Surgical Adhesions: Implications for Women s Health. Part Two of a Two-Part Series. Carol Burke, MSN, RNC-OB, APN

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2 NE Surgical Adhesions: Implications for Women s Health Part Two of a Two-Part Series Carol Burke, MSN, RNC-OB, APN

3 Objectives Upon completion of this activity, the learner will be able to: 1. Identify specific surgical precautions recommended to minimize the risk and extent of adhesion formation during surgery. 2. List adhesion-preventing agents for which there is sufficient evidence regarding effectiveness, risk and benefits, safety and indications for use. 3. Describe patient education related to the risk for adhesion formation following abdominal or pelvic surgery and subsequent adverse effects. Continuing Nursing Education (CNE) Credit A total of 1.5 contact hours may be earned as CNE credit for reading the complete two-part series on surgical adhesions, and for completing an online post-test and participant feedback form. To take the test and complete the participant feedback form, please visit awhonn.org. Certificates of completion will be issued on receipt of the completed participant feedback form and processing fees. AWHONN is accredited as a provider of continuing nursing education by the American Credentialing Center s Commission on Accreditation. Accredited status does not imply endorsement by AWHONN or ANCC of any commercial products displayed or discussed in conjunction with an educational activity. AWHONN also holds a California BRN number, California CNE provider #CEP580. This activity is supported by an educational grant from Genzyme. INTRODUCTION Adhesions are a common consequence of abdominal and pelvic surgery. Cesarean birth and hysterectomy are the two most common surgical procedures performed in the United States on reproductive-age women (Centers for Disease Control and Prevention [CDC], 2009). Intra-abdominal adhesions occur in 55 percent to 100 percent of patients with abdominal or pelvic surgery as a result from peritoneal trauma and aberrant wound healing processes (Liakakos, Thomakos, Fine, Dervenis, & Young, 2001; Lyell, 2011). Both laparotomy and laparoscopic procedures result in adhesion formation. Due to the significant morbidity associated with adhesion formation, great efforts have been made to alter the pathogenic process (described in part one of this series). These strategies may generally be described as (1) minimizing peritoneal injury during surgery, (2) reducing the local and inflammatory response, (3) inhibiting the coagulation cascade and promoting fibrinolysis and (4) using barriers for separation of surfaces at high risk for adhesion formation. Surgeons make individual judgments based on safety, perceived benefits and cost when deciding whether to use adhesion-reduction products. Clinical and cost evidence to reduce the burden of adhesion-related readmissions should also be considered. Part one of this series provided an overview of the pathogenesis, prevalence and adverse effects of adhesion formation. Part two discusses clinical approaches to preventing or reducing adhesions, including using meticulous surgical technique and physical barriers to decrease tissue apposition (tissue in close proximity) during the immediate postoperative period. REDUCTION AND PREVENTION STRATEGIES Meticulous Surgical Technique Surgical best practices to minimize peritoneal injury during surgery and subsequent adhesion formation are listed in Box 1 (Robertson & Lefebvre, 2010). Strict adherence to the principles of surgery including minimization of trauma to issue, tissue hydration, use of the least reactive sutures and meticulous control of bleeding is critical to minimize postoperative adhesions. For both obstetric and gynecologic surgery, delicate handling of tissues will help to avoid tissue trauma. But with every surgery, a certain amount of tissue injury will occur. Carol Burke, MSN, RNC-OB, APN, is a perinatal clinical nurse specialist at Northwestern Memorial Hospital, Prentice Women s Hospital in Chicago, IL. The author and planners of this activity report no conflicts of interest or relevant financial relationships. There is no discussion of off-label drug or device use in this article. This activity is supported by an educational grant from Genzyme. Address correspondence to cburke@nmh.org. Abstract: Adhesions are a common consequence of abdominal and pelvic surgery, but there is a low level of awareness about adhesions and adhesions prevention among both health care professionals and consumers. Strategies to try to reduce or prevent the formation of postsurgical adhesions include meticulous surgical technique and use of physical separation barriers. Nurses can play a role in educating patients about the risks and implications of adhesions. DOI: /j X x Keywords: adhesions adhesions prevention gynecologic surgery S14 SUPPLEMENT February March 2012

