Adhesion-related small-bowel obstruction after gynecologic
operations
Sundus Al-Took, MD, Robert Platt, PhD, and Togas Tulandi, MD
Montreal, Quebec, Canada
OBJECTIVE: Our purpose was to evaluate a possible relationship between adhesion-related small-bowel
obstruction and gynecologic operations.
STUDY DESIGN: The records of all female patients with the diagnosis of small-bowel obstruction from 1989 to
1996 were studied. The cause of bowel obstruction, the type and technique of previous operations, and whether
the parietal peritoneum was closed at the completion of the procedure or was left open were evaluated.
RESULTS: Among 262 women the most common cause of small-bowel obstruction was intra-abdominal adhesions (37.0%). Among 92 women with adhesion-related small-bowel obstruction, 35 women (38%) had undergone a previous abdominal hysterectomy. The incidence of small-bowel obstruction after an abdominal
hysterectomy was 16.3 per 1000 hysterectomies. The incidence of small-bowel obstruction after cesarean
delivery (5/10,000 cesarean deliveries) was significantly less than after other abdominal operations.
Adhesions were found between the small bowel and the pelvis in 14 women (29.8%), and all were in women
who had undergone a hysterectomy. In 33 others (70.2%) the adhesions were found between the previous
abdominal incision and the intestine. The median interval between the initial operation and the small-bowel
obstruction was 5.3 years.
CONCLUSION: The most common cause of small-bowel obstruction is postsurgical adhesions. Adhesionrelated small-bowel obstruction is commonly found after an abdominal hysterectomy. Bowel obstruction can
occur many years after the initial abdominal surgery. (Am J Obstet Gynecol 1999;180:313-5.)
Key words: Adhesion, bowel obstruction, hysterectomy, cesarean delivery
Intestinal obstruction is a frequently encountered problem, and postsurgical adhesions are the most common
cause of bowel obstruction.1-5 Previous reports suggest
that hysterectomy is one of the most common causes of intestinal obstruction.2, 3 However, in gynecologic literature,
this subject has been getting only limited attention. The
reason is that most patients with bowel problems seek advice from a general surgeon and not from a gynecologist.
The purpose of this study was to evaluate a possible relationship between adhesion-related small-bowel obstruction and gynecologic operations.
for benign conditions. There were 6480 cesarean deliveries. Each medical record was reviewed thoroughly for the
cause of bowel obstruction and the type and technique
of previous operations. We also evaluated whether the
parietal peritoneum was closed at the completion of the
procedure or was left open to heal by secondary intention. Non-adhesion-related bowel obstructions were excluded from the analysis.
Data were analyzed using the Student t test, χ2 test,
and life-table analysis.
Results
Material and methods
The medical records of all female patients with the diagnosis of small-bowel obstruction from 1989 to 1996 at
the Royal Victoria Hospital were evaluated. During this
period we encountered 813 colectomies, 2140 hysterectomies, 924 adnexal operations, and 245 myomectomies
From the Departments of Obstetrics and Gynecology, Pediatrics, and
Epidemiology and Biostatistics, McGill University.
Received for publication May 7, 1998; revised August 25, 1998; accepted September 14, 1998.
Reprint requests: Togas Tulandi, MD, McGill Reproductive Center,
Women’s Pavilion, 687 Pine Ave West, Montreal, Quebec, Canada
H3A 1A1.
Copyright © 1999 by Mosby, Inc.
0002-9378/99 $8.00 + 0 6/1/94464
Among 262 women the most common cause of smallbowel obstruction was intra-abdominal adhesions, which
occurred in 97 women (37.0%), and the second was
intra-abdominal malignancy, in 74 women (28.2%).
Another common cause was inflammatory bowel disease,
which affected 22 women (8.4%). Other causes included
radiation enteritis and incarcerated hernia.
Of all the women with adhesion-related small-bowel
obstruction, 92 women had a history of previous abdominal operations and 5 women had never undergone any
abdominal operations. Among the 92 women with postsurgical adhesions, 47 (51.1%) had undergone previous
gynecologic operations and 45 (48.9%) had had previous nongynecologic operations. The mean age of these
patients was 48.5 ± 1.7 (range, 20-86 years). All previous
313
314 Al-Took, Platt, and Tulandi
February 1999
Am J Obstet Gynecol
Table I. Type of previous gynecologic operations in
women with postsurgical adhesion-related small-bowel
obstruction
Women with
bowel obstruction
Type of
operation
Hysterectomy
Adnexal surgery
Myomectomy
Cesarean delivery
Total
operations
No.
Per 1000
operations
2140
924
245
6480
35
8
1
3
16.3*
8.7
3.9
0.5*
*P < .0001.
Fig 1. Cumulative probability of small-bowel obstruction after
gynecologic operations, as a function of interval between
surgery and small-bowel obstruction. Time zero was considered
the day of gynecologic operation. The median interval of
surgery to small-bowel obstruction was 5.3 years.
adhesions at the site of closure of the pelvic peritoneum.
The cumulative probability of adhesion-related smallbowel obstruction after gynecologic operation, as a function of the interval between surgery and small-bowel obstruction, is depicted in Fig 1. The median interval
between the initial operation and the small-bowel obstruction was 5.3 years.
Comment
operations were done by laparotomy. The type of the previous gynecologic operations is listed in Table I.
Adhesion-related small-bowel obstruction after a hysterectomy was encountered in 35 (38.0%) of 92 patients.
