesions result from the presence of ischaemic tissue within the abdominal cavity. These precipitate an inflammatory vascular response from neighbouring healthy tissue. Foreign material within the peritoneal cavity can produce granulomas and adhesions, either as the sole precipitating factor or as an additional stimulus to the ischemic tissue. It is well documented that starch-powdered gloves are inappropriate for abdominal surgery.

Intraperitoneally, starch particles can initiate inflammatory reactions and the formation of adhesions probably due to reduced peritoneal fibrinolysis. If already injured mesothelial peritoneal surface is exposed to starch, more dense adhesions are created than in the case of peritoneal trauma or starch separately.

The primary intention of this thesis was to investigate whether glove powder, i.e. starch particles, could migrate from the vagina into the abdominal cavity and cause adverse reactions. The second objective was to evaluate the effect of starch on the implantation of endometriosis and the development of adhesions.

In a rabbit model starch particles (BiosorbTm) were deposited intravaginally and any retrograde transportation of starch from the vagina into the intraabdominal cavity was studied on different days. The presence of starch particles in cell smears and biopsies from the genital cavity indicated that retrograde migration of starch powder placed in the vagina did occur. The transportation time for most starch particles seemed to be three days.

In a further animal study, intravaginal starch combined with a standard intra-abdominal surgical trauma three days later generated dense intra-abdominal adhesions. A clinical study in humans was carried out where one study group underwent a pelvic examination with powdered gloves one day before abdominal hysterectomy and another group four days before. There were significant differences in the retrograde migration of starch particles between those examined with powered gloves one day before surgery. The difference was less marked in patients who had been examined four days before surgery.

To study the effect of starch particles on endometriosis in vitro, a human endometriotic cellline was cultured with different concentrations of starch particles. Starch particles inhibited the proliferation of endometriotic cells in vitro. The intraperitoneal growth of endometriosis and the development of adhesions were investigated in vivo in SCID mice after intraperitoneal injections of cells from a human endometriotic cell culture together with starch particles. There were significant differences between the developments of adhesions. No significant differences in the development of endometriotic glands were found.

Conclusions: These studies, the rabbit model and the human model, indicate that there is a retrograde migration of glove powder from the vagina to the intraabdominal cavity. Combined with a surgical intra-abdominal trauma intraperitoneal starch particles can cause subsequent post-operative- adverse tissue reactions and together with endometriotic cells cause adhesions in vivo but with a delayed effect compared to starch alone. Today, powder-free gloves are in almost universal use at abdominal operations in the Western World, so the problem from this cause has been more or less eliminated. However, cheaper, starchpowdered gloves, and starch-powdered covers for ultrasound vaginal transducers, may still be used in vaginal examination. Our studies indicate that this should be avoided.