Gynecological Surgery

, Volume 4, Issue 3, pp 161–168 | Cite as

Postoperative abdominal adhesions and their prevention in gynaecological surgery. Expert consensus position

  • Rudy Leon DeWildeEmail author
  • Geoffrey Trew
  • on behalf of the Expert Adhesions Working Party of the European Society of Gynaecological Endoscopy (ESGE)
Review Article


Adhesions are the most frequent complication of abdominopelvic surgery, yet many surgeons are still not aware of the extent of the problem and its serious consequences. While adhesions may cause few or no detrimental effects to patients, in a considerable proportion of cases there are major short- and long-term consequences, including small-bowel obstruction, infertility and chronic pelvic pain. Adhesions complicate future surgery with important associated morbidity and expense—and a considerable risk of mortality. Despite advances in surgical techniques in recent years, the burden of adhesion-related complications has not changed. Adhesions should now be considered the most common complication of abdominopelvic surgery. Adhesiolysis remains the main treatment, despite the fact that adhesions reform in most patients. Developments in adhesion-reduction strategies and new agents now offer a realistic possibility of reducing the risk of adhesions forming and can improve the outcomes for patients and the associated onward burden. This consensus position represents the collective views of 35 gynaecologists with a recognised interest in adhesions. The position is presented in two parts. The first part reviews the published literature on the extent of the problem of adhesions, and the second part considers the opportunities to reduce their incidence. It also provides collective proposals on the actions that European gynaecologists should take to avoid causing adhesions. Importantly it also advises that it is now time to inform patients of the risks associated with adhesion-related complications during the consent process. With increasing evidence to support the efficacy of adhesion-reduction agents to complement good surgical practice, all surgeons should act now to reduce adhesions and fulfil their duty of care to patients.


Adhesions Adhesiolysis Guidelines Gynaecology Surgery 


Adhesions are the most frequent complication of abdominal surgery and may represent one of the greatest unresolved medical problems in medicine today [1], yet many surgeons are still not aware of the extent of the problem and its serious consequences.

Sixty to 90% of patients who have undergone major gynaecological surgery will develop adhesions [2]. Adhesiolysis remains the main treatment, despite the fact that adhesions reform in most patients (mean 85%) regardless of the method of adhesiolysis used or the type of adhesion being lysed [3].

While adhesions may cause few or no detrimental effects to patients, in a considerable proportion of cases there are serious short- and long-term consequences, with important associated morbidity and expense—and a considerable risk of mortality.

Recent epidemiological data have demonstrated the true extent of adhesion-related complications, and evidence is emerging on the level of associated risk for patients. Despite advances in surgical techniques in recent years, the burden of adhesion-related complications has not changed [4, 5]. While laparoscopic procedures are commonly believed to be less adhesiogenic and cause fewer de novo adhesions to form compared to open surgery [6, 7], for many procedures, the comparative risk of adhesion-related complications following open and laparoscopic gynaecological surgery is similar [5].

Developments in adhesion-reduction strategies and new agents do, however, now offer a realistic possibility of reducing the risk of adhesions forming and thus may improve the outcomes for patients and the associated onward burden. The importance of providing clear recommendations on adhesions and their prevention following gynaecological surgery is very apparent.

For this reason, and following recent reviews by colleagues in the United Kingdom [8] and Germany [9], an Expert Working Party under the auspices of the 15th Annual Congress of the European Society of Gynaecological Endoscopy (ESGE) was convened to increase awareness and offer practical proposals to minimise the problem.

The project, while conceived by two of us (RDW, GT), involved a Working Party of 35 gynaecologists with a recognised interest in adhesions (see Appendix), all of whom contributed actively to the development of this paper through reviews, inputs and consensus proposals, with the majority also attending the consensus workshop held during the 15th Annual Congress of the ESGE. The project progressed in accordance with accepted processes for the development of consensus statements (see “Consensus process including conflict of interest”).

The project is presented in two parts. The first as published here, provides an overview of the published literature on the extent of the problem of adhesions. The second appears in the next issue of Gynecological Surgery and considers the opportunities to reduce the problems of adhesions. Consensus proposals on the actions that European gynaecologists should now take are also provided in part 2. These proposals are collective opinion and should not be used for performance measure or competency purposes. Together these two papers provide a collective consensus position which it is hoped will raise the level of awareness and understanding of adhesions, and the associated health-care burden and costs, thereby encouraging heightened discussions and actions to address this area of unmet need.


