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Abdominal Adhesions

- Prior abdominal surgery - History of abdominal infection or pelvic inflammatory disease - Bowel complaints may include: - Crampy abdominal pain - Nausea, vomiting - Minimal to no flatus - Loud bowel sounds (borborygmi) - Abdominal distension

- Vital sign abnormalities (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: - Abdominal distention - Tympany - Altered bowel sounds

- Most common complication is bowel obstruction (either partial or complete) - Chronic pelvic pain - Infertility - Surgical complications: - Prolonged surgery - 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.

para>Small bowel obstructions in patients without a history of abdominal surgery should not be routinely ascribed to adhesive disease without further workup, to exclude obstruction due to malignancy or other processes (4)[C].

HISTORY

  • Prior abdominal surgery
  • History of abdominal infection or pelvic inflammatory disease
  • Bowel complaints may include:Crampy abdominal painNausea, vomitingMinimal to no flatusLoud bowel sounds (borborygmi)Abdominal distension
  • If involving a pelvic structure, complaints may include:Lower abdominal pain (either chronic or acute)InfertilityNausea/vomiting

PHYSICAL EXAM

  • Vital sign abnormalities (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:Abdominal distentionTympanyAltered bowel sounds

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

  • No lab or imaging tests definitively demonstrate adhesions. Workup should include WBC, lactate, electrolytes, BUN/creatinine
  • Imaging modalities such as supine and erect abdominal x-ray (4)[B], water-soluble oral-contrasted CT scan (4)[B], and water-soluble contrast follow-through can help diagnose small bowel obstruction (SBO) (4)[A].

TREATMENT

SURGERY/OTHER PROCEDURES

  • Nasogastric decompression for patients with evidence of partial SBO without specific indications for surgery (4)[A]
  • AdhesiolysisPerformed for symptomatic complications of adhesions, although criteria for surgery in these cases depends on the specific complicationIndications for adhesiolysis in setting of SBO include signs of strangulation or peritonitis, surgery within 6 weeks, carcinomatosis, irreducible hernia, no signs of resolution within 72 hours (4)[A].With adhesiolysis, there is always the risk of new adhesions.
  • Laparoscopic: primarily for pelvic adhesionsAppropriate for highly selected patient (4)[B]May be most effective in removing abdominal wall adhesions and least effective for adnexal adhesions (5)[C]Helps treat chronic pelvic pain only when severe
  • Open: primarily for peritoneal adhesionsLaparotomy is the preferred surgical resolution to SBO related to adhesions in cases of failed conservative management (4)[B].

ONGOING CARE

PROGNOSIS

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

COMPLICATIONS

  • Most common complication is bowel obstruction (either partial or complete)
  • Chronic pelvic pain
  • Infertility
  • Surgical complications:Prolonged surgeryIntraoperative bleedingTrocar injury (adhesions to ventral abdominal wall)Conversion of laparoscopy to laparotomyInadvertent enterotomy or other organ damageProlonged length of hospital stayPostoperative morbidity/mortality is slightly higher than virgin abdomen.

REFERENCES

11 Arung W, Meurisse M, Detry O. Pathophysiology and prevention of postoperative peritoneal adhesions. World J Gastroenterol. 2011;17(41):4545-4553.22 Robb WB, Mariette C. Strategies in the prevention of the formation of postoperative adhesions in digestive surgery: a systematic review of the literature. Dis Colon Rectum. 2014;57(10):1228-1240.33 van der Wal JB, Iordens GI, Vrijland WW, et al. Adhesion prevention during laparotomy: long-term follow-up of a randomized clinical trial. Ann Surg. 2011;253(6):1118-1121.44 Di Saverio S, Coccolini F, Galati M, et al. Bologna guidelines for diagnosis and management of adhesive small bowel obstruction (ASBO): 2013 update of the evidence-based guidelines from the world society of emergency surgery ASBO working group. World J Emerg Surg. 2013;8(1):42.55 Ward BC, Panitch A. Abdominal adhesions: current and novel therapies. J Surg Res. 2011;165(1):91-111.

ADDITIONAL READING

  • Blumenfeld YJ, Caughey AB, El-Sayed YY, et al. Single-versus double-layer hysterotomy closure at primary caesarean delivery and bladder adhesions. BJOG. 2010;117(6):690-694.
  • 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.
  • Dupr © A, Lefranc A, Buc E, et al. Use of bioresorbable membranes to reduce abdominal and perihepatic adhesions in 2-stage hepatectomy of liver metastases from colorectal cancer: results of a prospective, randomized controlled phase II trial. Ann Surg. 2013;258(1):30-36.
  • 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.
  • Oua ¯ssi 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.

SEE ALSO

Algorithm: Intestinal Obstruction; Infertility

CODES

ICD10

  • K66.0 Peritoneal adhesions (postprocedural) (postinfection)
  • Q43.3 Congenital malformations of intestinal fixation
  • N99.4 Postprocedural pelvic peritoneal adhesions
  • N73.6 Female pelvic peritoneal adhesions (postinfective)

ICD9

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

SNOMED

  • adhesion of abdominal wall (disorder)
  • peritoneal adhesion (disorder)
  • Congenital intestinal adhesions (disorder)
  • Postprocedural pelvic peritoneal adhesions (disorder)
  • Female pelvic peritoneal adhesions
  • Adhesion of intestine (disorder)

CLINICAL PEARLS

  • Abdominal adhesions result primarily from abdominal infection or trauma (including surgery).
  • Most adhesions are asymptomatic; the most common complication is bowel obstruction (partial or complete).
  • The degree of pain does not correlate with the number of adhesions.