Postoperative Adhesive Obstructions

Adhesions (A) can form within the peritoneal cavity after abdominal surgery, especially if there is an underlying inflammatory condition such as appendicitis (B) or inflammatory bowel disease. The incidence of adhesive intestinal obstruction following a laparotomy is approximately 2%. Most adhesive obstructions occur within 3 months of the laparotomy, and 80% occur within 2 years. Adhesive obstructions tend to be more common in children than in adults.

The patient presents with abdominal cramps, nausea, vomiting, abdominal distension, and increased bowel sounds. In the early postoperative period, it may be difficult to distinguish an adhesive obstruction from a paralytic ileus. The presence of abdominal cramps and increased bowel sounds favors the diagnosis of adhesive obstruction.

Most adhesive obstructions resolve with nasogastric decompression and intravenous fluids. Surgery is indicated if the patient does not improve significantly in 6 to 12 hours. Factors that favor early operation include severe pain, localized guarding or tenderness, fever, tachycardia, and leukocytosis. Give antibiotics before surgery to reduce the risk of postoperative infection. All adhesions should be lysed during the procedure.

The following measures can reduce the incidence of postoperative adhesions:

• Gentle handling of tissues during surgery.

• Avoidance of excessive use of dry pads and sponges.

• Minimal use of foreign materials (eg, excessively long sutures).

• Avoidance of mass ligatures of the omentum or the mesentery.

• Proper lavage of residual blood from the abdomen.

• Use of laparoscopic surgery.