Adhesions have been the subject of research for many years with the first case of fatal adhesion-related intestinal obstruction reported as far back as 1872 [10]. Despite considerable research into adhesions through the years, resulting in improvements in surgical techniques and the use of powder-free surgical gloves, the problem remains as most surgeons are still not fully aware of the magnitude and consequences of adhesions. This lack of awareness has been cited by Ellis as the greatest impediment to reducing adhesion formation, which he aptly described as ‘a sense of fatalism affecting the surgical community, akin to the attitude of surgeons to wound infection in the days before Lister’ [11].

The epidemiology and clinical importance of adhesions

There is strong evidence that the real extent of adhesions and adhesion-related complications is underestimated by most surgeons for the following reasons:
  • Adhesive complications occur unpredictably, often many years after a procedure.

  • The complications are often treated by physicians or specialists other than the initial operating surgeon.

  • The aetiology of adhesion formation is still incompletely understood.

  • There has been a long track record of failure or limited use of traditional adhesion-prevention strategies, until the recent introduction of newer agents.

  • Although adhesions can be present, they may be asymptomatic so they remain undiagnosed in most cases.

Following initial practice-based research [12, 13, 14, 15], the Surgical and Clinical Adhesions Research (SCAR) group has quantified the epidemiology and burden that adhesions pose to patients, surgeons and health services. The initial study followed up adhesion-related hospital readmissions in Scotland for 10 years in a cohort of patients undergoing open abdominal or pelvic surgery [16]. The SCAR Group found that over the study period, up to one in three patients were readmitted at least twice for adhesion-related problems (or other surgery potentially complicated by adhesions) and, moreover, the readmissions continued steadily throughout the 10 years. This research also indicated that patients undergoing open surgical procedures on the colon and rectum [17] and on the fallopian tubes, ovaries and uterus [4] were at most risk of adhesion-related readmissions. The SCAR group subsequently reported that for therapeutic and diagnostic laparoscopic procedures (i.e. all laparoscopic procedures undertaken with the exception of low-risk tubal sterilisations), the risk of adhesion-related readmission was comparable to that of gynaecological laparotomy [5]. The group concluded that despite advances in surgical technique, the burden of adhesion-related readmissions continues.

Other studies report that the incidence of adhesions following gynaecological laparoscopic surgery is 70–100%, diagnosed by second-look analysis [18, 19]. Laparoscopic surgery is generally considered to be accompanied by reduced de novo adhesion formation in comparison to laparotomy [19, 20, 21], while reformation is similar. However, a meta-analysis revealed comparable results for open versus laparoscopic surgery for both formation of de novo adhesions and reformation following adhesiolysis [22]. It is postulated that the environment of the pneumoperitoneum [23] and the surgeon’s training may also play an important role in the incidence of adhesions [24].

Pathogenesis of adhesions

In simple terms, adhesions are abnormal attachments between tissues and organs [25] and may be congenital or acquired [26]. The development of acquired adhesions is a generalised phenomenon in response to trauma to the peritoneum. The trauma may be inflammatory or surgical, and may include exposure to infection or intestinal contents, ischaemia, irritation from foreign materials (such as sutures, gauze particles or, historically, glove powder), desiccation, or overheating by lamps or irrigation fluid [27].

The peritoneum is the most extensive serous membrane in the body, serving to minimise friction and facilitate free movement of abdominal viscera, to resist and localise infections and to store fat. It comprises a single-cell layer of mesothelium lying on a submesothelial connective tissue matrix which contains numerous capillaries and lymphatic channels which open into the mesothelial cell monolayer. The surface of the mesothelium is coated in phospholipid (Fig. 1).
Fig. 1

Anatomy of the peritoneum

This mesothelial monolayer is extremely delicate and hence susceptible to damage, although it also has excellent healing properties provided that there is no ongoing inflammation which reduces fibrinolytic activity or deprives tissues of oxygen.

The pathogenesis of adhesion formation is complex, with many factors involved [28, 29] (Fig. 2).
Fig. 2

Summary of normal tissue repair and adhesion formation following surgical trauma [28]

Histopathological studies demonstrate a clear sequence of events from injury to the formation of adhesions. In general, abrasion and other trauma during surgery lead to the disruption of the peritoneal mesothelium and fibrin is then released along with a cascade of other elements, including leukocytes and mesothelial cells. The fibrin is deposited at the damaged surfaces as a result of bleeding and post-traumatic inflammation.

