Lasers in Surgery and Medicine 47:817–823 (2015)

Prevention of Abdominal Adhesions and Healing Skin After

Peritoniectomy Using Low Level Laser
Mara L.C.D. Teixeira, PT, MSc, Leonardo S. Vasconcellos, MD, PhD, Tharcisio G. Oliveira, MD, MSc,
Andy Petroianu, MD, PhD, and Luiz R. Alberti, MD, PhD

Department of Surgery, Medical School of the Federal University of Minas Gerais, Post Graduation Course of Santa Casa
de BH, Belo Horizonte, Brazil

Background: Adhesions commonly occur after abdominal a thin layer of connective tissue, a slightly thicker tissue
surgery and can cause bowel obstruction, chronic abdominal containing blood vessels and nerves, or can represent a
pain, and infertility. Their prevention remains a challenge. direct contact between the surfaces of two bodies.
Objectives: To evaluate the effects of the application of Adhesions can be found in the peritoneal, pericardial,
low-level lasers on the prevention of adhesions and pleural, uterus, joints, or ocular chambers. Adhesions in
scarring of the skin after peritoniectomia. the abdominal cavity are known as peritoneal adhesions,
Method: Twenty-four New Zealand breed male rabbits, since the visceral or parietal peritoneum is always
approximately 2 months of age, were randomly divided into involved. Its incidence after surgery is high and can occur
3 groups (n ¼ 8): GC—control group not subjected to laser, in up to 93% of all laparotomies [1].
GL1—group with laser application at a dose of 0.2 J, and Adhesions are associated with the risk of death, as they
GL2—group with laser application at a dose of 3.6 J. All are related to serious complications, such as intestinal
animals received a longitudinal midline incision and a obstruction, which can also cause chronic abdominal pain
bilateral resection of the peritoneal fragment, measuring and female infertility. These are the most prevalent causes
3  1 cm2. The animals received a laser treatment of one of acute and recurrent obstruction of the small intestine
application every 24 hours, beginning at the time of surgery and are associated with mortality rates of up to 15% [1,2].
and lasting for a period of 4 days. After 14 days post- Peritoneal trauma, foreign bodies, tissue ischemia, and
surgery, the animals were killed and adhesion formation infections of the abdominal viscera are the main factors
was evaluated qualitatively and quantitatively by means of associated with the formation of postoperative adhesions,
a laparotomy shaped inverted “U”, which allowed for the but the specific pathophysiology of adhesions remains
verification of the broad wall of the abdominal cavity and uncertain [1]. According to Henrrick et al. (2001), adhesion
organs. Differences were considered significant at P < 0.05. formation is a consequence of peritoneal injury with local
Results: The adhesion formation was observed in 100% of the ischemia and false regeneration [2].
rabbits from groups GC and GL1, as compared to 37.5% of This serosanguineous peritoneal injury can cause an
the rabbits from group GL2 (P < 0.01). The evaluation of the inflammatory reaction that can lead to fibrin deposits.
vascularization and tenacity of adhesions among the groups Well-oxygenated and intact mesothelial cells produce
showed no significant difference. In groups CG and GL1, 72% plasminogen activators, which smooth the fibrin clots
and 83% of adhesions were verified between visceras, formed after injury. The proliferation of mesodermal cells
respectively whereas in GL2 occurred among abdominal regenerates a single layer of mesothelium between three
wall. The tensile strength of the skin between the groups was and five days after injury. In experimental wounds,
not significant (P ¼ 0.3106). The resistance of abdominal wall fibrinolytic activity could be identified three days after
segments without skin he resistance of skin segments between the lesion and before the reconstruction of the integrity of
groups GL2 and GC were higher than in GL1 (P ¼ 0.01). the mesothelium. This process is rapid and generally
Conclusion: Low-level LASER is effective in preventing reproduces the peritoneal wall with no formation of
intra-abdominal adhesions in rabbits without compromis-
ing strength and healing of the abdominal wall. Lasers
Surg. Med. 47:817–823, 2015. ß 2015 Wiley Periodicals, Inc.
Conflict of Interest Disclosures: All authors have completed
Key words: peritoneal adhesions; photobiostimulation and submitted the ICMJE Form for Disclosure of Potential
laser; low-power laser irradiation; low-level laser; low-power Conflicts of Interest.
Contract grant sponsor: CNPq and FAPEMIG.
laser therapy; laser therapy; healing; rabbit; tensile strength

Correspondence to: Luiz R. Alberti, MD, PhD, Department of
Surgery, Medical School of the Federal University of Minas
Gerais, Post Graduation Course of Santa Casa de BH, Belo
Horizonte 30220-000, Brazil. E-mail: [email protected]
INTRODUCTION Accepted 14 September 2015
Adhesions are defined as abnormal connections of organs Published online 28 September 2015 in Wiley Online Library
(wileyonlinelibrary.com).
or body structures. These connections, or bridges, can form DOI 10.1002/lsm.22423

ß 2015 Wiley Periodicals, Inc.

