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Postoperative peritoneal adhesions in adults and their prevention

Alan H DeCherney, MD
Senthil Kumar, MS, FRCS (Ed), FRCS (Gen Surg)
Section Editors
Tommaso Falcone, MD, FRCSC, FACOG
Hilary Sanfey, MD
Deputy Editor
Wenliang Chen, MD, PhD


Postoperative peritoneal adhesions have important consequences to patients, surgeons, and the health system. The adhesions that form in the abdomen following abdominal or pelvic surgery are a normal response to injury of the peritoneal surfaces during surgery, and although adhesions have some beneficial effects, they also cause significant morbidity, including adhesive small bowel obstruction, female infertility, chronic abdominal pain, and increased difficulty with subsequent surgery [1,2]. These issues have refocused attention on our understanding of adhesions, their clinical consequences, and methods of prevention. A number of animal studies and human interventional trials have evaluated a variety of techniques and materials designed to reduce and prevent postsurgical adhesions. Only a handful of agents have been proven safe and effective in humans, and fewer have an evidence base that justifies routine use.

The epidemiology, pathogenesis, approach, and importance of preventing postoperative peritoneal adhesions in adults are reviewed here. The diagnosis and management of small bowel obstruction and infertility are discussed elsewhere. (See "Management of acute perioperative pain" and "Epidemiology, clinical features, and diagnosis of mechanical small bowel obstruction in adults" and "Evaluation of female infertility".)


Postoperative adhesions cause significant morbidity, including bowel obstruction, female infertility, and chronic abdominal and pelvic pain [3-6].

Intestinal obstruction – Adhesions are the most common cause of intestinal obstruction in Western countries [7-9]. The incidence varies widely with the nature of the index surgery and the duration of follow-up [7,10-13]. Open gynecologic procedures, ileal pouch-anal anastomosis, and open colectomy are associated with the highest risk of adhesive small-bowel obstruction [14]. The incidence of small bowel obstruction resulting from postoperative adhesions increases with each subsequent procedure performed in the management of bowel obstruction. In one national study 5.7 percent of 21,347 readmissions were classified as relating directly to adhesions, and 3.8 percent required operation [12]. The risk factors associated with small bowel obstruction due to adhesions are discussed separately.

Infertility – Infertility in women can result from pelvic adhesions, which can interfere with ovum capture and transport or from tubal or intrauterine adhesions that hinder sperm transport or embryo implantation. Whereas pelvic peritoneal adhesions and tubal abnormalities are each responsible for approximately 10 percent of cases of female infertility, intrauterine adhesions are a relatively rare cause of infertility. (See "Overview of infertility", section on 'Causes of infertility' and "Intrauterine adhesions: Clinical manifestation and diagnosis".)

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Literature review current through: Nov 2017. | This topic last updated: Mar 05, 2017.
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  1. ten Broek RP, Stommel MW, Strik C, et al. Benefits and harms of adhesion barriers for abdominal surgery: a systematic review and meta-analysis. Lancet 2014; 383:48.
  2. Diamond MP, Freeman ML. Clinical implications of postsurgical adhesions. Hum Reprod Update 2001; 7:567.
  3. Davey AK, Maher PJ. Surgical adhesions: a timely update, a great challenge for the future. J Minim Invasive Gynecol 2007; 14:15.
  4. Schreinemacher MH, ten Broek RP, Bakkum EA, et al. Adhesion awareness: a national survey of surgeons. World J Surg 2010; 34:2805.
  5. Wilson MS. Practicalities and costs of adhesions. Colorectal Dis 2007; 9 Suppl 2:60.
  6. De Wilde RL, Brölmann H, Koninckx PR, et al. Prevention of adhesions in gynaecological surgery: the 2012 European field guideline. Gynecol Surg 2012; 9:365.
  7. Al-Took S, Platt R, Tulandi T. Adhesion-related small-bowel obstruction after gynecologic operations. Am J Obstet Gynecol 1999; 180:313.
  8. Ouaïssi M, Gaujoux S, Veyrie N, et al. Post-operative adhesions after digestive surgery: their incidence and prevention: review of the literature. J Visc Surg 2012; 149:e104.
  9. Barmparas G, Branco BC, Schnüriger B, et al. The incidence and risk factors of post-laparotomy adhesive small bowel obstruction. J Gastrointest Surg 2010; 14:1619.