During wound healing, fibrin deposits from damaged mesothelium enlarge to form a bridge between opposing tissue surfaces. Locally generated fibrinolytic factors are released which may degrade all or part of this fibrin bridge. However, surgery, infection and hypoxia dramatically diminish fibrinolytic activity and, under these circumstances, fibroblasts and other cells may migrate across the bridge remnants transforming it into an adhesion [30] (Fig. 3).
Fig. 3

Development of adhesions [30]

The process of adhesion formation commences from the moment of peritoneal injury during surgery, as a result of which the inflammatory cascade is triggered. While the severity and extent of adhesions may change over weeks or months, the question of whether or not an adhesion develops at all is determined in the 3–5 days after peritoneal trauma takes place, i.e. after surgery has been carried out [31]. It is during this post-surgical period that the fibrin layer is reduced through fibrinolysis and the peritoneal membrane either becomes fully re-epithelialised or not. If fibrinolysis does not occur, an irreversible tissue bridge (adhesion) develops, which strengthens within the following weeks and months and in which blood vessels and nerve fibres may form [32].

The interaction of the acute-phase inflammatory protein cascade is, however, not fully understood, nor is its role in changing gene expression patterns and regulating both normal and adhesion fibroblasts [1, 33]. Adhesion formation is a multigenic phenomenon and the role of different activators and factors in this complex process is a matter of considerable research, aimed at not only improving our understanding of the development of adhesions, but also, most importantly, finding optimal strategies for adhesion prevention [28, 29]. The most promising avenues of research are strategies to separate damaged peritoneal surfaces, the fostering of the process of fibrinolysis and the regulation of hypoxia and prevention of angiogenesis. While the latter approaches are currently still only a research hope, the former is already an available option that surgeons can consider using.

Adhesion-related complications

Although adhesions are now the most frequent complication of abdominopelvic surgery, it is not possible to identify which particular adhesions will cause complications.

The most frequent adhesion-related complications are secondary infertility in women (20–40% of cases are caused by adhesions [34, 35]) and small-bowel obstruction (74% of cases are adhesion-related [36]). Adhesions are also thought to be a significant cause of chronic pelvic pain in many patients [27, 32, 37], but this relationship still requires further investigation. While most patients will develop adhesions following surgery [2], the majority will not experience these problems and may not be aware of their adhesions unless they have further surgery.

For patients undergoing subsequent surgery, adhesions pose an important complicating factor with adhesions from previous surgery significantly increasing operating time [38, 39]. In addition, even in the hands of experienced surgeons, there is a 19% risk of inadvertent enterotomy at reoperative laparotomy [40] and a 10–25% risk of bowel injury in laparoscopic adhesiolysis [41]. In medicolegal terms, tissue damage to underlying structures is the most common factor in successful surgical negligence suits [42]. The associated costs of adhesions to health services, patients and society are significant and continue to increase.


Adhesions are the leading cause of secondary infertility in women. They affect fertility adversely by distorting adnexal anatomy and by interfering with gamete and embryo transport. They have been shown to cause peritoneal infertility in 15–20% of women [34, 35, 43]. Furthermore, tubal-related problems account for up to 40% of female infertility cases, with identifiable causes including post-infectious, endometriosis-related and post-surgical adhesion formation [44, 45].

While infertility often has multifactorial causes, there is a clear-cut correlation between adhesions and infertility. In women with infertility as a result of adnexal adhesions, pregnancy rates of 32 and 45% at 12 and 24 months respectively have been reported following adhesiolysis, compared with 11 and 16% at corresponding time intervals in untreated women [46]. A follow-up period of 3 years reported higher pregnancy rates in women who underwent tubal surgery compared with those who did not (29 vs 12%) [47]. In women followed for an average 49 months after tubal surgery, term pregnancy rates correlated with adhesion scores as assigned using the American Fertility Society classification for adnexal adhesions [48].

Small-bowel obstruction

In the treatment of adhesion-related small-bowel obstruction, outcomes following medical management have been shown to be worse if the adhesions resulted from previous appendicectomy or tubal or ovarian surgery [49].

Small-bowel obstruction (SBO) is the most serious adhesion-related complication with a 10% risk of mortality [50] if not diagnosed and treated immediately. While the risk of SBO is highest after colorectal surgery, it is also a significant problem following gynaecological surgery. In the SCAR study, 4.5% of readmissions following gynaecological laparotomy were for SBO [16].

A recent retrospective analysis of all SBO admissions in two hospitals during the period January 1998 to December 2005 showed that in non-oncological cases, 50.4% of admissions were the result of previous gynaecological surgery with total abdominal hysterectomy cited as the most common cause of SBO [51]. In this study, a total of 13.6 cases per 1,000 resulted in SBO, 75% of these being diagnosed as complete SBO.

