Adhesion-related small-bowel obstruction after gynecologic operations

doi:10.1016/S0002-9378(99)70205-X

American Journal of Obstetrics and Gynecology

Volume 180, Issue 2, February 1999, Pages 313-315

https://doi.org/10.1016/S0002-9378(99)70205-X Get rights and content

Abstract

Objective: Our purpose was to evaluate a possible relationship between adhesion-related small-bowel obstruction and gynecologic operations. Study Design: The records of all female patients with the diagnosis of small-bowel obstruction from 1989 to 1996 were studied. The cause of bowel obstruction, the type and technique of previous operations, and whether the parietal peritoneum was closed at the completion of the procedure or was left open were evaluated. Results: Among 262 women the most common cause of small-bowel obstruction was intra-abdominal adhesions (37.0%). Among 92 women with adhesion-related small-bowel obstruction, 35 women (38%) had undergone a previous abdominal hysterectomy. The incidence of small-bowel obstruction after an abdominal hysterectomy was 16.3 per 1000 hysterectomies. The incidence of small-bowel obstruction after cesarean delivery (5/10,000 cesarean deliveries) was significantly less than after other abdominal operations. Adhesions were found between the small bowel and the pelvis in 14 women (29.8%), and all were in women who had undergone a hysterectomy. In 33 others (70.2%) the adhesions were found between the previous abdominal incision and the intestine. The median interval between the initial operation and the small-bowel obstruction was 5.3 years. Conclusion: The most common cause of small-bowel obstruction is postsurgical adhesions. Adhesionrelated small-bowel obstruction is commonly found after an abdominal hysterectomy. Bowel obstruction can occur many years after the initial abdominal surgery. (Am J Obstet Gynecol 1999;180:313-5.)

Section snippets

Material and methods

The medical records of all female patients with the diagnosis of small-bowel obstruction from 1989 to 1996 at the Royal Victoria Hospital were evaluated. During this period we encountered 813 colectomies, 2140 hysterectomies, 924 adnexal operations, and 245 myomectomies for benign conditions. There were 6480 cesarean deliveries. Each medical record was reviewed thoroughly for the cause of bowel obstruction and the type and technique of previous operations. We also evaluated whether the parietal

Results

Among 262 women the most common cause of small-bowel obstruction was intra-abdominal adhesions, which occurred in 97 women (37.0%), and the second was intra-abdominal malignancy, in 74 women (28.2%). Another common cause was inflammatory bowel disease, which affected 22 women (8.4%). Other causes included radiation enteritis and incarcerated hernia.

Of all the women with adhesion-related small-bowel obstruction, 92 women had a history of previous abdominal operations and 5 women had never

Comment

In this study, intra-abdominal adhesions, especially postsurgical adhesions, are the most common cause of small-bowel obstruction. This is in agreement with previous reports.1, 6 In a large study of 1252 bowel obstructions during a 10-year period, 37% of the obstructions were due to adhesion and 79% of these adhesions were postoperative.¹ Ellis⁶ also noted that one third of all bowel obstructions were caused by adhesions.

Previous studies3, 7 have shown that more than one half to three fourths

References (13)

HB Krebs et al.
Mechanical intestinal obstruction in patients with gynecologic disease: a review of 368 patients
Am J Obstet Gynecol
(1987)
BJ Monk et al.
Adhesions after extensive gynecologic surgery: clinical significance, etiology and prevention
Am J Obstet Gynecol
(1994)
RF Buckman et al.
A physiologic basis for the adhesion-free healing of deperitonealized surfaces
J Surg Res
(1976)
T Tulandi et al.
Closure of laparotomy incisions with or without peritoneal suturing and second-look laparoscopy
Am J Obstet Gynecol
(1988)
JF Perry et al.
Intestinal obstruction due to adhesions: a review of 388 cases
Ann Surg
(1955)
GF Melody
Intestinal obstruction following gynecologic surgery
Obstet Gynecol
(1958)

There are more references available in the full text version of this article.

