Adhesiolysis & surgery for small bowel obstruction

Adhesions are bands of internal scar tissue inside the abdomen — most commonly formed after previous surgery, but sometimes after inflammation or for no obvious reason. Most adhesions cause no problems. Occasionally, though, a band of scar tissue catches a loop of small bowel and kinks or twists it — and the result is a small bowel obstruction, where the bowel cannot pass its contents downstream.

Adhesiolysis is the operation that releases these adhesions. The bowel is carefully traced from top to bottom, the offending band is identified, divided, and any damaged segment of bowel is dealt with.

The important context: most episodes of adhesional obstruction settle without an operation — around 70–80% with conservative treatment alone. Surgery is reserved for the situations where it is needed.

Surgery for adhesional obstruction is indicated when:

• Conservative management has not worked — typically after 3–5 days without resolution
• There are signs the bowel itself is suffering (ischaemia) — severe constant pain, peritonism (a rigid, tender abdomen), abnormal blood test results suggesting the bowel is in trouble, or worrying features on the CT scan
• A closed-loop obstruction is identified on imaging — a particular pattern where a segment of bowel is trapped with no escape, which is dangerous and needs urgent surgery
• Recurrent obstruction in someone who has now had multiple episodes, where the conversation about preventative surgery becomes worthwhile

• Relieves the obstruction — bowel contents can flow normally again
• Prevents progression to ischaemia when there is any concern about blood supply
• Allows damaged bowel to be removed if a segment has already been compromised
• Laparoscopic where feasible — in published series, fewer new adhesions tend to form than after open surgery, and recovery is generally faster

Adhesiolysis is a careful operation but it has specific considerations:

• Bowel injury during the operation (called enterotomy) is the most important specific risk. Adhesions can be densely stuck to bowel and very careful technique is needed. If the bowel is damaged during release, the affected segment is resected.
• New adhesions can form after the operation itself — surgery can paradoxically create new adhesions. This is the central frustration of adhesion surgery, and the reason it is not undertaken lightly.
• Conversion from laparoscopic to open is common where adhesions are extensive — this is not a failure, it is a judgement call to do the operation safely
• Wound infection, incisional hernia, ileus (a temporary slowdown of bowel function) — all recognised after major abdominal surgery
• The general risks of major abdominal surgery

Most adhesiolysis is performed urgently rather than electively. Where time allows:

• Fluid resuscitation, correction of electrolyte abnormalities, antibiotics, and adequate analgesia
• A CT scan to define the level of obstruction and identify any worrying features
• Consent covering the possibility of bowel resection and (very occasionally) stoma formation

Surgery is performed at Warringal Private Hospital or Epworth Eastern under general anaesthetic. The approach is laparoscopic where the patient's condition and previous surgical history allow, and open otherwise.

What happens during the operation:

• The bowel is carefully traced from the stomach end to the colon, releasing any adhesions encountered
• The specific band causing the obstruction is identified and divided
• Any damaged or ischaemic bowel is assessed
• If a segment needs to be removed, this becomes a small bowel resection with the bowel rejoined (sometimes with a temporary loop ileostomy if the patient is unstable)

Operating time varies considerably — from 1 hour for a single straightforward band to 4+ hours for extensive adhesions.

Recovery depends on whether bowel needed to be resected and whether the operation was laparoscopic or open.

• Laparoscopic adhesiolysis without resection — typically 2–4 nights in hospital
• Open surgery and/or resection — typically 5–7 nights

Early mobilisation, return of bowel function, and gradual reintroduction of food are the focus. Detailed aftercare follows the Bowel Surgery Aftercare guide.

A post-operative review is arranged within 2–6 weeks of discharge. This review is provided at no charge.

Patients who have had one episode of adhesional obstruction — surgical or conservative — are at higher risk of another. The risk of recurrence after adhesiolysis is around 20–30% over the following years, and published series report lower recurrence after laparoscopic surgery than after open. There is no proven way to prevent recurrence; some patients find dietary adjustments help (avoiding very large, fibrous, hard-to-digest meals).

The threshold for surgery in adhesional obstruction is balanced carefully. For patients showing signs of ischaemia or failing conservative management, surgery is offered promptly. For recurrent obstruction in patients with extensive adhesions, surgery is offered selectively and the rationale is discussed carefully — repeat operations carry diminishing returns. Where possible, a laparoscopic approach is used to reduce new adhesion formation.

Have questions about this procedure?

If you have questions or would like to be seen, Mr Nguyen consults at his rooms in Heidelberg and operates at Warringal Private and Epworth Eastern. A GP or specialist referral is needed to make an appointment.

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