5-Minute Clinical Consult

Abdominal Adhesions

Basics

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

Description

Adhesions form from pathological healing:

  • Adhesions may be congenital or acquired.
  • Acquired adhesions are usually the result of surgery, traumatic injury, or postinflammatory injury.
  • Adhesions are not mere nonfunctioning scars; they can be highly vascular and cellular (1).
  • Adhesions vary in structure from thin membranous tissue, to thick fibrous tissue with neurovascular structures, to direct connections between organs (2).
  • Although most adhesions are asymptomatic, some patients may experience small bowel obstruction, infertility, chronic pain, and surgical complications.

Epidemiology

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

Etiology and Pathophysiology

  • Congenital: Abnormality formed during organogenesis
  • Acquired adhesions
  • Postinflammatory: From diverticulitis, appendicitis, endometriosis, peritonitis, radiotherapy, long-term peritoneal dialysis, and inflammatory bowel disease, among others. Adhesion formation is part of our innate peritoneal defense mechanism
  • Posttrauma: Physical trauma to the abdomen, including surgery
  • Postinflammatory and postoperative: Imbalance between fibrin deposition and breakdown (2,4):
    • 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

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 (2):
    • Laparoscopic surgery is associated with decreased adhesion formation and decreased risk of complications, when compared with open procedures.
    • Intraoperative techniques have been shown to have decreased adhesion formation, such as (5):
      • Minimal peritoneal trauma
      • Delicate handling of tissue
      • Irrigation
      • Meticulous hemostasis
      • Decreased operating time
      • Reduction of 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 adhesion prevention and complication reduction (2,6,7).
    • Barrier liquids have even less data (8).
    • 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 (2,8).

Diagnosis

Adhesions are primarily diagnosed through patient history and/or intraoperatively (either laparoscopically or through a laparotomy). A greater number of adhesions does not correlate with more symptoms (1)

ALERT
SBO without surgical history should not be blamed on adhesions. Further workup is required in these cases.

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

Initial Tests (lab, imaging)
  • No lab or imaging test can demonstrate adhesions.
  • However, imaging modalities such as KUB and CT scan can diagnose complications that arise from adhesions, such as SBO.

Treatment

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

Ongoing Care

Prognosis

  • Adhesions are typically asymptomatic. However, once present, they cannot be fully removed.
  • No single approach has been satisfactory in removing adhesions
  • Possible complications can occur at any time.

Complications

  • Most common complication is bowel obstruction (either partial or complete).
  • Chronic pelvic pain
  • Infertility
  • Surgical complications (4,9):
    • 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 mordbidty/mortality is slightly higher than virgin abdomen.

Additional Reading

  • 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. Epub 2010 Mar 30.  [PMID:20352368]
  • 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. Epub 2011 Jan 21.
  • Esposito AJ, Heydrick SJ, Cassidy MR, et al. Substance P is an early mediator of peritoneal fibrinolytic pathway genes and promotes intra-abdominal adhesions formation. J Surg Res. 2013;181(1):25–31.  [PMID:22765994]
  • Garrett KA, Church J. History of hysterectomy: A significant problem for colonoscopists that is not present in patients who have had sigmoid colectomy. Dis Colon Rectum. 2010;53(7):1055–1060.  [PMID:20551759]
  • Munireddy S, Kavalukas SL, Barbul A. Intraabdominal healing: Gastrointestinal tract and adhesions. Surg Clin North Am. 2010;90(6):1227–1236.  [PMID:21074038]
  • Sikirica V, Bapat B, Candrilli SD, et al. The inpatient burden of abdominal and gynecological adhesiolysis in the US. BMC Surg. 2011;11:13. Epub 2011 Jun 9.  [PMID:21658255]
  • Stones RW, Mountfield J. Interventions for treating chronic pelvic pain in women. Cochrane Database Syst Rev. 2000;(4):CD000387.
  • Ward BC, Panitch A. Abdominal adhesions: Current and novel therapies. J Surg Res. 2011;165(1):91–111. Epub 2009 Oct 2.  [PMID:20036389]

See Also

Small Bowel Obstruction; Chronic Pelvic Pain; Infertility

Codes

ICD-9

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

ICD-10

  • 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

SNOMED

  • 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 (either partial or complete).
  • Minimizing abdominal inflammation and trauma, including surgery, is the most effective, current means of adhesion prevention.
  • Degree of pain does not correlate with quantity of adhesions.

Authors


Karen Cherian, MD
David O. Parrish, MD

Bibliography

  1. Lauder CI, Garcea G, Strickland A, et al. Abdominal adhesion prevention: Still a sticky subject? Digestive Surgery. 2010;27(5):347–358.  [PMID:20847564]
  2. Arung W, Meurisse M, Detry O. Pathophysiology and prevention of postoperative peritoneal adhesions. World J Gastroenterol. 2011;17(41):4545–4553.  [PMID:22147959]
  3. Ouaïssi M, Gaujoux S, Veyrie N, et al. Post-operative adhesions after digestive surgery: Their incidence and prevention: Review of the literature. J Visc Surg. 2012;149(2):e104–e114. Epub 2012 Jan 20.  [PMID:22261580]
  4. Hellebrekers BW, Kooistra T. Pathogenesis of postoperative adhesion formation. Br J Surg. 2011;98(11):1503–1516. Epub 2011 Aug 23.  [PMID:21877324]
  5. Hackethal A, Sick C, Szalay G, et al. Intraabdominal adhesion formation: Does surgical approach matter? Questionnaire survey of South Asian surgeons and literature review. J Obstets And Gynaecology Research. 2011;37(10):1382-1390.
  6. 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. Epub 2012 Apr 15.  [PMID:22837733]
  7. Ahmad G, Duffy JM, Farquhar C, et al. Barrier agents for adhesion prevention after gynaecological surgery. Cochrane Database Syst Rev. 2008;16(2):CD000475.
  8. Kumar S, Wong PF, Leaper DJ. Intra-peritoneal prophylactic agents for preventing adhesions and adhesive intestinal obstruction after nongynaecological abdominal surgery. Cochrane Database Syst Rev. 2009;(1):CD005080. Epub 2009 Jan 21.  [PMID:19160246]
  9. van Goor H. Consequences and complications of peritoneal adhesions. Colorectal Dis. 2007;9(Suppl 2):25–34.  [PMID:17824967]


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