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Paper text:
seprafilm ( genzyme corp . , cambridge , ma , usa ) , composed of sodium hyaluronate and carboxymethylcellulose , was approved by the u.s . food and drug administration ( fda ) in 1996 and is one of the adhesion barriers widely used in surgery today .
this product is indicated for abdominal or pelvic laparotomy surgery to reduce the incidence , extent , and severity of postoperative adhesions .
however , seprafilm is seldom used in laparoscopic surgery because of its tendency to break apart when it is inserted into the abdominal cavity through a trocar , resulting in a high placement failure rate .
several techniques of insertion of seprafilm have been developed , but some require special equipment and some are complicated . moreover , seprafilm placement in single - port surgery is more difficult than in multiport surgery .
this work presents a modified approach to seprafilm placement , in which the seprafilm is prepared by softening and rolling before insertion into the abdomen .
this proposed method is a better method that combines and simplifies the two previously reported methods .
forty - six patients were recruited into this study . they had undergone single - port ( n = 26 ) or multiport ( n = 20 ) laparoscopic gynecology surgery including the insertion of seprafilm between december 2014 and january 2016 . after the major laparoscopic procedures were performed , seprafilm was prepared and placed as follows .
seprafilm and its paper backing ( figure 1a ) were cut together into 4 equal pieces ( figure 1b ) .
each piece of the film was placed on damp gauze until it naturally curled up ( 68 seconds ) ( figure 1c ) .
two pieces of the film were rolled up with the backing ( from the seprafilm package ) .
the roll was gripped with forceps ( figure 1d ) and insert into the abdominal cavity through the 11-mm trocar sleeve ( figure 1e , 1f ) .
( b ) the film is cut , together with its paper backing sheet , into 4 equal pieces .
( c ) a piece is placed on moistened gauze to soften it until it naturally curls up .
( d ) two pieces are rolled up in 1 backing sheet , and gripped with an intestine - holding forcep .
( e , f ) the roll is inserted into the abdominal cavity through the 11-mm trocar . in multiport
laparoscopy , after the abdominal cavity was entered , another forceps was used to unroll the seprafilm ( figure 2a ) and move the first piece to the intended site ( figure 2b ) , followed by the second piece ( figure 2c ) .
the other 2 pieces were placed in the same manner . in the single - port laparoscopy ,
only 1 forcep was used to unroll the seprafilm and subsequently move it to the intended site ( figure 2d  f ) .
some skill was needed to remove the 2 residual paper sheets in the abdomen , grasping one corner of the paper ( fig .
2 g ) , pulling it out gently and rotating it at the same time so that the paper could be rolled and passed through the 11-mm trocar or single port ( figure 2h ) without friction ( figure 2i ) .
the placement of seprafilm in multiport ( a  c ) and single - port ( d  f ) procedures and removal of the residual paper holders ( g  i ) .
placement of the first ( b ) and the second ( c ) layers of film .
one corner of the paper backing is grasped ( g ) and pulled out and rotated ( h ) via the 11 mm - trocar and completely removed through the trocar ( i ) .
the number of successful insertions and placements of seprafilm was calculated and the time from the moistening of the film until all pieces were positioned were reviewed in every case .
the definitions of successfully placed seprafilm were as follows : in myomectomy , the film framed the suture line , 1 cm away the line ; in total and subtotal hysterectomy , the film framed the endocervical region and bilateral peritoneum opening ; in sacrocolpopexy , the film framed the anterior , posterior , and lateral peritoneal suture lines ; in ovarian cystectomy , the film was placed on the lower and upper surface of the ovary ; in cancer surgery , the film was placed on the rough surfaces of all surgical sites .
total time needed for application in the different groups was compared by student 's t test .
regarding the placement , the success rate of placement at the intended site in all surgeries was 95.7% . in the single - port surgery group ,
the placement failed in 2 cases ( 92.3% success rate ) , whereas in the multiport surgery group , the placement had a 100% success rate .
the application time was significantly longer in the single - port surgery group than in the multiport group ( 4.4  1.59 vs 3.4  1.13 minute ; p = .013 by student t test ) ( table 1 ) .
the application time in single - port surgery was significantly longer than in the multiport setting ( 4.4  1.59 vs 3.4  1.13 min , p = 0.013 ) .
if the package of seprafilm is opened too early , the sheet becomes too soft and sticky to handle .
conversely , if the package is opened just before use , the sheet is stiff and breaks easily , ultimately causing a failed placement .
therefore , the ideal timing for opening the package of seprafilm is often difficult to discern .
