A European survey on awareness of post-surgical adhesions among gynaecological surgeons
© The Author(s) 2013
Received: 8 October 2013
Accepted: 13 November 2013
Published: 27 November 2013
The present survey was conducted among gynaecological surgeons from several European countries to assess the actual knowledge and practice related to post-surgical adhesions and measures for reduction. From September 1, 2012 to February 6, 2013, gynaecological surgeons were invited to answer an 18-item online questionnaire accessible through the ESGE website. This questionnaire contained eight questions on care settings and surgical practice and ten questions on adhesion formation and adhesion reduction. Four hundred fourteen surgeons participated; 70.8 % agreed that adhesions are a source of major morbidity. About half of them declared that adhesions represented an important part of their daily medical and surgical work. About two thirds informed their patients about the risk of adhesion. Most cited causes of adhesions were abdominal infections and extensive tissue trauma, and endometriosis and myomectomy surgery. Fewer surgeons expected adhesion formation after laparoscopy (18.9 %) than after laparotomy (40.8 %); 60 % knew the surgical techniques recommended to reduce adhesions; only 44.3 % used adhesion-reduction agents on a regular basis. This survey gives a broad picture of adhesion awareness amongst European gynaecological surgeons, mainly from Germany and the UK. The participants had a good knowledge of factors causing adhesions. Knowledge of surgical techniques recommended and use of anti-adhesion agents developed to reduce adhesions need to be improved.
Post-surgical adhesions—abnormal fibrous connections developing between the peritoneum and organs as a sequel to surgical trauma—are the most frequent complication of abdominal surgery and may represent one of the greatest unmet medical needs of the moment .
Yet, many surgeons are still not aware of the extent of the problem and its serious consequences, such as chronic pelvic pain and small bowel obstruction. In addition, post-surgical adhesions are a frequent cause of dyspareunia and secondary infertility.
In a previous survey conducted among gynaecological surgeons in German hospitals, adhesions were believed to develop in 15 % of cases after laparoscopy and 40 % after laparoscopy .
In symptomatic patients, removal of post-surgical adhesions requires a new surgical intervention (adhesiolysis). However, adhesiolysis is often followed by adhesion reformation. In this situation, earlier precautions aiming to prevent post-surgical adhesions are of paramount importance.
Developments in adhesion-reduction strategies and new agents now offer a realistic possibility of reducing the risk of adhesions forming and, thus, may improve the outcomes for patients and the associated onward burden.
Based on the fact that for an adhesion to form, there must be a prolonged contact between two areas of injury, two measures are currently recommended to minimise post-surgical adhesions: good surgical practice with minimal tissue trauma, and in addition, anti-adhesion agents used intra-operatively to minimise contact between injured parts of the peritoneum and an adjacent organ . Both measures aim to reduce the abnormal healing process that results in the formation of adhesions.
In this context, the actual knowledge and practice of gynaecological surgeons with regard to this complication of their interventions was assessed in several European countries. A survey was conducted in order to document the awareness of the risk of post-surgical adhesions amongst gynaecological surgeons, the knowledge of measures to be taken to minimise this complication of surgery, the surgical procedures likely to cause extensive adhesions, the information given to the patients about the risk of post-surgical adhesions during the consenting process, and subsequently the actual practice regarding the prevention of adhesions.
Gynaecological surgeons were recruited through the micro-website dedicated to post-surgical adhesions developed by the European Society for Gynaecological Endoscopy (ESGE) (http://www.esge.org/index.php?option=com_surveyforce&view=survey&Itemid=101). Both members and non-members of the ESGE could participate.
Website visitors were invited to fill in an 18-item online questionnaire (Appendix). On top of the questionnaire, the micro-website featured a printable information leaflet for patients about the risk of adhesions and a pictorial version of the ESGE expert consensus position on the prevention of post-surgical adhesions .
No financial incentives were proposed to the survey participants.
Due to the nature of the survey, the statistics were purely descriptive and expressed in percentages. Means and standard deviations, medians, minimum, and maximum were calculated where applicable. These calculations were not corrected for missing data.
Between September 1, 2012 and February 6, 2013, 233 gynaecological surgeons completed the whole questionnaire; another 181 participated in the survey but left at least one question unanswered.
Out of the 414 participants, 356 (86 %) downloaded the ESGE expert consensus position paper on adhesions.
