Adhesions: An update

Pelvic adhesions can be the result of pelvic inflammation, endometriosis, or surgical trauma. Even when surgery is performed with strict adherence to microsurgical principles, postoperative adhesions occur in 51-100% of cases.1 Adhesions resulting from surgical procedures may cause considerable pain and impair fertility. Subsequent surgical procedures become more difficult and occasionally emergency exploratory laparotomy for bowel obstruction is necessary. Complications such as these can present at any time, and are a lifetime concern for patients having even one laparotomy.2,3 In fact, adhesions causing postoperative bowel obstruction more than 10 years after the initial surgery have been reported.2,3 Clinically, adhesions may affect the practicing obstetrician during a repeat cesarean section by preventing emergency delivery, thereby placing the fetus at risk, increasing operative time, and increasing risk to the mother with higher risk of injury to the bladder, bowel, and uterus upon reentry. Similarly, the practicing gynecologist may be affected by adhesions causing pelvic and abdominal pain and even intestinal obstruction decades after the initial surgery. The cost of caring for these complications has been estimated at $1.3 billion annually.4 The significant socioeconomic cost of adhesions has prompted over a century of published literature documenting the search for operative strategies which may lead to a safe reduction or prevention of adhesions. These strategies have focused on minimizing surgical trauma, the use of barriers to prevent adhesions, and the use of medications both locally and systemically. In this article we will present the different modalities available to the obstetrician/gynecologist to prevent and treat adhesions, and discuss the evidence in the literature supporting or refuting them.