Postoperative abdominal adhesions

Adhesions after surgery, also known as postoperative adhesions, are a common consequence of abdominal surgery. Common abdominal procedures, such as an appendectomy, caesarean section, or bowel surgery, can lead to the development of postoperative adhesions. Research shows that approximately 89% to 95% of patients develop adhesions after one or more abdominal surgeries (Chen et al., 2023). This makes adhesions one of the most common long-term consequences of abdominal surgery.

In clinical practice, adhesions can play an important, yet often underestimated, role in persistent complaints. Their potential impact is not always recognised during standard postoperative care. As a result, symptoms such as pain, a pulling or tight sensation, restricted movement, or functional bowel complaints are not always immediately linked to previous surgery.

While writing my thesis, I became increasingly interested in this subject. Precisely because adhesions are so common, yet remain relatively unknown, my interest continued to grow. The complexity of adhesions and the influence they can have on different systems within the body make them a fascinating topic, both within conventional medicine and from a broader perspective on the human body.

What many people do not know is that they can also consult an osteopath for these types of complaints. Osteopathy focuses, among other things, on improving tissue mobility and supporting the body as a whole. For some patients, osteopathic treatment may therefore be a valuable addition to their recovery process.

This article takes a closer look at what adhesions are, how they develop, and what consequences they may have. It also explores the different ways in which symptoms, particularly pain, can present and how these may be recognised in clinical practice.

Causes

Abdominal adhesions most commonly develop after surgery, although they can have other causes as well. Inflammation within the abdomen, such as pelvic inflammatory disease or endometriosis, can irritate the peritoneum and cause organs to adhere to one another. Radiation therapy to the abdomen or pelvis, for example as part of cancer treatment, can also damage the peritoneum and may lead to the formation of adhesions over time.

In rare cases, adhesions are congenital and therefore present from birth, without any previous surgery or inflammation.

Although there are several possible causes, this article focuses primarily on adhesions that develop after surgery. During an operation, tissue is damaged and the affected area may temporarily receive less oxygen. This response can disrupt the normal healing process, leading to excessive formation of connective tissue and the development of adhesions.

The development of adhesions

The peritoneum is a thin, smooth membrane that surrounds and protects the organs within the abdominal cavity. Under healthy conditions, it allows the organs to move smoothly against one another without friction or “sticking” together. This is important because the abdominal organs are constantly moving, for example during digestion and breathing. In addition, the peritoneum plays an active role in healing after injury, inflammatory responses, and immune defence within the abdominal cavity. It is also involved in pain perception: some parts transmit pain signals more clearly than others, which is why abdominal pain cannot always be precisely localised.

The development of adhesions is closely related to the way the peritoneum heals after injury, for example following surgery or inflammation. This healing process differs from that of the skin. Whereas a skin wound heals from the edges inward, the peritoneum repairs the entire damaged surface at the same time. As a result, healing is relatively rapid and usually takes place within a few days.

It is during this early healing phase that the risk of adhesion formation arises. Immediately after injury, a clotting response occurs in which fibrin forms a temporary “sticky layer” to seal and protect the damaged area. At the same time, an inflammatory response begins, involving white blood cells and other cells that remove damaged tissue and coordinate the healing process.

During normal healing, this fibrin layer is broken down within a few days and replaced by smooth, functional peritoneal tissue. When this process is disrupted, for example by extensive tissue damage or persistent inflammation, the fibrin layer may remain in place and gradually develop into connective tissue.

In the days that follow, fibroblasts contribute to the formation of new tissue by producing collagen as part of the scarring process. Initially, this tissue is still relatively loose and adaptable, but it gradually becomes stronger and more organised through a process known as remodelling.

When this healing response is excessive or prolonged, it can reduce the ability of organs to move freely against one another and may result in the formation of permanent adhesions.

Complications of adhesions

Abdominal adhesions can begin to form during or shortly after surgery, but they may not cause symptoms until years later. Because they can develop gradually, the connection with a previous abdominal operation is not always immediately recognised. As a result, adhesions may remain unnoticed for a long time as a possible cause of symptoms.

The symptoms can vary considerably. Many people experience mild or vague complaints such as bloating, changes in bowel habits, or mild abdominal pain. In other cases, the consequences can be more serious.

For example, adhesions around the fallopian tubes can interfere with the function of the reproductive organs, making it more difficult to become pregnant. Research has shown that women who have undergone certain types of abdominal surgery, such as bowel surgery, may have a lower chance of becoming pregnant compared with women who have not had surgery, suggesting that adhesions may play a role.

