Postoperative adhesions have become the most common complication of open or laparoscopic abdominal surgery and a source of major concern because of their potentially dramatic consequences. The proposed guideline is the beginning of a major campaign to enhance the awareness of adhesions and to provide surgeons with a reference guide to adhesion prevention adapted to the conditions of their daily practice. The risk of postoperative adhesions should be systematically discussed with any patient scheduled for open or laparoscopic abdominal surgery prior to obtaining her informed consent. Surgeons should adopt a routine adhesion reduction strategy with good surgical technique. Anti-adhesion agents are an additional option, especially in procedures with a high risk of adhesion formation, such as ovarian, endometriosis and tubal surgery and myomectomy. We conclude that good surgical practice is paramount to reduce adhesion formation and that anti-adhesion agents may contribute to adhesion prevention in certain cases.Any surgery in the abdomen can lead to adhesion formation and potential morbidity. There is evidence to support the use of hyaluronic acid derivatives, PEG based derivatives and solid barrier agents derived from oxidized regenerated cellulose, namely Interceed, during laparoscopy or laparotomy in benign gynaecological surgery to reduce the incidence, severity and proportion of adhesion formation. There is also evidence to support the use of hyaluronic acid derivatives during hysteroscopic surgery to reduce the incidence of intra–uterine adhesion formation. However, there is little evidence to support the use of pharmacological and hydrofloatation agents including Icodextrin in gynaecological surgery. There is no apparent benefit of using adhesion prevention agents at caesarean section. As most of the economic modelling is not based in contemporary health economies, further evidence is required before recommending anti–adhesion agents in current gynaecological practice.

1. 1
POSTOPERATIVE
ADHESIONS
DR ALKA MUKHERJEE
MBBS DGO FICOG FICMCH PGDCR PGDMLS
MA(PSY)
DR ALKA MUKHERJEE NAGPUR

2. DR ALKA MUKHERJEE
MBBS DGO FICOG FICMCH PGDCR PGDMLS MA(PSY)
Director & Consultant At Mukherjee Multispecialty Hospital
MMC ACCREDITATED SPEAKER
MMC OBSERVER MMC MAO – 01017 / 2016
Present Position
 Director of Mukherjee Multispecialty Hospital
 Hon.Secretary INTERNATIONAL COUNCIL FOR HUMAN RIGHTS
 Hon.Secretary NARCHI NAGPUR CHAPTER (2018-2020)
 Hon.Secretary AMWN (2018-2021)
 Hon.Secretary ISOPARB (2019-2021)
 Life member, IMA, NOGS, NARCHI, AMWN & Menopause Society,
India, Indian medico-legal & ethics association(IMLEA), ISOPRB,
HUMAN RIGHTS
 Founder Member of South Rapid Action Group, Nagpur.
 On Board of Super Specialty, GMC, IGGMC, AIIMS Nagpur,
NKPSIMS, ESIS and Treasury, Nagpur for “ WOMEN SEXUAL
HARASSMENT COMMITTEE.”
mukherjeehospital@yahoo.com
www.mukherjeehospital.com
https://www.facebook.com/
Mukherjee Multispeciality
https://www.instagram.com/
Achievement
 Winner of NOGS GOLD MEDAL – 2017-18
 Winner of BEST COUPLE AWARD in Social
Work - 2014
 APPRECIATION Award IMA - MS
 Past Position
 Organizing joint secretary ENDO-GYN 2019
 Vice President IMA Nagpur (2017-2018)
Vice President of NOGS(2016-2017)
Organizing joint secretary ENDO-GYN
Organizing secretary AMWICON – 2019

3. ADHESIONS
• Intra-abdominal adhesions may be classified as
congenital or acquired.
• Congenital adhesions are a consequence of
embryological anomaly in the development of the
peritoneal cavity
Adhesions are fibrinous bands between and within organs
that develop after aberrant healing; they are formed
commonly after surgery and/or infection as a consequence
of inflammation.
