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Background: postoperative adhesions are a significant health problem with major implications on quality of life and health care expenses. The purpose of this review was to investigate the efficacy of preventative techniques and adhesion barriers and identify those patients who are most likely to benefit from these strategies., Methods: the National Library of Medicine, Medline, Embase, and Cochrane databases were used to identify articles related to postoperative adhesions., Results: ileal pouch-anal anastomosis, open colectomy, and open gynecologic procedures are associated with the highest risk of adhesive small-bowel obstruction (class I evidence). Based on expert opinion (class III evidence) intraoperative preventative principles, such as meticulous hemostasis, avoiding excessive tissue dissection and ischemia, and reducing remaining surgical material have been published. Laparoscopic techniques, with the exception of appendicitis, result in fewer adhesions than open techniques (class I evidence). Available bioabsorbable barriers, such as hyaluronic acid/carboxymethylcellulose and icodextrin 4% solution, have been shown to reduce adhesions (class I evidence)., Conclusions: postoperative adhesions are a significant health problem with major implications on quality of life and health care. General intraoperative preventative techniques, laparoscopic techniques, and the use of bioabsorbable mechanical barriers in the appropriate cases reduce the incidence and severity of peritoneal adhesions., (2011 Elsevier Inc. All rights reserved.)

Background: Despite its advantages, iatrogenic gallbladder perforation with resultant spillage of bile and gallstones is not uncommon during laparoscopic cholecystectomy. Although this is not generally considered a significant problem, spilled gallstones may cause problems even years after the operation. Hyaluronic acid has been introduced into clinical practice and successfully used to decrease postoperative adhesions after abdominopelvic surgery. In this study, we investigated the effectiveness of a hyaluronic-acid derivative in preventing complications related to spilled gallstones and bile leakage in an experimental study., Methods: In 60 Wistar-Albino rats, an upper-midline abdominal incision was made, and the rats were divided into 5 groups (n = 12 in each group) as follows: group I = laparotomy alone; group II = laparotomy and intraperitoneal instillation of sterile bile plus gallstones; group III = laparotomy and instillation of infected bile and gallstones; group IV = laparotomy and instillation of sterile bile and gallstones plus hyaluronic acid; and group V = laparotomy and instillation of infected bile and gallstones plus HA. A second-look laparotomy was performed on postoperative day 10 to assess intraperitoneal adhesions and abscesses. Intraperitoneal adhesions were scored, and breaking strengths of gallstones were measured., Results: Adhesion scores were significantly higher in groups II and III compared with groups I, IV, and V (P < 0.05). There was a statistically significant decrease in breaking strengths and adhesion scores in groups IV and V compared with groups II and III (P < 0.001)., Conclusions: Whether infected or not, spilled gallstones and bile caused postoperative adhesions in this experimental model. An HA derivative significantly prevented postoperative adhesions and decreased breaking strengths. Further clinical studies are needed to validate these findings., (Copyright 2004 Excerpta Medica, Inc.)

Background: Depression of fibrinolysis is known to be a major mechanism for postoperative adhesion formation. Because aprotinin inhibits fibrinolysis it may lead to an increase in adhesion formation whereas its anti-inflammatory effects may lead to a decrease in adhesion formation. Our aim is to clarify conflicting results in previous literature., Methods: Basal levels of intestinal hydroxyproline (OHP) content and local fibrinolytic activity (LFA) were determined using naive groups. In the experiment groups, adhesions were created by scraping and creating a transient ischemia of a segment of terminal ileum. Group I and II rats were injected subcutaneous (s.c.) normal saline (NS) for 3 days and single dose intraperitoneal (i.p.) NS, respectively. Group III and IV rats were injected s.c. aprotinin for 3 days and single dose i.p. aprotinin, respectively. Group V rats were injected intramuscular methylprednisolone (MP) for 3 days. LFA and OHP levels were determined on the second and fifth postoperative days. The severity of adhesion formation was graded on the fifth day., Results: Aprotinin decreased both the severity of adhesions and OHP levels whereas MP decreased only the severity of adhesions. There was an early depression of LFA at the second day in both NS and MP groups increasing to basal levels at the fifth day. OHP levels showed significant correlation with adhesion severity., Conclusion: Results showed that aprotinin decreased intra-abdominal adhesion formation probably by preventing early depression of LFA.

The effect of bile and gallstones on the peritoneal cavity was evaluated in an experimental animal study. Ninety male Sprague-Dawley rats were randomly allocated to one of six groups (n = 15). Groups 1 to 3 received an intraperitoneal injection (2 mL) of saline, sterile bile, and infected bile, respectively. Groups 4 to 6 underwent a lower midline abdominal incision (3 to 5 mm). In groups 4 and 5, a single gallstone (< 3 mm diameter) was placed in the right upper quadrant and, after closure of the wound, the animals were injected with sterile bile and infected bile, respectively. Group 6 animals underwent laparotomy alone, followed by injection of sterile saline (2 mm). All animals were killed at 4 weeks and the peritoneal cavity was carefully examined. No intra-abdominal lesions were noted in groups 1 to 3. Adhesions were noted in 11 (73%) and 10 (67%) animals of groups 4 and 5, respectively. Two intra-abdominal abscesses were noted in group 4 animals. No intra-abdominal lesions were noted in any group 6 animals. This study suggests that bile in combination with gallstones in the peritoneal cavity is associated with an increased risk of intra-abdominal adhesion formation and possible abscess formation, and that every attempt should be made to retrieve stones lost during cholecystectomy.

The effect of aprotinin on the clinical and pathologic course of experimentally induced peritonitis in the rat was studied. Peritonitis was induced in 40 rats by creating a closed ileal loop 4 cm long 5 cm from the ileocecal valve. The rats were divided into two groups of 20 rats each. Group 1 served as a control group, whereas each animal in Group 2 received a bolus dose of aprotinin (10 ml) intraperitoneally immediately after closing the laparotomy. In the aprotinin-treated group, survival was drastically increased (p less than 0.01) and formation of adhesions and abscesses was considerably reduced. The results of peritoneal cultures showed a decreased incidence of Escherichia coli and Clostridia in the aprotinin-treated group. We conclude that the administration of aprotinin significantly prolongs the survival time of animals with peritonitis and reduces the development of adhesions and abscesses in the peritoneal cavity. This beneficial effect can be attributed to decreased fibrinogen deposits within the peritoneal cavity and the stabilization of the organism after bacterial shock. Thus, bacteria were more susceptible to cellular and noncellular clearing mechanisms.