Intestinal and pelvic adhesions: causes and treatment after surgery

Following any abdominal or pelvic surgery, a thin web of connective tissue—adhesions—can form on the internal surfaces. These adhesions typically cause no symptoms, but sometimes they "glue" intestinal loops and adjacent organs together, impairing their mobility and patency. This leads to three main clinical scenarios: adhesive intestinal obstruction, chronic or episodic abdominal/pelvic pain, and, in some women, fertility problems. According to international reviews, adhesions are the leading cause of small bowel obstruction (approximately 60% of cases). [1]

The incidence of adhesions depends on the type of procedure and access method. After major open surgery, adhesions occur in the vast majority of patients; laparoscopy reduces the risk but does not eliminate it. Even years later, adhesions remain a cause of repeat hospitalizations and reoperations—a significant "hidden" cost of these procedures. [2]

In recent years, much has changed in approaches: low-dose CT protocols have emerged for rapid obstruction verification, trial tests with water-soluble contrast (the so-called "Gastrografin Challenge") have been developed for conservative resolution of partial blockages, and, in preventative care, updated barrier materials and more gentle techniques have been developed. However, there is no universal "magic pill": success is a combination of competent surgery, adequate diagnostics, and careful monitoring. [3]

Epidemiology and burden

According to large reviews, adhesions form in 67-93% of patients after abdominal surgery; after open gynecological procedures, the figure reaches 97%. However, they are not clinically significant in everyone: in a minority, they lead to obstruction, pain, or infertility. [4]

However, adhesions are the number one cause of small bowel obstruction in emergency surgery (approximately 60-70% of cases). This means that in a person with a history of "bloating + vomiting + gas retention" and recent surgery, the likelihood of an adhesive obstruction is very high. [5]

The economic burden is enormous: repeat hospitalizations, obstruction surgeries, prolonged sick leave, and the costs of pain management and reproductive technologies in women with adhesive pelvic disease. Cost-effectiveness analyses highlight that targeted use of anti-adhesion barriers in "risky" surgeries may be offset by a reduction in recurrent problems. [6]

Table 1. Epidemiological landmarks

Indicator	Rating / fact
Formation of adhesions after abdominal surgery	67-93%
After open gynecological surgery	up to 97%
Cause of small bowel obstruction #1	postoperative adhesions (~60%)
Trend in laparoscopy	Lower frequency, but risk remains
[7]

Reasons

An adhesion is the result of natural healing of the peritoneum after injury (incision, coagulation, excision, infection). If opposing surfaces touch and "fibrin glue" forms between them, and it is not broken down promptly by enzymes, a persistent connective tissue septum develops. Any "raw-to-raw" tissue contact is a risk factor. [8]

The more severe the peritoneal trauma (open access, long incisions, coagulation burns, talc/starch, blood/bile in the cavities), the higher the risk of adhesions. Specific areas that are particularly susceptible include the iliac fossa after appendectomy, the pelvis after gynecological procedures, the mesenteric root, and the abdominal wall after colorectal surgery. [9]

Risk factors

Surgical factors include: open access, prolonged surgery, extensive coagulation and tissue ischemia, foreign particles (talc/starch from gloves, suture material), and hemorrhage into the cavity. Laparoscopy reduces the risk, but does not eliminate it. [10]

Patient-dependent factors include: previous surgeries, peritonitis/infection, severe inflammatory response, hemostatic and healing disorders (anemia, hypoproteinemia), and endometriosis. In women, the contribution of adhesions to chronic pelvic pain and infertility is higher. [11]

Table 2. Who is at risk?

