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www.uptodate.com 2017 UpToDate

Postoperative peritoneal adhesions in adults and their prevention

Authors: Alan H DeCherney, MD, Senthil Kumar, MS, FRCS (Ed), FRCS (Gen Surg)
Section Editors: Tommaso Falcone, MD, FRCSC, FACOG, Hilary Sanfey, MD
Deputy Editor: Wenliang Chen, MD, PhD

All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2017. | This topic last updated: Mar 05, 2017.

INTRODUCTION Postoperative peritoneal adhesions have important consequences to patients, surgeons,

and the health system. The adhesions that form in the abdomen following abdominal or pelvic surgery are a
normal response to injury of the peritoneal surfaces during surgery, and although adhesions have some
beneficial effects, they also cause significant morbidity, including adhesive small bowel obstruction, female
infertility, chronic abdominal pain, and increased difficulty with subsequent surgery [1,2]. These issues have
refocused attention on our understanding of adhesions, their clinical consequences, and methods of
prevention. A number of animal studies and human interventional trials have evaluated a variety of
techniques and materials designed to reduce and prevent postsurgical adhesions. Only a handful of agents
have been proven safe and effective in humans, and fewer have an evidence base that justifies routine use.

The epidemiology, pathogenesis, approach, and importance of preventing postoperative peritoneal adhesions
in adults are reviewed here. The diagnosis and management of small bowel obstruction and infertility are
discussed elsewhere. (See "Management of acute perioperative pain" and "Epidemiology, clinical features,
and diagnosis of mechanical small bowel obstruction in adults" and "Evaluation of female infertility".)

INCIDENCE AND BURDEN Postoperative adhesions cause significant morbidity, including bowel
obstruction, female infertility, and chronic abdominal and pelvic pain [3-6].

Intestinal obstruction Adhesions are the most common cause of intestinal obstruction in Western
countries [7-9]. The incidence varies widely with the nature of the index surgery and the duration of
follow-up [7,10-13]. Open gynecologic procedures, ileal pouch-anal anastomosis, and open colectomy
are associated with the highest risk of adhesive small-bowel obstruction [14]. The incidence of small
bowel obstruction resulting from postoperative adhesions increases with each subsequent procedure
performed in the management of bowel obstruction. In one national study 5.7 percent of 21,347
readmissions were classified as relating directly to adhesions, and 3.8 percent required operation [12].
The risk factors associated with small bowel obstruction due to adhesions are discussed separately.

Infertility Infertility in women can result from pelvic adhesions, which can interfere with ovum capture
and transport or from tubal or intrauterine adhesions that hinder sperm transport or embryo implantation.
Whereas pelvic peritoneal adhesions and tubal abnormalities are each responsible for approximately 10
percent of cases of female infertility, intrauterine adhesions are a relatively rare cause of infertility. (See
"Overview of infertility", section on 'Causes of infertility' and "Intrauterine adhesions".)

Chronic abdominal pain The relationship between adhesions and chronic abdominal or pelvic pain is
poorly defined. However, there is some evidence indicating that dense adhesions can limit organ
mobility, which may cause visceral pain [2,15,16]. (See "Treatment of chronic pelvic pain in women".)

Adhesions, which are found in up to 95 percent of patients who have subsequent surgery, can impose
technical difficulties and increase risk for complications that may include [17-19]:

Difficult abdominal access related to loss of tissue planes or distorted anatomy

 Inability to perform laparoscopic surgery, continuous ambulatory dialysis or other intraabdominal drug
delivery
Inadvertent injury to the small bowel, bladder, or ureters
Increased duration of surgery and prolonged anesthesia
Increased blood loss

Nearly one percent of all general surgical admissions and three percent of all laparotomies relate directly to
adhesions [20], which increases the burden of care (economic, manpower, logistics).

Complications related to or resulting from postoperative adhesions increase the surgical workload and
hospital utilization and tax other healthcare resources, resulting in a significant economic burden; the
overall estimated annual costs of managing adhesion-related complications exceed $2 billion in the
United States [21].