4 BOX 1 METICULOUS SURGICAL TECHNIQUE TO REDUCE ADHESION FORMATION Handle tissues delicately Achieve optimal hemostasis Minimize or avoid the introduction of foreign material Use powder-free gloves Minimal use of suture material Excision of abnormal tissues Precise alignment and approximation of tissue planes Pelvic lavage Prefer minimally invasive approaches Minimize the risk of infection Source: Robertson & Lefebvre (2010) Adhesions are not always preventable, despite meticulous surgical technique (Awonuga, Saed, & Diamond, 2009). Before abdominal wall closure, it is advisable to perform careful, though not excessive, hemostasis and repeated irrigation with saline and Ringer solutions. Use of humidified and warmed gases with laparoscopy will reduce the risk of mesothelial injury (Brüggmann et al., 2010). Laparotomy vs. Laparoscopy There are comparisons to be made between laparotomy (open procedure) and laparoscopy using microsurgery. Adhesions occur after intra-abdominal and pelvic surgery whether it is performed through a laparotomy incision or via the laparoscope (Adamson, 2011). Laparotomy requires more tissue disruption and dissection, requiring more foreign material, and more time and risk of exposing the intra-abdominal area to air that can lead to drying of the tissues. Laparoscopic surgery has many advantages. Laparoscopic surgical procedures have been associated with fewer postoperative adhesions because of decreased tissue drying, less pain, shorter hospitalization and recovery times and lower cost than laparotomy (Adamson, 2011; Tulandi, 2000). When feasible, a laparoscopic surgery is preferred to an abdominal approach (Robertson & Lefebvre, 2010). Peritoneal Closure The parietal and visceral peritoneum is a clear membrane that lines the abdominal and pelvic cavities and organs within these cavities. During cesarean, the peritoneum is entered in order to expose the uterus. Following the disruption, mesothelial cells begin simultaneous repair; whether there is benefit in closing the parietal peritoneum in this circumstance has been debated with inconclusive results (Bamigboye & Hofmeyr, 2008; Bates & Shomento, 2011). Abdominal wound healing and adhesion formation has been the focus of intensive research (Munireddy, Kavalukas, & Barbul, 2010). There is a high incidence of pelvic adhesive disease after cesarean (Morales, Gordon, & Bates, 2007). Pregnancy related changes, including the presence of inflammatory cytokines and blood loss with cesarean, may contribute to adhesion formation (Lyell, Caughey, Hu, & Daniels, 2005). If the peritoneum is not closed, the enlarged uterus following delivery may disrupt the supportive matrix and result in adhesion formation to surrounding structures, including the fascia to the omentum and uterus (Lyell et al., 2005). Adhesion interference has been Tissue injury and an inflammatory response have been identified as instrumental in the organization of fibrin into adhesions found to significantly delay delivery with repeat cesarean leading to a potential negative impact on the neonate (Greenberg, Daniels, Blumenfeld, Caughey, & Lyell, 2011; Morales et al.). One study noted that parietal peritoneal closure during cesarean was associated with fewer dense and filmy intra-abdominal and pelvic adhesions by seven-fold at repeat cesarean delivery (Lyell et al.). The authors recommended considering closure of either the rectus muscle or peritoneum at primary cesarean (Lyell et al.). By contrast, a 2008 Cochrane review found there is evidence of benefit in short-term, immediate post-op outcomes and duration of surgery with non-closure of the peritoneum compared with routine closure (Bamigboye & Hofmeyr, 2008). Shorter duration of the operation may have clinical benefits in terms of reduced risk of infection and post-op complications, such as paralytic ileus due to decreased exposure of the peritoneal cavity. Using fewer sutures would reduce cost. There is also evidence supporting the theory that suturing the peritoneum increases the risk of adhesions (Komoto et al., 2006). The data in the Cochrane review on long-term benefit and the impact of adhesions from peritoneal non-closure are viewed as inadequate to inform practice for cesarean birth (Bamigboye & Hofmeyr; Bates & Shomento, 2011). Adhesiolysis Adhesions, if present, usually need to be lysed during surgery CNE February March 2012 SUPPLEMENT S15

