What is lysis of adhesions?

What is Lysis of Adhesions

Lysis of adhesions (adhesiolysis) is a surgical procedure that involves cutting and dividing fibrous scar tissue bands (adhesions) that abnormally connect organs or surfaces within the abdominal cavity, performed primarily to treat small bowel obstruction and, more controversially, chronic abdominal pain. 1, 2

Definition and Mechanism

Adhesiolysis is the surgical division of adhesions—fibrous tissue bands that connect surfaces or organs within the peritoneal cavity that are normally separated. 2, 3 These adhesions typically form after peritoneal injury from abdominal surgery, trauma, or inflammation, though they can also be congenital in origin. 3

The procedure can be performed through two approaches:

• Laparoscopic adhesiolysis: Uses minimally invasive techniques with small incisions and camera guidance 4, 5
• Open adhesiolysis: Traditional approach through laparotomy incision 1, 5

Primary Indications

Acute Small Bowel Obstruction (Primary Indication)

Adhesiolysis is definitively indicated for adhesive small bowel obstruction (ASBO) when:

• Complete bowel obstruction is present 2
• Non-operative management has failed 2
• Signs of bowel ischemia, strangulation, or peritonitis develop 3

Adhesions cause 55-75% of all small bowel obstructions, making this the most common indication for the procedure. 3 The risk is highest following colorectal, oncologic gynecological, or pediatric surgery. 1

Chronic Abdominal Pain (Controversial Indication)

The role of adhesiolysis for chronic abdominal pain remains controversial and is not routinely recommended. 6 The World Society of Emergency Surgery guidelines explicitly limit their scope to acute bowel obstructions rather than chronic pain management. 6 However, recent evidence suggests potential benefit in highly selected patients with dense, vascularized adhesions identified on advanced imaging like cineMRI. 7, 8

Surgical Approach Selection

Laparoscopic adhesiolysis should be considered the preferred approach when feasible, particularly in patients with suspected simple band adhesions. 6, 5

Advantages of Laparoscopic Approach:

• Lower overall complication rates (43% vs 67.9% for open) 5
• Reduced postoperative pain 6, 4
• Earlier return of bowel function 6
• Shorter hospital stays 5
• Lower mortality 5
• Less additional adhesion formation 6, 4

Patient Selection Factors:

• Younger patients with fewer previous operations are better candidates 5
• Simple band adhesions or internal hernias without need for bowel resection have best outcomes 5
• Complex matted adhesions may require open approach 5
• Conversion to open occurs in approximately 38.5% of cases 5

Significant Risks and Complications

Iatrogenic bowel injury is the most serious complication of adhesiolysis, occurring in 6.3-26.9% of laparoscopic cases—higher than open surgery. 6

Types of Bowel Injuries:

• Seromuscular injury: Damage to visceral peritoneum and smooth muscle layer without entering the bowel lumen 1, 2
• Enterotomy: Full-thickness injury where the mucous layer or lumen is visible, or intestinal contents leak 1, 2
• Delayed diagnosed perforation: Unrecognized bowel injuries that cause postoperative deterioration after the abdomen is closed 1, 2

Other Important Complications:

• Recurrence of adhesions is common, with 12% of non-operatively treated patients readmitted within 1 year, rising to 20% after 5 years 1
• Risk of recurrence is slightly lower after operative treatment: 8% after 1 year and 16% after 5 years 1
• Acute postoperative pain from the procedure itself, which is self-limited 6

Clinical Outcomes

For acute small bowel obstruction, adhesiolysis is both diagnostic and therapeutic, allowing direct visualization and division of obstructing bands. 3 In properly selected patients undergoing laparoscopic adhesiolysis for ASBO, the open approach was found to be an independent risk factor for overall complications compared to laparoscopic (Odds Ratio = 2.89; 95% CI 1.1-7.6). 5

For chronic abdominal pain, evidence is insufficient to make definitive conclusions, with benefit ranging from 16-88% across studies that showed high risk of bias. 8 One randomized trial showed benefit only in patients with dense and vascularized adhesions. 8

Critical Caveats

• Patient selection is the strongest key factor for success, particularly for laparoscopic approach 5
• Recurrence requires ongoing monitoring and potential repeat interventions 6, 2
• The procedure carries significant risks, particularly bowel injury with laparoscopic approaches in complex cases 6
• Use of adhesion barriers during operative treatment can reduce risk of recurrence 7