Page 85 - Postoperative Intra-Abdominal Adhesions- New insights in prevention and consequences

Introduction
The formation of intra-abdominal adhesions remains a common serious
problem in surgical practice. Formation of adhesions is observed after
both open and laparoscopic surgery, with a reported incidence as high as
97% [1,2]. Complications of intra-abdominal adhesions include intestinal obstruction, chronic pain, infertility, and troublesome reinterventions. Of
all patients undergoing open abdominal surgery, 35% will be readmitted
for complications related to adhesions [3]. The cumulative risk of
adhesive small-bowel obstruction after colectomy is 11%–25% after
one year and 30% after 10 years [4,5]. During reintervention, some
extent of adhesiolysis is unavoidable, leading to inadvertent enterotomy
in 19% of patients owing to the severity of the adhesions or to iatrogenic 5 bowel injury [6].
Adhesion formation is initiated by the inflammatory response following visceral damage as a result of intra-abdominal surgery and infection [7]. The underlying mechanism is local tissue ischemia and mesothelial injury. The mesothelial and submesothelial cells express proteases and protease inhibitors, disrupting the balance between coagulation and fibrinolysis and creating fibrous bands that form adhesions [7,8]. Furthermore, inflammation intensifies this reaction by attracting and activating fibroblasts and disrupting fibrinolysis [9,10]. Adhesion formation is controlled by macrophages and T lymphocytes and takes place mainly during the first two weeks of healing, before the defect has been covered with mesothelium [11–13]. Adhesion formation can be prevented by a physical barrier that separates the injured tissue from adjacent organs and the peritoneum during the crucial healing period [2,14–16].
Abdominal surgery for intra-abdominal infection with peritonitis is associated with high morbidity and mortality rates and complicated frequently by abscess formation. In peritonitis, severe inflammation of the peritoneum occurs, increasing adhesion formation. Prevention of adhesion formation after peritonitis seems the ultimate challenge for proving the effectiveness of an anti-adhesion barrier. It also is crucial
Adhesion barrier and peritonitis
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