5 to perform the intended operation. The presence of adhesions makes surgery more hazardous because of the risk of injury to the bowel, bladder, blood vessels and ureters. Adhesions reform approximately 90 percent of the time following adhesiolysis and the procedure is sometimes viewed as self-defeating (Adamson, 2011). Removal of adhesions via laparoscopy to release the fallopian tubes and ovaries may benefit fertility in select patients Removal of adhesions via laparoscopy to release the fallopian tubes and ovaries may benefit fertility in select patients. Women with small amounts of filmy adhesions leading to interruption of tubal mobility over the ovary can benefit greatly from adhesiolysis with resulting pregnancy rates up to 70 percent (Adamson, 2011). As the extent and density of the adhesions increase, the chance of pregnancy success decreases. Physical separation of traumatized areas represents an important clinical strategy for adhesion prevention Reducing Local and Inflammatory Response Tissue injury and an inflammatory response have been identified as instrumental in the organization of fibrin into adhesions (Robertson & Lefebvre, 2010). Avoiding talcum powder on gloves and excessive suture material are advocated as means of preventing inflammation following surgery. Strict adherence to sterile technique will decrease the risk of bacterial infection. Corticosteroids, heparin, antihistamines, and nonsteroidal anti-inflammatories (NSAIDS) have all been used by various routes in an effort to decrease adhesion formation by separation of peritoneal surfaces. No clinical study has yet demonstrated a clear adhesion-reducing benefit of these substances. A meta-analysis did not show any evidence of a significant difference or a beneficial effect for steroids, and, in fact, steroids were associated with delayed wound healing (Metwally, Watson, Lilford, & Vanderkerchove, 2006). Inhibiting the Coagulation Cascade Adhesion formation results from a cascade of events and is regulated by a variety of cellular and humoral factors. Adhesions form when fibrinolysis is suppressed and fibrin persists. Fibrin is then infiltrated by fibroblasts, which organize into fibrin bands that form adhesions. NSAIDS have been considered to prevent postoperative pelvic adhesions by blocking the production of thromboxanes, which lead to the formation of adhesions. However, lack of adequate studies evaluating their efficacy has limited the clinical use (González-Quintero & Cruz-Pachano, 2009) Therefore, there is a need for better understanding of the peritoneal wound environment in order to design effective therapies to achieve optimal wound healing. Physical Separation Barriers Physical separation of traumatized areas represents an important clinical strategy for adhesion prevention. This strategy for adhesion prevention is based on the use of liquid or solid adhesion barriers to physically separate any injured tissue. The ideal adhesion barrier should lead to effective tissue separation, remain effective during the critical 7-day peritoneal healing period, be biodegradable, promote wound healing and not lead to an inflammatory response due to the presence of foreign material (Bates & Shomento, 2011; González-Quintero & Cruz-Pachano, 2009). Keeping the peritoneal surfaces apart during this time theoretically forces healing to occur only over the injured surfaces without adhesion development between adjacent tissue surfaces. Peritoneal adhesions remain a relevant clinical problem despite the currently available prophylactic barrier materials because the optimal material has not yet been found (Brochhausen, et al., 2011). Many of the devices that are currently available have been reported to have varying degrees of effectiveness in reducing or preventing adhesions. Hydroflotation and physical barrier products are used for postsurgical application with the intention of reducing or preventing adhesion formation. Hydroflotation