- Pathologic bands of scar tissue that form between two previously separated structures within the abdomen
- Adhesions most commonly between:
- Bowel loops
- Abdominal wall
- Adhesions may be congenital or acquired.
- Acquired adhesions are usually the result of surgery, traumatic injury, or postinflammatory injury.
- Adhesions are not merely nonfunctioning scars; they can be highly vascular and cellular.
- Adhesions vary in structure. They can be thin membranous tissue or thick fibrous tissue with neurovascular structures, or even direct connections between organs.
- Although many adhesions are asymptomatic, small bowel obstruction (SBO), infertility, and chronic pain are the most common complications.
- True incidence is difficult to determine because some adhesions are asymptomatic.
- Postoperative: 63–97% develop in the 10 years following laparotomy.
- 1/3 of patients with open pelvic or abdominal surgery are readmitted for possible adhesive disease.
- Laparoscopy reduces adhesion formation by 45% with a concurrent reduction in the need for reoperation.
- Open colorectal and ovarian surgeries have the highest risk of adhesion formation.
- Congenital (4.7%)
- Inflammatory (2.3%)
Etiology and Pathophysiology
- Congenital: formed during organogenesis
- Acquired adhesions
- Postinflammatory: most commonly from diverticulitis, appendicitis, endometriosis, peritonitis, radiotherapy, long-term peritoneal dialysis, and inflammatory bowel disease. Adhesion formation is part of the normal peritoneal defense mechanism.
- Posttraumatic: physical trauma to the abdomen
- Postinflammatory and postoperative: imbalance between fibrin deposition and breakdown (1)[C]
- Increased fibrinogen from inflammatory and procoagulatory response mediated by plasminogen activator inhibitor-1 (PAI-1)
- Decreased fibrinolysis by decrease in tissue plasminogen activator (tPA)
- Morbidity caused by the anchoring of organs to nearby structures, impeding normal movement and promoting kinks, deformity, and blockage
- Emergency surgery; pelvic surgery
- Lower gastrointestinal procedures
- Age <60 years
- History of abdominal infection, inflammation, surgery, or other trauma (2)[C]
- Primary prevention: Avoid abdominal infection or need for abdominal surgery.
- Surgical technique
- Laparoscopic surgery is associated with less adhesive disease.
- Intraoperative techniques that reduce adhesions:
- Minimal peritoneal trauma
- Delicate tissue handling
- Meticulous hemostasis
- Decreased operating time
- Reduce foreign body, synthetic material, blood, necrotic material.
- Other modalities:
- Barrier films such as Seprafilm, Gore-Tex, and Interceed have had mixed results preventing adhesions and reducing complications (3)[A],(4)[B].
- Medications such as NSAIDs, steroids, vitamin E, and tPA do not conclusively decrease adhesions.
Adhesions are primarily diagnosed through patient history and/or intraoperatively. The number of adhesions does not correlate with symptoms.
SBO in patients without a history of abdominal surgery should not be routinely ascribed to adhesive disease without excluding malignancy or other processes (5)[C].
- Prior abdominal surgery
- History of abdominal infection or pelvic inflammatory disease
- Bowel complaints:
- Crampy abdominal pain
- Nausea, vomiting
- Minimal to no flatus
- Loud bowel sounds (borborygmi)
- Abdominal distension
- If involving a pelvic structure, complaints may include:
- Lower abdominal pain (either chronic or acute)
- Vital sign abnormalities (evidence of ischemia, dehydration, or infection)
- Diffuse abdominal tenderness
- Peritoneal signs: guarding, rebound, rigidity
- Abdominal scars
- In the case of SBO:
- Abdominal distention
- Altered bowel sounds
Diagnostic Tests & InterpretationInitial Tests (lab, imaging)
- No lab or imaging tests definitively demonstrate adhesions. Workup should include WBC, lactate, electrolytes, BUN/creatinine.
- Imaging modalities such as supine and erect abdominal x-ray (5)[B], water-soluble oral-contrasted CT scan (5)[B], and water-soluble contrast follow-through can help diagnose SBO (5)[A].
- Nasogastric decompression for patients with suspected partial SBO without specific indications for surgery (5)[A]
- Performed for symptomatic complications of adhesions, although criteria for surgery in these cases depends on the specific complication
- Indications for adhesiolysis in setting of SBO include signs of strangulation or peritonitis, surgery within 6 weeks, carcinomatosis, irreducible hernia, no resolution within 72 hours (5)[A].
- With adhesiolysis, there is always the risk of new adhesions.
