The hymn “Blessed Be the Tie That Binds” describes bonds between like-minded people. But for surgical patients, no blessing is associated with the binding ties of tissues that form scars as a result of surgery. Adhesions that form in the surgical site create problems ranging from minor discomfort to intense pain. Some patients experience ischemic tissue and obstruction as the adhesive bands become more fibrous over time. The incidence of postoperative surgically induced adhesions ranges from 55% to 95%.^{1 (Level A)} It is important that we understand how adhesions form and how to care for patients with them to improve outcomes.

 

Adhesions can form if breaches occur in the two-layer semipermeable membrane that lines body cavities, such as the pericardium, peritoneum and pleura. The membrane houses a single layer of flat mesothelial cells in between its two layers: the parietal (outer) layer and visceral (inner) layer.² The intact mesothelial surface secretes a lubricating transudate over the visceral surface of internal organs. This process prevents the organs from rubbing together and transports leukocytes in response to inflammation. Transudate is a natural lubricating fluid that contains plasminogen, which prevents significant buildup of fibrin (a stringy, sticky natural protein found in body fluids). The buildup of fibrin is one of the main causes of adhesions.² Breaches in the mesothelial surface with areas of resultant ischemia allow fibrin to accumulate and form strands of dense tissue that encircle and encase surrounding structures.³

 

Areas that have not been exposed to surgery are often called “virgin territory,” and adhesions are not generally found within the tissues.² Working in a “virgin abdomen” is less complicated because structures are less distorted by postoperative scarring. Adhesions (or synechiae) generally form within body spaces and over organs in response to damage to the mesothelium during surgical incision and retraction.² Other causes of adhesions include extreme inflammation, infection, foreign body reaction and trauma.¹

 

No blood tests exist to indicate the risk for postoperative adhesions.^{1 (Level A)} A patient’s condition, such as a predisposition for intense inflammatory response, can signal an increased risk. In the average patient, no clear way exists to predict adhesion formation. But structural differences between the sexes place females at increased risk for surgical adhesions. The male pelvis is contained within a closed peritoneal sac with no natural external entry points. Male reproductive structures are extraperitoneal and isolated from external sources of direct contact with harmful materials in the environment. The female system is covered with peritoneum but has direct openings to the external environment through the lumen of the fallopian tubes.² The internal openings of the fallopian tubes open into the peritoneal sac. These openings create direct entry points for infection, foreign material and external contaminants that can damage the mesothelial surface, which may cause adhesions and primary infertility caused by pelvic inflammatory disease.