In a woman with uterine adhesion to the anterior abdominal wall at a prior cesarean section scar, what is the risk of developing additional adhesions after future abdominal surgery and how should this be evaluated and managed?

Risk of Additional Adhesions After Cesarean Section

Women with uterine adhesion to the anterior abdominal wall from a prior cesarean section face a 28-59% risk of developing additional adhesions at future abdominal surgery, with risk increasing substantially with each subsequent cesarean delivery. 1

Quantifying the Risk

The risk of adhesion formation is directly proportional to the number of prior cesarean sections:

• After one cesarean section: 32% risk of adhesions at subsequent surgery 1
• After two cesarean sections: 42% risk of adhesions 1
• After three or more cesarean sections: 59% risk of adhesions 1

For context, women with no prior cesarean section have only a 10% baseline risk of adhesions during gynecologic surgery, making the odds ratio 5.18 (95% CI: 4.70-5.71) for those with any prior cesarean delivery. 1

Additional Risk Factors That Amplify Adhesion Formation

Beyond the number of cesarean sections, specific patient and surgical factors further increase adhesion risk:

• Maternal age ≥35 years at time of cesarean: 28% increased risk (aOR: 1.28,95% CI: 1.05-1.55) 1
• BMI ≥30: 91% increased risk (aOR: 1.91,95% CI: 1.49-2.45) 1
• Postpartum infection: 55% increased risk (aOR: 1.55,95% CI: 1.05-2.30) 1

Clinical Implications of Existing Uterine-Abdominal Wall Adhesions

The presence of uterine adherence to the anterior abdominal wall creates specific surgical hazards:

• Bladder injury risk: Dense adhesions increase the likelihood of bladder injury during repeat cesarean section, requiring cystotomy repair 2
• Increased operative time: Extensive adhesiolysis is required before accessing the uterus 2
• Higher hysterectomy rates: Severe adhesions may necessitate hysterectomy when complications occur 3
• Bowel involvement: 29% of anterior abdominal wall adhesions involve bowel, creating additional surgical complexity 4

Evaluation Strategy

For women with known uterine-abdominal wall adhesions planning future surgery, preoperative imaging should include ultrasound or MRI to map adhesion extent, as these modalities have superior accuracy compared to clinical assessment alone. 5

The World Journal of Emergency Surgery recommends CT imaging for surgical planning when adhesive disease is suspected, with 76% accuracy for determining adhesion extent compared to operative findings. 6

Management Approach for Future Abdominal Surgery

Surgical Technique Modifications

Laparoscopic approaches should be strongly considered when feasible, as they reduce de novo adhesion formation with reoperation rates of 1.4% versus 3.8% after open procedures. 7

Key technical principles to minimize additional adhesion formation include:

• Use bipolar electrocautery or ultrasonic devices instead of monopolar cautery, which increases adjacent tissue temperature by 47°C versus only 0.6-1.2°C with modern energy sources 7
• Meticulous surgical technique with gentle tissue handling and minimizing ischemia 2
• Avoid powdered gloves which promote adhesion formation 2

Adhesion Barrier Application

The American College of Surgeons recommends hyaluronate carboxymethylcellulose (Seprafilm®) as the most evidence-based adhesion barrier, reducing reoperation rates for adhesive complications by 51% (RR 0.49,95% CI 0.28-0.88). 5, 7

Alternative barrier options include:

• Icodextrin (Adept®): Liquid barrier particularly useful in laparoscopic procedures, reduces adhesive small bowel obstruction recurrence (RR 0.20,95% CI 0.04-0.88) 7
• Oxidized regenerated cellulose: Requires strict hemostasis for effectiveness 5

Special Considerations for High-Risk Patients

The World Journal of Emergency Surgery emphasizes that younger patients warrant more aggressive adhesion prevention strategies due to higher lifetime risk of recurrent adhesive complications. 7

For women with multiple prior cesarean sections (≥2) and additional risk factors (obesity, advanced age, prior infection), both primary prevention (meticulous technique) and secondary prevention (adhesion barriers) should be employed. 7, 1

Long-Term Complications Beyond Surgical Risk

Uterine-abdominal wall adhesions are associated with:

• Chronic pelvic pain: Reported in case series of women with uterine adherence 3
• Infertility: Adhesions may contribute to subfertility through mechanical factors 3
• Small bowel obstruction: The risk of adhesive small bowel obstruction is highest following gynecologic surgery, with 10% developing at least one episode within 3 years 8

Common Pitfalls to Avoid

• Underestimating adhesion severity: The 37% overall adhesion rate after cesarean section means more than one-third of women will have significant adhesions at subsequent surgery 1
• Failing to counsel about cumulative risk: Each additional cesarean exponentially increases adhesion burden 1
• Not using adhesion barriers in high-risk cases: Evidence-based barriers reduce complications but are underutilized 5, 7