How can adhesions be prevented during surgery?

Adhesion Prevention During Surgery

Adhesion formation can be effectively reduced through minimally invasive surgical techniques and the use of specific adhesion barriers, with hyaluronate carboxymethylcellulose showing the strongest evidence for reducing reoperations for adhesive small bowel obstruction. 1

Surgical Techniques to Prevent Adhesions

Minimally Invasive Approaches

• Laparoscopic surgery shows modest but significant reduction in adhesion formation compared to open procedures (reoperation rates of 1.4% vs 3.8%) 1
• However, laparoscopy alone is not a complete solution for preventing adhesive small bowel obstruction 1

Specific Surgical Techniques

• Minimize tissue trauma by limiting tissue manipulation, packing, and crushing 2
• Achieve optimal hemostasis, as bleeding increases adhesion formation 1, 2
• Avoid foreign body reactions by:
  • Using powder-free gloves (starch powder significantly increases adhesions) 1
  • Being cautious with mesh placement for abdominal wall reconstruction 1
• Choose appropriate energy devices:
  • Bipolar electrocautery and ultrasonic devices cause less peritoneal injury than monopolar electrocautery 1
• Liberal irrigation of the abdominal cavity during and at the end of procedures 3
• Consider antibiotic administration (particularly metronidazole) in septic conditions, which may reduce adhesion formation 1

Adhesion Barriers

Most Effective Barriers

1. Hyaluronate carboxymethylcellulose (Seprafilm®):

   • Strongest evidence for reducing reoperations for adhesive small bowel obstruction
   • Reduces incidence of reoperations by 51% (RR 0.49,95% CI 0.28-0.88) 1
   • Most suitable for open surgery, though laparoscopic placement has been described
   • Cost-effective in open colorectal surgery 1
   • Particularly effective following myomectomies 2

2. Icodextrin 4% solution (Adept®):

   • Liquid barrier applicable in both open and laparoscopic surgery
   • Good safety profile
   • Reduces ASBO recurrence following surgery for ASBO (RR 0.20,95% CI 0.04-0.88) 1
   • Easier to apply than solid barriers in laparoscopic procedures 1, 4

3. Polyethylene glycol (Sprayshield®/Spraygel®):

   • Gel barrier suitable for both open and laparoscopic surgery
   • Reduces adhesion scores in clinical trials
   • Limited data on long-term adhesion-related complications 1

4. Oxidized regenerated cellulose (Interceed®):

   • Solid barrier most suitable for open surgery
   • Reduces adhesion formation (RR 0.51,95% CI 0.31-0.86)
   • Should NOT be used when hemostasis is incomplete as it may increase adhesion risk 1, 2
   • Primarily studied in gynecological procedures 1

Patient Selection for Barrier Use

• Younger patients have higher lifetime risk for recurrent adhesive small bowel obstruction and may benefit most from adhesion barriers 1
• Patients at high risk of forming clinically significant adhesions:
  • Those with endometriosis or pelvic inflammatory disease 2
  • Patients undergoing myomectomy 2
  • Patients undergoing colorectal surgery 1
  • Patients with previous episodes of adhesive small bowel obstruction 1

Secondary Prevention After ASBO

• For patients who have already had surgery for adhesive small bowel obstruction:
  • Icodextrin 4% solution reduced recurrence rates from 11.11% to 2.19% over 41.4 months 1
  • Hyaluronate carboxymethylcellulose may be more efficacious but is less practical in laparoscopic settings 1

Important Considerations and Pitfalls

• The risk of adhesions increases with each abdominal/pelvic surgery performed on a patient 2
• No single modality completely prevents adhesion formation - use multiple strategies 5
• Adhesion barriers should complement, not replace, good surgical technique 2, 5
• Delayed diagnosis of adhesions is a common cause of malpractice claims (70%) 1, 4
• Complete hemostasis is essential when using oxidized regenerated cellulose, as it may increase adhesion risk if bleeding continues 2
• The risk of adhesion-related complications is lifelong, not just limited to the immediate postoperative period 4