Category	Examples
Technology/Access	Open surgery, long-term coagulation
Contamination of the cavity	Blood, bile, intestinal contents
Foreign particles	Talc/powder, fibers, suture material
Story	Repeated laparotomies, peritonitis
For women	Pelvic surgeries, endometriosis
[12]

Pathogenesis

Peritoneal healing triggers an inflammatory cascade: fibrin pulls the "wounds" together to close the defect. If fibrinolysis (fibrin dissolution) is delayed, the "temporary glue" transforms into a strong collagen bridge. Vessels and nerves grow within it, forming a mature adhesion, sometimes a "cord" or "web." [13]

The danger lies not in the "thread" itself, but in the mechanics: the adhesion can tug on the intestinal loops, limiting their mobility or creating a "window"/loop where the intestine becomes wedged—this is adhesive obstruction. In the pelvis, adhesions alter the topography of the tubes and ovaries, interfering with egg transport. [14]

Symptoms

Adhesive disease manifests itself in different ways. Some experience a sudden attack: cramping pain, bloating, vomiting, stool retention, and gas—signs of obstruction. Others experience chronic or intermittent pain, a pulling/twisting sensation, bloating after eating, and occasional bowel problems. Women may experience dyspareunia and difficulty conceiving. [15]

During examination, obstruction often reveals swelling, a "splashing noise," tenderness, and sometimes traces of previous surgeries. But the final word rests with visualization. [16]

Complications

The main problem is adhesive intestinal obstruction (AIO). Partial cases may resolve without surgery, while complete/strangulating cases lead to intestinal ischemia, perforation, and peritonitis. Recurrent episodes are not uncommon: each subsequent surgery can cause new adhesions. [17]

Long-term consequences include chronic pain and impaired fertility (especially after pelvic interventions). At the health care system level, adhesions are a significant cause of rehospitalizations and costs. [18]

Table 3. "Red flags" - see a doctor immediately

Sign	Why is it dangerous?
Vomiting, increasing bloating, no gas/stool	Possible obstruction
Constant, increasing pain, "board-like" abdomen	Ischemia/perforation, peritonitis
Fever, severe weakness	Systemic reaction
Blood in stool/vomit	Severe complication
[19]

Diagnostics

Step 1 - Clinical examination + tests. Examination, palpation, surgical history. Tests - to assess severity (electrolytes, hemoconcentration, leukocytosis, C-reactive protein, lactate). [20]

Step 2: Visualization. If obstruction is suspected, a low-dose CT scan of the abdomen shows fluid levels, the "transition point," dilated loops, and signs of strangulation (wall thickening, decreased contrast, mesenteric "swirl sign"). In children/pregnant women, the first step may be ultrasound; in the case of pelvic adhesions, an MRI (including kinematic techniques) is needed to assess organ connections. Sometimes, an adhesion is not directly visible, but rather through indirect signs. [21]

Step 3: Diagnostic tactics for partial ACN. In hospital, a water-soluble contrast agent (e.g., Gastrografin) is used as a diagnostic and, to some extent, therapeutic test: if the contrast agent reaches the colon within a few hours, there is a high probability of successful resolution without surgery. If not, this is an argument in favor of surgery. [22]

Table 4. What each method shows

Method	Strengths	When appropriate
Ultrasound	No radiation, bedside	Children/pregnancy; dynamics; pelvis
CT (low-dose)	Quickly and accurately finds the "transition point"	Suspected ACN in adults
MRI/kinetic techniques	Good for the pelvis and soft tissues	Suspected pelvic adhesions, endometriosis
Contrast test (WSCAs)	Predicts the outcome of conservative management	Partial ACN in hospital
[23]

Differential diagnosis

Adhesive obstruction can mask hernias, tumors, Crohn's disease, biliary and renal colic, diverticulitis, and sometimes the effects of medications (opioids) or metabolic disorders. In women, this can include ovarian cysts/torsion and pelvic inflammatory disease. Key factors include surgical history, CT/ultrasound images, and progression with conservative therapy. [24]

Treatment

1) If there are signs of strangulation/peritonitis, surgery is the only option. Every hour counts: urgent laparoscopic/open adhesiolysis is needed, with an assessment of intestinal viability and, if necessary, resection. [25]

2) Partial adhesive obstruction without any "red flags." Treatment is conservative: intravenous fluids, electrolyte correction, gastric decompression with a catheter, pain relief, and early mobilization. Water-soluble contrast (Gastrografin) is used according to protocol: it helps predict the outcome and often stimulates resolution of the blockage on its own. Lack of contrast in the colon within the prescribed time frame is a signal for surgery. [26]