818 TEIXEIRA ET AL.

adhesion. Moreover, improper fibrinolysis allows the C. Aspect of the abdominal wall after resection.
proliferation of fibroblasts to produce fibrous adhesions. D. Perioperative application of low-intensity lasers in
With hypoxia, the fibrin matrix is invaded by fibroblasts, Groups GL1 and GL2 at four points, located 1 cm from
with the stimulation of angiogenesis and collagen synthe- each other, two on the right side and two on the left side,
sis. Fully developed fibrous adhesions begin to form after in locations where the patches had been removed.
10 days and reach their complete form between 2 and E. Continuous suture of the wound in layers (aponeurosis,
3 weeks after injury [3]. parietal peritoneum, and skin) with 3–0 nylon thread.
Prophylactic measures have been taken to reduce F. Postoperative application of low-intensity lasers in
adhesion formation, aimed at reducing the inflammatory Groups GL1 and GL2 at four points, located 1 cm from
response and coagulation and to prevent prolonged contact each other, two on the right side and two on the left side,
between surfaces connected by means of siliconized effects; in locations where the patches had been removed.
however, to date, none have shown to be fully effective and All animals were subjected to the same procedure as the
safe in reducing adhesions [4,5]. GC group but without the application of low-intensity lasers.
The low intensity laser, also called low-power or bio- The skin of the animals from the GL1 and GL2 groups
stimulant, has been used since the late 60’s to heal wounds received one daily application of low-intensity laser at the
and ulcers. Although the laser is already used on a large same dose used in the perioperative period, every 24 hours,
scale, to facilitate the healing process for at least 50 years, beginning with the surgery and continuing for four
studies evaluating the effect of this therapy on the consecutive days. Each application was performed at
formation of adhesions have yet to be published [6,7]. four points, two on the right side and two on the left
The aim of this study was to evaluate the effects of low- side, spaced 1.5 cm from the midline, with a 1 cm distance
intensity lasers on the formation, morphology, and between the points of application (Fig. 1F).
inflammatory aspects of abdominal adhesions and the All animals were killed on the 14th post-operative day by
scarring of the skin after peritoniectomy in rabbits. applying an intramuscular anesthesia with ketamine
hydrochloride at a dose of 50 mg/kg.
METHOD
The abdominal cavity was examined after extensive
The present study was conducted at the Laboratory of longitudinal midline incision in the shape of an inverted
Experimental Surgery, Federal University of Minas Gerais “U” surrounding the surgical scar.
(UFMG), in accordance with recommendations set forth in the The qualification and quantification of adhesions were
International Protection of Animals and the Brazilian Code of based on the study of MORENO-EGEA (1993), in a
Animal Experimentation (1988), and was approved by the modified form [8].
Ethics Committee on Animal Experimentation from UFMG. The following parameters of adhesions were evaluated:
Twenty-four adult male New Zealand rabbits (Orycto-
galus cuniculus) were divided randomly into three groups. 1. Animal-free grip: related to the number of animals
At the beginning of the experiment, all rabbits weighed, on where there was no formation of adhesion;
average, 2.350  240 g. 2. Count: related to the amount of adhesions found;
The animals were randomly divided into three groups: 3. Area: measured using digital calipers, two measure-
ments were conducted by adhesion, the first referring to
 GC (n ¼ 8) control group, without LASER; the contact surface between the attached structures and
 GL1 (n ¼ 8) Group submitted to LASER: 0.2J of dose, the second referring to the thickness of the grip.
fluence of 5J/cm2 power of 0,005W, duration of 40 The area of adhesion was calculated from these two
seconds per point, spot area, 0,04 cm2; dimensions;
 GL2 (n ¼ 8) Group submitted to LASER: 3.6J of dose, 4. Tenacity: adhesions were characterized as loose (that
fluence of 90J/cm2 power of 0.04W, duration of 90 second adherence would be peeled easily without requiring
per point, spot area, 0,04 cm2. dissection) and firm (when there was need for dissection
The animals had their abdomens shaved and were then to be separated);
anesthetized with a deep intramuscular gluteus of Keta- 5. Vascularization: presence or absence of blood vessels in
mine hydrochloride at 20 mg/kg, together with a 2% adhesion, without the use of a magnifying glass and by
Xylazine at a dose of 6 mg/kg. Antibiotic prophylaxis optical microscopy;
with Cephalexin monohydrate was applied at a dose of 6. Location: classified as follows: adhesion between the
50mg/kg and was administered intramuscularly 30 mi- parietal peritoneum and omentum, between the bowel
nutes before carrying out the following procedures. and omentum, between other organs and the bowels,
The surgery was performed according to the following and between the parietal peritoneum and the bowels;
steps (Fig. 1): For the mechanical test of the tensile strength of the skin
A. Median longitudinal laparotomy measuring 7 cm in and the abdominal wall without the skin, a universal
1
length, 4 cm distal to the xiphoid process; testing machine, Kratos model DEK 200 kgf with a load
B. Resection of parietal peritoneum fragment of 1  3 cm2, cell of 20 kgf, was used.
using a template to standardize the size of all excised The abdominal wall was removed, and a specimen was
fragments. taken with a scalpel, using a plastic mold, aimed at
 PREVENTION OF ABDOMINAL ADHESIONS WITH LASER 819