the uncertainty discourages surgeons from adopting seprafilm , especially in laparoscopic surgeries , even though it can decrease the formation of adhesions .
first , cut the film in pieces and roll together with a soft plastic holder . then insert the roll into the abdomen via a 1012 mm trocar ,
place the film pieces at the intended sites , and remove the soft plastic holder sheets .
the major disadvantage of this method is that the soft plastic holder reflects light that makes the film difficult to differentiate from the plastic holder .
in addition , the holder is not hard enough to protect the seprafilm during insertion .
the second method involves cutting and rolling the seprafilm , and inserting it into an inducer via a trocar for placement .
the disadvantage of this method is the need for special equipment and the success rate is low , only 31.5% in one report .
two of the latest methods reported in 2014 have been proposed to eliminate the disadvantages mentioned above .
chuang et al proposed the use of 2 layers of seprafilm so that it does not stick to the plastic covering , facilitating the removal of the second layer of film from the placement site .
kusuki et al suggested moistening the seprafilm before introducing it into the abdomen cavity by opening the valves of a 12-mm trocar and using no holder .
our proposed method combines and modifies the methods of chuang and kusuki , and allows the simple and successful application of seprafilm .
first , the backing paper is sturdy enough and makes insertion through the 11-mm trocar easier than the plastic sheet .
third , after placing the first piece of seprafilm , the surgeon can move the second layer to cover additional areas .
our application successful rate of seprafilm is 95.7% versus the 80% reported in kusuki et al .
seprafilm is seldom used in single - port access laparoscopic surgery because of the difficulty in applying it to the desired place . using our modified technique ,
there were only 2 cases of failure in placing the film in single - port access laparoscopy . in our opinion , these failures may have been caused by the prolonged manipulation of the seprafilm , making it too sticky to apply .
use of only 1 forcep to manipulate the film also increased the difficulty of application . according to the result in our study , the placement time was also longer in the single - port than in the multiport setting , probably owing to the limited space and the limited range of motion of the forcep .
possible solutions to this problem are using a flexible grasper for manipulation and regular practice with a training box .
the average time of placing seprafilm in this study was below 5 minutes , less time than reported in the 2 recent studies mentioned earlier ( 8 minutes and 10 minutes ) .
the time reduction is probably due to easier entry and ease of distinguishing the seprafilm from the backing paper .
in addition , inserting 2 layers of film at the same time definitely takes less time than inserting 1 sheet at a time .
we have demonstrated that when seprafilm is prepared by moistening and rolling with the backing paper , it is simple to apply in both single and multi - port surgeries .
background and objectives : postoperative adhesions occur less often in laparoscopies than in laparotomies , but the incidence can be reduced further . 
 seprafilm , a sodium hyaluronate / carboxymethylcellulose absorbable barrier , was developed to prevent adhesions after abdominal surgery , and is approved for postoperative adhesion prevention . 
 however , seprafilm is seldom used in laparoscopic surgery because of its tendency to break apart when it is inserted into the abdominal cavity through a trocar , resulting in a high placement failure rate . we propose a better method for applying the adhesion barrier seprafilm in single- or multiport gynecologic surgery.methods:this is a retrospective analysis of patients who underwent multi- or single - port gynecologic laparoscopies from december 2014 through january 2016 in buddhist tzu chi general hospital , hualien , 46 patients received seprafilm ( genzyme corp . , cambridge , ma , usa ) via the proposed method . 
 a piece of seprafilm was cut into quarters . to moisten and soften the seprafilm , 
 each piece was placed on a wet wrung gauze until it became naturally curled . 
 two pieces of the film were rolled up with the backing paper that came from the package of seprafilm . holding the rolled seprafilm with a grasper , 
 the surgeon delivered it into the abdomen through a 11-mm trocar.results:the success rates of seprafilm insertion and correct placement were 100% ( 46/46 ) and 95.7% , respectively . in 2 single - port ( 2/26 ) 
 laparoscopic surgeries , the placement of the film failed ; all placements in the multiport laparoscopic surgeries were successful ( 20/20 ) . the average time required for placement of pieces of seprafilm per surgery was 4.0  1.47 minutes among all surgeries ; significantly more time was needed in the single - port surgeries ( mean , 4.4  1.59 minutes ) than in the multiport surgery ( mean , 3.4  1.13 minutes ) ( p < .05).conclusions : this method of seprafilm placement is a simple technique that does not need special equipment and ensures a high success rate . 
 the placement of the film takes longer in single - port surgeries than in multiport surgeries .