Pathophysiology, prevention and treatment of postoperative peritoneal adhesions: a WSES narrative

BACKGROUND: Adhesions are a common complication following surgery, and they can cause significant morbidity. However, adhesions are not easily diagnosed with imaging, and often only become apparent when they cause intestinal obstruction symptoms. The pathophysiology of adhesion formation is complex, thus despite advances in surgical techniques and postoperative care, adhesions remain a persistent problem in clinical practice. Despite evidence for efficacy of some strategies in reducing adhesion formation question remain regarding the indications and impact on clinically relevant outcomes. The paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a thorough examination of the pathophysiological mechanisms underlying adhesion formation and assess the efficacy of existing preventive strategies to guide future research and clinical practice in the management of adhesions. METHODS: Study design and Framework This position paper was developed in accordance with the World Society of Emergency Surgery (WSES) methodology for consensus-based guidelines. The objective was to synthesize current evidence on adhesion pathophysiology and translate it into a clinically applicable "Narrative". Expert Panel Selection and Composition: The expert panel was composed of international specialists in general, trauma, and emergency surgery. Experts were selected based on their clinical leadership and academic contributions to the fields of peritoneal surgery and postoperative complication management. The panel included senior representatives from major surgical departments in Singapore (Sengkang and Singapore General Hospital), The Netherlands (Radboud University), and Italy (University of Bologna and Bufalini Hospital). Literature Search and Evidence Synthesis: A comprehensive search was conducted across major medical databases (e.g., PubMed, Scopus, Cochrane Library) to identify literature concerning the pathophysiology and prevention of adhesions. The search strategy employed Medical Subject Headings (MeSH) descriptors and keywords including: "peritoneal adhesions," "postoperative adhesions," "adhesion prevention," "adhesion barriers," "carboxymethylcellulose," "hyaluronic acid," "icodextrin," "oxidized regenerated cellulose," "polyethylene glycol," "adhesive small bowel obstruction," "adhesiolysis". No language restrictions were applied to the search strategy. A total of 56 studies were selected, including systematic reviews, meta-analyses, randomized clinical trials (RCTs), and retrospective cohort studies. The panel focused on clinically relevant outcomes, specifically looking for evidence that connected interventions to reduced rates of adhesive small bowel obstruction (ASBO) and reoperation. Studies were screened based on their ability to address three specific pillars: surgical approach (MIS vs. Open), technical manoeuvres (haemostasis and tissue handling), and the use of mechanical or chemical adjuncts. Consensus Achievement and Formulation: The recommendations were developed through a structured, iterative revision process: Literature Synthesis: Lead authors performed the primary review and drafted the pathophysiological and preventative sections. Internal Peer Review: The manuscript underwent rigorous revision by the international expert panel to reach a consensus on the position statements. Final Validation: All authors reviewed and approved the final manuscript and the resulting "Bundle" recommendations to ensure they were supported by the cited data. RESULTS: A total of 56 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been included in this paper to be discussed. Surgical techniques, as well as chemical and mechanical barriers were discussed in depth in this paper to come up with the recommendation. CONCLUSION: The WSES expert panel suggests the following bundle to reduce postoperative peritoneal adhesions: Bundle 1: Whenever possible, opt for minimally invasive surgery (MIS) or laparoscopic procedures. Bundle 2: Good surgical techniques. Bundle 3: Utilise barriers.