Fig. 1. Following the surgical procedure and LASER therapy: (A) Median longitudinal laparotomy
measuring 7 cm long, 4 cm distal to the xiphoid process. (B) Resection of parietal peritoneum
fragment using a template to standardize the size of every fragment excised. (C) Aspect of the
abdominal wall after resection. (D) Perioperative application of low intensity LASER Groups GL1
and GL2 in four points, 1 cm distant from each other, two on the right side and two on the left side, in
places where the patches were removed. (E) Continuous suture the wound in plans (aponeurosis and
parietal peritoneum and skin) with nylon 3-0. (F) Postoperative application of low intensity LASER
Groups GL1 and GL2 in four points, 1 cm distant from each other, two on the right side and two on
the left side, in places where the patches were removed.

standardizing the specimens. The surgical scar was placed Categorical variables were compared among the groups
in the center of the mold. using the Freeman-Halton test, an extension of the exact
The skin was separated from the rest of the abdominal test. Quantitative variables were compared among the
wall using a scalpel. The fragments of the abdominal wall groups using ANOVA. When a significant difference was
without the skin and the skin itself were placed in vials, identified, the Tukey HSD test was performed to verify
individually identified, and moistened with gauze soaked which groups were different. Statistical analyzes were
in saline. Assays were performed in a maximum period of 3 considered significant at P < 0.05.
hours after the preparation of the test specimens.
The information collected was entered into Excel spread- RESULTS
sheets. Analyses were performed using free calculators One hundred percent of the animals in the GC and GL1
available at electronic addresses: http://faculty.vassar.edu/ groups presented adhesion formation, whereas in the GL2
lowry/anova1u.html for the ANOVA and Tukey HSD Test group, only 37.5% of the animals presented this type of
and http://faculty.vassar.edu/lowry/fisher23.html for the formation. The number of adhesions found in the animals
Freeman-Halton test, an extension of the exact test. from the GC and GL1 groups was 3.12  0.83 and
The results were obtained using frequency and percen- 2.88  1.96, respectively, while in the group GL2, this
tages for categorical variables and characteristics of value was 0.38  0.52. When the area was measured in the
measures of central tendency (mean and median) and CG and GL1 groups, the values reached 1.17  0.89 cm2
dispersion (standard deviation) for quantitative variables. and 2.00  0.93 cm2, respectively, whereas in the GL2
820 TEIXEIRA ET AL.