  10. Lower AM, Hawthorn RJ, Ellis H, et al. The impact of adhesions on hospital readmissions over ten years after 8849 open gynaecological operations: an assessment from the Surgical and Clinical Adhesions Research Study. BJOG 2000; 107:855.
  11. Lower AM, Hawthorn RJ, Clark D, et al. Adhesion-related readmissions following gynaecological laparoscopy or laparotomy in Scotland: an epidemiological study of 24 046 patients. Hum Reprod 2004; 19:1877.
  12. Ellis H, Moran BJ, Thompson JN, et al. Adhesion-related hospital readmissions after abdominal and pelvic surgery: a retrospective cohort study. Lancet 1999; 353:1476.
  13. Al-Sunaidi M, Tulandi T. Adhesion-related bowel obstruction after hysterectomy for benign conditions. Obstet Gynecol 2006; 108:1162.
  14. Schnüriger B, Barmparas G, Branco BC, et al. Prevention of postoperative peritoneal adhesions: a review of the literature. Am J Surg 2011; 201:111.
  15. van Goor H. Consequences and complications of peritoneal adhesions. Colorectal Dis 2007; 9 Suppl 2:25.
  16. Practice Committee of the American Society for Reproductive Medicine, Society of Reproductive Surgeons. Pathogenesis, consequences, and control of peritoneal adhesions in gynecologic surgery. Fertil Steril 2007; 88:21.
  17. ten Broek RP, Schreinemacher MH, Jilesen AP, et al. Enterotomy risk in abdominal wall repair: a prospective study. Ann Surg 2012; 256:280.
  18. ten Broek RP, Strik C, Issa Y, et al. Adhesiolysis-related morbidity in abdominal surgery. Ann Surg 2013; 258:98.
  19. Van Der Krabben AA, Dijkstra FR, Nieuwenhuijzen M, et al. Morbidity and mortality of inadvertent enterotomy during adhesiotomy. Br J Surg 2000; 87:467.
  20. Ellis H. The clinical significance of adhesions: focus on intestinal obstruction. Eur J Surg Suppl 1997; :5.
  21. Sikirica V, Bapat B, Candrilli SD, et al. The inpatient burden of abdominal and gynecological adhesiolysis in the US. BMC Surg 2011; 11:13.
  22. Reed KL, Fruin AB, Bishop-Bartolomei KK, et al. Neurokinin-1 receptor and substance P messenger RNA levels increase during intraabdominal adhesion formation. J Surg Res 2002; 108:165.
  23. Brüggmann D, Tchartchian G, Wallwiener M, et al. Intra-abdominal adhesions: definition, origin, significance in surgical practice, and treatment options. Dtsch Arztebl Int 2010; 107:769.
  24. Hellebrekers BW, Kooistra T. Pathogenesis of postoperative adhesion formation. Br J Surg 2011; 98:1503.
  25. Ellis H. Medicolegal consequences of postoperative intra-abdominal adhesions. J R Soc Med 2001; 94:331.
  26. Cheong YC, Laird SM, Li TC, et al. Peritoneal healing and adhesion formation/reformation. Hum Reprod Update 2001; 7:556.
  27. Monk BJ, Berman ML, Montz FJ. Adhesions after extensive gynecologic surgery: clinical significance, etiology, and prevention. Am J Obstet Gynecol 1994; 170:1396.
  28. Arung W, Meurisse M, Detry O. Pathophysiology and prevention of postoperative peritoneal adhesions. World J Gastroenterol 2011; 17:4545.
  29. Attard JA, MacLean AR. Adhesive small bowel obstruction: epidemiology, biology and prevention. Can J Surg 2007; 50:291.
  30. diZerega GS. Biochemical events in peritoneal tissue repair. Eur J Surg Suppl 1997; :10.
  31. Diamond MP, El-Hammady E, Wang R, et al. Regulation of expression of tissue plasminogen activator and plasminogen activator inhibitor-1 by dichloroacetic acid in human fibroblasts from normal peritoneum and adhesions. Am J Obstet Gynecol 2004; 190:926.
  32. Demco L. Pain mapping of adhesions. J Am Assoc Gynecol Laparosc 2004; 11:181.
  33. 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.