Hydroflotation is the instillation of crystalloid or colloid solutions into the abdominal and pelvic cavity to separate organs and thereby decrease the risk of adhesion formation. In hydroflotation, absorbable intra peritoneal solutions are poured into the abdominal cavity prior to abdominal closure. Crystalloid solutions (Ringers lactate or normal saline) have been used without success as it is theorized that they are absorbed too quickly before fibrinolysis is complete. High molecular weight dextran-70 has also been used for hydroflotation. It was theorized that drawing fluid into the peritoneal cavity produces a flotation of pelvic structures. However, concerns are raised about excessive fluid shifts that may lead to cardiovascular compromise (González-Quintero & Cruz- Pachano, 2009). Another attempt at hydroflotation is the use of 4 percent icodextrin as a pharmacologic agent, approved by the FDA for use in laparoscopy. This fluid reservoir acts as a colloid osmotic agent and is retained in the peritoneal cavity for 3 to 4 days, S16 SUPPLEMENT February March 2012

6 decreasing adhesion formation by providing a temporary separation of peritoneal surfaces from each other until it is eliminated via the kidney (Brown et al., 2007). This product has been shown to slightly decrease adhesion formation when compared to lactated Ringer s solution. Treatment-related complications, including excessive edema of the labia, vulva and vagina, have been reported after use (Menzies, Pascual, & Walz, 2006). BARRIER PRODUCTS Barrier agents create a synthetic barrier between opposing pelvic structures during tissue healing. A main theoretical concern is that they could cause a foreign material reaction, thus contributing to adhesion formation. Evidence appears to reflect that this is not the case (González-Quintero & Cruz-Pachano, 2009). Oxidized Regenerated Cellulose Oxidized regenerated cellulose is FDA approved for laparotomy use. It is applied to organs to protect and separate them during the healing process. This product forms a gelatinous coating over the applied tissue, which is reabsorbed in about 2 to 4 weeks. This coating is designed to decrease the formation of fibrin bridges, which may lead to adhesion formation. Oxidized regenerated cellulose can be applied to injured surfaces following careful hemostasis. Moistening of the membrane prevents it from slipping off the intended organ. In a Cochrane analysis (Ahmad et al., 2008), researchers concluded that oxidized regenerated cellulose led to a reduction in the occurrence of pelvic adhesions after gynecological laparotomy. But caution is advised as concerns have been raised with this formulation because of an apparent ineffectiveness in the presence of blood (Ahmad et al.; Wiseman, Trout, Frandlin & Diamond, 1999). When hemostasis is not achieved prior to application, this product may aggravate rather than prevent adhesion formation (Ahmad et al.). Sodium Hyaluronic Acid and Carboxymethylcellulose Sodium hyaluronic acid and carboxymethylcellulose are FDAapproved agents for use in laparotomy. Hyaluronic acid is a naturally occurring polysaccharide found in many tissues in the human body. Carboxymethylcellulose is also a polysaccharide and a derivative of cellulose. Both are common components in pharmaceuticals, foods and cosmetics. When used together as a barrier product, these agents are designed to separate planes of tissue after surgery for 7 days. After a week, the product turns to a gel and is eventually reabsorbed and eliminated by the body. Unlike oxidized regenerated cellulose, there is no evidence that the presence of blood enhances the development of adhesions when this product is used. This agent is perhaps the most widely studied adhesion barrier, with more than 20 published studies among more than 4,600 patients (Ahmad et al., 2008; Diamond & The Seprafilm Adhesion Study Group, 1996). In a prospective, double-blind, multicenter, randomized, controlled study, the extent of adhesions was reduced in myomectomy patients evaluated by second-look laparoscopy for adhesion incidence and severity. Expanded Polytetrafluoroethylene Expanded polytetrafluoroethylene has a structure that prevents cellular growth. It is non-inflammatory and non-absorbable. It does not adhere to tissue and must be sutured in place. Data on clinical efficacy exist but are limited. In a trial of 27 women, the Myomectomy Adhesion