Evidence-based prevention of post-operative adhesions.

Despite decades of research, numerous new product ideas and 'carefully considered opinions' of recognized experts, very few products for the prevention of post-operative adhesions have met the requirements for Level 1 evidence of safety and efficacy. Those that have are useable only at laparotomy. Several new liquid products intended for use at laparoscopy are in various stages of development and clinical investigation. Hopefully, some will prove to be both simple to use and efficacious. Even if this occurs, it must be remembered that a reduction in post-operative adhesions does not necessarily produce a better clinical outcome. Our common sense suggests that fewer adhesions should logically result in less pain, more pregnancies, fewer bowel obstructions and less long-term morbidity. We believe that 'fewer adhesions' is a good thing, but we have no controlled human trials to prove this. How much of a reduction in post-operative adhesions is necessary before it is clinically relevant? A single adhesion in the wrong anatomic location may be catastrophic. How do we measure this? Until these and other questions have been answered (if ever), we have nothing more than educated guesses that all these efforts are warranted.