The estimated prevalence of intra-abdominal adhesions after a laparotomy is 95%.1 Menzies2 classified adhesions as congenital or acquired. Congenital adhesions are present from birth as embryological anomalies in the development of the peritoneal cavity, whereas an inflammatory process or, more commonly, surgery produces acquired adhesions. Injury to the peritoneum and peritoneal ischemia during surgery predisposes to adhesion formation.3 These adhesions can cause bowel obstructions and pain, and untreated bowel obstruction has a high incidence of mortality.
We and others previously reported that the most common cause of bowel obstruction is adhesions; and in gynecology, adhesion-related bowel obstruction is commonly found after an abdominal hysterectomy.4,5 Whether hysterectomy by other approaches play a role in the occurrence of adhesion-related bowel obstruction remains unclear. The purpose of our study is to evaluate the occurrence of small bowel obstruction after hysterectomy.
MATERIALS AND METHODS
We examined the medical records of women who were admitted to the McGill University Health Center, the Royal Victoria Hospital, and the Sir Mortimer B. Davis, Jewish General Hospital, Montreal, with a diagnosis of small bowel obstruction during the period January 1998 to December 2005. The Director of Professional Services of McGill University Health Center and the Research Ethics Committee of Sir Mortimer B. Davis, Jewish General Hospital approved the study. The diagnosis of complete bowel obstruction was established by the clinical picture, radiological findings, and operative findings, and partial obstruction was diagnosed when both clinical and radiological criteria were met (Fig. 1).
The clinical criteria consisted of abdominal pain, vomiting, cessation of flatus and bowel movement, and varying degrees of abdominal distention. The radiological criteria included the findings of air-fluid levels on the upright view of a plain abdominal X-ray, whereas computed tomography scan shows a discrepancy in the caliber of proximal and distal small bowel. Gas and fluid fill and dilate the proximal loops of intestines. Absence of air or fluid in the distal small bowel or colon suggested a complete obstruction.
In those with complete obstruction, we evaluate the site of adhesions and determine whether the visceral or parietal peritoneum was closed during the hysterectomy. As in our standard practice, we used polyglactin 3-0 to close the peritoneum. Cases with small bowel obstruction related to multiple abdominal surgeries, carcinoma, or inflammatory bowel disease were excluded from the analysis.
Data were analyzed using Student t test or χ2 when appropriate. The rate of bowel obstruction was evaluated by using a life-table analysis. The differences are considered to be statistically significant if P<.05.
Of the total 326 cases, we excluded four cases due to incomplete data information. Of the remaining 322 cases, the main causes of bowel obstruction were intra-abdominal adhesions (n=135, 41.9%) and abdominal malignancy (n=129, 40.1%). Other causes were inflammatory bowel disease (n=36, 11.2%), strangulated hernia (n=18, 5.6%), and radiation-induced colitis (n=4, 1.2%).
After excluding oncologic cases, of the 135 cases of adhesion-related small bowel obstruction, gynecologic operations played the main role in the occurrence of bowel obstruction (n=68, 50.4%). Non gynecologic operations accounted for small bowel obstruction in 25.2% (n=34) and multiple abdominal operations in 24.4% (n=33) of cases. Adhesion-reducing substance was not used in all cases at the initial surgery. The types of obstetrics and gynecologic operation preceding small bowel obstruction are depicted in Table 1. The mean age of the patients at the time of diagnosis of small bowel obstruction in all cases with adhesion-related small bowel obstruction was 60.7±16.0 years, and in cases with hysterectomy-related small bowel obstruction, mean age was 59.4±14.7 years. We calculated the incidence of small bowel obstruction related to the type of operation by using the number of operations performed during the period January 1998 to December 2005.
In our series, we did not encounter any small bowel obstruction after hysterectomy, myomectomy, or adnexal surgery by laparoscopic approach (Table 1). Total abdominal hysterectomy was the most common cause of small bowel obstruction (13.6 per 1,000 TAHs), and cesarean delivery was the least common cause (1 per 1,000 cesarean deliveries). Assuming that hysterectomies could be performed by either TAH or laparoscopic supracervical hysterectomy, the reduction in the absolute risk of small bowel obstruction is 13.6 per 1,000 cases, or 73 patients should undergo laparoscopic supracervical hysterectomy to prevent one from having small bowel obstruction.
The cumulative probability of adhesion-related small bowel obstruction after hysterectomy for benign condition is shown in Figure 2. The median interval between the hysterectomy and small bowel obstruction was 4 years (95% confidence interval [CI] 0.9–10.7 years). A case of incomplete small bowel obstruction was found after a vaginal hysterectomy. Of the remaining 49 cases of TAH-related small bowel obstruction, complete obstruction was found in 36 cases (74%) (Table 1).
