How to prevent an episode of Adhesive Small Bowel Obstruction (SBO)?

Prevention of Adhesive Small Bowel Obstruction

The most effective prevention strategy is using laparoscopic surgery whenever feasible combined with adhesion barriers, particularly hyaluronate carboxymethylcellulose (Seprafilm®) in open procedures or icodextrin (Adept®) in laparoscopic cases. 1, 2

Primary Prevention During Initial Surgery

Surgical Approach Selection

• Laparoscopic surgery reduces adhesion formation significantly compared to open surgery, with reoperation rates for adhesive SBO of 1.4% versus 3.8% after open procedures 2
• Minimally invasive techniques reduce de novo adhesions in areas away from the surgical site, though not necessarily at the incision site itself 1, 2

Intraoperative Technical Considerations

• Use bipolar electrocautery or ultrasonic devices instead of monopolar electrocautery to minimize peritoneal injury 2
  • Ultrasonic devices increase adjacent tissue temperature by only 0.6°C compared to 47°C with monopolar instruments 2
  • Bipolar devices increase temperature by only 1.2°C 2
• Practice meticulous surgical technique with gentle tissue handling 3

Adhesion Barrier Application

For Open Colorectal Surgery:

• Hyaluronate carboxymethylcellulose (Seprafilm®) is the most evidence-based barrier, reducing reoperations for adhesive SBO by 51% (relative risk 0.49,95% CI 0.28–0.88) 1, 2
• This solid barrier is most suitable for open surgery, though laparoscopic placement has been described 1
• Cost-effective in open colorectal procedures 1

For Laparoscopic Surgery:

• Icodextrin (Adept®) is the preferred liquid barrier due to ease of application in both open and laparoscopic approaches 1
• Has a good safety record and low cost 1
• Polyethylene glycol (Sprayshield®/Spraygel®) is an alternative gel barrier easy to apply laparoscopically, though fewer studies exist on long-term outcomes 1

Special Circumstances:

• Consider intraperitoneal metronidazole in contaminated or septic surgical fields based on animal data showing reduced adhesion formation 2

Secondary Prevention (Preventing Recurrence After ASBO Surgery)

Patient Risk Stratification

• Younger patients have higher lifetime risk for recurrent ASBO and warrant more aggressive adhesion prevention strategies 1, 4, 2
• 12% of non-operatively treated patients are readmitted within 1 year, rising to 20% after 5 years 4
• 8% of operatively treated patients experience recurrence after 1 year and 16% after 5 years 4

Adhesion Barrier Selection for Recurrence Prevention

• Icodextrin (Adept®) dramatically reduces ASBO recurrence from 11.11% to 2.19% after surgery for ASBO (relative risk 0.20,95% CI 0.04–0.88) 1, 2
• This liquid barrier can be administered in both laparotomy and laparoscopic surgery 1
• Hyaluronate carboxymethylcellulose may be more efficacious for preventing adhesion reformation (which is more challenging than preventing de novo adhesions), but is less practical in laparoscopic surgery 1
• Hyaluronate carboxymethylcellulose reduces recurrence from 4.5% to 2.0% at 24 months 4

Common Pitfalls to Avoid

• Do not assume all SBO in patients with prior surgery is adhesive—consider recurrent cancer, occult hernia, or bowel ischemia as alternative diagnoses 4, 5
• Avoid monopolar electrocautery when bipolar or ultrasonic devices are available 2
• Do not neglect adhesion barrier application in younger patients who face decades of recurrence risk 1, 2
• Remember that oxidized regenerated cellulose (Interceed®) has only been studied in gynecological procedures and is not recommended for general surgery ASBO prevention 1

Algorithm for Adhesion Prevention Strategy

Step 1: Choose Surgical Approach

• Laparoscopic if feasible → reduces baseline adhesion risk 1, 2
• If open surgery required → proceed to Step 2

Step 2: Select Energy Device

• Bipolar electrocautery or ultrasonic devices preferred 2
• Avoid monopolar electrocautery 2

Step 3: Apply Adhesion Barrier Based on Surgical Approach

• Open colorectal surgery: Hyaluronate carboxymethylcellulose (Seprafilm®) 1, 2
• Laparoscopic surgery: Icodextrin (Adept®) 1
• Surgery for existing ASBO: Icodextrin (Adept®) for secondary prevention 1, 2

Step 4: Risk-Stratify for Aggressive Prevention

• Younger patients: Apply both primary and secondary prevention strategies aggressively 1, 2
• Older patients: Standard barrier application based on surgical approach 2