  34. Stricker B, Blanco J, Fox HE. The gynecologic contribution to intestinal obstruction in females. J Am Coll Surg 1994; 178:617.
  35. Hull TL, Joyce MR, Geisler DP, Coffey JC. Adhesions after laparoscopic and open ileal pouch-anal anastomosis surgery for ulcerative colitis. Br J Surg 2012; 99:270.
  36. Burns EM, Currie A, Bottle A, et al. Minimal-access colorectal surgery is associated with fewer adhesion-related admissions than open surgery. Br J Surg 2013; 100:152.
  37. Keckstein J, Ulrich U, Sasse V, et al. Reduction of postoperative adhesion formation after laparoscopic ovarian cystectomy. Hum Reprod 1996; 11:579.
  38. Levrant SG, Bieber EJ, Barnes RB. Anterior abdominal wall adhesions after laparotomy or laparoscopy. J Am Assoc Gynecol Laparosc 1997; 4:353.
  39. Yesildaglar N, Koninckx PR. Adhesion formation in intubated rabbits increases with high insufflation pressure during endoscopic surgery. Hum Reprod 2000; 15:687.
  40. Ahmad G, O'Flynn H, Hindocha A, Watson A. Barrier agents for adhesion prevention after gynaecological surgery. Cochrane Database Syst Rev 2015; :CD000475.
  41. Zeng Q, Yu Z, You J, Zhang Q. Efficacy and safety of Seprafilm for preventing postoperative abdominal adhesion: systematic review and meta-analysis. World J Surg 2007; 31:2125.
  42. Moreira H Jr, Wexner SD, Yamaguchi T, et al. Use of bioresorbable membrane (sodium hyaluronate + carboxymethylcellulose) after controlled bowel injuries in a rabbit model. Dis Colon Rectum 2000; 43:182.
  43. Tzianabos AO, Cisneros RL, Gershkovich J, et al. Effect of surgical adhesion reduction devices on the propagation of experimental intra-abdominal infection. Arch Surg 1999; 134:1254.
  44. Beck DE. The role of Seprafilm bioresorbable membrane in adhesion prevention. Eur J Surg Suppl 1997; :49.
  45. Beck DE, Cohen Z, Fleshman JW, et al. A prospective, randomized, multicenter, controlled study of the safety of Seprafilm adhesion barrier in abdominopelvic surgery of the intestine. Dis Colon Rectum 2003; 46:1310.
  46. Vrijland WW, Tseng LN, Eijkman HJ, et al. Fewer intraperitoneal adhesions with use of hyaluronic acid-carboxymethylcellulose membrane: a randomized clinical trial. Ann Surg 2002; 235:193.
  47. Cohen Z, Senagore AJ, Dayton MT, et al. Prevention of postoperative abdominal adhesions by a novel, glycerol/sodium hyaluronate/carboxymethylcellulose-based bioresorbable membrane: a prospective, randomized, evaluator-blinded multicenter study. Dis Colon Rectum 2005; 48:1130.
  48. Becker JM, Dayton MT, Fazio VW, et al. Prevention of postoperative abdominal adhesions by a sodium hyaluronate-based bioresorbable membrane: a prospective, randomized, double-blind multicenter study. J Am Coll Surg 1996; 183:297.
  49. Fazio VW, Cohen Z, Fleshman JW, et al. Reduction in adhesive small-bowel obstruction by Seprafilm adhesion barrier after intestinal resection. Dis Colon Rectum 2006; 49:1.
  50. Kusunoki M, Ikeuchi H, Yanagi H, et al. Bioresorbable hyaluronate-carboxymethylcellulose membrane (Seprafilm) in surgery for rectal carcinoma: a prospective randomized clinical trial. Surg Today 2005; 35:940.
  51. Salum M, Wexner SD, Nogueras JJ, et al. Does sodium hyaluronate- and carboxymethylcellulose-based bioresorbable membrane (Seprafilm) decrease operative time for loop ileostomy closure? Tech Coloproctol 2006; 10:187.
  52. Inoue M, Uchida K, Miki C, Kusunoki M. Efficacy of Seprafilm for reducing reoperative risk in pediatric surgical patients undergoing abdominal surgery. J Pediatr Surg 2005; 40:1301.