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4. What we should know about postoperative adhesions and
their consequences
 Adhesions have become the most frequent
complications of abdominal surgery—93 % of patients
undergoing any abdominal/pelvic surgery are affected
and an important source of postoperative problems
 The overall risk of adhesion-related readmission
following either laparoscopic or open surgery is
comparable
 Over one third of patients who undergo extensive open
surgery seem to be readmitted with adhesion-related
complications within 10 years
 Adhesions are involved in 56 % of re-intervention
complications Seventy-four percent of cases of bowel
obstruction are due to post-surgical adhesions
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5. • Adhesions are associated with a marked risk of
enterotomy jeopardising 19 % and 10–25 % of
patients undergoing open and laparoscopic surgery,
respectively
• Adhesions are responsible for 20–40 % of secondary
infertility cases in women In addition, adhesions
generate a high number of reinterventions, increase
hospital stays, extend reintervention times and can
make it impossible to apply minimally invasive
surgery.
• Last but not least, managing adhesions and their
related complications impose an enormous economic
burden
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6. ACQUIRED ADHESIONS
• Acquired adhesions result from the inflammatory
response of the peritoneum that arises after intra-
abdominal inflammatory processes (e.g. acute
appendicitis, pelvic inflammatory disease, exposure to
intestinal contents and previous use of intrauterine
contraceptive devices), radiation and surgical trauma.
• Majority of acquired adhesions (about 90%) are post-
surgical.
• Fibrous bands that form between tissues and organs,
often as a result of injury during surgery. They may be
thought of as internal scar tissue that connects tissues
not normally connected.
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7. HOW ADHESION FORMS ?
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8. • Abdominal surgery is the most frequent cause of abdominal
adhesions. Surgery related causes include
 Cuts involving internal organs
 Handling of internal organs
 Drying out of internal organs and tissues
 Contact of internal tissues with foreign materials, sutures, powder
from gloves, gauze particles etc.),
 Blood or blood clots that were not rinsed away during surgery
abdominal adhesions can also result from inflammation not related
to surgery, including
– Appendix rupture
– Radiation treatment
– Gynecological infections
– Abdominal infections
 Rarely, abdominal adhesions form without apparent cause.
TISSUE TRAUMA, INFECTION,
ISCHAEMIA, REACTION TO FOREIGN
BODIES
HAEMORRHAGE, TISSUE
OVERHEATING OR DESICCATION
AND EXPOSURE TO IRRIGATION
FLUIDS.
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9. INCIDENCE
The incidence of intra-abdominal adhesions:
 After general surgical abdominal operations - 67% to
93% and
 After gynecological procedures - 60% to 90%
Adhesion formation - common post-operative
complications .
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10. SYMPTOMS
1. Asymptomatic or
2. Present with a broad spectrum of clinical problems:
 Intestinal Obstruction,
 Chronic Pelvic Or Abdominal Pain And
 Female Infertility,
 Requiring Re-admission And
 Often Additional Surgery, While At The Same Time
 They Can Complicate Future Surgical Procedures.
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11. The consequences of adhesion formation
 subfertility,
 development of chronic abdominal pain
 and dyspareunia (difficult or painful sexual
intercourse) (SRS 2007).
 A recent study demonstrated that in women
with a known reason for small bowel
obstruction, adhesions were the single most
common cause (Ten Broek 2013).
DR ALKA MUKHERJEE NAGPUR 11

12. PREVENTION OF ADHESIONS
 The major strategies for adhesion prevention in gynecological
surgery aims:
1. Optimization of surgical technique - proper surgical technique - a
mainstay for prevention of adhesion formation.