Adhesions increase the risk for medical malpractice claims arising from abdominal and pelvic surgery
[4,22,23]. Data from the medical defense union in the United Kingdom identified 77 claims related to
adhesions over a six-year interval [22]. Allegations included a failure to warn of the risk during the
consent process, visceral injuries that occurred during laparoscopy or laparotomy, the failure to use
specific measures to prevent adhesions, the failure to diagnose or delays in diagnosis of complications,
and chronic pain and infertility.

PATHOGENESIS At the molecular level, adhesion formation involves a complex interaction of cytokines,
growth factors, cell adhesion molecules, neuropeptides, and numerous other factors secreted by cells in or
near the area of trauma [24,25]. The early balance between fibrin deposition and degradation (ie, fibrinolysis)
appears to be a critical factor in the pathogenesis of adhesions [26-30]. Peritoneal healing differs from wound
healing in that it heals as a surface rather than from edge to edge (like skin). Healing involves a uniform,
relatively rapid re-epithelialization, regardless of the size of the injury.

Injury to peritoneal surfaces induces a repair response, which consists of an inflammatory reaction involving
cellular elements, and also tissue and coagulation factors [29,31]. The inflammatory response results in fibrin
deposition at the site of injury within three hours after tissue trauma and peaks on postoperative day four to
five. Postsurgical peritoneal repair begins with coagulation, which triggers the release of a variety of chemical
messengers that mediate a cascade of events. Some of the principal cellular elements involved include
leukocytes (polymorphonuclear neutrophils and macrophages) and mesothelial cells. Macrophages, which
exhibit increased phagocytic, respiratory burst, and secretory activities, comprise the majority of the local
leukocyte population five days after injury. Macrophages also recruit new mesothelial cells onto the surface of
the injury, which first aggregate to form small islands across the injured area and then proliferate into sheets
of cells that eventually re-epithelialize the entire surface, usually by five to seven days after surgical injury.

The progenitor to adhesions is the fibrin gel matrix, which develops in several steps, which include the
formation and degradation of fibrin polymer and its interaction with fibronectin and a series of amino acids.
Protective fibrinolytic enzyme systems in the peritoneal mesothelium, such as the tissue plasminogen
activator (tPA) system, can remove the fibrin gel matrix. The pivotal events that determine the path of healing
are the opposition of two damaged surfaces and the extent of fibrinolysis. If complete fibrinolysis and
resorption of degradation products occurs, reepithelialization will result in a smooth tissue surface, but if that
process is disturbed and fibrinolysis does not occur, connective tissue scar and adhesions develop from the
ingrowth of fibroblasts, capillaries, and nerves. Surgery diminishes fibrinolytic activity dramatically by
increasing levels of plasminogen activator inhibitors and by reducing tissue oxygenation [30,31]. Fibrinolysis
also can be impaired by thermal injury, desiccation, ischemia, foreign bodies, blood, bacteria, and some
drugs; genetic polymorphisms also may play a role in the host's inflammatory and healing response.

CLINICAL PRESENTATIONS AND DIAGNOSIS Most adhesions are clinically silent. More than 75
percent of patients with symptomatic adhesions have a history of prior surgery, and the remainder has a
history of an intraabdominal or pelvic inflammatory process. When symptoms occur, adhesions may manifest
as intestinal obstruction, chronic pain, and, in women, as infertility. The risk factors and clinical features for
each of these are described in the linked topics.

Adhesions are the most common cause of intestinal obstruction in Western countries, and should be
suspected in any patient with a history of prior abdominal or pelvic surgery who presents with signs and
symptoms of obstruction. The presentation can be acute or subacute. (See "Epidemiology, clinical
features, and diagnosis of mechanical small bowel obstruction in adults", section on 'Risk factors'.)

Chronic abdominal pain, chronic pelvic pain, and/or dyspareunia [32]. (See "Evaluation of the adult with
abdominal pain" and "Causes of chronic pelvic pain in women".)

Infertility. (See "Overview of infertility" and "Causes of female infertility" and "Evaluation of female
infertility".)