  53. Diamond MP. Reduction of adhesions after uterine myomectomy by Seprafilm membrane (HAL-F): a blinded, prospective, randomized, multicenter clinical study. Seprafilm Adhesion Study Group. Fertil Steril 1996; 66:904.
  54. Dimitrijevich SD, Tatarko M, Gracy RW, et al. In vivo degradation of oxidized, regenerated cellulose. Carbohydr Res 1990; 198:331.
  55. Greenblatt EM, Casper RF. Adhesion formation after laparoscopic ovarian cautery for polycystic ovarian syndrome: lack of correlation with pregnancy rate. Fertil Steril 1993; 60:766.
  56. The efficacy of Interceed(TC7)* for prevention of reformation of postoperative adhesions on ovaries, fallopian tubes, and fimbriae in microsurgical operations for fertility: a multicenter study. Nordic Adhesion Prevention Study Group. Fertil Steril 1995; 63:709.
  57. Tinelli A, Malvasi A, Guido M, et al. Adhesion formation after intracapsular myomectomy with or without adhesion barrier. Fertil Steril 2011; 95:1780.
  58. Azziz R. Microsurgery alone or with INTERCEED Absorbable Adhesion Barrier for pelvic sidewall adhesion re-formation. The INTERCEED (TC7) Adhesion Barrier Study Group II. Surg Gynecol Obstet 1993; 177:135.
  59. Franklin RR. Reduction of ovarian adhesions by the use of Interceed. Ovarian Adhesion Study Group. Obstet Gynecol 1995; 86:335.
  60. Li TC, Cooke ID. The value of an absorbable adhesion barrier, Interceed, in the prevention of adhesion reformation following microsurgical adhesiolysis. Br J Obstet Gynaecol 1994; 101:335.
  61. Saravelos H, Li TC. Post-operative adhesions after laparoscopic electrosurgical treatment for polycystic ovarian syndrome with the application of Interceed to one ovary: a prospective randomized controlled study. Hum Reprod 1996; 11:992.
  62. Sekiba K. Use of Interceed(TC7) absorbable adhesion barrier to reduce postoperative adhesion reformation in infertility and endometriosis surgery. The Obstetrics and Gynecology Adhesion Prevention Committee. Obstet Gynecol 1992; 79:518.
  63. Mais V, Ajossa S, Piras B, et al. Prevention of de-novo adhesion formation after laparoscopic myomectomy: a randomized trial to evaluate the effectiveness of an oxidized regenerated cellulose absorbable barrier. Hum Reprod 1995; 10:3133.
  64. Mais V, Ajossa S, Marongiu D, et al. Reduction of adhesion reformation after laparoscopic endometriosis surgery: a randomized trial with an oxidized regenerated cellulose absorbable barrier. Obstet Gynecol 1995; 86:512.
  65. Wiseman DM, Gottlick-Iarkowski L, Kamp L. Effect of different barriers of oxidized regenerated cellulose (ORC) on cecal and sidewall adhesions in the presence and absence of bleeding. J Invest Surg 1999; 12:141.
  66. An expanded polytetrafluoroethylene barrier (Gore-Tex Surgical Membrane) reduces post-myomectomy adhesion formation. The Myomectomy Adhesion Multicenter Study Group. Fertil Steril 1995; 63:491.
  67. Haney AF, Hesla J, Hurst BS, et al. Expanded polytetrafluoroethylene (Gore-Tex Surgical Membrane) is superior to oxidized regenerated cellulose (Interceed TC7+) in preventing adhesions. Fertil Steril 1995; 63:1021.
  68. Mettler L, Audebert A, Lehmann-Willenbrock E, et al. A randomized, prospective, controlled, multicenter clinical trial of a sprayable, site-specific adhesion barrier system in patients undergoing myomectomy. Fertil Steril 2004; 82:398.
  69. Tjandra JJ, Chan MK. A sprayable hydrogel adhesion barrier facilitates closure of defunctioning loop ileostomy: a randomized trial. Dis Colon Rectum 2008; 51:956.
  70. Mettler L, Hucke J, Bojahr B, et al. A safety and efficacy study of a resorbable hydrogel for reduction of post-operative adhesions following myomectomy. Hum Reprod 2008; 23:1093.
  71. Johns DA, Ferland R, Dunn R. Initial feasibility study of a sprayable hydrogel adhesion barrier system in patients undergoing laparoscopic ovarian surgery. J Am Assoc Gynecol Laparosc 2003; 10:334.