- Laparoscopic: primarily for pelvic adhesions
- Appropriate for highly selected patient (5)[B]
- May be most effective in removing abdominal wall adhesions and least effective for adnexal adhesions (6)[C]
- Helps treat chronic pelvic pain only when severe
- Open: primarily for peritoneal adhesions
- Laparotomy is the preferred surgical resolution to SBO related to adhesions in cases of failed conservative management (5)[B].
- Adhesions are typically asymptomatic. Once present, they cannot be fully removed.
- No single approach has been satisfactory in removing adhesions.
- Most common complication is bowel obstruction (either partial or complete).
- Chronic pelvic pain
- Surgical complications:
- Prolonged surgery
- Intraoperative bleeding
- Trocar injury (adhesions to ventral abdominal wall)
- Conversion of laparoscopy to laparotomy
- Inadvertent enterotomy or other organ damage
- Prolonged length of hospital stay
- Postoperative morbidity/mortality is slightly higher than virgin abdomen.
- Diamond MP, Burns EL, Accomando B, et al. Seprafilm(®) adhesion barrier: (2) a review of the clinical literature on intraabdominal use. Gynecol Surg. 2012;9(3):247–257. [PMID:22837733]
- Hellebrekers BW, Kooistra T. Pathogenesis of postoperative adhesion formation. Br J Surg. 2011;98(11):1503–1516. [PMID:21877324]
- Kumar S, Wong PF, Leaper DJ. Intra-peritoneal prophylactic agents for preventing adhesions and adhesive intestinal obstruction after non-gynaecological abdominal surgery. Cochrane Database Syst Rev. 2009;(1):CD005080. [PMID:19160246]
- Lauder CI, Garcea G, Strickland A, et al. Abdominal adhesion prevention: still a sticky subject? Dig Surg. 2010;27(5):347–358. [PMID:20847564]
- Ouaïssi M, Gaujoux S, Veyrie N, et al. Post-operative adhesions after digestive surgery: their incidence and prevention: review of the literature. J Visc Surg. 2012;149(2):e104–e114. [PMID:22261580]
- Stommel MW, Ten Broek RP, Strik C, et al. Multicenter observational study of adhesion formation after open-and laparoscopic surgery for colorectal cancer. Ann Surg. 2018;267(4):743–748. [PMID:28207436]
- K66.0 Peritoneal adhesions (postprocedural) (postinfection)
- N73.6 Female pelvic peritoneal adhesions (postinfective)
- N99.4 Postprocedural pelvic peritoneal adhesions
- Q43.3 Congenital malformations of intestinal fixation
- 568.0 Peritoneal adhesions (postoperative) (postinfection)
- 614.6 Pelvic peritoneal adhesions, female (postoperative) (postinfection)
- 751.4 Anomalies of intestinal fixation
- 197201009 Postprocedural pelvic peritoneal adhesions (disorder)
- 204748003 Congenital intestinal adhesions (disorder)
- 29886007 Adhesion of intestine (disorder)
- 30689000 adhesion of abdominal wall (disorder)
- 62394006 Female pelvic peritoneal adhesions
- 70190001 peritoneal adhesion (disorder)
- Abdominal adhesions result primarily from abdominal infection or trauma (including surgery).
- Most adhesions are asymptomatic; the most common complication is bowel obstruction (partial or complete).
- Pain does not correlate with the number of adhesions.
Charles K. Grigsby, MD
Andrew B. Mitchell, MD
Adel M. Abuzeid, MBBS
- Arung W, Meurisse M, Detry O. Pathophysiology and prevention of postoperative peritoneal adhesions. World J Gastroenterol. 2011;17(41):4545–4553. [PMID:22147959]
- Moris D, Chakedis J, Rahnemai-Azar AA, et al. Postoperative abdominal adhesions: clinical significance and advances in prevention and management. J Gastrointest Surg. 2017;21(10):1713–1722. [PMID:25203381]
- Robb WB, Mariette C. Strategies in the prevention of the formation of postoperative adhesions in digestive surgery: a systematic review of the literature. Dis Colon Rectum. 2014;57(10):1228–1240. [PMID:21502860]
- van der Wal JB, Iordens GI, Vrijland WW, et al. Adhesion prevention during laparotomy: long-term follow-up of a randomized clinical trial. Ann Surg. 2011;253(6):1118–1121. [PMID:24112637]
- Di Saverio S, Coccolini F, Galati M, et al. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2013 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World J Emerg Surg. 2013;8(1):42. [PMID:20036389]
- Ward BC, Panitch A. Abdominal adhesions: current and novel therapies. J Surg Res. 2011;165(1):91–111. [PMID:20036389]
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