This work also suggested that laparoscopic hysterectomy and other procedures did not carry such a high risk of SBO, but the numbers of laparoscopic procedures were more limited. This recent study supports previous findings highlighting the important risk of SBO following gynaecological laparotomy [2, 49, 52, 53, 54, 55, 56, 57].

Chronic pelvic pain

A relationship between adhesions and pelvic pain, although controversial, is also apparent. An analysis of 11 studies involving a total of almost 1,000 patients suffering from pelvic pain demonstrated adhesions as being the most common associated pathology in 40% of cases [32].

However, the pathophysiological connection between adhesions and pain remains unclear. It is uncertain which mechanisms trigger adhesion-related pain under physiological conditions, but nerve fibres are often present in adhesions [58, 59] and may be involved in the aetiology. Patients have been shown to experience pain when adhesions are touched [60], and this observation has been further supported in various pain-mapping studies [61, 62].

Whether or not adhesiolysis provides an improvement in chronic pelvic pain is uncertain. While retrospective and prospective studies have shown improvement in 50–90% of cases after laparoscopic adhesiolysis [63, 64, 65, 66, 67, 68], only very few studies fulfilled the conditions of a controlled or even prospective randomised design. In randomised studies, the evidence is more ambiguous, and it is unclear if adhesiolysis is a successful treatment option in the majority of women [41, 69]. As there is a known high rate of reformation of adhesions following surgery (mean reformation rate of 85%) regardless of the method of adhesiolysis [3], and as chronic pain may have multifactorial causes, e.g. psychosomatic, it is not surprising that the role of adhesiolysis as a treatment for chronic pain is uncertain. The risk of intestinal perforation that occurs during laparoscopic procedures for symptomatic adhesions is also high—reported as up to 25% of patients [41, 70]. In a recent review, van der Wal and colleagues noted that considering the risk of complications associated with laparoscopic adhesiolysis, it should no longer be recommended as a therapy for adhesion-related chronic abdominal pain [70]. A critical analysis of the existing literature is therefore needed to further assess the therapeutic effect of adhesiolysis in patients with pelvic pain.

The cost of adhesions

Pre-existing adhesions significantly prolong the duration of surgery [38, 39] and lead to considerable complications in an important percentage of patients. This is particularly the case in accidental intestinal enterotomy which is accompanied by an increased need for intensive care facilities, extended hospitalisation and increased ward costs [40, 41].

A survey in 1993 in Sweden—a country with a population of some 7.1 million—found that total care costs (including costs for sick leave) for adhesive SBO amounted to at least €10 million per year (US$13 million) [71]. The costs of all hospitalisations for adhesiolysis in the United States in 1994 were estimated to be around €1 billion (US$1.33 billion), of which approximately €596 million (US$764 million) was for hospitalisations directly attributable to adhesions [72].

Using the SCAR data [16, 17], the average length of hospital stays for adhesion-related general and gynaecological surgery in 1994 showed that treatment costs for adhesion-related surgical procedures in Scotland represented 2% of expenditure on hospital and community sector services in that year [73], being over £6 million (~€9 million). This was a conservative estimate of the true costs. A subsequent cost model developed by Wilson and co-workers based on the SCAR data predicted that the direct annual cost of adhesion-related readmissions for the United Kingdom as a whole within the first year after initial lower abdominal surgery would be in excess of approximately €36 million (£24.2 million), rising to €141 million (£95.2 million) in the 10th year after surgery [74]. Wilson et al. estimated that the cumulative year-on-year direct costs of adhesion-related readmissions for a 10-year period would be more than €843 million (£569 million) in the UK population (approximately 58 million in 1999).

Extrapolation of these cost data across Europe or on a global scale indicates the extent of the problem of adhesion-related complications and highlights the concern that adhesion-related events represent a huge burden for health-care resources and funding.

In part 2, the opportunities to reduce the burden of adhesions are reviewed and consensus proposals on action for European gynaecologists to take are presented.



The consensus project and manuscript development were facilitated by Corvus Communications Limited under the direction of Rudy DeWilde and Geoffrey Trew. Special thanks for the work of Alison Crowe, Alastair Knight and Jill Kirkdale in patiently supporting and encouraging all Adhesions Working Party members to actively contribute and provide feedback on all stages of the project development.


