Prevention of Adhesions in Gynecological Surgery: The 2016 Expert
Gynecology & Obstetrics

Gynecology & Obstetrics
Open Access

ISSN: 2161-0932

Opinion Article - (2017) Volume 7, Issue 2

Prevention of Adhesions in Gynecological Surgery: The 2016 Experts Recommendations on Adhesion Prophylaxis

De Wilde RL1*, Alvarez J2, Brölmann H3, Campo R4, Cheong Y5, Sardo ADS6, Koninckx P7, Lundorff P8, Pawelczyk L9, Roman H10, Torres-de-la-Roche LA11 and Wallwiener M12
1Clinic of Gynecology, Obstetrics and Gynaecological Oncology, Medical Campus, University Hospital for Gynecology, Pius-Hospital Oldenburg, University of Oldenburg, Germany
2Hospital Universitario Infanta Sofía, San Sebastián de Los Reyes, Spain
3Department of Obstetrics and Gynecology, VU University Medical Centre, Amsterdam, The Netherlands
4LIFE, Leuven Institute for Fertility and Embryology, Leuven, Belgium
5Human Development and Health, Faculty of Medicine, University of Southampton and Complete Fertility Centre, Southampton, UK
6First Department of Obstetrics and Gynecology, Aristotle University of Thessaloniki, Thessaloniki, Greece
7Department of Obstetrics and Gynecology, Privathospitalet Mølholm, Vejle, Denmark
8Division of Infertility and Reproductive Endocrinology, Poznan University of Medical Sciences, Poznan, Poland
9LIFE, Leuven Institute for Fertility and Embryology, Leuven, Belgium
10Hopitaux De Rouen - Clinique Gynecologique et Obstetricale, Rouen Cedex, France
11Department of Gynecology and Obstetrics, Carl von Ossietzky Universität, Oldenburg, Germany
12Department of Obstetrics and Gynecology, University Clinic, Heidelberg, Germany
*Corresponding Author: De Wilde RL, Clinic of Gynecology, Obstetrics and Gynaecological Oncology, Medical Campus, University Hospital for Gynecology, Pius-Hospital, University of Oldenburg, Georgstrasse 12, 26121 Oldenburg, Germany, Tel: 49-4412291501 Email:


Post-operative adhesions are frequent sequela of abdominal and gynaecological surgery. They are associated with a high level of morbidity. This “field guideline” was written by a panel of European experts (anti-adhesions in gynecology expert group (ANGEL) and the European Society of Gynaecological Endoscopy (ESGE), adhesion research special interest group. It aims to provide surgeons with a quick reference guide to adhesion prevention adapted to the conditions of their daily practice.

Keywords: Adhesions; Adhesiolysis; Adhesion prevention; Treatment guidelines; Anti-adhesion agents

Adhesion Prevention

It is well known that peritoneal adhesions, which could appear consequently to an inflammatory process or after surgical trauma, involve a broad spectrum of expensive, painful and difficult to treat sequela. Indistinctly of open or endoscopic surgery, the most frequent morbidities associated to adhesions are infertility, chronic abdominal pain, bowel obstruction, dyspareunia, and inadvertent enterotomy in subsequent abdominal procedures [1].

After operative hysteroscopy and sharp curettage, intrauterine adhesions also may cause ameno- or hypomenorrhea, cyclic pelvic pain, infertility, recurrent pregnancy loss and abnormal placentation [2]. Although the clinical consequences of intrauterine adhesions besides hypo- and amenorrhoea have not been elucidated yet, an association with infertility, miscarriage, premature delivery and abnormal placental invasion of the myometrium in subsequent pregnancies is suspected [2,3].

Additionally, the lysis of adhesions is followed by adhesion reformation [4] and no anti-adhesion agent had proved to prevent them at all. Therefore, symptoms related with adhesions or their complications increase the necessity of re-interventions, longer hospital stays, extend re-intervention times and limit the use of minimally-invasive techniques [5].

Consequently, the cost to patients and the health system increases: in the UK readmissions cost £24.2 and £95.2 million at 2 and 5 years after surgery, respectively [6]. Despite this evidence, little has been invested in adhesion related research, prevention and or treatment. Moreover, many physicians are not aware of its impact on health-cost, litigation claims [7], and finally on the quality of life of their patients.