A diagnosis of adhesions is often based on initial clinical suspicion in an relevant context, which may then be
confirmed by direct examination of the abdomen or pelvis via laparoscopy or laparotomy, or with indirect
methods, such as imaging, which is less accurate and may include ultrasound (demonstrating reduced
visceral sliding) or magnetic resonance of the abdomen. Computed tomography (CT) of the abdomen (with
oral contrast) and gastrointestinal follow-through studies are less useful in the diagnosis of adhesions, but
can play a role in the management of patients with suspected small bowel obstruction relating to adhesions.
(See "Epidemiology, clinical features, and diagnosis of mechanical small bowel obstruction in adults", section
on 'Diagnosis'.)

INDICATIONS FOR ADHESIOLYSIS The indications for surgical lysis of adhesions depend upon the
clinical presentation.

For patients with signs and symptoms of bowel obstruction, abdominal exploration and lysis of adhesions
(adhesiolysis) may be needed to manage complications related to obstruction (perforation, ischemia).
Adhesiolysis also may be indicated for those with partial obstruction who do not respond to conservative
management. (See "Overview of management of mechanical small bowel obstruction in adults", section
on 'Failure of nonoperative management'.)

For treatment of infertility and recurrent pregnancy loss, lysis of pelvic adhesions, or of intrauterine
adhesions, may improve fecundity and decrease risk for pregnancy loss. (See "Treatments for female
infertility" and "Intrauterine adhesions".)

Performing adhesiolysis for pain relief can be effective in certain subsets of patients [2]. Unfortunately,
even after lysis, adhesions often re-form. (See "Overview of management of mechanical small bowel
obstruction in adults" and "Differential diagnosis of sexual pain in women", section on 'Pelvic adhesions'.)

MEASURES FOR PREVENTING PERITONEAL ADHESIONS

Fundamentals Methods for preventing adhesions are directed at the mechanisms of adhesion formation.
Preventive measures may (see 'Pathogenesis' above):

Minimize injury
Introduce a barrier between injured surfaces
Prevent coagulation of the serous exudate
Remove or dissolve the deposited fibrin
Inhibit the fibroblastic response to the tissue injury
Involve recombinant tissue plasminogen activator and novel fibrinolytics

Methods for preventing adhesions can be classified broadly as technical measures, physical barriers, which
may be solid or liquid, and pharmacologic therapies [3,25]. Given that no specific pharmacologic therapy has
been approved for clinical use in the United States, the discussion below focuses on technical measures and
physical barriers.
 Technical measures limit or prevent the initial peritoneal injury. (See 'Surgical techniques' below.)

Barrier agents act primarily as a physical separation between the fibrin-coated peritoneal surfaces
predisposed to adherence. Barrier agents may be solid or liquid materials. (See 'Physical barriers'
below.)

Pharmacologic therapies may be administered locally or systemically and interfere with or modify the
peritoneal response to injury. (See 'Ineffective and potentially harmful therapies' below.)

Surgical techniques

Gentle tissue handling Good surgical technique is the first defense against adhesion formation.

Meticulous hemostasis and gentle, minimal tissue handling are important for limiting the extent of the initial
peritoneal injury [16]. Damage to the serosa can be prevented by minimizing trauma, bleeding, and ischemia,
and by keeping the surgical field moist with frequent irrigation to prevent tissues from drying out.

Traditional laparotomy sponges can be abrasive and should be avoided. Many pelvic surgeons place these
sponges in sterile plastic bags, thus preventing the braided cloth from touching the peritoneum when packing
is required.

Removing the talc or starch from gloves before entering the peritoneal cavity is a simple, but often neglected,
measure that eliminates a source of irritation that predisposes can lead to adhesion formation. The
introduction of potentially reactive foreign bodies (eg, excess suture material, lint, talc) should be minimized
to reduce the number of nidi for fibrin deposition. Fine, nonreactive suture material should be used wherever
possible; silk sutures, which are fibrogenic, should be avoided in the abdomen.

The incidence of adhesions is similar regardless of whether the peritoneum is reapproximated after
laparotomy [13,33,34]. Although closing the parietal peritoneum is usually unnecessary, when circumstances
require, fine absorbable suture should be used. Suture materials like polyglactin stimulate little tissue
reactivity and are thus preferred over more reactive materials such as chromic catgut sutures, or silk.