Detailed analysis of cases with complete small bowel obstruction after hysterectomy revealed that the adhesions causing small bowel obstruction were adherent to the previous laparotomy incision in 27 cases (75%) and to the vaginal vault in nine others (25%). In all cases of TAH, reperitonealization of the visceral peritoneum was performed. The parietal peritoneum was closed in 25 cases and was left unsutured in 24 others.
Using the Cox proportional hazards model, we evaluated the effects of peritoneal closure. Controlling for age, peritoneal closure was not associated with small bowel obstruction (coefficient 0.36, standard error 0.75, hazard ratio 1.7, 95% CI 0.4–7.3, P not significant).
One of the complications of abdominal surgery is intra-abdominal adhesion, and most studies suggest that more than a half of patients with adhesion-related small bowel obstruction had previous gynecologic or obstetric operations.4–10 Confirming previous reports,1,4–9 we found that adhesions play a major role in the occurrence of small bowel obstruction. After gynecologic operations for benign condition, total abdominal hysterectomy was most commonly associated with small bowel obstruction. The fact that 75% of the cases were complete small bowel obstruction suggests the severity of the condition.
We did not encounter any small bowel obstruction after laparoscopic surgery in gynecology, including laparoscopic supracervical hysterectomy. Our results are limited by the small number of laparoscopic supracervical hysterectomy procedures in our series. In any event, it is unlikely that this is related to the supracervical nature of the procedure. The most likely explanation is that laparoscopy is associated with less serosal injury and less adhesion formation than laparotomy.11–13 This is due to minimal tissue handling and manipulation of the internal organs in laparoscopy. Also at laparoscopy, we perform surgery in a closed environment, maintaining tissue moistness, and contamination with glove powders or lint is nonexistent. In addition, the tamponade effect of carbon dioxide (CO2) pneumoperitoneum facilitates hemostasis. Compared with laparotomy, laparoscopy is also associated with less incidence of infection. We did not perform laparoscopic-assisted vaginal hysterectomy, and the number of cases with laparoscopic total hysterectomy was too small to be included. In any event, we did not encounter small bowel obstruction following laparoscopic total hysterectomy.
Whether the use of adhesion-reducing substance at hysterectomy would have decreased the incidence of small bowel obstruction is unknown. Fazio et al,14 however, reported that application of bioresorbable membrane consisting of hyaluronic acid and carboxymethylcellulose (Seprafilm, Genzyme Corporation, Cambridge, MA) after intestinal resection reduces the incidence of adhesion-related small bowel obstruction. In their study, half of the patients experienced small bowel obstruction within 6 months after the initial operation. Our patients did not use adhesion-reducing substance.
The adhesions causing small bowel obstructions were adhered to previous laparotomy incisions in 75% and to the vaginal vault in 25% of the cases; in our previous report, they were 85% and 15%, respectively.4 The parietal peritoneum was sutured in approximately half of the cases. It appears that closure of the parietal peritoneum does not contribute to the occurrence of adhesion-related small bowel obstruction. It is possible that this is solely due to a type 2 error.
Several randomized trials have shown that closing either the parietal or the visceral peritoneum is unnecessary.15 Closing of the peritoneum is associated with a longer operating time and more postoperative pain, and there is a suggestion that it might cause more adhesion formation than non closure. The adhesion formation after laparotomy with peritoneal closure was 22.2% and without peritoneal closure, 16%.16 Ellis17 noted that there have been increasing medical-legal claims arising from adhesion-related complications. He stated, “peritoneal defects and the pelvic floor should be left open since they rapidly reperitonealized.”
In contrast to results from nonpregnant patients, in a nonrandomized study, Lyell et al18 found that closure of the parietal peritoneum at cesarean delivery was associated with less adhesion formation than nonclosure. Although they excluded cases with permanent sutures, they did not state the type of sutures used to close the peritoneum. It is known that reactive suture materials such as catgut predispose to adhesion formation.
Peritoneal closure is associated with more postoperative pain. Studies of closure of both the parietal and visceral peritoneum at cesarean delivery suggest that peritoneal nonclosure does not promote, and might even decrease, adhesion formation.14,19–21 In a review of nine randomized trials, the authors found less postoperative fever and reduced hospital stay when the visceral peritoneum or both the visceral and parietal peritonea were not sutured.22 They concluded that there is no evidence to justify the time and cost involved in peritoneal closure. In view of small bowel obstruction, its incidence after cesarean delivery is only one per 1,000 cesarean deliveries.
