Different surgical techniques to reduce post-operative adhesion formation: a systematic review and meta-analysis.

INTRODUCTION Adhesion formation is the most common complication following peritoneal surgery and the leading cause of small bowel obstruction, acquired infertility and inadvertent organ injury at reoperation. Using a 'good surgical technique' is advocated as a first step in preventing adhesions. However, the evidence for different surgical techniques to reduce adhesion formation needs confirmation. METHODS Pubmed, Embase and CENTRAL were searched to identify randomized controlled trials that investigated the effect of various aspects of surgical technique on adhesion-related outcomes. Clinical outcomes and incidence of adhesions were the primary endpoints. Identification of papers and data extraction were performed by two independent researchers. RESULTS There were 28 papers with 27 studies included for a systematic review. Of these, 17 studies were eligible for meta-analysis and 11 for qualitative assessment only. None of the techniques that were compared significantly reduced the incidence of adhesive small bowel obstruction. In a small low-quality trial, the pregnancy rate increased after subserous fixation of suture knots. However, the incidence of adhesions was lower after laparoscopic compared with open surgery [relative risk (RR) 0.14; 95% confidence interval (CI): 0.03-0.61] and when the peritoneum was not closed (RR 0.36; 95% CI: 0.21-0.63). CONCLUSIONS None of the specific techniques that were compared reduced the two main adhesion-related clinical outcomes, small bowel obstruction and infertility. The meta-analysis provides little evidence for the surgical principle that using less invasive techniques, introducing less foreign bodies or causing less ischaemia reduces the extent and severity of adhesions.

Efficacy of polyethylene glycol adhesion barrier after gynecological laparoscopic surgery: Results of a randomized controlled pilot study.

Postoperative adhesions are the most frequent complication of peritoneal surgery, causing small bowel obstruction, female infertility and chronic pain. This pilot study assessed the efficacy of a sprayable polyethylene glycol (PEG) barrier in the prevention of de novo adhesions. 16 patients undergoing laparoscopic gynecological surgery were randomly assigned by shuffled sealed envelopes to receive either the adhesion barrier or no adhesion prevention. Incidence and severity of adhesions were scored at eight sites in the pelvis and reassessed by second look laparoscopy. Adhesion prevention was considered successful if no de novo adhesion were found at second look laparoscopy. One patient was excluded before randomization. Nine patients were randomized to treatment and six patients to control group. De novo adhesions were found in 0/9 patients who received the PEG barrier compared to 4/6 without adhesion prevention (0% vs. 67%, P = 0.01). Reduction in adhesion score was significantly greater in patients receiving PEG barrier (-2.6 vs. -0.06, P = 0.03). Meta-analysis of three randomized trials demonstrated that PEG barrier reduces the incidence of adhesions (odds ratio [OR] = 0.27; 95% CI 0.11-0.67). From this study, PEG barrier seems effective in reducing postoperative formation of de novo adhesions.