Postoperative Adhesions: From Formation to Prevention

Zeynep Alpay, MD; Ghassan M. Saed, PhD; Michael P. Diamond, MD

Disclosures

Semin Reprod Med. 2008;26(4):313-321. 

In This Article

Abstract and Introduction

Abstract

Postoperative intra-abdominal and pelvic adhesions are the leading cause of infertility, chronic pelvic pain, and intestinal obstruction. It is generally considered that some people are more prone to develop postoperative adhesions than are others. Unfortunately, there is no available marker to predict the occurrence or the extent and severity of adhesions preoperatively. Ischemia has been thought to be the most important insult that leads to adhesion development. Furthermore, a deficient, suppressed, or overwhelmed natural immune system has been proposed as an underlying mechanism in adhesion development. The type of surgical approach (laparoscopy or laparotomy) and closure of peritoneum in gynecologic surgeries and cesarean section have been debated as important factors that influence the development and extent of postoperative adhesions. In this article, we have reviewed the current state of adhesion development and the effects of barrier agents in prevention of postoperative adhesions.

Introduction

Postoperative intra-abdominal and pelvic adhesions are a leading cause of infertility, chronic pelvic pain, and intestinal obstruction. Although not commonly recognized, the incidence ranges between 55% and 95% after abdominal or pelvic surgery.[1] It is generally considered that some people are more prone to develop postoperative adhesions than are others. Unfortunately, there is no available marker to predict the occurrence or the extent and severity of adhesions preoperatively. Additionally, there are no available serum markers or imaging studies that are generally considered to be able to predict the incidence, severity, or extent of adhesions.

Adhesions are nonanatomic connections of fibrous tissue between normal peritoneal surfaces. Postoperatively, they have been classified as de novo or reformed ( Table 1 ).[1] De novo, or type 1, adhesions are adhesions that develop (i.e., are newly formed) at sites that did not have adhesions at an initial surgical procedure. In contrast, re-formed, or type 2, adhesions are classified as adhesions that develop at the sites of previous adhesiolysis. Types 1 and 2 are further classified into A and B subgroups. Subgroup A adhesions are seen at the sites where no operative procedure was performed (type 1A) excluding prior adhesiolysis (type 2A). In contrast, subgroup B adhesions develop at the sites that underwent surgical procedures without adhesiolysis (type 1B; e.g., myomectomy, ovarian cystectomy, etc.) or in addition to adhesiolysis (type 2B).

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