3) Surgical treatment. If there is no effect and/or deterioration occurs, perform adhesiolysis. When possible and experienced, laparoscopic approach is used (fewer new adhesions, shorter recovery time), but in cases of pronounced "massive" conglomerates or risk of intestinal damage, an open approach is more reliable. The key to success is a gentle technique: minimal coagulation, atraumatic instruments, careful hemostasis, warm irrigation, and no "debris" in the wound. [27]

4) Intraoperative prophylaxis. The surgeon adopts a "gentle" approach (minimal tissue contact, warm isotonic solution, talc-free), and uses anti-adhesion barriers as indicated: hyaluronate-carboxymethylcellulose (Seprafilm®), 4% icodextrin solutions, and modern hydrogels/films. In certain patient categories, the use of barriers is associated with a reduced risk of clinically significant obstruction and reoperations; however, the evidence base is heterogeneous, and decisions are made on a case-by-case basis, tailored to the specific type of surgery and risk. [28]

Table 5. When to proceed conservatively and when to the operating room

Situation	Tactics	Comment
Suspected strangulation/peritonitis	Urgent surgery	Don't waste time on conservatives
Partial ACN, stable patient	Conservative + water-soluble contrast	Re-evaluation by the hour; clear threshold for surgery
No effect/worsening	Surgery (preferably laparoscopy if possible)	Depends on experience and the pattern of adhesions
Relapses in a "difficult" patient	Individualized plan; discussion of adhesiolysis risks	High risk of recurrence
[29]

Adhesion Prevention: What Really Works

Technique is paramount. Less trauma means fewer adhesions: neat tissue, minimal electrocoagulation, meticulous hemostasis, cavity irrigation, removal of clots and foreign particles, "talc-free" (powdered gloves are a thing of the past). Laparoscopy is preferable to open surgery whenever possible. [30]

Anti-adhesion barriers. Membranes based on hyaluronate-carboxymethylcellulose (Seprafilm®) and some bioresorbable hydrogels/films have been shown in some studies to reduce the severity and prevalence of adhesions and possibly the risk of clinically significant obstruction, particularly in colorectal and gynecological surgery. Icodextrin 4% in solution reduces recurrent episodes in patients undergoing surgery for ANC, but the effect depends on the technique and selection. The decision is individualized, taking into account the benefit and cost. [31]

Table 6. Brief guide to barriers (landmarks)

Class	Examples	What do they promise?	Comment
Membranes	Hyaluronate-CMC (Seprafilm®)	Fewer adhesions, fewer clinical events in individual series	Do not glue to the anastomosis (as per instructions); the team's experience is important
Solutions	Icodextrin 4%	Reduction of relapses in selected	The data is heterogeneous and is used selectively.
Hydrogels/films	Different platforms	Physical barrier for 5-7 days	Evidence varies; cost/access
[32]

Prognosis and quality of life

Most cases of partial adhesive obstruction can be resolved without surgery, especially with water-soluble contrast protocols. However, recurrences are possible, and the risk of new adhesions after adhesiolysis is not zero. This should be discussed frankly with the patient. [33]

With proper prophylaxis during the initial surgery and careful technique during repeat procedures, the burden of adhesions can be significantly reduced. With regard to chronic pain and fertility, decisions are made on a targeted basis (targeted laparoscopic adhesiolysis in an expert center is sometimes beneficial). [34]

FAQ

Is this "forever"? Can adhesions be "dissolved" with pills?

There are no pills that dissolve established adhesions. However, some functional episodes (partial obstruction) resolve with conservative therapy; preventing new adhesions is the task of surgery and proper technique. [35]

Is surgery always necessary for obstruction?

No. In cases of partial adhesive obstruction without signs of strangulation, infusions, decompression, and water-soluble contrast according to protocol often help. Lack of effect or "red flags" are a reason to operate. [36]

Does laparoscopy really reduce the risk of adhesions?

On average, yes: there is less trauma to the peritoneum compared to open surgery. However, adhesions are also possible after laparoscopy, especially with long/complex interventions and inflammation. [37]

Should everyone install a non-adhesive barrier “just in case”?

No. The decision is individual: the type of surgery, the patient's risks, the team's experience, and the cost. For "risky" patients and certain interventions, barriers are justified, but they are not a substitute for gentle technique. [38]