Page 26 - Postoperative Intra-Abdominal Adhesions- New insights in prevention and consequences

Chapter 2
patients as was diagnostic laparoscopy alone [32]. Recently these results were confirmed in a prospective cohort study demonstrating that adhesiolysis in itself does not affect functional status and quality of life six months after surgery [33].
The adhesion related complications and hospital re-admissions have an enormous impact on healthcare economics worldwide. Already in 1988 the costs attributable to adhesiolysis were estimated on more than $ 1 billion in the US alone [34]. More recently an economic model based on data of the third SCAR study has been revised with 2006 costs [35, 36]. The cumulative, year-on-year, direct costs of adhesion-related re-admissions due to lower abdominal surgery with the exception of appendectomy were estimated to be over €908 million for a 10-year period in the UK. Nonetheless, since gynaecological and other abdominal surgery was not taken into account the entire economic burden of postoperative abdominal adhesions is expected to be much larger.
Adhesion prevention
Prevention of the development of postoperative abdominal adhesions can be approached with two main strategies; one is accurate surgical technique to minimize trauma to the peritoneum and the other includes the use of adjuvants, whether pharmacological or as a solid barrier [37, 38].
Surgical technique
Cautiously conducted surgery in compliance with microsurgical principles should be one of the fundamentals of surgery since every injury to the peritoneum potentially results in adhesion formation [38]. Forceps, retractors and clamps should not be placed on structures not intended for dissection, reducing serosal denudation and vascular trauma. Additionally meticulous surgery also includes diligent hemostasis. Blood and clot in association with a peritoneal wound constitute a potentiating factor, because additional fibrin has to be degraded by the fibrinolytic activity of the peritoneum [12]. In animal studies large blood clots induced adhesion formation, whereas smaller amounts did not [39]. Frequent irrigation and aspiration should be utilized when needed and
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