  1. 1.
    Diamond MP, El-Hammady E, Wang R, Kruger M, Saed G (2004) Regulation of expression of tissue plasminogen activator and plasminogen activator inhibitor-1 by dichloroacetic acid in human fibroblasts from normal peritoneum and adhesions. Am J Obstet Gynecol 190:926–934PubMedCrossRefGoogle Scholar
  2. 2.
    Monk BJ, Berman ML, Monitz FJ (1994) Adhesions after extensive gynecologic surgery: clinical significance, etiology and prevention. Am J Obstet Gynecol 170:1396–1403PubMedGoogle Scholar
  3. 3.
    Diamond MP, Freeman ML (2001) Clinical implications of postsurgical adhesions. Hum Reprod Update 7:567–576PubMedCrossRefGoogle Scholar
  4. 4.
    Lower AM, Hawthorn RJS, Ellis H, O’Brien F, Buchan S et al (2000) The impact of adhesions on hospital readmissions over ten years after 8489 open gynecological operations: an assessment from the Surgical and Clinical Adhesions Research Study. Br J Obstet Gynaecol 107:855–862Google Scholar
  5. 5.
    Lower AM, Hawthorn RJS, Clark D, Boyd JH, Finlayson AR et al (2004) Adhesion-related readmissions following gynaecological laparoscopy or laparotomy in Scotland: an epidemiological study of 24,046 patients. Hum Reprod 19:1877–1885PubMedCrossRefGoogle Scholar
  6. 6.
    Diamond MP, Daniell JF, Feste J, Surrey MW, McLaughlin DS et al (1987) Adhesion reformation and de novo adhesion formation after reproductive pelvic surgery. Fertil Steril 47:864–866PubMedGoogle Scholar
  7. 7.
    Pados G, Devroey P (1992) Adhesions. Curr Opin Obstet Gynecol 4:412–418PubMedGoogle Scholar
  8. 8.
    Trew G, Lower A (2004) Consensus in adhesion reduction management. The Obstetrician & Gynaecologist 6:1–16CrossRefGoogle Scholar
  9. 9.
    Rimbach S, Korell M, Tinneberg HR, DeWilde RL (2004) Adhesions and their prevention in gynaecologic surgery: current status and consensus based on four workshops. Geburtsh Frauenheilk 64:891–899CrossRefGoogle Scholar
  10. 10.
    Bryant T (1872) Clinical lectures on intestinal obstruction. Med Tim Gaz 1:363–365Google Scholar
  11. 11.
    Ellis H (1998) The magnitude of adhesion related problems. Ann Chir Gynaecol 87:9–11PubMedGoogle Scholar
  12. 12.
    Menzies D, Ellis H (1990) Intestinal obstruction from adhesions — how big is the problem? Ann R Coll Surg Engl 72:60–63PubMedGoogle Scholar
  13. 13.
    Ellis H (1983) Prevention and treatment of adhesions. Infect Surg 11:803–817Google Scholar
  14. 14.
    Menzies D (1992) Peritoneal adhesions. Incidence cause and prevention. Surg Annu 24(Part 1):27–45PubMedGoogle Scholar
  15. 15.
    Holmdahl L, Risberg B (1997) Adhesions: prevention and complications in general surgery. Eur J Surg 163:169–174PubMedGoogle Scholar
  16. 16.
    Ellis H, Moran BJ, Thompson JN, Parker MC, Wilson MS et al (1999) Adhesion-related hospital readmissions after abdominal and pelvic surgery: a retrospective cohort study. Lancet 353:1476–1480PubMedCrossRefGoogle Scholar
  17. 17.
    Parker MC, Ellis H, Moran BJ, Thompson JN, Wilson MS et al (2001) Postoperative adhesions: ten-year follow-up of 12,584 patients undergoing lower abdominal surgery. Dis Colon Rectum 44:822–830PubMedCrossRefGoogle Scholar
  18. 18.
    Canis M, Chapron C, Mage G, Pouly JL, Wattiez A et al (1992) Second-look laparoscopy after laparoscopic cystectomy of large ovarian endometriomas. Fertil Steril 58:617–619PubMedGoogle Scholar
  19. 19.
    Operative Laparoscopy Study Group (1991) Postoperative adhesion development after operative laparoscopy: evaluation at early second-look procedures. Fertil Steril 55:700–704Google Scholar
  20. 20.
