Adhesions are one of those surgical complications we’d all prefer to never think about—but we don’t get that luxury. They’re common, costly, and often underestimated. Whether it’s a patient returning with chronic abdominal pain, secondary infertility, or adhesive small bowel obstruction, adhesions remain a persistent reminder that the operation doesn’t end when the skin is closed.
The good news: prevention is possible. Not perfect prevention—at least not yet—but with the right strategies, we can meaningfully reduce risk. Below, We’ll walk through the most effective, evidence-based approaches, the pitfalls to avoid, and where innovation might take us next.
1. Meticulous Surgical Technique: The Non-Negotiable Foundation
Let’s start with the obvious: no technology or pharmacological trick can replace good surgery. Gentle tissue handling, meticulous hemostasis, minimizing trauma, and avoiding desiccation and ischemia remain the backbone of adhesion prevention. Every unnecessary suture, every bit of char from cautery, every missed bleeder that leaves a hematoma—all of these set the stage for peritoneal inflammation and adhesion formation [Schnüriger et al., 2011; Koninckx et al., 2016; Robb & Mariette, 2014].
Shorter operative times also matter. The longer the peritoneum is exposed to trauma, ischemia, and air, the more likely adhesions will form. Thorough peritoneal lavage at the end of surgery is a simple but underused step that helps clear debris and pro-inflammatory material [Robb & Mariette, 2014].
Takeaway: every surgeon already knows this—but the difference between “good enough” and “meticulous” can translate into fewer complications months or years later.
2. Laparoscopy: Less Trauma, Fewer Adhesions
The transition from open surgery to minimally invasive techniques hasn’t just reduced recovery times—it’s also reshaped adhesion risk. Multiple studies show that laparoscopy is associated with lower adhesion rates compared to open surgery, except in appendicitis where the data is mixed [Schnüriger et al., 2011; ten Broek et al., 2016; Mais, 2014].
Why? Reduced tissue trauma, less desiccation, and less exposure to foreign material. In short: less inflammation.
But here’s the nuance: laparoscopy is not adhesion-proof. Adhesions still form, and the clinical consequences can still be significant. So, while laparoscopy is part of the solution, it’s not the solution alone.
3. Bioabsorbable Adhesion Barriers: The Best Evidence-Based Add-On
When the surgical field is hostile—prior surgery, extensive dissection, high risk of bowel obstruction—adhesion barriers are the next line of defense.
The most studied options are:
- Hyaluronic acid/carboxymethylcellulose (Seprafilm®)
- Oxidized regenerated cellulose (Interceed®)
- Icodextrin 4% solution (Adept®)
Meta-analyses and systematic reviews demonstrate that these agents reduce the incidence, extent, and severity of adhesions, and in some cases reduce reoperations for adhesive small bowel obstruction [Robb & Mariette, 2014; ten Broek et al., 2014; Huy et al., 2025].
The American Society for Reproductive Medicine specifically recommends hyaluronic acid–based barriers in gynecologic surgery [Fertility and Sterility, 2006]. In randomized trials, adhesion reduction is consistently in the 40–60% range, which is clinically meaningful [ten Broek et al., 2014].
Cautionary note: Seprafilm® should not be placed directly over fresh bowel anastomoses—it increases risk of abscess and leak [Zeng et al., 2007; Kumar et al., 2009]. Interceed® is safer but must be placed in a hemostatic field to be effective. Icodextrin® is generally well tolerated, though rare cases of sterile peritonitis have been reported [Catena et al., 2012; diZerega et al., 2002].
Takeaway: barriers aren’t perfect, but in high-risk cases, they’re one of the few interventions proven to matter.
4. Emerging Biomaterials: Hydrogels and Zwitterionic Polymers
If the past decade has taught us anything, it’s that biomaterials evolve quickly. Hydrogel-based barriers are now being engineered for better coverage and resistance to protein and cell adhesion, while zwitterionic polymers show almost complete resistance to fouling in experimental models [Lin et al., 2025; Zhang et al., 2020].
The clinical data isn’t here yet, but the lab results are promising. Think of these as the next generation of adhesion prevention—potentially superior in biocompatibility, handling, and long-term outcomes.
5. Adjunctive Strategies: Experimental, but Intriguing
Several adjunctive strategies are being investigated:
- Peritoneal conditioning with cooling, humidified gas, or nitric oxide supplementation
- Pharmacologic modulation with agents like dexamethasone
- Electrical muscle stimulation, which in animal models reduced adhesions when combined with Seprafilm® [Koninckx et al., 2016; Mais, 2014; Fakhradiyev et al., 2020]
Right now, these remain experimental. They’re not ready for routine use, but they represent an expanding horizon for innovation.
6. Populations That Benefit Most
Not all patients need adhesion barriers. Evidence suggests the greatest benefit in:
- Gynecologic surgery, particularly myomectomy, ovarian surgery, and endometriosis procedures [Ahmad et al., 2020; Schaefer et al., 2024].
- Colorectal surgery, especially in patients with prior operations or inflammatory conditions [ten Broek et al., 2014].
- Repeat operations or any surgery with extensive peritoneal trauma.
In low-risk cases, barriers may not justify the added cost or risk. Individualization is key.
Practical Checklist for Surgeons
Here’s a distilled, evidence-based framework you can apply tomorrow:
- Meticulous technique—gentle handling, hemostasis, lavage.
- Laparoscopy when feasible—fewer adhesions, faster recovery.
- Selectively apply adhesion barriers in high-risk surgeries. Avoid Seprafilm® on fresh anastomoses.
- Individualize—consider procedure type, prior surgeries, patient comorbidities.
- Stay curious—emerging biomaterials and adjunctive strategies may reshape prevention in the next decade.
Final Thoughts
Adhesion prevention isn’t glamorous. It doesn’t end up on conference slides as often as robotic platforms or new suture technologies. But it’s one of the most tangible ways we can improve long-term outcomes for our patients.
The real opportunity lies in combining what we already know—meticulous technique, minimally invasive approaches, selective barrier use—with the innovations on the horizon. If the next generation of biomaterials delivers on its promise, we might finally move from “adhesion reduction” toward “adhesion elimination.”
Until then, the responsibility sits squarely with us: to operate as though every unnecessary adhesion is preventable—because more often than not, it is.