5-Minute Clinical Consult

Abdominal Adhesions


  • Intra-abdominal adhesions are pathologic bands of scar tissue that form between 2 previously separated structures.
  • Adhesions can be between:
    • Omentum
    • Bowel loops
    • Abdominal wall


Adhesions form from pathologic healing

  • 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 from thin membranous tissue, to thick fibrous tissue with neurovascular structures, to direct connections between organs.
  • Although most adhesions are asymptomatic, some patients may experience small bowel obstruction, infertility, chronic pain, and surgical complications.


  • True incidence is difficult to determine, as some patients have asymptomatic adhesions.
  • Postop: 63–97% develop over 10 years post laparotomy.
    • 1/3 of patients with open pelvic/abdominal surgery are readmitted for possible adhesion-related complications.
    • Laparoscopy reduces adhesion formation by 45% and reduces the need for reoperation.
    • Open colorectal surgeries and open 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 normal peritoneal defense mechanism.
  • Posttrauma: physical trauma to the abdomen, including surgery
  • Postinflammatory and postoperative: imbalance between fibrin deposition and breakdown (1)[C]
    • Increased fibrinogen from inflammatory and procoagulatory response mediated by plasminogen activator inhibitor (PAI-1)
    • Decreased fibrinolysis by decrease in tPA
    • Morbidity caused by the anchoring of organs to nearby structures, impeding normal movement and promoting kinks, deformity, and blockage

Risk Factors

History of the following:

  • Abdominal inflammation
  • Abdominal surgery
  • Abdominal insults

General Prevention

  • Primary prevention: Avoid abdominal infection or need for abdominal surgery.
  • Surgical technique
    • Laparoscopic surgery is associated with decreased adhesion formation compared with open procedures.
    • Intraoperative techniques have been shown to have decreased adhesion formation:
      • Minimal peritoneal trauma
      • Delicate handling of tissue
      • 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 in terms of preventing adhesions and reducing complications.
    • Medications such as NSAIDs, steroids, vitamin E, and tPA have not conclusively been shown to decrease adhesions. Most are still being studied in animal models.


Adhesions are primarily diagnosed through patient history and/or intraoperatively. The number of adhesions does not correlate with symptoms.

Small bowel obstructions in patients without a history of abdominal surgery should not be ascribed to adhesive disease without further workup (2)[C].


  • Prior abdominal surgery
  • History of abdominal infection or pelvic inflammatory disease
  • If involving the bowel, complaints may include the following:
    • Crampy abdominal pain
    • Nausea
    • Vomiting
    • Minimal to no flatus
    • Loud bowel sounds (borborygmi)
    • Abdominal distension
  • If involving a pelvic structure, complaints may include the following:
    • Lower abdominal pain (either chronic or acute)
    • Infertility
    • Nausea/vomiting

Physical Exam

  • Vital signs (evidence of ischemia, dehydration, or infection)
  • Fever
  • Tachycardia
  • Diffuse abdominal tenderness
  • Peritoneal signs: guarding, rebound, rigidity
  • Abdominal scars
  • In the case of small bowel obstruction, may see the following:
    • Abdominal distention
    • Tympany

Diagnostic Tests and Interpretation

Initial Tests (lab, imaging)
  • No lab or imaging tests definitively demonstrate adhesions.
  • Imaging modalities such as KUB and CT scan can diagnose complications such as SBO.


Surgery/Other Procedures

  • Adhesiolysis
    • Performed for symptomatic complications of adhesions, although criteria for surgery in these cases depends on the specific complication
      • With adhesiolysis, there is always the risk of 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 (3)[C]
    • 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.
  • Nasogastric decompression for patients with evidence of SBO.

Ongoing Care


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


  • Most common complication is bowel obstruction (either partial or complete).
  • Chronic pelvic pain
  • Infertility
  • Surgical complications:
    • Prolonged surgery due to necessary lysis of adhesions
    • 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.

Additional Reading

  • Ahmad G, Duffy JM, Farquhar C, et al. Barrier agents for adhesion prevention after gynaecological surgery. Cochrane Database Syst Rev. 2008;(2):CD000475.
  • Barmparas G, Branco BC, Schnüriger B, et al. The incidence and risk factors of post-laparotomy adhesive small bowel obstruction. J Gastrointest Surg. 2010;14(10):1619–1628.
  • Diamond MP, Burns EL, Accomando B, et al. Seprafilm® adhesion barrier: (2) a review of the clinical literature on intraabdominal use. Gynecol Surg. 2012;9(3):247–257.
  • Esposito AJ, Heydrick SJ, Cassidy MR, et al. Substance P is an early mediator of peritoneal fibrinolytic pathway genes and promotes intra-abdominal adhesion formation. J Surg Res. 2013;181(1):25–31.
  • Hackethal A, Sick C, Szalay G, et al. Intra-abdominal adhesion formation: does surgical approach matter? Questionnaire survey of South Asian surgeons and literature review. J Obstet Gynaecol Res. 2011;37(10):1382–1390.
  • Hellebrekers BW, Kooistra T. Pathogenesis of postoperative adhesion formation. Br J Surg. 2011;98(11):1503–1516.
  • Lauder CI, Garcea G, Strickland A, et al. Abdominal adhesion prevention: still a sticky subject? Dig Surg. 2010;27(5):347–358.  [PMID:20352368]
  • Ouaïssi M, Gaujoux S, Veyrie N, et al. Post-operative adhesions after digestive surgery: their incidence and prevention: review of their literature. J Visc Surg. 2012;149(2):e104–e114.
  • Sikirica V, Bapat B, Candrilli SD, et al. The inpatient burden of abdominal and gynecological adhesiolysis in the US. BMC Surg. 2011;11:13.  [PMID:22765994]
  • van Goor H. Consequences and complications of peritoneal adhesions. Colorectal Dis. 2007;9(Suppl 2):25–34.  [PMID:20551759]



  • 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


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


  • 134339005 Congenital adhesions
  • 197201009 Postprocedural pelvic peritoneal adhesions (disorder)
  • 30689000 adhesion of abdominal wall (disorder)
  • 62394006 Female pelvic peritoneal adhesions
  • 70190001 peritoneal adhesion (disorder)

Clinical Pearls

  • Abdominal adhesions result primarily from abdominal infection or trauma, including surgery.
  • Although typically asymptomatic, the most common and significant complication is bowel obstruction (partial or complete).
  • Degree of pain does not correlate with the number of adhesions.


Mark B. Stephens, MD, MS, FAAFP, CAPT, MC, USN


  1. Arung W, Meurisse M, Detry O. Pathophysiology and prevention of postoperative peritoneal adhesions. World J Gastroenterol. 2011;17(41):4545–4553. [PMID:22147959]
  2. Catena F, Di Saverio S, Kelly MD, et al. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2010 evidence-based guidelines of the World Society of Emergency Surgery. World J Emerg Surg. 2011;6:5. [PMID:21255429]
  3. Ward BC, Panitch A. Abdominal adhesions: current and novel therapies. J Surg Res. 2011;165(1):91–111. [PMID:20036389]

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