SUMMARY:

Postoperative adhesions are associated with significant adverse outcomes including infertility and bowel obstruction. ASRM, based on evidence review, found that

• Microsurgical technique remains integral for reducing adhesion risk
• No evidence was found for anti-inflammatory agents
• Insufficient evidence for peritoneal instillation of icodextrin
• No evidence for lysis of adhesions to improve pain, treat infertility or reduce bowel obstruction
• “No substantial evidence that the use of FDA approved anti-adhesion barriers improves fertility, decreases pain, or reduces the incidence of postoperative bowel obstruction”

Surgical Technique – Microsurgical Principles

• Benefits of minimally invasive surgery include reduction in
  • Tissue injury | Organ handling/trauma | Exposure to foreign bodies (sponges, surgical gloves) | Infection risk
• Good surgical technique (laparotomy or laparoscopy) includes
  • Gentle tissue handling | Minimizing residual blood and serosanguinous fluid | Length/size of incisions | Removal of necrotic tissue | Nonreactive sutures | Sterile technique

Evidence for Other Adhesion Reducing Options

• Systemic anti-inflammatories
  • Currently, there is no evidence to support the use of anti-inflammatory agents such as steroids for adhesion reduction  
• Peritoneal instillation for hydroflotation  
  • 32% dextran 70 or crystalloid solutions used to detach surgical layers and adjacent structures
    • Currently, no evidence to support the use of this technique, either alone or with additives (e.g., corticosteroids or heparin) for adhesion reduction
  • Icodextrin 4% solution
    • Osmotic agent that draws fluid in to the peritoneum for a few days post-surgery
    • While approved by the FDA, ASRM cites a systematic review that “concluded that there is insufficient evidence for its use as an adhesion preventing agent”  
• Surgical Adhesion Barriers
  • Modifed sodium hyaluronic acid (HA) and carboxymethyl cellulose (CMC) approved by FDA for laparotomy
    • ASRM cites systematic reviews and clinical trials that found “limited evidence for its effectiveness for preventing adhesion formation after myomectomy” and “no overall difference in the incidence of postoperative small-bowel obstruction”
  • Oxidized regenerated cellulose approved by FDA for laparotomy
    • Absorbs within 2 weeks after application
    • ASRM does cite RCTs that demonstrate reduction in new and recurrent adhesions (50 to 60%) for both laparotomy and laparoscopy
    • Limited evidence that this product “improves fertility, decreases pain or bowel obstruction”

KEY POINTS:

• Despite use of good technique, adhesions are “a natural consequence of tissue trauma and healing”
• Some procedures are known to be more closely associated with adhesion formation (e.g., myomectomy), regardless of optimal technique
  • Following laparotomy: 90%
  • Following laparoscopy: 70%
• Closure of parietal peritoneum at time of laparotomy
  • May be of benefit: 22% vs 16% with closure
  • Ovarian cancer: Increased adhesions with closure
  • Cesarean section: Less adhesions
• Adhesiolysis for chronic abdominal and pelvic pain
  • ASRM considers the association between postoperative adhesions and chronic abdominal/pelvic pain to be “unclear”
  • Extent of adhesions and pain are not well correlated
  • Adhesiolysis may be beneficial in the setting of dense adhesions
  • ASRM cites a blinded RCT (Swank et al., Lancet 2003) that demonstrated improvement in chronic abdominal pain following laparoscopy, whether or not  adhesiolysis was performed, with no statistical difference between groups  

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Learn More – Primary Sources:

Postoperative adhesions in gynecologic surgery: a committee opinion

Laparoscopic adhesiolysis in patients with chronic abdominal pain: a blinded randomised controlled multi-centre trial

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