Multicenter Study Group reported a significant reduction in adhesion formation to the uterine surface following its application as compared with controls (Myomectomy Adhesion Multicenter Study Group, 1995). It has been suggested that the membrane can probably be left in place indefinitely and does not require removal (González-Quintero & Cruz-Pachano, 2009). Cross-linked Esters of Hyaluronic Acid A viscous gel composed of cross-linked esters of hyaluronic acid has been shown to reduce formation of intra-abdominal adhesions following laparoscopic surgery (Mais, Bracco, Litta, Gargiulo, & Melis, 2006). In a prospective, randomized, controlled multicenter study a total of 45 women were enrolled with 24 randomized to the treatment group and 21 to the control group. Spray application of the adhesion barrier allowed adherence to tissue and was found to significantly decrease adhesion formation in these women undergoing myomectomy (Mettler, Audebert, Lehmann-Willenbrock, Schieve, & Jacobs, 2003). PATIENT EDUCATION CNE Women considering gynecologic surgery may not know or understand the risks and benefits of laparoscopy versus laparotomy In both gynecologic and obstetric surgery, it is generally agreed that the use of the least invasive method is preferred, if a choice is involved, while considering the patient and anticipated pathology. Women considering gynecologic surgery may not know or understand the risks and benefits of laparoscopy versus laparotomy. Physician preferences may also be a factor. Understanding the benefits of minimally invasive techniques and access to organs will help women understand the process. VBAC Trends Liability pressures, hospital administrative restrictions and physician and patient preference have affected vaginal birth after cesarean (VBAC) and cesarean birth trends. By 2007, February March 2012 SUPPLEMENT S17

7 almost 91 percent of low-risk women with a prior cesarean had a repeat cesarean birth (Lyell et al., 2011). Lack of access to hospital support during a planned VBAC has led to a decrease in the availability of this option for many women. Some providers do not offer the option of trial of labor after cesarean to their patients. The American College of Obstetricians and Gynecologists (ACOG, 2010) reports the risk of uterine rupture or dehiscence is approximately 4 percent to 9 percent of classic scars and 0.7 percent to 1.5 percent of lowtransverse scars. The National Institutes of Health (NIH) Consensus Development Conference on vaginal birth after cesarean recommended that a trial of labor after cesarean is a reasonable Patient education is instrumental in patient autonomy and decisionmaking, and its value cannot be underestimated, especially in a discussion about adhesion formation option for many women with a previous cesarean birth and that maternity care providers and health care organizations should decrease or eliminate barriers to a trial of labor after cesarean (Cunningham et al., 2010). Women should be informed of the risks associated with repeat cesarean, including the increased incidence of adhesion formation as well as the increased incidence of placenta previa and abnormal placentation that can occur in subsequent pregnancies. Women at high risk for adhesion formation may benefit from the use of adhesion barrier products. Women should ask their provider about potential use of these materials. The surgeon s preference as well as the cost and availability of these products impact their use. Patient education is instrumental in patient autonomy and decision-making, and its value cannot be underestimated, especially in a discussion about adhesion formation. NURSING IMPLICATIONS Nurses have both a challenge and an opportunity in providing patient education and creating awareness within the workplace regarding the risk of adhesion formation. The issue of adhesion formation is usually overlooked in the counseling and consent process (Schreinemacher, 2010). Therefore, patient education resources provided to women should include the potential risk of chronic pain, infertility and small bowel disorders, especially because the risk for visceral ischemia and obstruction continues for years following each procedure. Patient education should also state that the risk of adhesion development increases with every abdominal or pelvic surgery. Each surgery needs to be carefully considered and the risk/ benefit balance thoroughly discussed