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].

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

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.

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.