The median interval between the hysterectomy and small bowel obstruction was 4 years. At this time, a general surgeon usually manages the patient. Gynecologists should be aware that hysterectomy, especially by the abdominal approach, could lead to small bowel obstruction.
We conclude that hysterectomy plays a major role in the occurrence of adhesion-related small bowel obstruction. Closure of the parietal peritoneum does not contribute to the occurrence of adhesion-related small bowel obstruction, and small bowel obstruction rarely occurs after laparoscopic supracervical hysterectomy.
1. Menzies D, Ellis H. Intestinal obstruction from adhesions: how big is the problem? Ann R Coll Surg Engl 1990;72:60–3.
2. Menzies D. Peritoneal adhesions: incidence, cause, and prevention. Surg Annu 1992;24:27–45.
3. diZerega GS. Peritoneum, peritoneal healing, and adhesion formation. In: diZerega GS, editor. Peritoneal surgery. New York (NY): Springer-Verlag; 2000. p. 3–38.
4. Al-Took S, Platt R, Tulandi T. Adhesion-related small-bowel obstruction after gynecologic operations. Am J Obstet Gynecol 1999;180:313–5.
5. Thompson JS, DiBaise JK, Iyer KR, Yeats M, Sudan DL. Postoperative short bowel syndrome. J Am Coll Surg 2005;201:85–9.
6. Kossi JA, Salminen PT, Laato MK. Surgical workload and cost of postoperative adhesion-related intestinal obstruction: importance of previous surgery. World J Surg 2004;28:666–70.
7. Lawal OO, Olayinka OS, Bankole JO. Spectrum of causes of intestinal obstruction in adult Nigerian patients. S Afr J Surg 2005;43:34–6.
8. Monk BJ, Berman ML, Montz FJ. Adhesions after extensive gynecologic surgery: clinical significance, etiology, and prevention. Am J Obstet Gynecol 1994;170:1396–1403.
9. Krebs HB, Goplerund DR. Mechanical intestinal obstruction in patients with gynecologic disease: a review of 368 patients. Am J Obstet Gynecol 1987;157:577–83.
10. Strickler B, Blanco J, Fox HE. The gynecologic contribution to intestinal in females. J Am College Surg 1994;178:617–20.
11. Gutt CN, Oniu T, Schemmer P, Mehrabi A, Buchler MW. Fewer adhesions induced by laparoscopic surgery? Surg Endosc 2005;18:898–906.
12. Schafer M, Krahenb hl L, Buchler MW. Comparison of adhesion formation in open and laparoscopic surgery. Dig Surg 1998;15:148–52.
13. Lundorff P, Hahlin M, Kallfelt B, Thorburn J, Lindblom B. Adhesion formation after laparoscopic surgery in tubal pregnancy: a randomized trial versus laparotomy. Fertil Steril 1991;55:911–5.
14. Fazio VW, Cohen Z, Fleshman JW, van Goor H, Bauer JJ, Wolff BG, et al. Reduction in adhesive small-bowel obstruction by Seprafilm adhesion barrier after intestinal resection. Dis Colon Rectum 2006;49:1–11.
15. Tulandi T, Al-Jaroudi D. Nonclosure of peritoneum: a reappraisal. Am J Obstet Gynecol 2003;189:609–12.
16. Tulandi T, Hum HS, Gelfand MM. Closure of laparotomy incisions with or without peritoneal suturing and second-look laparoscopy. Am J Obstet Gynecol 1988;158:536–7.
17. Ellis H. Medicolegal consequences of postoperative intra-abdominal adhesions. J Roy Soc Med 2001;94:331–2.
18. Lyell DJ, Caughey AB, Hu E, Daniels K. Peritoneal closure at primary cesarean delivery and adhesions. Obstet Gynecol 2005;106:275–80.
19. Hojberg KE, Aagaard J, Laursen H, Diab L, Secher NJ. Closure versus non-closure of peritoneum at cesarean section—evaluation of pain: a randomized study. Acta Obstet Gynecol Scand 1998;77:741–5.
20. Stark M, Chavkin Y, Kupfersztain C, Guedj P, Finkel AR. Evaluation of combinations of procedures in cesarean section. Int J Gynaecol Obstet 1995;48:273–6.
21. Joura EA, Nather A, Hohlagschwandtner Husslein P. Peritoneal closure and adhesions. Hum Reprod 2002;17:249–50.
22. Bamigboye AA, Hofmeyr GJ. Non-closure of peritoneal surfaces at caesarean section: a systematic review. S Afr Med J 2005;95:123–6.