group, the average area reached 0.50  0.76 cm . Regard-

2
DISCUSSION
ing toughness (fine or strong) and vascularization (vascu-
lar or avascular), no differences could be found among the Abdominal adhesions remain a challenge for health care
groups. When the location of adhesions in the GC and GL1 professionals, especially for surgeons. These formations
groups was assessed, these formations could be identified are commonly related to hospital readmission after
in the intestines (72% and 83%, respectively), whereas in abdominal and pelvic surgery, bowel obstruction, as well
the GL2 group, the intestines showed no sign of these as female infertility and pain [9]. Furthermore, they
formations in 100% of the cases (Table 1). represent a considerable socio-economic burden on the
The evaluation of the skin’s and the abdominal wall’s health system in many countries [10,11].
resistance had the objective of determining whether or Adhesiolysis (lysis of adhesions) is the only known form of
not irradiation by low-intensity lasers would have any treatment currently used to combat abdominal adhesions.
effect on this resistance. Upon analyzing the limit of However, this procedure carries a greater risk of perioperative
tensile strength of the skin, no difference among the complications and a high recurrence rate. Moreover, it is
three groups could be observed. When analyzing the unable to prevent the recurrence of adhesions that could lead
limit of tensile strength of the abdominal wall (not to future intestinal obstruction [9].
including the skin), no difference could be identified Fevang et al. (2004) illustrated that approximately 30%
between the GC and GL2 groups. However, this value of all patients undergoing adhesiolysis due to an obstruc-
did prove to be higher than that found in the GL1 group tion of the small intestine required a second operation to
(Table 2). remove recurring adhesions [12].

TABLE 1. Characteristics of Peritoneal Adhesions in Different Groups

Groups GC GL1 GL2 P-value

Number 25 23 3
0.000a
GL2 < GC ¼ GL1b
Presence of adhesions
Presence 8 (100%) 8 (100%) 3 (37.5%)
Absent — — 5 (62.5%)
0.003c
Area (cm2) 1.75  0.89 2.00  0.93 0.50  0.76
0.006a
GL2 < GC ¼ GL1b
Sites
Wall and omentum 7 (28%) 4 (17%) 3 (100%)
Omentum and intestines 9 (36%) — —
Other organs and intestines 1 (4%) 5 (22%) —
Wall and intestines 8 (32%) 14 (61%) —
Intestinal involvement 8 (100%) 8 (100%) 0 (0.0%)
Vascularization (valued without
magnifying glass)
Vascularizada 20 (80%) 20 (86,96%) 3 (100%)
Avascularizada 5 (20%) 3 (13.04%) —
0.8240c
Vascularization (by microscopy)
Vascularized 25 (100%) 23 (100%) 3 (100%)
No vascularized — — —
Tenacity
Firm 9 (36%) 15 (65%) 3 (100%)
Loose 16 (64%) 8 (35%) —
0.710c
CG, Control Group; GL1, Low Dose Group LASER, GL2, High Dose Group LASER. The number values, presence of adhesion sites,
vascularization and tenacity are absolute.
The area values were calculated per animal by total.
a
Anova.
b
Tukey test for multiple comparison tests.
c
Freeman-Halton test, extension of Fisher’s exact test.
 PREVENTION OF ABDOMINAL ADHESIONS WITH LASER 821

TABLE 2. Limit Tensile Strength of Skin and Wall Without Skin of the Three Groups on the 14th Postoperative
Day

Groups GC GL1 GL2 P-value

2
Limit of tensile strength of skin (kgf/mm ) 4.23  1.20 3.10  1.79 3.42  1.25 0.3106a
Limit of tensile strength of wall 3.70  0.89 2.79  0.74 4.88  1.21 0.001a
without skin (kgf/mm2) GC¼GL1, GC¼GL2
GL2>GL1b
CG, Control Group; GL1, Low Dose Group LASER, GL2, high Dose Group LASER.
The values expressed as mean  standard deviation.
a
Anova.
b
Tukey test for multiple comparison analysis.