Laparoscopic surgery Laparoscopy offers certain advantages over open abdominal surgery with
respect to adhesion formation. The abdominal incisions are small and there is less handling of tissue and
exposure to foreign bodies, all of which may help to decrease tissue trauma, compared with laparotomy, and
thus to reduce the risk for adhesion formation, especially to the abdominal wall [35-37]. Other relative
advantages and disadvantages of laparoscopic surgery are discussed in separate topic reviews for specific
procedures.

Laparoscopic surgery certainly does not guarantee the prevention of adhesions [38]; longer durations of
surgery and high insufflation pressures can even increase the risk for adhesion formation [39]. In one study,
the Scottish National Health Service Medical Record Linkage Database was used to select a cohort of 8849
women who had open gynecological surgery in 1986 and all readmissions in the subsequent 10 years were
reviewed for potential adhesion-related disease [10,11]. The overall rate of readmission directly related to
adhesions was 2.9/100 initial operations. When laparoscopic sterilization procedures were excluded, the risk
for adhesion-related readmission was comparable for open and laparoscopic gynecological surgery [11].

Physical barriers Physical barriers include solid materials (absorbable sheets, nonabsorbable prosthetic
materials), and viscous fluids introduced into the abdomen. All are aimed at keeping damaged peritoneal
surfaces separated during the first five to seven days after surgery, until after re-epithelialization has
occurred. Although barriers do appear to limit the extent of adhesion formation, whether they improve
clinically important outcomes by reducing the risks for intestinal obstruction, infertility, and chronic abdominal
or pelvic pain is less clear [1,40]. (See 'Effectiveness of physical barriers' below.)

The addition of physical barriers is not without risk or cost. The use of the barriers described below prolongs
operative time, which increases hospital costs, which is compounded further by the cost of the product itself,
for an estimated total of $400 to $700 per procedure. However, when these barriers accomplish what they
are designed to do, the benefit of avoiding future surgery outweighs these issues.

Concerns that some barrier agents may predispose to an increase in the incidence of septic complications
[41-43] have not been proven, but barriers should not be used to wrap intestinal anastomoses because the
practice may increase the risk for leak [44,45]. In one multicenter trial, 1791 patients having abdominopelvic
surgery (the majority for inflammatory bowel disease) were randomly assigned to receive a hyaluronic acid
sheet as an adhesion barrier, or no treatment [45]. There was no significant difference between the groups in
the incidence of abscess (4 versus 3 percent, respectively) or pulmonary embolism (<1 percent in both
groups). However, a subpopulation of patients in whom the adhesion barrier was wrapped around a fresh
bowel anastomosis more frequently developed anastomotic leak and leak-related events, such as fistula
formation, peritonitis, abscess formation, and sepsis.

Solid barriers (sheets) Two absorbable membrane sheets are commercially available. One is an
oxidized regenerated cellulose sheet, (Interceed) and the second is a sodium hyaluronate-based
carboxymethylcellulose sheet (Seprafilm). Both appear safe and effective for preventing adhesions between
surfaces to which they are applied, but are somewhat difficult to handle and do not prevent adhesion
formation at other sites within the abdomen. In addition, there is one nonabsorbable solid barrier (expanded
polytetrafluoroethylene) that has been found to prevent adhesions in clinical studies.

Hyaluronic acid sheets Hyaluronic acid sheets (hyaluronate carboxymethylcellulose) are

transparent, absorbable membranes that last for seven days, during which time they prevent the juxtaposition
of traumatized tissues. The barrier is a brittle film that tends to fracture when bent at sharp angles, making it
unsuitable for laparoscopic application.

