What surgical techniques can prevent post-operative adhesions?

Surgical Techniques to Prevent Post-Operative Adhesions

The most effective strategy combines laparoscopic surgery when feasible with hyaluronate carboxymethylcellulose (Seprafilm®) adhesion barrier placement, which reduces reoperations for adhesive small bowel obstruction by 51% (RR 0.49). 1

Primary Surgical Approach

Minimally Invasive Technique

• Laparoscopic surgery reduces adhesion formation compared to open surgery, with reoperation rates for adhesive small bowel obstruction of 1.4% versus 3.8% after open procedures. 1
• However, the effect is modest when controlling for procedure type and indication, with randomized trials showing no significant difference (OR 0.50,95% CI 0.20-1.2). 1
• Laparoscopic approaches reduce de novo adhesions in areas away from the surgical site, though not necessarily at the incision site itself. 1

Tissue Handling Principles

The fundamental approach requires minimizing surgical trauma through meticulous technique: 1

• Limit tissue packing, crushing, and manipulation to only what is strictly necessary 2
• Achieve optimal hemostasis before closure 2
• Minimize peritoneal injury through careful dissection 1

Energy Device Selection

Use bipolar electrocautery or ultrasonic devices instead of monopolar electrocautery to reduce peritoneal injury and adhesion formation. 1, 3

• Ultrasonic devices increase adjacent tissue temperature by only 0.6°C compared to 47°C with monopolar instruments 3
• Bipolar devices increase temperature by only 1.2°C 3

Foreign Body Avoidance

Critical risk factors to eliminate include: 1

• Avoid starch-powdered gloves - use powder-free alternatives 1
• Minimize mesh use when possible in abdominal wall reconstruction 1
• Avoid talcum powder and other contaminants 2

Peritoneal Closure

Do not close the peritoneum - leaving it open reduces adhesion incidence (RR 0.36,95% CI 0.21-0.63). 4

Adhesion Barrier Application

Primary Prevention - Hyaluronate Carboxymethylcellulose (Seprafilm®)

This is the most evidence-based adhesion barrier for general surgery, particularly in colorectal procedures: 1

• Reduces reoperations for adhesive small bowel obstruction by 51% (RR 0.49,95% CI 0.28-0.88) in three trials with 1,132 patients 1
• Cost-effective in open colorectal surgery 1
• Best suited for open surgery, though laparoscopic placement has been described 1
• Particularly recommended for high-risk patients: those with endometriosis, pelvic inflammatory disease, or undergoing myomectomy 2

Alternative Barriers

Icodextrin (Adept®) - liquid barrier: 1

• Easy to apply in both open and laparoscopic surgery 1
• Reduces ASBO recurrence after surgery for ASBO (RR 0.20,95% CI 0.04-0.88) 1
• Good safety record in general and gynecological surgery 1

Oxidized regenerated cellulose (Interceed®): 1, 2

• Only use if complete hemostasis is achieved - may increase adhesions if bleeding persists 2
• Primarily studied in gynecological procedures 1
• Not recommended for general surgery ASBO prevention 1

Polytetrafluoroethylene (Gore-Tex): 2

• More effective than no barrier or oxidized cellulose 2
• Permanent material typically requiring removal 1

Special Considerations for Septic Conditions

In contaminated or septic surgical fields, consider intraperitoneal metronidazole based on animal data showing reduced adhesion formation. 1

Secondary Prevention

For patients undergoing surgery for existing adhesive small bowel obstruction, use icodextrin barrier to prevent recurrence (reduces recurrence from 11% to 2%). 1

High-Risk Patient Identification

Younger patients warrant more aggressive adhesion prevention due to higher lifetime risk of recurrent adhesive small bowel obstruction and should receive both primary and secondary prevention strategies. 1

Common Pitfalls to Avoid

• Do not use Interceed® without achieving complete hemostasis - it paradoxically increases adhesions in the presence of blood 2
• Laparoscopy alone is not sufficient prevention - must combine with other strategies 1
• Every additional surgery increases adhesion risk - carefully consider surgical necessity 2
• Avoid assuming all adhesion barriers are equivalent - evidence quality varies significantly 1