In order to enhance the awareness of adhesions, to promote scientific research and to improve adhesion-related outcomes after gynaecological surgeries, we have updated our ANGEL statement [5], providing physicians a quick reference guide to adhesion prevention, based on the best scientific evidence and expertise.

This up-dated “field guideline” (Table 1), is adapted to clinical routine and could be used as a tool in the decision-making process during the pre-surgical counselling of patients, answering frequent patients concerns on the problematic of post-operative adhesions. Again, we encourage surgeons to adopt effective measures to prevent postoperative adhesions [5,8,20-23], by following five basic rules of post-operative adhesion prevention suggested in our previous statement (Table 2), to which we added new recommendations when planning endometriosis surgery (Rule 3b) [23,24], or intrauterine procedures (Rules 3f, 4p and 4q) [23,25]. In regards to routine second look hysteroscopy as a prophylactic action, there is weak evidence favoring it to prevent intrauterine synechiae (Table 2) [25].

Concern What does the evidence says? Refs.
When do adhesions appear? Abdominopelvic adhesions could develop after an abdominal or pelvic infection, or after an abdominal and gynecological surgery. [8]
How often does this occur? 1.5% in general population.
93% of patients after any abdominal or pelvic surgery.
19-90% after a postpartum uterine curettage.
33% after a hysteroscopic resection of sub-mucosal fibroids.
Which are the consequences of adhesions? 30% of patients will be readmitted due a complication within 10 years.
74% of cases of bowel obstruction are due to post-surgical adhesions.
56% of complications following re-interventions.
19% of enterotomy in subsequent open abdominal surgeries.
10-25% of enterotomy in subsequent laparoscopic surgeries.
20-40% of secondary female infertility.
Could future pregnancies be affected? Adhesions could increase the risk of miscarriage, premature delivery and placental invasion of the myometrium. [2,16]
Is there any difference between open and endoscopic procedures? There is an overall risk of adhesion-related readmission following either laparoscopic or open surgery.
Adhesions limit the use of minimal invasive techniques.
How do adhesions impact the health costs? More re-admissions and re-interventions.
Longer operation times.
Longer hospital stays.
More disability.
Based on, modified and updated from the ANGEL statement [5].

Table 1: Quick reference guide to counsel patient on the problematic adhesions.

1. The risk of post-operative adhesions should be systematically discussed with any patient scheduled for open or laparoscopic abdominal or intrauterine surgery prior to obtaining his/her informed consent.
2. Surgeons need to act to reduce post-operative adhesions in order to fulfill their duty of care towards patients undergoing abdominal-pelvic or intrauterine surgery.
3. Surgeons should adopt a routine adhesion reduction strategy at least for patients undergoing high-risk surgery based on the previously published ANGEL Adhesion score [23]. Interventions include:
a) Ovarian surgery
b) Endometriosis surgery [24]
c) Tubal surgery
d) Myomectomy
e) Adhesiolysis
f) Uterine curettage and hysteroscopic surgery (Adhesiolysis, myomectomy, septum resection).
4. Good surgical technique is fundamental to any adhesion reduction strategy:
a) Carefully handle tissue with field enhancement (magnification) techniques.
b) Focus on planned surgery and, if any secondary pathology is identified, question the risk: benefit ratio of surgical treatment before proceeding.
c) Perform diligent haemostasis and ensure adequate use of cautery.
d) Reduce cautery time and frequency and aspirate aerosolised tissue following cautery.
e) Exercise tissue rather than coagulate to reduce fulguration, e.g. in endometriosis.
f) Reduce duration of surgery.
g) Reduce pressure and duration of pneumoperitoneum in laparoscopic surgery.
h) Reduce risk of infection.
i) Reduce drying of tissues.
j) Use frequent irrigation and aspiration in laparoscopic and laparotomic surgery.
k) Limit use of sutures and choose fine non-reactive sutures.
l) Avoid foreign bodies when possible.
m) Avoid non-peritonised implants and meshes.
n) Minimize use of dry towels or sponges in laparotomy.
o) Use starch- and latex-free gloves in laparotomy.
p) Avoid mechanical uterine curettage. Medical management of spontaneous or induced abortion may be recommended rather than surgical management. In case of uterine curettage - use aspiration technique.
q) Reduce the use of electrosurgical energy in hysteroscopic surgery (rather use “cold” mechanical instruments).
5. Surgeons should consider the use of adhesion reduction agents as part of the adhesion reduction strategy:
a) Give special consideration to agents with data supporting safety in routine surgery and efficacy in adhesion prevention.
b) Practicality, ease of use, and cost of agents should influence selection for routine practice.
Based and updated from the ANGEL statement [5].