2. Use of adhesion-prevention agents.
 Laparoscopic surgery in gynecology represents the most innovative
surgical approach, compared with laparotomy since it has been
shown from a large number of clinical, and also experimental
studies, that it is associated with less development of de novo
adhesions
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13. The six basic rules of postoperative adhesion prevention in
gynaecological surgery
1. The risk of postoperative adhesions should be
systematically discussed with any patient scheduled for
open or laparoscopic abdominal surgery prior to
obtaining his/her informed consent
2. Surgeons need to act to reduce postoperative
adhesions in order to fulfill their duty of care towards
patients undergoing abdominal surgery
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14. 3. Surgeons should adopt a routine adhesion
reduction strategy at least for patients undergoing
high-risk surgery, including:
• Ovarian surgery
• Endometriosis surgery
• Tubal surgery
• Myomectomy
• Adhesiolysis
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15. 4. Good surgical technique is fundamental to any adhesion
reduction strategy
 Carefully handle tissue with field enhancement
(magnification) techniques
 Focus on planned surgery and, if any secondary pathology is
identified, question the risk: benefit ratio of surgical
treatment before proceeding
 Perform diligent haemostasis and ensure diligent use of
cautery
 Reduce cautery time and frequency and aspirate aerosolised
tissue following cautery
 Excise tissue—reduce fulguration
 Reduce duration of surgery
 Reduce pressure and duration of pneumoperitoneum in
laparoscopic surgery
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16.  Reduce risk of infection
 Reduce drying of tissues
 Use frequent irrigation and aspiration in laparoscopic
and laparotomic surgery when needed
 Limit use of sutures and choose fine non-reactive
sutures
 Avoid foreign bodies when possible—such as
materials with loose fibres
 Avoid non-peritonised implants and meshes
 Minimal use of dry towels or sponges in laparotomy
 Use starch- and latex-free gloves in laparotomy
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17. 5. Surgeons should consider the use of adhesion reduction
agents as part of the adhesion reduction strategy:
• Give special consideration to agents with data
supporting safety in routine surgery and efficacy in
adhesion prevention
• Practicality, ease of use, and cost of agents should
influence their selection for routine practice
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18. 6. Good medical practice implies that any serious or
frequently occurring risks be discussed before obtaining
the patient’s informed consent prior to surgery
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19. • For women undergoing gynaecological surgery, and
particularly those undergoing tubal and ovarian surgery
procedures, who wish to conceive, the implementation
of good surgical practice, together with the adoption of
adhesion-reduction agents, is paramount to reduce
adhesion formation.
• As all healthcare providers, surgeons have the duty to
protect patients by providing the best standards of
care—this includes taking steps to reduce adhesion
formation.
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20. HOW TO CHOOSE ADHESION PREVENTION
AGENTS
• Surgeons should consider the use of adhesion reduction
agents as part of the adhesion reduction strategy.
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21. WHEN TO USE ?
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22. NON PHARMACOLOGICAL AGENTS
• Modern non-pharmacological agents are available as
films, gels, powder or fluids, and have shown to be safe
and effective to reduce the risk of post-operative
adhesions , although, the new substances lack long-term
evidence
• Ahmad G, O’Flynn H, Hindocha A, Watson A (2015)
Barrier agents for adhesion prevention after
gynaecological surgery. Cochrane Database of
Systematic Reviews.
• Qin F, Ma Y, Li X, Wang X, Wei Y, et al. (2015) Efficacy and
mechanism of tanshinone IIA liquid nanoparticles in
preventing experimental postoperative peritoneal
adhesions in vivo and in vitro. Int J Nanomedicine 10:
3699-3717.
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23. HOW TO SELECT NON PHARMACOLOGICAL
AGENTS?
The selection will depend on
the
1. Type of surgery,
2. Extension of the surface to
be covered,
3. Presence of diffuse
bleeding,
4. Expected use of post-
operative drainage and
5. Costs.
• For example, some substances
should not be applied on bleeding
surfaces, on sutured bowel or in the
uterine cavity, and films should not
be overlapped.
• In addition, surgeons should follow
the mode of use specified by the
producer, and keep in mind that
most of agents are not
recommended in presence of
infection, malignancy, bowel leakage
or for intravascular use.
• On the other hand, non-
pharmacological agents , which have
proved to be ineffective or to impair
with the normal postsurgical re-
epithelialization process, like
colloids, crystalloids or steroids
should not be used.
De Wilde RL, Brölmann H, Koninckx PR, Lundorff P, Lower AM, et al. (2012) The Anti-Adhesions in Gynecology
European field guideline. Gynecol Surg 9: 365-368.