Care settings and levels of activity
Mean and median numbers of interventions performed in 2010 in the gynaecology departments of the survey respondents (all participating countries)
Mean ± SD
1,213 ± 1,719
606 ± 710
389 ± 1,033
Summary of the number of surgical interventions performed in 2010 per hospital type: Germany and UK data
Type of hospital
Percentage of participants providing data on number of interventions % (n/N)
Laparotomies mean number ± SD
Laparoscopies mean number ± SD
Vaginal route mean number ± SD
1,236.7 ± 1,344.8
1,624.7 ± 1,730.0
998.7 ± 1,390.2
1,649.4 ± 1,086.6
827.6 ± 512.9
437.4 ± 333.2
409.5 ± 302.2
750.0 ± 589.7
1,518.2 ± 1,647.2
622.7 ± 562.7
265.9 ± 208.6
780.3 ± 819.8
383.1 ± 796.4
1,155.8 ± 1,214.1
1,192.7 ± 1,425.4
748.3 ± 1,163.7
1,200.0 ± 1,131.4
Selected results of the present survey, presented after Hackethal et al 
% of participants
Adhesions considered as a major source of morbidity
Adhesions considered as an important part of daily medical work
Adhesions considered as an important part of daily surgical work
Estimated incidence of adhesions post-laparotomy
Estimated incidence of adhesions post-laparoscopy
Patients informed of risk of adhesions during consenting
Regular use of anti-adhesion agents
Anti-adhesion agents considered as cost-effective
Anti-adhesion agents considered as too expensive
Anti-adhesion agents considered as insufficiently refunded
Consider themselves as well informed about adhesions
Source of adhesion knowledge
Discussions with colleagues
Continuous medical education
Surgical procedures leading to intra-abdominal adhesion formation
The type of surgery in benign conditions leading to intra-abdominal adhesions with the estimated likelihood on a scale from 0 (unlikely) to 4 (highly likely)
Type of surgery
Median score ± SD of 5-point Likert rating scale
3.6 ± 0.6
2.8 ± 0.8
3.4 ± 0.7
2.6 ± 0.9
3.3 ± 0.7
2.5 ± 0.9
2.9 ± 0.8
2.6 ± 0.8
3.1 ± 0.6
2.0 ± 0.7
2.2 ± 0.8
2.5 ± 0.8
Among the different gynaecological operations, endometriosis surgery and myomectomy were thought to be the most likely to be associated with adhesions (Table 4). The risk was considered low with caesarean section and only occasionally associated with ectopic pregnancy, single port, and NOTES.
Considerations regarding surgical adhesion induction
Parameters influencing adhesion formation and the estimated likelihood on a scale from 0 (unlikely) to 4 (highly likely)
Median score ± SD of five-point Likert rating scale
Infections within abdomen
3.7 ± 0.7
Extensive tissue trauma
3.7 ± 0.6
3.6 ± 0.8
3.6 ± 0.6
Foreign body incompatibility
3.2 ± 1.0
Quantity of sutures/staples/meshes
3.2 ± 0.9
Blood in abdomen
3.2 ± 0.9
3.2 ± 0.9
Chronic inflammatory bowel diseases
3.1 ± 1.0
Affinity to reduce wound healing
2.8 ± 0.9
Virtually all the gynaecological surgeons (94.8 % of 238 responders) considered that good surgical practice was important to prevent post-surgical adhesions. They were 60.5 and 55.3 %, respectively, to consider antiadhesive barriers and peritoneal conditioning as important.
Indications for surgical adhesiolysis
The main reasons for adhesioysis were symptoms (95.0 % of the responders), infertility (93.7 %), young age (73.5 %), and previous surgery (68.9 %); 53.4 % of the responders declared that adhesiolysis was performed in all patients.
Awareness of anti-adhesion agents
Summary of different adhesion prophylaxis products, knowledge of their existence, use, and importance rated on a scale from 0 (do not know this agent) to 2 (used it within the last 6 months)
Adhesion prophylaxis products
Known (% of participants)
Used (% of participants)
1.3 ± 0.6
Adept/Icodextrin 4 %
1.1 ± 0.7
1.0 ± 0.7
0.9 ± 0.7
0.9 ± 0.7
0.7 ± 0.6
0.8 ± 0.6
0.6 ± 0.6
For 77.5 % of 236 responders, adhesion prevention was deemed cost-effective because it eliminates further adhesion-related interventions. However, a majority declared that antiadhesive barriers are too expensive and insufficiently refunded by health insurance systems (71.6 and 75.8 %, respectively).
More than 60 % of the survey participants estimated they were adequately informed about the pathogenesis of adhesions and the techniques recommended and agents proposed to prevent adhesions.
Table 3 indicates the relative importance of sources of this knowledge.
Intraoperative adhesion assessment
The criteria useful for a classification of the risk of adhesions in routine practice were the area coverage for 95.3 % of the 236 responders, the location for 93.2 %, the macroscopic evaluation for 92.4 %, the organs involved for 91.5 %, and the lysis characteristics for 79.7 %.
This survey reflects a strong interest of participating European gynaecological surgeons in post-surgical adhesions and their prevention measures. More than 90 % of participants declared their awareness on adhesions and over 95 % agreed that good surgical practice may reduce the formation of adhesions. In line with conventional knowledge, they were a majority to consider that laparoscopic interventions are associated with a much lower incidence of adhesions than laparatomic interventions, although strong evidence supporting this assertion is lacking.
The survey participants had a good knowledge on factors associated with a high risk of post-surgical adhesion formation, similar to those quoted in the literature . Surgery for endometriosis was thought to be majorly associated with the formation of adhesions, followed by myomectomy, adhesiolysis, and adnexial surgery. These results were independent of the type of surgical approach, laparotomy or laparoscopy. However, the assumption that laparoscopic adnexal surgery was associated only occasionally with a limited risk of adhesion formation, would need to be confirmed by a wider scale study.