Table 2: The five basic rules of postoperative adhesions prevention in gynaecological surgery–updated 2016.

The present field-guideline is also provided with a flow chart when the usage of an adhesion barrier is considered during an abdominal surgery, either by laparoscopy or laparotomy (Figure 1). The decision should be based on the preoperative and intraoperative risks, according to our previously published Adhesion Risk Score, ARS [25] and to the desire of the patient. Because of the amount of variables to be calculated to establish the individual preoperative and perioperative risk, ongoing studies of our group report that, to have the ARS available as a poster or screen in the operating room facilitates this calculation in few minutes and helps surgeons to apply anti-adhesion agents only to patients who benefit most of them.


Figure 1: Flow chart for adhesion prevention using adhesion barrier after gynaecological surgery.

The preoperative risk sub-score evaluates the presence of previous abdominal/pelvic surgery, history of post-surgical adhesions, concomitant abdominal or gynecological inflammation and/or infection, endometriosis, cancer, radiation therapy in intra-abdominal cancer, keloid scarring, intraperitoneal bleeding, postoperative infection and postoperative complications e.g. fistulas, abscesses. The perioperative risk assessment focuses on quality of existing adhesions, severity of adhesions, procedure duration, type and site of surgery, use of electrical scalpel, excessive bleeding, procedure complexity or extent of surgery e.g. enterotomy, oncological surgery, surgery in multiple quadrants e.g. adhesiolysis, ovarian carcinoma surgery, excessive coagulation, >2 cm2 intra-abdominal placement of foreign bodies e.g. meshes, and peritoneal closing. The summarizing score establishes if the surgery is at low, medium or high risk of postoperative adhesions.

The medium to high-risk range suggests the use of an anti-adhesion agent, especially after extensive adhesiolysis, procedures on the tubes, ovaries and after fertility surgeries. Although adequate surgical technique is the basis of adhesion prevention, the use of anti-adhesion agents is clinically beneficial and economically justifiable, because they reduce the burden of complications, improve the patient´s quality of live, and reduce costs associated with peritoneal adhesions to the health system [22,26-28].

Modern non-pharmacological agents are available as films, gels, powder or fluids, and have shown to be safe and effective to reduce the risk of post-operative adhesions [29], although, the new substances lack long-term evidence [30-32]. The selection will depend on the type of surgery, extension of the surface to be covered, presence of diffuse bleeding, expected use of post-operative drainage and costs. For example, some substances should not be applied on bleeding surfaces, on sutured bowel or in the uterine cavity, and films should not be overlapped [32]. In addition, surgeons should follow the mode of use specified by the producer, and keep in mind that most of agents are not recommended in presence of infection, malignancy, bowel leakage or for intravascular use. On the other hand, non-pharmacological agents [5], which have proved to be ineffective or to impair with the normal postsurgical re-epithelialization process, like colloids, crystalloids or steroids should not be used.

Regarding operative hysteroscopy, there is limited evidence of the effectivity of hormonal or antibiotic therapies, alone or in combination with other products, to reduce the risk of uterine synechiae after gynaecological and obstetrical procedures [25,33]. In contrast, antiadhesion gels have shown to be safe and effective (Level of evidence 1b), but more evidence is needed to establish which group of women would benefit most of this practice [25].


The burden of disease of peritoneal adhesions continues to be a challenge for surgeons and patients. We do encourage physicians to follow the present recommendations and flow chart, that could facilitate their own daily practice and, thereby, giving patients the best medical care. In the meanwhile, we will be paying attention to new evidence in order to up-date our risk score, flow chart and recommendations.


Funding for the preparation of this manuscript was provided by Nordic Pharma.