A meta-analysis of eight randomized trials of patients undergoing intestinal surgery [45-52] demonstrated that
treatment with hyaluronic acid sheets reduced intraabdominal adhesions significantly but did not reduce the
incidence of postoperative intestinal obstruction (odds ratio 0.98, 95% CI 0.78-1.23). Hyaluronic acid sheet
use also increased septic complications such as abdominal abscess (odds ratio 1.64, 95% CI 1.06-2.54) and
anastomotic leak (odds ratio 2.03, 95% CI 1.18-3.50) [41]. One of the trials included in the meta-analysis,
however, did demonstrate a 47 percent reduction (absolute risk reduction 1.6 percent) in adhesive small
bowel obstruction requiring reoperation by using hyaluronic acid sheets after a mean follow-up of 3.5 years.

A randomized trial of 127 women undergoing gynecologic surgery showed that treatment of patients after
uterine myomectomy with hyaluronic acid sheets significantly reduced the incidence, severity, extent, and
area of postoperative uterine adhesions at second look laparoscopy, without causing adverse events [53].
However, the rate of postoperative intestinal obstruction was not reported.

Hyaluronate carboxymethylcellulose (Seprafilm, Sanofi) is supplied in 5 x 6 inch sheets. The desired shape is
cut and the material is carefully applied with clean instruments over the surgical site. Care should be taken to
avoid contacting the viscera and other tissues prior to final placement and the barrier is best applied with
instruments because the membrane can easily stick to gloves and become displaced. The paper backing on
the film is then removed carefully, keeping the membrane at the operative site; suturing is unnecessary.

Oxidized regenerated cellulose Oxidized regenerated cellulose (ORC) is a commonly employed

absorbable adjuvant used for hemostasis. (See "Overview of topical hemostatic agents and tissues
adhesives", section on 'Oxidized regenerated cellulose'.)

ORC creates a temporary barrier that prevents adhesions when applied to injured tissue. Initial studies using
a version of the product with a loose weave (Surgicel), were inconclusive but suggested some benefit. The
knit of the ORC barrier was subsequently modified to create the ORC product used currently (Interceed). The
material is effective for reducing postsurgical adhesions because it is absorbed over an interval, which
presumably, allows sufficient time for fibrin-clot dissolution and reepithelialization of the traumatized
peritoneum [54]. A systematic review and meta-analysis identified 11 trials using ORC in gynecologic surgery
[37,55-64]. The pooled estimate for three trials comparing ORC with no barrier and judged to have a low risk
for bias observed that ORC significantly reduced risk of adhesions (relative risk [RR] 0.51, 95% CI 0.31-0.86)
[1].

Interceed is supplied in sheets measuring 1.5 x 2 inches or 3 x 4 inches. The smaller size is appropriate for
laparoscopic placement. The barrier is degraded and absorbed within two weeks of application. Application
requires several steps:

The operative site should exhibit normal hemostasis, and be free of blood, which reduces the
effectiveness of ORC [65].

Excess fluid should be removed from the peritoneal cavity by gentle aspiration after placing the patient in
a reverse Trendelenburg position.

The Interceed barrier should completely cover the affected area of the operative site and can be
moistened gently with sterile irrigant to help maintain its position. Suturing is unnecessary.

Expanded polytetrafluoroethylene Expanded polytetrafluoroethylene (ePTFE) is a nonabsorbable,

flexible prosthetic material used for a variety of surgical reconstructions. The ePTFE is trimmed to overlap the
denuded area by 1 cm and sutured into place with nonabsorbable sutures, usually a 7-0 or 8-0 nylon or
polypropylene.

A small trial of patients having open myomectomy randomly assigned 28 subjects to application of ePTFE
suture over the uterine incision or to no barrier [66]. At second-look laparoscopy, more patients receiving
ePTFE were adhesion-free compared with untreated controls (55 versus 7 percent).

Another small trial involving 32 patients compared ePTFE and ORC in pelvic reconstructive surgery by
placing ePTFE on one pelvic sidewall and ORC on the other [67]. Among the 29 patients who had second-
look laparoscopy, both ORC and ePTFE decreased adhesions but ePTFE was judged more effective (figure
1). More sidewalls covered with ePTFE had no adhesions (21 versus 7). The ePTFE membrane was
removed at laparoscopy in all patients who had a successful second-look procedure.

