Pathogenesis of Adhesions and the Risk of Complications

The clinical burden of adhesions is extensive

Adhesions and their caused complications have already been known for 150 years. Bryant published one of the first data on adhesions in 1872, as he described a patient case that showed intestinal obstruction caused by intra-abdominal adhesions after removal of an ovarian tumor. ²⁰Only a few years later Dembrowski published study data on an animal model which already confirmed a correlation of foreign bodies and adhesions. ²²

Intra-abdominal adhesions arise from aberrant peritoneal wound healing processes, any mesothelial damage by surgical trauma or bacterial inflammation can lead to their formation. ²¹

Day 1

Adhesion formation begins immediately following surgery. Macrophages and fibroblasts migrate to the wound surface and fibrin matrix is formed

Day 3

The fibrin matrix continues to develop with the proliferation of fibroblasts. Vascularization begins

Day 5

The adhesion is increasingly vascular and organized in structure.

Day 7

Adhesion is mature and may continue to develop. But no new adhesions form.

Studies imply that a source of adhesion formation is the pathological reduction of fibrinolysis capacity. ¹⁷

The process of adhesion formation is a multifactor process, while fibrinolysis capacity is one of the suggested influencers which is affected by multiple factors. ¹⁷

Detailed insights on the development and causes of adhesions are not yet fully confirmed but a study published in 2021 found that macrophages play a significant role in developing adhesions. ³⁸

Adhesion types

Adhesions appear in two different types, either they are congenital adhesions which “arise during physiological organogenesis”¹⁷or are caused inflammatory diseases such as endometriosis, peritonitis or inflammatory following radiotherapy or peritoneal dialysis. ^23-25

The second type is acquired adhesions which arise after surgeries and appear in up to 100% of patients postoperatively.⁴

Consequences of Adhesions

Unlike other postop complications, such as wound infection or anastomotic leakage, consequences of adhesions include possible lifelong risks^31-32

Major cause of small bowel obstruction (74% are adhesion related) ²
Major contributory factor to chronic pelvic pain (up to 40% of cases) ²⁸
Chronic lower abdominal pain severely impairs the quality of life of those affected and forms the indication for 30% to 50% of all laparoscopies and 5% of hysterectomies ²⁹

Leading cause of secondary infertility in women (20%–40% of cases) ³⁷
Paraovarian peritubal adhesions can block the fallopian tube and consequently lead to ectopic pregnancy ³⁰
In patients needing further surgery (56% of cases)
Leading to injury at reoperations

Patients in high risk of postoperative adhesions

Adhesions appear in up to 100% of patients after gynecological surgery. ⁴ When undergoing adnexal surgery patients develop ovarian adhesions even in 90% of cases. ²⁶

Specific patient factors and certain surgeries increase the risk of adhesions development⁴

Patients who already had adnexal or bowel surgery
Patients with inflammatory disease
Patients with Endometriosis ²⁷
Patients undergoing Myomectomies ²⁷, Hysterectomies ²⁷, and Adhesiolysis ²⁷

Diagnosis

Adhesions can be confidently diagnosed intraoperatively while no other imaging can guarantee a secure clear diagnosis. Ultrasound or MRI could imply diagnosing adhesions by detecting reduced movement in the abdominal cavity due to connecting adhesions. ¹⁷