Description

• Adhesions form from pathological healing:
  • Adhesions can be considered congenital or acquired.
  • Acquired adhesions are usually the result of surgery, traumatic injury, or postinflammatory injury (e.g., infection, Crohn disease).
• Adhesions can also vary in structure from thin membranous tissue, to thick fibrous tissue with neurovascular structures, to direct connections between organs (1).
• Although adhesions are asymptomatic for most individuals, for some they can be the cause of significant consequences such as small bowel obstruction, infertility, chronic pain, and surgical complications.

Epidemiology

• Postop:
  • 63–97% develop over 10 years for laparotomy (1).
  • 1/3 of patients with open pelvic/abdominal surgery are readmitted for possible adhesion related complications (1).
  • Laparoscopic approach reduces formation by 45%, and reduces need for reintervention (2)
  • Open colorectal surgeries and open ovarian surgeries have the highest risk of adhesions formation.
• Congenital (4.7%)
• Inflammatory (2.3%)

Risk Factors

History of:

• Abdominal inflammation
• Abdominal surgery
• Abdominal insults

General Prevention

• Primary prevention: Wherever possible, avoid risk factors for development of abdominal infection or need for abdominal surgery.
• Surgical technique (1):
  • Laparoscopic surgery is associated with decreased adhesion formation and decreased risk of complications.
  • Intraoperative techniques have been shown to have decreased adhesion formation, such as:
    • Minimizing peritoneal trauma
    • Delicate handling of tissue
    • Irrigation
    • Meticulous hemostasis
    • Decrease operating time
    • Reduction of foreign body
• Other modalities:
  • Barrier films such as Seprafilm, Gore-Tex, and Interceed have shown to have mixed results in terms of adhesion prevention and complication reduction (1,3,4).
  • Barrier liquids have even less data (5).
  • Medications such as NSAIDs, steroids, vitamin E, and tPA have not had conclusive evidence of decreasing adhesions. Most are still being studied in animal models (1,5)

Pathophysiology

• Congenital: Abnormality formed during organogenesis
• Postinflammatory and postoperative: Imbalance between fibrin deposition and breakdown (1,6):
  • Increased fibrinogen from inflammatory and procoagulatory response mediated by plasminogen activator inhibitor (PAI1) and tissue factor
  • Decreased fibrinolysis by decrease in tPA
  • Morbidity caused by the anchoring of organs to nearby structures thereby impeding normal movement and promoting kinks, deformity, and blockage

Etiology

• Congenital: Abnormality formed during organogenesis
• Postinflammatory: From diverticulitis, appendicitis, endometriosis, peritonitis, radiotherapy, long-term peritoneal dialysis, inflammatory bowel disease
• Posttrauma: Physical trauma to the abdomen, including surgery

History

• Prior abdominal surgery
• History of abdominal/pelvic inflammatory disease or infection
• If involving the bowel, complaints may include:
  • Crampy abdominal pain
  • Nausea
  • Vomiting
  • Minimal to no flatus

• If involving a pelvic structure, complaints may include:
  • Lower abdominal pain (either chronic or acute)
  • Infertility
  • Nausea/Vomiting

Physical Exam

• Abdominal scars
• In the case of small bowel obstruction, may see:
  • Abdominal distention
  • Tympany
• Be aware of possible ischemia with signs including:
  • Fever
  • Tachycardia
  • Diffuse abdominal tenderness
  • Peritoneal signs: Guarding, rebound, rigidity

Diagnostic Tests and Interpretation

• No lab or imaging test can demonstrate adhesions.
• However, imaging can diagnose complications to adhesions such as the abdominal x-ray and CT scan for SBO.

Surgery/Other Procedures

• Adhesiolysis:
  • Performed for symptomatic complications of adhesions, though criteria for surgery in these cases depends on the specific complication:
    • With adhesiolysis, there is always the risk of induction of new adhesions.
• Laparoscopic: Primarily for pelvic adhesions:
  • May be most effective in removing adhesions to the abdominal wall, and least effective for those affecting the adnexa
  • Helpful in treating chronic pelvic pain only when affected by severe adhesions
• Open: Primarily for peritoneal adhesions:
  • Laparotomy is preferred surgical resolution to SBO related to adhesions in cases of failed conservative management

Prognosis

• Adhesions are typically asymptomatic. However, once present, they cannot be fully removed.
• Possible complications can occur at any time.

Complications

• The most common and significant complication is bowel obstruction (either partial or complete).
• Chronic pelvic pain
• Infertility
• Surgical complications (7):
  • Prolonged surgery due to necessary lysis of adhesions
  • Intraoperative bleeding
  • Trocar injury
  • Conversion of laparoscopy to laparotomy
  • Inadvertent enterotomy or other organ damage
  • Prolonged length of hospital stay

See Also

Small Bowel Obstruction; Chronic Pelvic Pain; Infertility

ICD-9

• 568.0 Peritoneal adhesions (postoperative) (postinfection)
• 751.4 Anomalies of intestinal fixation
• 751.8 Other specified anomalies of digestive system

ICD-10

• K66.0 Peritoneal adhesions (postprocedural) (postinfection)
• Q43.3 Congenital malformations of intestinal fixation

SNOMED

• 30689000 Adhesion of abdominal wall (disorder)
• 70190001 Peritoneal adhesion (disorder)
• 134339005 Congenital adhesions