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24. PHARMACOLOGICAL ANTI-ADHESIVE
AGENTS
I. Fibrinolytic agents
II. Anticoagulants
III. Anti-inflammatory agents
IV. Antibiotics
V. Other agents
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25. PHARMACOLOGICAL AGENTS
• Peritoneum has an
extremely rapid absorption
mechanism, that limits the
half life and efficacy of many
intra-peritoneally
administered agents.
• Anti-adhesion agents must
not affect normal wound
healing, which has steps in
common with adhesion
formation (fibrinous
exudate, fibrin deposition,
fibroblast activity and
proliferation). Trew, G:
Postoperative adhesions and
their prevention. Rev.
Gynaecol. Perinat.Pract.
2006;6: 47–56.
• A wide variety of
pharmacological agents have
been used in attempts to prevent
or attenuate the formation of
post-surgical adhesions, but none
of them has been found to be
effective.
• The use of drugs for adhesion
prevention has some obstacles
that affect their efficacy.
• Ischaemia and inadequate blood
supply are important factors in
adhesion formation and these
also decrease systemic drug
delivery inhibiting their
effectiveness.
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26. NON-STEROIDAL ANTI-INFLAMMATORY
DRUGS
• Non-steroidal anti-inflammatory drugs (NSAID) affect
adhesion formation by several mechanisms.
1. They act by modifying arachidonic acid metabolism and
altering cyclooxygenase activities.
2. This results in decreased vascular permeability, platelet
aggregation, and coagulation and enhanced macrophage
function.
• A number of locally and systemically administered NSAID
have been used in experimental trials.
• Their clinical efficacy is questionable probably because of
inadequate concentrations at the sites of surgical trauma or
by rapid absorption from the peritoneal membrane
. Risberg, B. Adhesions: preventive strategies. Eur. J. Surg. Suppl 1997;32: 39.
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27. ANTIBIOTICS
• Antibiotics are commonly used for prophylaxis against
post-operative infections and hence may retard the
inflammatory response that leads to adhesion
formation.
• Peritoneal irrigation with antibiotic solutions does not
reduce adhesion formation, while it has been shown
that in some cases it may promote them.
Rappaport, W.D., Holcomb, M., Valente, J., Chvapil, M. Antibiotic irrigation and the formation of
intraabdominal adhesions. Am. J. Surg. 1989;158: 435–437.
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28. FLUID BARRIERS
• An ideal barrier agent because their action is not limited
to the site of application.
• Their function is provided by hydrofloration of intra-
peritoneal structures in the liquid that is infused into the
peritoneal cavity at the end of the surgical procedure.
• Hydrofloration provides a temporary separation
between raw peritoneal surfaces allowing independent
healing without the formation of adhesions.
• Possibly, fluid circulation in the peritoneal cavity
contributes to the prevention of adhesion formation by
diluting fibrinous exudates released from traumatized
surfaces
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29. FLUID BARRIERS
• Fluid barriers may prevent adhesion formation both at the
traumatized area and elsewhere in the pelvis.
• The instillation of fluids in the peritoneal cavity may be
associated with some undesirable side effects, such as
leakage from the incision, labial oedema, feeling of fluid
moving around, abdominal discomfort, abdominal distension
and complications such as pulmonary and peripheral
oedema.
• Large volumes of intra-peritoneal fluids may decrease the
peritoneum ability to confront bacterial infections.
(Sutton, C., Minelli, L., Garcıa, E., et al.)
• Use of icodextrin 4% solution in the reduction of adhesion
formation after gynaecological surgery.
(Gynecol. Surg. 2005;2: 287–296.)
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30. DR ALKA MUKHERJEE NAGPUR 30

31. ANTI-ADHESIVE BARIER METHODS
a. Solid barriers (membranes, gel)
b. Endogenous tissue
c. Fluid barriers
d. Exogenous materia
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32. ANTI-ADHESIVE BARRIERS
• The failure of pharmacological regimens to prevent
adhesion formation has led to the revival of the barrier
technique.
• With the barrier technique, traumatized peritoneal
surfaces are kept separated, during mesothelial
regeneration, thus precluding adherence of adjacent
organs and tissues and reducing the development of
adhesions.
• The separation can be achieved by the use of solid
(films or gels) or fluid barriers.