with a woman by her surgeon. Circulating and first assistant nurses working within the surgical arena play a vital role in establishing a surgical environment that minimizes the potential for adhesion formation. Broadly, they are responsible for upholding the standards of asepsis, and they can promote the use of non-powdered gloves, understand the impact of aggressive tissue handling on adhesion formation and support the use of adhesion barrier materials, as appropriate. RN First Assistant Role Nurses working as first assistants have a role in the following meticulous surgical techniques: (Association of perioperative Registered Nurses, 2007) Maintain and monitor the sterile field. Maintain tissue hydration by occasional application of saline solution to minimize drying of mesothelial surfaces, as directed by the surgeon. Apply pressure to maintain hemostasis, as indicated. Avoid overzealous use of suction, which can lead to tissue injury. Minimize the use of suture, instrumentation and foreign material placed intraoperatively. Coagulate bleeding vessels with careful use of electrosurgical devices, as directed. Assist with irrigation of the abdominal cavity with normal saline to remove any residual blood clots or pooling of blood within the abdominal cavity, as directed. Preferentially use latex-free and powder-free gloves. With laparoscopy, use minimal insufflation pressure. RN Circulator Role With both gynecologic and obstetric surgery, the nurse as circulator is responsible for flow and efficiency in the operating room and promoting an environment that minimizes the risk of infection. Close scrutiny of the sterile field is critical because intra-abdominal infection can lead to further inflammation and adhesion development. The woman s risk for microbial contamination should be evaluated based on her history, labor course and current physiologic data. ACOG recommends that women having cesarean birth receive antibiotics within 60 minutes of surgery unless a woman has been receiving appropriate antibiotics prior to the procedure (ACOG, 2010a). Optimal organization of the operating room, assurance of appropriate equipment and staffing readiness will assure coordinated, efficient support for the case. If requested by the surgeon, adhesion reduction materials are secured prior to the S18 SUPPLEMENT February March 2012

8 case. Ready supplies and control of the environment will help decrease the length of the case. A surgical time greater than 38 minutes has been correlated with an increase in surgical site infection rates in obese women undergoing cesarean (Opoien, Valbo, Grinde-Andersen, & Walberg, 2007). CONCLUSION Because adhesions are common sequelae of abdominal and pelvic surgeries, best practice dictates that strategies to prevent or minimize their development are needed. Intra-abdominal and pelvic adhesions are a major cause of morbidity following both laparoscopy and laparotomy. A laparoscopic surgical approach is preferable to an abdominal approach because it is associated with fewer postoperative adhesions and a vaginal or laparoscopic hysterectomy is preferable to an abdominal hysterectomy (Mettler, 2003). The low level of awareness of adhesions among health care professionals and consumers contrasts with the likelihood of adhesion formation following obstetric and gynecologic surgical procedures. Surgeons may rely on meticulous surgical technique alone as their anti-adhesion strategy, despite the increasing evidence of the efficacy of anti-adhesion agents. Physicians generally have marginal acceptance of adhesionreducing products evidenced by a low usage of adhesion barriers. At most, the use is 5 percent during appropriate procedures (Wilson, 2007). Because of their infrequent use, it is often difficult to arrange for these products to be available possibly because there is no provision for their reimbursement under the diagnosis-related groups system. Nonetheless, using a low-cost adhesion reduction product today with a 25 percent reduction in readmission would provide cost savings within the third year of use and save up to $50 million over the next 10 years (Wilson, 2007). Controversial study findings have led to a lack of consensus on the utilization of adhesion-reducing products and strategies. Insufficient evidence is the result of a limited number of studies, the relative small numbers of patients studied, the large variety of factors influencing adhesion development, and numerous scoring systems. There is a need for more awareness and high-quality research on strategies to limit or prevent adhesion formation in women requiring obstetric and gynecologic surgery. The need is all the more critical in view of the rising rate of both obstetric and gynecologic surgical procedures in the U.S. today. NWH REFERENCES Adamson G. D. (2011). The modern role of reproductive surgery. Clinical Obstetrics and Gynecology, 54, Ahmad, G., Duffy, J. M, Farquhar, C., Vail, P., Vanderkerchove, A. W., & Wiseman D. (2008). Barrier agents for adhesion prevention after gynecological surgery. 