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Burden of adhesions in abdominal and pelvic surgery: systematic review and met-analysis

BMJ 2013; 347 doi: (Published 03 October 2013) Cite this as: BMJ 2013;347:f5588
  1. Richard P G ten Broek, PhD candidate1,
  2. Yama Issa, PhD candidate1,
  3. Evert J P van Santbrink, gynaecologist2,
  4. Nicole D Bouvy, surgeon3,
  5. Roy F P M Kruitwagen, gynaecologist4,
  6. Johannes Jeekel, surgeon5,
  7. Erica A Bakkum, gynaecologist6,
  8. Maroeska M Rovers, senior epidemiologist7,
  9. Harry van Goor, surgeon1
  1. 1Department of Surgery, Radboud University Nijmegen Medical Center, PO Box 9101, 6500 HB Nijmegen, Netherlands
  2. 2Department of Reproductive Medicine, Reinier de Graaf Group, Voorburg, Netherlands
  3. 3Department of Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
  4. 4Department of Obstetrics and Gynaecology, and GROW—School for Oncology and Developmental Biology, Maastricht University Medical Centre, Maastricht, Netherlands
  5. 5Department of Neuroscience, Erasmus Medical Center, Rotterdam, Netherlands.
  6. 6Department of Obstetrics and Gynaecology, Onze Lieve Vrouwe Gasthuis Amsterdam, Netherlands
  7. 7Departments of Operating Rooms and Health Evidence, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands
  1. Correspondence to: R P G ten Broek Richard_tenBroek{at}
  • Accepted 20 August 2013


Objective To estimate the disease burden of the most important complications of postoperative abdominal adhesions: small bowel obstruction, difficulties at reoperation, infertility, and chronic pain.

Design Systematic review and meta-analyses.

Data sources Searches of PubMed, Embase, and Central, from January 1990 to December 2012, without restrictions to publication status or language.

Study selection All types of studies reporting on the incidence of adhesion related complications were considered.

Data extraction and analysis The primary outcome was the incidence of adhesive small bowel obstruction in patients with a history of abdominal surgery. Secondary outcomes were the incidence of small bowel obstruction by any cause, difference in operative time, enterotomy during adhesiolysis, and pregnancy rate after abdominal surgery. Subgroup and sensitivity analyses were done to study the robustness of the results. A random effects model was used to account for heterogeneity between studies.

Results We identified 196 eligible papers. Heterogeneity was considerable for almost all meta-analyses. The origin of heterogeneity could not be explained by study design, study quality, publication date, anatomical site of operation, or operative technique. The incidence of small bowel obstruction by any cause after abdominal surgery was 9% (95% confidence interval 7% to 10%; I2=99%). the incidence of adhesive small bowel obstruction was 2% (2% to 3%; I2=93%); presence of adhesions was generally confirmed by emergent reoperation. In patients with a known cause of small bowel obstruction, adhesions were the single most common cause (56%, 49% to 64%; I2=96%). Operative time was prolonged by 15 minutes (95% confidence interval 9.3 to 21.1 minutes; I2=85%) in patients with previous surgery. Use of adhesiolysis resulted in a 6% (4% to 8%; I2=89%) incidence of iatrogenic bowel injury. The pregnancy rate after colorectal surgery in patients with inflammatory bowel disease was 50% (37% to 63%; I2=94%), which was significantly lower than the pregnancy rate in medically treated patients (82%, 70% to 94%; I2=97%).

Conclusions This review provides detailed and systematically analysed knowledge of the disease burden of adhesions. Complications of postoperative adhesion formation are frequent, have a large negative effect on patients’ health, and increase workload in clinical practice. The quantitative effects should be interpreted with caution owing to large heterogeneity.

Registration The review protocol was registered through PROSPERO (CRD42012003180).


  • We thank I Gerych, General Surgery Department, Danylo Halytsky Lviv National Medical University, Ukraine, for his help in translating articles written in Russian.

  • Contributors: RPGtB was involved in study design and design of data collection tools, collected and analysed data, and drafted the article. YI collected and analysed data and critically reviewed the article. EJPvS, NDB, FPMK, JJ, and EB were involved in study design and critically reviewed the article. MMR was involved in study design, critically revised the review protocol, and critically reviewed the article. HvG was involved in study design, supervised data collection, and critically reviewed the article. All authors gave final approval of the article. RPGtB and HvG are the guarantors.

  • Funding: No external funding has been obtained for this research.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: Not needed.

  • Data sharing: Technical appendix, statistical code, and dataset are available from the corresponding author at richard_tenbroek{at}

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