Abdominal Adhesions: Prevention and Treatment

by Subhuti Dharmananda, Ph.D., Director, Portland, Oregon

Adhesions are strands or of scar tissue (fibrin bands; see illustration, below)
that form in response to abdominal surgery and extend beyond the specific site o
f incision, sometimes forming separately from the incision site within the perit
oneum. Scar tissue that mends the incision is normal, but the adhesions form add
itionally under some circumstances that are not fully understood. There are spec
ific features of a surgical procedure that help induce the formation of adhesion
s. For example, drying of the tissues during surgery increases adhesion formatio
n, a situation remedied by paying attention to the arid conditions and correctin
g them during then procedures. Intentional drying of the tissues, by applying ga
uze, is an otherwise desirable procedure to aid the surgeon's view of the area,
but because of increased adhesions, it must be minimized. Tissues that become dr
y should be quickly moistened and air (carbon dioxide) that is passed over the s
urgery site to maintain cleanliness also must contain adequate moisture to preve
nt rapid drying of the exposed fluids. Laparotomy (open abdominal surgery) is mo
re likely to produce adhesions than surgery performed via laparoscopy in which a
small scope with attached microsurgical instruments is inserted through a slit
in the abdomen (1-3).
Left: a representation of a normal peritoneum, the transparent membrane that wra
ps the pelvic and abdominal organs. Right: after surgical trauma, fibrous bands
of collagen grow as part of the normal healing process and form adhesions. Adhes
ions connect tissues or structures that are normally separate. Adhesions in the
abdomen or pelvic area can lead to infertility, pelvic pain, small bowel obstruc
tion, or the need for repeat surgery (1).
The incidence of adhesions following abdominal surgery is cumulative with multip
le surgeries and female gynecological surgeries give a particularly high rate of
adhesions. In one study, autopsy investigations indicated a 90% incidence of ad
hesions in patients with multiple surgeries, 70% incidence of adhesions in patie
nts with a gynecologic surgery, a 50% incidence of adhesions with appendectomy,
and a greater than 20% incidence of adhesions in patients with no surgical histo
ry. Adhesions may occur as the result of tissue damage to the abdomen besides su
rgery, including traumatic injury, inflammatory disease, intraperitoneal chemoth
erapy, and radiation therapy (1).
The most frequent problem with adhesions is a constriction of the small intestin
e, producing constipation (sometimes complete bowel blockage, requiring emergenc
y treatments). Abdominal pain is another common symptom, caused when the bands o
f scar tissue bind up the internal organs so that movements pull on them. Linkag
e of menstruation to changes in bowel function (e.g., inducing diarrhea) may occ
ur as the result of scar tissue attaching the uterus to the intestine. Adhesions
may also impair fertility in women by causing blockage of the fallopian tubes.
It has been estimated that:
At least one-third of women who suffer from pelvic pain have adhesions as a caus
e of or contributor to the pain.
Adhesions involving the ovaries or fallopian tubes are responsible for 15-20 per
cent of female infertility cases.
Small bowel obstruction is often a surgical emergency and is particularly common
after gynecological surgery.
To prevent adhesion formation, surgeons may now apply a fine fabric barrier to s
urround the organs, thus isolating them from the scar tissue strands (the barrie
r dissolves after the surgery). Although adhesions can be removed by surgical in
tervention (adhesiolysis) using a laparoscopic technique (4), recent studies sug
gested that such surgery produces limited benefits that are often short-term. Ma
ny patients are treated with multiple adhesiolysis procedures in an attempt to i
mprove the symptoms of adhesions. Each year, 400,000 adhesiolysis procedures are
performed in the U.S., costing the health care system about $2 billion in hospi
talization and surgeon expenses.
Most times, adhesions cause few, if any, notable effects. But, for those who do
suffer from their adverse effects, the question arises as to whether the adhesio
ns can be reduced or eliminated by methods other than further surgery.