Abstract

PIP: This literature review attempts to enumerate possible etiologies of postoperative peritoneal adhesions as well as to suggest preventitive measures. The theory that the cause of adhesions was development of fibrous tissue resulting from the destruction of serosa at surgery is discussed, but the author points out that numerous experimental and clinical experiences point to a more complicated etiology. Serosal defects do heal, and not necessarily through adhesion formation, as shown in experimental animals; therefore a new notion of the process of peritoneal repair was advanced which, simply stated, sees free-floating macrophages as the principal source of new serosa. So other areas and tissue types are probably the source of adhesions. The discussion of these other etiological factors include ischemic tissue as a source of adhesions and foreign body causes of granuloma and adhesions (primarily surgical glove powder). In terms of adhesion prevention, many approaches have been tried from using prophylactic agents to inhibit the formation of fibrin in peritoneal exudate (agents such as sodium citrate, heparin, and anticoagulants), use of enzymes and fibrinolytic agents, such as streptokinase and hyaluronidase, to introduction of inert polysiloxanes for prevention at the time of surgery. The use of cortisone, which has been reported to have good results, is also discussed. Finally, the control of distribution of adhesions by plicative techniques is enumerated. With the up-to-date knowledge that adhesions which develop after abdominal operations represent a vascular response by surrounding structures to the stimulus of ischemic tissue or foreign material within the peritoneal cavity, rather than a healing mechanism for serosal defects, a rational approach toward operating on adhesions is presented; this technique requires scrupulous surgical procedure, freedom from foreign body intrusion, the leaving open of serosal defects (rather than pulling together under tension), and, frequently, attempts to surgically ensure that the inevitable adhesion formation occurs in areas which are innocuous to adjacent structures.