Medical Management for Postoperative Adhesions
The primary medical management for preventing postoperative adhesions involves intraoperative application of adhesion barriers, with hyaluronate carboxymethylcellulose (Seprafilm®) being the most evidence-based option for open colorectal surgery, reducing reoperations for adhesive small bowel obstruction by 51%. 1
Primary Prevention Strategy
First-Line Adhesion Barrier Selection
For open colorectal surgery, use hyaluronate carboxymethylcellulose (Seprafilm®) as it demonstrates the strongest evidence for reducing clinically significant outcomes—specifically, it reduces the risk of reoperations for adhesive small bowel obstruction (RR 0.49,95% CI 0.28–0.88) based on three trials involving 1,132 patients. 1 This barrier is cost-effective in open colorectal procedures and has been validated in both general surgery and gynecological operations. 1
For laparoscopic procedures, use icodextrin 4% (Adept®) as the liquid formulation allows easy application during minimally invasive surgery with a good safety record in both general surgery and gynecological procedures. 1 While polyethylene glycol gel barriers (Sprayshield®/Spraygel®) are also suitable for laparoscopic application, they have fewer studies and no data on long-term adhesion-related complications. 1
Mechanism of Action
Adhesion barriers function as physical spacers that separate injured peritoneal surfaces during the healing phase, preventing fibrinous attachments from forming permanent adhesions. 1 They must be inert to the immune system and slowly degradable to maintain separation during the critical healing period. 1
Secondary Prevention (After Surgery for Existing Adhesive Small Bowel Obstruction)
For patients undergoing surgery to treat adhesive small bowel obstruction, apply icodextrin 4% barrier to prevent recurrence, as this reduces ASBO recurrence from 11.11% to 2.19% over a mean follow-up of 41.4 months (RR 0.20,95% CI 0.04–0.88). 1 This represents an 80% relative risk reduction in recurrence. 2
While hyaluronate carboxymethylcellulose may be more efficacious for preventing adhesion reformation (which is more challenging than preventing de novo adhesions), icodextrin is favored for its low cost, excellent safety profile, and practical application in both open and laparoscopic approaches. 1
Adjunctive Surgical Technique Modifications
Energy Device Selection
Use bipolar electrocautery or ultrasonic devices instead of monopolar electrocautery to minimize peritoneal injury. 2 Monopolar instruments increase adjacent tissue temperature by 47°C compared to only 0.6°C with ultrasonic devices and 1.2°C with bipolar devices, resulting in less tissue trauma and adhesion formation. 2
Contaminated/Septic Fields
Consider intraperitoneal metronidazole in contaminated or septic surgical fields, as animal data demonstrate reduced adhesion formation under these conditions. 1
Foreign Body Considerations
Avoid starch-powdered gloves and carefully select mesh materials for abdominal wall reconstruction, as foreign body reactions significantly aggravate adhesion formation. 1
Barriers NOT Recommended for General Surgery
Do not use oxidized regenerated cellulose (Interceed®) for preventing adhesive small bowel obstruction in general surgery patients. 1 While this barrier reduces adhesion formation in gynecological procedures (RR 0.51,95% CI 0.31–0.86), no studies demonstrate efficacy in preventing subsequent adhesive small bowel obstruction in general surgery populations. 1
High-Risk Patient Considerations
Younger patients warrant more aggressive adhesion prevention strategies as they face higher lifetime risk of recurrent adhesive small bowel obstruction and should receive both primary prevention (barrier application during initial surgery) and secondary prevention strategies (barrier application if surgery for ASBO becomes necessary). 2
Common Pitfalls to Avoid
Laparoscopic surgery alone is insufficient: While laparoscopic approaches reduce adhesion formation away from the surgical site compared to open surgery (reoperation rates 1.4% vs 3.8%), they do not prevent adhesions at the incision site itself, so barrier application remains necessary. 2
Timing matters: Adhesion barriers must be applied intraoperatively as they act as physical spacers during the healing phase; there is no effective medical treatment for established adhesions beyond surgical adhesiolysis. 3
Hemostasis requirements vary: Oxidized regenerated cellulose requires strict hemostasis for effectiveness, while hyaluronate carboxymethylcellulose does not have this limitation. 4