    Lundorff P, Hahlin M, Källfelt B, Thorburn J, Lindblom B (1991) Adhesion formation after laparoscopic surgery in tubal pregnancy: a randomized trial versus laparotomy. Fertil Steril 55:911–915PubMedGoogle Scholar
  21. 21.
    Nezhat CR, Nezhat FR, Metzger DA, Luciano AA (1990) Adhesion reformation after reproductive surgery by videolaseroscopy. Fertil Steril 53:1008–1011PubMedGoogle Scholar
  22. 22.
    Wiseman DM, Trout JR, Diamond MP (1998) The rates of adhesion development and the effects of crystalloid solutions on adhesion development in pelvic surgery. Fertil Steril 70:702–711PubMedCrossRefGoogle Scholar
  23. 23.
    Binda MM, Molinas CR, Koninckx PR (2003) Reactive oxygen species and adhesion formation. Clinical implications in adhesion prevention. Hum Reprod 18:2503–2507PubMedCrossRefGoogle Scholar
  24. 24.
    Luciano A (1984) Laparotomy vs laparoscopy. In: diZerega GD (ed) Treatment of post surgical adhesions, progress in clinical and biological research, vol 358. Wiley-Liss, New York, pp 35–44Google Scholar
  25. 25.
    Wiseman D (1994) Polymers for the prevention of surgical adhesions. In: Domb AJ (ed) Polymeric site-specific pharmacotherapy. Wiley, New York, pp 370–421Google Scholar
  26. 26.
    Ellis H (1982) The causes and prevention of intestinal adhesions. Br J Surg 69:241–243PubMedCrossRefGoogle Scholar
  27. 27.
    Holmdahl L, Risberg B, Beck DE, Burns JW, Chegini N et al (1997) Adhesions: pathogenesis and prevention — panel discussion and summary. Eur J Surg 163:56–62Google Scholar
  28. 28.
    diZerega GS (2000) Peritoneum, peritoneal healing, and adhesion formation In: diZerega GS (ed) Peritoneal surgery. Springer-Verlag, New York, pp 3–37Google Scholar
  29. 29.
    Molinas CR, Binda MM, Koninckx PR (2006) Angiogenic factors in peritoneal adhesion formation. Gynecol Surg 3:157–167CrossRefGoogle Scholar
  30. 30.
    Holmdahl L (1999) Making and covering surgical footprints. Lancet 353:1456–1457PubMedCrossRefGoogle Scholar
  31. 31.
    Harris ES, Morgan RF, Rodeheaver GT (1995) Analysis of the kinetics of peritoneal adhesion formation in the rat and evaluation of potential antiadhesive agents. Surgery 117:663–669PubMedCrossRefGoogle Scholar
  32. 32.
    diZerega GS (1997) Biochemical events in peritoneal tissue repair. Eur J Surg 577(Suppl):10–16Google Scholar
  33. 33.
    Rout UK, Saed GM, Diamond MP (2005) Expression pattern and regulation of genes differ between fibroblasts of adhesion and normal human peritoneum. Reprod Biol Endocrinol. DOI  10.1186/1477782731
  34. 34.
    Hershlag A, Diamond MP, DeCherney AH (1991) Adhesiolysis. Clin Obstet Gynaecol 34:395–402CrossRefGoogle Scholar
  35. 35.
    Mishell DR, Davajan V (1991) Evaluation of the infertile couple. In: Mishell DR Jr, Davajan V, Lobo RA (eds) Infertility contraception and reproductive endocrinology, 3rd edn. Blackwell Scientific, Boston, pp 557–570Google Scholar
  36. 36.
    Menzies D (1993) Postoperative adhesions: their treatment and relevance in clinical practice. Ann R Coll Surg Engl 75:147–153PubMedGoogle Scholar
  37. 37.
    Rapkin AJ (1986) Adhesions and pelvic pain: a retrospective study. Obstet Gynaecol 68:13–15Google Scholar
  38. 38.
    Coleman MG, McLain AD, Moran BJ (2000) Impact of previous surgery on time taken for incision and division of adhesions during laparotomy. Dis Colon Rectum 43:1297–1299PubMedCrossRefGoogle Scholar
  39. 39.
    Beck DE, Ferguson MA, Opelka FG, Fleshman JW, Gervaz P et al (2000) Effect of previous surgery on abdominal opening time. Dis Colon Rectum 43:1749–1753PubMedCrossRefGoogle Scholar
  40. 40.
    van der Krabben AA, Dijkstra FR, Nieuwenhuijzen M, Reijnen MMPJ, Schaapveld M et al (2000) Morbidity and mortality of inadvertent enterotomy during adhesiotomy. Br J Surg 87:467–471CrossRefGoogle Scholar