Most of our data are in agreement with those of a previous survey performed in 2010 among heads of gynaecological departments in Germany (Table 3) . In particular, the estimated risks of post-surgical adhesions are similar in both surveys and confirm that laparoscopic procedures are commonly believed to be less adhesiogenic and cause fewer de novo adhesions compared to open surgery . However, for complex laparoscopic procedures, the comparative risk of adhesion-related complications following open and laparoscopic gynaecological surgery is similar [5, 10].
The rate of information about post-surgical adhesions given to the patients (Table 3) was markedly lower in our survey than in the Hackethal survey . Conversely, we report here a more frequent use of anti-adhesion agents (44.3 vs 22.0 %). Elucidating whether these differences are linked to the mode of recruitment of the two surveys (open to all gynaecological surgeons visiting the ESGE website or through a direct contact with the heads of gynaecological departments in Germany) is beyond the scope of the present work.
The data presented here suggest that efforts should be made to increase awareness of the risk of post-surgical adhesions and knowledge of the preventive measures. About one third of surgeons considered themselves as not adequately informed about the pathogenesis of adhesions and the preventive measures. Consistent with this finding, about 40 % ignored the existence of one or more of the antiadhesive barriers currently marketed and utilization of these agents was clearly sub-optimal.
Furthermore, we noted a distinct discrepancy between the knowledge of the existence of adhesion prophylaxis products of nearly more than half of the respondents (ranging from 48.3 to 63.8 % )compared to low percentage of participants routinely using barriers (ranging from 4.6 to 38.2 % regarding the usage in the last 6 months). Some products such as Seprafilm ® had an inverse ratio with the highest awareness (63.8 %) compared to low routine usage (only 4.6 %). In addition, barriers such as Icodextrin were rated as important by a large number of participants, despite the scientific evidence.
This could be explained by contortioned perception due to lack of awareness of scientific sources such as the ESGE consensus paper .
The fact that lactated Ringer’s solution was considered as the most frequently used prevention method and ranked as most important could be explained by cost-driven considerations due to a lack of reimbursement as well clearly shows the need for evidence based education.
There is also a need for improvement of patient information and consenting about the risk of post-surgical adhesions. It has been shown in a population of patients from Germany and the UK that less than 50 % were aware of adhesions and even fewer were informed about the possible complications of adhesions; 46 % of patients cited the surgeon lack of knowledge as the reason for not informing them . Comparatively, the higher rate of patient information reported by our survey participants seems encouraging—but might be due to a selection bias: the majority of surgeons that volunteered to answer our questionnaire had probably a strong interest in adhesion-related issues.
Cost considerations may contribute to the limited regular use of antiadhesive barriers. These survey participants considered such barriers as too expensive and insufficiently refunded by health systems. These opinions were already expressed by the German survey participants . Thus, regarding the economical impact of intraoperative utilization of antiadhesive barriers, there seems to be a gap between the opinion of gynaecological surgeons and that of decision-makers who shape national public health policies. While the former are sensitive to the potential long-term benefits of antiadhesive barriers, the latter are most probably motivated by immediate reduction of healthcare-related expenses. Furthermore, the evidence for the use of antiadhesion barriers is limited. Though, in experimental and clinical studies, adhesion reduction works in reducing adhesions, there is a lack of efficacy in terms of clinical benefits (i.e. reduction of pain and improved fertility).
Limitations of this survey should be taken into account when interpreting its results.
As all surveys, this one was based on self-reporting of information by the participants and the data were not censored. Many participants did not answer all questions and no methodology was planned to recover the missing data. Also, whether our survey describes accurately the opinions of the whole community of European gynaecological surgeons is questionable. However, the wide variation in the number of interventions performed would suggest that the participants were at least representative of the different levels of experience of European gynaecologists in current practice.
In summary, the present survey gives a broad picture of awareness of post-surgical adhesions and their reduction among European gynaecological surgeons. Results are generally encouraging but emphasize the necessity to continue educational activities in order to optimize the rate of practitioners applying the measures recommended to reduce this common complication of gynaecological surgery. In particular, a widespread dissemination of the field guidelines on the prevention of adhesions in gynaecological surgery published in 2012  is warranted. An information leaflet has also been published to help surgeons inform their patients about the risk of adhesions, their potential complications, and their reduction measures .
Reducing the personal and economical burden of post-surgical adhesions should become a common goal for all gynaecological surgeons. The present survey shows that further efforts should be made to ensure that all women—in particular those wishing to conceive—can benefit from the solutions designed to reduce post-surgical adhesions and their complications.
Conflict of interest
This study was supported by an unrestricted grant of Nordic Pharma. Michal Mara, Arnaud Wattiez, Hans Brölmann and Per Lundorff declare no conflict of interest. Philippe Robert Koninckx is stockholder of Endosat NV. Andreas Hackethal consults NordicPharma, Ethicon, Fisher&Paykel, Olympus and Terumo. Markus Wallwiener consults Nordic Pharma. Rudy Leon De Wilde consults Karl Storz, Nordic Pharma, Terumo, Actamax and Bayer. This article does not contain any studies with human or animal subjects performed by the any of the authors
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