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9 Close scrutiny of the sterile field is critical because intra-abdominal infection can lead to further inflammation and adhesion development S20 SUPPLEMENT February March 2012

10 Komoto, Y., Shimoya, K., Shimizu, T., Kimura, T., Hayashi, S., Temma-Asano, K., Murata, Y. (2006). Prospective study of non-closure or closure of the peritoneum at cesarean delivery in 124 women: impact of prior peritoneal closure at primary cesarean on the interval time between first cesarean section and the next pregnancy and significant adhesion at second cesarean. Journal of Obstetrics and Gynaecology Research, 32, Liakakos, T., Thomakos, N., Fine, P. M., Dervenis, C., & Young, R. I. (2001). Peritoneal adhesions: etiology, pathophysiology and clinical significance. Recent advances in prevention and management. Digestive Surgery, 18, Lyell, D. J. (2011). Adhesions and perioperative complications of repeat cesarean delivery. American Journal of Obstetrics & Gynecology, 205, S11 S18. Lyell, D. J., Caughey, A. B., Hu, E., & Daniels, K. (2005). Peritoneal closure at primary cesarean delivery and adhesions. Obstetrics & Gynecology, 106, Mais, V., Bracco, G. L., Litta, P., Gargiulo, T., & Melis, G. B. (2006). Reduction of postoperative adhesions with an auto-crosslinked hyaluronan gel in gynecological laparoscopic surgery: a blinded, controlled, randomized, multicentre study. Human Reproduction, 21, Menzies, D., Pascual, M. H., & Walz, M. K. (2006). Use of Icodextrin 4% solution in the prevention of adhesion formation following general surgery: from the multicentre ARIEL Registry. Annals of The Royal College of Surgeons of England, 88, Mettler, L. (2003). Pelvic adhesions: laparoscopic approach. Annals of the New York Academy of Sciences, 997, Mettler, L., Audebert, A., Lehmann-Willenbrock, E., Schieve, K., & Jacobs, V. R. (2003) Prospective clinical trial of SprayGel as a barrier to adhesion formation: an interim analysis. The Journal of the American Association of Gynecologic Laparoscopists, 10, Metwally, M., Watson, A., Lilford, R., & Vanderkerchove, P. (2006). Fluid and pharmacological agents for adhesion prevention after gynaecological surgery. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD Morales, K. J., Gordon, M. C., & Bates, G. B. (2007). Postcesarean delivery adhesions associated with delayed delivery of infant. American Journal of Obstetrics & Gynecology, 196, e1 461.e6. Munireddy, S., Kavalukas, S. L., & Barbul, A. (2010). Intra-abdominal healing: gastrointestinal tract and adhesions. Surgical Clinics of North America, 90, Opoien, H. K., Valbo, A., Grinde-Andersen, A., & Walberg, M. (2007). Post-cesarean surgical site infections according to CDC standards: Rates and risk factors. A prospective cohort study. Acta Obstetricia et Gynecologica Scandinavica, 86, Robertson, D., & Lefebvre, G. (2010). Adhesion prevention in gynaecological surgery. SOGN Clinical Practice Guideline No Journal of Obstetrics and Gynaecology Canada, June, Schreinemacher, M. H. (2010). Adhesion awareness: a national survey of surgeons. World Journal of Surgery, 34, The Myomectomy Adhesion Multicenter Study Group. (1995). An expanded polytetrafluoroethylene barrier (Gore-Tex Surgical Membrane) reduces post-myomectomy adhesion formation. Fertility & Sterility, 63, Tulandi, T. (2000). Bowel obstruction after gynecologic operations. Contemporary OB/GYN, 45, 122. Wilson, M. S. (2007). Practicalities and costs of adhesions. The Association of Coloproctology of Great Britain and Ireland, 9, Wiseman, D. M., Trout, J. R., Frandlin, R. R., & Diamond, M. P. (1999). Meta-analysis of the safety and efficacy of an adhesion barrier (Interceed TC7) in laparotomy. Journal of Reproductive Medicine, 44, CNE February March 2012 SUPPLEMENT S21