Liquid barriers (instillates)

Polyethylene glycol Polyethylene glycol adhesion barrier (Spraygel, Sprayshield) is a synthetic

hydrogel that forms within seconds after simultaneous spray of two solutions of polyethylene glycol-based
(PEG) liquids onto targeted tissue. Crosslinking between the solutions forms an absorbable, flexible,
adherent gel barrier that remains intact for five to seven days before degrading into its components, which
are then resorbed and excreted through the kidneys. Spraygel is available in Europe, but is not yet approved
for use in the United States.

An early trial comparing PEG with placebo in women undergoing myomectomy observed a greater than60
percent lower adhesion score in treated patients at time of second-look laparoscopy, with no adverse effects
[68]. A later systematic review [1], identified seven trials comparing PEG with placebo [68-73]. Whereas the
pooled results of four of these trials did not yield a significant difference in the overall incidence of adhesions,
adhesion scores were lower in those receiving PEG. A later trial confirmed the safety profile of Spraygel, but
also failed to demonstrate the barrier was effective for preventing adhesions [74].

Icodextrin solution A 4% isosmolar solution of icodextrin (Adept) is an alpha-1,4 glucose polymer

with prolonged peritoneal residence. It is used as an irrigant during surgery (minimum 100 mL/30 minutes)
and is the most promising intraoperative instillate for adhesion prevention. It can be used following
laparoscopic adhesiolysis and is the only agent approved in the United States for preventing peritoneal
adhesions in gynecologic laparoscopy.

At completion of the procedure, all the irrigant is removed and 1000 mL of fresh icodextrin 4% is instilled into
the peritoneal cavity and left as a fluid reservoir [75]. The solution is slowly absorbed via the lymphatic
system, broken down by amylase, and metabolized to glucose (40 g per liter of instillate) over a period of up
to four days, thus acting to separate traumatized tissue surfaces during the period of healing when adhesions
would normally form. Adept is contraindicated in patients with known or suspected allergy to cornstarch-
based polymers (eg, icodextrin, or with maltose or isomaltose intolerance, or with glycogen storage disease)
[76]. Icodextrin 4% is also contraindicated in the presence of gross abdominal-pelvic infection.

A meta-analysis of four trials comparing icodextrin to no treatment or placebo concluded that icodextrin
reduced the incidence of small bowel obstruction (data from a single study, 2 versus 11 percent), but did not
reduce adhesion formation or the need for reoperation for adhesive small bowel obstruction (relative risk
0.33, 95% confidence internal 0.03-3.11) [1].

Hyaluronic acid solution, gel, and powder Hyaluronic acid is an anionic, non-sulfated
glycosaminoglycan distributed in connective tissue [77-79].

A systematic review identified four trials comparing hyaluronic acid-containing solutions with placebo [80-83],
found no difference in overall mean adhesions scores, but also that the solutions significantly reduced the
proportion of women with adhesions or the extent of adhesions at time of second-look laparoscopy (odds
ratio [OR] 0.31, 95 % CI 0.19-0.51) and the number of women with increased adhesion scores (OR 0.28, 95
% CI 0.12-0.66) [78].

A powder form of Hyaluronic acid/Carboxymethylcellulose (Sepraspray Adhesion Barrier) has been evaluated
in the setting of laparoscopic colorectal resections, but was found to produce more adverse events [84].

Ineffective and potentially harmful therapies A number of other agents have been applied in attempts
to prevent postoperative peritoneal adhesions but are considered generally ineffective and possibly harmful.

Since adhesion formation involves an inflammatory reaction, systemic antiinflammatory agents have been
viewed as having potential value in efforts to prevent adhesion formation. A systematic review of randomized
trials comparing the use of glucocorticoids or promethazine versus no treatment for adhesion prevention after
gynecological surgery found no evidence for a beneficial effect of treatment [85], but the small number of
studies and subjects precluded a confident conclusion. Although there is evidence from animal studies that
ketorolac, interleukin 10, and interleukin 4 have efficacy for reducing adhesion formation [86-88], there are no
clinical trials of nonsteroidal antiinflammatory drugs for this purpose involving humans.

