Adhesion Formation and Prevention

Danielle Luciano, MD
Center for Fertility and Women’s Health, New Britain, CT

Adhesion formation occurs in 75-90% of patients following major gynecologic surgery. Six percent of all hospital readmissions result from adhesions; 22% occur in the first year after surgery, costing 1.3 billion dollars a year. Adhesions cause pelvic pain, infertility, bowel obstruction and difficult repeat surgery. Forty percent of all repeat surgeries are complicated by adhesions.

This article will review the pathophysiology of adhesion formation and preventative measures that can be taken to minimize adhesion reformation and de novo adhesion formation.

Pathophysiology of Adhesions

Adhesions are abnormal attachments of tissue surfaces that are consequences of the natural healing process. Surgical tissue trauma (mechanical, thermal, desiccation, infection, ischemia, abrasion, radiation) initiates a cascade of inflammatory events to heal the injured tissue. Vasoactive substances and inflammatory exudates are released and fibrous scars form over the injured area. Normally within three days these scars are broken down by a process of fibrinolysis. If peritoneal trauma is too severe or this fibrinolytic process does not occur, more fibrin is deposited and capillary development occurs, leading to permanent adhesion formation.

Pelvic pain resulting from adhesion formation is poorly understood as some patients with extensive adhesions will have minimal pain and some patients with minor adhesions will have severe pain. Pain may be associated with tension or stretching of adhesions on the organs; immunohistochemical studies have demonstrated the presence of nerve fibers in adhesions. Location of adhesions seem also to predict pain as adhesions involving the bowel seem to cause more pain than adhesions at other sites. Studies suggest that pain can be reduced by 40-90% following adhesiolysis in pelvic pain patients with adhesions as the only pathologic finding.

Adhesions are the cause of infertility in 15-20% of patients. Adhesions around the ovary can affect follicular growth, and peritubal adhesions can affect tubal motility and ovum transport. Adnexal adhesions also increase the risk of ectopic pregnancy. Studies suggest adhesiolysis in patients with adhesion related infertility can result in pregnancy rates of 38-52%.¹

Adhesions cause about 70% of all bowel obstructions; 20% occur in the first month after surgery. A review of hospital admissions for small bowel obstruction at a university hospital in Canada looked at antecedent gynecologic surgeries and percent occurrence of small bowel obstruction (SBO). Total abdominal hysterectomy was associated with the highest rate of SBO (1.4%) followed by open adnexal surgery (0.81%). In this study there were no SBO following laparoscopic surgery.

One complication of adhesions not often considered is difficulty during repeat surgeries. Studies done by colorectal surgeons demonstrated increased OR time of 18 minutes per previous surgery and increased risks of inadvertent enterotomy and conversion from laparoscopy to laparotomy.¹ Complex repeat surgeries, as well as pelvic pain, infertility and increased risk of bowel obstruction reinforce the need to attempt to minimize adhesion formation following surgery.

Prevention of Adhesions

Adhesions form following the majority of gynecologic procedures. Measures that have been developed attempting to prevent adhesions include: proper surgical technique, pharmacologic treatment, and surgical barriers. Minimally invasive surgical technique with meticulous hemostasis is essential to avoid unnecessary peritoneal injury. The surgeon should avoid excessive coagulation of tissue that can lead to ischemia, and avoid foreign body contamination with extra suture material and powdered gloves. A statistically significant decrease in adhesion reformation and de novo adhesion formation was seen in studies comparing laparoscopy with laparotomy.

Pharmacologic therapies have been studied for efficacy in reducing adhesion formation and unfortunately have not been shown to be effective. Both local and systemic NSAID and corticosteroids have been studied with no difference in adhesion formation
Antibiotics both intravenous as well as used as peritoneal instillates have not been shown to be effective, and neither has heparin as a peritoneal lavage or left in situ. Streptokinase has been tried as well with no efficacy. This has led to the ASRM Practice committee to recommend not using anti-inflammatory agents and peritoneal instillates as they have not demonstrated benefits for reducing postoperative adhesions.²

Surgical barriers have been developed to reduce adhesion reformation, and they have been found to be effective. Gortex, Interceed, and Seprafilm have been approved by the FDA for use in laparotomy and have been found to be effective in reducing adhesion reformation. Adept, an isotonic 4% icodextrin solution, is the only adhesion barrier approved by the FDA for use with laparoscopy and has been shown to reduce adhesions by approximately 30% compared to lactated ringers.

A recent study looking at adhesion reformation following laparoscopic adhesiolysis suggests that adhesions that reform are more likely to occur on the adnexa and that new adhesions were more likely to be dense, involve less than one third of the organ, and occur on the adnexa as well. Endometriosis did not seem to affect the reformation of adhesions however a greater percentage of patients without endometriosis had de novo adhesion formation than patients with endometriosis.

Preventing adhesions especially around the adnexa is important in gynecologic surgery to avoid the consequences of pelvic pain, infertility, bowel obstruction and difficult repeat surgery. Consequently I would like to strongly echo the ASRM practice committee recommendation that efforts to minimize adhesion formation should be implemented, and they should include not only minimally invasive surgical techniques with excellent hemostasis but also the proper use of effective adhesion reducing surgical devices.

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Practice Committee of the American Society of Reproductive Medicine. Control and prevention of peritoneal adhesions in gynecologic surgery. Fert Ster. 2006;86(4):S1-S5.
²Kligman I. Immunohistochemical demonstration of nerve fibers in pelvic adhesions. Obstet Gynecol. 1993; 82(4):566-8.
Steege JF. Resolution of chronic pelvic pain after laparoscopic adhesiolysis. Am J Obstet Gynecol. 1991; 165(2):278-81.
Al-Sunaidi M, Tulandi T. Adhesion-related bowel obstruction after hysterectomy for benign conditions. Obstet. Gynecol. 2006;108(5):1162-6.
³Luciano AA, Maier DB, Nulsen JC, Whitman GF, Koch EI: A comparative study of postoperative adhesion formation following laser surgery by laparoscopy versus laparotomy in the rabbit model. Obstet Gynecol. 1989;74:220-224.
⁴Luciano AA, Montanino-Oliva M. Comparison of postoperative adhesion formation laparoscopy versus laparotomy. Infertil Reprod Med Clinics N Amer. 1994;5(3):437-44.
⁵DeCherney AH, Chang WY, Marin CM. Preventing adhesions after abdominal myomectomy: tools and techniques. OBG Management. 2003;6:18-37.
⁶Brown CB, Luciano AA, Martin D, Peers E, Scrimgeour A, diZerega GS. Adept (icodextrin 4% solution) reduces adhesions after laparoscopic surgery for adhesiolysis: a double blind, randomized, controlled study. Fert Ster. 2007;88(5):1413-26.
⁷Luciano DE, Roy G, Luciano AA. Adhesion reformation after laparoscopic adhesiolysis: where, what type, and in whom they are most likely to recur. J Min Inv Surg. 2008 in press
⁸Practice Committee of the American Society of Reproductive Medicine. Pathogenesis, consequences and control of peritoneal adhesions in gynecologic surgery. Fert Ster. 2007;88(1):21-6.

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