All named authors meet the International Committee of Medical Journal Editors (ICMJE) criteria for authorship for this manuscript, take responsibility for the integrity of the work as a whole, and have given final approval to the version to be published.

Medical Writing

Editorial assistance in the preparation of the manuscript was provided by Laurence Saya, MD, Altius Pharma CS, France, and Luz Angela Torres-de la Roche. Support for this assistance was funded by Nordic Pharma.


All members of the ANGEL group received fees to attend the meeting of the adhesion working group.


  1. De Wilde RL, Trew G (2007) Postoperative abdominal adhesions and their prevention in gynaecological surgery. Expert consensus position. GynecolSurg 4:161-168.
  2. Deans R, Abbott J (2010) Review of intrauterine adhesions. J Minim Invasive Gynecol 17:555-569.
  3. March CM (1995) Intrauterine adhesions. ObstetGynecolClin North Am 22: 491-505.
  4. Herrmann A, De Wilde RL (2016) Adhesions are the major cause of complications in operative gynaecology. Best Pract Res ClinObstetGynaecol35: 71-83.
  5. De Wilde RL, Brölmann H, Koninckx PR, LundorffP, LowerAM,et al. (2012) The Anti-Adhesions in Gynecology Expert Panel (ANGEL). Prevention of adhesions in gynaecological surgery: the 2012 European field guideline. GynecolSurg 9:365-368.
  6. Wilson MS,Menzies D, Knight AD, Crowe AM (2002) Demonstrating the clinical and cost effectiveness of adhesion reduction strategies. Colorectal Dis 4:355-360.
  7. Wallwiener M, Koninckx PR, Hackethal A, et al. (2014) A European survey on awareness of post-surgical adhesions among gynaecological surgeons. GynecolSurg 11:105-112.
  8. Hirschelmann A, Tchartchian G, Wallwiener M, Weyhe D, Hackethal A, et al. (2012) A review of the problematic adhesion prophylaxis in gynaecological surgery. Arch GynecolObstet 285:1089-1097.
  9.  Hooker AB, Lemmers M, Thurkow AL, Heymans MW, Opmeer BC, et al. (2014) Systematic review and meta-analysis of intrauterine adhesions after miscarriage: prevalence, risk factors and long-term reproductive outcome. Hum Reprod Update 20:262-278.
  10. Guida M, Acunzo G, Di SpiezioSardo A, Bifulco G, Piccoli R, et al. (2004) Effectiveness of auto-crosslinked hyaluronic acid gel in the prevention of intrauterine adhesions after hysteroscopic surgery: a prospective, randomized, controlled study.Hum Reprod 19: 1461-1464.
  11. Monk BJ, Berman ML, Montz FJ (1994) Adhesions after extensive gynecologic surgery: clinical significance, etiology, and prevention. Am J ObstetGynecol 170:1396-1403.
  12. Ellis H (1998) The magnitude of adhesion related problems. Ann ChirGynaecol 87:9-1.
  13. Ellis H, Moran BJ, Thompson JN, Parker MC, Wilson MS, et al. (1999) Adhesion-related hospital readmissions after abdominal and pelvic surgery: a retrospective cohort study. Lancet 353:1476-1480.
  14. Hershlag A, Diamond MP, DeCherney AH (1991)Adhesiolysis. ClinObstetGynecol 34:395-402.
  15. Mishell DR, Davajan V (1991) Evaluation of the infertile couple. Infertility contraception and reproductive endocrinology, (3rdedtn) Blackwell, Boston.
  16. Di SpiezioSardoA , Calagna G, Scognamiglio M, De Wilde RL (2016) A review on the prevention of intrauterine post-surgical adhesions. Eur J ObstetGynecolReprodBiol 203: 182-192.
  17. Van Der Krabben AA, Dijkstra FR, Nieuwenhuijzen M,Reijnen MM, Schaapveld M, et al. (2000) Morbidity and mortality of inadvertent enterotomy during adhesiotomy. Br J Surg 87:467-471.
  18. Swank DJ, Swank-Bordewijk SC, Hop WC, van Erp WF, Janssen IM, et al. (2003) Laparoscopic adhesiolysis in patients with chronic abdominal pain: a blinded randomised controlled multi-centre trial. Lancet 361:1247-1251.