  72. Banasiewicz T, Horbacka K, Karoń J, et al. Preliminary study with SprayShield™ Adhesion Barrier System in the prevention of abdominal adhesions. Wideochir Inne Tech Maloinwazyjne 2013; 8:301.
  73. Ten Broek RP, Kok-Krant N, Verhoeve HR, et al. Efficacy of polyethylene glycol adhesion barrier after gynecological laparoscopic surgery: Results of a randomized controlled pilot study. Gynecol Surg 2012; 9:29.
  74. Tchartchian G, Hackethal A, Herrmann A, et al. Evaluation of SprayShield™ Adhesion Barrier in a single center: randomized controlled study in 15 women undergoing reconstructive surgery after laparoscopic myomectomy. Arch Gynecol Obstet 2014; 290:697.
  75. Brown CB, Luciano AA, Martin D, et al. Adept (icodextrin 4% solution) reduces adhesions after laparoscopic surgery for adhesiolysis: a double-blind, randomized, controlled study. Fertil Steril 2007; 88:1413.
  76. http://www.baxterbiosurgery.com/us/resources/pdfs/adept/ADEPT_Instructions_For_Use.pdf (Accessed on May 12, 2014).
  77. Tang CL, Jayne DG, Seow-Choen F, et al. A randomized controlled trial of 0.5% ferric hyaluronate gel (Intergel) in the prevention of adhesions following abdominal surgery. Ann Surg 2006; 243:449.
  78. Metwally M, Gorvy D, Watson A, Li TC. Hyaluronic acid fluid agents for the prevention of adhesions after fertility-preserving gynecological surgery: a meta-analysis of randomized controlled trials. Fertil Steril 2007; 87:1139.
  79. Mais V, Cirronis MG, Peiretti M, et al. Efficacy of auto-crosslinked hyaluronan gel for adhesion prevention in laparoscopy and hysteroscopy: a systematic review and meta-analysis of randomized controlled trials. Eur J Obstet Gynecol Reprod Biol 2012; 160:1.
  80. Johns DB, Keyport GM, Hoehler F, et al. Reduction of postsurgical adhesions with Intergel adhesion prevention solution: a multicenter study of safety and efficacy after conservative gynecologic surgery. Fertil Steril 2001; 76:595.
  81. Lundorff P, van Geldorp H, Tronstad SE, et al. Reduction of post-surgical adhesions with ferric hyaluronate gel: a European study. Hum Reprod 2001; 16:1982.
  82. Pellicano M, Bramante S, Cirillo D, et al. Effectiveness of autocrosslinked hyaluronic acid gel after laparoscopic myomectomy in infertile patients: a prospective, randomized, controlled study. Fertil Steril 2003; 80:441.
  83. Diamond MP. Reduction of de novo postsurgical adhesions by intraoperative precoating with Sepracoat (HAL-C) solution: a prospective, randomized, blinded, placebo-controlled multicenter study. The Sepracoat Adhesion Study Group. Fertil Steril 1998; 69:1067.
  84. Berdah SV, Mariette C, Denet C, et al. A multicentre, randomised, controlled trial to assess the safety, ease of use, and reliability of hyaluronic acid/carboxymethylcellulose powder adhesion barrier versus no barrier in colorectal laparoscopic surgery. Trials 2014; 15:413.
  85. Metwally M, Watson A, Lilford R, Vandekerckhove P. Fluid and pharmacological agents for adhesion prevention after gynaecological surgery. Cochrane Database Syst Rev 2006; :CD001298.
  86. LeGrand EK, Rodgers KE, Girgis W, et al. Comparative efficacy of nonsteroidal anti-inflammatory drugs and anti-thromboxane agents in a rabbit adhesion-prevention model. J Invest Surg 1995; 8:187.
  87. Montz FJ, Monk BJ, Lacy SM, Fowler JM. Ketorolac tromethamine, a nonsteroidal anti-inflammatory drug: ability to inhibit post-radical pelvic surgery adhesions in a porcine model. Gynecol Oncol 1993; 48:76.
  88. Holschneider CH, Nejad F, Montz FJ. Immunomodulation with interleukin-10 and interleukin-4 compared with ketorolac tromethamine for prevention of postoperative adhesions in a murine model. Fertil Steril 1999; 71:67.