Cited by (122)

Prediction of intraperitoneal adhesions in repeated cesarean sections: A Systematic review and Meta-analysis
2023, European Journal of Obstetrics and Gynecology and Reproductive Biology
With the rate of repeated cesarean sections on the rise, intraperitoneal adhesions caused by repeated cesareans could give rise to maternal morbidity during delivery. As a result, it's critical to have the ability to predict adhesions. The current meta-analysis aims to determine if intraperitoneal adhesions are likely to be present based on the characteristics of the cesarean scar, striae gravidarum, and sliding sign.
We systematically searched electronic databases before retrieving articles up until October 13th, 2022 for analysis. After data extraction and literature screening, we first performed a quality assessment using the QUADAS-2 score system. Following that, a bivariate random-effect meta-analysis model was used to obtain the combined diagnostic and predictive values. To pinpoint the origins of heterogeneity, we conducted a subgroup analysis. Fagan's Nomogram was used to validate the clinical utility. Sensitivity analysis was used to gauge the reliability of each included study, and Egger's test and funnel plot asymmetry was used to investigate publication bias.
25 studies totaling 1840 patients with intra-abdominal adhesions and 2501 controls without adhesions were included in the systematic review. Diagnostic values from 8 studies regarding skin characteristics were combined, and the results for depressed scar showed: sensitivity[95 %CI] = 0.38[0.34–0.42]; Specificity[95 %CI] = 0.88[0.85–0.90]; DOR[95 %CI] = 4.78[2.50–9.13]; AUC = 0.65. Negative sliding sign from 7 studies, although not showing a diagnostic difference between cases and controls, had excellent predictive values: sensitivity[95 %CI] = 0.71[0.65–0.77]; Specificity[95 %CI] = 0.87[0.85–0.89]; DOR[95 %CI] = 6.88[0.6–78.9]; AUC = 0.77. Subgroup analysis illustrated non-Turkish studies to reveal more significant associations than Turkish studies.
Our meta-analysis found that the occurrence of adhesions can be predicted by the characteristics of abdominal wounds, particularly depressed scar, and scar width, as well as a negative sliding sign following a previous cesarean section.
Does surgeon seniority affect adhesion assessment at cesarean delivery? A prospective study
2023, AJOG Global Reports
Intraabdominal adhesions may develop following cesarean delivery and are considered a major concern.
This study aimed to determine the effect of surgeon seniority in evaluating intraabdominal adhesions at cesarean delivery.
A prospective study to estimate interrater reliability between surgeons was conducted. Women who underwent cesarean delivery (January–July 2021) in a single tertiary university-affiliated medical center were included. Blinded questionnaires assessing adhesions were completed by the surgeons. Questions were limited to 4 main anatomic sites and 3 possible categories of adhesion (each site was scored between 0 and 2; the sum score range was 0–8). The surgeons were ranked by increasing seniority (1–4) as: (1) junior residents (less than half of residency completed), (2) senior residents (more than half of residency completed), (3) young attending physicians (attending physicians for <10 years), and (4) senior attendings (attending physicians for >10 years). The weighted percentage of agreement was calculated between the 2 surgeons assessing the same adhesions. Scoring differences between the 2 surgeons (senior vs less senior) were also calculated.
A total of 96 pairs of surgeons were included in the study. The sum interrater reliability found in the weighted agreement tests between surgeons was 0.918 (confidence interval, 0.898–0.938). When scoring differences between surgeons (senior vs less senior) were calculated, nonsignificant difference was found (mean sum score difference of 0.09 with a standard deviation of 1.03 in favor of the more experienced surgeon).
Surgeon seniority does not affect subjective scoring of adhesion reports.
Small bowel obstruction after caesarean section: Laparoscopic management. Two case reports
2020, International Journal of Surgery Case Reports
Caesarean section is the most common abdominal surgery performed on women worldwide. Adhesions represent a severe complication of cesarean section and can cause different degrees of bowel obstruction.
