Postoperative adhesions and their prevention

The fact that adhesions can form following abdominal surgery has been known since the beginning of surgery. Yet during the early years of surgery, adhesion formation received little attention, the focus being on infection and survival. In the seventies clinical endocrinology developed explosively, driven by the introduction of oral contraceptives and by the introduction of radioimmunoassays—a technique that permitted for the first time the assay of reproductive hormones—and reproductive medicine and infertility became a subspecialty. Simultaneously, reproductive surgery developed and the prevention of postoperative adhesion formation became important. Microsurgery was introduced (1) first as a magnification tool permitting tubal reanastomosis and developing subsequently as a principle of surgery emphasizing the prevention of desiccation and gentle tissue handling (Fig. 1). Prevention of adhesion formation was mainly based upon careful observational medicine and common sense, and most of the principles became only much later experimentally confirmed. Some mistakes, however, were also introduced such as the free peritoneal graft to cover denuded peritoneal areas, a technique shown later to be strongly adhesiogenic (2). The history of surgery and adhesion prevention cannot be viewed separately from the development of endometriosis and endometriosis surgery because cystic ovarian endometriosis is strongly associated with adhesion formation and also because endometriosis surgery is the most frequently performed fertility surgery. Diagnosis of infertility and of endometriosis and their treatment has driven the development of diagnostic laparoscopy complemented with minor laparoscopic surgical interventions and by microsurgery. When lightweight endoscopic cameras were introduced in the mid-eighties, endoscopic surgery developed explosively replacing microsurgery and also laparotomy not only in gynecology but also in abdominal surgery and urology. This had important consequences for fertility and endometriosis surgery and for our awareness of adhesion formation. Until the early nineties, fertility surgery with prevention of adhesion formation had remained centralized in highly specialized fertility centers (3,4). We then witnessed in parallel the increasing use and success of IVF and the development of more advanced endoscopic surgery such as deep endometriosis and bowel, pelvic floor, and oncologic surgeries. With laparoscopic reproductive surgery becoming mainstream surgery, the microsurgical focus on the prevention of adhesion formation got lost. Indeed outside reproductive surgery, adhesion formation was widely considered as an unavoidable byproduct of surgery, which could largely be prevented by good quality surgery. In retrospect, it is astonishing how fast the principles of microsurgery became by and large forgotten, with the overall belief that laparoscopic surgery was “minimal invasive” surgery and thus even better than microsurgery and that adhesion formation would rapidly become a minor problem (5,6). With the realization that laparoscopic surgery was not the solution to prevent adhesion formation (7,8), laboratory research on and clinical interest in adhesion formation revived and new products were developed. Only in the last decade, we have become aware of the clinical importance of adhesion formation, mainly though the SCAR studies (9–11). These studies clearly demonstrated that the incidences of bowel obstruction and of reoperation due to postoperative adhesions keep increasing linearly for at least 10 years and are much higher than anticipated. In addition, the awareness of postoperative adhesions as a cause of infertility and pain grew. With the awareness of the clinical importance, we realized the associated costs, the market potential, and the necessity of randomized clinical trials for new products. “Quality of surgery” obviously being a key element in these trials, we realized that quality control of the individual surgical procedure was close to non-existent (12), and video registration was introduced as a monitoring aid for these trials. And simultaneously also came the awareness that quality of surgery might be variable—that good quality surgery cannot be considered as universal with obvious consequences for the interpretation of adhesion formation statistics. In conclusion, postoperative adhesion formation has never received the attention it deserves as evidenced by the absence of adequate keywords to search the literature. Only very recently the clinical importance has been acknowledged (13–17), stimulating research and the foundation of a dedicated society, the PAX society, today called the Peritoneum and Surgery Society (P&S), spanning gynecology and surgery.