Crystalloid solutions should not be expected to prevent adhesion formation because of their short
intraperitoneal time of residence, and the prediction is consistent with clinical observation [89]. The instillation
of fluid into the peritoneal cavity at the conclusion of surgery is associated with numerous theoretical and
practical concerns [90-95]. Fluid overload may potentially lead to pulmonary edema and may cause
abdominal pain and dyspnea. Fluid may potentially leak through laparoscopic incisions, which may cause
distress to the patient and require frequent bandage replacement. Extravasation to the vulvar region has
been reported in up to 2 percent of patients receiving dextran 70 [95]. Excess intraperitoneal fluid also may
reduce opsonization of foreign cells, impair host-cell phagocytosis, and lead to infectious complications. In
one animal study, dextran significantly reduced adhesion formation but resulted in peritonitis rather than in
abscesses as was observed with instillation of saline [96].

However, it is possible that continuous lavage with crystalloid solutions may be beneficial, although further
study is required. In one trial of laparoscopic myomectomy patients, postoperative peritoneal lavage with
Ringers Lactate solution for 48 hours reduced adhesion formation assessed by second look laparoscopy 8 to
10 weeks later [97]. The rates of postoperative complications and small bowel obstruction were not reported.

Other solutions instilled into the peritoneum to reduce adhesion formation have been evaluated and are
ineffective. A systematic review found no significant benefit from the use of intraoperative irrigation or infusion
of various drugs and liquids, including intraperitoneal steroids (one trial, 61 subjects), dextran (two trials, 210
subjects), or heparin (one trial, 63 subjects) [85]. Antibiotic solutions also are ineffective for preventing
adhesions and, in rats, irrigation of the abdominal cavity with cefazolin and tetracycline resulted in increased
formation of peritoneal adhesions [98].
EFFECTIVENESS OF PHYSICAL BARRIERS

Reducing adhesive obstruction Several of the barrier agents appear to be effective for reducing the
incidence and extent of adhesions, but convincing effectiveness for reducing the incidence of adhesive bowel
obstruction is available only for hyaluronic acid sheets [1,49,99].

A systematic review and meta-analysis identified nine trials [44,49-53,100-103] comparing hyaluronic acid
sheet (Seprafilm) to no barrier [1]. Five studies compared the incidence of reoperations for adhesive small
bowel obstruction; three trials were in patients having colorectal surgery and the other two involved hepatic
and gastric surgery. The use of hyaluronic acid sheets significantly reduced the risk for reoperation for
adhesive small bowel obstruction, compared with no barrier, in patients having colorectal surgery (risk ratio
[RR] 0.49, 95% CI 0.28-0.88).

A separate review and meta-analysis [41] identified eight trials comparing Seprafilm to no barrier in 4203
patients [45-52]. Although the incidence of severe adhesions (Grade 2 or 3) was significantly lower in the
group receiving Seprafilm (odds ratio [OR] 0.45, 95% CI 0.22-0.93), the incidence of intestinal obstruction
after abdominal surgery was not different.

In a systematic review of trials comparing icodextrin to no adhesion barrier or placebo, icodextrin significantly
reduced the incidence of small bowel obstruction by any cause (relative risk RR 0.20, 95% CI 0.04-0.88), but
the incidence of reoperation for adhesive small bowel obstruction was not different [1].

Improving fertility The effect of adhesion barriers (oxidized regenerated cellulose, ePTFE, instillates) on
rates of miscarriage or pregnancy in women following gynecologic surgery is unknown. Although many
studies have examined surrogate endpoints such as adhesion or fertility scores, most have not studied the
effect of adhesion barriers on conception, miscarriage, or live birth rates [55,56,75,78,85,99,104,105]. At
present, there is no evidence for higher pregnancy or live birth rates with the use of adhesion barriers.

In one systematic review, no trials were identified reporting data on pregnancy rates for ORC, icodextrin, or
PEG [1]. In another that identified four trials, hyaluronic acid solutions had no significant effect on subsequent
pregnancy rates [78].