We report two unusual cases of small bowel obstruction treated with laparoscopic approach after caesarean section performed for gynecological pathologies. In the first one small bowel obstruction was due to volvulus caused by a severe pelvic adhesion syndrome; in the second one, occlusive picture was related to presence of multiple adhesion phenomena between the sigmoid colon and the right ovary as result of abdominal hysterectomy.
The incidence of small bowel obstruction after caesarean section is very low and postoperative adhesions represent the main cause. Diagnosis was established by clinical signs, radiological and intraoperative findings. Laparoscopic approach can be the treatment of choice only in selected patients. In presence of dense adhesions, inability to visualize the site of obstruction, iatrogenic intestinal perforation, bowel necrosis and technical difficulties, conversion to open surgery is mandatory.
In selected patients with small bowel obstruction laparoscopy is a safe and feasible procedure if conservative measures fail.
Postoperative adhesions in gynecologic surgery: a committee opinion
2019, Fertility and Sterility
Postoperative adhesions are a natural consequence of surgical tissue trauma and healing and may result in infertility, pain, and bowel obstruction. Adherence to microsurgical principles and minimally invasive surgery may help to decrease postoperative adhesions. Some surgical barriers have been demonstrated to be effective for reducing postoperative adhesions, but there is no substantial evidence that their use improves fertility, decreases pain, or reduces the incidence of postoperative bowel obstruction. This document replaces the document, “Pathogenesis, consequences, and control of peritoneal adhesions in gynecologic surgery: a committee opinion,” last published in 2013.
Effect of remote cesarean delivery on complications during hysterectomy: a cohort study
2017, American Journal of Obstetrics and Gynecology
Cesarean delivery is performed frequently worldwide, and follow-up studies that report complications at subsequent surgery are warranted.
The aim of the study was to investigate the association between a previous abdominal delivery and complications during a subsequent hysterectomy and to estimate the fraction of complications that are driven by the presence of adhesions.
This was a longitudinal population-based register study of 25354 women who underwent a benign hysterectomy at 46 hospital units in Sweden 2000–2014.
Adhesions were found in 45% of the women with a history of cesarean delivery. Organ injury affected 2.2% of the women. The risk of organ injury (adjusted odds ratio, 1.74; 95% confidence interval, 1.41–2.15) and postoperative infection (adjusted odds ratio, 1.26; 95% confidence interval, 1.15–1.39) was increased with previous cesarean delivery, irrespective of whether adhesions were present or not. The direct effect on organ injury by a personal history of cesarean delivery was estimated to 73%, and only 27% was mediated by the presence of adhesions. Previous cesarean delivery was a predictor of bladder injury (adjusted odds ratio, 1.86; 95% confidence interval, 1.40–2.47) and bowel injury (adjusted odds ratio, 1.83; 95% confidence interval, 1.10–3.03), but not ureter injury. A personal history of other abdominal surgeries was associated with bowel injury (adjusted odds ratio, 2.27; 95% confidence interval, 1.37–3.78), and the presence of endometriosis increased the risk of ureter injury (adjusted odds ratio, 2.15; 95% confidence interval, 1.34–3.44).
Previous cesarean delivery is associated with an increased risk of complications during a subsequent hysterectomy, but the risk is only partly attributable to the presence of adhesions. Previous cesarean delivery and presence of endometriosis were major predisposing factors of organ injury at the time of the hysterectomy, whereas background and perioperative characteristics were of minor importance.
Small bowel volvulus around caesarian section scar adhesions
2017, Radiology Case Reports

View all citing articles on Scopus

^☆: Reprint requests: Togas Tulandi, MD, McGill Reproductive Center, Women’s Pavilion, 687 Pine Ave West, Montreal, Quebec, Canada H3A 1A1.

^☆☆: 6/1/94464

View full text

Adhesion-related small-bowel obstruction after gynecologic operations☆,☆☆

Abstract

Section snippets

Material and methods

Results

Comment

Am J Obstet Gynecol

Am J Obstet Gynecol

J Surg Res

Am J Obstet Gynecol

Intestinal obstruction due to adhesions: a review of 388 cases

Ann Surg

Intestinal obstruction following gynecologic surgery

Obstet Gynecol