Description

• 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.

Epidemiology

Incidence

• 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

Risk Factors

• Emergency surgery; pelvic surgery
• Lower gastrointestinal procedures
• Age <60 years
• History of abdominal infection, inflammation, surgery, or other trauma (2)[C]

General Prevention

• 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
    • Irrigation
    • 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.

History

• 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)
  • Infertility
  • Nausea/vomiting

Physical Exam

• Vital sign abnormalities (evidence of ischemia, dehydration, or infection)
• Fever
• Tachycardia
• Diffuse abdominal tenderness
• Peritoneal signs: guarding, rebound, rigidity
• Abdominal scars
• In the case of SBO:
  • Abdominal distention
  • Tympany
  • Altered bowel sounds

Diagnostic Tests & Interpretation

Initial 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].

Surgery/Other Procedures

• Nasogastric decompression for patients with suspected partial SBO without specific indications for surgery (5)[A]
• Adhesiolysis
  • 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].

Prognosis

• Adhesions are typically asymptomatic. Once present, they cannot be fully removed.
• No single approach has been satisfactory in removing adhesions.

Complications

• Most common complication is bowel obstruction (either partial or complete).
• Chronic pelvic pain
• Infertility
• 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.

See Also

• Algorithms: Infertility
• Intestinal Obstruction

ICD-10

• 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

ICD-9

• 568.0 Peritoneal adhesions (postoperative) (postinfection)
• 614.6 Pelvic peritoneal adhesions, female (postoperative) (postinfection)
• 751.4 Anomalies of intestinal fixation

SNOMED

• 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)