  89. diZerega GS. Contemporary adhesion prevention. Fertil Steril 1994; 61:219.
  90. Ricaurte E, Hilgers TW. Safety of intraperitoneal 32% dextran 70 as an antiadhesion adjuvant. J Reprod Med 1989; 34:535.
  91. Sites CK, Jensen BA, Glock JL, et al. Transvaginal ultrasonographic assessment of Hyskon or lactated Ringer's solution instillation after laparoscopy: randomized, controlled study. J Ultrasound Med 1997; 16:195.
  92. Rose BI, MacNeill C, Larrain R, Kopreski MM. Abdominal instillation of high-molecular-weight dextran or lactated Ringer's solution after laparoscopic surgery. A randomized comparison of the effect on weight change. J Reprod Med 1991; 36:537.
  93. Tulandi T, Hilton J. Effect of intraperitoneal 32% dextran 70 on blood coagulation and serum electrolytes. J Reprod Med 1985; 30:431.
  94. Weinans MJ, Kauer FM, Klompmaker IJ, Wijma J. Transient liver function disturbances after the intraperitoneal use of 32% dextran 70 as adhesion prophylaxis in infertility surgery. Fertil Steril 1990; 53:159.
  95. Tulandi T. Transient edema after intraperitoneal instillation of 32% dextran 70. A report of five cases. J Reprod Med 1987; 32:472.
  96. Fabri PJ, Ellison EC, Anderson ED, Kudsk KA. High molecular weight dextran--effect on adhesion formation and peritonitis in rats. Surgery 1983; 94:336.
  97. Abu-Elhasan AM, Abdellah MS, Hamed HO. Safety and efficacy of postoperative continuous intra-peritoneal wash with lactated Ringer's for minimizing post-myomectomy pelvic adhesions: a pilot clinical trial. Eur J Obstet Gynecol Reprod Biol 2014; 183:78.
  98. Rappaport WD, Holcomb M, Valente J, Chvapil M. Antibiotic irrigation and the formation of intraabdominal adhesions. Am J Surg 1989; 158:435.
  99. Farquhar C, Vandekerckhove P, Watson A, et al. Barrier agents for preventing adhesions after surgery for subfertility. Cochrane Database Syst Rev 2000; :CD000475.
  100. Hayashi S, Takayama T, Masuda H, et al. Bioresorbable membrane to reduce postoperative small bowel obstruction in patients with gastric cancer: a randomized clinical trial. Ann Surg 2008; 247:766.
  101. Dupré A, Lefranc A, Buc E, et al. Use of bioresorbable membranes to reduce abdominal and perihepatic adhesions in 2-stage hepatectomy of liver metastases from colorectal cancer: results of a prospective, randomized controlled phase II trial. Ann Surg 2013; 258:30.
  102. Park CM, Lee WY, Cho YB, et al. Sodium hyaluronate-based bioresorbable membrane (Seprafilm) reduced early postoperative intestinal obstruction after lower abdominal surgery for colorectal cancer: the preliminary report. Int J Colorectal Dis 2009; 24:305.
  103. van der Wal JB, Iordens GI, Vrijland WW, et al. Adhesion prevention during laparotomy: long-term follow-up of a randomized clinical trial. Ann Surg 2011; 253:1118.
  104. Ahmad G, Mackie FL, Iles DA, et al. Fluid and pharmacological agents for adhesion prevention after gynaecological surgery. Cochrane Database Syst Rev 2014; :CD001298.
  105. Bosteels J, Weyers S, Mol BW, D'Hooghe T. Anti-adhesion barrier gels following operative hysteroscopy for treating female infertility: a systematic review and meta-analysis. Gynecol Surg 2014; 11:113.
  106. Tulandi T, Collins JA, Burrows E, et al. Treatment-dependent and treatment-independent pregnancy among women with periadnexal adhesions. Am J Obstet Gynecol 1990; 162:354.
  107. Swank DJ, Swank-Bordewijk SC, Hop WC, et al. Laparoscopic adhesiolysis in patients with chronic abdominal pain: a blinded randomised controlled multi-centre trial. Lancet 2003; 361:1247.
  108. Keltz MD, Gera PS, Olive DL. Prospective randomized trial of right-sided paracolic adhesiolysis for chronic pelvic pain. JSLS 2006; 10:443.