Bowel problems are also relatively common. Adhesions are an important cause of small bowel obstruction, in which the intestine becomes partially or completely blocked. Although a complete obstruction is relatively uncommon, it can be a serious condition requiring hospital admission or surgery. The risk depends mainly on the location and nature of the adhesions, rather than simply on the number of previous operations.

Adhesions may also contribute to chronic abdominal pain. Tension or pulling forces on the organs can trigger pain signals in the peritoneum. At the same time, this relationship is not always straightforward: not everyone with adhesions experiences pain, and surgical removal of adhesions does not always result in lasting symptom relief. In addition, further surgery carries a renewed risk of forming new adhesions.

Treatment of adhesions: surgery or not?

Although increasing attention is being paid within medicine to preventing adhesions, in practice it is not always possible to avoid them completely. When adhesions cause symptoms, the focus shifts to treatment.

In practice, treatment usually involves a surgical procedure in which the adhesions are released. This can be done either through laparoscopy or open abdominal surgery.

A laparoscopic approach is often preferred because it is less invasive and is generally associated with fewer complications and a faster recovery. However, this technique is not suitable in every situation. In cases of severely distended bowel, extensive or complex adhesions, or limited visibility, open abdominal surgery may be safer. This gives the surgeon more space and a better overview, which can reduce the risk of accidental injury to surrounding organs.

The results of surgery to release adhesions, particularly in patients with chronic abdominal pain, are highly variable. This means that the procedure does not have the same effect for everyone. Research shows that a substantial proportion of patients experience little or no improvement in their symptoms after surgery. In some cases, symptoms may even worsen. Interestingly, outcomes are sometimes comparable to those of patients who underwent laparoscopy alone without any adhesions actually being treated. In other words, releasing adhesions does not always appear to be more effective than doing nothing. This raises questions about how effective this type of surgery truly is as a treatment for pain.

The decision to treat adhesions is therefore not straightforward. In acute situations, such as bowel obstruction, surgery is often necessary. In other cases, treatment requires careful consideration of the limited chance of symptom improvement against the risks associated with another operation.

Osteopathy

Within osteopathy, postoperative adhesions are viewed in the context of the relationship between local tissue changes in the abdomen and the functioning of the body as a whole. Adhesions may not only affect mobility within the abdominal region, but may also influence tension patterns, posture, and the mobility of other areas of the body.

Treatment focuses on restoring freedom of movement, with particular attention to the myofascial system. Gentle manual techniques are used to reduce areas of tension and restriction and to support a more balanced distribution of mechanical load throughout the body.

In practice, this may contribute to greater overall comfort, improved mobility, and a reduction in secondary complaints associated with compensatory patterns in other regions, such as the back, pelvis, or thorax.

Research into visceral mobilisation techniques suggests that they may have positive effects on tissue recovery and mobility during the early postoperative phase. This supports the idea that manual approaches may contribute to a more favourable recovery environment following surgery.

It is important to emphasise that osteopathy cannot remove or dissolve existing adhesions. Treatment instead focuses on improving the mobility of the surrounding tissues and structures. This may help improve the overall movement and function of the area and support the body in functioning more effectively within the limitations that remain.

Adhesions and delayed symptoms

The literature mainly refers to adhesions: bands of connective tissue that form between structures that are normally separate, usually as a result of surgery or inflammation. These changes can develop relatively quickly, but they do not always cause symptoms immediately.

In some cases, symptoms may remain absent for a long period of time. The body is able to adapt, to a certain extent, to altered mechanical relationships and reduced mobility within the abdomen. As a result, restrictions may not initially be noticeable. Symptoms may only develop when the tissues are placed under greater strain or become less flexible, for example as a pulling sensation or a feeling of restriction in the abdomen or surrounding structures. This may help explain why, in some cases, symptoms only appear years after surgery.

When mobility decreases, a vicious cycle may develop: reduced movement can lead to increased stiffness and tension within the tissues, which in turn further limits the ability of structures to move freely in relation to one another. This may increase the mechanical load on the system, contributing to a further loss of flexibility and the persistence or worsening of symptoms.

From a functional perspective, movement of organs and surrounding tissues is considered important for maintaining smooth gliding surfaces and normal function. When this mobility decreases, it may contribute to stiffness and less optimal interaction between different structures.