  41. 41.
    Swank DJ, Swank-Bordewijk SC, Hop WC, van Erp WF, Janssen IM et al (2003) Laparoscopic adhesiolysis in patients with chronic abdominal pain: a blinded randomised controlled multi-centre trial. Lancet 361:1247–1251PubMedCrossRefGoogle Scholar
  42. 42.
    Pownall M (1999) Tissue damage is commonest cause of surgical negligence suits. BMJ 318:692Google Scholar
  43. 43.
    Marana R, Muzii L (2000) Infertility and adhesions. In: diZerega GS (ed) Peritoneal surgery. Springer-Verlag, New York, pp 329–333Google Scholar
  44. 44.
    Canis M, Mage G, Pouly JL, Manhes H, Wattiez A et al (1991) Laparoscopic distal tuboplasty: report of 87 cases and a 4-year experience. Fertil Steril 54:616–621Google Scholar
  45. 45.
    Posaci C, Camus M, Osmanagaoglu K, Devroey P (1999) Tubal surgery in the era of assisted reproduction technology. Clinical options. Hum Reprod 14(Suppl 1):120–136PubMedGoogle Scholar
  46. 46.
    Tulandi T, Collins JA, Burrows E, Jarrell JF, McInnes RA et al (1990) Treatment-dependent and treatment-independent pregnancy among women with periadnexal adhesions. Am J Obstet Gynecol 162:354–357PubMedGoogle Scholar
  47. 47.
    Wu CH, Gocial B (1988) A pelvic scoring system for infertility surgery. Int J Fertil 33:341–346PubMedGoogle Scholar
  48. 48.
    Marana R, Rizzi M, Muzii L, Catalano GF, Caruana P et al (1995) Correlation between the American Fertility Society classifications of adnexal adhesions and distal tubal occlusion, salpingoscopy, and reproductive outcome in tubal surgery. Fertil Steril 64:924–929PubMedGoogle Scholar
  49. 49.
    Meagher AP, Moller C, Hoffmann DC (1993) Non-operative treatment of small bowel obstruction following appendicectomy or operation on the ovary or tube. Br J Surg 80:1310–1311PubMedCrossRefGoogle Scholar
  50. 50.
    Menzies D, Parker M, Hoare R, Knight A (2001) Small bowel obstruction due to postoperative adhesions: treatment patterns and associated costs in 110 hospital admissions. Ann R Coll Surg Engl 83:40–46PubMedGoogle Scholar
  51. 51.
    Al-Sunaidi M, Tulandi T (2006) Adhesion-related bowel obstruction after hysterectomy for benign conditions. Obstet Gynecol 108:1162–1166PubMedGoogle Scholar
  52. 52.
    Al-Took S, Platt R, Tulandi T (1999) Adhesion-related small-bowel obstruction after gynecologic operations. Am J Obstet Gynecol 180:313–315PubMedCrossRefGoogle Scholar
  53. 53.
    Cox MR, Gunn IF, Eastman MC, Hunt RF, Heinz AW (1993) The operative aetiology and types of adhesions causing small bowel obstruction. Aust NZ J Surg 63:848–852Google Scholar
  54. 54.
    Melody GF (1958) Intestinal obstruction following gynecologic surgery. Obstet Gynecol 11:139–147PubMedGoogle Scholar
  55. 55.
    Krebs HB, Goplerud DR (1987) Mechanical intestinal obstruction in patients with gynecologic disease: a review of 368 patients. Am J Obstet Gynecol 157:577–583PubMedGoogle Scholar
  56. 56.
    Soo KC, Davidson T, Parker M, Paterson I, Paterson A (1988) Intestinal obstruction in patients with gynaecological malignancies. Ann Acad Med Singapore 17:72–75PubMedGoogle Scholar
  57. 57.
    Johnson N, Barlow D, Lethaby A, Tavender E, Curr E et al (2006) Surgical approach to hysterectomy for benign gynaecological disease (review). Cochrane Database Syst Rev. DOI  10.1002/14651858
  58. 58.
    Tulandi T, Chen MF, Al-Took S, Watkin K (1998) A study of nerve fibers and histopathology of postsurgical, postinfectious, and endometriosis-related adhesions. Obstet Gynecol 92:766–768PubMedCrossRefGoogle Scholar
  59. 59.
