Postsurgical Adhesions

Michael P. Diamond, M.D.

This issue of Seminars in Reproductive Medicine deals with the enormous problem of postoperative adhesion development and its reduction/prevention. It is a problem that is not limited to reproductive endocrinologists or even obstetricians and gynecologists. Rather, it is a problem that exists for physicians of all surgical specialties. However, there are major dilemas with the “problem” of adhesions.

First is the lack of recognition by many people, including surgeons, of the extent to which adhesions are a problem. Because there are no widely accepted imaging modalities or serum markers to diagnose the incidence, extent, and severity of adhesions, the high frequency (ranging from 55 to 100% in some series) of development is not readily defined. An important corollary to this first point is recognition of not only the high frequency of adhesion re-formation but also the frequent occurrence of de novo adhesion formation (development of adhesions at sites that have not undergone adhesiolysis).

Second, to assess the efficacy of surgical approaches, techniques, equipment, and antiadhesion adjuvants, “second-look” surgeries are usually needed, but their performance has been challenged for logistical, financial, and ethical reasons. Thus identification of patient populations that would benefit from second-look procedures are desirable, as are mechanisms to pay for such procedures.

Third, when considering conduct of surgical procedures, including adhesiolysis, all surgeons and surgeries are not necessarily equal. Different surgical approaches or the skill of the surgeon can greatly affect postoperative adhesion development and thus confound interpretation of the success of a novel approach, technique, piece of equipment, or antiadhesion device in a way that is very different from, for example, the use of a new drug for treatment of hypertension, which is provider independent.

The fourth problem is that, while trying to reduce or prevent adhesion development, the approach, technique, equipment, or antiadhesion adjuvant must not adversely affect normal tissue healing. Thus it is desirable to prevent “healing” (which in essence is the end product of what an adhesion represents) at nonanatomic sites while preserving healing at desirable sites, such as the abdominal wall incision(s) and sites of bowel, vessel, or tubal repair/anastomosis. A corollary thus is that the adhesion development process per se is not bad (as this is what is needed for normal healing), but its occurrence at undesired sites is what needs to be targeted for reduction/prevention.

When considering specific approaches, techniques, equipment, and antiadhesion adjuvants, an important fifth problem is that whereas we ideally may want to prevent adhesions (or at least the “bad” ones), we may need to settle for reduction and not complete elimination. This in turn creates the challenge of identifying how much reduction is important? Phrased differently, how much reduction is clinically and/or statistically significant? Is reduction of one adhesion or one site with adhesions sufficient? What about two? Does it depend upon what the adhesion burden was initially? How do you factor in procedures in which there is likely to be no adhesions initially such as those for uterine fibroids and dermoid cysts? In such patients, adhesion scores at second-look are often increased above initial adhesion scores, and thus consideration must be given as to how to quantify less marked increases in adhesion scores. Of course, all of these considerations assume there exists a reproducible system for adhesion scoring.

Again considering approaches to reducing adhesion development, the sixth problem is linking adhesion reduction to improved clinical outcome. In gynecologic surgery, for example, it is adhesions involving the ovaries and tubes that are thought to most impair pregnancy outcome, but pregnancy initiation is also affected by factors such as age of the couple (particularly the female partner), the occurrence of divorce, and other infertility factors, to name only a few. Similarly, bowel obstruction as an end point is limited because of the time frame over which it can develop, from immediately postoperatively to more than 20 years later. Even use of such apparently quantitatively possible end points such as entry time into the abdominal cavity with localization of the surgical site of interest can be confounded by whether it is the attending physician, fellow, or resident who is acting as the primary surgeon.

The seventh and final problem I will describe is the lack of an identified section within NIH to serve as a common study group to review applications on postoperative adhesion development. Lack of focused funding opportunities, and possible underappreciation of the clinical significance of adhesions to adverse clinical outcomes, have contributed to assignment of applications on adhesions to multiple different study sections, including general medicine.

Having presented many of the problems of the problem of postoperative adhesion development, I believe we have established the basis for this issue of Seminars in Reproductive Medicine, which is dedicated to this problem. These articles will further develop these problems and/or provide possible solutions to them. I am indebted to the authors for providing these contributions. Articles represented include those summarizing many of the molecular biologic events leading to adhesion development, the role of physical properties of the operating milieu such as insufflation gas temperature and flow rate, novel agents for reduction of postoperative adhesions, and enlightening of what the future may hold.

I wish you good reading.