Within osteopathy, the focus is therefore on improving mobility throughout the system. The aim is not to remove the adhesions themselves, but to optimise the function and mobility of the body within the existing situation, with the goal of interrupting this vicious cycle and reducing symptoms.

Fascia, pain and adhesions: an integradet perspective

Referred pain and the distortion of pain location

Pain associated with adhesions cannot always be traced back to its exact source. This can partly be explained by referred pain, in which pain is perceived in a different location from where it actually originates. This is particularly common with visceral structures such as the internal organs.

The explanation lies in the way nerve signals are processed. Nerve signals from organs, muscles, and the skin can converge within the same regions of the spinal cord. As a result, the nervous system may be less able to accurately distinguish where the signal originates, causing pain to be “projected” to another part of the body. A classic example is a heart attack, in which pain may radiate to the arm, shoulder, or jaw. This mechanism may contribute to the variable and less clearly defined pain patterns associated with abdominal adhesions.

Persistent pain and central sensitisation

When pain persists for a prolonged period, not only the local tissue situation plays a role, but also the way in which the nervous system processes signals. With ongoing or repeated stimulation, central sensitisation can develop, causing the pain system to become more sensitive.

The pain pathways in the spinal cord and brain can, as it were, become “primed”: signals are transmitted more quickly and more strongly, while inhibitory systems become less effective. This can lead to allodynia, in which normally non-painful stimuli cause pain, and hyperalgesia, in which pain is experienced more intensely.

This mechanism may play a role in persistent abdominal complaints, including symptoms in which adhesions are involved. Although central sensitisation may decrease when the ongoing stimulation is reduced, in some cases the nervous system can remain more sensitive for a prolonged period.

As a result, pain is not always a direct reflection of the local tissues, but may also reflect changes in the way pain signals are processed within the nervous system.

The fascial network and the influence of adhesions

Fascia is a continuous network of connective tissue that links muscles, organs, and other structures and allows movement between them. This network extends throughout the entire body, meaning that different regions are mechanically interconnected.

Abdominal adhesions can restrict the local mobility of tissues. This may lead to altered tension within the surrounding connective tissue and can affect adjacent regions, such as the pelvis and lower back. Through the fascial network, these changes may also extend further to other parts of the body, including the shoulders or legs.

The diaphragm plays an important role in this process because of its direct relationship with the abdominal organs and breathing. Changes in this region may therefore influence both local and more global movement patterns. The extent to which adhesions contribute to symptoms in distant areas varies from person to person, but they may be associated with a broader pattern of complaints than those limited to the abdominal region alone.

What does the science say?

One of the more consistent and promising findings in the current literature comes from a review by Lackner (2017), “The Pathophysiology of Postoperative Peritoneal Adhesions – Osteopathy as a Treatment Option?”. This review provides an overview of several studies examining osteopathic and manual techniques for adhesion-related complaints.

The findings suggest that techniques aimed at improving tissue mobility, such as osteopathic manipulative techniques and myofascial approaches, are associated with reductions in symptoms including pain, functional limitations, and bowel-related complaints. In addition, the literature repeatedly describes improvements in the function of the organ systems involved and in overall quality of life.

Lackner concludes that osteopathic approaches are primarily aimed at restoring mobility and reducing restrictions within tissue structures, which may clinically contribute to symptomatic improvement in patients with adhesion-related complaints.

This supports the idea that osteopathic interventions may provide a valuable contribution as part of a supportive approach to adhesion-related complaints, particularly by improving function and reducing symptoms.

Did you know?

 A particularly interesting fact to finish with: your organs do not remain completely still inside your abdomen. With every breath, they move along with the diaphragm. The kidneys are a good example: during quiet breathing, they often move just less than one centimetre up and down on average. With deeper breathing, this movement can increase to approximately one to four centimetres.

This movement is more important than you might think. Organs not only need to carry out their own functions, but also need to glide smoothly in relation to surrounding membranes, connective tissue, blood vessels, and other organs. Breathing acts as a natural pump in this process, repeatedly creating movement, pressure changes, and circulation within the abdomen and chest.

When tissue is less able to move freely, for example due to scar tissue or adhesions following surgery or inflammation, this can restrict the natural gliding motion between structures. As a result, increased tension may develop in the surrounding tissues, which in some people can contribute to abdominal complaints, a pulling sensation, or pain.

In other words: breathing is not just about moving air. With every breath, your entire inner world moves gently along with it.