    Sulaiman H, Gabella G, Davis C, Mutsaers SE, Boulos P et al (2001) Presence and distribution of sensory nerve fibers in human peritoneal adhesions. Ann Surg 234:256–261PubMedCrossRefGoogle Scholar
  60. 60.
    Almeida OD, Val-Gallas JM (1997) Conscious pain mapping. J Am Assoc Gynecol Laparosc 4:587–590PubMedCrossRefGoogle Scholar
  61. 61.
    Demco L (2004) Pain mapping of adhesions. J Am Assoc Gynecol Laparosc 11:181–183PubMedCrossRefGoogle Scholar
  62. 62.
    Demco LA (2000) Pain referral patterns in the pelvis. J Am Assoc Gynecol Laparosc 7:181–183PubMedCrossRefGoogle Scholar
  63. 63.
    Howard FM (1993) The role of laparoscopy in chronic pelvic pain: promise and pitfalls. Obstet Gynecol Surv 48:357–387PubMedCrossRefGoogle Scholar
  64. 64.
    Ford JC, English J, Giannopoulos T (2003) Long-term follow up of pain and quality of life scores after laparoscopic adhesiolysis. Rev Gyn Pract 3(Suppl):abstract 001Google Scholar
  65. 65.
    Malik E, Berg C, Meyhöfer-Malik A, Haider S, Rossmanith WG (2000) Subjective evaluation of the therapeutic value of laparoscopic adhesiolysis: a retrospective analysis. Surg Endosc 14:79–81PubMedCrossRefGoogle Scholar
  66. 66.
    Nezhat FR, Crystal RA, Nezhat CH, Nezhat CR (2000) Laparoscopic adhesiolysis and relief of chronic pelvic pain. JSLS 4:281–285PubMedGoogle Scholar
  67. 67.
    Saravelos HG, Li TC, Cooke ID (1995) An analysis of the outcome of microsurgical and laparoscopic adhesiolysis for chronic pelvic pain. Hum Reprod 10:2895–2901PubMedGoogle Scholar
  68. 68.
    Swank DJ, van Erp WFM, Repelaer van Driel OJ, Hop WCJ, Bonjer HJ et al (2003) A prospective analysis of predictive factors on the results of laparoscopic adhesiolysis in patients with chronic abdominal pain. Surg Laparosc Endosc Percutan Tech 13:88–94Google Scholar
  69. 69.
    Peters AAW, Trimbos-Kemper GCM, Admiraal C, Trimbos JB, Hermans J (1992) A randomised clinical trial on the benefit of adhesiolysis in patients with intraperitoneal adhesions and chronic pelvic pain. Br J Obstet Gynaecol 99:59–62PubMedGoogle Scholar
  70. 70.
    Van der Wal JBC, Halm JA, Jeekel J (2006) Chronic abdominal pain: the role of adhesions and benefit of laparoscopic adhesiolysis. Gynecol Surg 3:168–174CrossRefGoogle Scholar
  71. 71.
    Ivarsson ML, Holmdahl L, Franzen G, Risberg B (1997) Cost of bowel obstruction resulting from adhesions. Eur J Surg 163:679–684PubMedGoogle Scholar
  72. 72.
    Fox Ray N, Denton WG, Thamer M, Henderson SC, Perry S (1998) Abdominal adhesiolysis: inpatient care and expenditures in the United States in 1994. J Am Coll Surg 186:1–9CrossRefGoogle Scholar
  73. 73.
    Parker MC on behalf of the SCAR Study Steering Group (1999) The economic and practical implications of adhesive small bowel disease. ASCRS and Tripartite Meeting Adhesions Symposium, Washington DC, USAGoogle Scholar
  74. 74.
    Wilson MS, Menzies D, Knight AD, Crowe AM (2002) Demonstrating the clinical and cost effectiveness of adhesion reduction strategies. Colorectal Dis 4:355–360PubMedCrossRefGoogle Scholar
  75. 75.
    American College of Chest Physicians (2007) Definitions of ACCP evidence-based guidelines, consensus statements, and other reviews and projects. (Cited 2 Jul 2007)

Copyright information

© Springer-Verlag 2007

Authors and Affiliations

  • Rudy Leon DeWilde
    • 1
    Email author
  • Geoffrey Trew
    • 2
    • 3
  • on behalf of the Expert Adhesions Working Party of the European Society of Gynaecological Endoscopy (ESGE)
  1. 1.Department OBGYNPius-HospitalOldenburgGermany
  2. 2.Reproductive Medicine & SurgeryHammersmith & Queen Charlotte’s HospitalLondonUK
  3. 3.Imperial College, University of LondonLondonUK

Personalised recommendations