These data also suggest that surgery performed to lyse These investigations have shown that low-intensity
the adhesion is almost as adhesion-inducing as the original lasers play an important role in wound healing, in
transaction. Two thirds of all bowel obstructions occurred activating the photobiostimulation of injured tissues, in
within the first five years, nearly one fourth in the 10 accelerating tissue repair, in modulating the inflamma-
subsequent years, and in many patients the risk was still tory process, as well as in reducing acute pain due to
present even 20 years later. This clearly places adhesions the inflammatory process. Several previous studies
in the category of long-term complications [12]. have shown that lasers regulate the release of cytokines
The prevention of the formation of adhesions should responsible for fibroblast proliferation and collagen
therefore be the focus of attention. Peritoneal trauma synthesis, thus, improving collagen deposition, and
represents the basis for the formation of adhesions after further resulting in the improved organization of architec-
abdominal surgery [9]. According to Arung et al. (2011), tural collagen fibers [20]. A study conducted in burned
only meticulous surgical techniques can be recommended showed increased deposition of type III collagen in the
to reduce the formation of adhesions, as well as reduce the laser irradiated animals when compared with control,
morbidity and mortality rates stemming from these [9]. non-irradiated, after 16 days of lesion, indicating that the
Several agents and their abilities to prevent the laser treatment is able to accelerate the proliferative
formation of postoperative adhesions were investigated. phase of healing [21].
These agents worked to change the activation of fibrinoly- Considerable variation in the research project, method-
sis, hinder coagulation, decrease inflammatory response, ology, and irradiation parameters used limited the
inhibit collagen synthesis, or create a physical barrier comparison of results among studies [22–24].
between adjacent surfaces of wounds. The results, per- To define the parameters of laser application, it is
formed in animal models are encouraging, but most are necessary to consider a wide range of variables. What
contradictory [13–16]. determines whether the light is photobiostimulating or is
In the present work, rabbits were chosen as an detrimental to the tissue is the intensity (I), also called
experimental model. In the literature, the rabbit has irradiance or power density. Intensity is defined as the
been used in approximately 35% of the complex musculo- useful laser power, expressed in watts (W), divided by
skeletal studies in biomedical sciences. Most studies the irradiated area expressed in square centimeters (cm2).
present the advantage of size, ease of handling, and the The fluence (F), also called energy density or energy dose
fact that they reach skeletal maturity, after sexual (ED), is the term used to describe the rate of energy applied
maturity, at around six months of age. Moreover, rabbit to the biological tissue and is determined by multiplying
skin is also quite similar to human skin. the intensity (expressed in Watts per square centimeter
The peritoniectomy model is devoted to the experimental or W/cm2) by the exposure time (in seconds), which is
induction of adhesion formation [3,16]. In the present expressed in Joules per square centimeter (J/cm2).
study, such an intervention proved to be effective, since all Also present is the physical quantity of energy (E) that,
animals in the control group (CG) presented adhesions. in the application of laser light, represents the amount of
This finding is consistent with the literature, which laser being deposited upon the tissue and is calculated by
identifies the peritoneum’s aggression as a cause of multiplying the optical power of the appliance (expressed
adhesions [17]. The etiology of these would be related to in watts) by the exposure time (expressed in seconds). The
failures in the peritoneal repair mechanism, in turn result is represented as the unit joule (J) [25].
causing scarring that develops at trauma sites after Most works describe the dose fluence (J/cm2), others in
surgery [10,18]. Joules (J), but most fail to inform other parameters, such as
The use of low-level lasers with the aim of aiding in wavelength, energy deposited in the tissue density energy
tissue repair has been widely researched since 1963. beam area, time of application, peak power (continuous),
Six review articles, published between 2006 and 2010, medium power (pulsed mode), and power density. The lack
and a meta-analysis [19], published in 2009, evaluated of comprehensive data makes it difficult to reproduce and
these lasers’ effects on wound healing and pain relief. compare results [19,25].
822 TEIXEIRA ET AL.