The incidence of small-bowel obstruction after hysterectomy was 35 per 2140 hysterectomies (16.3/1000). The
most common nongynecologic operation related to
small-bowel obstruction was colectomy, which had been
performed in 13 (14.1%) of the 92 women. The incidence of small-bowel obstruction after colectomy was 13
per 813 (15.9/1000) colectomies. This was not significantly different from that after hysterectomy, adnexal
surgery, or myomectomy. The incidence of small-bowel
obstruction after cesarean delivery was significantly less
than after other abdominal operations. Among 47
women who had had previous gynecologic operations,
adhesions that caused bowel obstruction were found between the small bowel and the pelvis in 14 women
(29.8%), and all were in women who had undergone a
hysterectomy. In 33 others (70.2%) the adhesions were
found between the previous abdominal incision and the
intestine. Among these, the parietal peritoneum was sutured in 20 women and was left open to heal by secondary intention in 10 women. The type of peritoneal
closure was not stated for 3 women. Twenty-one women
had a vertical incision, and the remainder had a
Pfannenstiel incision. In those with peritoneal closure
the peritoneum was closed vertically regardless of the
type of abdominal incision. Among women who had had
a previous hysterectomy, adhesions to the previous abdominal incision were responsible for small-bowel obstruction in 15% of cases. In 85% of cases, the cause was
In this study, intra-abdominal adhesions, especially
postsurgical adhesions, are the most common cause of
small-bowel obstruction. This is in agreement with previous reports.1, 6 In a large study of 1252 bowel obstructions during a 10-year period, 37% of the obstructions
were due to adhesion and 79% of these adhesions were
postoperative.1 Ellis6 also noted that one third of all
bowel obstructions were caused by adhesions.
Previous studies3, 7 have shown that more than one
half to three fourths of patients with adhesion-related
small-bowel obstruction had previous gynecologic or obstetric operations. Confirming these reports, we found
that among women with adhesion-related small-bowel
obstruction, 51.1% of them had undergone previous gynecologic operations. Intra-abdominal malignancy accounted for 28% of all cases of small-bowel obstruction.
It is possible that, with the improvement in cancer treatment, more patients will survive the disease but more
small-bowel obstruction will be encountered.
Melody2 in 1957 reviewed 487 consecutive gynecologic
operations and reported that 2.8% of patients who had undergone a hysterectomy subsequently had small-bowel obstruction, whereas the incidence was only 0.3% after other
gynecologic operations. Ratcliff et al3 in 1983 evaluated
small-bowel obstruction and previous gynecologic surgery
in 79 patients. Of these patients, 49 (83%) had undergone
previous abdominal surgery; abdominal hysterectomy was
the most common antecedent procedure, 33 (67%) of the
49 women having had this operation. We found a high
percentage of small-bowel obstruction after abdominal
hysterectomy. However, the incidence (16.3%) is not significantly different from that after adnexal surgery (8.7%),
Al-Took, Platt, and Tulandi 315
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Am J Obstet Gynecol
myomectomy (3.9%), or colectomy (15.9%). Note that
the denominators used in our study were derived from the
same period (1989-1996), whereas the median interval between the initial operation and the small-bowel obstruction was several years. Accordingly, they may not represent
a true denominator.
It appears that the reason for the high rate of smallbowel obstruction after hysterectomy is that this gynecologic operation is one of the most common. After hysterectomy, adhesions involving the site of closure of the
pelvic peritoneum were responsible for bowel obstruction in 85% of cases, with adhesions to the anterior abdominal wall occurring in another 15%. This is in contrast to small-bowel obstruction after other abdominal
operations, in which the obstruction is usually due to adhesions to the previous abdominal incision. Small-bowel
obstruction is encountered very rarely after cesarean delivery (5 cases per 10,000 cesarean deliveries).
Stricker et al7 reported that among 100 cases of smallbowel obstruction, postoperative adhesion was the main
cause. The operative report of the previous operation could
be evaluated in 11 patients; in 9 patients whose peritoneum
was sutured, the adhesions were found at the site.
Traditionally, closure of an abdominal incision includes suturing of the parietal peritoneum. Suturing the peritoneum
appears to have a more anatomic result than leaving it to
heal by secondary intention. However, the presence of ischemic tissue by sutures causes a predisposition to adhesion
formation.8 In 1977 Ellis and Heddle9 reported that peritoneal closure played no role in the healing of the laparotomy incision. There was no difference in the postoperative
complication rate or in the incidence of wound dehiscence
and incisional hernia between peritoneal closure and nonclosure.10 Tulandi et al11 also noted that there was no difference in the complication rate, wound healing, and adhesions to the laparotomy incision after closure with or
without peritoneal suturing. Several investigators6, 12 have
reported that, in animal models, laparotomy closure without peritoneal suturing healed with a lower incidence of adhesions to the wound. In the present study, we could not determine the incidence of small-bowel obstruction after
peritoneal closure or nonclosure. It is possible that peritoneal suturing is not only unnecessary but is associated
with a greater risk of small-bowel obstruction.
Confirming previous reports,3, 7 we found a very low frequency of intestinal obstruction after a previous cesarean
delivery. The reason might be that the incision was in the
anterior portion of the lower uterine segment. It has been
shown that, in myomectomy, an anterior uterine incision is
associated with less adhesion formation than is a posterior
incision.13 Myomectomy often causes adhesion formation,
but we encountered only 1 patient with bowel obstruction
resulting from postmyomectomy adhesions.
The interval between the initial laparotomy and the
bowel obstruction varies from 1 month to more than 20
years. The median interval in our study was 5.3 years.
This suggests that small-bowel obstruction can occur
long after a gynecologic operation. At this time a general
surgeon usually manages the case, and the treating gynecologist might not be aware of this complication.
We conclude that the most common cause of smallbowel obstruction is postsurgical adhesions. Adhesionrelated small-bowel obstruction is often found after an
abdominal hysterectomy. Small-bowel obstruction can
occur many years after the initial abdominal surgery.
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