A review of five trials that compared anti-adhesion barrier gels with another barrier gel, placebo, or no
adjunctive therapy after hysteroscopic surgery included only one small study that reported pregnancy or live
birth (but not miscarriage) rates; although the incidence of new adhesions was reduced, there was no
difference in any of the more important clinical outcomes. [105]. More well-designed and adequately powered
randomized studies are needed to assess whether the use of any anti-adhesion barriers can improve
reproductive outcomes.

Given the absence of evidence that any anti-adhesion agent can improve clinical outcomes, surgical
adhesiolysis remains an important treatment option. Among infertile women with adnexal adhesions,
pregnancy rates were lower in women with untreated adhesions compared with those who had adhesiolysis
[106]. Pregnancy rates in treated women were 32 percent after 12 months and 45 percent after 24 months,
compared with 11 percent and 16 percent, respectively, in control subjects. (See "Treatments for female
infertility", section on 'Tubal factor infertility and adhesions'.)

Lessening chronic pain No studies have assessed the effect of adhesion preventive strategies on
chronic abdominal pain. Adhesiolysis for reducing chronic pain has been studied in two small trials with
conflicting results [107,108].

SUMMARY AND RECOMMENDATIONS

The adhesions that form in the abdomen after abdominal or pelvic surgery result from tissue trauma and
subsequent healing, and are a normal response of the peritoneal surfaces to surgical injury. Adhesion
formation involves a complex interaction of many cell-secreted factors in areas of surgical trauma. The
 balance between fibrin deposition and degradation (ie, fibrinolysis) appears to be the critical factor in
adhesion formation. (See 'Incidence and burden' above and 'Pathogenesis' above.)

Although adhesion formation is integral to the healing process, they can cause significant morbidity.
Adhesions are the most common cause of bowel obstruction and should be suspected in any patient
with a history of prior abdominal or pelvic surgery who presents with signs and symptoms of bowel
obstruction. Other clinical consequences of adhesions include infertility and chronic abdominal pain.
(See 'Clinical presentations and diagnosis' above.)

Surgical lysis of adhesions may be indicated under the following clinical circumstances (see 'Indications
for adhesiolysis' above):

For patients who develop signs and symptoms of postoperative bowel obstruction that persists after
conservative management

For treatment of infertility and recurrent pregnancy loss

The first line defense against adhesion formation is meticulous surgical technique. Although laparoscopy
generally results in less tissue trauma than laparotomy, the incidence and severity of postoperative
adhesions after laparoscopy is not necessarily lower than after laparotomy. (See 'Surgical techniques'
above.)

For patients at high risk for developing adhesions having laparotomy (eg, gynecologic surgery, repeat
laparotomy), we suggest using a solid physical barrier such as Interceed (oxidized regenerated
cellulose) for adhesion prevention, rather than a liquid barrier agent, or no barrier (Grade 2B). (See
'Physical barriers' above.)

For patients undergoing laparoscopic lysis of adhesions, we suggest the use of liquid barrier agents such
as icodextrin (Grade 2C). (See 'Icodextrin solution' above.)

We suggest avoiding the use of nonbarrier intraabdominal fluid solutions, antibiotics, and antithrombotic
agents because they are ineffective and potentially harmful (Grade 2B). (See 'Ineffective and potentially
harmful therapies' above.)

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Topic 2891 Version 15.0

GRAPHICS

Efficacy of ePTFE and ORC in preventing adhesions

Expanded polytetra-fluorothylene (Gore-Tex Surgical Membrane) is superior to

oxidized regenerated cellulose (Interceed TC7) in preventing adhesions.

* Expanded polytetrafluoroethylene (ePTFE).

Oxidized regenerated cellulose (ORC).

Reproduced with permission from: Haney, AF, Hesla, J, Hurst, BS, et al.

Graphic 56961 Version 2.0

Contributor Disclosures
Alan H DeCherney, MD Nothing to disclose Senthil Kumar, MS, FRCS (Ed), FRCS (Gen Surg) Nothing to
disclose Tommaso Falcone, MD, FRCSC, FACOG Nothing to disclose Hilary Sanfey, MD Nothing to
disclose Wenliang Chen, MD, PhD Nothing to disclose

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