According to the World Association for Laser Therapy The lack of difference between the tenacity of adhesions
(WALT), the application of 1–4 J Final energy is required to among the groups suggests that the application of low-
achieve photobiostimulating effects caused by low-intensi- intensity lasers did not affect the quality of the treated
ty lasers at wavelengths ranging from 780 to 904 nm, tissue. Although there are no similar studies, some
considering that no reference table exists for the wave- investigations have shown that the application of low-
length of 660 nm. In this study, two laser doses were used, intensity lasers does not alter the quality of the formed scar
one outside the therapeutic window (5J/cm2 for 40 second tissue and only accelerates the healing process, which
¼ 0.2 J) and one near the bottom of the window (90J/cm2 for could explain, in theory, the lack of difference among
90 s ¼ 3.6 J) to determine if the therapeutic window, groups [19,22–24].
according to that proposed by WALT would also apply to In the present work, a total of 53 adhesions formed: 45
the laser wavelength of 660 nm [26]. (84.90%) could be observed when viewed by the naked eye;
There is great confusion in relation to units of measure- when the evaluation was performed by light microscopy,
ment for laser application. Some authors report that 100% could be viewed. This finding is in agreement with
parameter in fluence (J/cm2) and other in energy (J). These the literature which describes adhesions as highly
measurement units differ widely. The original work of vascularized tissue containing well-developed arterioles,
Mester (1985) used a dose of 4 J and many authors use capillaries, and venules [16].
values close to 4J/cm2 believing to be using the value The greater involvement of small and large intestine
proposed by Mester [6]. In fact, they are quite different. We adhesion is similar to findings from other reports, (1,4).
used in Group 1 dose as close to 4 J/cm2 (not therapeutic However, at a dose of 3.6 J (within the therapeutic window),
dose, but very used in papers) and in G2 the value closer to the application of low-intensity lasers was able to minimize
4J (therapeutic dose) in order to demonstrate that the this involvement. All adhesions developed in the GL2
therapeutic response is totally different if we vary the group (3.6 J) involved only the abdominal wall and the
deposited energy this way. omentum. According to the literature, the low-intensity
One of the difficulties in conducting research on lasers accelerate the healing process. It is possible to
adhesion formation has been the lack of uniformity in conclude that a faster healing process also presents the
the classifications and interpretations of adhesions in the severity of the adhesions. Hence, bowel adhesions are less
literature [4,5]. Most methods, using various parameters, likely to become symptomatic and cause acute abdomen [4].
consist of indexes and fail to accurately report the The aim of biomechanical studies is to determine the
evaluations of each. The use of subjective terms, like mechanical properties of a material, which, depending on
“small number”,“generalized adhesions”, “limited vascu- its physical characteristics, can be submitted to tensile
larization”, “moderate adhesions”, and “minimal adhe- strength, torsion, compression, and bending [29]. The
sions” also make it difficult to compare results [5]. present study was carried out to test the tensile strength in
In assessing the presence or absence of adhesions, the an attempt to identify whether or not the application of
low-intensity lasers, at a dose of 3.6 J (within the low-intensity lasers are able alter this limit of scar tissue
therapeutic window) in the GL2 group, were able to on the skin and on the abdominal wall, not including
significantly reduce these formations. The application at a the skin. This study sought to identify the elastic limit, i.e.,
dose of 0.2 J (outside the therapeutic window) in the GL1 the point at which the fabric undergoes no permanent
group, presented results that were similar to the CG group. deformation. By halting the test before this point and
The index of the animals from the GL2 group that were free removing the traction force, the specimen returned to its
of adhesions (62.5%) was superior to that achieved by original shape, like a rubber band.
1
Seprafilm resorbable membrane (51%), currently consid- Laser application, either within (3.6 J-GL2) or outside
ered one of the most effective methods of reducing the the therapeutic window (0.2 J-GL1), did not alter the limit
1
formation of adhesions. However, the use of Seprafilm of the skin’s tensile strength when compared to the CG (no
significantly increases the incidence of abdominal abscess- treatment). This finding is consistent with the literature,
es and fistulas, as well as dehiscences of anastomoses, confirming that the application of low-intensity lasers does
which can potentially contaminate surgery [27]. not alter the quality of the scar tissue, which could explain
At a dose of 3.6 J (within the therapeutic window), the the lack of difference among groups [23,24].
application of low-intensity lasers proved effective in As there is no bone support on the wall of the abdominal
reducing the area of adhesions that had developed. cavity, its strength is derived entirely from the shape of its
Unfortunately, measuring the area of adhesion formation soft tissue structures. The strength of the abdominal wall
is quite unusual in the findings from prior medical is of great importance because its weakening is primarily
literature, making it difficult to compare the data from responsible for the formation of hernias and eviscerations.
this experiment [28]. The difficulty of measuring this Laser application in (3.6 J-GL2) or outside the therapeutic
parameter can also be a limiting factor, since adhesions are window (0.2 J-GL1) did not alter the tensile strength
not presented uniformly. In this paper, the method used is limit of the abdominal wall when compared to the CG
original and sought data that referred to the contact (no treatment), showing that laser applications cause no
between the adhered surfaces. Further research should be weakening of the abdominal wall and are safe for use in
conducted to clarify the pathophysiological mechanisms of abdominal surgery, especially as regards the formation of
this reduction. hernias and eviscerations.
 PREVENTION OF ABDOMINAL ADHESIONS WITH LASER 823

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