Medical Management of Post-Operative Adhesions
The primary goal of medical management for post-operative adhesions is prevention rather than treatment, as there are no effective medical therapies to dissolve existing adhesions once formed. 1
Primary Prevention Strategy (During Initial Surgery)
For patients undergoing open colorectal surgery, apply hyaluronate carboxymethylcellulose (Seprafilm®) as the first-line adhesion barrier, which reduces reoperations for adhesive small bowel obstruction by 51% (RR 0.49,95% CI 0.28–0.88) based on three trials involving 1,132 patients. 2, 1
For laparoscopic procedures, use icodextrin 4% (Adept®) as the preferred barrier due to its practical application in minimally invasive surgery and good safety profile. 2, 1
Mechanism of Action
Adhesion barriers function as physical spacers that separate injured peritoneal surfaces during the critical 5-7 day healing phase, preventing fibrinous attachments from forming permanent adhesions. 2 These barriers must be:
- Inert to the immune system 2
- Slowly degradable to maintain separation during healing 2
- Applied directly to injured peritoneal surfaces 2
Surgical Technique Modifications
Use bipolar electrocautery or ultrasonic devices instead of monopolar electrocautery to minimize peritoneal injury, as monopolar instruments increase adjacent tissue temperature by 47°C compared to only 0.6°C with ultrasonic devices. 2, 1
Additional intraoperative considerations include:
- Avoid starch-powdered gloves due to foreign body reaction 2
- Consider intraperitoneal metronidazole in contaminated or septic surgical fields 2, 1
- Minimize surgical trauma and tissue ischemia 2
Secondary Prevention (After Surgery for Existing ASBO)
For patients undergoing surgery to treat adhesive small bowel obstruction, apply icodextrin 4% barrier to prevent recurrence, which reduces ASBO recurrence from 11.11% to 2.19% over 41 months (RR 0.20,95% CI 0.04–0.88). 2, 1 This represents an 80% relative risk reduction in recurrence. 1
While hyaluronate carboxymethylcellulose may be more efficacious for preventing adhesion reformation, icodextrin is favored for its:
- Lower cost 2
- Excellent safety record 2
- Practical application in both open and laparoscopic approaches 2, 1
High-Risk Populations Requiring Aggressive Prevention
Young patients warrant both primary and secondary adhesion prevention strategies due to their higher lifetime risk of recurrent ASBO, as adhesion-related complications can occur decades after the initial surgery. 2, 1 In pediatric patients, adhesion barriers reduced ASBO incidence from 4.5% to 2.0% at 24 months. 2
Pregnant patients with ASBO have a 94% failure rate with non-operative management and 17% fetal loss rate, making primary prevention during any abdominal surgery in women of childbearing age particularly critical. 2
Barriers NOT Recommended
Do not use oxidized regenerated cellulose (Interceed®) for preventing adhesive small bowel obstruction in general surgery patients, as no studies demonstrate efficacy in preventing subsequent ASBO in this population. 1
Critical Clinical Caveat
There are no effective medical therapies to dissolve or treat existing adhesions once formed. 3, 4 Adhesiolysis (surgical division of adhesions) requires a second operation and frequently triggers recurrent adhesion formation. 3 This underscores why prevention during the index operation is the only truly effective strategy for reducing adhesion-related morbidity and mortality. 2, 5