  19. Lower AM, Hawthorn RJ, Clark D, Boyd JH, Finlayson AR, et al. (2004) Adhesion-related readmissions following gynaecological laparoscopy or laparotomy in Scotland: an epidemiological study of 24 046 patients. Hum Reprod 19:1877-1885.
  20. Trew G (2004) Consensus in adhesion reduction management. The ObstetGynaecol 6(S2):1-16.
  21. De Wilde RL, Trew G (2007) Postoperative abdominal adhesions and their prevention in gynaecological surgery. Expert consensus position. Part 2—steps to reduce adhesions. GynecolSurg 4:243-253.
  22. Diamond MP, Wexner SD, diZereg GS, Korell M, Zmora O, et al. (2012) Adhesion prevention and reduction: current status and future recommendations of a multinationalinter-disciplinary consensus conference. SurgInnov17:183-188.
  23. Robertson D, Lefebvre G, Leyland N, Wolfman W, Allaire C, et al. (2012) Adhesion prevention in gynaecological surgery. J ObstetGynaecol Can 32:598-608.
  24. De Wilde RL, Alvarez J, Brölmann H, Campo R, Cheong Y, et al. (2016) Adhesions and endometriosis: challenges in subfertility management: (An expert opinion of the ANGEL-The ANti-Adhesions in Gynaecology Expert PaneL-group). Arch GynecolObstet294:299-301.
  25. Di SpiezioSardo A, Calagna G, Scognamiglio M, O'Donovan P, Campo R, et al. (2016) Prevention of intrauterine post-surgical adhesions in hysteroscopy. A systematic review. Eur J ObstetGynecolReprod Biol. 203: 182-92.
  26. Lundorff P, Brölmann H, Koninckx PR (2015) Anti-Adhesions in Gynaecology Expert Panel (‘ANGEL’). Predicting formation of adhesions after gynaecological surgery: development of a risk score. Arch GynecolObstet 292: 931-938.
  27. ten Broek RPG, Issa Y, van Santbrink EJ, Bouvy ND, Kruitwagen RF, et al. (2013) Burden of adhesions in abdominal and pelvic surgery: systematic review and meta-analysis. Centre for Reviews and Dissemination (UK) 347: f5588.
  28. Majewsky WD (2005) Long-term outcome, adhesions, and quality of life after laparoscopic and open surgical therapies for acute abdomen. SurgEndosc19: 81-90.
  29. AhmadG, O’FlynnH, Hindocha A,WatsonA (2015) Barrier agents for adhesion prevention after gynaecological surgery.Cochrane Database of Systematic Reviews.
  30. Gao X, Deng X, Wei X, Shi H, Wang F, et al. (2013) Novel thermosensitive hydrogel for preventing formation of abdominal adhesions. InterantionalJournal Nanomedicineof abdominal adhesions. Int J Nanomedicine8: 2453-2463.
  31. Qin F, Ma Y, Li X, Wang X, Wei Y, et al. (2015) Efficacy and mechanism of tanshinone IIA liquid nanoparticles in preventing experimental postoperative peritoneal adhesions in vivo and in vitro. Int J Nanomedicine 10: 3699-3717.
  32. Brown CB, Luciano AA, Martin D, Peers E, Scrimgeour A, et al. (2007) Adept (icodextrin 4% solution) reduces adhesions after laparoscopic surgery for adhesiolysis: a double-blind, randomized, controlled study. FertilSteril 88:1413-1426.
  33. Fuchs N, Smorgick N, Ben Ami I, Vaknin Z, Tovbin Y, et al. (2014)Intercoat (Oxiplex/AP Gel) for Preventing Intrauterine Adhesions After Operative Hysteroscopy for Suspected Retained Products of Conception: Double-Blind, Prospective, Randomized Pilot Study. J Minim Invasive Gynecol. 21:126-130.
Citation: De Wilde RL, Alvarez J, Brölmann H, Campo R, Cheong Y, et al. (2017) Prevention of Adhesions in Gynecological Surgery: The 2016 Experts Recommendations on Adhesion Prophylaxis. Gynecol Obstet (Sunnyvale) 7:428.

Copyright: © 2017 De Wilde RL, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.