ABDOMINAL ADHESIONS

BASICS

1)   _Intra-abdominal adhesion are pathologic bands of scar tissue that form between 2 previously separated structures .

2)   _Adhesions can be between: 

A.   Omentum
B.   Bowel loops
C.   Abdominal wall

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·     - DESCRIPTION

1)   _Adhesions form from pathologic healing

2)   _Adhesions may be congnital or acquired

3)   _Acquired adhesions are usually the result of surgery, traumatic injury, or postinflammatory injury

4)   _Adhesions are not merely nonfunctioning scars; they can be highly vascular and cellular

5)   _Adhesions vary in structure from thin membranous tissue, to thick fibrous tissue with neurovascular structures, to direct connections between organs

6)   _Although most adhesions are asymptomatic, some patients may experience small bowel obstruction, infertility, chronic pain, and surgical complications

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·     - EPIDEMIOLOGY

Incidence

1)   _True incidence is difficult to determine, as some patients have asymptomatic adhesions.

2)   _Postop: 
63–97% develop over 10 years post laparotomy.

A.   1/3 of patients with open pelvic/abdominal surgery are readmitted for possible adhesion-related complications.

B.   Laparoscopy reduces adhesion formation by 45% and reduces the need for reoperation.

C.    Open colorectal surgeries and open ovarian surgeries have the highest risk of adhesion formation.

3)   _Congenital (4.7%)

4)   _Inflammatory (2.3%)

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·     - ETIOLOGY

1)   _Congenital: 
formed during organogenesis

2)   _Acquired adhesions

3)   _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.

4)   _Posttrauma: 
physical trauma to the abdomen, including surgery

5)   _Postinflammatory and postoperative: 
imbalance between fibrin deposition and breakdown (1)[C]

6)   _Increased fibrinogen from inflammatory and procoagulatory response mediated by plasminogen activator inhibitor (PAI-1)

7)   _Decreased fibrinolysis by decrease in Tpa

8)   _Morbidity caused by the anchoring of organs to nearby structures, impeding normal movement and promoting kinks, deformity, and blockage

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·     - RISK-FACTORS

History of the following:

1)   _Abdominal inflammation

2)   _Abdominal surgery

3)   _Abdominal insults

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·     - GENERAL-PREVENTION

1)   _Primary prevention: 
Avoid abdominal infection or need for abdominal surgery.

2)   _Surgical technique

A.   Laparoscopic surgery is associated with decreased adhesion formation compared with open procedures.

B.   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

3)   _Other modalities:

A.   Barrier films such as Seprafilm, Gore-Tex, and Interceed have had mixed results in terms of preventing adhesions and reducing complications.

B.   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.

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

☢ - ALERT
Small bowel obstructions in patients without a history of abdominal surgery should not be ascribed to adhesive disease without further workup

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·     - SIGNS-SYMPTOMS-History

1)   _Prior abdominal surgery

2)   _History of abdominal infection or pelvic inflammatory disease

3)   _If involving the bowel, complaints may include the following:

A.   Crampy abdominal pain

B.   Nausea

C.    Vomiting

D.   Minimal to no flatus

E.    Loud bowel sounds (borborygmi)

F.    Abdominal distension

4)   _If involving a pelvic structure, complaints may include the following:

A.   Lower abdominal pain (either chronic or acute)

B.   Infertility

C.    Nausea/vomiting

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·     - SIGNS-SYMPTOMS-Physical-Exam

1)   _Vital signs (evidence of ischemia, dehydration, or infection)

2)   _Fever

3)   _Tachycardia

4)   _Diffuse abdominal tenderness

5)   _Peritoneal signs: guarding, rebound, rigidity

6)   _Abdominal scars

7)   _In the case of small bowel obstruction, may see the following:

A.   Abdominal distention

B.   Tympany

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·     - TESTS

Initial-Evaluation-Initial -Tests 

1)   _No lab or imaging tests definitively demonstrate adhesions.

2)   _Imaging modalities such as KUB and CT scan can diagnose complications such as SBO.

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TREATMENT

SURGERY

1)   _Adhesiolysis

A.   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.

2)   _Laparoscopic: primarily for pelvic adhesions

A.   May be most effective in removing adhesions to the abdominal wall, and least effective for those affecting the adnexa

B.   Helpful in treating chronic pelvic pain only when affected by severe adhesions

3)   _Open: 
primarily for peritoneal adhesions

A.   Laparotomy is preferred surgical resolution to SBO related to adhesions in cases of failed conservative management.

4)   _Nasogastric decompression for patients with evidence of SBO.

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ONGOING CARE

PROGNOSIS

1)   _Adhesions are typically asymptomatic. Once present, they cannot be fully removed.

2)   _No single approach has been satisfactory in removing adhesions.

COMPLICATIONS 

1)   _Most common complication is bowel obstruction (either partial or complete).

2)   _Chronic pelvic painInfertility

3)   _Surgical complications:

A.   Prolonged surgery due to necessary lysis of adhesions

B.   Intraoperative bleeding

C.    Trocar injury (adhesions to ventral abdominal wall)

D.   Conversion of laparoscopy to laparotomy

E.    Inadvertent enterotomy or other organ damage

F.    Prolonged length of hospital stay

G.   Postoperative morbidity/mortality is slightly higher than virgin abdomen.

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REFERENCES

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1)   _Arung W, Meurisse M, Detry O. 
Pathophysiology and prevention of postoperative peritoneal adhesions.
World J Gastroenterol. 2011;17(41):4545–4553. 

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. 

3)   _Ward BC, Panitch A.
Abdominal adhesions: current and novel therapies. J Surg Res. 2011;165(1):91–111.

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PEARLS

1)   _Abdominal adhesions result primarily from abdominal infection or trauma, including surgery.

2)   _Although typically asymptomatic, the most common and significant complication is bowel obstruction (partial or complete).

3)   _Degree of pain does not correlate with the number of adhesions.

With Regards

   👨l_Abdulbast Al-gabry💫