(Trew, G: Postoperative adhesions and their prevention.
Rev. Gynaecol. Perinat.Pract. 2006;6: 47–56.)
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33. ANTI-ADHESIVE BARRIERS
• Anti-adhesive barriers are currently the most useful
adjuvant for prevention of post-operative adhesion
formation.
• Numerous substances have been used as mechanical
barriers to separate tissue surfaces.
• Most of these materials are of historical interest only
and had no effect or even aggravated adhesion
formation.
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34. SURGICAL ADHESION BARRIERS
• Surgical barriers may help to decrease postoperative
adhesion formation but cannot compensate for poor
surgical technique
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35. INTERCEED
• Oxidized regenerated cellulose (Interceed) is an
absorbable adhesion barrier that requires no suturing.
• It is degraded into monosaccharides and absorbed
within 2 weeks after application.
• The product has been shown to reduce adhesion
formation in randomized controlled clinical trials , all of
which have demonstrated benefit for reducing the
incidence and extent of new and recurrent adhesions by
50%–60% after both laparoscopic and open abdominal
surgical procedures.
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36. INTERCEED
• However, there is scant evidence that the reduction in
adhesions resulting from use of oxidized regenerated
cellulose improves fertility.
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37. INTERCEED
• Complete hemostasis must be achieved, as the product
is rendered ineffective when saturated with blood.
• A study in humans (in contrast to the results from
animal studies) found that adding heparin to oxidized
regenerated cellulose provided no additional benefit .
• Oxidized regenerated cellulose (in the form of
Interceed) has been approved by the FDA for use in the
United States for reducing adhesions.
Reid RL, Hahn PM, Spence JE, Tulandi T, Yuzpe AA, Wiseman DM. A
randomized clinical trial of oxidized regenerated cellulose adhesion barrier
(Interceed, TC7) alone or in combination with heparin. Fertil Steril 1997;
67:23–9.
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38. FIBRIN GLUE
• Fibrin glue (Tissucol; Baxter International, Deerfield, IL,
USA) is a biological product.
• Fibrin glue is made by mixing human fibrinogen with
bovine thrombin, calcium and factor XIII.
• Obviously, the use of human blood products raises a
theoretical risk for transmission of infectious diseases.
• According to the pathogenesis of adhesions,
application of fibrin glue at the traumatized peritoneal
surfaces should increase adhesion formation.
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39. FIBRIN GLUE
• Possibly, fibrin glue application confines fibrin
deposition and averts the development of attachments
between opposing tissue surfaces.
• In animal studies, the use of fibrin glue has been shown
to decrease adhesion formation and reformation but
clinical data are limited. Fibrin glue has not been
approved by the FDA for use in USA.
• So far, no relevant data from trials in humans have
been published.
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40. THE IDEAL ADHESION BARRIER
 The ideal adhesion barrier should meet the following
criteria:
 (1) achieves effective tissue separation;
 (2) has a long half-life within the peritoneal cavity so
that it can remain active during the critical 7-day
peritoneal healing period;
 (3) is absorbed or metabolized without initiating a
marked proinflammatory tissue response;
 (4) remains active and effective in the presence of
blood;
 (5) does not compromise wound healing; and
 (6) does not promote bacterial growth.
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41. TAKE HOME MESSAGE
• There is no evidence that anti-inflammatory agents
reduce postoperative adhesions.
• There is insufficient evidence to recommend peritoneal
instillates such as icodextrin to reduce adhesions.
• The FDA-approved surgical barriers Seprafilm,
Interceed, and the Gore-Tex Surgical Membrane have
been demonstrated effective for reducing postoperative
adhesions.
• However, there is no substantial evidence that their use
improves fertility, decreases pain, or reduces the
incidence of postoperative bowel obstruction.
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42. TAKE HOME MESSAGE
• Good surgical technique was advocated as the main
way to prevent postoperative adhesions.
• This included strict adherence to the basic surgical
principles of minimizing tissue trauma with meticulous
hemostasis, minimization of ischemia and desiccation,
and prevention of infection and foreign body retention.
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43. 43DR ALKA MUKHERJEE NAGPUR